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ICSM Year 6 + edits > Medicine - Gastroenterology > Flashcards

Medicine - Gastroenterology Flashcards

1
Q

Describe and differentiate the symptoms of mild, moderate and severe flares of ulcerative colitis

A

Mild: <4 stools per day, little blood
Moderate: 4-6 stools per day, varying blood
Severe: >6 stools per day, bloody diarrhoea, systemic upset

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2
Q

What is the name of the criteria used to stage IBD, and what are the 6 criteria?

A 
Truelove and Witts: 
Heart rate
Temperature
Bowel movements 
PR bleeding 
Haemoglobin
ESR
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3
Q

Recall 2 typical histological findings of the gut layer for Crohn’s and then UC

A

Crohn’s: Increased goblet cells, granulomas

UC: Decreased goblet cells, crypt abscesses

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4
Q

What is the most common affected portion of the bowel in Crohn’s vs UC?

A

Crohn’s: terminal ileum (so RIF mass)

UC: rectum

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5
Q

Describe the typical features of inflammation in Crohn’s vs UC

A

Crohn’s: Skip lesions, rose-thorn ulcers, cobblestoning, string sign of kantor (narrow ileum stricture)
UC: ‘lead-pipe’, pseudo-polyps, thumbprinting

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6
Q

Which type of IBD carries the highest risk of colorectal cancer?

A

UC

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7
Q

In which form of IBD are fissures more common and why?

A

Crohn’s - because it affects the full thickness of the bowel wall

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8
Q

Differentiate the appearance of stool in active Crohn’s vs UC

A

Crohn’s: non-bloody diarrhoea

UC: bloody diarrhoea which may contain mucous

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9
Q

Which type of IBD is associated with gallstones and why?

A

Crohn’s

Bile acids are not properly absorbed as terminal ileum is affected

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10
Q

In which form of IBD can surgery be curative?

A

UC

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11
Q

Recall the possible extra-intestinal manifestations of IBD

A 
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)
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12
Q

Describe the process of inducing remission in Crohn’s

A

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

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13
Q

Describe the process of maintaining remission in Crohn’s

A

First line: DMARDs (eg azothioprine)

Alternatives: infliximab/ aminosalicylates

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14
Q

Describe the management of UC

A

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

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15
Q

What is the main side effect of aminosalicylates to remember?

A

Acute pancreatitis

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16
Q

In which form of IBD is surgical management most useful?

A

UC

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17
Q

What are the options for surgery in UC?

A

Emergency:
Hartmann’s protosigmoidectomy + end ileostomy –> later IPAA (ileal-pouch ana anastomosis)

Non-emergency:
Protocolectomy + IPAA or
Panprotocolectomy + end ileostomy

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18
Q

What are the criteria used to diagnose IBS?

A

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
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19
Q

Recall the grading of haemarrhoids

A

1st: in rectum after defaecation
2nd: prolapse at defaecation, spontaneous reduction
3rd: prolapse at defaecation, manual reduction
4th: persistently prolapsed

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20
Q

What is the first line management of haemorrhoids?

A

Increased fruit/ fibre
Stool softener
Topical analgesics
Topical steroids (suppository)

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21
Q

Recall some non-operative ways of managing haemorrhoids?

A

Rubber-band ligation
Sclerotherapy
Electrotherapy
Infrared coagulation

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22
Q

Recall 3 surgical options for managing haemorrhoids

A

Haemarrhoidectomy
Haemorrhoidopexy
HALO (haemorrhoidal artery ligation operation)

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23
Q

What is the standard treatment for C diff enterocolitis?

A

PO vancomycin
2nd line fidaxomicin
If severe/unresponsive –> IV vanc + met

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24
Q

Which bacteria demonstrates “tumble weed motility”?

A

Listeria monocytogenes

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25
Q

How can listeria gastroenteritis be treated?

A

Amoxicillin/ ampicillin

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26
Q

Which 3 antibiotics are most associated with causing C diff enterocolitis?

A

Cephalosporin
Clindamycin
Ciprofloxacin

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27
Q

Which gastroenteritis-causing pathogen is associated with undercooked seafood?

A

Vibrio parahaemolyticus

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28
Q

Which gastroenteritis-causing pathogen is associated with shellfish handlers?

A

Vibrio vulnificus (in immunocompetent usually causes cellulitis/ nec. fasciitis)

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29
Q

Recal the site of absorption of iron, folate and B12

A

Iron: Duodenum
Folate: Jejunum
B12: Ileum

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30
Q

Which skin condition is pathognomonic for coeliac disease?

A

Dermatitis herpetiformis

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31
Q

Describe the appearance of stool in coeliac disease

A

Waterey, grey, frothy

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32
Q

What system is used to grade coeliac disease?

A

Marsh system

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33
Q

Recall some typical histological findings in coeliac disease

A

Villous atrophy and crypt hyperplasia

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34
Q

Recall the name of the scoring system used to diagnose appendicitis and its components

A

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)

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35
Q

Recall some eponymous signs on examination that are indicative of appendicitis

A

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

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36
Q

What does rebound tenderness indicate about appendicitis?

A

That it involves peritoneum

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37
Q

What sign can be used to demonstrate a retrocaecal appendix?

A

Pain on extending hip (Psoas sign)

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38
Q

How should an un-perforated appendix be managed?

A

Prophylactic antibiotics followed by laparoscopic appendectomy

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39
Q

How should a perforated appendix be managed?

A

Abdominal lavage

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40
Q

What is “Amirand’s triangle”?

A

Triad of conditions that predisposes to gallstone disease:
Low lecithin
Low bile salts
High cholesterol

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41
Q

How can the symptoms of cholecystitis and cholangitis be differentiated?

A 
Cholecystitis = no jaundice
Cholangitis = obstructive jaundice
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42
Q

How can the symptoms of cholecystitis and biliary colic be differentiated?

