Gastroenterology Flashcards
What is Rovsigs sign?
RIF pain on palpation of LIF
Second line for C.diff
Oral findaxomicin
First line for primary biliary cholangitis
Ursodeoxycholic acid
What is PBC
Chronic autoimmune liver disease associated with other autoimmune conditions
What is the defect in Wilson’s disease
ATP7B gene located on chromosome 13
What are Kayseri Fleischer rings?
Green brown rings in the periphery of the iris
What is the most common cause of hepatocellular carcinoma in uk
Hep C
Adverse effects of metoclopramide?
Extrapyramidal effects
Diarrhoea
Hyperprolactinaemia
Tardive dyskinesia
Parkinsonism
Another name for vit c
ascorbic acid
First line for constipation in IBS?
Isphagula husk
diagnostic investigation of choice for pancreatic cancer
High-resolution CT scanning
increased ALT and AST suggest what
hepatocyte damage
Assessing the AST:ALT ratio can help what
identify possible alcoholic hepatitis. Ratio values higher than 2 suggest alcohol as a cause. In this patient, the AST:ALT ratio is less than 1, and this suggests non-alcoholic fatty liver disease
How to treat acute hypophosphatemia?
IV infusion of phosphate polyfusor
What is used to induce remission in crohns?
Glucocorticoids
What does the liver feel like in RHF if hepatomegaly?
firm, smooth, tender liver edge. May be pulsatile
Metabolic alkalosis may be caused by
loss of hydrogen ions or a gain of bicarbonate. It is due mainly to problems of the kidney or gastrointestinal tract
Inital management of severe alcoholic hepatitis?
Corticosteroids
Why is a raised urea seen in an acute upper GI bleed?
a raised urea may be seen due to the ‘protein meal’ of the blood
Treatment of alcoholic ketoacidosis?
infusion of saline & thiamine.
What is Budd-Chiari syndrome?
Hepatic vein thrombosis. It is usually seen in the context of underlying haematological disease or another procoagulant condition.
What management if NAFLD found on US?
Enhanced liver fibrosis to check for fibrosis
What is Globus hystericus
There may be a history of anxiety
Symptoms are often intermittent and relieved by swallowing
Usually painless - the presence of pain should warrant further investigation for organic causes
First line for wilsons?
penicillamine
The AST/ALT ratio in alcoholic hepatitis is what?
2:1
Why do peole with coeliac require regular immunisations
functional hyposplenism
What is Peutz-Jeghers syndrome?q
autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles.
What is carcinoid syndrome?
usually occurs when metastases are present in the liver and release serotonin into the systemic circulation
may also occur with lung carcinoid as mediators are not ‘cleared’ by the liver
What abx is associated with high risk of C diff?
Clindamycin
Features in pernicipus anaemia?
anaemia features
lethargy
pallor
dyspnoea
neurological features
peripheral neuropathy: ‘pins and needles’, numbness. Typically symmetrical and affects the legs more than the arms
subacute combined degeneration of the spinal cord: progressive weakness, ataxia and paresthesias that may progress to spasticity and paraplegia
neuropsychiatric features: memory loss, poor concentration, confusion, depression, irritabiltiy
other features
mild jaundice: combined with pallor results in a ‘lemon tinge’
glossitis → sore tongue
Investigation findings in Wilson’s disease?
slit lamp examination for Kayser-Fleischer rings
reduced serum caeruloplasmin
reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin): free (non-ceruloplasmin-bound) serum copper is increased
increased 24hr urinary copper excretion
the diagnosis is confirmed by genetic analysis of the ATP7B gene
Why should PPIs not be prescribed until after GI bleed?
They mask the site of bleeding
Alcohol units calculation?
volume (ml) * ABV / 1,000
Who commonly presents with biliary colic?
female, forties, fat and fair
Presentation of biliary colic?
RUQ pain, intermittent, usually begins abruptly and subsides gradually. Attacks often occur after eating. Nausea is common.
Triad in ascending cholangitis?
fever (rigors are common)
RUQ pain
jaundice
Presentation of acute cholecytitis?
