Gastrointestinal Flashcards
What is an MRCP?
Magnetic Resonance Cholangiopancreatography
What is an OGD?
Oesophagogastroduodenoscopy
What is the name of this tube? What is it used for?
sengstaken-blakemore tube.
Used to compress bleeding of haemorrhaging vessels in stomach and the oesophagus.
What are the main treatments for a varices bleed?
Sangtaken Blakesmore tube.
The patient requires an endscopy as soon as he has been stabilised and iv terlipressin is also started as soon as possible if variceal bleeding is suspected. Ocreotide as a second management. IV antibiotics should also be given for suspected variceal bleeds.
Sclerotherapy and long term beta blocker to reduce bleeding risks
What is the Childs Pugh Score?
A score from 1-3 where the criteria are EHABIA
Encephalopathy
Hb
Albumin
Bilirubin
INR
Ascites
Define perforated viscus?
An organ with an abnormal opening often is referred to as a perforated viscus. Viscus technically means a hollow organ found inside the body. Examples of these hollow organs mostly are found in the chest and abdomen such as the stomach, appendix, intestines, spleen, gallbladder, and urinary bladder.
What are some features of acute alcohol withdrawal?
Alcohol withdrawal is associated with:
anxiety and restlessness (and not somnolence)
tremor
sweating
headache
nausea and vomiting (but not diarrhoea)
tachycardia (not bradycardia) +/- palpitations
If more severe patients can also experience
hallucinations (typically visual)
seizures
delirium (delirium tremens)
How should acutealcohol withdrawal be treated?
IV thiamine (pabrinex) supplementation is important to prevent Wernicke’s encephalopathy. IV administration is best – IV doses should be given slowly (≥ 10mins) to reduce incidence of anaphylaxis. Oral supplementation is often given after initial IV supplementation.
Give benzodiazepeines and use 4 hour observations to check on patient.
Glucose should not be given before thiamine supplementation (unless critical hypoglycaemia) as this can precipitate Wernicke’s encephalopathy.
Arrange gastroenterology review
What is the relationship between Wernicke’s encephalopathy and Korsakoff’s psychosis?
Wernicke’s encephalopathy is reversible but needs prompt treatment with thiamine (B1) to prevent progression to Korsakoff’s psychosis (permanent loss of short-term memory).
What causes a high SAAG?
A high SAAG (>1.1 g d/L) indicates portal hypertension and can occur in the following:
cirrhosis
alcoholic hepatitis
portal vein thrombosis
massive hepatic metastases
heart failure
What causes a low SAAG?
peritoneal carcinomatosis
infection (including TB)
pancreatitis
nephrotic syndrome
serositis (including lyphoma)
What could cause jaundice and upper GI pain in a young woman who doesn’t drink?
Autoimmune hepatitis
What are patients with autoimmune hepatitis at risk of?
Patients with with AIH are at increased risk of hepatocellular carcinoma (especially those with cirrhosis) and should be regularly screened for the development of the condition.
What is PBC?
This patient has lethargy and pruritus with minor increase in AST/gamma-GT and increase of alkaline phosphatase. This is a typical presentation of PBC – primary biliary cholangitis (previously called primary biliary cirrhosis). PBC is a disease of uncertain aetiology, which may be autoimmune and is most common in middle-aged women. Many cases are detected by random detection of high alkaline phosphatase and no other symptoms. There is progressive inflammation and destruction of interlobular bile ducts with fibrosis and cholestasis and ultimately cirrhosis. Pruritus may be intractable and the cause is unknown – it does not relate to deposition of bile acids in the skin, nor to severity of disease. It may require liver transplantation if all other treatments fail to resolve it.
How do you treat PBC?
Once diagnosis made treatment is important to prevent progression, with ursodeoxycholic acid. Cholestyramine is used to alleviate pruritus but must be given at least 2 hours apart from ursodeoxycholic acid. Ultimately patients may need transplantation. Vitamins
What atre two of the main symptomns of PBC?
Pruitis and fatigue
What types of auto-antibodies are involved in autoimmune hepatitis?
Anti-ANA, antiDsDNA and antip53
How is AIH treated?
Prednisone and azathioprine
What are some features of chronic pancreatitis?
Pain
Malasborption
Weight loss
Diabetes
How is chronic pancreatitis imaged?
