Gastroenterology Flashcards
1
Q
Describe and differentiate the symptoms of mild, moderate and severe flares of ulcerative colitis
A
Mild: <4 stools per day, little blood
Moderate: 4-6 stools per day, varying blood
Severe: >6 stools per day, bloody diarrhoea, systemic upset
2
Q
What is the name of the criteria used to stage IBD, and what are the 6 criteria?
A
Truelove and Witts: Heart rate Temperature Bowel movements PR bleeding Haemoglobin ESR
3
Q
Recall 2 typical histological findings of the gut layer for Crohn’s and then UC
A
Crohn’s: Increased goblet cells, granulomas
UC: Decreased goblet cells, crypt abscesses
4
Q
What is the most common affected portion of the bowel in Crohn’s vs UC?
A
Crohn’s: terminal ileum (so RIF mass)
UC: rectum
5
Q
Describe the typical features of inflammation in Crohn’s vs UC
A
Crohn’s: Skip lesions, rose-thorn ulcers, cobblestoning, string sign of kantor (narrow ileum stricture)
UC: ‘lead-pipe’, pseudo-polyps, thumbprinting
6
Q
Which type of IBD carries the highest risk of colorectal cancer?
A
UC
7
Q
In which form of IBD are fissures more common and why?
A
Crohn’s - because it affects the full thickness of the bowel wall
8
Q
Differentiate the appearance of stool in active Crohn’s vs UC
A
Crohn’s: non-bloody diarrhoea
UC: bloody diarrhoea which may contain mucous
9
Q
Which type of IBD is associated with gallstones and why?
A
Crohn’s
Bile acids are not properly absorbed as terminal ileum is affected
10
Q
In which form of IBD can surgery be curative?
A
UC
11
Q
Recall the possible extra-intestinal manifestations of IBD
A
A PIE SAC Aphthous ulcers Pyoderma gangrenosum (skin ulcers) I (eye) = uveitis, iritis, episcleritis Erythema nodosum Sclerosing cholangitis (UC Only) Arthritis Clubbing (Crohn's moreso)
12
Q
Describe the process of inducing remission in Crohn’s
A
Steroids:
If mild: oral prednisolone
If severe: IV hydrocortisone
If no improvement after 5 days –> infliximab
Oral budesonide can be used in disease between the distal ileum and the ascending colon
Nutritional:
Replace diet with whole protein modular diet - excessively liquid, for 6-8 weeks - this helps to replace lost weight
13
Q
Describe the process of maintaining remission in Crohn’s
A
First line: DMARDs (eg azothioprine)
Alternatives: infliximab/ aminosalicylates
14
Q
Describe the management of UC
A
Severe disease:
Fulminant: IV steroids and anti-TNF (ciclosporin/infliximab)
Non-fulminant: oral aminosalicylates and corticosteroids with topical aminosalicylates
Non-severe disease:
1st line:
If distal colitis –> oral + topical aminosalicylates
If extensive colitis (past splenic flexure) –> topical and oral salicylates
2nd line:
Topical –> oral corticosteroids
3rd line:
Oral tacrolimus
4th line: biologics
5th line: surgery
15
Q
What is the main side effect of aminosalicylates to remember?
A
Acute pancreatitis
16
Q
In which form of IBD is surgical management most useful?
A
UC
17
Q
What are the options for surgery in UC?
A
Emergency:
Hartmann’s protosigmoidectomy + end ileostomy –> later IPAA (ileal-pouch ana anastomosis)
Non-emergency:
Protocolectomy + IPAA or
Panprotocolectomy + end ileostomy
18
Q
What are the criteria used to diagnose IBS?
A
It’s a diagnosis of excusion based on the ROME III criteria:
- Improvement with defaecation
- Change in stool frequency
- Change in stool form/ appearance/ consistency
19
Q
Recall the grading of haemarrhoids
A
1st: in rectum after defaecation
2nd: prolapse at defaecation, spontaneous reduction
3rd: prolapse at defaecation, manual reduction
4th: persistently prolapsed
20
Q
What is the first line management of haemorrhoids?
