GASTRO GAP Flashcards
INV FOR ZOLLINGER ELLISON
Diagnosis
fasting gastrin levels: the single best screen test
secretin stimulation test
GI Enzymes:
MALTASE
SUCRASE
LACTASE
MALTase = 2 glucose - NestoMALT - Double Glucose= Glucose + Glucose
sucRase = glucose + fRuctose
LACtase = glucose + gaLACtose
Hepatic vs Cholestatic Picture
proportionate rise in ALT > proportionate rise in ALP = hepatitic
hePAtitic e alP kom thake
proportionate rise in ALT < proportionate rise in ALP = obstructive/cholestatic
Alcoholic Liver Disease
gamma-GT is characteristically elevated
the ratio of AST:ALT is normally > 2, a ratio of > 3 is strongly suggestive of acute alcoholic hepatitis
Jejunal villous atrophy causes
Jejunal villous atrophy
Whilst coeliac disease is the classic cause of jejunal villous atrophy there are a number of other causes you need to be aware of
Causes
coeliac disease
tropical sprue
hypogammaglobulinaemia
gastrointestinal lymphoma
Whipple’s disease
cow’s milk intolerance
Hepa B Serology
‘S’ is sinister
HbsAg shows ongoing infection either Acute or chronic means sinister is there.
Anti-Hbs is anti sinister: means immunized against sinister through vaccine or developed immunity after sin.
‘C’ is caught: anti- Hbc means have caught the virus at some stage. not positive in vaccine. Igm is for 6 months then igG after 6 months implying chronic infection.
‘E’ for enfectivity. HbeAg means ongoing enfection.
Inv for Primary Biliary Cholangitis
- anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific
- smooth muscle antibodies in 30% of patients
- raised serum IgM
imaging
required before diagnosis to exclude an extrahepatic biliary obstruction (typically a right upper quadrant ultrasound or magnetic resonance cholangiopancreatography (MRCP)
Pancreatic Cancer Presentation
The patient’s history (weight loss, jaundice, pruritis and steatorrhea), examination (palpable gallbladder - Courvoisier’s sign) and blood tests (obstructive jaundice) are most suggestive of pancreatic cancer. High resolution CT is the diagnostic investigation of choice.
Presentation of Biliary colic
The patient presents with colicky right upper quadrant pain after eating a fatty meal in the background of a raised body mass index. The likely diagnosis is biliary colic.
Inv for Gilbert
Investigation and management
investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid
no treatment required
OGD finding of gastric cancer
Signet Ring
Villousb adenoma
Diarrhoea + hypokalaemia → villous adenoma
RX Ulcerative Colitis
Inducing remission:
1. Treating mild-to-moderate ulcerative colitis
proctitis:
- topical (rectal) aminosalicylate: rectal mesalazine
- oral aminosalicylate
- topical or oral corticosteroid
proctosigmoiditis and left-sided ulcerative colitis
- topical (rectal) aminosalicylate
- a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
- if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
-
extensive disease
topical (rectal) aminosalicylate and a high-dose oral aminosalicylate:
if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
Severe colitis
should be treated in hospital
IV steroids are usually given first-line
IV ciclosporin may be used if steroids are contraindicated
if after 72 hours there has been no improvement, consider adding IV ciclosporin to IV corticosteroids or consider surgery
Maintaining remission
Following a mild-to-moderate ulcerative colitis flare
proctitis and proctosigmoiditis
topical (rectal) aminosalicylate alone (daily or intermittent) or
an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
an oral aminosalicylate by itself: this may not be effective as the other two options
left-sided and extensive ulcerative colitis
low maintenance dose of an oral aminosalicylate
Following a severe relapse or >=2 exacerbations in the past year
oral azathioprine or oral mercaptopurine
Other points
methotrexate is not recommended for the management of UC (in contrast to Crohn’s disease)
there is some evidence that probiotics may prevent relapse in patients with mild to moderate disease
Maintainence of Remission of UC
Maintaining remission
1. Following a mild-to-moderate ulcerative colitis flare
a. proctitis and proctosigmoiditis
- topical (rectal) aminosalicylate alone (daily or intermittent) or
- an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
- an oral aminosalicylate by itself: this may not be effective as the other two options
b. left-sided and extensive ulcerative colitis
low maintenance dose of an oral aminosalicylate
**
2. Following a severe relapse or >=2 exacerbations in the past year**
oral azathioprine or oral mercaptopurine
NICE Bariatric Referral Cut-offs
with risk factors (T2DM, BP etc): > 35 kg/m^2
no risk factors: > 40 kg/m^2
Achalasia XRay
oesophageal manometry
excessive LOS tone which doesn’t relax on swallowing
considered the most important diagnostic test
Drugs causing hepatocellular disease
mnemonic for DRugs causing hepatocellular disease:
Peter- Paracetamol
Had- Halothane
Epilepsy- sodium valproated and phenytoin
And- amiodrone
Alcoholic- Alcohol
TB- anti-tbs
he Met- Methyldopa
dr. Mel Nora- MAOI, Nitrofurantoin
in the STATes- Statins
The following drugs tend to cause cholestasis (+/- hepatitis)
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine
MNEMONIC: PASS FOR
phenothiazines
antibiotics
anabolic steroids
sulphonylureas
FOR-
FIBRATES
OCPS
RARE- NIFEDIPINES.
Drugs causing Liver cirrhosis
Methotrexate
Methyldopa
aMiodarone
Pancreatitis causes
Popular mnemonic is GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
Scorings of Liver Cirrhosis
Child Pugh
MELD score (Model for End-Stage Liver Disease)
Child Pugh Score consists of
Bilirubin
Prothombin Time
Albumin
Encephalopathy
Ascites
Rx of Achalasia Cardia
- pneumatic (balloon) dilation is increasingly the preferred first-line option
- surgical intervention with a Heller cardiomyotomy should be considered if recurrent or persistent symptoms
- Intra-sphincteric injection of botulinum toxin is sometimes used in patients who are a high surgical risk
- drug therapy (e.g. nitrates, calcium channel blockers) has a role but is limited by side-effects
Rovsing sign
Psoas Sign
Rovsing’s sign (palpation in the LIF causes pain in the RIF) is now thought to be of limited value
psoas sign: pain on extending hip if retrocaecal appendix
Some common factors indicating severe pancreatitis include:
However, some common factors indicating severe pancreatitis include:
age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST
Causes of Pancreatitis
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
Alcoholic Ketoacidosis
It typically presents with a pattern of:
Metabolic acidosis
Elevated anion gap
Elevated serum ketone levels
Normal or low glucose concentration
Haemochromatosis
Genetics
HFE gene on chromosome 6
Autsomal recessive
Peutz-Jeghers syndrome
- autosomal dominant
- responsible gene encodes serine threonine kinase LKB1 or STK11
- numerous hamartomatous polyps in the gastrointestinal tract
- pigmented freckles on the lips, face, palms and soles.-
- 50% of patients will have died from another gastrointestinal tract cancer by the age of 60 years.
Dabigatran is reversed by
**Idarucizumab
**
Brand name of dabigatran is Pradaxa®, which is reversed by Praxbind (idarucizumab)
- RivaroXaban, apiXaban, and edoXaban all ‘ban Xa’ = factor Xa inhibitors Antidote: andeXanet alpha
Da(BI)gatran (bi = 2) = factor 2a (thrombin) inhibitor
Antidote: (IDA)rucizumab = (I)nhibits (DA)bigatran*
Angiodysplasia
- IDA
- GI Bleed (Positive FIT, but negative OGD/Colonoscopy- needs Capsule endoscopy)
- Aortic Stenosis
