Gastro/hepatology Flashcards
C diff gram stain
anaerobic gram positive
Anti mitochondrial antibodies seen in what ?
PBC
Rx of puritus
Cholestyramine
Usual bugs which cause a liver abscess
E coli
Klebsiella
[staph aureus, strep enterococcus]
Candida 10%
Amoeba 10%
Where are amoebic abscesses in liver usually found? Spread from gut how?
Right lobe
Through portal system
Usual diagnostic test for liver abscess
Ultra sound
Staph food poisoning means it is producing what? Onset?
Enterotoxin
fast (often by 2-4 hours)
Salmonella after eating what? how long before symptoms ?
Poultry / eggs / milk
12-72hrs
[usually bloody diarrhoea due to ability of organism to invade mucosa]
Listeria seen following eating what? Key features to make suspicious ?
Unpasteurised dairy products
Mild diarrhoea + headache/confusion (CNS infection)
-Seen in sepsis of elderly and pregnant
Most common cause of infantile gastroenteritis
Rotavirus
Salmonella gram stain
gram negative
Shigella appearance on gram stain
Gram negative rod
First line Abx for
etamoeba histalogica?
Campylobacter?
giardia?
salmonella?
Shigella?
amoeba - Metronidazole
Campylobacter - metronidazole followed by diloxanide
giardia - metronidazole
salmonella - None if healthy. Cipro/trimethoprim for >50 , immunocompromised or have prosthetic valves etc
Shigella - None if healthy, cipro if severe
Colostrum perfringes time to symptoms?
6-12 hrs
yersinia enterocolitica is a rare food poisoning from uncooked meat. Time to symptoms? What are the symptoms and rx?
1 -4 days - probs back from india
Severe diarrhoea / renal impairment
Cipro
What is the hydrogen breath test used for?
Lactose intolerance / bacterial overgrowth
Coeliac which cell in pathogenesis? Genetic assoc? 1st/ second antibody test?
T-helper
HLA-DQ2 (95%), HLA-DQ8 (5%)
Anti-ttg, then anti-endomysial if only weakly positive
What do all people with coeliac get?
Ca + vit D
[Need to check bone mineral density 1 year following diagnosis too]
Skin condition related to coeliac
dermatitis herpeitformis
Flu like illness -> painless jaundice? Important test?
Gilberts syndrome
[inherited disorder of bilirubin metabolism]
-> Isolated unconjugated hyperbilirubinaemia
Need to test direct(conjugated) and uncongugated.
Direct/conjugated will be low
Blood test for rotor syndrome? Inheritance
Autosomal Recessive
Causes a conjugated(direct) hyperbilirubinemia
(>50%)
Rotor syndrome and Dubin johnson syndrome are both recessive and cause conjugated hyperbilirubinemia. How to differentiate?
Liver biopsy in Dubin johnson would show darkly pigmented hepatocytes
Rotor would have norma histology
unconjugated hyperbilirubinaemia in neonates?
crigler-najjar syndrome
[Crawling Wriggler = crigler]
What happens in primary sclerosing cholangitis?
Chronic progressive inflammatory condition which leads to fibrosis and strictures of bile ducts
PSC linked to? Risk of?
IBD
Cholangiocarcinoma
Non-obstructive deranged LFTs with raised IgM?
IgG?
IgM - primary biliary cirrhosis
IgG - Active chronic hepatitis
3 ways of testing for H pylori
Urea breath test (carbon-13 injested)
Stool antigen
CLO test (during endoscopy)
Where do you biopsy in people with H pylori at endoscopy? Why?
Antrum
Helpful for determining abx sensitivities
General Rx for dyspepsia ? if H pylori positive ?
PPI for 8 weeks
Add 1 week of amox/clari
Fever, anorexia and malaise which settle before -> Deranged LFTs and jaundice ? Incubation period?
Hep A
12-24 days
Briefly on the types/ transmission of Hep virus. Which are RNA ?
A - Fecal oral, RNA
-No chronic state
B- Blood/sex, DNA
C- Blood/Sex, RNA
D- Blood borne. Depends on HepB for replication. IncompleteDNA.
-Chronic if Hep B chronic
E- Fecal oral/Vertical.
-Chronic only if immunocompromised
Test for acute/past Hep A?
HAV-IgM + IgG = acute infection
HAV-IgG but not IgM = Past infection (IgGONE)
Indicator of current HepB infection?
Infection in past 6 months? Which always positive if past infection?
HBVsAg
HBV-IgM
HBV-IgG
Hep B antibodies if immunised?
