Gastro Flashcards
investigation for definitive diagnosis of Zollinger-Ellison Syndrome
Secretin Stimulation test
3 features of Zollinger-Ellison syndrome
multiple GI ulcers
diarrhoea
malabsorption –> weight loss
gold standard for diagnosis of achalasia
oesophageal manometry
first line: endoscopy
which condition shows Bird Beak sign on barium swallow
achalasia
management of chronic pancreatitis[2]
insulin replacement
Creon (pancreatic enzymes)
mode of inheritance of hereditary haemochromatosis
autosomal recessive
HFE gene
what must be checked before starting IV mannitol
cardiac function as it can precipitate arrhythmias
what does cryoprecipitate replace
fibrinogen therefore ideal for DIC
mode of inheritance of Gilbert’s syndrome
autosomal recessive
which type of ulcer is worse on eating
gastric
which type of ulcer is more likely to become malignant
gastric
most common bacteria involved in SBP [2]
E.coli and Klebsiella
first line treatment for acute constipation
ispaghula husk (bulk forming_
second line treatment for acute constipation
macrogol (osmotic laxative)
how is oesophageal metaplasia treated
endoscopic surveillance every 3-5 years
gold standard diagnostic for PSC
MRCP
non-invasive and fewer risks than ERCP
Gene involved in HNPCC
MSH2 (60%)
MLH1(30%)
Gene involved in FAP
APC
most common inheritable form of colorectal cancer
mode of inheritance
HNPCC
autosomal dominant
2nd most common inheritable form of colorectal cancer
mode of inheritance
FAP (rare <1%)
autosomal dominant
what other cancer can those with HNPCC get
endometrial
What other tumours are patients with FAP at risk of?
duodenal tumours
what are the features of Gardener’s syndrome
Variant of FAP with:
osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin
which part of the colon does HNPCC tend to affect most
proximal colon
How much weight loss is diagnostic of malnutrition
Unintentional weight loss greater than 10% within the last 3-6 months
what BMI define malnutrition
<18.5
what combination of BMI and weight loss defines malnutrition
a BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months
screening tool for malnutrition
Malnutrition Universal Screening Tool (MUST)
which LFTs are raised in PSC
BR
GGT
ALP
which coagulation parameter is raised in acute liver failure
PT
what breath sign is associated with acute liver failure
fetor hepaticus
when is oral rifaximin used in treatment of hepatic encephalopathy
when treatment is refractory to oral lactulose
antihypertensive contraindicated in hiatus hernia
CCB
of the three types of jaundice, which one has ABSENT urobilinogen
post hepatic i.e obstructive as conjugated BR does not make it
ABs in PBC
AMA
diagnosis of Whipple’s disease
jejunal biopsy
management of Whipple’s disease
co-trimoxazole
how long should PPI be stopped before endoscopy
2 weeks
If endoscopy is negative consider 24-hr oesophageal pH monitoring (the gold standard test for diagnosis)
indication for liver transplant in non-paracetamol induced liver failure
PT >100
How is low-grade dysplasia on endoscopy managed
6 monthly surveillance and high dose PPI
most useful blood test for haemochromatosis
transferrin saturation
which water soluble vitamin in absorbed in the ileum
B12
What is the pathophysiology of delirium tremens?
unopposed glutamate activity
Acute alcohol consumption causes an increase in GABA neurotransmission. This is an inhibitory neurotransmitter. However, in those with chronically high alcohol intake, a compensatory decrease in GABA neurotransmission and increase in the excitatory neurotransmitter glutamate occurs.
This means that in cases of acute alcohol cessation, as in cases of delirium tremens, the upregulated glutamate is no longer opposed by GABA. This generates an overall excitatory state.
histological features of coeliac disease [3]
villous atrophy
crypt hyperplasia
intraepithelial lymphocytes
which site of the gut affected by Crohn’s contributes to gallstone formation?
