GI 2 Flashcards
1
Q
How do gallstones cause acute pancreatitis?
A
As gallstones become lodged in Sphincter of Oddi which blocks the release of pancreatic juices.
2
Q
Causes of acute pancreatitis (IGETSMASHED)?
A
I - Idiopathic
G - Gallstones
E - Ethanol
T - Trauma e.g. knife
S - Steroids
M - Mumps
A - Autoimmune diseases
S - Scorpion sting
H - Hypertriglyceridaemia & hypercalcaemia
E - post-ERCP
D - Drugs e.g. sulfa drugs, protease inhibitors, bendroflumethiazide
3
Q
How can calcium levels cause pancreatitis?
A
Hypercalcaemia can cause acute pancreatitis
4
Q
One complication of pancreatitis is a pseudocyst. What is this?
A
Forms when fibrous tissue surrounds the liquefactive necrotic tissue of pancreas.
Fibrous tissue develops a cavity which fills up with pancreatic juice.
Features:
- abdo pain
- loss of appetite
- palpable tender mass that follows a bout of pancreatitis
Can rupture –> haemorrhage,
Can get infected –> abscess
5
Q
What is the best investigation for a pancreatic pseudocyst?
A
Abdo CT scan
6
Q
What are some complications of acute pancreatitis?
A
1) Pancreatic pseudocyst
2) Hypovolaemic shock (haemorrhage from damaged vessels)
3) DIC
4) ARDS
7
Q
What is the leading cause of death among people with acute pancreatitis?
A
ARDS
8
Q
How is calcium affected in acute pancreatitis?
A
HYPOcalcaemia (despite hypercalcaemia causing acute pancreatitis)
9
Q
What amylase level indicates acute pancreatitis?
A
> 3x upper limit of normal
10
Q
Hb as prognostic marker in acute pancreatitis?
A
Low Hb carries worse prognosis
11
Q
what are 2 genetic causes of chronic pancreatitis?
A
1) CF
2) Haemochromatosis
12
Q
What is Charcot’s triad?
What does it indicate?
A
1) Fever
2) RUQ pain
3) Jaundice
Indicates ascending cholangitis
13
Q
What is a quick and accurate test for detecting common bile duct dilatation in ascending cholangitis?
A
US abdo/pelvis
14
Q
Which option can provide both diagnosis and therapy via biliary decompression in ascending cholangitis?
A
ERCP
15
Q
How can chronic pancreatitis increase risk of osteoporosis?
A
Due to impaired absorption of calcium & vitamin D as well as chronic inflammation.
16
Q
What does the ‘double duct’ sign on MRCP indicate?
A
Pancreatic cancer –> dilatation of both the common bile duct and pancreatic duct.
17
Q
What is a key indicator of pancreatitis severity?
A
Hypocalcaemia
18
Q
What is Reynolds Pentad?
What condition does it indicate?
A
Indicates ascending cholangitis:
1) fever
2) RUQ pain
3) jaundice
4) shock
5) altered mental status
19
Q
What is the preferred diagnostic test for chronic pancreatitis?
A
CT pancreas - looking for pancreatic calcification
20
Q
What is Richter’s hernia?
A
A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect.
Richter’s hernia can present with strangulation without symptoms of obstruction.
21
Q
How does hepatitis A present?
A
- flu like symptoms
- RUQ pain
- tender hepatomegaly
- deranged LFTs
22
Q
What is a key sign of a perforated bowel on AXR?
A
Normally on AXR should only be able to see the luminal surface of the bowel (visible as outlined by gas) but NOT the serosal side.
In a perforated bowel, the serosal surface is visible due to presence of gas.
23
Q
What infection can cause dysentery, liver abscesses, colonic abscesses, or inflammatory masses in the colon?
A
Entamoeba histolytica (amoebiasis)
24
Q
What malignancy is most associated with acanthosis nigricans?
A
GI adenocarcinoma
25
What is the most important aspect of acute pancreatitis management?
Fluid resuscitation (due to 3rd space loss)
26
What is Budd Chiari syndrome?
Obstruction to hepatic venous outflow.
AKA hepatic vein thrombosis.
27
What triad of features is seen in Budd Chiari syndrome?
