Block 32 Week 3&4 Flashcards
1
Q
Paget’s disease of the nipple?
A
- rare condition associated with breast cancer. It causes eczema-like changes to the skin of the nipple - It’s usually a sign of breast cancer in the tissue behind the nipple.
2
Q
ductal vs lobular carcinomas?
A
- ductal carcinomas are more likely to present with a discreet lump but lobular carcinoma may be harder to detect
3
Q
/PVD - lipodermatosclerosis
A
refers tochanges in the skin of the lower legs. It is a form of panniculitis (inflammation of the layer of fat under the skin)
4
Q
UC?
A
- begins in rectum and extends proximaly
- Mostly pathological findings limited to mucosa and submucosa
5
Q
Changes seen in UC?
A
- Muscularis propria only affected in fulminant disease
- Distorted crypt architecture
- Crypt abscesses
6
Q
Who does UC affect more?
A
- less common in smokers
- increased in caucasians, jews and females
7
Q
UC peaks?
A
15-25 and 55-65
8
Q
histological changes seen in IBD?
A
9
Q
Symptoms of UC?
A
- dominant Sx is diarrhoea
- often associated w bleeding PR
- often freq of small stools w urgency - inflamed rectum loses ability to distend and relax
10
Q
Other findings of UC?
A
- fatigue
- malaise
- weight loss
- fever
- tachycardia
11
Q
CD can affect…
A
- can affect anywhere from mouth to anus
- transmural inflammation
- granulomas but these are more common in submucosa
12
Q
3 major patterns of CD?
A
- ileeocaecal disease - 40%
- confined to SI - 30%
- confined to colon - 25%
13
Q
Who does CD affect more?
A
- Increased incidence in Caucasians, Jews and slight female preponderance
- More common in smokers
14
Q
peaks in CD?
A
15-25 and 55-65 years of age
15
Q
Symptoms of CD?
A
- diarrhoea
- abdominal pain
- weight loss
- fatigue
- low grade fever
16
Q
CD activity index?
A
17
Q
Harvey-bradshaw index?
A
- score <4 = in remission
- score 5-8 = moderate activity
- score >8 = severe active disease
- crohns
18
Q
investigations?
A
- flexible sigmoidoscopy/ colonoscopy and biopsies
19
Q
radiology?
A
- plain AXR - thumbprinting
- CT
- MR enterography
- small bowel follow-through meal
20
Q
test for IBD?
A
- faecal calprotectin
21
Q
Tx of IBD?
A
- aminosalicyclates
- mainly mesalazine
- others: olsalazine, sulphasalazine, balsalazide
22
Q
UC scan
A
23
Q
stovepipe sign
A
24
Q
aminosalicyclates r used for?
A
- prevention of CRC
- high dose to prevent remission
25
side effects of aminosalicyclates?
* rashes
* headache
* diarrhoea
* reversible infertility
* intestinal nephritis
26
corticosteroid with a low first pass metabolism?
prednisolone
27
corticosteroids with a high first pass metabolism?
beclomethasone
28
nutrition for IBD?
* elemental or semi elemental diets
29
immunomodulators for IBD?
- Azathioprine
- mercaptopurine
- methotrexate
- ciclosporin
- mycophenolate
- cytokine modulators
30
azathioprine?
* Affects purine (A+G) synthesis
* Decreases T-lymphocytes
31
side effects of azathioprine?
* Side effects; up to 30% don’t tolerate
* Dangerous neutropenia
32
mercaptopurine?
* active metabolite of azathioprine
33
methotrexate?
* antifolate
* once weekly
* fibrosis
34
Tx pathway of IBD?
35
Ciclosporin?
* calcineurin inhibitor
* CN activates T cells
36
rescue therapy in UC?
Ciclosporin
37
mycophenolate?
* affects guanine (purine) synthesis in B and T lymphocytes
38
TNF-a?
activates NF-KB which induces apoptosis
39
drugs that inhibit TNF-a?
