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Gastroenterology Flashcards

1
Q

Dyspepsia: Defn

A

= pain/reflux/vomiting/indigestion/heartburn for 4 weeks

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2
Q

Dyspepsia: causes

7

A
  1. Uninvestigated (not had an OGD)
  2. Functional dyspepsia (= symptoms following a normal OGD; may need long-term acid suppression treatment)
  3. GORD (= ‘endoscopically-determined reflux disease’ eg leading to oesophagitis)
  4. Peptic ulcer disease
  5. Barrett’s (= metaplastic change of squamous mucosa, increased risk of adenocarcinoma)
  6. Upper GI cancer
  7. Medications - NSAIDs, steroids, bisphosphonates, calcium blockers, alpha blockers
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3
Q

Dyspepsia:
‘Uninvestigated’ Mx

(2)

A

Choose one of two strategies:

  1. Full-dose PPI for 1 month

OR

  1. Test for H Pylori (urea breath test/stool antigen) +/- eradication therapy

(If symptoms persist after choosing one, then try the other strategy)

Gastro referral/OGD if recurrent or refractory symptoms despite primary care treatment

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4
Q

Dyspepsia:

H Pylori eradication

A

7 day triple therapy

PPI (eg lansoprazole 30mg)
+ Amoxicillin 1g BD
+ Clarithromycin 500mg BD / Metronidazole 400mg BD

(Second line: various options including levofloxacin, tetracycline, tripotassium)

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5
Q

Suspected oral cavity cancer

A

—> urgent dentist/oral surgeon review in 2 weeks, if…

Lump on lip or in oral cavity

Red patches +/- white patches in oral cavity (erythroplakia/erythroleukoplakia)

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6
Q

Peptic ulcers (gastric v duodenal)

A

Gastric:

  • Repeat OGD to confirm healing (+ H.pylori test repeat if appropriate) 6 - 8 weeks after treatment
  • May need long term acid suppression treatment

Duodenal:

  • Repeat H.pylori test if appropriate 6-8 weeks after treatment
  • May need long term acid suppression treatment

I.e. difference is gastric needs repeat OGD, (duodenal doesn’t)

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7
Q

PPI

CI; Cautions, SE

A

CI:
- 2 weeks before endoscopy (may mask symptoms of upper GI cancer)

Cautions, if risk of:

  • Osteoporosis
  • Hypomagnesaemia

SE include:

  • Headache, dizziness
  • GI (diarrhoea, N&V, abdo pain)
  • Dry mouth
  • Peripheral oedema
  • Fatigue, sleep disturbance
  • Myalgia, pruritis
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8
Q

Barrett’s oesophagus

=, cause, Sx, Dx, risk, Mx 3 & 3

A

= metaplastic changes of squamous mucosa - dysplasia can be low/high grade

Main cause: GORD

Sx: Barrett’s itself has no symptoms, but often people have Sx of GORD

Dx: At endoscopy

Increased risk of adenocarcinoma - needs monitoring, e.g. regular endoscopies, biopsies

Mx:
1 Lifestyle changes
2. Test and treat H Pylori
3. May need long-term acid suppression Rx

Dysplasia Mx options:

  • mucosal resection
  • radiofrequency ablation
  • Oesophagectomy
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9
Q

Jaundice - Pre-hepatic

4

A

= too much unconjugated hyperbilirubinaemia

  • Physiological, e.g. neonatal
  • Gilbert’s (inherited metabolic disorder - defect in conjugation of BR —> raised unconjugated levels —> Jaundice): no Rx. Think about in questions which mention jaundice + stress/fever/exercise/pregnancy
  • Thalassaemia
  • Haemolytic anaemias
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10
Q

Jaundice - hepatic

5

A 
Hepatitis (infectious, alcohol, AI, drugs)
Cirrhosis
Liver mets
Drugs (e.g. Abx, antiepileptics)
Haemochromatosis
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11
Q

Jaundice - post-hepatic

3

A

Gallstones

Common bile duct stricture

Ca of head of pancreas

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12
Q

Jaundice - admission

6

A
  1. Red flag Sx
  2. BR >100
  3. Abnormal clotting profile/showing signs of coagulopathy
  4. Abnormal renal function
  5. Suspected paracetamol OD
  6. Frail or significant comorbidities
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13
Q

NAFLD

A
  • Aim for recommended target of 10% weight loss over 6 months

Hepatology referral:

  • High risk of advanced liver fibrosis
  • Signs of advanced liver disease on examination
  • Uncertainty in diagnosis

Ix - may include liver fibroscan and biopsy

2º care may use pioglitazone or vitamin E drug treatment (off-label) in addition to lifestyle changes.
Ultimately there may be a role for liver transplantation.

