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
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
3
Q
Most common deficiency in coeliac disease
A
- IDA
2, folate
3.B12 def
4
Q
Complication of coeliac disease
A
Osteoporosis
T cell lymphoma - rare
5
Q
Important association of coeliac disease
A
Dermatitis herpetiformis
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
7
Q
What should be done for biopsy of a suspected coeliac disease patient to be accurate?
A
Reintroduce gluten 6 weeks before biopsy
8
Q
Treatment of coeliac disease
A
Gluten free diet
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
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
11
Q
What increases risk of Crohns but decreases risk of Ulcerative colitis
A
Smoking - increased risk in CD , decreases UC
12
Q
Kantor’s string sign seen in
A
Crohn’s
Small bowel enema = string sign , thorn ulcers and fistula
13
Q
Treatment CD
A
Oral pred - 1st line to induce remission
2nd line - budesonide
- if not give - mesalazine
14
Q
Treatment of UC
A
1st line - 5 ASA (Mesalazine)
In severe exacerbation - IV hydrocortisone
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
16
Q
Achalasia is RF for
A
SCC of upper 2/3 of oesophagus
17
Q
Adenocarcinoma of the oesophagus is common in
A
GERD
Barrett’s oesophagus
18
Q
What is achalasia
A
Inability to relax lower oesophageal sphincter
- due to loss of normal neural structure
(Raised lower oesophageal resting pressure)
19
Q
Achalasia
Features
A
Progressive dysphagia - solids + liquids
Regurgitation
- can lead to aspiration pneumonia
Wt loss, chest pain
20
Q
Explain the Relationship b/w tobacco and alcohol in achalasia
A
No relation
However they are linked to oesophageal ca
21
Q
Achalasia
Investigations
A
X ray - mega oesophagus - large dilated
Barium meal - birds peak @ distal end
Most accurate - oesophageal manometry
22
Q
Birds beak appearance on barium meal
A
Achalasia
23
Q
Most accurate test for diagnosis of achalasia
A
Oesophageal manometry
24
Q
Treatment of achalasia
A
Dilation of LES
25
“Regurgitation” seen in :
Achalasia
| Pharyngeal pouch - halitosis, gurgling sound in chest , lump in throat sensation
26
Risk factors for oesophageal ca
```
Old age
Weight loss
Smoking, alcohol
Anemia
Progressive dysphagia - solids + liquids
Hx of Barrett’s
Hx of GERD
```
27
Diagnostic investigation of oesophageal ca
Endoscopy + biopsy
28
Most common type of oesophageal ca
Adenocarcinoma
29
Precursor for adenocarcinoma of oesophagus
Barrett’s
30
What is associate with more risk for oesophageal SCC
Achalasia
| Smoking
31
Site of SCC vs Adenocarcinoma in oesophagus
Upper 2/3 - SCC
| Lower 1/3 - adenocarcinoma
32
features of Zenker’s diverticulum
= pharyngeal pouch
| Dysphagia + halitosis + chronic cough - esp at night + regurgitation of stale food/fluid
33
What is CI in zenker’s diverticulum
| What should be done instead
Endoscopy- May perforate pouch
Barium swallow
34
Causes of B 12 deficiency
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
```
35
Features of B12 deficiency
Peripheral paresthesia
Impaired position and proprioception
Dementia - memory loss and difficulty thinking
Untreated - permanent ataxia
36
Hypersegmented neutrophils on blood smear
Macrocytic anemia
B12 deficiency / folate deficiency
Raised MCV and homocysteine
37
B12 vs folate deficiency
B12 - vegans - no meat or fish or dairy
Folate - don’t eat veggies
Gastric or ileal resection, pernicious anemia - B12 deficiency
38
Treatment of B12 def
IM hydroxycobalamin
39
Investigation in acute flare of ulcerative colitis
| Treatment
Abdominal X-ray
- toxic mega colon
IV hydrocortisone
40
When should you suspect severe colitis (UC exacerbation)
```
Rule of 6 30 90
> 6 bowel movements + visible blood
ESR >30
HR >90 mild tachy
Temp >37.8
Anemia
```
41
Thumb printing on abdominal X-ray , dilated colon
Thumb printing/ pseudopolyps - mural oedema esp transverse colon
= toxic megacolon
42
```
Abnormal LFTs (raised ALT AST bilirubin)+ 2ry amenorrhoea in young-middle age female
Suspect
```
Autoimmune hepatitis - tends to progress to Cirrhosis
ALT AST bilirubin - raised ,
ALP - normal or mildly elevated
Usually assoc with another autoimmune disease
43
Alcoholic liver disease - features
