GI Flashcards
1
Q
Define Crohns
A
Chronic inflammatory disease characterised by transmural inflammation anywhere from mouth to anus
Characterised by skip lesions and non caseating granulomas
2
Q
What are three microscopic features of Crohns?
A
Fissuring Ulcers
Lymphoid and Neutrophil aggregates
Non caseating granulomas
3
Q
Give 3 presentations of Crohns
A
Diarrhoea
Abdominal Pain
Weight Loss
4
Q
What are three extra-enteral manifestations of Crohns?
A
Skin - Erythema Nodosum
Eyes - Episcleritis/Iritis/Conjunctivitis
Joint - Ankylosing Spondylitis
5
Q
Define UC
A
Chronic inflammation of mucosa and submucosa affecting the rectum and extending proximally
Continuous in nature
6
Q
What are three microscopic features of UC?
A
Crypt Abscesses
Pseudopolyps
Hyperaemic Mucosa
7
Q
Give three presentations of UC
A
Episodic Diarrhoea
Blood and Mucous
Cramping
8
Q
What is faecal calprotectin and when is it raised?
A
Indicates neutrophil migration into intestinal mucosa (higher the level, the more inflammation)
9
Q
What would you see on an Abdo Xray of IBD?
A
Mucosal Thickening
?Proximal Constipation
?Toxic Megacolon
10
Q
What are the endoscopy options for IBD?
A
Colonoscopy - proximal large bowel disease
Flexible Sigmoidoscopy - safest if diarrhoea is bloody
Capsule Endoscopy - Small Bowel
11
Q
When would you do an MRI in IBD?
A
For Small Bowel Crohns
For Peri-Anal disease in Crohns
12
Q
What is the induction management for Crohns?
A
Mild - Prednisolone Orally 40mg for 1/52
Mod/Severe - IV Hydrocortisone and VTE Prophylaxis
13
Q
What is the induction management for UC?
A
Mild - Mesalazine and Prednisolone Enemas
Mod - Mesalazine and Oral Prednisolone
Severe - IV Hydrocortisone, Cyclosporine
14
Q
What is the maintenance therapy for IBD?
A
Step Ups
Steroids
Azathioprine
Infliximab
15
Q
When is Azathioprine started in IBD?
A
If unresponsive to steroids
If requiring more than two rescue therapies a year
16
Q
Other than nausea, give two side effects of Azathioprine
A
Pancreatitis
Leucopenia
17
Q
How does Infliximab work? What do you have to test for prior to prescription?
A
Prevents neutrophil aggregation and granuloma formation
Check for underlying malignancy and TB
18
Q
Define Coeliac
A
Immune mediated inflammatory systemic disorder provoked by gluten
19
Q
Describe the pathophysiology of Coeliac disease
A
Associated with HLA DQ2 and HLA DQ8
Lengthening of intestinal crypts
Lymphocytes infiltrate epithelium
20
Q
Give 5 presentations of Coeliac Disease
A
Bloating Diarrhoea Weight Loss Steatorrhoea Abdo Pain
21
Q
What blood tests would you carry out for suspected Coeliac disease?
A
Total IgA
tTG-IgA (AKA Tissue Transglutaminase IgA)
22
Q
What other investigation (not bloods) would you carry out for suspected Coeliac disease
A
OGD and Duodenal Biopsy
Showing villous atrophy and intraepithelial lymphocytosis
23
Q
Give four complications of Coeliac Disease
A
Small Bowel Lymphoma
Small Bowel Cancer
Osteoporosis
Neuropathy
24
Q
What are the 5 Key Questions to ask a patient presenting with Dysphagia?
A
1) Was there difficulty swallowing both solids and liquids from the start?
2) Is it difficult to initiate swallowing?
3) Is swallowing painful?
4) Is dysphagia intermittent or getting worse?
5) Does neck bulge and gargle on drinking?
25
Give two physical causes of Oesophageal Dysphagia
Tumour
| Stricture
26
Give two neuromuscular causes of Oesophageal Dysphagia
Achalasia
| Presbyoesophagus
27
How would you investigate Physical causes vs Neuromuscular?
Physical with OGD
| Neuromuscular with Barium Swallow
28
What is Oropharyngeal Dysphagia?
Difficulty getting food to leave the mouth due to lack of coordination
29
Give a brief outlne of the four stages of Hepatic Encephalopathy
1 - Poor Memory and Sleep
2 - Asterixis, Agitation
3 - Drowsy
4 - Coma
30
What does a raised ALT indicate vs a raised ALP?
