01 CARDIOVASCULAR 01.08 03 GASTROINTESTINAL MEDICINE 04 NEUROLOGY 04.

13
• Deep vein thrombosis (DVT) & GENERAL SURGERY • Spinal disorders
01.01 • Pulmonary embolism (PE) 04.01 Headaches - Brown-sequard syndrome
• Acute coronary syndrome • Infective endocarditis 03.01 - Subacute combined degeneration
- STEMI, NSTEMI, unstable angina • Pericarditis • Gallbladder disorders 04.02 Neurodegenerative disorders - Friedrich's ataxia
- ECG cardiac territories • Constructive pericarditis - Acute cholecystitis • Dementias • Delirium - Anterior spinal artery occlusion
• Hypertension - Ascending cholangitis - Syringomyelia
- Antihypertensives 01.09 - PSC & PBC 04.03 Neurodegenerative – movement - Tabes dorsalis
• Cardiac tamponade • Liver cancers – hepatocellular disorders, incl Parkinson's, • Neurofibromatosis
01.02 • Antihypertensives (continued) carcinoma & cholangiocarcinoma Huntington's and motor neuron disease • Tuberous sclerosis
• Ischaemic heart disease • Other drugs (adenosine, amiodarone,
• Atrial fibrillation anti-platelets) 03.02 04.04 Infections 04.14
• Adult life support • DLVA rules on cardiovascular disorders • Alcohol-related liver disease • Bacterial & viral meningitis • Restless legs syndrome
• Wilson’s disease • Encephalitis • Abnormal involuntary movements
01.03 01.10 Vascular surgery • Haemochromatosis • Brain & spinal epidural abscesses • DLVA rules for neurological disorders
• Ventricular fibrillation • Peripheral arterial disease • Aphasia DDx
• Ventricular tachycardia • Aortic aneurysm 03.03 04.05 Infections • Wernicke's encephalopathy
• Bradycardia: peri-arrest • Aortic dissection • Hepatitis A, B, C, E • Specific infxns: toxoplasmosis, primary • Charcot-Marie-Tooth syndrome

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• Tachycardia: peri-arrest • Varicose veins • Autoimmune hepatitis CNS lymphoma, cryptococcosis, PML
• Pacemakers • Lower leg ulcers • Non-alcoholic fatty liver disease • Glasgow Coma Scale (GCS)
05 OPHTHALMOLOGY
• Cardiac enzymes • Ankle-brachial pressure index (ABPI) • CSF interpretation table
03.04 05.01 Blindness
01.04 • Paracetamol overdose 04.06 Epilepsy / seizures
• Retinal detachment
• Electrocardiogram (ECG) 02 RESPIRATORY • Disorders of the pancreas • Seizures, incl status epilepticus
• Retinal artery & vein occlusion
• Arrhythmias, including Wolff-Parkinson- - Acute & chronic pancreatitis • Psychogenic non-epileptic seizures
• Retinal migraine
White syndrome, Wellen's syndrome, 02.01 - Pancreatic cancer • Anticonvulsants / antiepileptics
• Giant cell arteritis • Optic neuritis
junctional escape rhythm • Asthma • COPD - Neuroendocrine tumours
• Papilloedema
• Respiratory failure • Small bowel bacterial overgrowth 04.07
• Vitreous haemorrhage
01.05 syndrome • Syncope
• DDx – loss of colour vision
• Long QT syndrome 02.02 • Brain tumours
• DDx – blurred vision
• Short QT syndrome • Lung cancers 03.05 • IBD – Crohn's & UC • Brain lesions localisation (smx)
• Brugada syndrome • Mesothelioma • Coeliac disease 05.02 Red eye
• Atrial flutter • Bronchiectasis 04.08 Strokes
• Glaucoma – closed-angle
• Shock (÷ different types) • Idiopathic pulmonary fibrosis 03.06 • TIA & ischaemic stroke
• Anterior uveitis
• Appendicitis - Classifications by arteries, smx
• Episcleritis & scleritis
01.06 02.03 • Small & large bowel obstructions • Haemorrhagic stroke • Keratitis
• Valve disorders – mitral stenosis, mitral • Pneumonia – CAP + HAP • Hernias • Common meds in ophthalmology
regurg, aortic stenosis, aortic regurg - In immunocompromised patients 04.09 Brain bleeds
• Conjunctivitis (on 05.03)
• Murmurs (DDx) • Tuberculosis 03.07 • Subarachnoid haemorrhage
• Rheumatic fever • Anal fissures & fistulae, haemorrhoids • Subdural & extradural haemorrhage
05.03 External eye problems
• Prosthetic heart valves 02.04 • Colorectal cancer • Cerebral aneurysm
• Blepharitis • Blepharospasm
• Pulses (different types, eg pulsus • Sarcoidosis
• Ectropion & entropion
paradoxus) • Pneumothorax 03.08 04.10 Weakness DDx
• Pingucela • Hordeolum / stye
• Heart sounds • Pleural effusions • GORD, gastritis, peptic ulcer disease • Ophthalmic shingles
• Cystic fibrosis • Oesophageal conditions 04.11 Neuroinflammatory disorders
01.07 • Oxygen therapy • ERCP, TIPS • Multiple sclerosis
05.04 Age-related conditions
• Hypertrophic obstructive • Guillain Barre syndrome • Glaucoma – open-angle
cardiomyopathy (HoCM / HCM) 03.09 – Upper & lower GI bleeding • Chronic inflammatory demyelinating
• Age-related macular degeneration
• Arrhythmogenic right ventricular (poly)neuropathy
• Cataracts
cardiomyopathy (ARVC) 03.10 • Myasthenia gravis
• Diabetic neuropathy
• Dilated cardiomyopathy • Irritable bowel syndrome (IBS) • Orbital & periorbital celluitis
• Chronic heart failure • Diverticular disease 04.12
• Ischaemic bowel disease • CT head – indications
05.05 • Thyroid eye disease
• Abdominal pain DDx • Head injury
• Strabismus / squints
• Intracranial pressure – ↑ &↓
• Pupil problems
3a – Primer on anaesthetics
• Tropical eye diseases
• General anaesthesia & airway adjuncts
• Regiona/local anaesthesia
• Post-op nausea & vomiting
Acute cholecystitis Primary sclerosing cholangitis Primary biliary cholangitis Hepatocellular carcinoma Cholangiocarcinoma

D: acute inflammation of the gall bladder D: chronic, progressive, cholestatic liver D: chronic disease of the small D: aka hepatoma. Primary cancer arising D: aka biliary tree cancer; cancer
("cystits") disease. Characterised by inflammation intrahepatic bile ducts that is from hepatocytes in predominantly arising from the bile duct epithelium
and fibrosis of the bile ducts, causing characterised by progressive bile duct cirrhotic liver ÷ intrahepatic or extrahepatic
R: gallstones, severe illness, TPN, DM
multi-focal stricture formation. damage (and eventual loss) occurring in • 3rd most common cause of cancer
A: 90% gallstones the context of chronic portal tract worldwide R: >50yo, cholangitis (esp primary
P: obstruction causes acute inflammation inflammation sclerosing cholangitis), other bile duct
R: male (2:1), IBD (75%, typically UC),
of the gallbladder problems
❗️ genetics R: cirrhosis, chronic HBV (most common
jaundice does not normally occur ∵ R: female (10:1), >45yo, PMH or FHx of cause worldwide), HCV (most common in
bile can still pass into the cystic ducts autoimmune disorders Europe), ↑alcohol use, DM, obesity, FHx

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A/P: >95% are adenocarcinomas; most
- only occurs in Mirizzi's syndrome where A/P: likely immune related. Inflammation
are infiltrating nodular or diffusely
gallbladder inflammation ↑pressure on
and injury of medium and large bile
ducts → strictures → fibrosis → bile A/P: autoimmune disease – A/P: chronic inflammation and cirrhosis; infiltrating
contiguous biliary ducts
stasis → stones and liver damage antimitochondrial abs (95%). any condition leading to cirrhosis is thus
S/Smx: RUQ pain and tenderness, (1) biliary epithelial cells damaged and a risk factor S/smx:
Murphy's +ve, palpable mass (rare), s/smx destroyed + (2) chronic portal tract • Persistent biliary colic smx
of inflammation S/smx: abd pain, pruritis, fatigue, wt loss, inflammation → bile stasis, fibrosis, S/smx: tends to present late :( • A/w anorexia, jaundice, wt loss
fever, jaundice. Also steatorrhea, cirrhosis • Palpable mass in RUQ
Ix: labs – LFT usually normal • Cirrhosis: jaundice, ascites, RUQ pain,
☝🏻 US ✌🏻 MRCP ± ERCP
splenomegaly, ascites, encephalopathy
S: abd pain, pruritis, fatigue, wt loss,
hepatomegaly, pruritus, splenomegaly
- may present decompensated
• ± Sister Mary Joseph nodes (periumbili-
cal lymph node) and Virchow nodes
Mx: IV abx, then elective early lap chole Ix: LFTs (ALP, GGT, AST, ALT, bilirubin, fever, jaundice. Also steatorrhea, • raised AFP (left supra-clavicular node)
(w/in 1w). If not fit for surgery, long-term albumin), FBC, PT, antibodies, abd US, splenomegaly, ascites, encephalopathy • Raised Ca19-9 levels - useful for
ursodeoxycholic acid MRCP, ERCP, CT. **imaging is essential detecting cholangiocarcinoma in pts
Ix: screening with US (± AFP) should be
for Dx – strictures. ** p-ANCA Ix: LFTs, FBC, PT, antibodies, MRCP, with PSC
considered for high risk groups (pts with
Ascending cholangitis liver biopsy. antimitochondrial abs existing cirrhosis)
Mx of early disease Ix: LFTs, Ca19-9, CEA, Ca-125,
D: acute, ascending inflammation of the • Conservative: lifestyle ∆ Dx based on Mx: abdominal US, CT/MRI
biliary tree - Mx of pruritus (1) cholestatic LFTs • early disease: surgical resection
- Mx of hepatic osteopenia – Cal+D, (2) auto-abs – antimitochondrial abs or • liver transplantation Mx: • Surgery if resectable
R: >50yo, gallstones, benign or malignant bisphosphonate, HRT PBC-characteristic ANA • radiofrequency ablation • If unresectable, liver transplant ±
stricture, post-procedure injury of bile ducts - ERCP and balloon dilation of stricture (3) compatible or diagnostic liver • transarterial chemoembolisation chemo/radiotherapy if possible
(eg ERCP), hx of 1' or 2' sclerosing • End stage liver disease: liver transplant histology on biopsy – +ve for classic • sorafenib: multikinase inhibitor • Palliation if extensive disease
cholangitis
bile duct lesions, portal tract
A: gallstones stuck in the biliary tree, and Hepatic osteopenia arises due to inflammation, granuloma formation P: 5y survival for symptomatic HCC is 0-
biliary obstruction impairment of bile function → ↓abs of 10% - very aggressive tumour. For all, 5y
Origins of secondary liver tumours
fat soluble vitamins, incl Vit D Common in men: stomach, lung, colon
P: then causes bacterial seeding in the Mx: ursodeoxycholic acid [bile acid survival is 20% Common in women:
gallbladder + sludge formation analogue; ↓chol saturation of bile] &/or breast, colon, stomach, uterus
→ haematogenous spread can lead to P: high risk of cirrhosis and attendant obeticholic acid. See also general Mx of Less common in either: pancreas,
sepsis too problems, cholangiocarcinoma, other PSC. leukemia, lymphoma, carcinoid tumours
S/smx: Charcot's triad – fever, RUQ pain, cancers and osteoporosis. ↑morbidity -
jaundice / Reynolds' pentad (+ shock, median survival from time of Dx to death Mx of pruritus
altered mental stasis) or liver transplant is 7-14y. Can recur in ☝🏻 colestyramine [bile acid seques- Primary liver tumours
Ix: labs – ↑ inflammation, ∆ LFTs (stasis
10-20% of pts post-transplant. trant, ↑excretion of bile] **bad taste
☝🏻 ✌🏻 naltrexone, rifampin
❌
picture). US Benign • Cysts
Malignant - regardless of type, prognosis
avoid antihistamines ∵ no effect • Haemangioma (common; F>M 5:1)
Mx: IV abx, resus, then ERCP w/in 24-48h is poor
to relieve obstruction • HCC • Cholangiocarcinoma • Adenoma (common; tx only if smx
P: ↑risk of mortality from liver and non- • Angiosarcoma or >5cm)
liver related causes (?linked to inflam). • Hepatoblastoma • Focal nodular hyperplasia
Biliary colic: spasmodic pain that arises Acalculous cholecystitis ↓QoL – itch and fatigue. Disease itself • Fibrosarcoma • Fibroma
from contraction of the gallbladder or • D: gallbladder inflam with no gallstones may progress slowly and pt may not • Hepatic GIST • Benign GIST (=leiomyoma)
biliary ducts around gallstones • A/w ongoing illness (eg DM, organ suffer heavily from it
• "Fat, female, fertile and in their forties" failure)
• Pt is systemically well, but this can • S/smx: pt is more unwell than in normal
progress to acute cholecystitis cholecystitis – high fever, shock
• Eventually will require cholecystectomy to • Mx: cholecystectomy
manage root cause

