Breakdown Biliverdin Bilirubin Plasma Bilirubin (CHOLESTATIC) OBSTRUCTIVE JAUNDICE
of Hb (insoluble or UNCONJUGATED)
bound to albumin = CONJUGATED bilirubin
Blood = conjugated hyperbilirubinaemia
Urine [since water sol]
of RBC Uptake into liver from Dark urine
Spleen Less conjugated bilirubin
Excess bilirubin production: Causes:
C Bilirubin conjugated with Choledochal cyst
A Haemolysis gluconuric acid by Ciliary Atresia
B Liver uptake hepatocytes MURAL / INTRINSIC
(soluble or CONJUGATED)
C Conjugation Liver cell transport abnormalities
= UNCONJUGATED bilirubin Cholangiocarcinoma
Blood = unconjugated Mirrizi syndrome (GS in cystic duct
hyperbilirubinaemia or GB)
Not in urine [since water insol] Infestation
Physiological (neonatal) Portal lymphadenopathy
haemolysis Chronic Pancreatitis
Dyserythropoeisis Pancreatic C
Glyuronyl transferase deficiency Ampullary/ duodenal tumour
Gilbert’s Syndrome (2-
7% of population)
Portal Hydrolised by Stercobilogen
HEPATIC JAUNDICE Circulation bacterial flora
Conjugated hyperbilirubinaemia may also be caused by hepatic
jaundice disorders though Unconjugated hyperbilirubinaemia is
Hepatocyte damage +/- some cholestasis
Viruses Absorbed Urobilogen- Oxidised
Hep ABC into blood water sol and Stercobilin
CMV colourless (brown colour)
Septicaemia Excreted in urine Excreted in
Leptospirosis (as Urobilin???) faeces
A1 antitrypsin deficiency
Wilson’s disease (Disorder of copper met KF rings)
Budd Chiari syndrome (Hepatic venous obstruction)
Failure to excrete conjugated bilirubin
Dubin Johnson syndrome
Right heart failure
BILIRUBIN AND JAUNDICE…
GALLSTONES Cholecystitis- see another card
Def Calculus formed in the gallbladder or biliary passages Mucocele GB
AKA- biliary calculus, cholelith Def: Continuous secretion of mucous + common BD
PP ♀>♂ (2:1), though elderly ratio is equal plug ( infection = ‘Empyema’)
USA / Europe / Australia > India / Far East / Africa Ca secreted into GB lumen = ‘Porcelain GB’
Cause Fat, Female, Fair, Forty, Fertile
Sickle cell disease (bilirubin), Cirrhosis, crohn disease, WITHIN BILE DUCTS
Diabetes, Pancreatic disease, Hyperparathyroidism, Pregnancy Obstructive Jaundice
Path Most are mixed, but stones are classified into: Def: Gallstones cystic duct (stricturing of hepatic
CHOLESTEROL- > in developed countries, 80%, radiolucent, duct = ‘Mirrizzis Syndrome’ / Pancreatitis )
large, Female, Fat, Forty Tx: ERCP + Cholecystectomy
PIGMENT- irregular, radiolucent, small, haemolysis Cholangitis
Only 10% are radio-opaque Bile duct inflammation
S&S 90% asymptomatic SS: RUQ pain + jaundice + rigors (CHARCOT’S Triad)
Rest biliary colic / cholecystitis Tx: Cefuroxime + Metronidiazole
Tx IVI, NBM WITHIN GUT
IV Antibiotics Gallstone Ileus
Oral Bile Acids / Bile Salt Therapy Def: Gallstone perforates duodenum / stomach
Lithotrypsy / ERCP + Cholecystectomy Dx: AXR- air in CBD. Small bowel fluid levels, stone
Comp WITHIN GALLBLADDER Fistulae
Biliary Colic- see another card Def: b/w GB + duodenum / stomach
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Dx: Abdo XR- air in biliary tree EARLY LATE
N/ N/ N
BILIARY COLIC & CHOLECYSTITIS unconjugated
Def Main difference = inflammatory component Bilirubin
Cause Gallstones Common BD Urinary bilirubin
Path = dark urine
S&S Biliary Colic: Urobilogen
RUQ sudden onset pain- 2 hrs (<6) + jaundice = pale stools
Cholecystitis: Reticulocytes >2% N N N
Epigastic pain > RUQ (70%/20%) LFTS
Radiation: Peritonitis R Scapula Alkaline
GB mass + N/V + Jaundice phosphatase
Murphy’s sign: 2 fingers over GB, inspiration, pain, -ve left side Y-gt transaminase N N
DDx Cholecystitis: PUD, Hepatitis, Liver Absess, Pancreatitis, C of Liver / Transaminases N N
Bile Ducts / GB, Cholangitis. Lactate
Inv BILIARY COLIC: dehydrogenase
AXR Calc stones in < 20%
Oral Cystography Def Inflammation of liver necrosis
CHOLECYSTITIS: Cause VIRUSES: Hepatitis Viruses, EBV, CMV
WCC IATROGENIC / DRUGS: OH, Drugs (e.g. Paracetamol)
US Thick GB mass- >3mm, distended GB, pericholecystic BILIARY DISEASE / OBSTRUCTION: Ascending cholangitis,
fluid + stones Cancer, Bud Chiari syndrome: Thrombus Obstruction hep
LFTS veins congestion disrupted function.
Amylase Path Vac Spread Tx Incubation
Bilirubin A Oral Supportive OH 2-6 /52
Alk Phos B Blood Supportive OH 4-20 /52
C Blood Interferon 2-26 /52
Tx Biliary Colic:
D () B Blood Interferon 6-9 /52
Opiod (Not morphine as pressure in sphincter of oddi)
E Oral Prevention 3-8 /52
Cholecystectomy Needle stick injury risk from infected pt: Hep B (30%), Hep C (10%), HIV (0.1%)
Transmission for Hep B: Sexual (10%), Vertical (70%).
Cholecystitis HEPATITIS C:
A Range of 6 viruses (1-6). Genotype 1 & 4 > difficult to treat than 2 & 3.
OH + Hep C Exponential inflammation and cirrhosis.
NG decompression within 48 hrs
Of those infected with Hep C: 80% retain virus, 20% are clear.
Of those 80% who are infected and retain the virus
Antibiotics: Cefuroxime and metronidazole
80% clear but ½ relapse once off the drugs. 20% Cirrhosis
Risk of Hep C transmission is 6% for both sexual and vertical.
Comp Chronic Cholecystitis: stones chronic inflammation vague
abdominal discomfort + distension
Interferon Tx is 6/12 for Types 2&3 (12/12 for others + 12/52 response
testing). S/E for 1st 24hrs are bad, then poor for day 2, then fine during
JAUNDICE day 3.
Def Yellow appearance: skin / sclera / mucous membranes Interferon Benefit: B- Acute Not useful
bilirubin detectable at 3mg / dL or 40 micromol/l Interferon Benefit: B- Chronic 40% patients have benefit
PP Interferon Benefit: C- Acute Unknown
Cause Contacts A Alcohol Interferon Benefit: C- Chronic 20% patients eradicate disease
Hx Anaemia B Blood Anaemia / Disease Interferons are naturally occurring proteins which are released to stimulate
Travel C Contacts with Jaundice the immune system. Also used for: Hairy cell leukaemia, AIDS-related Kaposi's
Had it before D Drugs sarcoma, Genital warts.
Operations E ERCP S&S ACUTE HEPATITIS:
Drugs F Foreign travel, FHx Jaundice- dark urine, light stools
Extra Hepatic Causes G Gallstones Hepatomegaly
Sexual Preference H Hepatitis Fatigue, malaise, lethargy
Hep C risk if haemophiliac due to many blood transfusions. RUQ pain, N/V, Fever / headache
Path See Diagram at beginning LIVER FAILURE:
S&S COURVOISIER’S RULE: Oedema ( albumin) + ascites
Silent jaundice, palpable GB = Not gallstones (may be C) Hepatic encephalopathy
MURPHY’S SIGN: Hyperoestrogenaemia
2 fingers over GB, inspiration, pain, -ve left side = Cholecystitis GI bleeding
HAEMOLYTIC Bruising (due to circulating coagulation factors)
Eg. Gilberts Syndrome, Dark stools + urine, Pallor- anaemia, Hypoglycaemia (due to hepatic gluconeogenesis)
Splenomegaly- activity VIRAL HEPATITIS:
HEPATOCELLULAR May be prodromal flu like symptoms: Fever, Malaise,
Disease of liver parenchyma…prevents bilirubin bile Arthralgia, Myalgia
Viruses, Drugs, OH, Toxins, Abscesses, RHF Later due to stretching of liver capsule: Nausea, Anorexia,
CHOLESTATIC Jaundice, Itching, Abdominal pain
Obstruction of bile flow, pale stools + dark urine Only 1/3 of Hep C Infections S&S
MURAL / INTRINSIC: cholangitis, cholangiocarcinoma, DDx Cholecystitis, cholelithiasis, cholangitis, biliary cirrhosis, haemolytic
Mirrizzi’s syndrome anaemia, pancreatic C
INTRA LUMINAL: Infection, gallstones Inv / Clinical Hepatic E: 1st sign is affected circadian rhythm.
EXTRINSIC: Portal lymphadenopathy, Chronic pancreatitis, Dx Join dots. Construct a star.
Pancreatic C, Ampullary / Duodenal C AST / ALT
: Liver cell damage (In 1 week may be
DDx Obstructive patten due to swelling.)
Inv / FBC Hb ALP / GGT : Biliary epithelium damage (GGT also with OH)
Dx U+Es Complications Bilirubin
Clotting PT time , Haemolytic / Cholestatic Albumin / PT
LFTS Bilirubin: conj, unconj, urobilogen Virology A- AST / ALT/ IgM
ALP: obstructive- from liver collecting ducts Auto Abs B- HbsAg
AST / ALT: cell damage- constituents of Paracetamol CDE- Anti HCV / HDV / HEV antibodies
hepatocytes Autoimmune: Autoimmune antibodies
Virology EBV / CMV / HAV / HBV / HCV
US Dilated biliary tree, gallstones, Scarring/ vascular
Urine Bilirubin in prehepatic- since water insoluble flow damage of liver / GB
Urobilogen absent in obstructive
US Bile duct dilation- obstructive jaundice ERCP
If not Liver Bx
TYPE OF HAEM- HEPATO- HEPATO- OBST-
JAUNDICE OLYTIC CELLULAR CELLULAR RUCTIVE
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Tx Nutrition Dx WCC & Platelets (hypersplenism)
IV fluids U&E Urea & Creatinin (If U, C = bleeding
Tx Nausea / Pruritis somewhere; If U, C = Deep cirrhosis =
Antiviral Tx: B+C A+E Hetatorenal syndrome)
Autoimmune- corticosteroids INR
Paracetalmol overdose – N acetylcysteine LFTs (may be N Bilirubin,
Liver Transplant if severely Transaminases
Mx damaged) Alk Phos- biliary epithelial damage
Comp GGT biliary epithelial damage + OH
CIRRHOSIS Glucose Gluconeogenesis
Def Irreversible damage to the liver US Hepatomegaly / Splenomegaly.
