Gastroenterology Flashcards by Derin King

What are some signs of chronic stable liver disease?

multiple spider neavi, dupuytrens contracture, palmar erythema, gynaecomastia

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What are the findings, investigation and management for alcoholic hepatitis?

Fever, jaundice. RUQ pain and tenderness

LFTS - AST>ALT. Usually 2:1
(STop taking alcohol)
Mallory bodies on biopsy
Macrocytic Aneamia may occur

Supportive: stop drinking alcohol,nutrition, B1 and thiamine, consider corticosteroids

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What are the investigations and management for ascites?

Paracentesis of ascitic fluid

Transudate fluid = due to high pressure in hepatic portal vein/portal hypertension

Exudate fluid = protein rich and usually due to inflammation and malignancy

SAAG = serum albumin - albumin level of ascitic fluid

SAAG <1.1 = tuberculosis, pancreatitis, peritoneal cancer, infections, nephrotic syndrome

SAAG>1.1= cirrhosis, heart failure, portal vein thrombosis, budd-chiari syndrome

Sodium restriction, spironolactone (an aldosterone antagonist)
large volume paracentesis, TIPSS

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What is cirrhosis?
history and examination findings?
Investigations?
Management?

Management of oesophageal varices complication?

The end stage of any liver disease e.g viral hepatitis, alcoholic hepatitis, NAFLD. Liver is fibrosed with nodules.

Portal hypertension signs: Ascites, Blood in vomit and melena
Jaundice and pruritus
Chronic liver disease findings
Low platelet common finding

TRANSIENT ELASTOGRAPHY = 1st line investigation

Treat underlying cause, avoid alcohol and hepatotoxic drugs
2nd line = liver transplant or TIPS

Oesophageal varices complication of cirrhosis.
Acute bleeding = Resus + Terlipressin and octreotide
Bleeding prevention = beta blocker/ endoscopic ligation

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What are the findings, investigation and management for autoimmune hepatitis?

Abdominal discomfort, Hepatomegaly, jaundice
Signs of chronic liver disease or portal hypertension may be present
RFs: female(amenorrhea common), other autoimmune diseases

Investigations
LFTs - raised, especially ALT & AST
Serum globulin - usually elevated, not specific

Management = corticosteroids for acute = prednisolone. Add on immunsuppresant (azathioprine) for ongoing

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What clasic triad is seen in liver failure?

jaundice, coagulopathy (INR >1.5), and hepatic encephalopathy (impaired awareness, sleep alterations, reduced attention)

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What are the findings in B12 deficiency? Management?

Megaloblastic anemia - fatigue, pallor, angular chelitis
Peripheral neuropathy - paresthesias
dementia/cognitive impairment
sub-acute combined spinal degeneration - ataxia(+ve rombergs) and signs and symptoms of lower motor neuron lesion (weakness, hyporeflexia, decreased vibration sense,)

Acute with symptoms - cyanocobalamin/ hydroxocobalamin IM
Acute without symptoms - dietary supplementation + vitamins + potentially above

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How does a folate deficiency present?

Megaloblastic anemia with absence of neurological signs

Prolonged diarrhea - tropical sprue, coeliac disease, IBD

Associated with pregnancy and chronic alcohol intake

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What are the findings, investigation and management for acute cholangitis?

fever, jaundice, and right upper quadrant pain (Charcot’s triad).

Rfs: history of cholelithiasis, primary or secondary sclerosing cholangitis, stricture of the biliary tree (benign or malignant), or post-procedure injury of bile ducts

LFTs - raised - ALP > AST/ALP
Ultrasound - dilated bile duct, common bile duct stones, ERCP to look for obstruction

IV antibiotics (piperacillin/tazobactam) + biliary decompression

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How do you investigate and manage acute pancreatitis?

Serum lipase and amylase = elevated 3x upper limit
LFTs and serum calcium - rule out causes of pancreatitis

Fluid resus, analgesia, consider ERCP

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What are the findings and management for an anal fissure?

Pain while pooping, blood on toilet paper, located posteriorly because are is poorly perfused. No abdominal pain, altered bowel habits, or weight loss

High fibre diet = first line. Can add topical glyceryl nitrate or topical diltiazem.
Resistant - botox injection, surgical sphincterotomy

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What investigation can be carried out for appendicitis?

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What are the findings and management for diverticular disease?

LLQ abdominal pain
Abrupt, painless bleeding may occur
Constipation

Diverticulosis vs diverticulitis(fever, leukocytosis)

Diverticulosis - dietary changes, consider analgesia
Diverticulitis - Oral Co-Amoxiclav if uncomplicated, complicated acute diverticulitis (abscess, perforation,fistula, sepsis, intestinal obstruction) give co-amoxiclav with metronidazole

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What are the history and examination findings for gastric cancer?

