Gastroenterology Flashcards
1
Q
Common causes of steatorhoea
A
- Chronic pancreatitis
- Crohn’s disease
- Obstructed biliary flow
- Coeliac disease
2
Q
Acute mesenteric Ischaemia VS
Chronic mesenteric ischaemia VS
Acute on chronic mesenteric ischaemia VS
Acute pancreatitis VS
Chronic pancreatitis
A
- Acute mesenteric ischaemia: predisposing factors of ischaemia >> High amylase, abdominal pain, vomiting
- Chronic mesenteric ischaemia: predisposing factors of ischaemia >> normal amylase, abdominal pain after meal for a long time
- Acute on chronic mesenteric ischaemia: predisposing factors >> high amylase, acute abdominal pain, vomiting, abdominal pain after meal for a long time
- Acute pancreatitis: Factors of GET SMASHED > Acute severe abdominal pain, raised amylase [-ve/absent factors for ischaemia]
- Chronic pancreatitis: Mainly alcohol, other risk factors > steatorrhoea, weight loss, chronic pain, recent onset DM
3
Q
Mixed cryoglobinaemia (type 2 cryoglobinaemia) a/w HCV >>> C/F & Findings
A
- C/F:
- Meltzer’s triad:
- Pulpable purpura (non-blancing rash)
- Arthralgia (swelling, stiffness)
- Myalgia
- Livedo reticularis
- Glomerulonephritis (MCGN/MPGN)
- Meltzer’s triad:
- Dx: Histology
- Low C4
- RF +ve
- Criculating cryoglobulin
- IOC: HCV serology
4
Q
Hepatocellular carcinoma VS differentials
A
- Raised AFP >>>>> rules out other hepatic cause
- Absence of acute s/s >>> HCC;
- Presence of acute S/S, jaundice, abdominal pain> may indicate acute HBV infection, alcoholism etc.
- Weight loss >>> HCC
- NO weight loss in chronic active hepatitis, Acute HBV, Alcoholism, and SBP
- Worsening ascites >>> HCC
- Tender ascites + acute abdominal pain >>> SBP
5
Q
Weight loss in colon cancer > cause
A
Anorexia
- In absence of anorexia > consider the following factors
- Dysguesia (Loss of taste) > seen in cancer patients > very few weight loss
- TNF (role in weight loss still unclear)
- IL-6 (role in weight loss still unclear)
6
Q
Cause of Dysguesia (taste changes) in cancer patients
A
- Opioid analgesics
- Cancer chemotherapy
- Antibiotics
- Radiation therapy to head, neck
- Dry mouth
- Dental problems
- Mouth infection
- Nausea, Vomiting
7
Q
Patient is on parenterial nutrition for UC >>> develops symptoms of deficiency >>>
Most common feature of the following deficiencies:
- Chromium deficiency
- Copper deficiency
- Magnesium deficiency
- Selenium deficiency
- Zinc deficiency
A
- Chromium deficiency (RARE) >> glucose intolerence
- Copper deficiency (RARE) >> cardiac dysrrythmias, altered lipoprotein metabolism
- Magnesium deficiency >> hypocalcaemia, neuromuscular excitability
- Selenium deficiency (seen as “Keshan disease” in areas where soil has low selenium content) >> cardiomyopathy
- Zinc deficiency (IBD patients loose more amount of zinc from gut) >> dermatitis, alopecia
*** Parenteral nutrition has risk of low Mg
*** IBD has risk of low Zn
*** If IBD + Parenteral nutrition >>> decide by looking at ‘presentations’
8
Q
Colonoscopy finds polyps in the gut:
Predict ‘risks of malignant change’ from ‘features of polyp’
A
- Low risk for malignant change:
- Pedunculated (Stalked) polyp
- Tubular architecture
- Size <1.5cm
- High risk for malignant change:
- Sessile (flat) polyps
- Villous architecture
- Severe dysplasia
- Squamous cell carcinoma
- Size >1.5cm
*** If multiple polyps are found > do frequent colonoscopy
9
Q
Drug-induced chronic hepatitis & other causes of chronic hepatits (figure)
A
10
Q
Drug induced hepatitis VS Differentials
A
- Drug induced hepatitis (DIH) vs Autoimmune hepatitis
