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Gastroeneterology Flashcards

1
Q

What is the secondary prophylaxis of Hepatic encephalopathy?

A

Lactulose and rifaximin

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2
Q

What is the first-line management for hepatic encephalopathy?

A

Lactulose

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3
Q

What are the features of autoimmune hepatitis?

A

Present with signs of chronic liver disease

Acute hepatitis: Fever, jaundice

Amenorrhoea

ANA/SMA/LKM1 antibodies, raised IgG levels

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4
Q

What is the management of autoimmune hepatitis?

A

Steroids

Immunosuppressants - Azathioprine

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5
Q

What autoantibodies are associated with type autoimmune hepatitis?

A

Anti-nuclear (ANA)

Anti-smooth muscle (SMA)

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6
Q

What screening investigation is performed in haemochromatosis?

A

Transferrin saturation

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7
Q

What is the presentation of haemochromatosis?

A

Bronze tint of the skin
Chondrocalcinosis of the finger joints
Raised glucose
Liver disease

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8
Q

Which gene is associated with haemochromatosis?

A

HFE gene

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9
Q

What is the typical iron study profile in a patient with haemochromatosis?

A

Transferrin saturation raised
Raised ferritin
Low TIBC

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10
Q

What is the first-line management of haemochromatosis?

A

Venesection is the first-line management

Desferrioxamine is second line

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11
Q

Which criteria is used in the diagnosis of IBS?

A

Rome criteria

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12
Q

What is the presentation of IBS?

A 
altered stool passage (straining, urgency, incomplete evacuation)
abdominal bloating (more common in women than men), distension, tension or hardness
symptoms made worse by eating
passage of mucus
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13
Q

What is the Rome IV diagnostic criteria for IBS?

A

Recurrent abdominal pain for >3 months with 2 of the following:

1) Related to defecation
2) Associated with a change in frequency of the stool
3) Associated with a change in form (appearance)

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14
Q

What medication is used to induce remission in Crohn’s disease?

A

Prednisolone

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15
Q

What are the presenting features of oesophageal varices?

A

Usually a large volume of fresh blood. Swallowed blood may cause melena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed.

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16
Q

What are the presenting features of a Mallory-Weiss tear?

A

Typically brisk small to moderate volume of bright red blood following a bout of repeated vomiting. Malena rare. Usually ceases spontaneously.

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17
Q

What is the management of variceal bleeding?

A

terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices
transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures

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18
Q

What is Peutz-Jeghers Syndrome?

A

Numerous hamartomatous polyps in the GI tract

Pigmented freckles on he lips, face, palms and soles

Intestinal obstruction

GI bleeding

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19
Q

What is the investigation of choice for suspected perianal fistulae in Crohn’s?

A

MRI pelvis

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20
Q

What is administered to induce remission in a severe acute exacerbation of UC?

A

Intravenous corticosteroids

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21
Q

Per the Truelove and Witt’s criteria how many bowel motions is associated with severe UC?

A

> 6 bowel motions a day with blood and fever

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22
Q

What drug is used to maintain remission in UC?

A

Methotrexate

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23
Q

What is administered to induce remission in moderate-mild flares of UC?

A

Oral corticosteroid

Oral or topical Sulfalazine

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24
Q

Melanosis coli is associated with what?

A

Associated with laxative abuse (Senna)

