Gastroenterology Flashcards
Name some functions of the liver
- Carbohydrate metabolism (via glucagon)
- Lipid metabolism
- Formation of cholesterol
- Vitamin (A,D,E,K) storage and metabolism
- Bile production and secretion
- Protein synthesis - albumin, coagulation factors, plasma proteins
- Immunity (via Kuppfer cells)
- Drug metabolism
- Phase 1 (oxidation/reduction by P450
- Phase 2 (conjugation)
What is portal hypertension?
Pressure in portal vein > 12 mmHg
Name some causes of portal hypertension
- Prehepatic
- Portal vein thrombosis
- AV fistula
- Splenomegaly
- Hepatic
- Cirrhosis
- Chronic hepatitis
- Chronic pancreatitis
- Biliary cirrhosis
- Primary sclerosing cholangitis
- Post-hepatic
- IVC obstruction
- Right heart failure
- Hepatic vein thrombosis
- Constrictive pericarditis
Name the portosystemic anastamoses in portal hypertension
- Oesophageal varices (left gastric → azygous)
- Haemorrhoids (superior rectal → inferior rectal)
- Caput medusae (umbilical → epigastric
Name some clinical features of portal hypertension
- Portosystemic anastomoses
- Ascites
- Splenomegaly (+ thrombocytopenia)
- Hepatomegaly
- Liver failure
- Variceal bleeding (haematemesis
Name some investigations into portal hypertension
- Bloods - FBC, U&E, LFT, clotting
- Hepatitis screen (A, B, C, D, E, CMV, EPV)
- Ultrasound/CT (portal vein > 13mm)
- Transabdominal Doppler Ultrasound
- Hepatic Venous Pressure Gradient (HVPG)
- Assesses severity
How is portal hypertension treated?
- Transjugular Intrahepatic Portosystemic Shunting (TIPS) = shunt between portal vein and hepatic vein
- Prevent bleeding
- B blockers
- Nitrates
- Vasopressin/terlipressin
- Band ligation of varices
- Balloon tamponade
- Treat ascites (paracentesis)
- Treat hepatic encephalopathy
- Liver transplant
How is ascites treated?
- Paracentesis
- Albumin replacement
- Salt restriction
- Spironolactone
How is hepatic encephalopathy treated?
- Low protein intake
- Lactulose (30ml) - excrete ammonia and nitrous toxins
- Enema
- Antiobiotics (rifaximin) - decrease concentration of ammonia-producing bacteria in colon
How is ascites treated?
- Paracentesis + albumin replacement IV
- Salt restricted diet
- Spironolactone - blocks aldosterone receptor in collecting tubule (counteracts salt-retention function of aldosterone)
- TIPS
What is cirrhosis?
Fibrosis of the liver parenchyma with nodular regeneration and hepatocellular necrosis
- Micronodular = uniform nodules < 4mm
- Macronodular = larger nodules, irregularly distributed
- Mixed
Name some causes of cirrhosis
- Congenital
- Haemachromatosis
- Wilsons (copper)
- A1 anti trypsin deficiency
- Acquired
- Excess/chronic alcohol intake
- Chronic hepatitis
- Primary biliary cirrhosis
- Gallstones
- Hepatic vein obstruction
- Idiopathic
Name some clinical features of cirrhosis (decompensated)
- Jaundice
- Spider naevi
- Ascites
- Low albumin
- Clotting disorders
- Portal hypertension
- Encephalopathy
- Gynaecomastia
- Testicular atrophy
How is cirrhosis investigated?
- Metabolic screen (serum copper)
- Hepatitis screen (A, B, C, D, E, CMV, EBV)
- Autoimmune screen
- AMA (PBC)
- Anti smooth muscle (hepatitis, PBC)
- LFTs
- Abdo ultrasound / CT
- Liver biopsy
How is cirrhosis managed?
- Alcohol abstinence / addiction programme
- Weight loss
- Treat causes
- Hepatitis B - interferon alpha
- Hepatitis C - ribavirin
- Autoimmune - immunosuppression
- Gallstones - cholecystectomy
- Transplant
Name the common LFTs. How are they interpreted?
- ALT more specific
- AST:ALT > 2 = alcoholic liver disease
- AST:ALT ratio = 1 = viral hepatitis

What are the risk factors for developing hepatocellular carinoma?
- Viral hepatitis
- Chronic alcoholism
- Smoking
- > 70 years
- Aflatoxin exposure (molds)
- Family history
- Contraceptives
- Androgens
What are clinical features of hepatocellular carcinoma?
- Cirrhosis
- Dull ache in RUQ
- Ascites
- Jaundice
- Hepatomegaly (irregular and craggy)
- Systemic
- Fatigue
- Weight loss
- Lethargy
How is hepatocellular carinoma investigated?
