GASTROENTEROLOGY Flashcards

Question

Differential for raised isolated ALT

Answer 1

Viral hepatitis Blood transfusion - think HCV or HBV e.g. haemophiliac

Answer 2

Failure of LOS relaxation 1/1000 PEOPLE ``` manometry = failure of peristalsis in distal oesophagus Endoscopy = normal or LOS fails to relax on swallow ``` intermittent symptoms hallitosis from residual food aspiration due to recurrent nocturnal aspiration

Answer 3

1. Resus - activate major haemorrhage protocol 2 fluids and blood products 3. urgent variceal banding and commence terlipressin TERLIPRESSIN / SOMATOSTATIN / OCTREOTIDE good evidence to support reduced re-bleeding rate and early complications Sclerotherpay is superior to balloon tamponade but not to banding

Answer 4

``` Remember PBC 90% female with ANTI MITOCHONDRIAL ABS >45 smokers post pregnancy trigger intrahepatic biliary only NO CANCER NO IBD RA / hashimotos + sjorgrens +coeliac ``` UDCA Response to UDCA predicts better outcome failed response add in budesonide / pred Colestyramine for pruritis (binds bile salts for excretion) Osteoporosis Bisphosphonates and exercise Vit D Liver transplant Once jaundiced survival is <2 years

Answer 5

``` Remember PSC Intra or extrahepatic biliary Associated with anti-smooth muscle PR3 - anca (P-ANCA) and ANA 60% men non smokers ASSOC IBD and HCC / COLON ``` no cure - same as PBC Treatment UDCA bisphosphonates and vit D and diet + oestrogens Liver transplant

Answer 6

Birds beak appearance caused by barium hold up caused by impaired peristalsis and failure of LOS relaxation Diffs: Oesophagial Ca - pseudo achalasia Compressive bronchial cancer manometry gold standard progress to endoscopy to visualise

Answer 7

Raised resting LOS pressure | non propagated lower oesophagial body contractions

Answer 8

raised GGT | raised lithium levels

Answer 9

AST: ALT ratio ``` ALD = AST x2 : ALD i.e. ratio >2 abdo USS Na recurrent ascites HCV/HBV status ALC liason nurse ```

Answer 10

Autosomal dominant condition more common in Ashkenazi Jews MUTATION IN serine threonine kinase 11 Significant risk of malignant tranformation almost 50% with PJ develop cancer and die by age 57 STOMACH / COLON / PANC / BREAST - macular oral pigmentation crossing vermillion border (mucocutaenous melanocytic macules) - hamartomatous polyps Mx: yearly mammography / uss endoscopy yearly abdo uss

Answer 11

Triad: Iron def Oesophagial webs + Dysphagia Angular chelitis RF for SCC of oesophagus

Answer 12

Diagnosis of exclusion for state of malabsorption on returning from abroad Typically thought to be due to floral imbalance Common caribbean and far east small intestinal malabsorption due to infection See villous atrophy crypt hypertrophy megaloblastic / macrocytic anaemia due to folate and b12 fat malabsorption Rx: abx for 6/12 Tetracyclin ampicillins b12 and folate replacement

Answer 13

Deficiency of niacin or tryptophan (precursor) A) Primary deficiency B) Secondary - malabsorption state e.g. tropical sprue / coeliac -consumptive state - carcinoid tumours use native tryptophan and convert this to serotonin. This prevents production of niacin and thus pellagra diarrhoea dementia dermatitis death confusion / inattention / memory loss / thick skin Substrate for serotonin production deficiency = dementia replace with nicotinic acid

Answer 14

Spontaneous oesophagial rupture secondary to vomiting - Epigastric pain radiating to back - dyspnoea - pleural effusion - empyema - surgical emphysema of neck

Answer 15

``` SBS -chronic malabsorption of b12 / folate (IF binds b12 for absorption ileum) - macrocytic anaemia - Dermatitis (no linoleic acid absorption) -chronic diarrhoea + dehydration -dumping syndrome -weight loss - bile salt malabsorption - fatty stools Abnormal 14C glycolate test (also seen in bacterial overgrowth and H.Pylori) - can also be done with 13C ``` ``` Rx: Parenteral nutrition loperamide codeine teduglutide = GLP-2 agonist which slows gastric transit and after 6 months reduces TPN top up requirments by 20-100% ```

Answer 16

Heightened Gastrin production - GASTRINOMA 1. FASTING GASTRIN LEVEL ON 3 SEP DAYS -release is pulsatile 3 normal = gastrinoma unlikely 2. secretin stimulation test 3. basal acid output Treatment: Excision ocreotide IFN / chemo

Answer 17

1. PSC (anti smooth muscle / malignancy / UDCA / >men) 2. seronegative spondyloathropathy or RA like 3. Uveitis or episcleritis 4. PYODERMA GANGRENOSUM (failed wound healing / stoma ulcers / new ulcers - TOPICAL TAC / oral/ IV pred or inflix or tac) 5. Gall stones- Bile acid malabsorption and Bact overgrow 6. erythema nodosum

Answer 18

weight loss

Answer 19

B cell lymphoma associated with H.Pylori infection. Urease 13/14 breath test drink radio-labelled compound detect radio-isotope in expired breath only if h.pylori present treat anyway due to incidence of fa;se negative Treatment: 1 H.Pylori eradication = remission in 75% of cases if not - chemo and resect

Answer 20

Rare multi system disorder caused by T.Whippelei. - cardiac / pericarditis / endocard / conduction defects - Diarrhoea - weight loss - cerebellar ataxia / seizures / CN lesions - pleurisy / fibrosis - pigmentation - fatty stool - lymphadenopathy Diag: histology Acid Schiff positive mcrophages in small intestine mucosa flattened villi - Coeliac / tropical sprue Treat abx 30% relapse

Answer 21