A

Biliary colic = RUQ pain

Cholecystitis = RUQ pain + fever

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43
Q

What is Charcot’s triad?

A

Triad of classical symptoms of ascending cholangitis
Jaundice
RUQ pain
fever

Acute can present atypically

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44
Q

Investigation findings for Acute cholangitis

A

Lab: raised WBC / CRP
LFT: Choleistasis signs (raised GGT, ALP, ALT)
Imaging: signs of biliary dilitation
Blood culture if feverish

Definite: inflam, cholestasis, imaging finding

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45
Q

First line imaging for Acute cholangitis

A

RUQ ultrasound
Dilation of common bile duct

CT with IV contrast if US inconclusive

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46
Q

What is Reynauld’s pentad?

A 
Pentad of classical symptoms of severe ascending cholangitis 
Jaundice
RUQ pain
Fever
Hypotension
Confusion
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47
Q

Management of Acute cholangitis

A

Admit to hospital
Confirmation of the diagnosis, including abdominal ultrasound and blood tests (such as a white blood cell count, C-reactive protein, and serum amylase).
Monitoring (for example blood pressure, pulse, and urinary output).
Treatment (may include intravenous fluids, antibiotics, and analgesia).
Surgical assessment for cholecystectomy.
Patient NPO

Consider biliary drainage depending on type of cholangitis (2 or more), type 3 within 24 hours

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48
Q

First line for biliary drainage in AC

A

Therapeutic ERCP guided transpapillary biliary drainage

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49
Q

Complications of Acute Cholangitis

A

Sepsis
septic shock,
MODS (multiple organ dysfunction syndrome)
Pyogenic liver abscess
Pericholecystic abscess
Biliary stricture

mortality rate 5-10% - higher if biliary decompression surgery

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50
Q

Most common bacteria for ascending cholangitis

A

E.Coli

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51
Q

Within what time frame should a laparoscopic cholecystectomy be performed for cholecystitis?

A

1 week (use antibiotics whilst waiting)

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52
Q

What is “Mirizzi syndrome”?

A

Impaction of common hepatic duct by a GB stone

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53
Q

What is the pathophysiology of “porcelain gallbladder”?

A

Chronic cholecystitis can –> calcification of GB walls

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54
Q

Recall some complications of acute cholecystitis

A 
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)
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55
Q

What is a SeHCAT study?

A

Selenium in Homocholic Acid Taurine - assesses bile acid retention to see if this is cause of diarrhoea

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56
Q

How can diarrhoea post-cholecystectomy be managed?

A

Cholestyramine (binds to bile acids and makes the biologically inactive)

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57
Q

How can ascending cholangitis be managed?

A

IV antibiotics followed by therapeutic ERCP within 48 hours

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58
Q

Define Acute Cholangitis (ascending)

A

Bacterial infection of the biliary tract usually secondary to biliary obstruction

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59
Q

Aetiology and RF of Acute cholangitis

A

Biliary tract obstruction leading to bile stasis with increased intraductal pressure -> bacterial translocation into bile ducts -> ascends

Choledocholithiasis (most common)
Biliary strictures (infectious (HIV), inflam (PSC), ERCP
Malignancy (Cholangiocarcinoma)
Contamination of bile duct with pancreatic
Acute Pancreatitis

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60
Q

Epi of Acute Cholangitis

A

9% Gallstones (chollithiasis)
Equal in gender
50-60 yr old

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61
Q
A
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62
Q

What are the key symptoms of cholangiocarcinoma?

A

Palpable gallbladder, obstructive jaundice

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63
Q

What is the gold-standard investigation for staging cholangiocarcinoma?

A

ERCP

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64
Q

Recall and compare the symptoms of PBC vs PSC

A

PBC:
Pruritis, obstructive jaundice, RUQ pain in 10%, hyperholesterolaemia

PSC:
Pruritis, obstructive jaundice, steatorrhoea, splenomegaly

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65
Q

Recall and compare the antibodies involved in PBC vs PSC

A

PBC: AMA
PSC: p-ANCA

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66
Q

Recall and compare the best way to investigate PBC vs PSC

A

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)

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67
Q

Recall and compare the management approaches for PBS vs PSC

A

PBS: ursodeoxycholic acid + cholestyramine + prednisolone for associated autoimmune disease

PSC: observation –> liver transplant

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68
Q

What % of patients with PSC get cholangiocarcinoma?

A

10%

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69
Q

Which autoimune gallbladder disease is associated with IBD?

A

PSC (ulcerative colitis)

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70
Q

How are the 3 types of autoimmune hepatitis characterised?

A

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

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71
Q

What are the key symptoms of autoimmune hepatitis?

A

Amenorrhoea

Chronic liver disease OR acute hepatitis

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72
Q

Which type of autoimmune gallbladder disease can affect extrahepatic ducts?

A

PSC

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73
Q

How is autoimmune hepatitis managed?

A

Steroids + azothioprine

Eventual liver transplantation

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74
Q

What are the 4 signs of portal hypertension?

A 
SAVE
Splenomegaly
Ascites
Varices
Encephalopathy
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75
Q

What is the triad of symptoms of Wernicke’s encephalopathy?

A

Ataxia
Confusion
Ophthalmoplegia

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76
Q

Recall the mainstay of management for hepatic vs wernicke’s encephalopathy

A

Hepatic encephalopathy: lactulose + rifaximin

Wernicke’s encephalopathy: thiamine, magnesium, folic acid

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77
Q

What are the principles of managing ascites?

A

Diet: restrict EtOH and fluids, daily weights

Diuretics: spironolactone (+/- furosemide)

Prophylaxis (for SBP): ciprofloxacin + propranolol

For refractory disease: TIPPS/ transplant

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78
Q

What is an abdominal paracentesis procedure used to treat?

