Gastroenterology Flashcards
1
Q
what are the 3 stages of alcohol-related liver disease?
A
- alcoholic fatty liver
- alcoholic hepatitis
- cirrhosis
2
Q
is alcoholic hepatitis reversible?
A
if mild, it can be reversed with permanent abstinence
3
Q
what is the recommended alcohol consumption?
A
- 14 units / week for both men and women
- spread over 3 or more days
4
Q
what are the CAGE questions?
A
- Cut down - ever thought you should?
- Annoyed - when people comment on your drinking?
- Guilty - ever felt like this over your drinking?
- Eye-opener - ever drink first thing in the morn?
5
Q
what are the 2 screening tools for alcohol misuse?
A
- CAGE
- AUDIT
6
Q
complications of alcohol misuse?
A
- alcoholic liver disease (ALD)
- cirrhosis
- HCC
- wernicke-korsakoff syndrome
- pancreatitis
- alcoholic myopathy
7
Q
signs of ALD? hint: there’s a LOT
A
- jaundice
- hepatomegaly
- spider naevi
- palmar erythema
- gynaecomastia
- bruising (abnormal clotting)
- ascites
- caput medusae
- asterixis (flapping tremor)
8
Q
what are caput medusae?
A
superficial epigastric veins that are engorged
9
Q
investigations and findings in ALD?
A
- bloods (lots of things)
- USS (increased echogenecity)
- fibroscan (shows degree of cirrhosis)
- endoscopy (to find and treat oesophageal varices)
- CT / MRI (fatty changes, HCC, HSM, ascites)
- liver biopsy (to confirm diagnosis)
10
Q
findings of blood tests in ALD?
A
- FBC (raised MCV, macrocytic anaemia)
- LFT (raised ALT, AST and gamma-GT, low albumin)
- clotting (raised PTT)
- UEs (deranged)
11
Q
management of ALD?
A
- stop drinking permanently
- start detox regime
- thiamine supplements and high protein diet
- treat complications of cirrhosis
- liver transplant if severe enough
12
Q
complications of cirrhosis?
A
- portal HTN
- varices
- ascites
- hepatic encephalopathy
13
Q
key criterion to be eligible for liver transplant?
A
they must have abstained from alcohol for 3 months prior to referral
14
Q
alcohol withdrawal symptoms at 6-12 hours?
A
- tremor
- sweating
- headache
- craving
- anxiety
15
Q
alcohol withdrawal symptoms at 12-24 hours?
A
hallucinations
16
Q
alcohol withdrawal symptoms at 24-48 hours?
A
seizures
17
Q
what presents 24-72 hours after start of alcohol withdrawal?
A
delirium tremens
18
Q
mortality rate of untreated delirium tremens?
A
35%
19
Q
presentation of delirium tremens?
A
- acutely confused
- delusions, hallucinations
- severe agitation
- tremor
- tachycardia
- HTN
- hyperthermia
- ataxia
- arrhythmias
20
Q
management of alcohol withdrawal?
A
- chlordiazepoxide for 7 days
- disulfiram (unpleasant reaction to alcohol)
- IV pabrinex (B vitamins), then PO thiamine (B1)
21
Q
what drug class is chlordiazepoxide?
A
benzodiazepine
22
Q
how does alcohol excess cause Wernicke-Korsakoff syndrome?
A
- alcohol stops thiamine (B1) absorption
- thiamine deficiency causes WKS
23
Q
features of Wernicke’s encephalopathy? is it reversible?
A
- confusion
- oculomotor disturbances
- ataxia
- yes
24
Q
features of Korsakoff’s syndrome? is it reversible?
A
- anterograde and retrograde amnesia
- behavioural changes
- no
25
4 most common causes of cirrhosis?
- ALD
- NAFLD
- hepatitis B
- hepatitis C
26
less common causes of cirrhosis?
- autoimmune hep
- PBC
- haemochromatosis and Wilsons disease
- alpha-1 antitrypsin deficiency
- cystic fibrosis
- drugs
27
drug causes of cirrhosis?
- amiodarone
- methotrexate
- sodium valproate
28
signs O/E in cirrhosis?
- jaundice
- hepatosplenomegaly (HSM)
- spider naevi
- palmar erythema
- gynaecomastia and testicular atrophy
- bruising
- ascites
- caput medusae
- asterixis
29
what is the tumour marker for hepatocellular carcinoma (HCC)?
alpha-fetoprotein
30
how is HCC screened for in cirrhosis patients?
6-monthly AFP levels and liver USS
31
first line investigation to assess fibrosis in NAFLD?
enhanced liver fibrosis (ELF) blood test
32
USS changes seen in cirrhosis?