- Both: More in Female, Anti-LKM Ab +ve, deranged LFTs, Jaundice, hepatomegaly
- DIH has short history; Autoimmune hepatitis has long history
- DIH has causative drug; Autoimmune doesn’t have
- DIH vs PBC
- DIH has very high ALT, AST ::::: PBC has very high ALP + relatively normal ALT, AST
- DIH has anti-LKM Ab +ve ::::: PBC has AMA Ab +ve
- DIH vs PSC
- DIH has very high ALT, AST ::::: PSC has very high ALP + relatively normal ALT, AST
- DIH has anti-LKM Ab +ve ::::: PSC has ANCA +ve
- DIH vs Gallstones
- DIH has very high ALT, AST ::::: Gallstones has very high ALP + relatively normal ALT, AST
- DIH has anti-LKM Ab +ve ::::: Gallstone has no such Ab
- Drug-induced hepatitis, hepatitis B, C vs Drug-induced cholestasis +/- hepatitis
- Hepatittis has normal ALP ::::: Cholestasis has very high ALP
- Then, look into drugs of each category of hepatitis, cholestasis and cirrhosis
11
Q
NAFLD vs Differentials
A
*** If obesity, DM, GDM + high ALT >>> consider NAFLD (since it has very high prevalence ~25% in general population
*** ALT >> AST is a criteria for NALFD, however, if only ALT is given >>> consider very high ALT
- NAFLD vs Autoimmune hepatitis
- NAFLD has no positive auto-ab; Autoimmune hepatitis has positive auto-antibody
- NAFLD vs PBC
- NAFLD is asymptomatic; PBC has pruritus, lethargy
- NAFLD has no auto-Ab; PBC has AMA positive
- NAFLD vs Gallstone
- NAFLD is asymptomatic; Gallstone has abdominal pain
- NAFLD vs Cirrhosis
- NAFLD has normal bilirubin, PT, Platelet count; Cirrhosis has high bilirubin, high PT, and low Platelet count
12
Q
Crohn’s disease:
Epidemiology
A
- 6-10% of individuals with IBD have one or more affected relatives
- High co-efficient of heritability for Crohn’s disease.
- high heritability co-efficient suggests how phenotype in an individuals is due to genetic defects among the individuals of a community
- High heritability suggests > variation is due to genetics
- Low heritabiltiy suggests > variation is due to environmental factors
- CD is more in female slightly (M:F = 1:1.2)
- CD occurs at more early median age in females than males
- CD is more in Jews >>> than non-jews; and Ashkenazi jews >>> Sephradic jews
- NO proven link between CD and TB
13
Q
Chronic diarrhoea + scleroderma/systemic /CREST syndrome > Dx > Tx
(= Intermittent bloating, diarrhoea + above)
A
Small Bowel Bacterial Overgrowth (SBBOS)
TOC: Metronidazole
If not available, Rifaximine
14
Q
Chronic diarrhoea + Diverticulosis > Dx > Tx
A
Small Bowel Bacterial Overgrowth (SBBOS)
TOC: Metronidazole
If not available, Rifaximine
15
Q
Chronic diarrhoea + Neonates with congenital GI abnormalities > Dx > Tx
A
Small Bowel Bacterial Overgrowth (SBBOS)
TOC: Metronidazole
If not available, Rifaximine
(SBBOS can later cause bile acid diarrhoea type -3)
16
Q
Chronic diarrhoea + IBD (UC or CD) + steatorrhoea, flatulence, Low vitamin B12 (+/- its features) > Dx > Tx
A
Small Bowel Bacterial Overgrowth (SBBOS)
TOC: Metronidazole
If not available, Rifaximine
SBBOS can later cause bile acid darrhoea
17
Q
Chronic diarrhoea + any of:
(Metformin intake/
DM patients taking multiple meds/
Ileal resection/
Cholecystectomy/)
or SeHCAT test +ve
> Dx > Ix > Tx
A
Dx: Bila acid diarrhoea
Ix: SeHCAT test
Tx: Cholestyramine
18
Q
Chronic diarrhoea + crohn’s disease > D/D > Tx
A
- If steatorrhoea, flatulence, low vitamin B12 > Dx: SBBOS > TOC: Rifaximin, Metronidazole (SBBOS can cause type-3 bile acid diarrhoea)
- If absence of such > Dx: Type-1 bile acid diarrhoea (bile acid malabsorption) > TOC: Cholestyramine
19
Q
