Gastro Flashcards
primary biliary cholangitis M rule and path
raised IgM
anti mitochondrial abs (m2 subtype)
Middle aged females
Raised ALP bc obstructive ( autoimmune destruction of bile ducts in liver (chronic inflam = fibrosis of duct walls) = cholestasis and obstruction) which may lead to cirhosis
primary biliary cholangitis presentation and complications
middle aged women
fatigue, pruritis, jaundice
xanthelsma/xanthomata
Hyperpigmentation over pressure points
10% RUQ pain
clubbing n hepatosplenomegaly
late = may progress to liver failure
primary biliary cholangitis ix
immune
- AMA ABs
- IgM
LFT - Raised ALP
RUQ Ultrasound or MRCP - to exclude extrahepatic biliary obstruction
Primary biliary cholangitis Mx
1st line = ursodeoxycholic acid
itch = cholestyramine
fat soluble vitamine supplements
liver transplant if bilirubin> 100
PPI SE
hyponatramia hypomagnasaemia
osteoporisis –> inc risk of fractures
increased risk of C.diff
refeeding syndrome electrolytes n what do they cause
hypophosphataemia !!
hypokalaemia
hypomagnesaemia
hypophos = muscle weakness, myocardial ->cardiac failure, diaphragm ->resp failure
hypomag = predispose to torsades de pointes
coprescribed w isonizid and why
pridoxine (vitamin b6) to prevemt peripheral neuropath
pharyngeal pouch ix and def mx
barium swallow w dynamic vid fluroscopy
surgical myotomy and resection
what to give before endoscopy in pt w sustpected variceal haemorhage
terlipressin and abx
prophylaxis of variceal haemorrhage
propanolol
ligation (EVL) (if medium to large varicies) 2 weekly until all eradicated (+PPI to prevent evl ulceration)
all fails = Transjugular intrahepaatic portosystemic shunt (TIPSS)
alcoholic ketoacidosis when it happens n tx
chronic alcoholics after period of reduced food intake
IV fluids and thiamine
(rehydrate and prevent wernickes)
ascites secondary to liver cirrhosis duiretic
aldosterone - spironalactone
liver abcess tx
abx and image guided percutaneous drainage
if fails = surgical resection
Hydatid cyst = surgical resection 1st Differentiate from abcess by CT = better circumscribed
upper GI bleed vs lower GI bleed
drop in haem
high urea = upper GI
how long stop PPI before endoscopy
2 weeks
liver cirhosis dx and monitoring
also who to screen with it
transient elastography (measures liver stiffness)
hep C
men >50units week alcohol women > 35
people dx w alchol related liver disease
Further investigations in pt w new liver cirrhosis dx
endoscopy to check varices
liver US 6monthly =/- Alpha feta protein to check hepatocellular Ca
constipation and diarohea in IBS tx
bulk forming laxative ie isphagula husk
avoid lactulose (increases gas = worsens sx )
constipation >12 months and max doses of previous laxatives from different classes not helped = linaclotide
diahorea = loperamide
dont use PPI w what
clopidegrel = reduces efficacy
pancreatic Ca presentation n what type
painless obstructive jaundice ( cholestatic LFTs)
pale stools, dark urine, itchiness
many pt non specific ie anorexia, wt loss, epigastric pain
maybe abdo mass
loss of exocrine fxn = steatorrhea
loss of endo fxn = DM
most are adenocarcinoma of head
pancreatic ca ix
high resolution CT
double duct sign (dilitation of common bile ducts and pancreatic ducts
pancreatic ca mx n Ses
most not suitable for surg at dx (only 20%)
whipples for resectable lesions on head. SE = dumping syndrome and peptic ulcer disease
adjuvent chemo post surg
ERCP with stenting for palliation
spontaneous bacterial peritonitis (SBP) what is it n sx
Ascitic fluid infection
peritonitis in pt w ascites 2ndy to liver cirrhosis
= ascites abdo pain and fever
SBP dx, mc organism mx
dx = paracentesis neutrphils > 250
E.coli
Mx = Iv cefotaxime
when to give proph abx in ascites
prevous episode of SBP
fluid protein< 15g/l and (childpugh>9 or hepatorenal syndrome)
oral cipro or norfloxacin
UC flare severity
mild = <4stools a day small blood
mod = 4-6, varying blood no system upset
sever= >6 bloody a day + system upset
small bowel bacterial overgrowth syndrome (SBBOS)
RFs, sx,
RFS =
neonates w congen GI abnormal
