gastro SBAs Flashcards
Levels of plasma bilirubin when jaundice is clinically visible
> 35umol/L
Most appropriate screening investigation in AAA
Abdominal USS
Least invasive and safest screening
Predisposing factors for HCC
Hep B
Hep C
Aflatoxin
Liver cirrhosis
Treatment for C diff
Oral/IV metronidazole
±vancomycin if pseudomembranous colitis and severe
Barrett’s oesophagus definition
55-65years, M>F 2:1
metaplastic replacement of lower oesophageal normal squamous epithelium by columnar epithelium.
GORD -> Barrett’s -> premalignant condition to oesophageal adenocarcinoma
Coeliac disease definition and histology
Chronic intestinal malabsorption and inflammation due to small intestine mucosal damage and intolerance to gluten.
Histology: villous atrophy, flat smooth mucosa, crypt hyperplasia of dyodenum, cuboidal epithelium
Barrett’s oesophagus Rx
Diet
PPIs, H2 receptor antagonist
Surveillance endoscopy + biopsy
(Ablation and surgical resection)
Dermatitis herpetiformis (intense itchy elbow, knees, buttocks blisters) are present in …
Coeliac disease
other PC: malnutrition, abdo discomfort, pain, wt loss, steatorrhoea, diarrohea, anaemia i.e. pallor
IgG anti-gliadin (AGA) is associated with…
Coeliac disease
Diagnostic
Tissue transglutaminase autoantibody is asscoiated with…
Coeliac disease
Diagnostic test for hiatus hernia
Upper GI barium meal/swallow
CXRs can be normal, but some show air fluid level above L hemi-diaphragm
Duodenal ulcers secondary to H pylori infection (90%) diagnostic test
CLO breath test (rapid urease test) to confirm presence of bacteria
IgG serology
Stool antigen test
Treatment for duodenal ulcers due to H.pylori
7 day course of triple therapy: PPI and 2 Abx e.g. 20mg omeprazole, 1g amoxicillin, 500mg clarithromycin
Causes of portal HTN
Pre-hepatic (portal vein thrombosis, splenic vein thrombosis)
Hepatic (cirrhosis 80%, schistosomiasis, sarcoid, congenital fibrosis)
Post-hepatic (Budd-Chiari syndrome, RHF, constrictive pericarditis)
Drugs that induce liver cirrhosis
Methotrexate
Amiodarone
Methyldopa
Appropriate investigations for patient with IDA and red flag symptoms (wt loss)
upper and lower GI endoscopy
Gastroenteritis is usually limiting and will not require pharmacological therapy. Mainstay of treatment involves…
Increase oral fluid intake
Anti-emetics
(only when very severe give IV fluids and cultured bacteria give Abx)
Budd-Chiari syndrome results from hepatic vein outflow obstruction. Triad of symptoms includes…
Acute abdo pain
Hepatomegaly
Ascites
Liver cirrhosis histology
Loss of normal hepatic architecture
Bridging fibrosis
Nodular regneration
(biopsy confirms the diagnosis)
Causes of liver cirrhosis
Alcoholism NASH Chronic HepB/C Autoimmune Budd-Chiari syndrome
Ascites Rx
Low salt diet
Fluid restriction
Osmotic diuretic e.g. mannitol
Primary sclerosing cholangitis can cause
cholangiocarcinoma
Crohn’s disease histology and barium-swallow
Transmural, non-caseating granulomatous inflammation
Fissuring ulcers
Neutrophil infiltrates
Cobblestoning and rose-thorn ulcers
Ulcerative colitis histology
Inflammatory infiltrates
Mucosal ulcers
Goblet cell depletion
Crypt abscesses
Chronic liver disease Rx
Treat the cause (e.g. AI hepatitis)
Symptomatic
Immunosuppressants (corticosteroids or steroid-sparing agents e.g. azathioprine)
Liver transplantation for decompensated liver cirrhosis.
Prophylaxis for prevention of variceal bleeding due to portal HTN
Primary: non-selective b-blockers, e.g. propanolol, ± endoscopic banding ligation
Secondary: i.e. post-variceal bleed, also consider TIPPS or surgical shunts
Pseudomembranous colitis (type of infectious colitis) definition
Caused by C diff (Gram +ve anaerobic bacillus) toxins (A and B). Formation of adherent inflammatory membrane overlying sites of mucosal injury within the colon. Accumulates neutrophils, fibrin, mucous and necrotic epithelial cells forming a ‘summit lesion’.
