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Medicine > Gastro > Flashcards

Gastro Flashcards

1
Q

definition of diarrhoea?

A

increased stool water

-> increased freq

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2
Q

definition of steatorrhoea?

A

increased stool fat

-> pale, float, smelly

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3
Q

Causes of bloody diarrhoea?

A

vascular: ischaemic colitis
infective: campylobacter, shigella, salmonella, e coli, c diff

Inflammatory: UC, crohns

Neoplastic: polyps, colorectal ca

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4
Q

differential for pus w diarrhoea?

A

IBD

diverticulitis

abscess

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5
Q

differential for mucus w diarrhoea?

A

IBD

colorectal ca

polyps

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6
Q

diarrhoea due to systemic disease?

A

hyperthyroid

autonomic neuropathy

carcinoid

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7
Q

diarrhoea assoc w drugs?

A

Abx

PPI, cimetidine

NSAIDs

digoxin

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8
Q

Ix of Diarrhoea?

A

Bloods: anaemia, WCC, U+Es

ESR/CRP

coeliac serology: anti-TTG or anti-endomysial Abs

Stool culture: MCS and c diff toxin

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9
Q

Mx of diarrhoea?

A

tx cause

oral or IV rehydration

codeine phosphate or loperamide after each loose stool

anti emetic if assoc w n+V: e.g. prochlorperazine

abx e.g. cipor in infective diarrhoea -> systemic illness

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10
Q

risk factors for c diff pseudomembranous colitis?

A

abx use e.g. clindamycin, cephalosporins, augmentin, quinolones

increased age

in hospital: contact, length of stay

PPIs

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11
Q

complications of pseudomembranous colitis?

A

paralytic ileus

toxic dilatation -> perforation

multi organ failure

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12
Q

features of pseudomembranous colitis?

A

severe systemic features: fever, dehydration

Abdo pain, bloody diarrhoea, mucus PR

pseudomembranes (yellow plaques) seen on flexi sig

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13
Q

Mx of C diff Pseudomembranous colitis?

A

General:

stop causative abx

avoid antidiarrhoeals and opiates

1st line: Metronidazole 400mg TDS Po 10-14d

2nd: Vanc 125 mg PO 10-14d

Urgent colectomy may be needed if toxic megacolon, deteriorating condition, raised LDH

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14
Q

Mx of recurrence of C diff pseudomembranous colitis?

A

repeat course of metro 10-14d

if further relapses -> vanc

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15
Q

Mx if extremely severe C dff colitis?

A

Vancomycin 1st line PO may add metro IV

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16
Q

What determines severe pseudomembranous colitis?

A

WCC >15

Cr >50% above baseline

Temp >38.5

Clinical / radiological evidence of severe colitis

1 or more of the following

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17
Q

definition of IBS?

A

disorders of enhanced visceral perception -> bowel symptoms for which no organic cause can be found

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18
Q

Diagnosis of IBS?

A

ROME criteria

Abdo discomfort/ pain for ≥12 wks which has 2 of:

  • relieved by defecation
  • diarrhoea/ constipation
  • change in stool form: pellets, mucus

+2 of:

  • urgency
  • incomplete evacuation
  • abdo blating/ distension
  • mucous PR
  • worsening symptoms after food

Exclusion criteria:

>40yo, bloody stool, anorexia, weight loss, diarrhoea at night

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19
Q

Ix of IBS?

A

Bloods: FBC, ESR, LFT, coeliac serology, TSH

Colonoscopy: if > 60 yo or any features of organic disease

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20
Q

Mx of IBS?

A

Exclusion diets can be tried

Bulking agents for constipation and diarrhoea (e.g. fybogel)

antispasmodics for colic/ bloating e.g. mebeverine

Amitriptyline may be helpful

CBT

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21
Q

definition of constipation?

A

Infrequent Bowel movements (≤ 3/wk) or passing BMs less often than normal or w difficulty, straining or pain.

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22
Q

Causes of constipation?

A

Mechanical obstruction: adhesions, hernia, cancer, inflamm strictures

non-mechanical: post op ileus

pain: anal fissure
endocrine: hypothyroid, hypoCa/K, uraemia

Neuro: MS, myelopathy, cauda equina

elderly

diet/ dehydration

IBS

toxin: opioids, anti muscarinics

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23
Q

Mx of constipation?

A

General: drink more, increase dietary fibre

Bulking agents to increase faecal mass -> increase peristalsis

e.g. bran, ispaghula husk (fybogel), methylcellulose

Osmotic agents to retain fluid in bowel

e.g. lactulose

Stimulant: increase intestinal motility and secretion

e.g. senna

Softeners e.g. liquid paraffin

enemas: e.g. phosphate enema (osmotic)

Suppositories: Glycerol (stimulant)

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24
Q

When are bulking agents for constipation contraindicated?

A

fybogel (Ispaghula husk), bran, methylcellulose

obstruction, faecal impaction

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25
Q

when are stimulant laxatives contraindicated?

A

Obstruction

acute colitis

e.g. Senna, Bisacodyl, Docusate sodium

Glycerol suppositories

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26
Q

definition of dysphagia?

A

difficulty swallowing

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27
Q

Inflammatory causes of Dysphagia?

A

tonsillitis, pharyngitis

Oesophagitis: GORD, candida

Apthous ulcers

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28
Q

Mechanical causes of dysphagia?

A

Luminal:

large food bolus

Mural:

Benign stricture (plummer vinsoons, oesophagitis, trauma eg. OGD)

Malignant Stricture

Pharyngeal pouch

Extra mural:

Lung Ca, rolling hiatus hernia, mediastinal LNs, retrosternal goitre, thoracic aortic aneurysm

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29
Q

Causes of dysphagia?

A

inflammatory: inc infection

Mechanical block: luminal, mural, extramural

Motility: local, systemic

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30
Q

Motility disorders causing dysphagia?

A

local:

achalasia

diffuse oesophageal spasm

nutcracker oesophagus

bulbar/ pseudobulbar palsy (CVA/ MND)

systemic:

systemic sclerosis/ CREST

Myasthenia gravis

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31
Q

dysphagia for liquids and solids at start?

A

motility disorder

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32
Q

dysphagia for solids first then liquids?

A

stricture/ expanding mass

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33
Q

intermittent dysphagia for liquids and solids?

A

oesophageal spasm

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34
Q

dysphagia

neck bulges or gurgles on drinking?

A

pharyngeal pouch

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35
Q

odonophagia (pain) + dysphagia?

A

Ca, oesophageal ulcer, spasm

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36
Q

signs of dysphagia?

A

Cachexia

Anaemia

Virchows node

Neurology

Signs of systemic disease e.g. scleroderma

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37
Q

Ix of Dysphagia?

A

Bloods: FBC, U+E

CXR

OGD

Barium swallow

oesophageal manometry

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38
Q
A

Achalasia

birds beak sign on barium swallow

  • dilated tapering oesophagus
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39
Q
A

Diffuse oesophageal spasm

Ba swallow shows corkscrew oesophagus

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40
Q

definition of dyspepsia?

A

non specific group of symptoms:

epigsatric pain, bloating, heartburn

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41
Q

ALARM symptoms of dyspepsia?

A

Anaemia

Loss of weight

Anorexia

Recent onset progressive symptoms

Melaena or haematemesis

Swallowing difficulty

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42
Q

Causes of dyspepsia?

