Gastro Flashcards
What is achalasia
Impaired oesophageal peristalsis due to degen of myenteric neurones (Auerbach’s plexus)
Symptoms of achalasia
gradual dysphasia
weight loss
heart burn
chest pain
regurgitation (cough, aspiration)
Gold standard diagnosis of achalasia
oesophageal manometry
high tone of LOS when swallowing, no peristalsis lower oesophagus
Management achalasia
1) pneumatic dilation
2) Hellers cardiomyotomy
Botox injections, meds (CCB, nitrates)
Appendicitis common ages
10-20
Appendicitis symptoms
pain central -> RIF (24h)
N&V
anorexia
low grade fever
appendicitis signs
Tender over McBurneys Point
Rovsings sign (RIF tenderness when palpating LIF)
Guarding and rebound tenderness (suggests rupture and perionitis)
Appendicitis Diagnosis
Clinical + high inflam markers
US pelvis in women/kids
CT if unsure
serum/blood HCG to rule out ectopic
diagnostic laparoscopy if sypmtomatic but investigations normal
Causes of acute pancreatitis
Gallstones, Alcohol, post ERCP
How do gallstones cause acute pancreatitis?
Block ampulla of Vater causing build up of bile/pancreatic juice causing inflamation
How does alcohol cause pancreatitis?
acute - directly toxic to pancreatic cells
chronic- causes fibrosis which leads to loss of function of pancreatic cells
How does acute pancreatitis present?
epigastric pain
N&V
Systemically unwell
Acute pancreatitis signs
abdo pain
Cullens
Grey Turners
How do you diagnose acute pancreatitis?
Clinically + amylase 3x normal upper limit
US to show cause - gallstones
CT abdo - look for complications
How do you assess severity of acute pancreatits?
Glasgow Score
How do you manage acute pancreatitis?
Supportive
Fluid resus, analgesia, treat gallstones
?IV Abx if complications
Complications of pancreatitis
Peripancreatic fluid collections
pseudocysts
pancreatic necrosis
abscess
haemorrhage
Causes of chronic pancreatitis
80% alcohol
cystic fibrosis, ductal obstruction
Sypmtoms of chronic pancreatitis
pain (15-20mins after eating)
steatorrhoea
diabetes (loss of endocrine function)
Investigations in chronic pancreatitis
Abdo XR, abdo CT show pancreatic calcification
faecal elastase to assess exocrine function
Management of chronic pancreatitis
lifestyle
analgesia
pancreatic enzyme replacement
What is alcoholic ketoacidosis
large alcohol intake, small food intake (or vomit foot which has been consumed) become malnourished. Following alcohol binge body breaks down fat producing ketones -> ketoacidosis
How do you treat alcoholic ketoacidosis
IV saline and thiamine
Acute and chronic management of anal fissure
Acute <6/52: stool softener, lubricant, topical analgesia
Chronic >6/52: topical GTN, refer for surgery (sphincterotomy) or botulinum toxin
What is angiodysplasia
vascular deformity of the gastrointestinal tract which predisposes to bleeding and iron deficiency anaemia
How do you diagnose and manage angiodysplasia?
Diagnosis
colonoscopy
mesenteric angiography if acutely bleeding
Management
endoscopic cautery or argon plasma coagulation
antifibrinolytics e.g. Tranexamic acid
oestrogens may also be used
what is liver cirrhosis and what are the main causes?
