Gastroentrology Flashcards
A classic presentation of pancreatic cancer?
painless jaundice
pale stools/ dark urine/ pruritus
Cholestatic liver function test
Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
*** other features
however, patients typically present in a non-specific way with anorexia, weight loss, epigastric pain
loss of exocrine function (e.g. steatorrhoea)
loss of endocrine function (e.g. diabetes mellitus)
atypical back pain is often seen
migratory thrombophlebitis (Trousseau sign) is more common than with other cancers
INV of pancreatic cancer
ultrasound has a sensitivity of around 60-90%
high-resolution CT scanning is the investigation of choice if the diagnosis is suspected
imaging may demonstrate the ‘double duct’ sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts
MGT of pancreatic cancer
less than 20% are suitable for surgery at diagnosis
a Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas
Side-effects of a Whipple’s include dumping syndrome and peptic ulcer disease
adjuvant chemotherapy is usually given following surgery
ERCP with stenting is often used for palliation
Hepatobiliary disease and related disorders
viral hepatitis
Congestive hepatomegaly
Biliary colic
Acute cholecystitis
Ascending cholangitis
Gallstone ileus
Cholangiocarcinoma
Acute pancreatitis
Pancreatic cancer
Amoebic liver abscess
Viral hepatitis
N/V, anorexia, myalgia, lethargy, RUQ pain- risk factors foreign travel or IVD use.
Congestive hepatomegaly
Biliary colic RUQ pain, intermittent, usually begins abruptly and subsides gradually. Attacks often occur after eating. Nausea is common.
Acute cholecystitis Pain similar to biliary colic but more severe and persistent. The pain may radiate to the back or right shoulder. pyrexia and +ve Murphy’s sign
Ascending cholangitis An infection of the bile ducts commonly secondary to gallstones. Classically presents with a triad of:
fever (rigors are common)
RUQ pain
jaundice
Gallstone ileus- SBO secondary to an impacted gallstone. It may develop if a fistula forms between a gangrenous gallbladder and the duodenum. Abdominal pain, distension and vomiting are seen.
Cholangiocarcinoma- Persistent biliary colic symptoms, associated with anorexia, jaundice and weight loss. A palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen
Acute pancreatitis- Usually due to alcohol or gallstones
Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) is described but rare
Pancreatic cancer Painless jaundice is the classical presentation of pancreatic cancer. However pain is actually a relatively common presenting symptom of pancreatic cancer. Anorexia and weight loss are common
Amoebic liver abscess Typical symptoms are malaise, anorexia and weight loss. The associated RUQ pain tends to be mild and jaundice is uncommon.
Crohn’s disease MGT: inducing remission
Advise pt to stop smoking
Inducing remission
- glucocorticoids is 1st line OR budesonide (in a subgroup of patients)
- enteral or elemental feeding
- 5-ASA (mesalazine) - 2nd line
- Azathioprine and mercaptopurine (add-on to induce remission but not use as monotherapy)
- infliximab can be used in refractory causes or in fistulating crohn’s
- metronidazole is used in isolated peri-anal disease
Crohn’s disease MGT: maintaining remission
stopping smoking is a priority (remember: smoking makes Crohn’s worse, but may help ulcerative colitis)
azathioprine or mercaptopurine is used first-line to maintain remission
+TPMT (thiopurine methyltransferase) activity should be assessed before starting (to prevent hepatotoxicity)
methotrexate is used second-line
surgery in Crohn’s disease
80% of pts with crohn’s end up having surgery
ileoceal resection
segemental small bowel resections
stricturoplasty
perianal fistulae
I&D for perianal fistulae
complications of crohn’s dx
small bowel cancer (standard incidence ratio = 40)
colorectal cancer (standard incidence ratio = 2, i.e. less than the risk associated with ulcerative colitis)
osteoporosis
complications of crohn’s dx
small bowel cancer (standard incidence ratio = 40)
colorectal cancer (standard incidence ratio = 2, i.e. less than the risk associated with ulcerative colitis)
osteoporosis
Drugs causing liver cholestasis (+/- hepatitis)
COCPs
antibiotics: flucloxacillin, co-amoxiclav,
erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas (glicazide)
fibrates
rare reported causes: nifedipine
Drugs causing hepatocellular
paracetamol
sodium valproate, phenytoin
MAOIs
halothane
anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
statins
alcohol
amiodarone
methyldopa
nitrofurantoin
Drugs that can cause liver cirrhosis
methotrexate
methyldopa
amiodarone
obesity + deranged LFTs
?non-alcoholic fatty liver disease
A BMI >30 kg/m², increased hepatic echogenicity on liver ultrasound, and an ALT:AST ratio >2 are strongly indicative of non-alcoholic fatty liver disease.
