Gastroenterology Flashcards
A 7m old child presents with recurrent milky vomiting and low weight for age. On further questioning of the primigravida mother, she informs you that the child was born prematurely and she has noticed that the child has a chronic cough and hoarse cry. Examination is unremarkable.
What is the likely diagnosis?
What is the cause of this in infants? - what age does it usually resolve by?
What is the management if:
a) no effect on growth
b) effect on growth
GORD
Immaturity of the lower oesophageal sphincter - age 1y
- *Management:**
- No effect on growth:* conservative advice
- Effect on growth:* gaviscon mixed with feeds/ omeprazole!
What antibodies are present in coeliac disease?
What type of Ig are these antibodies?
When testing for these antibodies, what do you also need to test for to avoid a false negative result?
Anti-tissue transglutaminase (anti-TTG) & anti-endomysial (anti-EMA)
IgA antibodies
Total IgA levels - some people are IgA deficient so their total IgA will be low, even if they have coeliacs
What type of bilirubin is always abnormal in infants?
When ordering LFT’s, what should you order specificially to determine the cause of jaundice?
What would you expect the stools of a baby with biliary atresia (obstruction of bile flow) to look like?
Conjugated bilirubin!!
Split bilirubin
Pale, chalky white stools
For an (ex)alcoholic to be eligible for a liver transplant REFERRAL, they have to abstain from alcohol for how long?
Alcohol abstinence for 3 months before a referral for a transplant can be made.
A 2y old child presents with 4 month history of passage of foul smelling explosive stools 3-4/day, tiredness, pallor & poor weight gain. They have just developed an itchy rash on their abdomen.
What is the likely diagnosis? - name of the rash?
What investigations would you do to confirm this condition?
What is the gold standard investigation to confirm the diagnosis?
Coeliac’s disease - dermatitis herpetiformis
- *Antibodies:**
1) Anti-TTG plus total IgA
2) Anti-EMA (if anti-TTG were positive)
Duodenal biopsy (via endoscopy)
Having a H.pylori infection increases the risk of what condition?
How is H.pylori infection treated & how long for?
What is Barretts oesophagus & what causes it?
Barretts oesophagus increases the risk of what?
What is the a) prevention & b) treatment of Barretts oesophagus?
Stomach cancer (MALT)
Triple therapy for 7 days:
~ PPI (eg omeprazole)
~ 2x antibiotics
A premalignant change from squamous to columnar epithelium in the lower oesophagus - caused by persistent reflux (GORD)
Adenocarcinoma
Prevention: PPI’s (eg omeprazole)
Treatment: ablation of dysplastic cells
A 3-week-old boy presents to paediatric A&E with persistent vomiting. The mother reports that vomiting always occurs soon after feeds and often hits the kitchen walls.
On abdominal examination, there are no peritonitic features, but, a small, firm, olive shaped mass is palpable in the epigastric area.
What is the likely diagnosis?
What is the investigation of choice?
What is the definitive management?
Pyloric stenosis
Abdominal US
Management: surgery (laparoscopic pyloromyotomy)
Explain the routes of transmission of each type of viral hepatitis:
A - faecal-oral route
B - bodily fluids / vertical transmission (mother-baby)
C - bodily fluids
- *D -** bodily fluids
- *** can only survive in patients who also have a Hep B infection ****
E - faecal-oral route
List some signs of liver disease: (9)
- Jaundice
- Hepatomegaly
- Spider naevi
- Palmar erythema
- Gynaecomastia
- Bruising (due to abnormal clotting as the liver produces the clotting factors!)
- Ascites
- Flapping tremor
- Caput medusae
Refeeding syndrome can occur in people who havent eaten for how many days?
What happens to K, phosphate & Mg2+ if food is reintroduced too fast to someone with anorexia?
What are 3 common symptoms/ signs seen in refeeding syndrome?
5+ days
Levels fall resulting in depletion of all 3 electrolytes!
