GI Flashcards
What genes is coeliac disease associated with?
HLA-DQ2 + HLA-DQ8
Investigations for coeliac disease?
serum IgA transglutaminase antibody (tTGA) + total IgA
GOLD STANDARD diagnostic test - OGD and duodenal/jejunal biopsy
Skin condition associated with coeliac?
dermatitis herpetiformis
complications of coeliac?
- anaemia
- hyposplenism
- osteoporosis
- lactose intolerance
- enteropathy-associated T-cell lymphoma of the small intestine
- sub-fertility
scoring system for NAFLD?
FIB-4 (fibrosis - 4) or NFS (NAFLD fibrosis score)
LFT pattern for NAFLD with advanced fibrosis?
- bilirubin may be raised
- AST > ALT ratio
- low albumin
Most common causes of hepatocellular carcinoma?
Chronic hepatitis B or C
What do you use to screen for hepatocellular carcinoma?
USS +/- alpha-fetoprotein
Who should be considered for screening of hepatocellular carcinoma?
high risk groups such as patients with liver cirrhosis secondary to hepatitis C/B or haemochromatosis or men with alcoholic liver cirrhosis
Management of hepatocellular carcinoma?
- if early - surgical resection
- liver transplant
- radiofrequency ablation
- transarterial chemoembolisation
- sorafenib - a multikinase inhibitor
Typical symptoms of UC?
- bloody diarrhoea
- abdo pain in lower left quadrant
- tenesmus
- urgency
-extra-intestinal symptoms
Examples of extra-intestinal symptoms of IBD?
- arthritis
- erythema nodosum
- episcleritis
- osteoporosis
- PSC
- uveitis
- pyoderma gangrenosum
- clubbing
Investigation for diagnosis of UC?
- colonoscopy + biopsy
severity of UC classification?
mild - <4 stools/day + small amount of blood
moderate - 4-6 stools/day, varying amounts of blood
severe - >6stools/day bloody, systemic upset
Treatment for mild-moderate UC?
- topical (rectal) aminosalicylate (mesalazine)
if not change within 4 weeks then: - oral aminosalicylate
- oral corticosteroid
treatment for severe UC?
- should be treated in hospital
- iV steroids - first line
- IV ciclosporin if steroids contraindicated
treatment for severe relapse or >/= 2 exacerbations of UC in a year?
oral azathioprine or oral mercaptopurine
treatment for mild-moderate UC flare?
aminosalicylate (either topical or oral - depending on flare)
Adverse effects of PPI’s?
- hyponatraemia
- hypomagnasaemia
- osteoporosis
- microscopic colitis
- increased risk of c.diff infections
Gold standard investigation for coeliac following serology?
endoscopic intestinal biopsy (jejunal)
Two main causes of duodenal ulcers?
H.pylori
NSAID’s
hiatus hernia investigation?
- barium swallow
- endoscopy
hiatus hernia management?
- conservative e.g. weight loss
- medical e.g PPI
- surgical
management of diverticulitis?
oral antibiotics (co-amoxiclav OR cefalexin + metronidazole OR trimethoprim + metronidazole) + liquid diet + analgesia
if symptoms don’t settle within 72 hours then admit and IV antibiotics
most common cause of large bowel obstuction?
colon cancer
investigations for large bowel obstruction?
Abdominal Xray
CT
management of large bowel obstruction?
- nil by mouth + IV fluids + NG tube with free drainage
- conservative management can be trailed if low risk
- IV antibiotics if risk of perforation or surgery
- surgery
investigation for upper GI bleed?
- the Glasgow-Blatchford score at first assessment
- resus
- endoscopy (OGD) within 24 hours
management of non-variceal upper GI bleed?
- PPI
- If further bleeding then options include repeat endoscopy, interventional radiology and surgery
management of variceal upper GI bleed?
- terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
- band ligation for oesophageal varices and injections of N-butyl-2-cyanoacrylate for gastric varices
- transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures
Investigation of acute cholecystitis?
USS - 1st line
- if unclear then cholescintigraphy (HIDA scan)
treatment of acute cholecystitis?
intravenous antibiotics
cholecystectomy (laparoscopic - within 1 week of diagnosis)
antibodies for primary biliary cholangitis?
