Gastrointestinal Flashcards
1
Q
Peptic ulcer disease presentation (+ ALARMS)
A
- epigastric pain, worse on eating and lying flat (if duodenal, eating may relieve)
- usually prostaglandins reduce acid release and increase mucus, so NSAIDs are key in disease
- malignancy risk ALARMS symptoms for red flags: Anaemia Loss of weight Anorexia Recent onset Melaena/haematemesis Swallowing difficulty
Ix
- carbon13 breath test for H pylori (all duodenal)
- endoscopy if concern re perforation or malignancy
- Rockhall score to risk stratify (if can send home and OP)
Mx
- lifestyle - smoking, alcohol, steroids, NSAIDs stop
- Helicobacter pylori eradication with PPI + clarithromycin + amoxicillin
- PPI (omeprazole) / H2 antagonist (ranitidine) / antacid (sodium bicarbonate) / misoprostol (mucus protection)
- surgery if perforated and bleeding
2
Q
Iron deficiency anaemia
A
Common! 14% menstruating women.
Symptoms
- fatigue, dyspnoea, faintness, palpitations, headache, tinnitus, anorexia, angina
Signs if chronic
- koilonychia, atrophic glossitis, angular cheilitis, conjunctival pallor
RFs
- Helminth (hookworm) infection
- chronic blood loss
- iron poor diet
- malabsorption (coeliac)
- pregnancy
Ix
- blood film - microcytic, hypochromic anaemia
- low serum ferritin (stores used up)
- increased total iron binding capacity (transferrin)
Mx
- treat cause
- oral ferrous sulfate for 3mo after return to baseline
- IV iron only if oral impossible
3
Q
Diverticular disease
A
= herniation of mucosa and submucosa through muscular wall of colon
= diverticulitis if inflammation/infection
- diverticular is asymptomatic
- diverticulitis
- – chronically - recurrent dull lower left quadrant pain, change in bowel habit, low grade fever
- – acutely - diffuse pain, rebound tenderness, abscess formation, bleeding perforation
RFs
- age >50 (and increasing)
- low dietary fibre
+ obesity, NSAID use
Ix
- FBC - leukocytosis
- CXR (rule out)
- CT abdomen
Mx
- analgesia, fibre supplementation
- oral abx if infected diverticulitis
- treat complications as necessary (surgery if perf)
- elective surgery for recurrent
4
Q
Colorectal polyps
A
= projection from colonic mucosal surface, neoplastic or non-neoplastic
- mostly asymptomatic
- most CR cancers arise from adenoma polyps
Risk factors
- increasing age
- family history - FAP (APC mutation), HNPCC (DNA mismatch repair mutation), Peutz-Jeghers syndrome (STK11 gene mutation)
- previous hx of polyps
- acromegaly
- IBD
- obesity
Ix and Mx
- colonoscopy, flexible sigmoidoscopy
- double contrast barium enema
- narrow band imaging
- > endoscopic polypectomy
- > surveillance
- > colectomy if FAP (100% risk cancer)
5
Q
Biliary colic
A
Stage 1 gallstone disease - when pain due to stones passing through bile ducts
- RUQ pain lasting several hours, onset 2-3 hours after fatty meal, can radiate to shoulder
RFs
- fat female fertile forty fair
- rapid weight loss
- drugs
- > cholecystitis more if - severe illness, diabetes
- > cholangitis more if - fhx sclerosing cholangitis, ERCP, strictures
Ix and Mx
- USS to visualise stones
- bloods to rule out progression
- conservative - cut fat out of diet
- analgesia
6
Q
Cholecystitis
A
Stage 2 gallstone disease - inflammation of bile duct when stone is blocking (rarely acalculous)
- RUQ pain + fever + Murphy’s sign (catch breath when pressure on costal margin and inhale)
Ix and Mx
- USS to visualise stones
- bloods - raised CRP/WCC, deranged LFTS (more rise in ALP than ALT)
- analgesia
- IV abx
- ERCP to diagnose and extract stones in CBD
- or cholecystectomy
7
Q
Ascending cholangitis
A
Stage 3 gallstone disease - obstruction of the CBD leads to bacterial seeding of biliary tree, so infection
- RUQ pain + fever + jaundice (Charcot’s triad)
- risk sepsis!
