GI Medicine Flashcards
3 sources of ALP?
Liver
Bone
Placenta
Causes of an isolated ALP?
Pregnancy
Adolescence
Bone - tumour, Paget’s disease, osteomalacia
Major causes of raised ALP + GGT?
Bile duct obstruction
PSC
Cholestasis - drug induced
Liver malignancy
3 causes of an isolated raised bilirubin?
Haemolytic anaemia
Gilbert’s syndrome
Crigler-Najjar
5 broad areas of causes of acute abdomen?
Inflammation Obstruction Ischaemia Perforation Rupture
Inflammatory causes of acute abdomen?
‘Itises’ - appendicitis, diverticulitis, cholecystitis/angitis pancreatitis, salpingitis
Ischaemic causes of acute abdomen?
Strangulated hernia
Volvulus
Thromboembolism
Ovarian cyst torsion, testicular torsion
Perforation causes of acute abdomen?
Perforated ulcers, tumours etc
Diverticulum
Biliary pancreatitis
Bowel perforation (toxic megacolon)
Rupture causes of acute abdomen?
AAA
Ovarian cyst rupture
Ectopic pregnancy rupture
What are the 4 cardinal signs of GI obstruction?
Pain (colicky)
Vomiting
Bloating/distension
Absolute constipation
What symptoms does gastric outflow obstruction/upper GI obstruction cause?
Vomiting - undigested food
What symptoms does high small bowel obstruction cause?
Colicky pain
Vomiting, may be bilous if below ampulla of vater
Common cause of terminal ileal obstruction?
IBD - crohns
Symptoms of lower GI obstruction?
Central colicky pain
Vomiting - may be brown, feculent
Abdominal distension
What symptoms can sigmoid colon obstruction cause?
Colicky pain
Vomiting late feature
Distension
Absolute constipation
What normal anatomical feature can prevent perforation in end-colon obstruction?
Ileo-cecal valve incontinence
Underlying pathophysiology of GORD?
Incompetence of lower esophageal sphincter
Complications of GORD?
Oesophagitis
Ulcers
Strictures
Barretts oesophagus -> adenocarcinoma
What is Zollinger-Ellison syndrome?
Gastrin-secreting tumours leading to chronic or recurrent duodenal ulcers
What is the triad of tumours involved in MEN1!
Parathyroid
Pituitary
Gastrin-secreting - Zollinger Ellison
What common GI complaint can steroids cause?
GORD
2 rashes associated with IBD?
Erythema nodosum
Pyoderma gangrenosum
What effect does smoking have on UC?
Makes it better
What effect does smoking have on Crohn’s disease?
Makes it worse
Which IBD does smoking make worse (ie quitting makes symptoms better)?
Crohns
What part of the GI tract does UC affect?
Universally rectum, ascends upwards but colon only
What does biopsy show in UC?
Intramural lesions - only part way through thickness of biopsy but all the way along
Where does crohns typically affect?
Ileo-colic (but anywhere from mouth to anus)
What does biopsy show on Crohn’s disease?
Transmural skip lesions
What is a known complication of Crohn’s disease which can result in vomiting, pain and abdominal distension?
Strictures - stenosis
In which IBD is surgery less helpful?
Crohn’s
What immunology blood results are suggestive of autoimmune hepatitis?
Raised IgG
Raised ANA
Raised ASMA (anti-smooth muscle autoantibodies)
Typical sex and age of presentation for AIH?
Female 15-25 or 45-55
What liver enzymes are typically elevated in AIH?
Transaminases +/- ALP, GGT
What is the pathophysiological background of primary biliary cirrhosis (PBC)?
Autoimmune destruction of interlobular bile ducts (Herring canals) leading to intrahepatic cholestasis
What does the intrahepatic cholestasis in PBC cause?
Inflammation, scarring, fibrosis and cirrhosis
Common early symptoms of PBC?
TATT
Pruritis
What is an intrahepatic cholestatic picture of LFTs?
