GI Flashcards
Ascites: a high SAAG gradient (> 11g/L) indicates _______.
portal HTN
Serum ascites albumin ratio: shows proportion of protein in serum vs. in ascites. Bc serum protein is still high, we know that ascitic fluid is transudate- fluid thats leaked from altered hydrostatic forces across an INTACT membrane. most common cause is portal HTN secondary to liver cirrhosis.
jaundice and a painful, distended abdomen that exhibits tympanic resonance in the periumbilical area and dullness in the flanks - what does pt have?
ascites
jaundiced woman with ascities has ‘ tortuous, palpable swelling is present in the paraumbilical region’ - what is it?
caput medusae—a swollen network of paraumbilical veins—indicates abdominal wall vein distension
Ascitic tap: which conditions have SAAG > 11 and which have SAAG < 11?
SAAG > 11
- cirrhosis/alcoholic liver disease
- liver failure
- liver mets
(all cause portal HTN)
- HF
- pericarditis
SAAG < 11
- hypoalbuminaemia: nephrotic syndrome, malnutriion
- malignancy
- infetion
- pancreatitis
- bowel obstruction
- post-operative
basically inflammation causes increased cappillary permeability and causes proteins to leak
Vitamin deficiencies:
- B1
- B2
- C
- D
- B1 (thiamine): linked to Wernicke’s
- B2 (riboflavin): anguar cheilitis (cracked skin around mouth)
- C (ascorbic acid): scurvy (bleeding gums, loosened teeth)
- D (colecalciferol): teeth strength
firstline to maintain remission in Crohn’s
azathiopurine/mercatopurine
early signs of _______ are fatigue, erectil dysfunction and arthralgia. Which marker is raised?
What is the pattern of iheritance
haemochromatosis due to iron deposition in different tissues.
AST
autosomal recessive
wilsons and haemochromatosis - what is the diff?
copper in ilsons is deposited in basal ganglia, causing chorea, speech problems, parkinsons etc.
iron in haemochromatosis is deposited in liver, joints, pituitary gland. bronze skin pigmentation, DM.
which features of haemochromatosis are reversible with Tx?
cardiomyopathy
skin pigmenation
what parameteres to monitor when checking effectiveness of haemochromatosis tx?
transferrng saturation + serum ferritin
1st line therapy for C diff. infection
2nd line
oral vancomycin
oral fidaxomicin
asymptomatic gallstones - tx?
observation, esp if located in gallblader. If i commob bile duct consider surgical Mx.
__________ can be a useful diagnostic marker for HCC
Raised AFP
Pt on PPI waiting to get endoscpy - advice?
stop PPI 2 weeks before endoscopy
Stopping medications before OGD (1-4):
1 day =
2 weeks =
3 days =
4 weeks =
1 day = gaviscon
2 weeks = PPIs
3 days = ranitidine
4 weeks = antibiotics
B12 deficiency - what do you investigate? what is an early sign on blood flim?
intrinsic factor antibodies
hyperegmented polymorphs
Patients suffering from C. difficile need isolation for at least ________
48 hours
Wilson’s disease - _______ total serum copper
reduced
_______artery is at risk with duodenal ulcers on the posterior wall
Gastroduodenal
what is the M rule for PBC?
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
how does PBC typically present? What condition is it frequently associated with?
typically presents in middle-aged women with jaundice, itch and fatigue. Bloods show cholestatic LFTs with raised IgM and anti-mitochondrial antibodies
Sjogrens
what will bloods show in autoimmune hepatitis?
IgG and ANA (anti-nuclear) or SMA (anti-smooth muscle) antibodies. ALT is also typically raised
how does PSC present? what ab are positive?
PSC typically presents in 20-40-year-old males with jaundice, itch and fatigue. It is strongly associated with ulcerative colitis. Bloods show P-ANCA antibodies.
tx for PBC?
- urodeoxycholic acid (helps move bile through your liver, preventing damage)
- pruritus: cholestyramine
what is diagnostic for portal HTN?
A raised SAAG (>11g/L)
sudden onset abdominal pain, ascites, and tender hepatomegaly –> ?
Budd-Chiari syndrome
what is Budd-Chiari syndrome?
RFs?
Ix
hepatic vein thrombosis, is usually seen in the context of underlying haematological disease or another procoagulant condition.