Pain similar to biliary colic but more severe and persistent. The pain may radiate to the back or right shoulder.
The patient may be pyrexial and Murphy’s sign positive (arrest of inspiration on palpation of the RUQ)
What is melanosis coli and what is it associated with?
disorder of pigmentation of the bowel wall. Histology demonstrates pigment-laden macrophages
It is associated with laxative abuse, especially anthraquinone compounds such as senna
Baretts oesophagus treatment?
high-dose proton pump inhibitor
whilst this is commonly used in patients with Barrett’s the evidence base that this reduces the change of progression to dysplasia or induces regression of the lesion is limited
endoscopic surveillance with biopsies
for patients with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years
if dysplasia of any grade is identified endoscopic intervention is offered. Options include:
radiofrequency ablation: preferred first-line treatment, particularly for low-grade dysplasia
endoscopic mucosal resection
Prophylaxis of variceal haemorrhage medication?
propranolol
reduced rebleeding and mortality compared to placebo
What is seen in a severe C diff infection?
↑ WCC ( > 15 x 109/L)
or an acutely ↑ creatinine (> 50% above baseline)
or a temperature > 38.5°C
or evidence of severe colitis(abdominal or radiological signs)
Management of proctitis?
topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates
if remission is not achieved within 4 weeks, add an oral aminosalicylate
if remission still not achieved add topical or oral corticosteroid
TRUElove and Witt’s
T - Temp > 37.8
R - Rate > 90
U - (Uh)naemia Hb < 105
E - ESR >30
What is Courvoisier’s law?
in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
most common form of inherited colon cancer?
HNPCC
What really helps me with IDA vs ACD is the following:
-Ferritin is storing iron. So if we have chronic disease we are storing all the iron out of the blood so bacteria cant use it so ferritin is high.
-Transferring is transferring Iron around the body. If we are deficient iron we send out loads of transferring to go out into the body searching for iron. So transferring is high.
-Ferritin and Transferrin are always opposite (in terms of high or low)
-Transferrin and Total Iron Binding Capacity (TIBC) are always the same (in terms of high or low)
first-line medication for primary biliary cholangitis
Ursodeoxycholic acid
What is used to monitor treatment in haemochromatosis
Ferritin and transferrin saturation
Management of NAFLD?
the mainstay of treatment is lifestyle changes (particularly weight loss) and monitoring
there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g. metformin, pioglitazone)
Management of extensive UC?
topical (rectal) aminosalicylate and a high-dose oral aminosalicylate:
if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
Management of lfie threatening C diff
oral vancomycin AND IV metronidazole
specialist advice - surgery may be considered
Symptoms of coeliac?
Chronic or intermittent diarrhoea
Failure to thrive or faltering growth (in children)
Persistent or unexplained gastrointestinal symptoms including nausea and vomiting
Prolonged fatigue (‘tired all the time’)
Recurrent abdominal pain, cramping or distension
Sudden or unexpected weight loss
Unexplained iron-deficiency anaemia, or other unspecified anaemia
Associations with H pylori?
peptic ulcer disease
95% of duodenal ulcers
75% of gastric ulcers
gastric cancer
B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of patients)
atrophic gastritis
Drugs associated with drug induced cholestasis?
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine
Features of carcinoid tumours?
flushing (often the earliest symptom)
diarrhoea
bronchospasm
hypotension
right heart valvular stenosis (left heart can be affected in bronchial carcinoid)
other molecules such as ACTH and GHRH may also be secreted resulting in, for example, Cushing’s syndrome
pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour
Most common site affected by Crohn’s?
Ileum
What is acute liver failure?
rapid onset of hepatocellular dysfunction leading to a variety of systemic complications.
Causes of acute liver failure
paracetamol overdose
alcohol
viral hepatitis (usually A or B)
acute fatty liver of pregnancy
How is function of the liver assessed?
assessed by looking at the prothrombin time and albumin level.
What is loperamide?
μ-opioid receptor agonist which does not have systemic effects as it is not absorbed through the gut
First line investigation for acute mesenteruc ischaemia?
