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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
Q

How do you maintain remission in severe UC?

A

If severe relapse or >=2 exacerbations in past yr: oral azathioprine/mercaptopurine

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26
Q

What are the ix results of CD?

A

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

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27
Q

How do you induce remission in CD?

A

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

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28
Q

What should be assessed before offering azathioprine/mercaptopurine?

A

TPMT Activity

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29
Q

How is severe active CD defined?

A

CDAI >=300 or Harvey-Bradshaw >8

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30
Q

How do you maintain remission in CD?

A

Stop smoking, first line azathioprine/mercaptopurine, second line methotrexate, monitor esp for cancer and neutropenia

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31
Q

When should you screen IBD pts?

A

Offer if sx started 10yrs ago: low risk 5y, med risk 3y, high risk 1y

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32
Q

What constitutes med + high risk when it comes to screening IBD pts?

A

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

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33
Q

Meds that inc risk of c diff (3)

A

Cephalosporins
Clindamycin
PPIs

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34
Q

What does the duodenal biopsy show in coeliac disease?

A

Villous Atrophy

Crypt Hyperplasia

Inc Intraepithelial Lymphocytes

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35
Q

How do you mx uninvestigated dyspepsia sx?

A

Full dose PPI for 1m OR test for h pylori after 2wks off PPI and tx if pos

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36
Q

What is the ix for carcinoid tumours?

A

Urinary 5-HIAA

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37
Q

Acute tx of variceal haemorrhage

A

A-E, FFP/Vit K, Terlipressin, prophylactic abx, endoscopic band ligation, TIPSS

If uncontrolled: Sengstaken-Blakemore tube

38
Q

What is the PHE severity scale for c diff?

A

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
Q

Tx for C Diff

A

Oral Metronidazole 10-14d

If unresponsive/sev use oral vancomycin

If life threatening use IV metronidazole + oral vancomycin

40
Q

How do you dx PBC?

A

The M Rule: AMA M2 subtype + raised serum IgM

41
Q

Mx of PBC

A

Ursodeoxycholic acid, cholestyramine for pruritus, fat soluble vit supplementation

If bilirubin >100 consider liver transplant

42
Q

Why should vit B12 always be given before folate if deficient in both?

A

Prevent subacute combined degeneration of the spinal cord

43
Q

What is Courvoisier’s law?

A

The presence of painless obstructive jaundice suggests a palpable gallbladder is unlikely to be due to gallstones

44
Q

What is the ‘double duct’ sign?

A

The presence of simultaneous dilatation of the common bile and pancreatic ducts

45
Q

What is the grading for hepatic encephalopathy?

A

I: irritability

II: confusion + inappropriate behaviour

III: incoherent + restless

IV: coma

46
Q

List precipitating factors of hepatic encephalopathy

A 
Infection
GI Bleed
Post TIPSS
Constipation
Sedatives
Diuretics
HypoK
ReF
47
Q

Mx of Hepatic Encephalopathy

A

Tx any underlying precipitating cause, lactulose first line, rifaximin secondary prophylaxis

48
Q

What are the scoring systems used to classify severity of liver cirrhosis?

A

Child-Pugh: bilirubin, prolonged PT, albumin, encephalopathy, ascites

Model for End-Stage Liver Disease ie MELD: bilirubin, INR, serum creatinine

49
Q

Meds that cause HypoNa (2)

A

PPI + SSRI

50
Q

What should be excluded when diagnosing UC?

A

Infection

Ischaemia

Drug Related

51
Q

Why is faecal calprotectin useful?

A

It’s a non-specific sign of inflammation so can help to distinguish b/w IBD vs IBS and also track disease remission

52
Q

Ix for UC

A

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
Q

What should be avoided in fulminant disease during UC ix as they precipitate TMC? (2)

A

Contrast + Colonoscopy

54
Q

Manifestations of UC

A 
Arthritis
PSC
Erythema Nodosum
Pyoderma Gangrenosum
Iritis
Uveitis
55
Q

What UC sequelae should you think about if the pt w rising ALP, jaundice, RUQ pain?