``` Fever abdominal pain weight loss malabsorption watery diarrhoea ``` liver abscess - usually single right lobe mutliple left sided abscesses also possible Rx: trophozoite is susceptible to metronidazole 10 day course

Answer 22

Conditions: Pyrexia >6 stools per day without improvement after 72 hours or worsening symptoms HD compromise no history of IBD

Answer 23

``` Immunosuppressive therapy options following liver transplantation • Cortisone preparations (e. g. prednisolone or prednisone) • Cyclosporin A • Tacrolimus • Azathioprine • Mycophenolate Mofetil • Combination of the above medications ```

Answer 24

PSEUDOMEMBRANOUS COLLITIS Yellow plaques on flexi-sigmoidoscopy Mort in elderly = 10% Rx: Vancomycin - oral = 0 absorption so good for gut treatment Metronidazole Cholestyramine may be useful to reduce diarrhoea

Answer 25

Late onset in gestation DIC raised wcc Raised ALT Nausea and vomiting low albumin prolonged PT indicating abnormal synthetic function encephalopathy if enters decoompensated liver disease May need ITU admission May also require FFP / cryo precipitate protein restriction to reduce ammonia laxatives

Answer 26

Bile acid transporter defect Last trimester Prutiris jaundice prolonged PT due to vit K deficiency

Answer 27

``` B12 is coupled to IF for absorption in TI Therefore a) ileal disease Crohns ileal resection TB ``` b) Pernicious anaemia ``` c) b12 excess utilisation with little to absorb bacterial overgrowth diverticula fistulae radiation enteritis systemic sclerosis ```

Answer 28

Iron storage disoder leading to iron overload and deposition in organs causing systemic dysfunction and CLD. - weakness - fatigue - bronze diabetes - impotence - depression - Cardiomyopathy - Signs of CLD Most common mutation C282Y = HFE mutation Diagnosis 1) transferrin saturation >55% 2) genotyping 3) biopsy if remains unclear RX: Weekly venesection until transferrin <16% Aim ferritin <50% Desferoxamine iron chelation

Answer 29

Glasgow criteria for pancreatitis: PANCREAS - >3 = severe ``` Pa02 <8 Age >55 Neutrophils >15 Calcium <2 (norm 2.25-2.5 mmol/l) Renal Urea >16 Enzymes - LDH>600 or ASt>2000 Albumin <32 Sugar >10 ``` Causes: I GET SMASHED IDIOPATHIC GALL STONES ETOH TRAUMA or Mechanical - sphincter of Odi dysfunction STEROIDS MUMPS AUTO IMMUNE IGG4 SCORPION STINGS HEREDITARY and hypercalcaemia and hypertrigyceridaemia - CF / PRIMARY CILIARY DYSK / AIH ERCP DIURETICS - THIAZIDE / THIAZIDE LIKE / LOOPS

Answer 30

AST:ALT 2:1

Answer 31

6 monthly OGDs | Oral omeprazole 40mg OD or equiv

Answer 32

Associations: SBS post small bowel - crohns - obstruction / mechanical / ischaemic / Dumping syndrome in Ziehl Niehsson gastrinoma Systemic sclerosis Wartery diarrhoea malabsorption Fatty vitamin dieficiency - prolonged INR / steatthorhoea / offensive stool / b12 def - mixed motor and sensory neurop / folate def = macrocytic anaemia / iron def anaemia (normocytic or micro) / bile salt malaborption Test: Increased hydrogen on H breath test

Answer 33

``` A BLATCHFORD AT PRESENTATION ROCKALL POST ENDOSCOPY 1. Massive transfusion protocol + /- sengstaken tube 2.PLT transfusion only if - PLT<50 - active bleeding 3. FFP if PT is x1.5 4. Reverse Warfarin with PTC / berryplex 5. Prep endoscopy ```

Answer 34

Stratify patients based on risk of mortality into intervention tiers - Hb - urea - BP - M/F - HR>100 - meleana? - syncope? - liver disease? - HF? 0 = likely no need for intervention >0 = itervention higher scores corrolate with mortality

Answer 35

``` A BLATCHFORD AT PRESENTATION ROCKALL POST ENDOSCOPY 1. Massive transfusion protocol + /- sengstaken tube 2.PLT transfusion only if - PLT<50 - active bleeding 3. FFP if PT is x1.5 4. Reverse Warfarin with PTC / berryplex 5. IV Terlipressin for 5 days 6. Neomycin or rifaximin 5. Prep endoscopy ``` Oesophageal varices - band ligation - Transjugular intrahepatic portosystemic shunts (TIPS) Gastric varices - endoscopic injection of N-butyl-2-cyanoacrylate - TIPS ifnot controlled by N-butyl-2-cyanoacrylate.

