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EXAM 2 > Gastro 9.5 > Flashcards

Gastro 9.5 Flashcards

1
Q

Hydatid cysts - tapeworm parasite Echinococcus granulosis - outer fibrous capsule formed containing multiple small daughter cysts

  • what type of reaction?
  • clinical features?
  • Ix?
  • Rx?
A
  • cysts are allergens -> type 1 hypersensitivity reaction
  • 90% in liver & lungs, Sx if >5cm
  • morbidity: cyst bursting, infection, organ dysfunction & anaphylaxis
  • if rupture: biliary colic, jaundice, urticaria
  • CT to differentiate hydatid vs amoebic vs pyogenic
  • Surgery ( do not rupture cyst wall, sterilise contents first)
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2
Q

Causes of acute pancreatitis

A

Gallstones
ETOH
Trauma
Steroids
Mumps, coxsackie B
Autoimmune (IgG4) eg PAN, Ascaris infection
Scorpion venom
Hypertriglyceridaemia, hyperchlyomicronaemia, hypercalcaemia, hypothermia
ERCP
Drugs: azathioprine, mesalazine, furosemide, bendroflumethiazide, valproate, pentamidine

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3
Q

Achalasia = failure of LOS to relax & oesophageal peristalsis due to degenerative loss of ganglia from Auerbach’s plexus -> LOS contracts, oesophagus above dilates. Middle-age
Features?
Ix?
Rx?

A
  • dysphagia solids & liquids, variation in severity, heartburn, regurgitation, malignant change in small number
  • Dx = manometry: XS LOS tone doesn’t relax on swallow
  • also barium swallow: fluid level, birds beak, corkscrew; CXR: wide mediastinum, fluid level
  • Rx = intra-sphincteric injection of botulinum, Heller cardiomyotomy, balloon dilation
  • Drugs to help lower oesophageal pressure = calcium channel blockers, nitrates
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4
Q

Max dose of 1% lidocaine for a 66kg person?
Lidocaine = rapid onset of action, anaesthesia lasts 1h
- what is the max safe dose?
- and if mixed with adrenaline?

A

20ml of 1% or 10ml 2% lidocaine solution

  • 3mg/kg
  • adrenaline increases duration of action and reduces blood loss 2ry to vasoconstriction - NEVER use near extremities (ischaemia)
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5
Q

What are the absorbable sutures? When do they disappear?

A

PDS
Dexon
Vicryl
- usually disappear after 7-10days

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6
Q

What are the non-absorbable sutures? when are the usually removed?

A 
Silk
Novafil
Prolene
Ethilon
- usually 7-14days
face 3-5
scalp, limbs, chest 7-10
hand, foot, back 10-14
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7
Q

3 types of colon cancer?

A

sporadic 95%
- series of genetic mutations; >50% show allelic loss of APC gene
- others inc activation of K-ras oncogene, p52 deletion & DCC tumour suppressor genes -> invasive car
HNPCC 5%
FAP <1%

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8
Q

HNPCC 5% of bowel ca
= auto Dom, poorly diff, highly aggressive
- 7 mutations - genetics?
- amsterdam criteria?

A
  • affect genes involved in DNA mismatch repair -> micro satellite instability
  • MSH2 60%; MLH1 30%
  • higher risk of other cancers e.g. endometrial
  • at least 3 family members with colon ca
  • cases span 2+ generations
  • at least 1 case Dx before age 50
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9
Q

FAP = A. dom bowel ca <1%

  • hundreds of polyps by age 30-40 -> carcinoma
  • genetics?
  • Gardners syndrome?
A
  • APC tumour supp gene mutation on chr 5
  • analyse DNA from WBCs
  • total colectomy with ileo-anal pitch in their 20s
  • at risk of duodenal tumours

Gardners = FAP + osteomas of skull & mandible, retinal pigmentation, thyroid ca, epidermoid cysts of skin

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10
Q 
PBC = autoimmune damage to interlobular bile ducts due to chronic inflamm -> progressive cholestasis with may progress to cirrhosis - itching in middle aged F
Ass?
Dx?
Rx?
Complications?
A
  • Sjogrens 80%, RA, systemic sclerosis, thyroid disease
  • AMA M2 subtype 98%, smooth m Ab 30%, raised serum IgM
  • cholestyramine for itch, fat-soluble vitamins, ursodeoxycholic acid, liver Tx if Bili >100 (graft recurrence can occur but not usually a problem)
  • cirrhosis
  • osteomalacia & osteoporosis
  • significantly inc risk of HCC
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11
Q

Budd-Chiari = hepatic vein thrombosis
Features?
Causes?
Ix?

A
  1. sudden onset severe abdo pain
  2. ascites
  3. tender hepatomegaly
  • procoagulant: PRV, OCP, pregnancy, thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C&S deficiencies

Ix = Doppler flow studies

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12
Q

Carcinoid syndrome usually occurs when mets in the liver release serotonin into systemic circulation
- may also occur with lung carcinomas as mediators aren’t ‘cleared’ by the liver
Features?
Ix?
Rx?

A
  • flushing earliest, diarrhoea, bronchospasm, hypotension, right heart valvular stenosis (left can be affected in bronchial carcinoid)
  • ACTH & GHRH eg Cushings
  • pellagra rarely (dietary tryptophan -> serotonin)

Ix: urinary 5-HIAA, plasma chromogranin A y

Rx = somatostatin analogues eg octreotide, cyproheptadine may help diarrhoea

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13
Q

Flushing earliest, diarrhoea, bronchospasm, hypotension, right heart valvular stenosis
Dx?

A

carcinoid syndrome

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14
Q

Long Hx of diarrhoea with signs consistent of tricuspid regurgitation

  • Dx?
  • path findings of heart disease?
A

Carcinoid syndrome = paraneoplastic syndrome caused by endogenous secretion of serotonin

  • endocardial plaques of fibrous tissue that may involve: tricuspid, pulmonary, cardiac chambers, venue cave, PA & coronary sinus
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15
Q

Resuscitation in upper GI bleed?

