Gastroenterology Flashcards
1
Q
What is achalasia
A
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter due to degenerative loss of ganglia from Auerbach’s plexus
2
Q
Demographic achalasia
A
Typically presents in middle age
Equally common in men and women
3
Q
Features achalasia
A
Dysphagia of liquid and solids
Typically variation in severity of symptoms
Heartburn
Regurgitation of food, may lead to cough, aspiration pneumonia
4
Q
Most important diagnostic test achalasia
A
Oesophageal manometry
5
Q
Findings oesophageal manometry in achalasia
A
Excessive LOS tone which doesn’t relax on swallowing
6
Q
Findings barium swallow in achalasia
A
Grossly expanded oesphagus with fluid level
Birds beak appearance
7
Q
CXR findings achalasia
A
Wide mediastinum
Fluid level
8
Q
First line treatment achalasia
A
Pneumatic (balloon) dilation
9
Q
Advantage of pneumatic dilatation over surgery in achalasia
A
Less invasive, quicker recovery time than surgery
10
Q
Why do patients need to be low surgical risk for pneumatic dilatation achalasia
A
Surgery may be required if complications occur
11
Q
Surgical options achalasia
A
Heller cardiomyotomy
12
Q
When to consider Heller cardiomyotomy in achalasia
A
Recurrent or persistent symptoms
13
Q
Options for high surgical risk patients in achalasia
A
Intra-sphincteric injection of botulinum toxin
14
Q
Drugs used in achalasia
A
Nitrates
Calcium channel blocker
15
Q
Limitations of drug therapy in achalasia
A
Limited by side effects
16
Q
Causes of acute liver failure
A
Paracetamol overdose
Alcohol
Viral hepatitis (usually A or B)
Acute fatty liver of pregnancy
17
Q
Features acute liver failure
A
Jaundice
Coagulopathy - raised prothrombin time
Hypoalbuminaemia
Hepatic encephalopathy
Renal failure (hepatorenal syndrome)
18
Q
Oesophageal causes haematemesis
A
Oesophageal varices
Oesophagitis
Cancer
Mallory Weiss tear
19
Q
Gastric causes haematemesis
A
Gastric ulcer
Gastric cancer
Dieulafoy lesion
Diffuse erosive gastritis
20
Q
What is Dieulafoy lesion
A
Arteriovenous malformation
21
Q
Presentation Dieulafoy lesion
A
Often no prodromal features
May produce quite considerable haemorrhage
May be difficult to detect endoscopically
22
Q
Presentation diffuse erosive gastritis
A
Usually haematemesis and epigastric discomfort
Large volume haemorrhage may occur with considerable haemodynamic compromise
23
Q
Duodenal causes haematemesis
A
Duodenal ulcer
Aorto-enteric fistula
24
Q
Where are duodenal ulcers usually sited
A
Posteriorly
25
Complications of posteriorly sited duodenal ulcers
May erode the gastroduodenal artery
26
Presentation duodenal ulcers
Haematemesis
Melena
Epigastric discomfort
27
Gastric vs duodenal ulcer presentation
Duodenal ulcer pain occurs several hours after eating
28
Who gets aortic-enteric fistulas
Patients with previous abdominal aortic aneurysm surgery
29
What risk assessment for haematemesis at first assessment
Glasgow-Blatchford score
30
Purpose of Glasgow-Blatchford score in haematemesis
Help decide if patients can be managed as outpatients or not
31
Risk assessment to be done after endoscopy in haematemesis
Rockall score
32
Purpose of Rockall score
Provides percentage risk of rebleeding and mortality
33
Things in Rockall score
- Age
- Features of shock
- Co-morbidities
- Aetiology of bleeding
- Endoscopic stigmata of recent haemorrhage
34
Things in Blatchford score
- Urea and Hb
- Systolic BP and HR
- Presentation with melaena and syncope
- Hepatic or cardiac disease
35
What Blatchford score can be considered for early discharge
0
36
Use of platelet transfusion in haematemesis
If active bleeding and platelets less than 50
37
Use of FFP in haematemesis
Fibrinogen less than 1g/L, or
Prothrombin time or APTT greater than 1.5x normal
38
Use of prothrombin complex in haematemesis
Patients taking warfarin and actively bleeding
39
Timeframe for endoscopy in haematemesis
Immediately after resuscitation in severe bleeding
All patients within 24 hours
40
Who has PPIs haematemesis
Patients with non-variceal bleeding and sigmata of recent haemorrhage on endoscopy
41
Management of variceal bleeding before endoscopy
Terlipressin
Prophylactic antibiotics
42
Management variceal bleeding at endoscopy
Band ligation for oesophageal varices
Injections of N-butyl-2-cyanoacrylate for patients with gastric varices
43
Management variceal bleeding not controlled by endoscopy
Transjugular intrahepatic portosystemic shunts (TIPS)
44
Screening questionnaires used for problem alcohol drinking
AUDIT
FAST
CAGE
45
How many questions in AUDIT
10
46
Minimum, maximum, and problem scores AUDIT
Minimum = 0
Maximum = 40
8+ in men/7+ in women = strong likelihood of hazardous/harmful alcohol consumption
15+ in men/13+ in women = alcohol dependence
47
What is AUDIT-C
Abbreviated form of audit consisting of 3 questions
48
Minimum and maximum scores in FAST and problem score
Minimum = 0
Maximum = 16
Hazardous drinking = 3
49
What is first question of FAST, and how to interpret
“How often do you have 8 (men)/6 (women)+ drinks on on occasion”
If answer never, not misusing alcohol
If answer is weekly, daily, or almost daily, patient is hazardous, harmful, or dependent drinker
50
How is CAGE interpreted
4 questions, 2 or more positive answers considered ‘positive’ result
51
Diagnostic criteria alcohol problem drinking
Need 3+:
- Compulsion to drink
- Difficulties controlling alcohol consumption
- Physiological withdrawal
- Tolerance to alcohol
- Neglect of alternative activities to drinking
- Persistent use of alcohol despite evidence of harm
52
Government recommendations alcohol
Men and women should drink no more than 14 units per week
If drinking as much as 14 units per week, spread evenly over 3 days or more
53
How much is one unit of alcohol
Equal to 10ml pure ethanol, e.g.
