Gastro Flashcards
1
Q
What investigation would you get for suspected appendicitis?
A
Normally a clinical dx
You may need to get a pelvic USS to exclude ovarian cyst accident
CT abdomen - if uncertain
2
Q
What score can you use for appendicitis
A
Alvarado score
>4 is high likelyhood of it being appendicitis
3
Q
What are the three signs you can get in appendicitis
A
Rosvig’s sign
Cope’s sign
Psoas sign
4
Q
What is Rosvig sign
A
Pain worse in RIF when pressing down on LIF
5
Q
What is Cope sign
A
Pain on passive flexion and internal rotation of hip
6
Q
What is Psoas sign, and what does it indicate exactly
A
Pain on extending hip
Indicates RETROCAECAL APPENDIX
7
Q
How would you manage appendicitis
A
start prophylactic antibiotics before surgery
THEN laparoscopic appendicectomy
8
Q
what extra thing must you do if appendicitis is perforated
A
ABDOMINAL LAVAGE
9
Q
What is ascending cholangitis
A
INFECTION of the biliary traact
10
Q
What causes ascending cholangitis
A
Obstruction + infection
Obstruction can be caused by:
- gallstones
- ERCP
- cholaangiocarcinoma
- pancreatitis
- PSC
11
Q
How will pt with ascending cholangitis present
A
ACUTELY UNWELL - MAY BE SEPTIC
Charcot’s triad: fever + RUQ pain + jaundice
Reynaud’s pentad: + hypotension + confusion
12
Q
How do you investigate and manage suspected ascending cholangirtis
A
Bloods: Raised ALP and GGT
Ix: USS biliary tract (will show thickened wall and bile duct dilatation)
ERCP (ix and mx) - to clear obstruction
If cause was gall stones, may need cholecystectomy
13
Q
How do you manage acute cholangitis
A
IV Abx AND ERCP within 24-48h
14
Q
What are the three types of gallbladder disease you can get?
A
BILIARY COLIC: stones causing pain in gallbladder neck
CHOLECYSTITIS: inflammation of gallbladder
ASCENDING CHOLANGITIS: inflammation of bile duct
15
Q
Describe the three types of gall stones
A
cholesterol (if fat, poor diet)
pigment (if haemolytiic anaemia)
mixed
16
Q
What are RF for gallstones
A
Fat Fair Fourty Female FH
+ OCP, pregnancy, haemolytic anaemia
17
Q
What is a biliary colicj
A
stones in the neck of gallbladder causing pain on contraction
18
Q
Describe the pain in a biliary colic
A
Colicky (intermittent)
Triggered by eatiing fatty foods
Sudden, dull
In RUQ
19
Q
How do you investigate for gallbladder pathology
A
Abdo USS of gallbladder and bile ducts
MRCP if nothing visible (and suspected cholecystitis / biliary colic)
20
Q
what do you see on USS of gallbladder in pathology
A
thickened wall
Bile duct dilatation
Gallstones
21
Q
How do you manage biliary colic
A
IV analgesia
elective cholecystectomy within 6 weeks
22
Q
What are symptoms of cholecystitis
A
Pain (constant, RUQ) + fever
23
Q
How do you manage acute cholecystitis
A
IV Abx
IV analgesia, antiemetics
Laparoscopic cholecystectomy (<72h)
24
Q
What are symptoms and signs of pancreatitis
A
severe epigastric pain radiating to back, N&V
Cullen’s (periumbilical), grey turner sign (retroperitoneal=
25
What Ix must you get for acute pancreatitis
serum amylase 3x normal upper range (although does not correlate to disease severity)
consider serum lipase (more S&S, not as available)
ABG (will need PO2 for Glasgow score)
FBC, U&E, LFT, Albumin, BG, calcium
USS (exclude gallstones)
CT abdo (if clinical uncertainty)
26
What scoring systems can you use for acute pancreatitis
Ranson
Apache II
Modified Glasgow
27
What are the contents of the glasgow score
```
PANCREAS
PaO2 <8
