Gastroenterology Flashcards
1
Q
What is Rovsigs sign?
A
RIF pain on palpation of LIF
2
Q
Second line for C.diff
A
Oral findaxomicin
3
Q
First line for primary biliary cholangitis
A
Ursodeoxycholic acid
4
Q
What is PBC
A
Chronic autoimmune liver disease associated with other autoimmune conditions
5
Q
What is the defect in Wilson’s disease
A
ATP7B gene located on chromosome 13
6
Q
What are Kayseri Fleischer rings?
A
Green brown rings in the periphery of the iris
7
Q
What is the most common cause of hepatocellular carcinoma in uk
A
Hep C
8
Q
Adverse effects of metoclopramide?
A
Extrapyramidal effects
Diarrhoea
Hyperprolactinaemia
Tardive dyskinesia
Parkinsonism
9
Q
Another name for vit c
A
ascorbic acid
10
Q
First line for constipation in IBS?
A
Isphagula husk
11
Q
diagnostic investigation of choice for pancreatic cancer
A
High-resolution CT scanning
12
Q
increased ALT and AST suggest what
A
hepatocyte damage
13
Q
Assessing the AST:ALT ratio can help what
A
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
14
Q
How to treat acute hypophosphatemia?
A
IV infusion of phosphate polyfusor
15
Q
What is used to induce remission in crohns?
A
Glucocorticoids
16
Q
What does the liver feel like in RHF if hepatomegaly?
A
firm, smooth, tender liver edge. May be pulsatile
17
Q
Metabolic alkalosis may be caused by
A
loss of hydrogen ions or a gain of bicarbonate. It is due mainly to problems of the kidney or gastrointestinal tract
18
Q
Inital management of severe alcoholic hepatitis?
A
Corticosteroids
19
Q
Why is a raised urea seen in an acute upper GI bleed?
A
a raised urea may be seen due to the ‘protein meal’ of the blood
20
Q
Treatment of alcoholic ketoacidosis?
A
infusion of saline & thiamine.
21
Q
What is Budd-Chiari syndrome?
A
Hepatic vein thrombosis. It is usually seen in the context of underlying haematological disease or another procoagulant condition.
22
Q
What management if NAFLD found on US?
A
Enhanced liver fibrosis to check for fibrosis
23
Q
What is Globus hystericus
A
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
24
Q
First line for wilsons?
A
penicillamine
25
The AST/ALT ratio in alcoholic hepatitis is what?
2:1
26
Why do peole with coeliac require regular immunisations
functional hyposplenism
27
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.
28
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
29
What abx is associated with high risk of C diff?
Clindamycin
30
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
31
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
32
Why should PPIs not be prescribed until after GI bleed?
They mask the site of bleeding
33
Alcohol units calculation?
volume (ml) * ABV / 1,000
34
Who commonly presents with biliary colic?
female, forties, fat and fair
35
Presentation of biliary colic?
RUQ pain, intermittent, usually begins abruptly and subsides gradually. Attacks often occur after eating. Nausea is common.
36
Triad in ascending cholangitis?
fever (rigors are common)
RUQ pain
jaundice
37
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)
38
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
39
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
40
Prophylaxis of variceal haemorrhage medication?
propranolol
reduced rebleeding and mortality compared to placebo
41
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)
42
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
43
TRUElove and Witt's
T - Temp > 37.8
R - Rate > 90
U - (Uh)naemia Hb < 105
E - ESR >30
44
What is Courvoisier's law?
in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
45
most common form of inherited colon cancer?
HNPCC
46
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)
47
first-line medication for primary biliary cholangitis
Ursodeoxycholic acid
48
What is used to monitor treatment in haemochromatosis
Ferritin and transferrin saturation
49
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)
50
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
51
Management of lfie threatening C diff
oral vancomycin AND IV metronidazole
specialist advice - surgery may be considered
52
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
53
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
54
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
55
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
56
Most common site affected by Crohn's?
Ileum
57
What is acute liver failure?
rapid onset of hepatocellular dysfunction leading to a variety of systemic complications.
58
Causes of acute liver failure
paracetamol overdose
alcohol
viral hepatitis (usually A or B)
acute fatty liver of pregnancy
59
How is function of the liver assessed?
assessed by looking at the prothrombin time and albumin level.
