Gastro Flashcards
1
Q
Complications of Crohn’s?
A
small bowel cancer
colorectal cancer
osteoporosis
2
Q
Indications for surgery in Crohn’s?
A
around 80% of patients with Crohn’s disease will eventually have surgery
stricturing terminal ileal disease → ileocaecal resection
segmental small bowel resections
stricturoplasty
perianal fistulae
perianal abscess
acute GI bleed
3
Q
what is the M rule for PBC?
A
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
4
Q
Clinical features of PBC?
A
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
5
Q
Mx of PBC?
A
- first-line: ursodeoxycholic acid
slows disease progression and improves symptoms - pruritus: cholestyramine
- fat-soluble vitamin supplementation
- add prednisolone if associated autoimmune disease
- liver transplantation
e.g. if bilirubin > 100 (PBC is a major indication)
recurrence in graft can occur but is not usually a problem
6
Q
Complications of PBC?
A
cirrhosis → portal hypertension → ascites, variceal haemorrhage
osteomalacia and osteoporosis
significantly increased risk of hepatocellular carcinoma (20-fold increased risk)
7
Q
Ix/ diagnosis of PBC?
A
Bloods:
cholestatic liver biochemistry (raised GGT/ALP, normal transaminases)
immunology:
anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific
Anti-SMA in 30% of patients
raised serum IgM
imaging:
required before diagnosis to exclude an extrahepatic biliary obstruction (typically a right upper quadrant ultrasound or magnetic resonance cholangiopancreatography (MRCP)
8
Q
What is PBC?
A
Bile ducts damaged by a chronic inflammatory process causing progressive cholestasis
9
Q
which conditions are associated with PBC?
A
Sjogren’s syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease
10
Q
Alcoholic ketoacidosis biochemistry?
A
Metabolic ketoacidosis with normal or low glucose: Metabolic acidosis Elevated anion gap Elevated serum ketone levels Normal or low glucose concentration
11
Q
Mx alcoholic ketoacidosis?
A
infusion of saline and thiamine
12
Q
What is the most common cause of hepatocellular carcinoma?
A
Chronic hepatitis B is the most common cause of HCC worldwide
chronic hepatitis C is the most common cause in Europe.
13
Q
What are the main risk factors for HCC?
A
liver cirrhosis, for example secondary to: hepatitis B & C alcohol haemochromatosis primary biliary cirrhosis
14
Q
Management HCC?
A
early disease: surgical resection liver transplantation radiofrequency ablation transarterial chemoembolisation sorafenib: a multikinase inhibitor
15
Q
Who is screened for HCC?
A
patients liver cirrhosis secondary to hepatitis B & C or haemochromatosis
men with liver cirrhosis secondary to alcohol
+ AFP screening as raised in HCC
16
Q
What is the management of a variceal bleed?
A
ABC: patients should ideally be resuscitated prior to endoscopy
correct clotting: FFP, vitamin K
vasoactive agents: terlipressin
prophylactic IV antibiotics: quinolone
both terlipressin and antibiotics should be given before endoscopy in patients with suspected variceal haemorrhage
endoscopy: endoscopic variceal band ligation
Sengstaken-Blakemore tube if uncontrolled haemorrhage
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
17
Q
Variceal bleed prophylaxis?
A
propranolol: reduced rebleeding and mortality compared to placebo
endoscopic variceal band ligation (EVL) - should be performed at two-weekly intervals until all varices have been eradicated
Proton pump inhibitor cover
18
Q
what is seen on barium enema of UC?
A
loss of haustrations
superficial ulceration, ‘pseudopolyps’
long standing disease: colon is narrow and short -‘drainpipe colon’
19
Q
what is the most most common organism found on ascitic fluid culture in SBP?
A
E.coli
20
Q
What are the features of SBP?
A
Ascites
abdominal pain
fever
21
Q
How do you diagnose SBP?
A
USS to confirm ascites
paracentesis: neutrophil count > 250 cells/ul
MCS: the most common organism found on ascitic fluid culture is E. coli
22
Q
what is the management of SBP?
A
Piptazobactam or cefotaxime
prophylaxis: ciprofloxacin + propanolol
23
Q
when should antibiotic prophylaxis be given to patients with ascites?
A
Antibiotic prophylaxis should be given to patients with ascites if:
patients who have had an episode of SBP
patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
NICE recommend: ‘Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved’
24
Q
What vaccine should those with coeliac disease get annually?
A
pneumococcal due to hyposplenism
Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every 5 years
Currrent guidelines suggest giving the influenza vaccine on an individual basis
25
what are the risk factors for Barrett's oesophagus?
gastro-oesophageal reflux disease (GORD) is the single strongest risk factor
male gender (7:1 ratio)
smoking
central obesity
26
What is Barrett's oesophagus?
Barrett's refers to the metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium.
27
What are the three conditions causing ischemia to the lower GI tract?
acute mesenteric ischaemia
chronic mesenteric ischaemia
ischaemic colitis
28
What are the risk factors for bowel ischaemia?
increasing age
atrial fibrillation - particularly for mesenteric ischaemia
other causes of emboli: endocarditis, malignancy
cardiovascular disease risk factors: smoking, hypertension, diabetes
cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use
29
What are the features of ischaemic bowel?
```
abdominal pain
physical exam findings
rectal bleeding
diarrhoea
fever
bloods typically show an elevated white blood cell count associated with a lactic acidosis
```
30
What is the management of acute mesenteric ischaemia?
urgent surgery is usually required
| poor prognosis, especially if surgery delayed
31
What causes acute mesenteric ischaemia?
embolism resulting in occlusion of an artery which supplies the small bowel
classically history of af
32
What is chronic mesenteric ischaemia?
Colickly, intermittent abdominal pain occurs
'intestinal angina'
non specific
33
What is the management of ischaemic colitis?
- usually supportive
- surgery may be required in a minority of cases if conservative measures fail. Indications would include generalised peritonitis, perforation or ongoing haemorrhage
34
What investigations are done for ischaemic colitis?