PP Malignancy. Obstructive Jaundice.
Cause Commonest AFP Marker for Liver C
OH Bx Dx
Chronic HBV and HCV infection Endoscopy Oesophageal Varices (Ulcer is still most
Others common cause of GI bleed even with OV)
Haemochromatosis (Tanned appearance) Ascitic Tap WCC>250cm3 = Spont bacterial peritonitis
Chronic active hepatitis Protein, M&C, Cytology.
Sclerosing cholangitis CT:Triple Phase Normal / Portal / Arterial
Budd Chiari syndrome CHILD’S GRADING OF LIVER DISEASE
Wilson’s disease (Copper met- blue cornea ring) Excrete… Produce…. Signs…
A1 antitrypsin deficiency Grade Serum Serum PT Asc Encep Operative
Drugs: Amiodarone, Methyldopa Bilirubin Albumin Mortality
Chronic HF A Normal >35 g/L <4 None 2%
Unknown Cause in 30%- Cryptogenic cirrhosis B 20-50 mcmol/L 30-35 g/L 4-6 Mild 10%
Pathology: C >50 mcmol/L <30 g/L >6 Severe 50%
Disruption Of Formation of Haphazard Widespread Mx GENERAL MEASURES
Normal fibrous scar regeneration of metabolic Nutritional supplements: Thiamine, Vit K.
Sinusoidal tissue by hepatocytes in dysfunction Protein diet (if encephalopathy), OH
Architecture Stellate cells nodules weight loss and US and a-fetoprotein every 3/12 to screen for hepatocellular C
wasting Relief of symptoms
Antihistamines for pruritis
Alters Blood Oral bile acids to entero hepatic circulation
Flow through Function
Regular small meals may compensate for loss of hepatic
Liver storage capacity and may minimise weight .
INR: Fresh frozen plasma
Platelets: Platelet transfusion
Varices Plasma Varices: Banding and drugs.
Rupture Proteins SPECIFIC TX
Pressure in Portal oesophagus Interferon A: Improves liver biochemistry; May retard
Vein (PORTAL and rectum
hepatocellular C in HCV induced cirrhosis
HYPERTENSION) Also caput
medusae due Penicillamine for Wilsons Disease
to umbilicus ASCITES
Spenomegaly Fluid restriction
Low salt diet
Accumulation Spironolactone- dose every 48 hrs (Don’t want to empty
of bilirubin & intravascular vol too quickly- have to wait for interstitial fluid to
Splenic Vein other toxins diffuse back in)
Chart daily weight: Aim for weight loss of < ½ kg / day
If response if poor, add frusemide PO.
Check U&E and creatinin regularly
Paracentesis (Removal of large vol of fluid from abdo cavity).
Mesenteric Albumin: But expensive and only has 7 day half life.
Pooling of platelets - Vein
Congestion SPONTANEOUS BACTERIAL
Tx: Cefuroxime + metronidiazole
Prophylaxis: Ciprofloxacin or Trimoxazole
Comp Portal Hypertension, Variceal Haemorrhage, Ascites
Spontaneous bacterial peritonitis (Caused by translocation of
Encephalopathy- toxin Clotting gram -ve bacteria from intestinal lumen protein rich ascitic
Transudation of fluid into
laden blood bypasses Factors fluid. High mortality especially when liver disease advanced).
peritoneal cavity - Ascites
liver Hepatic encephalopathy, Liver Flap (asterixis), Constructional
Apraxia- inability to draw simple shapes, Drowsiness Coma.
Tx with Laxatives to intestinal bacterial load. Dx with EEG (3
spike) due to ammonia from bacteria. Tx Amoxicillin to
Spontaneous Bacterial Hepatorenal syndrome
Peritonitis (due to conc Hepatocellular carcinoma
anti bacterial fluid) Coagulo-pathy
DEF: Assoc w OH abuse (+ other thiamine deficiency causes)
PATH Acute capillary haemorrhages, astrocytosis and neuronal
S&S Liver has large FUNCTIONAL RESERVE CAPACITY. Extensive death in upper brainstem and diencephalon Triad of S&S:
damage may remain clinically undetected (COMPENSATED) until S&S:
CONFUSION: Acute confusional state
Hand to Toe: Lemon on sticks…
OPTHALMOPLEGIA: Nystagmus, Bilateral LR Palsy,
Palmar erythema, Dupuytren’s contracture, Clubbing,
Fixed Pupils, Papilloedema (Rare)
ATAXIA: Broad Based Gait, Cerebellar Signs in limbs,
Vestibular Paralysis, Peripheral Neuropathy (esp legs)
Kaiser rings (blue corneal), Jaundice, Plethoric face, Anaemia
Fetor Hepatis- acidic sweet smell breath COMP: If Untreated Transition from Reversible Wernicke’s
Spider naevi, Gynacomastia, Bruising, Muscle wasting Irreversible Korsakoff Psychosis ( Short Term Memory,
Ascites Disordered time appreciation, Confabulation.)
Hepatomegaly- nodular liver. Small if advanced INV: Plasma pyruvate, RBC Transketolase.
Splenomegaly TX: Thiamine (Urgent:Once amnesia, only 50% improve)
Caput medusae: check w finger compression- N flow towards Prog 5 year survival = 50%
umbilicus Poor prognostic indicators
Peripheral oedema (due to protein, renin breakdown) Serum Na = <110g/L
DDx Serum albumin = <25g/L
Inv / FBC Hb, INR
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INFLAMMATORY BOWEL DISEASE (grey = Crohn’s only) Diverticular disease
ULCERATIVE COLITIS CROHN’S DISEASE Colonic carcinoma or polyp
Def Chronic, relapsing disorder of Chronic granulomatous Haemorrhoids
rectum and colon disease affecting any of gut Rectal trauma e.g. Biopsy
PP ♂>♀ ♀>♂ LESS COMMON:
Men Smoking = risk Smoking = risk Anal fissure
U.C. Incidence= > Incidence= < Massive upper gastrointestinal bleeding
Smke Bimodal Peaks,20-35,50-65 Bimodal Peaks, 20-30, Inflammatory bowel disease
> Jews > Caucasians > >50 Ischaemic colitis
African US Meckel's diverticulum
Cause Hookworm, particularly in the tropics
Path Infective colitis e.g. Campylobacter
S&S Bloody, mucus, diarrhoea, +/- Bloody, mucus (I=, C =) Solitary ulcer of rectum
tenesmus Diarrhoea / steatorrhoea Path
Abdominal pain / cramps- I= Pain due to Obstruction S&S UPPER Bleed:
Defecation relieves Weight since eating = pain Haematemesis (May be bleeding down to Lig of
Rectum…Proctitis Rectal Sparing Trietze…connects R Diaphragm to Coeliac Trunk,
Sigmoid...Proctosigmoiditis I=Ileal Disease = 40% Holding the DJ flexure in position)
All……….Pancolitis C= Crohns Colitis = 30% Black coffee grounds when less severe
Both = 30% Melena (Bacterial degeneration). UGI bleeding,
Extra Venous Thrombosis Appendicitis although RHS colonic & small bowel lesions can
Int Clubbing, Oral Ulcers, Fatty Liver Clubbing, Oral Ulcers, F Liver occasionally be responsible
S&S Arthritis Maroon Jejunum Caecum
Pyoderma Gangrenosum LOWER Bleed:
COF Iritis Renal Stones Red with clots when from Colon / Rectum
Erythema Nodosum Gallbladder Stones Massive rectal bleeding usually from distal colon,
PIE Sclerosing Cholangitis (> with UC) Sclerosing Cholangitis rectum or from a major bleeding site higher in GI.
SAC Ankylosing Spondylitis (> UC) Ank Spondylitis Syncope, Oliguria (volume depletion hypotension)
Cholangio Carcinoma Anaemia symptoms: HR, BP, Pallor, Sweating,
DDx Infectious colitis, arthritis, E Coli, Campylobacter, Shigella, Postural drop.
Salmonella, Colorectal C, Malabsorption syndromes Evidence of liver disease
Diverticulitis, Ischemic Colitis DDx
Inv / FBC, U+Es, CRP, LFTs, Blood Cultures, Serum Fe +B12 Stool MC+C Inv / FBC Anaemic
Dx AXR Faecal shadowing, mucosal thickening, colonic Dx U&Es Renal F
dilation, perforation Also: Urea due liver metabolism of blood by liver.
Rectal Bx Inflammation, Ulcers, Crypt abscesses Urea : Creatinine Ratio
Barium E Haustra, granular mucosa, shortened colon, PT If suggestion of liver disease or anticoagulated pts
Colon / Sigmoid- Rectal Sparing, Skip Lesions, Strictures, Image UGI…Endoscopy: ID cause in >90%.
oscopy Coblestoning Image Sigmoidoscopy: 10% of lower G.I. bleeds occur within
LP =UC = Crypt abscesses RGS STUFF = Crohn’s D LGI reach of a sigmoidoscope. If -ve
Rectal sparing Colonoscopy: ASAP with emergency prep of gut by
Granulomas administration of 500 ml 10% mannitol, 10 mg
Skip lesions metoclopramide and plenty of water. If -ve…consider:
Strictures Technetium scintiscan: Good at localising lesion.
Mucosal Transmural inflammation Subsequent Mx would include arteriography +/or Sx
Mucosal Ulcers Rosethorn * Mesenteric angiography: Sensitive test if bleeding
Fissures brisk: > 1-2 ml/min
Fistulas Tx ASSESS USING THE ROCKALL SCORE
Lead Piping (haustra loss) Inform Surgeons of admission.
