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Gastroenterology Flashcards

1
Q

What test can be used to confirm gilbert’s syndrome

A

nicotininc acid test. Gilberts is due to a mutation in the gene for the enzyme glucuronyl transferase, which helps to break down bilirubin in the liver. The nicotinic acid test can confirm this diagnosis as it leads to an exaggerated and prolonged increase in serum unconjugated bilirubin levels in patients with Gilbert’s syndrome due to impairment of hepatic uptake and conjugation of bilirubin.

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2
Q

What scoring system can be used to assess likelihood of acute appendicitis

A

The correct answer is the Alvarado score. It consists of eight different criteria (symptoms, signs and laboratory results) and divides patients into appendicitis unlikely, possible, probable and definite.

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3
Q

What drugs cause a hepatocellular picture of drug induced liver disease

A

paracetamol
sodium valproate, phenytoin
MAOIs
halothane
anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
statins
alcohol
amiodarone
methyldopa
nitrofurantoin

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4
Q

What drugs cause a cholestasis +/- hepatitis drug induced liver disease

A

combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine

*risk may be reduced with erythromycin stearate

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5
Q

What drugs cause liver cirrhosis drug induced liver disease?

A

methotrexate
methyldopa
amiodarone

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6
Q

What are the features of type 1 autoimmune hepatitis

A

Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)

Affects both adults and children

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7
Q

What are the features of type 2 autoimmune hepatitis

A

Anti-liver/kidney microsomal type 1 antibodies (LKM1)

Affects children only

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8
Q

What are the features of type 3 autoimmune hepatitis

A

Soluble liver-kidney antigen

Affects adults in middle-age

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9
Q

What are the features of type 3 autoimmune hepatitis

A

Soluble liver-kidney antigen

Affects adults in middle-age

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10
Q

What drug should be avoided in IBS?

A

Lactulose- is a synthetic disaccharide that works by drawing water into the bowel, softening stools and increasing bowel movements. However, it can also cause bloating, flatulence, and abdominal discomfort, which are common symptoms of IBS.

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11
Q

What are the two types of HRS and what are the prognosis of both of them

A

TYPE 1: 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

TYPE 2: Slowly progressive
Prognosis poor, but patients may live for longer

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12
Q

What is the management of hepatorenal syndrome?

A

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

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13
Q

What is the most common SBP organize

A

E.coli

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14
Q

When should antibiotic prophylaxis be given in patients with ascites?

A

-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’

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15
Q

What is the mamangement of life threatening CDI?

A

ORAL VANC AND IV METRONDIAZOLE

Oral vancomycin has low systemic absorption, making it effective at managing intestinal infections. It can also be given NG or as an enema if needed. Other recommendations include bowel rest, fluid and electrolyte replacement and cessation of medications that impair gut motility.

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16
Q

What characterises mild C. difficle

A

normal WCC

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17
Q

What characterises moderate C. diff

A

↑ WCC ( < 15 x 109/L)
Typically 3-5 loose stools per day

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18
Q

What characterises severe CD?

A

↑ 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)

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19
Q

What characterises life threatening CD?

A

Hypotension
Partial or complete ileus
Toxic megacolon, or CT evidence of severe disease

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20
Q

What are some of the histological features of chrohn’s disease?

A

Inflammation in all layers from mucosa to serosa
increased goblet cells
granulomas

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21
Q

What are some of the histological features of UC?

A

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

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22
Q

What are some of the endoscopic features of Chrohn’s

A

Deep ulcers, skip lesions - ‘cobble-stone’ appearance

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23
Q

What are some of the endoscopic features of UC?

A

Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)

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24
Q

When is glasgow blatchford score used in UGI bleed?

A

First assessment (F next to G)

helps clinicians decide whether patient patients can be managed as outpatients or not

