Respiratory & Gastroenterology Flashcards
1
Q
Stepwise management of asthma in adults
A
1) SABA
2) SABA + ICS
3) SABA + ICS + leukotrine receptor antagonist
4) SABA + ICS + LABA
5) Switch ICS/LABA fr MART that includes low dose ICS e.g, fostair
2
Q
Severe asthma attack signs
A
PEFR 33-50%
RR >25
HR >110
Struggle to complete full sentences
3
Q
Life threatening asthma attack signs
A
PEFR <33% O2 Sats <92% Silent chest Cyanosis Normal CO2 - as feeble respiratory effort Bradycardia
4
Q
Management of asthma attack
A
Nebulised salbutamol
Oral prednisolone - continued for 5 days
Nebulised ipratropium bromide - if severe or life threatening
IV magnesium sulphate - if severe of life threatening
IV aminophylline - considered by seniors if severe
Intubation and ventilation - for patients who fail to respond
5
Q
Criteria for discharge following asthma attack
A
Stable for 12-24 hours - on no nebulisers or oxygen
Inhaler technique checked
PEF >75% predicted
6
Q
COPD CXR Signs
A
Hyperinflation
Flat hemidiaphragm
Bullae - large bullae may mimic pneumothorax
7
Q
Staging of COPD
A
Based on FEV1 (of predicted) Stage 1 >80% Stage 2 50-80% Stage 3 30-50% Stage 4 <30%
8
Q
What vaccinations do COPD patients get?
A
Annual influenza
One off pneumococcal
9
Q
Medical management of COPD
A
1st line - SABA or SAMA 2nd line: - no steroid responsiveness - LABA + LAMA - steroid responsiveness - LABA + ICS 3rd line - theophylline
10
Q
What features suggest steroid responsiveness in COPD?
A
Hx of asthma
High eosinophil count
Substation variation of FEV1 over time
Substation variation of PEF over time
11
Q
What is the most common infective organisms for exacerbation of COPD
A
Haemophilus influenza
12
Q
Management of COPD Exacerbation
A
Increased bronchodilator use, consider using nebs
Prednisolone 30mg for 5 days
Abx course - if sputum present or clinical signs of pneumonia (Amoxiciilin, clarithromcycin or doxycycline)
BIPAP - if type II respiratory failure develops
13
Q
Which abx is given as oral prophylactic therapy in COPD?
A
Azithromycin (given either every day or 3x a week)
14
Q
Which COPD pt’s are considered for Long term oxygen therapy
A
FEV1 <30% Cyanosis Polycythemia Peripheral oedema Raised JVP Sats <92% on room air Two ABGs showing pO2 <7.3kPa
15
Q
Which is the most common causative organism of community acquitted pneumonia?
A
Streptococcus pneumonia
16
Q
Which causative pneumonia organism is more common in diabetics and alcoholics?
A
Klebsiella
17
Q
Which causative pneumonia organism is more common in immunocompromised patients
A
Pneumocystis jirovecii
18
Q
CURB65 scoring points
A
C - confusion U - urea >7 R - resp >30 B - BP <90/60 65 - AGE >65
19
Q
In what CURB65 score would you admit to hospital?
A
1-2 intermediate risk
3-5 high risk
Both in hospital
20
Q
Investigations for pneumonia
A
Bloods - FBC, U&Es, LFTs, CRP CXR Blood and sputum cultures ABG? Pneumococcal and legionella urinary antigen tests
21
Q
Medical management of pneumonia
A
Low risk - amoxicillin 5 day course
Moderate/high risk - amoxicillin + clarithromycin 7-10 day course
22
Q
How long after pneumonia can patients take to feel back to normal
A
Up to 6 months
23
Q
Two types of pneumothorax
A
Primary - no background of lung disease
Secondary - background of lung disease e.g, COPD
24
Q
Primary pneumothorax management
A
<2cm - discharge and review
>2cm - aspirate (chest drain if aspirate doesn’t clear symptoms)
25
Secondary pneumothorax management
<1cm and asymptomatic - admit and given oxygen and watch
1-2cm and asymptomatic - aspirate (chest drain if fails)
>2cm - chest drain
Symptomatic - chest drain
>50 years old - chest drain
26
Signs of tension pneumothorax
Hx of trauma
Trachea deviation to opposite side
Hyper-resonance on affected side
Signs of shock - reduced BP
27
Features of idiopathic pulmonary fibrosis
```
Restrictive pattern on spirometry
Progressive dyspnoea
Bibasal fine end inspiratory crackles
Dry cough
Clubbing
```
28
CXR findings of idiopathic pulmonary fibrosis
Interstitial shadowing - irregular peripheral opacities (ground glass)
29
CT findings of idiopathic pulmonary fibrosis
Honeycombing
30
Management of idiopathic pulmonary fibrosis
Pulmonary rehabilitation
Supplementary oxygen
Prognosis poor and may require lung transplant
31
What is extrinsic allergic alveolitis (EAA)?
