extra gastro Flashcards
what deficiencies cause angular chelitis
iron,
zinc
vitamins from the B group
- riboflavin (B2),
- niacin (B3),
- pyridoxine (B6),
- folate (B9)
- cyanocobalamin (B12)
if a pt is having a UC flare up and isn’t improving on oral and topical ASA what do you do
ADD oral prednisolone to the ASA
what are the components used to work out child pugh score for liver cirrhosis
bilirubin (high)
albumin (low)
PT (prolonged)
encephalopathy (marked)
ascites (marked)
(indicate poor prognosis of the liver cirrhosis)
what is small bowel overgrowth syndrome and what is the initial ix for it, in which pts shield you consider it
increase in number of bacteria in the small bowel
hydrogen breath test
consider in diabetic pts with symptoms of IBS
dull RUQ pain and raised Alanine aminotransferase in a pt with congestive fear failure
congestive hepatomegaly
what does raised alanine aminotransferase indicate
liver damage
what class of antibodies are raised in PBC
IgM (IgG is raised in AI hepatitis)
This middle-aged woman presents with itch along with clinical evidence of ascites (shifting dullness) and xanthelasma. Blood testing demonstrated deranged liver function tests with an obstructive pattern
diagnosis
PBC
what is the cause of Pigment laden macrophages suggestive of melanosis coli in the intestine
laxative abuse
which 2 meds are given for oesophageal varicose
terlipressin
prophylactic abx
then do endoscopic variceal band ligation and can give propanolol to reduce rebreeding
alcoholic pt with haematemsis and epigastric pain
likely diagnosis
oesophageal varicies
endoscopic intestinal biopsy showed villous atrophy, crypt hyperplasia, and an increase in intraepithelial lymphocytes
diagnosis
coeliac
pt with liver cirrhosis and ascites presents with abdo pain and fever
diagnosis?
SBP
pt has haematemesis several Horus after eating, what type of peptic ulcer is it and which artery is impacted
duodenal ucler
gatsroduodenal artery
which lung cancer presents with clubbing and gynaecomastia
adenocarcinoma
which lung cancers can cause flushing, and how to differentiate between them
carcinoid - not related to smoking
small cell lung cancer - heavily related to smoking
which typo of asthma med can cause cushingoid features
ORAL steroids - not inhaled, rare
difference between stool c diff antigen test vs stool c diff toxin test
antigen - shows exposure to the bacteria, past or present
toxin - shows current infection
urine copper, and serum caerulopasmin levels in Wilsons
urine copper raised
serum caerulopasmin reduced
(In Wilson’s disease, copper is instead deposited in tissue, thereby reducing the apparent need for caeruloplasmin, thereby reducing its levels in the blood)
how long should c diff pts be isolated for
until they’ve had no diarrhoea for 48 hrs
mx for hugh grade dysplasia in oesophagus
endoscopic intervention
oesophagectomy reserved for if dysplasia invaded submucosa/supporting tissues
M rule for PBC
Primary biliary cholangitis - the M rule
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
abdominal distension, discomfort, and evidence of transudative ascites, alongside a SAAG of 12 g/L
diagnosis
portal htn
- not Budd chiari, would be more pain and would present with signs of liver failure eg jaundice, encephalopathy, coagulopathy
what is a jejunal biopsy used for
coeliac
tx for c diff which presents with sepsis or grossly dilated colon, or if to doesn’t respond to just the oral vancomycin
oral vancomycin (standard c diff tx) AND IV metranidazole
tx for acute alcoholic hepatitis
prednisolone
which IBD has crypt abscess and only mucosa inflammation
uc
how many bowel movements for mild uc and for moderate uc
less than 4 - mild
4 to 6 - moderate
what is the stool pattern for overflow diarrhoea and how do you treat it
type 7 stools with intermittent hard stools.
