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MRCP > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Cause of pancreatitis in pregnancy

A

Gallstones

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2
Q

Budd Chiari syndrome

A

Hepatic VEin thrombosis - seen in haem conditions

Assoc:

  • Polycythaemia ruba vera
  • Thrombohilia - PRotein C + S deficiency, antithrombin C deficiency, Portein C resistance
  • Preg
  • OCP

Ft:

  • Sudden onset abdo pain
  • Ascites
  • Tender hepatomegaly

Inx:
- US doppler flow

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3
Q

Jejunal villous atrophy

A 
Coeliac dx 
Whipples dx 
hypogammaglobulinaemia
Tropical sprue 
Cows milk intolerance
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4
Q

Prophylaxis of variceal bleads

A

Propanolol - 1st line

Variceal band ligation + PPI cover whilst - ive very large

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5
Q

Bariatric surgery

A

Consider if BMI>40 or NMI >30 + Comoridities

Alla appropriate non surgical measures have failed fot >6/12

They are receiving or will receive specialist mx

fit for surgery

comitted to LT follow up

BMI 30 - 39 -> gastric banding
NMI>40 –> gastrectomy or sleeve.

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6
Q

Severity of Lover cirrhosis

A 
PT time 
bilirubin 
Albumin
Presence of ascites 
presence of encephalopathy
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7
Q

Hep B and pregnancy

A

Screen all preg women

BEbies born to chronically infected or acute infection during pregnancy –> complete vax + HEp B Ig

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8
Q

Vitamin deficiency in GAstric Bypass

A

NEarly all gastric bypass ops = bypass duodenum

dueodenum = IRon absorption

therefore all menstruating women likely Fe deficient

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9
Q

Secondary prophylacys of hepatic encephalopathy

A

Lactulose 1st line

2nd line - Rifaxamin

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10
Q

Liver abscess

A

tx - percut Drainage + abx

abx - Amox + cipro + metro

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11
Q

PBC associartions

A

Sjrogrens - most assoc.
Systemic sclerosis
RA
Thyroid dx

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12
Q

PAncreatic secretions 0- Exocrine and endocrine

A

Exocrine:

  • Trypsinogen
  • Chemotrypsinogen
  • Pancreatic amylase
  • lipase

Endo:

  • Glucagon
  • Insulin
  • Somatostatin
  • pancreatic polypeptide.
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13
Q

Gut hormones

A

Gastrin:

  • S = G cells in Antrum of stomach
  • Stim = AA + GAstric distension
  • A= H+, pepsin, IF secretion

Cholecystokinin:

  • S = Duodenum + Jej
  • stim = AA + Fats + Peptides
  • A = PAnreatic + GB secretions

Secretin:

  • S= duodenum + Jej
  • stim = H+ small bowel
  • PAncreatin NaHCO3- & delay gastric emptying

Somatostatin:

  • D cells of panceas
  • Vagal + adrenergic
  • inhibit gastric H+ & pancreatic secretions.

VIP:

  • SI
  • NEural
  • Inhibits H+ & epsin –> increases pancreatic secretions

GIP:

  • Duod + jej
  • gluc fat AA
  • inhib H+/increase insuli/decrease motility
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14
Q

Fe Metabolism

A

Absorption - upper SI

Bound to Transferrin as Fe 3*
Stored as ferritin

Causes of increase Fe:

  • Vitamin C
  • Gastric H+

Causes of decreased Fe:

  • PPI
  • Tetracycline
  • Tannine - in tea
  • Gastric Achlorydia
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15
Q

Folate metab

A

Foudn in leafy greens

abs in duod/jej

Drugs that stop metab:

  • MTX
  • Trimethoprim
  • Pyrimethamine

Drugs that reduce reabs:
- Phenytoin

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16
Q

Causes of low Vit B12

A

PErnicoius anaemia
post gastrectomy
disorder of terminal ileum - CROHNS
VEgan/low protein diet

Features:

  • MAcrocytic anaemia
  • Sore tongue + kmouth
  • Ataxia/mood

Mx:
- if neuro –> HYDROXOCABALAMIN

if folic A low - replace B12 1st to stop SCDC

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17
Q

Achalasia

A

adnormal peristalsis + Lack of relaxation of LOS

Ft:

  • Dysphagia - both liquids + Solids
  • Varies in severit
  • Regurgitation

inx:
MANOMETRY - most important
- Ba swallow –> birds beak appearance

Mx:

  • Botulinnum toxin inject
  • Hellers cariomyotomy
  • pneumatic ballon dilatation
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18
Q

Dyspepsia referral criteria

A

Urgent:

  • Dysphagia
  • Uppe abdo mass
  • > 55 and - abdo pain/reflux/dspepsia

Non-urgent:

  • Haematemesis
  • > 55 w/ - tx resistant / upper abdo mass + low Hb/ high platelets and sx
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19
Q

Drug causes of dyspepsia

A

Direct causes:

  • NSAIDs
  • Steroids
  • Bisphosphonates

Drugs causing relax of LOS:

  • Nitrates
  • CCB
  • Theophyline
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20
Q

H.Pylori

A

Gram negative

assoc:

  • PUD
  • GAstric Ca
  • B cell lymphoma of MALT
  • Atrophic gastritis

Inx:

  • Diagnosis - 13C urea breath test or stool culture:
  • Erradication = Urea breath test

