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BPT Clinical Exam > Gastro Long > Flashcards

Gastro Long Flashcards

1
Q

IBS Hx

A
  1. Sx that led to diagnosis
    - Abdo pain + diarrhea/constipation/mixed
    - No alarm features: Bleeding, anaemia, weight loss, vomiting, dysphagia, onset >age 50, nocturnal Sx
    - No organic cause
  2. Risk factors
    - Hx of Gastroenteritis
    - FHx
    - Food intolerances
    - Hx of physical/sexual abuse
    - Previous somatisation disorder
    - Anxiety/depression
    - Low birth weight
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2
Q

ROME 4 criteria

A

For IBS

  1. Abdo pain associated with change in bowel habits
  2. Two of the following
    - pain relieved or aggravated by defecation
    - Pain associated with more frequent or less frequent stools
    - Pain associated with looser or harder stools
  3. Occurs over a period of at least 3 months and began >6 months ago
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3
Q

Ix for IBS

A

Coeliac testing to rule it out
FBE to assess for anaemia
CRP for IBD
Food diary for food intolerance

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4
Q

Mx IBS

A
  1. Diet High in insoluable fibre
  2. Low FODMAP diet
  3. Osmotic laxatives for constipation, not discomfort
  4. Loperamide for diarrhea
  5. Mebeverine or peppermint oil for pain
  6. Low dose TCA for pain and diarrhea
    - SSRI Moderately effective
  7. Avoid narcotics
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5
Q

Associated complications with previous peptic ulcer surgery

A
  • Pain/bloating due to bile reflux gastritis
  • Recurrent ulceration
  • Early or late dumping
  • Post vagotomy diarrhea
  • Anaemia due to iron/B12/Folate deficiency
  • Osteomalacia/Osteoporosis
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6
Q

Causes of lack of response to a Gluten free diet in Coeliac disease

A
  • Incorrect diagnosis
  • Patient not adhering to the diet
  • Collagenous sprue
  • Intestinal lymphoma
  • Diffuse ulceration
  • Other intercurrent disease
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7
Q

Complications of Coeliac

A

T cell lymphoma
Ulceration of small bowel
Incidence of carcinoma of the GI tract is slightly higher

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8
Q

Malabsorption/chronic Diarrhea Sx Hx

A
  • Steatorrhea
  • Weight loss
  • Weakness (from K+ deficiency)
  • Anaemia
  • Bone pain (osteomalacia)
  • Glossitis and angular stomatitis (Vitamin B group deficiency)
  • Bruising (Vit K Deficiency)
  • Oedema (Protein deficiency)
  • Peripheral neuropathy
  • Skin rash (eczema, dermatitis herpetiformis)
  • Amenorrhea (protein depletion)
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9
Q

Malabsorption/chronic Diarrhea etiology questions

A
  • Gastrectomy/bowel surgery
  • Hx of liver or pancreatc disease
  • Drugs (e.g. ETOH, neomycin, choletyramine)
  • Hx off crohns
  • Previous RTx
  • Gluten free diet treatment at any stage
  • Hx of DM
  • Risk factors for HIV infection
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10
Q
  1. Ix for malabsorption
A

Big 6 screening tests

  • Low serum iron
  • Prolonged PT
  • Low Calcium
  • Low cholesterol
  • Low carotene
  • Positive Sudan stain of the stool for fat

Fecal fat estimation over 3 days
-Abnormal if >7 grams

Glucose or lactulose breath hydrogen test for SIBO

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11
Q
  1. Evaluate the consequences of malabsorption
A 
FBE and focus on red cell indices
Iron studies
Folate
B12
Albumin
Vid D, CMP, ALP
Clotting profile
Cholesterol and carotene
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12
Q
  1. Find the cause of Malabsorption
A
  • XR: blind loops, diverticula etc
  • Gscope and small bowel Bx
  • Anti endomysial (Tissue transglutaminase) best screening for Coeliac, if negative check IgA for deficiency
  • Faecal fat levels - if greatly elevated than likely pancreatic disease
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13
Q

Causes of abnormal B12 absoprtion

A

Ileal disease
SIBO
PErnicious anaemia
Pancreatic disease

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14
Q

Cause and Tx of malabsorption:

Lipolytic phase defects

A

Chronic pancreatitis
CF

Mx
REverse causes
Pancreatic enzymes
Medium chain triglycerides

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15
Q

Cause and Tx of malabsorption:

Miceller Phase defect

A

Extrahepatic biliary obstruction
CLD
SIBO
Terminal ileal disease -Crohns, resection

Mx
REverse causes
Cholestyramine if bile acid cathartic effect is important
Medium chain triglycerides for steatorrhea
Fat soluable vitamine supps

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16
Q

Cause and Tx of malabsorption:

Mucosal and deliver phase defects

A 
Coeliac disease
Tropical sprue
Lymphoma
Whipple's Disease
Small bowel ischemia
Amyloidosis
Hypogammaglobinemia
HIV

