Gastrointestinal Flashcards
1
Q
Upper GI bleed: score for admission / intervention risk + parameters + use of score
A
Blatchford Score Parameters:
Blood urea nitrogen
Hb
Systolic BP
Other (HR>100, melena, syncope, hepatic pathology, HF)
Score: 0 = low risk, outpt 1-5 = admit 5< = high risk of intervention
2
Q
Upper GI bleed: score for prognosis + parameters + use of score
A
Rockall Score (post-OGD)
Age
Shock (HR, BP)
Co-morbidities
Dx on OGD
Evidence of bleeding on OGD
Score gives % risk of mortality on rebleed
3
Q
Upper GI bleed: DDx
A
PUD (40%, usually DU)
Gastritis (20%)
Mallory-Weiss
Varices
Oesophagitis
Ca stomach / oesophagus
4
Q
Sepsis Six
A
Give 3 things:
- O2 high-flow (maintain >94%)
- IV fluids
- IV antibiotics
Take 3 things:
- blood cultures
- blood lactate
- urinary catheter (monitor output hourly)
5
Q
Drug-induced liver disease: which drugs induce liver disease with a hepatocellular picture on LFTs?
A
SAM’S HEPATIC
Statins
Amiodarone
Methyldopa
Sodium valproate, phenytoin
Halothane (an anaesthetic)
ETOH
Paracetamol
Antibiotics: nitrofurantoin
TB drugs: isoniazid, rifampicin, pyrazinamide
Inhibitors of MAO
Cirrhosis-causing drugs (methotrexate, methyldopa, amiodarone)
6
Q
Drug-induced liver disease: which drugs induce liver disease with a cholestatic picture on LFTs?
A
CAAPS
COCP
Antibiotics: flucloxacillin, co-amoxiclav, erythromycin
Anabolic steroids, testosterone
Phenothiazines: chlorpromazine, prochlorperazine
Sulphonylureas (gliclazide)
7
Q
IBS: red flags for other causes
A
- unexplained wt loss
- rectal bleeding
- FHx of bowel/ovarian Ca
- >60y old + increasingly frequent/loose stools for the past 6w
- anaemia
- abdominal masses
- rectal masses
- inflammatory makers for IBD
(NICE)
8
Q
IBS: diagnostic criteria
A
Rome IV Criteria (2016):
recurrent abdominal pain/discomfort on average +1d/w in the last 3m and associated with 2+ of
related to defecation
change of stool frequency
change of stool form
(UpToDate, BMJ)
9
Q
Identify appropriate investigations for irritable bowel syndrome (IBS)
A
Bloods: FBC, ESR, CRP, anti-TTG or anti-endomysial Abs
Mainly to exclude other diagnoses (IBD, malignancy, coeliac)
(NICE)
10
Q
Generate a management plan for irritable bowel syndrome (IBS)
A
- Conservative
- Education
- reduce stress, increase exercise
- dietary: regular meals, 8 cups of fluids /d, max 3 caffeinated drinks, reduce EToH, reduce intake ‘resistant starch’ (processed food), max 3 fresh fruit/d
- if diarrhoea - avoid sorbitol (sweetener). If bloating - eat oats
- try altering amount of fibre in diet (reduction), try exclusion diets (FODMAP)
- Probiotics, alternative medicine
- Education
- Medical
- Antispasmodics PRN (eg dicyclomine)
- If stool too loose: loperamide
- If stool too hard: laxatives
- 1st line: Movicol (avoid lactulose)
- 2nd line: Linaclotide (if no response for 12m)
- 2nd line: TCAs
- 3rd line: SSRIs
- Psychological
- CBT - if not response to medical mx over 12m
(NICE)
11
Q
What is the scoring system for the severity of pancreatitis
A
Modified Glasgow Imrie Score: PANCREAS
PaO2 <8kPa
Age >55
Neutrophils (WCC) >15x10^9
Calcium <2
Renal (Urea) >16 mmol/L
Enzymes: LDH>600, AST>200
Albumin <32 g/L
Sugars >10 mmol/L
Score calculates severity at 48h from admission. <3 = mild/moderate. 3+ = severe pancreatitis (consider HDU)
12
Q
Explain the aetiology / risk factors of pancreatitis
A
GET SMASHED
Gallstones
EToH
Trauma
Steroids
Mumps
Autoimmune
Scorpion bite
Hypercalaemia, hyperlipidaemia
ERCP
Drugs (mesalazine, azathioprine, furosemide, sodium valproate)
13
Q
Identify the possible complications of pancreatitis (acute and chronic)
A
- Short:
- Electrolyte / endocrine: hypocalcaemia, hypoglycaemia, hyperglycaemia
- Pancreatic: pancreatic abscess/effusion/pseudocyst, necrotising pancreatitis
- Systemic: AKI, ARDS, SIRS, DIC, haemorrhage (GI or intraperitoneal), MODS
- Long: pancreatic insufficiency, chronic pancreatitis, portal vein thrombosis, enteric fistula, intestinal obstruction
(BMJ, UpToDate)
14
Q
Generate a management plan for acute pancreatitis
A
- Medical (ABCDE):Initial
- IV fluids (normal saline, if fluids resus needed). Measure UO /h
- High-flow O2 (if not saturating at 94%)
- Analgaesia (WHO ladder, often IV opiates eg fentanyl)
- IV Abx (if cholecystitis or infective)
- Enteral feeding - if tolerated
- Surgical
- If gallstones:
- ERCP w/i 72h onset of pain
- Cholecystectomy (same admission, unless prolonged disease course)
- If gallstones:
(NICE, UpToDate)
15
Q
How can the three types of AI hepatitis be differentiated on serology?
