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GI Flashcards

1
Q

What are the 3 steps of alcoholic liver disease?

A

Alcohol related fatty liver
alcoholic hepatitis
Cirrhosis

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2
Q

What is the recommended alcohol consumption in a week?

A

14 units a week spread over 3 days. No more than 5 units in a day

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3
Q

What is the screening tool for harmful alcohol use and what are the questions?

A

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

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4
Q

What do blood tests show in alcohol abuse?

A

FBC- raised MCV

LFTs- ALT and AST raised. Gamma GT is escpecially high. Low albumin due to reduced synthetic function of the liver

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5
Q

What can be seen on ultrasound of a fatty liver?

A

Increased echogenicity

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6
Q

Which scan is used to assess cirrhosis?

A

Fibroscan

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7
Q

Which test is used to confirm alcohol related liver changes?

A

Biopsy

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8
Q

What is the timeline of symptoms in alcohol withdrawal?

A

6-12 hours: tremor, sweating, headache, craving, anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: delirium tremens

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9
Q

What are the symptoms of delirium tremens?

A 
Acute confusion
Severe agitation
Delusions and hallucinations
Tremor
Tachycardia
Hyperthermia
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10
Q

Which tool can be used to score patients withdrawing from alcohol?

A

CIWA-Ar

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11
Q

How is alcohol withdrawal managed?

A

Chlordiazepoxide

Pabrinex

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12
Q

What causes korsakoffs syndrome?

A

Thiamine deficiency

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13
Q

What is the triad of symptoms found in wernicke’s encephalopathy

A

Confusion
Oculomotor disturbances
Ataxia

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14
Q

What are the features of korsakoff’s syndrome?

A

Memory impairment

Behavioural changes

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15
Q

What are the 4 most common causes of liver cirrhosis?

A

Alcoholic liver disease
Non-alcoholic liver disease
Hepatitis B
Hepatitis C

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16
Q

What is seen on bloods in someone who has liver cirrhosis?

A

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

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17
Q

What is the first line test for assessing fibrosis in non-alcoholic fatty liver disease?

A

ELF blood test (enhanced liver fibrosis)

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18
Q

What is seen on ultrasound of a cirrhotic liver?

A

Nodularity of the surface

Corkscrew appearance of the arteries

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19
Q

How is cirrhosis scored?

A

using the child-pugh socre. The minimum score is 5 and the max is 15

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20
Q

Where do varices usually occur?

A

Gastro-oesophageal junction
Ileocaecal junction
Rectum
anterior abdominal wall

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21
Q

How can varices be managed?

A

propanolol reduces portal hypertension
Elastic band ligation
Injection of sclerosant
Transjugular intra-hepatic portosystemic shunt

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22
Q

how can bleeding oesophageal varices be managed?

A

Vasopressin analogues
Correct coagulopathy with vitamin K and fresh frozen plasma
Urgent endoscopy

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23
Q

How does spontaneous bacterial peritonitis present?

A 
asymptomatic
Fever
Abdominal pain
derranged bloods
Ileus
Hypotension
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24
Q

What is the management of Spontaneous bacterial peritonitis?