Anti-HBs but not Anti-HBc
HepC current infection maker? Prev?
Hep-C PCR
Anti-HCV antibodies confirm exposure
HepB/C pharmalogical Rx
Hep B - pegylated interferon alpha-2a
Heb C - DAAs (direct acting antivirals)
Which are longer; diverticular or malignant strictures? Other differences between the two
Diverticular are longer
They do NOT have apple core appearance
Smooth walled
No mucosal disruption
Indications for elective surgery in diverticulosis
Diverticulitis in <50, or 2+ episodes in >50
Fistulae
Chronically immunosuppressed
Perf / abscess
Variceal haemorrhage. What drug as secondary prophylaxis? Why?
Propranolol
Reduced portal hypertension and cirrhosis progression
Where are bile acids re-absorbed? What does this lead to if you have surg there? Management of this?
Terminal ileium (ileocaecal)
70% of Crohn’s affects here
It can lead to chronic diarrhoea due to bile acids causing increased colonic motility and stimulating water secretion.
Cholestyramine
Which virus causes most rapid acute hepatic failure
Hep A
A= Acute
How many people with hep c clear spontaneously/
20-50%
Random glucose level for diabetes
> 11
Multiple adenomas/ soft tissue tumours eg lipomas
Intestinal bowel Ca young ~35
Hypertrophy of retinal epithelium
Syndrome? Rx?
Gardner syndrome - Dominant
Total colectomy after the development of colonic polyps
Intestinal harmatomas + peri oral pigmented macules?
Peutz-jeghers syndrome
oesophageal Ca where most common for SCC? adenocarcinoma?
SCC - mid thoracic
Adeno - lower oesophagus
Tylosis is what? Key risk?
Dominant disorder causing hyperkeratosis of palms and soles
Oesophageal Ca
What testing might you do for metastatic oesophageal adenocarcinoma?
HER2 receptor testing
The best test for confirming H pylori eradication? When would you use an invasive test?
13CUrea breath test
Endoscopy if complex peptic ulcer disease or MALT lymphoma
What are juvinile polyps, how do they present and Rx?
The most common cause of polyps in kids - usually in rectum
Present with prolapse / bleeding in kids
Treated with excision
Single reddish/purple intestinal polyp
Benign lymphoma
How to differentiate benign and malignant lymphoma on histology?
Benign has well-defined geminal centre
Smooth muscle intestinal tumour?
Leiomyoma (GIST)
Hard, pedunculated tumour
fibroma
Who gets no surveillance colonoscopy if known polyps?
> 75
Life expectancy < 10 years
Following curative resection of Ca, how long for surveillance colonoscopy?
1 year
When would you repeat colonoscopy after 2-6months
Following resection of large non-pedunculated polyps to check the site of resection.
[Will then get another at 12 months if satisfactory]
Arthralgia, cough, lymphadenopathy, pyrexia
Periodic acid-schiff (PAS) positive macrophages on biopsy? Rx?
Whipples disease (Tropheryma whipplei)
Requires Ceftriaxone / Benpen [followed by - 1-2 years of trimethoprim / sulfamethoxazole]
[Relapse in 40% of cases]
Gradual onset bloody diarrhoea, Ulceration on sigmoidoscopy. Hx of travel to funky place. Diagnosis? Rx?
Amoeba
[be aware stool sampling only detects in 50%, PCR / serology useful]
Metronidazole
Blood test usually raised in parasite infection
eosinophils
Some worms spread from animals to humans
sheep and goats?
Pigs?
Sails?
Key other bits the question will give….
sheep, dogs and goats - hydatid (Echinococcus granulosus)
Often chronic cough / general abdo Sx from cysts forming in liver/lungs
Sometime neuro Sx
Pigs - Cysticercosis (tapeworm Taenia solium)
Seizures
Sails - Shisto
Bladder / GI + risk of bladder Ca
Intense perianal itching at night in the UK bug?
Threadworm
[enterobius vermicularis]
How does hookworm present?
Symotomatic anaemia
Skin lesions and progressive blindness
onchocerciasis (river blindness)
Profound often unilateral leg swelling
lymphatic filariasis
Intensely itchy erythematous papular rash within 24 hrs of swimming
Shisto
[Self limiting]
When does shisto usually present? What is this called sometimes and how?
4-8 weeks post exposure
Fever, itch, diarhorrea, hepatosplenomegaly, wheeze and cough
[Katayama fever]
Where does chronic shisto affect?