Truelove and Witts criteria measures the severity of UC. Criteria includes:
- Opening bowels >6x day with large amounts of blood per rectum
- > 37.8oC
- > 90bpm HR
- <10.5/dl Hb
- > 30mm/h ESR
Rockall score will assess…
risk of rebleeding/mortality pre and post-endoscopy
Which hepatitis is usually from contaminated water
Hep A
faecal-oral route
Treatment of Hep A
No treatment - conservative
Symptomatic (antiemetics, antipyretics, cholestyramine for pruritis)
Hep A signs and symptoms
Prodrome of fever, malaise, anorexia and nausea. Followed by dark urine, pale stools, jaundice ~3weeks. Spleen or liver may be palpable.
Hep B and E have similar clinical features.
Which hepatitis is usually from IVDU or sexually transmitted
Hep B and C
Hep B can also be vertically transmitted. Hep C is more likely to be involved with IVDU
Chronic extra-hepatic features of HepB and HepC
Rashes
Arthralgia
Glomerulonephritis (= renal dysfunction)
Hep C signs and symptoms
Acute flu-like infection, usually asymptomatic/mild.
Most develop chronic infection that predisposes to liver cirrhosis development
5 days after a bowel resection for cancer, a 70 year old man gets a swinging fever + becomes confused
Post-surgery = risk of developing an abscess. A swinging fever is strongly indicative of an abscess and a blood culture is required to identify the pathogenic organism. Percutaneous or surgical drainage will usually be required with appropriate antimicrobial therapy.
Salmonella gastroenteritis Rx
Ciprofloxacin Abx
±anti-emetics if N+v is bad
Irritable bowel syndrome Rx
Anti-spasmodics to relieve abdo pain/discomfort
e.g. peppermint oil, dicycloverine
Laxatives can also be used e.g. lactulose
IBD diagnosis with…
endoscopy and biopsy
and -ve stool culture to rule out infectious gastroenteritis
Toxic megacolon
Complication of UC, associated with risk of perforation. Associated with bowel adenocarcinoma and PSC
Ulcerative colitis Rx
- 5-ASA (mesalazine) - induces and maintains remission
- IV corticosteroids
- For moderate-severe disease give immunosuppressants (azathioprine) and TNF-a inhibitors (inflixmab)
ACUTELY: IV fluids + steroids first
Crohn’s disease Rx
- Corticosteroids
- 5-ASA analogues (mesalazine)
- Steroid-sparing immunosuppressants (azathioprine)
- TNF-a inhibitors (infliximab)
Surgery
ACUTELY: IV fluids + steroids first
Idiopathic thrombocytopenia Rx
IV immunoglobulin
A 65 year old man had an elective AAA repair 5 days ago. He now has abdo distension & left sided abdominal pain. He is passing a small amount of blood & mucus per rectum.
Ischaemic colitis = insiduous focal/diffuse abdo pain over hrs/days. The recent operation has resulted in an incomplete blood supply to that part of the bowel
Types of ischaemic bowel disease
- acute mesenteric ischaemia (SMA)
- chronic mesenteric ischaemia (due to atherosclerosis)
- ischaemic colitis/chronic colonic ischaemia (IMA)
A 58 year old male has had increasing difficulty swallowing. He has lost 10kg in 2 months. Upper GI endoscopy shows circumferential irregular & ulcerated mass in mid-oesophagus
Dysphagia, weight loss and the irregular shaped mass = malignancy. Tumours in the upper 2/3 of oesophagus are SCC and the lower 1/3 are adenocarcinomas. The main test to order is an OGD with biopsy.
A 50 year old man with 1month Hx of progressive abdominal distension preceded by increased tiredness, SOB on exertion + weight loss of 10kg. There is a non-tender irregular mass in RIF
10kg wt loss, fatigue, non-tender irregular RIF mass = caecal carcinoma. R-sided colorectal cancer tends to present with anaemia.
Progressive abdominal distension indicates the presence of peritoneal secondaries, which causes vague symptoms.
A 70 year old man presents with a 2 day history of constipation, anorexia and pain in the left iliac fossa. On examination he is pyrexial (37.6 C) and there is localised tenderness and rebound in the left iliac fossa. White cell count is 14.0units
Symptomatic diverticulitis = fever, high WCC and LLQ pain.
RFs for diverticular disease: low dietary fibre and advanced age.