- LFTs
- Alpha fetoprotein (AFP) > 500 ng/ml in 70% of cases
- Ultrasound
- Staging CT scan
- Needle biopsy
What is the management for hepatocellular carinoma?
- Surgical resection (if no cirrhosis)
- Transplant
- Image-guided ablation
- Transarterial chemoembolisation
Which malignancies metastasises to the liver?
- Bowel (portal system)
- Breast
- Pancreas
- Stomach
- Lung
Name some pre-hepatic causes of jaundice
Excessive red cell breakdown
- Haemolytic anaemia
- Transfusion reaction
- Congenital red cell abnormalities
- Sickle cell
- Spherocytosis
- Gilberts Syndrome (familial non-haemolytic anaemia)
Normal urine and stool colour
Name some causes of hepatic jaundice
Dysfunction/obstruction in liver
- Infection = hepatitis, EBV, CMV
- Drugs = paracetemol overdose, antipsychotics, antibiotics (tetracycline, erythromycin)
- Alcoholic liver disease
- CIrrhosis
- Haemochromatosis
- Carcinoma
Dark urine
Name some causes of post-hepatic jaundice
Biliary obstruction
- Gallstones
- Bile duct stones
- Cholangiocarcinoma
- Pancreatic cancer (head) - PAINLESS JAUNDICE
- Strictures (surgery)
- Pancreatitis
- Biliary cirrhosis
Dark urine and pale stools (less stercobilinogen in faeces)
How is jaundice investigated?
- Bloods - LFTs, PT, FBC, U&E. clotting
- Urinanalysis (high urobilinogen = haemolytic anaemia)
- Hepatitis screen
- Blood film (haemolysis)
- Ultrasound scan - liver, gall bladder, bile ducts, pancreas (obstructive)
- MRCP - visualise biliary tree (T2)
- Liver biopsy (hepatitis)
What pattern of LFTs would you see in each type of jaundice

How is jaundice managed?
- General
- IV fluids
- Monitor urine output
- vit K 10mg (if inc PT)
- Nutrition
- Treat infection
- Anti-histamine (itching)
- Treat encephalopathy
- Treat underlying causr
- Haemolytic anaemia = steroids
- Gallstones = ERCP, cholecystectomy, stent
- Liver disease = transplant
Name some complications of jaundice
- Hepatorenal syndrome
- Deranged coagulation
- Cholangitis
- Hepatic encephalopathy
- Immunosuppresion
What is hepatorenal syndrome?
The development of kidney failure in patients with advanced liver disease.
Thought to be caused by systemic vasoconstriction
What are the different types of hiatus hernia?

Name some risk factors for developing hiatus hernia
- Age
- Loss of diaphragmatic tone
- Increasing intra-abdominal pressures
- Increased size of oesophageal hiatus
- Pregnancy
- Obesity
- Ascites
- Female
- Previous surgery
What are clinical features of hiatus hernia?
- GORD - burning epigastric pain
- Worse lying flat
- Vomiting
- Weight loss
- Early satiety
- Bleeding
- Hiccups
- Dysphagia
How is hiatus hernia investigated?
- OGD (endoscopy)
- Barium swallow
- CT abdo and thorax (exclude malignancy)
How is hiatus hernia managed?
- Conservative
- Stop smoking
- Lose weight
- Reduce alcohol
- Pharmacological
- PPI
- Antacids
- Mucosal protectants
- Promotilants (metoclopramide)
- Surgical (if persistent symptoms, complications or nutritional failure)
- Curoplasty = hernia reduced from thorax
- Fundoplication = gastric fundus wrapped around lower oesophagus to strengthen LOS
Name some complications of hiatus hernia
- Volvulus (Borchadt’s triad)
- Severe epigastric pain
- Retching (but no vomiting)
- Inability to pass NG tube
- Hernia recurrence
- Bloating (can’t belch)
- Fundal necrosis
- Dysphagia
What is a peptic ulcer? Where is it most common?
Break in the lining of the GI tract
Most common in lesser curve of stomach and proximal duodenum
Name some causes of peptic ulcers
- H-pylori (gram negative bacillus)
- Female
- NSAIDs (inhibit prostaglandin synthesis)
- High alcohol intake
- Steroid use
- Chemotherapy
What are the clinical features of peptic ulcers?
- Epigastric pain
- Worse with eating if stomach
- Worse with empty stomach if duodenal
- Nausea
- Anorexia
- Weight loss
How are peptic ulcers investigated?
- Gastroscopy / OGD
- Histology biopsy
- Rapid urease ‘CLO’ test (H pylori)
- H pylori test
- Carbon-13 breath urea breath test
- Serum antibodies
- Stool antigen
- FBC (anaemia/bleeding)
How are peptic ulcers managed?
