GI Flashcards
what GI condition is PSC commonly found in
Ulcerative colitis
give 5 managements in PSC
- Lifestyle (e.g. avoid alcohol)
- Sx e.g. cholestyramine for pruritus
- Supplementation of fat soluble vitamins (A,D,E,K)
- ERCP dilation of strictures
- Liver transplantation (in cases complicated by chronic liver disease and/or hepatobiliary malignancies).
Tx for H.pylori infection
triple therapy:
2xAbx + 1 PPI
Metronidazole/amoxicillin, clarithromycin & PPI (omeprazole/lansoprazole etc)
think 2 Abx are needed to tackle the bacteria
What 3 psych conditions are associated with EDs?
personality disorders
OCD
anxiety
give 5 features of anorexia
Amenorrhoea
* Lanugo hair is fine, soft hair across most of the body
* Hypokalaemia
* Hypotension
* Hypothermia
* Changes in mood, anxiety and depression
* Solitude
* Cardiac complications (arrhythmia, cardiac atrophy and sudden cardiac death).
what blood findings are indicative of bulimia
Alkalosis (vomiting `HCL from stomach)
Hypokalaemia
what are the GI findings of bulimia
mouth:
* Erosion of teeth
* Swollen salivary glands (swelling of face & under the jaw)
* Mouth ulcers
* reflux and irritation
non-GI
* Russell’s sign
apart from slef=-help resources & coun6sellin6g, n6ame 2x psych Mx for eatin6g disorders
CBT
SSRI- in CAMHS
what characteristics put people at risk of refeeding syndrome
1 BMI<20
2 little intake >/= 5 days
what are the biochemical findings in refeeding syndrome (MG, K, PO43-)
hypomagnesaemia
hypokalaemia
hypophosphataemia
Mx in refeeding Syndrome ( x5)
- Slowly reintroducing food with restricted calories
- Mg, K, phosphate and glucose monitoring along with other routine bloods
- Fluid balance monitoring
- ECG monitoring (in severe cases)
- Supplementation with electrolytes and vitamins,
what are the features of Crohns disease which differentiate it from UC (X5)
Crows NESTS
No blood/mucus
Entire GI tract (mouth to anus - inc. mouth ulcers)
Skip lesions on endoscopy ( alternate areas of disease w/ no disease)
Terminal ileum most affected & Transmural (full thickness inflammation)
Smoking is a risk factor
strictures & fistulas also present
what are the features of UC which differentiate it from Crohns (x7)
You see (UC) CLOSE UP
Continuous inflammation
Limited to colon&rectum
Only superficial mucosa affected
Smoking protective
Excrete blood & mucous
Use aminosalicylates
Primary sclerosing cholangitis
what 5 non-GI conditions can occur in IBD
- Erythema nodosum (tender, red nodules -inflammation of the subcut fat)
- Pyoderma gangrenosum (rapidly enlarging, painful skin ulcers)
- Enteropathic arthritis
- Primary sclerosing cholangitis (esp in UC)
- Red eye conditions (e.g., episcleritis, scleritis and anterior uveitis)
IBD Mx is split into mx acute exacerbation, and maintaining remission
what is the management in an acute UC exacerbation
Acute
mild-mod
1st line - aminosalicylate (Mesalazine)
2nd line - corticosteroid (prednisolone)
sev
IV steroid (hydrocortisone)
IBD Mx is split into mx acute exacerbation, and maintaining remission
what is the management in maintaining remission in UC
1st line aminosalicylate - Masalazine
Azathioprine
Mercaptopurine
IBD Mx is split into mx acute exacerbation, and maintaining remission
what is the management in an acute exacerbation in Crohns
1st line Steroid (oral pred / IV hydrocortisone
Enteral nutrition
IBD Mx is split into mx acute exacerbation, and maintaining remission
what is the management in maintaining remission in Crohns
1st line either Aathiprine/ Mercaptopurine
2nd Methotrexate
(1st line similar to UC, but remember you see closeUp - Use of aminosalicylate (mesalazine) is only in UC)
In what age groups isUC common
The peak incidence of ulcerative colitis is in people aged 15-25 years and in those aged 55-65 years.
