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Pocket MSRA - Book 1 > Gastroenterology & Hepatology > Flashcards

Gastroenterology & Hepatology Flashcards

1
Q

What is Achalasia and what mechanism underlies it?

A

Motility disorder of the lower oesophagus
Degeneration of Auerbach’s plexus
-uncoordinated peristalsis
-lower sphincter fails to relax

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2
Q

How does achalasia present?

A

Dysphagia for both solids AND liquids
Halitosis
Increased risk of SCC

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3
Q

How can achalasia be investigated?

A

Manometry - high pressure
Barium swallow - Bird’s beak/dilated tapering of oesophagus

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4
Q

How is achalasia treated?

A

CCB/nitrates
Endoscopic dilation
Heller’s myotomy

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5
Q

What is the MoA of Cyclizine as an anti-emetic and in which circumstances is it effective?

A

H1 antagonist
GI causes
Emetogenic chemo
PONV
Vestibular causes

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6
Q

What D2 antagonists are commonly used as antiemetics?

A

Metoclopramide
Haloperidol
Domperidone
Prochlorperazine

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7
Q

In which circumstances are D2 antagonists effective as antiemetics?

A

GI causes
Emetogenic chemo
Vestibular causes
Opiates

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8
Q

What are the side effects of D2 antagonists?

A

Prokinetic (not used in BO)
Dystonias
Oculogyric crises

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9
Q

What is the MoA of Ondansetron as an anti-emetic and in which circumstances is it effective?

A

5-HT3 antagonist
Emetogenic chemo
Surgery

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10
Q

What scoring systems can be used for UGI bleeds?

A

Rockall
Glasgow-Blatchford

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11
Q

Describe the Rockall score

A

Risk stratification (mortality)
Done pre/post endoscopy

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12
Q

What criteria make up the Rockall score?

A

Age
Shock
Co-morbidity
POST-ENDOSCOPY DX
SIGNS OF HAEMORRHAGE ON ENDOSCOPY

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13
Q

Describe the Glasgow-Blatchford Score

A

Risk stratifies patients for inpatient vs outpatient endoscopy in UGI bleed

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14
Q

What is a Mallory-Weiss tear?

A

Mucosal tear caused by persistent vomiting or retching
-arterial bleed
-self limiting

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15
Q

What are the complications of a Mallory-Weiss tear?

A

Generally self limiting
Boerrhave syndrome

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16
Q

What is Boerrhave syndrome?

A

Oesophageal RUPTURE due to vomiting against closed glottis

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17
Q

How does Boerrhave syndrome present?

A

SEVERE retrosternal chest pain
Respiratory distress
SC emphysema
-Hamman sign

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18
Q

What is Hamman sign?

A

Crunching sound on ascultation due ot mediastinal emphysema

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19
Q

What are the common causes of UGI bleeds?

A

Mallory-Weiss tears
Peptic ulcers
Varices

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20
Q

How can gastric and duodenal ulcers be distinguished?

A

Gastric ulcers - pain WITH meals
Peptic ulcers (4x more common) - pain AFTER meals

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21
Q

What are the risk factors for gastric ulcers?

A

H. pylori infection
Smoking
NSAIDs/steroids
Reflux
Delayed gastric emptying
Burns (Curling’s ulcer)
Neurosurgery (Cushing’s ulcer)

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22
Q

What are the risk factors for peptic ulcers?

A

H. pylori infection
Smoking
NSAIDs/steroids
Increased gastric emptying
Blood group O

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23
Q

What is Zollinger-Ellison syndrome?

A

Gastrin secreting pancreatic adenoma
-associated w/ MEN 1

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24
Q

When should Zollinger-Ellison syndrome be suspected?