Treat with faecal disimpaction
smooth enlarged firm tender liver with pulsatile edge
cause
right heart failure
diagnostic test for psc
MRCP
the antibodies are not specific so not diagnostic
gold standard ix to diagnose pancreatic cancer
HRCT
management of psc and pbc
ursodeoxycholic acid - all pts should be started on
but only defective tx for if they develop end stage liver failure is liver transplant
but can give symptomatic relief eg
cholestyramine for priorities
lifestyle mods for fatigue
why could oxycodone result in urinary retention
its an opioid which can cause constipation, which in turn causes urinary retention
how soon before upper GI endoscopy should PPIs be stopped
Proton pump inhibitors should be stopped 2 weeks before an upper GI endoscopy
what does monopsony test check for
glandular fever
main side effect of aminosalicylates and how to check for it
agranulocytosis
FBC
what is hepatorenal syndrome and what is used to treat it
a type of functional kidney impairment that occurs in patients with advanced liver disease
key features include
- ascites
- low urine output
- significant increase in serum creatinine
Terlipressin is the recommended first-line treatment for HRS
reduced libido, erectile dysfunction, muscle pain, suntan colour of skin
diagnosis
haemochromatosis
H pylori eradication meds
PPI + amoxicillin + clarithromycin
or
PPI + metronidazole + clarithromycin
common side effect of PPIs
hyponatraemia
what do pts recovering from SBP need to be discharged with
ciprofloxacin - abx prophylaxis
which alcohol cessation med cant be given to pts with liver cirrhosis
naproxen
DOAC advice regarding upper GI endoscopy
low-risk endoscopic procedures
- the morning dose of DOAC on the day of the procedure should be omitted
high-risk endoscopic procedures
- the last dose of DOAC be taken ≥ 48 hours before the procedure
main side effect of long term PPI usage
osteoporosis - fractures
first and second line tx for haemochromatosis
1st - venesection
2nd - desferrioxamine
which skin condition is a risk factor for small bowel bacterial overgrowth syndrome
scleroderma
tx for small bowel bacterial overgrowth syndrome
rifaximin antibiotic
Proliferation of ductal epithelial cells without evidence of basement membrane invasion
ductal carcinoma in situ
What drug will you administer to reduce the risk of isoniazid induced peripheral neuropathy?
Pridoxine (vitamin B6)
what is pseudomembranous colitis, cause of it and how it appears on sigmoidoscopy
swelling or inflammation of the large intestine (colon) due to an overgrowth of Clostridioides difficile (C difficile) bacteria
looks like yellow plaques on sigmoidoscopy
What feature should be used to determine the severity of c diff infection?
WCC
A barium swallow shows a dilated oesophagus that tapers at the lower oesophageal sphincter.
diagnosis
achalasia
diet recommendation for pts being tested for coeliac disease with upper GI endoscopy
Patients must eat gluten for at least 6 weeks before they are tested
A 54-year-old female presents one week following a hip replacement with profuse diarrhoea. What is the most likely diagnosis?
c Diff
(patient would have been given broad-spectrum antibiotics at the time of the operation)
most common site for UC
RECTUM
NOT SIGMOID COLON
prophylaxis tx for oesophageal varices
beta blockers
(terlipressin + abx is used in acute bleeding to treat it )
what medications need to be stopped before the urea breath test for H pylori, and how long before do they need to be stopped
no antibiotics in past 4 weeks,
no antisecretory drugs (e.g. PPI) in past 2 weeks
triad of intestinal angina
severe, colicky post-prandial abdominal pain,
weight loss,
abdominal bruit
what is secondary peritonitis
occurs when a patient develops an peritoneal infection secondary to another infection, such as diverticulitis or appendicitis.
