GI Flashcards
amylase level greater than what is considered to be diagnostic of pancreatitis
1000u/l
can raised serum amylase levels diagnose pancreatitis
no but can suggest it as other things also raise it and in severe pancratitis serum amylase can be normal
sudden osnet abdo pain, vomitting profusely and pain in epigastric region that radiates to back , drank alot of alcohol
pancreatitis
symptoms of exacerbation of crohns
bloody bowel motions, fatigue, tachycardia, elevated inflammatory markers
chrons disease exacerbation and acutely unwell treatment?
IV hydration, electrolyte replacement and corticosteriods
macrocytic anaemia results from
increased utilisation of vitamin B12 by colonised bacteria
steatorrhoea is caused by
reduced conc. of conjugated bile acids
— can convert conjugated bile acids to unconjugated bile acids, which results in impaired micelle formation
bacteriodes
diarrhoe is due to
steatorrhea
Bacterial overgrowth syndrome constitutes a group of disorders characterised by
diarrhoea, steatorrhoea and macrocytic anaemia
anatomic stasis due to duodenal or jejunal diverticula can result in the development of
bacterial overgrowth syndrome
acquired deficiency of intrinsic factor is seen in
pernicious anaemia
pernicious anaemia does not have
diarrhoea or steatorrhoea
calcification of the pancreas
chronic pancreatitis
chronic pancreatic insufficiency is most commonly associated with chronic pancreatitis caused by
high alcohol intake or cystic fibrosis
Fish tapeworm infestation cause
vitamin b12 deficiency,but steatorrhoea, diarrhoea, jejuna diverticula make bacterial overgrowth syndrome more likely
history of HIV, white mass on lateral aspect of tongue which cannot be scraped off
oral hairy leukplakia
first line treatment for oral hairy leukoplakia
antivirals
oral hairy leukplakia
a non- premaliganant Epstein-barr virus manifestation
oral candiasis can typically be
scraped off with a tongue blade
white lacy patches
oral lichen planus
what deficincey is common in alcoholics
B1 (thiamine)
thiamine deficiency causes
Wernicke’e encephalopathy - confusion, coma, ataxia, nystagmus, with the preservation of pupillary responses
vitamin b3 deficiency (niacin) causes
pellagra characterised by diarrhoea, dermatitis and dementia
vitamin A deficiency causes
photophobia, dry conjunctiva, dry cornea, dry scaly skin, anaemia and growth retardation- it is essential for retinal pigments, epithelial maturation and bone development
Vitamin — deficincy may present in patients with alcholic cirrhosis
K
acute abdo pain, rapidly developing asictes, elevated liver enzymes, enlarged caudate lobe,
hepatous venous outflow obstruction or Budd Chairi syndrome
In Budd -chairi syndrome, venous thrombosis forms anywhere from the hepatic venules up to the entrance of the
Inferior vena cava
Most commonly in budd-chiari syndrome, the venous thrombosis is with the
hepatic vein
firts line diagnostic investigation for hepatic venous obstruction
Ultrasound doppler
Management steps for budd-chairi syndrome
initially- anticoagulation
secondly- angioplasty with/out stenting or thromlysis
third line- Transjugular intrahepatic portosystemic shunt ( TIPSS)
- liver transplant
treatment for Budd chairi syndrome , if AST >1000
liver transplantation
features of crohns disease
anorexia, fatigue, perianal and perioral ulceration, joint pain, rashes such as erythema nodosum
typically presents with bloody diarrhoea and mucus
ulcerative colitis
epigastric pain and heartburn symptoms
peptic ulcer disease
right upper quadrant pain and symptoms may be aggravated bu eating foods high in fat
gall stones
left iliac fossa abdominal pain - common in elderly
diverticulitis
corkscrew appearance on oesophagus
oesophageal spasm
barium swallow- post cricoid web , iron deficiency anaemia and dysphagia
Plummer vinson syndrome
spontaneous rupture of the oesophagus after forceful and severe vomitting. classically occur after excessive overeating and alcohol consumption. left sided pleural effusions is often an early finding on a CXR
boerhaave syndrome
bloody diarrhoea, tenesmus (feeling as though he needs to empty his bowels) and left lower quadrant tenderness point to
inflammatory bowel disease (Uc or crohns)
flu-like illness, anorexia, nausea and vomitting, general malaise followed by acute hepatitis with __ tenderness, jaundice pale stools and dark urine if cholestasis develops and on palpatation hepatomegaly will likely be present
= acute hepatitis A infection ]-common in north africa
RUQ
is there a significant risk of acute hepatitis A infection progressing to cirrhosis
NO!
