GI and Liver Flashcards
1
Q
What is Barrett’s oesophagus?
A
Metaplasia of the lower oesophageal mucosa
2
Q
What changes occur in Barrett’s?
A
Squamous epithelium –> Columnar epithelium
3
Q
What is the mx of Barrett’s?
A
High dose PPI
Endoscopic survilliance
If dysplasia present- radiofrequency ablation or resection
4
Q
List 3 RF of Barrett’s?
A
Male
GORD
Obesity (Central)
Smoking
5
Q
What is Haemochromotosis?
A
An autosomal recessive disorder of iron absorption and metabolism thus iron accumulation
6
Q
List the sx of haemochromotosis?
A
Liver cirrhosis
Jaundice
Hyperpigmemtation (Bronze/slate grey)
Hair loss
ED
Amenorrhoes
Diabetes
Malabsorbtion issues
7
Q
What first and GS ix is indicated in haemochromotosis and what are the results?
A
1st- iron studies
Ferritin- High
TIBC- Low
Transferrin- High
GS- Genetic testing (if heriditary component)
other- Liver biopsy, CT abdo
8
Q
What is the mx of haemochromotosis?
A
1st line- Weekly venesection
2nd line- Deferoxamine
additionally inform patients to avoid alcohol
9
Q
List 4 red flags for gastric cancer?
A
Unexplained weight loss
New onset dyspepsis >55
Unexplained persistent vomitting
Epigastric pain
Odonophagia
Worsening dysphagia
10
Q
What is the Ix of choice in gastric cancer?
A
OGD with biopsy
11
Q
List 3 RF for gastric cancer?
A
H pylori
Smoking
Pernicious anaemia
Blood group A
12
Q
What are the 2 areas of lymphatic spread in gastric cancer?
A
Left supraclavicualr node (Virchow’s node)
Periumbilical node (Sister mary joseph node)
13
Q
What antibodies are present in Autoimmune hepatitis?
A
ANA
Anti smooth muscle
Anti soluble liver antigen
14
Q
What antibodies are present in PBC?
A
Anti mitochondrial antibodies
15
Q
What is Primary sclerosisng cholangitis?
A
chronic condition of unknown cause characterised by inflammation and fibrosis of intra and extraheaptic ducts
16
Q
What 2 conditions are closely linked with PSC?
A
Ulcerative colitis (most common) , HIV, and Chrons
17
Q
What blood marker can differentiate between an upper and lower GI bleed?
A
High urea levels- present in upper GI bleed
18
Q
What sx are present in PSC?
A
Jaundice
Pruritus
RUQ pain
Fatigue
19
Q
What LFT markers suggest a diagnosis of PSC?
A
High billirubin and ALP
20
Q
What blood markers are used to monitor management in haemochromatosis?
A
Ferritin (below 50ug/L)
Transferrin Saturations (below 50%)
21
Q
List the common abx causes of C.diff?
A
Clindamycin
2nd and 3rd gen cephalosporins
Co-amoxiclav
Ciprofloxacin
22
Q
What conservative measures should be taken if a patient on the ward has c-diff?
A
Side room, wash hands, dispose of gloves and aprons
23
Q
What is the 1st line Abx for c-diff?
A
Oral vancomycin 10 days
24
Q
What is the 2nd line Abx for c-diff?
A
Oral Fidaxomicin
25
What is the 3rd line Abx for c-diff?
IV metronidazole + Oral vancomycin
26
What other alternative therapies other than Abx can be used to treat c-diff?
Bezlotuxmab- monoclonal antibody which targets c-diff toxin B
Faecal microbiota transplant- may be considered for patients who have had 2 or more prev episodes
27
What is Plummer visson syndrome?
Characterised by dysphagia, IDA, Glossitis, cheliosis, and oesophageal webs
28
What is Crohn's disease?
An inflammatory bowel disease characterised by transmural inflammation of the GI tract
29
List the 4 layers o the gastric mucosa?
Mucosa
Submucosa (mesissners plexus)
Muscularis propria (Aurchbachs plexus)
Serosa
30
List the features of crohns?
Non-specific sx (WL and lethargy)
Diarrhoea
Abdo pain (RIF)
Perianal disease
31
What will be seen on the histology findings in Crohn's?
Inflammation in all layers
Increased Goblet cells
Granulomas
32
What will be seen in endoscopy of Crohn's?
