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110 Cards in this Set

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Mouth ulcer - systemic disorders, infection, dermatology
Crohn's, ulcerative colitis' coeliac
others: lupus, behcet' neutropenia' Reiter's
ten, erythema multiforme, pemphigus, bullous pemphigoid...
Herpes simplex I / II (fever), cocksackie A, other herpes, syphilis, TB
Mouth ulcers - associated drugs
Antimalarials, methyldopa, tolbutamide, penicillamine, gold salt
Mouth ulcers R/x
No specific Rx. Try corticosteroids, chlorhexidine mouthwash etc
Leukoplakia cause, ivx, Rx
DDx candida
Etoh, smoking, premalignant
always biopsy. Isotretinoin.
Glossitis - red, smooth, sore tongue causes
Vit B12, folate, iron, nicotinic acid, riboflavin, candida
Acute sialadenitis - causes
Mumps or bacteria: staph aureus, strept pyogenes, strep pneumonia
sarcoidosis: Heerford syndrome
Salivary gland obstruction - sx
Painful swelling submandibular gland, palpable stone
Parotitis, uveitis, low-grade fever - dx?
Heerford syndrome
Parotitis, uveitis, low-grade fever, lacrimal gland enlargement. - Dx?
Mikulicz syndrome
Salivary gland neoplasms how common, what type?
3% of all tumors,pleomorphic adenoma most common, 15% malignant transformation
Dysphagia - DDx
Tonsillitis, neuromuscular: bulbar palsy, myasthenia gravis; motility: achalasia, diffuse spasm, presbyoesophageus, DM, chagas' extrinsic pressure: mediastinal lymphadenopathy, goitre, LA ^ intrnsic lesion: FB, stricture, ring, web, pharyngeal pouch
Oesophageal disorders - what Ivx?
barium swallow/meal
OGD
Monometry
pH monitoring
Hiatus hernia - how common?
30% of > 50's
Hiatus hernia - diagnostic significance?
Not significant symptoms due to reflux
What arw the ntireflux mechanismsbod the stomach?
LOS = distal 4 cm, intraabdominal part of oesophageus, mucosa folds, contractions of diaphragm ' pinchcock like effect'
GORD symptoms
Heartburn - positional, worse with hot liquids/alcohol
regurgitation leading to coughing and nocturnal asthma
GORD how is the initial mgm?
Initial treatment if pt <45 unless alarm sx (dysphagia, wt loss, protracted vomiting, anorexia, haematemesis/malaena)
* barium swallow+water siphon test: severity, hiatus hernia
* 24h manometry and pH study: before considering surg, corelation between sx and episodes of pH <4
GORD initial Rx?
50% can be mgm c :
risk factor modification, raising head if bed, simple antacids.
GORD indications for surgery?
Severe reflux, documented with 24h pH monitoring and oesophagitis on OGD failed to be controlled by meds or young that would need long term Rx
GORD and established reflux oesophagitis - mgm?
Long term PPI and regular OGD surveillance for complications
GORD - complcations?
* Barret's
* peptic stricture
* adeno Ca
Achalasia - what initial investigations? What would they show?
CXR - dilated oesophagus, fluid level, no fundal gas
Barium swallow - dilatation, lack of peristalsis, swan neck deformity
OGD - exclude Ca
Manometry, CT scan
Achalasia - R/x?
first choice: pneumatic dilatation
alternative: botox
elderly: nifedipine 20mg S/L
if medical Rx fails: surgical divisiono
Oesophageal diverticulum - what types?
pharyngeal pouch (above upper sphincter)
near the middle (traction diverticulum)
above lower sphincter (epiphrenic diverticulum)
dysphagia, iron deficiency, glossitis and angular stomatitis - Dx?
Plummer-Vinson syndrome
What is a Schatzky ring?
Narrowing lower end of oesophagus due to ridge of mucosa.
Benign stricture - Rx?
dilatation, occasionally surgery
oesophageal infections in immuncompromised patients - what organisms?
candida, herpes, cytomegaly virus
Oesophageal rupture - cause? management?
violent vomiting (boerhaven syndrome)
CXR (hydropneumothorax), gastrografin surgical repair
Oesophageal Ca - commonest location?
40% middle (SCC) 45% lower third (AdenoCa)
Oesophageal Ca - epidemiology and geographical variation
highest incidence in Iran, china, africa.
SCC more common in men
usual age 60 - 70
Oesophageal Ca - risk factors for SCC
Tobacco, EtOH, Plummer-Vinson, Achalasia, Coeliac, radiotherapy for breast Ca,
Oesophageal Ca - risk factors for AdenoCa
GORD, Barrett's
Tobacco smoking
Obesity
Radiotherapy for breastCa
Major risk factor for Oesophageal Ca?
Barrett's
Risk increased 30 - 40 fold.
worsening dysphagia, initially for liquids then for solids, weight loss and anorexia - Dx?
oesophageal Ca
Oesophageal Ca - Ivx?
initially OGD or barium swallow
CT/MRI thorax and abdomen: volumem local invasion, lymphnodes
endoscopic USS: depth of tu
PET: sensitivity for distant mets as CT/MRI but specificity higher
Oesophageal Ca - Success rate for surgery?
