Gastro Flashcards
Name Charcot’s triad and what is the disease
Fever
RUQ pain
Jaundice
Ascending Cholangitis
Management of ascending cholangitis
IV Abx
ERCP after 24-48 hours to relieve any obstruction
Indications for Acetylecysteine in paracetamol OD
Staggered OD (spread over >1hour)
Unsure time of ingestion
Over or above treatment line on plasma PCM vs time graph
Criteria for liver transplant in paracetamol OD
Arterial pH < 7.3, 24 hours after ingestion (MOST IMPORTANT FACTOR) or all of the following: prothrombin time > 100 seconds creatinine > 300 µmol/l grade III or IV encephalopathy
systolic BP <80 also poor prognostic marker.
Gastrin - stimulated by, inhibited by, secreted from, effect
St: Proteins, stomach distension, vagal stimulation
In: somatostatin, stomach acid (neg fb)
G cells in Antrum of stomach duodenum and pancreas
Increase histamine -> acid production
Define Zollinger-Ellison syndrome
features
Increased gastrin secretion (increases gastric acid secretion) usually from a gastrin secreting tumour
Usually 30% have MEN-1 (parathyroid (95%), pituitary (70%), pancreas (50%), also adrenal and thyroid)
gastric ulcers, diarrhoea, malabsorption
Dyspepsia red flags
Unintentional weight loss Iron deficiency anaemia Malaena Persistent vomiting Epigastric mass Progressive dysphagia
Mx of dyspepsia in community
- Review medications for possible causes of dyspepsia
- Lifestyle advice
- Trial of full-dose PPI for one month
- ‘Test and treat’ using carbon-13 urea breath test
If >55 and symptoms persistent/recent onset/unexplained -> OGD
Complications of coeliacs disease
Hyposplenism
Anaemia: iron, b12 and folate def
osteoporosis
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility, unfavourable pregnancy outcomes
rare: oesophageal cancer, other malignancies
Conditions associated with coeliac disease
Dermatitis herpetiformis (vesicular pruritic rash) Type 1 DM Autoimmune hepatitis HLA - DQ2/DQ8 (95%) HLA - B8 (80%)
Indications for coeliac screening
Other conditions: T1DM, autoimmune thyroid, dermatitis herpetiformis, 1st degree relative of coeliac
Sx: anaemia, persistent/intermittent diarrhoea/vomiting/abdo pain/ abdo distension/ weight loss/ TATT/ FTT`
what is a gastric MALT lymphoma
Rx?
mucosa-associated lymphoid tissue lymphoma due to chronic inflammation
80-90% due to H.pylori infection, eradicate HP and resolution occurs in the majority
what are the features of the Child-Pugh classification for liver cirrhosis?
bilirubin albumin PT ascites encephalopathy
severity graded A-C
typical causes of watery diarrhoea
E.coli - travellers, watery diarrhoea, abdo cramps and nausea.
Cholera - profuse watery diarrhoea, leading to dehydration and weight loss
typical causes of bloody diarrhoea
amoebiasis - gradual onset bloody diarrhoea, abdo pain lasting several weeks.
shigella - bloody diarrhoea, vomiting and abdo pain
treatment of hepatitis C
interferon-alpha and ribavirin
treatment is successful if serum HCV RNA is negative 6/12 after end of treatment (successful ~55% of pts)
smooth muscle antibody association
autoimmune hepatitis
causes of villous atrophy
coeliacs tropical sprue hypogammaglobulinaema GI lymphoma Whipples disease (chronic bact. infection) lactose intolerance
acute management of oesophageal variceal bleed
ABCDE
terlipressin - C/I in pregnancy (vasopressor)
prophylactic Abx
endoscopic band ligation
prophylaxis of oesophageal varices
propanolol - reduced rebleeding
endoscopic band ligation and PPI
features in the Rockall score
pre-gastroscopy:
age - 60-80/>80
shock - no shock/tachycardia/hypotension
comorbidities - HF or IHD/RF or LF, metastases
post gastroscopy:
Dx - mallory weiss or none seen/all other Dx/malignancy
major stigmata of recent GI bleed - blood or clot or active bleed
Mx of C.dif
oral metronidazole for 10-14 days
if severe/non responding then oral vancomycin
if life threatening then oral vanc and IV met
most common site of inflammation in UC, and in Crohns
UC - rectum
CD - terminal ileum
most common extra-intestinal feature of IBD
arthritis
pathology of primary biliary cirrhosis
classic presentation
autoimmune chronic inflammation causing progressive cholestasis leading to cirrhosis.