A

Tense ascites

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79
Q

What is the most common pathogen in SBP?

A

E coli

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80
Q

What investigation is used to confirm ascites?

A

USS abdomen

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81
Q

How can SBP be confirmed?

A

Ascitic tap with PMN>250 and MC+S

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82
Q

What drugs are used to treat vs as prophylaxis for SBP

A

Treatment: piptazobactam/cefotaxime

Prophylaxis: ciprofloxacin + propranolol

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83
Q

When should SBP prophylaxis be started?

A

Ascites protein <15g/L

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84
Q

What is the screening test for haemachromatosis?

A

Transferrin saturation - >55% in males and >50% in females may indicate further investigation

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85
Q

What stain can be used on liver biopsy to identify haemachromatosis?

A

Perl’s stain

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86
Q

What is the 1st and 2nd line management for haemachromotosis?

A

1st line: Venesection

2nd line: Desferrioxamine

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87
Q

Describe the typical presentation of NAFLD

A

Acute weight loss followed by jaundice

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88
Q

Recall the order in which you would order investigations for NAFLD

A

1st: LFTs (ALT will be > AST)
2nd: USS (will show increased echogenicity)
3rd: Enhanced Liver Fibrosis (ELF) panel OR a fibroscan
4th: Liver biopsy

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89
Q

What are the components of an ELF panel?

A

Hyaluronic acid
Procollagen III
Tissue inhibitor of metalloproteinase 1

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90
Q

What is the mainstay of management for NAFLD?

A

Lifestyle changes and wt loss

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91
Q

What are the classical symptoms of acute pancreatitis?

A

Severe epigastric pain radiating through to back with nausea and vomiting

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92
Q

What is Cullen’s sign and what diagnosis does it support?

A

Cullen’s sign = “superficial oedema with bruising in the subcutaneous fatty tissue around the peri-umbilical region”
Indicative of acute pancreatitis

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93
Q

What is Grey Turner’s sign and what diagnosis does it support?

A

Grey-Turner’s sign = flank bruising

Indicative of acute pancreatitis

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94
Q

How raised is serum amylase likely to be in acute pancreatitis?

A

> 3 times the upper limit of normal (in 75% of patients)

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95
Q

What is the most specific marker for acute pancreatitis that will be raised in the blood?

A

Serum lipase

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96
Q

What criteria are used to grade severity of acute pancreatitis?

A

Glasgow-Imrie

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97
Q

What criteria are used to estimate prognosis in acute pancreatitis?

A 
PANCREAS
PaO2 <8 
Age >55
Neutrophils >15
Calcium <2
Renal urea >16
Enzymes (LDH>600, AST/ALT >200) 
Albumin <32
Sugar >10
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98
Q

How long does an acute episode of pancreatitis have to last for to be considered ‘severe’?

A

> 48 hours

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99
Q

Recall and differentiate between the management of acute pancreatitis vs necrotising pancreatitis?

A

For both:
Fluids, analgesia (stat boluses of IV morphine until comfortable), enteral feeding maintained, correct the cause
Only if necrotising: antibiotics

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100
Q

Recall some possible early complications of acute pancreatitis

A

Haemorrhage
SIRS/ARDS
Hyperglycaemia (see pancreas critera)
Hypocalcaemia (see pancreas criteria)

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101
Q

Recall some possible late complications of acute pancreatitis

A

25% –> peri-pancreatic fluid collection
Pseudocysts (appear at around 4w)
Pancreatic abscess (infected pseudocyst)
Pancreatic necrosis

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102
Q

What % of chronic pancreatitis is due to alcohol excess?

A

80%

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103
Q

What are the signs and symptoms of chronic pancreatitis?

A

Symptoms: epigastric pain, typically worse 15-30 mins post-prandially
Signs: Steatorrhoea, diabetes

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104
Q

What investigations can be done in suspected chronic pancreatitis?

A

USS for gallstones
Contrast-enhanced CT
Faecal elastase (measures exocrine function)
Screen for diabetes and osteoporosis

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105
Q

What is faecal elastase used to measure?

A

Exocrine function

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106
Q

What histological type of cancer are 80% of pancreatic cancers?

A

Adenocarcinomas

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107
Q

What is the classical presentation of pancreatic cancer?

A

Painless obstructive jaundice, painless palpable gallbladder (courvoisier’s law), FLAWS
Symptoms of lost exocrine/endocrine function

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108
Q

What is trousseau’s sign of malignancy, and in which types of cancer is it sometimes observed?

A

Migratory superficial thrombophlebitis (moves from one leg to the other)
Strongly associated with adenocarcinoma of the pancreas and lung

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109
Q

What is the pathognemonic sign on High Resolution CT for head of the pancreatic/bile duct cancer?

A

“Double duct” sign

Shows simultaneous dilation of CBD and pancreatic duct

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110
Q

What is the definitive management of pancreatic cancer?

A

Whipple’s procedure

Pancreaticoduodenectomy

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111
Q

What are the common complications of Whipple’s procedure?

A 
Dumping syndrome (gastric emptying of contents into duodenum too fast) 
PUD (if delayed gastric emptying instead of dumping syndrome) 
Bile/pancreatic link
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112
Q

What is the non-surgical management of pancreatic cancer (eg if metastatic/ unsuitable for resection)?

A

ERCP with stenting

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113
Q

What classification is used for diverticular disease?

A

Hinchey classification

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114
Q

What is the investigation of choice for:

a) acute diverticulitis
b) chronic diverticular disease?

A

a) CT abdomen

b) barium enema (can’t do in acute phase as may cause perforation)

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115
Q

How does the management of mild and severe diverticular disease differ?

