more GI Flashcards
first line of moderate exacerbation of UC
aminosalicyclate eg mesalazine or sulfasalazine
– are second line to mild to moderate exacerbation of UC
steriods eg prednisolone
treatment for acute/ severe exacerbation of crohns/ UC for those not responding to steriods
infliximab
patient with UC, suffering severe abdomen pain and fever after taking anti-diarrhoeals, should consider
toxic megacolon and this should be X-ray of the abdomen
patient from India, abdominal complaints that did not respond to antibiotics, now got weightloss and anorexia,
intestinal tb
what test for intestinal tb
ileal biopsy
raised anti-tissue transglutaminase antibody is associated with
Coeliac disease
– is a disease of the small intestine caused by gluten sensitivity
coeliac disease
villous atrophy
coeliac disease
anti-thyroid stimulating hormone receptor antibodies
graves disease
type 1 diabetes results in destruction of
islet cells
patient with end stage liver disease presents with painful abdomen, ascites, fever what should you do
ascitic tap- investigation
investigation of choice for coeliac disease
anti- TTG
classic presentation of primary biliay cholangitis
increasing jaundice, pruritus (itchy skin), arthralgia (pain in a joint). hepatomegaly, clubbing, xanthelasmata (yellow collection on skin typically around eyelid), hyperpigmentation(patches of skin become darker)
appropriate investigation for primary biliary cholangitis
anti-mitochondrial antibodies
21y/o with 2 week of jaundice, preceded by anorexia, athralgia, fever and a tender, enlarged liver
acute hepatitis
investigation for this Hep A immunoglobulin M (IgM)
most common cause of acute hepatitis
Hep A
Haemochromatosis presents with
iron overload: jaundice, hepatomegaly, arthritis, hyperpigmentation, infertility, small testes
investigation for heamochromatosis
high ferritin or iron levels
associated with human leukocyte antigen A3
haemochromatosis
ascending cholangitis triad
pyrexia/rigours, jaundice, RUQ abdo pain
investigatio for ascending cholangitis
ERCP
increasing jaundice, breathless on exercise and recurrent lung infections,show obstructive pattern
alpha 1 antitryptysin
kayser fleischer rings ( greenish-brownish rings due to copper depostition in the cornea of the eye)
Wilsons disease
children and young people, with hepatic problems and neurological symotoms such as dysarthria (speech disorder), tremor, involuntary movements
wilsons disease
treatment for wilsons disease
penicillamine
PBC typically presents
middle aged females, itching ,jaundice and sjogrens syndrome
bronzing of the skin
haemochromatosis
hereditary non-polyposis colorectal cancer syndrome has what approx liftetime risk for developing colorectal cancer
50-70%
patients presents with acute cholangitis and has raised CRP, what next
prompt IV antibiotics
suitable choice of antibiotics for acute cholangitis
piperacillin and tazobactam
fever, heart mumur, arthritis
infective endocarditis
infective endocarditis iv drug users
staph aureus
infective endocarditis with prosthetic heart valves or central venous access lines- surgery?
staph epidermis
treatment of suspected infective endocarditis w no prosthetic heart valves
amoxicillin and gentamicin
what can put you at increased risk of hepatotoxicity following paracetemol overdose
anorexia
– commonly seen in alcohol withdrawl due to malnutrition. Need to be careful of re-feeding syndrome. alcohol can cause a metabolic acidosis
hypophosphataemia
seizures in alcohol withdrawl are
common
intermittent dysphagia, more diffult swallowing liquids than solids
neuromuscular conditions- (result in abnormal peristalsis of the oesophagus)- oesophageal dysmotility.