HEP A and E transmitted by the
fAEcal -oral route
hep b and c by blood products and sexual intercourse and other ways
raised neutrophil count in ascites fluidin patient with cirrhosis of the liver and asictes
Spontaneous bacterial peritonitis
- serious complicatio and occur in approx 8% of cases of cirrhosis with ascites
- high mortality rate and high recurrence rate
most reflective of synthetic liver function
- pro-thrombin time and albumin
(pro-thrombin timw increases and is an indicator of acute sythetic function, albumin gives an indication of synthetic liver function over a longer period, given the half life 20 days in serum)
ALP would be raised in
cholestatic disease
ALT and AST represent liver
parenchymal function
hepatic portal vein is formed by the union of the
superior mesenteric and spenic veins
liver in patient is cirrhotic and and — vein is obstructed, this is the cause of caput medusae
hepatic portal
tropical sprue presents with
chronic dirarrhoea, weight loss, vitamin b12 and folate deficiencies- seen in tropical countires like india
predominant mononuclear cell infiltration and less villous atrophy throughout the intestine
tropical sprue
treatment of tropical sprue
broad spectrum antibiotics
presentation of somatostatinoma
gallstones, weight loss, diarrhoea and diabetes mellitus
Glucagonoma typically presents with
diabetes mellitus, weight loss, anaemia, and classical rash is necrolytic migratory erythema
insulinoma presents with
sweating, weight gain, light-headedness and loss of consciousness- exacerbated by exercise or fasting
gastrinoma characterised by
peptic ulceration, gastric acid hypersecretion, non B cell islet tumour of the pancreas
VIPoma presents with
severe watery diarrhoea, which therefore gives significant hypokalemia, and achlorhydria
abdo pain which radiates to the back, significant elevation in amylase levels following endoscopic retrograde cholangiopancreatography (ERCP)
Post ERCP pancreatitis
vomitted bright red blood twice, palpable spleen tip, spider naevi over the check neck and arms
oesophageal varices
spleonmegaly and spider narvi are suggestive of
chronic liver failure with portal hypertension
immediate management of oesophageal varices
resuscitation, PPI, urgent endoscopy to diagnose and treat teh source of bleeding
Mallory-weiss tear classicaly occurs after severe
retching and vomitting or coughing
red flags for malignancy
appetite and anaemia
red flags for malignancy and luminal obstruction what investigation
colonoscopy
most common causes of exudative ascites are
infection or malignancy
causes of transudative ascites
-cardiac failure, portal hypertension, fulminant hepatic failure, budd-chairi syndrome
relatively common in elderly, muscle and joint pain, fatigue, red dots on the skin (perifollicular heamorrhages), bleeding and inflammation of the gums (gingivitis) ,easy brusing
scurvy (VITAMI C DEFICIENCY)
hypothyroidism is more likely to do what to weight
weight gain
and dry, coarse skin
lead posioning
abdo pain, confusion, headaches
while vitamin K deficiency may cause bleeding and easy brusing, it is much less common than
vitamin C defiency
you would expect a raised plasma urea level in
gastric ulcer
urea is produced as a by-product from the digestion of
blood
epigastric pain, which ususally occurs before meals or at night, relieved by eating or drinking milk
duodenal ulcer
duodenal ulcers usually occur in the presence of oversecretion of gastric acid
causes of duodenal ulcer:
HELICOBACTER PYLORI,NSAIDS, STERIODS AND ASPIRIN
GASTRIC ULCERS ARE LESS COMMON THAN DUODENAL ULCERS AND PATIETNS WITH GASTRIC ULCERS TEND TO HAVE
NORMAL OR LOW SECRETION OF GASTRIC ACID
solitary, well defined painful lesion in mouth
aphthous ulcer - benign oral lesion found in approx 20% of the population
- common triggers coffee and chocolate
first line management of aphthous ulcer
topical steriods and topical lidocaine for pain control
shaggy, white patch on the lateral aspect of the tongue
oral hairy leukoplakia
oral steriods should eb used cautiously in patietns with daiebets as they can cause
hyperglycaemia
treatment for oesophageal varices in patient with known alcoholic liver disease
non-specific beta blockers- nadolol and propanolol
blood and tender iliac fossa hint
UC
Ulcerative colitis is strongly associated with
primary sclerosing cholangitis
UC raised
ALP, ASMA, isolated ALP is often observed
what reduces surface mucus secretion
Aspirin
taking aspirin with — has been shown to reduce the risk of GI bleeding and peptic ulceration
PPI
aspirin causes increased acid production from gastric parietal cells as — normally inhibit acid secretion
prostaglandins
