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Gastro Flashcards

1
Q

How severe would an anaemia need to be to warrant a 2ww referral for upper and lower GI endoscopy in a man?

A

<110 (at any age)

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2
Q

How long does it typically take for oral iron supplementation to have an affect?

A

2-3 months for a decent response.

RL is the absorption of oral iron from GIT. Shortest possible time interval is 2-4 weeks.

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3
Q

What is the Mx of patients with iron-deficiency anaemia prior to surgery?

A

Oral iron if time period to surgery long enough (2-3 months)
If not, or intolerant of oral iron:
- Blood transfusion or
- IV iron (ferric carboxymaltose) 1g, repeated after 1 week.

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4
Q

What is the first-line therapy for C. Diff diarrhoea?
What if this is ineffective or severe infection?
What if it’s life-threatening?

A

Oral metronidazole for 10-14 days

If ineffective or severe infection: Oral vanc

Life-threatening: Oral vanc + IV metro

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5
Q

What are the features of overflow diarrhoea?

Mx?

A 
Type 7 (liquid) stills with intermittent hard stool.
Mx: High dose macrogol laxatives
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6
Q

What is the surgical treatment of achalasia?

A

Heller cardiomyotomy

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7
Q

When is surgical intervention indicated in achalasia?

A
  • <40 who will require lifelong dilations or botulinum injections
  • Recurrent/persistant symptoms after multiple non-surgical interventions
  • Patients who choose surgery initially
  • High risk for perforation with pneumatic dilation (prev oesophagogastric junction surgery)
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8
Q

What is achalasia?
Features?
What is the classical appearance on barium swallow?

A

Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter, due to loss of ganglia from Auerbach’s plexus.

  • Middle aged M/F
  • Dysphagia of BOTH liquids and solids
  • Typically variation in severity of symtpoms
  • Heartburn
  • Regurgitation of food (-> cough, aspiration)
  • Small number of patients may have malignant change

Barium swallow: ‘bird’s beak’ appearance

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9
Q

What is the most important Ix in suspected achalasia?

A

Manometry

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10
Q

What is the most common site affected in UC?

A

Rectum

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11
Q

What is the peak incidence of UC?

A

Bimodal:
15-25 years
55-65 years

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12
Q

What are the features of UC?

A
  • Bloody diarrhoead
  • Urgency
  • Tenesmus
  • Abdo pain, especially LLQ
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13
Q

What are the extra-intestinal features of UC?

A 
Primary sclerosising cholangitis
Uveitis
Arthritis
Erythema nodosum
Pyoderma gangrenosum
(Colorectal ca)
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14
Q

What is Plummer-Vinson syndrome?

Triad?

A

Triad of:

  • dysphagia (due to post-cricoid webs)
  • glossitis
  • iron-deficiency anaemia
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15
Q

How would you calculate alcohol units when given a volume and %?

A

Units = volume (ml) * ABV / 1000

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16
Q

What is the government advice regarding the number of units alcohol/week?

A

Men and women: no more than 14 units /week.

If you do drink as much as 14 units, best to spread this evenly over 3 days or more.

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17
Q

What is the inheritance pattern of HNPCC?

What cancers are they at risk of?

A

AD

90% develop colon cancers, typically proximal colon (poorly differentiated and highly aggressive).
Second highest risk is endometrial ca.

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18
Q

What is the first line investigation of someone with iron-deficiency anaemia?

A

anti-TTG (coeliac)

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19
Q

What is Peutz-Jeghers syndrome?
Inheritance?
Other features?

A

AD
Numerous hamartomatous polyps in GIT (mainly small bowel)
50% die from GIT ca by age 60.

  • Pigmented lesions on lips, oral mucosa, face, palms and soles
  • Intestinal obstruction
  • GI bleeding
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20
Q

What tests are best to look at the functioning of the liver? (e.g. in monitoring cirrhosis)

A
  • Prothrombin time (raised)

- Albumin level (low)

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21
Q

What test would you do following incidental finding non-alcoholic fatty liver disease on US?