Raised lactate
What is a seton?
piece of surgical thread that is run through the fistula to allow continuous drainage while the fistula is healing. This ensures that the fistula doesn’t heal containing pus within, which would result in further abscess formation.
Management of perianal abscess?
- requires incision and drainage combined with antibiotic therapy
- a draining seton may also be placed if a tract is identified
Most common organism on SBP?
E. coli
AXR findings in UC?
In acute exacerbations, plain film abdominal radiographs (AXR) or CT imaging can be used to assess for toxic megacolon (Fig. 3C) and/or the presence of a bowel perforation. AXR features of acute ulcerative colitis flares also include mural thickening and thumbprinting, indicating a severe inflammatory process in the bowel wall; in chronic cases of UC, a lead-pipe colon is often described (best seen on barium studies).
Features of MEN-1
- parathyroid (95%): hyperparathyroidism due to parathyroid hyperplasia
- pituitary (70%)
- pancreas (50%, e.g. Insulinoma, gastrinoma)
- also: adrenal and thyroid
What is zollinger Ellison Syndrome?
condition characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas. Around 30% occur as part of MEN type I syndrome
What is primary biliary cholangitis?
chronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1). The aetiology is not fully understood although it is thought to be an autoimmune condition. Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis which may eventually progress to cirrhosis. The classic presentation is itching in a middle-aged woman
First line for primary biliary cholangitis?
ursodeoxycholic acid
* slows disease progression and improves symptoms
Why do high urea levels indicate an upper GI bleed over Lower?
when upper GI bleeding occurs, the blood is digested into proteins. These proteins are transported to the liver via the portal vein and metabolized to urea in the urea cycle. This is likely a presentation of a perforated peptic ulcer. Upper GI bleedings can result in melaena as the blood gets digested through the lower GI tract.
Features of oesophageal cancer?
Dysphagia may be associated with weight loss, anorexia or vomiting during eating
Past history may include Barrett’s oesophagus, GORD, excessive smoking or alcohol use
Features of achalasia?
Dysphagia ofboth liquids and solids from the start
Heartburn
Regurgitation of food - may lead to cough, aspiration pneumonia etc
Children with tracheo-oesophageal fistulas will commonly developwhat?
oesophageal strictures following repair. These may require regular dilations throughout childhood.
Management to mild to moderate UC proctitis flare?
- topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates
- if remission is not achieved within4 weeks,add an oral aminosalicylate
- if remission still not achieved add topical ororal corticosteroid
Management to mild to moderate UC proctosigmoiditis and left-sided ulcerative colitis flare?
- topical (rectal) aminosalicylate
- if remission is not achieved within 4 weeks,add a high-dose oral aminosalicylateOR switch to a high-dose oral aminosalicylate and a topical corticosteroid
- if remission still not achieved stop topical treatments and offer an oral aminosalicylate andan oral corticosteroid
What is melanosis coli?
disorder of pigmentation of the bowel wall. Histology demonstrates pigment-laden macrophages
It is associated with laxative abuse, especially anthraquinone compounds such as senna
Features of duodenal ulcer?
These are usually posteriorly sited and may erode thegastroduodenal artery. However, ulcers at any site in the duodenum may present with haematemesis, melena and epigastric discomfort.
The pain of a duodenal ulcer is slightly different to that of gastric ulcers and often occurs several hours after eating. Periampullary tumours may bleed but these are rare.
Classic history of pain several hours after eating is more characteristic of what?
Duodenal ulcer compared to gastric
Blood vessel responsible in duodenal ulcer?
Gastroduodenal
What is hapatorenal syndrome?
Occurs when the kidneys stop working well in people with serious liver problems. Less urine is produced by the body, so waste products that contain nitrogen build up in the bloodstream (azotemia). The disorder occurs in up to 1 in 10 people who are in the hospital with liver failure.
Management of hepatorenal syndrome?
- vasopressin analogues, for example terlipressin, have a growing evidence base supporting their use. They work by causing vasoconstriction of the splanchnic circulation
- volume expansion with 20% albumin
- transjugular intrahepatic portosystemic shunt
What does anti-HBc imply?
previous (or current) infection. IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months. IgG anti-HBc persists
What does anti-HbS imply?
implies immunity (either exposure or immunisation). It is negative in chronic disease
Management of recurrent episodes of C diff?