60
What is loperamide?
μ-opioid receptor agonist which does not have systemic effects as it is not absorbed through the gut
61
First line investigation for acute mesenteruc ischaemia?
Raised lactate
62
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.
63
Management of perianal abscess?
* requires incision and drainage combined with antibiotic therapy
* a draining seton may also be placed if a tract is identified
64
Most common organism on SBP?
E. coli
65
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).
66
Features of MEN-1
* parathyroid (95%): hyperparathyroidism due to parathyroid hyperplasia
* pituitary (70%)
* pancreas (50%, e.g. Insulinoma, gastrinoma)
* also: adrenal and thyroid
67
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
68
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
69
First line for primary biliary cholangitis?
ursodeoxycholic acid
* slows disease progression and improves symptoms
70
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.
71
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
72
Features of achalasia?
Dysphagia of both liquids and solids from the start
Heartburn
Regurgitation of food - may lead to cough, aspiration pneumonia etc
73
Children with tracheo-oesophageal fistulas will commonly develop what?
oesophageal strictures following repair. These may require regular dilations throughout childhood.
74
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 within 4 weeks, add an oral aminosalicylate
* if remission still not achieved add topical or oral corticosteroid
75
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 aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
* if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
76
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
77
Features of duodenal ulcer?
These are usually posteriorly sited and may erode the gastroduodenal 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.
78
Classic history of pain several hours after eating is more characteristic of what?
Duodenal ulcer compared to gastric
79
Blood vessel responsible in duodenal ulcer?
Gastroduodenal
80
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.
81
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
82
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
83
What does anti-HbS imply?
implies immunity (either exposure or immunisation). It is negative in chronic disease
84
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
85
Management of UC Following a severe relapse or >=2 exacerbations in the past year
* oral azathioprine or oral mercaptopurine
86
The causes of ascites can be grouped into what?
those with a serum-ascites albumin gradient (SAAG) <11 g/L or a gradient >11g/L as per the table below
87
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
88
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
89
Treatment for achalasia?
pneumatic (balloon) dilation is 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 a Heller cardiomyotomy should be considered if recurrent or persistent symptoms
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
90
Drugs for maintaining remission in crohns?
* stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis)
* azathioprine or mercaptopurine is used first-line to maintain remission
+TPMT activity should be assessed before starting
* methotrexate is used second-line
91
Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg indicates what?
Chronic HBV infection
92
Histology findings in crohns?
* inflammation in all layers from mucosa to serosa
* goblet cells
* granulomas
93
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
94
Features of acute cholecytisis?
Right upper quadrant pain
Fever
Murphys sign on examination
Occasionally mildly deranged LFT's (especially if Mirizzi syndrome)
95
Features of cholangitits?
Patient severely septic and unwell
Jaundice
Right upper quadrant pain
96
Gold standard for oesophageal cancer?
Endoscopy
97
What is Wilson’s disease?
Autosomal recessive disorder 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 the ATP7B gene located on chromosome 13.
98
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 and psychiatric problems are 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
99
What is pharyngeal pouch?
posteromedial diverticulum through Killian's dehiscence. Killian's dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles. It is more common in older patients and is 5 times more common in men
100
Features of pharyngeal pouch?
* dysphagia
* regurgitation
* aspiration
* neck swelling which gurgles on palpation
* halitosis
101
A nice way of remembering the Child-Pugh score
A - albumin
B - bilirubin
C - clotting
D - distention (ascites)
E - encephalopathy
102
Antibiotic prophylaxis should be given to patients with ascites if:
* patients who have had 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 prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved'
103
Side effects mesalazine?
GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis
104
Management of life threatening C diff infection?
* oral vancomycin AND IV metronidazole
* specialist advice - surgery may be considered
105
How to work out units of alcohol?
ABV% times Volune (litres)
106
One unit of alcohol is equal to in ethanol?
10ml of pure ethanol
107
How long before procedure should PPi be stopped?
2 weeks
108
HBsAg positive, anti-HBs negative, IgM anti-HBc positive suggests what?
Acute infection
109
Histology findings of UC?