Known as hypersensitivity pnemonitis. Immune complex mediated tissue damage in responsive to inhaled organic particles
32
Types of extrinsic allergic alveolitis
Bird fanciers lung - avian proteins from bird droppings
Farmers lung - spores from wet hay
Malt workers lung - Aspergillus clavatus
Mushroom workers lung - termophilic actinomycetes
33
What is alpha-1 antitrypsin deficiency?
Deficiency in A1AT
Enzyme which is usually produced by liver and acts to protect cells from neutrophil elastase enzymes which break down elastin
34
Pathogenesis of kartagener’s syndrome
Dynein arm defect results in immotile cilia
35
Features of kartagener’s syndrome (primary ciliary dyskinesia)
```
Dextrocardia (or complete sinus inversus) - quiet heart sounds
Bronchiectasis
Recurrent sinusitis
Subfertlity
Diabetes
```
36
How is pleural fluid aspiration carried out
Using 21G needle and 50ml syringe
| USS guidance
37
What is pleural fluid tested for once aspirated?
```
PH
Protein
Lactate dehydrogenase (LDH)
Cytology
Microbiology
```
38
What are the two types of causes for pleural effusion and how can you tell the difference by protein content
Exudates - protein level >30g/L
| Transudate - protein level <30g/L
39
When is lights criteria used?
If protein content in pleural effusion is between 25-30
40
How can you determine if pleural fluid is exudate using lights criteria?
Pleural fluid protein: serum protein ratio >0.5
Pleural fluid LDH: serum LDH ratio >0.6
Pleural fluid LDH more than 2/3rd the upper limits of normal LDH
41
Causes of transudate pleural effusion
Congestive heart failure
Liver cirrhosis
Hypoalbuminaemia
Nephrotic syndrome
42
Causes of exudate pleural effusion
```
Malignancy
Infection
Trauma
Pulmonary infarction
Pulmonary embolism
```
43
When would you insert chest drain for pleural effusion?
If fluid is turbid/cloudy
| If pH is <7.2 - as this suggest an empyema is forming
44
What is sarcoidosis?
Multisystemic disorder characterised by non caseating granulomas
45
What are the features of sarcoidosis
```
Erythema nodosum
Bilateral lymphadenopathy
Dyspneoa
Polyarthralgia
Systemic symptoms - malaise, weight loss,
Lupus pernio (on skin)
```
46
What is acute respiratory distress syndrome (ARDS)
Increased permeability of alveolar capillaries leading to fluid accumulation in alveoli
(Non cardiogenic pulmonary oedema)
47
Causes of acute respiratory distress syndrome
```
Sepsis
Pneumonia
Massive blood transfusion
Smoke inhalation
Acute pancreatitis
```
48
Management of acute respiratory distress syndrome
Managed in ITU
| Oxygenation/ventilation
49
What is the common lung pathology that occurs postoperatively
Atelectasis - occurs 72 hours postoperatively
| Airways become obstructed by bronchial secretions
50
Management of atelectasis
Position patient upright
| Chest physiotherapy
51
Different types of ectopic production in small cell lung cancers and what they cause
ADH - causing hyponatraemia
ACTH - cushings
Lambert-Eaton syndrome - muscle weakness
52
What is the gold standard for diagnosis in mesothelioma?
Thorascopic biopsy
53
What are the causes of complete white on on CXR where the trachea is pulled toward the Opicification
Pneumonectomy
| Complete lung collapse
54
What are the causes of complete white out on CXR where the trachea is central?
Consolidation
Pulmonary oedema
Mesothelioma
55
What are the causes of a complete white out on the CXR where the trachea is pushed away from Opicification?
Pleural effusion
Diaphragmatic hernia
Large thoracic mass
56
What are the two drugs licensed for use in smoking cessation
Varenicline - nicotinic partial agonist
| Bupropion - norepinephrine and dopamine reuptake inhibitor
57
How can you distinguish Lambert Eaton syndrome from myasthenia gravis?