Mx 7/7:

  • PPI + Amox + Clari
  • PPI + Metro + Cari
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21
Q

GORD - indications for UGI endoscopy

A
  • > 55
  • sx >4/52 or tx resistant
  • Dysphagia
  • WL
  • Relapsing/remitting

if neg endoscopy –> 24 hr oesophageal pH monitoring

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22
Q

Barretts

A

Squamous –> columnar

pre malignant

RF:

  • GORD - greatest
  • smoking
  • Obesity
  • Male

Mx;

  • Endoscopic surveillance - 3-5 yrs
  • high dose PPI
  • if dysplasia –> ressection or ablation
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23
Q

Oesophageal Ca

A

Adenocarcinoma = most common
- can have sq cell

Majority effect MIDDLE 3rd of oesophagus

RF:

  • GORD
  • Barretts
  • EtOH
  • Achalasia
  • plummer-Vinson syndrome - sq cell
  • procssed meat - Sq cell

H.PYLORI NOT ASSOC - MAY BE PROTECTIVE

Inx:
UGI endoscopy
CT TAP for staging –> no mets –> endoscopic US
Peritoneal dx –> Laproscopy

Mx:
- Surgery + adjuvant chemo

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24
Q

Acute UGIB causes

A

Oesophageal:

  • mallory weiss
  • oesophagitis
  • varices
  • Ca

Gastric

  • Gastritis
  • Ca
  • Dieulafoy lesion
  • gastric ulcer

Duodenal:
- Posterior sited ulcer

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25
Q

Risk assessment in UGIB

A 
glasgow blatchford score - pre endoscop --> >0 --> Mx 
Hb
urea 
SBP 
Tachy 
Malena 
syncope 
hepatic dx or CFx
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26
Q

UGIB - Non variceal bleed

A

PPI post endoscopy

Further bleed –> rescope –> IR/Surgery

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27
Q

UGIB initial mx

A

A–> E
maj haem protocol

FFP if:

  • fibrinogen <1
  • INR >1.5x BL

Plt transfusion:
- Active bleed + plt <50

If taking warfarin –> PTCC

All PT –> endoscopy within 24 hrs

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28
Q

UGIB - variceal blled mx

A

Terlipressin + Abx

Endoscopy –> VBL (oesophageal) / N-butyl-2-cyanoacrylate inject (Gastric)

Fx of above – TIPSS

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29
Q

UGIB - idnications for surgery

A

> 60
fx of endoscopic intervention
rebleed
known CVD with poor tolerance for hypotension

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30
Q

Zollinger-Ellison syndrome

A

Increased gastrin production

Raised gastric acid - - > low b12 - - - > MACROCYTIC ANAEMIA

 assoc w. Men type 1 
ft:
- Multiple P~Ud
- diarrhoea
- malasorption

Inx: Fasting gastrin levels

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31
Q

Gastric Ca

A

Epidemiology:

  • affects 70-80 yrs
  • JApanese/chinese/finland/columbia
  • M>F

Histology –> SIGNET RING

Assox:
Blood Group A
H.pylori
Polyps
pericious anaemia 
smoking 
diet - Na / spicy / nitrates

Inx:

  • Endoscopy + biopsy
  • stagbg = Endo US or CT TAP
Mx:
- PRooximl dx - 5 -10cm cm from G.O.jn -->  subtotal gastrectomy 
- <5cm --> total gastrectomy 
- nodal disection
adjuvant chemo
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32
Q

Gastroparesis

A

Causes:

  • IDiopathic
  • DB
  • ANS
  • Post vagotomy

Inx - Ba Swallow

Mx:

  • dietary mod
  • motility agents - DOMPERIDONE/ metoclop/erythromycin
  • if severe or asp pnuemo –> feeding Jej
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33
Q

Dumping syndrome

A

complication of gastric surger & whipples

inapprop. metab response to eating:
- early syndrome = half hour
- late syndrome = 1-3 hrs

Sx:
- palpitations/headache/sweating/hypotension/light headed

Early dumping:

  • rapid gastric emptying
  • Mx = small frew high protein + fat meals

Late dumping:

  • Hypogycaemia due to rebound hyperinsulinaemia.
  • Mx - High carb meal.
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34
Q

acute Pancreatitis - causes

A

GETSMASHED

  • AI = PAN
    H = hypertriglycerides, hyperchylomicron, hypercalcaemia, hypothermia

Drugs - AZA, mesalazine, furosemide, bendroflumethazide, steroids, pentamidine, Na Valproate.

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35
Q

Acute PAncreatitis - inx + scoring

A

AMylase >3x ULN

US abdo –: G.stone dx

Scoring = glasgow
Pao2 <8 
Age >55 
Neutrophils >15 
Ca <2
Renal urea >16 
Enzyme LDH >600/AST>2000
Alb <32 
sugars >10

Score >3 –> SEVERE

CRP 150 = severe

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36
Q

PAncreatitis Mx

A

Feed –> decrease bacterial translocation
Analgesia
FLUID

G.stone obstructing biliary tree –> ERCP
Cholecystectomy

Infected necrosis –> drainage

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37
Q

Complicatuos f pancreatitis

A

pancreatic fluid collection - spont resolves

pseudocyst - observe 12/52 –> fx to resolve –> surgery

Necrosis –> if sterille = conservatibe/ if infected –> Drain

Abscess –> DRAIN

Haemorrhage

ARDS

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38
Q

Chronic oancreatitis

A

Main cause : EtOH

PThers:

  • genetic - CF/haemochromatosis
  • ductal obstruct - stones, tumour, structural

Px:

  • Pain = 15-30 mins after meal
  • 5 - 25yr olds - steatorhea
  • > 20 yrs - DB

inx

  • CT ABDO
  • Faecal Elestase !!!!

