Gastro Flashcards
what is portal hypertension
increased resistance and pressure in the portal system due to fibrosis affecting the blood flow through the liver
blood test to show liver function
PT
common causes of live cirrhosis
- alcohol
- NAFLD
- hepatitis B
- hepatitis C
rarer causes of liver cirrhosis
- autoimmune hepatitis
- PBC
- haemochromatosis
- Wilson’s disease
- A1AD
- CF
- drugs (methotrexate, amiodarone, sodium valproate)
signs of liver cirrhosis
- cachexia
- jaundice
- asterexis
- splenomegaly
- hepatomegaly
- ascites
- spider naevi
- excoriations
- small nodular liver
non-invasive liver screen
- USS
- hepatitis B and C serology
- autoantibodies
- immunoglobulins
- caeruloplasmin (wilson’s)
- A1AT levles
- ferritin and tansferrin
autoantibodies related to the liver
- antinuclear antibodies
- smooth muscle antibodies
- antimitochondrial antibodies
- antibodies to liver kidney microsome type 1
LFTs
ALP
ALT
AST
Bilirubin
Albumin
PT
Urea and creatinine
AFP
ELF (enhance liver fibrosis)
what is AFP for
hepatocellular carcinoma
USS of liver cirrhosis
nodular surface
corkscrew appearance of arteries
enlarged portal vein
ascites
splenomegaly
how to assess stiffness of the liver
transient elastography
what is the MELD score
model for end stage liver disease. gives an estimate 3 month mortality
what is child pugh score
assess severity of cirrhosis and prognosis.
A albumin
B bilirubin
C clotting (INR)
D dilation
E encephalopathy
mx of liver cirrhosis
treat cause
monitor and manage complications
liver transplant
complications of cirrhosis
- Malnutrition and muscle wasting
- Portal hypertension, - oesophageal varices and bleeding
- Ascites and SBP
- Hepatorenal syndrome
- Hepatic encephalopathy
- Hepatocellular carcinoma
where does the portal vein come from
superior mesenteric and splenic veins
prophylaxis of oesophageal varices
propanolol
variceal band ligation
mx of bleeding oesophageal varices
terlipressin
broad spectrum abx
endoscopy and band ligation
next step if ligation doesn’t work for varices
- Sengstaken-Blakemore tube
- Transjugular intrahepatic portosystemic shunt (TIPS)
what is ascites
- fluid in the peritoneal cavity
- increased pressure in portal system causes fluid to leak out of capillaries and organs
type of ascites in cirrhosis
transudative (low protein content)
mx of ascites
- low sodium
- aldosterone antagonists
- paracentesis
- proph abx
-TIPS - liver transplant
what is Spontaneous bacterial peritonitis
infection in ascitic fluid and peritoneal lining without clear source
common organisms of SBP
- Ecoli
- Klebsiella pneumoniae
diagnosing SBP
ascites
abdominal pain
fever
paracentesis: neutrophil count > 250 cells/ul
Mx of SBP
- sample ascitic fluid
- IV broad spec abx (e.g. piperacillin with tazobactam)
most common organism in peritonitis secondary to peritoneal dialysis
Staphylococcus epidermidis
what is hepatorenal syndrome
impaired kidney function caused by changes in the blood flow to the kidneys relating to liver cirrhosis and portal hypertension
portal hypertension causes the portal vessels to release vasodilators, which cause significant vasodilation in the splanchnic circulation
= reduced BP, so kidneys use RAS to vasoconstrict
types of hepatorenal syndrome
type 1: rapid onset hepatorenal syndrome (less than two weeks) (typically post GI bleed)
type 2: more gradual decline in renal function and is generally associated with refractory ascites
mx of hepatorenal syndrome
- vasopressin analogue: terlipressin
- 20% albumin
- TIPS
what is hepatic encephalopathy
build up of neurotoxic substances that affect the brain (ammonia)
presentation of hepatic encephalopathy
reduced conciousness and confusion
grading of hepatic encephalopathy
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
mx of hepatic encephalopathy
- lactulose
- abx (reduce bacteria producing ammonia) usually rifaximin can also use meomycin and metronidazole
