gastro Flashcards
Alpha-1-antitrypsin deficiency: pathophysiology:
alpha-1-antitrypsin is a gene for a protease inhibitor
Elastase is an enzyme secreted by neutrophils. This enzyme digests connective tissues. Alpha-1-antitrypsin (A1AT) is mainly produced in the liver, travels around the body and offers protection by inhibiting the neutrophil elastase enzyme. A1AT is coded for on chromosome 14. In A1AT deficiency, there is an autosomal recessive defect in the gene for A1AT.
which organs does A1AT deficiency effect?
lungs and liver
- cirrhosis (50yos)
- bronchiectasis and emphysema (30yos)
cx of A1AT deficiency in liver over time?
hepatocellular carcinoma
which condition are all new T1DM’s investigated for as they are linked?
coeliac disease
what 2 findings will endoscopy and biopsy show in coeliac disease? (duodenal biopsy)
villous atrophy
crypt hypertrophy
how do you test for coeliac antibodies in a patient with IgA deficiency?
so anti-TTG and anti-EMA are both IgA - when these are tested for its important to test for total IgA abs too - if deficient they can be false negative
–> test for the IgG version of anti-TTG or anti-EMA antibodies or simply do an endoscopy with biopsies.
name some cx of untreated coeliac disease? (5)
vitamin deficiency anaemia OP ulcerative jejunitis EATL of the intestine NHL adenocarcinoma of small bowel
rare neurological presentation of coeliac?
peripheral neuropathy
cerebellar ataxia
epilepsy
what rash may be seen in coeliac disease - describe?
Dermatitis herpetiformis (an itchy blistering skin rash typically on the abdomen)
type of anaemia seen in coeliac?
anaemia secondary to iron, B12 or folate deficiency
could be either micro or macrocytic
Crohn’s (crows NESTS) mnemonic:
N – No blood or mucus (less common)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
Crohn’s is also associated with weight loss, strictures and fistulas, gallstones, increased goblet cells
Ulcerative Colitis (remember U – C – CLOSEUP):
C – Continuous inflammation L – Limited to colon and rectum (rectum commonest) O – Only superficial mucosa affected S – Smoking is protective E – Excrete blood and mucus U – Use aminosalicylates P – Primary Sclerosing Cholangitis
what is a useful investigation for IBD?
faecal calprotectin (90% cases)
diagnostic test for IBD?
endoscopy + biopsy
what type of condition is proctitis?
type of ulcerative collitis
should you start someone on suspected UC on anti-diarrhoea drugs?
no - can precipitate life threatening cx toxic megacolon
what cardiac cx of carcinoid syndrome ca?
pulmonary stenosis and tricuspid insufficiency
affects right side of heart
ix carcinoid syndrome?
urinary 5-HIAA
tx carcinoid syndrome?
somatostatin analogue - octreotide - sx relief
diarrhoea - cryptoheptadine
mild normocytic anaemia and raised urea on U&Es indicates:
GI bleed - especially in context of long term NSAID use with no PPI prescription
If ? GI bleed - ix?
endoscopy within 24 hours
tx for c diff 1st line?
oral metronidazole 10-14/7
2nd is PO vanc alone
c diff - what should happen to pt other than abx treatmetn?
isolated for 48 hours and barrier nursed
other than abx, main risk factor drug for c diff?
PPI
difference between toxin and antigen tests in c diff?
toxin in stool during current infection - stool sample
antigen just indicates exposure, not necessarily current infection - only tx if active infection
severe/resistant to 1st line c diff tx?
oral vancomycin
biologic tx c diff?
bezlotoxumab
Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg implies???
chronic current Hep B infection
anti-HBS positive, all else negative ->
had a vaccine
HBcAb +
HBsAg negative
__>
previous Hep B infection >6/12 ago, not a carrier
HBcAb +
HBsAg + ->
previous infection, now a carrier
4 months post- cholecystectomy - floating diarrhoea stools tx??
cholestryramine
what type of cancer does barret’s oesophagus and GORD increase risk of ?
adenocarcinoma of oesophagus
what type of cancer does achalasia increase the risk of?
squamous cell carcinoma of the oesophagus
which cancers affect which regions of the oesophagus?
upper 2/3 - squamous cell
lower 1/3 - adenocarcinoma
mx of severe alcoholic hepatitis?
prednisolone
gamma-GT is characteristically elevated
the ratio of AST:ALT is normally > 2, a ratio of > 3 is strongly suggestive of acute ______________?
alcoholic hepatitis
what formula is used in the acute setting to decide which alcoholic hepatitis patients would benefit from tx?