- nodular liver surface
- "corkscrew" appearance of hepatic arteries (compensating for portal HTN)
- enlarged portal vein with reduced flow
- fluid
- splenomegaly
33
what does fibroscan measure? how often should it be done in patients at high risk of cirrhosis?
- elasticity of the liver
| - every 2 years
34
risk factors for cirrhosis?
- hep C
- hep B
- heavy alcohol consumption
- existing ALD
- existing NAFLD with fibrosis on ELF test
35
what is the Child-Pugh score?
scoring system used to determine the severity and prognosis of cirrhosis
36
which 5 things are assessed in the Child-Pugh score?
- bilirubin
- albumin
- INR
- ascites
- encephalopathy
37
what is the MELD score? who is it used on? how often is it done?
- to check if pt with compensated cirrhosis needs dialysis
| - 6 monthly
38
how often does a patient with cirrhosis but no known varices need to be endoscopied?
every 3 years
39
complications of cirrhosis?
- malnutrition
- portal HTN
- varices, bleeding
- ascites, SPB
- hepatorenal syndrome
- encephalopathy
- HCC
40
management / prevention of malnutrition secondary to cirrhosis?
- regular meals every 2-3 hours
- low Na diet (stops fluid retention)
- high protein, high kcal diet
- avoid alcohol
41
what causes varices?
- portal venous system has increased pressure (HTN)
- blood gets backlogged
- results in swollen, tortuous vessels
42
common sites for variceal veins?
- gastro-oesophageal junction
- ileocaecal junction
- rectum
- anterior abdominal wall via umbilical vein (caput medusae)
43
management of stable varices?
- BB (propanolol)
- elastic band ligation
- sclerosant injection
44
management of portal HTN?
transjugular intrahepatic portosystemic shunt (TIPS)
45
management of bleeding oesophageal varices?
- vasopressin analogue (terlipressin)
- vit K and FFP to correct any coagulopathy
- prophylactic broad spectrum ABx
- endoscopy to inject sclerosant and elastic band ligation
- Sengstaken-Blakemore tube insertion
46
what is ascites? how does it develop?
- free fluid in the peritoneal cavity
| - increased pressure in portal system forces fluid to leak out
47
what type of ascites does cirrhosis cause?
transudative (low protein)
48
management of ascites?
- low Na diet
- aldosterone antagonist diuretic (spironolactone)
- paracentesis (ascitic tap or drain)
- prophylactic ABx against SBP (ciprofloxacin) in pts with low protein
- TIPS or liver transplant if severe
49
how might SBP present?
- asymptomatic
- fever
- abdo pain
- deranged bloods
- ileus
- hypotension
50
what might blood tests show in SBP?
- raised WBC
- raised CRP
- raised creatinine
- metabolic acidosis
51
which 4 organisms most commonly cause SBP?
- E. coli
- klebsiella pneumoniae
- staphylococcus
- enterococcus
52
management of SBP?
- take ascitic culture
| - then IV cephalosporin (cefotaxime)
53
how does hepatorenal syndrome develop?
- hypertension in portal system causes vessels to dilate
- dilatation activates renin-angiotensin system
- leads to renal vasoconstriction
- reduced circulation in kidneys
54
prognosis of hepatorenal syndrome?
fatal within a week if no liver transplant
55
management of hepatorenal syndrome?
liver transplant
56
what is the primary toxin responsible for hepatic encephalopathy? where does it come from? why do cirrhosis patients get a build up of this toxin?
- ammonia
- breakdown product from gut bacteria
- normally the liver can break down ammonia into harmless waste products but cirrhosis impairs this
57
presentation of hepatic encephalopathy?
- reduced consciousness
| - confusion
58
precipitating factors for hepatic encephalopathy?
- constipation
- electrolyte disturbance
- infection
- GI bleed
- high protein diet
- sedating drugs
59
management of hepatic encephalopathy?
- laxative (lactulose) to stop ammonia being absorbed
- ABx (rifaximin) to kill off some gut bacteria
- nutritional support
- nasogastric feeding
60
what are the stages of progression from NAFLD to cirrhosis?
- NAFLD
- NASH
- fibrosis
- cirrhosis
61
risk factors for NAFLD? (hint: think CVD risk factors)
- obesity
- poor diet
- T2DM
- high cholesterol
- ageing
- smoking
- HTN
62
what is included in a non-invasive liver screen?
- USS liver
- hep B and C serology
- autoantibodies
- immunoglobulins
- caeruloplasmin
- alpha-1 antitrypsin
- ferritin and transferrin saturation
63
which conditions might be shown by autoantibodies on a non-invasive liver screen?
- autoimmune hepatitis
- primary biliary cirrhosis
- primary sclerosing cholangitis
64
which conditions might be shown by immunoglobulins on a non-invasive liver screen?