- if jaundice and no fever, then Mirizzi’s syndrome, gallstone impacted on neck of gallbladder obstructing CBD
Ix and Mx
- USS to visualise stones
- bloods - raised CRP/WCC, deranged LFTS (more rise in ALP than ALT), check amylase in case of pancreatitis
- ABG if ? sepsis
- analgesia
- IV abx
- ERCP to diagnose and extract stones in CBD
- or cholecystectomy
8
Q
Hiatus hernia
A
= protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm
- heartburn (GORD), reflux, dull retrosternal pain, dysphagia/odynophagia, bowel sounds in chest, haemorrhage or obstruction in emergency
RFs
- obesity
- increasing age
- connective tissue disease
- chronic bouts of increased IA pressure (coughs / strenuous activity)
- surgical procedures around gastro oesophageal junction
Ix
- CXR
- contrast upper GI series
- OGD (oesophago-gastro-duodenoscopy)
- CT/MRI
Mx
- conservative - weight loss, dietary changes
- medical - PPIs
9
Q
Paraumbilical hernia
A
= defect in abdominal wall fascia near umbilicus allowing protrusion of the peritoneum (containing omentum or bowel)
- pain or hesitation on heavy lifting / coughing, hernia going ‘hard’ so gut strangulation, thrill felt when ask to cough
RFs
- obesity
- increasing age
- connective tissue disease
- chronic bouts of increased IA pressure (coughs / strenuous activity)
- surgical procedures around umbilicus
Ix - clinical diagnosis alone
Mx - surgical repair laparascopic or open, with mesh
10
Q
Inguinal hernia
A
= protrusion of abdominal or pelvic content through dilated internal inguinal ring (indirect) or through weakened inguinal floor (direct)
- groin/scrotal discomfort ± bulge, obstruction (distension/absent BS) in emergency, thrill when ask to cough
RFs
- obesity
- increasing age
- connective tissue disease
- chronic bouts of increased IA pressure (coughs / strenuous activity)
- surgical procedures around inguinal region
Ix - clinical diagnosis
Mx - surgical repair
11
Q
Obesity
A
= BMI >30
- multiple morbidities. Abdominal obesity more indicative of outcomes than peripheral obesity.
RFs - hypothyroidism, hypercorticolism, corticosteroid therapy
Mx
- conservative - diet, exercise, psychological therapy
- medical - appetite suppressors (GLP1 agonist liraglutide), lipase inhibitors (orlistat)
- surgical - sleeve gastrectomy, Roux-en-Y gastric bypass
12
Q
Gastroenteritis
A
= infection of GI tract, usually viral
See dehydration, + GI symptoms depending on type of enteric infection:
- type 1 - non-inflammatory watery
- type 2 - inflammatory dysentery (blood, mucus, leukocytes)
- type 3 - penetrating enteric fever (systemic infection)
Ix
- renal function (risk AKI)
- stool testing - culture for bacteria, antigen testing for viruses, microscopy for ova/parasites
Mx
- rehydration
- infection control
- rarely need medical/surgical intervention
13
Q
Gastroenteritis - Salmonella
A
- from contaminated poultry/dairy (never human-human)
- 1-3 days incubation, resolves in <1 week
- watery brown diarrhoea, can be systemic, can lead to colitis, bacteraemia, reactive arthritis
14
Q
Gastroenteritis - Shigella
A
- from faeco-oral (humans)
- incubation 1-7 days (shiga toxin)
- high fever, high WBC, when fever resolves then diarrhoea
- can lead to colitis
15
Q
Gastroenteritis - Campylobacter
A
- from undercooked poultry, commonest cause of food poisoning
- incubation 2-5 days, dysentry
- can leads to Guillain Barre syndrome (post infectious peripheral neuropathy)
16
Q
Gastroenteritis - E coli
A
- from faeco-oral (other humans)
- incubation 1-5 days, then abrupt onset D+V
- can cause haemorrhagic colitis
- HUS risk in E coli O157 type
17
Q
Gastroenteritis - C difficile
A
- hospital acquired diarrhoea
- spore forming, must hand wash not gel
- common post abx use
- dysentry picture
- can lead to toxic megacolon and perforation, pseudomembranous colitis
18
Q
Viral gastroenteritis
A
MOST COMMON
- D+V, sometimes mild fever
- no treatment as no sequelae, just rehydration needed
- all from faeco-oral spread
Rotavirus - outbreaks in institutions, late winter. 1 day incubation then abrupt onset, recovery in 48 hrs.
Norovirus - outbreaks in closed communities. 1 day incubation, then explosive D+V.
Enteric adenovirus - infantile diarrhoea in termperate climates. 10 day incubation, long lasting.
Astroviruses - infants and elderly, maybe co-infection, in winter.
