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Final Year > Laz - make a medic > Flashcards

Laz - make a medic Flashcards

1
Q

define achalasia

A

A disease characterised by intermittent dysphagia due to failure of relaxation of the lower oesophageal sphincter.

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2
Q

pathophysiology of achalasia?

A

Occurs due to degeneration of ganglion cells of the myenteric plexus in the oesophagus.

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3
Q

symptoms of achalasia - how does it present ?

A

Intermittent dysphagia involving solids and liquids

Regurgitation

Heartburn

Weight loss

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4
Q

ix for supsected achalasia ?

A

barium swallow - you would see Birds’ beak

CXR you would see widened mediastinum

Manometry: shows increased pressure at the lower oesophageal sphincter

Endoscopy: exclude malignancy

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5
Q

how to manage achalasia ?

A

Medical (aims to relax the lower oesophageal sphincter)

Nitrates

Calcium Channel Blockers (e.g. Nifedipine)

Surgical

Pneumatic dilation

Peroral endoscopic myotomy (POEM)

Botulinum toxin injection

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6
Q

path of coeliac disease

A

Inflammatory immune response to the gliadin component of gluten within the small bowel, resulting in intestinal malabsorption.

The presence of gluten within the duodenum triggers an immunological reaction resulting in a number of cellular and architectural changes within the lining of the duodenum

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7
Q

characteristic changes of GI in coeliac - and what part of GI?

A

duodenum:

Subtotal villous atrophy

Crypt hyperplasia

Increased intraepithelial lymphocytes

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8
Q

how does coeliac present ?

A

Chronic diarrhoea

Malabsorption of nutrients → Failure to thrive, weight loss

Tiredness

Abdominal discomfort

Itchy elbows (dermatitis herpetiformis)

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9
Q

ix for coeliac disease

A

FBC (anaemia)

iron and folate

Anti-tissue transglutaminase antibodies: positive

NOTE: This is an IgA antibody. Patients should also have their serum IgA levels measured as patient with selective IgA deficiency (relatively common in the population) would have a false negative anti-tTG result.

Anti-Endomysial Antibodies (IgA and IgG)

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10
Q

vaccine in coeliac disease ?

A

Patients with coeliac disease often have a degree of functional hyposplenism

For this reason, all patients with coeliac disease are offered the pneumococcal vaccine

Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every 5 years

Currrent guidelines suggest giving the influenza vaccine on an individual basis.

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11
Q

how does crohns present ?

A

Chronic diarrhoea (may be bloody)

Abdominal pain

Malaise

Weight loss

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12
Q

ix for crohns

A

Bloods

FBC: anaemia

CRP/ESR: raised

Imaging

CT Scan: inflammation of the bowel wall

Barium Follow-Through: identify strictures

Other

OGD/Colonoscopy and Biopsy

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13
Q

management for crohns

A

Inducing Remission

Initial Agents

Glucocorticoids

E.g. prednisolone, methylprednisolone, IV hydrocortisone

Consider enteral nutrition as an alternative to steroids in:

Children and young people with concerns about growth and side-effects

Consider budesonide in people with:

One or more of distal ileal, ileocaecal or right-sided colonic disease

AND
Conventional steroids are not appropriate (e.g. not tolerated)

Consider aminosalicylates if steroids are not tolerated (e.g. mesalamine/mesalazine or sulfasalazine)

Add-Ons

Consider adding azathioprine or mercaptopurine to steroid treatment if:

2 or more exacerbations in 12 months

Glucocorticoid dose cannot be tapered

WARNING: assess thiopurine methyltransferase (TPMT) levels before starting azathioprine or mercaptopurine

Consider methotrexate as a second-line add-on if azathioprine or mercaptopurine are not tolerated

Biologics

Consider infliximab or adalimumab for adults with severe active Crohn’s disease who have not responded to conventional therapy (immunosuppressants)

Maintaining Remission

Avoid smoking

NOTE: smoking makes Crohn’s worse and ulcerative colitis better

Offer azathioprine or mercaptopurine as monotherapy

Consider methotrexate if:

Needed methotrexate to maintain remission

Azathioprine and mercaptopurine not tolerated or contraindicated

Do NOT offer glucocorticoids to maintain remission

Maintaining Remission Post-Operatively

Consider azathioprine with metronidazole

Surgery

Consider surgery early on in the disease if it is mainly confined to the terminal ileum

Consider surgery in children and young people who have refractory disease or a growth impairment despite maximal medical treatment

Strictures

Consider balloon dilation

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14
Q

which biologics for crohns ?

A

infliximab or adalimumab

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15
Q

which bacteria give you bloody diarrheoa gastroenteritis ?

