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GI Flashcards

1
Q

what are worrying features of PR bleeding?

A 
tachycardic
dizziness
reduced GCS
abdo pain and weight loss
vomiting
hypotension
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2
Q

initial management of PR bleeding

A

A-E assessment
abdo exam
PR exam
protoscopy

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3
Q

what is included in the D part of an A-E assessment?

A

GCS, blood glucose, pupils

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4
Q

what are the key bloods of PR bleeding?

A 
FBC
clotting
U&Es
LFTs
group and save or cross match 2 units
glucose
lactate
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5
Q

what other investigations except bloods are needed in PR bleeding?

A

stool sample
faecal calprotectin
scoping- colonoscopy, proctosigmoidoscopy

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6
Q

differentials of PR bleeding?

A 
polyps
diverticular disease
haemorrhoids
fissures
IBD
Cancer
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7
Q

what type of bleeding does a fissue in ano produce?

A

bright red rectal bleeding

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8
Q

features of fissue in ano history?

A

Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation

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9
Q

features of fissue in ano exam?

A

muco-epithelial defect usually in the midline posteriorly

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10
Q

what type of bleeding do haemorrhoids produce?

A

Bright red rectal bleeding

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11
Q

hx of haemorrhoids?

A

Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool.
PAINLESS bleeding

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12
Q

examination of haemorrhoids?

A

Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable

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13
Q

tx of fissure in ano?

A

1st line- GTN ointment or distiazem cream
2nd line- botox
3rd line- Internal sphincterotomy

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14
Q

tx of haemorrhoids?

A

lifestyle advice
small haemorrhoids- injection sclerotherapy or rubber band ligation
external haemorrhoids- haemorrhoidectomy

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15
Q

what are external and internal haemorrhoids?

A

external- originate below the dentate line
painful, prone to thrombosis

internal- below dentate line
no pain

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16
Q

features of upper GI bleeding?

A

Haematemesis and/ or malaena
Epigastric discomfort
Sudden collapse

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17
Q

differentials of upper GI bleeding?

A

oesophageal

  • oesophagitis
  • cancer
  • Mallory Weiss tear
  • varices

gastric

  • gastric cancer
  • gastritis
  • gastric ulcer
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18
Q

ABCDE of upper GI bleeding?

A

admit to hosp
A-E assessment
- B- O2, ABG, sats probe, auscultate
-C- give fluids- 500mls stat, catheter, ?ECG, IV access
E- bleeding elsewhere, abdo pain, signs of chronic liver disease?

Bloods- cross match, FBC, LFTs, U&Es, clotting

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19
Q

what blood is urgently transfused in patients with ongoing bleeding and haemodynamic instability?

A

O negative blood pending cross matched blood

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20
Q

mx of upper GI bleeding after A-E?

A

make nil by mouth

correct clotting abnormalities- prothrombin complex if on warfarin or platelets if platelet count <50
fresh frozen plasma to patients who have fibrinogen <1 g/litre, or a prothrombin time (international normalised ratio) or APTT >1.5 times normal

urgent endoscopy within 24 hours

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21
Q

what do patients with suspected varices need prior to endoscopy?

A

terlipressin and prophylactic abx (quinolones)

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22
Q

mx of Mallory Weiss tear?

A

resolves spontaneously usually

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23
Q

cause of Mallory Weiss tear?

A

usually following comiting

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24
Q

cause of oesophagitis?

A

usually history of GORD symptoms

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25
Q

symptoms of varices?

A

usually large volume of fresh blood

swallowed blood can cause malaena

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26
Q

what is the risk assessment of acute upper GI bleeding due to varices or peptic ulcer disease?

A

use the Blatchford score at first assessment, and
the full Rockall score after endoscopy

Blatchford score of 0 may be considered for early discharge- urea, Hb, SBP, HR, presence of maleana, syncope, hepatic disease, Cardiac failure

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27
Q

mx of varices?

A 
NBM
fluids +/- blood
terlipressin and ABx
correct clotting
urgent OGD- band ligation if oesophageal varices and N-butyl-2-cyanoacrylate for patients with gastric varices

continued bleeding= TIPS surgery
prevention- propranolol
prescribe LMWH

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28
Q

Ix in change of bowel habit?

