Gastroenterology Flashcards
What are used in the management of severe alcoholic hepatitis?
Corticosteriods
What is a common diabetic drug which can cause cholestasis?
Gliclazide
What drugs can cause a liver injury?
Paracetomal
Sodium valproate, phenytoin
MAIOs
Anti-TB drugs (isonizaid, rifampicin, pyrazinamide)
Statins
Alcohol
Amiodarone
Methyldopa
Nitrofurantoin
Drugs that can cause liver cirrhosis
Methotrexate
Methyldopa
Amiodarone
Diagnostic test of choice for pancreatic ca
CT
Risk factors for pancreatic cancer
Older age
Smoking
Diabetes
Chronic pancreatitis
HNPCRC
Multiple endocrine neoplasia
BRCA2 gene
KRAS gene mutation
Presentation of pancreatic cancer
Painless jaundice
- Pale stools
- Dark urine
- itchy
Cholestatic LFTs
Anorexia
Epigastric pain
Loss of exocrine function (steatorrhoea)
Loss of endocrine function (DM)
Possible atypical back pain
What is courvoisiers law?
The prescence of painless obstructive jaundice and a palpable gallbladder is unlikely to be due to gallstones
Investigations of pancreatic cancer
USS
CT
What may imaging show classically in pancreatic cancer?
The “double duct” sign -> the presence of similtaneous dilatation of the common bile and pancreatic ducts
Treatment of pancreatic cancer
Whipples resection
Adjuvant chemotherapy
ERCP + stenting usually used for palliation
What is a whipples resection?
Pancreaticoduodenectomy
What genes are most strongly associated with coeliac disease?
HLA-DQ2 + HLA-DQ8
What is coeliac disease?
Autoimmune disease which causes a sensitivity to the protein gluten
Conditions that are associated with coeliac disease
Dermatitis herpatiformis (vesicular puritic skin eruption)
T1DM
Autoimmune hepatitis
IBS
Autoimmune thyroid disease
Signs/symptoms of coeliac disease
Chronic or intermittent diarrhoea
Failure to thrive or faltering growth in children
Persistent or unexplained GI symptoms including N+V
Prolonged fatigue
Recurrent abdo pain / cramping / distension
Sudden / unexpected weight loss
Unexplained IDA or other anaemia
Complications of coeliac disease
Anaemia
Hyposplenism
Osteoporosis
Osteomalacia
Lactose intolerance
Enteropathy-assosiated T cell lymphoma of the small intestine
Subfertility
Rarely oesophageal cancer or other malignancies
What electrolyte abnormalities are most commonly seen in refeeding syndrome
Hypophosphataemia
Hypomagnesia
Hypokalaemia
Where is the mutation if you have familial adenomatous polyposis?
A tumour supressor gene called adenomatous polyposis coli gene (APC)
What are the 3 types of colon cancers?
Sporadic (95%)
HNPCC (5%)
FAP (<1%)
Inheritance of HNPCC
Autosomal dominant
Another name for HNPCC
Lynch syndrome
Most common genes in HNPCC
MSH2
MLH1
What other cancer except CRC are patients with HNPCC at risk of?
Endometrial
What criteria is used to aid diagnosis of HNPCC?
Amsterdam criteria
Amsterdam criteria of HNPCC
At least 3 family members with colon cancer
The cases span at least 2 generations
At least one case diagnosed before 50 y/o
Patients with FAP, alongside CRC are also at risk of what?
Duodenal tumours
What test is recommended for post eradication H pylori treatment?
Urea breath test
HbsAg implies what?
Acute Hep B disease (1-6months)
Surface antigen first marker to be produced in infection
If HbsAg present > 6 months, what does this imply?
Chronic disease i.e. infective
What does anti-Hbs imply?
Immunity (exposure or immunisation)
It is negative in chronic disease
What does anti-HbC imply?
Previous or current infection
What is HbeAg a marker of?
HBV replication and infectivity
What may trigger an UC flare?
Stopping smoking
Stress
NSAIDs
Abx
What is classed as mild UC?
<4 stools per day +/- blood
Nil systemic disturbance
Normal ESR + CRP
What is classed as moderate UC?
4-6 stools per day
Minimal systemic disturbance
What is classed as severe UC?
> 6 Stools / day -> containing blood
Evidence of systemic disturbance e.g.
- fever
- tachycardia
- abdo pain / distension / reduced bowel sounds
- anaemia
- hypoalbuminaemia
What is the most common cause of HCC worldwide?
Chronic hep B
What is the most common cause of HCC in europe?
Chronic hep C
Main risk factor for HCC
Liver cirrhosis
Risk factors for HCC
Liver cirrhosis
- hepatitis
- alcohol
- haemachromatosis
- PBC
alpha-1-antitrypsin defieicny
hereditary tyrosinosis
glycogen storage disease
aflatoxin
OCP
Anabolic steriods
Male
Diabetes
Metabolic syndromes
When does HCC tend to present?