Maddrey’s discriminant function (DF)
prothrombin time and bilirubin concentration
78-year-old man is brought into the emergency department with severe haematemesis. He is brought for urgent endoscopy, which shows oesophageal varices. first line during endoscopy to stop the bleeding?
band ligation
Sengstaken-Blakemore tube
TIPSS if ligation fails
Prophylaxis of variceal haemorrhage:
Propranolol
EVL
raised bili
bigger raise in ALP and GGT than ALT - dx?
obstructive jaundice
cardinal sign of pancreatic ca?
painless jaundice
what does a ‘double-duct’ sign indicate?
pancreatic ca on CT
simultaneous dilatation of the common bile and pancreatic ducts
increased echogenicity of the liver. The patient is 1.8m in height and weighs 120kg. Their abdomen is distended. The patient is currently on no medications, drinks no more than 2 pints of cider a week and is a non-smoker. best advice to give?
lose weight - first line for NAFLD
advice on alcohol intake units:
they advise ‘if you do drink as much as 14 units per week, it is best to spread this evenly over 3 days or more’
commonest manifestation of crohn’s disease in children?
abdo pain
Positive antimitochondrial antibodies are commonly associated with which condition?
Primary billiary cholangitis
what should AI hepatitis show on LFTs?
predominantly raised ALT, AST compared with ALP (also raised, but not by as much)
which 2 vessels does a transjugular intrahepatic portosystemic shunt (TIPS) procedure connect??
hepatic vein and portal vein
PBC - the M rule:
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
what disease presents with the triad of sudden onset abdominal pain, ascites, and tender hepatomegaly?
Budd-Chiari syndrome
USS is ix of choice with doppler flow
what is a saag used for??
to determine whether if the ascites has been caused by portal hypertension or not. A raised SAAG (>11g/L) indicates that it is portal hypertension that has caused the ascites
what is the pathology of budd-chiari syndrome?
hepatic vein thrombosis
what is the single strongest risk factor for the development of Barrett’s oesophagus?
GORD
then male, smoking, obesity
The Mackler triad for Boerhaave syndrome:
vomiting, thoracic pain, subcutaneous emphysema. It typically presents in middle aged men with a background of alcohol abuse
Severe vomiting → painful mucosal lacerations at the gastroesophageal junction resulting in haematemesis. Common in alcoholics is which syndrome??
Mallory-Weiss syndrome
Triad of: dysphagia (secondary to oesophageal webs) glossitis iron-deficiency anaemia which syndrome?
Plummer-Vinson syndrome
tx: iron supplementation and dilation of the webs
in macrocytic anaemia picture - which antibodies test for?
Intrinsic factor abs
more specific than anti gastric parietal cell abs
odynophagia indicates???
oesophageal cancer
2ww
LFTs in paracetamol OD:
hepatocellular picture:
high ALT, normal ALP, ALT/ALP ratio high
PT a better marker - v increased
which drugs can cause a cholestatic picture on LFTs?
COCP
abx
steroids
sulfonylureas
72-year-old man presents to the GP with trouble swallowing. On further questioning, he explains that some of the food is coming back up and his breath smells much worse than normal.
Given the most likely diagnosis, what is the most appropriate management?
likely dx - Pharyngeal pouch requires surgical treatment
tx for oesophageal spasm?
CCB
treatment for myasthenia gravis:
acetylcholinesterase inhibitors
classical ‘bird’s beak’ appearance of the lower oesophagus that is seen in::
achalasia
dysphagia of BOTH liquids and solids indicates a dx of:
achalasia
lack of lower oesophageal sphincter relaxing during swallowing
lead pipe colon on barium enema?
UC
tenesmus is a symptom seen in ?
