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Medical Finals 2020 > Gastroenterology and Hepatobiliary > Flashcards

Gastroenterology and Hepatobiliary Flashcards

1
Q

What test do you do in order to investigate potential PBC or PBS?

A

Magnetic resonance - cholangiopancreatography (MRCP)

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2
Q

What is the associated condition for Primary Sclerosing Cholangitis?

A

Ulcerative colitits

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3
Q

What are the key differentiating features of Crohn’s in comparison to Ulcerative Colitits?

A

Crohn’s - transmural, granulomas (cobblestone mucosa), skip lesions, discontinuous lesions, strictures)

Ulcerative Colitis - submucosa, crypts, continuous inflammation

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4
Q

What is your drug of choice to manage Crohn’s?

A

Methotrexate or infliximab

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5
Q

How do you treat UC flares?

A

Prednisolone

Usually on azathioprine
- 5-aminosalycylic acid

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6
Q

What does a lack of abdominal breathing potentially indicate?

A

Peritonitis

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7
Q

What diet is helpful for IBS treatment?

A

FODMAP diet - Fermentable Oligo-di-monosaccharides and polyols

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8
Q

What histological feature is seen in coeliac disease?

A

Villous atrophy
Flat mucosa
Marked crypt hyperplasia

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9
Q

What are some associated conditions in coeliac disease?

A

Dermatitis herpetiformis (vesicular, pruritic skin eruption)
Autoimmune disorders (T1DM)
IBS
Autoimmune thyroid disease

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10
Q

How might coeliac disease present?

A 
Malnutrition, failure to grow
Weight loss
GI symptoms: persistent vomiting/nausea/diarrhoea
Abdominal pain, cramping, distension
Unexplained iron deficiency anaemia
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11
Q

A gentleman with a heavy drinking habit presents with mild jaundice and a palpable painless gallbladder. What is the most likely diagnosis?

A

Malignancy of gallbladder or pancreas

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12
Q

What is Courvoisier’s sign?

A

Painless enlarged gallbladder and mild jaundice = NOT gallstones

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13
Q

What is a classical presentation of pancreatic cancer?

A

Painless jaundice

Non-specific - weight loss, anorexia, epigastric pain

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14
Q

What is the procedure for surgical resection of the pancreas head?

A

Whipple’s resection (pancreaticoduodenectomy)

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15
Q

What is used to determine liver cirrhosis severity?

A 
Bilirubin
Albumin
PT
Encephalopathy
Ascites
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16
Q

What is the most common part of the colon affected by ischaemic colitis?

A

Splenic flexure

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17
Q

What are some common features of ischaemic colitis?

A 
Abdominal pain (acute mesenteric ischaemia) - sudden onset, severe, out of keeping with physical exams
Rectal bleeding
Diarrhoea
Fever
Raised WCC
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18
Q

What is the difference between acute mesenteric ischaemia and ischaemic colitis?

A

Mesenteric ischaemia - affects the small bowel, often embolic cause, hx of AF, urgent surgery required
Ischaemic colitis - transient compromise to blood flow - inflammation, ulceration and haemorrhages occur

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19
Q

What are some classic features of a carcinoid tumour?

A

Flushing, sweating, diarrhoea, bronchoconstriction

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20
Q

What test is diagnostic for c difficile?

A

C difficile toxin

First line therapy is PO metronidazole for 10-14 days

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21
Q

What does achalasia increase your risk for?

A

Squamous Cell Carcinoma

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22
Q

What is Barrett’s Oesophagus?

A

Dysplasia of squamous cells in oesophagus to columnar epithelium.
Risk factor in adenocarcinoma
Treat with PPI + endoscopic surveillance

If dysplasia then consider ablation or resection

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23
Q

What are some causes of acute pancreatitis?

A 
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps/Malignancy
Autoimmune
Scorpion stings
Hyperlipidaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs
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24
Q

What is a common but non-liver feature of Wilson’s Disease?