03.01 GI / GS – Liver: Gall bladder, Cancers

03.02 GI / GS – Liver: ALD, Wilson’s, Haemochromatosis

Alcohol-related liver disease Varices + bleeding Alcohol withdrawal Wilson's disease Copper Haemochromatosis Iron
• 2/2 portal hypertension, causing
distention of oesophageal veins, Smx are brought on by abstinence from
D: liver damage caused by chronic heavy
alcohol intake. 3 stages: steatosis,
↑bleeding, ↑risk of death alcohol in a person with alcohol
D: autosomal recessive disorder of
excessive copper deposition
D: autosomal recessive disorder.
dysregulated dietary iron absorption and
alcoholic hepatitis (inflammation & dependence. Characterised by increased iron release from
Mx • Prophylaxis: β-blocker, band overactivity of the sympathetic
necrosis), and alcoholic liver cirrhosis R: ATP7B gene mutation, FHx macrophages
ligation, TIPSS nervous system
R: ↑alc use, hep C, female (most cases
• Acute: - ABCDE + resus • Chronic alcohol use → ↑regulation R: middle age, M>F, Caucasian (1:10
are male, but F tolerance for alc is lower)
- Correct clotting (FFP, platelets, etc) of NMDA receptors, ↓regulation of A/P: ATP7B encodes a metal P-type
carry mutation; 1:200 prevalence – more
- Terlipressin (2nd line: octreotide) GABA receptors. ATPase for trans-membrane transport of
- Prophylactic abx – quinolones • ↓blood ethanol conc → imbalance Cu within hepatocytes. No protein → common than CF), FHx
↓excretion from liver + copper overload

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A/P: upregulation of alcohol and acetal- - Endoscopy ± band ligation, between stimulatory NMDA and
aldehyde dehydrogenase which reduce Sengstaken-Blakemore tube, TIPSS in hepatocytes + overflow into circulation A/P: HFE gene mutation (chr 6) →
inhibitory GABA systems in the CNS
NAD to NADH → ↑NADH:NAD inhibits • Excessive stimulatory effect leads or organs ↑absorption of Fe
gluconeogenesis and ↑fatty acid Ascites to development of clinical s/smx of
oxidation → fatty infiltration in liver. = abnormal collection of fluid in the alcohol withdrawal S/smx 2/2 Cu deposition in organs: S/smx:
upgregulation of CYP2E1 generates abdomen • onset 10-25yo – children usually liver • early smx: fatigue, erectile dysfunction
more free radicals.↑TNF-a and ↑ ROS in • in ArLD, this is 2/2 portal HTN Dx is usually clinical (Hx, O/E) disease, adolescents psychiatric and arthralgia (often of the hands)
mitochondria of Kupffer cells. Inflamm rxn • Smx start at 6-12h, usually autonomic • Liver: hepatitis, cirrhosis • 'bronze' skin pigmentation
drives liver damage. Mx • ↓dietary Na ± fluid restriction smx eg tremor, sweating, ↑HR, anxiety • Neurological • diabetes mellitus
• Aldosterone antagonists, eg • Seizures – peak incidence at 36h - basal ganglia degeneration • liver: stigmata of chronic liver disease
S/Smx: • May be asmx until spironolactone ± loop diuretics • Delirium tremens - speech, behavioural, psychiatric hepatomegaly, cirrhosis, hepatocellular
decompensation (body cannot cope • Drainage of tense ascites - peak incidence at 48-72h problems (eg depression, mania, etc) deposition)
with liver damage anymore) - for large volume paracentesis, IV - coarse tremor, confusion, delusions, - asterixis, chorea, dementia, • cardiac failure (2/2 dilated
• Abdominal pain, hepatomegaly albumin required to prevent circulatory auditory and visual hallucinations, parkinsonism cardiomyopathy)
• Decompensated liver disease dysfunction and death fever, ↑HR • Kayser-Fleischer rings (50% in all, 90% • hypogonadism (2/2 cirrhosis and
- haemetemesis - melena • Prophylactic PO ciprofloxacin to in those with neuro issues) pituitary dysfunction – hypogonado-
- venous collaterals (eg spider naevi) prevent spontaneous bacterial Glasgow modified alcohol withdrawal • Renal tubular acidosis (esp Fanconi trophic hypogonadism)
- splenomegaly - jaundice peritonitis (in some pts) scale (GMAWS) - 0, 1 or 2 pts for each syndrome) Complications
- palmar erythema - asterexis • Consider TIPSS • Tremor • Sweating • Haemolysis • Blue nails • Reversible: cardiomyopathy, skin
- ascites - hepatic encephalopathy • Hallucinations • Orientation pigmentation
Hepatic encephalopathy • Agitation Ix: • Eyes: slit-lamp • Irreversible: cirrhosis, DM, hypogona-
Ix: LFTs, FBC, U&Es (+Mg, PO4), • neuropsychiatric syndrome caused • ↓ serum caeruplasmin dism, arthropathy
clotting, hepatic US. Consider ammonia, by acute or chronic advanced hepatic Clinical institute withdrawal assessment • ↓ total serum copper
folate, viral hep serology, liver biopsy. insufficiency – likely due to excess of alcohol, revised (CIWA-Ar) scale is • ↑ 24h urinary Cu excretion Ix: • Iron studies
- ↑transferrin saturation >50-55%
ammonia & glutamine more detailed; max 67 points • Dx confirmed by genetic analysis
• AST:ALT >2 in 70% of cases • metabolic encephalopathy (↑NH4), - probably better for delirium tremens
- ↑ferritin (can be normal early on)
• ↑ALP & GGT – a/w cholestasis brain atrophy and/or brain oedema Mx: • ☝🏻 penicillamine (chelates Cu) - ↓TIBC (∵ no more capacity)
• ↓Na in advanced ALD; ↓K, ↓Mg –
muscle weakness; ↓Mg can cause Grade 1 (early smx)
Mx (if GMAWS ≥2 or CIWA-Ar ≥10)
• Admit under medics if complex
•✌🏻 trientine hydrochloride • Genetic testing (for HFE mutation),
• ?? tetrathiomolybdate (new) • Others: LFTs, biopsy
withdrawals (DT, seizures, etc)
persistent hypoK, predisposing to
seizures during alcohol withdrawal
• Trivial lack of awareness
• Sleep rhythm alterations •☝🏻 chlordiazepoxide or diazepam
Mx: ☝🏻venesection – tailored to
(long-acting benzodiazepine)
• Shortened attention span
✌🏻
- lorazepam if liver failure ↓transferrin <50%, ferritin <50µg/L
✌🏻
Complications: hepatic encephalopathy,
portal HTN (+esophageal varices), GI
• Impaired addition/subtraction
• Euphoria or anxiety - ?irritable ✌🏻
- carbamazepine
Spontaneous bacterial peritonitis
• D: peritonitis occuring in patients with
desferrioxamine
• Thiamine (or Pabrinex) to prevent
bleeds, coagulopathy, renal failure, ascites 2/2 liver cirrhosis
G2 • Confusion and inappropriate Wernicke's or Korsakoff
hepatorenal syndrome, sepsis - Most commonly caused by E. coli
behaviour • S/smx: ascites, abdo pain, fever
Alcoholic hepatitis G3 • Incoherent and restless Hepatorenal syndrome: kidneys • Dx/Ix: paracentesis (neutrophil count
= acute episodes of inflammation G4 • Coma ↓↓blood flow distribution in response to >250 cells/µL + culture)
• S/smx: rapid onset of jaundice, the altered blood flow in the liver, which • Mx: ☝🏻 IV cefotaxime
Mx • Tx underlying cause (eg infxn) ↓MAP due to extreme vasodilation
☝🏻
malaise, tender hepatomegaly, etc • Prophylaxis with PO ciprofloxacin or
• Ix: AST:ALT >2 • Lactulose (↑excretion of NH4) + norfloxacin if
• Mx: glucocorticoids rifaximin (↓NH4 production – 2ndary - Previous episode of SBP
- Maddrey's discriminant function used prophylaxis) - Fluid protein <15 g/L and Child-Pugh
to determine who will benefit score ≥9 or hepatorenal syndrome
✌🏻
- Pentoxyphylline
Hepatitis A Hepatitis B Hepatitis C Autoimmune hepatitis Non-alcoholic fatty liver
disease (NAFLD)
D: liver infection caused by HBA. HBA is D: liver infection caused by HBV. HBV is D: liver infection caused by HBC. HCV is D: Chronic inflammatory disease of the
an RNA virus transmitted by the faecal- a dsDNA virus transmitted by blood, an RNA virus transmitted by blood, liver of unknown aetiology D: spectrum of liver disease –
oral route. sexual activity or vertically. sexual activity or vertically. Chronic infxn • Type I: ANA &/or anti-smooth muscle macrovesicular hepatic steatosis with no
≥6mo of persistent serum HCV RNA. abs – affects both adults & children excessive alcohol intake
R: travel to endemic areas, consumption R: perinatal exposure, high risk sexual • Type II: Anti-liver/kidney microsomal • Steatosis = fat in the liver
of contaminated food/water, MSM, IVDU, behaviours, IVDU, birth in endemic R: needle stick injury (2% transmission), type 1 antibodies – affects children only • Steatohepatitis = fat + inflammation
childcare centre region, FHx, hx of incarceration perinatal exposure (6%, ↑risk if +HIV), • Type III: Soluble liver-kidney antigen – = non-alcoholic steatohepatitis (NASH)
high risk sexual behaviours (~5%), IVDU, affects adults in middle-age - Fibrosis, cirrhosis
A/P: virus replicates in hepatocytes, A/P: liver damage likely 2/2 host's heavy alcohol use, HIV, incarceration