Deep ulcers
Skip lesions- Cobblestone appearance
33
What will be the findings in radiology of Crohn's?
Strictures- Kantor's string sign
Proximal bowel dilation
Rose thorn ulcers
Fistulae
34
What is the 1st line mx of inducing remission in crohn's?
Oral/Topical/IV glucocorticoids
35
What is the 1st line tx to maintain remission in crohns patients?
Stop smoking
1st line- Azathioprine or Mercaptopurine
36
What is the 2nd line tx to maintain remission in crohns patients?
Methotrexate
37
What should be tested in patients prior to starting azathioprine or mercaptopurine?
assess thiopurine methyltransferase (TPMT) activity
38
What is UC?
a type of IBD that characteristically involves rectum and extends proximally
39
What are the features of UC?
Bloody diarrhoea
Abdominal pain in LLQ
Tenesmus
40
What are the features seen on histology in UC?
No Inflammation beyond submucosa
Crypt abscesses
Depletion of goblet cells
41
What are the features seen on endoscopy in UC?
Pseudopolyps
42
What are the features seen on radiology in UC?
Loss of haustrations
pseudopolyps
'Drainpipe colon' (colon is narrow)
43
How is the severity of UC classified?
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
44
What is the 1st line mx to induce remission in UC?
Topical aminosalicylate
45
If remission is not achieved using the 1st line mx in UC what further mx should be added?
Add oral aminosalicylate
46
What is the mx of severe colitis?
should be treated in hospital
IV steroids are usually given first-line
-IV ciclosporin may be used if steroids are contraindicated
47
What is 1st line tx for maintaining remission in UC?
Topical (rectal) aminosalicylate
48
What is the tx for maintaining remission following a severe relapse or >=2 exacerbation in the past year?
Oral azathioprine or oral mercaptopurine
49
What blood test distinguishes between IBS and IBD?
Faecal calprotectin
50
What is Coeliac's disease?
A systemic autoimmune disease triggered by dietary gluten peptides that cause inflammation in the small bowel
51
What are the signs and sx of Coeliacs?
- Diarrhoea
- Steatorrhoea
- Abdominal pain
- Bloating
- Irritable bowel syndrome
- Faltering growth
- Prolonged fatigue
- Mouth ulcers
- Deficiencies
- Dermatitis herpetiformis
52
List the complications of coeliac's?
anaemia- Iron, Folate, Vitb12
Hyposplenism
Osteoporosis
Enteropathy assocated T cell lymphoma
53
What is the 1st line Ix for coeliacs?
Tissue transglutaminase (TTG) antibodies (IgA)
54
What is the GS Ix for coeliacs?
Endoscopic intestinal biopsies
55
What findings on endoscopy and biopsy are supportive of coeliacs disease?
villous atrophy
crypt hyperplasia
increase in intra epithelial lymphocytes
lamina propria infiltration with lymphocytes
56
What is the mx of coeliac's disease?
Gluten free diet
57
What foods should be avoided in coeliacs?
Wheat; bread, pasta, pastry
Barley; beer
Rye
Oats
58
List foods which are gluten free?
Rice
potatoes
Corn (Maize)
59
What advice should be given to patients with suspected coeliacs before they undergo any testing?
Should eat gluten for 6 weeks prior
60
List the RF of GORD?
Obesity
Smoking
Alcohol
Coffee
Drugs (TCAs, CCBs, Nitrates)
Over-eating , eapsecially fatty meals
Hiatus hernia
Pregnancy
61
What is the 2 main contributing factors of GORD?
Lower oesophageal sphincter abnormalities
Transient LOS relaxation
62
List the sx of GORD?
Heartburn- retrosternal sensation worse by stooping, straining and lying
Belching
Acid Brash
Odynophagia
Nocturnal asthma
63
What is the GS Ix for GORD?
Oesophageal manometry
64
What is the mx of GORD?
Lifetsyle inetrventions
PPIs
65
What is the mx of a perianal fistula in a patient with Crohn's?
Oral metronidazole
66
What are the two types of oesophageal cancer?
1. Adenocarcinoma
2. Squamous cell carcinoma
67
What are the RF for oesophageal adenocarcinoma?
GORD
Barretts
Smoking
Obesity
68
What part of the oesophageal adenocarcinoma?
Lower 1/3rd of oesophagus (More prevalent in developed world)
69
What part of the oesophageal squamous cell carcinoma?
Upper 2/3rds of oesophagus
70
List the RF for oesophageal squamous cell carcinoma?
