Gastro Flashcards
How severe would an anaemia need to be to warrant a 2ww referral for upper and lower GI endoscopy in a man?
<110 (at any age)
How long does it typically take for oral iron supplementation to have an affect?
2-3 months for a decent response.
RL is the absorption of oral iron from GIT. Shortest possible time interval is 2-4 weeks.
What is the Mx of patients with iron-deficiency anaemia prior to surgery?
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.
What is the first-line therapy for C. Diff diarrhoea?
What if this is ineffective or severe infection?
What if it’s life-threatening?
Oral metronidazole for 10-14 days
If ineffective or severe infection: Oral vanc
Life-threatening: Oral vanc + IV metro
What are the features of overflow diarrhoea?
Mx?
Type 7 (liquid) stills with intermittent hard stool. Mx: High dose macrogol laxatives
What is the surgical treatment of achalasia?
Heller cardiomyotomy
When is surgical intervention indicated in achalasia?
- <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)
What is achalasia?
Features?
What is the classical appearance on barium swallow?
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
What is the most important Ix in suspected achalasia?
Manometry
What is the most common site affected in UC?
Rectum
What is the peak incidence of UC?
Bimodal:
15-25 years
55-65 years
What are the features of UC?
- Bloody diarrhoead
- Urgency
- Tenesmus
- Abdo pain, especially LLQ
What are the extra-intestinal features of UC?
Primary sclerosising cholangitis Uveitis Arthritis Erythema nodosum Pyoderma gangrenosum (Colorectal ca)
What is Plummer-Vinson syndrome?
Triad?
Triad of:
- dysphagia (due to post-cricoid webs)
- glossitis
- iron-deficiency anaemia
How would you calculate alcohol units when given a volume and %?
Units = volume (ml) * ABV / 1000
What is the government advice regarding the number of units alcohol/week?
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.
What is the inheritance pattern of HNPCC?
What cancers are they at risk of?
AD
90% develop colon cancers, typically proximal colon (poorly differentiated and highly aggressive).
Second highest risk is endometrial ca.
What is the first line investigation of someone with iron-deficiency anaemia?
anti-TTG (coeliac)
What is Peutz-Jeghers syndrome?
Inheritance?
Other features?
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
What tests are best to look at the functioning of the liver? (e.g. in monitoring cirrhosis)
- Prothrombin time (raised)
- Albumin level (low)
What test would you do following incidental finding non-alcoholic fatty liver disease on US?
Enhanced liver fibrosis (ELF) test to check for advanced fibrosis.
What would you see on Hep B serology if patient had previous immunisation?
Positive anti-HBs
Negative Anti-HBc and HBsAg
What would you see on Hep B serology if patient had previous infection?
What would determine if they were a carrier or not?
anti-HBc positive
+
HBsAg positive if carrier, negative if not.
What does HbeAg mean on Hep B serology?
It results from breakdown of core antigen, so is a marker of infectivity.
What is the most common type of inherited colorectal cancer?
HNPCC (5%)
In general, what are raised aminotransferases (AST, ALT) associated with?
(= Transaminitis)
Associated with hepatocellular damage. ALT is more specific for liver damage.
What would a transaminitis with a ratio of AST:ALT of 1 suggest?
Liver ischaemia - CCF, ischaemic necrosis and hepatitis
What would a transaminitis with a ratio of AST:ALT of >2.5 suggest?
Alcoholic hepatitis
What would a transaminitis with a ratio of AST:ALT of <1 suggest?
High rise in ALT is specific for hepatocelluar damage
- Paracetamol OD with hepatocellular necrosis
- Viral hepatitis, ischaemic necrosis, toxic hepatitis
What is raised ALP indicative of?
Primarily associated with cholestasis and malignant hepatic infiltration
- Marker of rapid bone turnover and extensive bony mets
What is raised GGT indicative of?
Sensitive to EtOH ingestion
- Marker of hepatocellular damage but non-specific
- Sharp rise in biliary and hepatic obstruction
What does raised AST suggest?
Released into serum in proportion to cellular damage, most elevated in acute phase of cellular necrosis. Also raised in cardiac, MSK trauma, kidney disease.
What LFT is most specific for damage to liver itself?
ALT, but levels are not related to degree of liver cell necrosis.
What are the demographics and features of primary biliary cirrhosis?
What would you expect on LFT?
Middle aged, female. Lethargy and pruritus.
