Medicine: Gastro Flashcards
Tx pathway for bleeding varices on OGD
Band ligation, sclerotherapy, balloon tamponade, TIPSS, surgery
The point at which bleeding stops band to eradicate varices then regular F/U or if recur surg referral
Achalasia vs Nutcracker Oesophagus
Manometry
Tx of Achalasia
Aim to loosen the lower oesophageal sphincter
Med: CCBs + Nitrates (but not first line)
Intv: balloon dilatation + botulinum toxin injection
Surg: Heller’s myotomy +/- Nissen fundoplication
Plus referral to SALT
What is the weak area called that leads to a pharyngeal pouch?
Killian’s Dehiscence
PVS Triad
Dysphagia, IDA, Webs
What is characteristic of angiodysplasia on endoscopy?
Cherry Red Spot
What is the anatomical significance of the dentate line?
Watershed separating different epithelial types and NV/lymph supply
Above: columnar, autonomic, branches of inf mesenteric, mesenteric LNs
Below: stratified squamous, somatic, branches of internal iliac, inguinal LNs
Ix for Rectal Bleeding
- A-E + Resus
- Protoscopy +/- Rigid Sigmoidoscopy
- OGD/Colonoscopy
- Mesenteric/CT Angiography
- Radionuclide Imaging
What bilirubin is required to become visibly jaundiced?
> 40uM
What are the clinical signs of chronic stable liver disease? (4)
PDGS
Palmar Erythema
Dupuytrens Contracture
Gynaecomastia
Spider Naevi
What are the clinical signs of portal HTN? (4)
SAVE
Splenomegaly
Ascites
Varices
Enlarged Abdo Veins
Imaging for PSC
US + MRCP
When would you ix for UC?
Diarrhoea >4wks +/- blood, abdo pain, systemic sx
Which hepatitis virus inc the risk of HCC?
B
What are the indications for an ascitic tap?
Sx (tense or SOB) + Diagnostic (SBP)
What extra intestinal features are related to disease activity in IBD?
Erythema Nodosum + Episcleritis
What extra intestinal features are unrelated to disease activity in IBD?
Pyoderma Gangrenosum + Uveitis
IBD: Episcleritis vs Uveitis
Episcleritis is more common in CD
Uveitis is more common in UC
What are the findings of UC on imaging?
Endoscopy: pseudopolyps
Barium swallow: loss of haustrations
AXR: lead pipe colon in long standing disease
Mx of UC
Consrv: red stress + NSAIDs
Mx: Inducing -> Maintaining
What constitutes mild-sev UC flares?
The Montreal Classification
Mild <4 stools/d w no systemic disturbance
Mod 4-6 stools/d w minimal systemic disturbance
Sev >6 stools/d w abdo tenderness, fever, tachycardia, anaemia, hypoalbuminaemia
How do you induce remission in mild-mod UC?
Proctitis: topical 5-ASA, if not achieved @4wks add oral 5-ASA, if subacute add topical/oral corticosteroid
Proctosigmoiditis + L Sided UC: topical 5-ASA, if not achieved @4wks add high dose oral 5-ASA +/- change topical 5-ASA to topical corticosteroid, if subacute stop topical and do both orally
Extensive: topical 5-ASA and high dose oral 5-ASA then if not achieved @4wks stop topical and do both orally
How do you induce remission in severe UC?
Tx in secondary care w IV steroids first line
If CI/no improvement after 72hrs use/add IV ciclosporin and consider surgery
How do you maintain remission in mild-mod UC?
Proctitis + Proctosigmoiditis: topical 5-ASA +/-/or oral 5-ASA
L Sided UC + Extensive: low maintenance dose of oral 5-ASA
How do you maintain remission in severe UC?
If severe relapse or >=2 exacerbations in past yr: oral azathioprine/mercaptopurine
What are the ix results of CD?
Bloods: anaemia, low vit B12 and D, raised inflam markers esp CRP
Stool: inc faecal calprotectin
Histology: transmural inflam, goblet cells, granulomas
Small bowel enema: Kantor’s string sign w proximal bowel dilation, rose thorn ulcers, fistulae
How do you induce remission in CD?
If first px or single inflam exacerbation in 12m period: glucocorticosteroid/ budesonide
If steroid dose cannot be tapered or >=2 inflam exacerbation in 12m period: above + azathioprine/mercaptopurine/methotrexate
If unresponsive/CI to conventional therapy or >12m after tx started: infliximab +/- adalimumab
If child/young person: consider enteral nutrition w an elemental diet
If limited to distal ileum: consider surgery
What should be assessed before offering azathioprine/mercaptopurine?
