g a s t r o

Question 1

what are the key sx seen in patients with gastro/hepatology disease

Answer 1

abdominal pain
jaundice
haematemesis 
malaena
diarrhoea
nausea and vomiting

Question 2

what are differentials for abdominal pain

Answer 2

https://litfl.com/abdominal-pain-ddx/

Question 3

what are differentials for haematemesis

Answer 3

VINTAGE

1. Varices
2. Inflammation
    Oesophago-gastro-duodenitis  PUD: DU is commonest cause
3. Neoplasia
    Oesophageal or gastric Ca
4. Trauma
    Mallory-Weiss Tear = Mucosal tear due to vomiting
    Boerhaave’s Syndrome  Full-thickness tear, 2cm proximal to LOS
5. Angiodyspepsia and vascular abnormalities
    Angiodysplasia
    HHT
    Dieulafoy lesion: rupture of large arteriole in stomach or
   other bowel
6. Generalised bleeding diathesis
    Warfarin, thrombolytics  CRF
7. Epistaxis

Question 4

what are the differentials for dysphagia

Answer 4

1. Inflammatory
 Tonsillitis, pharyngitis
 Oesophagitis: GORD, candida
 Oral candidiasis
 Aphthous ulcers
2. Mechanical Block 
Luminal
 FB
 Large food bolus 
Mural
 Benign stricture
 Web (e.g. Plummer-Vinson)
 Oesophagitis
 Trauma (e.g. OGD)
 Malignant stricture
 Pharynx, oesophagus, gastric
 Pharyngeal pouch 
 Extra-mural
 Lung Ca
 Rolling hiatus hernia
 Mediastinal LNs (e.g. lymphoma) 
 Retrosternal goitre
 Thoracic aortic aneurysm
3. Motility Disorders
  Local
 Achalasia
 Diffuse oesophageal spasm
 Nutcracker oesophagus
 Bulbar / pseudobulbar palsy (CVA, MND)
4. Systemic
 Systemic sclerosis / CREST  MG

Question 5

what are the differentials for diarrhoea

Answer 5

1. Acute
   Suspect gastroenteritis Travel, diet, contacts?
2. Chronic
    Diarrhoea alternating ̄c constipation: IBS
    Anorexia, ↓wt., nocturnal diarrhoea: organic cause
3. Bloody
    Vascular: ischaemic colitis
    Infective: campylobacter, shigella, salmonella, E. coli,
   amoeba, pseudomembranous colitis
    Inflammatory: UC, Crohn’s
    Neoplastic: CRC, polyps
4. Mucus
    IBS, CRC, polyps
5. Pus
    IBD, diverticulitis, abscess

Question 6

what are the ddx for jaundice

Answer 6

pre hepatic = excess BRR production = haemolytic anaemia, ineffective erythropoiesis (thalassaemia)

hepatic unconjugated = reduced BR uptake: drugs - contrast, RMP, CCF

hepatic unconjugated = reduced BR conjugation: hypothyroidism, Gilbert’s, Crigler-Najjar

hepatic uncojugated = neonatal jaundice = both increase production and reduced conjugation

Question 7

what are the features to ask about in history of suspected upper GI bleed

Answer 7

Previous bleeds
 Dyspepsia, known ulcers
 Liver disease or oesophageal varices
 Dysphagia, wt. loss
Drugs and EtOH
 Co-morbidities

Question 8

what are signs to look out for O/E in upper GI bleed

Answer 8

signs of CLD
PR:melaena
Shock?
 Cool, clammy, CRT>2s
 ↓BP (<100) or postural hypotension (>20 drop)  ↓ urine output (<30ml/h)
 Tachycardia
 ↓GCS

Question 9

what are the common causes of upper GI bleeding

Answer 9

PUD: 40% (DU commonly)
 Acute erosions / gastritis:20%
Mallory-Weiss tear: 10%
 Varices: 5%
Oesophagitis: 5%
Ca Stomach / oesophagus:<3%

Question 10

what score is used to determine severity of bleed/ mortality

Answer 10

Rockall score
can be done pre and post endoscopy

Initial score pre-endoscopy

 Age
 Shock: BP, pulse
 Comorbidities

Final score post-endoscopy
Final Dx + evidence of recent haemorrhage:

 Active bleeding
 Visible vessel
 Adherent clot

Initial score ≥3 or final >6 are indications for surgery

Question 11

what are oesophageal varices and what is the pathophysiology. which veins are affected

Answer 11

Portal HTN → dilated veins sites of porto-systemic anastomosis: L. gastric and inferior oesophageal veins

Question 12

what are the causes of portal HTN

Answer 12

Pre-hepatic: portal vein thrombosis

Hepatic: cirrhosis (80% in UK), schisto (commonest
worldwide), sarcoidosis.

