Gastro II Flashcards
Haemophilus influenzae
Plummer-Vinson syndrome
What is Reynold’s pentad? [1]
What does it indicate? [1]
Charcots triad + hypotension and confusion
Ascending cholangitis
The King’s College Hospital Criteria for Liver Transplant in non-paracetamol related liver failure can be used to answer this question. They state that the criteria for liver transplant are
[1] OR
Any three of: [3]
The King’s College Hospital Criteria for Liver Transplant in non-paracetamol related liver failure can be used to answer this question. They state that the criteria for liver transplant are
Prothrombin time >100 seconds OR
Any three of:
Drug-induced liver failure
Age < 10 or > 40
1 week from 1st presentation of jaundice to encephalopathy
Prothrombin time >50s
Bilirubin ≥300µmol/L.
Bariatric surgery is immediately offered if BMI is whaT? [1]
> 50 = first line treatment
Describe the three types of bariatric surgery? [3]
laparoscopic-adjustable gastric banding (LAGB)
* it is normally the first-line intervention in patients with a BMI of 30-39kg/m^2
produces less weight loss than malabsorptive or mixed procedures but as it has fewer complications
sleeve gastrectomy
* stomach is reduced to about 15% of its original size
intragastric balloon
* the balloon can be left in the stomach for a maximum of 6 months
How do you investigation for ? Boerhaaves [1]
CT contrast swallow
How do you treat Hep A? [1]
This is managed conservatively with supportive care and tends to be self-resolving.
If normal triple therapy does not work for PPI - how can you alter treatment? [1]
If triple therapy fails to eradiate H. Pylori the first time, the treatment can be repeated with metronidazole replacing clarithromycin, whichever was not used in the initial course
Which biological therapy can be used to treat GIST? [1]
Imatinib
Biological agents:
Which of the following is used when treating renal transplants?
Basiliximab
Etanercept
Bevacizumab
Adalimumab
Cetuximab
Biological agents:
Which of the following is used when treating renal transplants?
Basiliximab
Etanercept
Bevacizumab
Adalimumab
Cetuximab
Biological agents:
Which of the following is used when treating EGF positive colorectal cancers?
Basiliximab
Etanercept
Bevacizumab
Adalimumab
Cetuximab
Biological agents:
Which of the following is used when treating EGF positive colorectal cancers?
Basiliximab
Etanercept
Bevacizumab
Adalimumab
Cetuximab
C for Colorectal
Biological agents:
Which of the following is used intreating Crohns? [2]
Basiliximab
Etanercept
Bevacizumab
Adalimumab
Cetuximab
Biological agents:
Which of the following is used intreating Crohns?
Basiliximab
Etanercept
Bevacizumab
Adalimumab
Cetuximab
Basiliximab is used to treat renal transplants
What is it’s MoA?
Tyrosine kinase inhibitor
TNF alpha inhibitor
Anti VEGF
Epidermal growth factor inhibitor
IL2 binding site
Basiliximab is used to treat renal transplants
What is it’s MoA?
Tyrosine kinase inhibitor
TNF alpha inhibitor
Anti VEGF
Epidermal growth factor inhibitor
IL2 binding site
Cetuximab is used to treat EGF +ve colorectal cancers.
What is it’s MoA?
Tyrosine kinase inhibitor
TNF alpha inhibitor
Anti VEGF
Epidermal growth factor inhibitor
IL2 binding site
Cetuximab is used to treat EGF +ve colorectal cancers.
What is it’s MoA?
Tyrosine kinase inhibitor
TNF alpha inhibitor
Anti VEGF
Epidermal growth factor inhibitor
IL2 binding site
Bevacizumab is used to treat colorectal cancer and renal and glioblastomas.
What is it’s MoA?
Tyrosine kinase inhibitor
TNF alpha inhibitor
Anti VEGF
Epidermal growth factor inhibitor
IL2 binding site
Bevacizumab is used to treat colorectal cancer and renal and glioblastomas.
What is it’s MoA?
Tyrosine kinase inhibitor
TNF alpha inhibitor
Anti VEGF
Epidermal growth factor inhibitor
IL2 binding site
How do you treat acute pancreatitis? [5]
fluid resuscitation
* aggressive early hydration with crystalloids. In severe cases 3-6 litres of third space fluid loss may occur
aim for a urine output of > 0.5mls/kg/hr
intravenous opioids are normally required to adequately control the pain
patients should not routinely be made ‘nil-by-mouth’ unless there is a clear reason e.g. the patient is vomiting
- enteral nutrition should be offered to anyone with moderately severe or severe acute pancreatitis within 72 hours of presentation
NICE state the following: ‘Do not offer prophylactic antimicrobials to people with acute pancreatitis’:
- Even though they present with raised WCC
Surgery if indicated
A patient has suspected acute pancreatitis.
Imaging reveals they have gallstones.
