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RACP > Gastroenterology > Flashcards

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
Q

Nutrient absorption

A
26
Q

B12 deficiency testing

A

Schilling test

High methylmelonic acid (MMA)

High of Homocysteine

Anti - IF Ab (more specific for perncious anaemia)

Anti- Pariatel cell Ab

27
Q

Rome 3 Criteria for functional constipation

A

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
Q

Coeliac Investigations

A

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
Q

Azathioprine Side effects

A

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
Q

Zollinger-Ellison syndrome

A
  • Gastrinoma; Neuroendocrine tumour that secretes gastrin which causes hyper secretion of acid in stomach
  • Measure serum gastrin
  • Dx with Somatostatin receptor scintigraphy
31
Q

Transcobalamin II (TCII) deficiency

A

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
Q

Primary Biliary Cirrhosis

A

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
Q

Primary Sclerosing cholangitis

A

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
Q

Colorectal cancer mutations

A

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
Q

Contraindications to Peg IFN use in Hepatitis

A

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
Q

Dumping syndrome

A

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
Q

Hep B serology - Acute, Chronic, Resolved, Vaccinated, Susceptible

A
  • 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
Q

Pre-core Mutant Hep B

A

A variety of hepatitis B virus that does not produce hepatitis B virus e antigen (HBeAg)

HBsAg+
HBsAb-
HBcAb+
HBeAg-

39
Q

Induction treatment Crohns

A

Mild

  • Prednisolone
  • Budesonide for ill disease

Severe

  • Hydrocortisone
  • Methyl Pred
  • AZA
  • 6MP
  • MTX

Non responsive

  • Infliximab
  • Adalilumab
  • Vedolizumab
40
Q

Maintenance Therapy Crohns

A
  • AZA
  • 6MP
  • MTX

If fistulating

  • Infliximab
  • Adalimumab
  • Vaedolizumab
41
Q

UC induction

A
  • 5-ASA - oral/rectal combination
  • Steroids - oral /rectal
  • AZA
  • 6-MP
  • MTX

If non-response after 3 months

  • Infliximab
  • Vedolizumab
  • Ciclosporin
42
Q

UC Maintanence

A
  • Oral or Rectal 5-ASA
  • Aza
  • 6MP
  • MTX

If non-responsive

  • Infliximab
  • Vedolizumab
  • Surgery
43
Q

Definition Portal HTN

A

pressure > 10mmHg

Liver stiffness > 25

Liver stiffness > 15 with platelets < 150

pressure > 12mmHg at risk of ascites and varicies

44
Q

Mimics Coeliacs

A
  • Tropical Sprue
  • CVID (Manifests as low levels of serum IgG, IgA and IgM with loss of antibody production)
  • H pylori
  • Crohns
  • NSAIDs
  • Olmesartan
45
Q

Eosinophilic Oesophagitis

A

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
Q

GORD/pathological reflux

A

4% time

pH < 4 throughout whole oesophagus (not just distal)

Nocturnal/supine symptoms

Scope only required for caucasian, middle to older obese males

47
Q

Risk factors for oesophageal SCC

A
  • Smoking
  • EtoH
  • Asian/African
  • Achalasia
  • Low SES
  • Poor PO hygiene
  • Thoracic radiation
  • HPV
  • non-epidermolytic palmoplantar keratoderma
48
Q

Plummer Vinson Syndrome

A

Upper oesophageal web and Fe deficiency

49
Q

Forrest Criteria

A
  • 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
Q

Activation pancreatic enzymes

A

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
Q

Types dumping syndrome

A

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
Q

Complication Coeliac Disease

A
  • 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
Q

IBD Medications

A

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
Q

Why are Gastrin levels high in pernicious anaemia?

A

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
Q

Management of hepatorenal syndrome

A

Terlipressin - splanchnic vasocontrictor

Albumin as fluid resus

Bridge to transplant, not curative

RACP (17 decks)

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