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Gastroenterology Flashcards

1
Q

What are aphthous ulcers?

A

Shallow, painful ulcers with inflammatory haloes that heal without scarring
Often recur

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2
Q

List aetiology/risk factors for aphthous ulcers

A 
Inflammatory bowel disease
Iron deficiency
Infection
Trauma
Pemphigus/pemphigoid
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3
Q

Outline treatment for aphthous ulcers

A

Avoid oral trauma, acidic food/drink
Steroid lozenges
Tetracycline/antimicrobial mouthwash
Oral prednisolone if severe

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4
Q

What is leucoplakia?

A

Mucosal white patch that does not rub off and is not attributable to another disease process
Usually pre-malignant

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5
Q

List aetiology/risk factors of leucoplakia

A

EB virus causes oral hairy leucoplakia esp in HIV

Transient candidiasis/SLE/trauma

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6
Q

All leucoplakia should be referred for biopsy. True/False?

A

True, when in doubt

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7
Q

What is oral thrush?

A

White patches on buccal mucosa caused by candidiasis

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8
Q

List aetiology/risk factors for oral thrush

A 
Elderly
Immunosuppression
Diabetes
Antibiotics
Long-term steroid + inhaler use
Malignancy
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9
Q

Outline treatment for oral thrush

A

Nystatin suspension
Amphoterecin lozenges
Oral fluconazole

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10
Q

Describe the typical appearance of oral squamous cell carcinoma

A

Raised ulcer with firm edges

Found at floor of mouth or on lateral tongue

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11
Q

List aetiology/risk factors for oral squamous cell carcinoma

A

Smoking
Alcohol
Family history
Soft areas are high-risk sites

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12
Q

Outline treatment for oral squamous cell carcinoma

A

Radiotherapy

Surgery

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13
Q

What is GORD?

A

Reflux of stomach acid causes inflammation of oeseophagus

Can lead to basal zone hyperplasia and metaplasia

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14
Q

List aetiology/risk factors for GORD

A 
Incompetent lower oeseophageal sphincter
Hiatus hernia
Obesity
Increased acid secretion
Pregnancy
Achalasia surgery
Overeating/heavy fatty meals
Drugs (tricyclics, anticholinergics, nitrates)
H. pylori
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15
Q

List clinical features of GORD

A 
"Heartburn"
Worse lying down and after meals
Relieved by antacid
Belching, regurgitation of food
Waterbrash
Odynophagia
Nocturnal asthma/cough
Laryngitis
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16
Q

What investigations would you do for GORD?

A

Trial PPI for 2 weeks + antacid
Endoscopy if over 55 yo, symptoms longer than 4 weeks, dysphagia or weight loss
24h manometry +/- pH monitoring if normal endoscopy
Barium swallow if indicated e.g. hernia

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17
Q

Outline treatment of GORD

A

Lifestyle improvement (smoking, weight, raise bed, small regular meals, avoid hot/spicy food/drinks)
Antacid for symptom relief
PPI (omeprazole)
H2 antagonist may be tried (ranitidine)
Surgery (endoscopic fundoplication to repair LOS) if unresponsive

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18
Q

What is Barett’s oesophagus?

A

Metaplastic change from stratified squamous to columnar epithelium due to persistent acid abuse
Mucosa becomes unstable and susceptible to dysplasia

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19
Q

How would you investigate Barett’s oesophagus?

A

Endoscopy and biopsy

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20
Q

Outline treatment of Barett’s oesophagus

A

Avoid acidic food/drink
PPI
Argon
Mucosal resection/RF ablation

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21
Q

What is achalasia?

A

Failure of relaxation of lower oesophageal sphincter due to degeneration of myenteric plexus

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22
Q

List clinical features of achalasia

A

Intermittent dysphagia
Regurgitation
Substernal pain/cramping
Weight loss

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23
Q

What investigations would you do for achalasia?

A

CXR shows dilated oesophagus

Barium swallow shows bird-beak appearance

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24
Q

Outline treatment of achalasia

A

Endoscopic balloon dilation
Heller’s cardiomyotomy + PPI
Botox injection
Ca channel blocker