CT is the most accurate technique for demonstrating the gland calcification, atrophy and duct dilatation that occur in chronic pancreatitis. Chronic inflammatory masses may occur (pancreatic pseudocysts) and these can be very hard to differentiate from carcinoma.
MRCP may be helpful as it is non-invasive and could give additional information about the pancreas and ducts.
ERCP should not be used as a purely diagnostic tool due to its significant complication rate. It is mostly a therapeutic procedure to retrieve retained common bile duct stones. ERCP= excavation of gall stones
What are some features of chronic pancreatitis?
Carcinoma occurs in 2-3%.
Intractable pain is a common feature of chronic pancreatitis and can cause problems with addiction to opiates prescribed for it.
Pseudocyst formation occurs due to destruction of the pancreatic parenchyma, resulting in fluid filled sacs containing blood, pancreatic enzymes and necrotic debris. They can increase in size over time
Constipation is not usually a feature of chronic pancreatitis (loss of pancreatic exocrine function usually results in diarrhoea)
When can a patient be started on an NG tube?
A patient can be started on an NG feed if the aspirate has a pH <5.5. An aspirate with a pH of 5.0 reflects the acidic environment of the stomach and indicates the correct placement of the tube. The guide-wire of the NG tube should be removed once the pH has been confirmed and the feeding tube can then be taped into place.
What are some complications of cirrhosis?
Ascites is caused partly by portal venous hypertension but probably also by “weeping” of hepatic lymph from the surface of the cirrhotic liver.
Cirrhotic patients with portal hypertension are prone to Gram negative peritonitis.
Cancer. Hepatocellular carcinoma is a well recognized complication of cirrhosis particularly if the cirrhosis has been caused by viral hepatitis.
Coagulopathy occurs because of interference with hepatic production of coagulation factors.
Encephalopathy is due to failure of removal of cerebro-toxic substances from the blood when the cirrhotic liver begins to fail.
What are markers of:
AIH
PBC
Haemochromatosis
Alcoholism
Hepatitis C
Anti-smooth muscle antibodies and anti mitochondrial antibodies are typical of autoimmune hepatitis and primary biliary cirrhosis respectively.
High serum transferrin reflects the iron overload in haemochromatosis.
Although not specific or always present, the combination of steatosis and Mallory’s hyaline on liver biopsy is suggestive of alcoholic hepatitis.
Injecting drug use points to hepatitis C virus infection (injecting drug users are also at risk of hepatitis B)
What are the most likely causes of upper GI bleed?
Gastric erosions 25%
DU 25%
GU 20%
Mallory Weiss Tear 10%
Oesophagitis 10%
Rare causes:neoplasm, dueodenitis, dieulefoy’s lesion and AV malformation
What score can be used to assess bleeding?
/glasgow-blatchford-bleeding-score-gbs
What is terlipressin?
Synthetic analogue of vasopressin. Reduces portal pressure. Long half-life so given intermittently i.e. 2mg i.v. every 6 hours Meta-analysis,20 RCT’s, 1609 patients. Compared to placebo: Reduced rebleed rate: R.Risk 0.63 Reduced 30/7 mortality: R.Risk 0.66 THEREFORE, in contrast to PPI, it is important to give terlipressin even before endoscopy if varices bleeding.
What increases risk of variceal bleed and what can be given?
A bacteremia and therefore antibiotics are given
What are the stages of treatment for an acute varices bleed?
Fluids/ oxygen
Antibiotics
Terlipressin
OGD
Band ligation
Balloon tamponade
Rescue TIPS
What is the mortality associated with a variceal bleed?
30%
What is used for balloon tamponade?
Sengstaken Tube:
What is Courvoisier’s sign?
Courvoisier’s sign refers to painless palpable gallbladder with jaundice.
What are symptoms of ulcerative colitis?
Symptoms of UC
Gastrointestinal symptoms: diarrhoea containing blood/mucus, tenesmus or urgency, pain in the left iliac fossa.
Systemic symptoms: weight loss, fever.
What treatment can be given to help avoid confusion in older people with hepatic encephalopathy?
Lactulose
What is the NICE guideline for managing medium or large varices?
Currently, the two most widely used modalities to prevent variceal bleeding are pharmacologic (non-selective beta-blockers [NSBB] such as propranolol) and endoscopic (variceal band ligation [VBL]) which have replaced sclerotherapy in the recent years.
What provides long term prophylaxis against varices bleeding?
Propanolol
What is the Rockall risk score?
