Gastroenterolgy + Endocrinology Flashcards
What is Budd-Chiari syndrome?
hepatic disease caused by obstruction of hepatic venous outflow
triad: hepatomegaly, abdo pain, ascites, jaundice
treatment:
-drain ascites
-anti-coags
-surgery?
Where does the coeliac trunk, superior and inferior mesenteric arteries orginate?
T12- C
L1- S
L3- I
What is the difference in blood results between hypothyroidism, secondary hypothyroidism, euthyroid sick syndrome, hyperthyroidism and secondary hyperthyroidism?
hypothyroidism = T4 low and TSH high
hyponatremia, Raised Bilirubin, ALT
secondary hypothyroidism = T4 is low and TSH low/normal
euthyroid sick syndrome = Low T3, Normal or low TSH, normal T4
hyperthyroidism = High T4, low TSH
secondary hyperthyroidism = high T4, high TSH
What does a positive Murphy’s sign suggest?
palpate gallbladder and if positive –> cholecystitis
What is the average age to diagnose type 1 diabetes?
12
What is diverticular disease/diverticulitis?
Affects LARGE colon
Diverticular disease/diverticulosis= small bulges or pockets (diverticula) develop in the lining of the intestine = supportive treatment
Diverticulitis = these pockets become inflamed or infected = treatment below
pain, constipation, diarrhoea, sometimes blood, mucus if infected
colonoscopy + CT scan
diet change, paracetamol NOT NSAIDs, antibiotics-Co-amoxiclav, surgery
What is the management for small bower obstruction caused by adhesions?
smALL bowel obstruction = bowel lines cross ALL the way across
No surgery needed–> insert NG tube to allow bowel rest, give fluids, anti-emetics and pain relief
What is Coeliac’s disease, symptoms, investigations and management?
Autoimmune disorder where gluten is not broken down fully and leads to chronic inflammation and malabsorption
Symptoms:
rash, change in bowel habits, fatigue, iron and B12 deficiency, osteomalacia
Investigations:
-TTG (tissue transglutaminase) Antibodies
-IgA anti-endomysial antibody (EMA)
-duodenal endoscopy biopsy which shows:
villous atrophy, raised intra-epithelial lymphocytes and crypt hyperplasia
Management:
Gluten free diet
Pneumococcal vaccine every 5 years
Correct anaemia
Refer to dietician
How do you treat hypoglycaemia?
Conscious: oral glucose, don’t stop insulinun
conscious or unable to swallow: subcut or IM glucagon
What is Cori’s disease?
Glycogen storage diseases (GSDs) are a group of inherited genetic disorders that cause glycogen to be improperly stored in the body.
Children with glycogen storage diseases have a buildup of abnormal amounts or types of glycogen in their tissues.there are 8 types and Cori is number THREE
symtpoms:
Swollen abdomen due to an enlarged liver
Growth delay during childhood
Low blood sugar
Elevated fat levels in blood
muscle weakness (hypotonia): main one
What is zinc deficiency?
-low zinc levels causing reduced taste, growth and sexual maturity
-causes acrodermatitis enteropathica (recurrent infection)
diagnosed by measuring:
-zinc
-high zinc in morning and low in evening
-increased zinc with diuretics but decreased in COCP and steroids
-high copper in zinc deficiency
What is volvulus?
abnormal twisting of a part of the large or small intestine –> bowel obstruction
abdominal pain and tenderness
vomiting green bile
nausea
distended abdomen
bloody stool
constipation
shock
examine stool for blood, barium X-rays, CT, sigmoidoscopy
Clinically, how can you tell if it’s a direct or indirect hernia?
Ultrasound = most reliable
press on the hernia and if hernia reappears it is more likely to be a direct inguinal hernia whereas if it does not, it is more likely to be an indirect inguinal hernia
What is the difference between fresh blood and melena in stool?
fresh blood = lower GI bleed
melena = upper GI bleed, reverse warfarin if on it and keep off blood thinners
What organs are retroperitoneal?
