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
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)
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