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cellular damage may be mediated by immune response to viral antigens. no vaccination available!! R: F>M, genetic pre-disposition (HLA B8, R: obesity, insulin resistance or T2DM,
Th1. DR3), other autoimmune disorders dyslipidaemia, HTN, metabolic syn, rapid
A/P: majority of pts fail to clear virus, wt loss, hepatotoxic meds, TPN
S/Smx: • Incubation 6-20w a/w: pernicious anaemia, UC, glomerulo-
S/Smx: • onset ~2-4w after infxn which may lead to progressive liver
• May be asymptomatic nephritis, autoimmune thyroiditis,
• Prodromal illness (fever, NV, bowel ∆, • Acute episode: fever, jaundice, ↑LFTs damage. Hepatic inflammation and autoimmune haemolysis, DM, PSC A/P: insulin resistance → ↑excessive
flu-like smx, etc) before jaundice • Long-term complications fibrosis due to inflammatory reaction triglyceride in liver → hepatic steatosis.
• Hepatomegaly & RUQ pain in 70-80% - Chronic hepatitis (5-10%) 2nd hit or oxidative injury triggers
S/Smx: • Incubation 6-9w S/smx:
of symptomatic pts - Fulminant liver failure (1%) inflammatory reaction and fibrosis.
• S/smx of chronic liver disease
• Clay coloured stools - HCC - Glomerulonephritis • 30% develop symptoms in acute
episode: flu-like illness, jaundice, ↑LFTs
• Acute hepatitis: fever, jaundice etc
- Polyarteritis nodosa (only 25% present in this way) S/Smx: • Usually asymptomatic
Ix: LFTs (AST, ALT, bilirubin), U&E, PT, • Fulminant hepatic failure very rare, but
- Cyroglobulinaemia • Amenorrhoea in F (common) • Hepatomegaly ± ?non-specific smx
IgM anti-HAV. Consider PCR would present with decompensation
• If fibrosis/cirrhosis develops: jaundice,
• Chronic hepatitis C (55-85%)
Ix: LFTs, FBC, U&Es, coag profile, HBV - Arthralgia, arthritis - Sjogren's Ix: ANA/SMA/LKM1 antibodies, ↑IgG portal hypertension, etc
Mx: • Confirmed infxn: supportive bloods. If more severe liver damage - Cirrhosis (5-20%) - HCC • Liver biopsy: inflammation extending
symptomatic care (eg paracetamol, expected, US, CT and biopsy - Cryoglobulinaemia beyond limiting plate 'piecemeal Ix: LFTs, FBC, metabolic panel, lipid
metoclopramide, chlorpheniramine, etc) - Chronic hepatitis: ground-glass - Porphyria cutanea tarda necrosis', bridging necrosis panel, clotting, albumin, iron studies –
• Avoid alcohol, avoid work/school until hepatocytes on histology - Glomerulonephritis mainly as baseline
not infectious (~7d after smx onset) Mx: steroids, other immunosuppressants, • Enhanced liver fibrosis (ELF) blood
• Ensure good hygiene to ↓spread Mx: pegylated interferon-α, antivirals, Ix: HCV antibody enzyme immunoassay, liver transplantation test to check for advanced fibrosis
• Vaccination only for those at high risk
(single dose + booster 6-12mo after)
❗️
liver transplant. IMMUNISATION PCR, LFTs. Consider testing for co-infxns - Hyaluronic acid, procollagen III, tissue
(HBV, HIV) inhibitor of metalloproteinase 1
- Travel to endemic areas • If ELF unavailable, FIB4 score or
- Chronic liver disease (eg hep B/C) C/P: 95% of immunocompetent pts with
Mx: • acute & chronic infxn Mx same NAFLD fibrosis score may be used
- Haemophiliacs receiving platelets acute infxn will achieve seroconversion in
– start on antivirals asap • Fibroscan (transient elastography –
- IVDU - MSM - (others) absence of tx. Rarely, liver failure,
• Monitor bloods (FBC, metabolics, how bouncy the liver is)
cirrhosis. Hepatocellular carcinoma
(HBV accounts for 50% of cases BCG) at 4w while on antivirals (esp
P: 85% have full recovery w/in 3mo, rivabarin) AST, ALT >1-4x ULN. ↑ALT more
worldwide).
nearly all recover w/in 6mo. In 10-20% of • Sustained virologic response = than AST. AST:ALT <1
smx pts, prolonged course possible. undetectable HCV RNA ≥12w after tx
Fulminant course very rare Hep B tests Mx: • Lifestyle modification – wt loss
completion
• If ongoing infxn, monitor for progression • Tx insulin resistance, hyperlipid.
HBsAg: acute infxn + infectious • Vit E a/w improved clinical outcomes
of liver disease
HBsAb/anti-HBs: protected against • No evidence for ursodeoxycholic acid
Hepatitis E
infxn [previous infxn or vaccinated] • Severe disease may require TIPS and
P: 10y survival 79%. Among pts who
Hep E - faecal-oral route, esp
→ HBs is given as vaccination, so if pt develop cirrhosis, decompensation
liver transplant
is +ve for only HBsAb = vaccination occurs in 30% at 10y. Higher morbidity
contaminated water. Usually self-limiting P: • "bland" steatosis – good prognosis,
infxn, resolves w/in 2-6w. Flu-like smx, than HIV, but possibly due to lifestyle
HBcAb: previous or current infxn stable disease.
abd pain, jaundice, itching, rash, joint issues rather than HCV infxn.
• NASH progressive, esp with comorbi-
pain, slight hepatomegaly. Rarely IgM anti-HBc: acute infxn dities (DM, high BMI) – 9 to 20%
fulminant hepatitis. Supportive care. IgG anti-HBc: past infxn Child-Pugh scoring MELD formula
progress to cirrhosis
• Bilirubin • Bilirubiun
• Albumin • Creatinine
Infxn with Hep D can only occur with • Prothrombin time • INR
current Hep B infxn. • Encephalopathy
• Ascites
03.03 GI / GS – Liver: Hepatitis
03.04 GI / GS – Paracetamol OD, Pancreas

Paracetamol overdose Acute pancreatitis Chronic pancreatitis Pancreatic cancer Neuroendocrine tumours

1. Time of overdose D: disorder of the exocrine pancreas, a/w D: Recurrent or persistent pancreatic D: primary pancreatic ductal adeno- Aka carcinoid tumours
2. Amount ingested acinar cell injury with local and systemic inflammation, resulting in scarring and carcinoma (>90% of pancreatic cancers) • Secretory NETs that release serotonin,
3. Weigh pt → ≥40kg vs <40kg inflammatory responses. loss of function. ÷ 4 types: recurrent kinins, and other vasoactive peptides
↳ <40kg - look up Toxbase acute, idiopathic, chronic relapsing, or R: smoking, FHx, other hereditary cancer • Carcinoid syndrome develops only in
4. Calculate mg/kg R: middle-aged, gallstones, alcohol, established chronic syndromes (eg Peutz-Jeghers, HNPCC, 40% pts with NETs
hypertrigly, drugs (azathioprine, BRCA2, KRAS gene mutation), • If NETs metastasise to the liver, 95% of
Staggered OD (taken over ≥1h) thiazides, furosemide), ERCP, trauma, R: >75% a/w chronic alcohol use. pancreatitis, DM pts will have smx
• start SNAP protocol stat SLE, Sjogren's. Others: smoking, FHx, coeliac