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25
When is Rockall used
After endoscopy provides a percentage risk of rebleeding and mortality includes age, features of shock, co-morbidities, aetiology of bleeding and endoscopic stigmata of recent haemorrhage
26
What is the proper name for thread worm?
Enterobius vermicularis perianal itching, particularly at night girls may have vulval symptoms
27
What the NICE bariatric referral cut offs
with risk factors (T2DM, BP etc): > 35 kg/m^2 no risk factors: > 40 kg/m^2
28
What are types of bariatric surgeries?Primarily restrictive operations
-laparoscopic-adjustable gastric banding (LAGB) it is normally the first-line intervention in patients with a BMI of 30-39kg/m^2 produces less weight loss than malabsorptive or mixed procedures but as it has fewer complications -sleeve gastrectomy stomach is reduced to about 15% of its original size -intragastric balloon the balloon can be left in the stomach for a maximum of 6 months
29
What are types of bariatric surgeries? Primarily malabsorptive operations
biliopancreatic diversion with duodenal switch usually reserved for very obese patients (e.g. BMI > 60 kg/m^2)
30
What are types of bariatrics surgeries? Mixed operations of both restrictive and malabsorptive
Roux-en-Y gastric bypass surgery
31
How is C. Diff spread
Faeco-oral via spores
32
What is the IBS A-C
Abdominal pain, and/or Bloating, and/or Change in bowel habit
33
When is a positive diagnosis of IBS made?
should be made if the patient has abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms: -altered stool passage (straining, urgency, incomplete evacuation) -abdominal bloating (more common in women than men), distension, tension or hardness -symptoms made worse by eating -passage of mucus
34
What should be done to ensure a gastric ulcer has resolved
NICE guidance on peptic ulcers states 'ensure all people with a proven gastric ulcer have a repeat endoscopy to confirm healing, and Helicobacter pylori re-testing (if appropriate)'. this is done by urea breath test
35
When should urea breath tests NOT be used
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)
36
What type of bilirubin does gilberts have
unconjugated hyperbilirubinaemia (i.e. not in urine). jaundice may only be seen during an intercurrent illness, exercise or fasting
37
What is gold standard test for GORD?
24hr oesophageal pH monitoring
38
What is primary biliary cholangitis commonly seen in and what is the M rule?
Primary biliary cholangitis is a chronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1).- the M rule IgM anti-Mitochondrial antibodies, M2 subtype Middle aged females
39
What are some associations of PBC?
Sjogren's syndrome (seen in up to 80% of patients) rheumatoid arthritis systemic sclerosis thyroid disease
40
What are some clincial features of PBC?
early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus cholestatic jaundice hyperpigmentation, especially over pressure points around 10% of patients have right upper quadrant pain xanthelasmas, xanthomata also: clubbing, hepatosplenomegaly late: may progress to liver failure
41
What is the diagnosis of PBC made by?
-immunology anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific smooth muscle antibodies in 30% of patients raised serum IgM -imaging required before diagnosis to exclude an extrahepatic biliary obstruction (typically a right upper quadrant ultrasound or magnetic resonance cholangiopancreatography (MRCP)
42
What is the management of PBC?
-first-line: ursodeoxycholic acid slows disease progression and improves symptoms -pruritus: cholestyramine -fat-soluble vitamin supplementation -liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) recurrence in graft can occur but is not usually a problem
43
What is the most accurate way to characterise a oesophageal/gastric cancer depth?
Endoscopic ultrasound (EUS) is better than CT or MRI in assessing mural invasion
44
When does FIT testing occur?
every 2 years to all men and women aged 60 to 74 years in England, 50 to 74 years in Scotland. Patients aged over 74 years may request screening
45
What autoimmune antibody can be used for c.difficle
Bezlotoxumab
46
What are the risk factors for SBBOS?
neonates with congenital gastrointestinal abnormalities scleroderma diabetes mellitu
47
What is the diagnosis for SBBOS?
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
48
What are the symptoms of SBBOS?
Overlap with IBS chronic diarrhoea bloating, flatulence abdominal pain
49
What is the management of ongoing diarrhoea in chrohns' patient post resection with normal CRP?
cholestyramine
50
What is the current guidelines for asymptomatic gallstones?
Observation Asymptomatic gallstones which are located in the gallbladder are common and do not require treatment. However, if stones are present in the common bile duct there is an increased risk of complications such as cholangitis or pancreatitis and surgical management should be considered.
