Gastro Flashcards
A 62 year old man with hx of chronic alcohol abuse presents with 2 day hx of deteriorating confusion.
On examination he is drowsy, has a temp of 39, pulse of 110, and small amount of ascites. Examination of cns reveals left sided hemiparesis with up going left plantar response. What is likely diagnosis?
Cerebral abscess
What is the most common cause of severe viral gastroenteritis worldwide?
Rotavirus
How does rotavirus infection spread?
Faeco oral route
In which patients is rotavirus most common?
Children 6m to 6y
How does rotavirus lead to diarrhoea and vomiting?
RNA virus replicates in intestinal mucosal cells
Damages transport mechanisms leading to salt and water depletion
How is a diagnosis of rotavirus made?
Clinical features
Stool culture - virus
PCR
What is treatment for rotavirus?
Rehydration
Correction of electrolyte imbalances
What is jaundice? When is it clinically detectable?
Yellow discolouration of sclera, skin and mucous membranes as a result of accumulation of bile pigments (bilirubin)
Clinically detectable at >50micromol/L
What HPC questions are important in a patient with jaundice? And what differentials do these questions highlight?
Abdo pain: gallstones, cholangitis, pancreatic Ca
Colour of urine/stool – conjugated bilirubin
Pruritis – cholestasis
Fever, rigors – cholangitis
Alcohol intake - cirrhosis
Blood transfusions - haemolytic transfusion reaction
Recent travel - hepatitis
Drug history including IVDU - hepatitis
What is courvoisiers law?
In presence of jaundice, enlarged gallbladder is unlikely to be due to gallstones/chronic cholecystitis
What is Murphys sign?
Tenderness elicited on palpation at the midpoint of the right subcostal margin on inspiration
What signs might you look for in a patient with jaundice on examination?
General inspection – ascites, widespread jaundice
Hands – palmar erythema, Duputryen’s, clubbing, asterixis, leukonychia
Sclera - icterus
Mouth - fetor hepaticus
LN in neck
Upper chest – spider naevi, gynaecomastia, ecchymosis
Abdomen – hepatosplenomegaly, ascites, caput medusae
Why do you get palmar erythema in cirrhosis?
Impaired breakdown of sex hormones
What is Charcots triad?
RUQ pain
Jaundice
Fever
Ascending cholangitis
How is jaundice classified? Give examples of each
Pre-hepatic: haemolysis
Intra-hepatic: Viral hepatitis, Cirrhosis, Alcoholic hepatitis, Drugs
Post-hepatic: Obstruction, Cholangitis
What are differences between unconjugated and conjugated bilirubin?
Conjugated: Converted to urobilinogen and excreted giving stool its dark colour, Hyperbilirubinaemia
Unconjugated: Not water soluble, Does not pass into urine as bound to albumin, Mild jaundice as liver usually handles increased bilirubin
Which enzyme conjugates bilirubin in the liver? What is it conjugated with?
Glucuronyltransferase
Conjugates with glucuronic acid
How does haem get metabolised to bilirubin?
Haem oxygenase converts haem to biliverdin
Biliverdin reductase converts to bilirubin
What are the main bilirubin products found in the urine and faeces?
Breakdown products of urobilinogen
Urine: urobilin
Faeces: stercobilin
What differences in LFTs would you see in intra or extra hepatic jaundice?
Intrahepatic: Transaminases very high : Alk Phos high
Extrahepatic: Transaminases high : Alk Phos very high
What investigations would you do for a patient who is jaundice?
Bedside: Urine
Bloods: FBC, LFTs, U+Es, Clotting (PT/INR)
Imaging: USS abdomen – identify obstruction
Special tests: Serum autoimmune antibody tests (ANA, ASMA, anti-smooth muscle, liver/kidney microsomal antibodies), Serum viral markers (hep A, B, C)
What is the management for alcoholic hepatitis?
Supportive: Adequate nutritional intake – may require NG
Corticosteroids: Evidence to suggest reduces inflammatory process
What are some causes of hepatitis?
Toxic damage Drugs Poisons/chemical Alcohol Infections Viral Bacterial Fungal Protozoa Immunological damage Autoimmune
What are differences between acute and chronic viral hepatitis?
Acute (<6months): Fever / nausea / malaise / myalgia, Hepatomegaly, Pain, Jaundice
Chronic (>6 months): May be asymptomatic, Symptoms associated with cirrhosis
What is Gardners syndrome?
Hereditary dominant condition Multiple osteomas - skull bones Cutaneous soft tissue tumours Polyposis coli Thyroid tumours Hypertrophy of pigment layer of retina Liver tumours
What is the management of acute pancreatitis?
IV fluids Sliding scale insulin Nasogastric suction Antibiotics Analgesia
What is the typical endoscopic appearance of a GIST?
Discrete
Well defined single lesion
Normal mucosa covering surface
What is the Glasgow score for pancreatitis? PANCREAS
P Arterial O2: <8 scores 1
A ge: > 55 scores 1
N eutrophils/ White cell count: >15 scores 1
C Serum calcium: <2 scores 1
R renal function, Serum urea: >16 scores 1
E nzymes: LDH > 600 or AST/ALT >200 scores 1
A Serum albumin: <32 scores 1
S ugar, Blood glucose: >10 scores 1
What is abetalipoproteinanemia?
Bassen kornzweig syndrome
Problems with normal absorption of fat and fat soluble vitamins
Mutation in microsomal triglyceride transfer protein resulting in deficiency of apo B48 and B100
Failure to thrive, diarrhoea, acanthocytosis, steatorrhoea
What is blind loop syndrome?
Small intestinal bacterial overgrowth syndrome
Derangement to normal physiological processes of digestion and absorption - impaired micelle formation
Vit B12 deficiency/ADEK, fat malabsorption, steatorrhoea, intestinal wall injury
What type of virus is rotavirus?
Double stranded RNA
Which is the most common virus responsible for causing diarrhoea worldwide?
Rotavirus
Which virus can follow ingestion of dust containing faecal material?
Hepatitis A
A 19 year old man is being investigated for suspected ileal crohns. What imaging should be done?
MR enterography
A 64 year old woman with painless jaundice is being investigated for suspected carcinoma of the head of the pancreas. What imaging should be performed?
CT scan with contrast - determine if resectable or if any mets
What is the most common gastrointestinal symptom of systemic sclerosis?
Progressive dysphagia
Why do patients with systemic sclerosis get progressive dysphagia?
Initially decrease in incidence and amplitude of contractions of lower oesophagus and incomplete relaxation of lower oesophageal sphincter
Resting tone of sphincter is reduced allowing reflux -> oesophagitis, shortening of oesophagus, stricture formation
A 54 year old woman was referred for abnormal LFTs. She had symptoms of fatigue and itching for 3 months. She drank 5 units of alcohol a week and did not use recreational drugs. She had no significant medical history. Her BMI is 24. She had hepatomegaly but was not jaundiced. USS liver was normal. Investigations show: albumin 38, ALT 40, ALP 286, bilirubin 27. What would be the most likely diagnosis?
Primary biliary cirrhosis
What is the pathology underlying primary biliary cirrhosis?
Autoimmune condition
T cell mediated destruction of intrahepatic bile ducts due to breakdown of immune tolerance to mitochondrial antigens accompanied by ductopenia
Antimitochondrial antibodies in 95%
Why does a normal USS liver make primary sclerosing cholangitis less likely than primary biliary cirrhosis?
PSC usually evidence of strictures or dilatation on abdo USS
What is transaminitis and when is it common?
Raised ALT and AST
Autoimmune hepatitis/other causes of hepatitis
If there is a markedly raised ALP but only a small raise in ALT, what does this suggest?
Cholestatic picture
What is the classic triad of mesenteric ischaemia?
Gastrointestinal emptying
Abdominal pain
Underlying cardiac disease
What symptoms of mesenteric ischaemia represent advanced ischaemia?
Nausea Vomiting Abdominal distension Ileus Frank peritonitis Gross or occult blood per rectum Shock
What are risk factors for mesenteric ischaemia?
Congestive heart failure Cardiac arrhythmias particularly AF Recent MI Atherosclerosis Underlying hypercoagulable state Hypovolaemia
A 65 year old male presents with abdominal pain. He gives a past history of stroke and MI. On examination there is distension of the abdomen and the stools were maroon coloured. Lactate is 5mmol/L. What is the likely diagnosis ?
Acute mesenteric ischaemia
What is the most common cause of unconjugated hyperbilirubinaemia?
Gilbert’s syndrome
What might precipitate Gilbert syndrome?
Dehydration
Fasting
Menstrual periods
Stress - illness or exercise
What are characteristics of chronic pancreatitis?
Chronic epigastric pain Bloating Steatorrhoea Loss of weight Diabetes
What are causes of chronic pancreatitis?
Alcohol
Duct obstruction - gallstones
Pancreatic cancer
Which GI cancer does coeliac disease increase the risk of?
Intestinal lymphoma
How does chlorpromazine cause acute cholestasis?
Interferes with hepatocyte secretion of bile
How do aflatoxins and mycotoxins lead to hepatocellular carcinoma?
