GI inc liver Flashcards
what is acute cholangitis?
infection of the biliary tree caused by biliary outflow obstruction
how does acute cholangitis present?
RUQ pain
fever
jaundice
what is biliary colic?
RUQ pain caused by impacted gallstone at the neck of the gallbladder
what is the trigger for biliary colic?
consumption of fatty foods
how does biliary colic present?
RUQ pain
no fever no jaundice
how does cholecystitis present?
RUQ pain
fever
no jaundice
what is the pathophysiology of acute pancreatitis?
inflammation caused by hypersecretion or back flow of exocrine enzymes which result in auto digestion of the pancreas
what are the causes of pancreatitis?
I - idiopathic
G - gallstones
E - ethanol
T - trauma
S - steroids
M - malignancy / mumps
A - autoimmumne disease
S - scorpion sting
H - hypercalcaemia
E - ERCP
D - drugs
how does acute pancreatitis present?
epigastric pain that radiates to back, is worse after meals and is better leaning forward
nausea and vomiting
decreased appetite
what is the diagnostic criteria for acute pancreatitis?
2 of 3 of:
abdo pain and history suggestive of acute pancreatitis
serum amylase / lipase over 3x the upper lim of normal
imaging findings suggestive
what are the 2 most common causes of acute pancreatitis?
gallstones and alcohol
what is the management of gallstone pancreatitis?
ERCP
cholecystectomy on all pts in the same hospital admission
what is the management of alcohol induced pancreatitis?
benzos for withdrawal
thiamine, folate and B12
how does the pain in appendicitis migrate?
initially it produces umbilical pain
as it progresses it produces localised pain in the right iliac fossa
what is Murphys triad in appendicitis?
low grade fever
nausea and vomiting
right iliac fossa pain
what is the first line imaging in appendicitis?
ultrasound
what is the management of appendicitis?
appendectomy
what is cholecystitis?
inflammation of the gallbladder usually secondary to gallstones
what is the most common type of colorectal cancer?
adenocarcinoma
what do most colorectal cancers arise from?
pre cancerous polyps
what is reccomended for pts who have red flag symptoms for colorectal cancer?
faecal immunoglobulin testing (FIT)
what happens if the FIT is positive?
the pt should be referred on an urgent suspected cancer pathway (2 wk wait)
what is the gold standard diagnostic test for colorectal cancer?
colonoscopy
almost all coeliac pts are positive for what?
HLA DQ2
which antibody is diagnostic of coeliac if strongly positive?
anti tTG
how often do pts w/ coeliac disease need the pneumococcal vaccine?
every 5 yrs
what are diverticula?
mucosal out-pouches in the colonic musculature
what its diverticulosis?
the presence of diverticula w/out symptoms
what antibiotic is most commonly used for the treatment of a diverticulitis flare?
co amoxiclav
what is the management of a pt w/ dysphagia (difficulty swallowing)?
urgent 2 wk referral for endoscopy
how long do you need to stop a PPI before a h. pylori test?
2 wks
what is Barretts oesophagus?
when the lower oesophageal epithelium changes from squamous to columnar epithelium (metaplasia) due to chronic acid reflux
what is the risk of Barretts oesophagus?
it is a pre malignant condition and a significant risk factor for developing oesophageal adenocarcinoma
what is Zollinger-Ellison syndrome?
a rare condition where a duodenal or pancreatic tumour secretes excess quantities of gastrin (hormone that stimulates acid secretion)
what is the likely diagnosis when there is a metabolic acidosis and hypokalaemia?
prolonged vomiting
what is involved in a trans jugular intrahepatic portosystemic shunt (TIPS)?
connecting the hepatic vein into the portal vein
what is the management of pharyngeal pouch?
surgical repar
how does a pharyngeal pouch present?
dysphagia
halitosis
regurgitation
coeliac disease increases the risk of developing which cancer?
T cell lymphoma
a recurrent episode of c diff w/in 12 wks of symptom resolution should be treated w/ what?
fidaxomicin
what is the first line treatment for c diff?