-progressive dysphagia for liquids more than solids, severe episodes of chest pain accompanying dyspahgia, barium swallow shows birds peak, mamoetry reveal abnormally high lower oesophageal sphincter tone that fails to relax on swallowing
achalasia
sensation of food getting stuck
GORD
22y/o studying hard for exams, intermittent abdo apin and bloating, change in bowel habit and going to loo helps to relieve her abdominal pain
Irritable bowel syndrome -
diagnosis of irritable bowel syndrome
recurrent abdo pain or discomfort at least 1 day per week in the last 3 months with 2 or more of the following:
- improvement with defecation
- onset associated with change in frequency of stool
- onset associated with change in form (appearance) of stool
treatment for colicky abdo pain with irritable bowel syndrome
Mebeverine
widened mediastium
achalasia
best investigation for suspected achalasia is
oesophageal manometry study
most people with diverticulitis remain
asymptomatic
25% of people with this get symtpoms such as Left lower quadrant pain, worsened by eating and relieved after bowel emptying
diverticulitis
evidence of diverticular inflammation suggested by
tachycardia and fever
prolonged laxtive use or abuse can cause
melanosis coli
macrophages containing lipofuscin in the mucosa -toad back appearance
melanosis coli
crypt abscesses
UC
non caseating granuloma in the mucosa,cobblestone
crohns disease
crohns -
uc-
- diarrhoea( usually without blood, but not uncommonly with), abdo pain, general malaise and weight loss
bloody diarrhoea, abdo pain , malaise and weight loss
vitamin B – in chronic alcohol users
1
all patients with altered mental status or nutritional deficiency should have
thiamine repletion
encephalopathy (altered mental state), oculomotor dysfunction (eye coordination) , gait ataxia (abnormal uncoordinated movements)
wernicke’s encephaolpathy - alcoholics
prolonged vitamin b12 defiency causes
macrolytic anaemia
epigastric pain radiating to back, nausea and vomitting, post hepatic jaundice( indicated by severely raised ALP, mildly raised AST and raised bilirubin)
pancreatitis
if been vomitting since morning,
NG tube can be used for air and fluid removaland used to put liquid food into the stomach
treatment for pancreatitis
Admission, IV fluids, anagesia, nil by mouth, NG tube
expect –hepatic jaundice fromm malaria
pre
raised bilirubin, low haemoglobin, ALT and ALP are normal
Pre hepatic jaundice
young perosn drank too much alcohol and being vomitting alot. now vomitting blood
mallory -weiss tear- longitudinal mucosal laceration at the gastro-oesophageal junction or cardia as a result of repeated retching. if bp, pulse, Hb normal then can be discharged home next morning
most common cause of nodular hepatomegaly
liver metastases
Alt would be elevated
Cirrhosis
severe flare up of UC
Corticosteriods added to oral mesalazine
moderate exacerbation of uc treatment
add topical aminosalicylate to oral mesalazine
most common carcinoma of anal tract
squamous cell carcinoma -associated with HPV infection - transmitted by anal intercourse
ampullary carcinoma
v rare
- abdo pain, distended and palpable gall bladder
plummer vinson syndrome is associated with squamous cell carcinomas of upper GI tract especially the pharynx and oesophagus
features of plummer vinson syndrome
oesophageal webs, dysphagia, iron deficiency anaemia, glossitis
what intestinal disease requires bloof tests and small intestinal biopsy for acurate diagnosis
Coeliac disease
foamy macrophages containin gnumerous acid fst bacilli
myobacterium avium infection
had abdo surgery and now presents with malabsorption, low vitamin b12, high serum folate
Small intestinal bacterial overgrowth (SIBO)
gold investigation for SIBO
culture of small intestinal fluid aspirate
cope’s sign
pain of apeendicitis is stimulated by the flexion and internal rotation of the hip
pembertons sign
elicted when a patient with superior vena cava obstruction raises the hands above their head
murphys sign
inspiration during palpitation of the right upper quadrant elicits pain if the gallbladder is inflamed
Psoas sign
test for appendicitis
rovsing sign
another test for appendicitis, palpitation in the left iliac fossa reproduces pain in the right iliac fossa
MRI appropriate for
pelvic floor dysfunctions
- feeling of incomplete defaecation
- straining
weight loss and painless jaundice, repeated admissions of pancreatitis
pancreatic cancer
risk factors for pancreatic cancer
chronic pancreatitis, alcohol, smoking, diabetes,
the patient has dyspepsia ( epigastric pain during and after eating), most likely due to peptic ulcer disease (—-)
as it wakes her up at night
one of the causes of peptic ulcer disease is primary hyperparathyroidism which results in excess gastric acid secretion by inducing
hypercalcaemia (elevated serum calcium)
redcurrant jelly in nappy
meckels diverticulum suspected
in meckels diverticulum,
two or more types of tissue can be present
rectal involvement is associated with
UC
transmural inflammation, fistulae and —are typical of crohns
abscesses
— affects only the mucosa and submucosa so is less prone to forming fistuale and abscesses
UC
most important medication for variceal bleeds is
terlipressin