Mx:

  • Creon
  • Vit ACE
  • Analgesia
  • DB - insulin
  • abstinence form alcohol
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39
Q

Pancreatic Ca

A 
Assoc:
- Age 
smoking 
-DB
- Chronic pancreatitis
 HNPCC
- MEN
- BRCA2

Px:

  • painless jaundice
  • courvoissser’s lae
  • trousseaus sign

inx - high res CT

Mx:

  • <20 % resectable
  • Whipples procedure + adjuvant chemo
  • Palliative ERCP Stenting
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40
Q

sulphasalazine side effects

A

Diarrhoea
skin rash
male infertility
agranulocytosis

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41
Q

melanosis coli

A

pigment laden macrophages

assoc with laxative abuse

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42
Q

Insulinoma

A

px:

  • early am and premeal hypoglycaemia
  • raised insulin
  • raised C-peptide
  • reaised pre-insulin:insulin

inx:
0 supervised prologed fasting
- CT pancrease

Mx:

  • surggery
  • if not a candidate Diazoxide + Somatostatin
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43
Q

colorectal Ca screening PPV

A

5 - 15%

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44
Q

VIPoma

A

VIP produce in SI + Pancrease –> increases pancreatic + Interstinal secretions.

It inhibits H+/pepsinogen

Ft:

  • LOADS OF DIARRHOEA
  • WL
  • Dehydration
  • low CL-
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45
Q

Glucagonoma

A

alpha cells

Ft

  • charcetristic rash = migratory neccrolytic erythema
  • WL
  • Glucose intolerance
  • DB
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46
Q

Somatostatinoma

A

Secreted by D cells

Ft:

  • DB
  • GB dx
  • Diarrhoea
  • WL
  • Steatorhea
  • hypochlorydia
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47
Q

Coeliac dx

A

Assoc w/ HLA DQ2 & DR8

anti-TTG = 1st line
anti endomysial Ab

both IgA - when tested for need to be on gluten for at least 6/52

Biopsy:

  • Villous trophy
  • lymphocyte infiltration of lamina propria
  • increased intraepthelial lymphocytes

TTG used to assess compliance to gluten free diet;

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48
Q

coeliac dx complications

A 
anaemia - Folate >B12
hyposplenism
osteoperosis/osteopaenia 
lactose intoerance 
enteropathy assoc. lymphoma 
decreased fertility.
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49
Q

Brush border enzymes and their products

A

Maltase - Gluc + gluc

sucrase - Gluc + fructose

lactase - Gluc + galactose

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50
Q

carcinoid syndrome

A

mets –> liver

Ft:

  • 1st sign = flushing
  • diarrhoea
  • bronchospasm
  • hypotension
  • R sided heart valve complications

inx:
- Urinary catecholamines = Urinary 5-HIAA

Mx:
- Octeotride - somatostatin analgue - s.e –> Gallstones
Diarrhoe = Cryoheptadine

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51
Q

Whipples dx

A

Remeber the @old man with the whip in the rave pixorise vide

G+
PAS + Foamy Mac 
Steatorhea - golden butts 
Cardiac psigns  - heart shaped couches 
neuro signs - old man wearing helmet

Inx = Jejunal biopsy

MX:
IV penicillin –> co-trimoxazole for 12/12

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52
Q

Angiodysplasia

A

Vascular malformation - seen in elderly

-A-ngiodysplasia is assoc withj -A-ortic stenosis

Inx:

  • colonoscopy
  • acute bleed = mesenteric angio

mx

  • endoscopic cautery or argon laser.
  • TXA
  • Oestrogen
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53
Q

Refeeding syndrome

A

Metabolic derangement when someone in previous catabolic stateis fed abruptly

sudden switch to anabolic –> surge in insulin –> Increase uptake of gluc, mg, po4-,K+ –> low levels in blood

Mx if not eaten for 5days or more –> reefed at 50% og required daily intake for 2/7

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54
Q

refeeding syndrome RF - High risk

A

One of :

  • BMI<16
  • WL >15% (3-6/12)
  • low intake >10 days
  • already low electolytes

2 of:

  • BMI <16.5
  • WL >10%
  • not eaten > 5 days
  • EtOH/Insulin/ chemo/.steroids/ diuretucs
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55
Q

Malnutrition

A

Definition

BM( <18.5 or unintentional WL >10%

NMI <20 + WL >5%

Acreen - MUST

Mx:
- Dietician –> FOOD FIRST PLAN –< fx –> PO nutritional supplement.

