GI Flashcards
Define Crohns
Chronic inflammatory disease characterised by transmural inflammation anywhere from mouth to anus
Characterised by skip lesions and non caseating granulomas
What are three microscopic features of Crohns?
Fissuring Ulcers
Lymphoid and Neutrophil aggregates
Non caseating granulomas
Give 3 presentations of Crohns
Diarrhoea
Abdominal Pain
Weight Loss
What are three extra-enteral manifestations of Crohns?
Skin - Erythema Nodosum
Eyes - Episcleritis/Iritis/Conjunctivitis
Joint - Ankylosing Spondylitis
Define UC
Chronic inflammation of mucosa and submucosa affecting the rectum and extending proximally
Continuous in nature
What are three microscopic features of UC?
Crypt Abscesses
Pseudopolyps
Hyperaemic Mucosa
Give three presentations of UC
Episodic Diarrhoea
Blood and Mucous
Cramping
What is faecal calprotectin and when is it raised?
Indicates neutrophil migration into intestinal mucosa (higher the level, the more inflammation)
What would you see on an Abdo Xray of IBD?
Mucosal Thickening
?Proximal Constipation
?Toxic Megacolon
What are the endoscopy options for IBD?
Colonoscopy - proximal large bowel disease
Flexible Sigmoidoscopy - safest if diarrhoea is bloody
Capsule Endoscopy - Small Bowel
When would you do an MRI in IBD?
For Small Bowel Crohns
For Peri-Anal disease in Crohns
What is the induction management for Crohns?
Mild - Prednisolone Orally 40mg for 1/52
Mod/Severe - IV Hydrocortisone and VTE Prophylaxis
What is the induction management for UC?
Mild - Mesalazine and Prednisolone Enemas
Mod - Mesalazine and Oral Prednisolone
Severe - IV Hydrocortisone, Cyclosporine
What is the maintenance therapy for IBD?
Step Ups
Steroids
Azathioprine
Infliximab
When is Azathioprine started in IBD?
If unresponsive to steroids
If requiring more than two rescue therapies a year
Other than nausea, give two side effects of Azathioprine
Pancreatitis
Leucopenia
How does Infliximab work? What do you have to test for prior to prescription?
Prevents neutrophil aggregation and granuloma formation
Check for underlying malignancy and TB
Define Coeliac
Immune mediated inflammatory systemic disorder provoked by gluten
Describe the pathophysiology of Coeliac disease
Associated with HLA DQ2 and HLA DQ8
Lengthening of intestinal crypts
Lymphocytes infiltrate epithelium
Give 5 presentations of Coeliac Disease
Bloating Diarrhoea Weight Loss Steatorrhoea Abdo Pain
What blood tests would you carry out for suspected Coeliac disease?
Total IgA
tTG-IgA (AKA Tissue Transglutaminase IgA)
What other investigation (not bloods) would you carry out for suspected Coeliac disease
OGD and Duodenal Biopsy
Showing villous atrophy and intraepithelial lymphocytosis
Give four complications of Coeliac Disease
Small Bowel Lymphoma
Small Bowel Cancer
Osteoporosis
Neuropathy
What are the 5 Key Questions to ask a patient presenting with Dysphagia?
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?
Give two physical causes of Oesophageal Dysphagia
Tumour
Stricture
Give two neuromuscular causes of Oesophageal Dysphagia
Achalasia
Presbyoesophagus
How would you investigate Physical causes vs Neuromuscular?
Physical with OGD
Neuromuscular with Barium Swallow
What is Oropharyngeal Dysphagia?
Difficulty getting food to leave the mouth due to lack of coordination
Give a brief outlne of the four stages of Hepatic Encephalopathy
1 - Poor Memory and Sleep
2 - Asterixis, Agitation
3 - Drowsy
4 - Coma
What does a raised ALT indicate vs a raised ALP?
ALT - damage to hepatocytes
ALP - damage to bile ducts
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)
Name two autoantibodies associated with Primary Biliary Cirrhosis
AMA (Antimitochondrial Antibodies)
SMA (Smooth Muscle Antibodies)
Name 6 components of a liver screen
Hepatitis Serology Iron Studies (Transferrin and Ferritin) Autoantibodies Immunoglobulins Ceruloplasmin Alpha - 1 Antitrypsin
What are the three most common causes of Chronic Liver Disease?
Alcoholic Liver Disease
Non Alcoholic Steatohepatitis (NASH)
Hep B and C
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
What is autoimmune hepatitis?
Autoantibodies against hepatocyte surface antigens
Describe the presentation of autoimmune hepatitis
Acute hepatitis
Jaundice
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
What is the risk if a patient has IBD and PSC?
Increased risk of colorectal malignancy
What is Haemachromatosis?
