General Medicine: Gastroenterology Flashcards
Who gets an urgent endoscopy?
All with dysphagia or upper abdo mass
>-55 yrs with weight loss + reflux symptoms
How do you test for H. pylori? How do PPIs play a role
Urea breath test or stool antigen test
Must be 2 weeks off PPI for test
What do you do if there is Peptic ulcer disease with
+ve H. Pylori
-ve H. Pylori
+ve: PPI + Amoxicillin + metronidazole/ clarithromycin for 7 days
-ve: PPIs/H2RA for 1 month
How do you treat a patient with GORD that does not respond to initial PPI treatment
If endoscopy +ve: 2x dose 1 month
If endoscopy -ve: H2RA/ prokinetic
How do you treat barrett’s oesophagus?
High dose PPI
Endoscopic surveillance every 3-5 years
Resect/ablate if dysplasia identified
How can pain help differentiate peptic ulcers?
Worse when hungry, relieved on eating: Duodenal
Pain worse on eating: Gastric
Patient with duodenal ulcer has a 30 minute history of vomiting, low BP and high HR, what has likely happened and how is it treated?
Duodenal artery bleed
IV PPIs
Endoscopic treatment
What would indicate ulcer perforation
Clinically
On imaging
Acute abdomen/peritonism
CXR/CT showing free air
How does coeliac differ clinically from IBS or IBD
No PR bleeding like IBD
Pain following gluten consumption, not on eating and relieved on defecation like IBS
How do you investigate for coeliac
IgA (Anti-Ttg/EMA) AFTER 6 weeks gluten
Jejunum biopsy if confirmation needed
How do you manage coeliac disease?
Gluten free diet
When would you clinically suspect IBS?
6 months abdo pain, altered stool form and 2 of:
- Altered stool passage
- Bloating
- Worse on eating
- Mucus
What tests confirm IBS
-ve inflammatory, coeliac and faecal calprotectin
How do you treat IBS
- Loperamide if diarrhoea, non-lactulose laxative for constipation
- Tricyclics
- SSRIs
How can Crohn’s and UC be distinguished clinically
Crohn’s: Skin tags and mouth ulcers
Ulcerative Colitis: Bloody diarrhoea + mucus
Which IBD is associated with
Gallstones
PSC
Renal stones
Crohn’s: Stones
UC: PSC
Goes beyond mucosal
Goblet cells
Granulomas
Which IBD involves the above 3 features
Crohn’s
Crypt abcesses and pseudopolyps are features of which IBD?
UC
Which IBD has cobblestoning?
Crohn’s
What is the gold standard investigation for IBD? What is the exception to this?
Endoscopy + biopsy
Don’t perform if severe colitis, use flexible sigmoidoscopy
For Crohn’s remission, how do you
Induce
Maintain
Induce
1. Glucocorticoids
2. Mesalazine
3. Azathioprine/mercaptopurine
Maintain
- Stop smoking
1. Azathioprine/mercaptopurine
2. Methotrexate if TPMT activity has been checked
For UC remission, how do you
Induce
Maintain
Induce
Mild moderate:
1. Topical AS
Proct: oral AS/steroid
Severe: IV steroids + ciclosporin if no improvement
Maintain
Mild-moderate:
Top/oral/both AS
Severe or >=2 relapses per year: oral immunosuppressants
How do you manage a perianal abscess in Crohn’s?
Incision and drainage
Draining seton if tract identified
How do you manage perianal fistulae in Crohn’s?
MRI to visualise extent
Oral metronidazole +/- anti-TNF agents if symptomatic
Compare the complications of Crohn’s and UC
Crohn’s: Bowel cancer (small>large), osteoporosis
UC: Colorectal cancer
43 year old woman presents with a 3 month Hx fatigue, joint pain and now a 1 month history of hair loss and bronzed skin, what is the likely diagnosis?
Haemochromatosis (CH6-HFE mutation)
More likely in >40s and post-menopausal women (period removes iron)
Why is transferrin saturation better than serum ferritin?
90% of raised serum ferritin due to other causes (CKD, ALD, cancer) not iron overload
How do you calculate transferrin saturation? How does this explain a raised result in haemochromatosis?
Serum iron / TIBC Iron overload (high iron) / reduced binding (due to genetic defect)
How do you manage haemochromatosis? What is the metrics for success?