No inflammation beyond submucosa (unless fulminant disease) - inflammatory cell infiltrate in lamina propria
* neutrophils migrate through the walls of glands to form crypt abscesses
* depletion of goblet cells and mucin from gland epithelium
* * granulomas are infrequent
110
Features of gastric cancer?
abdominal pain
* typically vague, epigastric pain
* may present as dyspepsia
weight loss and anorexia
nausea and vomiting
dysphagia: particularly if the cancer arises in the proximal stomach
overt upper gastrointestinal bleeding is seen only in a minority of patients
if lymphatic spread:
* left supraclavicular lymph node (Virchow's node)
* periumbilical nodule (Sister Mary Joseph's node)
111
The following drugs tend to cause cholestasis (+/- hepatitis):
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine
112
if dysplasia of any grade in Barretts oesophagus is identified endoscopic intervention is offered. Options include:
* radiofrequency ablation: preferred first-line treatment, particularly for low-grade dysplasia
* endoscopic mucosal resection
113
Large-volume paracentesis for the treatment of ascites requires what?
Albumin 'cover'. Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality
114
What is pout jegher’s syndrome?
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. Although the polyps themselves don't have malignant potential, around 50% of patients will have died from another gastrointestinal tract cancer by the age of 60 years.
115
Complications of coeliac disease?
* anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
* hyposplenism
* osteoporosis, osteomalacia
* lactose intolerance
* enteropathy-associated T-cell lymphoma of small intestine
* subfertility, unfavourable pregnancy outcomes
* rare: oesophageal cancer, other malignancies
116
What is Gilbert’s?
autosomal recessive* condition of defective bilirubin conjugation due to a deficiency of UDP glucuronosyltransferase. The prevalence is approximately 1-2% in the general population.
117
What is TPMT?
enzyme involved in the metabolism of azathioprine and mercaptopurine. Some people have a deficiency of TPMT due to genetic mutations and those are at a greater risk of experiencing side effects from conventional doses of azathioprine or mercatoprurine therapy
118
First line to maintain remission in Crohns?
Azathroprine or mercaptopurine
119
n pancreatic cancer, 3 different abdominal masses may be present:
hepatomegaly (metastases)
gallbladder (Courvoisier's law)
epigastric mass (primary)
120
Investigations for pancreatic cancer?
ultrasound has a sensitivity of around 60-90%
high-resolution CT scanning is the investigation of choice if the diagnosis is suspected
imaging may demonstrate the 'double duct' sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts
121
Treatment of recurrent C diff?
Oral fidaxomicin
122
Management of hepatic encephalopathy?
lactulose first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy
lactulose is thought to work by promoting the excretion of ammonia and increasing the metabolism of ammonia by gut bacteria
antibiotics such as rifaximin are thought to modulate the gut flora resulting in decreased ammonia production
123
H pylori eradication manageemnt?
PPI + amoxicillin + clarithromycin, or
PPI + metronidazole + clarithromycin
124
The following drugs tend to cause cholestasis (+/- hepatitis):
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine
125
Why should metoclopramide be avoided in bowel obstruction?
Should be avoided as it is a pro-kinetic anti-emetic so could cause a perforation in bowel obstruction.
126
Diagnosis of C diff?
is made by detecting C. difficile toxin (CDT) in the stool
C. difficile antigen positivity only shows exposure to the bacteria, rather than current infection
127
Adverse effects of PPIs?
hyponatraemia, hypomagnasaemia
osteoporosis → increased risk of fractures
microscopic colitis
increased risk of C. difficile infections
128
What is small bowel bacterial overgrowth syndrome?
disorder characterised by excessive amounts of bacteria in the small bowel resulting in gastrointestinal symptoms.
129
Features of small bowel bacterial overgrowth syndrome?
* chronic diarrhoea
* bloating, flatulence
* abdominal pain
130
Diagnosis of small bowel bacteria overgrowth syndrome?
* hydrogen breath test
* small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce
* clinicians may sometimes give a course of antibiotics as a diagnostic trial
131
What does anti HbS imply?
Implies immunity
132
Budd chiari syndrome triad?
sudden onset abdominal pain, ascites, and tender hepatomegaly
133
AST/ALT ratio in alcohol hepatitis?