- 25ml spirits
- 1/3 pint of peer
- half 175ml glass of red wine
54
How to calculate units in a drink
(Millilitres x ABV)/1000
55
What is alcohol ketoacidosis
A non-diabetic euglycaemic form of ketoacidosis
56
What causes alcohol ketoacidosis
Alcoholics often not eat regularly and may vomit food they do eat, leading to episodes of starvation → malnourishment → body breaks down fat, producing ketones
57
Presentation alcohol ketoacidosis
Metabolic acidosis
Elevated anion gap
Elevated serum ketone levels
Normal or low glucose concentration
58
Treatment alcoholic ketoacidosis
Infusion of saline and thiamine
59
Purpose of thiamine in alcoholic ketoacidosis
To avoid Wernicke encephalopathy/Korsakoff psychosis
60
Investigation findings alcoholic liver disease
Elevated gamma-GT
Ratio of AST:ALT >2 (>3 strongly suggestive of acute alcohol hepatitis)
61
Management acute episodes of alcoholic hepatitis
Glucocorticoids, e.g. prednisolone
Pentoxyphylline - not as good as glucocorticoids
62
How to determine who would benefit from glucocorticoids
Maddrey’s discriminat function, calculated using prothrombin time and bilirubin concentration
63
Mechanism 5-ASA
Released in colon and not absorbed, acts locally as anti-inflammatory, mechanism not understood but may inhibit prostaglandin synthesis
64
Examples aminosalicylates
Sulphasalazine
Mesalazine
Olsalazine
65
What is in sulphasalazine
Sulphapyridine (a sulphonamide) and 5-ASA
66
Side effects sulphasalazine caused by sulphapyridine
- Rashes
- Oligospermia
- Headache
- Heinz body anaemia
- Megaloblastic anaemia
- Lung fibrosis
67
SEs all aminosalicylates
GI upset
Headache
Agranulocytosis
Pancreatitis
Interstitial nephritis
68
What is mesalazine
Delayed release form of 5-ASA
69
Investigation unwell patient on aminosalicylates
FBC
70
Risk of pancreatitis sulphasalazine vs mesalazine
Pancreatitis 7 times more common in patients taking mesasalazine
71
What is angiodysplasia
Vascular deformity of GI tract, predisposes to bleeding and iron deficiency anaemia
72
Associations angiodysplasia
Aortic stenosis (debated)
73
Demographic angiodysplasia
Generally seen in elderly patient
74
Features angiodysplasia
Anaemia
GI bleeding - if upper GI, melena. If lower GI, brisk, fresh PR bleeding
75
What does ascites with SAAG (serum ascites albumin gradient) >11g/L indicate
Portal hypertension
76
Liver causes ascites with SAAG >11g/L
Cirrhosis/alcoholic liver disease
Acute liver failure
Liver metsL
77
Cardiac causes ascites with SAAG >11g/L
Right heart failure
Constrictive pericarditis
78
Other causes ascites with SAAG >11g/L
Budd-Chiari syndrome
Portal vein thrombosis
Veno-occlusive disease
Myxoedema
79
Causes ascites with SAAG <11g/L
Hypoalbuminaemia, e.g. nephrotic syndrome, severe malnutrition
Peritoneal carcinomatosis
Tuberculous peritonitis
Pancreatitis
Bowel obstruction
Biliary ascites
Post-op lymphatic leak
Serositis in connective tissue disease
80
Conservative management ascites
Reduce dietary sodium
Fluid restriction if sodium <125mmol/L
81
Medical management ascites
Aldosterone antagonists, e.g. spironolactone +/- loop diuretics
Prophylactic antibiotics to reduce risk of SBP
82
Prophylactic antibiotics ascites
Oral cipo or nofloxacin
83
Who is offered prophylactic antibiotics in ascites
People with cirrhosis and ascites with ascitic protein 15g/L or less
84
Invasive management ascites
Drainage if tense
Transjugular intrahepatic portosystemic shunt in some patients
85
What is required for large volume paracentesis for treatment of ascites
Albumin
86
Complications paracentesis for ascites
Circulatory dysfunction if large volume (>5L)
Hepatorenal syndrome
Dilution hyponatraemia
Asciters recurrence
87
Associations autoimmune hepatitis
Other autoimmune disorders
Hypergammaglobulinaemia
HLA B8
HLA DR3
88
Type 1 autoimmune hepatitis antibodies
ANA and/or SMA
89
Demographic T1 autoimmune hepatitis
Adults and children
90
Type 2 autoimmune hepatitis antibodies
Anti-liver/kidney microsomal type 1 antibodies (LKM1)
91
Demographic T2 autoimmune hepatitis
Children
92
Type 3 autoimmune hepatitis antibodies
Soluble liver-kidney antigen
93
Demographic type 3 autoimmune hepatitis
Adults in middle age
94
Presentation autoimmune hepatitis
Acute hepatitis - fever, jaundice (25%)
Amenorrhoea
May present with chronic liver disease
95
Immunoglobulins in autoimmune hepatitis
Raised IgG levels
96
Liver biopsy autoimmune hepatisi
Inflammation extending beyond limiting plate
Piecemeal necrosis
Bridging necrosis
97
Management autoimmune hepatitis
Steroids
Other immunosuppressants, e.g. azathioprine
Liver transplantation
98
What is Barrett's oesophagus
Metaplasia of lower oesophageal mucosa, with usual squamous epithelium being replaced by columnar epithelium
99
Management Barrett's oesophagus
High dose PPI
100
Management Barrett's oesophagus with metaplasia
Endoscopy surveillance with biopsies every 3-5 years
101
Management Barrett's oesophagus with dysplasia
Endoscopic intervention - radio frequency ablation first line, endoscopic mucosal resection second line
102
Cause of primary bile-acid malabsorption
Excessive production of bile acid
103
Secondary causes bile acid malabsorption
Ileal disease, e.g. Crohns
Cholecystectomy
Coeliac disease
Small intestinal bacterial overgrowth
104
Features bile acid malabsorption
Steatorrhoea
Vitamin ADEK malabsorption
105
Investigation bile acid malabsorption
SeHCAT - nuclear medicine test, scans done 7 days apart to assess retention/loss of radio labelled SeHCAT
106
Management bile acid malabsorption
Bile acid sequestrates, e.g. cholestyramine
107
What is Budd-Chiari syndrome
Hepatic vein thrombosis