Urinary - terminal haematuria / fibrosis / calcification
Bowel/liver - Bloody diarrhoea, splenomegaly, ascites, GI bleeding [Due to periportal fibrosis -> portal HTN]
Hydatid cysts often form in liver / occasionally brain / lungs. Key complication if they rupture
Anaphylaxis
Asymptomatic eosinophilia might be a parasitic infection. What 2 other causes do you need to consider
eosinophilic granulomatosis with polyangiitis (EGPA) [Churg strauss]
Drug reaction
Pharmalogical Rx of…
Isolated hydatid cysts
Lymphatic Filiarasis
Onchocerciasis
Shisto
Hook worm
Threard worm
Round worm
Strongyloides
[Harry Potter Loves Dieing Only Iv Some People with Strong Ish/Abs]
Isolated hydatid cysts - Prolonged praziquantel/albendazole [Usually requires srug drainage/ hypertonic saline injection]
Lymphatic Filiarasis - Diethlycarbazine
Onchocerciasis - Ivermectin [one dose]
Shisto - praziquantel
Hook worm - Mebendazole
Threard worm - Mebendazole
Round worm - Mebendazole
Strongyloides - ivermectin / abendazole
Which parasite might last for decades causing vague symptoms such as bulky loose stool, bloating / discomfort and eosinophilia but not have any changes on biopsy?
Strongylotide
AFP?
CA-19-9?
CA-125?
CEA?
AFP - Liver
CA 19-9 - Pancreatic [ usually post-resection for monitoring recurrence]
CA 125 - Ovarian
CEA - Colorectal [but also sometimes pancreas/gastric/breast/thyroid]
Cancer which has epigastric pain which is ‘relieved by sitting forwards? What other presenting things with it?
Pancreatic
Obstructive LFTs
Thromboembolic disease
What is archalasia? Characteristic appearance on barium swallow?
Hypertensive lower oesophageal sphincter that fails to relax and some reduced peristalsis
[Usually get simultaneous dysphagia to solids and liquids, unlike in Oeseophageal Ca where starts with solids then goes to liquids]
Dilated oesophagus with ‘birds beak’ tapering
Which infection might cause secondary oesophageal achalasia? Also causes which issues?
Chagas disease
[parasite Trypanosoma cruzi - found in Brazil]
Cardiomyopathy, megacolon, megaduodenum, megaureter
‘corkscrew’ appearance of the oesophagus on barium swallow? Other key Ix and finding?
Oesophageal spasm
Manometry - high amplitude simultaneous peristalsis with long durations
Drug Rx of achalasia
Can use CCBs / nitrates prior to eating
[Usually surgical though]
Oesophageal spasm management
Trial of PPI first to rule out GORD
CCBs/nitrates/antidepressants
Surgical Rx of Achalasia
Balloon dilation or Cardiomyotomy
[cardia is part of oesophagus not the heart silly]
Can also use botox injection
Surgical Rx of oesophageal spasm
Botox
dilation
myotomy
What is zollinger-ellison syndrome also called? Blood test?
Gastrinoma -> recurrent peptic ulcers and diarrhoea
Serum gastrin
Iron deficiency anaemia + aortic stenosis? Ix?
Angiodysplasia
[causes GI bleeding, usually colonic]
coloscopy [Can get a second one if not found on the first and then capsule endoscopy]
Angiodysplasia [abnormal, tortuous, dilated small blood vessel in the mucosal and submucosal layers of the GI tract] + telangiectasia of skin and mouth
olser-weber-rendu
Differentiate angiodysplasia and haemangioma in bowel
Angiodysplasia - abnormal, tortuous, dilated small blood vessel in the mucosal and submucosal layers of the GI tract
Haemangioma usually cavernous, involve full thickness and often in rectum
Ix for small bowel overgrowth syndrome? Gold standard test?
Which two usual types of malabsorbtion do you get? Rx
Lactulose breath test
Gold standard is culture of small intestinal fluid (>105 CFU/ml)
-b12 deficiency (from bacteria using it) but often high folate from bacteria producing it
-fat malabsorbsion including Vit ADE [but not K as bacteria produce it] due to deconjugation of bile salts from bacteria
ABx for 2 weeks - lots of options [frequent relapses]
Which deficiency most common when
-Partial gastrectomy / duodenum?
-Jejunum ?
- terminal ileum?
Dude Is Just Feeling Ill Bro
-Duodenum Partial gastrectomy = iron
As iron absorbed in the first part of the duodenum
-Jej - Folate
- terminal ileum = b12
What does reduced bile acids lead to?
Steathorrea
Any red flag symptom with reflux
SCOPE SCOPE SCOPE
[Lethargy, itching, riased ALT, raised ++ ALP.]
