Gastro Flashcards
Treatment of anal fissure?
o <6 weeks (acute):
Dietary advice (high fluid, high fluid)
1st line: bulk-forming laxatives
Optional: lubricants (petroleum jelly), analgesia (not opioids), steroids
o >6 weeks (chronic):
Above continued
1st line: topical GTN (or topical diltiazem or topical nifedipine)
2nd line (after 8 weeks 1st line): sphincterotomy (clean cut in sphincter), botox toxin
Ix consistent with alcoholic hepatitis?
o GGT very raised
o AST: ALT >2
Management of alcoholic hepatitis?
o Prednisolone (high DF)
o Pentoxyphylline
Budd-Chiari Syndrome
- Caused by blockage of the hepatic vein (T1 = thrombosis; T2 = tumour occlusion)
o RFs: OCP, PRV, thrombophilia, pregnancy - S/S: abdominal pain, ascites, tender hepatomegaly
- Ix: abdominal USS with doppler
Achalasia
- S/S: sudden-onset solid AND liquid dysphagia, halitosis, heartburn, regurgitation
- Ix: LOS manometry (excessive LOS tone), barium swallow (bird’s beak), CXR
- Mx: Heller cardiomyotomy > botulinum intra-sphincteric injection, oesophageal balloon dilatation
What is Carcinoid Syndrome?
- Carcinoid syndrome usually occurs with liver metastases that release serotonin into the systemic circulation
Signs of carcinoid syndorme?
o Flushing (often earliest symptom), diarrhoea
o Bronchospasm, hypotension Pulmonary stenosis = ESM, right-side
o Cardiac (right heart valvular stenosis – pulmonary stenosis; left heart can be affected in bronchial carcinoid)
o Endocrine (i.e. Acromegaly (GHRH) and Cushing’s (ACTH))
o Pellagra (dietary tryptophan is diverted to serotonin by the tumour)
Dermatitis, diarrhoea, dementia
Niacin B3 deficiency
Ix and mx of serotonin syndrome?
o Urinary 5-hydroxyindolacetic acid (5-HIAA; serotonin metabolite)
o Plasma chromogranin A y
o Somatostatin analogues e.g. octreotide
o Diarrhoea: cyproheptadine may help
Causes of C.diff?
o Ampicillin, amoxicillin, co-amoxiclav
o Cephalosporin
o Clindamycin
o Quinolones
Management of c.diff
o 1st episode, mild-moderate oral metronidazole 10-14 days
o 2nd episode, severe oral vancomycin 10-14 days
o Life-threatening, ileus oral vancomycin + IV metronidazole 10-14 days
Treatment of Small Bowel Overgrowth (SBO)?
o ABx (rifaximin > co-amoxiclav, metronidazole)
Ix of small bowel overgrowth syndrome?
- Signs & symptoms (similar to IBS):
o Chronic diarrhoea
o Bloating, flatulence
o Abdominal pain - Investigations:
o Hydrogen breath test
o Small bowel MC&S [not commonly used]
o Diagnostic ABx course
o Folate high (as bacteria produce it)
Treatment of Perianal Abscess?
- S/S: pain worse on sitting, discharge, hardened perianal area
- Mx: 1st line: I&D under LA (packed or left open) – ABx are rarely used unless systemic upset
o Urgent (2ww) OGD criteria:
Dysphagia
Upper abdominal mass (? stomach cancer)
Age ≥55yo AND weight loss AND (any of):
* Dyspepsia
* Reflux / GORD Ix/Mx: BNF GORD
* Upper abdominal pain
“treatment-resistant dyspepsia, what needs to be done?
Non-urgent OGD
Treatment for H.pylori eradication?
PPI+amoxicillin+clari/met?
Surgery name: Indication: refractory GORD, hiatus hernia
Nissen fundoplication (gold-standard):
o H. pylori complications?
PUD (95% of duodenal ulcers, 75% of gastric ulcers)
Gastric cancer
MALToma (B cell lymphoma of MALT; mx: eradication of H pylori regression in 80% of patients)
Atrophic gastritis
Ix for acute diverticulitis?
CT abdomen
Ix for chronic diverticular disease?
Barium enema
Mx of acute diverticulitis?
Severe: IV ABx, drip and suck, Hartmann’s, primary anastomosis
Mild: PO Abx
S/S of pancreatic cancer?
o Classically painless jaundice (Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones; however, normally anorexia, WL, epigastric pain)
Signs of obstructive jaundice?
Pale stools, dark urine, and pruritus
Cholestatic LFTs (AST/ALT normal, ALP/GGT raised, BR raised)
- Investigations for pancreatic cancer?
