Gastro Flashcards
What are the causes of diarrhoea
Infective - camp, shig, e coli Inflammatory - IBD Neoplastic - CRC, polyps Drugs - co amoxyclav, PPI, NSAIDS, digoxin Endocrine - t4 raised Vascular - ischemic colitis
c dif - +ve or -ve?
gramm positive spore forming anaerohbe
risk factors for c dif?
hospital stay
age
abx - Clindamycin, coamoxyclav, cephalosporins, quinolones
PPI
What is pseudomembranous colitis
a presentation of c dif diarrhoeal infection found on flexi sig - yellow cornflake like plaques
assocaited with mucus and even bloody diarrhoea with abdo pain
high fever and dehydration
What are the complications of c dif?
toxic dilation leading to perforation -colectomy
paralytic ileus
multi organ failure
recurrence due to residual spores
what test should be ordered to diagnose c dif
toxin A and B immunoassay
stool culture, leucocytosis
What is the management regime for c dif?
stop the offending abx
metronidazole 500mg TDS 2 weeks
Vancomycin 125mg QDS oral if severe or if pregnant
Can add IV met if fulminant
Metronidazole can be given IV but vancomycin cannot for this indication
How can you tell if someone has severe c dif?
one of:
WCC greater than 15
Cr >50% above base
radiological or clinical evidence of severe colitis
What should be avaoided in c dif
codeine phosphate and loperamide
Agents for constipation?
BOSSES Bulking - Methylcellulose, ispagula husk Osmotic - Lactulose, MgSO4, macrogols (polyethylese glycol) Stimulant - Senna Enemas - phosphate (osmotic) Softeners - docusate sodium
Causes of constipation?
Most common - opiates inactivity, dehydration, poor diet.
Obstruction - mechanical or ileus
What is IBS
a disorder of Enhanced visceral perception causing bowel symptoms without any organic cause
How do you diagnose IBS
Manning criteria (or rome) Abdominal pain + atleast 2 of:
feeling of incomplete evacuation increased frequency at onset of pain loseness at onset of pain visible distension and bloating mucus relief of pain with defecation
What tests should be done in IBS
FBC
coeliac serology
stool culture
colonoscopy and biopsy
Management for IBS
Laxactives - bulk forming antispasmodics - mebeverine Exclusion diets amytriptiline CBT
Differentials for dysphagia
Inflammatory - Pharyngitis/osophagitis, apthous ulcers
Mechanical block
Luminal - bolus/FB
Mural - stricture
Extramural - compressive mass being cancer or goitre
Motility disorder
local - achalasia
Systemic - MG/systemic sclerosis
investigating dysphagia
Bloods CXR OGD Contrast swallow with fluoroscopy Manometry
2 secondary causes of achalasia
oesophageal cancer and chagas disease
What classification system is used to grade the severity of liver cirrhosis
Child pugh - 5 things
Albumin Bilirubin Ascites Enephalopathy Prothrombin time
What are the two types of HNPCC?
Lynch 1 : right sided CRC
Lynch 2 : CRC + gastric endometrial, prostate, breast
MSH2 gener of chr 2p (or MLH1)
How do you diagnose HNPCC?
> 3 family members over 2 generations with 1 under 50
321 rule - amsterdam criteria
What is budd chiari
Hepatic venous outflow obstruction due to a thrombus.
how should you investigate budd chiari
dopplers USS
What are the causes of portal hypertension
Pre hepatic - Portal thrombosis
Hepatic - cirrhosis, Schistosomiasis
Post hepatic - Budd chiari, Right heart failure, constrictive pericarditis, TR
Name 3 portosystemic anastomosis sites
oesophageal varices - left gastric/inf. oesophageal veins
caput medusae - umbilical/abdominal wall
hemorrhoids - super rect/inferior rectal veins
What is encephalopathy?
accumulation of ammonia and toxins in the brain due to the diversion of toxins from the portal system directly into the systemic flow. this causes the production of glutamine causing cerebral odema
what are the presenting symptoms of encephalopathy
dysarthria asterixes confusion constructional apraxia seizures
What are the precipitants of hepatic encephalopathy?
HEPATICS - constipation most common
Haemorrhage electrolytes poisins alcohol tumours: HCC infection: SBP Constipation Sugar low
recent TIPS - can cause it. may need occluding
What is the management for encephalopathy
lactulose
nurse at 20% head up
rifaximin or other anaerobic tagetting abx for those resistant to lactulose
4 outcomes of portal hypertension?
