Gastro I Flashcards
State the incubation times for common causes of gastroenteritis [4]
How do you treat Campylobacter jejuni infection? [3]
- Clathromycin (1st line)
- Azithromycin
- Ciprofloxacin
A patient has recently eaten fried rice left at room temperature. They are reported vomitting and then diarrhoea.
What is the most likely pathogen causing these symptoms? [1]
Bacillus cereus
What syndrome can Shigella cause? [1]
Name two treatments [2]
haemolytic uraemic syndrome:
Treatment of severe cases is with azithromycin or ciprofloxacin.
How do you treat Giardia lamblia? [2]
tinidazole or metronidazole
How do you differentiate between moderate and severe C. diff infection? [1]
A raised WBC count (but less than 15 * 109 per litre) is indicative of a moderate C. difficile infection.
If the WBC count is greater than 15 * 109 per litre, it is indicative of a severe infection.
Describe diagnostic investigations for GORD [3]
Therapeutic trial of PPI:
- i.e. 40mg of omeprazole for 2 weeks and if the symptoms are completely resolved on that and no alarm symptoms, this may be a reasonable diagnostic tes
Endoscopy (NB: ~ 50% have no lesions);
- used to create Los Angeles scoring system for oesophagitis
Oesophageal function testing:
- can monitor pH over 24 hours using a small sensor
Describe the LA Classification of oesophagitis [4]
Grade A
- At least one mucosal break, up to 5 mm, that does not extend between the tops of two mucosal folds
Grade B:
- At least one mucosal break, more than 5 mm long, that does not extend between the tops of two mucosal folds
Grade C:
- At least one mucosal break that is continuous between the tops of two or more mucosal folds but which involve less than 75% of the circumference
Grade D:
- At least one mucosal break which involves at least 75% of the esophageal circumference
State the therapeutic management for GORD
- Therapeutics [4]
- Surgery [1]
Drugs:
If no red flags: 4 week PPI course:
- omeprazole
Antiacids: Mg trisilicate
Alginates: Gaviscon
Acid suppression:
- PPIs: omeprazole and lansoprazole
- or H2 receptor antagonists: famotidine or ranitidine
Surgery:
- laparoscopic fundoplication: tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter
Describe the treatment for
non-dysplastic BO [2]
low-grade dysplasia BO [2]
high-grade dysplasia [3]
non-dysplastic BO:
- PPI (omeprazole)
- Anti-reflux surgery (Nissen fundoplication)
low-grade dysplasia BO
- radiofrequency ablation
- consider PPI
high-grade dysplasia
- radiofrequency ablation
- consider PPI
- oesophagectomy
How do you diagnose EoO? [1]
How do you treat? [2]
Diagnose: biopsy
Tx: swallow inhaled steroids; exclusion diet
State five drug classes that can cause GORD [5]
- tricyclic
- anticholinergics
- nitrates
- CCBs
- NSAIDs
What is the seroligcal test of choice for a coeliac patient with IgA defiency? [1]
IgG DGP (deamidated gliadin peptide)
Which three antibodies are related to coeliac? [3]
Anti-tissue transglutaminase antibodies (anti-TTG)
Anti-endomysial antibodies (anti-EMA)
Anti-deamidated gliadin peptide antibodies (anti-DGP)
Why may coeliac disease lead to fat malabsorption? [2]
Decrease in absorptive surface area
Decrease in absorption of fat soluble vitamins: ADEK
Describe what is meant by refractory coeliac disease [1]
Describe the two classifcations [2]
Refractory coeliac disease: persistent or recurrent symptoms and signs of malabsorption despite adherence to a strict gluten-free diet for at least 12 months. Believed to be independent of gluten since the gluten-free diet is not effective in preventing the lymphocytes from increasing.
Type I:
- Have < 20% abnormal lymphocytes
Type II:
- Have >20% abnormal lymphocytes
State why and explain which type of refractory coeliac disease is more prone to cancers [2]
Type II:
- Type II have a greater than 50 percent chance of the abnormal lymphocytes spreading outside the gut
- Causes: developing enteropathy-associated T-cell lymphoma (EATL)
Which type of cancer in the GI tract do coelaic patients suffer a risk of developing? [1]
Small bowel adenocarcinoma
A transjugular intrahepatic portosystemic shunt (TIPS) procedure connects the [] to the []
A transjugular intrahepatic portosystemic shunt (TIPS) procedure connects the hepatic vein to the portal vein
What do you give to treat minor and major salicylate poisoning? [2]
If overdoses are recent, administer activated charcoal
However, more significant overdoses may require alkalinisation with IV sodium bicarbonate in order to maintain blood pH at 7.5-8.0 , and enhance salicylate excretion.