A

Inflammation: GORD, gastritis, Peptic ulcer disease

Ca: oesophageal, gastric

Functional: non-ulcer dyspepsia

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43
Q

initial mx of new onset dyspepsia?

A

OGD if >55 or ALARMS

try conservative measures for 4 wks:

stop drugs NSAIDs, CCBs (relax LOS)

Lose weight, stop smoking, less alcohol

avoid hot drinks, spicy food

OTC antacids, alginates (gaviscon)

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44
Q

mx of new onset dyspepsia if conservative measures dont work after 4 wks?

A

Test for H pylori if no improvement: breath or serology

+ve -> eradication therapy

-ve -> PPI trial for 4 wks

consider OGD if no improvement

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45
Q

Mx of proven GORD?

A

Full dose PPI e.g. omeprazole/ lansoprazole

(inhibits acid secretion) for 1-2 mo

then low dose PPI PRN

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46
Q

Mx of proven peptic ulcer disease?

A

Full dose PPI e.g. lansoprazole for 1-2mo

H pylori eradication if positive: Omeprazole, clari, amoxicillin

Endoscopy to check for resolution if gastric ulcer

then low dose PPI PRN

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47
Q

What is H Pylori eradication therapy?

A

note: PPIs and cimetidine -> false -ve C13 breath tests -> stop 2 wks before

7 days tx

PAC 500:

PPI lansoprazole 30mg BD, Amoxicillin 1g BD, Clarithromycin 500mg BD

or

PMC 250:

PPI lansoprazole 30mg BD, Metronidazole 400mg BD, Clarithromycin 250mg BD

95% success, failure due to poor compliance -> add bismuth

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48
Q

what medications may cause False -ve C13 breath and antigen tests for H pylori?

A

PPI

cimetidine

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49
Q

Differentials for Haematemesis?

A

Vascular: Oesophageal varices, Angiodysplasia, Dieulafoy lesion (rupture of large arteriole in stomach)

Inflammation: PUD (DU most common cause), oesophago/ gastro/ duodenitis

Trauma: mallory-weiss tear, Boerhaave’s Syndrome, Hereditary Haemorrhagic Telangiectasia (Osler-Weber-Rendu)

General bleeding diasthesis: Warfarin, thrombolytics, liver failure

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50
Q

Differential for Rectal Bleeding?

A

Vascular: Haemorrhoids, lower GI bleed, ischaemic colitis, HHT (osler weber rendu), angiodysplasia

Diverticulae

Infection: Campylobacter, Shigella, Salmonella, C diff, E col

Inflammation: UC, Crohns

Neoplasia

Polyps

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51
Q

When is jaundice visible?

A

at 3x Upper normal limit

50 uM

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52
Q

How is Hb converted to unconjugated Br?

A

by splenic macrophages

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53
Q

How is unconj Br converted to conj Br?

A

by BR-UDP-glucuronyl transferase in liver

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54
Q

what makes stools dark?

A

stercobilinogen (brown)

which was converted from urobilinogen

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55
Q

Causes of post hepatic jaundice?

A

Obstruction:

stones, ca of pancreas

drugs

PBC, PSC

biliary atresia

cholangioca

choledochal cyst

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56
Q

hepatic causes of jaundice?

A

decreased Br uptake:

drugs- contrast, rifampicin

CCF

decreased Br conjugation:

Gilberts (AD), Hypothyroidism, Crigler-Najjar (AR)

hepatocellular dysfunction:

  • congenital: HH, Wilsons, a1ATD
  • infection: Hep A/B/C, CMV, EBV
  • toxin: alcohol, drugs
  • Autoimmune hepatitis
  • Neoplasia: mets, HCC
  • Vasc: budd-chiari

decreased hepatic br excretion:

Dubin-Johnson

Rotors

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57
Q

Hepatic causes of jaundice?

due to hepatocellular dysfunction

A
  • congenital: HH, Wilsons, a1ATD
  • infection: Hep A/B/C, CMV, EBV
  • toxin: alcohol, drugs
  • Autoimmune hepatitis
  • Neoplasia: mets, HCC
  • Vasc: budd-chiari
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58
Q

What causes hepatic jaundice due to decrease br conjugation?

A

Gilberts (AD), Hypothyroidism, Crigler-Najjar (AR)

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59
Q

causes of pre-hepatic jaundice?

A

increased Br production

Haemolytic anaemia

ineffective erythropoiesis e.g. thalassaemia

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60
Q

What causes hepatic jaundice due to decreased br uptake?

A

drugs: contrast, rifampicin

CCF

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61
Q

What is Gilberts syndrome?

A

auto dom

partial UDP-GT deficiency

jaundice occurs during intercurrent illness

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62
Q

diagnosis of Gilberts?

A

increased unconj Br on fasting

normal LFTs

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63
Q

What is Crigler Najjar syndrome?

A

rare auto recessive

total UDP-GT deficiency

cant conjugate Br

  • > severe neonatal jaundice and kernicterus
    tx: liver transplant
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64
Q

Mx of Crigler Najjar?

A

liver transplant

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65
Q

Drug induced jaundice

what drug causes haemolysis?

A

antimalarials e.g. dapsone

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66
Q

drug induced jaundice

what drugs cause hepatitis?

A

Paracetamol OD

Rifamp, Isoniazid, Pyrazinamide

Valproate

Statins

Halothane

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67
Q

drug induced hepatitis

what drugs cause cholestasis?

A

fluclox

co-amoxiclav

OCP

sulfonylureas

chlorpromazine, prochlorperazine

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68
Q

Ix of Jaundice

Post hepatic obstruction?

A

Pale stools, dark urine

Urine: high bilirubin, no urobilinogen

LFTs: high conj Br, high ALP (higher than raise in ALT/AST), high GGT

Abdo US: ducts > 6mm, ERCP/ MRCP

Abs: anti-mitochondrial, ANCA, ANA

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69
Q

Ix of jaundice?

hepatic cause

A

Urine: high Br, high urobilinogen

LFTs: usually high conj Br,

high AST and ALT (if AST VV high -> alcohol, if ALT vv high -> viral)

GGT high

Function: low albumin, prolonged PT

FBC: anaemia

Abs: Anti-SMA, LKM, SLA, ANA

a1AT, ferritin, caeruloplasmin

Liver biopsy

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70
Q

Ix of jaundice?

pre hepatic cause

A

Urine: no Br, high urobilinogen, high Hb

LFTs: high unconj Br, LDH, AST

FBC and blood film

Coombs test

Hb electrophoresis

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71
Q

Causes of Liver Failure?

A

Cirrhosis

Acute:

infection- Hep A/B, CMV, EBV, leptospirosis

Toxin- alcohol, paracteamol, isoniazid, halothane

Vasc: budd chiari

Other- wilsons, autoimmune hepatitis

Obs- eclampsia, acute fatty liver of pregnancy

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72
Q

Signs of liver failure?

A

jaundice

oedema + ascites

bruising

encephalopathy - asterixis

fetor hepaticus

signs of cirrhosis/ chronic liver disease

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73
Q

Ix of Liver Failure?

A

FBC

U+Es: hepatorenal syndrome

LFTs: low albumin

Clotting: raised INR

Glucose

ABG: metabolic acidosis

Cause: ferritin, a1AT, caeruloplasmin, Abs, paracetamol levels

Hepatitis viral serology

Blood and urine culture

ascites tap for MCS + clinical chemistry

Imaging: CXR, Abdo US + portal vein duplex

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74
Q

what is hepatorenal syndrome?