High resolution CT - double duct” sign – presence of simultaneous dilatation of CBD and pancreatic duct)
Can also do an USS
Functions of the pancreas?
-Exocrine (digestion)
-Endocrine (produces insulin)
Management of pancreatic cancer?
Difficult to treat definitely as it often presents late.
o Definitive:
Whipple’s resection (pancreaticoduodenectomy), ix: resectable lesions in the head of pancreas
* Less than 20% suitable at presentation (CI: any invasion/metastasis)
Adjuvant chemotherapy is usually given following surgery
o Symptomatic (i.e. non-surgical):
ERCP with stenting
Causes of pancreatitis?
I GET SMASHED
Investigations for pancreatitis:
Serum amylase (look for >3x normal)
Lipase is a more sensitive marker
USS (i.e. for gallstones)
Contrast-enhanced CT
Scoring criteria for pancreatitis?
PaO2 <8kPa
Age >55yo
Neutrophils >15x109/L
Ca2+ <2mmol/L Ca2+ complexes with FFAs from released lipases so lower = worst
Renal urea >16mmol/L N.B. hypercalcaemia can CAUSE pancreatitis
Enzymes (LDH >600, AST/ALT >200)
Albumin <32g/L
Sugar >10mmol/L
Management of acute pancreatitis?
Acute pancreatitis - Fluids, analgesia (IV morphine, 1-2mg STAT boluses until comfortable)
Necrotising pancreatitis - fluids, analgesia, ABx
Key features:
* Maintain enteral route of feeding
* No ABx unless indicated
* Aggressive fluid resuscitation (3-6L of redistribution can occur)
* Correct the cause (GET SMASHED) – MRCP, ERCP
Management of infected pseudocyst?
mx: trans-gastric drainage / endoscopic drainage
Chronic pancreatitis: s/s & ix?
o Signs & Symptoms:
Pain is typically worse 15 to 30 minutes following a meal
Steatorrhoea (5 and 25 years after the onset of pain)
DM (>20 years after symptoms begin)
o Investigations:
USS (i.e. for gallstones)
Contrast-enhanced CT
Faecal elastase (measures exocrine function)
Screening (DM w/ annual HbA1c; osteoporosis w/ annual DEXA)
Ix for NAFLD?
1st LFTs (ALT > AST), lipids, cholesterol
2nd USS (increased echogenicity)
3rd Enhanced Liver Fibrosis (ELF) panel blood test OR a Fibroscan:
4th liver biopsy
Inheritance pattern of haemochromatosis?
Autosomal recessive
Sign of haemachromatosis on liver biopsy?
Perl’s stain
Management of haemachromatosis?
o Management:
1st: venesection (TF kept <50%)
2nd: desferrioxamine
Causes of SBP?
Cause E. coli > Klebsiella, Strep [complicated by hepatorenal symptoms in 30%]
Ix of SBP?
USS (confirm ascites) ascitic tap PMN >250/mm3 + MC+S
Management and prophylactic treatment for SBP?
Mx: piptazobactam (tazocin) or cefotaxime
Prophylaxis: ciprofloxacin + propranolol (beta blocker)
* If you have an ascites and a protein (not SAAG) of ≤15g/L, then START prophylaxis
* I.E. you don’t need a previous episode of SBP to warrant ciprofloxacin
Why do you get gynaecomastia in liver disease?
o Chest (gynaecomastia (failure of liver to break oestradiol down)
4 causes of massive splenomegaly?
CML, Myelofibrosis, Malaria, Lymphoma
Signs of portal hypertension?
Splenomegaly
Ascites
Varices
Encephalopathy
Remember by acronym SAVE
Look for caput medusae
Ix for suspected liver disease?
I would like to check external genitalia, look for hernias, stool sample
o Bloods (FBC, U&Es, LFTs, CRP, clotting, AFP, iron studies, hepatitis serology, autoantibodies, caeruloplasmin)
USS abdomen (± Fibroscan ± biopsy)
Haematoxylin and Eosin (H&E)
Prussian blue (iron)
PAS (A1AT)
Rhodamine (copper)
Congo red (amyloidosis)
o Endoscopy (OGD, colonoscopy)
Management of ascites?
o Diet restrict ETOH and fluids (if Na+ <125mmol; <1.5L fluids/day), low Na+, daily weights
o Diuretics spironolactone (± furosemide)
o Prophylaxis (SBP) ciprofloxacin + propranolol
o Refractory TIPS, transplant
Management of liver decompensation?
Lactulose, diuretic
PBC antibodies?
