GI Flashcards
What are the 3 steps of alcoholic liver disease?
Alcohol related fatty liver
alcoholic hepatitis
Cirrhosis
What is the recommended alcohol consumption in a week?
14 units a week spread over 3 days. No more than 5 units in a day
What is the screening tool for harmful alcohol use and what are the questions?
CAGE questionaire
C- have you ever thought about cutting down?
A- do you get annoyed when other people comment on your drinking?
G- do you ever feel guilty about your drinking?
E- eye-opener. Ever drink in the morning to help with your hangover/ nerves
AUDIT questionnaire is a better way of screening but is longer
What do blood tests show in alcohol abuse?
FBC- raised MCV
LFTs- ALT and AST raised. Gamma GT is escpecially high. Low albumin due to reduced synthetic function of the liver
What can be seen on ultrasound of a fatty liver?
Increased echogenicity
Which scan is used to assess cirrhosis?
Fibroscan
Which test is used to confirm alcohol related liver changes?
Biopsy
What is the timeline of symptoms in alcohol withdrawal?
6-12 hours: tremor, sweating, headache, craving, anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: delirium tremens
What are the symptoms of delirium tremens?
Acute confusion Severe agitation Delusions and hallucinations Tremor Tachycardia Hyperthermia
Which tool can be used to score patients withdrawing from alcohol?
CIWA-Ar
How is alcohol withdrawal managed?
Chlordiazepoxide
Pabrinex
What causes korsakoffs syndrome?
Thiamine deficiency
What is the triad of symptoms found in wernicke’s encephalopathy
Confusion
Oculomotor disturbances
Ataxia
What are the features of korsakoff’s syndrome?
Memory impairment
Behavioural changes
What are the 4 most common causes of liver cirrhosis?
Alcoholic liver disease
Non-alcoholic liver disease
Hepatitis B
Hepatitis C
What is seen on bloods in someone who has liver cirrhosis?
LFTs are often normal but in decompensated cirrhosis, all LFTs are deranged
Albumin and PT are useful markers of synthetic function. Will be lower in worse disease
Hyponatraemia indicates fluid retention in severe disease
Alpha-fetoprotein is a marker for HCC and should be checked every 6 months
What is the first line test for assessing fibrosis in non-alcoholic fatty liver disease?
ELF blood test (enhanced liver fibrosis)
What is seen on ultrasound of a cirrhotic liver?
Nodularity of the surface
Corkscrew appearance of the arteries
How is cirrhosis scored?
using the child-pugh socre. The minimum score is 5 and the max is 15
Where do varices usually occur?
Gastro-oesophageal junction
Ileocaecal junction
Rectum
anterior abdominal wall
How can varices be managed?
propanolol reduces portal hypertension
Elastic band ligation
Injection of sclerosant
Transjugular intra-hepatic portosystemic shunt
how can bleeding oesophageal varices be managed?
Vasopressin analogues
Correct coagulopathy with vitamin K and fresh frozen plasma
Urgent endoscopy
How does spontaneous bacterial peritonitis present?
asymptomatic Fever Abdominal pain derranged bloods Ileus Hypotension
What is the management of Spontaneous bacterial peritonitis?
IV cephalosporins such as cefotaxime
What are the 4 stages of non-alcoholic fatty liver disease?
- NAFLD
- Non-alcoholic steatohepatitis
- Fibrosis
- Cirrhosis
What is the test which can confirm NAFLD?
Ultrasound
What are the first and second line recommended investigations for assessing fibrosis?
Enhanced liver fibrosis blood test (ELF test)
NAFLD fibrosis score
What is the management of NAFLD?
Weight loss Exercise Stop smoking Control of diabetes Avoid alcohol
What are the symptoms of hepatitis?
Abdominal pain Fatigue Itching Muscle and joint aches Nausea and vomiting Jaundice Fever (if viral)
What do the LFTs look like in hepatitis?
Raised transaminases (AST/ALT) with proportionally less of a raise in ALP
What type of virus is hepatitis A?
RNA
How is hepatitis A transmitted?
