Gastro Flashcards
What do you need to test for before starting azathioprine or mercaptopurine in Crohn’s?
thiopurine methyltransferase (TPMT) activity, the enzyme that metabolises Aza
Diagnosis of hep c active on bloods
HCV RNA
Hep b serology of ongoing infection
HBsAg either acute or chronic if present for> 6 months
what does Anti HBc serology indicate?
Caught -negative if immunised
Implies previous or current infection
How do you diagnose spontaneous bacterial peritonitis
Paracentesis with neutrophil count above 250
What calls release gastrin
G cells in antrum of stomach
Increases gastric motili
What cells release CCK
I cells in upper small intestine
Increases pancreatic enzymes, gallbladder contraction, decreased gastric emptying
What cells release secretion
S cells in upper small intestine
Increases bicarb rich foods from pancreas
What cells release somatostatin
D cells in pancreas and stomach…
They decrease acid gastrin pancreatic enzymes insulin
Red flags of IBS diagnosis
Onset over 60
Family history of bowel or ovarian cancer
Unexplained weight loss
Rectal bleeding
hereditary non-polyposis colorectal cancer (HNPCC) due to a defect in the MSH2 gene. What is the function of this gene?
DNA mismatch repair,
Criteria for liver transplant after paracetamol
pH <7.3 12 hours after ingestion Or Prothrombin >100 Creatanine >300 Grade 3 or 4 encephalopathy
Xray features of chronic pancreatitis
30% show pancreatic calcification, but CT is more sensitive
investigations for chronic pancreatitis
XR may show calcification (30%)
CT has sens/spec of 85% or so
faecal elastase may be used to assess exocrine function if imaging inconclusive
What is Courvoisier’s sign
- a palpable gallbladder in the presence of painless jaundice is unlikely to be gallstones.
Only present in 15% of pancreatic cancers
What is the management of severe alcoholic hepatitis?
prednisolone 40mg/day for 28 days
determine severity by a Maddrey discriminant function value >32
Steroids reduced mortality by 39% at 28 days in STOPAH trial
Most common cause of HCC worldwide and in europe?
Worldwide Hep b
Europe hep c
Travellers diarrhoea differentials
Long incubation period- amoebiosis
Long duration of illness- giardiasis
Acute- E.coli - most common
Symptoms of ascending cholangitis
Charcot’s cholangitis triad: fever, jaundice and right upper quadrant pain
65 yr old man with BG of ischemic heart disease and hypertension presents with pr bleeding and abdo pain. Worse after eating. Diagnosis and location?
Ischaemic colitis… Most likely splenic flexure, where it is border of two different arteries (sup/inf mesenteric)
Thumbprinting on AXR
Barium swallow of a patient who can’t eat solids+liquid, mild weight loss, regurgitation…
Achalasia - Dilated tapering oesophagus
Barium swallow of patient with significant risk factors, can’t swallow solids and liquids and significant weight loss…
Cancer. Oesophageal structure with Apple core
Immunoglobulin related to alcoholic liver disease ,autoimmune hepatitis and primary biliary cirrhosis
IgA
IgG
IgM
Alphabetical
Why should patient with Coeliac disease have pneumoncoccal vaccine and booster every five years?
functional hyposplenism
Ulcer… Pain relieved by eating.
Duodenal ulcer
Gastroduodenal artery
Troublesome dyspepsia, not settled with PPI. 6 watery stools a day. Ogd showed erosions and ulcers
What is diagnosis and test to perform?
Fasting gastrin for Zollinger Ellison syndrome
… Not h pylori because of loose stools, erosions
Causes of rise in ALT and AST vs rise in ALP and GGT
Hepatocellular picture caused by paracetamol, valproate, phenytoin alcohol
Cholestatic eg caused by fluclox, cocp
Test to diagnose h pylori
13c urea breath test -very sensitive and specific, noninvasive
Can’t have had PPI for 2/52 or Abx for 4/52
(remember Rapid urease CLO test is from biopsy)
Triggers for liver decompensation in patient with chronic liver disease
Infection
Constipation
Electrolyte imbalance
Management of Gastric MALT lymphoma
H pylori eradication
Diagnosis of cirrhosis liver
Fibroscan -transient elastography
Severe hepatitis in a pregnant woman who’s been travelling to North Africa - what is likely cause?
