general Flashcards
Upper GI bleeds is proximal the ligament of
ligament of Trietz
lower GI bleeds is distal to the
ligament of Trietz
upper GI bleeds clinical features
haematemesis, melaena, elevated urea, dyspepsia, reflux, epigastric pain, NSAIDS use
lower GI bleed features
fresh, magenta stools, normal urea, painless, common in elderly
most common cause of an upper GI bleed?
peptic ulcer
Zollinger Ellison syndrome is
gastrin secreting pancreatic tumour that causes recurrent poor healing duodenal ulcers
Mallory Weiss tear is typically at the
oesophago-gastric junction
diuelafoy refers to
submucosal arteriolar vessel eroding through mucosa
lower GI haemorrhage Angiodysplasia treatment
Aargon phototherapy, tranexamic acid, thalidomide
acute GI bleeding Meckel’s diverticulum diagnostic investigation
nuclear scintigraphy
treatment of GI bleed in terms of circulation
wide bore access for fluids and blood
blood samples
catheter
tranexamic acid
haemorrhagic stroke features
high respiratory rate rapid pulse anxiety clammy, cool skin low urine output low blood pressure
bleeding uncontrolled at endoscopy treatment
sengstaken-blakemore tube trnasjugular intrahepatic porto-systemic shunt
recommended units of alcohol
6
FAST positive score to perform an AUDIT
> 3
AUDIT SCORE OF >20
possible dependence
AUDIT SCORE OF 16-19
higher risk
AUDIT SCORE OF 8-15
increasing risk
AAT to ALT ratio
> 2
causes of hepatic encephalopathy
Infection Drugs Constipation GI Bleed Electrolyte Disturbance
Glasgow hepatitis score criteria
Age WCC urea INR bilirubin
alcoholic hepatitis nutritional support requires
thiamine
small intestine is how long?
6m
small bowel is renewed every
4-6 days
large bowel turnover is every
3-8 days
intrinsic neuromuscular control of the small and large bowel
myenteric plexus via Meissener’s plexus
Auerbach Plexus
Meissener’s plexus location
base of submucosa
Auerbach plexus location
inner circular, and outer longitudinal layers of the muscularis propria
Crohn’s disease genetic association
NOD 2 gene
Ulcerative Colitis gene association
HLA
pANCA positive in which patients of IBD
75% in UC
11% in CD
ulcerative have granulomas?
no
Crohn’s disease granulomas
yes non-caseating granulomas
dysplasia in hindgut commonly
adenoma tubular
low grade adenoma dysplasia of the lower gut
increased nuclear number and size, reduced mucin
high grade dysplasia adenoma of the lower gut
carcinoma in situ, crowded, irregular, not yet invasive.
genetics of colorectal carcinoma
FAP
HNPCC
Peutz-Jeghers
congenital ano-rectal abnormalities
imperforate anus
uro-genital fistulae
hirschprung’s myenteric plexus deficiency
acquired ano-rectal abnormalities
haemorrhoids, fissure, abscesses, fistula in ano, ulceration, cancer, control of continence
procedure for prolapse and haemorrhoids
stapled anopexy
most likely site for a colo-rectal cancer site
left colon
anal squamous cancer treatment
radiotherapy
rectal adenocarcinoma treatment
neo adjuvant chemorad
laparoscopic resection
Dukes A 5yr survival
> 90% submucosa
drugs for acid suppression
antacids, H2 receptor antagonists, proton pump inhibitors
drugs affecting GI motility
anti-emetics, anti-muscarinics, anti motility
drugs affecting IBD
aminosalicylates, corticosteriods, immuno- suppressants, biologics
drugs affecting intestinal secretions
bile acid sequestrates and ursodeoxycholic acid
antacids contain what metals?
