GASTRO Flashcards
Treatment for Wilson’s disease?
Penicillamine (chelates copper).
Wilson’s disease is caused by excessive deposition of what?
Copper.
Name the 3 tissues most commonly affected in Wilson’s disease.
Liver, brain and corneas.
Blood test used to diagnose Wilson’s disease?
Caeruloplasmin (reduced in Wilson’s disease).
**Note that there is also reduced total serum copper but free (non-bound) copper is increased.
3 types of ischaemia in the lower GIT?
1) Acute mesenteric ischaemia.
2) Chronic mesenteric ischaemia.
3) Ischaemic colitis.
Features of the abdominal pain in acute mesenteric ischaemia?
1) Sudden in onset
2) Severe
3) Pain out of keeping with clinical findings
Bloods results in lower bowel ischaemia?
Raised WCC associated with a lactic acidosis.
Ix of choice for bowel ischaemia?
CT.
Cause of acute mesenteric ischameia?
Commonly an embolism occluding an artery that supplies the small bowel (E.G. superior mesenteric artery).
Where does ischaemic colitis most commonly occur?
Splenic flexure (and other ‘watershed’ areas).
Why does ischaemic colitis most commonly occur at the splenic flexure?
This is the border of the territories supplied by the superior and inferior mesenteric arteries.
What sign may be seen on XR in a patient with ischaemic colitis?
‘Thumbprinting’ due to mucosal oedema or haemorrhage.
Indications for surgery in ischaemic colitis?
Perforation, ongoing haemorrhage, generalised peritonitis.
What should patients that have ascites with protein contents <15 be given and why?
Prophylactic antibiotics against SBP (normally ciprofloxacin or norfloxacin).
Prophylactic ABx should be continued until ascites have resolved.
3 main features of spontaneous bacterial peritonitis?
Ascites
Abdominal pain
Fever
How is SBP diagnosed?
Paracentesis demonstrating neutrophil count >250.
Most common organism isolated from ascitic drainage in those with SBP?
E. coli
Gold standard investigation for suspected oesophageal cancer?
Endoscopy.
Most common type of oesophageal cancer?
Adenocarcinoma.
Adenocarcinoma of the oesophagus is more likely in which patients?
Those with GORD or Barrett’s oesophagus.
Where does adenocarcinoma of the oesophagus most commonly occur?
Lower third of the oesophagus near the GOJ.
Briefly describe the pathogenesis of appendicitis.
1) Lymphoid hyperplasia of faecoliths.
2) Obstruction of appendices lumen.
3) Gut organisms invade appendix wall.
4) Causes oedema, ischaemia, infection ± perforation.
Why does pain from appendicitis begin at the umbilicus and migrate to the right iliac fossae?
Appendix is midgut structure.
Initially pain is caused by visceral stretching of the appendix lumen.
When appendix becomes inflamed, the inflammation spreads to the parietal peritoneum causing pain to localise to the RIF.
Features of appendicitis?
Umbilical pain localising to RIF
Anorexia
Mild pyrexia (37.5-38) - anything higher is more likely to be mesenteric adenitis.
1-2 episodes of vomiting (marked vomiting is unusual).
Perfuse diarrhoea is rare but pelvic appendicitis can cause local rectal irritation + some loose stools.
Main triad of symptoms in appendicitis?
Abdominal pain
Anorexia
Nausea
Signs of generalised peritonitis?
Rebound + percussion tenderness
Guarding + rigidity
What sign can a pelvic appendicitis cause?
Right sided tenderness upon DRE
What are the 2 classical signs of appendicitis that can be elicited?
Rovsing's sign Psoas sign (pain on extending hip if there is a retrocaecal appendix)
FBC result commonly seeing those with appendicitis?
Neutrophil predominant leucocytosis.
What might urinalysis show in a patient with appendicitis?
Leucocytosis without nitrites.
**Use urinalysis to exclude pregnancy, renal colic and UTI.
Who can be diagnosed clinically with appendicitis?
Thin, male patients with a high likelihood of appendicitis.
What investigation is commonly used in females with suspected appendicitis?
USS.
What sign upon USS is pathologic of appendicitis?
The presence of free fluid around the appendix.
What score is used to estimate the risk of a patient developing a pressure sore?
Waterlow score.
What scoring system is used to screen for malnutrition?
MUST.
What does a positive HBsAg test suggest?
Acute or chronic active hepatitis B.
- *Implies acute disease if present for 1-6 months.