Age >55
Neutrophils
Calcium LOW
Urea high
Enzymes high (LDH>, AST/ALT>200)
ALbumin (<32)
Sugar >10
```
28
How do you manage pancreagtitis
SUPPORTIVE tx
aggressive IV fluid resus > maintainance
analgesia (IV morphile 1-2mg STAT boluses until comfortable)
antiemetics
Consider NG tube and fluid balance chart (catheter)
Correct cause f possble
29
Pancreatits complications
EARLY: DIC, ARDS, hypocalcaemia, hyperglycaemia
LATE: pseudocyst, pancreatic abscess, pancreatic necrosis
30
What classification can you use for diverticulitis
Hinchley classification 1-4
31
What investigation do you go for acute diverticulitis
CT abdomen (never colonoscopy acutely, as perforation risk)
32
What is the management of acute diverticulitis
IV Abx, IV fluids, analgesia - NBM
If severely unwell: Hartmann's procedure (sigmoid colectomy with end colostomy > anastamosis at later date, only possible in 50% of patients)
33
what is the region affected by UC
UC Region: colon only (it's in the name!) - starts in rectum and runs towards proximal colon (max until iliocaecal valce)
34
what is the levels of the gut layers affected by UC
UC: Mucosa and submucosa only (SUPERFICIAL - remember that this condition affects less of everything compared to chron's)
35
What is the inflammation like pathologically for UC (so on biopsy?
continuous (leadpipe)
pseudo-polyps
thumbprinting
36
what condition is rellated to UC
PSC
37
What are typical symptoms of UC
BLOODY diarrhoea
MUCOUS
LIF pain
tenesmus
38
what is the layer affected by CD
Transmural, with NON CASEATING GRANULOMAs
39
what is the region of gut affected by CD
ALL OF IT
| Mouth to anus
40
what is the most common region affected by CD D
Terminal ileum
41
what are signs on biospy of histology for CD
skip lesions
rose thorn ulcers
cobblestoning
string of kantor (narrow ileum stricture)
42
what IBD condition are abscesses / fissures common in
in CHRON's
43
What are chron's sx
non bloody diarrhoea
RIF mass and pain
mouth ulcers, fissures in ano, perianal skin tags
FAILURE TO THRVE
44
How unwell are patients during flares between CD and UC
CD: systemically unwerll
UC: well
45
what personal factor can precipitate a UC flare?
stopping smoking
46
what are extra intestinal manifestations of IBD
```
A PIE SAC
aphtous ulcers
pyoderma gangrenosum
iritis, uveitis, episcleritis
erythema nodosum
sclerosing cholangitis (primary - UC)
arthritis
clubbing
```
47
What investigations shoulld you get for suspected IBD
faecal calprotectin (marker of inflamm)
Bloods (FBC, UE, CRP, LFT, pANCA)
Scope (colonoscopy +-OGD for chron's)
Biopsy
48
what is the two key steps in mx of chron''s
Induce remission >> maintain remission
49
how do you indduce remission in chron's
Steroids, then biologics
Nutritional: repllace diet with whole protein modular diet (excessively liquid for 6-8 weeks)
50
How do you maintain remission in chron's
(beware that continuing steroids can have long term consequences)
1. stop smoking
2. DMARD (e.g. azatioprine, mercaptopurine, methotrexate)
Alternatives to DMARD: aminosalicylate, biological thherapoy
also remember to vaccinate (not with live vaccines though)
51
How do you manage UC
Mesalazine FIRST
| Then steroids and biologics ( Aminosallycates, azathioprine, mercaptopurine)
52
What must you always measure before starting someone on azathioprine
TPMT (enzyme required for its breakdown)
if TPMT is low, give methotrex instead
53
Which IBD type is surgery curative for?