A

ABCDE

  • platelets if <50
  • FFP if fibrinogen <1 or PT/APTT >1.5
  • PCC if bleeding on warfarin
  • OGD immediately if severe, otherwise within 24h
  • PPIs AFTER OGD if non-variceal with bleed on ogd
  • repeat OGD, IR/surgery if further bleed
  • Pre-OGD consider terlipressin & proph Abx
  • band ligation for oesophageal varices
  • N-butyl-2-cyanoacrylate injections if gastric varices
  • TIPS if varical bleeding not controlled
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16
Q

Chronic pancreatitis affects exocrine & endocrine function

  • causes?
  • features?
  • Ix?
  • Rx?
A
  • 80% ETOH, 20% unexplained
  • genetic = CF, haemochromatosis
  • ductal obstruction: tumours, stones, structural abnormalities inc pancreas divisum & annular pancreas
  • pain worse after meal, steatorrhoea, diabetes
  • AXR: pan calcification
  • CT 85% spec 80% sens
  • faecal elastase can assess exocrine function

Rx = enzymes, analgesia, antioxidants

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17
Q

Aspirin in pts following upper GI bleed in whom haemostasis has been achieved?

A

Continue aspirin when it is being used for 2ry prevention of vascular events

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18
Q

Coeliac disease: gluten enteropathy leading to villous atrophy -> malabsorption
- dermatitis herpetiformis, T1DM, AIhepatitis
Dx?
Ix?

A

Dx = immunology & jejunal Bx

  • villous atrophy & immunology normally reverses on a gluten-free diet
  • anti-TTG 1st choice most specific
  • anti-endomyseal (but it is IgA)
  • anti-gliadin (IgA/IgG) NOT recommended by NICE
  • anti-casein found in some

Duodenal Bx: subtotal villous atrophy, crypt hyperplasia, increase in intraepithelial lymphocytes, lamina propria infiltration with lymphocytes

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19
Q

Gilbert’s syndrome: autosomal rec of defective bilirubin conjugation due to deficiency of UDP glucuronosyltransferase in 1-2%
features?
Ix?

A
  • unconjugated hyperbilirubinaemia (not in urine)
  • jaundice in response to phys stress eg exercise, illness, fasting
  • Rise in bilirubin following prolonged fasting or IV nicotinic acid
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20
Q

33F 4 days increasing lethargy, reduced exercise tolerance, dark urine.
PMH: UC, started sulfasalazine recently for a flare, had been well controlled with no immunosuppressants
O/e conjunctival pallor, abdo DNT, resp/cardio/neuro normal except for a mild systolic murmur & sinus tachycardia. Rectal exam empty, no oral ulcers
Hb 89
MCV 85
Plts 356
WCC 12.1
CRP 30
LDH 2400
Blood film: Heinz bodies, reticulocytsosis
Most appropriate immediate Rx?

A

Stop Sulfasalazine

  • Heinz bodies = small inclusion bodies in RBCs due to oxidative damage to Hb
  • sulfasalazine, dapsone, ribavirin & paraquat ingestion poisoning leads to oxidation of Fe2+ to Fe3+, forming metHb
  • when overwhelmed, RBCs undergo oxidative damage & cell death -> haemolysis -> raised LDH++
  • metHb is converted to hemichromes & eventually precipitated to Heinz bodies

Rx of oxidative haemolytic anaemia = stop offending drug, bloods should normalise within weeks
(transfusion prior to stopping drug would result in further haemolysis)

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21
Q

Wilsons disease = A recessive XS copper deposition in tissues -> increased copper absorption from small bowel & decreased hepatic copper excretion into bile
- defect in ATP7B gene on chr 13
- onset of Sx between 10-25yrs
- children: liver disease; young adults: neuro disease
Features?
Dx?
Rx?

A
  • hepatitis, cirrhosis
  • basal ganglia degeneration, speech, behavioural & psych problems, anxiety, chorea, dementia
  • cornea: Kayser-Fleischer rings
  • blue nails, haemolysis
  • kidneys: RTA type 2
    , Fanconi: aminoaciduria, glycosuria, phosphaturia
  • reduced serum caeruloplasmin, reduced serum copper, increased 24h urinary copper excretion
  • Rx = Penicillamine (chelates copper) or TRIENTINE hydrochloride eg if penicillin allergy
  • tetrathiomolybdate under Ix
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22
Q

Extra-intestinal manifestations of IBD related to disease activity?

A

arthritis: pauciarticular
erythema nodosum
episcleritis (CD)
osteoporosis

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23
Q

Extra-intestinal manifestations of IBD unrelated to disease activity?

A 
arthritis: symmetric, polyarticular
uveitis (UC)
pyoderma gangrenosum
clubbing
PSC (UC)
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24
Q

Pathology in UC?

Barium enema in UC?

A
  • raw red mucosa that bleeds easily, no inflammation beyond submucosa unless fulminant
  • widespread ulceration with preservation of adjacent mucosa (pseudo polyps)
  • inflammatory cell infiltrate in lamina propria
  • neutrophils migrate through walls of glands to form crypt abscesses
  • goblet cell depletion & mucin from gland epithelium

Barium enema: loss of haustra, superficial ulcers/pseudopolyps, long standing disease: drainpipe short & narrow colon

Nb pts more likely to be pANCA +ve

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25
Q 
Hepatic encephalopathy: XS ammonia &amp; glutamine absorption from bacterial breakdown of proteins in gut
features?
grading?
precipitating factors?
Rx?
A 
- confusion, asterix (arrhythmic negative myoclonus 3-5Hz), constructional apraxia, triphasic slow waves on EEG, raised ammonia level
I irritable
II confusion, inappropriate
III incoherent, restless
IV coma
  • infection eg SBP, GI bleed, post-TIPS, constipation, sedatives/diuretics, hypokalaemia, renal failure, increased dietary protein(uncommon)
  • Rx the cause
  • 1st = regular Lactulose: aim for 3 stools/day and continue for prevention of recurrent episodes
  • +/- Rifaximin for 2ry prophylaxis: add-on for prevention of recurrent episodes after the 2nd episode
  • lactulose: promotes ammonia excretion & increases metabolism of ammonia by gut bacteria; Rifaximin modulates gut flora -> decreased ammonia production
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26
Q

RUQ pain & malaena & jaundice after liver Bx
Dx?
how?