10 days of vancomycin
what is the likely diagnosis of a pt w/ T2DM and abnormal LFTs?
non alcoholic fatty liver disease
what does positive anti-HBc IgG indicate?
chronic hepatitis B
think C and G are kinda similar
what does positive anti-HBc indicate?
acute hepatitis B infection
think A and B are close together in alphabet
which medications are a risk factor for c dif?
PPIs
what is the investigation of choice for a suspected pharyngeal pouch?
barium swallow w/ fluoroscopy
what is primary biliary cholangitis?
a chronic liver disorder commonly seen in females - thought to be autoimmune
what is the M rule for primary biliary cholangitis?
IgM - raised serum IgM
anti Mitochondrial antibodies, M2 subtype
Middle aged women
what its life threatening c dif treated w/?
oral vancomycin and IV metronidazole
what is GORD caused by?
stomach acid flowing through the lower oesophageal sphincter and into the oesophagus
what is a hiatus hernia?
when the stomach herniates up through the diaphragm
what are the 3 key complications of hernias?
incarcerations
obstruction
strangulation
what is incarceration (hernia complication)?
when the hernia cannot be reduced back into its proper place
what is obstruction (hernia complication)?
when the hernia causes an obstruction in the passage of faeces through the bowel
what is strangulation (hernia complication)?
when the hernia is non reducible and the base of the hernia twists cutting off the blood supply
what is an indirect inguinal hernia?
when the bowel herniates through the inguinal canal
where does the inguinal canal run between?
the deep inguinal ring and the superficial inguinal ring
what does a direct inguinal hernia occur due to?
a weakness in hesselbachs triangle
how can you differentiate a direct inguinal hernia from an indirect inguinal hernia?
when pressure is applied over the deep inguinal ring an indirect hernia will remain reduced whereas it will not stop herniation for a direct inguinal hernia
what is a femoral hernia?
when there is herniation of abdominal contents through the femoral canal
what is a sliding hiatus hernia?
when the stomach slides up through the diaphragm w/ the gastro-oesophageal junction passing up into the thorax
what is a rolling hiatus hernia?
when a separate part of the stomach folds around and enters through the diaphragm opening along w/ the oesophagus
what is autoimmune hepatitis?
a rare cause of chronic hepatitis (inflammation in the liver)
who does type 1 autoimmune hepatitis usually affect?
women in their 40s-50s
what is a hepatitis picture on bloods?
raised ALT and AST
no change to ALP
what immunoglobulin is raised in autoimmune hepatitis?
IgG
what are the liver biopsy findings of autoimmune hepatitis?
interface hepatitis
plasma cell infiltration
what is the management of autoimmune hepatitis?
high dose steroids (prednisolone)
immunosuppressants (azothioprine)
what is the most common viral hepatitis in the world?
hepatitis A
how is hepatitis A diagnosed?
IgM antibodies
what is the management of hepatitis A?
usually self limiting
how is hepatitis A transmitted?
faecal oral route
usually through contaminated foods
what type of virus is hepatitis A?
RNA
what type of virus is hepatitis B?
double stranded DNA
how is hepatitis B transmitted?
through blood or bodily fluids
mother to baby (vertical transmission)
what does HBsAg indicate in hepatitis B?
active infection
what does HBeAg indicate in hepatitis B?
high infectivity
what does HBcAb indicate in hepatitis B?
current or past infection
what does HBsAb indicate?
vaccination, past or current infection
what is HBV DNA in hepatitis B?
a direct count of the viral load
what type of virus is hepatitis C?
an RNA virus
how is hepatitis C transmitted?
blood and bodily fluids
what is the management of hepatitis C?
it is curable w/ direct acting antiviral medications
what is the duration of treatment for hepatitis C?
8-12 wks
what type of virus is hepatitis D?
RNA virus
hepatitis D pts can only survive in pts w/ what?
hepatitis B
what is the impact of hepatitis D on hepatitis B?
increases the severity and complications of hepatitis B
what type of virus is hepatitis E?
