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4th year presentations > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

What are aphthous ulcers?

A

Shallow, painful ulcers with inflammatory haloes that heal without scarring
Often recur

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2
Q

List aetiology/risk factors for aphthous ulcers

A 
Inflammatory bowel disease
Iron deficiency
Infection
Trauma
Pemphigus/pemphigoid
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3
Q

Outline treatment for aphthous ulcers

A

Avoid oral trauma, acidic food/drink
Steroid lozenges
Tetracycline/antimicrobial mouthwash
Oral prednisolone if severe

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4
Q

What is leucoplakia?

A

Mucosal white patch that does not rub off and is not attributable to another disease process
Usually pre-malignant

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5
Q

List aetiology/risk factors of leucoplakia

A

EB virus causes oral hairy leucoplakia esp in HIV

Transient candidiasis/SLE/trauma

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6
Q

All leucoplakia should be referred for biopsy. True/False?

A

True, when in doubt

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7
Q

What is oral thrush?

A

White patches on buccal mucosa caused by candidiasis

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8
Q

List aetiology/risk factors for oral thrush

A 
Elderly
Immunosuppression
Diabetes
Antibiotics
Long-term steroid + inhaler use
Malignancy
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9
Q

Outline treatment for oral thrush

A

Nystatin suspension
Amphoterecin lozenges
Oral fluconazole

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10
Q

Describe the typical appearance of oral squamous cell carcinoma

A

Raised ulcer with firm edges

Found at floor of mouth or on lateral tongue

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11
Q

List aetiology/risk factors for oral squamous cell carcinoma

A

Smoking
Alcohol
Family history
Soft areas are high-risk sites

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12
Q

Outline treatment for oral squamous cell carcinoma

A

Radiotherapy

Surgery

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13
Q

What is GORD?

A

Reflux of stomach acid causes inflammation of oeseophagus

Can lead to basal zone hyperplasia and metaplasia

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14
Q

List aetiology/risk factors for GORD

A 
Incompetent lower oeseophageal sphincter
Hiatus hernia
Obesity
Increased acid secretion
Pregnancy
Achalasia surgery
Overeating/heavy fatty meals
Drugs (tricyclics, anticholinergics, nitrates)
H. pylori
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15
Q

List clinical features of GORD

A 
"Heartburn"
Worse lying down and after meals
Relieved by antacid
Belching, regurgitation of food
Waterbrash
Odynophagia
Nocturnal asthma/cough
Laryngitis
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16
Q

What investigations would you do for GORD?

A

Trial PPI for 2 weeks + antacid
Endoscopy if over 55 yo, symptoms longer than 4 weeks, dysphagia or weight loss
24h manometry +/- pH monitoring if normal endoscopy
Barium swallow if indicated e.g. hernia

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17
Q

Outline treatment of GORD

A

Lifestyle improvement (smoking, weight, raise bed, small regular meals, avoid hot/spicy food/drinks)
Antacid for symptom relief
PPI (omeprazole)
H2 antagonist may be tried (ranitidine)
Surgery (endoscopic fundoplication to repair LOS) if unresponsive

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18
Q

What is Barett’s oesophagus?

A

Metaplastic change from stratified squamous to columnar epithelium due to persistent acid abuse
Mucosa becomes unstable and susceptible to dysplasia

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19
Q

How would you investigate Barett’s oesophagus?

A

Endoscopy and biopsy

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20
Q

Outline treatment of Barett’s oesophagus

A

Avoid acidic food/drink
PPI
Argon
Mucosal resection/RF ablation

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21
Q

What is achalasia?

A

Failure of relaxation of lower oesophageal sphincter due to degeneration of myenteric plexus

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22
Q

List clinical features of achalasia

A

Intermittent dysphagia
Regurgitation
Substernal pain/cramping
Weight loss

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23
Q

What investigations would you do for achalasia?

A

CXR shows dilated oesophagus

Barium swallow shows bird-beak appearance

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24
Q

Outline treatment of achalasia

A

Endoscopic balloon dilation
Heller’s cardiomyotomy + PPI
Botox injection
Ca channel blocker

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25
Q

What are the most common types of oesophageal cancer?

A

Squamous or adenocarcinoma

50% middle oesophagus, 30% lower oesophagus, 20% upper oesophagus

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26
Q

List aetiology/risk factors for oesophageal cancer

A 
Low vitamin A and/or C
Smoking
Alcohol excess
Achalasia
Plummer-Vinson syndrome
Obesity
Barett's oesophagus
Reflux oesophagitis
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27
Q

List clinical features of oesophageal cancer

A 
Dysphagia
Weight loss
Retrosternal chest pain
Hoarse voice
Cough
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28
Q

What investigations would you do for oesophageal cancer?

A

Barium swallow
CXR
Endoscopy + biopsy
CT staging

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29
Q

Outline treatment of oesophageal cancer

A

Palliative care
Surgery if no invasion/wide mets/poor fitness
If localised T1/T2 disease, may try radical oesophagectomy

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30
Q

What is gastritis?

A

Inflammation and mucosal injury to stomach lining

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31
Q

List aetiology/risk factors for gastritis

A

Acute (chemicals, trauma, burns, infection)
H. pylori
Chronic (NSAID, alcohol, GORD, smoking)
Autoimmune (pernicious anaemia)

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32
Q

List clinical features of gastritis

A

Heartburn
Epigastric pain, esp on eating/hunger
Bloating, fullness
ALARM Symptoms (anaemia, loss of weight, anorexia, recent onset, malaena, swallowing difficulty)

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33
Q

What investigations would you do for gastritis?