- autoimmune hepatitis
| - primary biliary cirrhosis
65
marker of Wilsons disease on a non-invasive liver screen?
caeruloplasmin
66
which condition would cause low alpha-1 antitrypsin on a non-invasive liver screen?
alpha-1 antitrypsin deficiency
67
markers of hereditary haemochromatosis on a non-invasive liver screen?
raised ferritin and transferrin saturation
68
which autoantibodies are on the non-invasive liver screen?
- antinuclear antibodies (ANA)
- smooth muscle antibodies (SMA)
- antimitochondrial antibodies (AMA)
- LKM-1 antibodies
69
investigations in NAFLD?
- liver USS (very basic, doesn't show much)
- ELF blood test
- NAFLD fibrosis score if ELF unavailable
- fibroscan is 3rd line
70
management of NAFLD?
- weight loss
- exercise
- stop smoking
- control DM, BP and cholesterol
- avoid alcohol
- if liver fibrosis present then give vit E / pioglitazone
71
causes / types of hepatitis?
- alcoholic
- NAFLD
- viral (A-E)
- autoimmune
- drug-induced
72
how might hepatitis present?
- asymptomatic
- abdo pain
- fatigue
- pruritis
- muscle and joint aches
- nausea and vomiting
- jaundice
- fever (if viral)
73
what are the LFT findings in hepatitis?
- AST and ALT rise disproportionately higher than ALP does
| - raised bilirubin
74
which 2 enzymes are transaminases?
- AST
| - ALT
75
what is the most common viral hepatitis worldwide?
hep A
76
what type of organism causes hep A? what is the route of transmission?
- RNA virus
| - faeco-oral route
77
presentation of hep A? (hint: there is cholestasis) signs on examination?
- nausea
- vomiting
- anorexia
- jaundice
- dark urine
- pale stools
- moderate hepatomegaly
78
what type of organism causes hep B? what is the route of transmission?
- DNA virus
| - blood / bodily fluid contact and vertical transmission
79
what % of hep B cases go on to become chronic? how quickly do the rest recover from it?
- 10-15%
| - within 2 months
80
which viral marker indicates active hep B infection?
surface antigen (HBsAg)
81
which viral marker indicates high infectivity of hep B infection?
E antigen (HBeAg)
82
which viral marker indicates past / current hep B infection?
core antibodies (HBcAb)
83
which viral marker indicates vaccination / past / current hep B infection?
surface antibody (HBsAb)
84
which viral marker is a direct count of hep B viral load?
hep B virus DNA (HBV DNA)
85
which 2 viral markers are tested for in screening for hep B?
- core antibodies (HBcAb) for past infection
| - surface antigens (HBsAg) for active infection
86
management of hep B?
- screen for other bloodborne viruses and STDs
- refer to GI, ID or hepatology for specialist input
- notify PHE
- stop smoking and alcohol
- education on reducing transmission
- antiviral meds
- liver transplant if end stage disease
87
what are the possible complications of hep B? how can these be screened for?
- cirrhosis (fibroscan)
| - HCC (USS)
88
what type of organism causes hep C? what is the route of transmission?
- RNA virus
| - blood / bodily fluid contact
89
what % of hep C cases become chronic? is it curable?
- 75%
| - yes, with direct acting antiviral medication
90
complications of hep C?
- cirrhosis
| - HCC
91
how is hep C screened for? how is the diagnosis confirmed?
- hep C antibody test to screen
| - hep C RNA testing to confirm (shows viral load)
92
management of hep C?
- screen for other bloodborne viruses and STDs
- refer to GI, ID or hepatology for specialist input
- notify PHE
- stop smoking and alcohol
- education on reducing transmission
- direct acting antivirals (DAAs) for 12 weeks
- liver transplant if end stage disease
93
what type of organism causes hep D? what is the route of transmission?
- RNA virus
| - faeco-oral route
94
presentation of hep D? management of hep D?
- mild illness, self-resolving within a month
- notify PHE
- reassure that no treatment is needed
95
pathophysiology of autoimmune hepatitis?
T cells of immune system recognise liver cells as foreign and attacks them
96
what age group does type 1 autoimmune hep present in? how might it present?
- adults
| - postmenopausal women with fatigue and liver disease signs O/E, less acute presentation
97
what age group does type 2 autoimmune hep present in? how might it present?
- children
| - teens / 20yos with acute hepatitis, raised AST/ALT and IgG, jaundice, very acute presentation
98
which autoantibodies are found in type 1 autoimmune hep?
- antinuclear antibodies (ANA)
- anti-smooth muscle antibodies (anti-actin)
- anti-soluble liver antigen (anti-SLA)
99
which autoantibodies are found in type 2 autoimmune hep?
