GI incorrects Flashcards
30 YO woman. diagnosed with iron deficiency. been taken iron supplements. some looseness of her stools and
low hemoglobin, low mcv, low ferritin
anti-ttg
coeliac disease most likely 30
pernicious anemia would cause macrocytic anemia! and iron deficiency anemia
Patient with hepatomegaly and T2DM. 16 units of alcohol a week. Alt is raised all other LFTs normal. Ferritin very raised. Most appropriate next investigation?
management?
Transferrin saturation to investigate hemochromatosis
venesection
desferroxiamine second line
A 53 year old man has increasing abdominal swelling over several weeks,
with severe abdominal pain developing over the past 12 hours. He drinks one
to two bottles of vodka per day.
He has jaundice. His temperature is 37.6°C. He has spider naevi and
prominent veins on his abdominal wall. His abdomen is diffusely tender.
Investigations:
Haemoglobin 136 g/L (130–175)
White cell count 9.6 × 109
/L (3.8–10.0)
Platelets 160 × 109
/L (150–400)
INR 1.2 (1.0)
ALT 350 IU/L (10–50)
ALP 140 IU/L (25–115)
Bilirubin 78 μmol/L (<17)
Ultrasound scan of abdomen shows ascites with mild hepatosplenomegaly.
what is the most appropriate next step?
ascitic tap!!! - would reveal wbcs with neutrophil predominance
Spontaneous bacterial peritonitis (SBP) should
be suspected in patients with ascites due to cirrhosis who develop symptoms
such as fever, abdominal pain or tenderness, and confusion.
A 53 year old woman has 6 months of worsening tiredness.
She has jaundice, xanthelasma and 7 cm non-tender hepatomegaly.
Investigations:
INR 1.2 (1.0)
ALT 60 IU/L (10–50)
ALP 302 IU/L (25–115)
Bilirubin 50 µmol/L (<17)
Antinuclear antibodies 1:40 (negative at 1:20)
Antimitochondrial antibodies 1:320 (negative at 1:20)
Ultrasound scan of abdomen hepatosplenomegaly, no biliary dilatation
diagnosis?
most appropriate treatment?
primary billiary cirrhosis!!! -> raised ALP, AMA positive, no evidence of obstruction!!!
ursodeoxycholic acid!!!
which type of inflammatory bowel disease involves presence of crypts abscesses!! and depletion of goblet cells?
Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
ulcerative colitis
vs deep ulcers in chrons disease
A 57-year-old woman presents to the Emergency Department with a two-day history of abdominal pain and fever. She has a significant medical history of severe alcoholism, consuming at least 65 units of alcohol per week for the past 10 years. On examination, she appears to be in pain, exhibits a distended abdomen without shifting dullness, and has a jaundiced sclera.
raised lfts
most likely diagnosis?
managment?
alcoholic hepatitis!!
glucocorticoids!! eg prednisolone!!!!
this is not alcohol withrdawal!
this is not hepatic encephalopathy as there is no confusion, if it was, you would use rifaximin
First episode of C difficile treatment?
A recurrent episode of C. difficile within 12 weeks of symptom resolution should be treated wit
treatment for life threatening c difficile infection and criteria?
oral vancomycin aloneee for 10 days.
second line = oral fidoxmycin. must stop oral vancomycin first!!
still doesnt clear up = oral vancomycin + iv metro
oral!! fidaxomicin!!
Oral vancomycin and IV metronidazole. hypotension, ileus, or toxic megacolon.
name the types of surgery based on the location of the colon cancer
Sigmoid colon = High anterior resection
Upper rectum = Anterior resection
Low rectum = Anterior resection
Anal verge = Abdomino-perineal excision of rectum
the colon itself = hemicolectomy
A 55-year-old man presents to the emergency department with progressive abdominal swelling and no significant past medical history. On examination, his abdomen is distended and shifting dullness is present. Fluid aspiration from his abdomen and subsequent blood tests reveal the following results:
Serum albumin 31 g/L
Ascites albumin 11 g/L
What is the most likely cause of his presentation?
a high SAAG gradient (> 11g/L) indicates portal hypertension!!
