GI2.txt

no

• PROGRESSIVE, unrelenting dysphagia
• weight loss
• cervical lymphadenopathy
• retrosternal chest pain

• regional lymph nodes in 50% at diagnosis
• gastric glands
• then liver

• A: penetrated muscular mucosa may have gone into submit or musc propria but confined to bowel wall & LN-ve
• B: extension through the bowel wall into mesorectal/pericolic fat/ LN-ve
• C: involvement of regional LN (C2 - apical LN)
• D: distant mets eg liver or lung, bone peritoneal cavity

hiatus hernia complication

• muscles of the cardia (LOS) are cut to allow food and lqd to pass to stomach
• surgical Rx of achalasia as LOS cant relax properly

• Ba swallow to check for leak post surgery
• Risk: perforation and stomach acids easily reflux up so may also need partial fundoplication to reduce post op acid reflux!

• rising: gastro oes junction
• falling: distal and body

antrum (nb anatomy: fundus - body - antrum - pyloric canal - pylorus)

• chronic inflam of stomach muscosa leading to LOSS OF GASTRIC GLANDULAR cells. they are replaced by intestinal and fibrous tissue
• cause: persistent infection with H pylori or autoimmune

stomach doesn't have glands anymore so reduced secretion of HCl acid, pepsin, intrinsic factor leading to DIGESTIVE PROBLEMS, vitamin B12 deficiney MEGALOBLASTIC ANAEMIA

parietal cells

G cells in stomach, duodenum, pancreas

parietal cells

• arteriopaths
• AF - arterial embolus
• previous TIA

splenic flexure as it is the site of watershed between superior and inferior mesenteric arteries

• foregut: coeliac axis, also but to jéjunum
• midgut: lower duod to 2/3 of TC: superior mesenteric artery
• hindgut: distal third TC to rectum: inferior mesenteric artery

• bleeding: occult, dark colour
• small bowel obstruction

change in bowel habit: inc frequency with caecal

chronic peptic ulceration and a narrowed pylorus forms.

vomiting large amounts of food a few hours after meals

• must correct the hypochloraemic, hypokalaemic metabolic alkalosis
• endoscopic balloon dilatation (NB risk of perf)
• maximal acid suppression
• if unsuccess: do drainage procedure e.g. gastro-enterstomy or pyloroplasty and highly SELECTIVE vagotomy

hypertrophy of muscle surrounding pylorus which spasms as the stomach empties

• presentation: not at birth, but in first 3-8wks
• projectile vomiting (non bilious as bile cant pass back into stomach!)
• poor feeding, weight loss, failure to thrive
• hunger
• belching
• colic

• palpating a pyloric mass in the RUQ during a feed
• visible gastric peristalsis passing from LUQ

• metabolic alkalosis due to projectile vomiting and loss of H+ions from gastric juice
• so water and electrolyte deplete NEEDS CORRECTING before surgery

• correct U&E and fluid
• Ramstedt's pyloromyotomy

• congenital jejunal diverticulae
• occur on mesenteric border

remnant of vitellointestinal duct

on ANTEMESENTERIC border in the distal ileum

• gastric type epithelium which can BLEED and may cause PAIN due to gastric acid secretion
• pancreatic type epithelium

radionucleotide scan and laparotomy

acute appendicitis

superiorly and medially

• homocystinuria
• lens: downwards dislocated
• heart not affected
• mental retardation
• respond to pyridoxine

tinkling

• suspected STRANGULATION: irredicuble hernia
• failure of resolution with conservative Rx

• smaller calibre loops
• central, multiple loops
• valvuli conniventes: folds that go from wall to wall all the way across the lumen, more regular than hausfrau
• grey: contains air and fluid

• larger calibre lumen
• peripheral loops
• hausfrau: do not go all the way across lumen, but may appear so in creation angles
• blacker: contain gas

ileus

2.5cm

• normal: 5cm
• dilated > 6cm

• protrusion of rounded indentations of thickened mural folds into the lumen
• large bowel ischaemia

gas outside the lumen, on both sides of the bowel wall on supine AXR

• calcification of the GB
• due to chronic inflammation secondary to GS or adenocarcinoma

• post ERCP
• post surgery
• anaerobic cholangitis
• recent stone passage
• biliary-enteric fistula
• incompetence of sphincter of oddi

• sentinel loop of intraluminal gas
• RUQ: cholecystitis
• LUQ: pancreatitis
• RLQ: appendicitis
• LLQ: diverticulitis

• portal vein gas: goes Peripheral in liver. surgical EMERGENCY as it may imply dead gut somewhere
• biliary tree: gas will be in the centre of the liver, not emergency