- nutritional support
stages of alcohol related liver disease
- Alcoholic fatty liver
- alcoholic hepatitis
- cirrhosis
complications of alcohol during pregnancy
- SGA
- Fetal alcohol syndrome
- miscarriage
- preterm delivery
complications of alcohol
- Alcohol-related liver disease
- Cirrhosis and its complications (e.g., hepatocellular carcinoma)
- Alcohol dependence and withdrawal
- Wernicke-Korsakoff syndrome
- Pancreatitis
- Alcoholic cardiomyopathy
- Alcoholic myopathy, with proximal muscle wasting and weakness
- Increased risk of CVD
- Increased risk of cancer, particularly breast, mouth and throat cancer
examination findings with excess alcohol
- tremor
- smell of alcohol
- slurred speech
- telangiectasia
- bloodshot eyes
Ix for alcoholic liver disease
- raised MCV
- AST: ALT 1.5:1
- raised ALT, AST, GGT, ALP, Bilirubin
- low albumin
- increased PT
- deranged U&E in hepatorenal syndrome
Mx of alcohol related liver disease
- stop drinking
- CBT
- detox regimen
- thiamine and high protein diet
- corticosteroids to reduce inflammation
- treat complications
- liver transplant
- pentoxyphylline sometimes used
questionnaires for alcohol dependence
CAGE
AUDIT
Alcohol withdrawal sx
- 6-12 hours: tremor, sweating, headache, craving and anxiety
- 12-24 hours: hallucinations
- 24-48 hours: seizures
- 24-72 hours: delirium tremens
what is delirium tremens
medical emergency
extreme excitability of the brain and excessive adrenergic activity
presentation of delirium tremens
- Acute confusion
- Severe agitation
- Delusions and hallucinations
- Tremor
- Tachycardia
- Hypertension
- Hyperthermia
- Ataxia (difficulties with coordinated movements)
- Arrhythmias
Mx of alcohol withdrawal
- chlordiazepoxide
- pabrinex
- thiamine
what is wernicke-korsakoff syndrome
excess vit b1 (thiamine) deficiency
features of wernicke’s encephalopathy
- confusion
- oculomotor disturbances
- ataxia
features of korsakoff syndrome
- memory impairment
- behavioural changes
- often irreversible
stages of NAFLD
- NAFLD
- NA steatohepatitis
- fibrosis
- cirrhosis
RFs for NAFLD
- middle age
- obesity
- poor diet and activity
- T2DM
- high cholesterol
- high BP
- smoking
- metabolic syndrome (HTN, obesity and diabetes)
Ix for NAFLD
- raised ALT
- USS increased echogenicity
- ELF (>10.51 advanced fibrosis, <10.52 unlikely advanced fibrosis)
- transient elastography
- liver biopsy (gold standard)
Mx of NAFLD
- weight loss
- healthy diet and exercise
- avoid alcohol and smoking
- control diabetes, BP and cholesterol
- refer
- specialist: vit E, pioglitazone, bariatric surgery and liver transplant
what is hepatitis
inflammation of the liver
Hepatitis A
- contaminated food/water
- faeco-oral route
- RNA
- pruritis, jaundice, dark urine, pale stool
- vaccine available
- mx- supportive
hepatitis B
blood/bodily fluids
DNA
Vaccine available
Mx- supportive/antiviral
most recover in 1-3 months
Hepatitis C
blood
RNA
no vaccine
mx- direct acting antiviral
complication of hepatitis C
HCC
liver cirrhosis
hepatitis D
always with hep B
RNA
no vaccine
Mx- pegylated interferon alpha
hepatitis E
faeco-oral route
RNA
no vaccine
Mx- supportive
other causes of hepatitis
- alcoholic
- NA steatohepatitis
- autoimmune
- drug induced (paracetamol)
presentation of viral hepatitis
- asymptomatic
- abdo pain
- flu like sx
- pruritis
- jaundice
hepatic pictures LFTs
high ALT and AST
less of a rise in ALP
bilirubin
types of autoimmune hepatitis
Type 1: women, 40-50, fatigue
Type 2: children, girls, acute hepatitis and jaundice
Ix for autoimmune hepatitis
- high AST and ALT
- minimal ALP change
- raised IgG
- liver biopsy
Type 1:
- ANA, anti smooth muscle antibody, anti-SLA/LP
Type 2:
- Anti-liver kidney microsomes-1, anti-liver cytosol antigen type 1
Mx of autoimmune hepatitis
- high dose steroids
- immunosuppressants (azathioprine)