UC
54
What type of surgery is typically done for UC
Hartmann's proctosigmoidoscopy + end ileostomy > later IPAA
55
what is classic presentation of IBS
```
young
femaille
anxious, stressed, depressed
pain
bloating and diarrhoea / constipation
```
56
How do you diagnose IBS
Diagnosis of EXCLUSION, based on ROME III criteria
- improvement with defecatioon
- change in stool frequency
- change in stool form / appearance / consistency
57
What are haemorrhoids
vascular cushions that protrude through the rectum via straining on defecation
58
What are the four classes of haemorrhoids
1: in rectum
2. prolapse through anus, reduce spontaneously
3. prolapse though anus, manual reduction
4. persistently prolapsed (not prolapsed)
59
where are haemorrhoids usualy found
3, 7, 11 oclock
60
what type of procedure may need to be done if suspecting internal haemorrhoids
proctoscopy / sigmoidoscopy
61
how do you manage haemorrhoids
Conservative: increase fluid/fibre,
Medical: stool softener, topical analgesia, steroids
Non-operative: rubber band ligation, sclerotherapy
Operative: haemorrhoidectomy
62
what is coeliac disease due to and what does it cause in the GI tract
due to AUTOIMMUNITY to gliadin (gluten, wheat, barley, rye)
leads to shorter villli and flat mucosa
63
What is coeliac diisease incidence
bimodal (infants or middle aged)
64
What are the AI HLA associations of coeliac
HLA DQ2, HLA DQ8
65
What are symoptoms of coeliac
watery frothy stooll (staethorroea)
Failure to thrive
Insufficient growth in chikldren
66
what skin condition is pathomnemonic for coeliac
derrmatitis herpetiformis
67
What substances can someone with coeliac be deficient to
iron
B12
folate
68
what else must you screen for if suspecting coelilac disease
T1DM, Ai thyroid disease, IBS, coeliac
69
What initial investigations must you do for coeliac
Bloods: anti-TTG + Total IgA, FBC (iron deficiency), vit B12 / folate, vit D, + blood smear (target cells and howell-jolly)
70
how do you confirm coeliac + findings
OGD + duodenal / jejunal biopsy (villous atrophy, crypt hyperplasia, intra epithelial lymphocytes)
71
How do you manage coeliac
GLUTEN FREE DIET LIFELONG
dietician referral if problems adhering to diet
annual 6-12 month review
72
what is the difference in terms of location between PBC and PSC
```
PBC = intrahepatic bile ducts only
PSC = intra and extrahepatic bile ducts
```
73
Define PBC
chronic inflammation to INTRAHEPATIC bile duct, causing progressive cholestasis > CIRRHOSIS
presumed AI ORIGIN
74
What are other conditions associated with PBC
Sjogren
RhA
thyroid disease
systemic sclerosis
75
what are classical sx of PBC
itching in a middle aged woman
- pruritus
- obstructive jaundice
RUQ pain
76
What investigations should you get for PBC
Liver panel: raised GGT/ALP, normal transaminase
Autoantibodies: AMA, high IgM serum
Biopsy (only if in doubt)
77
How do you manage PBC
ursodeoxycholic acid
fat soluble vitaminb supplements
consider cholestyeramine for pruritus, pred if other AI disease
for end stage disease: liver transplant
78
What rule can you use to remember PBC
Rule of Ms
Middle aged women
AMA
raised IgM
79
What is PSC
biliary disease caused by INFLAMM and FIBROSIS in INTRA and EXTRAhepatic bile ducts
80
What condition is PSC associated with
UC
81
Sx of PSC
pruritus
obstructive jaundice
RUQ pain
staethorroea
82
Ix PSC
positive pANCA
MRCP > ERCP (beaded appearance)
Biopsy of duct (fibrous, obliterative cholangitis - onion skinn)
