MRCP2 Flashcards
Ulcer: Pain relieved by eating
Duodenal ulcer
Ulcer: Pain while eating?
Gastric ulcer
What is Cullen’s sign?
Periumbilical discolouration (Cullen’s sign)
What is grey turner’s sign ?
flank discolouration (Grey-Turner’s sign)
Tinkling bowel sounds?
Intestinal obstruction
Cause if achalasia?
degenerative loss of ganglia from Auerbach’s plexus
Features of achalsia?
dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food
may lead to cough, aspiration pneumonia etc
malignant change in small number of patients
Best investigation for achalasia?
LOS manometry
barium swallow
shows grossly expanded oesophagus, fluid level
‘bird’s beak’ appearance
chest x-ray
wide mediastinum
fluid level
Surgery of choice for achalasia?
pneumatic (balloon) dilation
If recurrent symptoms: Heller cardiomyotomy
Pancreatitis causes?
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
Upper GI bleed: Oesphagitis?
Small volume of fresh blood, often streaking vomit. Malena rare. Often ceases spontaneously. Usually history of antecedent GORD type symptoms.
mall to moderate volume of bright red blood + repeat vomiting
Mallory weiss syndrome
NSAID use + haematemesis + epigastric discomfort
Diffuse erosive gastritis
Usually haematemesis and epigastric discomfort. Usually there is an underlying cause such as recent NSAID usage. Large volume haemorrhage may occur with considerable haemodynamic compromise
What artery is often implicated in duodenal ulcer ?
Gastroduodenal
Previous aortic surgery + major haemorrhage?
Aorto-enteric fistula
Constitutional symptoms + dyspepsia +/- major haeemorhage
Gastric cancer
How to risk stratify patient with haematemesis?
Blatchford scale
helps clinicians decide whether patient patients can be managed as outpatients or not
How to assess mortality of patient AFTER ENDOSCOPY?
rockall score is used after endoscopy
provides a percentage risk of rebleeding and mortality
includes age, features of shock, co-morbidities, aetiology of bleeding and endoscopic stigmata of recent haemorrhage
When is a platelet transfusion needed in haematemesis?
> 50
When is FFP needed in major haemorrhage?
fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal
Management of non-variceal bleeding?
PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy
Management of variceal bleeding?
terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
Management of gastric varices?
band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices
If varcies are not managed with band ligation or N-butyl-2-cyanoacrylate?
transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures
What are the types of alcoholic liver disease?
alcoholic fatty liver disease
alcoholic hepatitis
cirrhosis
What is the classic LFT picture for alcoholic liver disease?
gamma-GT is characteristically elevated
AST:ALT is normally > 2, a ratio of > 3 is strongly suggestive of acute alcoholic hepatitis
Management of alcoholic liver disease?
Prednisolone
pentoxyphylline
What is alkaptonuria?
rare autosomal recessive disorder of phenylalanine and tyrosine metabolism
lack of the enzyme homogentisic dioxygenase (HGD)
Features of alkaptonuria?
pigmented sclera
urine turns black if left exposed to the air
intervertebral disc calcification may result in back pain
renal stones
Multi-level intervertebral disc calcification with disc space narrowing
Treatment of alkaptonuria?
high-dose vitamin C
dietary restriction of phenylalanine and tyrosine
What is the side effect of sulphasalazine?
rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis
What is the difference between sulphasalaine and mesalazine?
Mesalazine –> delayed release 5 ASA
Side effect of mesalazine?
GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis
Which 5 ASA causes pancreatitis?
Mesalazine
Management of angiodysplasia?
endoscopic cautery or argon plasma coagulation
antifibrinolytics e.g. Tranexamic acid
oestrogens may also be used
Most common organism to cause ascending cholangitis?
E coli
Features of ascending cholangitis?
Charcot’s triad of right upper quadrant (RUQ) pain, fever and jaundice occurs in about 20-50% of patients
hypotension and confusion are also common (the additional 2 factors in addition to the 3 above make Reynolds’ pentad)
Management of ascending cholangitis?
intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
What does a SAAG > 11 indicate typically?
Portal vein hypertension
Causes of high SAAG ascites?
Liver disorders are the most common cause
cirrhosis/alcoholic liver disease
acute liver failure
liver metastases
Cardiac
right heart failure
constrictive pericarditis
Other causes
Budd-Chiari syndrome
portal vein thrombosis
veno-occlusive disease
myxoedema
Causes of low SAAh ascites?
Hypoalbuminaemia
nephrotic syndrome
severe malnutrition (e.g. Kwashiorkor)
Malignancy
peritoneal carcinomatosis
Infections
tuberculous peritonitis
Other causes
pancreatitisis
bowel obstruction
biliary ascites
postoperative lymphatic leak
serositis in connective tissue diseases
What is the risk of drainage of a large volume ascites?
paracentesis induced circulatory dysfunction can occur due to large volume paracentesis (> 5 litres). It is associated with a high rate of ascites recurrence, development of hepatorenal syndrome, dilutional hyponatraemia, and high mortality rate
What should be offered to patients as a prophylaxis of ascites > 15G/L
Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less, until the ascites has resolved’
HLA type associated with autoimmune hepatitis?
HLA B8
HLA DR3.
What are the three types of autimmune hepatitis?
Type 1 –> ANA + Smooth muscle antibody
Type 2 –> Anti-liver/kidney microsomal type 1 antibodies (LKM1)
Type 3 –> Soluble liver-kidney antigen
What autimmune hepatitis affects both adults and children?
Type 1
What autoimmune hepatitis only affects children?
Type 2
What autoimmune hepatitis only affects adults?