- recurrent infection occurs in around 20% of patients, increasing to 50% after their second episode
- within 12 weeks of symptom resolution: oral fidaxomicin
- after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin
Management of UC Following a severe relapse or >=2 exacerbations in the past year
- oral azathioprine or oral mercaptopurine
The causes of ascites can be grouped intowhat?
those with a serum-ascites albumin gradient (SAAG) <11 g/L or a gradient >11g/L as per the table below
Management of ascites?
- reducing dietary sodium
- fluid restriction is sometimes recommended if the sodium is < 125 mmol/L
- aldosterone antagonists: e.g. spironolactone
- drainage if tense ascites (therapeutic abdominal paracentesis)
- a transjugular intrahepatic portosystemic shunt (TIPS) may be considered in some patients
Inducing remissions in crohns?
glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients
enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children)
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective
azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine
infliximab is useful in refractory disease and fistulating Crohn’s. Patients typically continue on azathioprine or methotrexate
metronidazole is often used for isolated peri-anal disease
Treatment for achalasia?
pneumatic (balloon) dilationis increasingly the preferred first-line option
* less invasive and quicker recovery time than surgery
* patients should be a low surgical risk as surgery may be required if complications occur
surgical intervention with aHeller cardiomyotomyshould be considered ifrecurrent or persistentsymptoms
intra-sphincteric injection of botulinum toxin is sometimes used in patients who are a high surgical risk
drug therapy (e.g. nitrates, calcium channel blockers) has a role but is limited by side-effects
Drugs for maintaining remission in crohns?
- stopping smoking is a priority (remember: smoking makes Crohn’s worse, but may help ulcerative colitis)
- azathioprine or mercaptopurineis used first-line to maintain remission
+TPMT activityshould be assessed before starting - methotrexate is used second-line
Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAgindicates what?
Chronic HBV infection
Histology findings in crohns?
- inflammation in all layers from mucosa to serosa
- goblet cells
- granulomas
What is acalculous cholecystitis?
Patients with intercurrent illness (e.g. diabetes, organ failure)
Patient of systemically unwell
Gallbladder inflammation in absence of stones
High fever
Features of acute cholecytisis?
Right upper quadrant pain
Fever
Murphys sign on examination
Occasionally mildly deranged LFT’s (especially if Mirizzi syndrome)
Features of cholangitits?
Patient severely septic and unwell
Jaundice
Right upper quadrant pain
Gold standard for oesophageal cancer?
Endoscopy
What is Wilson’s disease?
Autosomal recessivedisorder characterised by excessive copper deposition in the tissues. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson’s disease is caused by a defect in theATP7Bgene located onchromosome 13.
Features of Wilsons?
- liver: hepatitis, cirrhosis
- neurological:
- basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus
- speech, behavioural andpsychiatric problemsare often the first manifestations
- also:asterixis,chorea,dementia, parkinsonism
- Kayser-Fleischer rings
- green-brown rings in the periphery of the iris
- due to copper accumulation in Descemet membrane
- present in around 50% of patients with isolated hepatic Wilson’s disease and 90% who have neurological involvement
- renal tubular acidosis(esp. Fanconi syndrome)
- haemolysis
- blue nails
What is pharyngeal pouch?
posteromedial diverticulum through Killian’s dehiscence. Killian’s dehiscence is a triangular area in the wall of the pharynxbetween the thyropharyngeus and cricopharyngeus muscles. It is more common in older patients and is 5 times more common in men
Features of pharyngeal pouch?
- dysphagia
- regurgitation
- aspiration
- neck swelling which gurgles on palpation
- halitosis
A nice way of remembering the Child-Pugh score
A - albumin
B - bilirubin
C - clotting
D - distention (ascites)
E - encephalopathy
Antibiotic prophylaxis should be given to patients with ascites if:
- patients who havehad an episode of SBP
- patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
- NICE recommend: ‘Offer prophylacticoral ciprofloxacin or norfloxacinfor people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved’
Child pugh classification
Blatchord score