A

Enhanced liver fibrosis (ELF) test to check for advanced fibrosis.

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22
Q

What would you see on Hep B serology if patient had previous immunisation?

A

Positive anti-HBs

Negative Anti-HBc and HBsAg

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23
Q

What would you see on Hep B serology if patient had previous infection?
What would determine if they were a carrier or not?

A

anti-HBc positive
+
HBsAg positive if carrier, negative if not.

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24
Q

What does HbeAg mean on Hep B serology?

A

It results from breakdown of core antigen, so is a marker of infectivity.

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25
Q

What is the most common type of inherited colorectal cancer?

A

HNPCC (5%)

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26
Q

In general, what are raised aminotransferases (AST, ALT) associated with?

A

(= Transaminitis)

Associated with hepatocellular damage. ALT is more specific for liver damage.

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27
Q

What would a transaminitis with a ratio of AST:ALT of 1 suggest?

A

Liver ischaemia - CCF, ischaemic necrosis and hepatitis

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28
Q

What would a transaminitis with a ratio of AST:ALT of >2.5 suggest?

A

Alcoholic hepatitis

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29
Q

What would a transaminitis with a ratio of AST:ALT of <1 suggest?

A

High rise in ALT is specific for hepatocelluar damage

  • Paracetamol OD with hepatocellular necrosis
  • Viral hepatitis, ischaemic necrosis, toxic hepatitis
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30
Q

What is raised ALP indicative of?

A

Primarily associated with cholestasis and malignant hepatic infiltration
- Marker of rapid bone turnover and extensive bony mets

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31
Q

What is raised GGT indicative of?

A

Sensitive to EtOH ingestion

  • Marker of hepatocellular damage but non-specific
  • Sharp rise in biliary and hepatic obstruction
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32
Q

What does raised AST suggest?

A

Released into serum in proportion to cellular damage, most elevated in acute phase of cellular necrosis. Also raised in cardiac, MSK trauma, kidney disease.

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33
Q

What LFT is most specific for damage to liver itself?

A

ALT, but levels are not related to degree of liver cell necrosis.

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34
Q

What are the demographics and features of primary biliary cirrhosis?
What would you expect on LFT?

A

Middle aged, female. Lethargy and pruritus.

M rule:

  • IgM
  • anti-Mitochondrial antibodies, M2 subtype (98%)
  • Middle aged females.
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35
Q

What diarrhoea-causing organism are you at risk at catching from swimming pools? Also causes greasy stools

A

Giardia (resistant to chlorination)

Greasy, floating stools due to fat malabsorption

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36
Q

If taking a PPI or H2 blocker, when should these be stopped prior to endoscopy?

A

At least 2 weeks - could mask underlying pathology.

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37
Q

What features would make you refer a patient for endoscopy under 2ww?

A
  • All patients with dysphagia
  • All patients with upper abdo mass consistent with stomach ca
  • > 55 with weight loss, plus any of: upper abdo pain, reflux or dyspepsia.
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38
Q

What is Rovsing’s sign?

A

Palpation of the left LQ increases the pain felt in right LQ - indicates appendicitis.

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39
Q

What is carcinoid syndrome?

What marker is most commonly used in diagnosis?

A

Usually occurs when liver mets release serotonin into the systemic circulation

Features:

  • Flushing
  • Diarrhoea
  • Bronchospasm
  • Hypotension

Ix:
Urinary 5-HIAA (24hr collection)
(or plasma chromogranin A y)

40
Q

Which antibiotics are strongly linked to development of C. diff?
What is the syndrome of intestinal damage called?

A

Cephalosporins (cef-) and quinolones (-floxacin)

  • Clinadmycin (highest risk)
  • Ciprofloxacin

= Pseudomembranous colitis

41
Q

What are the two most common organisms found in pyogenic liver abscesses?