A

Less than 55yo: test of H. pylori

Over 55yo or ALARM Symptoms: endoscopy

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34
Q

Outline treatment for gastritis

A

Stop dyspeptic drugs, lifestyle changes
Antacids
PPI
H2 antagonists

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35
Q

Duodenal ulcers are more common than gastric ulcers. True/False?

A

True

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36
Q

List aetiology/risk factors for peptic ulcer disease

A 
H. pylori
Drugs (NSAID, steroid)
Smoking
Reflux disease
Increased gastric acid secretion
Delayed gastric emptying
Blood group O
Stress
Neurosurgery (increased ICP, Cushing ulcers)
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37
Q

List clinical features of peptic ulcer disease

A

Epigastric pain, esp meal-related, relieved by drinking/eating cold stuff
May have weight loss
Epigastric tenderness
Feeling of fullness

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38
Q

What investigations would you do for peptic ulcer disease?

A

H. pylori stool antigen/C13 breath test/IgG serology
Stop PPI 2 weeks before endoscopy
Ulcer biopsy for histology and cytology

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39
Q

Outline treatment for peptic ulcer disease

A

H. pylori eradication (amoxicillin/metronidazole, omeprazole, clarithromycin)
Bismuth chealate alternative to antibiotics
Antacids
PPI
H2 antagonists

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40
Q

What is gastroparesis?

A

Delayed gastric emptying due to autonomic neuropathy

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41
Q

List clinical features of gastroparesis

A

Fullness, bloating
Nausea, vomiting
Weight loss
Abdo pain

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42
Q

What investigation would you do for gastroparesis?

A

Gastric scintigraphy with 99-technitium meal

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43
Q

Outline treatment for gastroparesis

A 
Anti-emetic
Tetracycline
Erythromycin has anti-emetic properties
Liquid diet
Nutritional support, NG tube
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44
Q

Which type of gastric cancer is most common?

A

Adenocarcinoma occuring at gastro-oesophageal junction

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45
Q

List aetiology/risk factors for gastric adenocarcinoma

A 
H. pylori causing gastritis causing metaplasia causing dysplasia causing carcinoma !
Japanese people
Pernicious anaemia
Blood group A
Atrophic gastritis
Smoking
Poor diet
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46
Q

List clinical features of gastric cancer

A 
Epigastric pain
Dyspepsia
Weight loss
Haematemesis
Dysphagia
Epigastric mass
Anaemia
Hepatomegaly, jaundice
Enlarged left supraclavicular node (Virchow's node)
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47
Q

What investigations would you do for gastric cancer?

A

Gastroscopy and multiple biopsies

USS/CT staging

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48
Q

Outline treatment of gastric cancer

A

If distal 2/3, partial gastrectomy
If proximal 1/3, total gastrectomy
Combination chemotherapy

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49
Q

What type of blood would make you think of an upper GI bleed?

A

Haematemesis with dark coffee ground substance

Malaena with black tarry stools

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50
Q

List aetiology/risk factors for upper GI bleeding

A 
Peptic ulcers (45%)
Gastritis (15%)
Oesophageal varices
Mallory-Weiss tear
Reflux oesophagitis
Malignancy
Drugs (NSAID, steroid, thrombolytic, anticoagulants)
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51
Q

List clinical features of upper GI bleeding

A 
Peripheral shutdown (cool, clammy, prolonged cap refill)
Reduced Glasgow Coma Score
Haematemesis
Malaenia
Tachycardia, hypotension
Weight loss
Dysphagia
Signs of chronic liver disease
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52
Q

What investigations would you do for upper GI bleeding?

A

Organise CXR, ECG, ABG’s
Crossmatch blood
Urgent endoscopy
Severity 100 rule (systolic less than 100, pulse over 100, Hb less than 100)
Rockall scoring to predict rebleed and mortality

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53
Q

Outline basic treatment of upper GI bleeding

A

ABCDE approach
Large bore IV cannulae, take blood for crossmatch, FBC, U+E, LFT, clotting
Transfuse O- blood
Catheterise and monitor urine output

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54
Q

Outline treatment for peptic ulcer upper GI bleed

A

IV PPI after endoscopy
Oral fluids if no haemodynamic compromise
Adrenaline injection
Heater probe coagulation/surgical clipping

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55
Q

Outline treatment for oesophageal varices

A

Terlipressin
Early OGD + EVL (Sengstaken-Blakemore tube)
Propranolol and banding if bleed stops
TIPSS if rebleeds

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56
Q

What is oesophageal varices?

A

Portal hypertension causes dilated collateral veins usually in lower oesophagus

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57
Q

List aetiology/risk factors for oesophageal varices

A

Pre-hepatic (portal vein thrombosis, splenic vein thrombosis)
Intra-hepatic (cirrhosis, schistosomiasis, sarcoidosis)
Post-hepatic (Budd-Chiari, right heart failure, pericarditis)
Alcohol abuse

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58
Q

What is coeliac disease?

A

T-cell mediated autoimmunity to gluten, causing malabsorption and villus atrophy

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59
Q

List aetiology/risk factors for coeliac disease

A

HLA DQ2/DQ8
Autoimmunity
Dermatitis herpetiformis

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60
Q

List clinical features of coeliac disease

A 
Steatorrhoea
Diarrhoea
Abdo pain
Bloating
Nausea, vomiting
Aphthous ulcers
Angular stomatitis
Weight loss
Fatigue
Weakness
Mood disorder
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61
Q

What investigations would you do for coeliac disease?