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56
Q

Vitamins

A

B6 - pyridoxine

  • Caused - Inz
  • peripheral neuropathy / sideroblastic anaemia

B1 - Thiamine

  • EtOH, Malnutrtion
  • W-K encephalopathy
  • Dry + wet beri beir

B3 - Niacin

  • Hartnups dx, Carcinoid
  • Pellagra = dermatitis, dementia, diarrhoea

B2 - Riboflavin
- Angular chellitis

B12

  • Pernicious anaemia/ post gastrectomy/ crohns/vegan/metformin
  • Peripheral neuropathy, ataxia, neuro-psychm macrocytic anemia, sore tongue _+ mouth

C

  • scurvy
  • poor wound healing/bleeding gums/haematuria/epistaxis
  • gen malaise
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57
Q

SB bacterial overgrowth syndrome

A

RF:

  • Congenital abnormalities
  • Scleroderma
  • DB

Ft:
- IBS like picture - diarrhoea, bloating, flatulence

Inx: _ HYDROGEN BREATH TEST

Mx:

  • Tx underlying
  • RIFAXIMIN
58
Q

Crohns - Px/Inx

A

Mouth –> anus patchy inflamm of all layers = “cobblestone”

Histology

  • all layers
  • increased goblet cells
  • granulomas

Px: most common on adult = diarrhoea, most common in child = Abdo pain

inx:
- faecal calprotectin 
- CRP relates to DX ACTIVITY 
- Colonoscopy + Biopsy 
SB enema --> strings of Kantor + Rose thorn Ulcers

Complication:
- SB cancer
osteoporosis
colorectal Ca

59
Q

Crohns mx

A

General

  • stop smoking
  • decrease NSAIDs

Indicing remission:

  • 1) Steroids +/- enteral
    2) Mesalazine
    3) MTX/AZA or mecatopurine
    4) Infliximab

NB - Use inflix if fistula. need to check TPMT activity before Aza and mecatopurine

Mainaining:

1) Aza or metacopurine
2) ASA (prev surgery) or MTX

Surgery - if stricture or fistula

60
Q

UC Px/ Inx

A

More likely to px with bloody diarrhoea and tenesmus + LLQ pain

Pathology:

  • limited to submucosa
  • decreased goblet cells
  • don’t get granulomas
  • Crypt abscess
  • inflamm cell infiltrate of LP

Inx:

  • Colonoscopy + biops
  • SB enema - Loss of hgaustra –> V sev –> LEAD PIPE COLON

Severity:

  • Mild - <4 stools/day w/ little blood
  • Mod - 4-6 stools/day - no systemic upset
  • Sev - > 6 stools/day w/ systemic upset.
61
Q

UC Mx - inducinf remission

A

Mild – Mod procttiis:

1) rectal Mesalasine
2) PO mesalazine
3) PO/topical steroid

Mild- mod proctosigmoiditis + L side Dx:

1) Rectal Mesalasine
2) PO mesalasin
3) PO Mesalazine + topical steroid
4) PO Mesalazine + PO steroid

Mild - mod - extensive dx:

1) PO + Topical meselazine
2) PO Mesalazine + PO steroid

Sev colitis:

1) IV STEROID or CICLOSPORIN
2) not resolved in 72 hrs –> +Ciclosporin or go to surgery.

62
Q

UC maintaining remission

A

Mild - mod proctitis:
- Meslazine - PO or topical or combo

Mild to mod L side dx
- PO Mesalazine

Sev relapse or >2 exac in a yr:
- Aza or mercaptopurine - TMPT activity

63
Q

IBD 0 extraintestinal dx

A

Related to dx activity:

  • arthritis - puaciarticular
  • episcleritis
  • Erythema Nodosum
  • osteoporosis
Unrelated to sx activity 
- periarticular arthritis 
- uveitis 
- pyoderma gangrenosum 
clubbinf
PSC
64
Q

UC and colorecyal Ca

A 
High risk:
- Dx > 10yrs 
Px < 15yr sold 
- pancolitis
- unremitting dx
- poor complains

Suveillance:
Low riks - 5 yrs
- no complicated L side dx
- no inflamm on endo or histo

Med risk - 3 yrs:

  • Ext dx w/ mild inflamm
  • Fhx of colorectal Ca >50

High =1yr:

  • Mod–> sev inflamm
  • FHx <50 yrs
  • Complications - strictures, dysplasia, PSC
65
Q

C.Diff

A

Produces and exotoxin –> pseudomembranous colitris

RF:

  • Cephlasporin > Clindamycin
  • PPI

inx:
- Cdiff toxin in stool

Mx:

  • PO metronidazole
  • if sev or Fx 1st line –> PO Vanc or Fidaoxamicin
  • life threatening —> IV metro + PO Vanc

Ft of life threatentingL

  • WCC>15.0
  • Cr > 1.5X BL
  • Temp > 38
  • Sev colitis on radiology
66
Q

Peutz - Jeghers syndrome

A

AD

Harmatomas

Ft:

  • harmatomatous polyps in GIT
  • Pigmented lesions on lips, oral muco, palms,Intestinal obstruct
  • GI malignancy

Mx = conservative

67
Q

Coagulopathy of liver dx

A

Factor 8 is paradoxically increased.

This is because it is made in endothelial cells all around body, not just liver !!
Also it is cleared by the liver therefore it is not cleared !!!

As a result despite increase bleed risk, CLD pt tstill at risk of VTE

68
Q

Colorectal Ca

A

SPoradic 95%

HNPCC 5%

  • AD
  • PRoximal colon, poorly differentiated + VV agressive
  • Amsterdam critea >3 family members, cross 2 generations or >1 diagnosed < 50yrs

FAP<1%

  • AD - APC gene on chromsome 5
  • Multiple polyps
  • Gardners syndrome - FAP + OSteomas + retinal pigmentation + thyroid Ca + epidermal Cysts
69
Q

Colorectal Ca screening

A

Every 2 yrs

60-74 UK
50-74 scotlnd

FIT - better than FOB - only 1 sample and only detects human Hb.

