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Revision > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Coeliac disease

  • cause
  • pathology
A

Autoimmune malabsorption disease
Caused by gluten sensitivity

Eating gluten - causes villous atrophy of the GIT - results in malabsorption - IDA, folic acid deficiency Vit B12 deficiency, malabsorption of fat

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2
Q

Manifestations of coeliac disease

A 
Chronic or intermittent diarrhoea
Steatorrhoea
Foul smelling stool
Abdominal discomfort 
Weight loss
IDA - most common, —> folate deficiency then vit B12
Manifestations of anemia - fatigue
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3
Q

Most common deficiency in coeliac disease

A
  1. IDA
    2, folate
    3.B12 def
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4
Q

Complication of coeliac disease

A

Osteoporosis

T cell lymphoma - rare

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5
Q

Important association of coeliac disease

A

Dermatitis herpetiformis

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6
Q

Diagnosis of coeliac disease

  • 1st line
  • confirmation test
A

+ve TTG and IgA
Positive endomysial antibodies

Jejunal or duodenal biopsy
= shows villous atrophy, crypt hyperplasia, increased inter-epithelial lymphocytes

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7
Q

What should be done for biopsy of a suspected coeliac disease patient to be accurate?

A

Reintroduce gluten 6 weeks before biopsy

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8
Q

Treatment of coeliac disease

A

Gluten free diet

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9
Q

Features of Crohn’s disease

  • endoscopy
  • histology
  • examination
A

Endoscopy - skip lesions, transmural deep ulcers, cobblestone appearance

Histology - granuloma, increased goblet cells

Ex - abd pain or mass on RIF

Non bloody diarrhoea
Weight loss
Fistula, perianal fistulas
Aphthous ulcers - more common here than in UC

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10
Q

Features of ulcerative colitis
Barium enema -
Histology -
Others

A

Loss of haunt ration, drain pipe appearance - barium enema

Crypt abscesses, decreased goblet cells

LL abdominal pain
Bloody diarrhoea more common
Primary sclerosing cholangitis
Aphthous ulcers

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11
Q

What increases risk of Crohns but decreases risk of Ulcerative colitis

A

Smoking - increased risk in CD , decreases UC

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12
Q

Kantor’s string sign seen in

A

Crohn’s

Small bowel enema = string sign , thorn ulcers and fistula

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13
Q

Treatment CD

A

Oral pred - 1st line to induce remission
2nd line - budesonide
- if not give - mesalazine

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14
Q

Treatment of UC

A

1st line - 5 ASA (Mesalazine)

In severe exacerbation - IV hydrocortisone

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15
Q

Barrett’s oesophagus

A

Lower oesophagus metaplasia (lower 1/3)
Squamous —> columnar epithelium with goblet cells

Precancerous lesion that can develop into adenocarcinoma

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16
Q

Achalasia is RF for

A

SCC of upper 2/3 of oesophagus

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17
Q

Adenocarcinoma of the oesophagus is common in

A

GERD

Barrett’s oesophagus

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18
Q

What is achalasia

A

Inability to relax lower oesophageal sphincter
- due to loss of normal neural structure
(Raised lower oesophageal resting pressure)

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19
Q

Achalasia

Features

A

Progressive dysphagia - solids + liquids
Regurgitation
- can lead to aspiration pneumonia
Wt loss, chest pain

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20
Q

Explain the Relationship b/w tobacco and alcohol in achalasia

A

No relation

However they are linked to oesophageal ca

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21
Q

Achalasia

Investigations

A

X ray - mega oesophagus - large dilated
Barium meal - birds peak @ distal end
Most accurate - oesophageal manometry

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22
Q

Birds beak appearance on barium meal

A

Achalasia

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23
Q

Most accurate test for diagnosis of achalasia

A

Oesophageal manometry

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24
Q

Treatment of achalasia

A

Dilation of LES

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25
Q

“Regurgitation” seen in :

