Clinical Flashcards
Name 5 disease of the upper GI tract which cause upper abdo or retrosternal discomfort.
Oesophageal reflux, oesophageal cancer, gastritis, peptic ulcers, gastric cancers
What causes a hiatus hernia?
Oesophageal reflux
Name 2 complications of oesophageal reflux
Healing by fibrosis
Barrett’s oesophagus (squamous to glandular)
Name the two histological types of oesophageal cancer.
Squamous carcinoma (from smoking and alcohol) Adenocarcinoma
What does adenocarcinoma develop from?
Barretts oesophagus
Obesity = risk
What is the prognosis of oesophageal cancer?
<5% 5 year survival
Describe helicobacter pylori
grame -ve
in gastric mucous
increases acid production
What does H. pylori cause?
Peptic ulceration, stomach cancer
Name the 3 types of gastritis.
Type A (autoimmune) - atrophy, loss of acid secretion Type B (bacterial) - H.Pylori Type C (chemical injury) - e.g NSAIDs
What are complications of peptic ulceration?
Bleeding, perforation, healing by fibrosis
What is the 5 year survival for stomach cancer?
<20%
What is the histology of stomach cancer?
Adenocarcinoma
What are the 3 types of jaundice?
Pre-hepatic, hepatic and post-hepatic
Describe pre-hepatic jaundice
Breakdown of Hb in spleen
Doesn’t impact liver
Describe hepatic jaundice
Uptake of bilirubin by hepatocytes, conjugation occurs.
Cholestasis, intra-hepatic bile obstruction and hepatic cirrhosis can result
What is cholestasis?
Accumulation of bile within hepatocytes
What is cholelithiasis?
Gallstones
Describe post-hepatic jaundice
Chronic or acute inflammation of gall bladder or extra-hepatic duct obstruction
Causes = cholelithiasis, bile duct tumours, being stricture, external compression tumours
What blood results would be indicative of hepatic jaundice?
High ALT and GGT
What blood results would be indicative of obstructive (post-hepatic) jaundice?
High alkaline phosphatase and bilirubin
What are the causes of acute liver disease?
Viral (hepatitis), drugs, ischaemia, auto-immune, bile duct obstruction
How does acute liver disease present?
Malaise, abdo pain, anorexia, hepatomegaly, jaundice
What is the management for acute liver disease?
Fluid monitoring, microbiology, bloods, ? liver transplant, feeding
What is the difference in pathology of acute and chronic liver disease?
Acute = inflammation Chronic = fibrosis and cirrhosis
How does chronic liver disease present?
Oesophageal varices - haematemesis, melaena, splenomegaly, caput medusae, rectal varices, fetor hepaticus, coma, spider naevi, jaundice, ascites etc
Describe cirrhosis
Diffuse process of whole liver - normal liver structure replaced by nodules of hepatocytes of fibrous tissue
Where is diverticular disease most commonly found?
Sigmoid colon
What are the causes of acute cholecystitis?
90% = gallstones 10% = blockage in cystic duct
Describe the neuronal control of intestinal motility.
Intrinsic = myenteric plexus "Meissner's and Auerbach's" Extrinsic = ANS
Describe idiopathic IBD.
Chronic inflammation from inappropriate or persistent activation of mucosal immune system driven by. normal intraluminal flora
Where is inflammation present in Crohn’s?
Mouth to anus
Where is inflammation present in Ulcerative Colitis?
Colon only
In what IBD condition would you find “skip lesions”, non-ceseating granulomas and “cobblestone” ulcerations?
Crohn’s
In what IBD condition would you find pseudopolyps and NO granulomas?
Ulcerative colitis
What does ischaemic enteritis effect?
SI, LI or both
Name 4 potential routes of spread of stomach cancer
Direct, lymphatics, blood, transcolemic
What are the causes of bilateRAL leg Swelling?
Right heart failure, Albumin low, Large abdo mass, Sitting
What are the causes of ascites?
Cancer, portal hypertension, cirrhosis
What causes portal hypertension?
Splenomegaly
Oesophageal varices
If cancer in lower oesophagus what is the likely diagnosis?
Adenocarcinoma (from Barrett’s oesophagus)
If cancer in upper oesophagus what is the likely diagnosis?
Squamous cell carcinoma (alcoholic)
Describe Dukes staging
A - limited to wall
B - spread beyond muscularis externally
C1 - positive lymph nodes, highest node (around mesenteric artery) spared
C2. - highest node involved
What is ERCP?
Endoscopic Retrograde Cholangio-pancreatography
- visualises ampulla, biliary system and pancreatic ducts
- stone removal, biopsy, stenting
What is enteroscopy used to visualise?
Small intestine
What are the pros and cons of MRCP?
Pro - no risk of pancreatitis
Con - can’t do interventional procedures
What are the relevant GI blood tests?
