• Diagnostic*criteria*include*hyperglycaemia;*pH*<*7.

3;*reduced*bicarbonate;*raised*ketones;*metabolic*acidosis*
with*increased*anion*gap.*
• Management:*IV*fluid*(0.9%*NaCl)*is*firstUline*followed*by*IV*insulin*(0.1*U/kg/hr).*
• Management:*5%*dextrose*if*blood*glucose*<*15*mmol/l;*KCl*infusion*if*hypokalaemic.*
• Complications:*hypokalaemia*can*be*caused*by*insulin*treatment*(which*causes*potassium*to*move*into*cells)*
which*leads*to*arrhythmias.*Although*diabetic*ketoacidosis*is*associated*with*loss*of*electrolytes,*potassium*
is*kept*normal*or*high*due*to*metabolic*acidosis*which*exchanges*H+*into*cells*and*potassium*out.*
• Complications:*cerebral*oedema*is*a*common*complication*of*fluid*resuscitation*during*diabetic*ketoacidosis;*
hypokalaemia*and*hypoglycaemia*may*also*occur*due*to*fluid*therapy.*
Type*2*diabetes*
• Caused*by*a*relative*deficiency*of*insulin*due*to*insulin*resistance*caused*by*excess*adipose*tissue.*
• Typically*occurs*in*adults;*commonly*an*incidental*finding*or*presentation*of*polydipsia*and*polyuria.*
• Risk*factors:*strongly*associated*with*obesity.*
• Features:*polydipsia,*polyuria,*weight*loss.*
• Diabetic*ketoacidosis*is*extremely*rare*in*type*2.*
• Management:*mild*progressive*disease*can*be*treated*with*lifestyle*interventions.*
• Management:*firstUline*drug*is*metformin*if*HbA1c*>*48*mmol/mol.*(6.5%)*
• Management:*secondUline*drugs*should*be*added*if*HbA1c*>*58*mmol/mol*(7.5%)*and*includes*
sulphonylureas,*gliptins,*pioglitazone,*SGLTU2*inhibitors.*
• Management:*thirdUline*is*to*add*another*hypoglycaemic*if*HbA1c*remains*high*or*consider*insulin*therapy.*
• Management:*consider*using*triple*therapy*of*exenatide*+*metformin*+*sulphonylurea*if*BMI*>*35*and*insulin*
is*contraindicated*or*weight*loss*would*benefit*the*patient;*only*continue*exenatide*if*there*is*a*reduction*of*
HbA1c*of*at*least*11*mmol/mol*and*weight*loss*of*3%*of*initial*body*weight*in*6*months.*
• Management:*target*of*lifestyle*+*metformin*treatment*is*HbA1c*<*48*mmol/mol;*target*of*any*further*
therapy*is*HbA1c*<*53*mmol/mol.*
• Management:*blood*pressure*should*be*controlled*<*140/80*mmHg*(<*130/80*mmHg*if*endUorgan*damage);*
ACE*inhibitor*is*firstUline*and*offer*statin*if*Qrisk*score*>*10%*(basically*all*patients*with*diabetes).*
• Monitoring:*HbA1c*followUup*every*3U6*months*until*stable,*then*6*monthly.*
Hyperosmolar*hyperglycaemic*state*
• Many*cases*occur*in*newly*diagnosed*type*2*diabetes.*
• Precipitating*conditions:*infection,*high*dose*steroids,*myocardial*infarcion,*vomiting,*thromboembolism,*
poor*treatment*compliance*in*diabetes.*
• Features:*severe*hyperglycaemia,*dehydration,*renal*failure;*no*significant*ketonuria.*
• Investigations:*blood*tests*show*higher*blood*glucose*(>*30*mmol/l),*mild*hyperketonaemia*and*higher*pH**
(>*7.3)*than*diabetic*ketoacidosis.*
• Management:*fluid*resuscitation*is*firstUline*followed*by*control*of*blood**glucose*with*insulin.*
Maturity*onset*diabetes*of*the*young*(MODY)*
• Autosomal*dominant*disorder*that*causes*features*similar*to*type*2*diabetes*in*younger*patients*that*are*not*
overweight.*
• Management:*sulphonylurea*is*firstUline.*MODY*is*very*sensitive*to*sulphonylureas.*

* 40*
Latent*autoimmune*diabetes*of*adults*(LADA)*
• Autoimmune*diabetes*that*presents*later*in*life*unlike*type*1*and*often*gets*misdiagnosed*as*type*2.*
• Typically*seen*in*30U50*year*olds*and*is*not*associated*with*increased*adiposity.*
Obesity*
• Management:*firstUline*is*diet*and*exercise.*
• Management:*orlistat*is*a*pancreatic*lipase*inhibitor*(prevents*fat*absorption);*consider*in*obese*adults.*
Adverse*effects*include*faecal*urgency,*faecal*incontinence,*flatulence.*
HbA1c*
• Measures*average*blood*glucose*over*past*3*months.*
• Reduced*RBC*lifespan*can*make*HbA1c*appear*lower*than*it*actually*is.*Occurs*in*sickle*cell*anaemia,*
hereditary*spherocytosis,*GP6D*deficiency.*
• Increased*RBC*lifespan*can*make*HbA1c*appear*higher*than*it*actually*is.*Occurs*in*folic*acid*deficiency,*iron*
deficiency*anaemia,*splenectomy.*
Glucose*tolerance*test*
• Fasting*blood*glucose*measurement*after*a*75*g*glucose*load;*repeat*measurement*after*2*hours*to*see*body’s*
response.*
• 2*hour*GTT:*glucose*level*<*7.8*mmol/l*is*normal.*
Diabetic*neuropathy*
• Management:*firstUline*drugs*for*neuropathic*pain*is*amitriptyline,*duloxetine,*gabapentin*or*pregabalin;*
switch*to*an*alternative*if*one*drug*is*not*effective.*
• Management:*tramadol*is*indicated*for*severe*exacerbations*of*neuropathic*pain;*refer*patients*to*pain*clinic.*
Diabetic*foot*
• Neuropathy*presents*as*loss*of*sensation.*
• Ischaemia*due*to*peripheral*arterial*disease*presents*as*absent*foot*pulses,*reduced*ABPI*and*intermittent*
claudication.*
• Management:*screen*annually*(pain*sensation,*vibration,*foot*pulses).*
• Management:*provide*education*about*foot*care;*refer*any*problems*other*than*simple*calluses*to*diabetic*
foot*centres.*
• Complications:*callus*formation,*ulceration,*Charcot’s*arthropathy,*cellulitis,*osteomyelitis,*gangrene.*
Diabetic*gastroparesis*
• Autonomic*neuropathy*of*vagus*nerve*that*leads*to*paralysis*of*stomach*leading*to*delayed*emptying.*
• Features:*bloating,*vomiting,*impaired*glucose*control.*
• Management:*prokinetic*agents*are*firstUline*(metoclopramide,*doperidone,*erythromycin).*
Lupus*nephritis*
• Renal*disease*of*systemic*lupus*erythematosus*that*may*lead*to*diffuse*proliferative*glomerulonephritis.*
• Management:*treatment*of*hypertension,*corticosteroids,*immunosuppressants.*
Stress*response*
• Pituitary*gland*releases*ACTH*(to*stimulate*production*of*cortisol*from*adrenal*glands)*and*GH**
(prevents*muscle*protein*breakdown*and*promotes*tissue*repair).*
• Cortisol*feedback*mechanism*is*impaired*during*a*stress*response*to*allow*persistently*high*levels;**
metabolic*effects*include*glycogenolysis,*gluconeogenesis,*antiUinflammatory*and*mineralocorticoid*effects.*

* 41*
• ADH*is*released*as*it*is*an*important*vasopressor*and*enhances*haemostasis.*
• Renin*is*released*to*increase*sodium*reabsorption.*
• Insulin*release*is*inhibited*to*cause*hyperglycaemia;*glucagon*is*released.*
• Testosterone*and*estrogen*release*is*inhibited.*
*
ENT*
Sore*throat*
• Includes*pharyngitis,*tonsilitis,*laryngitis.*
• Centor*criteria:*tonsillar*exudate;*tender*cervical*lymphadenopathy;*history*of*fever;*absence*of*cough.*
• Centor*criteria:*if*3*or*more*criteria*are*present*there*is*a*50%*chance*that*it*is*due*to*Group*A*Streptococcus.*
• Management:*firstUline*is*paracetamol*or*ibuprofen*for*pain*relief.*
• Management:*antibiotics*should*be*given*to*patients*with*marked*systemic*symptoms;*immunocompromised*
patients;*history*of*rheumatic*fever;*acute*sore*throat*with*3*or*more*Centor*criteria.*
• Management:*firstUline*antibiotic*is*phenoxymethylpenicillin*(penicillin*VK)*or*erythromycin*(if*penicillinU
allergic).*
Acute*tonsilitis*
• Most*common*bacteria*is*Streptococcus&pyogenes.*
• Features:*pharyngitis,*fever,*malaise,*lymphadenopathy.*
• Features:*tonsils*are*generally*swollen*and*may*have*white*pustules*(bacterial).*
• Management:*bacterial*infection*is*treated*with*penicillin*type*antibiotics.*
Peritonsillar*abscess*(Quinsy)*
• Complication*of*bacterial*tonsilitis.*
• Features:*severe*throat*pain*that*localises*to*one*side,*deviation*of*uvula*to*unaffected*side,*reduced*neck*
mobility,*trismus*(difficulty*opening*mouth).*
• Management:*needle*aspiration*under*LA.*
Tonsillectomy*
• Indicated*for*people*that*have*tonsilitis*five*or*more*times*a*year*for*at*least*one*year*in*total.*
• Also*offered*to*patients*with*obstructive*sleep*apnoea*due*to*enlarged*tonsils;*peritonsillar*abscess*that*is*
unresponsive*to*treatment;*recurrent*febrile*convulsions*due*to*tonsilitis.*
Sinusitis*
• Most*common*infectious*agents*are*Strep&pneumoniae,&Haemophilus&influenzae*and*rhinovirus.*
• Predisposing*factors:*local*infection,*nasal*obstruction,*smoking.*
• Features:*facial*pain*(frontal*pressure*pain*worse*on*bending*forward),*nasal*discharge,*nasal*obstruction*
(cannot*breath*through*nose),*postUnasal*drip*(chronic*cough).*
• Management:*treatment*is*supportive*with*analgesia*and*intranasal*decongestants.*
• Management:*offer*antibiotics*(phenoxymethylpenicillin*firstUline)*if*symptoms*do*not*improve*after*10*days*
or*get*worse*after*getting*better.*
• Management:*recurrent*or*chronic*sinusitis*is*treated*with*intranasal*corticosteroids.*
Allergic*rhinitis*(Hayfever)*
• May*be*seasonal,*perennial*(throughout*the*year)*or*occupational.*

* 42*
• Features:*sneezing,*bilateral*nasal*obstruction,*clear*nasal*discharge;*postUnasal*drip.*
• Management:*intranasal*corticosteroids*(firstUline),*oral*antihistamines*(secondUline).*Oral*corticosteroids*for*
severe*exacerbations.*
PostUnasal*drip*
• Excessive*mucus*production*by*nasal*mucosa*that*may*lead*to*chronic*cough*or*bad*breath.*
Sialolithiasis*(Salivary*calculi)*
• 80%*of*salivary*gland*stones*occur*in*submandibular*glands*(usually*radioUopaque).*
• Features:*recurrent*unilateral*colicky*pain*and*swelling*after*eating.*
• Investigations:*sialography*(to*identify*site*of*obstruction*and*stones).*
Siladenitis*
• Usually*occurs*as*a*result*of*Staph&aureus*infection*or*blockage*of*salivary*duct*secondary*to*stones.*
• Duct*may*reveal*pus*leakage*or*erythema.*
Parotid*gland*tumour*
• Most*common*salivary*gland*tumour.*
• 80%*of*these*are*pleomorphic*adenomas.*
• Pleomorphic*adenoma:*benign*and*presents*as*a*slow*growing,*painless*lump.*
• Management:*superficial*parotidectomy*(complication*includes*CN*VII*damage).*
Benign*paroxysmal*positional*vertigo*(BPPV)*
• Features:*sudden*onset*vertigo*triggered*by*changes*in*head*position*and*lasts*10U20*seconds;*may*be*
associated*with*nausea.*
• Positive*DixUHallpike*manoeuvre*test.*
• Management:*usually*resolves*spontaneously*after*a*few*weeks*to*months.*
• Management:*Epley*manoeuvre*can*provide*effective*sympomatic*relief.*
Meniere’s*disease*
• Disorder*of*inner*ear*of*unknown*cause*that*is*typically*unilateral*(bilateral*symptoms*may*develop*after*a*
number*of*years).*
• More*common*in*middleUaged*adults.*
• Features:*recurrent*episode*of*vertigo,*tinnitus*and*hearing*loss*(sensorineural)*that*lasts*from*minutes*to*
hours;*sensation*of*fullness*in*ear*is*common.*
• Signs:*nystagmus,*positive*Romberg*test.*
• Management:*acute*episodes*are*treated*with*prochlorperazine;*betahistine*may*help*prevent*episodes.*
• Management:*ENT*referral*is*required*and*patients*should*not*drive*until*symptomatic*control*is*achieved.*
Vestibular*neuronitis*
• Vertigo*that*often*develops*following*a*viral*infection.*
• Features:*recurrent*vertigo*attacks*lasting*hours*to*days,*horizontal*nystagmus,*nausea*and*vomiting;**
no*hearing*loss*or*tinnitus.*
• Management:*acute*episodes*are*treated*with*prochlorperazine;*chronic*symptoms*are*treated*with*
vestibular*rehabilitation*exercises.*
Viral*labyrinthitis*
• Associated*with*recent*viral*infection.*

* 43*
• Features:*sudden*onset*vertigo*associated*with*nausea*and*vomiting;*hearing*may*be*affected.*
• Management:*usually*lasts*2U3*weeks*before*it*resolves*itself.*
Otitis*media*
• ViralUinduced*middle*ear*effusions*secondary*to*eustacian*tube*dysfunction.*
• Features:*ear*pain,*fever,*discharge*(if*tympanic*rupture).*
• Management:*prescribe*antibiotics*if*symptoms*last*>*4*days*and*fails*to*improve,*systemic*symptoms*(fever),*
patient*is*immunocompromised,*patient*is*<*2*years*and*has*bilateral*otitis*media,*perforation*occurs,*or*
there*is*discharge*in*the*canal*(yellowUgreen*discharge).*
• Management:*firstUline*antibiotic*is*amoxicillin*(erythromycin*if*penicillinUallergic).*
Glue*ear*
• Otitis*media*with*effusion;*peak*age*of*presentation*is*2*years.*
• Features:*hearing*loss*is*usually*the*presenting*feature;*secondary*problems*such*as*speech*and*language*
developmental*delay*may*be*seen.*
• Audiogram:*conductive*hearing*loss.*
• Management:*grommets.*
Otitis*externa*
• Causes:*bacterial*infection*(Staph&aureus,&Pseudomonas&aeruginosa),*fungal*infection,*seborrhoeic*dermatitis,*
contact*dermatitis.*
• Features:*unilateral*otalgia,*itching,*discharge*(rupture),*reduced*hearing*(conductive*hearing*loss).*
• Otoscopy:*red,*swollen*or*eczematous*canal;*tympanic*membrane*may*not*be*visible.*
• Management:*topical*antibiotics*+/U*steroid;*secondUline*is*treatment*of*other*possible*underlying*causes.*
• Management:*chronic*cases*can*be*treated*with*antifungal*and*antibacterial*ear*drops.*
Malignant*otitis*externa*
• Uncommon*type*of*otitis*externa*found*in*immunocompromised*individuals*or*diabetics.*
• Most*common*bacteria*is*Pseudomonas&aeruginosa.*
• Features:*severe*unrelenting*deepUseated*otalgia,*temporal*headache,*purulent*otorrhoea;**
dysphagia,*hoarseness*and*facial*nerve*dysfunction*are*seen*less*commonly.*
• Management:*antimicrobial*agents*and*topical*agents.*
Perforated*tympanic*membrane*
• Most*commonly*caused*by*infection.*
• Management:*no*treatment*is*required*as*it*will*heal*after*6U8*weeks;*advise*to*avoid*getting*water*in*ear.*
• Management:*prescribe*antibiotics*if*it*occurred*following*an*episode*of*acute*otitis*media*(as*it*is*likely*to*be*
an*acute*otitis*media*with*perforation).*
• Management:*myringoplasty*may*be*performed*in*the*tympanic*membrane*does*not*heal*itself.*
RamsayUHunt*syndrome*
• Caused*by*reactivation*of*varicella*zoster*virus*in*cranial*nerve*VII.*
• Features:*auricular*pain*(first*feature),*facial*nerve*palsy,*vesicular*rash*around*ear,*vertigo,*tinnitus;*
otoscopy*may*reveal*vesicles.*
• Management:*oral*aciclovir*and*corticosteroids.*
Otosclerosis*