ALT - damage to hepatocytes
| ALP - damage to bile ducts
31
What is Gamma GT?
An enzyme found in hepatocytes and biliary tract
| Needs to be raised alongside ALP (as ALP can also be raised in increased bone turnover)
32
Name two autoantibodies associated with Primary Biliary Cirrhosis
AMA (Antimitochondrial Antibodies)
| SMA (Smooth Muscle Antibodies)
33
Name 6 components of a liver screen
```
Hepatitis Serology
Iron Studies (Transferrin and Ferritin)
Autoantibodies
Immunoglobulins
Ceruloplasmin
Alpha - 1 Antitrypsin
```
34
What are the three most common causes of Chronic Liver Disease?
Alcoholic Liver Disease
Non Alcoholic Steatohepatitis (NASH)
Hep B and C
35
What is PBC? Give three feature?
Autoimmune granulomatous inflammation of intra and extrahepatic bile ducts
Associated with AMA antibody
More common in Women
Asymptomatic raised ALP
36
What is autoimmune hepatitis?
Autoantibodies against hepatocyte surface antigens
37
Describe the presentation of autoimmune hepatitis
Acute hepatitis
| Jaundice
38
What is PSC? How do patients present?
Primary Sclerosis Cholangitis is progressive cholestasis with bile duct inflammation and strictures
Presents as pruritus with or without fatigue
39
What is the risk if a patient has IBD and PSC?
Increased risk of colorectal malignancy
40
What is Haemachromatosis?
Autosomal Recessive (HFE gene) of increased iron absorption leading to deposition in skin/joints/organs
41
Why do women with Haemachromatosis present later than men?
Menstrual blood loss is protective
42
What are the early and late presentations of HH?
Early - may be asymptomatic or have lethargy/anthralgia
| Late - Slate grey pigmentation, Chronic Liver Disease, Dilated Cardiomyopathy
43
What would the serology of HH show?
Raised LFTs
Raised Transferrin Saturation
Raised Ferritin
44
How would you manage HH?
Therapeutic Venesection
Avoid alcohol
Avoid uncooked seafood (listeria thrives on high iron)
45
What is WIlson's Disease?
Autosomal recessive disorder of copper excretion with deposition in liver and CNS
46
Give 4 presentations of Wilson's Disease
CNS Signs (Dysarthria, Dysphagia)
Slow Cognition
Decreased Libido
Kayser Fleischer Ring
47
What would the serology of Wilson's Disease show?
Raised LFTs
Low Serum Copper
Low Serum Ceruloplasmin
(HIGH URINARY COPPER)
48
Define Cirrhosis
End pathology of Chronic Liver Disease implying irreversible liver damage
49
Give three histological features of Cirrhosis
Loss of Architecture
Fibrosis
Nodular Regeneration
50
Give 5 signs of Cirrhosis OE
```
Clubbing
Palmar Erythema
Dupuytren's Contracture
Spider Naevi
Gynaecomastia
```
51
Name 3 features of Liver Failure
Coagulopathy (synthetic failure)
Encephalopathy (PADC)
Ascites
52
What is the risk of Ascites?
Spontaneous Bacterial Peritonitis
53
Apart from Liver Failure, give two complications of Cirrhosis?
Portal Hypertension
| Hepatocellular Carcinoma
54
What drug would you give for hepatic pruritus?
Colestyramine
55
What medical management would you give for Hepatic Encephalopathy? How do they work?
Lactulose - decreases ammonia reabsorption
| Rifaximin - eliminates ammonia producing bacteria
56
What medical management would you give for Ascites?
Fluid restriction and spironolactone
57
What is the difference between intentional weight loss and weight loss from illness?
Weight loss whilst unwell will be from muscle not fat
58
What is the MUST score?
Malnutrition Universal Screening Tool
| Identifies adults who are malnourished or at risk of malnourishment
59
What are the five stages of MUST screening?
1) BMI
2) %unplanned weight loss scored via table
3) Establish acute disease effects and score
4) Add 1,2,3 and give an overall score
5) Refer to guidelines
60
What would you do for 'Low Risk' patients following MUST screening?
Routine clinical care
| Repeat screning
61
What would you do for 'Medium Risk' patients following MUST screening?
Document dietary intake for 3 days
Adequate - continue to repeat screenings
Inadequate - follow local policy
62
What would you do for 'High Risk' patients following MUST screening?
Refer to dietician or nutritional support team
63
Give three reasons so many patients are malnourished
NBM
Increased requirements
Direct effect of treatment (N&V)
64
How can you ensure an NG tube is inserted correctly?