A
Type 1: ANA +ve and/or smooth-muscle Ab +ve, adults + children
Type 2: anti-liver/kidney microsomal type 1 Ab +ve, children only
Type 3: soluble liver-kidney antigen, middle-aged adults
(passmedicine)
16
Q
What are the main risk factors for AI hepatitis?
A
RFs:
- female
- genetic: HLA B8, HLA DR3
- PMHx: AI dx, hypergammaglobinaemia
(passmedicine)
17
Q
Identify appropriate investigations for autoimmune hepatitis
A
- Confirm diagnosis
- Bloods: LFTs, ANA, SMA, anti liver/kidney microsomal type 1 Ab
- Biopsy: piecemeal necrosis, bridging necrosis
- Plan tx:
- Bloods: FBC, UEs, clotting
18
Q
Generate a management plan for autoimmune hepatitis
A
- Medical
- Steroids
- Immunomodulators: azathioprine
- Surgical
- Liver transplant
(passmedicine)
19
Q
Identify the possible complications of autoimmune hepatitis
A
- Immediate: acute liver failure
- Early: azathioprine-associated SEs (infections, neutropenia, pancreatitis)
- Late: hepatocellular carcinoma, end-stage liver disease, steroid-associated SEs (DM, osteoperosis, obesity, HTN),
(BMJ)
20
Q
Summarise the prognosis for patients with autoimmune hepatitis
A
Morbidity: 80% achieve remission w/i 3y. On long-term azathioprine, ~20% relapse.
Mortality: 10y survival >90%
(BMJ)
21
Q
Define primary sclerosing cholangitis
A
Primary sclerosing cholangitis is a biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts
(passmedicine)
22
Q
Explain the risk factors of primary sclerosing cholangitis
A
- Female, 40s
- PMH:
- ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC
- Crohn’s (much less common association than UC)
- HIV
- ANCA +ve, anti-smooth muscle Ab +ve
(passmedicine)
23
Q
Summarise the epidemiology of primary sclerosing cholangitis
A
13 / 100 000
F:M 2:1
Typically presents around 40y
(BMJ)
24
Q
Generate a management plan for primary sclerosing cholangitis
A
- Conservative: healthy diet + wt, limit ETOH
- Medical
- Symptom control
- Pruritus relief: Colestyramine (or rifampicin, sertraline)
- ergocalciferol + calcium carbonate if osteopenic OR bisphosphonates +/- HRT if osteoperotic
- Symptom control
- Interventional procedure
- ERCP + stenting: if acutely ill + biliary stricture
- Surgical
- Liver transplant: if end-stage liver disease
(BMJ)
25
Identify the possible complications of primary sclerosing cholangitis
Immediate: acute liver failure (hepatic encephalopathy, bacterial cholangitis)
Early: fat soluble vitamin (ADEK) deficiencies
Late: chronic liver disease (ascites, oesophageal varices, choledocholithiasis)--\> cirrhosis, cholangiocarcinoma (in 10%), HCC, increased risk of colorectal cancer
*(passmedicine)*
26
Summarise the prognosis for patients with primary sclerosing cholangitis
Mortality: median survival 7-14y. After transplant 10y survival is 70%
Morbidity: up to 35% undergo liver transplant
*(BMJ)*
27
Generate a management plan for ulcerative colitis
* Remission induction (medical, depends on severity)
* Mild/moderate 1st presentation or exacerbation of proctocolitis:
* 1st: rectal and/or oral aminosalicylates (mesalazine)
* +/- oral beclometasone diproprionate
* 2nd: rectal and/or oral steroids (preferable if subacute)
* No response at 4w: combine 1 + oral 2
* Still no repsonse at 4w: consider oral tacrolimus
* Last line: infliximab
* Acute severe:
* 1st: IV corticosteroids
* 2nd: IV ciclosporin (if steroids CI, not tolerated)
* 72h or progressing: 1 + 2 or surgery
* Vaccinations (before starting immunosuppressants)
* flu, pneumococcal, HepB, HPV, VZV (if seronegative)
* Maintenance of remission
* Mild/moderate: aminosalicylate (oral or rectal or both)
* Extensive (left-sided): oral aminosalicylate
* All extents (or acute severe, or 2 episodes/y requiring steroids):
* 1st: oral azathioprine or oral mercaptopurine
* 2nd: oral aminosalicylates (if 1 CI, not tolerated)
* Monitor growth/bone health in children on steroids
*(NICE)*
28
What are the risk factors for ulcerative colitis?
