Gastro Flashcards
Peripheral stigmata of chronic liver disease
Palmar erythema
Spider naevi
Dupytrens contracture
Gynaecomastia
Caput medusae
Splenomegaly
Why do you get splenomegaly in ALD?
Portal HTN
What is a fibroscan for
To quantify liver fibrosis
What are the majority of gastric cancers
Adenocarcinomas
Arising from the glandular epithelium
RFs for gastric cancers
Japanese
H pylori
Hypochlorodyia
- pernicious anaemia
- chronic atrophic gastritis
- partial gastrectomy
FH
Male
Age
High salt / nitrates ./ processed foods
Gastric polyps
What is virchows node
A palpable lymph node in the left supraclavicular fosssa, which indicates the spread of an Upper GI malignancy
What is PSC
Progressive bile duct inflammation, stricturing and cholestasis which is autoimmune medicated
Results in scarring of the bile ducts and accumulation of toxins
60-70% of people with PSC have what?
UC
How is PSC diagnosed?
MRCP
Presentation of PSC
Asymptomatic
Fatigue
Pruritis
Obstructive jaundice
Cirrhosis/hepatic failure
Which blood test is raised in PSC?
ALP
What antibodies may be present in PSC?
Anti smooth muscle
Anti-nuclear antibodies
What relieves itching in PSC?
Cholestyramine
Tumour marker for CRC
CEA
Tumour marker for pancreatic ca
CA19-9
The combination of liver disease, resp disease and a FH of resp disease indicates what?
a-1 anti trypsin defieincy
Liver biopsy findings of a1 anti trypsin defiiency
PAS positive, diastase resistant globulesin periportal hepatocytes
What antibodies are seen in PBC
Anti-mitochondrial Abs (AMA)
Raised IgM
Rash assosciated with coaeliac
Dermatitis herpetiformis
Antibodies used in the detection of coeliac disease
Anti-endomysial IgA
Anti-gliadin IgG
Anti-reticulin IgM or IgG
Anti-TTG
Definitive test of coeliac disease
Duodenal biopsy
When drugs have a high rate of first pass metabolism, what does this mean?
High liver extraction
Drugs that have a high rate of first pass metabolism
Propranolol
Verapramil
Morphine
Pathophysiology of haemachromatosis
Decreased plasma hepcidin
C282Y mutation (Genetic code for HFE protein)
What can give rise to BOTH intra and extra hepatic bile duct dilatation
PSC
Cholangiocarcinoma
What organism is responsible for > 50% of SBP
E coli
Features of haemachromatosis
Hepatic dysfunction
Diabetes
Joint pains
increased skin pigmentation
Gene change in haemachromatosis
HFE gene
What is in excess of haemachromatosis
Iron
What is in excess of wilsons disease
Copper
What is the most common complication of H pylori
DU
Histology of CD
Transmural (full thickness)
Patchy skip lesions
Non caesating granulomas
Histology of UC
Inflammation confined to mucosa and submucosa
Histological changes to crypts are common, including crypt distortion, neutrophilic crypt distraction and crypt abscesses
Treatment of aspirin overdose
Activated charcoal
Causes of drug induced hepatitis
Fenofibrate
Methyldopa
Carbamazepine
Nitrofurantoin
Isoniazid
When are black pigment gallstones often seen
Haemolysis
Cirrhosis
When are brown pigment gallstones seen
Very rarely seen in UK
Stasis and infection in the biliary system
Prescence of E coli or Klebsiella
WHat makes up 80% of gallstones in the UK
Cholesterol
Assosiations of cholesterol gallstones
Hypertriglyceridaemia
What is the appearance of a bird beak on barium swallow indicatative of ?