19
Q
Oesophageal reflux and GORD
A
= gastric contents ascend back to oesophagus or beyond
- 10-20% population
- heartburn - burning in chest after meals, worse lying or bending down
- acid regurgitation - sour/bitter taste in mouth
+ maybe dysphagia, laryngitis, enamel erosion, halitosis
RFs
- hiatus hernia
- old age
- fhx of GORD
- obesity
Ix and Mx
- PPI trial for 8 weeks to see if improve
- lifestyle - weight loss, eliminate chocolate / caffeine / alcohol / spicy / acidic food)
- OGD to see if oesophagitis (erosion, ulceration, strictures) or Barrett’s oesophagus (stratified squamous not columnar epithelium)
- if non-reponsive - oesophageal manometry, barium swallow, oesophageal capsule endoscopy
- H2 antagonist (ranitidine) can be added if PPI inadequate
Beware ALARMS symptoms, so immediate endoscopy (anaemia, weight loss, anorexia, recent progression, melaena/haematemesis, swallowing difficulty)
20
Q
Oesophageal varices
A
= dilated submucosal veins in lower third of oesophagus
- result of portal hypertension usually, from cirrhosis
Presentation
- nil direct, usually found due to cirrhosis
- if bleed, see haematemesis ± melaena
- signs of liver disease - alcohol abuse, spider naevi, jaundice, encephalopathy, hepatitis, caput medusae, haemorrhoids
Ix
- OGD
- to look for liver disease - FBC, coagulation, LFTs, U+Es, hepatitis serology
Mx
- cirrhosis, no varices - monitor
- small varices - B blocker + monitor
- large varices - endoscopic variceal ligation/banding + beta blockers + monitor
- acute bleed - fluid resus + vasoactive drugs + emergency endoscopic variceal ligation/banding
21
Q
Crohn’s disease
A
= chronic inflammatory disease, transmural granulomatous inflammation affecting any part of the gut mouth - anus (especially terminal ileum)
- diarrhoea, abdo pain, weight loss, fatigue, fever, malaise
- bowel ulceration, abdo tenderness/mass, perianal abscess/fistulae/skin tags, anal strictures, clubbing, skin / joint / eye problems
- may present with obstruction or perforation
RFs
- caucasian
- age 15-40 or 60-80
- fhx
- smoking
Ix
- colonoscopy + biopsies
- FBC (anaemia, leucocytosis)
- iron studies (deficiency)
- serum B12 (terminal ileum)
- serum folate
- raised CRP
- CT abdo
- MC+S of stool to exclude bacteria
- faecal calprotectin (inflammation)
Mx
- try diet change
- 1st - immunosuppression (steroids, azathioprine)
- 2nd - anti-TNF biologics (infliximab, adalimumab)
- surgery likely needed, in perforation, obstruction or toxic megacolon NOT curative
22
Q
Ulcerative colitis
A
= relapsing remitting inflammation of colonic mucosa, in rectum or colon (never above ileocaecal valve)
- episodic or chronic diarrhoea ± blood and mucus, crampy abdo pain, bowel frequency related to severity, urgency / tenesmus, systemic symptoms in attacks
- may be no signs, maybe fever, tender distended abdo, clubbing, aphthous oral ulcers, erythema nodosum, pyoderma gangrenosum, conjunctivitis, episceleritis, iritis, arthritis, AS, PSC
- risk toxic megacolon, cancer
RFs
- fhx
- HLA B27
- gastroenteritis
- recently stopped smoking
Ix
- colonoscopy + biopsies
- FBC (anaemia, leucocytosis)
- iron studies (deficiency)
- serum B12 (terminal ileum)
- serum folate
- raised CRP
- CT abdo
- MC+S of stool to exclude bacteria
- faecal calprotectin (inflammation)
Mx
- 5 ASA eg mesalazine PR
- topical steroid foams PR
- oral prednisolone if severe (4-6 motions/day) for episode then wean
- admit for hydration if severe - IV fluids, IV steroids, colectomy if needed
- biologics / surgery if needed
23
Q
Alcoholic liver disease
A
Stage 1 - steatosis (fatty liver)
Stage 2 - hepatitis (inflammation and necrosis)
Stage 3 - cirrhosis (fibrosis)
- RUQ pain
- hepatomegaly
(+ cirrhosis symptoms)
RFs
- male more common, but female more severe progression
- prolonged heavy alcohol consumption
- hepatitis C
Ix
- serum AST and ALT rise (more than ALP)
- serum bilirubin rise
- serum albumin lower
- hepatic USS
Mx
- alcohol withdrawal management - psychological + benzo (lorazepam)
- weight reduction, smoking cessation
- hepatitis immunisation
- sodium restriction + diuretics if oedematous
- liver transplant
24
Q
Cirrhosis
A
- end stage of any chronic liver disease (hepatitis B, C, alcohol misuse, NAFLD)
- risk of ascites, variceal haemorrhage, jaundice, portosystemic encephalopathy, hepatorenal syndrome (AKI), hepatopulmonary syndrome (over perfusion), hepatocellular carcinoma
Compensated cirrhosis = no evidence of complications
Decompensated = when you get the signs:
- haematemesis, coffee-ground vomit and melaena (from varices); constitutional symptoms (weight loss, fever, fatigue)
- jaundice, leuconychia, palmar erythema, spider naevi, Dupuytren’s, telengiectasia, distended abdomen, hepatosplenomegaly, caput medusae, oedema
Ix
- raised AST, ALP, ALT, bilirubin
- low serum albumin
- proloned PTT and aPTT
- low platelet count
- transient elastography (USS)
- abdo MRI/CT
- upper GI endoscopy
Mx
- treat underlying liver disease, sodium restriction and diuretic
- liver transplant
25
Portal hypertension
When liver damage (cirrhosis / schistosomiasis) causes blood to backlog in portal venous system
- asymptomatic until complications...
