Gastro Flashcards
What should patients with coeliac receive every 5 years?
PCV vaccine due to hyposplenism
What should patients with spontaneous bacterial peritonitis receive?
Abx prophylaxis
Patients with raised platelets and nausea need what?
Non urgent referral for endoscopy
Management of patient with suspected upper GI bleed?
endoscopy within 24 hours of admission
What is the treatment of wilsons?
Penicillamine
Sudden onset severe abdo pain with vomiting and rapid bloody diarrhoea?
Acute mesenteric ischaemia
Raised transferrin and ferritin with low TIBC suggests what?
Haemochromatosis
Sudden onset abdo pain in someone with peptic ulcer disease?
Perforated peptic ulcer
How are perforated peptic ulcers managed?
- Erect CXR which shows free air under diaphragm
- Refer to general surgery
Tx of C diff?
- Oral vancomycin for 10 days
- If reoccurs: oral fidaxomicin
Anti-mitochondrial antibodies suggest what?
Primary Biliary Cholangitis
First line medication for PBC?
Ursodeoxycholic acid
What is associated with UC?
Primary sclerosing cholangitis
Investigation of choice for suspected pancreatic cancer?
High resolution CT
Management of liver abscess?
Percutaneous drainage with IV Abx - usually amoxicillin, ciprofloxacin and metronidazole
Vomiting followed by severe chest pain and signs of shock?
Oesophageal rupture (Boerhaave syndrome)
What cancer is associated with PSC patients?
Cholangiocarcinoma
What does pernicious anaemia predispose to?
Gastric carcinoma
Management of C diff if symptoms still ongoing after 10 days?
Oral vancomycin and IV Metronidazole
What should be measured to monitor treatment of haemachromatosis?
Transferrin saturation and serum ferritin
Management of haemachromatosis?
- Venesection
- Desferrioxamine
What should be given to patients with suspected variceal bleeding before endoscopy?
Terlipressin
Coeliac disease increased risk of which cancer?
enteropathy associated T cell lymphoma of small intestine
Diarrhoea with greasy stools in swimming pool user?
Giardia lamblia
What is SAAG (serum ascites-albumin gradient) used to measure?
- Portal HTN
- If >11, then portal HTN
How is dyspepsia managed?
- Trial of PPI for 1 month OR test and treatH pylori
- If either is unsuccessful, try the other approach
What are patients with haemochromatosis at risk of?
Hepatocellular carcinoma -> screening with US needed
sweet and fecal breath is indicative of what?
Liver failure
When should PPIs be stopped before upper GI endoscopy?
2 weeks before
Which artery is most likely to be the source of bleeding for someone with peptic ulcer disease?
Gastroduoedenal artery
Tenesmus is generally associated with which IBD?
Ulcerative Colitis
Crohn’s Disease
N – No blood or mucus (PR bleeding is less common)
E – Entire gastrointestinal tract affected (from mouth to anus)
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor
Other
- Terminal ileum
- Ulcer, cobblestone appearance
- Non-caseating granulomas
Ulcerative Colitis
C – Continuous inflammation
L – Limited to the colon and rectum
O – Only superficial mucosa affected
S – Smoking may be protective (ulcerative colitis is less common in smokers)
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary sclerosing cholangitis
What is the histology of UC?
- Large bowel
- Mucosal involvement only
- Crypt abscess, reduced goblet cells and no granulomas
- Continuous inflammation
- Pseudo polyps and ulcers may form
What is the histology of Crohns?
- Entire GI tract affected
- Transmural inflammation
- Non-caseating granulomas
- Discontinuous inflammation (skip lesions)
- Cobblestone appearance: fissures and deep ulcers
- Fistula formation
Diarrhoea, fatigue, osteomalacia?
Coeliac disease
What is carcinoid syndrome?
A condition usually when metastases are in the liver and then release serotonin into circulation
How does carcinoid syndrome present?
- Flushing
- Diarrhoea
- Bronchospasm
- Hypotension
- urinary 5-HIAA should be measured with ocreotide to treat
What is a key intervention in patients with asictes?
Restrict dietary sodium
Management of Barret’s?
High dose PPI + endoscopic surveillance
What should be avoided in patients with severe colitis?