Autosomal Recessive (HFE gene) of increased iron absorption leading to deposition in skin/joints/organs
Why do women with Haemachromatosis present later than men?
Menstrual blood loss is protective
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
What would the serology of HH show?
Raised LFTs
Raised Transferrin Saturation
Raised Ferritin
How would you manage HH?
Therapeutic Venesection
Avoid alcohol
Avoid uncooked seafood (listeria thrives on high iron)
What is WIlson’s Disease?
Autosomal recessive disorder of copper excretion with deposition in liver and CNS
Give 4 presentations of Wilson’s Disease
CNS Signs (Dysarthria, Dysphagia)
Slow Cognition
Decreased Libido
Kayser Fleischer Ring
What would the serology of Wilson’s Disease show?
Raised LFTs
Low Serum Copper
Low Serum Ceruloplasmin
(HIGH URINARY COPPER)
Define Cirrhosis
End pathology of Chronic Liver Disease implying irreversible liver damage
Give three histological features of Cirrhosis
Loss of Architecture
Fibrosis
Nodular Regeneration
Give 5 signs of Cirrhosis OE
Clubbing Palmar Erythema Dupuytren's Contracture Spider Naevi Gynaecomastia
Name 3 features of Liver Failure
Coagulopathy (synthetic failure)
Encephalopathy (PADC)
Ascites
What is the risk of Ascites?
Spontaneous Bacterial Peritonitis
Apart from Liver Failure, give two complications of Cirrhosis?
Portal Hypertension
Hepatocellular Carcinoma
What drug would you give for hepatic pruritus?
Colestyramine
What medical management would you give for Hepatic Encephalopathy? How do they work?
Lactulose - decreases ammonia reabsorption
Rifaximin - eliminates ammonia producing bacteria
What medical management would you give for Ascites?
Fluid restriction and spironolactone
What is the difference between intentional weight loss and weight loss from illness?
Weight loss whilst unwell will be from muscle not fat
What is the MUST score?
Malnutrition Universal Screening Tool
Identifies adults who are malnourished or at risk of malnourishment
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
What would you do for ‘Low Risk’ patients following MUST screening?
Routine clinical care
Repeat screning
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
What would you do for ‘High Risk’ patients following MUST screening?
Refer to dietician or nutritional support team
Give three reasons so many patients are malnourished
NBM
Increased requirements
Direct effect of treatment (N&V)
How can you ensure an NG tube is inserted correctly?
Test pH
CXR (especially if on PPIs)
What is Polymeric Feeding?
Unaltered molecules of carbohydrates/proteins/fats for people who can digest and absorb normally
What is Elemental Feeding?
Nutritive substances in amino acid and monosaccharide form for patients that require pre-digestion
What is the ROCKALL score?
Predicts the risk of death and rebleeding from an upper GI bleed
Done pre and post endoscopy
Give 5 contributions to the ROCKALL score
Age Co-Morbidity Shock Source of Bleeding Stigmata of recent bleeding
What is the Blatchford Score?
Used to predict the need for intervention in a GI bleed (intervention being transfusion or therapeutic endoscopy)
Give 5 parameters used in the Blatchford Score
Blood Urea Systolic BP Malaena HR>100 Syncope
What is the most common cause of GI bleeds?
Peptic Ulcers
Give a three step management plan for Variceal Bleeds
1) Fluid Rescucitation
2) IV Terlipressin (no IHD) and IV antibiotics
3) Urgent Endoscopy
Describe the two endoscopy management options for a Varcieal Bleed
Banding (Mechanical obstruction to flow) Sengstaken Blakemore (Tube with a single balloon)
Describe the TIPSS procedure
Transjugular Intrahepatic Portosystemic Shunt
Establishes communication between Hepatic Portal Vein and Hepatic Vein in an attempt to reduce portal hypertension
What is Dieulofoys?
Rupture of an unusually large arteriole
How would you manage a Non Variceal bleed?
Most stop on their own
IV fluids, bloods
If continues do radiological embolisation
Give two examples of malignant liver tumours
Hepatocellular carcinoma
Cholangiocarcinoma
Give three examples of benign liver tumours
Cysts
Hemiangiomas
Adenomas
What is Achalasia?
Impaired peristalsis of smooth muscle layer of lower oesophagus causing functional stenosis/stricture
Give 5 presenting features of Achalasia
Dysphagia (solid>liquid) Food Bolus Impaction Regurgitation Retrosternal Chest Pain Heartburn
What would a CXR of Achalasia show?
Vastly dilated oesophagus behind the heart (bird beak)
Manometry is the gold standard investigation for Achalasia. What would you do before and why?
Barium Swallow in case of puncturing malignancy
What would Manometry of Achalasia show?