51
What investigations are done for chronic pancreatitis
-abdominal x-ray shows pancreatic calcification in 30% of cases -CT is more sensitive at detecting pancreatic calcification. Sensitivity is 80%, specificity is 85% -functional tests: faecal elastase may be used to assess exocrine function if imaging inconclusive
52
What does PPI increase risk of
C. difficle and microscopic colitis AND OSTEOPOROSIS
53
What gene/chromosome is affected in wilson's disease?
responsible defective gene (ATP 7B) is on chromosome 13, and this codes for a copper-transporting P-type adenosine triphosphate.
54
What is enhanced liver fibrosis blood test
ELF blood test is a combination of hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1. An algorithm based on these values results in an ELF blood test score, similar to triple testing for Down's syndrome
55
What test is most suggestive of wilsons's
serum caeruloplasmin is decreased. Caeruloplasmin is a copper-carrying protein, and its synthesis is impaired in Wilson's disease due to intracellular copper overload.
56
What is whipple's disease?
rare multi-system disorder caused by Tropheryma whippelii infection. It is more common in those who are HLA-B27 positive and in middle-aged men.
57
What are the features of whipple's disease
malabsorption: diarrhoea, weight loss large-joint arthralgia lymphadenopathy skin: hyperpigmentation and photosensitivity pleurisy, pericarditis neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus
58
What does a jejunal biopsy show in whipple's disease?
deposition of macrophages containing Periodic acid-Schiff (PAS) granules
59
What is post cholecystectomy syndrome?
Post-cholecystectomy syndrome is a recognised complication of cholecystectomies. The pathology behind the syndrome isn't completely clear, however there is some association with remnant stones and biliary injury. Pain is often due to sphincter of Oddi dysfunction and the development of surgical adhesions.
60
What are the features of post cholecystectomy syndrome
Typically symptoms of dyspepsia, vomiting, pain, flatulence and diarrhoea occur in up to 40% patients post surgery.
61
What is the treatment of post cholecystectomy syndrome?
low-fat diet and the introduction of bile acid sequestrants, such as Cholestyramine, to bind the excess bile acids and thus preventing lower gastrointestinal signs. Proton-pump inhibitors like Lansoprazole do play a role, if the patient is complaining of dyspeptic like symptoms. Antibiotics and pancreatic enzyme replacements= NO ROLE
62
What are the risk factors for non alcoholic fatty liver disease?
Obesity, type 2 DM, hyperlipidaemia, jejunoileal bypass, sudden weight loss, starvation
63
What protein in ascites is cut off for prophylactic antibiotics for SBP?
<15, this is because it is a transudative fluid -Increased risk of developing SBP due to a larger osmotic gradient for translocation of substances and bacteria from the bowel to cause peritoneal fluid seeding.
64
What test stays positive after H. Pylori eradication
Serology
65
What is the causes of acute pancreatitis (IGETSMASHED)
Gallstones Ethanol Trauma Steroids Mumps (other viruses include Coxsackie B) Autoimmune (e.g. polyarteritis nodosa), Ascaris infection Scorpion venom Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia ERCP Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
66
What are the crest syndrome features of systemic sclerosis?
Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
67
With NAFLD what investigation is recommended to monitor for advanced liver fibrosis
enhanced liver fibrosis (ELF) testing is recommended to aid diagnosis of liver fibrosis, and this should be repeated every 3 years
68
What are the electrolyte abnormalities in refeeding syndrome?
hypophosphataemia hypokalaemia hypomagnesaemia: may predispose to torsades de pointes abnormal fluid balance
69
What patients are at high risk of refeeding syndrome if they have one or more of:
-BMI < 16 kg/m2 -unintentional weight loss >15% over 3-6 months -little nutritional intake > 10 days -hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)
70
What patients are high risk of refeeding syndrome if they have two or more of:
-BMI < 18.5 kg/m2 -unintentional weight loss > 10% over 3-6 months -little nutritional intake > 5 days history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids
71
What do NICE recommend in terms of feeding requirements if a patient hasn't eaten for >5 days
aim to re-feed at no more than 50% of requirements for the first 2 days.
72
What is reversible with treatment in haemaochromatosis
Cardiomyopathy and skin pigmentation
73
How is peutz-jegher's syndrome inherited
Autosomal dominant
74
What are the features of peutz jegphers 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
75