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25
What is the presentation of melanosis coli on histology?
Disorder of pigmentation of the bowel wall, histology demonstrates pigment-laden macrophages
26
What complication of UC is associated with cholestasis?
Primary sclerosing cholangitis
27
Isoniazid therapy can cause what type of vitamin deficiency?
B6 deficiency causing peripheral neuropathy
28
What is the first-line investigation of Budd-Chiari syndrome?
Ultrasound with Doppler flow studies
29
What is GORD?
Gastro-oesophageal reflux disease is defined as the inflammation of the oesophageal lining due to the reflux of gastric contents into the oesophagus and oral cavity.
30
What is the pathophysiology of GORD?
* Increased frequency of transient lower oesophageal sphincter relaxation. * Decreased resting LOS pressure * Reduced saliva production (Xerostomia) – disturbs pH clearance leading to increased irritation of mucosal oesophageal lining. * Abnormal peristalsis  Reduced volume clearance.
31
What is the definition of a sliding hiatal hernia?
In a sliding hiatal hernia, the stomach is distended through the diaphragm superiorly, increasing gastric acid reflux into the distal oesophagus and gastroesophageal junction.
32
What is the definition of a rolling hiatus hernia?
In a rolling hiatus hernia, the gastroesophageal junction is intact, the herniated portion of the stomach is alongside the oesophagus. • Surgical emergency because the stomach can become ischaemic. • Barium swallow shows barium in the fundus of the stomach superior to the diaphragm.
33
What is the presentation fo GORD?
Heart-burn - Post-prandial burning sensation in the chest Aggravated by: - Lying supine - Bending - Large meals - Drinking alcohol Waterbrash Aspiration Dysphagia
34
What is waterbrash?
Regurgitation of an excessive accumulation of saliva from the lower part of the oesophagus
35
What are the symptoms of aspiration pneumonia?
Hoarseness, laryngitis, nocturnal cough, and wheee
36
What are the investigations for GORD?
Clinical diagnosis OGD & biopsy 24-48 ambulatory pH monitoring Oesophageal manometry Barium swallow
37
What is the first-line management for GORD?
20mg PPI (Omeprazole) for initial course of 8 weeks
38
What are the surgical management for GORD?
* Dilatation peptic strictures | * Laparoscopic Nissen’s fundoplication.
39
What lifestyle changes are made for GORD?
``` o Weight loss o Elevating head of bed o Avoiding provoking factors o Smoking cessations o Lower fat meals and avoiding large meals in the evening. ```
40
What are the two types of oesophageal cancer?
Adenocarcinoma | Squamous cell carcinoma
41
What cell type is implicated in adenocarcinoma?
Columnar glandular epithelium
42
Which type of oesophageal cancer is more prevalent in developing countries?
Squamous cell carcinoma
43
Which type of oesophageal cancer is more prevalent in the Western world?
Adenocarcinoma
44
What are the risk factors for squamous cell carcinoma?
``` Alcohol Tumour Plummer-Vinson syndrome Achalasia Scleroderma Coeliac disease Nutritional deficiencies Dietary toxins (e.g., nitrosamines – cured meats, pickles) ```
45
What are the risk factors for adenocarcinoma?
GORD | Barrett’s oesophagus
46
What is the most common presenting complaint for oesophageal cancer?
Dysphagia
47
How does dysphagia present in oesophageal cancer?
Dysphagia for solids progressing to liquids.
48
What is the presentation for oesophageal cancer?
Odynophagia- Pain on swallowing Weight loss Hoarseness - Upper oesophageal tumous can impinge the recurrent laryngeal nerve Dysphagia Regurtiation Cough Fatigue
49
What are the metastatic signs in oesophageal cancer?
Supraclavicular lymphadenopathy Hepatomegaly Hoarseness Signs of broncopulmonary involvement
50
What is the first-line investigation for Oesophageal cancer?
OGD with biopsy
51
What is the most common site of squamous cell carcinomas within the oesophagus?
Upper two-thirds of the oesophagus
52
What is the most common site of adenocarcinomas within the oesophagus?
Lower 1/3 of oesophagus
53
What is the preferred modality for regional staging of oesophageal cancer?
Endoscopic ultrasound
54
What radiological modality is used to stage oesophageal cancer?
CT chest and abdomen
55
What is the definitive management for stage 0 or initial stage oesophageal cancers?
Endoscopic resection w/wo mucosal ablation (radiofrequency) Oesophagectomy
56
What type of oesophagectomy is performed in the management of oesopahgeal cancer?
Ivor-Lewis type oesophagectomy
57
Define acute cholangitis?
Acute cholangitis is an infection of the biliary tree
58
What is the aetiology of acute cholangitis?
Due to obstruction of the gallbladder or bile duct due to gall stones - ERCP - Tumours - Bile duct strictures or stenosis - Parasitic infection
59
What type of bacteria is associated with ascending cholangitis?
Enteric bacteria - E.coli, Klebsiella, Entercoccous
60
What is the presentation of ascending cholangitis?
Charcot's triad of symptoms - RUQ pain and tenderness - Jaundice - Fever with rigors Pruritus Pale stools
61
What is Charcot's triad?
RUQ pain and tenderness Jaundice Fever
62
What is Reynold's Pentad?
``` Mental confusion Septic shock-hypotension -RUQ pain -Jaundice -Fever ```
63
What is the first-line diagnostic investigation for ascending cholangitis?
Abdominal ultrasound - stones and dilatation of the common bile duct
64
What blood test findings are seen in ascending cholangitis?
Raised inflammatory markers - CRP/ESR -LFTs - Hyperbillurubinaemia, raised serum transaminases, and alkaline phosphatase
65
What is the first-line management for ascending cholangitis?
Intravenous broad-spectrum antibiotics + rehydration using saline bolus fluid
66
What is the definitive management for ascending cholangitis?
Endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction Cholecystectomy is there are underlying gallstones
67
What is acute cholecystitis?
Inflammation of the gallbladder predominantly due to an impacted gallstone obstruction within the cystic duct or gallbladder neck -Bile stasis and mucous production can result in gallbladder distension
68
What is the presentation of acute cholecystitis?
``` Constant RUQ pain Tenderness in RUQ Palpable mass Fever Nausea Right shoulder tip pain Localised peritonism ``` Guarding Rebound tenderness Murphy's sign positive
69
What is Murphy's sign positive?
Right hypochondrial tenderness worsens on inspiration.
70
What is the gold-standard investigation for acute cholecystitis?
Abdominal ultrasound of the biliary tree
71
What does an abdominal ultrasound reveal in acute cholecystitis?
* Pericholecystic fluid * Distended gallbladder * Thickened gallbladder wall (>3mm) * Gallstones * Positive sonographic Murphy’s Sign
72
What does an FBC reveal in acute cholecystitis?
Neutrophilia | And moderate leucocytosis
73
Deranged LFTs in acute cholecystitis may suggest what?
Deranged LFTs may indicate Mirizzi syndrome - a gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct
74
What is the definitive management for acute cholecystitis?
Cholecystectomy | + Conservative management - ABx
75
What is the presentation of biliary colic?
colicky right upper quadrant abdominal pain worse postprandially, worse after fatty foods the pain may radiate to the right shoulder/interscapular region nausea and vomiting are common in contrast to other gallstone-related conditions, in biliary colic there is no fever and liver function tests/inflammatory markers are normal
76
Where does biliary colic pain radiate to?
Right scapula
77
What can exacerbate biliary colic pain?
Precipitated by a fatty meal
78
What are the main risk factors for biliary colic?
Fat: obesity is thought to be a risk factor due to enhanced cholesterol synthesis and secretion Female: gallstones are 2-3 times more common in women. Oestrogen increases activity of HMG-CoA reductase Fertile: pregnancy is a risk factor Forty
79
What is the pathophysiology of biliary colic?
occur due to ↑ cholesterol, ↓ bile salts and biliary stasis | the pain occurs due to the gallbladder contracting against a stone lodged in the cystic duct
80
What is the gold-standard investigation for biliary colic?
Abdominal ultrasound
81
What is the definitive management for biliary colic?
Elective laparoscopic cholecystectomy
82
What is cirrhosis?
A condition in which the liver responds to hepatocyte injury/death by replacing damaged hepatic parenchyma with fibrous tissue and nodules.
