Gastro Flashcards
HCC surveillance
For high risk patients:
- cirrhosis secondary to HBV, HCV, haemochromatosis, male alcoholics (who would comply), males w/ PBC
- some non-cirrhotics with HBV/HCV
6 monthly USS abdo and AFP -> CT triple phase thereafter
Colonoscopic surveillance for colorectal cancer
Low risk: 1-2 polyps, both <1cm
-> 5 year surveillance initially
Intermediate risk: 3-4 small polyps OR 1 polyp >1cm
-> 3 year surveillance initially
High risk: >4 small polyps OR >2 polyps >1cm
-> 1 year surveillance initially
IBD - start after 10 years with disease
Lower risk: 5 year follow up colonoscopy
- Extensive colitis with no active inflammation
- OR left sided colitis
- OR Crohn’s colitis of <50% colon
Intermediate risk: 3 year colonoscopy
- Extensive colitis with mild active inflammation
- OR post-inflammatory polyps
- OR family history of colorectal cancer in a first degree relative aged 50 or over
Higher risk: 1 year follow up colonoscopy
- Extensive colitis with moderate/severe active inflammation
- OR stricture in past 5 years
- OR dysplasia in past 5 years declining surgery
- OR primary sclerosing cholangitis / transplant for primary sclerosing cholangitis
- OR family history of colorectal cancer in first degree relatives aged <50 years
Acromegaly
- colonoscopy at age 40
+/- follow up depending on findings
- if elevated IGF1 - every 3 years
Barrett’s surveillance
Metaplasia, no dysplasia:
1) <3cm & gastric metaplasia -> repeat OGD and if still same, consider discharge
2) <3cm & intestinal metaplasia - repeat OGD every 3-5 years
3) >3cm - repeat OGD every 2-3 years
Dysplasia:
1) Unsure if dysplasia - repeat OGD with high dose PPI
2) Low grade dysplasia - repeat OGD every 6 months until 2x non-dysplastic OGD
3) High grade dysplasia - mdt and therapeutic intervention - radiofrequency ablation (if flat) OR endoscopic resection (if macroscopically visible)
H Pylori
When to test:
- uncomplicated dyspepsia after 1 month PPI
- OR phx gastro-duodenal ulcers
Tests:
- urea breath test: most accurate
- stool helicobacter antigen: next best
- serology: low cost, low accuracy but good negative predictive
Treat if positive:
1) 7 days: PPI + amox + metro OR clari
2) PPI + amox + clari/metro alternative
3) PPI + amox + tetracycline OR levofloxacin
Re-test for H Pylori if:
- associated peptic ulcer / MALT lymphoma
- severe symptoms / recurrent
- NB: if acid suppression required, use H2 antagonist
Hereditary colorectal cancer causes
1) HNPCC (hereditary non polyposis colorectal cancer)
- AD DNA mismatch repair genes
- most common inherited cause
- upper / lower GI ca, ovarian, endometrial
- amsterdam II criteria: 3-2-1
- 3 family members with relevant cancers
- 2 generations affected
- 1 or more ca before age 50
- colonoscopic surveillance by age 20-25 or 5 yrs before youngest age of familial ca -> 2 yearly screening
2) familial adenomatous polyposis
- AD APC tumour suppressor gene
- carpet of polyps
- start screening around aged 10 yearly
- by aged 30 typically have subtotal colectomy & IPAA
- subtype: Gardner’s syndrome
Whipple’s disease aetiology and ix
- tropheryma whippelii
- hla b27 linkage
- more common middle aged men
- multisystem disorder
- OGD: jejunal biopsy - macrophages in lamina propria with periodic acid schiff granules
- exclude DDx
Whipple’s disease sx
- MSK: arthralgia (migratory large joint usually), arthritis
- GI: vague abdo pain, malabsorption
- neuro: myoclonus, dementia, ataxia, opthalmoplegia, seizures
- lymphadenopathy
- cardio: endocarditis, pericarditis
- pulmonary: pleural effusion, chronic cough, ILD-like pulmonary HTN
Whipple’s disease mx
IV penicillin / ceftriaxone
AND
12 months PO co-trimoxazole
Primary sclerosing cholangitis liver biopsy histology
Onion skin
Primary biliary cirrhosis/cholangitis liver biopsy histology
- Dense lymphocytic infiltrate of portal tracts
- Focal / variable granulomatous destruction of medium-sized interlobular bile ducts
Bacillus cereus gastroenteritis features
- enterotoxin mediated
- 1-4 hour onset
- reheated rice
- profuse vomiting +/- diarrhoea (watery)
S Aureus gastroenteritis
- enterotoxin mediated
- few hours onset
- usually related to dairy consumption
Campylobacter jejuni gastroenteritis
- 48 hour onset
- contaminated food e.g. chicken
- fever, abdo pain
- vomiting
- diarrhoea (may be bloody)
Carcinoid syndrome
- symptoms resulting from well differentiated NETs of GI tract and lungs - symptoms related often to serotonin production +/- other hormones.
