Gastroenterology 2.0 Flashcards
What would you see on LFTs for a patient with alcoholic hepatitis
GGT elevated
Elevated AST:ALT, with a ration of > 2:1
a ratio of > 3:1 is strongly suggestive of acute alcoholic hepatitis
ALT > AST for viral hepatitis
What investigations should you do for a patient with suspected IBD?
FBC, UEs, LFTs, TFTs, coeliac serology, faecal calprotectin, stool culture
Calproctin >50 abnormal >150 highly suggestive of IBD, can be used as a marker of disease activity
Lifestyle advice for patients with IBD
- Smoking cessation (reduces flares/severity in chrohns, reduces overall CVD risk)
- Generally healthy diet (increase omega acids in UC)
- Weight bearing exercise (mood and to prevent osteoporosis from freauent steroid use)
- Psychological coping skillds
What are the 4 types of treatment we use to control IBD
What ones do we comomonly use
5-aminosalicylates, corticosteroids, immunomodulatory medicines and biologics
5-ASA’s: sulfasalazine, mesalazine
Steroids: PO prednisone, hydrocortisone acetate enaemas
Immunomodulators: azathioprine, mercaptopurine, MTX (2nd line)
biologics: idalizumab and adalimumab
What is the mortality rate from bowel cancer for people with IBD?
How to we monitor for this
10-15%
Monitor with a c-scope at the 10 year mark, then every1-5yrs depending on risk
What contraceptives should be avoided in patients with IBD
COCP: may not be absorbed in patients with severe Chrohns
Depo-provera can cause reduced bone density, as can IBD
IBD medications and pregnancy
MTX is teratogenic, should be stopped >3/12 prior to trying to concieve
Biologics (inflixumab/adalizumab) can crosss the placenta in the first trimester, however this hasn’t been linked to negative outcomes
What test do you need to do prior to starting azathioprine or mercaptopurine and why
Serum thiopurine methyltransferase (TPMT) needs to be checked.
1 out of 150 are TMPT-deficient
TMPT deficient patients develop severe bone marrow toxicity on standard levels of thiopurines
How do we use ASA’s for IBD and in what form
Oral 5-ASA’s are often first line for mild-moderate IBD
much more effective in UC then Chrohns
high dose when initiating or during a flare, then slowly taper down
Can use suppositories for rectal disease and enemas for left sided disease
What are the most common brand forms of 5-ASA’s
what dose do we use for flares vs maintenance
Pentasa (mesalazine) - releases in the small and large intestine
- 4g for flares, 2g for maintenance
Asacol (mesalazine) - releases in the terminal ileum and colon
- 1.6g TDS for flares, 400-800mg for maintenance
Side effects to monitor for pt’s on 5-ASAs
Blood dyscrasisa
- Patients should be advised to report any unexplained bleeding, bruising, fever, malaise, purpura, or sore throat
- monitor FBC, LFTs, UEs
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how are steroids (prednisone, hydrocort acetate enema) used in patients with IBD
Used to manage flares / induce remission
- often used if an ASA is ineffective at controlling symptoms
- commonly used initially in pts with severe chrohn
- NOT for IBD maintenance treatment (avoid long-term use)
Monitor risk of osteoporosis and osteonecrosis with oral corticosteroid use
dose of steroid in a flare
Pred: initially 40 mg daily for at least two weeks, then reduce dose by 5 mg per week
Hydrocortisone acetate (enema): 1 (approximately 90–100 mg) OD for 2 weeks then once daily on alternate days
when do we use immunomodulators (azathioprine, mercaptopurine, MTX)
when ASA’s are ineffective and pts are requiing multiple courses of steroids
What should we know about 5-ASA’s and fertility
No affect on female fertility
Sulfasalazine can reduce sperm count and sperm motility.
This is reversible and usually returns to normal 2 to 3 months after you stop taking sulfasalazine.
Extra intestinal side effects or complications of coeliacs disease
headache, fatigue
dermatitis herpatiformis
Loss of dental enamel , angular stomatitis
Iron b12, folate deficiency
Elevated liver enzymes
osteoporosis
GI malignancy or T-cell lymphoma
Genes associated with coeliacs
Serology ?
HLA DQ2 and HLA DQ8
Anti-TTG, do with IgA (need to be having >5g/day for 4 weeks prior)
- if above high > will reflex due EMA -TTG
- if IgA low > will do DGP-TTG
IgA deficient pts will give you a false neg, when they are actually high
Red flags for dyspepsia
First presentation >50yrs ( or >40 years if Māori, Pacific, Asian descent)
FHX gastric cancer (especially if <50yrs)
Severe or persistent dyspepsia despite treatment
Coughing spells or nocturnal aspiration
Dysphagia
Weight loss
IDA
bleeding (haemtemesis, malaena
Palpable abdominal mass
Persistent or protracted vomiting
Medications that can cause dyspepsia
NSAIDs
Aspirin, clopidogrel, other anticoagulants
bisphosphonates
steroids
H.pylori serology is not available in NZ, what do we use instead
Faecal (antigen) test:
- requires a fresh stool sample (must arrive within 48 hours, otherwise freeze the sample).
- demonstrates active infection, so suitable for diagnosis and follow-up testing.
False negative results occur if recent antibiotics (1 month) or proton pump inhibitor (PPI) (2 weeks) before testing.
only do test of cure if ongoing symptoms at 3/12 or known complications
difference between a femoral and inguinal hernia on exam
Inguinal: medial and above pubic tubercle
Femoral: lateral and below pubic tubercle (under inguinal ligmaent next to femoral vessels)
hepatitis B bloods
HbsAg: surface antigen (active infection)
HbcAg: core antigen (active infection)
HbeAg: Envelope antigen (active infection) indicates greater infectivity and increased risk of chronic liver disease.
viral DNA (active infection)
Hb core IgM antibodies: immediate immune response (active infection or recovery)
Hb core IgG antibodies: later immune reaction (chronic infection)
Anti-HbS: recovery (post infection or immunisation)
Antibodies for autoimmune hepatitis
Antinuclear antibody (ANA), anti‑smooth muscle antibody (ASMA), anti‑mitochondrial antibody (AMA)
What is needed to calculate a Fib4 score
how do we use the score
ALT, AST, PLT, age
Do fibro scan if
≤ 60 years and score ≥ 1.3
> 60 years and score ≥ 2
otherwise, recheck score in 2 yrs
25% have NAFL, 5-15% develop fibrosis
