GI medicine 2 Flashcards
Budd-Chiari Syndrome
- What is it?
- What can cause it?
- What clinical features are seen?
- What investigation should be done?
- thrombosis of the hepatic portal vein
- polycythaemia
- thrombophilia: activated protein c resistance, protein C and S deficiency, antithrombin III deficiency
- pregnancy
- COCP
- severe, sudden abdominal pain
- ascites
- tender hepatomegaly
- US with doppler
Carcinoid Tumours
- What are they?
- What clinical features are seen?
- What investigations can be done?
- How is it treated?
- liver mets (sometimes lung tumour) causing release of serotonin
NOTE: because can be lung tumour could also appear with Cushing’s as tumour secretes ACTH too
- flushing
- diarrhoea
- bronchospasm (therefore hear a wheeze)
- hypotension
mnemonic: pretty girl tumour
- urine 5-HIAA
- plasma chromogranin A y
- somatostatin analogues - octreotide
Clostridium difficile
- What antibiotics can cause it?
- How is it diagnosed?
- How is it treated if
a) first episode
b) recurrent episode
c) life-threatening (+ when would this be?)
- clindamycin
- cephalosporins (start cef/ceph)
- co-amoxiclav
- ciprofloxacin (and other fluoroquinolones)
- c. diff stool TOXIN
(antigen only confirms the presence of the bacteria) - a)
1st line: oral vancomycin
2nd line: oral fidaxomicin
3rd line: oral vancomycin + IV metronidazole
b) oral fidaxomicin (alternatively can give oral vancomycin if after 12 weeks)
c)
if hypotensive, ileus or toxic megacolon
oral vancomycin and IV metronidazole
Coeliac disease
- What is it associated with:
a) conditions?
b) HLA class - What clinical features are seen?
- What complications can be seen?
- a)
- dermatitis herpetiformis
- autoimmune: autoimmune hepatitis, type 1 diabetes
b) HLA-DQ2 (95%) and HLA-DQ8
- diarrhoea
- abdominal pain + bloating
- weight loss
- fatigue
- unexplained anaemia
- children: failure to thrive / altering growth
- lactose intolerance
- enteropathy-associated T cell lymphoma of the small intestine
- subfertility, hypoSplenism
mnemonic: LES (Claire’s dad) has coeliac
Coeliac Disease Investigations
- What investigations are done?
- What must you ensure prior to testing?
- serology: transglutaminase antibodies (IgA)
- endoscopy + biopsy: villous atrophy, crypt hyperplasia, increased intraepithelial lymphocytes, infiltration of lymphocytes into lamina propria
NOTE: therefore if IgA is low TTG test is null and void
- patient has continued gluten free diet (if possible) for at least 6 weeks prior to testing
How is coeliac disease managed?
gluten-free diet avoid: wheat: bread, pasta, pastries barley: beer rye oats (however some can tolerate)
NOTE: whiskey is made with barley but this is removed during distillation so is therefore safe to drink
+ pneumococcal vaccine with booster every 5 years due to hyposplenism
- Which GI cancer is Lynch syndrome (HNPCC) highly associated with?
- Which cancer is this most mutation next most likely to cause in
a) females
b) males
- colorectal cancer
2.
a) endometrial cancer
b) pancreatic cancer
Cancer referral
- When should you make
a) urgent referral
b) non-urgent referral - What should be done if a patient has reflux symptoms but does not meet the referral criteria?
1.
a)
- dysphagia
- abdominal mass consistent with stomach cancer
=/> 55 with weight loss AND one of:
- upper abdominal pain
- dyspepsia
- reflux
b)
haematemesis
=/> 55 with:
- treatment resistant dyspepsia
- anaemia + upper abdominal pain
- low platelets with an upper GI symptom
- N+V with another upper GI symptom
NOTE: upper GI symptoms: N+V, reflux, dyspepsia, abdo pain, weight loss
- Review medications for possible causes of dyspepsia
- Lifestyle advice
- Try PPI for one month OR a ‘test and treat’ approach for H. pylori
if symptoms persist after either of the above approaches then the alternative approach should be tried
What features are associated with oesophageal candidiasis?
- HIV
- steroid inhaler use
Ferritin
- a) How often is increased ferritin due to iron overload?
b) What can you use to determine if the increased ferritin is due to iron overload? - What can cause iron overload?
- What can cause increased ferritin but not iron overload?
- What can cause decreased ferritin?
- a) 10%
b) transferrin saturation
- primary: hereditary haemochromatosis
secondary: repeated blood transfusions
- inflammation (as ferritin acute phase reactant)
- alcohol
- liver disease
- chronic kidney disease
- malignancy
- iron deficiency anaemia
Gastric Cancer
- What are the risk factors?
- What clinical features are seen?
- What investigations are done?
- h. pylori
- atrophic gastritis
- diet: nitrates and salt
- smoking
- blood type
- abdominal pain +/- dyspepsia
- nausea and vomiting
- dysphagia
- weight loss and anorexia
mnemonic: think of one leading to the other
3. endoscopy + biopsy: signet ring cells (more indicates worse prognosis)
GORD
- What are the indications for endoscopy?
- What should you consider if endoscopy is negative?
- How should it be managed if
a) endoscopically proven oesophagitis?
b) endoscopically negative
- > 55 years old
- symptoms > 4 weeks or persisting despite treatment
- relapsing of symptoms
- weight loss
- dysphagia
- 24hr oesophageal pH monitoring which is gold standard test
- a) PPI for 1 month, double dose if no response
b) PPI for 1-2 months, offer H2RA or pro kinetic (e.g. cisapride, domperidone, metoclopramide) if no response
Gilbert’s Syndrome
- What is it?
- What clinical feature is seen?
- What is seen on investigation?
- deficiency of glucoronosyltransferase
(used to conjugate bilirubin) - jaundice on illness, exercise, fasting
- unconjugated hyperbilirubinaemia following prolonged fasting or IV nicotinic acid
(no need to recheck blood results in future can simply reassure)
Haemochromatosis
- What is it?
- What clinical features are seen?
- Which complications are reversible?
- disorder of iron absorption and metabolism resulting in iron accumulation
- early: fatigue, impotence, arthralgia (often hands)
- bronze skin pigmentation
- liver cirrhosis
- diabetes
- heart failure (dilated cardiomyopathy)
- hypogonadism (2nd to cirrhosis + pituitary dysfunction)
- skin pigmentation
- cardiomyopathy
Haemochromatosis Investigation and Management
- Investigation
a) What will be seen on iron studies?
b) What tests are diagnostic?
c) What is seen on XR? - How is it managed?
- a)
- raised ferritin
- transferrin saturation >55% males >50% females
b) Liver biopsy: Perl’s stain
c) chondrocalcinosis
- 1st line: venesection
2nd line: desferrioxamine