A
Increased fruit/ fibre
Stool softener
Topical analgesics
Topical steroids (suppository)
21
Q
Recall some non-operative ways of managing haemorrhoids?
A
Rubber-band ligation
Sclerotherapy
Electrotherapy
Infrared coagulation
22
Q
Recall 3 surgical options for managing haemorrhoids
A
Haemarrhoidectomy
Haemorrhoidopexy
HALO (haemorrhoidal artery ligation operation)
23
Q
What is the standard treatment for C diff enterocolitis?
A
Metronidazole –> vancomycin
24
Q
Which bacteria demonstrates “tumble weed motility”?
A
Listeria monocytogenes
25
How can listeria gastroenteritis be treated?
Amoxicillin/ ampicillin
26
Which 3 antibiotics are most associated with causing C diff enterocolitis?
Cephalosporin
Clindamycin
Ciprofloxacin
27
Which gastroenteritis-causing pathogen is associated with undercooked seafood?
Vibrio parahaemolyticus
28
Which gastroenteritis-causing pathogen is associated with shellfish handlers?
Vibrio vulnificus (in immunocompetent usually causes cellulitis/ nec. fasciitis)
29
Recal the site of absorption of iron, folate and B12
Iron: Duodenum
Folate: Jejunum
B12: Ileum
30
Which skin condition is pathognomonic for coeliac disease?
Dermatitis herpetiformis
31
Describe the appearance of stool in coeliac disease
Waterey, grey, frothy
32
What system is used to grade coeliac disease?
Marsh system
33
Recall some typical histological findings in coeliac disease
Villous atrophy and crypt hyperplasia
34
Recall the name of the scoring system used to diagnose appendicitis and its components
Alvarado score:
Signs:
RLQ tenderness (+2)
Fever
Rebound tenderness
Symptoms:
Anorexia
Nausea/vomiting
Pain migration to RLQ
Lab:
Leucocytosis (WBC > 10,000) (+2)
Left shift (>75% neutrophils)
35
Recall some eponymous signs on examination that are indicative of appendicitis
Rovsing's sign: Pain greater in RIF than LIF when LIF pressed
Cope's sign: Pain on passive flexion and internal rotation of the hip
36
What does rebound tenderness indicate about appendicitis?
That it involves peritoneum
37
What sign can be used to demonstrate a retrocaecal appendix?
Pain on extending hip (Psoas sign)
38
How should an un-perforated appendix be managed?
Prophylactic antibiotics followed by laparoscopic appendectomy
39
How should a perforated appendix be managed?
Abdominal lavage
40
What is "Amirand's triangle"?
Triad of conditions that predisposes to gallstone disease:
Low lecithin
Low bile salts
High cholesterol
41
How can the symptoms of cholecystitis and cholangitis be differentiated?
```
Cholecystitis = no jaundice
Cholangitis = obstructive jaundice
```
42
How can the symptoms of cholecystitis and biliary colic be differentiated?
Biliary colic = RUQ pain
| Cholecystitis = RUQ pain + fever
43
What is Charcot's triad?
Triad of classical symptoms of ascending cholangitis
Jaundice
RUQ pain
fever
44
What is Reynauld's pentad?
```
Pentad of classical symptoms of severe ascending cholangitis
Jaundice
RUQ pain
Fever
Hypotension
Confusion
```
45
Within what time frame should a laparoscopic cholecystectomy be performed for cholecystitis?
1 week (use antibiotics whilst waiting)
46
What is "Mirizzi syndrome"?
Impaction of common hepatic duct by a GB stone
47
What is the pathophysiology of "porcelain gallbladder"?
Chronic cholecystitis can --> calcification of GB walls
48
Recall some complications of acute cholecystitis
```
Chronic diarrhoea (GB removal --> more bile reaches large intestine --> more water and salt draw into bowel)
Vitamin ADEK malabsorption (can --> bleeding due to less 2,7,9,10 production)
```
49
What is a SeHCAT study?