Late
Presentation of liver disease
Jaundice
Ascites
RUQ pain
Hepatomegaly
Itchy
Splenomegaly
What tumour marker is looked at in HCC?
AFP
What is the screening is used for HCC?
USS
Who often gets screening for HCC?
Patients with liver cirrhosis 2ndry to hep B, C or haemachromatosis
Men with liver cirrhosis secondary to alcohol
Treatment of HCC
Early disease; surgical resection
Liver transplant
Radiofrequency ablation
Transaterial chemoembolisation
Sorafenib
What is whipples disease caused by?
Tropheryma whippelii infection
Who is whipples disease more common in?
HLA-B27 positive
Middle aged men
Presentation of whipples disease
Malabsorption; diarrhoea, weight loss
Large joint arthralgia
Lymphadenopathy
Hyperpigmentation and photosensitvity
Pleurisy
Pericarditis
Neurological sx; rare
Investigatin of whipples disease
Jejunal biopsy
Finding of biopsy in whipples disease
Deposition of macrophages containing PAS granules
Treatment of whipples disease
Oral co-trimox for a year
Sometimes followed by a course of IV penicillin
What is the strongest risk factor for anal cancer?
HPV infection
Increasing risk factors for HPV infection
Anal intercourse
High lifetime number of sexual partners
Risk factors for anal cancer
HPV
MSM
HIV
Immunosuppressive medications
Cervical cancer / CIN
Smoking
Presentation of anal cancer
Perianal pain
Perianal bleeding
Palpable lesion
Faecal incontinence
Fistulas
Investigations of anal cancer
CT/MRI/PET
Biopsy
What is Budd-Chiari syndrome?
Hepatic vein thrombosis
Causes of budd chiari syndrome
Polycythaemia rubra vera
Thrombophilia
Pregnancy
COCP
Triad of budd chairi syndrome
Abdominal pain, severe, sudden onset
Ascites
Tender hepatomegaly
Initial Ix for budd chairi syndrome
USS with doppler flow studies
What is the main risk factor for cholangiocarcinoma?
PSC
Presentation of cholangiocarcinoma
Persistent biliary colic symptoms
Anorexia
Jaundice
Weight loss
Palpable mass RUQ
Periumbilical lymphadenopathy and left supraclavicular adenopathy
What tumour marker may be raised in cholangiocarcinoma?
CA 19-9
Most appropriate treatment for variceal haemorrhage whilst waiting for endoscopy?
Terlipressin
Prophylaxis of variceal haemorrhage
Propranolol
Endoscopic band ligation
TIPSS
What can happen if H pylori is left untreated?
PUD
Gastric cancer
B cell lymphoma of malt tissue
Atrophic gastritis
Treatment of H pylori
7 day eradication therapy of
- PPI + amoxicillin + (clarithromycin or metronidazole)
- PPI + Clari + metronidazole if pen allergic
Most common causes of acute upper GI bleed
Oesophageal varices
Peptic ulcer disease
Presentation of upper GI bleeding
Haematemesis
Melena
Raised urea
What is the screening test for haemachromatosis?
Transferrrin saturation > ferritin
What gene are family members tested for in haemachromatosis?
HFE genetic testing
What is haemachromatosis?
Autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation
What is the typical iron study in a patient with haemachromatosis?
Transferrin saturation > 55% in men or >50% in women
Raised ferritin and iron
Low TIBC
Management of haemachromatosis
- Venesection
- Desferrioxamine
If C diff does not respond to first line treatment, in the abscence of life threatning features, what should be used next?
Oral fidaxomicin
Risk factors for C diff
C antibiotics
PPIs
Presentation of C diff
Abdo pain
Diarrhoea
Raised WCC
Complication of C diff
Toxic Megacolon
Diagnostic testing of C diff
C diff toxin in stool
1st line treatment of C diff
Oral vancomycin for 10 days
Second line treatment of C diff
Oral fidaxomicin
Third line treatment for C diff
Oral vanc +/- IV metronidazole
What is seen on a CXR characteristically with achalasia?
Retro-cardiac air fluid level
Wide mediastinum
What is achalasia?
Failure of oesophageal peristalsis and relaxation of the LOS due to generative loss of ganglia from Aucherbachs plexus i.e. LOS contracted, oesophagus above dilatated
Presentation of achalasia
Dysphagia of both SOLIDS AND LIQUIDS
Variation in severity of symptoms
Heartburn
Regurgitation of food (may lead to cough, aspiration pneumonia etc)
Definition of dysphagia
Difficulty swallowing
Investigations of achalasia
Oesophageal mamometry
Barium swallow
CXR
Treatment of achalasia
Pneumatic ballon dilatation
Surgical intervention with Heller cardiomyotomy if recurrent or persistent symptoms
Intra-sphincteric injection of botulinium toxin in patients high surgical risk
What inheritance is haemachromatosis?