108
Cause Budd-Chiari syndrome
Polycythaemia rubra vera
Thrombophilia
Pregnancy
COCP
109
Features Budd-Chiari syndrome
Abdominal pain - sudden onset, severe
Ascites → abdominal distention
Tender hepatomegaly
110
Investigation Budd-Chiari syndrome
Ultrasound with Doppler flow studies
111
When do carcinoid tumours cause carcinoid syndrome
Usually when mets present in liver → release serotonin into systemic circulation
May also occur with lung carcinoid - mediators not cleared by the liver
112
Features carcinoid syndrome
Flushing
Diarrhoea
Bronchospasm
Hypotension
Right heart valvular stenosis
Other molecules e.g. ACTH and GHRH may be secreted
Pellagra
113
Cause pellagra in carcinoid syndrome
Dietary tryptothan diverted to serotonin by the tumour
114
Investigation carcinoid syndrome
Urinary 5-HIAA
Plasma chromogranin A
115
Management carcinoid syndrome
Somatostatin analogues, e.g. octreotide
116
Management diarrhoea caused by carcinoid syndrome
Cyproheptadine
117
What kind of bacteria is C diff
Anaerobic gram positive rod
118
Risk factors C diff
Second and third gen cephalosporins
Clindamycin
PPI
119
Transmission C diff
Faecal-oral route by ingestion of spores
120
Features C diff
- Diarrhoea
- Abdominal pain
Severe toxic megacolon may develop
121
Characteristic investigation findings C diff
Raised WCC
122
Criteria mild C diff
Normal WCC
123
Criteria moderate C diff
Raised WCC
Typically 3-5 loose stools/day
124
Criteria severe C diff
Raised WCC, or acutely raised creatinine (>50% baseline), or temp >38.5
Evidence of severe colitis, e.g. abdominal or radiological signs
125
Criteria life threatening C diff
Hypotension
Partial or complete ileus
Toxic megacolon
CT evidence of severe disease
126
Diagnostic criteria C diff
Detection of C difficult toxin in stool
C. diff antigen = exposure, not current infection
127
First line C diff
Oral vancomycin 10 days
Stop other antibiotic therapy if possible
128
Second line C diff
Oral fidaxomicin
129
Third line C diff
Oral vancomycin +/- IV metronidazole
130
Management recurrence C diff within 12 weeks of symptom resolution
Oral fidaxomicin
131
Management recurrence C diff after 12 weeks of symptom resolution
Oral vancomycin or fidaxomicin
132
Treatment life threatening C diff infection
Oral vancomycin and IV metronidazole
Specialist advice - surgery may be considered
133
Other treatment options C diff
Bezlotoxumab (not supported by NICE)
Faecal microbiota transplant
134
When is faecal microbiota transplant considered in C diff
Patients with 2 or more previous episodes
135
Liver failure clotting factors
All clotting factors are low except VIII (can be high)
136
Gene associations coeliac disease
HLA-DQ2
HLA-DQ8
137
Signs/symptoms that need screening for coeliac
- Chronic or intermittent diarrhoea
- Failure to thrive/faltering growth
- Persistent or unexplained GI symptoms, inc N&V
- Prolonged fatigue
- Recurrent abdo pain, cramping, distention
- Sudden/unexpected weight loss
- Unexplained anaemia
138
Conditions that need screening for coeliac
- Autoimmune thyroid disease
- Dermatitis herpetiformis
- IBS
- T1DM
- First degree relative with coeliac
139
Complications coeliac
- Anaemia
- Hyposplenism
- Osteoporosis, osteomalacia
- Lactose intolerance
- Enteropathy-associated T-cell lymphoma of small intestine
- Subfertility, unfavourable pregnancy outcomes
- Oesophageal cancer
140
Cause of anaemia in coeliac disease
Iron deficiency
Folate deficiency
Vitamin B12 deficiency
141
How long before testing for coeliac does patient need to reintroduce gluten if stopped eating
6 weeks
142
Diagnosis of coeliac
Serology + endoscopic intestinal biopsy
143
Serology tests coeliac
Tissue transglutaminase (TTG)
Endomyseal antibody
144
Why is endomyseal antibody testing needed in coeliac
To look for selective IgA deficiency, which would give false negative coeliac result
145
Who needs endoscopic intestinal biopsy to look for coeliac disease
All patients with suspected coeliac disease
146
Where is biopsied suspected coeliac
Traditionally duodenum, but jejunal biopsies sometimes done
147
Findings on biopsy coeliac disease
- Villous atrophy
- Crypt hyperplasia
- Increase in intraepithelial lymphocytes
- Lamina propria infiltration with lymphocytes
148
Forms of inherited colon cancer
Hereditary non-polyposis colorectal cancer (Lynch syndrome) HNPCC
Familial adenomatous polyposis FAP
149
Inheritance HNPCC
Autosomal dominant
150
Features of colorectal cancer in HNPCC
- Often proximal colon
- Poorly differentiated
- Highly aggressiveW
151
Second most common cancer associated with HNPCC
Endometrial cancer
152
Inheritance FAP
Autosomal dominant
153
Management FAP
Total proctocolectomy with ileal pouch anal anastomosis in 20's
154
What other tumours FAP patients at risk of
Duodenal
Variant Gardner's syndrome - osteomas of skull and mandible, retinal pigmentation, thyroid carcinoma, epidermoid cysts on skin
155
Presentation Crohn's disease
Non-specific symptoms e.g. weight loss, lethargy
Diarrhoea - can be bloody
Abdominal pain
Perianal disease, e.g. skin tags, ulcers
156
Bloods Crohn's disease
Raised inflammatory markers
Anaemia
Low B12 and vitamin D
157
Which extra-intestinal manifestations of Crohn's and UC are related to disease activity
Pauciarticular asymmetric arthritis
Erythema nodosum
Episcleritis
Osteoporosis
158
Which extra-intestinal manifestations of Crohn's and UC are unrelated to disease activity
Polyarticular symmetric arthritis
Uveitis
Pyoderma gangrenosum
Clubbing
Primary sclerosing
159
Episcleritis UC vs Crohns
More common in Crohns
160
Primary sclerosing cholangitis UC vs Crohns
Much more common in UC.