A 
Bloods- FBC, U&amp;E, LFT, CRP, TFT, glucose, calcium, iron studies, haematinics
Anti-TTG, IgA, anti-endomysial 
Stool sample
AXR
Scoping
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29
Q

what is H.Pylori associated with?

A

peptic ulcer disease
gastric cancer
Bcell lymphoma of MALT tissue
atrophic gastritis

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30
Q

what type of bacterial is H.Pylori?

A

gram negative bacteria

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31
Q

mx of H.pylori?

A

eradication may be achieved with a 7 day course of
a PPI + amoxicillin + clarithromycin, or
a PPI + metronidazole + clarithromycin

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32
Q

What is the definition of GORD?

A

symptoms of oesophagitis secondary to refluxed gastric contents

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33
Q

Mx of endoscopically proven oesophagitis?

A

full dose PPI for 1-2 months
if response then low dose treatment as required
if no response then double-dose PPI for 1 month

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34
Q

Mx of negative reflux disease?

A

full dose PPI for 1 month
antacids e.g Gavison
if no response then H2RA or prokinetic for one month

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35
Q

what is barrett’s oesophagus?

A

metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium

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36
Q

what cancer is increased risk in barrett’s oesophagus?

A

oesophageal adenocarcinoma

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37
Q

RFs for barrett’s oesophagus?

A

GORD
male gender
smoking
central obesity

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38
Q

mx of barrett’s oesophagus?

A

endoscopy recommended every 3-5 years for metaplasia
high dose PPI

for dysplasia- endoscopic mucosal resection
radiofrequency ablation

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39
Q

NICE guidelines for urgent referral for endoscopy?

A
  1. all patients with dysphagia
  2. all patients with upper abdo mass consistent with stomach cancer
  3. patients >55 with weight loss AND ONE OF:
    - upper abdo pain
    - reflux
    - dyspepsia
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40
Q

non urgent referral for endoscopy?

A
  1. haematemesis
  2. > 55 and treatment resistant dyspepsia or upper abdo pain with low Hb or raised platelets with N&V, wt loss, reflex etc
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41
Q

test for H.pylori?

A

carbon-13 urea breath test or a stool antigen test

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42
Q

treating patients with dyspepsia who don’t meet referral guidelines?

A
  1. Review medications for possible causes of dyspepsia
  2. Lifestyle advice
  3. Trial of full-dose proton pump inhibitor for one month OR a ‘test and treat’ approach for H. pylori
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43
Q

RFs for gastric cancer?

A 
H.pylori infection
pernicious anaemia
smoking
blood group A
salty/spicy diet
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44
Q

histology of gastric cancer?

A

signet ring cells

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45
Q

features of gastric cancer?

A

dyspepsia
N&V
anorexia and weight loss
dysphagia

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46
Q

Ix of gastric cancer?

A

endoscopy with biopsy
staging: CT or endoscopic USS
PET CT

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47
Q

tx of gastric cancer?

A

subtotal gastrectomy if proximally sites disease >5-10cm from OG junction

total gastrectomy if tumour <5cm from OG junction

lymphadenectomy

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48
Q

Ix of oesophageal spasm?

A 
upper GI endoscopy
oesophageal manometry
oesophageal pH studies
barium swallow
USS
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49
Q

Mx of oesophageal spasm>

A 
dietary modification
trial of PPI to rule out GORD
nitrates
CCBS
anti-depressants
botox injection
surgery
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50
Q

red flags of IBS?

A

> 60 years old
rectal bleeding
unexplained/unintentional weight loss
FH bowel or ovarian cancer

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51
Q

diagnosis of IBS?

A

6 months of:

  • abdo pain and/or
  • bloating and/or
  • change in bowel habit
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52
Q

other features of IBS?

A 
usually abdo pain is relieved by defecation
altered stool passage
worse with eating
passage of mucus
fatigue
nausea
backache
bladder symptoms
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53
Q

Ix of IBS in primary care?

A

FBC
ESR/CRP
coeliac screen (TTG antibodies)

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54
Q

mx of IB?

