Gastro and Liver Flashcards
How do you diagnose C Diff?
Stool specific antigen testing
What is the 1st, 2nd and 3rd line treatments of C.Diff?
- oral vancomycin 10 days
- oral fidaxomicin
- oral vancomycin + IV metronidazole
What is the most common type of oesophageal cancer in the UK?
adenocarcinoma
What is the first line treatment for life-threatening C.Diff infection?
oral vancomycin and IV metronidazole
What tests should be done for someone with a new diagnosis of NAFLD?
enhanced liver fibrosis test
What are the risk factors for squamous cell cancer of the oesophagus?
smoking, alcohol, achalasia, diets rich in nitrosamines
What blood marker is used to measure acute liver failure?
INR (short half-life) - it is a measure of liver function as it is made by the liver
What are the features of acute liver failure?
jaundice, coagulopathy (raised prothrombin time), hypalbuminaemia, hepatic encephalopathy
What two blood markers do you use to measure liver function?
Albumin and prothrombin time/INR
What is the most common causative organism of travellers diarrhoea?
E.Coli
What are the features of campylobacter infection?
a flu-like prodrome, crampy abdominal pain, fever and diarrhoea which may be bloody
What are the features of staphylococcus aureus food poisoning?
Severe vomiting, short incubation period
What medication would you use first line to induce remission of a crohn’s flare-up?
Glucocorticoids
What is the treatment of a perianal fistula in Crohn’s patients?
Metronidazole
What are the symptoms of achalasia?
Dysphagia of both liquids and solids
heartburn
regurgitation of food - aspiration pneumonia
What are the clinical features of primary biliary cholangitis?
Fatigue, itching (raised ALP), jaundice, usually in middle aged-females, raised IgM
What is the first line management of primary biliary cholangitis?
Ursodeoxycholic acid (secondary bile acid that helps with gallstones and cirrhosis)
What is the management of a severe flare-up of UC?
IV corticosteroids and IV ciclosporin (or surgery)
What are the causes of acute pancreatitis?
IGETSMASHED - idiopathic, gallstones, ethanol, trauma, steroid use, mumps, autoimmune, scorpion stings, hypercalcaemia, hypothermia and hypertriglyceridemia, ERCP, drugs
What is the truelove and Witts severity score for?
Assessing the severity of ulcerative colitis in adults
What are the criteria for the Truelove and Witts severity score - for severe?
- blood in the stool, passing more than 6 stools a day
- temp > 37.8
- HR > 90
- anaemia
- ESR > 30
What is the first line management of a mild-moderate flare of distal UC?
Rectal aminosalicyclates = mesalazine
What are the guidelines for treating a mild-moderate flare of UC?
- rectal aminosalicylate
- if no remission in 4 weeks add oral aminosalicylate
- add topic or oral corticosteroid
What is the management of severe colitis?
- admission to hospital
- IV steroids 1st line - if not IV ciclosporin
- if no improvement in 72hrs add ciclosporin
Which organisms are likely to cause an infection in peritoneal dialysis?
Staph epidermidis and staph aureus
Alcoholism can increase the risk of what type of bleed?
Variceal
What is definitive management of variceal bleeding?
Endoscopic variceal band ligation
What is the management of acute variceal bleeding?
IV terlipressin and prophylactic antibiotics
then ligation surgery
What is the management of a pyogenic liver abscess?
Percutaneous drainage and antibiotics
What is the first line medication for inducing remission of crohns disease?
Prednisolone
What is the first-line investigation for bowel perforation?
erect chest X-Ray
How many weeks must patients eat gluten before a coeliac test?
6 weeks
What is the gold standard diagnostic tool for coeliac disease?
Endoscopic intestinal biopsy
What is the first line investigation for coeliac disease?
tissue transglutaminase IgA
What is Budd-Chiari syndrome?
hepatic vein thrombosis - can be due to haematological disease or procoagulant condition
What are the features of Budd-Chiari syndrome?
sudden onset, severe abdominal pain, ascites, tender hepatomegaly
What investigation do you do for suspected budd-chiari syndrome?
utrasound with doppler
What is the Duke’s classification for?
Colorectal cancer staging
What are the Duke’s criteria categories?
A - tumour confined to mucosa
B - tumour invading bowel wall
C - lymph node metastases
D - distant metastases
Which scoring system is used to assess upper GI bleed?
Rockall score - used after endoscopy (rockall-rebleeding)
How can you distinguish between an upper and lower GI bleed on blood results?
Raised urea in upper GI bleed due to ‘protein meal’
Which scoring system is used to assess if a GI bleed can be managed as an outpatient or not?
Glasgow-Blatchford
What is the management of variceal bleeding?
- terlipressin and prophylactic antibiotics
- band ligation
- endoscopy within 24 hours
Which scan is used to assess the severity of liver fibrosis?
Transient elastography (fibroscan)
Patients starting rituximab should be screened for which condition?