- Arrhythmia’s
- Confusion
- Death
What is the 1st line antibiotic used to treat a C. Difficile infection?
Oral vancomycin
List the 4 places in which varices (as a result of portal hypertension) form:
- Gasto-oesophageal junction
- Ileocaecal junction
- Rectum
- Anterior abdominal wall via the umbilical vein (caput medusae)
If thumbprinting is noted on an abdominal xray, what condition does this indicate?
What is this condition?
Ischaemic colitis
It occurs when there is an acute, but transient disruption to the blood supply of the large bowel → inflammation, ulceration & haemorrhage
Explain the physiology behind liver cirrhosis causing portal hypertension:
Chronic inflammation of the liver → liver cirrhosis
Liver cirrhosis is when the hepatocytes undergo fibrosis and there is a lot of scarring and nodules of scar tissue within the liver.
The fibrosis changes the liver’s normal structure → increased resistance to the blood trying to get into the liver
→ PORTAL HYPERTENSION
Alcoholics are often deficient in which vitamin?
Prolonged deficiency can result in which 2 conditions?
~ Which one is reversible, which one is irreversible?
Thiamine (vitamin B1)
- Wernicke’s encephalopathy - reversible
- Korsakoffs syndrome - irreversible
Which vitamin is commonly prescribed for alcoholics as part of their management plan?
What is the purpose of prescribing this vitamin?
Thiamine (as alcoholics neglect a normal diet, they are usually deficient)
Thiamine prevents Wernicke’s Encephalopathy
Ulcerative colitis is often associated with what biliary condition?
Which gender does this condition more commonly affect?
Primary sclerosing cholangitis
Males
What part of the GIT does coeliacs disease affect & what is the main histological finding seen?
List some clinical features seen in coeliac disease: (6)
What condition is closely associated with coeliac disease?
Small bowel (esp jejenum) - villous atrophy
- Failure to thrive (in children)
- Diarrhoea
- Weight loss
- Fatigue
- Dermatitis herpetiformis (itchy rash, usually on abdomen)
- Malabsorption
Type 1 diabetes (as well as other autoimmune conditions)
What are the 3 symptoms of Murphy’s Triad?
What condition do these symtpoms point towards?
List 3 complications of this condition:
What is the definitive management of this condition?
Abdominal pain, vomiting, fever
Appendicitis
1) Abscess formation
2) mass
3) peritonitis
Surgical removal of appendix
If someone has a positive HBsAg (Hep B surface antigen), what does this indicate regarding Hep B infection?
They currently have an active infection
List 3 screening tools used to identify an alcohol problem:
CAGE - score of 2+ indicates alcohol problem
AUDIT
FAST
The presence of crypt abscesses on colonoscopy would indicate which IBD?
Ulcerative colitis
What part of the GIT does coeliacs disease affect & what is the main histological finding seen?
List some clinical features seen in coeliac disease: (6)
What condition is closely associated with coeliac disease?
Small bowel (esp jejenum) - villous atrophy
- Failure to thrive (in children)
- Diarrhoea
- Weight loss
- Fatigue
- Dermatitis herpetiformis (itchy rash, usually on abdomen)
- Malabsorption
Type 1 diabetes (as well as other autoimmune conditions)
Name the 2 commonest methods used to prevent varicele bleeding in a patient with a known varicele:
~ medical
~ endoscopic
If these methods don’t work, what may be done instead?
Medical: Propanolol (reduces portal-hypertension as it’s a non-selective beta blocker)
Endoscopic: Elastic band ligation
- *TIPS** (transjugular intra-hepatic portosystemic shunt)
- a connection is made between the hepatic vein & portal vein and a stent is inserted. This relieves pressure in the portal system and varices.*
How is a peptic ulcer diagnosed?
~ what can be done at the same time to check for H.pylori infection?
Endoscopy
~ rapid urease test (CLO test)
Name the reversible neurological condition commonly seen in alcoholics:
~ What causes this condition?