Smoking
Alcohol
Achalsia
Plummer visson
Diets rich nitrosamine
71
List the causes of acute pancreatitis?
**I GET SMASHED**
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion sting
Hypercalcaemia
ERCP
Drugs (NSAIDs, Azathioprine, Furosemide)
72
List the 2 most common causes of acute pancreatitis?
Gallstones and Alcohol
73
List the clincial features/sx of acute pancreatitis?
Epigastric pain radiating to the back
Nausea and Vomiting
Epigastric tenderness
74
List the signs that may be found on examination in acute pancreatitis?
Cullen’s sign - periumbilical bruising
Grey-turner’s sign - bruising in the flanks
75
What Ix are done for acute pancreatitis?
Serum amylase or serum lipase (3 x the upper limit of normal - diagnostic)
USS- Gallstones
Contrast CT- pancreatic oedema
76
How is the severity of pancreatitis classified?
Glasgow score (score of >=3 predicts severe pancreatitis)
Mnemonic - PANCREAS:
PaO2 < 8 / Age > 55 / Neutrophils > 15 / Ca < 2 / Renal – Urea > 16 / Enzymes – AST>200/LDH>600 / Albumin < 32 / Sugar >10
77
What are the causes of chronic pancreatitis?
The primary cause of chronic pancreatitis is chronic alcohol excess.
Cystic fibrosis
Pancreatic cancer
78
List the sx of chronic pancreatitis?
Epigastric pain, typically exacerbated after eating fatty food and relived by sitting forward
Bloating
WL
Steatorrhoea
Diabetes mellitus
79
What Ix are done in chronic pancreatitis?
Amylase/lipase are often normal in chronic disease
Low faecal elastase - demonstrates exocrine dysfunction
Imaging
AXR - pancreatic calcification
CT - pancreatic atrophy, calcification, pseudocysts
80
What is the mx of chronic of pancreatitis?
Management of underlying causes
Exocrine supplementation
CREON / pancreatin – 50,000 units with each meal + 25,000 with snacks
Analgesia
81
What is acute cholangitis?
bacterial infection due to bile duct obstruction. Most commonly due to E.coli
82
What are the clinical features of Acute cholnagitis?
Charcot's triad (fever, right upper quadrant pain, jaundice)
Reynolds' pentad (Charcot’s plus hypotension, altered mental status) in severe case
Nausea/vomiting, lethargy, pale stools and dark urine
83
What is the 1st line imaging in acute cholangitis?
USS
84
What would blood tests show in acute cholangitis?
Elevated liver function tests (raised ALP and/or bilirubin)
Elevated inflammatory markers
85
What is the 1st line and GS mx for acute cholangitis?
Immediate:
IV fluids
Antibiotics- for example ceftriaxone and metronidazole
Definitive:
(ERCP) or (PTC)
86
What are the stages of alcoholic liver disease?
ALD has 3 stages of liver damage:
1. Fatty liver (Steatosis)
2. Alcoholic hepatitis (Inflammation and necrosis)
3. Alcoholic liver cirrhosis
87
What are the LFTs in alcoholic liver disease?
Liver Function Tests (LFTs):
AST > ALT: Typically in a ratio greater than 2:1,
Elevated bilirubin: Reflecting impaired liver function.
Alkaline phosphatase (ALP): May be moderately elevated.
88
What is the mx of alcoholic liver disease?
Alcohol cessation
Nutritional support
1st line- Glucocorticoids (If severe)
2nd line- Pentoxifylline
89
List the sx of appendicitis?
Abdominal pain
Classically vague, central abdominal pain which subsequently migrates to the right iliac fossa
Nausea and vomiting, anorexia
90
What are the examination signs/findings
Abdominal pain, worst over McBurney’s point, with rebound and percussion tenderness
Rovsing’s sign - RIF pain on palpation of LIF
Psoas sign - RIF pain with extension of right hip
91
What is the 1st line imaging in appendicitis?
USS
92
What is the classification of ascites?
The SAAG
SAAG > 11 = Portal hypertensive ascites
SAAG < 11 = Non portal hypertensive ascites
93
List the causes of asictes wih SAAG >11
Liver cirrhosis
Alcoholic hepatitis
Acute liver failure
Budd chiari / portal vein obstruction
Spontaneous bacterial peritonitis (SBP)
Heart failure
94
List the causes of ascites with SAAG <11
Nephrotic syndrome
Hepato-renal syndrome
Protein losing enteropathies
Peritoneal carcinoma or TB
95
What is the mx of ascites?
