GI Medicine Flashcards
1
Q
3 sources of ALP?
A
Liver
Bone
Placenta
2
Q
Causes of an isolated ALP?
A
Pregnancy
Adolescence
Bone - tumour, Paget’s disease, osteomalacia
3
Q
Major causes of raised ALP + GGT?
A
Bile duct obstruction
PSC
Cholestasis - drug induced
Liver malignancy
4
Q
3 causes of an isolated raised bilirubin?
A
Haemolytic anaemia
Gilbert’s syndrome
Crigler-Najjar
5
Q
5 broad areas of causes of acute abdomen?
A
Inflammation Obstruction Ischaemia Perforation Rupture
6
Q
Inflammatory causes of acute abdomen?
A
‘Itises’ - appendicitis, diverticulitis, cholecystitis/angitis pancreatitis, salpingitis
7
Q
Ischaemic causes of acute abdomen?
A
Strangulated hernia
Volvulus
Thromboembolism
Ovarian cyst torsion, testicular torsion
8
Q
Perforation causes of acute abdomen?
A
Perforated ulcers, tumours etc
Diverticulum
Biliary pancreatitis
Bowel perforation (toxic megacolon)
9
Q
Rupture causes of acute abdomen?
A
AAA
Ovarian cyst rupture
Ectopic pregnancy rupture
10
Q
What are the 4 cardinal signs of GI obstruction?
A
Pain (colicky)
Vomiting
Bloating/distension
Absolute constipation
11
Q
What symptoms does gastric outflow obstruction/upper GI obstruction cause?
A
Vomiting - undigested food
12
Q
What symptoms does high small bowel obstruction cause?
A
Colicky pain
Vomiting, may be bilous if below ampulla of vater
13
Q
Common cause of terminal ileal obstruction?
A
IBD - crohns
14
Q
Symptoms of lower GI obstruction?
A
Central colicky pain
Vomiting - may be brown, feculent
Abdominal distension
15
Q
What symptoms can sigmoid colon obstruction cause?
A
Colicky pain
Vomiting late feature
Distension
Absolute constipation
16
Q
What normal anatomical feature can prevent perforation in end-colon obstruction?
A
Ileo-cecal valve incontinence
17
Q
Underlying pathophysiology of GORD?
A
Incompetence of lower esophageal sphincter
18
Q
Complications of GORD?
A
Oesophagitis
Ulcers
Strictures
Barretts oesophagus -> adenocarcinoma
19
Q
What is Zollinger-Ellison syndrome?
A
Gastrin-secreting tumours leading to chronic or recurrent duodenal ulcers
20
Q
What is the triad of tumours involved in MEN1!
A
Parathyroid
Pituitary
Gastrin-secreting - Zollinger Ellison
21
Q
What common GI complaint can steroids cause?
A
GORD
22
Q
2 rashes associated with IBD?
A
Erythema nodosum
Pyoderma gangrenosum
23
Q
What effect does smoking have on UC?
A
Makes it better
24
Q
What effect does smoking have on Crohn’s disease?
A
Makes it worse
25
Which IBD does smoking make worse (ie quitting makes symptoms better)?
Crohns
26
What part of the GI tract does UC affect?
Universally rectum, ascends upwards but colon only
27
What does biopsy show in UC?
Intramural lesions - only part way through thickness of biopsy but all the way along
28
Where does crohns typically affect?
Ileo-colic (but anywhere from mouth to anus)
29
What does biopsy show on Crohn's disease?
Transmural skip lesions
30
What is a known complication of Crohn's disease which can result in vomiting, pain and abdominal distension?
Strictures - stenosis
31
In which IBD is surgery less helpful?
Crohn's
32
What immunology blood results are suggestive of autoimmune hepatitis?
Raised IgG
Raised ANA
Raised ASMA (anti-smooth muscle autoantibodies)
33
Typical sex and age of presentation for AIH?
Female 15-25 or 45-55
34
What liver enzymes are typically elevated in AIH?
Transaminases +/- ALP, GGT
35
What is the pathophysiological background of primary biliary cirrhosis (PBC)?
Autoimmune destruction of interlobular bile ducts (Herring canals) leading to intrahepatic cholestasis
36
What does the intrahepatic cholestasis in PBC cause?
Inflammation, scarring, fibrosis and cirrhosis
37
Common early symptoms of PBC?
TATT
| Pruritis
38
What is an intrahepatic cholestatic picture of LFTs?
Raised ALP and GGT
39
What are 4 diagnostic blood test markers of PBC?
Anti-mitochondrial Abs (AMA)
Raised IgM
Cholestatic picture - raised GGT and ALP
40
Which of PBC/PSC is autoimmune?
PBC
41
What will PBC eventually lead to?
Liver cirrhosis
42
Early treatments of PBC?
UDCA
| Questran
43
What vitamin supplementation can be given for PBC?
Fat-soluble (ADEK)
44
Underlying pathophysiology of PSC?
Intra - and extra-hepatic bile duct sclerosis, scarring and eventually cirrhosis
45
What other GI condition does PSC have a big link with?
UC
46
In whom is PSC more common?