A

IV cephalosporins such as cefotaxime

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25
What are the 4 stages of non-alcoholic fatty liver disease?
1. NAFLD 2. Non-alcoholic steatohepatitis 3. Fibrosis 4. Cirrhosis
26
What is the test which can confirm NAFLD?
Ultrasound
27
What are the first and second line recommended investigations for assessing fibrosis?
Enhanced liver fibrosis blood test (ELF test) NAFLD fibrosis score
28
What is the management of NAFLD?
``` Weight loss Exercise Stop smoking Control of diabetes Avoid alcohol ```
29
What are the symptoms of hepatitis?
``` Abdominal pain Fatigue Itching Muscle and joint aches Nausea and vomiting Jaundice Fever (if viral) ```
30
What do the LFTs look like in hepatitis?
Raised transaminases (AST/ALT) with proportionally less of a raise in ALP
31
What type of virus is hepatitis A?
RNA
32
How is hepatitis A transmitted?
Faeco-oral route
33
What type of virus is hepatitis B?
DNA virus
34
What does a high number or surface antigen (HBsAg) imply?
Active infection
35
What does a high level of E-antigen (HBeAg) suggest?
Marker of viral replication and implies high infectivity
36
What do core antibodies (HBcAb) suggest?
Implies past or current infection
37
What does surface antibody (HBsAb) suggest?
implies vaccination, past or current infection
38
What type of virus is Hepatitis C?
RNA
39
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
40
What kind of virus is hepatitis D?
RNA
41
What type of virus is hepatitis E?
RNA
42
Which hepatitis can only survive in co-infection with hepatitististis B?
D
43
Which age group does type 1 autoimmune hepatitis affect?
Adults
44
Which age group does type 2 autoimmune hepatitis affect?
Children (el nino)
45
What is the treatment of autoimmune hepatitis?
Prednisolone
46
What is haemochromatosis?
An iron storage disorder which results in excessive total body iron and deposition of iron in tissues
47
What inheritance pattern is haemochromatosis?
Autosomal recessive
48
When does haemochromatosis present?
Typically after the age of 40 when the iron load becomes symptomatic. Presents later in females due to menstruation
49
What are the symptoms of haemochromatosis?
``` Memory and mood disturbance Hair loss Chronic tiredness Skin pigmentation (bronze) Erectile dysfunction/ ammenorrhea Joint pain ```
50
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
51
What are the complications of haematochromatosis?
Cardiomyopathy (iron deposits in the heart) HCC Hypothyroidism Chrondrocalcinosis/ pseudogout
52
What is the management of haemochromatosis?
Venesection Monitoring serum ferritin Avoid alcohol Genetic counselling
53
What is wilson's disease?
Excessive accumulation of copper in the body
54
What is the genetic inheritance of wilson's disease?
Autosomal recessive
55
What is the presentation of wilsons disease?
Dysarthria, dystonia, parkinsonism Psychosis or depression Kayser-fleischer rings in the cornea Liver cirrhosis Haemolytic anaemia Osteopenia
56
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
57
What is the management of Wilson's disease?
Penicillamine | Trientene
58
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
59
What are the features of alpha-1-antitrypsin deficiency?
Liver cirrhosis after 50 years old | Bronchiectasis and emphysema after 30 years old
60
How is alpha-1-antitrypsin deficiency diagnosed?
Low serum alpha-1-antitrypsin Liver biopsy shows cirrhosis and acid-schiff-positive staining globules
61
What is the management of alpha-1-antitrypsin deficiency?
Stop smoking Symptomatic management Organ transplant
62
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
63
What is the presentation of primary biliary cirrhosis?
``` Fatigue Pruritis GI pain Jaundice Pale stools Xanthoma ```
64
How is primary biliary cirrhosis diagnosed?
ALP is raised Anti-mitochrondrial antibodies raised Liver biopsy
65
What is the management of primary biliary cirrhosis?
Urseodeoxycholic acid (reduces GI uptake of cholesterol) Colestyramine prevents bile acid sequestration in the gut
66
What is primary sclerosing cholangitis?
Intrahepatic or extrahepatic ducts become strictured or fibrotic which leads to chronic bile obstruction
67
Which other disease is primary sclerosing cholangitis strongly associated with?
Ulcerative colitis
68
What is the presentation of primary sclerosing cholangitis?
``` Jaundice Chronic RUQ pain Pruritis Fatigue Hepatomegaly ```
69
How is primary sclerosing cholangitis diagnosed?
Gold standard is an MRCP
70
What is the management of primary sclerosing cholangitis?
Liver transplant (curative) Colestyramine ERCP
71
What are the main risk factors for HCC?
Viral hepatitis (B and C) Alcohol NAFLD
72
Which cancer is primary sclerosing cholangitis related to?
Cholangiocarcinoma
73
What is the tumour marker for HCC?
Alpha-fetoprotein
74
What is the tumour marker for cholangiocarcinoma?
CA19-9
75
What is the lining of the oesophagus?
Squamous epithelial lining
76
What is the lining of the stomach?
Columnar epithelia lining
77
What is the presentation of GORD?
``` Heartburn Acid regurg Retrosternal or epigastric pain Bloating Nocturnal cough Hoarse voice ```
78
What are the red flag symptoms for 2 week wait referral?
``` Dysphagia >55 Weight loss N+V Low haemoglobin raised Platelet count ```
79
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
80
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
81
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