* Rosethorn ulcers: Deep ulcers which may eventually form fistula Protect airway + NBM
Tx Prednisolone + Prednisolone Cannula: Large bore in to Antecubital fossae
Sulphasalazine (work well) Sulphasalazine (< evidence) Grouping, X-match, Hg, U&Es, PT, LFT's.
Azathioprine Azathioprine IVI (1-2 litres of colloid) + O- blood
NMB, IV fluids, IM vits NMB, IV fluids, IM vits (INR + Correct clotting: Vit K, platelet concentrate)
Colectomy (if = ) Surgery never curative CVP line
Mx Catheterise and monitor urine output
Nil by mouth until endoscopy
Comp Toxic megacolon (>UC) Fistula (>crohn’s)
H2-antagonist, e.g. ranitidine 300 mg at night
Risk of malignancy - Abdominal mass (>crohn’s)
OGD Endoscopy for Dx
lymphoma, carcinoma (>UC) Steatorrhoea (>crohn’s)
Surgery Thermal ablation / colectomy
Tx 2 Specific Tx of Causes…
BLEEDING PEPTIC ULCER
Bleeding often stops spontaneously (in 80-90% of cases)
PP Most common GI emergency: 50-120 H admission per yr per 100 000
Injection sclerotherapy, e.g. with adrenaline
35-50% Peptic Ulcer (NSAIDs, H Pylori)
Other techniques: Heater probe and laser.
10-20% Gastric Erosion (NSAIDs, OH)
10% Oesophagitis (Usually with hiatus hernia)
Wait for the bleeding to stop spontaneously
5% Vascular Malformation
If bleeding continues then options include:
5% Mallory Weiss tear (Retching)
2-9% Varices (Liver disease, Portal vein thrombosis) Oversewing at bleeding point
2% Cancer of the stomach or oesophagus Sengstaken-Blakemore tube (Balloon Tamponade).
0.2% Aortoduodenal fistula (Aortic graft) EROSIVE GASTRITIS
Cause PHARYNX: If bleeding continues, may require Sx (partial gastric resection)
UGI Vomiting of swallowed blood from a nasal bleed If gastritis related to NSAIDs / aspirin / OH then bleeding usually
OESOPHAGUS: stops quickly. Stop aspirin / NSAID and initiate PPI.
Oesophagitis due to a hiatus hernia OESOPHAGEAL VARICES…Tx in the following order
Oesophageal varices Endoscopy: Band ligation (tie a rubber band around) then
Mallory-weiss tear sclerotherapy (injection to close off vessels)
Carcinoma Vasoactive Drugs – Vasopressin (ADH), Terlipressin, Octreotide
STOMACH: (Somatostatin Analogue).
Gastritis - alcoholic, drug-induced, biliary, irritant If Endoscopic & Drug Tx Fail Balloon Tamponade
Gastric ulcer (20%) (Sengstacken Blakemore Tube)
Gastric carcinoma Radiological - Transjugular Intrahepatic Porto-Systemic Shunt
Benign tumours e.g. Leiomyoma (TIPPS)
DUODENUM: Sx: Oesophageal transection
Duodenal ulcer (40%) LOWER GI BLEEDS:
Duodenitis Take a supportive 'wait-and-see' stance
Cause COMMON CAUSES: Surgical colectomy or hemicolectomy
LGI Angiodysplasia Colonoscopic electrocoagulation of bleeding spots
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Prog Find Rockall Score for prognosis of UGI Bleeds. Takes into Disruption of mucosa:
account…Age, Shock, Comorbidity, Endoscopy Dx, Infection Infection: Viral, Salmonella, Shigella, Giardia
UGI: 20% require surgery. 10% mortality from such events. 25% Ischaemia Ischaemia
will rebleed after admission and of these, a third will die. Poor Inflammation Inflammation: Eg. IBD, Vasculitis, Cancer, OH,
prognostic factors include old age, shock at presentation, ABx, Propanalol
varices and rebleeding. Hist Travel, Dietary, Sexual Hx
LGI: ~ 10% die. 75% of those presenting to H will stabilise with Clostridium Difficile is common 2/7 – 1/12 after broad spec ABx
only resuscitative measures, e.g. blood transfusion. S&S ACUTE: Gasteroenteritis
GASTROINTESTINAL PERFORATION BLOODY: Campylobacter, Shigella, Crohns / UC, Isc colitis
Def Stomach contents peritoneal cavity ( peritionitis) FRESH BLOOD: Haemorrhoids, Diverticulitis, Colon C
PP Frequency: Duodenal > Gastric MUCUS: IBS, Colonic Adenocarcinoma
Cause NSAIDS often cause PUS: IBD, Diverticulitis
Path SMALL BOWEL: RIF / periumbilical pain not relieved by
S&S Pain defecation, steatorrhoea
Sudden severe pain LARGE BOWEL: Watery stool, +/- blood / mucus, pelvic pain
Distribution following content spread over peritoneum relieved by defecation, tenesmus, urgency
Initial in upper adbo then generalised NON GI CAUSE: Drugs, medication
Shoulder tip pain due to irritation of diaphragm DDx See above
Shallow respiration Inv / FBC, MCV, U&Es, ESR, CRP, TFTs, Igs
Limitation of diaphragm movement Dx Faecal Fat, Stool M+C, Barium E, Sigmoidoscopy.
Shock Tx Tx cause
Board like rigidity of abdomen Oral Rehydration (if bad saline + K + IVI)
DDx Antibiotics unless infective diarrhoea
Inv / CXR Air below diaphragm (50% cases) Codeine: slows transit time
Dx If not, water soluble contrast will confirm leakage Specifics:
Tx Resuscitation Antibiotics Dysentery
Surgical Tx 5ASAs IBD
Mx Avoid NSAIDs Enzyme supplements Pancreatic Disease
Comp Peritonitis Somatostatin Secretary diarrhoea caused by hormone
Mortality 25% secreting tumours
PEPTIC ULCER DISEASE CONSTIPATION
Def Ulcer in wall of stomach or duodenum resulting from digestive Def May be self perpetuating (H2O withdrawn at distal intestine)
action of gastric juice on mucous membrane when latter is N = 3/day 1 every 3 days
rendered susceptible to its action Tenesmus: Sense of incomplete evacuation
Ulcer: Local defect or excavation, of surface of an organ or Cause CONGENITAL
tissue, produced by sloughing of inflammatory necrotic tissue. Hirschsprung’s - myenteric nerves absent from distal colon
PP 10% of adults C chronic obstruction massively dilated, faeces filled proximal
♂>♀ (Duodenal = 4:1, Gastric = 2:1) O colon (MEGACOLON)
DUODENAL GASTRIC N Imperforate Anus, (Pyloric Stenosis, Duodenal Atresia)
4 x > common S OBSTRUCTION
Young ♂ Elderly T Painful local lesions urge to defecate: E.g. prolapsed
90% H Pylori 70% H Pylori, 30% NSAIDS I haemorrhoids, anal fissures.
50%: ant wall, dist to 90%: lesser curve P Local obstruction pain / difficulty in defecation: E.g. Tumour
pyloric Junction A Stricture: IBD, Diverticulitis, Ischaemia.
Cause T NEUROLOGICAL
Path H Pylori: Produces ammonia from urea = pH for survival E Damage to brain/ spinal cord can lead to chronic constipation /
NSAIDS, Steroids incontinence: E.g. Multiple Sclerosis, Peripheral Neuropathy
Smoking ( healing) STRESS
Blood Group O, Neurosurgery, Z/E syndrome Intestinal motility may be due to sympathetic autonomic
nerve activity. People who are severely injured or otherwise
S&S Pain: burning epigastric / RUQ
unwell may be constipated for a few days
Gastric: worse with food
Duo: better with food and worse 2-3 hrs post food. Hypothyroidism
Bleeding: Haematemesis, Melaena IONS
Perforation: Rebound tenderness, severe pain Ca ( intestinal motility), K
DDx Gastritis, Gasric C, Oesophageal / Gastric varices, Oesophageal C, Opiates, Antidepressants, Others with anticholinergic effects
Pancreatitis, Pancreatic C, Cholecystitis, Gasteroenteritis Oral iron supplements, Antacids- aluminium containing
Inv / Double contrast barium meal Endo+ Bx if ulcer (since some=C) Stimulant Laxatives: Prolonged use of Senna Depletes
Dx Endoscopy and Bx enteric neurons Colonic atonia
Breath Test Urease 5HT antagonists- that have been used for diarrhoea in IBS.
[Gastrin] Z/E ABDOMINAL SX
Microbiology Gold S for H Pylori but slow Paralytic Ileus from abdominal surgery
Tx Histamine H2 Receptor Antagonists- Cimetidine TOO LITTLE WATER
H+K+ ATPase (PPI)- Lansoprazole Dehydration
Antacids / Alginates (SE= constipation) EXCESS FIBRE (and of course, too little)
Colloidal Bismuth compounds (protect mucosa)- Fibre: when water volume
Mx Stop smoking / bad food / NSAIDS / OH Fibre: when water volume defecation
H Pylori: PPI + 2 Abs frequency + harder
(Lansoprazole + Amoxicillin + Erythromycin 1/52). FASTING reflex colonic activity + stool volume
Have Lanzoprazpole in A&E and H Pylori will vanish! decline in defecation frequency
Comp Perforation S&S Dietary Hx, Weight loss
Look for Associated S&S: Rectal Bleeding, Abdominal
DIARRHOEA Distension, Bowel Sounds. Most important Examination is…
Def Passing of excess volume of stool PR: If Stool ++: More Likely to be functional
Usually accompanied by: Frequency of defecation, Liquidity PR: If Stool +/-: Less Likely to be functional i.e. obstruction
May contain > fat when caused by malabsorption Barium / Colonoscopy
Normal stool volume = 200-300ml/day DDx See above
Cause Dysmotility motility transit time Inv / Investigate when a new symptoms in > 40s.