scleroderma
DM
crohns
features overlap w IBS
chronic diarrhoea
bloating flatulence
abdo pain
SBBOS dx and mx
dx
hydrogen breath test
if inconclusive = small bowel aspirate n culture
clinicans sometimes give abx course as diagnostic trial
mx
corection of underlying disorder
abx = rifaximin 1st (also coamox and metroni)
gastric ulcer presentation
pain during or after eating bc stomach produces acid to food
duodenal ulcer presentation
pain when stomach empty ie several hours after food
improved by eating
prolonged vomiting electrolytes n why
metabolic acidosis (inc pH and bicarb =)
hypokalaemia
too much vom = fluid loss = RAAS activated = more Na resorb at DCT (water follows) to inc blood vol = therfore by exchanging K –> too much k lost
crohns flare isolated peri anall disease
metronidazole
inducing remision in crohns
glucocorticoids
2nd line = mesalazine
add on aziathioprine/mercaptopurine or methotrex
when to use infliximab in crohns flare
refractory disease
fistulating crohns
pt typically continue on azath or methotre
maintaining crohns remission
stop smoking
1st line = azathioprine or mercaptoprurine (CHECK TPMT)
2nd = methotrexate
acalculous cholecystitis
inflammation of gallbladder with no stones
pt w underlying comorb eg DM, vasculitis, organ failure SLE
systemically unwell high fever RUQ pain, no jaundice
mx
pt fit = cholesystectomy
unfit = percut cholecystostomy
Crohns features NESTS
N no blood or mucus
E entire GI tract (mouth to anus)
S Skip lesions endoscopy
T terminal ileum most affected + Transmural inflam (full thickness)
S smoking risk factor
UC features CLOSEUP
C Continuous inflam
L limited to colon and rectum
O only superficial mucosa affected
S smoking protective
E Excrete blood and mucus
U Use aminosalicytes
P Primary sclerosing cholangitis
child with tracheooesphageal fistula followinf repair may develop
benign oesophageal fistulas
proctitis meaning
inflammation of anus and lining of rectum
chronic mesenteric ischaemia triad
intestinal angina
severe colicky post prandial abdo pain
weight loss
abdominal bruit
Budd chiari syndrome what is it, triad and ix
hepatic vein thrombosis usually seen in context of underlying procoagulant condition (inc preg and COCP)
triad
sudden onset sever abdo pain
ascites and abdo distension
tender hepatomegaly
Ix - US w doppler flow studies
ascites tap serum acistic albumin gradient (SAAG) <11g/l
hypoalbunaemia: nephrotic, severe malnut (kwashiorkor)
malignancy; peritoneal carcinomatosis
Infections; tuberculous peritonitis
others; pancreatitis, bowel obs. biliary ascites
post op lymphatic leak, serositis in connective tissue disease
ascites tap serum acistic albumin gradient (SAAG) >11g/l
indicates portal htn
liver: cirhossis, acute failure, liver mets
Cardiac: RHF, constrictive pericarditis
Other: budd chiari, portal vein thromb, veno occlusive disease, myxoedema
liver decompensation what is it and trigger factors ABCDI
significant decline in cirrhosis pts (jaundice and confusion)
Alcohol
bleeding
constipation
drugs (sedatives) or dehydration
infection
upper GI bleed score post endoscopy
Rockall score used after endoscopy and provides a percentage risk of rebleeding and mortality
investigation for perianal fistulae in pt w crohns
MRI pelvis
achalasia investigations
oesophageal manometry
- excessive LOS tone which doesn’t relax on swallowing
barium swallow
- grossly expanded oespgagus
- BIRDs beak appearence
Chest xray
- wide mediastinum n air fluid level (bc lack of peristalsis)
primary sclerosing cholamngitis asx w which IBD
UC
TIPSS tx for osephageal varcies can cause what
excerbation of hepatic encephalopathy
bc shunt = blood bypasses liver into systemic cirulation w/o metabolism of nitrogenous waste products = build of ammonia which crosses BBB
haemorrhoids grading
grade 1 - do not prolapse out of anal canal
grade 2 - prolapse on defecation but reduce spontaneously
grade 3 - manually reduced
grade 4 cannot be reduced
mallory weiss tear
superficial tear of mucosa
post binge vomitting ie night out
self limiting
boerhaaves syndrome path signs, ix, tx