Faeco-oral route
What type of virus is hepatitis B?
DNA virus
What does a high number or surface antigen (HBsAg) imply?
Active infection
What does a high level of E-antigen (HBeAg) suggest?
Marker of viral replication and implies high infectivity
What do core antibodies (HBcAb) suggest?
Implies past or current infection
What does surface antibody (HBsAb) suggest?
implies vaccination, past or current infection
What type of virus is Hepatitis C?
RNA
How is hepatitis C screened for?
Hep C antibody is the screening test
Hep C RNA testing is used to confirm the diagnosis of hep C
What kind of virus is hepatitis D?
RNA
What type of virus is hepatitis E?
RNA
Which hepatitis can only survive in co-infection with hepatitististis B?
D
Which age group does type 1 autoimmune hepatitis affect?
Adults
Which age group does type 2 autoimmune hepatitis affect?
Children (el nino)
What is the treatment of autoimmune hepatitis?
Prednisolone
What is haemochromatosis?
An iron storage disorder which results in excessive total body iron and deposition of iron in tissues
What inheritance pattern is haemochromatosis?
Autosomal recessive
When does haemochromatosis present?
Typically after the age of 40 when the iron load becomes symptomatic. Presents later in females due to menstruation
What are the symptoms of haemochromatosis?
Memory and mood disturbance Hair loss Chronic tiredness Skin pigmentation (bronze) Erectile dysfunction/ ammenorrhea Joint pain
How is haemochromatosis diagnosed?
Serum ferritin. This is an acute phase reactant so a serum transferritin should also be performed to see if there is iron overload (high) or infection/ NAFLD (low)
Liver biopsy with Perl’s stain
CT abdo
MRI
What are the complications of haematochromatosis?
Cardiomyopathy (iron deposits in the heart)
HCC
Hypothyroidism
Chrondrocalcinosis/ pseudogout
What is the management of haemochromatosis?
Venesection
Monitoring serum ferritin
Avoid alcohol
Genetic counselling
What is wilson’s disease?
Excessive accumulation of copper in the body
What is the genetic inheritance of wilson’s disease?
Autosomal recessive
What is the presentation of wilsons disease?
Dysarthria, dystonia, parkinsonism
Psychosis or depression
Kayser-fleischer rings in the cornea
Liver cirrhosis
Haemolytic anaemia
Osteopenia
How is Wilson’s disease diagnosed?
Serum caeruloplasmin (low is suggestive of Wilson’s)
Liver biopsy is the gold standard
24 hour urine copper assay
What is the management of Wilson’s disease?
Penicillamine
Trientene
What is the pathophysiology of alpha-1-antitrypsin deficiency?
Elastase is an enzyme which is secreted by neutrophils and this enzyme digests connective tissues. Alpha-1-antitrypsin is mainly produced in the liver and it inhibits the neutrophil elastase enzyme. Without this there is liver cirrhosis, bronchiectasis and emphysema
What are the features of alpha-1-antitrypsin deficiency?
Liver cirrhosis after 50 years old
Bronchiectasis and emphysema after 30 years old
How is alpha-1-antitrypsin deficiency diagnosed?
Low serum alpha-1-antitrypsin
Liver biopsy shows cirrhosis and acid-schiff-positive staining globules
What is the management of alpha-1-antitrypsin deficiency?
Stop smoking
Symptomatic management
Organ transplant
What is primary biliary cirrhosis?
Immune system attacks the small bile ducts within the liver. Causes cholestasis which leads to increased back pressure, fibrosis, cirrhosis and liver failure
What is the presentation of primary biliary cirrhosis?
Fatigue Pruritis GI pain Jaundice Pale stools Xanthoma
How is primary biliary cirrhosis diagnosed?
ALP is raised
Anti-mitochrondrial antibodies raised
Liver biopsy
What is the management of primary biliary cirrhosis?
Urseodeoxycholic acid (reduces GI uptake of cholesterol)
Colestyramine prevents bile acid sequestration in the gut
What is primary sclerosing cholangitis?