() Eg. Hyperthyroidism, Autonomic neuropathy w Dm, Dx Bloods FBC, U &Es, ESR, LFTS, TFTs, Ca, K
‘DOSI’ Addison’s ( stress hormones) Barium E > useful than colonoscopy as IDs neoplasia
Osmotic Unabsorbed osmotic solutes H20 absorption and megacolon)
Eg. Lactase deficiency, Disaccharide deficiency, Sigmoidoscopy Mucus
Pancreatitis, Bile salt malabsorption (Crohn’s, ileal Tx Tx Cause.
resection, bacterial overgrowth Fibre diet, Fluids (unless obstruction / megacolon)
Secretary Diffuse mucosal disease absorption << secretion Laxatives in following order:
E.g. Cholera: Stim Cl- lumen (Na + H2O follow). Bulk Laxatives- FyBogel,
E. Coli, Neurohormones (VIP-oma, Gastrin-oma, Osmotic Laxatives- lactulOse, MOvicol
Serotonin) Stool Softeners- Arachis oil
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Stimulant Laxatives- Senna, (Picolax: Used for bowel prep) Rarely, schizophrenia
VOMITING (& NAUSEA) Normal physiological response: Stress, Travel, Pregnancy.
Def NAUSEA: Radiation therapy
Dysporic desire to vomit Mesenteric arterial occlusion
Often acconmpanies by distaste for food and appetite. Hepatic and biliary disease: Cirrhosis, Acute cholecystitis
Although often precedes vomiting, either may occur in isolation. Pancreatic disease: Ruptured pancreas, Acute pancreatitis
RETCHING: Disseminated malignancy, Hereditary spherocytosis, Testicular
Rhythmic reverse peristaltic activity of stomach & oesophagus torsion, Twisted ovarian cyst
Accompanied by contraction of abdominal muscles. Tx Regard vomiting as protective mechanism: Treat Cause.
During retching, oesophagus dilates and may accumulate For treating minor event causes…
vomitus that is subsequently expelled. Motion sickness and vestibulocochlear dysfunction
VOMITING: Acetylecholine (Ach) receptor antagonists
Forceful expulsion of food out of mouth Histamine H1 receptor antagonists
Usually accompanied by Block stimuli to CTZ
Salivation, Sweating, HR Dopamine D2 receptor antagonists
Vomiting different from passive regurgitation (stomach contents Phenothiazides
and partly digested food reflux mouth). Metoclopramide (Cholinergic Effect Also
Path MUSCULAR COORDINATION GOJ tone, stomach emptying )
Relaxation of Gastro-oesophageal sphincter Block VC & afferents of GI tract.
Reverse peristalsis of stomach and oesophagus (and ileum) Serotonin (5HT) receptor antagonists
Contraction of abdominal muscles and diaphragm Ondansetron
Intra abdominal and intra thoracic pressure Mechanism of action unknown
*Epiglottis shuts off larynx Cannabinoids
*Larynx drawn forward and up by muscles in jaw and neck. Comp The strong propulsive forces generated during retching and
*Soft palate drawn up closing nasoparynx. vomiting can tear oesophageal mucosa
*In unconscious / inebriated individuals, these protective MALLORY WEISS tear haematemesis
mechanisms are disrupted and vomitus may be aspirated. Usually superficial and heals rapidly.
Chronic vomiting e.g. bulimia may lead to…
CORTEX, THALAMUS & CHEMICAL STIMULI Acid damage to teeth and gums
HYPOTHALAMUS (Blood borne) Fluid and electrolytes dehydration and altered
Morphine blood chemistry
Meningitis Digoxin Loss of Gastric contents
Inter-cranial pressure, migraine HCG in pregnancy Hypokalaemia
Disgusting sites Systemic illness- diabetic Hyponatraemia
Strong emotions ketoacidosis, uraemia. Metabolic alkalosis
Loss of Intestinal contents
D2 Metabolic acidosis
Motion sickness & Aspiration
diseases of INNER EAR
CHEMORECEPTOR INTESTINAL OBSTRUCTION
TRIGGER ZONE in floor of 4th Def
Ach ventricle lies outside BBB. PP
Cause Georges Cat HAD FF TITS
Vestibulo cochlear Small Bowel
Nerve Gallstone ileus
VOMITING CENTRE Herniae external/internal
5HT (Dorsal part of Medulla Foreign body- cocaine
Vagal & Intusucception
Splanchnic Nerves TB- accounts for 7% of small bowel obstruction
Sigmoid or Caecal volvulus *** (Risk: Pyloric Stenosis,
GI TRACT & OTHER VISCERA VOMITING Congenital Bands, Paraoesophageal hernia)
DDx GATROINTESTINAL S&S Anorexia
Gastroenteritis: Short lived. Assoc with fever. Nausea / Vomiting with relief (early with SB)
Food poisoning: Infective, irritative and toxic agents.
Colicky abdo pain (with SB- More constant with LB)
GI Obstruction. Abdominal dissention (less with SB)
METABOLIC Constipation (need not be absolute if obstruction is high)
Uraemia, e.g. secondary to renal failure Tinkling bowel sounds
Hypercalcaemia ***vomiting / non productive retching, regurgitation of saliva,
Diabetic Ketoacidosis failure to pass NG tube
Addisonian crisis DDx
NEUROLOGICAL Inv / AXR horizontal fluid levels
Raised intracranial pressure, Head injury Dx *** gastric dilation + double fluid levels laparotomy
Vestibular neuronitis, Meniere's disease, Benign positional
vertigo, Middle ear surgery
NG tube- drip & suck
DRUG / CHEMICAL Correct U&E imbalance
Ipecacuanha for intentional emesis, e.g. In certain cases of Strangulation requires urgent surgery- within 1 hr
poisoning Small bowel obstruction with gross dilation >8cm and
Opioid analgesics tenderness over caecum also requires urgent surgery-
General anaesthetics perforation is nearby!
Anti-parkinsonian drugs: Levodopa and bromocriptine
POST OPERATIVE GASTRO OESOPHAGEAL REFLUX DISEASE (GORD)
Paralytic ileus Def Periodic episodes of gastroesophageal reflux usually
Mechanical obstruction accompanied by heartburn and that may histopathological
Agents administered, e.g. General anaesthetics, analgesics, in the oesophagus
cytotoxic chemotherapy PP UK Prevalence: 30%
Procedure itself, e.g. Gastrectomy causing bilious vomiting Cause LES dysfunction
PSYCHOLOGICAL Recently ingested fat in duodenum
Bulimia nervosa, Psychogenic vomiting, Conversion disorders, Progesterone (pregnancy & pill)
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Fat / Chocolate / Caffiene / OH / Smoking The 4 above lead to…Premature activation of zymogen granules
Hiatus Hernia (30% of >50s)
20%: Rolling / Paraoesophageal (GOJ remains in Release of proteases
abdo, but stomach herniates alongside
80%: Sliding / Diaphragmatic (GOJ slides up into Digestion of pancreas and surrounding tissue.
chest) S&S Pain: steady / severe / epigastric / 1-4 hrs post meal / when
Others leaning forward / Radiates to back
Oesophageal Candidiasis N/V
Suicide attempts (Bleach, Battery acid) Guarding / Rebound tenderness (may be retroperitoneal)
Oesophageal ulcers caused by tablets are trapped above Fever
strictures: K+ supplements / NSAIDS Hypovolaemia…oliguria
Path Develops when oesophageal mucosa is exposed to gastric contents Discolouration of
for prolonged periods of time. Flanks (Grey Turners sign- Also AAA Rupture , RTA)
S&S Chest Pain- 75% pts- GORD- mimicks angina Periumbilical region (Cullen’s sign- Due to Enzymes)
Provoked by straining / lying down Erythema Albigme: Skin that is chronically exposed to infrared
Waterbrash radiation e.g. Hot Water bottle which may relieve pain. More
Persistant non productive cough often with Chronic Pancreatitis.
Dysphagia DDx Biliary Colic, Cholecystitis, PUD, Perforated viscus, Small bowel
Choking- (reflux irritates larynx) obstruction, Abdo , Dissecting aneurysm, Renal colic, DKA, Ectop
Odynophagia pregnancy rupture, Mesenteric ischaemia / thrombosis
Loss of dental enamel Inv / O2 & ABC
Hoarse voice Dx Ca : Due to Lipase combining with it
DDx Gasritis, Gastric , Oesophageal Varices, PUD, Pancreatitis during digestion of tissue (Like soap!)
Inv / Endoscopy >40 yrs, >4 weeks LDH
Dx + / - pH mon, + / - manometry Amylase > 1000: biliary disease
(pH <4 for >6-7% study time= Dx) 200-500: OH pancreatitis
Barium Swallow May show hernia WCC
FBC Anaemia Glucose
Tx Stop smoking / OH / late meals / aggravating diet / lying flat / Urea
that aggravate: NSAIDS, Nitrates Transaminase
Step down Management: AXR Exclude perforation / obstruction
Antacids [Mg trisilicate mix] / Alginates [Gaviscon] US / CT Pancreatic Swelling (GS, Biliary
obstruction), Peripancreatic Fluid
Full Dose PPI [lansoprazole] ESR / CRP
GLASGOW CRITERIA- > 3 = Severe (PANCREAS)
GOOD RESPONSE BAD RESPONSE Other score systems: Ranson Criteria; APACHE II
PPI maintenance dose Consider pH monitoring Age >55
Neutrophils > 15 x109 / litre (WBCs)
H2 Receptor antagonists [ranitidine] Good Bad Calcium < 2 mmol/l
(Help symptoms only) Response
Renal Function >16 mmol/l ((Urea after rehydration))
Enzymes: LDH, ALT (LDH) > 600 U/I; (ALT) > 200 U/I
Comp BARRET’S OESOPHAGUS
Albumin <32 g/l
(40x risk of , incidence in white ♂)
Sugars > 10 mmol/l
Haematemesis Tx NBM (ng tube)
Dysphagia IVI (plasma expanders)
Melaena Pethidine (morphine constricts sphincter of oddi)
Tx: Laser ablation (old) O2
Tx: Oesophageal Resection (young) ABx: Cefuroxime
MALLORY WEISS TEAR ERCP: gallstone removal
Haematemesis Comp SYSTEMIC
Dx: Bx Shock (Inflammation dilation of blood vessels)
Tx: PPI + Balloon dilation Systemic inflammatory response syndrome (SIRS):
OESOPHAGITIS Renal failure
Ranges from mild redness severe bleeding and ulceration Paralytic ileus
Correlation b/w symptoms and endoscopic findings Vomiting
ANAEMIA Hyperglycaemia (Distruption of islets of Langerhans with
Long-standing oesophagitis blood loss iron deficient altered insulin/glucagons axis)
anaemia. Serum albumin conc ( Capillary permeability)
Almost all have large hiatus hernia. PANCREATIC
BENIGN OESOPHAGEAL STRICTURE Necrosis
Long-standing oesophagitis fibrous strictures. Abscess
Most pts: Pseudocyst: Enzymes breakdown of duct allows juice to
Elderly, Poor oesophageal peristaltic activity, Hx of accumulate elsewhere e.g. in the lesser peritoneal sac (B/w
heart burn but not always stomach and duodenum). Tx Percutaneous Drainage.