transmural spontanous rupture of oesphagus into chest
pt chronic wreching ie alcoholic or bulimic
fever dyspnea severe onset chest pain
air in mediatinum (sc emphysema) cxr and physical
IX - CT contrast barium swallow
tx - thoracotomy and lavage <12 hrs
acute mesenteric ischaemia
embolism in artery supplying small bowel
usually hx of AF
severer sudden onset abdo pain out of keeping with physical exam
increased lactate
immediate laparotomy
chronic mesenteric ischaemia
‘GI angina’
colicky intermittent abdo pain w eating = avoid eating n wt loss
Ischaemic colitis
what is it
where
pt
ix
tx
acute transient compromise in blood flow to large bowel –> leading to inflam, ulceration and haemorhage
watershead areas ie splenic flexure
pt maybe hypotensive bc something else then == Painful bright red blood per rectum
abdo XR = thumbprinting
tx supportive unless too bad (peritonitis, perf etc) = surgery
mesalazine complication
pancreatitis
less so in sulfasalazine
associations with h.pylori
1 peptic ulcer disease (duo>gastric)
2 gastric adenocarcinoma
3 B cell lymphoma
4 atrophic gastritis
how to calculate units of alcohol
(ml x %)/1000
ie 25ml spirit (ABV 40%) = 25x40/1000 = 1unit
Vitamin C defiiciency
scurvy
easy bruising, gum bleeding, lethary, joint pain
poor diet ie nutrional deficiency
crohns sign on exam
abdo mass palpable in right iliac fossa (terminal ileum)
anaemia of chronic disease blood
serium iron low
total iron binding capacity = dec/normal
serum ferritin = Normal/ increased
iron def anaemia blood
serum iron low
TIBC = increased
serum ferritin = decreased
pancreatic cancer Ix and dx
USS first
High res CT for definitive
double duct sign ie common bile and pancreatic duct dilatation
life threat C diff
oral vanc
IV metronidazole
autoimmune hepatitis
antibodies
pt
ix
tx
anti smooth muscle
ANA
(Type2 kids only = antiliver/kidney LKM1)
young female
amenorhea
deranged LFTs
signs of chronic liver disease or acute hep ie fever jaundice
ix = liver biopsy, piecemeal necrosis and bridging necrosis
mx = steroids and azathioprine (immunosup)
liver transplant
haemochromatosis genetic
autosomal recessive
drug induced cholestatic +/- hepatitis
COCP
abx - fluclox. coamx, erthryro
anabolic steroids, testosterone
sulfonurea
coeliax disease associated Ca
enteropathy-associated T cell lymphoma
abx causing c diff
clindamycin
ceftriaxone
Peutz jeghers syndrome
autosomal dominant condition
hamartomous polyps in GI (mainly small bowel)
- ie common PC is small bowel obstruction bc intussusception
age 10-15
pigmented lesions on lips, oral mucosa, face palms and soles
predict mortality in liver cirrhosis pt
child pugh score
what blood marker to use to asses severity of liver cirrhosis
albumin
hepatic encephalopathy tx
lactulose and rifaximin
loperamide mechanism and indication
opioid receptor agonist (only on gut)
anti diarhoea
1st line IBS accordind to sx
pain = anti spasmodic
constipation = laxatives (avoid lactulose) ( if nothing works or constipated>12mths = 2ndline linaclotide)
Diarhorea = loperamide
barium enema UC
lead pipe colon in distal paart
ie loss of haustral markings
caused of increased ferritin without iron overload (ie normal transferrin saturation)
inflammation
alcohol excess
liver disease
ckd
malignancy
best measure of liver function in acute liver failure
prothombin
bc shorter half life than albumin sp changes more suddenly
initial screening test for haemochromatosis
general pop: transferrin sat> ferritin
family members: genetic testing
alcoholic hepatitis liver enzymes
AST/ALT 2:1 ratio
raised GGT
NAFLD found incidentally on uss
enhanced liver fibrosis (ELF) blood test
to check for fibrosis
lymphatic spread of gastric ca
left supraclavicular node (virchows)
periumbilical nodule (sister may joseph)
diagnosis of gastric ca
OGD with biopsy
signet ring cells –> more of them = worse prog
CT for staging
pt on aminosalicylate becomes unwell soar throat fatigue bleeding guma
agranulocytosis CHECK FBC
surgucak tx of achalasia if recurrent sx post pneumatic balloon dilation
what if high surgical risk?