Lambert Eaton - weakness is often relieved temporarily after exertion or physical exercise
Myasthenia gravis - weakness is worse with activity
58
What are the common causes of lobar collapse?
Lung cancer
Asthma - due to mucous plugging
Foreign body
59
What are the signs of lobar collapse on CXR?
Tracheal deviation towards side of collapse
Mediastinal shift towards side of collapse
Elevation of the hemidiaphragm
60
Which lobe is aspiration pneumonia most likely to occur in?
Right lower lobe - as this is more vertically orientated
61
What is the histopathology of coeliac disease?
Sensitivity to gluten protein
| Repeated exposure to gluten leads to villous atrophy which in turn causes malabsorption
62
Which diseases are associated with coeliac disease?
Autoimmune thyroid disease
Dermatitis herpetiformis
IBS
Type 1 diabetes
63
Symptoms of coeliac disease
Unexplained gastro symptoms e.g, diarrhoea, nausea, vomiting
Abdominal pain, cramping or distention
Iron deficiency anaemia
Weight loss
64
Which cancer is associated with coeliac disease?
Enteropathy-associated T cell lymphoma of the small intestine (EATL)
65
Which antibodies are associated with coeliac disease?
TTG
| IgA
66
Why must patients continue taking gluten diet while being tested for disease
So they can produce antibodies which can be screened for
67
Management of coeliac disease
```
Gluten free diet
Pneumococcal vaccine (every 5 years) - as patients with coeliac disease have a degree of functional hyposplenism
```
68
Which medications increase risk of peptic ulcers?
NSAIDs
SSRIs
Corticosteroids
Bisphosphonates
69
What is Zollinger-Ellison syndrome?
Rare gastrin secreting tumour
| Increases risk of peptic ulcer disease
70
Difference between gastric and duodenal ulcers?
Gastric - pain worse by eating
| Duodenal - pain relieved by eating
71
What is H-Pylori eradication therapy?
Omeprazole
| Amoxicillin + clarithromycin
72
Test for H-Pylori
Urea breath test
| Stool antigen test
73
What is Gilbert’s syndrome?
Recessive condition - defective bilirubin conjugation due to lack of enzyme
Results in increase in unconjugated hyperbilirubinaemia
Jaundice may only be seen during intercurrent illness, exercise or fasting
74
Diagnosis of liver cirrhosis
Fibroscan
75
Causes of decompensated liver disease
```
Constipation - due to accumulation of toxic products
Infection
Dehydration
Upper GI bleed
Increased alcohol uptake
```
76
What is spontaneous bacterial peritonitis?
Form of peritonitis usually seen in patients with ascites secondary to liver disease
Ascitic fluid infection
77
Features of spontaneous bacterial peritonitis
Ascites
Abdominal pain
Fever
78
Diagnosis of spontaneous bacterial peritonitis
Paracentesis - neutrophil count >250 cells
79
Most common organism causing spontaneous bacterial peritonitis?
E.Coli
80
Management of spontaneous bacterial peritonitis
IV cefotaxime
81
Which patients with liver cirrhosis should be given prophylactic abx for spontaneous bacterial peritonitis?
Previous episode fo SBP
Ascitic fluid protein <15
Child-Pugh score >0
Hepatorenal syndrome
82
3 types of antibodies in autoimmune hepatitis
ANA - anti neutrophilic antibodies
SMA - anti smooth muscle antibodes
LKM1 - anti liver/kidney type 1 antibodies
83
Management of autoimmune hepatitis
Steroids
Immunosupression e.g, azathioprine
Liver transplantation
84
What is Wilson’s disease
Excessive copper deposition in tissues
| Due to defect in ATP7B gene on chromosome 13
85
What age does Wilson’s disease usually present?
Aged 10-25
86
Clinical features of Wilson’s disease
Liver symptoms - hepatitis/cirrhosis
Neurological symptoms - behavioural and psychiatric problems
Eye signs - green/brown rings in eyes due to copper accumulation (Kayser-fleischer rings)
Kidney symptoms - renal tubular acidosis (esp. fanconi syndrome)
87
Diagnostic investigation in Wilson’s disease
Reduced serum caeruloplasmin - 95% of copper is carried by this so as it is used up it is lower in serum levels
88
Management of Wilson’s disease
Penicillamine - this chelates copper
89
What is hepatorenal syndrome?