RNA virus
how is hepatitis E transmitted?
faecal oral route
what is the management of hepatitis E?
nothing it is usually self limiting
what are haemorrhoids?
enlarged anal vascular cushions
what are haemorrhoids assoc w/?
constipation / straining
increased abdo pressure from weight lifting and coughing
pregnancy
obesity
increased age
what are the anal cushions?
specialised submucosal tissue that contain connections between the arteries and the veins
what is a first degree haemorrhoid?
no prolapse
what is a second degree haemorrhoid?
prolapse on straining and return inside the anus when relaxing
what is a third degree haemorrhoid?
prolapses on straining and does not return on relaxing but can be pushed back inside
what is a fourth degree haemorrhoid?
permanently prolapsed
how do haemorrhoids present?
fresh bright red blood on wiping that is not mixed in w/ the stool
what are the features of Crohns disease?
N - no blood or mucus
E - entire GI tract affected (mouth to anus)
S - skip lesions on endoscopy
T - terminal ilium most affected and transmural thickness
S - smoking is a risk factor (don’t set the nest on fire)
what are the features of ulcerative colitis?
C - continuous inflammation
L - limited to the colon and rectum
O - only superficial mucosa affected
S - smoking may be protective
E - excrete blood and mucus
U - use aminosalicylates
P - primary sclerosising cholangitis
what is the initial test for inflammatory bowel disease?
faecal calceprotein
what is the investigation of choice for inflammatory bowel disease?
colonoscopy w/ multiple intestinal biopsies
explain the management of mild to moderate ulcerative colitis?
aminosalicylate (e.g. mesalazine) first line
corticosteroids (e.g. prednisolone) second line
what is the management of severe ulcerative colitis?
iv steroids
what is the most definitive management for ulcerative colitis and why
removal of the entire large bowel and rectum (panproctocolectomy)
because ulcerative colitis only affects the large bowel and rectum
how is remission induced in crohns disease?
steroids (oral prednisone or IV hydrocortisone) first line
what is used first line for maintaining remission in crohns disease?
aziothioprine
how long does a pt need to have had symptoms for before a diagnosis of IBS can be made?
6 months
in patients w/ suspected variceal haemorrhage what should be given before endoscopy?
ABs ans terlipressin
what is the first line treatment for diarrhoea in IBS?
loperamide
what is the best marker for acute liver dysfunction and why?
prothrombin time
because liver enzymes are misleading in the context of acute liver failure and so coagulation factors and albumin are more indicative of the organs current state
prothrombin time has a shorter half life than albumin making it a better measure of acute liver failure
what are pts on long term PPIs at risk of getting?
c diff
what electrolyte imbalance can PPIs cause and how?
hyponatraemia through SIADH
what can be used to stop an uncontrolled variceal haemorrhage?
insertion of a sengstaken - Blakemore tube
what is the screening tool used to screen for malnutrition?
MUST
what is the first line antibiotic used to treat c diff?
vancomycin
what is the technique to stop variceal bleeding if it is oesophageal?
endoscopic band liigaton
what is the double duct finding on MRCP indicative of?
pancreatic cancer
what is the double duct sign on MRCP?
dilation of the common bile ducts and the pancreatic duct
pts w/ haemocrhomatosis are at increased risk of what?
hepatocellualr carcinoma
what is the most common cause of hepatocellualr carcinoma worldwide?
chronic hepatitis B
what is the inheritance pattern of Wilsons disease?
autosomal recessive
what is Wilsons disease?
autosomal recessive disorder that results in excess copper deposition in the tissues (esp brain liver and cornea)
what age is the typical onset of symptoms of Wilsons disease?
10-25 y/o
how do children w/ Wilsons typically present?
liver disease
how do young adults w/ Wilsons typically present?
neurological symptoms
what are the ALT, urinary copper and serum caeruloplasmin findings in Wilsons disease?
ALT raised
urinary copper raised
serum caeruloplasmin reduced
what blood test can be used to differentiate an upper GI bleed from a lower GI bleed?
high urea levels indicate an upper GI bleed
what is the hallmark symptom of refeeding syndrome?
hypophosphataemia
which 2 electrolyte imbalances can cause torsades de points in refeeding syndrome?
hypokalaemia
hypomagnesaemia
which cereals contain gluten?
wheat
barley
rye
oats
what is used in the management of crohns patents who develop perinanal fistulas?
oral metronidazole
what is hepatorenal syndrome?