A

Haemobilia

  • bleeding into biliary tree following connection between splanchnic circulation & intra/extrahepatic biliary system
  • eg Bx needle hit splanchnic vein
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27
Q

3rd trimester itching & jaundice?

Rx?

A

Intrahepatic cholestasis of pregnancy

  • ursodeoxycholic acid for Sx relief, weekly LFTs, induction at 37/40
  • inc rate of stillbirth
  • there can be a prolonged PT & inc tendency to bleed
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28
Q

3rd trimester/immediate post-partum abdo pain, nausea/vomit, headache, jaundice, hypoglycaemia?

A

Acute fatty liver of pregnancy

  • ALT >500
  • if severe -> pre-eclampsia
  • supportive care, delivery is definitive once stabilised
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29
Q

Causes of ascites with SAAG >11g/L

A 
cirrhosis
ETOH hepatitis
cardiac
mixed
massive liver mets
fulminant hepatic failure
Budd-Chiari
portal vein thrombosis
vena-occlusive disease
myxoedema
fatty liver pregnancy
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30
Q

Causes of ascites with SAAG <11g/L

A 
peritoneal carcinomatosis
TB peritonitis
pancreatic ascites
bowel obstruction
biliary ascites
post-op lymphatic leak
serositis in CT diseases
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31
Q

Rx of ascites?

A
  • reduce dietary sodium
  • fluid restrict if na <125
  • AA eg spironolactone
  • drain if tense (therapeutic abdo paracentesis)
  • proph Abx to reduce risk of SBP: Ciprofloxacin/norfloxacin if ascitic protein 15 or less, until ascites has resolved
  • consider TIPS in some

Nb paracentesis is not C/I in pts with abnormal clotting - most will have prolonged PT & some thrombocytopenia - but e.g. if severe thrombocytopenia, most would give platelets etc

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32
Q

Paracentesis induced circulatory dysfunction (PICD) - 2ry to fluid shifting after large volumes (>5L) paracentesis -> decreased circulating volume & renal dysfunction
Dx?
Prevention?

A
  • increase of >50% of baseline plasma renin activity to >4ng/ml/h on day 5-6 post paracentesis
  • limit volume of fluid removed to 5-6L at a time
  • give albumin as a plasma expander if >5L ascitic fluid removed
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33
Q

Crohns disease: INDUCING remission:

  • 1st line
  • 2nd line
  • Add on Rx
  • if refractory/fistulating
  • if isolated peri-anal disease
A
  • 1st glucocorticoids (or budesonide)
  • 2nd 5-ASA eg Mesalazine if steroids not effective
  • Add-on Rx e.g. Azathioprine/Mercaptopurine/MTX (not monoRx)
  • Infliximab if refractory/fistulating (& cont Azathioprine/mesalazine)
  • Metronidazole if isolated peri-anal disease
  • enteral feed with elemental diet can help
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34
Q

Crohns disease: MAINTAINING remission?

A
  • stop smoking
  • 1st Azathioprine/Mercaptopurine
  • 2nd MTX
  • consider 5-ASA e.g. mesalazine if pt has had previous surgery
  • 80% eventually have surgery
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35
Q

Refeeding syndrome: metabolic abnormalities when feeding someone after a period of starvation - when extended period of catabolism ends abruptly with switching to carb metabolism
What are the metabolic consequences?
Who are considered high risk?

A
  • low phosphate
  • low K
  • low Mg (torsades)
  • abnormal fluid balance
  • > organ failure

1+ of:

  • BMI<16
  • unintentional weight loss >15% over 3-6months
  • little nutritional intake >10 days
  • low K, phosphate, Mg before feeing

2+ of:

  • BMI<18.5
  • unintentional weight loss >10% over 3-6months
  • little nutritional intake >5days
  • Hx of ETOH abuse, drug Rx in insulin, chemo, diuretics, antacids

Nb:
if a pt hasn’t eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days

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36
Q 
Haemochromatosis: auto rec of iron absorption &amp; metabolism -> ion accumulation - caused by inheritance of HFE gene on both copies of chr 6
- genetic testing of family members
- transferrin sat to screen general pop
Dx tests?
typical iron study profile?
Rx?
A
  • molecular genetic testing: C282Y & H63D mutations
  • liver B: Perl’s stain
  • transferrin sat >55% men or >50% women
  • raised ferritin >500 & iron
  • low TIBC

Venesection is 1st line - transferrin sat should be kept <50% and ferritin <50

  • indicated in all with ferritin >1000
  • typical initial regime is 400-500mls every 1-2weeks, then every 2-4months when levels fall to 50-100
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37
Q

Microscopic colitis = chronic inflammatory condition of gut - as common as classic IBD but different
Dx middle-age F>M
RFs?
Features?

A

RFs = smoking & drugs: NSAIDs, PPIs, SSRIs

  • watery diarrhoea
  • faecal urgency & incontinence
  • abdominal pain
  • constitutional Sx
  • non-specific findings inc mild anaemia, raised inflame markers, autoAb e.g. RF & ANA
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38
Q

Bile acid malabsorption

  • 1ry XS production
  • 2ry reduced absorption: ill disease e.g. Crohns, cholecystectomy, coeliac disease, small bowel bacterial overgrowth
  • steatorrhoea, vit A, D, E, K malabsorption

Ix?
Rx?

A

SeHCAT = Ix of choice

  • nuclear medicine
  • scans 7 days apart to assess retention/loss of radio labelled SeHCAT

Rx with bile acid sequestrates e.g. cholestyramine

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39
Q

Target HbA1c in chronic pancreatitis 2ry to resection?

