Gastroenterology Flashcards

Question

Dx of Wilsons

Answer 1

**Reduced serum caeruloplasmin** **Reduced serum copper** (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) **Increased 24hr urinary copper excretion**

Answer 2

Penicillamine

Answer 3

Autosomal recessive

Answer 4

Peptic ulcer disease

Answer 5

7 days of: PPI + amox + clarithromycin or PPI + metronidazole + clarithromycin

Answer 6

Infrequent stools Difficulty passing stools Sensation of incomplete emptying

Answer 7

Sx for at least 12 weeks in last 6 months

Answer 8

Unknown cause

Answer 9

Due to drug/medical condition

Answer 10

Manage **underlying causes/drugs** Lifestyle- **increase fibre, fluid intake, activity levels** If faecal loading/impaction manage this 1st **Laxatives** (*titrate to produce soft formed stool w/out straining at least 3x per week*): 1) **Bulk forming** e.g. ispaghula 2) **Osmotic** e.g. macrogol (1st line)/lactulose/phosphate enema 3) **Stimulant** e.g. Senna, docusate, bisacodyl, sodium picosulfate

Answer 11

osmotic laxative + stimulant laxative

Answer 12

Stool patterns: * **Fewer than three complete stools per week** (unless exclusively breastfed, when stools may be infrequent). * **Hard, large stool**. * '**Rabbit droppings**' stool. * **Overflow soiling** in children older than 1 year of age (commonly very loose, smelly stools, which are passed without sensation or awareness) Symptoms associated with defecation in a child at any age: * **Distress or pain** on passing stool. * **Bleeding associated with hard stool**. * **Straining**. Symptoms associated with defecation in a child older than 1 year of age: * **Poor appetite that improves with passage of large stool.** * Waxing and waning of abdominal pain with passage of stool. * Evidence of '**retentive posturing**' — typical posture is straight-legged, on tiptoes with an arched back. * **Anal pain.** Past history of constipation. Previous or current anal fissure.

Answer 13

* Offering reassurance that underlying causes of constipation have been excluded. * Advising that **idiopathic constipation is treatable with laxatives**, although they **may need to be taken for several months.** * Offering sources of information and support. * Treating faecal impaction with a recommended disimpaction regimen. * Starting maintenance laxative drug treatment if impaction is not present or has been successfully treated. * Advising on **behavioural interventions** such as scheduled toileting, use of a bowel habit diary, and reward systems. * Arranging regular follow-up to assess adherence and response to treatment. * Considering the need for specialist referral if symptoms do not respond to optimal treatment in primary care, or if there is faecal impaction and the child is very distressed.

Answer 14

Movicol 1st line If not working after 2 weeks add stimulant laxative e.g. Senna Once disimpacted start maintenance laxatives

Answer 15

**Osmotic laxatives** - increase fluid in large bowel, softening stool and stimulating peristalsis **e.g. Movicol, lactulose** **Stimulant laxatives** - cause peristalsis by stimulating colonic and rectal nerves **e.g. Senna, Docusate, Bisacodyl, Sodium picosulfate**

Answer 16

H.pylori infection NSAIDs

Answer 17

Haemorrhage Perforation Gastric outlet obstruction Gastric malignancy (increased risk in *H.pylori* positive gastric ulcer disease)

Answer 18

_Lifestyle measures:_ * Weight loss * Avoid triggers e.g. coffee, chocolate, tomatoes, fatty, spicy foods * Smaller meals * Eat meals 3-4 hours before bed * Stop smoking * Reduce alcohol Manage stress/anxiety/depression _Medication review:_ * **Stop NSAIDs** * Consider reducing or stopping (if possible and appropriate) any other potential ulcer-inducing drugs, such as: *Aspirin, bisphosphonates, corticosteroids, potassium supplements, selective serotonin reuptake inhibitors (SSRIs), or recreational drugs such as crack cocaine.* **Test for *H.pylori:*** carbon-13 urea breath test or stool antigen test (no PPI for 4 weeks, no abx for 2 weeks): * If **positive and not associated with NSAIDs**, prescribe **eradication therapy** * If **positive and associated with NSAIDs**, give **full dose PPI for 2 months then eradication** therapy * If **negative** prescrive f**ull dose PPI 4-8 weeks**