Young males
47
Under what circumstances is PSC often diagnosed?
Often in the context of UC with deranged LFTs
48
What feature of early PSC may distinguish it from PBC?
Still have TATT, pruritis etc.
| RUQ pain may be present
49
What 3 conditions may result from PSC?
Cholangiocarcinoma
Liver cirrhosis
Liver cancer
50
2 blood tests indicative of PSC?
ANCA
| IgG
51
What can ERCP/MRCP show in PSC?
Beading of the bile ducts
52
What does disappearance of the psoas outlines on AXR indicate?
Bleed
53
What 2 veins converge to form the hepatic portal vein?
Splenic vein
| Superior mesenteric vein
54
What 3 classic liver disease signs does portal hypertension cause?
Caput medusae (collateral vessels)
Varices (portocaval anastamoses)
Ascites
55
What 2 vessels converge to form the hepatic vein?
Hepatic portal vein
| Hepatic artery
56
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
```
57
What is the spectrum of non-alcoholic fatty liver disease?
Fatty liver -> NASH -> NASH cirrhosis
58
What common antibiotic used for treatment of cellulitis can cause LFT derangement?
Flucloxacillin
59
What are 2 signs on examination that are more common in ALD than non-ALD?
Parotid megaly
| Dupuytrens contracture
60
What is the underlying problem in pre-hepatic jaundice?
Increased bilirubin production - usually haemolysis
61
What type of bilirubin is high in pre-hepatic jaundice?
Unconjugated bilirubin
62
Describe the typical colour in pre-hepatic jaundice?
Lemon tinge jaundice
63
What are the urine and stools like in pre-hepatic jaundice?
Normal because unconjugated bilirubin is not water soluble so doesn't enter urine
64
What is the underlying pathophysiology of intrahepatic jaundice?
Altered excretion - liver causes e.g. Hepatitis, cirrhosis, cancers
65
Under what circumstances can you get pale stools and pruritis in intrahepatic jaundice?
If this is coexistent cellular cholestasis
66
What is the underlying pathology behind cholestatic jaundice?
Obstruction of bile ducts
67
What symptoms does obstructive jaundice typically yield?
```
Itching
Pale stools
Dark urine
Abdominal pain
Weight loss, fever, anorexia
```
68
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
69
Major causes of acute pancreatitis?
Gallstones
Drugs
Alcohol
Trauma
70
What are the symptoms of acute pancreatitis?
Severe epigastric pain radiating to back
| Fever, anorexia, nausea and vomiting, tachycardia, sweating
71
What is elevated classically in acute pancreatitis but not necessarily in chronic?
Serum amylase
72
Management of acute pancreatitis?
Supportive - fluid, analgesia etc.
Get CT/USS or MRCP
ERCP particularly used to treat stones
Other surgery
73
What is the major cause of chronic pancreatitis?
Alcohol
74
What symptoms are more typical of chronic pancreatitis than acute?
Chronic or recurrent epigastric pain
Diarrhoea, weight loss
Malnutrition
75
What test is more suitable than serum amylase when looking for chronic pancreatitis?
Fecal elastase
76
3 risk factors for pancreatic cancer?
Smoking
Alcohol
Chronic pancreatitis
77
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
78
What can be inserted via ERCP to improve bile flow in blocked or obstructed ducts?
Biliary stents
79
What is Murphys sign?
Acute pain on inspiration when palpating just under gallbladder
Positive in acute cholecystitis
80
Is jaundice likely in acute cholecystitis?
No as no bile duct involvement
81
What is cholangitis?
Inflammation of the common bile duct normally due to gallstones
82
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
83
Charcot's triad of cholangitis?
Fever
Obstructive Jaundice
RUQ pain
84
Management of cholangitis?
ERCP to remove stones
| Later cholecystectomy particularly if recurrent
85
What does a cholangiocarcinoma typically cause?
Painless jaundice and deranged LFTs
86
What tumour marker is raised in cholangiocarcinoma?
Ca19-9
87
What condition can give rise to silver stools?
Peri-amullary carcinoma - tumour causes obstructive jaundice (pale stools) and also melena (black stools)
88
What are the 3 types of gallstone?
Cholesterol
Pigment stones
Mixed
89
What types of gallstones are radiographically visible?
Mixed/pigment stones with high calcium
90
What is the relationship between eating fatty foods and cholecystitis?
Eating fatty foods causes pain due to increased bile and stone blockage
91
Differentiating factors between cholecystitis and cholangitis?
Murphys sign positive in cholecystitis
| Jaundice in cholangitis only
92
What is a gallstone ileus?
Complication of chronic cholecystitis whereby a gallstone gets into small intestine and causes obstruction, usually at ileocecal valve
93
History suggestive of gallstone ileus?
Recurrent RUQ pain as indicative of chronic cholecystitis
| Followed by acute abdomen - signs of lower GI obstruction
94
Where does the majority of intussusception occur in kids? What symptoms does this cause?
Ileo-coecal
| So causes lower GI obstruction Sx
95
At what ages does intussusception typically occur?
5-12 months
96
What is the most common type of intussusception?