Abdominal pain, weight loss
proximal or gastro-oesophageal junction tumours = dysphagia
RFs: pernicious anemia, H pylori, nitrosamines(smoked foods),family history(e-cadherin mutations), smoking

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What are the findings investigation and managment for gastric perforation?

Results in Peritonitis: Abdominal pain, GUARDING, REBOUND TENDERNESS

Erect Chest X-Ray

Pre-operative -NGT NBM & IV fluids. Antibiotics - cefuroxime and metronidazole

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Hiatus hernia findings?
Investigations?
Management?

HEARTBURN(usually underling GORD), REGURGITATION, DYSPHAGIA, COUGH
RF: obesity

(barium esophagram)

Uncomplicated sliding hiatus hernias = (PPIS, weight loss, avoid large meals)
Complicated hiatus hernias (bleeding, volvulus, or obstruction, paraesophageal) = surgical repair.

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A groin mass that is visible or palpable or groin discomfort might be an?

Inguinal hernia

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Femorla hernis are located __ the inguinal ligament

Direct inguinal hernias are _ to inferior epigastric artery and indirect inguinal hernias are _ to the vessels

Below

Medial

Lateral

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What are the findings, investigation and management for Mesenteric adenitis?

Abdominal pain - usually RLQ
Abdominal tenderness, fever, mesenteric lymph node enlargement
Usually Viral infection e.g. gastroenteritis, bacterial infection, IBD, lymphoma

abdominal ultrasound

Analgesia, antibiotics if necessary

What are the findings, investigation and management for esophageal cancer?

Progressive dysphagia, first solids then liquids, odynophagia
Weight loss

Investigation - OGD with biopsy 1st line. Barium swallow can show stricture/apple core sign

Management - early stage = esophagectomy

Lower oesophagus = adenocarcima - Barrets, obesity, smoking
Upper oesophagus = squamous cell - smoking, alcohol

What are the investigations, findings and management for pancreatic cancer?

Weight loss
Obstructive jaundice with palpable non-tender gallbladder (courvoisier sign - indicates p. Cancer or cancer of biliary tree)

Ultrasound followed by CT if suggestive of cancer

Whipple procedure, chemo, radio

What are the findings investigation and management for a perianal fistula

Frequent anal abscesses
Pain and swelling around the anus
Bloody or foul-smelling drainage (pus) from an opening around the anus
Pain with bowel movements, bleeding

Proctoscopy, MRI imaging

Fistulotomy

What are the findings, investigation and management for cholecystitis?

Pain/tenderness in RUQ - may be referred to the right shoulder
Signs of inflammation - fever, elevated wcc, elevated CRP and ESR
Palpable mass
Nausea
Positive murphy’s sign - pain on inspiration during RUQ palpation

Ultrasound

Antibiotics, analgesia, fluid resus, cholecystectomy

What are the findings, investigation and management for coeliac disease?

Diarrhea/steatorrhea
Bloating, abdominal pain/discomfort 
Dermatitis herpetiformis 
Iron deficiency anemia, fatigue
suggested by positive immunoglobulin A tissue transglutaminase serology, but must be confirmed by duodenal biopsy and histology.

Crisis = corticosteroid = budesonide/prednisolone
Coeliac disease = gluten free diet + ergocalciferol and calcium carbonate (vitamin and mineral supplementation)