AKI in pts w/ advanced liver disease
what is type 1 hepatorenal syndrome?
rapid onset (less than 2 wks)
what is type 2 hepatorenal failure?
more gradual decline in renal function typically associated w/ refractory ascites
what is the first line management for small bowel bacterial overgrowth syndrome?
rifaximin
what should be used to treat pts w/ ascites secondary to alcoholic cirrhosis?
spironolactone
what is pernicious anaemia?
an autoimmune condition that results in reduced absorption of vitamin B12 due to antibodies targeting intrinsic factor
when is endoscopic intervention required for Barretts oesophagus?
when there is dysplasia of any grade identified
what is the diagnostic investigation of choice for pancreatic cancer?
high resolution CT scan
what is the likely diagnosis when there is dysphagia to both solids and liquids?
achalasia
what is seen on a barium enema of a pt w/ ulcerative colitis?
loss of haustral markings giving a lead pipe colon appearance
are the majority of pancreatic cancers endocrine cancers or exocrine cancer?
95% exocrine
painless obstructive jaundice is what until proven otherwise?
pancreatic cancer
what are the majority of pancreatic cancers?
adenocarcinomas
where in the pancreas do most pancreatic cancers occur?
the head of the pancreas
what are the 4 sites that pancreatic cancers usually metastasise to?
the liver
the peritoneum
the bones
the lungs
give 4 features of the presentation of pancreatic cancer?
jaundice
pale stools
dark urine
generalised itching
what is an important consideration if a pt has worsening glycemic control despite good compliance and good lifestyle modificaitons?
pancreatic cancer
what is the likely diagnosis when there is jaundice and a palpable gallbladder?
cholangiocarcinoma or pancreatic cancer
the diagnosis is unlikely to be gallstones
what is migratory thrombophlebitis and what is it indicative of?
blood clot in inflamed blood vessels that recurs at dif times and dif locations
indicative of pancreatic cancer
how is pancreatic cancer diagnosed?
imaging (CT scan)
and biopsy of lesion
which tumour marker may be raised in pancreatic cancer?
Ca 19 - 9
which type of oesophageal cancer develops as a result of GORD?
adenocaricinoma
what is used for the prophylaxis of bleeding in stable oesophageal varices?
propanolol first line
variceal band ligation if beta blockers are contraindicated
what is spontaneous bacterial peritonitis?
an infection developing in the ascitic fluid and peritoneal lining w/out a clear source of infection
what are the 2 most common causative organisms in spontaneous bacterial peritonitis?
e coli
klebsiella
what is hepatorenal syndrome?
impaired kidney function caused by changes to the blood flow to the kidneys relating to liver cirrhosis and portal hypertension
what is the most common cause of ascites?
portal hypertension which is usually due to liver cirrhosis
what is haemochromatosis?
an iron storage disorder that results in excess total body iron and the deposition of iron in body tissues
what is the inheritance pattern of the mutation on the HFE gene seen in haemochromatosis?
autosomal recessive
when does haemochromatosis typically present and why?
after the age of 40 as it takes time for enough iron to build up in the body to cause symptom
after menopause in women as menstruation actively gets rid of iron
how does haemochromatosis present?
hair loss
cognitive issues
chronic fatigue
bronzed skin
sexual dysfunction and amenorrhoea
joint pain
what are the blood tests findings that indicate iron overload and so haemochromatosis?
high ferritin
high transferrin saturation
low total iron binding capacity
what is the management of haemochromatosis?
venesection
what is the likely diagnosis of green watery diarrhoea following choecystectomy?
bile acid malabsorption
what is the treatment of bile acid malabsorption?
cholestyramine
what is the most common cause of gastrointestinal varices?
portal hypertension
what is the main complication that pts w/ primary sclerosing cholangitis are at risk of?
cholangiocarcinoma
what is the most common cause of pseudomembranous colitis?
c diff
how does Budd chiari syndrome present?
triad of:
sudden onset abdo pain
ascites
tender hepatomegaly
what is Budd chiari syndrome?
hepatic vein thrombosis
what is Gilberts syndrome?
a hereditary condition in which pts have transient raises in bilirubin esp during times of stress
what is the best marker used to monitor treatment in haemochromatosis?