* infliximab and adalimumab inhibit TNFa
* used in severe crohns not responding to conventional drugs
40
Side effect of infliximab and adalimumab?
* hepatosplenic T cell lymphoma
* especially in young males
41
surgery for UC?
* toxic megacolon/ acute colitis
* failure to respond to medical therapy
* colectomy is curative
42
surgery for CD?
* High rate of disease recurrence after surgery
43
inducing remission in crohns?
* offer monotherapy of a conventional glucocorticoid to induce remission
* aminosalicyclates if ^ are CI or if the person can't tolerate them
44
what should not be used to induce remission in CD?
azathioprine, mercaptopurine or methotrexate as monotherapy to induce remission
45
what to check for azathioprine?
TPMT activity
46
How is remission induced in UC?
in mild to moderate UC: aminosalicyclate
47
risk factors CD?
* Fhx
* smoking
* prev GE
* NSAIDs
48
Crohns vs UC?
* UC: continous inflammation of the mucosa starting in the rectum in most cases and is limited to the colon
* CD: transmural patchy inflammation throughout the GIT - MOUTH TO ANUS
49
genetics in CD?
* disrupted microflora-immune response
* association between SNP in NOD2 (CARD15) gene and crohns
50
increased risk of CD...
* smoking increases risk of CD but is protective in UC
* western diets, abs and contraceptive use increases risk of CD
51
Perianal CD?
* About a third of patients suffer from perianal CD - e.g. skin tags, fissures, fistulae, abcesses, or anal canal stenosis
52
Pathological changes of CD mneumonic?
53
CD - ? appearance of mucosa?
* cobblestone appearance which is caused by small superficial ulcers which become deep with a wavy margin
* bowel wall thickening, lumen narrowing, deep ulcers, fistulae and fissues may also occur
54
microscopic changes in CD?
* lymphoid hyperplasia and non-caseating granulomas
* skip lesions and transmural ulceration
55
Sx of CD?
* nausea and vomiting
* fatigue
* low grade fever
* weight loss
* abd pain
* diarrhoea (+/- blood)
* rectal bleeding
* perianal disease
56
Signs of CD?
* pyrexia
* Dehydration
* Angular stomatitis
* Aphthous ulcers
* Tachycardia
* Hypotension
* Abdominal pain, mass and distension
57
MSK manifestation of CD?
* peripheral arthiritis
58
Skin changes in CD?
* erythema nodosum
* pyoderma gangrenosum
59
Erythema nodosum?
* Erythema nodosum, a panniculitis, is characterised by reddened, raised, tender nodules.
60
pyoderma gangrenosum?
pyoderma gangrenosum presents with ulcerating nodules characterised by black (gangrenosum) edges and central pus (pyoderma).
61
eye changes in CD?
* episcleritis
* uveitis
* conjuncitivitis
62
which EIM can precede intestinal disease?
apthous ulcers
63
primary sclerosing cholangitis in CD?
* Primary sclerosing cholangitis may occur but is more common in UC
* fatty liver disease and gallstones are more common
64
other extra-intestinal mainfestations of CD?
* Renal calculi
* Osteoporosis
* B12 deficiency
* Pulmonary disease
* Venous thrombosis
* Anaemia
65
investigations of CD?
* macroscopic assessment and histological evidence (e.g. biopsy) of inflammation typical of CD
* stool microscopy, culture, parasites, C diff toxin
* faecal calprotectin - released following degranulation of neutrophils
66
Endoscopic Ix of CD?
* colonoscopy - can do a tissue biopsy
* upper GI endoscopy - biopsy needed to differentiate CD from other pathology
67
inducing remission in CD?
* budesonide
* systemic corticosteroids if the patient doesn't resond to budesonide or if they have moderate-severe crohns e.g. prednisolone
68
Inducing remission in M-S CD?
immunosuppressive therapy e.g. azathioprine or methotrexate
69
CD - maintenance therapy?
