Gastroenterology Flashcards
Why is lactulose used in the management of hepatic encephalopathy?
Reduce generation of ammonia by bacteria in the gut and reduce the absorbability of ammonia from the gut
What is the optimum endoscopic therapy for bleeding oesophageal varicies?
VBL
What are the clinical features of each grade of hepatic encephalopathy?
Grade 0 No abnormality
Grade 1 Alterations in behaviour, mild confusion, disordered sleep
Grade 2 Lethargy, moderate confusion, asterixis
Grade 3 Somnolent but can be roused
Grade 4 Coma
What is the gold standard investigation for diagnosing coeliac disease?
Endoscopy with duodenal biopsy
To be performed after positive serology
What is seen on duodenal biopsy in coeliac disease?
Villous atrophy
Crypt hyperplasia
Increase in intra-epithelial lymphocytes
What are the first line serology investigations for coeliac disease?
Total IgA
IgA tissue transglutaminase (TTG)
Does hepatitis A increase the risk of hepatocellular carcinoma?
No
What is the treatment for Hep A?
Supportive, usually self limiting
Features of Crohn’s disease
Affects anywhere from mouth to anus Skip lesions Inflamation is transmural Fissuring ulcers Lymphoid and neutrophil aggregates Non caseating granulomas Increased incidence in smokers
Features of UC
Always affects the rectum, extends proximally Continuous Mucosa and sub mucosa inflammation only Crypt abscesses Decreased incidence in smokers
What tests should be considered for patients with a change in bowel habit?
Blood tests - FBC (anaemia, raised platelet count), U&E (derrange electorlytes, AKI), CRP (inflmation, can indicate IBD)
Stool tests - culture (r/o infective collitis), faecal calprotectin (active IBD)
Simple imaging - AXR (proximal constipation, toxic megacolon)
Endoscopy - felxi sig (safest test in bloody diarrhoea), colonoscopy (to look for proximal disease), capsule endoscopy (visualise small bowel mucosa)
Cross sectional imaging - CT abdomen (acute compliactions), MRI enterography (small bowel crohn’s, fistulas), MRI rectum (perianal crohns)
Why do patients with acute IBD need prophylactic heparin when staying in hospital?
High risk of VTE
What are the rescue therapies in UC?
Ciclosporin
Biologics (e.g. Infliximab)
Surgery
What are the rescue therapies for Crohns disease?
IV hyrdocortisone - first line
Biologics (e.g. Infliximab)
Surgery
What is used to maintain remission in UC
Mesalazine (5-ASAs)
IF INEFFECTIVE
Sulfasalazine
Azathiprine and biologics (e.g. Infliximab)
What drugs are used to maintain remission in Crohn’s disease?
Azithioprine
Biologics (e.g. Infliximab)
What histological changes will be seen in UC?
Non-granulomatous inflammation of the mucosa and submucosa
Crypt abcesses
Goblet cell hypoplasia
Pseudopolyps
What is the cardinal feature of UC?
Bloody diarrhoea
Symptoms of UC
Proctitis, inflmmation confinded to the rectum only
Bloody diarrhoea
PR bleeing
Mucus discharge (PR)
Increased frequency and urgency of defecation
Tenesmus
Systemic symptoms: malaise, anorexia, low-grade pyrexia
Features of severe UC
>6 bowel movements per day Visable Blood Pyrexia Tachycardia ESR>30 Anaemia
Complications of UC
Toxic megacolon Colorectal carcinoma Osteoperosis Puchitis Bowel perforation
What curative surgery can be used to manage UC?
Total proctocolectomy
Why do patients with UC typically require segmental bowel resection, typically needing a subtotal colectomy defunctioning stoma?
In a flare of IBD primary anastomosis is not adivsed
AXR features of UC flares
Mural thickening, thumbprinting, lead-pipe colon
What are some extra-intestinal manifestations of IBD?
MSK - enteropathic arthritis (large joints such as sacroilliac), clubbing (Crohns- metabolic bone disease)
Skin - erthema nodosum, (Crohn’s, pyoderma gangrenosum)
Eyes - episcleritis, anterior uveitis, iritis
Hepatobillary - primary sclerosing cholangitis (more with UC), cholangiocarcinoma, gallstones
Renal - Renal stones in Crohn’s disease
Which IBD has a cobblestone appearance?
Crohn’s
What are the biggest risk factors for Crohn’s disease?
Family history
Smoking
How does Crohn’s disease present?
Episodic abdominal pain
Diarrhoea, which may contain blood or muscous
Systemic symptoms: malaise, anorexia, low-grade fever
Malnourishment and malabsorption (failure to thrive in children)
Oral Apthous ulcers
Perianal disease including perianal abscess
Wha
Gold standard investigation for Crohns?
Colonoscopy
What score can be used to grade the severity of Crohn’s disease?
Montreal score:
Age, behaviour, location
How might CT imaging be usefull in Crohns?
Bowel obstruction from stricturing
Bowel perfoation
INtra abdominal collections
How is treatment in haemochromatosis monitored?
Ferritin and transferrin saturation
What triad does chronic mesenteric ischaemia often present with?
Severe, colicky post-prandial abdominal pain
Weight loss
Abdominal bruit
What will the acid base status of a patient with mesenteric ischemia be and why?
Metabolic acidosis
Low bicarbonate
What triad may mesneteric ischemia present with?
CVD
Soft tender abdomen
High lactate
In hepatomegaly secondary to right sided heart failure, what is found on examination of RUQ?
Pulsatile, smooth, tender, liver edge
Why should colonoscopy be avoided in patients with severe colitis?
Risk of perforation
What may be seen on CT abdomen of a patient with pancreatic cancer?
Double duct sign - simultaneous dilatation of the common bile duct and pancreatic ducts
What kind of duct dilation will primary sclerosing cholangitis cause?