Hepatitis B (as rituximab can cause b cell suppression and therefore hep b proliferation)
Which condition tends to have crypt abscesses?
Ulcerative colitis
What is the management of a variceal bleed?
- terlipressin
- Abx
- endoscopy after these
What are the features of primary biliary cholangitis? (Tariq wuz ere lol)
deranged LFTs, RIGHT upper tummy pain (ouchie :( ), fatigue, itch, jaundice, hyperpigmentation over pressure points
- AMA antibodies, raised IgM
What imaging should be done in suspected primary biliary cholangitis?
MRCP
What is the management of primary biliary cholangitis?
- ursodeoxycholic acid
- cholestyramine for itching
What is peutz-jeghers syndrome?
autosomal dominant - polyps in GI tract, causes small bowel obstruction, intussusception, pigmented lesions on lips/face/palms and soles
Which form of IBD is usually associated with bloody diarrhoea?
Ulcerative collitis
Which form of IBD has a cobble-stone appearance and skip lesions?
Crohn’s disease
What is a whipples resection?
pancreatoduodenectomy - for tumours of the head of the pancreas
What test confirms a C.Diff infection?
C.Diff toxin in stool
Which drugs should be stopped in a CDiff infection?
Opiates and others that slow GI motility
Can predispose to toxic megacolon
What are the features of Crohn’s disease?
diarrhoea - non bloody, mouth-anus, skip lesions, inflammation on all layers, goblet cells and granulomas, bowel obstruction/fistulae, weight loss
What are the features of ulcerative collitis?
rectum to ileocaecal valve, continuous disease, crypt abscesses, no inflammation beyond submucosa, bloody diarrhoea, uveitis, colorectal cancer, primary sclerosing cholangitis
What is the gold standard test for coeliac disease?
Small bowel biopsy
What condition has a ‘double duct’ sign?
Pancreatic cancer - dilated pancreatic and CB duct
When are ALP and ALT raised?
ALP - pipes (extra/intraluminal)
ALT - tissues (liver)
What is the management of a bleeding gastric ulcer?
IV PPI, endoscopic intervention
What is Gilbert’s syndrome?
Autosomal recessive defective bilirubin conjugation due to lack of UDP glucuronsyltranferase
Causes jaundice when fasting/ill
No treatment required
What is the first line pharmacological treatment of anal fissures?
bulk forming laxatives, then Topical Glyceryl trinitrate
What is the management of acute pancreatitis?
fluid resuscitation
analgesia
nutrition - enteral if vomiting
What are the features of gastric cancer?
abdo pain, weight loss, N+V, dysphagia, virchow’s node, periumbilical nodule (sister mary joseph’s node)
How do you distinguish between colic, cholecystitis and cholangitis symptomatically?
biliary colic: RUQ pain
Cholecystitis: RUQ pain and fever
Cholangitis: RUQ pain, fever and jaundice
What are cullens and grey-turners signs a sign of?
acute pancreatitis
What are the features of biliary colic?
RUQ pain, worse with fatty food, no fevers or other systemic issues, nausea and vomiting, LFTs and inflammatory markers normal
What is the management of biliary colic?
laparoscopic cholecystectomy
Which form of IBD is better in smokers?
UC - use cigarettes
What is used to manage an acute flare up of crohns?
glucocorticoids 1st line
5-ASA (mesalazine) 2nd line
What is used to maintain remission in crohns or severe UC?
azathioprine, mercaptopurine
What is the management of a variceal bleed?
terlipressin, prophylactic IV abx, endoscopic ligation
propranolol for prophylaxis
What is globus pharyngis?
persistent sensation of having a lump in the throat, usually painless
Why does hepatic encephalopathy occur?
excess absorption of ammonia and glutamine from bacterial breakdown in gut
What drugs can be used to prevent hepatic encephalopathy?
lactulose (promotes excretion of ammonia) and rifaximin (abx modulates gut flora)
What common signs are seen on examination in appendicitis?
rebound and percussion tenderness, guarding, rosving’s sign (palpation in LIF causes pain in RIF), psoas sign (pain in extending hip if retrocaecal appendix)
What is the first line and then gold standard investigation for coeliac disease?
1st line: TTG (can do IGA)
gold standard: endoscopic intestinal biopsy - duodenum
What is the management of wilson’s disease?
Penicillamine (copper chelation), pr trientine hydrochloride
What blood results do you see in Wilson’s disease?
reduced caeruloplasmin, reduced total serum copper, free serum copper increased, increased urinary copper excretion
- diagnosis made by ATP7B gene analysis
What are the features of Wilson’s disease?
- liver, brain and cornea
- hepatitis, jaundice
- speech and psych problems, asterixis, chorea, parkinsonism
- kayser-fleisher rings
- haemolysis, blue nails
What is the first line management of constipation?
- bulk-forming laxative such as ispaghula husk
- Osmotic laxative such as macrogol
What type of laxative is senna?
Stimulant
How do you determine between different types of ascites?