SAD PUCKER
suprarenal (adrenal) glands
aorta/IVC
duodenum: 3rd part
pancreas
ureters
colon: ascending + descending
kidney
Esophagus
Rectum
What is the difference between an inguinal and femoral hernia anatomically?
Inguinal = medial to pubic tubercle
femoral = lateral to pubic tubercle
What hormones does the posterior pituitary secrete?
ADH/vasopressin and oxytocin.
What are the 6 hormones that the anterior pituitary gland secretes?
FLAT-PeG
FSH
LH
ACTH
TSH-thyroid
Prolactin
Growth hormone
What is the difference between salmonella and e.coli?
If it’s from undercooked food e.coli affects lasts longer whereas salmonella is usually just a day.
How is diabetes diagnosed?
Fasting serum glucose: >7mmol
random serum glucose: >11.1 mmol
HbA1c: >6.5%
2hr glucose test: GTT>11.1
What is Wilson’s disease?
rare autosomal recessive disorder that causes copper to accumulate in your liver, brain and other vital organs.
ATP7B gene
-LFTs, 24hr urine copper
-Fatigue, lack of appetite or abdominal pain
-psychosis
-A yellowing of the skin and the whites of the eye (jaundice)
-Golden-brown eye discoloration (Kayser-Fleischer rings)
-Fluid buildup in the legs or abdomen
-Problems with speech, swallowing or physical coordination
-Uncontrolled movements or muscle stiffness
-D-penicillamine tablets (related to penicillan)
-Trientine tablets
-zinc
What are haemorrhoids (piles)?
lumps inside and around your anus
common in straining when pooing, pregnancy, long-term constipation, persistent cough, age
bright red blood after you poo
itchy anus
feeling like you still need to poo after going to the toilet
mucus in your underwear or on toilet paper- SLIMY POO
lumps and pain around your anus
increase fibre in diet
warm bath
Witch hazel wipes (Tucks) - local anaesthetic
hydrocortisone cream
What is Barrett’s oesophagus and the treatment?
Columnar lined oesophagus due to acid reflux
caused by GORD/hiatus hernia
stop NSAIDs
start PPI e.g. omeprazole for ONE MONTH and then test for H.pylori if not helpful
start H2 antagonists e.g. famotidine (anti-acid)
What is a normal blood glucose?
4-8
Normal plasma glucose: 4-6
below 4, on the floor
What is the clinical difference between biliary colic, cholecystitis and cholangitis?
biliary colic = ONLY colicky RUQ pain = analgesia + fat free diet
cholecystitis = prolonged RUQ pain and fever
acute cholangitis = RUQ pain, fever and jaundice
Why is urea raised in GI bleeds?
blood is digested to protein
What drugs could you give to type 2 diabetes for treatment and how do you choose which one?
Metformin
gliclazide: blocks potassium, calcium comes in, insulin released
saxagliptin: inhibits DPP-IV
Exenatide: incretin mimetics activates GLP-1, injection, in obese people
Dapagliflozin: Gliflozins, blockes sodium/glucose2 symporter in nephron, increased chance of UTIs, used in cardiac failure
1st: metformin and titrate up slowly each week. If not working try modified release metformin.only add a second drug if HbA1c is >58 (not including dapagliflozin)
2nd: metformin + dapagliflozin (risk of developing cardiovascular disease)
3rd: metformin + gliptin or sulfonylurea (that order) +/- dapagliflozin
What is Hirschbrungs disease?
