Gastroenterology Flashcards
Presentation of boerhaves
Vomiting hisotry
Tearing chest pain
Vomiting blood
Crepitus on ausculataion of chest
What is use of amylase in pancreatitis
Diagnostic value but no prognostic value
Lipase is the most sensitive and specific
Investigations for chronic pancreatitis
CT pancreas for diagnosis
Faecal elastase for monitoring exocrine function
Management of acute pancreatitis
A-E
Extensive fluids
IV opioids
Fed orally with whatever can tolerate
LMWH
What causes jaundice and intermittent pain post cholecystectomy
Common bile duct gallstones
What is investigation of choice for boerhaaves syndrome
CT contrast swallow
Person with crohns has jaundice
Bile duct stones as reduced enterophepatic recycling
What causes a patient to become breathless post laparascopic surgery
Surgical emphysema
What is the gingko sign
In subcut emphysema you can get outlining of the pectoralis muscles
RUQ pain and fever, how differentiate cholangitis and cholecystitis
In cholangitis it is likely that LFTs would be raised
What are the types of haemorrhoid
Internal
- above dentate line
- no pain typically
External
- below dentate line
- painful and thrombose
*dentate line separates upper and lower anus
Management of asymptomatic hernia if not fit for surgery
Hernia truss- like a strap
Associations of sigmoid volvulus
Old
Constipation
Chagas disease
Neurological conditions- parkinsons, DMD
Management of sigmoid volvulus
Rigid sigmoidoscopy with patient in left lateral position with rectal tube insertion later to drain
If unstable may need hartmanns or laporotomy
Management of caecal volvulus
Operative- may need right hemicolectomy
What counts as dilated small bowel, large bowel and caecum
SB- 3cm
LB- 6cm
Caecum- 9cm
Management of post operative ileus
If severe then NG tube on free drain and NBM
Acute vs chronic anal fissure
Acute= <6 weeks
Chronic= >6 weeks
What must do if anal fissure found elsewhere to posterior midline
Exclude other causes like crohns
How manage an acute anal fissure
Advice about softening stool with lots of water and fibre
Bilk forming laxatives
Topical lidocaine
Can consider GTN
How manage a chronic anal fissure
First line is topical GTN
What do if topical GTN not effective after 8 weeks for anal fissure
Refer to surgery for either sphincterctomy or botulinum toxin
What causes a cardiac failure patient to have a poor appetite and feel bloated
Ascites
What type of cancer is anal
Squamous cell carcinoma
Risk factor for anal cancer
HPV
Differentials for an itchy anus
Haemorrhoids
Anal cancer
What makes a hernia incarcerated
If it cant be reduced
What makes a hernia strangulated
If blood supply becomes restricted
What is management plan for hepatic adenoma
If haemorrhagic or other severe symptoms then surgery to remove
How do amoebic abscess appear on USS
Fluid filled with poorly defined boundaries
Aspiration of what liver lesion gives odourless fliod with anchovy paste consistency
Amoebic abscess
What is treatment of amoebic abscess
Metronidazole
Management of hydatid (echinococcus) cysts
Mebendazole
Surgical resection
NOT PERCUTANEOUS
What is cullens sign vs grey turners
Bruising around the umbilicus= cullens
Bruising in the flanks= grey turners
Causes of cullens sign
Pancreatitis
Ectopic pregnancy
What is boas sign
Hyperasthesia (extreme sensitivity) in the area beneath the right scapula
What can lead to faecal matter passing from the vagina
Diverticular disease causing fistula
How manage thrombolysed haemrrohoids
Will eventually resolve
Ice packs
Stool softeners
Analgesia
Can consider referral if within 72 hours and excruciatingly painful
What organism gives foul smelling stool that floats
Giardia
What organism is associated with lactose intolerance during its infection
Giardia
Where are the majority of colorectal cancers
Rectum
What do if male over 60 presents with IDA
Refer under 2WW for colonoscopy
Factors indicating a hernia is strangulated vs incarcerated
Blood in stool
Severe pain
Bowel obstruction
What is seen on AXR of caecal volvulus
Centrally dilated loops of bowels
