Gastro Flashcards
Plummer vinson syndrome
Triad of:
dysphagia (secondary to oesophageal webs)
glossitis
IDA
Treatment includes iron supplementation and dilation of the webs
D2 Antagonist
Metoclopramide - prokinetic Domperidone - prokinetic Prochlorperazine - Vestibular/GI causes Haloperidol - drug causes >> dystonias and oculogyric crisis in young
H2 antagonist
cyclizine - GI
cinnarizine - vestibular
5HT3 antagonist
Ondansetron - chemo
Zollinger Ellison Syndrome
gastroma > gastrin > gastroduodenal ulcres > abdo pain, diarrhoea,
PPI
Dx fasting gastrin
MEN1
Duodenal ulcer
Blood O- more common before meals milk helps night
Gastric ulcer
elderly, lesser curve
after meals
better with antacids
biopsy (cancer)
Dx HH
Liver biopsy - Perls stain – iron loading
Complications HH
hypogonadism cardiomyopathy skin changes - bronze diabetes cirrhosis
PBC
Autoimmune AMA, raised IgM, middle aged women Cholestasis > fibrosis > HCC (check AFP bi yearly), cirrhosis Tx - ursodeoxycholic acid
Primary sclerosing cholangitis
Ulcerative colitis ANA liver biopsy - fibrous obliterative cholangitis beading ERCP/ MRCP -- dx men high risk ca - yearly colonoscopy and US
Autoimmune hep
young middle age women
T1 - AMA, SMA -kids, middle age
T2: kids, Anti liver anti kidney microsomal - LKM1
T3: Anti soluble liver antigen
Signs chronic liver disease, 25% acute, amenorrhea
associations - autoimmune disorders, hypergammaglobulinaemia and HLA B8, DR3
liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
Mx: steroids, azathioprine, liver transplantation
Wilsons
Copper > liver, basal ganglia AR low serum copper and caeruloplasmin high urinary copper 24hr Tx penicillamine
Cholangiocarcinoma
flukes
slow growing
ERCP, surgery
75% cant have surgery, 75% re occur
Ulcerative colitis
PSC > UC
Uveitis > UC
no inflammation beyond submucosa
ulceration ('pseudopolyps')
lamina propria
crypt abscesses
loss of haustrations
'drainpipe colon'Tx UC
topical (rectal) aminosalicylate (mesalazine) - mild mod
severe - IV steroids then IV ciclosporins
Crohns tx
Inducing remission:
glucocorticoids , budesonide
ASA - mesalazine
Maintaining remission
azathioprine or mercaptopurine
methotrexate
Investigations Crohns
increased faecal calprotectin
Complications Crohns
small bowel cancer
colorectal cancer
osteoporosis
Explosive diarrhoea
cholera; giardia; yersinia; rotavirus.
White cells: absent
in amoebiasis, cholera, E. coli and viruses
Clostridium difficile
Gram positive rod
exotoxin > intestinal damage > pseudomembranous colitis.
broad-spectrum antibiotics, 2nd/3rd gen cephalosporins, PPIs
diarrhoea, abdo pain, raised WCC
> toxic megacolon
Diagnosis -CDT stool
Clostridium difficile antigen -exposure
oral metronidazole 10-14 days
severe / not responding -oral vancomycin / fidaxomicin
life-threatening - oral vancomycin and IV metronidazole
Cryptosporidiosis
protozoa
Ziehl-Neelsen stain (acid-fast stain) of the stool - red cysts of Cryptosporidium
Travellers’ diarrhoea
Escherichia coli.
acute food poisoning
Staph aureus, Bacillus cereus or Clostridium perfringens.
