Gastro Flashcards
What investigation would you get for suspected appendicitis?
Normally a clinical dx
You may need to get a pelvic USS to exclude ovarian cyst accident
CT abdomen - if uncertain
What score can you use for appendicitis
Alvarado score
>4 is high likelyhood of it being appendicitis
What are the three signs you can get in appendicitis
Rosvig’s sign
Cope’s sign
Psoas sign
What is Rosvig sign
Pain worse in RIF when pressing down on LIF
What is Cope sign
Pain on passive flexion and internal rotation of hip
What is Psoas sign, and what does it indicate exactly
Pain on extending hip
Indicates RETROCAECAL APPENDIX
How would you manage appendicitis
start prophylactic antibiotics before surgery
THEN laparoscopic appendicectomy
what extra thing must you do if appendicitis is perforated
ABDOMINAL LAVAGE
What is ascending cholangitis
INFECTION of the biliary traact
What causes ascending cholangitis
Obstruction + infection
Obstruction can be caused by:
- gallstones
- ERCP
- cholaangiocarcinoma
- pancreatitis
- PSC
How will pt with ascending cholangitis present
ACUTELY UNWELL - MAY BE SEPTIC
Charcot’s triad: fever + RUQ pain + jaundice
Reynaud’s pentad: + hypotension + confusion
How do you investigate and manage suspected ascending cholangirtis
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
How do you manage acute cholangitis
IV Abx AND ERCP within 24-48h
What are the three types of gallbladder disease you can get?
BILIARY COLIC: stones causing pain in gallbladder neck
CHOLECYSTITIS: inflammation of gallbladder
ASCENDING CHOLANGITIS: inflammation of bile duct
Describe the three types of gall stones
cholesterol (if fat, poor diet)
pigment (if haemolytiic anaemia)
mixed
What are RF for gallstones
Fat
Fair
Fourty
Female
FH
+ OCP, pregnancy, haemolytic anaemia
What is a biliary colicj
stones in the neck of gallbladder causing pain on contraction
Describe the pain in a biliary colic
Colicky (intermittent)
Triggered by eatiing fatty foods
Sudden, dull
In RUQ
How do you investigate for gallbladder pathology
Abdo USS of gallbladder and bile ducts
MRCP if nothing visible (and suspected cholecystitis / biliary colic)
what do you see on USS of gallbladder in pathology
thickened wall
Bile duct dilatation
Gallstones
How do you manage biliary colic
IV analgesia
elective cholecystectomy within 6 weeks
What are symptoms of cholecystitis
Pain (constant, RUQ) + fever
How do you manage acute cholecystitis
IV Abx
IV analgesia, antiemetics
Laparoscopic cholecystectomy (<72h)
What are symptoms and signs of pancreatitis
severe epigastric pain radiating to back, N&V
Cullen’s (periumbilical), grey turner sign (retroperitoneal=
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)
What scoring systems can you use for acute pancreatitis
Ranson
Apache II
Modified Glasgow
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
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
Pancreatits complications
EARLY: DIC, ARDS, hypocalcaemia, hyperglycaemia
LATE: pseudocyst, pancreatic abscess, pancreatic necrosis
What classification can you use for diverticulitis
Hinchley classification 1-4
What investigation do you go for acute diverticulitis
CT abdomen (never colonoscopy acutely, as perforation risk)
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)
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)
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)
What is the inflammation like pathologically for UC (so on biopsy?
continuous (leadpipe)
pseudo-polyps
thumbprinting
what condition is rellated to UC
PSC
What are typical symptoms of UC
BLOODY diarrhoea
MUCOUS
LIF pain
tenesmus
what is the layer affected by CD
Transmural, with NON CASEATING GRANULOMAs
what is the region of gut affected by CD
ALL OF IT
Mouth to anus
what is the most common region affected by CD D
Terminal ileum
what are signs on biospy of histology for CD
skip lesions
rose thorn ulcers
cobblestoning
string of kantor (narrow ileum stricture)
what IBD condition are abscesses / fissures common in
in CHRON’s
What are chron’s sx
non bloody diarrhoea
RIF mass and pain
mouth ulcers, fissures in ano, perianal skin tags
FAILURE TO THRVE
How unwell are patients during flares between CD and UC
CD: systemically unwerll
UC: well
what personal factor can precipitate a UC flare?
stopping smoking
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
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
what is the two key steps in mx of chron’’s
Induce remission»_space; maintain remission
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)
How do you maintain remission in chron’s
(beware that continuing steroids can have long term consequences)
- stop smoking
- DMARD (e.g. azatioprine, mercaptopurine, methotrexate)
Alternatives to DMARD: aminosalicylate, biological thherapoy
also remember to vaccinate (not with live vaccines though)
How do you manage UC
Mesalazine FIRST
Then steroids and biologics ( Aminosallycates, azathioprine, mercaptopurine)
What must you always measure before starting someone on azathioprine
TPMT (enzyme required for its breakdown)
if TPMT is low, give methotrex instead
Which IBD type is surgery curative for?
