gastro Flashcards
1
Q
70y M
surgical outpatient clinic
change in bowel habit 3months - increased freq of loose stools and occasional constipation
systemically unwell - malaise, lethargy, reduced appetite, nausea but no vomiting, night sweats, difficulty sleeping
lost 3kg weight past month
no blood in stool
civil engineer - work in developing countries
apyrexial
abdo - fullness in right iliac fossa - tender
no lymphadenopathy
Hb 99 (135-180 g/L)
WCC 8 (4-11 x109/L)
MCV 85 (76-100 fL)
Na+ 141 (136-145 mM)
K+ 4.2 (3.5-5.1 mM)
Ur 7.3 (1.7-8.3 mM)
Cr 80 (62-106 µM)
Alb 30 (35-52 g/L)
CRP 43 (0-5 mg/L)
ESR 56 (0-15 mm/h)
which two investigations will be most helpful
how urgently should these investigations be requested
A
CT abdo pelvis
colonoscopy - allows for histological diagnosis
done within 2 weeks - high suspicion of malignancy
2
Q
what are associated with right iliac fossa mass
A
caecal carcinoma
appendix abscess
chrons disease
hepatomegaly - can extend into RIF and so can the normal variant, Riedel’s lobe
3
Q
CT scan - inflammatory stricturing of the caecum and terminal ileum.
colonoscopy - significant inflammatory change in the caecum and terminal ileum.
Biopsies were taken from this area.
The colonoscopic and radiographic appearances suggest Crohn’s disease or infection.
What two infectious organisms could be responsible?
A
Tuberculosis
Yersinia
patient has ileal-caecal TB
tuberculosis and yersinia can both mimic ileo-caecal chrons disease
CXR should be performed to demonstrate previous/active pulmonary TB (half of patients dont present with hx of pulmonary TB)
rare causes in UK - look for travel in hx
4
Q
colonoscopic and radiographic appearances suggest Chron’s disease or infection
Histology confirmed diffuse infiltration of the caecum and terminal ileum, with the presence of non-caseating granulomas as well as mixed acute and chronic inflammatory changes.
no evidence of carcinoma or lymphoma
productive cough for few weeks - one episode of haemoptysis
CXR - what are the findings?
most likely underlying diagnosis given the chest radiograph?
would you be confident to diagnose chrons and start on steroids?
A
bilateral ill defined upper lobe infiltrates/consolidation
tuberculosis
no - TB more likely with CXR findings - treat TB after obtaining sputum sample
5
Q
management for TB
A
RIPE
Rifampicin - 6 months
Isoniazide - 6 months
Pyrazinamide - 2 months
Ethambutol - 2 months
6
Q
24yr W
presents to GP with husband
eyes looked yellow for past 3 days
2 wk hx lethargy, anorexia, non-specific upper abdo pain
no alcohol excess
no travel abroad recently
4months ago - borderline hypothyroidism - no treatment
jaundiced but euthyroid (normal thyroid function)
multiple spider naevi on anterior chest wall
liver palpable 3cm below costal margin
spleen palpable 2cm below costal margin
Hb 119 120-155 g/L
WCC 4.5 4-11 x109/L
Plt 156 150-450 x109/L
Ferritin 670 13-150 µg/L high
Bili 56 2-17 µM high
ALP 230 35-104 iu/L high
ALT1230 <31 IU/L high
INR 1.0 0.9-1.2
what are the three main differential diagnoses at this stage
A
autoimmune hepatitis (particularly in young women) - can develop spider naevi and enlarged spleen even without cirrhosis
viral hepatitis
- hepatits likely diagnosis as spider naevi and splenomegaly suggest cirrhosis/ portal HTN (doesnt fit thyroid disease)
non-alcoholic fatty liver disease (but doesnt usually present acutely with jaundice)
hypo and hyperthyroidism –> abnormal LFTs and jaundice (in severe disease and with coexisting heart failure)
high ferritin reflects acute phase response - hemochromatosis (excess iron –> liver damage) presents after 5th decade <– normal transaminases in haemochromatosis
7
Q
24yr W
presents to GP with husband
eyes looked yellow for past 3 days
2 wk hx lethargy, anorexia, non-specific upper abdo pain
no alcohol excess
no travel abroad recently
4months ago - borderline hypothyroidism - no treatment
jaundiced but euthyroid (normal thyroid function)
multiple spider naevi on anterior chest wall
liver palpable 3cm below costal margin
spleen palpable 2cm below costal margin
ALT significantly raised
ALP and bilirubin raised
ferritin significantly raised
viral serology -ve
total protein and serum globulins raised
ANA +ve
smooth muscle antibody (SMA) +ve
liver ultrasound normal
most appropriate next step in management
A
liver biopsy
- high clinical suspicion of AIH (type 1) - cant be diagnosed without liver histology
after diagnosis:
high dose steroids then addition of azathioprine
test TMPT levels (chemical in bone) before starting azathiaprine - can cause myelosuppression
8
Q
24yr W
presents to GP with husband
eyes looked yellow for past 3 days
2 wk hx lethargy, anorexia, non-specific upper abdo pain
no alcohol excess
no travel abroad recently
4months ago - borderline hypothyroidism - no treatment
jaundiced but euthyroid (normal thyroid function)
multiple spider naevi on anterior chest wall
liver palpable 3cm below costal margin
spleen palpable 2cm below costal margin
ALT significantly raised
ALP and bilirubin raised
ferritin significantly raised
viral serology -ve
total protein and serum globulins raised
ANA +ve
smooth muscle antibody (SMA) +ve
liver ultrasound normal
percutaneous liver biopsy (shown in pic)
what is the most likely diagnosis
A
autoimmune hepatitis
florid interface hepatitis (ie inflammation spilling over the portal tract limiting membrane on to the hepatocytes)
inflammatory exudate is rich in plasma cells
AIH most likely - female, elevated globulins, -ve viral serologies, no drug hx
bile ducts normal therefore primary biliary cholangitis unlikely
9
Q
A
10
Q
24yr W
presents to GP with husband
eyes looked yellow for past 3 days
2 wk hx lethargy, anorexia, non-specific upper abdo pain
no alcohol excess
no travel abroad recently
4months ago - borderline hypothyroidism - no treatment
jaundiced but euthyroid (normal thyroid function)
multiple spider naevi on anterior chest wall
liver palpable 3cm below costal margin
spleen palpable 2cm below costal margin
ALT significantly raised
ALP and bilirubin raised
ferritin significantly raised
viral serology -ve
total protein and serum globulins raised
ANA +ve
smooth muscle antibody (SMA) +ve
liver ultrasound normal
percutaneous liver biopsy (shown in pic)
started on Prednisolone 30mg - rapid clinical and biochem remission
azathiprine added and steroids tapered
after 3months LFT normal, asymptomatic
daily meds: pred 5mg, azathioprine 50mg
she requests if she can discontinue her drugs - what should you advise?