Strong RFs:
* IBD FHx
* HLA-B27
* infection: enteritis is RF for relapse
Weak RFs:
* NSAIDs
* Non-smoker
*(BMJ)*
29
Identify appropriate investigations for ulcerative colitis
Confirm diagnosis
* Stool studies: cultures and faecal calprotectin (bowel inflammatory marker)
* Bloods: CRP, ESR (at same time: FBC, LFTs (assoc w primary sclerosing cholangitis), UEs
* Colonoscopy + biopsy
* Consider: AXR, double-contrast barium enema
Screen for complications
* Colonoscopy (Ca screening in long-standing cases)
* (BMJ)*
30
Identify the possible complications of ulcerative colitis
* Early: inflammatory pseudopolyps, toxic megacolon, infection, perforation, lower GI bleed
* Late: benign stricture, colonic adenocarcinoma, primary sclerosing cholangitis
## Footnote
*(BMJ)*
31
Summarise the prognosis for patients with ulcerative colitis
Mortality: slightly higher overall mortality compared to general population. Toxic megacolon most common cause of death
Morbidity: 2/3 pts relapse w/i 10y of dx. 20-30% require colectomy.
*(UpToDate, BMJ)*
32
Outline clinical features which may enable you to distinguish between Crohn's disease and ulcerative colitis
*(passmedicine)*
33
Ascending cholangitis: Charcot's triad
Fever + RUQ pain + jaundice
34
Summarise the epidemiology of ascending cholangitis
50-60y
M=F
*(BMJ)*
35
Explain the aetiology of ascending cholangitis
* Gallstones - most common cause. 1% risk
* ERCP - 1% risk
* Primary sclerosing cholangitis
* Benign biliary stricture (chronic pancreatitis, chemoradiotherapy, post-surgical)
* Malignant biliary stricture (cholangiocarcinoma, pacreatic ca, ampullary ca)
*(BMJ)*
36
Generate a management plan for ascending cholangitis
Medical (ABCDE)
* Sepsis six: including IV antibiotics (1st: tazocin or cef + met)
* Analgaesia: IV opiates
* Urgent biliary decompression (w/i 24-48h depending on severity)
* ERCP + lithotripsy
* Percutaneous transhepatic cholangiography (if ERCP CI)
Surgical (largely replaced by non-operative techniques)
* Biliary decompression; or choledocotomy + T-tube insertion; or lap cholecystectomy
* + analgaesia + IV antibiotics
*(BMJ)*
37
Identify the possible complications of ascending cholangitis
Early: sepsis, MODS, acute pancreatitis
Late: post-interventional impaired biliary drainage
*(BMJ)*
38
Summarise the prognosis for patients with acute cholangitis
Rapid biliary decompression associated with good outcome
Poor prognostic factors: hyperbilirubinaemia, high fever, high WCC, elderly, hypoalbuminaemia, requiring surgical intervention
*(BMJ)*
39
Identify appropriate investigations for ascending cholangitis
Confirm diagnosis
* Bloods: CRP, ESR, FBC, LFTs, UEs, cultures
* Imaging: USS abdo (90% show dilation of CBD)
* ECRP is therapuetic
*(passmedicine)*
40
GP: what are the recommendations for 2w-wait referral for ?colonic malignancy
_Referral from GP - 2w wait_
* All pts with
* \>40 + unexplained wt loss + abdo pain
* \>50 + unexplained rectal bleeding
* \>60 + IDA or change in bowel habit
* faecal occult blood +ve
* Consider pts with
* rectal / abdominal mass
* unexplained anal mass / ulceration
* \<50 + rectal bleeding + abdo pain / wt loss / IDA / change in bowel habit
*(passmedicine, NICE)*
41
Generate a management plan for haemorrhoids
* Conservative:
* Increase dietary fibre, increase fluid intake
* Medical
* Topical anaesthetics + topical steroids
* Rubber band ligation: outpt
* Doppler guided haemorrhoidal artery ligation
* Surgical: only for large symptomatic haemorrhoids, not reponsive to previous tx
* Stapled haemohorroidopexy
## Footnote
*(passmedicine)*
42
What are the possible causes of ascites?