List the triad of presenting features seen in this condition:
What is the treatment of it?
If left untreated, what can it progress into?
Wernicke’s encephalopathy
~ Thiamine (B1) deficiency
1) Ataxia (problems with coorindation, balance & speech)
2) Confusion
3) Opthalmoplegia/ nystagmus
Treatment: IV thiamine (usually given as pabrinex)
Korsakoff’s syndrome (irreversible brain damage)
What medication is given to patients experiencing symptoms of alcohol withdrawal?
How long is this drug prescribed for?
What other medication is prescribed to these patients as part of their withdrawal programme?
Chlordiazepoxide
5-7 days
IV Pabrinex (high dose vitamin B, including thiamine)
What common hallucination is associated with delirium tremens?
Visual hallucinations involving insects
A deficiency in which vitamin can result in Korsakoff’s syndrome?
Thiamine - B1
Name the test used to differentiate between IBD & IBS:
What criteria is used to assess severity of UC?
Name the 1st line medication used to induce
a) remission
b) maintenance of Crohn’s
Name the 1st line medication used to induce
a) remission
b) maintenance of UC
Faecal calprotectin
Truelove & Witts criteria
Crohn’s:
Remission: Steroids (eg, prednisolone)
Maintenance: Azathioprine (immunosuppressant drug)
UC:
Remission: Aminosalicylate (5ASA) - eg mesalazine
Maintenance: Aminosalicylate (5ASA) - eg mesalazine
Lynch syndrome (HNPCC) is caused by mutations in what?
What mode of inheritance is seen in Lynch syndrome?
What are the 3 commonest cancers associated with the condition?
DNA mismatch repair genes
Autosomal dominant
** Colon cancer ** - commonest in distal colon
• Endometrial
• Ovarian
What must be prescribed when performing an ascitic drain to reduce mortality risk?
IV albumin (aka, alba)
Diuretic-resistant ascites can be treated with what?
TIPS procedure (this reduces pressure within the portal vein)
Which antibody is commonly positive in UC, primary sclerosing cholangitis & autoimmune hepatitis?
p-ANCA
In terms of blood results, viral hepatitis and autoimmune hepatitis will cause a raised AST & ALT +/- bilirubin. What other blood results allow you to distinguish between a viral or autoimmune cause of hepatitis?
Autoimmune hepatitis will always ha a raised IgG but a viral cause won’t.
A 60-year-old lady presents to the GP with chronic diarrhoea. After further questioning, she has had ongoing daily bloating, and flatulence.
What is the most likely diagnosis?
Small intestinal bacterial overgrowth
What blood test is used to distinguish between IBD & IBS?
What tumour marker is commonly raised in hepatocellular carcinoma?
What test is used to screen for bowel cancer in people over 50?
Faecal calprotectin
Alpha-fetoprotein
FIT test
If a split bilirubin shows high levels of conjugated bilirubin, what underlying problem does this indicate?
What is biliary atresia? - what investigation would you do (other than split bilirubin)
What 3 features might biliary atresia present with?
What is the management of biliary atresia?
Biliary tree obstruction (bile is unable to be transported to the bowel)
Congenital condition in which there is absent / stenoised bile duct - prevents bile (and conjugated bilirubin) being transported to bowel
~ abdominal US
1) Jaundice
2) Pale, chalky white stools
3) Hepatosplenomegaly
Surgery - kasai portoenterostomy (small intestine is attached directly to the liver)
What is the cellular pathology that results in pernicious anaemia?
Autoimmune attack against intrinsic factor → B12 cannot be absorbed without intrinsic factor and patient becomes anaemic
List some of the most important complications of liver cirrhosis: (4)
Portal hypertension
Varices
Ascites
Hepatocellular carcinoma
Name the tumour marker of hepatocellular cancer that can be checked in a simple blood test:
Alpha-fetoprotein
What are the 4 commonest causes of liver cirrhosis?
