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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
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2
Q

GORD

A

higher risk of reflux if

  • hernia, obesity,
  • preg, smoking, alc
  • upper GI motility problem
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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&raquo_space; liq = stricture

constant, painful, progressive, WL = malig

intermittent = spasm

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3
Q

barrets

A

columnar metaplasia
chronic reflux oesophagitis, ?haematemesis ?dysphagia

biopsy - ?premalignant

    • mucosectomy
    • laser ablation
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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
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5
Q

dispepsia ALARMS symptoms

A 
anaemia
loss of weight
anorexia
recent onset, progressive
malaena (or haematem)
swallowing probs
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6
Q

dyspepsia differentials

A

peptic ulcer (duo, gastric)
oesophagitis/gord (if strong heart burn element)
inflammation (duodenitis/gastritis)
malignancy (ALARMS)

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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
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8
Q

duodenal vs gastric ulcer

A

duodenal more common

relieved by food

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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

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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

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11
Q

H Pylori eradication

A

PPI, clarithromycin, (amox or metron)

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12
Q

atrophic gastritis

A

causes pernicious anaemia
-lack of IF means low vit B12

see anti- parietal cell and intrinsic factor

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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

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14
Q

red flags in bowel*

A

blood
weight loss
family - bowel and ovarian
over 60y

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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

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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

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17
Q

UC path

higher assoc CRC

A 
MUCOSAL
pseudopolyps
inflam infiltrate
reduced goblets, gran
loss of haustrations (drainpipe)

comp: toxic megacolon, perf

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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
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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

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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

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21
Q

CD treat

A

acute: steroid

remission: mesal,
disease modifiers: azathrio, methotrex, influximab

stop smoking
surgery

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22
Q

Liver enzymes

A

hepatocellular: AST, ALT

biliary outflow: ALP, GGT

alcohol: AST:ALT 2:1

viral - deranged enzymes but not biliubin

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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

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24
Q

raised unconjugated bilirubin

A

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)
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25
Q

raised conjugated bilirubin (>20%)

A

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)

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26
Q

alcoholic liver disease

A

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
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27
Q

Viral hepatitis Sx

A

nausea, vom, anorexia
myalgia
lethargy
RUQ pain

maybe jaundice

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28
Q

Hep B serology

A

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

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29
Q

Hep A Virus (E also similar)

A

RNA
self limiting acute
- malaise anorexia n+v ?jaundice
ALT>AST

IgM - confirms virus
IgG - immune

T: supportive

risk: travelling, shellfish, water

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30
Q

Hep B Virus

A

DNA

acute illness mild or asymto
10% get chronic/carrier
- risk cirrhosis, HCC

risk: sex, iv drug, tattoo

T: interferon
antivirals (lamivudine etc)

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31
Q

Hep C Virus

A

RNA

progressive chronic (no acute form)
- present w chronic fatigue

risk: blood products,haemophilia, drugs
treat: interferon and ribavarin

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32
Q

post hepatic

A
  • higher % conjug >40%
  • ALP
  • enlarged liver, dilatation

gallstones, cancer
pbs, psc, biliary atresia

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33
Q

Biliary Colic

A

RUQ pain

  • intermittent
  • worse after food

“female fat fair forty”

first line: NSAID
then surgery

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34
Q

Acute Cholecystitis

fat female forty

A

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
Q

Ascending Cholangitis

= emergency

A

infection in CBD

charcots triad:
FEVER, rigors - very unwell
RUQ pain
JAUNDICE

severe: hypotension, confusion

fluid
abx

36
Q

autoimmune hepatitis

A

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
Q

primary biliary cirrhosis

A

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
Q

primary sclerosing cholangitis

A

UC, 2:1 male
chronic biliary obstruc

ANA, SMA, ANCA, IgG
(ama -ve)

risk of cholangiocarinoma

colestyramine for pruritis,
vit replace
transplant

39
Q

primary sclerosis cholangitis

A

ASSOC W UC
non malig non bacterial inflam and fibrosis

jaundice, pruritis , hepatomeg

40
Q

haemochromatosis

A

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
Q

hepatorenal syndrome

A

renal failure in pt w chronic liver disease

42
Q

Wilson’s disease

A

autosomal recessive, chrom 13

diag: low caeruloplasmin, inc urinary Cu
affects: brain liver cornea nails
tx: penicillamine

43
Q

Budd Chiari

A

thrombosis in hepatic vein
HEPATOMEG
ASCITES
ABDO PAIN

no jaundice

44
Q

alpha 1 antitrypsin defic

A

emphys, liver (cholestatic), hcc

45
Q

drugs causing liver disease

A

amiodarone
methotrexate
isoniazid
phenytoin

46
Q

causes of cirrhosis summary

A 
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
Q

cirrhosis sequelae

A 
liver failure (decompensation)
-clotting fail (raised PT)
-ascites (low albumin)
-encephalopathy
also low Ig's

portal htn

  • ascite caput medusae
  • splenomegaly
  • varices
48
Q

acute variceal bleed

A

resus (avoid saline in liver dis - hypernatr)
vit k and ffp if clotting probs (often seen in liver disease)
terlipressin, abx
banding, sclerotherapy