transferrin saturation
what is melanosis coli and what is it most commonly assoc w/?
a disorder of pigmentation of the bowel wall
most commonly assoc w/ laxative abuse
what are the 2 electrolyte imbalances that PPIs can cause?
hyponatraemia
hypomagnasaemia
why is osteomalacia seen in untreated coeliac disease and how does this present?
osteomalacia seen in untreated coeliac disease due to reduced absorption of vitamin D
indicated by low levels of Ca, phosphate and vitamin D
what is the most prominent symptom of crohns disease in children?
abdominal pain
what is Plummer Vinson syndrome?
triad of:
dysphagia
iron deficiency anaemia
glottitis
what is mailer Weiss syndrome?
severe vomiting leads to mucosal lacerations at the gastroesoohageal junction leading to haematemesis
common in alcoholics
what is boerhaave syndrome?
severe vomiting leads to oesophageal rupture
what is the AST:ALT ratio in alcoholic hepatitis?
> 2
what is hepatorenal syndrome?
a functional kidney impairment seen in pts w/ liver disease
what are the 3 key features of hepatorenal syndrome?
ascites
low urine output
significant increase in serum creatinine
what is the first line treatment for hepatorenal syndrome?
terlipressin
how does terlipressin help in hepatorenal syndrome?
causes splanchnic vasoconstriction which reduces portal pressure and improves renal blood flow
what is type 1 hepatorenal syndrome?
rapidly progressive
very poor prognosis
what is type 2 hepatorenal syndrome?
slowly progressive
poor prognosis
how can phaeochromocytoma be differentiated from carcinoid syndrome?
both present very similarly but phaeochromocytoma causes pale and meaty skin whereas carcinoid syndrome causes dry and flushed skin
what are the characteristic findings of autoimmune hepatitis?
+ve anti ANA
+ve anti smooth muscle
raised IgG
what is peutz jegher syndrome?
an autosomal dominant condition where pts develop polyps throughout the GI tract and melanotic macula’s on the mouth, lips, genitals, palms and soles
what is the risk w/ peutz jegher syndrome?
that the polyps develop into cancer
what is the management of any pt w/ Barretts oesophagus when high grade dysplasia is identified?
endoscopic mucosal therapy
which area is most likely to be affected by ischaemic colitis?
the splenic flexure
what are the blood test findings of small bowel ischaemia?
high WCC
metabolic acidosis
what is used to induce remission in crohns disease?
steroids
what is used to maintain remission in crohns disease?
azathioprine or mercaptourine
how does boerhaave syndrome present?
an episode of vomiting followed by severe chest pain and shock
how can hepatitis b immunity from natural infection be differentiated from immunity due to vaccination?
anti HBs +ve in both natural infection and vaccination
anti HBc only +ve in immunity from natural infection
how does Wilsons disease present?
a combination of neurological symptoms and liver symptoms
what do signet ring cells on biopsy indicate?
gastric adenocarcinoma
what is the most commonly used diagnostic marker for carcinoid syndrome?
5 HIAA
what is the first line test used to diagnose all bowel over growth syndrome?
hydrogen breath test
what is the treatment for Wilsons disease?
penicillamine
what is the only test recommended for H pylori erradication?
urea breath test
in a pt w/ variceal haemorrhage, what should be given before they have an endoscopy?
terlipressin and IV ABs
which antibody may be positive in primary sclerosing cholangitis?
pANCA
what must you look at in order to be able to interpret TTG levels in coeliac disease?
IgA level
what is the first line for inducing remission in crohns disease?
glucocorticoids (prednisolone)
what is the first line for maintaining remission in crohns disease?
azathioprine
what is used to treat bile acid malabsorption?
cholestyramine
how should pts w/ severe colitis be investigated?
flexible sigmoidoscopy
because colonoscopy should not be done due to risk of perforation
what is the nail change seen in crohns disease and why does it occur?
koilonychia
occurs due to iron deficiency anaemia
what are the biopsy findings of coeliac disease?
villous atrophy
crypt hyperplasia
intraepithelial lymphocytes
pts w/ coeliac disease are at an increased risk of developing which cancer?
enteropathy assoc T cell lymphoma
what is the inheritance pattern of Peutz Jeghers syndrome?
autosomal dominant
what is the surgical treatment of achalasia?
