High Yield Exam Cram Flashcards
Which cells in the stomach produce mucous?
Mucous cells
Name the two nerve plexuses that give the gut independent neural control
Submucosal + myenteric plexuses = enteric nervous system (ENS)
Which cells in the stomach produce pepsinogen?
chief cells
Which cells in the stomach produce hydrochloric acid and intrinsic factor?
Parietal cells
What is intrinsic factor required for?
vitamin B12 absorption
What produces intrinsic factor?
Parietal cells
Where in the body is vitamin B12 absorbed?
Terminal ileum
Which glands produce bicarbonate?
Brunner’s glands
Explain where the secretions from the exocrine and endocrine pancreas are secreted to and what they are
Endocrine pancreas -> secretes insulin into blood
Exocrine pancreas -> secretes bicarb and digestive enzymes into duodenum
Why doesn’t the pancreas digest itself?
Enzymes made in the pancreas are inactivated and then become active in duodenum when they come into contact with Enterokinase (a brush border enzyme)
What are the constituent monomers of lactose
glucose + galactose
What brush border enzyme breaks down lactose?
Lactase
What are the constituent monomers of sucrose?
glucose + fructose
What brush border enzyme breaks down sucrose?
sucrase
What are the constituent monomers of maltose?
glucose + glucose
What brush border enzyme breaks down maltose?
Maltase
What are the fat soluble vitamins?
A, D, E, K
What is segmentation?
Pushes chyme back and forwards to mix and aid digestion
When does segmentation occur?
Occurs while you are still eating
Name the two different types of anal sphincters
internal anal sphincter (smooth muscle under automatic control)
external anal sphincter (skeletal muscle under voluntary control)
What is the most common typeof GI cancer
Adenocarcinoma
How do you differentiate an upper and lower GI bleed?
High urea = upper GI bleed
How should GI bleeds be investigated?
Endoscopy
Colonoscopy
What is the name of the scoring system used to assess the likelihood that somebody has had a GI bleed
Glasgow-Blachford Score
What is the Rockall score used for?
Estimating the risk of re-bleeding and mortality
What is a Mallory-Weiss tear?
tear and bleeding associated with vomiting
What is Boerhaave’s and what is the triad associated with it?
Full thickness perforation of oesophagus.
Triad of Vomiting, chest pain, surgical emphysema.
Look out for gastric contents in chest cavity.
What are the red flag symptoms associated with GORD?
- Dysphasia
- Weight loss
- > 55
- Mass on palpation
- Low haemoglobin
- Raised platelet count
What is the surgical management of GORD
Nissan Fundoplication
What is the classical finding on barium swallow in diffuse oesophageal spasm?
Corkscrew
How is diffuse oesophageal spasm managed?
Muscle relaxants
How does diffuse oesophageal spasm present?
Severe, episodic chest pain with or without dysphasia
How does achalasia look on barium swallow?
Bird’s beak
What causes achalasia?
loss of the myenteric plexus ganglion cells in lower oesophagus -> lack of relaxation
How does achalasia present?
Dysphasia to solids and liquids at the same time
How can achalasia be managed?
balloon dilatation +/- botulism
or
Heller cardiomyotomy
What kind of cancer tends to affect the upper 2/3rds of the oesophagus?
Squamous cell carcinoma
What kind of cancer tends to affect the lower 1/3 of the oesophagus?
Adenocarcinoma
What condition pre-disposes to oesophageal adenocarcinoma?
Barrett’s oesophagus
Explain the process that sees normal oesophageal cells become an adenocarcinoma
Stratified squamous epithelium -> METAPLASIA ->
Simple columnar epithelium -> DYSPLASIA->
Adenocarcinoma
How is an oesophageal cancer imaged?
endoscopy, contrast swallow, CT
What are the two options to help prevent rupture of oesophageal varices?
- Propranolol
- Band ligation
What are the acute management options in oesophageal varices?
Broad spectrum abx
Terlipressin
Bind ligation
Sengstaken-Blakemore tube
TIPSS stenting can be used in cases of re-bleeding
What test is used to identify H. Pylori?
Urease breath test
What drug must be stopped prior to urease breath test and for how long before must it be stopped?
must be off PPI for 2 weeks!
If symptoms have not cleared, when should patients be re-tested for H.Pylori?
4 weeks
What is the treatment for H.Pylori?
clarithromycin, amox, omeprazole (abx for 7 days)
What is Zollinger-Ellison Syndrome?
