Gastroenterology Flashcards
Define Symptoms of dyspepsia
Also known as indigestion:
Heartburn/ retrosternal pain Pain related to eating food Early satiety Belching Nausea G.I pain
2-5 hours following food intake, there is pain, what type of peptic ulcer is this related too?
Duodenal Ulcer
Why must gastric ulcers be biopsied?
Because they have an increased risk of developing into malignant ulcers.
What are the broad types of stomach cancer?
Adenocarcinoma
- intestinal type
- diffuse type
MALT
Following a diagnosis of gastric cancer, what important investigation should be next done?
H.Pylor testing
CT of Abdomen, thorax and pelvis to look for metastasis
What is the treatment of gastric cancer?
Stages 0 -1: endoscopic removal
Proximal cancers: Total Gastrectomy
Distal cancers (Antrum or pylorus): Partial Gastrectomy
+
Neoadjuvant and adjuvant chemotherapy
Reconstruction surgery:
- Roux-Y- Reconstruction (attaching Distal oesophagus to the intestines)
What investigations can be done into H.Pylori?
Biopsy Sample:
- Urea and pH reagent
Non - invasive samples:
- Urea breath test
- Stool antigen testing
- blood serology
*urea breath test works by given Urea to drink which has radioisotope carbon 14 in it. When broken down this carbon is realised as CO2 and detected. demonstrates Urease activity is occurring in the stomach
before non - invasive testing a person should be omitted from PPIs as these can create false negatives.
Stress ulcers can occur because of:
Alcohol
Trauma/ sepsis
Intracranial pressure - cushing’s
What is the definition of Liver failure and list some causes:
Failure of the liver which is recognised by:
- coagulopathy (INR >1.5)
- Encephalopathy
- Jaundice
Causes:
- infections
- Toxins
- vascular
- alcohol
- autoimmune
What things must one be aware off in liver failure?
Sepsis
Bleeding (varicies)
Hypoglycaemia
cerebral oedema
What is the initial management of acute liver failure?
Admit to ICU - these patient deteriorate fast
ABCDE A Protect air way - NG tube to remove gastric contents 20 degree head tilt to maintain airway and reduce intracranial pressure
B
C:
- LFTs
- FBC
- U&Es
- INR
Catheterisation to monitor fluids
D
Blood glucose monitoring every 4 hours
- place on Dextrose
- Avoid sedative drugs if possible.
Maintain nourishment
- thiamine
- folate supplements
Treat complications
What signs may you see in liver cirrhosis?
Leukonychia
hypoalbuminemia
Increased INR
Finger clubbing
Palmer erythema
Spider navi
Gynecomastia
Loss of body hair
Reduced testi size
Jaundice
Ascites
What is the definitive diagnostic procedure for cirrhosis?
Liver biopsy
- fibrosis
- nodular formation
- loss of normal architecture
Done under US/ CT guidance
*can only be done when INR <1.5
What are the management options for hepatorenal syndrome?
Albumin
Terlipressin
TIPSS
What management can be implemented for encephalopathy?
Lactulose
Rifaximin - antibiotic that reduces gut flora that produce ammonia
What are the causes for acute pancreatitis?
Gall stones Ethanol Trauma Steroids Mumps Autoimmune Scorpion venom Hypertriglyceraemia, hypercalamia, hypothermia ERCP Drugs - azathioprine
GET SMASHED
What is the most common presentation of Crohn’s in children?
Abdominal Pain
If a patient has suspected C. Diff infection, what is the most appropriate management?
Metronidazole initiated
+
48 hours isolation
What is the definitive diagnosis of C.Diff?
Stool analysis for C.diff Toxins
If a person has severe ascites, what is the management and what must be considered when doing so?
Large volume paracentesis
- up to 5L
this is to prevent fluid shifts.
if 5L is given then albumin must also be given along side.
What is the criteria for SBP? what other investigations should be done and what is the common pathogens?
SAAG <11.1g/L
Bacterial count >250
Cultures should also be done. Most common bacteria include: E.Coli Klebsiella S. Pneumonia
What is the prophylactic treatment for varices?
Beta Blockers
Yearly endoscopic assessment
What cancer is HNPCC also correlated with in females?