A

Multiple ulcers of stomach/duodenum
FHx
Associated w/ MEN 1
-parathyroid adenoma –> sx hypercalcameia

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25
How should Zollinger-Ellison syndrome be ix?
Gastrin levels Scintigraphy (octreoscan) Check for hepatic mets (20%)
26
Why are post. duodenal ulcers high risk?
Near to gastroduodenal aa -can erode into it
27
How should UGI bleeds be managed?
Airway, NBM IVI + RBC + correct clotting abnormalities Abx cover Urgent endoscopy +/- -endotherapy -embolisation (IR) or surgery -sengsataken-blakemore tube 72hrs PPI POST-ENDOSCOPY If variceal -Terlipressin -TIPS
28
How does Terlipressin work?
Vasoconstriction -reduces portal pressure -renoprotective
29
What is the major s/e of Terlipressin?
Vasoconstriction of coronary vessels -arrhythmias -MI
30
What is the TIPS procedure?
Trans-jugular intrahepatic portal systemic stenting
31
What are the common s/e of PPIs?
Hyponatraemia/hypomagnesaemia Diarrhoea (C. diff) Tubular interstitial nephritis Osteoporosis Interacts w/ Clopidogrel
32
How does GORD present?
Dyspepsia post meals Water-brash (salivation) Nocturnal asthma Chronic cough/sore throat Sinusitis
33
What are the two types of hiatus hernia?
Sliding (most common) Rolling (para-oesophageal) -higher risk of strangulation
34
What lifestyle advice should be given for GORD?
Stop smoking Small regular meals Reduce hot drinks/EtoH/citrus/spicy food/caffeine Avoid eating <3hr before bed Sleep more upright
35
How can GORD be managed medically?
Antacids PPI H2RA if refractory
36
How can GORD be managed surgically?
Nissen fundoplication Hiatal hernia repair
37
What are the common s/e of H2 receptor antagonists?
Diarrhoea/GI upset Liver dysfunction CYP450 inhibition - CIMETIDINE ONLY
38
What are the common causes of dyspepsia?
Ulcers GORD Oesophagitis/gastritis/duodenitis Malignancy
39
What are the red-flag sx for gastric ca in dyspeptic patients?
ALARMS 55 Anaemia Wt loss Anorexia Recent onset/progressive sx Melaena/haematemesis Swallowing difficulties >55
40
How should dyspepsia be treated?
If ALARMS 55 +ve - 2ww gastroscopy If ALARMS 55 -ve -lifestyle changes and 4/52 review -if no improvement test/treat H. pylori
41
How should H. pylori infection be ix?
C13 breath test
42
How is H. pylori infection treated?
Triple therapy 4/52 -PPI -Amoxicillin -Clarithromycin/Metronidazole
43
How can functional dyspepsia be managed?
PPIs CBT Low-dose amitriptylien ON
44
What is Barrett's oesophagus?
Metaplasia of stratified squamous to columnar epithelium 2o GORD -risk of progression to adenocarcinoma
45
How should Barrett's oesophagus be managed?
If no dysplasia AND <3cm --> discharge If no dysplasia AND >3cm --> surveillance every 2-3 years If low-grade dysplasia --> repeat endoscopy 6/12 +/- RF ablation If high-grade dysplasia or carcinoma-in situ --> endoscopic resection +/- RF ablation
46
What are the distinguishing features of Ulcerative Colitis?
Mucosal/submucosal (superficial) Rectum to caecum (continuous) LLQ pain w/ bloody diarrhoea Crypt abscesses Pseudo-polyps, haustral loss (lead-piping) Smoking PROTECTS Middle aged males
47
What are the distinguishing features of Chron's?
Full-thickness w/ fissures/fistula Mouth to anus (skip lesions) RLQ pain w/ non-bloody darrhoea Lymphoid aggregates w/ granulomas Cobblestone appearance, strictures Smoking INCREASES RISK M=F
48
What are the extra-intestinal manifestations of UC?
Arthritis (ank spond) Uveitis Erythema nodosum Pyoderma gangrenosum PRIMARY SCLEROSING CHOLANGITIS p-ANCA positive
49
What are the extra-intestinal manifestations of Chron's?
Arthritis (ank spond) Uveitis Erythema nodosum Pyoderma gangrenosum OXALATE STONES (renal colic)
50
What are the complications of UC?
Toxic megacolon Ca
51
What are the complications of Chron's?
Malabsorption Fistula Ca
52
What is the Truelove-Witts score and what criteria are included in it?