2:1
134
Third line for c diff?
oral vancomycin +/- IV metronidazole should be tried
135
First line investigation in severe colitis?
colonoscopy should be avoided due to the risk of perforation - a flexible sigmoidoscopy is preferred
136
Dysplasia on biopsy in Barrett’s oesophageal management?
Endoscopic mucosal resection
137
Features of pharyngeal pouch?
* dysphagia
* regurgitation
* aspiration
* neck swelling which gurgles on palpation
* halitosis
138
What should be used to manage an uncontrolled varicella haemorrhage if OGD not ready?
Insert a Sengstaken-Blakemore tube
139
What is an aorto enteric fistula?
In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage
140
How to remember to replace B12 before folate?
B is before f in the alphabet
141
Patients with ascites secondary to liver cirrhosis should be given what?
aldosterone antagonist
142
Definitive management of oesophageal varices?
TIPS
143
Histology findings in crohns?
Inflammation in all layers from mucosa to serosa
* increased goblet cells
* granuloma
144
Side effects of sulphalazine?
Rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis
145
Mr Lynch is a CEO
Colorectal cancer
Endometrial cancer
Ovarian cancer
146
Memory aid for TB drug side effects?
RifamPEEcin
IsoNERVEzid
PyraLIVERmid
EYEthambol
147
Mneumonic for Plummer vinson?
Dysphagia, Iron deficiency anemia, Esophageal webs
148
Acute treatment of varicella haemorrhage?
ABC
Correct clotting
Vasoactive agents- terlipressen
Prophylactic IV abx- offer prophylactic for people with cirrhosis who have a GI bleed
Endoscopic varicella band ligation
Sengstaken-Blakemore tube if uncontrolled haemorrhage
TIPPS if all else fails
149
Prophylaxis of variceal haemorrhage
Propanolol
Endoscopic varicela band ligation: ◦ performed at two-weekly intervals until all varices have been eradicated. proton pump inhibitor cover is given to prevent EVL-induced ulceration
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) may be used if the above measures are unsuccessful in preventing further episodes
150
Metabolic ketoacidosis with normal or low glucose. Think what?
Alcoholic ketoacidosis
151
Typical iron study profile in patient with haemochromatosis
* transferrin saturation > 55% in men or > 50% in women
* raised ferritin (e.g. > 500 ug/l) and iron
* low TIBC
152
How many stools for mild UC?
Fewer than four stools daily, with or without blood
153
How many stools for moderate UC?
Four to six stools a day, with minimal systemic disturbance
154
How many stools for severe UC?
More than six stools a day, containing blood
155
Child pugh classification
156
What are the ANCA antibodies associated wtih?
small vessel vasculitides with c-ANCA primarily associated with granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis.
On the other hand, p-ANCA can be found in broad range of conditions including primary sclerosing cholangitis, autoimmune hepatitis and ulcerative colitis.
157
Important vaccine information for coeliac disease?
Patients with coeliac disease often have a degree of functional hyposplenism
For this reason, all patients with coeliac disease are offered the pneumococcal vaccine
Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every 5 years
Currrent guidelines suggest giving the influenza vaccine on an individual basis.
158
Blatchord score
159
A repeat endoscopy given two previous treatments of an ulcer is unlikely to be effective and it would be more appropriate to proceed to
surgical exploration and repair of the ulcer at laparotomy
160
Features of a carcinoid tumour?
Bradykinin and serotonin = flushing, diarrhoea, wheezing; Can produce pituitary hormones so flushing + anything else still consider this as the top choice
161
Management of carcinoid tumours?
somatostatin analogues e.g. octreotide
diarrhoea: cyproheptadine may help
162
Investigations for carcinoid tumours?
urinary 5-HIAA
plasma chromogranin A y
163
What is achlasia?
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated.
164
Gold standard fr diagnosis of coeliac?
Endoscopic intestinal biopsy
165
You cannot interpret TTG level in coeliac disease without looking at what
IgA levels
166
serology investigations in coeliac
tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE
endomyseal antibody (IgA)
needed to look for selective IgA deficiency, which would give a false negative coeliac result
anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE
anti-casein antibodies are also found in some patients§§§
167
Management of svere alcpoholic hepatits?
Prednisollone
168
What is pellagra?
Vitamin B3 defiencny (niacin)
169
Features of vitamin B3 deficiency (Pellagra)?