Achalasia
Treatment of wilsons disease
Penicillaemine
Blood and urine findings in wilsons disease
Decreased serum copper and caeroplasmin
Increased urinary copper excretion
What is boerhave syndrome
Oesophageal rupture following repeated and severe vomiting
What is a diuefloys lesion
Bleeding from a totorous dilated artery in the mucosa of the GI tract, usually the stomach
Blood features of pernicious anaemia
Increased bilirubin
Megaloblastic anaemia
Antibodies of pernicious anaemia
Anti parietal cell Abs (90%)
Anti-thyroid Abs (50%)
Treatment of pernicious anaemia
VitB12 injections
What is there an increased incidence of in the elderly with pernicious anaemia
Gastric carcinoma
Imaging modality if suspecting appendicitis
CT
Histology of CD
Transmural inflammation
Skip lesions
Fissuring ulcers
Mucosal ulcers
Lymhpoid aggregates
Neutrophil infiltrates
Non ceseating granulomas
Histology of UC
Mucosa and submucosa only
Inflammatory cell infiltrate
Crypt abscesses
ALT to AST ratio in NAFLD rather than ALD
ALT : AST > 2 suggests NAFLD rather than ALD
Haematological S/Es of ribavirin (Hep C Tx)
Haemolytic anaemia
Nausea / vomiting
Dry mouth
Stomatitis
`
Test to assess pancreatic exocrine function
Faecal elastase
Inheirtance of gardener syndrome
AD
Features of gardener syndrome
Multiple adenomatous intestinal polyps
Colonic carcinoma
Osteomas
Soft tissue tumours including lipomas, fibromas and epidermal cysts
Congenital hypertrophy of retinal pigment epithelium
Genetics of gardener syndrome
Mutation on APC gene on chromosome 5q21
What kind of polyps are most concerning for the development of CRC
Serrated polyps
What kind of anaemia does vit B12 malabsorption give
Macrocytic
Treatment of tropical spruae
Tetracycline
Folic acid
S/Es azathioprine
Pancreatitis
Hypersensitivity reactions
Intestinal nephritis (rare)
Bone marrow suppression
Liver disease
What part of a feed in an alcoholic patient can increase the risk of encephalopathy and why
Protein rich feeds
Adds to the total ammonia burden
Features of Menetriers disease
Rare condition
Giant gastric folds, predominantly in the fundus and body of the stomach
Histology
- gastric pits
- gland atrophy
- increase in mucosal thickness
Presentation of menetriers disease
Epigastric pain
Mild hypoalbuminuaemia
No gastric acid production in advanced cases
What is the most sensitive test for Hep C infection
HCV RNA
What does the spleenic artery supply
The spleen
What does the gastroepiploic artery predominantely supply
The stomach
What does the anterior superior pancreaticoduodenal artery supply
Anterior duodenum
Pancreas
What does the proximal gastroduodenal artery supply
Pylorus
Proximal duodenum
Then gives rise to several branches including
- posteior superior pancreaticoduodenal artery
What does the posterior superior pancreaticoduodenal artery supply
Posterior aspect of the duodenum
Overall mortality rate from vairceal bleeds
30%
Assosiations of anti-LKM positive antibodies
Autoimmune hepatitis
Drug induced hepatitis
Drugs that are known to cause chronic hepatitis
Methyldopa
Ketonazole
Isoniazid
Nitrofurantoin
WHat are the most common areas for ischamemic colitis and why
Splenic flexure
Sigmoid colon
The two blood circulations meet here and have limited collateral networks making ischaemic damage more common (watershed areas)
Features of achalasia
Abrupt onset dysphagia - fluids then liquids
Often without weight loss
Regurgitation
Night time cough
Sore throat in the morning
Investigation of achalasia
OGD to rule out carcinoma
Barium swallow (rats tail appearance at lower sphincter)
Pull through manometry (most specific)
What is Gilberts syndrome
Mild loss of glucuronosyltransferase activity
AR inheritance
Failure of conjugation results in an uncongjugated hyperbiliruaemia
Episodes of jaundice induced by fasting and are self limiting
Where are amino acids absorbed
Jejunum
What is suggestive of wernickes in a patient who seems likely to have ALD
Opthalmoplegia
Ataxia
Confusion
Lacks specific neurological signs
Visual and hearing disturbance
Changes in cognition
Seizures
Important and dangerous complication of E coli 0157
HUS
Features of HUS
Haemolytic anaemia
AKI
Thrombocytopenia
What can C diff cause on proctoscopy
Inflammed rectum
Treatment of C diff
Vancomycin
Tests for Hep A
HAV - IgM (Hep A immunoglobulin) and HAV - IgG (Hep A immunoglobulin G)
Positive HAV-IGM and HAV-IGG means what
Acute Hep A is likely
Positive HAV-IGG and negative HAV-IGM means what
Past Hep A or previous immunisation
What rises in acute hep B infection
Hepatitis surface antigen (HBsAg)
When the Hep B surface antigen is detectable, what is detectable roughly at the same time
Hepbatitis B e antigen
Hepatitis B virus DNA
What does the prescence of Hep B surface antigen, Hep B e antigen and Hep B virus DNA indicate?