- *Implies chronic disease if present for >6 months.
What does a positive anti-has imply?
Immunity (either from exposure or immunisation).
What does a positive anti-HBc (HbcAg) imply?
Previous or current infection.
What do the presence of anti-HBc and IgM suggest?
Acute or recent (within 6 months) hepatitis B infection.
What do the presence of anti-HBc and IgG suggest?
Previous hepatitis B infection (>6 months ago).
What is HbeAg a marker for?
Hepatitis B disease activity.
Hepatitis B serology in a patient who has been immunised?
Anti-HBs positive.
All others negative.
Hepatitis B serology in a patient with previous hepatitis who is not a carrier?
HbcAg positive.
HbsAg negative.
Hepatitis B serology is a patient with previous hepatitis who is a carrier?
HbcAg and HbsAg positive.
Classical symptoms of cholelithiasis?
Colicky RUQ pain
Pain occurs postprandially
Symptoms normally worse following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.
Standard diagnostic work up for cholelithiasis?
LFTs + USS
Presentation of acute cholecystitis?
RUQ pain (constant rather than colicky)
Fever
Murphy’s sign positive
Mildly deranged LFTs
Presentation of ascending cholangitis?
Patient severely septic and unwell
Jaundice
RUQ pain
Presentation of gallstone ileus?
Hx of cholelithiasis or cholecystitis
Known present gallstones
Small bowel obstruction (constant or intermittent)
3 triggers of a UC flare?
Stress
Medications (NSAIDs/ antibiotics)
Smoking cessation
Features of a mild UC flare?
<4 stools a day (bloody or non-bloody)
No systemic disturbance
Normal ESR and CRP
Features of a moderate UC flare?
4-6 bloods or non-bloody stools a day.
Minimal systemi disturbance.
Features of a severe UC flare?
> 6 bloody stools a day
Evidence of systemic disturbance (fever, tachycardia, abdominal tenderness/distension, reduced bowel sounds, anaemia, hypoalbuminaemia).
When is a TIPS procedure indicated in patients with oesophageal bleeding?
When there is ongoing acute bleeding despite repeated endoscopic therapy.
What is a TIPS procedure?
Transjugular intrahepatic portosystemic shunt.
A stent is inserted into the liver parenchyma that connects the systemic and portal venous systems.
This decreases portal blood pressure and usually controls vatical bleeding.
2 most common causes of acute upper GI bleeding?
Oesophageal varices
Peptic ulcer disease
Typical features of upper GI bleeding?
Haematemesis (bright red or coffee ground)
Malena (black, tarry stools)
Raised urea (protein meal)
Hepatomegaly, obesity + abnormal LFTs?
?NAFLD
What type of bacteria is clostridium difficile?
Gram positive rod
The does clostridium difficile infection develop?
When the normal gut flora are suppressed by broad spectrum antibiotics.
What is the leading cause of clostridium difficile?
2nd and 3rd generation cephalosporins.
What finding on an FBC is characteristic of clostridium difficile infection?
Raised WCC.
Management of C. Diff infection in a patient suffering with their first episode?
1st line = oral vancomycin for 10 days
2nd line = oral fidaxomicin
3rd line = oral vancomycin ± IV metronidazole
Management of C. Diff infection in a patient suffering from a recurrent episode?
If recurrent episode is within 12 weeks of symptom resolution: oral fidaxomicin.
If recurrent episode is >12 weeks after symptom resolution: oral vancomycin or fidaxomicin.
Management of C. Diff infection in a patient suffering with a life-threatening C. Diff infection?
Oral vancomycin + IV metronidazole.
Presence of the ‘double duct’ sign on MRCP suggests a diagnosis of what?
Pancreatic cancer.
**Double duct sign = visible dilatation of the CBD and the pancreatic duct which is indicative fo pancreatic cancer (head of the pancreas).
Describe the classic features of pancreatic cancer.
Painless jaundice.
Pale stools + dark urine.
Pruritis.
Cholestatic LFTs.
Ix of choice if pancreatic cancer is suspected?
High resolution CT
What can constipation cause in patients with liver cirrhosis?
Liver decompensation.
Why should opioids be stopped in C. Diff infection?
Because they are anti-peristaltic so can predispose to toxic megacolon by slowing the clearance of the C. Diff toxin.
What diagnosis should you consider in a patient with a metabolic ketoacidosis but a normal or low glucose level?
Alcoholic ketoacidosis.
What is the first line treatment for diarrhoea in IBS?
Loperamide.