Dermatitis, diarrhoea, dementia/delusions, leading to death
170
What is ischaemic hepatitis?
diffuse hepatic injury resulting from acute hypoperfusion (sometimes known as 'shock liver'). It is not an inflammatory process. It is diagnosed in the presence of an inciting event (e.g. a cardiac arrest) and marked increases in aminotransferase levels (exceeding 1000 international unit/L or 50 times the upper limit of normal). Often, it will occur in conjunction with acute kidney injury (tubular necrosis) or other end-organ dysfunction.
171
Type 1 hepatorenal syndrome?
Rapidly progressive
Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks
Very poor prognosis
172
Featiures of type 2 hepatorenal syndrome?
Slowly progressive
Prognosis poor, but patients may live for longer
173
First line for primary biliary cholangitits?
Ursodeoxycholic acid
174
Key investigation for patients taking aminosalicylates and become unwell (mesalazine. and sulphasalzine)
FBC due to risk of agranulocytosis
175
What is a sister mary joseph's node?
palpable nodule in the umbilicus due to metastasis of malignant cancer within the pelvis or abdomen
176
Gallstone ileus plain film X ray
Small bowel obstruction and air in the biliary tree
177
Featuees of a pharyngeal pouch?
dysphagia
regurgitation
aspiration
neck swelling which gurgles on palpation
halitosis
178
What is a pharyngeal pouch?
posteromedial diverticulum through Killian's dehiscence. Killian's dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles
179
Investigations for pharyngeal pouch?
barium swallow combined with dynamic video fluoroscopy
180
H pylori eradication regimens?
PPI + amoxicillin + clarithromycin, or
PPI + metronidazole + clarithromycin
181
Features of chronoc mesenteric ischaemia?
severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit
182
What is ischaemic colitis?
acute but transient compromise in the blood flow to the large bowel
183
Where is ischaemic colitis most likely to occur?
Watershed areas. Splenic flexure. As on borders of terriotory supplied by superior and inferior mesenteric arteries
184
Triad in mesenteric ischaemia?
high lactate and soft but tender abdomen, CVD
185
wHAT BOWEL part most commonly affected in mesenteric ischaemia?
Small bowel
186
What part of bowel most commonly affected in ischaemic colitis?
Large bowel
187
Manageemnt of patients with dyspepsia who don't have criteria for endoscopy?
1. Review medications for possible causes of dyspepsia
2. Lifestyle advice
3. Trial of full-dose proton pump inhibitor for one month OR a 'test and treat' approach for H. pylori
if symptoms persist after either of the above approaches then the alternative approach should be tried
188
Management of hepatic encephalopathy?
treat any underlying precipitating cause
NICE recommend lactulose first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy
lactulose is thought to work by promoting the excretion of ammonia and increasing the metabolism of ammonia by gut bacteria
antibiotics such as rifaximin are thought to modulate the gut flora resulting in decreased ammonia production
other options include embolisation of portosystemic shunts and liver transplantation in selected patients
189
What should be given before endoscopy in patients with suspected variceal haemorrhage?
terlipressin and antibiotics
190
Invvestigations for primary sclerosing cholangitis?
endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) are the standard diagnostic investigations, showing multiple biliary strictures giving a 'beaded' appearance
p-ANCA may be positive
there is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often described as 'onion skin'
191
Grading of hepatic encephlopathy?
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
192
What LFTs suggest an obstructive cause for the jaundice?
bigger raise in ALP and GGT than ALT
193
Management of a pharyngeal pouch?
Surgery
194
What does anti HBc imply?
implies 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
195
What is HbeAg?
breakdown of core antigen from infected liver cells as is, therefore, a marker of infectivity. Marker of HBV replication and infectivity
196
What is anti-HBs?
implies immunity (either exposure or immunisation). It is negative in chronic disease
197
What is transient elastography useful for?
useful for diagnosing and monitoring the severity of liver cirrhosis
198
What is type I autoimmune hepatitis?
Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)
Affects both adults and children
199
Autoimmune type II hepatitis?
Anti-liver/kidney microsomal type 1 antibodies (LKM1)
Affects children only
200
Charactristic features of autoimmune hapatitis?
Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels
201
What is ALP?
produced by the cells lining the bile ducts. Hence the levels in the blood will rise in obstructive disease.
202
wHAT ARE AST and ALT?
both produced by hepatocytes. In hepatocellular disease, hepatocytes release these enzymes into the blood stream, hence explaining the raised ALT in this question.
203
Best way to assess liver funtion?
Prothrombin time and albumin level
204
most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease
Thrombocytopenia (platelet count <150,000 mm^3)
205
How much would you expect AST top be reaised in chronic hepatitis?
10 times
206
How would urea change in advanced liver disease?
Decreased as liver makes urea
207
eatures of Peutz-Jeghers syndrome?
hamartomatous polyps in the gastronintestinal tract (mainly small bowel)
small bowel obstruction is a common presenting complaint, often due to intussusception
gastrointestinal bleeding
pigmented lesions on lips, oral mucosa, face, palms and soles
208
Why is MRCP better than ERCP?
Less invasive
209
Management of bile acid malabsorptuon?
bile acid sequestrants e.g. cholestyramine
210
symptomatic perianal fistulae management?
Oral metronidazole
211
Pernicious anaemia predisposes to what cancer?
Gastric carcinoma
212
Acute hypoperfusion (e.g. low BP secondary to blood loss) may result in what liver conditio?
Ischaemic hepatitis
213
What is the apple core sign?
constriction of the lumen of the colon by a stenosing annular colorectal carcinoma
214
Complications of coeliac disease?
anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
hyposplenism
osteoporosis, osteomalacia
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility, unfavourable pregnancy outcomes
rare: oesophageal cancer, other malignancies
215
Cause of vitamin B6 deficinecy?
Isoniazid therapy
216
Consequences of vitamin B6 deficiency
peripheral neuropathy
sideroblastic anemia
217
What is a dieulafoy lesion?
Often no prodromal features prior to haematemesis and melena, but this arteriovenous malformation may produce quite a considerable haemorrhage and may be difficult to detect endoscopically
abnormally large artery (a vessel that takes blood from the heart to other areas of the body) in the lining of the gastrointestinal system
218
What is oesophageal varices?
Usually a large volume of fresh blood. Swallowed blood may cause melena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed
Enlarged veins in the eosophagus
219
What is used to monitor tresatment in haemachromatosis?
Ferritin and tranferrin saturation
220
Management of bile acid malabsorption?
bile acid sequestrants e.g. cholestyramine
221
Investigations for bile acid malabsorpion?
the test of choice is SeHCAT
nuclear medicine test using a gamma-emitting selenium molecule in selenium homocholic acid taurine or tauroselcholic acid (SeHCAT)
scans are done 7 days apart to assess the retention/loss of radiolabelled 75SeHCAT
222
The AST/ALT ratio in alcoholic hepatitis is what?
2:1
223
Risk factors for SCC?
smoking
alcohol
achalasia
Plummer-Vinson syndrome
diets rich in nitrosamine
224
Conditions associated with NAFLD?
obesity
type 2 diabetes mellitus
hyperlipidaemia
jejunoileal bypass
sudden weight loss/starvation
225
Features of Budd-Chiari syndrome?
abdominal pain: sudden onset, severe
ascites → abdominal distension
tender hepatomegaly
226
Investigations for budd-chiari syndrome?
ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation
227
Features of Budd Chiari Syndrome?
Budd-Chiari syndrome is a condition in which the hepatic veins (veins that drain the liver) are blocked or narrowed by a clot (mass of blood cells). This blockage causes blood to back up into the liver, and as a result, the liver grows larger
228
What is a carcinoid syndrome?
occurs when a rare cancerous tumor called a carcinoid tumor secretes certain chemicals into your bloodstream, causing a variety of signs and symptoms. A carcinoid tumor, which is a type of neuroendocrine tumor, occurs most often in the gastrointestinal tract or the lungs.