magnesium or aluminium
alginates mechanism for working
gel that floats on stomach
H2 receptors antagonists block which receptor
histamine
H2 receptor antagonists indicated for
GORD/peptic ulcer disease
side effects of PPI’s
GI upset, C.difficile infection hypomagnesaemia, B12 deficiency
mechanism of prokinetic agents on GI motility
parasympathetic control of smooth muscle and sphincter tone via Ach
vomiting centre is located
medulla
anti-motility drug mechanism for GI
opiate receptors to decrease ACh release
anti spasmodics mechanisms
- anti-cholinergic muscarinic antagonists
- direst smooth muscle relaxants
- Calcium CB’s
types of laxatives
bulk
osmotic
stimulant
softeners
contraindications and side effects of aminosalicylates in IBD
caution in renal impairment
may cause GI upset, blood dyscasias, renal impairment
IBD corticosteriods concerns
osteoporosis, weight gain, infection, addisonian crisis
IBD immunosuppressants mechanism
prevents formation of purines for Dna synthesis
adverse effects of immunosuppressants in IBD
bone marrow suppression, hypersensitivity, organ damage, drug interactions
biologics name
anti TNF alpha antibodies infliximab
cautions and effects of infliximab
TB, MS, pregnancy and infections.
effects are infection, reactions, anaemia, demyelination, malignancy, thrombocytopenia
drugs affecting biliary secretions
cholestyramine, ursodexycholic acid
mechanism of cholestyramine for biliary secretions
reduces bile salts, enables excretion as insoluble complex
cholestyramine side affects
reduces absorption of other drugs, affects fat soluble vitamin absorption and decrease vitamin K levels
ursodeoxycholic acid uses in what conditions
gallstones, Primary biliary cirrhosis
ursodeoxycholic acid mechanism for action
inhibits enzymes for cholesterol formation, slowly dissolves non-calcified stones
factors affecting absorption in the GI- drugs
pH, gut length, transit time
distribution GI affects - drugs
low albumin
metabolism GI affects -drugs
liver enzymes, increased gut bacteria, liver blood flow, gut wall metabolism
excretion affects in GI - drugs
biliary excretion
severity of liver disease classification
child-pugh classification
criteria for child Pugh classification
bilirubin, albumin, PT, encephalopathy, ascites
dangerous drugs to consider with liver disease
warfarin, aspirin, opiates
second leading cause of cancer death in the western world is
colorectal cancer
95% of colorectal cancers are what pathology?
adenocarcinomas
strongest risk factor for colorectal cancer
sporadic with no familial/genetic influence
2 histological types of colorectal adenoma polyps
tubular(75%) /villous
oncogenes involved in colorectal adenoma
k-ras, c-myc
loss of tumour suppressor genes in colorectal adenoma
APC, p53, DCC
Chemotherapy for treatment in colorectal cancer for
adjuvant, DUKES C +B, cleans up micrometastases
agent for chemotherapy in colorectal cancer
5-FU
radiotherapy in colorectal cancer is used only for
rectal cancer
Dukes stage A colorectal cancer 5yr survival percentage
83%
DUKES stage D colorectal cancer 5yr survival percentage
3%
age 50-74 receive a FOBT every how many years?
2 years
heritable conditions for colorectal cancer
FAP - familial adenomatous polyposis
HNPCC- hereditary non-polyposis colorectal cancer
FAP is a … condition (penetration)
autosomal dominant
FAP receives what medication as a form of prevention
NSAIDS chemoprevention
out of 2000 people in regards to bowel cancer how many people have cancer?
1
high risk features in rectal bleeding
persistent changes in bowel habit, with anal symptoms (>6 weeks), right sided abdominal mass, palpable rectal mass, unexplained iron deficiency
5 ethics
autonomy, equity, justice, beneficence, malfeasance
functional GI disorder’s examples
oesophageal spasm, non-ulcer dyspepsia, biliary dyskinesia, irritable bowel syndrome, slow transit constipation, drug related effects
causes of non-ulcer dyspepsia
reflux, low grade duodenal ulceration, delayed gastric emptying, irritable bowel syndrome
functional causes of vomiting
migraine, drugs, pregnancy, cyclical vomiting syndrome, alcohol.