Mx
Reverse causes
Fat soluable vitamin supps

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17
Q

Coeliac MX

A
  • Gluten free diet: Exclude wheat, rye and barley
  • -Sx improve in weeks and histo in months
  • Reasonable to re-biopsy in 3 months to confirm histo healing
  • IF lack of response to gluten free diet: inadvertant gluten exposure, or another problem (lactose intolerance, pancreatic insufficiency, SIBO), refractory sprue (may respond to steroids), or lymphoma (T cell enteropathy - unresponsive to steroids)
  • Pneumococcal vaccine - due to hyposplenism of coeliac disease
  • OP Ix and management
18
Q

Causes of Colitis

A
  • IBD
    • Infections, including C. Diff
    • Radiation
    • Ischemic Colitis
    • Diversion colitis
    • Toxic exposures
    • Microscopic or collagenous colitis
      • Lymphocytic colitis
19
Q

MAnifestations of Crohns

A

• Local Disease
○ Anorectal disease (fissures, fistula, pararectal abscess, rectovaginal fistula)
○ Obstruction (usually terminal ileum); stricturing; SBO
○ Fistula
○ Toxic megacolon and perforation
○ Carcinoma of small and large bowel
• Extracolonic Manifestations
○ PSC
○ Gallstones
○ Urate and calcium oxalate stones, pyelonephritis, hydronephrosis
○ Malabsorption due to small bowel involvement
○ Osteomalacia
○ Poor wound healing
○ Plus the ones below for UC

20
Q

MAnifestations of UC

A

• Local Disease
○ Toxic megacolon
○ Perforation
○ Massive Hemorrhage
○ Strictures
○ Carcinoma of colon
• Extracolonic Manifestations
○ Liver disease: Fatty liver, PSC, Cirrhosis, Carcinoma of bile duct, Amyloidosis
○ Blood disorders: Anaemia, Thromboembolism
• Arthropathy: Peripheral; Ank Spond
• Skin and Mucus membranes: Ulcers, Pyoderma Gangrenosum, Erythema nodosum (coincides with active disease)
• Ocular: Uveitis, conjunctivitis, episcleritis

21
Q

Ix for IBD

A
  1. Exclude infections
    - CASES
    - Gonorrhea and syphillus in MSM
    - Immunosuppressed: HSV, CMV, Cryptosporidium, TB
  2. AXR
    - Bowel wall thickening (oedema), gaseous distension, toxic megacolon, SBO
  3. Blood count
    - Anaemia, WCC, ESR, CRP
  4. LFTs, UECs
    - Liver disease, renal stones, amyloidosis
  5. Cscope
  6. Antibody testing
    - p ANCA negative, and ASCA psotive (anti saccharomyces cerevisiae antibodies) - specific for crohns over UC
22
Q

Severity of UC

A

Mild: <4 bowel motions/day, minimal bleeding, normal temp and pulse

Acute severe: >6 motions/day, profuse bleeding, Temp >37.5, pulse >90, abdo tenderness

Fulminant: >10 motions/day, continuous bleeding, fever and tachycardia, abdo tenderness and distension

23
Q

Mx of UC

A

Acute attack

  • Correct hypokalemia
  • Avoid barium enema, opiates and anticholinergics to prevent toxic megacolon or perforation
  • If severe, IV ABx
  • IV Steroids
  • -IF unresponsive to steroids, IV cyclosporin/infliximab rescue as alternative to colectomy
  • Surgical review and stoma therapist contact early

Chronic management

  • SSZ or Mesalazine
  • Chronic steroid use des not reduce relapse rate
  • Correct IRon and folate deficiency
  • AZA and 6-mercaptopurine for repeated episodes of UC
  • Proctitis: Topical steroids or mesalazine enema BD + PO immunosuppressant
  • Cancer screening
24
Q

Indications for Surgery in UC

A

Chronic ill health
SEvere disease
Complications: PErforation, massive bleeding
Severe disease not responding to optimal medical treatment in 7-10 days

All manifestations are cured by colectomy except:
-Ank Spond, liver disease, and occasional PG

25
Q

Mx of Crohns

A
  • SSX and Mesalazine more effective in colonic disease
  • Steroids more effective in small bowel disease
  • Budesonide useful in ileocolonic disease
  • AZA and 6 mercaptopurine useful for those who cannot cease steroids and to reduce relapse (including post resection surgery); MTX is alternative if AZA fails
  • Diarrhea in ileal disease: bile salt sequestering (Cholestyramine, colestipol)
  • Severe perianal disease: MEtronidazole or Cipro; AZA
  • TNF Alpha inhibitors for refractory fistulas
  • Surgery: resections for fistulas, stricturplasty if obstruction
26
Q

Testing prior to starting AZA or 6MP and monitoring

A

Prior:
-TPMT

Monitoring:

  • FBE weekly in 1st month, then 2nd weekly in 2nd month, then monthly
  • LFTs monthly
27
Q

SE of AZA or 6MP

A 
Leukopenia
Pancreatitis
Allergy (Fever, rash, arthritis)
Lymphoma
Can be continued in pregnancy if cannot use other therapy
28
Q

Testing prior to starting MTX and monitoring

A

Prior

  • Start folic acid
  • Baseline LFTs
  • Counsel to avoid ETOH
  • Rule out Hep B and C