* thiopurines, methotrexate and biologics
* considered in patients with recurrent flares, moderate-to-severe disease, or poor prognostic features (e.g. extensive disease).
70
thiopurines mechanism?
azathioprine and mercaptopurine - purine synthesis inhibition in lymphocytes
* check TPMT levels!!
71
what to check b4 methotrexate use?
* check renal and liver function before use
72
side effects of methotrexate?
* bone marrow suppression, hepatotoxicity, pulmonary toxicity
73
management of perianal disease ?
* Control perianal sepsis (e.g. antibiotics)
* Evaluation (e.g. MRI or examination under anaesthesia)
* Surgical intervention (e.g. abscess drainage or seton for fistula)
74
surveillance colonoscopy?
* patients with IBD in the UK are offered surveillance ileocolonoscopy between 6-10 years following diagnosis to screen for dysplasia
* patients w primary sclerosing cholangitis are at a paticularly high risk of cancer
75
UC is more common in which populations?
Jewish
76
environmental factors contributing to UC?
milk consumption, bacterial microflora alteration and medications like OCP and NSAIDs
77
Pattern of UC?
* UC affects the rectum (proctitis) first and then extends proximally to the colon
* most patients (50%) suffer from proctitis only
78
pancolitis?
inflammation of the entire colon
79
what does pancolitis put you at risk of?
- backwash ileitis
- reflux of colonic contents into the distal few centimetres of the ileum through the ileocaecal valve
80
macroscopic changes of UC?
* continuous inflammation that extends proximally along the colon
* may be inflammatory polyps
81
Microscopic changes of UC?
* crypt abcesses and goblet cell depletion
* increased inflammatory infiltration into the lamina propria, which is largely neutrophilic.
82
Hallmark of UC?
bloody diarrhoea/ rectal bleeding
83
Symptoms of UC?
* Weight loss
* Fatigue
* Abdominal pain
* Loose stools
* Rectal bleeding
* Tenesmus (incomplete emptying)
* Urgency
84
Signs of UC?
* Febrile
* Pale
* Dehydrated
* Abdominal tenderness
* Abdominal distension/mass
* Tachycardic, hypotensive
85
Major complication of UC?
* toxic megacolon is a major complication
86
TMC?
medical emergency - toxic, non obstructive dilatation of the colon
87
When should TMC be suspected?
* UC + abdominal distension and tenderness -> suspect TMC
88
Systemic symptoms suggestive of TMC?
* Fever
* Tachycardia
* Hypotension
* Dehydration
* Altered mental status
* Biochemical abnormalities (e.g. leukocytosis, anaemia, and electrolyte derangements)
89
most common manifestation of UC?
ARTHIRITIS - can be simple peripheral arthititis or spondylarthropathy e.g. ankylosing spondyliti
90
90
91
Eye related manifestation of UC?
* uveitis is strongly assoc w UC
* episcleritis
91
other MSK features of UC?
osteopenia/ osteoporosis, clubbing of hands and feet
92
mouth changes seen in UC?
Apthous ulcers
93
skin changes assoc w UC?
Erythema nodosum and pyoderma gangrenosum
94
hepatobiliary manifestation of UC?
* fatty liver disease and autoimmune liver disease
* most commonly: primary sclerosing cholangitis
95
96
Link between PSC and UC?
* up to 95% of patients w PSC have UC - suspect PSC in any UC patient who has an isolated rise in ALP
97
haem manifestations of UC?
* anemia
* thromboembolism
98
Ix of UC?
* Stool microscopy, culture & sensitivities
* Ova, cysts and parasites
* C. diff toxin (CDT)
* Faecal calprotectin (marker of intestinal inflammation)
99
bloods for UC?
* FBC
* LFTs
* U&Es
* magnesium
* autoantibodies - e.g. p-ANCA
100
Imaging for UC?
* abd X ray for looking at dilatation of the bowel and perforations
101
Endoscopy for UC?