A

Medical:
Mild: PO antibiotics
Severe: IV antibiotics (cef + met) + drip and suck (due to BO) + soluble, high-fibre diet

Surgical (only if severe)
Hartmann’s –> primary anastomosis

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116
Q

Recall some indications for an urgent (2ww) OGD on suspicion of gastric/oesophageal malignancy?

A

Dyspepsia
Upper abdominal mass
Age >55 AND weight loss AND any of dyspepsia/GORD/upper abdo pain
nb if no weight loss –> NON-urgent OGD

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117
Q

What is the gold standard test for diagnosis of GORD?

A

24 hour oesophageal pH monitoring

118
Q

What is the mechanism by which H pylori vs GORD produce dyspepsia?

A

H pylori –> ulcers –> dyspepsia

GORD –> dyspepsia

119
Q

What are the 3 ways in which you can test for H pylori?

A
  1. Carbon-13 urea breath test
  2. Stool antigen test
  3. Lab-based serology
120
Q

What is the mainstay of management for H pylori?

A

Clarithromycin, amoxicillin, PPI

121
Q

How does the medical management differ between endoscopically-proven vs endoscopically-negative GORD?

A

Proven: 2 months PPI trial followed by 1 month trial of double dose, 2nd line = add H2-RA

Negative: 1 month trial of PPI, 2nd line = H2-RA

122
Q

What is the surgical management option for refractory GORD?

A

Nissen fundoplication

123
Q

What are the most common complications of nissen fundoplication?

A

Gas-bloat syndrome (can’t belch/vomit)

Dysphagia (if wrap is too tight)

124
Q

What is Maddrey’s discriminant function?

A

For alcoholic hepatitis:

Predicts prognosis and who will benefit from steroids

125
Q

Define Alcoholic Hepatitis

A

Alcoholic hepatitis is a clinical syndrome with a broad range of manifestations, from vague malaise to fulminant liver failure.

Alcoholic hepatitis should be suspected in patients with prolonged heavy alcohol use and recent-onset jaundice fever, leukocytosis and tender hepatomegaly

.

126
Q

Risk factors AH

A

History of chronic heavy alcohol use
Cigarette smoking
Genetic predisposition
Female sex
Nutritional factors: obesity, malnutrition
Viral hepatitis: e.g., hepatitis C

127
Q

Symptoms of AH

A

Acute Hepatitis: Jaundice, hepatomegaly, fatigue etc
Alcohol withdrawal symptoms: tremor, agitation, seizures
Long term alcohol: dupeytrens, rhinophyma
Cirrhosis: ascites etc

128
Q

How is Alcoholic Hepatitis diagnosed

A

Onset jaundice past 8 weeks
> 6months regular alcohol consumption (60g per day M, 40g F)
AST:ALT ratio 1.5

129
Q

Treatment of AH

A

Alcohol cessation
MDF above 32 - glucocorticoid therapy
treat other causes e.g. AKI, cirrhosis, infection, sepsis
If very severe, Liver transplant

130
Q

What score is used to stage liver cirrhosis?

A

Childs Pugh

131
Q

What is Budd Chiari syndrome and how is it classified?

A

Syndrome caused by blockage of the hepatic vein
Type 1 = thrombosis
Type 2 = tumour occlusion

132
Q

What are the possible signs and symptoms of Budd-chiari syndrome?

A

Abdominal pain, ascites, tender hepatomegaly

133
Q

What is the gold standard investigation for budd-chiari syndrome?

A

Abdominal USS with doppler

134
Q

What are the 3 best investigations when suspecting achalasia? What signs would be shown on it?

A

LOS manometry - lack of co-ordinated peristalsis + no relaxation of LOS
Barium swallow - bird beak appearance (dilation of proximal oesophagus with stenosis of GO junction) + delayed emptying
CXR - mediastinal widening
Endoscopy - retained food

135
Q

Define Achalasia

A

Achalasia is a failure of the lower esophageal sphincter (LES) to relax that is caused by the degeneration of inhibitory neurons within the esophageal wall.

136
Q

What is the aetiology / risk factors of Achalasia?

A

Primary (most common) - no known cause
Secondary (cause of obstruction mimicking it) - Oesophageal cancer
Stomach cancer and other extraesophageal cancers (symptoms may be due to mass effect or paraneoplasia)
Chagas disease
Amyloidosis
Neurofibromatosis type I
Sarcoidosis

137
Q

Summarise the epi of Achalasia

A

Most commonly occurs middle aged
1.6/100’000

138
Q

Main symptoms of Achalasia

A

Progressive dysphagia solids and liquids (obstruction = solids only)
Regurg
Retrosternal Pain
Weight Loss

139
Q
A
140
Q

Recall some signs and symptoms of the carcinoid syndrome, and recall which hormone is responsible for these symptoms

A

Flushing, diarrhoea, bronchospasm, hypotension, pulmonary stenosis, pellagra, endocrine over-function
Serotonin

141
Q

What 2 investigations can be used to investigate the carcinoid syndrome?

A

Urinary 5-HIAA

Plasma chromogranin A y

142
Q

What is the first line management for the carcinoid syndrome?

A

Somatostatin analogues eg octreotide

143
Q

Recall some antibiotics that may predispose to C diff infection

A 
Amoxicillin
Ampicillin
Cephalosporin (eg cefuroxime, ceftriaxone) 
Clindamycin
Co-amoxiclav 
Quinolones
144
Q

Recall the management of C diff colitis

A

1st episode: oral metronidazole
2nd episode/ severe 1st: oral vancomycin
Life-threatening/ ileus: oral vancomycin + IV metronidazole
ALL antibiotics over 10-14 day period

145
Q

Recall 3 risk factors for small bowel overgrowth

A

Neonates with congenital abnormalities
Diabetes mellitus
Scleroderma

146
Q

Recall the signs and symptoms of small bowel overgrowth

A

Very similar to IBS
Chronic diarrhoea
Bloating and flatulence
Abdominal pain

147
Q

Recall 3 ways of investigating for a small bowel overgrowth

A

Hydrogen breath test
Folate (will be high as bacteria produce it)
Diagnostic course of antibiotics

148
Q

What is the usual first line antibiotic for small bowel overgrowth?