1st line:Venesection
2nd: Desferrioxamine
<50% transferrin / <50ug/l ferritin
What is the venesection regime for haemochromatosis?
Initial: 500ml every 1-4 weeks
Maintenance: 3-4 year
How should the following be screened for haemochromatosis?
General population
Family members
General: Transferrin
Family: HFE mutation
What pattern of inheritance is haemochromatosis?
Autosomal recessive
23 year old patient presents with tremor, poor memory and a history of deteriorating mental health. They also have blue nails and appear slightly yellow. What is the suspected diagnosis?
Wilson’s disease
Presents in 10-25yrs olde, younger show liver signs first, older show neurological signs
Neuropsychiatric changes with jaundice/blue nails + Kayser-Fleischer rings
What is the underlying pathology of Wilson’s disease
AR inheritance of ATP7B gene
Reduced hepatic excretion and increased intestinal absorption of copper
What are the 1st line and GS tests for Wilson’s disease?
1st line
Reduced serum caeruloplasmin (.’. total serum as 95% of this is in caeruloplasmin)
Raised 24hr copper excretion
GS: Genetics for ATP7B gene
What is the management of Wilson’s disease?
Penicillamine
Which hepatitis are spread via
Faeco-oral
Bodily
fAEco-oral
Rest are bodily fluids
Which hepatitis have vaccines?
A+B
Which hepatitis are RNA-based?
A, C, E
Which hepatitis are only acute in nature?
A+E (get it, cos its acute?)
A: 2-4 week incubation
E: 3-8 weeks
Since hep A+E are both acute and faeco-oral, how can you tell them apart?
A: younger (inc children), Hx recent foreign travel
E: Older men, between tropic of cancer and equator (Latin, top half of Africa, SE asia), Hep B infection
Ultimately serology tells them apart
How can you clinically distinguish Hep A+ B
Itch and joint pain more common in B
B spread through bodily fluids
Which hepatitis is most associated with transient jaundice, fatigue, joint pain but typically asymptomatic
Hep C
How do you screen and diagnose Hep C
Screen with Antibodies
Confirm with PCR
How do you treat for Hepatitis A-E
A: Supportive, avoid alcohol, 2 immunisations
B: 1. peg-IF 2. Antivirals; immunise sex partners
C: Combo of protease inhibitors +/- ribavirin
D: Interferon, may need transplant
E: Supportive
Amenorrhea + jaundice +/- fever in a young female is most likely what condition?
Autoimmune hepatitis
Amenorrhea most common feature, acute fever and jaundice only in 25% patients
In suspected AIH, what do the following liver screen results mean
Raised IgG
ANA
SMA
LKM1
Soluble liver/kidney antigen
IgG: Common to all forms
ANA + SMA: Type 1 (adults + children)
LKM1: Children only
Soluble: Type 3, middle aged adults
Following serology for AIH, what would help confirm diagnosis
‘Piecemeal’ necrosis on liver biopsy
How do you manage AIH
Steroids/Immunosuppressants
Liver transplant if this fails
Differentiate NAFLD And ALD in terms of
Clinical features
Bloods
Imaging
Treatment
NAFLD // ALD
Asymptomatic // liver disease picture
ALT > AST // AST > ALT, raised gGT
USS echogenicity, Fibrosis on ELF // none specific
Weight loss, monitoring // Prednisilone
What are the causes of acute liver failure
Paracetamol overdose
Alcohol
Hep A+B
Acute fatty liver of pregnancy
Acute history of jaundice + confusion + flapping tremor indicates what
Acute liver failure
What is the best lab test to determine acute liver failure
Check PT and albumin for synthetic function
LFTs still useful
What imaging can help identify cirrhosis
1st: USS
Fibroscan or ELF better but not widely used
What is the treatment for acute liver failure?
Vit K to improve PT
Lactulose 10-20ml/8 hrs
Cefotaxmine
Stop drugs, monitor CVD and renal function
What electrolyte needs to be avoided if an acute liver failure patient has CLD/ascites
Na+
Would increase fluid retention
6 month history of fatigue + weight loss. Also have red hands, distended abdo veins and splenomegaly. Suggests what?
Chronic liver failure
What indicates decompensation of liver failure
Jaundice + ascites + confusion
Variceal bleeds and easy brusing
How can you grade hepatic encephalopathy
I: Change in mood, cant draw star
II: Confused
III: InCoherent
IV: Coma
What features would prompt thoughts of hepatorenal syndrome in a cirrhosis patient? How can you treat it?