Duodenal or pancreatic tumour produces excess gastrin. Causes gastric ulcers.
When should patients treated for a gastric ulcer be re-scoped?
4-8 weeks after treatment
How can a gastric ulcer be differentiated from a duodenal ulcer?
Peptic = worse on eating
Duodenal = relieved on eating, sore 2-3 hrs later
What is an absolute contraindication to NG tube?
Basal skull fracture
What should the pH of safe NG aspirate be?
<5
What are the surgical resection options for a gastric cancer?
- Subtotal Gastrectomy (preserving some of the stomach)
Total Gastrectomy and Roux en Y reconstruction (remove the stomach and attach the distal oesophagus to small bowel
What is ALWAYS the distal margin when resecting a gastric tumour, regardless of where it is?
1st part of the duodenum
When would bariatric surgery be considered?
BMI > 35 and you have made efforts at weight loss
Name the causes of acute liver injury
- Viruses (hepatitis)
- Alcohol
- Drugs
- Prolonged bile duct obstruction
What are the 4 most common causes of liver cirrhosis?
Alcoholic liver disease
Non-alcoholic fatty liver disease
Hepatitis B
Hepatitis C
What is the difference between compensated and decompensated liver disease?
Compensated = patient is well and bloods are not deranged
Decompensated = AHOY
- Ascites
- Hepatic encephalopathy
- Oesophageal varies bleeding
- Yellow (jaundice)
Which scans are useful for identifying liver cirrhosis?
liver ultrasound (increased echogenicity) or a fibro scan
What blood test can be used to identify cirrhosis?
Enhanced liver fibrosis (ELF) blood test
What is the gold standard for diagnosing liver cirrhosis?
Liver biopsy
What is the function of the Child-Pugh score?
Assesses severity of cirrhosis and prognosis
How should patient’s with liver cirrhosis be monitored?
MELD score done every 6 months to estimate 3 month mortality
Ultrasound and AFP every 6 months to screen for hepatocellular carcinoma
Endoscopy every 3 years to check for oesophageal varices
What are the 3 basic steps in the pathological progression of alcoholic liver disease?
- Fatty change
- Alcoholic hepatitis
- Cirrhosis
What is the function of the AUDIT questionnaire?
Screens for harmful alcohol use
What blood test finding is classical for alcoholic liver disease?
AST:ALT >2:1
What occurs at the following times during alcohol withdrawal:
6-12 hours
12-24 hours
24-48 hours
24-72 hours
?
6-12 hours = tremor, sweating, headache, craving & anxiety
12-24 hours = hallucinations
24-48 hours = seizures
24-72 hours = delirium tremens
What would you expect to see in a patient withdrawing from alcohol at 6-12 hours after their last drink?
tremor, sweating, headache, craving & anxiety
What would you expect to see in a patient withdrawing from alcohol at 12-24 hours after their last drink?
Hallucinations
What would you expect to see in a patient withdrawing from alcohol at 24-48 hours after their last drink?
seizures
What would you expect to see in a patient withdrawing from alcohol at 24-72 hours after their last drink?
delirium tremens
What can be used in acute withdrawal to:
A) Manage symptoms
B) protect against wernicke’s encephalopathy
Chlordiazepoxide (benzo)
Pabrinex (thiamine B1)
What scoring system is used to estimate the amount of liver scarring in non-alcoholic fatty liver disease?
NAFLD (Non-Alcoholic Fatty Liver Disease) Fibrosis Score
What characteristic blood test finding is seen in non-alcoholic fatty liver disease?
ALT: AST >1:5
Which hepatitis strain is a notifiable disease?
All strains!
Which Hepatitis strains are
A) DNA viruses
B) RNA viruses
Hep B is the only DNA, the rest are all RNA viruses.
How is acute hepatitis managed?
Supportive management for all
+ antivirals for Hep B & C
+ pegylated interferon alpha for 48 weeks for Hep D
Which strains of hepatitis are spread via the fecal-oral route?
A & E
Which strain of hepatitis can you NOT vaccinate against?
C
Which strain of hepatitis can only occur in combination with a current hepatitis B infection
Hepatitis d
What does the hepatitis surface antibody indicate?
current infection or recent vaccine (not +ve in chronic infection)
What does the hepatitis E antibody indicate?
the virus is currently replicating and the patient is infectious
What does the hepatitis c antibody indicate?
high IgM = acute infection
Low IgM = chronic infection
IgG +ve = previous infection
Who gets Type 1 autoimmune hepatitis?