A

Antibodies: alpha-gliadin, ttG, endomysial
Duodenal biopsy shows intraepithelial lymphocytes, subtotal villus atrophy, crypt hyperplasia
DEXA scan to assess osteoporosis

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62
Q

Outline treatment of coeliac disease

A

Gluten-free diet

Oral dapsone

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63
Q

List aetiology/risk factors for intestinal failure

A 
Coeliac disease
Chronic pancreatitis
Inflammatory bowel disease
Extensive surgery (short-gut syndrome)
Reduced bile secretion
Whipple's disease
Drugs (metformin)
Bacterial overgrowth
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64
Q

List clinical features of intestinal failure

A 
Diarrhoea
Weight loss
Lethargy
Steatorrhoea
Anaemia
Bleeding
Oedema
Neuropathy
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65
Q

What investigations would you do for intestinal failure?

A 
FBC, U+E, folate/B12
Coeliac screen
Albumin
Stool microscopy
Barium follow-through
Breath hydrogen (bacteria)
Endoscopy + biopsy
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66
Q

Outline treatment of intestinal failure

A

Acute: parenteral nutrition via central/peripheral vein
Oral refeeding with supplements
Enteral feeding (NG, NJ, PEG)
Total parenteral nutrition

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67
Q

List aetiology/risk factors of small bowel obstruction

A

Luminal (gallstone ileus, food, bezoar, tumour)
Occlusion (atherosclerosis, strangulation, hernia, adhesion)
IBD
Intussuception
Constipation
Paralytic ileus

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68
Q

List clinical features of small bowel obstruction

A 
Abdo colicky pain
Distention
Tenderness
Tinkly bowel sounds
Faeculent vomiting
Constipation
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69
Q

What investigations would you do for small bowel obstruction?

A

Abdo XR shows valvulae conniventes - central gas shadows that completely cross lumen
FBC, U+E, ABG’s
Enema XR
PR exam

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70
Q

Outline treatment of small bowel obstruction

A

Analgesia, fluids, nutritional replacement
Drip + suck NG tube
Catheterisation
Surgery if perforation/strangulation/ischaemia

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71
Q

What is gastric volvulus?

A

Twisting of gastro-oesophageal junction

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72
Q

List aetiology/risk factors for gastric volvulus

A

Paraoesophageal hernia
Congenital anomaly
Bowel malformation
Pyloric stenosis

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73
Q

List clinical features of gastric volvulus

A 
Vomiting, wretching
Pain
Failure to pass NG tube
Saliva regurgitation
Dysphagia
Noisy gastric peristalsis relieved by lying down
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74
Q

What investigation would you do for gastric volvulus?

A

Erect AXR shows gastric dilation and fluid level

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75
Q

Outline treatment of gastric volvulus

A

Resuscitation

Laparoscopic surgery

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76
Q

What is Meckel’s diverticulum?

A

Remnant of ompalomesenteric duct, 60cm from ileeocaecal valve, containing gastric and pancreatic tissue

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77
Q

List clinical features of Meckel’s diverticulum

A

Asymptomatc
Painless malaena
Abdo pain

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78
Q

Outline treatment of Meckel’s diverticulum

A

Laparoscopic surgical resection if bothersome

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79
Q

What is Crohn’s disease?

A

Chronic inflammatory disease characterised by transmural granulomatous inflammation affecting any part of the GI tract

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80
Q

List aetiology/risk factors for Crohn’s disease

A

Genetics (NOD2, CARDI5)
Smoking
Infective gut commensals
Typically young children to 40 year olds

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81
Q

List clinical features of Crohn’s disease

A 
Diarrhoea
Abdo pain
Weight loss
Fever
Malaise
Skin tags
Painful ulcers
Abscesses
Abdo mass
Perianal abscess, fistulae
Extra-intestinal (clubbing, erythema nodosum, pyoderma gangrenosum, conjunctivitis, episcleritis, arthritis)
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82
Q

What investigations would you do for Crohn’s disease

A

Bloods
Stool microscopy and culture to exclude infection
Sigmoidoscopy, rectal biopsy/colonoscopy/capsule endoscopy
MRI for pelvic disease/fistulae

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83
Q

Outline treatment for Crohn’s disease

A

Oral prednisolone short-term
Admit if severe attack for IV steroid
Immunosuppression (azathioprine, methotrexate)
Anti-TNF (infliximab)
Surger (resection, stricturoplasty, fistula repair)
Treat perianal disease

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84
Q

What is ulcerative colitis?

A

Relapsing and remitting inflammatory bowel disease involving rectum and extending proximally (no skip lesions)

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85
Q

List aetiology/risk factors for ulcerative colitis

A

E. coli adhesin-expressing strains
Genetics
Typically 20-40 year ols

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86
Q

List clinical features of ulcerative colitis

A 
Gradual diarrhoea, bloody/mucousy
Crampy abo pain
Increased bowel frequency
Urgency
Tenesmus
Incontinence
Night-rising
Lower abdo pain
Extra-intestinal (clubbing, erythema  nodosum, apthous ulcers, episcleritis)
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87
Q

Define severe ulcerative colitis

A 
More than 6 bloody stools a day + 1 of
Fever
Tachycardia
Anaemia
Raised ESR
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88
Q

What investigations would you do for ulcerative colitis?

A

Bloods
Stool microscopy and culture, C. diff toxin
AXR mucosal thickening, toxic megacolon query
Sigmoidoscopy/colonoscopy
Biopsy shows crypt abscesses, inflammatory infiltrate

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89
Q

Outline treatment of ulcerative colitis

A

Mild: prednisolone + mesalazine, foam enema
Mod: prednisolone + 5-ASA + steroid enema
Sev: IV hydrocortisone, rectal steroid, stepdown to Mod treatment
Immunosuppresion
Anti-TNF
Surgery (proctocolectomy with end ileostomy, ileorectal anastomosis/pouch)

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90
Q

What is diverticular disease?