Simple telescoping I.e. Non-pathological lead point
97
What 2 signs on examination are suggestive of intussusception?
Palpable sausage-shaped mass in RUQ
| Dances sign - no bowel in RLQ
98
What stool is typical of intussusception?
Mucoid, Redcurrant diarrhoea
99
Typical USS sign of intussusception?
Target/donut sign
100
What investigation is first line for intussusception?
Abdominal US
101
Why is GORD so common in kids?
Functional immaturity of the lower esophageal sphincter
102
When does childhood GORD normally resolve by?
1 year
103
Symptoms of childhood GORD?
Recurrent regurgitation and non-forceful vomiting
| Abdo pain presenting as crying, non-feeding, FTT, behavioural problems
104
What constitutes an apparent life threatening event in kids in the context of GORD?
Cyanosis, apnoea, floppy baby (decreased tone), choking/gagging
105
Complications of childhood GORD?
Sandifer syndrome
Oesophagitis -> herniae, strictures
Aspiration pneumonia, wheeze, cough etc.
106
Initial management of childhood GORD?
Conservative - food thickeners, postural changes, high frequency low volume feeds
107
What is a common differential for GORD in kids?
Cows milk protein allergy
108
3 causes of unconjugated jaundice in young kids?
Rhesus haemolytic disease of newborn
Breast milk jaundice
Hypothyroidism
109
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
110
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
111
What is kernicterus?
Encephalopathy secondary due unconjugated jaundice, may result from 'physiological' jaundice in kids
112
What is opisthotonos?
Back arching secondary to kernicterus
113
Causes of early jaundice (less than 24 hours)?
Acute intravascular haemolysis - rhesus disease, ABO, G6PD, spherocytosis
114
What is TPN jaundice?
Jaundice as a result of TPN, resulting in stodgy enterohepatic circulation and raised bilirubin
115
What is Crigler-Najjar?
Glucoronyl transferase deficiency -> massive unconjugated bilirubin so pre-hepatic jaundice
116
When and in whom does pyloric stenosis present?
Boys with a family history
| At 2-7 weeks birth age regardless of gestational age
117
Clinical features of pyloric stenosis?
Vomiting - increasing frequency over time eventually becoming projectile
Hunger post-vomiting
Faltering growth
118
Diagnosing pyloric stenosis?
Test feed: look for olive-like mass in RUQ and visible gastric peristalsis
119
What is the definitive management of pyloric stenosis?
Pyloromyotomy
120
What is Meckels Diverticulum?
Ileal remnant of vitello-intestinal duct which can contain ectopic gastric mucosa
121
If symptomatic, how can Meckels Diverticulum present?
```
Severe rectal bleeding
As intussusception (pathological lead point), diverticulitis or volvulus
```
122
Investigation for Meckel Diverticulum?
Technetium scan (shows ectopic gastric mucosa)
123
What is malrotation/volvulus?
Improper attachment of gut mesentery, predisposing to malrotation of gut
124
2 ways that malrotation can present?
Obstruction (bilous vomiting, abdo pain, distension)
| Ischaemic bowel if blood supply compromised
125
Major RFs for NEC?
Prematurity
Low birth weight
PDA
126
When does NEC typically present?
3-10 days after birth, although can be up to 3 months
127
Early signs of NEC?
Non-specific (feeding problems, vomiting, abdo distension, sepsis)
128
GI Sx of NEC?
Abdo distension, erythema, visible abdo loops
Altered stool pattern (blood Mucoid) and bilous vomiting
Decreased bowel sounds
129
What investigation is diagnostic and must be done urgently if suspecting NEC?
AXR - pneumatosis intestinalis (gas in bowel wall)
130
Clinical features of duodenal ulcers?
Burning 'right' epigastric pain
Pain is often 2-3 hours after eating but initially relieved by food
Nocturnal pain
131
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
132
Clinical features of gastric ulcers?
Burning 'left' epigastric pain worse within 1 hr of food
| Often related to anorexia, weight loss
133
What is Dubin Johnson syndrome?
Isolated raised conjugated bilirubin (no LFT derangement)
134
4 RFs for diverticular disease?
Age (>50)
Smoking
Obesity
Low dietary fibre
135
Describe the pain associated with diverticular disease?
Non-specific LLQ pain, worse on eating and eased by flatus and passing stool
136
What is the difference in diverticular disease presentation between Asian and non-Asian populations?
RLQ more common in Asians
137
Symptoms of diverticulitis?
CIBH - usually diarrhoea, bloody, may be frank haemorrhage
LLQ pain and pseudo-obstruction
Fever, tachycardia
Anorexia, nausea, vomiting
138
Most common complication of diverticulitis? When is it most likely to occur?
Abscess formation; most likely after 1st acute presentation
139
Common fistulae associated with diverticular disease?
Colovesicular
| Colovaginal
140
Appropriate investigation for diverticulitis? What should be avoided in the acute phase?
```
CT
Avoid endoscopy (do as OP) but do flexisig if bleeding
```
141
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.
142
When has physiological jaundice usually settled down by?
10-14 days - any longer consider prolonged jaundice
143
Rash associated with coeliac disease?
Dermatitis herpetiformis