- anti-liver kidney microsomes-1 (anti-LKM1)
| - anti-liver cytosol antigen type 1 (anti-LC1)
100
how is the diagnosis of autoimmune hep confirmed?
liver biopsy
101
management of autoimmune hep?
- high dose prednisolone initially
- then azathioprine
- lifelong drugs
- can recur in a transplanted liver
102
what is haemochromatosis?
a genetic iron storing disorder which causes an excess of total body iron
103
which gene mutation (and chromosome) is associated with haemochromatosis?
mutation in the HFE gene on chromosome 6
104
inheritance pattern for haemochromatosis?
autosomal recessive
105
typically which age would haemochromatosis present at?
> 40 years old
106
why does haemochromatosis present later in females?
menstruation actively eliminates iron from the body
107
presentation of haemochromatosis?
- chronic tiredness
- joint pain
- bronze pigmentation of skin
- hair loss
- erectile dysfunction
- amenorrhoea
- cognitive (memory / mood disturbance)
108
investigations for haemochromatosis?
- serum ferritin level (diagnostic)
- transferrin saturation - to see whether you need to do genetic testing
- genetic testing (gold standard)
- liver biopsy with Perl's stain
- CT abdo
- MRI liver and heart
109
complications of haemochromatosis?
- T1DM (iron in pancreas)
- liver cirrhosis, HCC (iron in liver)
- endocrine and sexual problems (hypogonadism, impotence, amenorrhoea, infertility), from iron in pituitary and gonads
- hypothyroidism (iron in thyroid)
- cardiomyopathy (iron in heart)
- chrondocalcinosis, arthritis (iron in joints)
110
management of haemochromatosis?
- weekly venesection
- monitor serum ferritin
- treat complications
111
what is wilson's disease?
excessive accumulation of copper in body tissues
112
which gene mutation (and on which chromosome) causes wilson's disease?
"Wilson disease protein" on chromosome 13
113
inheritance pattern of wilson's disease?
autosomal recessive
114
how does wilson's disease affect the liver?
- copper accumulating in the liver
- this causes chronic hepatitis
- then cirrhosis
115
neurological symptoms in wilson's disease?
- concentration and coordination difficulties
- dysarthria (speech)
- dystonia (abnormal muscle tone)
116
how could wilson's disease cause parkinsonism?
copper deposits in the substantia nigra (basal ganglia)
117
psychiatric symptoms of wilson's disease?
- depression
| - psychosis
118
describe copper deposits in the eyes. how are these investigated?
- Kayser-Fleischer rings in cornea
| - slit lamp examination
119
other than liver / neuro / psych, what are the other features of wilson's disease?
- haemolytic anaemia
- renal tubular acidosis
- osteopenia
120
initial investigation in wilson's disease?
serum caeruloplasmin
121
what is caeruloplasmin?
a protein which carries copper in the blood
122
gold standard investigation in wilson's disease?
liver biopsy
123
other than serum caeruloplasmin and liver biopsy, which other investigations can be done for wilson's disease?
- 24H urine copper assay
- serum copper (low)
- MRI brain (nonspecific changes)
124
management of wilson's disease?
copper chelation:
- penicillamine
- trientene
125
what is alpha-1 antitrypsin (A1AT) deficiency?
inherited deficiency of alpha-1 antitrypsin (a protease inhibitor)
126
which chromosome carries the gene for A1AT?
chromosome 14
127
what are the 2 main organs affected by A1AT deficiency? what happens to them?
- liver (cirrhosis)
| - lungs (pulmonary basal emphysema)
128
investigations in A1AT deficiency?
- serum A1AT blood test (low), screening test
- liver biopsy (acid-Schiff-positive globules)
- genetic testing for A1AT gene
- high res CT thorax (emphysema)
129
management of A1AT deficiency?
- stop smoking (to stop emphysema progression)
- symptomatic management
- organ transplant for end stage liver / lung disease
- monitor for complications (e.g. HCC)
130
pathophysiology of primary biliary cirrhosis (PBC)?
- immune system attacks the small bile ducts of the liver
- causes obstruction of bile flow
- bile acids, bilirubin and cholesterol are not excreted properly so blood levels rise
- results in pruritus, jaundice, fatty stools etc.
- eventually: fibrosis, cirrhosis and liver failure
131
what are xanthelasma? what are xanthoma?
- cholesterol deposits in the skin
| - same but larger ones
132
presentation of PBC?
- fatigue
- pruritus
- abdo pain
- jaundice
- pale, greasy stools
- xanthoma and xanthelasma
- signs of cirrhosis and liver failure (ascites, splenomegaly, spider naevi etc)
133
risk factors for PBC?