A

PSC

56
Q

Comps of UC

A 
PR Bleeding
Perforation
PE
Fulminant Colitis
TMC
57
Q

Ix for Gastric Cancer

A

Dx Endoscopy and Biopsy + Staging CT CAP +/- EUS, PET, Lap

58
Q

At what distance from the OGJ does gastric cancer become oesophageal?

A

<2cm

59
Q

How is gastric cancer staged?

A

AJCC 8th Edition TNM 2017: clinical, pathological, following neoadjuvant therapy

60
Q

Gastric Cancer RFs

A

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
Q

LBO

A

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
Q

What is an apple core lesion on a double contrast enema most suggestive of?

A

Recto-Sigmoid Tumour

63
Q

Tx of Sigmoid Volvulus

A

PR flatus tube using rigid sigmoidoscope on ward - look out for decompensation

Endoscopy

64
Q

Tx of Pseudo-Obstruction

A

Treat cause + oral laxatives

Endoscopy

65
Q

Sigmoid Volvulus vs Pseudo-Obstruction

A

The presence of the classic birds beak and coffee bean signs + there’s no other bowel markings in a sigmoid volvulus

66
Q

How is pancreatitis diagnosed?

A

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
Q

Why might serum amylase not be as high as you’d except?

A

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
Q

Amylase vs Lipase

A

You only need one and amylase is more readily available however lipase is more sensitive and specific esp when alcohol related

69
Q

How is the severity of pancreatitis scored?

A

Specific: Glasgow, Ranson (Alcohol), Modified Ranson (Alcohol and GS)

Generic: APACHE

70
Q

Modified Glasgow Criteria

A 
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
Q

What glasgow score requires transfer to HDU/ITU?

A

> =3

72
Q

Mx of Pancreatitis

A

Admit Resus Monitor

Tx Cause: US-MRCP-ERCP + contact ETOH team and watch for withdrawal

Prevent Comps: VTE + PPI

73
Q

What are the causes of pancreatitis?

A

I GET SMASHED: idiopathic, gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion venom, hyperlipidaemia hypercalcaemia hypothermia, ERCP, drugs

74
Q

What should you except if at a week a pt with pancreatitis isn’t improving or is getting worse?

A

CT scan: pseudocyst, necrosis, bleeding - consider abx and enteral feed where possible

75
Q

How can you establish the dx of pancreatic exocrine insufficiency?

A

Faecal Elastase

76
Q

Cholangitis: Charcot’s Triad

A

RUQ Pain, Jaundice, Fever

77
Q

Cholangitis: Reynold’s Pentad

A

Charcot’s, Shock, Altered Mental Status

78
Q

Mx of Cholangitis

A

Admit Resus Monitor

Sepsis Bundle + Tx Cause

79
Q

Why are four ports used for a lap chole?

A

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
Q

Mx of Crohn’s Flare

A

Involve the gastro team, induce remission, rehydrate and monitor fluid balance, check refeeding bloods and replace electrolytes, VTE prophylaxis, consider abx

81
Q

Mx of Chronic Crohn’s

A

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
Q

Why might serum amylase be higher than excepted?

A

Renal Failure

83
Q

Where do pseudocysts form as a late comp of pancreatitis @ >=6w?

A

Lesser Sac

84
Q

What is Admirand’s triangle?

A

Inc risk of stone if: dec lecithin, dec bile salts, inc cholesterol

85
Q

When should you perform a lap chole for acute cholecystitis?

A

Within 7d of sx onset to red duration of hosp admission w IV abx in the meantime

86
Q

Comps of GS

A

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
Q

What is Mirizzi syndrome?

A

Obstruction of the common hepatic duct caused by extrinsic compression from an impacted stone in the infundibulum of the gallbladder or cystic duct

88
Q

What is a porcelain gallbladder?

A

Calcification believed to be brought on by excessive gallstones

89
Q

Tx of Cholangitis

A

Abx + Biliary Drainage

90
Q

Cholangiocarcinoma RFs

A 
Age
PSC
Choledocholithiasis
Alcoholic Liver Disease
Hep B and C
91
Q

What is the double duct sign on HRCT?

A

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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