Heller cardiomyotomy
what is the most significant lab finding in Wilsons disease?
reduced serum caeruloplasmin
what is caeruloplasmin?
a copper carrying protein
why is serum caeruloplasmin reduced in wilsons disease?
because its synthesis is impaired in wilsons disease due to intracellular copper overload
in ascites what does a high serum ascitic albumin gradient (SAAG) >11g/l indicate?
portal hypertension and so likely liver cirrhosis
what is the primary treatment of wilsons disease?
penicillamine (metal chelating agent used to remove the excess copper)
where is the most common site affected in UC?
the rectum
which medications should be stopped in c diff iinfectons?
oromorph
what are the findings of someone who has hep B immunity only through vaccination?
anti HBs positive
all others negative
which 2 things are used to monitor treatment in haemochromatosis?
ferritin and transferrin saturation
what is used for h pylori eradication therapy?
PPI + clarithromycin + metronidazole
OR
PPI + clarithromycin + amoxicillin
what is used to treat the symptoms of carcinoid syndrome?
octreotide (somatosatin analogue)
a lemon tinge to the skin is assoc w/ what and why does it occur?
assoc w/ pernicious anaemia
occurs due to pallor due to anaemia and mild jaundice due to haemolysis
what is the investigation of choice for perinea fistulae in pts w/ crohns?
MRI pelvis
how are liver abscesses managed?
ABs and drainage
what is used for the prophylaxis of variceal bleeding?
propanolol
what can be used to differentiate IBD from IBS in primary care?
faecal calprotectin
what is the likely diagnosis when the pt has jaundice, hepatomegaly an raised ANA and anti smooth muscle antibodies?
autoimmune hepatitis
which is better for haemochromatosis screening, transferrin saturation or ferritin?
transferritin saturation
how does hepatitis A present?
flu like symptoms
RUQ pain
tender hepatomeglay
deranged LFTs
how can you differentiate ascending cholangitis from hepatitis A?
a flu like prodrome and tender hepatomegaly suggests hepatitis A
they will both present w/ fever, jaundice and RUQ pain
which vitamin is teratogenic if taken in high doses?
vitamin A
which inflammatory bowel disease is associated with gallstones and why?
crohns disease
because the terminal ileum is affected and this is the area that absorbs bile salts therefore gallstones can form
what is used to maintain remission in a pt w/ UC who has had more than 2 exacerbations in the last year requiring steroids?
oral azathioprine
what is used for determining the severity of c diff infection?
white cell count
what is the first line medication for primary biliary cholangitis?
ursodeoxycholic acid
what is used for prophylaxis for patients who have had a previous episode of spontaneous bacterial peritonitis?
cirpfloxacin
what is the likely diagnosis when there is liver failure following cardiac arrest?
ischaemic hepatitis
how can you differentiate an upper GI bleed from a lower GI bleed?
urea levels are raised n an upper GI bleed
what is the first line laxative used?
bulk forming laxative e.g. isphagula husk
what is an upper GI bleed classified as?
a bleed w/ an origin above the ligament of Treitz
what blood gas abnormality is seen w/ persistent vomiting?
metabolic alkalosis
what is needed for large volume paracentesis and why?
albumin cover
to reduce postparacentesis circulatory dysfunction
what are the xray findings of gallstone ileus?
small bowel obstruction
air in the biliary tree
what are the xray finings of sigmoid volvulus?
coffee bean sign
what is used for the secondary prophylaxis of hepatic encephalopathy?
lactulose and rifaximin
barretts oesophagus increases the risk of having which cancer?
adenocarcinoma of the oesophagus
achalasia increase the risk of having which cancer?
squamous cell carcinoma of the oesophagus
when should PPIs be stopped before an upper GI endoscopy?
2 wks before
what is used for prophylaxis of oesophageal bleeding?
propranolol
what is the most common site affected by crohns disease?
ileum
what is the classic triad of mesenteric ischaemia?
history of cardiovascular disease
high lactate
soft but tender abdo