Type 3
Features of autoimmune hepatitis?
acute hepatitis: fever, jaundice etc (only 25% present in this way)
amenorrhoea (common)
liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
Management of autoimmune hepatitis?
- Prednisolone
- Liver transplant
What can bile acid malabsorption lead to?
Steatorrhea
Malabsorption of vitamins A, D, E, K
Causes of bile acid malabsorption?
cholecystectomy
coeliac disease
small intestinal bacterial overgrowth
Investigation of choice for bile acid malabsorption?
SeHCAT
- nuclear mediciune scan
- scans are done 7 days apart rto see loss of radioactive isotope
Management of bile acid malabsorption?
cholestyramine
What is the triad of budd chiari?
abdominal pain: sudden onset, severe
ascites → abdominal distension
tender hepatomegaly
What does barret’s oesphagus refer to?
Metaplasia of LOS from squamous –> columnar
of oesophageal adenocarcinoma, estimated at 50-100 fold
Risk factors for Barret’s oesphagus?
gastro-oesophageal reflux disease (GORD) is the single strongest risk factor
male gender (7:1 ratio)
smoking
central obesity
Is alcohol a risk factor for Barret’s?
It is not an independent risk factor
Management of Barret’s?
High dose PPI
Endoscopy every 3-5 years
How do you manage dysplasia found in Barret’s?
dysplasia of any grade is identified endoscopic intervention is offered. Options include:
radiofrequency ablation:
Identify bleeding source when OGD + colonoscopy fail?
Capsule endoscopy
Features of carcinoid tumour?
flushing (often the earliest symptom)
diarrhoea
bronchospasm
hypotension
right heart valvular stenosis (left heart can be affected in bronchial carcinoid)
May also secrete:
- ACTH –> Cushings
Pellagra
Investigations for carcinoid tumour?
urinary 5-HIAA
plasma chromogranin A y
Management of carcinoid tumour?
somatostatin analogues e.g. octreotide
diarrhoea: cyproheptadine may help
Mechanism of cholesytramine?
decreases bile acid reabsorption in the small intestine, therefore upregulating the amount of cholesterol that is converted to bile acid.
What is the main action of cholestyramine ?
Reduces LDL cholesterol
What are the adverse effects of cholestyramine?
abdominal cramps and constipation
decreases absorption of fat-soluble vitamins
cholesterol gallstones
may raise level of triglycerides
Crohns disease bowel resection + diarrhoea - how to manage?
Cholestryamine
Genetic causes of chronic pancreatitis?
genetic: cystic fibrosis, haemochromatosis
Ductal causes of chronic pancreatitis?
ductal obstruction: tumours, stones, structural abnormalities including pancreas divisum and annular pancreas
What is the features of chronic pancreatitis?
pain is typically worse 15 to 30 minutes following a meal
steatorrhoea: symptoms of pancreatic insufficiency usually develop between 5 and 25 years after the onset of pain
diabetes mellitus develops in the majority of patients. It typically occurs more than 20 years after symptom begin
What medication is a risk factor for clostrium difficle?
PPI’s
What is the gram stain of c difficle?
anaerobic gram-positive, spore-forming, toxin-producing bacillus
Major complication of C difficle?
Toxic megacolon
Features of moderate C difficle?
↑ WCC ( < 15 x 109/L)
Typically 3-5 loose stools per day
Features of severe C difficle?
↑ WCC ( > 15 x 109/L)
or an acutely ↑ creatinine (> 50% above baseline)
or a temperature > 38.5°C
or evidence of severe colitis(abdominal or radiological signs)
Features of life threatening C difficle?
Hypotension
Partial or complete ileus
Toxic megacolon, or CT evidence of severe disease
Treatment during first episode of C difficle?
first-line therapy is oral vancomycin for 10 days
second-line therapy: oral fidaxomicin
third-line therapy: oral vancomycin +/- IV metronidazole
Treatment during recurrent episode of C difficle?
recurrent infection occurs in around 20% of patients, increasing to 50% after their second episode
within 12 weeks of symptom resolution: oral fidaxomicin
after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin
Management of life threatening C difficile?
oral vancomycin AND IV metronidazole
specialist advice - surgery may be considered
Two episode of recurrent C difficile management?
faecal microbiota transplant
Complications of Coeliac disease?
anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
hyposplenism
osteoporosis, osteomalacia
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility, unfavourable pregnancy outcomes
Associated conditions of coeliac disease?
Autoimmune thyroid disease
Dermatitis herpetiformis
Irritable bowel syndrome
Type 1 diabetes
First-degree relatives (parents, siblings or children) with coeliac disease
HLA type assocaited with coeliac disease?
HLA-DQ2 (95% of patients)
HLA-DQ8 (80%).
What do patients need to be doing before coeliac disease ?
Must be eating gluten 6 weeks prior to test
What is the first line serology test for coeliac?
Anti TTG (IgA)
What must be tested with other coeliac serology ? And why?
endomyseal antibody (IgA)
+
Selective IgA deficiency - may give false positive
What is the gold standard diagnosis of coeliac disease?
the ‘gold standard’ for diagnosis - this should be performed in all patients with suspected coeliac disease to confirm or exclude the diagnosis
Findings on biopsy that are consistent with coeliac disease ?
villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes
What are the ways of diagnosis colon cancer - what is gold standard?
Goldstandard: Colonoscopy
Other options:
double-contrast barium enema and CT colonography.
How is colon cancer stages?
CT chest abdomen pelvis
How is rectal cancer staged?
rectal cancer will also undergo evaluation of the mesorectum with pelvic MRI scanning.
Tumour marker for colon cancer?
CEA
Gene mutation in HNPCC?