229
Management of carcinoid tumours?
somatostatin analogues e.g. octreotide
diarrhoea: cyproheptadine may help
230
What antibiotics should not be used before an H pylori test?
should not be performed within 4 weeks of treatment with an antibacterial or within 2 weeks of an antisecretory drug (e.g. a proton pump inhibitor)
231
Investigations for achalasia?
oesophageal manometry
excessive LOS tone which doesn't relax on swallowing
considered the most important diagnostic test
barium swallow
shows grossly expanded oesophagus, fluid level
'bird's beak' appearance
chest x-ray
wide mediastinum
fluid leve
232
Diagnosis of C diff?
is made by detecting C. difficile toxin (CDT) in the stool
C. difficile antigen positivity only shows exposure to the bacteria, rather than current infection
233
What should be stopped in C dff?
medications which are anti-motility and anti-peristaltic should be held. Anti-peristaltic drugs such as opioids can predispose to toxic megacolon by slowing the clearance of the Clostridium difficile toxin. If possible, antibiotics should also be held to allow normal intestine flora to be re-established, though the antibiotics used to treat the Clostridium difficile should be continued.
234
Derugs that cause cholestasis
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine
235
What antibiotics are strongly linked to C diff?
Cephalosporins, not just clindamycin
236
Maintaining remission in crohns?
as above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis)
azathioprine or mercaptopurine is used first-line to maintain remission
+TPMT activity should be assessed before starting
methotrexate is used second-line
237
HNPCC genes associated with it?
MSH2 (60% of cases)
MLH1 (30%)
238
What examinatioj needs to be dome to rule ou tt conditions other than appendicities in RIF pain?
Examination of the scrotum
239
What does a TIPS procedure do?
Connects the hepatic vein and the portal vein, although can connect the portal vein to the IVC.
240
Plummer vinson syndrome triad?
dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia
241
What is plummer vinson syndrome?
A disorder marked by anemia caused by iron deficiency, and a web-like growth of membranes in the throat that makes swallowing difficult. Having Plummer-Vinson syndrome may increase the risk of developing esophageal cancer.
242
a high SAAG gradient (> 11g/L) indicates what?
Portal hyopertensin
243
What is charcot's triad?
o RUQ pain
o Fever
o Jaundice
Seen in acute cholangitis
244
Why do cramps happen?
Contractions due to a blockage
245
Biliary colic vs acute cholangitis
Biliary colic is not infection so no fever
No raised inflammatory markers
246
Common types of stones?
Cholestrol and pigment stones
247
Why are gallstones more common in fat, fertile, fourty yo females?
Oestrogen
248
What is cholangiocarcinoma?
Cancer of the bile duct walls
249
What is courvoisier law?
In a jaundiced patient and can feel the gallbladder underlying cause is not gallstones
250
How to interpret LFTs?
Bilirubin raised means it jaundiced
ALT/AST: More hepatic
Alkaline phos: More bile duct
251
How do we compare ALT and ALP?
A greater than 10-fold increase in ALT and a less than 3-fold increase in ALP suggests a predominantly hepatocellular injury.
A less than 10-fold increase in ALT and a more than 3-fold increase in ALP suggests cholestasis.
It is possible to have a mixed picture involving both hepatocellular injury and cholestasis.
252
A raised GGT can be suggestive of WHAT?
biliary epithelial damage and bile flow obstruction. It can also be raised in response to alcohol and drugs such as phenytoin. A markedly raised ALP with a raised GGT is highly suggestive of cholestasis.
253
A raised ALP in the absence of a raised GGT should raise your suspicion of
non-hepatobiliary pathology. Alkaline phosphatase is also present in bone and therefore anything that leads to increased bone breakdown can elevate ALP.
254
What is albumin?
synthesised in the liver and helps to bind water, cations, fatty acids and bilirubin. It also plays a key role in maintaining the oncotic pressure of blood.
255
Albumin levels can fall due to:
Liver disease resulting in a decreased production of albumin (e.g. cirrhosis).
Inflammation triggering an acute phase response which temporarily decreases the liver’s production of albumin.
Excessive loss of albumin due to protein-losing enteropathies or nephrotic syndrome.
256
What is PT?
measure of the blood’s coagulation tendency, specifically assessing the extrinsic pathway. In the absence of other secondary causes such as anticoagulant drug use and vitamin K deficiency, an increased PT can indicate liver disease and dysfunction. The liver is responsible for the synthesis of clotting factors, therefore hepatic pathology can impair this process resulting in increased prothrombin time.
257
wHY IS pt, aptt and INR better than albumin?
More acute picture of injury