Toxins induce a specific mutation in the tumour suppressor gene p53 leading to tumourigenesis
What is the Rockall scoring system used for?
Identify patients at risk of adverse outcome following acute upper gastrointestinal bleeding
What are the clinical features used to calculate a Rockall score?
Age: 60-79 score 1, 80 an above score 2
Shock: pulse over 100/systolic over 100 score 1, systolic less than 100 score 2
Co-morbidities: CHF, IHD score 2, Renal failure, liver failure, metastatic cancer score 3
Diagnosis: Mallory Weiss score 0, all other score 1, GI malignancy score 2
Evidence of bleeding: score 2
Score less than 3 carries good prognosis
Total score more than 8 carries high risk of mortality
What is a Glasgow-Blatchford bleeding score used for?
Stratifies upper GI bleeding patients who are “low-risk” and candidates for outpatient management
What are the clinical features used to calculate a Blatchford bleeding score?
Blood urea raised: up to 6 points Haemoglobin low: up to 6 points Systolic blood pressure: up to 3 points Pulse >100 = 1 point Presentation with melaena = 1 point presentation with syncope = 2 point Hepatic disease = 2 point Cardiac failure =2 point Total score 6 or more: over 50% chance of needing an intervention
What is the best single screening test for Zollinger-Ellison syndrome?
Fasting serum gastrin
What gastric pH is highly suggestive of Zollinger-Ellison syndrome?
Less than 2.0
What is a secretin stimulation test and how is used to diagnose Zollinger-Ellison syndrome?
2-U/kg bolus of secretin is administered intravenously after an overnight fast, and serum levels of gastrin are determined at 0, 2, 5, 10, and 15 minutes. An increase in serum gastrin of greater than 200 pg/mL is diagnostic
What are the antibiotics of choice to treat antibiotic associated colitis?
Oral vancomycin or metronidazole
What are the normal and deficient genes in alpha 1 antitrypsin deficiency? Which are the least and most severe genotypes?
M is normal gene S: associated with 60% production Z: 15% production PiMM: 100% (normal) PiMS: 80% of normal serum level of A1AT PiSS: 60% of normal serum level of A1AT PiMZ: 60% of normal serum level of A1AT PiSZ: 40% of normal serum level of A1AT PiZZ: 10-15% (severe alpha 1-antitrypsin deficiency)
What are the intestinal features of Crohn’s disease?
Bowel frequency
Diarrhoea
Apthous ulcers
Perianal fistulae
What are the extra intestinal features of Crohn’s disease?
Spondyloarthropathy
Uveitis
Episcleritis
How is a diagnosis of acute hepatitis B made?
Presence of:
Hepatitis B surface antigen- HBsAg
IgM antibodies to hepatitis B core antigen- IgM anti-HBc
How is a diagnosis of acute hepatitis A made?
Positive IgM antibodies to hep A virus- IgM anti-HAV
What does the presence of IgG anti-HAV antibody in a patient with acute hepatitis suggest?
Illness is not caused by hep A
How is a diagnosis of acute hep C made?
Anti-HCV antibody
HCV RNA
How is a diagnosis of acute hep E made?
Pronounced elevation of Alk phos
Presence of serum IgM anti-HEV
What is Weil’s disease?
Severe form of Leptospirosis
Headaches, muscle pains, fevers, bleeding from lungs, meningitis, jaundice, kidney failure, bleeding
How is leptospirosis infection spread?
Who is particularly at risk?
Direct contact with infected soil, water or urine
Organism enters through skin abrasions/cuts
Sewage workers
In what proportion of patients admitted with cirrhotic ascites does spontaenous bacterial peritonitis occur?
15%
With regard to differentiation of transudate from exudate, what is the preferred means for characterizing ascites?
Serum-ascitic albumin gradient (SAAG)
Transudative ascites occurs when a patient’s SAAG level is greater than or equal to 1.1 g/dL
What are causes of transudative ascites?
Hepatic cirrhosis Alcoholic hepatitis Heart failure Fulminant hepatic failure Portal vein thrombosis
What are causes of exudative ascites?
Peritoneal carcinomatosis Inflammation of the pancreas or biliary system Nephrotic syndrome Peritonitis Ischemic or obstructed bowel
What organisms commonly cause spontaneous bacterial peritonitis?
Escherichia coli
Klebsiella pneumoniae
Enterococcal species
Streptococcus pneumoniae
What are indications for a diagnostic paracentesis?
New-onset ascites: Fluid evaluation helps to determine etiology, differentiate transudate versus exudate, detect presence of cancerous cells
Suspected spontaneous or secondary bacterial peritonitis
What are indications for a therapeutic paracentesis?
Respiratory compromise secondary to ascites
Abdominal pain or pressure secondary to ascites (including abdominal compartment syndrome)
What are contraindications for paracentesis?
An acute abdomen that requires surgery is an absolute contraindication
Severe thrombocytopenia (platelet count <20) and coagulopathy (INR >2.0) are relative contraindications Patients with an INR greater than 2.0 should receive fresh frozen plasma (FFP) prior to procedure
Patients with a platelet count lower than 20 should receive an infusion of platelets before the procedure
Pregnancy
Distended urinary bladder
Abdominal wall cellulitis
Distended bowel
Intra-abdominal adhesions
What should fluid from a diagnostic paracentesis be tested for?
Cell count Culture Protein Glucose LDH CEA Alk phos
What is CEA?
Carcinoembryonic antigen
Glycoprotein shed from the surface of malignant cells
What are the grades of hepatic encephalopathy?
Grade 1: drowsy but coherent, mood change
Grade 2: drowsy, confused at times, inappropriate behaviour
Grade 3: very drowsy and stuporous but rousable
Grade 4: comatose, barely rousable
What treatment should be given for suspected spontaneous bacterial peritonitis?
Broad spec Abx for enteric organisms and gram positive cocci e.g. Cefotaxime
How does Terlipressin control variceal bleeding?
Causes splanchnic vasoconstriction
Why is a low protein diet recommended for patients with chronic liver disease?
Protein breakdown in the bowel results in ammonia production which is implicated in precipitation of hepatic encephalopathy
A 50 year old lady is referred for a barium swallow after a 6 month Hx chest pain associated with dysphagia. The scan shows a corkscrew pattern, what is the likely diagnosis?
Diffuse oesophageal spasm
What is the treatment for diffuse oesophageal spasm?
Calcium channel blockers
A 50 year old alcoholic man with a 2 year history of dyspepsia is found by his GP to be anaemic. An endoscopy shows part of the stomach through the hiatus alongside the oesophagus with the sphincter below the diaphragm. What is the likely diagnosis?
Para oesophageal hiatus hernia
A 70 year old Iranian man presents with progressive dysphagia and weight loss. An endoscopy reveals a 40% circumferential tumour in the proximal third of the oesophagus. What is the likely diagnosis?
Squamous cell carcinoma
A 30 year old man presents to ED after collapsing. He initially complained of severe chest pain following 2 episodes of forceful vomiting. A chest X-ray shows air in the mediastinum and neck and a pleural effusion. What is the likely diagnosis?
Oesophageal perforation - Boerhaaves syndrome
What can be used to confirm the diagnosis of oesophageal perforation?
Gastrograffin swallow
A 28 year old lady is referred for a barium swallow after a long Hx of dysphagia for both solids and liquids associated with regurgitation. The scan shows tapering of the lower end of the oesophagus. What is the likely diagnosis?
Achalasia
What is the treatment for achalasia?
Endoscopic pneumatic dilatation of the oesophagus
Endoscopic injection of Botox
Surgical division of the sphincter
What are the manning criteria for diagnosis of IBS?
Abdominal distension Pain relief with bowel action More frequent stools with onset of pain Looser stools with onset of pain Passage of mucus Sensation of incomplete evacuation
Which drugs can cause acute pancreatitis?
Steroids Oestrogens Thiazides Valproate Azathioprine Cisplatin Vinca alkaloids
What are the 2 most common causes of acute pancreatitis?
Gallstones and alcohol
What is the initial management for a patient with acute pancreatitis?
Analgesia NBM IVI NG tube Urinary catheter Score for severity using Glasgow score If severe: HDU and pancreatic specialist
What is the safest management for patients with acute mesenteric ischaemia?
Laparotomy
Excision of non viable bowel
Defunction, to return another day
What is the management for anal fissure?
Topical GTN
Sphincterectomy
What acute medical events may precipitate colonic pseudo-obstruction?
Pneumonia
Myocardial infarction
Hypoxia
How can you exclude mechanical large bowel obstruction?
Rectal examination
Rigid sigmoidoscopy
Plain X-ray
CT scan
How do you manage colonic pseudo obstruction?
IVI Correct electrolyte abnormalities Avoid opioid analgesia Nasogastric aspiration Rectal tube Enema Ocreotide infusion IV neostigmine Colonoscopic decompression Surgery
How might you drain a pelvic abscess?
Spontaneous
Surgically per rectum
Radiologically guided
In what time frame should a post operative ileus resolve?