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• send bloods 4h after last ingestion A/P: 65% head of pancreas, 15% body, R: MEN1, ~50yo A/P: unknown
0-4h A/P: [I GET SMASHED] - idiopathic, 10% tail, 10% multifocal. LN mets
A/P: Alcohol, CF, haemochromatosis, or
• If <1h, consider activated charcoal gallstones, ethanol, trauma, steroids, ductal obstruction (incl anatomical common, also perineural and vascular S/smx (Carcinoid syndrome):
if pt has no acute smx mumps, autoimmune, scorpion sting, invasion. Distant mets usually found in • "B-FDR": bronchospasm, flushing,
anomalies such as annular pancreas)
repeated inflammation → collagen
• Send bloods 4h after last ingestion hyperlipidaemia, ERCP, drugs (see below) liver, lung, skin and brain diarrhoea, right heart valvular stenosis
• If bloods ≥100 mg/L paracetamol at 4h, deposits, fibrosis, pain, etc • Hypotension
start SNAP S/Smx: • severe epigastric pain radiating • Other molecules such as ACTH and
S/smx:
4-8h • Send bloods stat to back (stabbing pain, worsens on GHRH may also be secreted
S/Smx: • abdo pain – epigastric, dull, • classically, painless jaundice
• Start SNAP stat if bloods not likely to movement; pt may be in fetal position)
• A/w NV, abdo tenderness, systemically radiates to back, ↓by sitting forwards, + pale stools, dark urine, pruritus - Cushing's may develop
return in 8h • Hepatomegaly, gb mass (Courvoisier's • Pellagra can rarely develop as dietary
unwell (possible shock) worsens ~30min after eating
• When bloods return, continue SNAP if law = painless obstructive jaundice), tryptophan is diverted to serotonin by
above tx line • jaundice • steatorrhea
epigastric mass the tumour
Haemorrhagic pancreatitis: ecchymotic • ± wt loss (∵ fear of food causing pain)
8-24h • Send bloods immediately
bruising (1%) Cullen's (periumbilical), • malnutrition • NV • bloating • Non-specific smx: anorexia, wt loss
• Start SNAP immediately if >150mg/kg
Grey-Turner's (flanks), Fox's (inguinal lig) • DM (~20y after smx begin) • Loss of exocrine function eg Ix: U&Es, VIP radioimmunoassay, LFTs,
ingested
steatorrhea urinary 5-HIAA, plasma chromogranin A
• When bloods return, continue SNAP if • Loss of endocrine function, eg DM
Dx confirmation (≥2 of 3):
above tx line Ix: AXR (pancreatic calcification in 30%),
• upper abdo pain • Atypical back pain Mx: somatostatin analogues (octreotide),
CT, functional tests (faecal elastase to Ax
• ↑lipase or amylase 3x ULN
>24h • Send bloods immediately
• Migratory thrombophlebitis (Trousseau cyproheptadine (for diarrhea), PERT, etc
• Start SNAP if jaundice or hepatic exocrine function if inconclusive)
- Amylase 90% sens for pancreatitis sign), which can lead to DVT/PE
tenderness +ve
- Lipase more sens/spec but often less
• When bloods return, start SNAP if Mx: • Stop alcohol and smoking
available; longer half-life – useful for Ix: US sens 60-90%, high res CT best if
- INR >3 - ALT >3x ULN • Ref to dietician (small meals, high
late presentations Dx suspected
- paracetamol detected protein), pancreatic enzyme
• characteristic imaging findings (CT, - double duct sign = simultaneous Small bowel bacterial
replacement therapy (PERT).
MRCP, US – but only request if doubt) dilation of common bile and overgrowth syndrome
SNAP: 1st bag NAC 100 mg/kg over 2h, • Pain Mx – step-wise analgesia
Other Ix: FBC+diff, CRP (>200 high risk pancreatic ducts
2nd bag NAC 200 mg/kg over 10h → • Endoscopic procedures to dilate
D: ↑↑ bacteria in small intestine
of developing necrosis), U&Es (look for • Ca19-9 • LFTs (cholestatic)
total 300 mg/kg over 12h strictures, remove stones, drain cysts,
AKI and hypovolemia), O2 sats, LFTs
(↑ALTs - ?gallstones as cause)
• N-acetylcysteine anaphylactoid rxn etc. Surgical decompression or PPPD. causing dysfunction
Mx:
- pause infusion RF: neonates with congenital GI abn,
• <20% suitable for surgery at Dx
- antihistamine, eg chlorpheniramine
- salbutamol nebs if bronchospasm
Mx: ❗️ aggressive IV fluids + analgesia
P: 20-30% lower survival than gen pop.
Cardiovascular disease most common
• Whipple's resection (PD/PPPD) for
scleroderma, DM
S/smx: chronic diarrhoea, bloating,
• Offer enteral nutrition (NGT) for pts with resectable lesions at head of pancreas
- ondansetron 4 mg IV for N&V cause of death in alcoholic pancreatitis. flatulence, abd pain
moderate to severe pancreatitis - SE: dumping syndrome, PUD Dx: hydrogen breath test
- restart tx when pt is settled • Adjuvant chemo after surgery
- NBM only for specific reasons (eg pt Mx: correction of underlying disorder
keeps vomiting) • ERCP with stenting for palliation
Risk factors for hepatotoxicity: pts ± rifaximin, co-amoxiclav, or
• Do not offer routine / prophylactic abx metronidazole
taking enzyme-inducing drugs
• Surgery or procedures (ERCP, chole- P: mean survival <6mo. 5y survival 3%,
(rifampicin, phenytoin, carbamazepine, cystectomy, drainage, etc) as indicated
chronic alcohol excess, St John's wort), Glasgow score using Drugs a/w pancreatitis 5-14% with Whipple's/PPPD.
malnourished pts PANCREAS mnemonic: • Azathioprine
** Acute alcohol intake ?protective Complications: PaO2 <8 kPa • Mesalazine
• Peripeancreatic fluid collections – Age >55 • Bendroflumethiazide
aspirate and drain Neutrophils (WBC >15) • Furosemide
Liver transplantation
• Pseudocysts (~4w) – observe for 12w; Calcium <2 (hypoCa) • Steroids
(King's College Criteria)
half resolve, other tx with cystectomy uRea >16 • Sodium valproate
• Arterial pH <7.3, 24h after ingestion
• Pancreatic necrosis – conservative Mx Enzymes (AST/ALT>200) • Didanosine
• PT >100s + SrCr > 300 umol/L
• Pancreatic abscess – requires drainage Albumin <32 • Pentamidine
+ grade III or IV encephalopathy
• Haemorrhage • ARDS Sugar (glucose >10)
 Crohn's disease Ulcerative colitis Coeliac disease
Mx
D: a type of IBD characterised by Mx D: a type of IBD characteristically Inducing remission in mild to mod UC D: a systemic autoimmune disease triggered
transmural inflammation of the GIT Inducing remission involving the rectum, extending (1) Proctitis by dietary gluten peptides found in wheat, rye,
• Glucocorticoids (topical, PO, IV) proximally to affect a variable length of 1️⃣ Rectal mesalazine barley and related grains
± enteral feeding the colon 2️⃣
✌🏻
R: white ethnicity and Ashkenazi Jewish PO mesalazine if remission not
ancestry, age 15-40yo or 50-60yo, • 5ASA, eg mesalazine achieved w/in 4w R: FHx, IgA def, T1DM, autoimmune thyroid
FHx of CD • Add-ons: azathioprine, mercapto- R: FHx of IBD, HLA B27, infection ± topical/PO corticosteroids disease
purine, methotrexate (2) Proctosigmoiditis
• In refractory disease and fistulas: A/P: • unknown cause. ? genetics 1️⃣ Rectal mesalazine
2️⃣

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A/P: • unknown cause. ? genetics A/P: gluten peptides trigger innate and
adaptive immune reaction → villous atrophy,
infliximab • inflammation limited to the submucosa PO mesalazine ± topical corticosteroids
• inflammation is transmural - all layers
→ ↑risk of strictures, fistulas and • Isolated peri-anal disease: (unless fulminant disease) if remission not achieved w/in 4w
adhesions
metronidazole • inflammation limited to colon, unless 3️⃣ stop topical, PO mesalazine and PO
hypertrophy of intestinal crypts,
↑lymphocytes in epithelium and lamina propria
• Mouth to anus, skip lesions!
Maintaining remission
incompetent ileocecal valve steroids → GI smx and malabsorption
☝🏻
(3) Extensive disease
• 80% involve small bowel, usually in
Azathioprine, mercaptopurine 1️⃣ PO mesalazine + PO steroids
2️⃣
the ileum; ~30% have ileitis exclusively S/smx:
- TPMT activity must be assessed ↑mesalazine dose if remission not S/Smx: • Diarrhoea: chronic or intermittent
✌🏻 Methotrexate
• Bloody diarrhoea
• Urgency • Tenesmus achieved w/in 4w
• GI smx (persistent or unexplained) – nausea,
vomiting, abdo pain, cramping, distention
S/smx Inducing remission in severe UC
• Abd pain, esp in LLQ
• Non-specific, including wt loss, fatigue Surgery • Admit – IV steroids or ciclosporin - Lactose intolerance may develop
• Extra-intestinal features
• Diarrhoea ± bloody (colitis) • Stricturing ileal disease – ileocecal • After 72h, if no improvement, add • Wt loss (sudden or unexpected)

☝🏻
• Abdo pain, esp in children resection ciclosporin or consider surgery • Fatigue or failure to thrive
• Perianal disease, eg skin tags Ix: • Colonoscopy - likely 2/2 iron-deficiency anaemia (or other
• Segmental small bowel resection
• Extra-intestinal features (esp in pts • Stricturoplasty - Avoid in severe colitis due to risk of anaemias), or vitamin deficiencies
perforation; flexible sigmoidoscopy Maintaining remission
with colitis or perianal disease) • Mx of perianal fistulae (1) Proctitis ± sigmoiditis Comnplications: • Hyposplenism
preferred
- Ix: MRI • topical mesalazine daily or as and when • Anaemia (2/2 iron, folate or B12 deficiency)
- No inflammation beyond submucosa,
Ix: • Bloods (FBC – anaemia, ↑CRP/ - PO metronidazole, draining seton necessaryand/or PO mesalazine • Osteoporosis, osteomalacia
(↓risk abscess)
widespread ulceration with
ESR, ↓vit B12, ↓vit D); stool (↑faecal (2) Extensive disease • Enteropathy-associated T-cell lymphoma of
'pseudopolyps',
calprotectin) • Mx of perianal abscess: I&D + abx ± • Low maintenance dose of PO mesalazine small intestine
draining seton • Histology: inflammatory cells within the
- Can use CRP to track disease activity • Subfertility • Oesophageal cancer
lamina propria, crypt abscesses (∵
❗️
• Colonoscopy: deep ulcers, skip lesions Severe relapse or
neutrophils), depletion of goblet cells
Other notes Ix: Pts should be on gluten-full diet ≥6w
☝🏻
• Histology: transmural inflammation, and mucin ≥2 exacerbations in past year
goblet cells, granulomas • Stop smoking • PO azathioprine • Serology - IgA-TTG
• Barium enema: loss of haustrations,
• Small bowel enema: • ?? stop NSAIDs/COCP • PO mercaptopurine + Endomyseal ab (IgA) to r/o IgA deficiency
superficial ulceration, 'psueudopolyps',
- high s/s for exam of terminal ileum • Endoscopic intestinal biopsy [gold standard]
'drain-pipe colon' (short and narrow
- strictures: 'Kantor's string sign' C: small bowel cancer (40x risk), • PO methotrexate is not recommended - duodenum usually, or jejunum
colon)
• Stool sample: ↑faecal calprotectin
- Proximal bowel dilation colorectal cancer (2x), osteoporosis • ? probiotics may be useful - findings as above (under A/P)
- 'Rose thorn' ulcers • Other Ix to look for complications, eg FBC to
- Fistulae Mayo classification look for anaemia
Toxic megacolon • Stool frequency
Extra-intestinal features IgA-tTG = IgA tissue transglutaminase
Crohns disease activity index • total or segmental non-obstructive • Rectal bleeding
• General wellbeing
of both CD and UC • Findings on endoscopy
colonic distension a/w systemic Mx: • Gluten-free diet
• Abdominal pain toxicity • Physician's global assessment • Immunisations: pneumococcal vaccine every
Related to disease activity
• Number of liquid stools/day
• Arthritis: pauciarticular, asym • Complication of colitis ± C.diff infxn 5y (due to hyposplenism – ↑susceptibility to
• Abdominal mass Truelove & Witts severity index
• Erythema nodosum • Diagnostic criteria (≥3 + XR) encapsulated organisms) + influenza yearly
• Complications • Stool frequency (≥6 severe)
• Episcleritis - Fever >38.6ºC - HR >120
– Arthralgia – Uveitis - WBC >10.5 - Anaemia • Blood in stool
• Osteoporosis • T>37.8˚C P: good - 90% complete, lasting resolution of
– Erythema nodosum - Radiographical evidence
– Pyoderma gangrenosum • HR>90 (severe) smx on gluten-free diet. <1% refractory.
Unrelated to disease activity • Mx: treat underlying cause
– Aphthous ulcers • Anaemia
• Arthritis: polyarticular, sym - If C.diff +ve, IV abx
– Anal fissure – New fistula • ESR (>30 severe) Dermatitis herpetiformis - intensely
• Uveitis - If severe colitis flare, IV steroids
– Abscess - If no improvement in 72h, surgery pruritic papulovesicular lesions that occur
• Pyoderma gangrenosum
symmetrically over extensor surfaces of
• Clubbing
arms and legs, buttocks, trunk, neck and
• PSC (more common in UC)
scalp. Almost always a/w coeliac disease.

