Gastroenterology for Finals Flashcards
What is the criteria for 2WW referral in suspected upper GI malignancy?
- Dysphagia
OR - Age over 55 with weight loss and: Reflux symptoms, dyspepsia or epigastric pain
What is the eradication therapy for H. pylori in patients who are not allergic to penicillin?
Omeprazole 20mg BD
Amoxicillin 1g BD
Clarithromycin 500mg BD
All for 7 days
What is the eradication therapy for H. pylori in patients who are allergic to penicillin?
Omeprazole 20mg BD
Metronidazole 400mg BD
Clarithromycin 500mg BD
All for 7 days
What is the inheritance pattern of Wilson’s disease?
Autosomal recessive
What is the pathophysiology of Wilson’s disease?
Normally, the small amount of copper that is ingested is absorbed in the small intestine and incorporated into a carrier protein ‘caeruloplasmin’ in the liver. In Wilson’s disease, the absorption process is normal but there is a problem when incorporating the copper into the carrier protein and subsequently it’s excretion. Copper therefore accumulates.
What is a Kayser-Fleischer ring?
Copper deposition in the iris seen in Wilson’s disease
What are the stages of hepatic encephalopathy?
I = Lethargy, insomnia II = Confusion III = Drowsiness IV = Coma
Which part of the GI tract does ulcerative colitis affect?
Colon and rectum - rectum is ALWAYS affected
True / False: Smoking has a protective effect in ulcerative colitis
True
Which tool is used to assess the severity of ulcerative colitis?
Truelove - Witts criteria
What is measured in the Truelove-Witts criteria?
Number of bowel motions per day Rectal bleeding Temperature Haemoglobin Resting pulse ESR (and/or CRP)
What is the management of acute severe colitis?
- Blood cultures to rule out infective cause
- Monitor observations and stool habit
- Daily bloods (especially FBC, U+E, CRP)
- Flexible sigmoidoscopy
- Steroids 100mg hydrocortisone QDS IV then switch to oral
- VTE prophylaxis
- AXR to rule out toxic megacolon
- Good response to steroids: Switch to oral steroids and add 5-ASA
- No response to steroids: Consider surgery e.g. subtotal colectomy, consider rescue therapy i.e. cyclosporin and infliximab
Which drugs are used in the medical ‘rescue’ therapy of acute severe colitis?
Infliximab
Cyclosporin
True / False: Colonoscopy is a useful investigation in acute severe colitis?
False - There is a high risk of perforation so not performed in acute severe colitis…do a flexible sigmoidoscopy instead
Which part of the GI tract is affected in Crohn’s?
The entire GI tract can be affected, but particularly affects terminal ileum
Do ‘Skip lesions’ occur in Crohn’s or ulcerative colitis?
Crohn’s
What antibodies are important in Coeliac disease?
Anti-TTG (tissue transglutaminase) antibodies
Anti-endomysial antibodies
What is the ‘gold standard’ test for Coeliac disease?
Biopsy of the D2 section of duodenum
Which antibodies are important in primary biliary cirrhosis?
Anti-mitochondrial antibodies
Which LFTs are usually raised in a ‘cholestatic’ picture?
ALP and GGT
What is jaundice?
Visble hyperbilirubinaemia
Does jaundice of a pre-hepatic cause give a conjugated or unconjugated hyperbilirubinaemia?
Pre-hepatic jaundice = Unconjugated
The presence of bilirubin in the urine excludes WHAT as a cause of jaundice?
Presence of bilirubin in urine excludes pre-hepatic causes of jaundice, as unconjugated bilirubin (as seen in pre-hepatic causes) is too large to be excreted via kidneys
What are the causes of unconjugated hyperbilirubinaemia?
Pre-hepatic causes…
- Haemolysis
- Impaired conjugation e.g. Gilbert’s syndrome, Crigler-Najjar syndrome
- Drugs e.g. gentamicin, contrast agents, rifampicin, chloramphenicol
- Physiological neonatal jaundice
Are the levels of urobilinogen high or low in post-hepatic (conjugated) hyperbilirubinaemia?