Anti michondrial antibodies (AMA)
> 60y + iron deficiency anaemia - what should you be suspicious of + do?
colorectal cancer - refer to colorectal services to get a colonoscopy + OGD
Tumour marker for colon cancer (not diagnostic)?
CEA - used to see disease progression / establish treatment
Bowel cancer screening test?
faecal occult blood (qFIT)
prophylaxis for oesophageal bleeding?
non-cardioselective B-blocker e.g. propanolol
which antibodies are raised in autoimmune heptaitis?
anti-nuclear (ANA) +/- anti smooth muscle
which antibodies are raised in autoimmune hepatitis?
anti-nuclear (ANA) +/- anti smooth muscle (Type 1)
anti-liver/kidney microsomal type 1 antibodies (KLM1) - type 2 (affects children only)
management of autoimmune hepaitits?
steroids
other immunosuppressants such as azathioprine
liver transplant
Management of primary biliary cholangitis?
Ursodeoxycholic acid - 1st line
Pruritus = cholestyramine
fat-soluble vitamin supplementation
liver transplantation
e.g. if bilirubin > 100 (PBC is a major indication)
What is barrett’s oesophagus?
metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium.
Management of Barrett’s oesophagus?
- High-dose proton pump inhibitor
- Endoscopic surveillance with biopsies
for patients with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years
If dysplasia of any grade is identified endoscopic intervention is offered. Options include:
- radiofrequency ablation - 1st-line
- endoscopic mucosal resection
Management of hepatic encephalopathy?
Lactulose - 1st line (removes ammonia from system)
rifaximin - if lactulose not working
What is thought to cause hepatic encephalopathy?
Excess absorption of ammonia and glutamine from bacterial breakdown of proteins in the gut.
Encephalopathy + coagulopathy + jaundice = ?
acute liver failure
severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit = ?
Intestinal angina (or chronic mesenteric ischaemia)
Causes of acute pancreatitis?
G - gallstones
E - ethanol
T - trauma
S - steroids
M - mumps
A - autoimmune (Polyarteritis Nodosa/SLE)
S - scorpion bite
H - Hypercalcaemia, hypertriglycerideaemia, hypothermia
E - ERCP
D - drugs
Stabbing-like, epigastric pain which radiates to the back that is relieved by sitting forward or lying in the fetal position + vomiting = ?
acute pancreatitis
Investigations for acute pancreatitis?
U&E + FBC
amylase (3x limit is suggestive) and lipase (more sensitive)
LFT - may be deranged if gallstones
imaging (USS, MRCP, ERCP, CT) - to look for underlying cause
Management of acute pancreatitis?
- fluids
- analgesia
- anti-emetics
- treat underlying cause e.g. ERCP for gallstones, antibiotics if infection
What is acute cholangitis?
infection of the biliary tree - most commonly caused by obstruction (gallstones)
Investigations for acute cholangitis?
FBC
U&E
Creatinine
ABG’s - metabolic acidosis if severe
LFT’s - ↑bilirubin, ↑ALP, ↑AST ↑ALT
CRP - ↑
blood cultures
USS
ERCP
Management of acute cholangitis?
IV antibiotics
ERCP or surgical drainage
What is Charcot’s triad?
right upper quadrant pain, fever and jaundice - classically linked to ascending cholangitis.
Investigations for alcoholic liver disease?
- LFTs - ALT/AST raises, Gamma-GT - raised. Low albumin in severe disease. raised bilirubin if cirrhosis
- elevated prothrombin
- deranged U&E’s
USS
Management of acute alcoholic hepatitis?
glucocorticoids e.g. prednisolone
Symptoms of alcohol withdrawal based on time?
6-12 hours: tremor, sweating, headache, craving and anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: “delirium tremens”
Management of alcohol withdrawal?
Chlordiazepoxide (“Librium”) or diazepam
+
IV high-dose B vitamins (pabrinex). + regular lower dose oral thiamine.
What comes first Wernicke’s encephalopathy or Korsakoffs syndrome?
Wernicke’s
Features of Wernicke’s encephalopathy?
- Confusion
- Oculomotor disturbances (disturbances of eye movements)
- Ataxia (difficulties with coordinated movements)
Features of Korsakoffs syndrome?