Post-hepatic: Budd-Chiari, RHF, constrict pericarditi

Question 13

what is the first line and second line bleed prevention for oesophageal varices

Answer 13

1O: β-B, repeat endoscopic banding

2O: β-B, repeat banding, TIPSS

Question 14

how does TIPPS work

Answer 14

interventional radiology creates articifical channel between hepatic vein and portal vein = reduce portal pressure

Question 15

describe the acute management of upper GI bleed

Answer 15

 100% O2, protect airway
 2 x 14G cannulae + IV crystalloid infusion up to 1L.
 Bloods: FBC, U+E (↑ urea), LFTs, clotting, x-match
6u, ABG, glucose
Blood if remains shocked
 Group specific or O- until X-matched
Variceal Bleed
 Terlipressin IV (splanchnic vasopressor)
 Prophylactic Abx: e.g. ciprofloxacin 1g/24h
Maintenance
 Crystalloid IVI, transfuse if necessary (keep Hb≥10)
 Catheter + consider CVP (aim for >5cm H2O)
 Correct coagulopathy: vit K, FFP , platelets
 Thiamine if EtOH
 Notify surgeons of severe bleeds
Urgent Endoscopy Haemostasis of vessel or ulcer:
 Adrenaline injection
 Thermal / laser coagulation
 Fibrin glue
 Endoclips
Variceal bleeding:
 2 of: banding, sclerotherapy, adrenaline,
coagulation
 Balloon tamponade ̄c Sengstaken-Blakemore tube
 Only used if exsanguinating haemorrhage or failure of endoscopic therapy
 TIPSS if bleeding can’t be stopped endoscopically
After endoscopy
 Omeprazole IV + continuation PO (↓s re-bleeding)
 Keep NBM for 24h → clear fluids → light diet @ 48h
 Daily bloods: FBC, U+E, LFT, clotting
 H. pylori testing and eradication
 Stop NSAIDs, steroids et.c.
Indications for Surgery
 Re-bleeding
 Bleeding despite transfusing 6u
 Uncontrollable bleeding at endoscopy
 Initial Rockall score ≥3, or final >6.
Open stomach, find bleeder and underrun vessel.

Question 16

describe the macroscopic similarities and differences between UC and Crohn’s

Answer 16

UC = rectum and colon + backwash ileus. continuous distribution, no strictures.

Crohn’s = mouth to anus esp terminal ileum. skip lesions. strictures.

Question 17

describe the microscopic similarities and differences between UC and Crohn’s

Answer 17

UC = mucosal, crypt abscesses, shallow borad ulceration, pseudopolyps, drainpipe colon due to loss of haustral markings, string sign of Kantour - narrowing of lumen

Crohn’s = transmural, cobblestone mucosa, fibrosis, non caseous granuloma, fistulae, rose thorn ulcers

Question 18

describe the aetiology of UC and Crohn’s

Answer 18

UC = smoking protective, TH-2 mediated 
`Crohn's = smoking increases risk, TH1/TH17 mediated

Question 19

describe the presentation, sx in IBD and differences in UC vs Crohn’s

Answer 19

systemic = fever, malaise, anorexia, wt loss in active disease

abdominal = diarrhoea (bloody in UC), abdominal discomfort, tenesmus, faecal urgency

Question 20

what are the clinical signs seen in IBD

Answer 20

tender, distended abdomen
aphthous ulcers, glossitis
abdominal tenderness

Crohn’s;

RIF mass
perianal abscess, fistulae
tags
anal/ rectal strictures

Question 21

what are extra abdominal manifestations of IBD

Answer 21

1. Joints
Arthritis (non-deforming, asymm) Sacroiliitis
Ank spond
2. HB
PSC + cholangiocarcinoma (esp. UC) Gallstones (esp. Crohn’s)
Fatty liver
3. Other
Amyloidosis
Oxalate renal stones (esp. Crohns)
4. Skin
Clubbing
Erythema nodosum
Pyoderma gang (esp. UC)
5. Eyes
Iritis
 Episcleritis
Conjunctivitis