Lynch syndrome
MSH2 (60% of cases)
MLH1 (30%)
Affect genes involved in DNA mismatch repair leading to microsatellite instability
Inheritance of HNPCC?
Autosomal dominant
Other causes associated in HNPCC ( Lynch) ?
Endometrial
Stomach,
Liver,
Kidney,
Brain, and.
Certain types of skin cancers.
Amsterdam criteria for lynch syndrome?
at least 3 family members with colon cancer
the cases span at least two generations
at least one case diagnosed before the age of 50 years
Mutation in FAP ?
tumour suppressor gene called adenomatous polyposis coli gene (APC), located on chromosome 5
Feature of Gardner’s syndrome?
osteomas of the skull and mandible
retinal pigmentation
thyroid carcinoma
epidermoid cysts on the skin
COlonic polyps
Variant of FAP
Most common type of mutation in sporadic colorectal carcinoma?
Loss of APC
Others include loss of P53 and K-ras
FIT test results?
5 out of 10 patients will have a normal exam
4 out of 10 patients will be found to have polyps which may be removed due to their premalignant potential
1 out of 10 patients will be found to have cancer
Who is bowel screening done on?
ffering screening every 2 years to all men and women aged 60 to 74 years in England, 50 to 74 years in Scotland
Investigation findings in crohn’s?
raised inflammatory markers
increased faecal calprotectin
anaemia
low vitamin B12 and vitamin D
Extra-instestinal manifestations related to disease activity in IBD?
Arthritis: pauciarticular, asymmetric
Erythema nodosum
Episcleritis
Osteoporosis
Most common extra-intestinal manifestation in crohn’s disease?
Arthritis
Extra-instestinal manifestations not related to disease activity in IBD?
Arthritis: polyarticular, symmetric
Uveitis
Pyoderma gangrenosum
Clubbing
Primary sclerosing cholangitis
IBD: Uveitis ?
UC
IBD: episcleritis
Crohn’s
IBD: Primary sclerosis cholangitis ?
UC
IBD: Goblet cell + Granuloma?
Crohn’s
Histology in crohn’s disease ?
inflammation in all layers from mucosa to serosa
goblet cells
granulomas
Small bowel enema for crohn’s disease?
high sensitivity and specificity for examination of the terminal ileum
strictures: ‘Kantor’s string sign’
proximal bowel dilation
‘rose thorn’ ulcers
fistulae
What marker can be used to correlate disease in crohn’s?
CRP
Crohns + smoking
Exacerbates
UC + smoking
Protects
How to induce remission in crohns’ disease?
Firstline: Glucocorticoids or Budesonide
Secondline: 5-ASA drugs (e.g. mesalazine)
What drugs can be added in to help induce remission on crohn’s, but cannot be monotherapy?
Can also be used to maintain remission
azathioprine or mercaptopurine
Methotrexate
Disease refractory crohn’s management?
Infliximab
Fistulating crohn’s management
Infliximab
Management of isolated perianal disease in corhn’s ?
Metronidazole
Imaging of choice for suspected perianal disease?
MRI
Management of complex fistula in crohn’s disease?
draining seton is used for complex fistulae
Management of stricturing iela disease ?
ileocaecal resection
What test should be done before starting azathiorpine / metacaptopurine ?
assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine
Signs of decompensated liver disease?
Asterixis
Jaundice
Hepatic encephalopathy
Constructional apraxia (ask to draw a clock face)
Causes of decompensated liver disease?
Infection - pneumonia, spontaneous bacterial peritonitis, viruses (hepatitis B, C)
Drugs - paracetamol, anaesthetic agents
Toxin - alcohol, Amanita phalloides mushroom
Vascular - Budd-Chiari syndrome, vena-occlusive disease
Haemorrhage - Upper gastrointestinal bleed
Constipation
Management of decompensated liver disease?
Enhance nitrate clearance with phosphate enemas
Aim for 3 stools per day
Use lactulose : lactulose to enhance binding of nitrate in the intestine.
Definitions of diarrhoea?
Diarrhoea: > 3 loose or watery stool per day
Acute diarrhoea < 14 days
Chronic diarrhoea > 14 days
What is the most common cause of diarrhoea in children?
Rotavirus
Most common cause of chroic diarrhoea in infants?
cows’ milk intolerance
Undigested food + diarrhoea?
Toddler’s diarrhoea
Barium swallow + corkscrew appearance?
Diffuse oesphageal spasm
Treatment of diverticulitis?
if the symptoms don’t settle within 72 hours, or the patient initially presents with more severe symptoms, the patient should be admitted to hospital for IV antibiotics
Drugs that cause a hepatocellular picture?
paracetamol
sodium valproate, phenytoin
MAOIs
halothane
anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
statins
alcohol
amiodarone
methyldopa
nitrofurantoin
Drug that cause a cholestatic picture?
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine
Drugs that cause cirrhosis?
methotrexate
methyldopa
amiodarone
What is Dubin Johnson syndrome?
benign autosomal recessive disorder hyperbilirubinaemia (conjugated, therefore present in urine)
defect in the canillicular multispecific organic anion transporter (cMOAT) protein
Dysphagia: Odonophagia + no weight loss + GORD
Oesophagitis
Dysphagia: HIV / steroid use ?
Oesophageal candidiasis
Pharyngeal pouch
More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen
Management for feeding > 4 weeks?
Gastric feeding > 4 weeks consider long-term gastrostomy
Complications of enteral feeding?
diarrhoea
aspiration
metabolic
hyperglycaemia
refeeding syndrome
Risk factor of developing eosinophilic oesphagitis?
