Cardiomyotomy (Heller’s procedure)
Surgical treatment of achalasia
Grey Turner’s sign?
Flank bruising (suggests retroperitoneal inflammation of bleeding, e.g. ruptured abdominal aneurysm, ruptured ectopic pregnancy, PANCREATITIS, or abdominal trauma)
Most common presentation of Meckel’s diverticulum?
Painless rectal bleeding
May present with “redcurrant jelly” stool on the nappy
Intussussception
Swirled mesentery on CT scan
Internal herniation of bowel
Diffuse distension throughout the small and large bowel
May occur following abdominal surgery
Can be caused by fracture of the thoracolumbar spine
Paralytic ileus (adynamic obstruction)
Recognised complications of diverticular disease?
Haemorrhage
Colocutaneous fistula
Pneumaturia
Linked with HLA-B8?
Coeliac
Where does pancreatic cancer usually arise from?
The head of the pancreas
-It is an adenocarcinoma
Most common cause of acute pancreatitis?
Gallstones and alcohol
Amylase levels to diagnose pancreatitis?
Pancreatitis diagnosed when amylase is five times the upper limit of normal
Recognised complications of ileostomies?
Dermatitis Renal calculi Gallstones Salt and water depletion Parastomal hernia (most common complication!)
What is GORD associated with?
Smoking, high alcohol intake, hiatus hernia, pregnancy, obesity, systemic sclerosis and tight clothes (lol)
Patients may complain of heartburn, an acid taste in mouth (acid brash), excess salivation (waterbrash), difficulty swallowing and nocturnal asthma?
GORD
A 35 year old housewife ahs notcied progressivley worsening difficulty swallowing over several years. She has been trouble by regurgitation of undigested food, halitosis and suffers from fits of coughing when lying flat
Achalasia
DIAGNOSIS MAY BE OBVIOUS ON CHEST RADIOGRAPH (wide mediastinum and shadow behind the heart)
- usually presents 30-40 years
- more common in women
- dysphagia gradually progresses over the years
- regurgitation of partially digested food
- halitosis
- foul eruption
- patients may aspirate = coughin
Plummer-Vinson syndrome
Iron-deficiency anaemia, angular chelitis and dysphagia due to a postcricoid oesophageal web
This condition is premalignant and should be biopsied
Cephalic phase of gastric acid secretion
Triggered by sight. smell, thought and taste of food
Stimulated by VAGUS nerve
Gastric phase of acid secretion
Most significant phase
Initiated by presence of food in the stomach, particularly protein rich food
Intestinal phase of gastric acid secretion
Least significant phase
The presence of amino acids and food in the duodenum stimulate acid production
Three factors which stimulate gastric acid secretion
Acetylcholine (from parasympathetic neurons of the vagus nerve that innervate parietal cells directly)
Gastrin (produced by pyloric G cells)
Histamine (produced by mast cells)
Which cells produce histamine?
Mast cells
Three factors which inhibit gastric acid secretion?
Somatostatin
Secretin
Cholecystokinin
What do ALP and GGT reflect?
Obstructive disease
Which organ synthesises vitamin K?
The liver
Kawasaki’s disease?
Acute systemic vasculitis, involving medium sized vessels, affecting mainly children under 5 years
- very frequent in Japan
- infective trigger suspected
-early diagnosis is crucial to prevent cardiac complications
Clinical features of Kawasaki’s disease
- Fever (lasts more than 5 days)
- Bilateral conjunctival congestion
- Dryness and redness of lips and oral cavity
- acute cervical lymphadenopathy
- Polymorphic rash
- Redness and oedema of palms and soles
A 3 year old boy is brought into the Emergency department with a 5 day history of fever and irritability, with red eyes and reduced eating for the last 24 hours. On examination he was noted to have dry cracked lips, mild conjunctivitis and cervical lymphadenopathy
Kawasaki’s disease
Treatment = IV immunoglobulin and aspirin
Barking cough, harsh stridor and hoarseness, usually preceded by fever and coryza
Croup
-symptoms often begin (and are worse) at night
(acute epiglottitis tends to have onset over hours, with no preceding coryza or cough. It will have drooling saliva and a soft stridor)
Treatment for infected chicken pox?