What are epigastric hernias versus paraumbilical hernias
Epigastric- lie between umbilicus and xiphisternum
Paraumbilical- either directly above or below the umbilicus
What are the 2 types of cholecystectomy and when do
Laparascopic- either elective or if stable within a week of cholecystectomy
Open with kocher incision- haemodynamic instability
Causes of proctitis
IBD
C diff
Gonorrhoea
Chlamydia
Shigella
How to differe between haemorrhoids and fissure
Fissure painful
Haemorrhoids only painful if thrombosed
What are the dukes criteria for colorectal cancer
A- confined to mucosa
B- invading the bowel wall
C- lymph node mets
D- distant mets
What are topical anal fissure treatments
GTN
Diltiazem
How can colovesical fistulas present
Passing stool and air in the urine
How image colovesical fistulas
Abdominal CTs
If have diverticular disease causing obstruction, how manage
Laparotomy
What is difference in management for bilateral vs unilateral inguinal hernias
Bilateral= laparoscopic
Unilateral= open
Both mesh repair
Difference between indirect and direct inguinal hernias
Direct hernias go through weakness in hasselbachs triangle
Indirect enter the inguinal canal through the superfical ring
Which syndromes presdispose you to hamartomas
Cowden disease
Peutz jeughers
Syndrome with freckling and colorectal cancer
Peutz jeughers
What is a richter hernia
When wall of bowel herniates through fascial defect
What is different about presentation of richter hernia
Presents with strangulation symptoms but without obstructive sx
How differentiate whether large or small bowel dilated
Small bowel has lines going across- valvulae conniventes
Large bowel has haustra
What is management of cholecystitis
Do cholecystectomy within 1 week if not then do in 6 weeks
What is scoring system for pancreatitis severity
Glasgow imrie- done 48 hours after onset
Inducing remission in mild to moderate UC
Mild to moderate left sided UC
1st= rectal mesalazine
2nd= oral mesalazine
3rd= oral or topical steroid
Mild moderate extensive UC
1st= rectal and oral mesalazine
2nd= stop topical and offer oral mesalazine and corticosteroid
Inducing remission in severe UC
Admit to hospital
IV steroids
What can give IV as alternative to steroids in severe UC
IV ciclosporin
Maintaining remission following UC flare
Mild to moderate proctosigmoiditis
- topical ASA or oral and topical ASA
Mild to moderate extensive UC
- oral ASA
Severe or over 2 exacerbations in last year
- oral azathioprine or mercatopurine
What test use for post eradication therapy of H pylori
Urease breath test
First line management of haemochromatosis
Venesection
Second line option for haemochromatosis after venesection
Desferrioxamine
Aims of venesection treatment in haemochromatosis ie what monitor
Keep transferrin saturations below 50%
Keep ferritin below 50
Most useful screening test for haemochromatosis
Transferrin saturations
How screen family members of haemochromatosis patient
Genetic testing for HFE mutation
Investigations for haemochromatosis
Iron screen
LFTs
Molecular test
Liver biopsy
MRI can quantify liver iron
What scan quantify liver iron quantity
MRI
Oesophageal causes of upper GI bleeding
Varices
Cancer
Oesophagitis
Mallory weiss tear
Gastric causes of upper GI bleeds
Ulcer
Cancer
Dieulafoy lesion
Erosive gastritis
Duodenal causes of upper GI bleeding
Ulcers
Aorto-enteric fistula
What causes aorto-enteric fistula
Recent abdominal aortic aneurysm aneurysm surgery
What causes massive GI bleeding in post abdominal aortic aneurysm surgery
Aorto-enteric fistula
2 most common causes of upper GI bleeds
Peptic ulcer disease
Oesophageal varices
How risk assess patient with upper GI bleed
Glasgow batchford score on first assessment
What use to risk stratify upper GI bleed patients post endoscopy
Rockall
How can manage upper GI bleed with batchford of 0
Discharge
Resus management of upper GI bleed
ABC
Offer FFP, plt transfusions or prothrombin complex depending on blood features
Wide bore access
Offer endoscopy
When give platelet transfusion in upper GI bleed
Plts less than 50
Management of variceal bleeding