* 44*
• Autosomal*dominant*condition*caused*by*replacement*of*normal*bone*by*vascular*spongy*bone.*
• More*common*in*females*and*typically*affects*young*adults.*
• May*be*precipitated*by*pregnancy*in*those*who*are*genetically*predisposed.*
• Features:*bilateral*progressive*conductive*deafness,*tinnitus,*family*history.*
• Otoscopy:*normal*tympanic*membrane.*
• Management:*hearing*aids*and*stapedectomy.*
Mastoiditis*
• Infection*of*mastoid*bone*in*ear;*patient*is*typically*very*unwell.*
• Features:*otalgia*(severe,*classically*behind*ear),*recurrent*otitis*media,*fever,*anterior*displacement*of*ear,*
mastoid*inflammation*(swelling,*erythema,*tenderness);*ear*discharge*if*eardum*as*perforated.*
Cholesteatoma*
• Abnormal*benign*skin*growth*in*middle*ear.*
• Caused*by*recurrent*middle*ear*infections*but*is*also*found*in*children*with*a*cleft*palate.*
• Features:*foul*smelling*discharge,*hearing*loss.*
• Features*caused*by*local*invasion*include*vertigo,*facial*nerve*palsy,*cerebellopontine*angle*syndrome.*
• Otoscopy:*attic*crust*in*uppermost*part*of*eardrum.*
Presbyacusis*
• AgeUrelated*sensorineural*hearing*loss.*
• Audiometry:*bilateral*high*frequency*hearing*loss.*
OtotoxicityUcausing*drugs*
• Aminoglycoside*(eg.*gentamicin);*quinine;*frusemide;*aspirin;*cytotoxic*agents.*
Audiogram*
• FirstUline*investigation*for*any*hearing*change.*
• Interpretation:*anything*above*the*20*dB*line*is*normal*hearing.*
• Interpretation:*both*air*and*bone*conduction*are*impaired*in*sensorineural*hearing*loss;*
only*air*conduction*is*impaired*in*conductive*hearing*loss;**
both*air*and*bone*conduction*are*impaired*(but*air*worse)*in*mixed*hearing*loss.*
Rinne’s*test*
• Tuning*fork*is*placed*on*the*mastoid*process*(bone*conduction)*until*sound*is*no*longer*heard*and*then*
transferred*to*the*external*acoustic*meatus*(air*conduction).*
• If*bone*conduction*>*air*conduction*this*indicates*conductive*deafness*(air*conduction*is*normally*superior*to*
bone*conduction).*
Weber’s*test*
• Tuning*fork*is*placed*in*the*middle*of*forehead*and*patient*is*asked*which*side*ls*loudest.*
• In*unilateral*sensorineural*deafness,*sound*localises*to*the*unaffected*side;*
in*unilateral*conductive*deafness,*sound*localises*to*the*affected*side.*
Nasopharyngeal*carcinoma*
• SCC*of*nasopharynx.*
• Associated*with*EBV*infection.*

* 45*
• Features:*otalgia*(referred*pain),*unilateral*serous*otitis*media,*nasal*obstruction,*nasal*discharge,*epistaxis,*
cervical*lymphadenopathy,*cranial*nerve*palsy.*
• Investigations:*CT/MRI*is*firstUline.*
• Management:*radiotherapy.*
Nasal*polyps*
• Associated*with*asthma,*aspirin*sensitivity,*infective*sinusitis,*cystic*fibrosis.*
• Features:*nasal*obstruction,*rhinorrhoea,*sneezing,*poor*sense*of*taste*and*smell.*
• Management:*all*patients*should*be*referred*to*ENT;*topical*corticosteroids*may*shrink*the*polyp*size.*
Nasal*septal*haematoma*
• Complication*of*nasal*trauma*that*may*develop*into*septal*necrosis*if*untreated.*
• Features:*nasal*obstruction*(most*common),*pain,*rhinorrhoea.*
• Signs:*bilateral*red*swelling*arising*from*nasal*septum.*
• Management:*immediate*surgical*drainage*and*IV*antibiotics.*
Gingivitis*
• Usually*secondary*to*poor*dental*hygiene.*
• Simple*gingivitis:*painless,*red*swelling*of*gum*margin*that*bleeds*on*contact.*
• Acute*necrotizing*ulcerate*gingivitis:*painful*bleeding*gums*with*halitosis*and*punchedUout*ulcers*on*gums;*
refer*to*dentist*and*treat*with*oral*metronidazole*and*chlorhexidine*mouthwash.*
Gingival*hyperplasia*
• May*be*caused*by*acute*myeloid*leukaemia.*
• Drug*causes:*phenytoin,*ciclosporin,*CCBs*(especially*nifedipine).*
Black*hairy*tongue*
• Discolouration*of*tongue*(black,*brown,*green,*etc.)*
• Predisposing*factors:*poor*oral*hygiene,*antibiotics,*ENT*radiotherapy,*HIV,*IV*drug*use.*
• Management:*tongue*scraping;*topical*antifungal*if*Candida*infection.*
Head*and*neck*cancer*
• Suspect*if*patient*presents*with*a*neck*lump,*hoarseness,*persistent*sore*throat*or*persistent*mouth*ulcer.*
• >*45*year*old*patient*that*presents*with*persistent*unexplained*hoarseness*or*lump*in*neck*should*be*
referred*for*investigation*for*cancer.*
Neck*lumps*
• Most*common*cause*is*reactive*lymphadenopathy*–*look*for*a*history*of*local*infection*or*viral*illness.*
• Lymphoma:*rubbery,*painless*lymphadenopathy*that*may*be*accompanied*by*night*sweats*and*
splenomegaly.*
• Thyroid*swelling:*lump*that*moves*upwards*on*swallowing;*thyroid*symptoms*may*be*present.*
• Thyroglossal*cyst:*more*common*in*patients*<*20*years*and*presents*as*a*midline*lump*between*the*isthmus*
of*thyroid*and*hyoid*bone*that*moves*upwards*with*protrusion*of*tongue.*
• Pharyngeal*pouch:*posteromedial*herniation*that*if*large,*will*present*as*a*midline*lump*in*the*neck*that*
gurgles*on*palpation.*Typical*symptoms*are*dysphagia,*regurgitation,*aspiration,*chronic*cough.*
• Carotid*aneurysm:*pulsatile*lateral*neck*mass*that*does*not*move*on*swallowing.*
Branchial*cyst*

* 46*
• Benign*defect*of*branchial*arches*that*produces*a*cyst*at*neck*that*may*enlarge*following*a*respiratory*tract*
infection.*
• Features:*asymptomatic*lateral*neck*lump*anterior*to*the*sternocleidomastoid*muscle,*typically*on*the*left*
side;*slowly*enlarging,*smooth,*soft,*fluctuant,*nonUtender,*no*movement*on*swallowing,*no*transillumination.*
• Investigations:*ultrasound;*FNA*(to*rule*out*malignancy).*
• Management:*can*be*treated*conservatively*or*surgically*excised.*
*
Ethics*
DoctorUpatient*relationship*
• In*the*event*of*an*error,*clinicans*should*inform*the*patient,*apologise,*explain*the*potential*effects*of*the*
error*and*offer*an*appropriate*resolution.*
• You*should*not*receive*any*gift*that*may*be*seen*to*affect*the*way*you*treat*the*patient*in*the*future*or*your*
doctorUpatient*relationship.*
Professionalism*
• All*doctors*are*accountable*for*decisions*they*make*and*not*for*the*decisions*of*others;*however*senior*
clinicians*can*be*accountable*to*ensure*junior*doctors*have*the*capacity*to*perform*jobs*but*not*their*
decisions*themselves.*
• Any*risk*posed*by*your*health*to*your*patients*should*be*assessed*by*an*appropriately*qualified*professional.*
• Wherever*possible*avoid*prescribing*medicines*to*yourself*or*anyone*whom*you*have*a*close*personal*
relationship.*
Confidentiality*
• Consent*must*be*obtained*for*disclosure*of*any*clinical*information*to*a*person*outside*of*her*care,*including*
their*admission*to*the*hospital.*
• You*may*disclose*information*of*infectious*communicable*disease*if*you*think*someone*else*is*at*risk*of*
infection*and*the*patient*cannot*be*persuaded*to*inform*them;*attempt*to*persuade*the*patient*before*you*
makde*the*disclosure.*
Competence*
• Patient*must*be*able*to*understand*and*retain*information;*patient*must*be*able*to*weigh*the*information*and*
make*a*decision;*patient*must*believe*that*the*information*is*true;*patient*must*be*able*to*communicate*their*
decision.*
Consent*
• When*an*emergency*arises*and*it*is*not*possible*to*find*out*a*patient’s*wishes,*you*can*treat*them*without*
their*consent*provided*the*treatment*is*immediately*necessary*to*prevent*serious*deterioration.*
• Decisions*about*CPR*is*medical*and*is*not*an*intervention*that*patients*or*their*next*of*kin*can*demand,*
especially*in*cases*where*it*would*not*appropriate*from*a*medical*perspective.*However,*all*CPR*decisions*
should*be*communicated*to*patients*and*family.*
• Patients*<*16*years*old*may*consent*to*treatment*if*they*are*deemed*to*be*competent*but*may*not*refuse*
treatment*which*is*deemed*in*their*best*interest.*
• Patients*<*16*years*old*may*consent*to*COC*if*they*understand*the*clinician’s*advice,*cannot*be*persuaded*to*
involve*parents,*are*likely*to*have*sex*with*or*without*contraception*and*it*is*in*the*patient’s*best*interests.*
Advanced*directives*

* 47*
• Patient’s*preferences*with*respect*to*medical*treatment*should*they*become*unable*to*express*those*wishes*
directly;*must*be*written*when*patient*is*of*sound*mind.*
• Must*be*followed*unless*the*decision*was*legally*withdrawn,*another*person*has*those*powers*due*to*Lasting*
Power*of*Attorney,*patient*has*competently*changed*their*mind,*there*are*reasonable*grounds*that*
circumstances*exist*that*the*person*would*have*chosen*differently*in*new*circumstances.*
• In*an*event*of*resuscitation*and*patient*has*not*placed*an*advance*decision,*the*most*senior*clinician*must*
make*a*decision*on*basis*of*the*patient’s*best*interests*and*views*of*close*relatives*may*be*sought*to*
determine*any*previously*expressed*wishes*or*ascertain*wishes*of*patient.*
• Cannot*be*used*to*demand*unreasonable*treatment*and*best*practice*still*applies.*
• Lasting*power*of*attorney:*appointing*a*person*to*act*on*their*behalf*should*they*lose*capacity*in*the*future.*
DVLA*
• Absolute:*severe*anxiety*or*depression*with*cognitive*or*behavioural*disturbance,*acute*psychotic*disorder,*
mania,*schizophrenia.*
*
Gastroenterology*
Dysphagia*
• Structural*obstruction*will*affect*solids*first;*neurological*dysfunction*will*affect*fluids*first.*
Dyspepsia*
• Patients*with*dyspepsia*and*have*either*dysphagia,*an*upper*abdominal*mass*suspicious*of*stomach*cancer*
or*is*>*55*years*with*weight*loss*and*GI*symptoms*should*be*given*an*endoscopy*within*2*weeks.*
• Patients*with*dyspepsia*and*haematemesis*should*be*given*a*nonUurgent*endoscopy.*
• Patients*>*55*years*with*treatmentUresistant*dyspepsia*or*gastric*cancer*red*flags*should*be*given*a**
nonUurgent*endoscopy.*
• Patients*with*dyspepsia*who*do*not*meet*referral*criteria*should*be*given*a*trial*of*full*dose*PPI*for*1*month*
or*a*‘test*and*treat’*approach*for*H.pylori.*
Acute*upper*GI*bleeding*
• Use*Blatchford*score*at*first*assessment*(0*=*early*discharge;*high*score*indicates*endoscopy).*
• Rockall*score*predicts*mortality*after*endoscopy.*
• All*patients*should*have*endoscopy*within*24*hours.*
• Patients*with*haemoglobin*<*110*g/l*should*be*urgently*referred*for*upper*and*lower*GI*endoscopy.*
• Patients*on*PPI*should*stop*at*least*2*weeks*prior*to*endoscopy*as*it*may*mask*underlying*pathology.*
• Management:*fluid*resuscitation,*platelet*transfusion,*fresh*frozen*plasma*and*prothrombin*complex*may*be*
required*if*patient*is*hypovolaemic.*
• Management:*nonUvariceal*bleeding*found*on*endoscopy*should*be*treated*with*PPIs.*
Variceal*bleeding*
• Management:*resuscitation*if*hypovolaemic.*
• Management:*terlipressin*is*a*vasoactive*agent*and*helps*prevents*recurrent*bleeding.*
• Management:*prophylactic*quinolones*have*been*shown*to*reduce*mortality*in*patients*with*liver*cirrhosis.*
• Management:*band*ligation*should*be*used*for*oesophageal*varices.*
• Management:*NUbutylU2Ucyanoacrylate*injection*should*be*used*for*gastric*varices.*

* 48*
• Management:*prophylactic*treatment*includes*propanolol*(reduces*rebleeding)*and*endoscopic*band*ligation.*
Gastroesophageal*reflux*disease*
• First*presentation*of*GORD*should*be*treated*using*dyspepsia*guidelines.*
• Management:*endoscopically*positive*GORD*is*treated*with*full*dose*PPI*for*1U2*months.**
If*effective*then*use*low*dose*PPIs*as*required;*if*no*response*then*trial*double*dose*PPIs*for*1*month.*
• Management:*endoscopically*negative*GORD*is*treated*with*full*dose*PPI*for*1*month.*
If*effective*then*use*low*dose*PPIs*as*required;*if*no*response*then*trial*H2*blockers*or*prokinetics*for*1*
month.*
• Complications:*oesophagitis,*ulcers,*anaemia,*Barrett’s*oesophagus,*benign*strictures,*oesophageal*cancer.*
Achalasia*
• Failure*of*oesophageal*peristalsis*and*relaxation*of*lower*oseophageal*sphincter.*
• Features:*dysphagia*of*both*liquids*and*solids,*heart*burn,*regurgitation*of*food.*
• Investigations:*firstUline*is*manometry*(shows*excessive*LOS*tone*which*does*not*relax*on*swallow).*
• Investigations:*barium*swallow*(shows*dilated*oesophagus*that*tapers*at*LOS;*‘bird*beak’*appearance).*
• Management:*intraUsphincteric*injection*of*botulinum*toxin;*surgical*option*is*Heller*cardiomyotomy.*
• Complications:*cardiomyotomy*may*cause*GORD*and*require*longUterm*PPI*use.*
Oesophagitis*
• Causes:*infection,*bisphosphonates,*NSAIDs.*
• Features:*odynophagia*with*no*weight*loss*and*systemically*well.*
Oesophageal*candidiasis*
• Risk*factors:*immunosuppression*(HIV,*steroid*use,*systemic*antibiotics).*
• Features:*odynophagia*and*dysphagia;*history*of*HIV.*
MalloryUweiss*tear*
• Tearing*of*inner*lining*of*the*gastroesophageal*junction*due*to*excess*vomiting.*
• Features:*haematemesis*(bright*red*blood),*recurrent*vomiting.*
Barrett’s*oesophagus*
• Metaplasia*of*lower*oesophageal*mucosa*from*squamous*to*columnar*epithelium.*
• Risk*factors:*GORD,*smoking.*
• Associated*with*increased*risk*of*oesophageal*adenocarcinoma.*
• Histology:*columnar*epithelium*that*resemble*other*parts*of*GI*tract*(eg.*villi).*
• Management:*high*dose*PPI*therapy*and*endoscopic*surveillance.*
• Management:*metaplasia*is*monitored*with*endoscopy*every*3U5*years;*dysplasia*is*treated*using*endoscopic*
mucosal*resection*or*radiofrequency*ablation.*
Oesophageal*cancer*
• Risk*factors:*GORD,*Barrett’s*oesophagus,*smoking,*alcohol,*achalasia.*
• Risk*factors:*Barrett’s*oesophagus*increases*risk*of*adenocarcinoma;*achalasia*increases*risk*of*SCC.*
• Features:*progressive*dysphagia*(solid*then*liquid)*associated*with*weight*loss,*anorexia,*vomiting;*history*of*
Barrett’s*oesophagus,*GORD,*achalasia,*smoking,*alcohol*abuse.*
• Damage*to*laryngeal*nerve*may*cause*hoarseness*of*voice.*
• Investigations:*upper*GI*endoscopy*is*firstUline;*CT*for*staging.*