A 
Staph aureus (children)
E. Coli (adults)
42
Q

What is the Mx of pyogenic liver abscesses?

A

Abx: Amox + cipro + metronidazole
Plus image-guided percutaneous drainage.

If penicillin allergy: cipro + clindamycin

43
Q

What is the most common cause of hepatocellular carcinoma in the UK?

A

Hep C (Heb B most common worldwide)

44
Q

What is used to induce remission in UC?

A
  • Rectal aminosalicylates (mesalazine) or steroids for distal colitis
  • Oral aminosalicylates

2: Oral prednisolone (wait 4 weeks to assess failure of 1st line)

If severe: Admit. IV steroids.
(Severe = >6 bloody stools per day + features of systemic upset)

45
Q

What is used to maintain remission in UC?

A
  • Oral aminosalicylates (mesalazine)

- Azathioprine and mercaptopurine

46
Q

What is the first-line management of IBS by predominant symptom?

A

Pain: antispasmodics
Constipation: Laxatives (avoid lactulose)
Diarrhoea: Loperamide

47
Q

What might be a typical history of oesophageal candidiasis?

A
  • Treatment with systemic abx
  • Odynophagia (painful swallowing)
  • Episodic dyphagia
48
Q

What is the inheritance pattern of haemochromatosis?

A

AR

49
Q

What is haemochromatosis?

Features?

A

AR disorder of iron absorption and metabolism -> iron accumulation.

Asymptomatic in early disease, initial symptoms non-specific (lethargy, arthralgia)

Features:

  • Early: fatigue, erectile dysfunction and arthralgia (often hands)
  • ‘Bronze’ skin pigmentation
  • DM
  • Hepatomegaly, cirrhosis, (hepatocellular deposition)
  • Cardiac failure (2nd to dilated cardiomyopathy)
  • Hypogonadism (2nd to cirrhosis and pituitary dysfunction
  • Arthritis (hands)
50
Q

Which features of haemochromatosis are reversible with treatment?

A
  • Cardiomyopathy
  • Skin pigmentation

(Irreversible: Liver cirrhosis, DM, hypogonadism, arthropathy)

51
Q

What are the associations with H. pylori infection?

A

Strongest association: Peptic ulcers (95% of duodenal, 75% of gastric)

  • Gastric Ca
  • B cell lymphoma of MALT tissue
  • Atrophic gastritis
52
Q

What are the two regimes for eradication of H. pylori?

A

1: PPI + amox + clarithro
2: PPI + metro + clarithro

53
Q

What would positive anti-smooth muscle antibody, positive anti-nuclear antibody suggest? Antimitochondrial antibodies are negative.

A

Autoimmune hepatitis

Primary biliary cirrhosis unlikely with negative antimitochondrial

54
Q

What are the drug causes of pancreatitis? (8)

A
  • Azathioprine
  • Mesalazine
  • Didanosine
  • Bendroflumethiazide
  • Furosemide
  • Pentamidine
  • Steroids
  • Sodium valproate
55
Q

What is globes pharyngis?

Characteristically, what is most difficult to swallow?

A

= Globus hystericus
Persistent sensation of having a ‘lump in the throat’ where there is none.
Often intermittent symptoms, relieved by swallowing food or drink.
Usually painless - if pain present, further Ix.

Swallowing saliva is more difficult.

56
Q

What score should be used to screen if patients with NAFLD need further testing?

A

Enhanced liver fibrosis score

57
Q

What is the investigation of choice in cirrhosis screening?

A

Transient elastography

58
Q

What investigations would you do in a new diagnosis of cirrhosis?

A

Upper endoscopy to check for varices

Liver US every 6 months, +/- alpha-veto protein : hepatocellular ca.

59
Q

What is the modified glasgow score?

What are the parameters?

A

Calculated to predict the severity of pancreatitis.
3+ within 48 hours of onset indicates severe pancreatitis.