severe epugastri pain and vomitting bright red blood, cool extremities, asicitc abdo, spider naevi on neck
oesophageal variceal blled
if suspect inflammatory bowel disease what investigation is essential
Plain abdominal film - to exclude dilatation of the colon. crohns may exhibit small bowel dilatation of abdo xray
not do – if moderate to sever inflammatory bowel disease as there is a high risk for perforation and this would be considered after resolution of the flare
colonscopy
recommended that all patients presenting with diarrhoea undergo
rigid sigmoidoscopy
- however perform abdo film/xray before this invasive invesigation
why is urseodeoxycholic acid given to patients with PBC, when treatment of choice is liver transplant
reduces the rate of liver failure in paitents with PBC
patient has NGT tube inserted and and what precaution before starting enetral feeding
Chest radiograph - confirm NGT placement
How should NGT tube be placed
down the midline,past the carina (bifurcation of the trachea), past the level of the diaphragm, deviates to the left with the tip seen in the stomach
2 jobs of ngt
enteral feeding/ medication administation
decompression of the stomach
what hormone inhibits gastrin secretion
somatostatin
– and – aggrevates irritable bowel syndrome
caffeinated and fizzy drinks
PBC- lethargy, weakness and increasing itch -alkaline phosphatase raised
autoimmune hepatitis-
PSC- ASMA and ANCA may be positive- diagnosis MRCP or ERCP - beaded appearance
fever, rash, malaise, arthrirtis
can develop peptic ulcers secondary to
corticosteriod and naproxen use
peptic ulceration usually due to
h.pylor(gram negative)
NSAIDs
patient with peptic ulcer disease tends to present with
dyspepsia
what test is used in the diagnosis of helicobacter infection
rapid urease test
h.pylor produces the enzyme — that converts urea to ammonia and carbon dioxide
urease
extra intestinal features of Inflammatory Bowel disease
athralgia (joint pain without inflammation), arthritis(without inflammation), Polyarthritis, sacroiliitis
severe epigastric pain that radiates to back
acute pancreatitis
amylase raises after onset of — and returns to normal in approx 5 days
acute pancreatitis
in severe alochols this is not the case
palpable gall bladder, RUQ itch,
cholangiocarcinoma
features of cholangiocarcinoma
raised CA 19-9 and CEA, normal AFP
middle aged women, intense itching and fatigue
Primary biliary cholangitis
dilated oesophagus
achalasia
achalasia: disorder of motility caused by failure of the
oesophageal sphincter to relax
what can be used to relax the sphincter in achalasia
calcium channel blockers and nitrates
unstable observations , a tender abdomen with history of ulcerative colitis is concerning for
toxic megacolon
- abdo x ray should be ordered to assess for this- transverse colon will typically be dilated >6cm which is diagnostic of TM
what criteria is used for morphological classification of intestinal biopsy in coeliac disease
Marsh criteria
crypt abscesses are typical for
ulcerative colitis
stricturing of bowel wall and fistula formation is in UC or crohns
crohns
is the risk of malignancy significantly lower in. crohns disease or UC
crohns disease
student binge drinks every weekend for past year and now vomitting has a bit of blood
Barrets oesophagus
- short history of alcohol excess so unlikely to present with varices or ulcers
- can give PPI
24hrs of vomitting and now has blood
mallory-weiss syndrome - tear in the mucosa as a result fo prolonged vomiting episode
diclofenac and other non-steriodal anti-inflammatory medications increase the risk of – by inhibiting the production of prostaglandins
peptic ulceration
epigastric pain afetr meals , black tarry stools, coffe ground vomitting
upper GI heamorrhage secondary to bleeding peptic ulcer
long history of excess alcohol, massive haematemesis, jaundice, hypotensive and tachycardic
oesophageal varices
most common cuase of oesophageal or gastric varices is
alcohol
intermittent haemoptysis, small amounts of haematemesis, telangiectasia(dilated or broken blood vessels) on face
Osler-weber -rendu syndrome
in IV drugs users there is a high incidence of
Human immunodeficiency virus(HIV), hepatitis viruses or tb
cryptospordium is an infection that can be acquired by immunocomprised ie drug users and thos who have had tb
profuse watery diarrhoea, abdo cramps, fever
student w 12 hours of vomitting, abdo pain, watery diarrhoea
food poisoning
most common cause of diarrhoea in young people
food poisioning or acute gastroenteritis
diagnosis of UC
endoscopic biopsies
Almost always a consequence of chronic alcohol misuse. steatorrhoea( pale, foul-smelling stool that is hard to flush away). abdo pain, diarrhoea
Chronic pancreatitis
- not always present with epigastric pain that radiates to back and relieved on sitting forward and worse on eating
change in bowel habit and blood in the stool should immediately be referred for 2 week pathway of suspicion of
colorectal carcinoma
12 cm dilatation of the transverse colon and has UC
Toxic megacolon
medications for toxic megacolon
IV corticosteriod (hydrocortisone), LMWH ( as high risk of venous thromboembolism) , fluids, reassess after 72 hrs
Iv infliximab is secodn line for severe active – in patients who fail to respond to IV steriod treatment.