Autosomal recessive
Presentation of haemachromatosis
Fatigue
Erectile dysfunction
Arthralgia (often in hands)
Bronze skin pigmentation
DM
Sigmata of chronic liver disease
Cardiac failure 2ndrly to dilated cardiomyopathy
Hypogonadism 2ndry to cirrhosis and pituitary dysfunction
Arthritis (particularly of hands)
1st line test for coeliac disease
Tissue transglutaminase antibodies
First line investigations for coeliac disease
- TTG antibodies
- Endoscopic intestinal biopsy
Biopsy Findings supportive of coeliac disease
Villous atrophy
Crypt hyperplasia
Increase in intraepithelial lymphocytes
Lamina propria infiltration with lymphocytes
Sulphazalazines such as mesalazine can cause what in men?
Oligospermia and infertility
Complications of acute pancreatitis
Peripancreatic fluid collections
Pseudocysts
Pancreatic necrosis
Pancreatic abscess
Pancreatic haemorrhage
Acute respiratory distress syndrome
What antibiotic is a well recognised cause of cholestasis?
co-amoxiclav
How does gastrin work?
Increases H+ secretion by gastric parietal cells
If a patient who had severe UC has had a severe relapse or >2 exacerbations in the past year, what should they be given?
Oral azathioprine or oral mercaptopurine
Treatment for proctitis in UC
Topical rectal aminosalicylate
If remission is not achieved within 4 weeks, add oral aminosalicylate
If remission still not achieved, add topical or oral corticosteriod
Treatment for proctosigmoiditis and left sided colitis
Topical rectal aminosalicylate
If remission not achieved within 4 weeks, add high dose oral aminosalicylate or switch to high dose oral aminosalicylate and a topic corticosteriod
If remission still not achieved stop topical treatments and offer oral aminosalicylate and oral corticosteriods
Treatment for extensive UC disease
Topical rectal aminosalicylate and high dose oral aminosalicylate
If remission not achieved in 4 weeks, stop topical treatments and offer high dose aminosalicylates and oral corticosteriods
Treatment of severe colitis
IV steriods
If no improvement by 72 hrs, consider adding IV ciclosporin or consider steriods
What hormone is released in response to a fatty meal and what cells release this?
CCK
Released by I cells
What is a recognised complication of cholecystectomies?
Post cholycystectomy syndrome
Incidence of post cholycystectomy syndrome
up to 40%
Presentation of post cholycystecotmy syndrome
Dyspepsia
Vomiting
Pain
Flatulence
Diarrhoea
Management of post cholycystectomy syndrome
Low fat diet
Bile acid sequestrants e.g. cholystyramine
PPIs symptomatically
Where is somastatin released from?
D cells in the pancreas and stomach
Presentation of oesophageal cancer
Anorexia / weight loss
Dysphagia - progressive
Vomiting during eating
Assosiations of oesophageal cancer
Barretts oesophagus
GORD
Smoking
Alcohol XS
Risk factors for oesophageal candidiasis
HIV
Steriod inhaler use
Who is a pharyngeal pouch common in?
Older men
Presentation of pharyngeal pouch
Dysphagia
Regurgitation
Aspiration
Chronic cough
Halitosis
What is a pharyngeal pouch?
A posteriomedial herniation between thyropharyngeus and cricopharyngeus muscles
Presentation of myasthenia gravis
Progressive fatigue
Dysphagia with both liquids and solids
Extraocular muscle weakness / ptosis
Extrinsic causes of dysphagia
Mediastinal masses
Cervical spondylosis
Oesophageal wall causes of dysphagia
Achalasia
Diffuse oesophageal spasm
Hypertensive lower oesophageal spasm
Intrinsic causes of dysphagia
Malignancy
Strictures
Oesophageal web
Schtazi webs
Neurological causes of dysphagia
CVA
Parkinsons disease
MS
Brainstem pathology
Myasthenia gravis
Treatment of wilsons disease
Penicillamine
Inheritance of wilsons disease
Autosomal Recessive
What is wilsons disease?
Autosomal recessive disorder characterised by exessive copper deposition in tissues
What genetic abnormality causes wilson disease?
Defect in ATP7B gene located on chromosome 13
Presentation of wilsons disease
Hepatitis
Liver cirrhosis
Basal ganglia degeneration
Speech, behavioural and psychiatric problems
Aterixis
Chorea
Dementia
Parkinsonism
Kayser FIscher rings
Renal tubular acidosis
Haemolysis
Blue nails
What are katser fischer rings?
Green brown rings in the periphery of the iris
Investigations for wilsons disease
Slit lamp examination
Low serum careoplasmin
Reduced total serum copper
Free serum coppler is increased
Increased 24hr urinary copper excretion
How is the diagnosis of wilsons disease confirmed?
Genetic analysis of the ATP7B gene
How does penicillamine work in wilsons disease?
Chellates copper
