Gastroenterology Flashcards
1
Q
dysphagia
A
mechanical
- stricture (malig or benign)
- extrinsic (goitre, ca)
- pharyngeal pounch (oldies)
motility
- achalasia
- spasm
- system sclerosis
- neurolog - stroke; mg/ms/mnd
other
- oesophagitis
- globus histericus
2
Q
GORD
A
higher risk of reflux if
- hernia, obesity,
- preg, smoking, alc
- upper GI motility problem
2
Q
dysphagia history
A
ask about
- solids v liquids
- pain
- pattern
- regurg, wet voice, coughing
- lump in throat
- WEIGHT LOSS
liquid and solids = neuro (diff doing swallow motion)
solids»_space; liq = stricture
constant, painful, progressive, WL = malig
intermittent = spasm
3
Q
barrets
A
columnar metaplasia
chronic reflux oesophagitis, ?haematemesis ?dysphagia
biopsy - ?premalignant
- mucosectomy
- laser ablation
4
Q
GORD
A
higher risk of reflux if
- hernia, obesity,
- preg, smoking, alc
- upper GI motility problem
history
- site, onset, charact
- exacerbate - food
- what has helped
any GI symptoms: ESWAB
- energy
- swallowing
- weight
- appetite
- blood
5
Q
dispepsia ALARMS symptoms
A
anaemia loss of weight anorexia recent onset, progressive malaena (or haematem) swallowing probs
6
Q
dyspepsia differentials
A
peptic ulcer (duo, gastric)
oesophagitis/gord (if strong heart burn element)
inflammation (duodenitis/gastritis)
malignancy (ALARMS)
7
Q
peptic ulcer
A
general - smoking, nsaids/aspirin, h pylori
may cause upper gi bleed
duodenal
- pain before meals, relieved by eating
gastric
- pain follows meals (may see weight loss)
- relieved by antacids
8
Q
duodenal vs gastric ulcer
A
duodenal more common
relieved by food
9
Q
peptic ulcer complications
A
BLEEDING
- abc resus
- endoscope: adrenaline, thermal coag
- abx and ppi
PERFORATION - -> acute abdomen
- Ix: abdo pain bloods (fbc ue lft, amylapse/lipase, group and save) - erect cxr, ecg
- nil by mouth
- pethidine, prochlorpromazine, laparoscopic repair
- abx and ppi
also OBSTRUCTION
10
Q
dyspepsia ix/mgmt
A
> 55 or ALARMS –> endoscope
otherwise
1) lifestyle, stop nsaids, antacids
2) either - test and treat hpylori
or – PPI 1 month
11
Q
H Pylori eradication
A
PPI, clarithromycin, (amox or metron)
12
Q
atrophic gastritis
A
causes pernicious anaemia
-lack of IF means low vit B12
see anti- parietal cell and intrinsic factor
13
Q
Zollinger Ellison
A
gastrin producing tumour
multiple duodenal ulcers
–epigastric pain and diarrhoea
1/3 have MEN type 1
-parathyroid, pancreas, pituitary, gastrinoma
diag: fasting GASTRIN levels
Tx: omeprazole
14
Q
red flags in bowel*
A
blood
weight loss
family - bowel and ovarian
over 60y
15
Q
IBS
A
abdo pain
- rel by defac/ brough by food
- w altered stool freq/form (consti/diarr)
2 of:
bloat
mucus
passage - urgency, strain, tenesmus
also:
lethargy, nausea
back ache
bladder sx
16
Q
IBS mx options
A
diet - keep diary, exclusion
bulking agents for constip/diarh
loperamide (immodium) for diarh
mebeverine, buscapan for colic/bloating
amitriptyline for pain
17
Q
UC path
higher assoc CRC
A
MUCOSAL pseudopolyps inflam infiltrate reduced goblets, gran loss of haustrations (drainpipe)
comp: toxic megacolon, perf
18
Q
UC s&s
A
bloody diarr
urgency, tenesmus
pain LLQ
other arthritis, uveitis can get mouth ulcers erythema nodosum, pyoderma gangrenosum *primary sclerosing cholangitis risk crc