A

Blood diarrhoea

More commonly associated with ‘CHESS’ bacteria (Campylobacter, Haemorrhagic E.coli, Entamoeba histolytica, Salmonella, Shigella)

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16
Q

ix for gastroenteritis

A

Bloods

U&E: assess extent of dehydration

Stool

Faecal microscopy and culture

Faecal C. difficile toxin assay

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17
Q

how to manage gastroenteritis ?

A

Usually managed conservatively with oral fluid rehydration as the disease is normally self-limiting

Correct electrolyte imbalances

Antibiotics may be considered in severe infection

18
Q

risk factors for GORD ?

A

Obesity

Pregnancy

Hiatus Hernia

Alcohol excess

Smoking

19
Q

how does GORD present ?

A

Epigastric pain

NOTE: check for triggers (e.g. spicy food)

Abnormal taste in mouth

Dysphagia

Chronic cough (worse at night and when lying down)

20
Q

ix for GORD ?

A

Largely a clinical diagnosis

Bloods

FBC: anaemia may be suggestive of a bleeding ulcer/malignancy

Other

ECG (always consider cardiac causes of chest/epigastric pain)

24 hour oesophageal pH monitoring

Upper GI endoscopy (exclude malignancy)

Helicobacter pylori breath test and stool antigen

NOTE: 2 week washout period following PPI treatment must be observed before testing for H. pylori

21
Q

Explain H pylori breath test ?

A

H pylori express Urease enzyme

patient swallows pill containing urea with carbon-13/14 isotope. If H pylori present, then CO2 is produced with the isotope. Therefore if labelled CO2 is detected by the analyser, then H pylori is present

22
Q

GORD management

A

Conservative

Weight loss

Avoid precipitants (e.g. alcohol, spicy food)

Stop smoking

Sleep propped up

Uninvestigated Dyspepsia

Offer empirical high-dose PPI therapy for 4 weeks for people with uninvestigated dyspepsia

Offer H. pylori ‘test and treat’

Offer histamine antagonist (e.g. nizatidine) if there is an inadequate response to the PPI

Gastro-oesophageal Reflux Disease

Offer full-dose PPI for 4-8 weeks

If symptoms recur after initial treatment, offer long-term PPI at lowest dose possible that achieves symptom control

Offer histamine antagonist if the response to the PPI is inadequate

Referral to gastroenterologist for persistent/refractory GORD

Surgical

Nissen fundoplication

23
Q

what is zollinger-ellison syndrome ?

A

Zollinger-Ellison syndrome is a rare condition where a duodenal or pancreatic tumour secretes excessive quantities of gastrin.

Gastrin is a hormone that stimulates acid secretion in the stomach. Therefore, there is excess production of stomach acid, resulting in severe dyspepsia, diarrhoea and peptic ulcers.

Gastrin-secreting tumours (gastrinomas) may be associated with multiple endocrine neoplasia type 1 (MEN1), an autosomal dominant genetic condition, which can also cause hormone-secreting tumours of the parathyroid and pituitary glands.

24
Q

how does IBS present ?

A

Bloating

Abdominal discomfort (often relieved by defecation)

Constipation and diarrhoea

25
Q

ix for IBS ?

A

Often a diagnosis of exclusion

Tests to Exclude Other Causes

Coeliac Disease: FBC, anti-tTG antibodies

IBD: faecal calprotectin, endoscopy

26
Q

how to manage IBS ?

A

Conservative

Advice and reassurance

Encourage identification of precipitants

Stress management (exercise, mindfulness, gut-directed hypnotherapy)

Medical

If predominantly diarrhoeal symptoms:

Reduce intake of insoluble fibre

If predominantly symptoms of constipation:

Try soluble fibre supplements (e.g. ispaghula) or foods high in fibre

Consider bulk-forming laxatives or loperamide depending on nature of symptoms

If complaining of abdominal pain:

Consider antispasmodic (e.g. mebeverine hydrochloride or hyoscine butylbromide)

Consider trial of low-dose tricyclic antidepressant (e.g. amitriptyline)

Consider trial of SSRI

Consider referral to dietician for specialised diet (e.g. FODMAP)

27
Q

who gets a mallory weiss tear ?

A

Alcohol excess

Bulimia

28
Q

how does mallory weiss tear present ?

A

Epigastric discomfort

Recent history of severe vomiting

Haematemesis

Melaena

29
Q

ix and mx for mallory weiss tear

A

Usually does not require active investigation and management

Bloods

FBC: microcytic anaemia

Other

OGD (looking for varices)

Management

Heals spontaneously the majority of the time

Consider PPIs

Interventional

Endoscopy and sclerotherapy

30
Q

causes / risk factors for peptic ulcer disease ?

A

Helicobacter pylori

Drugs (NSAIDS, steroids, bisphosphonates, SSRIs, aspirin)

Smoking

Alcohol Excess

31
Q

pathophysiology for peptic ulcer disease ?

A

Development of ulcers within the gastric and duodenal mucosa due to increased exposure to stomach acid.