P aO2
A ge
N eutrophilia
C alcium
R enal function
E nzymes (LDH, AST)
A lbumin (low)
S ugar (high)
60
Q

What are the risks of taking PPIs longterm?

A
  • Can mask symptoms of gastric ca

- Increased risk of osteoporosis and fractures (malabsorption of ca and mg)

61
Q

What type of oesophageal ca is associated with GORD/Barretts?

A

Adenocarcinoma

62
Q

What is acalculous cholecystitis?

Typical patient?

A

Gallbladder inflammation in the absence of stones.

  • Systemically unwell
  • High fever
  • Intercurrent illness (DM, organ failure)
63
Q

What is gallstone ileus?

A

Mechanical bowel obstruction, caused by gallstone impaction.

64
Q

What is (ascending) cholangitis?

A

Infection of the bile duct, usually from bacteria ascending from the duodenum. Usually occurs when bile duct already partially obstructed by gallstones.

65
Q

What are the features of a gallbladder abscess?

A

Usually a prodromal illness

  • Right upper quadrant pain
  • Swinging pyrexia
  • May be systemically unwell
  • Not generally peritonitis
66
Q

What is acute cholecystitis?

A

Inflammation of the gallbladder, usually secondary to gallstone blocking duct

67
Q

What are the features of acute cholecystitis?

A
  • RUQ pain
  • Fever
  • Murphy’s sign (press at R costal margin and ask patient to breathe in, pain on inspiration - gallbladder descent)
  • Mildly deranged LFTs
68
Q

What is Mirizzi syndrome?

A

Common hepatic duct obstruction caused by gallstone impaction in cystic duct or neck of gallbladder -> compression.

  • Jaundice
  • Fever
  • RUQ pain
  • Deranged LFTs
69
Q

What is Gilbert’s syndrome?

A

AR condition - defective bili conjugation.

  • Unconjugated hyperbilinaemia (high bili in blood but not in urine)
  • Viral infections are common triggers for rise in bili -> jaundice
70
Q

What is the Ix for Gilbert’s syndrome?

A

Rise in bili following prolonged fasting or IV nicotinic acid.
NB. No treatment required.

71
Q

What are the components of the Child-Pugh classification?

A

NB. Severity of liver cirrhosis

  • Bili
  • Albumin
  • Prothrombin time prolongation
  • Encephalopathy
  • Ascites
72
Q

What is the MELD score?

A

A measure of 3 month mortality in liver cirrhosis, using:

  • Bili
  • Creatinine
  • INR
73
Q

What is the first-line mx of Wilson’s disease?

A

Penicillamine (chelates copper)

74
Q

How is Wilson’s disease diagnosed?

A
  • Reduced serum caeruloplasmin
  • Reduced serum copper (2 to lack of caeruloplasmin which carries)
  • Increased urinary 24hr copper excretion
75
Q

In general terms, what does a massive rise in ALP and GGT with a modest rise in ALT mean?

A

Obstructive cause of jaundice - in absence of pain = pancreatic mass. with pain = gallstones. CT.

76
Q

Other than broad-spec antibiotics, what drugs would increase the risk of c. diff infection in those with previous episode?

A

Acid suppression - particularly PPIs, but also H2.

77
Q

What is the acute treatment of variceal haemorrhage?

A
  • ABC: resus prior to endoscopy
  • correct clotting (FFP + vit K)
  • Terlipressin
  • Prophylactic abx if known liver cirrhosis
  • Endoscopic variceal band ligation
  • Sengstaken-Blakemore tube if uncontrolled haemorrhage
  • Transjugular intrahepatic portosystemic shunt (TIPSS) if all else fails
78
Q

What is the prophylaxis of variceal haemorrhage?

A
  • Propanolol
  • Endoscopic vatical band ligation
  • PPI to prevent EVL-induced ulceration
79
Q

What is the mx of hepatic encephalopathy?