terminal ileum
here, bile salts are reabsorbed usually
treatment of dermatitis herpetiformis
dapsone (abx)
surgical treatment of hiatus hernia and indication
Nissen’s fundoplication
when resistant to medication
AB in PBC
Positive Anti-mitochondrial antibodies (AMAs) in >90% of individuals
Raised serum IgM
anti-smooth muscle in 30%
main risk factor of MALT
H.pylori
main risk for EATL
coeliac disease
which fruit juice is an enzyme inhibitor
grapefruit
how is small bowel disease in Crohns best investigated
MRI small bowel as OGD won’t go far enough
what does Senna abuse cause?
melanosis coli
how many bowel movements in mild UC flare
<4 per day, little blood
how many bowel movement in moderate UC flare
4-6 per day, varied blood, no systemic features
how many bowel movements in severe UC flare
> 6 per day, systemic features
Gut layer features in UC
decreased goblet cells
crypt abscesses
Gut layer features in Crohn’s [2]
increased goblet cells
granulomas
most commonly affected part of the GIT in UC
rectum (LIF)
most commonly affected part of the GIT in Crohns
terminal ileum (RIF)
which IBD has rosethorn ulcers and cobblestoning
Crohns
which IBD has abscesses or fissures, how should they be investigated
Crohns; with a pelvic MRI
which IBD presents with non-bloody diarrhoea
Crohns
in which IBD is surgery not curative
Crohns
Extra-intestinal manifestations of IBD
A- Aphthous Ulcers
P- Pyoderma gangrenosum
I- iritis, anterior uveitis, episcleritis
E- Erythema nodosum
S- Sclerosing cholangitis (UC)
A- Arthritis
C- Clubbing (CD)
Drug for inducing remission in Crohns
steroids
mild: pred
severe: IV hydrocortisone
distal ileal: budesonide
drug for maintaining remission in Crohns
azathioprine or mercaptopurine
alt: aminosalicylates or biologics
treatment of severe fulminant UC
IV steroids
when should a colectomy done in UC flare
no improvement with steroids in 72 hours
inducing remission in UC flare
topical aminosalicylates e.g. mesalazine
2nd line: steroids
what is the emergency surgery done in UC
Hartman’s proctosigmoidectomy + end ileostomy
eventually Ileal Pouch Anal Anastamosis
how does IBS present?
young, female, anxious, stressed and may have depression, pain, bloating diarrhoea/constipation
How is IBS diagnosed as a diagnosis of exclusion
based on ROME III criteria:
- improvement with defaecation
- change in stool frequency, form, appearance, consistency
investigation of haemorrhoids
abdo exam with DRE
proctoscope/sigmoidscope for internal haemorrhoids
1st line treatment of haemorrhoids [3]
increased fluid and fibre intake
stool softener
topical analgesic
treatment of listeria monocytogenes gastroenteritis
amoxicillin or ampicillin
treatment of salmonella type, paratyphi gastroenteritis
ceftriaxone
cipro if sensitive
treatment of a campylobacter jejuni gastroenteritis
usually self limiting but if severe clarithromycin or ciprofloxacin
describe the stools in coeliac
watery, grey, frothy stool (increased fat)
which haematinics can be deficient in coeliac disease, where are they absorbed
iron (duodenum), folate (jejenum) and ileum (B12)
most sensitive AB for diagnosing coeliac
anti TTG (do alongside IgA)
management of coeliac disease
- gliadin/gluten free diet
- dietician referral with annual review
biochemical abnormalities in acute cholecystitis
ALP and amylase slightly raised
normal ALT/AST
what is Mirizzi syndrome
common hepatic duct stone impaction
treatment of ascending cholangitis [2]
IV ABx and ERCP after 24-48 hours
Charcot’s triad in ascending cholangitis
fever
jaundice
RUQ pain
how does cholangiocarcinoma present
obstructive jaundice, red flag symptoms
often asymptomatic
investigating of suspected gallbladder cancer
CT abdo
ERPC for staging
treatment of resectable and non-resectable gallbladder cancer
resectable–> cholecystectomy
non-resectable –> chemoradiotherapy +- stenting
what is PBC associated with
autoimmune diseases e.g. Sjogrens, RhA, thyroid disease
biochemical abnormalities in PBC
raised GGT/ALP
normal transaminases
management of PBC
1st line: ursodeoxycholic acid
pruritus: cholestyramine
fat-soluble vitamin supplementation
liver transplantation
e.g. if bilirubin > 100 (PBC is a major indication)
AB in PSC
pANCA
diagnostic investigation of PSC
MRCP shows beaded appearance of biliary structures
management of PSC
observation, liver transplant
complications of PSC [2]
cholangiocarcinoma
colorectal cancer
AB in Type 1 autoimmune hepatitis [2]
ANA and ASMA
AB in Type 2 autoimmune hepatitis
anti LKM