19
Q
Crohns
A
TRANSMURAL
granuloma and inc goblets
non bloody diarrhoea
WL
upper GI: ulcers in mouth
abdo mass RIF
athritis, uveitis
erythema nodosum
pyoderma gangrenosum
anaemia
comps: fistula, obstruction, malab, stones
scan: rose torn ulcer, cobblestone
20
Q
UC treatment
A
vs flare up
-rectal mesalazine is best
or steroid
for remission
oral mesalazine
azathioprine
(not methotrexate - only in CD)
surgery
21
Q
CD treat
A
acute: steroid
remission: mesal,
disease modifiers: azathrio, methotrex, influximab
stop smoking
surgery
22
Q
Liver enzymes
A
hepatocellular: AST, ALT
biliary outflow: ALP, GGT
alcohol: AST:ALT 2:1
viral - deranged enzymes but not biliubin
23
Q
liver disease signs
A
Clubbing, palmar erythema
Leukonych, liver spots,
Dupuytrens
LIVER FLAP
Itch, bruise
Spider naevi
Hair loss, gynecomastia, testic
Ascites, splenomeg, caput medusa
jaundice
enceph (lactulose, enema)
fetor hepatis
24
raised unconjugated bilirubin
conjugated is less than 20%
points to pre-hepatic
HAEMOLYSIS
not affect stool and urine
inc reticulocytes
liver enzymes not affected (just bili)
```
Breast milk/neonatal
Gilberts disease (benign, usually young)
Crigler Najjar (neonate, no conjugated, CNS)
```
25
raised conjugated bilirubin (>20%)
points to cholestasis (hepatic or postheptic)
pruritis and jaundice noticeable
stool and urine affected
nb dark urine but urobilinogen is low (as this is the stuff recycled from gut)
26
alcoholic liver disease
3 patterns
fatty liver
- in 50% heavy drinkers but reversible
- raised liver enzymes but not bilirubin (no jaunidce) and not impair clotting
- hepatomegaly
- reversible on cessation
acute alcoholic hepatitis
- affects liver enzymes as well as bilirubin and clotting
- present w sudden jaundice and hepatitic picture
- hepatomegaly ++
```
alcoholic liver cirrhosis
- from chronic alcohol abuse - over 20 years
- small liver
- bilirubin/jaunidce, clotting affected
- but liver enzymes may normalise
--> portal htn, varices, ascites
15% risk hcc
```
27
Viral hepatitis Sx
nausea, vom, anorexia
myalgia
lethargy
RUQ pain
maybe jaundice
28
Hep B serology
anti-HBs: immune (either vaccine or infected)
anti-HBc: past infection
HBe: currently infective
anti-HBe: low infectivity, reocvering
HBs: virus present, either infected or carrier
29
Hep A Virus (E also similar)
RNA
self limiting acute
- malaise anorexia n+v ?jaundice
ALT>AST
IgM - confirms virus
IgG - immune
T: supportive
risk: travelling, shellfish, water
30
Hep B Virus
DNA
acute illness mild or asymto
10% get chronic/carrier
- risk cirrhosis, HCC
risk: sex, iv drug, tattoo
T: interferon
antivirals (lamivudine etc)
31
Hep C Virus
RNA
```
progressive chronic (no acute form)
- present w chronic fatigue
```
risk: blood products,haemophilia, drugs
treat: interferon and ribavarin
32
post hepatic
- higher % conjug >40%
- ALP
- enlarged liver, dilatation
gallstones, cancer
pbs, psc, biliary atresia
33
Biliary Colic
RUQ pain
- intermittent
- worse after food
"female fat fair forty"
first line: NSAID
then surgery
34
Acute Cholecystitis
fat female forty
inf of GB 2dry to GS
hx of GS - biliary colic
RUQ pain
- severe and persistent
- radi to back, shoulder