Liver disorders are the most common cause
cirrhosis/alcoholic liver disease
acute liver failure
liver metastases
Cardiac
right heart failure
constrictive pericarditis
Other causes
Budd-Chiari syndrome
portal vein thrombosis
veno-occlusive disease
myxoedema
low saag indicates a peritoneal cause of ascites, including tuberculous peritonitis and peritoneal mesothelioma or nephrotic syndrome
Patients aged ≥ 60 years with anaemia (even in the absence of iron deficiency) should have a FIT test first to determine need for urgent colorectal cancer pathway referral
If a mild-moderate flare of distal ulcerative colitis doesn’t respond to topical (rectal) aminosalicylates then oral aminosalicylates should be added. still no response, oral corticosteroids.
how should a severe flare be treated?
signs of a severe flare?
admission and iv steroids
Features of severe disease include
>6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers/ an ESR >30mm/hour.
A 64-year-old man presents to the emergency department with abdominal pain that ‘comes and goes’ over the course of the past day. He is vomiting and hasn’t been able to eat. On examination, he has scleral icterus. There is guarding in the right upper quadrant. His heart rate is 110bpm, respiratory rate 25/min, temperature 37.9ºC, BP 100/60 mmHg.
What is the most likely diagnosis?
acute cholangitis!!!
note acute cholecystitis does not cause jaundice. lfts may be normal in acute cholecystitis and amylase may be slightly raised vs 3x upper limit criteria in pancreatitis
similarly fever in cholecystitis and not in biliary colic
ascites secondary to liver cirrhosis treatment?
spirinolactone
how should a colonic tumour with signs of perforation be managed?
(extraluminal air and a paracolic fluid collection). signs and symptoms of perforation (shallow breathing, abdominal distension, hypotension and tachycardia).
end colostomy/ end stoma
hemorrhoids grading system
Grade I Do not prolapse out of the anal canal
Grade II Prolapse on defecation but reduce spontaneously
Grade III Can be manually reduced
Grade IV Cannot be reduced
Ulcerative colitis inducing remission?
Chrons disease inducing remission?
maintaining remission in these conditions?
ulcerative colitis
mild to moderate
= salisciliates (topical/rectal first then oral), then ORAL glucocorticoids
(note you dont stop one, you just add on the next if not enough)
Severe
= IV glucocorticoids. if still not resolving consider IV ciclosporin or surgery
Features of severe disease include
>6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers/ an ESR >30mm/hour.
*note -> if lesion extends past the left-sided colon, oral aminosalicylates should be added to rectal aminosalicylates as first line, as enemas only reach so far
chrons disease
= glucocorticoids immediately to induce remission!! oral topical or iV. eg prednisolone.
maintaining remission
topical mesalazine is used in UC as first line!!! azathioprine and mercaptopurine are reserved for severe or repeated relapses (>/= 2 admissions in last year). think of it as uc is not as extensive as chrons so start with something weaker first = topical mesalazine!!!!!
chrons = azathiprine, mercaptopurine!!!! are first line. can also try methotrexate
He has just returned from a week in Morocco.
Starting on the last day of his holiday, he described watery diarrhoea 4-5 times per day. He describes some mild cramping pains in his abdomen and nausea, but no vomiting. There is no blood in the stool.
He is afebrile and his observations are all normal.
most likely causative organism?
ecoli = travellers diarrhea
not cholera as no signs of dehydration or systemic upset
A 45-year-old man presents with an episode of alcoholic pancreatitis. He makes slow but steady progress. He is reviewed clinically at 6 weeks following admission. He has a diffuse fullness of his upper abdomen and on imaging a collection of fluid is found to be located behind the stomach. His serum amylase is mildly elevated. Which of the following is the most likely explanation?
pseudocyst!!!