ABC
IV access
Terlipressin and prophylactic abx
Endoscopy- band ligation for oesophageal varices or ablation with N-butyl-2-cyanoacrylate for gastric varcies
Transjugular intrahepatic portosystemic shunts if these fail
What do if endoscopy band ligation and cryoablation fail
Transjugular intrahepatic portosystemic shunts
What is a transjugular intrahepatic portosystmic shunt
Shunt created between portal vein and systemic vein to reduce portal HTN
What is difference in endoscopy management of gastric vs oesophageal varcies
Oesophageal- band ligation
Gastric- ablation with N-butyl-2-cyanoacrylate
If have post hepatic cause of jaundice, what would indicate pancreatic cancer over PSC or PBC
Anorexia
Smoking hx
How investigate post streptococcal glomereulonephritis
Anti streptolysin titre
Complement levels- low C3
How differentiate between IgA nephropathy and post strep glomerulonephritis
IgA 1-2 days after infection vs 1-2 weeks in PSG
Proteinuria and low complement in PSG
What is most likely abdo mass felt on examination of pancreatic cancer
Hepatomegaly from mets
What is trousseaus sign and what seen in
Migratory thrombophlebitis seen often in pancreatitis
What is courvoisiers law
In presence of painless jaundice, palpable gallbladder most likely caused by pancreatic cancer
What is double duct sign
Dilatation of the pancreatic and common bile ducts from pancreatic cancer
Inheritance of wilsons and haemochromatosis
AR
Signs on examination of wilsons
Blue nails
Keyser fleischer rings- brown ring
Neurological manifestations of wilsons
Basal ganglia deposition
- chorea
Cerebellar
- tremor
Dysarthria
Psychiatric
- depression
- mania
- pscyhosis
RFs for non-alcoholic fatty liver disease
Obestiy
T2DM
High lipids
Sudden weight loss/starvatino
What effect can rapid weight loss have on the liver
NAFLD
Which liver enzyme is most raised in NAFLD
ALT greater than AST
Investigation findings of NAFLD
ALT greater than AST
Increased echogenicity in liver on USS and fibroscan
What is first line investigation for NAFLD
Enhanced liver fibrosis blood test- combination of proteins which gives a score
Management of variceal haemorrhages
ABC
Terlipressin
Corrective blood products if indicated
IV quinolones if cirrhosis
What do if medical options for stopping variceal bleedings have not work and still awaiting OGD
Sengstaken blakemore tube
What is main complication of transjugular intrahepatic portosystemic shunt
Exacerbation of hepatic encephalopathy
Treatment options for variceal bleeds
Blood products depending on situation
- FFP
- platelets
- prothrombin complex
Terlipressin
Antibiotics if cirrhosis
OGD
Sengstaken blakemore tube
TPISS
What can be done to prevent further varcieal haemorrhages
Prophylactic propanolol
Endoscopic ligation
TIPSS
First line dementia investigations
In primary care do baseline bloods
- FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12 and folate
In secondary care when referred to memory clinic do neuroimaging
Histology of crohns
Inflammation in all layers from mucosa to serosa
Increased goblet cells
Granulomas
Histology of UC
Inflammaion confined to submucosa
Crypt abscesses
Goblet cells depletion
Endoscopy appearance of crohns
Deep ulcers
Cobble stone appearance
Skip lesions
Endoscopy of UC
Widespread ulceration
Pseudopolyps
Radiological choice for crohns vs UC
Crohns- small bowel enema
UC- barium enema
Small bowel enema findings in crohns
Strictures
Proximal bowel dilatoin
Rose thorn ulcers
Fistulae
Barium enema findings in UC
loss of haustrations
superficial ulceration, ‘pseudopolyps’
Management of alcoholic hepatitis
Prednisolone
LFT ratios in alcoholic hepatitis
AST:ALT normally >2 but >3 is indicative of alcoholic hepatitis
What are types of GI ischaemic disease
Acute mesenteric ischaemia
Chronic mesenteric ischaemia
Ischaemic colitis
Main rf mesenteric ischaemia
AF
Presentation of mesenteric ischaemia
Acute onset abdo pain
Very severe and out of keeping with physical exam
Management of acute mesenteric ischaemia
Laparotomy ASAP
Presentation of chronic mesenteric ischaemia
Intestinal angina