alarming symptoms for functional bowel diseases and stools
age >50 short symptom history unintentional weight loss nocturnal symptoms male sex cancer history anaemia rectal bleeding recent antibiotics mass
investigations for functional bowel diseases
FBC, blood glucose, U+E, thyroid, coeliac, FIT, sigmoidoscopy, colonoscopy
functional causes of constipation
megacolon, idiopathic constipation, depression, psychosis, and institutionalised patients
organic causes of constipation
stricture, tumours, diverticular disease, proctitis and anal fissures
systemic causes of constipation
diabetes, hypothyroidism, hypercalcaemia
neurogenic causes of constipation
autonomic neuropathies, Parkinson’s disease, strokes, MS, spina bifida
clinical features of IBS
pain, altered habit, bloating, belching, wind, flatulence, mucus
NICE diagnostic criteria
mucus, abdominal bloating, symptoms made worse by eating, altered stool passage
calprotectin is released by
inflamed gut mucosa, differentiates by IBS and IBD
FODMAP
fermentable oligo, di, and mono saccharides and polyols
fructose, lactose, fructans, galactans and polyols
IBS drugs for pain
antispasmodics, linaclotide, antidepressants
IBS drugs for bloating
probiotics, linaclotide
IBS drugs for constipation
laxatives (bulking, softeners, stimulants, osmotic), linaclotide
diarrhoea IBS treatment
antimotility agents
FODMAP
psychological interventions for functional bowel disease
relaxation, hypnotherapy, CBT, psychodynamic
relaxation training for functional bowel disease uses
diarrhoea and psychological co-morbidity
hypnotherapy for functional bowel disease uses
pain, constipation, flatulence, anxiety
CBT for functional bowel disease uses
abdominal pain, bloating, flatulence
psychodynamic interpersonal therapy for functional bowel disease uses
history of abuse
IBS - D impact on intestinal motility
stronger frequent contractions
IBS -C impact on intestinal motility
contractions reduced
peristaltic rhythm is generated by pacemaker cells in the longitudinal muscles is every .. minutes
~3 minutes
function of somatostatin
controls secretion of insulin and glucagon
what is the name of the membrane bound enzyme that convers trypsinogen to trypsin
enterokinase
enzyme that cleaves peptide bonds
proteases
nucleases enzyme function
hydrolyses DNA/RNA
enzyme responsible for collagen digestion
elastases
phospholipids into fatty acids enzymes
phospholipases
starch to maltose + glucose enzyme
alpha amylase
zymogen secreted by what hormone?
Cholecystokinin
what converts CO2 + H2O into H2CO3
carbonic anhydrase
adenosine cyclase converts ATP into what?
cAMP
ATP conversion into cAMP is regulated by
histamine and prostaglandins via G proteins and adenosine cyclase
gastrin and acetylcholine regulate protein kinases via
Ca
defect in absorbing an intrinsic factor results in
pernicious anaemia
oesophagus mucosa is
stratified squamous non-keratinised epithelium
in the small intestine there is the crypts of
Leiberkuhn
lymphoid aggregations in the small intestine are called
peyer’s patches
Paneth cells
synthesize antimicrobial peptides and proteins
intestinal cells that synthesize antimicrobial peptides and proteins in crypts
Paneth cells
innate immune cells
neutrophil, eosinophil, basophil, mast cell, monocyte, dendritic cell, macrophage, natural killer cell
adaptive immune cell
CD4 T cell CD 6 T cell B Cell memory cell plasma Cell
what are the three signals that determine a T Cell response
MHC peptide-TCR
CD80-CD28
cytokine
integrins are
transmembrane proteins
bedside investigations
BMI, pulse oximetry, ECG, capillary glucose, urinalysis
urine collections analyse what
5HIAA, catecholamines
risks for upper GI endoscopic investigations
aspiration, perforation, haemorrhage
risks for colonoscopy investigations
perforation, haemorrhage, renal impairment
ECRP investigation risks
pancreatitis, haemorrhage, perforation, infection, mortality
submucosal neurone plexus
Meissner’s plexus parasympathetic
myenteric plexus is between what two muscular layers
circular and longitudinal muscle
antibiotic use impact on the GI microbiome
reduces diversity and increases Enterobacteriaceae
mechanisms of action for probiotics
competition, bioconversion, production of vitamins, direct antagonisms, competitive exclusion, barrier function, reduce inflammation, immune stimulation
selected prebiotics
FOS & Inulin, galactose, lactulose
endoscopy ALARMS
anorexia loss of weight anaemia recent onset melaena swallowing problems
H. Pylori +/- and description
negative spiral shaped microaerophilic flagellated
H. Pylori has infected how many people
50% of the world
H. pylori urease dependent diagnostic tests
breath tests 13C or 14C carbon dioxide
or
ammonia utilised in urease tests
gastritis causes
autoimmune
bacterial
chemical bile
H. pylori triple therapy
clarithromyocin 500mg
amoxycillin
PPI omeprazole
7 days
complications of peptic ulcer
acute bleeding, chronic bleeding, perforation, fibrotic stricture, gastric outlet obstruction
gastric outlet obstruction blood key markers
low cl
low na
low K
renal impairment
cholangiocarcinoma risk factors
PSC, congenital cystic disease, Biliary enteric drainage, thorotrast, hepatolithiasis, carcinogens
acute inflammation of hepatitis A, and E on the liver outcome
resolution
acute inflammation of hepatitis A, B, E, on the liver outcome
failure if severe damage
acute inflammation of the liver outcome via hepatitis b, C
progression to chronic hepatitis and cirrhosis B, C
haemoglobin is broken down in the
Spleen
haemoglobin forms
haem and globin
Primary biliary cholangitis is what disease?