Investigations
| 'thumbprinting' may be seen on abdominal x-ray due to mucosal oedema/haemorrhage
35
Where is ischaemic colitis most likely to occur?
'watershed' areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.
36
What is ischaemic colitis?
Ischaemic colitis describes an acute but transient compromise in the blood flow to the large bowel. This may lead to inflammation, ulceration and haemorrhage.
37
What are some adverse effects of metoclopramide?
extrapyramidal effects: oculogyric crisis. This is particularly a problem in children and young adults
hyperprolactinaemia
tardive dyskinesia
parkinsonism
should also be avoided in bowel obstruction due to prokinesis
38
what are the complications of coeliac disease?
anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
hyposplenism
osteoporosis, osteomalacia
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility, unfavourable pregnancy outcomes
rare: oesophageal cancer, other malignancies
39
what is seen on duodenal biopsy in coeliac?
complete atrophy of the villi with flat mucosa
marked crypt hyperplasia
Intraepithelial lymphocytosis
Dense mixed inflammatory infiltrate in the lamina propria.
40
coeliac associated conditions?
```
Autoimmune thyroid disease
Dermatitis herpetiformis
Irritable bowel syndrome
Type 1 diabetes
First-degree relatives (parents, siblings or children) with coeliac disease
```
41
S/S coeliac?
Chronic or intermittent diarrhoea
Failure to thrive or faltering growth (in children)
Persistent or unexplained gastrointestinal symptoms including nausea and vomiting
Prolonged fatigue ('tired all the time')
Recurrent abdominal pain, cramping or distension
Sudden or unexpected weight loss
Unexplained iron-deficiency anaemia, or other unspecified anaemia
42
What does a high SAAG indicate?
A high SAAG (>11g/L)
portal hypertension and the ascitic fluid is a transudate. liver cirrhosis/failure/mets -> most common
right heart failure, pericarditis
hepatic failure
venous occlusion (e.g. Budd Chiari syndrome)
alcoholic hepatitis
myxoedema
43
What does a low SAAG indicate?
```
A low SAAG (<11g/L)
ascitic fluid is an exudate.
malignancy
infection
pancreatitis
nephrotic syndrome
bowel obstruction
```
44
what is the management of ascites?
```
reduce dietary sodium
fluid restriction if sodium <125
spironolactone
drainage if tense ascites
paracentesis
prophylactic ciprofloxacin
TIPS
```
45
What is the Child pugh score for?
Child–Pugh score is used to assess the prognosis of chronic liver disease, mainly cirrhosis
46
What is the triad of liver failure?
encephalopathy, jaundice and coagulopathy
47
What are some causes of acute liver failure?
paracetamol overdose
alcohol
viral hepatitis (usually A or B)
acute fatty liver of pregnancy
48
what are some features of acute liver failure?
```
jaundice
coagulopathy: raised prothrombin time
hypoalbuminaemia
hepatic encephalopathy
renal failure is common ('hepatorenal syndrome')
```
49
What is the best way to assess 'synthetic liver function'?
PT
| albumin level
50
What is type 1 hepatorenal syndrome?
Type 1 is a rapid onset hepatorenal syndrome (less than two weeks). This typically occurs following an acute event such as an upper GI bleed
51
What is type 2 hepatorenal syndrome?
Type 2 is a more gradual decline in renal function and is generally associated with refractory ascites
52
What is the pathophysiology behind hepatorenal syndrome?
vasoactive mediators cause splanchnic vasodilation which in turn reduces the systemic vascular resistance. This results in 'underfilling' of the kidneys.
53
What are the features of type 1 hepatorenal syndrome?
Rapidly progressive
Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks
Very poor prognosis
54
What are the features of type 2 hepatorenal syndrome?
Slowly progressive
| Prognosis poor, but patients may live for longer
55
What is the management of hepatorenal syndrome?
vasopressin analogues, for example terlipressin, have a growing evidence base supporting their use. They work by causing vasoconstriction of the splanchnic circulation
volume expansion with 20% albumin
transjugular intrahepatic portosystemic shunt
56
What is the most common type of pancreatic cancer?
adenocarcinoma at the head of the pancreas (80%)
57
What are the associations with pancreatitis?
```
increasing age
smoking
diabetes
chronic pancreatitis (alcohol does not appear an independent risk factor though)
hereditary non-polyposis colorectal carcinoma
multiple endocrine neoplasia
BRCA2 gene
KRAS gene mutation
```
58
What are the investigations for pancreatic cancer?
ultrasound has a sensitivity of around 60-90%
high-resolution CT scanning is the investigation of choice
imaging may demonstrate the 'double duct' sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts
59
What is courvoisiers law?
in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
60
What is the management of pancreatic cancer?
less than 20% are suitable for surgery at diagnosis
a Whipple's resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple's include dumping syndrome and peptic ulcer disease
adjuvant chemotherapy is usually given following surgery
ERCP with stenting is often used for palliation
61
How do you calculate units in a drink?
multiply the number of millilitres by the ABV and divide by 1,000. For example:
62
what are some features of hepatic encephalopathy?
confusion, altered GCS
asterix: 'liver flap', arrhythmic negative myoclonus with a frequency of 3-5 Hz
constructional apraxia: inability to draw a 5-pointed star
triphasic slow waves on EEG
raised ammonia level
63
what is the grading of hepatic encephalopathy?
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
64
What may precipitate hepatic encephalopathy?
```
infection e.g. spontaneous bacterial peritonitis
GI bleed
post transjugular intrahepatic portosystemic shunt
constipation
drugs: sedatives, diuretics
hypokalaemia
renal failure
increased dietary protein (uncommon)
```
65
What is the management of hepatic encephalopathy?
treat any underlying precipitating cause
NICE recommend lactulose first-line + rifaximin for the secondary prophylaxis of hepatic encephalopathy
embolisation of portosystemic shunts
liver transplantation in selected patients
66
How is the severity of flares in UC assessed?