Aetiology and Risk Factors

Occurs due to excessive acid and pepsin activity and insufficient mucosal defence systems

32
Q

how does peptic ulcer disease present ?

A

Epigastric pain

Gastric: may occur whilst eating food

Duodenal: may occur hours after eating food

Melaena

33
Q

pain characteristics gastric vs duodenal ulcer and why ?

A

gastric = pain often worsens by eating as food stimulates acid production in stomach

duodenal = pain worse when hungry/empty stomach or at night. No food to neutralise the acid. pain is relieved by eating.

34
Q

ix for peptic ulcer disease

A

FBC: microcytic anaemia

U&E: raised urea may be suggestive of upper gastrointestinal bleed

Other

Endoscopy and Biopsy

Required urgently in patients with dysphagia, significant acute gastrointestinal bleeding or those aged 55 years or older with unexplained weight loss and symptoms of upper abdominal pain, reflux or dyspepsia

Urease Breath Test (non-invasive detection of H. pylori)

CT Scan (in cases of perforation)

35
Q

management of peptic ulcer disease

A

Management

Lifestyle changes (e.g. smoking cessation)

Review drug history, consider reducing/substituting NSAIDs

Offer H. pylori eradication therapy (three treatments, twice daily for 7 days) if tested positive for H. pylori

PPI (e.g. omeprazole)

Amoxicillin
Clarithromycin OR Metronidazole
NOTE: clarithromycin can be given with metronidazole in penicillin-allergic patients, other options include levofloxacin and tetracyclines

Offer patients with an ulcer and H. pylori a repeat endoscopy 6-8 weeks after beginning treatment to confirm healing

Offer high-dose PPI for 4-8 weeks then low-dose if symptoms recur

Offer histamine antagonist if the response to treatment with a PPI is inadequate

Interventional

Endoscopy and Sclerotherapy/Coagulation

36
Q

features of UC

A

Chronic diarrhoea

Rectal bleeding

Tenesmus

Abdominal pain

Weight loss

Extra-GI Manifestations (uveitis, erythema nodosum)

37
Q

Ix for UC

A

FBC: raised inflammatory markers

Other

Stool: faecal calprotectin

Endoscopy (Flexible Sigmoidoscopy or Colonoscopy)

38
Q

management for UC

A

Severity can be assessed using the Truelove and Witts severity index

Mild-to-Moderate Disease

Proctitis

Induce Remission

1st Line: Topical Aminosalicylate

2nd Line: Add Oral Aminosalicylate

3rd Line: Add Topical OR Oral Steroid

Maintain Remission

Topical Aminosalicylate

Oral Aminosalicylate with Topical Aminosalicylate

Oral Aminosalicylate Alone

Proctosigmoiditis and Left-Sided Ulcerative Colitis

Induce Remission

1st Line: Topical Aminosalicylate

2nd Line: Add High-Dose Oral Aminosalicylate OR Switch to High-Dose Oral Aminosalicylate AND Topical Steroid

3rd Line: Stop Topical Treatment AND Start Oral Aminosalicylate AND Oral Steroid

Maintain Remission

Oral Aminosalicylate

Extensive Disease

Induce Remission

1st Line: Topical Aminosalicylate AND High-Dose Oral Aminosalicylate

2nd Line: Stop Topical Aminosalicylate AND Start High-Dose Oral Aminosalicylate AND Oral Steroid

Maintain Remission

Oral Aminosalicylate

All Types of Disease

Consider Oral Azathioprine or Oral Mercaptopurine to maintain remission:

After 2 or more exacerbations requiring corticosteroids in 12 months

If remission is not maintained by aminosalicylates alone

Severe Disease (either first presentation or acute exacerbation)

Step 1: IV Corticosteroids (e.g. Hydrocortisone 100 mg QDS)

Alternative: IV Ciclosporin

Step 2: Add IV Ciclosporin and Consider Surgery - if little/no improvement in 72hrs

Alternative: Infliximab

Features Increasing the Need for Surgery

> 8 bowel motions per day

Pyrexia

Tachycardia

Abdominal X-ray showing colonic dilatation (toxic megacolon)

Low albumin, low haemoglobin, high platelet count, CRP above 45 mg/L

39
Q

how to manage alc hep?

A

Alcohol Abstinence

Alcohol Withdrawal: Chlordiazepoxide + Pabrinex

Symptomatic

Ascites: drain, diuretics, albumin

Encephalopathy: lactulose, rifaximin

Nutritional Supplementation

Consider steroid treatment

Sometimes used in severe alcoholic hepatitis with a Maddrey’s Discriminant Function of 32 or more

Consider liver transplantation

40
Q

LFT pattern in alc hep?

A

gamma-GT is characteristically elevated

the ratio of AST:ALT is normally > 2, a ratio of > 3 is strongly suggestive of acute alcoholic hepatitis

41
Q
A

Final Year (4 decks)

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