A
AIH therapy at least two yrs after blood tests have normalised before discontinuing therapy
liver biopsy before stopping therapy
if stopped before two yrs most patients relapse
life long therapy: patients with cirrhosis, severe initial presentation, prior relapse
11
Q
patient is on azathioprine for autoimmune hepatitis. patient informs you that they are 12 weeks pregnant. she has read up about the side effects of azathioprine and is concerned. what should be your advice
A
continue current medication
safe to be on azathioprine whilst pregnant
risk of stopping is greater than risk of teratogenic effects
12
Q
what are the signs and symptoms of autoimmune hepatitis
A
female
jaundice
hepatosplenomegaly
raised LFTS
-ve viral serology
+ve ANA and SMA
13
Q
79yr M
acute stroke
unsafe swallow
NG tube inserted but hard to aspirate any gastric contents
most appropriate next management step
A
CXR
must be confirmed in right position before being flushed or used
14
Q
CXR shown below
what position is the NG tube
A
down the right main bronchus
15
Q
what should the pH level be between for an NG tube aspirate to check if its in the right position
what if the pH is not within range
A
pH btwn 1-5.5
if not within range or aspirate cant be obtained - CXR
16
Q
58yr M
gastro outpatients
4month hx gradually progressive dysphagia
initially discomfort with solids now cant tolerate solids and only small quantities of fluid
hx of probable GORD with heartburn and belching over yrs
weight loss 6mnths
10-15 cigarettes per day
drinks 2-3 pints per day
meds: antacid liquid med
no lymphadenopathy
no abdo masses
two most likely diagnoses
most appropriate next investigation
A
oesophageal stricture:
peptic stricture (hx of GORD more likely to mean peptic in origin)
oesophageal carcinoma
oesophagogastroduodenoscopy (OGD) - 2ww pathway
- would diagnose peptic stricture and oesophageal carcinoma
17
Q
A
18
Q
OGD shows stricture in lower third of oesophagus
biopsies show inflammation only
which two initial treatments should this patient be offered
A
proton pump inhibitor
balloon dilatation, following benign biopsy - treatment for symptomatic benign peptic strictures
endoscopy and biopsy confirmation of benign disease needed
treatment of GORD - PPI
19
Q
patient underwent balloon dilation of peptic stricture
immediately post-procedure he experienced chest pain and SOB
which diagnosis would you consider
which further investigations would you arrange urgently
A
oesophageal perforation
- most common complication of balloon dilatation - may cause mediastinitis. surgical emphysema may be palpable in neck
do CT scan with oral contrast - for perforation post-oesophageal dilatation suspected
20
Q
presentation of peptic ulcer disease
A
epigastric pain
dyspepsia (indigestion)
heartburn
duodenal - pain may be relived by eating
gastric - pain with meals
21
Q
causes of peptic ulcer
A
h.pylori
NSAIDs
also consider steroids, alcohol, SSRIs
22
Q
complications of peptic ulcers
A
haematemesis (erosion usually into gastroduodenal artery)
perforation (peritonitic)
can also see malaena, anaemia, weight loss
23
Q
investigations for peptic ulcer disease
A
first Ix: H.pylori breath test
ALARM syptoms: endoscopy
- Anorexia
- Loss of weight
- Anaemia due to iron deficiency
- Recent onset of persistent symptoms: vomiting
- Malaena, haematemesis
>55 + weight loss + upper abdo pain/reflux/ dyspepsia –> endoscopy
new onset dysphagia –> endoscopy
24
Q
management for peptic ulcer disease
A
if h.pylori +ve –> triple therapy:
- one week triple therapy: PPI + clarithromycin + amoxicillin/metronidazole
review after 4 weeks with urea breath test - if not eradicated repeat Rx
if h.pylori -ve: PPI or H2 antagonist (ranitidine) for 4weeks
25
what is Zollinger ellison syndrome
gastrin secreting tumour - cause of dyspepsia
26
symptoms of iron deficiency anaemia
SOB, fatigue, palpitations
27
causes of iron deficiency anaemia
blood loss - menorrhagia, GI bleed
malabsorption - coeliac disease, gastrectomy
diet - seen in pregnancy
28
investigations for iron deficiency anaemia
FBC:
- microcytic anaemia: decreased MCV, decreased ferritin
- isolated inreased urea + normal creatinine --\> large protein meal
29
management of iron deficiency anaemia
if Hx of **menorrhagia --\> oral iron**
otherwise scope for GI bleed
**UGI endoscopy and colonoscopy**
30
what is the difference between diverticulosis and diverticulitis
diverticulosis = the disease process
diverticulitis: acutely inflamed
31
symptoms and signs of diverticulitis
LIF pain
fever
constipation (or diarrhoea)
32
investigations and management of diverticulitis
investigations:
**CT abdo**
increased WCC, increased CRP
do not do colonoscopy acutely due to perforation risk
management:
NBM
IV fluids
abx
analgesia
33
diverticular complications
**perforation** --\> peritonitis, shock, **free gas on CXR**
Rx: **consider Hartmann's procedure**
Haemorrhage --\> rectal bleeding
**abscess --\> swinging fever** (subdiaphragmatic)
stricture
fistula - bladder, uterus, vagina, skin
34
what is familial adenomatous polyposis (FAP)
auto dominant
many polyps by 20's
APC gene mutation
100% chance of cancer if not removed
35
what is Peutz-Jeghers syndrome
auto dominant
pigmentation around lips
increased cancer risk in other organs
36
juvenile hamartomatous polyps
may see bleeding, intussusception
37
what are pseudopolyps
scar tissue surrounding areas of intact mucosa (looks like polyps)
38
what is lynch syndrome
HNPCC (hereditory non polyposis colorectal cancer)
39
investigations and management for colorectal cancer
Ix:
**colonoscopy + biopsy**
CT colonography
Mx:
surgery, chemo
40
TNM staging of cancer
stage I: in mucosa and muscular layer
stage IIa: grown through the wall of organ but not spread
IIb: growth through visceral peritoneum
IIc: grown into nearby structures
Stage III: metastasis to lymph nodes
stage IVa: mets to one other distant organ
IVb: many other distant organs
41
what surgical approach would you use for a low rectal tumour
abdominoperineal (AP) resection
excision of distal colon, rectum and anal sphincters - colostomy
42
what surgical approach would you use for a high rectal tumour
anterior resection
\>5cm from anus
rectal sphincter remains intact and functioning if anastamosis performed
43
what surgical approach would you use for a sigmoid colon tumour
sigmoidcolectomy
44
what surgical approach would you use for a descending colon tumour
left hemicolectomy
45
what surgical approach would you use for a caecal/ ascending colon tumour
right hemicolectomy and extended right hemicolectomy
extended for any transverse colon cancers
46
risk factors for gallstones
fair, fat, fertile, female, forty
white
increased BMI
middle aged woman
47
what is biliary colic and what symptoms do you get
stone stuck/ compressed into GB neck/ cystic duct
continuous **RUQ pain** , nausea, vomiting
attacks usually \<6hr, often **after fatty food**
48
investigations and management for biliary colic
Ix:
normal inflammatory markers
LFTs - raised ALP
USS abdo
Mx:
analgesia
elective cholecystectomy - 4-6 weeks
49
RUQ pain
fever
local peritonism
pain lasts \>12hrs
murphys sign positive
diagnosis?
cholecystitis
50
investigations and management for acute cholecystitis
LFTs - ALP raised
WCC & CRP raised
USS
Mx: urgent cholecystectomy if peritonitis or worsening signs
IV fluids, abx
51
RUQ pain
fever
jaundice
ascending cholangitis
= inflammation + infection of biliary tract
stone moved to CBD
classic triad of symptoms
52
investigations and management for ascending cholangitis
**ERCP**: to confirm and remove CBD stones
IV fluids
abx
53
what is a gallstone ileus + management?
small bowel obstruction
**AXR**: bowel obstruction, air in biliary tree
stone usually stuck in terminal ileum
remove with **enterotomy**
54
what is Mirrizzi's syndrome
extrinsic compression of hepatic duct from a compacted stone in the cystic duct
symptoms: RUQ pain, fever, jaundice
55
what is a gall bladder mucocele
distended gall bladder filled with clear fluid
usually from an outflow obstruction - stone in cystic duct
56
what is a gallbladder empyema
complication of cholecystitis
pus in gallbladder
57
what is a hernia (inguinal + femoral)
passage of tissue from a site where it is normally found to a site where it is not normally found
cough impulse
cannot get above
reducible
can become:
irreducible/incarcerated - cant push back to correct location
strangulated - constriction leads to ischaemia, pain - can perforate
58
risk factors for hernias (inguinal + femoral)
things that increase abdo pressure
- obesity
increased age
surgery
cough
constipation
pregnancy
59
what is a femoral hernia and what are the symptoms of strangulation
rarer than inguinal hernias
more common in women
often irreducible
often strangulate --\> repair urgently
strangulation:
- colicky abdo pain
signs of bowel obstruction
lump below inguinal ligament
60
what are indirect inguinal hernias
most common
all ages
through inguinal canal via **deep inguinal ring**
can strangulate so **repair**
61
what are direct inguinal hernias
through weakness in posterior wall of inguinal canal
reduce easily and rarely strangulate
62
causes of upper GI bleed
mallory weiss tear
varices
**ulcers**
gastritis
malignancy
63
presentation of upper GI bleed
haematemesis or malaena
64
management of upper GI bleed
ABCDE
fluid resus
bloods inc crossmatch
**urgent endoscopy**
if cant control bleed then surgery
terlipressin if varices suspected
**Blatchford score** (need for intervention) first, **Rockall score** (adverse outcome) after endoscopy
65
what is the blatchford score
to determine risk (and therefore need for intervention) of upper GI bleed
50% chance of need for intervention if 6 or more points
blood urea
Hb \<100 = 6
systolic BP
pulse \> 100 = 1
presentation with malaena = 1
presentation with syncope = 2
hepatic disease = 2
cardiac failure = 2
66
what is the Rockall score
adverse outcome of upper GI bleed
age
60-79 = 1
80\> = 2
shock
tachycardia \>100bpm = 1
hypotension SBP \<100 = 2
comorbidities
Cardiac failure, IHD or any major co-morbidity = 2 points
renal failure, liver failure, or metastatic disease = 3 points
7/7 is 50% chance mortality
after diagnosis: out of 11
Mallory-Weiss tear, no lesion seen nor SRH (stigmata of recent haemorrhage) = 0 points
All other diagnoses apart from GI malignancy = 1 point
GI malignancy = 2 points
major stigmata of recent haemorrhage:
None or dark spot only = 0 points
Blood, adherent clot, spurting vessel = 2 point
score over 8 = high risk of mortality
67
what is the main risk factor for upper GI ulcers
NSAID use
68
usually healthy
been out binge drinking
repeated vomiting
and then blood in vomit
diagnosis?
mallory weiss tear
69
chronic alcohol excess
malnourished
massive haematemesis
diagnosis?
varices
70
heartburn
epigastric pain
dysphagia
dignosis
oesophagitis
71
severe epigastric pain
radiate to back
nausea + vomiting
diagnosis?
acute pancreatitis
72
causes of pancreatitis
I GET SMASHED
idiopathic
**gall stones**
**ethanol**
trauma
steroids
mumps
autoimmune
scorpion bite
hypercalcaemia, hypertriglyceridaemia
ERCP
drugs
73
investigations and management of acute pancreatitis
raised **amylase (or lipase**) - 3 times upper limit of normal
glasgow score: PANCREAS
Mx:
supportive - IV fluids, analgesia
74
what is the glasgow score
for pancreatitis - gallstone and alcohol induced
score of 3 or more indicates severe pancreatitis --\> ITU
PANCREAS
P - PaO2 \<8kPa
A - Age \>55-years-old.