• pain: HIGHER in the abdomen
• distension: less
• vomiting: earlier

• pain: constant
• AXR shows gas proximal to blockage but not in rectum unless PR done
• if ileocaecal valve is competent (i.e. doesn't allow reflux) then pain may be felt over distended caecum

• no pain
• just constipated
• bowel sounds absent

• sharper, more constant pain (not colicky)
• localised pain
• peritonism
• fever
• high WCC

• LBO & strangulation: surgery soon
• LBO, ileum: manage conservatively then may need surgery

• NGT: suck
• iv fluids: drop
• correct electrolyte abN
• NBM: rest the bowel

colonoscopy but risk perforation: gastrografin - LEVEL of obstruction. therapeutic action against mild mechanical obstruction

• LBO with tenderness over a grossly dilated caecum (>12cm needs urgent decompression)
• occurs when the ileocaecal valise remains competent despite bowel distension

water soluble enema to try to clear the obstruction and correct fluid imbalance

kidney

no

• PaO2 < 8kPa
• Age > 55
• Neutrophils: WBC >15
• Calcium < 2mmol/l
• Renal function: urea>16mmol/l
• Enzymes: LDH>600iu, AST>200iu/L
• Albumin>32g/l (serum)
• Sugars > 10mmol/l

UC

diverticular disease

sentinel mucosal tag externally

hard faeces makes defaecation v.painful and spasm of sphincter so constrict inferior rectal artery --> ischaemia and healing difficult

• hard faeces
• crohns
• syphilis
• Trauma
• anal cancer

• conservative: stool softeners, extra dietary roughage
• medical: GTN (SE headache, post hypo), calcium channel blocker diltiazem ointment
• injection: botulinum toxin
• surgical: lateral internal sphincterotomy

• crohn's
• TB
• diverticular disease
• start as perianal abscess: sepsis in anal gland - force out through canal to perianal skin or vaginal skin

• low: fistula does not cross the sphincter muscles above the dentate line
• high: fistula does cross the sphincter muscles above the dentate line

• rapid onset perianal pain
• skin: swollen, red
• systemic: fever, tachycardia

• 1. PR, perineum
• 2. EUA - probe through external opening of fistula to identify the tract and internal opening
• 3. end anal ultrasound with H202 if cant find tract with EUA
• 4. MRI
• 5. flexi sig: if suspect colorectal DISEASE e.g. crohns

• medical: antibiotics, anti inflame (if IBD)
• surgical: drain acute sepsis
• low fistula: lay OPEN track by putting metal probe into fistula and cut through tissue onto probe
• then remove all granulation tissue, allow to heal SPONTANEOUSLY (secondary intention) = FISTULOTOMY
• high fistula: SETON - large silk suture passed through fistula track and tied off on outside. TIGHTEN every 2 weeks so it cuts through to surface, with fistula healing by SCAR tissue behind it. cant lay open high fistula as will damage sphincters

• it determines the path of the fistula track between openings
• if anterior external opening: means fistula runs directly in a straight line into anal canal
• if posterior external opening: the internal opening is always at 6o'clock i.e. it curves to the posterior midline of the canal

spongy vascular cushions which line the anus and contribute to anal closure at 3, 7, 11 which are attached by smooth muscle and elastic tissue but are prone to displacement and disruption and can protrude to form piles

• effect of gravity (our erect posture)
• increased anal tone
• effects of straining at stool due to constipation
• all make the vascular cushions bulky and loose and so protrude to make piles

bright red, as blood loss is from capillaries of the underlying lamina propria.

• painless: no sensory fibres above dentate line (squamomucosal junction)
• painful: if they thrombose when they protrude and are gripped by the anal sphincter, blocking venous return

• constipation with prolonged straining
• congestion from a pelvic tumour, pregnancy, CCF, portal hypertension
• differential anal pain

• 3, 7, 11 oclock lithotomy position
• this is where the superior rectal vein branches enter the muscle

• the vascular cushions protrude through a TIGHT anus
• become more congested
• so hypertrophy again to protrude again more READILY
• the protrusions then strangulate as tight anus

• 1st degree: remain in rectum
• 2nd degree: prolapse through anus on defaecation but spontaneously reduce
• 3rd degree: prolapse through anus on defaecation but need manual digital reduction
• 4th degree: remain persistently prolapsed

• bright red rectal bleeding, coating stools or dripping into pain after defaecation
• mucous discharge
• pruritis ani
• severe anaemia
• mild incontinence of flatus as there is imperfect closure of anal cushions

• abdominal examination: rule out other disease
• PR exam: external, prolapsing haemorrhoids. cannot palpate internal
• proctoscopy: internal haemorroids
• sigmoidoscopy: rectal pathology up to rectosigmoid junction