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25
What are the most common types of oesophageal cancer?
Squamous or adenocarcinoma | 50% middle oesophagus, 30% lower oesophagus, 20% upper oesophagus
26
List aetiology/risk factors for oesophageal cancer
``` Low vitamin A and/or C Smoking Alcohol excess Achalasia Plummer-Vinson syndrome Obesity Barett's oesophagus Reflux oesophagitis ```
27
List clinical features of oesophageal cancer
``` Dysphagia Weight loss Retrosternal chest pain Hoarse voice Cough ```
28
What investigations would you do for oesophageal cancer?
Barium swallow CXR Endoscopy + biopsy CT staging
29
Outline treatment of oesophageal cancer
Palliative care Surgery if no invasion/wide mets/poor fitness If localised T1/T2 disease, may try radical oesophagectomy
30
What is gastritis?
Inflammation and mucosal injury to stomach lining
31
List aetiology/risk factors for gastritis
Acute (chemicals, trauma, burns, infection) H. pylori Chronic (NSAID, alcohol, GORD, smoking) Autoimmune (pernicious anaemia)
32
List clinical features of gastritis
Heartburn Epigastric pain, esp on eating/hunger Bloating, fullness ALARM Symptoms (anaemia, loss of weight, anorexia, recent onset, malaena, swallowing difficulty)
33
What investigations would you do for gastritis?
Less than 55yo: test of H. pylori | Over 55yo or ALARM Symptoms: endoscopy
34
Outline treatment for gastritis
Stop dyspeptic drugs, lifestyle changes Antacids PPI H2 antagonists
35
Duodenal ulcers are more common than gastric ulcers. True/False?
True
36
List aetiology/risk factors for peptic ulcer disease
``` H. pylori Drugs (NSAID, steroid) Smoking Reflux disease Increased gastric acid secretion Delayed gastric emptying Blood group O Stress Neurosurgery (increased ICP, Cushing ulcers) ```
37
List clinical features of peptic ulcer disease
Epigastric pain, esp meal-related, relieved by drinking/eating cold stuff May have weight loss Epigastric tenderness Feeling of fullness
38
What investigations would you do for peptic ulcer disease?
H. pylori stool antigen/C13 breath test/IgG serology Stop PPI 2 weeks before endoscopy Ulcer biopsy for histology and cytology
39
Outline treatment for peptic ulcer disease
H. pylori eradication (amoxicillin/metronidazole, omeprazole, clarithromycin) Bismuth chealate alternative to antibiotics Antacids PPI H2 antagonists
40
What is gastroparesis?
Delayed gastric emptying due to autonomic neuropathy
41
List clinical features of gastroparesis
Fullness, bloating Nausea, vomiting Weight loss Abdo pain
42
What investigation would you do for gastroparesis?
Gastric scintigraphy with 99-technitium meal
43
Outline treatment for gastroparesis
``` Anti-emetic Tetracycline Erythromycin has anti-emetic properties Liquid diet Nutritional support, NG tube ```
44
Which type of gastric cancer is most common?
Adenocarcinoma occuring at gastro-oesophageal junction
45
List aetiology/risk factors for gastric adenocarcinoma
``` H. pylori causing gastritis causing metaplasia causing dysplasia causing carcinoma ! Japanese people Pernicious anaemia Blood group A Atrophic gastritis Smoking Poor diet ```
46
List clinical features of gastric cancer
``` Epigastric pain Dyspepsia Weight loss Haematemesis Dysphagia Epigastric mass Anaemia Hepatomegaly, jaundice Enlarged left supraclavicular node (Virchow's node) ```
47
What investigations would you do for gastric cancer?
Gastroscopy and multiple biopsies | USS/CT staging
48
Outline treatment of gastric cancer
If distal 2/3, partial gastrectomy If proximal 1/3, total gastrectomy Combination chemotherapy
49
What type of blood would make you think of an upper GI bleed?
Haematemesis with dark coffee ground substance | Malaena with black tarry stools
50
List aetiology/risk factors for upper GI bleeding
``` Peptic ulcers (45%) Gastritis (15%) Oesophageal varices Mallory-Weiss tear Reflux oesophagitis Malignancy Drugs (NSAID, steroid, thrombolytic, anticoagulants) ```
51
List clinical features of upper GI bleeding
``` Peripheral shutdown (cool, clammy, prolonged cap refill) Reduced Glasgow Coma Score Haematemesis Malaenia Tachycardia, hypotension Weight loss Dysphagia Signs of chronic liver disease ```
52
What investigations would you do for upper GI bleeding?
Organise CXR, ECG, ABG's Crossmatch blood Urgent endoscopy Severity 100 rule (systolic less than 100, pulse over 100, Hb less than 100) Rockall scoring to predict rebleed and mortality
53
Outline basic treatment of upper GI bleeding
ABCDE approach Large bore IV cannulae, take blood for crossmatch, FBC, U+E, LFT, clotting Transfuse O- blood Catheterise and monitor urine output
54
Outline treatment for peptic ulcer upper GI bleed
IV PPI after endoscopy Oral fluids if no haemodynamic compromise Adrenaline injection Heater probe coagulation/surgical clipping
55
Outline treatment for oesophageal varices