- Symptoms usually arise when tumours metastasize to liver and release this into systemic circulation
- diarrhoea
- flushing
- restrictive pericarditis -> right heart valvular disease
- wheeze
- telangiectasia
- other hormones produced inc: GnRH (acromegaly), ACTH (cushing’s)
- Ix: urinary 5-HIAA, serum chromogranin A, CT CAP +/- MRI
- Mx: octreotide (symptoms), surgical resection
Familial Mediterranean fever
- AR X-some 16
- Ashkenazi Jews and Turkish / Armenian / Arabic
- recurrent fever and peritonitis
- Mx: colchicine
King’s college criteria for liver transplant in paracetamol overdose
ph < 7.3
OR
in 24 hr period, all of
- INR > 6 (PT >100s)
- creatinine > 300
- grade III or IV encephalopathy
Treatment of HCC in chronic hep C
- evidence of cirrhosis? -> liver transplantation if single mass <5cm or up to 3 lesions <3cm
- no evidence of cirrhosis? -> consider resection
PBC bloods
Anti mitochondrial antibodies (M2 subtype is most specific)
Elevated IgM
Elevated HDL
Antibodies in autoimmune hepatitis
Raised IgG
- type 1: ANA / anti-SMA - all ages
- type 2: anti liver/kidney microsomal type 1 (LKM1) - children only
- type 3: soluble liver-kidney antigen - middle age
Liver biopsy autoimmune hepatitis
Piecemeal necrosis / bridging necrosis - used for confirmation of diagnosis
Chromogranin A
Raised in the majority of NETs except insulinomas
Washout period for H Pylori breath testing
- 6 weeks abx
- 2 weeks PPI
Treating Hep B
1) peg Interferon alpha-2a
2) entecavir & tenofovir
IF
- > 30yrs AND >2000 copies AND raised ALT on 2 tests >3 months apart
- < 30 yrs AND > 2000 copies AND raised ALT (2 tests) AND fibrosis/inflammation on scan
- any patient >20000 copies AND raised ALT (2 tests)
- any patient with transient elastostography > 11kpa
Bacterial overgrowth features and aetiology
- malabsorptive symptoms
- can occur with diverticular disease or radiation enteritis
- b12 malabsorption
- BUT bacteria produce folate - can be elevated
- can lead to SCDC
GVHD post liver transplant
- approx 15 days post transplant
- jaundice and deranged LFTs
- maculopapular rash
- colitis
- pancytopenia
- ix: liver USS / doppler -> biopsy (skin / GI / bone marrow), exclude infectious causes e.g. cmv
Mx: - adjust immunosuppressant medication dose
- skin: topical steroids / topical tacrolimus
- liver: systemic steroid
- GI: systemic + non-abosorbable steroid; octreotide for diarrhoea
Hep C in pregnancy advice
- vertical transmission 1.5-5%
- mode of delivery does not affect
- no evidence not to breastfeed
- testing baby: RNA 2-6 months, serology at 14 months
- ribavirin is teratogenic - should not be used in pregnancy -> aim to eradicate virus before trying for a family
Side effects of ileal resection
- reduced bile salt reabsorption -> increased chance of stone formation & diarrhoea (give cholestyramine)
- decreased vitamin b12 absorption
Hepatitis E
Similar to hepatitis A - symptoms, faeco-oral transmission and epidemiology
Increased chance of fulminant hepatitis during pregnancy
Sphincter of Oddi dysfunction
Recurrent biliary abdo pain +/- elevated cholestatic LFTs +/- radiological evidence of impaired biliary drainage