A

Neuropsychiatric symptoms

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25
What is Wilson's Disease?
``` Autosomal recessive Copper deposition in the tissues Hepatitis, cirrhosis Basal ganglia degeneration, speech, behavioral and psychiatric problems Chorea, dementia, asterixis Kayser-Fleischer rings (red in eyes) ```
26
How do you diagnose and manage Wilson's Disease?
Low serum caeruloplasmin, Low serum copper, increased urine copper Penicillamine
27
What is a sign on biopsy of laxative abuse?
Melanosis coli
28
What is Budd-Chiari Syndrome and when can it occur?
Hepatic vein thrombosis | Seen in underlying haematological disease (polycythaemia, thrombophilia, pregnancy, COCP)
29
What is diagnostic of Budd-Chiari syndrome?
ultrasound with Doppler flow studies
30
What are the symptoms of Budd-Chiari Syndrome?
Abdominal pain (sudden onset, severe) Ascites Tender hepatomegaly
31
What is the best test to determine liver cirrhosis?
Transient elastography (fibroscan)
32
What are the most common features of IBS?
Feeling of incomplete stool evacuation Back pain Lethargy Nausea Consider diagnosis in abdominal pain, bloating or change in bowel habit for at least 6 months
33
What is a common cause of diarrhoea post-travelling?
E-coli causes travellers diarrhoea, commonly with nausea and abdominal cramps.
34
What are some risk factors for Barrett's oeseophagus?
GORD Male Smoking
35
What cardiac abnormalities are associated with carcinoid syndrome?
Pulmonary stenosis and tricupsid insufficiency | It affects the right side of the heart
36
How do you treat carcinoid syndrome?
Octreotide - somatostatin analogue
37
What is Gilbert's Syndrome?
``` Benign Inability to conjugate bilirubin Autosomal recessive Occurs during illness, fasting, stress, lack of sleep, dehydration, alcohol excess Reassure ```
38
What is Primary Biliary Cholangitis?
``` Autoimmune (F>M) Interlobular bile duck inflammation Progressive cholestasis and cirrhosis Itching, hepatosplenomegaly IgM, anti-mitochondrial antibodies ```
39
What are causes of liver cirrhosis?
Alcohol NAFLD Viral Hep B and Hep C
40
What is the management for a liver abscess?
Drainage and antibiotics (amox + cipro + metro)
41
What is the gold standard investigation for oesophageal cancer?
Endoscopy
42
When are gallstones treated?
Symptomatic patients - done with surgery (laparoscopic cholecystectomy) or ERCP
43
What are some classic differentiating features between Crohn's and UC?
UC - continuous disease of IC valve to rectum, no inflammation beyond submucosa, crypt abscesses Bloody diarrhoea more common, pseudopolyps Crohn's - skip lesions, mouth to anus, inflammation all levels, goblet cells, granulomas
44
Which type of jaundice presents as dark urine and pale stools?
Obstructive jaundice (cholestasis)
45
What deficiency is coeliac disease associated with?
Iron, folate and B12
46
Give some differential diagnosis of abdominal pain.
``` Biliary cholic, cholecystitis Cholangitis Pancreatitis (often painless) Hepatitis Appendicitis Renal colic Gynae - ectopic, PCOS, fibrinoids, endometriosis Splenic trauma Peptic ulcer disease AAA ```
47
What are the five 'F's of abdominal distension?
``` Fat Fluid Faeces Foetus Flatus ```
48
What are the nine regions of the abdomen?
``` Hypochondriac - R and L Epigastric Lumbar - R and L Umbilical Iliac region R and L Hypogastric ```
49
What are causes of GORD?
``` NSAIDs Pregnancy Obesity Smoking Alcohol ```
50
What is dyspepsia?
Reflux and epigastric pain due to indigestion
51
What is dysphagia?
Problems swallowing
52
How is GORD managed?
Lifestyle changes PPI - 30mg omeprazole or lansoprazole H2RA: ranitidine
53
What are some side effects of PPIs?
SE: bone demineralisation
54
How is h. pylori treated?
PPI/H2RA | x2 antibiotics
55
What is a common cause of an ulcer?
H. pylori NSAIDs Smoking
56
Are they any differences between a gastric ulcer and a duodenal ulcer other than site?
Gastric/Peptic - less common, bleeding and haematemesis | Duodenal - more common, malaena