49
Q

Cholangiocarcnoma

A

persistent biliary colic
WL, anorexia, jaundice
mass RUQ (Courvoisiers sign)
virchows node

50
Q

Gallstone ileus

A

small bowel obstr second to gall stone

abdo pain, distension, vomiting

51
Q

acute pancreatitis

A

alcohol, gallstones
mumps
steroids
trauma (ercp)

severe epigastric pain
vomiting, fever, tenderness

cullers and greys-turner signs

raised amylase, lipase (longer)
PETHIDINE analgesia

52
Q

chronic pancreatitis

main cause of malabs after chrons and coeliac

A

c: alc, stones, tumour, cf, hh, hyperparathy

pain boring through to back
bloating, steator, wl

mx: analgesia, CREON, vitamins

53
Q

acute appendicitis

A

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
Q

ischaemic bowel

A 
severe sudden abdo pain
shock
bloody diarhoea
metabolic acidosis - lactate
history/risk of vascular disease/atheroma
55
Q

coeliac features and comps

A 
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
Q

coeliac management

A

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
Q

pancreatic cancer

A

painless jaundice

anorexia wl

prothrombotic - get clots

58
Q

colorectal cancer

A

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
Q

anal cancer

A

scc

herpes simplex virus
- homosexuals

60
Q

causes of constipation

A

gen:

  • fluid, diet,
  • routine, psycho

anorectal
- fissure

met

  • hypothy
  • hypercalc

drugs

  • opiates
  • tca (anti cholinergics)

IBS (alt w diarr)
obstruction - crc

61
Q

Laxatives

A 
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
Q

diarrhoea

A

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
Q

gastroenteritis

A 
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
Q

diverticular disease

A

high fiber diet reduces risk of -itis

barium enema
sigmoidoscopy

treat of chronic diverticulitis
- fiber diet, antispas (mebeverine, hyoscine), lax (ispagh, lactulose)

65
Q

diverticulitis

A 
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
Q

meckels diverticulum

A

diff diag for appendicitis

67
Q

Alcohol units

A 
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
Q

alcohol withdrawal (dt)

A

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
Q

alcohol dependancy

A

b1 defic

  • -> wernicke (opthal, atax, conf)
  • -> korsikoff (anterograde amnesia)

macrocytic anaemia
cardiomyopathy (dilated)
pancreatitis, gastritis, fatty liver

AUDIT better than CAGE

70
Q

pyloric stenosis

A

under 6 months (commonly under 6 weeks)
projectile/persistent vomiting
failure to gain weight

hypochlo, hypokal, alkalosis

US

71
Q

intussusception

A

under 18months
intermittent screaming, drawing knees up, going pale
red current jelly stool
sausage mas in abdo and on US

T: enema, insufflation

72
Q

vitamin deficiency

A

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
Q

whipples disease

A

rare multisystem infection
hla b27, mid age men

gi, joint, skin, lymphoma etc

jej biopsy - macrophage PAS +

t: 1 year abx

74
Q

spontaneous bacterial peritonitis

A

complication of ascites

see sudden deterioration in pt w ascites

ecoli kleb strep

75
Q

carcinoid tumours

A

gi, lung, ovaries
- secreting tumours

tx: octreotide

76
Q

peutz jager syndrome

A

freckles on mouth/lips

hamartomatous polyps in bowel

high risk cancer (commonly bowel and pancreas, also lung, breast, ovary)
- have regular surveillance

77
Q

endoscopy

A

stop anacid/ppi beforehand

dont drive w/in 24hrs (sedation)

78
Q

flexi sigmoidoscopy

A

phosphate enema

pr exam

79
Q

Paracetamol overdose

A

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
Q

paracetamol overdose worse if…

A

on P450 inducer

  • phenytoin, carbamez
  • rifampicin
  • st johns

malnourished, underweight
- because normal metab is by glutathione which comes from food

81
Q

summary: causes of hepatomegaly

A

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
Q

causes of splenomegaly

A

massive

  • CML
  • myelofibrosis
  • malaria

others

  • other leukaemias and lymphomas
  • causes of cirrhosis
  • haemolysis - genetic or acquired
  • glandular fever
  • RA, SLE, sarcoid
83
Q

mesenteric ischaemia

A

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
Q

mirizzis syndrome

A

stone in cystic duct which presses on common bile duct

differentiate from choledocholithiasis on mrcp or us

85
Q

Osler weber rendau

A

Hered telangectasia

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