Gastroenterology 🍽 Flashcards
what’s the tumour marker associated with HCC and germ cell cancers
AFP
what is coeliac disease
systemic autoimmune condition triggered by dietary gluten peptides
what is H.Pylori
a gram negative bacterium that releases urease that neutralises the pH of the stomach and damages the epithelium.
causes approx 90% of duodenal ulcers
signs and symptoms of coeliac disease
Chronic or intermittent diarrhoea
Failure to thrive or weight loss (in children)
Prolonged fatigue
Abdominal pain, cramping or distension
how is coeliac disease diagnosed
made by a combination of serology and endoscopic intestinal biopsy
what serology tests would you do when investigating coeliac disease
tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE
after positive serology tests for coeliac disease or high clinical suspicion with negative serology what do you do
gold standard diagnostic test is with OGD and duodenal/jejunal biopsy
clinical features associated with vitamin C deficiency
Spontaneous bleeding and bruising
Gingival swelling
Coiled hairs
Teeth loss
what do patients with vitamin b1 (thiamine) deficiency present with
wernickes encephalopathy
Wet beriberi (high output cardiac failure)
Dry beriberi (peripheral neuropathy)
personal or family history of autoimmune conditions
results in deranged transaminases + normal/slightly elevated ALP
hepatomegaly
fatigue
loss of appetite
presentation of autoimmune hepatitis
what type of antibodies are most likely to be raised in a patient with autoimmune hepatitis
most common type (TYPE 1) has raised anti-smooth muscle antibodies and anti-nuclear antibodies
what is ulcerative colitis
form of Inflammatory bowel disease
autoimmune condition
inflammation starts at rectum
sx of UC
Gastrointestinal symptoms: diarrhoea containing blood/mucus, tenesmus or urgency, pain in the left iliac fossa.
Systemic symptoms: weight loss, fever.
how is UC diagnosed
usually a biopsy and colonoscopy is done
pANCA positive
raised WBC/CRP
anaemia
calproectin raised
stool cultures
what will a colonoscopy show with UC
continuous inflammation with an erythematous mucosa, loss of haustral markings, and pseudopolyps.
what will a biopsy show with UC
loss of goblet cells
crypt abscess, and inflammatory cells
what are carcinoid tumours
rare, slow-growing tumours that develop in neuroendocrine system
some can secrete hormones like serotonin
usually occurs when patient has liver metastases
clinical features of carcinoid tumours that patients with liver metastases present with
Abdominal pain
Diarrhoea
Flushing
Wheeze
Pulmonary stenosis
mx of carcinoid tumours
octreotide - somatostatin analogues
clinical features of liver failure
hepatic encephalopathy
abnormal bleeding
jaundice
ascites
pathophysiology of hepatic encephalopathy
in liver failure ammonia accumulates in circulation
ammonia can cross blood-brain barrier where its detoxified by astrocytes which form glutamine through amidation of glutamate
excess glutamine disrupts the osmotic balance and the astrocytes begin to swell, giving rise to cerebral oedema.
four stages of hepatic encephalopathy
- Altered mood and behaviour, disturbance of sleep pattern and dyspraxia
- Drowsiness, confusion, slurring of speech and personality change
- Incoherency, restlessness, asterixis
- Coma
four stages of hepatic encephalopathy
- Altered mood and behaviour, disturbance of sleep pattern and dyspraxia
- Drowsiness, confusion, slurring of speech and personality change
- Incoherency, restlessness, asterixis
- Coma
what is Gilberts syndrome
autosomal recessive condition resulting in defective bilirubin conjugation
how do patients typically present with Gilberts syndrome
jaundice often precipitated by stress or an infection
what is Wilsons disease
autosomal recessive condition
accumulation of copper in liver causing oxidative stress and leading to destruction of hepatocytes
kayser-fleischer rings
how does Wilsons disease present in adults
CNS sx; Parkinsonism, dementia etc
kayser-fleischer rings
mood symptoms
cognition defects
how does Wilsons disease present in children
as liver disease symptoms such as
liver cirrhosis
hepatitis
acute liver failure
a low level of ? is diagnostic of Wilsons disease
caeruloplasmin
sx of acute pancreatitis
stabbing-like, epigastric pain which radiates to the back that is relieved by sitting forward or lying in the fetal position
Vomiting is highly associated with this.