Barrett’s oesophagus VS differentials
A
- Pathognomic signs:
- Gastric looking mucosa spreading to lower oesophageal sphicter
- Columnar metaplasia
- New velvet-like mucosa of lower oesophagus
- Barrett’s VS Achalasia
- Barrett’s have above findings ::::: Achalasia: Absence of above findings + hiypertensive (high tone) of LES
- Achalasia is a oesophageal motility disorder
- Barrett’s VS Erosive oesophagitis
- Both may have heart burn, dyspepsia, regurgitation, mucosal change
- In the lower oesophagus, Barett’s > gastric mucosa, velvety-like mucosa ::::: Erosive oesophagitis > erosion of oesophageal own mucosa itself
- In the lower oesophagus, Barett’s > Columnar epithelium ::::: Erosive oesophagitis > Squamous epithelium
20
Q
Chronic pancreatitis VS differentials
A
- Key features:
- Alcohol is the most common cause in adults
- Weight loss is important for diagnosis
- Serum amylase can be normal
- Other imporant features: Pain worse fater a meal, chronic diarrhoea
- C.P vs Acute pancreatitis:
- Both > Alcohol, epigastric pain
- C.P > Chronic pain ::::: A.P > Acute severe pain
- C.P > Chronic diarrhoea ::: A.P > Acute/absent diarrhoea
- C.P > weight loss ::::: A.P > absent weight loss
- C.P > pain worse after a meal ::::: A.P > rare
- C.P. > often normal amylase ::::: A.P > always raised amylase
- C.P vs PUD
- Both > Chronic abdominal pain, weight loss
- C.P. > Diarrhoea ::::: PUD > Absent
- C.P vs Coeliac disease
- Both > Diarrhoea, weight loss
- C.P > Abdominal pain ::::: Coeliac disease > NO abdominal pain
- C.P vs Cirrhosis of liver
- Both > Alcohol history
- C.P > Diarrhoea, epigastric pain, weight loss ::::: Cirrhosis > Absent those + Ascites
21
Q
Lactose intolerence VS differentials
A
- A change of diet (from Easi-Asian or African diet to European diet/Western diet) or
- Taking more European/Western diet (which is dairy-rich)
- Intake of dairy-rich diet
- Any ‘change of diet’ due to recent travel to ‘anywhere’
- Recent Giardia infection (/given its Tx Tinidazole)
- After any of above 6 > if intermittent diarrhoea, bloating >>> Dx: Lactose intolerence
- Lactose intolerance VS IBS
- Both > Intermittent diarrhoea, bloating +/- abd. pain
- L.I. > Above history/recent GI infection :::: IBS: Absent of above such history
- Lactose intolerence VS Coeliac disease
- Both > possible diarrhoea, cramping, pain, bloating distension etc,
- L.I. > Above history/recent GI infection ::::: Coeliac disease > Absent of such history
- L.I. > more in people of Africa or East-Asia origin ::::: Coeliac > more in western, europe, ireland origin people
- Lactose intolerance VS Chronic pancreatitis
- L.I. > Intermittent diarrhoea, bloating ::::: C.P. > Chronic diarrhoea
22
Q
Cause of gynaecomastia in cirrhosis
A
- 1st cause: Altered oestrogen metabolism >>> high level of oestrogen
- 2nd cause: If we started on ‘spironolactone (aldosterone antagonist’ >>> Side-effect
23
Q
Facts on Gamma-glutamyl tranferase (GGT)
A
- GGT in raised in fatty liver disease
- In hepatic metastasis >>> high GGT + high ALP (not alone GGT)
- A rise does NOT always indicate liver pathology; Phenytoin and alcohol mildly increase GGT
- It can be high in pancreatic carcinoma suggesting liver pathology (consider if pain radiates to back, high viscosity etc. pacreatic features)
- Raised transaminases (ALT, AST) indicate infectious liver disease; Raised GGT indicates cholestasis
- GGT is present in many tissues, including liver
- In pregnancy > GGT is normal; ALP is elevated (due to placental source)
24
Q
Venesection is a useful treatment for - ?