- liver transplant is end stage liver disease
what is haemochromatosis
AR
iron storage disorder
HFE gene on Chr 6
Presentation of haemochromatosis
- > 40y/o
- fatigue and joint pain
- bronze skin
- Testicular atrophy
- Erectile dysfunction
- Amenorrhoea
- Cognitive symptoms (memory and mood disturbance)
- Hepatomegaly
diagnosis of haemochromatosis
- serum ferritin
- transferrin
- genetic testing
- liver biopsy
- MRI
causes of raised serum ferritin
- Haemochromatosis
- Infections (it is an acute phase reactant)
- Chronic alcohol consumption
- Non-alcoholic fatty liver disease
- Hepatitis C
- Cancer
Complications of haemochromatosis
- Secondary diabetes (iron affects the functioning of the pancreas)
- Liver cirrhosis
- Endocrine and sexual problems (hypogonadism, erectile dysfunction, amenorrhea and reduced fertility)
- Cardiomyopathy (iron deposits in the heart)
- Hepatocellular carcinoma
- Hypothyroidism (iron deposits in the thyroid)
- Chondrocalcinosis (calcium pyrophosphate deposits in joints) causes arthritis
Mx of haemochromatosis
- venesection
- monitor serum ferritin
- monitor and treat complications
what is wilson’s disease
AR
accumulation of copper particularly in liver
Chr13
features of wilson’s
- teenagers/young adult
- Kayser Fleischer rings
- chronic hepatitis, cirrhosis
- neuro: tremor, dysarthria, dystonia, Parkinsonism
- psych: abnormal behaviour, depression, cognitive impairment, pyschosis
- haemolytic anaemia
diagnosis of wilson’s
- low serum caeruloplasmin
- 24hr urine copper assay
- liver biopsy
- MRI brain (double panda sign)
- negative coomb’s test
- genetic testing
Mx of wilson’s
copper chelation with:
- penicillamine
- trientine
other mx
- zinc salts
- liver transplant
organs affected in A1AD
- lungs: COPD and bronchiectasis. reduces elasticity
- liver: dysfunction, fibrosis, cirrhosis
chromosome effected in A1AD and inheritance
SERPINA1 gene Chr 14
Autosomal co-dominant
less commonly associated conditions with A1AD
- panniculitis
- granulomatosis with polyangiitis
how to diagnose A1AD
- genetic testing
- low serum A1A
assess lung/liver damage:
- CXR, CT thorax, Pulm FT
- liver biopsy
Mx of A1AD
- stop smoking
- symptomatic mx
- organ transplant
- monitor for complications
- screen family
- can give IV A1A, not by NICE
what is PBC
autoimmune
attack small bile ducts in liver –>obstructive jaundice and liver disease
where is bile produced
liver
where is bile stored
gall bladder
Cause of itching and jaundice
itching- raised bile acids
jaundice- raised bilirubin
xanthelasma
cholesterol deposits
presentation of PBC
- white woman 40-60
- fatigue
- pruritis and excoriations
- GI sx and abdo pain
- jaundice
- pale, greasy stool
- dark urine
- xanthelasma
- hepatomegaly
Ix for PBC
- raised ALP (obstructive)
- AMA (most specific)
- ANA
Mx of PBC
- ursodeoxycholic acid (protects cholangiocytes from inflammation)
other
- obeticholic acid
colestyramine
- replace fat soluble vitamins
- immunosuppression
- liver transplant
complications of PBC
- vitamin defeciency (A,D,E,K)
- osteoporosis
- hyperlipidaemia
- sjogren’s
- connective tissue diseases
- thyroid disease
what is PSC
inflammation of of the bile ducts
stiffening/hardening of bile ducts
what is PSC associated with
ulcerative colitis
risk factors for PSC
- male
- 30-40
- UC
- FH
Presentation of PSC
- RUQ pain
- pruritis
- fatigue
- jaundice
- hepatosplenomegaly
Ix for PSC
- raised ALP
- p-ANCA
- ANA
- Anti-smooth muscle antibodies
- MRCP (shows strictures)
- colonoscopy (for UC)
Mx of PSC
- no treatments
- ERCP for strictures (+abx)
- liver transplant in advanced
- colestyramine for pruritis
complications of PSC
- biliary strictures
- acute bacterial cholangitis
- cholangiocarcinoma
- cirrhosis
- fat soluble vit deficiency
- osteoporosis
- colorectal cancer in UC
what is IgG4 related sclerosing cholangitis
like PSC but has elevated IgG4.
