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Gastroenterology Flashcards

1
Q

Definition Barretts

A

Classical > 3cm +/- Tongues

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2
Q

Prague Criteria for Barretts

A

C - degree circumferential disease

M - Maximal Barrett oesophagus segment length

For example, Barrett oesophagus extending circumferentially for 2 cm above the squamocolumnar junction but with tongues of Barrett oesophagus extending 5cm = C2M5.

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3
Q

Surveillance Barretts

A

Risk of progression to adenocarcinoma

  1. 5% if nil dysplasia; 3-5 year surveillance
  2. 7% Low-grade dysplasia, 6 monthly surveillance

7% High-grade dysplasia for surgery (or ablation if not fit for surgery)

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4
Q

SBP Diagnosis

A

Leuks > 500, with > 250 neutrophils

If predominantly lymphocytes > neutrophils, consider diagnosis of peritoneal carcinomatosis or Tb

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5
Q

Definition Hepatorenal syndrome

A

Relative lack of circulatory volume due to pooling in splanchnic blood flow

  • Serum Cr > 133, without improvement with volume expansion & cessation of diuretics
  • Urine Na < 20, no proteinurea
  • Absence of other causes - new nephrotoxic drugs, shock

Types

Type 1; acute - x 2 baseline Cr over 2 weeks without improvement with volume expansion, diuretics or cessation of nephrotoxic drugs **expedite referral for transplant**

Type 2; slow and indolent progression with diuretic resistant ascites

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6
Q

HNPCC

A

Cancer with NO POLYPS- a patient with have a finding of colon cancer on scope, but the rest of the colon will be normal without polyps

Associated with microsatellite instability
Associated with MSH2 (60%) -“S for second & serious”, MLH1 (30%) gene mutation which are DNA mismatch repairs.

Most commonly cancer of the proximal colon
Associated with high risk of endometrial (80% lifetime risk), ovarian, stomach, small intestine, hepatobiliary, urinary tract, brain and skin cancers.

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7
Q

Kings criteria for Liver Transplant (Paracetamol Overdose)

A

“Acute PCM”

  • Acidosis
  • Prothrombin time > 100, INR > 6.5
  • Cr > 300
  • Mental state reduced, encephalopathy grade 3-4
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8
Q

Kings criteria for Liver Transplant (Not Paracetamol Overdose)

A

Prothrombin time > 100, INR > 6.5

OR, any 3 of;
- Non Hep A/B viral hepatitis, drug induced or indeterminate aetiology
- Time from jaundice to encephalopathy > 7 days
- Age < 10, > 40
- Prothrombin time > 50, INR > 3.5
Serum Bili > 17

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9
Q

Autoimmune Hepatitis

A

Commonly young females

Type 1

  • associated with Autoimmune conditions (SLE, T1DM, UC, Coeliacs, Vasculitis)
  • Anti-Smooth muscle Ab positive

Type 2

  • Anti -Liver-kidney-microsomal Ab → Anti- LKM1
  • High IgG (hypergammaglobinaemia)

Requires lifelong immunosuppression i.e. Pred or Azathioprine

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10
Q

Hep C treatment

A

If no cirrhosis, or pregnant - Maviret - “M for Mum”

  • Glecaprevir (protease inhibitor)
  • Pibrentasvir (NS5A inhibitor)

If cirrhotic - Epclusa “C for cirrhosis”

  • Velpatasvir (NS5a inhibitor)
  • Sofosbuvir (Nucleoside RNA polymerase inhibitors)
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11
Q

H.Pylori treatment

A

Triple therapy
Amoxicillin
Clarithromycin, or Metronidazole if sensitivity available
PPI

SALVAGE

  1. Levofloxacin triple therapy
    Amoxicillin
    Levofloxacin
    PPI
  2. Quadruple therapy
    Bismuth salt
    Tetracycline
    Metronidazole
    PPI
  3. Rifabutin triple therapy
    Amoxicillin
    Rifabutin
    PPI

CAG A = gastric
CAG B = duodenal

Proof of cure with C13 Urea breath test, faecal antigen or biopsy, at least 4 weeks after treatment. Serologic testing is not used to confirm H. pylori eradication because it can remain positive in the absence of active infection.