- splenomegaly
- GI bleed (melaena, haematemesis, coffee ground vomit)
- ascites
- encephalopathy
- low PLT count
Ix
- proctoscopy (dilated veins)
- endoscopy (varices)
- USS (ascites, splenomegaly, nodular liver, low portal flow rate)
Mx
- lifestyle - no alcohol / drugs, low sodium diet
- B blockers
- band varices endoscopically
- surgery - transjugular intrahepatic portosystemic shunt, distal splenorenal shunt
26
Hepatitis
Viral, alcoholic or autoimmune
- beware fulminant in severe, with 80% mortality, usually from co-infected HBV and HBC
- fever
- RUQ pain
- jaundice, pruritis
- myalgia, arthralgia
- nausea, anorexia
- dark urine, pale stools
Ix
- deranged LFTs
- hepatitis viral antigen/antibody testing
- USS (exclude gallstones or cancer)
Mx
- acute: avoid drugs, IV fluids and check LFTs
- chronic: interferon and antiviral therapy
- stop drinking!
- autoimmune: immunosuppressants, anti-inflammatories
27
Viral hepatitis
Hep A
- faeces
- acute only
- can be immunised
Hep B
- blood
- percutaneous / permucosal / sex
- chronic
- can be immunised
```
Hep C
- blood
percutaneous / permucosal / sex
- chronic
- can't be immunised
```
Hep D
- blood
- percutaneous / permucosal / sex
- chronic
- can be immunised
Hep E
- faeces
- faeco-oral
- acute only
- can't be immunised
28
Oesophageal cancer
- dysphagia, weight loss, retrosternal chest pain, ± hoarseness and cough if in top 1/3rd
Squamous cell carcinoma
- upper 2/3rds
- from genetics + tobacco/alcohol use
(more risk if poor diet, hot drinks, male)
Adenocarcinoma
- lower 1/3rd
- GORD -> metaplasia -> Barrett's oesophagus -> adenocarcinoma
(more risk if hiatus hernia, poor diet, hot drinks, male)
Ix
- OGD with biopsy
- FDG-PET scan for metastasis
Mx
- endoscopic resection ± ablation
- oesophagectomy
- pre-op chemo depending on size
29
Gastric cancer
Adenocarcinoma
- vague epigastric pain
- weight loss
- anaemia
- rarely melaena
- Virchow's node
RFs
- male
- pernicious anaemia
- H pylori infection
- cured meats? (N nitroso compounds)
- fhx
- smoking
Ix
- upper endoscopy with biopsy
Mx
- surgical resection ± chemoradiotherapy
Beware MALT lymphoma (from H pylori), can be cured with abx alone if caught early!
30
Pancreatic cancer
Adenocarcinoma of pancreatic ducts in head of pancreas, poor prognosis (only presents when big enough to compress CBD)
- painless jaundice
- weight loss
- persistent back pain (retroperitoneal mets)
RFs
- smoking
- fhx
- familial cancer syndromes
- age 65-75
Ix
- elevated LFTs
- abdo USS - pancreatic mass, dilated bile ducts, liver mets
Mx
- surgical resection (rarely possible)
- late stage - endoscopic stent insertion to keep bile duct patent, palliative chemo
31
Liver cancer
Hepatocellular carcinoma, usually following cirrhosis, then metastasis quickly
- hepatomegaly
- abdo distension
- weight loss
± variceal bleeding, oedema, encephalopathy, jaundice, palmar erythema/spider naevi
RFs
- male
- cirrhosis - chronic hep B/C, alcoholism
- diabetes
- obesity
- fhx
Ix
- FBC - microcytic anaemia, thrombocytopaenia
- LFTs - low albumin, raised enzymes and bilirubin
- elevated INR
- viral hepatitis panel
- liver USS
- alpha fetoprotein (HCC)
Mx
- surgical resection
- liver transplantation
- chemoradiotherapy adjunct
32
Haemorrhoids
- when haemorrhoidal cushions (normal anatomical structures) enlarge (symptomatic if protrude outside anal canal)
- bright red rectal bleeding on defaecation / wiping, especially when straining
- perianal pain, discomfort, itching
RFs
- middle aged - elderly
- constipation
- pregnancy
- presence of space occupying pelvic lesion
Ix
- PR (visual inspection)
- colonoscopy / flexi sigmoidoscopy to rule out other causes of GI bleed
Mx
- diet and lifestyle (fibre)
- topical steroid cream
- rubber band ligation / surgical haemorrhoidectomy
33
Upper GI bleed
- anywhere proximal to the ligament of Treitz (duodenojejunal flexure)
- nausea
- haematemesis
- coffee-ground vomit
- melaena (tarry stool)
- anaemia - fatigue, pallor, SOB
RFs
- NSAIDs
- alcoholism
- chronic liver disease
- H pylori
Causes:
1. peptic ulcer disease
2. ruptured oesophageal varices
+ gastric/oesophageal cancer, oesophagitis, Mallory-Weiss tears
Ix and Mx
- group and save, cross match, VBG
- endoscopy to diagnose and treat
- fluid resus
- Glasgow-Blatchford bleeding score to decide if manage as OP or need immediate management
34
Acute pancreatitis
= inflammation and auto-digestion of pancreas, usually due to gallstones or alcohol excess
- severe stabbing epigastric pain radiating to back, worsening with movement
- nausea, vomiting, anorexia
- abdominal bruising (Grey-Turner's on flanks, Cullen's paraumbilical)
- sepsis - if infected big mortality!