A

Achalasia

Pharyngeal pouch - halitosis, gurgling sound in chest , lump in throat sensation

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26
Q

Risk factors for oesophageal ca

A 
Old age 
Weight loss
Smoking, alcohol
Anemia 
Progressive dysphagia - solids + liquids
Hx of Barrett’s 
Hx of GERD
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27
Q

Diagnostic investigation of oesophageal ca

A

Endoscopy + biopsy

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28
Q

Most common type of oesophageal ca

A

Adenocarcinoma

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29
Q

Precursor for adenocarcinoma of oesophagus

A

Barrett’s

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30
Q

What is associate with more risk for oesophageal SCC

A

Achalasia

Smoking

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31
Q

Site of SCC vs Adenocarcinoma in oesophagus

A

Upper 2/3 - SCC

Lower 1/3 - adenocarcinoma

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32
Q

features of Zenker’s diverticulum

A

= pharyngeal pouch

Dysphagia + halitosis + chronic cough - esp at night + regurgitation of stale food/fluid

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33
Q

What is CI in zenker’s diverticulum

What should be done instead

A

Endoscopy- May perforate pouch

Barium swallow

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34
Q

Causes of B 12 deficiency

A

Pernicious anemia - most common
- caused by autoimmune gastric atrophy , usually assoc with autoimmune disease

Total gastrectomy - impaired B12 absorption 
Crohns 
Chronic pancreatitis - malabsorption 
Coeliac disease - malabsorption 
Vegans
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35
Q

Features of B12 deficiency

A

Peripheral paresthesia
Impaired position and proprioception
Dementia - memory loss and difficulty thinking

Untreated - permanent ataxia

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36
Q

Hypersegmented neutrophils on blood smear

A

Macrocytic anemia
B12 deficiency / folate deficiency

Raised MCV and homocysteine

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37
Q

B12 vs folate deficiency

A

B12 - vegans - no meat or fish or dairy
Folate - don’t eat veggies

Gastric or ileal resection, pernicious anemia - B12 deficiency

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38
Q

Treatment of B12 def

A

IM hydroxycobalamin

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39
Q

Investigation in acute flare of ulcerative colitis

Treatment

A

Abdominal X-ray
- toxic mega colon

IV hydrocortisone

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40
Q

When should you suspect severe colitis (UC exacerbation)

A 
Rule of 6 30 90 
> 6 bowel movements + visible blood
ESR >30
HR >90 mild tachy 
Temp >37.8 
Anemia
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41
Q

Thumb printing on abdominal X-ray , dilated colon

A

Thumb printing/ pseudopolyps - mural oedema esp transverse colon
= toxic megacolon

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42
Q 
Abnormal LFTs (raised ALT AST bilirubin)+ 2ry amenorrhoea in young-middle age female 
Suspect
A

Autoimmune hepatitis - tends to progress to Cirrhosis
ALT AST bilirubin - raised ,
ALP - normal or mildly elevated

Usually assoc with another autoimmune disease

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43
Q

Alcoholic liver disease - features

A

Ascites haematemesis jaundice
Hepatomegaly spider naevi

AST > ALT (both raised) GGT also raised

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44
Q

Management of alcoholic liver disease

A

Stop alcohol

Consider transplant after alcohol abstinence in late cases

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45
Q

HELLP vs acute fatty liver of pregnancy

A

HELLP - hemolysis therefore low Hb

AFLP = ELLP + low glucose +- raised ammonia

  • can have DIC - prolonged PT PTT
  • vomiting
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46
Q

Risk factors for AFLP

A

Pre eclampsia
Prime
Multiple pregnancies

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47
Q

AFLP - presentation

A

Nausea vomiting abd pain fever headache jaundice
Occurs in late pregnancy >30 weeks , can occur immediately after deliver

Rare but life threatening - severe hypoglycaemia and abnormal clotted -cosm - death

