Gastroenterology Flashcards by Kavindu Appuhamy

Which medications can increase risk of C. diff?

Broad spectrum antibiotics
PPIs

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What is the management of C.diff?

1st line = Oral vancomycin
2nd line = Oral fidaxomicin
3rd line = oral vancomycin +/- IV metronidazole

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Which antibodies are associated to pernicious anaemia?

Intrinsic factor antibodies
Gastric parietal cell antibodies

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Features of pernicious anaemia…

General anaemia features = lethargy, pallor, dyspnoea
Neurological features = peripheral neuropath - ‘pins and needles’, numbness, subacute degeneration of the spinal cord –> ataxia, progressive weakness, spasticity
Other features = macroglossia

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Which clotting factors are affected in liver disease?

All clotting factors except factor VIII (which is produced in endothelial cells across body, not just liver)

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What is a severe adverse effect of aminosalicylates?

Associated with Agranulocytosis –> signs= sore throat, fever, fatigue, bleeding gums

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What are some extra-intestinal features of Crohn’s?

Related to disease activity
Arthritis - asymmetric
Erythema nodosum
Episcleritis
Osteoporosis

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What test is used to for re-testing after H.Pylori eradication?

Urea breath test - only offered re-test if poor compliance with eradication therapy, family hx of gastric malignancy, pt has requested re-testing

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What LFTs are seen in liver dysfunction/ hepatocellular picture?

Raised ALT
Normal ALP
Ratio of ALT/ALP = 5x

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What LFTs are seen in cholestasis?

Raised ALP
Normal ALT
Ratio of ALT/ALP = <2

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Management of Crohn’s…

Inducing remission:
1st line = Glucocorticoids
2nd line = Mesalazine
3rd line = Azothioprine can be used in combination (NOT as monotherapy)
In refractory disease = Infliximab

Maintaining remission:
1st line = Azothioprine / mercaptopurine
2nd line = Methotrexate

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What is the acute management of variceal haemorrhage?

Initially ABC resuscitation
Terlipressin and IV prophylactic antibiotics to be given
Endoscopic variceal band ligation
Transjugular intrahepatic portosystemic shunt (TIPSS) used if above measures fail

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What is used as prophylaxis of variceal haemorrhage?

Propranolol –> reduce rebleeding risk
Endoscopic variceal band ligation

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What does HBsAg positive indicate?

Surface antigens present –>Current/ acute infection - first marker to appear

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What does HBsAg persisting over 6 months indicate?

Chronic disease

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What does Anti-HBs indicate?

Immunity or exposure (after which they have produced antibodies)

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What does Anti-HBc indicate?

Previous or current infection

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What does IgM anti-HBc indicate?

Appears during acute infection, present around 6 months

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What does IgG anti-HBc indicate?

IgG persists after the acute phase of infection - chronic disease

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What are the features of autoimmune hepatitis?

Signs of chronic liver disease (hepatomegaly, spider naevi)
Fever and jaundice seen in autoimmune hepatitis
Amenorrhoea

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What is the management of ulcerative colitis?

Inducing remission:
In proctitis and proctosigmoiditis –> Topical aminosalicylate
If no remission within 4 weeks: Add oral aminosalicylate
If remission still not achieved –>oral corticosteroid
In extensive disease –> topical aminosalicylate + high dose oral aminosalicylate

Maintaining remission:
Topical +/- oral aminosalicylates
**After severe relapse or >2 exacerbations in a year –> Azothioprine

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What is the management of severe UC?

Admission for IV steroids
2nd line = IV ciclosporin

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What conditions are associated with PBC?

Sjorgens syndrome (80% of patients)
Rheumatoid arthritis
Systemic sclerosis

What are the clinical features of PBC?

Cholestatic jaundice
Raised ALP on routine LFTs
Pruririts, hypermigmentation

What antibodies are associated with PBC?

- AMA - Smooth muscle antibodies - Serum IgMWh

Which drugs can cause cholestasis?

- Combined oral contraceptive pill - Antibiotics - flucloxacillin, co-amoxiclav - Sulphonylureas e.g. gliclazide

What investigation is used to diagnose NAFLD if suspected from USS?

Enhanced liver fibrosis (ELF) blood test

What investigations are carried out to diagnose coeliac disease?

1. Ant-TTG AND total IgA 2. Duodenal biopsy if suspected after antibody testing

What are the features of IBS?