A

Rifamixin

149
Q

What is Mackler’s triad?

A

The triad of symptoms seen in Boerhaave’s syndrome:
Chest pain
Vomiting
Subcutaneous emphysema

150
Q

In PUD, which artery is most likely to be a major source of bleeding?

A

Gastroduodenal artery

151
Q

When should opioid analgesia NOT be used following major abdominal surgery, and what alternative should be used?

A

In respiratory disease eg COPD

Alternative is epidural anaesthesia

152
Q

How should autoimmune hepatitis be treated?

A

30mg prednisolone PO, followed by introduction of azothioprine
MUST have confirmation of diagnosis from biopsy first unless there is a CI to biopsy

153
Q

How long does autoimmune hepatitis need to be treated for?

A

At least 2 years after blood results normalise before discontinuing therapy

154
Q

How should benign peptic strictures be managed?

A

PPI to treat underlying GORD

Balloon dilatation following benign biopsy

155
Q

What is the most common complication of balloon dilatation of a peptic stricture?

A

Oesophageal rupture (which may cause mediastinitis)

156
Q

How can oesophageal rupture be imaged best?

A

CT with oral contrast

157
Q

Recall some extra-articular manifestations of UC - saying which are related to disease activity and which are not

A 
Examples of extra-intestinal conditions related to activity of colitis:
Erythema nodosum
Aphthous ulcers
Episcleritis
Anterior uveitis
Acute arthropathy

Not related to activity of colitis:
Sacroiliiitis /Ankylosing spondylitis
Primary sclerosing cholangitis

(info from capsule case 202)

158
Q

What is the 1st line management for acute severe ulcerative colitis?

A

IV hydrocortisone

159
Q

How can blood glusose be used to assess liver function?

A

Assesses synthetic function

160
Q

How should variceal bleeds be managed when there is haemodynamic instability?

A
  1. Fluid resuscitation with blood transfusion
  2. IV vasopressin analogue eg terlipressin
  3. IV antibiotics
  4. Refer to endoscopy

nb. No IV PPI given prior to endoscopy

161
Q

What is the best surgical management for bleeding varices?

A

Band ligation or sclerotherapy

162
Q

What is the most appropriate long term management of varices?

A

Non-cardioselective beta blocker

163
Q

If variceal bleeding cannot be stopped with ligation, how can it be managed?

A

Insertion of Sengstaken Blakemore tube

164
Q

What are the 5 components of the Childs Pugh score?

A 
Serum bilirubin
Serum albumin
Prothrombin time
Presence of ascites 
Presence of encephalopathy
165
Q

Recall some differentials for the cause of ascites depending on whether the SAAG is low or high

A

High: portal HTN secondary to cirrhosis/ alcoholic hepatitis/ heart failure/ portal vein thrombosis

Low: peritoneal cause eg. malignancy, infections, pancreatitis and nephrotic syndrome

166
Q

If someone has a diagnostic ascitic tap, what 7 tests should the fluid be sent for?

A 
Culture and sensitivity 
Cytology 
LDH 
Glucose 
Total protein content 
Albumin concentration 
Cell count and differential
167
Q

Which 2 investigations are best for imaging chronic pancreatitis?

A

CT

MRCP

168
Q

Recall 2 drugs and 2 drug classes that can cause drug-induced liver damage

A

Roziglitazone
Flucloxacillin
Macrolides
Statins

169
Q

When is mesenteric angiography used?

A

To find the source of a GI bleed when endoscopy cannot do so

170
Q

What is the programme for screening for hepatocellular carcinoma?

A

In patients with cirrhosis, ultrasound every 6 months with additional CT/MRI if focal lesions seen on USS

171
Q

What is BAM?

A

Bile acid malabsorbption
Bile acids enter colon –> too many bile acids in colon –> profuse waterey diarrhoea
Should be halted by fasting

172
Q

Recall some examples of secretory diarrhoea

A

C diff
E coli 157
Cholera
Neuroendocrine tumours eg vasointestinal peptide-oma –> profound hypokalaemia without being fasted

173
Q

Recall 3 examples of inflammatory diarrhoea

A

UC
Crohn’s
Shigella

174
Q

Recall 4 examples of diarrhoea due to abnormal motility

A

Hyperthyroidism
Autonomic neuropathy (in DM)
Stimulant laxatives eg senna
IBS

175
Q

What is the histological finding of “owl’s eyes” pathognemonic for?

A

CMV

176
Q

What is Zollinger Ellison syndrome?

A

A rare digestive disorder caused by a neuroendocrine tumour that produces gastrin which leads to excess gastric acid. This excess gastric acid can cause peptic ulcers in the stomach and intestine

177
Q

How should autoimmune hepatitis be treated (broadly)?

A

Prednisolone and azothioprine

178
Q

How to choose ERCP vs MRCP?

A

ERCP is only now used as a therapeutic test - do this if worried about cancer (to take samples) or if there is something you can stent

MRCP is purely diagnostic (eg for PSC, see beading)

179
Q

Recall 3 GI causes of clubbing

A

GI malignancy
IBD
Chronic liver disease

180
Q

What is the cause of leukonychia?

A

Hypoalbuminaemia

181
Q

Recall 3 differentials for hepatomegaly

A

Hepatitis
NAFLD
Haematological malignancy

182
Q

How can you tell the spleen and kidney apart on palpation, apart from location?