- middle aged women
- other autoimmune disease (thyroid, coeliac etc)
- rheumatoid disease (systemic sclerosis, sjogren's, RA etc)
134
investigations in PBC?
- LFTs
- autoantibodies
- liver biopsy
135
blood results in PBC?
- LFT shows raised ALP early on
- anti-mitochondrial antibodies present, most specific to PBC, diagnostic if present
- anti-nuclear antibodies present in 35%
- raised ESR
- raised IgM
136
management of PBC? how do each of them help?
- ursodeoxycholic acid (reduces cholesterol absorption in gut)
- colestyramine (reduces pruritus by binding to bile acids)
- liver transplant
- steroids (immunosuppression)
137
2 most important complications of PBC?
- cirrhosis
| - portal hypertension
138
pathophysiology of primary sclerosing cholangitis?
intrahepatic / extrahepatic bile ducts get strictured and fibrotic
139
which other condition is PSC associated with?
ulcerative colitis
140
risk factors for PSC?
- male
- age 30-40
- PMHx of UC
- FHx
141
presentation of PSC?
- jaundice
- chronic RUQ pain
- pruritus
- fatigue
- hepatomegaly
142
LFT findings in PSC?
- "cholestatic" picture
- raised ALP early
- then other enzymes and bilirubin rise later
143
are antibody tests useful in PSC investigation?
- only in finding out if there is an autoimmune element
| - none are sensitive / specific to PSC so not useful in diagnosing it
144
which autoantibodies are found in PSC?
- antineutrophil cytoplasmic antibody (p-ANCA), seen in up to 94%
- antinuclear antibodies (ANA) in 77%
- anticardiolipin antibodies (aCL) in 63%
145
gold standard investigation for PSC? what does it show in PSC?
- magnetic resonance cholangiopancreatography (MRCP)
- it's an MRI of liver, bile ducts and pancreas
- shows bile duct lesions and strictures
146
complications in PSC?
- acute bacterial cholangitis
- cholangiocarcinoma
- colorectal cancer
- cirrhosis and liver failure
- biliary strictures
- fat soluble vitamin (ADEK) deficiencies
147
management of PSC?
- ERCP to dilate and stent strictures
- ursodeoxycholic acid to stop cholesterol absorption
- cholestyramine to help with pruritus
- liver transplant
148
what does ERCP stand for? where does it go through? what happens?
- endoscopic retrograde cholangio-pancreatography
- through the mouth and oesophagus etc down to the sphincter of Oddi
- then into ampulla or Vater and into bile ducts
- any strictures are stented
149
what are the 2 types of primary liver cancer?
- hepatocellular carcinoma (HCC), 80%
| - cholangiocarcinoma, 20%
150
risk factors for HCC?
- hep B / C infection
- alcohol
- NAFLD
- any other cause of cirrhosis
- A1AT deficiency
- being male
- metabolic syndrome (e.g. DM)
151
which condition is associated with cholangiocarcinoma?
PSC (10% of cholangiocarcinoma patients have it)
152
presentation of liver cancer?
- asymptomatic for years initially
- weight loss
- abdo pain
- anorexia
- N+V
- jaundice - painless in cholangiocarcinoma
- pruritus
153
investigations in liver cancer?
- alpha-fetoprotein (AFP)
- CA19-9
- USS liver
- CT, MRI to stage
- ERCP to take biopsies or diagnose cholangiocarcinoma
154
tumour marker for HCC?
alpha-fetoprotein (AFP)
155
tumour marker for cholangiocarcinoma?
CA19-9
156
management of HCC?
- if caught before mets, transplant is curative
| - kinase inhibitors (all end in -fenib)
157
prognosis of HCC?
- poor because presents late
- resistant to chemo and radiotherapy
- kinase inhibitors extend lifespan by months
158
management of cholangiocarcinoma?
- if caught before mets, surgical resection is curative
| - ERCP to stent bile duct being compressed by tumour, relieves obstructive symptoms
159
prognosis of cholangiocarcinoma?
- poor
| - resistant to chemo and radiotherapy
160
what is a hemangioma?
- a common benign liver tumour
| - found incidentally
161
what are the chances of a hemangioma becoming cancerous? how are they monitored and treated?
- nil
| - no monitoring or treatment needed
162
what is a focal nodular hyperplasia?
- a benign liver tumour made of fibrotic tissue
- found incidentally
- linked to oestrogen so more common in women on COCP
163
how are focal nodular hyperplasias monitored and treated?
- no monitoring or treatment needed
| - no malignant potential
164
most common acute indications for a liver transplant?
- acute viral hepatitis
| - paracetamol OD
165
factors making a liver transplant unsuitable?