Selenium in Homocholic Acid Taurine - assesses bile acid retention to see if this is cause of diarrhoea
50
How can diarrhoea post-cholecystectomy be managed?
Cholestyramine (binds to bile acids and makes the biologically inactive)
51
How can ascending cholangitis be managed?
IV antibiotics followed by therapeutic ERCP within 48 hours
52
What are the key symptoms of cholangiocarcinoma?
Palpable gallbladder, obstructive jaundice
53
What is the gold-standard investigation for staging cholangiocarcinoma?
ERCP
54
Recall and compare the symptoms of PBC vs PSC
PBC:
Pruritis, obstructive jaundice, RUQ pain in 10%, hyperholesterolaemia
PSC:
Pruritis, obstructive jaundice, steatorrhoea, splenomegaly
55
Recall and compare the antibodies involved in PBC vs PSC
PBC: AMA
PSC: p-ANCA
56
Recall and compare the best way to investigate PBC vs PSC
PBC: cholestatic liver biochemistry and AMA blood test (biopsy is diagnostic but often not carried out)
PSC: MRCP is preferred to start (rosary sign), then p-ANCA + BIOPSY ('onion skin' appearance of obliterated cholangitis)
57
Recall and compare the management approaches for PBS vs PSC
PBS: ursodeoxycholic acid + cholestyramine + prednisolone for associated autoimmune disease
PSC: observation --> liver transplant
58
What % of patients with PSC get cholangiocarcinoma?
10%
59
Which autoimune gallbladder disease is associated with IBD?
PSC (ulcerative colitis)
60
How are the 3 types of autoimmune hepatitis characterised?
T1: high titres of ANA or ASMA - adults and children
T2: Anti-LKM-1,2,3 - affects children
T3: Anti-SLA (soluble liver antigen) - middle age
61
What are the key symptoms of autoimmune hepatitis?
Amenorrhoea
| Chronic liver disease OR acute hepatitis
62
Which type of autoimmune gallbladder disease can affect extrahepatic ducts?
PSC
63
How is autoimmune hepatitis managed?
Steroids
| Eventual liver transplantation
64
What are the 4 signs of portal hypertension?
```
SAVE
Splenomegaly
Ascites
Varices
Encephalopathy
```
65
What is the triad of symptoms of Wernicke's encephalopathy?
Ataxia
Confusion
Ophthalmoplegia
66
Recall the mainstay of management for hepatic vs wernicke's encephalopathy
Hepatic encephalopathy: lactulose + rifaximin
| Wernicke's encephalopathy: thiamine, magnesium, folic acid
67
What are the principles of managing ascites?
Diet: restrict EtOH and fluids, daily weights
Diuretics: spironolactone (+/- furosemide)
Prophylaxis (for SBP): ciprofloxacin + propranolol
For refractory disease: TIPPS/ transplant
68
What is an abdominal paracentesis procedure used to treat?
Tense ascites
69
What is the most common pathogen in SBP?
E coli
70
What investigation is used to confirm ascites?
USS abdomen
71
How can SBP be confirmed?
Ascitic tap with PMN>250 and MC+S
72
What drugs are used to treat vs as prophylaxis for SBP
Treatment: piptazobactam/cefotaxime
Prophylaxis: ciprofloxacin + propranolol
73
When should SBP prophylaxis be started?
Ascites protein <15g/L
74
What is the screening test for haemachromatosis?
Transferrin saturation - >55% in males and >50% in females may indicate further investigation
75
What stain can be used on liver biopsy to identify haemachromatosis?
Perl's stain
76
What is the 1st and 2nd line management for haemachromotosis?
1st line: Venesection
| 2nd line: Desferrioxamine
77
Describe the typical presentation of NAFLD
Acute weight loss followed by jaundice
78
Recall the order in which you would order investigations for NAFLD
1st: LFTs (ALT will be > AST)
2nd: USS (will show increased echogenicity)
3rd: Enhanced Liver Fibrosis (ELF) panel OR a fibroscan
4th: Liver biopsy
79
What are the components of an ELF panel?
