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130 Cards in this Set

  • Front
  • Back

Outline the 9 main aetiologies of malabsorption and give an archetypal example of each

Unavailability of pancreatic enzymes


Pancreatic insufficiency




Unavailability of bile secretion


Cholestasis




Other stuff on the way


Bacterial preabsorption




Primary mucosal cell abnormalities


Disaccharidases deficiency




Reduced intestinal surface area


Coeliac/Crohn's disease




Lymphatic obstruction


Lymphoma




Infection


Giardia lamblia




Iatrogenic


Gastrectomy


Resection of small bowel

Course of blood to and from the oesophageal varices

Portal vein ➙ Coronary (left gastric) veins ➙ Oesophageal vein ➙ Azygous veins ➙ vena cavae

Portal vein ➙ Coronary (left gastric) veins ➙ Oesophageal vein ➙ Azygous veins ➙ vena cavae

Course of blood to and from the caput medusae

Portal vein ➙ Paraumbilical vein ➙ Superficial epigastric veins ➙ External iliac vein ➙ Common iliac vein ➙ IVC

Portal vein ➙ Paraumbilical vein ➙ Superficial epigastric veins ➙ External iliac vein ➙ Common iliac vein ➙ IVC

Name one factor that precipitates cirrhosis in liver diseases

Binge drinking (this is the same that also precipitate hepatitis in alcoholic liver disease)

Name the following sign, explain its pathogenesis and significance.

Name the following sign, explain its pathogenesis and significance.

Grey Turner's sign: Bleeding in the retroperitoneal space




Indicative of damage to retroperitoneal organs. Typically due to acute pancreatitis wherein pancreatic enzymes digest blood vessels.

2 early complications of acute pancreatitis

Multi-organ failure (e.g. renal failure, ARDS)


DIC (due to systemic inflammation)


Sepsis


Hypocalcaemia


Hyperglycaemia

What function of the pancreas is mostly affected by pancreatitis?

Exocrine (digestive enzymes)

3 signs and symptoms of chronic pancreatitis

Non-acute epigastric pain radiating to the back relieved by sitting forward


Bloating


Steatorrhoea

These red areas have been appearing at different places in the body and look inflamed. What is the name of the sign, its pathogenesis and its significance?

These red areas have been appearing at different places in the body and look inflamed. What is the name of the sign, its pathogenesis and its significance?

Trousseau's sign of malignancy


Due to thrombophlebitis (inflammation caused by thrombus)

Suggestive of malignancy (principally pancreas cancer)

Three most likely cause of acute pancreatitis in the UK

Gallstones (60%)


Alcohol (20%)


Idiopathic (10%)

Four outcomes of acute pancreatitis

Chronic pancreatitis


Pancreatic necrosis


Pancreatic abscess


Pseudocyst (fluid filled cavity without epithelium)


Resolution

4 aetiologies of chronic pancreatitis

(Thinks of alcohol and obstruction as the two aetiologies of acute pancreatitis)




Chronic alcoholism


Chronic duct obstruction


Repeated acute pancreatitis


Idiopathic

3 stimuli of pancreatic exocrine function

Secretin (secreted by the duodenum in response to acid)


Cholecystokinin (secreted by the duodenum in response to fatty acids and amino acids)


Acid, AA, peptides in duodenum

Presentation of acute pancreatitis

Sudden onset of severe epigastric pain radiating to the back relieved by sitting forward accompanied by vomiting (prominent)

11 causes of pancreatitis

I GET SMASHED


Idiopathic


Gallstones


Ethanol


Trauma


Steroids


Microorganisms (mostly viral: Coxsackie B, mumps, hepatitis, HIV)


Autoimmune


Scorpion stings


Hypercalcaemia/hyperlipidaemia/hypothermia


ERCP


Drugs

Name 3 drugs that may cause pancreatitis

Furosemide (low volume ⇒ ischaemia)


Corticosteroids


Cimetidine (anti-H2)


Antiretrovirals

Name and compare two biochemical tests useful in diagnosing pancreatitis

Amylase


Peaks at 12 hours


Returns to normal at 4 days


Good specificity


Average sensitivity


Cheap




Lipase (all x2)


Peaks at 24 hours


Returns to normal at 8 days


Very good specificity


Very good sensitivity


Expensive

High amylase and high lipase: 3 differential diagnosis

Pancreatitis


Intestinal obstruction


Perforation

What electrolytes disturbance may be observed in severe acute pancreatitis and why?