57
What is the name of the test for the bacteria that causes ulcers?
13C breath test
58
What are potential differentials for an upper GI bleed?
``` Gastric ulcer Oesophageal varices Liver disease Mallory-Weiss tear Malignancy ```
59
What drug can you give to treat oesophageal varices?
Propranolol hydrochloride If haemorrhaging can give terlipressin
60
What are the two MAIN causes of pancreatitis?
Gallstones | Alcohol
61
What are two typical signs of pancreatitis?
Grey-Turner's Sign - discolouration in the flanks, a result of blood leaking into subcut tissues Cullen's Sign - grey discolouration around umbilicus
62
What is the abbreviated Glasgow scale used for?
Pancreatitis severity assessment | APACHE II used too
63
How do you treat pancreatitis?
IV fluids, O2 Antibiotics Monitor urine output Analgesia for pain
64
What is the difference between primary and secondary peritonitis?
Primary - spontaneous bacterial peritonitis (occurs in compromised immune systems) Secondary - occurs due to underlying pathology (pancreatitis, surgery, bowel perforation, appendicitis, ectopic, bowel infarct
65
Abdominal pain that improves when a hand is laid on it may indicate...
Peritonitis
66
What is Rovsing's sign?
When pressing on the left iliac fossa, pain may be felt on the right iliac fossa.
67
What is paralytic ileus?
Cessation of peristaltic waves in the gut, occur as a result of abdominal distension
68
What is the most common cause of infective diarrhoea?
E.coli | 0157
69
What infective cause is bloody diarrhoea associated with?
Shigella
70
What is rice water diarrhoea associated with?
Cholera
71
What antibiotics are associated with clostridium difficile?
Clindamycin Ciprofloxacin Co-amoxiclav Cephalosporins
72
How do you treat c. difficile?
Metronidazole, PO vanc or rifampicin. | Stop current antibiotics
73
Give 5 investigations you can do in pancreatitis and their expected result?
``` Amylase - raised WCC - raised Lactate - raised CRP - raised Abdominal CT - loss of fat, pancreatic oedema ```
74
Give 4 investigative tests you can do in peritonitits and their expected result?
``` WCC - raised Platelets - raised CRP - raised bHCG - negative, rule out pregnancy Ascitic tap - organisms growing ECG - normal, rule out cardiac causes ```
75
What 3 primary histological features will you see in Crohn's disease?
Skip lesions Transmural inflammation (all layers of the bowel wall) Granulomas Discontinuous inflammation
76
What 2 primary histological features will you see in Ulcerative Colitis?
Mucosal inflammation only | Continuous inflammation
77
Which inflammatory bowel disease affects the whole of the GI tract?
Crohn's | UC only affects the colon
78
Give 5 extra-intestinal features of ulcerative colitis?
``` Uveatis Mouth ulcers (orofacial granulomatosis) Erythema nodosum (red lumps) Arthritis Ankylosing spondylitis ```
79
Fecal calprotectin is used for which disease?
IBD
80
What are classic symptoms of IBS?
Abdominal pain Bloating Lethargy, nausea, back ache Change in bowel habit, often symptoms improve with defecation, change in tool frequency
81
What is involved in the management of IBS?
Education Change in diet (avoid insoluble fibres, eat fruit, fluids, avoid caffeine) Pharmacological - antispasmodics (mebeverine, buscopan), laxatives CBT, psycholoical
82
What are the 5 pathophysiologies involves in malnutrition?
``` Defective intraluminal digestion Insufficienct absorptive area Lack of digestive enzymes Defective epithelial transport Lymphatic obstruction ```
83
What antibodies are involved in a coeliac screen?
Anti-tissue transglutaminase (tTG) Anti-endomysial antibody (EMA) Immunoglobulins Jejunal biopsy
84
How might coeliac disease present?
``` Bloating Abdominal pain Diarrhoea, steatorrhoea Weight loss, malabsorption Rash (dermatitis herpetiformis) ```
85
What classification is used to stage coeliac disease?
Marsh Classification
86
How is coeliac disease treated?
Gluten-free diet
87