Endometrial cancer
What is the criteria for severe C.Diff? What is the first line medication for severe?
WWC >15 Shock >50% baseline creatinine Fever >38.5 Radiological findings - colonic diameter
first line medication for C.Diff is Vancomycin
If a patient with Hepatitis B has acute deterioration in their liver functioning and is an IVDU, what should you worry about?
Hepatitis D
- super infection.
Risk factor being IVDU
Before carrying out the urea breath test, what must the patient be free off?
> 4 weeks ago last use of antibiotics
>2 weeks ago lasy use of PPIs
What are the classic signs of a pharyngeal pouch?
Regurgitation
Foul smelling breath
dysphagia
Which hepatitis viruses are most likely to induce acute hepatitis?
A and B
In acute pancreatitis, what symptoms may point towards the underlying etiology?
Hepatitis - alcohol
Swollen parotid gland
- mumps
Xanthoma
- hypercholesterolemia
In acute pancreatitis what investigations should be done?
Amylase
- 3x normal
ABG
- assess oxygenation and acid balance
LFTs
- obstruction the cause
CT
- this is best way to establish the severity
US
- if gallstones
ERCP
- if LFTs worsen and gallstones are suggested
- done after acute phase
CRP
- higher = more severe
What are the early complications of acute pancreatitis?
Shock
ARDS
- pleural effusions can develop
DIC
AKI
Hypoglycaemia
Hypocalcaemia
What are some late complications of pancreatitis?
Pancreatic necrosis
- antibiotics
- necrosectomy
Pseudocyst
- 4 weeks later
- remaining fever
- amylase remains high
Bleeding
- erosion into the splenic artery
What are the causes of gastritis?
H. Pylori
NSAIDs
Autoimmune destruction
Pyloric obstruction
Where are gastric ulcers most likely to be situated?
First part of duodenum
Lesser curvature of the stomach
WHat drugs are associated with Gastritis and peptic ulcers?
NSAIDS
SSRIs
Bisphosphonates - need to be taken standing up for 30mins
Steroids
What investigations should be done into suspected gastric carcinoma?
Endoscopy with biopsy
Endoscopic ultrasound
CT for staging
If there is an upper G.I bleed, where is it anatomically?
Above the ligament of Treitz / suspensory ligament of the duodenum
What are the differentials of upper G.I bleed?
Peptic ulcers Esophagitis Oesphageal varices Mallory Weiss tears AVM gastric Carcinomas
What does coffee ground blood suggest?
Suggest the blood has been oxidised by the acid in the stomach and that it has either:
- stopped
or
- was a small amount
What is the name for PR bleeding?
Haematochezia
What key blood tests should be done in gastro- bleeding?
FBC
- Hb (may not have changed in acute)
U&Es
- urea and kidney function
LFTs
- to assess if any risk from varices
Group and save/ cross match if serious
Coagulation studies
- to rule out bleeding disorders
What are the endoscopic options for stopping peptic ulcer bleeding?
Thermocoagulation therapy
Clipping
Adrenaline - induce vasospasm
What are the endoscopic options for stopping variceal bleeding?
Endoscopic Oesphageal banding
Endoscopic sclerotherapy
Sengstaken Blakemore tube
What are the treatment options for diverticulosis?
Colonoscopy thermocoagulation therapy
Injection of epinephrine
Vessel embolism
If not able to control bleeding then:
- segmental colectomy
What is gold standard for assessing dysphagia in the setting of suspected esophageal cancer?
endoscopy
What drug should be used in acute alcohol withdrawal to stop hallucinations and induce calmness?
Chlordiazepoxide
What type of IBD causes granulomas?
Crohn’s
What is the management for achalasia?
Calcium channel blockers
Intersphincteric Botulism injection
Balloon dilation
Heller’s myotomy
Which drugs are likely to cause pancreatitis?
azathioprine
mesalazine
sodium valproate
Steroids
What viral hepatitis is most likely in the UK to cause liver cancer?
Hepatitis C in the UK
Hepatitis B in the world
What other cancer are patients with HNPCC with MSH2 gene likely to get?
Endometrial
Pancreatic
If gallstones are discovered incidentally, what should their management be?