responds well to steroids
main type of primary liver cancer
HCC
RFs for HCC
MAIN= liver cirrhosis due to:
- alcohol, NAFLD, hep B/C, PSC
screening for liver cirrhosis
USS and AFP to check for HCC every 6 months
presentation of liver cancer
usually present late
- FLAWS
- N&V
- jaundice
- pruritis
- upper abdo mass
Ix for liver cancer
- AFP
- USS
- CT/MRI
- biopsy
Mx of liver cancer
poor prognosis
- surgery if early: resection or liver transplant
- radiofrequency or microwave ablation
- TACE
What is cholangiocarcinoma
cancer in bile ducts: majority adenocarcinoma
assoc with PSC
features of obstructive jaundice
- pale stools
- dark urine
- pruritis
tumour marker for cholangiocarcinoma
CA19-9
what is haemangioma
benign tumour of liver
no treatment needed
what is focal nodular hyperplasia
benign liver tumour of fibrotic tissue
no treatment needed
what is living donor transplant
part of liver transplanted and both regenerate to 2 fully functioning livers
what is split donation
split the liver of a deceased person into two and transplant the two parts into two patients and have them regenerate to function normally in both
indication for liver transplant
acute liver failure (acute viral hepatitis, paracetamol overdose)
chronic liver failure
surgical incisions in liver transplant
- rooftop
- mercedes benz
post liver transplant care
- immunosuppression (steroids, azathioprine, tacrolimus)
- lifestyle
- monitor for rejection
cell lining in oesophagus
oesophagus = squamous epithelial lining
stomach= columnar epithelial lining
most common type of oesophageal cancer
- adenocarcinoma (history of Barrett’s and GORD)
- 2nd MC SCC
where is adenocarcinoma of oesophagus
Lower third - near the gastroesophageal junction
where is SCC of oesophagus
Upper two-thirds of the oesophagus
presentation of oesophageal cancer
- dysphagia: the most common
- anorexia and weight loss
- vomiting
other possible features include: odynophagia, hoarseness, melaena, cough
triggers for GORD
- greasy/spicy foods
- coffee/tea
- alcohol
- NSAIDs
- stress
- smoking
- obesity
- hiatus hernia
presentation of GORD
- dyspepsia
- heartburn
- acid regurgitation
- retrosternal/epigastric pain
- bloating
- nocturnal cough
- hoarse voice
red flags for GORD
- dysphagia
- > 55
- weight loss
- upper abdo pain
- reflux
- treatment resistant dyspepsia
what is hiatus hernia
herniation of the stomach up through the diaphragm
types of hiatus hernia
- Type 1: Sliding
- Type 2: Rolling
- Type 3: Combination of sliding and rolling
- Type 4: Large opening with additional abdominal organs entering the thorax
sliding- stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up into the thorax
rolling- separate portion of the stomach (i.e., the fundus), folds around and enters through the diaphragm opening, alongside the oesophagus
Mx of GORD
- lifestyle changes
- stop NSAIDs
- antacids
- PPI
- Histamine H2 receptor antagonists
- surgery (laprascopic fundoplication)
Which investigations are required by surgeon’s before fundoplication is performed?
manometry and oesophageal pH
what is H.pylori
gram negative aerobic bacteria
conditions associated with H.pylori
- peptic ulcer disease
- gastric cancer
- B cell lymphoma
- atrophic gastritis
Ix for H.pylori
- Stool antigen test
- Urea breath test using radiolabelled carbon 13
- H. pylori antibody test (blood)
- Rapid urease test during endoscopy
mx of h.pylori
triple therapy
(PPI + amoxicillin + clarithromycin/metronidazole) for 7days
test if h.pylori not eradicated
urea breath test 4 weeks post
what is barrett’s oesophagus
metaplasia. lower oesophageal epithelium changes from squamous to columnar epithelium
pre-malignant
risk factor for oesophageal adenocarcinoma
Barrett’s oesophagus
Mx of Barrett’s oesophagus
- endoscopic monitoring
- PPIs
- endoscopic ablation
what is Zollinger-Ellison Syndrome
- rare
- duodenal or pancreatic tumour secretes excessive quantities of gastrin.