* 49*
• Management:*oesophagectomy*and*adjunctive*chemotherapy.*
Pharyngeal*pouch*
• Posteromedial*diverticulum*through*pharynx*that*is*more*common*in*older*patients.*
• Features:*dysphagia,*regurgitation,*aspiration,*halitosis*(bad*breath);*neck*swelling*which*gurgles*on*
palpation.*
• Management:*surgery*to*close*defect.*
PlummerUVinson*syndrome*
• Triad*of*dysphagia,*glossitis*and*iron*deficiency*anaemia.*
Globus*pharyngis*
• Persistent*sensation*of*having*a*lump*in*the*throat*when*there*is*none.*
• Symptoms*(dysphagia,*discomfort*swallowing*saliva)*are*intermittent*and*relieved*by*swallowing.*
Cyclical*vomiting*syndrome*
• Severe*nausea*and*sudden*vomiting*that*lasts*hours*to*days*with*prodromal*intense*sweating*and*nausea.*
• Features:*vomiting,*weight*loss,*reduced*appetite,*abdominal*pain,*diarrhoea,*dizziness,*photophobia,*
heacache.*
• May*be*precipitated*by*a*triggering*factor.*
• Investigations:*pregnancy*test*to*rule*out*pregnancy;*U&E*for*electrolytes.*
• Management:*acute*treatment*consists*of*analgesia*and*antiemetics*(ondansetron).*
• Management:*avoidance*of*triggers*and*prophylactic*drugs*(amitriptyline,*propanolol,*topiramate).*
Peptic*ulcer*disease*
• Risk*factors:*NSAID,*alcohol*abuse,*SSRIs,*steroids.*
• Features:*epigastric*pain,*upper*GI*bleeding*(haematemesis,*melaena).*
• Duodenal*ulcers*(more*common)*cause*pain*relieved*by*eating;*gastric*ulcers*cause*pain*worsened*by*eating.*
• Investigations:*CT*if*in*diagnostic*doubt*of*perforation.*
• Manamgement:*surgery*for*perforation.*
• Complications:*perforation*results*in*sudden*onset*epigastric*pain*that*may*develop*into*generalised*
abdominal*pain*with*signs*of*peritonitis.*
Gastric*cancer*
• More*common*in*Asians*and*older*people.*
• Associated*with*H.pylori*infection,*gastric*adenomatous*polyps,*pernicious*anaemia,*smoking,*high*salt*and*
nitrates*diet.*
• Features:*dyspepsia,*nausea*and*vomiting,*dysphagia,*anorexia,*weight*loss.*
• Investigations:*endoscopy*with*biopsy;*CT*for*staging.*
• Histology:*signet*ring*cells*(higher*number*has*worse*prognosis).*
• Management:*gastrectomy.*
Helicobacter&pylori*infection*
• GramUnegative*bacteria*that*colonises*gastric*antrum*and*causes*irritation*which*leads*to*increased*gastrin*
release*and*higher*levels*of*gastric*acid*resulting*in*ulcers.*
• Associated*with*peptic*ulcer*disease*(95%*of*duodenal*ulcers,*75%*of*gastric*ulcers),*gastric*cancer*and*
atrophic*gastritis.*

* 50*
• Investigations:*urea*breath*test*is*firstUline;*should*not*be*performed*within*4*weeks*of*antibiotic*therapy*or*
2*weeks*of*PPI.*Stool*antigen*test*is*an*alternative.*
• Mangement:*eradication*therapy*is*PPI*+*amoxycillin*+*clarithromycin;*or*PPI*+*metronidazole*+*
clarithromycin.*
• Urea*breath*test*is*the*only*test*recommended*for*confirming*H.pylori*postUeradication*therapy.*
HaemolyticUuraemic*syndrome*
• Haemorrhagic*gastroenteritis*accompanied*by*a*triad*of*haemolytic*anaemia*(raised*urea),*renal*failure*and*
thrombocytopenia.*
• Management:*conservative;*antibiotics*are*contraindicated.*
ZollingerUEllison*syndrome*
• Condition*characterised*by*excessive*levels*of*gastrin,*usually*from*gastrinoma*of*deuodenum*or*pancreas.*
• Associated*with*MEN*I.*
• Features:*multiple*gastroduodenal*ulcers,*diarrhoea,*epigastric*pain.*
• Investigations:*fasting*gastrin*level*is*the*best*screening*test.*
Jaundice*
• Features:*lethargy,*abdominal*pain,*pruritus,*vomiting,*fever.*
• Signs:*yellow*sclera,*dark*urine,*pale*stool.*
• Investigations:*LFTs*and*ultrasound*of*liver*and*biliary*tree*is*firstUline;*yields*information*about*duct*
dilatation,*gallstones*and*other*masses.*
• Investigations:*perform*CT*scan*if*pancreatic*cancer*is*suspected.*
• Investigations:*perform*MRCP*or*MRI*if*liver*cancer*or*cholangiocarcinoma*is*suspected.*
• Investigations:*FBC*is*useful*for*determining*whether*the*cause*of*isolated*hyperbilirubinaemia*is*due*to*
haemolysis*or*Gilbert’s*syndrome.*
Liver*function*test*interpretation*
• AST/ALT*is*associated*with*hepatocellular*damage;*ALP*is*associated*with*cholestasis.*
• GGT*is*sensitive*to*alcohol*ingestion*and*cholestasis.*
• Albumin:*low*levels*indicate*liver*dysfunction*or*increased*plasma*volume*(and*rarely*malnutrition);*
high*levels*indicate*dehydration.*
• Prehepatic:*normal*or*high*bilirubin,*normal*ALT/AST,*normal*ALP.*
• Hepatic:*high*bilirubin,*very*high*ALT/AST,*high*ALP.*
• Posthepatic:*very*high*bilirubin;*high*ALT/AST;*very*high*ALP.*
Acute*pancreatitis*
• Causes*(GET*SMASHED):*gallstones,*ethanol,*trauma,*steroids,*mumps,*autoimmune*disease,*scorpion*bite,*
hypertriglyceridaemia,*hypercalcaemia,*hypothermia,*ERCP,*drugs*(sodium*valproate,*steroids,*azathioprine,*
frusemide,*bendroflumethiazide,*mesalazine).*
• Features:*severe*epigastric*pain*(radiates*to*back*in*50%*of*cases),*vomiting,*low*grade*fever.*
• Signs:*tender*abdomen,*ileus.*
• Investigations:*pancreatic*lipase*or*amylase;*imaging*as*per*gallstones.*
• Management:*gallstone*should*be*treated*with*cholecystectomy*or*ERCP*if*the*biliary*system*is*obstructed.*

* 51*
• Management:*if*pancreatitis*causes*infected*necrosis*then*perform*radiological*drainage*or*surgical*
necrosectomy.*
• Complications:*peripancreatic*fluid*collection*that*may*develop*into*a*pseudocyst*or*an*abscess;*pancreatic*
necrosis.*
Pseudocyst*
• Due*to*peripancreatic*fluid*collection,*typically*occurs*4*weeks*or*more*after*an*acute*pancreatitis.*
• 75%*are*associated*with*persistent*mild*elevation*of*amylase.*
• Investigations:*CT,*ERCP*or*endoscopic*ultasound.*
• Management:*50%*resolve*spontaneously*so*management*is*initially*conservative.*
• Management:*if*patient*is*symptomatic,*perform*a*fine*needle*aspiration*or*endoscopic*cystogastrostomy.*
Pancreatic*abscess*
• IntraUabdominal*collection*of*pus*that*typically*occurs*as*a*result*of*an*infected*pseudocyst.*
• Management:*transgastric*drainage*or*endoscopic*drainage.*
Pancreatic*necrosis*
• Complication*of*pancreatitis.*
• Infected*necrosis*may*lead*to*haemorrhage.*
• Management:*sterile*necrosis*is*treated*conservatively*and*infected*necrosis*requires*a*FNA*and*surgery.*
Pancreatic*cancer*
• Classically*painless*jaundice*(but*epigastric*pain*is*common).*
• Associated*with*old*age,*smoking,*diabetes,*chronic*pancreatitis,*HNPCC,*BRCA2*gene,*MEN.*
• Features:*painless*jaundice,*anorexia,*weight*loss,*back*pain,*steatorrhoea,*atypical*back*pain;**
palpable*gallbladder.*
• Investigations:*LFT*shows*raised*ALP*and*GGT.*
• Investigations:*USS*(60%*sensitivity);*CT*scan*is*diagnostic.*
• Management:*Whipple’s*(pacreaticoduodenectomy)*is*performed*for*resectable*lesions*at*the*head*of*
pancreas*followed*by*adjuvant*chemotherapy.*
• Management:*ERCP*with*stenting*is*often*used*for*palliative*management.*
Chronic*pancreatitis*
• Mostly*due*to*alcohol*abuse*and*other*cases*are*idiopathic.*
• Associated*with*development*of*diabetes.*
• Features:*pain*that*is*worse*following*a*meal,*steatorrhoea.*
• Investigations:*AXR*is*firstUline*but*CT*is*much*more*sensitive*and*specific.*
• AXR:*pancreatic*calcification.*
• Investigations:*faecal*elastase*may*provide*assessment*of*exocrine*function*if*imaging*is*inconclusive.*
• Management:*pancreatic*enzyme*supplementation*and*analgesia.*
Gallstones*(Cholelithiasis)*
• Features:*colicky*RUQ*pain;*worse*following*a*fatty*meal.*
• Investigations:*ultrasound*(firstUline);*MRCP*can*visualise*gall*bladder*and*pancreas*to*identify*stones.*
• Investigations:*ERCP*is*endoscopic*imaging*that*can*also*remove*stones*and*place*bile*duct*stents.*
• Management:*asymptomatic*gall*stones*do*not*require*treatment.*

* 52*
• Management:*symptomatic*gall*stones*are*removed*by*ERCP*or*laparoscopic*cholecystectomy.*
Choledocholithiasis*
• Obstructive*jaundice*caused*by*gallstones*in*common*bile*duct.*
• Features:*jaundice.*
• Management:*ERCP,*cholecystectomy.*
• Complications:*gallstones*present*in*the*common*bile*duct*may*cause*ongoing*jaundice*and*pain*despite*
cholecystectomy.*
Biliary*colic*
• Caused*by*gallstone*blocking*the*bile*duct.*
• Features:*intermittent*colicky*sharp*RUQ*pain*that*usually*begins*abruptly*and*subsides*gradually;*radiation*
to*right*shoulder*or*back,*nausea*and*vomiting,*attacks*often*worse*after*eating*(especially*fatty*food).*
• Investigations:*as*per*gallstones.*
• Management:*laparoscopic*cholecystectomy.*
• Complication:*obstructive*jaundice*(pale*stool,*dark*urine).*
Acute*cholecystitis*
• Inflammation*of*gallbladder*that*develops*usually*due*to*obstruction*of*cystic*duct*by*gallstone.*
• Features:*RUQ*pain*that*may*radiate*to*back*or*right*shoulder,*fever;*Murphy’s*positive.*
• Murphy’s*sign:*palpation*of*RUQ*during*deep*inspiration*causes*pain*as*the*inflamed*gallbladder*descends.*
• Investigations:*as*per*gallstones.*
• Blood*results:*raised*CRP*and*white*cells.*
• Management:*IV*antibiotics*and*cholecystectomy.*
• If*symptoms*develop*without*the*presence*of*gallstones,*it*is*acalculus*cholecystitis.*
Cholangitis*
• Infection*of*bile*duct*as*a*result*of*biliary*stasis*from*obstruction*(usually*by*gallstones).*
• Common*organism*is*E.coli.*
• Features:*RUQ*pain,*jaundice,*fever,*hypotension,*confusion.*
• Management:*fluid*resuscitation,*broadUspectrum*IV*antibiotics.*
• Management:*ERCP*for*gallstones*retrieval.*
Primary*biliary*cholangitis*
• Exam*hint:*jaundice*and*pruritus*in*middleUaged*female.*
• Chronic*liver*disorder*that*commonly*affects*middleUaged*females*characterised*by*inflammation*of*bile*duct.*
• Associate*with*Sjogren’s*syndrome,*rheumatoid*arthritis,*systemic*sclerosis,*thyroid*disease.*
• Features:*pruritus,*cholestatic*jaundice,*clubbing,*hepatosplenomegaly,*xanthelasma,*xanthomata.*
• Investigations:*antiUmitochondrial*antibodies*M2*subtype*is*present*in*98%*of*patients*(high*specificity).*
• Investigations:*raised*serum*IgM*and*ALP.*
• Management:*pruritus*is*treated*with*cholestyramine;*fat*soluble*vitamin*supplementation.*
• Management:*ursodeoxycholic*acid*can*prevent*further*formation*of*gallstones.*
• Complications:*malabsorption,*coagulopathy,*sicca*syndrome*(dry*mouth),*portal*hypertension,*
hepatocellular*cancer.*
Primary*sclerosing*cholangitis*

* 53*
• Biliary*disease*characterised*by*inflammation*and*fibrosis*of*hepatic*bile*ducts.*
• Highly*associated*with*ulcerative*colitis*(80%*of*patients*have*ulcerative*colitis).*
• Features:*cholestasis*(jaundice,*pruritus),*RUQ*pain,*lethargy.*
• Investigations:*ERCP*is*firstUline.*ANCA*may*be*positive.*
• ERCP:*multiple*biliary*strictures,*‘beaded’*appearance.*
• Complications:*cholangiocarcinoma,*increased*risk*of*colorectal*cancer.*
Cholangiocarcinoma*
• Liver*tumour*that*arises*in*the*bile*duct.*
• Common*complication*of*primary*sclerosing*cholangitis*(main*risk*factor).*
• Features:*persistent*biliary*colic;*anorexia,*jaundice*(gradual*onset*obstructive*pattern),*weight*loss.*
• Signs:*palpable*mass*in*RUQ*(Courvoisier’s*sign),*periumbilical*lymphadenopathy*(Sister*Mary*Joseph*nodes),*
left*supraclavicular*lymphadenopathy.*
• Courvoisier’s*sign:*palpable*enlarged*gallbladder*that*is*nonUtender*and*accompanied*by*painless*jaundice*is*
likely*to*be*cancer*of*gallbladder*or*pancreas.*
• Sister*Mary*Joseph*nodes:*palpable*nodule*in*umbilicus*due*to*metastasis*of*cancer*within*pelvis*or*abdomen.*
• Investigations:*deranged*LFTs;*CT/MRI*and*MRCP*are*imaging*methods*of*choice.**
• Investigations:*CA*19U9,*CEA*and*CA125*are*often*elevated.*
• Management:*surgical*resection*is*best*chance*of*cure;*palliative*care*is*important.*
• Prognosis:*5*year*survival*is*10%.*
Gallbladder*abscess*
• Features:*RUQ*pain,*pyrexia,*systemically*unwell.*
• Investigations:*ultrasound*+/U*CT.*
Gilbert’s*syndrome*
• Autosomal*recessive*condition*of*defective*bilirubin*conjugation.*
• Features:*jaundice,*unconjugated*hyperbilirubinaemia*(no*bilirubin*in*urine*dipstick*depite*high*bilirubin*
levels).*
• Management:*no*treatment*is*required.*
Hepatomegaly*
• Common*causes:*early*stage*cirrhosis*with*a*nonUtender*and*firm*liver,*malignancy*(hard*irregular*liver*edge)*
and*right*heart*failure.*
Acute*liver*failure*
• Rapid*onset*hepatocellular*dysfunction.*
• Causes:*paracetamol*overdose,*alcohol,*viral*hepatitis*(usually*A*or*B),*acute*fatty*liver*of*pregnancy.*
• Features:*jaundice,*coagulopathy*(raised*APPT),*hypoalbuminaemia,*hepatic*encephalopathy,*renal*failure.*
• Investigations:*APTT*is*raised;*serum*albumin*is*reduced.*
• Investigations:*liver*enzymes*are*poor*indicators.*
Hepatic*encephalopathy*
• Associated*with*liver*disease;*caused*by*excess*absorption*of*ammonia.*
• Precipitating*factors:*infection,*GI*bleed,*constipation,*hypokalaemia,*renal*failure,*alcohol,*post*transjugular*
intrahepatic*portosystemic*shunt,*drugs*(sedatives,*diuretics).*

