Medicine - Gastroenterology Flashcards
Describe and differentiate the symptoms of mild, moderate and severe flares of ulcerative colitis
Mild: <4 stools per day, little blood
Moderate: 4-6 stools per day, varying blood
Severe: >6 stools per day, bloody diarrhoea, systemic upset
What is the name of the criteria used to stage IBD, and what are the 6 criteria?
Truelove and Witts:
Heart rate
Temperature
Bowel movements
PR bleeding
Haemoglobin
ESR
Recall 2 typical histological findings of the gut layer for Crohn’s and then UC
Crohn’s: Increased goblet cells, granulomas
UC: Decreased goblet cells, crypt abscesses
What is the most common affected portion of the bowel in Crohn’s vs UC?
Crohn’s: terminal ileum (so RIF mass)
UC: rectum
Describe the typical features of inflammation in Crohn’s vs UC
Crohn’s: Skip lesions, rose-thorn ulcers, cobblestoning, string sign of kantor (narrow ileum stricture)
UC: ‘lead-pipe’, pseudo-polyps, thumbprinting
Which type of IBD carries the highest risk of colorectal cancer?
UC
In which form of IBD are fissures more common and why?
Crohn’s - because it affects the full thickness of the bowel wall
Differentiate the appearance of stool in active Crohn’s vs UC
Crohn’s: non-bloody diarrhoea
UC: bloody diarrhoea which may contain mucous
Which type of IBD is associated with gallstones and why?
Crohn’s
Bile acids are not properly absorbed as terminal ileum is affected
In which form of IBD can surgery be curative?
UC
Recall the possible extra-intestinal manifestations of IBD
A PIE SAC
Aphthous ulcers
Pyoderma gangrenosum (skin ulcers)
I (eye) = uveitis, iritis, episcleritis
Erythema nodosum
Sclerosing cholangitis (UC Only)
Arthritis
Clubbing (Crohn’s moreso)
Describe the process of inducing remission in Crohn’s
Steroids:
If mild: oral prednisolone
If severe: IV hydrocortisone
If no improvement after 5 days –> infliximab
Oral budesonide can be used in disease between the distal ileum and the ascending colon
Nutritional:
Replace diet with whole protein modular diet - excessively liquid, for 6-8 weeks - this helps to replace lost weight
Describe the process of maintaining remission in Crohn’s
First line: DMARDs (eg azothioprine)
Alternatives: infliximab/ aminosalicylates
Describe the management of UC
Severe disease:
Fulminant: IV steroids and anti-TNF (ciclosporin/infliximab)
Non-fulminant: oral aminosalicylates and corticosteroids with topical aminosalicylates
Non-severe disease:
1st line:
If distal colitis –> oral + topical aminosalicylates
If extensive colitis (past splenic flexure) –> topical and oral salicylates
2nd line:
Topical –> oral corticosteroids
3rd line:
Oral tacrolimus
4th line: biologics
5th line: surgery
What is the main side effect of aminosalicylates to remember?
Acute pancreatitis
In which form of IBD is surgical management most useful?
UC
What are the options for surgery in UC?
Emergency:
Hartmann’s protosigmoidectomy + end ileostomy –> later IPAA (ileal-pouch ana anastomosis)
Non-emergency:
Protocolectomy + IPAA or
Panprotocolectomy + end ileostomy
What are the criteria used to diagnose IBS?
It’s a diagnosis of excusion based on the ROME III criteria:
- Improvement with defaecation
- Change in stool frequency
- Change in stool form/ appearance/ consistency
Recall the grading of haemarrhoids
1st: in rectum after defaecation
2nd: prolapse at defaecation, spontaneous reduction
3rd: prolapse at defaecation, manual reduction
4th: persistently prolapsed
What is the first line management of haemorrhoids?
Increased fruit/ fibre
Stool softener
Topical analgesics
Topical steroids (suppository)
Recall some non-operative ways of managing haemorrhoids?
Rubber-band ligation
Sclerotherapy
Electrotherapy
Infrared coagulation
Recall 3 surgical options for managing haemorrhoids
Haemarrhoidectomy
Haemorrhoidopexy
HALO (haemorrhoidal artery ligation operation)
What is the standard treatment for C diff enterocolitis?
PO vancomycin
2nd line fidaxomicin
If severe/unresponsive –> IV vanc + met
Which bacteria demonstrates “tumble weed motility”?
Listeria monocytogenes
How can listeria gastroenteritis be treated?
Amoxicillin/ ampicillin
Which 3 antibiotics are most associated with causing C diff enterocolitis?
Cephalosporin
Clindamycin
Ciprofloxacin
Which gastroenteritis-causing pathogen is associated with undercooked seafood?
Vibrio parahaemolyticus
Which gastroenteritis-causing pathogen is associated with shellfish handlers?
Vibrio vulnificus (in immunocompetent usually causes cellulitis/ nec. fasciitis)
Recal the site of absorption of iron, folate and B12
Iron: Duodenum
Folate: Jejunum
B12: Ileum
Which skin condition is pathognomonic for coeliac disease?
Dermatitis herpetiformis
Describe the appearance of stool in coeliac disease
Waterey, grey, frothy
What system is used to grade coeliac disease?