features of NAFLD
usually asymptomatic
hepatomegaly
ALT is typically greater than AST
increased echogenicity on ultrasound
what is included in the enhanced liver fibrosis (ELF) blood tests that are used to check for advanced fibrosis
the ELF blood test is a combination of hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1. An algorithm based on these values results in an ELF blood test score
MGT of NAFLD
lifestyle changes (particularly weight loss) and monitoring
Tests for H Pylori
Urea breath test
- avoid within 4 weeks of abx treatment, 2 weeks of PPI
- can be used to test for eradication
Rapid Urease test (biopsy)
Serum antibody test
- remains positive after eradication
Culture of gastric biopsy
Gastric biopsy
Stool antigen test
inheritance mode of haemochromatosis
Autosomal recessive
Presenting features of haemochromatosis
early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands)
‘bronze’ skin pigmentation- reversible
diabetes mellitus- irreversible
liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition)- irreversible
cardiac failure (2nd to dilated cardiomyopathy)- reversible
hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism)- irreversible
arthritis (especially of the hands)- irreversible
clotting profile in liver failure
all clotting factors are low except for factor VIII which is supra-normal
Carcinoid tumors/ syndrome
- features
- INV
- MGT
Features
- because of the effects of serotonin on ciruculation
- Diarrhea/ flushing/ itching/ bronchospasm/ hypotension/ rt valvular stenosis/ cushing’s syndrome/ pellagra
INV
- urinary 5-HIAA (hydroxyindoleacetic acid)
- plasma chromogranin A y
MGT
- somatostatin analogues e.g. octreotide
- diarrhoea: cyproheptadine may help
Monitoring patients with haemochromatosis
Ferritin and transferrin saturation are used to monitor treatment in haemochromatosis
Typical iron study profile in a patient with haemochromatosis
transferrin saturation > 55% in men or > 50% in women
raised ferritin (e.g. > 500 ug/l) and iron
low TIBC
How do you diagnose haemochromatosis + MGT
Dx
molecular genetic testing for the C282Y and H63D mutations
liver biopsy: Perl’s stain Diagnostic tests
molecular genetic testing for the C282Y and H63D mutations
liver biopsy: Perl’s stain
Joint x-rays characteristically show chondrocalcinosis
MGT
Venesection is the first-line treatment
monitoring adequacy of venesection: transferrin saturation should be kept below 50% and the serum ferritin concentration below 50 ug/l
desferrioxamine may be used second-line
IBD - similarities and differences
Both UC and CD have
- diarrhoea
- Arthritis
- Erythema nodosum
- pyoderma gangrenosum
CD
- Mouth –> anus skip lesions/cobble-stone
- all layers inflammed/ goblet cells/ granulomas
- bowel obstruction
- fistulae
UC
- ileocaecal valve -> rectum
- no inflammation beyond the submucosa, crypt abscesses
- associated with PSC
- higher risk of CA compared to CD
MGT of UC ( inducing remission)
mild- moderate
proctitis
-> topical/ rectal aminosalicylate (mesalazine) –> add on oral mesalazine if no resmission in 4 weeks –> if no remission then oral corticosteroids
procotsigmoiditis and lt sided UC
–> topical/ rectal aminosalicylate –> if no remission in 4 weeks then add high does oral aminosalicylate OR swich to high dose oral aminosalicylate and oral coritcosteroid
Extensive disease
–> topical/ rectal and oral aminosalicylate–> if no remission in 4 weeks then stop topical treatment and oral high dose oral aminosalicylate and steroid
=====================
Severe colitis
admit to hospital
IV steroids - if contraindicated then IV ciclosporin
if no improvement in 72hrs then add IV ciclosporin or consider surgery
MGT of UC (maintaining remission)
mild to moderate
Proctitis/ proctosigmoiditis
- topcia 5ASA alone , OR
- oral 5ASA + topical rectal 5ASA, or
- oral ASA as monotherapy (not as effective)
lt-sided and extensive UC
- low maintaenance does of an oral 5ASA
following a severe relapse or two or more exacerbations in the past year
- oral azathioprine or oral mercaptopurine
SBP
- features
- Diagnosis
- MGT
- Prophylaxis
Features