Endoscopy -> risk of perforation -> use flexible sigmoidoscopy instead
What are the red flags for GI cancer?
new-onset dyspepsia in a patient aged >55 years
unexplained persistent vomiting
unexplained weight-loss
progressively worsening dysphagia/
odynophagia
epigastric pain
fatigue, erectile dysfunction and arthralgia?
Haemochromatosis
How can haemochromatosis present?
- Bronze skin
- Diabetes
- Liver disease
- Cardiac failure secondary to dilated cardiomyopathy
- Arthritis
signet ring cells are indicative of?
Gastric adenocarcinoma
How does achalasia present?
- Dysphagia of liquids and solids
- Heartburn
- Regurgitation of food
How is achalasia investigated?
- Gold standard: Oesophageal manometry which shows excessive lower oesophageal sphincter tone
- Barium swallow shows bird’s beak appearance
How is achalasia managed?
- Pneumatic balloon dilation
- Surgical intervention: Heller cardiomyotomy
What sign may be seen in pancreatic cancer?
Double duct sign -> dilated common bile duct and dilated pancreatic duct
What does Riglers sign indicate?
- Gas in the peritoneal cavity: sign of perforation
How should gallstones be managed?
If asymptomatic and in the gallbladder, no treatment needed
If in the common bile duct, surgery should be considered
If symptomatic, surgery
What is acute mesenteric ischaemia?
Occlusion of an artery supplying the small bowel, usually superior mesenteric artery
History of AF is common
Sudden-onset, severe pain with normal examination
How does acute mesenteric ischaemic be managed?
- Test serum lactate which will be raised
- Urgent surgery needed
What is ischaemic colitis?
Occlusion of blood flow to the large bowel resulting in inflammation, ulceration and haemorrhage
Where is ischaemic colitis most likely to occur?
Splenic flexure
How will ischaemic colitis be managed?
Abdo X ray - thumbprinting seen
Supportive treatment, surgery if severe
How should a severe flare of UC be treated?
IV corticosteroids
Iron defiency anaemia vs. anaemia of chronic disease
TIBC is high in iron deficiency but low/normal in chronic disease
Think of TIBC as the amount of space in the body to store iron: this will be high in iron deficiency as no iron
What should be given alongside isoniazid to prevent peripheral neuropathy?
Pyridoxine (vitamin B6)
T2DM with abnormal LFTs
NAFLD
What blood test can be done alongside incidental findings of NAFLD?
Enhanced liver fibrosis test
Which drugs are used to maintain remission in Crohns?
Azathioprine or mercaptopurine
Mild vs Moderate vs Severe flares of UC
Mild - <4 stools daily with no systemic disturbance
Moderate - 4-6 stools per day with minimal systemic disturbance
Severe - >6 stools per day with systemic disturbance
What is a severe complication of IBD flare up?
Toxic megacolon -> abdo X-ray needed
Which scores are used in acute GI bleeds?
- Glasgow Blatchford score to identify who can be managed as outpatient
- Rockall score done after endoscopy to identify risk of rebleeding
Alcohol units formula?
volume (ml) * ABV / 1,000
What can be given as prophylaxis for episodes of hepatic encephalopathy?
Lactulose
Metabolic alkalosis + hypokalaemia
Vomiting
Which tool is used to assess for malnutrition in patients?
MUST - malnutrition universal screening tool
What is small bowel bacterial overgrowth syndrome?
- Excessive bacteria in the small bowel
- Diabetes and Scleroderma are associated with this
- Presents like IBS: abdo pain, diarrhoea, bloating
- Hydrogen breath test to diagnose
- Abx usually rifaximin used to treat alongside correcting cause
severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit
Intestinal angina/chronic mesenteric ischaemia
What is alcoholic ketoacidosis?
- Euglycaemic ketoacidosis seen in those who drink alcohol excess
- Presents with metabolic acidosis, elevated ketones but NORMAL/LOW glucose levels
- Tx with IV fluids and thiamine
Which test should be used to test for eradication of H pylori?
Urea breath test
What is the most common cause of inherited colorectal cancer?
HNPCC - hereditary nonpolyposis colorectal cancer
What are aminosalicylates associated with?
Agranulocytosis - check FBC
Pain on swallowing (odynophagia) can be a sign of what?