auto-immune
PBC normally affects
females 9:1
PBC normally has what biomarkers in serum?
anti-mitochondrial auto-antibodies, and Raised serum alkaline phosphatase
pathology of PBC
granulomatous inflammation involving bile ducts, loss of intrahepatic bile ducts, progression to cirrhosis
metabolic disorders that may lead to cirrhosis
primary haemochromatosis ( excess iron) Wilson’s disease (excess copper)
Crohn’s and UC classification
Montreal classification
ulcerative colitis markers - specific
fever > 37.5C tachycardia >90/min ESR(CRP) raised anaemia hb <10g/dl albumin <30g/l leucocytosis, thrombocytosis
IBD inflammatory indices
high ESR, CRP high platelet high WCC low Hb low albumin Calprotectin
Crohn’s disease specific histological markers
granulomas
IBD extra intestinal manifestations
eyes (uveitis, episcleritis, conjunctivitis) joints (sacroiliitis, monoarticular arthritis ankylosing arthritis) Renal calculi (CD) liver and biliary tree (fatty change, pericholangitis, sclerosing cholangitis, gallstones) Skin (pyoderma gangerosum, erythema nodosum, vasculitis)
IBD differential diagnosis
chronic diarrhoeas, Ileo-caecal TB, colitis (infective, amoebic, ischaemia colitis)
IBD out patient management
5ASA
steroids
immunosuppression
IBD hospital managment
steroids anticoagulation infliximab surgery cyclosporine
mild to moderate UC 1st line therapy is
5ASA
optimal dosage of prednisolone for UC
40mg per day
what antibiotic is offered in Crohn’s peri-anal disease
metronidazole
Crohn’s surgical indications
failure of medical management relief of obstructive symptoms management of fistulae management of intra-abdominal abscess management of anal conditions
Crohn’s recurrence post surgery
50%
synthetic function of liver
clotting factors, bile acids, carbohydrates, proteins, lipids, hormones
what hormones are formed in the liver
angiotensinogen and insulin like growth factor
detoxification liver functions
urea production from ammonia, detoxification of drugs, bilirubin metabolism, breakdown of insulin and hormones.
liver storages
glycogen, vitamins A, D, B12, K and stores copper and iron.
raised aminotransferases suggests what involvement?