A 
Spleen: 
Moves down with inspiration 
You cannot get above it 
Has a notch 
Dull to percussion 
Not ballotable
183
Q

Recall 3 differentials for splenomegaly

A

Haematological malignancies
Alcohol misuse
Primary sclerosing cholangitis

184
Q

Recall 3 differentials for enlarged kidneys

A

Renal vein thrombosis (usually UL)
Obstructive uropathy
PCKD

185
Q

Recall 3 causes of ascites

A

Portal hypertension
Constrictive pericarditis
Ovarian malignancy

186
Q

Recall some causes of cholestasis

A

Pancreatic cancer physically obstructing the gut
PBC (nb AMA pos, high IgM)
Chronic active hepatitis (anti-nuclear factor pos, high IgG)

187
Q

What drugs must be stopped to make a carbon13 Urea breath test reliable?

A

Amoxicillin 4w prior

PPI 2w prior

188
Q

What is the difference in the metabolic derangement that can be caused by diarrhoea vs vomiting?

A

Diarrhoea: normal anion gap acidosis
Vomiting: alkalosis

189
Q

What vaccine is given every 5 years in coeliac disease?

A

Pneumococcal

190
Q

How should a mild-moderate flare of UC be managed?

A

In a mild-moderate flare of ulcerative colitis extending past the left-sided colon, oral aminosalicylates should be added to rectal aminosalicylates, as enemas only reach so far (Passmed)

191
Q

What medication change is required for gastroscopy?

A

Stop PPI (eg omeprazole) 2w before procedure

192
Q

How should nutrition be managed in acute pancreatitis?

A

All patients with moderate to severe acute pancreatitis should be offered enteral nutrition (eg normal feeding or ng tube if needed) within 72 hours. They should only be offered parenteral nutrition if they cannot tolerate food (eg profuse vomiting).

193
Q

How can Crohn’s increase the risk of gallstones?

A

Terminal ileitis can reduce bile salt resorption

194
Q

In which patients with sigmoid volvulus would you NOT treat with a therapeutic flexible sigmoidoscopy?

A

In patients with sigmoid volvulus who have bowel obstruction with symptoms of peritonitis

195
Q

If mild/mod C difficile does not respond to oral vancomycin, what should be used 2nd line?

A

Oral fidaxomicin

If more severe infectiom = oral vancomycin + IV metronidazole

196
Q

How should high grade dysplasia in Barret’s oesophagus be managed?

A

Endoscopic ablation

197
Q

What are the grades of hepatic encaphalopathy?

A

Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma

198
Q

How might subcutaneous emphysema appear on examination?

A

Mild crepitus in the epigastric region

199
Q

What are the 2 most important blood tests for monitoring haemachromatosis?

A

Ferritin and transferrin saturation

200
Q

How is alcoholic ketoacidosis managed?

A

Infusion of thiamine and saline

201
Q

What is the limit of protein concentration in ascites for giving antibiotic prophylaxis, and what antibiotic is used?

A

Give antibiotics if protein concentration <15g/L

Abx of choice = ciprofloxacin

202
Q

If coeliac needs to be confirmed by biopsy, what is biopsied?

A

Jejunum

203
Q

Define Alcohol withdrawal

A

Alcohol withdrawal syndrome (AWS) refers to the excitatory state that develops after a sudden cessation of or reduction in alcohol consumption following a period of prolonged heavy drinking

204
Q

What is Delirum Tremens

A

Delirium (delirium tremens) — this occurs in around 2% of cases. It has a rapid onset, is difficult to control, and is a medical emergency. Symptoms tend to appear 48-72 hours after the last alcoholic drink and may include:
Profound confusion/delirium.
Visual, auditory, and tactile hallucinations — this affects up to 25% of people.
Coarse tremor.
Features of clinical instability, such as tachycardia, fever, ketoacidosis, and circulatory collapse.

205
Q

Management of Patients with Alcohol Withdrawal

A

DT - > Admit to hospital
first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam in hepatic failure.

206
Q

What should patients with a suspected Upper Gi bleed get on admission?

A

Upper GI tract endoscopy within 24 hrs - based of glasgow-blatchford score

207
Q

What is the management of Wilsons disease?

A

Penicillamine - chelates copper

208
Q

Main identifying feature of Wilsons disease?

A

Kayser-Fleischer rings
Blue Nails
Haemolysis
Renal Tubular acidosis
Basal Ganglia Degeneration

209
Q

Sudden onset, severe abdominal pain associated with vomiting and a rapid episode of bloody diarrhoea is suggestive of what?

A

Acute mesenteric ischaemia

210
Q

What is the main test for Acute mesenteric ischaemia suspicion?

A

Venous blood gas - elevated lactate and acidosis
Then CT angiography

211
Q

First line for C.difficile

A

Oral Vancomycin

212
Q

What are the cancers associated with lynch syndrome?

A

Endometrial Cancer

213
Q

What is the investigation of choice for someone with a suspected perianal fistulae with Crohn’s?

A

MRI Pelvis

214
Q

What is the best investigation for a perforated peptic ulcer?

A

Erect CXR

215
Q

Main drug to induce remission of Crohn’s

A

Glucocorticoids

216
Q

Recurrent episodes of C.diff within 12 weeks of symptom resolution treatment?

A

Oral fidaxomicin

217
Q

Patient has bleeding gums and receding hair?

A

Scurvy - Vit C deficiency

218
Q

Suspected SBP with cirrhosis and ascites what is the most important lab test?

A

Ascitic fluid polymorphonuclear leukocyte count

more then 250 cells / mm3

219
Q

What is a birdbeak sign on x-ray associated with?

A

Sigmoid volvulus

220
Q

What is a whirl sign on x-ray associated with?

A

Sigmoid volvulus

221
Q

Most appropriate investigation for suspected volvulus?

A

Abdominal CT scan

222
Q

How early should a cholecystectomy happen after acute cholecystitis?

A

Within 1 week

223
Q

How is diverticulitis with acute PR bleeding managed?