Answer 19

* Rapid onset * Recent vomiting/diarrhoea * Feels unwell * Crampy abdominal pain * Flu-like symptoms * Pyrexia * Other household members/contacts affected

Answer 20

* **Viral** infection- norovirus, sapovirus, rotavirus * **Bacteria**l causes- *Salmonella, Camylobacter, E.coli, Shigella, C.difficile.* * **Parasitic**- *Cryptosporidium, Giardia, Entamoeba histolytica, and Cyclospora.*

Answer 21

Bacterial: Campylobacter jejuni, Salmonella, Escherichia coli O157:H7, Vibrio parahaemolyticus, Shigella, Yersinia, Aeromonas, Clostridium difficile. Viruses: cytomegalovirus. Parasites: Entamoeba histolytica, schistosomiasis.

Answer 22

Common amongst travellers Watery stools Abdominal cramps and nausea

Answer 23

Prolonged, non-bloody diarrhoea

Answer 24

Profuse, watery diarrhoea Severe dehydration resulting in weight loss Not common amongst travellers

Answer 25

Bloody diarrhoea Vomiting and abdominal pain

Answer 26

Severe vomiting Short incubation period

Answer 27

A **flu-like prodrome** is usually **followed by crampy abdominal pains, fever and diarrhoea** which **may be bloody** May mimic appendicitis Complications include Guillain-Barre syndrome

Answer 28

_Two types of illness are seen_ * **vomiting within 6 hours**, stereotypically due to **rice** * **diarrhoeal illness occurring after 6 hours**

Answer 29

Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks

Answer 30

_Incubation period:_ * 1-6 hrs: Staphylococcus aureus, Bacillus cereus\* * 12-48 hrs: Salmonella, Escherichia coli * 48-72 hrs: Shigella, Campylobacter * \> 7 days: Giardiasis, Amoebiasis

Answer 31

**Fluid intake** **Oral rehydration salts in children/adults with risk factors** (\>60yrs, frail, comorbidities) **Antidiarrhoeal drugs and anti-emetics are not usually necessary** (anti-diarrhoeals may be used in adults for symptom control, loperamide is 1st line but do not use if blood/mucus, high fever, E.coli 0157 or Shigellosis. Can use metoclopramide if severe vomiting) **Treat cause** e.g. antibiotics for Entamoeba, Campylobacter (severe sx only), Giardia

Answer 32

Suspected: * Cholera * Bloody diarrhoea due to gastroenteritis * Food poisoning * Haemolytic uraemic syndrome

Answer 33

**Metronidazole** 400mg TDS 5-10d **Followed by diloxanide** 500mg TDS 10d

Answer 34

**Supportive** Avoid anti-motility drugs Advise against NSAIDs

Answer 35

**Metronidazole** 400mg TDS 5d or 500mg BD 7-10d or 2g OD 3d

Answer 36

**Antibiotics not recommended for healthy people** Consider abx if \>50yrs, immunocompromised or cardiac valve disease/endovascular abnormalities: ciprofloxacin 500mg BD 1d

Answer 37

* Constipation. * Straining while trying to pass stools. * Ageing. * Heavy lifting. * Chronic cough. * Conditions that cause raised intra-abdominal pressure (such as pregnancy and childbirth).

Answer 38

Non-surgical treatments include rubber band ligation, injection sclerotherapy, infrared coagulation/photocoagulation, and bipolar diathermy and direct-current electrotherapy. Surgical treatments include haemorrhoidectomy, stapled haemorrhoidectomy, and haemorrhoidal artery ligation.