What is the single laboratory finding that should prompt an immediate consideration of liver cirrhosis and urgent review by hepatology?
Platelet count = 90 x 10^9/ L
AST = 80 U/ L with ALT=85 U/ L
ALP = 155 g/ L
Urea = 11 mmol/L
Hb = 85 g/ L
What is the single laboratory finding that should prompt an immediate consideration of liver cirrhosis and urgent review by hepatology?
Platelet count = 90 x 10^9/ L
Thrombocytopenia (platelet count < 150,000 mm^3) is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease
Name a pneumonic for remembering the drugs that can cause pancreatitis [5]
SSAND
steroids, sodium valproate, azathioprine, NSAIDs, diuretics
The ‘double duct’ sign may be seen in [] cancer
Acanthosis nigricans is associated with [] cancer.
The ‘double duct’ sign may be seen in pancreatic cancer
Acanthosis nigricans is associated with gastric cancer
What results in a FBC and LFT would indicate alcohol excess? [2]
Isolated rise in GGT in the context of a macrocytic anaemia suggests alcohol excess as the cause
What treatment do you give to somone for N&V from a migraine? [1]
A prokinetic such as metoclopramide is the recommended antiemetic in these patients, as it helps to relieve the gastric stasis that can slow the transit and absorption of drugs during an acute migraine attack.
On examination, there is a single irregular deep ulcer on her right shin. The ulcer has a pustular surface and a blue overhanging edge.
What does this describe? [1]
pyoderma gangrenosum
Alendronate is indicated for the treatment of postmenopausal osteoporosis and is known to increase the risk of [2]
Alendronate is indicated for the treatment of postmenopausal osteoporosis and is known to increase the risk of oesophagitis and oesophageal ulcers
You suspect that a patient has had a paracetamol OD.
How do you determine if you should give NAC ASAP or investigate their paracetamol levels? [1]
N-acetylcysteine should be started immediately in staggered overdose, ingestion more than 15 hours ago or if there is uncertainty about timing.
If ingestion occurred 4 to 15 hours ago, a blood paracetamol level should be taken, and treatment commenced accordingly.
A patient presents with these changes to their nails.
You find they are suffering from micocytic anaemia.
What is the most likely cause?
Thalassemia
Anemia of chronic disease
Iron deficiency
Lead poisoning
Sideroblastic anemia.
A patient presents with these changes to their nails.
You find they are suffering from micocytic anaemia.
What is the most likely cause?
Thalassemia
Anemia of chronic disease
Iron deficiency
Lead poisoning
Sideroblastic anemia.
A patient presents with hypoalbuminemia.
Which nail changes are you likely to see
Clubbing
Koilonychia
Leuconychia
Mees’ lines
Onycholysis
A patient presents with hypoalbuminemia.
Which nail changes are you likely to see
Clubbing
Koilonychia
Leuconychia
Mees’ lines
Onycholysis
A patient has stage 4 CKD.
What nail change might you expect to see
Clubbing
Koilonychia
Leuconychia
Mees’ lines
Onycholysis
A patient has stage 4 CKD.
What nail change might you expect to see
Clubbing
Koilonychia
Leuconychia
Mees’ lines
Onycholysis
A patient presents with this nail change. What systemic condition is likely to have caused this? [1]
Psoriasis
A patient presents with these nail changes. You find out that they have normal iron levels.
What infective organism might cause this? [1]
Koilonychia refers to spoon-shaped nails. Can be caused by:
* Iron deficiency anaemia (e.g. Crohn’s disease)
* Lichen planus
* Rheumatic fever: therefore Streptococcus pyogenes
A patient has been diagnosed with lung cancer and are recieving chemotherapy. .
What nail change might you expect to see
Clubbing
Koilonychia
Leuconychia
Mees’ lines
Onycholysis
A patient has been diagnosed with lung cancer and are recieving chemotherapy. .
What nail change might you expect to see
Clubbing
Koilonychia
Leuconychia - chemotherapy can cause
Mees’ lines
Onycholysis
What are the three differentials for asterixis? [1]
CO2 retention (e.g. COPD)
Uraemia
Hepatic encephalopathy
A patient has these hands. Alongside cardio-resp diseases, what might a gastro differential be? [1]
IBD
Aspirational pneumonia in a COPD patient is most likely to be
Streptococcus pneumoniae
Staphylococcus aureus
Haemophilus influenzae
Pseudomonas aeruginosa
Klebsiella
Aspirational pneumonia in a COPD patient is most likely to be
Streptococcus pneumoniae
Staphylococcus aureus
Haemophilus influenzae
Pseudomonas aeruginosa
Klebsiella
NB: all causes of gram positive aspirational pneumonia
Name 2 cause of gram -ve aspirational pneumonia [2]
Bacteroides
Prevotella
Fusobacterium
Peptostreptococcus
According to the King’s College Criteria, a poor outcome in liver failure from paracetamol toxicity is predicted by: [1]
OR
combination of all three of [3]
pH < 7.3 24 hours after the overdose.
or, all three of the following:
Prothrombin time >100seconds or INR >6.5 seconds.