* colonoscopy
* biopsies for histological assessment
* sigmoidoscopy can be used as an alternative
102
Truelove and Witts?
* scores UC severity
* into mild, moderate and severe
103
Inducing remission: mild to moderate UC?
* mild to moderate UC: initially 5-ASA agents - topically +/- orally
* Patients with extensive UC (e.g. pancolitis or left-sided colitis) should be treated with both oral and topical (e.g. enemas) 5-ASAs.
104
104
105
inducing remission for severe UC?
* patients who fail to respond to 5-ASAs or those w moderate to severe UC can be treated w systemic corticosteroids as a 6-8 wk course
106
Maintenance therapy for UC?
* thiopurines
* biologics
* in patients who don't respond to remission therapy or steroid dependent or >2 flares in a 12 month period
107
surgery for UC?
* principle surgical option in UC is proctocolectomy followed by ileal pouch anal anastomosis (IPAA) or end ileostomy.
108
management of acute severe UC?
* High dose corticosteroids IV with PPI
* VTE prophylaxis: LMWH
* antibiotics: broad spectrum
* hydration and nutrition
109
How can an upper GI bleed present?
* severe bleeding w haematemesis, hametochezia and hypotension
* coffee ground vomiting (exclude bowel obstruction)
* gradual bleeding w melena
* occult bleeding detected by positive tests for blood in stool, anaemia
110
causes of UGIB?
111
Assessment of an UGIB?
* FBC, PT and PTT
112
If the patient is unstable with an UGIB...
* O2
* fluid of 500ml in less than 15 min
* continous monitoring - nEWS
* catheter and monitor urine output
113
UGIB - resus - transfusion?
* for patients w massive bleeding
* prothrombin complex concentrate or vitamin K -> Warfarin
* recomb factor 7a when other methods fail
114
warfarin reversal?
prothrombin complex concentrate or vitamin K
115
2 methods used to assess risk in an UGIB?
* Glasgow-Blatchford score
* Rockall score
116
Rockall score?
* incorporates clinical and endoscopic findings
* evaluates risk of re-bleeding or death
117
history with an UGIB?
* ulcers
* recent trauma
* liver disease
* varices
* alcoholism - MWT or oesophageal varices
* vomiting
118
UGIB history - medications?
* medications that interefere w coagulation - NSAIDS, aspirin, dipyridamol
119
physical exam w an UGIB?
* jaundice
* ascites and other signs of liver disease
* tumour mass
* bruit
120
NG aspiration?
* clear and bile stained - can have bleeding distal to pylorus
* bloody
121
Tx of an upper GIB is dependent on
whether it's variceal or non variceal bleeding
122
Cirrhosis/ variceal bleeding Tx?
* IV Terlipressin - vasopressin analogue
* or somatostatin/ octreotide
* ECG >65 yrs
123
Terlipressin caution?
* Be careful w Telipressin in patients w IHD or PVD as it can worsen it
124
what else should be prescribed for an UGIB patient - variceal bleeding?
* IV ab as infections more common in ppts w cirrhosis and UGI bleeding
* 7 day broad spectrum abs
125
Other things to do during management of UGIB?
* fluid resus
* coagulopathy common and should be addressed
126
126
127
method of stopping bleeding for an UGIB?
* balloon tamponade to stop the bleeding - balloon at the G-E junction
* temporary method until patient stabilised
* sig risk of ischaemia if the tube is left for more than 24 hrs
127
endoscopy with an UGIB?
* endoscopy: looking for oesophageal gastric varices
* Gastroesophageal varices occur in ~30% of cirrhosis patients
128
Methods of stopping oesophageal varices from bleeding?
* band ligation - best option (during endoscopy)
* stent insertion - applies pressure
* TIPS (transjugular intrahepatic portosystemic shunts) if bleeding is not controlled by band ligation
128
when does endoscopy be done for an UGIB?