Question 22

what are the complications seen in IBD

Answer 22

1. toxic megacolon = diameter greater than 6cm, risk of perforation
2. malignancy = CRC, cholangiocarcinoma
3. strictures = obstruction
4. venous thrombosis

Crohns

1. fistulae
2. strictures = obstruction
3. abscesses = abdominal, anorectal
4. malabsorption = fat = gallstones, steatorrhoea, b12 megaloblastic anaemia, vit d osteomalacia, protein oedema

Question 23

what investigations are required in ulcerative IBD

Answer 23

Bloods:
 FBC: ↓Hb, ↑WCC  LFT: ↓albumin
 ↑CRP/ESR
 Blood cultures
Stool
 MCS: exclude Campy, Shigella, Salmonella…  CDT: C. diff may complicate or mimic
Imaging
 AXR: megacolon (>6cm), wall thickening  CXR: perforation
 CT
 Ba / gastrograffin enema
 Lead-pipe: no haustra
 Thumbprinting: mucosal thickening
 Pseudopolyps: regenerating mucosal island
Ileocolonoscopy + regional biopsy: Baron Score

Question 24

how is the severity of UC determined

Answer 24

Truelove and Witts criteria

motions, PR bleed, temp, HR, Hb, ESR

mild, moderate and severe

Question 25

How is acute severe UC managed

Answer 25

``` Resus: Admit, IV hydration, NBM  Hydrocortisone: IV 100mg QDS + PR  Transfuse if required  Thromboprophylaxis: LMWH  Monitoring  Bloods: FBC, ESR, CRP, U+E  Vitals + stool chart  Twice daily examination  ± AXR ```

Question 26

describe the acute complications of severe UC

Answer 26

1. Perforation  Bleeding  Toxic megacolon (>6cm)  VTE

Question 27

in severe acute UC if no improvement vs improvement

Answer 27

Improvement → oral therapy  Switch to oral pred + a 5-ASA  Taper pred after full remission No Improvement → rescue therapy  On day 3: stool freq >8 or CRP >45  Predicts 85% chance of needing a colectomy during the admission  Discussion between pt, physician and surgeon  Medical: ciclosporin, infliximab or visilizumab (anti-T cell)  Surgical

Question 28

what drugs are used to induce UC remission

Answer 28

Oral Therapy  1st line: 5-ASAs  2nd line: prednisolone Topical Therapy: mainly left-sided disease  Proctitis: suppositories  More proximal disease: enemas or foams  5-ASAs ± steroids (prednisolone or budesonide)

Question 29

what drugs are used to maintain remission in UC

Answer 29

1st line: 5-ASAs PO – sulfasalazine or mesalazine  Topical Rx may be used in proctitis  2nd line: Azathioprine or 6-mercaptopurine  Relapsed on ASA or are steroid-dependent  Use 6-mercaptopurine if azathioprine intolerant  3rd line: Infliximab / adalimumab

Question 30

what are the indications for surgery in UC

Answer 30

Toxic megacolon  Perforation  Massive haemorrhage  Failure to respond to medical Rx

Question 31

what investigations are required for IBD Crohn's, what results are expected

Answer 31

Bloods: (top 3 are severity markers)  FBC: ↓Hb, ↑WCC  LFT: ↓albumin  ↑CRP/ESR  Haematinics: Fe, B12, Folate  Blood cultures Stool  MCS: exclude Campy, Shigella, Salmonella...  CDT: C. diff may complicate or mimic Imaging  AXR: obstruction, sacroileitis  CXR: perforation  MRI  Assess pelvic disease and fistula  Assess disease severity  Small bowel follow-through or enteroclysis  Skip lesions  Rose-thorn ulcers  Cobblestoning: ulceration + mural oedema  String sign of Kantor: narrow terminal ileum Endoscopy  Ileocolonoscopy + regional biopsy: Ix of choice  Wireless capsule endoscopy  Small bowel enteroscopy

Question 32

how is severity of Crohn's determined

Answer 32

temp, albumin reduces, ESR, CRP, WCC, HR increases

Question 33

describe how acute severe Crohn's is managed

Answer 33

``` Resus: Admit, NBM, IV hydration  Hydrocortisone: IV + PR if rectal disease  Abx: metronidazole PO or IV  Thromboprophylaxis: LMWH  Dietician Review Elemental diet  Liquid prep of amino acids, glucose and fatty acids  Consider parenteral nutrition  Monitoring  Vitals + stool chart  Daily examination ```