Intrahepatic or extrahepatic ducts become strictured or fibrotic which leads to chronic bile obstruction
Which other disease is primary sclerosing cholangitis strongly associated with?
Ulcerative colitis
What is the presentation of primary sclerosing cholangitis?
Jaundice Chronic RUQ pain Pruritis Fatigue Hepatomegaly
How is primary sclerosing cholangitis diagnosed?
Gold standard is an MRCP
What is the management of primary sclerosing cholangitis?
Liver transplant (curative)
Colestyramine
ERCP
What are the main risk factors for HCC?
Viral hepatitis (B and C)
Alcohol
NAFLD
Which cancer is primary sclerosing cholangitis related to?
Cholangiocarcinoma
What is the tumour marker for HCC?
Alpha-fetoprotein
What is the tumour marker for cholangiocarcinoma?
CA19-9
What is the lining of the oesophagus?
Squamous epithelial lining
What is the lining of the stomach?
Columnar epithelia lining
What is the presentation of GORD?
Heartburn Acid regurg Retrosternal or epigastric pain Bloating Nocturnal cough Hoarse voice
What are the red flag symptoms for 2 week wait referral?
Dysphagia >55 Weight loss N+V Low haemoglobin raised Platelet count
What is the management of GORD?
Lifestyle advice (smaller, regular meals, weight loss, avoid acidic and spicy food)
Gaviscon and Rennie
PPI- omeprazole, lansoprazole
Ranitidine
Laparoscopic fundoplication
Why does H.pylori cause dyspepsia?
It breaks into the gastric mucosa to avoid the stomach acid which damages the lining
It produces ammonia to neutralise the stomach acid
How is H.pylori tested for?
Need to have 2 weeks without PPI for accurate results
Urea breath test
Stool antigen test
Rapid urease test
How is H.pylori eradicated?
Triple therapy: PPI + 2 antibiotics for 7 days (usually clarithromycin and amoxicillin)
What is Barret’s oesophagus?
When constant acid reflux metaplasia from squamous to columnar epithelium. It is managed with PPIs and monitoring
What is the presentation of peptic ulcers?
Epigastric discomfort N+V Dyspepsia Bleeding causing haematemesis Iron deficiency anaemia
How does eating effect the pain of a gastric ulcer vs a duodenal ulcer?
Eating worsens the pain of gastric ulcers and improves the pain of duodenal ulcers
What is the management of peptic ulcers?
High dose PPI
How are peptic ulcers diagnosed?
Endoscopy. During endoscopy a rapid urease test (CLO) would be performed to check for H.pylori
What are the common causes of upper GI bleeding?
Oesophageal varices
Mallory-weiss tear
Ulcers of the stomach or duodenum
Cancers of the stomach or duodenum
What is the presentation of an upper GI Bleed
Haematemesis
Coffee-ground vomit
Malaena
Haemodynamic instability
What is the scoring system used in suspected upper GI bleed?
Glasgow-blatchford score. A score >0 indicates a bleed
Why does serum urea increase in GI bleed?
Urea is a breakdown product when blood is digested within the GI tract
What is the rockall score?
Used for patients who have had an endoscopy to calculate their risk of rebleeding
What is the management of upper GI bleed?
ABATED A-ABCDE B-Bloods A-Access T-Transfuse. crossmatch 2 units E-Endoscopy D-Drugs (stop anticoag)
What should be given if oesophageal varices are suspected as a cause of upper GI bleed?
Terlipressin
Prophylactic broad spectrum antibiotics
What are the features of Crohn’s disease?
NESTS N-No blood or mucus E- Entire GI tract S- Skip lesions T- Terminal ileum is most affected. Transmural S- Smoking is a risk factor
What are the features of UC?
CLOSEUP
C-continuous inflammation L- limited to colon and rectum O- only superficial mucosa S- Smoking is protective E- Excrete blood and mucus U- Use aminosalicylates P- primary sclerosing cholangitis
How do you test for IBD?