Intra-hepatic
In a patient with previous hepatitis B immunisation, what will be seen on serology?
anti-HBsAg positive
All others negative
What will be positive on Hep B serology in patients who have had previous Hep C (>6months ago)?
anti-HBc
What will hep B serology show if a patient is carrying Hep B?
HBsAg positive
What anti-emetic should be avoided in bowel obstruction?
Avoid metoclopramide in bowel obstruction
What is the most common organism found on ascitic culture?
E coli
What is the ‘M rule’ in primary billary cholangitis?
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
In autoimmune hepatitis which antibodies and immunoglobins will be positive/raised?
Antinuclear antibody
Anti smooth muscle antibody
IgG
Clinical features of IBS?
Bloating Change in bowel habit Abdominal pain and distension, relieved by defecation Mucus in stool Back pain Urinary symptoms Fatigue Symptoms made worse by eating
How should a suspected perianal fistula be investigated?
MRI pelvis
What iron study findings will be present in patients with untreated heriditory haemochromatosis?
Raised transferritin saturation
Raised ferritin
Low total iron binding capacity
Which part of the colon is most likely to be affected by ischemic colitis?
Splenic flexure
What is Wilson’s disease?
Wilson’s disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues.
What liver pathology can arise secondary to Wilson’s disease?
Copper deposition leading to hepatitis or cirrhosis
What physical findings may be present in a patient with Wilson’s disease?
Kayser-Fleischer rings (green-brown rings in the periphery of the iris)
Blue nails
What psychiatric symptoms can Wilson’s disease cause?
Psychosis
Dysphagia equally to both solids and liquids from the outset is characteristic of what?
Achlasia
How may haematomochrosis present clinical features wise?
Bronze appearance of the skin Hepatomegaly Bilateral joint pain due to chondrocalcinosis of the joints Weakness Hyperglycaemia
What is used to screen for Wilson’s disease?
Serum Caeruloplasmin
reduced
Best measure of acute liver failure?
Prothrombin time
What does a high SAGG indicate
Portal hypertension
What is the acute management of severe alcoholic hepatitis?
corticosteroids
What is Peutz-Jeghers syndrome
Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract
What drugs tend to cause drug induced cholestasis?
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
What kind of GI bleed does a high urea suggest?
Lower GI bleed
What is the The Mackler triad for Boerhaave syndrome?
Subcutaneous emphysema
Thoracic pain
Vommting
(Oesophageal rupture)
Why are anti-motility drugs like loperamide, sometimes used to treat diahorrea, contraindicated in patients with Crohns during a flare up?
Anti-motility drugs, such as loperamide, should be avoided in acute attacks, as these can precipitate toxic megacolon.
Why should colonoscopic surveillance be offered to people with Crohns, and under what circumstance?
Due to increased risk of colorectal malignancy, colonoscopic surveillance is offered to people who have had the disease for over ten years and have over one bowel segment affected.
When is surgical management indicated in Crohn’s?
Failed medical management
Strictures
Perforation
Surgeons will take a bowel sparing approach
What surgeries may be performed to manage Crohns?
Ileocaecal resection
Small or large bowel resection
Surgery for peri-anal disease (I&D, laying open of fistulae, seton insertion)
Stricturoplasty
Complication of Crohn’s disease?
Fistula (enterovesical, enterocutaneous, rectovaginal) Stricture formation Recurrent perianal fistulae GI mallignancy Malabsorption Osteoperosis Gallstones Renal stones
What is the stepwise progression of alcoholic liver disease?
- Alcohol related fatty liver
- Alcoholic hepatitis
- Cirrhosis
How long does it take to reverse alcohol related fatty liver after alcohol cessation?
2 weeks
Is alcoholic hepatitis reversable?
With permanent abstinence
Is alcoholic liver cirrhosis reversable?
No but alcohol cessation will prevent further damage
What is the reccomended limit of alcohol consumption?
14 units a week, over 3+ days
No more than 5 units in one day
What is the CAGE question used to screen for alcohol missuse?
Cut down
Annoyed
Guilty
Eye opener
What score on the AUDIT questionaire indicated harmful alcohol use?
8 or more
What are the complications of alcohol abuse?
Alcoholic liver disease Cirrhosis Hepatocellular carcinoma (2* to cirrhosis) Dependence, withdrawal WKS, wernicke korsakoff syndrome Pancreatitis Alcoholic cardiomyopathy Clotting problems
What may be found on examination of a patient with liver disease?
Jaundice Hepatomegaly Spider naevi Palmar erythema Gynaecomastia Brusing (abnormal clotting) Ascites Capur meduase (engoged superficial epigastric veins) Asterixis
What may be seen on LFTs in alcoholic liver disease?
Elevated transaminases (AST, ALT) with abnormal AST:ALT ratio
Particularly raised gamma-GT
Low albumin
Elevated bilirubin
In liver disease, what does low albumin indicate?
Reduced synthetic function of the liver
What AST:ALT is indicative of alcoholic liver disease?
> 2
ie. AST is twice that of ALT
What might be abnormal in the FBC of a patient with alcoholic liver disease?
Raised MCV
Why may U&Es be derranged in a patient with alcoholic liver disease?
Hepatorenal syndrome
Why are CT and MRI useful in liver disease?
Look for fatty infiltration of the liver, hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes, ascities
When is liver biopsy reccomended in patients with alcoholic liver disease?
When steroid treatment is being considered
What is the role of endoscopy in suspected portal hypertension?
Assess for and treat oesophogeal varicies
What scan can be used to check the elasticity of the liver and assess the degree of cirrhosis?
FIbroscan (USS)
What scan can be used to check the elasticity of the liver and assess the degree of cirrhosis?
FIbroscan (USS)