High cardiac sphincter pressure with incompleterelaxation on swallowing
What are the two management options for Achalasia?
Heller Myotomy (dividing the cardiac sphincter) Pneumatic Dilation (balloon catheter to rupture muscle without breaking mucosa)
What is Eosinophiilic Oesophagitis
Oesophageal symptoms with infilatration of eosinophils into oesophageal epithelium
Originally a type of GORD unresponsive to PPIs
What would you see on a biopsy of Eosinophilic Oesophagitis?
More than 15 Eosinophils per field
Describe the conservative management of Eosinophilic Oesophagitis
Elemental feeding (amino acid) for 6/52 Exclusion of food groups based on allergy testing
Describe the pharmacological management of Eosinophilic Oesophagitis
Fluticasone Inhaler (sprayed into mouth and swallowed, no eating/drinking for 30 mins after)
What drugs if taken incorrectly may be mistaken for GORD?
NSAIDs
Doxycycline
Bisphosphonates
Give 3 drugs that are a risk factor for GORD. Why?
Anticholinergics
Nitrates
CCBs
Relax cardiac sphincter
Give 3 requirements for urgent endoscopy
Dysphagia
Over 55 AND Weight Loss AND Another GI Symptom
ALARM symptoms
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
Give two other investigations you could do for GORD
Barium Swallow
24h pH monitoring
Give 4 pharmacological treatment options for GORD
Antacids/Alignates
Lansopazole (30mg OD)
Ranitidine
Metacloperamide (Prokinetic)
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
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
Give 5 foods rich in Vitamin C
Grapefruit Oranges Broccoli Tomatoes Cabbage
Give 3 physiological uses of Vitamin C
Collagen Formation
Fascilitating Iron Absorption
Anti-Oxidant
Give 5 signs of Scurvy
Anorexia Gingivitis Halitosis Muscle weakness Gum bleeding
What is Pellagra?
Defiency of Niacin (Vitamin B3)
Give 3 sources of Niacin
Beans
Milk
Converted from Tryptophan in deficient states (this is inhibited by Isoniazid - hence give Pyrazinamide)
What is Niacin used for?
Precursors for vital metabolic enzymes NAD and NADP
What is the triad of Pellagra?
Diarrhoea
Dementia
Dermatitis (Casal’s Necklace)
How would you diagnose and manage Pellagra?
Diagnosed - Low levels of Niacin metabolites
Managed - Nicotinamide
What is Beri Beri?
Thiamine (Vitamin B1) Deficiency
Give 3 risk factors for Beri Beri
Alcoholism
Aids
Hyperemesis Gravidarum
Describe the two types of Beri Beri
Wet - Symptoms of Heart Failure
Dry - Symptoms are Neurological/Muscular
How would you manage Beri Beri?
Oral Thiamine
Diet - Whole grains, Lean pork, Legumes
What is Xeropthalmia?
Vitamin A Deficiency
What is primary and secondary Xeropthalmia
Primary - Poor Diet
Secondary - Propblem with storage/transport of Vitamin A (eg Cystic Fibrosis)
Give 3 examples of Vitamin A rich food
Liver
Milk
Eggs
What is Vitamin A used for
Converted to photoreceptor pigment in retina
Regulates gene expression and differentiation
Give four presentations of Xeropthalmia
Night time blindness
Conjunctival Dryness
Bitots Spots (abnormal squamous cell proliferations)
Skin and hair dryness
What are Carcinoid tumours?
Originate from Enterochromaffin cells and are able to produce Serotonin
Commonly found in appendix, ileum and rectum
What is an Octreoscan?
Radioactive scan for carcinoid tumours
What pharmacological management would you use for Carcinoid Tumours?
Octreotide - Somatostatin analogie that will prevent carcinoid crisis
What is the triad of Hepatorenal Syndrome?
Cirrhosis
Ascites
Renal Failure
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
What is the diagnostic criteria for Hepatorenal Syndrome?
Cirrhosis with ascites
Serum creatinine>1.5mg/dl
Absence of shock/hypovolaemia/nephrotoxins/parenchymal renal disease
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
Give 2 examples of H1 receptor antagonist anti-emetics
Cyclizine
Cinnarizine
Give 4 examples of D2 receptor antagonists. Give a use.
Metaclopramide Domperidone Prochlorperazine Haloperidol Hyperemesis Gravidarum
Name a 5HT3 antagonist and its use
Ondansetron
PONV
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)
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)
What is the triad of Wernicke’s Encephalopathy?
Opthalmoplegia, Ataxia, Confusion
How does Korsakoff Syndrome present?
Targets the Limbic System:
Impaired Memory (anterograde and retrograde)
Confabulation (making up information to replace lost memories)
