GI Flashcards
What is psuedomembranous colitis
What abx are associated with it
Blood results
Severe inflammation of the colon usually due to overgrowth of C Diff
Clindamycin
Penicillins
Cephalosporins
Leukocytosis
Complications of pseudomembranous colitis
Paralytic ileus
Perf
Multi organ failure
Sx of pseudomembranous colitis
Diarrhoea - may be mucusy or bloody, can be up to 15 times a day
Fever
Abdo pain
Dehydration
Hx of abx
Medical/organic causes of diarrhoea (non GI system)
Hyperthyroidism
Pancreatic insufficiency
Causes of acute diarrhoea
Abx
Gastroenteritis - adeno,rhino,enterovirus
Definition of chronic diarrhoea
4 weeks
> or = 3 stools per day
Ix for pseudomembranous colitis
FBC - raised WCC
CRP
Stool culture
Abdo xray
Consider sigmoidoscopy
Rx of pseudomembranous colitis - general, non-severe, severe, toxic megacolon
Stop causative abx
Avoid antidiarrhoeals and opiates
Side room
1st line non severe - metronidazole
1st line severe - oral vancomycin if fails to improve add IV metronidazole
Toxic megacolon - urgent colectomy
Define constipation
Less than 3x week
Or
Less often than normal with difficulty straining
Causes of constipation
OPENED IT
Obstruction - mechanical (hernia, adhesions, ca)
Pain - anal fissures
Endocrine - hypothyroid, hypocalcium, hypopitassium
Neuro - MS, CES
Elderly
Diet/dehydration
IBS
Toxins - opioids
Causes of chronic diarrhoea
IBD
Coeliacs
Rx of constipation
Treat underlying cause
Diet and lifestyle advice - fibre (lentils, beans, veg) and hydration
Can give laxatives, PR if impacted
Types of laxatives, examples and MOA
Osmotic - lactulose, draw fluid into gut
Stimulant - senna. Bisacodyl, sodium picosulfate : induce peristalisis
Bulk forming - ispaghula : indigestible so stay in bowel to bulk stool and induce peristalsis
Example of a stool softener
Docusate sodium
Example of a suppository
Glycerol (stimulant laxative)
What is used for an enema
Phosphate enema
Medical rx of IBS
Antispasmodics - buscopan, mebeverine
Loperamide for diarrhoea
Lifestyle - reduce caffeine, stay hydrated
Dx of the dysphagia if:
Liquids and solids
Solids>liquids
Difficulty making swallowing
Odynophagia
Neck bulges or gurgles
Motility disorder
Stricture
Bulbar palsy
Ca, oesophageal ulcer, spasm
Pharyngeal pouch
How long before an OGD do you need to stop PPIs
2 weeks
Pathophys of achalasia
Degeneration if myenteric plexus causes LOS to not relax
Achalasia presentation
Dysphagia - both liquid and solid
Regurge
Weight loss
Arching if neck/standing sitting up straight
Complication of achalasia
Oesophageal Ca
Sign on barium swallow for achalasia
Bird beak sign
Rx of achalasia
Surgical cardiomyotomy
Can also do botox or medical rx with CCBs or nitrates
How does diffuse oesophageal spasm present
Intermittent dysphagia with chest pain
Red flags with dyspepsia
ALARMS
Anaemia/bleeding
Loss of weight
Anorexia
Recent onset and progressive
Maleana or haematemesis
Swallowing difficulty
Rx of dyspepsia if >60 or ALARMS
OGD 2ww
Rx of dyspepsia is no alarming criteria and <60
Conservative and then ix if continues
Stop NSAiDs/CCBs,
Stop smoking
Stop alcohol
Modify diet
Weight loss
Try anatacids.