5-15% of + tests –> colorectal Ca

Flexsig- one of test

  • @55 yrs
  • can opt in until 60

in addition to above - offer FOBT if:

  • > 50 + abdo mass or WL
  • > 60 + anaemia.
70
Q

Colorectal Ca referral

A

Ugent:

  • =/>40 + Abdo pin + WL
  • =/>50 + Rectal bleed
  • =/> 60 w/ IDA or chaneg in bowel habit
    • FOBT

Consider:

  • Rectal/abdo mass
  • anal mass/ulceration
  • < 50 + rectal bleed + one other sx.
71
Q

IBS

A

Diagnosis: - 6/12

Abdo pain - relief on defecation or assoc with change in bowel habit 
and 2/4 of:
- Bloating
- alt stool passing
- sx worse on eating 
- Passing mucus

inx - FBC/ESR/Coeliac screen

Mx - 1st line:

  • Diet advice - avoif high fibre
  • Diarrhoea - loperamide
  • Constipation - LAxatives –> fx –> Lincosamie
  • pain - antispasmodic

Mx: 2nd line:

  • Lincosamide
  • TCA
  • CBT
72
Q

GI Infections

A

1 - 6hrs:

  • Staph A - projectile vomit
  • Bacillus cerus - Rice - <6hr = vomit >6hrs diarrhoea
12-48 hrs:
\+ Salmonella 
- G- nacillus 
- pea soup diarrhoea
- rose spots 
- usueal SL --> Fx --> Cipro

+E.coli
- Traveller diarrhoea = watery

48-72 hours:
+ Shigella:
- BLOODY diarrhoea
- useually SL –> if sev –> Cipro

+ Campylobacter:

  • Non bloody diarrhoea
  • FLU-LIKE PRODROME
  • GBS/ reiters
  • Usually SL –> sev –> Clarithromycin or Cipro

> 7/7:
+ Giardiasis:
- non-blood diarrhoea –> malabsorption/lactose intolerance
- Mx = metronidazole

+ Amoebiasis:

  • Prolonged BLOODY diarrhoea
  • HOT STOOL MICROSCOPY
  • get amoebic liver abscess
  • mx = Metro + Luminal amoebicide (If invasivve dx)
73
Q

Pre - hepatic jaundice

A

Increased RBC BD:

G6PD deficiency:

  • AR –> decreased glutathiazone –> increase susceptble to O2 stress.
  • NEONATAL jaundice
  • HEINZ BODIES + SPLENOMEGALU

HEreditary spherocytosis:

  • RBC BD in microcirculation –> destryed in SPLEEN
  • Fx to thrive
  • SPLENOMEGALY

Congenital hyperbilirubinaemia:

Gilberts

  • relative loss of UDP GT –> decreased conjugation
  • Jaundice worse in INTERCURRENT ILLNESS OR EX
  • inx - prolonged fasting –> measure Bili

Criggler - NAjjar

  • More severe than gilberst –> ABSOLUTE LOSS of UDP GT
  • dont survive long
  • 2 types, tpe 1 is more sev. than type 2
74
Q

Hepatic jaundice

A

Hepatitis

ALD

Wislons dx

Drugs:

  • Phenobarbital
  • Amoxicillin
  • other abx

Rotor syndrome:

  • AR
  • defect in hepatc uptale + storage

Dubllin Johnson sndrome:

  • iranian jews
  • MDRP2
  • Decrease hepatic excreton –> GROSSLY BLACK LIVER

Liver Cirrhosis

Hepatic MEts

Cardiac fx

75
Q

Wilsons dx

A

AR

increase DI absorbtion of Cu + decreased HEpatic excretion of Cu –> deposits in tissuess

Px 10-25 yrs

  • 1sst sign in children = liver dx
  • 1st sign in adults = neur-psych
  • he fx
  • KAiser - flaischer rings
  • RTA
  • BLue nails

Inx:

  • low serum Cu + Caeruloplasmin
  • Increased 24 hr urinary Cu excretion

MX:
- PENICILLAMINE

76
Q

post-hepatic JAundice - Gallstones

A

Female/fair/fat/forty/fertile

Mx:

  • Asx and G stone in GB –> dont need to tx
  • ASx and Gstone in CBD –> Tx

Complications:

  • Biliary colic –> US –. LAp CHole
  • Cholecystitis –> Abx –> choecystitis within 48hrs
  • GB Abscess –> drain
  • Chokangitis - Charcots triad or reynalds pentad
  • G stone ileus –> SBO –> lap
  • Acalculous Cholecysttiis – cholecystectomy
  • Acute pancreatitis
77
Q

Post HEpatic JAundice - other causes

A

PAncreatic Ca

PBC:

  • AMA M2/ASMA/ IgM
  • mx : UDA, Cholecystyramine, Vitamins
  • If Bili >100 –> ?liver transplant
  • Complications - osteomalacia/osteoperosis, Cirrhosis, Heptocellular Ca

PSC:

  • Assoc UC
  • Inx - ERCP/MRCP, ANCA +
  • ncreased risk of Cholangiocarcinoma + colrectal Ca

LN

78
Q

Liver cirrhosis - liver biopsy features

A

Alcohol steatohepatitis:

-Macrovesicular fatty change with giant mitochondria, spotty necrosis and fibrosisi

Liver cirrhosis:
- Xs collagen and extracellular matrix deposition in periportal and pericentral zones leading to the formation of regenerative nodules.