* endoscopy should be done immediately after resus for unstable patients w severe bleeding
* all other patients with UGI bleeding need one within 24hrs
129
how to stop gastric varices from bleeding?
* endoscopic injection of cyanoacrylate (sclerotherapy)
* TIPS (shunt) if bleeding isn't controlled
130
main cause of non-variceal UGIB?
PUD
131
CT angiography for UGIB?
* for patients who are haemodynamically Unstable
* fastest and least invasive method
* catheter angiography -> source of bleeding can be embolised
132
If the source of bleeding can't be identified with CT angiography?
immediate OGD
133
Sugery for UGIB?
* last resort
* shock
* failure of endoscopic manegement
* recurrent haemorrhages after intial stabilization
* continued slow bleeding with a transfusion
134
methods of dealing with non variceal bleeding - during endoscopy?
* Adrenaline injection plus
* thermal modalities e.g. heater probe
* mechanical modality (clips)
* haemostatic powders
135
Other management methods of non variceal bleeding?
* PPIs
* H pylori eradication
* antithrombin therapy interupted
136
How are oral AC reversed?
inhibitors (idarucizumab or andexanet)
137
when should AC be restarted for low vs high thrombotic risk patients?
* low thrombotic risk - restart warfarin in 7 days
* high thrombotic risk - LMWH after 48 hrs
138
Re-bleeding?
* related to size and location - posterior duodenum carries a higher risk
* repeat endoscopy for patients who re-bleed
139
MWT?
* Lower part of oesophagus/ lesser curvature
* lesion usually stops bleeding w/o therapy
140
Acute haemorrhagic gastritis is when?
* related to stress or medications like NSAIDs
* whole gastric mucosa bleeds
141
AHG treatment?
* stop NSAIDs
* give H2 receptor blockers, PPIs
* anti- H pylori therapy
142
if bleeding doesn't stop w AHG then give?
IV somatostatin
143
last resort for AHG?
gastrectomy
144
lower GI bleeding?
* distal to LoT
* less frequent than UGI bleeding
* majority of cases from colon, and is more common in men
145
how to distinguish between an upper and lower GI bleed?
NG aspiration
146
causes of a LGIB
147
Oakland score?
- LGIB
* helps u decide if the patient needs admittance
* less than 8 means the patient can be seen as an outpatient
148
Tx pathway for a LGIB?
149
Ix of a LGIB?
* haemodynamic instability may indicate an upper GI bleed so
* CT angiography first
* if inconclusive -> OGD
150
LGIB - if a colonoscopy isn't feasible then?
* If bleeding volume means that colonoscopy is not feasible or is ineffective -> selective mesenteric arteriography
151
Tx of LGIB?
* vasopression infusion and embolization of bleeding vessels
152
Acute UGIB?
* Medical emergency
* divided into variceal and non-variceal
* death from exsanguination is uncommon
153
Summary for management of an UGIB?
* history and exam
* resus
* investigation
154
Common causes of an UGIB?
* PUD
* gastritis
* gastric ulcer
* varices
* cancer - ooesephageal or gastric, duodenal is rare
155
Things to ask in an UGIB history?
* volume
* type of blood loss
* fresh haemetemsis
* coffee ground vomit
* maleana
* fresh PR blood
156
oesphagitis?
heartburn, occassionaly chest pain often worse on lying down
157
gastritis?
dyspepsia - e.g. epigastric often burning pain
158
gastric or duodenal ulcer?
dyspepsia, nausea, vomiting, weight loss
159
varices?
history of liver disease, excess alcohol
160
cancer?
malaise, weight loss, vomiting, early satiety
161
meds history for UGIB?
NSAIDs, steroids, AC meds including warfarin
162
Examination for an UGIB?
* pulse, BP, pallor, cap refill
* postural drop
* signs of anemia
* stigmata of CLD
* working out if the patient has shock
163
Ix for UGIB summary?