Hepatitis E
pregnant women are at particular risk
20% Mortality in third trimester
Severe hepatitis in a pregnant woman who’s been travelling to North Africa - what is likely cause?
Hepatitis E
pregnant women are at particular risk
20% Mortality in third trimester
abdominal distension, hepatosplenomegaly and rose spots on her abdomen… Organism?
Salmonella typhi infections –Typhoid/paratyphoid.
They also appear in C.psittaci infections although it is more associated with typhoid than psittacosis.
Plummer-Vinson syndrome triad
glositis, iron def anaemia, dysphagia (secondary to oesophageal webs)
Great prog with iron and widening esophagus
biggest risk factor for developing Barrett’s Oesophagus
GORD is strongest
7:1 male:female too
interestingly, alcohol isn’t independent RF, but if a RF for GORD and Oesoph Ca
What is gold standard investigation for ?Gastro-oesophageal reflux disease
24hr oesophogeal pH monitoring, but only done if endoscopy negative
differentials of loss of distal oesophageal peristalsis
Achalasia - with increased LOS pressure on manometry
Scleroderma - with decreased LOS pressure on manometry
What are the restrictions to Urea breath test for H Pylori
should not be done within 4 weeks of Abx or 2 weeks of PPI
Patient presents with dyspepsia, no alarm symptoms, what is the management?
Trial one month PPI and lifestyle changes, then test
Test first (or in parallel with PPI trial) patients who are high risk - older people, individuals of North African ethnicity, and from a known high risk area
When do you do H Pylori test?
dyspepsia following trial of PPI (or if older or north african before trial)
If symptoms persist
Prior to NSAIDs if history of peptic ulcers / bleeds
Unexplained IDA following normal endoscopy
prognosis of Peutz-Jeghers syndrome
50% die by 60yr of a GI cancer (although their polyps don’t have malignant potential)
what blood group is associated with Gastric Cancer?
blood group A: gAstric cAncer
what is current guidance for Colorectal cancer screening in England?
Faecal Immunochemical Test (FIT) screening every two years for all 60-74yr old, can request after that
ALSO one-off flexisig at 55yr
What are the statistics re colonoscopy following abnormal faecal immunochemical test?
1/10 cancer
4/10 polyp, which may be removed
5/10 normal exam so bleeding could haev been peptic ulcer, angiodysplasia etc
which is more common -hereditary non-polyposis colorectal carcinoma or familial adenomatous polyposis
hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
familial adenomatous polyposis (<1%)
diagnostic test for Zollinger Ellison Syndrome
Serum gastrin levels followed by radiological or nuclear localisation
Secretin stimulation test - Gastrin should be suppressed but if it increases by >200 fifteen mins after secretin IV then 100% specific
management and prognosis of Gastric MALT lymphoma?
80% respond to H Pylori erradication so very good prognosis
What blood marker is important for Acute Pancreatitis prognosis?
CRP (>150), but isn’t in Glasgow, APACHE II or Ranson
what is double duct sign and in what condition is it seen?
Pancreatic cancer can cause CBD and pancreatic duct obstruction +jaundice + dilatation
blood marker for PAncreatic cancer prognosis
Ca 19-9 at presentation and post-op
what is the most common Extra-intestinal feature of inflammatory bowel disease?
Arthritis
Usually asymmetrical, pauciarticular (less than 4joints) is related to disease activity
Associations between inflammatory bowel disease and eye disease
Episcleritis (predominantly Crohn's) and Uveitis (predominantly Ulcerative Collitis)
Marker of Ulcerative collitis severity?