A

renal failure in pts w advanced chronic liver failure

diagnosis of exclusion

cirrhosis -> splanchnic arterial vasodilation -> effective circulatory vol -> RAS activation -> renal arterial vasoconstriction

persistent underfilling of renal circ -> failure

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75
Q

Classification of Hepatorenal syndrome?

A

Type 1: rapidly progressive deterioration (survival <2 wks)

Type 2: steady deterioration (survival 6 mo)

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76
Q

Mx of Hepatorenal syndrome?

A

IV albumin + splanchnic vasoconstrictors (terlipressin)

Haemodialysis as supportive mx

Liver transplant

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77
Q

Mx of Liver Failure?

A

Manage in ITU

tx underlying cause

good nutrition - via NGT w high carbs

thiamine supplements

prophylactic PPIs vs stress ulcers

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78
Q

Monitoring in Liver Failure?

A

Fluids: urinary and central venous catheters

Bloods: daily FBC, U+E, LFT, INR

Glucose: 1-4 hrly + 10% dextrose IV 1L /12h

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79
Q

Complications of liver failure?

A

Bleeding: Vit K, platelets, FFP, blood

Sepsis: tazocin

Ascites: fluid+salt restrict, spiro, fruse, tap, daily weight

Hypoglycaemia: regular BMs, IV glucose if <2 mM

Encephalopathy: avoid sedatives, lactulose

Seizures: lorazepam

Cerebral oedema: mannitol

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80
Q

prescribing in liver failure?

what to avoid

A

avoid: opiates, oral hypoglycaemics, Na-containing IVI

warfarin effects increase

hepatotoxic drugs: paracetamol, methotrexate, isoniazid, salicylates, tetracycline

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81
Q

Poor prognostic factors in liver failure?

A

grade 3/4 hepatic encephalopathy

age >40

albumin<30g/L

raised INR

drug induced liver failure

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82
Q

Criteria for Liver Transplant in Paracetamol induced liver failure?

A

pH< 7.3 24h after ingestion

or all of:

PT>100s

Cr >300

Grade 3/4 encephalopathy

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83
Q

Kings College Hospital Criteria for liver transplant in non-paracetamol induced liver failure?

A

PT> 100s

or 3 out of 5 of:

  • drug induced
  • age <10 or >40
  • >1 wk from jaundice to encephalopathy

PT> 50s

BR>300

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84
Q

causes of cirrhosis?

A

Common:

chronic Alcohol

chronic Hep C and hep B

Non-alcoholic fatty liver disease/ NASH

Other:

genetic: wilsons, a1ATD, HH, CF

AI: AIH, PBC, PSC

Drugs: methotrexate, amiodarone

neoplasm: HCC, mets

Vasc: budd chiari, RHF, constrictive pericarditis

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85
Q

signs of cirrhosis in hands?

A

clubbing

leuconychia (hypoalbumin)

Terry’s nails (white proximally, red distally)

Palmar erythema

Dupuytrens contracture

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86
Q

Signs of cirrhosis in the face?

A

Pallor: ACD

Xanthelasma: PBC

Parotid enlargement: alcohol excess

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87
Q

signs of cirrhosis in the trunk?

A

spider naevi (>5, fill from the centre)

gynaecomastia

loss of secondary sexual hair

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88
Q

signs of cirrhosis in the abdomen?

A

striae

hepatomegaly (may be small in late disease)

splenomegaly (portal HTN)

dilated superficial veins (caput medusae)

testicular atrophy

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89
Q

signs of chronic liver disease?

A

palmar erythema

dupuytrens contracture

gynaecomastia

spider naevi

clubbing

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90
Q

signs of decompensation -> liver failure?

A

jaundice

encephalopathy: asterixis

hypoalbuminaemia -> oedema + ascites

coagulopathy -> bruising

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91
Q

signs of portal HTN?

A

splenomegaly

ascites

varices: oesophageal varices, caput medusa

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92
Q

complications of cirrhosis?

A

decompensation -> liver failure

(jaundice, encephalopathy, oedema, bruising)

Portal HTN: splenomegaly, ascites, varices

spontaneous bacterial peritonitis

increased risk of HCC

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93
Q

Ix of cirrhosis?

A

Bloods:

FBC: low WCC, low Pl indicate hypersplenism

LFTs

Prolonged INR

low Albumin

find cause:

alcohol: high MCV, GGT

NASH: hyperlipidaemia, high glucose

infection: hepatitis, EBV, CMV serology

Genetic: ferritin, a1AT, caeruloplasmin (low in wilsons)

Autoimmune: Abs

Ca: alpha-fetoprotein

Abdo US + Portal Vein Duplex

Ascitic Tap + MCS

Liver Biopsy

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94
Q

what tumour marker is assoc w HCC?

A

Alpha fetoprotein

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95
Q

what may you see on abdo US + portal vein duplex in cirrhosis?

A

small/ large liver

focal lesions

reversed portal vein flow

ascites

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96
Q

Ascitic tap + MCS in cirrhosis?

A

PMN > 250 mm3 indicated SBP

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97
Q

general mx of cirrhosis?

A

good nutrition

alcohol abstinence: baclofen can help reduce cravings

colestyramine for pruritus

screening for HCC: US and AFP & oesophageal varices: endoscopy

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98
Q

tx of wilsons?

A

penicillamine

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99
Q

tx of PBC?

A

ursodeoxycholic acid

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100
Q

tx of Hep C virus -> Cirrhosis?

A

IFNa

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101
Q

Monitoring for varices in cirrhosis?

A

OGD screening + banding

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102
Q

Monitoring for HCC in cirrhosis?

A

US + AFP every 3-6 mo

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103
Q

Mx of ascites in cirrhosis?

A

fluid and salt restrict

spironolactone

frusemide

ascitic tap

daily weights

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104
Q

Mx of coagulopathy in cirrhosis?

A

Vit K

platelets

FFP

blood

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105
Q

Mx of encephalopathy in cirrhosis?

A

avoid sedatives, lactulose+/- enemas, rifaximin

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106
Q

Mx of hepatorenal syndrome in cirrhosis?

A

IV albumin + terlipressin

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107
Q

Mx of Spontaneous bacterial peritonitis in cirrhosis?

A

Tazocin

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108
Q

What is Child-Pugh Grading of cirrhosis?

A

predicts risk of bleeding, mortality and need for tx

Graded A-C using severity of 5 factors

Albumin

Bilirubin

Clotting

Distension: ascites

Encephalopathy

Score >8 = significant risk of variceal banding

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109
Q
A
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110
Q

Causes of Portal HTN?

A

Pre-hepatic:

portal vein thrombosis e.g. pancreatitis

Hepatic:

cirrhosis (most common), schisto (most common worldwide), sarcoidosis

Post Hepatic: Budd Chiari, constrictive pericarditis, congestive HF -> congestive splenomegaly

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111
Q

Where are the likely locations for porto-systemic anastamoses?

A

Oesophageal varices:

left and short gastric veins + inf oesophageal veins

Caput Medusae:

Peri umbilical veins + superficial abdo wall veins

rectal (haemorrhoids):

Superior rectal veins + inf and mid rectal veins

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112
Q

difference between caput medusae and prominent abdo veins?