Ascites haematemesis jaundice
Hepatomegaly spider naevi
AST > ALT (both raised) GGT also raised
44
Management of alcoholic liver disease
Stop alcohol
| Consider transplant after alcohol abstinence in late cases
45
HELLP vs acute fatty liver of pregnancy
HELLP - hemolysis therefore low Hb
AFLP = ELLP + low glucose +- raised ammonia
- can have DIC - prolonged PT PTT
- vomiting
46
Risk factors for AFLP
Pre eclampsia
Prime
Multiple pregnancies
47
AFLP - presentation
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
48
Diagnstic test for AFLP
Liver biopsy
49
Risk factors for cholecystitis
5 F s
| Fair fat female fertile over 40
50
Cholecystitis treatment
NPO , analgesia
IV fluids and antibiotics
NICE : early lap w/in 1 week of dx
51
Stones in CBD in an asymptomatic patient
| What should be done
ERCP or lap chole
Stone in CBD - treat regardless of symptoms
52
Plummer Vinson syndrome
| Treatment
Post cricoid oesophageal - painless intermittent dysphagia
IDA
T- iron supplements + webs dilatation
53
2 medications that can worsen GERD and oesophagitis
NSAIDs
Bisphosphonate
Can lead to benign oesophageal stricture
= persistent dysphagia w/o regurgitation
54
Barrett’s vs benign oesophageal stricture
Both have dysphagia
- persistent in BOS
- occasional in Barrett’s
55
Acute pancreatitis
| RFs
Gallstones, alcoholism
Trauma
ERCP
56
Investigation for acute pancreatitis
Lipase - more specific and sensitive (>3x upper limit)
Amylase
Confirm dx with Ct w/ contrast
57
Management of acute pancreatitis
Initial - supportive
= iv fluids, analgesics
IV Imipenem for moderate to severe cases
Surgical debridement only in cases of necrosis - minimally invasive
58
Acute cholangitis
Investigation
Treatment
FRJ (Charcot’s triad) +- hypOtension and leukocytosis)
US and blood cultures
Fluid resusc, broad spec ABx
Correct any coagulopathy
Early ERCP
59
Organisms that cause bloody diarrhoea
Campylobacter
Shigella
Salmonella
60
Treatment of pseudomembranous colitis
Oral metronidazole
Oral vancomycin
61
Diarrhoea hours after eating meal
| Likely causative organism
Staph toxin
62
Oesophageal ca with liver mets
| Treatment
End stage oesophageal ca - inoperable
| Relieve dysphagia - stenting (endoluminal)
63
How long after gastrectomy does B12 deficiency develop
1- 2 years
| Cobalamin stores so it takes time
64
Right supraclavicular mass
| Ddx
Oesophageal ca
Lung ca
Hodgkin’s lymphoma
65
RFs for primary biliary cirrhosis
3 Ms
Anti mitochondrial antibodies
Middle aged female
IgM
Others: pruritus, raised ALP, jaundice
66
Common association of primary biliary cirrhosis
Sjögren’s syndrome
67
Primary sclerosing cholangitis
Diagnosed by
Common association
ERCP
| IBD - esp UC
68
Treatment of
primary biliary cirrhosis
primary sclerosing cholangitis
Ursodeoxycholic acid
Cholestyramine
Same treatment for both
69
Albumin infusion
| - how does it alleviate ascites and oedema
Increases on on oncotic (colloid osmotic) pressure - shift of fluids from extravascular to intravascular compartments
70
Treatment of ascites 2ry to liver cirrhosis
Spironolactone
| Albumin infusion
71
Treatment perforated peptic ulcer
NPO
IV fluids antiemetic - metoclopramide 10 mg
Analgesia, IV antibiotics
Urgent surgery
72
H.Pylori management
Triple therapy
PPI amoxicillin clarithromycin 7-14 days
E.g 20 mg BID PPI, amox 0 1g BID, 500mg BID clarithromycin
73
How long should meds be stopped before testing for h.pylori
28 days before - ABx
| 14 days before - PPI
74
How do you ret-test for H.pylori after full course treatment
Carbon 13 urea breath test
- if not available - stool antigen
Serology cant be used
Antibodies stay for long time after successful eradication
75
Treated H pylori pt with persistent sx
| Test to be done
C-13 urea breath test
76
>= 55 YO + dyspepsia + weight loss
| Next step
Urgent upper GI endoscopy to exclude oesophageal/gastric ca
77
Gastric Ulcers at various sites that are resistant to treatment
Suspect
Zollinger-Ellison syndrome
78
Zollinger-Ellison syndrome
| Features
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
Diagnosis of ZES
Fasting gastrin level
Or
Secretin stimulation test
80
Treatment mild to mod UC
Rectal mesalazine
| If no response - oral mesalazine
