Gastrointestinal Flashcards
Is PSC or PBC associated with IBD?
Primary sclerosing cholangitis (PSC)
What disease is associated with IBD?
Primary sclerosing cholangitis
Is PSC associated with IBD?
yes
Is PBC associated with IBD?
no
what is the typical PBC patient?
middle aged woman presenting with: pruritus + jaundice + pigmentation
What is the typical PSC patient?
usually the middle-aged man presenting with: pruritus + jaundice + abdominal pain
raised ALP, negative AMA
associated with IBD
features of Crohn’s disease
mouth - anus can be affected
weight loss, diarrhoea, abdo pain, strictures, fistulae
cobble-stoning (barium), rose-thorn ulcers, granulomas
features of UC
colon only
diarrhoea + blood/mucus
fever, tachycardia, toxic megacolon in severe acute UC
barium: loss of haustra, sigmoid - oedematous, friable mucosa
what does elevated AST and ALT with AST > ALT suggest?
alcoholic hepatitis/liver dysfunction
what does elevated AST and ALT with ALT > AST suggest?
viral hepatitis
What would a raised GGT and ALP suggest?
bile obstruction
what is the pathophysiology of achalasia?
ganglion cell degeneration in the mesenteric plexus. this leads to loss of inhibitory cells causing over stimulation of the LOS and failure to relax -> dysphagia
what are the most common causes of ascending cholangitis?
gallstones or strictures (benign or malignant in the bile duct)
what are the forms of alcohol liver disease?
alcoholic fatty liver
alcoholic hepatitis
chronic cirrhosis
what are the presentations of decompensated liver failure?
jaundice
ascites
hepatic encephalopathy
variceal haemorrhage
what 2 antibiotics are generally used to cover GI organisms?
cefuroxime and metronidazole
what are the major types of autoimmune hepatitis?
TYPE 1 - 80%, classic
all ages, mainly young women. ANA, ASMA, AAA, anti-SLA
TYPE 2 - young girls w/ other autoimmune disease (e.g. thyroid). ALKM-1 antibodies and ALC-1 antibodies
what are the changes that occur in Barret’s oesophagus?
the normal squamous epithelium is replaced by columnar epithelium
what are the symptoms of GORD?
heartburn
nausea
water-brush
bloating, belching
burning pain on swallowing
dry cough at night
what is a cholangiocarcinoma?
it is a primary adenocarcinoma of the biliary tree
what is the association with cholangiocarcinoma?
generally a rare condition but related to parasite infections
whats the most common type of gallstone?
what are the other types?
most common = mixed stone
pure cholesterol stone, pigment stones
what might cause cholecystitis in the absence of a gallstone?
starvation
TPN
narcotic analgesia
immobility
what kind of gallstones are haemolytic anaemias such as sickle cell a risk factor for?
pigment stones
how would you manage cholecystitis?
if just biliary colic advise low fat diet
acute cholecystitis -> analgesia, anti-emetics, NMB, IV fluids, antibiotics if signs of infection
cholecystectomy (open or laparoscopic), either elective or urgent
what is the difference between compensated and decompensated cirrhosis?
in compensated the patient has clinical and histological findings of cirrhosis but synthetic function of liver is intact
in decompensated cirrhosis the synthetic function of the liver is impaired with complications
what are the most common causes of cirrhosis?
alcoholic liver disease (2nd to alcoholism)
chronic hepatitis C or B infections
causes of cirrhosis?
alcohol
autoimmune - AI hepatitis, PBC, PBC
viral - hepatitis B + C
drugs - amiodarone, methotrexate
genetic - haemochromatosis, wilson’s, alpha-1 anti def
Budd-chiari syndrome
NASH
what clotting factors are made by the liver?
2, 7, 9, 10
what is the worst Child-Pugh grading for cirrhosis?
stage C
(A is the mildest), scores > 8 mean high risk for bleeds
what procedure might help reduce portal HTN?
TIPS procedure
what is the definitive treatment for cirrhosis?
liver transplant
what are the common causative organisms of SBP?
E. coli and kleibsella
what is coeliac disease?
when T cells respond to gluten causing an intolerance reaction which over time leads to villous atrophy, crypt hyperplasia and malabsorption
lose immune tolerance to gliadin peptide antigens
what skin condition is a sign of coeliac disease?
dermatitis herpetiformis
what is the most common type of colon cancer?
adenocarcinoma
what is the typical presentation of a left sided malignancy?
PR bleeding + mucus
altered bowel habit
tenesmus/ PR mass
less common - obstruction
what is the typical presentation of a right sided malignancy?
constitutional symptoms (FLAWS) iron deficiency anaemia weight loss abdominal pain/discomfort in the lower abdo (rare)
what is the tumour marker for colon cancer?