Importantly, past medical history and social history is vital. A recent alcoholic binge or a history of gallstones are highly suggestive.
blood investigations for acute pancreatitis
An amylase 3x the upper limit of normal is extremely suggestive of acute pancreatitis
Lipase is a more sensitive and specific marker than amylase and should be used if available - also will be 3x higher than normal
What is Grey-Turners sign
Bruising along flanks and indicates retro peritoneal bleeding which is highly associated with acute pancreatitis
What is the Cullens sign
Indicates bruising around peri-umbilical area which is highly associated with acute pancreatitis
What imaging do you use to investigate acute pancreatitis
Not useful for diagnosis but useful for causes
USS - Gallstones
MRCP - obstructive pancreatitis
ERCP
CT - at a later stage for complications
How is the severity of pancreatitis measured
Using the Glasgow scale
Usually done at admission and 48 hours after
A score of 3 or more indicated transfer to ITU/HDU
Aim of mx of pancreatitis
To maintain electrolyte imbalances and compensate for third space losses seen
Mx of pancreatitis
Mainly supportive care
Fluid resuscitation
For alcohol withdrawal what should be prescribed to prevent wernickes encephalopathy
Pabrinex
For alcohol withdrawal what should be prescribed to patients experiencing delirium tremens
Oral lorazepam as first line
In an alcohol withdrawal seizure what should be prescribe
Rapid acting benzodiazepine - IV lorazepam
What is alpha 1 anti trypsin deficiency
Inherited condition that affects lungs, emphysema, and liver, cirrhosis and HCC.
Pathophysiology of alpha 1 antitrypsin deficiency
Without alpha 1 antitrypsin there is less defence against neutrophil elastase which destroys the alveoli
Process is exacerbated in smokers
Presentation of alpha 1 antitrypsin deficiency
COPD 30-40 years old
Neonatal jaundice
Deranged LFTs in adults with no other identified cause
Clinical features of ascending cholangitis
CHARCOTS TRIAD
RUQ pain
Fever
Jaundice
severely septic and unwell
mx of UC
aminosalicylates(mesalazine) rectal + oral
steroids oral then IV
IV ciclosporin if severe
smoking is a protective factor - only condition
how does oesophagitis present
retrosternal pain
small volume of blood §
mx of oesophagitis
PPI cover for 8 weeks if not resolving test for H.pylori - urea breath test
what is erosive gastritis
inflammation and erosion of gastric mucosa
most commonly due to NSAIDS, H pylori and alcohol
presentation of erosive gastritis
qepigastric pain, dyspepsia
early satiety
small volume bleeding
what is peptic ulcer disease
deeper erosions
ulcers either of gastric or duodenal mucosa
larger volume of bleeding
peptic ulcer disease how does it present if its a gastric ulcer
pain on eating
peptic ulcer disease how does it present if its a duodenal ulcer
pain relief on eating
cholelithiasis
gallstones
what is diverticulosis
characterised by multiple outpouchings of bowel wall (diverticular) most commonly in sigmoid colon
most accurate term for diverticular simply being present
when symptomatic - diverticular disease is the term
how does diverticular disease present
mostly symptomatic but can present with
constipation +/- bleeding
LLQ abdo pain
what is diverticulitis
inflammation of diverticula commonly affecting over 60s with low-fibre diet
where do non-congenital diverticula form
sigmoid colon
where do congenital diverticula form
caecum - meckers diverticulum
how does diverticulitis present
low grade fever
LLQ pain
polyuria
what sign would indicate an emergency in patient with diverticulitis
acute abdomen - severe pain, sepsis, perforation
investigations - diverticulitis
contrast CT
raised WBC/CRP
negative dipstick
positive FOBT
pts with diverticulitis what is the mx - ladder
no abx + pain relief
then
oral abx + pain relief
then if no relief
IV Abx or surgical resection
what is crohns disease
chronic relapsing IBD
seen anywhere from mouth to anus
most common in Caucasians