RFs: polycythaemia rubra vera, thrombophilia, pregnancy, COCP
Ix: doppler US
Patients with haemochromatosis are at an increased risk of __________ (check with US)
hepatocellular carcinoma
A 41-year-old man with cerebral palsy is admitted with abdominal pain and diarrhoea. His carers report him passing 5-6 watery stools per day for the past four days. On examination he has a mass in the left side of the abdomen.
Dx?
Constipation causing overflow
A 37-year-old woman presents with a three week history of diarrhoea and crampy abdominal pains. On examination she is noted to have a number of perianal skin tags.
Dx?
Crohn’s
Acute causes of diarrhoea:
1.May be accompanied by abdominal pain or nausea/vomiting:
2.Classically causes left lower quadrant pain, diarrhoea and fever:
3.More common with broad spectrum antibiotics, Clostridioides difficile is also seen with antibiotic use:
- A history of alternating diarrhoea and constipation may be given
- gastroenteritis
- diverticulitis
- abx therapy
- constipation causing overdlow
Chronic causes of diarrhoea:
- A history of alternating diarrhoea and constipation may be given:
- Crampy abdominal pain and weight loss are also common. Faecal urgency and tenesmus may be seen:
- Crampy abdominal pains and non-bloody diarrhoea. Other features include malabsorption, mouth ulcers, perianal disease and intestinal obstruction
- Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss and anorexia:
- In children may present with failure to thrive, diarrhoea and abdominal distension. In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may coexist
- IBS
- UC
- Crohn’s
- Colorectal cancer
- Coeliac disease
A recurrent episode of C. difficile within 12 weeks of symptom resolution should be treated with oral __________
fidaxomicin
A 28-year-old pregnant lady presents to the Emergency Department in a confused and agitated state. She is itching her arms vigorously and on examination, the patient complains of right side abdominal pain during palpation. As she tries to speak, the doctor notes her breath has a sweet, fecal smell. Which of the following is the most likely diagnosis?
Fetor hepaticus, sweet and fecal breath, is a sign of liver failure
Phaeochromocytoma removal: what drug do you give before betablocker?
phenoxybenzamine (alpha-blocker)
Coeliac disease increases the risk of developing this malignancy:
T-cell lymphoma
longterm omeprazole use increases your risk of
- osteoporosis
- C diff. infrction
what finding on barium swallow is consistent with oesophageal cancer?
irregular narrowing of mid-thoracic oesophagus
__________is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease
Thrombocytopenia (platelet count <150,000 mm^3) is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease
Coeliac’s disease: blood film abnormality?
Coeliac’s is associated with hyposplenism.
Hyposplenism is associated with Howell-Jolly body, target cells and acanthocytes.
painless jaundice + sudden weight loss =
NAFLD (acute on chronic)
Weight loss triggers catabolism of peripheral adipose reserves and importation of toxic lipids to the liver which trigger steatosis, inflammation and hepatocyte cell death. This manifests with deranged serum liver enzymes and raised bilirubin
A _____________ may be used to stop an uncontrolled variceal haemorrhage
Sengstaken-Blakemore tube
diarrhoea, palpitations, flushing + weight loss + hepatomegaly =
carcinoid tumour
The secretion of serotonin by this cancer causes diarrhoea, flushing and palpitations (which can be accompanied by tachycardia).
Carcinoid Syndrome:
FIVE HT
Flushing
Intestinal (Diarrhoea)
Valve Fibrosis (Tricuspid Regurg & Pulmonary Stenosis)
whEEze: Bronchoconstriction
Hepatic Involvement (1st pass metabolism bypassed)
Tryptophan Deficiency (Pellagra)
1st line to induce remission in Crohns disease
glucocorticoids only
Obesity with abnormal LFTs - ?