* 54*
• Features:*confusion,*asterixis*(liver*flap),*inappropriate*behaviour,*telangiectasia;*coma*if*severe.*
• Management:*treat*underlying*cause.*
• Management:*lactulose*(firstUline)*with*addition*of*rifaximin*(antibiotic)*for*secondary*prophylaxis.*
• Management:*last*options*include*embolisation*of*portosystemic*shunts*and*liver*transplantation.*
NonUalcoholic*fatty*liver*disease*
• Fatty*liver*changes*similar*to*those*seen*in*alcoholic*hepatitis*in*the*absence*of*a*history*of*alcohol*abuse.*
• Associated*with*obesity,*hyperlipidaemia,*type*2*diabetes,*sudden*weight*loss.*
• Features:*usually*asymptomatic;*hepatomegaly.*
• Investigations:*ALT*and*AST*is*raised;*ALT*is*raised*to*a*greater*extent*than*AST.*
• Investigations:*ultrasound*may*show*increased*echogenecity*and*fatty*changes.*
• Investigations:*enhanced*liver*fibrosis*blood*test*can*screen*for*advanced*fibrosis.*
• Management:*lifestyle*changes*(particularly*alcohol*reduction*and*weight*loss).*
Cirrhosis*
• Causes:*alcohol,*nonUalcoholic*fatty*liver*disease,*viral*hepatitis.*
• Features:*thrombocytopaenia*due*to*splenomegaly*(overactive*spleen),*macrocytic*anaemia*(fewer*
megakaryocytes*are*produced*by*damaged*liver).*
• Investigations:*thrombocytopaenia*is*the*most*sensitive*and*specific*lab*result*for*diagnosis*of*cirrhosis*in*
patients*with*chronic*liver*disease.*
• Investigations:*raised*AST*is*a*better*indicator*than*ALT*for*cirrhosis.*
• Investigations:*offer*transient*elastography*to*people*with*hepatitis*C,*alcoholUrelated*liver*disease*and*
severe*alcohol*abusers.*Liver*biopsy*is*definitive.*
• Management:*offer*upper*endoscopy*to*newly*diagnosed*patients*to*check*for*varices*and*a*liver*ultrasound*
every*6*months*to*screen*for*hepatocellular*cancer.*
• Poor*prognostic*factors:*high*bilirubin,*low*albumin,*raised*APTT,*encephalopathy,*ascites.*
Hepatorenal*syndrome*
• Rapid*deterioration*in*kidney*function*in*patients*with*cirrhosis*or*liver*failure.*
• Portal*hypertension*results*in*release*of*vasoactive*mediators*which*cause*splanchic*vasodilation*to*increase*
blood*flow*to*GI*organs.*This*decreases*the*effective*circulatory*volume*and*leads*to*renin*release*and*renal*
vasoconstriction*leading*to*underperfusion*of*kidneys.*
• Types:*1)*generally*rapidly*progressive;*2)*slowly*progressive.*
• Management:*liver*transplant;*transjugular*intrahepatic*portosystemic*shunt*(TIPSS).*
• Management:*vasopressin*analogues*such*as*terlipressin*can*vasoconstrict*splanchnic*circulation.*
BuddUChiari*syndrome*
• Occlusion*of*hepatic*veins*that*drain*the*liver*and*result*in*portal*hypertension.*
• Causes:*thrombophilia,*pregnancy,*COC.*
• Features:*abdominal*pain*(sudden,*severe),*ascites*and*hepatomegaly.*
Viral*hepatitis*
• Often*caught*during*overseas*travel.*
• Features:*nausea*and*vomiting,*anorexia,*myalgia,*lethargy,*RUQ*pain.*
Hepatitis*A*

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• Caused*by*RNA*picornavirus*(incubation*period*2U4*weeks).*
• Transmission*by*faecalUoral*spread;*commonly*via*anal*oral*sex.*
• Features:*fluUlike*illness*associated*with*jaundice*and*hepatosplenomegaly.*
• Management:*conservative;*complications*are*rare*and*no*increased*risk*of*hepatocellular*carcinoma.*
• PostUexposure*prophylaxis:*hepatitis*A*immunoglobulin*if*person*was*not*previously*vaccinated.*
• PostUexposure*prophylaxis:*plus*hepatitis*A*vaccine*with*a*booster*if*person*was*previously*vaccinated.*
Hepatitis*B*
• Serology:*HBs*antigen*indicates*an*ongoing*infection*that*is*either*acute*or*chronic*(>*6*months).*
• Serology:*antiUHBs*indicates*immunity*(either*exposure*or*immunisation).*Negative*in*chronic*disease.*
• Serology:*antiUHBc*confirms*previous*or*current*infection*(negative*is*patient*is*immunised).*
• Serology:*IgM*antiUHBc*indicates*acute*infection*(1U6*months).*
• Management:*treat*with*interferonUalpha;*consider*other*antiviral*medication.*
• PostUexposure*prophylaxis:*hepatitis*B*immunoglobulin*if*person*was*not*previously*vaccinated.*
• PostUexposure*prophylaxis:*plus*hepatitis*B*vaccine*with*a*booster*if*person*was*previously*vaccinated.*
Hepatitis*C*
• Only*30%*of*patients*are*symptomatic.*
• Risk*factors:*IV*drug*users,*vertical*transmission,*sexual*contact.*
• Features:*jaundice,*fatigue,*arthralgia;*transient*rise*in*serum*aminotransferase.*
• Investigations:*PCR*–*HCV*RNA*indicates*current*infection.*
• Investigations:*antiUHCV*positive*indicates*current*or*recently*cleared*infection.*
• Management:*15U45%*of*patients*will*clear*virus*and*the*remainder*develop*chronic*hepatitis*C.*
• Management:*monthly*PCR*monitoring*until*seroconversion*occurs;*then*give*interferonUalpha*and*ribavirin.*
Chronic*hepatitis*C*
• Persistent*HCV*RNA*in*blood*for*>*6*months.*
• Complications:*rheumatological*disease,*Sjogren’s*syndrome,*cirrhosis,*hepatocellular*cancer,*
membranoproliferative*glomerulonephritis.*
• Management:*treat*according*to*viral*genotype;*protease*inhibitors*+/U*ribavirin.*
Hepatitis*D*
• Requires*hepatitis*B*to*develop.*
• Transmission*by*bodily*fluids*(needle*exchange).*
• Associated*with*fulminant*hepatitis,*chronic*hepatitis,*cirrhosis.*
• CoUinfection:*simultaneous*infection*of*hepatitis*B*and*D.*
• Superinfection:*hepatitis*B*and*subsequent*development*of*hepatitis*D.*
• Investigations:*diagnosis*is*made*with*PCR.*
Hepatitis*E*
• Caused*by*RNA*hepatitis*E*virus.*
• Transmission*by*faecalUoral*route*(typically*seafood*and*uncooked*pork).*
• Features:*similar*to*hepatitis*A*but*with*significant*mortality*during*pregnancy.*
• Management:*conservative;*not*associated*with*chronic*disease*or*increased*risk*of*hepatocellular*cancer.*
Autoimmune*hepatitis*

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• Associated*with*autoimmune*disorders*and*ANA/SMA/LKM1*antibodies.*
• Features:*signs*of*chronic*liver*disease*and*acute*hepatitis*(jaundice,*fever),*amenorrhoea.*
• Investigations:*ALT/AST*is*raised*more*than*ALP.*
• Management:*steroids*and*other*immunosuppressants.*Liver*transplant*may*be*required.*
Ischaemic*hepatitis*
• Diffuse*hepatic*injury*resulting*from*acute*hypoperfusion.*
• Diagnosed*in*presence*of*a*precipitating*event*(eg.*MI)*and*raised*ALT*>*1000*u/l.*
Liver*abscess*
• PusUfilled*lesion*in*liver*caused*by*conditions*such*as*appendicitis*or*biliary*sepsis.*
• Features:*RUQ*pain,*fever;*jaundice*is*seen*in*50%.*
• Investigations:*USS*(fluidUfilled*cavity,*hyperechoic*walls*if*chronic).*
Pyogenic*liver*abscess*
• Most*common*organisms*are*Staph&aureus*in*children;*E.coli*in*adults.*
• Features:*RUQ*pain*and*fever*with*deranged*LFTs.*
• Investigations:*CT.*
• Management:*amoxicillin*+*ciprofloxacin*+*metronidazole;*if*penicillinUallergic*–*ciprofloxacin*+*clindamycin.*
• Management:*image*guided*percutaneous*drainage*may*be*required;*surgical*resection*if*infection*does*not*
resolve.*
Hepatocellular*carcinoma*
• Most*common*liver*tumour*(5*year*survival*of*15%).*
• Risk*factors:*chronic*hepatitis*B*and*C,*alcohol,*haemochromatosis,*primary*biliary*cirrhosis,*liver*cirrhosis.*
• Features:*jaundice,*RUQ*pain,*ascites,*pruritus,*hepatomegaly,*splenomegaly,*weight*loss;*alcohol*abuse.*
• Investigations:*ultrasound*and*alphaUfetoprotein*is*firstUline;*CT/MRI*is*diagnostic,*PET*for*metastases.*
• Investigations:*LFTs*are*raised*but*are*not*specific.*
• Investigations:*elevated*alphaUfetoprotein*(AFP)*is*a*useful*marker*for*monitoring.*
• Investigations:*avoid*biopsy*(due*to*seeding*of*tumour*cells).*
• Screening:*consider*USS*screening*for*patients*with*liver*cirrhosis*secondary*to*hepatitis*B,*hepatitis*C*or*
alcohol*abuse.*
• Management:*surgical*resection*for*early*localised*cancer;*liver*transplantation*and*radiotherapy*are*options.*
• Management:*sorafenib*(multikinase*inhibitor)*can*be*used*to*treat*metastatic*disease.*
Liver*cell*adenoma*
• Benign*liver*lesion*that*mostly*occur*in*women*with*elevated*estrogen*levels.*
• Usually*sharply*demarcated*from*normal*liver.*
• Investigations:*USS*(lesion*of*mixed*echoity*and*heterogenous*nature).*
Liver*haemangioma*
• Benign*liver*lesion*of*tangled*network*of*blood*vessels*that*is*normally*separated*from*an*otherwise*normal*
liver*by*a*ring*of*fibrous*tissue.*
• Features:*reddish*purple*hypervascular*lesions*on*liver.*
Carcinoid*syndrome*
• Caused*by*metastases*of*neuroendocrine*tumours*to*the*liver*that*release*serotonin*into*systemic*circulation.*

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• Features:*serotonin*causes*flushing*(often*earliest*symptom),*diarrhoea,*abdominal*pain,*bronchospasm,*
hypotension,*right*heart*valvular*stenosis;*accompanied*by*malignancy*symptoms*(weight*loss,*fatigue).*
• Investigations:*urinary*5UHIAA,*plasma*chromogranin*A.*
• Management:*somatostatin*analogues*(eg.*octreotide).*
Haemochromatosis*
• Autosomal*recessive*disorder*of*iron*absorption*and*metabolism*that*results*in*excess*iron*accumulation.*
• Early*features:*fatigue,*erectile*dysfunction,*arthralgia.*
• Late*features:*bronze*skin*pigmentation,*arthritis,*diabetes,*chronic*liver*disease,*hepatomegaly,*cirrhosis,*
cardiomyopathy,*hypogonadism.*
• Investigations:*iron*study*shows*raised*transferrin*saturation,*raised*ferritin,*low*total*iron*binding*capacity.*
• Investigations:*XUray*of*joints*show*chondrocalcinosis.*
• Investigations:*C282Y*and*H63D*mutations*are*diagnostic.*
• Management:*regular*venesection*is*main*treatment.*
Wilson’s*disease*
• Autosomal*recessive*disorder*characterised*by*excessive*copper*deposition*in*tissues.*
• Onset*of*symptoms*is*10U25*years;*children*usually*present*with*symptoms*of*liver*disease*and*young*adults*
with*neurological*features.*
• Features:*speech*and*behavioural*problems,*hepatitis,*cirrhosis,*basal*ganglia*degeneration,*asterixis,*chorea,*
dementia,*jaundice,*KayserUFleischer*rings*(brown*rings*surrounding*iris),*renal*tubular*acidosis,*haemolysis,*
blue*nails.*
• Investigations:*reduced*serum*caeruloplasin*(carrier*of*copper),*reduced*serum*copper*(because*copper*is*
stored*in*tissues),*increased*urinary*copper.*
• Management:*penicillamine*is*firstUline*drug;*trientine*hydrochloride*is*an*alternative.*
PeutzUJeghers*syndrome*
• Autosominal*dominant*condition*characterised*by*numerous*hamartomatous*polyps*in*GI*tract.*
• Associated*with*pigmented*freckles*on*lips,*face,*palms*and*soles.*
• Features:*abdominal*pain*intestinal*obstruction*(eg.*intrussusception),*GI*bleeding.*
Ascites*
• Exam*hint:*consider*if*there*is*a*distended*abdomen*with*history*of*alcohol*excess,*cardiac*failure.*
• Accumulation*of*fluid*within*abdomen*usually*caused*by*portal*hypertension.*
• Investigations:*raised*serum*ascitesUalbumin*gradient*(normal*is*<*11*g/l)*indicates*portal*hypertensionU
caused*ascites.*
• Management:*reduction*of*dietary*sodium;*spironolactone,*drainage.*
• Management:*large*volume*drainage*requires*an*albumin*infusion*to*reduce*postparacentesis*circulatory*
dysfunction.*
Melanosis*coli*
• Disorder*of*pigementation*of*bowel*wall.*
• Associated*with*laxative*abuse.*
• Histology:*pigmentUladen*macrophages.*
Malnutrition*

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• Defined*as*BMI*<18.5*or*unintentional*weight*loss*greater*than*10%*within*last*3U6*months.*
• Screening*is*mostly*done*using*MUST*tool;*dietician*support*is*needed*if*patient*is*high*risk.*
Alcohol*
• Men*and*women*should*not*drink*more*than*14*units*a*week;*best*to*spread*this*evenly*over*>*3*days.*
• AUDIT*is*recommended*by*NICE*as*firstUline*alcohol*abuse*screen.*
Other*
• Urea:*raised*in*upper*GI*bleeding*due*to*breakdown*of*RBC*in*stomach.*
• Bilirubin:*may*be*raised*due*to*haemolysis.*
*
General*surgery*
Abdomen*
• Causes*of*pain:*peptic*ulcer*disease,*acute*pancreatitis,*biliary*colic,*acute*cholecystitis,*appendicitis,*
diverticulitis,*bowel*obstruction,*AAA.*
• Causes*of*tenderness:*appendicitis,*mesenteric*adenitis,*Mittelschmerz,*FitzUHugh*Curtis*syndrome,*ruptured*
AAA,*perforated*peptic*ulcer,*intestinal*obstruction,*mesenteric*infarction.*
• Causes*of*distension:*pregnancy,*bowel*obstruction,*ascites,*urinary*retention,*ovarian*cancer.*
Colonic*bleeding*
• Different*to*melaena*(black*stool)*because*blood*does*not*spend*enough*time*in*GI*tract*if*originating*from*
bowels.*
• RightUsided*bleeding*is*darker*coloured*than*leftUsided*bleeding.*
• Investigations:*PR*exam,*proctoscopy.*
• Management:*consider*admission*is*patient*is*>*60*years,*haemodynamically*unstable,*profusely*bleeding,*
anticoagulated*or*has*significant*comorbidities.*
• Management:*correction*of*any*haemodynamic*compromise*is*required*as*firstUline*management.*
• Management:*further*investigation*would*be*a*colonoscopy*in*a*stable*patient*or*an*angiogram*in*an*unstable*
patient*to*identify*a*bleeding*source.*
• Management:*:*surgery*is*indicated*if*bleeding*continues*despite*endoscopic*intervention,*recurrent*bleeding,*
or*patient*is*known*high*risk*of*haemodynamic*instability.*If*source*of*colonic*bleeding*is*unclear*and*surgery*
is*required,*perform*a*laparotomy.*
Rectal*bleeding*
• Bright*red*blood*indicates*rectal*origin;*dark*blood*suggests*a*more*proximal*bleed*or*upper*GI.*
• Investigations:*PR*exam*+*sigmoidoscopy.*
• Investigations:*perform*colonoscopy*if*accompanied*by*change*in*bowel*habit*or*there*is*suspicion*of*IBD.*
Oesophageal*rupture*
• Complete*disruption*of*oesophageal*wall*in*absence*of*preUexisting*disease.*
• Suspect*in*patients*with*severe*chest*pain,*signs*of*pneuomnia*and*vomiting*in*the*absence*of*cardiac*
findings*and*a*history*that*does*not*fit*with*pneumonia.*
• Investigations:*erect*CXR*shows*infiltrate*or*effusion*in*90%*of*cases.*
Irritable*bowel*syndrome*(IBS)*
• Features:*abdominal*pain,*altered*bowel*habit;*lethargy,*nausea,*backache,*bladder*symptoms.*

