Gastroenterology Flashcards
Inducing remission in UC
1)Proctitis
- topical (rectal) aminosalicylate
- after 4 weeks, add an oral aminosalicylate
- add topical or oral corticosteroid
2) proctosigmoiditis and left-sided ulcerative colitis
- topical (rectal) aminosalicylate
- after 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
- stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
3) extensive disease
- topical (rectal) aminosalicylate and a high-dose oral aminosalicylate
- after 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
4)SEVERE colitis
-admit
- IV steroids are usually given first-line
(IV ciclosporin may be used if steroids are contraindicated)
- after 72 hours add IV ciclosporin to IV corticosteroids or consider surgery
Maintenance of remission in UC
Following a mild-to-moderate ulcerative colitis flare:
1) proctitis and proctosigmoiditis
- topical (rectal) aminosalicylate alone (daily or intermittent) or
- an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
- an oral aminosalicylate by itself: this may not be effective as the other two options
2)left-sided and extensive ulcerative colitis
- low maintenance dose of an oral aminosalicylate
3)Following a severe relapse or >=2 exacerbations in the past year
- oral azathioprine or oral mercaptopurine
Inducing remission in Crohn’s disease
1st line- glucocorticoids (PO, topical or IV)
2nd line- 5-ASA drugs e.g. mesalazine
3rd line- can add on azathioprine or mercaptopurine
NOTE: metro used for isolated peri-anal disease
Maintaining remission in Crohn’s disease
1st line- azathioprine or mercaptopurine (NOTE: TPMT activity should be assessed before starting)
2nd line- methotrexate is used second-line
What is the most useful investigations to monitor response to haemochromatosis management?
Ferritin and transferrin saturation
What are the possible adverse effects of metoclopramide?
1) extrapyramidal effects
-acute dystonia e.g. oculogyric crisis
2) diarrhoea
3) hyperprolactinaemia
4) tardive dyskinesia
5) parkinsonism
What are ALT, ALP and ALT/ALP ratio in hepatocellular disease (paracetamol OD)?
Raised (at least 2 fold) ALT, ALP normal, ALT/ALP high (5+)
What are ALT, ALP and ALT/ALP ratio in Cholestatic disease?
Normal ALT. Raised ALP (at least 2 fold), ALT/ALP <2
How do you treat bile acid malabsorption?
Cholestyramine
What are risk factors for small bowel bacterial overgrowth syndrome?
neonates
scleroderma
diabetes mellitus
What are both types of oesophageal cancer associated with?
Adenocarcinoma- Barrett’s oesophagus (US/UK)- lower third
Squamous cell carcinoma- Achalasia (third world)- upper two thirds
What is TIBC in IDA vs in Anaemia of Chronic disease?
IDA- high TIBC
Anaemia of Chronic Disease- low/normal
What is Peutz-Jeghers syndrome?
- Autosomal dominant
-Hamartomatous polpypis in GI tract (mainly small bowel)
-Can present as small bowel obstruction or GI bleeding
-Pigmented lesions on lips, oral mucosa, face, palms and soles
How do you treat a complex perianal abscess?
Seton placement
How do you treat someone with both vitamin B12 and folic acid deficiencies?
treat the B12 deficiency first to avoid precipitating subacute combined degeneration of the cord
Administer intramuscular vitamin B12 followed by oral folic acid
How does achalasia present?
dysphagia of BOTH liquids and solids
What are the investigations for achalasia?
1) oesophageal manometry
- considered the most important diagnostic test
2) barium swallow
- ‘bird’s beak’ appearance
3) chest x-ray
- wide mediastinum
- fluid level
What is the Glasgow-Blatchford score?
helps clinicians decide whether patients can be managed as outpatients or not in the context of GI bleeds
What is the Rockall score?
used after endoscopy
provides a percentage risk of rebleeding and mortality
Management of non-variceal bleeds?
PPIs then endoscopy
Management of variceal bleeds?
1st: terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
2nd: band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices
3rd: transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures
What is the management of alcoholic hepatitis?
1) glucocorticoids (e.g. prednisolone) during acute episodes
2) pentoxyphylline is also sometimes used
What is angiodysplasia?
Angiodysplasia is a vascular deformity of the gastrointestinal tract which predisposes to bleeding and iron deficiency anaemia.
How is angiodysplasia diagnosed?
- colonoscopy
- mesenteric angiography if acutely bleeding
What is the management of angiodysplasia?
- endoscopic cautery or argon plasma coagulation
- antifibrinolytics e.g. Tranexamic acid
- oestrogens may also be used
What are the clinical features of Budd-Chiari syndrome?
TRIAD
1) abdominal pain: sudden onset, severe
2) ascites → abdominal distension
3) tender hepatomegaly
What is the investigation for Budd-Chiari?
ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation
What are the investigations for carcinoid tumours?
1) urinary 5-HIAA
2) plasma chromogranin A y
What is the management of carcinoid tumours?
1) somatostatin analogues e.g. octreotide
2) diarrhoea: cyproheptadine may help
What is management of cyclical vomiting?
1) Avoidance of triggers
2) Prophylactic treatments e.g. amitriptyline, propranolol and topiramate.
3) Acute episodes: Ondansetron, prochlorperazine and triptans
What is the mode of inheritance of haemochromatosis?
Autosomal recessive
What are the complications of haemachromatosis?
Reversible:
Cardiomyopathy
Skin pigmentation
Irreversible:
Liver cirrhosis**
Diabetes mellitus
Hypogonadotrophic hypogonadism
Arthropathy
What is the mode of inheritance in Gilbert’s syndrome?
Autosomal recessive
What is the most common cause of hepatocellular carcinoma worldwide and in Europe?
Worldwide: Hep B
Europe: Hep C
What is Whipple’s disease?
- rare multi-system disorder caused by Tropheryma whippelii infection. - - - more common in those who are HLA-B27 positive and in middle-aged men.
What is the investigation for Whipple’s disease and what do you expect to see?
jejunal biopsy: shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules
What is the management of Whipple’s disease?
oral co-trimoxazole for a year (lowest risk of relapse)
Sometimes preceded by course of IV penicillin
What is the mode of inheritance of Wilson’s disease?
Autosomal recessive
What is the management of Wilson’s disease?
penicillamine (chelates copper)
Which organism causes D&V with short incubation period?
Staph Aureus
Watery diarrhoea and profuse vomiting 1-6hrs after food
What are the grades of haemorrhoids?
1- do not prolapse
2-prolapse on defecation but reduce spontaneously
3- need manual reduction
4- cannot be reduced
Duodenal vs peptic ulcers
Peptic- worsened by eating
Duodenal- relieved by eating
WHat is asscociated with H. Pylori?
Peptic ulcer disease
MALT
Gastric adenocarcinoma
Menetrier’s disease
Cornararitis (inflammation of cornonary arteries)
IDA
What is the most common location of colorectal cancer?
Rectum mostly
Then sigmoid
What are the causes of bloody diarrhoea?
- Salmonella
- E. Col
- Entamoeba
- Campylobacter
- Shigella
- Yersinia entrecolitica