A

Endoscopic haemostasis

224
Q

What is rigler’s triad?

A

Pneumobilia
SBO
Ectopic calcified gallstone

225
Q

Where is a indirect inguinal hernia found?

A

Midpoint of inguinal ligament

226
Q

What treatment is offered for IBS patients who can not tolerate laxatives?

A

Lubiprostone

227
Q

Acute UC first line investigation

A

CT abdomen - shows colonic dilatation and perforation / abscess formation

228
Q

Adverse affects of proton pump inhibitors

A

hyponatraemia, hypomagnasaemia
osteoporosis → increased risk of fractures
microscopic colitis
increased risk of C. difficile infections

229
Q

Main results of Wilsons disease investigations

A

reduced serum caeruloplasmin
reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
free (non-ceruloplasmin-bound) serum copper is increased
increased 24hr urinary copper excretion
the diagnosis is confirmed by genetic analysis of the ATP7B gene

230
Q

First line for diarrhoea in IBS

A

Loperamide

231
Q

What would differentiate viral hepatitis from autoimmune?

A

A patients young age and positive antibody tests

232
Q

Liver with neurological disease and signs of dysarthria / tremor

A

Wilsons disease

233
Q

Most common organism in ascitic fluid

A

e.coli

234
Q

What could high urea levels with low Hb indicate?

A

Upper GI bleed

235
Q

If a SAAG comes back with >11g/L and Budd-chiari syndrome is present what is the cause?

A

Portal hypertension from hepatic vein thrombosis

236
Q

Which anaemia is linked to autoimmune disease?

A

Pernicious

237
Q

If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year: what should they be given?

A

Oral azathioprine / oral mercaptopurine to maintain remission

238
Q

How are liver abscess managed?

A

drainage (typically percutaneous) and antibiotics
amoxicillin + ciprofloxacin + metronidazole
if penicillin allergic: ciprofloxacin + clindamycin

most common = e.coli

239
Q

Main investigation for liver cirrhosis

A

Transient elastography (measures liver stiffness) and acoustic radiation force impulse

240
Q

Dysplasia on biopsy with Barrett’s requires

A

Endoscopic intervention

radiofrequency ablation: preferred first-line treatment, particularly for low-grade dysplasia
endoscopic mucosal resection

241
Q

Features of Hepatorenal syndrome and how is it treated

A

ascites, low urine output, and a significant increase in serum creatinine

Terlipressin - inducing splanchnic vasoconstriction which reduces portal pressure and improves renal blood flow

242
Q

What is this?

A

Apple cork sign - Oesophageal cancer

243
Q

Tired, middle aged women with high ALP and GT

A

PBC

lethargy and pruritus

244
Q

Symptoms of plummer-vinson syndrome

A

iron deficiency anaemia, dysphagia due to esophageal webs, and atrophic glossiti

245
Q

bacteria resistent to chlorination and causes fat malabsorption

A

giardia

246
Q

Features of Pancreatic cancer

A

painless jaundice with pale stools

hepatomegaly: due to metastases
gallbladder: Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
epigastric mass: from the primary tumour

exo and endocrine function loss

high res ct - double duct

247
Q

Features of haemochromatosis

A

early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands)
‘bronze’ skin pigmentation
diabetes mellitus
liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition)
cardiac failure (2nd to dilated cardiomyopathy)
hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism)
arthritis (especially of the hands)

248
Q

Achalasia increases the risk of what type of cancer of the oesophagus

A

SCC

249
Q

Main RF of C.diff

A

Clinda
Cephalo
PPIs

250
Q

Main features of C.diff

A

diarrhoea
abdo pain
raised WCC
toxic megacolon potentially

mod = wcc, severe = colitis + cr, life = hypotension,t.mc

251
Q

How is c.diff diagnosed?

A

c.diff toxin in stool
c.diff antigen only shows exposure rather than infection

252
Q

mx of C.diff

A

first = oral van - 10 day, then fida, then van + IV met
Recurrent - within 12 - fid, after 12 oral van or fid
life - both van and met

isolate side room no diarrhor 48 hrs

253
Q

Biochem of refeeding

A

low phos, low K, low mag

cardiac, resp failure, neuro, haemo and rhabdo

re feed 50%

254
Q

Glutan free foods

A

rice, potato, corn (maize)

255
Q

Coeliac vaccination

A

booster pneumococcal every 5 yrs
one influenza

256
Q

Associations with PBC

A

Sjogren’s syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease

257
Q

Raised in PBC

A

AMA
IgM

258
Q

Treatment for pruritus

A

cholestyramine

259
Q

Complications of PBC

A

Cirrhosis
osteomalacia
HCC

260
Q

Definitions of diarrhoea

A

Diarrhoea: > 3 loose or watery stool per day
Acute diarrhoea < 14 days
Chronic diarrhoea > 14 days

261
Q

Associations with panceratic cancer

A

age, smoking, diabetes, chronic pancreatitis, HPC, MEN, brca2, kras

262
Q

Reversible complications of haemochromatosis

A

cardiomyopathy, skin pigmentation

263
Q

Mx of constipation

A

bulk forming laxative - ispaghula
second - osmotic laxative - macrogol

264
Q

Complications of constipation

A

overflow diarrhoea
acute urinary retention
haemorrhoids

265
Q

Risk factors for oesophageal adenocarcinoma

A

GORD
Barrett’s oesophagus
smoking
obesity

266
Q

Risk factors for SCC of oesophagus

A

smoking
alcohol
achalasia
Plummer-Vinson syndrome
diets rich in nitrosamines

surgical resection

267
Q

What PPIs decrease the efficiency of clopidogrel

A

omeprazole and esomeprazole

268
Q

Anti-emetic for migraines

A

Metoclopramide - do not take for longer than 5 days

269
Q

3 main signs of IBS

A

Abdominal pain, and/or
Bloating, and/or
Change in bowel habit

270
Q

Drugs that cause cholestasis

A

combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine

271
Q

Drugs for liver cirrhosis

A

methotrexate
methyldopa
amiodarone

272
Q

What is melanosis colid and its associations

A

pigment laden macrophages
laxative abuse, especially anthraquinone compounds such as senna

273
Q

What features does HCC not have?