A

blood flow down below the umbilicus: portal HTN

blood flows up below the umbilicus: IVC obstruction

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113
Q
A

Caput Medusae

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114
Q

pathophysiology of hepatic encephalopathy?

A

decreased hepatic metabolic function -> diversion of toxins from liver directly into systemic system

ammonia accumulates and pass to brain where astrocytes clear it causing glutamate -> glutamine

high glutamine -> osmotic imbalance -> cerebral oedema

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115
Q

classification of hepatic encephalopathy?

A
  1. Confused - irritable, mild confusion, sleep inversion
  2. Drowsy - disoriented, slurred speech, asterixis
  3. Stupor - rousable, incoherent
  4. Coma - unrousable, upgoing plantars
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116
Q

presentation of hepatic encephalopathy?

A

Asterixis, ataxia

confusion

dysarthria

constructional apraxia

seizures

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117
Q

precipitants of hepatic encephalopathy?

A

Haemorrhage: varices

Electrolytes: low K/Na

Poisons: diuretics, sedatives, anaesthetics

Alcohol

Tumour: HCC

Infection: SBP, pneumonia, UTI

Constipation (commonest cause)

Sugar (glucose) e.g. low calorie diet

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118
Q

Ix of hepatic encephalopathy?

A

raised plasma NH4

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119
Q

Mx of hepatic encephalopathy?

A

Nurse 20o head up

correct any precipitants

avoid sedatives

Lactulose +/- PO4 enemas to decrease Nitrogen-forming bowel bacteria

Consider rifaximin PO to kill intestinal microflora

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120
Q

pathophysiology of ascites?

A

back pressure -> fluid exudation

decrease in effective circulating vol -> RAS activation

In cirrhosis: low albumin -> low plasma oncotic pressure

all lead to fluid within abdominal space

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121
Q

symptoms of ascites?

A

distension -> abdo discomfort and nausea

dyspnoea

decreased venous return

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122
Q

differential of ascites?

A

according to Serum Ascites Albumin Gradient (SAAG)

SAAG >/= 1.1g/dL = Portal HTN (97% accuracy)

  • pre, hepatic and post
  • 80% due to cirrhosis

SAAG < 1.1g /dL = other causes

Neoplasia: peritoneal, ovarian

Inflammation e.g. pancreatitis

Nephrotic syndrome

Infection: TB peritonitis

123
Q

Ix of ascites?

A

Bloods: FBC, U+E, LFTs, INR, chronic hepatitis screen

US: confirm ascites, liver echogenicity, PV duplex

Ascitic tap: MCS, Cytology, chemistry, SAAG = serum albumin - ascites albumin

Liver biopsy

124
Q

Mx of ascites?

A

daily weight aiming for = 0.5kg/d reduction

fluid restrict <1.5L /d and low Na diet

spironolactone + frusemide (if response poor)

therapeutic paracentesis w albumin infusion (100ml 20% albumin/ L drained)

Refractory: TIPSS

125
Q

prophylaxis against spont bacterial peritonitis if high recurrence?

A

ciprofloxacin long term

126
Q

features of splenomegaly?

A

splenic congestion

hypersplenism: overactive spleen, removes blood cells too early and too quickly (low WCC, low Pl)

127
Q

alcoholism effects on the body?

A

Liver:

fatty liver -> hepatitis -> cirrhosis

AST:ALT>2, raised GGT

GIT:

gastritis, erosions

PUD

varices

pancreatitis

carcinoma

CNS:

poor memory/ cognition

peripheral neuropathy (mainly sensory)

*Wernickes encephalopathy: confusion, ataxia, ophthalmoplegia

Korsakoffs: amnesia -> confabulation

Fits, falls

Heart:

arrhythmias e.g. AF

dilated cardiomyopathy

high BP

Blood:

raised MCV

folate / B12 deficiency -> macrocytic anaemia

128
Q

Features of alcohol withdrawal?

A

10-72h after last drink

raised HR, low BP, tremor

confusion, fits, hallucinations esp formication (DTs)

129
Q

Mx of alcohol withdrawal acutely?

A

Tapering regimen of chlordiazepoxide PO

/ lorazepam IM

thiamine - Pabrinex

130
Q

Mx of alcohol withdrawal long term?

A

Group therapy (AA) or self help

Baclofen: reduce cravings

Acamprosate: reduce cravings

Disulfiram: aversion therapy

131
Q

presentation of alcoholic hepatitis?

A

anorexia

D/V

tender hepatomegaly

ascites

severe: jaundice, bleeding, encephalopathy

132
Q

Ix of alcoholic hepatitis?

A

Bloods: high MCV, GGT, AST:ALT>2

ascitic tap

abdo US + PV duplex

133
Q

Mx of alcoholic hepatitis?

A
  1. corticosteroids (mx of severe alcoholic hepatitis)

stop alcohol

tx withdrawal

Pabrinex

optimise nutritiion

daily weight, LFT, U+E, INR

mx complications of liver failure

134
Q

cause of Hep D infection?

A

prior Hep B infection

135
Q

presentation of viral hepatitis?

A

prodromal phase: seen in Hep A/ B

flu-like, malaise, arthralgia, nausea

distaste for cigarettes in Hep A

icteric phase:

Acute jaundice in A>B>C (99, 75, 25%)

hepatitis - abdo pain, hepatomegaly, cholestasis: dark urine, pale stools

Extraheparic features due to complexes (esp Hep B):

urticaria, vasculitic rash

cryoglobulinaemia

PAN

GN

Arthritis

136
Q

Ix that confirms dx of chronic Hep B?

A

HBsAg +ve > 6mo

137
Q

Ix that confirms dx of chronic Hep C?

A

HCV RNA +ve > 6mo

138
Q

Which viral hepatitis is more likely to develop into chronic hepatitis?

A

Hep C: 80%

-> 20% develop cirrhosis

Hep B: 10%

-> 5% develop cirrhosis

139
Q

Ix of viral hepatitis?

A

FBC, LFTs, clotting

Hep A/B/C serology

140
Q

Mx of acute viral hepatitis?

A

supportive:

no alcohol, avoid hepatotoxic drugs e.g aspirin

141
Q

Mx of chronic Hep B?

A

PEG-IFN alpha, IFN alpha 2a

antivirals e.g tenoforvir, lamivudine

142
Q

Mx of chronic Hep C?

A

PEG-IFN

+ ribavarin

US surveillance for HCC

143
Q

what is non alcoholic fatty liver disease?

A

hepatitis and cirrhosis assoc w insulin resistance and metabolic syndrome

NASH is most extreme form and -> cirrhosis in 10%

144
Q

risk factors of Non alcoholic fatty liver disease?

A

obesity

HTN

T2DM

hyperlipidaemia

145
Q

presentation of NAFLD?

A

mostly asymptomatic

hepatomegaly and RUQ discomfort may be present

metabolic syndrome: central obesity

146
Q

what is metabolic syndrome?

A

central obesity (high waist circumference) + 2 of:

high triglycerides

low HDL

HTN

hyperlipidaemia: DM, IGT, IFG

147
Q

Ix of NAFLD?

A

BMI

Glucose, fasting lipids

raised transaminases: AST:ALT<1

liver biopsy

148
Q

mx of NAFLD?

A

lose weight

control HTN, DM, lipids

149
Q

what is Budd Chiari syndrome?