A
Cardiomyopathy (/cardiac failure) a/w Haemochromatosis
- upto 2 times per week >>> improve symptoms and reduce the need of diuretic therapy
25
TOC for Gastric MALT (Mucosa associated Lymphoid Tissue)
* H. pylori eradication therapy
* **_As 95% cases of MALT lymphoma are A/W H. pylori_**
26
Vitamin C is essential for which process of collagen synthesis ?
Hydroxylation of procollagen priline and lysine
27
Organ that comes in direct contact with lef kidney (not seperated by visceral peritoneum) \>\> so, has more risk in nepherectomy
* **_Pancreas_**
* _Left supra-renal gland_
* Colon
\*\*\* Add left-colonic flexure in the section of left kidney (with peritoneum in between)
\*\*\* Distal part of small intestine includes jejunum
\*\*\* Kidneys are retroperitoneal organ between T12 to L3 vertebrae
\*\*\* Right is placed superiorly than left kidney
28
Limited haematemesis + stable patient + O/E: normal + Hb normal + H/OO aspirin intake \> Dx
Gastric erosion
29
Mechanism of action of lactulose
30
Altered bowel habit + blood in the stool + polyp in the descending colon at Duke A stage \>\>\> further approach/ time interval of colonoscopy
31
Site of 'amino acid' absorption
Jejunum
32
BSG guidlines on 'follow-up' period for 'adenomatous polyp or dysplastic polyp' in the colon
33
Patient has history of cystic fibrosis (/pancreatic insufficiency) + steatorrohea + on pancreatic supplements \>\>\> goes on a trip to India \>\>\> worsening of stetorrhoea + Low BMI \>\>\> 1st line IOC
72-hour faecal fat analysis
## Footnote
\*\*\* Then, we can do small bowel imaging, biopsy, endoscopy
\*\*\* Faecal elastase is NOT helpful (a test for chronic pancreatitis), as patient is already previously diagnosed with pancreatic insufficiency
34
TOC to achieve sustained remission in UC or CD
**Azathioprine**
## Footnote
Alternative: Mercaptopurine
35
Long history of indigestion + dysphagia to both solid and liquid + episodes of regusgitation that helps to releive feelings of fullness and retrosternal pain \>\>\> Dx
(NO weight loss, O/E normal)
Achalasia cardia
36
UC on treatment (maximal mesalazine, steroid enema, prednisolone) \> acute attack \>
## Footnote
**Criteria for progression to colectomy**
* Stool frequency \>8/day
* If stool is 3-8/day \>\>\> CRP \>45 is a/w progression to colectomy
\*\*\* not associated Hb, WBC count
\*\*\* **Colonic diameter \>5.5cm \> urgent surgical referral** *(not associated with oucomes on day 3 particularly)*
37
The most common site of ischaemic colitis
Splenic flexure
## Footnote
2nd common: Descending colon/sigmoid colon
38
Hepatitis C + transient raised rash on legs + some mild joint pain - \>\>\> The condition most commonly a/w HCV
Mixed cryoglobulinaemia
39
Contraindications of percutaneous liver biopsy
1. Deranged clotting; INR \> 1.5
2. Low platelets \<50 x109/L
3. Anaemia *(not included in pastest)*
4. Haemagioma suspected
5. Hydarid cyst OR suspected echinococcus infection
6. Bile duct obstruction/dilatation
7. Uncocoperative patient
8. Severe/Tense ascites *(not the mild ascites)*
9. Difficulty body habitus
40
Patient with aspirin/clopidogrel history due to cardiac disease \>\>\> collapse \>\>\> findings that is most specific for upper GI bleeding
High urea \>6.5
N: 2.5 to 6.5 mmol/L
\*\*\* Why: As bleeding in upper GIT \> blood goes into digestion \> as it is a source of protein \> produces 'urea' as by-product
\*\*\* NO other signs: low Hb, epigastric tenderness are as specific as it for upper GI bleeding
41
Investigation for 'flare of acute severe ulcerative colitis' ?