Rockall risk scoring system attempts to identify patients at risk of adverse outcome following acute upper gastrointestinal bleeding
What does ALT and ALP need to rise by or decrease by for it to be a biomarker?
Increase by 10 or decrease by 10
Increase by 3 or decrease by 3
Where is ALT found? What is it a marker for?
ALT is found in high concentrations within hepatocytes and enters the blood following hepatocellular injury. It is, therefore, a useful marker of hepatocellular injury.
What is ALP a marker for?
ALP is particularly concentrated in the liver, bile duct and bone tissues. ALP is often raised in liver pathology due to increased synthesis in response to cholestasis. As a result, ALP is a useful indirect marker of cholestasis.
What is gamma glutamyl transferase a marker of?
A raised GGT can be suggestive of biliary epithelial damage and bile flow obstruction.
What is AST and ALP likely to be in pre-hepatic jaundice?
Normal levels
Haemolysis or Gilberts syndrome
Complete the following:
Normal urine + normal stools =
Dark urine + normal stools =
Dark urine + pale stools =
Normal urine + normal stools = pre-hepatic cause
Dark urine + normal stools = hepatic cause
Dark urine + pale stools = post-hepatic cause (obstructive)
What is an ERCP?
Endoscopic retrograde cholangiopancreatography, or ERCP, is a procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. It combines X-ray and the use of an endoscope—a long, flexible, lighted tube.
ALT > AST is associated with ________________
AST > ALT is associated with __________________
ALT > AST is associated with chronic liver disease
AST > ALT is associated with cirrhosis and acute alcoholic hepatitis
What does a typical liver screen show?
LFTs
Coagulation screen
Hepatitis serology (A/B/C)
Epstein-Barr Virus (EBV)
Cytomegalovirus (CMV)
Anti-mitochondrial antibody (AMA)
Anti-smooth muscle antibody (ASMA)
Anti-liver/kidney microsomal antibodies (Anti-LKM)
Anti-nuclear antibody (ANA)
p-ANCA
Immunoglobulins – IgM/IgG
Alpha-1 Antitrypsin (to rule out alpha-1 antitrypsin deficiency)
Serum Copper (to rule out Wilson’s disease)
Ceruloplasmin (to rule out Wilson’s disease)
Ferritin (to rule out haemochromatosis)
What is the ratio of men to women with PSC?
7:1
\What are some causes of post hepatic jaundice?
Causes of post-hepatic jaundice
Impaired excretion of conjugated bilirubin results is cholestasis. Conjugated bilirubin is water soluble, making the urine dark. Less bilirubin reaches the gut, so pale stools also result. Pruritus also suggests an obstructive problem. These so-called post-hepatic causes include:
Primary biliary cirrhosis
Primary sclerosing cholangitis
Common bile duct gallstones or Mirrizi’s syndrome (CBD compression from a gallstone in the cystic duct)
Drugs, including coamoxiclav, flucloxacillin, nitrofurantoin, steroids, sulfonylureas
Malignancy, such as head of the pancreas adenocarcinoma, cholangiocarcinoma
Caroli’s disease
Biliary atresia
What does triple therapy involve?
She is prescribed triple therapy with omeprazole, amoxicillin and clarithromycin twice daily for seven days
If H pylori persists despite 2 a day of clindamcyin, amoxicillin and omeprazole, try ___________________________
Metronidazole, amoxicillin and omeprazole for 7 days
What is the alvarado score for?
Acute pancreatitis
What are the main ducts leading to the common bile duct?
R. and l. hepatic duct –> common hepatic duct
Cystic duct + common hepatic duct –> common bile duct
Common bile duct and pancreatic duct –? sphincter of oddi
What is the procedure for helping to remove gallstones?
ERCP and Sphincterotomy
What is the normal half life of vitamin K dependent clotting factors? Why is this relevant?
5-72 hours
Liver damage can cause reduced synthesis of clotting factors
What are some symptoms of cholecystectomy syndrome?
Dyspepsia, nausea and vomiting.
Flatulence, bloating and diarrhea.
Persistent pain in the upper right abdomen.
Name a drug that causes post-hepatic jaundice
Co-amoxiclav and fluclox
What does cholestasis mean?
Obstructive
What are some examples of hepatatic jaundice?