Progression to chronic Hep B
What does IgM anti-HepBc indicate
Presence of infection last 6 months
What does IgG anti-hepBC indicate
Past infection
Persists for life
WHat does anti-HBs without anti-HepBc mean
A marker of immunisation
What confirms exposure to Hep C
anti-HCV antibodies
What confirms ongoing infection in Hep C
HCV-PCR
What is whipples disease
Infectious condition by bacterium trophyerma whippleli
Investigation of whipples disease
Biopsy of small intestina lamina propria
- infiltration by PAS positive macrophages containing gram positive bacilli
Treatment of whipples
Prolonged treatment with co-trimoxazole
Ceftriazxone
Penicillin
Criteria for liver transplant secondary to paracetomal OD
ph <7.3
INR > 6.5 and creatinine > 230 and grade 3/4 HE
Extraintestinal manifestation assosiated with HCV
Mixed cryoglobuninuria
Presentation of mixed cryoglobuniuria
Arthralgia
Palpable purpura
Signs of organ involvement sudch as nephropathy
Presentation of villous adenomas
Hypokalaemia, hypochloroic metabolic acidosis
Copious diarrhoea
IDA
Indications for referral to fundoplication
Young age
Persistent reflux symptoms despite maximal PPI therapy
Ongoing resp symptoms
What does protein C deficiency make you have
A hypercoagulable state
Causes of bacterial overgrowth syndrome
Upper GI surgeyr
Immunosuppresion
Chronic illlness e..g ESRF / liver cirrhosis
Use of PPIs
Conditions that affect gut motility e.g. diabetes
Scleroderma
CD
Investigations for bacterial overgrowth syndrome
Hydrogen breath test
What is Budd Chairi syndrome
Obstruction to the venous outflow system of the liver due to the obstruction of the hepatic vein
Who is at risk of getting Bud Chairi syndrome
Hypercoagulable states
- leukaemia
- polycythaemia
- COCP
Presentation of budd chairi syndrome
Abdominal pain
Nausea
Vomiting
Tender hepatomegaly
Ascites
Investigations for pernicious anaemia
Anti parietal and anti intrinsic cell antibodies
Pathological cause of wernickes
thiamine (vit B1) deficiency
What is melanis coli secondary to
Laxative use
What at baseline is the best marker for prognosticating treatment for Hep C
Viral genotyping
Characteristic sign on AXR for sigmoid volvulus
Coffee bean sign (ennourmously dilated bowel loop)
8 criteria of the glasgow severity score for acute pancreatitis
age > 55
PO2 < 8
WCC > 15
corrected ca < 2
ALT > 200
LDH > 600
Glucose > 10
Urea > 16
Albumin < 32
What is a well known recognised feature of active small bowel crohns disease
Finger clubbing
What should be offered to patients with suspected variceal bleeding
IV terlipressin
Features of dublin Johnson syndrome
Defective hepatic secretion of conjugated bilirubin
Results in mild conjugated hyperbiliuranaemia (high direct bilirubin)
AR inheritance
Liver biopsy - dark granular pigments
No Tx required
What does pseudomembranous colitis occur secondary to?