81
Maintaining remission of UC
Oral mesalazine
Or
Oral azathioprine/mercaptopurine
82
Med to induce remission of CD
Oral pred
83
Med to maintain remission of CD
Oral azathioprine or mercaptopurine
84
Hereditary haemochromatosis
- inheritance pattern
- manifestations (5)
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
Most accurate diagnostic test for achalasia
Oesophageal manometry
86
Antibiotics that can cause pseudomembranous colitis
Clindamycin
Amoxicillin, ampicillin, co amoxiclav
Broad spec cephalosporin , quinolones
87
Treatment of pseudomembranous colitis
Oral metronidazole
| Oral vancomycin
88
Mediastinitis
- anterior
- posterior
Treatment
```
Ant = pain mainly subcostal
Post = pain mainly epigastric - radiates to interscapular region
```
T= antibiotics and perforation repair
89
TTF-1 is a marker for
1ry pulmonary adenocarcinoma
TTF = thyroid transcription factor 1
90
Metastasis of pulmonary adenocarcinoma
Haematogenous - to liver mainly
91
Diffuse oesophageal spasms
| Features
Retrosternal chest pain - intermittent unpredictable and severe
+ dysphagia
Aggravated by cold drinks
92
diffuse oesophageal spasm
Investigations
- most accurate
Barium meal = corkscrew appearance of oesophagus
Most accurate - Manometric studies
=== high intensity disorganised contractions
93
Treatment of diffuse oesophageal spasm
CCB - nifedipine
Nitrates
“Spasms take 2 Ns ”
94
Liver biopsy shows large amounts of iron pigment within hepatocytes
Haemochromatosis
95
Liver biopsy shows large amounts of iron pigment within Kupffer cells
Haemosiderosis
96
Causes of clubbing
```
CLUBBING
Cyaotic HD, CF
Lung ca,abscess
UC,CD
Bronchiectasis
Benign mesothelioma
IE, idiopathic pulmonary fibrosis
Neurogenic tumours
GIT disease
```
97
Management of impacted stool
Phosphate enema
| Unless young and healthy —> glycerol suppositories
98
Management of hard stool (not impacted)
Stool softeners
99
Constipation with soft stools
| Management
High fibre diet
Senna - 1st line
Lactulose or Macrogol - 2nd line
100
Management of constipation in pregnancy
1st line - ispaghula husk
2- Lactulose (osmotic)
3- senna (stimulant)
101
Possible cause of overflow (spurious) diarrhoea
Opioids - they reduce intestinal peristalsis
102
Why is acute cholecystitis fairly common in pregnancy
Pregnancy changes composition of bile + slows emptying of the gallbladder
- gallstone formation
ALP is normally elevated in pregnancy and early postpartum
103
```
Anemia in pregnancy
1st trimester
2nd trimester
3rd trimester
Postpartum
```
1 - <11
2nd & 3rd trimester - <10.5
Post partum - <10
104
Old age, weight loss, chronic abdominal pain and anemia
Suspect
What investigation
Colon ca
| Colonoscopy
105
Major cause of chronic pancreatitis
Alcohol
| Others - autoimmune, smoking
106
Acute vs chronic pancreatitis
Serum amylase and lipase - not usually very elevated in chronic case
107
Gold standard investigation of chronic pancreatitis
Spiral CT abdomen w/ contrast
| - Showa pancreatic calcification
108
Useful investigation in chronic pancreatitis
Fecal elastase = low
| Fecal chymotrypsin
109
Management of acute oesophageal variceal bleed
ABC incl IV fluids
Terlipressin & ABx prophylaxis - before endoscopy
Endoscopy - 1. Band ligation if not sclerotherapy
If not controlled with above - TIPS
110
Gilberts syndrome
- inheritance pattern
- cause
Autosomal recessive
Unconjugated (indirect) hyperbilirubinemia
Decreased UGT-1 enzyme - conjugates bilirubin with glucuronic acid
Can be precipitated by infection stress fasting etc
111
Features of Gilbert’s syndrome
| Labs
Usually asymptomatic but can present with
Jaundice +- hx of recent infection
LFTs normal, mild rise in bilirubin
Urine dipstick normal
Normal reticulocytes
112
Dubin Johnson’s syndrome vs Gilbert’s
Dubin = raised conjugated bilirubin (direct) + abnormal urine dipstick
Urine dipstick - hyperbilirubinemia
Gilberts - isolated jaundice (raised bilirubin) + other tests normal
113
Site of main absorption of iron
Duodenum
114
Site of main absorption of folic acid
Duodenum and jejunum
115
Site of main absorption of B12
Terminal/distal ileum
116
Site of main absorption of bile salts
Terminal/distal ileum
117
Majority of nutrients absorbed in