- ascites
- abdominal pain
- fever
Dx
- paracentesis - High neutrophil count >250cells/ul
- E coli is the most common orgamism
MGT
- IV Cefotaxime
Prophylaxias to a pt with ascites if
- previous episode of SBP
- fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
NICE recommend: ‘Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved’
Oseophageal cancer
- most common
Hx of GORD or reflux –>adenocarcinoma
smoking/ alcohol/ achalasia –> SCC
Dx, staging and MGT of oesophgeal CA
DX
- endoscopy and biopsy
Staging
- initial staging- CT
- if no mets seen/ occult mets suspected PET scan or laparoscopy
- locoregional staging - endoscopic US
Treatment
- operable dx –> ivor lewis oesophagectomy
- adjuvent chemotherapy
complication of ivor lewis oesophagecomty –> anastomotic leak –> mediastinitis
Iron defiency anaemia vs. anaemia of chronic disease
TIBC is high in IDA, and low/normal in anaemia of chronic disease
Anaemia of chronic disease
normochromic/hypochromic, normocytic anaemia
reduced serum and TIBC
normal or raised ferritin
Pernicious anaemia - Dx/ MGT/ Complications
Dx
- macrocytic anaemia
- maybe low plts and WCC
- antibodies
anti intrinsic factor antibodies: sensivity is only 50% but highly specific for pernicious anaemia (95-100%)
anti gastric parietal cell antibodies in 90% but low specificity so often not useful clinically
MGT
- Replace vit B12
- folic acid supplementation maybe required
Complications
- neuro features - subacute combined degeneration of the cord
- increased risk of gastric cancer
SEs of PPI
hyponatraemia, hypomagnasaemia
osteoporosis → increased risk of fractures
microscopic colitis
increased risk of C. difficile infections
SEs of PPI
hyponatraemia, hypomagnasaemia
osteoporosis → increased risk of fractures
microscopic colitis
increased risk of C. difficile infections
when should you avoid using metoclopramide
Metoclopramide should be avoided in bowel obstruction, but may be helpful in paralytic ileus.
Adverse effects
extrapyramidal effects
acute dystonia e.g. oculogyric crisis
this is particularly a problem in children and young adults
diarrhoea
hyperprolactinaemia
tardive dyskinesia
parkinsonism
when should you avoid using metoclopramide
Metoclopramide should be avoided in bowel obstruction, but may be helpful in paralytic ileus.
Adverse effects
extrapyramidal effects
acute dystonia e.g. oculogyric crisis
this is particularly a problem in children and young adults
diarrhoea
hyperprolactinaemia
tardive dyskinesia
parkinsonism
Primary biliary cholangitis
- associations
- Dx
- MGT
associated with sjogren syndrome/ RA/ systemic sclerosis/ thyroid disease
DX
- anti-mitochondrial antibodies
- smooth muscle antibodies
- rasied serum IgM
- imaging: ultrasound or MRCP
MGT
first-line: ursodeoxycholic acid slows disease progression and improves symptoms
pruritus: cholestyramine
fat-soluble vitamin supplementation
liver transplantation e.g. if bilirubin > 100 (PBC is a major indication)
recurrence in graft can occur but is not usually a problem
Coeliac disease - INV
- manifestiations include dermatitis herpitformis
serology
- TTG antibodies (first choice)
- endomyseal antibody (IgA)
serum IgA tissue transglutaminase antibody (tTGA) and total IgA are first line
- You cannot interpret TTG level in coeliac disease without looking at the IgA level
Endoscopic intestinal biopsy - either duodenum or jujenum (gold standard)
findings supportive of coeliac disease:
villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes
CLO for H pylori
Rapid urease test, also known as the CLO test (Campylobacter-like organism test), is a rapid diagnostic test for diagnosis of Helicobacter pylori.
What are the consequences of vitamin B6 deficiency
peripheral neuropathy
sideroblastic anemia
Metabolic ketoacidosis with normal or low glucose
Alcoholic Ketoacidosis
It typically presents with a pattern of:
Metabolic acidosis
Elevated anion gap
Elevated serum ketone levels
Normal or low glucose concentration
The most appropriate treatment is an infusion of saline & thiamine. Thiamine is required to avoid Wernicke encephalopathy or Korsakoff psychosis.