Mild: <4 stools/day little blood
Moderate: 4-6 s/d, varying blood
Severe: >6 bloody stools, systemic upset
67
Which criteria may be used to assess severity of IBD
True-Love and Witt's
68
what are the investigations for IBD?
```
bloods: FBC, U&E, CRP, LFTs, pANCA
stool cultures, scope, colonoscopy
faecal calprotectin
barium or gastrograffin enema
acute - CTAP
```
C-reactive protein correlates well with disease activity IN Crohn's
69
Extra-intestinal manifestations of IBD?
```
A PIE SAC
aphthous ulcer [CD>UC]
pyoderma gangrenosum
eye - iritis, uveitis, episcleritis [CD>CD]
erythema nodosum
sclerosis cholangitis [UC]
arthritis
clubbing [CD>UC]
```
70
What are the symptoms of Crohn's?
```
non bloody diarrhoea
RIF mass
gallstones
anal fissures
perianal skin tags
```
71
what is the pattern of inflammation in Crohn's
skip lesions
rose thorn ulcers
cobblestoning
string sign of Kantor (narrow ileum stricture)
72
What are the symptoms of UC?
bloody diarrhoea + mucous diarrhoea
LIF pain
nocturnal incontinence
tenesmus
73
what is the pattern of inflammation in UC?
```
Continuous lead pipe
pseudo polyps
thumb printing
PSC
CRC risk higher in UC
```
74
How does Crohn's affect the gut layer?
transmural (goblet,granulomas)
75
How does UC affect the gut later?
mucosa and submucosa (goblet cells, crypt abscess)
76
How do you induce remission in Crohn's
Pharmacological:
mild: oral prednisolone 300 mg
severe: IV hydrocortisone - no improvement after 5 days -> IV infliximab.
Distal ileal, ileo-caecal, R sided colonic -> oral budesonide
Nutritional:
Whole protein modular diet for 6-8w
77
How do you maintain remission in Crohn's?
STOP SMOKING
1: DMARDs (azathioprine, mercaptopurine)
2: vaccines (no live - pneumococcal, influenza)
alternative: aminosalicylates, anti-TNF abs in infliximab
78
What needs to be checked before starting a patient on azathioprine/6MP?
TPMT levels
| use methotrexate instead if low
79
what is the management of UC?
1: distal colitis: topical aminosalicylates (4w) -> oral +/- topical
extensive colitis past splenic flexure: topical + oral aminosalicylates
2: topical -> oral beclomethasone
3: oral tacrolimus
4: biologics (infliximab, adalimumab)
5: surgery
80
what is the management of severe UC?
Fulminant: IV steroids +/- ciclosporin/infliximab (if not improvement in 72h then colectomy)
Non fulminant: topical aminosalicylates + oral + oral corticosteroid
after severe or >=2 exacerbations in past year -> oral azathioprine or 6MP
81
what surgery is used in UC?
- emergency: Hartmann's proctosigmoidectomy + end ileostomy + later ileal pouch anal anastomosis (IPAA)
- proctocolectomy + IPAA
- panproctocolectomy + end ileostomy
82
What surgery is used in Crohn's?
proctectomy (not that useful)
83
What is the classic presentation of IBS?
young female, anxious, stressed and may have depression, pain , bloating, diarrhoea/constipation
84
How is IBS diagnosed?
Diagnosis of exclusion based on ROME III criteria
- improvement with defecation
- change in stool frequency
- change in stool form/appearance/consistency
85
What is the management of IBS?
1: Diet and lifestyle
2nd: meds
86
What causes haemorrhoids?
displacement of anal cushions via gravity, straining and increased anal tone
87
What are the types of haemorrhoids?
1: in rectum after defecation
2: prolapse through anus at defecation, spontaneous reduction
3: prolapse through anus at defecation, manual reduction
4: persistently prolapsed
88
What are the investigations for haemorrhoids?
abdo exam
DRE
proctoscopy, sigmoidoscopy
89
what is the management of haemorrhoids?
1: increased fluids/fibre, stool softener, topical analgesics, steroids
2: rubber band ligation, sclerotherapy, electrotherapy, infraredcoagulation
3: haemorrhoidectomy, haemorrhoidopexy, HALF
90
What is the treatment for botulinum gastroenteritis?
anti-toxin
91
What is the treatment for c.diff
metronidazole
| vancomycin
92
what is the treatment for listeria ?
amoxicillin
| ampicillin
93
What is the treatment for salmonella typhi/paratyphi?
ceftriaxone initially
| switch to cipro if sensitive
94
What is the treatment for vibrio parahaemolyticus?
doxycycline
95
What is the treatment for vibrio vulnificus?
doxycycline
96
What is the treatment for severe campylobacter jejune?
SL
| treat if severe-> clarithromycin or cipro
97
What is the treatment for entamoeba histolytic?
metronidazole
| paromomycin
98
What is the treatment for giardiasis lamblia?
metronidazole
99
What is the treatment for cryptosporidium parvum?
paromomycin
100
What is coeliac?
autoimmunity to gliadin (in gluten, wheat, barley and rye) -> shorter villi and flat mucosa
101
what genetic associations does coeliac have?
HLA DQ2 and DQ8
102
S/S of coeliac?
pathogneumonic = dermatitis herpetiformis (pruritic papulovesicular elbow/knee rash)
watery, grey, frothy stool
IDA >folate def >B12 def
103
where is iron absorbed?
duodenum
104
where is folate absorbed?
jejunum
105
where is b12 absorbed?
ileum
106
what are the investigations for coeliac?
IgA TTG
If IgA deficient - do IgGDGP
IgA EMA is helpful but less sensitive
FBC, BLOOD SMEAR (iron def, vit b12/folate def, vit D def,)
107
What is seen on blood smear in coeliac?
target cells
| howell Jolly bodies
108
How is diagnosis of coeliac confirmed?