Low
What are the causes of post-hepatic jaundice?
- Gallstones
- Tumour
- Biliary atresia
- Cholecystitis and cholangitis
Does jaundice of a post-hepatic cause give a conjugated or unconjugated hyperbilirubinaemia?
Post hepatic jaundice = Conjugated
Does jaundice of an intra-hepatic cause give a conjugated or unconjugated hyperbilirubinaemia?
Intra-hepatic jaundice = Conjugated
Give 3 causes of a massive transaminitis
Acute viral hepatitis
Drug induced liver failure
Ischaemic hepatitis
What are the different types of gallstones?
Pigment stones
Cholesterol stones
Mixed
True / False: Most gallstones appear on x-ray
False - Most gallstones are radiolucent so do not appear on x-ray
What is Charcot’s triad?
Sign of cholangitis - RUQ pain, fevers jaundice
Which blood marker(s) is classically raised in acute pancreatitis?
Amylase
Serum lipase - more specific for pancreatitis
Give some drug causes of acute pancreatitis
Steroids 5-ASAs e.g. sulphasalazine, mesalazine Azathioprine Sodium valproate Furosemide
What are the causes of acute pancreatitis?
Gallstones Ethanol (alcohol) Trauma Steroids Mumps Autoimmune e.g. SLE Scorpion bites Hyperlipidamia, hyperparathyroidism ERCP, emboli Drugs e.g 5-ASAs (sulphasalazine, mesalazine), azathioprine Neoplasm
Which tool can be used to assess severity of pancreatitis?
Glasgow Score
What parameters are measured in the Glasgow score for acute pancreatitis?
PaO2 less than 8kPa (respiratory failure) Age over 55 Neutrophilia Calcium low (less than 2mmol/L) Renal function (urea more than 16) Enzymes (AST or LDH raised) Albumin less than 32 Sugar (glucose!) more than 10mmol/L
Give 3 investigations which might be done in the assessment of a patient with dysphagia
Endoscopy
Barium swallow
Manometry
What are the features of Plummer-Vinson Syndrome?
Iron deficiency anaemia
Oesophageal webs
Dysphagia
Glossitis
What is the most common histology of oesophageal cancer?
65% are adenocarcinomas
What is the appearance of achalasia on barium swallow?
‘Bird beak’ or ‘rats tail’
What is the mechanism by which achalasia occurs?
Failure of the lower oesophageal sphincter to relax due to abnormality of the nerve supply
What is the treatment for achalasia?
- Nitrates or calcium channel blockers relax the sphincter if not too severe
- Botox lasts about 6/12
- Endoscopic dilatation
- Heller’s cardiomyotomy cuts the muscle at the lower oesophageal sphincter
Which is more common, duodenal or gastric ulcers?
Duodenal ulcers are more common
What is haemochromatosis?
Autosomal recessive disorder of iron metabolism, causing increased iron deposition in tissues
Which tissues might be particularly affected in haemochromatosis?
Liver Joints Heart Pituitary Pancreas Adrenals Skin
Give some clinical features of haemochromatosis
Slate-grey skin appearance Arthralgia Tiredness Hypogonadism, erectile dysfunction, gynacomastia Chronic liver disease - cirrhosis and hepatomegaly Dilated cardiomyopathy Arrhythmias Diabetes Low renin, low aldosterone
What is the treatment for haemochromatosis?
Venesection
Monitor LFTs, glucose
Low iron diet
Screening for 1st degree relatives
Which parameters are assessed in the Child-Pugh score?
Remember ABCDE: Albumin Bilirubin Clotting (Prothombin time) Distension i.e. ascites Encephalopathy
What does the Child-Pugh score assess?
The severity of liver cirrhosis and the risk of variceal bleeding
What is the Blatchford score?
Risk stratification tool for determining whether patients with upper GI bleed require urgent endoscopy or whether it can be outpatient
What is the Rockall score?
Mortality predictor for patients with upper GI bleed
What is used for secondary prevention of variceal bleeding?
Propranolol
What is the treatment for active variceal bleeding?