Severity score for UC -motions/day -PR bleed -fever -resting HR -Hb -ESR
53
What maintenance therapy is used for UC?
Mild - 5-ASA (mesalazine) Moderate -steroids (remission) then 5-ASA -monoclonal biologics
54
What is the management of severe/acute UC?
Admission IV/PR steroids Ciclosporin/Infliximab if poorly responding Colectomy if not improving/toxic megacolon
55
What maintenance therapy is used for Chron's?
Mild/Mod -steroids PO/PR -azathioprine/6-mercaptopurine --> methotrexate -monoclonal biologics
56
What levels should be checked before starting Azathioprine/6-mercaptopurine in Chron's?
Thiopurine methyltransferase/TPMT activity -if low/absent use MTX instead
57
What surveillance is offered in IBD?
Colonoscopy -if presenting w/ sx >10 yrs High risk - every 1 yr Intermediate risk - every 3 yrs Low risk - every 5 yrs
58
How does infective colitis present?
Profuse watery diarrhoea - characteristic smell in C. diff Raised inflammatory markers/low albumin Pseuodemembrane on endoscopy
59
What are the complications of infective colitis?
Ileus --> toxic megacolon (>5.5cm) --> perforation Complications of diarrhoea/volume loss e.g. AKI
60
What drugs should be avoided in infective colitis?
Antibiotics PPIs Anti-spasmodics
61
How should infective colitis be managed?
Metronidazole +/- Vancomycin Colectomy if uncontrolled
62
How does infective gastroenteritis present?
Predominantly vomiting More rapid onset Can cause bloody diarrhoea
63
What are the common bacterial causes of food poisoning and which foods are they found in?
Campylobacter - poultry Salmonella - poultry, uncooked eggs S. aureus - sliced meat, creams B. cereus - reheated rice/soup Listeria - unpasteurised milk, refrigerated meat, raw veg E. coli - unpasteurised milk, raw fruit/veg, undercooked ground beef Norovirus - shellfish
64
What are the key characteristics of Norovirus?
1/7 incubation 2/7 D&V V. infectious - spread by food/contact Dx - stool antigen
65
What are the key characteristics of Rotavirus?
1-3/7 incubation 1/52 D&V Dx - stool antigen PPx - live vaccine 12/52 & 8y/o
66
What are the key characteristics of Campylobacter jejuni?
2-5/7 incubation Dysentery + pain + headache Tx - Clarithyromcyin/Ciprofloxacin Cx - Sepsis, hepatitis, pancreatitis, reactive arthritis, GBS, miscarriage
67
What are the key characteristics of Salmonella?
6hr-3/7 incubation Dysentery + cramps Tx - Clarithromycin/Ciprofloxacin Cx - Sepsis, meningitis, osteomyelitis + septic arthritis
68
What are the key characteristics of Staph aureus?
30min-6hr incubation Sudden D&V + cramps
69
What are the key characteristics of Bacillus cereus?
8-16hr incubation D&V - self limiting
70
What are the key characteristics of Listeria monocytogenes?
Variable incubation Flu-like sx --> diarrhoea if immunocompromised Tx - amoxicillin Cx - abscess, endocarditis, mengoencephalitis, pregnancy loss, preterm delivery
71
What are the key characteristics of E.coli ?
0157:H7 E.coli (shiga toxin producing) --> haemorrhagic colitis Cx - 10% HUS, renal damage DO NOT GIVE ABX - increases risk HUS
72
What are the key characteristics of Shigella?
1-2/7 incubation Dysentery, tenesmus Cx - reactive arthritis, HUS, megacolon
73
What are the key characteristics of Vibrio cholorae?
2-5/7 incubation Watery diarrhoea Tx - electrolyte replacement
74
What are the key characteristics of Giardia?
1-3/52 incubation Faecal-oral spread Persistent diarrhoea, flatulence, bloating, malabsorption sx (weeks - months) Dx - stool microscopy, need 3 samples Tx - metronidazole
75
What are the key characteristics of Cryptosporidium?
Self-limiting diarrhoea in immunocompetent Severe/chronic in immunosuppressed
76
What are the key characteristics of Enatamoeba histolytica?
Faecal-oral spread Dx - microscopy Tx - metronidazole Cx - liver abscess, toxic megacolon, appendicits
77
What are the presenting features of Coeliac disease?