Do breath test and stool sample for H Pylori
H Pylori triple therapy
7 days of PPI, Amoxicillin and clarithro
Or metronidazole if pen allergy
ADRs of PPIs
Hyponatramia
Osteoporosis
Increased risk of C Diff
Microscopic colitis
Risk factors for PUD
Alcohol
Smoking
H Pylori
NSaids
Steroids
Bisophosphonates
Ix for PUD
H pylori breath testing C12
OGD
Bloods
Gastrin if ZE suspected
What is the Glasgow blatchford score used for
Predict the need to treat pts with upper gi bleeds
Presentation of GORD
Halitosis
Chrinic cough
Burning related to meals, lying down
Burping
Surgery used for severe GORD
Nissen fundoplication
Types of hiatus hernia, which one is worse
Sliding
Rolling - can become strangulated
What is diagnostic ix for hiatus hernia
Ba Swallow
CXR - will show has bubble and fluid level in chest cavity
Ddx for haematemesis VINTAGE
Varices
Inflammation
Neoplasia
Trauma eg MW, boerhaaves
Angiodysplasia
General eg warfarin
Epistaxis
If urea is raised but creatinine is normal what blood test should you check and why
Hb for upper gi bleed
What is the rockall score
Predicts risk of re bleeding in upper GI bleed
What dx does coffee ground vomit suggest
PUD
Immediate rx of upper GI bleed
Resuscitation
Consider terlipressin (variceal)
Urgent endoscopy
What meds must you give in/after urgent OGD for upper GI bleed
What else should you do (ie what info is important for nurses)
Adrenaline
Antibiotics
Offer vit k
Keep NBM for 24hrs
Causes of prehepatic jaundice
Excess biliruben production - haemolytic anaemia
Or ineffecive erythropoeisis eg SCD, G6PD, thalassaemia
Causes of hepatic jaundice
Drugs - rifampicin, isoniazid, ethmbutol
Hepatitis
Cirrhosis
Congenital causes - haemochromatosis, wilsons, a1ATD
Autoimmune
Alcohol
Infectious - cmv, ebv, hep abc
Post hepatic causes
Cholestasis
Pancreatic cancer
Biliary atresia
Signs of liver failure
Jaundice
Oedema and ascitis
Encephalopathy
Signs of portal hypertension in cirrhosis
Pathophys of hepatorenal syndrome
Cirrhosis - release of mediators causing splanchnic artery vasodilation, reduces vascular resistance - RAAS activation - renal artery vasoconstriction
Persistent hypoperfusion - failure
Rx of hepatorenal syndrome
IV albumin
Spanchnic vasoconstrictor - terlipressin
Haemodialysis
Liver transplant
Rx if liver failure
Rx of underlying cause
Good nutrition - NGT
Thiamine supplements
Complications of liver failure
Bleeding
Sepsis
Ascites
Hypoglycaemia
Encephalopathy - seizures, cerebral oedema
Drug for cerebral oedema
Mannitol
Drug for ascites
Spiro
Drugs to avoid in liver failure
Opiates
Hypoglycaemics
Na containing IVI
Caution - warfarin
Hepatotoxic drugs - paracetamol, methotrexate, isoniazid, tetracyclines
Signs of cirrhosis in hands
Hepatic flap
Duputyrons
Spider naevi
Leuconychia
Clubbing
Palmar erythema
Causes of cirrhosis
Alcohol excess
Chronic HepC
NASH/NAFLD
hepB
a1AT
wilsons
haemochromatosis
What ix suggest that cirrhosis is caused by:
- alcohol
- NAFLD
- infection
- genetics
- increased MCV, increased GGT
- hyperlipidaemia, increased glucose
- serology positive
- genetic stuff
What imaging is used for cirrhosis
US liver
Complications of cirrhosis
SBP
Portal htn and varices
Wernickes encephalopathy and korsakoff psychosis
Rx of wilsons drug
Penicillamine
Rx of ascites
Fluid and salt restriction
Spiro
2nd line furosemide, tap, daily weights
Pathophys of ascites
portal hypertension
Splanchnic vasodilation
RAAS activation
Sodium and water retention
PLUS Hypoalbuminaemia
Leads to ascites
Blood results of alcoholism
Increased Mcv anaemia
Folate deficiency
Rx of alcohol withdrawal in hospital
Chlordiazepozide
Thiamine (pabrinex)
Sx of alcoholic hepatitis
Tender hepatomegalt
Anorexia
Diarrhoea
Vomiting
Ascites
Jaundice, varices, encephalopathy if severe
What is NAFLD
Non alcoholic fatty liver disease caused by insulin resistance and metabolic syndrome
NASH is most common form
Examination findings in NAFLD
Truncal obesity
Hepatosplenomegaly
Hx of obesity, diabetes, htn etc
What makes up metabolic syndrome
Obesity
HTN
High fasting glucose/insulin resistance
High triglycerides
Low HDL cholesterol
Rx of NAFLD
Diet and lifestyle changes
Control htn, dm
What is budd chiari syndrome
Hepatic vein obstruction - ischaemia and hepatocyte damage - insidious cirrhosis and liver failure
Causes of budd chiari
Hypercoaguable state
Myeloproliferative disorders eg PV
HCC local tumour
Triad for Budd Chiari presentation
RUQ
Hepatosplenomegaly
Ascites
What is hereditary haemochromotosis