Answer 36

Reduces rebleed risk by 50% and surgical intervention by 40% - meta-analysis of 21 RCTs H2 inhibitors (ranitidine) are less effective Note for PPI post stabilisation!

Answer 37

Can be associated with a mixed cryoglobulinaemia can present at ay time Associated with systemic vasculitis and purpuric presentation This may result in nephritic presentation Treatment is focused on the reduction of systemic viraemia which is though to drive the process Note there may be crossover in HIV HIV associated nephropathy is an FSGS pattern and associated with heavy heavy proteinurea

Answer 38

``` History sodium alginate lansoprazole omeprazole -both associated with lymphocytic colitis and hyponatraemia -omeprazole can also interfere with cyt p450 OGD h.pylori eradication ```

Answer 39

Crohns treat with topical tac oral pred iv hydrocort if widespread

Answer 40

``` Parenteral nutrition Creon loperamide codeine teduglutide = GLP-2 agonist which slows gastric transit and after 6 months reduces TPN top up requirments by 20-100% ```

Answer 41

``` diet weight loss Liraglutide - reduces hepatic steatosis - aids weight loss -stabilises glycaemia TIPS / banding / terlipressin ```

Answer 42

Ascites Asterixis Altered GCS

Answer 43

Alcohol related liver disease Congestive cardiac failure Metastases Plus Infection Auto immune (PSC PBC AIH) Infiltrative (amyloid CML)

Answer 44

``` Liver screen HAV HBV HCV CMV EBV HIV A1 ANTI TRYPSIN AFP Ferritin if >500 HFE AND IN 30s Caeruloplasmin and Copper AIH - antimitochondrial ``` Plus ``` INR AND ALB for synthetic function LFTs Liver biopsy Liver USS with Dopplers ERCP (PSC brushings ) ```

Answer 45

``` CXR AND CT PET LIVER BIOPSY MDT RESECTION RFA ```

Answer 46

``` Hepatic Encephalopathy G1 disorientated G2 Confused G3 fluctuant GCS cannkt fimmow commands G4 Flat and depressed GCS and death SBP Wcc >250 on tap Variceal haemorrhage ```

Answer 47

``` Prognostic indicator of mortality 1 year Encephalopathy Ascites Inr and albumin Br ``` <6 100%survival 1 year 7-9 81% survive 1 year 10-15 45% survive 1 year

Answer 48

``` Drain Pleurex (palliative) Abstinence Low salt and nitrogen diet Spironolactone Transplant ```

Answer 49

Massive >8cm Myelofibrosis or myeloproloferative (P rubra vera) and CML CLL or Non hodgkins or hairy cell lymphoma Malaria and Leishmaniasis ``` Moderate >4cm Myelofibrosis or proliferative Haemolysis Chronic Infectious hepatitis or EBV Gaucher amyloid sarcoid TV ``` Minor Tip ITP / AIHA /Haemolysis Portal HTN Infection acute Hav hev hbv hcv ebv htlv ``` Myeloproliferative or lymphoproliferative CML / MYELOFIBROSIS Infectious Malaria/ TB/ Leishmaniasis Haemolysis B THAL / ITP /Autoimmune /sickle cell Infiltrative Gaucher / amyloid/ sarcoid ```

Answer 50

``` FBC - raised wcc - raised plt - raised rbc / rdw Calcium and ACE LFTS BNP Viral screen ABDO USS FILM nuclear inclusions / blasts - myeloprololif Smear +ve old small wcc - CLL Tear drop poikilocytosis high basophil and eosonophil myeloproliferative ``` Hb electrophoresis ``` SPECIAL JAK 2 for Polycythaemia rubra vera BCR ABL for CML Protein elec and IGs for MGUS SMG MM MPL for myelofibrosis Malaria screen thick and thin film trophozoites ```

Answer 51

``` CIRRHOTIC LIVER DISEASE -ALD NAFLD SARCOID AMYLOID Acute liver failure -PCT OD and Viral hep plus PBC PSC HCC -HFE / viral hep / etc ```

Answer 52

``` Ciclosporin Nifedipine Phenytoin Scurvy AML Pregnancy Familial ```

Answer 53

``` Bcc and Melanoma X 10 Scc X 100 Acitinic keratosis Viral warts Cellulitis ```

Answer 54

``` Immunosuppression -PCP / CMV / viral hep or TB Side effects -Tac tremor and HTN Ciclosporin gumnhypertrophy and nephro tox -Chronic Rejection Minor HLA incompatibility Recurrence of original disease Skin malignancy Other malignancy or lymphoma ```

Answer 55

CIRRHOSIS ALF HCC