CRP indicated inflammation and active disease
Faecal calprotectin is a sensitive and specific screening test
What is the management of Crohn’s?
Induce remission through steroids
Add immunosupression if doesn’t work (azathiopurine)
Maintain remission through azathiopurine or mercaptopurine
What is the management of UC?
Induce remission:
1st amiosalicylate such as mesalazine
2nd steroids
Maintain remission:
Mesalazine
Surgery: removing colon and rectum
What are the symptoms of IBS?
Diarrhoea Constipation Fluctuating bowel habit Abdominal pain Bloating Worse by eating Improved by opening bowels
How should IBS be investigated?
Normal bloods
Do faecal calprotein to exclude IBD
Do anti-TTG antibodies to exclude coeliac
How is IBS managed?
Low FODMAP diet CBT Loperamide for diarrhoea Laxatives for constipation Antispasmodics for cramps (buscopan)
Which antibodies are associated with coeliacs disease?
anti-tissue transglutaminase (anti-TTG) and anti-endomysial (anti-EMA)
What is seen on histology of the bowel mucosa in coeliac’s?
Villous atrophy
Crypt hypertrophy
Which autoimmune disease is strongly linked with coeliac’s?
Type 1 diabetes
How is coeliac’s diagnosed?
Anti TTG antibodies and histology shwoing villous atrophy and crypt hypertrophy
How does appendicitis present?
Central abdominal pain which moves down to the right iliac fossa within 24 hours, becoming localised there
At which anatomical landmark can tenderness be identified in appendicitis?
McBurney’s point (one third of the distance from the ASIS to the umbilicus)
What is rovsig’s sign?
palpation of the left iliac fossa causes pain in the RIF
Which 3 signs potentially indicate a ruptured appendix?
Rebound tenderness
Percussion tenderness
Pertitonitis
How is appendicitis diagnosed?
Diagnosis is based on the clinical presentation and raised inflammatory markers
CT and ultrasound can aid a diagnosis
Diagnosis is confirmed by a diagnostic laparoscopy
What is an appendix mass?
When the omentum surrounds and sticks to the inflammed appendix
What is the management of appendicitis?
Appendicectomy by laparoscopic surgery
What is third-spacing?
The abnormal loss of fluid from the intravascular space into the GI tract
What are the “big three” causes for bowel obstruction?
Adhesions
Hernia
Malignancy
What is a closed loop obstruction?
There are two points of obstruction along a bowel meaning that there is a middle section which will continue to expand leading to ischaemia and perforation
What is the presentation of bowel obstruction?
Vomiting (green and bilious) Abdominal distention Diffuse abdominal pain Absolute constipation and lack of flactulance Tinkling bowel sounds
What is the finding in an abdominal x-ray of bowel obstruction?
Distended loops of bowel
What may be seen on venous blood gas of someone with bowel obstruction?
Metabolic alkalosis
What can be seen on erect chest x-ray of bowel perforation
Air under the diaphragm
What is the definitive management of bowel obstruction?
Exploratory surgery
Adhesiolysis
Hernia repair
Emergency resection
What is ileus?
A condition which affects the small bowel where peristalsis stops and causes a pseudo-obstruction (functional obstruction)
What are common causes of ileus?
Injury
Handing of the bowel during surgery
Inflammation or infection
Electrolyte imbalance
What are the symptoms of ileus?
Similar to bowel obstruction
Green vomiting
Abdominal distention
Absolute constipation and lack of flatulence
What is the management of ileus?
Nil by mouth
NG tube
IV fluid
What is volvulus?
When the bowel twists around itself and the mesentery that it is attached to. This leads to a closed-loop bowel obstruction which leads to ischaemia
What are the two main types of volvulus?
Sigmoid volvulus and caecal volvulus
What is a sigmoid volvulus?
Twist in the sigmoid colon. Caused by chronic constipation. High association with a high fibre diet and excessive use of laxatives
What is the presentation of volvulus?
Same as bowel obstruction (again)
How is volvulus diagnosed?
Abdominal x-ray shows the coffee bean sign
Contrast CT is the diagnostic test
How is volvulus managed?