OGD + duodenal biopsy
| very young children: EMA and HLA DQ2/DQ8 testing
109
What is seen on duodenal biopsy in coeliac?
villous atrophy, crypt hyperplasia, increased IELs
110
What is the management of coeliac?
MDT
remove all wheat, rye and barley for life
dietician referral - annual 6-12m review
education
warn of non adherence: micronutrient deficiency, osteoporosis, EATL, hyposplenism.
111
what is the gold standard investigation for oesophageal cancer?
endoscopy + biopsy
112
What is the most common type of oesophageal cancer?
adenocarcinoma
113
what are the features of oesophageal cancer?
dysphagia: the most common presenting symptom
anorexia and weight loss
vomiting
other possible features include: odynophagia, hoarseness, melaena, cough
RF: Barrett's oesophagus, GORD, excessive smoking or alcohol use
114
how is oesophageal cancer diagnosed?
Upper GI endoscopy with biopsy is used for diagnosis
Endoscopic ultrasound is the preferred method for locoregional staging
CT scanning of the chest, abdomen and pelvis is used for initial staging
FDG-PET CT may be used for detecting occult metastases if metastases are not seen on the initial staging CT scans.
Laparoscopy is sometimes performed to detect occult peritoneal disease
115
what is the management of oesophageal cancer?
Operable disease is best managed by surgical resection - the most common procedure is an Ivor-Lewis type oesophagectomy
The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis resulting in mediastinitis
In addition to surgical resection many patients will be treated with adjuvant chemotherapy
116
what investigations can be used for appendicitis?
```
Mostly diagnosed clinically
CT abdo/USS
Urinalysis: mildly elevated leukocytes
DRE: right sided pain
bloods: increased inflammatory markers, increased WCC
```
117
what score can be used to grade appendicitis?
Alvarado score
118
What are the S/S of appendicitis?
Rovsings sign
Cope's sign
Psoas sign - retrocaecael appendix
Rebound tenderness
N&V
loose stools
anorexia
mild pyrexia
119
What is the management of acute appendicitis?
IV abx alone are successful in majority but expect recurrence within 12m
laparoscopic appendicectomy
perforation -> abdominal lavage
appendix mass -> broad spectrum abx and interval appendicectomy
120
What is Admirands triangle?
conditions for crystallised cholesterol and gallstones
- low lecithin
- low bile salts
- high cholesterol
121
What is acute cholecystitis?
inflammation of gallbladder often due to stone impaction in hartmann's pouch
122
What is the sequelae of acute cholecystitis?
1. resolution and recurrence
2. gangrene and rarely perforation
3. chronic cholecystitis
4. empyema
123
what is the presentation of acute cholecystitis?
RUQ pain - may radiate to scapula and epigastrium
fever
vomiting
124
what blood results are seen in acute cholecystitis?
ALT/AST normal
BR normal
amylase slightly high
ALP slightly high
125
what is seen on examination of acute cholecystitis?
```
local peritoneum in RUQ
tachycardia and shallow breathing
+/- jaundice
Murphy's sign +ve
Boas sign +ve
```
126
what investigations are done for acute cholecystitis?
Urine: bilirubin, urobilinogen
Bloods: FBC (raised WCC), U&E (dehydration), amylase, LFT, G&S, clotting CRP
Imaging: AXR, erect CXR, US, hIDA cholescintigraphy, MRCP if dilated ducts
127
what are the symptoms of chronic cholecystitis?
```
flatulent dyspepsia
vague upper abdominal discomfort
bloating, distension
nausea,
flatulence
```
128
Ix for chronic cholecystitis?
AXR: porcelain gallbladder (chronic calcification)
US: stones, fibrotic, shrunken gallbladder
MRCP
129
Management of chronic cholecystitis?
Medical: bile salts
Surgical: elective cholescystectomy
ERCP first if US shows dilated ducts and stones
130
Management of acute cholecystitis?
C: NBM, fluids resuscitation
analgesia
M: Abx: cefuroxime and metronidazole (80-90% settle over 24-48h)
S: elective Surgery at 6-12 weeks when inflammation settled
if <72h may perform lap whole in acute phase
131
What are the complications of chronic cholecystitis?
cholangiocarcinoma
132
What is the Mirizzi syndrome?
large stone in gall bladder obstructs common hepatic duct
| obstructive jaundice
133
complications of laparoscopic cholecystectomy?
diarrhoea - give cholestyramine
Vitamin malabsorption (A,D,E,K) - Can cause bleeding though reduced vit K
Jaundice - ligation fo CBD/CHD, sepsis, CBD stone
134
What are the risk factors for biliary colic?
female, fat, forties. fair
135
What symptoms are seen in ascending cholangitis?
Charcots triad
fever>RUQ pain > jaundice
Reynolds pentad
+ hypotension
+confusion
136
What % of gallstones are radio-opaque
10%
137
What is seen on ultrasound of gallstones?
acoustic shadow
dilated ducts >6mm
Inflamed GB wall
138
Management of ascending cholangitis?
```
C: fluids, antiemetics, analgesia
M:IV cef and met
S: Surgical referral
ERCP
open or lap stone removal +/- tube drain
```
139
What are the RFs for cholangiocarcinoma?
```
GB disease
polyps
infection
porcelain GB
PSC
obesity
smoking
```
140
What are the S/S of cholangiocarcinoma?
asymptomatic
RUQ, anorexia, n&v, malaise, WL, palpable GB
obstructive jaundice
141
What are the investigations for cholangiocarcinoma?
```
LFTs (abnormal
CA-19, CEA
USS
CT abdo
ERCP (gold standard for staging)
MR (staging)
```
142
Management for cholangiocarcinoma?