MURPHY'S SIGN
mild fever, ?peritonism (local guarding)
WCC inc, ?nausea+vom
fluid, abx, analg
surgery once settled
35
Ascending Cholangitis
= emergency
infection in CBD
charcots triad:
FEVER, rigors - very unwell
RUQ pain
*JAUNDICE*
severe: hypotension, confusion
fluid
abx
36
autoimmune hepatitis
young and middle aged women
IgG, infiltration of WC's
other autoimmune ie arthritis, GN, UC
antibodies: ANA, SMA, IgG
treat: steroids +/- azathio, transplant
20% chronic
37
primary biliary cirrhosis
autoimmune (ra, thyroid, sjogrens)
mid aged women
IgM
AMA
raised ALP, bilirubin, ITCHING
dry mouth (sicca synd)
jaundice, clubbing, organomeg, portal htn
risk HCC
replace vitamins (otherwise clotting and osteomala)
colestyramine for itch
transplant
38
primary sclerosing cholangitis
UC, 2:1 male
chronic biliary obstruc
ANA, SMA, ANCA, IgG
(ama -ve)
risk of cholangiocarinoma
colestyramine for pruritis,
vit replace
transplant
39
primary sclerosis cholangitis
ASSOC W UC
non malig non bacterial inflam and fibrosis
jaundice, pruritis , hepatomeg
40
haemochromatosis
inherited - auto rec chrom 6 hfe gene
tiredness, arthralgia
grey skin
diabetes
gonadal failure
liver, heart, joints, pancreas
tx: venesection
low iron diet
screen relatives
41
hepatorenal syndrome
renal failure in pt w chronic liver disease
42
Wilson's disease
autosomal recessive, chrom 13
diag: low caeruloplasmin, inc urinary Cu
affects: brain liver cornea nails
tx: penicillamine
43
Budd Chiari
thrombosis in hepatic vein
HEPATOMEG
ASCITES
ABDO PAIN
no jaundice
44
alpha 1 antitrypsin defic
emphys, liver (cholestatic), hcc
45
drugs causing liver disease
amiodarone
methotrexate
isoniazid
phenytoin
46
causes of cirrhosis summary
```
viral - hep b/c (hcc risk)
alcohol
- other toxins (methotrex, amiod)
metabolic
- hh, w, alpha, nash
autoimmune
- aih: sma igG
- pbc: ama igM (hcc risk)
- psc: panca (cc risk)
venous - chronic budd chiari
```
causing acute liver disease
- viral (hep a)
- alcohol
- gallstone
47
cirrhosis sequelae
```
liver failure (decompensation)
-clotting fail (raised PT)
-ascites (low albumin)
-encephalopathy
also low Ig's
```
portal htn
- ascite caput medusae
- splenomegaly
- varices
48
acute variceal bleed
resus (avoid saline in liver dis - hypernatr)
vit k and ffp if clotting probs (often seen in liver disease)
terlipressin, abx
banding, sclerotherapy
49
Cholangiocarcnoma
persistent biliary colic
WL, anorexia, jaundice
mass RUQ (Courvoisiers sign)
virchows node
50
Gallstone ileus
small bowel obstr second to gall stone
| abdo pain, distension, vomiting
51
acute pancreatitis
alcohol, gallstones
mumps
steroids
trauma (ercp)
severe epigastric pain
vomiting, fever, tenderness
cullers and greys-turner signs
raised amylase, lipase (longer)
PETHIDINE analgesia
52
chronic pancreatitis
main cause of malabs after chrons and coeliac
c: alc, stones, tumour, cf, hh, hyperparathy
pain boring through to back
bloating, steator, wl
mx: analgesia, CREON, vitamins
53
acute appendicitis
pain starts central may be colicky - referred visceral pain
- then moves to RIF due to somatic pain from parietal peritoneum
patient is very still (unlike renal colic)
n+v, ?constip, anorexia
tachy, febrile
rigid, tender, guarding