N - Neutrophilia: WCC \>15x10(9)/L.
C - Calcium \<2 mmol/L
R - Renal function: Urea \>16 mmol/L
E - Enzymes: LDH \>600iu/L; AST \>200iu/L
A - Albumin \<32g/L (serum)
S - Sugar: blood glucose \>10 mmol/L
75
76
causes of RUQ pain
cholecystitis
pyelonephritis
hepatitis
pneumonia
77
causes of LUQ pain
gastric ulcer
ureteric colic
pyelonephritis
pneumonia
78
causes of RLQ pain
appendicitis
ureteric colic
inguinal hernia
chrons
UTI
gynae
testicular torsion
79
causes of LLQ pain
UC
diverticulitis
UTI
ureteric colic
gynae
testicular torsion
inguinal hernia
80
epigastric pain
gastric ulcer
pancreatitis
cholecystitis
MI
81
periumbilical pain
AAA
appendicits
small bowel obstruction
large bowel obstruction
82
what test should you do in a woman with abdo pain
urine pregnancy test (HCG) - to rule out ectopic
83
most common cause of bowel obstruction
adhesions
84
pain
distension
vomiting
absolute constipation
chrons patient recently underwent surgery
most likely diagnosis
adhesions
85
coffee bean AXR
most likely diagnosis
volvulus
86
investigations and management for obstruction
AXR
need NG tube and Iv fluids "drip and suck"
surgery if does not settle or worsening signs
87
what does this sign show
apple core sign
sign of colorectal cancer
88
what does this xray show
small bowel obstruction
89
what does the AXR show
coffee bean sign
sigmoid volvulus
90
what does this AXR show
large bowel obstruction
91
what does this AXR show
with air under diaphragm
riglers sign -both sides of wall of intestine can be seen
pneumoperitoneum - free air in abdo
causes of pneumoperitoneum:
- perforated abdominal viscus (e.g. perforated bowel, perforated duodenal ulcer)
- recent abdominal surgery
92
what does this AXR show
IBD
**Thumbprinting**: mucosal **thickening of the haustra** due to inflammation and oedema causing them to appear like thumbprints projecting into the lumen.
**Lead-pipe** (**featureless**) colon: **loss of normal haustral markings** secondary to **chronic** colitis.
**Toxic megacolon**: **colonic dilatation** without obstruction associated with colitis.
93
abdo pain, rigidity, guarding
may also have N+V, fever, signs of sepsis
what does this x ray show
free gas under diaphragm on erect CXR --\> **perforation**
94
what are the main causes of perforation
2ndry to **OBSTRUCTION**
**perforated ulcer**
**malignancy**
**diverticulitis**
**appendicitis**
IBD
infection e.g c.difficile
95
colicky umbilical pain that moves to constant RIF pain - may be guarding, rebound tenderness
fever + systemic signs - increased HR
anorexia
vomiting
diarrhoea
constipation
rovsings sign +ve
diagnosis?
appendicitis
rovsings sign +ve: palpating LLQ illicits pain in RLQ
96
investigations and management for appendicitis
clinical dx
but can do USS or CT
difinitive treatment: laparoscopic appendicectomy
97
pale stool
post hepatic obstruction - biliary or pancreatic duct obstruction
e.g. pancreatic cancer, stones
98
steatorrhoea cause
pale, foul smelling, floats
coeliac
pancreas pathology
99
blood mixed into faeces
causes
infections
UC
colon cancer
100
blood when wiping
causes
haemorrhoids
anal fissure
101
causes of diarrhoea in young people
infection
IBD
IBS
coeliac
102
causes of diarrhorea in old people
cancer
IBS
diverticular disease
bacterial overgrowth -e.g. in diabetes
chrons (2nd age peak)
103
progressive dysphagia (problems with food then drink)
weight loss
fatigue
oesophageal cancer
104
what does the image show
bird beak appearance on barium swallow
--\> achalasia
105
causes of an oesophageal stricture
**chronic GORD**
hiatus hernia
106
investigations for dysphagia
**endoscopy** +/- barium swallow (more Ix for achalasia)
107
how does UC and chrons present
UC: LLQ pain, bloody diarrhoea
Chrons: RLQ pain, bloody diarrhoea, can have ulcers in mouth
108
what is angiodysplasia and what is Ix and Mx
angiodysplasia
- **vascular malformation** - often lesions in caecum or ascending colon
fresh **PR blood**. may also see malaena
Ix: **colonoscopy** - visualise lesion
Mx: conservative, or **cauterisation** if does not cease
109
pale stools
dark urine
jaundic
increased ALP
conjugated hyperbilirubinaemia
diagnosis?
post hepatic jaundice
110
causes of post hepatic jaundice
gall stones
cancer of head of pancreas
cholangiocarcinoma - bile duct cancer
111
short episodes of jaundice
in young adult
otherwise well
brought on by stress, illness, fasting
diagnosis?
management?
**Gilberts syndrome**
**short episodes of jaundice**
inherited condition
cant process bilirubin properly
often presents in young adults
otherwise well
**no treatment needed**
112
what does increased conjugated bilirubin mean
post hepatic jaundice
113
what does increased unconjugated bilirubin show
pre or intra hepatic jaundice
114
what does increased ALT/AST mean
problem in the liver
115
what does increased ALP/gamma GT mean
problem in biliary system or lower
**ALP** can be **raised in pregnancy** and in **bone disorders** too
116
what does increased amylase/lipase mean
pancreatitis if \>3x upper limit of normal
117
heartburn
acid regurgitation
retrosternal or epigastric pain
bloating
nocturnal cough
hoarse voice
diagnosis?