Steatorrhoea Wt loss Anaemia (B12/folate) +/- B12 neuropathy
78
What are the extraintestinal manifestations of Coeliac disease?
Dermatitis herpetiformis Osteoporosis/osteopenia Hyposplenism --> need flu/pneumococcal vaccines GI T-cell lymphoma/ca
79
How should suspected Coeliac disease be ix?
Anti-Ttg -check IgA levels alongside Duodenal bx Trial gluten-free diet
80
How is coeliac disease tx?
Gluten free diet lifelong Dapsone - dermatitis herpetiformis
81
What are the diagnostic criteria for IBS?
Rome criteria Recurrent abdo pain >1/7 per week in last 3 /12 AND >2 of -defecation related/relieved -change in stool frequency -change in stool form -no red flags
82
How should IBS be managed?
Constipation-predominant -water/fibre intake -bulk forming laxatives (macrogol) -stimulant laxatives(senna) Diarrhoea-predominant -loperamide Colic/bloating -anti-spasmodics (mebeverine, hyoscine) Visceral pain -low dose Amitriptyline FODMAP diet
83
What are the consequences of B1 (thiamine) deficiency?
Wernicke encephalopathy -confusion + opthalmoplegia + ataxia Korsakoff syndrome -psychosis + personality change + permanent memory loss Dry beriberi -polyneuritis w/ muscle wasting Wet beriberi -high output HF
84
What are the consequences of B2 (riboflaviin) deficiency?
Cheilosis of lips
85
What are the consequences of B3 (niacin) deficiency?
Pellagra -dermatitis -diarrheoa -dementia -death
86
What are the consequences of B6 (pyridoxine) deficiency?
Neuropathy Seizures Sideroblastic anaemia S/e of Isoniazid
87
What are the consequences of B9 (folate) deficiency?
Megaloblastic anaemia
88
What are the consequences of B12 (cobalamin) deficiency?
Megaloblastic anaemia Subacute combined degeneration of cord
89
How does Subacute combined degeneration of cord present?
Loss of proprioception/vibration sense (dorsal column) Pyramidal/UMN signs + distal paraesthesia (lateral corticospinal) Ataxia (spinocerebellar) Mixed LMN/UMN
90
What are the consequences of Vit A deficiency?
Night blidness Keratomalacia Sicca/xeropthalmia Bitot spots Immunosuppression Dry skin
91
What are the consequences of Vit D deficiency?
Decreased Ca/PO4 High PTH - 2o hyperparathyroidism High ALP Rickets (children) OR osteomalacia (adults) -bony pain & weakness
92
What are the consequences of Vit E deficiency?
Haemolytic anaemia Blisters Neurological presentation similar to SACDC
93
What are the consequences of Vit K deficiency?
Clotting defects (protein C, S, factors 2/7/9/10)
94
What are the consequences of Vit C (ascorbate) deficiency?
Scurvy -swollen gums -petechiae -poor wound healing
95
Which vitamins are fat-soluble?
ADEK
96
What are the distinguishing features of pre-hepatic jaundice?
Increased UNCONJUGATED bilirubin Increased urobilinogen Normal urine/stools Gallstones
97
What are the distinguishing features of hepatic jaundice?
Increased UNCONGJUGATED/CONJUGATED bilirubin Dark urine Normal stools
98
What are the distinguishing features of post-hepatic jaundice?
Increased CONJUGATED bilirubin Decreased urobilinogen/sterocobilinogen Dark urine Pale stools + steatorrhoea Pruritis
99
What are the causes of pre-hepatic jaundice?
Haemolysis Ineffective EPO (B12 deficiency)
100
What are the causes of hepatic jaundice?
Hepatitis Cirrhosis Drugs Gilbert's
101
What are the causes of post-hepatic jaundice?
Cholangitis Pancreatitic ca Cholangiocarcinoma Parasites Liver flukes Strictures
102
What is Gilbert's syndrome?
Intermittent jaundice during times of stress Due to lack of UGT-1A1 activity (conjugates bilirubin) BENIGN
103
What commonly prescribed drugs are hepatotoxic?
Paracetamol TB drugs Valproate Statins COC MAO inhibitors Halothane anaesthetics
104
What are the LFT changes of alcoholic liver disease?
AST>ALT High bilirubin Normal ALP High GGT (Macrocytosis)
105
What are the LFT changes of NAFLD?
Mildly raised ALT (ALT > AST)
106
What are the LFT changes of ischaemic liver disease?