A

1st line-
pain: antispasmodic e.g. mebeverine
constipation- loperamide
diarrhoea- laxatives but avoid lactulose (use linaclotide if conventional laxatives not working)

2nd line- low dose TCA e.g. amitriptyline

psychological intervention- CBT, hypnotherapy

dietary advice- regular small meals, avoid fizzy drinks, not too much fibre

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55
Q

causes of acute diarrhoea? (<14 days)

A

gastroenteritis
diverticulitis
antibiotic therapy
constipation causing overflow

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56
Q

causes of chronic diarrhoea?

A

IBS
IBD
colorectal cancer
coeliac disease

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57
Q

common drugs causing constipation?

A 
iron
NSAIDS
antimuscarinics- procyclidine, antidepressants
antiepileptic drugs
antihistamines
diuretics
opiates
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58
Q

mx of constipation?

A

bulk forming laxatives- fybogel (ispaghula husk), methylcellulose

osmotic laxatives (soften stool)- lactulose, polyethylene glycol

stimulant laxative- Bisacodyl, senna, sodium picosulfate

stop/treat the caues

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59
Q

complications of constipation?

A

overflow diarrhoea, acute urinary retention, haemorrhoids

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60
Q

presentation of constipation in very elderly?

A

nausea/loss of appetite
overflow diarrhoea
urinary retention
delirium/ confusion

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61
Q

2 week wait of colorectal cancer referral?

A
  • Patients >40 years with unexplained weight loss AND abdo pain
  • Patients >50 years with unexplained rectal bleeding
  • Patients >60 with iron deficiency anaemia OR change in bowel habit
  • FOBT positive
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62
Q

who is FOBT offered to?

A

every 2 years to men and women aged 60-74 years

may be given to younger patients with symptoms of abdo pain and weight loss or change in bowel habit or rectal bleeding

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63
Q

how does FOBT work?

A

uses antibodies that recognises human haemoglobin

patients with abnormal results offered a colonoscopy

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64
Q

most common locations of colorectal cancer?

A

rectal (40%)

sigmoid (30%)

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65
Q

3 types of colon cancer?

A
  1. sporadic (95%)
  2. hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
  3. Familial adenomatous polyposis (FAP, <1%)
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66
Q

Amsterdam criteria for HNPCC?

A
  • at least 3 family members with colon cancer
  • the cases span at least 2 generations
  • at least one case diagnosed before the age of 50 years
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67
Q

features of crohn’s disease?

A

diarrhoea usually non-bloody
weight loss more prominent
upper GI symptoms, mouth ulcers, perianal disease
abdo mass in RIF

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68
Q

extra intestinal features of crohn’s disease?

A

gallstones (secondary to reduced bile acid reabsorption)
arthritis
erythema nodosum
pyoderma gangrenousm

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69
Q

complications of crohns

A

obstruction
fistula
strictures
colorectal cancer

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70
Q

pathology of crohn’s?

A

lesions anywhere from mouth to anus

skip lesions may be present

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71
Q

histology of crohn’s?

A
  • inflammation in all layers from mucosa to submucosa
  • increased goblet cells
  • granulomas
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72
Q

endoscopy of crohn’s?

A

deep ulcers
skin lesions
cobblestone appearance

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73
Q

radiology of crohn’s?

A

strictures- kantors string sign
proximal bowel dilatation
rose thorn ulcers
fistulae

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74
Q

features of UC?

A

Bloody diarrhoea more common
abdo pain in left lower quadrant
tenesmus

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75
Q

extra intestinal features of UC?

A 
primary sclerosing cholangitis
uveitis
arthritis
erythema nodosum
pyoderma gangrenosum
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76
Q

complications of UC?

A

Risk of colorectal cancer higher in UC than crohns

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77
Q

pathology of UC disease

A

inflammation always starts at rectum and never spreads beyond ileocaecal valve
CONTINUOUS disease

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78
Q

histology of UC disease

A

no inflammation beyond submucosa
crypt abscesses
depletion of goblet cells

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79
Q

endoscopy of UC?