GORD
118
red flag signs for endoscopy referral
**dysphagia**
age \>55
weight loss
upper abdo pain/reflux
treatment resistant dyspepsia (indigestion)
nausea & vomiting
low haemoglobin
raised platelet count
119
when would you get an urgent referral for endoscopy
upper GI bleed - fresh blood, coffee ground vomit, malaena
120
lifestyle management of GORD
reduce tea, coffee, alcohol
weight loss
avoid smoking
smaller, lighter meals
avoid heavy meals before bed
stay upright after meals
121
management for GORD
acid neutralising PRN:
- gaviscon
- rennie
PPI: (reduce acid secretion)
Omeprazole
lansoprazole
ranitidine - H2 receptor antagonist (reduce stomach acid)
alternative to PPIs
surgery for reflux - laparoscopic fundoplication
122
dyspepsia (indigestion) investigations
h.pylori urea breath test
has to be taken before starting PPI or not taken a PPI in two weeks
endoscopy if red flag symptoms
123
management of H.pylori
thriple therapy
PPI
2 x Abx - amoxicillin + clarithromycin for 7 days
use urea breath test to check for eradication after treatment
124
what is the change of cells in Barretts oesophagus
metaplasia from squamous to columnar epithelium
leads to improvement in reflux symptoms
premalignant - risk of adenocarcinoma
125
management for Barretts oesophagus
monitored for adenocarcinoma - **regular endoscopy**
**PPI**
**ablation treatment** during endoscopy - photodynamic therapy, laser therapy, cryotherapy - for patients with **dysplasia**
aspirin can reduce rate of adenocarcinoma
126
chrons pathophysiology
crows **NESTS**
**N - No blood or mucous** (less common)
**E- Entire GI** tract
**S- Skip lesions** on endoscopy
**T- Terminal ileum** most affected & Transmural (full thickness inflammation
**S-Smoking** - risk factor (dont set nest on fire)
chron's also associated with weight loss, strictures and fistulas
127
ulcerative colitis pathophysiology
(U - C -\> CLOSE UP)
C- **Continuous inflammation**
L- Limited to **colon and rectum**
O- Only **superficial mucosa affected**
**S- Smoking** is **protective**
**E- Excrete blood** and **mucus**
**U**- **Use** **aminosalicylates**
**P-Primary Sclerosing Cholangitis**
128
testing for IBD
routine bloods for anaemia, infection, TFTs, LFTs, CRP (for active disease)
**faecal calprotectin** (released by intestine when inflamed) - **screening test**
**endoscopy (OGD and colonoscopy) with biopsy - diagnostic**
USS, CT, MRI - to look for complications - fistulas, abscesses, strictures
129
management of chrons
**inducing remission**:
- first line: **steroids** - oral pred or IV hydrocortisone
add immunosuppressants (biologics) if steroids arent working e.g. azathioprine, methotrexate, infliximab
**maintaining remission**:
first line: **azathioprine, mercaptopurine**
alternatives: methotrexate, infliximab, adalimumab
surgery:
when disease only affects distal ileum - surgical resection
surgery to treat strictures and fistulas
130
management of UC
**inducing remission**:
**mild to moderate**:
first line: aminosalicylate (e.g. **mesalazine** oral or rectal)
second line: corticosteroids- pred
**severe** disease:
first line: **IV corticosteroids** (hydrocortisone)
second line: IV ciclosporin
**maintaing remission:**
**aminosalicylate** (**mesalazine**)
azathioprine
mercaptopurine
surgery:
UC affects colon and rectum - **panproctocolectomy**
left with **ileostomy or ileo-anal anastomosis** (J-pouch)
131
which type of IBD has no inflammation beyond submucosa
UC
132
which type of IBD has loss of haustrations on barium enema
UC - with toxic megacolon
133
which type of IBD has mouth ulcers
chrons
134
which type of IBD is most likely to have a fistula
chrons
135
136
which IBD is more likely to have gallstones 2ndry
chrons
common 2ndry to reduced bile acid reabsorption
as well as oxalate renal stones
137
which IBD is more likely to have primary sclerosing cholangitis
UC
138
which IBD has a greater risk of colorectal cancer
UC
139
which IBD has a greater risk of fistula
chrons
140
which IBD has skip lesions
chrons
141
what is the diagnosis
cobblestone appearance
--\> Chrons
142
diagnosis?
UC
lead pipe appearance on AXR
- loss of haustrations
- toxic megacolon
ulcers seen on colonoscopy
143
diagnosis?
chrons
- rose thorn appearance
144
diagnosis
Chrons
- Kantor's string sign
145
which IBD has crypt absesses and depletion of globlet cells
UC
146
which IBD has bloody diarrhoea
UC
147
which IBD has perianal disease
chrons
148
which IBD has increased goblet cells
chrons
149
which IBD has tenesmus as a presenting feature
UC
150
which IBD has pseudopolyps seen on endoscopy
UC
151
which IBD has weight loss
chrons
152
153
which cancers is a patient at increased risk of following radiotherapy for prostate cancer
increased risk of bladder, colon, rectal cancer
154
management for prostate cancer
localised prostate cancer (T1/T2):
conservative: active monitoring + watch and wait
radical prostatectomy
radiotherapy: external beam + brachytherapy
localised advanced prostate cancer (T3/T4):
- hormonal therapy
- radical prostatectomy: erectile dysfunction common complication
radiotherapy: increased risk of bladder, colon and rectal cancer
metastatic prostate cancer disease - hormonal therapy :
- synthetic GnRH agonist e.g. goserelin
- anti-androgen
- orchidectomy
155
4yr old boy
discharged from hospital 6 wks ago - viral gastroenteritis
now has 4-5 loose stools a day - for last 4 wks
most likely diagnosis
lactose intolerance
transient lactose intolerance common complication of viral gastroenteritis
Mx: removal of lactose from diet for a few months then reintroduction
156
most common cause of gastroenteritis in children
treatment
rotavirus - diarrhoea (+ fever + vomiting for first 2 days)
diarrhoea can last up to a week
treatment = rehydration
157
most common cause of chronic diarrhoea in infants
cow's milk intolerance
other causes:
- toddlers diarrhoea
- coeliac disease
- post-gastroenteritis lactose intolerance
158
alcoholic liver disease progression
1. alcohol related fatty liver
- build up of fat in liver
reversible in around 2 weeks if stop drinking
2. alcoholic hepatitis
- chronic drinking -\> inflammation in liver
- reversible with permanent abstinence
3. cirrhosis
- scar tissue - irreversible
159
what is the recommended alcohol consumption
no more than 14 units per week - spread evenly over 3 or more days
no more than 5 units in a day
160
complications of alcohol
alcoholic liver disease
cirrhosis and complications e.g. hepatocellular carcinoma
alcohol dependence and withdrawal
Wernicke- Korsakoff Syndrome
pancreatitis
alcoholic cardiomyopathy
161
signs of liver disease
jaundice
hepatomegaly
spider naevi
palmar erythema
gynaecomastia
brusing - due to abnormal clotting
ascites
caput medusae - engorged superficial epigastric veins
asterixis - flapping tremor
162
163
investigations for alcoholic liver disease
bloods:
- FBC - raised MCV
LFTs - raied ALT & AST, particularly raised gamma GT
ALP raised later in disease
low albumin
raised bilirubin in cirrhosis
clotting - raised prothrombin time due to reduced synthetic function of liver
U+Es deranged in hepatorenal syndrome
USS:
increased echogenicity - fatty changes early on
cirrhosis - fibroscan
endoscopy - oesophageal varices - portal HTN
CT & MRI
- fatty infiltration
hepatocellular carcinoma
hepatosplenomegaly
abnormal blood vessel changes
ascites
liver biopsy
- to confirm diagnosis of alcohol related hepatitis or cirrhosis
164
mangement for alcoholic liver disease
stop drinking permanently
detox regime
nutritional support with vitamins (thiamine)
steroids - improve short term outcomes
treat complications (portal HTN, varices, ascites, hepatic encephalopathy)
referral for liver transplant in severe disease - must abstain from alcohol for 3 months prior to referral
165
how many hrs after alcohol ceasation does delerium tremens present
24-72hrs
166
patient chronic alcoholic
caesed drinking 48hrs ago
presenting with acute confusion
severe agitation
delusions and hallucinations
tremor
tachycardia
HTN
hyperthermia
ataxia (difficulty coordinating movements)
arrhythmias
diagnosis and management
delerium tremens
management: benzodiazepine - chlordiazepoxide PO 5-7 days
IV high dose vitamin B (pabrinex) - followed by lower dose oral thiamine
167
what comes first Wernicke's encephalopathy or Korsakoffs syndrome
Wernicke's encephalopathy
168
chronic alcoholic recent caesation
confusion
oculomotor disturbances
ataxia
diagnosis
Wernicke's encephalopathy
given thiamine to prevent Korsakoffs syndrome
169
recent chronic alcohol caesation
memory impairment (retrograde and anterograde)
behavioural changes
diagnosis?
Korsakoffs syndrome - irreversible
full time institutional care
170
35y M
RUQ pain - past 24hrs
pruritis + fever
no weight loss
ongoing treatment of Hep B
compliant with meds
no alcohol
uses recreational drugs
jaundiced
needle track marks on arm
most likely diagnosis:
peptic ulcer
gallstones
hepatocellular carcinoma
hepatitis D superinfection
alcoholic liver disease
hepatitis D superinfection
differential for chronic hep B patients with acute flare up
risk factors IVDU
171
what other Hep virus does hepatitis D need to replicate
hep D needs hep B to replicate
172
how is hep B transmitted
exchange of bodily fluids
173
how is hep D transmitted
exchange of body fluids
174
175
how to diagnose hepatitis D
management
reverse polymerase chain reaction of hep D RNA
management: interferon
176
differentials for raised ALP + raised calcium
bone metastases
hyperparathyroidism
177
differentials for raised ALP + low calcium
osteomalacia
renal failure
178
17yr F
six wk hx nausea + abdo discomfort
Hb low
ALP raised
most likely diagnosis
pregnancy
ALP significantly raised in pregnancy
179
causes of dupuytren's contracture
thickening of palmar fascia in hand - most commonly to little and ring fingers
causes:
manual labour
phenytoin treatment
alcoholic liver disease
diabetes
trauma to hand
180
management for dupuytrens contracture
surgical treatment when metacarpophalangeal joints cannot be straightened and therefore hand cant be placed flat on table
181
43yr M
homeless
fever
yellow skin
for 1 wk
muscle and joint pains
mild abdo discomfort
IVDU - 2 yrs
drinks 15 units alcohol per week
visible needle track marks both arms
temp 38.2
mild hepatomegaly
LFTs raised (ALT)
hep B test:
HBsAg: +ve
anti -HBs: -ve
IgM anti-HBc: +ve
most likely diagnosis?