A
  • Treat precipitating cause
    1: Lactulose (promotes excretion and metabolism of ammonia)
    2: Rifaximin (modulates gut flora - decreases ammonia production)
  • Embolise porto-systemic shunts
  • Liver transplant
80
Q

What type of cells are seen in gastric adenocarcinoma?

How does this impact prognosis?

A

Signet ring cells.

More cells = worse prognosis

81
Q

What are the associations with gastric adenocarcinoma?

A
  • H.pylori
  • Blood group A
  • Gastric adenomatous polyps
  • Pernicious anaemia
  • Smoking
  • Diet: Salty, spicy, nitrates
82
Q

How is gastric adenocarcinoma:

  • Diagnosed?
  • Staged?
A

Diagnosis: Endoscopy with biopsy
Staging: Endoscopic US or CT (Chest-abdo-pelvis)

83
Q

What is the treatment of a gastric adenocarcinoma?

- Subdivide by distance from OG junction

A
  • Proximal, 5-10+cm from OG junction: Sub-total gastrectomy
  • <5cm from OGJ: Total gastrectomy
  • Type 2 junctional tumours (extending into oesophagus): Oesophagogastrectomy

+ D2 lymphadenectomy
+ Chemo

84
Q

Which patients are most likely to present with autoimmune hepatitis?
What other features might they have?

A

Young women

  • Other autoimmune disorders
  • Amenorrhea
  • Signs of chronic liver disease
  • Acute hepatitis (fever, jaundice etc)
85
Q

How long after abx or PPI can a urea breath test be accurately used to detect H pylori?

A

Abx: >4 weeks
PPI: >2 weeks

86
Q

Why is urea raised following significant upper GI bleed?

A

Acts as a protein meal

87
Q

Which of the 4 TB drugs can cause a peripheral neuropathy? Why?
How is this normally avoided?

A

Isoniazid - can cause B6 deficiency. (Also sideroblastic anaemia)

Give prophylactic pyridoxine hydrochloride at same time.

88
Q

What is Whipple’s disease?

A

Rare multi-system disorder caused by Tropheryma whippelii infection.
More common in middle-aged men who are HLA-B27 positive

89
Q

What is the Ix of Whipple’s disease? What would it show?

A

Jejunal biopsy

- Deposition of macrophages containing periodic acid-Schiff (PAS) granules

90
Q

What is the Mx of Whipple;s disease?

A

Oral co-trimoxazole for a year (lowest relapse rate). Sometimes preceded by course of IV penicillin

91
Q

What are the features of Whipple’s disease?

A
  • Malabsorption: diarrhoea, weight loss
  • Large-joint arthralgia
  • Lymphadenopathy
  • Hyperpigmentation skin and photosensitivity
  • Rarely, near symptoms
92
Q

What is the classical LFT picture in alcoholic hepatitis?

What would you see on a liver screen?

A

AST:ALT in 2:1 ratio
Raised GGT and bilirubin

Liver screen:

  • Negative heb B and C
  • Raised ferritin (chronic use)
  • NORMAL transferrin (excludes iron overload)
93
Q

What cardiac abnormalities are associated with carcinoid syndrome?

A

Right sided pathology, TIPS:

Tricuspid insufficiency and pulmonary stenosis

94
Q

Why do patients with coeliac disease require regular immunisations?

A

Functional hyposplenism

Therefore give pneumococcal vaccine and consider flu vaccine.

95
Q

What index is used to assess the severity of UC in adults?

What are the parameters?

A

Truelove and Witt’s

Severe=
Frequency of stool: 6+
Temperature >37.8
HR: >90
Anaemia: <10.5
ESR: >30

NB. Any severe features warrant emergency admission to hospital and IV corticosteroids

96
Q

What would be indicative of toxic megacolon in UC on AXR?

A

Transverse colon diameter >6cm

97
Q

When would you give prophylaxis against spontaneous bacterial peritonitis in cirrhosis?
What would you give?

A
  • Ascites
    AND
  • Protein conc <=15g/L
    Or previous episode

Oral cipro or norfloxacin until ascites resolves.

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