Resectable-> cholecystectomy (+/- debunking)
| Non resectable -> chemoradiotherapy +/-stenting
143
What is acute gallstone ileus?
large stone >2.5 cm erodes from GB -> duodenum
| may impact in distal ileum -> obstruction
144
What are the signs of gallstone ileus?
riglers triad:
pneumobilia
small bowel obstruction
gallstones RLQ
145
Mx of gallstone ileus?
stone removal via enterotomy
146
What is PSC?
a biliary disease characterised by inflammation and fibrosis of intra and extra hepatic bile ducts
147
What are the associations with PSC?
UC (80% with PSC have UC)
Crohn's
HIV
148
What are the S/S OF PSC?
```
pruritis
obstructive jaundice
splenomegaly
raised ALP
Steatorrhoea
```
p-ANCA, male, 40-60, iBD
149
what are the investigations for PSC?
Diagnostic: MRCP (preferred) > ERCP 'beaded appearance from biliary strictures
p-ANCA
anti-SMA
Biopsy of bile duct (fibrous, obliterative cholangitis often described as onion skin)
150
What is the management of PSC?
Observation (surveillance colonoscopy, DEXA) -> LIVER TRANSPLANT
151
What are the complications of psc?
cholangiocarcinoma (10%), colorectal cancer, hepatic osteoporosis/osteopenia
152
What are the associations with autoimmune hepatitis?
AI disorders, hypergammaglobulinaemia, HLAB8, HLA DR3
153
What are the 3 types of autoimmune hepatitis and their associations?
T1: ANA or Anti SMA - affects adults and children
T2: Anti-LKM 1,2,3 affects children only
T3: Anti-soluble liver antigen (anti-SLA and anti-LP), affects middle aged adults
154
What are the signs and symptoms of autoimmune hepatitis?
amenorrhoea (common)
| chronic liver disease OR acute hepatitis
155
What are the investigations for autoimmune hepatitis?
antibodies: ANA,SMA,LKM1
raised IgG
biopsy: inflammation extending beyond limiting plate - 'piecemeal necrosis', bridging necrosis
156
What is the mx for autoimmune hepatitis?
steroids +/- azathioprine
| liver transplantation
157
What are the features of Wernicke's ?
```
COAT
Confusion
ophthalmoplegia
ataxia
thiamine deficiency
```
158
What are the features of korsakoffs?
```
RACK
retrograde amnesia
anterograde amnesia
confabulation
korsakoff psychosis
```
159
What are the S/s of chronic stable liver disease?
palmar erythema
dupuytrens
clubbing
eyes: kayser Fleischer (wilsons), corneal arcus
gynaecomastia, axillary hair loss, spider naevi
160
what are some S/S of acute decompensation?
portal hypertension [SAVE]
- Splenomegaly
- Ascites
- Varices
- Encephalopathy
Failed synthetic function
Failed clotting factor and albumin
Failed clearance bilirubin
Failed clearance of ammonia -> encephalopathy -> asterixis
161
What are the investigations for suspected liver disease?
```
Bloods: FBC, U&E, CRP, clotting, AFP, iron studies, hepatitis serology, autoantibodies, caeruloplasmin
USS abdomen (+/ fibroscan +/-biopsy)
Endoscopy (OGD, colonoscopy)
```
162
what is the management of hepatic encephalopathy?
lactulose
| rifaximin
163
what is the management of weirnickes?
thiamine, Mg2+, folic acid
164
what's the management of decompensation liver disease?
lactulose, diuretic, TIPPS
165
What may cause liver decompensation?
```
CONSTIPATION
SBP
GI bleed
Renal failure
Hypokalaemia
```
166
What is the management of ascites?
Diet - restrict ETOH and fluids (if Na<125; <1.5L a day), low Na, daily weight
Diuretics - spironolactone + furosemide
SBP prophylaxis - ciprofloxacin + propanolol
if ascites and protein of <= 15g/L start prophylaxis immediately
167
what is the cause of SBP?
E.coli> Klebsiella >strep
168
Ix Sbp?
```
USS - confirm ascites
ascitic tap (PMN >250mm^3 +MC&S)
```
169
Mx SBP?
Piptazobactam or cefotaxime
170
What is the prophylaxis for SBP?
Ciprofloxacin + propanolol
171
What is haemochromatosis?
AR disorder of iron absorption and metabolism results in iron accumulation
172
What is the gene for haemochromatosis
AR HFE gene on both copies Chr 6
173
What are the investigations for haemochromatosis?
Iron studies - TF saturation >55% M, >50% F
- Ferritin raised
- Iron raised
- TIBC reduced
Liver biopsy - Perl stain
XR - chonedrocalcinosis (calcium inarticulate cartilage)
174
What is the management of haemochromatosis?
1. venesection (TF kept <50%)
| 2. Desferrioxamine
175
What is NAFLD?
Key hepatic manifestation of metabolic syndrome
| liver disease not caused by alcohol
176
steatosis vs steatohepatitis?
steatosis is fatty liver
| steatohepatitis is inflamed fatty liver
177
What are some associated factors wth NAFLD?
Obesity
T2DM
hyperlipidaemia
sudden weight loss or starvation
178
What are the investigation for NAFLD?
1. LFTs (ALT>AST), lipids, cholesterol
2. USS (increased echogenicity)
3. Enhanced liver fibrosis (ELF) panel OR a fibroscan
4. liver biopsy
179
What does an ELF panel consist of ?
hyaluronic acid
procollagen III
tissue inhibitor of metalloproteinase 1
180
What is a fibroscan?
liver stiffness measurement
181
who is fibroscan offered to?
HCV infection
ETOH related liver disease
Men >50 u/week ETOH
Women >35u/week ETOH
182
Mx NAFLD?
Lifestyle changes and WL
monitoring
ongoing research into gastric banding/insulin sensitising drugs
183
What are some causes of pancreatitis?
```
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia
ERCP
Drugs
```
184
what are some S/S pancreatitis?
severe epigastric pain radiates through to back
N&V
Cullens/Grey-Turner's sign
Rare: ischaemic retinopathy
185
What are some investigations for pancreatitis?
serum amylase (>3x ULN, raised in 75%)
serum lipase (more sensitive and specific than amylase)
USS - gallstones
Contrast enhanced CT
186
What is the prognostic score for pancreatitis?