3-4 days
Small bowel mobility usually in 24
Gastric motility in 3-4 days
What is required if a post operative ileus has not resolved after 4 days?
Nasogastric aspiration - prevent gastric dilatation and risk of aspiration pneumonitis
IVI
Correct electrolytes
Minimal oral fluids
An 82 year old man with a long Hx of dementia and advanced oesophageal carcinoma is admitted from a nursing home as an emergency with sudden onset total dysphagia. He is unable to tolerate solids or liquids which he immediately regurgitates. He had been stented 2 weeks previously and had initially had excellent symptomatic relief. Examination is unremarkable. What is the likely diagnosis?
Bolus obstruction due to inadvertent ingestion of a large piece of food
Stent displacement other option but tends to occur early with metal stents before they are fully deployed
A 19 year old student experiences worsening dysphagia for 3 months. She has lost a stone in weight and has had 2 courses of antibiotics for persistent chest infection. What is the likely diagnosis?
Achalasia with aspiration pneumonias
A 55 year old vagrant man has a long history of recurrent epigastric pain. He presents with weight loss and severe vomiting. On admission he is noted to be dehydrated and abdominal examination demonstrates succussion splash. What is the likely diagnosis?
Pyloric stenosis secondary to long history of peptic ulceration which has been left untreated, healing with scarring
What is gallstone ileus?
Inflamed gallbladder adheres to small bowel and with time the gallstone erodes through and migrates distally, usually occluding the distal ileum
How do you manage gallstone ileus?
Laparotomy
Stone extraction through proximal enterotomy
Why do patients with pancreatitis sit forward?
Allows stomach and small bowel to fall away from the pancreas into the retroperitoneum
An 85 year old lady who previously declined a cholecystectomy is admitted as an emergency with diffuse abdominal pain and vomiting. She has a tachycardia and is hypotensive 80/50. On examination her abdomen is rigid. What is the likely diagnosis? What needs to be done?
Biliary peritonitis
Laparotomy with extensive washout of the peritoneal cavity
What is the dukes grading system for colonic carcinoma?
A: confined to bowel wall B: reaches serosa C1: local nodes involved C2: apical nodes involved D: distant metastasis
What is the treatment for anal fissure?
GTN cream
What is the treatment for sigmoid volvulus?
Urgent endoscopic decompression
Sigmoid colectomy
Percutaneous endoscopic colostomy
What imaging/special test should be done when achalasia is suspected?
Oesophageal manometry
What does oesophageal manometry show in achalasia?
Absence of peristaltic waves
High resting intra oesophageal pressure
Impaired relaxation of lower oesophageal sphincter
High resting lower oesophageal sphincter pressure
A 62 year old woman undergoes OGD for dysphagia and is seen to have a suspicious looking lesion in the distal oesophagus. A biopsy is taken which confirms adenocarcinoma. What is the next step?
CT scan to look for distant mets
A 44 year old woman has been taking high dose proton pump inhibitor for 2 years for reflux oesophagitis but barely has control of her symptoms. An OGD has confirmed the presence of reflux oesophagitis. She is keen on anti reflux surgery. What should be done next?
24 hour pH studies provide a modified DeMeester score and manometry to exclude motility disorder
What is a DeMeester score?
Measure of acidity and a surrogate of severity of GORD Supine reflux Upright reflux Total reflux Number of episodes Number of episodes longer than 5 mins Longest episode
A 55 year old smoker has been diagnosed with oesophageal carcinoma. He is otherwise fit and well. A CT scan of the chest and abdomen is reported as normal. What is the next step?
Endoluminal ultrasound for further staging to look for signs of irreducibility such as invasion into the pericardium or pleura
Why does bleeding happen in diverticular disease?
Perforating vessels are eroded
What is an indication for colectomy in diverticular disease?
Large volume bleed or recurrent bleeds
In a case of angiodysplasia with ongoing bleeding and visualisation on imaging is poor, what other method can be used to image?
Red cell scan or angiography
A 37 year old farmer presents with a gradual onset of malaise, headaches, myalgia and night sweats. He has lymphadenopathy and hepatomegaly. His chest xray is normal. His 2-mercaptoethanol test is positive. What does he have?
Brucellosis
What causes Brucellosis?
Ingestion of unpasteurized milk or undercooked meat from infected animals, or close contact with their secretions
What is the best test for Brucellosis?
2-mercaptoethanol test
Tube agglutination which tests for anti-O-polysaccharide antibody
Titre of 1:160 is diagnostic
What type of bug is Brucella?
Gram negative coccobacillus
What are the symptoms/features of Brucellosis?
Malaise Headache Night sweats Lymphadenopathy Hepatosplenomegaly Orchitits Osteomyelitis Meningoencephalitis Endocarditis
What is the treatment for Brucellosis?
6 weeks of combined doxycycline and rifampicin
When is the optimal time to assess paracetamol level after an overdose with respect to determining need for n-acetylcysteine?
4 hours after
If a very significant overdose is suspected or the patient presents more than 4 hours after, treatment should be started expectantly
How is n-acetylcysteine treatment administered?
Loading dose over 1 hour
Infusions at 4 hours and 16 hours
What should be done for a patient with an allergic reaction to n-acetylcysteine who has taken a paracetamol overdose?
Slow the infusion rate
Give IV corticosteroids and/or antihistamines
If still not tolerating - oral methionine
What is pseudoxanthoma elasticum? How does it present?
Abnormalities in collagen and elastic tissue affecting skin, eye and blood vessels
GI bleeding
Premature atherosclerosis -CAD
Intermitttent claudication
Yellow papular skin lesions, lax skin
Peau d’orange retina, angioid streaks radiate from optic nerve
An 11 year old boy presents to ED with massive haematemesis. He is found to be very tall and thin and has loose lax and wrinkled skin. What is the diagnosis?
Pseudoxanthoma elasticum
What are complications of a duodenal ulcer if left untreated?
Perforation
Gastric outlet obstruction
Haemorrhage
What are clinical signs of gastric carcinoma?
Epigastric mass
Jaundice
Ascites
Enlarged supraclavicular (virchows) node, Troisiers sign
A 30 year old man is being investigated after being admitted for haematemesis. An OGD reveals multiple large deep peptic ulcers, he has a ten month history of chronic diarrhoea and is found to have a high serum gastrin level. What is the diagnosis?
Zollinger Ellison syndrome
What are risk factors for oesophageal cancer?
Smoking Alcohol GORD Barrett's oesophagus Achalasia Plummer-Vinson syndrome Diets rich in nitrosamines Coeliac disease Scleroderma
How is diagnosis of oesophageal cancer made?
Upper GI endoscopy first line
Staging initially CT chest, abdomen and pelvis
If overt metastatic disease, further complex imaging unnecessary
If CT does not show metastatic disease, then local stage assessed by endoscopic ultrasound
Staging laparoscopy is performed to detect occult peritoneal disease PET CT is performed in those with negative laparoscopy
How is oesophageal cancer managed?
Operable disease - surgical resection, Ivor- Lewis oesophagectomy or transhiatal resection (for distal lesions), a left thoraco-abdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis
In addition to surgical resection many patients will be treated with adjuvant chemotherapy
What is an Ivor Lewis oesophagectomy?
Mobilisation of the stomach and division of the oesophageal hiatus
Abdomen is closed and a right sided thoracotomy performed
Stomach is brought into the chest and the oesophagus mobilised further
An intrathoracic oesophagogastric anastomosis is constructed
A 65-year-old male undergoes a Hartmann’s procedure for a sigmoid cancer. On day 2 post-op, nurses are concerned as his colostomy has not passed any wind or stool yet and he is complaining of increasing bloatedness. You review the patient and witness him vomit profusely. How would you manage this?
Conservative with nasogastric tube insertion for stomach decompression for symptom control and placing the patient nil by mouth to allow bowel rest
What is the management of mesenteric ischaemia?
Initial management includes analgesia, fluids and keeping the patient nil by mouth
Definitive treatment includes thrombolytic therapy, angioplasty or surgery
What are predisposing factors for mesenteric ischaemia?
Increasing age
Atrial fibrillation
Other causes of emboli: endocarditis
Cardiovascular disease risk factors: smoking, hypertension, diabetes
Cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use
What are features of small and large bowel which can help you detect small and large bowel obstruction on X-ray?
Small bowel: Maximum normal diameter = 35 mm, Valvulae conniventes extend all the way across
Large bowel: Maximum normal diameter = 55 mm, Haustra extend about a third of the way across
What is the management of ascending cholangitis?
Intravenous antibiotics
Endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
In colorectal cancer patients who’s tumours lie below the peritoneal reflection, what type of imaging should be done to evaluate staging?
MRI
What are some factors which will affect the healing of a colorectal anastamosis?
Adequate blood supply
Mucosal apposition
No tissue tension
Which chemotherapy agents are used as adjuncts in colorectal cancer?
5FU
Oxaliplatin
What are surgical options for rectal cancer?
Anterior resection and total mesorectal excision
Abdomino perineal excision of rectum (APER) - if sphincter involved or very low tumour
Why is neoadjuvant radiotherapy an option for rectal cancer when it isn’t for colorectal?