first line treatment for Hep C
Direct acting antivirals
diarrhoea, wheezing, flushing, weight loss
Neuroendocrine tumour
most common site for gastrin secreting tumours that cause zollinger- ellison syndrome
First/ second parts of duodenum
what is infectious mononucleosis
glandular fever
20y/o student w fever, sore throat, tender cervical lymphadenopathy and enlarged tender liver
glandular fever - enlarged over or spleen in 10% of cases - causative organism - epstein barr virus
glandular fever patients should avoid what in the first month
contact sports or heavy lifting
diagnosis for glandular fever
MONOSPOT TEST( PAUL BUNNELL)
Altered bowel habit and has lost weight recently
colorectal cancer with liver metastasis
liver metastases commonly arise from
bowel and breast cancer
abdominal swelling, hepatomegaly, lower limb oedema, SOB, past history of rheumatic fever and has hypertension
Congestive cardiac failure
(right heart failure is often a forgotten cause of ascites and hepatomegaly)
In tric regurg the enlarged liver may be pulsatile
feeling tired and diarrheoa, brusing tendency, large beefy tongue, lymphadenopathy and hepatomegaly
Amyloidosis
lumps and generalised symptoms- unintentional weight loss, fever, night sweats, involvement of liver, spleen, bone marrow
lymph node pain on drinking alcohol is said to be a feature of
hodgkin’s disease
around 70-90% of patients with PSC (primary sclerosing cholangitis) have
inflammatory bowel disease
gold invstigation for PSC
ERCP
beaded appearance of biliary ducts, and liver biopsy showing – skin appearance
onion
PSC - posive
PBS-positive
(antibody)
ANCA
AMA
ascending cholangitis triad
jaundice, abdo pain and fever
High serum amylase and serum lipase levels may indicate — -induced pancreatitis
hypertriglyceridaemia
invstigation to check if a peptic ulcer has perforated
erect CXR
(show air under the diaphragm if a peptic ulcer has perforated)
hyper/hypocalcaemia in acute pancreatitis
HypOcalcaemia
symptoms that change at different points in the menstrual cycle is not an unusual finding in
IBS
much older than 26, acute onset lower abdo pain, altered bowel habit, rectal bleeding and fever
diverticulitis
advacned disease of chronic pancreatitis has
steatorrhoea
upper abdominal discomfort related to eating, without any consistent disturbance of bowel habit
peptic ulcer disease
what needs to be avoided ebefore doing the hydrogen breath test
smoking
avoid carbs the night before
post partum, on the pil, RUQ painn, nausea and vomiting, hepatosplenomegaly, ascites
Budd-chairi syndrome
budd-chiarai syndrome commonly results in
hepatosplenomegaly and ascities
-associated with pregnancy and being post partum- use of pill can increase risk
rise in bilirubin, young, no liver disease, jaundiced
gilberts syndrome
death or jaundice in neonate
Crigler Najjar
accumulate copper
wilsons disease
recurrent episodes of cholangitis
caroli’s syndrome
elevated ferritin points towards a diagnosis of
Haemochromatosis
bronze diabetes
haemochromatosis
low ceruloplasmin, along with high urinary copper is typical of
Wilson’s disease
positive AMA
PBC
high transferrin saturation
haemochromatosis- iron overload leading to liver cirrhosis, bronze colour to the skin
positive ANA or anti-SMA
autoimmune hepatitis
history of travel, lack of drug use, blood transfusion and unprotected sex , what hep
A
- eating shellfish, water contaminated by sewage, crowded, poor sanitation
hep B and – are cotransmitted
D
hep C is contacted by
saliva and blood
Hep B is contracted by
blood, saliva, sexual contact
yellow fever assoiated with travel to
tropical rainforests
young person, flu like symptoms, mild janudice, raised bilirubin
gilberts syndrome
RUQ pain and fever, but no jaundice
Cholecystitis
HIV patient, pain affectid right side of face and got a rash affecting right cheek and right side of his palate
Shingles (herpes zoster)
most common cause of mouth ulcers particularly in young people
recurrent apthous stomatitis
behcet disease is common in asian and mediterranean countries eg
turkey
recurrent orogenital ulceration plus any no. of systemic manifestations eg joint pain, acne like lesions
behcets disease
associated with HLA-B51
behcets disease
common drugs that cause stevens johnson sydrome
allopurinol, antiepileptics, trimethoprim
lesions on skin, oral ulceration, crusting of the lips
stevens johnson sydrome
small pale papule on upper lip which develops into a large, painless indurated ulcer
syphillis
spleonmegaly and spider naevi are suggestive of chronic liver failure with portal hypertension. portal hypertension can lead to —- which can rupture, causing severe bleeding, manifested as heamatemesis.