fbc (raised wcc), ue (dehydr?),
get surgical opinion
∆∆ - do beta HCG, amylase, abdo xray
ABC, fluid, analg, antiemetic, abx, nil by mouth
54
ischaemic bowel
```
severe sudden abdo pain
shock
bloody diarhoea
metabolic acidosis - lactate
history/risk of vascular disease/atheroma
```
55
coeliac features and comps
```
adbo pain
steatorrhoea
vomiting
malaise, weakness, weight loss
anaemia (combined fe and folate defic)
```
ulcers
risk of cancer - gi cancers and lymphoma
dermatitis herpetiformis
hyposplenism
56
coeliac management
test anti-ttg, duodenal biopsy - villous atrophy
gluten found in wheat rye barley
- pasta and bread out
rice and potatoes ok
oats - not clear
main comps are malabsorption
fe, folate, vit d
- monitor bloods, look for mouth ulcers/stomatitis, anaemia, osteomalacia
dermatitis herpetiformis is assoc
57
pancreatic cancer
painless jaundice
anorexia wl
prothrombotic - get clots
58
colorectal cancer
familial
- FAP (apc gene) - prophylactic colectomy age 20
- HNPCC (mlh, msh gene) - aut dom, annual surveil, linked to breast cancer
```
dukes staging
A submucosa
B serosa
C lympho nodes
D metastasized
```
59
anal cancer
scc
herpes simplex virus
- homosexuals
60
causes of constipation
gen:
- fluid, diet,
- routine, psycho
anorectal
- fissure
met
- hypothy
- hypercalc
drugs
- opiates
- tca (anti cholinergics)
IBS (alt w diarr)
obstruction - crc
61
Laxatives
```
bulking agents (take w water)
- bran, ispaghula,
```
```
stool softeners (good for painful perianal dis)
-arachis oil
```
stimulant (avoid in obst, colitis, avoid prolonged use)
- senna (good vs opiate), bisacodyl
- docusate sodium, danthron (also softeners)
osmotic
- lactulose (used in hepatic enceph)
- movicol (na salts), mg salts
62
diarrhoea
generally self limiting
rest, fluid and dioralyte
stool sample if severe, invasive, infective
scope if prolonged
frequent small passages - IBS
profuse, watery, night time - suggest organic
blood - IBD, CRC, bacterial infection
acute onset - infective
63
gastroenteritis
```
commonly viral (rotavirus)
bacterial
- in hosp, c dif (pseudomembranous)
```
- campylo - bloody, gram neg spiral, common food eg bbq
- salmonella - bloody, gram neg rod
- shigella - also gram neg rod
- bacilis cereus - gram pos, rice, quick onset, nausea and vom
- shigella (gram neg rod, dodgy restaurants, febril/meningism)
- cholera (water; "rice-water stools", gram neg comma shape)
- ecoli 157 (profuse watery, may later see blood, HUS, gram neg bacillus)
- HIV: cryptosporidium
fast onset post food - staph aureus and bacilus cereus
antibiotics usually not necessary
over 5 days - stool sample
over 3 weeks --> colonoscopy
chronic diarr
- giardiasis (st petersburg, water)
- inflam bowel disease
64
diverticular disease
high fiber diet reduces risk of -itis
barium enema
sigmoidoscopy
treat of chronic diverticulitis
- fiber diet, antispas (mebeverine, hyoscine), lax (ispagh, lactulose)
65
diverticulitis
```
ACUTE
pain lower, lif, central - worse w move
distension
n+v
constip (>diar)
```
local guard, mass, tender
rest, fluid, analg, abx, antispas
CHRONIC
mimic CRC and IBD
blood/mucus/malaena/mass
diar/constip, distension, pain
66
meckels diverticulum
diff diag for appendicitis
67
Alcohol units
```