Answer 39

**Impaired respiration** **Respiratory depression** **Hypotension** **Hypertension** (amphetamines, phencyclidine, cocaine) **Cardiac conduction defects/arrythmias** (TCAs, anti-psychotics, some anti-histamines) **Hypothermia** (esp. OD of barbiturates/phenothiazines) **Hyperthermia** (CNS stimulants) Convulsions Methaemoglobinaemia

Answer 40

* Carbamazepine * Dapsone * Phenobarbital * Quinine * Theophylline

Answer 41

Ataxia Nystagmus Dysarthria Drowsiness Coma Hypotension Acidosis Aspiration of vomit

Answer 42

Conservative management Maintain airway Reduce risk of aspiration Measure blood glucose and give glucose if needed

Answer 43

Hyperventilation causing respiratory alkalosis Tinnitus Deafness Vasodilation Sweating Coma (uncommon) Acid-base disturbances- metabolic acidosis

Answer 44

**Measure plama salicylate, pH and electrolytes** **Activated charcoal** if within 1hr on ingesting \>125mg/kg aspirin **Replace fluid** losses **IV sodium bicarbonate** (after **correcting K+**) **Haemodialysis if severe** (plasma-salicylate [\>700mg/L] or severe metabolic acidosis)

Answer 45

Coma Respiratory depression Pinpoint pupils Hypotension Hypothermia Hyporeflexia

Answer 46

_King's College Hospital criteria for liver transplantation (paracetamol liver failure)_ **Arterial pH \< 7.3, 24 hours after ingestion** or all of the following: * **prothrombin time \> 100 seconds** * **creatinine \> 300 µmol/l** * **grade III or IV encephalopathy**

Answer 47

**Flumazenil** The **majority of overdoses are managed with supportive care only due to the risk of seizures with flumazenil**. It is generally only used with severe or iatrogenic overdoses.

Answer 48

* **IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity** * arrhythmias: class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation. Class III drugs such as amiodarone should also be avoided as they prolong the QT interval. Response to lignocaine is variable and it should be emphasized that c**orrection of acidosis is the first line in management of tricyclic induced arrhythmias** * **dialysis is ineffective in removing tricyclics**

Answer 49

Early features relate to anticholinergic properties: **dry mouth, dilated pupils, agitation, sinus tachycardia, blurred vision.** Features of **severe poisoning** include: * **arrhythmias** * **seizures** * **metabolic acidosis** * **coma** **ECG changes** include: * **sinus tachycardia** * **widening of QRS** * **prolongation of QT interval** Widening of QRS \> 100ms is associated with an increased risk of seizures whilst QRS \> 160ms is associated with ventricular arrhythmias

Answer 50

_Management_ * if bradycardic then **atropine** * **in resistant cases glucagon** may be used

Answer 51

Acid reflux into oesophagus

Answer 52

Heartburn Acidic taste Belching Dysphagia Uncommon: Hoarseness Persistent cough Asthma type symptoms

Answer 53

Stricture Barrett's oesophagus Oesophageal cancer (risk slightly increased)

Answer 54

Omeprazole/lansoprazole Ranitidine

Answer 55

chronic condition reflux of gastric contents into oesophagus

Answer 56

Heartburn Acid regurgitation

Answer 57

Obesity Smoking Alcohol Coffee Stress Pregnancy Drugs- Ca channel blockers, anticholinergics, theophylline, benzos, nitrates (all decrease lower oesophageal sphincter pressure)

Answer 58

**Lifestyle advice** Sleep with head of bead raised Medication review **Full dose PPI** for 4 weeks for proven GORD or 8 weeks if severe oesophagitis

Answer 59

Barrett's oesophagus (10-15%) Oesophageal Ca (1-10% of those above) Oesophageal ulcers Anaemia Stricture Aspiration pneumonia