M rule:
- IgM
- anti-Mitochondrial antibodies, M2 subtype (98%)
- Middle aged females.
What diarrhoea-causing organism are you at risk at catching from swimming pools? Also causes greasy stools
Giardia (resistant to chlorination)
Greasy, floating stools due to fat malabsorption
If taking a PPI or H2 blocker, when should these be stopped prior to endoscopy?
At least 2 weeks - could mask underlying pathology.
What features would make you refer a patient for endoscopy under 2ww?
- 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.
What is Rovsing’s sign?
Palpation of the left LQ increases the pain felt in right LQ - indicates appendicitis.
What is carcinoid syndrome?
What marker is most commonly used in diagnosis?
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)
Which antibiotics are strongly linked to development of C. diff?
What is the syndrome of intestinal damage called?
Cephalosporins (cef-) and quinolones (-floxacin)
- Clinadmycin (highest risk)
- Ciprofloxacin
= Pseudomembranous colitis
What are the two most common organisms found in pyogenic liver abscesses?
Staph aureus (children) E. Coli (adults)
What is the Mx of pyogenic liver abscesses?
Abx: Amox + cipro + metronidazole
Plus image-guided percutaneous drainage.
If penicillin allergy: cipro + clindamycin
What is the most common cause of hepatocellular carcinoma in the UK?
Hep C (Heb B most common worldwide)
What is used to induce remission in UC?
- 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)
What is used to maintain remission in UC?
- Oral aminosalicylates (mesalazine)
- Azathioprine and mercaptopurine
What is the first-line management of IBS by predominant symptom?
Pain: antispasmodics
Constipation: Laxatives (avoid lactulose)
Diarrhoea: Loperamide
What might be a typical history of oesophageal candidiasis?
- Treatment with systemic abx
- Odynophagia (painful swallowing)
- Episodic dyphagia
What is the inheritance pattern of haemochromatosis?
AR
What is haemochromatosis?
Features?
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)
Which features of haemochromatosis are reversible with treatment?
- Cardiomyopathy
- Skin pigmentation
(Irreversible: Liver cirrhosis, DM, hypogonadism, arthropathy)
What are the associations with H. pylori infection?
Strongest association: Peptic ulcers (95% of duodenal, 75% of gastric)
- Gastric Ca
- B cell lymphoma of MALT tissue
- Atrophic gastritis
What are the two regimes for eradication of H. pylori?
1: PPI + amox + clarithro
2: PPI + metro + clarithro
What would positive anti-smooth muscle antibody, positive anti-nuclear antibody suggest? Antimitochondrial antibodies are negative.
Autoimmune hepatitis
Primary biliary cirrhosis unlikely with negative antimitochondrial
What are the drug causes of pancreatitis? (8)
- Azathioprine
- Mesalazine
- Didanosine
- Bendroflumethiazide
- Furosemide
- Pentamidine
- Steroids
- Sodium valproate
What is globes pharyngis?
Characteristically, what is most difficult to swallow?
= 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.
What score should be used to screen if patients with NAFLD need further testing?
Enhanced liver fibrosis score
What is the investigation of choice in cirrhosis screening?
Transient elastography
What investigations would you do in a new diagnosis of cirrhosis?
Upper endoscopy to check for varices
Liver US every 6 months, +/- alpha-veto protein : hepatocellular ca.
What is the modified glasgow score?
What are the parameters?
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)
What are the risks of taking PPIs longterm?
- Can mask symptoms of gastric ca
- Increased risk of osteoporosis and fractures (malabsorption of ca and mg)
What type of oesophageal ca is associated with GORD/Barretts?
Adenocarcinoma
What is acalculous cholecystitis?
Typical patient?
Gallbladder inflammation in the absence of stones.
- Systemically unwell
- High fever
- Intercurrent illness (DM, organ failure)
What is gallstone ileus?
Mechanical bowel obstruction, caused by gallstone impaction.
What is (ascending) cholangitis?
Infection of the bile duct, usually from bacteria ascending from the duodenum. Usually occurs when bile duct already partially obstructed by gallstones.
What are the features of a gallbladder abscess?
Usually a prodromal illness
- Right upper quadrant pain
- Swinging pyrexia
- May be systemically unwell
- Not generally peritonitis
What is acute cholecystitis?
Inflammation of the gallbladder, usually secondary to gallstone blocking duct
What are the features of acute cholecystitis?