A

widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps

80
Q

radiology of UC

A

On barium enema:
loss of haustrations
superficial ulceration, ‘pseudopolyps’
long standing disease: colon is narrow and short -‘drainpipe colon’

81
Q

mx of crohn’s

A

inducing remission-

  • glucocorticoids
  • budesonide
  • 5-ASA drugs e.g. mesalazine are 2nd line
maintaining remission-
- stopping smoking
1st line- azathioprine or mercaptopurine
2nd line- methotrexate
TNF inhibitors- infliximab

surgery

82
Q

mx of UC (mild and moderate)

A

proctitis- rectal aminosalicylate e.g. mesalazine
change to oral after 4 weeks if no improvement
oral corticosteroids

maintaining remission with topical or oral aminosalicylate

83
Q

mx of UC (severe)

A 
should be treated in hospital
IV steroids 1st line
analgesia
fluids
IV ciclosporin added if no improvement after 72 hours
surgery
84
Q

what is coeliac disease and the pathology?

A

an autoimmune disease caused by sensitivity to gluten

repeated exposure leads to villous atrophy which in turn causes malabsorption

85
Q

associations with coeliac disease?

A 
thyroid disease
dermatitis herpetiformis
IBS
T1DM
1st degree relative with coeliac disease
86
Q

S&Ss of coeliac disease?

A 
chronic or intermittent diarrhoea
failure to thrive or faltering growth
prolonged fatigue
recurrent abdo pain, crampy or distension
sudden or unexpected weight loss
unexplained iron-deficiency anaemia
87
Q

immunology of coeliac disease?

A

TTG antibodies
Endomyseal antibody
anti-casein antibodies

88
Q

jejunal biopsy findings of coeliac disease?

A

villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes

89
Q

tx of coeliac disease?

A

gluten free diet

pneumococcal vaccine- due to association with functional hyposplenism

90
Q

complications of coeliac disease?

A 
anaemia
hyposplenism
OP, osteomalacia
lactose intolerance
gastric lymphoma e.g. MALT
subfertility
oesophageal cancer
91
Q

Ix of IBD?

A

WCC and CRP raised
faecal calprotectin
AXR
colonoscopy

92
Q

3 fat soluble vitamins that are reduced in malabsorption?

A

ADEK
A deficiency- poor vision
D- rickets, osteomalacia
K- clotting abnormalities

93
Q

life-threatening causes of abdo pain?

A 
Perforation
Bowel infarct/ischaemia
Obstruction
Acute pancreatitis
AAA
Appendicitis
Strangulated hernia
MI
Acute cholangitis
Ruptured ectopic
Ovarian torsion
94
Q

key investigations for abdo pain?

A 
bloods- FBC, U&amp;E, LFT, amylase
MSU- b-HCG (need to rule out pregnancy)
ECG (?MI)
Erect CXR (?perforation)
AXR (?bowel obstruction)
CT KUB (?renal stone)
USS (hepatobiliary causes)
CT abdo
95
Q

pathophysiology of acute pancreatitis?

A
  • autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis
96
Q

causes of pancreatitis?

A 
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune e.g. polyarteritis nodosa
Scorpion venom
Hypertriglyceridaemia, calcaemia,hyperthermia
ERCP
Drugs (azathioprine, mesalazine, furosemide, steroids)
97
Q

features of acute pancreatitis?

A

Severe epigastric pain that may radiate through to the back
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign)

98
Q

Ix of acute pancreatitis?

A 
raised amylase seen in 75%
hyperglycaemia (less insulin production)
serum lipase
neutrophilia
elevated LDH and AST
99
Q

causes of false positive amylase?

A

pancreatic pseudocyst
perforated viscus
acute cholecystitis
DKA

100
Q

mx of acute pancreatitis?

A 
IV fluids
O2
analgesia
catheter
NBM
treat cause
101
Q

cause of chronic pancreatitis?

A

alcohol (80%)
genetic- CF, haemochromatosis
ductal obstruction

102
Q

feature of chronic pancreatitis?

A

pain is typically worse 15-30 mins following a meal
steatorrhoea
DM develops later

103
Q

Ix of chronic pancreatitis?

A

AXR- pancreatic calcification
CT-pancreatic calcification
faecal elastase may assess exocrine function

104
Q

mx of chronic pancreatitis?

A

pancreatin- contains protease, lipase, amylase (taken with food)
analgesia- NSAIDs and opiates

105
Q

SE of pancreatin?