79
Q

What decreases accuracy of 13C-urea breath test

A

No abx or 4/52

No PPI 2/52

80
Q

HELLP vs AFLP

A

HELLP:

  • HAemolysis
  • Elevated LFT
  • Low Platelet

Alcoholic fatty liver of preg:

  • No haemolysis on blood fim
  • ALT >500
  • Hypoglycaemia
81
Q

Acute UGIB caused by a duodenal ulcer - what artery is likely to be affected?

A

Gastroduodenal artery

posterior site DU

82
Q

IF you ?ischaemic bowe in the Q what may they give you in the Q stem on bloods?

A

Raised LActate
low pH on Acidosis
high RR and Low HCO3- - compensation of metabolic acidosis

83
Q

Ascites

A 
TransudaTE (saag >11)
- CHfx
- Hep CV thrombosis 
- Cirrhosis 
EtOH 
- Mixed
- Hep Fx
- Budd-chiari 
_ Veno-occlusive dx 
-Fatty liver of preg

Exudate (SAAG <11)

  • Malignancy
  • Infection
  • TB
  • Pancreatitis
  • Bowel obstruction

Mx:

  • Fluid srestric + Na rresitrict
  • Catheter - UO
  • Daily wait
  • Spironolactone
  • Prophylactic Ciprofloxacin
  • TAP –> S.e ++ Panncreatic circulatory dysfn - therefore if large vol, give albumin cover.
  • TIPSS
84
Q

Hepatorenal syndrome

A

pathophysiology = complex - thought to ?> be splanchnic VD –> decrerase renal perf –> RAAS –> Renal VC

2 Types:
- Type 1 - V rapid onsetr + agress - 2 x Cr BL or 1.5 x Cr Clx in 2/52

  • Type 2 - slower + better prognosis

Mx:

  • Terlipressin
  • 20 albumin –> vol expansion
  • TIPSS
85
Q

SBP

A

Paracentesis –> neutrophil count > 250

Mx : IV cefotaxime

in pt with ascites give prophylaxis if:

  • =>1 episode of SBP
  • Fluid proten <15g/L or CHild pugh >9 or HRS
86
Q

Hepatitis A

A 
Hep A 
- Faecal oral 
- RNA 
- Flu-like prodrome 
- Mx = supportive 
Vax = yes
87
Q

Hep B serology

A

HBsAg = acute dx = 1-6/12 or chronic if present >6/12
anti-HBsAg = immunity
anti-HBc Ag = infection - previous or current
HBeAG = marker of infectivity

88
Q

Hep B

A

Hep B - Chronic:

  • Blood bourne
  • DNA
  • Jaundice/ fever . transaminases
  • Mx = pegylate ifn-alpha +/- tenofovir.entecavir/talbivudir
  • complications - 50% –> Chronic Hep = ground glass hepatocytes
  • Complications: fulminante hep Fx/ Hepatocellular Ca/ GN/PAN
  • VAX -= YEss - all children in UK + Occupational risk
89
Q

Hep C

A

CHRONIC

Blood borne/sexual

RNA

Acute hepatitis less sever the A + B

Inx = HCV RNA

Complications

  • Rheumatic dx
  • Sjrogrens
  • Cirrhosis
  • Hepatocellular Ca
  • membranoprolif GN
  • Porphyria

Mx:

  • Protease inhibitor (-navir-) +/- Ribavirin
  • used to be ifn alpga

S.e of ribavirin:

  • Haemolytic anaemia
  • Cannot become pregnant <6/12 after stopping

IFN-alpha:

  • flu like
  • depression
  • fatigue
  • leukopaenia
  • thrombocytropenia
90
Q

Hep D

A

Exacerbated HEp B

no chronicitiy of itself
no vax

blood-borne

91
Q

Hep E

A

faecal -oral
RNA
- Acute self limiting

HIGH MORTALITY during PREH

no vax

92
Q

AI Hepatitis

A

assoc w/ other AI conditions/hypogammaglobulinaemia/ HLAB8/DR3

Type 1 - ANA/ASMA - affects both adult and child

Typ II = LKM1 - Kids

Type III - Soluble liver-kidney Ag - Adults

Inx:
- CLD signs
Amennorhea

  • ANA/ASMA/LKM1/IgM !!!!!!!
  • liver buiopsy –> Necxrosis = piecemeal or bridging

Mx:

  • IS/Steroids
  • Liver transplant
93
Q

Drug induced hepatitis

A

Cholestatic

  • Fluclox
  • Erythromycin
  • OCP
  • Anabolic steroids

True hep

  • Statin
  • Anti-TB - Inz
  • Ketoconaxole
  • I.s.