NAFLD
________ are used in the management of severe alcoholic hepatitis
Corticosteroids
A severe flare of ulcerative colitis should be treated in hospital with ________
IV corticosteroids
IV ciclosporin if steroids C/I
stop taking PPIs_____ weeks before endoscopy
2
1st line Mx of ascities
spironolactone
fluid restriction is sometimes recommended if the sodium is < 125 mmol/L
drainage if tense ascites
Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less, until the ascites has resolved
In patients with severe colitis, _______should be avoided due to the risk of perforation - a ____________is preferred
colonoscopy
flexible sigmoidoscopy
__________________________________ is used to screen patients for malnutrition
The Malnutrition Universal Screening Tool (MUST)
Screening Tools for:
1. Acute appendicitis
2. Liver Cirrhosis
3. Upper GI Bleed
4. Acute pancreatitis
- Alvardo
- Child-Pugh
- Glasgow-Blatchford
- Glasgow-Imrie criteria
Early signs of ________________are fatigue, erectile dysfunction and arthralgia
haemochromatosis
Iron MAN:
Metacarphpphalangeal
Arthralgia
No energy
erectile dysfunction
Mesalazine > sulfasalazine in terms of
pancreatitis risk
_____________ is the only test recommended for H. pylori post-eradication therapy
Urea breath test
This test should be conducted at least four weeks after completing antibiotic treatment or two weeks following the discontinuation of antisecretory medications such as omeprazole.
most common cause of inherited colorectal cancer
HNPCC (Lynch syndrome)
Red flag symptoms for gastric cancer includes
new-onset dyspepsia in a patient aged >55 years
unexplained persistent vomiting
unexplained weight-loss
progressively worsening dysphagia/
odynophagia
epigastric pain
signet ring vells on OGD
gastric cancer
Higher numbers of signet ring cells are associated with a worse prognosis
_________________is key in determining the severity of C. difficile infection
The white cell count
Bleeding gums and receding, think ________
scurvy
What must be administered before endoscopy in pt with variceal haemorrhage?
Terlipressin + IV Abx
A combination of liver and neurological disease points towards
Wilson’s disease
___________________________ are the characteristic electrolyte disturbances seen in patients with refeeding syndrome.
______________ is the hallmark of refeeding syndrome.
Hypophosphataemia, hypokalaemia and hypomagnesaemia
hypophosphataemia: musckle weakness, cardiac and respiratory failure
oeliac disease increases the risk of developing what malignancy?
enteropathy-associated T cell lymphoma
A 32-year-old lady presents with dysphagia. She has a 10 year history of anaemia secondary to menorrhagia and has been strongly resistant to treatment.
Plummer Vinson syndrome (oesophageal web) may occur in association with iron deficiency anaemia (although rare).
In a mild-moderate flare of ulcerative colitis extending past the left-sided colon, ________________ should be added
oral aminosalicylates should be added to rectal aminosalicylates, as enemas only reach so far
UC with severe relapse or >=2 exacerbations in the past year
oral azathioprine or oral mercaptopurine
we look for _________ in all suspected irritable bowel syndrome (IBS) patients to rule it out
coeliac antibodies
____________is indicated in patients with ongoing acute bleeding despite repeated endoscopic therapy
Surgery
Courvoisier’s law states that a palpable mass in the RUQ is more likely to be
a malignant obstruction of the common bile duct rather than obstruction due to stones
A 56-year-old man is admitted with a profuse upper gastro intestinal haemorrhage. He is relatively malnourished and has evidence of gynaecomastia.
Patients presenting with gastrointestinal bleeding and evidence of established liver disease may have portal hypertension and develop variceal haemorrhage. The patient may have evidence of jaundice, gynaecomastia, spider naevia, caput medusae and ascites. The bleeding is usually profuse and painless.
Which condition is associated with gallstone development
Crohn’s
Crohn’s disease can result in terminal ileitis, this is the section of the bowel where bile salts are reabsorbed. When this area is inflamed and the bile salts are not absorbed and people are prone to development of gallstones.
Other risk factors for the development of gallstones include;
Increasing age
Family history.
Sudden weight loss - eg, after obesity surgery.
Loss of bile salts - eg, ileal resection, terminal ileitis.
Diabetes - as part of the metabolic syndrome.
Oral contraception - particularly in young women
what is Maddrey’s discriminant function?
Calculation used to determine whether gluccocorticoid therapy should be commenced in patient with alcoholic hepatitis.
Used bilirubin + prothrombin time
Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels are characteristic of
autoimmune hepatitis
________________ is the mainstay of treatment in haemochromatosis
Regular venesection
A 42-year-old man presents to the GP with a 2 year history of watery diarrhoea which is green in colour, associated with abdominal bloating and cramping. He reports no blood in his stool, and denies fevers or weight loss. Other than a previous cholecystectomy he is fit and well, and takes no regular medications. His doctor suspects the diarrhoea is a complication following his cholecystectomy.
What is next most appropriate step in his management?