hep C infection
alcoholic liver disease
chronic hep B infection
previous hep B vaccination
acute hep B infection
acute hep B infection
HBsAg: surface antigen
= ongoing infection, acute infection (present 1-6months) or chronic if \>6months
causes production of anti-HBs: immunity (either exposure or immunisation)
-ve in chronic disease
anti-HBc: previous (or current) infection
anti-HB**c** = **c**aught ie negative if immunized
IgM anti-HBc: acute or recent hep B infection (present ~6mnths)
IgG anti-HBc persists
hbeAg: shows breakdown of core antigen from infected liver cells: marker of infectivity
HBsAg +ve
anti-HBs -ve
IgM anti-HBc +ve
= acute infection
IgM = acute infection
chronic infection = IgG anti-HBc +ve
anti-HBc +ve, HBsAg +ve: previous hep B, now a carrier
anti-HBs +ve, HBsAg -ve, anti-HBc -ve = previous vaccine
182
the 4 degrees of haemorrhoids
venous 'vascular cushions' enlarged due to increased pressure (eg. 2ndry to straining in constipation)
1st degree: no prolapse
2nd degree: prolapse when straining and return on relaxing
3rd degree: prolapse when straining, do not return on relaxing but can be pushed back
4th degree: prolapsed permanently
183
differentials for right red blood on toilet paper
haemorrhoids
anal fissure (tear or open sore (ulcer))
184
constipation
painless bright red bleeding on toilet paper
sore anus
feeling a lump around or in anus
diagnosis?
haemorrhoids
185
investigations and management for haemorrhoids
external haemorrhoids visible on inspection
internal haemorrhoids - proctoscopy
management:
- consider differentials (fissure, cancer, IBD)
- symptomatic: anusol cream, local anaesthetic (instillagel), topical steroids
- laxatives to treat constipation
- band ligation
- surgical haemorrhoidectomy
186
4 main causes of liver cirrhosis
alcoholic liver disease
non-alcoholic fatty liver disease
hepatitis B
hepatitis C
187
jundice
hepatosplenomegaly
palmar erythema
spider naevi
gynaecomastia
ascites
caput medusa
flapping tremor
diagnosis
liver cirrhosis
188
189
what screening test for hepatocellular carcinoma do you do for someone with liver cirrhosis
USS + alpha fetoprotein (tumor marker)
every 6 months
190
dignostic test for non-alcoholic fatty liver disease
enhanced liver fibrosis (ELF) blood test
\<7.7 = none to mild fibrosis
\>7.7 to 9.8 = moderate fibrosis
\>9.8 = severe fibrosis
191
USS:
nodularity of surface of liver
corkscrew appearance to arteries with increased flow
enlarged portal vein with reduced flow
ascites
splenomegaly
diagnosis
liver cirrhosis
192
when should a fibroscan be carried out of the liver
tests elasticity of liver - assesses degree of cirrhosis
restest every 2 yrs in patients at risk of cirrhosis:
- hep C
- heavy alcohol drinkers (men\>50 units or women\>35 units per week)
- diagnosed alcoholic liver disease
- non alcoholic fatty liver disease + evidence of fibrosis on ELF blood test
- chronic hep B (yrly)
193
what is the investigation for oesophageal varices
endoscopy when portal HTN is suspected
194
what is used to confirm the diagnosis of liver cirrhosis
what is the scoring system for cirrhosis
liver biopsy
child-pugh score for cirrhosis
bilirubin
albumin
INR
ascites
encephalopathy
scores from 5-15
MELD score - every 6 months in patients with compensated cirrhosis
percentage estimated 3 month mortality - guides referral for liver transplant
195
management for cirrhosis
**USS + alpha fetoprotein** - every **6 months** for **HCC**
**endoscopy every 3 yrs** in patients without known varices
**high protein, low sodium** diet
**MELD score** - every **6 months**
consideration of **liver transplant**
managing complications
196
how do varices form
liver cirrhosis causing increased resistance of blood flow in liver
--\> increased back pressure in portal system (portal HTN)
back pressure causes swollen veins (varices)
197
treatment of stable varices
**propanolol** - decreases portal HTN - beta blocker
**elastic band ligation of varices**
injection of sclerosant
**transjugular intra-hepatic portosystemic shunt** (sent from portal vein into hepatic vein without having to travel through liver)
198
management for bleeding varices
resus:
- vasopressin analogues (terlipressin) - vasoconstriction
- correct coagulopathy with vit K and fresh frozen plasma
- prophylactic broad spec abx
consider intubation and intesive care
urgent endoscopy
- injection of sclerosant into varices - inflammatory obliteration
- elastic band ligation
sengstaken-blakemore tube - inflatable tube inserted into oesophagus to tamponade the bleeding varices - used when endoscopy fails
**AT PEST**
**- ABCDE - vit K + fresh frozen plasma**
**- terlopressin**
**- prophylactic abx**
**- endoscopy**
**- sengastaken-blakemore tube**
**- Transjugular intrahepatic portosystemic shunt**
199
what is ascites
management for ascites caused by cirrhosis of the liver
ascites: fluid in peritoneal cavity
portal HTN causes leaking from capillaries in liver and bowel into peritoneal cavity
management:
- low sodium diet
- anti-aldosterone diuretics (spironolactone)
- paracentesis (ascitic tap/ drain)
- prophylactic abx (ciprofloxacin)
- consider TIPS
- consider liver transplantation
200
criteria for diagnosis of IBS
diagnosis of exclusion:
- normal FBC, ESR, CRP
- faecal calprotectin -ve to exclude IBD
- -ve coeliac disease serology (anti-TTG antibodies)
- cancer not suspected or excluded
201
symptoms of IBS
symptoms for \>6months
abdo pain/ discomfort:
- relieved on opening bowels or
- associated with change in bowel habit
AND 2 of:
- abnormal stool passage (urgency, straining, incomplete evacuation)
- bloating
- worse symptoms after eating
- PR mucus
can also have nausea, lethargy, backache, urinary symptoms
202
management of IBS
healthy diet and exercise
- **low FODMAP**
trial of **probiotic** supplements - 4 weeks
first line management:
- **loperamide** - for diarrhoea
- laxatives for constipation (avoid lactulose)
(linaclotide after 12months if other laxatives failed)
- **hyoscine butylbromide (Buscopan**) - antispasmodic for cramps
second line:
- amitriptyline (tricyclic antidepressant)
third line: SSRIs antidepressants
CBT
203
30yr F
abdo pain associated with alternating diarrhoea + constipation
which is least consistent with a diagnosis of irritable bowel
- feeling of incomplete stool evac
- waking at night due to pain
- abdo bloating
faecal urgency
passage of mucous with stool
waking at night due to pain
204
24 F
few wks hx diarrhoea, passing mucus, lethargy, abdo discomfort relieved by defaecation
blood tests: Na+: 138 (N)
K+ 4.0 (N)
urea: 4.5 (N)
cr: 80 (N)
Hb: 11 -low (115-160)
platelets: 320 (N)
WBC: 4.0 (N)
CRP: 1.0 (N)
TTG antibody: -ve
which one of the following would be most suitable for her:
- linaclotide
- codeine
- sertraline
- loperamide
- amitripyline
IBS
- relief on defaecation + normal bloods
loperamide for diarrhoea
205
24y M
9 month hx diarrhoea
investigations all normal
IBS
most appropriate management
loperamide
first line treatment of diarrhoea in IBS
206
35Y F
abdo pain associated with bloating for 6 months
which of the following symptoms is least associated with a diagnosis of IBS
- feeling of incomplete stool evacuation
weight loss
back pain
lethargy
nausea
207
48y M
known liver cirrhosis
A&E: malaise + abdo tenderness
jaundice
tender hepatomegaly
drinks heavily - ~ 35 units per week
Hb 135 (135-180)
platelets 140 (150-400)
neutrophils 23 (2-7)
bilirubin 46 (3-17)
ALP 120 (30-100)
ALT 342 (3-40)
albumin 34 (34-54)
suspect alcoholic hepatitis
most appropriate treatment for acute severe alcoholic hepatitis as determined by the Maddrey discriminant function
IV abx
liver transplant
prednisolone
chlordiazepoxide
prednisolone 40mg/day for 28 days
- corticosteroids used to manage severe alcoholic hepatitis
208
30yr unkempt F
no fixed abode
severe right upper quadrant pain
decreased consciousness levels
vomiting
confused and combative
thin
jaundiced
large bruises on arms and legs
needle track marks noted on anterior cubital fossa
abdo exam - tenderness in RUQ
RR: 22
O2 sats: 98% on air
HR: 112
BP: 103/98
temp: 37.8
GCS: 12
Hb: 102 (115-160)
MCV: 101 (82-100)
WBC: 12 (4-11)
INR:2.5 (\<1.1)
bilirubin: 89 (high)
ALT: 375 (high)
AST: 790 (extra high)
ALP: 170 (slightly high)
GGT 425 (high)
amylase 350 (slightly high)
diagnosis
alcoholic hepatitis
AST/ALT ration of 2:1 = alcoholic hepatitis
AST raised over ALT suggests cirrhosis
209
which one of the following is least useful in assessing severity of liver cirrhosis
ALT
prothrombin time
bilirubin
presence of ascites
presence of encephalopathy
ALT