Allergies/ asthma: suffering from food/ environmental allergies or atopic dermatitis and asthma increases the risk of diagnosis
Male sex
Family history of eosinophilic oesophagitis or allergies
Caucasian race
Age between 30-50
Coexisting autoimmune disease e.g. coeliac disease
Gold standard diagnosis of eosinophilic oesphagitis?
Endoscopy: diagnosis can only be made on the histological analysis of an oesophageal biopsy.
Oesphagus: epithelial desquamation, eosinophilic microabscesses, and abnormally long papillae
Eosinophilic oesphagitis
Management of eosinophilic oesphagitis?
Dietary modification
Topical steroids e.g. fluticasone and budesonide
Oesphageal dilitation
Causes of raised calprotectin?
bowel malignancy
coeliac disease
infectious colitis
use of NSAIDs
Fever + RUQ pain
Acute cholecystitis
Fever + RUQ + Jaundice
Cholangitis
Patients with intercurrent illness + RUQ + Fever ?
Acalculous cholecystitis
Management of acalculous cholecystitis?
cholecystectomy, if unfit then percutaneous cholecystostomy
What is dumping syndrome?
Complication post gastrectomy
early dumping : food of high osmotic potential moves into small intestine causing fluid shift
late dumping (rebound hypoglycaemia): surge of insulin following food of high glucose value in small intestine - 2-3 hours later the insulin ‘overshoots’ causing hypoglycaemia
Comlications of gastrectomy ?
Dumping syndrome
Weight loss, early satiety
Iron-deficiency anaemia
Osteoporosis/osteomalacia
Vitamin B12 deficiency
Risk factors for gastric cancer?
Helicobacer pylori
atrophic gastritis
diet
salt and salt-preserved foods
nitrates
smoking
blood group
Lymphatic spread of gastric cancer?
left supraclavicular lymph node (Virchow’s node)
periumbilical nodule (Sister Mary Joseph’s node)
signet ring cells
Gastric cancer
H pylori + paraproteinaemia?
MALToma
Thread worm + pruritus ani
Enterobius vermicularis
Treatment of enterobius vermiculus
Treatment is with mebendazole
Features of Ancylostoma duodenale
Hookworms that anchor in proximal small bowel
Most infections are asymptomatic although may cause iron deficiency anaemia
Larvae may be found in stools left at ambient temperature, otherwise infection is difficult to diagnose
Infection occurs as a result of cutaneous penetration, migrates to lungs, coughed up and then swallowed
Asciariasis?
Due to infection with roundworm Ascaris lumbricoides
Infections begin in gut following ingestion, then penetrate duodenal wall to migrate to lungs, coughed up and swallowed, cycle begins again
Diagnosis is made by identification of worm or eggs within faeces
Treatment is with mebendazole
What is haemobilia?
connection between splanchnic circulation and either the intrahepatic or extrahepatic biliary system
haracterized by right upper quadrant pain, evidence of upper GI bleeding and jaundice.
Management of haemochromatosis?
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)
What are the reversible complications of haemochromatosis?
Cardiomyopathy
Skin pigmentation
Transaminitis
What are the irreversible complications of haemochromatosis?
Liver cirrhosis**
Diabetes mellitus
Hypogonadotrophic hypogonadism
Arthropathy
Inheritance of haemocrhomatosis?
Autosomal recessive
How to screen for haemochromatosis/
For proband: Transferin saturation - most useful marker
For family members: HFE mutation
Typical iron study for haemochromatosis?
transferrin saturation > 55% in men or > 50% in women
raised ferritin (e.g. > 500 ug/l) and iron
low TIBC
Treatment for haemochromatosis?
- Venesection: kept below 50% and the serum ferritin concentration below 50 ug/l
- Desferroxime
Management of H pylori ?
eradication may be achieved with a 7-day course of
a proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole)
if penicillin-allergic: a proton pump inhibitor + metronidazole + clarithromycin
What is used to determine a postivie heptitis?
HbeAG
What shows that you have caught hepatitis B ?
Anti HBc
Features of viral hepatitis
nausea and vomiting, anorexia
myalgia
lethargy
right upper quadrant (RUQ) pain
Questions may point to risk factors such as foreign travel or intravenous drug use.
Biliary collic + palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node)
Cholangiocarcinoma
Heart failure + RUQ pain
Congestive cardiomyopathy
What is the mechanism of hepatorenal syndrome?
vasoactive mediators cause splanchnic vasodilation which in turn reduces the systemic vascular resistance
results in ‘underfilling’ of the kidneys
Features of type 1 hepatorenal syndrome?
Rapidly progressive
Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks
Very poor prognosis
Features of type 2 hepatorenal syndrome?
Slowly progressive
Prognosis poor, but patients may live for longer
What is hirchsprung disease?
Aganglionic segment of bowel
Associationed with hirchsprung disease?
3 times more common in males
Down’s syndrome
Diagnosis of hirchsprung disease?
abdominal x-ray
rectal biopsy: gold standard for diagnosis
What type of hypersensitivity is hydatid cysts?
Type 1 hypersensitivity
What causes hydatid cysts in the liver?
Echinococcus granulosus.
What is the best imaging modality for hydatid liver cysts?
ultrasound if often used first-line
CT is the best investigation to differentiate hydatid cysts from amoebic and pyogenic cysts
How should hydatid liver cyst be monitored?
Serology
How best to diagnose hydatid liver cysts?
Serology
How to differentiate between small or large bowel obstruction?
Valvulae conniventes extend all the way across
Haustra extend about a third of the way across
Inherited causes of Jaundice:
Conjugated?
Dubin-Johnson syndrome
Rotor syndrome
Inherited causes of Jaundice:
Unconjugated?