UC
– is characterised by tachycardia, fever, hypotension, dilatation usually of the transverse colon greater tham 6cm
toxic megacolon
most specific antibody for autoimmune hepatitis
anti-smooth muslce antibodies
antibody associated with primary biliary cholangitis
anti-mitochondrial antibodies
test that h. pylori has been eradicated following treatment
13C urea breath test
red flag symptoms suggesting organic cause of abdo pain rather than irritable bowel sydnrome
unintentional weight loss, rectal bleeding, family history of bowel or ovarian cancer, older than 60 with a change in bowel habit
plummer vinson syndrome is a disease characterised by
dysphagia, iron deficiency anaemia, glossitis
what is it that causes dysphagia in plummer vinson sydrome
oesophageal web
treatment of plummer-vinson syndrome
iron supplements
dysphagia to both solids and liquids, PPI therapy failing and upper endoscopy normal. CXR normal. ECG normal. what investigation
oesophageal manometry
-consistent with achalasia
what is barium swallow helpful for
obstruction, evidence of reflux, or strictures in the oesophagus
associations of gastric cancer
pernicious anaemia, blood group A, smoking diet, H.pylori
H. pylori is not a risk for —cancer
Gastric cardia
hep B is more common in what countries
sub-saharan africa and east asia
hep c is more common in what countries
african countries such as egypt, easter european adn latin america
Liver cirrhosis causes:
DR- DRUGS- AMIODARONE, METHYLDOPA, METHOTREXATE
H-HEPATITIS - B AND C
E- ENZYME DEFICIENCY- alpha 1 antitrypsin deficiency
P-primary biliary cirrhosis/ primary sclerosing cholangitis
A- alcohol abuse -chronic
T- tyrosinosis
I-indian childhood
Cryptogenic/CF/ copper deposition; wilsons disease/ haemoChromatosis
Autoimmune hepatitis
DR HEPATICA
how does haemochromatosis present
cirrhosis, hyperpigmentation, arthritis, diabetes
inflammatory infiltrates with plasma cells, lymphocytes and eosinophils in the lamina propria and thick subepithelial collagen band
collagenosu colitis
treatment- anti-diarrhoeal- Loperamide
period acid -schiff (PAS) positive macrophages
whipples disease
-treatment- ceftriaxone or penicillin V
motile spiral shaped bacteria
campylobacter, most common cause of acute diarrhoea in UK - usually from poultry or dairy products
treatment of severe acute diarrhoea of campylobacter
erthyromycin
(ciprofloxacin or azithromycin as alternatives)
- if not severe then rehydrate
most common mode of transmission of Hep C
exposure of infected blood
hep c is what kind of virus
RNA
diarrhoea, facial flushing, bronchospasm
carcinoid syndrome - raised 5 -HIAA is suggestive
important medication for variceal bleed is
terlipressin
haematemesis of bright red blood, alcoholic, cool extremities, guardin gover the epigastric rehion, ascitic, spider naevi on chest and neck
variceal bleed
follwing terlopressin for variceal bleed what is next
band ligation and if this does not control the bleed, intra-hepatic portosystemic shunt (TIPS)
50% of those with hep B develop
jaundice
most people 65-75% of hep c are
assymptomatic
when –is greater than 1000, the most likeley cause is hepatitis
ALT
hep — =ASIA
B
thickened small bowel folds on barium swallow
tropical sprue
Giardia lamblia is a flagellated
protozoan - contaiminaetd water or poor cooking -street stalls
diagnosis of trpoical sprue
indentifying cysts or trophozoites in stool sample
treatment for giardiasis
rehydration and oral metronidazole
been travelling and diarrhoea more than a week
giardiasis
symtoms improves if eats fewer dairy products
lactose intolerance
used to decrease diarrhoea in chronic pancreartitis/CF
pancreatin
anti diarrhoeal used in acute
loperamide
anti-diarrhoeals used in chrons, PBC, pruritus, hypercholestolaemia
colestyramine
oesophagus hiatus at what level
T10
inferioru vena cava at diaphgram
T8
aorta at diaphragm
T12
T12
aorta, azygous vein, thoracic duct
what is commonly graded on the LA classification
oesophagitis
colon malignancy is staged by
dukes staging system /TNM
cirrhosis of the liver staging system
Child-pugh
peptic ulcers classification system is
johnson
glossitis (beefy red tongue)
vitamin b12 deficiency
vitamin b12 is found in
meat, fish and dairy products
- absorbed in the terminal ileum
- strict vegans likely to present with this
antibody present in some crohn’s patietns
saccharomyces cerevisiae
pANCA is associated with
UC
triad for pellagra
diarrhoea, dermatitis (could be rash on hand), dimentia
pellagra is
niacin (vitamin b3) deficiency
scurvy can present with red dots on the skin but also with
bleeding gums adn joint pain
SLE presents with
painful swollen joints and red butterfly rash over the face
fevers and mouth ulcers are also common
abdo pain that raidates to back or worse lying down
pancreatitis
bruising around umbillicus is classical of
retroperitoneal haemorrhaeg(cullens sign)
if coeliac trunk is obstructed this will affect the stomach…
duodenum, gallbladder, pancreas, spleen, liver , abdominal portion of the oesophagus
jejunum and ileum are supplied by
superior mesenteric arteries
what supplies the transverse colon
proximal 2/3rds = right and middle colic arteries
distal 1/3=left colic artery
what supplies the descending colon
left colic artery
