Passmed - Gastro Flashcards
Metabolic alkalosis + hypokalaemia →
? Prolonged vomiting
Metabolic alkalosis causes?
vomiting / aspiration
(e.g. peptic ulcer leading to pyloric stenos, nasogastric suction)
vomiting may also lead to hypokalaemia
diuretics
liquorice, carbenoxolone
hypokalaemia
primary hyperaldosteronism
Cushing’s syndrome
Bartter’s syndrome
Metabolic alkalosis?
Metabolic alkalosis may be caused by a loss of hydrogen ions or a gain of bicarbonate. It is due mainly to problems of the kidney or gastrointestinal tract
PPI adverse effects?
hyponatraemia, hypomagnasaemia
osteoporosis → increased risk of fractures
microscopic colitis
increased risk of C. difficile infections
Loperamide, a mu-receptor agonist anti-diarrhoeal agent, adverse effects?
dry mouth, constipation and dizziness
Beta blocker adverse effects?
bronchospasm, cold peripheries and fatigue
Primary sclerosis cholangitis investigation?
MRCP
Pancreatic cancer features?
classically painless jaundice (pale stools, dark urine, and pruritus; cholestatic liver function tests)
Abdominal mass
Often 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 (Trousseau sign) more common than with other cancers
Pancreatic cancer abdo masses that 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
Double duct sign?
Pancreatic cancer
the presence of simultaneous dilatation of the common bile and pancreatic ducts
Pancreatic cancer investigations?
USS (60-90% sensitivity)
HRCT scanning is investigation of choice if the diagnosis is suspected
imaging may demonstrate the ‘double duct’ sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts
Pancreatic cancer management?
less than 20% are suitable for surgery at diagnosis
a Whipple’s resection (pancreaticoduodenectomy) for resectable lesions in the head of pancreas.
adjuvant chemotherapy is usually given following surgery
ERCP with stenting is often used for palliation
Whipple’s resection
(pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas.
Side-effects - dumping syndrome and peptic ulcer disease
Coeliac disease management?
Avoid gluten
Immunisation (due to hyposplenism)
Coeliac disease investigations?
tTG-IgA Test
+ IgA antibody
Iron defiency anaemia vs. anaemia of chronic disease
TIBC is high in IDA, and low/normal in anaemia of chronic disease
Anaemia of chronic disease bloods?
normochromic/hypochromic, normocytic anaemia
reduced serum and TIBC
normal or raised ferritin
Iron deficiency anaemia bloods?
TIBC raised
Ferritin low
first line antibiotic for use in patients with C. difficile infection
Oral vancomycin
life-threatening C. difficile infection treatment
ORAL vancomycin and IV metronidazole
life-threatening C. difficile infection treatment
ORAL vancomycin and IV metronidazole
IBS considered if following symptoms for 6 months: ABC
Abdominal pain, and/or
Bloating, and/or
Change in bowel habit
A positive diagnosis of IBS should be made if the 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
Primary care investigations for IBS?
full blood count
ESR/CRP
coeliac disease screen (tissue transglutaminase antibodies)
Primary biliary cholangitis - the M rule
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
Most important intervention to stop further Crohn’s episodes?
Smoking cessation
A severe flare of ulcerative colitis should be treated…
in hospital with IV corticosteroids
Adenocarcinoma is now the most common type of oesophageal cancer and is more likely to develop in patients with a history of…
gastro-oesophageal reflux disease (GORD) or Barrett’s.
gold standard for diagnosis of coeliac disease
Endoscopic intestinal biopsy
Coeliac -> koilonychia?
Koilonychia = sign of hypochromic anemia (esp iron-def)
Bloating, fatigue, foul-smelling and greasy stools combined with her elevated serum anti-tTG levels = coeliac disease -> malabsorption in the gut due to villous atrophy -> iron-def anaemia because dietary iron is not adequately absorbed. Iron deficiency -> koilonychia.
metastatic HCC treatment?
Sorafenib
Mesenterio ischaemia triad?
CVD, high lactate and soft but tender abdomen
first-line in maintain remission in ulcerative colitis patients with proctitis and proctosigmoiditis?
A topical (rectal) aminosalicylate +/- an oral aminosalicylate is used
E.g. topical mesalazine
first-line medication for primary biliary cholangitis?
Ursodeoxycholic acid
mainstay of treatment in haemochromatosis
Regular venesection
desferrioxamine may be used second-line
mild-to-moderate exacerbation of left-sided ulcerative colitis management?
topical (rectal) mesalazine or sulphasalazine - topical aminosalicylates
Severe ulcerative colitis management?
IV steroids
(IV ciclosporine if steroids contraindicated)
HBsAg positive, anti-HBs negative, IgM anti-HBc positive
Acute hepatitis B
Courvoisier’s law
A palpable, non tender, enlarged gallbladder accompanied with painless jaundice is unlikely to be due to gallstones. Instead consider malignancy
HBsAg negative, anti-HBs positive, IgG anti-HBc positive
previous infection, not a carrier
(vaccine would only lead to anti-HBs antibodies)
C. diff management?
first-line therapy is oral vancomycin for 10 days
second-line therapy: oral fidaxomicin
third-line therapy: oral vancomycin +/- IV metronidazole
Life-threatening - oral vancomycin AND IV metronidazole
Aminosalicylates?