1) abdo pain: sudden onset, severe
2) ascites: abdo distension
3) tender hepatomegaly
28
What is Budd Chiari syndrome often associated with?
Haematological disease or another procoagulant condition:
1) antiphospholipid syndrome
2) polycythaemia rubra vera
3) thrombophilia e.g. activated protein C resistance
4) pregnancy
29
What is the AST/ALT ratio in alcoholic hepatitic?
2:1
30
What is the key risk factor for cholangiocarcinoma?
Primary sclerosing cholangitis
31
The development of jaundice in association with a smooth RUQ mass is typical of what?
Distal biliary obstruction 2ary to pancreatic malignancy
32
What is the gold standard investigation & intervention for acute cholangitis?
ERCP
33
What 4 drugs are a risk factor for peptic ulcer disease?
1) SSRIs
2) Corticosteroids
3) NSAIDs
4) Bisphosphonates
34
What is involved in the management of a perforated peptic ulcer?
1) ABCDE
2) IV fluids
3) NG tube insertion
4) NBM
5) IV PPIs
6) IV Abx
7) Endoscopy
35
Role of NG tube insertion in a perforated peptic ulcer?
To reduce the amount of gastric fluids in the GI tract, and therefore reduce the amount to escape into the peritoneum.
36
What is there excess of in Zollinger Ellison syndrome?
Gastrin --> increased stomach acid production.
37
Why are IV fluids needed in perforated peptic ulcer?
As many patients with be fluid depleted due to the ulcer bleeding and re-distribution of fluid to the third space.
38
Who should H. pylori test be offered to?
Anyone with dyspepsia
39
What vaccination is recommended in coeliac?
Pneumococcal vaccine (with booster every 5 years)
40
Is a CXR or AXR more specific for identifying pneumoperitoneum (perforated bowel)?
CXR
41
What is spontaneous bacterial peritonitis (SBP)?
A form of peritonitis usually seen in patients with ascites 2ary to liver cirrhosis.
42
Features of SBP? (3)
1) ascites
2) abdo pain
3) fever
43
How is a diagnosis of SBP made?
Paracentesis --> neutrophil >250
44
What is the most common organism found on ascitic fluid culture in SBP?
E. coli
45
Mx of SBP?
IV cefotaxime
46
When should prophylactic oral ciprofloxacin or norfloxacin be offered for SBP?
For people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved.
47
What location of duodenal ulcers is most likely to cause major upper GI haemorrhage?
What artery is involved?
Posteriorly sited duodenal ulcer
Gastroduodenal artery
48
Mx of dysplasia on biopsy in Barrett's oesophagus?
Endoscopic intervention (mucosal intervention)
49
What do carcinoid tumours secrete?
1) Serotonin
2) Can also secrete ACTH & GnRH --> can cause Cushing's
50
What SAAG gradient is raised?
>11 g/L
51
What does a high SAAG gradient (> 11g/L) indicate?
Portal hypertension e.g. in cirrhosis
52
What investigation will confirm the most likely diagnosis of C. diff?
Stool C. diff toxin
(Note - C. difficile antigen positivity only shows exposure to the bacteria, rather than current infection)
53
Lab results in Wilson's disease?
1) ALT raised
2) Urinary copper raised
3) Serum caeruloplasmin reduced
54
What is associated with pulsatile hepatomegaly?
RHF
55
What score estimates the risk of an upper GI bleed?
Glasgow-Blatchford score
56
What Glasgow-Blatchford score indicates a high risk for an upper GI bleed?
>0
Consider early discharge in patients with a score of 0.
57
What drug is used for the PROPHYLAXIS of variceal haemorrhage?
Propanolol
58
Is a non-haemolytic febrile reaction more common with RBC or platelet transfusion?
Platelets
59
What can blood product transfusion complications be broadly classified into?
1) Acute haemolytic
2) Non-haemolytic
3) Minor allergic
4) Anaphylaxis
5) TACO
6) TRALI
60
How many units of blood should be crossmatched in an upper GI bleed?
2 units
61
Who is anaphylactic reaction to transfusion thought sometimes seen in?
Those with IgA deficiency and IgA antibodies
62
Management of a non-haemolytic febrile reaction?
1) Stop or slow transfusion
2) Paracetamol
3) Monitor
63
Management of an acute haemolytic reaction to transfusion?