80% 5-year survival if Tu not infiltrated outside wall.
Oesophageal Ca - Palliative Rx?
stent insertion, photo/laser coagulation of tumor, chemoradiation
Where is H.pylori found?
gastric ANTRUM
peptic ulcer - clinical features
epigastric pain
DU pain at night and worse when hungry
back pain - suggest penetration
peptic ulcer - non-invasive Ivx?
* 13C urea breath test - sens 97% specific 96%. Also used to demonstrate eradication after Rx.
* serological: 90% sens/specif.
* stool test sens 97% specif 97% good for control of eradication but need to be off PPI for 1/52
how can successful eradication of peptic ulcers been demonstrated?
13C breath test
peptic ulcer - invasive Ivx?
OGD with rapid urease test, culture (abx sensitivities!). Histology: giemsa staining.
Suspected peptic ulcer disease - how is the initial mgm?
pt <55 with typical sx and H.p positive can be eradicated without further Ivx
unless "alarm symptoms".
older pt. must have OGD and biospy (rule out Ca).
Whom to give eradication Rx?
All patients with peptic ulcer should have eradication Rx.
Should H.p pos patient without ulcer have eradication?
controversial
How successful is eradication? How frequently does re-infection occur?
90% success, reinfection less than 1%
Prescribe eradication Rx!
PPI + 2 abx for 1 week:
omeprazole 20mg, metronidazole 400mg BD, clarithromycin 500mg BD
OR
omeprazole 20mg, clarithromycin 500mg BD, amoxycillin 1g BD
How long is PPI rx in pt with ulcer?
eradication + 3-4 weeks PPI
peptic ulcer - How can success be measured? How is the follow up?
clinically: resolution of symptoms
if symptoms persist, 13C breath test or stool test. In gastric ulcer - re OGD 6/52 to exclude malignancy
Complications of peptic ulcer disease?
Haemorrage
Perforation
Gastric outlet obstruction
AdenoCa
Gastric B lymphoma (H.p)
How many % on NSAIDs develop ulcers? How many have symptoms?
50% develop ulcers
5% symptomatic
Causes of ulcerative gastropathy?
NSAIDS
H.pylori
Alcohol
trauma, severe stress
portal gastropathy (renal or liver disease)
Which patients on NSAIDs should receive prophylactic gastroprotective therapy?
>65 ye ars
hx of peptic ulcer with complications
on corticosteroids and anticoagulants
What problems does a patient with Menetrier's disease get?
hyperchlorhydria (needs PPI)
peripheral oedema (protein loss)
premalignant condition
How do you manage dyspepsia/indigestin initially?
if <45 and no alarm symptoms, serologic test for H.p and PPI/eradication if positive. If remains symptomatic investigate
>45 or alarm symotoms must have OGD to rule out serious pathology.
Gastric AdenoCa: Epidemology
Japan > USA
age 50 - 70, rare <30
Gastric AdenoCa: Risk factors
Hp status (class I gastric carcinogen WHO)
diet: high salt, nitrates
achlorhydria
smoking
Blood group A
pernicious anaemia
Gastric AdenoCa: Sx
epigastric pain (main sx) indistinguishable from ulcer pain!
anorexia, wt loss, nausea
dysphagia (fundal tu)
vomiting (pyloric tumor)
Gastric AdenoCa: Metastases
peritoneum (ascites), liver, bone, brain, lung
Gastric AdenoCa: physical signs to look out for
50% palpable mass
virchow's node
dermatomyositis
acantosis nigricans
Adeno Ca: Ivx
bloods, OGD, CT, USS
CT: limited value assessing local invasion.
endoscopic USS penetration into wall and lymph nodes
Adeno Ca: survival rates
EGC 90% 5 years
later 50%
only 10% 10 year survival though
How should you manage gastric polyps?
removal only for adenomatous polyps
usually not premaligant lesions (in the stomach, malignancy arises de novo)
Malaena - where is the site of bleeding?
above and including the caecum
Do corticosteroids cause GI bleed?
in usual doses not
Do anticoagulants cause GI bleed?
not on their own, but can augment
Can low dose ASA cause GI bleed?
yes it can!
GI bleed: How many patients stop bleeding without intervention in 48 hours?
85%!
GI bleed: When to transfuse?
if shocked
if Hb <10 and still bleeding.
GI bleed: Mortality
age: if <60 mortality <0.1%
>80 mortality 20%
GI bleed: when do most rebleeds occur?
within 48 hours
GI bleed: what can be done to reduce rebleeding rate?
intervention at endoscopy
PPI therapy for ulcer pt
GI bleed: What patient can be safely discharge early?
haemodynamically stable
no stigmata of recent haemorrage on OGD
GI bleed: Pt with chronic peptic ulcer - what needs to be doen?