Ladies, during or after menopause.
Who gets type 2 autoimmune hepatitis?
Children
How does type 1 autoimmune hepatitis present?
fatigue and features of liver disease
How does type 2 autoimmune hepatitis present?
Symptoms of acute hepatitis
Which autoantibodies are associated with
A) Type 1 autoimmune pancreatitis
B) Type 2 autoimmune pancreatitis
Type 1: - ANA & anti-SMA
Type 2: - Anti-LKM1 & anti-LC1
How is autoimmune pancreatitis managed?
Steroids
Azathioprine
How is a paracetamol OD managed if the patient presents within the 1st hour?
1st hr = activated charcoal
What timeframe is considered a ‘staggered overdose”?
taken over >1hr
What is the treatment of a staggered overdose?
NAC regardless
What could be causing acute SOB in response to NAC?
a non-IgE mediated mast cell release
Explain the dosing of NAC
What criteria must be met in order to qualify for a liver transplant following a paracetamol overdose?
pH < 7.3, 24 hours after ingestion
or all of: INR > 6.5, creatinine >300, grade III or IV encephalopathy
What causes ascites?
portal hypertension resulting from cirrhosis
How should new onset ascites be investigated?
diagnostic paracentesis
What are the two different types of ascitic fluid and what do they indicate?
Transudative (low protein) = cirrhosis
Exudative (high protein) = infection or malignancy
How should ascites be managed?
Low sodium diet
Regular, high calorie meals
Spirnolactone
Ascitic tap/drain
Abx
TIPS
What are the 2 most common bacterial causes of spontaneous bacterial peritonitis?
e.coli or Klebsiella
What is hepatorenal syndrome?
Liver cirrhosis and portal hypertension causes impaired blood flow to the kidneys
How is hepatorenal syndrome managed?
volume expansion fluids with albumin
vasopressors which vasodilate splanchnic vessels
Stents
Liver transplantation
What is hepatic encephalopathy?
Hepatic encephalopathy is confusion (graded 1-4) caused by ammonia build up resulting from liver disease
How is hepatic encephalopathy managed?
Manage with lactulose and broad spectrum abx (rifaximin)
What are the main risk factors for hepatocellular carcinoma?
Alcoholic liver disease
Non-alcoholic fatty liver
Hepatitis B & C
What is the tumour marker for hepatocellular carcinoma?
Alpha-fetoprotein (AFP)
How are at risk patients monitored for hepatocellular carcinoma?
screened every 6 months with ultrasound and AFP
At what plasma level does jaundice become visible?
50 micromols/L
List the 3 types of jaundice and their basic patholphysiology
- Pre-hepatic jaundice caused by increased release of haemoglobin from red blood cells
- Hepatic jaundice caused by poor bile metabolism
- Post-hepatic jaundice caused by Cholestasis or Intrahepatic Bile Duct Obstruction
What is the mode of inheritance for haemochromatosis?
Autosomal recessive
What is the gene mutation in haemochromotosis and what chromosome is It on?
282Y mutation in HFE gene on chromosome 6
What happens in Hemochromatosis
Excess iron deposition in tissues
How is Hemochromatosis managed?
Venesection
What is the inheritance pattern in Wilson’s disease?
Autosomal recessive
which protein is mutated in Wilson’s disease and where can it be found?
Chromosome 13- mutation of copper transporting protein
What happens in Wilson’s disease?
- Excessive copper deposition in body tissues
How does Wilson’s disease cause neurological signs?
Copper deposits in the brain
what is the ocular finding in Wilson’s disease?
Keyser-Fleischer rings
How is Wilson’s disease diagnosed
serum caeruplasmin
How is Wilson’s disease treated?
copper chelation (penicillamine or trientine)
How should gall bladder polyps be managed?
<5mm = leave alone
5-9mm = observe
> 1cm = resect
What is Cholelithiasis?
gallstones
What is choledochal-lithiasis?
gallstones in the bile duct
What is the difference between primary and secondary choledochal-lithiasis?
primary = a gall stone forms in the bile duct
secondary = the stone travels from the cystic duct and lodges in the bile duct
What are gallstones most commonly formed from?
cholesterol
Which demographic tends to get gallstones?
- Fat
- Female
- Forty
- Fair
- Fertile
What condition is Murphy’s sign a useful diagnostic test for?