- Memory impairment (retrograde and anterograde)
- Behavioural changes
Treatment of Wernicke-Korsakoff Syndrome (WKS)?
thiamine supplementation and alcohol abstaining
Ascites drug management?
spironolactone
What is primary sclerosing cholangitis?
biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts.
How does primary sclerosing cholangitis present?
- cholestasis - jaundice, pruritus, raised bilirubin + ALP
- right upper quadrant pain
- fatigue
Investigations for primary sclerosing cholangitis?
ERCP or MRCP - diagnostic (shows ‘beaded’ appearance)
p-ANCA +ve
ANA and Anticardiolipin antibodies may also be raised - less common
Complications of primary sclerosing cholangitis?
- cholangiocarcinoma (in 10%)
- increased risk of colorectal cancer
Conditions associated with primary sclerosing cholangitis?
UC
crohns
HIV
Management of primary sclerosing cholangitis?
Liver transplant - curative
ERCP - to dilate and stent
Colestyramine - helps with pruritus
What is primary biliary cirrhosis (cholangitis)?
Primary biliary cirrhosis is a condition where the immune system attacks the small bile ducts within the liver.
Clinical features of PBC?
normally middle aged woman
fatigue
pruritus
jaundice
abdo pain
pale stool
xanthelasma / xanthoma
may progress to liver failure
Components of Glasgow - blatchford score?
Urea
hb
Systolic BP
HR
Malaena
Syncope
Causes of upper GI bleed?
- oesophageal varices
- Mallory - Weiss tear
- gastric ulcers / duodenal ulcers
- malignancy
Why does urea rise in upper GI bleed?
The blood in the GI tract gets broken down by acid and digestive enzymes - one of the breakdown products is urea- the urea is then absorbed by the intestines
Clinical features of appendicitis?
- Peri-umbilical pain which radiates to the RIF
- N&V
- mild temperatures (37.5-38 degrees celsius)
- anorexia
- Rovsing sign
- Psoas sign
Management of appendicitis?
- Appendectomy
- IV prophylactic antibiotics
if perforated then copious abdominal lavage.
Inguinal vs femoral hernia locations?
inguinal - superior and medial to pubic tubercle
femoral - inferior and lateral to pubic tubercle
What is Budd-chiari syndrome?
hepatic vein thrombosis
Causes of Budd-chairi syndrome?
- polycythaemia rubra vera
- thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies
- pregnancy
- combined oral contraceptive pill (20% of cases)
Features of budd-chairi syndrome?
abdominal pain
tender hepatomegaly
ascites
Investigations for budd-chairi syndrome?
USS with doppler flow studies
PSC diagnostic investigation?
MRCP
Barretts oesophagus - what change?
stratified squamous -> simple columnar
most common site of colorectal cancer?
rectal (40%)
sigmoid (30%)
What is the initial and what is the definite investigation for bowel obstruction?
initial - abdominal XRAY
definite - abdominal CT
H.pylori treatment?
clarithromycin/metronidazole, amoxicillin and omeprazole
Diverticulitis hospital antibiotics management?
IV ceftriaxone + metronidazole
Haemochromatosis investigations?
Raised transferrin saturation and ferritin,
low TIBC
SBP - when do you require prophylactic antibiotics + antibiotic of choice?
Patients who have previously suffered an episode of spontaneous bacterial peritonitis and who have a fluid protein <15 g/l require antibiotic prophylaxis, this is most commonly ciprofloxacin or norfloxacin.
SBP treatment?
intravenous cefotaxime
Pancreatitis prognostic criteria - what indicates severe?
Modified glasgow score
>/= 3
What are the different domains in the modified glasgow scale?
P - PaO2 <8kPa
A - Age >55-years-old
N - Neutrophilia: WCC >15x10(9)/L
C - Calcium <2 mmol/L
R - Renal function: Urea >16 mmol/L
E - Enzymes: LDH >600iu/L; AST >200iu/L
A - Albumin <32g/L (serum)
S - Sugar: blood glucose >10 mmol/L
H.pylori post eradication therapy investigation?
Urea breath test
Colostomy vs ileostomy?
colostomy - flat
ileostomy - sprouted