Terlipressin Early OGD + EVL (Sengstaken-Blakemore tube) Propranolol and banding if bleed stops TIPSS if rebleeds
56
What is oesophageal varices?
Portal hypertension causes dilated collateral veins usually in lower oesophagus
57
List aetiology/risk factors for oesophageal varices
Pre-hepatic (portal vein thrombosis, splenic vein thrombosis) Intra-hepatic (cirrhosis, schistosomiasis, sarcoidosis) Post-hepatic (Budd-Chiari, right heart failure, pericarditis) Alcohol abuse
58
What is coeliac disease?
T-cell mediated autoimmunity to gluten, causing malabsorption and villus atrophy
59
List aetiology/risk factors for coeliac disease
HLA DQ2/DQ8 Autoimmunity Dermatitis herpetiformis
60
List clinical features of coeliac disease
``` Steatorrhoea Diarrhoea Abdo pain Bloating Nausea, vomiting Aphthous ulcers Angular stomatitis Weight loss Fatigue Weakness Mood disorder ```
61
What investigations would you do for coeliac disease?
Antibodies: alpha-gliadin, ttG, endomysial Duodenal biopsy shows intraepithelial lymphocytes, subtotal villus atrophy, crypt hyperplasia DEXA scan to assess osteoporosis
62
Outline treatment of coeliac disease
Gluten-free diet | Oral dapsone
63
List aetiology/risk factors for intestinal failure
``` Coeliac disease Chronic pancreatitis Inflammatory bowel disease Extensive surgery (short-gut syndrome) Reduced bile secretion Whipple's disease Drugs (metformin) Bacterial overgrowth ```
64
List clinical features of intestinal failure
``` Diarrhoea Weight loss Lethargy Steatorrhoea Anaemia Bleeding Oedema Neuropathy ```
65
What investigations would you do for intestinal failure?
``` FBC, U+E, folate/B12 Coeliac screen Albumin Stool microscopy Barium follow-through Breath hydrogen (bacteria) Endoscopy + biopsy ```
66
Outline treatment of intestinal failure
Acute: parenteral nutrition via central/peripheral vein Oral refeeding with supplements Enteral feeding (NG, NJ, PEG) Total parenteral nutrition
67
List aetiology/risk factors of small bowel obstruction
Luminal (gallstone ileus, food, bezoar, tumour) Occlusion (atherosclerosis, strangulation, hernia, adhesion) IBD Intussuception Constipation Paralytic ileus
68
List clinical features of small bowel obstruction
``` Abdo colicky pain Distention Tenderness Tinkly bowel sounds Faeculent vomiting Constipation ```
69
What investigations would you do for small bowel obstruction?
Abdo XR shows valvulae conniventes - central gas shadows that completely cross lumen FBC, U+E, ABG's Enema XR PR exam
70
Outline treatment of small bowel obstruction
Analgesia, fluids, nutritional replacement Drip + suck NG tube Catheterisation Surgery if perforation/strangulation/ischaemia
71
What is gastric volvulus?
Twisting of gastro-oesophageal junction
72
List aetiology/risk factors for gastric volvulus
Paraoesophageal hernia Congenital anomaly Bowel malformation Pyloric stenosis
73
List clinical features of gastric volvulus
``` Vomiting, wretching Pain Failure to pass NG tube Saliva regurgitation Dysphagia Noisy gastric peristalsis relieved by lying down ```
74
What investigation would you do for gastric volvulus?
Erect AXR shows gastric dilation and fluid level
75
Outline treatment of gastric volvulus
Resuscitation | Laparoscopic surgery
76
What is Meckel's diverticulum?
Remnant of ompalomesenteric duct, 60cm from ileeocaecal valve, containing gastric and pancreatic tissue
77
List clinical features of Meckel's diverticulum
Asymptomatc Painless malaena Abdo pain
78
Outline treatment of Meckel's diverticulum
Laparoscopic surgical resection if bothersome
79
What is Crohn's disease?
Chronic inflammatory disease characterised by transmural granulomatous inflammation affecting any part of the GI tract
80
List aetiology/risk factors for Crohn's disease
Genetics (NOD2, CARDI5) Smoking Infective gut commensals Typically young children to 40 year olds
81
List clinical features of Crohn's disease
``` Diarrhoea Abdo pain Weight loss Fever Malaise Skin tags Painful ulcers Abscesses Abdo mass Perianal abscess, fistulae Extra-intestinal (clubbing, erythema nodosum, pyoderma gangrenosum, conjunctivitis, episcleritis, arthritis) ```
82
What investigations would you do for Crohn's disease
Bloods Stool microscopy and culture to exclude infection Sigmoidoscopy, rectal biopsy/colonoscopy/capsule endoscopy MRI for pelvic disease/fistulae
83
Outline treatment for Crohn's disease
Oral prednisolone short-term Admit if severe attack for IV steroid Immunosuppression (azathioprine, methotrexate) Anti-TNF (infliximab) Surger (resection, stricturoplasty, fistula repair) Treat perianal disease
84
What is ulcerative colitis?
Relapsing and remitting inflammatory bowel disease involving rectum and extending proximally (no skip lesions)
85
List aetiology/risk factors for ulcerative colitis
E. coli adhesin-expressing strains Genetics Typically 20-40 year ols