SAVE Splenomegaly Ascites Varices Encephalopathy
what is the serum ascites albumin gradient
in portal hypertension the concentration of albumin in the blood should be 11g/l higher than in the ascitic tap
a value of less than 11 means the cause is neoplastic, inflammatory, infectious or due to nephrotic syndrome
How do you manage someone with ascites?
History Examine Obs Bloods: FBC LFT UE Clotting glucose Hepatitis screen USS Ascitic tap - SAAG, AFB MCS cytology
DAILY WEIGHTS
Fluid and salt restrict
frusemide and spironolactone
HAS if draining ascites
What is the management for SBP?
cefotaxime with albumin
lifelong abx prophylaxis due to high recurrence
What are the causes of liver chirosis?
Inherited - a1at, HH, wilson CF Infectious - hepatitis B/C CMV EBV AI- PBC PSC AIH Malignant - HCC/ mets Drugs - amiodarone, methtrexate. alcohol metabolic: NASH
what are the most common causes of chirrosis
alcohol
NASH
hep c and b
What are the signs of cirrhosis?
Hands - palmar erythema, leuconychia clubbing dupytrens
face: pallor, xanthelasma, parotid enlargement.
Trunk: spider naevi(press them) gynaecomastia
abdo - striae ascites caput hepatomegaly, splenomegaly testicular atrophy
What is acanthosis nigricans assocaited with?
rule out malignancy (gastric)
insulin resistance and cushings
Complications of cirrhosis
liver decompensation portal hypertension - ascites, splenomegaly, varices, encephalopathy SBP risk of HCC hepatorenal syndrome
How do you remedy hepatorenal syndrome
splanchnic vasoconstrictors
liver transplant
haemodialysis
HAS
What are the signs of decompensated liver failure?
ascites jaundice encephalpathy - asterixs and constructional apraxia faetor hepaticus bruising odema
How do you manage someone with liver failure?
Clotting - vit K, platelets FFP
Ascites - fruse, spiro, daily weight, HAS
Encephalopathy - 20degs, lactulose, anaerobic abx
cerebral odema - mannitol
seizures - lorazepam
sepsis - abx taz
glucose - glucose regular BM
What things shouyld be monitored in liver failure
Glucose
Fluid balance
clotting
daily bloods - UE LFT INR
What medications should be avoided in liver failure
hepatotoxic drugs - paracetamol, methotrexate, isoniazid
opiates
What is the general community management of a patient with alcoholic cirrhosis?
abstain from alcohol use group therapy, CBT, naltrexone or acamprosate to reduce cravings disulfiram for aversion quit smoking weight loss cholestyramine if itchy
manage complications and screen.
What score is a significant risk of bleeding on child pugh
8
What is the management for severe UC
Admit, rehydration, NBM 100mg IV hyrocortisone QDS + PR transfuse if blood loss Anticoagulate with LMWH Monitor for complications
What are the complications of severe UC flare?
toxic megacolon sepsis Perforation bleed out thromboembolic event
What is the drug of choice in UC maintenance
mesalazine or 5-ASA they are the same
What are the signs of hereditary haemochromatosis
MEALS
Myocardial involvement - arrythmias and dilated cardiomyopathy
Endocrine - pancreas DM, hypogonadism (erectile dys)
Arthritis - 2nd and 3rd MCP joints
Liver cirrhosis
Skin - bronzed diabetes
How do you investigate HH?
bloods - FBC LFT iron studies
Echo
plain film of arthritic joints - shows chondrocalcinosis
liver biopsy
What is an ELF score and when is it used?
enhanced liver fibrosis score
used in new diagnosis of NAFLD to test for advanced fibrosis
10.51 is the cutoff
offer every 3 years to adults
What should be used to diagnose liver fibrosis in hep C
transient elastography scan
What score is used for determining the mortality of a suspected upper GI bleed
Glasgow blatchford score
Haemaglobin Blood pressure sex Urea Pulse>100 Malaena syncope hepatic failure cardiac failure
What are the extra GI manifestations of IBD:
Hands - clubbing
eyes - iritus
mouth - apthous ulceres
joints - arthritis sacroileitus
skin - pyoderma gangrenosum, erythema nodosum
HPB - PSC +cholangiocarcinoma, gallstones, fatty liver,
other - amyloid/renal stones
Cause of ground glass opacity on AXR
fluid in the abdomen
ant ttg vs EMA
ttg more sensitive and cheaper but less specific