Sulphasalazine, mesalazine, olsalazine
variety of haematological adverse effects, including agranulocytosis
The following drugs tend to cause a hepatocellular picture:
paracetamol
sodium valproate, phenytoin
MAOIs
halothane
anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
statins
alcohol
amiodarone
methyldopa
nitrofurantoin
The following drugs tend to cause cholestasis (+/- hepatitis):
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine
Patients with ascites secondary to liver cirrhosis should be given
an aldosterone antagonist e.g. spironolactone
Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg
chronic HBV infection
Coeliac disease increases the risk of developing
anaemia
hyposplenism
osteoporosis, osteomalacia
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility, unfavourable pregnancy outcomes
Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels
autoimmune hepatitis
Type I autoimmune hepatitis?
Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)
Affects both adults and children
Type II autoimmune hepatitis?
Anti-liver/kidney microsomal type 1 antibodies (LKM1)
Affects children only
Type III autoimmune hepatitis?
Soluble liver-kidney antigen
Affects adults in middle-age
Alcoholic hepatitis management?
Glucocorticoids (e.g. prednisolone)
diagnostic investigation of choice for pancreatic cancer
High-resolution CT scanning
investigation of choice for suspected perianal fistulae in patients with Crohn’s
MRI
Liver failure triad?
encephalopathy, jaundice and coagulopathy
Acute liver failure features?
jaundice
coagulopathy: raised prothrombin time
hypoalbuminaemia
hepatic encephalopathy
renal failure is common (‘hepatorenal syndrome’)
In life-threatening C. difficile infection treatment is with
ORAL vancomycin and IV metronidazole
key investigation for a suspected perforated peptic ulcer
Erect chest x ray
Overflow diarrhoea =
type 7 stools with intermittent hard stools. Treat with faecal disimpaction
MSH2/MLH1 gene mutations are associated with
hereditary non-polyposis colorectal carcinoma
Early signs of haemochromatosis are
fatigue, erectile dysfunction and arthralgia
Vomiting / aspiration ABG
metabolic alkalosis
Hepatic encephalopathy management?
Lactulose
Primary biliary cholangitis - the M rule
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
Crypt abscesses associated with?
UC
? may be useful for diagnosing and monitoring the severity of liver cirrhosis
Transient elastography
The AST/ALT ratio in alcoholic hepatitis is
2:1
Raised transferrin saturation and ferritin, with low TIBC is the characteristic iron study profile
in haemochromatosis
Early signs of haemochromatosis are…
fatigue, erectile dysfunction and arthralgia
A combination of liver and neurological disease points towards
Wilson’s disease
x should be co-administered with isoniazid to prevent y
x - Pridoxine (vitamin B6)
y - peripheral neuropathy
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)
Severe UC management
IV corticosteroids (hydrocortisone or methylprednisolone) in order to induce remission
upper gi bleed vs lower gi bleed urea
high can suggest upper
In an acute upper GI bleed, the x can identify low risk patients who may be discharged
Glasgow-Blatchford score
If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given either
oral azathioprine or oral mercaptopurine to maintain remission
Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg implies
chronic HBV infection
HBsAg positive, anti-HBs negative, IgM anti-HBc positive
acute infection
SAAG > 11g/L - indicates x
x = portal hypertension
causes of SAAG >11g/L (transudate)
Portal hypertension
Liver disorders most common cause - cirrhosis/alcoholic liver disease, acute liver failure, liver mets
Cardiac - right heart failure, constrictive pericarditis
Other - Budd-Chiari syndrome, portal vein thrombosis, veno-occlusive disease, myxoedema
Causes of SAAG <11g/L (exudate)
Hypoalbuminaemia
nephrotic syndrome
severe malnutrition (e.g. Kwashiorkor)
Malignancy - peritoneal carcinomatosis
Infections - tuberculous peritonitis
Other - pancreatitis, bowel obstruction, biliary ascites, postoperative lymphatic leak, serositis in connective tissue diseases
transudate vs exudate SAAG?
transudate = SAAG >11g/L
exusate = SAAG <11g/L
Ciprofloxacin and omeprazole are high-risk for
Clostridium difficile
Patients with Crohn’s who develop a perianal abscess require
incision and drainage
x is the only test recommended for H. pylori post-eradication therapy
Urea breath test
H. pylori eradication:
PPI + amoxicillin + clarithromycin, or
PPI + metronidazole + clarithromycin
Primary sclerosing cholangitis can have positive
p-ANCA
A non-cardioselective B-blocker (NSBB) is used for the prophylaxis of
oesophageal bleeding
Haemochromatosis inheritance pattern
autosomal recessive
signet ring cells
Gastric adenocarcinoma
Surgical treatment of achalasia
Heller cardiomyotomy
Iron defiency anaemia vs. anaemia of chronic disease:
TIBC is high in IDA, and low/normal in anaemia of chronic disease
Budd-Chiari syndrome presents with the triad of
sudden onset abdominal pain, ascites, and tender hepatomegaly
Acute mesenteric ischaemia causes a raised
lactate
Metabolic alkalosis + hypokalaemia →
?prolonged vomiting
If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given either
oral azathioprine or oral mercaptopurine to maintain remission
Histology of coeliac disease:
villous atrophy, raised intra-epithelial lymphocytes, and crypt hyperplasia
Ferritin is low in iron deficiency anaemia but x in anaemia of chronic disease
high or normal
x with biopsy is the investigation of choice for suspected gastric cancer
Oesophago-gastro-duodenoscopy
x are the investigations of choice in primary sclerosing cholangitis
ERCP/MRCP
Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg implies x
chronic HBV infection
Both x should be given before endoscopy in patients with suspected variceal haemorrhage
terlipressin and antibiotics