> 6 bloody stools a day and signs of systemic illness is severe
management of Crohn’s vs Ulcerative Colitis to induce remission?
Crohn’s is managed by glucocorticosteroids first line, aminosalicylate (ASA)second line
UC is ASA first line, topical if possible. Except in severe - IV steroids +/- ciclosporin or surgery
What is the diagnosis with a jejunal biopsy shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules?
Whipple’s Disease - symptoms diarrhoea/weight loss
W: worn out joints, weight loss H: hyperpigmentation I: intestinal malabsorption P: pleurisy, photosensitivity P: pericarditis, PAS nodules L: lymphadenopathy E: elevated macrophages
patient with Irritable bowel syndrome hasn’t responded to antispasmodics, laxatives and amitriptyline for 12 months. what is next step?
psychological interventions like CBT
causeS of villous atrophy
Coeliac dsease Tropical Sprue Hypogammaglobulinaemia GI lymphoma Whipple's disease Cow's milk intolerance
Numerous Howell-Jolly bodies and pencil cells seen……diagnosis
Howell-Jolly bodies are seen in hyposplenism and pencil cells are a feature of iron-deficiency. Both of these are seen in coeliac disease.
symptoms of whipple’s disease
W: worn out joints, weight loss H: hyperpigmentation I: intestinal malabsorption P: pleurisy, photosensitivity P: pericarditis, PAS nodules L: lymphadenopathy E: elevated macrophages
most common bacteria in spontaneous bacterial peritonitis
E coli
Diagnosis of spontaneous bacterial peritonitis
pericentesis: neutrophils >250cells/ul
how do you diagnosis portal venous hypertension?
serum ascites albumin gradient (SAAG) above 11g/L
SAAG = (serum albumin) − (albumin level of ascitic fluid)
the high pressure in the liver leaves the albumin in serum…
features of portal venous hypertension, mneumonic
Ascites Bleeding (varices, haemorrhoids) Caput medusa Diminished liver function Enlarged spleen
is albumin a good measure of hepatic function?
yes, but has 20d half-life so not usefully in acute setting
which comes first Wernicke’s or Korsakoff’s?
if Wernicke’s encephalopathy is not treated with thiamine, then it progresses to Korsakoff’s Syndrome
what is xerostomia?
dry mouth
middle aged female presents with xerostomia and fatigue with ALP 292. what is diagnosis?
primary biliary cirrhosis
what is the diagnosis in patient with beaded appearance on MRCP, showing multiple billiary strictures?
primary sclerosising cholangitis
what is most common cause of bilary disease in patients with HIV?
sclerosing cholangitis due to infections like CMV , Cryptosporidium
what gene is defective in Wilson’s disease?
ATP7B on chromosome 13
autorecessive
diagnostic tests for Wilson’s disease?
increased 24hr urinary copper excretion
Counterintuitively LOW serum copper (as 95% of copper is carried by caruloplasmin, which is also degraded quickly in wilson’s)
What disorder is most strongly associated with primary biliary cirrhosis?
Sicca AKA Sjogren’s syndrome in 80%
What is increased risk of developing hepatocellular cancer in pt with primary biliary cirrhosis?
20x normal population
How do you diagnose Gilbert
rise in bilirubin following prolonged fasting or IV nicotinic acid
Describe Budd-Chiari syndrome
aka hepatic vein thrombosis
Usually seen in prothrombotic patients
Ruq pain, tender hepatomegaly and ascites
USS
What is the BMI cut off for bariatric referral?
Obesity - NICE bariatric referral cut-offs
with risk factors (T2DM, BP etc): > 35
no risk factors: > 40
Patient presents with diarrhoea and colonoscopy biospy shows pigment laden macrophages… Diagnosis?
laxative abuse
What histology might you saw in gastric adenocarcinoma?