ALT ++++ High LDH
107
What are the LFT changes of drug induced liver disease?
ALT ++++
108
What are the LFT changes of acute viral hepatitis?
ALT +++ High bilirubin
109
What are the LFT changes of chronic viral hepatitis?
ALT ++
110
What are the LFT changes of autoimmune hepatitis?
ALT +++ (in young woman of child-bearing age)
111
What are the LFT changes of a cholestatic problem?
High ALP & GGT (>AST/ALT)
112
What are the potential causes of a massively raised ALT (1000s)?
Acute viral hepatitis Drug-induced/toxic Ischaemic liver disease (Budd-Chiari) Autoimmune liver disease
113
What are the complications of alcohol hepatitis?
Cirrhosis Portal HTN --> ascites, splenomegaly, portosystemic shunts HCC risk Malnutrition --> peripheral neuropathy, macrocytic anaemia Dilated cardiomyopathy
114
What are the common complications of alcohol withdrawal?
Delirium tremens -visual/tactile hallucinations + haemodynamic instability + confusion/tremors --> seizures -10-72hrs Wernicke/Korsakoff's
115
How should acute alcohol withdrawal be managed?
Thiamine (Pabrinex) Chlordiazepoxide
116
What are the consequences of liver failure?
Failure of synthetic function - clotting, low Alb, low oestrogen (UGI bleed) Failure of metabolic function - hypoglycaemia, jaundice Failure of toxin clearance - encephalopathy, sepsis Abnormal haemodynamics Hepatorenal syndrome
117
How should liver failure be managed?
Diet - low salt/fluid restricted Spironolactone high dose Paracentesis (replace w/ HAS) TIPS
118
What is spontaneous bacterial peritonitis?
Infection of ascitic fluid -WCC >300-500 million/L -neutrophils >250 million/L
119
What organisms commonly cause spontaneous bacterial peritonitis?
E. coli Klebsiella Streptococci
120
What is the management of spontaneous bacterial peritonitis?
Tx - IV Ceftriaxone (empirical) + targeted abx PPx - PO Ciprofloxacin
121
How should hepatorenal syndrome be managed?
Stop diuretics Salt-poor albumin infusion Dialysis/TIPS/transplant Avoid hypoK
122
How does acute/decompensated liver failure present?
Triad of: -jaundice -upper GI bleed/coagulopathy -encephalopathy
123
What medications should be avoided in acute liver failure?
Constipating meds Sedatives PO hypoglycaemics 0.9% NaCl CYP450 inhibitors Hepatotoxics
124
How should encephalopathy in acute liver failure be managed?
Reduce nitrogen load -avoid constipation/UGI bleed/transfusion/AKI Tx - Lactulose (traps Ammonia in gut) PPx - Rifaximin (kills nitrogen forming gut flora)
125
What scoring system can be used to assess Cirrhosis, and what criteria are included?
Child-Pugh -encephalopathy -ascites -bilirubin -PT -ascites
126
What are the risk factors for NAFLD?
Age Obesity Dyslipidaemia Diabetic HTN/vasculopathy
127
How should suspected NAFLD be ix?
Elastrography USS (fibroscan) Biopsy
128
How should NAFLD be managed?
Address obesity/cardiovascular risk factors Avoid EtoH
129
What are the key features of Hepatitis A?
2-6/52 incubation Constitutional sx + arthralgia Spread by faecal-oral route
130
What are the key features of Hepatitis E?
Constitutional sx + arthralgia Present in pigs, seafood and contaminated water High mortality in pregnancy --> fulminant hepatitis
131
What are the key features of Hepatitis B?
DNA virus 1-6/12 incubation Spread by blood/sex
132
What is significant about the presence of HBeAG/HBV DNA?
Indicates infectivity
133
What is significant about the presence of HBcAb (core)?
Not present in vaccinated groups Implies acute/past infection
134
What is the management of Hepatitis B?
PPx - vaccination Tx - INF a, Tenofovir
135
What are the non-hepatic complications of Hepatitis B?
Polyarteritis nodosa Membranous nephropathy
136
What are the key features of Hepatitis C?
RNA virus Spread by blood Chronic cirrhosis HIV co-infection common
137
What is the management of Hepatitis C?
Sofosbuvir/ledipasvir (inhibitors) Ribavirin (nucleoside analogue) HIV testing/treatment