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12
Q

Leptin

A

Appetite suppressant and increases energy expenditure

At the arcuate nucleus of hypothalamus

  • inhibits neurotransmitters; Neuropeptide Y & Agouti-related peptide
  • Stimulates neurotransmitters; POMC a& MHC
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13
Q

Liver transplant criteria HCC

A

Single lesion 1- 5cm lesion
< 3 lesions, < 3cm in size
No metastatic disease

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14
Q

Contraindications to Liver transplant

A
  • Morbid obesity > 40 BMI
  • Current EtOH intake - abstinence 3-6 months
  • Cardiopulmonary disease
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15
Q

Child Pugh Score

A

ABCDE

Albumin
Bilirubin
Coagulation
Drain or dullness (for ascites)
Encephalopathy

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16
Q

Crohns extra-intestinal manifestations that don’t correlate with disease activity

A

Pyoderma gangrenous
Primary sclerosing cholangitis
Small joint and axial arthritis
Uveitis

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17
Q

Crohns extra-intestinal manifestations that correlate with disease activity

A

Episcleritis
Large joint Arthritis
Erythema Nodosum
Apthous Ulcers

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18
Q

Crohns genetic predisposition

A

Nod2/CARD15 gene variants

  • worse phenotype
  • associated with early initial surgery due to stricturing disease and surgical recurrence in Crohn’s disease

pANCA negative, ASCA positive

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19
Q

Coeliac genetic predisposition

A

HLA DQ 2/8

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20
Q

Ustekinumab

A

Anti -IL 12 and 23 for psoriasis and associated peripheral arthropathy & inflammatory bowel disease

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21
Q

Serological markers IBD

A
  • pANCA -, ASCA + = Crohns
  • pANCA +, ASCA - = UC
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22
Q

Vedolizumab

A

Treatment IBD

Vedolizumab; alpha4, beta7 integrin receptor inhibitor

Prevents inflammatory cells translocating into gut

Gut specific - does not work for extra-intestinal manifestations

Safest, give to travellers to Tb endemic areas, elderly and cancer patients

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23
Q

Hep B in pregnancy

A
  • Tenofovir in third trimester if VL > 10^5, but stop in postpartum period
  • Vaccination
  • Hep B immunoglobulin & vaccination given to baby within 12 hours
  • Reduces risk of vertical transmission by 95%
  • Breast feeding does not increase risk!
24
Q

Causes of B12 deficiency

A

Pernicious anaemia
- Anti-IF Ab (specificity 100%)
- Anti-parietal cell Ab
- Elevated gastrin
- Low pepsinogen I, low ration pepsinogen I: II Terminal ileum disease
Gastrectomy
Pancreatic insufficiency
Veganism
Atrophic gastritis
Small bowel bacterial overgrowth
Neomycin blocking agents
Metformin