A

irritation of the mouth
perianal rash
N&V
abdo discomfort

106
Q

endocrine and exocrine role of the pancreas?

A

endocrine- regulate blood sugar- insulin, glucagon, somatostatin
exocrine- bicarb and digestive enzymes

107
Q

surgical causes of acute abdomen?

A

infective- GE, appendicitis, pyelonephritis, diverticulitis, PID
Inflammatory- pancreatitis, peptic ulcer disease
Vascular- MI, mesenteric ischaemia, ruptured AAA
Traumatic- ruptured spleen
Metabolic- renal/ureteric stones, DKA

108
Q

what is biliary colic?

A

pain caused by the gallbladder contracting against a stone lodged in the cystic duct

109
Q

what is cholithiasis vs cholecystitis vs choledocholithiasis?

A

Cholithiasis= gallstones in gallbladder

Cholecystitis= inflamed gallbladder due to gallstones (raised WCC and CRP), continuous pain

Choledocholithiasis=gallstones in the common bile duct

110
Q

RFs for biliary colic?

A

Fat: enhanced cholesterol synthesis and secretion
Female: Oestrogen increases activity of HMG-CoA reductase
Fertile: pregnancy is a risk factor
Forty

111
Q

cause of gallstones?

A

occur due to ↑ cholesterol, ↓ bile salts and biliary stasis

112
Q

features of biliary colic?

A

colicky abdominal pain, worse postprandially, worse after fatty foods. The pain may radiate to the right shoulder
nausea and vomiting are common

113
Q

Ix for gallstones?

A

Abdo USS

LFTs

114
Q

mx for biliary colic?

A

If imaging shows gallstones and history compatible then laparoscopic cholecystectomy

115
Q

features of acute cholecystitis?

A

Right upper quadrant pain
Fever
Murphys sign on examination
Occasionally mildly deranged LFT’s (especially if Mirizzi syndrome)

116
Q

Ix for acute cholecystitis?

A

1st line- USS
2nd line- cholescintigraphy (HIDA) scan
bloods- WCC, CRP, serum amylase

117
Q

tx of acute cholecystitis?

A

IV antibiotics

early laparoscopic cholecystectomy within 1 week of diagnosis

118
Q

what is ascending cholangitis?

A

ascending infection of the biliary tree

typically E.coli

119
Q

Charcot’s triad for cholangitis?

A

RUQ pain
jaundice
RUQ pain

hypotension and confusion are also common

120
Q

Mx of cholangitis?

A

intravenous antibiotics

endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction

121
Q

complications of cholangitis?

A 
severe sepsis
liver abscesses
liver failure
AKI
septic shock
122
Q

what is the common bile duct formed from?

A 
cystic duct (from gall bladder)
and common hepatic duct (from liver)

goes into pancreas to join with pancreatic duct

enters duodenum at sphincter of Oddi

123
Q

RFs of peptic ulcer disease?

A

H.Pylori
drugs- NSAIDs, SSRIs, corticosteroids, bisphosphonates
Zollinger-Ellison syndrome- gastrin secreting tumour

124
Q

features of peptic ulcer disease?

A

epigastric pain
nausea
duodenal ulcers- pain relieved by eating
gastric ulcers- worsened by eating

125
Q

Ix of peptic ulcer disease

A

urea breath test or stool antigen test (tests for H.pylori)

126
Q

tx of peptic ulcer disease

A

if H.pylori negative -> PPI (omeprazole) given until the ulcer is healed

if H.pylori positive -> eradication therapy given

127
Q

features of acute appendicitis?

A

peri-umbilical pain to RIF
vomiting once or twice
mild pyrexia
anorexia
if perforation -> generalised peritonitis
DRE may reveal boggy sensation of pelvic abscess is present

128
Q

diagnosis of acute appendicitis?

A

raised inflammatory markers
neutrophils- predominantly leucocytes
urinalysis- rule out pregnancy, renal colic and UTI
USS

129
Q

Tx of appendicitis?

A

appendicectomy
prophylactic IV Abx reduces wound infection
abdo lavage

130
Q

what is diverticulosis?

A

multiple outpouchings of the bowel wall, most commonly in the sigmoid colon

131
Q

what is diverticular disease?