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• Diagnostic*criteria:*abdominal*pain*relieved*by*defaecation*or*associated*with*change*in*bowel*habit*in*
addition*to*2*of*the*following*–*altered*stool*passage*(straining/urgency/incomplete*evacuation),*abdominal*
bloating*or*distension,*symptoms*made*worse*by*eating,*passage*of*mucus*covered*stool.*
• Red*flags:*rectal*bleeding,*weight*loss,*family*history,*old*age*(>60*years).*
• Investigations:*FBC,*CRP,*coeliac*disease*screen*(TTG).*
• Investigations:*CA125*should*be*measured*in*women*over*50*who*experience*symptoms*of*IBS*because*IBS*
rarely*presents*for*first*time*in*women*of*this*age*(rule*out*ovarian*cancer).*
• Management:*firstUline*drug*is*antispasmodic*agent*for*pain,*laxatives*(but*not*lactulose)*for*constipation,*
loperamide*for*diarrhoea;*secondUline*treatment*is*lowUdose*tricyclic*antidepressants*(eg.*amitriptyline).*
• Management:*general*dietary*advice*includes*eating*regular*meals,*restricting*tea/coffee/alcohol/fizzy*and*
reduced*intake*of*processed*foods.*
Irritable*bowel*disease*(IBD)*
• Features*more*common*in*UC:*bloody*diarrhoea,*abdominal*pain*in*LLQ,*tenesmus.*
• Features*more*common*in*Crohn’s:*nonUbloody*diarrhoea,*weight*loss,*perianal*disease,*mouth*ulcers,*
abdominal*mass*palpable*in*RIF.*
• Features*in*both:*diarrhoea,*arthritis,*erythema*nodosum*and*pyoderma*grangrenosum.*
• Associations*in*UC:*primary*sclerosing*cholangitis,*uveitis,*colorectal*cancer.*
• Associations*in*Crohn’s:*bowel*obstruction,*gallstones,*fistulas,*episcleritis.*
• Histology*in*UC:*inflammation*always*starts*at*rectum*and*is*continuous;*has*no*inflammation*beyond*
submucosa*and*shows*widespread*pseudopolyps*(ulceration*with*preservation*of*adjacent*mucosa*which*
look*like*polyps)*
• Histology*in*Crohn’s:*lesions*may*be*seen*anywhere*along*GI*tract*and*skip*lesions*may*be*present;*
inflammation*in*all*layers*and*increased*goblet*cells*and*granulomas,*deep*ulcers,*skip*lesions.*
Crohn’s*disease*
• IBD*that*commonly*affects*the*terminal*ileum*and*colon*but*can*be*seen*anywhere*along*GI*tract*in*skip*
lesion*patterns.*
• Features:*diarrhoea*(most*prominent*symptom*in*adults),*abdominal*pain*(most*prominent*in*children),*
altered*bowel*habit,*malaise,*Crohn’s*colitis*may*cause*bloody*diarrhoea;*weight*loss,*lethargy.*
• Signs:*perianal*fissures,*skin*tags*or*fistulae.*
• Histology:*inflammation*in*all*layers*from*mucosa*to*serosa,*skip*lesions,*goblet*cells,*granulomas.*
• Blood*results:*raised*CRP,*raised*faecal*calprotectin,*anaemia,*low*vitamin*B12*and*vitamin*D.*
• Faecal*calprotectin:*marker*released*in*bowel*inflammation*–*sign*of*IBD*and*excludes*IBS.**
• Barium*enema:*strictures,*proximal*bowel*dilation,*fistulae,*ulcers.*
• Investigations:*CRP*correlates*well*with*disease*activity;*colonoscopy*is*investigation*of*choice*(deep*ulcers,*
skip*lesions).*
• Management:*induce*remission*medically.*Glucocorticoids*(eg.*IV*hydrocortisone)*is*firstUline;*5UASA*drugs*
(eg.*mesalazine)*are*secondUline*but*not*as*effective;*azathioprine,*mercaptopurine*or*methotrexate*may*be*
used*as*an*addUon*medication*to*induce*remission*but*is*not*used*as*monotherapy.*
• Management:*maintaining*remission*–*smoking*cessation;*azathioprine*or*mercaptopurine*as*firstUline*drugs*
to*maintain*remission,*methotrexate*is*secondUline;*80%*of*patients*will*eventually*have*surgery.*
• Management:*surgery*may*provide*symptomatic*improvement*and*required*for*complications.*

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• Management:*terminal*ileum*is*the*most*commonly*affected*site*and*may*be*treated*with*ileocaecal*resection.*
• Complications:*fistulae,*abscess*formation,*strictures.*
Ulcerative*colitis*
• IBD*that*always*starts*at*rectum*in*a*continuous*pattern*and*never*spreads*beyond*ileocaecal*valve;*peak*
incidence*is*15U25*y.o*and*55U65*y.o.*
• Features:*bright*red*bleeding*often*mixed*with*stool,*bloody*diarrhoea,*urgency,*tenesmus,*abdominal*pain,*
weight*loss,*mucus*in*stool.*
• Features:*rectum*is*most*affected.*
• Signs:*proctitis*(most*common*finding),*perianal*disease*is*usually*absent.*
• Blood*results:*raised*inflammatory*markers*and*faecal*calprotectin.*
• Histology:*no*inflammation*beyond*submucosa,*pseudopolyps,*continuous*disease,*crypt*abscess.*
• Barium*enema:*loss*of*haustrations,*superficial*ulceration,*pseudopolyps;*narrow*colon*in*long*standing*
disease.*
• Management:*inducing*remission*–*firstUline*treatment*is*oral*aminosalicylates*(eg.*mesalazine)*and*people*
who*fail*to*respond*are*given*oral*prednisolone;*severe*colitis*requires*admission*and*IV*steroids*are*usually*
given.*
• Management:*inducing*remission*–*for*distal*colitis,*rectal*aminosalicylates*have*been*shown*to*be*superior*
to*oral.*
• Management:*maintaining*remission*–*firstUline*treatment*is*oral*aminosalicylates*with*azathioprine*and*
mercatopurine.*
• Management:*indications*for*surgery*are*disease*that*requires*maximum*treatment*or*prolonged*courses*of*
steroids.*
• Management:*a*flare*in*symptoms*requires*an*abdominal*xUray*to*rule*out*toxic*megacolon*(transverse*colon*
>*6*cm*with*systemic*upset).*
• Severity*classification:*mild*=*fewer*than*4*stools*a*day,*no*systemic*disturbance;*moderate*=*4U6*stools*a*day,*
minimal*systemic*disturbance;*severe*=*6+*stools*a*day*containing*blood,*systemic*disturbance*(fever,*
tachycardia,*abdominal*tenderness,*distension,*anaemia)*–*requires*hospitalisation.*
Diverticular*disease*
• Herniation*of*colonic*mucosa*through*muscular*wall*of*colon.*
• Typical*site*is*between*taenia*coli*of*sigmoid*colon*where*vessels*pierce*muscle*to*supply*the*mucosa.*
• Features:*altered*bowel*habir,*bleeding,*abdominal*pain.*
• Diverticular*bleeding*presents*as*a*sudden*onset*profuse*dark*bleeding*that*ceases*spontaneously.*
• Investigations:*colonoscopy,*CT*abdomen.*
• Investigations:*acutely*unwell*surgical*patients*should*be*investigated*with*AXR*(for*perforation)*and*CT*
abdomen*(for*inflammation,*abscess*formation).*
• Management:*mild*attacks*of*diverticulitis*may*be*managed*with*antibiotics*at*home;*if*ineffective*then*give*
IV*ceftriaxone*+*metronidazole*at*hospital.*
• Management:*recurrent*episodes*may*require*segmental*resection;*abscesses*can*be*drained*surgically*and*
faecal*peritonitis*requires*resection.*
• Complications:*diverticulitis,*haemorrhage,*development*of*fistula;*perforation*may*lead*to*development*of*
abscess*of*faecal*peritonitis.*

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Diverticulitis*
• Inflammatory*attack*of*diverticular*disease.*
• Features:*abdominal*pain*and*tenderness*(classically*LLQ),*altered*bowel*habit,*anorexia,*nausea*and*
vomiting,*diarrhoea,*fever.*
• Investigations:*raised*CRP,*white*cells.*
• Management:*mild*attacks*can*be*treated*with*oral*antibiotics;*severe*attacks*require*nil*by*mouth,*IV*fluids*
and*IV*antibiotics*(cephalosporin*+*metronidazole).*
• Complications:*abscess*formation,*peritonitis,*obstruction,*perforation.*
Bowel*obstruction*
• Features:*colicky*abdominal*pain,*vomiting,*abdominal*distension,*constipation;*peritonism*may*occur*if*
there*is*local*necrosis*of*bowel*loops.*
• Causes:*small*bowel*obstruction*is*most*commonly*caused*by*adhesions.*
• Causes:*large*bowel*obstruction*is*most*commonly*caused*by*bowel*cancer.*
• AXR:*dilated*bowels,*fluid*level.*
• AXR:*small*bowel*maximum*normal*diameter*is*35*mm;*valvulae*conniventes*extend*all*the*way*across.*
• AXR:*large*bowel*maximum*normal*diameter*is*55*mm;*haustra*only*extends*oneUthird*of*the*way*across.*
• Management:*surgical.*
Sigmoid*volvulus*
• Twisting*of*sigmoid*colon*resulting*in*compromised*blood*flow*and*large*bowel*obstruction.*
• Associated*with*old*age,*chronic*constipation,*Parkinson’s*disease,*Duchenne*muscular*dystrophy,*
schizophrenia.*
• Features:*constipation,*abdominal*distension,*nausea*and*vomiting,*abdominal*pain.*
• AXR:*large*bowel*obstruction*(dilated*loop*of*colon*with*airUfluid*level),*coffee*bean*sign,*lack*of*haustra.*
• Management:*rigid*sigmoidoscopy*with*rectal*tube*insertion*for*decompression.*
• Management:*if*patient*has*symptoms*of*peritonitis*then*perform*urgent*laparotomy.*
Caecal*volvulus*
• Features:*similar*to*sigmoid*volvulus.*
• AXR:*large*bowel*obstruction*(dilated*loop*of*colon*with*airUfluid*level),*intact*haustra.*
Gallstone*ileus*
• Small*bowel*obstruction*secondary*to*an*impacted*gallstone.*
• May*develop*from*fistula*formation*between*gangrenous*gallbladder*and*duodenum.*
• Features:*abdominal*pain*(RUQ),*abdominal*distension,*vomiting.*
• AXR:*small*bowel*obstruction,*air*in*biliary*tree.*
• Management:*laparotomy*and*removal*of*gallstone*from*small*bowel.*
Constipation*overflow*
• Featurse:*abdominal*pain,*diarrhoea*(watery*stool);*palpable*abdominal*mass.*
Colorectal*cancer*
• Rectum*is*most*common*location*(40%);*sigmoid*colon*(30%).*
• 90%*of*cancers*are*adenocarcinomas.*
• APC:*tumour*suppressor*gene*that*is*affected*by*mutations*in*up*to*80%*of*sporadic*colorectal*cancers.*

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• Screening:*every*2*years*to*people*aged*60U74*years*in*form*of*faecal*occult*blood*test*(FOBT);**
follow*up*abnormal*results*with*colonoscopy.*
• Screening:*offer*FOBT*to*patients*who*experience*altered*bowel*habit*or*iron*deficiency*anaemia*and*patients*
>*50*years*with*unexplained*abdominal*pain*or*weight*loss.*
• Features:*rectal*bleeding,*altered*bowel*habit,*weight*loss,*abdominal*pain,*abdominal*mass,*iron*deficiency*
anaemia.*
• Investigations:*FOBT,*colonoscopy,*CT*abdomen.*CT/MRI*for*staging.*
• Urgent*referral*(<*2*weeks)*if*patient*is*>*40*years*with*unexplained*weight*loss*and*abdominal*pain;*
>*50*years*with*unexplained*rectal*bleeding;*>*60*years*with*iron*deficiency*anaemia*or*altered*bowel*habir;*
FOBT*positive.*
• Consider*urgent*referral*if*there*is*a*rectal*or*abdominal*mass;*unexplained*anal*mass*or*anal*ulceration;*
<*50*years*with*rectal*bleeding*and*either*abdominal*pain,*altered*bowel*habit,*weight*loss*or*iron*deficiency*
anaemia.*
• Management:*Hartmann’s*procedure*is*resection*of*rectosigmoid*colon*with*formation*of*an*end*colostomy*
instead*of*an*anostamoses*–*indicated*in*settings*where*healing*on*anastomosis*is*unlikely*(eg.*weak*blood*
supply,*peritonitis,*unstable*patient).*
• Dukes’*criteria*estimates*5*year*survival:*A)*tumour*confined*to*mucosa*(95%);**
B)*tumour*invading*bowel*wall*(80%);*c)*lymph*node*metastases*(65%);*d)*distant*metastases*(5%).*
Colon*cancer*
• Management:*surgical*resection;*chemotherapy*is*often*5FU*+*oxaliplatin*combination*therapy.*
• Management:*tumour*in*caecal,*ascending*or*proximal*transverse*colon*is*treated*with*right*hemicolectomy;*
distal*transverse*or*descending*colon*is*treated*with*left*hemicolectomy;**
sigmoid*colon*is*treated*with*high*anterior*resection.*
Rectal*cancer*
• Feature:*Bright*red*blood*that*is*mixed*in*stool*accompanied*by*change*in*bowel*habit;*tenesmus*may*be*
present.*
• Investigations:*PR*exam*(abnormal*mass).*
• Investigations:*MRI*of*rectum*can*identify*resection*margins*and*mesorectal*nodal*disease.*
• Management:*surgical*resection*with*either*an*anterior*resection*or*an*abdominoUperineal*excision*of*
rectum.*Total*mesorectal*excision*is*gold*standard.*
• Management:*tumour*in*upper*or*mid*rectum*(proximal*2/3)*is*treated*with*anterior*resection;*
low*rectum*to*anal*verge*(distal*1/3)*or*involvement*of*sphincter*complex*is*treated*with*abdominoUperineal*
excision*of*rectum.*
• Management:*patients*with*T3*disease*are*offered*neoadjuvent*radiotherapy*prior*to*resectional*surgery;*
chemoUradiotherapy*is*offered*to*patients*with*T4*disease.*
Hereditary*nonpolyposis*colorectal*cancer*(HNPCC)*
• Most*common*form*of*hereditary*colorectal*cancer*(5%*of*all*cases)*
• Associated*with*increased*incidence*of*colorectal*cancer,*endometrial*cancer,*renal*disease*and*CNS*disease.*
• Features:*tumours*are*more*likely*to*be*rightUsided;*histologically*more*likely*to*be*mucinous*and*have*dnse*
lymphocytic*infiltrates.*

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• Diagnostic*criteria:*three*individiuals*in*at*least*two*successive*generations*+*one*cancer*diagnosed*under*
age*of*50.*
Familial*adenomatous*polyp*(FAP)*
• Autosomal*condition*associated*with*mutated*APC*gene.*
• Characterised*by*adenomatous*polyps*in*colon*and*rectum.*
• Lifetime*incidence*of*colorectal*cancer*if*untreated*is*100%.*
Bowel*ischaemia*
• Consists*of*acute*mesenteric*ischaemia*and*ischaemic*colitis.*
• Risk*factors:*shares*risk*factors*of*thromboemboli.*
• Features:*abdominal*pain,*rectal*bleeding,*diarrhoea,*fever,*raised*WBC.*
• Investigations:*CT.*
Acute*mesenteric*ischaemia*
• Caused*by*an*embolism*resulting*in*occlusion*of*an*artery*that*supplies*the*small*bowel;*predisposed*by*AF.*
• Features:*sudden*abdominal*pain,*forceful*evacuation;*pain*is*typically*greater*than*physical*signs*would*
suggest*(severe*abdominal*pain*despite*soft*and*tender*abdomen).*
• Investigations:*serum*lactate*(raised)*is*firstUline,*metabolic*acidosis*may*be*present;*CT/MRI*is*diagnostic.*
• Management:*immediate*laparotomy*and*resection*of*affected*segments.*
• Chronic*mesenteric*ischaemia*(intestinal*angina)*is*relatively*rare*but*is*characterised*by*a*triad*of*severe*
colicky*abdominal*pain*that*is*worse*after*eating,*weight*loss*and*an*abdominal*bruit.*
Ischaemic*colitis*
• Caused*by*transient*compromise*(ebolism)*in*blood*flow*to*large*bowel*leading*to*inflammation,*ulceration*
and*haemorrhage;*more*likely*to*occur*in*watershed*areas*such*as*the*splenic*flexure.*
• Features:*mild*abdominal*pain,*bloody*diarrhoea,*nausea*and*vomiting.*
• AXR:*‘thumbprinting’*due*to*mucosal*oedema/haemorrhage.*
Small*bowel*bacterial*overgrowth*syndrome*(SBBOS)*
• When*excessive*amounts*of*bacteria*in*small*bowel*causes*GI*symptoms.*
• Risk*factors:*neonates*with*congenital*GI*abnormalities,*scleroderma,*diabetes.*
• Features:*chronic*diarrhoea,*bloating,*flatulence,*abdominal*pain.*
• Investigations:*diagnosed*by*hydrogen*breath*test.*
• Management:*antibiotic*therapy*with*rifaximin;*coUamoxiclav*or*metronidazole*is*also*effective.*
Appendicitis*
• Features:*epigastric*pain*that*localises*to*RIF;*anorexia,*lowUgrade*fever,*nausea*and*vomiting.*
• Signs:*localised*tenderness,*rebound*tenderness,*Rovsing’s*positive.*
• Rovsing’s*sign:*pain*in*RIF*when*palpating*LIF.*
• Investigations:*WBC,*CRP,*amylase,*urine*dipstick.*
• Management:*appendicectomy;*patients*without*peritonitis*may*be*given*broadUspectrum*antibiotics*and*
receive*an*elective*appendicectomy.*
Pseudomyxoma*peritonei*
• Rare*mucinous*tumour*that*most*commonly*arises*from*the*appendix.*
• Features:*accumulation*of*large*amounts*of*mucinous*material*in*abdominal*cavity.*