03.05 GI / GS – IBD & Coeliac

03.06 GI / GS – Appendicitis, SBO, LBO, Hernias, Pilonidal disease

Appendicitis Small bowel obstruction Large bowel obstruction Hernias

D: acute inflammation of the vermiform D: mechanical disruption in the patency D: mechanical disruption in the patency D: the protrusion of viscera through the Inguinal hernias
appendix of the small intestines of the large intestines wall of a cavity in which its contents are • 75% of abdo wall hernias, M>>F
contained • Located above and medial to pubic
A: obstruction of the lumen of the R: previous abdominal surgery (causing R: colorectal cancer (and its risk factors), tubercle
appendix (eg by faecolith, normal stool adhesions), malrotation, Crohn's, hernia, diverticular disease, current/previous ÷ congenital vs acquired • Rarely strangulate
or lymphoid hyperplasia) appendicitis, intestinal malignancy, hernia, gynaecological conditions, • Acquired hernias arise due to weak- • ÷ direct and indirect hernias, but Mx is
P: obstruction + growth of bacteria → intussusception, volvulus previous abdominal surgery, previous ness of abdominal wall due to aging or the same
↑pressure and distention radiotherapy previous surgery + ↑abdo pressure (eg
heaving lifting, pregnancy) Femoral hernias

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S/smx: • F>M, esp in multiparous women
S/smx: Alvarado score • Diffuse, central abdominal pain A: • 60% colorectal cancer ÷ characteristics • Located below and lateral to pubic
• Migration of abdominal pain =1 • Nausea, vomiting • 20% diverticular strictures • Reducible: the hernia can go away by tubercle
- general at first as only visceral - typically bilious (green) vomit • 5% volvulus (sigmoid in older, caecal in • High risk of incarceration and
manipulation (eg pressing down)
peritoneum is affected • Constipation with complete obstruction younger) • Irreducible strangulation → must be repaired
- localises to right iliac fossa (RIF) after and lack of flatulence • Rarely, endometriosis
24-48h when parietal peritoneum is • Incarcerated: irreducible + painful
• ± abdominal distention • Strangulated: blood supply has been Umbilical hernia
affected • ± Tinkling bowel sounds • Symmetrical bulge under umbilicus
S/smx: compromised, leading to ischaemia
- worse on movement, eg coughing
↳ in children, ask them to hop on left Ix: • CXR (to look for abdominal
• Constipation ± absence of flatus
Paraumbilical hernia
to right leg to test ("hop test") • Abdominal pain ± distention S/smx: dependent on type of hernia and
perforation – free air) • NV (late sign) where it is located • Asymmetric bulge above/below the
• Anorexia (no hunger) =1 • abdominal XR (dilated small bowel • ± Peritonism if perforated bowel • Hernias should have cough impulse umbilicus
• Nausea =1 ≥9 in males or >3cm thick ± fluid levels)
• Tenderness in RLQ =2 ≥10 females – (ie ask the pt to cough, and the hernia
• CT scan to confirm Epigastric hernia
• Rebound pain =1 very likely Ix: • CXR (to look for abdominal should expand)
• Fever (>37.3ºC) =1 appendicitis perforation – free air) ↳ helps to differentiate between other • Lump in the midline between
Mx: swellings, eg hydrocele xiphisternum and umbilicus
• Leucocytosis =1 • abdominal XR
• NBM + IV fluids + Ryles tube • If strangulated: pain, fever, peritonism • R: extensive physical training, chronic
• Shift of WBC count to the left - >6cm for colon is abnormal
- "drip and suck" – Ryles tube helps to (eg abdo rigidity), bowel obstruction (eg coughing, obesity
(neutrophil predominant) =1 - >9cm for caecum is abnormal
• Others relieve pressure - if there is an incompetent ileocaecal NV, distention), bowel ischaemia (eg
• ± Gastrografin (a contrast dye that is malaena) Incisional hernia
- Rovsing's sign: palpating LLQ causes valve, the small bowel may be
osmotic in nature) • up to 10% of abdominal operations
pain in RLQ distended too (>3cm)
- Psoas sign: pain on extending hip if • Surgery if not settled • CT scan to confirm Ix: clinical Dx ± CT to guide surgical
Spigelian hernia
appendix is retrocaecal management
• aka lateral ventral hernia
- Guarding and rigidity Mx:
Imaging (abdo XR) • hernia through the spigelian fascia
• NBM + IV fluids + Ryles tube Mx:
• Small bowel: valvulae conniventes • Located roughly beside the rectus
Ix & Mx: • Conservative Mx may be sufficient • Hernias should be treated even if asmx abdominis muscles anteriorly
• bloods – CRP, ↑WCC (as above) that extend all the way across – trial for 72h if tolerated (prevents future problems)
• urine dip – r/o pregnancy, UTI • Large bowel: haustra extend about • Surgery – urgent if perforated bowel • Most can be managed electively unless Obturator hernia
there is incarceration or strangulation →
• If Alvarado 4-6, CT scan; score ≥7, 1/3 of the way across + IV abx
• F>M
refer to surgeons emergency • Hernia passing through the obturator
• Imaging • Mesh repair – a mesh is placed to foramen
- not generally indicated unless unsure reinforce the abdominal wall • Typically presents with bowel
about Dx; ↑CRP + clinical picture Pilonidal disease S/smx: • Painful ± purulent discharge • Unilateral inguinal hernias: open obstruction + strangulation
should be sufficient (esp in kids) • Fluctuant swelling at the sacrum-coccyx approach
- US not useful to visualise appendix, • May be cyclical (comes and goes) • Bilateral and recurrent inguinal hernias: Richter hernia
D: "ingrown hairs" in the skin of the natal
but can help look for gynaecological
cleft of the sacrococcygeal area → chro-
laparoscopic approach • Herniation of only part of the bowel wall
pathologies that may present similarly Mx: • Asymx: clean carefully + hygiene • If pt not fit for surgery, hernia support
nic inflammatory reaction through a fascial defect
If suspected appendicitis, • Symptomatic: I&D of sinuses, allow wound belts are the next best option - ie not the whole circumference of the
• Refer to surgeons + NBM to close by secondary intention bowel, but part of it
R: M>F, 16-40yo, FHx
• Prophylactic IV abx, eg co-amoxiclav - Pain relief • Strangulation but no bowel obstruction
+ metronidazole - Abx if infected / abscess
• Appendicectomy (usually laparascopic) A/P: ingrown hair → inflammation → • If chronic or recurrent, excision of sinuses
• If pt is not fit for surgery, IV abx may be sinus formation + discharge ± infection (including complete excision of cavities)
all that is needed (but risk of recurrence
12-24%)
 Anal fissures Anal fistulae Haemorrhoids Colorectal cancer

D: a split in the skin of the distal anal D: chronic manifestation of the acute D: vascular-rich connective tissue D: cancers of the colon Ix: • bloods (FBC – looking for iron deficiency
canal. perirectal process that forms an anal cushions located within anal canal (3, 7 • majority are adenocarcinomas anaemia)
• chronic: >6w, usually with features, eg abscess. When the abscess is drained, & 11 o'clock). • 66% arise in the colon, 30% rectum • endoscopy + colonoscopy if source of occult
indurated edges, skin tags, visible an epithelialised track can form that • Internal haemorrhoids lie proximal to • others: carcinoid tumours, GI stromal blood cannot be established ("up and down")
internal anal sphincter fibres connects the abscess in the anus/ rectum dentate line, external haemorrhoids cell tumours (GISTs), lymphomas • CTTAP for staging
with the perirectal skin. distal.
Dukes' classification 5y survival
R: hard stool, pregnancy (3rd trim or Classes of internal haemorrhoids R: ↑age, FHx, genetic syndromes (eg A: tumour confined to mucosa 95%
post-partum), opiates (↑constipation), R: Crohn's, M>F (2:1), obstetric injury, • Grade 1: protrusion w/in anal canal Lynch), inflammatory bowel disease (esp B: invading bowel wall 80%
STIs (eg HIV, syphilis) pelvic radiation, rectal foreign bodies, • 2: beyond anal canal, but reduces pancolitis and left-sided colitis), obesity C: lymph node mets 65%

© quackquackmed.com
infxn (eg chlamydia L, TB), malignancy spontaneously on cessation of straining
D: distant mets 5%
A/P: hard stools tear the anal skin from • 3: reduces on manual pressure S/smx:
the pectin at the dentate line. Likely an A/P: cryptoglandular fistulas originate • 4: irreducible • altered bowel habits 🚩 🚩 → 2ww referral
ischaemic ulcer ∵ poor circulation and from infected anal crypt glands. In • rectal bleeding of any kind 🚩 Mx • Pts who meet any
• Definitive Mx: resection
spasm of internal anal sphincter → Crohn's, penetrating inflammation causes R: 45-65yo, constipation, pregnancy, • abdo pain and discomfort
these fistulae to form. space-occupying pelvic lesion • unexplained weight loss 🚩 - caecal, ascending or proximal transverse

🚩
↓healing colon tumour: right hemicolectomy
• anaemia - distal transverse, descending colon tumour:
A/P: straining → haemorrhoids are pulled
S/Smx: • Non-healing anorectal abscess - any new iron deficiency anaemia in an
S/Smx: • Pain on defecation ("passing left hemicolectomy
❗️
broken glass") → DO NOT do a DRE following drainage or chronic pus/
pustule-like lesion in perianal area
lower and engorged → bleeding occurs elderly pt should be a red flag
• bowel obstruction 🚩🚩 - sigmoid colon: high anterior resection
• Tearing or burning sensation when epithelial lining is torn (preserves part of the rectum)
• Intermittent rectal pain with defecation,
• Fresh blood on wiping (PR bleeding), - rectal tumours: anterior resection
sitting, activity.
• Anal spasm • ± sentinel pile (20%) S/Smx: PR bleeding (fresh), perianal Screening: Home-based faecal - anal verge tumours: abdomino-perineal
• Others: pruritus, excoriation,
• Visible fissure (40%) pain/discomfort ± pruritus, palpable immunochemical test (FIT) excision of rectum
induration.
lesion or mass • a type of faecal occult blood test • Most pts will have an anastomosis where the
Ix: clinical Dx, no tests at initial • uses antibodies that specifically proximal and distal segments of the colon are
presentation. 2nd line: anal manometry Ix: Clinical Dx. Imaging for complex recognise human Hb joined together
Ix: anoscopic exam, colonscopy or flex
and US in resistant fissures fistulae (esp in Crohn's) may be required • every 2y in 60-74yo in England - in emergency settings, end colostomies may
sig ± FBC, stool for occult haem (if no
– MRI, endosonography, fistulography • every 2y in 50-74yo in Scotland be needed which can be reversed (ie
significant tissue seen on exam)
Mx: Conservative for acute <1w – ↑fibre,
(contrast + XR) • pts ≥75yo can request screening anastomosed later on), eg Hartmann's pouch
Mx: conservative: ↑fibre, fluids ± topical
fluids. Sitz bath, stool softeners and • pts are informed whether test was • Chemotherapy or radiotherapy are likely
Mx: EUA, fistulotomy (cut open the tract, normal or abnormal – if abn, pts are indicated (before/after)
analgesics steroids if pruritic
• Medical for chronic >6w: topical GTN or curette, marsupialisation, packing). offered a colonoscopy (1 in 10 will
Draining seton, etc, for complex fistulae • Surgical: rubber band ligation.
CCBs – 6-8w even if smx resolve early - Other options: sclerotherapy, photo- be found to have cancer)
(↑risk of recurrence) coagualtion, arterial ligation, staples.
• surgical tx ↑rate of healing but risk of P: if non-complex fistula, low recurrence,
- Surgical haemorrhoidectomy for
incontinence but risk of incontinence
grade 4 or external haemorrhoids
- Lateral internal sphincterotomy (LIS) -
a small portion of anal sphincter
muscle is cut to ↓spasm and pain,
P: recurrence likely if risk factors
continue Surgical option best outcome,
promote healing
with <20% recurrence low re-treatment
rates compared to rubber band ligation.
P: 60% achieve healing at 6-8w; further
Low anterior High anterior Sigmoid Left hemi- Right hemi-
20% heal after topic diltiazem. Some may Low anterior resection (LAR) vs Hartmann's procedure
resection resection colectomy colectomy colectomy
relapse. Around 30% require surgery. Abdomino-perineal resection (APR) • sigmoid colectomy
• APR removes tumour along with • end colostomy + rectal
anal canal and sphincter complex pouch (Hartmann's pouch)
• LAR preserves remaining • reversal considered 3mo
anorectum (& sphincter complex) after initial surgery