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14
Q

Liver cirrhosis

=; Types 2; Ix; Mx

A

End stage of many liver conditions that cause parenchyma damage —> eventually leads to fibrosis and portal hypertension

Types:

  • Compensated (liver still functioning, no obvious signs)
  • Decompensated (liver damaged to point where clinical signs develop, e.g. ascites, jaundice)

Ix:
If suspected, can arrange transient elastography testing, but most refer to gastro/hepatology.

Mx: aim to slow progress (e.g. stop alcohol) and reduce complications (e.g. varies, ascites, encephalopathy)

Irreversible —> may need transplantation

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15
Q

Hepatitis A

A

= inflammation of liver due to hepatitis A virus

Faeco-oral transmission

Usually self limiting. Usually lasts under 2 months

Dx: through Hepatitis A IgM or IgG / Hep A RNA detection

May have raised ALT, ALP, BR, PT

4 phases:

  1. Incubation
  2. Prodromal (flu-like and GI symptoms) - up to 2 weeks
  3. Icteric (pruritis, hepatomegaly, fatigue) - up to 3 months
  4. Convalescent (malaise, hepatic tenderness) - up to 6 months

No long-term sequelae - supportive treatment.

Local health unit notification - a notifiable disease.

Vaccination for those at risk of acquiring (eg. Travel to high prevalence areas or IV drug user)

Monitor LFTs/PT depending on levels

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16
Q

Hepatitis B

A

= inflammation of liver due to hepatitis B virus

Transmission: perinatally, sexual contact, IVDU, transfusion, tattoo, needle-stick, surgery abroad, etc.

Initially acute infection - fever, malaise, nausea, RUQ pain, jaundice
Chronic infection - usually asymptomatic, may have signs of chronic liver disease

Serology:

  • HBsAG (surface antigen) - 1st marker to rise in acute infection
  • IgM anti-HBc - 1st antibody to rise
  • IgG anti-HBc - usually persists for life (therefore indicates past infection)
  • Immunisation indicated by Anti-HBs without Anti-HBc

Chronic hep B - 8-20% get cirrhosis (2-5% get HCC)

Symptomatic care (no cure) & refer to hepatology/gastro/ID

Local health protection unit notification (notifiable disease!)

Offer contacts vaccination (e.g. household contacts, IVDU):
- Usually 3 doses at 0, 1, 6 months (can be more rapid programme at 0, 1, 2 months)

17
Q

Hepatitis C

A

= slow, progressive liver disease

Transmission routes similar to Hep B

Test for antibodies and Hep C RNA:
+ve… repeat again
-ve… repeat in 3-6 months if at risk

Complications…cirrhosis (10-30%), HCC (1-3%)

Local health protection unit notification (notifiable disease!)

Refer to hepatology/gastro/ID:

  • will get antiviral meds (e.g. Sofosbuvir, Ledipasvir) which are replacing interferon use
  • Liver transplant
18
Q

Charcot’s triad

A

For cholangitis (infection of common bile duct) - ADMIT!