161
Uveitis UC vs Crohns
More common in UC
162
Smoking and Crohn's
Patients should be strongly advised to stop smoking
163
First line for inducing remission in Crohns
Glucocorticoids - ora, topical, or IV
164
Second line for inducing remission in Crohns
5-ASA, e.g. mesalazine
165
Role enteral feeding with elemental diet in inducing remission in Crohns
May be used in addition to or instead of other measures to induce remission, particularly if concerns about side effects of steroids e.g. in young children
166
Drugs used as add-on therapy in inducing remission in Crohn's
Azathioprine
Mercaptopurine
Methotrexate
167
Role of infliximab inducing remission in Crohn's
Refractory disease/fistulating Crohn's
168
Role metronidazole inducting remission in Crohn's
Often used for isolated perianal disease
169
First line maintenance of remission Crohn's
Azathioprine or mercaptopurine
170
Second line maintenance of remission Crohn's
Methotrexate
171
Surgical options Crohn's
- Ileocaecal resection
- Segmental small bowel resections
- Stricturoplasty
- Surgery for perianal fistula or abscess
172
When is ileocaecal resection done in Crohn's
Stricturing terminal ileal disease
173
Investigation perianal fistulae in Crohn's
MRI
174
Purpose of MRI in perianal fistulae in Crohn's
- Determine presence of fistula or abscess
- Determine if fistula is simple (low fistula) or complex (high fistula that passes through or above muscle layers)
175
Medical treatment perianal fistula in Crohns
- Oral metronidazole
- Anti-TNF agents, e.g. infliximab
176
Surgical treatment complex fistula in Crohns
Draining seton
177
Treatment perianal abscess in Crohns
Incision and drainage with antibiotic therapy
Draining seton if tract is identified
178
Complications Crohn's
Small bowel cancer
Colorectal cancer
Osteoporosis
179
What should be checked before offering azathioprine or mercaptopurine in Crohns
TPMT activity
180
Presentation cyclical vomiting syndrome
Severe nausea and vomiting lasting hours to days
Prodromal intense sweating and nausea
Well in between episode
May also have weight loss, reduced appetite, abdominal pain, diarrhoea, dizziness, photophobia, headache
181
Prophylaxis cyclical vomiting syndrome
Amitriptyline
Propanolol
Topiramate
182
Acute treatments cyclical vomiting syndrome
Ondansetron
Prochlorperazine
Triptans
183
When is stool culture required in diarrhoea
- Systemically unwell needing hospital admission
- Blood or pus in stool
- Immunocompromised
- Recent ABx, PPI, or hospital admission
- Recent foreign travel
- Public health indication - diarrhoea in high risk people, suspected food poisoning
184
Blood findings diarrhoea
AKI
Hypokalaemia
Hyponatraemia
185
Presentation diverticulitis
Left iliac fossa pain and tenderness
Anorexia, nausea, and vomiting
Diarrhoea
Features of infection - pyrexia, raised WCC and CRP
186
Management diverticulitis
Mild attacks treated with oral antibiotics
More significant episodes - NBM, IV fluids, IV antibiotics
187
IV antibiotics in severe diverticulitis
Cephalosporin + metronidazole
188
Complications diverticulitis
Abscess formation
Peritonitis
Obstruction
Perforation
189
Drugs causing hepatocellular picture of liver disease
Paracetamol
Sodium valproate, phenytoin
MAOIs
Halothene
Anti-tuberculosis - isoniazid, rifampicin, pirazinamide
Statins
Alcohol
Amiodarone
Methyldopa
Nitrofurantoin
190
Drugs causing cholestatic picture of liver disease
COCP
Antibiotics - fluclox, co-amox, erythromycin
Anabolic steroids, testosterones
Phenothiazines - chlorpromazine, prochlorperazine
Sulphonylureas
Fibrates
191
Drugs causing liver cirrhosis
Methotrexate
Methyldopa
Amiodarone
192
2WW referral dyspepsia (oesophageal/stomach)
- Dysphagia
- Upper abdominal mass consistent with stomach cancer
- Aged ≥55 with weight loss + any of upper abdo pain, reflux, dyspepsia
193
Non-urgent referral for dyspepsia
Haematemesis
≥55 with;
- Treatment resistent dyspepsia
- Upper abdominal pain with low haemoglobin levels
- Raised platelet count with any of: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
- Nausea and vomiting with any of: weight loss, reflux, dyspepsia, upper abdominal pain
194
Treatment for dyspepsia not needing referral
- Review medications
- Lifestyle advice
- Trial full dose PPI for 1 month, or 'test and treat' approach for H pylori
195
Testing method for H pylori at initial diagnosis
Carbon-13 urea breath test or stool antigen test
196
Test of cure H pylori
Not required if symptoms resolved
If repeat testing required, carbon-13 urea breath test
197
Investigation dysphagia
Urgent endoscopy in all cases
198
Features of CREST syndrome
- Calcinosis
- Raynaud's phenomenon
- Oesophageal dysmotility
- Sclerodactyly
- Telangiectasia
199
Features globus hystericus
- History of anxiety
- Symptoms intermittent and relieved by swallowing
- Usually painless
200
Role of ferritin
Intracellular protein that binds iron and stores it to be released in a controlled fashion at sites where iron is required
201
Definition increased ferritin levels
>300 in men/post menopausal women
>200 in premenopausal women
202
Causes of raised ferritin without iron overload
- Inflammation (ferritin is acute phase reactant)
- Alcohol excess
- Liver disease
- CKD
- Malignancy
203
Causes of raised ferritin with iron overload
Primary iron overload, e.g. hereditary haemochromatosis
Secondary iron overload, e.g. repeated transfusion
204
Investigation to determine if iron overload present
Transferrin saturation
205
Normal transferrin saturation
<45% in women
<50% in men
206
Cause reduced ferritin
Iron deficiency anaemia (as iron and ferritin bound)
207
Presentation gallstones
Colicky RUQ occuring after meals
Symptoms worst following fatty meal
208
Investigation gallstones
- Abdominal ultrasound
- Liver function tests
209
Investigation suspected CBD stones
MRCP
Intraoperative imaging
210
Management biliary colic
Laparoscopic cholecystectomy
211
Features acute cholecystitis
RUQ pain
Fever
Murphys sign
Occasionally midly deranged LFTs, esp Mirizzi syndrome
212
Management acute cholecystitis
Cholecystectomy, ideally within 48 hours of presentation
213
Features gallbladder abscess
Usually prodromal illness and RUQ pain
Swinging pyrexia
Patient may be systemically unwell
Generalised peritonism not present
214
Imaging gallbladder abscess
USS +/- CT
215
Management gallbladder abscess
Ideally surgery (subtotal cholecystectomy may be needed if Calot's triangle is hostile)
In unfit patients, percutaneous drainage
216
Features cholangitis
Patients severely unwell and septic
Jaundice
RUQ pain
217
Management cholangitis
Fluid resuscitaiton
Broad spectrum IV antibiotics
Correct coagulopathy
Early ERCP
218
Features gallstone ileus
Small bowel obstruction, may be intermittent
219
Management gallstone ileus