Ileostomy – loop/end Colostomy – loop/end

• Mid/distal small bowel • Any part of large bowel
• Spouted • Flush Abdomino-perineal Total procto- Subtotal Total abdominal Extended right
• Prominent mucosal folds • Flat mucosal folds resection colectomy colectomy colectomy hemicolectomy
• Dark pink / red • Light pink
• Most commonly on right side • Most commonly on left side

03.07 GI / GS – Colorectal surgery

03.08 GI / GS – Upper GI stuff, ERCP, TIPS

GORD Gastritis Peptic ulcer disease Oesophageal conditions

D: smx/complications arising from reflux D: histological presence of gastric D: break in mucosal lining of stomach or Mallory-Weiss tear Hiatus hernia
of gastric contents into the esophagus, mucosal inflammation duodenum >5mm in diameter, with depth • D: Superficial mucosal laceration of the • D: Protrusion of the stomach through
oral cavity or lung to the submucosa. oesophagus the diaphragm into the thoracic cavity
→ ulcers smaller than this or without • R: heavy alcohol use, bulimia nervosa, • R: obesity, ↑abdominal pressure
R: H. pylori infxn, NSAIDs, steroids, alc hyperemesis gravidarum, GORD (eg multiparity, ascites)
R: FHx, ↑age, hiatus hernia, obesity use, toxic ingestions, prev gastric obvious depth = erosions
• S/smx: pt usually has Hx of retching or • S/smx: heartburn, dysphagia,
surgery, critically ill pts, autoimmune vomiting regurgitation, chest pain
A/P: ↑relaxation of lower oesophageal disease R: H. pylori infxn, NSAIDs, SSRIs, - streaks of fresh blood in vomit • Ix: barium swallow, endoscopy
sphincter allows reflux of gastric steroids, bisphosphonates, smoking, - no other systemic smx • Mx: weight loss, PPIs
A/P: H. pylori induces severe inflam → ↑age, personal hx of PUD, FHx, ITU pts

© quackquackmed.com
contents • Mx: pt may need antiemetic to stop - Surgery only if refractory
• Severity of damage depends on gastric mucin degradation, ↑mucosal vomiting (and therefore stop the cause
duration of contact with gastric permeability → gastric epithelial A/P: inbalance btwn factors that damage of the Mallory-Weiss tear) Plummer-Vinson Syndrome
contents, what contents, and resistance cytotoxicity the gastroduodenal mucosal lining and • D: rare condition characterised by
of epithelium to damage NSAIDs and alcohol: ↓gastric mucosal defense mechanisms (mucus bicarb Boerhaave syndrome classic triad
• Acid in lower oesophagus → vagal blood flow, loss of mucosal protective layer secreted by mucus cells). • D: spontaneous rupture of the - iron-deficiency anaemia
stimulation → chronic coughing, throat barrier. NSAIDs ↓prostagladins. • gastric ulcers: secretion of gastric oesophagus - oesophageal webbing
clearing. Autoimmune gastritis: antiparietal cell acid low or normal • R: similar to Mallory-Weiss tear, - dysphagia
antibodies (abs) stimulate inflam → • duodenal ulcers: ↑↑gastric acid ∵ H. essentially anything that ↑↑intra-abdo- • R: middle-aged women, coeliac,
S/Smx: • Heartburn (esp after meals) loss of parietal and chief cells pylori impairs secretion of somatostatin minal pressure Crohn's, RA, thyroid disease
• Dyspepsia • Regurgitation Gastric atrophy and acid blocking meds: • Zollinger-Ellison: NET ↑gastric acid • S/smx: triad of vomiting, lower thoracic • A: unknown ?autoimmune
• Cough (esp at night when lying down) ↑pH, disrupt acid barrier to bacterial pain, and subcutaneous emphysema • S/smx: as above
• Halitosis, globus, enamel erosion overgrowth S/Smx: • Ix: CXR may show widened - glossitis (big tongue)
• Bloating • Epigastric pain, "pointing sign" (pt can mediastinum + CT contrast swallow - angular cheilitis (red, swollen patches
🚩 dysphagia, haemetemesis, melena, S/Smx: • Epigastric discomfort ± NV point to particular spot) • Mx: thoracotomy and lavage at corners of the mouth)
persistent vomiting, wt loss, anemia → • ↓appetite. - Gastric: pain on eating ± 1-2h after - <12h onset, primary repair • Ix: barium swallow ± videofluoroscopy,
2ww URGENT REF 🚩 • If severe: acute abd pain, ↑↑emesis, - Duodenal: pain several hours after - >12h, insertion of T tube to create a endoscopy (to look for oesophageal
fever, altered reflexes and cognitive eating controlled fistula between the webs)
Ix: GORD is a clinical Dx; PPI trial first. impairment (if 2/2 B12 deficiency), • Nausea, vomitting, diarrhoea oesophagus and skin (allows for - other tests as necessary to r/o
± pH monitoring, esophageal manometry, glossitis • Early satiety, wt loss drainage of blood out) malignant causes
barium swallow, OGD. • Smx of anaemia (eg fatigue) • P: up to 40% mortality, delays >24h a/w • Mx: - iron supplementation
Indications for UGI endoscope: Ix: H. pylori urea breath test, fecal • If bleeding: haemetemesis, melaena, very high mortality - may require endoscopic dilation if
• >55yo • smx >4w or despite tx antigen test, FBC ± histology, endoscopy, ↓BP, ↑HR • Complications: severe sepsis 2/2 to severe
• Dysphagia • Relapsing smx serum B12, cultures, parietal cell abs, • If perforated: pain, shock, syncope mediastinitis (entry of gut contents - advise pt to eat slowly, chew
• Wt loss intrinsic factor abs. into the thorax) thoroughly
Ix in acute settings: See also 06.06 ENT – Dysphagia for Oesophageal carcinoma and Barrett's oesophagus
Mx: • Lifestyle ∆ (wt loss, ↓triggers, stop Mx of H. pylori infxn: • Erect CXR (to check for free air under
smoking, avoid late night eating) •☝🏻 triple tx (PPI + clarithromycin, diaphragm → perforation),
• Bloods (incl G&S, cross match)
• If not endoscopically proven, treat as amoxicillin or metronidazole) x14d
per dyspepsia •✌🏻 quadruple tx (PPI, bismuth, Other Ix: H. pylori testing, FBC, etc ERCP Endoscopic retrograde
cholangiopancreatography
TIPS Transjugular intrahepatic
portosystemic shunt
- Review meds - Full dose PPI tetracycline, metronidazole) x14d
• Endoscopically proven Mx of non H. pylori induced gastritis: Mx: • Bleeding or perforation: - ABCDE + Indications: Indications:
- Full dose PPI 1-2mo • Stop offending drugs resus, IV PPI • Extraction of biliary stones • Oesophageal or gastric varices 2/2
- If response, then ↓dose, continue • Autoimmune gastritis: B12 ☝🏻
- Endoscopic interventions • Relief of jaundice 2/2 benign or portal hypertension
- If no response, then 2x dose supplements ✌🏻
- Interventional radiology or surgery malignant strictures with stents • Budd-Chiari syndrome
• Endoscopically -ve • Stable: tx underlying cause + PPI • Ampullary biopsy, biliary brushings
- Full dose PPI for 1mo P: if H. pylori is untx, ↑risk of gastric - H. pylori +ve: H. pylori eradication Interventional radiology procedure
- If response, then ↓dose prn (limit cancers. Untx gastritis ↑risk of PUD. Consent: risks of pancreatitis, cholangitis, • Right internal jugular vein cannulated
number of repeat prescription) Generally good prognosis except for P: With PPIs, duodenal ulcers heal w/in bleeding, perforation. 1/50. • Catheter advanced to hepatic vein
- If no response, then ∆ to H2RA or phlegmonous gastritis (rare disorder) 4w, gastric ulcers w/in 8w. If H. pylori ↳ usually the right HV
prokinetic for 1mo eradication, prognosis is good. • Venogram (XR) obtained
1. Advance side-viewing endoscope to
Stopping medications before OGD • NSAID-induced ulcers – low rate of • Direct needle towards right portal vein
2nd part of duodenum
P: most pts have smx control w/ PPIs – 1d: gaviscon For urea breath recurrence if stopped. • Dilate angioplasty balloon
2. Locate, cannulate ampulla
most pts relapse if PPI therapy is 2w: PPI test: stop PPI and • Deploy stent, widen to ~8mm
3. Sphincterectomy (knife/balloon) prn
stopped. 3d: H2RA abx Oesophageal cancer → see ENT 4. Do definitive procedure
• Confirm placement with venogram
4w: abx 06.06, section under Dysphagia
 Upper GI bleed UGIB Lower GI bleed

D: GI blood loss whose origin is proximal DDx (localising bleed) Ix D: GI blood loss whose origin is distal to DDx (localising bleed)
to the ligament of Treitz at the Stomach (continued) • Glasgow-Blatchford score to the ligament of Treitz at the Colon and rectum (continued)
duodenojejunal junction • Dieulafoy lesion (vascular malformation determine whether pts need to be duodenojejunal junction • Irradiation colitis or proctitis
in the GI tract) admitted - Hx of radiotherapy
S/smx - often no prodromal features prior to - Composed of urea, Hb, SBP, HR, S/smx: - Smx typically occur ~9w to 4mo after
• Haemetemesis bleed, but can produce considerable liver disease, heart disease, and • Haematochezia = fresh blood PR radiation injury
= blood in vomit haemorrhage whether pt presents with melaena - Bright red blood – may be mixed with - S/smx: diarrhea, rectal pain or
- ranges from bright red to "cofffee • Hereditary haemorrhagic telangectasia and syncope stool or on toilet paper (when wiping urgency, faecal incontinence,