83
What are the risk factors for cirrhosis?
* Chronic alcohol use * Hepatitis C infection * Chronic hepatitis B infection * Autoimmune hepatitis * Hereditary haemochromatosis * Wilson disease * Alpha 1-anittrypsin deficiency * Intravenous drug use * Other: Unprotected intercourse, obesity, and blood transfusion.
84
What is the presentation of cirrhosis?
Abdominal distension due to ascites in portal hypertension Jaundice and pruritus - Decompensated cirrhosis secondary to reduced hepatic excretion of conjugated BR. Haematemesis and melaena • Hand and nail features: Leukonychia, palmar erythema, and spider naevi. - Leukonychia (white nails) – Secondary to hypoalbuminemia - Polished nails – Secondary to excessive scratching in pruritus - Palmar erythema – Redness of thenar and hypothenar eminences, - Spider naevi – Blanch on pressure and spider-like branches fill from a central arteriole. - Bruising, finger clubbing and cholesterol deposits in palmar creases in primary biliary cholangitis. - Dupuytren contracture in alcohol-related liver disease • Facial features: - Spider naevi – Blanch on pressure and spider-like branches fill from a central arteriole. - Telangiectasia – Red focal lesions resulting from irreversible dilatation of small blood vessels in the skin. - Bruising, rhinophyma, parotid gland swelling - Red tongue in alcohol-related liver disease. - Seborrheic dermatitis, jaundiced sclera and xanthelasma. • Abdominal features - Caput medusa – Collateral circulation of the abdominal wall around the umbilicus. - Bruising - Hepatomegaly - Splenomegaly - Abdominal distension – Particularly in the flanks with shifting dullness and fluid thrill secondary to ascites. - Hepatic bruit – Present with a vascular hepatoma - Loss of secondary sexual hair and testicular atrophy in men.
85
What facial features are seen in decompensated cirrhosis?
- Spider naevi – Blanch on pressure and spider-like branches fill from a central arteriole. - Telangiectasia – Red focal lesions resulting from irreversible dilatation of small blood vessels in the skin. - Bruising, rhinophyma, parotid gland swelling - Red tongue in alcohol-related liver disease. - Seborrheic dermatitis, jaundiced sclera and xanthelasma.
86
What abdominal features are seen in decompensated cirrhosis?
- Caput medusa – Collateral circulation of the abdominal wall around the umbilicus. - Bruising - Hepatomegaly - Splenomegaly - Abdominal distension – Particularly in the flanks with shifting dullness and fluid thrill secondary to ascites. - Hepatic bruit – Present with a vascular hepatoma - Loss of secondary sexual hair and testicular atrophy in men.
87
What hand and nail features are seen in decompensated cirrhosis?
• Hand and nail features: Leukonychia, palmar erythema, and spider naevi. - Leukonychia (white nails) – Secondary to hypoalbuminemia - Polished nails – Secondary to excessive scratching in pruritus - Palmar erythema – Redness of thenar and hypothenar eminences, - Spider naevi – Blanch on pressure and spider-like branches fill from a central arteriole. - Bruising, finger clubbing and cholesterol deposits in palmar creases in primary biliary cholangitis. - Dupuytren contracture in alcohol-related liver disease.
88
What is hepatic fetor?
Sweet putrid smell of the breath
89
What are the LFT findings in cirrhosis?
AST and ALT levels increase with hepatocellular damage - Raised BR - GGT elevated - Reduced albumin - Reduced serum sodium
90
What is the definitive investigation for cirrhosis?
Liver biopsy
91
What does a liver biopsy reveal in cirrhosis?
Most specific and sensitive test for diagnosis of cirrhosis. - Result: Architectural distortion of the liver parenchyma with formation of regenerative nodules.
92
What are the coagulation study findings in decompensated liver cirrhosis?
Prolonged prothrombin time Reduced platelet count - Thrombocytopenia INR
93
What should be performed if ascites is present?
Peritoneal tap for microscopy and culture to identify for spontaneous bacterial peritonitis.
94
What investigation is performed in NAFLD?
Transient elastrography
95
What scoring criteria is used in liver disease to assess the severity of cirrhosis?
Child-Pugh Score?
96
What parameters are assessed in the Child-pugh score?
``` Bilirubin (umol/l) Albumin (g/l) Prothrombin time (seconds prolonged) Encephalopathy Ascites ```
97
What is SBP?
• Spontaneous bacterial peritonitis (SBP) – An ascitic tap with neutrophils >250mm3 indicates SBP. Patients with a low ascitic albumin are especially at risk  Treated with prophylactic antibiotics.
98
Why do oesophageal varices occur?
Portal hypertension leads to dilatation of oesophageal veins. The veins are susceptible to rupture (fatal in patients with coagulopathy).
99
What bile-acid sequestrants are used to manage pruritus?
Cholestyramine
100
What is the management of ascites?
Fluid restriction and low-salt diet Consider Spironolactone and furosmide
101
What is the prophylactic management for recurrent episodes of hepatic encephalopathy?
Lactulose and rifaximin
102
What is the definitive treatment for liver cirrhosis?
Liver transplant
103
What scoring system is used to assess the survival benefit of a liver transplant?
MELD
104
Which disease is associated with a secondary cause of achalasia?
Chagas disease
105
What is achalasia?
Failure of the LOS to relax resulting in apersistalsis - Degeneration of the myenteric plexus to produce NO and VIP
106
What is the presentation of achalasia?
Dysphagia of both solids and liquids Regurgitation due to food trapped in the oesophagus Gradual weight loss -Due to lack of food ingestion
107
What is the gold-standard investigations for achalasia?
High resolution oesophageal manometry - Incomplete relaxation and Aperistalsis at the LOS
108
What are the other investigations performed in achalasia?
Upper GI Endoscopy - Retained food debris with dilated wall Barium swallow - Birds beak appearance
109
What is seen in a barium swallow for achalasia?
Birds beak appearance
110
What is the management for achalasia?
Heller's cardiomyotomy
111
What are the risk factors for GORD?
``` Hiatus hernia Obesity Gastric acid hypersecretion Alcohol Smoking Pregnancy LOS tone reducing drugs (TCAs) ```
112
What are the main presenting features of GORD?
``` Post-prandial pain Acid regurgitation - bitter Waterbrash Odynophagia Chronic cough or nocturnal asthma ```
113
What is the gold-standard investigation for GORD?
Resolution of symptoms after 8 week PPI trial
114
What is the surgical management for GORD?
Nissen fundoplication | Magnetic bead banding
115
What are the risk factors for PUD?
``` H.pylori NSAIDs - Reduced bicarbonate production Smoking Increased/decreased gastric emptying Gastric specific ulcers - Cushing (Vagus) and Curling ulcers ```
116
What are the two types of peptic ulcers?
Duodenal ulcers | Gastric uclers
117
What enteroendocrine hormone is secreted in Zollinger Ellison Syndrome?
Gastrin
118
What is the PUD presentation?
Epigastric pain (pointing sign) Directly after meal = gastric ulcer N&V Mild weight loss
119
What are the complications of PUD?
Haemorrhage Perforation Obstruction
120
What is the gold-standard investigation for PUD?
Upper GI endoscopy - reveal ulcerations
121
What investigations are performed for PUD?
Upper GI Endoscopy (Gold) -H pylori tests - Urea breath test and stool antigen test (test after 6-8 weeks9 Serum fasting gastrin level
122
What lifestyle changes are recommended in PUD?
Smoking cessation | Reducing alcohol intake
123
What medical therapy is indicated in H.pylori positive PUD?
Triple therapy PPI , amoxicillin, clarithromycin 7 day eradication therapy -Consider metronidazole if contraindicated
124
What is the management of H.pylori negative PUD?
Offer 4-8 weeks of PPI therapy
125
Define gastritis?
Histological presence of mucosal inflammation
126
What are the two types of hernias?
``` Hiatus hernias Sliding hernias (80%) ```
127
Define hiatus hernia?
Protrusion of abdominal contents into the thorax - usually stomach
128
What is the most common hiatus hernia?
Sliding hernia
129
What are the risk factors for hiatus hernias?
Obesity | Increasing intra-abdominal pressure
130
What are the presentation of hiatus hernia?
Asymptomatic GORD symptoms (Worse when lying flat) Palpitations or hiccups indicate pericardial irritation
131
What is the gold standard investigation for hiatus hernia?