TPMT Activity
How is severe active CD defined?
CDAI >=300 or Harvey-Bradshaw >8
How do you maintain remission in CD?
Stop smoking, first line azathioprine/mercaptopurine, second line methotrexate, monitor esp for cancer and neutropenia
When should you screen IBD pts?
Offer if sx started 10yrs ago: low risk 5y, med risk 3y, high risk 1y
What constitutes med + high risk when it comes to screening IBD pts?
Med: mild active inflam, post inflam polyps, fhx CRC first degree relative >50
High: mod/sev active inflam, PSC, colonic stricture or dysplasia in past 5y, fhx CRC any relative <50
Meds that inc risk of c diff (3)
Cephalosporins
Clindamycin
PPIs
What does the duodenal biopsy show in coeliac disease?
Villous Atrophy
Crypt Hyperplasia
Inc Intraepithelial Lymphocytes
How do you mx uninvestigated dyspepsia sx?
Full dose PPI for 1m OR test for h pylori after 2wks off PPI and tx if pos
What is the ix for carcinoid tumours?
Urinary 5-HIAA
Acute tx of variceal haemorrhage
A-E, FFP/Vit K, Terlipressin, prophylactic abx, endoscopic band ligation, TIPSS
If uncontrolled: Sengstaken-Blakemore tube
What is the PHE severity scale for c diff?
Mild: normal WCC
Mod: inc WCC <15 and typically 3-5 loose stools/d
Sev: inc WCC >15, Cr >50%, temp >38.5°, evidence of sev colitis
LT: hypotension, ileus, toxic megacolon
Tx for C Diff
Oral Metronidazole 10-14d
If unresponsive/sev use oral vancomycin
If life threatening use IV metronidazole + oral vancomycin
How do you dx PBC?
The M Rule: AMA M2 subtype + raised serum IgM
Mx of PBC
Ursodeoxycholic acid, cholestyramine for pruritus, fat soluble vit supplementation
If bilirubin >100 consider liver transplant
Why should vit B12 always be given before folate if deficient in both?
Prevent subacute combined degeneration of the spinal cord
What is Courvoisier’s law?
The presence of painless obstructive jaundice suggests a palpable gallbladder is unlikely to be due to gallstones
What is the ‘double duct’ sign?
The presence of simultaneous dilatation of the common bile and pancreatic ducts
What is the grading for hepatic encephalopathy?
I: irritability
II: confusion + inappropriate behaviour
III: incoherent + restless
IV: coma
List precipitating factors of hepatic encephalopathy
Infection GI Bleed Post TIPSS Constipation Sedatives Diuretics HypoK ReF
Mx of Hepatic Encephalopathy
Tx any underlying precipitating cause, lactulose first line, rifaximin secondary prophylaxis
What are the scoring systems used to classify severity of liver cirrhosis?
Child-Pugh: bilirubin, prolonged PT, albumin, encephalopathy, ascites
Model for End-Stage Liver Disease ie MELD: bilirubin, INR, serum creatinine
Meds that cause HypoNa (2)
PPI + SSRI
What should be excluded when diagnosing UC?
Infection
Ischaemia
Drug Related
Why is faecal calprotectin useful?
It’s a non-specific sign of inflammation so can help to distinguish b/w IBD vs IBS and also track disease remission
Ix for UC
Bloods: FBC ESR CRP U+E LFT Culture
Stool: MCS, c diff toxin, faecal calprotectin
AXR/CT: to exclude comps of the UC
Endoscopy: both to view the appearance and take biopsies UC vs CD + exclude ischaemia and solitary rectal ulcer syndrome
What should be avoided in fulminant disease during UC ix as they precipitate TMC? (2)
Contrast + Colonoscopy
Manifestations of UC
Arthritis PSC Erythema Nodosum Pyoderma Gangrenosum Iritis Uveitis
What UC sequelae should you think about if the pt w rising ALP, jaundice, RUQ pain?
PSC
Comps of UC
PR Bleeding Perforation PE Fulminant Colitis TMC
Ix for Gastric Cancer
Dx Endoscopy and Biopsy + Staging CT CAP +/- EUS, PET, Lap
At what distance from the OGJ does gastric cancer become oesophageal?
<2cm
How is gastric cancer staged?