- Conservative
- Stop smoking
- Weight loss
- Reduce alcohol intake
- Avoid NSAIDs
- PPI (8 weeks) omeprazole
- Antacids (gaviscon)
- If H pylori postive = antibiotic regime
- Surgery (if complications, outlet obstruction or failure of medical therapy)
- Partial gastrectomy
- Selective vagotomy
How is H pylori treated?
7 day, twice daily course of:
- PPI (omeprazole 20-40mg)
- Amoxicillin
- Clarithromycin or metronidazole
If allergic to penicillin = PPI, clarithromycin and metronidazole
Name some complications of peptic ulcers
- Acute upper GI bleeding
- Pyloric stenosis
- Iron deficiency anaemia
- Perforation
- Gastric outlet obstruction
What is Zollinger-Ellison syndrome?
Hypergastrinaemia causing extensive ulceration. Caused by gastrinoma (intrapancreatic)
Name some risk factors for developing a gastic adenocarcinoma
- > 50
- Male
- H pylori
- Smoking
- East asian
- Chronic gastritis
- Blood group A
- Excess alcohol
- High salt diet
- Family history
What are the clinical features of gastic adenocarcinoma?
- Dyspepsia
- Dysphagia
- Nausea and vomiting
- Melaena
- Haematemesis
- Systemic = weight loss, anaemia, lethargy
- Epigastric mass
- Virchow’s node
How is gastic adenocarcinoma investigated?
- Bloods
- CEA (carcinoembryonic antigen) in 50%
- FBC
- LFTs
- OGD / endoscopy
- Biopsies
- CT chest-abdo-pelvis (metastases)
- Staging laparascopy (peritoneal metastases)
How is gastic adenocarcinoma treated?
- Adequate nutrition
- Peri-op chemotherapy
- Curative resection (if T1/2, N0/1, P0) = gastrectomy
- Endoscopic Mucosal Resection if T1
- Palliatve if T3 or more
- Chemo
- Gastrectomy/bypass
- Stenting
What are the complications of gastic adenocarcinoma?
- Gastric outlet obstruction
- Iron deficiency anaemia
- Perforation
- Malnutrition
What are the risk factors for developing GORD?
- Age
- Obesity
- Alcohol
- SMoking
- Caffeine
- Fatty foods
- Previous surgery
What is GORD? What causes it?
Acid from the stomach leaks up into the oesophagus
- Reduced LOS tone
- Increased intragastric pressure
What are the clinical features of GORD?
- Dyspepsia / chest pain
- Burning
- Retrosternal
- Worse with lying down, straining, after meals and bending over
- Excessive belching
- Odynophagia
- Chronic cough
What are the red flags of GORD symptoms?
- Dysphagia
- Weight loss
- Early satiety
- Loss of appetite
How is GORD investigated?
- Endoscopy (if red flags, new onset or failure of medical treatment)
- 24 hour pH monitoring
- Demeester score > 14.72
- Oesophogeal manometry (motor function test) via a high-resolution catheter
- Excludes motility disorder
How is GORD managed?
- Conservative
- Avoid precipitants (alcohol, caffeine, fatty foods)
- Weight loss
- Stop smoking
- Pharmacological
- PPI (omeprazole 20mg OD)
- Antacids (Gaviscon)
- Metoclopramide 10mg tds (increases gastric and oesophageal emptying)
- Surgery (if persistent symptoms, complications or avoidance of long term PPI therapy)
- Laparascopic fundoplication (Nissen’s) = wrap fundus around intra-abdominal oedeophagus
What are the complications of GORD?
- Aspiration pneumonia
- Barrett’s oesophagus
- Oesophagitis
- Stricutres
- Malignancy
What are the complications of fundoplication surgery?
During:
- Bleeding requiring transfusion
- Injury to intra-abdominal organs (mainly spleen)
After:
- Dysphagia
- Bloating
- Inability to vomit
- Dumping syndrome = food moves too quickly from the stomach to the duodenum
What is Barrett’s Oesophagus?
Metaplasia of the lower oesophageal epithelial lining from stratified squamous to simple columnar due to chronic acid reflux
How is Barrett’s oesophagus investigated?
Biopsy of oesophageal epithelium via endoscopy
How is Barrett’s oesophagus managed?
- Lifestyle advice
- Stop smoking
- Weight loss
- Diet change
- PPI (omeprazole)
- Stop NSAIDs/other meds that affect acidity
- Routine endoscopy
- GORD = every 2-5 years
- low grade = every 6 months
- high grade = every 3 months
- If premalignant lesion = Endoscopic Mucosal Resection (EMR)
- If carcinoma = oesophagectomy
What are the types of oesophageal cancer and risk factors for both?