Laparotomy and removal of gallstone from small bowel - enterotomy must be made proximal to site of obstruction, not at site of obstruction
Do not interfere with fistula between gallbladder and duodenum
220
Features acalculous cholecystitis
- Incurrent illness, e.g. diabetes, organ failure
- Systemically unwell
- Gallbladder inflammation in absence of stones
- High fever
221
Management acalculous cholecystitis
If patient fit, cholecystectomy
If unfit, percutaneous cholecystostomy
222
Management asymptomatic gallstones
Leave unless causing problems
223
Treatment biliary colic in very frail patient
Ultrasound guided cholecystostomy
224
Risks of ERCP
Bleeding
Duodenal perforation
Cholangitis
Pancreatitis
225
Most common type of gastric cancer
Gastric adenocarcinoma
226
Risk factors gastric cancer
H pylori infection
Pernicious anaemia, atrophic gastritis
Diet high in salt or nitrates
Japanese or Chinese
Smoking
Blood group A
227
Features gastric cancer
- Abdominal pain - typically vague, epigastric, may present as dyspepsia
- Weight loss and anorexia
- Nausea and vomiting
- Dysphagia
- Overt upper GI bleeding in minority of patients
228
Features gastric cancer with lymphatic spread
Virchow's node (left supraclavicular node)
Sister Mary Joseph's nodule (periumbilical nodule)
229
Initial investigation gastric cancer
Oesophago-gastric-duodenoscopy with biopsy
230
Characteristic biopsy finding gastric cancer
Signet ring cells - high numbers = worse prognosis
231
Staging investigation gastric cancer
CT CAP
232
Management gastric cancer
Surgery - endoscopic mucosal resection, partial or total gastrectomy
Chemotherapy
233
Indications for endoscopy in GORD
Age >55
Symptoms >4 weeks or persistent symptoms despite treatment
Dysphagia
Relapsing symptoms
Weight loss
234
Investigations if endoscopy negative in GORD
Consider 24-hour oesophageal pH monitoring
235
What is Gilberts syndrome
Condition of defective bilirubin conjugation due to deficiency of UDP glucuronosyltransferase
236
Inheritance Gilbert's syndrome
Autosomal recessive
237
Features Gilbert's syndrome
Unconjugated hyperbilirubinaemia - may only be seen during intercurrent illness, exercise, or fasting
238
Investigation Gilbert's syndrome
Rise in bilirubin following prolonged fasting or IV nicotinic acid
239
Treatment Gilbert's syndrome
No treatment required
240
What is haemochromotosis
Autosomal recessive disorder of iron absorption and metabolism → iron accumulation
241
Inheritance haemochromotosis
Autosomal recessive
242
Early features of haemochromotosis
Fatigue
Erectile dysfunction
Arthralgia
243
Later features of haemochromotosis
Bronze skin pigmentation
Diabetes mellitus
Liver signs - stigmata of chronic liver disease, hepatomegaly, cirrhosis
Cardiac failure
Hypogonadism
244
Cause of cardiac failure in haemochromotosis
Dilated cardiomyopathy
245
Cause of hypogonadism in haemochromotosis
Cirrhosis and pituitary dysfunction
246
Reversible complications of haemochromotosis
Cardiomyopathy
Skin pigmentation
247
Irreversible complications of haemochromotosis
Liver cirrhosis
Diabetes mellitus
Hypogonadotrophic hypogonadism
Arthropathy
248
Screening for haemochromatosis in the general population
Transferrin saturation
249
Screening for haemachromatosis in family members
Genetic testing for HFE mutation
250
Typical iron study profile in patient with haemochromatosis
Transferrin saturation >55% in men or >50% in women
Raised ferritin and iron
Low TIBC
251
Further tests in haemochromatosis
Liver function tests
Molecular genetic testing for C282Y and H63D mutations
MRI
252
Purpose of MRI in haemochromatosis
Quantify liver and/or cardiac iron
253
Role of liver biopsy in haemochromatosis
Now generally only used if suspected hepatic cirrhosis
254
First line treatment haemochromatosis
Venesection
255
Monitoring of adequacy of venesection in haemochromatosis
Transferrin saturation should be kept below 50%, and serum ferritin concentration below 50ug/L
256
Second line treatment haemochromatosis
Desferrioxamine
257
H pylori gram +ve or -ve
-ve
258
What conditions can H pylori cause
Peptic ulcer disease - 95% of duodenal ulcers, 75% of gastric uulcers
Gastric cancer
B cell lymphoma of MALT tissue
Atrophic gastritis
259
H pylori and GORD
Association clear, no role in GORD for H pylori eradication
260
Management H pylori
Eradication with 7 days of PPI + amox + clari or metronidazole
If pen allergic, PPI + metronidazole + clari
261
How is urea breath test done?
Patients consume drink containing carbon isotope 13 enriched urea. After 30 minutes, patient exhales into glass tube.
262
When can urea breath test be done re. medications
Not within 4 weeks of treatment with an antibacterial, or within 2 weeks of anti-secretory drug
263
What happens in rapid urease test (CLO test)
Biopsy sample mixed with urea and pH indicator, colour change if H pylori urease activity
264
Disadvantage of serum antibody testing for H pylori
Remains positive after eradication
265
Use of culture of gastric biopsy for H pylori
Provides information on antibiotic sensitivity
266
What test is used to check for H pylori eradication
Breath test
267
Features hepatic encephalopathy
Confusion, altered GCS
'Liver flap' - arrhythmic negative myoclonus with frequency of 3-5Hz
Constructional apraxia - inability to draw a 5-pointed star
268
EEG findings hepatic encephalopathy
Triphasic slow waves
269
Grading hepatic encephalopathy
Grade I - irritability
Grade II - confusion, inappropriate behaviour
Grade III - incoherent, restless
Grade IV - coma
270
Factors precipitating hepatic encephalopathy
Infection, e.g. SBP
GI bleed
Post TIPS
Constipation
Drugs
Hypokalaemia
Renal failure
Increased dietary protein
271
Drugs precipitating hepatic encephalopathy
Sedatives
Diuretics
272
First line treatment hepatic encephalopathy
Lactulose
273
Secondary prophylaxis hepatic encephalopathy
Rifaximin
274
Interpretation of positive HBsAg hepatitis B serology
Usually acute disease
If present for >6 months, implies chronic disease
275
Interpretation positive anti-HBs hepatitis B serology
Immunity - exposure or immunisation
Negative in chronic disease
276
Interpretation positive anti-HBc hepatitis B serology
Previous or current infection
IgM anti-HBc appears during acute or recent (6 months) hep B infection. IgG anti-HBc persists
277
Interpretation HbeAg hepatitis B serology
Current infection
278
Most common cause hepatocellular carcinoma worldwide
Chronic hepatitis B
279
Most common cause hepatocellular carcinoma in Europe
Chronic hepatitis C
280
Risk factors hepatocellular carcinoma
Liver cirrhosis (most important)
Alpha-1 antitrypsin deficiency
Hereditary tyrosinosis
Glycogen storage disease
Aflatoxin
Drugs
Porphyria cutanea tarda
Male sex
Diabetes mellitus, metabolic syndrome
281
Drugs risk factors for hepatocellular carcinoma
OCP
Anabolic steroids