A

Outpouching of the gut wall, usually due to high luminal pressure, usually at sigmoid colon
Diverticulitis: inflamed diverticula

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91
Q

What is the main cause of diverticular disease?

A

Low-fibre diet

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92
Q

List clinical features of diverticular disease

A 
Abdo pain
Altered bowel habit
Nausea
PR bleed
Flatulence
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93
Q

What investigations would you do for diverticular disease?

A

PR exam
Sigmoidoscopy
Barium enema
CT scan

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94
Q

Outline treatment of diverticular disease

A 
Increase fibre intake
Percutaneous drainage
Hartmann procedure (remove sigmoid colon, attach colostomy)
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95
Q

Outline treatment for diverticulitis

A 
Co-amoxiclav + metronidazole
Analgesia
Nil by mouth, IV fluids
Drain abscesses
Hartmann procedure
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96
Q

What is irritable bowel syndrome?

A

Functional GI disorder with abdo symptoms with no identifiable cause

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97
Q

List aetiology/risk factors for irritable bowel syndrome`

A 
Visceral hypersensitivity
Poor diet
Infection
Codeine
Psychiatric disease
98
Q

List clinical features of irritable bowel syndrome

A 
Bloating
Abdo pain
Increased frequency
Mucus stool
Tenesmus
Worse after eating
99
Q

What red flags would point away from a diagnosis of irritable bowel syndrome?

A 
Age over 50
Recent onset
Night waking
Weight loss
Anaemia
Bloody diarrhoea
100
Q

What is the Rome III criteria for irritable bowel syndrome?

A

Abdo pain for 3 days per month for 3 months + 2 of
Improvement with defecation
Change in frequency
Chang in appearance of stool

101
Q

Outline treatment of irritable bowel syndrome

A 
Improve diet
Fewer meals
Symptom relief
Antispasmodic (mebeverine, hyoscine)
Antidiarrhoeal (loperamide)
Antidepressant
102
Q

What is pseuomembranous colitis?

A

Colitis caused by C. diff infection (gram + superbug)

103
Q

List aetiology/risk factors for pseudomembranous colitis

A

Elderly
Hospitalisation
Broad-spec antibiotics

104
Q

List clinical features of pseudomembranous colitis

A

Colicky pain
Fever
Diarrhoea +/- blood
Multiorgan failure

105
Q

What investigations would you do for pseudomembranous colitis?

A

C. diff stool toxin - culture, ELISA, PCR

Colonoscopy shows yellow adherent plaques on inflamed mucosa

106
Q

Outline treatment of pseudomembranous colitis

A

Stop causative antibiotic
Metronidazole oral if moderate
Vancomycin oral if severe
Urgent colectomy if toxic megacolon

107
Q

What is the Rome criteria for constipation?

A

Constipation + presence of 2 symptoms during bowel movements (straining, lumpy stools, tenesmus, sensation of anorectall obstruction, manual maneuvres)
Less than 3 movements a week

108
Q

List aetiology/risk factors for constipation

A 
Poor diet
Low exercise
Inappropriate environment 
Anal disease
Intestinal obstruction
Metabolic (hypercalcaemia, hypothyroid, hypokalaemia)
Drugs (opiates, anticholinergics, iron)
Neuromuscular disorder
Chronic laxative use
Psych disturbance
109
Q

What investigations would you do for constipation?

A 
PR exam
Stool exam
Refer if weight loss/blood/anaemia
Sigmoidoscopy
Barium enema
110
Q

Outline treatment for constipation

A 
Lifestyle advice
Stool softeners
Senna
Bulking agents
Lactulose
Stimulant/osmotic laxatives
111
Q

What is jaundice?

A

Yellow pigmentation of skin, sclerae and mucosa due to increased plasma bilirubin

112
Q

List prehepatic causes of jaundice

A

Excess haemolysis
Ineffective erythropoiesis
Kernicterus (infants deposit Br in basal ganglia)

113
Q

List intrahepatic causes of jaundice

A 
Hepatitis
Cirrhosis
Pregnancy
Haemochromatosis
Alpha-1-antitrypsin deficiency
Budd-Chiari syndrome
Wilson's disease
114
Q

List post-hepatic causes of jaundice

A 
Gallstones
Primary biliary cirrhosis
Primary sclerosing cholangitis
Pancreatic cancer
Biliary stricture
115
Q

List drugs that can cause jaundice

A 
Antimalarials
Paracetamol overdose
TB drugs
Sodium valproate
Flucloxacillin
116
Q

List clinical features of jaundice

A 
Yellow eyes/skin
Hepatosplenomegaly
Ascites
Chronic liver disease signs
Pale stools, dark urine (obstructive jaundice)
117
Q

What investigations would you do for jaundice?

A 
LFT's
FBC, U+E
Viral markers
Urinary bilirubin
Clotting
US scan to assess bile ducts
MRCP/ERCP if gallstones
118
Q

Acute liver failure only occurs in a previously healthy liver. True/False?

A

True

119
Q

What is fulminant hepatic failure?

A

Severe liver impairment in less than 2 weeks

120
Q

What is hyperacute liver failure?