```
Causes:
I idiopathic
G gallstones
E ethanol
T trauma
S steroids
M mumps
A autoimmune
S scorpion
H hyperlipidaemia
E ERCP
D drugs (azathioprine, thiazide, furosemide)
```
Ix
- big rise in serum amylase and lipase (>3x upper limit of normal)
- AXR
- USS
- Glasgow pancreatitis score (PaO2, age, neutrophils, calcium, renal function, enzymes, albumin, sugar)
35
Acute abdomen
Abdo pain + any other GI symptom depending on cause
OBSTRUCTION
- adhesions, incarcerated/strangulated hernia, volvulus, intussusception, GI malignancy
INFLAMMATION
- cholecystitis, appendicitis, pancreatitis, diverticulitis, UC, Crohn's
PERFORATION
- gastric ulcer, Mallory-Weiss tear
GYNAE
- ectopic, ruptured ovarian cyst, ovarian torsion, PID
VASCULAR
- AAA dissection, mesenteric ischaemia, abdo wall haematoma, sickle cell crisis
INFECTION
- hepatic abscess, hepatitis, gastroenteritis
+ biliary colic
Ix
- AXR and erect CXR
- CT abdo/pelvis
- FBC and serum electrolytes
- endoscopy
36
Intestinal obstruction presentation
Presentation
- vomiting, nausea, anorexia, colicky pain
- SBO - vomiting early, less distension, pain higher
- LBO - vomiting later, more distension, constipation more pronounced (faeces and flatus)
Simple BO - one obstruction, no vascular compromise
Closed loop BO - at two points (eg sigmoid volvulus) forming distended loop of bowel at risk of perforation
Strangulated BO - vascular compromise, looks iller than you expect, sharper more constant localised pain, peritonism
37
Causes of bowel obstruction
Small bowel
- adhesions
- hernias
Large bowel
- colon carcinoma
- constipation
- diverticular stricture
- volvulus
- sigmoid (elderly, constipated, comorbid)
Rarely...
- Crohn's stricture
- gallstone ileus
- intussusception
- TB
- foreign body
38
Investigations and management of bowel obstruction
1st - drip and suck (NG and IV fluids)
```
AXR - if SBO then dilated intestinal loops with visible plicae circulares, absence of gas in rectum; if LBO then gaseous distension of large bowel, kidney bean if volvulus
Erect CXR (pneumoperitoneum)
CT abdo/pelvis
Emergency surgery if strangulated
```
39
Peritonitis
- severe generalised abdo pain, exacerbated by any movement
- board-like rigidity, guarded abdomen
- absent BS
(beware sepsis, shock, abscess)
Infectious or non-infectious causes:
- perforated gastric/duodenal ulcer
- perforated diverticulum / appendix / bowel / gallbladder
- cirrhosis
Ix
- bloods inc amylase (pancreatitis may present this way but doesn't need laparotomy!)