A
  • both alpha & beta cells removed in pancreatectomy
  • reducing intensity of any counter regulatory response to hypoglycaemia
  • impacts on prospects of recovery & increases severity of individual events
  • so more lax HbA1c target instigated
  • eg HbA1c 53
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40
Q

What drug enhances the effects and increases the toxicity of azathioprine?

A

Allopurinol

- reduce dose of Azathioprine to 1/4 but significant & v specialist

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41
Q

Gastric cancer

  • histology?
  • Ass?
  • features?
  • Ix?
  • intestinal metaplasia -> dysplasia -> cancer
  • TNM staging, risk of LN involvement is related to size & depth of invasion; early cancers confined to submucosa have a 20% incidence of LN metastasis
A
  • signet ring cells: large vacuole of mucin which displaces nucleus to one side, higher numbers = worse prognosis
  • H. pylori, blood group A, gastric adenomatous polyps, pernicious anaemia, smoking, diet
  • dyspepsia, nausea & vomiting, anorexia & weight loss, dysphagia
Dx = endoscopy &amp; Bx
staging = CT or endoscopic US (eUS superior to CT)
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42
Q

Gastric ca tumours of GOJ classification?

A

type 1 - true oesophageal cancers, may be ass with Barretts
type 2 - carcinoma of cardia, arising from cardiac type epithelium or short segments with intestinal metaplasia at the OGJ
type 3 - subcardial cancers that spread across the junction, involve similar nodal stations to gastric ca

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43
Q

Staging & Rx of gastric ca?

A
  • CT CAP routine 1st line
  • laparoscopy to identify occult peritoneal disease
  • PET CT esp for junctional tumours
  • Subtotal gastrectomy for proximally sited disease 5-10cm from OGJ
  • Total gastrectomy if tumour <5cm from OGJ
  • Oesophagogastrectomy for type 2 junctional tumours extending into oesophagus
  • Endoscopic submucosal resection in early gastric cancer confined to mucosa/submucosa
  • Lymphadenectomy/D2 nodal dissection
  • Most receive chemo pre/post op
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44
Q

Colorectal ca in UC

  • lesions can be multifocal
  • factors that increase risk?
  • colonoscopy surveillance?
A
  • disease duration >10years, pts with punctilios, onset before 15yrs old, unremitting disease, poor compliance to Rx

Low risk = 5yr colonoscopy

  • extensive colitis with no active endoscopic/histological inflammation
  • or left-sided colitis
  • or Crohns colitis <50% of colon

Intermediate = 3yr colonoscopy

  • extensive colitis with mild active inflammation
  • or post-inflammatory polyps
  • or FHx colorectal ca in 1st degree relative aged 50+

Higher risk = annual colonoscopy

  • extensive colitis with mod/severe inflame
  • or stricture in last 5yrs
  • or dysplasia in last 5yrs declining surgery
  • or PSC/Tx for PSC
  • or FHx colorectal ca in 1st degree relative <50yrs
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45
Q

UC severity?

A

Mild - <4stools/day small amount blood

Mod 4-6stools/day varying blood, no systemic upset

Severe >6stools/day + features of systemic upset e.g. fever, tachycardia, anaemia, raised inflammatory markers

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46
Q

UC Rx INDUCING remission?

A
  • Distal/Rectal colitis: Topical aminosalicylates or steroids
  • Oral aminosalicylates
  • Oral prednisolone 2nd line if aminosalicylates fail - wait 4wks before deciding

IV steroids 1st line for severe colitis

  • assess response after 3-5days
  • rescue therapy = Infliximab or cyclosporin if disease remains severely active
  • if inadequate response of infliximab at day 5-7 then consider colectomy
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47
Q

UC Rx MAINTAINING remission?

A
  • oral aminosaicylate eg mesalazine
  • azathioprine & mercaptopurine
  • some evidence probiotics may prevent relapse
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48
Q

C diff = gram +ve rod - produces exotoxin which causes bowel damage leading to pseudomembranous colitis
RFs = Abx, PPIs
Features = diarrhoea, abdo pain, raised WBC, toxic megacolon if severe
Dx = CD toxin in stool
Rx?

A
  • oral metronidazole
  • oral van if not responding or severe
  • fidaxomicin if not responding or multiple comorbidities
  • oral vanc + IV metronidazole for life-threatening infections
  • Bezlotoxumab is a mAb which targets C diff toxin B

colonoscopy: yellow membranes in an inflamed colon suggests pseudomembranous colitis

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49
Q

Laparoscopy complications?

A
  • GA risk
  • vasovagal reaction e.g. bradycardia in response to abdo distension
  • extra-peritoneal gas insufflation: surgical emphysema
  • injury to GI tract
  • injury to blood vessels e.g. common iliac, deep inferior epigastric artery
50
Q

Volvulus = torsion of colon around its mesenteric axis -> compromised blood flow & closed loop obstruction
- 80% sigmoid 20% caecum (retroperitoneal in most so not at risk of twisting but in 20% there’s developmental failure of peritoneal fixation of proximal bowel)
Features?
Dx?
Rx?

A
  • constipation, abdo bloating/distension, abdo pain, nausea/vomiting
  • AXR
  • Sigmoid: LBO + coffee bean sign
  • Caecal: SBO

Sigmoid -> rigid sigmoidoscopy with rectal tube insertion
Caecal -> operative, often right hemicolectomy

51
Q

Post-gastrectomy syndromes?
(Roux en Y reconstruction gives best functional outcomes; where a gastrojejunostomy is performed as reconstruction following distal gastrectomy, the gastric emptying is generally better if the jejunal limbs are tunneled in the retrocolic plane)

A 
small capacity (early satiety)
dumping syndrome
bile gastritis
afferent loop syndrome
efferent loop syndrome
anaemia/B12 deficiency
metabolic bone disease
52
Q

Postprandial hypoglycaemia after gastric bypass or bariatric surgery?

A

Late dumping syndrome = postprandial hyperinsulinemic hypoglycaemia, presents months-years post-op, managed with diet changes

(Early dumping syndrome = rapid emptying of food into the small bowel-> colicky abdominal pain, diarrhoea & nausea = much more common complication of bariatric surgery)

53
Q

Prophylaxis of variceal bleed?