Rectum is an extraperitoneal structure
What is a Hartmans procedure?
Resection of sigmoid colon
End colostomy
What are risk factors for anal fissures?
Constipation
Inflammatory bowel disease
Sexually transmitted infections - HIV, syphilis, herpes
What are management steps for acute and chronic anal fissures?
Dietary advice: high fibre diet, high fluid intake
Bulk forming laxatives
Lubricants such as petroleum jelly before defecation
Topical anaesthetics
If chronic (over 6 weeks)
Topical GTN
If after 8 weeks not effective, refer for surgery or Botox
What is the NHS colorectal cancer screening program?
Screening every 2 years to people aged 60-74 years in England
Patients over 74 may request screening
Eligible patients are sent faecal occult blood tests through the post
Patients with abnormal results are offered colonoscopy
As part of the colorectal cancer screening service, what proportion of patients who had positive faecal occult blood tests and therefore were offered colonoscopy will actually turn out to have cancer?
4/10 will have polyps which may be removed due to premalignant potential
1/10 will be found to have cancer
What is courvoisiers law?
In the presence of a palpably enlarged gallbladder which is nontender and accompanied by painless jaundice, the cause is unlikely to be gallstones
What is the minimum number of biopsies that should be obtained on OGD when oesophageal cancer is suspected?
8
In the presence of cirrhosis, what size of liver lesion is highly suggestive of malignancy? What test can be done to back this up?
Over 2cm
Alpha foetoprotein - level over 400
What organism causes amoebic liver abscess?
Entamoeba histolytica
How do you treat an amoebic liver abscess?
Metronidazole
A 42 year old lady presents with right upper quadrant pain and a sensation of abdominal fullness. An ultrasound scan demonstrates a 6.5cm hyperechoic lesion in the right lobe of the liver. Serum AFP is normal. What is it?
Haemangioma
In which patients are you most likely to see a liver cell adenoma?
Women in their 3rd to 5th decade
On oral contraceptives
What is a major predisposing factor for liver abscess?
Biliary sepsis
What are common symptoms of liver abscess?
Fever
Right upper quadrant pain
Jaundice
What causes hyatid liver cysts?
Echinococcus infection
What are some causes of small bowel obstruction?
Incarcerated hernia
Crohn’s disease
Internal malignancy
Adhesions
What are complications of small bowel obstruction?
Intestinal necrosis
Sepsis
Multi organ failure
How are flares of UC classified?
Mild: fewer than 4 stools/day with/without blood, no systemic disturbance, normal ESR and CRP
Moderate: 4-6 stools/day, minimal systemic disturbance
Severe: more than 6/day with blood, systemic disturbance - fever, tachy, abdo tenderness, distension, reduced bowel sounds, anaemia, Hypoalbuminaemia
A 15 year old boy is admitted with colicky abdo pain for 6 hrs. On examination he has a soft abdomen. He has brown spots around his mouth feet and hands. His mother underwent surgery for intussusception aged 12 and has similar skin lesions, what is the most likely underlying diagnosis?
Peutz jeghers syndrome
Pigmented skin lesions, hamartomatous polyps resulting in intussusception and an autosomal inheritance pattern
Which patients are identified as being malnourished?
BMI less than 18.5
Unintentional weight loss of over 10% in 3-6 months
BMI less than 20 and unintentional weight loss over 5% over 3-6 months
Which patients are identified as at risk of malnutrition?
Eaten little or nothing over 5 days, who are likely to eat little for a further 5 days
Poor absorptive capacity
High nutrient losses
High metabolism
What are the guidelines on identifying a patient suitable for parenteral nutrition?
Identity as malnourished or at risk
Identify unsafe/inadequate oral intake or non functional GI tract/perforation/inaccessible
A 65 year old man with a history of dyspepsia is found to have a gastric MALT lymphoma on biopsy. What treatment should be offered?
H pylori eradication
What blood test results would you expect in mesenteric ischaemia?
Elevated WBC associated with acidosis and raised lactate
What are the guidelines for 2 week wait referral for colorectal services?
Patients >= 40 years with unexplained weight loss and abdominal pain
Patients >= 50 years with unexplained rectal bleeding
Patients >= 60 years with iron deficiency anaemia or change in bowel habit
Tests show occult blood in their faeces
Consider if: rectal or abdominal mass, unexplained anal mass or anal ulceration, patients < 50 years with rectal bleeding and unexplained symptoms/findings: abdominal pain, change in bowel habit, weight loss, iron deficiency anaemia
Who gets faecal occult blood test screening?
Every 2 years to all men and women aged 60 to 74 years Patients aged over 74 years may request screening
In addition FOBT should be offered to:
Patients >= 50 years with unexplained abdominal pain or weight loss
Patients < 60 years with changes in their bowel habit or iron deficiency anaemia
patients >= 60 years who have anaemia even in the absence of iron deficiency
What are causes of mesenteric adenitis?
Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp
What is triple therapy for eradication of h pylori?
Proton pump inhibitor
Amoxicillin
Metronidazole or clarithromycin
For one week with PPI continuing after
A 60 year old man underwent a whipples procedure one week ago. He is recovering well then suddenly drops his BP and has a Hb of 65 down from 106 the previous day. What investigation should be carried out?
Coeliac angiography - imaging plus embolisation if a bleeding point is identified
What are some risk factors for colonic carcinoma?
High fat, low fibre diet Age over 50 Personal Hx colorectal adenoma or carcinoma 1st degree relative with colorectal cancer Familial polyposis coli Gardner syndrome Turcot syndrome Juvenile polyposis syndrome Peutz Jeghers syndrome HNPCC UC and Crohns
What is Gardner syndrome?
Autosomal dominant form of polyposis characterised by presence of multiple polyps in colon together with tumors outside the colon including osteomas of the skull, thyroid cancer, epidermoid cysts, fibromas
What is Turcot syndrome?
Mismatch repair cancer syndrome -biallelic DNA mismatch repair mutations
Neoplasia typically occurs in both gut and the central nervous syste. In the large intestine, familial adenomatous polyposis occurs; in the CNS, brain tumors
What are risk factors for Crohn’s disease?
Smoking Family history COCP Diet Ethnicity
Which HLA is associated with Crohn’s disease?
HLA DR1
An 82 year old presents with constipation, colicky abdominal pain and abdominal distension. He complains of passing motions covered in blood and slime for 2 months. What is the likely diagnosis?
Carcinoma of the recto sigmoid junction
What are risk factors for colonic carcinoma?
Increasing age
High fat diet
Inflammatory bowel disease
Family history - bowel cancer, hereditary polyposis
What is left sided colon cancer more likely to present with?
Obstructive symptoms: tenderness, distension Cachexia Hepatomegaly Ascites Rectal mass Blood and slime
What is the most common cause of morbidity with gastroenteritis?
Dehydration
Over what time frame should viral gastroenteritis resolve?
3 - 8 days
When is coeliac disease most commonly diagnosed?
8-12 months
30-50 years
Where do peptic ulcers most commonly occur?
Duodenum (80%)
Stomach (20%)
What is the most common cause of upper GI haemorrhage?
Gastritis
How does peptic ulceration present?
Electively: nausea, intermittent epigastric pain
Emergency: acute upper GI bleed, perforation
What percent of gastric ulcers are malignant?
10%
How many biopsies should be taken from the edge of gastric ulcers seen at OGD?
Minimum of 6
What are some causes/associations of dupuytrens contracture?
Epilepsy/anti convulsant drugs Peyronies disease Alcoholic liver disease Diabetes Smoking Trauma Heavy manual labour AIDS
How is hep A transmitted?
Faecal oral route
What is the incubation period of hep A?
2-6 weeks
What type of virus is hep A?
Unenveloped RNA virus
What serology is present with hep A?
HAV IgM antibody - acute active infection
HAV IgG antibody - previous infection or vaccination
How is Hep E transmitted?
Faecal oral route
Who is particularly vulnerable to hep E virus severity?
Pregnant women
What type of virus is hep E?
Single stranded non enveloped RNA virus
How is hep C transmitted?
Blood borne transmission
What type of virus is hep C?
Enveloped RNA virus
What is the incubation period of hep C?
6-9 weeks
What proportion of hep C acute infections will progress to chronic?
75%
What will hep C serology show?
HCV IgG antibody - infection at some point
HCV RNA PCR - can detect virus early, decreasing PCR suggests resolution
What is the aim of hep C management?
Prevent cirrhosis, liver failure or development of hepatocellular carcinoma
What early treatment can be given to reduce risk of developing chronic infection in hep C?
Interferon alpha
Ribavirin
How is hep B transmitted?
Blood borne transmission
What type of virus is hep B?
Double stranded DNA
What proportion of acute hep B infections progress to chronic?
20%
What complication is hep B linked with?
Hepatocellular carcinoma
What is the incubation period for hep B?
40-160 days
What will hep B serology show in acute infection?
HBsAg present - ongoing infection
HBeAg present - acute viral replication
Anti HBc IgM
HBV DNA by PCR present
What will serology show in chronic hep B infection?