Jejunum
118
Abdominal migraine
Features
Dx criteria
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
Treatment of abdominal migraine
Reassurance
120
Acute gastroenteritis in hospital patients
Causative organism
Management
Norovirus
| Isolate for 48 hrs after diarrhoea resolves
121
Features of pancreatic ca
Painless jaundice
RUQ mass , hepatomegaly , wt loss
Palpable non tender GB , atypical back pain
+- palpable epigastric lump, palpable liver, GB
+- ascites
122
Investigation of choice for diagnosing pancreatic ca
HRCT
| US - 60-90% sensitivity
123
Management of pancreatic ca
Whipples resection - for resectable lesions
+ adjuvant chemo
ERCP with stenting for palliation
124
Gold standard method to diagnose oesophageal ca
Upper GI endoscopy + Biopsy
125
Risk factors GORD
```
Obesity
Pregnancy
Smoking
Large meals
Intake - coffee chocolate alcohol fat
CCBs, nitrates, antimuscarinic
Systemic sclerosis
Hiatus hernia
```
126
Management of GORD
Endoscopically
-proven
-negative
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
First line treatment of salmonella
Ciprofloxacin
128
1st line treatment Campylobacter
Erythromycin or clarithromycin
| 2- cipro
129
Spontaneous bacterial peritonitis
Investigation - initial , most accurate
Initial management
Neutrophil count from ascitic fluid aspirate
Most accurate - ascitic fluid aspirate culture
Organism gains access to peritoneum via blood
IV ABx
130
Drugs that can cause drug induced hepatitis
```
Co amoxiclav
Clavulanic acid - highly toxic to liver
Flucloxacillin
Steroids
Sulphonylureas
```
131
New onset dysphagia
| next step
Urgent endoscopy - regardless of age or other symptoms
132
Hepatitis A
IP
Organism
Transmission
2-4 weeks
RNA picornavirus
Faecal - oral spread
Shellfish - reservoirs ( think hep A after seafood meal )
133
Investigation hep A
IgM antibodies to hep A virus
| If IgG +ve - check igMto see if acute
134
Lab hep A
Raised LFTs - ALT much higher than AST; ALP, bilirubin
IgM, IgG
IgG - detectable for life
135
Hep B
IP
Features
Complications
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
Management of hep B
Pegylated INF alpha - reduces viral replication
| Tenofovir,entecavir, telbivudine
137
1st Marker to become abnormal hep B infection
HBsAg
138
Marker for Hep B that indicates high infectivity
HBeAg
139
What indicates recent vaccination for hep B
Anti-HBs
140
Marker for past hep B infection
Anti HBc
141
Hep C
| IP
RNA flavivirus
| 6-9 weeks
142
Potential complications of hep C
```
Arthralgia and arthritis
Sjögren’s
Cirrhosis, HCC
Cryoglobulinemia
Porphyria cutaneous tarda
Membrane proliferative glomerulonephritis
```
143
Treatment hep C
Protease inhibitors - daclatasuvir +sofosbuvir or sof +simprevir
W or w/o ribavirin
144
Side effects of ribavirin
Haemolytic anemia
Cough
Teratogenic
145
Hep D
| Treatment
Single strand RNA
Interferon - used but with poor evidence base
146
Hep E
IP
Organism
RNA hepesvirus
3-8 weeks
Fecal oral spread
147
Curling’s ulcer
| Tx
Develops after stress - surgery , serious infection, burining
IV PPI , shift to oral after 72 hrs
148
New onset in an over 40 YO with hx of alcohol
+ abnormal LFTs and wt loss
Suspect
Pancreatic ca
| Do CT abdomen
149
Most definitive investigation for IBD
Colonoscopy
150
IBD vs IBS
Fecal calprtectin
| - raised in active IBD, normal in IBS
151
Any dyspepsia patient that has been on treatment for at least 1 month with no improvement should have what done?
OGD endoscopy
Urgent - if they have dysphagia
152
Treatment of hiatus hernia
Medical - PPIs
Surgery - lap fundoplication
= consider if sx persist
153
IBS should be considered :
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
IBS management
Low FODMAP diet
Antispasmodics - me ever INR, peppermint oil
Laxatives - ispaghula husk
Loperamide
155
Upper GI endoscopy preparation
6hr fasting - before procedure
| - small amount of fluid acceptable up to 2hr before procedure
156
IV N acetyl cysteine started immediately in paracetamol overdose when:
```
Unknown dose
Unknown/ doubtful time of ingestion
Staggered dose
Presents > 8hrs after ingestion
Unconscious
Liver tenderness and jaundice
```
157
When should you refer to liver specialist centre
pH < 7.3 after 24 hrs