AB in Type 2 autoimmune hepatitis
anti soluble liver antigen
investigation for autoimmune hepatitis [3]
ANA/SMA/LKM1 antibodies
raised IgG levels
liver biopsy showing piecemeal necrosis
management of autoimmune hepatitis [2]
steroids
liver transplant
4 causes of massive splenomegaly
CML
myelofibrosis
malaria
lymphoma
treatment of Wernicke’s encephalopathy
Thiamine (pabrinex)
magnesium
folic acid
management of ascites [5]
- restrict fluids and alcohol
- low sodium diet
- spironolactone
- drainage if tense ascites
- prophylaxis for SBP: ciprofloxacin+ propanolol
management of refractory ascites
TIPSS
transplant
initial investigation for SBP
abdo USS to confirm ascites
then do ascitic tap and fluid MC&S
polymorphonuclear cell level in SBP
> 250
treatment of SBP
tazocin (piptazobactam) or cefotaxime
prophylaxis of SBP
ciprofloxacin + propanolol
which stain is used on liver biopsy in haemochromatosis
Perl’s stain
management of haemochromatosis [2 lines]
1st line: venesection
2nd: desferrioxamine
4 Iines of investigation of NAFLD
1st: LFTs
2nd: USS
3rd: enhanced liver fibrosis panel or fibroscan
4th: liver biopsy
management of NAFLD
lifestyle measures
most specific and sensitive bloods for acute pancreatitis
serum lipase
investigations for acute pancreatitis
serum lipase and amylase
USS and constrast CT abdo
severity score in pancreatitis: PANCREAS
▪ P
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ Sugar>10mmol/L
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ Sugar>10mmol/L
severity score in pancreatitis: PANCREAS
▪ PaO2 <8 kPa
▪ A
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ Sugar>10mmol/L
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ Sugar>10mmol/L
severity score in pancreatitis: PANCREAS
▪ PaO2 <8 kPa
▪ Age>55yo
▪ N
▪ Ca2+ <2mmol/L
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ Sugar>10mmol/L
severity score in pancreatitis: PANCREAS
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ Sugar>10mmol/L
severity score in pancreatitis: PANCREAS
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ C
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ Sugar>10mmol/L
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ Sugar>10mmol/L
severity score in pancreatitis: PANCREAS
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ R
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ Sugar>10mmol/L
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renal urea >16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ Sugar>10mmol/L
severity score in pancreatitis: PANCREAS
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renal urea>16mmol/L
▪ E
▪ Albumin<32g/L
▪ Sugar>10mmol/L
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ Sugar>10mmol/L
severity score in pancreatitis: PANCREAS
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ A
▪ Sugar>10mmol/L
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32
▪ Sugar>10mmol/L
severity score in pancreatitis: PANCREAS
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ S
▪ PaO2 <8 kPa
▪ Age>55yo
▪ Neutrophils>15x109/L
▪ Ca2+ <2mmol/L
▪ Renalurea>16mmol/L
▪ Enzymes(LDH>600,AST/ALT>200)
▪ Albumin<32g/L
▪ Sugar>10mmol/L
management of acute pancreatitis [3]
fluids
IV morphine
enteral feeding
management of necrotising pancreatitis [4]
fluids
analgesia
IV morphine
enteral feeding
3 early complications of acute pancreatitis
haemorrhage
SIRS, ARDS
hypocalcaemia and hyperglycaemia
4 late complications of chronic pancreatitis and their management [4Ps]
peri-pancreatic fluid collection (admit+bowel rest)
pseudocyst (imaging, observe, -ostomy or aspirate)
pancreatic abscess (drainage)
pancreatic necrosis (conservative)
signs and symptoms of chronic pancreatitis [3]
- pain worse after a while after meal
- steatorrhoea
- occurs on background of long standing DM
what measures exocrine function in the context of pancreatitis
faecal elastase
imaging for chronic pancreatitis
USS (for gallstones)
contrast CT abdo
most common type of pancreatic cancer
adenocarcinoma
genetic risk factors for pancreatic cancer [4]
BRCA2
MEN
KRAS
HNPCC (Lynch syndrome)
classic symptom of pancreatic cancer
painless obstructive jaundice
i.e. pale stools, dark urine, pruritus
what is Courvoisier’s Law
in the presence of painless obstructive jaundice, a mass is unlikely to be gallstones
biochemical abnormality in pancreatic cancer
ALP/GGT raised
BR raised
ALT/AST normal
what is Trousseau sign in the context of pancreatic cancer
migratory thrombophlebitis
main investigation of pancreatic cancer?