Hypocalcaemia


Pancreatic enzymes in the circulation damage fat cells which release TAGs. TAGs are then broken down to free FA by free pancreatic lipase in the circulation. Free FA have 2 negative charges and therefore bind calcium (precipitation of calcium).




Note: hypercalcaemia is a cause of pancreatitis

What imaging should be used in pancreatitis?

USS of RUQ to check for stones (if AST raised)




CT to monitor progression and check for potential carcinoma

Where should the stone be to cause pancreatitis?

At the sphincter of Oddi

How would you assess the severity of acute pancreatitis?

Glasgow criteria – PANCREAS


(Notice that amylase is not part of it)


PaO2 (< 8kPa due to respiratory failure)




Age (> 55)


Neutrophilia


Calcium (Low due to binding to free FA but watch out for correction due to low albumin)


Renal function (High urea due to possible thrombus in the renal artery and dehydration secondary to chemical burn oedema)


Enzymes (High LDH as it is present in pancreatic cells and high AST if there is a stone)


Albumin (Low due to malabsorption)


Sugar (High blood glucose due to low insulin)

Name 4 physical signs of acute pancreatitis

Grey Turner's sign (digestion of blood vessels)


Cullen's sign (same as Cullen but ventrally)


Tachycardia


Fever


Jaundice


Tenderness in abdomen


Shock


Ileus

What investigations would you do to confirm pancreatitis and assess its severity?

Amylase




Then, think of Glasgow criteria:


ABG


Blood: FBC, U&E, Calcium, AST, LDH, Albumin


BM

What does U&E typically contain?

Urea


Creatinine


eGFR


Potassium


Sodium

Outline the management of pancreatitis

1. Assess severity with Glasgow score


2. NBM and NG tube


3. IVI with lots of saline to counter third-space sequestration


4. Analgesia: pethidine* (morphine would contract the sphincter of Oddi more)


5. Monitor: BP, HR, PaO2


6. ERCP for gallstone removal

It is often said that pancreatitis causes third-spacing. What do you understand by this and what causes it in pancreatitis?

Third space is the transcellular space wherein fluid does not usually accumulate (e.g. peritoneal cavity).

In pancreatitis, fluid collects into the peritoneal cavity due to chemical burn (pancreatic enzyme-driven).

What analgesia should be given in acute pancreatitis?

Pethidine (an opioid)

Two complications of chronic pancreatitis

Diabetes mellitus


Malabsorption

5 RF for pancreatic tumour

Smoking


Alcohol


High fat diet


Diabetes mellitus


Chronic pancreatitis

How is the presentation of pancreatic cancer related to its location

Painless jaundice => Head


Epigastric pain radiating to the back and relieved by sitting forward => Body or tail

A patient presents with painless jaundice. You suspect pancreatic tumour but on examination, he has a palpable gallbladder. What is the diagnosis?

It can still be pancreatic tumour. The gallbladder is typically palpable (My guess: swollen due to backflow due to obstruction)

Name 4 physical signs of pancreatic tumour

"Everything swells"


Jaundice


Palpable gallbladder


Hepatomegaly


Splenomegaly


Lymphadenopathy


Ascites

What results do you expect to see in blood tests of pancreatic cancer?

Cholestatic jaundice


GGT raised


ALP raised


Conjugated bilirubin raised

What specific blood test may you request to confirm the diagnosis of pancreatic cancer?

CA 19-9

What initial imaging would you use in a patient in whom you suspect pancreatic cancer?

