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Focused Xtra > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

How does Wilson’s disease present?

A

liver: hepatitis, cirrhosis
neurological:
basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus
speech, behavioural and psychiatric problems are often the first manifestations
also: asterixis, chorea, dementia, parkinsonism
Kayser-Fleischer rings
green-brown rings in the periphery of the iris
due to copper accumulation in Descemet membrane
present in around 50% of patients with isolated hepatic Wilson’s disease and 90% who have neurological involvement
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails

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2
Q

How do we treat Wilson’s disease?

A

Penicillamine

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3
Q

How do we treat ascites secondary to liver cirrhosis?

A

Patients with ascites secondary to liver cirrhosis should be given an aldosterone antagonist. In ascites, aldosterone antagonists (such as spironolactone) are the preferred diuretic as they combat sodium retention. Due to this, patients should also be commenced on a low-salt diet.

Furosemide is a useful diuretic in combination with spironolactone, however, it is ineffective at blocking aldosterone (and its sodium retaining effects in the distal tubule and collecting duct).

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4
Q

What is the M rule in primary biliary cholangitis?

A

Primary biliary cholangitis - the M rule
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females

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5
Q

How do we induce remission in mild-moderate UC?

A

Topical (rectal) aminosalicylate

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6
Q

Name the most common anti-emetic that can cause EPSEs

A

Metoclopramide can cause extrapyramidal side effects, most commonly acute dystonia causing oculogyric crises, as is described in the history above. (eyes trapped in strange position, unable to move)

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7
Q

What is the first line management of NAFLD?

A

Weight loss

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8
Q

How do we manage ? variceal bleeding?

A

Terlipressin and prophylactic antibiotics is correct. This woman has a history of alcoholic liver cirrhosis, making variceal bleeding the most likely cause of the haematemesis. NICE recommends giving both terlipressin and prophylactic antibiotics before endoscopy. Bacterial infections occur in about 20% of patients with cirrhosis with upper gastrointestinal bleeding within 48 hours of admission which increases the mortality rate. Thus, it is important to prescribe prophylactic antibiotics. Terlipressin reduces portal blood flow, portal systemic collateral blood flow, and variceal pressure which reduces the risk of rebleeding.

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9
Q

Primary sclerosing cholangitis is most associated with…

A

UC

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10
Q

What test is recommended after H pylori eradication therapy?

A

Urea breath test

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11
Q

What is a severe flare of UC?

A

Stools 6+ a day + features of systemic upset

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12
Q

When do we omit PPIs prior to endoscopy?

A

2/52

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13
Q

Which vitamin is teratogenic in high doses?

A

Vitamin A

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14
Q

When is the Blatchford score used?

A

The Blatchford score is used to determine the severity of a suspected GI bleed and whether or not the patient needs admitting +/- the requirement for urgent upper GI endoscopy.

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15
Q

What is the AST/ALT ratio in alcoholic hepatitis?

A

The AST/ALT ratio in alcoholic hepatitis is 2:1

Salt (AST) before Lime (ALT) in your Tequila shot (alcohol)

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16
Q

How does pharyngeal pouch present?

A

A pharyngeal pouch, also known as Zenker’s diverticulum, is a condition where a small sac forms in the throat just above the oesophagus. This man’s symptoms of intermittent dysphagia (difficulty swallowing), halitosis (bad breath), and nocturnal coughing are characteristic of this condition. The coughing may be due to aspiration of food trapped in the pouch, while halitosis results from bacterial breakdown of retained food.

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17
Q

Where would you see Murphy’s sign?

A

Acute cholecystitis, not biliary colic

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18
Q

How do we interpret antibodies in hepatitis?

A

Anti-HBc = cirrhosis (previous or current infection)
Anti-HBs = safe (you are safe because of your immunisations)
HBsAg = AAAA s*** oh no you have new disease

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19
Q

How do we determine acute liver failure?

A

Prothrombin time is the most accurate determinate of acute liver failure as it is a measurement of the liver’s synthetic function.

Shorter half-life than albumin

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20
Q

Which blood group is a risk factor with gastric cancer?

A

Blood group A

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21
Q

How do we maintain remission in Crohn’s disease

A

Azathioprine or mercaptopurine is used first-line to maintain remission in patients with Crohn’s

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22
Q

What is the picture of liver disease seen in pcm overdose?

A

Hepatocellular

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23
Q

Which antibiotic can cause c diff?

A

Clindamycin

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24
Q

What is CA125 used for?

A

Ovarian ca

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25
Q

How does carcinoid syndrome present?

A

flushing, diarrhoea, bronchospasm, hypotension, and weight loss

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26
Q

How do we investigate carcinoid syndrome?

A

The investigation for this is urinary 5-HIAA, as the tumour will secrete serotonin.

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27
Q

What is giardia lamblia?

A

Giardia causes fat malabsorption, therefore greasy stool can occur. It is resistant to chlorination, hence risk of transfer in swimming pools.