1) Stop transfusion
2) Resus with IV saline
3) Confirm diagnosis:
- check patient's name/name on blood product
- send blood for direct Coombs test, repeat typing and XM
64
What is a transfusion-associated circulatory overload (TACO) caused by?
(2)
1) Pre-existing heart failure
2) Excessive rate of transfusion
65
Features of transfusion-associated circulatory overload (TACO)?
(2)
1) HTN
2) Pulmonary oedema
66
What artery supplies the foregut?
Coeliac artery
67
What are 2 main complications of an acute haemolytic transfusion reaction?
1) DIC
2) Renal failure
68
Features of an acute haemolytic reaction to transfusion?
Symptoms begin minutes after transfusion starts:
1) hypotension
2) agitation
3) fever
4) abdo & chest pain
69
What is the hindgut supplied by?
Inferior mesenteric artery
70
How does the management of non-variceal vs variceal bleeding differ?
Variceal --> terlipressin & prophylactic Abx BEFORE endoscopy
Non-variceal --> PPIs AFTER proven on endoscopy
71
What artery is the midgut supplied by?
Superior mesenteric artery
72
What classic triad of features is seen in chronic mesenteric ischaemia?
1) Central colicky abdo pain
2) Weight loss (due to avoiding food)
3) Abdominal bruit
73
What is an infective transfusion reaction often associated with?
vCJD
74
Where is the splenic flexure located?
Between transverse colon & descending colon (i.e. left quadrant)
75
Where in the abdo can Meckel's diverticulum cause pain?
RLQ
76
What is the 1st line for revascularisation in chronic mesenteric ischaemia?
Endovascular procedures i.e. percutaneous mesenteric artery stenting
77
What is the mx of patients with oesophageal variceal bleeding in patients who are TOO UNSTABLE to be sent for endoscopy?
Insertion of a Sengstaken-Blakemore tube.
This is inserted through the nose or mouth and can be used to temporarily stop variceal haemorrhage via the inflation of balloons.
78
What landmark allows the categorisation of the bleed during urgent endoscopy (i.e. into upper & lower GI bleed) ?
The ligament of Treitz
79
What is the ligament of Treitz?
The suspensory muscle of the duodenum that is found at the duodenojejunal flexure.
This marks the boundary between the 1st and 2nd parts of the small intestine.
80
What is the formal boundary between the upper and lower GI tracts?
Ligament of Treitz
81
What condition does abdo pain + blood & leucocytes on a dipstick indicate?
Renal stones
82
1st line investigation in renal stones?
Non-constrast CT abdo & renal tract
83
If all other measures fail in the treatment of bleeding oesophageal varices, what is the mx option?
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) --> this connects the hepatic vein to the portal vein
84
What does a TIPSS connect?
The hepatic vein to the portal vein
85
What is a common complication of TIPSS?
exacerbation of hepatic encephalopathy (i.e. inadequate metabolism of nitrogenous waste products by liver)
86
What condition is Fitz Hugh Curtis syndrome associated with?
PID
87
Symptoms of lactic acidosis?
- N&V
- exhaustion & fatigue
- fast deep breathing (respiratory compensation)
- muscle pain & weakness
88
Do high urea levels indicate an upper or lower GI bleed?
Upper
89
What is a key complication of Chagas disease?
Sigmoid volvulus
90
Does an asymmetrical presentation suggest psoriatic arthritis or rheumatoid?
Psoriatic
91
What is the ELF test?
A blood test used to measure degree of liver fibrosis in NAFLD.
92
What test is used to confirm the diagnosis of cirrhosis?
Liver biopsy
93
Give 3 drugs that can cause cirrhosis
1) methotrexate
2) amiodarone
3) sodium valproate
94
What is a Sengstaken-Blakemore tube?
Tube inserted into oesohagus to tamponade the bleeding varices (mx option in oesophageal varices).
95
What 2 veins are connected in a TIPS?
Portal & hepatic vein
96
What is the Abx of choice in hepatic encephalopathy?
Rifaximin
As it is poorly absorbed and stays in GI tract.
97
When are prophylactic antibiotics indicated in ascites in cirrhosis?Wha
When ascitic fluid protein is <15 g/l
98
What are the 2 most common organisms causing spontaneous bacterial peritonitis (SBP)?