Upper GI endoscopy
132
What does a CXR reveal in hiatus hernia?
Retrocardiac bubble
133
What is the surgical management for hiatus hernia?
Fundoplication
134
What is the aetiology o Barret's oesophagus?
Metaplasia of normal stratified squamous epithelium to columnar epithelium
135
What is the gold standard investigation for Barrett's oesophagus?
Upper GI endoscopy with biopsy (Revealing columnar epithelium)
136
What is the management of non-dysplastic Barrett's oesophagus?
Maximise PPI therapy and surveillance every 2 years
137
What is the management for low-grade dysplasia?
Monitor every 6 months to assess growth
138
What is the definitive management for high-grade dysplasia?
Therapeutic intervention - radiofrequency ablation or endoscopic mucosal resection for nodular growths.
139
Smoking increases what type of oesophageal carcinoma?
Squamous cell carcinoma
140
What is the presentation of oesophageal cancer?
Dysphagia - first solids progressing to liquids Rapid weight loss Hoarseness
141
What is the gold standard investigation for oesophageal cancer?
Upper GI Endoscopy with biopsy
142
Define gastric cancer
Neoplasm originating in any portion of the stomach (Adenocarcinoma) Intestinal - H.pylori associated diffuse - E-cadherin associated
143
What are intestinal gastric cancers associated with?
H.pylori
144
What are the main risk factors for gastric cancers?
Pernicious anaemia H pylori Nitrosamines
145
What is the presentation of gastric cancer?
Vague epigastric abdominal pain Weight loss common Lymphadenopathy (Left supraclavicular- Virchow's node) Sister mary joseph nodule Krukhenberg tumour- ovaries
146
What is the gold standard investigation for gastric cancer?
Upper GI endoscopy with biopsy
147
What does a biopsy reveal in gastric cancer?
Signet ring cells
148
Define Mallory-Weiss Tear
Longitudinal lacerations in the mucosa and submucosa near the GOS Self-limiting
149
What are the risk factors for a Mallory-Weiss tear?
Persistent retching, coughing, vomiting, or straining found in alcoholics and bulimics (Increase in intra-abdominal pressure)
150
What is the presentation of Mallory-Weiss tear?
``` Haematemesis is the most common Light-headed/dizziness Postural hypotension Dysphagia Melanea ```
151
What is the gold standard investigation in a MW tear?
Upper GI Endoscopy
152
What happens to the serum urea in an upper GI bleed?
Serum urea increases (Breakdown of erythrocytes)
153
What risk assessment scores are associated in upper GI bleeds?
Rockall Score | Glasgow-Blatchford score
154
What is the first-line management of a Mallory-Weiss tear?
Endoscopy inject adrenaline or conduct band ligation to stop bleeding Anti-secretory therapy (PPI) before endoscopy. - seems to reduce re-bleed Anti-emetics to prevent recurrence Second line - sengstaken-Blakemore tube
155
What biochemical marker is raised in an acute upper GI bleed?
Urea - may be seen due to the protein meal of blood
156
What is the Glasgow-Blatchford score?
the Glasgow-Blatchford score at first assessment | helps clinicians decide whether patient patients can be managed as outpatients or not
157
What is the Rockall score?
he Rockall score is used after endoscopy provides a percentage risk of rebleeding and mortality includes age, features of shock, co-morbidities, aetiology of bleeding and endoscopic stigmata of recent haemorrhage
158
What is the first-line management of varcieal bleeding after resuscitation with FFP and fluids?
Terlipressin and prophylactic Abx
159
What is the endoscopic therapy for oesophageal varices?
Endoscopic variceal band ligation SUPERIOR >> to endoscopic sclerotherapy
160
What is the management of oesophageal varices if band ligation is unsuccessful?
Insertion of Sengstaken-Blakemore tube
161
What is the prophylactic treatment for variceal haemorrhage?
Propanolol - reduced rebleeding
162
What is the most common type of colonic cancer?
Adenocarcinoma
163
What do colonic cancers arise from?
Dysplastic adenomatous polyps
164
What genes are implicated in colonic cancer?
HNPCC (Lynch Syndrome) FAP Peutz-Jeghers syndrome
165
What is HNPCC?
Hereditary non-polyposis colorectal cancer Fhx of bowel cancer at a young age Symptomatic 30 yo's Colonoscopy - tumour without polyps (Not FAP)
166
what is Petuz-Jeghers syndroms?
Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles. Although the polyps themselves don't have malignant potential, around 50% of patients will have died from another gastrointestinal tract cancer by the age of 60 years.
167
What are the UK cancer screening programmes?
Breast Cervical Bowel
168
What are the clinical features for Peutz-Jeghers syndrome?
Features hamartomatous polyps in GI tract (mainly small bowel) pigmented lesions on lips, oral mucosa, face, palms and soles intestinal obstruction e.g. intussusception gastrointestinal bleeding
169
What gene is associated with FAP?
APC gene
170
What is the management for FAP?
Annual screening sigmoidoscopy Polyps found = Resectional surgery Resection and pouch Vs subtotal colectomy and IRA
171
What biochemical screening test is available for colorectal cancer?
Faecal Immunochemical Test (FIT) tests
172
What is the FIT test?
Type of faecal occult blood test which uses antibodies that specifically recognise human haemoglobin
173
What is the age threshold to be invited for a flexible sigmoidoscopy screening for bowel cancer?
Age 55 years
174
What are the main risk factors for colorectal cancer?
Increasing age Obesity IBD (UC)
175
What is the presentation of colonic cancer?
Change in bowel habits Rectal bleeding (Mixed in the stool and not bright red) Weight loss - FLAWs Tenesmus Anaemia symptoms
176
What are the indications for a 2WW for colonic cancer?
NICE updated their referral guidelines in 2015. The following patients should be referred urgently (i.e. within 2 weeks) to colorectal services for investigation: patients >= 40 years with unexplained weight loss AND abdominal pain patients >= 50 years with unexplained rectal bleeding patients >= 60 years with iron deficiency anaemia OR change in bowel habit tests show occult blood in their faeces (see below) An urgent referral (within 2 weeks) should be 'considered' if: there is a rectal or abdominal mass there is an unexplained anal mass or anal ulceration patients < 50 years with rectal bleeding AND any of the following unexplained symptoms/findings: abdominal pain change in bowel habit weight loss iron deficiency anaemia
177
A male >55 with FLAWs and altered bowel habits is associated with what
Colorectal cancer
178
What may tenesmus suggest?
A rectal mass
179
What is the most common cause of iron deficiency in men over 60?
Colorectal cancer
180
What does an FBC reveal in colorectal cancer?
Iron deficiency anaemia
181
What examination features are associated with colonic cancer?
Anaemia features Palpable mass (Late) Distension/ascites (late) Lymphadenopathy (late)
182
How is colorectal cancer staged?
CT chest/abdomen/pelvis
183
What is the management of colonic cancer within the Caecal, ascending or proximal transverse colon?
Right hemicolectomy with ileocolic anastomosis
184
What is the surgical management for a colonic cancer residing within the Distal transverse, descending colon?
Left hemicolectomy with colo-colon anastomosis
185
What is the surgical management for sigmoid colon cancer?
High anterior resection
186
What is the surgical management for an anal verge colonic cancer?
Abdomino-perineal excision of rectum
187
What is the diagnostic investigation for colonic cancer?
Colonoscopy and biopsy
188
What does a double-contrast barium enema reveal in colonic cancer?
Apple core lesion - cancer causing strictures
189
What cancer marker is associated with colonic cancer?
Carcinoembryonic antigen | -Used to monitor for recurrence in patients post-operatively to assess response to treatment
190
What is the first-line Investigation for suspected colonic cancer?
2WW referral | W LFTs and FBC & DRE
191
What criteria is used to stage colonic cancer?
Duke's staging + TNM classification
192
Apple core lesions (on a barium contrast double enema) are associated with what pathology?
Colonic cancer
193
What is Duke A staging in colonic cancer?
Tumour confined to the mucosa
194
What is Duke's B staging in colonic cancer?
Tumour invading the bowel wall
195
What is Duke C staging in colonic cancer?
Lymph node metastases
196
What is the definitive treatment for colorectal cancer?