This is less frequently associated with ascites and a more obvious focus of infection would be noted.
what is a key differential for abdominal pain and fever in patients with cirrhosis and portal hypertension
SBP
what nail changes can be seen in coeliac
koilonychia
Coeliac disease is associated with iron, folate and vitamin B12 deficiency
what condition causes nail pitting
psoriasis
what condition causes Onycholysis
psoriasis or fungal nail infections
what condition causes Subungual keratosis
psoriasis or fungal nail infections
what does hoarseness of voice indicate in a pt with dysphagia
oesophageal carcinoma - tumour compresses recurrent laryngeal nerve
what is the time frame for endoscopy for pts suspected of upper GI bleed
All patients with suspected upper GI bleed require an endoscopy within 24 hours of admission
give 2 other cancers caused by HNPCC aside from colorectal cancer
endometrial cancer - 2nd most common
pancreatic cancer
which cancer does pernicious anaemia predispose to
gastric cancer
triad of sudden onset abdominal pain, ascites, and tender hepatomegaly
Budd chiari
fatigue, erectile dysfunction and arthralgia in a man
haemachromatosis
tx for suspected variceal haemorrhage
terlipressin and IV antibiotics
THEN endoscopy and band ligation
4 main adverse effects of PPI use
hyponatraemia, hypomagnasaemia –> muscle aches
osteoporosis → increased risk of fractures
microscopic colitis
increased risk of C. difficile infections
which abx classically cause c diff
clindamycin
or 3rd generation cephalosporins eg cefotaxime
first line laxative for IBS
bulk
recommended anti emetic for migraine
metoclopramide
PPI used in pts on clopidogrel
lansoprazole
(omeprazole interacts with clopidogrel)
what 2 things are monitored during haemachormatosis tx
Ferritin and transferrin saturation
which antibodies are used to diagnose pernicious anaemia
Intrinsic factor antibodies
first line test for coeliac
ttg abs
train of Plummer Vinson syndrome
iron deficiency anaemia, dysphagia due to esophageal webs, and atrophic glossitis
presents before adolescence with progressive gait instability (ataxia), dysarthria, loss of deep tendon reflexes and hypertrophic cardiomyopathy
diagnosis
Friedreichs ataxia
in which condition is Metaplastic columnar epithelium seen in the oesophagus
barrets oesophagus
diagnostic UC investigation during an acute flare up
would usually be colonoscopy
but during flare up you would confirm its UC by doing a FLEXIBLE SIGMOIDOSCOPY instead
diagnostic ix for suspected Mallory weiss tear vs boerrhaves
suspected Mallory weiss: endoscopy
suspected boerrhaves: CT contrast swallow
(if they have haematomesis and are haemodynamically stable its more likely to be mallory weiss)
non bloody prolonged history of diarrhoea, normal CRP, low calcium and vit D
diagnosis
coeliac
(IBD HAS RAISED CRP)
which condition is a major risk factor for cholangiocarcinoma
PSC
common side-effect of metoclopramide
Diarrhoea
what is sweet and fecal breath a sign of
it is fetter hepatics and a sign of acute liver failure
when do you test for h pylori in a pt with upper GI discomfort or bloating
testing for Helicobacter pylori is done if symptoms persist despite treatment with a proton pump inhibitor
so start PPI tx first then if sx continue, a 2 week washout period is recommended after stopping the proton pump inhibitor prior to testing for Helicobacter pylori
what is a CLO test
CLO stands for Campylobacter-like organism and is also known as the Rapid Urease Test. This diagnostic test is used for the detection of Helicobacter pylori by finding the presence of urease.
what grade on hepatic encephalopathy is coma
grade IV
which IBD is associated with gallstones
crohns
- Crohn’s disease can result in terminal ileitis, this is the section of the bowel where bile salts are reabsorbed. When this area is inflamed and the bile salts are not absorbed and people are prone to development of gallstones.
iron, transferrin, TIBC and MCV in anaemia of chronic disease
decreased iron
normal or decreased transferrin
decreased TIBC
normocytic or microcytic
(Anaemia of chronic disease is the body’s physiological response to a danger, such as a potentially harmful pathogen. Like humans, pathogens require iron for metabolism and survival. Therefore, in ACD, the body reduces iron available for pathogens by circulating less around the blood. This means that transferrin decreases.