Kidney failure seen in people with severe liver damage
Due to vasoactive mediators which cause splanchnic vasodilation - this results in less blood flow to the kidneys and causes kidney decline
90
Two types of hepatorenal syndrome
Type 1 - rapidly progressive, very poor prognosis
| Type 2 - slowly progressive, still poor prognosis but patients live longer
91
Management of hepatorenal syndrome
Terlipressin - causes vasoconstriction of splanchnic circulation
Transjugular intrahepatic portosystemic shunt - connects the inflow portal vein to the outflow hepatic vein
92
What is budd-chiari syndrome?
Hepatic vein thrombosis
| Due to obstruction to hepatic venous outflow
93
Causes of budd chairi syndrome
Coagulopathy (causing hyper coaguloble state which causes thrombosis in hepatic vein and reduced outflow) - e.g, polycythaemia rubra vera, thrombophillia, antiphospholipid syndrome
Obstructive cause (physical obstruction to hepatic vein) - e.g, tumour compressing on hepatic vein
94
Triad of budd-chiari syndrome
Abdominal pain - severe sudden onset
Ascites
Tender hepatomegaly
95
What is achalasia?
Failure of relaxation of the lower oesophageal sphincter
| Usually due to the degenerative loss of ganglia from auerbach’s plexus (myenteric plexus in oesophageal wall)
96
Clinical presentation of achalasia
Dysphagia to both liquids and solids from beginning
Heartburn
Regurgitation of food
97
What does a barium swallow show in patients with achalasia?
Birds beak appearance - due to grossly expanded oesophagus
98
Management of achalasia
Intra-sphincteric injection of botulinum toxin
Laproscopic heller cardiomyotomy - surgery in which the sphincter muscle is cut to open passage between oesophagus and stomach
99
What is Barrett’s oesophagus
Metaplasia of lower oesophageal mucosa - squamous epithelium leads to columnar epithelium due to repeated exposure to stomach acid
100
How often do patients with Barrett’s Oesophagus undergo endoscopy?
Every 3-5 years to check for malignant transformation (dysplasia)
101
Two types of oesophageal cancer and where they are located
Squamous cell - upper 2/3rds of oesophagus
| Adenocarcinoma - lower 1/3rd of oesophagus
102
Where are the majority of pancreatic cancers located?
Head of pancreas - they are adenocarcinomas
103
What is courvoisier’s law?
In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
104
What is trousseau sign?
Migratory thrombophlebitis
Where pancreatic cancer is associated with repeated attacks of multiple thrombosis at different and changing sites due to procoagulant factors formed by cancer cells
This presents as carpopedal spasm (which can be brought on by inflating a sphygmomanometer) - adduction of thumb, flexion of metacarpophalangeal joins, flexion of wrist
105
What is the sign on USS in pancreatic cancer?
Double duct sign - simultaneous dilation of common bile duct and pancreatic ducts
106
What is the surgical procedure called used to remove head of pancreas cancers
Whipple’s resection (pancreaticoduodectomy)
107
What are the 2 genetic mutations linked to colon cancer and their prevalence?
Hereditary non-polyposis colorectal carcinoma (HNPCC) - 5%, due to mutation in MSH2 or MSH1
Familial adenomatous polyposis (FAP) - 1%, due to mutation in APC
108
Histopathology of Crohn’s disease
Inflammation across all layers of bowel wall down to serosa
Skip lesions
Can occur anywhere from mouth to anus
109
Stepwise management of inducing remission in Crohn’s disease
1st line - glucocorticoids, e.g, prednisolone
2nd line - 5-ASA drugs e.g, mesalazine
3rd line - azathioprine
4th line - infliximab
110
What has to be checked before starting patients on azathioprine
Thiopurine methyltransferase (TPMT) activity - as this is responsible for the metabolism of azathioprine
111
Which type of inflammatory bowel disease may smoking help?