what sign is seen?
HRT-CT
double duct sign- dilatation of common bile duct and pancreatic duct
definitive management of pancreatic cancer
Whipple’s resection
treatment of symptomatic pancreatic cancer for nonsurgical candidate
ERCP with stenting
what is Saint’s triad
Diverticular disease
Diaphragmatic hernia (hiatus)
Stones (cholelithiasis)
investigation of acute diverticulitis
CT abdo
investigation of chronic diverticular disease
barium enema
treatment of acute mild diverticulitis
ABx
treatment of acute severe diverticulitis [3]
IV abx
drip and suck
may do Hartmann’s with a primary anastomosis
treatment of chronic diverticular disease
soluble, high fibre diet
Requirement of urgent 2WW OGD in GORD [3]
dysphagia
upper abdo mass
age >=55 and weight loss with: dyspepsia; reflux; upper abdo pain
requirement for non urgent OGD in GORD
haematemesis
age >=55 with: treatment resistant dyspepsia upper abdo pain with low Hb; N&V; raised plt
what is done if OGD is -ve in investigation of dyspepsia
24 hour oesophageal pH monitoring
1st line treatment of dyspepsia
review medications for causes of dyspepsia and give lifestyle advice
2nd line treatment of dyspepsia
full dose PPI for 4 weeks or test and treat H.pylori
3 methods of testing for H.pylori
carbon 13 urea breath test
stool antigen
serology
how is test of cure done in dyspepsia treatment for H.pylori
carbon 13 urea test
treatment of H.pylori
amoxicillin + clarithromycin + omeprazole
how is OGD proven oesophagi’s treated
1 month PPI
followed by another month
then another month with double dose
what medication is added to PPI in the treatment of oesophagitis proven on OGD
H2 RA
how is endoscopically negative reflux treated
1 month PPI
2nd: 1 month H2 RA
indications for Nissen fundoplication in dyspepsia treatment [2]
refractory GORD
hiatus hernia
complication: gas-bloat syndrome
gram stain of H.pylori
gram -ve
Associated diseases with H.pylori [4]
duodenal and gastric ulcers
gastric cancer
MALToma
atrophic gastritis
why must albumin cover be given when doing large volume paracentesis
large-volume paracentesis for the treatment of ascites requires albumin ‘cover’.
Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality
paracentesis induced circulatory dysfunction can occur due to large volume paracentesis (> 5 litres). It is associated with a high rate of ascites recurrence, development of hepatorenal syndrome, dilutional hyponatraemia, and high mortality rate
what causes a SAAG >11
what does this indicate overall
Liver disorders are the most common cause
- cirrhosis/alcoholic liver disease
- acute liver failure
- liver metastases
Cardiac
- right heart failure
- constrictive pericarditis
Other causes
Budd-Chiari syndrome
portal vein thrombosis
veno-occlusive disease
myxoedema
indicates portal hypertension
what causes a SAAG <11
Hypoalbuminaemia
nephrotic syndrome
severe malnutrition (e.g. Kwashiorkor)
Malignancy
peritoneal carcinomatosis
Infections
tuberculous peritonitis
Other causes
pancreatitis
bowel obstruction
biliary ascites
postoperative lymphatic leak
serositis in connective tissue diseases
how do you calculate SAAG
serum albumin concentration - ascitic albumin concentration
what may cause gallstone ileus
if a fistula forms between the gallbladder and duodenum
how does gallstone ileum present
like bowel obstruction: Abdominal pain, distension and vomiting are seen.
