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Year 5/6 > Medicine: Gastro > Flashcards

Medicine: Gastro Flashcards

1
Q

Tx pathway for bleeding varices on OGD

A

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

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2
Q

Achalasia vs Nutcracker Oesophagus

A

Manometry

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3
Q

Tx of Achalasia

A

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

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4
Q

What is the weak area called that leads to a pharyngeal pouch?

A

Killian’s Dehiscence

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5
Q

PVS Triad

A

Dysphagia, IDA, Webs

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6
Q

What is characteristic of angiodysplasia on endoscopy?

A

Cherry Red Spot

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7
Q

What is the anatomical significance of the dentate line?

A

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

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8
Q

Ix for Rectal Bleeding

A
  1. A-E + Resus
  2. Protoscopy +/- Rigid Sigmoidoscopy
  3. OGD/Colonoscopy
  4. Mesenteric/CT Angiography
  5. Radionuclide Imaging
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9
Q

What bilirubin is required to become visibly jaundiced?

A

> 40uM

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10
Q

What are the clinical signs of chronic stable liver disease? (4)

A

PDGS

Palmar Erythema
Dupuytrens Contracture
Gynaecomastia
Spider Naevi

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11
Q

What are the clinical signs of portal HTN? (4)

A

SAVE

Splenomegaly
Ascites
Varices
Enlarged Abdo Veins

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12
Q

Imaging for PSC

A

US + MRCP

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13
Q

When would you ix for UC?

A

Diarrhoea >4wks +/- blood, abdo pain, systemic sx

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14
Q

Which hepatitis virus inc the risk of HCC?

A

B

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15
Q

What are the indications for an ascitic tap?

A

Sx (tense or SOB) + Diagnostic (SBP)

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16
Q

What extra intestinal features are related to disease activity in IBD?

A

Erythema Nodosum + Episcleritis

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17
Q

What extra intestinal features are unrelated to disease activity in IBD?

A

Pyoderma Gangrenosum + Uveitis

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18
Q

IBD: Episcleritis vs Uveitis

A

Episcleritis is more common in CD

Uveitis is more common in UC

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19
Q

What are the findings of UC on imaging?

A

Endoscopy: pseudopolyps

Barium swallow: loss of haustrations

AXR: lead pipe colon in long standing disease

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20
Q

Mx of UC

A

Consrv: red stress + NSAIDs

Mx: Inducing -> Maintaining

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21
Q

What constitutes mild-sev UC flares?

A

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

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22
Q

How do you induce remission in mild-mod UC?

A

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

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23
Q

How do you induce remission in severe UC?

A

Tx in secondary care w IV steroids first line

If CI/no improvement after 72hrs use/add IV ciclosporin and consider surgery

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24
Q

How do you maintain remission in mild-mod UC?