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ground" vomit - autosomal dominant disorder - If score = 0, consider early discharge after a poo) obstructed defecation
• Melaena - bleeds tend to occur in mucosae, eg • Rockall score, used AFTER endoscopy • Melaena (as per UGIB) • Solitary rectal ulcer
= digested blood in poo nasal bleeds, GI bleeds to determine risk of rebleeding and • Occult bleeding – blood cannot be - + passage of mucus, straining during
- in contrast to fresh blood PR (aka Duodenum mortality visibly seen, but is revealed on faecal defecation, tenesmus
haematochezia), melaena is black and • Duodenal ulcer • Endoscopy occult blood test
tarry (sticky) - bleeds at gastroduodenal artery - offered immediately after resus in pts Anus
• ↑urea due to ↑digested protein most common with severe bleed DDx (localising bleed) • Haemorrhoids
- pain occurs hours after eating - ALL pts should have endoscopy Small intestines • Fissure-in-ano
DDx (localising bleed) • Aorto-duodenal fistula within 24h • Meckel's diverticulum • Carcinoma
Swallowed blood - occurs in pts with abdominal aortic - tends to occur in children and young • Trauma
• Epistaxis (nosebleed) aneurysm surgery Mx adults
• Haemoptysis • Duodenal diverticulae • RESUS - painless melaena or hematochezia; Others
Oesophagus - 90% are asymptomatic - ABC, 2x wide bore IV access "currant jelly" bleeding • Endometriosis
• Varices - rarely can cause bleeding, obstruction, - platelet transfusion if platelet <50 - abdo mass may be palpated - Possible Hx of dysmenorrhea, pelvic
- large amount of fresh blood vomitted infxn, perforation - FFP if fibrinogen <1g/L or PT or • Intussusception pain, dyspareunia, infertility
± melaena • Invasive pancreatic tumours APTT >1.5x normal - bloody stool occurs with abdo pain,
- may stop spontaneously, but rebleeds • Haemobilia - PCC + vitamin K if pts are on warfarin vomiting and SBO See also underlying disorders in UGIB
are common = bleeding from and/or into the biliary and actively bleeding - if occurring in adults, a lead point due
• Mallory-Weiss tear tract • Mx of non-variceal bleeds to cancer is often present Ix:
- small to moderate amounts of fresh - most of them are iatrogenic, 2/2 - DO NOT give PPIs before endoscopy; • Mesenteric infarction • DRE if pt is not in pain
blood after vomiting and retching invasive procedures eg ERCP give after - periumbilical pain that is sudden, - if painless: diverticular disease more
• Reflux oesophagitis - classic triad of RUQ pain, jaundice, severe – out of proportion to initial common in older adults
❗
- if further bleeds, repeat endoscopy, ref
- small amount of fresh blood, like overt UGIB to interventional radiology and upper physical exam - do not do DRE in anal fissure
streaks in vomit GI surgery • Aortoenteric fistula • Faecal occult blood testing if micro-
- Hx of GORD DDx (underlying disorders) • Mx of variceal bleeds = wall of aorta erodes into adjacent GI scopic blood is suspected, eg iron
• Oesophageal carcinoma • Bleeding disorders - terlipressin and prophylactic abx at system deficiency anaemia in older population
- variable amounts of blood - liver disease associated presentation - usually occurs 2/2 endovascular • Faecal calprotectin if suspecting IBD
- a/w s/smx of cancer – dysphagia, wt - thrombocytopaenia ↳ give before endoscopy surgical interventions • Colonoscopy for direct visualisation of
loss, etc - haemophilia - band ligation for oesophageal - "herald" GI bleeds often occur, lesions
Stomach • Drugs varices; injections of cyanoacrylate for followed by catastrophic massive • Barium enema
• Peptic ulcer - anticoagulation - aspirin gastric varices bleeds that are life-threatening • Angiography (in acute bleeding phase)
- Small bleeds - NSAIDs - steroids - Sengstaken-Blakemore tube if
- Presents more often as iron • Others uncontrolled bleeding Colon and rectum Mx:
deficiency anaemia - uraemia - TIPS offered if bleeding cannot be • Colorectal cancer • Resus as per UGIB
- Erosion into significant vessel may - connective tissue disorders controlled with above measures • Polyps • Deal with underlying condition
cause major haemorrhage • Prophylaxis of variceal bleeds • Diverticular disease
- May have Hx of NSAID or steroid use - propranolol • Inflammatory bowel disease
without PPI cover - endoscopic variceal band ligation • Ischaemic colitis
• Gastric cancer (carcinoma, GIST) • Rectal prolapse
- range of presentations • Angiodysplasia
- typically >60yo
- painless hematochezia
- ± Hx of ESRD, von Willebrand
disease, aortic stenosis or
anticoagulant therapy

03.09 GI / GS – GI bleeding
03.10 GI / GS – IBS, Diverticular disease, Ischaemic bowel disease, Abdominal pain DDx and red flags

Irritable bowel syndrome Diverticular disease Ischaemic bowel disease Abdominal pain DDx
Gastroduodenal Urinary tract Peritoneum
D: chronic condition characterised by abd D: clinical state caused by smx pertaining D: umbrella term including • GORD • Cystitis • Peritonitis
pain assoc w/ bowel dysf. No structural to colonic diverticula • Acute mesenteric ischaemia • Peptic ulcer • Acute retention of urine
abn. Multifactorial. • Colonic diverticulosis = herniation of ↳ further ÷ into embolic, thrombotic • Gastritis • Acute pyelonephritis Abdominal wall
mucosa and submucosa through or venous • Malignancy • Ureteric colic • Strangulated hernia
R: phy&sex abuse, PTSD, <50yo, F>M muscular layer of the colonic wall. • Chronic mesenteric ischaemia • Gastric volvulus • Hydronephrosis • Rectus sheath haematoma
(2:1), previous enteric inxn, FHx, stress • Diverticulitis = inflammation of • Colonic ischaemia • Tumour • Cellulitis
diverticula, possibly ∵ infxn Intestinal • Pyonephrosis
R: ↑age, smoking, hypercoagulable state • Appendicitis • Polycystic kidney Retroperitoneal

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A/P: ∆ gastric motility, inflam or immune
system involvement, microbiota ∆, bile R: >50yo, low dietary fibre ± ↑salt, meat, (eg previous VTE), atrial fibrillation, MI, • Obstruction • Haemorrhage (eg
acid malabsorption. Dysfunction in motor sugar intake, obesity, NSAID and opioid Hx of vasculitis • Diverticulitis Gynaecological anticoagulants)
and sensory aspects of GIT. use • Gastroenteritis • Ruptured ectopic
A: embolism (50%), thrombosis (15- • Mesenteric adenitis pregnancy Referred pain
A/P: low fibre diet → ↑intestinal transit 20%), vasculitis, venous thrombosis • Strangulated hernia • Torsion of ovarian cyst • Myocardial infarction
Dx - consider if ≥6mo of ABC
time → ↑stool vol → ↑intraluminal (5%), hypoperfusion (eg shock, heart • IBD + Celiac + lactose • Ruptured ovarian cyst • Pericarditis
• abdominal pain &/or
• bloating &/or • change in bowel habit pressure and colonic segmentation → failure, recent surgery) • Intussusception • Salpingitis • Testicular torsion
predisposes to diverticula formation P: ischaemia 2/2 hypoperfusion of • Volvulus • Severe dysmenorrhoea • Pleurisy
+ve diagnosis if ≥2 of 4 + pain relieved by intestinal segment • TB • Mittelschmerz • Herpes zoster
defecation: • Endometriosis • Lobar pneumonia
• altered stool passage S/Smx:
S/smx: Hepatobiliary • Red degeneration • Thoracic spine disease,
• abd bloating, distension, tension or • Generally diverticula are asmx → • Abdominal pain severe, sudden-onset, • Cholecystitis of a fibroid e.g. disc, tumour
hardness becomes symptomatic when there
out of keeping with physical findings • Cholangitis
• smx made worse by eating is inflammation (diverticulitis)
• PR bleeding – melaena • Hepatitis Vascular 'Medical' causes
• passage of mucus • LLQ abd pain, ↑WCC, fever ± PR • Aortic aneurysm • Hypercalcaemia
bleeding, bloating, constipation,
Ix: urgent CT scan with contrast or CT Pancreatic • Mesenteric embolus • Uraemia
Ix: FBC, ESR/CRP, coeliac disease diarrhoea
angiogram, erect CXR (will show free air • Pancreatitis • Mesenteric angina • Diabetic ketoacidosis
screen (IgA TTG) • DRE: tenderness, palpable mass
if perforation present) • Malignancy (claudication) • Sickle cell disease
• Enquire for red flags: rectal bleeding, • Mesenteric venous • Addison’s disease
unexplained wt loss, FHx of bowel or Ix: FBC, U&Es, CRP. Splenic thrombosis • Acute intermittent porphyria
Mx:
ovarian cancer, >60yo • colonoscopy, CT cologram or • Infarction • Ischaemic colitis • Henoch–Schönlein purpura
• Resus + supportive
barium enema • Spontaneous rupture • Acute aortic dissection • Tabes dorsalis
• Empirical IV abx
Mx: • if acutely unwell, CXR and AXR
☝🏻
• Immediate laparotomy is usually
antispasmodic agents, laxatives
🚩
Hinchey severity classification required, esp if signs of advanced
(not lactulose), loperamide Red flags R hypochondrium Epigastric L hypochondrium
🚩
I: para-colonic abscess ischaemia
↳ consider linaclotide if max severe pain • Liver + GB • Stomach • Spleen • Pancreas
🚩
II: pelvic abscess • Thereafter, Mx of risk factors – pt may
loperamide or constip ≥12mo signs of shock • R kidney + adr • Transverse colon • L kidney + adr
✌🏻 🚩
III: purulent peritonitis need to be on LMWH
low dose TCAs (amitriptyline 5-10 mg IV: faecal peritonitis peritoneal signs • Small intestine • Liver, spleen, • Descending colon
preferred to SSRIs) (rebound tenderness, • Ascending colon pancreas, SI
Others Mx: ↑dietary fibre intake ↓bowel sounds, new
• psychological: CBT, etc or worsening ascites, R flank Umbilical L flank
• mild attacks: conservative - abx
• do not encourage use of acupuncture fever/chills) • Liver + GB • SI (incl • L kidney
🚩
• peri-colonic abscesses: drained
or reflexology abdo distension • Ascending colon duodenum) • Descending colon
🚩
surgically or radiologically
• general dietary advice blood in stool / urine
🚩
• recurrent episodes requiring admission:
- regular meals, eat slowly anorexia, wt loss RIF Hypogastric LIF
🚩
segmental resection
- limit tea/coffee intake, consider • Hinchey IV: resection + stoma; high abdo mass / • Ileocecal junction • Bladder • Descending and
limiting intake of high fibre foods, limit organomegaly • Appendix • Sigmoid colon sigmoid colon
🚩
risk of post-op complications
fresh fruit to 3 portions fever ± Ovaries, fallopian ± Uterus ± Ovaries, fallopian
- for wind and bloating consider ↑oat 🚩 jaundice tube ± Male repro tube
intake and linseeds
P: 1/3 pts have recurrent diverticular
disease, mostly w/in 5y (↑risk in young 🚩 awakening pain /
pts, abscess formation at index Dx). A/w nocturnal pain
P: normal life expectancy, and no long- high mortailty, ↓response to therapy.
term complications, but ↓QoL. After surgery, 1/4 pts remain
symptomatic.
 General anaesthesia Airway adjuncts