Necrosis:

  • Tetrahydrochloride ingestion
  • Paracetamol OD
94
Q

Liver Cirrhosis

A

Inx of choice = TRANSIENT ELASTOGRAPGY
- Fibroscan = measures stiffness

Endoscopy - varices

Screemomg - Liver US +/- AFP

  • Hep C
  • EtOH intake - >50 for M and > 35 units for F
  • ALD

Scoring =
MELD - Bili/Cr/INR

 Child pugh score
- Bili 
Alb 
PTT
Enceph 
Ascites
95
Q

child pugh score

A

BIli:

  • <34 = 1
  • 34 - 50 = 2
  • > 50 = 3

Alb
>35 = 1
28 - 35 = 2
<28 = 3

PTT:
<4 = 1
4-6 =2
>6 = 3

Enceph AND ascites
none = 1
mod = 2
marked = 3

Severtity
A = <7
B = 7-9
C = >9

96
Q

Prtal HTN - causes

A

causes:

  • cirrhosis
    -Portal V thrombosis
  • budd - chairi
  • R HFx
    Vholangio-carcinoma/hepatocellular Ca
  • Constrictive pericarditis
  • Splemic V Thrombosi s
97
Q

prophylaxis form Variceal bleed

A

1) Propanolol
2) VBL>Sclerotherapy (cover w/ PPI)

VBL used 1st line if Cirrhosis + med/lrg varices

98
Q

Hepatic Encephalopathy

A

Ft:

  • GCS change
  • Asterix - 3-5hz
  • construcytional apraxia

Inx:

  • Raised ammonia
  • EEG - Transient slow waves

PRecipitants:

  • Infection
  • GIB
  • TIPSS
  • CONSTIP{ATION
  • Drugs - sedatives/diuretics
  • hypokalaemia
  • Renal Fx
  • High protein diet

Mx:

  • Tx precipitant
  • !st line = Lactulose
  • 2nd line = + Rifaximin
99
Q

Hep encephalopathy - GCS grades

A

grade 1: irritable
grade 2 0- confusion/inappropriate
grad 3 - incoherent/relestless
grade 4 - coma

100
Q

PBC complications

A

Osteomalacia/osteoporosis
- Sjrogrens
portal HTN
Hepatocellular Ca - 20 x risk increase.

101
Q

Haemochromatosis

A

HFE gene on chromosome 6

Ft:

  • Fatigue / erectile dysfn/ arthralgia = early
  • Bronnze skin
  • CLD
  • DB
  • Cardiomyopathy
  • Hypogonadism = hypogonadotrophic = Pit dysfn

Inx:

  • general population transferrin saturation +/- ferritin
  • FHx +ve –> HFE gene
  • Tranferrin > 55% in M or >50% F
  • ferritin >500
  • Fe Raised
  • TIBC reduced

Mx:
- Venesectuin - aim to keep trasnferin saturation <50% and Feritin <50

102
Q

Which complications of haemochromatosis = reversible>

A

Skin pigmentation

Cardiomyopahty

103
Q

Paracytic liver ingections

A 
Hytadid dx:
- ingestion  
-dog taperowmr 
- larvae --> blood --> liver cysts 
Mx = surgical + bendazole

Schistomiasis:
- Parasite penetrates skin when in infected H2O

Schistom HAematobium –> Renal –> bladder clac/haematuria - Mx = Praziquantel

-Schistoma Mansonium/japonicum –> Liver Cirrhoss
VAriceal Dx

  • Schistoma intercalatum/mekongi —> intestinal dx
104
Q

Liver abscess

A

Pyogernic:

  • Drain + IV ABx = Amoc + cipro + metro
  • pen allergy = Cipro + clinda

Amoebic:

  • Anchovy paster
  • Prodrome of diarrhoeal illness
  • Mx = metro
105
Q

hepatocellular carcinoimna

A 
Rf:
- Liver citrrhosis - any cause
- Alpha-1 antitrypsin 
- Heriditary tyronsinosis 
- glycogen storage dx
- Alfatoxin 
Drugs = OCP/ Anabolic steroids 
- male

Screening:

  • US +/- AFP
  • cirrhosis secondary to hep B/C/haemochromatosis
  • men with ALD
Mx:
- Early = resection 
- Albumin 
Sorafenib = multikinase inhibitor 
- Transarterial chemoembolisattion 
- liver transplant
106
Q

Cholangiocarcinoma - features

A

Biliary colic

post-hep jaundice

Courvosers sign = palpable mass inRUQ + jaundice

sister mary joseph nodule = periumbilical LN

Virchows node

Mx:

  • v.few suitable for surgery
  • palliative stenting
107
Q

NAFLD

A

Insulin resistance

spectrum disorder:

  • steatosis
  • steatohepatitis
  • steatohepatis (NASH) = Same changes as ALD

Assoc

  • obesity
  • DB2
  • lipids
  • jujenoileal bypass
  • sudden WL ot starvations

Inx:
- Liver screen ALT > AST rise
- Enhanced lifer fibrosis blood tersts
Fibroscan + FIB4 score

Mx:

  • WL
  • Adv dx –> specialit
108
Q

Ascites and protein concentration <15 but no bacteria yet…… what should be done re abx

A

Give prophylaxis ciprofloxacin or norfloxacin

109
Q

PSC investigation of choice?

A

ERCP - - > bead like appearance

110
Q

Most common organism. In SBP

A

E. Coli

111
Q

Contraindications to liver biopsy

A
  • extrahepatic biliary obstruct - as use ERCP/MRCP
  • deranged clotting - INR>1.4
  • Low platelets - <60
  • anaemia
  • hytadid cyst
  • haemangioma
  • uncooperative pt
  • ascites
112
Q

Gastric MALT

A

Feature of dysoepsia and weight loss

Lymohima cekls pressnt on bioosy

Most conmonky assoc h. Pylori,.