A

Propranolol
= non-cardioselective beta blocker - works by producing splanchnic vasoconstriction & reducing portal venous inflow, limiting blood flow to the hepatic varices and reduces the pressure causing a smaller chance of bleeding

EVL: endoscopic variceal band ligation at 2weekly intervals until all varies eradicated with PPI cover to prevent EVL induced ulceration

54
Q

Rx of vatical bleed?

A

ABCDE, correct clotting with FFP, vit K

  • vasoactive agents: Terlipressin benefits initial haemostasis & prevents rebleeding (also octreotide)
  • prophylactic Abx in pts with cirrhosis e.g. quinolone
  • OGD: endoscopic band ligation
  • Sengstaken-Blakemore tube if uncontrolled haemorrhage
  • TIPSS if above all fail
55
Q

Chronic diarrhoea with a v large stool volume maintained whilst fasting - Dx?

A

VIPoma

  • suggested by a secretory diarrhoea (not osmotic)
  • VIP hormone stimulates secretion & inhibits absorption of sodium, chloride, potassium & water within small bowel & increases bowel motility
  • secretory diarrhoea, hypokalaemia, dehydration
56
Q 
Barretts = metaplasia of lower oesophageal mucosa: squamous -> columnar that resembles cardiac stomach region or small bowel (with goblet cells, brush border)
- inc risk adenoca
RFs?
Rx?
Endoscopic surveillance?
Rx?
A
  • GORD strongest RF
  • male, smoking, central obesity
  • Rx = high-dose PPI, endoscopic surveillance with biopsies
  • surveillance for pts with metaplasia (but not dysplasia) recommended every 3-5years
  • intervention offered if there is ANY grade of DYSPLASIA i.e. endoscopic mucosal resection or radio frequency ablation
57
Q

Pseudomyxoma peritonei = rare mutinous tumour most commonly arising from appendix
- characterised by accumulation of large amounts of mutinous material in abdominal cavity
Rx?

A
  • surgical: cytoreductive surgery +/- peritonectomy, combined with intra-peritoneal chemo with mitomycin C
58
Q 
Small bowel overgrowth syndrome = XS amounts of bacteria in small bowel -> GI Sx
RFs?
Features?
Dx?
Rx?
A
  • neonates with GI abn, scleroderma, DM
  • chronic diarrhoea, bloating, flatulence, abdo pain, weight loss, it B12 malabsorption, impaired absorption of fat-soluble vitamins

Dx: hydrogen breath test, small bowel aspirate & culture but invasive - sometimes Abx given as a Dx trial

Rx: correct underlying disorder, Abx = Rifaximin

59
Q

Best Rx for alcoholic hepatitis that improves survival at 28 days?

A

Prednisolone

60
Q

MDS score in alcoholic hepatitis?

A

> 32 ass with 50% mortality within 2months indicating need for Rx
- give vitamin replenishment & nutritional support & PREDNISOLONE

(Pentoxifylline may reduce mortality in presence of hepatorenal syndrome)

61
Q

Common drugs causing cholestatic jaundice?

+/- hepatitis

A
  • Flucloxacillin, Co-amoxiclav, Erythromycin
  • Sulfonylureas
  • Fibrates
  • Chlorpromazine, prochlorperazine
  • OCP
  • Anabolic steroids, testosterone
62
Q

Drugs that cause hepatocellular picture?

A
  • paracetamol
  • sodium valproate, phenytoin
  • amiodarone
  • nitrofurantoin (chronic use: hepatic necrosis)
  • methyldopa
  • MAO-Is
  • anti-TB RIP
  • statins
  • ETOH
  • halothane
63
Q

Drugs that can cause cirrhosis?

A

MTX
Amiodarone
Methyldopa

64
Q

Thiamine = water soluble vitamin B complex
- TTP = one of its phosphate derivatives that is a coenzyme in the enzymatic reactions:
- pyruvate dehydrogenase complex
- pyruvate decarboxylase in ETOH fermentation
- alpha-ketoglutarate dehydrogenase complex
- branched-chain amino acid dehydrogenase complex
- 2-hydroxyphytanoyl-CoA lyase
- transketolase
Therefore is important in catabolism of sugars & AAs -> so consequences of thiamine deficiency are seen 1st in highly aerobic tissues e.g. brain & heart

Causes?
Conditions ass with thiamine deficiency?

A
  • XS ETOH & malnutrition
  • Wernicke’s encephalopathy: nystagmus, ophthalmoplegia, ataxia
  • Korsakoff’s: amnesia, confabulation
  • Dry beri beri: peripheral neuropathy, muscle pain
  • Wet beri beri: dilated cardiomyopathy

Nb clinical ass between hyperemesis gravidarum & thiamine deficiency esp when prolonged and dietary intake compromised

65
Q

SBP: ascites, abdo pain, fever
Dx?
Rx?
Abx prophylaxis?

What else has been shown to reduce mortality?

A
  • paracentesis neutrophil count >250cells
  • commonest organism = E. coli on ascitic tap
  • Rx = IV Cefotaxime
    Abx prophylaxis should be given to pts with ascites if:
  • they have had an ep of SBP
  • fluid protein <15 of Child-Pugh 9+ or hepatorenal syndrome
  • NICE: offer proph oral Cipro or norfloxacin for people with cirrhosis & ascites with an ascitic protein 15 or less until ascites has resolved
  • HAS to rehydrate inc cirrhosis with SBP
66
Q

Decompensated liver disease:

  • causes?
  • signs?
  • Rx?
A

infection: pneumonia, SBP, hep B/C
drugs: paracetamol, anaesthetic agents
toxins: etoh, Amanita phalloides mushroom
vascular: Budd-chiari syndrome, veno-occlusive disease
haemorrhage: upper GI bleed
constipation

  • asterixis
  • jaundice
  • hepatic encephalopathy
  • constructional apraxia

Rx the cause etc
- enhace nitrate clearance with phosphate enemas aiming for minimum 3 loose stools/day & lactulose to enhance binding of nitrate in intestine

67
Q

Someone decompensated with ascites treated for SBP
- lab calls and says ascitic tap is mixed growth
Most likely cause?