TIBC measures the number of binding sites on transferrin available for iron. It therefore also increases in ID and decreases in ACD)
A 56-year-old man is admitted with a profuse upper gastro intestinal haemorrhage. He is relatively malnourished and has evidence of gynaecomastia
cause of bleeding
Oesphageal varices
Patients presenting with gastrointestinal bleeding and evidence of established liver disease may have portal hypertension and develop variceal haemorrhage. The patient may have evidence of jaundice, gynaecomastia, spider naevia, caput medusae and ascites. The bleeding is usually profuse and painless.
what is a Dieulafoy lesion
single large tortuous arteriole in the sub mucosa of GI system
small lesions of the artery cause GI bleeding
what investigation is done to diagnose and monitor liver cirrhosis after their is suspicion of them from the bloods and history
transient elastography, often known by the trade name Fibroscan
liver biopsy is only done if aetiology is unclear from non invasive testing
what type of anaemia causes a lemon tinge to the skin and why
pernicious anaemia
combination of pallor and mild jaundice - due to haemolysis
if a pt had H pylori and their symptoms resolve after the 2 week course of tx, do you need to repeat the urea breath test after
no
there is no need to check for H. pylori eradication if symptoms have resolved following test and treat
what dies swinging fever indicate
abscess
25 yr old female presents with secondary amenorrhoea and jaundiced sclera. On examination spider naevi are present along with tender hepatomegaly
diagnosis
autoimmune hepatitis
which condition presents with dysphagia to both solids and liquids simultaneously from the onset
achalasia
intermittent dysphagia (difficulty swallowing), halitosis (bad breath), and nocturnal coughing
diagnosis
pharyngeal pouch / zenkers diverticulum
which part of colon inmost like to be affected by ischaemic colitis
splenic flexure
cause of Liver failure following cardiac arrest
ischaemic hepatitis
what is diversion colitis
a nonspecific inflammatory disorder that occurs in segments of the colon and rectum that are diverted from the fecal stream by surgery (eg, creation of a loop colostomy/ileostomy or an end colostomy/ileostomy with closure of the distal colon segment [eg, Hartmann’s procedure
what can cause abnormal fluid balance (peripheral and pleural oedema) and arrhythmias
refeeding syndrome
when are biologics used for uc
inducing remission in people with severe active disease which has not responded to conventional therapy
how does diverticulitis present
severe left lower quadrant pain,
guarding
fever,
elevated white blood cell count
constipation and less commonly diarrhoea
N&V
bloody faeces
abdominal pain worsens post prandially and is relieved by defecation
positive anti-nuclear and/or anti-smooth muscle antibodies in a female with malaise, fever, jaundice
likely diagnosis
AI hepatitis
how should a recurrent episode of C. difficile within 12 weeks of symptom resolution be treated
oral fidaxomicin
common drug associated with drug-induced cholestasis
oral contraceptive pill
which vitamin is teratogenic in high doses
vit A
a 55-year-old woman presents with swallowing difficulties for the past 5 weeks. She has also noticed some double vision
diagnosis
myasthenia gravis
what is kaposi’s sarcoma
disease in which cancer cells are found in the skin or mucous membranes that line the gastrointestinal (GI) tract, from mouth to anus, including the stomach and intestines. These tumors appear as purple patches or nodules on the skin and/or mucous membranes and can spread to lymph nodes and lungs.
problems with dysphagia to only solids, no weight loss, no abnormality on endoscopy, but small mass felt in neck
diagnosis
pharyngeal pouch
diagnostic ix for pharyngeal pouch
barium swallow with fluoroscopy
slate grey appearance of skin + joint issues/oseteoarthiritis
diagnosis
haemachromatosis
how to calculate units of alcohol
Alcohol units = volume (ml) x ABV / 1,000
ABV = alcohol by volume eg if its 5% then ABV = 5, not 0.05
T2DM with abnormal LFTs (high AST and ALT –> hepatic picture)
likely diagnosis?