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48
Q

Diagnstic test for AFLP

A

Liver biopsy

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49
Q

Risk factors for cholecystitis

A

5 F s

Fair fat female fertile over 40

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50
Q

Cholecystitis treatment

A

NPO , analgesia
IV fluids and antibiotics

NICE : early lap w/in 1 week of dx

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51
Q

Stones in CBD in an asymptomatic patient

What should be done

A

ERCP or lap chole

Stone in CBD - treat regardless of symptoms

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52
Q

Plummer Vinson syndrome

Treatment

A

Post cricoid oesophageal - painless intermittent dysphagia
IDA

T- iron supplements + webs dilatation

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53
Q

2 medications that can worsen GERD and oesophagitis

A

NSAIDs
Bisphosphonate

Can lead to benign oesophageal stricture
= persistent dysphagia w/o regurgitation

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54
Q

Barrett’s vs benign oesophageal stricture

A

Both have dysphagia

  • persistent in BOS
  • occasional in Barrett’s
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55
Q

Acute pancreatitis

RFs

A

Gallstones, alcoholism
Trauma
ERCP

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56
Q

Investigation for acute pancreatitis

A

Lipase - more specific and sensitive (>3x upper limit)
Amylase

Confirm dx with Ct w/ contrast

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57
Q

Management of acute pancreatitis

A

Initial - supportive
= iv fluids, analgesics

IV Imipenem for moderate to severe cases
Surgical debridement only in cases of necrosis - minimally invasive

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58
Q

Acute cholangitis
Investigation
Treatment

A

FRJ (Charcot’s triad) +- hypOtension and leukocytosis)

US and blood cultures

Fluid resusc, broad spec ABx
Correct any coagulopathy
Early ERCP

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59
Q

Organisms that cause bloody diarrhoea

A

Campylobacter
Shigella
Salmonella

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60
Q

Treatment of pseudomembranous colitis

A

Oral metronidazole

Oral vancomycin

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61
Q

Diarrhoea hours after eating meal

Likely causative organism

A

Staph toxin

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62
Q

Oesophageal ca with liver mets

Treatment

A

End stage oesophageal ca - inoperable

Relieve dysphagia - stenting (endoluminal)

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63
Q

How long after gastrectomy does B12 deficiency develop

A

1- 2 years

Cobalamin stores so it takes time

64
Q

Right supraclavicular mass

Ddx

A

Oesophageal ca
Lung ca
Hodgkin’s lymphoma

65
Q

RFs for primary biliary cirrhosis

A

3 Ms
Anti mitochondrial antibodies
Middle aged female
IgM

Others: pruritus, raised ALP, jaundice

66
Q

Common association of primary biliary cirrhosis

A

Sjögren’s syndrome

67
Q

Primary sclerosing cholangitis
Diagnosed by
Common association

A

ERCP

IBD - esp UC

68
Q

Treatment of
primary biliary cirrhosis
primary sclerosing cholangitis

A

Ursodeoxycholic acid
Cholestyramine

Same treatment for both

69
Q

Albumin infusion

- how does it alleviate ascites and oedema

A

Increases on on oncotic (colloid osmotic) pressure - shift of fluids from extravascular to intravascular compartments

70
Q

Treatment of ascites 2ry to liver cirrhosis

A

Spironolactone

Albumin infusion

71
Q

Treatment perforated peptic ulcer

A

NPO
IV fluids antiemetic - metoclopramide 10 mg
Analgesia, IV antibiotics
Urgent surgery

72
Q

H.Pylori management

A

Triple therapy
PPI amoxicillin clarithromycin 7-14 days
E.g 20 mg BID PPI, amox 0 1g BID, 500mg BID clarithromycin

73
Q

How long should meds be stopped before testing for h.pylori

A

28 days before - ABx

14 days before - PPI

74
Q

How do you ret-test for H.pylori after full course treatment

A

Carbon 13 urea breath test
- if not available - stool antigen

Serology cant be used
Antibodies stay for long time after successful eradication

75
Q

Treated H pylori pt with persistent sx

Test to be done

A

C-13 urea breath test

76
Q

> = 55 YO + dyspepsia + weight loss

Next step

A

Urgent upper GI endoscopy to exclude oesophageal/gastric ca

77
Q

Gastric Ulcers at various sites that are resistant to treatment
Suspect

A

Zollinger-Ellison syndrome

78
Q

Zollinger-Ellison syndrome

Features

A

Gastrinomas in duodenum or pancreas. Assoc with MEN1
Excess gastrin released - stimulates parietal cells of stomach to release more HCl - multiple ulcers