bilirubin, albumin, PTT, encephalopathy, ascites: child-pugh classification
bilirubin, creat, INR: MELD score
210
65y M
liver cirrhosis of unknown cause
which one is the most likelt to indicate poor prognosis
ALT \>200
caput medusae
ascites
gynaecomastia
splenomegaly
ascites
in child-pugh classification
211
35yr
IVDU
diagnosed with Hep C after abnormal LFTs
assessed for liver cirrhosis
most appropriate test to perform
**transient elastography - fibroscan**
now investigation of choice to detect liver cirrhosis
all hep C patients assessed for liver cirrhosis
also endoscopy - to check for varices in new diagnosis of cirrhosis
USS + alpha fetoprotein - check for HCC
212
55y M
worsening tiredness
bruising
chronic liver disease 2ndry to chronic hep C
suspects cirrhosis
single lab finding that should prompt immediate consideration of liver cirrhosis and urgent review by hepatology :
- platelet count = 90 (150-400)
ASR= 80 ALT= 85
ALP=155
urea=11 (2-7)
Hb=85 (135-180)
thrombocytopenia (platelet count \<150)
most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease
AST/ALT raised \>2.5
urea: decrease expected
anaemia
213
67 M
chronic hep B
stable for past 10yrs
yelloowing of skin
confusion
which of the foloowing may cause this mans liver decompensation
- high carbohydrate diet
- low protein diet
- diarrhoea
- constipation
- high fibre diet
constipation
- trigger for liver decompensation in cirrhotic patients
due to accumulation of toxic products in body
other causes of liver decompensation:
- infection
- electrolyte imbalances
- dehydration
- upper GI bleeds
- increased alcohol intake
214
causes of hepatitis
alcohol hepatitis
non-alcoholic fatty liver disease
viral hepatitis
drug induced hepatitis
215
presentation of hepatitis
abdo pain
fatigue
pruritis (itching)
muscle and joint aches
nausea + vomiting
jaundice
fever (viral hepatitis)
high AST & ALT
less raised ALP
high bilirubin
216
which viral hepatitis are transmitted via **faecal oral route**
acute or chronic
treatment?
vaccine?
**A&E**
**acute**
hep A can cause cholestasis - dark urine, pale stools, hepatomegaly
**no treatment needed**
vaccine available for hep A not hep E
217
which viral hepatitis is a DNA virus
hep B
218
which hepatitis are spread by **blood and bodily fluids** and are therefore increase risk for **IVDU**
hep B, C, D
219
which other hepatitis does hep D need to survive
treatment?
hep B infection
attaches to HBsAg antigen
increases the complications and disease severity of hep B
no treatment
220
what are risk factors for hep B
sharing **needles** (IVDU or tattoos)
**sexual** intercourse
can be passed by vertical transmission from mother to child during **pregnancy**
221
222
what are the viral markers for hep B
HBsAg: surface antigen - active infection
HBeAg: E antigen - marker of viral replication - high infectivity
HBcAb: core antibodies - past or current infection
HBsAb: surface antibodies - vaccine, past or current infection
HBV DNA: hep B virus DNA - direct count of viral load
HBsAg +ve, everything else -ve: vaccination
HBsAg +ve, HBsAb +ve, IgM HBcAb +ve, HBeAg +ve (acute infection)
IgG HBcAb +ve: chronic
HBsAb +ve, HBcAb +ve, HBsAg -ve : past infection
223
management of hep B
routine **vaccination**
**screen** people at risk
screen for other blood born viruses (Hep C, HIV) + STDs
refer to gastro, hepatology, infectious diseases for specialist
**notify public health**
stop smoking and alcohol
education about reducing spread
testing for complications:
- **fibroscan** for cirrhosis
- **USS** for HCC
- **antivirals** - slow progression - **pegylated interferon**
- **liver transplant** for end stage liver disease
224
testing for hep C
hep C **antibody - screening** test
hep C **RNA testing - diagnostic**
225
management for hep C
screening at risk patients
screen for other blood born conditions
notify public health
stop smoking and alcohol
refer for specialist
education on reducing spread
**fibroscan** - cirrhosis
**USS** - HCC
direct acting **antivirals 8-12 wks - ribavirin**
**liver transplant** for end-stage liver disease
226
what are the two types of autoimmune hepatitis
type 1: in adults
type 2: in children
type 1:
usually women
late 40/50s
around or after menopause
can affect children aswell
both types can cause amenorrhoea
fatigue
features of liver disease on examination
autoantibodies (ANA, anti-actin (antismooth muscle antibody (SMA), anti-SLA/LP)
type 2:
teenage or early 20s
acute hepatitis with high AST, ALT + jaundice
IgG levels raised
autoantibodies (anti LKM1 and anti-LC1)
227
diagnosis and management of autoimmune hepatitis
diagnosis: liver biopsy - 'piecemeal necrosis'
treatment:
- high dose steroids (**prednisolone**)
+ **azathioprine** introduced later as pred weened off
228
25yr F
periods have stopped
copper coil
several -ve home pregnancy tests
RUQ pain + reduced appetite
hepatomegaly
yellow sclera
bilirubin: 25
ALP: 200
ALT:420
GGT:72
albumin:28
ANCA -ve
Antimitochondrial antibdosy -ve
ANA raised
anti-tripsin antibody raised
first line treatment
severe autoimmune hepatitis
type 1
first line: steroids
autoimmune hepatitis can often cause ammenorrhoea
229
26Y F
RUQ pain
yellow sclera
hepatomegaly
which of the following set of bloods would most support a diagnosis of autoimmune hepatitis?
```
ALT = 3 - 40 iu/l
AST = 3 - 30 iu/l
ALP = 30 - 100 iu/l
```
a) ALT & AST 250, ALP 120, antimitochrondial ab -ve
b) ALT & AST 250, ALP 600, antimitochrondial ab -ve
c) ALT & AST 55, ALP 600, antimitochrondial ab -ve
d) ALT & AST 55, ALP 600, antimitochrondial ab +ve
e) ALT & AST 250, ALP 600, antimitochrondial ab +ve
ALT & AST 250, ALP 120, antimitochrondial ab -ve
autoimmune hep more likely to show predominantly raised ALT/AST than ALP
antimitochrondial ab -ve in autoimmune hep
antimitochrondial ab +ve in primary biliary cirrhosis
230
22 M
abdo pain - 1day hx getting worse RUQ
fever + malaise over last wk
10 units a week
non smoker
no drugs
recently returned from travelling south east asia - hostels, eating street food
no vaccines - malaria prophylaxis
sexually active - long term female partner
jaundice
hepatomegaly
no splenomegalu or lymphadeonpathy
bloods, USS - no abnormalities
what is the treatment and prognosis
consuming undercooked meat/ unclean water in developing countries --\> risk factor for hepatitis A
hep E is usually pig meat related
symptoms for hep A 2-4 weeks after transmission
supportive treatment
no risk of hepatocellular carcinoma
231
who should be vaccinated for hep A
travellers - in high or intermediate prevalence aged\>1
chronic liver disease
haemophilia
men who have sex with men
IVDU
occupational risk: lab workers, large residential institutions, sewage workers, workers with primates
232
23yr F
10-week booking scan
well, at 9+4 weeks gestation
routine bloods including hep B virus serology
HBsAg +ve
Anti-HBsAg IgG -ve
Anti-HBsAg IgM -ve
anti-HBcAg IgG +ve
how would you describe her HBV status
current chronic HBV infection
HBsAg +ve : current infection
anti-HBcAg IgG +ve : caught the infection, IgG: chronic
233
weight loss
abdo pain
anorexia
nausea + vomiting
jaundice
pruritis
diagnosis
hepatocellular carcinoma
234
painless jaundice
weight loss
cholangiocardinoma
presents with painless jaundice (similar to pancreatic cancer)
235
what is a risk factor disease for cholangiocarcinoma
primary sclerosing cholangitis
236
investigations for liver cancer
alpha-fetoprotein: hepatocellular carcinoma
CA19-9: cholangiocarcinoma
USS to identify tumours
CT/MRI diagnosis and staging
ERCP for biopsies to diagnose cholangiocarcinoma
237
treatment for hepatocellular carcinoma
HCC very poor prognosis
**resection** in early disease
**liver transplant** when HCC is isolated
**kinase inhibitors** - inhibit proliferation of cancer cells: **sorafenib, regorafenib, lenvatinib** - extend life by months
**HCC resistant to chem and radiotherapy**
238
treatment of cholangiocarcinoma
poor prognosis
**srugical resection** early on
**ERCP - stent** to improve symptoms - draining bile
**resistant to chemo and radiotherapy**
239
what is a haemangioma
common benign tumour of liver
no symptoms
no potential for cancer
no treatment or monitoring needed
240
what is focal nodular hyperplasia
benign liver tumour of fibrotic tissue
asymptomatic
no malignant potential
related to oestrogen - more common in women and on oral contraceptive pill
no treatment or monitoring needed
241
upper abdo/back pain
painless obstructive jaundice
unintentional weight loss
pale stools
steatorrhoea (fatty stools)
dark urine
palpable mass in epigastric region
diagnosis?