Colicky abdo pain after eating
Weight loss
What is thumbprinting on AXR seen in
Ischaemic colitis
What is ischaemic colitis
Acute but transient vascular compromise to large bowel leading to ulceration and haemorrhage
Management of ischaemic colitis
Conservative
Surgery if needs be
Investigation of choice for ischaemic colitis
CT
Rfs for ischaemic colititis
CVD rfx
Can get in young people following use of cocaine
What can cause ischaemic colitis in young person
Cocaine use
Man with IHD and HTN presents with abdo pain and bleeding
Ischaemic colitis
Features of ischaemic bowel disease
abdominal pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings
rectal bleeding
diarrhoea
fever
bloods typically show an elevated white blood cell count associated with a lactic acidosis
Blood findings in ischaemic bowel disease
WCC raised
Lactic acidosis
Antibiotics associated with c diff
Clindamycin
Cephalosporins (2nd and 3rd gen)
What is test for c diff
Toxin PCR assay from stool sample
What does positive c diff antigen indicate
Only exposure to bacteria rather than infection
Management of life threatening C diff
IV metro
Oral vancomycin
What makes c diff life threatening
Hypotension
Ileus
Toxic megacolon
Mild, moderate and severe c diff criteria
Mild- normal WCC
Moderate- WCC up but less than 15
Severe- above 15
Management of non lifethreatening c diff
Oral vanco first line
Second line c diff maangement
Oral fidaxomicin
Third line c diff management
Oral vanco and IV metro
Investigation of choice for budd chiari
US with doppler studies
Triad for budd chiari
Abdo pain, severe and sudden
Ascites-> abdominal distension
Tender hepatomegalyR
Rfs for budd chiari
Polycythaemia rubra vera
COCP
Pregnancy
Thrombophilias- protein C resistance, antithrombin deficiency, protein S and C deficiency
Which cancer does barretts oesophagus lead to
Adenocarcinoma
What does grey coloured stools indicate
Steatorrhoea
What are 2 lymph node signs of gastric cancer
Virchows node
Sister mary joseph nodule- periumbilical
Notable foods which do not contain gluten
Rice
Potato
Corn
Maize
How manage liver abscesses
Drainage and antibiotics
When testing for coeliac how long must be eating gluten for beforehand
6 weeks
Inducing remission in crohns disease
Glucocorticoids- oral or IV depending on severity
Second line drug for inducing remission in crohns
5-ASAs
First line for maintaining remission in crohns
Azathioprine or mercatopurine
What need to mesure bfore starting azathioprine
TPMT
Investigation of choice for perianal fistula
MRI
Management of symptomatic perianal fistula
Oral metronidazole
Management of perianal abscess
Incision and drainage
What can be used for complex perianal fistulae
Draining seton
Early signs of haemochromatosis
Fatigue
Arthralgia
Erectile dysfunction
Antibodies for T1 autoimmune hepatitis
ANA
Anti smooth muscle
Raused IgG
Antibodies for T2 autoimmune hepatitis
Anti liver kidney type 1 microsomal
What give for bile acid bile absorption
Cholestyramine
Causes of bile acid malabsorption
Ileal disease- crohns
Cholecystectomy
Coeliac disease
Management of H pylori ulcers
Triple therapy
- PPI
- 2 of amoxicillin, clarithomycin or metronidazole
If associated with NSAIDs give 2 months PPI first then abx
In a TIPSS, where is connection made between
Hepatic and portal vein
What is MOA of metoclopramide
Dopamine 2 receptor antagonist
Side effects of metocloprmaide
Extrapyramidal side effects
Diarrhoea
High prolactin
If patient to have endoscopy what do with PPI or omeprazole
Stop 2 weeks prior
If uncertain what use to differentiate upper from lower GI bleed
Serum urea
What is melanosis coli
Pigment disorder in the bowel caused by laxatives
What causes pigment laden macrophages in the bowel
Melanosis coli
What is most common cause of melanosis coli
Laxatives
Risk factors for squamous cell carcinoma in oesophagus
Achalasia
Plummer vinson
Smoking
Alcohol
What on examination suggests peritonitis
Guarding
Rigid abdomen
Distension
Diffuse pain all over
Which artery most likely involved in bleeding posterior duodenal ulcer disease
Gastroduodenal