- AXR
- erect CRX
- blood gas
- CT
Mx
- treat cause
- IV fluids
- correct electrolytes
- triple therapy abx (metronidazole, gentamicin, coamoxiclav)
- surgery - exploration and lavage
40
GI perforation
- upper GI perf more rapid onset of symptoms than lower GI perf
- severe pain at site, intensified by movement
- nausea, vomiting, haematemesis, melaena
- fevers
- peritonitis rigid abdomen
Ix
- AXR
- CT abdo/pelvis
- FBC - WCC and CRP
Mx
- drip and suck to rest bowel (if patient stable)
- surgery - laparoscopy to close perforation and washout peritoneum
41
Acute appendicitis
- usually due to obstruction then infection
- surgical emergency as risk of perforation
Presentation
- anorexia 1st
- then abdo pain, starts mid abdo then localises over hours to RLQ (McBurney's sign), worse on movement and coughing
- then vomiting
+ rebound tenderness, reduced BS, fever, Rovsing's signs, Psoas sign, obturator sign
Ix
- FBC - mild leucocytosis
- USS may help
- CT abdo/pelvis
- clinical diagnosis
Mx
- open or laparoscopic appendectomy
- IV abx
42
Acute liver failure
Rare - rapid decline in hepatic function
- jaundice
- coagulopathy (INR>1.5)
- hepatic encephalopathy (mood, sleep, motor disturbance)
- abdo pain, RUQ tenderness
- nausea, vomiting
- hepatomegaly (not splenomegaly)
- absence of peripheral stigmata or liver disease
Causes
- paracetamol hepatotoxicity (50%)
- acute viral hepatitis / autoimmune hepatitis / drug induced liver injury
Ix
- LFTs - enzymes and bili raised
- INR >1.5
- FBC
- ABG (metabolic acidosis, raised lactate)
Mx
- ICU
- liver transplantation in 50%
- acetylcysteine if paracetamol overdose
43
Malabsorption syndrome
Weight loss, + ___ depending on deficiency
Causes
- coeliac, Crohn's, chronic pancreatitis, cystic fibrosis
- damage to intestine from trauma or infection
- congenital defects (eg biliary atresia)
- radiation injury
- drugs (tetracycline)
- parasitic infection
- enzyme deficiency
Ix
- stool test
- bloods - B12, vit D, folate, iron, calcium, albumin
- breath test (lactose intolerance)
- CT
- ODG with biopsy
- colonoscopy with biopsy
Mx
- enzyme / vitamin supplementation
- diet change
- abx / antiparasitic if infective
44
Chronic pancreatitis
- recurrent abdo pain (+ progressive scarring and loss of pancreatic function)
- malabsorption, weight loss
- steatorrhoea
- diabetes
- pancreatic calcifications
Causes
- alcohol abuse (80%)
- idiopathic (smoking, fhx, coeliac increase, cystic fibrosis, autoimmune risk)
- recurrent acute pancreatitis
Ix
- blood glucose rise
- CT scan (calcifications)
- abdo USS
- AXR (calcifications)
- faecal elastase
Mx
- stop smoking and drinking, low fat diet
- analgesia
- pancreatic enzymes + PPI
- lithotripsy
- surgical - distal pancreatectomy, biliary decompression
45
Cholangiocarcinoma
= malignancy of bile duct epithelium (intra or extrahepatic)
- gradual onset painless jaundice, with cholestasis in LFTs
RFs
- age >50
- any problem with biliary system (cholangitis, stones, structural disorder, primary sclerosing cholangitis)
- cirrhosis
- alcoholic liver disease
- hep B / C
Ix
- raised bilirubin and gamma GT
- raised ALP>ALT
- serum CA 19-9
- abdo USS
Mx
- surgical resection + adjunctive chemoradiotherapy
- liver transplant
- commonly not curable
46
Functional GI disorders
eg IBS, where symptoms cannot be explained by detectable disease
- common in young adult women
Ix
- clinical diagnosis
- blood and urine tests
- stool tests
- breath tests for bacterial overgrowth
- motility testing
- colonoscopy
- give dietary and lifestyle advice (high fibre, low FODMAP)
- anti-spasmodics (mebeverine)
- laxatives/loperamide
47
Autoimmune hepatitis
= chronic inflammatory, unknown cause
- genetic disposition + environmental trigger eg infection
- painless jaundice
- fatigue / malaise
- anorexia
- abdo discomfort
- hepatomegaly
- peripheral stigmata of liver disease (pruritis, arthralgia, spider angiomata, acne)
Ix
- LFTs - high serum globulin, raised AST, ALT > ALP, gamma GT
- low serum albumin
- autoantibodies present
Mx
- watch and wait
- steroids
- immunosuppressant (azathioprine)
- liver transplantation
48
Paracetamol overdose
>4g in 24 hours (especially with alcohol)
- causes excess metabolite NAPQI, and direct hepatotoxicity
- nausea, vomiting, RUQ pain
Ix
- serum paracetamol levels (onto nomogram)
- raised serum AST/ALT
Mx