USS (or CT)

Which imaging would you use to confirm diagnosis of and assess staging of pancreatic cancer?

Endoscopic ultrasonography (EUS)

Endoscopic ultrasonography (EUS)

When is pancreatoduodenectomy indicated?

Consider in pPancreatic cancer with no mets and patient fit (but most won't be suitable)

What is the most common management of pancreatic cancer?

Palliative


1. Refer to palliative team


2. Stent to reduce jaundice


3. Big doses of opiates

Lifetime incidence of appendicitis?

6%

How does appendicitis occur?

Gut organisms invade the appendix wall after lumen obstruction (lymphoid hyperplasia, feacaloma, worms)

Beside the characteristic pain, name two other features of the presentation of appendicitis.

Anorexia


Constipation (or sometimes diarrhoea)

Name three specific tests that can be used to help the diagnosis of appendicitis

Rebound tenderness




Rovsing's sign


Pain in RIF > Pain in LIF when LIF is pressed.




Psoas sign


Pain when extending the hip (if retrocaecal appendix)




Cope sign


Pain on flexion and internal rotation of the right hip

Name two blood results expected in appendicitis

Raised WCC (neutrophils)


Raised CRP

Name 3 signs of appendicitis elicited on general inspection

All due to pain on moving:


Pain on coughing


Immobile


Shallow breaths

Course of action if suspected appendix

Laparoscopic appendicectomy (20% will be false positives and removed anyway)


+ ABx pre-op (metronidazole)

26 year old female presents with symptoms of appendicitis. Name 3 tests that you would do.

FBC (raised neutrophils)


CRP


Pregnancy test


Urinalysis (very important as UTI may mimic appendicitis)

Three complications of appendicitis

Perforation


Appendix mass (inflamed appendix covered by omentum => Exclude colonic tumour)


Appendix abscess (if appendix mass fails to resolve)

A patient had symptoms of appendicitis 1 week ago but controlled it well with analgesia. He now presents to the hospital as he has higher fever and pain. His temperature is 38°C. Explain what may have happened. What would you do?

Appendix abscess


Try drainage (USS-guided) or ABx

Why is the pain of the appendicitis initially located in the epigastric region? Why is it not lateralised?

Viscera (and visceral peritoneum) have no somatic innervation. The brain associates the pain to a location whose dermatome corresponds to the same spinal level as the entry point of the C-fibres (from viscera). The C-fibres enter the spinal cord on both sides preventing any laterality and at multiple levels (=> Multiple dermatomes are possibly involved).

What physical event causes the pain from appendicitis to move from periumbilical to McBurney's point?

The peritoneum overlying the appendix gets progressively irritated. As long as only the visceral peritoneum is affected, the pain remains referred to periumbilicum (the visceral peritoneum does not have somatic innervation).

As soon as the parietal peritoneum (which has somatic innervation) is irritated, the pain moves to McBurney's point.

Outline the separation of the foregut, midgut and hindgut and name their arterial supply, the main nerve and the location of the referred pain.

Foregut – Proximal to D2


Coeliac trunk


Greater splanchnic nerve => Epigastrium referral




Midgut – D3 (distal to bile duct) to 2/3 of transverse colon


SMA


Lesser splanchnic nerve => Periumbilical referral




Hindgut – 2/3 of transverse colon to upper anal canal


IMA


Lumbar splanchnic nerve => Suprapubic referral

Explain one reason why appendicitis may present without pain at the specific location. What would you do then?

Ectopic appendix:


Retrocaecal (gas-filled caecum protects the appendix)


Entirely within the pelvis

DRE will elicit pain if the appendix is in the pelvis.

Name 2 differential diagnosis of appendicitis in children

Mesenteric adenitis*


Meckel's diverticulitis*

Name 5 differential diagnosis of appendicitis in adults

Ectopic pregnancy


Ovarian cyst




Crohn's disease


Meckel's diverticulitis


Gastroenteritis




Pancreatitis


Renal colic

Name 3 differential diagnosis of appendicitis in elderly

Sigmoid diverticulitis


Caecal tumour


Caecal diverticulitis


Ovarian tumour


Ovarian cyst


Ovarian infection

Why should you do a DRE in patients with suspected appendicitis (2)?

