Gastroenterology Flashcards
Coeliac disease
- cause
- pathology
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
Manifestations of coeliac disease
Chronic or intermittent diarrhoea Steatorrhoea Foul smelling stool Abdominal discomfort Weight loss IDA - most common, —> folate deficiency then vit B12 Manifestations of anemia - fatigue
Most common deficiency in coeliac disease
- IDA
2, folate
3.B12 def
Complication of coeliac disease
Osteoporosis
T cell lymphoma - rare
Important association of coeliac disease
Dermatitis herpetiformis
Diagnosis of coeliac disease
- 1st line
- confirmation test
+ve TTG and IgA
Positive endomysial antibodies
Jejunal or duodenal biopsy
= shows villous atrophy, crypt hyperplasia, increased inter-epithelial lymphocytes
What should be done for biopsy of a suspected coeliac disease patient to be accurate?
Reintroduce gluten 6 weeks before biopsy
Treatment of coeliac disease
Gluten free diet
Features of Crohn’s disease
- endoscopy
- histology
- examination
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
Features of ulcerative colitis
Barium enema -
Histology -
Others
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
What increases risk of Crohns but decreases risk of Ulcerative colitis
Smoking - increased risk in CD , decreases UC
Kantor’s string sign seen in
Crohn’s
Small bowel enema = string sign , thorn ulcers and fistula
Treatment CD
Oral pred - 1st line to induce remission
2nd line - budesonide
- if not give - mesalazine
Treatment of UC
1st line - 5 ASA (Mesalazine)
In severe exacerbation - IV hydrocortisone
Barrett’s oesophagus
Lower oesophagus metaplasia (lower 1/3)
Squamous —> columnar epithelium with goblet cells
Precancerous lesion that can develop into adenocarcinoma
Achalasia is RF for
SCC of upper 2/3 of oesophagus
Adenocarcinoma of the oesophagus is common in
GERD
Barrett’s oesophagus
What is achalasia
Inability to relax lower oesophageal sphincter
- due to loss of normal neural structure
(Raised lower oesophageal resting pressure)
Achalasia
Features
Progressive dysphagia - solids + liquids
Regurgitation
- can lead to aspiration pneumonia
Wt loss, chest pain
Explain the Relationship b/w tobacco and alcohol in achalasia
No relation
However they are linked to oesophageal ca
Achalasia
Investigations
X ray - mega oesophagus - large dilated
Barium meal - birds peak @ distal end
Most accurate - oesophageal manometry
Birds beak appearance on barium meal
Achalasia
Most accurate test for diagnosis of achalasia
Oesophageal manometry
Treatment of achalasia
Dilation of LES
“Regurgitation” seen in :
Achalasia
Pharyngeal pouch - halitosis, gurgling sound in chest , lump in throat sensation
Risk factors for oesophageal ca
Old age Weight loss Smoking, alcohol Anemia Progressive dysphagia - solids + liquids Hx of Barrett’s Hx of GERD
Diagnostic investigation of oesophageal ca
Endoscopy + biopsy
Most common type of oesophageal ca
Adenocarcinoma
Precursor for adenocarcinoma of oesophagus
Barrett’s
What is associate with more risk for oesophageal SCC
Achalasia
Smoking
Site of SCC vs Adenocarcinoma in oesophagus
Upper 2/3 - SCC
Lower 1/3 - adenocarcinoma
features of Zenker’s diverticulum
= pharyngeal pouch
Dysphagia + halitosis + chronic cough - esp at night + regurgitation of stale food/fluid
What is CI in zenker’s diverticulum
What should be done instead
Endoscopy- May perforate pouch
Barium swallow
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
Features of B12 deficiency
Peripheral paresthesia
Impaired position and proprioception
Dementia - memory loss and difficulty thinking
Untreated - permanent ataxia
Hypersegmented neutrophils on blood smear
Macrocytic anemia
B12 deficiency / folate deficiency
Raised MCV and homocysteine
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
Treatment of B12 def
IM hydroxycobalamin
Investigation in acute flare of ulcerative colitis
Treatment
Abdominal X-ray
- toxic mega colon
IV hydrocortisone
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
Thumb printing on abdominal X-ray , dilated colon
Thumb printing/ pseudopolyps - mural oedema esp transverse colon
= toxic megacolon
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
Alcoholic liver disease - features
Ascites haematemesis jaundice
Hepatomegaly spider naevi
AST > ALT (both raised) GGT also raised
Management of alcoholic liver disease
Stop alcohol
Consider transplant after alcohol abstinence in late cases
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
Risk factors for AFLP
Pre eclampsia
Prime
Multiple pregnancies
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
Diagnstic test for AFLP
Liver biopsy
Risk factors for cholecystitis
5 F s
Fair fat female fertile over 40
Cholecystitis treatment