Raised LDL cholesterol
PBC
Key risk for colorectal cancer in IBD?
duration of disease >10yrs
Age of onset <15
Widespread disease
Poor compliance
How do you measure hepatic encephalopathy ?
Conn score
0 - nil
1 - Lack of awareness. Anxiety / euphoria. Impaired addition
2 - Minimal disorientation to time/place. Inappropriate. Imapired subtraction
3 - Solomence / stupor. Responds to verbal stimulation
4 - coma
EEG in hepatic encephalopathy
high amplitude low frequency waves and triphasic waves
[not specific]
Why do you use rifaxamin in jhepatic encephalopathy
Decreases intesestinal production and absorbsion of ammonia
IBS symptoms in young. Mild iron anaemia, hypocalcaemia, hypoalbumin. What Ix first
Anti TTG
Well controlled type 1 diabetes. Why hypo after alcohol consumption
Low glycogen reserve
Best diuretic for ascites
spironolactone
[people with liver failure get splanchnic vasodilation -> stimulates RAAS and therefore aldosterone production.
Also metabolise aldosterone poorly in cirrhosis]
Oesophageal varicies drain into
Azygous vein -> SVC
What causes the renal failure in hepatorenal syndrome? Rx?
splanchnic vasodilation
Terlipressin (splanchnic vasoconstrictor]
What does omeprazole actually do?
Irreversibly bind to K+/H+ATPase pump.
[Pump has half life of 36 hours which is why effects dont last forever when take PPI]
What are red flag symptoms with reflux
Age >55 with ALARM
Anaemia
Loss of weight >10kg in 6 months
Anorexia
Recent onset worsening Sx
Melena / haematemesis
abetalipoproteinemia causes what
Lack of absorption of dietary fat + ADEK Vitamins
-> Rickets and clotting issues
High risk of re feeding with encephalopathy - what do you keep low in diet
Protein (as adds to ammonia burden)
Which aspergilous may increase risk of hcc
A. Flavus - from contaminated food
Produces Aflatoxin
Tired, Jaundiced, raised bilirubin, megaloblastic anaemia, angular stomatitis? Caused by? Rx?
pernicious anaemia
Anti-parietal antibodies which prevent production intrinsic factor which is required for B12 Absorption
[Bilirubinaemia due to increased turnover of immature RBCs]
IM b12
How to test B12 absorbstion
Schilling test (now rare as can just test for anti-parietal antibody)
Best long-term Rx of Archlasia
Balloon
Botox if elderly and not able to tolerate surg
Cocaine user. Bloody diarrhoea =? Where does it affect most? How to differentiate from IBD
Ischemic colitis
-Transient ischemic colitis which affects watershed areas of splenic flexure and rectosigmoid area
Faecal calprotectin will be normal / borderline
ESR / CRP will be normal / borderline
PSC affects all bile ducts but what is
Usual age?
Most linked to?
Key risk?
Management in late stage?
Men <50
UC (more than Crohns)
cholangiocarcinoma
Liver transplant only option in late-stage
Which sign is always related to portal hypertension? What pressure is hypertension
Caput medusae - distended periumbilical veins
These veins usually shrink away after birth and only recanalize following significant portal hypertension
> 12mmHg
What is budd chiari
obstruction of the hepatic vein due to
-tumour
-haem disease
-Contraceptive pill
What is TIPSS? What happens in 25%
Transjugular intrahepatic portosystemic shunting
Connects portal vein (high pressure) to hepatic vein (low pressure)
May precipitate hepatic encephalopathy in 24%
Key diagnositic test for achlasia
Oesophageal pull through manometry
Arthritis, tanned, Liver disease? Gene? Why do women present later in life?
Haemochromatosis
HFE [C282Y in white, H63D otherwise]
Women present later due to protective effect of menstruation
Best first line Ix in haemochromatosis
Transferrin saturation
Most important complications of haemochromatosis?
Gene implicated in cancer?
Diabetes (pancreatic deposits)
cirrhosis
HCC - 30% if C282Y gene
Cardiomyopathy
Where do most pancreatic Ca arise
70% in head of pancreas
Unoperable pancreatic Ca drug
Folfirinox
Diabetes, steoto/diarrhoea, gallbladder disease, weight loss, hypoCl = tumour producing what
Somatostatinoma
-> Inhibiton of insulin and pancreatic enzymes
Which renal transplant drug may give patietns a crohns-like entercolitis
Mycophenolate Mofetil
How do right sided colon cancers usually present
Symptomatic anaemia.