Surgical excision + adjuvant or neoadjuvant chemo/radiotherapy
197
What are the common metastasis for colorectal cancer?
Liver Lung Bone Brain
198
What is the most common site for colorectal cancer?
Rectal -40% | Sigmoid - 30%
199
What is Crohn's disease?
Transmural inflammation of the GI tract affecting any part of the mouth to anus Skips lesions
200
Where does Crohn's disease most commonly affect?
Terminal ileum and perianal areas
201
What type of inflammation is associated with Crohn's disease?
Non-caseating granuloma formation
202
What are the clinical features of Crohn's disease?
presentation may be non-specific symptoms such as weight loss and lethargy diarrhoea: the most prominent symptom in adults. Crohn's colitis may cause bloody diarrhoea abdominal pain: the most prominent symptom in children perianal disease: e.g. Skin tags or ulcers extra-intestinal features are more common in patients with colitis or perianal disease
203
What are the risk factors for Crohn's disease?
``` FHx Cigarette smoking Oral contraceptive pill Diet high in refined sugars ?NSAIDs ?not breastfed ```
204
Describe the epidemiology of Crohn's disease
Ashkenazi Jews Bimodal peak: 15-40 60-80
205
Describe the abdominal pain in Crohn's disease
Crampy or constant right lower quadrant and periumbilical pain (terminal ileum)
206
Describe the diarrhoea of Crohn's disease
Mucous Blood Pus Nocturnal
207
What peri-anal lesions are associated with CD?
Skin tags Fistulae Abscesses
208
What extra-intestinal manifestations are associated with CD?
Arthropathy (Joint pain) Skin lesions -Erythema nodosum -Pyoderma gangrenosum Ocular symptoms -Uveitis, Episcerltiis
209
What skin manifestations are associated with CD?
Erythema nodosum | Pyoderma gangrenosum
210
What is erythema nodsum?
Swollen fat under the skin causing bumps and patches that look red or darker than the surrounding skin
211
What is pyoderma gangrenosum?
Characterised by small red/purple bumps or blisters (Papules or nodules) eventually eroding to painful ulcers - rapid progression
212
What ocular symptoms are associated with CD?
Uveitis | Episcleritis
213
Where does pyoderma gangrenosum typically affect?
Affects the legs
214
What may be found during an oral exam in a patient with CD?
Aphthous ulcers
215
What is the most common site for abdominal tenderness in CD?
Terminal ileum
216
What inflammatory markers are raised in CD?
ESR CRP Faecal calprotectin
217
What is a high risk complication of Crohns?
Anaemia of chronic disease
218
What type of diarrhoea is associated w Crohns?
Secretory diarrhoea due depletion of bile salt reabsorption -Steatthorrhoea and increased gallstone formation
219
What vitamin deficiency may be associated with CD?
ADEK (Fat-soluble vitamins)
220
Severe ileal disease/resection can lead to what malabsorption?
B12 malabsorption
221
A plain AXR reveals what in Crohn's?
Bowel dilation
222
What is revealed by a CT in Crohn's?
Bowel wall thickening | Skip lesions
223
A bowel series X-ray with barium enema reveals what specific findings in Crohn's disease?
Rose thorn ulcers - Deep ulcerations String sign of Kantor - Fibrosis and strictures
224
String sign of Kantor reveals what in Crohn's disease?
Fibrosis and strictures
225
What do rose thorn ulcers represent in Crohn's disease?
Deep penetrating linear ulcers or fissuring seen within the stenosed terminal ileum
226
What is the confirmative test for Crohn's disease?
Colonoscopy and biopsy (Histological evidence)
227
What is seen on colonoscopy in Crohn's?
Ulcers Cobblestone appearance Skip lesions
228
What does String Sign of Kantor represent?
Oedema fibrosis with ulcerated mucosa - resembling fraying of string
229
How do you induce remission of Crohn's disease?
Oral or IV steroids -Prednisolone Budenoside
230
What is the maintenance therapy for Crohn's disease?
Immunomodulators - Azathioprine Mercaptopurine Methotrexate
231
What are the biological therapies administered for Crohn's?
Adalimumab Infliximab Vedolizumab
232
What is the mechanism of Infliximab?
TNF-a inhibitors
233
What is the worst complication for Crohn's disease?
Obstruction - stricturing | Management with Hartmann's operation or colectomy
234
What are the adjuncts in management for Crohn's disease?
Nutritional therapy Perianal disease mX Smoking cessation
235
What are the indications for surgical management in Crohn's?
For severe remissions/presentations Refractory disease Obstructed Pts
236
What is the first-line immunomodulator in the management of Crohn's?
Azathioprine
237
What is the first-line biological therapy for Crohn's?
Infliximab
238
What adjunctive therapy can be given for cramp relief in Crohn's?
Anti-spasmotics
239
What is the definition of UC?
Continuous and uniform inflammation of the large bowel (originating from the rectum)
240
Where does UC begin?
Rectum - extending proximally
241
What gene is associated with UC?
HLA-B27 | Also associated with Ankylosing spondylitis
242
Which colonic layer is affected by UC?
Mucosa
243
What are the risk factors for ulcerative colitis?
FHx HLA-B27 Non-smoking (Smoking is protective in UC)
244
What is the presentation of ulcerative colitis?
``` Bloody diarrhoea Rectal bleeding + mucous Abdominal pain + cramps Tenesmus Weight loss ```
245
What are extra-intestinal manifestations of UC?
``` Peripheral arthritis Ankylosing spondylitis Erythema nodosum Pyoderma gangrenosum Episcleritis> Uveitis ```
246
What examination findings may be seen in UC?
Anaemia signs - pallor DRE - gross or occult blood comes out Abdominal tenderness
247
Which liver pathology is highly associated with ulcerative colitis?
Primary sclerosing cholangitis
248
What blood investigations are to be performed in UC?
FBC - Anaemia LFTs - PSC CRP/ESR - Inflammation pANCA
249
What autoantibody is positive in UC?
pANCA
250
What is a severe complication of UC?
Toxic megacolon
251
What stool sample protein indicates inflammation in UC?
Faecal calprotectin
252
What signs may be seen in a plain AXR in UC?
``` Dilated bowel (>6cm = toxic megacolon) Thumbprinting ```
253
What is thumbprinting?
A radiographic sign of large bowel thickening - caused by oedema related to an infective or inflammatory process (colitis) Haustra become thickened at regular intervals appearing like thumprints projecting into the aerated lumen
254
What type of bowel enema is used in UC?
Double-contrast bowel enema
255
What sign is revealed in a double-contrast bowel enema in UC?
Lead-pipe appearance
256
What is the diagnostic investigation for UC?
Colonoscopy and Biopsy
257
What colonoscopy findings are seen in UC?
Continuous, erythema, bleeding, ulcers
258
What histological findings are associated with UC?
crypt abscess | Depletion of goblet cell mucin
259
What is used to induce remission in UC?
Topical or oral Mesalazine (5-ASA) and oral steroids - Oral beclamethasone
260
What is the normal maximum diameter of the small bowel?
35MM | Valvuae conniventes extend all the way across
261
What is the maximum normal diameter of the large bowel?
55mm | Haustra extend about a third of the way across
262
What is the first-line immunosuppressants in UC?
Methotrexate, Mercaptopurine, azathioprine
263
What is the main biologic involved in UC?
Infliximab Ciclosporin
264
What is the definitive cure of UC?
Total colectomy
265
What are the three main complications of UC?
Colonic adenocarcinoma Toxic megacolon Psc
266
Which dietary peptide is associated with coeliac disease?
Gliadin | Found in Wheat, rye and Barley
267
What does Coeliac disease result in?
Villous atrophy Hypertrophy of intestinal crypts Increased lymphocytes in the epithelium and lamina propria
268
What are the risk factors for coeliac disease?
FHx IgA deficiency T1DM Autoimmune thyroid disease F>M Western countries
269
What is the presentation of coeliac disease?
Diarrhoea (Chronic/intermittent) Bloating Abdominal pain and discomfort Extra-intestinal - Fatigue - weight loss - Dermatitis herpetiformis (elbows)
270
What dermatological manifestation is associated with coeliac disease?
``` Dermatitis herpetiformis (elbows) Bilateral itchy vesicles and plaques ```
271
Where does dermatitis herpetiformis affect?
Extensor surfaces, face, scalp, necl
272
What are the endoscopic findings in coeliac disease?
Loss of folds Visible fissures Nodular appearance Absent villi
273
What is the first-line investigation for coeliac disease?
Immunoglobulin A tissue transgutaminase (IgA tTG) -Elevated titre Do Serum IgA to screen for IgA deficiency -Consider IgG ttG