- stimulates acid secretion = severe dyspepsia, diarrhoea, peptic ulcer
what can gastrin secreting tumours be associated with
MEN1
what are more common peptic or duodenal ulcers
duodenal
which artery is commonly affected in duodenal ulcer
gastroduodenal artery
RFs for ulcer
H.pylori
NSAIDs
what increases stomach acid
- stress
- alcohol
- caffeine
- smoking
- spicy food
things that increase risk of bleeding from a peptic ulcer
- NSAIDs
- aspirin
- anticoagulants
- steroids
- SSRIs
presentation of peptic ulcers
- epigastric discomfort
- N&V
- dyspepsia
bleeding
- haematemesis
- coffee ground vomiting
- malaena
- fall in Hb/FBC
impact of food on peptic and duodenal ulcers
peptic- worse on eating
duodenal- better on eating
diagnosis of peptic ulcers
endoscopy: rapid urease test
Mx of peptic ulcers
- stop NSAID
- treat h.pylori
- PPIs
- repeat endoscopy 4-8 weeks to ensure healing
define upper GI bleeding
bleeding from oesophagus, stomach or duodenum
sources of upper GI bleeding
- peptic ulcers (MC)
- mallory weiss tear
- oesophageal varices
- stomach cancers
presentation of upper GI bleed
- haematemesis
- coffee ground vomit
- malena
presentation of mallory weiss tear
Occur after heavy retching or vomiting, which may be caused by binge drinking, gastroenteritis or hyperemesis gravidarum
scoring system to estimate risk of having upper GI bleed
Glasgow Blatchford score
score used after endoscopy to estimate the risk of rebleeding and mortality
Rockall score
define IBD
UC
Crohn’s
General presenting features of IBD
- Diarrhoea
- Abdominal pain
- Rectal bleeding
- Fatigue
- Weight loss
features of Crohns
- N: No blood or mucus (PR bleeding is less common)
- E: Entire gastrointestinal tract affected
- S: “Skip lesions” on endoscopy
- T: Terminal ileum most affected and Transmural (full thickness) inflammation
- S: Smoking is a risk factor (don’t set the nest on fire)
increased goblet cells
cobblestone appearance
non-caseating granuloma
most commonly affected site in Crohn’s
ileum
what is Crohn’s associated with
strictures and fistulas
Features of UC
- C: Continuous inflammation
- L: Limited to the colon and rectum
- O: Only superficial mucosa affected
- S: Smoking is protective
- E: Excrete blood and mucus
- U: Use aminosalicylates
- P: PSC
crypt abscesses, pseudopolyps
associated conditions with IBD
- erythema nodosum
- pyoderma gangrenosum
- enteropathic arthritis
- PSC
- red eye conditions (episcleritis, anterior uveitis)
Ix for IBD
- FBC
- CRP
- U&E, LFT< TFT
- anti-TTG
- stool MC&S
- faecal calprotectin
- colonoscopy (mild to mod UC, flexi sigmoid if severe)
Mx of acute UC
Mild to moderate
- Aminosalicylate (e.g., oral or rectal mesalazine) first-line
- Corticosteroids (e.g. oral or rectal prednisolone) second-line
Severe
- 1st line IV steroids
- IV ciclosporin, infliximab, surgery
Mx for maintaining remission in UC
- 1st line aminosalicylate
- azathioprine
- mercaptopurine
- permanent ileostomy or ileo-anal anastamosis permanent solution
Mx of acute Crohn’s
Mild
- 1st line steroids (prednisolone)
- enteral nutrition
- azathioprine, methotrexate
Severe
- IV hydrocortisone, metronidazole
Mx for maintaining remission Crohn’s
- Azathioprine
- Mercaptopurine
Surgery
- resecting distal ileum, treating strictures and fistula
which enzyme function needs to be checked before starting azathioprine
thiopurine methyltransferase (TPMT)
can lead to bone marrow suppression if deficient
what is IBS
functional disorder
Features of IBS
I- intestinal discomfort
B- bowel habit abnormality
S- Stool abnormality
DDx for IBS
- bowel cancer
- IBD
- coeliac
- ovarian cancer
- pancreatic cancer
Diagnosis of IBS
sx >6 months
and exclude other differentials
Mx of IBS
- lifestyle
- low FODMAP diet
- loperamide
- bulk forming laxatives
- antispasmodics
- linaclotide
what conditions is coeliac associated with
autoimmune conditions particularly T1DM and thyroid disease
antibodies related to coeliac disease
- Anti-tissue transglutaminase antibodies (anti-TTG)
- Anti-endomysial antibodies (anti-EMA)
- Anti-deamidated gliadin peptide antibodies (anti-DGP)
part of the bowel affected in coeliac
