Gastro Flashcards
Ulcerative colitis is associated with which biliary disease
Primary sclerosing cholangitis
Crohn’s disease usually has non-bloody diarrhoea vs bloody (in Ulcerative colitis).
Ulcerative colitis tends to have abdo pain in the LLQ, what does Crohn’s disease have in the RIF?
Abdominal mass palpable in the right iliac fossa - Crohn’s disease
Which type of inflammatory bowel disease has:
Lesions may be seen anywhere from the mouth to anus
Skip lesions may be present
Crohn’s disease
Endoscopy = deep ulcers, skip lesions with cobblestone appearance
Where is inflammation in Crohn’s disease versus Ulcerative colitis
Crohn’s disease - there is inflammation in all layers from mucosa to serosa - increased goblet cells, granulomas
Ulcerative colitis - no inflammation beyond submucosa (unless fulminant disease) - inflammatory cell infiltrate in lamina propria
Kantor’s string sign shows?
Strictures on small bowel enema
Crohn’s disease
Rose thorn ulcers indicates…
Crohn disease - on small bowel enema imaging
Also may see fistulae + strictures (Kantor’s string sign)
Loss of haustrations, psueodpolyps and narrowed/short colon (drainpipe colon) is seen in…
ulcerative colitis
Smoking worsens which inflammatory bowel disease
Crohn’s disease
Severity of ulcerative colitis flares
Mild, Moderate, Severe
Mild - <4 stools daily, no blood
Moderate - 4-6 stools daily
Severe - >6 stools daily, blood, systemic disturbance i.e. fever, tachycardia, anaemia, raised CRP/ESR
Peutz-Jeghers syndrome mode of inheritance
autosomal dominant
- hamartomatous polyps in the gastrointestinal tract, pigmented lesions on lips, oral mucosa, face, palms and soles.
- GI bleeds, small bowel obstruction
Hereditary non-polyposis colorectal carcinoma (HNPCC i.e. Lynch syndrome) is the most common form of genetic colon cancer. what is the mode of inheritance and common genes involved
automsal dominant
MSH2 (60% of cases)
MLH1 (30%)
familial adenomatous polyposis (FAP) has what mode of inheritance and what gene is mutated
Autosomal dominant
Adenomatous polyposis coli gene (APC) located on chromosome 5 is mutated. This is a tumour suppressor gene
The Amsterdam criteria are sometimes used to aid diagnosis of hereditary non-polyposis colorectal carcinoma (HNPCC) i.e. Lynch syndrome.
What are the 3 criteria
- at least 3 family members with colon cancer
- cases span at least two generations
- at least one case diagnosed before the age of 50 years
A variant of familial adenomatous polyposis (FAP) called Gardner’s syndrome can also feature…
- Osteomas of skull and mandible
- Retinal pigmentation
- Thyroid carcinoma
- Epidermoid cysts on the skin
Urgent 2ww criteria for upper GI referrals
- Dysphagia
- Upper abdominal mass
- Over 55 years, weight loss and one of the following: dyspepsia, reflux, upper abdominal pain
Patients who have reflux/dyspepsia who do not meet criteria for referral, what is the management
- Lifestyle
- PPI for 1 month
- or test and treat for H.pylori
What is the test for H.pylori
Carbon-13 urea breath test
Or stool Ag test
Or lab based serology
There is no need to check for H.pylori eradication if symptoms have resolved. However, if repeat testing is required, what test is used
Carbon-13 urea breath test
What is the treatment for H.pylori eradication
PPI + amoxicillin (or metronidazole) + clarithromycin
Which peptic ulcer is more common
DUODENAL ulcers
Child Pugh score for liver cirrhosis uses which 5 elements
- Bilirubin
- Albumin
- PT time
- Encephalopathy
- Ascites
The model for end stage liver disease (MELD) scoring system is used with Child Pugh score for liver disease now. What are the 3 elements of MELD
- Bilirubin
- Creatinine
- INR
What is management for C.diff
- Oral vancomycin for 10 days
- Oral fidaxomicin
- Oral vancomycin +/- IV metronidazole (for life-threatening)
What is the treatment of recurrent C.diff
(a) within 12 weeks
(b) after 12 weeks
(a) within 12 weeks - oral fidaxomicin
(b) after 12 weeks - oral vancomycin OR fidaxomicin
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
what condition
Primary biliary cholangitis