heller cardiomyotomy
intra-sphincteric botox injection
NAFLD LFTs
ALT>AST - Lard = NAFLD
can also have mild elevations of ferritn
alcoholic hepatitis LFTS
AST>ALT - Spritis = alocholic hepatitis
Differentiating betweem primary bilary cholangitis
and
primary sclerosing cholangitis
PBC = +ve anti mitochond
PSC = +ve anti smooth muscle and ANA
Asssociated w UC
wilsons age path
autosomal recessive
faulty gene = liver can excrete copper = build up in all tissues
wilsons disease deposits where n also other fx
liver
brain
cornea
kidneys
haemolysis
blue nails
wilsons disease neuro deposition where and manifestaions
basal ganglia degen bc deposits in it esp putamin and globus pallidus
speech behavour psych problems (usually 1st manifestations)
asterixes chorea dementia parkinsonim
copper deposition in cornea in wilsons
= keiscer fleicher rings in around iris bc accum in descement membrane
copper deposition in kidneys wilsons
renal tubular acidosis (esp fanconi syndrome)
wilsons IX
serum caeruloplasmin (reduced)
serum copper (reduced)
24hr urinary copper (increased
confirm dx genetic test of ATP7B gene
wilsons gene
ATP7B
wilsons tx
penicillamine
trientine hydrochloride
King’s College Hospital criteria for liver transplantation (paracetamol liver failure)
Arterial pH < 7.3, 24 hours after ingestion
or all of the following:
prothrombin time > 100 seconds
creatinine > 300 µmol/l
grade III or IV encephalopathy
used to monitor haemochromatosis
ferritin and transferrin saturation
mc cause hypopitruitrism
non secretetory pitruatry macroadenoma
early signs haemochromatosis
fatigue, erectile dysfunction and arthralgia
wilsons blood
reduced caeruloplasmin
anaemia of chronic disease bloods
normocytic
low serum iron
low TIBC
raised ferritin
pt w chronic illness
iron studies in haemochromatosis
raised transferrin saturation
raised ferritin
low TIBC
haemochromatosis fertility complication
non reversible
hypogonadotrophic hypogonadism
bc pitruatry dysfunction
gluten free foods
rice
pottatos
corn (maize)
gluten avoid food
wheet = bread pasta pastry
barley = beer
rye
oats
primary biliary cholangitis complications
complications;
- cirhosis -> portal HTN -> ascites, variceal haemorhage
- osteomalacia and porosis
- inc risk of hepatocellular ca
barrets oesphagus
metaplasia ie from squamous to columnar
may resemble that of stomach/small intest ie
goblet cells
brush border
paneth cells
barrets mx
PPI
if metaplasia = endoscopy 3-5yrs
dysplasia of any grade identified =
endoscopic radiofrequency ablation
endoscopic mucosal resection
volvulus types and ix
sigmoid
caecal
abdo xr
sigmoid volvulus signs associations n tx
large bowel obstruction coffee been sign on xr
older
chronic constipation
chagas disease
neuro - parkinsons, duchennes
shizophrenia
flatus tube (thru rectum)
caecal volvulus associations n tx
all ages
adhensions
pregnancy
small bowel obstruction on xr
right hemicolectomy
hep A sx
flu ike sx
RUQ pain
tender hepatomegaly
deranged LFTs
raised billirubin
raised ALT/AST
normal/slight raised ALP
anal fistula investigation
MRI pelvis
Hep E
spread
incubation
place
feaco oral
3-8 weeks
central n south east asia, north n west africa, mexico
significant mortality during pregnancy
hepatitis spread
A and E spead faecally
B-D spell BlooD
diarohea and wt loss differentials
IBD
IBS
colorectal ca
coeliac
thyrotoxicosis
chronic panc
crohns histology
endoscopy
inflammation all layers from mucoas to serosa
inc goblet cells
granulomas
skip lesions
cobblestoning
deep ulcers
mouth to anus
extraintestinal fx crohns