Increased intestinal iron absorption leading to deposition in multiple organs
Called bronze diabetes
Rx of hereditary haemochromotosis
Venesection
Presentation of a1AT deficiency
Neonatal and childhood Hepatitis
Cirrhosis
Emphysema
Clinical features of wilsons disease
Kayser fleischer rings
Liver disease - childhood presentation
Arthritis
Parkinsonism
RTA
Haemolytic anaemia
Rx of wilsons
Penicillamine lifelong
Avoid high cooper foods: liver, chocolate, nuts
What is primary biliary cholangitis
Intrahepatic bile duct destruction by chronic inflammation leading to cirrhosis
Who is primary biliary cholangitis common in
What immunology blood test is raised
Liver failure in a Middle age woman with signs of rheum/autoimmune conditions
IgM
Rx if primary biliary cholangitis
Pruritus: cholestyramine
Diarrhoea: codeine
Osteoporosis: bisphosphonates
ADEK vitamins
Ursodeoxycholic acid
Immune supression - pred, azathioprine
Liver transplant
How do PBC and PSC duffer
PBC effects only the intrahepatic billiary ducts
Complications of primary sclerosing cholestasis
Cirrhosis
Increased risk of cholangiocarcinoma and colorectal cancer
Disease commonly associated with primary sclerosing cholangitis
80% of those with PSC have IBD
Management of PSC
Same as PBC
Plus US gallbladder and Ca19-9
Plus colonoscopy for CRC
Presentation of cholangiocarcinoma
Fever
Malaise
Abdo pain
Ascites
Jaundice
Indications for liver transplant
Advanced cirrhosis
HCC
Cholangiocarcinoma
A1AT deficiency
Is smoking good or bad in IBD
Good for UC
Bad for chrons
Features of Crohns vs UC
Crohns
- transmural (full thickness) inflammation
- no PR blood or mucus
- entire gi tract affected
- skip lesions
- terminal ileum most common place affected (may be B12 deficient)
- perianal disease
UC
- only superficial mucosa effected
- blood and mucus PR
- only colon and rectum affected
- continuous inflammation
- associated with PSC
Extra gi presentations of IBD
Erythema nodosum
Pyoderma gangrenosum
PSC
Episcleritis, scleritis, anterior uveitis
Enteropathic arthritis
Diagnosing IBD ix
Fecal calprotectin
Colonoscopy
Acute UC rx
Mild/mod - aminosalicylate or oral pred
Severe - iv steroids
Maintenance UC rx
Aminosalicylate eg mesalazine first
Azathioprine
Surgical UC rx
Panproctocolectomy - will have perm ilieostomy or j pouch
Acute Crohns rx
Oral pred or IV hydro are first line
Enteral nutrition - special liquid diet
Azathioprine, methotrexate, infliximab if not working
Maintenance and surg rx of crohns
Azathioprine or mercaptopurine.
Methotrexate as 2nd line
Surgery - resect distal ileum, treat strictures and fistulas
Complications of IBD
Toxic megacolon (Uc)
CRC and cholangiocarcinoma
Strictures
Fistula (crohns)
AXR findings in UC
Lead pipe - no haustra
Thumbprinting - mucosal inflammation
Possible toxic megacolon
What do we also test for in pts with newly diagnosed T1DNM or autoimmune thyroid disease
Coeliacs
Microscopy findings in coeliacs
Villous atrophy and crypt hypertrophy
Main antibody associated with coeliacs .
What must you also test alongside this
Anti TTG (tissue transglutaminase)
IgA bc an IgA deficiency will mean the antibody test is negative even in crohns
Extra gi presentations of coeliacs
Dermatitis herpetiformis
Anaemia - bc low iron, b12, folate
Hyposplenism
Osteoporosis
Can lead to Lymphoma (enteropathy associate T cell lymphoma)
Risk factors of pancreatic ca
Smoking
Chronic pancreatitis
Alcohol
DM
HNPCC
MEN
BRCA2
Presentation of pancreatic ca
Male >60
Painless obstructive jaundice
Dark urine, pale stools
Epigastric pain radiating to back relieved sitting forwards
Anorexia and weight loss
Sudden onset dm in the elderly
Rx of pancreatic ca
Whipples procedure
Or palliation
A patient has no abdo pain, jaundice but has palpable gallbladder. Dx?
Courvosiers law says that painless enlarged gallbladder is unlikely to be gallstones
Consider pancreatic ca
Chronic pancreatitis presentation
Epigastric pain radiates to back, relieved by sitting up
Exacerbated by fatty food
Steatorrhoea
Weight loss
DM
Rx of chronic pancreatitis
Analgesia
Creon (pancreatic enzymes)
ADEK
Rx DM
Reduce fat intake
No alcohol
Presentation of B12 deficiency
Glossitis
Peripheral neuropathy
Subacute combined degeneration of the cord
Scurvy (vit c deficiency) presentation
Gingivitis
Bleeding gums
Muscle pain and weakness
Oedema
Corkscrew hairs
What factors are vit k dependent
2,7,9,10
Presentation of acute mesenteric ischaemia
Who is it likely in
Clot in superior mesenteric artery
Acute non specific abdo pain disproportionate to findings.