Presentation of peptic ulcer disease
Most common presentation is haematemesis
Malaena
Hypotension and tachycardia
Management of peptic ulcer bleeding
ABC
IV proton pump inhibitor after endoscopy
Endoscopic intervention
What are options if endoscopic intervention is unsuccessful for peptic ulcer bleeding
Interventional angiography with transarterial embolisation
Surgery
Additional management of coeliac
Due to functional hyposplenism, pneumococcal vaccine given every 5 years
Triad for plummer vinsons
Dysphagia
Glossitis
IDA
Which drugs can cause cirrhosis
Methotrexate
Amiodarone
Methyldopa
Sodium valproate
Mild, moderate and severe true love witts
Mild- Fewer than 4x a day
Moderate- four to 6x a day
Severe- over 6x a day with systemic upset
- fever
- tachycardia
- anaemia
- distension
If recurrent relapses of UC, what give
Azathioprine or mercatopurine
What is lynch syndrome
HNPCC
Long term risk of PPIs
Osteoprosis
What does a musty and sulfur breath smell suggest
Fetor hepaticus- liver failure
Management of dyspepsia with no red flag symptoms
Full dose PPI for 1 month
What is barretts oesophagus
Where squamous epithelium is replaced with columnar epithelium
First line for PBC
Ursodeoxycholic acid- can helo slow progression
What can be used to treat itching from obstructive liver problems
Cholestyramine
Treatment of PBC
Ursodeoxycholic acid
Fat soluble vitamins
Cholestyramine for itching
Liver transplant if necessary
Diagnostic investigation for PSC
MRCP
What malignancy does coeliac increase risk of
Enteropathy associated T cell lymphoma
What do for oral vanc and fidaxomicin refractory mild or moderate c diff
Change to oral vanc and IV metro
What is acalculous cholecystitis
Inflammation of the gallbladder in absence of gallstones
Typically seen in diabetic with intercurrent illness
Management of acalculous cholecystitis
Cholecystectomy
Outcomes supposed to be worse than in calculous
When do test for eradication of H pylori
6-8 weeks after
What is given for every patient with hepatic encephalopathy
Lactulose to promote excretion of ammonia
Rifamixin reduces ammonia production
When distinguishing between UC and Crohns from history, what does blood in stool point towards
UC
Management options for achalasia
Pneumatic balloon dilation
Heller cardiomyotomy
Intra sphincteric botulinum toxin
What use first line for achalasia
Pneumatic balloon dilation
What use for recurrent achalasia
Heller cardiomyotomy
What use for achalasia if high risk candidate for surgery
Intra sphincteric botulinum toxin
What is spontaneous bacterial peritonitis
Form of peritonitis seen in liver cirrhosis patients with ascites which becomes infected with bacteria
Most common cause of SBP
E coli
What is diagnostic for SBP
Paracentesis with neutrophil count over 250
Management of acute SBP
IV cefotaxime
What give long term if has episode of SBP
Ciprofloxacin prophylaxis
Which patients do you give prophylactic ciprofloxacin to
At least 1 episode of SBP
Low protein in ascites
When do you add an oral ASA to a mild/moderate UC flare
If extends beyond the left colon as enemas can only go so far
What does fever suggest about an UC flare up with regards to severity
Severe
Complications of GORD
oesophagitis
ulcers
anaemia
benign strictures
Barrett’s oesophagus
oesophageal carcinoma
MOA of terlipressin
Vasopressin analogue
What is advice to men and women around regarding alcohol intake
No more than 14 units a week
Spread evenly over 3 days or more
Causes of odonyphagia
Oesophageal candidiasis
Cancer
Eosinophillic oesophagitis
What is operation used for GORD
Fundoplication
What are investigations needed before fundoplication surgery
Oesophageal pH
Manometry
What is manometry
Study used which looks at how well nerves and muscles work in GI tract
Management of barretts oesophagus
PPI
Endoscopic surveillance
- if any dysplasia noted here intervention required
What do if any dysplasia noted on endoscopy of barretts patient
Endoscopic intervention
Options include radiofrequency ablation or resection
What happens to liver enzymes in end stage cirrhosis