Elicit pain in ectopic appendix


Rule out other differentials which may present with steatorrhoea due to malabsorption (pancreatitis, Crohn's coeliac) or with rectal bleeding (diverticulitis, tumour)

How would you distinguish appendicitis from mesenteric adenitis?

Mesenteric adenitis will usually present in children with history of recent viral illness and lymphadenopathy.

Where is Meckel's diverticulum located? What is it the remnant of?

Distal ileum 
Remnant of the yolk sac

Distal ileum


Remnant of the yolk sac

Why can Meckel's diverticulum cause GI bleeding? What type of bleed does it cause?

The yolk sac remnant may contain gastric and secrete gastric acid causing the bleed.




Blood can be either bright red or occult.

Name 3 complications of Meckel's diverticulum

Haemorrhage (25%)


Obstruction (25%)


Diverticulitis (15%)

Blood in the stool in a 2 year old boy but no haematemesis. Likely diagnosis?

Meckel's divericulum

Define hernia

Abnormal protrusion of a viscus (singular of viscera) out of its normal cavity

Surface anatomy of the deep inguinal ring

Mid-point of the inguinal ligament


(The mid-inguinal point is the femoral artery)

How do we differentiate a direct from an indirect hernia. Explain the surface anatomy of any structure you name.

1) Reduce hernia


2) Occlude deep ring with two fingers (mid-point of the inguinal ligament)


3) Ask pt to cough. If hernia pops out, then it’s a direct hernia 


What is the internal inguinal ring?

A synonym of the deep inguinal ring


The external ring is the superficial ring

Which inguinal hernia is usually more present in children and younger adults?

Indirect

Which inguinal hernia is usually more present in elderly?

Direct (weakness)

Which inguinal hernia is usually more present in males?

Both direct and indirect but more marked difference in indirect

Which inguinal hernia is usually bilateral?

Direct

Which inguinal hernia is usually unilateral?

Indirect

Which inguinal hernia can be painful?

Indirect

Which inguinal hernia may extend in scrotum?

Indirect (it goes down the inguinal canal)

Which inguinal hernia can obstruct?

Indirect

Where do inguinal hernia originate?

Indirect: Lateral to inferior epigastric artery

Direct: Medial to inferior epigastric artery

Indirect: Lateral to inferior epigastric artery


Direct: Medial to inferior epigastric artery

What is meant by incarceration of a hernia?

Content of the hernial sac is stuck inside by adhesion

What is meant by strangulated hernia?

Ischaemia occurs (need for urgent surgery as the patient becomes toxic)

Commonest abdominal hernia

Inguinal hernia (and among them indirect are commonest–80%)

Which inguinal hernia can obstruct is most common?

Indirect

Which inguinal hernia can strangulate?

Indirect

How can inguinal and femoral hernia be distinguished (3)?

Location (#1)


Femoral: neck is inferior to the inguinal ligament


Inguinal: neck is superior to the inguinal ligament




Orientation (#2)


Femoral points down


Inguinal points to the groin




Gender (#3)


Femoral are more likely in female


Inguinal are more likely in guys.

Name 5 characteristics of a hernia that you should elicit on examination

Side


Unilateral or bilateral


Origin (neck)


Reducibility


Incarceration


Obstruction


Strangulation




Note:


Obstruction typically precedes strangulation (exception: Richter's hernia)


Incarceration ⟹ Irreducible and painful


Strangulation ⟹ Irreducible, painful and toxic

Surface anatomy of the superficial inguinal ring

1cm superior and medial to the pubic tubercle

If you had to choose to have either a direct inguinal hernia, an indirect inguinal hernia or a femoral hernia, which one would you choose first, second and third and why?