Giardiasis
flagellate protozoan
chronic diarrhoea, malabsorption and lactose intolerance
metronidazole
Cholera
Profuse, watery diarrhoea
Shigella
Bloody diarrhoea
Campylobacter complications
GBS, Reiter’s syndrome, septicaemia, endocarditis, arthritis
Campylobacter
Gram-negative bacillus Campylobacter jejuni
bloody diarrhoea, may mimic appendicitis
rice
Bacillus cereus
Salmonella - bacteria type
aerobic, Gram-negative rods
Typhoid and paratyphoid
Salmonella symptoms
systemic upset
relative bradycardia
abdominal pain, distension
constipation: although Salmonella is a recognised cause of diarrhoea, constipation is more common in typhoid
rose spots: present on the trunk in 40% of patients, and are more common in paratyphoid
Salmonella complications
osteomyelitis (especially in sickle cell disease)
GI bleed/perforation
meningitis
cholecystitis
chronic carriage (1%, more likely if adult females
Osmotic laxatives
Lactulose, Movicol®, Magnesium salts, Phosphate enemas
Stimulant laxatives
senna , Docusate sodium, Glycerol suppositories ( sodium picosulfate)
Cullens sign
periumbilical
Turners sign
flanks
Courvoisiers sign
palpable gallbladder
jaundice
no pain
:> unlikely stone, think ca
Carcinoid tumours - ix and tx
Investigation
urinary 5-HIAA (metabolite of serotonin)
plasma chromogranin A y
Management
somatostatin analogues e.g. octreotide
diarrhoea: cyproheptadine may help
gastric cancer. histology
signet rings
Complication deficiency selenium
cardiomyopathy
Complication deficiency B6 (pyridoxine)
polyneuropathy
Complication deficiency Zinc
Acrodermatitis enteropathica
poor wound healing
Complication deficiency B 1 (thiamine)
Beriberi
wet - HF
dry - neuropathy
Wernicke’s encephalopathy
pellagra
nicotinic acid
diarrhoea, dementia, dermatitis
nicotinamide
xeropthalmia
vit a
blind
btots spots
Unconjugated hyperbilirubinaemia
Gilbert’s syndrome - mild deficiency of UDP-glucuronyl transferase
Crigler-Najjar syndrome - absolute deficiency
Conjugated hyperbilirubinaemia
Dubin-Johnson syndrome:
Iranian Jews
mutation in the canalicular multidrug resistance protein 2 (MRP2) results in defective hepatic excretion of bilirubin
grossly black liver
Rotor syndrome:
defect in the hepatic uptake and storage of bilirubin
benign
Peutz-Jeghers syndrome
gene encodes serine threonine kinase LKB1 or STK11
hamartomatous polyps in GI tract (mainly small bowel)
pigmented lesions on lips, oral mucosa, face, palms and soles
intestinal obstruction e.g. intussusception
gastrointestinal bleeding
GIT cancers
Melanosis coli
disorder of pigmentation of the bowel wall. Histology demonstrates pigment-laden macrophages
It is associated with laxative abuse, especially anthraquinone compounds such as senna
Previous Hep B immunisation
Anti HBS only
Hep B previously, now clear
anti HBsAg positive
anti HBcAg positive
All antigen negative
Hep B, chronic
All antigens and all antibodies - IgG as chronic
Hep A
benign, self limiting 2-4 incubation RNA picornavirus cholestatic LFTs At risk groups vaccinated
Hep B
DS hepadnavirus incubation 6-20 weeks ALT > AST Peg interferon alpha, now some antivirals Screen pregnant women
Hep C
RNA flavavirus
No vaccine
High risk transmission
Majority (60%) chronic
Chronic hep C treatment
Aim: sustained virological response
combination of protease inhibitors
+ / - ribavirin
Ribavirin
Tx chronic Hep C
SE: Haemolytic anaemia, cough, teratogenic (no preg <6/12)
Interferon alpha
Chronic hep c
Flu like symptoms, depression, fatigue, leukopenia, thrombocytopenia
Hep D
Single stranded RNA Parenteral Requires HBsAg Interferon tx (poor evidence) Coinfection/ superinfection
Hep E
RNA herpesvirus faecal oral 3-8 weeks incubation 20% mortality pregnancy vaccine in development not chronic
Autoimmune hepatitis T1
ANA/ SMA
adults, kids
Autoimmune hepatitis T2
LKMI
Anti liver/ kidney microsomal type 1 antibodies
Kids
Autoimmune hepatitis T3
Soluble liver kidney antigen
Middle aged adults
Wilsons
autosomal recessive
ATP7B gene, chromosome 13
reduced serum caeruloplasmin with reduced serum copper
increased 24hr urinary copper excretion
Wilsons treatment
penicillamine
trientine hydrochloride - chelating agent
HCC screening
US + - AFP
cirrhosis secondary to Hep B/C/ haemochromatis or alcohol
HH iron profile
transferrin saturation high
raised ferritin
low TIBC
Tx HH
venesection
Desferrioxamine
Who is at risk of liver cirrhosis?
Hep B/ C, BMI > 30, alcohol abuse, T2DM
Who do you offer transient elastography to?
Hep C, alcohol M>55 units, F> 35 units, alcohol related liver disease, NAFLD with ELF test > 10.5
Retest every 2 years
Cirrhosis risk screening
HCC - US and AFP 6 monthly
UGIE 3 yearly for varices
IBS management
2nd line = low-dose TCA (e.g. amitriptyline 5-10 mg)
if no improvement 1 year - CBT/ hypnotherapy/
Gastroparesis
Prokinetic agents:
Metoclopramide
Domperidone
Erythromycin