Reassurance.
Gallstones are common and if asymptomatic shouldn’t be treated
What are the autoantibodies that can be tested for in coeliac disease?
IgA antibodies against Endomysium / Anti - EMA
IgA against tTG / Anti - TTG
Deamidated gliadin peptide antibodies / Anti - DGPs
If a patient is IgA deficient and there is suspicion of celiac disease, what additional tests should be done?
deamidated gliadin peptide antibodies - Anti DGPs
+
Biopsy
What two other physical signs may be seen in acute appendicitis other than McBurney’s point?
Rovsing’s sign
Psoas Sign
If there is a reduced ceruloplasmin and reduced serum copper what is the likely diagnosis?
Wilson’s disease
*the low serum copper is counterintuitive but occurs since 95% of it is carried by the ceruloplasmin
What is first line medication for moderate UC flare?
Moderate flare: 4-6 stools, with varying blood and no systemic symptoms.
Topical mesalazine
If someone has Gilbert’s syndrome would you expect to see any bilirubin in the urine? and why?
No.
Because it is not conjugated thus is not water soluble.
Following an episode of SBP what medication should be they be started on?
Ciprofloxacin
Prophylactic antibiotic
What are the red flags for referral with a patient presenting with dyspepsia?
Dysphagia
Upper abdominal mass
> 55years + weight loss and:
- treatment resistant dyspepsia
- anaemia
- N&V
How is autoimmune liver disease managed and what are the autoantibodies associated?
Type 1:
- Anti Smooth muscle
- Anti - soluble liver antigen
- ANA
Type 2:
- Anti liver/ kidney microsomal type 1 antibodies (associated with type 2)
Managed:
- steroids
- azathioprine
- liver transplant
What would be two diagnostic features of haemochromatosis?
Increased ferritin
Increased Transferrin saturation (>50%)
Reduced TIBC/ transferrin
What scoring system is used for Liver cirrhosis?
Child Pugh Classification
What is the prophylactic management of variceal ulcers?
Propranolol
- if not previously bleed
Prevention of recurrent rebleeding:
- Propranolol
- 2 weekly banding to abolish the variceal
What are the biggest risk factors determining an anastomotic leak?
Blood supply
Tension
Seal of the stitches
What are some causes of intra abdominal sepsis?
Gallbladder gangrene
Ascending cholangitis
Cholecystitis
Pelvic abscess
Appendicitis mass
*all should get a CT
What are the two screening methods being used for colorectal carcinoma?
qFIT
- 50 to 74 years old (England 60-74)
- every 2 years
Flexible sigmoidoscopy
- one off >55 year old
What is the preferred initial triple therapy?
PPI \+ Amoxicillin \+ Clarithromycin
What is the best management for NAFLD?
Weight loss
In the setting on acute bleeding - when should PPIs be given?
After the endoscopy - otherwise they may hide the source of the bleeding
Where is the most likely place for ischemic colitis to affect?
Splenic flexure
What can cause a falsely elevated ca125?
Ascites - virtually all patients with ascites will have elevated CA125
What is the treatment of Hep B?
Refer to gastro
Contact public health
Fibroscan
Anti-virals
1st Line: Interferon Alpha
2nd line:
Nucleus reverse transcriptase Inhibitors
- tenofivir
- entacavir
What are the symptoms of carcinoid syndrome and what has to occur first in order for there to be these symptoms?
Facial flushing
Diarrhoea
Itching
Hear dysfunction
Asthma
- it must have metastasized to the liver
How is carcinoid syndrome investigated for?
24 hour 5HIAA urine test
- 5 hydroxyindoleacetic acid
CT Chest/ Abdo/ Pelvis
Octreoscan
Echocardiogram
- to establish for carcinoid disease of heart
How is carcinoid syndrome treated?
Octreotide
- blocks tumours mediators
Loperamide - for diarrhea
Surgical resection
- endoscopically
- radioablation
- segmental removal
- depends on size
- tumours are bright yellow
What is carcinoid crisis?