* FBC - hb, MCV
* U&Es - raised urea and creatine indicates UGIB
* clotting screen - espec if patient is on AC
* LFTs
* upper GI endoscopy - diagnostic test of choice
164
resus for a bleed?
* IV access
* catheter
* fluids
* blood
165
initial management of a non variceal bleed?
166
initial management of variceal bleeds?
* higher morbidity and mortality
* terlipressin - splenic vasoconstrictor, reduces portal hypertension
* IV broad spectrum ab
167
chronic LGIB - history?
* type of blood
* change in bowel habit
* mucus
* abd pain
* weight loss
* eye, joint or skin symptoms
168
overt GI bleed?
* if its on wiping - most likely an anal cause like haemorrhoids
169
anal causes of chronic GI bleeding ?
* piles
* fissure
* carcinoma
170
rectal causes of chronic GI bleeding?
* carcinoma
* inflammation
* polyps
171
colonic causes of chronic GI bleeding?
* cancer
* diverticular disease
* inflammation
* polyps
* angiodysplasia - fragile blood vessels
172
Severe overt lower GI bleeding is a ?
med emergency
173
assessment of a lower GI bleed
174
examination for lower GI bleeding?
175
investigations for LGIB?
* bloods
* colonoscopy
* alternatives - barium enema, CT colonography
176
What does chronic occult GI bleeding cause?
* causes iron deficieny anaemia
* microcyctic, hypochromic anaemia
* Fe can be falsely raised by inflammation
* faecal occult blood testing
177
diagnoses of upper GI Bleeds
178
fresh rectal bleeding commonly results from?
* fresh rectal bleeding commonly results from a source in a rectum or colon but large upper GI bleeds can also present w haematochezia
179
diverticulosis?
* most common cause of lower GI bleeding
* increases w age
180
Diverticular disease vs diverticulitis?
* Whilst diverticular disease bleeds are often painless, any bleeds secondary to diverticulitis can often be painful, due to the localised inflammation.
181
haemorrhoids?
* pathologically engorged vascular cushions in the anal canal
* can present as a mass, with pruritus, or fresh red rectal bleeding
* blood is classically on the surface of the stool or toilet pan, rather than mixed in with it.
182
RF of CRC?
* Family history
* Hereditary syndromes - lynch syndrome and FAP
* Inflammatory bowel disease
* Ethnicity - white
* Radiotherapy
* Obesity
* Diabetes mellitus
* Smoking
183
CRC most commonly affects?
* Most commonly affects left side of the colon
* mets mostly to liver
184
which cancers mets to the lung?
* Rectal cancers are more commonly associated with lung metastasis (prior to liver metastasis) due to direct haematogenous spread via the inferior rectal vein and IVC
185
Summary of CRC mets?
left sided -> liver
rectal -> lung
also peritoneum, brain and bone
186
pres of CRC?
* change in bowel habit, anaemia, weight loss
* Diagnosis frequently follows the recognition of an unexplained (and typically iron deficient) anaemia - a key indication for endoscopy.
187
Symptoms of CRC?
* Change in bowel habit
* Weight loss
* Malaise
* Tenesmus
* PR bleeding
* Abdominal pain
188
Signs of CRC?
* pallor
* abd mass
189
signs of metastatic disease from CRC?
* Hepatomegaly
* Jaundice
* Abdominal pain
* Lymphadenopathy
190
Right sided CRC?
* right sides lesions tend to develop as masses arising from a dyplastc polyp -> iron deficieny anaemia
191
Left sided CRC?
* left sided lesions - grow circumferentially creating an apple core appearance -> narrowing of lumen and symptoms of changes in bowel habit and obstruction
192
Right vs left sided CRC?
- right: iron def anemia
- left: apple core apperance -> obstruction
193
Screening for CRC?
* FIT test
* 60-74
194
RF for an UGIB?
* NSAIDs
* Anticoagulants
* Alcohol abuse
* Chronic liver disease
* Chronic kidney disease
* Advancing age
* Previous PUD or H. pylori infection
195
macronutrients (3)?