Test pH
| CXR (especially if on PPIs)
65
What is Polymeric Feeding?
Unaltered molecules of carbohydrates/proteins/fats for people who can digest and absorb normally
66
What is Elemental Feeding?
Nutritive substances in amino acid and monosaccharide form for patients that require pre-digestion
67
What is the ROCKALL score?
Predicts the risk of death and rebleeding from an upper GI bleed
Done pre and post endoscopy
68
Give 5 contributions to the ROCKALL score
```
Age
Co-Morbidity
Shock
Source of Bleeding
Stigmata of recent bleeding
```
69
What is the Blatchford Score?
Used to predict the need for intervention in a GI bleed (intervention being transfusion or therapeutic endoscopy)
70
Give 5 parameters used in the Blatchford Score
```
Blood Urea
Systolic BP
Malaena
HR>100
Syncope
```
71
What is the most common cause of GI bleeds?
Peptic Ulcers
72
Give a three step management plan for Variceal Bleeds
1) Fluid Rescucitation
2) IV Terlipressin (no IHD) and IV antibiotics
3) Urgent Endoscopy
73
Describe the two endoscopy management options for a Varcieal Bleed
```
Banding (Mechanical obstruction to flow)
Sengstaken Blakemore (Tube with a single balloon)
```
74
Describe the TIPSS procedure
Transjugular Intrahepatic Portosystemic Shunt
| Establishes communication between Hepatic Portal Vein and Hepatic Vein in an attempt to reduce portal hypertension
75
What is Dieulofoys?
Rupture of an unusually large arteriole
76
How would you manage a Non Variceal bleed?
Most stop on their own
IV fluids, bloods
If continues do radiological embolisation
77
Give two examples of malignant liver tumours
Hepatocellular carcinoma
| Cholangiocarcinoma
78
Give three examples of benign liver tumours
Cysts
Hemiangiomas
Adenomas
79
What is Achalasia?
Impaired peristalsis of smooth muscle layer of lower oesophagus causing functional stenosis/stricture
80
Give 5 presenting features of Achalasia
```
Dysphagia (solid>liquid)
Food Bolus Impaction
Regurgitation
Retrosternal Chest Pain
Heartburn
```
81
What would a CXR of Achalasia show?
Vastly dilated oesophagus behind the heart (bird beak)
82
Manometry is the gold standard investigation for Achalasia. What would you do before and why?
Barium Swallow in case of puncturing malignancy
83
What would Manometry of Achalasia show?
High cardiac sphincter pressure with incompleterelaxation on swallowing
84
What are the two management options for Achalasia?
```
Heller Myotomy (dividing the cardiac sphincter)
Pneumatic Dilation (balloon catheter to rupture muscle without breaking mucosa)
```
85
What is Eosinophiilic Oesophagitis
Oesophageal symptoms with infilatration of eosinophils into oesophageal epithelium
Originally a type of GORD unresponsive to PPIs
86
What would you see on a biopsy of Eosinophilic Oesophagitis?
More than 15 Eosinophils per field
87
Describe the conservative management of Eosinophilic Oesophagitis
```
Elemental feeding (amino acid) for 6/52
Exclusion of food groups based on allergy testing
```
88
Describe the pharmacological management of Eosinophilic Oesophagitis
Fluticasone Inhaler (sprayed into mouth and swallowed, no eating/drinking for 30 mins after)
89
What drugs if taken incorrectly may be mistaken for GORD?
NSAIDs
Doxycycline
Bisphosphonates
90
Give 3 drugs that are a risk factor for GORD. Why?
Anticholinergics
Nitrates
CCBs
Relax cardiac sphincter
91
Give 3 requirements for urgent endoscopy
Dysphagia
Over 55 AND Weight Loss AND Another GI Symptom
ALARM symptoms
92
Describe an endoscopic grading method for GORD
```
Savary Millar Grading
1 - Single/Multiple erosions on a single fold
2 - Multiple erosions on multiple folds
3 - Multiple circumferential erosions
4 - Ulcer/Stenosis/Shortening
5 - Barrett's Epithelium
```
93
Give two other investigations you could do for GORD
Barium Swallow
| 24h pH monitoring
94
Give 4 pharmacological treatment options for GORD
Antacids/Alignates
Lansopazole (30mg OD)
Ranitidine
Metacloperamide (Prokinetic)
95
What is Laproscopic Fundoplication?
A surgical technique used to treat disorders such as GORD
| Involves wrapping the fundus of the stomach around the lower oesophageal sphincter, enhancing it's strength
96
What are the two types of Hiatus Hernia?
