1. What are the drug causes of constipation?
    • opiates
    • aluminium hydroxide
    • iron
    • anticholinergics: tricyclics, phenothiazines
  2. name 3 anorectal causes of constipation
    • anal fissure
    • anal stricture
    • rectal prolapse
  3. what are general lifestyle causes of constipation?
    • poor diet
    • reduced fibre
    • reduced fluid intake or dehydration
    • low activity levels
    • IBS
    • old age
  4. name some hospital causes of constipation
    • post op pain
    • hospital environment: lack of privacy, having to use a bed pan
  5. name some causes of intestinal obstruction that will cause constipation
    • colorectal carcinoma
    • benign stricures: crohn's
    • diverticulosis
    • pelvic mass - fetus of fibroids (uterine aka leiomyoma)
    • pseudo obstruction
  6. what are the neuromuscular causes of constipation?
    • Hirschprung's disease
    • Chagas disease
    • Diabetic neuropathy
    • Systemic sclerosis
    • Spinal or pelvic injury - trauma or surgery
  7. what are the metabolic or endocrine causes of constipation?
    • hypothyroidism
    • hypercalcaemia
    • hypokalaemia
    • porphyria
    • lead poisoning
  8. how does carcinoma of the caecum usually present?
    • insidious way
    • microcytic anaemia
    • weight loss
    • ache or palpable mass in RIF
  9. what are typical features of IBS?
    • young patient
    • stress or dietary intolerance
    • alternating constipation and diarrhoea
    • cramp like abdo pains relieved by defaecation
    • abdo bloating
    • mucus PR
  10. how would you manage IBS? stepwise
    • 1. exclude other diagnosis: RBC, ESR, LFT, coeliac serology, urinalysis, sigmoidoscopy, rectal biopsy if YOUNG
    • 2. if over 45 and other marker of organic disease then do colonoscopy
    • 3. if diarrhoea prominent do LFT, stool culture, TFT, B12/folate, anti endomysial, barium follow through if small bowel disease, rectal biopsy
    • if IBS explain and reassure
    • food tolerance: exclusion diets
    • constipation: incerase fibre intake ispaghula, methylcullulose NB non fermentable fibre better as less gas and bloating (i.e. don't give lactulose)
    • diarrhoea: loperamide after each loose stool
    • colic and bloating: anti spasmodics - mebeverine
    • dyspeptic symptoms: metocloperamide or antacids
    • psychological: TCA amitriptyline may help but SE dry mouth, constipation..
  11. where is sigmoid volvulus more common? what diet?
    • equatorial countries
    • high fibre
  12. presentation of sigmoid volvulus?
    • pain
    • bloating
    • emergency sometimes
  13. what does plain AXR look like of sigmoid volvulus?
    large double colonic loop like COFFEE BEAN
  14. how do left sided colonic tumours present as opposed to R? why? 2 reasons
    • because L has more narrow calibre of colon
    • and more solid consistency of faeces as fluid has been absorbed
  15. what would AXR look like of sigmoid colon cancer?
    • gross faecal loading proximal to cancer
    • absence of bowel gas distally
  16. how does UC usually present?
    • 30s
    • chronic low grade illness
    • bloody diarrhoea
    • abdo pain
    • fever
    • extracolonic: arthritis, iritis, liver probs, rash
  17. how would you differentiate acute cholecystitis from biliary colic?
    • AC has fever, sometimes rigors, SEVERE RUQ pain, positive murphys sign
    • note if jaundice then must urgent US check GS in CBD as risk cholangitis
  18. An 83-year-old man presents following a collapse. He is not tachycardic but has a postural drop in blood pressure. He has mild epigastric discomfort. You note he has a history of arthritis and hypertension. diagnosis?
    • bleeding peptic ulcer
    • arthritis so on NSAID so bleed - hypovol - postural drop BP
    • why not tachycardic? as on a blockers for HTN
  19. what is the differential diagnosis for acute appendicitis?