25
Nutrient absorption
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26
B12 deficiency testing
Schilling test High methylmelonic acid (MMA) High of Homocysteine Anti - IF Ab (more specific for perncious anaemia) Anti- Pariatel cell Ab ![]()
27
Rome 3 Criteria for functional constipation
Types Colonic inertia - slow transit constipation Dyssenergic or pelvic floor dysfunction - outlet delay Diagnosis - Rome 3 criteria, at least 12 weeks in 12 months (does not need to be consecutive); * Must not meet criteria for IBS * Must not have alternating constipation and diarrhoea * Straining \> 25% defections * Sensation of incomplete evacuation/anorectal obstruction \> 25% defecations * Manual manoeuvres for \> 25% defecations * \< 3 defecations/week
28
Coeliac Investigations
Tissue Transglutaminase antibodies (tTG-IgA) with total IgA levels 3% of people will be IgA deficient (20% caucasians) which can cause a false negative, so always measure at same time De-amidated gliadin peptide (DGP-IgG) Endomysial antibody (EMA-IgG) Anti-gliadin antibody (AGA-Iga and IgG) Coeliac HLA genotyping - HLA DQ2, HLA DQ8 - has good negative predictive value (if negative - likely no coeliac) but poor positive predictive value given present in up to 50% community Endoscopy with biopsy (histology is gold standard - patients need to be consuming gluten), require at least 2 x biopsy from first part duodenum and 4 x biopsy from second part of duodenum
29
Azathioprine Side effects
Serum like sickness Bone marrow toxicity - Before initiation, must test for TPMT enzyme activity Hepatosplenic T-cell lymphoma \> 65 _or_ young males who are EBV seronegative Non-melanoma skin cancer Pancreatitis Hepatitis
30
Zollinger-Ellison syndrome
- Gastrinoma; Neuroendocrine tumour that secretes gastrin which causes hyper secretion of acid in stomach - Measure serum gastrin - Dx with Somatostatin receptor scintigraphy
31
Transcobalamin II (TCII) deficiency
Autosomal recessive disease marked by defective intestinal absorption of vitamin B12 Causes megaloblastic anaemia with normal serum B12 on testing due to circulating form of B12 being bound to transcoabalamin 1 rather than 2 Treat with massive PO intake B12
32
Primary Biliary Cirrhosis
Involves women \> 45, uncommon under 25 Fibrosis of smaller intrahepatic bile ducts Anti-mitochondrial Ab positive Rx with ursodeoxycholic acid or transplant Complicated by osteomalacia
33
Primary Sclerosing cholangitis
Fibrosis of the larger bile ducts Strongly associated with Ulcerative colitis (80%), but progressive despite IBD disease status Disease complicated by cholangiocarcinoma in 10%. Ursodeoxycholic acid is not useful - can increase risk of death in high doses No effective treatment
34
Colorectal cancer mutations
Colorectal Ca; MMR Familial adenomatous polypsis; APC- Adenomatous polyposis coli (APC) gene mutation on chromosome 5 HNPCC (Lynch syndrome) - MSH2 (60%) -“S for second most serious”, MLH1 (30%) gene mutation which are DNA mismatch repairs. Associated with microsatellite instability in colon tumor specimens
35
Contraindications to Peg IFN use in Hepatitis
Used for mild/mod Hep B when coexisting Hep D infection - Pregnancy and lactation - Cirrhosis - Uncontrolled depression, can cause psychiatric disorders! - Unstable cardiac/pulmonary condition
36
Dumping syndrome
Early - 15 mins - rapid delivery of hyperosmolar nutrients into gut causing GI symptoms, Vasomotor symptoms and hypoglycaemia Late - 2-3 hours - Rapid absorption of glucose causing a hyperinsulin state and hypoglycaemia
37
Hep B serology - Acute, Chronic, Resolved, Vaccinated, Susceptible
* Acute infection \< 6 months * HBsAg + * HBcAb + IgM * HBsAb - * Chronic infection * HBsAG + \> 6 months * HBcAB + IgG * HbsAB - * Resolved infection * HBsAg - * HBcAB+ IgG * HBsAB+ _(marker of immunity!)_ * Vaccinated * HBsAg - * HBcAB - * HBsAB + (will wain over time, vaccination is titre at \> 10 on ONE instance) * Susceptible * HBsAG - * HBcAB - * HBsAB -