HBsAg present
IgM core antibodies promoted to IgG - Anti HBcIgG
Variable HBeAg and HBV DNA - if present, risk of post necrotic cirrhosis and hepatocellular carcinoma
What will serology show if there is a resolved hep B infection?
HBsAg not present
IgG surface antibody present - anti HBs IgG
Anti HBc IgG likely present
No HBV DNA
What will serology show if a person is vaccinated against hep B?
Anti HBs IgG only
What is the management for hep B?
Admission if acutely unwell
Supportive management of symptoms - itching, nausea
Treatment of chronic compensated liver disease related to hep B - interferon alpha, anti retro viral
Monitor ALT, HBeAg, HBV DNA
Surveillance for development of cirrhosis/HCC
What type of virus is hep D?
Defective single stranded RNA virus
Which virus does hep D require the presence of in order to replicate?
Hep B
How can be hep D be acquired?
At the same time as HBV - co infection
Sometime after HBV - superinfection
Blood borne transmission
Which immunisation protects against hep D infection?
Hep B immunisation
What is the management for hep D?
Interferon
Liver transplant
Which HLA subtypes are associated with autoimmune hepatitis?
DR3 and DR4
What are the 2 types of autoimmune hepatitis?
Type 1: presence of ANA and ASMA
Type 2: presence of anti LKM1, anti LC1
How is autoimmune hepatitis diagnosed?
Raised circulating autoantibodies
Elevation of transaminases: ALT more than AST
Low albumin
Increased PT
How is autoimmune hepatitis managed?
Treatment indicated when transaminases 1.5x upper limit normal
Corticosteroids
Azathioprine - measure TPMT first
What risk stratification tools do you use for someone presenting with upper GI bleeding?
Blatchford score at first assessment
Rockall score pre/post endoscopy
What is the management for an acute upper GI bleed?
Resuscitation Terlipressin if suspect variceal bleed Antibiotic prophylaxis Endoscopy with band ligation Consider TIPS if not controlled
What are signs of decompensated liver disease?
Haematemesis/variceal bleed
Ascites
Hepatic encephalopathy
What proportion of blood flow to the liver is portal?
75%
What is fulminant hepatic failure?
When failure takes place within 8 weeks of the onset of the underlying illness
What is chronic decompensated hepatic failure?
Latent period >6 months
What are the causes of a distended abdomen?
Fat Fluid Faeces Flatus Foetus
What is the most common cause of ascites?
Cirrhosis
Why does ascites occur?
Increased hydrostatic pressure in hepatic sinusoids
Peripheral arterial vasodilation
Activation of RAAS
Renal salt and water retention
What is a complication of ascites?
Spontaneous bacterial peritonitis
Hyponatraemia
How can you determine whether ascites is transudate or exudate?
Serum ascites albumin gradient
How do you manage ascites?
Diuretics: dietary sodium restriction, spironolactone
Paracentesis: if resistance to medical treatment, albumin infusion
TIPS
What is the mechanism that leads to encephalopathy in cirrhosis?
Toxins bypassing liver
Ammonia produced in GI tract by bacteria degrading protein
What are features of encephalopathy?
Changes in behaviour, memory, concentration Insomnia Depression, euphoria, irritability Somnolence Disorientation Increased tone and hyperreflexia Coma
How is encephalopathy managed?
Minimise absorption of nitrogenous material: laxatives - lactulose TDS, reduces colonic pH and limits ammonia absorption
Antibiotics: rifaximin - reduce bowel organisms - reduced ammonia production
Maintain nutrition: protein initially restricted
What is a child Pugh score used to calculate?
Life expectancy in patients with cirrhosis
What is hepatorenal syndrome?
Peripheral vasodilation in advanced liver disease Fall in systemic vascular resistance Hypovolaemia Vasoconstriction of renal circulation Reduced renal perfusion - AKI Poor prognosis
What is abdominal migraine?
Cyclical vomiting syndrome
Attacks of vomiting precipitated by stress, infections, menses
What are poor prognostic features for a patient presenting with acute haematemesis?
Age above 70
Signs of shock (tachy, SBP less than 100)
Adherent clot
Visible vessel on endoscopic examination
Concomitant illness - cirrhosis, diabetes
Which antibiotic is used for travellers diarrhoea and non invasive diarrhoeal illness when treatment is necessary?
Clarithromycin
What is travellers diarrhoea?
At least 3 loose to watery stools in 24h with or without abdo cramps, fever, nausea, vomiting or blood in the stool
What does vitamin A deficiency cause?
Night blindness (nyctalopia)
What does vitamin B1 deficiency cause? (Thiamine)
Beri Beri: Polyneuropathy, Wernicke Korsakoff syndrome, Heart failure
What does vitamin B3 deficiency cause? (Niacin)
Pellagra: Dermatitis, Diarrhoea, Dementia
What does vitamin B6 deficiency cause? (Pyridoxine)
Anaemia
Irritability
Seizures
What does vitamin B7 deficiency cause? (Biotin)
Dermatitis
Seborrhoea
What does vitamin B9 deficiency cause? (Folic acid)
Megaloblastic anaemia
Deficiency during pregnancy: neural tube defects
What does vitamin B12 deficiency cause? (Cyanocobalamin)
Megaloblastic anaemia
Peripheral neuropathy
What does vitamin C deficiency cause?
Scurvy: gingivitis, bleeding
What does vitamin D deficiency cause?
Rickets
Osteomalacia
What does vitamin E deficiency cause?
Mild haemolytic anaemia in newborn infants
Ataxia
Peripheral neuropathy
What does vitamin K deficiency cause?
Haemorrhagic disease of the newborn
Bleeding diathesis
What are features of zollinger ellison syndrome?
Multiple gastroduodenal ulcers
Diarrhoea
Malabsorption
How is a diagnosis of zollinger Ellison syndrome made?
Fasting gastrin level
Secretin stimulation test
Which auto antibodies are associated with autoimmune hepatitis?
ANA
Anti smooth muscle
Anti liver kidney microsomal type 1
What are features of autoimmune hepatitis?
Signs of chronic liver disease Acute hepatitis: fever, jaundice Amenorrhoea ANA Anti smooth muscle antibody Raised IgG Liver biopsy: inflammation beyond limiting plate
What is management of autoimmune hepatitis?
Steroids
Immunosuppressant - azathioprine
Liver transplant
What is primary sclerosing cholangitis associated with?
UC
Crohns
HIV
What are features of primary sclerosing cholangitis?
Cholestasis: jaundice and pruritus
Right upper quadrant pain
Fatigue
How is primary sclerosing cholangitis investigated?
ERCP: shows multiple biliary strictures - beaded appearance
ANCA
Liver biopsy: fibrous obliterative cholangitis - onion skin
What are complications of primary sclerosing cholangitis?
Cholangiocarcinoma
Increased risk of colorectal carcinoma
What are presenting features of haemochromatosis?
Fatigue Erectile dysfunction Arthralgia Bronze skin pigmentation Diabetes mellitus Chronic liver disease Hepatomegaly Cirrhosis Cardiac failure (dilated cardiomyopathy) Hypogonadism (cirrhosis and pituitary dysfunction) Arthritis
What is mutated in haemochromatosis?
HFE gene on chromosome 6
What are features of c diff infection?
Diarrhoea
Abdominal pain
Raised WCC
Toxic megacolon if severe
What is the management for c diff infection?
Oral metronidazole for 10-14 days
If severe or not responding, oral vancomycin
If life threatening, oral vancomycin and IV metronidazole
What are complications of diverticular disease?
Diverticulitis Haemorrhage Abscess formation Post infective strictures Fistulae
A patient is found to be HBsAg and IgM Anti HBc positive. What is the appropriate management?
Bed rest - acute hepatitis B
A 50 year old man with chronic hep B has been on treatment for 7 months. He has developed tingling in his hands and is finding it increasingly difficult to climb stairs. Which medication is likely to be causing his symptoms?
Telbivudine - myopathy and peripheral neuropathy
A 34 year old HIV positive woman has been diagnosed with chronic hep B. She has recently missed a period and is concerned she might be pregnant. What is the optimum treatment for her?
Truvada - treatment of choice for chronic hep B if also HIV positive, safe in pregnancy
A 25 year old woman with confirmed chronic hep B is planning to become pregnant. What is the best treatment option?
Interferon
A 56 year old man receiving chemo for diffuse large B cell lymphoma has intra nuclear owls eyes inclusion bodies on histology. What treatment should be offered?
Ganciclovir - CMV
A 32 year old woman is admitted with acute renal failure. She is HBV positive and recently started a new treatment as her virus was lamivudine resistant. What has likely caused the renal failure?
Adefovir
A 55 year old man who has sex with men presents with general malaise, right upper quadrant pain and yellowing of the eyes. He has multiple casual sexual partners in the preceding months and admits to not always using a condom. On examination he is jaundiced, tender in RUQ and you can feel a liver edge. What is the most likely infection?
Hepatitis B
When should a diagnosis of IBS be considered?