  1. Fever
  2. Jaundice
  3. RUQ pain
19
Q

Acute pancreatitis

Causes 11; Sx 4; Key Ix; Mx 5

A

Causes - I GET SMASHED (first 4 are most common)
Idiopathic , Gallstones , Ethanol (alcohol) , Trauma
Steroids, Mumps (or other infections), Autoimmune, Scorpion bite, Hyperlipidaemia/hypercalcaemia/hyperparathyroidism, ERCP, Drugs (e.g. valproate, azathioprine)

Sx:

  • Epigastric pain (may ease with sitting forward)…
  • … radiates to back
  • Vomiting
  • Grey discolouration (paraumbilical = Cullen’s sign; flanks = Grey-Turner’s)

Key Ix is raised Amylase

Modified Glasgow Score used for predicting severity

Mx:

  1. Admit!
  2. IV fluids
  3. Analgesia
  4. Close monitoring
  5. May need ITU
20
Q

Chronic pancreatitis

A

Irreversible, fibrosis

Sx: epigastric pain, radiates to back, bloating, steatorrhea

Dysfunction…
Endocrine: less insulin —> diabetes
Exocrine: less digestive enzymes —> malabsorption

Mx:
Supportive, pain relief, dietician, etc.

21
Q

Pancreatic cancer

A

Sx:
Painless jaundice, Weight loss, Ascites

Surgical or palliative treatment
(Picked up quite late, and therefore also…)

…Poor prognosis: <5% 5-year survival

22
Q

Irritable Bowel Syndrome

=; RF 5; Sx 3; Dx 3; Ix 4 key +2; Diet 3; Rx 4; Refer

A

= functional bowel disorder, no clear cause, variety of symptoms, no Dx test, can have significant impact on QoL
- can be constipation or diarrhoea predominant

Possible risk factors:

  • Diet (alcohol, spicy food, caffeine)
  • genetics
  • GI infection
  • Antibiotics
  • Psychosocial factors

Consider if any ABC symptoms:
Abdominal pain , Bloating , Change in bowel habit —> PRESENT FOR 6 MONTHS

Dx:
Abdo pain present EITHER relieved by defecation OR assoc w altered bowel frequency/form

AND at least 2 of…
Altered stool passage
Abdo bloating/distension/tension/hardness
Sx worse with eating
Mucus PR

AND….
Differential ruled out

Ix:
FBC, ESR, CRP, coeliac antibody testing
+ Ca125 if considering ovarian cancer, fecal calprotectin if considering IBD

Diet advice:

  • Adjust fibre levels, caffeine low, carbonated drinks low, adequate fluids levels, max 3 portions fresh fruit per day, regular meals, etc
  • If probiotics - take for at least 4 weeks
  • May need dietician referral, e.g. for trial of low FODMAP diet

Rx:
Abdo pain/spasms —> Mebeverine, Peppermint oil, Alverine
Constipation —> bulk laxatives (e.g. ishagula) …NB Lactulose not recommended
Loose stool —> anti-motility drug - loperamide recommended
Second line if abdo pain persists: can consider low dose TCA (off label)

Refer to gastro…
Ongoing Sx which persist despite initial management or diagnostic uncertainty

23
Q

Coeliac Disease

A

= chronic, AI disorder against gluten —> damages lining of small intestine —> malabsorption and weight loss

Gluten found in wheat, barley, rye

Sx include:
Abdo pain
Loose stool
Fatigue

Ix:
1st line: IgA tTGA (tissue transglutaminase antibody) …….. if unavailable then IgA EMA (endomysial antibody)
NB stay on gluten whilst bloods!

If +ve —> refer for biopsy of small intestine (again stay on gluten!) - look for subtotal villus atrophy

Classic rash with coeliac disease: Dermatitis herpetiformis

Complications:

  • Anaemia (Fe, B12, folate)
  • Nutritoonal deficiency
  • Osteoporosis
  • Lymphoma

Treatment: gluten-free diet

Monitoring:
Usually annual bloods…coeliac serology, FBC, haematinics, LFTs, bone bloods

24
Q

Crohn’s disease: Mx

A

Admit if flare-up…

  • Severe diarrhea (6-8 times per day)
  • Fever, unwell, dehydrated, suspected obstruction, etc

Acute Mx: corticosteroids

Maintenance Mx:

  • Aminosalicylates (e.g. mesalazine)
  • Immunosuppressants (e.g. methotrexate, azathioprine)
  • Biologic therapy (e.g. infliximab)

Surgery may ultimately be needed

25
Q

Ulcerative colitis: Mx

A

Admit if severe UC:

  • 6-8 eps of loose stool per day
  • Blood in stool
  • Fever, dehydration, tachycardia, hypotension, raised inflammatory markers

Maintenance options:

  • Aminosalicylates (e.g. mesalazine)
  • Thiopurines (e.g. azathioprine, mercaptopurine)
  • Calcineurin inhibitors (e.g. ciclosporin)
  • Biologic therapy (e.g. infliximab)
26
Q

Familial Polyposis

A

Autosomal dominant (abnormality on APC gene) —> hundreds of polyps in the bowel

Sx: blood PR, loose stool - many present with colon cancer

Ix:

  • CEA (carcinoembryonic antigen)
  • Colonoscopy
  • Genetic testing

Treatment usually surgery due to cancer risk

27
Q

Colorectal cancer

A

2/3 in colon, 1/3 in rectum

Most are adenocarcinomas, develop from polyps

RFs include FHx, IBD, high meat low fibre diet, familial polyp condition

Varied presentation:

  • Left sided: bleeding, pain, obstruction, tenesmus
  • Right sided: anaemia, weight loss, mass

Ix: colonoscopy, sigmoidoscopy, barium enema, CT colonography, biopsy

Staging: Dukes A —> B (B = mets!)

Surgery:
E.g. right or left hemicolectomy, sigmoid colectomy, AP or anterior resection, chemo, RT

28
Q

BMI

A 
18.5 - 24.99 Healthy weight
25 - 29.99 Overweight
30 - 34.99 Obesity 1
35 - 39.99 Obesity 2
>40 Obesity 3

Complications:
CVD risk, DM, depression, cancer, fertility, MSK

29
Q

Weight gain: Mx

A

Orlistat (pancreatic lipase inhibitor):
BMI >30
Or
BMI >28 with risk factor (e.g. DM, HTN)

Liraglutide is an option but needs secondary care advice

Weight loss surgery…

1st line if BMI >50
Option if BMI >40 or BMI>35 with health problem that could benefit from weight loss

30
Q

Orlistat

=; dose; target; CI 2; cautions 2; SE 2

A

= lipase inhibitor. Works by reducing the absorption of dietary fat.

Recommended dose 120mg up to TDS:

  • taken with water
  • immediately before, during or up to one hour after each meal

Target - 5% weight loss in 12 weeks (discontinue if target not met)

Contraindications:

  • Chronic malabsorption syndrome
  • Chronic cholestasis

Cautions:
- CKD and/or volume depletion

SE:

  • GI: abdo pain, oily spotting, flatulence, fecal urgency, fecal incontinence, fatty stools
  • Headaches, resp infections, UTI, hypoglycaemia, fatigue, anxiety, gingival and tooth disorders, menstrual disturbances
31
Q

Leukaemia

=; types

A

= malignant cells take over bone marrow and may spill into general circulation

Acute - RAPID proliferation of cells

  • ALL (lymphoblastic): more common in children, acute illness, tiredness, non-specific joint aches —> initial Mx steroid, e.g. dex, vincristine
  • AML (myeloid): more common in older adults, pancytopenia, fever, infections —> Attempt to induce remission using cytotoxic agents, e.g. daunorubicin

Chronic - prolonged hx, rare in children

  • CLL: most >60yo, non-specific Sx, LNs, sometimes found through asymptomatic lymphocytosis —> monoclonal Abs, e.g. rituximab, purine analogues, steroids, RT, etc
  • CML: middle age/elderly, non-specific features, bleeding —> meds e.g. imatinib, stem cell transplantation
32
Q

Suspected adult leukaemia

A

Consider 48 hour FBC if any of…

Pallor
Fatigue
Unexplained fever
Recurrent infection
Unexplained bruising
Generalised LN
Unexplained bleeding
Unexplained petechiae
Hepatosplenomegaly
33
Q

Lymphoma

=; Types 2

A

= neoplastic disorder of lymphoid tissue

Hodgkin’s - may be younger
- Presence of Reed-Sternberg cells
- LNs, weight loss, night sweats, fever
—> meds: e.g. bleomycin, vinblastine

Non-Hodgkin’s - usually older
- Painless generalised lymphadenopathy
—> RT, meds eg. Rituximab

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