1. Direct inguinal hernia


Rarely strangulate




2. Indirect inguinal hernia


Can strangulate




3. Femoral hernia


Often strangulate

Name 5 differentials for a lump in the groin

Femoral hernia


Direct inguinal hernia


Indirect inguinal hernia


Saphena varix


Lipoma


Femoral aneurysm


Psoas abscess

Name two treatments that would be recommended/considered in femoral hernias

Surgery recommended either as:


1. Herniotomy: ligation and excision


2. Hernia repair: repair of the hernial defect



Inguinal hernia



Femoral hernia

Why may hernia occur in the femoral canal?

Femoral canal is loose allowing the adjacent femoral vein to dilate during exercise enabling adequate blood return

What forms the borders of the inguinal canal?

Floor: inguinal ligament


Roof: transverse abdominal muscle and internal oblique muscles
Anterior wall: External oblique muscles


Posterior wall: Transverse fascia (aponeurosis of transverse abdominis and parietal peritoneum)

Content of the inguinal canal in males and females



Ilioinguinal nerve


Spermatic cord (males)


- Vas deferens


- Obliterated processus vaginalis


- Lymphatics


- Arteries to the vas, cremaster and testis


- Pampiniform plexus and venous from vas, cremaster and testis


- Genital branch of the genitofemoral nerve and sympathetic nerve


Round ligament of the uterus (females)

What forms the borders of the femoral canal?

Anteriorly: Inguinal ligament


Posteriorly: Pectineal ligament and pectineus (muscle for adduction of the leg)


Medially: lacunar ligament and pubic bone


Laterally: femoral vein

Content of femoral canal

CLoquet's lymph node


Fat

How do direct inguinal hernia occur (mechanism and predisposition)?

Abdominal content pushes their way directly through the posterior wall of the inguinal canal.


Predispositions: increased intraabdominal pressure (constipation, heavy lifting, obesity, chronic cough, ascites, urinary obstruction...)

Why is it important to know how to differentiate between a direct and an indirect inguinal hernia?

For OSCE.
Little use in practice since the repair is the same in both.

Why is it important to know how to differentiate between a reducible and an irreducible inguinal hernia?

Irreducible require surgery

What 3 information/advice should you impart to patients before surgical repair of inguinal hernias?

Advice to diet (if over-weight)


Stop smoking before operation


Warn that hernias may recur (< 2%)

What is the surgical approach to repair an inguinal hernia?

Mesh repair

What is an incisional hernia? How are they treated?

Hernia caused by the breakdown of muscle closure after surgery (occurs in 10% of laparotomy)




Mesh repair (✔︎ less recurrence ✘ more infection)


Suture

Name 4 factors that predispose to incisional hernia

Wound infection (=> weaken the wall)


Steroid use, anaemia, or malnutrition at the time of original surgery


Midline laparotomy


Poor surgical techniques in abdominal sutures

When do incisional hernias occur after surgery?

Up to 5 years after

What is a Richter's hernia?

A hernia that involves only part of the bowel wall so that bowel obstruction (and its signs and symptoms) does not occur

A hernia that involves only part of the bowel wall so that bowel obstruction (and its signs and symptoms) does not occur

True or false: Richter's hernia are benign

False, because they cannot lead to obstruction, they may present late when they result in strangulation and necrosis in the absence of obstructive symptoms.

False, because they cannot lead to obstruction, they may present late when they result in strangulation and necrosis in the absence of obstructive symptoms.

Outline the pathological mechanism that leads to strangulation.

Venous and lymphatic occlusion ➙ oedema and raised venous pressure ➙ impeding arterial flow ➙ bowel necrosis andperforation

Name and describe one surface anatomy area through which direct hernia pass.