A

Perforation
- Ascites is normally sterile so any growth of organisms is indicative of infective pathology
- mixed growth suggests large communication of microbes into abdo cavity, which makes perforation most likely cause
(- Spontaneous peritonitis occurs with bacterial translocation across the bowel - usually a single species of normal gut flora as a pathogen)

68
Q

5-ASA is released in colon and not absorbed -> acts locally as anti-inflammatory, may inhibit prostaglandin synthesis

Sulfasalazine side-effects?

Mesalazine side-effects?

A

Sulfasalazine has combo with sulphonamide

  • rash, oligospermia, headache, heinz body anaemia, megaloblastic anaemia, lung fibrosis
    • others common to 5-ASAs

Mesalazine = delayed release form of 5-ASA
- GI upset, headache, agranulocytosis, interstitial nephritis, pancreatitis

69
Q

C/Is to percutaneous liver Bx?

A
  • deranged clotting INR>1.4
  • low platelets <60
  • anaemia
  • extrahepatic biliary obstructioni.e. cholestasis (can be bile leak leading to 2ry peritonitis)
  • hydatid cyst/malignant lesion - Bx can seed the lesion causing sepsis/dissemination
  • haemangioma
  • uncooperative pt
  • ascites
70
Q

H. pylori eradication Rx?

A
  • PPI + Amoxicillin + Clarithromycin

metronidazole if pen allergic

71
Q

GI parasite: Enterobiasis

  • common cause of pruritus anti
  • Dx?
  • Rx?
A 
Dx = scotch tape at anus to trap eggs and view microscopically
Rx = Mebendazole
72
Q

GI parasite: Ancylostoma duodenale = hookworm that anchors in proximal small bowel, mostly aSx or IDA
Dx?
Rx?

A
  • larvae may be found in stools left at ambient temp, otherwise difficult to Dx
  • infection occurs as a result of cutaneous penetration, migrates to lungs, coughed up & then swallowed
    Rx = mebendazole
73
Q

GI parasite: Ascariasis = roundworm infection that starts in the gut after ingestion, then penetrates duodenal wall t migrate to lungs, coughed up & swallowed, cycle begins again
Dx?
Rx?

A 
Dx = identification of worm/eggs within faeces
Rx = Mebendazole
74
Q

GI Parasite: strongyloidiasis (rare in west) - nematode living in duodenum of host
infection?
Dx?
Rx?

A
  • initial infection via skin penetration -> migrate to lungs coughed up & swallowed -> mature in small bowel -> excreted & cycle begins again
  • auto-infective cycle also recognised where larvae will penetrate colonic wall
  • can be aSx, may have rest disease & skin lesions
Dx = stool microscopy
Rx = mebendazole in UK
75
Q

GI parasite: Cryptosporidium = protozoal infection where organisms produce cysts which are excreted & produce new infections
Sx?
Dx?
Rx?

A
  • diarrhoea & crampy abdo pain, worse in immunocompromised
    Dx = cysts in stool
    Rx = Metronidazole
76
Q

GI parasite: Giardiasis = protozoal diarrhoeal infection as a result of ingestion of cysts
Sx?
Dx?
Rx?

A

= GI abdo pain, bloating, soft/loose stools
Dx = serology or stool microscopy
Rx = Metronidazole 1st line

77
Q

Autoimmune hepatitis

  • features?
  • associations?
  • Rx?
A
  • may present with signs of chronic liver disease
  • acute hepatitis in 25%
  • amenorrhoea common
  • ANA/SMA/LKM1 Ab, raised IgG
  • Bx: interface hepatitis: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
  • other AI disorders, hypergammaglobulinaemia, HLA B8, DR3

Rx = steroids, other immunosuppressants e.g. azathioprine, liver Tx

78
Q

Autoimmune hepatitis types?

A

Type I - ANA/anti-SMA, affects adults & kids

Type II - anti-LKM1, affects kids only

Type III - soluble liver-kidney Ag, affects middle aged adults

79
Q

Hepatitis D = ssRNA transmitted parenterally, requiring hep B sAg to complete its replication & transmission cycle
Dx?
co-infection?
super-infection?

A
  • reverse PCR of hepatitis D RNA
  • confection is hep B & D at the same time
  • superinfection is when a hep B sAg +ve pt develops hep D - ass with high risk fulminant hepatitis, chronic hepatitis status & cirrhosis
80
Q

Acute severe UC flare:
At day 3 a CRP>45 mg/l or a stool frequency of >8/day predicts the need for surgery in 85% of cases
- benefit of steroids?
- if no improvement?

A
  • IV steroids for 5 days with no additional benefit beyond 7 days
  • if no improvement seen after 72h of IV steroid or if pt deteriorates then URGENT surgical R/v and add Cyclosporin 2mg/kg/day
    (infliximab if C/I)
81
Q

Causes of raised faecal calprotectin?

A 
IBD (highly spec &amp; sens in adults, can be used to monitor response to Rx)
bowel ca
coeliac disease
infectious colitis
NSAIDs
82
Q

PPIs MoA & adverse effects?

A
  • H+/K+ ATPase of gastric parietal cell
  • low Na, Mg
  • osteoporosis
  • microscopic colitis
  • increased risk C diff
83
Q

In Crohns, Anti-TNF agents used in combination with immunomodulating agents are more effective at maintaining steroid-free clinical remission than when used as mono-therapy - what is the increased risk?

A

Non-melanoma skin cancer and others

84
Q

Ix to identify source of occult GI bleed when an OGD & colonoscopy have failed to show a cause - esp useful for pathology in the ileum?

A

Capsule endoscopy

85
Q

WHipple’s disease: Tropheryma whippelii infection rare multi-system disorder, more common in HLA-B27 +ve middle-aged men
Features?
Ix?
Rx?