Gilbert’s syndrome
Crigler-Najjar syndrome
Features of Gilbert’s syndrome?
autosomal recessive
mild deficiency of UDP-glucuronyl transferase
benign
Features of crigler - najjar syndrome type 1?
autosomal recessive
absolute deficiency of UDP-glucuronosyl transferase
do not survive to adulthood
Features of crigler - najjar syndrome type 2?
slightly more common than type 1 and less severe
may improve with phenobarbital
Features of Dubin Johnson syndrome?
autosomal recessive. Relatively common in Iranian Jews
mutation in the canalicular multidrug resistance protein 2 (MRP2) results in defective hepatic excretion of bilirubin
results in a grossly black liver
benign
What are the features of rotar syndrome?
autosomal recessive
defect in the hepatic uptake and storage of bilirubin
benign
Features of intrahpetic cholecystitis in pregnancy?
pruritus - may be intense - typical worse palms, soles and abdomen
clinically detectable jaundice occurs in around 20% of patients
raised bilirubin is seen in > 90% of cases
Management of intraheptic cholecystitis?
Induction of labour at 37-38 weeks
ursodeoxycholic acid
vitamin K supplementation
Where is iron absorbed mostly?
Duodenum
What vitamins can increase iron absorption?
Vitamin C
Gastric acid
What decreases iron absorption?
proton pump inhibitors
tetracycline
gastric achlorhydria
tannin
How is iron transported around the body?
carried in plasma as Fe3+ bound to transferrin
How is iron lost from the body?
Lost via intestinal tract following desquamation
Diagnostic criteria of IBS?
patient has abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms:
altered stool passage (straining, urgency, incomplete evacuation)
abdominal bloating (more common in women than men), distension, tension or hardness
symptoms made worse by eating
passage of mucus
Suggested blood to complete at GP for IBS?
full blood count
ESR/CRP
coeliac disease screen (tissue transglutaminase antibodies)
Management of IBS?
First-line pharmacological treatment - according to predominant symptom
pain: antispasmodic agents
constipation: laxatives but avoid lactulose
diarrhoea: loperamide is first-line
Linaclotide can be considered if there has been no benefit from different laxatives and the patient has had constipation for at least 12 months.
Second-line pharmacological treatment
low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors
Difference between mesenteric ischaemic and ischaemic colitis?
Small bowel –> mesenteric colitis
Urgent surgery – mesenteric colitis
Caused by embolism –> mesenteric colitis
large bowel –> ischaemic colitis
Thumb printing –> ischaemic colitis
Bloody diarrhoea –> ischaemic colitis
Features of ischaemic hepatitis?
increases in aminotransferase levels (exceeding 1000 international unit/L or 50 times the upper limit of normal)
Absolute contraindications to laparoscopic surgery?
haemodynamic instability/shock
raised intracranial pressure
acute intestinal obstruction with dilated bowel loops (e.g. > 4 cm)
uncorrected coagulopathy
Contraindications for liver biopsy?
Deranged clotting (e.g. INR > 1.4)
low platelets (e.g. < 60 * 109/l)
anaemia
extrahepatic biliary obstruction
hydatid cyst
haemoangioma
uncooperative patient
ascites
Causes of liver cirrhosis?
alcohol
non-alcoholic fatty liver disease (NAFLD)
viral hepatitis (B and C)
How should cirrhosis of the liver be diagnosed?
transient elastography and acoustic radiation force impulse imaging
Who need transient elastography testing?
people with hepatitis C virus infection
men who drink over 50 units of alcohol per week and women who drink over 35 units of alcohol per week and have done so for several months
people diagnosed with alcohol-related liver disease
What investigation do people with liver cirrhosis need regularly?
liver ultrasound every 6 months (+/- alpha-feto protein) to check for hepatocellular cancer
What is the rule of 2’s for merles diverticulum?
occurs in 2% of the population
is 2 feet from the ileocaecal valve
is 2 inches long
Child + very stable + intermittent intestinal bleeding>?
‘Meckel’s scan’ should be considered
Presentation of meckel’s diverticulum?
abdominal pain mimicking appendicitis
rectal bleeding
Meckel’s diverticulum is the most common cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years
intestinal obstruction
secondary to an omphalomesenteric band (most commonly), volvulus and intussusception
Imaging for heckles diverticulum?
Stable: 99m technetium pertechnetate,
Unstable: mesenteric arteriography
Causes of metabolic alkalosis
vomiting / aspiration
hypokalaemia
diuretics
liquorice, carbenoxolone
primary hyperaldosteronism
Cushing’s syndrome
Bartter’s syndrome
Adverse effects of spironolactone?
extrapyramidal effects
acute dystonia e.g. oculogyric crisis
this is particularly a problem in children and young adults
diarrhoea
hyperprolactinaemia
tardive dyskinesia
parkinsonism
Mechanism of metaclopramide?
D2 receptor antagonist
Risk factors for microscopic colitis?
smoking
drugs: NSAIDs, PPIs and SSRIs
Features of microscopic colitis?
watery diarrhoea
faecal urgency
abdominal pain
constitutional symptoms such as weight loss, lethargy and arthralgia may be present
non-specific investigation findings include mild anaemia and raised inflammatory markers. Autoantibodies such as rheumatoid factor and ANA may also be present
LFT suggestive of Non-alcoholic fatty liver disease ?
ALT is typically greater than AST
Types of non-alcoholic fatty liver disease?
steatosis - fat in the liver
steatohepatitis - fat with inflammation, non-alcoholic steatohepatitis (NASH), see below
progressive disease may cause fibrosis and liver cirrhosis
In an incidental finding of NAFLD, what blood test should be done?
enhanced liver fibrosis (ELF) blood test to check for advanced fibrosis
Oesphageal cancer + lower third of oesophagus
Adenocarcinoma
Risk factors for adenocarcinoma of oesophagus?