A

hepatic vein obstruction -> ischaemia and hepatocyte damage -> liver failure or insidious cirrhosis

150
Q

Causes of Budd Chiari Syndrome?

A

hypercoagulable states: myeloproliferative disorders (PV = commonest cause), PNH, anti phospholipid, OCP

Local tumour: HCC

Congenital: membranous obstruction of IVC

151
Q

presentation of Budd chiari syndrome?

A

RUQ pain: stretching of Glissons capsule

Hepatomegaly

Ascites: SAAG >/= 1.1g/dL

Jaundice + other features of liver failure

152
Q

Ix of budd chiari syndrome?

A

Bloods: FBC, clotting, LFTs

US + hepatic vein doppler

Ascitic tap: high protein + high SAAG

JAK2 mutation analysis, RBC CD55/59

153
Q

Mx of Budd Chiari syndrome?

A

anticoagulate unless varices present

ascites: fluid/ salt restrict, spiro, fruse, tap, daily weight

consider thrombolysis, angioplasty, TIPSS

transplant if fulminant hepatic failure or cirrhosis

tx underlying cause

154
Q

haemochromatosis inheritance?

A

auto recessive

155
Q

what gene is involved in haemochromatosis?

A

HFE gene

156
Q

what organs are involved in haemochromatosis?

A

liver (cirrhosis)
heart (cardiomyopathy), skin (bronzed pigmentation/ slate grey), pancreas (diabetes)
gonads (atrophy and impotence)

parathyroid (hypoCa, osteoporosis)

arthritis

157
Q

Perl’s Prussian blue stain +ve

A

haemochromatosis

158
Q

pathophysiology of hereditary haemochromatosis?

A

inherited, multisystem disorder resulting from abnormal iron metabolism

increased intestinal Fe absorption -> deposition in multiple organs

e.g. liver, heart, pancreas, pituitary, skin, parathyroids

159
Q

Ix of hereditary haemochromatosis?

A

Bloods: ↑LFT, ↑ferritin, ↑Fe, ↓TIBC, glucose, genotype

Xray: chondrocalcinosis

ECG, Echo: arrhythmias, cardiomyopathy

Liver biopsy: Perls stain to quantify Fe and severity

MRI: can estimate iron loading

160
Q

Mx of hereditary haemochromatosis?

A

Iron removal:

venesection - aim for Hct <0.5

Desferrioxamine 2nd line

General:

monitor DM

Low Fe diet

Screening:

Se ferritin and genotype

Screen 1st degree relatives

transplant in cirrhosis (cirrhotic pts have >10% risk of HCC)

161
Q

emphysema in lungs and cirrhosis - deficiency in?

A

alpha1- antitypsin

lack of inhibition of neutrophil proteases -> destruction of tissues

162
Q

what gene is implicated in Wilsons?

A

ATP7B gene

163
Q

Mutation in ATP7B gene

A

Wilsons disease

164
Q

inheritance in wilson’s

A

autosomal recessive

165
Q

features of Wilsons

A

multi-organ copper accumulation
-> cirrhosis, behavioural changes, depression, psychosis,
parkinsonism, seizures and dementia
cardiomyopathy

166
Q

kayser- Fleischer rings

A

wilsons

167
Q

pathophysiology of a1-antitrypsin deficiency?

A

a1AT inhibits neutrophil elastase

  • > emphysema in lungs
  • > hepatitis and cirrhosis in liver
168
Q

presentation of a1AT deficiency?

A

variable

  • neonatal and childhood hepatitis
  • cirrhosis

75% of adults have emphysema esp smokers

169
Q

Ix of a1AT deficiency?

A

Blood: low serum a1AT levels

Liver Biopsy: Periodic Acid Schiff+ve

CXR: emphysematous changes

Spirometry: obstructive defect

Prenatal diagnosis: possible by CVS

170
Q

Mx of a1AT deficiency?

A

mostly supportive for pulmonary and hepatic complications

quit smoking

can consider a1AT therapy from pooled donors

171
Q

what organs are affected in Wilsons disease?

A

Eyes: Kayser-Flesicher rings

Liver: acute hepatitis, fulminant necrosis -> cirrhosis

CNS: Parkinsonism, depression, psychosis

Joints: chrondrocalcinosis, osteoporosis

Kidney: osteomalacia

Haemolytic anaemia: coombs -ve

172
Q
A

Kayser Fleischer Rings

  • Wilsons
173
Q

When does wilsons disease present?

A

between childhood and 30

174
Q

Ix of Wilson’s Disease?

A

Bloods: low Cu, low Caeruloplasmin

high 24h urinary Cu

Liver biopsy: high hepatic copper

MRI: basal ganglia degeneration

175
Q

Mx of Wilsons Disease?

A

Diet: avoid high Cu foods: liver, chocolate, nuts

Penicillamine lifelong (Cu chelator)

Liver transplant if severe liver disease

genetic testing

176
Q

Types of autoimmune hepatitis?

A

Type 1: adults. SMA+ (smooth muscle Ab) in 80%, ANA + (10%), high IgG

Type 2: Young, LKM+ (Anti-Liver-Kidney Microsomal)

Type 3: Adult SLA+ (anti soluble liver antigen)

177
Q

presentation of autoimmune hepatitis?

A

teens and early 20s:

fatigue, fever, malaise

hepatitis

cushingoid: hirsute, acne, striae

polyarthritis

pulmonary infiltration

hepatosplenomegaly

Post/ peri-menopausal

  • present insidiously w chronic liver disease
178
Q

assoc conditions of autoimmune hepatitis?

A

autoimmune thyroiditis

DM

pernicious anaemia

PSC

UC

GN

AIHA (coombs +ve)

179
Q

Anti-smooth muscle ab?

A

Autoimmune Hepatitis

Type 1

180
Q

IX of autoimmune hepatitis?

A

LFTs, ↑IgG

Auto Abs: SMA, LKM, SLA, ANA

↓WCC and ↓Platelets = hypersplenism

Liver biopsy

181
Q

Anti-Liver Kidney Microsomal Ab?

A

Autoimmune hepatitis

kids

Type 2

182
Q

Mx of autoimmune hepatitis?

A

Immunosuppression

  • Prednisolone
  • Azathioprine

Liver transplant

183
Q

pathophysiology of primary sclerosing cholangitis?

A

inflammation, fibrosis and strictures in intra and extra hepatic ducts

chronic biliary obstruction -> secondary biliary cirrhosis -> liver failure

184
Q
A

Primary Sclerosing Cholangitis

M>F 2:1

may present asymptomatically

or

with jaundice, pruritus, fatigue, abdo pain

185
Q

signs of primary sclerosing cholangitis?

A

Hepatosplenomegaly

Obstructive Jaundice: dark urine, pale stools

186
Q

Complications of primary sclerosing cholangitis?

A

Bacterial cholangitis

increased risk of cholangiocarcinoma

increased risk colorectal cancer

187
Q

What is primary sclerosing cholangitis assoc w?

A

UC

3% of those w UC have PSC

80-100% of those w PSC have UC/ Crohns

188
Q

Ix of Primary sclerosing cholangitis?

A

LFTs: ↑ALP initially then ↑Br

Abs: pANCA (80%), ANA and SMA may be +Ve

ERCP/MRCP: beaded appearance of ducts

biopsy: fibrous, obliterative cholangitis

189
Q

ERCP/MRCP: beaded appearance of ducts

A

primary sclerosing cholangitis

190
Q

what Ab is assoc w PSC?