83
mx of PSC
supportive > liver transplant
84
how does gender change in PBC vs PSC
PBC mostly women,
| PSC mostly men
85
what signs can you find in chronic liver disease
hands: palmar erythema, duputyens, clubbing
eyes: specific for Wilson's Keiser-Fleisher ring, corneal arcus if hypercholesteraemia
Chest: gynaecomastia (failure of liver to break down cholesterol), axillary hair loss, spider naevi
86
What number of spider naevi is abnormal
anywhere > 5
87
Ix for suspected liver disease
```
Blood panel (FBC, UE, LFT, CRP, clotting, AFP, iron, hepatitis serology, autoantibodies, caeruloplasmi)
USS abdomen
consider fibroscan and liver biopsy
consider endoscopy to exclude other causes
```
88
How do you manage ascites
1. Restrict alcohol and fluids, low sodium diet, daily weights)
2. Diuretics (spironolactone +- furosemide)
3. Therapeutic paracentesis (if not responding to meds)
4. Prophylaxis for SBP (ciproflox + propanolol)
abdominal paracentesis (for tense ascites)
89
What is SBP
Spontaneous bacterial peritonitis (infection of ascitic fluid with no obvious cause)
90
How do you investigate SBP
```
USS (confirm ascites)
Ascitic tap (check neutrophils and SAAG)
```
91
How do you manage SBP
tazocin / cefotaxime
92
What is chromosomal inheritance pattern of haemochromatosis
Autosomal recessive - HFE gene mutation
93
What does haemochromatosis cause
Dirsorder of iron absorption and metabolism> excess iron accumulation > organ damage
94
How do you investigate haemochromatosis
Iron studies (transferrin saturation >50%, ferritin raised, iron raised, TIBC low)
Liver biopsy
95
How do you manage haemochromatosis
venesectiion (TF under 50% is aim)=
96
What is the progression of NAFLD
steatosis > staetohepatitis > cirrhosis
97
investigations ofr NAFLD
LFTpanel, lipds, cholesterol
USS
Enhalced liver fibrosis panel OR fibroscan
liver bioosy
98
How do you manage NAFLD
lifestly change, weight loss
99
Chronic paancreatitis symptoms
paain worse 15-30 mins after meal
staetoorrhoea
DM
100
What is the commonest cause of chronic pancreatitisa
ALCOHOL in 80% of cases
101
how to investigate chronic pancreatitis
Blood: faecal elastase (marker of pancreatic insufficiency)
USS (exclude gallstones)
contrast-enhanced CT
102
what is the most common type of pancreatic xcancer (location + histology)
head of pancreas, adenocarcinoma
103
what are classic sx of pancreatic cancer
painless jaundice
loss of exocrine function > staethorroea
loss of endocrine function > DM
thrombophlebitis
104
what ix need to be carried out for pancreatic cancer
HR-CT (double duct sign, simultaneous dilatation of CBD and pancrsatic duct)
USS
105
how do you manage pancreatic cancer
```
Whipple resection (pancreaticoduodonectomy) - although less than 20% are suitable
with adjuvant chemo
```
106
What requires a 2 wk urgent referra for OGD withGORD symptoms
```
dysphagia (suspect oesophageal cancer)
upper abdominal mass (suspect oral ancer)
Age > 55 AND WL and
- dyspepsia
- reflux/GORD
- Upper abdo pain
```
107
What requires nonurgent referra for OGD withGORD symptoms
```
haematemesis
Age >55 AND
- treatment resistant dyspepsia
- upper abdo pain with low Hb
- N&V+ reflux, WL, dyspepsia, upoper abdo pain
```
108
what do you do if GORD symptoms and OGD negative
24 h oesophageal pH monitoring
109
How do you manage GORD if no need to refer for OGD
1. review meds for possible dyspepsia causes and give lifestyle afdbvice