- N-acetylcysteine (to replenish stores of glutathione), when in toxic levels on nomogram
- anti-emetic (ondansetron)
- activated charcoal if <1hr from ingestion
49
Gilbert's syndrome
= inherited mild, non-haemolytic unconjugated hyperbilirubinaemia, manifesting as jaundice in periods of stress or infection
- no other symptoms, completely benign
- triggered by dehydration, missing meals, sleep deficiency, infection
- more common in men
Ix
- normal LFTs (and all else), except mild hyperbilirubinaemia - see jaundice when above 40
Mx
- avoid triggers, patient education
50
Haemochromatosis
= autosomal recessive multisystem disorder, where dysregulated iron metabolism -> depositions
- common, M>F, more in caucasian
- fatigue and myalgia primarily
+ arthraliga/myalgia, hepatomegaly, diabetes mellitus, impotence, loss of libido, skin pigmentation
Ix
- serum transferrin saturation >45%
- serum ferritin rise
- end-organ damage - LFTs rise, echo (heart damage), fasting blood sugar (pancreatic damage)
Mx
- conservative - avoid iron rich foods (liver, meat, eggs), yearly follow up if asymptomatic
- medical - phlebotomy, iron chelation therapy if anaemic/heart disease
51
Alpha1 antitrypsin deficiency
- mutation causing lung and liver damage via neutrophil elastase
- M>F, age 30-40s
- productive cough, SOB on exertion, wheeze
- ascites, hepatomegaly rarely
Ix
- low plasma AAT levels
- obstructive picture in pulmonary function
- CXR (emphysema)
- deranged LFTs
Mx
- smoking cessation
- COPD treatment
- AAT infusion (from donor blood)
- lung transplant
52
Wilson's disease
- autosomal recessive condition, dysregulated copper metabolism
- liver symptoms
- - vomiting, weakness, ascites, oedema, jaundice, pruritis
- brain symptoms
- - tremors, muscle stiffness, hallucinations, personality changes
- Kayser-Fleischer rings in eyes
Ix
- copper studies (raised free copper, low ceruloplasmin, total copper level low, raised urine copper
- genetic testing for ATP7B mutation
Mx
- low copper diet
- copper chelation
- liver transplant
53
Primary biliary cholangitis
= disease of the small intrahepatic bile ducts, with progressive bile duct damage (chronic autoimmune granulomatous inflammation)
- 10x more in F>M, middle age onset usually
- asymptomatic usually, on incidental finding raised ALP
- fatigue, pruritis (rarely jaundice)
- hepatomegaly, hypercholesterolaemia, xanthelasma
- cirrhosis and osteoporosis complications
Ix
- autoantibody screen (anti-mitochondrial antibodies)
- raised LFTs
- low serum albumin
Mx
- treat symptoms (pruritis, diarrhoea, osteoporosis)
- fat-soluble vitamin prophylaxis
- bile acid analogue ursodeoxycholic acid
- steroids
- azathioprine immunosupression
- liver transplant
54
Primary sclerosing cholangitis
= progressive cholestasis with bile duct inflammation and strictures
- associated with IBD, more in men, fhx
- pruritis
- fatigue
- if advanced then ascending cholangitis, cirrhosis, hepatic failure
Ix
- ALP rise>AST
- bilirubin rise
- lowered albumin
- ANA, SMA, ANCA maybe positive
- ERCP or MRCP to show duct strictures and dilatations
- liver biopsy shows fibrous obliterative cholangitis
Mx
- lifestyle (no alcohol)
- colestyramine for pruritis
- calcium and vit D supplementation, bisphosphonates if osteoporosis
- liver transplant only effective treatment
55
Budd-Chiari syndrome
= hepatic venous outflow obstruction
- F>M, 20-30s mostly
- caused by anything obstructing outflow (thrombosis, phlebitis, stenosis, external compression by abscess/tumour)
Triad presentation
- RUQ pain
- ascites
- hepatomegaly
Ix
- thrombophilia screening
- doppler USS
- LFTs
Mx
- anticoagulation
- thrombolysis if <72 hours onset
- surgery - hepatic angioplasty (interventional radiology) / surgical shunting around thrombosis / liver transplant
56
Antacids (alginates)
- to neutralise stomach acidity, alkaline ions
- in heartburn / indigestion, MILD symptoms of GORD
SEs
- if Mg containing, can cause diarrhoea
- if Al containing, can cause constipation
57
Histamine receptor 2 antagonists
eg ranitidine, cimetidine
- to block H receptors on parietal cells in stomach, so inhibiting cAMP dependent activation of proton pump, so decreasing production of stomach acid
- for peptic ulcer disease,
GORD, dyspepsia, prevention of ulcers
```
SEs
- diarrhoea
- hypotension
- cholestasis
(may mask cancer symptoms)
```
58
Gastric protection - four mechanisms of action