A

pANCA

also ANA, SMA

191
Q

Mx of primary sclerosing cholangitis?

A

No curative medical therapy -> transplant needed

Symptomatic tx:

pruritus: colestyramine, naltrexone

diarrhoea: codeine phosphate

Vit ADEK

Ursodeoxycholic acid - improves cholestasis

Abx for cholangitis

Interventional: Endoscopic stenting for dominant strictures

Liver transplant

Screening:

for cholangiocarcinoma: US + CA19-9

Colorectal Ca: colonoscopy

192
Q

what cancers are assoc w PSC?

due to increased risk

A

Cholangiocarcinoma

Colorectal Ca

193
Q

Pathophysiology of Primary Biliary Cirrhosis?

A

intrahepatic bile duct destruction by chronic granulomatous inflammation -> cirrhosis

194
Q

presentation of primary biliary cirrhosis?

A

F:M>>9

often asympto + diagnose incidentally

Pruritus, fatigue, pigmentation of face

Bones: osteoporosis, osteomalacia

Hepatosplenomegaly

Cirrhosis and coaugulopathy

Cholesterol: xanthelasma, xanthomata

Steatorrhoea

Jaundice occurs late

195
Q

What conditions are assoc w PBC?

A

Thyroid disease

RA, Sjogrens, scleroderma

Coeliac disease

196
Q

Ix of PBC?

A

LFTs: ↑↑ALP, ↑↑GGT, ↑AST/ALT

Abs: AMA +ve

↑IgM

↑cholesterol

+/-↑TSH

US to exclude extra-hepatic cholestasis

Liver biopsy: non-caseating granulomatous inflammation

197
Q

What ab is assoc w PBC?

A

Anti mitochondrial Ab

198
Q

Mx of PBC?

A

symptomatic:

pruritus- colestyramine, naltrexone

Diarrhoea- codeine phosphate

Osteoporosis- bisphosphonates

ADEK vitamins

Ursodeoxycholic acid - improves cholestasis

Liver transplant: end stage disease or intractable pruritus

199
Q

anti mitochondrial Ab?

A

PBC

200
Q

most common type of primary liver tumour?

A

90% HCC

201
Q

what are the most common type of tumour in liver?

A

90% of liver tumours are 2O metastases

202
Q

Symptoms of Liver Tumour?

A

Benign tumours are usually asymptomatic

Systemic: FLAW

RUQ pain: stretching of Glisson’s capsule

Jaundice is often late, except in cholangiocarcinoma

May rupture → intraperitoneal haemorrhage

203
Q

Signs of liver tumour

A

Hepatomegaly: smooth or hard and irregular

Signs of chronic liver disease

Abdominal mass

Hepatic bruit (HCC)

204
Q

Ix of liver tumour?

A

Bloods: LFTs, hepatitis serology, AFP

Imaging:

  • US or CT / MRI ± guided diagnostic biopsy
  • ERCP + biopsy in suspected cholangiocarcinoma

Biopsy (seeding may occur along tract)

Find primary: e.g. colonoscopy, mammography

205
Q

Causes of HCC?

A

*common in China and sub saharan Africa

Viral hepatitis (B/C/D)

Cirrhosis: ETOH, HH, PBC

Aflatoxins (produced by Aspergillus)

206
Q

Mx of HCC?

A

Resection of solitary tumours improves prognosis (13 → 59%), but 50% have recurrence.

Also: chemo, percutaneous ablation and embolization

207
Q

Causes of cholangiocarcinoma?

A

Flukes (Clonorchis)

PSC

Congenital biliary cysts

UC

208
Q

presentation of Cholangiocarcinoma?

A

Fever, malaise

Abdominal pain, ascites, jaundice

↑BR, ↑↑ALP

209
Q

Mx of cholangiocarcinoma?

A

30% resectable

Palliative stenting: percutaneous or ERCP

210
Q

Indications for Liver Transplant?

A

Advanced cirrhosis

HCC

211
Q

Contraindications of Liver Transplant?

A

Extra-hepatic malignancy

Severe cardiorespiratory disease

Systemic sepsis

HIV infection

Non-compliance w drug therapy

212
Q

Complications of Liver Transplant?

A

Acute rejection (T-cell mediated)

  • 50% @ 5-10 days
  • Pyrexia, tender hepatomegaly
  • ↑ or change immunosuppressants

Sepsis

Hepatic artery thrombosis

CMV infection

Chronic rejection (6-9mo): shrinking bile ducts

Disease recurrence (e.g. HBV)

213
Q

What immunosuppression therapy would be required post op in Liver Transplant?

A

Ciclosporin / Tacrolimus +

Azathioprine / Mycophenolate Mofetil +

Prednisolone

214
Q

Smoking in UC / crohns?

A

protective in UC

increases risk in crohns

215
Q

symptoms of Crohns vs UC?

A

UC:

usually bloody + mucus

tenesmus, faecal urgency

216
Q

Skin manifestations of IBD?

A 
erythema nodosum
Pyoderma gangrenosum (esp UC)

clubbing

217
Q

Abdominal Mass in IBD?

A

V rare in UC

common in Crohns: commonly RIF

but can affect anywhere in the tract

218
Q

Complications of Crohns?

A

Fistulae

  • enterocolonic, enterovesical, enterovaginal, perianal

Strictures -> obstruction

Abscesses: abdo, anorectal

Malabsorption of

  • fat -> steatorrhoea, gallstones
  • B12 -> megaloblastic anaemia
  • Vit D -> osteomalacia
  • protein -> oedema
219
Q

Complications of UC?

A

Toxic megacolon -> perforation

Bleeding

malignancy: CRC, cholangiocarcinoma

strictures -> obstruction

venous thrombosis

220
Q

Complications of stoma?

A

retraction

stenosis

prolapse

dermatitis

high output

221
Q

Complications of the Pouch after surgery for Crohns/ UC?

A

Pouchitis 50%: metro + cipro

decreased female fertility

Faecal leakage

222
Q

Colonoscopy shows

skip lesions, rose thorn ulcers, cobblestoning, String sign of Kantor?

A

Crohns

String sign of Kantor: narrow terminal ileum

223
Q

Pathophysiology of Coeliac Disease?

A

HLA-DQ2 (95%) and DQ8

CD8+ mediated response to gliadin in gluten

224
Q

Presentation of Coeliac Disease?

A

GI Malabsorption: fatigue, weakness, abdo distension + colic, Steatorrhoea, weight loss

Anaemia

Dermatitis herpetiformis, aphtous ulcers

increased risk of EATL, adenocarcinoma of small bowel

Immune assoc: IgA deficiency, T1DM, PBC

225
Q

what immune conditions are assoc w coeliac?

A

IgA deficiency, T1DM, PBC

226
Q

why are coeliac disease pts at higher risk of Renal stones?

A

Hyperoxaluria due to malabsorption of fat

227
Q

What Cancers are coeliac assoc w?

A

EATL

Adenoca of small bowel

228
Q
A

Dermatitis herpetiformis

Symmetrical vesicles, extensor surfaces

Esp. elbows

Very itchy

Responds to gluten-free diet or dapsone

Biopsy: granular deposition of IgA

229
Q

what skin rash is assoc w coeliac disease?

A

Dermatitis herpetiformis

230
Q

Mx of coeliac disease?