A

Encephalopathy within 7 days of onset of jaundice

121
Q

List aetiology/risk factors for liver failure

A

Infection (hepatitis, yellow fever, CMV, EBV)
Drugs (paracetamol OD, isoniazinde, azathioprine, methotrexate, oestrogen)
Budd-Chiari syndrome
Wison’s disease
Alcohol excess
Malignancy
Fatty liver

122
Q

List clinical features of liver failure

A 
Jaundice
Encephalopathy
Pear drops breath
Asterixis
Lethargy
Itch, pain
Hypoglycaemia
Signs of chronic liver disease
123
Q

What investigations would you do for liver failure?

A 
Deranged LFT's
CMV, EBV serology
Serum caeruloplasmin, ferritin
US scan liver size, Doppler flow study
Liver biopsy
124
Q

Outline management of liver failure

A

Acute: IV fluids, ABCDE, nutrition, glucose
Vitamin K + blood transfusion for bleeding
Ceftriaxone for infection
Fluid restrict + salt restriction if ascites
Lactulose if encephalopathy
Treat alcohol withdrawal and complications

125
Q

Outline treatment of hepatorenal syndrome

A 
IV albumin
Terlipression
Haemodialysis
TIPSS drainage
Liver transplant
126
Q

What is cirrhosis?

A

Irreversible stage of liver damage, with loss of hepatic architecture due to fibrosis and necrosis

127
Q

List aetiology/risk factors for cirrhosis

A 
Chronic alcohol abuse
Hepatitis B, C
NAFLD
Autoimmunity (PBC, PSC)
Haemochromatosis
Wilson's disease
Alpha-1-antritrypsin deficiency
Budd-Chiari syndrome
Drugs (amiodarone, methyldopa, methotrexate)
128
Q

List clinical features of cirrhosis

A

Chronic liver disease signs (spider naevi, jaundice, leuconychia, caput medusa, Dupuytren’s, xantheloma, telangiectasia, palmar erythema, clubbing)
Hepatomegaly
Ascites
Gynaecomastia
Asterixis
Complications (encephalopathy, sepsis, portal hypertension)

129
Q

What investigations would you do for cirrhosis?

A 
Deranged LFT's
PT time prolonged
Reduced albumin
Autoantibodies (ANA, AMA, SMA)
Alpha feto protein
Liver US scan for size, Doppler flow
Ascitic tap for microscopy
Liver biopsy
Child-Pugh scoring for cirrhosis and variceal bleed risk
130
Q

Outline treatment of cirrhosis

A

Support (nutrition, alcohol abstinence)
Ascites: fluid restrict, low-salt, spironolactone, paracentesis/TIPS
Lactulose prevents encephalopathy
Cholestyramine for itch
Interferon-alpha slows development into HCC from hepatitis C
Penicillamine for Wilson’s disease
Liver transplant

131
Q

How does non-alcoholic fatty liver disease (NAFLD) arise?

A

Steatosis (fat deposition) causes oxidative stress, leading to fibrosis and cirrhosis

132
Q

List aetiology/risk factors for NAFLD

A 
Obesity
Hypertension
Total parenteral nutrition
Type 2 diabetes
Hyperlipidaemia
133
Q

List clinical features of NAFLD

A 
Asymptomatic
Fatigue
Malaise
Hepatosplenomegaly
Signs of chronic liver disease in later stages
134
Q

What investigations would you do for NAFLD?

A

US scan shows fatty liver
Liver biopsy
Deranged LFT’s (AST, ALT)
Albumin assesses liver function

135
Q

Outline treatment for NAFLD

A

Lifestyle advice
Weight loss
Liver transplant

136
Q

What is primary biliary cirrhosis?

A

Interlobular bile ducts destroyed by chronic granulomatous inflammation, causing cholestasis, cirrhosis and portal hypertension

137
Q

List aetiology/risk factors for primary biliary cirrhosis

A

Autoimmunity

Females

138
Q

List clinical features of primary biliary cirrhosis

A 
Asymptomatic
Itch without rash
Lethargy
Jaundice
Xanthelasma
Osteoporosis
Hepatosplenomegaly
Signs of chronic liver disease
Malabsorption causes osteomalacia, coagulopathy
139
Q

What investigations would you do for primary biliary cirrhosis?

A

Cholestatic LFT’s
Decreased albumin
Antimitochondrial antibody, IgM
Liver biopsy

140
Q

Outline treatment of primary biliary cirrhosis

A

Ursodeoxycholic acid, cholestyramine
Azathioprine, prednisolone
Treat complications
Liver transplant

141
Q

What is hereditary haemochromatosis?

A

Autosomal recessive mutation in HFE gene on c6 causes excess iron absorption and increased iron deposition in organs

142
Q

List clinical features of hereditary haemochromatosis

A 
Tiredness
Arthralgia
Impotence
Slate-grey skin
Signs of chronic liver disease
Pituitary dysfunction (hypogonadism)
"bronze diabetic" due to deposit in pancrease
143
Q

What investigations would you do for hereditary haemochromatosis?

A 
Serum ferritin, iron, TIBC
HFE phenotype
LFT's
Glucose
Chrondocalcinosis on XR
Liver biopsy Perl's stain
IgG
144
Q

Outline treatment of hereditary haemochromatosis

A

Venesection 1 unit/week until iron deficient

Low iron diet

145
Q

What is Wilson’s disease?

A

Autosomal recessive disorder of gene encoding caeruloplasmin, causing excess copper in blood which is toxic to liver and CNS

146
Q

List clinical features of Wilson’s disease

A 
Signs of liver disease early in life
CNS/psych issues
Dystonia
Dysarthria
Tremor
Clumsiness
Parkinsonism
Kayser Fleischer rings in iris
Blue nails
Grey skin
Hypermobility
147
Q

What investigations would you do for Wilson’s disease?