```
Glasgow-Imrie
PaO2 <8kpa
Age >55yo
Neutrophils >15x10^9/L
Ca <2mmol/L
Renal urea >16 mmol/L
Enzymes (LDH>600, AST/ALT>200)
ALBUMIN <32g/L
Sugar >10 mmol/L
```
187
Management of acute pancreatitis?
fluids
analgesia (IV morphine, 1-2 mg STAT until comfortable)
key features:
- maintain enteral route of feeding
- no abx unless indicated
- aggressive fluid resuscitation (3-6L)
- correct cause - MRCP/ERCP
188
Management of necrotising pancreatitis?
fluids
analgesia
ABx
189
What are the complications of acute pancreatitis?
early:
- Haemorrhage
- SIRS, ARDS
- Hyperglycaemia, hypocalcaemia
Late:
peri-pancreatic fluid collection (admit + bowel rest)
pseudocysts (observe, cystogastrostomy/aspiration)
pancreatic abscess (infected pseudocyst -> trans-gastric drainage/endoscopic drainage)
pancreatic necrosis (conservative)
190
what are the S/S of chronic pancreatitis?
- pain is worse 15-30 mins following a meal
- steatorrhoea (5 and 25 years after the onset of pain)
- DM (>20 years after symptoms begin)
191
investigations of chronic pancreatitis?
USS (IE for gallstones)
Contrast enhanced CT
Faecal elastase (measures exocrine function)
Screening (DM and osteoporosis)
192
What is the most common type of pancreatic cancer?
80% adenocarcinoma
193
What are the types of diverticular disease?
Hinchey classificationL
- diverticular sieges (umbrella term)
- diverticulosis (asymptomatic outpouchings in the intestinal mucosa)
- diverticulitis (infected diverticulosis)
194
What is saints triad?
diverticular disease
diaphragmatic (hiatus) hernia
stones (cholelithiasis)
195
What are the investigations for diverticular disease?
acute (diverticulitis) - CT abdomen
| chronic (diverticular disease ) - barium enema
196
What is the management of acute diverticulitis?
mild - PO Abx
| Severe - IV Abx, drip and suck, hartmanns, primary anastomosis
197
What is the management of chronic diverticular disease?
soluble high fibre diet
| primary anastomosis
198
when should your refer for 2WW OGD?
```
dysphagia
upper abdominal mass (?stomach cancer)
age >=55yo AND weight loss AND any of
-dyspepsia
- reflux
- GORD
- upper abdominal pain
```
199
which drugs may exacerbate GORD?
alpha blockers,anticholinergics, benzodiazepines, beta blockers, bisphosphonates, CCB, corticosteroids and NSAIDs, nitrates, theophyllines
200
What is the management of GORD?
PPI 4-8w
| If no response then H2R antagonist
201
what is the management of dyspepsia?
antacids/ alginates for short term control
review meds
(test for H. pylori first)
PPI 4w
202
What is the criteria for non urgent OGD referral?
haematemesis
age >= 55yo AND
- treatment resistant dyspepsia
- upper abdominal pain with low Hb
- N&V + reflux, WL, dyspepsia or upper abdo pain
- Raised platelets + N&V, WL, reflux, dyspepsia or upper abdo pain
203
If OGD is negative what should be done next?
24 hour oesophageal pH monitoring
204
What is the management of dyspepsia?
1. review meds for possible causes + lifestyle advice
2. trial PPI for 4w or 'test and treat' H.pylori
3. the other one that has not been tried as above - wait 2w after trial PPI before H.pylori test
4. 'treatment resistant dyspepsia'-> Non urgent OGD
205
How do you test for H.pylori?
carbon-13 urea breath test OR stool antigen test OR lab based serology
- no abx in last 4 weeks
- no PPI in last 2 weeks
if repeat testing need use carbon-13 urea breath test
206
What is the management of H.pylori?
clarithromycin, amoxicillin, PPI
207
Is H.pylor gram +ve or -ve?
negative
208
What are some H.pylori associations?
PUD (95% duodenal ulcers, 75% gastric)
gastric cancer
MALToma
atrophic gastritis
209
what are the RF for gastric cancer?
smoking
diet
H.pylori
210
Ix gastric cancer?
staging CT
Virchows node
sister mary jospeh nodule
211
Mx gastric cancer?
endoscopic mucosal resection
partial gastrectomy
total gastrectomy
chemo
212
Complications of GORD/dyspepsia?
```
oesophagitis
ulcers
anaemia
benign strictures
Barrett's oesophagus
oesophageal carcinoma
```
213
What is the management of endoscopically proven oesophagitis?
if severe annual review and investigate GORD/barrett
1st: PPI for 4w then 4w then double dose for 4w
2nd: add H2 antagonist
214
What is the management of endoscopically negative reflux disease?
1. PPI (1 month)
| 2. H2RA (1 month)
215
Whats the surgical management of GORD?
```
Nissen fundoplication (gold standard)
for refractory GORD or hiatus hernia
```
216
What are the complications of Nissen fundoplication?
gas bloat syndrome (cant belch or vomit)
| dysphagia (wrap too tight)
217
Histology of barrett's oesophagus?
columnar
goblet cells
brush border
218
RF barrett's oesophagus?
GORD
male
smoking
obesity
219
Mx barrett's oesophagus?
metaplasia -> endoscopic surveillance and biopsy (every 3-5y)
high dose PPI
dysplasia -> endoscopic mucosal resection, radio frequency ablation
220
What is CA125 a marker for ?
ovarian ca
221
what is CA15-3 a marker for?
breast ca
222
What is Ca19-9 a marker for?
pancreatic cancer/ mutinous epithelial ovarian cancer
223
what is CEA a marker for ?
bowel cancer
224
what is inhibin a marker for ?
granulose cell tumours
225
what is AFP a marker for?
liver cancer
non-seminoma
teratoma
226
What is LDH a marker for?
seminoma (testicular)
227
What is B-hCG a marker fro?
choriocarcinoma
| non-seminoma (testicular)
228
what is MLH1/ML2 a marker for?