typically occurs 4 weeks or more after an attack of acute pancreatitis
Most are retrogastric
contrast pancreatic abscess which typically occur as a result of infected psuedocyst
A 22-year-old nurse is being screened for immunity to communicable diseases prior to commencing employment. The following results are found:
HBsAg negative
anti-HBs positive
anti-HBc (IgG) positive
Based on these results, what is the patient’s hepatitis B status?
previous infection not a carrier/resolved
due to hbc
meanwhile Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg implies chronic HBV infection
if HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective)
Anti-HBc implies previous (or current) infection. IgM anti-HBc appears during acute or recent
must distinguish chronic from acte infection
Patients must eat gluten for at least 6 weeks before they are tested for coeliac disease
woman with lynch sydrome
Other than colorectal cancer, what malignancy is this woman most at risk of developing?
endometrial cancer!!!
more common than ovarian!!
investigation and management of perianal fistula in chrons disease?
management of perianal abscess? how would this present differently?
mri pelvis!!! and oral metronidazole. symptoms of fistula = pain, drainage
incisicion and drainage. abscess
= tender lump next to her anus. On examination, it is warm, tender to touch, and somewhat fluctuant.
diverticular disease diagnosis?
CT abdomen and pelvis
colonoscopy
Which one of the following antibiotics is most likely to cause pseudomembranous colitis?
ceftriaxone!
Cephalosporins, eg cefaclor! and ceftriaxone not just clindamycin, are strongly linked to C.difficile
A 51-year-old woman presents to her general practitioner complaining of lethargy, pallor and dyspnoea. She has a past medical history of coeliac disease, currently managed with a gluten-free diet and hypothyroidism, managed with levothyroxine. The doctor ordered blood tests which show the following:
Hb 98 g/L (115 - 160)
Platelets 190 * 10 9/L (150 - 400)
WBC 5.6 * 10 9/L (4.0 - 11.0)
Reticulocytes 1.2 % (0.5 - 1.5)
MCV 98 fl (76 - 95 fl)
Ferritin 210 ng/mL (20 - 230)
Total iron binding capacity 330 µg/dL (250 - 450)
What is the most likely cause of her presentation?
pernicious anemia!
linked to autoimmune diseases eg thyroid disease
what condition is associated with the development of gallstones?
chrons disease
High quality evidence suggests that epidural analgesia helps to accelerate the return of normal bowel function after abdominal surgery
name some indicators of severe pancreatitis
age > 55 years
hypocalcaemia!!!!
hyperglycaemia!!! - must check blood sugars
hypoxia
neutrophilia
elevated LDH and AST
prognostic factors in pancreatitis
P - PaO2 <8kPa
A - Age >55-years-old
N - Neutrophilia: WCC >15x10(9)/L
C - Calcium <2 mmol/L
R - Renal function: Urea >16 mmol/L
E - Enzymes: LDH >600iu/L; AST >200iu/L
A - Albumin <32g/L (serum)
S - Sugar: blood glucose >10 mmol/L
acute anal fissure treatment?
chronic anal fissure treatment?
dietary advice: high-fibre diet with high fluid intake
bulk-forming laxatives are first-line
lidocaine
Chronic = topical GTN!±
still not resolved = surgery (sphincterotomy) or botulinum toxin
first line treatment of acute pancreatitis?
scoring system for acute pancreatitis?
IV fluid resuscitation + IV opioids!!!
patients dont need to be NBM unless vomiting, patients dont need antibiotics unless evidence of necrosis
glasgow score
which GI condition is associated with secondary osteoarthritis (with hook-like osteophytes at the 2nd and 3rd digits at the metacarpophalangeal joints being pathognomonic) and a slate-grey appearance of the skin.
hemachromatosis!!!
A 22-year-old man presents with 4 episodes of non-bloody diarrhoea in a 24-hour period. He has a past medical history of ulcerative colitis. Observations are within normal limits. He is started on rectal aminosalicylates however there is no improvement.