- significant other comorbid conditions (CKD, HF)
- excessive weight loss / malnutrition
- active hep B or C infection
- end stage HIV
- active alcohol use
166
how long does a patient need to be abstinent for before a liver transplant?
6 months
167
management post-liver transplant?
- lifelong immunosuppression with steroids, azathioprine and tacrolimus
- avoid alcohol and smoking
- treat any opportunistic infections
- monitor for new disease (hepatitis, PBC, cancer)
168
why is it important to monitor for cancer in liver transplant patients?
they're immunosuppressed which increases risk of malignancy significantly
169
signs of liver transplant rejection?
- abnormal LFTs
- fatigue
- fever
- jaundice
170
what is the histology of the oesophagus lining?
squamous epithelium
171
what is the histology of the stomach lining?
columnar epithelium
172
presentation of GORD?
- heartburn
- acid regurg
- retrosternal / epigastric pain
- bloating
- nocturnal cough
- hoarse voice
173
which investigation can be used in GORD? which patients need this done urgently?
- endoscopy, to assess for ulcers and malignancy
| - urgent if evidence of an UGIB or cancer
174
evidence of UGIB?
- melaena
| - coffee ground vomiting
175
red flags of cancer which warrant an urgent endoscopy referral?
- dysphagia at any age
- aged >55
- weight loss
- upper abdo pain and reflux
- Tx-resistant dyspepsia
- N+V
- low Hb
- raised platelets
176
lifestyle advice given in GORD?
- reduce tea, coffee, alcohol
- weight loss
- avoid smoking
- smaller, lighter meals
- avoid heavy meals before bed
- sit upright after meals
177
medication classes used in GORD? give examples
- acid neutralisers (gaviscon, rennie)
- PPIs (omeprazole, lansoprazole)
- H2 receptor antagonist (ranitidine)
178
surgical management of GORD? how does it work?
- laparoscopic fundoplication
| - tying the fundus up, making the LOS narrower
179
what type of bacteria is H. pylori?
gram -ve aerobic bacteria
180
how does H. pylori affect the stomach?
- damages the gastric lining
- causes gastritis
- increases risk of stomach cancer
- produces ammonia which also damages the lining
181
who gets offered H. pylori testing?
anyone with dyspepsia
182
what needs to be done prior to H. pylori testing to ensure accuracy?
no PPI use in the last 2 weeks
183
3 methods of testing for H. pylori?
- urea breath test
- stool antigen test (1st choice method, easiest to do)
- rapid urease test (CLO test), done in endoscopy
184
which substance is needed for the urea breath test?
radiolabelled carbon 13
185
what happens in a CLO test?
- biopsy of stomach taken in endoscopy
- urea added to it
- if H. pylori present, ammonia produced
186
eradication therapy for H. pylori? how long for?
- "triple therapy"
- 1 PPI (e.g. omeprazole)
- 2 ABx (e.g. amoxicillin and clarithromycin)
- 7 days
187
what is barretts oesophagus?
metaplasia of lower oesphageal mucosa from squamous to columnar epithelium
188
is barretts oesophagus dangerous?
- not by itself
| - premalignant for adenocarcinoma in some
189
monitoring of barretts oesophagus?
endoscopy to check for adenocarcinoma changes
190
management of barretts oesophagus?
- PPI
| - surgical ablation in those with dysplasia
191
what are peptic ulcers? most common type?
- includes gastric and duodenal ulcers
| - duodenal more common
192
pathophysiology of peptic ulcers?
2 main causes:
- breakdown of gastric / duodenal mucosa by drugs or H. pylori
- increased stomach acid
193
causes of increased stomach acid?
- stress
- alcohol
- caffeine
- smoking
- spicy foods
194
presentation of peptic ulcers?
- epigastric discomfort / pain
- N+V
- dyspepsia
- haematemesis (coffee ground)
- melaena
- Fe def anaemia (from constant bleeding)
195
how does eating affect gastric ulcers?
worsens the pain
196
how does eating affect duodenal ulcers?
eases the pain
197
investigations for peptic ulcers?
- endoscopy to Dx
- CLO test done at same time to check for H. pylori
- consider biopsy to rule out malignancy
198
management of peptic ulcers?
- same as GORD
| - high dose PPIs
199
complications of peptic ulcers?
- bleeding, can be life-threatening
- perforation, causing peritonitis and "acute abdomen"
- scarring and strictures of mucosa, can lead to pyloric stenosis
200
causes of UGIB?
- oesophageal varices
- Mallory-Weiss tear
- peptic ulcers
- stomach / duodenal cancers
201
presentation of UGIB?