Become low, aren’t elevated
Best measure of long term liver dysfunction
Albumin
What need to do if someone presents with sudden onset dysphagia of any age
Urgent endoscopy
If patient with history of tracheo-oesophageal fistula surgery presents with dysphagia, what is likely cause
Benign stricture
Prior to doing a urease breath test, when need to stop A) Antibiotics B) PPIs
Antibiotics- 4 weeks
PPIs- 2 weeks
What must always do in examination of a male with RIF or LIF pain
Examine testicles
What do yellow plaques on sigmoidoscopy suggest
Pseudomembranous colitis
Rfx for gastric cancer
Pernicious anaemia
H pylori
Smoking
How is cirrhosis best diagnosed
Liver fibroscan nowadays
Liver biopsy optimal in the past but very painful
What investigation is needed for all patients with new cirrhosis diagnosis
Endoscopy to look for varices
What investigations are done to monitor cirrhosis
Screening for HCC with USS and AFP every 6 months
Calculate MELD/ 6 months
Endoscopy every 3 years for varices
What is most sensitive and specific test for determining if chronic liver disease has converted to liver cirrhosis
Plt count under 150,000
Management of pharyngeal pouch
Refer to ENT
Mainstay is surgery
Can watch and wait if mild or unfit for surgery
What is the diagnosis
UC- leadpipe appearance
What is zenkers diverticulum
Pharyngeal pouch
Investigation of choice for pharyngeal pouch
barium swallow combined with dynamic video fluoroscopy
Pharyngeal pouch
What is SAAG + equation
Serum ascitic albumin gradient
Serum albumin- ascitic fluid albumin
SAAG over 11 causes
Liver problems cauing portal HTN
HF
Budd chiari
SAAG under 11 causes
Nephrotic syndrome
TB peritonitis
Pancreatitis
SBO
Peritoneal carcinomatosis
Serositis from connective tissue disorders
Wilsons disease management
Penicillamine
What on examination of abdomen can point to a diagnosis of intestinal angna
Bruit over abdomen
Best antibody for pernicious anaemia
Anti intrinsic factor
Dark blue spots in and around mouth in context of bowel problems
Peutz jeughers
First line for constipation in IBS
Bulk forming laxative (ispaghula husk)
Avoid stimulant laxative
If on clopidogrel, which PPI use
Lansoprazole as omeprazole decreases efficacy of clopidogrel
Which antiemetic give for migraine
Metoclopramide
What can trigger UC flares
Stress
Medications- NSAIDS and antibiotics
Cessation of smoking
What defines toxic megacolon
Transverse colon length over 6cm
How to prevent ascites
Dietary sodium restriction
What is serum copper in wilsons
Low
First line investigation for suspected perforated ulcer disease
Erect CXR
Patient with sudden extensive weight loss alongside raised liver enzymes
NAFLD
Most common side effect of metoclopramide
Diarrhoea
How decide which endoscopy to do to diagnose UC
Colonoscopy is preferred option however if severe inflammation evidence then do flexi sigmoidoscopy as risk of perforation
What does air in bile duct suggest
Fistula to bowel often causing gallstone ileus
Main side effects of aminosalicylates to be worried about
Agranulocytosis
Pancreatitis
UC due to loss haustration
What is occluded in budd chiari
Hepatic vein
Oesophageal candidiasis rfx
HIV
Steroid inhalers
IV abx
Oesophageal candidiasis presentation
Odonyphagia
Dysphagia
White streaks
What causes dysphagia in a oesophageal cancer survivor
Post radiotherapy fibrosis
Which medications must stop if have c diff
Opioids as anti peristalsic
What is the most common type of inherited colorectal cancer
HNPCC
What diagnoses malnutrition
Unintentional loss of 10% in last 6 months
How can refeeding present
Arrythmias
Poor fluid balance
What need to give alongside paracentesis
IV human albumin
Most common cause of HCC in world vs europe
World- Hep B
Europe- Hep C
First line investigation for mesenteric ischaemia
VBG
What is formal boundary between lower and upper GI bleeds
Ligament of treitz between the duodenum and jejunum
Causes of raised ferritin in absence of iron overload
Inflammation
Cancer
CKD
Alcohol
Liver disease
Causes of iron overload
HH
Transfusions
Other than potassium, what electrolyte can become very low after vomiting