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Spontaneous*bacterial*peritonitis*
• Form*of*peritonitis*usually*seen*in*patients*with*ascites*secondary*to*liver*cirrhosis.*
• Diagnosis:*neutrophil*count*>*250*cell/ul*on*paracentesis.*
• Management:*IV*cefotaxime.*
• Management:*antibiotic*prophylaxis*(ciprofloxacin*or*norfloxacin)*should*be*given*to*patients*with*ascites*
that*have*had*SBP*or*patients*with*cirrhosis*and*ascites*with*an*ascitic*protein*of*15*g/l*or*less.*
Anal*fissure*
• Tearing*of*squamous*lining*of*distal*anal*canal;*defined*as*chronic*if*present*for*>*6*weeks.*
• Risk*factors:*constipation,*IBD,*STIs.*
• Features:*painful,*bright*red*rectal*bleeding.*
• Management:*acute*cases*are*managed*with*bulkUforming*laxatives*(firstUline);*high*fibre*diet*with*high*fluid*
intake,*lubricant*use*before*defaecation*and*topical*anaesthetics*may*also*help.*
• Management:*chronic*cases*are*managed*as*above*plus*use*of*topical*GTN*or*topical*diltiazem*(firstUline);*
if*these*fail*use*botulinum*toxin*injection.*
Haemorrhoids*
• Enlarged,*symptomatic*haemorrhoidal*tissue*(mucosal*vascular*cushions)*found*in*3,*7*and*11*o’clock*
positions*of*the*anal*canal.*
• Classified*as*external*if*originated*below*dentate*line,*may*be*painful*as*more*likely*to*thrombose;**
classified*as*internal*if*originated*above*dentate*line,*generally*not*painful.*
• Features:*painless,*bright*red*rectal*bleeding*(most*common)*that*is*on*toilet*paper*but*not*mixed*with*stool;*
altered*bowel*habit,*history*of*straining,*pain*(only*if*piles*are*thrombosed).*
• Examination*will*show*normal*colon*and*rectum;*proctoscopy*is*required*to*show*internal*haemorrhoids.*
• Management:*increased*dietary*fibre*and*fluid*intake,*stool*softeners,*ice*compressions*and*topical*GTN*or*
diltiazem*to*reduce*sphincter*spasm*(acute*cases);*chronic*cases*with*marked*symptoms*may*benefit*from*
stapled*haemorroidopexy*and*large*haemorroids*may*be*managed*with*haemorroidectomy.*
• Management:*thrombosed*external*haemorrhoids*will*present*with*significant*pain*and*a*purlish,*oedamtous,*
tender*subcutaneous*perianal*mass;*manage*these*patients*supportively*with*stool*softeners,*ice*packs*and*
analgesia*–*usually*settles*within*10*days.*
Anal*cancer*
• Rare*malignancy*of*anal*canal*(anorectal*junction*to*anal*margin);*80%*are*squamous*cell*carcinomas.*
• Risk*factors:*HPV*infection*(anal*intercourse,*multiple*partners),*gay*sex,*HIV,*immunosuppression,*smoking,*
history*of*cervical*cancer.*
• Features:*perianal*pain,*perianal*bleeding,*faecal*incontinence,*pruritus*ani;*palpable*lesion*may*be*found.*
• Investigations:*PR*exam,*palpation*of*inguinal*lymph*nodes.*
• Investigations:*anoscopy*with*biopsy*(firstUline)*followed*by*CT.*
• Investigations:*test*patient*for*HIV*and*HPV.*
Pruritus*ani*
• Irritation*of*skin*around*anus*associated*with*underlying*perianal*disease.*
• Features:*perianal*itching,*occasional*mild*bleeding.*
• Management:*correction*of*underlying*disease*and*supportive*therapy.*
Proctitis*

* 65*
• Inflammation*of*anus*and*lining*of*rectum.*
• Features:*bright*red*rectal*bleeding,*nocturnal*diarrhoea,*faecal*incontinence.*
Solitary*rectal*ulcer*
• Associated*with*chronic*constipation*and*repeated*straining.*
• Features:*episodic*rectal*bleeding;*PR*exam*may*reveal*ulcer*in*rectum.*
• Investigations:*biopsy*is*required*to*exclude*malignancy.*
• Histology:*mucosal*thickening*and*fibromuscular*obliteration*(lamina*propria*replaced*with*collagen*and*
smooth*muscle).*
Perianal*abscess*
• Features:*perianal*pain*(too*sore*to*defaecate),*erythematous*swelling*near*anus;*some*may*have*fever.*
• Management:*incision*and*drainage,*leaving*cavity*open*to*heal*by*secondary*intention.*
Pilonidal*sinus*
• Occurs*as*a*result*of*hair*debris*creating*sinuses*in*skin*at*natal*cleft*(butt*crack)*which*develops*into*an*
abscess*after*acute*inflammation.*
• Features:*cycles*of*pain*and*discharge*from*sinus.*
• Management:*during*an*asymptomatic*period,*treat*with*excision*of*the*sinus*and*obliteration*of*underlying*
cavity*or*wide*local*excision*of*natal*cleft.*
Fistula*
• Abnormal*connection*between*two*epithelial*surfaces;*most*abdominal*fistulas*are*caused*by*diverticular*
disease*and*Crohn’s*disease.*
• Enterocutaneous*fistula:*links*intestine*to*skin*and*forms*as*a*result*of*rupture*of*an*abscess*cavity*onto*skin.*
• Enterocutaneous*fistula:*may*produce*high*volume,*electrolyte*rich*secretions*or*faecal*material*that*may*
lead*to*damage*of*skin.*
• Enterocolic*fistula:*involves*large*or*small*intestine.*
• Enterocolic*fistula:*originates*from*rupture*of*abscess*cavity*and*may*cause*bacterial*overgrowth*that*
precipitates*malabsorption*syndromes.*
• Anal*fistula:*enterocutaneous*fistula*that*persistently*discharges*onto*the*perineum.*
• Management:*will*heal*spontaneously*provided*there*is*no*underlying*IBD*or*distal*obstruction.*
• Management:*protection*of*overlying*skin*(eg.*with*stoma*bag),*a*high*output*fistula*may*be*more*
manageable*with*the*use*of*octreotide*(reduces*volume*of*pancreatic*secretions),*nutritional*complications*
may*require*total*parenteral*nutrition.*
Mesenteric*adenitis*
• Inflammation*of*lymph*nodes*in*abdomen,*usually*following*a*recent*upper*respiratory*tract*infection.*
• Features:*generalised*abdominal*pain*(localised*signs*are*rare),*high*fever.*
• Investigations:*WBC*may*be*slightly*raised*but*urine*dipstick*and*abdominal*USS*may*be*normal.*
• Management:*conservative.*
Abdominal*wall*hernia*
• Protrusion*of*organ*through*the*wall*of*cavity*that*normally*contains*it.*
• Risk*factors:*obesity,*ascites,*old*age,*surgical*wounds.*

* 66*
• Features:*palpable*lump,*cough*impulse,*pain,*obstruction,*strangulation*(infarction*of*bowel*due*to*
compromised*blood*flow).*
Inguinal*hernia*
• Most*common*hernia*(95%*of*cases*are*male);*strangulation*is*rare.*
• Features:*presents*with*groin*lump*located*above*and*medial*to*pubic*tubercle*that*disappears*on*pressure*
or*when*patient*lies*down;*symptoms*include*discomfort*and*aching*that*is*worse*with*activity.*
• Signs:*reducible*swelling*at*level*of*inguinal*canal,*cough*impulse,*does*not*transUilluminate,*not*possible*to*
get*above*the*swelling.*
• Management:*recommended*to*treat*medically*fit*patients*even*if*they*are*asymptomatic*with*an*open*
inguinal*hernia*repair*+/U*mesh*(reduces*risk*of*recurrence).*
• Management:*recurrent*hernias*are*managed*with*laparoscopic*mesh*surgery.*
• Complications:*surgery*may*cause*injury*of*ilioinguinal*nerve*resulting*in*severe*groin*pain.*
Femoral*hernia*
• Common*in*women,*especially*multiparous*ones.*
• Located*below*and*lateral*to*pubic*tubercle.*
• Management:*surgical*repair*due*to*high*risk*of*obstruction*and*strangulation.*
Hiatus*hernia*
• Herniation*of*part*of*stomach*above*the*diaphragm.*
• Hiatus*hernia:*typically*presents*with*a*longstanding*history*of*dyspepsia*in*patients*that*are*overweight.*
Shock*
• SIRS:*temperature*outside*36U38;*HR*>*90;*RR*>*20;*WBC*>*12.0*or*<*4.0.*
• Septic*shock:*sepsis*is*SIRS*accompanied*by*infection;*this*causes*extensive*cytokine*release*which*may*lead*
to*vasodilation*and*also*coagulation*and*fibrinolytic*suppression*which*leads*to*widespread*clotting*and*
stops*blood*from*circulating*to*organs*efficiently.*
• Septic*shock:*management*includes*haemodynamic*stabilisation*(IV*fluids),*aggressive*antibiotic*therapy,*
tight*glycaemic*control*and*monitoring*of*electrolytes.*
• Neurogenic*shock:*occurs*mostly*due*to*spinal*cord*transection*that*leads*to*either*decreased*sympathetic*
tone*or*increased*parasympathetic*tone,*which*causes*marked*vasodilation*and*thus*decreased*peripheral*
vascular*resistance*and*cardiac*output.*
• Neurogenic*shock:*treated*with*peripheral*vasoconstrictors.*
• Cardiogenic*shock:*main*cause*is*IHD.*
• Anaphylactic*shock:*severe*systemic*hypersensitivity*reaction.*
• Anaphylactic*shock:*treat*with*adrenaline*(IM*injection*in*anterolateral*aspect*of*middleUthird*of*thigh).*
• Haemorrhagic*shock:*class*I*=*<*15%*loss;*class*II*=*15U30%*loss;*class*III*=*30U40%*loss;*class*IV*=*>*40%*
loss.*
• Haemorrhagic*shock:*management*includes*controlling*the*bleeding,*restoring*circulating*volume**
(fluids,*transfusion).*
• Massive*haemorrhage:*defined*as*loss*of*more*than*one*blood*volume*(5*litres*in*normal*adult)*or*loss*of*
50%*of*circulating*blood*volume*in*3*hours.*
Organ*transplant*
• Graft*rejection*occur*due*to*differences*in*ABO*group,*HLA*and*minor*histocompatibility*antigens.*

* 67*
• ABO*incompatibility*will*result*in*hyperacute*organ*rejection.*
• There*are*four*important*HLA*alleles*that*should*be*matched*and*the*more*the*better*the*outcomes;*can*be*
managed*limitedly*using*immunosuppressive*regimes.*
Stomas*
• Stoma:*commonly*used*in*postUoperative*patients*to*drain*bowel*contents.*
• Loop*ileostomy:*temporary*stoma*used*to*defunction*the*colon*postUsurgery*by*diverting*faeces*away*from*
the*bowel,*allowing*it*to*restore*bowel*continuity;*site*of*access*is*RIF.*
• Loop*ileostomy:*reversed*once*anastomosis*has*healed*and*is*not*leaking;*can*be*checked*using*a*gastrografin*
enema*(if*there*is*a*leak*the*radiopaque*liquid*will*show*up*as*free*fluid*in*abdomen).*
• Loop*ileostomy:*may*cause*volume*depletion,*electrolyte*and*acidUbase*imbalance*(metabolic*acidosis)*if*
ileostomy*output*increases.*
• End*ileostomy:*stoma*used*to*redirect*ileum*out*of*skin*after*complete*excision*of*colon;*site*of*access*is*RIF.*
• Loop*colostomy:*temporary*stoma*used*to*defunction*a*distal*segment*of*colon;*site*of*access*depends*on*
segment*targeted.*
• End*colostomy:*stoma*used*to*redirect*part*of*colon*out*of*skin*after*excision*of*part*of*colon;*site*of*access*is*
either*RIF*or*LIF.*
• Caecostomy:*stoma*of*last*resort*where*a*loop*colostomy*is*not*possible;*site*of*access*if*RIF.*
Splenectomy*
• PostUop*patients*are*suspectible*to*Pneumococcus,*Haemophilus*and*Meningococcus*infections.*
• Management:*patients*should*receive*Hib*vaccine*2*weeks*prior*to*operation,*annual*influenza*vaccines*and*a*
pneumococcal*vaccine*every*5*years.*
• Management:*penicillin*V*prophylaxis*should*be*continued*for*at*least*2*years.*
Surgical*incisions*
• Midline*incision:*most*commonest*approach*to*abdomen;*great*for*laparotomy.*
• Kocher*incision:*cut*below*right*subcostal*margin;*cholecystectomy.*
• Lanz*incision:*cut*in*right*iliac*fossa;*appendicectomy.*
• Rooftop*incision:*cuts*under*bilateral*subcostal*margins;*pancreatectomy.*
• Pfannenstiel*incision:*cut*transverse*suprapubic*region;*caesarean*section.*
Other*
• Femoral*vessels:*femoral*nerve*is*lateral,*femoral*artery*is*in*middle,*femoral*vein*is*medial.*
• Pneumoperitoneum:*free*air*in*abdomen*(under*diaphgram)*that*may*be*demonstrated*by*CXR*or*CT;*
indicates*a*perforated*abdominal*viscus.*
*
Gynaecology*
Primary*dysmenorrhoea*
• Painful*periods*with*no*underlying*pelvic*pathology*often*characterised*by*suprapubic*cramping*pain*
radiating*down*thigh.*
• Affects*up*to*50%*of*women.*
• Management:*firstUline*is*NSAIDs*such*as*mefenamic*acid*or*ibuprofen*due*to*ther*inhibition*of*prostaglandin*
production;*COC*is*secondUline.*

* 68*
Secondary*dysmenorrhoea*
• Painful*periods*due*to*underlying*pathology.*
• Common*causes:*endometriosis,*adenomyosis,*PID,*fibroids.*
Menorrhagia*
• Heavy*menstrual*bleeding.*
• Causes:*PALM*COEIN.*
• Investigations:*FBC*(anaemia),*transvaginal*ultrasound.*
• Investigations:*test*for*coagulopathy*in*women*who*have*menorrhagia*since*menarche*or*features*of*
abnormal*coagulation.*
• Management:*firstUline*drugs*for*women*who*do*not*require*contraception*is*mefenamic*acid*500*mg*tds*
(preferable*if*there*is*pain)*or*tanexamic*acid*1*g*tds*(painless*bleeding).*
• Management:*firstUline*for*women*who*require*contraception*is*Mirena;*alternatives*are*COC*and*depo*
provera.*
Postcoital*bleeding*
• Causes:*cervical*ectropion,*cervicitis,*cervical*cancer,*polyps,*trauma.*
Endometriosis*
• Features:*pelvic*pain,*dysmenorrhoea,*deep*dyspareunia,*subfertility.*
• Signs:*tender*posterior*vaginal*fornix,*uterine*motion*tenderness,*visible*vaginal*endometriotic*lesions.*
• Investigations:*laparoscopy*is*firstUline*if*symptoms*are*significant*and*is*gold*standard.*
• Investigations:*USS*may*show*free*fluid*in*pelvis.*
• Management:*firstUline*for*symptomatic*relief*is*paracetamol*+*NSAIDs*and*COC*or*progestogen*therapy.*
• Management:*secondUline*is*a*GnRH*analogue*or*surgical*options*such*as*laparoscopic*excision*or*laser*
treatment*(may*improve*ferility).*
Endometrioma*
• Endometrial*tissue*of*the*ovary*that*presents*as*endometriosis*but*may*rupture.*
• Rupture*will*cause*sudden*intense*pain*accompanied*by*an*acute*abdomen.*
• USS:*free*fluid*in*pelvis.*
Endometrial*hyperplasia*
• Abnormal*proliferation*of*endometrium*that*may*develop*into*endometrial*cancer.*
• Management:*premenopausal*women*with*no*atypical*changes*may*be*treated*with*high*dose*progestogen*or*
Mirena*with*active*surveillance.*
• Management:*postmenopausal*women*or*any*atypical*changes*are*treated*as*endometrial*cancer*because*of*
future*risk*of*development.*
Endometrial*cancer*
• Risk*factors:*obesity,*excess*ovulation,*unopposed*estrogen,*tamoxifen,*PCOS,*diabetes,*Lynch*syndrome.*
• Postmenopausal*bleeding*is*endometrial*cancer*until*proven*otherwise.*Pain*and*discharge*is*unusual.*
• Consider*endometrial*cancer*in*women*aged*>*45*years*using*hormonal*contraception*with*vaginal*bleeding.*
• Investigations:*transvaginal*ultrasound*is*firstUline*followed*by*a*Pipelle*biopsy*or*hysteroscopy*with*
endometrial*biopsy.*
• Management:*total*hysterectomy*and*bilateral*salpingoUoophorectomy.*