Poo is sticky and sticks to walls of intestine —> no passage of poo
should be seen when they are born- failure to pass meconium!!
persistent constipation, swollen tummy, failure to pass poo in 48hrs, vomiting green bile
Rectal washouts and bowel irrigation
rectal biopsy + surgery is a must
When is the right time to perform an endoscopy?
between 6-24hrs of them presenting
Glasgow-Blatchford bleeding score:
0-23
0 being very low risk of mortality/complications with the endoscopy
What blood result would make acute pancreatitis stand out instead of it being acute cholecystitis, cholangitis or hepatitis?
acute pancreatitis would have a very high amylase
hepatitis: skewered LFTs
cholangitis: higher billirubin
How is DKA diagnosed and treated?
Hyperglycaemia (>11), ketonaemia (>3 and urine), acidosis (ph low <7.3)
treatment in this order:
-fluids (slowly to prevent cerebral oedema)
-insulin: 0.1 /kg/hour
-potassium
-if diabetic: continue long acting insulin but stop short acting
Hourly check of blood sugar
2hr check of potassium + HCO3
What are the symptoms of the following vitamin deficiencies:
B1-thiamine
B2- riboflavin
B3- niacin
B6- pyridoxine
B12- cobalamin
B1- tiredness, loss of appetite, muscle weakness
B2- fatigue, swollen throat, blurred vision, depression
B3- pellagra (dark, scaly rash to develop on skin areas exposed to sunlight), bright redness of the tongue, constipation/diarrhoea
B6- microcytic anemia, dermatitis with cheilosis (scaling on the lips and cracks at the corners of the mouth) and glossitis (swollen tongue), depression and confusion, and weakened immune function
B12- fatigue, SOB, pale, headaches, palpitations, weight/appetite loss, tinnitus, yellow skin tinge, mouth ulcers, pins and needles
Where is respiratory acidosis/alkalosis and metabolic acidosis/alkalosis seen?
respiratory acidosis = Too little ventilation e.g. COPD and asthma
respiratory alkalosis = Too much ventilation e.g. anxiety attack, brain disorders, chronic liver disease
metabolic acidosis = DKA
metabolic alkalosis = vomiting, diuretics, corticosteroid excess, Cushing’s, Conn’s (too much aldosterone)
What vitamin is given to alcoholics and why?
Vitamin B1- Thiamine
to prevent a type of brain damage called Wernicke encephalopathy- trio of symtpoms:
-confusion
-ataxia (inability to coordinate voluntary movement = liver flap!! If this is present then check ammonia!!)
-eye abnormalities
What is the normal units of alcohol a week for men and women?
14 units
Bottle of wine=10units
Could an alcoholic/heavy drinking present with blood in their vomit, if so, how?
liver damage –> portal hypertension –> varices in oesophagus –> vomiting with blood
They might present being distended abdomen with ascites, pain and jaundice
What is Addison’s disease?
not enough cortisol and aldosterone—> synacthen test
FATIGUE
ABDO PAIN
VOMITING
LOW BP
LOW SODIUM
hyperpigmentation- darkened skin
low mood
loss of appetite and unintentional weight loss
increased thirst
replace hormones + adrenal crisis/”Addisonian crisis” = give hydrocortisone
hydrocortisone (most of it given in morning) and fludrocortisone
What would be the most likely cause of splenic atrophy?
Bleeding—> anaemia—> !!coeliac disease !!
Can you stop taking steroids suddenly?
No, it has to be gradual as it can interfere with the adrenal glands + hormones.
ADRENAL CRISIS
How is acute cholecystitis treated?
antibiotics: cephalosporin (cefruoxime) OR piperacillin/tazobactam (tazocin) AND metronidazole
surgery: laparoscopic cholecystectomy within 1 week of diagnosis
How do gallstones present and how are they treated?