Conservative management (endoscopic decompression)
Laparotomy
Hartmann’s procedure
What are the 3 complications of hernias?
Incarceration
Obstruction
Strangulation
What is incarceration of a hernia?
A hernia cannot be reduced (stuck in the mud)
What is strangulation of a hernia?
Where a hernia is non-reducible and the base of the hernia becomes so tight that it cuts of the blood supply
What are the 3 management options for hernias?
Conservative
Tension-free repair
Tension repair
What is the difference between direct and indirect inguinal hernias?
An indirect hernia is when the bowel herniates through the inguinal canal.
A direct hernia occurs due to weakness in the abdominal wall at Hesselbach’s triangle
What are femoral hernias?
Herniation of the abdominal contents through the femoral canal. This occurs below the inguinal ligament
How do you differentiate between direct and indirect inguinal hernias?
If you reduce an indirect inguinal hernia and place pressure at the deep inguinal ring (half way between the ASIS and the pubic tubercle) then it will remain reduced as a direct will not.
What are obturator hernias?
When the abdominal or pelvic contents herniate through the obturator foramen. Usually happens due to defect in the pelvic floor
What is the sign indicative of a obturator hernia?
Howhip-Romberg sign= pain extending from the inner thigh to knee when the internally rotated
What is a hiatus hernia?
Herniation of the stomach through the diaphragm
What are haemorrhoids?
Enlarged anal vascular cushions
What are haemorrhoids usually associated with?
Pregnancy, obesity, increased age, increased intra-abdominal pressure (weightlifting or chronic coughing)
Where do anal cushions get their blood supply?
Rectal arteries
How do you classify haemorrhoids?
1st degree= no prolapse
2nd degree= prolapse on straining, return on relaxing
3rd degree= no return on relaxing but can be pushed back
4th degree= permenantly prolapsed
How are haemorrhoids diagnosed?
PR
Protoscopy
How are haemorrhoids managed?
Anusol (contains astringents which shrink the haemorrhoid) Anusol HC (+hydrocortisone)
Increasing fibre in diet and fluid intake
Rubber band ligation or injection sclerotheraoy
Haemorrhoid artery ligation
Haemorrhoidectomy
How do thrombosed haemorrhoids present?
VERY pain
appear purplish, very tender and swollen
What is diverticulosis?
Refers to the presence of diverticula, without inflammation or infection
What is diverticulitis?
Refers to the inflammation and infection of diverticula
How is diverticulosis managed?
The patient is often asymptomatic
If there are symptoms (lower left abdo pain and constipation) then try bulk-forming laxatives (isaghula husk). AVOID stimulant laxatives
How does acute diverticulitis present?
Pain and tenderness in the LIF Fever Diarrhoea N+V rectal bleeding
What is the management of acute diverticulitis?
Oral co-amoxiclav
Analgesia
If severe then admit. IV fluids. abx and CT. May need surgery for complications
What is the blood supply of the foregut?
Coeliac artery
What is the blood supply of midgut?
Superior mesenteric artery
What is the blood supply of the hindgut?
Inferior mesenteric artery
How does chronic mesenteric ischaemia present?
Colicky abdominal pain after eating
Weight loss
Abdominal bruit
How is chronic mesenteric ischaemia diagnosed?
CT angiography
What is the management of chronic mesenteric ischaemia?
Reducing modifiable risk factors
Secondary prevention
Revascularisation
What tends to cause acute mesenteric ischaemia?
Thrombus in the superior mesenteric artery (may be secondary to AF)
What is the diagnostic test for acute mesenteric ischaemia?
Contrast CT
What effect does bowel ischaemia have on the bloods?
metabolic acidosis
raised lactate
What is familial adenomatous polyposis?
Autosomal dominant disorder which causes the malfunctioning of the tumour suppressor genes which results in polyps (adenomas) developing along the large intestine
What is the management of familial adenomatous polyposis?
Patients usually have the whole large bowel removed prophylactically because there is a high chance that the polyps will become malignant
What is lynch syndrome and what is it’s inheritance pattern?