What is diverticular disease and what is the difference between diverticular disease and diverticulitis?
The presence of outpouchings in the gut wall | Diverticulitis - infection of these outpouchings - causes pain, inflammation and requires antibiotics
88
Does ascites occur with gallstones?
No
89
What is hepatorenal syndrome and how is it managed?
Vasoactive mediators cause splanchnic vasodilation which reduces systemic vascular resistance causing underfilling of the kidneys (decreased pressure causes water retention and renal vasoconstriction) Treat with terlipressin
90
What drug can be used to prevent bleeding in oesophageal varices?
Beta blocker
91
What is a sign that patients are at risk of refeeding syndrome?
Hypophosphataemia Low K+, Mg, thiamine deficiency
92
How does a cholangiocarcinoma present?
``` Jaundice Weight loss Pruritis Persistent Biliary Symptoms Affects up to 10% of PSC patients ```
93
What prophylactic treatment is given after SBP?
Ciprofloxacin
94
What is intussusception?
The telescoping on one piece of bowel into another | Commonest cause of obstruction
95
What is a common location for intussusception?
Ileo-caecal junction
96
What are your management options for intussusception?
``` Contrast enema (both diagnostic and therapeutic) Open/laparascopic reduction ```
97
What is the biggest risk factor for oesophageal cancer?
Smoking (especially squamous cell carcinoma)
98
What is the most common location of colorectal cancers? Do proximal or distal cancers have a better prognosis?
Sigmoid colon and rectum Proximal cancers have a worse prognosis as they present later
99
What family history has an influence in incidence of colorectal cancers?
Hereditary non-polyposis colorectal cancer (HNCC) | Familial Adenomatous polyposis (FAP)
100
What symptoms could someone with colon cancer present with?
``` PR bleeding Excess mucous Narrowing obstruction Constipation Colicky abdominal pain Abdominal distension ```
101
What tumour marker is used in colon cancer?
CEA - not diagnostic
102
What investigations are done in suspected colorectal cancer?
Colonscopy - gold standard (with biopsy) | Faecal occult blood - high specificity and low sensitivity
103
What staging criteria is used in colorectal cancers?
Duke's Staging Criteria
104
What are the 4 stages of Duke's Staging Criteria?
A - invasion into but not through the bowel wall B - invasion through the bowel wall penetrating the muscle layer but not involving lymph nodes C - lymph node involvement D - lymph nodes with widespread metastases
105
What is the tumour marker for pancreatic cancer?
Ca19-9
106
What are risk factors in hepatocellular carcinoma?
Alcohol Liver cirrhosis Viral Hep C
107
What is a good marker of hepatocellular carcinoma?
Alpha-feto protein
108
What alternative to chemo can you give for hepatocellular carcinoma?
Sorafenib Side effects - decreases platelets, increases BP, can't give in PVD or ACS
109
What is the most important electrolyte to be given in refeeding syndrome?
Phosphate
110
What is included in a NILS?
``` FBC LFT Clotting Cholesterol Blood Glucose Hep B & C, Viral Screen (CMV, EBV, HIV) Ferritin, Total Iron Binding Capacity Alpha-1-Antitrypsin Immunoglobulins AFP Serum copper, ceruloplasmin ```
111
What are some extra-hepatic signs of liver disease?
``` Dupuytren's contractures Spider naevi Spider angioma Caput medusa (enlarged veins) JVP rise Splenomegaly ```
112
What is the best indication of cholestatic injury?
Raised ALP and GGT
113
What blood tests give the best result of liver function?
Albumin Bilirubin PTT
114
What are some complications of a liver transplant?
Sepsis Malignancy outside the liver Shortage of donors Rejection
115
What is the score used to determine the severity of liver cirrhosis and what does it look at?
``` Child-Pugh Score Bilirubin Albumin INR Ascites Encephalopathy ```
116
What are common causes of liver cirrhosis?
Alcohol Viral hepatitis NAFLD
117
What symptoms do you get in liver cirrhosis?