- Alcohol related liver disease
- Non-alcoholic fatty liver disease
- Hepatitis B
- Hepatitis C
Explain the pathophysiology behind hepatic encephalopathy:
Name the commonest toxin involved in causing hepatic encephalopathy:
One function of the liver is detoxification. The liver usually converts toxins into harmless molecules that are then excreted. In liver disease, the liver isnt working as effectively as usual and so there is accumulation of harmful toxins in the blood which affect the brain.
Ammonia
What is Budd-Chiari syndrome?
What is the classic presenting triad of this syndrome?
A syndrome in which there is hepatic vein obstruction
1) severe abdominal pain
2) ascites
3) tender, hepatomegaly
How long must diarrhoea persist for to be referred to as chronic diarrhoea?
More than 4 weeks
In Alcohol Related Liver Disease there is a stepwise process of damage/disease progression.
Name the steps (1-3) and the physiology of liver damage in each stage. Which stages are (ir)reversible?
1. Alcohol related fatty liver
Alcohol causes build-up of fat in the liver. - reversible
2. Alcoholic hepatitis
Prolonged alcohol use (/binges) causes inflammation of the liver. - reversible with PERMANENT abstinence
3. Cirrhosis
Scar tissue formation in the liver. - irreversible, however abstinence will prevent further liver damage
What score is used to assess the severity of liver cirrhosis?
What score is used to guide whether a liver transplant may be needed in end stage liver disease (cirrhosis)?
Child-Pugh score
MELD score
What antibiotic is 1st line to treat the first episode (presentation) of a clostridium difficile infection?
If C. diff returns post treatment, what antibiotic is recommended to treat the recurring infection?
10 days of oral Vancomycin
Oral fidaxomicin
What is the initial & long term treatment of autoimmune hepatitis?
Which immunoglobulin will be raised in this presentation?
Which 2 auto-antibodies will commonly be raised?
- Initial:* high dose steroids (eg prednisolone)
- Long term:* immunosuppresants (eg azathioprine)
IgG
- *ANA** (anti-nuclear antibodies)
- *aSMA** (anti-smooth muscle antibodies)
Patients with liver disease should eat a diet that contains low/high amount of protein & sodium?
Protein: high
Sodium: low
Alcohol use increases the risk of developing which 3 cancers in particular?
Breast cancers
Mouth cancers
Throat cancers
What scoring system is used in a suspected upper GI bleed to establish the risk of an active bleed?
Explain the reason why urea rises in an upper GI bleed:
Glasgow-Blatchford Score
Blood from the bleed is broken down in the GI tract. One of the breakdown products is urea which is absorbed in the intestines!
List some features of UC: (CLOSEUP)
→ Continuous inflammation
→ Limited to colon & rectum
→ Only superficial mucosa affected
→ Smoking is protective
→ Excrete blood & mucus
→ Use aminosalicylates (1st line treatment)
→ Primary scleorising cholangitis
Roughly how long after stopping alcohol intake does delirium tremens present?
72 hours
What is the maximum recommended units of alcohol consumption per week, according to NICE?
14 units for both men and women
Name the condition that is a non-reversible memory disorder often seen in alcoholics.
Korsakoff’s syndrome
Name the 2 most commonly used screening tools to identify harmful alcohol use:
FAST (fast alcohol screening tool)
AUDIT (alcohol use disorders identification test)
~ patients fill this out themselves
What is haemolytic uraemic syndrome (HUS)?
What disease does HUS usually follow from?
What is the commonest organism that causes HUS & what investigation is used to identify it’s presence?
What are the characteristic triad of features seen with HUS?
→ What invstigations would be done for each feature to identify them?
HUS occurs when there is thrombosis in small blood vessels throughout the body
Gastroenteritis
E.coli - stool sample will identify it
1) Haemolytic anaemia → FBC, blood film
2) AKI → U&E’s to measure serum urea
3) Thrombocytopenia → FBC
What are the 2 simple investigations to look for H. Pylori infection?