A
  • malabsorption diarrhoea & weight loss, large-joint arthralgia, lymphadenopathy, skin: hyper pigmentation & photosensitivity, pleurisy, pericarditis, neuro Sx (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus

Ix = jejunal Bx showing deposition of macrophages containing PAS granules

Rx eg oral co-trimoxazole for a year

86
Q

Metoclopramide = D2 receptor antagonist mainly used for nausea, also GORD, pro kinetic action in gastroparesis, combined with analgesics for Rx of migraine

Adverse effects?

A
  • EPSEs: oculogyric crisis esp in children & young adults
  • hyperPRL
  • tardive dyskinesia
  • parkinsonism
  • avoid inbowel obstruction, may be helpful in paralytic ileus
87
Q

Rx oculogyric crisis

A

1st line Procyclidine = rapidly acting anticholinergic, with BZDs & anticholinergic antihistamines

88
Q

Rec acute pancreatitis with new diabetes & steatorrhoea, develops acute abdominal pain with normal amylase?

A

Acute on chronic pancreatitis

- amylase may not be raised if there is significantly poor residual pancreatic function

89
Q

Gastrectomy complications?

A
  • vit B12 deficiency, IDA, weight loss, early satiety, osteoporosis/osteomalacia
  • inc risk gallstones & gastric ca
  • dumping syndromes:
    early = food of high osmotic potential moves into small bowel causing fluid shift -> osmotic diarrhoea, small bowel distension, abdo pain, intravascular depletion
    late = rebound hypoglycaemia
90
Q

Colorectal ca Dukes classification & survival?

A 
A = confined to mucosa &amp; submucosa 95% M 100% F
B = extends through the muscular propria >80% M 90% F
C = regional LNs involved 65% M 65% F
D = distant spread >5% M 10% F
91
Q

Commonest organisms of pyogenic liver abscess?

Rx?

A

kids staph aureus
adults E coli
Rx = Amoxicillin + Ciprofloxacin + Metronidazole
If pen allergic = Ciprofloxacin + Clindamycin

92
Q

Recent appendicitis -> deranged LFTs, abdo pain, tenderness, raised inflame markers, febrile, palpable mass Dx?

A

Liver abscess

93
Q

Associated factors with NAFLD?

features?

A

obesity, T2DM, hyperlipidaemia, jejunoileal bypass, sudden weight loss/starvation
- aSx, hepatomegaly, ALT>AST, increased echogenicity on US

94
Q

If incidental NAFLD on US what is recommended?

A

ELF: enhanced liver fibrosis blood test to check for advanced fibrosis

  • combo of hyaluronic acid + pro collagen III + tissue inhibitor of metalloproteinase 1
  • if not available, can use the FIB4 score of NAFLD fibrosis score in combo with Fibroscan (liver stiffness measurement assessed with transient elastography)
95
Q

Liver abscess: rusty brown pus drained, microbiology for parasites -> Entamoeba histolytica
Rx?

A

Metronidazole

Diloxanide furoate should begin after to kill remaining amoeba in gut

96
Q

Increased stool frequency, urgency, incontinence and nocturnal seepage following ileal pouch-anal anastomosis after total colectomy in UC - Dx? Rx?

A

Pouchitis

  • metronidazole/ciprofloxacin
  • can become chronic leading to pouch failure and requiring pouch excision
97
Q

Vitamin B6 = pyridoxine, water-soluble b vitamin, converted to PLP (pyridoxal phosphate) = cofactor for many reactions inc transamination, deamination & decarboxylation
causes & consequences of deficiency?

A

Isoniazid Rx

  • peripheral neuropathy
  • sideroblastic anaemia
98
Q

In pts with known cirrhosis, what is the management of varices?

A

No varices -> rescope in 2-3yrs
Grade 1 varices -> rescope in 1 year
grade 2/3 varices or signs of bleeding -> non cardio selective beta blocker

99
Q

Anti-Saccharomyces cerevisiae antibodies are more likely to be positive in which IBD?

A

Crohn’s

100
Q

Dysphagia 2ry to oesophageal webs + glossitis + IDA

Dx? Rx?

A

Plummer-Vinson syndrome
rx = iron supplementation & dilation of webs
- the webs are premalignant for oesophageal SCC & pharyngeal SCC

101
Q

Hyperemesis gravidarum = extreme nausea & vomit in pregnancy, related to raised beta-hCG, most common between 8-12/40 but may persist to 20/40
Dx?
Ass?
Rx?

A
  • 5% pre-pregnancy weight loss
  • dehydration
  • electrolyte imbalance
  • multiple pregnancies, trophoblastic disease, hyperthyroid, nulliparity, obesity
  • 1st line antihistamines e.g. promethazine, or also cyclizine
  • 2nd line ondansetron & metoclopramide
  • may need admission for IV hydration
  • Wernicke’s (Give THIAMINE)
  • Mallord-Weiss tear
  • cnetral pontine myelinolysis
  • acute tubular necrosis
  • fetal: small for gestational age, pre-term
102
Q

What marker is most useful in determining his risk for developing cirrhosis from hepatitis B

A

hepatitis B DNA levels

- will determine viral load and quantify the level of infection

103
Q 
Lysosomal storage disorder of alpha-galactosidase-A
-> accumulation of creamed trihexoside
- angiokeratomas
- peripheral neuropathy of extremities
- renal failurw
Dx?
A

Fabry disease

104
Q

Commonest lysosomal storage disorder, of beta-glucocerebrosidase, resulting in accumulation of glucocerebrosidase in brain, liver, spleen

  • hepatosplenomegaly
  • aseptic necrosis of femur
A

Gaucher’s disease

105
Q

Lysosomal storage disease of Hexosaminidase A leading to accumulation go GM2 ganglioside within lysosomes
- developmental delay, cherry red spot on macula, liver & spleen normal size
Dx?

A

Tay-Sachs disease

106
Q

Glycogen storage disease of myophosphorylase/glycogen phosphorylase leading to skeletal muscle glycogen accumulation

  • myalgia
  • myoglobinuria with exercise
A

McArdle’s disease type V

107
Q

Recurrent cholecystitis, pneumobilia, SBO, abdo pain, distension
- Dx?