A

Lifelong gluten-free diet

  • Avoid: barley, rye, oats, wheat

OK: Maize, soya, rice

Verify diet by endomysial Ab tests

Pneumovax as hyposplenic

Dermatitis herpetiformis: dapsone

231
Q

Ix of Coeliac Disease?

A

Bloods: FBC, LFTs (↓alb), INR, Vit D and bone, red cell folate, serum B12

Abs : Anti-endomysial IgA (95% specificity), Anti-TTG IgA

Both ↓ w exclusion diet

Anti-gliadin IgG persist w exclusion diet)

IgA ↑ in most but may have IgA deficiency

Stools: Stool cysts and antibody: exclude Giardia

OGD and duodenal biopsy: Subtotal villous atrophy, Crypt hyperplasia, Intra-epithelial lymphocytes

232
Q

What is seen on OGD and biopsy in Coeliac Disease?

A

Subtotal villous atrophy, Crypt hyperplasia, Intra-epithelial lymphocytes

233
Q

What is the most specific ab for coeliac?

A

anti-endomysial IgA antibody

234
Q

causes of malabsorption?

A

Common in UK: Coeliac, Chronic pancreatitis, Crohn’s

Rarer

  • ↓Bile: PBC, ileal resection, colestyramine
  • Pancreatic insufficiency: Ca, CF, chronic panc
  • Small bowel: resection, tropical sprue, metformin
  • Bacterial overgrowth: spontaneous, post-op blind loops, DM, PPIs
  • Infection: Giardia, Strongyloides, Crypto parvum
  • post-gastrectomy dumping
235
Q

presentation of malabsorption?

A

Diarrhoea / Steatorrhoea

Wt. loss

Lethargy

236
Q

Risk factors for Pancreatic Cancer?

A

Smoking

Inflammation: chronic pancreatitis

Nutrition: ↑fat diet

EtOH

DM

237
Q

Most common type of pancreatic cancer?

which site?

A

Ductal Adenoca

head

238
Q

presentation of pancreatic cancer in the head?

A

Typically male >60yrs

painless obstructive jaundice w dark urine + pale stools

Anorexia and wt. loss

Acute pancreatitis

Sudden onset DM in the elderly

239
Q

Presentation of pancreatic cancer in the tail/ body of pancreas?

A

Typically male >60yrs

epigastric pain -Radiates to back, relieved sitting forward

Anorexia and wt. loss

Acute pancreatitis

Sudden onset DM in the elderly

240
Q

Signs of pancreatic cancer?

A

Epigastric mass

Jaundice

Palpable gallbladder

Thrombophlebitis migrans (Trousseau Sign)

Splenomegaly: PV thrombosis → portal HTN

Ascites

241
Q

Ix of pancreatic cancer?

A

Bloods: cholestatic LFTs, ↑Ca19-9, ↑Ca

Imaging

US: pancreatic mass, dilated ducts, hepatic mets, allows biopsy

Endoscopic US: better than CT/MRI for staging

ERCP -> Shows anatomy + Allows stenting

242
Q

Mx of Pancreatic Cancer?

A

Surgery

  • Fit, no mets, tumour ≤3cm (≤10% of pts)
  • Whipple’s pancreatoduodenectomy
  • Post-op chemo delays progression

Palliation

  • Endoscopic / percutaneous stenting of CBD
  • Palliative bypass surgery
  • Pain relief: may need coeliac plexus block
243
Q

what is the main surgery for pancreatic cancer in pts fit for surgery, tumour <3cm?

A

Whipples procedure

aka

pancreatiduodenectomy

  • take out gallbladder, head of pancreas, duodenum

stitch remain pancreas, end of stomach and bile duct directly to small intestine

244
Q

What pain relief is best for pts with Pancreatic cancer?

A

Coeliac plexus block

245
Q

Causes of Chronic Pancreatitis?

A

most common: Alcohol

Genetic; CF, HH, Hereditary pancreatitis

Immune: Lymphoplasmacytic sclerosing pancreatitis (↑IgG4)

Triglycerides ↑

Structural: Obstruction by tumour, Pancreas divisum

246
Q

Presentation of chronic pancreatitis?

A

Epigastric pain:

radiates through to back

Relieved by sitting back or hot water bottle → erythema ab igne

Exacerbated by fatty food or EtOH

Steatorrhoea

Wt. loss

DM

Epigastric mass: pseudocyst

247
Q

Ix of chronic pancreatitis?

A

↑ glucose

↓ faecal elastase

US: pseudocyst

AXR: speckled pancreatic calcifications

CT: pancreatic calcifications

248
Q

mx of chronic pancreatitis?

A

Medical:

Analgesia: may need coeliac plexus block

Creon - pancreatic enzyme replacement therapy

ADEK vitamins

DM Rx

Diet: No EtOH, ↓ fat, ↑ carb

Surgery:

Ind: unremitting pain, wt. loss

Pancreatectomy

249
Q

Complications of Chronic Pancreatitis?

A

Pseudocyst

DM

Pancreatic Ca

Biliary obstruction

Splenic vein thrombosis → splenomegaly

250
Q

Dry conjunctivae, develop spots (Bitots spots)

Corneas become cloudy then ulcerate

Night blindness → total blindness

What Vitamin is deficient?

A

Vit A -> xerophthalmia

251
Q

Diarrhoea, Dermatitis, Dementia

Also: neuropathy, depression, ataxia

which vitamin is deficient?

A

Vit B3 Niacin -> Pellagra

Causes: dietary, isoniazid, carcinoid syndrome

252
Q

Features of Pellagra?

A

Diarrhoea, dermatitis, dementia

(Niacin B3 deficiency)

253
Q

Features of Thiamine deficiency?

A

Wet Beri Beri: heart failure + oedema

Dry Beri Beri: polyneuropathy

Wernicke’s: ophthalmoplegia, ataxia, confusion

254
Q

↓ factors: 2, 7, 9, 10, C and S

Bruising, petechiae

Bleeding: e.g. epistaxis, menorrhagia

which vitamin is deficient?

A

Vit K

255
Q

Gingivitis

Bleeding: gums, nose, hair follicles (petechial)

Muscle pain / weakness

Oedema

Corkscrew hairs

which vitamin is deficient?

A

scurvy

vitamin c deficient

256
Q

Features of B12 deficiency?

A

Glossitis → sore tongue

Peripheral neuropathy: Paraesthesia, Early loss of vibration and proprioception → ataxia

SCDC: Dorsal and corticospinal tracts

Sensory loss and UMN weakness

Overall mixed UMN and LMN signs w sensory disturbance

Extensor plantars + absent knee and ankle jerks

257
Q

Which tracts are affected in subacute combined degeneration of cord?

A

Dorsal columns

+ corticospinal tracts

-> sensory loss and UMN weakness

258
Q

Why are there mixed UMN and LMN signs w sensory disturbance in B12 deficiency?

A

SCDC: loss of corticospinal tracts -> UMN weakness
Peripheral neuropathy -> LMN signs

259
Q

Features of B6 Pyridoxine neuropathy?

A

peripheral sensory neuropathy

260
Q

Flushing: paroxysmal, upper body ± wheals

Intestinal: diarrhoea

Valve fibrosis: tricuspid regurg and pulmonary stenosis

whEEze: bronchoconstriction

Hepatic involvement: bypassed 1st pass metabolism

Tryptophan deficiency → pellagra (3Ds)

A

Carcinoid Syndrome

261
Q

Ix of carcinoid syndrome?