U&Es, Calcium (hypo = differential for D&V), Magnesium, LFTs, CRP, Albumin, TFTs, FBC, Coagulation (hepatic dysfunction), haematinios, hepatic screen, celiac serology, tumour markers
What are the causes of dysphagia?
Benign or malignant stricture, motility disorders, eosinophilic oesophagitis, extrinsic compression
What are the investigations for dysphagia?
Endoscopy, barium swallow, oesophageal pH and manometry
What is the treatment for dysphagia?
Endoscopic balloon dilatation, botulinum injection
Define achalasia.
Failure of relaxation of LOS (from functional loss of myenteric plexus)
What are the symptoms of achalasia?
Progressive dysphagia, weight loss, chest pain, regurgitation and chest infections
What tests are carries out for achalasia?
Manometry
What treatment is given for achalasia?
Nitrates, CCBs, pneumatic balloon, botulinum, myotomy (surgical)
What is GORD?
Acid and bile exposure in lower oesophagus
What are the risk factors for GORD?
Pregnancy, obesity, drugs lowering LOS pressure, smoking, alcohol
What are the two types of hiatus hernia?
Sliding and para-oesophageal
What is the treatment for GORD?
Lifestyle change, antacids or alginates, add PPI and for refractory symptoms add H2 blocker
What is the treatment for Barrett’s oesophagus?
endoscopic mucosal resection
radio-frequency ablation
oesophagectomy (rare)
What are the symptoms of oesophageal cancer?
Progressive dysphagia, anorexia, weight. loss, odynophagia, chest pain, cough, pneumonia, vocal cord paralysis, haematemesis
What investigations are used for suspected oesophageal cancer?
Endoscopy and biopsy
Staging by CT, EUS, PET, Bone scan
What are the treatment options for oesophageal cancer?
Symptom palliation OR if localised = Surgical oesophagectomy +/- neoadjuvant or adjuvant chemotherapy
What are the treatment options for eosinophilic oesophagitis?
Topical/swallowed corticosteroids
Dietary elimination
Endoscopic dilatation
Describe the presentation of dyspepsia (organic vs functional).
Upper abdo discomfort, retrosternal pain, anorexia, nausea, vomiting, bloating, fullness, early satiety, heartburn
What can cause dyspepsia?
Upper GI: gastritis, peptic ulcer, gastric cancer, gall stones
Lower GI: IBS, Colon cancer, coeliac disease
Other: metabolic, cardiac, drugs
When should you refer to endoscopy?
ALARMS
What does ALARMS stand for?
Anorexia, Loss of weight, Anaemia, Recent onset >55y or persistent despite treatment, Melaena/hematemesis or Mass, Swallowing problems
What is the aetiology of peptic ulcers?
Men>Women Elderly Smoking NSAIDs Zollinger-Ellison syndrome Hyperparathyroidism Crohn's
What are the symptoms of peptic ulcers?
Epigastric pain, nocturnal hunger/pain, back pain, nausea, weight loss
What is the second most common malignancy?
Gastric cancer
What is the Correa Hypothesis of gastric cancer?
2 histopathological subtypes - Intestinal (majority) and diffuse
What is the management of gastric cancer?
Endoscopy, biopsy, staging radiology, MDT discussion, surgery and chemotherapy (rarely radiotherapy)
Describe the structure of H.pylori.
Gram -ve
Spiral-shaped
Flagellated
Microaerophilic
Name a type 1 carcinogen?
H.pylori
Discuss the divergent responses to H.pylori.
- Antral predominant –> DU disease
- Mild mixed gastritis —> no significant disease
- Corpus predominant —> gastric CA
How is H.pylori diagnosed?
Serology (IgG), 13C/14C urea breath. test, stool Ag. test, endoscopy, rapid slide urease test
How is H.pylori eradicated?
Triple therapy for 7 days: Clarithromycin (500mg bd), Amoxycillin (1g bd), PPI (omeprazole 20mg bd)
- If penicillin use tetracycline instead of amoxycillin
What conduits are used in oesophagectomy?
Stomach, transverse colon
When is surgery classed as bariatric?
BMI >35
What are the causes of acute pancreatitis?
GET SMASHED Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion venom Hyperlipidaemia, hypothermia and hypercalcaemia ERCP and emboli Drugs
What suggested acute pancreatitis?
Elevated serum amylase
What are the symptoms of acute pancreatitis?
Gradual or sudden severe epigastric pain or central abdominal pain, vomiting, nausea, collapse
What are the signs of acute pancreatitis?
Pyrexia, jaundice, shock, paralytic ileus, rigid abdomen, Cullen’s sign, Grey Turner’s sign, Tachycardia
What criteria is used to diagnose acute pancreatitis?
MODIFIED GLASGOW CRITERIA
Pa02 <8kPa Age >55y Neutrophilia Calcium <2mmol/l Renal function urea>16mmol/l Enzymes (LDH and AST) Albumin <32g/l Sugar >10mmol/l
What is the management of acute pancreatitis?