Hereditary nonpolyposis colorectal cancer
What are the red flags for bowel cancer?
Change in bowel habit Unexplained weight loss Rectal bleeding Unexplained abdominal pain Iron deficiency anaemia Abdominal or rectal mass
What is the screening programme for bowel cancer?
faecal immunochemical test (FIT).
people between 60 and 74 are sent a FIT test to do every 2 years, if positive they are sent for a colonoscopy
What is the gold standard test for bowel cancer?
Colonoscopy with biopsy
What are the stages of TNM classifcation?
T=tumour
Tx- unable to assess size
T1-submucosa involvement
T2-involvement of the muscularis propria
T3- involvement of the subserosa and serosa
T4- spread through the serosa (a) reaching other organs (b)
N= nodes NX= unable to assess nodes N0= no nodal spread N1= spread to 1-3 nodes N2= spread to more than 3 nodes
M= metastasis M0= non metastasis M1= metastasis
What are most gallstones made out of?
Cholesterol
What are the risk factors for gallstones?
The 4 Fs: Fat Fair Female Forty
How do gallstones present?
Biliary colic (severe, epigastric or RUQ pain)
Often triggered by meals
Lasts between 30 mins and 8 hours
May be associated with nausea and vomiting
What is the first line investigation for gallstones?
Ultrasound
Which scan should be used to investigate gallstones if ultrasound shows nowt?
MRCP
What is used to clear stones in bile ducts?
ERCP
What is acute cholecystitis?
Inflammation of the gallbladder
What is acute cholangitis
Inflammation of the bile ducts
What is the presentation of acute cholecystitis?
RUQ pain which radiates to the right shoulder
Fever Tachycardia Vomiting Murphy's sign Raised inflammatory markers
Which sign is suggestive of acute cholecystitis?
Murphy’s sign
Hand on RUQ, ask to breathe in, stimulation of the acute gallbladder will suddenly stop inspiration
How should patients with acute cholecystitis be managed?
Nil by mouth IV fluids Abx NG tube ERCP for stones Cholecystectomy
How does acute cholangitis present?
Charcot’s triad:
RUQ pain
Fever
Jaundice
How is acute cholangitis managed?
ERCP
PTC (percutaneous transhepatic cholangiogram)
What are the 2 most probable diagnoses when there is painless jaundice?
Cholangiocarcinoma
Pancreatic cancer
What is the tumour marker for cholangiocarcinoma and pancreatic adenocarcinoma?
CA19-9
What are the referral criteria for pancreatic cancer?
Over 40 with jaundice (2 week wait)
Over 60 with jaundice and any of: Diarrhoea Back pain Abdominal pain Nausea Vomiting Constipation New onset diabetes
For direct access CT abdo
What is trousseau’s sign of malignancy and which cancer is it suggestive of?
Migratory thrombophlebitis
Pancreatic adenocarcinoma
What is a whipple procedure?
Pancreaticoduodenectomy
What are the 3 main causes of pancreatitis?
Gallstones
Alcohol
Post-ERCP
What are the causes of pancreatitis?
I GET SMASHED
I- idiopathic G- Gallstones E- ethanol T- trauma S- Steroids M- mumps A- autoimmune S- Scorpion stings!! H- hyperlipidaemia E- ERCP D- Drugs
What is the presentation of acute pancreatitis?
Severe epigastric pain which radiates through the back
Associated vomiting
Abdominal tenderness
Systemically unwell
What is seen on bloods in acute pancreatitis?
Amylase
CRP
Ultrasound
CT abdomen
Which score is used to assess the severity of pancreatitis?
Glasgow
0 or 1= mild
2= moderate
3 or more= severe
What is the presentation of chronic pancreatitis?
Chronic epigastric pain
Loss of exocrine function
Loss of endocrine function ( o diabetes)
How is chronic pancreatitis managed?
Abstinence from alcohol and smoking Analgesia Replacement pancreatic enzymes (creon) Sub cut insulin ERCP with stenting Surgery