Oesophageal candida
What is used to determine the severity of the C diff infection?
WCC
Bleeding gums and receding
Scurvy
liver and neurological disease
Wilsons disease
Electrolyte imbalances of refeeding syndrome ?
Hypophosphataemia, hypokalaemia and hypomagnesaemia
Abdominal pain, Bloating and Change in bowel habit
IBS
Cholestasis vs liver damage on bloods?
Liver injury - >10 times increase in ALT and <3 times increase in ALP
Cholestasis - <10 times increase in ALT and >3 times increase in ALP
Which drugs can cause cholestasis?
- COCP
- Abx including flucloxacillin, co-amoxiclav
Coeliac disease is associated with deficiency of what?
iron, folate and vitamin B12 deficiency
Which IBD is associated with gallstones?
Crohns
What is used to assess whether glucocorticoid therapy may be beneficial in alcoholic hepatitis?
Maddreys function - serum bilirubin and prothrombin time
Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels
Autoimmune hepatitis
dysphagia, glossitis and iron-deficiency anaemia
Plummer-Vinson syndrome
watery green diarrhoea post cholecystectomy
Bile acid malabsorption -> treat with cholestyramine
What is decreased in Wilsons disease?
serum caeruloplasmin
Haemochromatosis is a cause of what?
Hypogonadotropic hypogonadism
Patients with a suspected GI bleed require what?
OGD within 24 hours
What LFTs can indicate pancreatic cancer?
Cholestatic picture
What is an unreliable indicator of iron stored in the body during illness?
Ferritin -> use transferrin saturation instead
What can be used to differentiate between and upper and lower GI bleed?
Urea levels - high in upper GI bleed
Investigations for PSC?
- US scan
- MRCP
What is used for prophylaxis of oesophageal bleeding?
Propranolol
Management of severe alcoholic hepatitis?
Steroids
Which cancers are associated with HNPCC?
- Colorectal
- Endometrial
- Ovarian
- Pancreatic
What is the treatment of hypophosphatemia?
Intravenous infusion of phosphate polyfusor
Most common organism causing SBP?
Gram negs - E coli, Klebsiella
Management of Dysplasia on biopsy in Barrett’s oesophagus
Endoscopic intervention
What should you test to screen for haemochromatosis?
Transferrin saturation
Psychosis is a complication of what?
Wilsons disease
What is the investigation of choice for perianal fistulae in Crohns?
MRI
Bleeding vs perforated peptic ulcer?
Perforated ulcer should present with signs of peritonitis e.g. abdo pain, distension, guarding
Deranged LFTs and AKI in someone with septic shock?
Think ischaemic hepatitis
Patients allergic to aspirin may also react with what?
Sulfasalazine
What is Richter’s hernia?
A rare hernia which causes a firm, erythematous mass -> often presents with symptoms of strangulation (ischaemia/necrosis over the skin)
What should be given for prophylaxis of variceal bleeds?
Propranolol
Management of SBP
Acute: IV Cefotaxime
Abx prophylaxis if they have ascites: Ciprofloxacin until ascites resolves
Back pain worse on lying down, appetite loss and weight loss
Pancreatic cancer
What is the most common type of oesophageal malignancy in patients with GORD?
Adenocarcinoma
What can cause a wheeze in people with GORD?
Inhalation of small amounts of gastric contents
What is the gold standard investigation for GORD?
Oesophageal pH manometry
What surgery can be done for GORD and what does this do?
Nissen fundoplication - fundus wrapped around the abdo oesophagus to improve strength of the gastro-oesophageal junction
What is a complication of Nissen fundoplication?
Dysphagia from compression of the junction
Examination signs of chronic liver disease
- Clubbing
- Palmar erythema
- Dupuytren’s contracture
- Hepatosplenomegaly
- Ascites
What are complications of liver cirrhosis?
- Encephalopathy
- Sepsis
- SBP
- Ascites
- Varices
What dietary advice would you give someone with ascites?
- Fluid restriction
- Low sodium
Why is lactulose given in encephalopathy?
Reduce number of nitrogen producing bacteria in the gut which contribute to hepatic encephalopathy
Why can anti-EMA antibodies be negative in severe malabsorption in coeliac?