* Confirmatory test: Flexible sigmoidoscopy
* Biopsy will be available within 72hours (ideally within 24hours)
* Do histopatholgical diagnosis within 5days \> to confirm the Dx and to exclude CMV
* If CMV +ve \>\>\> means poor treatment response and high relapse rate
\*\*\*Colonscopy and barium enema is contraindicated in this case due to risk of perforation
42
Tiredness, lethargy + previously diagnosed with IBS (without proper inv.) + mouth ulcers + IDA (= Low Hb, Low Ferritin) + Low Vitamin B12 \>\>\> Dx \>\>\> IOC
Dx: Coeliac disease
IOC: Anti-TTG IgA antibodies
\*\*\* Combined IDA + Low Vitamin B12 \> Dx: Coeliac;
Rules out pernicious anaemia (only low B12), and GI bleeding (only IDA)
\*\*\* Even if only IDA, BUT **_previously (mis)diagnosed with IBS by GP_** indicates coeliac disease
43
Indications of small bowel follow through
* Dysphagia
* Pharyngeal pouch
* Pyloric stenosis
* Bowel obstruction
* Volvulus
* Diverticula
\*\*\* Here, it may be needed, NOT usually needed
44
Increasing fatigue + previously Dx as IBS by GP + Low Hb + Low Ferritin (IDA) + normal B12, Folate \>\>\> Dx \>\>\> IOC
Dx: Coeliac disease
IOC: Anti-TTG IgA antibodies
\*\*\* Combined IDA + Low Vitamin B12 \> Dx: Coeliac;
Rules out pernicious anaemia (only low B12), and GI bleeding (only IDA)
\*\*\* Even if only IDA, BUT **_previously (mis)diagnosed with IBS by GP_** indicates coeliac disease
45
The component of lipid profile that is responsible for 'lipaemic sample'
Chylomicrons
## Footnote
\*\*\* Due to chylomicrons \> lipid profiles can be uniterpretable
46
Lipid profile: HDL and IDL
47
Lipid profile: LDL and VLDL
48
_Down syndrome + constipation_ + vomiting
O/E: Signs of bowel obstruction +/- X-ray of small bowel obstruction \>\>\>\>\> D/D \>\>\>\>\> Dx
* If children \>\>\>\>\> Dx: Intessusception
* If age is around or above 18 \>\>\>\>\> Dx: Meckel's diverticulum
49
Large variceal haemorrhage \>\>\>
Long term prophylaxis against further bleeding
**Propranolol**
## Footnote
\*\*\* Non-selective beta blockers \>\>\> reduce portal blood pressure \>\>\> prevent re-bleeding
50
Abdominal pain + _diarrhoea 6-8 times + blood, mucous_ + palpation: _tender abdomen, particularly on *left side*_ +
Rectal biopsy: _intense infiltration of mucosa and submucosa with neutrophils_, _crypt abscess_, _lamina propria with lymphoid aggregates, plasma cells, mast cells, eosinophils_ \>\>\> Dx
Ulcerative colitis
51
Bowel opens 6times/day + bloody diarrhoea + High CRP + high ESR +
Colonoscopy: only proctitis
Biopsy: Ulcerative colitis \>\>\> TOC
Rectal mesalazine
(as it is Distal UC)
\*\*\* In case of proximal UC \>\>\> 1st line: Oral mesalazine (aminoglycosides); 2nd line (less favoured than mesalazine): Oral steroid (short course of tappering dose)
52
Abdominal pain, vomiting, fever +
_tender epigastrium and RUQ +_
high ALT, high bilirubin +
_very high ALP + high amylase_ --- \>\>\> Dx
Obstruction at the distal common bile duct
(After pancreatic duct meets common bile duct)
53
Patient with Lynch syndrome (= HNPCC) + family history: father died of colon cancer:
Medication that will _reduce the risk of progression to colon cancer_ ?