Raised ALP and GGT
What are 4 diagnostic blood test markers of PBC?
Anti-mitochondrial Abs (AMA)
Raised IgM
Cholestatic picture - raised GGT and ALP
Which of PBC/PSC is autoimmune?
PBC
What will PBC eventually lead to?
Liver cirrhosis
Early treatments of PBC?
UDCA
Questran
What vitamin supplementation can be given for PBC?
Fat-soluble (ADEK)
Underlying pathophysiology of PSC?
Intra - and extra-hepatic bile duct sclerosis, scarring and eventually cirrhosis
What other GI condition does PSC have a big link with?
UC
In whom is PSC more common?
Young males
Under what circumstances is PSC often diagnosed?
Often in the context of UC with deranged LFTs
What feature of early PSC may distinguish it from PBC?
Still have TATT, pruritis etc.
RUQ pain may be present
What 3 conditions may result from PSC?
Cholangiocarcinoma
Liver cirrhosis
Liver cancer
2 blood tests indicative of PSC?
ANCA
IgG
What can ERCP/MRCP show in PSC?
Beading of the bile ducts
What does disappearance of the psoas outlines on AXR indicate?
Bleed
What 2 veins converge to form the hepatic portal vein?
Splenic vein
Superior mesenteric vein
What 3 classic liver disease signs does portal hypertension cause?
Caput medusae (collateral vessels)
Varices (portocaval anastamoses)
Ascites
What 2 vessels converge to form the hepatic vein?
Hepatic portal vein
Hepatic artery
What signs are more indicative of someone being in acute than chronic liver failure?
RUQ pain Nausea and vomiting Fever Encephalopathy Clotting dysfunction - PT up to 100 Late on - jaundice
What is the spectrum of non-alcoholic fatty liver disease?
Fatty liver -> NASH -> NASH cirrhosis
What common antibiotic used for treatment of cellulitis can cause LFT derangement?
Flucloxacillin
What are 2 signs on examination that are more common in ALD than non-ALD?
Parotid megaly
Dupuytrens contracture
What is the underlying problem in pre-hepatic jaundice?
Increased bilirubin production - usually haemolysis
What type of bilirubin is high in pre-hepatic jaundice?
Unconjugated bilirubin
Describe the typical colour in pre-hepatic jaundice?
Lemon tinge jaundice
What are the urine and stools like in pre-hepatic jaundice?
Normal because unconjugated bilirubin is not water soluble so doesn’t enter urine
What is the underlying pathophysiology of intrahepatic jaundice?
Altered excretion - liver causes e.g. Hepatitis, cirrhosis, cancers
Under what circumstances can you get pale stools and pruritis in intrahepatic jaundice?
If this is coexistent cellular cholestasis
What is the underlying pathology behind cholestatic jaundice?
Obstruction of bile ducts
What symptoms does obstructive jaundice typically yield?
Itching Pale stools Dark urine Abdominal pain Weight loss, fever, anorexia
What is the itching, pale stools and dark urine due to in obstructive jaundice?
Bile salts normally make stools dark but as they can’t reach GI tract they get absorbed into the bloodstream (pale stools). They are also insoluble so get peed out making pee dark. They are also irritant so cause itching
Major causes of acute pancreatitis?
Gallstones
Drugs
Alcohol
Trauma
What are the symptoms of acute pancreatitis?
Severe epigastric pain radiating to back
Fever, anorexia, nausea and vomiting, tachycardia, sweating
What is elevated classically in acute pancreatitis but not necessarily in chronic?
Serum amylase
Management of acute pancreatitis?
Supportive - fluid, analgesia etc.
Get CT/USS or MRCP
ERCP particularly used to treat stones
Other surgery
What is the major cause of chronic pancreatitis?
Alcohol
What symptoms are more typical of chronic pancreatitis than acute?
Chronic or recurrent epigastric pain
Diarrhoea, weight loss
Malnutrition
What test is more suitable than serum amylase when looking for chronic pancreatitis?
Fecal elastase
3 risk factors for pancreatic cancer?