erythema nodosum
iritis/conjuctivitis/episcleritis
larg joint arthritis
Ankspond
apthous ulceration
how doesinfliximab work in cohns
TNF inhib
tumor necrosis factor imporant in establishing inflammation and granulomatos inflammation
upper GI bleed causes
oesphageal varices
peptic ulcer
mallory weiss tear
gastric ca
oesphagitis
aortic enteric fistula
bleeding disorders
site of portosystemic shunts (bc liver cirhossis) and sx
superior rectal vein shunt –> haemorrhoids
paraumbilical vein shunt –> caput medusae
traumatic tap
blood makes way into LP
disease inc risk of berry aneurysms ie SAH
polycystic kidneys
ehlers danlos
coarctation of aorta
kernigs sign
bend hip and knee to 90degrees
pain when straightening knee =positive sign
=meningeal irritation
why is pain in appendicitis first felt in the periumbilical region before mcburneys point
Irritation of the visceral peritoneum by the inflamed appendix is felt in the T10 dermatome, which corresponds to the periumbilical region. This is because the visceral peritoneum has no somatic innervation, so the brain perceives visceral signals as being from the same dermatome as where the visceral signals enter the spinal cord. As the appendix is found in the midgut, the corresponding dermatome is T10 .
As the disease progresses, the parietal peritoneum becomes affected. As this receives somatic innervations, the pain is well
localised to the area o f inflammation. (1)
ALARMS sx dyspepsia
anaemia
loss of weight
anorexia
recent onset progressive sx
malena/haemetasis
swalling difficulty
virchows node
whats mc duo or gastric ulcer
duo = 4x more common
why do u get noctural asthma (wheeze) in GORD
inhalation of small amouns of gastric contents
indications for nisse fundo in gord
all 3 of
severe sx
refractory to medical therapy
confirmed reflux by ph monitering
hiatus herna types
sliding (MC) GOJ slides into chest
rolling
mixed
which hernia to repair
rolling bc may strangulate
post hep juaundice urine stools and why
dark urine
pale stools
billirubin that has conjugated with gluconuride in hepatocytes = water soluble
dissolves in urine
post hep jaundice ix
urine inc billirubin
bloods
abdo USS
ercp
panc ca therapeutic tx
ercp w stenting
cx persistent jaundice
inc suscept to infexn
pruritis
liver dysfxn
aki
hepatitis at risk groups
IVDU
sex workers
health workers
haemophiliacs
distaste for cigarrettes hep
viral hep A
viral hepatitis mx
supportive
no alcohol
or hepatotoxic dx ie aspirin
anti viral
indicated in chronic disease
hep b = PEGinterferon
hep C = PEGinterferon n ribvarin
hep b n c cx
chronic hep
cirhossis
hepatocell ca
hep b may also be infected w
hep c and d
HIV
blood for synthetic liver fxn
albumin
PT/INR
cirhossis cx
ascites
SBP
coagulopathy
encephalopathy
hypoglycaemia
portal htn sequelae cx
SAVE
splenomeg
ascites
varices (oesp,caput med, worsens existing piles)
encephalop
ascites mx
fluid restirct low na
ascitic tap
duiretics - spiro
albumin infusion
why lactulose in hepatic enceph
inc bowel transit
= reduce nitrogen producing bact in gut which contribute to hepatic enceph
coeliac path
autoimmune abs againt gluten
= modifed and presented to T cells
= inflam of small bowel
mc source gluten
wheat
why might anti endomysial abs be -ve inceoliacs
seevre malabsorb = Iga and other protein deficiency
coeliac histo
crypt hyperplasia
villous atrophy
lymphocytic infiltration
ca associated w coeliax
GI T cell lymphoma
gastric
oesphageal
unexplained iron def anaemia
colonscopy
id right sided colonic tumor
COLON ca rf
IBD
neoplastic polyps
HNPCC
low fibre