A

24h urinary copper
Serum caeruloplasmin
Liver biopsy
MRI CNS

148
Q

Outline treatment for Wilson’s disease

A

Avoid copper foods (chocolate, nuts, mushrooms, shellfish)
Lifelong penicillamine/trientine dihydrochloride
Liver transplant

149
Q

What is Budd-Chiari syndrome?

A

Hepatic vein obstruction due to thrombosis or malignancy leads to ischaemia and hepatocyte damage

150
Q

List aetiology/risk factors for Budd-Chiari syndrome

A

Hypercoaguability (OCP, pregnancy, malignancy, polycythaemia)
Liver/adrenal/renal tumour

151
Q

List clinical features of Budd-Chiari syndrome

A 
Liver failure
Insidious cirrhosis
Abdo pain
Hepatomegaly
Ascites
Portal hypertension
152
Q

What investigations would you do for Budd-Chiari syndrome?

A

US scan, hepatic vein Doppler
Angioplasty
TIPS
Ascitic tap

153
Q

Outline treatment of Budd-Chiari syndrome

A

Thrombolyse
Lifelong anticoagulation
Treat ascites
Liver transplant

154
Q

What is autoimmune hepatitis and its different types?

A

Inflammatory liver disease characterised by suppressor T cells and antibodies against hepatocytes
Type 1: adults, kids, ASMA/ANA antivodies
Type 2: girls, women, LKM1 antibody
Type 3: liver soluble Ag

155
Q

List clinical features of autoimmune hepatitis

A 
Fever
Malaise
Urticarial rash
Polyarthritis
Pleurisy
Reduced appetitie
Amenorrhoea
Young woman on pill
156
Q

What investigations would you do for autoimmune hepatitis?

A

Deranged LFT’s
AMA, ASMA, ANA, anti-KLM, IgG
Liver biopsy shows piecemeal necrosis, portal infiltrate

157
Q

Outline treatment of autoimmune hepatitis

A

Immunosuppression (azathioprine, prednisolone)
Ursodeoxycholic acid
Liver transplant

158
Q

Liver cancer is usually secondary (metastatic) from somewhere else. True/False?

A

True

Usually breast/bone/bronchus/GI tract

159
Q

List aetiology/risk factors for liver cancer

A 
Cirrhosis
Hepatitis
Alcohol excess
Drugs
Autoimmunity
Genetics
160
Q

List clinical features of liver cancer

A 
Fever
Malaise
Anorexia, weight loss
RUQ pain
Hepatomegaly
Jaundice
Signs of chronic liver disease
Abdo mass
Liver bruit
161
Q

What investigations would you do for liver cancer?

A

Bloods: FBC, clotting, LFT’s
Alpha-feto protein (HCC)
US scan or CT-guided liver biopsy
ERCP

162
Q

Outline treatment of liver cancer

A

Resection
Chemotherapy
Mostly palliative
Liver transplant

163
Q

Which cancer accounts for 90% of primary liver cancer?

A

Hepatocellular carcinoma

164
Q

List aetiology/risk factors for hepatocellular carcinoma

A 
China/sub-saharan Africa
Haemochromatosis
Viral hepatitis
Cirrhosis
Parasitic infections
Anabolic steroid use
165
Q

What is the commonest benign tumour of the liver?

A

Hemangioma, usually in non-cirrhotic patients

166
Q

How does hemangioma appear on US scan?

A

Well-demarcated echogenic spot

167
Q

What is alpha-1-antitrypsin deficiency?

A

Autosomal recessive disorder on c14 causing deficiency of alpha-1-antitrypsin, resulting in inflammation, emphysema and chronic liver disease

168
Q

List clinical features of alpha-1-antitrypsin deficiency

A

Breathlessness
Cholestatic jaundice
Signs of chronic liver disease

169
Q

What investigations would you do for alpha-1-antitrypsin deficiency?

A

Serum alpha-1-antitrypsin
Liver biopsy PAS +ve
Prenatal testing

170
Q

Outline treatment for alpha-1-antitrypsin deficiency

A

Human plasma alpha-1-antitrypsin if PEV less than 80% and patient not smoking
Liver transplant if decompensated cirrhosis

171
Q

Where are AST and ALT found and when are they released?

A

ALT: liver, kidney, muscle
AST: liver, heart, RBC
Released after hepatocellular injury

172
Q

What are the “true” liver function tests/markers of hepatic function?

A

Albumin
PT time
Bilirubin

173
Q

What are gallstones?

A 
Abnormal composition of bile causes hardening and stone formation
Pigment stones (haemolysis), cholesterol stones or mixed stones
174
Q

List aetiology/risk factors for gallstones

A

“Fat forty-year-old females with foetus”
Drugs
Cirrhosis
Diabetes

175
Q

List clinical features of gallstones

A 
Biliary colic (gallstone in CBD/cystic duct; colicky RUQ pain +/- back/shoulder radiation, tenderness, nausea)
Acute cholecystitis (infected gall bladder; continuous RUQ pain, shoulder pain, peritonism, fever, nausea/vomit, Murphy sign)
176
Q

What investigations would you do for gallstones?

A

Bloods: FBC (raised WCC), U+E, LFT’s
US scan thick-walled gallbladder, dilated CBD
MRCP/ERCP

177
Q

Outline treatment of gallstones

A

Analgesia for colic, nil-by-mouth
IV antibiotics if cholecystitis - cefuroxime
Cholecystectomy (laparoscopic if no perforation)

178
Q

What is ascending cholangitis?