282
Presentation hepatocellular carcinoma
Jaundice
Ascites
RUQ pain
Hepatomegaly
Pruritis
Splenomegaly
283
How to screen hepatocellular carcinoma
Ultrasound +/- alpha-fetoprotein
284
Who to screen hepatocellular carcinoma
Patients liver cirrhosis secondary to hepatitis B & C or haemochromatosis
Men with liver cirrhosis secondary to alcohol
285
Management options hepatocellular carcinoma
If early disease - surgical resection
Liver transplantation
Radiofrequency ablation
Transarterial chemoembolisation
Sorafenib
286
Features type 1 hepatorenal syndrome
Rapidly progressive
Doubling of serum creatinine to >221, or halving of creatinine clearance to less than 20ml/min over a period of less than 2 weeks
Very poor prognosis
287
Features type 2 hepatorenal syndrome
Slowly progressive
Prognosis poor, but patients may live for longer
288
Management hepatorenal syndrome
Vasopressin analogues, e.g. terlipressin
Volume expansion - 20% albumin
Transjugular intrahepatic portosystemic shunt
289
Presentation features more common in Crohns vs UC
Weight loss
Upper GI symptoms, mouth ulcers
Perianal disease
Abdominal mass in RIF
290
Presentation features more common in UC vs Crohn's
Bloody diarrhoea
Abdo pain LLQ
Tenesmus
291
Extra-intestinal manifestations more common in Crohn's vs UC
Gallstones
Oxalate renal stones
292
Extra-intestinal manifestations more common in UC vs Crohn's
Primary sclerosing cholangitis
293
Complications more common in Crohn's vs UC
Obstruction
Fistula
294
Complications more common in UC vs Crohn's
Colorectal cancer
295
Histology features of Crohn's
Inflammation in all layers from mucosa to serosa
Increased goblet cells
Granulomas
296
Histology features UC
No inflammation beyond submucosa (unless fulminant disease)
Neutrophils migrate through walls of glands to form crypt abscesses
Depletion of goblet cells and mucin from gland epithelium
Granulomas infrequent
297
Endoscopy Crohn's
Deep ulcers
Skip lesions → cobblestone appearance
298
Endoscopy UC
Widespread ulceration with preservation of adjacent mucosa - pseudopolyps
299
Small bowel enema finding Crohn's
Strictures - 'Kantor's string sign'
Proximal bowel dilatation
'Rose thorn' ulcers
Fistulae
300
Barium enema findings Crohns
Loss of haustrations
Superficial ulceration, pseudopolyps
In longstanding disease, colon narrow and short - drainpipe colon
301
Inherited causes unconjugated jaundice
Gilbert's syndrome
Crigler-Najjar syndrome
302
Inherited causes conjugated jaundice
Dubin-Johnson syndrome
Rotor syndrome
303
Inheritance pattern of inherited jaundice conditions
All autosomal recessive
304
Crigler-Najjar syndrome prognosis
Type 1 do not survive to adulthood
Type 2 less severe
305
Treatment Crigler-Najjar syndrome type 2
Phenobarbital
306
Features Dubin-Johnson syndrome
Relatively common in Iranian jews
Results in grossly black liver
Benign
307
Cause in rise in TIBC
IDA
Pregnancy, oestrogen
308
How to calculate transferrin saturation
Serum iron / TIBC
309
Blood results anaemia of chronic disease
Normochromic/hypochromic normocytic anaemia
Reduced serum and TIBC
Normal or raised ferritin
310
Diagnostic criteria IBS
Abdominal pain relieved by degeceation, or associated with altered bowel frequency, in addition to 2/4 of:
- Altered stool passage - straining, urgency, incomplete evacuation
- Abdominal bloating, distention, tension, or hardness
- Symptoms made worse by eating
- Passage of mucus
311
Red flag features suggesting not IBS
Rectal bleeding
Unexplained/unintentional weight loss
Family history of bowel or ovarian cancer
Onset after 60y/o
312
Suggested primary care investigations IBS
FBC
ESR/CRP
Coeliac disease screen
313
First line IBS treatment predominant pain
Antispasmodic agents
314
First line IBS treatment predominant constipation
Laxatives (avoid lactulose)
315
First line IBS treatment predominant diarrhoea
Loperamide
316
Second line treatment constipation IBS
Linaclotide
317
When to consider linaclotide IBS
Optimal or maximum tolerated doses of previous laxatives from different classes have not helped, and had constipation for at least 12 months
318
Second line treatment (all symptoms) IBS
Low dose TCA
319
When to consider psychological intervention IBS
If symptoms do not response to pharmacological treatments after 12 months - CBT, hypnotherapy, psychological therapy
320
Predisposing factors bowel ischaemia
Increasing age
AF (particularly mesenteric ischaemia)
Other causes of emboli - endocarditis, malignancy
CVS risk factors - smoking, hypertension, diabetes
Cocaine
321
Presentation bowel ischaemia
Abdo pain - sudden onset, severe, out of keeping with exam findings
Rectal bleeding
Diarrhoea
Fever
322
Investigation of choice bowel ischaemia
CT
323
Cause acute mesenteric ischaemia
Typically embolism resulting in occlusion of artery supplying small bowel e.g. superior mesenteric artery
324
Management acute mesenteric ischaemia
Urgent surgery
325
Presentation chronic mesenteric ischaemia
Colicky, intermittent abdominal pain
326
What is ischaemic colitis
Acute but transient compromise in the blood flow to large bowel → inflammation, ulceration, haemorrhage
327
Where in bowel ischaemic colitis more likely to occur
'Watershed' areas, e.g. splenic flexure, that are located at borders of territory supplied by superior and inferior mesenteric arteries
328
Investigation findings ischaemic colitis
Thumbprinting on AXR due to mucosal oedema/haemorrhage
329
Management ischaemic colitis
Usually supportive
Surgery may be required in minority of cases if conservative management fails
330
Indications for surgery ischaemic colitis
Generalised peritonitis
Perforation
Ongoing haemorrhage
331
Presentation malabsorption
Diarrhoea
Steatorrhoea
Weight loss
332
Intestinal causes of malabsorption
Coeliac disease
Crohn's disease
Tropical sprue
Whipple's disease
Giardiasis
Brush border enzyme deficiencies, e.g. lactase insufficiency
333
Pancreatic causes of malabsorption
Chronic pancreatitis
Cystic fibrosis
Pancreatic cancer
334
Biliary causes malabsorption
Biliary obstruction
Primary biliary cirrhosis
335
Other causes of malabsorption
Bacterial overgrowth, e.g. systemic sclerosis, diverticulae, blind loop
Short bowel syndrome
Lymphoma
336
What is melanosis coli
Disorder of pigmentation of bowel wall - pigment laden macrophages on histology
337
Cause melanosis coli
Laxative abuse, esp anthraquinone compounds e.g. senna
338
Mechanism metoclopramide
D2 receptor antagonist
339
Uses metoclopramide
Mainly used in management of nausea
GORD
Gastroparesis (prokinetic action)
Migraine
340
Why is metoclopramide useful in migraine
Migraine attacks result in gastroparesis, slowing absorption of analgesics
341
Adverse effects metoclopramide
Extrapyramidal effects - acute dystonia e.g. oculogyric crisis
Diarrhoea
Hyperprolactinaemia