274
What is the diagnostic investigation for coeliac disease?
Duodenal biopsy and endoscopy
275
What does an endoscopy reveal in coeliac diseae?
Villous atrophy | Crypt hyperplasia
276
What autoantibodies are associated with coeliac disease?
IgA ttg | Endomysial antibody
277
What is the management for coeliac disease?
Gluten-free diet -Vitamin + mineral supplements Refractory - refer to specialist
278
What is the definition of IBS?
Chronic condition characterised by recurrent abdominal pain associated with bowel dysfunction
279
What are the three types of IBS?
IBS with diarrhoea - IBSD IBS with constipation - IBS C IBS mixed type - IBSM
280
What are the risk factors for IBS?
History of Physical/Sexual Abuse PTSD PMHx: Acute bacterial gastroenteritis FHx
281
What is the epidemiology of IBS?
Females > M (2:1) | <50 Years.
282
What is the presentation of IBS?
Abdominal cramping in the lower/mid abdomen Alteration of stool consistency (diarrhoea/constipation) Defecation relieves abdominal pain/discomfort
283
What investigations would you perform to exclude IBS?
``` Anti-tTG (coeliac) Fecal calprotectin, lactoferrin (IBD) Serrum CRP (IBD) Colonoscopy (IBD) FBC (anemia – consider CRC) FOB test (CRC) ```
284
What lifestyle management is available for IBS?
``` Fibre Avoid: caffeine, lactose, fructose. Stress management Education + Reassurance + Probiotics ? ```
285
What is the medical therapy for IBS?
Laxatives (IBS-C) Antispasmotics (cramps) Antidiarrhoeals (IBS-D)
286
Define haemorrhoids
Vascular rich tissue cushions located within the anal canal
287
What is the aetiology of haemorrhoids?
Prolonged/ repetitive straining causes disruption of the tissues and results in elongation/dilation of the haemorrhoidal tissues.
288
What are the two types of haemorrhoids defined by the location to the dentate line?
External and internal
289
What is the dentate line?
The line between the simple columnar epithelium of the rectum and the stratified epithelium of the anal canal
290
What are grade 1 haemorrhoids?
No prolapse | Just prominent blood vessels, only bleeds
291
What are grade 2 haemorrhoids?
Prolapse upon bearing down but spontaneously reduce
292
What are grade 3 haemorrhoids?
Prolapse upon bearing down and requires manual reduction
293
What are grade 4 haemorrhoids?
Permanent prolapse and cannot be manually reduced
294
What does prolapse mean in relation to haemorrhoids?
Protrusion beyond the anal opening
295
What are the risk factors for haemorrhoids?
Constipation Pregnancy Space occupying pelvic lesions
296
What is the presentation of haemorrhoids?
Painless bleeding associated with defecation (Bright red) ``` Anal pruritus (itching) Palpable mass felt ```
297
Describe the bleeding with haemorrhoids
bright red associated with defecation | Painless
298
What is the 1st-line and diagnostic investigations for haemorrhoids?
Anoscopic examination | Visualise haemorrhoids and confirms diagnosis
299
What is the conservative management of haemorrhoids?
Constipation advice | Lifestyle discourage straining
300
What is the management of grade 1 haemorrhoids?
Topical corticosteroids (Alleviates pruritus)
301
What is the management of grade 2 and 3 haemorrhoids?
Rubber band ligation
302
What is the definitive management for grade 4 haemorrhoids?
Surgical haemorrhoidectomy
303
How does rubber band ligation work?
Helps to stop blood flowing to the haemorrhoid - haemorrhoid dries up and falls off on their own (1-2 weeks)
304
What is a haemorrhoidectomy?
First line treatment for grade 4 internal haemorrhoids. Under General anesthesia Only takes ~20 mins Surgeon excises or uses a stapler to remove haemorrhoids
305
What is a complication of a haemorrhoid?
Thrombosed haemorrhoid
306
What is the presentation of thrombosed haemorrhoids?
Significant pain and a tender lump OE: Purplish, oedematous subcutaneous perianal mass
307
What is the management of a thrombosed haemorrhoid?
Within 72 hours - consider for excision Managed with stool softners, ice packs, and analgesia
308
Define rectal prolapse
Rectum slides out of the anal canal
309
What is the cause of rectal prolapse?
Caused by long-term straining and anything causing weakness of pelvic floor muscles
310
What are the three types of rectal prolapse?
Internal Mucosal - the mucosa drops out External - Entire rectum drops out
311
What are the risk factors for rectal prolapse?
Chronic constipation + straining Weakened pelvic floor muscles - Natural birth - trauma obesity
312
What is the presentation of rectal prolapse?
Painless protruding mass following defecation Mucoid discharge incontinence
313
What is the first-line dan diagnostic investigation for rectal prolapse?
Clinical diagnosis OE: Visualise Ask the patient to strain to elicit prolapse
314
What is the mx for rectal prolapse?
DeLormes procedure
315
What is an anal fissure?
A split in the mucosal lining of the distal anal canal characterised by pain on defecation and rectal bleeding
316
What is the pathophysiology of anal fissures?
Hard stools tear the anal skin at the dentate line Poor blood supply can be a cause
317
What are the risk factors for anal fissures?
Hard stool Pregnancy Opiates
318
What is the presentation of anal fissures?
Pain on defecation Tearing sensation on defecation Fresh blood on toilet paper
319
What is the first line diagnostic investigation for anal fissures?
Clinical diagnosis EUAs
320
What is the first line management of anal fissures?
Manage constipation High fibre diet Adequate fluid intake Sitz baths Topical GTN Topical dilitiazem
321
What topical management is applied for analgesia in anal fissures?
Topical GTN
322
What is the management for persistent fissures?
Botox and surgical sphincterectomy
323
How does topical GTN work?
Relaxes the muscles around the anus to relive the pain
324
What is an anal fistula?
A connection between the last part of the bowel and the skin around the anus
325
What is the aetiology of anal fistula?
Clogged anal glands and anal abscesses Crohn’s disease Radiation (cancer) Trauma
326
What is the presentation of an anal fistula?
Frequent anal abscesses Pain and swelling around the anus Bloody / Foul smelling drainage (pus) “in underwear”
327
What is the investigation of anal fistula?
Opening the skin around the anus Not always visible Anoscope/rectoscope
328
What is the surgical management of an anal fistula?
Fistulotomy | Seton - surgical thread that is left in the fistula - allows it to drain and helps it heal.
329
What is an anal abscess?
An infection of the soft tissues and collection of puss around the anus
330
What are the risk factors for anal abscesses?
RISK FACTORS: Anal fistula Crohn’s disease Constipation
331
What is the presentation of anal abscess?
Perianal pain Not related to defecation Perianal swelling and tenderness
332
What is the first line investigation for anal abscess?
Clinical diagnosis | Visualise the abscess
333
What sit he definitive management for anal abscess?
Surgical drainage of the abscess
334
What is a pilonidal sinus?
Caused by the forceful insertion of hairs into the skin of the natal cleft in the sacrococcygeal area. Promotes inflammation and causes a sinus.
335
What is the presentation of pilondial sinus?
SACROCOCCYGEAL: Discharge – offensive, staining underwear Pain – worst on sitting down Swelling
336
What is the management of a pilonidal sinus?
Surgical treatment - excision + sinus Hair removal - laser
337
What are the things to note in a stoma?
Location (Right - ileostomy, left - colostomy) Number of lumens 2 = loop 1- end Flush or spouted ``` Comment on stoma bag -Solid/liquid Colour Blood mucous Inspect surrounding skin ```
338
How is unconjugated bilirurbin transported within the blood?
Associated with albumin
339
What is the definition of jaundice?
Increased bilirubin concentration in the blood
340
What are the breakdown products of haemoglobin?
Unconjugated bilirubin and iron
341
Which enzyme is responsible for conjugating bilirubin?
UDPGT
342
Where is conjugated bilirubin excreted into within the GI tract?
Duodenum
343
How is bilirubin secreted into the stools?
Stercobillin
344
How is conjugated bilirubin secreted into the urine?
Urobilinogen
345
What are the two common causes of pre-hepatic jaundice?
Haemolysis/Gilbert's
346
What is raised in pre-hepatic jaundice?
Unconjugated bilirubin
347
Which enzymes are elevated in hepatic causes of jaudnice?