Chloride
Grading of hepatic encephalopathy
Grade 1- irritable
Grade 2- confused or abnormal behaviour
Grade 3- incoherent and restless
Grade 4- coma
What do with antiplatelets for severe bleeding
Nothing
What is important test to do on examination if GI bleed
Check for postural drop
What will cause low urea
Liver disease
When do OGD if evidence of active bleeding
Within 4 hours
What does blood mixed in with stool tell you about location of the cancer
Unlikely to be a distal tumour as would be fresh in that instance
Presentation of chronic pancreatitis
Typically initially get epigastric pain then a few years later develop steatorrhoea
Management of steatorrhoea in chronic pancreatitis
Pancreatic enzyme replacement which will help absorb fats as less endogenous lipase production
Causes of cholangitis
Stones
Strictures
Malignancy
ECRP
Pancreatitis
Mirizis
Management of haemorrhoids (nonthrombosed) first line
Increasing fibre and fluid intake
If no response to increased fluid and fibre intake plus simple anaglesia, what do for painful haemorrhoids
Topical preparations including lidocaine and steroids
Management order for haemorrhoids
Primary care
- Increase fluid/fibre intake
- Topical preparations with steroids and lidocaine
Secondary care procedures
- sclerotherapy
- band ligation
Surgical
- haemorrhoidectomy
- artery ligation
- stapled haemorrhoidopexy
Factors which make encourage refer to hospital for haemorrhoids
Grade 3 or 4
Very large
Extremely painful
What comment on in examination of hernia which is helpful to assess risk
The neck size
Wide is low risk as hernia can fall out
Investigation for bile acid malabsorption
SeHCAT- nuclear medicine test
What drug can be used for treatment of abdominal pain associated with IBS
Meberverine hydrochloride (antispasmodic)
what do you need to monitor with chronic pancreatitis
HbA1c every 6 months
DEXA every 2 years
2 types of metaplasia in GORD
Squamous to columnar
1. with goblet cells= intestinal metaplasia
2. without goblet cells= gastric metaplasia
What is 2ww investigation for liver cancer
USS
Pancreatic cancer 2ww guidelines
Over 40 with jaundice
Over 60 with weight loss + 1 of
- Diarrhoea
- Back pain
- Abdominal pain
- Nausea
- Vomiting
- Constipation
- New-onset diabetes
2WW for upper GI sx (suspected stomach ca)
Anyone with dysphagia, or
Over 55 with weight loss and 1 of
- Upper abdominal pain
- Reflux
- Dyspepsia
Do endoscopy
GORD symptoms
Nocturnal cough
Dyspepsia
Hoarse voice
Metallic taste
GORD management
Lifestyle- avoid alcohol, smoking, spicy foods, eat early
PPI for 1 month
Options after include ranitidine, double PPI dose or gastro referral
Can consider nissen fundoplication
Long term GORD complications
Barrets
Adenocarcinoma
Strictures
What are tests for h pylori
Stool antigen test
Urea breath test using radiolabelled carbon 13
H. pylori antibody test
Rapid urease test performed during endoscopy (also known as the CLO test)
How does CLO test work
Done at endoscopy
Take sample then add to urea and test pH, will become alkaline if positve
Gastric vs duodenal ulcer presentation
Pain on eating in gastric
Weight loss likely in gastric vs can put on weight in duodenal
What do for follow-up if peptic ulcer identified on endoscopy
Need to repeat endoscopy 6-8 weeks later
Complications of peptic ulcers
Perforation
Cancer
Strictures leading to gastric outflow obstruction
Management of gastric outflow obstruction
Balloon dilatation or stent
Achalasia investigations
Endoscopy done first to rule out obstructive dysphagia causes
Special investigations include
- oesophageal manometry showing poor relaxation of lower sphincter (gold standard)
- barium swallow (birds beak)
- CXR will show widened mediastinum
Diffuse oesophageal spasm
Boerhaaves management
Thoracotomy with lavage
Eosinophilic oesophagitis features
Painful dysphagia
Inflammation leads to strictures and fibrosis
Inflammation with eosinophil infiltrates
Management of eosinophilic oesophagitis
Swallow steroid containing fluids which line oesophagus
Endoscopic dilation of strictures