Wilson’s disease
Haemachromatosis
HBV
HCV
AIH
PCB
NAFLD
Alcoholic liver disease
Chronic hepatitis
Alpha antitrypsin
Celiac
What causes hepatic encephalopathy?
Reduced removal of ammonia
What is TIPPS and what does it stand for?
Transjugular intraperitoneal portosystemic shunt
What does SBP stand for?
Spontaneous bacterial peritonitis.
SBP is diagnosed if the fluid contains neutrophils (a type of white blood cell) at greater than 250 cells per mm3 (equals a cell count of 250 x106/L) fluid in the absence of another reason for this (such as inflammation of one of the internal organs or a perforation).
What is a first line duiretic for NASH?
Spirolactone, whereas heart disease is furosemide
What is Budd Chiari syndrome?
Budd–Chiari syndrome is a very rare condition, affecting one in a million adults. The condition is caused by occlusion of the hepatic veins that drain the liver. It presents with the classical triad of abdominal pain, ascites, and liver enlargement. The formation of a blood clot within the hepatic veins can lead to Budd–Chiari syndrome.
What is a MELD score?
Model of end stage liver disease score
Dialysis?
INR?
Creatinine?
Sodium?
Why do patients with liver disease get hyponatremia?
Less albumin –> more water in tissues –> sodium becomes more diluted
What are some key tests for liver disease?
LFTs
U and E’s
Coagulation test (INR more standardised)
Liver screen
Doppler
What is the Childs Pugh score used for?
Mortality with liver disease
What is the Kings College Hospital admission score for?
Paracetemol overdose
Phosphate
Acidosis
Creatinine
INR
Lactate >3.5
Encephalopathy
What medication is used to induce remission in Chron’s? What is done to maintain remission?
Steroids
Mercaptopurine or azathioprine
What are some markers of primary sclerosing cholangitis?
ASMA and ANCA
High risk of pancreatitis post ERCP
What is the difference between Rotar Syndrome and Dubin Johnson
The liver appears black in Dubin Johnson as cannot excrete bile into cannilicus. Dubin Johnson is MRP2.
Rotar is a muation in OATP1.
What does SAAG stand for?
Serum ascitis albumin gradient
What is NAFLD and NASH? What is the link?
NASH is where a fatty infiltration becomes an inflammation. NASH starts with NAFLD or steatosis and progresses to hepatitis. Then NASH becomes cirrhosis.
What are some symptoms of mesenteric ischaemia?
abdominal pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings
rectal bleeding
diarrhoea
fever
bloods typically show an elevated white blood cell count associated with a lactic acidosis
How should ulcerative colitis be treated?
In a mild-moderate flare of ulcerative colitis extending past the left-sided colon, oral aminosalicylates should be added to rectal aminosalicylates, as enemas only reach so far
What does a bird beak appearance on a barium esophagram suggest?
Achalasia
What should be given to patients before undergoing paracentesis? What does it cause if it is not used?
Albumin cover is important in large-volume paracentesis with IV human albumin solution (HAS) to avoid paracentesis-induced circulatory dysfunction (PICD). PICD leads to faster accumulation of ascites, hyponatraemia, and renal impairment. It can affect as many as 80% of patients who have large-volume paracentesis without any additional therapeutic management (with volume expanders such as HAS).
What is acute cholecystitis?
Pain after a fatty meal, ingfection, pain and vomiting
What is Mirezzi syndrome?
Jaundice caused by stones compressing the bile duct
In what condition do you get the thumbprint sign?
Ischaemic colitis is a result of decreased blood flow through the mesenteric circulation resulting in pain, ischaemia and ultimately - gangrene. It has numerous causes including: embolism, thrombosis, atherosclerosis or decreased perfusion secondary to hypovolaemia and septic shock.
Natural history usually includes abdominal pain, nausea and vomiting and the speed of onset is determined by the pathophysiology. In this case a gentleman with vascular disease, the cause could be thrombosis or atherosclerosis but it is the speed of onset and new onset atrial fibrillation (AF) that points to a likely embolic cause. Examination reveals tenderness and an irregular pulse, confirmed as AF on ECG.
Investigations that are useful to diagnose ischaemic colitis include ABG - metabolic acidosis, elevated lactate and imaging. x-ray may show thumb printing although CT is the gold standard investigation.
Initial management includes analgesia, fluids and keeping the patient nil by mouth. Definitive treatment includes thrombolytic therapy, angioplasty or surgery.
When is 20% human albumin solution given?