Marsh system
Recall some typical histological findings in coeliac disease
Villous atrophy and crypt hyperplasia
Recall the name of the scoring system used to diagnose appendicitis and its components
Alvarado score:
Signs:
RLQ tenderness (+2)
Fever
Rebound tenderness
Symptoms:
Anorexia
Nausea/vomiting
Pain migration to RLQ
Lab:
Leucocytosis (WBC > 10,000) (+2)
Left shift (>75% neutrophils)
Recall some eponymous signs on examination that are indicative of appendicitis
Rovsing’s sign: Pain greater in RIF than LIF when LIF pressed
Cope’s sign: Pain on passive flexion and internal rotation of the hip
What does rebound tenderness indicate about appendicitis?
That it involves peritoneum
What sign can be used to demonstrate a retrocaecal appendix?
Pain on extending hip (Psoas sign)
How should an un-perforated appendix be managed?
Prophylactic antibiotics followed by laparoscopic appendectomy
How should a perforated appendix be managed?
Abdominal lavage
What is “Amirand’s triangle”?
Triad of conditions that predisposes to gallstone disease:
Low lecithin
Low bile salts
High cholesterol
How can the symptoms of cholecystitis and cholangitis be differentiated?
Cholecystitis = no jaundice
Cholangitis = obstructive jaundice
How can the symptoms of cholecystitis and biliary colic be differentiated?
Biliary colic = RUQ pain
Cholecystitis = RUQ pain + fever
What is Charcot’s triad?
Triad of classical symptoms of ascending cholangitis
Jaundice
RUQ pain
fever
What is Reynauld’s pentad?
Pentad of classical symptoms of severe ascending cholangitis
Jaundice
RUQ pain
Fever
Hypotension
Confusion
Within what time frame should a laparoscopic cholecystectomy be performed for cholecystitis?
1 week (use antibiotics whilst waiting)
What is “Mirizzi syndrome”?
Impaction of common hepatic duct by a GB stone
What is the pathophysiology of “porcelain gallbladder”?
Chronic cholecystitis can –> calcification of GB walls
Recall some complications of acute cholecystitis
Chronic diarrhoea (GB removal –> more bile reaches large intestine –> more water and salt draw into bowel)
Vitamin ADEK malabsorption (can –> bleeding due to less 2,7,9,10 production)
What is a SeHCAT study?
Selenium in Homocholic Acid Taurine - assesses bile acid retention to see if this is cause of diarrhoea
How can diarrhoea post-cholecystectomy be managed?
Cholestyramine (binds to bile acids and makes the biologically inactive)
How can ascending cholangitis be managed?
IV antibiotics followed by therapeutic ERCP within 48 hours
What are the key symptoms of cholangiocarcinoma?
Palpable gallbladder, obstructive jaundice
What is the gold-standard investigation for staging cholangiocarcinoma?
ERCP
Recall and compare the symptoms of PBC vs PSC
PBC:
Pruritis, obstructive jaundice, RUQ pain in 10%, hyperholesterolaemia
PSC:
Pruritis, obstructive jaundice, steatorrhoea, splenomegaly
Recall and compare the antibodies involved in PBC vs PSC
PBC: AMA
PSC: p-ANCA
Recall and compare the best way to investigate PBC vs PSC
PBC: cholestatic liver biochemistry and AMA blood test (biopsy is diagnostic but often not carried out)
PSC: MRCP is preferred to start (rosary sign), then p-ANCA + BIOPSY (‘onion skin’ appearance of obliterated cholangitis)
Recall and compare the management approaches for PBS vs PSC
PBS: ursodeoxycholic acid + cholestyramine + prednisolone for associated autoimmune disease
PSC: observation –> liver transplant
What % of patients with PSC get cholangiocarcinoma?
10%
Which autoimune gallbladder disease is associated with IBD?
PSC (ulcerative colitis)
How are the 3 types of autoimmune hepatitis characterised?
T1: high titres of ANA or ASMA - adults and children
T2: Anti-LKM-1,2,3 - affects children
T3: Anti-SLA (soluble liver antigen) - middle age
What are the key symptoms of autoimmune hepatitis?
Amenorrhoea
Chronic liver disease OR acute hepatitis
Which type of autoimmune gallbladder disease can affect extrahepatic ducts?
PSC
How is autoimmune hepatitis managed?
Steroids + azothioprine
Eventual liver transplantation
What are the 4 signs of portal hypertension?
SAVE
Splenomegaly
Ascites
Varices
Encephalopathy
What is the triad of symptoms of Wernicke’s encephalopathy?
Ataxia
Confusion
Ophthalmoplegia
Recall the mainstay of management for hepatic vs wernicke’s encephalopathy
Hepatic encephalopathy: lactulose + rifaximin
Wernicke’s encephalopathy: thiamine, magnesium, folic acid
What are the principles of managing ascites?
Diet: restrict EtOH and fluids, daily weights
Diuretics: spironolactone (+/- furosemide)
Prophylaxis (for SBP): ciprofloxacin + propranolol
For refractory disease: TIPPS/ transplant
What is an abdominal paracentesis procedure used to treat?
Tense ascites
What is the most common pathogen in SBP?
E coli
What investigation is used to confirm ascites?
USS abdomen
How can SBP be confirmed?
Ascitic tap with PMN>250 and MC+S
What drugs are used to treat vs as prophylaxis for SBP
Treatment: piptazobactam/cefotaxime
Prophylaxis: ciprofloxacin + propranolol