chronic scarring/damage to liver which leads to non reversible changes (fibrosis)
alcohol, NAFLD, viral hep B/C
Pathophysiology of liver cirrhosis
hepatocyte damage, stellate cells produce collagen, fibrosis/scar tissue formation
Main complications of liver cirrhosis
Portal hypertension -> ascites, splenomegaly, hepatorenal failure
Reduced liver function
Increased ammonia (hepatic encephalopathy)
Increased oestrogen (gynaecomastia, palmar erythema)
Increased uncong. bili (jaundice)
Decreased albumin
Decreased clotting factors
Symptoms of early liver cirrhosis
asymptomatic, general (fatigue, weight gain, weakness)
Symptoms of late stage liver cirrhosis
Jaundice, itch, ascites, confusion, bruising
Diagnosis of liver cirrhosis
biopsy (regenerative nodules, fibrosis)
Fibroscan (transient elastography)
Management of liver cirrhosis
stop drinking
antivirals (if hep +ve)
transplant
Screening for liver cirrhosis
fibroscan
Hep C +ve
men who drink >50 units/week
women who drink >35 units/week
alcohol related liver disease
Causes of acute liver failure
PCM OD
hep A/B
alcohol
fatty liver of pregnancy
In liver failure, which clotting factor is not low and why
factor VIII
Synthesised in endothelial cells throughout body not just liver
Requires good hepatic function to clear from blood stream
Scoring system for liver cirrhosis
Model for End-Stage Liver Disease (MELD)
Child-Pugh classification
Pathophysiology of alcoholic liver disease
alcohol converted to acetaldehyde in liver
this essentially causes neutrophils to invade liver
biproduct of conversion is NADH which causes more fatty acid production
Bloods which would indicate alcohol related liver disease
AST ++ ALT + GGT + ALP +
thrombocytopenia
Management of alcoholic liver disease
Stop drinking
steroids to suppress immune system
c. diff pathophysiology
anaerobic gram-positive, spore-forming, toxin-producing bacillus
transmission: via the faecal-oral route by ingestion of spores
c diff symptoms
diarrhoea
abdominal pain
a raised white blood cell count (WCC) is characteristic
if severe toxic megacolon may develop
Crohns colonscopy/biopsy findings
deep ulcers, skip lesions
transmural inflammation, goblet cells, granulomas cobblestone appearance
Crohns SB enema findings
Kantors String sign, rose thorn ulcers
Crohns management for inducing remission
1st line - glucocorticoids
2nd line - 5ASA e.g mesalazine
Crohns management for maintaining remission
1st line - azathioprine or mercaptopurine
2nd line - methotrexate
Extra intestinal features of inflam bowel disease related to disease activity
asymmetric arthritis
erythema nodosum
episcleritis
Extra intestinal features of inflam bowel disease not related to disease activity
symmetric arthritis
uveitis
pyoderma gangremosum
clubbing
primary sclerosing cholangitis
Colonoscopy/biopsy findings in UC
No inflam beyond submucosa
reduced goblet cells
crypt abscssess
ulceration and pseudopolyps
Barium enema findings in UC
reduced haustrations
pseudopolyps
drain pipe colon
Management for inducing remission in mild/mod UC
topical aminosalicylate -> PO aminosalicylate-> PO corticosteroids
Management for inducing remission in severe UC
admit
IV steroids +/- IV ciclosporin
Associations with autoimmune hepatitis
HLA DR3
autoimmune disorders
hypergammaglobulinaemia
Types of autoimmune hepatits
1: ANA and /or SMA (adults and kids)
2: LKM1 (kids)
3: Soluble liver-kidney antigen (adults)
Presentation of autoimmune hepatitis
chronic liver disease
acute hepatitis
amenorrhoea
Ix and Mx autoimmune hepatitis
ANA, SMA, LKM1
biopsy: piecemeal necrosis
Mx: steroids, transplant
Management of UGIB caused by varices
teripressin and Abx before endoscopy
band ligation
TIPS if above fails
symptoms of ascending colangitis
charcots triad
1) fever
2) RUQ pain
3) jaundice
+hypotension and confusion
Ix and mx ascending colangitis