- haematemesis (fresh blood in vomit)
- coffee ground vomit (digested blood)
- melaena (tarry stools)
- haemodynamic instability
- signs of underlying disease (e.g. pain, jaundice)
202
what is the Glasgow-Blatchford score?
risk of having an UGIB looking at various risk factors
203
why does urea rise in UGIB?
it is a breakdown product in the digestion of blood
204
what is the Rockall score?
risk of rebleeding and mortality after an endoscopy
205
management of UGIB?
- ABCDE
- IV fluid bolus
- Bloods
- Access (IV, 2 large bore cannulas)
- Transfuse blood
- Endoscopy, urgent within 24h
- Drugs, stop NSAIDs and anticoags
206
which bloods are requested in UGIB?
- FBC (Hb, platelets)
- UEs
- coagulation (INR)
- LFTs
- crossmatch 2 units of blood
207
management in UGIB with a massive haemorrhage?
transfuse blood, platelets and clotting factors (FFP)
208
when is prothrombin complex concentrate used in UGIB management?
patients on warfarin who are actively bleeding
209
additional management of suspected oesophageal varices in UGIB? (e.g. an alcoholic with a bleed)
- terlipressin
| - broad spectrum ABx (prophylaxis)
210
definitive management of UGIB?
- oesophagogastroduodenoscopy (OGD) to do interventions
- variceal banding
- cauterisation of bleeding vessels
211
crows NEST: features of crohn's disease? (hint: 2S and 2T), any others?
- No blood or mucus in stools (less common)
- Entire GI tract affected
- Skip lesions on endoscopy, Smoking is RF
- Terminal ileum affected most, Transmural inflamm
- others: weight loss, strictures, fistulas
212
uc CLOSEUP: features of UC?
- Continuous inflamm on endoscopy
- Limited to colon and rectum
- Only superficial mucosa affected
- Smoking is protective!!!
- Excreting blood and mucus
- Use aminosalicylates
- PSC is an association
213
overall presentation of IBD?
- diarrhoea
- abdo pain
- passing blood (UC)
- weight loss
214
investigations in IBD?
- bloods: FBC, TFT, LFT, UEs
- faecal calprotectin
- endoscopy with biopsy
- USS, CT, MRI to look for complications
215
screening for IBD?
faecal calprotectin
216
what is the diagnostic test for IBD?
endoscopy (OGD and colonoscopy) with biopsy
217
potential complications of IBD?
- fistulas
- abscesses
- strictures
218
management of crohn's?
- induce remission: steroids (pred or IV hydrocortisone)
- 2nd line is azathioprine
- maintaining remission: azathioprine, methotrexate, infliximab
- surgery
219
when can surgery be used to manage crohn's?
- when disease only affects the distal ileum
| - to treat strictures and fistulas secondary to crohn's
220
3 principles of IBD management?
- inducing remission
- maintaining remission
- surgery
221
management of UC?
- inducing remission in mild-mod disease: mesalazine, 2nd line is pred
- inducing remission in sev disease: IV hydrocortisone, 2nd line is IV ciclosporin
- maintaining remission: mesalazine, azathioprine
- surgery
222
which drug class is mesalazine?
aminosalicylate
223
surgical management of UC?
- total removal of colon and rectum
| - patient left with permanent ileostomy or J-pouch
224
what is IBS?
- irritable bowel syndrome
- abnormal functioning of an otherwise healthy bowel
- diagnosis of exclusion
225
which demographic are more likely to get IBS?
young females
226
symptoms of IBS?
- diarrhoea
- constipation
- mucus in stools sometimes
- fluctuating bowel habit
- abdo pain, worse after eating
- bloating
- symptoms improve on opening bowels
227
diagnostic criteria for IBS?
- must exclude other pathology
- normal FBC, ESR and CRP
- negative faecal calprotectin (IBD)
- negative anti-TTG antibodies (coeliac)
- cancer not suspected / excluded
228
advice given in management of IBS?
- reassurance
- adequate fluid intake
- regular small meals
- reduce processed foods
- limit caffeine and alcohol
- low FODMAP diet
229
medical management of IBS?
- trial probiotics for 4 weeks
- loperamide if diarrhoea
- laxatives if constipated
- buscopan for cramps
- 2nd line: amitriptyline
- 3rd line: SSRI
- CBT if distress
230
why is lactulose avoided in IBS management?
it causes bloating
231
which drug class is buscopan?
antispamodic
232
specialist laxative offered in IBS?
linaclotide
233
what is coeliac disease?
autoimmune condition where exposure to gluten causes inflammation in the small bowel
234
when does coeliac disease typically develop?
early childhood
235
autoantibodies found in coeliac disease?