Dysphagia: Worse for solids than liquids GASTRO INTESTINAL
Upper GI bleeding (Gastric or duodenal erosions)
ACUTE PANCREATITIS Variceal haemorrhage and erosion into colon (Splenic or portal
Def Inflammation of pancreas due to autodigestion by its own
Duodenal obstruction (Compression by pancreatic mass)
enzymes due to inappropriate activation
Obstructive jaundice (Compression of CBD)
PP 3% all abdo pain, 2-28 / 100,000
Cause Risks: Don’t GET SMASHED when Pregnant.
Ethanol (Common) Def Inflammation of vermiform appendix
Trauma PP Incidence in 20s & 30s
Steroids common - lifetime incidence of 6%
Mumps Cause Obstruction of appendix lumen
Autoimmune Path Obstruction with fecalith
Scorpion Venom Distension of appendix
Hyperlipidaemia & Hypothermia & Heredity & Ca lumen pressure
ERCP (Common) Venous engorgement & ischaemia
Drugs: Asathioprine, Asparaginase, Metacaptopurine, Bacterial invasion of wall
Penamidine, Didanosine, Thiazide Diuretics Inflammation
Path Defective intracellular transport & secretion of pancreatic Appendicitis
Reflux of infected bile or duodenal contents into pancreatic duct Rupture
e.g. sphincter of Oddi, disruption by gallstones Peritonitis
Hyperstimulation of pancreas, e.g. OH, fat S&S Pain: Central abdo colic as inflammation begins
Pancreatic duct obstruction e.g. choledocholothiasis, tumours Pain: shifts to RIF as peritoneum becomes inflamed
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Anorexia almost invariable + / - Vomiting Common cause of big PR bleeds
Constipation usual Tx: Transfusion may be needed
Diarrhoea may occur. Tx: Colonic resection
Tachcardia 5. FISTULAE
Fever- 37.5-38.5 Colon + small bowel / vagina / bladder (giving
Furred tongue pneumaturia, +/- intractable UTIs)
Lying still Tx: Colonic ressection
Foetor +/- flushed 6. ABSESSES
Coughing hurts Swinging fever
Shallow breaths Leucocytosis
Right Iliac fossa: Boggy rectal mass
Tenderness, guarding Tx: Pelvic absess- drain rectally
Rebound tenderness Tx: Subphrenic absess giving no signs- urgent US.
PR- painful on right Anti biotics with US guided drainage may be needed
ROSEVINGS SIGN: more pain in RIF than LIF when LIF is 7. STRICTURES POST INFECTIVE
pressed. May form from the sigmoid colon
Rotating a flexed right hip when supine (OBTURATOR SIGN)
or raising a straightened leg against resistance (PSOAS SIGN)
may elicit pain
Def In body weight beyond limitation of skeletal / physical
DDx Gastroenteritis, Perforated Peptic Ulcer, Meckels Diverticulum,
Cholecystitis, Mesenteric lymphadenitis, Intestinal obstruction,
Crohn’s, Diverticulitis, Renal Colic, Ectopic Pregnancy, Ruptured PP 50% UK overweight, 10% obese
ovarian follicle £½ billion a year in treatment costs to the NHS
Inv / WBC Cause BEHAVIOURAL
High fat diet
Dx AXR Soft tissue mass
US Dx if +ve, but not exclusion if –ve
OH (Stimulating appetite, Restraint)
CT Abscess formation Giving up smoking
Hx- Pelvic syndromes in ♀ ENDOCRINE
Tx IV fluids Hypothyroidism
Abs- Metronidiazole + Cefuroxime Insulinoma
Comp Perforation Peritonitis / Later Infertility in ♀ DRUGS
Appendix mass Antidepressants
Tx: NBM, Abs, Delayed Appendicectomy COC
Appendix absess Corticosteroids
Tx: Drainage (Laparotomy / PR), ABs GENETIC
Prada Willi Sydnrome
DIVERTICULAR DISEASE Path
Def DIVERTICULUM: an outpouching of the wall of gut S&S Underweight <18.5
DIVERTICULOSIS: that diverticula are present Normal 18.5-24.9
DIVERTICULITIS: inflammation within a diverticulum Overweight 25-29.5
PP 1/3 of Western world have diverticulosis by 60. Obese 30-39.5
Cause V Obese >40
Path fibre intra abdominal pressure mucosal herniation Abnormal walk to accommodate their weight- widened stance
S&S Diverticulosis: Asymptomatic / alternating bowel habit / lower stressing the joints Osteoarthritis (hips, knees, and
bowel pain relieved by bowel movement / flatulence ankles) Walking even more difficult Low back pain.
Diverticular Bleed: generally painless / signs of lower GI Fatigue Physical and social activities
bleeding Peripheral Oedema
Diverticulitis: Sweating (Relatively little body surface for their weight)
LIF pain with bowel movement: LIF > RIF Due to more solid Skin disorders (moisture is trapped in skin folds)
stool intra lumen pressure. Difficulty breathing (Lungs compressed by accumulation of
Inflammatory mass in LIF excess fat below the diaphragm)
Tenderness (rebound = perforation) DDx Pregnancy, Fluid overload (HF, Nephrotic syndrome, Ascites),
Fever Medication, Endocrine, Muscular development
DDx Inv / BMI Body Mass Index: Weight kg / height m2
Inv / PR exam May reveal most important competing Dx GHR Girth-height ratio (waist circumference
Dx diagnoses: Pelvic inflammation, Colonic C divided by height
WCC Mx Diet & exercise advice (exercise prescription)
ESR Diverticulitis… Tx Orlistat- Pancreatic / gastric lipases decreased absorption
Sigmoidoscopy Triad: LIF pain + fever + leukocytosis by 30%
Barium enema Sibutramine- 5HT agonist, B adrenoreceptors
Colonoscopy Vertical Banded Gastroplasty- pouch created from stomach
size + decreased outlet
US / CT CT may be > useful than US, & plain films
Gastric Bypass- staple across stomach rendering lower
may only be useful in showing vesical
stomach useless and connects top ½ to small intestine
smaller stomach + less absorption.
Tx Avoid Morphine due to colonic spasm
Comp Type II Dm- +113%
Comp Diverticulitis known as the LHS Appendicitis i.e. similar complications! Hyperlipidaemia
DASH & Follow Pretty Polly… Gallstones
1. PAINFUL DIVERTICULAR DISEASE
Especially in women
And non-alcoholic steatohepatitis
Pain: usually colicky, left sided, relieved by defecation Caner risk
Nausea, Flatulence Obstructive sleep apnoea
TX: fibre diet, Antispasmodics Psychological consequences
Surgical resection is occasionally resorted to.
2. DIVERTICULITIS CARCINOMA OF THE OESOPHAGUS
1 + PYREXIA PP 7th commonest cause of death from cancer in Worldwide.
WCC Incidence of 15+ in Eng/Wales is 5,736 / year
ESR Incidence worldwide is decreasing (c.f. Gastric C):
Tender colon + localised and generalised peritonism Most strongly linked to OH (especially spirits) and smoking.
TX: Bed rest, NBM, IV fluids, Antibiotics Distribution: Highest in China, Africa (Esp SAfrica), Iran.
(metronidazol, ciprofloxacin) Age: Uncommon before 50. Sex: M>F (7:1)
3. PERFORATION Risk LIFESTYLE: Risk ….for Squamous Cell Carcinoma i.e. Upper 2/3
Ileus, peritonitis +/- shock OH (20x: Esp Spirits. Latency 15-20 Years)
Mortality: 40% Smoking: (5x) Synergistic with OH.
Tx: Laparotomy SOCIOECONOMIC GROUPS: Group Risk
4. HAEMORRHAGE Dietary deficiencies of Protein, VitC, Riboflavin, Trace elements
Sudden and painless PAST MEDICAL HISTORY
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Achlasia, Plummer-Vinson syndrome: Oesophageal web Peritoneal portion of lesser sac drapes posteriorly over
Caustic injury (i.e. Acid ingestion) stomach.
HPV and Tylosis palmaris (hyperkeratosis with pitting of palms) Gastroesophageal junction limited or no serosal covering.
GORD: Highest risk for adenocarcinoma (i.e. Lower 1/3). R Anterior gastric surface adjacent to left lobe of liver and
Path Carcinoma commences as nodule Either papilliferous mass anterior abdominal wall.
(60%), ulcer (25%), or annular constriction, usually of cardia. L Part of stomach adjacent to spleen, left adrenal gland,
Historically: Majority were squamous. Adenocarcinoma superior portion of left kidney, ventral portion of pancreas, and
incidence rising rapidly and now accounts for 50%. transverse colon.
Squamous arises in upper 2/3 of oesophagus. Site of lesion classified on basis of relationship to long axis.
Adenocarcinoma arises in region of specialised 40% cancers develop in lower part ….CHECK!
columnar epithelium (SCE) metaplasia in lower 1/3 - 40% cancers develop in middle part
Barrett's oesophagus (See below). 15% cancers develop in upper part
BARRETT'S OESOPHAGUS: 10% cancers involve > one part.
Gastric / Intestinal metaplasia of mucosa of distal oesophagus. Recently, no of lesions discovered in prox stomach +/-
Most often acquired condition (Rarely congenital) and involving GOJ has increased.
represents important comp of long-standing GO reflux. Path 95% Adenocarcinomas. 3 Morphologies with Prog:
In acquired BO, GORD Causes squamous mucosa of Fungating tumours , Malignant ulcers , Infiltrating carcinoma
oesophagus Metaplastic Change Squamocolumnar Vascular supply relates to routes of hematogenous spread.
junction (ora serrata) migrates caudally. Vascular supply of stomach is derived from Coeliac artery.
Risk of Oesopageal Cancer x 25-130 / Stricture / Ulcer Coeliac A L Gastric A Upper R Stomach.
Dx: Endoscopy + Bx. Common hepatic A R Gastric A Lower Stomach
Invasion Progresses from Mucosa Submucosa Muscular R gastroepiploic A Lower portion of greater curvature.
layer Tracheobronchial / Aorta / Recurrent laryngeal nerve. Lymphatic drainage relates to areas of nodal involvement.