* carbs
* proteins
* lipids
196
micronutrients?
* minerals
* vitamins
* trace elements
197
functions of proteins?
* Structural i.e. Collagen in bone
* Regulatory i.e. Hormones like insulin
* Contractile i.e. Myosin and actin in muscle cells
* Immunological i.e. Antibodies
* Transport i.e. Haemoglobin
* Catalytic i.e. enzymes
198
lipids?
* Most plentiful lipid in your body
* Provide more than twice as much energy as carbohydrates or protein
199
steroids?
* such as cholesterol, bile salts, adrenocortical hormones, sex hormones
200
eiconasoids?
* Lipids derived from arachidonic acid
* 2 principle subclasses are prostaglandins and leukotrienes
* Involved in inflammatory reactions, gastric protection, airway calibre, clotting
201
water soluble vitamins?
▪Vitamin B1, B2, B6, B12, C, Folate and Niacin
▪Absorbed along with water in the GI tract
202
fat soluble vitamins?
▪Vitamin A, D, E, K
- Absorbed with other dietary lipids in small intestine – dependent on bile salts
203
antioxidant vitamins?
Vitamins C, E and Beta-carotene act as antioxidants – they inactivate oxygen free radicals which would otherwise damage DNA, cell membranes and structures within a cell
204
what must equal to maintain weight?
* intake and output must equal to maintain weight
205
vitamin deficienies table
206
basal energy expenditure?
rest energy required for metabolism
207
nutritional assessments?
* BMI - body mass index (weight (kg)/height (m2))
* Mid - arm circumference = muscle mass
* Skin - fold thickness = body fat
208
enteral feedinf?
▪Oral
▪Tube feeding
* preferred as lack of enteral feeding atrophies the intestinal epithelium + inc risk of sepsis
209
when is enteral feeding used?
* Cannot eat sufficient food
* Unconsciousness (tube feed)
* Dysphagia (tube feed)
* Loss of nutrients from fistulas/stomas
* Major illness/postoperatively
210
tube feeding?
* For patients with inadequate or unsafe oral intake
* Via a fine bore nasogastric tube
* Nasojejunal tube can be inserted in presence of gastroparesis or pancreatitis
211
complications of tube feeding?
insertion of tube into lungs, aspiration, nasal erosion, refeeding syndrome
212
enterostomy feeding?
* feeding for more than 4-6 wks
* usually inserted using PEG
213
risks of enterostomy feeding?
perforation, peritonitis, buried bumper syndrome, infected site, aspiration
213
parenteral feeding?
IV
214
when is parenteral feeding used?
* for those w unsafe oral or enteral intake
* non-functional, inaccessible or perforated GI tract
* requires use of solution containing macros and micros
215
how can parenteral feeding be done?
- short term feeding - peripheal cannula if no need for CV access
- PICC line
- central venous catheters
216
picc line?
peripherally inserted central catheter via basilic vein
217
central venous catheters?
subclavian line
218
what is common with a peripheral cannula for parenteral feeding?
thrombophlebitis
219
risks of central venous catheter insertion?
* Catheter related infection, blockage, venous thrombosis, fatty liver disease
220
refeeding syndrome?
* too rapid intro of feed following starvation
* can occur after enteral or parenteral feeding
221
why does refeeding syndrome occur?
* Results from a reduced carbohydrate intake secondary to starvation producing low insulin levels.
* Once feeding restarted increased insulin secretion occurs, which increases cellular uptake of PO4.
222
RS - when phosphate levels fall?
rhabdomyolosis, leucocyte dysfunction, respiratory/cardiac failure, muscle weakness, seizures, coma.
