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Flashcards in Hepto / Gastro Deck (42):

Describe the ligaments of the liver

Flaciform ligament attaches the anterior liver to anterior abdo wall. Contains the ligamentum teres (remnant of the umbilical vein)

Coronary + Triangular Ligaments (L. + R.) attach superior liver to diaphragm

Hepatoduodenal + Hepatogastric ligament make up lesser omentum

Posterior surfrace of the liver attached to IVC by hepatic veins


Describe the hepatic recesses

Subphrenic recess (L. + R.) between diaphragm and liver divided by falciform ligament

Subhepatic recess between liver and transverse colon

Morison's pouch: part of R. subhepatic space near the kidney. Deepest aspect of the peritoneal cavity. Where fluid collection occurs when supine


Glisson's Capsule?

Fibrous layer surrounding the liver


Lobes of the liver

L. + R. lobe divided by falciform ligament

Caudate lobe: upper aspect of posterior liver between IVC and ligamentum venosum (fetal ductus venosus)

Quadrate lobe: lower aspect of posterior liver between gallbladder and ligamentum teres (fetal umbilical vein)


Porta Hepatis

Fissure between caudate and quadrate lobe transmitting all vessels, nerves and ducts to the liver


Describe microscopic structure of the liver

Hepatocytes arranged into lobules, hexagonal shapes with central vein at the centre. At each corner of the lobules lie 3 vessels called portal triad (Artery, Vein and Duct). Portal traid also carries lymp vessels and vagus nerve


Arterial and Venous Supply to the liver

Arteries: Common hepatic A. (from coeliac trunk) 


Hepatic Portal Vein Veins: 3 hepatic veins into IVC


Nerve supply to liver.

Hepatic plexus containing

Sympathetic fibres from coeliac plexus

Parasympathetic fibres from vagus nerve


When would you perform a percutaneous liver biopsy

Abnormal LFTs with unknown cause

Hep C. Autoimmune or Herdiatary liver conditions

Following liver transplant


What things are important during when taking a GI history

Abdo Pain (SOCRATES)

Swallowing – difficulty swallowing or painful swallow

Indigestion – do they get reflux following a meal or when lying down

Nausea and vomiting (all the time or when eating, drinking, taking pills)?

Haematemesis – blood in vomit

Bowel habits – change in bowel habit is the most important thing (Frequency, Constipation, diarrhoea)

Stools Consistency and colour (Blood, melaena or mucus present, Difficulty flushing (steatorrhea), Incontinence/Urgency)

Tenesmus – the feeling of incomplete emptying

Ask about recent travel – GI infection is a likely differential after foreign travel


What should you look for in a GI exam upon general examination

Items around bedside (sickbowl/drip/feed)

General wellbeing (obvious jaundice)


What should you look for in a GI exam upon hand examination

* Koilonychia (hypochromic anaemia, iron deficiency especially) * Leuconychia (hypoalbuminaemia) Clubbing  * Malabsorption / Crohn's and Ulcerative Colitis / Cirrhosis * Also think about lung disease and heart disease such as chronic hypoxia, interstitial lung disease, lung cancer, endocarditis Palmar erythema * Portal hypertension, chronic liver disease (hepatitis, cirrhosis), polycythaemia * Also think about thyrotoxicosis, rheumatoid arthritis, eczema, psoriasis Dupuytren's contracture * Excessive alcoholism and liver disease Asterixis (hepatic flap) * sign of encephalopathy caused by cirrhosis


What should you look for in a GI exam upon arm inspection

Petechiae (small red bruised patches) * may be present in liver cirrhosis Look for signs of IV drug abuse * Hepatitis * Signs of scratching (from pruritis which is common in jaundice)


What should you look for in a GI exam upon face inspection

Eyes * Sclerae for jaundice * Conjunctivae for anaemia Mouth * Angular stomatitis (indicative of iron deficiency) Glossitis (shiny, smooth tongue) * Iron deficiency or pernicious anaemia (B12 deficiency) Ulceration * Crohn's disease * Candidiasis Neck * JVP * Lymphadenopathy (especially in Virchow's node)


What should you look for in a GI exam upon abdo inspection

* Spider Naevi (cirrhosis) * Caput medusae (portal hypertension) * Stoma Bag


What should you look for when palpating the abdo?