Creatinine >300Umol/L.
Grade 3 or 4 hepatic encephalopathy.
What are the different classes of blood loss? (% and volume lost?) [4]
Class 1:
- 10-15%
- 750mls
Class 2:
- 15-30%
- 1.5L
Class 3:
- 30-40%
- 2L
Class 4:
- >40%
- 3L
Which cannulae are wide bore? [4]
- 14G (300ml/min)
- 16G (150 ml/min)
- 17G
- 18G (75ml/min)
How do you optimise clotting:
- What levels should: platelets [1] and INR [1] be above/below? [2]
- Drug management? [2]
Platelets: > 50
INR: < 1.5
Do not give any anti-coagulants the Ptx may be on (warfarin, clopidogrel, aspirin, DOAC)
Reverse warfarin with vitamin K
What drugs might be prescribed if have an upper GI bleed? [2]
PPI:
- Decrease lesions identified at endoscopy level; but no difference in transfusion, surgery or mortality
- NICE does not rec. PPI before endoscopy
Tranexamic acid?
- improves clotting in area of GI bleeding, but may improve clotting with poor vascular blood flow & cause CAD.
Name the scoring system used to determine if risk of re-bleeding [1]
Which scores result in outpatient endoscopy [1]
Blatchford score
< 2: low risk - outpatient endoscopy
> 6: endoscopic Rx
Name another score (other than Blatchford score) for upper GI blleds [1]
What is important to note about this score [1]
Rockall score: needs endoscopic diagnosis to calculate full score
Describe management of high risk, actively bleeding ulcer [4]
Adrenaline:
- vasoconstriction
- causes local tamponade of blood vessels
Clip: closes bleeding
Diathermy: (therapeutic treatment that uses electric currents (radio and sound waves) to generate heat in layers of your skin below the surface)
Haemospray: powder in endoscope; promotes clotting}}
Describe the endoscopic management of varices [3]
Band ligation
Injection sclerotherapy (glue)
Sengestaken blakemore tube: compresses varices
Describe post-endoscopic treatment of varices [4]
- Beta blockers (reduce portal pressure: carvedilol; propanolol)
- Sequential banding procedures (close future varices)
- TIPPS: blood from portal vein goes straight from liver into systemic system (reduces pressure)
- Liver transplant
The NICE clinical knowledge summaries (updated January 2021) suggest management of uncomplicated diverticulitis in primary care with.. [4]
The NICE clinical knowledge summaries (updated January 2021) suggest management of uncomplicated diverticulitis in primary care with:
- Oral co-amoxiclav (at least 5 days)
- Analgesia (avoiding NSAIDs and opiates, if possible)
- Only taking clear liquids (avoiding solid food) until symptoms improve (usually 2-3 days)
- Follow-up within 2 days to review symptoms
How do you manage diverticulosis?
- Which laxatives are advised / not advised? [2]
Management is with increased fibre in the diet and bulk-forming laxatives (e.g., ispaghula husk). Stimulant laxatives (e.g., Senna) should be avoided
Describe management plan for upper bleeds [6]
The initial management can be remembered with the ABATED mnemonic:
A – ABCDE approach to immediate resuscitation
B – Bloods
A – Access (ideally 2 x large bore cannula)
T – Transfusions are required
E – Endoscopy (within 24 hours)
D – Drugs (stop anticoagulants and NSAIDs)
Describe the managment for patients who have recurrent peptic ulcers [3]
Reducing the NSAID dose & substituting the NSAID with paracetamol
If symptoms recur after initial treatment: offer a PPI at the lowest dose possible to control symptoms:
* esomeprazole
* lansoprazole
* omeprazole
Offer H2 antagonist therapy if there is an inadequate response to a PPI:
- famotidine
- nizatidine
BMJ Best Practise
Describe the treatment pathway for the initial resuscitation of perforated peptic ulcer disease [4]
IV fluids
Nasogastric tube insertion:
- reduces amount of gastric fluids in GIT AND allows nill by mouth
IV PPI
- loading and maintence doses
- enhance sealing of perforation
Antibiotics:
- stop sepsis due to leaking of fluids into peritoneum
Use one of the following methods to achieve haemostatic control of an actively bleeding ulcer via endoscopy:
A mechanical method (e.g., clips) with adrenaline (epinephrine)
Thermal coagulation with adrenaline
Fibrin or thrombin with adrenaline.
