Gastro Flashcards
Abx of choice for a patient who has a recurrent episode of C. difficile within 12 weeks of symptom resolution?
Fidaxomicin
Acute management of variceal UGIB?
A-E: patients should ideally be resuscitated prior to endoscopy
Correct clotting: FFP, vitamin K
Before endoscopy Terlipressing and Abx:
Vasoactive agents:
- Terlipressin - more evidence
Prophylactic IV antibiotics (quinolones)
Endoscopy: endoscopic variceal band ligation
Sengstaken-Blakemore tube if uncontrolled haemorrhage
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
- connects the hepatic vein to the portal vein
Bloods to monitor in haemochromotosis?
Ferritin and transferrin saturation
Foods hight in Vit D?
oily fish such as salmon, sardines, herring and mackerel, red meat, liver, egg yolks, fortified foods such as most fat spreads and some breakfast cereals
First line diuretics for ascites?
Spironolactone
Antibodies to order for pernicious anaemia?
Intrinsic factor antibodies are more useful than gastric parietal cell antibodies when investigating vitamin B12 deficiency, given low specificity of gastric parietal cell antibodies
Diagnostic features of IBS?
A positive diagnosis of IBS should be made if the patient has abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms:
- Altered stool passage (straining, urgency, incomplete evacuation)
- Abdominal bloating (more common in women than men), distension, tension or hardness
- Symptoms made worse by eating
- Passage of mucus
In hep B what does HBsAg mean?
HBsAg normally implies acute disease - best test to use for screening
In hep B what does Anti-HBs mean?
Anti-HBs implies immunity (either exposure or immunisation). It is negative in chronic disease
In hep B what does Anti-HBc mean?
Anti-HBc implies previous (or current) infection. IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months. IgG anti-HBc persists
Easy thing to remember for Hepatitis antibodies?
HBsAg = ongoing infection, either acute or chronic if present > 6 months
anti-HBc = caught, i.e. negative if immunized
Treatment for Primary biliary cholangitis?
Ursodeoxycholic acid
Features of primary biliary cholangitis?
Typically seen in middle-aged females (female:male ratio of 9:1).
Associated with
- Sjogren’s syndrome (seen in up to 80% of patients)
- Rheumatoid arthritis
- Systemic sclerosis
- Thyroid disease
Features:
- early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus
- cholestatic jaundice
- hyperpigmentation, especially over pressure points
around 10% of patients have right upper quadrant pain
- xanthelasmas, xanthomata
- also: clubbing, hepatosplenomegaly
- late: may progress to liver failure
Antibodies present in Primary biliary cholangitis?
- anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific
smooth muscle antibodies in 30% of patients
raised serum IgM
What would you give to reverse warfarin effects in an UGIB?
IV Prothrombin complex
Alcohol units calculation?
Alcohol units = volume (ml) * ABV / 1,000
AST:ALT ratio in NAFLD vs Alcoholic liver disease?
alcohol has AST:ALT ratio >2 in contrast to non-alcoholic fatty liver disease which is associated with an ALT:AST ratio >2.
Increased hepatic echogenicity on liver ultrasound likely means?
NAFLD
First line treatment for C.diff?
Oral vancomycin
When do you give abx prophylaxis in ascites?
Patients with ascites (and protein concentration <= 15 g/L) should be given oral ciprofloxacin or norfloxacin as prophylaxis against spontaneous bacterial peritonitis
Best H.pylori test?
Urea breath test.
What drugs cause cholestasis?
Combined oral contraceptive pill
Antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
Anabolic steroids, testosterones
Phenothiazines: chlorpromazine, prochlorperazine
Sulphonylureas
Fibrates
Incidental finding of NAFLD next step investigations?
Enhanced liver fibrosis (ELF) blood test to check for advanced fibrosis
Fibroscan.
Combination can be used to calculate predictor scores for fibrosis?