82
How is H.pylori eradicated?
Triple therapy: PPI + 2 antibiotics for 7 days (usually clarithromycin and amoxicillin)
83
What is Barret's oesophagus?
When constant acid reflux metaplasia from squamous to columnar epithelium. It is managed with PPIs and monitoring
84
What is the presentation of peptic ulcers?
``` Epigastric discomfort N+V Dyspepsia Bleeding causing haematemesis Iron deficiency anaemia ```
85
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
86
What is the management of peptic ulcers?
High dose PPI
87
How are peptic ulcers diagnosed?
Endoscopy. During endoscopy a rapid urease test (CLO) would be performed to check for H.pylori
88
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
89
What is the presentation of an upper GI Bleed
Haematemesis Coffee-ground vomit Malaena Haemodynamic instability
90
What is the scoring system used in suspected upper GI bleed?
Glasgow-blatchford score. A score >0 indicates a bleed
91
Why does serum urea increase in GI bleed?
Urea is a breakdown product when blood is digested within the GI tract
92
What is the rockall score?
Used for patients who have had an endoscopy to calculate their risk of rebleeding
93
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) ```
94
What should be given if oesophageal varices are suspected as a cause of upper GI bleed?
Terlipressin | Prophylactic broad spectrum antibiotics
95
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 ```
96
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 ```
97
How do you test for IBD?
CRP indicated inflammation and active disease Faecal calprotectin is a sensitive and specific screening test
98
What is the management of Crohn's?
Induce remission through steroids Add immunosupression if doesn't work (azathiopurine) Maintain remission through azathiopurine or mercaptopurine
99
What is the management of UC?
Induce remission: 1st amiosalicylate such as mesalazine 2nd steroids Maintain remission: Mesalazine Surgery: removing colon and rectum
100
What are the symptoms of IBS?
``` Diarrhoea Constipation Fluctuating bowel habit Abdominal pain Bloating Worse by eating Improved by opening bowels ```
101
How should IBS be investigated?
Normal bloods Do faecal calprotein to exclude IBD Do anti-TTG antibodies to exclude coeliac
102
How is IBS managed?
``` Low FODMAP diet CBT Loperamide for diarrhoea Laxatives for constipation Antispasmodics for cramps (buscopan) ```
103
Which antibodies are associated with coeliacs disease?
anti-tissue transglutaminase (anti-TTG) and anti-endomysial (anti-EMA)
104
What is seen on histology of the bowel mucosa in coeliac's?
Villous atrophy | Crypt hypertrophy
105
Which autoimmune disease is strongly linked with coeliac's?
Type 1 diabetes
106
How is coeliac's diagnosed?
Anti TTG antibodies and histology shwoing villous atrophy and crypt hypertrophy
107
How does appendicitis present?
Central abdominal pain which moves down to the right iliac fossa within 24 hours, becoming localised there
108
At which anatomical landmark can tenderness be identified in appendicitis?
McBurney's point (one third of the distance from the ASIS to the umbilicus)
109
What is rovsig's sign?
palpation of the left iliac fossa causes pain in the RIF
110
Which 3 signs potentially indicate a ruptured appendix?
Rebound tenderness Percussion tenderness Pertitonitis
111
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
112
What is an appendix mass?
When the omentum surrounds and sticks to the inflammed appendix
113
What is the management of appendicitis?
Appendicectomy by laparoscopic surgery
114
What is third-spacing?
The abnormal loss of fluid from the intravascular space into the GI tract
115
What are the "big three" causes for bowel obstruction?
Adhesions Hernia Malignancy
116
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
117
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 ```
118
What is the finding in an abdominal x-ray of bowel obstruction?
Distended loops of bowel
119
What may be seen on venous blood gas of someone with bowel obstruction?
Metabolic alkalosis
120
What can be seen on erect chest x-ray of bowel perforation
Air under the diaphragm
121
What is the definitive management of bowel obstruction?
Exploratory surgery Adhesiolysis Hernia repair Emergency resection
122
What is ileus?
A condition which affects the small bowel where peristalsis stops and causes a pseudo-obstruction (functional obstruction)
123
What are common causes of ileus?
Injury Handing of the bowel during surgery Inflammation or infection Electrolyte imbalance
124
What are the symptoms of ileus?
Similar to bowel obstruction Green vomiting Abdominal distention Absolute constipation and lack of flatulence
125
What is the management of ileus?
Nil by mouth NG tube IV fluid
126
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
127
What are the two main types of volvulus?
Sigmoid volvulus and caecal volvulus
128
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
129
What is the presentation of volvulus?
Same as bowel obstruction (again)
130
How is volvulus diagnosed?
Abdominal x-ray shows the coffee bean sign Contrast CT is the diagnostic test
131
How is volvulus managed?
Conservative management (endoscopic decompression) Laparotomy Hartmann's procedure
132
What are the 3 complications of hernias?
Incarceration Obstruction Strangulation
133
What is incarceration of a hernia?
A hernia cannot be reduced (stuck in the mud)
134