What is the treatment for primary biliary cholangitis
- ursodeoxycholic acid - slows progression and improves symptoms
- pruritus: cholestyramine
- fat-soluble vitamin supplementation
- liver transplantation
- if BR > 100
what antibody is seen in primary biliary cholangitis (cirrhosis)
anti-mitochondrial antibodies (AMA) M2 subtype
what scoring system is used for malnutrition
MUST score
giving a score out of 5:
BMI, unintentional weight loss, acute disease
What is the effect of insoluble fibre on people with IBS
Insoluble fibre (e.g. cereals, grains, brown rice) is bad and can cause diarrhoea and bloating
REDUCE it in IBS patients
IBS treatment for:
(a) pain
(b) constipation
(c) diarrhoea
(a) pain - antispasmodics
(b) constipation - laxatives, or if not working linaclotide
(c) diarrhoea - loperamide
Also consider TCAs (amitriptyline), CBT
Triad of cholangitis
Jaundice
Right upper quadrant pain
Fever, unwell
(n.b. there is no jaundice in acute cholecystitis)
Murphys sign (inspiration stops on palpation of the RUQ) on examination indicates which illness
Acute cholecystitis
(RUQ pain, fever)
4 risks of ERCP
Bleeding
Duodenal perforation
Cholangitis
Pancreatitis
What diabetic medication can cause cholestasis
Sulphonylureas
e.g. gliclazide
Non-urgent (not 2ww) referral for upper GI endoscopy criteria
- Haematemesis
- Patients over 55yo with any of:
- treatment-resistant dypsepsia
- upper abdo pain with low Hb
- high plts with: N+V, weight loss, reflux, dyspepsia, or upper abdo pain
- N+V with: weight loss, reflux, dyspepsia, or upper abdo pain
A palpable mass in the right upper quadrant (in cholangiocarcinoma) is called what sign
Courvoisier sign
seen in Cholangiocarcinoma
periumbilical lymphadenopathy - is called what sign
Sister Mary Joseph nodes
seen in Cholangiocarcinoma
Periumbilical bruising - is what sign
Cullen’s sign
seen in acute pancreatitis
flank bruising - is what sign
Grey-Turner’s sign
seen in acute pancreatitis
Painless jaundice is the classical presentation of…
pancreatic cancer
how to calculate units of alcohol
Volume (mls) x Alcohol by Volume ABV (%)] / 1000
Patients who have incidental finding of NAFLD on liver USS, in these patients, NICE recommends the use of the enhanced liver fibrosis (ELF) blood test to check for advanced fibrosis
What is the ELF blood test
Hyaluronic acid
Procollagen III
Tissue inhibitor of metalloproteinase 1
If ELF blood test is unavailable to assess for advanced fibrosis in NAFLD after liver USS, what should be done
- FIB4 score
- NALFD fibrosis score
- Fibroscan of liver
- Liver specialist referral if advanced fibrosis
What is an important blood test for somebody with inflammatory bowel disease on aminosalicylate (e.g. mesalazine) feeling unwell
Full blood count - check for agranulocytosis
Type I Autoimmune hepatitis antibodies
Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)
Type II Autoimmune hepatitis antibodies
Anti-liver/kidney microsomal type 1 antibodies (LKM1)
Affects children only
Type III Autoimmune hepatitis antibodies
Soluble liver-kidney antigen
3 investigations for achalsia
- Oesophageal manometry - excessive LOS tone which doesn’t relax on swallowing
- Barium swallow
- expanded oesophagus, fluid level
‘bird’s beak’ - CXR - wide mediastinum, fluid level
Treatment of achalsia
- Pneumatic balloon dilation
- Heller cardiomyotomy if recurrent/persistent
- Intra-sphincter botox injection if high surgical risk
- Meds e.g. nitrates, CCBs
Screening for haemochromatosis:
(a) general population
(b) family members
(a) transferrin sats > ferritin
(b) HFE genetic testing
what mode of inheritance is haemochromatosis
autosomal recessive
HFE gene on Chr 6 mutations
treatment of haemochromatosis
- venesection
- aim for transferrin sats <50%, and serum ferritin <50 - desferrioxamine
The risk of Crohn’s disease increases early after what operation
an appendicectomy
What is the strongest risk factor for the development of Barrett’s oesophagus
GORD
Barrett’s oesophagus refers to the metaplasia of the lower oesophageal mucosa. What cells are replaced here in the metaplasia?