- 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
What is Mirizzi syndrome?
Common hepatic duct obstruction caused by gallstone impaction in cystic duct or neck of gallbladder -> compression.
- Jaundice
- Fever
- RUQ pain
- Deranged LFTs
What is Gilbert’s syndrome?
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
What is the Ix for Gilbert’s syndrome?
Rise in bili following prolonged fasting or IV nicotinic acid.
NB. No treatment required.
What are the components of the Child-Pugh classification?
NB. Severity of liver cirrhosis
- Bili
- Albumin
- Prothrombin time prolongation
- Encephalopathy
- Ascites
What is the MELD score?
A measure of 3 month mortality in liver cirrhosis, using:
- Bili
- Creatinine
- INR
What is the first-line mx of Wilson’s disease?
Penicillamine (chelates copper)
How is Wilson’s disease diagnosed?
- Reduced serum caeruloplasmin
- Reduced serum copper (2 to lack of caeruloplasmin which carries)
- Increased urinary 24hr copper excretion
In general terms, what does a massive rise in ALP and GGT with a modest rise in ALT mean?
Obstructive cause of jaundice - in absence of pain = pancreatic mass. with pain = gallstones. CT.
Other than broad-spec antibiotics, what drugs would increase the risk of c. diff infection in those with previous episode?
Acid suppression - particularly PPIs, but also H2.
What is the acute treatment of variceal haemorrhage?
- 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
What is the prophylaxis of variceal haemorrhage?
- Propanolol
- Endoscopic vatical band ligation
- PPI to prevent EVL-induced ulceration
What is the mx of hepatic encephalopathy?
- 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
What type of cells are seen in gastric adenocarcinoma?
How does this impact prognosis?
Signet ring cells.
More cells = worse prognosis
What are the associations with gastric adenocarcinoma?
- H.pylori
- Blood group A
- Gastric adenomatous polyps
- Pernicious anaemia
- Smoking
- Diet: Salty, spicy, nitrates
How is gastric adenocarcinoma:
- Diagnosed?
- Staged?
Diagnosis: Endoscopy with biopsy
Staging: Endoscopic US or CT (Chest-abdo-pelvis)
What is the treatment of a gastric adenocarcinoma?
- Subdivide by distance from OG junction
- 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
Which patients are most likely to present with autoimmune hepatitis?
What other features might they have?
Young women
- Other autoimmune disorders
- Amenorrhea
- Signs of chronic liver disease
- Acute hepatitis (fever, jaundice etc)
How long after abx or PPI can a urea breath test be accurately used to detect H pylori?
Abx: >4 weeks
PPI: >2 weeks
Why is urea raised following significant upper GI bleed?
Acts as a protein meal
Which of the 4 TB drugs can cause a peripheral neuropathy? Why?
How is this normally avoided?
Isoniazid - can cause B6 deficiency. (Also sideroblastic anaemia)
Give prophylactic pyridoxine hydrochloride at same time.
What is Whipple’s disease?
Rare multi-system disorder caused by Tropheryma whippelii infection.
More common in middle-aged men who are HLA-B27 positive
What is the Ix of Whipple’s disease? What would it show?
Jejunal biopsy
- Deposition of macrophages containing periodic acid-Schiff (PAS) granules
What is the Mx of Whipple;s disease?
Oral co-trimoxazole for a year (lowest relapse rate). Sometimes preceded by course of IV penicillin
What are the features of Whipple’s disease?
- Malabsorption: diarrhoea, weight loss
- Large-joint arthralgia
- Lymphadenopathy
- Hyperpigmentation skin and photosensitivity
- Rarely, near symptoms
What is the classical LFT picture in alcoholic hepatitis?
What would you see on a liver screen?
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)
What cardiac abnormalities are associated with carcinoid syndrome?
Right sided pathology, TIPS:
Tricuspid insufficiency and pulmonary stenosis
Why do patients with coeliac disease require regular immunisations?
Functional hyposplenism
Therefore give pneumococcal vaccine and consider flu vaccine.
What index is used to assess the severity of UC in adults?
What are the parameters?
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
What would be indicative of toxic megacolon in UC on AXR?
Transverse colon diameter >6cm
When would you give prophylaxis against spontaneous bacterial peritonitis in cirrhosis?
What would you give?
- Ascites
AND - Protein conc <=15g/L
Or previous episode
Oral cipro or norfloxacin until ascites resolves.