Ulcerative colitis
Smoking makes Crohn’s disease worse
112
What medications are used to help maintain remission in Crohn’s disease
1st line - azathioprine
| 2nd line - methotrexate
113
Complications of Crohn’s disease
Intestinal fistulas
Bacterial overgrown
Perianal disease
Increased risk of small bowel and colorectal cancer
114
Histopathology of ulcerative colitis
```
Only inner layer of bowel wall
Loss of haustral markings
Appearance of psuedopolpys
Inflammation in continuous
Never spreads beyond ileocaecal valve
```
115
Extra-intestinal features of ulcerative colitis
Primary sclerosing cholangitis
Uveitis
Arthritis
Erythema nodosum
116
Management of remission of ulcerative colitis
1st line - topical (rectal) aminosalicylate e.g, mesalazine
2nd line - oral aminosalicylate e.g, mesalazine
3rd line - oral corticosteroids e.g, prednisolone
117
Flares of ulcerative colitis severity
Mild flare - <4 stools a day
Moderate flare - 4-6 stools a day
Severe flare - >6 stools a day, containing blood, systemic disturbance
118
Management of ulcerative colitis flares
Mild flare - rectal aminosalicylate e.g, mesalazine +/- oral mesalazine
Severe flare - hospital admission, IV corticosteroids, consider IV ciclosporin if not improving in 72 hours
119
Complications of ulcerative colitis
Toxic megacolon - transverse colon >6cm in diameter
120
Risk factors for C.Diff infection
Hospital
Antibiotic use
PPIs
121
Management of C.Diff
Oral metronidazole - 10-14 day course
| Oral vancomycin - if not responding to metronidazole
122
What is small bowel bacterial overgrown syndrome (SBBOS)?
Disorder characterised by excessive amounts of bacteria in the small bowel resulting in GI symptoms
Caused by anything that slows the bowel movements down so bacteria are able to multiply
123
Risk factors for SBBOS
```
Congenital GI abnormalties I
Post surgery
Divertulosis
Adhesions
Amyloidosis
Scleroderma
Diabetes
```
124
Management of SBBOS
Correct underlying disorder
| Antibiotic therapy - rifaximin is sometimes used if diagnosis is unclear to see if this helps
125
What is primary biliary cirrhosis/cholangitis?
Autoimmne condition where the interlobular bile ducts become damaged causes progressive cholestasis
This can eventually progress to cirrhosis
126
What is the M rule for primary biliary cirrhosis?
IgM antibodies
Anti Mitrochondrial antibodies, M2 subtype
Middle aged females
127
Management of primary biliary cirrhosis
Ursodeoxycholic acid
Symptomatic management of pruritis - cholestyramine
128
Which rheumatoid conditions are commonly associated with primary biliary cirrhosis?
Sjögren’s syndrome - sicca symptoms occur in 70% of cases
Rheumatoid arthritis
Systemic sclerosis
129
What is primary scleorosing cholangitis?
Biliary disease of unknown cause characterised by infalmmation and fibrosis of intra and extra hepatic ducts
130
Main association of primary sclerosing cholangitis
Ulcerative colitis
131
Cancer associated with primary sclerosing cholangitis
Cholangiocarcinoma
132
Types of bowel Ischaemia and characteristics
Acute mesenteric ischaemia - typically caused by embolism occlusion of artery, patients classically have AF, severe abdo pain
Chronic mesenteric ischaemia - intestinal angina, colicky abdo pain
Ischaemic colitis - acute but transient compromise in blood flow to small bowel
133
What can be seen on an abdo X-Ray in patients with ischaemic colitis
Thumb printing - due to mucosal oedema/haemorrhage
134
Which type of bowel ischaemia is cocaine use associated with?
Ischaemic colitis
135
Management of acute mesenteric ischaemia
Urgent surgery
136
Management of Ischaemic colitis
Supportive - analgesia, fluids
Thrombolytic therapy
Angioplasty
Maybe surgery
137
What is rosvig’s sign?
Appendicitis sign
| Palpation in left iliac Fossa causes pain in right iliac fossa
138
What are the metabolic abnormalities in refeeding syndrome?
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
139
Risk factors for refeeding syndrome
BMI <18
Unintentional weight loss >10% over 3-6 months
Little nutritional intake for >5 days
History of alcohol abuse, insulin use, chemotherapy, diuretics
140
Which is the only test licensed for use to check that H.Pylori eradication therapy has worked?
Urea breath test
141
Precipitating factors for hepatic encephalopathy
Infection e.g, spontaneous bacterial peritonitis
GI bleed
Constipation
Post transjugular intrahepatic portosystemic shunt
142
Management of hepatic encephalopathy
Lactulose - promotes secretion of ammonia
143
Prophylaxis of hepatic encephalopathy
Lactulose
| Rifaximin
144
Blood results findings in alcoholic hepatitis
Raised GGT
| Raised AST:ALT ratio