small bowel particularly jejunum
causes atrophy of intestinal villi
HLA genotypes associated with coeliac
HLA DQ2
HLA DQ8
Presentation of coeliac
- Failure to thrive in children
- Diarrhoea
- Bloating
- Fatigue
- Weight loss
- Mouth ulcers
Skin condition caused by coeliac
dermatitis herpetiformis (itchy, blistering skin rash)
how to diagnose coeliac
eat gluten for at least 6 weeks
- total IgA
- Anti-TTG
endoscopy (villous atrophy and crypt hyperplasia) : jejunal biopsy
Complications of coeliac
- nutritional deficienceis
- anaemia
- osteoporosis
- Hyposplenism (with immunodeficiency, particularly to encapsulated bacteria such as Streptococcus pneumoniae)
- Ulcerative jejunitis
- Enteropathy-associated T-cell lymphoma (EATL)
- Non-Hodgkin lymphoma
- Small bowel adenocarcinoma
causes of C.difficile
Cephalosporins
PPIs
how to diagnose c.difficile
c.difficile toxin in stool
Mx of c.difficile
first episode
10 days oral vancomycin
recurrent
<12 weeks: oral fidaxomicin
>12 weeks oral vancomycin or fidax
life threatening: oral vancomycin AND IV metronidazole
how to differentiate severity of C.difficile infection
white cell count
Watery travellers diarrhoea
enterotoxigenic E.coli infection
bloody diarrhoea
campylobacter jejuni
greasy floating stool, recent travel, swimming in water, foul smelling
giardia lamblia
Electrolyte disturbances seen in refeeding syndrome
- Hypophosphataemia
- hypokalaemia
- hypomagnesaemia
blood test to differentiate between Upper and lower GI bleed
high urea = upper GI
most common type of pancreatic cancer
80% adenocarcinoma at head of pancreas
associations with pancreatic cancer
- age
- smoking
- diabetes
- chronic pancreatitis
- hereditary non-polyposis colorectal carcinoma
- multiple endocrine neoplasia
- BRCA2 gene
- KRAS gene mutation
Features of pancreatic cancer
- painless jaundice
- pale stools, dark urine, and pruritus
- cholestatic liver function tests
- abdominal mass
- double duct sign on MRCP
what is courvoisier’s law
presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
Ix for pancreatic cancer
high resolution CT
Mx pancreatic cancer
- most not suitable for surgery
- Whipple’s resection
- ERCP and stent for palliative
what is Gilbert’s
AR
defective bilirubin conjugation due to a deficiency of UDP glucuronosyltransferase.
Features of Gilbert’s
isolated rise in bilirubin
episodes of jaundice during illness, exercise or fasting.
Feel well
what is carcinoid syndrome
- occurs when metastases are present in the liver and release serotonin into the systemic circulation
- may also occur with lung carcinoid as mediators are not ‘cleared’ by the liver
features of carcinoid syndrome
- flushing
- diarrhoea
- bronchospasm
- hypotension
- pellagra
Ix for carcinoid syndrome
- urinary 5-HIAA
- plasma chromogranin A y
Mx of carcinoid syndrome
- somatostatin analogues (octreotide)
- diarrhoea: cyproheptadine may help
medication that can cause cholestasis
co-amoxiclav
COCP
what is achalasia
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus
features of achalasia
- dysphagia of BOTH liquids and solids
- typically variation in severity of symptoms
- heartburn
- regurgitation of food
- may lead to cough, aspiration pneumonia etc
- malignant change in small number of patients
Ix of achalasia
oesophageal manometry
barium swallow
CXR
Mx of achalsia
- 1st: pneumatic (balloon) dilation
- Heller cardiomyotomy
what cancer does achalasia increase the risk of
squamous cell carcinoma of the oesophagus (upper 2/3s)
what is intestinal angina
triad of severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit
cause- atherosclerosis of GI arteries
what is budd chiari syndrome
hepatic vein thrombosis
causes of budd chiari syndrome
- polycythaemia rubra vera
- thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies
pregnancy - COCP
features of budd chiari syndrome
- abdominal pain: sudden onset, severe
- ascites → abdominal distension
- tender hepatomegaly
Ix for Budd Chiari syndrome
ultrasound with Doppler flow studies
organisms found in pyogenic liver abscesses
- Staphylococcus aureus = children
- Escherichia coli = adults.