what antibacterial med is associated with causing C.diff
clindamycin (typically ass.w/ diabetic foot)
also 2nd & 3rd gen cephalosporins
and PPIs
features of C.diff infection (x4)
diarrhoea
abdo pain
raised WCC ***characteristic
severe toxic megacolon may develop
Mx in c.diff 1st line
- first epsode
- life threatening
1st episode
Oral vancomycin 10days
life-threatening
oral vancomycin & IV metronidazole
Give 5 exam findings suggestive of excess Alcohol
- Smelling of alcohol
- Slurred speech
- Bloodshot eyes
- facial telangiectasia
- Tremor
which of the liver enzymes are cholestatic
ALP, GGT
which of the liver enzymes are hepatocellular
AST, ALT
(SALT = liver enzymes )
Raised ALT & AST levels indicate hepatocellular damage/injury/inflammation. Which of these hepatocellular enzymes are more specific to the liver>
ALT
think aLt - Lfor liver
when AST> ALT, what kind of damage to the liver is this indicative of?
> 1.5:1 AST:ALT - alcoholic liver disease
AST > ALT = cirrhosis & acute alcoholic hepatitis
AST < ALT = chronic Liver disease
raised ALP levels indicate can be caused by… (x2)
cholestasis
Bone disease
(ALP derived from biliary epithelium & bones)
if both raised but ALT > ALP = hepatocellular damage
if both raised but ALT < ALP = cholestasis
interpreting a rise in the biliary enzymes
ALP: high
GGT: normal
Bone disease ( pagets disease, Vit D deficiency, bony mets)
ALP = biliary and bone
ALP on its own is bone
interpreting a rise in the biliary enzymes
ALP: high
GGT: high
cholestasis, in biliray tree
interpreting a rise in the biliary enzymes
ALP: normal
GGT: high
excess alcohol
rise in bilirubin can be further investigated by requesting conjugated vs unconjugated bilirubin
causes of predominantly unconjugated hyperbilirubinaemia
Causes of predominantly
Pre-hepatic jaundice (e.g. haemolysis
Gilbert syndrome
Isolated bilirubin rise = pre-hepatic jaundice or Gilbert’s disease
Causes of predominantly conjugated hyperbilirubinaemia
Cholestasis
Hepatocellular jaundice*
what protein is used as a marker for liver function
albumin
Low albumin = Decreased synthetic function of the liver indicating severe liver disease.
give 2 questionnaires used to assess alcohol dependence
CAGE
C- CUT DOWN?
A – ANNOYED?
G – GUILTY?
E – EYE OPENER?
AUDIT
Alcohol Use Disorders Identification Test (AUDIT)
give the 4 stages of NAFLD
- Non-alcoholic fatty liver disease
- Non-alcoholic steatohepatitis (NASH)
- Fibrosis
- Cirrhosis
what liver enzyme will be raised in NAFLD & AFLD
ALT - the liver enzyme
in NAFLD, AST:ALT ratio >0.8 suggests advanced fibrosis
AST1.5 x greater that ALT (cirhoSiS and alcoholic hepatitiS) - alcohol-related liver disease
what scan diagnoses the presence of a fatty lilver
US
what is the Gold standard test to diagnose hepatic steatosis
liver biopsy
what are the 4 most common causes of liver cirhosis
- Alcohol-related liver disease
- Non-alcoholic fatty liver disease (NAFLD)
- Hepatitis B
- Hepatitis C
why is splenomegaly a finding in liver cirrhosis
splenomegaly occurs in liver cirrhosis due to portal hypertension
liver cirrhosis causes endocrine dysfunction, particularly raised oestrogens. what are the 2 findings in males
gynaecomasgtia
testicular atrophy
what causes leukonychia
leukonychia - white nails
liver cirrhosis –> reduced albumin production –> hypoalbunaemia –> leukonychia
what is the 1st line Ix for asessing fibrosis in NAFLD
ELF - enhanced liver fibrosis
- 10.51 or above – advanced fibrosis
- Under 10.51 – unlikely advanced fibrosis (NICE recommend rechecking every 3 years in NAFLD)
Give 5 investigations (non-bloods ) for diagnosing liver disease
US (fatty liver, screening tool for hepatocellular carcinoma)
Transient elastography ( fibroscan) - assess stiffness of liver using high frequency waves