A

Infection of bile duct/biliary tree due to gallstone in common bile duct

179
Q

List clinical features of ascending cholangitis

A

Cholestatic jaundice
Pale stools, dark urine
Itch
Charcot’s triad (fever, RUQ pain, jaundice)

180
Q

Outline treatment of ascending cholangitis

A

IV antibiotics

ERCP + sphincterotomy before cholecystectomy

181
Q

What is primary sclerosing cholangitis?

A

Non-malignant, non-bacterial inflammation and fibrosis of intra and extra -hepatic bile ducts

182
Q

List aetiology/risk factors for primary sclerosing cholangitis

A

Men
Ulcerative colitis
HLA-A1 DR3 B8
HIV

183
Q

List clinical features of primary sclerosing cholangitis

A 
Jaundice
Fatigue
Fever
Abdo pain
Hepatomegaly
184
Q

What investigations would you do for primary sclerosing cholangitis?

A

LFT’s (ALP) cholestatic pattern
ANA, SMA, pANCA antibodies
ERCP

185
Q

Outline treatment of primary sclerosing cholangitis

A

Cholestyramine for itch
Ursodeoxycholic acid to improve cholestasis
Immunosuppression (prednisolone, methotrexate)
Endoscopic stent
Liver transplant

186
Q

What is the most common biliary tree malignancy?

A

Cholangiocarcinoma

May be intra or extra hepatic

187
Q

List aetiology/risk factors for cholangiocarcinoma

A 
Flukes in the East
Primary sclerosing cholangitis
CA-199
Congenital cysts
Biliary surgery
188
Q

List liver, CNS, GI, Haem and Cardio manifestations of alcoholism

A

Liver: cirrhosis, hepatitis
CNS: poor cognition, neuropathy, cortical atrophy, fits, falls, haemorrhage, wide gait, confabulations, Korsasakoff-Wernicke syndrome
GI: obesity, diarrhoea, peptic ulcers, gastric erosions, varices, MW tear, pancreatitis, oral lesions
Haem: raised MCV, anaemia, haemolysis
Cardio: arrhythmias, hypertension, cardiomyopathy

189
Q

List clinical features of alcohol withdrawal

A 
Occurs 10-72 hours after last drink
Tachycardia
Hallucinations
Hypotension
Tremor
Confusion
Fits
Anger
190
Q

Outline the CAGE questionnaire for problem drinking

A 
feel the need to Cut down?
get Annoyed by criticism about drinking?
feel Guilty?
need an Eye-opener in the morning?
Yes to 2 or more indicates problem drinking
191
Q

Outline treatment of alcoholism

A

Acute withdrawal: BZD + thiamine
Prevention, self-help, group therapy
Relapse control (acamprosate reduces craving, disulfiram for dependence)

192
Q

List aetiology/risk factors for acute pancreatitis

A 
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmunity
Scorpion bites
Hypercalcaemia/lipidaemia
ERCP
Drugs
Malignancy
Oxidative stress
193
Q

List clinical features of acute pancreatitis

A 
Severe epigastric pain radiating to back, may relieve on sitting forward
Fever
Nausea, vomiting
Reduced appetite
Tachycardia
Hypotension
Rigid abdomen
Grey Turner sign (flank bruising)
Cullen sign (periumbilical bruising)
194
Q

What investigations would you do for acute pancreatitis?

A 
Amylase typically hugely raised
Serum lipase
FBC, U+E, ABG's, LFT's
AXR shows sentinel loop of proximal jejunum if ileus
Erect CXR to exclude perforation
195
Q

What is the Glasgow prognostic score for severe pancreatitis?

A 
3 or more abnormal values from following parameters indicates severe pancreatitis:
PaO2
Age
Neutrophilia
Calcium
Renal function
Enzymes
Albumin
Sugar
196
Q

Outline treatment of acute pancreatitis

A 
Nil-by-mouth, nutritional support (NG/NJ)
IV fluids
Catheterisation
Analgesia
ERCP if gallstones
Antibiotics
Drain abscess/laparotomy + debridement
197
Q

Endocrine and exocrine insufficiency occurs in chronic pancreatitis. True/False?

A

True

Chronic fibrosis and calcification of pancreas

198
Q

List aetiology/risk factors of chronic pancreatitis

A 
Alcohol abuse
Cystic fibrosis
Alpha-1-antitrypsin deficiency
Hyperparathyroidism
Pancreatic duct obstruction
199
Q

List clinical features of chronic pancreatitis

A

Epigastric pain radiating to back
Erythema ab igne (mottled greyness)
Steatorrhoea
Weight loss

200
Q

Outline treatment of chronic pancreatitis

A 
Analgesia
Stop alcohol
Address diabetes
Treat enzyme deficiency (CREON)
Pancreactectomy, pancreaticojejunostomy
201
Q

What is the most common type of pancreatic cancer?

A

Adenocarcinoma at head of pancreas/Ampulla of Vater

202
Q

List aetiology/risk factors of pancreatic cancer

A 
Smoking
Alcohol
Diabetes
Chronic pancreatitis
High fat diet
KRAS2 gene
Insulinomas, glucagonomas, gastrinomas, somatostatinomas
203
Q

List clinical features of pancreatic cancer

A 
Painless obstructive jaundice
Dark urine pale stools
Epigastric pain
Weight loss
Thrombophlebitis
Palpable gall bladder
Ascites
204
Q

What investigations would you do for pancreatic cancer

A

LFT’s
CA-199
US scan/CT shows pancreatic mass
Biopsy

205
Q

Outline treatment of pancreatic cancer

A 
Radical surgery (Whipple's procedure - pancreatoduodenectomy) if fit enough
Palliative care
206
Q

List aetiology/risk factors for appendicitis

A

Luminal obstruction by faecolith
Worms
Lymphoid hyperplasia
Hygiene hypothesis

207
Q

List clinical features of appendicitis

A 
Periumbilical pain that moves to RIF
Vomiting
Constipation
Anorexia
Tachycardia
Fever
Flushing
Guarding
Rebound tenderness
Rovsing sign (pain in RIF when LIF pressed)
Tender McBurney point
208
Q

What investigations would you do for appendicitis?