Monitoring

  • LFTs monthly for 3 months, then 3 monthly
  • Consider Liver Bx if >50% of LFTs abnormal in one year
29
Q

SE of MTX

A

Hepatotoxic
Bone marrow depression
Interstitial pneumonitis
Contraindicated in pregnancy/conception (men and women)

30
Q

Testing prior to starting anti TNF and monitoring

A

Prior:

  • Update immunisations
  • Pap smear
  • Rule out Hep B and C
  • Quantiferon
  • CXR for TB
  • Consider: HIV, VZV antibody, ANA, anti dsDNA testing

Monitoring:
-6 monthly review

31
Q

SE of Anti TNF

A 
Infusion reaction
Neutropenia
Infections
Hepatosplenic T cell lymphoma
Demyelinating disease
Heart failure
Skin rashes (psoriasis like)
Probably safe in pregnancy
32
Q

Cscope timing recommendations based on previous polyps

A

No polyps or small: 10 years
1-2 small tubular adenomas: 5-10 years
3-10 tubular adenomas or one or more tubular adenoma > 10 mm: 3 years
>10 adenomas: <3 years
One or more villous adenomas or sessile serrated polyps >10 mm: 3 years

33
Q

Hx in CLD patient

A
  • PHx of hepatitis or jaundice and contacts
  • ETOH intake
  • IVDU, sharing needles, sexual orientation, transfusions, tattoos
  • Diabetes, CCF, arthropathy (haemachromatosis)
  • Overseas travel (acute hepatitis)
34
Q

CAuses of cirrhosis

A
  • ETOH
  • Post viral (Hep B and C)
  • NASH
  • Drugs
  • Autoimmune chronic hepatitis
  • HAemachromatosis
  • Wilson’s Disease
  • PSC
  • PBC
  • Secondary biliary cirrhosis
  • Alpha 1 antitrypsin
  • CF
  • Budd-Chiari Syndrome
  • Cardiac failure, chronic constrictive pericarditis
  • Cryptogenic
35
Q

Complications of Cirrhosis

A
  1. Portal HTN and ascites
  2. Portal vein thrombosis
  3. SBP
  4. Hepatic encephalopathy
  5. Hepatorenal Syndrome
  6. HCC
  7. OP or osteomalacia
36
Q

Child Pugh score

A 
Albumin
Bilirubin
Ascites
Encephalopathy
INR

A - alb >35, Bili <35, no ascites or encephalopathy, INR <1.7

B- Alb 30-35, Bili 35-50, managable ascites, minimal encephalopathy, INR 1.7-2.3

C - Alb <30, Bili >50, bad ascites, advanced encephalopathy, INR >2.3

37
Q

Causes of SAAG >11

A

Cirrhosis
Alcoholic hepatitis
RHF, Constrictive pericarditis
Budd-chiari, inferior vena cava obstruction

38
Q

Crohns complications

A

• Local Disease
○ Anorectal disease (fissures, fistula, pararectal abscess, rectovaginal fistula)
○ Obstruction (usually terminal ileum); stricturing; SBO
○ Fistula
○ Toxic megacolon and perforation
○ Carcinoma of small and large bowel
• Extracolonic Manifestations
○ PSC
○ Gallstones
○ Urate and calcium oxalate stones, pyelonephritis, hydronephrosis
○ Malabsorption due to small bowel involvement
○ Osteomalacia
Poor wound healing

39
Q

UC complications

A

• Local Disease
○ Toxic megacolon
○ Perforation
○ Massive Hemorrhage
○ Strictures
○ Carcinoma of colon
• Extracolonic Manifestations
○ Liver disease: Fatty liver, PSC, Cirrhosis, Carcinoma of bile duct, Amyloidosis
○ Blood disorders: Anaemia, Thromboembolism
• Arthropathy: Peripheral; Ank Spond
• Skin and Mucus membranes: Ulcers, Pyoderma Gangrenosum, Erythema nodosum (coincides with active disease)
Ocular: Uveitis, conjunctivitis, episcleritis

40
Q

Indications for liver transplant

A 
 End stage (irreversible) liver failure
     Life expectancy <12/12
     Child-Pugh B/C
     MELD >14
 Hepatocellular carcinoma (UCSF)
     One HCC <6.5cm
     ≤3 HCC, ≤4.5 cm diameter
 Irreversible complications of liver disease
     Hepatopulmonary syndrome
     Massive polycystic liver disease
 Acute (Fulminant) Liver failure
41
Q

Liver Screen

A

 Alcohol, HBV, HCV
 Genetic: Wilson’s disease, Haemochromatosis, A1AT
defic
 Auto-immune: Primary biliary cirrhosis, primary
sclerosing cholangitis, Autoimmune hepatitis
 Other: NASH, drugs, budd chiari syndrome

42
Q

Liver Tx Chronic Cx

A 
Chronic rejection (Progressive cholestasis)
-Dx: liver biopsy 
Infections
SEs of immunosuppression
Malignancy 
Portal vein thrombosis 
Biliary strictures/leak
CVS risk
Bone health
Fatigue
Sexual dysfunction

Median survival 20 yaers

BPT Clinical Exam (11 decks)

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