138
What do anti-HCV/HCV PCR indicate about Hepatitis C infection?
Anti-HCV = exposure HCV PCR = ongoing/chronic
139
What are the complications of Hepatitis C?
Cryo-globulinamaemia Autoimmune disease (hepatitis, polymyositis, thyroiditis) Porphyria
140
What infective causes of hepatitis are there?
Hepatitis viruses EBV CMV MALARIA Yellow fever Leptospirosis
141
What is Fitz-High-Curtis syndrome?
Liver capsule inflammation due to transabdominal spread of chlamydia/gonorrhoea RUQ pain +/- PID +/- 'violin-string' adhesions
142
What are the two types of autoimmune hepatitis?
Type 1 (80%) - anti SM +ve, sometimes ANA + Type 2 - LKM1 +ve, ANA negative
143
What is the management of autoimmune hepatitis?
Steroids AZA Ciclosporin Transplant
144
What is Budd-Chiari syndrome?
Infarction of liver 2o hepatic vv obstruction
145
How does Budd-Chiari syndrome present?
PAINFUL hepatomegaly Ascites Abdo pain Cardiovascular shock
146
What are the risk factors for Budd-Chiari syndrome?
HCC Steroids
147
What is the management of Budd-Chiari syndrome?
Surgery -100% mortality if not treated
148
What are the distinguishing features of primary biliary cholangitis?
Middle aged women Obstructive jaundice Malabsorption Anti-mitochondrial Ab +ve ALP/cholesterol +++ Cirrhosis/HCC
149
What are the distinguishing features of primary sclerosing cholangitis?
Middle aged men w/ IBD Malabsorption Periductal fibrosis w/ onion-skin appearance MRCP - beaded appearance pANCA +ve ALP +++ High risk for cholangiocarcinoma
150
What is primary biliary cholangitis?
Autoimmune granulomatous destruction of INTRAHEPATIC bile duct
151
What is primary sclerosing cholangitis?
Fibrotic (strictures) of intra AND extrahepatic bile ducts
152
What are the common genetic causes of liver disease?
Wilson's Haemochromatosis A1AT
153
What is the underlying mechanism of Wilson's disease?
ATP7B ATPase mutation Lack of copper transport --> accumulation
154
What is the inheritance pattern of Wilson's disease?
Autosomal recessive
155
How does Wilson's disease present?
Haemolysis Arthritis, grey skin, blue nails Kayser-Fleischer rings CNS --> movement disorders + cognitive decline + depression
156
How should suspected Wilson's disease be ix?
24hr urinary excretion LFTs (mod raised) Serum Ca/caeruloplasmin LOW Biopsy Gene testing
157
What is the management of Wilson's disease?
Lifelong Penicillamine Liver transplant Avoid high copper foods - liver, chocolate, nuts, mushroom, shellfish
158
What are the s/e of Penicillamine?
Drug-induced lupus Nephrotic syndorme Pancytopenia
159
What is the underlying mechanism of haemochromatosis?
HFE mutations --> increased intestinal Fe absorption --> Fe excess
160
How does haemochromatosis present?
Arthritis + pseudogout of knee Slate-grey pigmentation Chronic liver disease --> HCC Dilated cardiomyopathy Insulin-dependent diabetes Hypongadism
161
How should suspected haemochromatosis be ix?
Ferritin/transferrin sats HIGH LFTs (mod raised) Biopsy (w/ Perl's/Prussian blue stain)
162
How is haemochromatosis managed?
Regular venesection Chelators (Desferrioxamine) Avoid Fe rich foods
163
What is the underlying mechanism of A1AT deficiency?
Inability to transport serine protease inhibitor out of liver Presents w/ liver/lung disease
164
How should suspected A1AT deficiency be ix?
A1AT levels (low) Spirometry (obstructive) Liver biopsy Genotyping
165
How should A1AT deficiency by managed?
Smoking cessation Vaccines IV A1AT Lung/liver transplant
166
What 1o tumours commonly metastatize to the liver?
Breast Bronchus Bowl Babies (uterus)
167
What are the risk factors for HCC?
Hep B/C Cirrhosis NAFLD Anabolic steroids Aflatoxin (aspergillus)
168
What benign masses are commonly found in the liver?
Haemangioma Adenomas -associated w/ COCP, anabolic steroids, pregnancy

Pocket MSRA - Book 1 (7 decks)

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