UC
What type of surgery is typically done for UC
Hartmann’s proctosigmoidoscopy + end ileostomy > later IPAA
what is classic presentation of IBS
young
femaille
anxious, stressed, depressed
pain
bloating and diarrhoea / constipation
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
What are haemorrhoids
vascular cushions that protrude through the rectum via straining on defecation
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)
where are haemorrhoids usualy found
3, 7, 11 oclock
what type of procedure may need to be done if suspecting internal haemorrhoids
proctoscopy / sigmoidoscopy
how do you manage haemorrhoids
Conservative: increase fluid/fibre,
Medical: stool softener, topical analgesia, steroids
Non-operative: rubber band ligation, sclerotherapy
Operative: haemorrhoidectomy
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
What is coeliac diisease incidence
bimodal (infants or middle aged)
What are the AI HLA associations of coeliac
HLA DQ2, HLA DQ8
What are symoptoms of coeliac
watery frothy stooll (staethorroea)
Failure to thrive
Insufficient growth in chikldren
what skin condition is pathomnemonic for coeliac
derrmatitis herpetiformis
What substances can someone with coeliac be deficient to
iron
B12
folate
what else must you screen for if suspecting coelilac disease
T1DM, Ai thyroid disease, IBS, coeliac
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)
how do you confirm coeliac + findings
OGD + duodenal / jejunal biopsy (villous atrophy, crypt hyperplasia, intra epithelial lymphocytes)
How do you manage coeliac
GLUTEN FREE DIET LIFELONG
dietician referral if problems adhering to diet
annual 6-12 month review
what is the difference in terms of location between PBC and PSC
PBC = intrahepatic bile ducts only
PSC = intra and extrahepatic bile ducts
Define PBC
chronic inflammation to INTRAHEPATIC bile duct, causing progressive cholestasis > CIRRHOSIS
presumed AI ORIGIN
What are other conditions associated with PBC
Sjogren
RhA
thyroid disease
systemic sclerosis
what are classical sx of PBC
itching in a middle aged woman
- pruritus
- obstructive jaundice
RUQ pain
What investigations should you get for PBC
Liver panel: raised GGT/ALP, normal transaminase
Autoantibodies: AMA, high IgM serum
Biopsy (only if in doubt)
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
What rule can you use to remember PBC
Rule of Ms
Middle aged women
AMA
raised IgM
What is PSC
biliary disease caused by INFLAMM and FIBROSIS in INTRA and EXTRAhepatic bile ducts
What condition is PSC associated with
UC
Sx of PSC
pruritus
obstructive jaundice
RUQ pain
staethorroea
Ix PSC
positive pANCA
MRCP > ERCP (beaded appearance)
Biopsy of duct (fibrous, obliterative cholangitis - onion skinn)
mx of PSC
supportive > liver transplant
how does gender change in PBC vs PSC
PBC mostly women,
PSC mostly men
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
What number of spider naevi is abnormal
anywhere > 5
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
How do you manage ascites
- Restrict alcohol and fluids, low sodium diet, daily weights)
- Diuretics (spironolactone +- furosemide)
- Therapeutic paracentesis (if not responding to meds)
- Prophylaxis for SBP (ciproflox + propanolol)
abdominal paracentesis (for tense ascites)
What is SBP
Spontaneous bacterial peritonitis (infection of ascitic fluid with no obvious cause)
How do you investigate SBP
USS (confirm ascites)
Ascitic tap (check neutrophils and SAAG)
How do you manage SBP
tazocin / cefotaxime
What is chromosomal inheritance pattern of haemochromatosis
Autosomal recessive - HFE gene mutation
What does haemochromatosis cause
Dirsorder of iron absorption and metabolism> excess iron accumulation > organ damage
How do you investigate haemochromatosis
Iron studies (transferrin saturation >50%, ferritin raised, iron raised, TIBC low)
Liver biopsy
How do you manage haemochromatosis
venesectiion (TF under 50% is aim)=
What is the progression of NAFLD
steatosis > staetohepatitis > cirrhosis
investigations ofr NAFLD
LFTpanel, lipds, cholesterol
USS
Enhalced liver fibrosis panel OR fibroscan
liver bioosy
How do you manage NAFLD
lifestly change, weight loss
Chronic paancreatitis symptoms