20% human albumin solution (HAS) has a number of uses in chronic liver disease, including: volume replacement after large volume paracentesis; the treatment of spontaneous bacterial peritonitis; and the management of hepatorenal syndrome. However, is not used as primary treatment for ascites, even in the context of hypoalbuminaemia.
What is the main treatment for ascites?
Spirnolactone
What are the symptons of peritonitis?
Board-like rigidity
Guarding
Rebound tenderness
Patient holding completely still
Reduced or absent bowel sounds
What are the symptoms of mesenteric ischaemia?
Nausea and vomiting
Distended abdomen
Soft abdomen (hard in peritonitis)
Can’t go to the toilet
Tympanic and tinkling
Closed or open loop
What happens in refeeding syndrome?
Switch to glucose, and thus increased insulin production • Phosphate is sucked into the cells for ADP and ATP pathways • Hypophosphataemia implicated in weakness, myalgia, rhabdomyolysis, dyspnoea, ataxia, delirium, convulsions and coma
Hypomangesiumia because of ATP and hypokalaemoa
Hypocalcemia causes tetany
What happens in thiamine deficiency?
Thiamine is essential for glucose metabolism: glycolysis and oxidative decarboxylation to produce energy • To add to the existing depletion, there is sudden high need for thiamine • Wernicke’s encephalopathy • More chronically Korsakoff’s syndrome • Dry beri-beri
Wernicke
Korsakoff
Dry Beri beri and wet (WKD)
What are some ways to weigh the body
BMI
DEXA
Triceps skin fold and anthropometrics
CT
Bioelectrical impedence
What is globus pharyngis
Globus pharyngis (also known as globus hystericus) is the persistent sensation of having a ‘lump in the throat’, when there is none. Symptoms are often intermittent and relieved by swallowing food or drink. Swallowing of saliva is often more difficult.
What does this show?
Globys pharyngeus (lump in throat)
What are some macroscopic features of Chrons?
Fissures
Lymphoid hyperplasia
Absecesses apthous ulcers
Granulomas
What are some features of UC?
Haemmorhage
Biochemical features of haemochromatois?
Ferritin - high
Serum iron - high
TIBC - low
Transferrin - high
Biochemical features of IDA?
Ferritin - low
Serum iron - low
TIBC - high
transferrin - low
What is the MUST score?
Malnutrition Universal Screening Tool
What does faceal elastase show?
Pancreatic insufficiency
What is globus pharyngeus?
Lump in throat - no know cause
What is the scoring system for UC?
True Love and Witts
(BFHE)
Blood/ bowel movements
Fever
Heart rate
Hb
ESR
What condition are people with celiac disease more at risk from?
Small bowel lymphoma and adenocarcinoma
What are the other symptoms of UC?
Pyoderma gangreosum
Uveitis
Biliary carcinoma
Episcleritis
Scleritis and sclerosing cholangitis
In Gilberts syndrome, what enzyme will be at normal levels?
UDP-glucuronosyltransferase
What happens to haemaglobin after acute blood loss? Why?
It actually stays at baseline because its a measure of Hb in plasma. If both are lost the concentration stays the same.It then lowers after adding fluid.
What is a key difference between IBS and IBD?
Waking at night
How do you calculate SBP?
An ascitic tap showing a neutrophil count/polymorphonuclear leukocyte count > 250/ul is diagnostic of SBP and 40% of 650 = 260.
What is the gold standard for celiac?
Duodenal biopsy and colonoscopy
What is used to decide someone needs a liver transplant?
According to the King’s College Criteria, a poor outcome in liver failure from paracetamol toxicity is predicted by:
pH <7.3 24 hours after the overdose.
or, all three of the following:
Prothrombin time >100seconds or INR >6.5 seconds.
Creatinine >300Umol/L.
Grade 3 or 4 hepatic encephalopathy.
Therefore, a pH of <7.30 alone is a high severity indicator and therefore most likely to be an indication for liver transplant.
41%
What is the Kings college criteria?
King’s College Hospital Criteria for Liver Transplant (paracetamol induced)
The criteria for paracetamol induced liver failure are as follows:
Arterial pH <7.3 24h after ingestion OR
Pro-thrombin time >100s
AND creatinine >300µmol/L
AND grade III or IV encephalopathy.
IBS vs IBD?
IBD worse at night - night time waking
Pain relieved by defecation = IBS