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28
Q

What is the most prevalent hepatitis in europe?

A

Hep C-Continental i.e Europe
Hep B-gloBe

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29
Q

When is the urea breath test accurate/

A

Urea breath test - no antibiotics in past 4 weeks, no antisecretory drugs (e.g. PPI) in past 2 weeks

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30
Q

Where do you find a faecal, sweet breath smell?

A

Liver failure

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31
Q

How do we diagnose non-alcoholic fatty liver disease?

A

US + enhanced liver fibrosis test (checks for advanced fibrosis)

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32
Q

How do we distinguish AFLD and NAFLD on LFT?

A

Alcoholic liver disease is typically associated with an AST:ALT ratio >2 in contrast to non-alcoholic fatty liver disease which is associated with an ALT:AST ratio <2.

33
Q

How do we diagnose spontaneous bacterial peritonitis>?

A

In suspected SBP- diagnosis is by paracentesis. Confirmed by neutrophil count >250 cells/ul

34
Q

What can PPIs increase the risk of?

A

Osteoporosis

35
Q

What is mesalazine?

A

Oral mesalazine is the correct answer. It is an aminosalicylate that exhibits an anti-inflammatory effect. Patients with extensive or left-sided ulcerative colitis should be taking oral aminosalicylate to maintain remission. Side effects include nausea, headache, agranulocytosis, pancreatitis, and interstitial nephritis

36
Q

How can we distinguish between IDA and anaemia of chronic disease?

A

Iron defiency anaemia vs. anaemia of chronic disease: TIBC is high in IDA, and low/normal in anaemia of chronic disease

Anaemia of chronic disease will also be normocytic, but will likely have a low or normal TIBC. This is because, in anaemia of chronic disease, there is not a lack of iron, but the iron is trapped elsewhere and not able to be used. For example, it is trapped in inflammatory tissue. However, since it is therefore still in the body, the capability of the body to attach to free iron and transport it around is reduced (or normal), represented by TIBC.

37
Q

Where do you see increased goblet cells?

A

Crohn’s. Crohn’s disease demonstrates skip lesions, deep ulcers, and inflammation is present in all layers from the mucosa to the serosa.

38
Q

What do you see on intestinal biopsy in UC?

A

Crypt abscesses, continuous inflammation, inflammation confined to the submucosa

39
Q

What is the most commonly affected site with Crohn’s? UC?

A

Ileum in Crohn’s
Rectum in UC

40
Q

How does enterotoxigenic e.coli present?

A

Watery travellers diarrhoea with stomach cramps and nausea

41
Q

How does C. jejuni present?

A

Campylobacter jejuni typically causes bloody stools and abdominal pain.

42
Q

Where do you see pseudopolyps on endoscopy?

A

UC

43
Q

Which anti-emetics do we avoid in bowel obstruction?

A

Metoclopramide, domperidone, etc has prokinetic properties, which can stimulate peristalsis within the bowel. This can exacerbate mechanical bowel obstruction and precipitate perforation.

44
Q

Which clotting factors are abnormal in liver failure?

A

Liver failure: all clotting factors are low except for factor VIII which is supra-normal

45
Q

Which clotting factors are abnormal in DIC?

A

All of them

46
Q

Where would you see Pigment laden macrophages suggestive of melanosis coli?

A

laxative abuse. Melanosis coli is a condition characterised by the presence of pigment-laden macrophages in the lamina propria of the colon. It is most commonly associated with chronic use or abuse of anthraquinone-containing laxatives, such as senna or cascara. The pigments are lipofuscin-like substances that accumulate within macrophages as a result of apoptosis and necrosis of colonic epithelial cells. Melanosis coli itself is generally considered to be a benign condition, but it can be an important clinical clue to underlying laxative abuse.

47
Q

Name four drugs that can cause cholestasis

A

combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
sulphonylureas
fibrates
rare reported causes: nifedipine

48
Q

How do we manage PBC??

A

Management
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

49
Q

How do we monitor treatment in haemochromatosis?

A

Ferritin and transferrin saturation are used to monitor treatment in haemochromatosis

50
Q

What is the most common extra-intestinal feature in both Crohn’s and UC

A

Arthritis

51
Q

Which type of cancer does Barrett’s oesophagus increase the risk of? Achalasia?

A

Whilst Barrett’s oesophagus increases the risk of oesophageal adenocarcinoma (columnar epithelium), achalasia increases the risk of squamous cell carcinoma of the oesophagus.

52
Q

What is a Dieulafoy lesion?

A

These small arterial lesions are a rare cause of bleeding and are characterised by a single large tortuous arteriole in the sub mucosa. Extra gastric lesions may occur. prominent blood vessel is identified in the mucosa approximately 6 cm from the O-G junction on the lesser curve of the stomach.

53
Q

How do oesophageal varices present?

A

Usually a large volume of fresh blood. Swallowed blood may cause melena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed.

54
Q

How does Mallory-Weiss tear present?