Flucloxacillin in conjunction with aciclovir
Mild dehydration
Few clinical signs of dehydration
-can be managed with oral rehydration solution for around 24 hours until vomiting and profuse diarrhoes subside
Moderate dehydration
5-10% body weight loss
-clinical signs of dehydration - thorsty, restless/lethargic, with reduced skin turgor, dry mucous membrane, rapid pulse, prolonged CRT, sunken eyes and anterior fontanelle
Managed with a trial of ORS but if no improvement, IV fluid should be given
Severe dehydration
> 10% body weight loss
Patients appear shocked, cold/drowsy and sweating with marked oliguria, rapid and weak pulse etc
IV fluid is indicated as an immediate resuscitation, and then subsequent rehydration allowing for deficit and ongoing fluid maintenance and losses
A 33 year old woman presents with severe abdominal pain radiating to the back. She is shocked and hyperventilating. There is no free gas on her erect chest x-ray. Opacity is noted at the level of the L1 vertebra
Pancreatitis
A 57 year old smoker presents with epigastric pain, sweating and is vomitting clear fluid. He has a ulse of 58bpm and a high JVP
MI
high JVP = right sided heart failure
A 43 year old man with MS presents with pulse of 120 and a rigid abdomen. He is apyrexial. There are no bowel sounds. He has recently completed a course of methylprednisolone
Perforated peptic ulcer
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 not he has a history of arthritis and hypertension
Bleeding peptic ulcer
Causes dysphagia for liquids more than solids
Oesophageal dysmotility
Dysphagia, regurgitation, cough, halitosis
Pharyngeal pouch
Caseating granuloma in Crohn’s or UC?
Crohn’s
Caseating granuloma in Crohn’s or UC?
Crohn’s
A 36 year old man is seen at outpatients clinic with the complaint of altered bowel habit. He reveals a 3 month history of increased frequency of motions of up to 8 times a day with PR blood on occasion. On examination he is tender on the left iliac fossa. He was unable to tolerate a PR examination. Liver funcion test at his GP surgery revealed a raised alkaline phosphatase (ALP)
Ulcerative colitis
A 36 year old man is seen at outpatients clinic with the complaint of altered bowel habit. He reveals a 3 month history of increased frequency of motions of up to 8 times a day with PR blood on occasion. On examination he is tender on the left iliac fossa. He was unable to tolerate a PR examination. Liver funcion test at his GP surgery revealed a raised alkaline phosphatase (ALP)
Ulcerative colitis
Condition associated with primary sclerosing cholangitis?
Ulcerative colitis
Condition associated with primary sclerosing cholangitis?
Ulcerative colitis
Antimitochondrial antibody
PBC
Anti-smooth muscle antibody
Chronic active hepatitis
Primary sclerosing cholangitis
Anti-endomysial, gliadin, transglutamase
Coeliac disease
Anti-gastric parietal cell and anti-intrinsic factor
Pernicious anaemia
Anti-dsDNA
SLE
Anti-dsDNA
SLE
Gastric/duodenal ulcers and acid production
Gastric ulcers are due to lowered mucosal resistance
Duodenal ulcers are associated with increased acid production
Which type of cancer increased risk in PSC?
Cholangiocarcinoma
Symptoms of PSC?
Deranged liver function tests, jaundice, itching, chronic fatigue
(ERCP or MRCP may show intrahepatic biliary duct stricture and dilatation, often with extrahepatic duct involvement)
Who is commonly affected by autoimmune hepatitis?
Middle aged females
Ascending cholangitis triad
Jaundice
Abdominal pain
Fever
Symptoms of NASH?
Most are asymptomatic but some report feelings of tiredness or epigastric fullness