A

symptomatic diverticulosis
altered bowel habits, colicky left-sided abdo pain, bleeding and bloating
treat with high fibre diet and drain any abscesses

132
Q

what is diverticulitis?

A

the infection of a diverticulum

133
Q

RFs for diverticulitis?

A 
Age
Lack of dietary fibre
Obesity: especially in younger patients 
Sedentary lifestyle
Smoking
NSAID use
134
Q

features of diverticulitis?

A

Severe abdominal pain in the left lower quadrant
N&V
Change in bowel habit: constipation is more common
Urinary frequency, urgency or dysuria (10-15%): this is due to irritation of the bladder by the inflamed bowel.
PR bleeding
Symptoms such as pneumaturia or faecaluria

135
Q

Ix of diverticulitis?

A

FBC: raised WCC
CRP: raised
Erect CXR: may show pneumoperitoneum in cases of perforation
AXR: may show dilated bowel loops, obstruction or abscesses
CT: this is the best modality in suspected abscesses
Colonoscopy: should be avoided initially due to increased risk of perforation in diverticulitis

136
Q

tx of diverticulitis?

A

oral antibiotics, liquid diet and analgesia
if the symptoms don’t settle within 72 hours, or more severe symptoms, the patient should be admitted to hospital for IV antibiotics

137
Q

features of intestinal obstruction?

A

colicky abdo pain and vomiting
abdo distension and constipation
peritonism

138
Q

RFs for obstruction?

A

malignancy
adhesions
strangulated hernia
volvulus

139
Q

mx of obstruction?

A

Abdominal film: small bowel loops with fluid levels
laparotomy
CT if suspect malignancy

140
Q

what are signs of peritonitis?

A

tenderness on palpation, guarding and rebound tenderness

patients are usually unwell and distressed, worse on movement

141
Q

causes of peritonitis?

A 
Appendicitis
Ectopic pregnancy
Infection with TB
Obstruction-colicky pain
Ulcer- epigastric pain radiating to shoulder
intraperitoneal dialysis
142
Q

what is spontaneous bacterial peritonitis?

A

a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis

143
Q

features of SBP?

A

ascites
abdominal pain
fever

144
Q

Diagnosis of SBP?

A

paracentesis: neutrophil count > 250 cells/ul

the most common organism found on ascitic fluid culture is E. coli

145
Q

mx of SBP?

A

IV cefotaxime

146
Q

when should Abx prophylaxis be given in patients with ascites?

A

patients who have had an episode of SBP
patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
NICE recommend: ‘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’

147
Q

what is acute mesenteric ischaemia and what causes it?

A

embolism e.g. superior mesenteric artery
classic history of AF
abdo pain is severe, sudden onset and out of keeping with physical exam findings

148
Q

mx of acute mesenteric ischaemia

A

urgent surgery is usually required

149
Q

what is ischaemic colitis?

A

acute but transient compromise in the blood flow to the large bowel
leads to inflammation, ulceration and haemorrhage

it is more likely to occur in areas such as splenic flexure

150
Q

Ix of ischaemic colitis?

A

AXR-thumbprinting due to mucosal oedema/haemorrhage, metabolic acidosis

151
Q

mx of ischaemic colitis?

A 
fluids
analgesia
NBM
surgery if perforation or haemorrhage
thrombolytic therapy, angioplasty
152
Q

what is acute liver failure?

A

jaundice, coagulopathy (raised PT time), hepatic encephalopathy and hypoalbuminaemia w/o cirrhosis

153
Q

causes of acute liver failure?

A

paracetamol OD
hepatitis
alcohol
acute fatty liver of pregnancy

154
Q

things to ask in acute liver failure?

A

history of:

  • IVDU
  • foreign travel
  • tattoos
  • sexual history
  • alcohol
155
Q

Ix of acute liver failure?

A

liver screen: LFTs, FBC, U&E, CRP, clotting
hepatitis serology- HbsAg
EBV and CMV serology
serum ceruloplasmin (Wilson’s disease)
A1AT levels
antimitochondrial, anti smooth muscle, ANA
Transferrin

156
Q

mx of acute liver failure?