Splenomegaly (liver actually shrinks due to scarring and fibrosis) Jaundice Pyrexia Ascites (low albumin, portal hypertension, varices) Systemic - malnutrition, coagulopathy, vit K deficiency, encephalopathy, hypoglycaemia)
118
What are some causes of acute liver failure and how might it present?
Paracetamol overdose Alcohol Viral Hep ``` Jaundice Coagulopathy (raised PT) Low albumin Hepatic encephalopathy (asterixis) Renal failure is common ```
119
How does vitamin C deficiency present?
Scurvy Lethargy, arthralgia, easy bruising, bleeding gums Common in low income backgrounds, elderly, alcoholics or in those with a poor diet.
120
What is Rovsing positive mean?
Appendicitis - palpation in the LIF causes pain in the RIF
121
What are early signs of haemochromatosis and what does the disease involve?
Fatigue, erectile dysfunction and arthralgia Autosomal recessive Disorder of iron absorption and metabolism resulting in accumulation
122
How does Addison's disease present acutely?
Abdominal pain, weight loss, nausea and vomiting
123
What do you give in the secondary prophylaxis of hepatic encephalopathy?
Lactulose and rifaximin
124
What test should be done before commencing azathioprine?
Thiopurine methyltransferase (TPMT) activity
125
What is the first line medication to prescribe in IBS?
Loperamide
126
What is the most common cause of EBP?
E.coli
127
Give some causes of unconjugated jaundice?
Haemolysis Gilbert's Syndrome Drugs Liver enzymes normal Stools normal or dark, urine normal
128
What are some causes of conjugated jaundice?
Viral hepatitis Alcohol and toxins - paracetamol Haemachromatosis, alpha-1-antitrypsin deficiency, Budd-Chiari Post-hepatic causes - gallstones, cholangitis
129
What do Mallory bodies on biopsy suggest?
Alcoholic liver disease
130
How might alcoholic liver disease present?
Malnutrition - ascites, thin arms/legs, iron deficiency anaemia Liver problems - jaundice, ascites, hepatosplenomegaly Face or skin involvement - spider naevi, easy bruising Endocrine - gynaecomastia, testicular atrophy Neuro - Wernicke-Korsakoff, peripheral myopathy, memory loss, encephalopathy, asterixis
131
What are the five metabolic changes that occur in paracetamol overdose?
``` Acute hepatitis Hypoglycaemia Metabolic acidosis Coagulopathy Renal failure ```
132
What is your management drug of choice for paracetamol overdose?
N-acetyl-cysteine (NAC)
133
Which viral hepatitis can cause chronic disease?
Hep B, C
134
What antibodies do you see in autoimmune hepatitis?
ANA positive Anti-smooth muscle antibody There may be an association with other autoimmune diseases
135
Steatohepatitis on biopsy indicates...?
Non-Alcoholic Fatty Liver Disease | Non-Alcoholic Steatohepatitis (NASH)
136
What is hepatorenal syndrome?
Renal failure secondary to cirrhosis, portal hypertension or ascites. There is low renal output due to peripheral vasodilation Decreased renal blood flow
137
What are low and high platelets referred to as..?
Thrombocytopenia - low | Thrombocythaemia - high
138
What kind of inheritance is haemochromatosis? | What is the pathology involved?
Autosomal recessive Iron deposition and organ failure
139
What two organs are involved with alpha-1-antitrypsin deficiency and what is the inheritance?
C14 genetic mutation Lungs and Liver (chronic inflammation)
140
What is a major risk factor in hepatic vein occlusion?
Thrombophilia - hypercoagulable state | Budd-Chiari Syndrome
141
What are the main risk factors for gallstones?
Fat Female Fertile
142
What are your management options for gallstones? Is there is a difference in management in symptomatic and asymptomatic?
Asymptomatic - don't treat Cholecystectomy Stone dissolution ERCP - sphincterotomy - for bile duct stones
143
What is Charcot's Triad and Reynold's Pentad and in what do they occur?
Triad - fever, RUQ pain, jaundice Pentad - hypotension, confusion + triad Ascending Cholangitis
144
What is the difference between ascending cholangitis and acute cholecystitis?