Abdominal pain
Bloating
Change in bowel habit
Present for at least 6 months
When can a positive diagnosis of IBS be made?
Abdominal pain relieved by defecation or associated with altered bowel frequency stool form and 2 of the following: Altered stool passage Abdominal bloating Symptoms made worse by eating Passage of mucus
What are important red flags to ask about when considering IBS as a diagnosis?
Rectal bleeding
Unintentional weight loss
Family history of bowel or ovarian cancer
Onset after 60 years of age
What does streptococcus bovis increase the risk of? How should it be investigated?
Colorectal cancer
Colonoscopy +/- CT abdo pelvis
Which patients need urgent referral for upper GI endoscopy on 2 week wait?
Patients who have dysphagia
Upper abdominal mass
Aged 55 and over who have weight loss and pain, reflux or dyspepsia
Which patients need non urgent referral for upper GI endoscopy?
Haematemesis
Patients 55 and over who have treatment resistant dyspepsia, upper abdo pain with low Hb, raised platelet count with nausea, weight los, reflux, dyspepsia, pain,
How are patients managed who do not meet the criteria for upper GI endoscopy but have undiagnosed dyspepsia?
Review medications for possible causes
Lifestyle advice
Trial of full dose PPI for 1 month or test and treat for h pylori
What test is recommended for h pylori?
Carbon 13 urea breath test, stool antigen test or lab based serology
Test of cure is carbon 13 urea breath test
How is remission induced in UC?
Distal colitis: rectal mesalazine
Oral aminosalicylates
Oral prednisolone second line if fail to respond (wait 4 weeks)
Severe colitis needs admission and IV steroids
How is the severity of UC decided?
Mild: <4 stools a day, small amount of blood
Moderate: 4-6 stools/day, varying blood, no systemic upset
Severe: >6 bloody stools/day and systemic upset
How is remission maintained in UC?
Oral aminosalicylates: mesalazine
Azathioprine and mercaptopurine
How should remission be induced in crohns?
Glucocorticoids Enteral feeding with elemental diet 5-ASA eg mesalazine second line Azathioprine or mercaptopurine as add on Infliximab in refractory disease and fistulating crohns
How is remission maintained in crohns?
Stop smoking
Azathioprine or mercaptopurine
Methotrexate second line
5-ASA - mesalazine if had previous surgery
A 46 year old man is being investigated for indigestion. Jejunal biopsy shows deposition of macrophages containing PAS positive granules. What is the most likely diagnosis?
Whipples disease
What is whipples disease?
Tropheryma whippelii infection
Common in those who are HLA B27 positive and middle aged men
What is Budd Chiari syndrome?
Obstruction to hepatic venous outflow usually due to a hypercoagulable state but can also be due to tumour
Venous congestion causes hepatomegaly and portal hypertension which can result in splenomegaly and ascites
What are some causes of budd chiari?
Polycythemia rubra Vera
Thrombophilia: activated protein c resistance, antithrombin III deficiency, protein c and s deficiency
Pregnancy
Oral contraceptive pill
What are features of budd chiari?
Abdominal pain, sudden onset, severe
Ascites
Tender hepatomegaly
What are features of whipples disease?
Malabsorption: diarrhoea, weight loss
Large joint arthralgia
Lymphadenopathy
Skin: hyperpigmentation and photosensitivity
Pleurisy
Pericarditis
Neurological symptoms: opthalmoplegia, dementia, seizures, ataxia, myoclonus
What is the management of whipples disease?
Oral co-trimoxazole for a year
Sometimes preceded by a course of IV penicillin
What is the prophylaxis for variceal haemorrhage?
Propranolol
Endoscopic variceal band ligation at 2 week intervals
PPI cover to prevent ulceration
Why might a patient with UC have ascites and peripheral oedema?
Protein losing enteropathy
A 58 year old gentleman, presenting to GP with epigastric pain
which occurs at varying times throughout day and night. Feels bloated at times with episodes of bletching. Feels nauseated. No regular prescribed medications. Has started new manual job so has been taking Ibuprofen regularly to relieve muscular aches and pains. Current smoker. Epigastric tenderness on examination. What are some differential diagnoses?
Gallstones – including cholecystitis, pancreatitis Gastric oesophageal reflux disease Peptic ulcer disease IBD Malignancy
What is dyspepsia?
Abdominal discomfort Bloating Satiety Nausea Loss of appetite Regurgitation
What are indications (red flags) for OGD?
Dysphagia Unexplained upper abdo pain with weight loss Upper abdo mass +/- dyspepsia Persistent vomiting and weight loss Unexplained weight loss Iron deficiency anaemia Unexplained worsening of dyspepsia Patients aged >55 years with unexplained and persistent recent onset dyspepsia
What investigations should be done for someone presenting with dyspepsia?
Bloods: FBC plus haematinics – iron deficiency anaemia
Imaging: Erect CXR, USS if suspect gallstones
Special tests: Endoscopy, H.pylori investigation
What is H pylori?
Gram negative urease-producing spiral shaped bacteria
Which conditions are associated with h pylori?
Chronic gastritis
Peptic ulcer disease
Gastric cancer
Gastric B cell lymphoma
How is h pylori diagnosed?
Non-invasive: C-urea breath test – ingest 13C-urea, broken down by H.pylori to produce 13C in expired breath. Stool antigen. Serum
Invasive: CLO test – pH dependent colour change due to presence of ammonia, Histology
What is the management for a duodenal ulcer?
Conservative: Smoking cessation advice, Stop NSAIDs – discuss harm after medical treatment
Medical: H. pylori eradication – 1st line PPI + amoxicillin + clarithromycin or metronidazole – for 7 days. Recurrence of symptoms – long term lowest dose PPI. Repeat endoscopy 6-8 weeks after treatment to assess
Surgical: Reserved for complications – haematemesis, perforation (duodenal > gastric)
What are some causes of haematemesis?
Oesophagitis Peptic ulcer Vascular malformations Varices Mallory Weiss tear Cancer Gastric erosion
24 year old, visits her GP with ongoing symptoms of tiredness / lethargy. Experiencing abdominal discomfort. Reduced appetite and weight loss. Daily episodes of diarrhoea. What are some differential diagnoses?
IBS
IBD
Coeliac disease
GI infection
In a young patient presenting with symptoms of IBS/coeliac. What investigations need to be done?
Bedside: Stool sample – culture
Bloods: FBC – anaemia, Haematinics, LFTs
Imaging: Plain AXR – if suspecting colitis
Special tests: Serum antibodies – total IgA and IgA tissue transglutaminase antibodies (tTG). Only accurate if remaining on gluten diet
What is coeliac disease?
Immune-mediated, inflammatory systemic disorder provoked by gluten and related prolamines, leading to malabsorption of nutrients
Multi-genetic disorder associated with HLA types
Familial tendency
Gliadin = toxic portion of gluten, Initiate inflammatory cascade
In which patients is serology for coeliac disease indicated?
Symptomatic patients Autoimmune disease (T1DM, Thyroid disease, Addison’s) IBS Unexplained osteoporosis 1st degree relative with coeliac (10-fold increase) Down’s syndrome (20-fold increase) Turner’s syndrome Infertility and recurrent miscarriage
What is the management for coeliac disease?
Long term gluten-free diet following confirmation of diagnosis
Annual review: Weight/height, Symptom control, Adherence to gluten-free diet, Consider specialist dietetic/ nutritional advice
Which patients should be screened for malnutrition?
All hospital admissions All 1st outpatient appt Care homes Registration at GP On clinical concern
Which patients may need nutritional support?
Malnourished patients
BMI < 18.5 kg/m2
>10% unintentional weight loss over 3-6 months
BMI <20 kg/m2 + 5% unintentional weight loss over 3-6 months
Which patients are at risk of malnutrition?
Eaten little or nothing for more than 5 days +/- likely to continue to eat little for the next 5 days
Poor absorptive capacity
What are the main electrolyte disorders in refeeding syndrome?
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Describe the pathology of refeeding syndrome
Starvation: protein catabolism, adjustment to new metabolic state
Refeeding: conversion to glucose metabolism, insulin release, intracellular shifts of phosphate, magnesium and potassium
What are 2 key investigations in chronic pancreatitis?
Faecal elastase
CT abdomen
Which condition is typified by a corkscrew oesophagus?
Oesophageal spasm
What can be trialled to treat oesophageal spasm?
Nitrates
Calcium channel antagonist
In which circumstances should you start acetylcysteine without knowing the plasma levels of paracetamol?
Uncertainty about time of overdose, but potentially toxic
Overdose staggered over longer than an hour
Overdose taken 8-36 hours before presenting
What is the treatment of choice for giardiasis?
Metronidazole
How is giardiasis transmitted?
Contamination of food or water with protozoan Giardia lamblia
What are the colorectal cancer referral guidelines? Who needs urgent referral?
Patients over 40 with weight loss and pain
Patients over 50 with unexplained rectal bleeding
Patients over 60 with iron deficiency anaemia or change in bowel habit
Tests show occult blood in faeces
Who should be offered faecal occult blood testing?