Cholecystitis
Explain cholecystitis
palpation of RUQ causes pain on expiration
What are the 2 causes of Ascending Cholangitis?
obstruction (e.g. stones/strictures) or infection introduced during ERCP
What is chariots triad and Reynolds pentad?
Charcot’s triad:
RUQ pain
Jaundice
Fever
Reynolds Pentad (Charcot’s triad + …):
Shock
Altered mental status
What is the difference between Primary biliary cholangitis and Primary sclerosing cholangitis
Primary biliary cholangitis = Intrahepatic duct damage. AMA antibody & IgM
Primary sclerosing cholangitis = Intra AND extrahepatic duct damage. pANCA antibody
What medication is given in Primary biliary cholangitis?
Ursodeoxycholic acid (helps the bile flow)
What characteristic finding might you see on MRCP in Primary sclerosing cholangitis?
presence of a stone and “beading” strictures in the biliary tree
Which autoimmune condition is associated with Primary sclerosing cholangitis?
ulcerative colitis
How is Primary sclerosing cholangitis managed?
Liver transplant and biliary stents
why must patients with primary sclerosis cholangitis be carefully observed?
A stricture carries a risk of cholangiocarcinoma developing
What is the most common presenting feature of cholangiocarcinoma?
Painless jaundice
What is the tumour marker for cholangiocarcinoma?
Ca 19-9
What is the most important step in the management of pancreatitis?
IV fluids
Describe Cullens sign. Which condition is it associated with?
bruising around umbilicus
Pancreatitis
Describe Grey-Turner’s sign. Which condition is it associated with?
bruising around flank, pancreatitis
What are the causes of pancreatitis?
Causes = I GET SMASHED
I -Idiopathic
G- Gallstones
E- Ethanol
T- Trauma
S-Steroids
M- mumps/coxsackie A- Autoimmunity & Ascaris infection
S- Scorpion venom
H- Hypertriglycerideaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
E-ERCP
D- Drugs
if you are sick <1 hour after eating, what is the likely cause?
Psychogenic
What is the mechanism of action of cyclizine?
Antihistamine (H1 antagonist)
What are the two big side effects of cyclizine?
Can precipitate cardiac failure
Sedating
what is the mechanism of action of Prochlorperazine/ Metoclopramide/ Haloperidol?
Dopamine antagonists
Which antiemetic is contraindicated in Parkinson’s?
Haloperidol and metoclopromide
What significant side effects are associated with metoclopromide?
Prokinetic side effects
Acute dystonic oculogyric crises
In which clinical scenarios are metoclopromide contraindicated?
bowel obstruction
Parkinson’s
What is the MOA of dexamthosone?
Neurokinin 1 receptor antagonists
What is the MOA of ondansetron?
5HT3-receptor antagonists
Give a brief explanation of refeeding syndrome
Refeeding with high levels of carbohydrates causes a rapid insulin spike. This causes extracellular ions such as potassium, calcium and magnesium to be pulled into cells. This drops the plasma concentrations of these ions which can destabilise the heart
What are hr electrolyte derangement associated with re-feeding syndrome?
Decreased Magnesium, potassium & phosphate
How is referring syndrome treated
Replace phosphate
What genotype is associated with coeliac disease?
HLA genotype (HLA-DQ2 or HLA-DQ8)
Which antibody is tested for in coeliac?
Anti-TTg
What is the gold standard for diagnosing coeliac?
duodenal biopsy (villous atrophy)
What must patients with suspected coeliac disease do prior to diagnostic biopsy?
Eat gluten for at least 6 week
What is the classic skin condition associated with coeliac disease?
Dermatitis herpetiform = caused by IgA deposits in skin
Describe the patient demographic affected by
A) Crohnes
B) UC
Where in the body is affected by
A) Crohnes
B) UC
What are the genes associated with
A) Crohnes
B) UC
Describe the features of
A) Crohnes
B) UC
Describe the extent of fibrosis in
A) Crohnes
B) UC
Describe the systemic manifestations of
A) Crohnes
B) UC
Describe flare management in
A) Crohnes
B) UC
Describe how to maintain remission in
A) Crohnes
B) UC
How is IBS defined?
presence of abdominal pain (for over 3 consecutive days in the last 3 months according to the ROME criteria) alongside altered bowel habits or abdominal bloating (or both) in the absence of any other symptoms
what is the difference between diverticulosis, diverticular disease & diverticulitis ?