Anti-mitochondrial antibodies
S/S of PBC?
o Signs & symptoms (“itching in a middle-aged woman”):
Pruritis Raised ALP AMA
Obstructive jaundice RUQ pain (10%) Raised IgM
Hypercholesterolaemia (xanthelasma) Mild Sjogren’s Middle-aged women (9: 1)
Ix for PBC?
Cholestatic liver biochemistry (raised GGT/ALP, normal transaminases)
Autoantibodies (AMA [98% of patients]; raised serum IgM)
Biopsy (this is required for a definitive diagnosis but not often carried out; only perform if doubt of dx)
Bloods, antibodies, biopsy
Tx for PBC?
1st line: ursodeoxycholic acid ± cholestyramine (pruritis) ± prednisolone (associated AI disease)
2nd line (end-stage): Liver transplantation (e.g. if bilirubin > 100 (PBC is a major indication)
Fat-soluble vitamin supplementation
ERCP ‘beaded’ appearance = which condition?
PSC
Antibodies in PSC?
pANCA
Ix for PSC?
Diagnostic: MRCP (preferred) > ERCP (‘beaded’ appearance from biliary strictures)
p-ANCA
Biopsy of bile duct (fibrous, obliterative cholangitis often described as ‘onion skin’)
plate ‘piecemeal necrosis’, bridging necrosis indicative of what?
Autoimmune hepatitis
Pain + fever + jaundice = ?
Cholangitis
Mx of acute cholecystits?
IV ABx + laparoscopic cholecystectomy (within 1 week)
S/s of acute cholangitis?
Charcot’s triad = fever > RUQ pain > jaundice (incl. blood test jaundice)
Reynold’s pentad = + hypotension, confusion
Mx of acute cholangitis?
IV ABx + ERCP (24-48 hours)
1st line in suspected GB cancer?
CT
* ERPC (gold-standard staging)
* MR abdomen (staging)
Coeliac disease gold standard diagnosis?
Duodenal biopsy
Most sensitive antibodies in coeliac disease?
Anti-TTG antibodies
Complications of coeliac disease?
micronutrient deficiency (vitamin D, iron), osteoporosis, EATL, hyposplenism)
Ix for appendicitis?
CT
Mild/moderate/severe IBD flare?
Mild (<4 stools/day, little blood)
Moderate (4-6 s/d, varying blood, no systemic upset)
Severe (>6 bloody stools, systemic upset)
Ix in IBD flare?
Investigations:
1st: bloods (FBC, U&Es, CRP, LFTs, pANCA) 1st: stool cultures
Scope (capsule endo, colonoscopy, etc.)
Faecal calprotectin
Barium (or gastrograffin) enema
Acute CT-AP
Histology crohn’s
Skip lesions, rose-thorn ulcers, cobblestoning
String sign of Kantor (narrow ileum stricture)
Granulomas, goblet cells
Histology UC
Continuous, ‘lead-pipe’, pseudo-polyps, thumbprinting
CRC risk higher in UC than CD, PSC
Mucosa & submucosa (goblet cells, crypt abscesses)
IBD extramaifestations:
A Aphthous ulcers [CD>UC]
P Pyoderma gangrenosum S Sclerosing cholangitis (primary) [UC]
I (eye) – iritis, uveitis, episcleritis [CD>UC] A Arthritis
E Erythema nodosum C Clubbing [CD>UC]
Inducing remission in Crohn’s?
o Mild oral prednisolone
o Severe IV hydrocortisone no improvement after 5 days IV infliximab
o Distal ileal, ilio-caecal, R-sided colonic oral budesonide
- Nutritional: can be very effective
o Replace diet with whole protein modular diet – excessively liquid, for 6-8 weeks
o Products are easily digested, provide all nutrients needed to replace lost weight
Maintaining remission in crohn’s disease?
- 1st: DMARDs (azathioprine (pro-drug 6MP), mercaptopurine, methotrexate)
o Check TPMT levels first: if low levels, consider methotrexate
o Vaccines (no live vaccines): pneumococcal, influenza - Alternative: aminosalicylates (e.g. mesalazine)
- Alternative: Anti-TNF antibodies in biologic therapies (e.g. infliximab)
SE of mesalazine?
Pancreatitis
Treatment of UC
1st line, distal colitis: topical (4 weeks) oral aminosalicylates (± topical)
1st line, extensive colitis (past splenic flexure): topical + oral aminosalicylates
2nd line: topical oral corticosteroid (beclomethasone)
3rd line: oral tacrolimus
4th line: biological agents (infliximab, adalimumab and golimumab)
5th line: surgery
Tx of severe UC, sudden onset?