Undress underlying cause
Salt and fluid restriction
Spironalactone
96
What is the abx of choice for tx of SBP?
Intravenous Tazocin (piperacillin-tazobactam)
97
What is cholecystitis?
Inflammation of gallbladder, most commonly due to gallstones
98
What sign are you looking for in acute cholecystitis?
Murphy’s sign- inspiration inhibited by pain on palpation when examiner’s hand positioned along costal margin)
99
What is the mx of acute cholecystitis?
Admit to hospital
Supportive
Intravenous fluids
Antibiotics
Analgesia
ERCP if stones in common bile duct
25-30% require surgery (cholecystectomy) or develop complications
100
What is Mirizzi Syndrome?
Stone in Hartmanns pouch or cystic duct causes compression of adjacent common hepatic duct (and therefore causes obstructive jaundice)
101
List the sx and signs of autoimmune hepatitis?
Fever
Jaundice
Amenorrhoea
Glomerulonephritis
acute hepatitis (deranged ALT/AST)
Fatigue
Anorexia
Hepatosplenomegaly
102
What would the bloods be in autoimmune heaptitis be?
Elevated AST/ALT
INR elevated
Antibodies
* Anti smooth muscle
* Anti liver Kidney microsomal
* Anti soluble liver antigen
**Hypergammaglobulinaemia **
103
What is the mx of autoimmune hepatitis?
initial mx- Prednisolone/steroids
Maintanence- Azathioprine
2nd line-immunosuppressants
Transplant
104
What is PBC?
an autoimmune condition that causes granulomatous inflammation of intrahepatic bile ducts, resulting in scarring and eventually leading to liver cirrhosis.
105
List the sx of PBC?
**Classically a middle-aged female with pruritus and fatigue**
Extreme fatigue
Pruritus (itching)
Xerosis (dry skin)
Sicca syndrome (dry eyes)
RUQ pain
Xanthelasma
Clubbing
Jaundice
106
What other autoimmune disease is strongly associated with PBC?
Sjogren's disease
107
What would the blood results be for PBC?
Abnormal LFTs- Raised ALP
Positive Anti-mitochondrial antibodies
Raised IgM
108
What is the 1st line imaging in PBC?
Abdominal USS- rule out extrahepatic biliary obstruction
109
What is the GS Ix for a diagnosis PBC?
Liver biopsy
110
What is the mx of PBC?
1st LINE: URSODEOXYCHOLIC ACID - reduces symptoms, slows disease progression
Symptom relief - cholestyramine can help pruritus
Liver transplant (especially once bilirubin >100)
111
List the complications of PBC?
Liver cirrhosis & portal hypertension resulting in varices, ascites etc
**Hepatocellular carcinoma**
112
What is PSC?
Inflammation of the intra AND extra hepatic bile ducts, with subsequent fibrosis
113
What Ix are indicated in PSC?
Deranged LFTS- cholestatic picture
Positive anti smooth muscle and P-ANCA
Hypergammaglobulinaemia
Imaging- ERCP/MRCP
114
What would be seen on imaging in PSC?
Multiple beaded biliary strictures seen on MRCP/ERCP
115
What is a complication of PSC?
Cholangiocarcinoma
116
What is acalculous cholecystitis?
No gallstones, often functional cystic duct obstruction
Risk factors- associated sepsis, trauma, major surgery, burns, on TPN
117
What sis the 1st line Ix for acute cholecystitis and list the findings?
Abdominal ultrasound-
Thickened gallbladder wall, gallstones or sludge in gallbladder or fluid around gallbladder
118
What is the most common type of colorectal cancer?
Adenocarcinoma
119
List the rf for colorectal cancer?
Increasing age
Hereditary syndromes
*Familial adenomatous polyposis
*Hereditary nonpolyposis colorectal cancer (Lynch Syndrome)
*Juvenile polyposis
Peutz-Jeghers syndrome
Increased alcohol intake
Smoking tobacco
Processed meat
Obesity
Previous exposure to radiation
Inflammatory bowel disease
120
List the signs and sx of colorectal cancer?
Rectal bleeding
Unexplained WL
Change in bowel habit
Abdominal pain
IDA
Bowel obstruction
121
What is the current NHS screening programme for bowel cancer?
