Tutorials; Cases Flashcards
IBD Mgmt Drugs Pyramid
- AMINOSALICYLATES: antiinflamm
>MESALAZINE = remission and maintenance in UC - CORTICOSTEROIDS = remission in both UC and CD, NOT MAINTENANCE
>pred.
> budesonide (better sfx profile)
!taper off
- IMM SUPPR. = THIOPRINE = azathioprine = reduces cell proliferation
CI in preg., hepatic impairment, elderlry
!bone marrow dysf., hepatic impairment, pancreatitis
- BIOLOGICS = monoclonal antibodies in IBD = block cytokine / white cell movement
* target immune mediators
CI = severe infection, prego and breast feeding, latent TB, MS, live vaccines
- Sx
Significance of corticosteroid use in IBD
Only to induce remission in both UC and CD but not for LT maintenance d/t sfx
Bile Acid Sequestrants
Bind to bile acid = bile acid and bile lost in stool
- for pruritis
- LDL lowering
> CHOLESTYRAMINE
Bile Acid Drugs
Managing cholesterol gall stones 1º Biliary Cirrhosis
= reduce cholesterol formation in liver; prevent cholesterol saturation
> URSODEOXYCHOLIC ACID
What secretes Pepsinogen
Pepsinogen is secreted from peptic (or chief) cells in the oxyntic gland.
What do parietal cells secrete
HCl
in response to eating a meal. Acid secretion is highly regulated, with paracrine (histamine), neural (acetylcholine), and hormonal (gastrin) factors acting in concert to regulate parietal cell function
T/F = Fructose is absorbed passively across the colonic eptihelium
FALSE
Fructose is absorbed passively (via GLUT - 5) across small intestinal villus epithelium
T/F = Vagal stimulation results in stimulation of a profuse watery salivary secretion.
FALSE
The vagus nerve does not innervate the head or neck. The facial and glossopharyngeal nerves stimulate secretion of watery saliva.
Bile Salt Reabs
Reabs at Distal ileum via HEPATIC PORTAL
T/F = Cholecystokinin causes the sphincter of Oddi to relax.
TRUE
CCK causes gallbladder contraction leading to bile expulsion. Co-ordinated relaxation of the sphincter of Oddi is required to permit bile entry into the duodenal mucosa
T/F = Stomach distension leads to inhibition of gastrin secretion
F
Stomach distension leads to stimulation of gastrin secretion
In which condition is villous atrophy a characteristic finding upon intestinal biopsy?
COELIAC DISEASE
Although some other conditions can cause villous atrophy, coeliac disease is the most commonly associated with this. Malabsorption occurs as a consequence of autoimmune destruction of villi in coeliac disease, which typically presents as diarrhoea, steatorrhea, weight loss, and vitamin deficiency.
How would you expect transferrin and ferritin levels to be effected by iron deficiency?
High transferrin, low ferritin
In Iron deficiency, the liver increases production of transferrin in order to increase iron uptake and maintain iron homeostasis. In contrast, ferritin acts as an iron store, so levels increase when there are high amount of iron in the blood, and decrease in iron deficiency. A low ferritin is the more sensitive marker of iron deficiency and is the more commonly used test.
Which of the following drugs commonly cause constipation as a side-effect?
Opioids
Hepatitis bloods
HBsAg = indicates a current infection.
Anti HBc = indicates a previous infection.
Vaccination = only Anti HBs
Current infection = HBsAg “mops up” any antibody to hepatitis B surface antigen, so the test for HBsAg will appear negative.
Acute hepatitis B infection, Anti HBc will be IgM,
Vs
Chronic infection = antibody to hepatitis B core will be IgG.
How is crohn’s disease definitively diagnosed?
ENDOSCOPE
- cobblestone
- mucosal inflamm
- skip lesions
What can be a side effect of use of proton pump inhibitors such as omeprazole?
Increased risk of C. Diff infection
Which auto antibodies are characteristic for primary biliary cholangitis?
antimitochondrial antibodies
Which of the following are signs of chronic liver disease?
spider naevi , palmar erythema , gynaecomastia, ascites
What concentration of neutrophils in an ascitic tap would indicate starting antibiotics for spontaneous bacterial peritonitis?