CEA
what might be seen on barium enema in patients with colon cancer?
apple core lesions
where does colon cancer often metastasis to?
liver
lung
bone
what is a sister mary joseph nodule a sign of?
metastatic abdominal cancer
what are common triggers for GORD?
hot drinks
alcohol
citrus fruits
tomatoes
fizzy drinks
spicy foods
coffee
chocolate
what pharmacological therapy can be given to GORD patients?
antacids and alginates (gaviscon) from OTC
PPI (lansoprazole 30mg) up to twice a day H2 antagonist (ranitidine) if incomplete response to PPI
what are the causes of a bloody infectious diarrhea?
CHESS
Campylo
entamoeba Histolytica
E. coli
Shigella
Salmonella
what might cause large bowel perforation?
diverticulitis
colon cancer
appendicitis
volvulus
toxic megacolon (UC)
what might cause gastric or duodenal perforation?
duodenal or gastric ulcer perforation
gastric cancer
what might cause small bowel perforation?
in general very rare
trauma
infection (TB)
crohns
what investigation is performed if you suspect oesophageal rupture?
gastrograffin swallow
what blood results would one expect in haemochromatosis?
raised serum iron
raised ferritin
low transferrin
low total iron binding capacity
what are the grades of haemorrhoids?
1 - protrude into anal canal
2 - protrude beyond anal canal, spontaneously reduce
3 - protrudes and required manual reduction
4 - protrudes and irreducible
what is the management of haemorrhoids?
reduce straining and time on low, increase fibre + fluids, stool softeners
1 - topical corticosteroids
2 + 3 - band ligation
4 - surgical haemorrhoidectomy
what is the leading cause of HCC?
chronic hepatitis infection
what is acute mesenteric ischaemia?
acute thrombo-embolic occlusion of the SMA
what is ischaemic colitis?
inflammation of the colon due to reduced blood supply
what is the stool test for IBD?
faecal calprotectin
what is the most common liver disease in the developed world?
non-alcoholic steatohepatitis
what is the difference between NAFLD and NASH?
NASH has hepatocyte degeneration as well as lobular infiltrates with steatosis
biopsy of liver may be required to confirm diagnosis between the 2
what are the causes of acute pancreatitis?
GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion bite
Hyperlipidaemia, hypercalcaemia, hypothermia
ERCP and emboli
Drugs
what are pre hepatic causes of portal HTN?
thrombosis
congenital stenosis or atresia
extrinsic compression
what are hepatic causes of portal HTN?
cirrhosis
schistosomiasis
sarcoidosis
myeloproliferative disease
congenital hepatic fibrosis
what are post hepatic causes of portal HTN?
Budd-Chiari syndrome
right heart failure
constrictive pericarditis
veno-occlusive disease
what infection may occur with hepatitis B?
hepatitis D
which hepatitis does hepatitis D occur with?
hep B
what hepatitis is most likely to cause:
a) acute infection
b) chronic infection
a) hepatitis A
b) hepatitis C
hep B can be either
what is the treatment for chronic hepatitis?
interferon alpha
which hepatitis do traveller usually get?
hep A
what hepatitis is associated with shellfish?
hep A
what is hepatitis E similar to?
hep A
which vitamins are fat soluble?
A D E K
what are the signs of chronic liver disease?
ABCDEFGHIJ+S
asterixis
bruising
clubbing
dupuytren’s contracture
palmar erythema
fetor hepaticus
gynaecomastia
hair loss
icterus/jaundice
spider naevi
leukonychia (due to hypoalbuminaemia)
causes of hepatomegaly
3 C’s and 1 I
cancer - primary or mets
cirrhosis - early on
cardiac - CCF, constrictive pericarditis
Infiltrative: fatty infiltrate, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative diseases
causes of jaundice
AADVM
alcohol
autoimmune
drugs
viral
biliary disease
causes of splenomegaly
HI HI
H- portal HTN
Haematological - lymphoproliferative diseases, myeloproliferative diseases or haemolytic anaemia
Infection: TB, brucellosis
infiltration: chronic inflammatory conditions (sarcoidosis)
differentials of epigastric pain:
stomach - peptic ulcer, GORD, gastritis, malignancy
acute pancreatitis
MI
ruptured aortic aneurysm
cholecystitis
hepatitis
differentials for RUQ pain
cholecystitis, cholangitis, gallstones (biliary colic)
hepatitis, abscess
basal pneumonia
appendicitis (retro-caecal or pregnancy more likely)
peptic ulcer
pancreatitis
pyelonephritis
differentials for right iliac fossa pain
appendicitis
mesenteric adenitis
colitis (IBD)
malignancy
ovarian cyst rupture
ovarian cyst twist
ovarian cyst bleed
Ectopic Pregnancy
testicular torsion
hernia
differentials of suprapubic pain
cystitis
urinary retention
testicular torsion/referred pain from epidiymis-orchitis
differentials for left iliac fossa pain
diverticulitis
colitis (IBD)
malignancy
ovarian cysts rupture/twist/bleed
Ectopic Pregnancy
testicular torsion
hernia
diffuse abdominal pain
Bowel obstruction
peritonitis
gastroenteritis
IBD
mesenteric ischaemia
DKA, Addison’s, hypercalcaemia
porphyria, lead poisoning
causes of an ascitic transudate?