- Abdominal pain relieved by defecation - Altered stool passage - straining, urgency, incomplete evacuation - Abdominal bloating - Sx made worse by eating - Passage of mucus

What is the biggest cause of hepatocellular carcinoma in the UK ? Worldwide?

UK = Hep C Worldwide = Hep B

What advice is give regarding PPI use in preparation for endoscopy?

Stop PPI use 2 weeks before endoscopy

What condition is UC most associated to?

PSC

What is the investigation of choice in bile acid malabsorption?

SeHCAT scan --> assess retention/loss of SeHCAT

What vitamin supplementation is teratogenic at high doses?

Vitamin A

What is Courvoiser's Law?

Palpable, non-tender, enlarged gallbladder + painless jaundice -->consider gallbladder malignancy (unlikely to be gallstones)

What is metoclopramide contraindicated in?

Bowel obstruction Parkinson's disease

What is the acute treatment for thrombosed haemorrhoids?

Thrombectomy -->removal of the clot to provide immediate relief

What is the diagnostic investigation for Crohn's?

CT scan

What is the best imaging for suspected colonic cancer?

Colonoscopy

What is the best imaging for anal fistulae?

MRI scan --> able to accurately delineate tracts

What size of AAA requires surgical repair?

AAA 4.5 - 5.4cm = require repeat USS in 3 months AAA > 5.5cm = elective repair (need to be reviewed by vascular surgeon within 2 weeks) AAA > 7ccm = urgent laparotomy required

What antibodies are associated with primary biliary cholangitis?

Anti-mitochondrial antibodies (AMA)

Features of acute mesenteric ischaemia?

- Sudden onset, severe abdominal pain --> usually not consistent with exam findings - Usually have history of AF --> emboli - Very serious, with poor prognosis if surgery is delayed

Features of chronic mesenteric ischaemia?

- Intermittent, colicky abdominal pain usually after eating --> "intestinal angina" - Fear of eating as a result --> weight loss - History of vascular disease

Features of ischaemic colitis?

- Abdominal pain - transient - Bloody diarrhoea - Typically "thumb-printing" may be seen on abdominal x-ray due to mucosal oedema

Key features of chronic pancreatitis?

- Post-prandial abdominal pain (15-30 mins post meal) - Steatorrhoea - Diabetes will eventually develop in most patients - Pancreatic calcification is seen - Minimal rise in amylase

What is the preferred imaging for acute pancreatitis?

Usually diagnosed clinically and imaging is not indicated in the acute phase --> focus on fluid resuscitation

Key features of acute pancreatitis...

- Central abdominal pain, radiating through to the back - Nausea and vomiting - Jaundice - Raised enzymes - amylase, lipase - Very high CRP in severe attack - Low Ca is seen

What is the treatment for H.Pylori?

Triple therapy: 7 day course of: PPI twice daily + amoxicillin+ clarithromycin OR metronidazole

Management of anal fissure...

Acute <6 weeks: - Stool softener - Dietary changes - increased fibre and water intake - Lubricant use before defecation Chronic >6weeks: - Topical GTN - 6-8 week course - If not effective after 8 weeks, consider botulinum toxin or surgery

Management of diverticulitis...

Mild flares can be treated with oral antibiotics If no improvement within 72 hours --> admit for IV antibiotics

Features of inguinal hernia...

- Located superior and medial to pubic tubercle - Disappear/ reduce manually or when lying down - Discomfort and ache

Which laxatives should be used in IBS and which should not?

Use: Bulk forming laxatives - isphalga husk, methylcellulose Do NOT use: lactulose --> causes abdominal cramps, flatulence - therefore will most likely worsen symptoms

What are the features of Wernicke's encephalopathy?

As a result of thiamine deficiency secondary to chronic alcoholism - Nystagmus - Ataxia - Confusion -->Can go onto develop Korsakoff's syndrome - long term memory loss with confabulation

What is the difference between left sided and right sided colonic carcinomas in presentation?

Left sided carcinoma: - Fresh rectal bleeding - Change in bowel habits Right sided carcinoma: - Iron deficiency anaemia in absence of rectal bleeding - Insidious onset

What is Budd-Chiari syndrome?

Disorder characterised by obstruction of hepatic venous outflow which may be caused by thrombosis or compression --> causes severe ascites and severe abdominal pain Associated with VTE risk factors