A

Proctitis + Proctosigmoiditis: topical 5-ASA +/-/or oral 5-ASA

L Sided UC + Extensive: low maintenance dose of oral 5-ASA

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25
How do you maintain remission in severe UC?
If severe relapse or >=2 exacerbations in past yr: oral azathioprine/mercaptopurine
26
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
27
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
28
What should be assessed before offering azathioprine/mercaptopurine?
TPMT Activity
29
How is severe active CD defined?
CDAI >=300 or Harvey-Bradshaw >8
30
How do you maintain remission in CD?
Stop smoking, first line azathioprine/mercaptopurine, second line methotrexate, monitor esp for cancer and neutropenia
31
When should you screen IBD pts?
Offer if sx started 10yrs ago: low risk 5y, med risk 3y, high risk 1y
32
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
33
Meds that inc risk of c diff (3)
Cephalosporins Clindamycin PPIs
34
What does the duodenal biopsy show in coeliac disease?
Villous Atrophy Crypt Hyperplasia Inc Intraepithelial Lymphocytes
35
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
36
What is the ix for carcinoid tumours?
Urinary 5-HIAA
37
Acute tx of variceal haemorrhage
A-E, FFP/Vit K, Terlipressin, prophylactic abx, endoscopic band ligation, TIPSS If uncontrolled: Sengstaken-Blakemore tube
38
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
39
Tx for C Diff
Oral Metronidazole 10-14d If unresponsive/sev use oral vancomycin If life threatening use IV metronidazole + oral vancomycin
40
How do you dx PBC?
The M Rule: AMA M2 subtype + raised serum IgM
41
Mx of PBC
Ursodeoxycholic acid, cholestyramine for pruritus, fat soluble vit supplementation If bilirubin >100 consider liver transplant
42
Why should vit B12 always be given before folate if deficient in both?
Prevent subacute combined degeneration of the spinal cord
43
What is Courvoisier’s law?
The presence of painless obstructive jaundice suggests a palpable gallbladder is unlikely to be due to gallstones
44
What is the ‘double duct’ sign?
The presence of simultaneous dilatation of the common bile and pancreatic ducts
45
What is the grading for hepatic encephalopathy?
I: irritability II: confusion + inappropriate behaviour III: incoherent + restless IV: coma
46
List precipitating factors of hepatic encephalopathy
``` Infection GI Bleed Post TIPSS Constipation Sedatives Diuretics HypoK ReF ```
47
Mx of Hepatic Encephalopathy
Tx any underlying precipitating cause, lactulose first line, rifaximin secondary prophylaxis
48
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
49
Meds that cause HypoNa (2)
PPI + SSRI
50
What should be excluded when diagnosing UC?
Infection Ischaemia Drug Related
51
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
52
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
53
What should be avoided in fulminant disease during UC ix as they precipitate TMC? (2)
Contrast + Colonoscopy
54
Manifestations of UC
``` Arthritis PSC Erythema Nodosum Pyoderma Gangrenosum Iritis Uveitis ```
55
What UC sequelae should you think about if the pt w rising ALP, jaundice, RUQ pain?
PSC
56
Comps of UC
``` PR Bleeding Perforation PE Fulminant Colitis TMC ```
57
Ix for Gastric Cancer
Dx Endoscopy and Biopsy + Staging CT CAP +/- EUS, PET, Lap
58
At what distance from the OGJ does gastric cancer become oesophageal?
<2cm
59
How is gastric cancer staged?
AJCC 8th Edition TNM 2017: clinical, pathological, following neoadjuvant therapy
60
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
61
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
62
What is an apple core lesion on a double contrast enema most suggestive of?
Recto-Sigmoid Tumour
63
Tx of Sigmoid Volvulus
PR flatus tube using rigid sigmoidoscope on ward - look out for decompensation Endoscopy
64
Tx of Pseudo-Obstruction
Treat cause + oral laxatives Endoscopy
65
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
66
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
67
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
68
Amylase vs Lipase
You only need one and amylase is more readily available however lipase is more sensitive and specific esp when alcohol related
69
How is the severity of pancreatitis scored?
Specific: Glasgow, Ranson (Alcohol), Modified Ranson (Alcohol and GS) Generic: APACHE
70
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 ```
71
What glasgow score requires transfer to HDU/ITU?
>=3
72
Mx of Pancreatitis
Admit Resus Monitor Tx Cause: US-MRCP-ERCP + contact ETOH team and watch for withdrawal Prevent Comps: VTE + PPI
73
What are the causes of pancreatitis?
I GET SMASHED: idiopathic, gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion venom, hyperlipidaemia hypercalcaemia hypothermia, ERCP, drugs
74
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
75
How can you establish the dx of pancreatic exocrine insufficiency?
Faecal Elastase
76
Cholangitis: Charcot’s Triad
RUQ Pain, Jaundice, Fever
77
Cholangitis: Reynold’s Pentad
Charcot’s, Shock, Altered Mental Status
78
Mx of Cholangitis
Admit Resus Monitor Sepsis Bundle + Tx Cause
79
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
80
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
81
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
82
Why might serum amylase be higher than excepted?
Renal Failure
83
Where do pseudocysts form as a late comp of pancreatitis @ >=6w?
Lesser Sac
84
What is Admirand’s triangle?
Inc risk of stone if: dec lecithin, dec bile salts, inc cholesterol
85
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
86
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
87
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
88
What is a porcelain gallbladder?
Calcification believed to be brought on by excessive gallstones
89
Tx of Cholangitis
Abx + Biliary Drainage
90
Cholangiocarcinoma RFs
``` Age PSC Choledocholithiasis Alcoholic Liver Disease Hep B and C ```
91
What is the double duct sign on HRCT?
The presence of simultaneous dilatation of the common bile and pancreatic ducts found in pancreatic cancer

Year 5/6 (20 decks)

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