A

Cholestatic picture

274
Q

good measures for liver function

A

coagulation and albumin

275
Q

How long before coeliac testing should patients eat glutan

A

6 weeks

276
Q

Diarrhoea, fatigue, osteomalacia

A

coeliac

277
Q

Metabolic ketoacidosis with normal or low glucose

A

alcohol

278
Q

Injections for b12 replacement

A

3 injections per week for 2 weeks followed by 3 monthly treatment of vitamin B12 injections

more frequent if neurological

279
Q

Maintain remission from UC Following a severe relapse or >=2 exacerbations in the past year

A

oral azathioprine or oral mercaptopurine

280
Q

what is transient elastography

A

rand name ‘Fibroscan’
uses a 50-MHz wave is passed into the liver from a small transducer on the end of an ultrasound probe
measures the ‘stiffness’ of the liver which is a proxy for fibrosis

281
Q

Crohns with perianal abscess

A

incision and drainage with AB therapy

282
Q

Definition of boundary of upper GI bleed

A

The definition of an Upper GI Bleed is a haemorrhage with an origin proximal to the ligament of Treitz

283
Q

Features of Peutz Jegher syndrome

A

Genetics: Autosomal dominant, linked to the LKB1 or STK11 gene.

Features:

Hamartomatous polyps in the gastrointestinal tract, mainly the small bowel.
Common presentations: small bowel obstruction, gastrointestinal bleeding, pigmented freckles on lips, face, palms, and soles.
Malignant Potential: Polyps are non-malignant, but patients have a 50% risk of developing another gastrointestinal cancer by age 60.

Management: Typically conservative; monitor for complications and increased cancer risk. Regular surveillance is essential

284
Q

What condition should metoclopramide be avoided in?

A

Bowel obstruction due to its pro-kinetic effects

285
Q

Features of perianal fistulae in crohns

A

Perianal Fistula in Crohn’s Disease:

  • Definition: Inflammatory connection between anal canal and perianal skin.
  • Imaging of Choice: MRI
    • Identifies abscess presence.
    • Determines fistula type (simple/complex).
  • Treatment Options:
    • Oral Metronidazole: For symptomatic perianal fistulae.
    • Anti-TNF Agents (e.g., Infliximab): Effective in closure and maintenance.
    • Draining Seton: Used for complex fistulae.
      • Seton Definition: Surgical thread in fistula to prevent premature closure.
      • Purpose: Prevents persisting fistula tracks, reducing abscess risk.
286
Q

Malnutrition

A

Malnutrition Flashcard:

  • Definition (NICE):
    • BMI < 18.5; or
    • Unintentional weight loss > 10% in the last 3-6 months; or
    • BMI < 20 and unintentional weight loss > 5% in the last 3-6 months.
  • Prevalence:
    • ~10% of >65-year-olds, mostly in those living independently.
  • Screening (MUST):
    • Utilize MUST for BMI, weight change, and acute disease.
    • Done on admission or when concerned.
    • Categorizes into low, medium, and high risk.
  • Management (NICE):
    • Dietician support for high-risk patients.
    • ‘Food-first’ approach with clear instructions.
    • ONS between meals, not instead of meals.
287
Q

Zollinger elison syndrome

A

Zollinger-Ellison Syndrome Flashcard:

  • Definition:
    • Excessive gastrin due to gastrin-secreting tumor.
    • Commonly in the duodenum or pancreas.
  • Association:
    • ~30% occur in MEN type I syndrome.
  • Features:
    • Multiple gastroduodenal ulcers.
    • Diarrhea.
    • Malabsorption.
  • Diagnosis:
    • Fasting gastrin levels: Best screening test.
    • Secretin stimulation test.
288
Q

Re feeding syndrome

A

Refeeding Syndrome Summary:

  • Definition:
    • Metabolic issues post-starvation with abrupt carbohydrate metabolism switch.
  • Key Metabolic Consequences:
    • Hypophosphatemia: Muscle weakness, cardiac/respiratory failure.
    • Hypokalemia.
    • Hypomagnesemia: Risk of torsades de pointes.
    • Fluid balance abnormalities.
  • Pathophysiology of Hypophosphatemia:
    • Shift to carbohydrate metabolism.
    • Intracellular phosphate movement.
    • Depleted phosphate stores.
  • Clinical Consequences:
    • Cardiac dysfunction, respiratory failure, neurological complications, hematological effects, rhabdomyolysis.
  • Prevention:
    • Identify high-risk patients.
    • Consider BMI, weight loss, nutritional intake, and history.
    • Restrict refeeding to ≤50% of requirements for the first 2 days if >5 days without eating.
289
Q

Alcohol units equation

A

Alcohol units = volume (ml) * ABV / 1,000

290
Q

Drugs that cause cholestasis

A

Clever Ants Fly Around Sultry Females, Preferring Sunny Environments

  • C: Combined Oral Contraceptive Pill
  • A: Antibiotics (Flucloxacillin, Co-amoxiclav, Erythromycin*)
  • F: Fibrates
  • A: Anabolic Steroids, Testosterones
  • S: Sulphonylureas
  • F: Phenothiazines (Chlorpromazine, Prochlorperazine)
  • P: Phenothiazines (Chlorpromazine, Prochlorperazine)
  • S: Sulphonylureas
  • E: Erythromycin* (Also in antibiotics, for reinforcement)

ICSM Year 6 + edits (28 decks)

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