**'PINCH'**
Portal HTN (esp cirrhosis)
Inferior vena cava obstruction
Neoplasms (ovarian malignancy, peritoneal mets)
Constrictive pericarditis
Hypoproteinaemia: nephrotic syndrome, liver failure, malabsorption
*(Meeran)*
43
Give the common causes of hepatomegaly
* Most common
* Cirrhosis
* Malignancy
* R-sided HF
* Less common
* Infective: viral, bacterial (Weil's)
* Myoproliferative (leukaemia, myelofibrosis)
* Biliary obstruction
44
Generate a management plan for Crohn's disease
* Conservative: stop smoking, some evidence for avoiding NSAIDs + COCP, monitor wt gain (children)
* Medical:
* Acute - induce remission
* 1st: steroids (oral/IV, topical in rectal disease)
* if not tolerated, consider budesonide or enteral elemental feeding
* 2nd: mesalazine
* 3rd: + azathioprine or mercaptopurine or methotrexate
* don't use these as monotherapy
* 4th: + infliximab (in refractory disease)
* Long-term - maintain remission
* 1st: azathioprine or mercaptopurine
* 2nd: methotrexate
* Surgical:eg limited ileocaecal resection
* SEs: perforation, obstruction, toxic megacolon
## Footnote
*(passmedicine)*
45
Give risk factors of Crohn's disease
RFs: genetic (FHx), smoking, ?COCP , ?NSAIDs, diet rich in refined sugars
## Footnote
*(BMJ)*
46
Identify the possible complications of Crohn's disease
Early: fistulae, perianal abscess
Late: malabsorption, strictures, toxic dilatation
*(AS)*
47
Summarise the prognosis for patients with Crohn's disease
10-20% have prolonged remission after initial presentation
80% have surgery
*(BMJ)*
48
Give potential causes of gynaecomastia
* Physiological (puberty)
* Congenital: Kleinfelter's Syndrome (47XXY)
* Failures: Cirrhosis and kidney failure
* Endocrine: hypoandrogenism (orchidectomy, prostate ca tx), Addison's, hyper/hypothyroidism
* Drugs: spironolactone, digoxin, finasteride
## Footnote
*(passmedicine, CfP)*
49
Give potential causes of dysphagia
* Obstructive
* Malignancy (oesophageal, gastric)
* Stricture
* Oesophageal web
* External compression: goitre, largyngeal Ca
* Motility disorder
* Achalasia
* Neurological: stroke, myasthenia gravis
* Neurodegenerative: Parkinsons +, MND
* Other: oesophagitis, phargngeal pouch, candida
## Footnote
*(500 SBAs)*
50
Give potential causes of portal hypertension
* Pre-hepatic: portal vein occlusion, splenic vein occlusion, nephrotic syndrome
* Hepatic
* Cirrhosis, sarcoidosis, myeloproliferative disorders, schistosomiasis
* Post-hepatic: hepatic vein occlusion, R-sided HF, constrictive pericarditis
## Footnote
*(path, 500 SBAs)*
51
Identify the possible complications of cirrhosis
* Liver failure:
* coagulopathy
* encephelopathy
* hypoalbuminism
* hypoglycaemia
* Portal hypertension:
* splenomegaly
* ascites (--\> spontaneous bacterial peritonitis)
* oesophageal varices (--\> UGI bleed)
* other portosystemic shunts
* Increased risk malignancy: HCC
## Footnote
*(500SBAs)*
52
Define cirrhosis
Irreversible liver damage. Histologically: loss of hepatic architecture + bridging fibrosis + nodular (micronodular \<3mm, macronodular \>3mm) regeneration. ‘Compensated’ = non-symptomatic. ‘Decompensated’ = at least one of ascites, bleeding (variceal), consciousness level drop.