Dont tend to get any altered bowel habit symptoms such as in descending / sigmoid Ca / rectal
[75% all cancers are sigmoid / rectal]
Who gets bowel screening
60-74 every 2 years
Gastrin secreted by? Does what?
Antral G cells in response to gastrointestinal luminal peptides
-> Acid secretion
- smooth muscle contraction
-mucosal growth
What does enteroglucagon do
Slows GI transit -> increases absorbtion
What does pancreatic polypeptide do?
Inhibits pancreatic enzyme secretion
What stimulates secretin? What does it do?
Duodenal acids stimulate
->Stimulates pancreatic enzymes
-reduces gastric acid secretion
Somatostatin does?
Inhibits gastrin secretion (and all GI secretions)
Reduces GI motility
Endocarditis and colorectal Ca
Strep Bovis
Why is capecitabine a good chemo drug
Can take orally -> then metabolised into 5-fluorouracil (great bowel Ca chemo drug)
Biopsy of UC would show….
Intense infiltration of mucosa with neutrophils
crypt abscesses
Lamina propria with lymphoid aggregates, plasma cells, mast cells and eosinophils
How to test pancreatic exocrine function? insufficiency?
PABA testing
Fecal elastase (should be >200mcg/G)
Oral contraceptive pill causes with hepatic tumour
Hepatic adenoma (benign)
Hallmark feature of refeeding
HypoPO4
Intestinal TB on CT
Mesenteric thickening with lymph node enlargement
What are 80% of gall stones made of? When would they be made of something different
Cholesterol
If haemolysis / cirrhosis - made of black pigment
What are 80% of gall stones made of? When would they be made of something different
Cholesterol
If haemolysis / cirrhosis - made of black pigment
Fever jaundice RUQ pain=? What Ix if no stones seen on MRCP?
Charcots triad
EUS -
[ERCP is always interventional. No longer used for assessment of stones as invasive with assoc risks]
What is couvoisier’s law
A palpable gallbladder in the presence of painless jaundice is unlikely to be caused by gallstones
What can be used to dissolve gallstones in those unfit for surg?
Ursodeoxycarbolic acid
Asymptomatic gall stones? Bile duct stones?
Gall = watch and wait (can try avoid fatty foods etc)
Bile duct - get them out as lots of complications
What causes howel-jolly bodies?
They are RBCs which still have thier nuclei which are usually removed by the spleen.
-Seen in splenectomy / asplenia
Functional hyposplenism - sickle cell anaemia, liver cirrhosis, SLE, rheumatoid arteritis, coeliac disease, inflammatory bowel disease, splenic artery / vein thrombosis, amyloidosis, sarcoidosis
How to test for bile acid malabsorption? Eg after terminal ilectomy
SeHCAT test
Most important physiological mechanism preventing reflux
Parasympatheic stimulation of lower circular smooth muscle fibres of oesophagus
Protein levels in ascites for transudate and exudate? Some examples of each.
Transudate <25g/L
-Cirrhosis, R heart failure, nephrotic syndrome / nephritis, bud-chiari
Exudate >35g/L
TB/infection eg SBP, malignancy, inflammation Eg Vasulitis, pancreatitis …
Milk-coloured fluid on ascitic tap =?
Chylous ascites
[ lipid-rich lymph into the peritoneal cavity. This usually occurs due to trauma and rupture of the lymphatics or increased peritoneal lymphatic pressure secondary to obstruction.]
How to identify portal hypertension usuing ascities
SAAG (Serum Ascities Albumin gradient)
Serum level minus Ascities level
> 1.1g/L =Portal hypertension
3 main causes of bud chiari
Tumour
Haem disease
Contraceptive pill
Pleural effusion, ascites and a benign ovarian tumour =
meigs syndrome
Which IBD drug causes pancreatitis
Azathioprine
What is usually a feature of chronic pancreatitis
Calification - seen on XR / CT
HNPCC Cancers
colorectal cancer (often proximal)
endometrial, ovarian, and skin cancers.
FAP vs HNPCC brain tumour
[Polyps + brain tumour = ]
FAP - Medulloblastoma
HNPCC - Glioblastoma
[Turcot syndrome]
FAP common cancers
Usually just 100s of polyps + ColoRECTAL Ca
duodenum, and cancer of the thyroid, pancreas, liver (hepatoblatoma), central nervous system (CNS), and bile ducts, although these typically occur in less than 10% of affected individuals.