classically: itching in middle aged woman
Associations of primary biliary cirrhosis
Sjogren’s syndrome (seen in 80%) (both DR3)
RA
Systemic sclerosis
thyroid disease
Ix of primary biliary cirrhosis
Mx
anti-mitochondrial antibodies - M2 subtype
raised serum IgM and ALP
Xanthelesma present
Mx: cholestyramine for pruritis
fat sol vitamins (DAKE) supplements
ursodeoxycholic acid (a bile salt replacement)
liver transplant if bilirubin >100
complications of PBC
malabsorption
sicca syndrome (70%)
portal hypertension
HCC (20 fold increase risk)
Mx of hepatorenal syn
terlipressin (vasoconstrict)
albumin solution to increase vol
transjugular intrahepatic portosystemic shunt
Features of Diptheria
Eastern European/Russia Grey tonsils Cervical lymphadenopathy Heart block Neuritis (cranial nerves)
Mx of UC - inducing remission
If mild/moderate: 1st line: oral mesalazine
2nd: add oral prednisolone to induce remission (after 4 week trial)
If severe: IV steroids first line
Classify severity of UC
mild <4 stools/day
mod 4-6, variable blood
severe: 6 bloody stools/day, systemic upset
Mx of UC - maintaining remission
oral mesalazine
azathioprine and mercaptopurine
probiotics for mild/moderate
note MTX not indicated for UC (unlike Crohns)
What is the rate of transmission of Hep C
from mother to child
during sex
needle stick injury
mother to child - 6%
breastfeeding is not contraindicated
sex 5%
needle stick 2%
how deep is the inflammation in UC
mucosa and submucosa
Mx of Crohns flare
stop smoking
steroids to induce remission and elemental diet
2nd line: mesalazine
3rd: add azathioprine or methotrexate
infliximab for refractory Crohns or fistulating
metronidazole for peri-anal disease
Causes of hepatosplenomegaly
chronic liver disease with portal HTN infections:malaria, hepatitis, glandular fever lymphoproliferative myeloproliferative amyloidosis
what is the increased risk of colorectal ca in pts with UC
factors increasing risk
10-20x general pop disease >10 yrs pancolitis unremitting disease onset before 15 yrs poor compliance with treatment
What is Peutz-Jegher’s syndrome?
inheritance?
features?
Auto dom
benign hamartomatous polyps in GI tract and hyperpigmented macules on lips and oral mucosa.
increased risk of GI cancer ~50% will have cancer by 60s
What is the function of the gene defect in FAP and in HNPCC
FAP - tumour suppressor gene defect
HNPCC (most common cause of familial CR ca) - DNA mismatch repair
What percentage of UC patients have primary sclerosing cholangitis?
4% of UC pts have PSC
80% of PSC pts have UC
Primary sclerosing cholangitis pathology
features
Ix of choice
complications
unknown cause
inflammation of intra and extra hepatic bile ducts
RUQ pain, cholestasis (jaundice and pruritis), fatigue
ERCP - multiple biliary strictures
complications: cholangiocarcinoma in 10%, increased risk of colorectal ca
Spontaneous bacterial peritonitis:
Dx
Mx
Dx: paracentesis neutrophils >250cells/ul
Mx: IV cefotaxime
Chance of having colorectal cancer with a positive faecal occult blood test
5-15%
colonoscopy post +FOB: 50% normal exam, 30-40% have polyps, 5-15% have colorectal cancer
features of the Glasgow-Blatchford score?
what is it used for?
urea, Hb, HR, malaena, syncope, liver disease, HF
Assess the likelihood of needing intervention as inpatient.
What is a significant serum ascites albumin gradient?
What does it signify?
SAAG >1.1 g/dL - portal hypertension
low SAAG - TB peritonitis, pancreatic or biliary ascites, nephritic syndrome
What is the significance of melanosis coli findings on colonoscopy?
Benign finding, secondary to senna or dantron abuse
Features of Wilson’s disease
Ix
Mx
Copper aggregation - autosomal recessive
abnormal LFTs and basal ganglia signs (dysarthria, ataxia)
neuro/psychiatric symptoms presenting feature in 40%
kayser-fleischer rings
Ix: 24 hour urinary copper excretion, liver biopsy is diagnostic
Mx: penicillamine or trientine to chelate the copper
Serological markers in UC and Crohns
UC - pANCA
Crohns - ASCA (anti-saccharomyces cerevisiae antibodies)
Useful in patients with indeterminate colitis (?Crohns ?UC)
features of a VIPoma
watery diarrhoea
hypokalaemia
achlorhydria (absent gastric acid production)
raised serum chromogranin A in all neuroendocrine tumours except insulinoma.
Mx of a VIPoma
octreotide (somatostatin) blocks action of VIP
surgical removal of tumour
Pathology and features of Whipple’s disease
abnormal immune response to intracellular organism tropheryma whippeli
seronegative arthropathy, weight loss, diarrhoea
cardiac complications in 30% (pericarditis, valvular disease)
CNS signs in 15% - occulomasticatory morphyria pathopneumonic
hypoalbuminaemia secondary to malabsorption due to flattening of intestinal villi
SIRS response, anaemia.
lipid deposition in the lamina propria of intestinal villi and lipid containing macrophages with sickle-like inclusion bodies and PAS positive staining.
what is the triad of features in microscopic colitis
Mx
watery diarrhoea
normal colonoscopy
inflammation of the lamina propria of the colon.
due to NSAIDs, PPI, ticlopidine and cimetidine
Mx - stop offending medication.
Dx and Rx of hepatitis C
hep C antibody and PCR positive
raised ALT and fibrosis score (US and liver biopsy)
pegylated interferon - SE flu-like illness, depression
ribavirin - SE anaemia
type 1+4 - 1yr Rx
type 2+3 - 6/12