Metastasise to periesophageal nodes Liver +/or Lungs Lymphatic drainage of stomach is complex.
Unfortunately, by time first S&S manifest, cancer already Primary drainage is along celiac axis.
spread to nodes (mediastinal, cervical, celiac) in most. Minor drainage occurs along splenic hilum, suprapancreatic
S&S 1) DYSPHAGIA (Solids Liquids) nodal groups, porta hepatis, and gastroduodenal areas.
2) WEIGHT LOSS (50% with osophageal carcinoma). Cause DIET
3) PAIN: Epigastric / retrosternal area. May also be bone pain. Risk: Pickled vegetables, Salted Fish, dietary salt,
4) HOARSENESS: Recurrent laryngeal nerve invasion (Poor smoked meats. Risk: Fruit & Vegetables rich in Vit C.
Prog as unresectable) HELICOBACTER PYLORI INFECTION
5) RESPIRATORY S&S: Aspiration of undigested food; Direct H pylori infection is assoc with chronic atrophic gastritis
invasion of tracheobronchial tree (Poor Prog as unresectable). Prolonged gastritis 6x Risk for Gastric cancer.
Lymphadenopathy in laterocervical / supraclavicular areas Assoc for tumours in antrum, body, fundus, BUT not Cardia
represents metastasis and, if confirmed by needle aspiration / PREVIOUS GASTRIC SURGERY
biopsy, is a contraindication to surgery. Rationale is surgery alters normal pH of stomach.
DDx Achalasia, Oesophageal Stricture GENETIC FACTORS
Inv / Barium First-line after history of dysphagia: Characteristic: Poorly understood: Pernicious Anaemia, Blood Gp A
Dx Swallow Irregular stricture + shouldered margins, 4-10 cm Path
long and often tortuous; a tracheo-oesophageal S&S EARLY DISEASE: No associated S&S;
fistula may also be demonstrated Indigestion, N&V, Dysphagia, Postprandial Fullness,
Endo + Bx Establishes Lesion Hist & Limits. Appetite, Weight .
May be Tx: Dilate, so nutrition before Sx. LATE COMPLICATIONS:
Cytology Wwashing / abrasion Tech – (Screening in China) EFFUSIONS: Peritoneal & Pleural;
CT Met: Mediastinal / Liver OBSTRUCTION of the gastric outlet, gastroesophageal
Bronchoscopy may be needed to exclude bronchial involvement in junction, or small bowel;
upper and middle-third lesions BLEEDING in stomach, O Varices, anastomosis after Sx;
US Met: Liver deposits JAUNDICE: Hepatomegaly Intrahepatic. Extrahepatic.
Mx Management dependent on lesion level and stage of disease. Inanition resulting from starvation or cachexia of tumor origin.
UPPER THIRD LESION SIGNS RELATE TO LATE EVENTS:
RadTx ( Dose) indicated for lesions up to 5 cm long. Palpable enlarged stomach with succussion splash
Vital structures in mediastinum closely related to upper third Primary mass (rare)
make Sx clearance and resection very difficult. Enlarged liver,
MIDDLE THIRD LESION Virchow (Left supraclavicular…aka Troisier's sign)
RadTx ( Dose) indicated for lesions up to 5 cm long. Sister Mary Joseph Node (Met in umbilicus- Anatomical region
Early tumours resectable. where peritoneum closest to skin. Rare.)
LOWER THIRD LESION Blumer shelf (PR Met: Growth in recto-uterine/vesical space)
Most accessible surgically; Adenocarcinomas radioresistant. Signs of weight loss
EXTENSIVE DISEASE Requires Palliation Of Dysphagia: Patients may have pallor from bleeding and anemia.
Endoscopic Laser Surgery for lesions < 8 cm long DDx Oesophageal Cancer, Oesophageal Stricture, Oesophagitis, Gastric
Oesophageal Stenting (Celestin tube) for lesions > 8 cm long Ulcers, Gastritis, Gastroenteritis, , Lymphoma, Malignant Neoplasms
Alternatives include: Oesophago-Gastrostomy / Oesophago- of Small Intestine
Jejunostomy / Short Course Radiotherapy Inv / Endos + Bx investigation of choice
Prog Prognosis dependent on the site. 5-year survival figures are: Dx Barium Meal Space Occupying Mass
Upper third tumours have a 20% 5-year survival Rigidity Of Adjacent Gastric Wall
Middle third tumours have a 6% 5-year survival Greater Curve Ulcer
Lower third tumours have a 15% 5-year survival Ulcer with irregular borders and disruption of
The prognosis also depends on: Size, Site, Depth, Node/Widespread normal mucosal folds
Metastases, Tumour grade, Lymphocytic response, General health. Contracted, non-distensible stomach
Fundic tumours difficult to evaluate because
CARCINOMA OF THE STOMACH of poor filling
PP 4th commonest cause of death from cancer in UK Mets? CXR. LFTS, Liver US,
Following bronchial, colorectal and breast. FBC & FOB Anaemia: 50%; FOB +ve in vast majority
Incidence of 15+ in Eng/Wales is 10,227 / year Mx Sx: (Partial / Total gastrectomy) is only curative Tx.
Incidence worldwide is decreasing (c.f. Oesophageal C): Palliation: Radiotherapy and chemotherapy are ineffective
Improved diet, esp fresh fruit and vegetables. Salt . Palliation: May also best served surgically. Esp if obstruction /
Improved housing conditions, e.g. less overcrowding, dysphagia is complication.
transmission of H pylori. Other procedures inc gastrojejunostomy, placing plastic tube at
Distribution: East Asia, especially Japanese. site of constriction in those with very short life-expectancy.
Age: 50 – 70, but any age. Sex: M>F (Slight) Screening by regular gastroscopy popular in Japan.
Anat Stomach begins at gastroesophageal J. Ends at duodenum. Early endoscopy considered in all dyspepsia > 35 years old
Stomach has 3 parts, which are semidisctinct histologically: Prog 5-year survival after Sx: 30-50% with stage II disease, 10-25% with
stage III disease. Sx Mortality rate at major centres < 3%.
CARDIA Uppermost Mucin-secreting cells
FUNDUS / Middle Mucoid, Chief, & Parietal cells. COLON CANCER
BODY (Largest) Def 3 principal cell biological processes which underlie the development
PYLORUS Last Mucus-Producing & Endocrine cells of cancer: Mutation, Proliferation, Apoptosis
PP 2nd most common cause of C
Stomach wall made up of 5 layers. From lumen out: Incidence: 50-60 / 100 000 UK, 30 000 cases per year
Mucosa, Submucosa, Muscular, Subserosal, Serosa. Rare in Africa and Asia (Environmental differences)
Peritoneum of greater sac covers anterior surface of stomach. In West, life risk 1:50 (1:17 with 1st degree relative)
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Synchronous (> than 1) tumours present in 2% cases
Rectal > ♂, Right Sided > ♀ SCLEROSING CHOLANGITIS (PRIMARY)
Risk Diet: Fat Fibre Cancer Previously Def PRIMARY (See below): Characterised by chronic inflammation +
Neoplastic Polyps Ulcerative Colitis fibrosis of bile duct.
DNA Age esp > 50 Familial risk SECONDARY - Bile duct strictures that result from:
CUFF Familial Polyposis Bile Duct Stones
FP is Autosomal Dominant Post-Operative - Especially postcholecystectomy
Histologically, 3 Types of Adenomatous Polyp: Villous / Tubular- Inf: Cryptosporidium, Microsporidia, CMV in AIDS
Villous [Most common] / Tubular (In order of Most potential for PP Rare disease. Unknown aetiology. M>F (7:3)
Malignant ) Assoc Assoc: 75% Cases assoc with IBD (Esp UC: 3-4% Cases).
Path Dukes grading of Colorectal Cancer Also: Retroperitoneal Fibrosis, Sarcoidosis, Riedel's thyroiditis.
A Tumour confined to bowel wall (adenocarcinoma) (95%) S&S Obstructive Jaundice
B Tumour extending through bowel wall Inv LFTs , Bx, ERCP, AutoAbdies
C Regional lymph nodes involved Mx Tx S&S. Ursodeoxycholic acid. Sx / Transplant
D Distant Metastasis (e.g. Liver) Comp End Stage Liver Disease.
S&S Mass Biliary Strictures, Infective Cholangitis, Cholangiocarcinoma.
Obstruction: N/V, Tachycardia, Sweating, BS Prog Mean survival for all patients is 7 years
Perforation BILIARY CIRRHOSIS (PRIMARY)
Haemorrhage Def PRIMARY: (See Below) Autoimmune disorder marked by chronic
Fistulae inflammation of intrahepatic bile ducts.
Fatigue Aka Destructive Sclerosing Cholangitis. Aka Cholangiolitis
Lymphadenopathy- groin SECONDARY results from obstruction of the extrahepatic ducts.
+ RHS = WAP + LHS = PowerPoint (PPT) Bile Duct Strictures, Gallstones, Sclerosing Cholangitis
Weight In bowel habit PP Rare disease. Unknown aetiology. F>M (9:1). Rare under 30.
Anaemia PR Bleeding Assoc Autoimmune Thyroiditis, Sjogren's syndrome, CREST
Pain- Abdominal PR Mass syndrome, Scleroderma, RA, Fibrosing Alveolitis
Path Both Primary & Secondary Micronodular hepatic cirrhosis.
S&S Pruritus & Fatigue. Later S&S include jaundice & abdo pain.
Inv / Fe Def Anaemia in Old ♂ = Col until proven otherwise Inv / LFTs & Lipids ( HDL)
Dx FBC + Faecal Oc Bl Anaemia Dx Liv Bx Diagnostic
LFTs/ Liv US/ CXR Liver / Lung Secondaries Antibodies 95% have anti-mitochondrial autoantibodies
PR / Protoscopy Mass ERCP Exclude other pathology.
Sigmoidoscopy / Barium Enema 1/3 Tumours detected TFTs T4
Colonoscopy (+ Bx) Most specific and sensitive Mx Tx S&S. Ursodeoxycholic acid. Sx / Transplant
Scrn SCREENING- Bowel Cancer Screening Programme 04/2006. Prog Survival from 5-20 years depending on time of presentation.
All (60-69) send FOB every 2 yrs. Potential to Mort by 20% DIFFERENCE BETWEEN THE TWO (PSC AND PBC)
Positive Colonocopy (/ Barium E / Flexible Sigmoidoscopy).