Answer 60

UGI sx present for \>4 weeks * Upper abdo pain/discomfort * Heartburn * Acid reflux * Nausea * Vomiting

Answer 61

* GORD * Peptic ulcer disease * Functional dyspepsia (non-ulcer dyspepsia)

Answer 62

* **Lifestyle modification**- weight loss, smoking cessation, reducing alcohol, smaller meals, avoid triggers (coffee, chocolate, tomatoes, fatty, spicy foods) * **Manage anxiety/depression/stress** * **Medication review** * **If sx persist, full dose PPI for 4 weeks OR H.pylori testing** (carbon-13 breath test)- if persist, try alternative strategy

Answer 63

* NSAIDs * alpha and beta blockers * Aspirin * Anti-cholinergics * Benzos * Bisphosphonates * Steroids * Nitrates * Theophyllines * TCAs

Answer 64

* Alarm symptoms- weight loss, recurrent vomiting, dysphagia, evidence of GI bleed * Frequency, duration and pattern of symptoms * Family hx of UGI malignancy * Lifestyle factors * Assess for stress/anxiety/depression * Review medication * Check weight and BMI * Check for signs of anaemia * Check for abdominal masses/tenderness * Check FBC for anaemia/raised platelets

Answer 65

Anyone with dysphagia \>55 with weight loss + upper abdominal pain/reflux/dyspepsia

Answer 66

Epigastric discomfort Gnawing/burning pain Nausea, vomiting, loss of appetite, belching, and bloating. Erosive gastritis= pain, bleeding or a stomach ulcer

Answer 67

H pylori test Stool test Endoscopy

Answer 68

H. pylori Excessive use of cocaine or alcohol Regularly taking aspirin, ibuprofen or other NSAIDs Stress Autoimmune

Answer 69

**Lifestyle modification**- smaller meals, avoid spicy/acidic/fried foods, reduce alcohol, manage stress ## Footnote **Antacids** **PPIs** **H2 receptor antagonists**

Answer 70

Stomach ulcer Stomach polyps Stomach tumours

Answer 71

**Haematemsis**, usually after **prolonged or forceful retching, coughing, straining or hiccupping**

Answer 72

**Resuscitation**- maintain airway, O2, 2 wide bore cannulae, send bloods, IVT/blood **Most patients stop bleeding spontaneously** *Some* require **endoscopic intervention**

Answer 73

**Dysphagia at any age** Age **55+** with **weight loss** and *any one of*: * **upper abdo pain** * **reflux** * **dyspepsia**

Answer 74

**Localised oesophageal adenocarcinoma**- surgical **resection** with **neoadjuvant chemoradiotherapy, *or* chemotherapy**( before, or before *and* after surgery) **Resectable non-metastatic SCC**- **radical chemoradiotherapy** or **chemoradiotherapy then surgical resection** Non-metastatic Ca but unsuitable for surgery- chemoradiotherapy, chemotherapy, local tumour treatment (stenting) or supportive care. **Advanced Ca- palliative combination chemotherapy** (5-fluorouracil or capecitabine + cisplatin1 or oxaliplatin)

Answer 75

**Benign** stricture- **Endoscopic dilatation** with baloon/bougie **Malignant** stricture- Surgical excision (**oescophagectomy**) *or* **stenting**

Answer 76

Variceal haemorrhage occurs from **dilated veins** (varices) **at the junction between the portal and systemic venous systems.** Occur due to **portal hypertension** - most common causes are **alcoholic and viral liver cirrhosis**. _Other causes:_ * *Prehepatic;* protal vein thrombosis/obstruction, fistula * *Intrahepatic;* acute hepatitis, schistosomiasis * *Posthepatic;* Budd-Chiari, compression (e.g. from tumour), constrictive pericarditis