non alcoholic fatty liver disease
Ulcerative colitis + cholestatis (e.g. jaundice, raised ALP)
PSC
what is is the investigation of choice for suspected carcinoid tumours
urinary 5-HIAA
After confirming elevated urinary 5-HIAA levels, further investigations such as colonoscopy and CT abdomen should be considered for localisation of the primary carcinoid tumour and staging of disease. They would not be diagnostic of a carcinoid in the absence of a positive urinary 5-HIAA.
describe testing for coeliac disease
pt must eat gluten for 6 weeks
then can test for IgA and for ttg antibodies *
and then can do upper GI endoscopy and duodenal biopsy
*This is because TTG antibodies are IgA type, but IgA deficiency is very common. Therefore, without confirming that overall IgA levels are normal, it would not be possible to exclude coeliac disease.
what is watery green diarrhoea post cholecystectomy is caused by and what medication can treat it
bile acid malabsorption
cholestryramine - bile acid sequestrant
pain in RUQ radiates to her back and tip of her right shoulder
diagnosis
and first line ix
acute cholecystitis if fever
biliary colic if no fever
ascending cholangitis if fever with jaundice
abdo US
what type of drug is terlipressin
vasopressin analogue
how does co amoxiclav cause jaundice
causes cholestasis
how is alcoholic ketoacidosis treated
infusion of saline and thiamine
when does alcoholic ketoacidosis happen
This occurs in chronic alcoholics following an episode of reduced intake of food
Once the person becomes malnourished, after an alcohol binge the body can start to break down body fat, producing ketones. Hence the patient develops a ketoacidosis
what is the mackler triad for boerrhaves
vomiting, thoracic pain, subcutaneous emphysema
what does it indicate of CT shows simultaneous dilatation of the common bile duct and pancreatic ducts
double duct sign —> pancreatic cancer
c diff tx algorithm
oral vancomycin
if doesn’t respond - oral fidaxomicin instead
if still doesn’t respond - oral vancomycin + IV metranidazole
or
life threatening c diff: oral vancomycin + IV metranidazole straight away
what does thumb prying of small bowel on AXR indicate
ischaemic colitis
gold standard ix for ischaemic colitis
CT
ABG for ischaemic colitis
metabolic acidosis with raised lactate
what is the eye manifestation of Wilsons called
Kayser-Fleischer ring
what is ALP level usually in a hepatocellular disease
normal ALP
liver abscess mx
drainage and abx
what is meckers diverticulum and how does it present
congenital abnormality of small bowel
presents before the age of 2
presents as GI bleeding
small bowel obstruction and pt has multiple small dark brown and blue macules in his buccal mucosa
diagnosis
Peutz Jeghers syndrome
mx and prophylaxis of oesphageal varices
terlipressin and IV. abx
then endoscopic band ligation
then propanolol prophylaxis
if propanolol or repeat endoscopic banding aren’t helping, can do TIPS procedure
what is given to mainsail remission in a uc patient with proctitis and protcosigmoiditis
topical mesalazine
what is given when the pt has had 2 or more uc flare ups within the last year
oral azathioprine
triad of CVD, high lactate and soft but tender abdomen
mesenteric ischasemia
what is the tx for severe alcoholic hepatitis
corticosteroids
what one thing would you test for if you wish to screen a patient for hepatitis B infection
HBsAg
what is refractory ascites
ascites that does not recede or that recurs shortly after therapeutic paracentesis, despite sodium restriction and diuretic treatment
often due to portal htn
what is hepatorenal syndrome and what is type 1 vs type 2
hepatic failure then renal failure
type 1 = acute onset (<2 weeks), after acute event eg upper GI bleed
type 2 = more gradual, associated wit refractory ascites - portal htn
what is a CLO test
CLO testing is a rapid urease test that is done during endoscopy to detect Helicobacter pylori
so is an invasive test and is not recommended for eradication testing unless a patient requires an endoscopy.