UC
ix a woman with microcytic anaemia picked up during an infective AECOPD. which blood tests should you add?
iron studies including TRANSFERRIN, TIBC
ferritin is unreliable during acute infection
A severe flare of ulcerative colitis should be treated in hospital with???????
IV hydrocortisone
which drug can be used to induce remission in a mild-moderate flare of ulcerative colitis, but is not suitable for induction of remission in severe cases.?
oral mesalazine
which UC drug particularly efficacious in distal proctitis but it is not suitable for acute SEVERE exacerbations.?
rectal mesalazine
which drug is most useful to maintain remission after exacerbations of UC (usually 2 in 1 year) which have required steroids.??
azathioprine PO
or PO mercaptopurine
2nd line in inducing remission of UC tx?
PO steroid
combination of liver and neurological disease points towards ______?
wilsons disease
copper
what is the treatment of choice for small bowel bacterial overgrowth syndrome?
rifaximin
risk factors for SIBO?
neonates
DM
scleroderma
50-F gastrointestinal clinic with jaundice. eyes were yellow over the past 2 weeks. fatigue and general itch over the past 3 months before her clinic appointment today. emollients have been trialled - no success. no abdominal tenderness. Excoriation was noted across her hands and feet. IgM. M2. raised alp, raised bili, ggt
dx?
primary biliary cholangitis
which tx slows progression of primary biliary cholangitis
ursodeoxycholic acid
2nd line Obeticholic acid
mx ascitis?
reduce dietary na, fluid restrict if na<125
spiro
drain if tense
Fetor hepaticus, sweet and fecal breath, is a sign of ?
acute liver failure
68M with T2DM is admitted to hospital unwell. has features of septic shock and RUQ tenderness. He is not jaundiced. Imaging shows a normal calibre bile duct and no stones in the gallbladder.
dx?
acalculous cholecystitis
43F known gallstones is admitted with a high fever and jaundice. looks extremely unwell. Her abdomen is generally soft although there is some mild tenderness in the RUQ.
dx?
cholangitis
34F is admitted with a 3/7 hx of colicky RUQ pain which radiates to her back. now more constant. On examination she is not jaundiced, but has a temperature of 38.5oC. She has localised peritonism in the RUQ.
dx?
acute cholecystitis
what generally used to induce remission of Crohn’s disease?
glucocorticoids only po,top,iv - any diet changes 2nd line sulfasalazine 3rd line azathioprine 4th infliximab
maintaining crohns remission?
azathioprine or mercaptopurine 1st line
stop smoking
2. MTX
mesalazine if had previous surgery
dypepsia + weight loss needs?
urgent referral
tx of variceal haemorrhage?
terlipressin
what is used in the management of upper GI bleeds which are not caused by variceal bleeding?
IV omeprazole
which drugs are strongly linked to Clostridium difficile?
clindamycin and cephalosporins
what is pseudomembranous colitis caused by ?
c.diff
XR: lead pipe appearance of the colon (red arrows). Ankylosis of the left sacroiliac joint and partial ankylosis on the right (yellow arrow), reinforcing the link with sacroilitis. dx?
UC
barium enema for UC:
3
loss of haustrations
superficial ulceration, ‘pseudopolyps’
long standing disease: colon is narrow and short -‘drainpipe colon’
which 2 drugs are used for the secondary prophylaxis of hepatic encephalopathy?
lactulose and rifaximin
Intestinal metaplasia with a villiform pattern noted. Multiple intermediate mucous cells and goblet cells noted. No dyplasia noted.
this oesophaageal biopsy report confirms:
barrets oesophagous
mx barrets oesophagus?
high dose PPI and endoscopic surveillance
In life-threatening Clostridium difficile infection treatment is with? (this can present as toxic megacolon)
PO vanc and IV metronidazole
abdominal radiograph shows large bowel distension (diameter > 5.5cm). in?
toxic megacolon
alcohol units equation =
volume (mls) x ABV (%) / 1000
Jaundice following abdominal pain and pruritus during pregnancy think
acute fatty liver of pregnancy
triad of CVD, high lactate and soft but tender abdomen:
mesenteric ischemia (aka intestinal angina) metabolic acidosis
Vitamin B12 deficiency is typically managed?
IM B12 injection replacement, loading regimen then 2-3 monthly injections