A

Child-Pugh score- assess prognosis of chronic liver disease
A-E
stop hepatotoxic drugs- NSAIDs, paracetamol, ACEi, erythromycin, statins
prophylactic Abx
IV fluids
lactulose- stops encephalopathy by binding to ammonia
escalate early

157
Q

mx of paracetamol overdose?

A

if patients present <1 hour, take activated charcoal to reduce absorption of the drug
Give acetylcysteine if there is a staggered overdose or there is doubt over the time of paragetamol ingestion

158
Q

what is included in the child pugh score?

A 
bilirubin
albumin
PT time
encephalopathy
ascites
159
Q

what are the investigations for non-alcoholic fatty liver disease?

A

ALT>AST
ELF test
Fibroscan
liver biopsy if advanced disease

160
Q

what is primary biliary sclerosis?

A

a rare liver disease typically presenting in middle-aged women
fatigue and itch
jaundice develops as disease progresses

161
Q

what is primary sclerosing cholangitis?

A

inflammation of intra and extra-hepatic bile ducts leading to fibrosis and stricture formation
associated with IBD and cholangiocarcinoma
bilirubin, ALP and gammaGT raised

162
Q

what is a whipple’s resection?

A

pancreaticoduodenectomy

163
Q

how is a hepatocellular carcinoma diagnosed?

A

CT/MRI

alpha-fetoprotein

164
Q

Ix of gastroenteritis?

A

stool sample- include C.diff toxin assay and norovirus PCR

bloods- high WCC, high CRP, high urea

165
Q

what is pseudomonas colitis most commonly caused by?

A

C.diff- ciprofloxacin

typically 3-9 days post Abx

166
Q

Symptoms of pseudomonas colitis?

A

green, foul smelling stool

167
Q

progression of pseudomonas colitis?

A

toxic megacolon

perforation

168
Q

tx of pseudomonas colitis?

A

metronidazole

2nd line- oral vancomycin

169
Q

causes and treatment of oesophageal varices?

A 
portal hypertension (due to liver cirhosis) causes dilated collateral veins
tx= beta blockers
170
Q

mx of haematemesis?

A

OGD within 24 hours
if varices -> IV terlipressin which constricts the splanchic arteries
Balloon tamponade if doesn’t work

171
Q

what’s included in the Rockall score?

A

risk of rebleeding score

  • age
  • shock
  • comorbidity
  • endoscopic findings- active haemorrhage
172
Q

what to do in a severe attack of UC?

A

do a plain AXR to exclude toxic megacolon (diameter >5.5cm) and assess faecal distribution

173
Q

complications of UC?

A 
perforation
bleeding
malnutrition
toxic megacolon
primary sclerosing cholangitis
colon cancer
174
Q

rash in coeliac disease?

A

dermatitis herpetiformis

175
Q

what score is used to assess the severity of acute pancreatitis?

A 
glasgow score
PANCREAS
PO2
Age >55
Neutrophils
Calcium
Renal function
Enzymes (LDH,AST)
Albumin
Sugar (BG)
176
Q

what anti-emetics are obstructed in mechanical bowel obstruction?

A

metoclopramide as it is prokinetic

177
Q

signs of acute mechanical intestinal obstruction?

A 
distension
tenderness
visible peristalsis
hernias
rectal mass on PR examination
tinkling bowel sounds (absent in paralytic ileus)
178
Q

complications of gallstones?

A 
biliary colic
cholestasis
empyema
obstructive jaundice
cholangitis
gallbladder perforation and peritonitis
gallstone ileus
179
Q

causes of peritonitis?

A 
Appendicitis
Ectopic pregnancy
Infection with TB
Obstruction- colicky pain
Ulcer- epigastric pain radiating to shoulder
Peritoneal dialysis
180
Q

RFs of jaudice?

A 
IVDU
Sex workers, MSM
Alcohol
Travel history
Healthcare workers
Drugs e.g. paracetamol
181
Q

blood tests to assess liver synthetic function?

A

Albumin (decreased)

INR- increased due to impaired synthesis of clotting factors and Vit K malabsorption

182
Q

blood tests to find cause of liver disease?

A 
FBC
Hep B&amp;C virus serology
A1AT
Copper studies
Iron studies- Exclude haemochromatosis
Autoantibodies- AMA (PBC), ANA, SMA
183
Q

complications of liver cirrhosis?