Lynch sundrome HNPCC
229
What is BRCA1/2 a marker for ?
M: breast (1,2), prostate (2)
W: breast (1,2), ovarian (1>2)
230
What are the S/S of anal fissure?
bright red rectal bleeding; 90% on posterior midline
231
what is the management of acute anal fissure?
<6 weeks
- dietary advice (high fluids)
- bulk firming laxatives
- optional: petroleum jelly, non opioid analgesia
232
what is the management of chronic anal fissure?
1st line: topical GTN or diltiazem or nifedipine
| 2nd: after 8w first line: sphincterotomy, botox toxin
233
What is the management of alcoholic hepatitis?
prednisolone (high DF)
| pentoxyphylline
234
Ix alcoholic hepatitis?
LFTs: GGT raised, AST:ALT >2
Maddrey score predicts who benefits from steroids
Child pugh score predicts prognosis of liver cirrhosis
235
How to work out maddrey score?
predicts prognosis and who benefits from steroids
DF = 4.6 x [PT-control time] +BR
DF>= 32 -> consider liver biopsy + corticosteroids
236
what is child pugh score based on?
```
Albumin
BR
Clotting (PT)
Distension (ascites)
Encephalopathy
```
```
A= 5-6 points
B= 7-9 points
C= 10-15 points
```
237
What causes Budd Chiari syndrome?
blockage of hepatic vein
polycythaemia rubra vera
thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies
pregnancy
combined oral contraceptive pill: accounts for around 20% of cases
238
What are the RFs for Budd Chiari syndrome?
OCP
PRV
thrombophilia
pregnancy
239
what are the types of Budd Chiari?
T1- thrombosis
| T2 -tumour occlusion
240
What are the S/S of budd chiari?
triad: abdominal pain, ascites, tender hepatomegaly
241
Ix budd chiari?
abdominal USS and doppler
| very sensitive
242
S/S of achalasia?
sudden onset solid and liquid dysphagia, halitosis, heartburn, regurgitation
Dysphagia of both liquids and solids from the start
Heartburn
Regurgitation of food - may lead to cough, aspiration pneumonia etc
243
Ix achalasia?
```
LOS manometry (excessive LOS tone)
barium swallow (birds beak)
CXR
```
244
Management achalasia?
heller cardiomyotomy >botulinum intra-sphincteric injection
| oesophageal balloon dilatation
245
What is seen in sigmoid volvulus?
coffee bean sign; not associated with malignancy
246
Mx of sigmoid volvulus?
sigmoidoscopy and air insufflation
247
what is seen in caecal volvulus?
embryo sign
| associated with malignancy
248
management of caecal volvulus?
surgery
right hemicolectomy
ileocolic anastomosis
caecostomy
249
what is carcinoid syndrome?
usually occurs with liver metastases that release serotonin into the systemic circulation
250
What are the S/S of carcinoid syndrome?
flushing (often earliest symptom)
diarrhoea
bronchospasm
hypotension
Cardiac - right sided valve stenosis/pulmonary stenosis (ESM)
Endocrine - acromegaly, cushings
Pellagra- dermatitis, diarrhoea, dementia (B3 deficiency)
251
What are the investigations of carcinoid syndrome?
urinary 5-hydroxyindolacetic acid
| plasma chromogranin A y
252
Management of carcinoid syndrome?
somatostatin analogues e.g. octreotide
| diarrhoea: cyproheptadinemay help
253
Malnutrition definition?
BMI <=18.5
Unintentioanl WL >10% within the last 3-6m
BMI <20 and unintentional WL>5% within last 3-6m
254
malnutrition Ix?
MUST screening tool
| low, med or high risk
255
Malnutrition mx?
dietician
food first approach (food ahead of supplements)
ONS (oral nutritional supplements
256
What are some causes of C.diff infection?
ampicillin, amoxicillin, co-amoxiclav
cephalosporin
clindamycin
quinolones
257
Ix c.diff
C.diff toxin
258
How is C.diff severity classified?
mild: normal WCC
moderate: raised WCC (<15), 3-5 loose stools/d
severe: raised WCC OR acutely raised creatinine (>50% above BL) OR temperature >38.5 or evidence of severe colitis
life-threatening: hypotension, partial or complete ileus, toxic megacolon or CT, evidence of severe disease
259
Management of C.diff?
mild/mod -> oral metronidazole (10-14days)
severe -> oral vancomycin (10-14days)
then try oral fidaxomicin
Life threatening/ileus -> oral vancomycin + IV metronidazole (10-14d)
260
what is small bowel overgrowth?
excess bacteria in small bowel -> GI symptoms
261
what are the RF for small bowel overgrowth?
neonates w congenital Gi anomalies, scleroderma, DM
262
What are the S/S for small bowel overgrowth?
chronic diarrhoea
bloating, flatulence
abdo pain
263
Ix for small bowel overgrowth?
hydrogen breath test
small bowel MC&S
diagnostic ABx course
folate HIGH as bacteria produce it
264
Management for small bowel overgrowth?
Rifamixin > co-amoxiclav, metronidazole
265
S/S perianal abscess?
pain worse on sitting, discharge, hardened perianal area
266
Mx perianal abscess?
1: I&D under LA (packed or left open)
| Abx rarely used unless systemic upset
267
What are the S/S of boerhaave's syndrome?
Mackler's triad
Chestpain
SC emphysema
vomiting
268
What is Zollinger Ellison syndrome?
Zollinger-Ellison syndrome is condition characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas
269
what are the associations with Zollinger ellison syndrome?
MEN1 (30%)
| duodenal/pancreatic tumour
270
Features of ZES?
multiple gastroduodenal ulcers
diarrhoea
malabsorption
271
Diagnosis of ZES?
fasting gastrin levels: the single best screen test
| secretin stimulation test
272
Which antiemetics should be avoided in bowel obstruction?
metoclopramide - pro kinetic
273
What is pseudomembranous coltitis and what is seen on imaging?