Rx: analgesia, oral Abx (IV if oral do not improve after 72hours)
Lithium overdose treatment
haemodialysis
VitB12 deficiency that is not corrected by administration of IF suggests…
It is not pernicious anaemia
Diagnosis is likely to be coeliac disease
Sister Mary Joseph’s nodule
Periumbilical nodule associated with GI/gynae cancer mets.
(gastric carcinoma presents similar to gastric ulcer but more chronic and with wt loss. RFs pernicious anaemia, H pylori)
Krukenberg’s nodule tumour
Ovarian metastases associated with GI (e.g. gastric carcinoma) or breast primary cancers.
Drugs that cause gallstones
Clavulanic acid/co-amoxiclav Penicillins Oestrogens Erythromycin Chlorpromazine
Rigler’s triad
Gallstone ileus
Pneumobilia
Small bowel obstruction
Glasgow criteria for acute pancreatitis
PANCREAS
3 or more of the criteria in the first 48hours indicates severe attack.
Rx: fluid ±electrolytes, urinary catheter, NG tube, analgesia ±anti-emetics, NBM
PaO2 <8kPa Age >55yrs Neutrophils >15x10^9/L Ca2+ <2mmol/L Renal function, urea >16mmol/L Enzymes, high LDH/high AST Albumin <32g/L Sugar, glucose >10mmol/L
Gastro causes of clubbing
Malabsorption (Coeliac) Amyloidosis (hepatic) GI lymphoma IBD Cirrhosis/PBC
IBD extra-intestinal manifestations
Aphthous ulcers (Crohn's Pyoderma gangrenosum Iritis (uveitis), scleritis, episcleritis Erythema nodosum Dermatitis herpetiformis Sclerosing cholangitis (pANCA in UC + PSC) Arthritis Clubbing
Abdo masses, anal ulcers or fistulae (Crohns)
Hep A and Hep E histology
Inflammatory cell infiltration of portal tracts, zone 3 necrosis and bile duct proliferation
Hep B and D (acute or chronic courses) signs and symptoms
Prodrome: 1-2weeks malaise, headache, anorexia, pyrexia, N+V, RUQ pain (±hepatosplenomegaly and cervical lymphadenopathy).
May experience serum sickness: fever, arthralgia, polyarthritis, urticaria, maculopapular rash
Jaundiice with dark urine and pale stools
Chronically: signs of chronic liver disease
Intestinal obstruction causes
lumen, wall, extrinsic
Lumen - meconium/gallstone ileus
Wall - adenocarcinoma, diverticuli
Extrinsic - volvulus, IBD (Crohn’s), adhesions, hernias
Diverticulitis presentations and complications
LIF pain
Fever
Increased inflammatory markers
Complications: abscess, perforation, fistula
What do the following sites absorb?
duodenum
jejunum
ileum (terminal)
duodenum - iron
jejunum - folate
ileum (terminal) - b12
‘Dude Is Just Feeling Ill Bro’
Beak-shaped barium swallow test results indicate…
achalasia
Colonic polyps definition
Protuberance into the lumen from normally flat colonic mucosa. Can be neoplastic (adenomas & ACs) and non-neoplastic (hyperplastic, inflammatory, hamartomatous)
Colonic polyps gold standard investigation
Colonoscopy
- when removed and biopsied they can be then histologically examined to determine their malignant potential
Colorectal carcinoma
Dukes staging and 5yr survival rates
A - confined to bowel wall (80-90%)
B - Through bowel wall, -ve LN (60%)
C - Through bowel wall, +ve LN (30%)
D - distant mets (<5%)
Diverticulae are commonest in which part of the colon
Sigmoid colon and descending colon. They are absent from the rectum.
(they can be R sided too however)
Botulinum toxin causes
paralysis.