Faecal immunochemical test (FIT) every 2 years for men and women age 60-74. If positive patients are referred for colonoscopy.
122
What is the 2ww referral criteria for suspected lower GI cancer?
Age 40 years or more:
Weight loss AND abdominal pain
Age 50 years or more :
Unexplained rectal bleeding
Age 60 years or more:
A change in bowel habit OR
Unexplained iron-deficiency anaemia
Positive FIT
123
What is the gold standard ix for colorectal cancer?
colonoscopy
if colonoscopy CI- CT colonoscopy
124
How is colorectal cancer tx monitored?
CEA levels can monitor treatment response or identify recurrence
125
What is the mx of acute constipation?
1. Underlying causes
2. Lifestyle measure- Increase dietary fibre, Ensure adequate fluid intake
mx-
1st line: Bulk-forming laxatives (e.g. ispaghula)
2nd line:
*If stools remain hard, add/switch to an osmotic laxative (e.g. macrogol).
*If macrogol is ineffective or not tolerated, offer lactulose
If stools are soft but difficult to pass:
Add a stimulant laxative.
126
What is the choice of laxative in opioid induced constipation?
Use osmotic laxative and stimulant laxative (or docusate).
127
What laxatives should be avoided in opioid induced constipation?
Avoid bulk-forming laxatives.
because they can worsen the problem by increasing stool bulk in the context of slow gut movement, leading to risks of obstruction or impaction.
128
What is the laxatives of choice in faecal impaction:
Hard stools: Start with high-dose macrogol, add stimulant if needed.
Soft stools: Consider bisacodyl suppository or mini enema if oral treatment fails.
129
What is diverticulosis?
The presence of asymptomatic diverticula
130
What is diverticular disease
The presence of diverticula with associated symptoms (abdominal pain, altered bowel habit)
131
What is Diverticulitis?
Inflammation of the diverticula, can be infective in aetiology
132
What are the features of acute diverticulitis?
Severe lower abdominal pain - classically sharp pain, worst in the LIF
Systemic upset - malaise, pyrexia, tachycardia
PR bleeding
Features of complications - abscess, perforation - referred to as complicated diverticulitis
133
What is the 1st line ix in acute diverticulitis?
CT abdomen-pelvis -
134
What is the mx of acute diverticulitis?
Admit if systemically very unwell/suspected complicated diverticulitis
PO Antibiotics: 1st Line (NICE): Co-amoxiclav 625mg TDS 5 days if managed in primary care
Penicillin allergy: cefalexin 500mg TDS plus metronidazole 400mg TDS 5 days
135
List the RF of gallstones?
Female
Obesity
Middle aged (> 40)
Pregnancy
Diabetes
Smoking
Ileal disease
Family history
TPN use
Prolonged fasting
136
What is biliary colic?
Gallbladder spasm against stone impacted in Hartmann's pouch (neck of gallbladder)
137
What are the sx of biliary colic?
Sudden onset RUQ pain
Colicky (intermittent) in nature
May radiate to shoulder blades/back
Worse following eating fatty foods
Pain resolves after a few hours
Associated nausea/vomiting
No fever
138
What are the Ix of biliary colic?
Bloods normal including LFTs
US abdomen
Gallstones present
139
What is the most common type of gastric cancer?
Adenocarcinomas most common
Histology
Signet ring cell appearance
140
What is zollinger Ellison syndrome?
Occurs in the presence of a gastrinoma – a tumour with autonomous secretion of gastrin resulting in high levels of gastric acid
30% of cases occur in the context of MEN1
141
What are the clinical features of zollinger Ellison syndrome?
Multiple gastro-duodenal ulcers
Epigastric pain, diarrhoea, malabsorption
142
WHat is the 1st line Ix of zollinger-Ellison syndrome?
First line: Fasting gastrin levels
Alt: Secretin stimulation test (secretin normally suppresses gastrin)
143
What is gilbert's syndrome?
Autosomal recessive condition in which there is a mild deficiency in UDP-glucuronyl transferase (UDP-GT)
144
What is the classic sx of Gilbert syndrome?
Jaundice during illness.
145
What are ix for gilberts syndrome?
Bilirubin - not in urine (unconjugated)
Diagnosis: Increased bilirubin after fasting or IV nicotinic acid
146
What is Budd chiari syndrome?
AKA Hepatic vein thrombosis, is usually seen in the context of underlying haematological disease or another procoagulant condition.
147