Elderly pt with AF
Diagnostic scan of choice for AMI
Contrast CT abdo
Triad of chronic mesenteric ischaemia
Colicky abdo pain
Weight loss
Abdominal bruit
MUST score
Find pic
Calculate alcohol units
Volume (ml) x % divided by 1000
Metabolic disturbances in refeeding syndrome
Hypo
- phosphate
- potassium
- magnesium
Who is at high risk of refeeding
Bmi less than 16
Little nutritional intake >10 days
Unintentional wl >15% over 3 months
Rx of severe alcoholic hepatitis (think inflammation)
Prednisolone
Complications of cirrhosis
SBP
Hepatorenal syndrome
PHTN, Varices
Malnutrition
Ascites
Hepatic encephalopathy
Scores used to assess prognosis in cirrhosis
MELD (model for end- stage liver disease)
Child Pugh score - Albumin, biliruben, clotting, dilation (ascites), encephalopathy
How does cirrhosis cause malnutrition
Reduced protein metabolism in the liver
Reduced ability to store glucose as glycogen
How does liver disease cause ascites
PHTN causes capillaries in abdominal cavity to leak
Reduced BP
RAAS activation causes increased sodium resorption
Leading to a transudative ascites
Most common organisms of sbp
Which complication of cirrhosis is it as a result of
E coli
Klebsiella pneumoniae
10-20% of pts with ascites as infection develops within the ascitic fluid
Rx of hepatic encephalopathy
(What is accummulating)
Lactulose - helps to reduce ammonia levels
Abx - to reduce number of intestinal bacteria producing ammonia
Nutritional support
Presentation of an iron overdose and why do some of these present
N+v
Diarrhoea
Black stool
Gi ulceration
Gi haemorrhage
Rectal bleeding
Haemodynamic collapse - free plasma iron is a potent vasodilator
Side effect of desferroxamine
Orange red urine
med of choice for campylobacter
clarithromycin
presentation of gilberts syndrome
episode of jaundice triggered by/associasted with dehydration, poor sleep, stress, physical exertion, illness.
lots normal bar bilirubin,
no other sx of liver disease
what is Small intestine bacterial overgrowth syndrome
ix
rf
rx
too much bacteria causing chronic diarrhoea, bloating, flatulance and abdominal pain
ix - hydrogen breath test
rf - diabetes, congenital gut issues, scleroderma
rx - abx - rifaxamin, metrodizole or co amox
rx for achalasia
cardiomyotomy
side effects of metoclopramide to be aware of
EPS eg acute dystonia, parkinsonism etc
Presentation of mesentaeric ischaemia
Acute onset generalised colicky abdo pain
Clinically shocked
Pain and shock disproportionate to clinical findings
Often in afib which throws off a clot into the mesenteric arteries
drug causes of pancreatitis
mesalazine,
azathioprine
steroids
sodium valproate
how is liver cirrhosis diagnosed - imaging of choice
fibro scan (transient elastography) (basically an ultrasound)
what are the best blood results to acutely measure the synthetic function of the liver
INR
Albumin - least of the 3
PT
drugs associated with cholestasis
COCP
co-amox
sulphonylureas
anabolic steroids
features of acute liver failure
jaundice
ascites
hypoalbuminaemia
coagulopathy
renal failure - hepatorenal syndrome
hepatic encephalopathy
rx of acute alcoholic hepatitis
prednisolone
Rx of ascites
Spironolactone
low salt intake
prophylactic abx to prevent against SBP
Paracentesis (drain) if tense ascites
first line drug used in hepatic encephalopathy and why
lactulose - thought to decrease ammonia
risk factors for hepatocellular carcinoma
biggest is liver cirrhosis! 2’ to alcohol, hep b, hep c, haemochromatosis,
a1AT
DM
tumour marker for HCC
AFP
what can trigger decompensation in liver cirrhosis
constipation
infection, electrolyte imbalances, dehydration, upper GI bleeds or increased alcohol intake.
wernickes triad
ataxia
ophthalmoplegia
confusion
microscopic findings in UC, crowns and coeliacs
All - lymphocytic infiltration
UC - crypt accesses and goblet cell loss
Cr - granulomas, lymphoid hyperplasia
Coe - villous atrophy and crypt hyperplasia
examination finding in liver in RHF
pulsatile smooth enlarged liver