Pseudomembranous colitis refers to swelling or inflammation of the large intestine (colon) due to an overgrowth of Clostridioides difficile (C difficile) bacteria
plain film: loss of bowel wall architecture and thumb printing
CT: moderate free fluid in pelvis and peritoneum
274
What is the most accurate determinant of liver failure?
PT as it is a measurement of the liver's synthetic function and has a shorter half life than albumin
275
Iron deficiency anaemia vs anaemia of chronic disease?
Iron defiency anaemia vs. anaemia of chronic disease: TIBC is high in IDA, and low/normal in anaemia of chronic disease
both microcytic anaemia
276
How to treat recurrent C.diff?
recurrent infection occurs in around 20% of patients, increasing to 50% after their second episode
within 12 weeks of symptom resolution: oral fidaxomicin
after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin
277
What is globus pharyngis?
Globus pharyngis (also known as globus hystericus) is the persistent sensation of having a 'lump in the throat', when there is none. Symptoms are often intermittent and relieved by swallowing food or drink. Swallowing of saliva is often more difficult.
278
globus pharyngis associations ?
anxiety
279
Causes of dysphagia?
Extrinsic
intrinsic
oesophageal wall
neurological
280
Extrinsic causes of dysphagia?
Mediastinal masses
| Cervical spondylosis
281
intrinsic causes of dysphagia?
Tumours
Strictures
Oesophageal web
Schatzki rings
282
oesophageal wall causes of dysphagia?
Achalasia
Diffuse oesophageal spasm
Hypertensive lower oesophageal sphincter
283
neurological causes of dysphagia?
```
CVA
Parkinson's disease
Multiple Sclerosis
Brainstem pathology
Myasthenia Gravis
```
284
Features of oesopahgitis?
There may be a history of heartburn
| Odynophagia but no weight loss and systemically well
285
Features of oesophageal candidiasis?
history of HIV or other risk factors such as steroid inhaler use
286
what is a pharyngeal pouch?
posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
287
Symptoms of pharyngeal pouch?
dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen
288
what are the features of gallbladder abscess?
prodromal illness and right upper quadrant pain
Swinging pyrexia
Patient may be systemically unwell
Generalised peritonism not present
289
mx gallbladder abscess?
Imaging with USS +/- CT Scanning
Ideally, surgery although subtotal cholecystectomy may be needed if Calot's triangle is hostile
In unfit patients, percutaneous drainage may be considered
290
what is calots triangle?
Calot triangle or cystohepatic triangle is a small (potential) triangular space at the porta hepatis of surgical importance as it is dissected during cholecystectomy. Its contents, the cystic artery and cystic duct
291
What are the risks of ERCP
Bleeding 0.9% (rises to 1.5% if sphincterotomy performed)
Duodenal perforation 0.4%
Cholangitis 1.1%
Pancreatitis 1.5%
292
What is pernicious anaemia?
autoimmune atrophic gastritis caused by auto abs vs parietal cells or intrinsic factor
293
pernicious anaemia associations?
AI: Thyroid disease, vitiligo, addisons, HPT,T1DAM
3X RISK GASTRIC CA
more common blood group A
294
Features of pernicious anaemia?
anaemia
neurological (neuropathy, SCDC, neuropsychiatric)
jaundice
glossitis
295
Ix pernicious anaemia?
FBC -> normocytosis, hyperhsegmented neuts, low WCC/plts
Vit b12/folate
Antibodies
296
Mx pernicious anaemia?
Vit b12 replacement IM
| folic acid supplementation
297
Ix Pharyngeal pouch?
barium swallow combined with dynamic video fluoroscopy
298
where does a pharyngeal pouch occur?
also known as Zenker's diverticulum) is a posteromedial diverticulum through Killian's dehiscence. Killian's dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles.
299
RF pharyngeal pouch?
5x more common in men
| more common in older patients
300
What is commonest extra-colonic malignancy of HNPCC?
endometrial>ovarian ca
301
What is lynch syndrome?
an autosomal dominant condition, is the most common form of inherited colon cancer. Around 90% of patients develop cancers, often of the proximal colon, which are usually poorly differentiated and highly aggressive
302
what criteria is used to aid diagnosis of lynch syndrome?
The Amsterdam criteria are sometimes used to aid diagnosis:
at least 3 family members with colon cancer
the cases span at least two generations
at least one case diagnosed before the age of 50 years
303
What is Gardners syndrome?
A variant of FAP causing osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin
304
what causes FAP?
due to a mutation in a tumour suppressor gene called adenomatous polyposis coli gene (APC), located on chromosome 5 which causes hundreds of polyps
305
How is FAP inherited
autosomal dominant
306
What are the three types of colon cancer?
sporadic (95%)
hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
familial adenomatous polyposis (FAP, <1%)
307
What is wilsons disease?
Wilson's disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues.
308
What causes Wilson disease?
defect in the ATP7B gene located on chromosome 13
309
At what age does onset of symptoms typically happen in Wilsons disease?
10-25y
310
What are some S/S of wilsons?
liver: hepatitis, cirrhosis
neurological:
- basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus
- speech, behavioural and psychiatric problems are often the first manifestations
- also: asterixis, chorea, dementia, parkinsonism
Kayser-Fleischer rings
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails
311
Ix wilsons?
- slit lamp examination for Kayser-Fleischer rings
- reduced serum caeruloplasmin
- reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
- free (non-ceruloplasmin-bound) serum copper is increased
- increased 24hr urinary copper excretion
- the diagnosis is confirmed by genetic analysis of the ATP7B gene
312
mx wilsons?
- penicillamine (chelates copper) has been the traditional first-line treatment
- trientine hydrochloride is an alternative chelating agent
- tetrathiomolybdate is currently under investigation