• conservative: stool softener
• inject sclerosant: 5% phenol in almond oil injected into pile above dentate line. this shrinks the H and causes scar formation SE: impotence, prostatitis
• rubber band ligation: SE bleeding, infection. cheap but needs skill
• Infra red coagulation: coagulates vessels and tethers mucosa to subcut tissue
• haemorroidectomy: excision of piles and ligation of vascular pedicles. day case may need 2 wks off work. SE haemorrhage or stenosis
• pre-op: 1 wks lactulose and metronidazole reduces pain and time off work

• constipaton
• infection
• stricure
• bleed

• perianal haematoma: rupture of small vein that drains anus, may see blue tinge under skin
• anal fissure: tear in mucosa of anal canal
• abscess
• tumour

• 5q21
• autosomal dominant

pigmented lesions on lips

PROLONGED antibiotic use (not prophylaxis)

malignancy

palpable abdo mass

• obstructed infected kidney: pyonephrosis
• Ix: IVU or US
• Rx: urgent nephrostomy drainage

high pressure non relaxing LOS

faecoliths

• 1 diverticulitis: altered bowel habit LIF colic, pyrexa, high WCC, high CRP/ESR, localised or generalised peritonism. bed rest, NBM, iv fluids, analgesia, antibiotics
• 2 perforation: ileum, peritonitis +/- shock. may need laparotomy Hartmann's (temporary colostomy and partial colectomy).
• 3 form fistulae into adjacent structures: enterocolic, colovaginal, colovesical (pneumaturia, intractable UTI). Rx: colonic resection
• 4 bleed: sudden and painLESS. bleeding stops with berets. may need transfusion. Rx: embolisation/colonic resection after locate bleeding points by angio/colonoscopy. diathermy and local adrenaline injection prevent need for surgery
• 5 abscess: swinging fever, high WCC, may have localising signs. Rx: antibiotics, US drainage
• bowel obstruction

• FBC: anaemia due to malabsorption or bleeding
• colonoscopy: visualise colonic mucosa, transmural inflammation, granuloma,

diabetic

• low fibre: leads to high intraluminal pressures which force mucosa to herniate through muscle layers of the gut at weak points,
• adjacent to PENETRATING VESSELS

sigmoid colon

muscle atrophy so no muscular layer

• diverticular bleed
• angiodysplasia: submucosal AVM. but most in right colon. do mesenteric angiography to diagnose angiodysplasia as it shows early filling at the site of lesion, then extravasation. do therapeutic embolisation during active bleeding.

• high fibre diet: wholemeal bread, fruit veg
• antispasmodics: mebeverine

• initial: bowel rest, fluids only, co-amoxiclav/metronidazole/ciprofloxacin
• if oral fluids cannot be tolerated - admit:
• analgesia, NBM, iv fluids, iv antibiotics: cefuroxime and metronidazole
• imaging: ultrasound: perforation, free fluid, collections
• contrast CT: more accurate
• do NOT do colonoscopy in acute attack
• surgery: if peritonitis suppurative or faecal

• ABC resuscitaion (fluids, oxygen)
• History and examination
• Tests: FBC, LFT, U&E, clotting, amylase, CRP, group and save (NB await Hb before cross match unless unstable and bleeding)
• ABG
• Imaging: plain AXR, erect CXR if suspect signs of perforation (sepsis, peritonism) or cardioresp comorbidity, if angiodysplasia suspected then angiography
• Fluids: 2 cannulae. urinary catheter. crystalloid replacement and maintenance ivi. transfusion rarely needed
• Antibiotics: if suspect sepsis or perforation - cefuroxime, metronidazole
• PPI: omeprazole as 15% are UGI bleeds
• Bed bound: pt may feel need to get out to pass stool but this could be another large bleed - result in collapse if they try to walk (postural hypo). DONT ALLOW MOBILISE AND TELL NURSE
• Stool chart: volume and frequency of motions. sample for MC&S
• Diet: clear fluids, need clear colon for colonoscopy
• Surgery: only if unremitting, MASSIVE BLEEDING

• Diverticulosis
• Colorectal cancer
• Haemorrhoids
• Angiodysplasia
• IBD: UC or Crohn's
• Perianal disease

• adenocarcinoma of small bowel
• T cell lymphoma

• icterus
• oesophageal varices
• diabetes mellitus
• thrombophlebitis

tip of the right 9th costal cartilage i.e. where R rectus sheath crosses costal margin

• R shoulder tip (Kehr's sign)
• as GB inflammation or distension irritates diaphragm innervated by phrenic nerve C345 which also provide sensation to R shoulder tip by supraclav nerves C345.

• gastric artery
• splenic artery
• hepatic artery

splenic vein into portal vein