- DR ABCDE approach
- Group and save, crossmatch 6 units
- Resuscitation, including transfusion if necessary
- IV antibiotics recommended for all patients with variceal bleeding
- Terlipressin until 5/7 after bleed stops
- Use Blatchford score to decide whether patient needs urgent or outpatient endoscopy
- Endoscopy for banding, scleotherapy
Stengstachen-Blackemore tube to tamponade bleeding - TIPS procedure
What is the pathological process in liver cirrhosis?
Fibrosis of hepatocytes, formation of nodules due to direct insult to hepatocytes
What is the King’s College Criteria for drug-induced liver failure?
- Arterial pH less than 7.3 less than 24 hours after ingestion
OR ALL of the following: - Prothrombin time more than 100s or INR more than 6.5
- Creatinine more than 300
- Grade III or IV encephalopathy
What is the King’s College criteria for non-drug induced liver failure?
- Prothrombin time more than 100s or INR more than 6.5
OR 3 out of 5 of the following: - Drug-induced liver failure
- Prothrombin time more than 50s or INR more than 3.5
- Bilirubin more than 300
- Age less than 10 or more than 40
- More than 1 week from first jaundice to encephalopathy
What drug might be useful in the treatment of ascites and why?
Spironolactone - Secondary hyperaldosteronism in liver failure due to low albumin states stimulating aldosterone production
How might ascites be managed?
Spironolactone
Loop diuretics
Salt and fluid restriction
Ascitic drain
What are the signs of decompensated liver disease?
Ascites
Jaundice
Hepatic encephalopathy
What drug is useful in the treatment of hepatic encephalopathy?
Lactulose - Reduces ammonia production
Why does hepatic encephalopathy occur in advanced liver disease?
Varices can open up in portal hypertension, and these varices can bypass the portal venous system and travel directly into the systemic circulation (a portal-systemic shunt). The liver normally filters out toxins e.g. ammonia, so blood from varices are unfiltered and so toxins can accumulate.
What is rifaximin used for?
Secondary prevention of hepatic encephalopathy
What are the causes of chronic liver disease?
Alcoholic liver disease
Metabolic liver disease: Wilson’s, haemochromoatosis, NASH, NAFLD
Drug-related liver disease
What is erythema ab igne?
Mottled dusky greyness on the abdomen seen in chronic pancreatitis
What are the causes of toxic megacolon?
Ulcerative colitis
Crohn’s disease
Pseudomembranous colitis
What is the main cause of chronic pancreatitis?
Alcohol
What does imaging show in chronic pancreatitis?
X-ray and CT show pancreatic calcification
What is the difference between a Mallory-Weiss tear and Boerhaave’s syndrome?
Mallory-Weiss = Linear lacerations at the gastro-oesophageal junction - not full thickness. Boerhaave's = Full thickness perforation of oesophagus
Compare the nature of the pain in a gastric ulcer to a duodenal ulcer
Gastric ulcer = Worsened by eating
Duodenal ulcer = Relieved by eating
What is Zollinger-Ellison Syndrome?
High levels of gastrin, usually from gastrinoma (might be seen in MEN1) which cause multiple gastroduodenal ulcers, diarrhoea, malabsorption.
What is Barrett’s oesophagus?
Metaplasia of oesophageal squamous epithelium into columnar cells due to chronic reflux and associated inflammation. Associated with increased risk of oesophageal malignancy so annual OGD required. High-dose PPI given.
List some causes of dysphagia
Neuromuscular e.g. myasthenia gravis Motility problem e.g. achalasia, oesophageal spasm Pharyngeal pouch Stricture - Benign: Oesophageal web - Malignant: Oesophageal cancer
What is Coeliac disease?
An autoimmune condition affecting the small bowel where an intolerance to gluten causes villous atrophy and malabsorption.
Which condition of the skin has an associated with coeliac disease?
Dermatitis herpetiformis
List some complications of coeliac disease
Anaemia Hyposplenism Dermatitis herpetiformis Osteoporosis Intestinal T cell lymphoma
What are the pathological features of Crohn’s disease?