PSC: Bile duct changes both intra- and extrahepatic
TWO TYPES OF FOB Test:
PSC: Antimitochondrial antibodies (AMA) absent
Guaiaco: Dietary restrictions (no red meat, fresh fruit, PSC: 80–90% of patients also have IBD disease
iron, Vit C, aspirin or other non-steroidal rheumatic PSC: Predominantly affects men
drugs for 3 /7 before). Requires 3 Evacuations. PSC: May also affect children and adolescents
Immunochemical: Requires only 1 Evacuation.
Mx Dukes A:: Colonic Resection (Colonoscopy BOWEL INFARCTION (Chronic & Acute)
Dukes B: 6/12 later)
Def Ischaemic bowel disease may be acute or chronic.
Dukes C: Colonic Resection + Chemo Most cases result from arterial occlusion, usually of SMA.
Dukes D: Palliative Care Small bowel affected uncommonly.
Prog Ischaemic injury to large bowel known as Ischaemic Colitis.
Anat: Coeliac Axis Duodenum (1st Part)
Blood SMA From Duodenum (2nd Part) Splenic Flexure of
IMA Splenic Flexure of Large Bowel Prox Rectum
Int Iliac artery Distal Rectum
Phy Potential areas of ischaemia are watershed between supplies…
Normally, intra-abdominal digestive organs receive 25% of CO.
Hypotension causes mesenteric arterial occlusion with shunting
of blood to heart and brain. Bowel can tolerate a 70% in
blood supply without damage. Mucosa is most vulnerable area;
muscularis propria, the least.
Ischaemia, i.e. an inadequate blood supply, results in tissue
hypoxia and accumulation of toxic waste products, which may
cause tissue necrosis, i.e. infarction.
Degree of bowel damage sustained depends upon:
Rapidity of ischaemia and its duration
Extent of any collaterals
CARCINOMA OF THE RECTUM
Metabolic requirements of the area affected
PP M=F; 1/3 Intestinal tumours. Affects > 20s, Mostly 50-70s. Nature of bowel flora – e.g. anaerobes such as Clostridia
Risk Ulcerative colitis, familial polyposis and pre-existing adenoma. species may produce toxins that accentuate damage
Path Majority Adenocarcinomas. May also be colloidal or papilliferous. Path Pathological features depend on severity of ischaemia.
S&S See CCC- Colon Cancer: LHS S&S Affected bowel appears red / purple. Often moist and dilated
DDx Benign rectal tumour, Carcinoma of sigmoid (prolapsed through with friable often haemorrhagic mucosa. Wall may tear easily
pouch of Douglas), Uterine / Ovarian Tumours, Secondaries In Pelvis and perforate.
Extension From Prostatic / Cervical Carcinoma, Endometriosis, In less severe lesions, there is mucosal necrosis which is
Diverticular Disease, Lymphogranuloma Inguinale, Amoebic reversible. mucosa regenerates if blood supply can be restored.
Granuloma In more severe injury, muscularis propria is damaged. Any
Inv / PR PR reveals carcinoma 90% of time. healing results in stricture.
Dx Sigmoid + Bx Class Divided into the following
Barium E Indicated if: growth not visible on Sigmoidoscopy, 2nd CHRONIC MESENTERIC ISCHAEMIA (Uncommon)
tumour suspected, Hx of UC / Familial Polyposis. Cause Atherosclerotic narrowing of main mesenteric arteries.
Rectal US Blood supply to gut adequate during rest but inadequate during
Mets? FBC, U&Es, LFTs, CXR, Liv US, IVU, active digestion.
Spred DIRECT Bowel Lumen, Muscular Wall, Adjacent S&S Colicky, Epigastric pain (30-60 mins after food); Relieved by
Organs, e.g. prostate, bladder, vagina, etc defaecation; Food fear Weight; abdominal bruit
LYMPHATIC Inf Mes nodes. Later: Iliac / Groin / Sup Clav Dx Angiography / Duplex ultrasound.
HAEMATOGENOUS Liver / Lungs Tx Surgical reconstruction of of mesenteric arteries.
TRANSCOELOMIC Peritoneal Cavity Seeding Prog 40% recurrence rate (Even With 3 Vessel reconstruction)
Mx Usually Surgical. RadTx / ChemoTx if Palliative ACUTE: SUPERIOR MESENTERIC ARTERY OCCLUSION
Prog See CCC- Colon Cancer (Duke’s Staging) Cause Thromboembolic arterial occlusion
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Mesenteric venous occlusion Painless diarrhea, Steatorrhea, Lactose / Gluten Intolerance
Systemic vasculitis (e.g. RA, SLE, PAN, Takayasu's arteritis) DDx Most Important are: Coeliac Disease, Colorectal Carcinoma, Colitis.
Cardiovascular causes (Shock, CCF, MI, AAA) Biliary Colic, Chronic Mesenteric Ischemia, Diverticulitis,
Secondary to intestinal obstruction Hypercalcemia, Hyperthyroidism, Hypothyroidism, Lactose
Strangulated hernia Intolerance, Pancreatitis- Chronic, PUD.
Intussusception: Usually in children Inv / Useful to screen for inflammation and other pathology: FBC, ESR,
Volvulus: Usually small bowel or sigmoid colon Dx CRP, LFTs. Others: TFTs, FOB, Anti-endomysial antibody
S&S HX: Classically elderly + PMHx of Cardiac or arterial disease.. Mx Explanation and symptomatic relief helps 75% patients
PAIN: Sudden, severe colicky abdominal pain. Occasionally, FIBRE CONTENT Dietary fibre should be gradually . Soluble
pain is vague and insidious. fibre e.g. isphaghula may benefit 40%. (Bran
VOMITING & DIARRHOEA can develop, and both may have a may be no better than placebo).
bloody element due to slow haemorrhage into bowel lumen ANTISPASMODICS Anti-muscarinic actions may relieve pain by
Minimal initially with pain out of proportion to examination (Esp mebeverine moderating smooth-muscle contractions.
findings. However, as necrosis passes outwards from the hydrochloride)
mucosa, GUARDING, TENDERNESS, abdominal PEPPERMINT OIL For colonic spasm and bloating
DISTENSION and an absence of bowel sounds are apparent. BULK-FORMING For constipation
SHOCK is a late sign. AGENTS
DDx LOPERAMIDE For diarrhoea
Inv / Diagnosis is often too late as clinical presentation often deceptive: OTHERS TCA: (Anticholinergic effect)
Dx Signs deceptively sparse and Inv usually inconclusive at an early Hypnotherapy, CBT
stage. Should always be suspected in arteriopath who develops Exclusion diet may help e.g. wheat flour, dairy produce, tea, coffee,
unexplained abdominal pain. Prompt laparotomy to search for 'pale citrus fruits, nuts, chocolate, food colourings, additives.
and pulseless' bowel is best policy. Prog Benign condition with an excellent long-term prognosis.
FBC May show leucocytosis 85% virtually symptom-free in short term
U&Es Mildly serum amylase 68% still virtually symptom-free 5 years later
inorganic phosphate = Intestinal infarction Tx response better in: F>M; Cnstipation > Diarrhoea; Short Hx;
Metabolic acidosis < 50% Post-infective / non-infective IBS recover over 6 years
Imaging AXR: Absence of bowel gas at first; later,
appearances of ileus, mucosal oedema and gas in COELIAC DISEASE (aka Celiac Sprue, aka Gluten-Sensitive Enteropathy)
bowel wall and portal vein Def Chronic disease of digestive tract that interferes with digestion and
Mesenteric angiography: often Dx, but difficult to do absorption of gluten (protein in wheat, rye, barley, &, sometimes oats)
in moribund patient PP INCIDENCE 1:3000.
Tx TX ANY UNDERLYING CONDITION, e.g. AF (Caution as AGE Bimodal: 8-12/12 & 3rd – 4th Decades.
digitalization Splanchnic vasoconstriction) SEX F>M (Slight)
CORRECT SHOCK: IV fluid (Monitor with CVP and Urine OP)
DISTRIBUTION W Europe, Aust, USA.
BICARBONATE may be needed to correct acidosis
RACE Rare in Africans / Asians.
ABx Pre-operatively, e.g. cefuroxime 750mg / 6 hourly
INTRA-ARTERIAL INFUSION of papaverine via angiogram FHx 10% Prevalence in 1st Degree Relatives.
catheter may relieve some of associated arterial spasm Cause
ANALGESIA Path Ingestion of gluten Immunologically mediated inflammatory
SURGERY: Lapartomy Reverisible / Irreversible Ischaemia response Damage to intestinal mucosa (Absence of intestinal villi
(Resection / Stoma) and lengthening of intestinal crypts characterize mucosal lesions in
ISCHAEMIC COLITIS untreated celiac sprue) Maldigestion & malabsorption.
Cause Same as ‘Acute: Superior Mesenteric Artery Occlusion’ S&S GASTROINTESTINAL SYMPTOMS:
DIARRHOEA: Common. Watery / Semiformed / Steatorrhoea.
S&S Hx: Vascular disease, Dm, Sx: Aneurysm, Sx: Ligation of IMA
Characteristic foul smell. May Electolyte Complications.
PAIN: Cramp-like, LHS abdominal pain which lasts for a few
FLATULENCE: Due to bacterial florae feasting on undigested &
hours, and followed by …
unabsorbed food materials.
RECTAL BLEEDING: Dark red, often without faeces, and may
occur 2-3 times over 12 hours. WEIGHT LOSS: Variable- Some patients may compensate for
NO ABDOMINAL MASSES. the malabsorption by dietary intake. Failure to gain weight is
common in infants and young children.
DDx May be difficult to distinguish bleeding of ischaemic colitis from that
WEAKNESS AND FATIGUE: Usually related to general poor
due to IBD, Diverticulitis or Carcinoma
nutrition. Severe anaemia Fatigue. Hypokalemia due to the
Inv / AXR Mucosal oedema at splenic flexure, (thumb printing); A
loss of potassium in the stool Muscle Weakness.
Dx single segment is affected with symmetrical stricture
ABDOMINAL BLOATING: Pain unusual with uncomplicated
B/En Support x-ray; C/I in acute illness (risk of perforation) CD. However, bloating / cramps with excessive flatus.
Endo Variable appearance from mild reddening to gangrene EXTRA GASTROINTESTINAL SYMPTOMS:
Hist Intramucosal haemorrhage, Fibrosis, Haemosiderin (rare). ANAEMIA: Absorption of iron / folate from Small bowel. If
severe CD with ileal involvement, May be B12 absorption.