Given botulinum antitoxin IM and manage in ITU
Giant mitochondria indicate…
alcoholic hepatitis
Synthetic function of the liver
Albumin
Clotting factors
Binding proteins for Fe and Cu
Metabolic function of the liver
Glucose homeostasis
Excretion of bile
Child-Pugh grading for liver cirrhosis criteria looks at
Albumin (low) Bilirubin (high) PT (prolonged) Ascites Encephalopathy
Wilson’s disease (autosomal recessive) = characterised by decreased biliary excretion of copper and accumulation in liver and brain (esp in BG). Signs and symptoms include
Liver - hepatitis, hepatosplenomegaly, jaundice, ascites/oedema, gynaecomastasia, bruising
Neuro - cerebellar problems
Eyes - Kayser-Fleischer rings
Bloods - abnormal LFTs, low serum caeruloplasmin and copper
24 urinary Copper - high
Liver biopsy - high copper
Poor prognostic factors for ulcerative colitis
ABCDEF criteria
Albumin (low) Blood PR CRP (high) Dilated loops of bowel Eight or more bowel movements per day Fever (>38oC in first 24hrs)
Diverticulosis Hinchley classification
IA - phelgmon (inflamed tissue)
IB, II - localised abscesses
III - perforation with purulent peritonitis
IV - faecal peritonitis
Hepatorenal syndrome in alcoholic hepatitis Rx
Glypressin
N-acetylcysteine
Inherited causes of liver cirrhosis
a1-antitrypsin deficiency Haemochromatosis Wilson's disease Galactosaemia CF NASH
[biliary - PBC, PSC
vascular - Budd-Chiari syndrome or hepatic venous congestion]
Type I autoimmune hepatitis autoantibodies
Occurs in all age groups (although mainly in young women)
ANA
ASMA
AAA
Anti-SLA
Type 2 autoimmune hepatitis autoantibodies
Occurs normally in girls and young women
Antibodies to liver/kidney microsomes
ALKM-1
ALC-1
Keratoconjunctivitis sicca may be associated with
Autoimmune hepatitis
Urinalysis results in Hep A and Hep E (acute infections)
Bilirubin +
High urobilinogen [hepatic jaundice picture. n.b. this is low in post-hepatic jaundice urine]
(n.b. dark urine, pale stools + jaundiced)
Chronic HepB Rx
Anti-virals
IFN-a
Nucleos/tide analogues
Chronic HepC Rx
IFN-a Nucleotide analogue (ribavirin)
Monitor HCV viral load after 12weeks of treatment, and USS
Iron accumulation in the liver in hereditary haemochromatosis is visualised using what stain
Perls’ stain
liver biopsy can assess tissue damage, MRI can estimate degree of iron loading
Organ damage in hereditary haemochromatosis
Liver - hepatomegaly, disease Joints - chondrocalcinosis, arthralgia Pituitary - hypogonadism Heart - arrythmias, HF Pancreas - DM
High eosinophils in which type of liver abscess?
Hydatid abscess
Caused by tapeworm (common in sheep rearing countries)
Stool MC&S - tapeworm eggs. USS localises mass. CXR for any R pleural effusion and raised hemidiaphragm.
Pyogenic liver abscess (i.e. E coli, Klebsiella, enterococcus) aspiration and culture results are…
polymicrobial
Entamoebic liver abscess (i.e. Entamoeba histolytica) aspiration and culture results are…
Like ‘anchovy sauce’ - fluid of necrotic hepatocytes and trophozoites
Bloods. Stool MC&S shows E histolytica. USS and CXR.
Time frames of liver failure (jaundice + encephalopathy) in the following: Hyperacute Acute Subacute Acute-on-chronic
Hyperacute - <7days
Acute - from 1-4weeks after onset
Subacute - 4-12weeks
Acute-on-chronic - acute deterioration (decompensation) in patients with chronic liver disease i.e. cirrhosis
A 28yr old man with Crohn’s disease complains of watery discharged from a puckered area 2cm from the anal canal. What is the likely diagnosis?
Anal fistula
Common complication of Crohn’s disease. A full PR examination is important to detect other causes of anal fistulae e.g. rectal carcinoma
Anti-endomysial antibodies are detected in…
Coeliac disease
also IgG anti-gliadin AGA and TTG antibodies
A 45yr old man presents with severe epigastric pain and vomiting. AXR shows absent psoas shadow and ‘sentinel loop’ of proximal jejunum. What is the likely diagnosis?
Acute pancreatitis
Absent psoas shadow = build up of retroperitoneal fluid.
Sentinel loop = segment of gas-filled proximal jejunum.
n.b. AXR can be normal in acute pancreatitis.
A 65 year old man presents with a 18 month Hx of recurrent attacks of epigastric pain lasting several weeks. The pain occurs straight after eating and is relieved by lying flat or vomiting. He avoids spicy foods and has lost 3kg in weight. O/E: midline epigastric tenderness. What is the likely diagnosis?
Gastric carcinoma
similar sign to gastric ulcer however more gradual onset and note that he has lost weight