What is the investigation that can be performed during an endoscopy?
- *1. Urea breath test**
- *2. Stool antigen test**
During endoscopy: Rapid urease test (biopsy of stomach mucosa is taken. Urea is added to it, and the pH is tested. If H.pylori are present, it will cause the pH to become alkaline as the bacteria produce ammonia)
What condition is associated with alcohol withdrawal?
~ How long after withdrawing alcohol does this usually present?
List some clinical features associated with this condition: (5)
What class of drugs are used to help prevent withdrawal symptoms? - Name the main drug used.
Delirium tremens
~ Presents 72h after stopping alcohol
- Confusion
- Hallucinations (visual & tactile (insects crawling under skin))
- Sweating
- Hypertension
- Seizures
Benzodiazepines (eg Chlordiazepoxide)
What symptoms/signs may someone with hepatic encephalopathy present with? (3)
What is the management of hepatic encephalopathy? (2)
- Confusion
- Reduced consciousness/ chronic sleepiness
- Coma
- *~ Laxatives /enema’s** (increased bowel movements help to remove ammonia (toxin) from the body)
- *~ Antibiotics, eg rifaximin** (decreases the num. of bacteria in the gut - the key source of ammonia production!) - bacteria produce ammonia when they breakdown protein!
What is the classic traid of clinical features seen in Wernicke’s encephalopathy?
Ataxia (lack of coordination of movements)
Ophthalmoplegia (paralysis of the eye muscles)
Encephalopathy/confusion (brain damage)
What is hepatitis?
Name the 5 main causes of hepatitis:
Inflammation of the liver
- Alcoholic hepatitis
- NAFLD
- Viral hepatitis (A-E)
- Autoimmune hepatitis
- Drug induced hepatitis (eg paracetemol overdose)
In alcohol withdrawal, what timeframe is delerium tremens most likely to develop within after their last alcoholic drink?
24 - 72h
List some features of Crohn’s: (NESTS) +2
→ NO blood/ mucus (uncommon)
→ Entire GI tract
→ Skip lesions on endoscopy
→ Terminal ileum most affected & Transmural thickness of inflammation
→ Smoking = risk factor
→ Weight loss
→ Structures/ fistulas
What condition presents with rapid onset confusion that is precipitated by alcohol withdrawal?
Delirium tremens
What is the treatment of a peptic ulcer?
What medications should these patients avoid in the future?
List 3 complications of peptic ulcers:
High dose PPIs (eg, omeprazole)
NSAIDs (eg ibuprofen, naproxen)
Complications:
• Bleeding from the ulcer
• Perforation of the ulcer → peritonitis
• Scarring & strictures → pyloric stenosis!
What are an Exomphalus and Gastroschisis? - whats the difference between them?
Exomphalus = herniation of abdominal contents at birth which ARE COVERED by the peritoneal membrane
Gastroschisis = herniation of abdominal contents at birth which AREN’T COVERED by the peritoneal membrane!
In what part of the GIT is vitamin B12 absorbed?
What molecule is needed for the absorption of B12?
Which cells secrete this molecule?
Ileum
Intrinsic factor
Parietal cells within the stomach
A 16y boy presents with central abdominal pain & haematuria for 1 week. He also complains of pain in both knees. Examination reveals a non-blanching purpuric rash on his legs & buttocks. Urine dip shows blood ++ & protein +, kidney function is abnormal.
What is the most likely diagnosis? - what is this?
List the 4 common presenting features of this condition:
What is the management of this condition?
What monitoring needs to be done? (2)
Henoch-Schonlein Purpura - A type of IgA vasculitis
- Purpura (rash on legs → buttocks)
- Joint pain (commonly knee’s & ankles)
- Abdominal pain
- Renal impairment
Management: supportive (analgesia, rest, hydration)
~ most usually resolve within 4-6 weeks.