86
List clinical features of ulcerative colitis
``` Gradual diarrhoea, bloody/mucousy Crampy abo pain Increased bowel frequency Urgency Tenesmus Incontinence Night-rising Lower abdo pain Extra-intestinal (clubbing, erythema nodosum, apthous ulcers, episcleritis) ```
87
Define severe ulcerative colitis
``` More than 6 bloody stools a day + 1 of Fever Tachycardia Anaemia Raised ESR ```
88
What investigations would you do for ulcerative colitis?
Bloods Stool microscopy and culture, C. diff toxin AXR mucosal thickening, toxic megacolon query Sigmoidoscopy/colonoscopy Biopsy shows crypt abscesses, inflammatory infiltrate
89
Outline treatment of ulcerative colitis
Mild: prednisolone + mesalazine, foam enema Mod: prednisolone + 5-ASA + steroid enema Sev: IV hydrocortisone, rectal steroid, stepdown to Mod treatment Immunosuppresion Anti-TNF Surgery (proctocolectomy with end ileostomy, ileorectal anastomosis/pouch)
90
What is diverticular disease?
Outpouching of the gut wall, usually due to high luminal pressure, usually at sigmoid colon Diverticulitis: inflamed diverticula
91
What is the main cause of diverticular disease?
Low-fibre diet
92
List clinical features of diverticular disease
``` Abdo pain Altered bowel habit Nausea PR bleed Flatulence ```
93
What investigations would you do for diverticular disease?
PR exam Sigmoidoscopy Barium enema CT scan
94
Outline treatment of diverticular disease
``` Increase fibre intake Percutaneous drainage Hartmann procedure (remove sigmoid colon, attach colostomy) ```
95
Outline treatment for diverticulitis
``` Co-amoxiclav + metronidazole Analgesia Nil by mouth, IV fluids Drain abscesses Hartmann procedure ```
96
What is irritable bowel syndrome?
Functional GI disorder with abdo symptoms with no identifiable cause
97
List aetiology/risk factors for irritable bowel syndrome`
``` Visceral hypersensitivity Poor diet Infection Codeine Psychiatric disease ```
98
List clinical features of irritable bowel syndrome
``` Bloating Abdo pain Increased frequency Mucus stool Tenesmus Worse after eating ```
99
What red flags would point away from a diagnosis of irritable bowel syndrome?
``` Age over 50 Recent onset Night waking Weight loss Anaemia Bloody diarrhoea ```
100
What is the Rome III criteria for irritable bowel syndrome?
Abdo pain for 3 days per month for 3 months + 2 of Improvement with defecation Change in frequency Chang in appearance of stool
101
Outline treatment of irritable bowel syndrome
``` Improve diet Fewer meals Symptom relief Antispasmodic (mebeverine, hyoscine) Antidiarrhoeal (loperamide) Antidepressant ```
102
What is pseuomembranous colitis?
Colitis caused by C. diff infection (gram + superbug)
103
List aetiology/risk factors for pseudomembranous colitis
Elderly Hospitalisation Broad-spec antibiotics
104
List clinical features of pseudomembranous colitis
Colicky pain Fever Diarrhoea +/- blood Multiorgan failure
105
What investigations would you do for pseudomembranous colitis?
C. diff stool toxin - culture, ELISA, PCR | Colonoscopy shows yellow adherent plaques on inflamed mucosa
106
Outline treatment of pseudomembranous colitis
Stop causative antibiotic Metronidazole oral if moderate Vancomycin oral if severe Urgent colectomy if toxic megacolon
107
What is the Rome criteria for constipation?
Constipation + presence of 2 symptoms during bowel movements (straining, lumpy stools, tenesmus, sensation of anorectall obstruction, manual maneuvres) Less than 3 movements a week
108
List aetiology/risk factors for constipation
``` Poor diet Low exercise Inappropriate environment Anal disease Intestinal obstruction Metabolic (hypercalcaemia, hypothyroid, hypokalaemia) Drugs (opiates, anticholinergics, iron) Neuromuscular disorder Chronic laxative use Psych disturbance ```
109
What investigations would you do for constipation?
``` PR exam Stool exam Refer if weight loss/blood/anaemia Sigmoidoscopy Barium enema ```
110
Outline treatment for constipation
``` Lifestyle advice Stool softeners Senna Bulking agents Lactulose Stimulant/osmotic laxatives ```
111
What is jaundice?
Yellow pigmentation of skin, sclerae and mucosa due to increased plasma bilirubin
112
List prehepatic causes of jaundice
Excess haemolysis Ineffective erythropoiesis Kernicterus (infants deposit Br in basal ganglia)
113
List intrahepatic causes of jaundice
``` Hepatitis Cirrhosis Pregnancy Haemochromatosis Alpha-1-antitrypsin deficiency Budd-Chiari syndrome Wilson's disease ```
114
List post-hepatic causes of jaundice
``` Gallstones Primary biliary cirrhosis Primary sclerosing cholangitis Pancreatic cancer Biliary stricture ```
115
List drugs that can cause jaundice
``` Antimalarials Paracetamol overdose TB drugs Sodium valproate Flucloxacillin ```
116
List clinical features of jaundice