Unusual sites, resistant to treatment
Watery/fatty diarrhoea

79
Q

Diagnosis of ZES

A

Fasting gastrin level
Or
Secretin stimulation test

80
Q

Treatment mild to mod UC

A

Rectal mesalazine

If no response - oral mesalazine

81
Q

Maintaining remission of UC

A

Oral mesalazine
Or
Oral azathioprine/mercaptopurine

82
Q

Med to induce remission of CD

A

Oral pred

83
Q

Med to maintain remission of CD

A

Oral azathioprine or mercaptopurine

84
Q

Hereditary haemochromatosis

  • inheritance pattern
  • manifestations (5)
A

Autosomal recessive
Intestinal absorption of iron increased - iron accumulation/ deposition in tissues

Liver - main organ of deposition
= hepatomegaly, cirrhosis —> hepatocellular ca = hepatoma
Pancreas - diabetes
Skin - bronze skin
Joint arthropathy
Heart - cardiomyopathy, arrhythmia, murmur SOB

85
Q

Most accurate diagnostic test for achalasia

A

Oesophageal manometry

86
Q

Antibiotics that can cause pseudomembranous colitis

A

Clindamycin
Amoxicillin, ampicillin, co amoxiclav
Broad spec cephalosporin , quinolones

87
Q

Treatment of pseudomembranous colitis

A

Oral metronidazole

Oral vancomycin

88
Q

Mediastinitis
- anterior
- posterior
Treatment

A 
Ant = pain mainly subcostal
Post = pain mainly epigastric - radiates to interscapular region

T= antibiotics and perforation repair

89
Q

TTF-1 is a marker for

A

1ry pulmonary adenocarcinoma

TTF = thyroid transcription factor 1

90
Q

Metastasis of pulmonary adenocarcinoma

A

Haematogenous - to liver mainly

91
Q

Diffuse oesophageal spasms

Features

A

Retrosternal chest pain - intermittent unpredictable and severe
+ dysphagia
Aggravated by cold drinks

92
Q

diffuse oesophageal spasm
Investigations
- most accurate

A

Barium meal = corkscrew appearance of oesophagus
Most accurate - Manometric studies
=== high intensity disorganised contractions

93
Q

Treatment of diffuse oesophageal spasm

A

CCB - nifedipine
Nitrates

“Spasms take 2 Ns ”

94
Q

Liver biopsy shows large amounts of iron pigment within hepatocytes

A

Haemochromatosis

95
Q

Liver biopsy shows large amounts of iron pigment within Kupffer cells

A

Haemosiderosis

96
Q

Causes of clubbing

A 
CLUBBING 
Cyaotic HD, CF 
Lung ca,abscess
UC,CD
Bronchiectasis
Benign mesothelioma 
IE, idiopathic pulmonary fibrosis
Neurogenic tumours 
GIT disease
97
Q

Management of impacted stool

A

Phosphate enema

Unless young and healthy —> glycerol suppositories

98
Q

Management of hard stool (not impacted)

A

Stool softeners

99
Q

Constipation with soft stools

Management

A

High fibre diet
Senna - 1st line
Lactulose or Macrogol - 2nd line

100
Q

Management of constipation in pregnancy

A

1st line - ispaghula husk
2- Lactulose (osmotic)
3- senna (stimulant)

101
Q

Possible cause of overflow (spurious) diarrhoea

A

Opioids - they reduce intestinal peristalsis

102
Q

Why is acute cholecystitis fairly common in pregnancy

A

Pregnancy changes composition of bile + slows emptying of the gallbladder
- gallstone formation
ALP is normally elevated in pregnancy and early postpartum

103
Q 
Anemia in pregnancy 
1st trimester
2nd trimester
3rd trimester
Postpartum
A

1 - <11
2nd & 3rd trimester - <10.5
Post partum - <10

104
Q

Old age, weight loss, chronic abdominal pain and anemia
Suspect
What investigation