A

FBC, U+E, inflammatory markers
US scan
Do not delay surgery

209
Q

Outline treatment of appendicitis

A

Prompt appendectomy

IV metronidazole + cefuroxime

210
Q

What are carcinoid tumours?

A

Tumours of enterochromaffin cell origin that produce 5-HT

May also secrete bradykinin, substance P, VIP, gastrin, insulin, glucagon, ACTH, PT hormone, thyroid hormone

211
Q

List common sites for carcinoid tumours

A 
Appendix
Ileum
Rectum
Ovary
Testis
Bronchi
212
Q

Which MEN syndrome - 1 or 2 - are carcinoid tumours associated with?

A

MEN1

213
Q

List clinical features of carcinoid tumours

A 
Appendicitis
RUQ pain
Bronchoconstriction
Paroxysmal flushing
Diarrhoea
Tricuspid regurgitation
CNS effects
Carcinoid crisis (shock)
214
Q

What investigations would you do for carcinoid tumours?

A 
24h urine 5-HT
US scan liver
CXR
CT abdo + plvis
Plasma chromograffin A
PET scan
215
Q

Outline treatment of carcinoid tumours

A

Octeotride/lareotide
Treat symptoms
Tumour resection

216
Q

What is a hernia?

A

Protrusion of viscus out of its normal body cavity

217
Q

List aetiology/risk factors for hernia

A 
Obesity
Pregnancy
Heavy lifting
Cough
Constipation
Abdo wall defects
218
Q

List clinical features of hernia

A

Femoral: mass in upper medial thigh, inferolateral to pubic tubercle
Inguinal: direct/indirect, superomedial to pubic tubercle
Paraumbilical: herniation of bowel + omentum
Incisional: breakdown of muscle post-surgery
Epigastric: weak linea alba

219
Q

Outline treatment of hernia

A 
Surgical repair
Treat complications (obstruction, strangulation)
220
Q

What is an indirect inguinal hernia?

A

Passes through internal inguinal ring (midpoint of inguinal ligament)

221
Q

What is a direct inguinal hernia?

A

Pushes through posterior wall of inguinal canal into Hesselbach triangle (medial to inferior epigastric arteries)

222
Q

List aetiology/risk factors for inguinal hernias

A 
Direct = young males
Indirect = old males
Cough
Increased intra-abdominal pressure
Patent processus vaginalis
223
Q

What is patent processus vaginalis?

A

Connection between peritoneal cavity and tunic vaginalis fails to close behind testis, causing indirect inguinal hernia formation
May result in hydrocele if peritoneal fluid collects

224
Q

Outline treatment of inguinal hernia

A

Lifestyle advice
Weight loss
Mesh repair to reinforce posterior wall

225
Q

What are haemorrhoids?

A

Swollen vessels in/around anus and rectum

Spongey vascular tissue at 3, 7 and 11 o’clock becomes displaced/disrupted

226
Q

List aetiology/risk factors for haemorrhoids

A 
Erect posture
Increased anal tone
Straining
Trauma
Constipation
Congestion
227
Q

List clinical features of haemorrhoids

A

Readily bleeding
Bright red blood around stool/paper/pan
Mucous discharge
Pruritis ani

228
Q

What investigations would you do for haemorrhoids?

A

PR exam
Abdo exam
Proctoscopy
Sigmoidoscopy

229
Q

Outline treatment of haemorrhoids

A 
Gel/cream
Ice pack
Stool softeners
Band ligation
Cryotherapy
Haemorrhoidectomy
Coagulation
Sclerosants
230
Q

List aetiology/risk factors for rectal prolapse

A

Lax sphincter
Prolonged straining
Neuropsychological disorder

231
Q

List clinical features of rectal prolapse

A

Loss of anal tone
Bleed
Mucous stool
“hanging” sensation

232
Q

Outline treatment for rectal prolapse

A

Rectopexy (fix rectum to sacrum) +/- mesh +/- rectosigmoidectomy
Stool softeners
Stop straining

233
Q

What is anal fissure?

A

Tear in squamous lining of lower anal canal, distal to the dentate line

234
Q

List aetiology/risk factors for anal fissure

A 
Hard faeces
Constipation
Rectal artery constriction
STD
IBD
Trauma
235
Q

List clinical features of anal fissure

A

Painful defecation, like shitting a shard of glass
Bleeding
Abscess

236
Q

Outline treatment for anal fissure

A

Stool softener
Local lidocaine ointment/GTN ointment
Lateral partial internal sphincterotomy

237
Q

What is anal fistula?

A

Abnormal communication between anal canal and skin

238
Q

List aetiology/risk factors for anal fistula

A 
Blockage of deep intramuscular gland ducts, causing abscess
Perianal sepsis
IBD
Diverticular disease
Rectal carcinoma
239
Q

What investigations would you do for anal fistula?

A

MRI
PR exam
Endoanal US scan

240
Q

Outline treatment for anal fistula

A

Fistulotomy + excision
Seton suturing
Drainage

4th year presentations (22 decks)

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