men 21 (4 in one day)
women 14 (3 in one day)
```
unit=(ml x %)/1000
ie (500ml x 5%)/1000= 2.5 units
25ml of 40% = exactly 1 unit
68
alcohol withdrawal (dt)
tachycardia, low bp
tremor, confusion, fits, hallucinations (visual and tactile)
```
tx:
librium (chlordiazepoxide) 2 weeks
pabrinex (vitamins)
acomprosate for anxiety
disulfuram - make you ill when drink alc
```
69
alcohol dependancy
b1 defic
- -> wernicke (opthal, atax, conf)
- -> korsikoff (anterograde amnesia)
macrocytic anaemia
cardiomyopathy (dilated)
pancreatitis, gastritis, fatty liver
AUDIT better than CAGE
70
pyloric stenosis
under 6 months (commonly under 6 weeks)
projectile/persistent vomiting
failure to gain weight
hypochlo, hypokal, alkalosis
US
71
intussusception
under 18months
intermittent screaming, drawing knees up, going pale
red current jelly stool
sausage mas in abdo and on US
T: enema, insufflation
72
vitamin deficiency
A - xeropthalma (blindness)
B1 (thiamine) - beriberi (HF w odedma or neuropathy)
- also wernike-korsikoff
B2 (riboflavin) - angular stomatitis
B6 (pyridoxine) - polyneuropathy
B12 - macrocytic anaem, neuropathy, glossitis
nicotinamide - pallagra - dementia, dermatitis, diarhoea
C - scurvy - cachectic, gingivitis, bleed
E - haemolysis
iron - glossitis, ang stom
73
whipples disease
rare multisystem infection
hla b27, mid age men
gi, joint, skin, lymphoma etc
jej biopsy - macrophage PAS +
t: 1 year abx
74
spontaneous bacterial peritonitis
complication of ascites
see sudden deterioration in pt w ascites
ecoli kleb strep
75
carcinoid tumours
gi, lung, ovaries
- secreting tumours
tx: octreotide
76
peutz jager syndrome
freckles on mouth/lips
hamartomatous polyps in bowel
high risk cancer (commonly bowel and pancreas, also lung, breast, ovary)
- have regular surveillance
77
endoscopy
stop anacid/ppi beforehand
dont drive w/in 24hrs (sedation)
78
flexi sigmoidoscopy
phosphate enema
| pr exam
79
Paracetamol overdose
150mg/kg
ACTIVATED CHARCOAL
check paracetamol levels after 4 hrs
-above threshold: IV ACETYLCYSTEINE
>8hrs give acetlecystein as wait for blood results if suspect big ingestion
80
paracetamol overdose worse if...
on P450 inducer
- phenytoin, carbamez
- rifampicin
- st johns
malnourished, underweight
- because normal metab is by glutathione which comes from food
81
summary: causes of hepatomegaly
all causes of cirrhosis plus
neoplasm
- primary, secondary
- blood cancers - leuk, lympho, myeloma
congestion
- budd chiari, rhf
infection
- glandular fever, malaria, amoeba
- hepatitis (mild hepato)
82
causes of splenomegaly
massive
- CML
- myelofibrosis
- malaria
others
- other leukaemias and lymphomas
- causes of cirrhosis
- haemolysis - genetic or acquired
- glandular fever
- RA, SLE, sarcoid
83
mesenteric ischaemia
blood supply to colon is sup and inf mesenteric
ischaemia due to thrombus, embolus, compression, spasm
pain, diarhoea (may see blood)
atheroma risk factors
develop metabolic acidosis late on - due to lactate
compli - obstruc/perf
do angiography and abg
treat w thrombolytic, angioplasty or resection
84
mirizzis syndrome
stone in cystic duct which presses on common bile duct
differentiate from choledocholithiasis on mrcp or us
85
Osler weber rendau
Hered telangectasia