2WW for UGI cancer
All patients who’ve got dysphagia
All patients who’ve got an upper abdominal mass consistent with stomach cancer
Patients aged >= 55 years who’ve got weight loss, AND any of the following:
upper abdominal pain
reflux
dyspepsia
Deranged LFT + 2ndry amenorrhoea in a young woman
–> autoimmunie hepatitis
Features
may present with signs of chronic liver disease
acute hepatitis: fever, jaundice etc (only 25% present in this way)
amenorrhoea (common)
ANA/SMA/LKM1 antibodies, raised IgG levels
liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
Management
steroids, other immunosuppressants e.g. azathioprine
liver transplantation
MGT of variceal haemorrhages
ABC
correct clotting: FFP/ vitamin K
vasoactive agents
- Terlipressin (benefits intially to stop bleeding, prevent rebleed, and reduce mortality)
- Octreodie (not as good as terlipressin)
Prophylactic antibiotics were shown to reduce mortality in pts with cirrhosis (quinolones = cipro, are commonly used)
–> endoscopic band ligation (it is superior to sclerotherapy)
Sengstaken-blakemore tube if uncontrolled haemorrhage
Transjugular intrahepatic protosystemic shunt (TIPSS) if above measures fail
Prophylaxis of variceal haemorrhage
Propranolol
endoscopic variceal band ligation (EVBL)- perform at 2wkly intervals until all varices have been banded
PPI cover is given to prevent EVBL induced ulceration
5ASA SEs
Sulphasalazine - rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis
+ mesalazine side effects
Mesalazine - GI upset, headache, AGRANULOCYTOSIS, pancreatitis*, interstitial nephritis
Olsalazine
HCC
- most common cause
- features
Cirrhosis is the main risk factor
hepatitis B most common cause worldwide
hepatitis C most common cause in Europe
features
- Jaundice/ ascites/ RUQ pain/ hepatomegaly/ pruritis/ splenomegaly
- decompensated LF in pts with CLD
- raised AFP
MGT
- early dx –> surgical rescetion
- liver transplation
- radiofrequency ablation
- transarterial chemoembolisation
- sorafenib: a multikinase inhibitor
A combination of liver and neurological disease points towards ?
Wilson’s disease
Wilson dx
- features
- INV
- MGT
Features (copper deposition in the brain/ liver/ cornea)
- hepatitis/ cirrhosis
- speech/ behavioural. psychiatric problems
- asterixis/ chorea/ dementia. parkinsonism
- kayser-fleishcer rings
- renal tubular acidosis ( esp fanconi syndrome)
- haemolysis
- blue nails
INV
- slit lamp examination for kayser-fleisher rings
- reduced serum caeruplasmin
- reduced total copper but increased free copper
- incrased 24hrs urinary copper excretion
- genetic analysis to confirm the diagnosis
MGT
- Penicillamine - first line
- trientine hydrochloride
Peutz-Jeghers syndrome
- mode of inheritance
- features
- MGT
autosomal dominant
features
hamartomatous polyps in the GI tract (mainly small bowel)
SBO is a common presenting complaint, often due to intussusception
GI bleeding
pigmented lesions on lips, oral mucosa, face, palms and soles
Management
conservative unless complications develop
Primary biliary cholangitis
rule of M
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
alcohol screening tools
AUDIT and AUDIT-C
FAST
CAGE
Diagnosis
ICD-10
(3 or more needed)
- compulsion to drink
- difficulties controlling alcohol consumption
- physiological withdrawal
- tolerance to alcohol
- neglect of alternative activities to drinking
- persistent use of alcohol despite evidence of harm
Extra-intestinal manifestations of IBD
Related to disease acitivity
- Arthritis: pauciarticular, asymmetric
- Erythema nodosum
- Episcleritis
- Osteoporosis
Unrelated to dx activity
- Arthritis: polyarticular, symmetric
- Uveitis
- Pyoderma gangrenosum
- Clubbing
- Primary sclerosing cholangitis
Arthritis is the most common extra-intestinal feature
Extra-intestinal manifestations of IBD
Related to disease acitivity
- Arthritis: pauciarticular, asymmetric
- Erythema nodosum
- Episcleritis
- Osteoporosis
Unrelated to dx activity
- Arthritis: polyarticular, symmetric
- Uveitis
- Pyoderma gangrenosum
- Clubbing
- Primary sclerosing cholangitis
Arthritis is the most common extra-intestinal feature
mild/ moderate/ severe UC flare ups
Mild
Fewer than four stools daily, with or without blood
No systemic disturbance
Normal erythrocyte sedimentation rate and C-reactive protein values
Moderate
Four to six stools a day, with minimal systemic disturbance
Severe
More than six stools a day, containing blood
Evidence of systemic disturbance, e.g.
fever
tachycardia
abdominal tenderness, distension or reduced bowel sounds
anaemia
hypoalbuminaemia
MGT of toxic megacolon
- aggresive medical therapy for the first 24-72 hours
if there is no sign of improvement - colectomy is performed
Dysphagia affecting both solids and liquids from the start?
condition
INV
MGT
Achalasia
INV
- manometry
- barrium swallow
- CXR
MGT
- Pneumatic (balloon) dilation - first line
- Heller cardiomyotomy
- intra-sphincteric infection of botulin toxin in pt with high surgical risk
- drug therapy (nitrates + CCB)
Classification of SAAG into?
> 11 -> this indicated portal hypertension
<11 -> nephrotic syndrome/ severe malnutrition/ malignancy/ infections TB
MGT of ascites
- reduce Na in diet
- fluid restriction (if Na is less 125)
- aldosterone antagonist - spironolactone
- drain if tense ascites
- prophylactic abx to reduce risk of SBP using copra or norfloxacin if ascitic protein is 15g/l or less
- TIPS