Gallstones + pancreatitis. Where is stone
Ampulla of vata (where ducts join)
What would be seen on biopsy of lymph glands in whipples (get lymphadenopathy). Why do they get deranged clotting
Diffuse histocytes
Malabsorbsion - Vit K
Variceal bleed. Terlipressin vs omeprazole
Terlipressin - and continued for 5 days / when definitive hemostasis.
[Omeprazole of no benefit if not bleeding peptic ulcer]
Which 2 chronic diseases have a high risk of gallstones
Crohns - terminal ileum
Hereditary spherocytosis
Stain for GIST tumours
CD117
Zollinger-Ellison syndrome cancers secrete? Key Sx?
Ix/Dx? Rx + rx for diarrhoea?
Gastrin
Pain and dyspepsia from multiple ulcers
Steat/diarrhoea from excess acid
High serum gastrin + increased acid output
Endoscopy +/- CT
High dose PPI
Ocretide for steatorrhoea
Resection
Peptic ulcer Surg -> delayed gastric emptying? Rx
Stricture
Endoscopic dilatation
Rx of HELLP
Mg
-> delivery
Emboli vs thrombosis in Small bowel ischemia
Thrombosis usuallly at origin of SMA -> fucks the lot
Emboli - usually lodge in Middle colic (first branch of SMA) and therefore spares first part of jej
MI and reflux disease. What interaction is likely
Omeprazole + clopidogrel (reduces clopidogrel)
Change to lansoprazole
PSC common immuno blood finding
p-ANCA
HLA-DR3 (Also seen in T1DM)
Autoimmune hepatitis antibodies
ANA
Anti-smooth muscle
PSC:
how high is the risk of cholangiocarcinoma
Male / female predominance?
How many have IBD?
30-40% risk of Ca
Males 70%
75% have IBD (or will have)
Thiamine is vitamin…
B1
How to make dx of c diff colitis
ELISA of toxins (a and b)
Systemic sclerosis. Why do they get long standing diarrhoea? rx?
Systemic sclerosis -> strictures / diverticulum in small bowel
-> slowed transit -> bacterial overgrowth
Rotating long term abx eg metronidazole / cipro
Only organ in contact with left kidney
Pancreas
What is lynch syndrome ? Drug which reduces risk of Ca?
HNPCC
Aspirin reduces risk of colorectal cancer
Which type of polyp has highest risk of colon Ca
serrated
(serrated are sad)
Pruritus and elevated bile acids in pregnancy? Risks? Dx?Rx?
Intrahepatic cholestasis of pregnancy
Preterm, baby death, Respiratory distress syndrome, meconium-stained amniotic fluid
-May get malabsorption of ADEK
raised serum bile acids
Ursodeoxycarbolic acid +/- delivery
Liver dysfunction in 3rd trimester risk? Rx?
Acute fatty liver of pregnancy
May get clotting abnormalities -> death
Prompt delivery
Shellfish -> couple of days then abrupt voluminous watery diarrhoea. Rx?
Cholera
Rehydration
Oral Abx Eg Doxy / cipro…
Which liver enzyme often increased in pregnancy
ALP -> secreted by placenta
Whipple’s -> 3 weeks (during treatment) get worsening of symptoms again =
Immune reconstitution inflammatory syndrome
(if no arthralgia consider C diff)
Drug other than terlipressin for variceal bleeding
Ocretide [think not Omeprazole but Ocretide]
[Works in lots of ways
-Splanchnic effects
-Decreases acid / panc enzymes [=good for ulcer bleed too]
-Increases oesophageal tone
-Inhibits peptic digestion of blood clots ]
UC mild and distal bum rx
rectal mesalazine
Lots of vomiting in pregnancy and mild deranged LFTS
Hyperemesis
How to monitor venesection for iron overload
Based on ferritin levels
Best Ix for suspected h PYLORI
Urea breath test
(stool test for kids who cant tollerate breath test)
Colon diameter in UC which prompts surg referral
> 5.5cm
What guides risk of early mets in colorectal ca
CEA levels
Refeeding and became profoundly weak what electrolyte to replace first
PO4
Age of onset of symptoms with Wilson’s? Gene? Serum /urine copper?
10-25 years
ATP7B gene
Serum copper and ceruloplasmin are usually low
Urine excretion also usually high
Who gets banding in varicies for secondary prevention
Grade 2 or 3 (or actively bleeding)
Grade 1 just get oral propranolol
Angioedema in the absence of urticaria is due to a deficiency of what
C1 esterase inhibitor
[Or taking ACEi]
Which bilirubin is direct?
Conjugated is Direct
UNconjugated is INdirect
Child / teen Presents with jaundice and conjugated (direct) hyperbilirubinaemia. Liver Biopsy shows dark pigmented granulocytes =?