A

Colon ca

Colonoscopy

105
Q

Major cause of chronic pancreatitis

A

Alcohol

Others - autoimmune, smoking

106
Q

Acute vs chronic pancreatitis

A

Serum amylase and lipase - not usually very elevated in chronic case

107
Q

Gold standard investigation of chronic pancreatitis

A

Spiral CT abdomen w/ contrast

- Showa pancreatic calcification

108
Q

Useful investigation in chronic pancreatitis

A

Fecal elastase = low

Fecal chymotrypsin

109
Q

Management of acute oesophageal variceal bleed

A

ABC incl IV fluids
Terlipressin & ABx prophylaxis - before endoscopy
Endoscopy - 1. Band ligation if not sclerotherapy

If not controlled with above - TIPS

110
Q

Gilberts syndrome

  • inheritance pattern
  • cause
A

Autosomal recessive
Unconjugated (indirect) hyperbilirubinemia

Decreased UGT-1 enzyme - conjugates bilirubin with glucuronic acid
Can be precipitated by infection stress fasting etc

111
Q

Features of Gilbert’s syndrome

Labs

A

Usually asymptomatic but can present with
Jaundice +- hx of recent infection

LFTs normal, mild rise in bilirubin
Urine dipstick normal
Normal reticulocytes

112
Q

Dubin Johnson’s syndrome vs Gilbert’s

A

Dubin = raised conjugated bilirubin (direct) + abnormal urine dipstick
Urine dipstick - hyperbilirubinemia

Gilberts - isolated jaundice (raised bilirubin) + other tests normal

113
Q

Site of main absorption of iron

A

Duodenum

114
Q

Site of main absorption of folic acid

A

Duodenum and jejunum

115
Q

Site of main absorption of B12

A

Terminal/distal ileum

116
Q

Site of main absorption of bile salts

A

Terminal/distal ileum

117
Q

Majority of nutrients absorbed in

A

Jejunum

118
Q

Abdominal migraine
Features
Dx criteria

A

5-9YO mainly , can occur in adults
No abnormal findings on examination

Paroxysmal attacks - peri umbilical pain (severe)
Last >/= 1 hr , interferes with activities
Associated headaches + 2 or more :
Anorexia
Nausea
Vomiting
Pallor

119
Q

Treatment of abdominal migraine

A

Reassurance

120
Q

Acute gastroenteritis in hospital patients
Causative organism
Management

A

Norovirus

Isolate for 48 hrs after diarrhoea resolves

121
Q

Features of pancreatic ca

A

Painless jaundice
RUQ mass , hepatomegaly , wt loss
Palpable non tender GB , atypical back pain
+- palpable epigastric lump, palpable liver, GB
+- ascites

122
Q

Investigation of choice for diagnosing pancreatic ca

A

HRCT

US - 60-90% sensitivity

123
Q

Management of pancreatic ca

A

Whipples resection - for resectable lesions
+ adjuvant chemo

ERCP with stenting for palliation

124
Q

Gold standard method to diagnose oesophageal ca

A

Upper GI endoscopy + Biopsy

125
Q

Risk factors GORD

A 
Obesity 
Pregnancy
Smoking 
Large meals 
Intake - coffee chocolate alcohol fat
CCBs, nitrates, antimuscarinic
Systemic sclerosis 
Hiatus hernia
126
Q

Management of GORD
Endoscopically
-proven
-negative

A

PPIs

Proven - PPI 1-2 months , if it works , low dose maintenance
If not - double doe of PPI

Endo negative = H2 receptor antagonist if no response , if it responds low dose PPI maintenance

127
Q

First line treatment of salmonella

A

Ciprofloxacin

128
Q

1st line treatment Campylobacter

A

Erythromycin or clarithromycin

2- cipro

129
Q

Spontaneous bacterial peritonitis
Investigation - initial , most accurate
Initial management

A

Neutrophil count from ascitic fluid aspirate
Most accurate - ascitic fluid aspirate culture
Organism gains access to peritoneum via blood