May cause recurrent pancreatitis
Mx:
- nifedipine (?similar to placebo)
- sphincterotomy
- botox injection (esp if pain but no elevated LFTs / radiological evidence)
Treatment of hepatitis B
Indications:
- without cirrhosis
- > generally observe if HBeAg + but treat if decompensate / flare
- > > 2000 copies, ALT >2x upper limit or 1-2x + liver biopsy mod-sev inflammation
- with cirrhosis
- > if detectable HBV DNA and decompensated
- > if HBV DNA >2000 and compensated
- > if HBV DNA <2000 but detectable, compensated liver disease but ALT rise
1) pegylated interferon 2 alpha
- NB: contraindicated in decompensated liver disease
2) tenofovir / entecavir
Zollinger-Ellison syndrome
= Gastrinoma
Increased acid -> peptic ulceration, deconjugation of bile salts -> fat malabsorption (+/- b12 deficiency)
1) OGD + h pylori testing (exclude other causes)
2) 3x fasting serum gastrin
3) secretin stimulation test (-> raised gastrin if +ve) in borderline cases
4) CT CAP / MRI imaging +/- EUS
Diagnostic tests for abdominal TB
- bloods: TB quantiferon, TB culture
- ascitic fluid: TB culture (<10%), TB PCR (better)
- laparoscopy & peritoneal biopsy (95%)
Treatment of radiation proctitis
- rectal sucralfate
- rectal steroids
- metronidazole
Pellagra
nicotinic acid (vitamin b3) deficiency OR B6 deficiency (precursor needed for nicotinamide) - dementia - dermatitis - diarrhoea - tremor / ataxia - insomnia - seizures - peripheral neuropathy - can be a side effect of carcinoid syndrome OR TB treatment (more commonly B6 -> give pyridoxine)
Thumbprinting sign
Non-specific sign of bowel mucosal oedema e.g. UC OR ischaemic colitis
Azathioprine & crohn’s in pregnancy
- folic acid supplementation
- continue same dose of azathioprine
Constipation predominant IBS
Soluble fibre supplementation e.g. ispahula husk or psyllium
RF small bowel lymphoma
coeliac disease (both B and T cell lymphomas) - poor adherence to gluten-free diet especially
Drug causes of pancreatitis
- steroids
- 6-MP/azathioprine, 5-ASA
- furosemide
- isoniazid, metronidazole
- statins
- amiodarone
- ACEi/ARBs
- valproate
Acute fatty liver of pregnancy vs intrahepatic cholestatis
Fatty liver: pain, jaundice, acute liver failure
Cholestasis: predominantly itching, jaundice, elevated liver enzymes +/- deranged INR
- Acute fatty liver mx: delivery
- Intrahepatic cholestasis mx: 1) USDA 2) cholestyramine (can give vit k deficiency)
Criggler-Najjar
- unconjugated hyperbilirubinaemia
- can be triggered by infection
- type 1 disease presents severely in the neonate -> kernicterus
- type 2 is less severe
- Mx: phototherapy, plasma exchange, phenobarbital
Dubin-Johnson syndrome
- AR conjugated hyperbilirubinaemia
- dark (melanin) granules on liver biopsy
- benign -> no treatment required
- normal urinary coproporphyrin excretion, with 80% being coproporphyrin I
Rotor syndrome
- benign mixed conjugated and unconjugated hyperbilirubinaemia
- no identified genetic basis to date
- normal liver histology
- increased 2x urinary coproporphyrin excretion, 65% being coproporphyrin I