Bile-acid malabsorption may be treated with cholestyramine
NICE advise the use of______________ to help differentiate between IBS and IBD in primary care
faecal calprotectin
If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given
either oral azathioprine or oral mercaptopurine to maintain remission
mescenteric ischaemia vs ischaemic colitis
A 76-year-old woman presents with abdominal pain, distension and vomiting. She recently had an episode of acute cholecystitis and is awaiting a cholecystectomy. She feels her symptoms have returned over the past few days. On examination her abdomen is distended.
This patient has developed small bowel obstruction secondary to an impacted gallstone.
__________is the treatment of choice for small bowel bacterial overgrowth syndrome
Rifaximin
raised amylase + low calcium =
acute pancreatitis
acute pancreatitis Ix
US
_____________ gastroenteritis is characterised by a short incubation period and severe vomiting
Staphylococcus aureus
________is an indicator of pancreatitis severity
hypocalcaemia
Ix for achalasia
- oesophageal manometry
- barium swallow - birds beak apperance
- chest xray - wide mediastinum
tx for achalasia
- pneumatic balloon dilation
how does mesenteric ischemia present
- Hx of Afib or CVD
- Diarrhoea, rectal bleeding
- Metabolic acidosis (dying tissue)
Causes and features of acute LF
causes: paracetamol OD, alcohol, viral hep (A and B), acute fatty liver of pregnancy
features: jaundice, coagulopathy (raised PT), hypoalbuminaemia, hepatic encephalopathy, renal failure
Tx for alcoholic ketoacidosis?
infusion of saline & thiamine
Tx of acute alcoholic hepatitis? Scoring system?
glucocorticoids - Maddrey’s discriminant function
SEs of sulfasalazine
rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis
SE of mesalazine
GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis
how to diagnose C.diff infection? What is characteristic of it?
C.diff toxin in stool (antigen positivity only shows exposure to bacteria, not infection)
WCC raised
genetic associations of colorectal cancer
HNPCC (Lynch syndrome), familial adenomatous polyposis (FAP)
Crohn’s: 1st line to induce remission, 1st line to maintain remission
- gluccocorticoids
- azathioprine/mercaptopurine
Who needs URGENT (2 week wait) referral for suspected GI cancer
- all pts with dysphagia
- all pts with upper abdominal mass (consistent with cancer)
- all pts aged >55 years who have weight loss AND
- upper abdo pain
- reflux
- or dyspepsia
Tx for cholangitis?
ERCP
lymphatic spread in gastric cancer
left supraclavicular lymph node (Virchow’s node)
periumbilical nodule (Sister Mary Joseph’s node)
what cells are seen in OGD for gastric cancer
signet cells
gold standard Ix for GORD
24-hr oesophageal pH monitoring
___________ is the most likely area to be affected by ischaemic colitis
The splenic flexure
difference between mesenteric ischaemia and IC
Tx for hepatic encephalopathy
- lactulose
- rifaximin
a palpable mass in RQ and perimbilical lymphadenopathy
cholangiocarcinoma: A palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen
what is raised in hepatocellualar cancer
AFP
liver cirrhosis - what scans?
- fibroscan to Dx
- endoscopy to check for varcies
- liver US every 6m with AFP for cancer
what is commonly associated with pancreatic cancer
migratory thrombophlebitis (Trousseau sign) is more common than with other cancers
Ix finding for pancreatic cancer
double duct sign on CT
pernicious anaemia increases your risk of
gastric cancer
‘is an appropriate first line test for diagnosis of small bowel overgrowth syndrome’ and Tx
Hydrogen breath testing
rifaximin
A 72-year-old man is admitted with an episode of brisk haematemesis. Following resuscitation an upper GI endoscopy is performed and a prominent blood vessel is identified in the mucosa approximately 6 cm from the O-G junction on the lesser curve of the stomach.
Dieulafoy lesion
These small arterial lesions are a rare cause of bleeding and are characterised by a single large tortuous arteriole in the sub mucosa. Extra gastric lesions may occur.
Acute pancreatitis may cause what e- abnormality
hypocalcemia
other signs: raised haematocrit, neutrophilia
Macrolides can cause ___________ on ECG
torsades de pointes
a-1 antitrypsin defiency
- which genetic defect?
- pattern of inheritance?
- test for liver cirrhosis?
- test for lung disease?
- which enzyme is damaging the tissues?