paain worse 15-30 mins after meal
staetoorrhoea
DM
What is the commonest cause of chronic pancreatitisa
ALCOHOL in 80% of cases
how to investigate chronic pancreatitis
Blood: faecal elastase (marker of pancreatic insufficiency)
USS (exclude gallstones)
contrast-enhanced CT
what is the most common type of pancreatic xcancer (location + histology)
head of pancreas, adenocarcinoma
what are classic sx of pancreatic cancer
painless jaundice
loss of exocrine function > staethorroea
loss of endocrine function > DM
thrombophlebitis
what ix need to be carried out for pancreatic cancer
HR-CT (double duct sign, simultaneous dilatation of CBD and pancrsatic duct)
USS
how do you manage pancreatic cancer
Whipple resection (pancreaticoduodonectomy) - although less than 20% are suitable
with adjuvant chemo
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
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
what do you do if GORD symptoms and OGD negative
24 h oesophageal pH monitoring
How do you manage GORD if no need to refer for OGD
- review meds for possible dyspepsia causes and give lifestyle afdbvice
- trial PPI (4 weeks= or test and treat for H pylori
How do you test for H pylori
C13 Urea breath test
OR stool antigen test
Or Lab based serology
How do you manage H pylori
CAP: clarythomycin, amoxicillin/metronidazolel, PPO
How do you treat GORD
trial PPI for 1 month then review
If refractory: nissen fundoplication
what score assesses prognosis of cirrhosis
Child’s Pugh ABCDE
Albumin
Bilirubin
Clotting (PT)
Disension (ascites)
Encepalopathy
How do you manage alcoholic hepatitis
consider pred
what abx can you give for C diff
oral metronidazole (mild)
oral vanc (severe)
oral vanc + IV met (life threatening9
what serology can you do for coeliacs disease
anti-TTg + total IgA
anti- EMA (less sensitive)
how does cholangiocarcinoma present
usually asumptomatic
RUQ, nausea, anorexia, vomiting, malaise, WL, palpable GB
Obstructive jaundice: pale stool, dark urine
how do you stage cholangiocarcinoma
CT abdo
ERCP fgold standard stating
how do you manage cholangiocarcinoma
cholecystectomy if resectable
chemotherapy + stenting if not resectable
is PSC or PBC more likelly to cause cholangocarcinoma
PSC – in 10% of patients
which IBD is most likeluy to cause fissures and fistulas
CHRONS
which IBD is smoking PROTECTIVE for
UC
what is the severity index for IBD
True Love and Witts criteria
causes of granuloma
TB (caseating)
Chron’s, sarcoid (non-caseating)
causes of subtotal villous atrophy (other than coeliac)
Giarda
Tropical sprie
infectious enteritis
lymphoma
Whipples infection
Lactose intolerance
Wernicke’s triad
Opthalmoplegia
Ataxia
Confusion
Korrsakoff’s
Wernicke’s PLUS confabulation and amnesia
How do you test for Wilson’s disease on blood test
serum caeruloplasmin
How do you test for Haemochromatosis on blood test
Iron panel (raised iron , raised ferritin, low TIBC)
when do you refer for an URGENT 2 week OGD
Dysphagia
Upper abdominal mass (? stomach cancer)
55yo + WL + dyspepsia / reflux / upper abdo pain
How do you manage dyspepsia
- review meds for possble causes, give lifestyle adice
- Test for H Pylori (stool antigen test) OR trial full dose PPI
How long myst you wait after PPI to test for H pylori
2 weeks
What is management if H pylori +ve
amoxicilli + clarythromycin + PPI for ONE WEEK
what are dangerous associations/ complications of H pylori
PUD
Gastric cancer
MALToma
Altriphic gastritis
How can you manage anal fissue
<6 weeks: dietary advice (more fluids), bulk forming laxatives, OTC analgesia
>6 weeks: topical GTN / diltaziem > sphincterotomy
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
how do you treat C diff (mild-moderate)
oral metronidazole
how do you treat C diff (severe, 2nd episode=
oral vanc
how do you treat LIFE THREATENING c diff
oral vanc + IV metronidazole
what ix confirms C diff dx
C diff TOXIN
which antibodies are elevated in AI hepatitis
ANA, ASMA
Anti-LMK
Anti-SLA
Raised IgG
S/S AI hepatitis
Jaundice, RUQ pain, fever
AMENORRHOEA
MX AI hep
steroids
liver transplant
what iss plummer vinson syndrome + triad
due to post cricoid webs, presents as:
- dysphagia
- glossitis
- IDA
triad of boerhaves oesophagus
Chest pain
SC emphysema
Vomiting