1. prevent acid secretion - PPI eg omeprazole
2. prevent activation of proton pump - antihistamine eg ranitidine
3. direct antacid to neutralise - alginates
4. protect mucosa using prostaglandin analogue eg misoprostol
59
Proton pump inhibitors
eg omeprazole, lansoprazole
- directly blocks production of H+ from parietal cells by inhibiting H/K ATPase
- for peptic ulcer disease, GORD, dyspepsia, prevention of ulcers
```
SEs
- headache
- nausea
- diarrhoea
- abdo pain
- fatigue
- dizziness
(may mask symptoms of gastric cancer)
```
60
Prostaglandin analogues
eg misoprostol
- PGE2 is protective as reduces acid secretion and increases mucus and HCO3
- for peptic ulcer disease, GORD, dyspepsia, prevention of ulcers
SEs
- diarrhoea
(NEVER in pregnancy - causes contraction of uterus and abortion)
61
Anti-emetics
Cyclizine
- H1 antagonist, to inhibit nucleus of solitary tract and inhibit vomiting centre
- good for GI causes
- SE of drowsiness
Metoclopramide
- D2 and 5HT3 antagonist, to inhibit CTZ
- good for GI causes and prokinetic (not for days after GI surgery)
- SEs extrapyramidal
Prochlorperazine
- D2 antagonist, to inhibit CTZ
- good for vestibular/GI causes
Ondansetron
- 5HT3 antagonist, to inhibit CTZ
- good for chemotherapy
62
Anti-diarrhoeal agents
eg loperamide, codeine
- opioids (but loperamide only in gut, doesn't cross BBB), so work by reducing gut motility and decreasing secretions
- for gastroenteritis, IBD, short bowel syndrome
```
SEs
- constipation
- sleepiness
- dry mouth
(never if blood in stool as risk toxic megacolon in colitis)
```
63
Aminosalicylates
eg sulphasalazine, mesalazine/5-ASA
- anti-inflammatories, for RA, UC, Crohn's etc
Sulphasalazine - DMARD for RA
Mesalazine better for IBD
SEs
- anorexia
- nausea
- headache
- rash
- bone marrow suppression
64
Prednisolone
- steroid to inhibit inflammation, for many inflammatory / autoimmune conditions, and as replacement therapy in Addison's
```
SEs (many)
- Cushing's syndrome
- bone loss
- yeast infections
- hyperglycaemia
(beware in pregnancy)
```
65
Laxatives
First always increase fibre, drink water, exercise regularly
1. Lubricants eg liquid paraffin
- can prevent absorption of some nutrients
2. Bulk-forming agents eg bran
- increase volume of non-absorbable food so attracting water and loosening stool (beware dehydration)
3. Intestinal stimulants eg senna, bisacodyl
- to stimulate contraction
4. Osmotic laxatives eg MgSO4, lactulose
- to keep poorly absorbed solutes in GI tract and promote movement of water into tract (beware dehydration)
5. Faecal softener eg docusate sodium
- to decrease surface tension of faeces and increase penetration of intestinal fluid
SEs
- diarrhoea, hypokalaemia
- abdo discomfort / cramps
- dehydration
66
Antispasmodics
eg mebeverine
- anticholinergic for IBS, to relax smooth muscle in gut
- for stomach cramps, persistent diarrhoea, flatulence
SEs
- constipation
- anorexia
67
Azathioprine
- immunosupressant, purine analogue so producing less DNA/RNA for WBC production
- for autoimmune conditions including Crohn's, UC, rheumatology conditions, or to prevent rejection after transplant
SEs
- bone marrow suppression
- vomiting
(not in pregnancy)
68
Helicobacter pylori eradication regimens
- after infection confirmed by breath test, stool sample, blood test or biopsy, needs to be eradicated to prevent ulcers, gastritis, gastric carcinoma, MALT lymphoma
- spiral shaped gram -ve which synthesises urease producing ammonia which neutralises acid
```
Triple therapy 1st:
- oral PPI
- clarithromycin
- amoxicillin
Quadruple therapy if no:
- oral PPI, bismuth (antacid), tetracycline, metronidazole
```
69
Ferrous sulphate
= iron, for iron deficiency anaemia treatment or prevention (absorption deficit, heavy periods, pregnancy, haemodialysis, low dietary iron)
- oral, IM or IV
```
SEs
- constipation or diarrhoea, with dark stool
- abdo pain
- iron overload / toxicity
(never in haemochromatosis)
```
70
Small molecule inhibitors
eg tofacitinib, JAK1 inhibtor
| - anti-inflammatory, so for RA now (maybe in future for IBD, psoriasis, AS)
71
Biologics
eg infliximab (IV infusion), adalimumab (SC injection)
- monoclonal IgG antibodies against TNFalpha
- so reduces inflammation
- for Crohn's, UC, rheumatological conditions
SEs
- infection
- reactivation of HepB or TB
- drug induced lupus
- hepatosplenic T cell lymphoma