Definitive differentiation between IDA and anaemia of chronic disease
Bone marrow biopsy: iron content EPO levels (although NB: CKD unreliable where both may co-exist)
Antibodies to help distinguish UC vs crohn’s
pANCA
- 60-70% UC vs 10-15% crohn’s
anti saccharomyces cerevisiae antibodies (ASCA) IgG
- 60-70% crohn’s vs 10-15% UC
Post transfusion purpura
human platelet antigen 1a mediated thrombocytopenia with purpura
occurs approx 1 wee
Mx IVIG, PLEX, high dose corticosteroids
Hydatid liver disease
- cause: tapeworm echinococcus granulosis
- faeco-oral transmission
- Ix: CT/USS - 40% cysts calcify
- Mx: aspiration (PAIR procedure) OR surgery (if complicated by daughter cysts) & adjunctive albendazole (monotherapy if very small cysts)
Pernicious anaemia ix
abs against intrinsic factor -> b12 malabsorption
Ix:
- elevated serum gastrin
- anti-IF / anti gastric parietal cell antibodies
Causes of false positive CA-125
- cirrhosis with ascites
- intra-abdominal cancers
- pancreatitis
- heart failure
- PID, endometriosis, fibroids
HIV cholangiopathy
- HIV-associated infections causing biliary stricturing
- e.g. cryptosporidium, CMV, giardia, mycobacterium
- Ix: HIV, serology, MRCP -> ERCP + brushings / biopsy
- Mx: treat cause, ursodeoxycholic acid, ERCP + sphincterotomy / stent depending on biliary tree findings
Pyoderma gangrenosum mx
PO steroids
Anti-TNF e.g. infliximab
Topical / PO calcineurin inhibitors e.g. tacrolimus
Melanosis coli
- brown pigmentation in colon
- causes: senna abuse
Tropical sprue
- Possible post gastroenteritis malabsorption syndrome (?bacterial overgrowth)
- Villous atrophy on OGD and b12/folate/iron deficiency
- Mx: vitamin supplementation and doxycycline
Nutcracker oesophagus
Cause of intermittent dysphagia
Oesophageal manometry >180 mmHg
Treatment of hepatitis C
Indications
- failure to reduce viral load by 2 log10 at week 4
- all patients with detectable RNA over 6 months
- genotyping
1) protease inhibitor combinations e.g. sofosbuvir
2) +/- peg interferon +/- ribavirin
Haemochromatosis diagnosis
Transferrin saturation >55% (50% in women)
Raised ferritin / iron
Low TIBC
HFE gene analysis
Crohn’s flare mx in pregnancy
Steroids - low foetal concentrations
Primary sclerosing cholangitis symptoms
Intermittent jaundice Pruritis Weight loss Fevers/night sweats Assoc diarrhoea (UC)
PSC mx
- Cholestyramine for pruritis
- No clear role for USDA - improves things biochemically but no effect on mortality / time to liver transplantation
- Ultimately liver transplant
Zieve syndrom
Triad
- haemolytic anaemia
- conjugated hyperbilirubinaemia
- hyperlipidaemia
Transient condition associated with alcohol abuse -> resolves with cessation
Traveller’s diarrhoea
Common pathogens: campylobacter, E Coli, salmonella, shigella, cholera
Mx
- ciprofloxacin + loperamide at onset can reduce durating by 2-3 days (other abx inc azithromycin)
- metronidazole if amoebic cause considered
UC flare mx in pregnancy
- prednisolone
- 5-ASA can be restarted as maintenance
- azathioprine also safe
Drug causes of bile salt malabsorption
Metformin
Gastro causes of iron deficiency anaemia