pancreatic cancer
- most commonly adenocarcinoma of head of pancreas --\> obstruction of bile duct --\> obstructive jaundice picture
Courvoisier's law: painless jaundice + non-tender palpable gallbladder = pancreatic cancer until proven otherwise
242
diagnosis of pancreatic cancer
**CA19-9** tumour marker (blood test)
**CT** can for staging
**endoscopic USS with biopsy**
243
management of pancreatic cancer
**whipple's** procedure:
- for tumour head of pancreas with no spread
- **removes head of pancreas, gallbladder, duodenum, pylorus**
- modified whipples: leaving pylorus - same success rates
distal pancreatectomy for tumour of body/ tail of pancreas
adjuvant chemo
late disease management
- palliative chemo to extend life
- bile duct stent
244
what is a hiatus hernia
symptoms
treatment
**herniation of stomach** through diaphragm
normally diaphragm helps maintain narrow sphincter- stops acid refluxing
when this is widened due to heniation-\> **symptoms: reflux**
treatment: **reflux meds**
or surgical repain if high risk of complication or severe symptoms
245
types of hiatus hernia
type 1: sliding
- stomach slides up through diaphragm
type 2: rolling
- separate portion of stomach (e.g. fundus) enters through diaphragm
type 3: mixed
- bit of both happens
type 4:
large hernia allows other intraabdominal organs to pass through
246
diagnosis with hep markers
active acute infection
low infectivity - e antigen -ve + low titre of HBV DNA
247
248
diagnosis?
chronic infection
IgG present
high infectivit: HBeAg +ve
249
diagnosis?
previous hep B infection which has now cleared
has IgG anti-HBc +ve
anti-HBs +ve
250
has booster Hep B vaccination a few wks ago after needle stick injury
diagnosis
anti-HBs +ve
antigens remove after a few weeks
251
risk factors for Hep B
MSM
IVDU
haemodyalysis patients
blood transfusion recipients
sub saharan africa, asia, pacific islands
252
incubation period for hep B to show symptoms
2-3 months
can be up to 6 months
253
complications of hep B
carrier/ chronic state
cirrhosis
hepatocellular carcinoma
254
management of hep B
acute phase: supportive
notify HPA - manage contacts
chronic:
- treat infection: antivirals + interferons
- no alcohol
- lose weight
- regular LFTs
6 monthly USS liver + AFP testing
fibroscan
pregnancy: vaccination, HBIG
255
256
55yr M
acute confusion
jaundice
ascites
lifelong abstinance from alcohol
anti HCV +ve
everything else -ve
hepatitis C
257
hep C serology testing
258
management for hep C
vaccinate for hep A and B
notify HPA
referral
contacts
smoking and alcohol cessation
acute:
- regular monitoring for clearance
- interferon
chronic:
- regular blood testing: viral load, clotting studies
liver USS
fibroscan
antivirals + interferon
259
30yr F
anti- vax person
reduced appetite
nausea
jaundiced
dark urine
just came back from nepal - drinking from wells
no IVDU, no sexual activity
diagnosis
hep A
- most common form of acute viral hepatitis
260
testing for hep A
IgM anti-HAV
261
management for hep A
supportive
avoid alcohol
pregnancy: risk of miscarriage
262
which hepatitis has ~75% conversion rate to chronic hep
hep C
263
what other viruses can cause hepatitis except A-E
CMV
EBV
adenovirus
HSV
264
which animal carries hep E
pigs
faeco-oral route
265
Q fever is a parasitic infection that can cause hepatitis
which microoganism is responsible
coxiella burnetii
Q fever: fever symptoms - look for coxiella burnetii when they cant find another cause
266
19yr F
sore throat
swollen glands on neck - tender
jaundice
diagnosis
Ix
**EBV**
- causing **glandular fever**/also called infectious mononucleosis
Ix: monospot test
267
gastric carcinoma which bacteria
heicobacter pylori
268
female, middle aged
episodic RUQ pain
diagnosis?
biliary colic
fat fair female fertile
269
65yr F
jaundice
weight loss
passing clay coloured stools
recurrent bouts of colicky RUQ pain
mass palpable in RUQ
diagnosis?
cholangiocarcinoma
pale stools + jaundice points to post hepatic
weight loss suggests cancer
biliary colic symptoms associated with anorexia, jaundice, weight loss
palpable mass: Couvoisier sign
periumbilical lymphadenopathy
270
fever
RUQ pain
jaundice
diagnosis
ascending cholangitis
triad of:
jaundice
RUQ pain
fever
271
murphys sign +ve
fever
RUQ pain
diagnosis
cholecystitis
dont have the triad
272
hx gallstones
abdo pain
distension
vomiting
gallstone ileus
small bowel obstruction 2ndry to impacted gallstone
273
painless jaundice
diagnosis
pancreatic cancer until proven otherwise
274
65y M
hx chronic hep B infection
symptoms of liver cirrhosis
alpha-fetoprotein elevated
diagnosis?
hepatocellular carcinoma
275
which IBD is gallstones linked with
chrons disease
276
which IBD has loss of goblet cells
ulcerative colitis
277
primary sclerosing cholangitis is associated with which IBD
Ulcerative colitis
4% of patients with UC have PSC
80% of patients with PSC have UC
278
279
ix for primary sclerosing cholangitis
ERCP or MRCP
beaded appearance
pANCA may be positive
280
complication of primary sclerosing cholangitis
cholangiocarcinoma (10%)
increased risk of colorectal cancer
281
duodenal vs gastric ulcer presentation
duodenal ulcer:
- epigastric pain relivied by eating
gastric ulcer:
- epigastric pain made worse by eating
both:
- hx of NSAID use and alcohol
- features of upper gastrointestinal haemorrhage (haematemesis, malaena)
282
30yr
foul smelling oily diarrhoea
abdo bloating
fatigue
weight loss
papulovesicular lesions on extensor aspects of arms
diagnosis?