Female, Fertile, Fat, Fair, and Forty
biliary colic pain/cholecystitis/epigastric, right quadrant, right shoulder pain/after fatty foods –> diagnosed by ultrasound
asymptomatic (80% of people are) = no treatment
symptomatic = laparoscopic cholecystectomy
How do you treat alcoholic hepatitis?
prednisolone
calculate Maddrey’s function by using bilirubin and prothrombin time
What is Mirizzi’s syndrome?
a complication of gallstones causing common hepatic duct obstruction
very rare
What does the ‘double-duct’ sign indicate?
dilatation of the common bile duct and pancreatic ducts –> pancreatic cancer
What is the treatment for a Mallory-Weiss tear?
calculate Glasgow Blatchford bleeding score (GBS)
PPI
terlipressin acetate
Stop NSAIDs/aspirin
give abx before endoscopy
How do you test for Cushing’s?
Overnight dexamethasone test
24hr urinary free cortisol
What is the difference anatomically between inguinal and femoral hernias?
femoral: inferior and lateral to pubic tubercle
inguinal: mid-point inguinal canal and direct hernias will reappear when pushed on
What can taking growth hormone make you at risk of developing?
Type 2 Diabetes
How do you treat hyperthyroidism?
carbimazole (ATD therapy) = to treat Grave’s
propranolol = Initial treatment to control symptoms (tremor, anxiety)
radioactive iodine: used in patients who relapse following ATD (anti-thyroid drugs) therapy or are resistant to primary ATD treatment
What is the most common complication of ERCP?
acute pancreatitis
What is cholestasis?
reduced or stopped bile flow
can be caused by COCP or abx e.g. co-amoxiclav or pregnancy WHEREAS hepatitis/hepatocellular would be from paracetamol, sodium valporate etc
itchy but NO rash
Yellowing of the skin and whites of the sclera
Loss of appetite
right upper quadrant pain
What is Rovsing’s sign and what is the treatment?
A positive Rovsing’s sign is characterised by right lower abdominal pain upon palpation of the left side of the lower abdomen –> acute appendicitis
appendicitis can also cause right sided tenderness on PR exam
Treatment:
-Group and save, coag and lactate!!
-laparoscopic appendectomy: an ultrasound is NOT needed before unless it’s a young woman to rule out other causes of pain
-IV abx BEFORE surgery
What is Boerhaave’s syndrome?
Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting. The rupture is usually on the left side.
sudden onset of severe chest pain
vomiting
Subcutaneous emphysema
Diagnosis is CT contrast swallow.
Treatment is with thoracotomy and lavage, if less than 12 hours after onset
surgery delayed beyond 12 hours is best managed by insertion of a T tube to create a controlled fistula between oesophagus and skin.
What is an insulinoma?
tumour deriving mainly from pancreatic Islets of Langerhans cells
hypoglycaemia
rapid weight gain
high insulin
CT pancreas
surgery
What is the difference between a MRCP and an ERCP?
MRCP should be done first unless gallstones have definitely been confirmed
MRCP = MRI
ERCP = endoscopy
What is alcoholic ketoacidosis?
non-diabetic form of ketoacidosis that occurs in people who regularly drink large amounts of alcohol. Often alcoholics will not eat regularly and may vomit food that they do eat, leading to episodes of starvation
It typically presents with a pattern of:
Metabolic acidosis
Elevated anion gap
Elevated serum ketone levels
Normal or low glucose concentration
treatment: infusion of saline & thiamine
What are the causes of pancreatitis?
GET SMASHED
gallstones
ethanol
trauma
steroids
mumps
autoimmune
scorpion sting
hypertriglycerides/hypercalemia
ERCP
drugs
What is Kaolin?
a drug used to treat diarrhoea
If someone has dysphagia of solids and liquids from the start, what are you thinking?
It is achalasia: can give a ‘bird’s beak’ appearance on a barium swallow –> pneumatic (balloon) dilation or Heller surgical procedure
if it was foods to start then eventually affected liquids, think more oesophageal cancer
What is the most common presentation of large bowel obstruction?
constipation BEFORE vomiting
What are the common symptoms for pre-hepatic, hepatic and post-hepatic jaundice?
hepatic = itchy (pruritus), pain/painless (cancer if painless?), fevers, loss of appetite
pre-hepatic = fatigued, dizzy, SOB, tachy
post-hepatic = painless if cancer obstructing, dark urine, pale stools
What size does a gallbladder need to be removed?