``` Yellow eyes/skin Hepatosplenomegaly Ascites Chronic liver disease signs Pale stools, dark urine (obstructive jaundice) ```
117
What investigations would you do for jaundice?
``` LFT's FBC, U+E Viral markers Urinary bilirubin Clotting US scan to assess bile ducts MRCP/ERCP if gallstones ```
118
Acute liver failure only occurs in a previously healthy liver. True/False?
True
119
What is fulminant hepatic failure?
Severe liver impairment in less than 2 weeks
120
What is hyperacute liver failure?
Encephalopathy within 7 days of onset of jaundice
121
List aetiology/risk factors for liver failure
Infection (hepatitis, yellow fever, CMV, EBV) Drugs (paracetamol OD, isoniazinde, azathioprine, methotrexate, oestrogen) Budd-Chiari syndrome Wison's disease Alcohol excess Malignancy Fatty liver
122
List clinical features of liver failure
``` Jaundice Encephalopathy Pear drops breath Asterixis Lethargy Itch, pain Hypoglycaemia Signs of chronic liver disease ```
123
What investigations would you do for liver failure?
``` Deranged LFT's CMV, EBV serology Serum caeruloplasmin, ferritin US scan liver size, Doppler flow study Liver biopsy ```
124
Outline management of liver failure
Acute: IV fluids, ABCDE, nutrition, glucose Vitamin K + blood transfusion for bleeding Ceftriaxone for infection Fluid restrict + salt restriction if ascites Lactulose if encephalopathy Treat alcohol withdrawal and complications
125
Outline treatment of hepatorenal syndrome
``` IV albumin Terlipression Haemodialysis TIPSS drainage Liver transplant ```
126
What is cirrhosis?
Irreversible stage of liver damage, with loss of hepatic architecture due to fibrosis and necrosis
127
List aetiology/risk factors for cirrhosis
``` Chronic alcohol abuse Hepatitis B, C NAFLD Autoimmunity (PBC, PSC) Haemochromatosis Wilson's disease Alpha-1-antritrypsin deficiency Budd-Chiari syndrome Drugs (amiodarone, methyldopa, methotrexate) ```
128
List clinical features of cirrhosis
Chronic liver disease signs (spider naevi, jaundice, leuconychia, caput medusa, Dupuytren's, xantheloma, telangiectasia, palmar erythema, clubbing) Hepatomegaly Ascites Gynaecomastia Asterixis Complications (encephalopathy, sepsis, portal hypertension)
129
What investigations would you do for cirrhosis?
``` Deranged LFT's PT time prolonged Reduced albumin Autoantibodies (ANA, AMA, SMA) Alpha feto protein Liver US scan for size, Doppler flow Ascitic tap for microscopy Liver biopsy Child-Pugh scoring for cirrhosis and variceal bleed risk ```
130
Outline treatment of cirrhosis
Support (nutrition, alcohol abstinence) Ascites: fluid restrict, low-salt, spironolactone, paracentesis/TIPS Lactulose prevents encephalopathy Cholestyramine for itch Interferon-alpha slows development into HCC from hepatitis C Penicillamine for Wilson's disease Liver transplant
131
How does non-alcoholic fatty liver disease (NAFLD) arise?
Steatosis (fat deposition) causes oxidative stress, leading to fibrosis and cirrhosis
132
List aetiology/risk factors for NAFLD
``` Obesity Hypertension Total parenteral nutrition Type 2 diabetes Hyperlipidaemia ```
133
List clinical features of NAFLD
``` Asymptomatic Fatigue Malaise Hepatosplenomegaly Signs of chronic liver disease in later stages ```
134
What investigations would you do for NAFLD?
US scan shows fatty liver Liver biopsy Deranged LFT's (AST, ALT) Albumin assesses liver function
135
Outline treatment for NAFLD
Lifestyle advice Weight loss Liver transplant
136
What is primary biliary cirrhosis?
Interlobular bile ducts destroyed by chronic granulomatous inflammation, causing cholestasis, cirrhosis and portal hypertension
137
List aetiology/risk factors for primary biliary cirrhosis
Autoimmunity | Females
138
List clinical features of primary biliary cirrhosis
``` Asymptomatic Itch without rash Lethargy Jaundice Xanthelasma Osteoporosis Hepatosplenomegaly Signs of chronic liver disease Malabsorption causes osteomalacia, coagulopathy ```
139
What investigations would you do for primary biliary cirrhosis?
Cholestatic LFT's Decreased albumin Antimitochondrial antibody, IgM Liver biopsy
140
Outline treatment of primary biliary cirrhosis
Ursodeoxycholic acid, cholestyramine Azathioprine, prednisolone Treat complications Liver transplant
141
What is hereditary haemochromatosis?
Autosomal recessive mutation in HFE gene on c6 causes excess iron absorption and increased iron deposition in organs
142
List clinical features of hereditary haemochromatosis
``` Tiredness Arthralgia Impotence Slate-grey skin Signs of chronic liver disease Pituitary dysfunction (hypogonadism) "bronze diabetic" due to deposit in pancrease ```
143
What investigations would you do for hereditary haemochromatosis?
``` Serum ferritin, iron, TIBC HFE phenotype LFT's Glucose Chrondocalcinosis on XR Liver biopsy Perl's stain IgG ```
144
Outline treatment of hereditary haemochromatosis