Hyaluronic acid
Procollagen III
Tissue inhibitor of metalloproteinase 1
80
What is the mainstay of management for NAFLD?
Lifestyle changes and wt loss
81
What are the classical symptoms of acute pancreatitis?
Severe epigastric pain radiating through to back with nausea and vomiting
82
What is Cullen's sign and what diagnosis does it support?
Cullen's sign = "superficial oedema with bruising in the subcutaneous fatty tissue around the peri-umbilical region"
Indicative of acute pancreatitis
83
What is Grey Turner's sign and what diagnosis does it support?
Grey-Turner's sign = flank bruising
| Indicative of acute pancreatitis
84
How raised is serum amylase likely to be in acute pancreatitis?
>3 times the upper limit of normal (in 75% of patients)
85
What is the most specific marker for acute pancreatitis that will be raised in the blood?
Serum lipase
86
What criteria are used to grade severity of acute pancreatitis?
Glasgow-Imrie
87
What criteria are used to estimate prognosis in acute pancreatitis?
```
PANCREAS
PaO2 <8
Age >55
Neutrophils >15
Calcium <2
Renal urea >16
Enzymes (LDH>600, AST/ALT >200)
Albumin <32
Sugar >10
```
88
How long does an acute episode of pancreatitis have to last for to be considered 'severe'?
>48 hours
89
Recall and differentiate between the management of acute pancreatitis vs necrotising pancreatitis?
For both:
Fluids, analgesia (stat boluses of IV morphine until comfortable), enteral feeding maintained, correct the cause
Only if necrotising: antibiotics
90
Recall some possible early complications of acute pancreatitis
Haemorrhage
SIRS/ARDS
Hyperglycaemia (see pancreas critera)
Hypocalcaemia (see pancreas criteria)
91
Recall some possible late complications of acute pancreatitis
25% --> peri-pancreatic fluid collection
Pseudocysts (appear at around 4w)
Pancreatic abscess (infected pseudocyst)
Pancreatic necrosis
92
What % of chronic pancreatitis is due to alcohol excess?
80%
93
What are the signs and symptoms of chronic pancreatitis?
Symptoms: epigastric pain, typically worse 15-30 mins post-prandially
Signs: Steatorrhoea, diabetes
94
What investigations can be done in suspected chronic pancreatitis?
USS for gallstones
Contrast-enhanced CT
Faecal elastase (measures exocrine function)
Screen for diabetes and osteoporosis
95
What is faecal elastase used to measure?
Exocrine function
96
What histological type of cancer are 80% of pancreatic cancers?
Adenocarcinomas
97
What is the classical presentation of pancreatic cancer?
Painless obstructive jaundice, painless palpable gallbladder (courvoisier's law), FLAWS
Symptoms of lost exocrine/endocrine function
98
What is trousseau's sign of malignancy, and in which types of cancer is it sometimes observed?
Migratory superficial thrombophlebitis (moves from one leg to the other)
Strongly associated with adenocarcinoma of the pancreas and lung
99
What is the pathognemonic sign on High Resolution CT for head of the pancreatic/bile duct cancer?
"Double duct" sign
| Shows simultaneous dilation of CBD and pancreatic duct
100
What is the definitive management of pancreatic cancer?
Whipple's procedure
| Pancreaticoduodenectomy
101
What are the common complications of Whipple's procedure?
```
Dumping syndrome (gastric emptying of contents into duodenum too fast)
PUD (if delayed gastric emptying instead of dumping syndrome)
Bile/pancreatic link
```
102
What is the non-surgical management of pancreatic cancer (eg if metastatic/ unsuitable for resection)?
ERCP with stenting
103
What classification is used for diverticular disease?
Hinchey classification
104
What is the investigation of choice for:
a) acute diverticulitis
b) chronic diverticular disease?
a) CT abdomen
| b) barium enema (can't do in acute phase as may cause perforation)
105
How does the management of mild and severe diverticular disease differ?