AST | ALT
348
What are the common hepatocellular causes of jaundice?
Hepatitis Viral, alcoholic, autoimmune, drug Cirrhosis
349
What are the common causes of obstructive jaundice?
``` Liver mass Gallstone PBC/PSC Pancreattic cancer Cholangiocarcinoma/Cancer Drug (ileus) ```
350
Which liver enzyme is elevated in obstructive jaundice?
ALP/GGT
351
what is the characteristic presentation of obstructive jaundice?
Dark urine (Conjugated bilirubin going into the urine) ``` Pale stools (lack fo stercobiliin) Pruritus (Bile salts into circulation) ```
352
Why is pruritus a presentation in obstructive jaundice?
Bile salts produced in the liver cannot enter the duodenum therefore leak into the circulation -Excoriations result from this
353
What are the markers of the function of the liver?
INR Prothrombin time Albumin level Platelet count
354
What is the presentation of hepatitis?
``` RUQ pain Jaundice hepatomegaly Joint pain Nausea Fatigue Dark urine ```
355
What are the three stages of alcoholic liver disease?
Steatosis (fatty) Alcoholic hepatitis (inflammation) Cirrhosis
356
What is the irreversible stage of alcoholic liver disease?
Cirrhosis
357
What are the symptoms of alcoholic hepatitis?
After long term alcohol use, but sometimes after binge Nausea, anorexia, weight loss, hepatomegaly Severe: fever, jaundice, tachycardia, tender hepatomegaly, bruising, encephalopathy, ascites
358
What FBC signs are seen in alcoholic hepatitis?
Macrocytic anaemia
359
What are the LFT results in alcoholic hepatitis?
AST:ALT ratio >2 Raised Bilirubin Raised GGT Decreased albumin Increased prothrombin time
360
Which liver enzyme is raised in alcoholic hepatitis?
AST:ALT >2
361
What is a sensitive marker of significant liver damage?
Prothrombin time (Prolonged)
362
What radiological investigation is performed for alcoholic hepatitis?
Hepatitic ultrasound
363
What does a liver biopsy reveal in alcoholic hepatitis?
Ballooning | Mallory bodies indicates hepatitis
364
What is the management indicated in alcohol abstinence?
Chlordiazepoxide
365
What is the management of Wernicke's Encephalopathy?
Thiamine-Pabrinex
366
What are the risk factors for non-alcoholic fatty liver disease?
``` Truncal obesity Insulin resistance/diabetes Hyperlipidasemia Hypertension Metabolic syndrome Short bowel syndrome TPN Signs of insulin resistance ```
367
What LFTs are seen in NAFLD?
AST:ALT elevated <1 GGT/ALP Check glucose (raised)
368
What is the management of NAFLD?
Diet and exercise; controlling RFs (e.g., statins for hypercholesterolaemia, good blood sugar control for diabetics with metformin/thiazolidinediones)
369
How is hepatitis A&E transmitted?
Faeco-oral spread (sex/comntaminedwater)
370
What is ht management of viral hepatitis A and E?
Supportive | Avoid alcohol/excess paracetamol
371
Which HepA antibody is raised in acute Hep A infection?
Anti-HAV IgM - raised for 6 weeks
372
Which HepA antibody is raised in chronic infections?
Anti-HAV IgG
373
which hepatitis infection is more likely to become chronic?
Hepatitis C
374
What are the risks associated with viral hepatitis C?
cirrhosis/hepatocellular carcinoma
375
What is the management of acute hepatitis C infections?
Antiviral- sofosbuvir, ledipasvir
376
What is the management of acute hepatitis B?
Supportive management
377
What is the management of chronic hepatitis B infection?
Anti-viral therapy treatment suppresses HB DNA replication peginterferon-a-2a OR tenofovir
378
Which antibody is raised in HepB vaccinted individuals?
Anti-HBs
379
Which antibody is raised in past infections of Hepatitis B?
Anti-HBc (IgG positive)
380
Which antibodies are raised in an acute infection of hepatitis B?
IgM Anti-HBc | HBsAg
381
Which antibodies are raised in a chronic infection of hepatitis B?
HBsAg | IgG positive Anti-HBc
382
How is hepatitis B transmitted?
Children more likely to be carriers/chronic Sexually transmitted, IVDU, vertical
383
How is hepatitis C transmitted?
Blood product spread (IVDU/transfusioN)
384
What are the symptoms of an acute HepA infection?
``` Nausea Vomiting + Diarrhoea Fever Jaundice RUQ abdominal pain ```
385
Which hepatitis is transmitted predominantly by contaminated blood products?
Hepatitis C
386
What LFTs are associated with viral hepatitis?
AST/ALT (in 1000s) | Viral serology
387
What LFTs are associated with drug-induced hepatitis?
AST/ALT (In 1000s) | Serum paracetamol concentration
388
What is the management of a paracetamol overdose?
N-acetyl cysteine
389
Which autoantibodies are associated with autoimmune hepatitis?
ANA/ASMA
390
What is the aetiology of cirrhosis?
Normal liver is replaced with fibrosis and nodules of regenerating hepatocytes can be stable or decompensated
391
What is the diagnostic investigation for liver cirrhosis?
Transient elastrography
392
What are the common causes of liver cirrhosis?
``` Alcohol misuse Viral hepatitis (B/C) Autoimmune hepatitis Haemcrhomatosis NASH Chronic billiary disease ```
393
What is the peripheral stigmata of chronic liver disease?
``` Clubbing Spider naevi Dupuytren's contracture Palmar erythem Gynaecomastia Bruising ```
394
What is the definition of portal hypertension?
Increased pressure in the portal vein due to cirrhosis
395
What are the signs of portal hypertension?
Distended veins (varices) -Caput medusae and oesophageal varices Ascites Splenomegaly
396
What is the management of cirrhosis?
Treat cause + avoid hepatotoxic drugs (alcohol, sedative,opiates, NSAIDs) Monitor risk of complications (MELD score, 6-month USS, endoscopy upon diagnosis and every 3 years).
397
What is. the management of hepatic encephalopathy?
Oral lactulose Oral rifaximin phosphate enema
398
What gut product is implicated encephalopathy?
Ammonia
399
What should be restricted in hepatic encephalopahty?
Short-term protein restriction
400
What is the management of ascites?
Sodium restriction Diuretics - furosemide and spironolactone Large volume paracentesis
401
What diuretics are used in the managemetn of ascites?
Furosemide and spironolactone
402
What ABx are used in the treatment of SBP?
Cefuroxime | Metronidazole
403
What neutrophil count is diagnostic of SBP?
>250 neutrophils
404
How is SBP diagnosed?
Paracentesis (Needle aspiration of the ascitic fluid) | Ascitic tap
405
What is the primary prophylaxis of varices?
Propranolol (Non-selective beta blocker)
406
What is the management of | ruptured oesophageal varices?
ABCDE assessment, IV/fluids and blood transfusion/resuscitation Terlipressin and ABx Endoscopic varcieal ligation immediately after resuscitation
407
What is the secondary prophylaxis of varices?
Non-selective beta blocker (to replace terlipressin after 2-5 days) TIPS procedure when EVL and beta-blocker fails to prevent
408
Which drug is associated with drug-induced cholestasis?
Co-amoxiclav Nitrofurantoin OCP
409
What is the characteristic sign of pancreatic cancer?
Painless palpable gallbladder (Courvoisier's law) and jaundice
410
What is the definitive management of biliary colic?
Analgesia+ elective lap chole
411
What is the initial management of acute cholecystitis?
Clear fluids only Analgesics Fluid resus Broad IV Abx
412
What is the definitive management of acute cholecystitis?
Lap chole (within 1 week)
413
What are the two investigations indicated for the diagnosis of acute cholangitis?
USS liver and biliary tree ERCP
414
What is the definitive management for ascending cholangitis?
Analgesia + ERCP+lap chole
415
What is the major component of gallstones?
Cholesterol
416
What are the components of pigment stones?
Calcium bilirubinate
417
What are the risk factors for gallstones?
``` Fair Fat Fertile Female Forty OCC, Crohn's ```
418
Where do most pancreatic cancers arise from?
Head of the pancreas
419
What is a common cause of pancreatic cancers?
MEN1
420
What are the risk factors for pancreatic cancer?
``` Age>60 Smoking Obesity T2DM Chronic pancreatitis ```
421
What are the signs and symptoms of pancreatic cancer?
``` FLAWs Steatorrhoea Loss of endocrine function - diabetes Painless jaundice Trosseau sign (Migratory thrombophlebitis) ```
422
What is trousseau sign in pancreatic cancer?
Migratory thrombophelbitis
423
What is Courvoisier's law?
In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
424
What tumour marker is associated with pancreatic cancer?
CA19-9
425
What is the diagnostic investigation for pancreatic cancer?
Biopsy via ERCP or EUS
426