A

Typically brisk small to moderate volume of bright red blood following a bout of repeated vomiting. Melena is rare. Usually ceases spontaneously.

55
Q

What is haemochromatosis?

A

Haemochromatosis is a condition characterised by iron overload, which can indeed lead to elevated ferritin levels. However, in this case, it’s less likely due to several reasons.

Firstly, the transferrin saturation level of this patient is 41%, which falls within the normal range (<50%). In haemochromatosis, transferrin saturation is typically greater than 45% in males and often significantly higher.

56
Q

What is the first-line treatment of mild-moderate UC?

A

In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is topical (rectal) aminosalicylates

57
Q

How do we manage severe UC?

A

IV steroids

58
Q

When do we give prothrombin complex concentrate?

A

This patient is presenting with upper GI bleeding, most likely due to a perforation, given his chronic usage of NSAIDs. The prothrombin complex concentrate has the duty of reversing the effects of warfarin, that this patient is taking for his atrial fibrillation

59
Q

When do we give PPI in upper GI bleed?

A

Following stabilisation, he will be sent to endoscopy to clarify the source of the bleeding. IV proton pump inhibitors are not indicated in the acute management of upper GI bleed but should be prescribed later, after endoscopy, if the cause was non-variceal.

60
Q

How do we investigate pancreatic ca?

A

HRCT

61
Q

Coeliacs disease increases the risk of which type of lymphoma?

A

Coeliac disease increases the risk of developing enteropathy-associated T cell lymphoma

62
Q

How do we manage hepatic encephalopathy?

A

Management of hepatic encephalopathy is designed to treat associated hyperammonemia. Of all the medications listed in this question, only lactulose is licensed for use in hepatic encephalopathy by the BNF. Lactulose works to inhibit production of ammonia in the intestine.

63
Q

How do we treat a recurrent episode of C. diff?

A

A recurrent episode of C. difficile within 12 weeks of symptom resolution should be treated with oral fidaxomicin

64
Q

How does achalasia present?

A

Clinical features
dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food
may lead to cough, aspiration pneumonia etc
malignant change in small number of patients

65
Q

What is achalasia?

A

Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women.

66
Q

How do we manage bile acid malabsorption?

A

Cholestyramine - removes excess bile preventing diarrhoea

67
Q

What is Peutz-Jeghers syndrome?

A

Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles. Although the polyps themselves don’t have malignant potential, around 50% of patients will have died from another gastrointestinal tract cancer by the age of 60 years.W

68
Q

Why does isoniazid cause peripheral neuropathy?

A

Isoniazid therapy can cause a vitamin B6 deficiency causing peripheral neuropathy

69
Q

How does Plummer-Vinson syndrome present?

A

Plummer-Vinson syndrome presents as a triad of iron deficiency anaemia, atrophic glossitis and oesophageal webs or strictures. Oesophageal webs are mostly located in the upper oesophagus and consist of multiple concentric narrowings.

70
Q

How does autoimmune hepatitis present?

A

Autoimmune hepatitis is condition of unknown aetiology which is most commonly seen in young females.

may present with signs of chronic liver disease
acute hepatitis: fever, jaundice etc (only 25% present in this way)
amenorrhoea (common)
ANA/SMA/LKM1 antibodies, raised IgG levels
liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis

71
Q

How do we monitor haemochromatosis

A

All patients diagnosed with haemochromatosis undergoing venesection should have monitoring of their transferrin saturation and serum ferritin until these are within range. Transferrin saturation measures the amount of iron bound to a protein (transferrin) in the blood. This is the first marker to rise in haemochromatosis and levels above 45% are considered too high. Serum ferritin concentration reflects iron stores in the body and is a useful prognostic test for predicting cirrhosis risk. It is important to monitor for a complication of phlebotomy known as iron avidity.

72
Q

What prophylaxis do we give for pts with ascites at risk of SBP?

A

Patients with ascites (and protein concentration <= 15 g/L) should be given oral ciprofloxacin or norfloxacin as prophylaxis against spontaneous bacterial peritonitis (G -ve cover)

73
Q

What anti-emetics would you give to a pt with migraine?

A

A prokinetic such as metoclopramide is the recommended antiemetic in these patients, as it helps to relieve the gastric stasis that can slow the transit and absorption of drugs during an acute migraine attack. In fact, NICE guidance on migraine suggests that it should be considered even in the absence of nausea and vomiting, solely due to its prokinetic effects.

74
Q

Which laxative is first line in treating pts with IBS?

A

A bulk-forming laxative such as isphagula husk is the first-line recommended pharmacological treatment for constipation in patients with IBS.

75
Q

What do we use as prophylaxis in oesophageal varices?

A

Propranolol (non-selective beta blocker)

76
Q

What is a seton?

A

A seton is a piece of surgical thread that is run through the fistula to allow continuous drainage while the fistula is healing. This ensures that the fistula doesn’t heal containing pus within, which would result in further abscess formation.

77
Q

Where do you see the double duct sign on MRCP?

A

Pancreatic ca

78
Q
A

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