1) E. coli
2) Klebsiella pneumoniae
99
What AST:ALT ratio is particularly suggestive of alcoholic liver disease?
>1.5
100
What scoring system can be used to describe the clinical state of patients with liver cirrhosis and to assess the severity of the condition?
Child Pugh score
101
What scoring system can be used to estimate 3m mortality risk in those with compensated cirrhosis?
MELD
102
What AUDIT score indicates harmful drinking?
≥8
103
When would transient elastography be used?
It is used where the enhanced liver fibrosis (ELF) test indicates advanced fibrosis.
104
Management of alcohol withdrawal?
1) Chlordiazepoxide (Librium)
2) High-dose B vitamins (Pabrinex)
3) Followed by long term oral thiamine
105
Peak incidence of hallucinations in alcohol withdrawal?
12-48h
106
Hallucinations vs delirium tremens in alcohol withdrawal?
Hallucinations --> exclusively subjective auditory disturbances and report them in clear consciousness unlike the confused state of a patient with delirium tremens.
Delirium tremens --> physical symptoms, confusion
107
Why is ferritin raised in PBC?
In extrahepatic biliary obstruction, hepatocyte damage 2ary to cholestasis leads to increased cellular release of ferritin.
Also, the release of cytokines in serum causes raised plasma ferritin levels (it is an acute phase protein).
108
What tool is used to screen patients for malnutrition?
The Malnutrition Universal Screening Tool (MUST)
109
What is malnutrition defined as?
1) BMI <18.5
or
2) unintentional weight loss greater than 10% within the last 3-6 months
110
What are the 3 early signs of haemochromatosis?
1) arthralgia
2) ED
3) fatigue
111
What is often used during acute episodes to determine who would benefit from glucocorticoid therapy?
Maddrey's discriminant function (DF) --> calculated by a formula using prothrombin time and bilirubin concentration
112
What is the investigation of choice for suspected carcinoid tumours?
Urinary 5-HIAA
113
How can co-amoxiclav affect the liver?
Co-amoxiclav is a well recognised cause of cholestasis
114
What is the first line test for diagnosis of small bowel overgrowth syndrome?
hydrogen breath testing
1) A fasted patient is given a high glucose drink.
2) Bacteria in the small bowel metabolise this glucose to hydrogen gas
3) The more bacteria there are in the small bowel, the more hydrogen will be exhaled
115
What must be prescribed alongside large volume paracentesis in the treatment of ascites?
IV human albumin solution
This reduces paracentesis-induced circulatory dysfunction and mortality
Important for me.
116
Mx of a recurrent episode of C. difficile within 12 weeks of symptom resolution?
Oral fidaxomicin
117
Mx of a recurrent episode of C. difficile >12 weeks of symptom resolution?
Oral vancomycin
118
What is the treatment of choice for small bowel bacterial overgrowth syndrome?
Rifaximin
119
What is a key side effect of clindamycin?
Risk of C. diff infection
120
What is indicated in mx of alcoholic hepatitis?
Prednisolone
121
What monoclonal Ab is sometimes used in the mx of C. diff?
bezlotoxumab
122
What C. diff antigen is specifically tested for in stool samples?
Glutamate dehydrogenase
123
What is the role of diazoxide?
Used to treat persistently low blood sugar levels caused by the body producing too much insulin.
124
If NAFLD is found incidentally, what test should be performed?
Enhanced liver fibrosis (ELF) blood test to assess for more severe liver disease.
125
What vitamin(s) does Pabrinex contain?
1) thiamine (B1)
2) riboflavin (B2)
3) pyridoxine (B6)
126
Patients who have ascites and a previous episode of SBP require prophylactic antibiotics.
What is the Abx of choice?
Ciprofloxacin or norfloxacin (fluoroquinolone)
127
What is vitamin B12?
Cobalamin
128
What is key in determining the severity of C. diff infection?
WCC
129
How is a diagnosis of C. diff infection made?
Made by detecting C. diff TOXIN (CDT) in the stool
Note - C. diff ANTIGEN positivity only shows exposure to the bacteria, rather than current infection
130
What is the best 1st line mx for NAFLD?
Weight loss
131