US
IV Abx
ERCP after 24-48hrs
How is ascites categorised
serum ascites albumin gradient more or less than 11
Causes of ascites SAAG <11
low albumin
malignancy
TB
pancreatitis
obstruction
Causes of ascites SAAG >11
liver: cirrhosis, ALF, mets
RHF, C pericarditis
Budd-Chiari
Management of ascites
spiro
drainage
prophylactic Abx ( SBP cipro) if ascitic protein <15
Presentation of SBP
abdo pain, ascites, fever
Ix, cause and Mx SBP
E. coli
paracentesis neutrophils >250
IV cefotax
What is Barretts and what are the risk factors
squamous cell -> columnar (goblet cells, brush border)
GORD, male, smoking
Management Barretts
high dose PPI
metaplasia: endoscopy 3-5 years
dysplasia: radio-frequency ablation
What is c. diff + risk factors + transmission
gram +Ve rod
clindamycin, cephlosporins, PPI
faeco-oral
Management of 1st episode c.diff
vanc -> findax -> vanc ± IV met
Management of 2nd episode c. diff
<12 weeks: PO findax
>12 weeks: PO findax or PO vanc
Coeliac associations
Dermatitis herpetiformis
HLA DQ2 and HLA DQ3
Complications coeliac
Anaemia
hyposplenism
OP
lactose intolerance
subfertility
Investigations of coeliac
eat gluten 6/52 prior
bloods: TTG antibodies, endomyseal anitbody
Biospy: villous atrophy
crypt hyperplasia
increased intraepithelial lymphocytes
lamina propria infiltration with lymphocytes
Management of coeliac
stop eating gluten
pneumococcal vaccine
What is haemochromatosis?
autosomal recessive
chromosome 6
accumlation of iron
How does haemachromatosis present, which features are reversible and irreversible
Rev
- bronze skin
-HF (DCM)
Irreversible
-DM
- liver disease
- arteritis
Investigations of haemachromatosis
transferrin saturation - >55% m >50% f
increased ferritin and iron
genetic testing
Mangement haemachromatosis
1st venesection aim transfer <50% and ferr <50
2nd desferrioxamine
What is Wilsons
autosomal recessive, chromosome 13
Increased copper
ATP7B gene
presentation of wilsons
hepatitis, cirrhosis
speech, behavioural
Kayer fletcher rings
blue nails
Diagnosis of Wilsons
Genetic analysis ATP7B gene
Slit lamp
Low serum caeruloplasmin
Management Wilsons
penicillamine
trientine hydrochloride
Management of hepatorenal syndrome
terlipressin
albumin
TIPS
Features of IBS
abdo pain relieved when bowels opened or associated with altered bowel frequency +2
-altered stool passage
-abdo bloating
-worse when eating
-passage of mucus
Red flags of abdo pain
Rectal bleeding
weight loss
Fhx
>60
What does thumbprinting on abdo XR indicate
ishaemic colitis, most likely at splenic flexure
What is Meckels Diverticulum
congenital remnant of vitellointestinal duct
How does Meckels present
usually asympotmatic
massive painless GI haemorrhage in kids
obstruction
Ix and Mx Meckels
Meckels scan or mesenteric arteriography
Surgical removal
Presentation of PBC
middle aged woman with itch
jaundice
hyperpigmentation
clubbing
liver failure (late)
(raised ALP incidental finding)
What conditions is PBC associated with?
Sjogrens
RA
systemic sclerosis
thyroid disease
How do you diagnose PBC
AMA M2
SMA
Raised IgM
MRCP
Mx PBC
ursodeoxycholic acid
Cholestyramine (itch)
liver transplant if bili >100
Complications of PBC
OP
hepatocellular ca
what is PSC
inflam and fibrosis of intra and extra hepatic bile ducts
How does PSC present
cholestasis: jaundice, itch, increased bili and ALP
RUQ pain
fatigue
What is PSC associated wtih
US
Crohns
HIV
How do you investigate PSC
ERCP/MRCP (beaded)
pANCA +ve
Biopsy - onion skin
Metabolic markers of refeeding syndrome
low Mg, K+ phosphate
What is Whipples
Rare multi-system disorder caused by tropheryma whippelii
Presentation of Whipples
middle aged man (HLA-B27)
diarrhoea, weight loss
lymphadenopathy
arthralgia
hyperpigment and photosensitivity
opthalmopegia
Whipples investigation
jejunal biopsy: macrophages containing PAS granules