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
135
What are the 3 management options for hernias?
Conservative Tension-free repair Tension repair
136
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
137
What are femoral hernias?
Herniation of the abdominal contents through the femoral canal. This occurs below the inguinal ligament
138
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.
139
What are obturator hernias?
When the abdominal or pelvic contents herniate through the obturator foramen. Usually happens due to defect in the pelvic floor
140
What is the sign indicative of a obturator hernia?
Howhip-Romberg sign= pain extending from the inner thigh to knee when the internally rotated
141
What is a hiatus hernia?
Herniation of the stomach through the diaphragm
142
What are haemorrhoids?
Enlarged anal vascular cushions
143
What are haemorrhoids usually associated with?
Pregnancy, obesity, increased age, increased intra-abdominal pressure (weightlifting or chronic coughing)
144
Where do anal cushions get their blood supply?
Rectal arteries
145
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
146
How are haemorrhoids diagnosed?
PR | Protoscopy
147
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
148
How do thrombosed haemorrhoids present?
VERY pain | appear purplish, very tender and swollen
149
What is diverticulosis?
Refers to the presence of diverticula, without inflammation or infection
150
What is diverticulitis?
Refers to the inflammation and infection of diverticula
151
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
152
How does acute diverticulitis present?
``` Pain and tenderness in the LIF Fever Diarrhoea N+V rectal bleeding ```
153
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
154
What is the blood supply of the foregut?
Coeliac artery
155
What is the blood supply of midgut?
Superior mesenteric artery
156
What is the blood supply of the hindgut?
Inferior mesenteric artery
157
How does chronic mesenteric ischaemia present?
Colicky abdominal pain after eating Weight loss Abdominal bruit
158
How is chronic mesenteric ischaemia diagnosed?
CT angiography
159
What is the management of chronic mesenteric ischaemia?
Reducing modifiable risk factors Secondary prevention Revascularisation
160
What tends to cause acute mesenteric ischaemia?
Thrombus in the superior mesenteric artery (may be secondary to AF)
161
What is the diagnostic test for acute mesenteric ischaemia?
Contrast CT
162
What effect does bowel ischaemia have on the bloods?
metabolic acidosis | raised lactate
163
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
164
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
165
What is lynch syndrome and what is it's inheritance pattern?
Hereditary nonpolyposis colorectal cancer
166
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 ```
167
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
168
What is the gold standard test for bowel cancer?
Colonoscopy with biopsy
169
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 ```
170
What are most gallstones made out of?
Cholesterol
171
What are the risk factors for gallstones?
``` The 4 Fs: Fat Fair Female Forty ```
172
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
173
What is the first line investigation for gallstones?
Ultrasound
174
Which scan should be used to investigate gallstones if ultrasound shows nowt?
MRCP
175
What is used to clear stones in bile ducts?
ERCP
176
What is acute cholecystitis?
Inflammation of the gallbladder
177
What is acute cholangitis
Inflammation of the bile ducts
178
What is the presentation of acute cholecystitis?
RUQ pain which radiates to the right shoulder ``` Fever Tachycardia Vomiting Murphy's sign Raised inflammatory markers ```
179
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
180
How should patients with acute cholecystitis be managed?
``` Nil by mouth IV fluids Abx NG tube ERCP for stones Cholecystectomy ```
181
How does acute cholangitis present?
Charcot's triad: RUQ pain Fever Jaundice
182
How is acute cholangitis managed?
ERCP | PTC (percutaneous transhepatic cholangiogram)
183
What are the 2 most probable diagnoses when there is painless jaundice?
Cholangiocarcinoma | Pancreatic cancer
184
What is the tumour marker for cholangiocarcinoma and pancreatic adenocarcinoma?
CA19-9
185
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
186
What is trousseau's sign of malignancy and which cancer is it suggestive of?
Migratory thrombophlebitis Pancreatic adenocarcinoma
187
What is a whipple procedure?
Pancreaticoduodenectomy
188
What are the 3 main causes of pancreatitis?
Gallstones Alcohol Post-ERCP
189
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 ```
190
What is the presentation of acute pancreatitis?
Severe epigastric pain which radiates through the back Associated vomiting Abdominal tenderness Systemically unwell
191
What is seen on bloods in acute pancreatitis?
Amylase CRP Ultrasound CT abdomen
192
Which score is used to assess the severity of pancreatitis?
Glasgow 0 or 1= mild 2= moderate 3 or more= severe
193
What is the presentation of chronic pancreatitis?
Chronic epigastric pain Loss of exocrine function Loss of endocrine function ( o diabetes)
194
How is chronic pancreatitis managed?
``` Abstinence from alcohol and smoking Analgesia Replacement pancreatic enzymes (creon) Sub cut insulin ERCP with stenting Surgery ```

Alice's finals cards (21 decks)

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