Venesection 1 unit/week until iron deficient | Low iron diet
145
What is Wilson's disease?
Autosomal recessive disorder of gene encoding caeruloplasmin, causing excess copper in blood which is toxic to liver and CNS
146
List clinical features of Wilson's disease
``` Signs of liver disease early in life CNS/psych issues Dystonia Dysarthria Tremor Clumsiness Parkinsonism Kayser Fleischer rings in iris Blue nails Grey skin Hypermobility ```
147
What investigations would you do for Wilson's disease?
24h urinary copper Serum caeruloplasmin Liver biopsy MRI CNS
148
Outline treatment for Wilson's disease
Avoid copper foods (chocolate, nuts, mushrooms, shellfish) Lifelong penicillamine/trientine dihydrochloride Liver transplant
149
What is Budd-Chiari syndrome?
Hepatic vein obstruction due to thrombosis or malignancy leads to ischaemia and hepatocyte damage
150
List aetiology/risk factors for Budd-Chiari syndrome
Hypercoaguability (OCP, pregnancy, malignancy, polycythaemia) Liver/adrenal/renal tumour
151
List clinical features of Budd-Chiari syndrome
``` Liver failure Insidious cirrhosis Abdo pain Hepatomegaly Ascites Portal hypertension ```
152
What investigations would you do for Budd-Chiari syndrome?
US scan, hepatic vein Doppler Angioplasty TIPS Ascitic tap
153
Outline treatment of Budd-Chiari syndrome
Thrombolyse Lifelong anticoagulation Treat ascites Liver transplant
154
What is autoimmune hepatitis and its different types?
Inflammatory liver disease characterised by suppressor T cells and antibodies against hepatocytes Type 1: adults, kids, ASMA/ANA antivodies Type 2: girls, women, LKM1 antibody Type 3: liver soluble Ag
155
List clinical features of autoimmune hepatitis
``` Fever Malaise Urticarial rash Polyarthritis Pleurisy Reduced appetitie Amenorrhoea Young woman on pill ```
156
What investigations would you do for autoimmune hepatitis?
Deranged LFT's AMA, ASMA, ANA, anti-KLM, IgG Liver biopsy shows piecemeal necrosis, portal infiltrate
157
Outline treatment of autoimmune hepatitis
Immunosuppression (azathioprine, prednisolone) Ursodeoxycholic acid Liver transplant
158
Liver cancer is usually secondary (metastatic) from somewhere else. True/False?
True | Usually breast/bone/bronchus/GI tract
159
List aetiology/risk factors for liver cancer
``` Cirrhosis Hepatitis Alcohol excess Drugs Autoimmunity Genetics ```
160
List clinical features of liver cancer
``` Fever Malaise Anorexia, weight loss RUQ pain Hepatomegaly Jaundice Signs of chronic liver disease Abdo mass Liver bruit ```
161
What investigations would you do for liver cancer?
Bloods: FBC, clotting, LFT's Alpha-feto protein (HCC) US scan or CT-guided liver biopsy ERCP
162
Outline treatment of liver cancer
Resection Chemotherapy Mostly palliative Liver transplant
163
Which cancer accounts for 90% of primary liver cancer?
Hepatocellular carcinoma
164
List aetiology/risk factors for hepatocellular carcinoma
``` China/sub-saharan Africa Haemochromatosis Viral hepatitis Cirrhosis Parasitic infections Anabolic steroid use ```
165
What is the commonest benign tumour of the liver?
Hemangioma, usually in non-cirrhotic patients
166
How does hemangioma appear on US scan?
Well-demarcated echogenic spot
167
What is alpha-1-antitrypsin deficiency?
Autosomal recessive disorder on c14 causing deficiency of alpha-1-antitrypsin, resulting in inflammation, emphysema and chronic liver disease
168
List clinical features of alpha-1-antitrypsin deficiency
Breathlessness Cholestatic jaundice Signs of chronic liver disease
169
What investigations would you do for alpha-1-antitrypsin deficiency?
Serum alpha-1-antitrypsin Liver biopsy PAS +ve Prenatal testing
170
Outline treatment for alpha-1-antitrypsin deficiency
Human plasma alpha-1-antitrypsin if PEV less than 80% and patient not smoking Liver transplant if decompensated cirrhosis
171
Where are AST and ALT found and when are they released?
ALT: liver, kidney, muscle AST: liver, heart, RBC Released after hepatocellular injury
172
What are the "true" liver function tests/markers of hepatic function?
Albumin PT time Bilirubin
173
What are gallstones?
``` Abnormal composition of bile causes hardening and stone formation Pigment stones (haemolysis), cholesterol stones or mixed stones ```
174
List aetiology/risk factors for gallstones
"Fat forty-year-old females with foetus" Drugs Cirrhosis Diabetes
175
List clinical features of gallstones
``` Biliary colic (gallstone in CBD/cystic duct; colicky RUQ pain +/- back/shoulder radiation, tenderness, nausea) Acute cholecystitis (infected gall bladder; continuous RUQ pain, shoulder pain, peritonism, fever, nausea/vomit, Murphy sign) ```
176
What investigations would you do for gallstones?
Bloods: FBC (raised WCC), U+E, LFT's US scan thick-walled gallbladder, dilated CBD MRCP/ERCP
177
Outline treatment of gallstones