Medical:
Mild: PO antibiotics
Severe: IV antibiotics + drip and suck (due to BO) + soluble, high-fibre diet
Surgical (only if severe)
Hartmann's --> primary anastomosis
106
Recall some indications for an urgent (2ww) OGD on suspicion of gastric/oesophageal malignancy?
Dyspepsia
Upper abdominal mass
Age >55 AND weight loss AND any of dyspepsia/GORD/upper abdo pain
nb if no weight loss --> NON-urgent OGD
107
What is the gold standard test for diagnosis of GORD?
24 hour oesophageal pH monitoring
108
What is the mechanism by which H pylori vs GORD produce dyspepsia?
H pylori --> ulcers --> dyspepsia
| GORD --> dyspepsia
109
What are the 3 ways in which you can test for H pylori?
1. Carbon-13 urea breath test
2. Stool antigen test
3. Lab-based serology
110
What is the mainstay of management for H pylori?
Clarithromycin, amoxicillin, PPI
111
How does the medical management differ between endoscopically-proven vs endoscopically-negative GORD?
Proven: 2 months PPI trial followed by 1 month trial of double dose, 2nd line = add H2-RA
Negative: 1 month trial of PPI, 2nd line = H2-RA
112
What is the surgical management option for refractory GORD?
Nissen fundoplication
113
What are the most common complications of nissen fundoplication?
Gas-bloat syndrome (can't belch/vomit)
| Dysphagia (if wrap is too tight)
114
What is Maddrey's discriminant function?
For alcoholic hepatitis:
| Predicts prognosis and who will benefit from steroids
115
What score is used to stage liver cirrhosis?
Childs Pugh
116
What is Budd Chiari syndrome and how is it classified?
Syndrome caused by blockage of the hepatic vein
Type 1 = thrombosis
Type 2 = tumour occlusion
117
What are the possible signs and symptoms of Budd-chiari syndrome?
Abdominal pain, ascites, tender hepatomegaly
118
What is the gold standard investigation for budd-chiari syndrome?
Abdominal USS with doppler
119
What are the 3 best investigations when suspecting achalasia?
LOS manometry
Barium swallow
CXR
120
Recall some signs and symptoms of the carcinoid syndrome, and recall which hormone is responsible for these symptoms
Flushing, diarrhoea, bronchospasm, hypotension, pulmonary stenosis, pellagra, endocrine over-function
Serotonin
121
What 2 investigations can be used to investigate the carcinoid syndrome?
Urinary 5-HIAA
| Plasma chromogranin A y
122
What is the first line management for the carcinoid syndrome?
Somatostatin analogues eg octreotide
123
Recall some antibiotics that may predispose to C diff infection
```
Amoxicillin
Ampicillin
Cephalosporin (eg cefuroxime, ceftriaxone)
Clindamycin
Co-amoxiclav
Quinolones
```
124
Recall the management of C diff colitis
1st episode: oral metronidazole
2nd episode/ severe 1st: oral vancomycin
Life-threatening/ ileus: oral vancomycin + IV metronidazole
ALL antibiotics over 10-14 day period
125
Recall 3 risk factors for small bowel overgrowth
Neonates with congenital abnormalities
Diabetes mellitus
Scleroderma
126
Recall the signs and symptoms of small bowel overgrowth
Very similar to IBS
Chronic diarrhoea
Bloating and flatulence
Abdominal pain
127
Recall 3 ways of investigating for a small bowel overgrowth
Hydrogen breath test
Folate (will be high as bacteria produce it)
Diagnostic course of antibiotics
128
What is the usual first line antibiotic for small bowel overgrowth?
Rifamixin
129
What is Mackler's triad?
The triad of symptoms seen in Boerhaave's syndrome:
Chest pain
Vomiting
Subcutaneous emphysema
130
In PUD, which artery is most likely to be a major source of bleeding?
Gastroduodenal artery
131
When should opioid analgesia NOT be used following major abdominal surgery, and what alternative should be used?
In respiratory disease eg COPD
| Alternative is epidural anaesthesia