C diff infection
Investigation for bile acid malabsorption
SeHCAT test
Investigation for haemachromatosis
Transferrin saturation
What does the prescence of multiple ulcers and hyperparathyroidism indicate
Zollinger ellison syndrome
What is zollinger ellison syndrome
Pancreatic tumour that secretes gastrin
Investigation of zollinger ellison syndrome
Serum gastrin level
Genetic tests for coaeliac
HLA DQ2 and HLA DQ8
Does smoking make UC better or worse
Better
Does smoking make CD better or worse
Worse
What is the classic histological finding of Hep E infection
Marked chloestasis
What stimulates gastrin release
Gastrointestinal luminal peptides
Stomach distension
Vagal stimulation
Hypercalcaemia
Blood tests in coaelic disease
Howel jolley bodies (due to functional hyposplenism)
anaemia (microcytic/ IDA)
What organism are you concerned if an HIV positivie patient with poor complicance with meds presents with diarrhoea
Cryptosporidium (voluminous diarrhoea ++)
CMV (slightly lower stool frequency, abdo pain and fever)
Microsporidium (VERY low CD4 counts < 50)
Isospora (when travel hx)
Mycobacterium avium intracellulare (assosiated with severe immunodeficiency and other organ systems involved e.g. resp)
Antibodies of autoimmune hepatitis
Smooth muscle antibodies (70%)
Anti-nuclear factor antibodies (70%)
anti-mitochondrial antibodies
Treatment of chlorea
Single dose of PO doxycycline 300mgg
What does thrumbprinting at the splenic flexure on a AXR indiciate
Ischaemic colitis
What happens to uric acid levels in the serum in wilsons disease
Low
Inheritance of peutz jeger syndrome
AD
What deficiency are hair loss and dermatitis classic of
zinc deficiency
Vitamin C role in collagen synthesis
Hyroxylation of procollagen proline and lysine
Presentation of vit b12 deficiency
Peripheral neuropathy
Angular stomatitis
Presentation of chronium deficiency
Impaired glucose metabolism and tolerance
Presentation of copper deficiency
Neurological sx - peripheral neuropathy or optic neuropathy
Anaemia and neutropenia
Presentation of selenium deficiency
Dilated cardiomyopathy
Disease assosiated with vitamin C deficiency
Scurvery
What causes enteric fever
Salmonella
Test for chronic enteric fever
Culture from intestinal secretions, faeces or urine
who gets hydatid disease
Sheep farming work
WHat causes hydatid disease
Propagating cysts formed by echinococcus granulosis
Cysts form in the liver and rarely in the lungs
Investigation and treatment of hydatid disease
USS
Potential surgery +/- albendazole
Blood film of HUS secondary to E coli 0157
Schisocytes
Daily potassium replacement
1mmol/kg/day
Example of a prokinetic drug used in gastroporesis
Domperidone
Investigation of a patient who you suspect is having a protein leaking enteropathy
stool sample for a1 antitrypsin
Treatment of giardia
Tinidazole
Common complication of giardia infection
Lactose intolerance
What is the most potent gastrin stimulator
amino acids
WHat does gastrin do?
Increased gastric motor activity
Acid secretion
Mucosal growth
Smooth muscle contraction
Quick way of inducing remission in severe IBD flare
Infliximab
Mutation of haemachromatosis
C282Y
What is GAVE also known as
Watermelon stomach
What are common in severe malnutrition
Steatohepatitis
Hypercholesteraemia
What is the most sensitive test for Hep B viral duplication
HBV DNA
Blood film for hyposplenism
Howell Jolley bodies
Calorie requirements to maintain weight
25-35kcal/kg
Genetic mutation of HNPCC
MSH2 mutation
Genetic mutation of FAP
APC mutation
Treatment of Hep B
Infection resolves in > 90% of adults who have acute Hep B without intervention
Observe and repeat measurement of Hep B PCR test
In younger age (infancy) and underlying immunosuppression - need treatment
Correct pH if a NG tube is placed in the stomach
1.5 - 3.5
What is the deficiency seen in roux-en-Y bypass surgery
Iron
Features of bechets disease
Anterior uveritis
Orogenital ulceration
Erythema nodosum
Prev DVT
Leukocyte antigen assosiation of Bechets disease
B-51
How long post EBV virus do you need to avoid contact sports
4 weeks
Worst prognostic factors of child pugh scoring
Moderate ascites
Bilirubin > 51.3
Albumin < 28
PT >6
INR > 2.3
Encephalopathy Grade 3-4
What should be given to patients who have an acute exacerbation of their UC with little or no improvement within 72 hours of starting their IV steriods or whose symptoms worsen at any time despite steriod treatment
Ciclosporin or infliximab
(surgery thereafter)
Where is gastrin produced
G cells in the pyloric antrum and duodenum
What causative organism would you think of for symptoms of diarrhoea only when travelling
E Coli
Most common site for gastrinomas
First part of the duodenum
One third of patients with achalasia have co-existing what
Malignancy