What surgery is indicated
ERCP
Early cholecystectomy
Radiological drainage or surgical necrosectomy
Debridement
A patient has suspected acute pancreatitis.
Imaging reveals they have gallstones.
What surgery is indicated
ERCP
Early cholecystectomy
Radiological drainage or surgical necrosectomy
Debridement
A patient has suspected acute pancreatitis.
Imaging reveals they an obstructed biliary tree.
What surgery is indicated?
ERCP
Early cholecystectomy
Radiological drainage or surgical necrosectomy
Debridement
A patient has suspected acute pancreatitis.
Imaging reveals they an obstructed biliary tree.
What surgery is indicated?
ERCP
Early cholecystectomy
Radiological drainage or surgical necrosectomy
Debridement
A patient has overdosed on paracetamol.
How do you decide their management depending on the length of time they overdosed? [2]
Patients with an overdose of < 150mg/kg that has been ingested within a 1 hour period - not staggered:
- Take blood paracetamol level and wait for result before initiating treatment
Staggered overdose:
- first line treatment is with N-acetylcysteine regardless of the time from ingestion
What is the difference in effect of exercise between UC & CD? [1]
:Regular active exercise reduces risks of developing Crohn’s (but not UC) & relapse of Crohn’s and possibly UC
Name three subtypes of UC [3]
Proctitis: Inflammation affecting the rectum only
Left-sided colitis: Inflammation affecting the rectum and the sigmoid and descending colon
Pancolitis: Inflammation affecting the whole colon, from the rectum to the ileo-caecal valve
How can you differentiate between UC and CD via endoscopy? [6]
UC:
- continuous inflammation:
- there is no areas of normal mucosa in-between areas of inflammation
- diffuse erythema
- friability, granularity
- loss of vascular pattern in the colon.
CD:
- incontinuous areas of inflammation normal bowel in-between inflammatory segments
- deep fissuring ulcers
- “cobblestoned” mucosa are present.
Describe how you differentiate between recent v chronic UC via a histology sample? [1]
Chronic:
- crypt architecture distortion: they look twisted and disorganised
When is surgery indicated for UC patients? [4]
Patient suffers from:
- toxic megacolon
- perforation
- severe bleeding
- fail to respond to medical therapy
Describe surgical managment of UC:
- Acute disease [1]
- Chronic disease [1]
Subtotal colectomy with end ileostomy and preservation of the rectum. For acute disease
Proctocolectomy: the surgical removal of the rectum and all or part of the colon, and is usually preceded by an ileostomy (standard procedure)
Describe the treatment plans for:
- Proctitis [2]
- Left sided colitis [3]
- Pancolitis [3]
Proctitis:
- Rectal 5-ASA (Mesalazine) suppositories are the first-line treatment
- Oral 5-ASA may be added to increase remission rates.
- Some cases of proctitis are ‘resistant’ to 5-ASA and may require oral prednisolone
Left-sided colitis:
- Topical 5-ASA enemas are the first line treatment (Mesalazine)
- The addition of an oral 5-ASA will increase remission rates
- Patients who do not respond or have worsening symptoms will need oral prednisolone
Pancolitis:
- Patients with mild-moderate symptoms can be treated with oral 5-ASA at an adequate dose (Mesalazine)
- The addition of a 5-ASA enema will increase remission rates. Patients who do not respond require oral prednisolone
(Zero to finals)
Mild to moderate acute ulcerative colitis is treated with [2]
Severe acute ulcerative colitis is treated with [1]
Other options for severe acute ulcerative colitis include: [3]
Mild to moderate acute ulcerative colitis is treated with:
* Aminosalicylate (e.g., oral or rectal mesalazine) first-line
* Corticosteroids (e.g., oral or rectal prednisolone) second-line
Severe acute ulcerative colitis is treated with:
* Intravenous steroids (e.g., IV hydrocortisone) first-line
Other options for severe acute ulcerative colitis include:
- Intravenous ciclosporin
- Infliximab
- Surgery
Zero to finals
Options for maintaining remission in ulcerative colitis are? [3]
Options for maintaining remission in ulcerative colitis are:
- Aminosalicylate (e.g., oral or rectal mesalazine) first-line
- Azathioprine
- Mercaptopurine
In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is [1]
In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is topical (rectal) aminosalicylates
State a key finding of UC under endoscopy [1]
Pseudopolyps: widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps
Describe a structural change that occurs as a response to active inflammation in UC patients [3]
Crypt abscesses form as a response to active inflammation.
Crypt abscesses are the accumulation of inflammatory cells within crypts, which are tube-like glands found in the lining of the gastrointestinal system (i.e., digestive tract). The accumulation of inflammatory cells can cause damage to the surrounding cells, thereby preventing the gland from functioning properly and secreting various substances.
The abscesses are commonly neutrophilic in UC.