All men and women aged 60 to 74 every 2 years
Patients over 50 with unexplained abdo pain or weight loss
Patients less than 60 with changes in bowel habit or iron deficiency anaemia
Patients over 60 who have anaemia even in absence of iron deficiency
What are risk factors for oesophageal candidiasis?
HIV/immunosuppression
Steroid inhaler use
What is a dieulafoys lesion?
Large tortuous arteriolar commonly in the stomach wall submucosally that erodes and bleeds
What are clinical features of iron deficiency anaemia on examination/history?
Glossitis Angular stomatitis Koilonychia Pica Conjunctival pallor
Why do alcoholics become thiamine deficient?
Alcohol interferes with active gastrointestinal transport of thiamine
If chronic liver disease: activation of thiamine pyrophosphate from thiamine is decreased and capacity of liver to store thiamine is diminished
Malnourishment
What can cause a thiamine deficiency?
Alcoholism
Vomiting during pregnancy
Dietary insuffiency
Gastric carcinoma
What is the definition of chronic hepatitis c?
Persistence of HCV RNA in blood for 6 months
What are potential complications of chronic hepatitis c?
Rheumatological: arthralgia, arthritis Eye: Sjögren's syndrome Cirrhosis Hepatocellular carcinoma Cryoglobulinaemia Porphyria cutanea tarda Membranoproliferative glomerulonephritis
What are complications of primary biliary cirrhosis?
Malabsorption Osteomalacia Coagulopathy Sicca syndrome Portal HTN Hepatocellular cancer
If a total paracentesis is used to treat tense ascites, what else should be done alongside?
6-8g albumin or colloid equivalent should be infused for every litre of ascitic fluid removed
Which investigation is most appropriate to check that a rectal anastamosis is sound prior to performing an ileostomy reversal?
Gastrografin enema
What are causes of raised ferritin without iron overload?
Inflammation Alcohol excess Liver disease CKD Malignancy
What is the Amsterdam criteria for diagnosis of HNPCC?
3 or more relatives with colorectal cancer, endometrial carcinoma, small bowel adenocarcinoma, ureter or renal pelvis cancer
2 or more successive generations affected
1 or more tumour before age 50
FAP excluded
Confirmed with histology
How does Chagas’ disease present?
Megaoesophagus or megacolon
Which patients most commonly get Chagas’ disease?
South American men between 20-40 years
What is the problem in Chagas’ disease?
American trypanosomiasis infection with Trypanosoma Cruzi
Causes denervation of myenteric Auerbachs plexus in bowel wall
What is gardners syndrome?
AD Familial colorectal polyposis
Skull osteoma, thyroid cancer and epidermoid cysts
Mutation to APC gene on chromosome 5
Most require colectomy to reduce risk of colorectal cancer
What is the recommendation for screening in patients with 2 first degree relatives with colon cancer?
Colonoscopy beginning at 35 or 5 years younger than earliest case in family
Every 5 years after that
Yearly FOBT
How should more serious liver disease be assessed for in a patient with NAFLD?
Enhanced liver fibrosis blood test: hyaluronic acid, procollagen III and TIMP1
What is the most common cause of liver disease in the developed world?
NAFLD
What is the key mechanism leading to steatosis in NAFLD?
Hepatic manifestation of metabolic syndrome
Insulin resistance leads to steatosis
What factors are associated with NAFLD?
Obesity Hyperlipidaemia T2DM Jejunoileal bypass Sudden weight loss/starvation
What are features of NAFLD?
Asymptomatic
Hepatomegaly
ALT>AST
Increased echogenicity on USS
What are colorectal 2ww referral criteria?
Patients 40 or more with unexplained weight loss and abdominal pain
Patients 50 or more with unexplained rectal bleeding
Patients 60 or more with iron deficiency or change in bowel habit
Tests show occult blood in faeces
Who is offered FOBT screening?
Every 2 years all men and women aged 60 to 74
Patients 50 or more with unexplained abdo pain or weight loss
Patients less than 60 with change in bowel habit or iron deficiency anaemia
Patients 60 or more with anaemia
What are risk factors for the development of c diff infection?
Increasing age Antibiotic use (particularly broad spec) IBD PPI use Long hospital stays Immunosuppression Surgery to GI tract
What type of bug is c diff? How does it cause pseudomembranous colitis?
Gram positive rod
Produces exotoxin which causes intestinal damage
What are features of c diff infection?
Diarrhoea
Abdominal pain
Raised white cell count
If severe - toxic megacolon
What is the management of c diff?
Oral metronidazole for 10-14 days
If severe or not responding - oral vancomycin
If life threatening - oral vancomycin and IV metronidazole
What is the pathophysiology of hepatorenal syndrome?
Vasoactive mediators cause splanchnic vasodilation which in turn reduces SVR
This in turn results in under filling of the kidneys
This is sensed by juxtaglomerular apparatus which activates RAAS causing renal vasoconstriction which is not enough to counterbalance
What is the pathophysiology of haemochromatosis?
Autosomal recessive disorder
Accumulation of iron in parenchymal organs
Gene mutations in HFE gene on chromosome 6 lead to reduced hepcidin production which in turn leads to increased ferroportin mediated iron efflux from storage and increased gut absorption
Excess iron produces free radicals which can lead to DNA damage, impaired protein synthesis, impaired cell integrity, cell injury and fibrosis
What are the types of hepatorenal syndrome?
Type 1: Rapidly progressive, doubling of serum creatinine to >221 in less than 2 weeks. Very poor prognosis
Type 2: slowly progressive. Poor prognosis but may live for longer
What are management options for hepatorenal syndrome?
Vasopressin analogues: terlipressin causes vasoconstriction of splanchnic circulation
Volume expansion with 20% albumin
Transjugular intrahepatic portosystemic shunt
Transplant
What are potential complications of an upper GI endoscopy?
Perforation Bleeding Reaction to sedation/anaesthetic Infection Aspiration pneumonia
What is a lundh test?
Direct test of pancreatic function in which duodenal contents collected for 2 hours following meal containing carbs, protein and fat
Low enzymatic activity - amylase, trypsin of lipase indicates pancreatic insufficiency
How is a diagnosis of Wilson’s disease made?
Reduced serum caeruloplasmin
Reduced serum copper
Increased 24h urinary copper excretion
Which conditions are associated with dupuytrens contracture?
Alcohol excess Liver cirrhosis AIDS Diabetes mellitus Phenytoin use Peyronie’s disease
If a patient has no response to hep B vaccine (anti HBs <10) what else needs to be done?
Test for current or past infection
Give further vaccine course (3 doses)
Test again
If still failed to respond then HBIG would be required for protection if exposed
What is gynaecomastia?
Presence of over 2cm palpable firm subareolar gland and ductal breast tissue
What are causes of gynaecomastia?
Lack of testosterone: congenital absence of testes, androgen resistance, klinefelters, orchitis, renal disease
Increased oestrogen: testicular tumours, cancer secreting hCG, adrenal tumour, congenital adrenal hyperplasia, liver disease, hyperthyroidism, obesity
Drugs: digoxin, metronidazole, ketoconazole, spironolactone, GnRH agonists, finasteride, anabolic steroids, antipsychotics
What investigations should be done for gynaecomastia?
Renal function LFTs TFTs Hormones: oesradiol, testosterone, prolactin, beta hCG, AFP, LH Karyotyping USS/mammogram USS testes CXR
How long before an endoscopy should omeprazole be stopped?
At least 2 weeks prior
What is SAAG?
Serum ascites albumin gradient
Value below 11 - not portal HTN
Value above 11- portal HTN
What are some causes of budd-chiari?
Polycythemia rubra Vera
Thrombophilia: activated protein c resistance, antithrombin III deficiency, protein c and s deficiencies
Pregnancy
Oral contraceptive pill
What is pseudomyxoma peritonei?
Rare mucinous tumour most commonly from appendix
Accumulation of large amounts of gelatinous material in abdomen
What is a urea breath test?
Patients consume drink containing carbon isotope 13 enriched urea
Urea broken down by h pylori urease
After 30 mins patient exhales into glass tube
Mass spec calculates amount of 13C CO2
Which drugs may interfere with the results of a urea breath test?
Antibiotics within 4 weeks
PPI within 2 weeks
What is a CLO test?
Rapid urease test
Biopsy sample mixed with urea and pH indicator
Colour change if h pylori urease activity
What is the first line management for hepatic encephalopathy? How does it work?
Lactulose orally or per rectum
Reduction of intestinal ammonia load through purgative action and inhibiting anmoniagenic coliform bacteria by acidifying colonic lumen
What is transient elastography?
Fibroscan
Uses 50mhz wave passed into liver from transducer on USS probe
Measures stiffness of liver which is a proxy for fibrosis
Who should be offered transient elastography?
People with hep C
Men who drink over 50 units/week and women who drink over 35 and have done so for several months
People diagnosed with alcohol related liver disease
What surveillance should patients with cirrhosis have?
OGD to check for varices in newly diagnosed
Liver USS every 6 months +/- alpha fetoprotein to check for hepatocellular cancer
Which bugs can cause gastroenteritis?