D: inducing loss of consciousness in a Induction of GA Most airway adjuncts help to open up the Supraglottic airway Endotracheal tube
controlled environment, to prevent Inhalation, eg sevoflurane, isoflurane airway to promote air delivery, but only ÷ laryngeal mask airway (LMA) & iGel • Tube inserted with the help of a
response to noxious stimuli - A/w malignant hyperthermia endotracheal intubation and tracheo- • The end of these airways sit at the laryngoscope or fibreoptic camera into
• Triad of analgesia, amnesia/hypnosis, Intravenous stomies properly protect the airway vocal cords and form a seal to block off the trachea
and muscle relaxation or paralysis • Propofol – fast acting and good the oesophagal opening, so they help to • Usually size 7 for women, size 8 for
recovery characteristics lower the risk of aspiration men – but may need to be resized
Oropharyngeal / Guedal airway (OPA)
Pre-op checks - Can cause hypotension • Measure by putting tube on pt's cheek, • However, because they do not go based on weight if not standard

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• Talking to pt – PMH, meds/allergies, • Thiopental – not used much nowadays with the wide part near the pt's front completely into the trachea, there is still • Depth of tube needs to be marked –
discussing any concerns, consenting pt • Ketamine – usually in paeds a risk of aspiration and thus cannot be usually 20-24 cm at the teeth → then
teeth; the smaller opening should sit on
to GA - Can cause hypertension properly said to fully protect the airway needs to be taped to secure
the angle of the jaw ("hard to hard")
- Ask pt about previous anaesthetic use, • In adults, insert upside down, then twist • Useful in the cases of short or low risk • Inflatable cuff helps to seal the trachea
or FHx of issues with anaesthesia Paralytic agents 180º when getting to the back of the procedures (eg incision and drainage of and prevent aspiration
• Risks to discuss: dental damage, sore • Used in operations where surgeons do simple abscesses)
throat
throat, post-op N&V, risks of MI & stroke not want change in abdominal pressure Laryngoscope
• Poorly tolerated in conscious or semi-
• Functional status (ASA grade) due to the diaphragm moving (eg conscious individuals as they can cause Laryngeal mask airway • Consists of "blades" and a torchlight
- 1 Normally fit and well laparoscopic procedures, major gag reflex • Reusable supraglottic device • Used to lift the soft tissues and the
- 2 Mild systemic disease, controlled abdominal surgery) • Some versions have seals that are epiglottis and directly visualise the
- 3 Severe systemic disease • Agents include suxamethonium and inflatable (better seal) and also gastric larynx so that the tube can be inserted
- 4 Incapacitating disease, threat to life rocuronium ports to allow for drainage/suction of into the trachea past the vocal folds
- 5 Moribund (won't survive >24h even • If used, will require intubation and secretions • Pt needs to be able to bend their neck
with operation) ventilation until pt regains ability to backwards so that laryngoscope can be
- 6 Brain dead - for organ donation maintain their own airway inserted
• Airway Ax "LEMON"
- Look externally, eg abnormal neck Nasopharyngeal airway (NPA)
Maintenance of GA
large tongue, dental issues, etc • = tube that goes through nostril to the
Maintenance of unconsciousness
- Evaluate 332 back of throat; helps bypass obstruct-
• Inhalation, eg sevoflurane
◊ 3 fingers between teeth ions in the mouth / base of tongue
• Intravenous, eg propofol
◊ 2 btwn hyoid and mentum • Measure by putting one end on tip of
Maintenance of analgesia
◊ 2 btwn hyoid and thyroid - Impt to remember that pt can be the nose, and the other end should sit
- Mallampati score (look it up) at the tragus of the ear ("soft to soft") iGel
unconscious but still experience pain –
this may be reflected in ↑HR, ↑BP
- Obstruction / obesity • Insert as if inserting an NG tube – aim • Single use supraglottic device
- Neck mobility – ↓in trauma, elderly • Opioids, eg remifentanil, alfentanil straight (not downwards) • Seal at the end is activated by body
• Contraindicated if suspected skull base temperature due to characteristics of
Pre-op instructions • Local anaesthetics
fracture (might go into the brain) the plastic used – no inflation required
• Meds to stop (unless otherwise directed
by surgeon/anaesthetist) Stopping/reversing GA
Bag-valve-mask (BVM)
- Anticoagulants (incl DOACs) usually • Usually involves stopping the induction/ • Mask has to be placed over nose and
stopped before op, and pt is usually on maintenance agent while maintaining
mouth (usually with head tilt-chin lift
enoxaparin injections as inpt. Seek the analgesic component
manoeuvre + tight seal)
• Compression of the bag → ↑pressure
clear instruction from consultant • Neostigmine can be given to reverse
residual muscle paralysis and ↓anti- Laryngoscope with blades →
- Antiplatelets: stop 5-7d before surgery
- If pt on dual antiplatelet therapy to cholinergic side effects (eg salivation)
→ opening of valve → air passes
through into the mask
prevent stent thrombosis, ?delay as pt wakes up Tracheostomies
• Can be hooked up to oxygen ± gas
surgery for 1y if possible. If not, seek • More predictable in total intravenous • Bypass upper airway, direct ventilation
supply for pre-oxygenation Tracheostomy tube
cardiology advice anaesthesia (TIVA) than with inhaled through trachea into lungs
• Allows for manual
- NSAIDs: stop agents • Cricothyroidectomy – done in
ventilation just
- Insulin: continue basal insulin, but • Variable time as to when pts wake up emergencies; incision made through
before intubation
skip oral hypoglycaemics and fast- • Should only be extubated when they membrane between cricoid and thyroid
acting insulin when NBM can obey commands and demonstrate cartilage, and tube is inserted through
- Contraceptive pill & HRT: stop 4w muscle tone (eg "squeeze my hand") incision
before major surgery, restart 2w after if • Surgical tracheostomy – incision made
pt mobile through trachea itself, and tracheostomy
• NBM 6h before surgery, clear fluids up is inserted through this incision
Diagrams from Wikipedia
till 2h before surgery

Anaesthetics Primer
Anaesthetics Primer

Post-op nausea & vomiting PONV

Regional / local anaesthesia Neuraxial blocks Epidural anaesthetic
• Injection of anaesthetic (eg LA, opioids) • Epidural space is larger than the
into the epidural or the subarachoid subarachnoid space, and a larger R: • Patient factors: F>M (3:1), previous
• Divided into peripheral nerve blocks Hx of PONV, obesity, motion sickness,
space volume of anaesthetic is needed
and neuraxial anaesthesia (further ÷ pre-op anxiety
- Injection level should be around L3/L4. • Can be given as a single dose, or a
spinal & epidural) • Anaesthesia; opioids (esp morphine),
L4/L5 level can be estimated as the catheter can stay in, hooked up to a
line between the iliac crests continuous infusion or patient-controlled nitrous oxide, etomidate, ketamine,
Peripheral nerve blocks - Not higher as spinal cord ends ~L1; analgesia (PCA) machine volatile agents
• Using local anaesthetics (LA) such as ↑risk of transecting spinal cord • Usually given in labour for pregnancy - TIVA with propofol ↓risk of PONV
lidocaine, bupivacaine and prilocaine • Needle passes through as catheter can sit in and allow for • Surgery type: GI, GU, gynae, neuro-

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- Long-acting: bupivacaine (also takes - Skin continuous anaesthesia surgery, ENT (specifically middle ear),
longer to work), levobupivacaine, - Subcutaneous fat • Risk ophthalmic
ropivacaine - Supraspinous ligament - Dural puncture leading to headache • Post-op factors: dehydration, ↓BP,
- Middle-acting: lidocaine (esp good for - Interspinous ligament ◊ Mx with caffeine & oral fluids, bed hypoxia, early oral intake
mucous membranes), prilocaine, - Ligamentum flavum rest, and analgesia.
mepivacaine - Epidural space ← epidural needle ◊ If headache > 24-48h, blood patch P: Common pathway is the stimulation of
- Short-acting: procaine - Dura mater stops here (introducing a small amount of pt's the vomiting centre in the medulla,
• Adrenaline can be mixed in - Arachnoid mater spinal needle own blood into CSF space to patch which itself is stimulated by
- Causes vasoconstriction so that the - Subarachnoid space ← stops here the dural puncture) • Higher centres (sensory input,
LA remain at the site of injection and is • This is a sterile procedure (requires - Vessel puncture and inadvertent personality, anxiety, etc)
effective for longer scrubbing in) injection: Mx with resuscitation • Chemoreceptor trigger zone (drugs)
- Also allows for higher doses of LA to • Usually some local anaesthetic (to the (symptomatic treatment) • Somatic and visceral afferents
be given since ↓risk of LA entering skin and surrounding soft tissue) is - Hypoventilation due to motor block of • Middle ear / labyrinth (eg motion)
systemic distribution given before the needle is advanced intercostal muscles – may require
Mx: • ↓anxiety before op
• Can be used to block specific nerves into the epidural or subarachnoid space ventilation
• ↓risk factors, eg hydration, oxygenation
(eg femoral nerve block for NOF#), or • Blocks are tested by using cold spray to - Inadvertent spinal anaesthesia – large
injected at incision sites during surgery determine dermatomal level at which volume injected into CSF (≈total • Good prevention of PONV esp in pts
Risks of LA the block ends spinal block): resuscitation required with known risk factors using anti-
• Systemic distribution (ie when LA is Absolute contraindications to neuraxial - Epidural haematoma / abscess: emetics (eg ondansetron, cyclizine)
accidentally injected intravenously) anaesthesia requires referral to neuro asap
- S/smx: perioral tingling, tongue numb- • Anticoagulant states (due to ↑risk of
ness, lightheadedness, tinnitus. If bleeding at the cord)
severe, can result in seizures, apnoea, • Local sepsis (risk of CSF infection)
cardiac depression, coma • Shock or hypovolaemic states
- Mx: stop LA • Raised ICP (risk of coning)
◊ 20% lipid emulsion (Intralipid) – • Unwilling or uncooperative pt (risk to pt
MOA: binds to LA in circulation & risk to healthcare staff)
◊ Resuscitate as necessary (may • Fixed output states (eg mitral and aortic
require intubation, ventilation, etc) stenosis)
◊ Seizure Mx
Spinal anaesthetic
• Other risks: failure, nerve injury,
• Aims to anaesthetise the spinal roots
bleeding
passing through the space
• Single dose – only suitable for short
procedures otherwise may wear out
• Risks
- some degree of lightheadedness and
↓BP – conservative Mx
- total spinal block (↓HR, ↓BP, anxiety,
apnoea, loss of consciousness);
requires resuscitation asap
- HA (possibly due to dural puncture)
- Urinary retention
- Permanent neurological damage (rare)