223
when does RS occur?
usually around day 4 of refeeding
224
Patients at high risk of refeeding syndrome include:
* BMI < 16kg/m2
* History of alcohol abuse
* Little or no nutritional intake for last 10 days
* Low levels of potassium, phosphate or magnesium prior to commencing feed
* Unintentional weight loss of > 15% last 3-6 months
* Those at high risk require additional vitamin supplements – thiamine/vitamin B/trace elements
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intestinal failure?
* intestinal failure is characterised by inadequate intake and absorption of nutrients
226
type 1 intestinal failure?
* post-op ileus or small intestinal obstruction, usually requires short term nutrition
227
type 2 intestinal failure?
* type 2 IF: greater than 28 days
* typical patients: complex CD, intestinal fistula, abd sepsis
228
type 3 intestinal failure?
* type 3: generally irreversible
* usually occurs as a consequence of massive bowel resection leading to short bowel syndrome
229
features of malabs - caloric?
weight loss with normal appetite
230
features of malabs - fat?
pale, greasy, offensive diarrhoea
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features of malabs - protein?
edema, muscle atrophy, amenorrhea
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features of malabs - carbs?
abd bloating, diarrhoea, flatus
233
features of malabs - B12?
* macrocytic anemia
* degeneration of SC
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Features of malabs - folic acid?
* folic acid: macrocytic anemia
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features of malabs - vitamin B?
glossitis, stomatitis, acrodermatitis, cheliosis
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features of malabs - iron?
* iron: microcytic anemia
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features of malabs - calcium and vitamin D?
osteomalacia, tetany
238
Features of malabs - vitamin A?
night blindness, follicular hyperkeratosis
239
features of malabs - vit K?
bleeding
240
CF of malabs
241
rationale for and practical implications of a gluten-free diet?
* coeliac disease
* demeatitis herpetiformis
* gluten ataxia
* wheat allergy
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Haemorrhoids?
* H: piles
* painless rectal bleeding
* usually on wiping
243
fissures?
* fissues: tear in the lining of the anus or anal canal
* peak 15-40 yrs old
244
causes of fissures?
* commonly due to local trauma from constipation, diarrhoea, anal sex
245
management of rectal bleeding?
* low hb: transfusion
* reversal of anticoagulation
- endoscopic haemostatis methods
- arterial embolisation
246
Endoscopic haemostasis methods?
- include injection (typically diluted adrenaline), contact
- non-contact thermal devices (such as bipolar electrocoagulation or
- argon plasma coagulation),
- mechanical therapies (endoscopic clips and band ligation)
247
arterial embolisation?
possible in those with an identified bleeding point
248
UC vs CD pain?
* Ulcerative colitis patients tend to have pain in the lower left part of the abdomen, while Crohn's disease patients commonly (but not always) experience pain in the lower right abdomen
249
UC vs CD
250
uc VS CD
251
# marker
what is seen more commonly in UC?
P-ANCA
252
Mild to moderate acute ulcerative colitis is treated with:
- Aminosalicylate (e.g., oral or rectal mesalazine) first-line
- Corticosteroids (e.g., oral or rectal prednisolone) second-line
253
Severe acute UC is treated w:
Intravenous steroids (e.g., IV hydrocortisone) first-line
254
Other options for severe acute ulcerative colitis include:
- Intravenous ciclosporin
- Infliximab
- Surgery
255
Options for maintaining remission in ulcerative colitis are:
- Aminosalicylate (e.g., oral or rectal mesalazine) first-line
- Azathioprine
- Mercaptopurine
256
Inducing remission in an exacerbation of Crohn’s disease is with:
- Steroids (e.g., oral prednisolone or IV hydrocortisone) first-line
- Enteral nutrition as an alternative, particularly where there are concerns about steroids affecting growth
257
Other ways of inducing remission in CD when steroids alone don't work?
- Azathioprine
- Mercaptopurine
- Methotrexate
- Infliximab
- Adalimumab
258
Maintaining remission in CD?
First-line for maintaining remission in Crohn’s is with either:
- Azathioprine
- Mercaptopurine
Methotrexate alt
259