What does a high-resolution CT scan reveal in pancreatic cancer?
Double duct sign
427
What is the first line radiological sign for pancreatic cancer?
Abdominal ultrasound
428
What is the definitive management for pancreatic cancer?
Whipple's resection + adjuvant chemo- pancreaticoduodenectomy only is resectable
429
What does double duct sign suggest?
Pancreatic cancer
430
What is cholangiocarcinoma?
Cancer arising in the bile ducts either intrahepatic or extrahepatic
431
What does Sister-Mary Joseph Nodule represent?
Periumbilical lymphadenopathy
432
What does a Virchow’s node represent?
supraclavicular lymphadenopathy
433
what is the presentation of cholangiocarcinoma?
Jaundice (painless) Palpable gallbladder Pruritus Pale stool, dark urine
434
Which tumour markers are raised in a cholangiocarcinoma?
CA19 | CEA
435
What. is the gold standard investigation for cholangiocarcinoma?
ERCP with biopsy
436
What is the initial radiological investigation for cholangiocarcinoma?
Abdominal USS
437
What is the management of cholangiocarcinoma?
Removal of bile duct – small and localised tumour Partial hepatectomy – intrahepatic Whipple’s procedure -- for distal bile duct tumours
438
Which biological therapy is indicated for hepatocellular carcinoma?
Sorafenib
439
What is the first-line investigation for pancreatic cancer?
CT abdomen
440
Which antibodies are associated with autoimmune hepatitis?
ANA ASMA Anti-LKM
441
Which autoantibodies are associated with Type 1 AIH?
Antinuclear antibodies
442
Which autoantibodies are associated with Type 2 AIH?
Antibodies to liver/kidney microsomes
443
What is the presentation of autoimmune hepatitis?
``` Fatigue/malaise Anorexia Abdominal discomfort Hepatomegaly Jaundice Amenrrhoea Epistaxis Stigmata of chronic liver disease ``` Pruritus, arthralgia, nausea, fever and spider angiomata
444
What LFTs are seen in AIH?
Raised AST, ALT, GGT, ALP and BR Low Albumin
445
What does an FBC reveal in AIH?
Low Hb, platelets, and WCC (Hypersplenism) Hypergammaglobulinemia
446
What is the diagnostic investigation for autoimmune hepatitis?
Liver biopsy
447
What does a liver biopsy reveal in autoimmune heaptitis?
Portal mononuclear and plasma cell infiltrate
448
What is the acute management for autoimmune hepatitis?
High-dose corticosteroids (prednisolone) followed by maintenance treatment with gradual reduction in dose
449
What is the maintenance management for autoimmune hepatitis?
Azathioprine or 6-mercaptopurine (steroid-sparing agents) with frequent LFT and FBC monitoring.
450
What should be monitored prior to initiating azathioprine or 6-MP?
TPMT1 activity
451
What is the definitive treatment for severe autoimmune hepatitis?
Liver transplantation
452
What are the prodromal period symptoms for acute hepatitis A?
Fever Malaise Nausea and vomiting
453
What are the hepatitis symptoms associated with acute hepatitis A?
Jaundice - 2 weeks after infection Hepatomegaly + RUQ pain Clay coloured stools Pruritus Dark urine
454
What is elevated in fulminant hepatitis?
Raised serum creatinine
455
What is the LFT picture in acute hepatitis A?
Raised AST, ALT, ALP and BR
456
What HepA antibodies are positive during an acute illness?
IgM Anti-HAV | Elevated for a period of 3-5 months
457
What HepA antibodies indicate recovery phase?
Anti-HAV IgG
458
What is the management for acute HepA?
Supportive care - bed rest and symptomatic treatment - Antipyretics - Anti-emetics - Cholestryamine for severe pruritus
459
How is HepB transmitted?
Sexual contact, blood, and vertical transmission (from mother to baby).
460
What are the prodrome symptoms for HepB?
* Malaise * Headache * Anorexia * Nausea and vomiting * Diarrhoea * RUQ pain * Serum-sickness type illness (e.g., fever, arthralgia, polyarthritis, urticaria, maculopapular rash).
461
What HepB antibodies are associated with HepB acute?
* HBsAg Positive | * IgM anti-HBcAg
462
What HBV antibodies are associated with chronic HepB?
* HBsAg positive | * IgG anti-HBcAg
463
What HBV Antibodies indicate a cleared HbV infection?
* Anti-HBsAg antibody positive | * IgG anti-HBcAg
464
What is the management for chronic HBV?
Entecavir Tenofovir Interferon Alpha
465
What is the transmission for HepC?
Transmission: Parenteral • Sexual transmission • Vertical transmission (Mother to child) N.B: Transmission is through percutaneous exposure to infected blood – Injection of illicit drugs or transfusion of contaminated blood products.
466
What is the ratio of AST/ALT associated with alcoholic liver disease?
>2
467
What electrolyte abnormality is associated with alcoholic hepatitis?
Hyponatremia
468
Define acute pancreatitis
Defined as the acute inflammatory process of the pancreas. • Mild: Minimal organ dysfunction and uneventful recovery (80%) • Severe: Organ failure and/or local complications  Necrosis, abscesses, and pseudocysts (20%),
469
What are the common causes of pancreatitis?
* Idiopathic * Gallstones * Ethanol- Alcohol causes 80% of cases * Trauma * Steroids * Mumps/HIV/Coxsackievirus (infection) and Malignancy (pancreatic) * Autoimmune * Scorpion Venom * Hypercalcemia/hyperPTH/hyperlipidaemia/hypothermia (metabolic disorder) * ERCP and emboli * Drugs (Sodium valproate, steroids, thiazides, and azathioprine)
470
What is the pain presentation for pancreatitis?
Epigastric pain radiating to the back Relieved by sitting forward or lying in the foetal position Aggravated by movement Associated with anorexia, nausea and vomiting
471
What are the signs of acute pancreatitis?
``` Epigastric tenderness Fever Shock (tachycardia, tachypnoea) Decreased bowel sounds (Ileus) Jaundice Tetany ```
472
What are the signs of severe haemorrhagic pancreatitis?
Cullen's sign Grey-turner sign Fox's sign Chvosteks sign
473
What does Cullen's sign represent?
Periumbillical bruising
474
What does Grey-turner sign represent?
Flank bruising
475
What is third spacing in acute pancreatitis?
Third-space fluid sequestration in pancreatitis is a result of release of inflammatory mediators, vasoactive mediators, and tissues  Vascular injury and increased capillary permeability * Extravasation of fluid into third space. * ARDs, pleural effusions, and AKI due to hypovolaemia.
476
What is the first-line diagnostic investigation for acute pancreatitis?
Serum amylase (3x upper limit of normal) -Does not correlate to disease severity
477
What are the other causes of elevated amylase?
Perforated duodenal ulcers, cholecystitis Ectopic pregnancy Mesenteric infarction
478
Which enzyme marker is a more accurate indicator for acute pancreatitis?
Raised serum lipase
479
What is the LFT picture for gallstone pancreatitis?
ALP> 150 u/L
480
Which blood markers are raised in acute pancreatitis?
CRP WCC Glucose - Reduced endocrine function U&Es
481
Which electrolyte is low in acute pancreatitis?
Calcium
482
What does an ABG reveal in acute pancreatitis?
Hypoxia | Metabolic acidosis
483
What radiological investigations are indicated in the diagnosis of acute pancreatitis?
Abdominal ultrasound - Identifies gallstones - Evidence of biliary dilatation
484
What does an AXR reveal in acute pancreatitis?
Sentinel loop sign - dilated proximal bowel loops adjacent to pancreas (Secondary localised inflammation)
485
What scoring criteria is used to assess the severity of acute pancreatitis?
Modified Glasgow Imrie score combined with CRP >210 mg/L
486
What are the parameters associated with a modified Glasgow imrie score?
``` pO2 <8kPa Age >55 WCC >15 Calcium <2 Urea >16 LDH OR AST >600 >200 Albumin >32 Glucose >10 ``` a score of >= 3 --> Severe disease
487
What is the acute management for acute pancreatitis?
* Fluid & electrolyte resuscitation (Balanced crystalloid) * Urinary catheter and NG tube if vomiting (Enteral > parenteral – Reduced infective complications). * Analgesia * Blood sugar control
488
What type of feed is recommended in acute pancereatitis?
Enteral feed
489
What is the definitive management for gallstone pancreatitis?
ERCP and Sphincterotomy Cholecystectomy early
490
What is the most common form of pancreatic cancer?
Ductal carcinoma (Exocrine portion of the pancreas)
491
Which antibiotics are the leading cause of Pseudomembranous colitis?
Clindamycin and cephalosporins
492
Which score is used to assess the risk of an upper GI rebleed after endoscopy?
Rockall score
493
Which HepB antibody suggests ongoing infection?
HbSAg

Phase1c Medicine (11 decks)

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