Tardive dyskinesia
Parkinsonism
342
Use of metoclopramide in bowel obstruction
Should be avoided in bowel obstruction, but may be helpful in paralytic ileus
343
Risk factors NAFLD
Obesity
T2DM
Hyperlipidaemia
Jejunoileal bypass
Sudden weight loss/starvation
344
Features NAFLD
Usually asymptomatic
Hepatomegaly
345
Bloods NAFLD
ALT>AST
346
USS NAFLD
Increased echogenicity
347
Further investigation if NAFLD found
Enhanced liver fibrosis blood test - check for advanced fibrosis
Used in combo with hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1
348
What to do if testing shows NAFLD with advanced fibrosis
Refer to liver specialist - biopsy for more accurate staging
349
Management NAFLD
Lifestyle changes, particularly weight loss and monitoring
350
Most common type oesophageal cancer
Adenocarcinoma
351
Location oesophageal adenocarcinoma
Lower third
352
Location oesophageal SCC
Upper 2/3
353
Risk factors oesophageal adenocarcinoma
GORD
Barrett's oesophagus
Smoking
Obesity
354
Risk factors oesophageal SCC
Smoking
Alcohol
Achalasia
Plummer-Vinson syndrome
Diets rich in nitrosamines
355
Features oesophageal cancer
Dysphagia
Anorexia and weight loss
Vomiting
Odynophagia
Hoarseness
Melaena
Cough
356
Diagnosis oesophageal cancer
Upper GI endoscopy
357
Investigation for staging oesophageal cancer
Endoscopic ultrasound for locoregional staging
CT CAP - FDG-PET CT for occult mets if not seen on initial CT
Laparoscopy sometimes to detect occult peritoneal disease
358
Treatment oesophageal cancer
Operable disease (T1N0M0) - surgical resection
Chemotherapy
359
Main complication surgical resection oesophageal cancer
Anastomotic leak → mediastinitis
360
What is Plummer-Vinson syndrome
Triad of:
Dysphagia secondary to oesophageal webs
Glossitis
Iron deficiency anaemia
361
Treatment Plummer-Vinson syndrome
Iron supplementation
Dilation of webs
362
What is Boerhaave syndrome
Severe vomiting → oesophageal rupture
363
Most common type of pancreatic cancer
Adenocarcinoma
364
Risk factors pancreatic cancer
Increasing age
Smoking
Diabetes
Chronic pancreatitis
Hereditary non-polyposis colorectal carcinoma
Multiple endocrine neoplasia
BRCA2 gene
KRAS gene mutation
365
Classic presentation pancreatic cancer
Painless jaundice - pale stools, dark urine, pruritis, cholestatic liver function tests
366
Abdominal masses in pancreatic cancer
Hepatomegaly - due to mets
Gallbladder
Epigastric mass - from primary tumour
367
Courvoisiers law
In presence of painless obstructive jaundice, palpable gallbladder unlikely to be due to gallstones
368
Other symptoms pancreatic cancer
Non specific presentation - anorexia, weight loss, epigastric pain
Loss of exocrine function eg steatorrhoea
Loss of endocrine function eg diabetes
Atypical back pain
Trousseau sign
369
What is Trousseau sign
Migratory thrombophlebitis
370
Investigation pancreatic cancer
High resolution CT scanning
371
Imaging pancreatic cancer
'Double duct' sign - simultaneous dilatation of common bile duct and pancreatic ducts
372
Treatment resectable pancreatic cancers
Whipple (pancreaticoduodenectomy) + adjuvant chemotherapy
373
SEs Whipple
Dumping syndrome
Peptic ulcer disease
374
Palliation pancreatic cancer
ERCP with stenting
375
What is pernicious anaemia
Autoimmune disorder affecting gastric mucosa resulting in vitamin B12 deficiency
376
Other causes of B12 deficiency (other than pernicious anaemia)
Atrophic gastritis (secondary to H pylori)
Gastrectomy
Malnutrition, e.g. alcoholism
377
Risk factors pernicious anaemia
Female
Middle to old age
Other autoimmune disorders - thyroid disease, T1DM, Addison's, rheumatoid, vitiligo
Blood group A
378
Features pernicious anaemia
Anaemia features - lethargy, pallor, dyspnoea
Neurological features
Mild jaundice
Atrophic glossitis → sore tongue
379
Neurological features pernicious anaemia
- Peripheral neuropathy - pins and needles, numbness, typically symmetrical, legs > arms
- Subacute combined degeneration of spinal cord - progressive weakness, ataxia, paresthesia → spasticity and paraplegia
- Neuropsychiatric features - memory loss, poor concentration, confusion, depression, irritability
380
FBC in pernicious anaemia
Macrocytic anaemia
Hypersegmented polymorphs on blood film
Low WCC and platelets
381
Antibodies in pernicious anaemia
Anti-intrinsic factor antibodies (highly specific)
Anti-gastric parietal cell antibodies (low specificity)
382
Management pernicious anaemia
IM vitamin B12 - if no neuro features, 3 injections/week for 2 weeks → 3 monthly. More frequent if neuro features
Folic acid supplements
383
Malignancy increased risk in pernicious anaemia
Gastric cancer
384
Inheritance Peutz-Jeghers syndrome
Autosomal dominant
385
Features Peutz-Jeghers syndrome
Hamartomatous polyps in GI tract, mainly small bowel → SBO due to intussusception, GI bleeding
Pigmented lesions on lips, oral mucosa, face, palms, soles
386
What is primary biliary cholangitis
Chronic liver disorder - autoimmune. Interlobular bile ducts damaged by chronic inflammatory process → progressive cholestasis → cirrhosis
387
Associations primary biliary cholangitis
Sjorgen's syndrome (80%)
RA
Systemic sclerosis
Thyroid disease
388
Presentation primary biliary cholangitis
Fatigue
Pruritis
Cholestatic jaundice
Hyperpigmentation, esp over pressure points
RUQ pain
Xanthelsmas and xanthomata
Clubbing
Hepatosplenomegaly
389
Blood tests primary biliary cholangitis
AMA antibodies
Raised serum IgM
390
First line management primary biliary cholangitis
Usodeoxycholic acid - slows progression and improves symptoms
391
Treatment pruritis in primary biliary cholangitis
Cholestyramine
392
Other treatments in primary biliary cholangitis
Liver transplant
Fat-soluble vitamin supplementations
393
Complications primary biliary cholangitis
Cirrhosis → portal hypertension → ascites, variceal haemorrhage
Osteomalacia and osteoporosis
Significantly increased risk of hepatocellular carcinoma
394
What is primary sclerosing cholangitis
Biliary disease characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts
395
Associations primary sclerosing cholangitis
UC (80%)
Crohn's
HIV
396
Features primary sclerosing cholangitis
Cholestasis - jaundice, pruritis
RUQ pain
Fatigue
397
Diagnostic investigation primary sclerosing cholangitis
ERCP or MRCP
398
Findings ERCP/MRCP primary sclerosing cholangitis
Multiple biliary strictures giving beaded appearance
399
Antibody in primary sclerosing cholangitis
pANCA
400
Findings liver biopsy primary sclerosing cholangitis
Fibrous, obliterative cholangitis often described as onion skin
401
Complications primary sclerosing cholangitis
Cholangiocarcinoma
Increased risk of colorectal cancer
402
Adverse effects PPIs
Hyponatraemia, hypomagnaseaemia
Osteoporosis → increased risk of fractures
Microscopic colitis
Increased risk of C.diff
403