- which genetic defect? alpha-1 antitrypsin gene on chromosome 4
- pattern of inheritance? AR
- test for liver cirrhosis? liver biospy shows cirrhosis and acid-schiff positive globules
- test for lung disease? high res CT thorax
- which enzyme is damaging the tissues? neutrophil elastase
Blockage of the ________ (billiary tree) does NOT cause jaundice
cystic duct or gallbladder
In patients with severe colitis, __________should be avoided due to the risk of perforation - a _______________ is preferred
colonoscopy
flexible sigmoidoscopy
___________ should be offered to anyone with moderately severe or severe acute pancreatitis
Enteral nutrition
Surgical treatment of achalasia -
Heller cardiomyotomy
how are severe UC exacerbations characterised
evere exacerbations are categorised by > 6 bloody stools per day with features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers).
Ongoing diarrhoea in Crohn’s patient post-resection with normal CRP →
cholestyramine
________ are part of the first-line recommended treatment for severe autoimmune hepatitis
Steroids
liver transplant criteria
Liver transplantation criteria in paracetamol overdose: pH < 7.3 more than 24 hours after ingestion
Or all of the following
- Prothrombin time > 100 seconds
- Creatinine > 300 µmol/L
- Grade III or IV encephalopathy
HNPCC is associated with
colorectal cancer
pancreatic cancer
endometrial cancer
double duct sign on Ct abdomen =
pancreatic cancer
__________ is the definitive diagnostic investigation for small bowel obstruction
CT abdo
pt presents 2 days after acute pancreatitis Sx start - what do you test?
lipase
Campylobacter infection is often self-limiting but if severe then treatment with
clarithromycin may be indicated
This patient is presenting with typical features of hepatitis: flu-like symptoms, right upper quadrant pain with tender hepatomegaly and hepatocellular liver function tests which show:
Raised bilirubin
Raised ALT/ AST
Normal or slightly raised ALP
Hep A
Men of any age with a Hb below 110g/L
should be referred for upper and lower GI endoscopy as a 2ww
Whilst Barrett’s oesophagus increases the risk of______________, achalasia increases the risk of ________________.
oesophageal adenocarcinoma
squamous cell carcinoma of the oesophagus
In an emergency setting, if a colonic tumour is associated with perforation the risk of an anastomosis is greater →
end colostomy
__________________causing ongoing jaundice and pain after cholecystectomy
Gallstones may be present in the CBD
Liver failure = triad of
encephalopathy, jaundice and coagulopathy
Total parenteral nutrition should be administered via
a central vein as it is strongly phlebitic
___________ can be used to assess the presence of fluid in the abdomen and thorax in trauma
FAST scans
_______ is the intervention of choice in patients with malignant distal obstructive jaundice due to unresectable pancreatic carcinoma
Biliary stenting
When testing for coeliac disease, the correct investigations are .
a paired tissue transglutaminase (TTG) and IgA
Patients with diverticulitis flares can be managed with oral antibiotics at home.
If they do not improve within 72 hours, admission to hospital for IV ceftriaxone + metronidazole is indicated
Fe/transferrin in haemochromatosis?
raised ferritin, raised transferrin
low TIBC
Large-volume paracentesis for the treatment of ascites requires
albumin ‘cover’. Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality
spontaenous bacterial peritonitis
1. acute Tx?
2. Longterm Tx?
acute: IV cefotaxime
long-term: ciprofloxacin
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.
Nasogastric tubes are ________ if pH <5.5 on aspirate
safe to use
if more >5.5, do CXR to confirm position of tube
PANCREAS mnemonic for prognostic factors in acute pancreatitis
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
Travel Hx + no organomegaly + jaundice–>
Hep A
A 29-year-old man who is known to have ulcerative colitis is admitted to hospital with a flare of his disease. For the past three days he has been passing up to five bloody stools per day. Over the past 24 hours he has also developed abdominal pain and a low grade pyrexia.
What is the most important next investigation to perform?
Abdo XRA (toxic megacolon)
Which anal fissures are a result of constipation and which suggest IBD?
constipation: anterior, posterior to midle
IBD: lateral
1st line Ix for Budd Chiari?
US with doppler flow
Colon cancer features but colonoscopy too difficult - Ix?
Computed tomography (CT) colonography (“virtual colonoscopy”)
Common cause of galbladder cancer?
UC
smoking + oesophageal cancer - what type?
squamous