Describe the post-op management of PPUs [2]
Upper endoscopy:
- ID cause of perforation & healing of ulcer
- Biopsy for H. pylori
H.pylori eradication:
- triiple therapy for 10-14 days
How do you calculate fluid maintenance in children? [1]
100ml/kg for the first 10kg, 50ml/kg for the next 10kg and 20ml/kg for every subsequent kg.
Which antibodies are raised in type 1 autoimmine hepatitis? [2]
Which Ig? [1]
ANA/SMA/LKM1 antibodies, raised IgG levels
liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
This would suggest which pathology? [1]
Autoimmune hepatitis
Describe how a liver biopsy might show autoimmune hepatitis [2]
liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
Which enzyme converts haemoglobin to biliverdin?
Biliverdin reductase
Haem oxygenase
Glucuronyl transferase
HMG-CoA
Dihydro-folate reductase
Which enzyme converts haemoglobin to biliverdin?
Biliverdin reductase
Haem oxygenase
Glucuronyl transferase
HMG-CoA
Dihydro-folate reductase
Which classification system is used to grade lower GI bleeds?
Oakland score
Los Angeles classification
Forrest classification
Glasgow-Imrie score
Glasgow-Blatchford score
Which classification system is used to grade lower GI bleeds?
Oakland score
Los Angeles classification
Forrest classification
Glasgow-Imrie score
Glasgow-Blatchford score
A 25 year old male with a history of coeliac disease presents with a bilateral, intensely itchy rash on his elbows. On examination there are numerous papulovesicular lesions with surrounding erythema and excoriation marks.
What is the most appropriate treatment option in this case?
A NSAIDs
B Oral corticosteroids
C Corticosteroid cream
D Moisturisers
E Dapsone
A 25 year old male with a history of coeliac disease presents with a bilateral, intensely itchy rash on his elbows. On examination there are numerous papulovesicular lesions with surrounding erythema and excoriation marks.
What is the most appropriate treatment option in this case?
A NSAIDs
B Oral corticosteroids
C Corticosteroid cream
D Moisturisers
E Dapsone
What is Heyde’s syndrome? [1]
Heyde syndrome is a multisystem disorder characterized by the triad of aortic stenosis (AS), gastrointestinal bleeding, and acquired von Willebrand syndrome.
A 24 year old female with a known history of Crohn’s disease presents with a painful, bilateral rash on her shins. There are numerous red-purple nodules approximately 2-6 cm in size scattered on both shins that are painful to touch.
What is the most appropriate treatment? [1]
Erythema nodosum is a self-limiting disease that can be treated with NSAIDs (e.g. naproxen). Steroids may be prescribed in some setting (e.g. sarcoidosis).
Which criteria is used to define Lynch syndrome based on family history?
A Duke criteria
B Amsel criteria
C Amsterdam criteria
D GOLD criteria
E West Haven criteria
Which criteria is used to define Lynch syndrome based on family history?
C Amsterdam criteria
AC can be remembered using the 3-2-1 rule:
- ≥3 family members affected (colorectal cancer or endometrial cancer)
- ≥2 two generations (e.g. parents and grandparents or parents and children)
- ≥1 family member diagnosed at young age (before 50 years old)
A 32-year-old woman presents to the GP with difficulty swallowing. This has been worsening over many years and can happen with both liquids and solids. She has modified her eating habits to smaller portions and softer food. She often regurgitates food many hours after eating. She undergoes a gastroscopy that is reported as normal. She is referred to the gastroenterology team for further investigation.
What would be the gold-standard investigation to make the diagnosis?
Gastroscopy under general anaesthetic
Barium swallow
High-resolution manometry
CT chest and abdomen
Gastric emptying studies
A 32-year-old woman presents to the GP with difficulty swallowing. This has been worsening over many years and can happen with both liquids and solids. She has modified her eating habits to smaller portions and softer food. She often regurgitates food many hours after eating. She undergoes a gastroscopy that is reported as normal. She is referred to the gastroenterology team for further investigation.
What would be the gold-standard investigation to make the diagnosis?
High-resolution manometry
- This patient likely has underlying achalasia of which high-resolution manometry is the gold-standard investigation.
- involves insertion of a catheter through the nose to sit within the oesophagus. This catheter contains multiple sensors that are able to determine the pressure at different points within the oesophagus.
NB: B: Barium swallow is an excellent test for achalasia that may show typical features but is not the gold-standard
Which criteria is used to describe Barrett’s endoscopically?
A Sidney
B Seattle
C Rome
D Prague
E Glasgow-Blatchford
Which criteria is used to describe Barrett’s endoscopically?
A Sidney
B Seattle
C Rome
D Prague
E Glasgow-Blatchford