Gastric adenocarcinoma - signet ring cells may be seen
how many types of Hepatorenal syndrome are there?
HRS - AKI (formally type 1) is acute - less than 2w, usually due to acute bleed e.g. variceal
HRS-CKD (formally Type 2) is a gradual decline in renal function and is generally associated with refractory ascites
There is also sub-acute or AKD
patient with AF presented with bloody diarrhoea and abdo pain. tender. Diagnosis?
Bicarb 18 (low) WCC 25
The low bicarbonate points to a metabolic acidosis - highly suggestive of mesenteric ischaemia.
what syndrome does C Diff cause?
Pseudomembranous colitis is caused by C Diff exotoxin causing intestinal damage
Multiple white plaques adhered to the gastrointestinal mucosa. on sigmoid
test to diagnose small bowel overgrowth syndrome
hydrogen breath test
Childs Pugh score
Albumin Bilirubin Coagulopathy (PT) Distension (ascites) Encephalopathy
(Used to calculate severity of liver cirrhosis)
Villous adenoma
Colonic polyp, potential malignant transformation
Diarrhoea
Classically large amount of mucus
Hypokal
Microcytic anaemia
Pregnant lady, jaundice abdo pain, deranged LFTs, hypoglycemia, blood film shows no evidence of haemolysis
Acute fatty liver of pregnancy
There would be haemolysis w HELLP
right upper quadrant pain, fever and jaundice
Charcot’s triad -ascending cholangitis
Typically e coli
Most common bacterial cause of ascending cholangitis
E coli
Assx w gallstones
Patient presents with erectile dysfunction, arthralgia, with evidence of chrondrocalcinosis
OE bronze skin, liver failure, dilated cardiomyopathy,
Haemochromatosis ,
Auto r
Prevalent of haemochromatosis
1 in 10 people of European descent carry a mutation in the genes affecting iron metabolism, mainly HFE
Prevalence in European 1/200
Childs Pugh score
Albumin Bilirubin Coagulopathy (PT) Distension (ascites Encephalopathy
Features of Post-cholecystectomy syndrome
Up to 40% of patients develop diarrhoea, dyspepsia, vomiting, pain…
Unclear pathology
Management of post cholecystectomy syndrome
bile acid sequestrants, such as Cholestyramine
PPI might help
Drug causes of acute pancreatitis
Mesalazine, sodium valproate, bendroflumethiazide, furosemide,
Alcohol ..
Population screening for haemochromatosis
Serum transferrin saturation
HFE gene analysis for family
Pernicious anaemia antibodies
anti gastric parietal cell antibodies (90%, but m specific)
Anti IF antibodies (50% but specific)
Ulcerative colitis - most common site affected
the rectum
Mx for Hepatic encephalopathy
Lactulose (increases ammonia excretion)
Then rifaximin (affects gut flora to decrease ammonia production)
severe acute alcoholic hepatitis is made
Which clotting factor is characteristically increased?
Factor VIII
Acute management of variceal bleeds
FFP vit k
Terlipressin
Prophylactic abx (reduce mortality)
endoscopic variceal band ligation
Prophylaxis with propranolol
mnemonic for DRugs causing hepatocellular disease:
Peter- Paracetamol Had- Halothane Epilepsy- sodium valproated and phenytoin And- amiodrone Alcoholic- Alcohol TB- anti-tbs he Met- Methyldopa dr. Nitro in- Nitrofurantoin STATes- Statins
Diarrhoea, PR bleed, pigmented freckles on the lips, face, palms and sole….diagnosis
Peutz-Jeghers syndrome
LKB1 or STK11
HBsAg meaning
Infected
Might be neg in window period with anti HBs also neg, but where anti HBc has developed… So is still infected.
Anti HBs simplified
Immunity
If there is also anti HBc then means you’re had caught up. If this is neg then you were vaccinated
Management of Whipple’s
oral Co-trimoxazole for a year (!)
Or IV Ceftriaxone