Hesselbach triangle
Inguinal ligament
Rectus muscle
Epigastric artery

Hesselbach triangle


Inguinal ligament


Rectus muscle


Epigastric artery

Indication for the surgical repair of inguinal hernia

Symptoms


Episodes of irreducibility


Bowelobstruction

Name 4 cardinal features of intestinal obstruction (both large and small bowel)

Constipation
Colicky pain
Vomiting
Distension

Constipation


Colicky pain


Vomiting


Distension

Characterise the obstruction in intestinal obstruction

Solid only if proximal (~ small intestine)


Absolute if distal (~ large intestine)

Outline the timing of colic pain, distension and vomiting in intestinal obstruction.

Colic pain – Early in obstruction then diseappears


Vomiting – Occurs earlier if small bowel obstruction than large bowel


Distension – Worsens with time (worse with large bowel obstruction)

How can small and large bowel obstruction typically be differentiated?

AXR

Outline 5 differences between small and large bowels seen on AXR

Outline how pain, vomiting, constipation and distension differ between small and large bowel obstruction

Constipation: solid only in small bowel, everything in large (this is not clear cut)




Pain: less constant in small bowel (peristalsis) and higher up




Vomiting: occurs earlier in small bowel obstruction




Distension: less bad in small bowel obstruction



What two clinical features would point to ileus rather than mechanical obstruction?

No pain


Bowel sounds absent (no tinckling)

Besides the location (small or large bowel) and the mechanism (functional or mechanical), what other question should you address in the clinical examination of bowel obstruction?

Is the obstruction simple, closed loop or strangulated?

Simple – One point of obstruction


Closed loop – Two point obstruction (e.g. volvulus)


Strangulated – Blood supply is compromised and there is sharper more localised pain (peritonism)

Besides cardinal signs of obstruction in general, what is the cardinal sign of strangulated obstruction specifically?

Peritonism

Two most likely causes of small bowel obstruction and four most likely causes of large bowel obstruction

Small bowel


Adhesions (#1)


Hernia




Large bowel


Colon cancer (#1)


Constipation


Diverticular strictures


Volvulus (sigmoid or caecal)

What specific cause of small bowel obstruction should you suspect in a patient who has had a abdominal surgery (4)?

Adhesions (even if surgery long in the past)


Hernia (incisional)


Paralytic ileus


Pseudo-obstruction

What specific cause of bowel obstruction should you suspect in a patient who has Crohn's disease?

Crohn's stricture

What specific cause of bowel obstruction should you suspect in a patient who has a history of gallstones?

Gallstones ileus

What specific cause of bowel obstruction should you suspect in a patient who is from the developing world?

TB

What is the mechanism of sigmoid volvulus?

Sigmoid colon twists on its mesentery

Complication of sigmoid volvulus

Perforation => Peritonitis => Death

Common treatment of sigmoid volvulus

Sigmoidoscopy and insertion of a flatus tube

What is the first line of management in intestinal obstruction?

Drip and suck


IV fluid to rehydrate and correct electrolyte imbalance (Drip)


NGT (to empty – Suck)

Other things to do


Analgesia


Erect CXR and AXR


Catheterise to monitor fluid balance


Blood tests

Outline the classic presentation of gastro-oesophageal obstruction

Classic triad


Vomiting (then retching)


Pain


Failed attempt to pass NGT

How does acute vs chronic intestinal obstruction influence your differential diagnosis?

Chronic is more likely to be functional (ileus or pseudo-obstruction)

True or false: colonic pseudo-obstruction presents with no feature on AXR.

False, the "pseudo" only refers to the absence of cause found.

False, the "pseudo" only refers to the absence of cause found.

Distinguish paralytic ileus from pseudo-obstruction

Paralytic ileus


Established absence of peristalsis (e.g. after abdominal surgery, spinal injury, hypokalaemia, hyponatraemia, TCA...)




Pseudo-obstruction


Presents like a mechanical obstruction but without an identified cause. Predisposition: surgery, trauma, post-partum

What specific cause of bowel obstruction should you suspect in a patient who has sustained spinal cord injury?

Paralytic ileus

What specific cause of bowel obstruction should you suspect in a patient who is hypokalaemic?

Paralytic ileus