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• Management:*progestogen*therapy*may*be*used*in*frail*old*women*who*cannot*receive*surgery.*
Atrophic*vaginitis*
• Diagnosis*of*exclusion*that*often*occurs*in*postmenopausal*women.*
• Features:*vaginal*dryness,*dyspareunia,*spotting.*
• Investigations:*firstUline*is*transvaginal*ultrasound*(to*exclude*endometrial*cancer).*
• Management:*topical*estrogen*cream*or*HRT.*
Adenomyosis*
• Features:*dysmenorrhoea,*menorrhagia;*enlarged,*irregular*uterus.*
• Investigations:*USS*is*firstUline;*MRI*is*gold*standard.*
• Management:*GnRH*agonist*and*hysterectomy.*
Fibroids*(leiomyoma)*
• Benign*smooth*muscle*tumour*of*uterus.*
• Features:*menorrhagia,*lower*abdominal*pain*(cramping*during*period),*bloating,*urinary*incontinence*
(larger*fibroids),*subfertility,*abdominal*mass.*
• Investigations:*tranvsvaginal*ultrasound*is*firstUline.*
• Management:*<*3*cm*indicates*medical*treatment*–*Mirena*is*firstUline;*alternatives*include*COC,*tranexamic*
acid.*
• Management:*>*3*cm*requires*surgical*options*–*myomectomy*(preserves*fertility),*endometrial*ablation,*
hysterectomy.*GnRH*analogue*may*be*used*before*surgery*to*reduce*size*of*fibroid.*
• Complications:*red*degeneration*is*when*fibroid*grows*so*large*it*can*no*longer*be*sustained*by*its*blood*
supply*and*undergoes*degeneration*and*haemorrhagic*infarction*to*cause*lowUgrade*fever,*pain*and*
vomiting.*May*occur*during*pregnancy*as*fibroids*are*sensitive*to*estrogen.*
Polycystic*ovarian*syndrome*
• Diagnostic*criteria:*2*of*3*–*polycystic*ovaries;*amenorrhoea;*hirsutism.*
• Features:*subfertility,*amenorrhoea/oligomenorrhoea,*hirsutism*(acne,*excess*hair),*obesity.*
• Investigations:*pelvic*USS*is*firstUline*and*shows*multiple*ovarian*cysts.*
• Investigations:*FSH/LH*is*raised;*testosterone*may*be*raised*or*normal.*
• Management:*COC*is*firstUline.*It*helps*by*regulating*the*cycle,*induces*a*monthly*period,*improve*hirsutism*
and*provide*contraception.*
• Management:*treatment*for*subfertility*is*weight*reduction*and*clomiphene*(firstUline);*metformin*is*
particularly*effective*for*obese*patients.*
• Complications:*subfertility,*diabetes,*endometrial*cancer,*stroke,*coronary*artery*disease,*obstructive*sleep*
apnoea.*
Ectopic*pregnancy*
• Typically*presents*with*a*6U8*week*history*of*amenorrhoea.*
• Features:*amenorrhoea,*severe*lower*abdominal*pain,*vaginal*bleeding,*haemodynamic*compromise.*
• Signs:*acute*abdomen,*cervical*excitation,*positive*pregnancy*result,*elevated*beta*HCG.*
• USS:*no*intrauterine*pregnancy,*adnexal*mass,*free*fluid*in*abdomen.*
• Ruptured*ectopic*pregnancy*may*cause*shoulder*tip*pain*which*indicates*peritoneal*bleeding.*

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• Management:*if*the*woman*is*in*pain,*fetal*heart*beat*is*present*or*the*pregnancy*has*ruptured*then*urgent*
surgery*is*required.*
• Management:*salpingectomy*is*firstUline*if*the*contralateral*fallopian*tube*is*healthy;*salpingotomy*is*
preferred*if*the*woman*has*other*risks*for*infertility*or*the*contralateral*fallopian*tube*is*damaged.*
• Management:*treat*expectantly*only*if*the*embryo*is*unruptured*and*<*30*mm*in*size,*there*is*no*fetal*heart*
beat,*beta*HCG*<*200*IU/l*and*declining,*and*patient*is*asymptomatic.*If*conditions*change*then*escalate*
treatment.*
• Management:*treat*medically*only*if*embryo*is*unruptured,*there*is*no*fetal*heart*beat*and*patient*is*not*
experiencing*pain.*Methotrexate*is*firstUline.*
• Most*common*location*is*ampulla*of*fallopian*tube;*rupture*is*more*likely*if*located*in*isthmus.*
Mullerian*agenesis*
• Typically*a*young*girl*with*primary*amenorrhea*who*develops*secondary*sex*characteristics*but*has*variable*
absence*of*female*sex*organs.*
Imperforate*hymen*
• Typically*a*young*girl*with*primary*amenorrhoea*that*still*suffers*cyclical*pain*and*has*developed*secondary*
sex*characteristics*(pubic*hair,*breasts).*
• BuildUup*of*menstrual*blood*in*vagina*may*cause*pelvic*pain.*
Hypothalamic*amenorrhoea*
• Secondary*amenorrhoea*caused*by*suppression*of*GnRH.*
• Causes:*stress,*excessive*exercise*or*eating*disorder.*
Ashermann’s*syndrome*
• Secondary*amenorrhea*caused*by*intrauterine*adhesions.*
• May*occur*following*dilation*and*curettage.*
Sheehan’s*syndrome*
• Secondary*amenorrhea*caused*by*postpartum*hypopituitarism*following*ischemic*necrosis*of*pituitary*gland*
due*to*blood*loss*and*hypovolaemic*shock*during*birth.*
• Features:*lack*of*postpartum*milk*production,*amenorrhoea.*
• Investigations:*prolactin*and*gonadotrophin*stimulation*tests*(reduced).*
Mittelschmerz*(ovulation*pain)*
• Features:*sudden*onset*midUcycle*(2*weeks*after*LMP)*abdominal*pain*that*usually*settles*over*24U48*hours.*
• Investigations:*FBC*and*urine*dipstick*are*normal;*USS*may*show*trace*of*free*fluid*in*pelvis.*
• Management:*conservative.*
Ovarian*mass*
• If*ultrasound*reveals*a*suspected*ovarian*cyst*or*tumour,*repeat*the*ultrasound*in*8U12*weeks*if*the*woman*is*
<*35*years*or*the*cyst*is*small*(likely*to*be*benign).*
• If*woman*is*>*35*years*or*postmenopausal*then*urgently*refer*to*gynaecology.*
Ovarian*cancer*
• Exam*hint:*old*women*with*pelvic*pain,*urinary*symptoms*and*bloating.*
• Most*common*site*of*lymphatic*spread*is*paraUaortic*lymph*nodes;*haematological*spread*is*to*liver.*
• Risk*malignancy*index*prognosis*depends*on*ultrasound*findings,*menopausal*status*and*CA125*level.*
• Stages:*1)*confined*to*ovary;*2)*spread*to*pelvis;*3)*spread*to*abdomen;*4)*distant*metastases.*

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• Risk*factors:*family*history*(BRCA1,*BRCA2),*excess*ovulation*(early*menarche,*late*menopause,*nulliparity),*
old*age.*
• Features:*abdominal*distension,*abdominal*pain,*pelvic*pain,*lethargy;*palpable*abdominal*or*pelvic*mass.*
• Investigations:*CA125*is*firstUline.*If*this*is*raised*(>*35*IU/ml)*then*perform*an*urgent*ultrasound*of*
abdomen*and*pelvis.*
• Investigations:*diagnosis*usually*requires*laparoscopy.*
• In*older*women,*an*urgent*referral*may*be*made*without*investigation*if*she*has*clinical*features*of*ovarian*
cancer*with*a*palpable*abdominal*or*pelvic*mass.*
• Management:*surgical*excision*and*adjunctive*chemotherapy.*
Ovarian*torsion*
• Features:*sudden*onset*unilateral*lower*abdominal*pain,*nausea*and*vomiting.*
• Signs:*unilateral*tender*adnexal*mass.*
• USS:*whirlpool*sign,*enlarged*ovary*at*midline,*free*fluid*in*pelvis.*
• Management:*laparoscopy*is*both*diagnostic*and*treatment.*
Ovarian*cyst*
• Types:*follicular*cysts*arise*due*to*failed*atresia*of*unused*follicles;*usually*regresses*after*several*cycles.*
• Types:*corpus*luteum*cysts*may*form*in*early*pregnancy;*usually*resolves*in*second*trimester.*
• Large*ovarian*cysts*may*become*symptomatic.*
• Features:*abdominal*distension,*dyspareunia,*increased*frequency*(due*to*increased*pressure*on*bladder).*
Teratoma*
• Contains*ectodermal*(eg.*hair),*mesodermal*(eg.*bone)*and*endodermal*tissue.*
• Mature*cystic*teratoma:*most*common*benign*ovarian*tumour*in*women*<*30*years.*
• Mature*cystic*teratoma:*associated*with*Rokitansky*protuberance.*
Meig’s*syndrome*
• Features:*benign*ovarian*tumour,*ascites,*pleural*effusion.*
Ovarian*hyperstimulation*syndrome*
• Complication*of*IVF*that*is*most*common*in*women*with*PCOS.*
• Presence*of*multiple*cysts*within*ovaries*results*in*increased*production*of*estrogen,*progesterone*and*
vasoactive*substances*such*as*vascular*endothelial*growth*factor.*
• Vasoactive*substances*increase*membrane*permeability*and*leads*to*loss*of*fluid*from*intravascular*
compartment*into*extravascular*compartment.*
• Features:*abdominal*pain,*bloating,*nausea*and*vomiting,*ascites,*oliguria.*
Cervical*cancer*
• Risk*factors:*HPV*(16/18),*smoking,*HIV,*multiple*partners,*early*age*of*first*intercourse.*
• Features:*abnormal*bleeding*(postcoital),*dyspareunia,*vaginal*discharge.*
• Management:*hysterectomy*for*early*stage*disease*in*postmenopausal*women.*
Cervical*screening*
• All*women*who*are*sexual*active*should*be*screened*from*20*years.*
• Normal*smear:*repeat*smear*in*3*years;*if*it*was*the*first*smear*within*5*years*repeat*in*12*months.*
• Unsatisfactory*smear:*repeat*smear*in*3*months;**if*this*occurs*for*3*consecutive*smears*refer*for*coloscopy.*

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• ASCUUS/LSIL*smear:*if*there*has*been*another*abnormal*result*in*last*5*years,*refer*for*colposcopy.*
• ASCUUS/LSIL*smear:*if*this*is*the*first*abnormal*result*in*last*5*years,*repeat*smear*in*12*months*if*patient*is*
20U29*years*or*refer*to*HPV*testing*if*patient*is**>*30*years.*
• ASCUUS/LSIL*smear:*if*the*12*month*repeat*smear*is*normal*then*do*another*repeat*smear*in*12*months;**
if*the*12*month*repeat*smear*is*abnormal*then*refer*for*coloscopy.*
• ASCUUS/LSIL*smear:*if*HPV*testing*is*negative*then*refer*for*cytology*in*12*months;*if*positive*then*refer*for*
colposcopy.*
• ASCUH/HSIL*smear:*refer*for*colposcopy.*
Cervical*ectropion*
• Proliferation*in*surface*area*of*columnar*epithelium*in*ectocervix*due*to*elevated*estrogen*levels.*
• Most*common*cause*of*postcoital*bleeding.*
• Consider*in*a*young*woman*with*postcoital*bleeding*with*normal*smear*results.*
Vulval*cancer*
• Usually*occurs*in*older*women.*
• Risk*factors:*HPV,*vulvar*intraepithelial*neoplasia,*lichen*sclerosus,*immunosuppression.*
• Features:*lump*or*ulcer*on*labia*majora;*itching,*irritation.*
Bartholin’s*abscess*
• Bartholin’s*glands*are*located*next*to*entrance*of*the*vagina,*when*they*become*infected*and*enlarge*they*
form*an*abscess.*
• Management:*marsupialisation*(surgical)*is*the*most*effective;*alternatives*are*antibiotics*or*word*catheter.*
Pelvic*inflammatory*disease*
• Usually*caused*by*ascending*infection*from*the*endocervix*–*most*commonly*Chlamydia&trachomatis.*
• Features:*pelvic*pain,*deep*dyspareunia,*vaginal*disharge,*irregular*cycle,*pyrexia,*dysuria;*cervical*excitation.*
• Investigations:*perform*chlamydia*and*gonorrhoea*screen.*
• Investigations:*hysterosalpingography*shows*bilateral*blocked*fallopian*tubes.*
• Management:*oral*ofloxacin*+*oral*metronidazole*+*IM*ceftriaxone*+*oral*doxycycline.*
Menopause*
• Perimenopause:*menopausal*symptoms*associated*with*amenorrhoea*for*less*than*12*months.*
• Contraception*use*is*recommended*until*12*months*after*LMP*in*women*>*50*years*and*24*months*after*LMP*
in*women*<*50*years.*
• Management:*vasomotor*symptoms*(flushing,*night*sweats)*can*be*treated*using*HRT.*
• Management:*women*with*no*uterus*can*receive*continuous*estrogen*HRT.*
• Management:*women*with*a*uterus*should*receive*combined*estrogen*and*progesterone*HRT*because*
progesterone*reduces*risk*of*endometrial*cancer.*If*woman*wants*only*estrogen*HRT*then*offer*her*Mirena.*
• Management:*women*with*a*uterus*should*receive*cyclical*therapy*if*their*LMP*was*<*1*year*ago;*
continuous*therapy*if*their*LMP*was*>*1*year*ago*or*they*have*had*cyclical*therapy*for*1*year.*
• Management:*nonUhormonal*methods*include*SSRIs,*venlafaxine*and*clonidine.*
• Management:*vaginal*atrophy*can*be*treated*using*topical*oestrogen.*
• Management:*vaginal*dryness*can*be*treaetd*using*vaginal*lubricant*or*moisturiser.*
Premature*ovarian*failure*

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• Onset*of*menopausal*symptoms*and*elevated*FSH/LH*before*age*of*40.*
• Risk*factors:*family*history,*exposure*to*chemotherapy*or*radiation,*autoimmune*disease.*
• Features:*postmenopausal*symptoms,*infertility,*secondary*amenorrhoea.*
• Blood*results:*raised*FSH/LH*levels,*reduced*estradiol*level.*
• Management:*COC*and*SSRIs*for*moderateUsevere*symptoms.*
Miscarriage*
• Transvaginal*ultrasound*showing*crownUrump*length*>*7*mm*and*no*fetal*heart*beat*is*diagnostic*of*a*
miscarriage.*
• Risk*factors:*obesity,*old*age,*smoking,*alcohol,*drug*use,*high*caffeine*intake,*drugs,*cervical*impotence,*
chronic*disease.*
Threatened*miscarriage*
• Typically*occurs*at*6U9*weeks.*
• Features:*mild*pain*or*painless*vaginal*bleeding;*cervical*os*is*closed.*
Incomplete*miscarriage*
• When*not*all*products*of*conception*have*been*expelled.*
• Features:*painful*vaginal*bleeding;*cervical*os*is*open.*
Complete*miscarriage*
• Features:*painful*heavy*vaginal*bleeding*with*clots;*cervical*os*is*open.*
• Pain*and*uterine*contractions*stop*after*expulsion*of*fetus.*
• USS:*empty*uterus.*
Inevitable*miscarriage*
• Categorisation*of*complete*or*incomplete*miscarriage*depending*on*complete*expulsion*of*contents.*
Missed*miscarriage*
• When*gestational*sac*contains*a*dead*fetus*without*features*of*expulsion.*
• Features:*light*vaginal*bleeding,*disappearance*of*symptoms*of*pregnancy;*cervical*os*is*closed.*
• Management:*expectant*management*is*firstUline**and*involves*waiting*for*miscarriage*to*complete.*
• Management:*medical*management*may*be*preferred*if*there*is*high*risk*of*haemorrhage*or*infection;*drug*of*
choice*is*misoprostol*with*antiemetics*and*pain*relief.*
• Management:*surgical*management*is*a*vacuum*aspiration*under*anaesthetic.*
Recurrent*miscarriage*
• Defined*as*3*or*more*consecutive*spontaneous*abortions.*
• Most*common*cause*of*recurrent*first*trimester*miscarriage*is*antiphospholipid*syndrome.*
Abortion*
• If*<*9*weeks*pregnant,*mifepristone*followed*by*misoprostol*48*hours*later.*
• If*<*13*weeks*pregnant,*surgical*dilation*and*suction*of*uterine*contents.*
• If*>*15*weeks*present,*surgical*dilation*and*evacuation*of*uterine*contents.*
• Complications:*infection.*
Urogenital*prolapse*
• Risk*factors:*old*age,*multiparity,*vaginal*delivery,*obesity.*
• Features:*heaviness,*bulging*sensation,*urinary*symptoms.*