Transmural inflammation, granulomas, increased goblet cells
What are the endoscopic findings in Crohn’s disease?
‘Cobblestone appearance’
Deep ‘rose thorn’ ulcers
Skip lesions
What are the main complications of Crohn’s disease?
Perforation Small bowel obstruction Abscess formation Fistulae formation (due to full-thickness involvement) Toxic megacolon Colon cancer
What are the pathological findings in ulcerative colitis?
- Continuous disease
- Does not extend proximal to ileocaecal valve
- Inflammation is NOT transmural
- Inflammatory infiltrates
- Reduced goblet cells
- Crypt abscesses
- Glandular distortion
- Mucosal ulcers
Are pseudopolyps typical of ulcerative colitis or Crohn’s?
Ulcerative colitis
What is a useful investigation to distinguish inflammatory bowel disease from IBS?
Faecal calprotectin - raised in IBD but not IBS
List some features which might be visible on abdominal x-ray of a patient with ulcerative colitis
Lead-pipe appearance of transverse colon
Loss of haustral markings
Thumb-printing
Toxic megacolon
What are the features of toxic megacolon?
Toxic: Fever, neurophilia, tachycardia, anaemia, dehydration, U+E disturbance, hypotension
Dilatation of the colon more than 6cm on AXR
What is the treatment for toxic megacolon?
Stool culture for ?infective cause
Fluid resuscitation
Drip and suck
Antibiotics
List some complications of ulcerative colitis
Perforation
Toxic megacolon
VTE
Colon cancer
What is the treatment for mild ulcerative colitis?
5-ASAs e.g. sulphasalazine, mesalazine
Short (2 week) course of steroids e.g. prednisolone
What test is required before commencing azathioprine therapy? Why?
TPMT (Thiopurine methyltransferase) test required as some patients may be prone to toxicity from azathioprine
Give some side effects of azathioprine
Bone marrow suppression
Pancreatitis
Hepatotoxicity
Nausea, vomiting
Primary sclerosing cholangitis is associated with ulcerative colitis or Crohn’s?
Ulcerative colitis
Which antibodies are associated with primary sclerosing cholangitis?
p-ANCA
Which antibodies are associated with primary biliary cirrhosis?
Anti mitochondrial antibodies
Give some features of primary sclerosing cholangitis
Fatigue
Itching
Cholestatic jaundice picture
Increased risk of colon cancer and cholangiocarcinoma
What investigations might you perform in suspected primary sclerosing cholangitis, and what might they show?
Bloods: p-ANCA, hypergammaglobulinaemia, LFTs show post-hepatic picture
ERCP: Beaded appearance of ducts
Liver biopsy: ‘Onion skin’ appearance
What is the treatment of primary sclerosing cholangitis?
Symptomatic e.g. cholestyramine for itching
Ursodeoxycholic acid
Liver transplantation
Compare the pathological process in primary biliary sclerosis and primary sclerosing cholangitis
PBC: Autoimmune inflammatory disorder of intra-lobular ducts where there is granulomatous inflammation causing cholestatis
PSC: Inflammation of intra- and extra-hepatic bile ducts causing fibrosis and stricture formation causing cholestasis
What is the treatment of primary biliary sclerosis?
Symptomatic:
- Itching = Cholestyramine, naltrexone, rifampicin
- Diarrhoea = Codeine phosphate
- Fat soluble vitamin prophylaxis = Vit A, D, K
Ursodeoxycholic acid may improve survival
Liver transplantation for end-stage disease
What is the most common cause of liver disease in the developed world?
NAFLD i.e. Non-alcoholic fatty liver disease
What might investigations show in Wilson’s disease?
Raised 24 hour urinary copper excretion
Low serum caeruloplasmin
Liver biopsy: High concentration of hepatic copper
What is the treatment for Wilson’s disease?
Low copper diet
Lifelong penicillamine
Liver transplantation
Screening for siblings
What are the causes of Duputren’s contracture?
Liver disease Alcohol excess Familial Manual labour Phenytoin