Smoking
Alcohol
Chronic pancreatitis
What is the typical picture of cancer of the head of the pancreas?
Obstructive jaundice - painless jaundice and itching
In the context of weight loss, TATT, deranged LFTs
What can be inserted via ERCP to improve bile flow in blocked or obstructed ducts?
Biliary stents
What is Murphys sign?
Acute pain on inspiration when palpating just under gallbladder
Positive in acute cholecystitis
Is jaundice likely in acute cholecystitis?
No as no bile duct involvement
What is cholangitis?
Inflammation of the common bile duct normally due to gallstones
What is ascending cholangitis/biliary sepsis?
Sepsis as a result of bacteraemia which is ascendant from GI tract via ampulla of vater. Stone blockage of CBD allows bacteria to pass through wall into blood
Charcot’s triad of cholangitis?
Fever
Obstructive Jaundice
RUQ pain
Management of cholangitis?
ERCP to remove stones
Later cholecystectomy particularly if recurrent
What does a cholangiocarcinoma typically cause?
Painless jaundice and deranged LFTs
What tumour marker is raised in cholangiocarcinoma?
Ca19-9
What condition can give rise to silver stools?
Peri-amullary carcinoma - tumour causes obstructive jaundice (pale stools) and also melena (black stools)
What are the 3 types of gallstone?
Cholesterol
Pigment stones
Mixed
What types of gallstones are radiographically visible?
Mixed/pigment stones with high calcium
What is the relationship between eating fatty foods and cholecystitis?
Eating fatty foods causes pain due to increased bile and stone blockage
Differentiating factors between cholecystitis and cholangitis?
Murphys sign positive in cholecystitis
Jaundice in cholangitis only
What is a gallstone ileus?
Complication of chronic cholecystitis whereby a gallstone gets into small intestine and causes obstruction, usually at ileocecal valve
History suggestive of gallstone ileus?
Recurrent RUQ pain as indicative of chronic cholecystitis
Followed by acute abdomen - signs of lower GI obstruction
Where does the majority of intussusception occur in kids? What symptoms does this cause?
Ileo-coecal
So causes lower GI obstruction Sx
At what ages does intussusception typically occur?
5-12 months
What is the most common type of intussusception?
Simple telescoping I.e. Non-pathological lead point
What 2 signs on examination are suggestive of intussusception?
Palpable sausage-shaped mass in RUQ
Dances sign - no bowel in RLQ
What stool is typical of intussusception?
Mucoid, Redcurrant diarrhoea
Typical USS sign of intussusception?
Target/donut sign
What investigation is first line for intussusception?
Abdominal US
Why is GORD so common in kids?
Functional immaturity of the lower esophageal sphincter
When does childhood GORD normally resolve by?
1 year
Symptoms of childhood GORD?
Recurrent regurgitation and non-forceful vomiting
Abdo pain presenting as crying, non-feeding, FTT, behavioural problems
What constitutes an apparent life threatening event in kids in the context of GORD?
Cyanosis, apnoea, floppy baby (decreased tone), choking/gagging
Complications of childhood GORD?
Sandifer syndrome
Oesophagitis -> herniae, strictures
Aspiration pneumonia, wheeze, cough etc.
Initial management of childhood GORD?
Conservative - food thickeners, postural changes, high frequency low volume feeds
What is a common differential for GORD in kids?
Cows milk protein allergy
3 causes of unconjugated jaundice in young kids?
Rhesus haemolytic disease of newborn
Breast milk jaundice
Hypothyroidism
What is physiological jaundice in young kids?
Occurs after 24 hours due to breakdown of fetal Hb, poor bilirubin metabolism and short lifespan of neonatal rbcs. Peaks at 3-4 days and is settled by 2 weeks
What is the importance of physiological jaundice?
Unconjugated bilirubin is lipid soluble so can end up crossing BBB and depositing in basal ganglia, causing kernicterus
What is kernicterus?