IV ABx

130
Q

Drugs that can cause drug induced hepatitis

A 
Co amoxiclav
Clavulanic acid - highly toxic to liver 
Flucloxacillin 
Steroids 
Sulphonylureas
131
Q

New onset dysphagia

next step

A

Urgent endoscopy - regardless of age or other symptoms

132
Q

Hepatitis A
IP
Organism
Transmission

A

2-4 weeks
RNA picornavirus
Faecal - oral spread
Shellfish - reservoirs ( think hep A after seafood meal )

133
Q

Investigation hep A

A

IgM antibodies to hep A virus

If IgG +ve - check igMto see if acute

134
Q

Lab hep A

A

Raised LFTs - ALT much higher than AST; ALP, bilirubin
IgM, IgG

IgG - detectable for life

135
Q

Hep B
IP
Features
Complications

A

Double stranded DNA hepadnavirus
6-20 weeks
Fever jaundice elevated liver trans amina she’s

Ground glass hepatocytes -light microscopy
Fulminant liver failure
HCC
Glomerulonephritis 
Poly arteritis nodosa
Cryoglubulinemia
136
Q

Management of hep B

A

Pegylated INF alpha - reduces viral replication

Tenofovir,entecavir, telbivudine

137
Q

1st Marker to become abnormal hep B infection

A

HBsAg

138
Q

Marker for Hep B that indicates high infectivity

A

HBeAg

139
Q

What indicates recent vaccination for hep B

A

Anti-HBs

140
Q

Marker for past hep B infection

A

Anti HBc

141
Q

Hep C

IP

A

RNA flavivirus

6-9 weeks

142
Q

Potential complications of hep C

A 
Arthralgia and arthritis 
Sjögren’s 
Cirrhosis, HCC 
Cryoglobulinemia 
Porphyria cutaneous tarda
Membrane proliferative glomerulonephritis
143
Q

Treatment hep C

A

Protease inhibitors - daclatasuvir +sofosbuvir or sof +simprevir
W or w/o ribavirin

144
Q

Side effects of ribavirin

A

Haemolytic anemia
Cough
Teratogenic

145
Q

Hep D

Treatment

A

Single strand RNA

Interferon - used but with poor evidence base

146
Q

Hep E
IP
Organism

A

RNA hepesvirus
3-8 weeks
Fecal oral spread

147
Q

Curling’s ulcer

Tx

A

Develops after stress - surgery , serious infection, burining
IV PPI , shift to oral after 72 hrs

148
Q

New onset in an over 40 YO with hx of alcohol
+ abnormal LFTs and wt loss
Suspect

A

Pancreatic ca

Do CT abdomen

149
Q

Most definitive investigation for IBD

A

Colonoscopy

150
Q

IBD vs IBS

A

Fecal calprtectin

- raised in active IBD, normal in IBS

151
Q

Any dyspepsia patient that has been on treatment for at least 1 month with no improvement should have what done?

A

OGD endoscopy

Urgent - if they have dysphagia

152
Q

Treatment of hiatus hernia

A

Medical - PPIs
Surgery - lap fundoplication
= consider if sx persist

153
Q

IBS should be considered :

A

Abd pain + bloating +- change in bowel habit
For at least 6 mo

Dx 
Abd pain relieved by defecaton + 2/4:
1- altered stool passage
Bloating 
Sx made worse by eating , relieved by defecation
Passage of mucus
154
Q

IBS management

A

Low FODMAP diet
Antispasmodics - me ever INR, peppermint oil
Laxatives - ispaghula husk
Loperamide

155
Q

Upper GI endoscopy preparation

A

6hr fasting - before procedure

- small amount of fluid acceptable up to 2hr before procedure

156
Q

IV N acetyl cysteine started immediately in paracetamol overdose when:

A 
Unknown dose
Unknown/ doubtful time of ingestion
Staggered dose
Presents > 8hrs after ingestion 
Unconscious 
Liver tenderness and jaundice
157
Q

When should you refer to liver specialist centre

A

pH < 7.3 after 24 hrs

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