what is the Sister Mary Joseph node
metastatic umbilical lesion - is an important finding in advanced malignancy
what needs to be done before starting treatment for PBC
MRCP or USS
exclude an extrahepatic biliary obstruction
Squamous cell cancer in the oesophagus: location?
upper two thirds
Squamous cell cancer in the oesophagus: risk factors
smoking
alcohol
achalasia
Plummer-Vinson syndrome
diets rich in nitrosamines
developing world
Adenocarcinoma of the oesophagus: location
bottom third
Adenocarcinoma of the oesophagus: risk factors [4]
where is it more common?
GORD
Barrett’s oesophagus
smoking
obesity
UK/US
diagnosis of oesophageal cancer
upper GI endoscopy with biopsy
what is transient elastography and what can it be used to measure the severity of
brand name ‘Fibroscan’
uses a 50-MHz wave is passed into the liver from a small transducer on the end of an ultrasound probe
measures the ‘stiffness’ of the liver which is a proxy for fibrosis which is a reflection of cirrhosis
triad in Budd Chiari syndrome
sudden onset abdominal pain, ascites, and tender hepatomegaly
key investigation in Budd Chiari syndrome
ultrasound with Doppler flow studies
first line treatment of c.diff
oral vancomycin
treatment of life threatening c.diff
oral vancomycin iv metronidazole
2nd line treatment for C.diff
oral fidamoxicin
how long ago should antibiotics and anti secretories be stopped before a urea breath test
antibiotics for 4 weeks
anti secretaries e.g. PPI for 2 weeks
Screening tool that helps clinicians decide whether patient patients can be managed as outpatients or not in suspected upper GI bleed
Glasgow-Blatchford (pre endoscopy)
Screening tool that provides a percentage risk of rebleeding and mortality after treatment of upper GI bleed
Rockall (post endoscopy)
A recurrent episode of C. difficile within _________ of symptom resolution should be treated with oral fidaxomicin
A recurrent episode of C. difficile within 12 weeks of symptom resolution should be treated with oral fidaxomicin
drugs that cause cholestasis
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
which is more common: pancreatic cancer or cholangiocarcinoma
pancreatic cancer
what is offered to coeliac patients
pneumococcal vaccine due to functional hyposplenism
booster every 5 years
triad of Wernicke’s encephalopathy
Confusion, gait ataxia, nystagmus + ophthalmoplegia
lymphoma associated with coeliac disease
enteropathy associated T cell lymphoma
adverse effects of PPI [4]
hyponatraemia, hypomagnasaemia
osteoporosis → increased risk of fractures
microscopic colitis
increased risk of C. difficile infections
diagnosis and treatment of small bowel bacterial overgrowth syndrome
hydrogen breath test
tx: treat underlying cause, rifixamin, co-amox, metro
risk factor for small bowel bacterial bacterial overgrowth syndrome
diabetes mellitus
scleroderma
M rule of PBC [3]
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
electrolyte abnormality with vomiting/aspiration
hypokalaemia
Triad of Plummer Vinson Syndrome
Triad of:
dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia
+ cheilitis
treatment of achalasia
pneumatic (balloon) dilation is increasingly the preferred first-line option
less invasive and quicker recovery time than surgery
patients should be a low surgical risk as surgery may be required if complications occur
surgical intervention with a Heller cardiomyotomy should be considered if recurrent or persistent symptoms
intra-sphincteric injection of botulinum toxin is sometimes used in patients who are a high surgical risk
drug therapy (e.g. nitrates, calcium channel blockers) has a role but is limited by side-effects
drug that may cause Heinz body anaemia
sulphasalazine
how is UC normally diagnoses, but when she it be avoided
what is used instead
normally with colonoscopy with biopsy
avoided in severe colitis, use a flexible sigmoidoscope instead to prevent risk of perforation
what should be given before endoscopy for variceal bleed
antibiotics and terlipressin
uncontrolled haemorrhage in variceal bleed, what should be inserted
Sengstaken-Blakemore tube
what is the preferred procedure done to treat variceal bleed during endoscopy
band ligation over sclerotherapy
how do oesophageal varices present