Serum-ascites albumin gradient (SAAG)
>11g/L = portal hypertension
<11g/L hypoalbuminemia, malignancy, infection
What is the management of ascites?
- fluid restriction, spironolactone
If tense - drainage, large volume paracentesis - requires IV albumin
Abx if infection
What are the features of bile acid malabsorption?
Green, watery diarrhoea - usually following cholecystectomy, coeliac or crohns.
Can cause steatorrhoea and lead to ADEK malabsorption
What is the treatment of bile-acid malabsorption?
Bile acid sequestrants - cholestyramine
What are the features of Borehave syndrome?
Vomiting, chest pain and subcut emphysema (suprasternal crepitus)
Oesophageal perforation due to forceful emesis
What is the characteristic appearance of primary sclerosing cholangitis on ERCP/MRCP?
Beaded - due to multiple biliary strictures
Which condition is associated with primary sclerosing cholangitis?
Ulcerative Colitis
Which test can be used to see if H.Pylori has been eradicated after therapy?
Urea breath test
What can you use to stop variceal bleeding if medication doesn’t work?
Sengstaken-Blakemore tube
If that doesn’t work: TIPS
What is the difference in presentation between an anal fissure and a fistula?
Fissure - previous constipation, very painful on defecation, some blood
Fistula - infection symptoms, pain and swelling around anus, bloody fluid
How do you investigate acute and chronic pancreatitis?
Acute - US abdo (diagnosis can be made without imaging)
Chronic - CT abdo - look for calcification
What should you do if there is a child with an inguinal hernia?
Urgent surgical referral as likely to strangulate
what can cause a pulsatile liver?
Dilated cardiomyopathy, tricuspid regurg and stenosis, right heart failure
What medication would you give after a variceal band ligation?
propranolol
what do you use to diagnose primary sclerosing cholangitis?
MRCP before ERCP
Which type of cancer is associated with primary biliary cholangitis?
cholangiocarcinoma
What is a common side effect of a TIPS procedure?
hepatic encephalopathy due to build up of nitrogenous waste
Which autoantibody is associated with primary sclerosing cholangitis?
p-ANCA
Which site is most commonly affected in UC?
rectum
What are the features of acute mesenteric ischaemia?
severe sudden onset abdominal pain, rectal bleeding, diarrhoea, fever, raised WCC and lactate
What is the first line investigation for acute mesenteric ischaemia?
CT
What is the acute management of severe ulcerative collitis?
IV steroids (or ciclosporin)
Which liver problem is associated with crohns?
gallstones
and cobblestones
What is the treatment of a perianal fistulae?
metronidazole
(do MRI to investigate)
Coeliac disease can cause deficiencies in which vitamins?
B12, folate, iron
What is the management of pernicious anaemia?
IM hydroxocobalamin 3 monthly injections
Which antibodies are associated with primary biliary cholangitis/cirrhosis?
Anti-mitochondrial antibodies
What is the pathophysiology of primary biliary cholangitis?
The cells lining the biliary tree are destroyed by the immune system, this leads to leakage of bile into bloodstream, causing jaundice, xanthomas and pruritis, can also cause raised ALP and GGT due to leakage
What is the management of primary biliary cholangitis?
Ursodeoxycholic acid (reduced cholesterol absorption in gut)
cholestryramine (binds to cholesterol reducing amount in blood)
What can be used to maintain remission in UC following a severe relapse?
Oral azathioprine/mercaptopurine
What are the classical features of achalasia?
Dysphagia of both liquids and solids from the start, regurgitation of food
What are the features of systemic sclerosis?
CREST syndrome - calcinosis, raynauds, esophageal dysmotility, sclerodactyly, telangiectasia
Which antibodies are associated with primary sclerosing cholangitis?
UC, anti-smooth muscle and anti-nuclear antibodies
What is the management of spontaneous bacterial peritonitis?
IV cefoTaxime to Treat
ciProfloxacin to Prevent
Which liver marker is high in alcoholic hepatitis?
AST (AST:ALT > 2)
What is the management of non-tense ascites?
reduce sodium and fluid, spironolactone (can add furosemide if not working)
How long before an endoscopy should PPIs be stopped?
2 weeks
What is the surgical intervention for achalasia?
Heller cardiomyotomy
What is the first line management of diarrhoea in IBS?
loperamide
What scoring systems are used for GI bleeds?
Blatchford before endoscopy
Rockall after
Which conditions affect folate absorption?
SIBO causes high folate as the bacteria produce folate
Coeliac causes low folate because damage to the duodenum means it is not absorbed
What are the features of wilson’s disease?
Behavioural, speech and psychiatric problems, asterixis, chorea, dementia. Low serum caeruloplasmin and total copper, but free copper is increased.
What is the management of Wilson’s disease?
Penicillamine (copper chelation)
What is the management of hypercalcaemia?
IV 0.9% saline (sodium drive renal excretion) and then bisphosphonates IV