A

Gallstone ileus
- rare complication of chronic cholecystitis when a gallstone passes through a fistula between GB & small bowel before becoming impacted at the ileocaecal valve

108
Q 
Pancreatic cancer - 80% are adenocarcinomas typically at head of pancreas
Associations?
Features?
Ix?
Rx?
A
  • age, smoking, diabetes, chronic pancreatitis, HNPCC, MEN, BRCA2 gene
  • painless jaundice, non-specific constitutional Sx, loss of exocrine Sx, loss of endocrine Sx, atypical back pain, migratory thrombophlebitis
  • Ix: US sens 60-90%, high-res CT is Ix of choice

Rx: <20% suitable for surgery at Dx

  • Whipple’s resection (pancreaticoduodenectomy) performed for resectable lesions at head of pancreas - side-effects inc dumping syndrome & peptic ulcer disease
  • adjuvant chemo
  • ERCP with stunting for palliation
109
Q 
Pancreatic cancer - 80% are adenocarcinomas typically at head of pancreas
Associations?
Features?
Ix?
Rx?
A
  • age, smoking, diabetes, chronic pancreatitis, HNPCC, MEN, BRCA2 gene
  • painless jaundice, non-specific constitutional Sx, loss of exocrine Sx, loss of endocrine Sx, atypical back pain, migratory thrombophlebitis
  • Ix: US sens 60-90%, high-res CT is Ix of choice

Rx: <20% suitable for surgery at Dx

  • Whipple’s resection (pancreaticoduodenectomy) performed for resectable lesions at head of pancreas - side-effects inc dumping syndrome & peptic ulcer disease
  • adjuvant chemo
  • ERCP with stunting for palliation
110
Q

Dx of liver cirrhosis??

Screening?

A
  • traditionally liver Bx
  • others inc transient elastography & acoustic radiation force impulse imaging
  • or enhanced liver fibrosis score to screen for pts who need further testing with nafld

Transient elastography = Fibroscan - uses 50MHz wave into liver from a small transducer on end of US probe
- measures stiffness of liver

Screening: transient elastography in:

  • people with hep C
  • men who drink >50units, F>30units/week
  • people with ETOH-related liver disease
  • upper OGD to check for varies in new Dx of cirrhosis
  • liver US every 6months +/- AFP to check HCC
111
Q

Screening Hep cell ca in high risk?

A
  • liver US every 6months +/- AFP to check HCC
112
Q

IBS med Rx?

A

Depends on predominant Sx

  • antispasmodic if pain
  • laxative (not lactulose) if constipation - if not responding can consider Linaclotide if persisted 12months and optimal/maximum tolerated doses from different classes not helped
  • loperamide if diarrhoea

2nd line pharm = TCAs low dose e.g. amitriptyline

113
Q

Clostridium difficile infections that don’t respond to metronidazole/vancomycin

A

Fidaxomicin

114
Q

Pernicious anaemia pathphys & features?

A
  • Ab to gastric parietal cells or intrinsic factor -> vit B12 deficiency
  • ass with thyroid disease, diabetes, Addisons, rheum, vitiligo
  • predisposes to gastric carcinoma
  • lethargy, weakness, dyspnoea, paraesthesia, mild jaundice, diarrhoea, sore tongue, retinal haemorrhages, mild splenomegaly, retrobulbar neuritis
115
Q

Dold standard diagnostic test for small bowel bacterial overgrowth?

A

Jejunal aspirate

116
Q 
iron metabolism:
absorption?
transport?
storage?
excretion?
A
  • absorbed in upper small bowel, 10% dietary absorbed, Fe2+ better absorbed, regulated by boys need, increased by it C & gastric acid
  • decreased by PPIs, tetracycline, gastric achlorhydria, tannin
  • transported in plasma as Fe3+ bound to transferrin
  • stored as ferritin in tissues
  • excreted via intestinal tract following desquamation
117
Q

Angiodysplasia is a vascular deformity of GI tract which predisposes to bleeding & IDA
- ass with aortic stenosis
Dx?
Rx?

A
  • colonoscopy
  • mesenteric angiography is acutely bleeding
  • endoscopic cautery or argon plasma coagulation
  • antifibrinolytics eg TXE
  • oestrogen may be used
118
Q

TIPSS = percutaneous creation of a low-pressure tract between the intrahepatic portal vein & hepatic vein, allowing blood to bypass the liver & lower portal pressure

  • 1ry indications?
  • absolute C/I?
  • relative C/I?
A
  • uncontrolled vatical bleed, refractory ascites & hepatic pleural effusion are main indications for TIPSS

Absolute C/I = severe & progressive liver failure (Child-Pugh >12), uncontrolled hepatic encephalopathy, right heart failure, uncontrolled sepsis, unrelieved biliary obstruction

Relative = severe uncorrectable coagulopathy, thrombocytopenia, portal & hepatic vein thrombosis, pulm HTN, central hepatoma

119
Q 
Gastric MALT lymphoma
- ass with H pylori
- good Px
- if low grade then 80% respond to triple Rx
Features?
A

paraproteinaemia
- ogd Biopsy of this area is reported as having large number of lymphocytes that have irregular nuclear contours with abundant cytoplasm

120
Q 
Oesophageal ca (adenoca commonest) - majority in middle 1/3 of oesophagus
RFs?
Features?
Dx?
Rx?
A
  • smoking, ETOH, GORD, Barrets, achalasia, Plummer-Vinson, SCC linked to diets rich in nitrosamines
  • dysphagia, anorexia, weight loss, vomiting etc
  • OGD
  • contrast swallow can help classify benign motility disorders but no place in assessment of tumours
  • staging CT - if negative then eUS for local staging
  • staging laparoscopy to detect occult peritoneal disease
  • PET CT if negative laparoscopy
  • Surgery: Ivor-Lewis oesophagectomy commonest
  • biggest surgical challenge is anastomotic leak, with intrathoracic anastomosis that will result in medistinitis with high mortality
  • adjuvant chemo

EXAM 2 (10 decks)

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