Analgesia for colic, nil-by-mouth IV antibiotics if cholecystitis - cefuroxime Cholecystectomy (laparoscopic if no perforation)
178
What is ascending cholangitis?
Infection of bile duct/biliary tree due to gallstone in common bile duct
179
List clinical features of ascending cholangitis
Cholestatic jaundice Pale stools, dark urine Itch Charcot's triad (fever, RUQ pain, jaundice)
180
Outline treatment of ascending cholangitis
IV antibiotics | ERCP + sphincterotomy before cholecystectomy
181
What is primary sclerosing cholangitis?
Non-malignant, non-bacterial inflammation and fibrosis of intra and extra -hepatic bile ducts
182
List aetiology/risk factors for primary sclerosing cholangitis
Men Ulcerative colitis HLA-A1 DR3 B8 HIV
183
List clinical features of primary sclerosing cholangitis
``` Jaundice Fatigue Fever Abdo pain Hepatomegaly ```
184
What investigations would you do for primary sclerosing cholangitis?
LFT's (ALP) cholestatic pattern ANA, SMA, pANCA antibodies ERCP
185
Outline treatment of primary sclerosing cholangitis
Cholestyramine for itch Ursodeoxycholic acid to improve cholestasis Immunosuppression (prednisolone, methotrexate) Endoscopic stent Liver transplant
186
What is the most common biliary tree malignancy?
Cholangiocarcinoma | May be intra or extra hepatic
187
List aetiology/risk factors for cholangiocarcinoma
``` Flukes in the East Primary sclerosing cholangitis CA-199 Congenital cysts Biliary surgery ```
188
List liver, CNS, GI, Haem and Cardio manifestations of alcoholism
Liver: cirrhosis, hepatitis CNS: poor cognition, neuropathy, cortical atrophy, fits, falls, haemorrhage, wide gait, confabulations, Korsasakoff-Wernicke syndrome GI: obesity, diarrhoea, peptic ulcers, gastric erosions, varices, MW tear, pancreatitis, oral lesions Haem: raised MCV, anaemia, haemolysis Cardio: arrhythmias, hypertension, cardiomyopathy
189
List clinical features of alcohol withdrawal
``` Occurs 10-72 hours after last drink Tachycardia Hallucinations Hypotension Tremor Confusion Fits Anger ```
190
Outline the CAGE questionnaire for problem drinking
``` feel the need to Cut down? get Annoyed by criticism about drinking? feel Guilty? need an Eye-opener in the morning? Yes to 2 or more indicates problem drinking ```
191
Outline treatment of alcoholism
Acute withdrawal: BZD + thiamine Prevention, self-help, group therapy Relapse control (acamprosate reduces craving, disulfiram for dependence)
192
List aetiology/risk factors for acute pancreatitis
``` Gallstones Ethanol Trauma Steroids Mumps Autoimmunity Scorpion bites Hypercalcaemia/lipidaemia ERCP Drugs Malignancy Oxidative stress ```
193
List clinical features of acute pancreatitis
``` Severe epigastric pain radiating to back, may relieve on sitting forward Fever Nausea, vomiting Reduced appetite Tachycardia Hypotension Rigid abdomen Grey Turner sign (flank bruising) Cullen sign (periumbilical bruising) ```
194
What investigations would you do for acute pancreatitis?
``` Amylase typically hugely raised Serum lipase FBC, U+E, ABG's, LFT's AXR shows sentinel loop of proximal jejunum if ileus Erect CXR to exclude perforation ```
195
What is the Glasgow prognostic score for severe pancreatitis?
``` 3 or more abnormal values from following parameters indicates severe pancreatitis: PaO2 Age Neutrophilia Calcium Renal function Enzymes Albumin Sugar ```
196
Outline treatment of acute pancreatitis
``` Nil-by-mouth, nutritional support (NG/NJ) IV fluids Catheterisation Analgesia ERCP if gallstones Antibiotics Drain abscess/laparotomy + debridement ```
197
Endocrine and exocrine insufficiency occurs in chronic pancreatitis. True/False?
True | Chronic fibrosis and calcification of pancreas
198
List aetiology/risk factors of chronic pancreatitis
``` Alcohol abuse Cystic fibrosis Alpha-1-antitrypsin deficiency Hyperparathyroidism Pancreatic duct obstruction ```
199
List clinical features of chronic pancreatitis
Epigastric pain radiating to back Erythema ab igne (mottled greyness) Steatorrhoea Weight loss
200
Outline treatment of chronic pancreatitis
``` Analgesia Stop alcohol Address diabetes Treat enzyme deficiency (CREON) Pancreactectomy, pancreaticojejunostomy ```
201
What is the most common type of pancreatic cancer?
Adenocarcinoma at head of pancreas/Ampulla of Vater
202
List aetiology/risk factors of pancreatic cancer
``` Smoking Alcohol Diabetes Chronic pancreatitis High fat diet KRAS2 gene Insulinomas, glucagonomas, gastrinomas, somatostatinomas ```
203
List clinical features of pancreatic cancer
``` Painless obstructive jaundice Dark urine pale stools Epigastric pain Weight loss Thrombophlebitis Palpable gall bladder Ascites ```
204
What investigations would you do for pancreatic cancer
LFT's CA-199 US scan/CT shows pancreatic mass Biopsy
205
Outline treatment of pancreatic cancer