- Squamous cell (middle and upper thirds)
- Smoking
- Alcohol
- Low vit A
- Chronic achalasia
- Adenocarcinoma (lower third)
- Barrett’s
- GORD
- High fat diet
What are the clinical features of oesophageal cancer?
- Dysphagia
- Progressively worsens from solids to liquids
- Haematemesis
- Significant weight loss
- Odonyphagia
- Productive cough
- Hoarseness (recurrent laryngeal nerve)
- Horner’s (sympathetic trunk)
- Neck swelling (IVC obstruction)
What is the NICE guidance on criteria for urgent endoscopy?
- New onset dysphagia
- > 55 years with
- Weight loss
- Upper abdominal pain
- Dyspepsia
Name some oesophageal motility disorders
Achalasia = failure of smooth muscle/LOS relaxation
Diffuse oesophageal spasm = multi-focal, high amplitude contractions of the oesophagus
How are oesophageal motility disorders investigated?
- Manometry
- Hypertonicity
- Failure of relaxation
- Repetitive, simultaneous, ineffective contractions (DOS)
- Barium swallow
- Cork screw (DOS)
- Bird’s beak (achalasia)
- OGD to exclude malignancy
How is achalasia managed?
- Conservative - lots of pillows, eat slowly, lots of fluids
- Botox injection into LOS
- Endoscopic balloon dilatation
- Laparascopic Heller’s myotomy
How is diffuse oesophageal spasm managed?
- Smooth muscle relaxants
- Nitrates
- CCB
- Benzodiazepines
- Pneumatic dilatation (rupture muscle fibres via balloon)
- Myotomy
Name some causes of acute pancreatitis
GET SMASHED
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps
- Autoimmune
- Scorpion sting
- Hypercalcaemia
- ERCP
- Drugs - azathioprine, NSAIDs, thiazide
How is acute pancreatitis classified?
- Oedematous (70%) = transient fluid collections
- Severe/necrotising = necrosis with psuedocysts
- Haemorrhagic (5%)
Name some clinical features of acute pancreatitis
- Sudden onset of severe epigastric pain
- Radiates to back
- Nausea and vomiting
- Fever
- Dehydration
- Hypotension
- Tachycardia
- Guarding
- Ecchymosis (retroperitoneal haemorrhage)
- Left flank (Grey-Turners)
- Periumbilical (Cullen’s)
How is acute pancreatitis investigated?
- Bloods
- Amylase (>1000 U) / lipase
- LFTs (cholestatic)
- FBC
- U+E
- Glucose
- AXR
- CT - pancreatic oedema, swelling
- US - identify gallstones
What AXR signs are present in acute pancreatitis?
- Absent psoas shoadow
- Sentinel loop sign
- Colon cut off sign (splenic flexure)
- Gallstones

Name a criteria for severe pancreatitis
Glasgow-Imrie criteria (score >/=3 within 48 hours)
- PaO2 < 8kPa
- Age > 55
- Neutrophils/WCC > 15000
- Corrected calcium < 2mmol/L
- uReas > 16 mmol/L
- Enzymes (AST > 200, LDH > 600)
- Albumin < 32g/L
- Sugar/glucose > 10mmol/L
How is acute pancreatitis managed?
- Large calibre IV access - crystalloid fluid up to 1L
- Catheterise and fluid balance chart
- Analgesia
- NG tube if vomiting
- IV antibiotics (IV imipenem) if severe
- Cholecystecomy if gallstones
- ERCP if bileduct stones
- CT-guided aspiration
Name some causes of chronic pancreatitis
- Chronic alcoholism
- Idiopathic
- Cystic fibrosis
- Recurrent acute pancreatitis
- Infection (HIV, mumps)
- Obstruction (stricture/tumour)
- Autoimmune (SLE, PBC)
Name some clinical features of chronic pancreatitis
- Chronic epigastric pain
- Radiates to back
- Worse with food and alcohol
- Eased when leaning forward
- Exocrine dysfunction (fat/protein malabsorption)
- Anorexia
- Weight loss
- Steatorrhoea
- Endocrine failure (loss of B islet cells) = diabetes mellitus
How is chronic pancreatitis managed?
- Analgesia
- Stop alcohol
- Diet - antioxidants, carbs, protein, low fat
- Exocrine enzyme supplements (Creon)
- Diabetes control (insulin)
- Surgery (treat cause)
- Whipple’s (pancreaticoduodenectomy)
- ERCP if duct stone
- Sphincterecomy
- Total pancreatectomy
Name some complications of chronic pancreatitis
- Pseudocyst
- Steatorrhoea
- Malabsorption
- Diabetes
- Effusions
- Ascites
- Malignancy
- Acute-on-chronic pancreatitis
Name some risk factors for pancreatic cancer
- Smoking
- Chronic pancreatits
- Diabetes
- High fat diet
- Alcoholism
- Genetics (MEN-1 syndrome)