Deficiency in proteins such as IgA
Haematemesis + distended abdomen
Variceal bleeding
What is an indicator of pancreatitis severity?
Hypocalcaemia
What is the most common cause of large bowel obstruction?
Tumour then volvulus/diverticular disease
What do Hepatitis B serology markers mean?
HBSAg - acute infection (if > 6 months then chronic infection)
Anti-HBs - immunity
Anti-HBc - previous/current infeection
Causes of different types of jaundice
Pre - Sickle cell, G6PD, Hereditary spherocytosis
Hepatic - Hepatitis, PBC, PSC, EPV, HCC
Post hepatic - biliary atresia, gallstones, pancreatitis
Stages of liver disease
Steatosis -> Fibrosis/Steatohepatitis -> Cirrhosis
When is liver transplant indicated in liver disease?
In chronic liver disease, patients must have stopped alcohol for atleast 6 months
What are complications of GORD?
- Barret’s
- Adenocarcinoma
- Oesophageal stricture
- Chronic cough
What are complications of UC?
- Colon cancer
- Toxic megacolon
- Bowel perforation
Where does volvulus cause large bowel obstruction?
Sigmoid
What is coffee bean sign indication of?
Sigmoid volvulus
What is the management of sigmoid volvulus?
Stable - rigid sigmoidoscopy with flatus tube insertion
Unstable - Urgent laparotomy
Palpable fullness in the gallbladder with painless jaundice?
Think pancreatic cancer
Fever, abdo pain, cirrhosis and portal HTN?
Think SBP
Hypertrophic pulmonary osteoarthropathy is associated with what?
Squamous cell carcinoma of lung
Achalasia increases the risk of what?
Squamous cell carcinoma of the oesophagus
What is the best way to assess someone response to Hep C treatment?
Viral load
Ongoing jaundice + pain post cholecystectomy?
Gallstone in common bile duct
Management of malignant distal obstructive jaundice due to unresectable pancreatic carcinoma
Biliary stenting
Flu like illness with RUQ pain, tender hepatomegaly and deranged LFTs?
Think Hep A
What would biliary colic blood show?
Everything normal
What should you not do in someone with suspected pancreatitis?
Make them nil by mouth - enteral feeding should be offered
What is the treatment for symptomatic perinala fistulae in Crohn’s?
Oral metronidazole
History of vascular disease and lactic
acidosis
Think mesenteric ischaemia
What is the most sensitive/specific test for pancreatitis?
Lipase
What is the marker of choice to assess liver synthetic function?
INR (prothrombin time)
What are some components of Child-Pugh score?
- Bilirubin
- Albumin
- PT
- Encephalopathy
- Ascites
What should be the first investigation in A+E if someone comes in with pain/vomiting?
Erect CXR to look for pneumoperitoneum suggestive of perforation
What are the components of Glasgow score for pancreatitis?
Pa02
Age > 55
Neutrophils
Calcium < 2
Renal function
Enzymes
Albumin
Sugar
Why is US scan helpful in pancreatitis?
Assess for presence of gallstones
What are the 2 signs of pancreatitis?
Grey Turners - Bruising along flanks suggestive of haemorrhagic pancreatitis (sign of retroperitoneal bleeding)
Cullen - Bruising around umbilicus
Pigmented gallstones are associated with what?
Sickle cell anaemia
pseudomembranous colitis is what?
C diff colitis
What is the treatment for cholecystitis?
IV Abx with laparoscopic cholecystectomy within 1 week of diagnosis
What can be used to manage complex anal fistulae?
Draining seton
What is the most common disease pattern in UC and Crohns?
UC - Proctitis
Crohns - Ileitis
What drugs should be stopped in C diff infection?
Opioids
anorectal pain and a tender lump on the anal margin
Thrombosed haemorrhoids
short incubation period and severe vomiting
Staph aureus gastroenteritis
Which Abx can be used for Campylobacter infection if severe/immunocompromised?
Clarithromycin
Charcot’s triad plus hypotension and confusion
Reynolds pentad
What is necessary before a diagnosis of PBC?
Imaging to exclude a extrahepatic biliary obstruction
Management of acute anal fissues?
Bulk forming laxatives
What is Troisier’s sign?
Enlarged hard left supraclavicular lymph node which indicates metastatic abdo malignancy
What are risk factors for gastric cancer?