Mx of liver abscess
- drainage (typically percutaneous) and antibiotics
- amoxicillin + ciprofloxacin + metronidazole
- if penicillin allergic: ciprofloxacin + clindamycin
what is plummer vinson syndrome
Triad of:
- dysphagia (secondary to oesophageal webs)
- glossitis
- iron-deficiency anaemia
mx of plummer vinson syndrome
iron supplementation and dilation of the webs
do you replace folate or b12 first and why
replace b12 first to prevent subacute combined degeneration of the cord
B before F
pathophysiology of pernicious anaemia
antibodies to intrinsic factor +/- gastric parietal cells
vit b12 deficiency
presentation of pernicious anaemia
- lethargy
- pallor (‘lemon tinge’)
- dyspnoea
- peripheral neuropathy
- subacute combined degeneration of the spinal cord
- atrophic glossitis
mx of pernicious anaemia
IM hydroxocobalamin 3x a week for 2 weeks then 3 monthly injections
which cancer does pernicious anaemia increase risk of
gastric cancer
treatment of ulcerative colitis that can cause anaemia
sulphasalazine
heinz body anaemia
triad for gallstones
RUQ pain
fever
jaundice
what is boerhaave syndrome
rupture of his oesophagus due to severe vomiting
features of boerhaave syndrome
Vomiting → severe chest pain, shock
crepitus on palpation of chest wall
severe diarrhoea acid base imbalance
hypokalaemic Hyperchloraemic hyponatraemic metabolic acidosis
features of diverticulitis
left lower quadrant pain, diarrhoea and fever
liver features in right heart failure
- one of the most common causes of hepatomegaly
- firm, smooth and tender to touch liver edge.
- PULSATILE: due to the back-up of blood due to the failure of the right side of the heart
adverse effects of PPIs
- hyponatraemia, hypomagnasaemia
- osteoporosis → risk of fractures
- microscopic colitis
- increased risk of C. difficile
which anatomical landmark will allow the categorisation of upper and lower GI bleed during urgent endoscopy?
ligament of Treitz
Upper GI Bleed is a haemorrhage with an origin proximal to the ligament of Treitz
name for palpable umbilical node.
Sister Mary Joseph node
It’s due to metastasis of malignant cancer within the pelvis or abdomen
Gastro cause of cause of hypogonadotrophic hypogonadism in men
haemochromatosis
Barrett’s metaplasia increases the risk of which cancer
adenocarcinoma of oesophagus
RFs for Small bowel bacterial overgrowth syndrome
- neonates with congenital gastrointestinal abnormalities
- scleroderma
- diabetes mellitus
Mx of Small bowel bacterial overgrowth syndrome
rifxaimin
features of pharyngeal pouch
Dysphagia, aspiration pneumonia, halitosis, regurgitation, chronic cough
presentation of ascending cholangitis
infection of the bile ducts commonly secondary to gallstones.
Triad:
1. RUQpain
2. rigors
3. jaundice
what condition can develop post ERCP
pancreatitis
what is gallstone ileus
small bowel obstruction secondary to an impacted gallstone.
Abdominal pain, distension and vomiting are seen.
oral aminosalicylates can cause what GI side effects
- diarrhoea
- N&V
- exacerbation of colitis
- acute pancreatitis (mesalazine > sulfasalazine)
what is murphy’s sign
palpating under the right costal margin causes to catch her breath.
acute cholecystitis
what drug will you administer to reduce the risk of isoniazid induced peripheral neuropathy
Pyridoxine (vitamin B6)
area most likely to be effected in ischaemic colitis
splenic flexure
triad for liver failure
- hepatic encephalopthy
- jaundice
- coagulopathy
condition associated with gallstone dvlpt
terminal ileitis (crohn’s)
CROHN’S GIVES STONES
where bile salts are reabsorbed
blood supply of duodenum
- D1-2 superior and descending (Proximal to the major duodenal papilla) is gastroduodenal artery
- D3-4 trasnverse and ascending (distal to the major duodenal papilla) is the inferior pancreaticoduodenal artery (branch of superior mesenteric artery)
blood supply of jejunum and ileum
SMA