Bleeding from UGI/LGI cancers
Malabsorptive syndromes inc coeliac, tropical sprue, bacterial overgrowth
Gastrectomy -> reduced acidification of ferric (3+) -> ferrous (2+) iron -> less absorbed in the duodenum
Site of folate absorption
Jejunum
Site of b12 absorption
Terminal ileum
Site of b3 (nicotinic acid) absorption
Duodenum
Bile salt malabsorption
- cause of chronic diarrhoea
- causes: terminal ileal resection, metformin, coeliac, small bowel bacterial overgrowth, cholecystectomy, chronic pancreatitis
- Ix: SeHCat scan OR 14C glycolate test
- Mx: cholestyramine
Risk factors for gastric cancer
- smoking and etoh
- nitrosamines (food additives)
- smoked foods
- chronic H Pylori
- gastritis with intestinal metaplasia
- hypertrophic gastritis
- pernicious anaemia
- occupational exposure: heavy metals, rubber, asbestos
Drug Mx of GIST
Imatinib
Etoh hepatitis immunoglobulins
Markedly raised IgA
Slightly raised IgM/IgG
Immunoglobulins in liver disease
EtoH hepatitis - IgA
Autoimmune hepatitis - IgG
Primary biliary sclerosis - IgM
Hepatic adenoma
- benign
- hypoechoic liver lesion on USS
- low AFP
- assoc w/ OCP/oestrogen -> cessation usually -> regression
- otherwise elective surgical resection if symptomatic
Familial adenomatous polyposis
- AD APC mutation (xsome 5)
- carpet of adenomas -> from age 10 start colonoscopic surveillance -> panproctocolectomy + IPAA
- assoc duodenal tumours
- Gardner’s syndrome: mandibular / skull osteomas, retinal pigmentation, thyroid carcinoma, epidermoid cyst
Maintenance therapy crohn’s
1) azathioprine if >2 flares in 1 year
2) methotrexate
3) ?5-ASA if previous surgery
4) infliximab - use if perianal disease / fistulating disease
Entamoeba histolytica liver abscess management
1) metronidazole
2) percutaneous drainage
3) surgical drainage
Mx achalasia
1) myotomy e.g. heller’s laparoscopic myotomy - if of good functional status OR POEM
2) pneumatic dilatation - if worse functional status
3) intrasphinteric botox
4) CCBs e.g. nifedipine, ISMN
Laxative abuse bloods
- hypokalaemia
- metabolic alkalosis
VIPoma
- profuse watery diarrhoea
- hypokalaemia
- hypochloraemic metabolic acidosis
Oral and oesophageal candidiasis
PO fluconazole > nystatin (even with AARTs)
Ulcerative colitis mx: mild-mod proctitis
1) Rectal 5-ASA (>rectal steroid)
2) + PO 5-ASA
3) + topical / PO steroid
Ulcerative colitis mx: mild-mod proctosigmoiditis
1) topical 5-ASA (enema > suppository)
2) + PO 5-ASA
OR switch to 5-ASA + steroid enema
3) stop all topicals -> PO 5-ASA + PO steroid
Ulcerative colitis mx: mild-mod extensive disease
1) topical + PO 5-ASA
2) stop topical -> PO 5-ASA + PO pred
Type of renal stones in patients with small bowel resections
Calcium oxalate stones… fat malabsorption -> reduced ability of calcium to bind dietary oxalate in the gut -> increased oxalate uptake
Reversible complications in haemochromatosis
- cardiomyopathy (DCM)
- skin pigmentation
Irreversible complications in haemochromatosis
- liver cirrhosis (although liver damage pre-cirrhosis is reversible)
- diabetes
- arthropathy
(- hypogonadotrophic hypogonadism)