Blood results are as follows:
Hb 145 g/L Male: (135-180)
Female: (115 - 160)
WBC 8.2 * 109/L (4.0 - 11.0)
Na+ 138 mmol/L (135 - 145)
K+ 4.4 mmol/L (3.5 - 5.0)
Urea 6.2 mmol/L (2.0 - 7.0)
Creatinine 74 µmol/L (55 - 120)
CRP 8 mg/L (< 5)
ESR 12 mm/hr Men: < (age / 2)
Women: < ((age + 10) / 2)
A colonoscopy is performed:
Colonoscopy Diffuse superficial ulceration from the rectum to the hepatic flexure
what treatment is indicated?
oral aminosalicylates as this is a mild to moderate flare!!
A 29-year-old man who is known to have ulcerative colitis is admitted to hospital with a flare of his disease. For the past three days he has been passing up to five bloody stools per day. Over the past 24 hours he has also developed abdominal pain and a low grade pyrexia. Bloods show the following:
Hb 13.9 g/dl
Platelets 422 * 109/l
WBC 10.1 * 109/l
ESR 88 mm/hr
CRP 198 mg/l
What is the most important next investigation to perform?
abdominal xray!!
to rule out toxic megacolon
management of acute diverticulitis?
management of recurrent acute diverticulitis requiring hospitalisation?
Mild attacks of diverticulitis may be managed conservatively with antibiotics.
Peri colonic abscesses should be drained either surgically or radiologically.
Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for a segmental resection.
Hinchey IV perforations (generalised faecal peritonitis) will require a resection and usually a stoma. This group have a very high risk of post operative complications and usually require HDU admission. Less severe perforations may be managed by laparoscopic washout and drain insertion.
A 40-year-old man with known diverticular disease diagnosed on colonoscopy 1 year previously is admitted with acute abdominal pain. His abdomen is maximally tender in the left iliac fossa and he describes pneumaturia. His GP has been giving him metronidazole for 2 days.
next step in management?
CT! to rule out fistula
pneumaturia = gas from bowel in urine/bubbles
An 83-year-old lady with known diverticular disease is admitted with a brisk PR bleed. On assessment the bleeding is settling and her abdomen is soft. Hb 10.2, other blood tests are normal
next step in management
active observation!!
Diverticular bleeds often settle spontaneously. Acute colonoscopy is rarely helpful. Isolated diverticular bleeds without evidence of infection do not necessarily require antibiotics.
A 72-year-old man is admitted with large bowel obstruction and CT scan suggests diverticular stricture in the sigmoid colon.
laparotomy
sliding hiatus hernia first line management?
Lifestyle advice weight loss and omeprazole
surgery not indicated unless complications e.g. upper GI haemorrhage or necrosis.
most common site affected by chrons disease?
ileum
A 54-year-old builder presents to his general practitioner with a lump in his groin. He has a past medical history of chronic obstructive pulmonary disease and no other past medical or surgical history. He reports the lump appeared three weeks ago, is mildly painful and has not grown in size. On examination, there is a reducible soft, single lump on the left side which lies superior to the pubic tubercle with no overlying skin changes. You suspect this is an indirect inguinal hernia.
what type of hernia does patient have? examination finding?
indirect inguinal hernia
No reappearance during coughing when covering the deep inguinal ring
Spontaneous bacterial peritonitis (SBP) is a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.
Features
ascites
abdominal pain
fever
Diagnosis?
the most common organism found on ascitic fluid culture?
Management?
paracentesis: neutrophil count > 250 cells/ul
ecoli
IV cefotaxime
A 67-year-old male presents to the emergency department complaining of new-onset pain in his left groin. On examination, a large, warm, non-reducible mass located inferolateral to the pubic tubercle can be observed. It is accompanied by erythema of the overlying skin. When asked, he admits to vomiting twice and passing stools with blood mixed in them once. He looks in pain and sweaty. He has a past medical history of peptic ulcer disease, managed with omeprazole.
Which one of the following is the most likely diagnosis?
Strangulated femoral hernia
A strangulated inguinal hernia would present with similar symptoms such as systemic upset, pain, erythema, vomiting, and bloody stools. But the mass would be superior and medial !!! to the pubic tubercle rather than inferolateral!!!