CT, MRI
Liver biopsy
what are the 2 classifications for the severity of liver cirrhosis
Child-pugh ( graded A,B,C - c being the worst)
MELD - model for end stage liver disease
predicts mortality ( the higher score, the higher percentage mortality) - use MELD every 6 months
what are the 5 factors of the Child Pugh- score
Albumin
bilirubin
clotting (INR)
dilation
Encephalopathy
what is the management in liver cirrhosis for
- NAFLD
- hepatitis C
- autoimmune hepatitis
NAFLD - lifestyle
Hep C - Antiviral drugs
Autoimmune hpatitis - immunosuppressants
what 4 features suggest the need for a liver transplant
liver transplant - in decompensated liver disease
“AHOY” mnemonic:
* A – Ascites
* H – Hepatic encephalopathy
* O – Oesophageal varices bleeding
* Y – Yellow (jaundice)
give the 1st and 2nd line Mx in preventing bleeding of oesophageal varices
1st Propanolol (non-selective B-blockers)
2nd variceal band ligation
what type of ascites is found in cirrhosis
transudative ( w protein content) ascites
what are the 2 most common causes of spontaneous bacterial peritonitis
E.Coli
klebsiella pneumoniae
10-20% of ascites pts develop this infection of ascitic fluid
what is the Mx in hepatorenal syndrome
hepatorenal syndrome: portal HTN – impaired –> impaired bloodflow to kidneys –> kidney function affected
Liver Transplant (otherwise poor prognosis)
Hepatic encephalopathy Mx (x3 )
Lactulose (2-3 soft stools/day) - ammonia & other toxin buildup –> neurotoxicity
Abx (e.g. rifaximin ) –> reduce intestinal bacteria prodcuing ammonia
Nutritional support ( NG feeding)
most common histological form of pancreatic cancer
adenocarcinoma
*most common location: head of pancreas)
complication of enlargement of head of pancreas in pancreatic cancer
bile duct compression –> block flow of bile from liver –> obstructive jaundice
4 common features of pancreatic cancer
obstructive jaundice (yellow skin & sclera, pale stools, dark urine, generalised itching)
non-specific upper abdo/back pain
palpable epigastric mass
change in bowel habit
nausea/vomiting
new onset/worsening of T2DM
criteria for referrel in suspecgted pancreas
> 40 with jaundice: (2ww)
> 60 weight loss +GI Sx (as pancreas sx unspecific) –> CT abdo
what 2 signs are associated with pancreatic cancer
courvoisier’s law - palpable gall bladder + jaundice = cholangiocarcinoma or pacreatic cancer ( less likely to be gallstones )
Trousseau’s sign - migratory thrombophlebitis is signs of malignancy (inflammation and thrombus in vessels, which recurrs in different locations over time) = malignancy (esp. pancreatic adenocarcinoma)
what is sed in the diagnosis for pancreatic cancer
CT thorax, abdo & pelvis + biopsy
aside from pancreatic cancer, CA 19-9 is also raised in …
cholangiocarcinoma
other non-malignant conditions
what scan is used to assess biliary obstruction
MRCP ( magnetic resonance cholangio-pancreatography)
what mxs are available in pancreatic cancer
surgical removal:
* Total pancreatectomy
* Distal pancreatectomy
* Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure)
* Radical pancreaticoduodenectomy (Whipple procedure)
curative surgery not an options for most, so palliative used
stents (biliary obstruction), surgery for Sx ( bypassing biliary obstruction)
palliative chemo/radio
what is the whipple proceducre
pancreaticodupdenectomy
used in head of pancreas where tumour has not spread
removes: head of pancreas, pylorus, duodenum, gallblader, bile duct, lymph nodes
what structure is left in place in the modified whipple procedure
pylorus
modified whipple procedure = pylorus-preserving pancreaticoduodenectomy (PPPD).
whipple procedure otherwise removes removes: head of pancreas, pylorus, duodenum, gallblader, bile duct, lymph nodes