parenchymal
what drugs can raise Gamma GT
NSAIDS
differential diagnosis for Jaundice
carotenemia
bilirubin detectable when exceeding …umol/L
34
complications of ERCP
sedation related
pancreatitis
cholangitis
sphincterotomy
chronic liver disease is when the disease persists longer than …months
6 months
presentation of compensated chronic liver disease
routinely detected on screening tests, abnormality of liver function tests
decompensated chronic liver disease clinical presentation
ascites
variceal
hepatic encephalopathy
new onset ascites requires what investigation
diagnostic paracentesis
SAAG >1.1g/dl
portal hypertension
massive metastatic spread
constrictive pericarditis
SAAG < 1.1g/dl
malignancy
Tb
pancreatic
uncontrolled variceal bleeding management
endoscopic band ligation
terlipressin
sengstaken-blakemore tube
hepatocellular carcinoma is associated with which viral hepatitis
B & C
hepatocellular tumour marker
AFP
external anal sphincter is comprised of
skeletal muscle
colon actively transports when from lumen into blood
sodium
bacterial fermentation in the colon produces
short chain fatty acids, vitamin K and gas
following retention of faecal material in constipation is there absorption of toxins
no
enterotoxigenic bacteria in the gut work through what mechanism
protein enterotoxins turn of intestinal chloride secretions from crypt cells increasing H20 secretions
enterotoxigenic bacteria via increasing chloride secretion through what secondary messengers
cAMP
cGMP
calcium
ligament separating the right and left liver lobes
falciform ligament which leads onto the round ligament
which lobe is next the gallbladder
quadrate lobe
which lobe is next to the inferior vena cava
caudate lobe
what components of bile is secreted by hepatocytes?
bile acids lecithin cholesterol bile pigments toxic metals
what components of bile solubilise fat and are synthesised in the liver?
bile acids
lecithin
cholesterol
how many grams of cholesterol is synthesised in a day?
0.5g
bile acids are conjugated with what prior to secretion?
glycine or taurine
1 word to describe the action of secretin
neutralisation
1 word to describe the action of Cholecystokinin
digestion
hepatic A and E are what sort of viruses?
enteric
hepatic B, C and D are what sort of viruses?
parental
hepatic A and E are what sort of infections?
self limiting acute
hepatic B, C and D are what sort of infections?
chronic
how many people a year die from hepatitis?
1 million
acute hepatitis A is diagnosed by what antibodies?
IgM
who receives a HAV immunisation?
travellers, patients with chronic liver disease, haemophiliacs, occupational exposure and gay community
HBV antigen HBsAg is indicative of what?
surface antigen
presence of virus
HBV antigen e HBeAg is indicative of what?
active replication
hepatitis core antigen HBV HbcAg is indicative of what
active replication
HBV DNA is indicative of what
active replication
IgM anti HBc antibody indicates what?
acute infection
IgG anti HBc HBV antibody indicates what?
chronic infection
anti HBe HBV antibody indicates what
inactive virus
HDV often co-infects with which virus?
HBV
HDV viral description
small RNA virus, no protein coat enveloped by HBsAg
NAFLD criteria
AGE diabetes BMI AST:ALT platelet count albumin
high risk NALFD stats
>45 diabetic >30BMI AST:ALT >1 low platelet count <150 low albumin <34
treatment for NAFLD
weight and exercise insulin sensitizers glucagon like peptides vitamin E farnesoid X nuclear receptor ligand
autoimmune hepatitis is influenced by which antibody
IgG
PSC is which gender dominant
male
what disease is pANCA positive
PSC
anti-liver transplant rejection drugs are
steroids
azathiopurine
cyclosporine
facultative anaerobic bacteria definition
can grow in presence and absence of O2
obligate anaerobe definition
cannot grow in presence of oxygen
what are the three short chain fatty acids produced by bacteria in the gut
butyrate, propionate, acetate
butyrate function in cells
epithelial cell growth and regeneration
propionate role in the liver
gluconeogenesis in the liver
satiety signalling
acetate role in the tissues and lipids
transported to peripheral tissues and involved in lipogenesis
right side of the colon in comparison to the left side of the colon in terms of microbiota metabolism
right is more carbohydrate rich
mildly acidic
rapid turnover
left side microbiota metabolism of the colon
little fermentable carbs
pH neutral
turnover slow
two mechanism of colonisation resistance against pathogens by microbes in the gut
barrier effect
active competitive exclusion
at what pH do pathogens optimally grow at
> 6
which side of the colon is more susceptible to disease?