AJCC 8th Edition TNM 2017: clinical, pathological, following neoadjuvant therapy
Gastric Cancer RFs
Intestinal vs Diffuse
Intestinal: H pylori, gastritis, gastric atrophy/resection result in less acid and more gastrin to induce epithelial proliferation
Diffuse: CDH1 mutation, FHx, blood group A
LBO
Mechanical vs Non-Mechanical
Mechanical: extraluminal (compression and torsion), luminal (neoplastic and stricture), intraluminal (faeces and FB)
Non-Mechanical: pseudo-obstruction w capacious and empty rectum
What is an apple core lesion on a double contrast enema most suggestive of?
Recto-Sigmoid Tumour
Tx of Sigmoid Volvulus
PR flatus tube using rigid sigmoidoscope on ward - look out for decompensation
Endoscopy
Tx of Pseudo-Obstruction
Treat cause + oral laxatives
Endoscopy
Sigmoid Volvulus vs Pseudo-Obstruction
The presence of the classic birds beak and coffee bean signs + there’s no other bowel markings in a sigmoid volvulus
How is pancreatitis diagnosed?
Clinically supported by abnormal serum findings ie >x2-4 UL of normal amylase
At admission you’d also do a blood gas to assess severity and erect CXR to exclude ddx then if they worsened a CT for any comps
Why might serum amylase not be as high as you’d except?
Pts with chronic episodes may not be able to amount such a response OR you’ve missed the peak as levels fall within 24-48h
Amylase vs Lipase
You only need one and amylase is more readily available however lipase is more sensitive and specific esp when alcohol related
How is the severity of pancreatitis scored?
Specific: Glasgow, Ranson (Alcohol), Modified Ranson (Alcohol and GS)
Generic: APACHE
Modified Glasgow Criteria
PaO2 <8kPa Age >55yrs Neutrophilia >15x10^9/L Calcium <2mmol/L Renal (Urea) >16mmol/L Enzymes (LDH) >600 IU/L Albumin <32g/L Sugar >10mmol/L
What glasgow score requires transfer to HDU/ITU?
> =3
Mx of Pancreatitis
Admit Resus Monitor
Tx Cause: US-MRCP-ERCP + contact ETOH team and watch for withdrawal
Prevent Comps: VTE + PPI
What are the causes of pancreatitis?
I GET SMASHED: idiopathic, gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion venom, hyperlipidaemia hypercalcaemia hypothermia, ERCP, drugs
What should you except if at a week a pt with pancreatitis isn’t improving or is getting worse?
CT scan: pseudocyst, necrosis, bleeding - consider abx and enteral feed where possible
How can you establish the dx of pancreatic exocrine insufficiency?
Faecal Elastase
Cholangitis: Charcot’s Triad
RUQ Pain, Jaundice, Fever
Cholangitis: Reynold’s Pentad
Charcot’s, Shock, Altered Mental Status
Mx of Cholangitis
Admit Resus Monitor
Sepsis Bundle + Tx Cause
Why are four ports used for a lap chole?
The first through the umbilicus for a camera, an epigastric port to elevate the fundus of the GB and two ports to operate through
Mx of Crohn’s Flare
Involve the gastro team, induce remission, rehydrate and monitor fluid balance, check refeeding bloods and replace electrolytes, VTE prophylaxis, consider abx
Mx of Chronic Crohn’s
Maintenance of remission, smoking cessation, disease monitoring, cancer screening, consider bone protection, pre-conception planning for females based on the drugs they’re on
Why might serum amylase be higher than excepted?
Renal Failure
Where do pseudocysts form as a late comp of pancreatitis @ >=6w?
Lesser Sac
What is Admirand’s triangle?
Inc risk of stone if: dec lecithin, dec bile salts, inc cholesterol
When should you perform a lap chole for acute cholecystitis?
Within 7d of sx onset to red duration of hosp admission w IV abx in the meantime
Comps of GS
In the GB and cystic duct: biliary colic, cholecystitis, mucocoele, empyema, carcinoma, Mirizzi syndrome
In the bile ducts: obstructive jaundice, cholangitis, pancreatitis
In the gut: GS ileus
What is Mirizzi syndrome?
Obstruction of the common hepatic duct caused by extrinsic compression from an impacted stone in the infundibulum of the gallbladder or cystic duct
What is a porcelain gallbladder?
Calcification believed to be brought on by excessive gallstones
Tx of Cholangitis
Abx + Biliary Drainage
Cholangiocarcinoma RFs
Age PSC Choledocholithiasis Alcoholic Liver Disease Hep B and C
What is the double duct sign on HRCT?
The presence of simultaneous dilatation of the common bile and pancreatic ducts found in pancreatic cancer