2. trial PPI (4 weeks= or test and treat for H pylori
110
How do you test for H pylori
C13 Urea breath test
OR stool antigen test
Or Lab based serology
111
How do you manage H pylori
CAP: clarythomycin, amoxicillin/metronidazolel, PPO
112
How do you treat GORD
trial PPI for 1 month then review
| If refractory: nissen fundoplication
113
what score assesses prognosis of cirrhosis
```
Child's Pugh ABCDE
Albumin
Bilirubin
Clotting (PT)
Disension (ascites)
Encepalopathy
```
114
How do you manage alcoholic hepatitis
consider pred
115
what abx can you give for C diff
```
oral metronidazole (mild)
oral vanc (severe)
oral vanc + IV met (life threatening9
```
116
what serology can you do for coeliacs disease
anti-TTg + total IgA
| anti- EMA (less sensitive)
117
how does cholangiocarcinoma present
usually asumptomatic
RUQ, nausea, anorexia, vomiting, malaise, WL, palpable GB
Obstructive jaundice: pale stool, dark urine
118
how do you stage cholangiocarcinoma
CT abdo
| ERCP fgold standard stating
119
how do you manage cholangiocarcinoma
cholecystectomy if resectable
| chemotherapy + stenting if not resectable
120
is PSC or PBC more likelly to cause cholangocarcinoma
PSC -- in 10% of patients
121
which IBD is most likeluy to cause fissures and fistulas
CHRONS
122
which IBD is smoking PROTECTIVE for
UC
123
what is the severity index for IBD
True Love and Witts criteria
124
causes of granuloma
TB (caseating)
| Chron's, sarcoid (non-caseating)
125
causes of subtotal villous atrophy (other than coeliac)
```
Giarda
Tropical sprie
infectious enteritis
lymphoma
Whipples infection
Lactose intolerance
```
126
Wernicke's triad
Opthalmoplegia
Ataxia
Confusion
127
Korrsakoff's
Wernicke's PLUS confabulation and amnesia
128
How do you test for Wilson's disease on blood test
serum caeruloplasmin
129
How do you test for Haemochromatosis on blood test
Iron panel (raised iron , raised ferritin, low TIBC)
130
when do you refer for an URGENT 2 week OGD
Dysphagia
Upper abdominal mass (? stomach cancer)
55yo + WL + dyspepsia / reflux / upper abdo pain
131
How do you manage dyspepsia
1. review meds for possble causes, give lifestyle adice
| 2. Test for H Pylori (stool antigen test) OR trial full dose PPI
132
How long myst you wait after PPI to test for H pylori
2 weeks
133
What is management if H pylori +ve
amoxicilli + clarythromycin + PPI for ONE WEEK
134
what are dangerous associations/ complications of H pylori
PUD
Gastric cancer
MALToma
Altriphic gastritis
135
How can you manage anal fissue
<6 weeks: dietary advice (more fluids), bulk forming laxatives, OTC analgesia
>6 weeks: topical GTN / diltaziem > sphincterotomy
136
What is Gilberts and how does it present
Deficiency in glucoronyl transferase (enzyme required for conjugation of bilirubin in the livrr)
Presents as asymptomatic jaundice during other infection
Self-resolving
137
how do you treat C diff (mild-moderate)
oral metronidazole
138
how do you treat C diff (severe, 2nd episode=
oral vanc
139
how do you treat LIFE THREATENING c diff
oral vanc + IV metronidazole
140
what ix confirms C diff dx
C diff TOXIN
141
which antibodies are elevated in AI hepatitis
ANA, ASMA
Anti-LMK
Anti-SLA
Raised IgG
142
S/S AI hepatitis
Jaundice, RUQ pain, fever
| AMENORRHOEA
143
MX AI hep
steroids
| liver transplant
144
what iss plummer vinson syndrome + triad
due to post cricoid webs, presents as:
- dysphagia
- glossitis
- IDA
145
triad of boerhaves oesophagus
Chest pain
SC emphysema
Vomiting