H.p status checked and eradicated if found and PPI continued for 4 weeks
GI bleed: How to manage Mallory-Weiss tear?
usually stops spontaneously. Can be d/c within 24 hours.
severe tears rarly need surgery.
GI bleed: overall mortality
5-12%
Causes of lower GI bleeding - from distal to proximal
haemorrhoids (small frequent bleeds)
colitis (crohns, UC)
diverticula
polyps (small frequent bleeds)
Colon Ca
ischaemic colitis
angiodysplasia
meckel's diverticulum
iron deficiency in a postmenopausal woman. Source?
in all men and postmenopausal women, iron deficiency anaemia due to blood loss is ALWAYS from GI tract and most commonly due to carcinoma.
when to use occult blood tests?
in premenopausal women
for population screening purposes
iron deficiency anaemia due to blood loss. What Ivx?
top tail endoscopy in same session
barium enema only if colonoscopy not available
if negative, small bowel follow through next.
enteroscopes if available
capsule endoscopy (90% bleeding sites found in study)
Investigations: Small bowel follow through
detects gross anatomy (diverticula, strictures, crohn's. dilatation of bowel and cange of folds indicate malabsofption
Differential diagnosis of malabsorption
coeliac disease
whipples disease
crohn's
dermatitis herpetiformis
tropical sprue
bacterial overgrowth
intestinal resection
radiation enteritis
parasite infestation (e.g giardia)
which cereals contain gluten?
rye, wheat, barley.
Coeliac disease: epidemology
any age, but mostly 50-60
coeliac disease: clincial features
asymptomatic
incidential finding of MCV ^
GI symptoms: diarrhea, steatorrhoe, discomfort, bloating (malabsorption)
mouth ulcers, angular stomatitis
coeliac disease: associated diseases
autoimmune: IDDM, thyroid, PBC, sjoegren, IBD, ....
coeliac disease: Ivx
mild moderate anaemia in 50%
folate deficiency almost always present
1. endomysial antibodies if positive endoscopy and biopsy
2. DEXA scan for all patients
coeliac disease: treatment and follow up
gluten free diet, haematinics.
follow up with serial antibody tests.
if progress suboptimal repeat biopsy
all patients should have pneumococcus vaccine!
coeliac disease: complications
lymphoma
ulcerative jejunitis
small bowel Ca (rare)
bacterial overgrowth - who is at risk?
elderly and pt with structural abnormality
pathophysiology of bacterial overgrowth
bacteriae deconjugate bile salts causing diarrhea and steatorrhoe
bacteria metabolize vit b12 (low)
produce folate (high)
how to confirm bacterial overgrowth?
hydrogen breath test
pathophysiology of ileal resection
loss of vit b12 and bile salt resabsorption
bile salts and fatty acids in colon cause diarrhea
increased bile salt production leads to lithogenic bile
increased colonic oxalate reabsorption leads to renal stones.
macrocytosis due to vit b 12 deficiency
treatment of illeal resection
vit b 12 injections, cholestyramine if diarrhea, low fat diet
Whippel's disease - sx
M > F
abdo pain, diarrhea
systemic features: fever, weight loss
can affect heart, lung brain.
peripheral lymphadenopathy
intestinal TB - presenting sx
abdo pain, diarrhea and systemic features: fever, weight loss, anorexia
or presents with acute obstruction or generalised peritonitis
intestinal TB DDx
consider in asian immigrants
DDx to crohn's and colon Ca
intestinal ischaemia - causes
1. arterial obstruction
mostly embolic - cardiac arrythmia or aortic disease occluding ostia or vasculitis
(thrombangiits and Takayasu's)
2. venous obstruction
3. non-occlusive: shock, massive reduced cardiac output.
acute instinal ischaemia - presenting features
hypertensive and ill patient
acute onset abdo pain and vomiting
abdo tenderness, absent bowel sounds
what is intestinal lymphagiectasia?
dilatation of lymphatics, primary or secondary to malignant obstruction, causing steatorrhoe and low protein with ankle oedema
what is abetalipoproteinaemia?
rare lack of apo B 100 and apo B 48, so chylomicrones not formed
clinically there is acanthocytosis, retinitis pigmentosa mental and neuro abnormalities preventable by Vit E injections.
when does carcinoid syndrome presents?
when there are liver mets
carcinoid syndrome: clinical features
spontaneous bluish-red flushing face and neck, abdo pain, watery diarrhoe.
cardiac: pulm. stenosis or tricuspid regurge
GI: hepatomegaly
carcinoid syndrome: Ivx
USS (mets), urine for 5-HIAA
carcinoid syndrome: treatment
somatostatin analogues.
What is Peutz-Jeghers syndrome?
mucocutaneous pigmentation and gastrointestinal polyps which are hamartomas.
Which gene involved in Peutz-Jeghers?
LKB1
Complications of Peutz-Jeghers?
polyps can bleed or obstruct and occasional malignant transformation
How to manage Peutz-Jeghers?
Individual polypectomy, 2 yearly follow up with Xray and endoscopy.