A 
renal failure
portal hypertension
coagulopathy
hepatocellular carcinoma (aFP)
hepatic encephalopathy- due to ammonia build up
Spontaneous bacterial peritonitis
184
Q

what is achalasia?

A

Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus i.e. LOS contracted, oesophagus above dilated.

185
Q

clinical features of achalasia?

A

dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food - may lead to cough, aspiration pneumonia etc
malignant change in small number of patients

186
Q

Ix of achalasia?

A

oesophageal manometry: excessive LOS tone which doesn’t relax on swallowing - considered most important diagnostic test
barium swallow shows grossly expanded oesophagus, fluid level, ‘bird’s beak’ appearance
CXR: wide mediastinum, fluid level

187
Q

tx of achalasia?

A

intra-sphincteric injection of botulinum toxin
Heller cardiomyotomy
pneumatic (balloon) dilation
drug therapy has a role but is limited by side-effects

188
Q

what does diffuse oesophageal spasm produce on barium swallow?

A

corkscrew appearance

189
Q

how are the causes of ascites differentiated?

A 
SAAG serum-ascites albumin gradient
>11g/L: transudate
Indicates portal hypertension
Cirrhosis
Alcoholic hepatitis
Cardiac ascites
Massive liver metastases
Fulminant hepatic failure
Budd-Chiari syndrome
Portal vein thrombosis
Veno-occlusive disease
Myxoedema
Fatty liver of pregnancy
<11g/L: exudate- infection, inflammation, malignancy
Peritoneal carcinomatosis
Tuberculous peritonitis
Pancreatic ascites
Bowel obstruction
Biliary ascites
Postoperative lymphatic leak
Serositis in connective tissue diseases
190
Q

mx of ascites?

A

reducing dietary sodium
fluid restriction is sometimes recommended if the sodium is < 125 mmol/L
aldosterone antagonists: e.g. spironolactone
drainage if tense ascites (therapeutic abdominal paracentesis)
large-volume paracentesis for the treatment of ascites requires albumin ‘cover’
paracentesis induced circulatory dysfunction can occur due to large volume paracentesis (> 5 litres). It is associated with a high rate of ascites recurrence, development of hepatorenal syndrome, dilutional hyponatraemia, and high mortality rate
prophylactic antibiotics to reduce the risk of spontaneous bacterial peritonitis
TIPS surgery may be considered- transjugular intrahepatic portosystemic shunt

191
Q

features of pancreatic cancer?

A

classically painless jaundice
Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones (
however, patients typically present in a non-specific way with anorexia, weight loss, epigastric pain
loss of exocrine function (e.g. steatorrhoea)
loss of endocrine function (e.g. diabetes mellitus)
atypical back pain is often seen

192
Q

mx of pancreatic cancer?

A

a Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple’s include dumping syndrome and peptic ulcer disease

193
Q

where are pancreatic cancers normally sites?q

A

head of the pancreas

194
Q

what is haemochromatosis?

A

autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation

195
Q

features of haemochromatosis?

A

early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands)
‘bronze’ skin pigmentation
diabetes mellitus
liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition)
cardiac failure (2nd to dilated cardiomyopathy)
hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism)
arthritis (especially of the hands)

196
Q

signs of liver cirrhosis?

A

Jaundice – caused by raised bilirubin
Hepatomegaly – however the liver can shrink as it becomes more cirrhotic
Splenomegaly – due to portal hypertension
Spider Naevi – these are telangiectasia with a central arteriole and small vessels radiating away
Palmar Erythema – caused by hyperdynamic cirulation
Gynaecomastia and testicular atrophy in males due to endocrine dysfunction
Bruising – due to abnormal clotting
Ascites
Caput Medusae – distended paraumbilical veins due to portal hypertension
Asterixis – “flapping tremor” in decompensated liver disease

197
Q

complications of cirrhosis?

A

Malnutrition
Portal Hypertension, Varices and Variceal Bleeding
Ascites and Spontaneous Bacterial Peritonitis (SBP)
Hepato-renal Syndrome
Hepatic Encephalopathy
Hepatocellular Carcinoma

finals (14 decks)

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