coeliac disease
283
20yrs
bloody diarrhoea
urgency
tenesmus
abdo pain (left lower quadrant)
diagnosis
Ulcerative colitis
284
IBS features
IBS considered with features for at least 6 months:
- abdo pain
- bloating
- change in bowel habit
positive diagnosis IBS:
- abdo pain relieved by defecation
- associated with altered bowel frequency or form
+ any two of:
- altered stool passage (straining, urgency, incomplete evacuation)
- abdo bloating
- symptoms made worse by eating
- passage of mucus
285
which liver disease is diabetes associated with
non-alcoholic fatty liver disease
286
Ix and Mx for non-alcoholic fatty liver disease
Ix:
ELF (enhanced liver fibrosis) blood test to check for advanced fibrosis
Mx:
lifestyle changes - weight loss
287
type 2 diabetes
mild hepatomegaly
drinks one glass of wine per week
slightly raised ALT
liver USS: echogenicity
diagnosis
alcoholic fatty liver disease
288
kayser fleischer rings
renal tubular acidosis
liver disease
diagnosis
Wilsons disease
copper deopsition
mutation in chromosome 13
kayser fleischer rings
renal tubular acidosis
289
most likely consequence of vitamin B1 deficiency
peripheral neuropathy
B1 : thiamine
can be caused by alcohol withdrawal
290
what type of ABG do you get from vomiting
metabolic alkalosis
291
patients with which conditions should be screened for coeliac disease
autoimmune thyroid disease
type 1 diabetes
screen for coeliac disease
292
complications of coeliac disease
small bowel T cell lymphoma
anaemia: iron, folate, vit B12 deficiency
lactose intolerance
293
HBsAg negative, anti-HBs positive, IgG anti-HBc negative
previous immunisation
294
watery diarrhoea after pneumonia
new marked neutrophilia
which bacteria
clostridium difficile
Features:
diarrhoea
abdominal pain
a raised white blood cell count (WCC) is characteristic
295
mx of Clostridium difficile
first line: oral metronidazole 10-14days
if severe or not responding: oral vancomycin
296
risk factor drugs for Clostridium difficile infection
clindamycin
PPI
297
298
metabolic ketoacidosis with normal or low glucose
alcohol
299
ascites: high SAAG gradient (\>11)
portal HTN
300
haemochromatosis
fatigue, erectile dysfunction, arthralgia
bronze skin pigmentation
cardiomyopathy
liver cirrhosis
diabetes mellitus
301
primary biliary cholangitis which antibodies
anti-mitochondrial antibodies (AMA) in 98%
302
coeliac disease antibody
TTG antibodies (IgA) first choice (anti-tissue transglutaminase antibody)
303
mesenteric ischaemia features
central abdo pain
AF other cardiovascular disease
diarrhoea, rectal bleeding
metabolic acidosis (due to dying tissue causing increase in lactic acid)
304
odynophagia + HIV
oesophageal candidiasis
305
complications of coeliac disease
anaemia: iron, folate, vit B12 deficiency
hyosplenism
osteoporosis, osteomalacia
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility
oesophageal cancer
306
strong FHx of colorectal and endometrial cancer
HNPCC (hereditary non-polyposis colorectal carcinoma)
307
symptoms of B1 (thiamine) deficiency
Wernicke's encephalopathy: nystagmus, ophthalmoplegia, ataxia
Korsakoff's syndrome: amnesia, confabulation
dry beriberi: peripheral neuropathy
wet beriberi: dilated cardiomyopathy
308
middle aged female
fatigue
pruritis
raised IgM
primary biliary cirrhosis
309
causes of metabolic alkalosis
vomiting/ aspiration
diuretics
hypokalaemia
cushings syndrome
primary hyperaldosteronism
Bartter's syndrome
310
causes of normal anion gap metabolic acidosis
diarrhoea
addisons disease
renal tubular acidosis
311
variceal haemorrhage Mx
ABC: resus prior to endoscopy
correct clotting: FFP, vit K
vasoactive agents: terlipressin
prophylactic IV abx in patients with liver cirrhosis
endoscopy - band ligation
Sengstaken-Blakemore tube if uncontrolled haemorrhage
transjugular intrahepatic portosystemic shunt (TIPSS) if above fail
312
prophylaxis of variceal haemorrhage
**propanolol**
variceal band ligation - performed at two-weekly intervals until all varices have gone
PPI prevent ulceration
313
314
315
316
317
best investigation to characterise course of anal fistula
pelvic MRI
318
gastric tubes aspirate under what pH are safe to use
aspirate pH \<5.5 = safe to use
over 5.5 = CXR
319
what surgical incision for open cholecystectomy
Kocher's
incision under right subcostal margin
320
surgical incision for appendectomy
Lanz
321
surgical incision for c-section
pfannenstiel's
322
surgical abdominal incisions
323
what do patients with GORD being considered for fundoplication surgery require
oesophageal PH
manometry studies (measures pressure within lower oesophageal sphincter and helps confirm diagnosis of GORD)
324
small bowel bacterial overgrowth syndrome mx
rifaximin
325
ix for small bowel bacterial overgrowth syndrome
hydrogen breath test
326
risk factors and features of small bowel bacterial overgrowth syndrome
risk factors:
- neonates with congenital gastro abnormalities
- scleroderma
- diabetes mellitus
features:
- chronic diarrhoea
- bloating, flatulence
- abdo pain
327
what do you need to monitor in patients with ileostomy
monitor fluid balance and stoma output - at risk of volume depletion, electrolyte and metabolic acidosis if the ieostomy ouptut increase of dietary intake is disrupted
328
most common causative agent for ascending cholangitis
E.coli
followed by Klebsiella
329
alcoholic ketoacidosis mx
IV saline 0.9% + thiamine (B1)
330
raised anion gap metabolic acidosis
raised serum ketones
normal/ low blood glucose
alcoholic ketoacidosis
occurs in chronic alcoholics following an episode of reduced intake of food
331
mx for severe flare of UC
treated in hopsital with IV corticosteroids
332
mx of anal fissure \<6 wks
anal fissure = tear
first line: bulk forming laxatives
high-fibre diet
lubricants
topical aneasthetics
analgesia
333
mx of chronic anal fissure (\>6 wks)
first line = GTN
if not effective after 8 wks then sphincterotomy (surgery) or botulinum toxin
334
surgical mx for achalasia
heller cardiomyotomy
other treatments:
- intra sphincteric injection of botulinum toxin
pneumatic (balloon) dilation
335
test to ensure there are no leaks in colorectal anastomosis
gastrografin enema
336
mild to moderate flare of UC extending past the left-sided colon mx
rectal + oral mesalazine
337
mx for acute episodes or alcoholic hepatitis
glucocorticoids (e.g. prednisolone)
Maddrey's discriminant function - to determine who benefits from glucocorticoids
calculated using prothrombin time (PT) and bilirubin
338
mx to maintain remission for severe relapse or \>=2 exacerbations in past year
oral azathioprine or oral mercaptopurine
339
epigastric pain + diarrhoea + gastroduodenal ulcers
Zollinger-Ellison syndrome
associated with multiple endocrine neoplasia type 1 (mainly associated with hyperparathyroidism)
340
flushing
diarrhoea
bronchospasm
hypotension
weight loss
carcinoid syndrome - mets in liver and release serotonin
341
ix for carcinoid tumours
urinary 5-HIAA
342
dysplasia on biopsy in Barrett's oesophagus
further treatment?
requires endoscopic intervention
- endoscopic mucosal resection
- radiofrequency ablation
343
mx for Barrets oesophagus
high dose proton pump inhibitor
endoscopic surveillance with biopsies:
- for patients with metaplasia (but not dysplasia) - endoscopy recommended every 3-5 yrs
endoscopic intervention for dysplasia
344
diagnosis?
barrets oesophagus
345
which conditions on diagnosis should be screened for coeliac disease
type 1 diabetes
autoimmune thyroid disease
346
pancreatic pseudocyst
peripancreatic fluid collection
typically occurs \>4wks after acute pancreatitis
mildly raised amylase
manage conservatively initially
347
why is epidural analgesia better after abdo surgery
faster return of normal bowel function after abdo surgery
348
histology:
villous atrophy, raised intra-epithelial lymphocytes and crypt hyperplasia
349
charcot's triad + hypotension + confusion
Reynold's pentad
350
AST:ALT ratio in alcoholic hepatitis
2:1
351
mild - moderate flare of distal UC first line mx
topical (rectal) amiosalicylates (mesalazine)
352
primary biliary cholangitis - the M rule
the M rule:
- IgM
anti-Mitochondrial antibodies (AMA), M2 subtype - found in 98%
Middle aged females
features:
- hx lethargy + pruritis
LFTS: ALP and GGT raised
353
itching in middle aged females
primary biliary cholangitis
354
most common extra-colonic malignancy of HNPCC
endometrial cancer
355
what other tumour is FAP at risk of
duodenal tumour
also Gardner's syndrome - osteomas of skull, mandible, rentinal pigmentation, thyroid carcinoma, epidermoid cysts
356
triad of:
encephalopathy
jaundice
coagulopathy
acute liver failure
jaundice
coagulopathy: raised prothrombin time
encephalopathy
renal failure is commone (hepatorenal syndrome)
357
what type of cancer do you get with Barrets oesophagus
adenocarcinoma of the oesophagus
358
mx of hepatorenal syndrome
vasopressin (terlipressin)
359
severity index for UC
Truelove witts severity index
360
atraumatic bilateral flank bruising
grey turners sign
acute pancreatitis
361
mx for primary biliary cholangitis
first line: Ursodeoxycholic acid
362
ix for primary sclerosing cholangitis
MRCP/ERCP
363
types of oesophageal cancer
adenocarcinoma:
- most common type in US/UK
- associated with GORD, barrett's oesophagus
- smoking, achalasia, obesity
- lower third of oesophagus near junction
squamous cell cancer
- more common in developing world
- upper two-thirds of oesophagus
- smoking, alcohol, plummer-vinson, achalasia, diets rich in nitrosamines
364
ix and mx of oesophageal cancer
ix: upper GI endoscopy
mx: resectable: surgerical resection - Ivor-Lewis oesophagectomy
365
most important viral infection in solif organ transplant recipients
cytomegalovirus
mx: ganciclovir
366
scoring system to measure severity of an upper GI bleed
Blatchford score
367
ix and mx for wilsons disease
ix: serum caeruloplasmin
mx: penicillamine
368
recently treated for pyelonephritis
now loose stools
diagnosis
mx
pseudomembranous colitis
from C.diff infection
usually occurs after being treated with abx
mx: oral metronidazole