1st ljne management is HPYLORI ERADICATION

113
Q

Bile. Acid Malabsorption

A

Bile acid is absorbed in the terminal. Ileum

Therefore seen jn those with Ileal resection or diseass (CHRONS)

Px is chronic diarrhoea ans burning sensatiom on passing faeces

Management is cholecystyramine

114
Q

Bile. Acid Malabsorption

A

Bile acid is absorbed in the terminal. Ileum

Therefore seen jn those with Ileal resection or diseass (CHRONS)

Px is chronic diarrhoea ans burning sensatiom on passing faeces

Management is cholecystyramine

115
Q

Heo B most important factor for determining progression to cirrhosis

A

HBV DNA titre

116
Q

PBC - The M ruke

A

Ig-M-

Anti-M-itochondrial Ab

-M-iddle. Aged female

Lft - - > raised alp and gamma-GT

Mx:
Puritus - cholecystyramine
Uro acid

117
Q

PBC criteria for liver transplant

A

Bili > 100

118
Q

Diagnosis of SBP

A

Paracentesis–”> netrophil vount >250

Most common organism = E. Coli

119
Q

Diagnosis of SBP

A

Paracentesis–”> netrophil vount >250

Most common organism = E. Coli

120
Q

Management of scute severe alcohokic hepatitis

A

Prednisolone

121
Q

Gilbert’s sybdrome

A

Unconjugated hyperbilirubinaemia

Jaundice on intervurrent illness

Investigatiin:

Rise in bilirubin followinf orolonged fasting or nicotinic acid

122
Q

Heoatorenall syndrome

A

Type 1 rapidly orgressive

Typd 2 slower

Mexhanizm - splanchnic vasodilation

. Mx
Terlipressin
Volume expansion wuth 20% albumin
TIPSS

123
Q

Menetriers disease

A

Characterised by massiv gastric folds in the fundus

Histology - hypertrophy of gastric pits, gkand atrophy amf increase overall. Mucosal thickness

Ft:
Epigastric paib
Diarrhoea
Hypoalbuminaemia

124
Q

Extra-intestina manifestations of IBD

  • A PIE SAC
A

Arthritis, ankylosing spsondylitis

PSC, Pyoderma gangrenosum, pleuritis, pancreatitis, perianal skin tag, psoriasis

I = eyes = iritis, uveitis, episcleritis, conjunctivitis

E = eryhema nodosum

Sacroilitis

Apthous ulcers

Clubbinc, cholelithiasis
renal calculi

125
Q

Carcinoid syndrome - False + on Urinary HIAA

A

Diet high in veg/nuts, therefore –> test after diet restriction

126
Q

Hepatic adenoma

A

benign lesion of liver seen in women of childbearing age assoc with OCP

127
Q

Immunoglobulin in gastro

A

IgA - A-lcohol

IgM - PBC - anti M-itochondrial Ab

IgG - AIH

128
Q

Hepatitis E

A

Rna
. Faecak. Oral

Severe ilness and death in pr-E-gnant women in yhe 3 (for E) trimester

129
Q

Colonoscopy surveillance

A

Low risk - 1 or.2 adenomas - 5rs

Med - 3 or 4 adenomas or. One >1cm - 3yrly

High - 5 or more…. Or at keazt 3 with one >1cm

130
Q

Peutz jegher

A

Mucosa pigmentation

Gu bleed

Chromosme 19 - AD

131
Q

Pathognomic finding of chronic oancreatitis

A

PANCREATIC CALC - Xray (alsp kn ERCP)

132
Q

What drug causes crohns like Enterocolitis in transplant patient

A

Mycophenelate mofetil

133
Q

Colonoscopy for dukaes A tumour

A

Colonoscopy annually for 2 years. Yhen 3 years

134
Q

Treatment of whipples of disease

A

Amoxicillin

135
Q

Most common cause of small bowel overgrowht

A

Radiation enteritis

136
Q

Travis or oxford criteria for UC

A

At day 3:.

Stool freq >8
Crp >45

85% need surgery

Theaes - INFLIXIMAB OR CICLOSPORIN

137
Q

Drug mimics of IBD

A

NSAIDs
Mycophenlate mofetil
Nicorandil

138
Q

If symptoms of Coeliac dx, but endomysial test neg, but still dignosis is coeliac

A

Coeliac dx - assoc IgA

however in Q stem if tehy state past histry of allerges, this may be indicating an IgA deficiency –> therefore endomysial = IgA test wil be negative !

139
Q

Pyoderma gangrenosum

A

If severe - topical tacrolimus
Ciclosporun if this fails (only available parenteral)

Can use topivle beclometasone if mild

140
Q

Hereditary haemochromatosis inheritance

A

Pseudo-dominant

141
Q

How to distinguish between protein losing enteropathy and nephrotic sydnrome

A

LOW TOTAL CHOLESTEROL

nephrotic syndrome loses proteins dependent on weight and charge. Cholesterol too big –> therefore not lost.

Investigation - Faecal alpha-1 antitrypsin

142
Q

Chronic Hep B carrier marker of infectivity

A

HBe antigen if present –> high infectivit

IF negative –> low infectivity

MRCP (20 decks)

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