A-E
Resus: Analgesia, fluids, blood transfusion, monitor urine, NG tube, O2, may need insulin
Specific: lifestyle changes, ERCP for gallstones. etc
What are complications of acute pancreatitis?
Abscess, psuedocyst
What causes chronic pancreatitis?
O A TIGER Obstruction of MPD Autoimmune Toxin (alcohol = 80%) Idiopathic Genetic Environmental Recurrence injuries
What are the symptoms and signs of chronic pancreatitis?
Abdo pain, weight. loss, exocrine and/or endocrine insufficiency, jaundice, portal hypertension, GI haemorrhage
What are the investigations for chronic pancreatitis?
Plain AXR, CT, USS, EUS, Bloods (decrease albumin, increase LFTs), ERCP, MRCP
What are the treatment options for chronic pancreatitis?
- Pain control (avoid alcohol, opiates)
2. Exocrine and endocrine control (low fat diet, insulin, pancreatic enzyme supplements)
What are the risk factors for pancreatic cancer?
Smoking, alcohol, diet, chronic pancreatitis, DM, age 60-80
What are the symptoms of pancreatic cancer?
Upper abdo pain, painless obstructive jaundice, weight loss, fatigue, vomiting, ascites, DM
What are the signs of pancreatic cancer?
Jaundice, hepatomegaly, abdo mass, tenderness, ascites, splenomegaly
What tests are carried out for pancreatic cancer?
ERCP2, USS, CT, MRI, EUS, bloods, CXR
*Tumour markers NOT very sensitive
What are the management options for pancreatic cancer?
<10% operable (pancreatoduodenectomy - Whipple’s procedure)
What is the survival rate after Whipple’s procedure for pancreatic cancer?
15% 5y survival
What are the main types of surgery for pancreatic cancer?
Kausch-Whipple
PPPD
Palliative drainage when obstructive jaundice or duodenal obstruction
What types of viral hepatitis are enteric and cause self-limiting acute infections?
A & E
What types of viral hepatitis are parenteral and cause chronic disease?
B, C and D
What type of hepatitis is mainly found in topical areas?
Hep A
What type of hepatitis is mainly found in sub-saharan Africa, South East Asia etc?
Hep B
What type of hepatitis causes an initial increase in IgM?
Hep A
How is Hep A transmitted?
faecal-oral, sexual, blood
What is the treatment for Hep B?
Pegylated interferon, oral antiretroviral (entecavir, tenofovir)
What type of hepatitis evades the immune system like HIV (requiring reverse transcriptase)?
Hep C
What is Hep E usually co-infected with?
HBV
What is the commonest cause of acute hepatitis in Grampian?
Hep E
What is non-alcoholic fatty liver disease associated with?
DM, Obesity, HPT, Hypertriglycerideamia, age, ethnicity, genetic factors
How is non-alcoholic fatty liver disease diagnosed?
AST/ALT ratio Enhanced liver fibrosis panel Cytokeratin - 18 USS Fibroscan mr/ct LIVER. BIOPSY = GOLD STANDARD!
What antibodies are raised in autoimmune hepatitis?
IgG
What antibodies are raised in primary biliary cholangitis?
IgM
What is characteristic in primary sclerosis cholangitis?
pANCA +ve
When is jaundice detectable in relation to circulating bilirubin?
Plasma bilirubin >34umol/L
When is jaundice categorised as unconjugated and conjugated?
Unconjugated = bilirubin complex with albumin in RBC. (pre-heaptic) Conjugated = with glucuronic acid in liver, through gut and into fences and urine (hepatic and post-hepatic)
What colour is urine and stool in pre-hepatic (unconjugated jaundice)?
Normal and normal
What colour is urine and stool in hepatic (conjugated jaundice)?
High coloured urine and normal stool
What colour is urine and stool in post-hepatic (conjugated jaundice)?
High coloured urine, pale stools
What are the signs of a pre-hepatic cause of jaundice?
Pallor
Splenomegaly
What are the signs of a hepatic cause of jaundice?
Spider naevi, ascites, asterixis
What are the signs of a post-hepatic cause of jaundice?
Palpable gall bladder
What is more specific, ALT or AST?
ALT
An increase in alkaline phosphatase is a sign of…
Post-hepatic obstruction
An increase in gamma GT is a sign of…
Excess alcohol consumption
What does prothrombin time suggest?
Stage of liver disease and determines who gets transplant
What does creatinine suggest?
Kidney function and survival from liver disease
A low albumin is a sign of?
Kidney disorders and malnutrition
What is the most important test to differentiate between intra- and extrahepatic obstruction?
Ultrasound
What are cons against ERCP instead of MRCP?
Has radiation
Uses sedation
Only images ducts
How does compensated liver disease present?
Abnormal LFTs detected on screening tests
How does decompensated liver disease present?
Ascites, spider naevi, variceal bleeding, hepatic encephalopathy
What procedure is carried out for new onset ascites?
Diagnostic paracentesis