The Truelove and Witts’ severity index is recommended by NICE when assessing the severity of ulcerative colitis in adults. Ulcerative colitis is classified as ‘severe’ in which instances? [5]
TRUElove and Witt’s
when the patient has blood in their stool, or is passing more than 6 stools per day plus at least one of the following features:
- T - Temp > 37.8
- R - Rate > 90
- U - (Uh)naemia Hb < 105
- E - ESR >30
Sulphasalazine may be used to treat UC.
Name a haematological SE of this treatment [1] and describe how this may present on blood smear [1]
Sulphasalazine may cause haemolytic anaemia
this can present withHeinz bodies
Sulphasalazine Heinz body
State the name of this symptom of Crohn’s [1]
Pyostomatitis vegetans: an inflammatory stomatitis
What sign of Crohn’s Disease are the arrows pointing to? [1]
Rosehorn ulcer
Name this EIM symptom of CD [1]
Aphthous ulcers
Name this EIM symptom of CD [1]
pyoderma gangrenosum
Describe the histopathological features of CD [1]
Non-caseating granuloma (w/ Langhan giant cells)
Name this symptom of CD [1]
Erythema Nodosum
Name this symptom of CD [1]
Pyoderma gangrenosum: large, painful sores (ulcers) to develop on your skin, most often on your legs.
Describe the management plan to induce remisison in mild-moderate [2] and moderate-severe patients [3]
mild-to-moderate CD:
- a course of exclusive enteral nutrition (EEN) can be considered over an 8 week period
- oral prednisolone (40mg/d for 1 week, then 5mg every week for 7 weeks)
moderate-to-severe CD:
- IV steroids: IV hydrocortisone or methylprednisilone
- there should be consideration of early introduction of immunosuppressive therapy: azathioprine or methotrexate alongside budesonide, prednisilone or hydrocortisone (These medications help with long-term control, but are not useful at initially inducing remission, which is why they are combined with steroids)
- - Biologicals: inflximab, adalimubab (anti-TNF); Vedolizumab (anti-integrins); Ustekinumab (anti-IL12/13)
Describe the managment for maintenence therapy for CD [3]
These are considered in patients with recurrent flares, moderate-to-severe disease, or poor prognostic features (e.g. extensive disease):
Thiopurines:
- azathioprine and mercaptopurine) work through purine synthesis inhibition in lymphocytes leading to immunosuppressive properties.
Methotrexate:
- inhibits dihydrofolate reductase. Has both immunomodulatory and anti-inflammatory properties. Must check liver and renal function before use. Given weekly. Major side-effects include bone marrow suppression, hepatotoxicity and pulmonary toxicity.
Biologics: this refers to monoclonal antibodies. Options include infliximab/adalimumab (tumour necrosis factor (TNF) alpha inhibitors), vedolizumab (alpha-4/beta-7 integrin inhibitor) and ustekinumab (IL-12/IL-23 inhibitor)
If a Crohn’s patient has had an ileocacel resection, why may diarrhoea occur? [1]
Name a drug that can treat this [1]
The patient most likely has a diagnosis of bile acid malabsorption as a complication of the ileocecal resection.
Treat using: Cholestyramine - bile acid sequestrant with the potential to control diarrhoea induced by bile acid malabsorption.
Which drugs are first line to induce remission in CD? [3]
glucocorticoids:
* prednisolone; hydrocortisone oral, topical or intravenous) are generally used to induce remission.
* Budesonide is an alternative in a subgroup of patients
Inducing Remission:
Which drugs are used as second-line to glucorticosteroids for CD? [2]
Which drugs may be added alongside ^? [2]
What is important to note about this^ [1]
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective
azathioprine or mercaptopurine may be used as an add-on medication to induce remission but is not used as monotherapy.
Inducing Remission:
Which drug is used to treat refractory CD? [1]
infliximab .
Inducing Remission:
Describe the management plan for treating fistulaes [3]
patients with symptomatic perianal fistulae are usually given oral metronidazole
(+)
Infliximab
(+)
draining seton
a seton is a piece of surgical thread that’s left in the fistula for several weeks to keep it open. This is useful because persisting fistula tracks after premature skin closure predispose to abscess formation
Maintaining remission
Which drugs are used as first line maintainene for CD? [2]
What is second line? [1]
azathioprine or mercaptopurine is used first-line to maintain remission
methotrexate is used second-line
Fistulas
In a patient with CD fistulas, what drugs are used if:
Symptomatic peri-anal fisutlae? [1]
To help close and maintain perianal fistulas? [1]
For complex fistulae? [1]
- patients with symptomatic perianal fistulae are usually given oral metronidazole
- anti-TNF agents such as infliximab may also be effective in closing and maintaining closure of perianal fistulas
- a draining seton is used for complex fistulae
What treatment is given for Crohn’s patients who develop a perianal fistula? [1]
Oral metronidazole