Sliding (80%) - GOJ slides up into chest
| Rolling (20%) - GOJ remains in stomach but bulge of stomach herniates either side
97
Give 5 foods rich in Vitamin C
```
Grapefruit
Oranges
Broccoli
Tomatoes
Cabbage
```
98
Give 3 physiological uses of Vitamin C
Collagen Formation
Fascilitating Iron Absorption
Anti-Oxidant
99
Give 5 signs of Scurvy
```
Anorexia
Gingivitis
Halitosis
Muscle weakness
Gum bleeding
```
100
What is Pellagra?
Defiency of Niacin (Vitamin B3)
101
Give 3 sources of Niacin
Beans
Milk
Converted from Tryptophan in deficient states (this is inhibited by Isoniazid - hence give Pyrazinamide)
102
What is Niacin used for?
Precursors for vital metabolic enzymes NAD and NADP
103
What is the triad of Pellagra?
Diarrhoea
Dementia
Dermatitis (Casal's Necklace)
104
How would you diagnose and manage Pellagra?
Diagnosed - Low levels of Niacin metabolites
| Managed - Nicotinamide
105
What is Beri Beri?
Thiamine (Vitamin B1) Deficiency
106
Give 3 risk factors for Beri Beri
Alcoholism
Aids
Hyperemesis Gravidarum
107
Describe the two types of Beri Beri
Wet - Symptoms of Heart Failure
| Dry - Symptoms are Neurological/Muscular
108
How would you manage Beri Beri?
Oral Thiamine
| Diet - Whole grains, Lean pork, Legumes
109
What is Xeropthalmia?
Vitamin A Deficiency
110
What is primary and secondary Xeropthalmia
Primary - Poor Diet
| Secondary - Propblem with storage/transport of Vitamin A (eg Cystic Fibrosis)
111
Give 3 examples of Vitamin A rich food
Liver
Milk
Eggs
112
What is Vitamin A used for
Converted to photoreceptor pigment in retina
| Regulates gene expression and differentiation
113
Give four presentations of Xeropthalmia
Night time blindness
Conjunctival Dryness
Bitots Spots (abnormal squamous cell proliferations)
Skin and hair dryness
114
What are Carcinoid tumours?
Originate from Enterochromaffin cells and are able to produce Serotonin
Commonly found in appendix, ileum and rectum
115
What is an Octreoscan?
Radioactive scan for carcinoid tumours
116
What pharmacological management would you use for Carcinoid Tumours?
Octreotide - Somatostatin analogie that will prevent carcinoid crisis
117
What is the triad of Hepatorenal Syndrome?
Cirrhosis
Ascites
Renal Failure
118
What is the pathophysiology of Hepatorenal Syndrome?
Portal hypertension reduces portal blood supply, causing blood to pool in splanchnic circulation
As a result you get vasodilation, and reduced BP
RAAS activated resulting in afferent vasoconstriction and AKI
119
What is the diagnostic criteria for Hepatorenal Syndrome?
Cirrhosis with ascites
Serum creatinine>1.5mg/dl
Absence of shock/hypovolaemia/nephrotoxins/parenchymal renal disease
120
What's the difference between Type 1 and Type 2 Hepatorenal Syndrome? How does their management differ?
1 - Doubling of serum creatinine in less than two weeks, usually preceded by infection. Managed with Terlipressin and ideally liver transplant.
2 - More steady deterioration. Managed with TIPS
121
Give 2 examples of H1 receptor antagonist anti-emetics
Cyclizine
| Cinnarizine
122
Give 4 examples of D2 receptor antagonists. Give a use.
```
Metaclopramide
Domperidone
Prochlorperazine
Haloperidol
Hyperemesis Gravidarum
```
123
Name a 5HT3 antagonist and its use
Ondansetron
| PONV
124
Give three differences between Gastric and Duodenal ulcers
Pain time after eating (1-2hrs G, 2-4hrs D)
Food aggravates pain (G), Food relieves pain (D)
Vomiting common (G), Vomiting uncommon (D)
125
What is Wernicke- Korsakoff Syndrome?
Encephalopathies as a result of Thiamine deficiency (Dry Beri Beri)
Wernickes Encephalopathy- Acute Reversible form (medical emergency)
Korsakoff Syndrome - Chronic and Irreversible form (from untreated Wernickes)
126
What is the triad of Wernicke’s Encephalopathy?
Opthalmoplegia, Ataxia, Confusion
127
How does Korsakoff Syndrome present?
Targets the Limbic System:
Impaired Memory (anterograde and retrograde)
Confabulation (making up information to replace lost memories)