Where the tumour outgrows its blood flow or is handled too much during surgery.
causes:
- life threatening vasodilation
- hypotension
- bronchoconstriction
Octreotide and supportive measures are needed
What are the features of malabsorption and name some common causes:
Diarrhea weight loss Pale Lethargy Bloating
Signs: anaemia Bleeding disorders oedema - albumin loss Metabolic bone disease
Causes:
- Coeliac disease
- Cystic fibrosis
- Chronic pancreatitis
- Crohn’s disease
- Bacterial overgrowth
- giardiasis infection
What investigations should be done into malabsorption?
Bloods:
- FBC
- Anaemia screen
- INR
- Celiac serology
Orifices:
- Sudan stain for fat globules
- stool microscopy
Endoscopy + Biopsy
Breath hydrogen analysis
- bacterial overgrowth
What are some of the complications of celiac disease?
Anaemia
Osteoporosis
Dermatitis herpetiformis
Enteropathy related T cell lymphoma
B12 deficiency - neurological abnormalities
Pneumococcal disease (Functional Hyposplenism)
What can be a mimic of IBS which one needs to be aware of?
Ovarian cancer
Endometriosis
What are the symptoms of IBS?
Abdominal discomfort Relieved by defecating Diarrhea/ constipation Mucus PR worsen symptoms after eating
What symptoms of IBS would make you think of other diseases?
>60 years old Anorexia loss of weight waking up at night mouth ulcers Abnormal CRP ESR
What investigations should be done into diarrhoea?
Bloods:
- FBC
- Anaemia Screen
- ESR
- CRP
- U&Es - K?
- Celiac serology
Orifices:
- Microscopy, cultures and sensitivities
- C. DIff toxin - if suspicion
- faecal elastase
- Sudan fat stain
Endoscopy/ colonoscopy if suspicion of underlying disease.
Video capsules.
How is Haemochromatosis diagnosed? and what are some complications?
Liver biopsy
- Pearl stain
Genetic testing
Liver failure
Joint damage
Diabetes
Cardiomegaly
What does C. Diff antigen show? and how should it be treated?
Show previous exposure.
does not suggest infection.
No treatment is required.
What investigation features would you expect to seein NAFLD?
Increased ALT>AST
Fibroscan Echogenicity
What is the genetic susceptibility into celiac disease?
HLA DQ2/ DQ8
What would be likely on the blood film of someone with celiac disease?
Howell jolly bodies
Target cells
- hyposplenism
- Iron deficiency
What investigations should be done into coeliac disease?
Bloods:
- FBC
- Haematinics
- LFTs - low albumin
- INR - Low - lack of vitamin K
- Bone profile
Orifices:
- Stool cysts - gardia
X-rays:
- Endoscopy + biopsy
Special tests:
- IgA
- Anti tTG
- Anti Endomysial
- Anti - deamidated gliadin peptide
What foods are okay to eat in coeliac disease?
Maize
Soya
Rice
What is the mediators of Crohn’s and Ulcerative colitis?
UC: TH2
Crohns: TH17
What investigations do you want into ascites? and what are the causes?
Cell count
Gram staining
Biochemistry - albumin level. proteins
Cytology - assess for malignancy
Amylase
High SAAG causes:
- Cardiac failure
- cirrhosis
- Budd Chiari
Low SAAG:
- Cancer
- pancreatitis
- TB infection
- SBP
- Serositis
If a person develops SBP what is there now an indication for?
Referral to Liver transplant clinic
What is the neuropsychiatric condition that can develop in cirrhosis and what are some signs of it?
Hepatic encephalopathy/ Portosystemic encephalopathy
- Reversal of sleep wake cycle
- Personality change
- Reduced intellect
- Asterixis
- Hyperreflexia
- Up going planters
- Foetor hepaticus
What additional tests can be done into Hepatic encephalopathy?
EEG
Visual evoked responses
Arterial Blood Ammonia
How do you assess for budd chiari syndrome?
Ultrasound with doppler flow
What are the grading scores for encephalopathy?
I - altered mood/ sleep disturbance
II - Drowsiness/ confusion / Asterixis
III - Incoherent / Clonus/ Nystagmus
IV: Coma
What are carcinoid tumours?
Neural Crest tumours that appear predominantly in the appendix.
- often cause obstruction or acute appendicitis
Only cause carcinoid syndrome when metastasized to the liver and release serotonin