Asymptomatic disease = diverticulosis
Symptomatic disease with no inflammation = diverticular disease
Symptomatic disease with inflammation = diverticulitis
What is the inheritance pattern of familial adenomatous polyposis?
Autosomal dominant
Which disease are you at increased risk of if you have familial adenomatous polyposis?
Bowel cancer
Which gene is affected in familial adenomatous polyposis and what chromosome is it on?
APC gene, chromosome 5
How does pre-cancerous familial adenomatous polyposis present?
Multiple adenomas throughout the colon
How is familial adenomatous polyposis monitored?
Annual colonoscopy from age 10/12
What prophylactic procedure can be offered to patients with familial adenomatous polyposis?
Prophylactic proctocolectomy usually by the age of 16 - 25 yrs
What is the inheritance pattern of Lynch syndrome?
autosomal dominant
Which condition does Lynch syndrome increase your risk of?
Bowel cancer
What is the genetic mutation in Lynch syndrome?
mutation in DNA mismatch repair genes (MLH1 & MSH2)
What genetic feature on Lynch syndrome tumours results in short, repeated DNA sequences?
Microsatellite instability
What side is the colorectal cancer usually on in Lynch syndrome patients?
Right side
What age do Lynch syndrome patients classically present with cancer?
40s
Lynch syndrome is associated with cancer at which other sites?
endometrial, genitourinary, stomach and pancreatic cancers
How is known Lynch syndrome monitored?
colonoscopy every two years from age 25
What is the inheritance pattern of MUTYH-associated polyposis?
autosomal recessive condition
What is the genetic mutation associated with MUTYH-associated polyposis?
MUTYH base excision repair gene
Which side of the colon are tumours caused by MUTYHassociated polyposis most likely to be on?
R
at what age is surveillance for MUTYH-associated polyposis commenced?
18 to 20 years old
What are the 3 biggest causes of bowel obstruction?
- Adhesions
- Hernias
- Malignancy
What x-ray sign indicates a volvulus?
Coffee bean sign
Is C.Diff gram positive or gram negative?
Gram positive
Is C.diff an aerobe or an anaerobe?
Anaerobe
Is c. diff a cocci or a bacilli?
Bacilli
How is c. diff tested for?
Stool antigen
Name the antibiotics likely to cause c. diff
- Clarithromycin
- Co-amoxiclav
- Ceftriaxone
- Ciprofloxacin
How is a 1st episode of c. diff treated?
oral vancomycin
How is life threatening c. diff treated?
oral vancomycin AND IV metronidazole
How is a recurrence of c.diff within 12 weeks treated?
oral fidaxomicin
What is the distinctive clinical finding in cholera?
“rice-water” stools
How is Giardia lamblia spread?
through contaminated water (commonly from private water supplies)
What kind of organism is Giardia?
Protozoa
What distinctive finding associated with Giardia can be found on stool microscopy?
cysts
What condition does Entamoeba histolytica cause?
amoebic dysentery
Name the hepatic complication of Entamoeba histolytica
amoebic liver cysts
Describe Rovsing’s sign
RIF pain on palpation of LIF
Where is McBurney’s point?
one third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus
What is the purpose of a loop stoma?
can be reversed – often used to divert bowel contents out of the bowel upstream of an anastomosis which is further down to allow it to heal (defunctioning)
Describe the difference between a direct and an indirect inguinal hernia
Are femoral hernias more common in males or in females?
Females
What are the three main complications of a hernia?
Bowel obstruction
Incarceration
Strangulation
What is the difference between incarceration and strangulation?
Incarceration = unable to reduce
Strangulation = sore (unable to reduce and ischaemic)
What can be given for symptomatic relief in cases of anal fissures?
GTN/ diliazem ointment and lignocaine ointment
What are the surgical management options for anal fissures?
Botox
Sphincterotomy
How is rectal prolapse managed?
Surgical management - rectopexy
What kind of laxative is ispaghula?
Bulk forming
Name 2 stool softening laxitives
Docusate
glycerol suppository
How do stool softening laxatives work?
Made up of detergent like molecules which incorporate more water
Name 2 osmotic laxatives
lactulose, laxido
How do osmotic laxatives work?
made of compounds which are not absorbed by the gut and therefore draw water into the gut.
Name a stimulating laxative
Senna
Explain how stimulating laxatives work
These drugs irritate the bowel which encourages peristalsis