How do you manage constipation?

``` Treatment of underlying cause Laxatives - ispaghula, methylcellulose Opioid induced - methylnatrexone Feacal impaction - evacuation Targeted treatment to cause ```

What are the findings, investigation and management for biliary colic?

RUQ pain - especially after a fatty meal, steady and lasting more than 15-30 minutes Nausea and vomiting Ultrasound - gallstones NSAIDS, scopolamine

What is the managenent for GORD?

PPIs

Findings, investigation and management for hemmorrhoids?

Rectal bleeding - bright red, in association with defecation/straining Perianal pain/discomfort Constipation=RF Anoscopic examination - hemmorrhoids Management Increase fiber and fluid intake Stage 1 = no prolapse = topical corticosteroids Stage 2 and 3 = prolapse upon hearing down but spontaneously reduce & requiring manual reduction = rubber band ligation Stage 4 = permanent prolapse can’t be reduced = hemmorrhoidectomy

What investigations and management are carried out for hypospleenism?

peripheral blood smear; including Howell-Jolly bodies, pitted erythrocytes, Vaccination against common infective organisms

What are the investigation findings in chrons disease? Management?

Plain AXR - bowel dilation Barium contrast - rose thorn ulcers, string sign of kantor Colonoscopy - cobblestone (c)hrons Histology - transmural involvement with non ceaesating granulomas = oral prednisolone/Iv hydrocortisone Maintaining remission= immunosuppressants/thioprines 1st line, biologic therapies second Aminosalicylates not used for crohns

What are the investigation findings in ulcerative colitis? | Management?

Plain AXR - thumbprinting Barium contrast - lead pipe Colonoscopy - continuous erythema, ulcers Histology - crypt abscess, depletion of goblet cell mucin Acute= IV hydrocortisone(steroid) 100mg every 6 hours. LMWH and adcal-d3 recommended Induction and maintenance of remission: 1. Aminosalicylates = 1st line (mesalazine, sulfasalazine) 2. Corticosteroids if uncontrolled by aminosalicylates 3. Immunosuppressants if still uncontrolled = azathioprine, methotrexate 4. Biological therapy last resort = infliximab * HLA-B27 association - 2 parts to gene = 2 part to name “U-C”

What is the management for peptic ulcer disease? Cause of refractory ulcers?

Bleeding ulcer = endoscopy No bleeding, H pylori negative = PPI No bleeding, h pylori positive = PPI + amoxicillin + clarithromycin/metronidazole Signs of rupture(peritonism) = Laparotomy as definitive management Refractory peptic ulcer may be due to Zollinger Ellison Syndrome. It is sometimes associated with MEN1. Investigate by measuring fasting serum gastrin

What are the findings, investigations, and management for heamochromatosis?

Triad - diabetes, skin pigmentation, cirrhosis Arthropathy - joint pain, especially MCP joints Hypogonadism - erectile dysfunction/reduced libido Fatigue, Restrictive cardiomyopathy may occur Transferrin saturation - raised >45% Serum ferritin - raised TIBC - low Repeated phlebotomy = 1st line Iron chelation = 2nd line e.g. deferasirox

What investigation and management for bowel obstruction?

CT Nil by mouth, Iv fluids, Nasogastric decompression + surgery

What are the findings in refeeding syndrome?

hypophosphataemia hypokalaemia hypomagnesaemia: may predispose to torsades de pointes abnormal fluid balance - peripheral oedema

What is an ileus and how do you investigate this?

Ileus is a slowing of gastrointestinal motility that is not associated with mechanical obstruction. Most commonly presents 2 to 3 days following surgery. CT abdomen and pelvis with IV or oral water-soluble contrast - distention of the stomach, fluid filled intestines, and no evidence of a transition zone between dilated and collapsed bowel

What is the treatment for hepatic encephalopathy?

Oral lactulose | Can also use oral rifaximin

A raised bilirubin with no other findings is likely to be caused by? What is the mode of inheritance?

Gilbert’s Syndrome | Autosomal recessive

Treatment for wernickes encephalopathy?

Iv pabrinex (contains thiamine)

Distinguish between diverticulosis and diverticulitis 1st line investigation?

Diverticulosis is asymptomatic. May have blood in stools Diverticulitis - left iliac fossa pain, fever, tachycardia, Abdo distension. May have blood in stools CT scan

Nausea and vomiting are associated more/earlier with which type of bowel obstruction? Risk factors for small and large bowel obstruction?

Small bowel obstruction Adhesions main in SBO Colorectal cancer main in LBO

IBS symptoms Investigation Management?

abdominal pain relieved by defecation or altered bowel frequency/ stool form. It is a diagnosis of exclusion after things like coeliac has been ruled out! Treatment = dietary and lifestyle advice

What is the treatment for gallstones?

Asymptomatic in gallbladder = no treatment unless porcelain gallbladder Asymptomatic in common bile duct = laparoscopic cholecystectomy due to risk of cholangitis or pancreatitis

Primary Sclerosing Cholangitis symptoms? Associated condition? Associated antibodies?

pruritus, RUQ pain, fatigue, jaundice associated with ulcerative colitis p-ANCA antibodies

Primary biliary cholangitis symptoms? Associated conditions? Antibodies?

jaundice, pruritus, (it is autoimmune) other autoimmune conditions AMA

Constipation treatment? Treatment for opioid induced constipation?

Conservative measures - increase fibre and fluids, exercise, balanced diet If conservative measures don’t work: - > 1st line = bulk forming laxatives ISPHAGULA/PSYLLIUM, METHYLCELLULOSE - > if unsuccessful, add an Osmotic laxative MACROGOL(polyethylene glycol) first then LACTULOSE DO NOT prescribe bulk forming laxatives for opioid induced constipation. Offer an osmotic laxative or a stimulant laxative (Senna) instead.