Cirrhosis + Ascites + Renal failure Type 1 (2 weeks): terlipressin + dialysis Type 2 (6 months): Hepatic portal stenting
Patient with fever, abdo pain and metabolic acidosis has you worried about what. How do you treat
Spontaneous bacterial peritonitis
Ascitic culture then immediate cephalosporin therapy
What are the 3 most common organisms involved with SBP?
E.Coli
K. Pneumoniae
G+ve coccus (staph, entero)
How do you treat the following complications of liver failure?
Malnutrition
Encephalopathy
Ascites
SBP
Varices
High calorie + protein, low salt meals every 2-3 hours
Lactulose
Spironolactone + restrict sodium
Ascitic culture + cephalosporin
Propanolol + band ligate/sclerose/TIPs if stable
Terlipressin, IV abx, Vit-k + fresh frozen plasma, band ligate
How can you identify if liver failure is due to paracetamol overdose?
Arterial pH <7.3 after 24hrs OR all 3 of
- PT >100s
- Creatinine >300umol/L
- Grade III/IV encephalopathy
What measure can help determine if ascites is liver related or not?
Serum Albumin Ascites Gradient
>11g indicates likely liver failure
How can hepatocellular and cholangiocarcinoma be differentiated
Clinically
Disease markers
Treatment
Hepatic // cholangio
Late liver symptoms, painful // painless RUQ mass, obstructive jaundice
AFP // CA 19-9
Resect if early, ablate + chemo + sorafenib if late // Surgery or palliative stening and chemo
What causative pathology is more associated with
Hepatocellular carcinoma
Cholangiocarcinoma
Cholangio: PSC
HCC: Hep B (world), Hep C (Europe), PBC, HC, Alcohol
How can you distinguish between coeliac and bacterial overgrowth syndrome based on lab findings?
Folate low in coeliac, high in overgrowth syndrome
How do PPIs and lithium affect sodium levels?
PPIs cause hypo
Lithium causes hyper
What does right sided tenderness on PR indicate
Acute appendicitis
Why do coeliacs require regular immunisations?
Functional hyposplenism
What LFT findings are seen in autoimmune hepatitis?
ALT/AST (intrahepatic) raised more than ALP (bile duct)
What causes pigment laden macrophages in intenstinal mucosa?
Laxative abuse
How do you manage a C.diff infection where
1st time
Recurrent
1st time
Oral vancomycin 10 days
Oral fidaxomicin
Oral vanc +/- IV metronidazole
Recurrent
<=12 weeks: oral fidaxomicin
>12 weeks: Oral vancomycin OR fidaxomicin
Life threatening
Oral vancomycin + IV metronidazole
What is the diagnosis and treatment for the following symptoms
Confusion, Hx alcohol abuse and malabsorption
Diarrhoea, Dermatitis, Dementia, beefy red tongue
Night blindness and dry eyes
Spontaneous bleeding and gingival swelling
Deficiencies in
B1 (thiamine)
B3 (nicotinamide)
A
Lethargy and fatigue with a macrocytic anaemia and megaloblasts means what
Diagnosis?
Treatment?
Anti-IF and parietal cell biospy
Lifelong cobalamin
INR vs albumin for acute liver failure detection?
INR
Albumin takes longer to drop so is seen in chronic liver failure
When is TIPSS considered for use?
Portal hypertension in Budd-Chiari
Refractory ascites
Secondary prophylaxis of variceal bleeding
Why does Crohn’s and terminal ileal disease cause gallstones?
Causes loss of bile salts
What is the dietary advice for IBS?
Fluids:
- 8 cups water/day
- Limit caffeine to <3 drinks/day
- Avoid alcohol fizzy drinks
Food:
- Regularity
- Reduce high fibre and fruit intake
- Oats/linseed if bloated
How can you differentiate IBD and anal fissure?
Anal fissure occurs at midline
Outline the acute and chronic management of anal fissure
acute
- Soften: High fibre, bulk laxatives (or lactulose)
- Lubrication
- Topical anaesthetics and analgesia
Chronic
- Add Top GTN
- Refer to surgery if 8 weeks no benefit
Outline the prevalence of colon cancer genetics
Sporadic 95%
HNPCC 5%
FAP <1%