GORD
Barrett’s oesophagus
smoking
obesity
Oesophageal cancer + upper two thirds of oesphagus?
Squamous carcinoma
Risk factors of squamous carcinoma of oesphagus?
smoking
alcohol
achalasia
Plummer-Vinson syndrome
diets rich in nitrosamines
What is required for local staging of oesophagus?
Endoscopic ultrasound
Diagnostic test for oesophageal carcinoma?
Upper GI endoscopy
Best test for staging of oesophagus?
CT scanning of the chest, abdomen and pelvis is used for initial staging
FDG-PET CT may be used for detecting occult metastases if metastases are not seen on the initial staging CT scans.
Laparoscopy is sometimes performed to detect occult peritoneal disease
Plummer vinson syndrome?
dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia
Management of Plummer Vinsons syndrome?
Treatment includes iron supplementation and dilation of the webs
Double duct sign?
Pancreatic carcinoma
Associations of pancreatic cancer?
increasing age
smoking
diabetes
chronic pancreatitis (alcohol does not appear an independent risk factor though)
hereditary non-polyposis colorectal carcinoma
multiple endocrine neoplasia
BRCA2 gene
KRAS gene mutation
What is trousseau sign?
migratory thrombophlebitis (Trousseau sign)
Features of pancreatic cancer?
classically painless jaundice
pale stools, dark urine, and pruritus
cholestatic liver function tests
the following abdominal masses may be found (in decreasing order of frequency)
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
many patients present in a non-specific way with anorexia, weight loss, epigastric pain
loss of exocrine function (e.g. steatorrhoea)
loss of endocrine function (e.g. diabetes mellitus)
atypical back pain is often seen
migratory thrombophlebitis
When is a whipples procedure required?
a Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas.
Side effect of whipples procedure?
dumping syndrome and peptic ulcer disease
Palliative management of pancreatic carcinoma?
ERCP stenting
Pathophysiology pernicious anaemia?
antibodies to intrinsic factor +/- gastric parietal cells
intrinsic factor antibodies → bind to intrinsic factor blocking the vitamin B12 binding site
gastric parietal cell antibodies → reduced acid production and atrophic gastritis. Reduced intrinsic factor production → reduced vitamin B12 absorption
Features of pernicious anaemia?
anaemia features
lethargy
pallor
dyspnoea
peripheral neuropathy: ‘pins and needles’, numbness. Typically symmetrical and affects the legs more than the arms
subacute combined degeneration of the spinal cord: progressive weakness, ataxia and paresthesias that may progress to spasticity and paraplegia
neuropsychiatric features: memory loss, poor concentration, confusion, depression, irritabiltiy
mild jaundice: combined with pallor results in a ‘lemon tinge’
glossitis → sore tongue
Investigation findings for pernicious anaemia?
full blood count
macrocytic anaemia: macrocytosis may be absent in around of 30% of patients
hypersegmented polymorphs on blood film
low WCC and platelets may also be seen
antibodies
anti intrinsic factor antibodies: sensivity is only 50% but highly specific for pernicious anaemia (95-100%)
anti gastric parietal cell antibodies in 90% but low specificity so often not useful clinically
Management of pernicious anaemia?
Vitamin B12 replacement:
- no neurological features: 3 injections per week for 2 weeks followed by 3 monthly treatment of vitamin B12 injections
- Given IM
Complication of pernicious anaemia?
Gastric cancer
Phenotype of peutzjeghers syndrome?
pigmented freckles on the lips, face, palms and soles.
numerous hamartomatous polyps in the gastrointestinal tract.
hamartomatous polyps in the gastronintestinal tract (mainly small bowel)
small bowel obstruction is a common presenting complaint, often due to intussusception
gastrointestinal bleeding
pigmented lesions on lips, oral mucosa, face, palms and soles
Inheritance of peutz joggers syndrome?
autosomal dominant
responsible gene encodes serine threonine kinase LKB1 or STK11
Where is most likely place for a pharyngeal pouch ?
posteromedial diverticulum through Killian’s dehiscence
Killian’s dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles
Features of pharyngeal pouch?
dysphagia
regurgitation
aspiration
neck swelling which gurgles on palpation
halitosis
What is the best investigation for pharyngeal pouch?
Barium swallow
How to different between Intrahepatic cholestasis of pregnancy and acute fatty liver?
Acute fatty liver –> third trimester / after delivery
Hypoglycaemia –> acute fatty liver
Pre-eclampsia –> acute fatty liver
ALT 500 –> acute fatty liver
associations between primary billiary sclerosis ?
Sjogren’s syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease
Features of primary billiard sclerosis?
early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus
cholestatic jaundice
hyperpigmentation, especially over pressure points
right upper quadrant pain
xanthelasmas, xanthomata
also: clubbing, hepatosplenomegaly
late: may progress to liver failure
Antibodies associated primary billiary sclerosis?
Raised IgM
anti-mitochondrial antibodies (AMA) M2 subtype
What is the best investigation for primary billiary sclerosis?
MRCP
Management of primary billiary sclerosis?
- first-line: ursodeoxycholic acid
Puritis: cholestyramine
Complications of primary billiary sclerosis?
cirrhosis → portal hypertension → ascites, variceal haemorrhage
osteomalacia and osteoporosis
significantly increased risk of hepatocellular carcinoma (20-fold increased risk)
What conditions are associated with primary sclerosing cholangitis?
ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC
Crohn’s (much less common association than UC)
HIV
Features of primary sclerosing cholangitis?
cholestasis
jaundice, pruritus
raised bilirubin + ALP
right upper quadrant pain
fatigue
How is primary sclerosing cholangitis diagnosed?
ERCP
MRCP
Shows multiple biliary strictures giving a ‘beaded’ appearance
What serological test may be positive in primary sclerosing cholangitis?
p-ANCA
Onion skin?
Primary sclerosing cholangitis
Complications of primary scerlosing cholangitis?
cholangiocarcinoma (in 10%)
increased risk of colorectal cancer
What is pseudomyxoma peritoni?
rare mucinous tumour most commonly arising from the appendix
What is the treatment for pseudomyoxoma peritoni?
surgical and consists of cytoreductive surgery (and often peritonectomy) combined with intra-peritoneal chemotherapy with mitomycin C
What pH abnormality is seen in pyloric stenosis?
hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
Features of pyloric stenosis?
‘projectile’ vomiting, typically 30 minutes after a feed
constipation and dehydration may also be present
a palpable mass may be present in the upper abdomen
What is the most likely organism to cause liver abscess?
Staphylococcus aureus in children and Escherichia coli in adults.
Management of liver abscess?
Drainage
Amoxicillin + Ciprofloxacin + Metronidazole
if penicillin allergic: ciprofloxacin + clindamycin
Riglers / Double wall sign?
Pneumoperitoneum
What is the biochemistry of refeeding syndrome?
hypophosphataemia
hypokalaemia
hypomagnesaemia: may predispose to torsades de pointes
abnormal fluid balance
What is the test for small bowel overgrowth syndrome?
Hydrogen breath test
Risks of small bowel overgrowth syndrome?
neonates with congenital gastrointestinal abnormalities
scleroderma
diabetes mellitus
What is antibiotic of choice for small bowel overgrowth syndrome?
Rifaxamin
Fever + Ascites + Abdominal pain ?
Spontaneous bacterial peritonitis
Paracentesis results from SBP?
paracentesis: neutrophil count > 250 cells/ul
the most common organism found on ascitic fluid culture is E. coli
Management of SBP?
IV cefotaxime
How to prevent SBP?
Give antibiotic prophylaxis if:
- Previous SBP
- fluid protein < 15
Offer ciprofloxacin or norfloxacin
What is the treatment for threadworms?
mebendazole
Mild UC?
mild: < 4 stools/day, only a small amount of blood
Moderate UC?
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
Severe UC?
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
Treatment of proctitis?
topical (rectal) aminosalicylate
If no remissino in 4 weeks then add an oral aminosalicylate
If remission still not achieved add oral corticosteroid
Management of left sided UC?
topical (rectal) aminosalicylate
If no remissino in 4 weeks then:
- high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
If remission still not achieved add oral corticosteroid
Severe colitis management?
IV steroids
How to maintain remission of proctitis and proctosigmoiditis?
topical (rectal) aminosalicylate alone (daily or intermittent)
an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent)
an oral aminosalicylate by itself:
How to maintain remission if > 2 exacerbations in a year?
oral azathioprine or oral mercaptopurine
Varices: antibiotic prophylaxis?
Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper gastrointestinal bleeding
Prophylaxis of variceal bleeds?
Propanolol
What is a villous adenoma?
secrete large amounts of mucous
non-specific lower gastrointestinal symptoms
secretory diarrhoea may occur
microcytic anaemia
hypokalaemia
What is vitamin A (retinol) used for?
converted into retinal, an important visual pigment
What is the consequences of Vitamin A deficiency?
night blindness
Consequences of thiamine deficiency?
Wernicke’s encephalopathy: nystagmus, ophthalmoplegia and ataxia
Korsakoff’s syndrome: amnesia, confabulation
dry beriberi: peripheral neuropathy
wet beriberi: dilated cardiomyopathy
Functions of vitamin D?
increases plasma calcium and plasma phosphate
increases renal tubular reabsorption and gut absorption of calcium
increases osteoclastic activity
increases renal phosphate reabsorption
Sigmoid volvulus associations?
older patients
chronic constipation
Chagas disease
neurological conditions e.g. Parkinson’s disease, Duchenne muscular dystrophy
psychiatric conditions e.g. schizophrenia
Caecal volvulous associations ?
all ages
adhesions
pregnancy
Management of sigmoid volvulus?
sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion
Management of caecal volvulus?
Right hemicolectomy is often needed
HLA association of whipples disease?
HLA B 27
Features of whipples disease?
malabsorption: diarrhoea, weight loss
large-joint arthralgia
lymphadenopathy
skin: hyperpigmentation and photosensitivity
pleurisy, pericarditis
neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus
Investigation findings of whipples disease?
jejunal biopsy shows deposition of macrophages containing Periodic acid-Schiff (PAS) granule
Gene defect in Wilsons disease?
defect in the ATP7B gene located on chromosome 13.
Management of Wilsons disease?
Penicillamine
Features of Wilson’s disease ?
liver: hepatitis, cirrhosis
neurological:
basal ganglia degeneration
Kayser-Fleischer rings
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails
Biochemistry for Wilsons disease/
reduced serum caeruloplasmin
reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
increased 24hr urinary copper excretion
What is Zollinger Ellison syndrome associated with?
MEN1
Features of Zollinger Ellison syndrome?
multiple gastroduodenal ulcers
diarrhoea
malabsorption
Single best screening test for Zollinger Ellison syndrome?
fasting gastrin levels: the single best screen test
Secretin stimulation test
Cirrhosis + Grade 1varices?
Rescope 1 year
Cirrhosis + Grade 2 varices?
Non-cardio selective beta blocker
Difference ebwteen type 1 and type 2 hepatorenal syndrome?