Dubin-johnson syndrome
Which food contains the most vit D
Oily fish
Key drug to help with carcinoid sx (flushing, wheeze, diarrhoea)
Ocretide (somatostatin analouge)
% mortality in bleeding varices
30%
Markers of mortality in acute liver failure
-Ie Indications for referral for Tx
Creatinine >300
INR >6.5
pH <7.3
Which gastric Ca do you get in H pylori
MALT (B cell) lymphoma
Low vit what is a risk for gastric Ca
Vit C
[And Vit D]
Wilson’s uric acid?
Low serum uric acid (due to high urinary excretion)
2 drugs which cause bile acid malabsorption
Metformin
Colchicine
who gets melanosis coli [darkish pigmented ] most commonly?
What if there were hyperpigmented spots in the mouth as well?
Chronic laxitives
Peutz-jehger (benign polyps mostly with dark areas)
Arthralgia and malabsorbtion got to think? Key Ix
Whipple’s
biopsy for PAS macrophages
carcinoid tumours usually bronchi or where in GI?
Jej / ileium
The cardiac issue in carcinoid
Fibrosis of heart valves
What does it mean if APTT does not correct on a 50:50 mixing study?
Presence of a Factor VIII inhibitor
[rather than factor VIII deficiency
If haemophilia / VWD it would correct on the mixing study]
Eg Phenytoin, penicillin, sulfa drugs
Chronic abdo pain, ERCP - no malignancy with calcification of pancreatic branches. Dx? Rx of pain?
Calcification = Chronic pancreatitis
Opiates are mainstay of pain control
Creon may help if Sx of steatohheora
What is kernicterus
unconjugated hyperbilirubin-induced neurotoxicity
-Seen in criggler Najjar but not gilbers
First line for isolated hyperbilirubin and anaemia
Coombs
Symptoms like coeliac but from a foreign place with megaloblastic anaemia and deficiencies? Rx?
Tropical sprue
Ampicillin / doxy for 4-6 weeks
> 65 and given course of abx. Now presents with cholestasis and arranged LFTs. Which Abx?
Co-amox
What is hairy leukoplakia?
EBV - white patch on the tongue with ‘hairy appearance’
Usually only in immunocompromosed / HIV
Loss of libido, joint pains, polyuria/dipsia, palmar erythema and spider naevi. Bm 10.8 random. Dx?
Haemochromatosis
Libido - loss of testosterone
Diabetes - pancreatic deposits
+ Markers of liver disease
Glasgow score for pancreatitis - PANCREAS
Pa0₂
Age
Neutrophilia (wcc)
Calcium
Renal (Urea )
Enzymes (AST /LDH)
Albumin
Sugar (Blood Glucose)
Pa0₂ <8 kPa
Age >55 years
WBC >15x10⁹/L
Calcium <2mmmol/l
Urea >16 mmol/L
AST >200 U/L
(LDH) >600 U/L
Albumin <32g/L
Blood Glucose >10 mmol/L
metformin assoc increased bile acid secretion. 1st line Rx?
Switch to MR metformin
Goes abroad and comes back with IBS symptoms. Treated with Abx but now has persistent diarrhoea. What has happened?
Giardia -> lactose intollerance
[takes weeks/months to resolve]
Giardia Rx
single dose Tinidazole
What does the C282Y gene lead to in Hamochromatosis
Decreased Hepcidin formation
[Impaires HFE to bind to beta-2-microglobulin and so it accumulates in intracellular space]
Abx for small bowel overgrowth
Metronidazole
Cipra
Co-amox
Gallstones leading to Derranged LFTs and raised amylase - where is stone
Distal common bile duct / ampulla of vata
Strep Bovis comes from where to cause endocarditis? Essential Ix after treatment?
Bowel
Needs colonoscopy to rule out GI malignancy
Features of severe UC attack
Number of poo
Temp
HR
Hb
ESR
> poos
37.8
Pulse >90
Hb anaemic
ESR >30
Protein losing enteropathies?
IBD
C.diff + CMV
Tb
Sarcoid
Connective tissue diseases
Obstructive jaundice. What are the 2 causes of intrahepatic and extrahepatic bile duct dilation?
PSC
Cholangiocarcinoma
Old - malaise nausea weight loss. Raised ALP and GGT. Epigastric tenderness on deep palpation
Pancreatic Ca
If not in the head it won’t cause obstructive jaundice until very big
Cholangiocarcinoma usually presents with
Obstructive jaundice
Who gets clubbing in crohns
Active small bowel disease
SBP most common bug? Rx?