> 250 cells per mm3
Essential mgmt of hepatic encephelopathy
Supportive care , Reversal of precipitating factors , Lactulose
All patients with hepatic encephalopathy should receive lactulose to reduce the nitrogenous load from the gut (the exact mechanism is unclear).
What would you expect to see upon endoscopy in ulcerative colitis?
Loss of vascular marking
Crypt abscesses
continuous uniform involvement
Which conditions have an association with coeliac disease?
AuImm conditions such as: Dermatitis Herpetiformis Insulin dependent diabetes mellitus Autoimmune thyroiditis Primary biliary cholangitis
Coeliac Disease complications
Small bowel lymphoma
Oesophageal carcinoma
Small bowel adenocarcinoma
What is the treatment for dermatitis herpetiformis?
similar presentation to herpes but associated with coeliac disease
> DAPSONE
GF DIET
Which stool test can be used to help diagnose inflammatory bowel disease?
Faecal calprotectin
functional causes of vomiting?
Pregnancy, Migraine, Alcohol
Definition of functional disorder
Functional disorders are those in which no clear structural or biochemical pathology can be demonstrated. In GI conditions they are characterised as disorders with:
No detectable pathology
Related to gut function
“Software faults”
Good long term prognosis
organic causes of constipation?
Anal fissure, Colonic tumour , Diverticular disease
Cases where PEG (Percutaneous endoscopic gastrostomy) tube appropriate
Motor neurone disease, oesophageal cancer , Prolonged period on ICU , Abdominal Malignancy
Refeediing Syndrome
Patients at risk of refeeding syndrome need their electrolytes monitored closely (initially daily bloods), with electrolyte supplementation given as required.
Hypokalemia, Hypomagnesemia , Hypophosphatemia
Which biochemical abnormalities may you expect to see in severe cases of anorexia nervosa?
Metabolic Alkalosis (loss of H+ in vomit) or diuretic abuse
Hyponatremia can result from diuretic abuse and pyschogenic polydipsia (occasionally seen in anorexia nervosa)
Hypokalemia
Which anti-emetic should be avoided in bowel obstruction?
Metoclopramide should be avoided as it is a pro-kinetic agent and can result in increased colicky pain.
What detail in a history should make you suspicious of raised intracranial pressure as a cause of vomiting?
Vomiting and nausea occur early in the morning
NG Indications
- Swallowing disorders
- Head and Neck Cancers
- Cystic Fibrosis
- Anorexia Nervosa
Nasojejunal indications
- Delayed gastric emptying
- Reflux causing an aspiration risk
- Upper GI surgery
- Pancreatitis
The role of Gastrin
(g cells)
- regulates HKATP on parietal = acidic env.
- Enterochromatifain-like cells stimulation releasing HISTAMINE
- Stimulated by lumen peptides
The role of Histamine
(from ISF), functions as a paracrine
- HKATP activity+
- released from ECL cells to act on parietal
The role of ACh
Vagal nerve cholinergic receptors, neuronic control
- (+) HKATP on parietal cells (cephalic phase)
- Vagal reflex stimualted upon stomach distension = act on parietal cells
- ACh activates ECL (gastric)
The role of prostaglandins
prevents cAMP formation and inhibitory to HKATP mechanism
The role of Secretin
Released from (S cells)
- triggered by acid in duo. = bicarb secretion
The role of Gastric inhibitory peptide
stiulated by fat and CHO in duodenum
= ⇩gastric secr. and parietal HCl
Regarding the MMComplex
- What initiates
- When it occurs
- Factors stopping it
- MOTILIN
- FASTING: stomach to distal ileum
- FOOD IN STOMACH stops MMC, starts segmentation
Associations 1º Sclerosing Cholangitis
UC
Cholangiocarcinoma
Associations 1º Biliary Cholangitis
Hepatocelular carcinoma
+ALP, ESR
Pathognomic Signs of Ceoliac
GF = relief
vllous atrophy, crypt hypertrophy
anti-TTG
Pathognomic signs of Small Bowel Obstruction
intermittent colick; relieved by vomit
frequent and larger volume vomit
focal tenderness
Pathognomic Signs of LBO
continuous pain
intermittent vomit
diffuse tenderness