oesophageal varices
occurs in patients after severe coughing, vomitting or retching
mallory weiss tear
sudden onset large volume of blood
oesophageal varices
oesophagitis is very
painful
symptoms of delirium tremens
agitation, hyperthermia, visual hallucinations
first line therapy for delirium tremens
Lorazepam
– lies at the severe end of the alcohol withdrawl spectrum
delirium tremens
histology shows acive inflammation
Helicobacter pylori gastritis
progressive painless jaundice. more common in men over 50, gives rise to hepatomegaly, stools paler than normal and urine darker,
cholangiocarcinoma
in acute cholecystitis you would expect
marked abdominal pain and pyrexia
haemolytic anaemia gives rise to
pre-hepatic jaundice, colour of urine and stool remains unchanged
if suspect obstruction , first line investigation is — of the abdomen
ultrasound
LFTs of an obstructive/ cholestatic
ALP and GGT raised more than AST or ALT
common causes of obstructive jaundice
gallstones within the comon bile duct
cancer within the head of the pancreas
certain autoimmune liver diseases (PSC or PBC)
what investigation after upper GI endoscopy, colonscopy and small bowel contrast study
capsule endoscopy- not if got swallowing disorder, stricture or fistula, suspected small bowel stenosis
malaena is due to GI bleeding so what investigation
endoscopy
what would you inject a bleeding ulcer withbefore it is clipped to prevent re-bleed
adrenaline
hepatocytes differentiate from the
endoderm
Mallory bodies are seen in
injured hepatocytes
what is the precursor of cirrhosis
bridging fibrosis
small dilated blood vessels on face and trunk, palmar erythema, dilation of the superificial abdominal veisn
cirrhosis or irreversible liver injury
triple therapy for H.pylor (common cause of peptic ulceration)
PPI including omeprazole, clarithromycin and amoxicillin
treatment for h.pylori if allergic to pencillin
PPI, clarithromycin and metronidazole
second line eradication fro h.pylori
Metronidazole or clarithromycin, bismuth, tetracycline and PPI
investigatio for non alcoholic fatty liver disease
ultrasound liver
-raised ALT, impaired glucose regulation referenced by teh thickened folds of skin in the axilla, high BMI
HBsAg indicates
current infection
HBeAg indicates
current infection (suggests highly active HBV)
if patients had HBeAb and not HBeAG this would suggest
chronic carrier state of low infectivity
presence of — would indicates immunity to HBV
HBV surface antibody
what region of the stomach is closest to the oesophagogastric junction
cardia
The cardia of the stomach surrounds the opening of the oesophagus into the stomach
duodenal ulcer is a type of
peptic ulcer disease
risk factors for peptic ucler disease
smoking, H.pylori infection, NSAIS, zollinger ellison syndrome
appendicitis
central abdominal pain that localises to the right iliac fossa with associated anorexia, fevers and peritonism
chronic mesenteric ischaemia
severe, colicky, post prandial abdo pain, weight loss, abdominal bruit
diverticulitis
left iliac fossa pain with rectal bleeding, fevers and tachycardia
pancreatitis
central abdominal pain radiating to the back in patients who have a history of gallstones, alcoholism, or abdominal trauma
hip pain more common in – than crohns
UC
Primary sclerosing cholangitis is a condition in which
inflammation, fibrosis and strictures of the intra and extra hepatic bile ducts occur
(MRCP shows multiple strictures in the biliary tree adn a characteristic ‘beaded’ appearance. Around 80% of patients with PSC will have UC)
cholangitis is
ascending infection of the biliary tree
cholecystitis refers to
inflammation of the gallbladder, most commonly caused by gallstones
findings of strictures on MRCP is more suggestive of
Primary sclerosing cholangitis
Primary biliary cholangitis is an
autoimmune disorder causing destruction of the small interlobular bile ducts, subsequent intrahepatic choleostasis causes fibrosis and ultimately cirrhosis of the liver
glasgow severity score is used for
severity stratification (within 48hrs of admission)
score of 3 or above indicates intensive care unit
not a parameter in glasgow severity scoring
serum amylase
- may be normal in severe pancreatitis and may be elevated in many other conditions.