IV steroids ± IV ciclosporin/infliximab (if no improvement in 72h) colectomy
Tx of UC with >2 or equal to 2 severe exacerbations yearly
oral azathioprine or oral mercaptopurine
Severe, non-fulimant UC disease treatment?
topical aminosalicylates + oral aminosalicylates + oral corticosteroid
Ix for haemorrhoids?
o Abdominal exam inc. DRE
Found commonly at 3, 7 and 11 o’clock
o Proctoscopy/sigmoidoscopy (internal haemorrhoids)
Mx of haemorrhoids?
o Medical, 1st line – increased fluid/fibre, stool softener, topical analgesics, steroids (supp.)
o Non-operative – rubber-band ligation, sclerotherapy (phenol), electrotherapy, infrared coagulation
o Surgical – haemorrhoidectomy, haemorrhoidopexy , HALO (Haemorrhoidal Artery Ligation Operation)
Bacillus cereus associated with what?
Reheated rice
Traveller’s diarrhoea
E.coli
Treatment for salmonella typhi?
Ceftriaxone, switch to cipro if sensitive
Multiplies in Peyer’s patches
Indolent, Rose spots, fever, constipation
Splenomegaly, anaemia, leucopoenia
Condition?
Typhoid
Dysentery organisms?
CHESS
Campylobacter, haemorrhagic E.coli, entamoeba histolytica, shigella, salmonella
Rice-water stool?
Cholera
Causative organism of GBS?
Campylobacter jejuni
Treatment of campylobacter jejuni
Clarithromycin or
Ciprofloxacin
Treatment for giardia?
Metronidazole
A 69-year-old male presents to the Emergency Department after several episodes of vomiting bright red blood. He has presented to the same hospital for spontaneous bacterial peritonitis, alcohol intoxication and peptic ulcer disease (PUD). The gastroenterology team reviewed the patient and performed an urgent gastroscopy, which revealed several oesophageal varices.
Which medication should be prescribed to this patient to reduce his chance of future variceal bleeding?
Propanolol
Angiodysplasia?
Aberrant bleeding blood vessels. Massive bleeding with haemodynamic instability may occur in 15% of patients, and a similar percentage present chronically with hypochromic microcytic anaemia. Angiodysplasia occurs with equal sex distribution and is most common in patients > 60 years of age. The treatment of choice is endoscopic ablation of abnormal vessels.
Best test to check for H. Pylori eradication?
The 13C urea breath test
A 58-year-old male is reviewed in the surgical clinic and presents with trouble defecating, and although he still passes his motions normally, over the past month, he has noticed the uncomfortable feeling of still wanting to defecate after passing his motions. During the past two weeks, he has noticed he has been passing mucus and some blood but no change in colour. Examination is unremarkable.
Which is the most appropriate investigation?
Colonoscopy
This patient is experiencing a change in bowel habit: difficulty in defecating, a sensation of incomplete emptying, and passing of mucus per rectum. The main differential diagnoses include colorectal cancer, colorectal polyps and diverticular disease. For the diagnosis of colon cancer, NICE recommends colonoscopy as an initial investigation in those without major co-morbidities. If a lesion is visualised, it can be biopsied, allowing a diagnosis of colon cancer. Flexible sigmoidoscopy, followed by barium enema, can be offered in those with major co-morbidities.
A 60-year-old male presents to the Emergency Department with central crushing chest pain radiating to his arm and jaw. His electrocardiogram (ECG) shows ST elevation in leads II, III and aVF, with reciprocal changes in I and aVL.
Which of the following vessels is likely to be blocked?
Right coronary artery
In a myocardial infarction affecting which artery, would you see ST elevation in leads I, aVL, V5 and V6 (i.e. the lateral leads, with reciprocal changes in the inferior leads II, III, and aVF).
the left circumflex artery
Left anterior descending artery infarction ECG changes?
ST elevation in V1-6 (anterior septal leads)
Viral causes of head and neck cancer?
HPV can cause oropharyngeal cancer.
EBV = nasopharyngeal
Borders of the anterior triangle?
Mandible, midline, sternocleidomastoid
Borders of the posterior triangle?
Sternocleidomastoid, clavicle, trapezius
Lumps in the midline?
Thyroglossal cyst, thyroid, dermoid cyst
Lumps in the anterior triangle?
Parotid gland pathology, submandibular gland pathology, carotid pathology, brachial cyst
Anterior OR posterior triangle?
Lymphadenopathy, sebaceous cyst, lipoma
Posterior triangle lumps?
Cervical rib, pharyngeal pouch, cystic hygroma (congenital deformity)
Treatment for a quinsy?
Drain it with a needle, antibiotics and fluids