A

↑ urine 5-hydroxyindoleacetic acid

↑ plasma chromogranin A

CT/MRI: find primary

262
Q

Mx of Carcinoid Syndrome?

A

Symptoms: octreotide or loperamide

Curative

  • Resection: tumours are v. yellow
  • Give octreotide to avoid carcinoid crisis

Carcinoid Crisis Rx: high-dose octreotide

263
Q

Mx of carcinoid crisis?

A

high dose octreotide

264
Q

where are most of the oesophageal cancers found?

A

in the middle third of the oesophagus.

265
Q

most common type of oesophageal cancer?

A

adenocarcinoma

(esp w hx of GORD/ Barrett’s)

266
Q

1st line Ix of Oesophageal carcinoma?

A

Upper GI endoscopy

267
Q
A

Oesophageal ca

Barium swallow - 5cm irregular narrowing of the mid-thoracic oesophagus with proximal shouldering

268
Q
A

Oesophageal carcinoma

Fluoroscopy - a region of fixed, irregular stricturing is seen in the distal oesophagus

269
Q

biggest surgical challenge in oesophageal cancer?

A

anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality.

270
Q

A transjugular intrahepatic portosystemic shunt procedure connects which two vessels?

A

hepatic vein to the portal vein

aims to treat portal hypertension by making route for blood to flow from the portal circulation to the systemic circulation, bypassing the liver.

271
Q

Prophylaxis of variceal haemorrhage?

A

propranolol: reduced rebleeding and mortality compared to placebo

endoscopic variceal band ligation (EVL)

Proton pump inhibitor cover is given to prevent EVL-induced ulceration.

272
Q

Why do patients with coeliac disease require regular immunisations?

A

Patients with coeliac disease often have a degree of functional hyposplenism. For this reason all patients with coeliac disease are offered the pneumococcal vaccine.

273
Q

SAAG value in ascites?

A

a high SAAG gradient indicates a transudate rather than exudate

A high SAAG (>11 g/L) is an indication of portal hypertension.

274
Q
A

Barium study is shown from a patient with worsening Crohn’s disease. Long segment of narrowed terminal ileum in a ‘string like’ configuration in keeping with a long stricture segment. Termed ‘Kantor’s string sign’.

275
Q

what blood result correlates well w crohns disease activity?

A

CRP

276
Q

By which mechanism does loperamide act through to slow down bowel movements?

A

stimulation of μ-opioid receptors in the submucosal neural plexus of the intestinal wall. This, in turn, reduces peristalsis of the intestines decreasing gastric motility.

277
Q

What cardiac abnormalities are associated with carcinoid syndrome?

A

tricuspid insufficiency and pulmonary stenosis

(TIPS)

278
Q

what drugs predispose a pt to duodenal ulcers?

A

NSAIDs, steroids and selective serotonin reuptake inhibitors (SSRI)

279
Q

advice regarding alcohol intake?

A

men and women should drink no more than 14 units of alcohol per week

‘if you do drink as much as 14 units per week, it is best to spread this evenly over 3 days or more’

280
Q

Complications of primary biliary cirrhosis?

A

malabsorption: osteomalacia, coagulopathy

sjogrens syndrome occurs in 70% of cases

portal hypertension: ascites, variceal haemorrhage

hepatocellular cancer (20-fold increased risk)

281
Q

At what vertebral level does the inf mesenteric artery branch from the aorta?

A

L3 vertebra.

282
Q

Risks of ERCP?

A

Bleeding 0.9% (rises to 1.5% if sphincterotomy performed)

Duodenal perforation 0.4%

Cholangitis 1.1%

Pancreatitis 1.5%

283
Q

most common familial cause of colorectal ca?

A

HNPCC

284
Q

diagnostic test for Primary sclerosing cholangitis?

A

ERCP is the standard diagnostic tool, showing multiple biliary strictures giving a ‘beaded’ appearance

285
Q

ix of pt for coeliac disease if on gluten free diet?

A

if possible, to reintroduce gluten for at least 6 weeks prior to testing.

286
Q

first-line treatment of hereditary haemochromatosis?

A

venesection

287
Q

What is the main benefit of prescribing albumin when treating large volume ascites’?

A

to reduce paracentesis-induced circulatory dysfunction and mortality

288
Q

definition of barrett’s oesophagus?

A

Metaplasia of squamous cells in lower 1/3 of oesophagus to column cells

289
Q

findings of inflammatory infiltrates coupled with mucosal ulcers, goblet cell depletion and crypt abscesses

A

Ulcerative colitis

290
Q

transmural, non-caseating granulomatous inflammation, coupled with fissuring ulcers, lymphoid aggregates and neutrophil infiltrates

A

Crohns

291
Q

if pt w ascites needs prophylaxis against spontaneous bacterial peritonitis, what abx should be used?

A

oral ciprofloxacin or norfloxacin

292
Q

Grading of hepatic encephalopathy?

A

Grade I: Irritability

Grade II: Confusion, inappropriate behaviour

Grade III: Incoherent, restless

Grade IV: Coma

293
Q

Mx of hepatic encephalopathy?

A

treat any underlying precipitating cause

1st line: lactulose

+/- rifaximin for secondary prophylaxis

Lactulose works to inhibit production of ammonia in the intestine-> decrease hyperammonaemia

294
Q

Precipitating factors of hepatic encephalopathy?

A

infection e.g. spontaneous bacterial peritonitis

GI bleed

post transjugular intrahepatic portosystemic shunt

constipation

drugs: sedatives, diuretics

hypokalaemia

renal failure

increased dietary protein (uncommon)

295
Q

What type of oesophageal ca does achalasia increase the risk of?

A

Squamous Cell Carcinoma

296
Q

What is considered in treatment of an acute flare of Crohn’s disease when symptoms don’t improve after 5 days of IV hydrocortisone?

A

Biologic therapy e.g. Infliximab

297
Q

Triad of Plummer Vinson Syndrome?

A

dysphagia (secondary to oesophageal webs)

glossitis

iron-deficiency anaemia

298
Q

mx of hepatorenal syndrome?

A

vasopressin analogues, e.g. terlipressin

  • vasoconstriction of the splanchnic circulation -> increase kidney filling

volume expansion with 20% albumin

transjugular intrahepatic portosystemic shunt

299
Q

histology showing signet ring sells?

A

gastric adenocarcinoma

300
Q

Mx of gastric tumour <5 cm from oesophagogastric junction?

A

total gastrectomy

if 5-10 cm away: sub total gastrectomy

+ lymphadenectomy

+/- chemo

301
Q

what is the most sensitive and specific lab finding indicating liver cirrhosis in the setting of patients with chronic liver disease?

A

Thrombocytopenia (platelet count <150,000 mm^3)

302
Q

most common organism found in pyogenic liver abscesses?

in adults

in children

A

adults: E coli
children: staph aureus

give abx and US guided perc drainage

303
Q

mx of dysplasia in Barrett’s oesophagus? but no carcinoma

A

endoscopic mucosal resection

or

radiofrequency ablation

304
Q

Ix fo choice to detect Liver cirrhosis in hep C?

A

transient elastography

measures the ‘stiffness’ of the liver which is a proxy for fibrosis

Medicine (16 decks)

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