Type 2 slow rising of creatinine
Type 1 rapid doubling of creatine - dies quickly
Management of diffuse oesphageal spasm?
Chest pain: Calcium channel blocker
dysphagia resistant to pharmacological therapies require more invasive or surgical treatments.
- Endoscopic Botox is beneficial but may require multi-level injections and repeat treatments
- Significant weight loss –> Consider pneumatic dilation
What is better: Banding or sclerotherapy?
Banding
Vitamin deficiency + adult ?
Osteomalacia
Non-variceal UGI bleed: do you give high dose PPI?
Give if PPI is not going to be given within 24 hours
Thumb print
Specific for nothing
Doesn ot mean ischaemic colitis
Just colitis in general
What is considered diagnostic of bile acid malabsorption?
A 7-day SeHCAT retention value of less than 15% is generally considered indicative of bile salt malabsorption
What pregnancy drug can cause hepatitis?
Labetalol
Coffee bean shape
Sigmoid volvulus
Zieves syndrome?
Zieve syndrome is a triad of symptoms: haemolytic anemia, cholestatic jaundice, and transient hyperlipidemia
Occur during withdrawal from prolonged alcohol abuse.
Features of pouchitis?
30 % of patients develop pouchitis
increased stool frequency, urgency, incontinence and nocturnal seepage.
Treatment of pouchitis?
Metronidazole
Hydatid cyst + hypotension +/- wheeze ?
Think type 1 hypersensitivity reaction
Differentiate between acute fatty liver of pregnancy and obstetric cholestasis?
Increased bile salts –> cholestasis
What can a TIPS procedure exacerbate?
hepatic encephalopathy
Criteria for 5 yearly check up colonoscopy?
Extensive colitis with no active endoscopic/histological inflammation
OR left sided colitis
OR Crohn’s colitis of <50% colon
Criteria for 3 yearly check up colonoscopy?
Extensive colitis with mild active endoscopy/histological inflammation
OR post-inflammatory polyps
OR family history of colorectal cancer in a first degree relative aged 50 or over
Criteria for yearly check up colonoscopy?
Extensive colitis with moderate/severe active endoscopic/histological inflammation
OR stricture in past 5 years
OR dysplasia in past 5 years declining surgery
OR primary sclerosing cholangitis / transplant for primary sclerosing cholangitis
OR family history of colorectal cancer in first degree relatives aged <50 years
Ascitic tap: Mixed growth
Think perforation
Antibiotic that causes cholestasis ?
Flucloxacillin
In haemodynamically stable patients, what Hb is require in upper go bleeding?
70-80
Do not over transfuse
In incomplete bowel obstruction, how can this be managed?
Metoclopramide
Make sure they pass flatus
Alternative to prednisolone in UC?
Budesonide
It is less good
Barrets oesphagus + low grade dysplasia?
Radiofrequency ablation
IBD + pANCA?
Ulcerative colitis
IBD + Anti-Saccharomyces cerevisiae antibodies
Crohn’s
lymphocytic infiltrate large bowel
microscopic colitis
Biologic therapy is considered in treatment of an acute flare of Crohn’s disease when symptoms don’t improve after 5 days of IV hydrocortisone
Biologic therapy is considered in treatment of an acute flare of Crohn’s disease when symptoms don’t improve after 5 days of IV hydrocortisone
What is the diagnostic test for Wilsons?
Gene test for ATP7B
light bright on use?
fat –> steatosis
What causes whipples disease?
Tropheryma whippelii infection
What is the treatment for whipples disease?
IV penicilline
High grade dysplasia + Barrets?
Endoscopic resection
Gallstone ileum may have pneumobillia?
Stone fistulas through into bowel
When can penacillamine not be used?
Penicillin allergy
Alternative: trientine
Screening for hepatocellular carcinoma in cirrhosis?
6 monthly
Ulcerative colitis + cholestatis (e.g. jaundice, raised ALP)
primary sclerosing cholangitis
Venesection regimen for haemochromatosis?
400-500 ml every 1-2 week
Surveillance for barrels with no risk factors?
3 years
Primary biliary cholangitis - the M rule
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
Hyperemesis can lead to…?
Thiamine deficiency
Wernickes
pellagra is deficiency of what?
Niacin
Test for autoimmune pancreatitis?
IgG4
burning pain and tingling in the hands and feet, particularly after exertion or when weather temperatures are extremely hot or cold.
fabrys
Low B12 + high follate?
Small bowel bacterial overgrowth
UC drug that causes heinz bodies?
Sulphasalazine
Heinz bodies indicate oxidative damage
Carcinoid syndrome - heart changes?
Fibrous endocardial thickeing
Can you take azathioprine in pregnancy ?
Yes
CT findings of poor visualization of the hepatic veins with hypoattenuation of the peripheral zones
Budd chiari
Hepatits B: Best level for determining if going to develope cirrhosis?
Hepatitis B DNA level
Complete bowel obstruciton secondary to metastasis?
Steroids
If a patient has a low TPMT test - what does this mean?
Do not treat with azathiprine
or
mercaptopurine
Carcinoid: What is the better test 24 urinary 5HIAA or plasma chromogranin?
24 urinary 5HIAA
Hepatic encephalopathy: Steroids?
Review use of steriods at 7 days
If not improving consider stopping
Acute dystonic reaction treatment - reaction from metoclopramide?
IV procyclidine
Sjorgans is associated with PBC
Sjorgans is associated with PBC
Joint complication related to haemocromatosis?
pseudogout
How to manage hepatorenal syndrome?
Terlipressin + Albumin
Diarrhoea, fatigue, osteomalacia
coeliac