Question 34

what action is taken when no improvement or improvement in acute sever crohn's

Answer 34

``` Improvement → oral therapy  Switch to oral pred (40mg/d) No Improvement → rescue therapy  Discussion between pt, physician and surgeon  Medical: methotrexate ± infliximab  Surgical ```

Question 35

what drugs are used to induce remission in Crohn's

Answer 35

``` Supportive  High fibre diet  Vitamin supplements Oral Therapy  1st line  Ileocaecal: budesonide  Colitis: sulfasalazine  2nd line: prednisolone (tapering)  3rd line: methotrexate  4th line: infliximab or adalimumab ```

Question 36

what investigations and management is given in Crohns peri anal disease

Answer 36

MRI + EUA Rx  Oral Abx: metronidazole  Immunosuppression ± infliximab  Local surgery ± seton insertion

Question 37

what drugs are used to maintain remission in Crohn's

Answer 37

1st line: azathioprine or mercaptopurine  2nd line: methotrexate  3rd line: Infliximab / adalimumab

Question 38

before using azathioprine what levels should be checked

Answer 38

+TPMT activity should be assessed before starting

Question 39

what are the indications for surgery in crohns

Answer 39

Emergency  Failure to respond to medical Rx  Intestinal obstruction or perforation  Massive haemorrhage  Elective  Abscess or fistula  Perianal disease  Chronic ill health  Carcinoma

Question 40

what is the pathophysiology behind coeliac disease

Answer 40

HLA-DQ2 (95%) and DQ8 CD8+ mediated response to gliadin in gluten

Question 41

how does coeliac present

Answer 41

GLIAD gi malabsoption = carbs, fat, protein, vitamins lymphoma and carcinoma = enteropathy associated T cell lymphoma, adenocarcinoma of small bowel immune associations = PBC, T1DM, IgA deficiency anaemia = MCV increased or decreased dermatological = dermatitis herpetiformis, aphthous ulcers

Question 42

what investigations are required in coeliac disease

Answer 42

Bloods: FBC, LFTs (↓alb), INR, Vit D and bone, red cell folate, serum B12  Abs  Anti-endomysial IgA (95% specificity)  Anti-TTG IgA  Both above ↓ ̄c exclusion diet  Anti-gliadin IgG persist ̄c exclusion diet)  IgA ↑ in most but may have IgA deficiency  Stools  Stool cysts and antibody: exclude Giardia  OGD and duodenal biopsy  Subtotal villous atrophy  Crypt hyperplasia  Intra-epithelial lymphocytes

Question 43

how is coeliac managed

Answer 43

``` Lifelong gluten-free diet  Avoid: barley, rye, oats, wheat  OK: Maize, soya, rice  Verify diet by endomysial Ab tests  Pneumovax as hyposplenic  Dermatitis herpetiformis: dapsone ```

Question 44

what is refeeding syndrome

Answer 44

emtabolic abnormalities which occur on feeding a person following a period of starvation. It occurs when an extended period of catabolism ends abruptly with switching to carbohydrate metabolism

Question 45

what are the metabolic consequences of referring syndrome

Answer 45

hypophosphataemia hypokalaemia hypomagnesaemia: may predispose to torsades de pointes abnormal fluid balance these abnormalities can lead to organ failure

Question 46

which patients are at high risk of re feeding syndrome

Answer 46

low BMI unintentional weight loss of 1-=15 percent over a few months little nutritional intake hx pf alcohol abuse, drug therapy inc insulin chemo

Question 47

if a patient hasn't eaten for > 5 days, aim to re-feed at

Answer 47

no more than 50% of requirements for the first 2 days

Question 48

histology in crohns vs UC

Answer 48

CROHNS = inflammation in all layers from mucosa to serosa increase goblet cells, granulomas UC = no inflammation beyond submucosa, inflammatory cell infiltrate in lamina propria, crypt abscess, depletion of goblet cells, no granulomas

Question 49

radiology in crohns vs UC

Answer 49

Crohns = small bowel enema = kantor string sign - structuring proximal bowel dilation rose thorn ulcers fistulae UC = loss of haustrations, pseudopolys, drainpipe colon

Question 50

pain on swallowing is known as

Answer 50

odynophagia