## Footnote
*(Y3 notes)*
53
Give causes of cirrhosis
* Most common
* Alcohol liver disease
* Viral hepatitis (HCV, HBV)
* Non-alcoholic fatty liver disease
* Congenital: hereditary haemocromotosis, Wilson's, alpha1 ATD, CF
* AI: autoimmune hepatitis, PBC, PSC
* Drugs: methotrexate, amiodarone, isoniazid
* Neoplasm: HCC, mets
## Footnote
*(AS)*
54
How is the severity of cirrhosis graded?
_Modified Child Pugh Score_
* Ascites: mild = 2, moderate+ = 3
* Encephelopathy: mild = 2, marked = 3
* Bilirubin: \<34 = 1, 34-50 = 2, 50+ = 3
* Albumin: \>35 = 1, 28-35 = 2, \<28 = 3
* PTT(s): \<4 = 1, 4-6 = 2, \>6 = 3
Total Score \<7 = A = 45% 5y survival
Total Score 7-9 = B = 20% 5y survival
Total Score 10+ = C = \<20% 5y survival
55
Identify appropriate investigations for cirrhosis
Confirm diagnosis:
* Bloods: FBC, UEs, clotting, LFTs, glucose, albumin
* Ascitic tap: chemistry, cytology, MC&S, SAAG
* Imaging: USS abdo
Screen causes:
* Viral: HBV, HCV
* NAFLD: lipids
* AI: AutoAbs (AMA, ANA, SMA, pANCA)
* Genetic: caeruloplasmin, ferritin
* Neoplasm: AFP, Ca199
*(AS)*
56
Generate a management plan for cirrhosis
* Conservative: Good nutrition (Ensure), ETOH abstinence, avoid NSAIDs/sedatives/opiates
* Medical:
* Symptomatic:
* cholestyramine (pruritus)
* Ascites – fluid restriction (\<1.5L/d), low-salt diet (40-100mmol/d), diuretics (spironolactone PO counters deranged renin-angiotensin system. +/- furosemide PO, watch Na), regular weights, target \<0.5kg/d
* Manage cause
* Antivirals (HCV, HBV)
* Primary biliary cirrhosis – high dose ursodeoxycholic acid
* Wilson’s disease – penicillamine
* Manage complications
* Portal hypertension/varices – β-blockers, regular endoscopy
* Laxatives, phosphate enema – remove toxins to reduce confusion
* Surgical
* Transplantation – only definitive Tx. Increase 5yr survival from ~20% in end-stage to ~70%
(Y3 notes)
57
Outline the potential causes of jaundice
* Pre-hepatic = haemolytic = unconjugated
* Inherited: eg sickle cell, G6PD
* Acquired:
* Immune: AIHA (warm/cold, drug induced (penicillin))
* Non-immune
* Infections: malaria
* MAHA: DIC
* Mechanical: valves
* Hepatic:
* Unconjugated: Gilberts, Crigler-Najjar (impared conjugation)
* Conjugated:
* Infective: viral (HBV, HCV, CMV, EBV), syphilis, Weils
* Inflammatory: alcoholic, AI, drugs (methotrexate, amiodarone, methyldopa)
* Malignancy: HCC, mets
* Metabolic: HH, Wilson's, alpha1ATD
* Post-hepatic = obstructive = conjugated
* Drugs: CAAPS
* Inflammatory: PSC, PBC
* Malignant: cholangiocarcinoma, pancreatic Ca
## Footnote
*(Y3 notes)*
58
How can you determine whether ascites is due to portal hypertension?
Serum Ascites Albumin Gradient (SAAG)
* SAAG \>= 1.1g/dL = transudative = Portal HTN (esp cirrhosis)
* SAAG \<1.1g/dL = exudative
* Infection: TB peritonitis
* Inflammation: pancreatitis
* Malignancy: peritoneal mets, ovarian Ca
* Nephrotic syndrome
*(AS)*
59
Identify appropriate investigations for Crohn's disease
* Confirm diagnosis:
* Bloods: ESR, CRP
* Stool: faecal calprotectin
* Imaging: colonoscopy (diagnostic) + biopsy
* Small bowel barium enema: rose-thorns, apple-core, Kantor's sign (string = stricture)
*(passmedicine)*
60
Define achalasia
failure of relaxation of the lower oesophageal spincter due to loss of ganglionic cells in myenteric plexus. Leads to dilation of upper oesophagus ('birds beak' appearance)
61
Generate a management plan for achalasia
* Medical:
* Nifedipine
* Botulinum toxin injecton
* Surgical:
* 1st lineHeller's myotomy: incise outer muscle layers of lower oesophagus
* +/- fundoplication (for reflux)
## Footnote
*(250 SBAs)*