- anti-tissue transglutaminase (anti-TTG)
| - anti-endomysial (anti-EMA)
236
which part of the GI tract is affected by coeliac disease?
jejunum (middle of small intestine)
237
pathophysiology of coeliac disease?
reaction to gluten causes atrophy of jejunal villi
238
presentation of coeliac disease?
- often asymptomatic
- FTT in young children
- diarrhoea
- fatigue
- weight loss
- mouth ulcers
- anaemia (Fe, B12 or folate def)
- dermatitis herpetiformis
239
which dermatological sign is seen in coeliac disease?
dermatitis herpetiformis
240
describe dermatitis herpetiformis
- itchy blistering rash
| - typically abdominal
241
rare neurological signs of coeliac disease?
- peripheral neuropathy
- cerebellar ataxia
- epilepsy
242
which condition is strongly associated with coeliac disease? how is this managed?
- T1DM
| - all type 1 diabetics are screened for coeliac disease
243
which gene is strongly associated with coeliac disease?
HLA-DQ2 (90% have it)
244
why is it important to test for total IgA in coeliac disease?
the autoantibodies (anti-TTG, anti-EMA) are IgA themselves, so if the patient is IgA deficient, these 2 will come back falsely negative
245
investigations to diagnose coeliac disease?
- all must be carried out whilst patient has gluten in their diet
- total IgA, then anti-TTG (1st), then anti-EMA
- endoscopy and biopsy
246
findings on endoscopy in coeliac disease?
- crypt hypertrophy
| - villous atrophy
247
which conditions are associated with coeliac disease?
autoimmune ones:
- T1DM
- thyroid disease
- autoimmune hepatitis
- PBC
- PSC
248
complications of untreated coeliac disease?
- vitamin def
- anaemia
- osteoporosis
- ulcerative jejunitis
- enteropathy-assoc T-cell lymphoma (EATL) of the intestine
- non-hodgkin lymphoma
- adenocarcinoma of small bowel (rare)
249
management of coeliac disease?
lifelong gluten free diet
250
risk factors for hepatocellular carcinoma (HCC)?
- cirrhosis secondary to any cause
- A1AT def
- drugs (COCP, anabolic steroid use)
- being male
- metabolic syndrome (e.g. DM)
251
prophylaxis of bleeding from oesophageal varices?
propanolol
252
management of a variceal bleed during endoscopy?
terlipressin
253
presentation of C. jejuni infection?
- prodrome of generally feeling unwell
- abdo pain (mimics appendicitis)
- bloody diarrhoea
254
which bacteria is associated with reheated rice?
bacillus cereus
255
eye signs of IBD?
- anterior uveitis (more in UC)
- episcleritis (more in crohn's)
- conjunctivitis
256
joint signs of IBD?
- arthralgia
- ankylosing spondylitis (UC)
- sacroiliitis
257
skin signs of IBD?
- erythema nodosum
| - pyoderma gangrenosum
258
which malignancies could raised AFP indicate?
- liver
| - testicular / yolk sac
259
which malignancy could raised hCG indicate?
testicular cancer
260
which malignancy could raised immunoglobulins indicate?
multiple myeloma
261
which malignancy could raised CA-19-9 indicate?
pancreatic cancer
262
which malignancies could raised CEA indicate?
- colon
| - stomach
263
what is cullen's sign? hint: seen in pancreatitis
bruising around umbilicus in pancreatitis with retroperitoneal haemorrhage
264
triad seen in mesenteric anaemia?
- Hx of CVD
- raised lactate
- soft but tender abdomen
265
key condition associated with gastroparesis?
DM
266
features of gastroparesis?
- N+V
- feeling full despite after a few bites
- abdo pain
- bloating
- poor HbA1C management if diabetic
267
how can gastroparesis be diagnosed?
solid meal gastric scintigraphy
268
management of gastroparesis?
- dietary modification
- domperidone
- metoclopramide / erythromycin (both aid motility)
269
features of vit C def?
- spontaneous bleeding / bruising
- gingivitis
- coiled hairs
- tooth loss
270
RFs for vit C def?
- famine
- war
- refugees
271
RFs for vit B1 (thiamine) def?
- chronic alcohol use
| - any cause of malabsorption
272
features of thiamine def?
- wernicke's encephalopathy
| - wet or dry beriberi
273
features of vit A def?
- night blindness
- xeropthalmia (collection of eye signs)
- complete blindness
274
RFs for C. difficile infection?
- broad-spectrum ABx
- healthcare settings incl. care homes
- age >65
- PPI use
- underlying diseases
- immunosuppression (e.g. HIV, chemo)
275
which underlying diseases can predispose to a C. diff infection?
- IBD
- cancer
- renal disease
276
management of c. diff?
- 1st line: PO vancomycin