Answer 77

Risk assessment- **Blatchford score** **Resuscitation**- assess airway, wide bore access x2, O2 if needed, fluids (crystalloid and colloid rapid infusion), transfuse blood ASAP, correct anaemia/coagulopathy **Terlipressin** until haemostasis achieved or 5 days completed **Urgent endoscopy**- band ligation, consider TIPS if bleeding not controlled Baloon tube tamponade (Sengstaken-Blakemore tube) can be used as temporary treatment for uncontrolled haemorrhage **Antibiotic prophylaxis** Should have **beta-blockers +/- nitrates** and **endoscopic screening and treatment long term**

Answer 78

Increasing age Male H.pylori Low vegetable/fruit consumption Smoking Familial risk

Answer 79

**Nutritional support** and **symptom control** **Surgery** is **treatment of choice** with **lymphadenectomy if curable** **Perioperative combination chemo** (5-fluoracil + epirubicin/cisplatin) Palliative- chemotherapy, traztuzumab, stenting, gastrectomy if obstructing

Answer 80

Diverticula are **sac-like protrusions of mucosa** through the muscular wall of the colon, which occur in the **sigmoid colon** in about 85% of people over the age of 80.

Answer 81

**Diverticulosis** = diverticula present, **no symptoms** **Diverticular disease** is a condition where **diverticula cause symptoms**, such as **intermittent lower abdominal pain**, without inflammation and infection. **Diverticulitis** is a condition where **diverticula become inflamed and infected**, typically causing **severe lower abdominal pain**, **fever**, general **malaise**, **change in bowel habit**, and occasionally **rectal bleeding**.

Answer 82

High fibre diet and adequate fluid Weight loss, quit smoking Bulk forming laxatives Simple analgesia

Answer 83

* **Intermittent abdominal pain** in the **left lower quadrant**. Pain **may be triggered by eating** and **may be relieved by the passage of stool or flatus**. * **Constipation**, **diarrhoea**, or occasional large **rectal bleeds**. * **Bloating** and the passage of **mucus** rectally. * **Tenderness** in the **left lower quadrant** on abdominal examination.

Answer 84

* **Constant abdominal pain**, **usually severe** and starting in the hypogastrium before localizing in the left lower quadrant, with **fever**. Note: in a minority of people and in people of Asian origin, pain may be localized in the right lower quadrant. * Change in bowel habit, and possible significant rectal bleeding. * Possible nausea, vomiting, dysuria, and urinary frequency. * A previous history of diverticulosis or diverticulitis. * Tenderness in the left lower quadrant, palpable abdominal mass or distention on abdominal examination.

Answer 85

If **mild and uncomplicated**- oral **co-amox** 1 week (if infection suspected) or **analgesia, clear fluids**, reintroduce solid food gradually as symptoms improve If more **severe/complicated**- **admit**, **IV antibiotics/fluids/analgesia**, **surgery** if complicated

Answer 86

_The classic symptoms are:_ * **Abdominal pain** — this is the primary presenting complaint, and it is typically described as a **peri-umbilical or epigastric pain that worsens during the first 24 hours (becoming constant and sharp) and migrates to the right iliac fossa (RIF)**. The pain is **typically worsened by movement.** * **Anorexia** — almost always present. * Nausea. * Constipation. * Vomiting (profuse vomiting may indicate development of peritonitis). _On examination, there may be:_ * **Tenderness on percussion, guarding, and rebound tenderness at the RIF** — these are the most reliable clinical findings. * Facial flushing, dry tongue, halitosis, low-grade fever (not more than 38°C), and/or tachycardia.

Answer 87

**Pregnancy test**- rule out **ectopic** **Urine dip**- exclude **UTI** (may be abnomral in 50% with appendicitis due to inflammation adjacent to bladder/UT) **Bloods**- **FBC** (neutrophil predominant lecuocytosis in 80-90%), **CRP** **Imaging**- **US** if dx doubtful, **CT** (more sensitive and specific)- enlarged appendix, wall thickening, fat stranding, wall enhancement.