- large volume of fresh blood
- melena due to swallowed blood
- haemodynamic compromise
- may stop spontaneously then rebleed
how does bleeding due to oesophagitis present [5]
- small volume of fresh blood
- blood streaked vomit
- no melena
- stops spontaneously
- antecedent GORD
how does bleeding oesophageal cancer present
- small volume upper GI bleed
- erosion of major vessel
- dysphagia and other constitutional ssx e.g. weight loss
how does a Mallory Weiss tear present
- brisk small to moderate volume bright red blood
- following a bout of repeated vomiting
- no melena
- usually stops spontaneously
how does a bleeding gastric ulcer present [3]
- small low volume bleeds
- iron def anaemia
- erosion of significant vessel may cause haemorrhage or haematemesis
how does bleeding gastric cancer present [3]
- frank haematemesis or vomit mixed with blood
- prodrome of dyspepsia and constitutional ssx
- vessel erosion causing haemorrhage
how does a Dieulafoy lesion present
- AVM that produces considerable haemorrhage
- haematemesis and melena
- difficult to detect endoscopically
how does diffuse erosive gastritis present
- haematemesis
- gastric discomfort
- usually with underlying cause e.g. recent NSAIDs
- large volume haemorrhage can occur with haem compromise
how does a bleeding duodenal ulcer present [5]
- haematemesis
- melena
- epigastric discomfort
- may erode gastroduodenal artery
- pain occurs several hours after eating
how does an aorto-enteric fistula present
- previous AAA surgery
- major haemorrhage with high mortality
Blatchford score 0, what should be done
early dischargesh
should PPI be given before endoscopy for suspected non-variceal upper GI bleed
no
treatment of alcoholic hepatitis [2]
glucocorticoids as determined by the Maddrey’s discriminant function (DF)
pentoxyphylline is also sometimes used
risk factors for Budd Chiari syndrome [4]
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
which volvulus is associated with malignancy
caecal
what sign does caecal volvulus show
embryo sign
treatment of sigmoid volvulus
rigid sigmoidoscopy with rectal tube insertion
what sign is seen in sigmoid volvulus
coffee bean sign
treatment of caecal volvulus
management is usually operative. Right hemicolectomy is often needed
features of carcinoid syndrome
flushing (often the earliest symptom)
diarrhoea
bronchospasm
hypotension
right heart valvular stenosis (left heart can be affected in bronchial carcinoid)
other molecules such as ACTH and GHRH may also be secreted resulting in, for example, Cushing’s syndrome
pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour
investigation for carcinoid syndrome [2]
urinary 5-HIAA
plasma chromogranin A y
management of carcinoid syndrome
somatostatin analogues e.g. octreotide
diarrhoea: cyproheptadine may help
what is carcinoid syndrome
usually occurs when metastases are present in the liver and release serotonin into the systemic circulation
Mackler’s Triad of Boerhaave’s syndrome
Chest pain
SC emphysema
Vomiting
which cancer is associated with apple core sign
oesophageal cancer
triad of intestinal angina/chronic mesenteric ischaemia
severe, colicky post-prandial abdominal pain
weight loss
abdominal bruit
features of Peutz-Jeghers syndrome
hamartomatous polyps in the gastronintestinal tract (mainly small bowel)
small bowel obstruction is a common presenting complaint, often due to intussusception
gastrointestinal bleeding
pigmented lesions on lips, oral mucosa, face, palms and soles
investigation of bile-salt malabsorption
SeHCAT
treatment of bile-salt malabsorption
bile acid sequestrants e.g. cholestyramine
what vitamin deficiency leads to angular cheilitis
riboflavin (B2)
which UC drug is more associated with pancreatitis
mesalazine
which IBD has pseudo polyps
UC
where is the biopsy taken in coeliac disease
jejunum
most immediate measure of loss of liver synthetic function
PT
why is C.diff difficult to treat
due to spore formation
C.difficile spores are resistant to many environmental stresses, including heat, disinfectants, and antibiotics, which makes them particularly difficult to eliminate. These spores can persist on surfaces for months, making them a significant source of transmission in healthcare settings.