Squamous epithelium is replaced by columnar epithelium
4 risk factors for Barrett’s oesophagus
- GORD - strongest risk factor
- Male gender (7:1)
- Smoking
- Obesity
Treatment of Barrett’s oesophagus
- High dose PPI
- Endoscopy surveillance with biopsies - metaplasia but not dysplasia has endoscopy every 3-5 years
- Dysplasia of any grade - endoscopic intervention e.g. radiofrequency ablation, or mucosal resection is offered
Haemochromatosis can lead to cirrhosis and pituitary dysfunction. What condition can this lead to
hypogonadotrophic hypogonadism
What are 2 reversible complications of haemachromatosis
- Cardiomyopathy
- Skin pigmentation
Other issues e.g. cirrhosis, T2DM, hypogonadotrophic hypogonadism, arthritis, are irreversible.
Systemic sclerosis CREST - what does this stand for
Calcinosis
Raynaud’s phenomenon
oEsophageal dysmotility
Sclerodactyly
Telangiectasia
Oesophagitis may also have a history of what symptom …
Heartburn
Alcohol can cause what type of anaemia
Macrocytic
Achalsia has dysphagia of which substances and at what onset
Dysphagia of both liquids and solids from the start
Dysphagia
History of anxiety
Symptoms are often intermittent and relieved by swallowing
Usually painless
What is the likely diagnosis
Globus hystericus
If laxatives don’t work in IBS, you can use Linaclotide. What is its mechanism of action
It is a GCC receptor agonist
Increases fluid in the intestinal lumen
Positive anti-HBc IgG
Positive HBsAg
Negative anti-HBc IgM Negative anti-HBc
What does this imply
Chronic HBV infection
Pernicious anaemia antibodies
antibodies to intrinsic factor +/- gastric parietal cells
Management of pernicious anaemia
Vit B12 replacement
IM hydroxycobalamin
3 injections per week for 2 weeks
Then 3 monthly
+/- folic acid
What is the most common cause of hepatocellular carcinoma
(a) worldwide
(b) Europe
(a) worldwide - Hep B
(b) Europe - Hep C
Four management options for hepatocellular carcinoma
- Surgical resection/liver transplant
- Radiofrequency ablation
- Transarterial chemoembolisation
- Sorafenib - multikinase inhibitor
What is the most common type of oesophageal cancer in:
(a) UK/US
(b) developing world
(a) UK/US - adenocarcinoma
(b) developing world - squamous cell carcinoma
What area of the oesophagus does adenocarcinoma affect (most common type in UK/US)
RFs: GORD, Barrett’s, smoking, obesity
Lower third
Near gastroesphageal junction
What area of the oesophagus does squamous cell carcinoma affect (most common type in developing world)
RFs: smoking, alcohol, achalasia, Pulmmer-Vinson syndrome, diets rich in nitrosamines
Upper two-thirds of oesophagus
Treatment of oesophageal cancers
Surgical resection (Ivor-Lewis)
+ chemotherapy
Big risk of anastomotic leak with mediastinitis
NICE recommend avoiding which laxative in the management of IBS
Lactulose
Colonoscopy biopsy:
Pigment laden macrophages suggestive of melanosis coli
What does this suggest
Laxative abuse
What daily supplement does the NHS advise may be beneficial for women who eat a vegan diet whilst breastfeeding?
Vitamin B12
also daily supplement of vit D 10mcg
Which five extra-intestinal manifestations of IBD are related to disease activity?
- Arthritis
- Erythema nodosum
- Episcleritis
- Osteoporosis
- apthous ulcers
Prophylaxis of variceal haemorrhage
- Propranlol
- Endoscopic variceal band ligation (EVL) with PPI cover
- TIPPSS
Acute treatment of variceal haemorrhage
ABC approach
1. Blood transfusion
2. Correct the clotting - FFP, vitamin K, platelet transfusions as required
3. Terlipressin - vasoactive agent
4. Or octreotide
5. IV antibiotics
6. Then to endoscopy for endoscopic variceal band ligation > endoscopic sclerotherapy
7. If uncontrolled bleed, for Sengstaken-Blakemore tube
8. TIPPS if above fails
A period of how long is typically used to assess response to treatment in patients with mild-moderate flares of ulcerative colitis
4 weeks
(if no remission after 4 weeks of topical ASA, add in oral or steroids!)