Extra-intestinal manifestations of Crohn’s disease is related to disease activity?
Erythema Nodosum.
most common extra-intestinal manifestation of Crohn’s disease?
Arthritis - pauciarticular (only a few joints), asymmetric
Extra intestinal manifestations of IBD?
Related to disease activity:
- Arthritis: pauciarticular, asymmetric
- Erythema nodosum
- Episcleritis
- Osteoporosis
Not related to disease activity:
- Arthritis: polyarticular, symmetric
- Uveitis
- Pyoderma gangrenosum
- Clubbing
- Primary sclerosing cholangitis
Smoking bad in UC or crohns?
Bad in crohns
Gold-standard diagnosis of Coeliac?
Intestinal biopsy (jejenum)
How to rule out toxic megacolon in UC flare?
AXR
What is Peutz-Jeghers syndrome?
Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles. Although the polyps themselves don’t have malignant potential, around 50% of patients will have died from another gastrointestinal tract cancer by the age of 60 years.
Primary sclerosing cholangitis associated with what IBD?
UC
Difference in PSC and PBC?
PBC
- Primary biliary cholangitis
- Autoimmune
- Middle aged females, AMA positive, associated with autoimmune diseases and treat with ursodeoxycholic acid
PSC
- Primary Sclerosing
- Unknown aetiology
- Associated with UC
- PANCA may be positive.
- Risk of developing cholangiocarcinoma and colorectal cancer
What is acahalsia?
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter
Dysphagia of BOTH liquids and solids
Mostly managed with surgical intervention
UC Inducing remission management?
The severity of UC is usually classified as being mild, moderate or severe:
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
Treating mild-to-moderate ulcerative colitis:
Proctitis:
- topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates
- if remission is not achieved within 4 weeks, add an oral aminosalicylate
- if remission still not achieved add topical or oral corticosteroid
Proctosigmoiditis and left-sided ulcerative colitis
- topical (rectal) aminosalicylate
- if remission is not achieved within 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
- if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
extensive disease
- topical (rectal) aminosalicylate and a high-dose oral aminosalicylate:
- if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
Severe colitis
- should be treated in hospital
- intravenous steroids are usually given first-line
- intravenous ciclosporin may be used if steroid are contraindicated
- if after 72 hours there has been no improvement, consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery
UC maintaining remission treatment?
Following a mild-to-moderate ulcerative colitis flare
proctitis and proctosigmoiditis:
- topical (rectal) aminosalicylate alone (daily or intermittent) or
- an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
- an oral aminosalicylate by itself: this may not be effective as the other two options
Left-sided and extensive ulcerative colitis:
- low maintenance dose of an oral aminosalicylate
Following a severe relapse or >=2 exacerbations in the past year:
- oral azathioprine or oral mercaptopurine
What is melanosis coli?
Melanosis coli is a disorder of pigmentation of the bowel wall. Histology demonstrates pigment-laden macrophages
It is associated with laxative abuse
Pseudopolyps - UC or crohns?
UC
What is cholestyramine used for?
Bile acid malabsorption e.g. after cholecytectomy
What can’t you have before a urea breath test for H.Pylori?
Urea breath test - no antibiotics in past 4 weeks, no antisecretory drugs (e.g. PPI) in past 2 weeks
Clotting factors in liver failure?
In liver failure, all clotting factors are low except for factor VIII which is high. Both PT and APTT can be prolonged.
Advice for stopping PPIs prior to endoscopy?
Stop 2 weeks prior.
Features of autoimmune hepatitis?
may present with signs of chronic liver disease
acute hepatitis: fever, jaundice etc (only 25% present in this way)
amenorrhoea (common)
ANA/SMA/LKM1 antibodies, raised IgG levels
liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
Treatment of severe C.Diff?
Oral vanc and IV metronidazole
increased goblet cells associated with?
Crohns
Bloods diarrhoea more common in UC or Crohns?
UC