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• Management:*firstUline*is*pelvic*floor*muscle*exercise*and*weight*loss.*
• Management:*interventions*include*ring*pessary*(older*women)*and*surgery.*
Urinary*incontinence*
• Risk*factors:*old*age,*pregnancy,*obesity,*hysterectomy,*family*history,*previous*pelvic*surgery.*
• Investigations:*bladder*diary,*urine*dipstick*and*culture.*
• Investigations:*urodynamic*studies*if*diagnosis*is*uncertain*or*suspected*overflow*incontinence.*
• Urge*incontinence:*increased*frequency*caused*by*an*overactive*bladder*(detrusor*overactivity).*
• Urge*incontinence:*firstUline*management*is*bladder*retraining.*
• Urge*incontinence:*antimuscarinics*(oxybutynin,*darifenacin,*tolterodine)*can*help*stabilise*bladder.**
Avoid*oxybutynin*in*frail*older*women*for*risk*of*fall.*
• Stress*incontinence:*urine*leakage*during*increase*in*abdominal*pressure*(eg.*coughing).*
• Stress*incontinence:*firstUline*management*is*pelvic*floor*muscle*training.*
• Stress*incontinence:*surgery*may*be*used*for*severe*cases*(eg.*tape*surgery).*
• Mixed*incontinence:*both*urge*and*stress*incontinence.*
• Overflow*incontinence:*involuntary*release*of*urine*caused*by*bladder*outlet*obstruction*(enlarged*prostate).*
• Consider*a*vesicovaginal*fistulae*in*women*from*poor*countries*with*continuous*dribbling*incontinence*
following*prolonged*labour.*Urinary*dye*study*can*identify*presence*of*fistulae.*
Other*
• Always*test*for*pregnancy*in*young*female*with*amenorrhoea.*
*
Haematology*
Coagulation*testing*
• Prothrombin*time*and*INR:*tests*the*extrinsic*pathway*and*detects*global*reduced*clotting*factor*synthesis*
and*increased*consumption*of*clotting*factors*(eg.*warfarin,*vitamin*K*deficiency,*liver*disease,*DIC).*
• APTT:*tests*the*intrinsic*pathway*and*detects*extrinsic*pathway*dysfunction*and*deficiency*of*factors*VIII*
(haemophilia*A/Von*Willebrands),*factor*IX*(haemophilia*B)*and*factor*XI*(haemophilia*C).*
• Antiphospholipid*syndrome:*may*misleadingly*cause*a*prolonged*APTT.*
• Bleeding*time:*tests*the*level*and*function*of*platelets.*
• Thrombin*time:*tests*the*level*and*function*of*fibrinogen.*
• Decreased*fibrinogen*level*suggests*they*have*been*used*up*for*clot*formation.*
• Raised*DUdimer*suggests*increased*fibrinolysis.*
Blood*film*
• Myelofibrosis:*tearUdrop*poikilocytes.*
• Hyposplenism:*target*cells,*HowellUJolly*bodies,*Pappenheimer*bodies.*
• Intravascular*haemolysis:*schistocytes.*
• Megaloblastic*anaemia:*hypersegmented*neutrophils.*
• Iron*deficiency*anaemia:*target*cells,*pencil*poikilocytes.*
Deep*vein*thrombosis*
• Risk*factors:*malignancy,*thrombophilia,*antiphospholipid*syndrome,*polycythaemia,*nephrotic*syndrome,*
sickle*cell*disease,*pregnancy,*postUsurgery,*immobilisation.*

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• Predisposing*drugs:*COC,*HRT,*tamoxifen,*raloxifene,*antipsychotics*(especially*olanzapine).*
• Wells*score:*estimates*likelihood*of*DVT.*
• Wells*score:*1*point*or*less*is*unlikely;*2*points*or*more*is*likely.*
• Investigations:*if*unlikely,*perform*a*DUdimer*test.*If*this*is*positive,*arrange*a*proximal*leg*vein*USS*within*4*
hours*–*if*USS*cannot*be*done*within*4*hours*administer*LMWH*whilst*waiting.*
• Investigations:*if*likely,*arrange*a*proximal*leg*vein*USS*within*4*hours*(give*LMWH*if*not*possible);*if*the*
result*is*negative,*perform*a*DUdimer*test.*
• Management:*LMWH*is*firstUline*and*should*be*continued*for*5*days*or*until*INR*is*2.0*or*above.*
• Management:*also*commence*anticoagulation*(eg.*warfarin)*within*24*hours*of*diagnosis*and*continue*for*at*
least*3*months,*when*the*patient*should*be*reassessed.*
• Management:*if*the*DVT*was*unprovoked*(no*obvious*cause)*then*continue*warfarin*for*6*months.*
• Pregnancy*is*a*hypercoagulable*state*due*to*increase*in*factors*VII,*VIII,*X*and*fibrinogen,*and*DVT*may*occur*
in*last*trimester.*Treat*with*LMWH*as*warfarin*is*contraindicated.*
• Offer*all*patients*diagnosed*with*unprovoked*DVT*the*following*investigations*for*cancer*–*CXR,*blood*tests*
(FBC,*serum*calcium,*LFTs)*and*urinalysis;*consider*abdominoUpelvic*CT*in*older*patients.*
• Consider*thrombophilia*screening*in*patients*with*unprovoked*DVT*–*antiphospholipid*antibodies,*
hereditary*thrombophilia*testing*(if*patient*has*another*firstUdegree*relative*who*has*had*DVT*or*PE).*
• Patients*with*major*risk*factors*for*DVT*should*consider*wearing*antiUembolism*stocking*on*long*flight.*
PostUthrombotic*syndrome*
• Complication*following*a*DVT*caused*by*chronic*venous*hypertension*from*venous*outflow*obstruction.*
• Features:*painful*and*heavy*calves,*pruritus,*swelling,*varicose*veins,*venous*ulceration.*
• Management:*compression*stockings,*leg*elevation.*
Von*Willebrand’s*disease*
• Most*common*inherited*bleeding*disorder*that*is*mostly*autosomal*dominant.*
• Caused*by*lack*of*von*Willebrand’s*factor*(which*promotes*platelet*adhesion*to*damaged*endothelium);**
vWF*also*binds*factor*VIII.*
• Types:*1)*partial*reduction*in*vWF*(most*patients);*2)*abnormal*vWF;*3)*total*lack*of*vWF*(autosomal*
recessive)*
• Features:*bleeding*after*mild*trauma;*epistaxis,*menorrhagia.*
• Coagulation*tests:*prolonged*bleeding*time,*prolonged*APTT;*reduced*factor*VIII.*
• Management:*tranexamic*acid*for*mild*bleeding.*
• Management:*desmopressin*raises*levels*of*vWF*by*inducing*release*of*vWF*from*endothelial*cells.*
• Management:*factor*VIII*concentrate*can*replenish*low*levels*of*factor*VIII.*
Haemophilia**
• Exam*hint:*haemarthrosis*(bleeding*into*joint)*without*trauma.*
• XUlinked*recessive*dosorder*of*coagulation*(90%*is*haemophilia*A).*
• Haemophilia*A*is*due*to*deficiency*of*factor*VIII;*haemophilia*B*is*due*to*lack*of*factor*IX.*
• Features:*haemarthrosis,*haematoma,*prolonged*bleeeding.*
• Coagulation*tests:*normal*bleeding*time,*prolonged*APTT,*normal*thrombin*time,*normal*prothrombin*time.*
Disseminated*intravascular*coagulation*

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• Dysregulation*of*processes*of*coagulation*and*fibrinolysis*leads*to*widespread*clotting*which*depletes*
clotting*factors*and*leads*to*bleeding.*
• Coagulation*tests:*low*platelet*count,*prolonged*bleeding*time,*prolonged*APTT,*prolonged*prothrombin*
time.*
Idiopathic*thrombocytopaenic*purpura*(ITP)*
• Autoimmune*disease*that*is*the*most*common*cause*of*primary*thrombocytopaenia.*
• Clinically*diagnosed*with*an*isolated*thrombocytopaenia*in*an*otherwise*healthy*patient*(coagulation*tests*
are*typically*normal).*
• More*commonly*seen*in*children*and*may*follow*an*infection*or*vaccination.*
• Features:*most*patients*present*with*anaemia*and*purpura*on*legs*due*to*blood*loss*and*low*platelets.*
• Management:*usually*selfUlimiting*within*1U2*weeks.*
• Chronic*ITP*is*more*common*in*young*and*middle*aged*women*and*tends*to*be*relapsingUremitting.*
Thrombophilia*
• Most*common*inherited*cause*is*factor*V*Leiden;*most*common*acquired*cause*is*antiphospholipid*
syndrome.*
• Causes:*deficiency*of*antithrombin*III,*protein*C*or*protein*S.*
• Causes:*may*be*caused*by*oral*contraceptive*pill.*
Factor*V*Leiden*
• Mutation*in*factor*V*Leiden*protein*means*that*activated*factor*V*is*inactivated*10*times*more*slowly*by*
activated*protein*C*than*normal.*
• Patients*are*at*higher*risk*of*venous*thrombosis.*
Hodgkin’s*lymphoma*
• Malignant*proliferation*of*lymphocytes*characterised*by*ReedUSternberg*cells.*
• Most*common*in*30s*and*70s.*
• Types:*nodular*sclerosing*type*is*most*common;*lymphocyte*predominant*type*has*the*best*prognosis;*
lymphocyte*depleted*type*has*the*worst*prognosis.*
• Features:*asymptomatic*lymphadenopathy*(painless,*nonUtender,*asymmetrical);*systemic*symptoms*(weight*
loss,*pruritus,*night*sweats,*fever)*occur*in*10%*of*cases,*severe*pain*on*alcohol*consumption.*
• Signs:*normocytic*anaemia,*eosinophilia,*raised*LDH.*
• Systemic*symptoms*are*associated*with*poor*prognosis.*
• Investigations:*diagnosis*requires*complete*lymph*node*biopsy*(ReedUSternberg*cells).*
• Management:*chemotherapy*and*radiotherapy.*
NonUHodgkin’s*lymphoma*
• Most*common*type*is*diffuse*large*B*cell*lymphoma.*
• Most*common*between*50U60*years.*
• Features:*painless*widespread*lymphadenopathy,*hepatosplenomegaly.*
• Signs:*raised*LDH,*paraproteinaemia,*autoimmune*haemolytic*anaemia.*
• Management:*rituximab,*antiUCD20*monoclonal*antibody,*stem*cell*transplantation.*
Burkitt’s*lymphoma*
• High*grade*B*cell*neoplasm*associated*with*cUmyc*gene*translocation.*

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• Associated*with*EBV*and*HIV*infection.*
• Investigations:*biopsy*reveals*‘starry*sky’*appearance*(lymphocytes*interspersed*with*macrophages*
containing*dead*apoptotic*tumour*cells).*
• Management:*chemotherapy;*tumour*lysis*syndrome*may*occur*as*a*sideUeffect*and*allopurinol*is*given*
before*chemotherapy*to*reduce*the*risk*of*this*occurring.*
• Tumour*lysis*syndrome:*characterised*by*hyperkalaemia,*hyperphosphataemia,*hypocalcaemia,*
hyperuricaemia;*in*addition*to*this,*increased*serum*creatinine,*arrythmia*or*seizure*is*required*for*
diagnosis.*
Chronic*lymphocytic*leukaemia*
• Most*common*form*of*leukaemia*in*adults.*
• Proliferation*of*B*cell*lymphocytes*characterised*by*peripheral*blood*lymphocytosis*(many*precursors)*and*
uncontrolled*proliferation*of*mature*lymphocytes*in*bone*marrow.*
• Features:*often*asymptomatic;*anorexia,*weight*loss,*bleeding,*infection,*nonUtender*lymphadenopathy,*
hepatosplenomegaly.*
• Blood*film:*smudge*cells*(also*known*as*smear*cells).*
• Complications:*hypogammaglobulinaemia*(leading*to*recurrent*infection),*warm*autoimmune*haemolytic*
anaemia,*transformation*to*high*grade*nonUHodgkin’s*lymphoma*(Richter’s*transformation).*
Richter’s*transformation*
• Occurs*when*leukaemia*cells*enter*the*lymph*node*and*transform*into*a*fast*growing*nonUHodgkin’s*
lymphoma.*
• Features:*chronic*lymphocytic*leukaemia*patient*+*lymph*node*swelling,*fever*without*infection,*weight*loss,*
night*sweats,*nausea,*abdominal*pain.*
Chronic*myeloid*leukaemia*
• Characterised*by*an*increase*in*granulocytes*at*different*stages*of*maturation.*
• Highly*associated*with*the*Philadelphia*chromosome.*
• Typically*presents*at*60U70*years.*
• Features:*anaemia*(lethargy),*weight*loss,*sweating,*splenomegaly*(plus*abdominal*discomfort).*
• Blood*film:*spectrum*of*myeloid*cells.*
• Management:*imatinib*is*firstUline.*
Gastric*MALT*lymphoma*
• Associated*with*H.pylori*in*95%*of*cases.*
• Management:*eradication*of*H.pylori.*
Multiple*myeloma*
• Neoplasm*of*bone*marrow*plasma*cells.*
• Peak*incidence*is*at*60U70*years.*
• Features:*bone*disease*(bone*pain,*osteolytic*lesions,*osteoporosis,*pathological*fractures),*anaemia,*
hypercalcaemia,*lethargy,*weight*loss,*infection,*renal*failure.*
• Investigations:*raised*ESR*and*osteoporosis*is*multiple*myeloma*until*proven*otherwise.*
• Investigations:*serum*protein*electrophoresis*looking*for*monoclonal*proteins*(IgG,*IgA),*Bence*Jones*protein*
testing,*increased*plasma*cells*in*bone*marrow.*

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• Investigations:*skull*XUray*or*CT/MRI*may*show*bone*lesions*(‘pepperpot’*skull).*
• Diagnostic*criteria:*major*criteria*include*plasmacytoma,*30%*plasma*cells*in*bone*marrow,*elevated*levels*of*
M*protein*in*blood*or*urine;*minor*criteria*include*osteolytic*lesions,*10U30%*plasma*cells,*mildly*elevated*
levels*of*M*protein.*
Anaemia*
• Macrocytic*anaemia:*causes*include*vitamin*B12*deficiency,*folate*deficiency.*
• Microcytic*anaemia:*causes*include*iron*deficiency*anaemia,*thalassaemia.*
• Normocytic*anaemia:*causes*include*anaemia*of*chronic*disease.*
• In*a*patient*with*both*vitamin*B12*and*folate*deficiency,*treat*with*IM*vitamin*B12*first*and*then*start*oral*
folic*acid*once*B12*levels*are*normal.*
Iron*deficiency*anaemia*
• Blood*film:*target*cells,*pencil*poikilocytes.*
• Iron*studies:*low*iron,*low*ferritin,*high*TBC.*
• Investigations:*antiUTTG*is*the*firstUline*investigation.*
• Management:*oral*iron*takes*>*1*month*to*take*effect;*IV*iron*takes*2*weeks;*blood*transfusion*is*immediate.*
Sickle*cell*anaemia*
• Autosomal*recessive*condition*that*results*in*synthesis*of*abnormal*haemoglobin.*
• More*common*in*people*of*African*descent.*
• Characterised*by*periods*of*good*health*and*intermittent*sickle*cell*crises.*
• Complications:*sickle*cell*crises,*of*which*are*four*types*(thrombotic;*sequestration;*aplastic;*haemolytic).*
Sickle*cell*crisis*
• Thrombotic*crisis:*preciptated*by*infection,*dehydration*and*deoxygenation.*
• Thrombotic*crisis:*causes*infarcts*in*various*organs*including*bones*(eg.*avascular*necrosis*of*hip,*handUfoot*
syndrome*in*children).*
• Sequestration*crisis:*sickling*within*organs*causes*pooling*of*blood*with*worsening*of*anaemia*and*
splenomegaly*(may*cause*abdominal*pain).*
• Sequestration*crisis:*may*cause*acute*chest*syndrome*which*consists*of*dyspnoea,*chest*pain,*pulmonary*
infiltrates*on*CXR*and*low*pO2.*
• Aplastic*crisis:*caused*by*infection*with*parvovirus.*
• Aplastic*crisis:*presents*as*a*sudden*fall*in*haemoglobin*and*low*reticulocyte*count.*
• Haemolytic*crisis:*rare*but*causes*a*fall*in*haemoglobin*due*to*increased*rate*of*haemolysis*and*high*
reticulocyte*count.*
• Management:*analgesia,*IV*fluids,*oxygen,*antibiotics*(if*there*is*infection),*blood*transfusion*(if*required).*
Hereditary*spherocytosis*
• Most*common*hereditary*haemolytic*anaemia*in*Europeans;*autosomal*dominant.*
• RBC*survival*is*reduced*because*of*abnormal*shpereUshaped*RBC*(spherocytes).*
• Features:*failure*to*thrive,*neonatal*jaundice,*gallstones,*splenomegaly,*haemolysis;*aplastic*crisis*
precipitated*by*parvovirus.*
• Investigations:*osmotic*fragility*test*is*diagnostic.*
• Management:*folate*replacement*and*splenectomy.*

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