sx of crohns disease
RLQ pain +/- mass
chronic diarrhoea, no bleeding
associated diseases with crohns disease
erythema nodusum
pyoderma gangrenosum
anterior uveitis
mx of crohns disease
smoking cessation
prednisolone for inducing remission
infliximab and adalimumab - for severe
mx of crohns disease - maintaining remission
azathioprine or mercaptopurine - first line
associated diseases with UC
osteoarthritis
ankylosing spondylitis
primary sclerosing cholangitis
erythema nodosum
pyoderma gangrenosum
uveitis
symptoms of cholestasis
jaundice
pruritus
raised bilirubin + ALP
what should you be looking out for in a patient with UC and showing symptoms of cholestasis
primary scleroising cholangitis
what is toxic megacolon
life threatening complication of UC
a severe form of colitis
systemic upset
if no improvement after 48-72 hours of IV steroids - emergency surgery
how to confirm dx of toxic megacolon
abdominal x ray
colonic dilation >6cm
what is oesophagitis
inflammation of oesophagus
most commonly due to continuous GORD
what is GORD
gastro-oesophageal reflux disease
problem with the lower oesophageal sphincter allowing acid to travel up oesophagus
sx of oesophagitis
heartburn - retrosternal burning pain
nausea +/- vomitting
odynophagia - painful swallowing
mx of oesophagitis
conservative and pharmocological measures
lifestyles changes - weight loss, smoking cessation, reducing alcohol
pharmacological - PPIs one month
mx of gastritis
H.pylori eradication - triple treatment
omeprazole + amoxicillin + metronidazole/clarithromycin
risk factors for peptic ulcer disease
NSAIDs
H.pylori
smoking
delayed gastric emptying
severe stress
mx of peptic ulcer disease
PPI cover for 4-8 weeks
surgery if perforation
mx of variceal bleeding
DR ABCDE
terlipressin - inhibits secretion of vasodilative hormones
propanolol - reduced rebreeding
risk factors for developing cholelithiasis
female sex
over 40
obesity
family history
rapid weight loss
pregnancy
COCP
complications of cholelithiasis
biliary colic
how would biliary colic present
colicky RUQ pain
worse after eating
no fever
negative Murphys sign
how would acute cholecystitis present
RUQ pain
fever
Murphys sign positive
nausea and vomiting
ix ascending cholangitis
raised LFTs, CRP, WBC
US abdomen - initial imaging
CT - radiopaque stones and anatomical detail of biliary duct
MRCP - most accurate to determine disease
mx ascending cholangitis
resuscitation - IV fluids and abx SEPSIS 6
ERCP
what is sepsis 6
- blood cultures
- O2 if required
- FBC and lactate
- give IV Abx
- IV fluids
- monitor urine output
ix of cholecystitis
USS - thickening of gallbladder wall
raised WBC and CRP
Mx of cholecystitis
IV fluids + abx
analgesia
cholecystectomy - definitive
what is primary biliary cholangitis
autoimmune
scarring and inflammation of bile ducts -> liver cirrhosis
clinical features of primary biliary cholangitis
extreme fatigue
pruritus
hepatosplenomegaly
jaundice
ix of primary biliary cholangitis
positive anti-mitochondrial antibodies in >90% patients
raised gamma GT, Antinuclear antibodies
hypercholesterolaemia
mx of primary biliary cholagitis
ursodeoxycholic acid
liver transplant
dx of primary sclerosing cholangitis
deranged LFTs
positive anti-smooth muscle and antinuclear antibodies
and ANCA
multiple beaded biliary strictures seen on MRCP
mx of primary sclerosing cholangitis
ursodeoxycholic acid
liver transplant
strictures dilated by ERCP
ix for Wilsons disease
genetic analysis of ATP7B gene
free serum copper - low
urinary copper - high
treatment of Wilson disease
chelating agents - penicillamine and Trientine - for initial
maintenance - zinc salts
what is haemochromatosis
autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation
how is haemochromatosis caused
inheritance of mutation in HFE gene on both copies
bronze skin
fatigue
liver cirrhosis
hypogonadism - amenorrhea, ED
cardiac failure
diabetes
features of haemochromatosis
ix/dx tests for haemochromatosis
deranged LFTs
raised serum ferritin