``` Radical surgery (Whipple's procedure - pancreatoduodenectomy) if fit enough Palliative care ```
206
List aetiology/risk factors for appendicitis
Luminal obstruction by faecolith Worms Lymphoid hyperplasia Hygiene hypothesis
207
List clinical features of appendicitis
``` Periumbilical pain that moves to RIF Vomiting Constipation Anorexia Tachycardia Fever Flushing Guarding Rebound tenderness Rovsing sign (pain in RIF when LIF pressed) Tender McBurney point ```
208
What investigations would you do for appendicitis?
FBC, U+E, inflammatory markers US scan Do not delay surgery
209
Outline treatment of appendicitis
Prompt appendectomy | IV metronidazole + cefuroxime
210
What are carcinoid tumours?
Tumours of enterochromaffin cell origin that produce 5-HT | May also secrete bradykinin, substance P, VIP, gastrin, insulin, glucagon, ACTH, PT hormone, thyroid hormone
211
List common sites for carcinoid tumours
``` Appendix Ileum Rectum Ovary Testis Bronchi ```
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Which MEN syndrome - 1 or 2 - are carcinoid tumours associated with?
MEN1
213
List clinical features of carcinoid tumours
``` Appendicitis RUQ pain Bronchoconstriction Paroxysmal flushing Diarrhoea Tricuspid regurgitation CNS effects Carcinoid crisis (shock) ```
214
What investigations would you do for carcinoid tumours?
``` 24h urine 5-HT US scan liver CXR CT abdo + plvis Plasma chromograffin A PET scan ```
215
Outline treatment of carcinoid tumours
Octeotride/lareotide Treat symptoms Tumour resection
216
What is a hernia?
Protrusion of viscus out of its normal body cavity
217
List aetiology/risk factors for hernia
``` Obesity Pregnancy Heavy lifting Cough Constipation Abdo wall defects ```
218
List clinical features of hernia
Femoral: mass in upper medial thigh, inferolateral to pubic tubercle Inguinal: direct/indirect, superomedial to pubic tubercle Paraumbilical: herniation of bowel + omentum Incisional: breakdown of muscle post-surgery Epigastric: weak linea alba
219
Outline treatment of hernia
``` Surgical repair Treat complications (obstruction, strangulation) ```
220
What is an indirect inguinal hernia?
Passes through internal inguinal ring (midpoint of inguinal ligament)
221
What is a direct inguinal hernia?
Pushes through posterior wall of inguinal canal into Hesselbach triangle (medial to inferior epigastric arteries)
222
List aetiology/risk factors for inguinal hernias
``` Direct = young males Indirect = old males Cough Increased intra-abdominal pressure Patent processus vaginalis ```
223
What is patent processus vaginalis?
Connection between peritoneal cavity and tunic vaginalis fails to close behind testis, causing indirect inguinal hernia formation May result in hydrocele if peritoneal fluid collects
224
Outline treatment of inguinal hernia
Lifestyle advice Weight loss Mesh repair to reinforce posterior wall
225
What are haemorrhoids?
Swollen vessels in/around anus and rectum | Spongey vascular tissue at 3, 7 and 11 o'clock becomes displaced/disrupted
226
List aetiology/risk factors for haemorrhoids
``` Erect posture Increased anal tone Straining Trauma Constipation Congestion ```
227
List clinical features of haemorrhoids
Readily bleeding Bright red blood around stool/paper/pan Mucous discharge Pruritis ani
228
What investigations would you do for haemorrhoids?
PR exam Abdo exam Proctoscopy Sigmoidoscopy
229
Outline treatment of haemorrhoids
``` Gel/cream Ice pack Stool softeners Band ligation Cryotherapy Haemorrhoidectomy Coagulation Sclerosants ```
230
List aetiology/risk factors for rectal prolapse
Lax sphincter Prolonged straining Neuropsychological disorder
231
List clinical features of rectal prolapse
Loss of anal tone Bleed Mucous stool "hanging" sensation
232
Outline treatment for rectal prolapse
Rectopexy (fix rectum to sacrum) +/- mesh +/- rectosigmoidectomy Stool softeners Stop straining
233
What is anal fissure?
Tear in squamous lining of lower anal canal, distal to the dentate line
234
List aetiology/risk factors for anal fissure
``` Hard faeces Constipation Rectal artery constriction STD IBD Trauma ```
235
List clinical features of anal fissure
Painful defecation, like shitting a shard of glass Bleeding Abscess
236
Outline treatment for anal fissure
Stool softener Local lidocaine ointment/GTN ointment Lateral partial internal sphincterotomy
237
What is anal fistula?
Abnormal communication between anal canal and skin
238
List aetiology/risk factors for anal fistula
``` Blockage of deep intramuscular gland ducts, causing abscess Perianal sepsis IBD Diverticular disease Rectal carcinoma ```
239
What investigations would you do for anal fistula?
MRI PR exam Endoanal US scan
240
Outline treatment for anal fistula
Fistulotomy + excision Seton suturing Drainage

4MB Medicine (My version) (19 decks)

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