Aspirin
54
Diarrhoea + gradual weight loss + abnormal blood film: _Howel-Jolly bodies_ + conjunctival pallor + mild ankle oedema + _Low Hb, Low MCV_ + mild high creatinine, ALT. mild low albumin \>\>\>
Dx
Coeliac disease
55
Patient with C/F of chronic pancreatitis \> Inv to assess pancreatic insufficiency
Feacal elastase
## Footnote
\*\*\* Pancreatic elastase is excreted in the feaces unchanged \> useful tool to represent pancreatic exocrine function
\*\*\* \> 200 mcg elastase/ gm of stool is normal; less than that means insufficiency
56
Use of faecal calprotectin &
Serum amylase
* Faecal calprotectin \> to differentiate IBD and IBS (if any doubt in history/features)
* Serum amylase is elevated in -
* Acute pancreatitis
* Acute mesenteric ischaemia
57
COPD + end-stage pancreatic cancer + severe SOB + taking MR morphine sulphate, naproxen, paracetamol, regular high-dose seretide + gross tense ascites + raised ALT, ALP, bilirubin + all other normal \>\>\>
Mx to give symptomatic relief
Ascitic drain
if still no releif \>\>\> oral diazepam
58
CLD + h/o several hematemesis + poor compliance with propranolol + _high urea_ \>\>\>
TOC
IV Terlipressin
## Footnote
\*\*\* High urea is specific for current active variceal bleeding \> so initial Tx is Terlipressin
59
Patient was on Tx in hospital for post-operative case, pneumonia, wound infection etc. \>\>\> develops worsening diarrhoea + brown water flecked with blood + high WBC, high creatinine \>\>\> IOC
CDT (clostridium difficile toxin)
60
Tiredness/lethargy + intermittent diarrhoea, bloating + stool is difficult to flush away + (low Hb + low MCV) + Low Ca \>\>\> Dx \>\>\> IOC
Dx: Coeliac disease
IOC: Anti-TTG antibodies
61
Dieulafoy's lesion
62
Hematemesis + uncontrollable retching \> then blood and vomit + normal Hb \>\>\> Dx
Mallory Weiss Tear
63
Non-bloody diarrhoea for months + weight loss + SOB + wheeze + facial flushing + CT shows small tumour with liver mets \>\>\> Dx \>\>\> Tx before surgery
* Carcinoid syndrome
* Tx before surgery: Octreotide
64
Modified Glasgow crietria for prdicting severity/prognosis of acute pancreatitis
* pO2 \<8kPa
* Age \>55years
* WBC \>15x109/L
* Corrected calcium \<2mmol/L
* ALT \>100 IU
* LDH \>600 IU
* Glucose \>10mmol/L
* Urea \<16 mmol/L
* Albumin \>32 g/L
To remember: **_pAW CAL GUA_**
65
Coeliac disease + bleeding abnormality (/increased susceptibility to bleeding) \> Cause
Vitamin K deficiency
66
Arthralgia + erectile dysfunction + deep tan + CLD + high levels of serum iron, ferritin, TIBC, glucose \>\>\> Dx
Haemochromatosis
67
Tiredness + abdominal pain + intermittent diarrhoea + weight loss + itchy vesicular rash on elbows, knees + microcytic hypochromic anaemia + low ferritin, folate, albumin \>\>\> Dx \>\>\> Inv
Dx: Coeliac disease
Inv: Duodenal biopsy (Only select when TTG-IgA is not in the option, or already done)
68
Recurrent bluish red rash on neck + facial telangiectasia + watery diarrhoea + wheeze + mild pedal oedema + high JVP + pansystolic murmur +
69
Polycythyemia rubra vera + acute \> abdominal pain, vomiting, nausea, abdominal distension, tender hepatomegaly + ascites \> high protein content \>\>\>\>\> DX
Budd-Chiari syndrome
70
Ulcerative colitis +
jaundice, pruritus, intermittent abdominal pain +
hepatosplenomegaly, mild ascites +
obstructive jaundice + AMA negative
\>\>\>\>\> DX
PSC (primary sclerosing cholangitis)
71