raised transferrin saturation
decreased TIBC - total from binding capacity
where is vitamin B12 normally absorbed in the body
terminal ileum
what is autoimmune hepatitis
chronic inflammatory liver disorder that can lead to cirrhosis, liver failure and death
predominantly affects women
what histological features would you see in a patient with coeliac disease
villous atrophy
crypt hyperplasia
inflammatory infiltration
Mx of coeliac disease
gluten-free diet
what are some extra-intestinal manifestations of coeliac disease
anaemia - malabsorption of iron and folate
osteoporosis - malabsorption of vitamin D and calcium
dermatitis herpetiformis - strong association
mx of dermatitis herpetiformis
dapsone
complications of coeliac disease
anaemia
hyposplenism
osteoporosis
enteropathy-associated T-cell lymphoma
small bowel lymphoma
when to suspect enteropathy-associated T-cell lymphoma
non-adherence to a gluten-free diet increases the risk
presents with weight loss or recurrence of symptoms such as diarrhoea and Abdo pain
associations of coeliac disease
positive family history
HLA-DQ2 allele and other autoimmune diseases such as T1 diabetes and thyroid diseases
when investigating coeliac disease if a patient is IgA deficient as well as anti-TTG IgA what else should you measure
Anti-TTG IgG
2 types of oesophageal cancers
Adenocarcinoma and squamous cell carcinoma
Difference between oesophageal adenocarcinoma and squamous cell carcinoma
Adenocarcinoma is associated with obesity and GORD
It is the most common type in Western Europe and USA
Barret’s oesophagus is also commonly associated with Adenocarcinoma
Presentation of oesophageal cancer
Progressive dysphasia from solids to liquids
Weight loss
Hoarseness can develop
what pathogen is the most common cause of food poisoning
campylobacter usually found in undercooked meat
treated with azithromycin/erythromycin
where does the pathogen e.coli come from and how does it manifest
traveller’s diarrhoea
comes from undercooked meat
how is E.coli treated
ciprofloxacin
how does the pathogen giardia manifest and what abx is used to treat it
comes from contaminated water
presents with foul-smelling, fatty and floaty stools
treated with metronidazole
what abx causes c.diff infection
clindamycin
ciprofloxacin
cephalosporins
penicillins
causes of splenomegaly
CHIASMA
congestion
haematological
Infarction
Acquired infections
Storage diseases
Masses
Autoimmune
mx wilsons disease
avoid high copper containing foods
lifelong pencillamine
what examination finding is most suggestive of a diagnosis of appendicitis
tenderness over McBurney’s point
central colicky abdo pain which localised to McBurney’s point
Rovsing’s sign may be present
appendicitis
common causes of ascites
CCCC
Cirrhosis
Carcinomatosis
Cardiac failure
Cidney (kidney, nephrotic syndrome)
causes of liver failure
HALTED
Hepatitis
Autoimmune hepatitis
Leptospirosis
Toxins
Enzyme deficiency - alpha 1 antitrypsin
Drugs
signs of chronic liver disease
ABCDEFGHIJ
Asterixis
Bruising/blood pressure
Clubbing/colour change of nails
Dupuytren’s contracture
Erythema/encephalopathy
F hepatic Fetor
Gynaecomastia
Hepatosplenomegaly
Increase in size of parotids
Jaundice
1st line treatment of ascites
spironolactone
causes of high SAAG (ascites) >1.1g/dL
cirrhosis
heart failure
Budd Chiari syndrome
constrictive pancreatitis
hepatic failure
causes of low SAAG (ascites) 1.1g/dL<
cancer of the peritoneum
TB and other infections
pancreatitis
nephrotic syndrome
A 30-year-old female presents feeling unwell for the last 12 hours.
She has a background of Crohn’s disease, for which she takes infliximab.
Her observations are as follows:
Heart rate 90 beats per minute
Blood pressure 110/90 mmHg
Temperature 38.1 °C
Her blood tests return as follows:
Haemoglobin 120g/L (130-180)
White cells 5 x10^9/L (4-11)
CRP <5
What is the best next step in the management of this patient?
admit for further investigations
why?
- those on biologics e.g infliximab are at a higher risk of infection