iron study profile in haemochromatosis for:
ferritin
transferrin saturation
transferrin levels/TIBC
high ferritin
high transferrin sats
low TIBC
For a patient with jaundice and a bilirubin greater than 100, when should they be seen by a specialist
SAME DAY admission
Urea breath test requires what prep beforehand
No antibiotics in past 4 weeks
No PPIs in past 2 weeks
what is the most common extra-intestinal feature in both Crohn’s and UC
arthritis
All male patients drinking more than 50 units per week, and female patients > 35 units, should be referred for what liver investigations (even if LFTs are normal)…
ELF test or fibroscan
Ratio of AST:ALT >3 suggests…
alcoholic hepatitis
2 medications that can be used for alcoholic hepatitis
Glucocorticoids e.g. prednisolone
Pentoxyphylline
What age does ulcerative colitis usually present?
BIMODAL
15-25
55-65
what two factors are used to monitor effectiveness of treatment in haemochromatosis
ferritin
transferrin sats
If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year, what should they be given to MAINTAIN remission?
Oral azathioprine or mercaptopurine
treating ulcerative colitis can be separated into which two categories
- inducing remission
- maintaining remission
What is the treatment for ulcerative colitis
- Inducing remission
- Topical rectal ASA
- If remission not achieved within 4 weeks, add high-dose oral ASA
- OR add topical/oral corticosteroid
Severe colitis will need hospitalisation and IV steroids (or cyclosporin after 72hrs or cannot take steroids, or consider surgery)
What is the treatment for ulcerative colitis
- Maintaining remission
- Topical (rectal) ASA
- Or topical ASA + oral ASA
- Or oral ASA alone (usually in L-sided and extensive UC)
- Following severe relapse or more than 2 exacerbations in 1 year, give oral azathioprine or oral mercaptopurine
what is the mode of inheritance of gilberts syndrome
autosomal recessive
gilberts syndrome has an increase in what type of bilirubin
unconjugated bilirubin
increases in response to stress, fasting, exercise. no treatment needed.
secondary amenorrhoea is common in which liver disorder
autoimmune hepatitis
patients with ulcerative colitis taking mesalazine are at risk of gastric side effect
PANCREATITIS
What medication prevents variceal bleeding
PROPRANOLOL
What medication TREATS variceal bleeding
Terlipressin
What drugs can increase the risk of Crohn’s disease relapse
NSAIDs
Treatment for Crohn’s disease
- inducing remission
- Steroids -budeonside is an alternative
- 2nd line = 5-ASA
- Azathioprine, methotrexate or mercaptopurine can be used as add-on but not as monotherapy
- Consider infliximab for fistulating + refractory
- Metronidazole for peri-anal
Enteral feeding with an elemental diet can be used
Treatment for Crohn’s disease
- maintaining remission
Azathioprine or mercaptopurine
Second line - methotrexate
What needs to be assessed before starting methotrexate
TPMT activity
For patients with Crohn’s disease who have symptomatic perianal fistulae, what medication are they usually given
Oral metronidazole
Suspected perianal fistulae in crohn’s disease, what is the investigation of choice
MRI
what is the BMI cut off score for diagnosing malnutrition
<18.5kg/m2
HBsAg usually implies what
Acute Hep B infection
If HBsAg is present for >6 months then what does this imply
Chronic disease i.e. infection Hep B infection
What does anti-HBs imply?
Immunity
either exposure or immunisation
- this is negative in chronic disease
What does anti-HBc imply
Previous or current Hep B infection
(IgM is acute/recent, IgG persists)
HbeAg is from the breakdown of core antigen from infected liver cells so what does it indicated
Infectivity and Hep B replication
What virus serology would previous Hep B immunisation show
Anti-HBs positive
All others negative
Anti-HBc positive
HBsAg negative
Previous Hep B (>6 months ago) infection
Not a carrier
Anti-HBc positive
HBsAg positive
Previous Hep B
Now a carrier (i.e. chronic infection)
what is prescribed to patients who drink alcohol excessively
oral thiamine
vitamin B co-strong is no longer recommended
how long do coeliac disease patients have to eat gluten for before they are tested (blood test for anti-TTG)
at least 6 weeks
what is a common cause of vitamin deficiencies in scleroderma
malabsorption syndrome
laxatives recommended for IBS
bulk-forming laxative
e.g. isphagula husk
what is tested for in blood to see appropriate response to Hep B vaccination
anti-HbS
what antibiotic is a cause of cholestasis/jaundice
flucloxacillin
patients with perianal disease in Crohn’s disease tend to have better or worse prognosis
worse