NPO , analgesia
IV fluids and antibiotics
NICE : early lap w/in 1 week of dx
Stones in CBD in an asymptomatic patient
What should be done
ERCP or lap chole
Stone in CBD - treat regardless of symptoms
Plummer Vinson syndrome
Treatment
Post cricoid oesophageal - painless intermittent dysphagia
IDA
T- iron supplements + webs dilatation
2 medications that can worsen GERD and oesophagitis
NSAIDs
Bisphosphonate
Can lead to benign oesophageal stricture
= persistent dysphagia w/o regurgitation
Barrett’s vs benign oesophageal stricture
Both have dysphagia
- persistent in BOS
- occasional in Barrett’s
Acute pancreatitis
RFs
Gallstones, alcoholism
Trauma
ERCP
Investigation for acute pancreatitis
Lipase - more specific and sensitive (>3x upper limit)
Amylase
Confirm dx with Ct w/ contrast
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
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
Organisms that cause bloody diarrhoea
Campylobacter
Shigella
Salmonella
Treatment of pseudomembranous colitis
Oral metronidazole
Oral vancomycin
Diarrhoea hours after eating meal
Likely causative organism
Staph toxin
Oesophageal ca with liver mets
Treatment
End stage oesophageal ca - inoperable
Relieve dysphagia - stenting (endoluminal)
How long after gastrectomy does B12 deficiency develop
1- 2 years
Cobalamin stores so it takes time
Right supraclavicular mass
Ddx
Oesophageal ca
Lung ca
Hodgkin’s lymphoma
RFs for primary biliary cirrhosis
3 Ms
Anti mitochondrial antibodies
Middle aged female
IgM
Others: pruritus, raised ALP, jaundice
Common association of primary biliary cirrhosis
Sjögren’s syndrome
Primary sclerosing cholangitis
Diagnosed by
Common association
ERCP
IBD - esp UC
Treatment of
primary biliary cirrhosis
primary sclerosing cholangitis
Ursodeoxycholic acid
Cholestyramine
Same treatment for both
Albumin infusion
- how does it alleviate ascites and oedema
Increases on on oncotic (colloid osmotic) pressure - shift of fluids from extravascular to intravascular compartments
Treatment of ascites 2ry to liver cirrhosis
Spironolactone
Albumin infusion
Treatment perforated peptic ulcer
NPO
IV fluids antiemetic - metoclopramide 10 mg
Analgesia, IV antibiotics
Urgent surgery
H.Pylori management
Triple therapy
PPI amoxicillin clarithromycin 7-14 days
E.g 20 mg BID PPI, amox 0 1g BID, 500mg BID clarithromycin
How long should meds be stopped before testing for h.pylori
28 days before - ABx
14 days before - PPI
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
Treated H pylori pt with persistent sx
Test to be done
C-13 urea breath test
> = 55 YO + dyspepsia + weight loss
Next step
Urgent upper GI endoscopy to exclude oesophageal/gastric ca
Gastric Ulcers at various sites that are resistant to treatment
Suspect
Zollinger-Ellison syndrome
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
Diagnosis of ZES
Fasting gastrin level
Or
Secretin stimulation test
Treatment mild to mod UC
Rectal mesalazine
If no response - oral mesalazine
Maintaining remission of UC
Oral mesalazine
Or
Oral azathioprine/mercaptopurine
Med to induce remission of CD
Oral pred
Med to maintain remission of CD
Oral azathioprine or mercaptopurine
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
Most accurate diagnostic test for achalasia
Oesophageal manometry
Antibiotics that can cause pseudomembranous colitis
Clindamycin
Amoxicillin, ampicillin, co amoxiclav
Broad spec cephalosporin , quinolones
Treatment of pseudomembranous colitis
Oral metronidazole
Oral vancomycin
Mediastinitis
- anterior
- posterior
Treatment
Ant = pain mainly subcostal Post = pain mainly epigastric - radiates to interscapular region
T= antibiotics and perforation repair
TTF-1 is a marker for
1ry pulmonary adenocarcinoma
TTF = thyroid transcription factor 1
Metastasis of pulmonary adenocarcinoma
Haematogenous - to liver mainly
Diffuse oesophageal spasms
Features
Retrosternal chest pain - intermittent unpredictable and severe
+ dysphagia
Aggravated by cold drinks
diffuse oesophageal spasm
Investigations
- most accurate
Barium meal = corkscrew appearance of oesophagus
Most accurate - Manometric studies
=== high intensity disorganised contractions
Treatment of diffuse oesophageal spasm
CCB - nifedipine
Nitrates
“Spasms take 2 Ns ”
Liver biopsy shows large amounts of iron pigment within hepatocytes
Haemochromatosis
Liver biopsy shows large amounts of iron pigment within Kupffer cells
Haemosiderosis
Causes of clubbing
CLUBBING Cyaotic HD, CF Lung ca,abscess UC,CD Bronchiectasis Benign mesothelioma IE, idiopathic pulmonary fibrosis Neurogenic tumours GIT disease
Management of impacted stool
Phosphate enema
Unless young and healthy —> glycerol suppositories
Management of hard stool (not impacted)