Risk factors small bowel bacterial overgrowth syndrome
Neonates with congenital GI abnormalities
Scleroderma
Diabetes mellitus
404
Presentation small bowel bacterial overgrowth syndrome
Chronic diarrhoea
Bloating, flatulence
Abdominal pain
405
Diagnosis small bowel bacterial overgrowth syndrome
Hydrogen breath test
Small bowel aspiration and culture
406
Management small bowel bacterial overgrowth syndrome
Rifaximin treatment of choice
Co-amox or metro effective in majority
407
Diagnosis spontaneous bacterial peritonitis
Paracentesis - neutrophil >250
408
Most common organism causing SBP
E. coli
409
Management SBP
IV cefotaxime
410
Criteria for prophylaxic antibiotics in patients with ascites
- Prev episode fo SBP
- Fluid protein <15g/L, and either Child-Pugh score of at least 9 or hepatorenal syndrome
411
Prophylactic antibiotic in ascites
Oral cipro or norfloxacin
412
Presentation UC
Bloody diarrhoea
Urgency
Tenesmus
Abdominal pain, esp left lower quadrant
Extra-intestinal features
413
Diagnostic investigation UC
Colonoscopy and UC
In patients with severe colitis, avoid colonoscopy due to risk of perf - flexi sig instead
414
Scope findings UC
Red, raw mucosa, bleeds easily
No inflammation beyond submucosa (unless fulminant disease)
Widespread ulceration with preservation of adjacent mucosa (pseudopolyps)
Inflammatory cell infiltrate in lamina propria
Crypt absses
Depletion of goblet cells and mucin
415
Barium enema findings UC
Loss of haustrations
Superficial ulceration, pseudopolyps
If longstanding, colon narrow and short
416
Criteria mild UC
<4 stools/day, small amount of blood
417
Criteria moderate UC
4-6 stools/day, varying amount of blood, no systemic upset
418
Criteria severe UC
>6 bloody stools/day
Features of systemic upset - pyrexia, tachycardia, anaemia, raised inflammatory markers
419
First line treatment mild/moderate UC with proctitis
Rectal aminosalicylate (mesalazine)
420
Second line treatment mild/moderate UC with proctitis
If remission not achieved in 4 weeks, add oral aminosalicylate
421
Third line treatment mild/moderate UC with proctitis
Add topical or oral corticosteroid
422
First line treatment mild/moderate UC with proctosigmoiditis and left sided disease
Rectal aminosalicylate
423
Second line treatment mild/moderate UC with proctosigmoiditis and left sided disease
If remission not achieved in 4 weeks, add high-dose oral aminosalicylate and topical corticosteroid
424
Third line treatment mild/moderate UC with proctosigmoiditis and left sided disease
Stop topical treatments, offer oral aminosalicylate and oral corticosteroid
425
First line treatment mild/moderate UC extensive disease
Topical (rectal) aminosalicylate and high dose oral aminosalicylate
426
Second line treatment mild/moderate UC extensive disease
If remission not achieved in 4 weeks, stop topical treatment and offer high dose oral aminosalicylate and oral corticosteroid
427
First line treatment severe UC
Hospital admission
IV steroids (IV ciclosporin if steroids CI)
428
Second line treatment severe UC
If no improvement after 72 hours, consider adding IV ciclosporin or consider surgery
429
Maintaining remission following mild/moderate UC flare with proctitis/proctosigmoiditis
Rectal aminosalicylate (daily or intermittent) +/- oral aminosalicylate
Or oral aminosalicylate (not as effective)
430
Maintaining remission following mild/moderate UC flare with left-sided and extensive disease
Low maint dose of oral aminosalicylate
431
Maintaining remission following severe relapse or ≥2 exacerbations in past year
Oral azathioprine or oral mercaptopurine
432
First line acute treatment variceal haemorrhage
Terlipressin
Prophylactic IV antibiotics
Endoscopy - band ligation (superior) or sclerotherapy
433
What IV antibiotics given in acute variceal haemorrhage
Quinolones
434
Second line treatment acute variceal haemorrhage
Sengstaken-Blakemore tube
435
Third line treatment acute varicael haemorrahge
TIPSS
436
Complication TIPSS
Exacerbation of hepatic encephalopathy
437
Prophylaxis variceal haemorrhage
Propanolol
Endoscopic variceal band ligation
TIPSS if above measures unsuccessful
438
How is endoscopic variceal band ligation carried out as prophylaxis for variceal haemorrhage
Should be performed at two weekly intervals until all varices have been eradicated
PPI cover to prevent EVL-induced ulceration
439
Who should be offered prophylactic endoscopic variceal band ligation
People with cirrhosis who have medium to large oesophageal varices
440
Presentation vitamin A deficiency
Night blindness
441
Vitamin A fat or water soluble
Fat
442
Vitamin B1 aka
Thiamine
443
Vitamin B1 fat or water soluble
Water
444
Causes B1 (thiamine) deficiency
Alcohol excess
Malnutrition
445
Conditions associated with B1 (thiamine) deficiency
Wernicke's encephalopathy
Korsakoffs syndrome
Dry beriberi
Wet beriberi
446
Features Wernicke's encephalopathy
Nystagmus
Opthalmoplegia
Ataxia
447
Features Korsakoffs syndrome
Amnesia
Confabulation
448
Features dry beriberi
Peripheral neuropathy
449
Features wet beriberi
Dilated cardiomyopathy
450
Vitamin B12 aka
Cobalamin
451
Causes B12 deficiency
Pernicious anaemia
Diphyllobothrium latum infection
Crohn's
452
Consequences B12 deficiency
Macrocytic, megaloblastic anaemia
Peripheral neuropathy
453
B12 water or fat soluble
Water
454
Vitamin B6 aka
Pyridoxine
455
B6 water or fat soluble
Water
456
Causes of B6 deficiency
Isoniazid therapy
457
Consequences B6 deficiency
Peripheral neuropathy
Sideroblastic anaemia
458
What is Whipple's disease
Rare multi-system disorder caused by Tropheryma whipellii infection
459
Risk factors Whipples disease
Middle aged men
HLA-B27
460
Features Whipple's disease
Malabsorption - diarrhoea, weight loss
Large joint arthralgia
Lymphadenopathy
Hyperpigmentation, photosensitivity
Pleurisy, pericarditis
Neurological symptoms - opthalmoplegia, dementia, seizures, ataxia, myoclonus
461
Investigations Whipple's disease
Jejunal biopsy - deposition of macrophages containing Periodic acid-Schiff granules
462
Management Whipple's disease
Oral co-trimoxazole for a year
Sometimes preceded by IV penicillin
463
Inheritance pattern Wilson's
Autosomal recessive
464
Onset of symptoms Wilson's disease
10-25
465
Features Wilson's disease
Hepatitis, cirrhosis
Neurological features
Kayser-Fleischer rings
Renal tubular acidosis
Haemolysis
Blue nails
466
Neurological features Wilsons' disease
Basal ganglia degeneration
Speech, behavioural, and psychiatric problems - often first manifestations
Asterixis
Chorea
Dementia
Parkinsonism
467
Investigation findings Wilsons
Reduced serum caeruloplamin
Reduced total serum copper, increased free serum copper
Increased 24hr urinary copper excretion
468
Confirmation of diagnosis Wilsons
Genetic testing ATP7B
469
First line Wilsons
Penicillamine (chelates copper)