low protein level
cirrhosis
cardiac failure
causes of an ascitic exudate
high protein level
malignancy in the abdomen, pelvis or peritoneum
infection = TB, pyogenic (cause formation of pus)
nephrotic syndrome (this is only because overall albumin is low)
budd-chiari syndrome
portal vein thrombosis
What does the celiac artery supply?
stomach
spleen
liver
gallbladder
part of the duodenum
what does the superior mesenteric artery supply?
small intestine
right colon
what does the inferior mesenteric artery supply?
left colon
rectum is supplied by a branch of the iliac artery
differentials for abdominal distention
THE 5 F’S
fluid (ascites)
flatus
fat
faeces
foetus
causes of bloody diarrhoea
infective colitis (campylobacter, E.coli, entaemoeba histolytica, salmonella, shigella)
inflammatory colitis (young)
ischaemic colitis (older)
diverticulitis
malignancy
What might cause a pre-hepatic jaundice?
increased haemolysis (e.g. haemolytic anaemia) Gilbert's syndrome (reduced glucuronidation)
what might cause a hepatic jaundice?
hepatitis (autoimmune, alcohol, drugs, viruses)
what might cause a post-hepatic jaundice?
gallstones in the common bile duct
stricture
cancer of pancreas head
What does thumb-printing on an AXR suggest?
mucosal oedema
What does featureless colon on an AXR suggest?
IBD
What medications should be given to patients presenting with variceal bleeding due to portal HTN?
terlipressin - induces splanchnic vasoconstriction reducing pressure in the portal system
Antibiotics -> taxosin
How would you manage a patient with an acute abdomen?
INVESTIGATIONS
bloods: FBC, U&Es, LFTs, CRP, G&S, clotting, x-match
erect CXR
may need CT
MANAGEMENT PLAN
- monitor vitals and urine output
- NBM and fluids
- analgesia
- anti-emetics
- Abx - cephalosporins, metronidazole
how would you manage a patient with ascites?
diuretics (spironolactone +/- furosemide)
dietary sodium restrictioni
fluid restrict if hyponatraemic
monitor weight daily
therapeutic paracentesis (drainage) with IV human albumin
How would you manage a patient present with hepatic encephalopathy?
lactulose (reduce gut transit time)
phosphate enemas
avoid sedation
treat any infection and exclude a GI bleed
what is the presenting complaint for an anal fissure/
severe pain on defecating
stool coated with small amount of bright red blood
What would you tell a patient with anal fissure and what might you prescribe?
increase fibre and fluid in their diet
GTN cream to vasodilate vessels improving blood flow to promote healing
what cancer is pernicious anaemia a RF for?
gastric cancer
what are the characteristic features of haemolytic uraemic syndrome?
microangiopathic haemolytic anaemia (MAHA)
acute renal failure (AKI)
thrombocytopenia
hernia superior and medial to pubic tubercle
inguinal hernia
location of superficial ring
half way between ASIS and pubic tubercle
differentiating direct and indirect inguinal hernia
direct
- medial to interior epigastric vessels
- not controlled by cough impulse
indirect
- lateral to inferior epigastric vessels
- controlled by pressure over the superficial ring
describe the serum ascites albumin gradient
what primary care test must be done prior to ?IBD diagnosis?
stool culture
exclude infective reason
ddx day 1 post-op acute abdomen
bleeding, iatrogenic perforation
ddx day 3-4 post-op acute abdomen
anastomotic leak, collection, paralytic ileus
treatment of pancreatitis due to hyperlipidaemia?
insulin infusion
complications of pancreatitis
- ARDS
- Dehydration - fluid third spaced, hypovolaemia, AKI etc
- Retroperitoneal haemorrhage
- Necrosis of pancreas
- Fluid collections - can become infected
- Pseudocyst - develops after 6 weeks
- Large collections, no real epithelial lining to the cyst hence known as pseudo
- Chronic pancreatitis
- Pancreatic insufficiency
triad of AAA (rupture)
diffuse mid-abdominal pain + shock + pulsatile abdominal mass
what is the management of C. DIff.
- 1st episode
- 2st line oral vancomycin for 10/7
- 2nd line is fidaxomicin
- 3rd line - oral vancomycin + IV metronidazole
- life-threatening - hypotension, partial/complete ileus, toxic megacolon, CT severe
- oral vancomycin + IV metronidazole
- specialist surgical consult