first line method to confirm safe placement of NG tube before commencing feeding
Aspirate 10ml and check the pH
if less than 5.5 then NG tube can be safely used
red flag of cancer
subacute first onset dysphagia which is limited to solids
painless jaundice, weight loss, epigastric discomfort, development of diabetes
pancreatic carcinoma
painless jaundice is significantly associated with pancreatic carcinoma
progressively worsening jaundice, weight loss, strong alcohol history
pancreatic cancer
presenting symptoms of cholangiocarcinoma
jaundice, abdominal pain, itching
nail clubbing, palmar erythema, spider naevi- no jaundice
chronic liver disease
first line treatments for autoimmune hepatitis
Azathioprine and prednisolone
deranged liver function tests, jaundice, itching and chronic fatigue
PSC
white lesion in mouth that can be easily scraped off treatment
Oral candidiasis - nystatin suspension- like mouth wash
RUQ pain, fever, elevated white cell count
acute cholecystitis
RUQ pain, fever, elevated white cell count
acute cholecystitis
management of acute cholecystitis
laparoscopic cholecystectomy
— classicaly presents gradually with difficulty swallowing both solids and liquids over time as the lower oesophageal sphincter fails to relax
achalasia
Long term reflux causes damage to the oesophageal epithelium, which is replaced by fibrosis and results in a stricture. This in itself leads to dysphagia but can also predispose to malignancy through a pre-malignant stage known as
Barret’s metaplasia
previously investigated for anaemia and now complains of dysphagia
Plummer-vinson sydrome
-occurs in pre-menopausal women
fibrosis resulting in disruption of normal liver architecture
alcoholic cirrhosis
deposition of excess lipids in hepatocytes
NAFLD
increase in portal blood pressure
portal hypertension - sequelae of alcoholic liver disease.
sclerosis of the intra and extrahepatic bile ducts
PSC- causes inflammation, fibrosis, and strictures of the bile ducts. Strong association with UC
investigations would best distinguish pernicious anaemia from otehr causes of malabsorption as the cause of low b12
intrinsic factor antibodies
PERNICIOUS ANAEMIA IS CAUSED BY
ANTIBODIES WHICH TARGET EITHER INTRINSIC FACTOR OR THE GASTRIC PARIETAL CELLS
C14 BREATH TESTS ARE USED IN THE IDENTIFICATION OF
H.PYLORI, A CAUSE OF PEPTIC ULCERS
TREATMENT FOR SEVERE TREATMENT RESISTANT C. DIFFICILE
IV METRONIDAZOLE OR FACEAL TRANSPLANT
NEEDS TO BE IV METRONIDAZOLE
CLASSIC SYMPTOMS OF HAEMORRHOIDS
fresh red blood and mucous after passing stool, pruritic anusm soreness around anus
risk factors for heamorrhoids
obesity, chronic constipation, coughing
Diverticulitis is characterised by passing fresh red blood per rectum, other associated symptoms are
nausea and vomitting, pyrexia and abdo pain
anal fissures associated with
sharp anal pain when stools are passed
blood supply to the stomach originates from the
coeliac trunk
coeliac trunk 3 main divisions:
Left gastric artery(oesophageal and stomach branch), common hepatic arery (proper hepatic artery, right gastric artery, gastroduodenal artery), splenic artery (short gastric arteries, branches to the pancreas)
In haemochromatosis there is increased risk of
hepatocellular carcinoma
is associated with haemochromatosis
arthropathy
p-ANCA is elevated in patients with
UC and or PSC
ASMA are markers for
autoimmune hepaitis
increased ASCA is associated with
crohns disease
elevated levels of Anti-dsDNA is found in
SLE
what nerves supply the muscularis externa of the oesophagus
vagus nerve
vagus nerve has a parasympathetic action and stimulate — and supply teh smooth muscle
peristalsis
At the gastro-oesophageal junction there is the lower oesophageal sphincter, that under the influence of the vagus nerve, relaxes to allow food to enter the stomach. In —- , there is increased tone of the lower oesophageal sphincter, incomplete relaxation ans lack of peristalsis. as a result has dysphagia and regurg
oesophageal achalasia
greater splanchnic nerves supply
enteric nervous system and the adrenals
— nerves supply msucles for swallowing
glossopharyngeal (parasympathetic)
are rice and potatoes gluten free
yes