E coli [then strep]
Cef / cipro are recommended
Familial hypercholesterolaemia is due to?
Familal hypertriglyceridemia?
Mixed hyperlipidaemia?
Deficiency of LDL receptor
Lipoprotein lipase
Apopprotein E2
Familial hypercholesterolaemia is due to?
Familal hypertriglyceridemia?
Mixed hyperlipidaemia?
Deficiency of LDL receptor
Lipoprotein lipase
Apoprotein E2
Suspect protein losing enteropathy. What stool Ix can you do?
Stool A1AT
- Doesn’t get degraded by bowel enzymes->indicator of other plasma proteins being found in the gut
Barrets oesophagus How often for endoscopy?- What to do if endoscopy demonstrates low-grade dysplasia (poorly differentiated cells)?
High grade?
Endoscopy every 2-5 years
Low grade - repeat biopsy and biopsy every 1cm
-Biopsy every 6 months
High grade
- If visible: endoscopic ablation + mucosal resection
-radiofrequency ablation
-Biopsy every 3 months
2 parts of bowel most at risk of ischemic colitis
Splenic flexure
Sigmoid
Which of the COX inhibitors has least risk of gastric ulceration?
Celecoxib
(COX-2)
Anti-LKM antibody found in both
Autoimmune hepatitis
Drug-induced hepatitis
-Think about this esp if they’ve been on drugs that cause hepatits+ short history of illness
4 classic causes of drug-induced hepatitis
Methyldopa
Isonazid
Nitrofurantoin
Ketoconazole
with aNtI-LKM
ALT:AST ratio >2 indicates
Non-alcoholic
AST:ALT > 2 is alcoholic
Most common cause of liver abscess?Differentiate from amoeba ?
Ecoli and S aureus
-Tend to occur quicker Eg 2 weeks after exposure
-Be multiple
-Pus filled (amoeba is non-pyogenic)
Upper GI bleed - what is shown to improve survival the most (pharma Rx)
Antibiotics
Then terlipressin
[ocretide no proven benefit]
Suspected giardia Dx?
Stool antigen test
[often need 3 stool samples to detect bug otherwise]
What might falsely elevate urinary 5-HAII levels
Diet rich in veg - often need to repeat after dietary restriction
When might eradication of H pylori in a MALT lymphoma not save the day
t (11:18)
What is most associated with H pylori
Duodenal ulcers - 90% have h pylori
[Gastric ulcer - 80%
MALT - 80%]
Epigastric pain. Endoscopy - giant gastric folds, gland atrophy and hyperplasia of gastric pits =? what key blood finding?
Menetriers disease
Hypoalbuminaemia (loss from gastric mucosa)
UC often has which antibody
p-ANCA
Severe malnutrition often get what as a result of the liver trying to maintain albumin concentrations through anabolic processes?
Steatohepatitis and hypercholesterolaemia
‘thumb printing’ on Xray usually found where indicating what?
Splenic flexure - ischemic colitis
Vinly cloride is assoc with which Ca?
Nickle?
Haemangiosarcoma of liver
Squamous cell of oral cavity
Coeliac non Bowel symptoms
Deratits herpetiformis
Mouth ulcers
Acute pancreatitis and lipaemic blood sample. What is cause?
chylomicrons
PBC common Ig raised? key Sx is advanced disease
IgM
Back pain in advanced disease
Key histological finding acute HepE
Marked cholestasis
Ulcerative colitis for many years, now 4 months of a mild increase in stool frequency. Key ix?
Urgent colonsocopy - high risk of colic adenocarcimona
Crohns peri anal abscess ix?
Pelvic MRI
[josh purves MRI fistulas]
Can crohns present in old people
Yep >60 happens
Ix to determine chronic carrier status of salmonella
Intestinal / stool / urine secretion culture
Wedged hepatic venous pressure measures what?
Hepatic sinusoids
Ribavirn key side effect
[used for hepC]
Haemolytic anaemia
Rx of isolated distal UC
Rectal mesalazine
Lansoprazole machanism
h+/K+ ATP pump blocker
New dyspepsia at what age is indication for referral for UGI scope
> 55
Barrets on biopsy
Normal oesophageal squamous epithelium replaced with collumnar and goblet cells
Indications for TIPPS
Uncontrolled bleeding varies
Refractory ascites
Hepatic pleural effusion (hydrothorax)
What time of day do people with functional bowel disorders not get diarrhoea
Through night
Peutz-Jegher inheritance? chrom? gene
Dominant
STK11/LBK1
Chrom 19