What are triggers of UC flares?
Stress, medications (NSAIDS, antibiotics), stopping smoking
76
What HLA gene is coeliac associated with
HLA-DQ2 (95% of patients) and HLA-DQ8 (80%).
77
What conditions should be screened for coeliac
Autoimmune thyroid disease Dermatitis herpetiformis Irritable bowel syndrome Type 1 diabetes First-degree relatives (parents, siblings or children) with coeliac disease
78
What are some 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
79
What % of chrohn's disease have small bowel invovlvement
80% of patients have small bowel involvement, usually in the ileum, with around 30% of patients having ileitis exclusively
80
What % of chrohn's disease have ileocolitis
50%
81
What % of chrohn's disease have colitis only
20%
82
What % of chrohn's disease have perianal disease
30%
83
What are some RF of HCC?
e main risk factor for developing HCC is liver cirrhosis, for example secondary* to hepatitis B & C, alcohol, haemochromatosis and primary biliary cirrhosis. Other risk factors include: alpha-1 antitrypsin deficiency hereditary tyrosinosis glycogen storage disease aflatoxin drugs: oral contraceptive pill, anabolic steroids porphyria cutanea tarda male sex diabetes mellitus, metabolic syndrome
84
What is the option for HCC: Child-Pugh A cirrhosis: No Portal HTN Single lesions <2cm
Surgical resection
85
What is the option for HCC :Child-Pugh A and B cirrhosis: 2-3 tumours <= 3 cm / 1 tumour <=5 cm No Vascular / Extrahepatic spread
Liver transplanation (bridge- TACE or RFA)
86
What is the option for HCC: Child-Pugh A or B cirrhosis: Good performance status, Vascular, Lymphatic / Extrahepatic spread
Tyrosine Kinase inhibitor, Sorafenib,
87
What is angiodysplasia?
vascular deformity of the gastrointestinal tract which predisposes to bleeding and iron deficiency anaemia. There is thought to be an association with aortic stenosis, although this is debated. Angiodysplasia is generally seen in elderly patients
88
How do you diagnose angiodysplasia
colonoscopy mesenteric angiography if acutely bleeding
89
What is the treatment for angiodysplasia
endoscopic cautery or argon plasma coagulation antifibrinolytics e.g. Tranexamic acid oestrogens may also be used
90
What is Heyde sydnrome
Heyde syndrome is a triad of aortic stenosis, an acquired coagulopathy and anaemia due to bleeding from intestinal angiodysplasia.
91
What does pseudoMembranous Colitis look like on sigmoidoscopy
White plaques NOTE IT IS C.DIFF
92
What is used to monitor treatment for haemochromatosis
Ferritin and transferrin saturation
93
What are the features of villous adenoma?
colonic polyps with the potential for malignant transformation. They characteristically secrete large amounts of mucous, potentially resulting in electrolyte disturbances. The vast majority are asymptomatic. Possible features: non-specific lower gastrointestinal symptoms secretory diarrhoea may occur microcytic anaemia hypokalaemia
94
What are the features of carcinoid syndrome including cardiac
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
95
What investigations are done for carcinoid syndrome?
urinary 5-HIAA plasma chromogranin A y
96
How much increase risk is there for HCC with primary biliary cholangitis/cirrhosis vs. general population
20 fold
97
What is the triad in budd chiari syndrome?
Ascites, abdominal pain, hepatomegagly (Tender)
98
What are causes of budd chiari sydnrome?
polycythaemia rubra vera thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies pregnancy combined oral contraceptive pill: accounts for around 20% of cases
99
What are the glasgow score for pancreatitis
PANCREAS
100
Apart from pancreatitis, what are some other causes of raised amylase?
Other causes of raised amylase include: pancreatic pseudocyst, mesenteric infarct, perforated viscus, acute cholecystitis, diabetic ketoacidosis
101
What is the typical demographic of esoinophilic oesphagitits
3:1 male:female ratio Average age at diagnosis is 30-50 years old rF: allergies/asthma, family hx, caucasian, coexisting autoimmune disease
102
What are the features of esosinophilic oesphagititis
dysphagia, strictures/ fibrosis (56%), food impaction (55%), regurgitation/ vomiting, anorexia
103
esosinophilic oesphagititis endoscopy features
diagnosis can only be made on the histological analysis of an oesophageal biopsy. There must be more than 15 eosinophils per high power microscopy field to diagnose the condition. Other findings on endoscopy include reduced vasculature, thick mucosa, mucosal furrows, strictures and laryngeal oedema. Histologically, the diagnosis is made more likely in the presence of epithelial desquamation, eosinophilic microabscesses, and abnormally long papillae
104
eosinophilic oesphagitits management
Dietiary modification, topical steroids, oesphageal dilation
105
eosinophilic oesphagitits complications

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