10mm = 1cm
What are the complications of thyroid surgery?
hypocalcaemia (cramps/spasms)
injury to recurrent laryngeal nerve
haematomas
What are the causes and lab tests for pre-hepatic, hepatic and post-hepatic jaundice?
pre = low Hb –> haemolysis, sickle cell, Rhesus incompatibility at birth
hepatic uncon = high AST, ALT and GGT –> Crigler-Najjar syndrome, Gilbert’s syndrome, ‘Physiological jaundice of the newborn’
hepatic con = high AST and ALT –> hepatitis, primary biliary cholangitis, Dubin-Johnson disease
post = high AST, ALT, GGT, ALP –> gallstones, cancer, primary biliary cholangitis
low albumin = chronic
long clotting times/factors = acute
How is ulcerative colitis seen on an CT, treated and what are the investigations?
Lead pipe appearance of the colon and pseudopolyps
faecal calprotectin
Flexible sigmoidoscopy is preferred
inducing remission = topical (rectal) aminosalicylate
maintaining remission = topical (rectal) aminosalicylate +/- oral aminosalicylate
severe relapse or 2 or more exacerbations in a year = oral azathioprine
severe flare up = IV hydrocortisone
What is the difference between ischaemiac colitis and mesenteric ischaemia?
Mesenteric ischaemia:
-caused by an embolism resulting in occlusion of an artery which supplies the small bowel
-patients have a history of atrial fibrillation
-severe, sudden onset abdo pain-high** lactate**, soft but tender abdo, abdo pain–> urgent surgery
Ischaemiac colitis:
-pain after a meal intermittent severe pain
-compromised blood flow to the large bowel
-‘thumbprinting’ may be seen on abdominal x-ray due to mucosal oedema/haemorrhage–> supportive management
What are the different types of hiatus hernias?
Sliding = more common, upper stomach moves into the chest area, can cause GORD
paraesophageal = larger portions of the stomach or even other parts of the bowel that are pushed up into the chest, surgery required
What is Zollinger-Ellison syndrome?
Rare condition in which one or more tumors grow in the pancreas or in the upper part of the small intestine. The tumors are called gastrinomas. These gastrinomas produce large amounts of the hormone gastrin.
Gastrin causes the stomach to produce too much acid, which leads to peptic ulcers
High serum gastrin levels and a reduced gastric pH
diarrhoea, belly pain, acid reflux–> long term complication of GORD
How do you tell the difference between a duodenal and a gastric ulcer?
gastric = worse with eating
duodenal = better with eating
What is bile-acid malabsorption and how do you treat it?
watery green diarrhoea post cholecystectomy
idiopathic, or seen in patient’s with Crohn’s disease
treatment = cholestyramine
What is thyrotoxicosis?
commonly caused by Grave’s disease and can be seen in pregnancy
TSH down, T4 and T3 up
give carbimazole unless:
first trimester of pregnancy give Propylthiouracil - second trimester, the woman should be switched back to carbimazole
How do you treat hypOcalcaemia and what are the symtpoms? What does it look like on an ECG?
10–20 mL, calcium gluconate injection 10%
paresthesia, muscle spasms, cramps, tetany, circumoral numbness, and seizures
Prolonged QT interval
What is primary hyperparathyroidism?
mostly caused by solitary adenoma
-bones: pain/fractures
-stones: polyuria, polydipsia, renal stones
-groans: constipation, peptic ulcers, pancreatitis
-moans: depression
Bloods: raised calcium, low phosphate, raised or normal PTH
X-ray: pepperpot skull
–> total parathyroidectomy and if not suitable for surgery then give calcimimetics
Learn the different quadrants of the abdomen and the differential diagnosis for each of them .