* Distended + Tense (suggests ascites) * Tenderness + Rigidity (suggests peritonitis) * Masses * Size of spleen/liver * Ballot kidneys (tumour/PCKD/hydronephrosis) * Aorta (should be pulsatile + non expansile)


What should you look for in a GI exam upon percussion and asculatation of Abdo

* Dullness (mass) * Size of bladder (fluid retention) * Shifting dullness/Fluid thrill (ascities) Bowel sounds  * Absent/Tinkling suggest BO * Frequent bowel sounds may be present prior to blockage


How should you finish a GI exam

* Periperal oedema (ankles + sacrum) * Examination of hernial orifices + DRE + external genitalia * ECG in patients with abdo pain (MI reffered pain) Check Obs chart * Temp * Weight * Stools * Fluid/Food intake


Causes of RUQ pain?

* Gallstones * Cholangitis * Hepatitis * Liver abscess * Cardiac/Lung causes


Causes of LUQ pain?

* Splenic Abscess * Acute Splenomegaly * Splenic Rupture


Causes of Epigastric Pain?

* Esophagitis * Peptic Ulcer * Perforated Ulcer * Pancreatitis


Causes of L. / R. Flank Pain?

* Ureteric Colic * Pyelonephritis


Causes of Umbilical Pain?

* Early appedicitis * Mesenteric adenitis * Meckel's diverticulitis * Lymphoma


Causes of RIF pain?

* Late appendicitis  * Crohn's disease * Caecum obstruction * Ovarian Cyst * Ectopic Preg * Hernias


Cause of LIF pain?

* Diverticulitis * UC * Constipation * Ovarian Cyst * Hernias


Causes of Suprapubic Pain?

* Testicular torsion * Urinary Retention * Cystitis * Placental Abruption


Cause + RF for GORD

Cause * Lax osophageal sphincter * reduced osophaheal motility * reduced stomach emptying RFs * Smoking  * Alcohol * Pregnancy * NSAIDS * Hiatus Hernia


Signs of GORD?

Epigastric Buring Pain * Relieved by eating * Worse lying down * Dysphagia + Odynophagia


Complications of GORD

Barrett's osophagus * Treated with osophageal resection/ablation Osophageal Ulceration * Bleeding + Anemia * Hemoptasis Osophageal Stricture * Obstruction causing dysphagia * Osophagitis * Aspiration


What grading systems are used to asses GORD?

* Savary Miller (1-5) * LA grading (A-D)


Differential's for GORD

OsophagitisInfectionPeptic UlcerGI malignancyMIGallstonesNon-ulcer dyspepsia 


Investigations of GORD

Can start treatment imediatly if simple case Endoscopy * Assess degree of dysplasia in Barrett's * Differentiate between gastric ulceration Barium swallow * Hiatus hernia Oesophageal pH * Acid reflux Urea breath test * H. pylori infection


Treatment for GORD?

Lifestyle Modifications * Smoking cessation * Reduce Weight * Reduce alcohol * Sleep with pillows under head * More frequent smaller meals * Avoid Food/Drink 3 hours prior to sleep * Stop Precipitating Drugs Medications * PPIs (Lansoprazole/Omeprazole) H2 receptor antagonists (Ranitidine)


Causes of post-op ileus

* Bowel obstruction * Intestinal atrophy * Paralysis


Different types of enteral feeding

* NG tube * Nasojejunal tube * Percutaneous endogastric gastrostomy (PEG) * Jejunostomy tube


In colorectal cancer are men or women more likely to get the cancer in a) colon b) rectum

Men = rectumWomen = colon


Is colorectal cancer more common on the left or right side of the colon?



Which gene is most important and specific to colorectal cancer

APC Adenomatous polyposis coli


What is an ulcer

Persistant breach of the epithelial linning


Classification for colorectal cancer and describe it.

Dukes' classification:A: confined to wall of bowelB: through the wall of bowelC: involved lymph nodesD: distant metastases


Most common organ for colorectal metastasis

Liver via venous portal system and lungs.


3 most common cause of small bowel obstruction

HerniaAdhesions TumourForeign body