38
Pre-core Mutant Hep B
A variety of hepatitis B virus that does not produce hepatitis B virus e antigen (HBeAg) HBsAg+ HBsAb- HBcAb+ HBeAg-
39
Induction treatment Crohns
Mild * Prednisolone * Budesonide for ill disease Severe * Hydrocortisone * Methyl Pred * AZA * 6MP * MTX Non responsive * Infliximab * Adalilumab * Vedolizumab
40
Maintenance Therapy Crohns
* AZA * 6MP * MTX If fistulating * Infliximab * Adalimumab * Vaedolizumab
41
UC induction
* 5-ASA - oral/rectal combination * Steroids - oral /rectal * AZA * 6-MP * MTX If non-response after 3 months * Infliximab * Vedolizumab * Ciclosporin
42
UC Maintanence
* Oral or Rectal 5-ASA * Aza * 6MP * MTX If non-responsive * Infliximab * Vedolizumab * Surgery
43
Definition Portal HTN
pressure \> 10mmHg Liver stiffness \> 25 Liver stiffness \> 15 with platelets \< 150 pressure \> 12mmHg at risk of ascites and varicies
44
Mimics Coeliacs
* Tropical Sprue * CVID (Manifests as low levels of serum IgG, IgA and IgM with loss of antibody production) * H pylori * Crohns * NSAIDs * Olmesartan
45
Eosinophilic Oesophagitis
Young males, Hx Atopy, Oesophageal eosinophils in mid to proximal oesophagus (if distal - more likely GORD) Does not need to have peripheral eosinophilia Rx Viscous Glucocorticoids + diet elimination
46
GORD/pathological reflux
4% time pH \< 4 throughout whole oesophagus (not just distal) Nocturnal/supine symptoms Scope only required for caucasian, middle to older obese males
47
Risk factors for oesophageal SCC
* Smoking * EtoH * Asian/African * Achalasia * Low SES * Poor PO hygiene * Thoracic radiation * HPV * non-epidermolytic palmoplantar keratoderma
48
Plummer Vinson Syndrome
Upper oesophageal web and Fe deficiency
49
Forrest Criteria
* 1a - ulcer with pulsating bleeding * 1b - ulcer with non-pulsatile bleeding * 2a - ulcer with non-bleeding visible vessel * 2b - ulcer with adherent clot * 2c - ulcer with hemetin on base * 3 - clean based 1a - 2b requires admission, IV PPI and re-scope 2c-3 can be discharged on oral PPI after scope
50
Activation pancreatic enzymes
Trypsinogen to trypsin via brush border enterokinase Prolipase to lipase via trypsin Procarboxypeptidase to carboxypeptidase via trypsin Chymotrypsinogen to Chymotrypsin via trypsin Proelastase to elastase via trypsin
51
Types dumping syndrome
Early - 15 minutes- Rapid delivery of nutrients into duodenum with hyperosmolar contents causing release of vasoactive agents, to cause vasomotor symptoms, GI symptoms and hypoglycaemia Late - 2-3 hours - Rapid absorption of glucose causing a hyperinsulin state and hypoglycaemia
52
Complication Coeliac Disease
* Hyposplenism (with encapsulated sepsis) - due to autoimmune origin * Lymphoma * Malnutrition - osteoporosis, Fe deficiency * Dermatocytosis Herpatiformis * Peripheral neuropathy * CVD due to protective factors of whole grains * Refractory coeliacs - failure of gluten free diet
53
IBD Medications
Always Measure Intra-abdominal Vascular Aneurysms (or) Go Under * ASA * Mercaptapurine * Infliximab - Anti-TNF - quickest, best for extra-intestinal manifestations * Vedolizumab - Alpha-4, Beta2 receptor inhibitors - safest for reactivation, Gut specific * Adalimumab -Anti-TNF * Golimumab - Anti-TNF * Ustekinumab - Targets IL12 & 23 - for psoriasis
54
Why are Gastrin levels high in pernicious anaemia?
Anti-pariatel Ab downregulate Pariatel cell secretion of HCl causing high pH which upregulates G cells to secrete Gastrin to attempt to stimulate further acid secretion from parietal cells
55
Management of hepatorenal syndrome
Terlipressin - splanchnic vasocontrictor Albumin as fluid resus Bridge to transplant, not curative

RACP (17 decks)

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