Management of PSC
Cholestyramine helps with itching
Stents if dominant stricture
Liver transplant definitive
PBC management
Ursodeoxycholic acid
Cholestyramine
Fat soluble vitamin replacements
Liver transplant
Investigations for autoimmune hepatitis
Antibodies- ANA, anti-smooth muscle
Liver biopsy will diagnose
Management of autoimmune hepatitis
Prednisolone and azathioprine
If severe then transplant
Chronic pancreatitis management
Pancreatic enzyme replacement
ERCP for strictures
Analgesia
Insulin regime if diabetic
Flexed middle finger that can be resolved by pulling out and hear a pop
Trigger finger
Investigations for wilsons
Low serum caeruplasmin
24 hour urinary copper collection
FBC- haemolytic anaemia
Liver biopsy
Presentation of HH
Bronze skin
DM
ED
Arthralgia
Pseudogout
Dilated CM
What do to diagnose HH
Liver biopsy
Liver MRI if CI as can quantify iron
Investigations for NAFLD
AST:ALT< 0.8
Ehanced liver fibrosis test
Do fibroscan if enhanced liver fibrosis test indicates severe fibrosis
Biopsy may be needed for diagnosis
When refer for NAFLD
Advanced fibrosis suggested on scan or NAFLD/enhanced fibrosis test
Diagnostic uncertainty
What can be secondary care NAFLD management
Vitamin E and pioglitazone
Transplant or bariatric surgery may be indicated
Stages to ALD vs NAFLD
ALD
1. Steatosis
2. Hepatitis- get fatty changes with necrosis
3. Cirrhosis
NAFLD
1. NAFLD
2. NASH
3. Fibrosis
4. Cirrhosis
Non-invasive liver screen if cause of hepatitis or cirrhosis unknown
Autoantibodies
- ANA
- ASMA
- AMA
- anti LKM-1
USS for NAFLD
Hepatitis serology
Caeruplasmin
Transferrin and ferritin
Alpha-1-antitrypsin levels
Causes of cirrhosis
NAFLD
Alcohol
Hep B,C
Wilsons
Haemochromatosis
Alpha 1 antitrypsin
Autoimmune
Drugs
PBC and PSC
Portal HTN signs
Splenomegaly
Oesophageal and rectal varices
Caput medusae
Decompensated liver disease signs
Jaundice making go yellow
Encephalopathy
Ascites
Oesophageal varices
Main management principle if signs of decompensated liver disease
Liver transplant
Liver cirrhosis management principles
Manage precipitating factor
Monitor and prevent complications
Causes malnutrition so ensuring see nutritionist
Liver transplant if needed
What do if cirrhosis endoscopy identifies non-bleeding varices
First line is to give propanolol
If CI then do band ligation
What can do for refractory ascites
TIPSS
2 main indications for TIPSS
Bleeding oesophageal varices
Refractory ascites
Management of hepatorenal syndrome
Can use terlipressin first line but poor mortality typically unless liver transplant
For alcoholic cirrhosis what is required to be eligible for transplant
Abstinent for 6 months
Antitrypsin inheritance
AD- codominant
Screening test for anti-trypsin
Serum antitrypsin levels
Management of alpha1 anti trypsin
COPD management inc stop smoking
Monitor for liver complications (cirrhosis and HCC)
Lung changes in alpha1 anti trypsin
Emphysema
Bronchiectasis
+ve TTG identified on bloods in GP what do
Refer to gastro for jejunal biopsy
How diagnose IBS
6 months of stomach pain/discomfort with 1 of
- relieved by defaecating
- change in bowel habit
- constipation/diarrhoea
Prof hanna definitive management of each haemorrhoid grade
1- conservative
2- rubber band ligation/sclerotherapy
3- rubber band ligation/sclerotherapy
4- haemorrhoidectomy
What is whipples disease
Multi system disorder caused by trophyrema whipplei seen in HLA B27 most commonly
Diagnosing whipples
Jejunal biopsy with periodic acid schiff
Management of whipples
Co trimoxazole
Presentation of whipples
Arthralgia
Malabsorption
Lymphadenopathy
Neuro problems
Pleurisy
Diverticulosis vs diverticular disease
Diverticulosis- outpouching
Diverticular disease- outpouchings with symptoms
What causes tropical sprue
Unknown exactly but a variety of viruses, parasites and bacteria
Villous atrophy with eosinophil infiltrates
Tropical sprue
Presentation of PBC
Itching
Lethargy
Hyperlipidaemia
Jaundice
Hepatosplenomegaly
Can get hyperpigmentation over pressure points
Blood findings of PBC
High anti-mitochondrial
IgM
Anti smooth muscle seen sometimes