    • appendicitis
    • PID or period (Mittelschmerz - painful ovulation in middle of cycle)
    • pancreatitis, perf peptic ulcer
    • ectopic pregnancy
    • neoplasia
    • diverticulitis
    • IBS
    • Cyst
    • IBD - crohns
    • Torsion ovary
    • Intussussception
    • Stone
  20. name 4 conditions or RF predispose to oesophageal cancer and why?
    • plummer vinson: IDA and oes web causing dysphagia its premalignant
    • achalasia: prolonged stasis contributes to mucosal changes
    • male
    • reflux oesophagitis: Barrett's oesophagus
  21. what are the complications of diverticular disease and how do they present?
    • haemorrhage: profuse bright red rectal bleed, NOT precipitated by defaecation
    • fistula due to per and abscess of inflamed diverticulum
    • skin fistula
    • bladder fistula: pneumaturia - air in urine
  22. what are pseudopolps and which disease are they a feature of?
    • areas of inflamed oedematous and swollen mucosa NEXT to the ulcerated areas of colon
    • ulcerative colitis
  23. name 3 conditions that cause fistula in ano?
    • Crohn's disease - confirm by biopsy
    • anorectal tumour
    • leukaemia patients have inc risk anorectal disorders esp. fissure in ano and fistula in ano
  24. what is the incidence of gastric adenocarcinoma like worldwide?
    • generally marked decrease in incidence (due to treating H pylori?)
    • but increase at GOJ (Barrett's?)
    • common in Japan
  25. what are the associations for gastric adenocarcinoma?
    • blood group A
    • lower social class
    • H pylori
    • atrophic gastritis
    • pernicious anaemia
    • adenomatous polyps
    • smoking
  26. name 3 pathological types of gastric adenocarcinoma:
    • polypoid
    • ulcerating
    • linitis plastic (leather bottle)
    • n.b. if confined to mucosa and submucosa then its 'early'
  27. what are the symptoms of gastric adenocarcinoma?
    • dyspepsia (above 50y and longer than 1 month)
    • dysphagia
    • weight loss
    • anaemia
    • vomiting
  28. what are the signs of gastric adenocarcinoma?
    • epigastric mass
    • Virchow's node: large left supraclav node (trosier's sign)
    • hepatomegaly - mets
    • jaundice
    • ascites
    • acanthosis nigricans
  29. spread of gastric adenocarcinoma?
    • local
    • lymphatic
    • blood
    • transcoelomic to ovaries = Krukenberg tumour
  30. investigations for gastric adenocarcinoma?
    • 1. gastroscopy and multiple biopsies around ulcer edge
    • NB malignant ulcers may appear to heal on drug treatment
    • 2. staging: EUS, CT, MRI
  31. treatment of gastric adenocarcinoma?
    • if tumour in distal 2/3: partial gastrectomy
    • proximal tumour: total gastrectomy
    • chemo:epirubicin, cisplatin, 5-FU
    • palliative: for obstruction, pain or haemorrhage
  32. what are the early complications of stomas?
    • haemorrhage at stoma site
    • dermatitis: effects of contents of stoma or due to contact dermatitis from allergy to adhesive appliance
    • high output: fluid and electrolyte loss esp. ileostomy
    • obstruction due to adhesions
    • stoma retraction
    • stoma ischaemia - change in colour to black
  33. what are the late complications of stomas?
    • parastomal hernia
    • psychological probs
    • prolapse of stoma
    • fistulae
    • dermatitis
    • renal calculi: high ileostomy losses - met acid and low urine volume
    • cholesterol GS: if loss of TI - interrupt enterohepatic circ of bile salts
  34. which part of the bowel does diverticular disease commonly affect?
    sigmoid colon
  35. what is the treatment for acute diverticular disease?
    • hospitalisation
    • rest
    • analgesia - avoid morphine as it increases muscle spasm
    • antibiotics: metronidazole
    • surgery rarely needed acutely
    • bleeding normally stops spontaneously and doesn't need treatment
  36. what are the complications of gastric surgery?
  37. which type of GS are associated with bacteria in the bile?
    pigment rather than cholesterol
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