Monitoring: needed whilst the disease is still active:
• urine dipstick (to monitor renal impairment)
• blood pressure (to monitor for hypertension)
Which type of peptic ulcer is most common?
The protective layer in the stomach can be broken down by 2 things resulting in an ulcer. What are these 2 things?
Duodenal ulcers
- Medications (NSAIDs/ steroids)
- H.Pylori infection
What is the 1st line diuretic used to treat ascites?
Why is this diuretic used 1st line?
If patients also have significant peripheral odema (in their ankles), what other diuretic is added to the regime?
Spironolactone
Spironolactone is an aldosterone antagonist.
A cirrhotic liver produces less albumin, which causes a reduction in the oncotic pressure within the blood vessels causing fluid to leak out of the blood vessels into the peritoneal cavity (= ascites). Less fluid in the vessels means that the kidneys arent as perfused as much so they activate the RAAS system which increases aldosterone, thus increasing fluid retention and worsening ascites!
Furosemide
Very high levels of bilirubin in infants can cause what serious condition?
What type of bilirubin causes this condition & why?
What is the treatment of raised unconjugated bilirubin levels?
If untreated, what can this result in?
Kernicterus
Unconjugated bilirubin - it’s fat soluble so can cross the BBB whereas conjugated bilirubin is water soluble so cannot cross the BBB
Phototherapy (babies are placed under blue light)
Encephaloptahy (seizures)/ cerebral palsy
Explain what you would expect to see in the LFT’s of someone with liver disease:
→ ALT
→ AST
→ GGT (gamma GT)
→ ALP
→ Albumin
→ Bilirubin
→ Prothombin time (for clotting)
- *ALT:** elevated
- *AST:** elevated
- *GGT:** elevated
- *ALP:** elevated in later disease
- *Albumin:** reduced
- *Bilirubin:** elevated in cirrhosis
- *Prothrombin time:** longer than normal (as liver is producing less clotting factors)
If someone is obese and has abnormal LFT’s, what conditon should you think of?
Non-alcoholic fatty liver disease
A 3y old boy presents with 5 days of vomiting and bloody diarrhoea. He is tolerating oral fluids and recently visited a petting zoo.
Examination showed no fever, HR 100, RR 25, no skin changes and mild general abdo discomfort.
What is the likely diagnosis? - likely causative organism?
What is a complication of this?
~ List the triad of features with this condition
What is the management of this boys condition?
Gastroenteritis - E.coli
Haemolytic uraemic syndrome:
• haemolytic anaemia (causing jaundice)
• AKI (causing high urea levels)
• thrombocytopenia
Conservative: encourage fluids
This barium enema is indicitive of what condition? - why?
- *Ulcerative colitis**
- ~ The whole colon is affected by an irregular mucosa with loss of normal haustral markings.*
Regarding Hepatitis B infection, what do the following biochemical markers mean/ indicate:
- HBsAg (Hep B surface antigen)
- HBeAg (Hep B E antigen)
- HBcAb (Hep B core antibodies)
- HBsAb (Hep B surface antibodies)
- HBV DNA (Hep B virus DNA)
1. HBsAg - indicates an active infection
2. HBeAg - marker of viral infection (so the acute phase of the disease when the virus is actively replicating)
~ the higher the HBeAg, the more infectious the person is ~
3. HBcAb - indicates a past or current infection
~ IgM version of HBcAb = active infection
~ IgG version of HBcAb = past infection (HBsAg will be negative)
4. HBsAb - indicates vaccination / past/ current infection
5. HBV DNA - viral load
List the common presenting symptoms of a peptic ulcer: (5)
How does eating affect the pain of a:
- gastric ulcer
- duodenal ulcer
- Pain/ discomfort in epigastric region
- N&V
- Dyspepsia (indigestion)
- Haematemesis (coffee ground vomit/ melaena)
- Iron deficiency anaemia (due to the ongoing bleeding)
- *1. Gastric ulcer -** worsens pain
- *2. Duodenal ulcer -** improves pain