left side
higher pH
slower transit
less substrate
name hexose sugars
glucose, galactose, fructose
lactose consists of
glucose + galactose
sucrose consists of
glucose + fructose
maltose consists of
glucose + glucose
alpha amylose is glucose linked in …
straight chains
amylopectin is glucose linked in
highly branched chains
glycogen and starch are monomers linked by
alpha 1,4, glyosidic bonds
alpha 1,4, glyosidic bonds in glycogen and starch are broken down by what enzyme and mechanism
hydrolysed by amylase
cellulose molecular structure
unbranched linear chains of glucose monomers linked by beta 1,4 glycosidic bonds
what transmembrane protein channels does fructose travel through
GLUT 5 then GLUT 2
what transmembrane protein channel does glucose exit the cell via
GLUT 2
triacylglycerol consists of
a glycerol and 3 stearic acids
fat soluble vitamins are
A, D,E, K
water soluble vitamins are
B group, C and folic acid
iron is transported across a brush border membrane ..
DMT1
iron in the blood binds to
transferrin
stored iron is incorporated into
ferritin
fixed components for nutritional demand
basal requirements membrane function
mechanical work
substrate turnover
variable component for nutritional demand
processing intake
physical activity
body temp
growth
BMI =
weight KG/ height squared (m)
BMI > 25 is
overweight
BMI > 30 is
obese
BMI <20
underweight
BMI < 16
severe consequences
high risk of refeeding problems criteria
BMI <16
no nutritional intake for 10 day
low potassium, phosphate or magnesium
history of drug use or alcohol
treatment to avoid refeeding problems
correct fluid depletion
thiamine before feeding
feed 5-10kcal/kg
gradual increase
acute pancreatitis is associated with a rise in which serum biomarker
amylase
75% of carcinoma of the pancreas is
duct cell mucinous adenocarcinoma
mean survival of pancreatic carcinoma inoperable
<6months
oesophagus ends at what vertebral level
T11-T12
hypermotility oesophageal disorders often present with what appearance on a BA swallow
corkscrew
cause of a hypermotility disorder is often
idiopathic
hypomotility often caused by
connective tissue disease, diabetes and neuropathy
complications of motility disorders
aspiration pneumonia, squamous cell oesophageal carcinoma
squamous cell carcinoma often occurs in the what part of the oesophagus
proximal and middle third
survival rate of oesophageal cancer
<10% 5yr
demographic details on a X-ray
name ID gender DOB date time location
GALT stands for
Gut Associated Lymphoid Tissue
vitamin A deficiency results in
night blindness
thiamine deficiency signs
memory, dementia
niacin deficiency signs
dermatitis, unexplained heart failure
vitamin C deficiency
scurvy
what is a skin manifestation of Coeliac disease
dermatitis herpetiformis
pathology of dermatitis herpetiformis
IgA deposit in skin
IgA or IgG more reliable in coeliac disease?
IgA if you make IgA
97% of coeliacs are positive in which genes?
HLA
Coeliacs are sensitive to which fraction of gluten?
Gliadin
Gluten is found in
wheat, rye and barley
Giardia Lamblia is responsible, is what, for what and responds to
unicellular parasite that causes malabsorption and responds t metronidazole
causative agent in whipples disease is
tropheryma whippelii
iron absorption takes place in what part of the small intestine
duodenum
crypt cells secrete
Cl + water
intracellular messengers involved in CFTR secretion of Cl
ATP into cAMP by adenylate Cyclase which then stimulates PKA which activates CFTR
pacemaker cells for segmental contractions are embedded in the
longitudinal muscle layer
migrating motility complex is initiated by what hormone
motilin
tumour markers for pancreatic cancer are
Ca19-9
O-A-TIGER causes of chronic pancreatitis
obstruction autoimmune toxin idiopathic genetic environmental recurrent injury
borborygmic stands for
rumbling/gurgling noise in the intestines
EUS investigation In oesophageal cancer is good for which staging
T/N
PET CT scan is good for which stage
M
side effects of laparoscopic hiatus hernia repair and fundoplication
dysphagia difficulty to belch gas bloating excessive flatulence diarrhoea
spread of oesophageal cancer via blood goes to
liver
autoimmune gastritis results in the loss of
intrinsic factor
decreased acid production
high mucous content glands are controlled by which receptors
sympathetic alpha 1 adrenoreceptors
high amylase content glands are controlled by which receptors
sympathetic amylase content beta 2 adrenoreceptors