Cholecystitis - inflammation/infection of GALLBLADDER | Cholangitis - obstruction causing infection of whole biliary tree and potentially the liver and gallbladder
145
Give 3 differences between PBC and PSC?
Primary Biliary Cholangitis/Cirrhosis - AMA positive, intrahepatic bile ducts, granuloma and ductopenia, RA association Primary Sclerosing Cholangitis - extrahepatic ducts, strictures, IBD (UC) link
146
What symptoms do you experience in bile duct obstructions?
Fatigue Pruritis Jaundice
147
Sudden onset dysphagia indicates?
Red flat | Requires urgent endoscopy regardless of age or other symptom
148
Give some differentials for dysphagia?
Dysphagia = problems swallowing Oesophageal cancer - associated weight loss, anorexia, vomiting, PMN smoking or alcohol, Barrett's oesophagus Oesophagitis - heartburn history, systemically well Oesophageal candidiasis - HIV hx, steroid use is a risk factor Achalasia - liquids and solids from the start, 'bird's beak' sign, heartburn, risk of cough and aspiration pneumonia Pharyngeal pouch - older men, posteromedial herniation, regurgitation, chronic cough, halitosis Systemic Scerolsis Myasthenia Gravis - extraocular muscle weakness Globus hystericus - anxiety history, symptoms relieved by swallowing, usually painless
149
Give 5 non-gastro-oesophageal causes of dysphagia?
Parkinson's, MND, MS, MG Systemic sclerosis Post-stroke/CVA
150
What is used in the management of severe acute alcoholic hepatitis?
Prednisolone
151
What does a paracetamol overdose do to the liver and how long does it take liver failure to develop?
Toxic metabolite – build up of NAPQI, binds to liver cell membranes causing necrosis It takes 72-96 hours, 3-4 days
152
How do you calculate alcoholic units?
Units = Volume (L) x ABV%
153
Which is worse after eating -peptic or duodenal ulcer?
Peptic ulcer worse after eating Duodenal ulcer - improved by eating, worse with stress and at night, radiates to back. Bleeding from gastroduodenal artery (first 2/3 of duodenum)
154
What is your first line test in primary sclerosing cholangitis?
USS MR cholagiopancreatography ULCERATIVE COLITIS LINK
155
What do you see in biopsies to suggest carcinomas?
Hyperchromic Pleomorphism Nuclear enlargement
156
What are signs of a paralytic ileus?
No bowel sounds No passing of gas or faeces Distended abdomen No rebound tenderness or guarding
157
What is your management of a paralytic ileus?
NG tube insertion | Nil by mouth
158
What are some causes of a raised serum ferritin?
Alcohol Obesity Inflammation Hemochromatosis
159
What are some hand signs of liver disease?
``` Duypetren's Contracture Clubbing Palmar erythma Terry's nails Asterixis Spider naevi ```
160
What are some features of autoimmune hepatitis?
- signs of chronic liver disease - acute presentation with fever, jaundice - amenorrhoea is common - ANA/SMA antibodies - liver biopsy will show inflammation Manage with steroids and immunosupressants
161
Pain in the epigastrium and vomiting is most likely due to what?
Pancreatitis - EPIGASTRIUM | RUQ consider gallstones/cholecystitis
162
When is a pancreaticoduodenectomy used?
Whipple's Procedure | Pancreatic carcinoma with no metastases
163
What is Rigler's sign?
Double wall sign on AXR that suggests free air in the abdomen
164
What might a raised ALP suggest?
- biliary cirrhosis - pregnancy - Paget's disease - hypercalcaemia - osteomalacia - bone metastases
165
How might a chlangiocarcinoma present?
RUQ mass malaise, weight loss anorexia, n+v RUQ pain patients may present with obstructive jaundice (pale stools, dark urine, pruritis)
166
What is the primary management for a cholangiocarcinoma?
- surgical resection This is contraindicated if the patient has metastatic disease, malignant ascites, vascular invasion (at risk of major bleed)
167
What is the most common cause of a liver abscess and your usual management?
Usual cause is e.coli (staph aureus in children) - Drainage and antibiotics - Amoxicillin + ciprofloxacin + metronidazole

Medical Finals 2020 (25 decks)

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