important side effect of clindamycin
diarrhoea
Clindamycin treatment is associated with a high risk of C. difficile
if a pt has lower abdo what are the 2 most common causes you must rule out
appendicitis
testicular torsion –> EXAMINE THE STCROTUM
what should its with new diagnosis of type 1 diabetes or autoimmune thyroid disease be tested for
coeliac
for which pts is ESWL used fr gallstones
pts with symptomatic gallstones who are not suitable for surgery or other txs have failed
what ratio of AST:ALT indicates alcholic hepatitis
2:1
describe the LFTs in hep A
high ALT, AST, ALP, bilirubin
It causes liver damage, but at the same time, it also causes cholestasis, which presents as posthepatic jaundice (dark urine, pale stools, moderate hepatomegaly). Hence, you would expect elevated ALP, AST and ALT, in addition to bilirubin,
first line mx for NAFLD
weight loss
- statins have NOT been shown to slow down progression of NAFLD
pt complains of lump in their throat and finds more discomfort on swallowing saliva compared to food or drink
diagnosis?
globus hystericus aka globus pharyngis
what type of drug is spironolocatone
aldosterone receptor antagonist
which veins does TIPS connect
hepatic vein
portal vein
what ix is recommended to confirm diagnosis of NAFLD
enhanced liver fibrosis (ELF) testing
is ALT a reflection of extent of liver cirrhosis
NO
which deficiencies is coeliac associated with
iron, folate and vitamin B12 deficiency
which infection does seafood such as shellfish predispose to
hepatitis A infections
which infections can present as triad of sore throat, pyrexia and lymphadenopathy
infectious mononucleosis
and CMV - but less common, presents in immunocompromised pts
how does portal hypertension affect the size of the liver
causes liver cirrhosis NOT hepatomegaly
what is the next investigation if a PPI dose has failed to stop symptoms of reflex and heartburn but the patient has not red flags
tets for H Pylori
when is a fistulotomy done instead of seton placement
fistulotomy - if fistula doesn’t pas through sphincter muscles or only passes through a small part of it
seton placement - can be done if fistula passes through sphincter muscle
what is a possible cause of 12 hour history of very severe abdo pain and bloody diarrhoea, but no infective sx or fever
acute mesenteric ischaemia
which IBD are pseudo polyps seen in
UC
first line ix if suspected upper GI bleed eg mallory Weiss tear
upper GI endoscopy within 24 hrs
first line ix if suspected perforated peptic ulcer
erect CXR
which ulcers cause pain when hungry, and are relieved by eating
duodenal uclers
A 4-year-old boy is investigated for chronic diarrhoea, abdominal bloating and failure to thrive
diagnosis
coeliac
three week history of diarrhoea and crampy abdominal pains and has perianal skin tags on examination
diagnosis
crohns
which cancer presents with cholestatic LFTs (eg high ALP) and osbtructive jaundice
pancreatic cancer
(not hepatocellular carcinoma)
ABG for prolonged diarrhoea
Normal anion gap metabolic acidosis is
ABG for ketoacidosis
Raised anion gap metabolic acidosis
ABG for Addisons
hyperkalaemic metabolic acidosis
ABG for opioid toxicity
hypercapnic respiratory acidosis (due to hypoventilation)
what landmark separates lower and upper GI bleeding
ligament of Treitz
what is the lifestyle modification recommended for ascites due to liver
REDUCE dietary sodium intake
low levels of which ion can cause tornadoes des pointes
magnesium - hypomagnesaemia
which meds should be stopped in c diff infection
opioids
what is seen in the colon in PSJ
HAMARTOMAS
when is vitamin K given for bleeding
if pt is on warfarin
pt has haematemsis due to variceal bleeding, has been given terlipressin and is awaiting OGD, but bleeding continues. what can be done in the meantime whilst awaiting OGD
inset a Sengstaken-Blakemore tube to control the bleeding
cause of neurological sx + raised ALT + normal bilirubin/albumin
Wilsons disease
(normal bilirubin/albumin show that its not acute liver failure so not hepatic encephalopathy)
what is oesophageal atresia
birth defect where upper and lower oesophagus dont connect