Stool softeners
Constipation with soft stools
Management
High fibre diet
Senna - 1st line
Lactulose or Macrogol - 2nd line
Management of constipation in pregnancy
1st line - ispaghula husk
2- Lactulose (osmotic)
3- senna (stimulant)
Possible cause of overflow (spurious) diarrhoea
Opioids - they reduce intestinal peristalsis
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
Anemia in pregnancy 1st trimester 2nd trimester 3rd trimester Postpartum
1 - <11
2nd & 3rd trimester - <10.5
Post partum - <10
Old age, weight loss, chronic abdominal pain and anemia
Suspect
What investigation
Colon ca
Colonoscopy
Major cause of chronic pancreatitis
Alcohol
Others - autoimmune, smoking
Acute vs chronic pancreatitis
Serum amylase and lipase - not usually very elevated in chronic case
Gold standard investigation of chronic pancreatitis
Spiral CT abdomen w/ contrast
- Showa pancreatic calcification
Useful investigation in chronic pancreatitis
Fecal elastase = low
Fecal chymotrypsin
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
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
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
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
Site of main absorption of iron
Duodenum
Site of main absorption of folic acid
Duodenum and jejunum
Site of main absorption of B12
Terminal/distal ileum
Site of main absorption of bile salts
Terminal/distal ileum
Majority of nutrients absorbed in
Jejunum
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
Treatment of abdominal migraine
Reassurance
Acute gastroenteritis in hospital patients
Causative organism
Management
Norovirus
Isolate for 48 hrs after diarrhoea resolves
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
Investigation of choice for diagnosing pancreatic ca
HRCT
US - 60-90% sensitivity
Management of pancreatic ca
Whipples resection - for resectable lesions
+ adjuvant chemo
ERCP with stenting for palliation
Gold standard method to diagnose oesophageal ca
Upper GI endoscopy + Biopsy
Risk factors GORD
Obesity Pregnancy Smoking Large meals Intake - coffee chocolate alcohol fat CCBs, nitrates, antimuscarinic Systemic sclerosis Hiatus hernia
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
First line treatment of salmonella
Ciprofloxacin
1st line treatment Campylobacter
Erythromycin or clarithromycin
2- cipro
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
Drugs that can cause drug induced hepatitis
Co amoxiclav Clavulanic acid - highly toxic to liver Flucloxacillin Steroids Sulphonylureas
New onset dysphagia
next step
Urgent endoscopy - regardless of age or other symptoms
Hepatitis A
IP
Organism
Transmission
2-4 weeks
RNA picornavirus
Faecal - oral spread
Shellfish - reservoirs ( think hep A after seafood meal )
Investigation hep A
IgM antibodies to hep A virus
If IgG +ve - check igMto see if acute
Lab hep A
Raised LFTs - ALT much higher than AST; ALP, bilirubin
IgM, IgG
IgG - detectable for life
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
Management of hep B
Pegylated INF alpha - reduces viral replication
Tenofovir,entecavir, telbivudine
1st Marker to become abnormal hep B infection
HBsAg
Marker for Hep B that indicates high infectivity
HBeAg
What indicates recent vaccination for hep B
Anti-HBs
Marker for past hep B infection
Anti HBc
Hep C
IP
RNA flavivirus
6-9 weeks
Potential complications of hep C
Arthralgia and arthritis Sjögren’s Cirrhosis, HCC Cryoglobulinemia Porphyria cutaneous tarda Membrane proliferative glomerulonephritis
Treatment hep C
Protease inhibitors - daclatasuvir +sofosbuvir or sof +simprevir
W or w/o ribavirin
Side effects of ribavirin
Haemolytic anemia
Cough
Teratogenic
Hep D
Treatment
Single strand RNA
Interferon - used but with poor evidence base
Hep E
IP
Organism
RNA hepesvirus
3-8 weeks
Fecal oral spread
Curling’s ulcer
Tx
Develops after stress - surgery , serious infection, burining
IV PPI , shift to oral after 72 hrs
New onset in an over 40 YO with hx of alcohol
+ abnormal LFTs and wt loss
Suspect
Pancreatic ca
Do CT abdomen
Most definitive investigation for IBD
Colonoscopy
IBD vs IBS
Fecal calprtectin
- raised in active IBD, normal in IBS
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
Treatment of hiatus hernia
Medical - PPIs
Surgery - lap fundoplication
= consider if sx persist
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
IBS management
Low FODMAP diet
Antispasmodics - me ever INR, peppermint oil
Laxatives - ispaghula husk
Loperamide
Upper GI endoscopy preparation
6hr fasting - before procedure
- small amount of fluid acceptable up to 2hr before procedure
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
When should you refer to liver specialist centre
pH < 7.3 after 24 hrs