Encephalopathy secondary due unconjugated jaundice, may result from ‘physiological’ jaundice in kids
What is opisthotonos?
Back arching secondary to kernicterus
Causes of early jaundice (less than 24 hours)?
Acute intravascular haemolysis - rhesus disease, ABO, G6PD, spherocytosis
What is TPN jaundice?
Jaundice as a result of TPN, resulting in stodgy enterohepatic circulation and raised bilirubin
What is Crigler-Najjar?
Glucoronyl transferase deficiency -> massive unconjugated bilirubin so pre-hepatic jaundice
When and in whom does pyloric stenosis present?
Boys with a family history
At 2-7 weeks birth age regardless of gestational age
Clinical features of pyloric stenosis?
Vomiting - increasing frequency over time eventually becoming projectile
Hunger post-vomiting
Faltering growth
Diagnosing pyloric stenosis?
Test feed: look for olive-like mass in RUQ and visible gastric peristalsis
What is the definitive management of pyloric stenosis?
Pyloromyotomy
What is Meckels Diverticulum?
Ileal remnant of vitello-intestinal duct which can contain ectopic gastric mucosa
If symptomatic, how can Meckels Diverticulum present?
Severe rectal bleeding As intussusception (pathological lead point), diverticulitis or volvulus
Investigation for Meckel Diverticulum?
Technetium scan (shows ectopic gastric mucosa)
What is malrotation/volvulus?
Improper attachment of gut mesentery, predisposing to malrotation of gut
2 ways that malrotation can present?
Obstruction (bilous vomiting, abdo pain, distension)
Ischaemic bowel if blood supply compromised
Major RFs for NEC?
Prematurity
Low birth weight
PDA
When does NEC typically present?
3-10 days after birth, although can be up to 3 months
Early signs of NEC?
Non-specific (feeding problems, vomiting, abdo distension, sepsis)
GI Sx of NEC?
Abdo distension, erythema, visible abdo loops
Altered stool pattern (blood Mucoid) and bilous vomiting
Decreased bowel sounds
What investigation is diagnostic and must be done urgently if suspecting NEC?
AXR - pneumatosis intestinalis (gas in bowel wall)
Clinical features of duodenal ulcers?
Burning ‘right’ epigastric pain
Pain is often 2-3 hours after eating but initially relieved by food
Nocturnal pain
Which form of peptic ulcer is worse when hungry and relived by eating? Why?
Duodenal ulcer, because eating makes pyloric sphincter close and so gastric juices stop emptying down
Clinical features of gastric ulcers?
Burning ‘left’ epigastric pain worse within 1 hr of food
Often related to anorexia, weight loss
What is Dubin Johnson syndrome?
Isolated raised conjugated bilirubin (no LFT derangement)
4 RFs for diverticular disease?
Age (>50)
Smoking
Obesity
Low dietary fibre
Describe the pain associated with diverticular disease?
Non-specific LLQ pain, worse on eating and eased by flatus and passing stool
What is the difference in diverticular disease presentation between Asian and non-Asian populations?
RLQ more common in Asians
Symptoms of diverticulitis?
CIBH - usually diarrhoea, bloody, may be frank haemorrhage
LLQ pain and pseudo-obstruction
Fever, tachycardia
Anorexia, nausea, vomiting
Most common complication of diverticulitis? When is it most likely to occur?
Abscess formation; most likely after 1st acute presentation
Common fistulae associated with diverticular disease?
Colovesicular
Colovaginal
Appropriate investigation for diverticulitis? What should be avoided in the acute phase?
CT Avoid endoscopy (do as OP) but do flexisig if bleeding
What defines prolonged jaundice? Causes?
Lasts over 14 days (/21 if preterm)
Common causes are breast milk, hepatitis, Galactosaemia, UTI, biliary atresia, TPN related, hypothyroidism, haematoma (instrumental delivery), Criggler Najjar etc.
When has physiological jaundice usually settled down by?
10-14 days - any longer consider prolonged jaundice
Rash associated with coeliac disease?
Dermatitis herpetiformis