IRRITABLE BOWEL SYNDROME BLEEDING: Vit K Absorption Prothrombin deficiency.
Def Functional GI disorder characterized by abdominal pain and altered OSTEOPENIA: Ca Absorption Bone pain
bowel habits in the absence of specific and unique organic pathology. NEUROLOGIC S&S: Ca Absorption Motor weakness,
PP Prevalence: 10 -15% of Gen population. 20-30% Consult GP. Paresthesias with sensory loss, and ataxia. Seizures might
F>M (2:1); Constipation predominant sufferers > common in F. develop because of cerebral calcifications.
Annual incidence 1-2%. Prevalence varies minimally with age. SKIN: Dermatitis herpetiformis (pruritic papulo-vesicular on
Cause Assoc: Panic disorder, Major Depression, Anxiety Disorder, extensors of extremities, trunk, buttocks, scalp, neck).
Hypochondriasis, Fibromyalgia HORMONAL: Amenorrhea, Delayed Menarche, Infertility in
Path Traditionally, a Dx of exclusion. No specific motility / structural women. Impotence and infertility in men.
correlates have been consistently demonstrated, so IBS remains a SIGNS:
clinically defined illness. ABDOMEN: Protuberant and tympanic due to distension of
S&S Rome II Criteria for Dx require patients must have following intestinal loops with fluids & gas. Possible ascites due to severe
continuous or recurrent symptoms for at least 3 months over 1 year: hypoproteinemia.
ABDOMINAL PAIN or discomfort characterized by following: WEIGHT LOSS: Inc muscle wasting or loose skin folds
Relieved by defecation OTHERS: Orthostatic Hypotension, Peripheral oedema,
Assoc with change in stool frequency Ecchymoses, Hyperkeratosis or dermatitis herpetiformis,
Assoc with change in stool consistency Cheilosis and glossitis, peripheral neuropathy
SUPPORTING SYMPTOMS include the following: SIGNS OF LATENT TETANY:
Altered stool frequency CHVOSTEK SIGN: Tapping course of facial nerve
Altered stool form Contraction of muscles of eye, mouth or nose.
Altered stool passage TROUSSEAU SIGN (Neuromuscular excitability due
Mucorrhea to Ca Spasms): Compression of forearm
Abdominal bloating or subjective distention Thumb is adducted, Fingers bunched, Wrist flexed.
IN MORE DETAIL: DDx Gastroenteritis, Giardiasis, Hypoalbuminemia, Hypocalcemia,
Pain frequently diffuse without radiation. Hypokalemia, Hypomagnesemia, Hypothyroidism, IBD, Iron
Common sites of pain include lower abdomen (Esp LLQ) Deficiency Anemia, IBS, Malabsorption
Symptoms may worsen in the perimenstrual period. Inv / Bloods Blood Film: Iron deficiency. B12 / Folate . MCV ,
Overall healthy appearance, but may be anxious. Dx PTT (Vit K )
S&S NOT CONSISTENT WITH IBS i.e. ORGANIC PATHOLOGY: Biochem Liver Function - hypoalbuminaemia in severely ill
Onset in middle age or older Ferritin, Vitamin D, Calcium may be reduced
Acute symptoms: IBS is defined by chronicity. Carbohydrate Malabsorption - Confirmed XTT, HBT.
Progressive symptoms, Nocturnal symptoms Bx Jejunal biopsy: Demonstrates characteristic histological
Anorexia or weight loss, Fever, Rectal bleeding lesion (See Path: Partial / subtotal villous atrophy).
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Gluten Free Diet 2 Bx at 9-12/12 N Mucosa. Therapeutic Paracentesis (4-6L)
Immune Gold Standard: Endomysial antibodies +/- Albumin (Acts as volume expander)
Also, IgA antibodies to gliadin in 80-90%. Then Move to Non Tense Mx
Imaging Barium Follow Through: Mucosal oedema & thickened NON TENSE:
jejunal folds. US: May show splenic atrophy. Rest, Salt, Spironolactone Weight (0.5kg/day)
RGC Rectal gluten challenge: Instill 10 g gluten into rectum; If not enough… Spironolactone +/- Frusemide.
Bx shows T lymphocytes in sensitised individuals Le Veen shunt (Peritoneo-Venous) for chronic cases.
XTT Xylose Absorption Test: D-xylose is pentose sugar 3
If fluid contains > 250 WBC/mm Empirical broad spec Abx
(Ingestion Jejunal absorption Excreted Comp Respiratory embarrassment when large volume ascites present
unchanged in urine). Absorption of xylose is measure Spontaneous bacterial peritonitis, esp in cirrhosis; suspect if
of intestine's ability to absorb monosaccharides. ascitic fluid leukocyte count is 500 /microlitre, or if > than 250
Absorption assessed from urine specimens collected. polymorphonuclear cells / microlitre
HBT Hydrogen Breath Test: Dx malabsorption of specific
carbohydrates. Sugars malabsorbed in SB pass to LB ZOLLINGER ELLISON SYNDROME
& metabolised by COLONIC bacteria Hydrogen Def Rare disorder. Characteristics
(diffuses rapidly across mucosa into blood Can be Severe peptic ulceration
measured in breath. Test commonly used to Dx lactose Gastric acid hypersecretion
intolerance but may be used to detect rarer conditions Non beta cell islet tumour of pancreas (gastrinoma)
Mx GLUTEN-FREE DIET: PP 0.1% of duodenal ulcers. Either sex. Any age (> common at 30-50)
Gluten found in wheat, rye, barley but not in rice and maize. Cause
Oats - whether toxic to patients with CD remains controversial. Path Gastrinoma secretes gastrin
Explaining disease, importance of diet (with regard to comps) Stimulating parietal cells to secrete acid and proliferate 3-6 fold
CLINIC FOLLOW-UP TO:
Check For Symptoms. FBC, Folate and iron So much acid that it reaches small intestine
Manage assoc problems, e.g. dermatitis herpetiformis
Detect And Manage complications. Reducing lumen pH to <2
Failure to respond may be a result of:
Dietary Lapse - Monitor Anti-Endomysial Antibodies Pancreatic lipase inactivated
Associated Lactose Intolerance due to mucosal damage
Vitamin Or Mineral Deficiency - Zn, Cu Bile salts precipitated
Concurrent Pancreatic Insufficiency
Development Of Malignancy Diarrhoea and steatorrhoea
Incorrect Original Diagnosis
Comp Lymphomas of GI Tract 90% tumours in pancreatic head / prox duodenal wall (>
Adenocarcinomas of GI tract common). Tumour size varies from 1mm 20cm
Risk Small bowel carcinoma: 80x Risk > 50% multiple Approx 1/2 2/3 malignant but slow growing
of … Oesophageal carcinoma (< commonly- bladder, breast, brain) 20-60% pts have adenomas of parathyroid and pituitary glands
Splenic Atrophy S&S Peptic ulcers: Multiple, Severe, May occur in unusual sites:
Miscarriage / baby with a congenital malformation in untreated Post bulbar duodenum, Jejunum, Oesophagus
pregnant women. Poor response to standard therapy
Short stature due to nutrient absorption during childhood Short Hx
when nutrition is critical to growth and development. Bleeding and perforation common
Diarrhoea in 1/3 pts
ASCITES: DIFFERENTIAL DIAGNOSES Barium meal showing abnormally coarse gastric mucosal folds
Def Abnormal collection of fluid in peritoneal cavity. DDx
Gravity Collection in flanks of supine pt: Inv / Aspiration Gastric Asp: Confirms hypersecretion of acid
When > 2 L accumulated – Percussion dull in flanks. Dx Serum Serum gastrin levels (10-1000 fold)
As fluid , dullness is detectable closer to the middle Other Secretin inj does little / nothing to gastrin levels in N
line + abdominal distension + umbilical inversion pts: With Syndrome there is paradoxical in gastrin
An area of central resonance will always persist. Imaging Tumour localisation:
Cause Classified with respect to protein content of peritoneal fluid. Endoscopic ultrasound
Trans: Result of hydrostatic pressure forcing fluid out of blood vessels. Radio labelled somatostatin receptor
<3g HEART: Cardiac Failure, Constrictive Pericarditis, Tricuspid Inc scintigraphy
Prot / HYPOPROTEINAEMIA: Nephrotic Synd, Liver F, Budd Chiari. Tx 30% small and single tumours can be localised and resected.
100ml Ovarian Tumours, e.g. Meig's syndrome (also pleural effusion) PPIs heal ulcers and relieve symptoms: > N dose required
Exud: INTRA-ABDOMINMAL CANCER: (Liver C, Mesothelioma…) Octreotide injections: Reduces gastrin secretion
> 3g INFECTION: Pyogenic, Tuberculosis (Tuberculous Peritonitis) Prog 5 year survival is 60-75%
Prot / INFLAMMATION: Pancreatitis
100ml IMMUNOLOGICAL: Lymphoedema
Other Chylous ascites occurs with massive obstruction of abdominal
lymphatic drainage. It is a milky white ascites, rich in
chylomicrons from mesenteric lymphatics. Usually 2o to
malignant involvement of para-aortic lymph nodes by
lymphoma or metastatic testicular tumour.
Less frequently, it is caused by:
Primary Fistula – Tx: Close with nonabsorbable sutures
Primary lymphatic disease
Other secondary causes:
Postoperative - very rarely
When surgery is unsuccessful use Leveen shunt
DDx Abdo Distension: Fat, Fluid, Flatus, Faeces, Foetus, F**kin big tumour
Inv / US
Dx Para- 30 - 50 ml Fluid withdrawn.
Cenesis Protein content: Albumin & Total Protein
Malignant cells, Bacteria, WBCs, Glucose
If WCC, i.e. > 250/mm cubed, which is predominantly
polymorphs, suggestive of spontaneous bacterial peritonitis..
> One type of organism suggests possible bowel perforation or
Serum-Ascites Albumin Gradient: Calculated by subtracting
[albumin] of ascitic fluid from [albumin] of serum specimen
obtained on same day. Gradient of > 1.1 g / dL = Portal HT.
Amylase Pancreatic ascites & gut perforation in peritoneal cavity
Smear Tuberculous smear and culture
Mx Management in Cirrhosis
Para-Cenesis then whether ascites is Tense / Non Tense…
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