- H pylori
- Gastric polyps
- Pernicious anaemia
- Gastric ulceration
What does TNM staging assess?
Size of tumour
Presence of lymph nodes
Evidence of metastases
What is the marker for HCC?
AFP
Surgical procedures for pancreatic cancer?
- Pancreaticoduodenectomy
- Whipples
flu-like symptoms, RUQ pain, tender hepatomegaly and deranged LFTs
Hepatitis A
Hepatitis serology
IgM - acute infection
IgG - chronic infection
Severe hepatitis in a pregnant woman
Hep E
Man returns from trip abroad with maculopapular rash and flu-like illness
Think HIV seroconversion
Undercooked pork?
Hepatitis E
Right-sided tenderness on PR exam
Acute appendicitis
What is the surgery for bilateral/recurrent inguinal hernias?
Laparoscopic repair with mesh
Mesalazine can cause what?
Drug induced pancreatitis
lemon tinge to the skin
Pernicious anaemia
pH < 7.3 at 24 hours post paracetamol overdose?
Liver transplant consideration
periodic acid-Schiff- (PAS-) positive macrophages
Whipples disease
dysphagia, iron deficiency anaemia and glossitis
Plummer Vinson syndrome
What is a TIPS procedure?
Artifical channel within the liver used for variceal bleeding refractory ascites
Major complication is hepatic encephalopathy
severe abdominal pain, ascites and tender hepatomegaly
Budd-Chiari syndrome
Which laxative to prescribe when starting patients on opiates?
Senna
Management of diverticulitis flare?
Oral Abx with admission to hospital if symptoms do not improve within 72 hours
Why give albumin for large volume ascites?
reduce paracentesis-induced circulatory dysfunction and mortality
What is usually normal with acute cholecystitis?
LFT tests
classic epigastric pain which is relieved on sitting forwards
Think chronic pancreatitis
What will AST:ALT ratio be in alcoholic hepatitis?
2:1
caput medusae and splenomegaly in a known alcoholic suggest what?
Portal HTN
Antibodies for PBC
Anti-mitochondrial - most common
Anti-smooth muscle
What does a score of 3 or more on Glasgow criteria suggest for pancreatitis?
May need ITU input
slate-grey skin pigmentation
Haemochromatosis
Diarrhoea after rice?
Bacillus cereus
What are the anti emetics of choice in gastroparesis?
- Metoclopramide
- Domperidone
fever, malaise, abdo pain and rose spots on trunk?
Typhoid fever -> treat with fluids and Ciprofloxacin
Raised ALP and bilirubin suggests what?
Cholestatic picture
What marker is raised in cholangiocarcinoma?
CA19-9
MSH2/MLH1 mutation?
HNPCC
What is the AST:ALT ratio in alcoholic liver disease?
2:1 - AST 2 times higher than ALT
Gastroenteritis incubation periods?
1-6 hours: Staph aureus
12-48 hours: Salmonella, E coli
48-72 hours: Shigella, Campylobacter
>7 days: Giardiasis, Amoebiasis
mural thickening of the colon and the presence of pericolic fat stranding in the sigmoid colon
Diverticular disease
What is the weight loss definition for malnutrition?
Loss of >10% in the last 3-6 months
What should the prothrombin time be in order to qualify for liver transplant?
> 100seconds
First line test for coeliac in GP?
Total IgA and IgA tissue transglutaminase
When should a repeat endoscopy be done after the start of PPI therapy for ulcer?
6-8 weeks
Autoimmune hepatitis antibodies?
Type 1 - ANA, anti-smooth muscle
Type 2 - Anti-LKM-1
What can help to confirm SBP from Ascitic fluid?
Raised neutrophils
triad of vomiting, pain and failed attempts to pass an NG tube
Gastric volvulus
Post prandial vomiting and abdo pain in someone with chronic pancreatitis?
Pancreatic pseudocyst
Blockage where does not cause jaundice?
Cystic duct or gallbladder
ALT/AST in the 10,000s?
Think paracetamol overdose
AST vs ALT
AST - alcohol overdose
ALT - drug overdose/viral hepatitis
Suspected cholecystitis in GP?
Refer to hospital for urgent admission
spiral or comma-shaped gram negative
Campylobacter