Viruses : Rotavirus, Adenovirus, astrovirus
Bacterial : Salmonella, Campylobacter, E coli 0157, Shigella
When should stool microbiology be performed in a person with gastroenteritis?
Travel abroad More than 7 days Blood in stool Immunocompromised Sepsis
What is the Mackler triad for boerhaave syndrome?
Vomiting
Thoracic pain
Subcutaneous emphysema
Which patients with ascites require antibiotic prophylaxis for SBP?
If they have had a previous episode of SBP
Fluid protein 15g/L or less and child Pugh score of at least 9 or hepatorenal syndrome
Prophylactic ciprofloxacin or norfloxacin
How is a diagnosis of SBP made?
Paracentesis: neutrophil count >250 cells/microL
What is the management of SBP?
IV cefotaxime
What is the Hinchey classification?
Classifies diverticular perforation
Stage 1: diverticulitis with pericolic abscess
Stage 2: diverticulitis with distant abscess (retroperitoneal or pelvic)
Stage 3: purulent peritonitis
Stage 4: faecal peritonitis
When do different features of alcohol withdrawal occur?
Symptoms: 6-12 hours
Seizures: 36 hours
Delirium tremens: 72 hours
Why does chronic alcohol consumption lead to withdrawal symptoms if stopped abruptly?
Chronic alcohol consumption enhances GABA mediated inhibition in CNS and inhibits NMDA glutamate receptors
Withdrawal causes the opposite so leading to overactivity and therefore seizures and delirium
What are the components of the child Pugh score?
All Alcoholics Bring Empty Prosecco Albumin Ascites Bilirubin Encephalopathy Prothrombin time
What criteria is used to assess severity of UC in adults? What classes as severe?
Truelove and Witts
Severe if: blood in stool or more than 6/day plus at least 1 of - temp over 37.8, heart rate over 90, Hb less than 105, ESR over 30
Which drugs contribute to causing c diff?
Clindamycin Cephalosporins Penicillins Fluoroquinolones PPIs
Which blood test is most suggestive of Wilson’s disease? Which other tests are useful in diagnosis?
Reduced serum caeruloplasmin
Reduced serum copper
Increased 24hr urinary copper excretion
What defines upper vs lower GI bleed?
Distal or proximal to the ligament of Trietz
What makes meckels diverticulum susceptible to bleeds?
Ectopic gastric/pancreatic mucosal tissue
What features are required for a diagnosis of IBS to be considered?
Abdo pain
Bloating
Change in bowel habit
For at least 6 months
What is the Rome 3 criteria for diagnosis of IBS?
Recurrent abdo pain 3 or more days per month in last 3 months associated with at least 2 of:
Pain/discomfort improved after defecation
Onset associated with change in frequency of stool
Onset associated with change in form of stool, alternating between diarrhoea and constipation
No evidence of inflam, anatomical, metabolic or neoplasticism process that could be causing symptoms
What are red flag symptoms which should be enquired about when suspecting IBS?
Rectal bleeding
Unintentional weight loss
FH bowel or ovarian cancer
Onset after age 60
What are suggested primary care investigations for IBS?
FBC
ESR/CRP
Coeliac screen (anti TTG)
What are features of primary biliary cirrhosis?
Granulomatous destruction of bile ducts Insidious pruritis then jaundice Sicca syndrome Finger clubbing Xanthomata and hyperlipidaemia Neuropathy Arthritis
What are risk factors for gallstones?
Fair Fat Forty Fertile Female
What is Dubin Johnson syndrome?
Autosomal recessive disorder causes isolated increase of conjugated bilirubin
Causes black liver
Due to mutation in multiple drug resistance protein 2
What is rotor syndrome?
Autosomal recessive disorder with isolated conjugated bilirubinaemia due to inability to excrete it
Why do diverticuli occur most frequently in sigmoid colon?
Faeces more solid here
Lumen smaller and less able to stretch
Where does angiodysplasia occur most commonly?
Caecum and ascending colon
What are problems with an end to end anastomosis?
Stricture
Leakage
Dehiscence
What are different types of bowel anastamosis?
End to end
Side to end
Side to side
What is suggested by AST>ALT with overall rise less than 5 times?
Alcohol related
Cirrhosis
At what level of bilirubin is jaundice clinically detectable?
Levels over 40
Why is there a coagulopathy in liver disease?
Failure of activation of vitamin k and therefore lack of Vit k dependent clotting factors
What are the 4 stages of liver disease?
Liver cell necrosis
Inflammatory infiltrate
Fibrosis by fibroblasts
Nodular regeneration which can be micro (viral) or macronodular (alcohol)
What is management of ascites?
Salt/fluid restrict
Diuretics particularly spironolactone
Paracentesis
Provide 20% albumin solution to prevent reaccumulation
What should be used to treat hepatic encephalopathy?
Lactulose - osmotic laxative - inhibiting bacterial growth which produce ammonia
What is the initial management of unruptured sigmoid volvulus?
Flatus tube insertion
Second line: insertion of percutaneous colostomy tube
What is the histology of coeliac disease?
Villous atrophy
Raised intra epithelial lymphocytes
Crypt hyperplasia
What is the acute treatment of variceal haemorrhage?
A to E
Correct clotting: FFP, vitamin K
Vasoactive agents: terlipressin
Prophylactic antibiotics if liver cirrhosis
Endocscopic variceal band ligation
Sengstaken blakemore tube if uncontrolled
Transjugular intrahepatic portosystemic shunt
What can be used for prophylaxis of variceal bleeding?
Propranolol
Endoscopic variceal band ligation at 2 weekly intervals until all varices eradicated
PPI cover to prevent EVL induced ulceration
What are causes of chronic liver disease?
Infective: hep B, hep C
Toxic: alcohol
Metabolic: NAFLD, haemochromatosis, alpha 1 antitrypsin, Wilson’s
Autoimmune: autoimmune hepatitis, PSC, PBC
How would you investigate the cause of chronic liver disease?
HBV and HCV serology Hx of alcohol excess Ferritin, transferrin Alpha 1 antitrypsin Caeruloplasmin Immunoglobulins Autoantibodies
What are features of decompensated liver disease?
Coagulopathy Asterixis Ascites Worsening jaundice Hypoglycaemia
What are complications of cirrhosis?
Portal HTN: variceal haemorrhage, SBP, thrombocytopenia
Hepatocellular failure: encephalopathy, Hepatocellular Ca, hypoalbuminaemia, coagulopathy
What are causes of splenomegaly?
Haem: CML, myelofibrosis, spherocytosis (may have had splenectomy in childhood)
Infective: malaria, EBV
Other: portal HTN, amyloidosis, sarcoidosis
What defines massive splenomegaly?
Extends beyond midline
What are indications for stoma in IBD?
Crohns: failure of medical management, obstruction, fistulae
UC: failure of medical management, toxic megacolon, malignancy
What types of stomas are done for IBD?
Crohns: de functioning loop ileostomy
UC: end ileostomy (pan proctocolectomy), diversion ileostomy with ileal rectal pouch formation
What are histological features of Crohns?
Presence of granuloma formation
Transmural inflammation
Lymphocytic infiltration
What are endoscopic differences between crohns and UC?
Crohns: inflammation is not continuous with presence of skin lesions, cobblestone appearance, mouth to anus, terminal ileum affected
UC: uniform inflammation, thin walls, loss of vascular pattern, rectum always affected, large bowel only
What are extra articular features of Crohns?
Erythema nodosum Pyoderma gangrenosum Iritis Conjunctivitis Episcleritis Large joint arthritis Ankylosing spondylitis Aphthous ulceration
What are complications of Crohns?
Perianal abscess and fistulae Enteric fistulae Perforated bowel Small bowel obstruction Colonic carcinoma Malnutrition
What drugs can contribute to an upper GI bleed?
NSAIDs Aspirin Corticosteroids Anticoagulants Thrombolytics
Explain how the urea breath test for h pylori works
H pylori produce urease to break down urea into ammonia and CO2
Radio isotope of carbon 13/14 in form of urea is ingested and radio isotope CO2 can be measured
What is gold standard test for GORD?
Oesophageal pH manometry
What is dumping syndrome?
Rapid gastric emptying due to food entering small bowel too quickly
After gastric surgery
Why might an anti endomysial antibodies be negative in a patient with severe coeliac disease?
Severe malabsorption can lead to IgA deficiency
What are histological features of coeliac disease?
Subtotal villous atrophy
Increased intraepithelial lymphocytes
Hypoplasia of small bowel architecture
Proliferation of crypts of Lieberkuhn
What cancers are associated with coeliac disease?
GI T cell lymphoma
Gastric
Oesophageal
Which antibodies can be tested for in coeliac disease?
Anti tissue transglutaminase
Alpha gliadin
Anti endomysial
What is post obstructive diuresis?
Urine output exceeding >200ml/hr after cleaning an obstruction
What drugs are required to be stopped before a urea breath test?
No abx for 4 weeks
No PPI for 2 weeks
