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Core Conditions > Gastrointestinal > Flashcards

Gastrointestinal Flashcards

1
Q

Describe the differences between ulcerative colitis and Crohn’s disease.

A

Ulcerative colitis is diffuse inflammation while Crohn’s disease is patchy inflammation.
UC is superficial (mucosal); CD is transmural
UC affects rectum and extends proximally; CD may affect any part of the GIT

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2
Q

What are some histological features of ulcerative colitis?

A
  • mucosal/submucosal inflammation
  • lymphocytic infiltrate
  • NO granulomas
  • goblet cell depletion
  • crypt distortion
  • cryptitis
  • crypt abscesses
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3
Q

What are some histological features of Crohn’s disease?

A
  • transmural inflammation
  • lymphocyte + macrophage infiltrate
  • granulomas in 50% cases *** if you see granulomas, then CD, not UC
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4
Q

What is the possible aetiology of IBD?

A
  1. Abnormal immune response
    - inappropriate activation of the immune system
    - failure to downregulate immune system
  2. Environmental triggers
    - diet, medications, psychological stress
    - smoking protects against UC
    - appendicetomy protects against UC
  3. Genetics
    - possible susceptibility genes (NOD2/CARD15 for Crohn’s)
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5
Q

How may IBD present in patient?

A 
Note: clinical presentation depends on location, extent and severity.
GI symptoms:
- abdominal cramps
- diarrhoea
- rectal bleeding
- urgency
- tenesmus
Systemic symptoms: 
- weight loss
- malaise
- anorexia
- fever 
- arthralgia
Perianal involvement (20-25%)
- abscesses
- fistulae
- fissures
Extraintestinal manifestations
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6
Q

What are the extraintestinal manifestations of IBD?

A 
Associated with active GI disease:
- oral ulcers
- erythema nodosum
- large joint arthritis
- episcleritis
Independent of GI disease:
- Primary Sclerosing Cholangitis (PSC)
- ankylosing spondylitis
- uveitis
- pyoderma gangrenosum
- kidney stones 
- gallstones
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7
Q

How do you differentiate IBD from IBS?

A 
History:
- systemic symptoms, e.g. weight loss
- nocturnal symptoms
- continuous (rather than intermittent) symptoms
- extraintestinal manifestations
- FHx of IBD
Examination:
- PR bleeding
- extraintestinal manifestations
- perianal involvement
Investigations:
- anaemia
- iron or other nutrient deficiencies
- raised inflammatory markers (CRP, ESR)
- elevated faecal calprotectin
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8
Q

How do we diagnose IBD?

A

Colonoscopy confirms diagnosis

  • it also determines the extent and severity of the disease
  • can also provide therapeutic dilatation of strictures
  • also surveillance for CRC
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9
Q

What are the distinguishing features of Crohn’s disease?

A
  1. Granulomas
  2. Asymmetrical involvement
  3. Focal lesions
  4. Strictures
  5. Skip lesions
  6. Fistulisation
  7. Small bowel involvement
  8. Rectal sparing
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10
Q

What are the goals of management for IBD?

A 
Short term goal = induce remission
- relieve symptoms and improve QOL
Long term goal = maintain remission
- control inflammation (w/o steroids)
- prevent flares
- prevent complications
- reduce need for hospitalisation or surgery
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11
Q

What are the complications of ulcerative colitis?

A 
Haemorrage
Growth retardation
Osteoporosis
Thromboembolism
Colorectal cancer
*Toxic megacolon
(*unique to UC)
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12
Q

What are the complications of Crohn’s disease?

A 
Haemorrage
Growth retardation
Osteoporosis
Thromboembolism
Colorectal cancer
*Strictures
*Fistulae
*Perforation
*Abscess
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13
Q

What are the key functions of the liver?

A
  1. Synthesis of clotting factors
  2. Glucose homeostasis
  3. Albumin synthesis
  4. Conjugation and clearance of bilirubin
  5. NH3 metabolism
  6. Drug metabolism
  7. Immune
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14
Q

What is the definition of acute liver failure?

A

Rapid deterioration of liver function (within 30 days), specifically characterised by encephalopathy due to excess ammonia.

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15
Q

What are the causes of chronic liver disease?

A

The Big 3:

  • HBV
  • HCV
  • Alcohol

Autoimmune 3

  • Autoimmune hepatitis (AIH)
  • Primary biliary cirrhosis (PBC)
  • Primary slcerosing cholangitis (PSC)

Metabolic 3:

  • Haemachromatosis
  • Wilson’s disease
  • Fatty liver disease (NASH)

Other 3:

  • Budd-Chiari (hepatic vein thrombosis)
  • Chronic biliary obstruction
  • alpha 1-antitrypsin deficiency
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16
Q

What is hepatitis and what are its causes?

A 
Hepatitis is inflammation of the liver.
Causes include:
- viruses
- alcohol
- drug-induced
- idiopathic
17
Q

How may someone with chronic liver disease present?

A
  1. Ascites, oedema (due to hypoalbuminaemia)
  2. Bleeding, bruising (due to reduced clotting factors)
  3. Jaundice (due to hyperbilirubinaemia)
  4. Encephalopathy (due to ammonia)
  5. Varcies +/- bleeding, ascites (due to portal HTN)
18
Q

What are some of the risk factors for chronic liver disease?

A 
These are risk factors for the possible causes of CLD:
Alcoholism (EtOH)
IVDU (Hep B or C)
Ethnic background (Hep B)
Obesity or T2DM (NASH)
Middle-aged women (autoimmune causes)
Ulcerative colitis (PSC)
19
Q

What are the three main things we are looking for on examination of a patient with chronic liver disease?

A
  1. Stigmata of chronic liver disease
  2. Signs of an underlying pathology
  3. Signs of decompensation
20
Q

What are some signs you may find on examination of a patient with chronic liver disease?

A 
Hands/arms
- clubbing (arterial hypoxaemia)
- leuconychia (hypoalbuminaemia)
- palmar erythema (oestrogen)
- Duputren's contracture (alcoholism)
- metabolic flap (ammonia)
- bruising
Face
- jaundice
- parotidomegaly (alcoholism)
Chest
- spider naevi (oestrogen, pathognomonic of cirrhosis)
- gynaecomastia (oestrogen)
- jaundice
Abdomen
- ascites
21
Q

What are the signs of decompensation in chronic liver disease?

A

These are signs that the liver is no longer able to perform its key functions:

  • ascites
  • hepatic encephalopathy
  • variceal bleeding
  • hepatorenal syndrome
  • bacterial peritonitis
22
Q

What investigations should you order for chronic liver disease?

A

Remember BRO
Bloods:
- FBE looking for thrombocytopaenia, neutrophilia
- UEC looking for indication of hepatorenal syndrome
- LFT looking for hypoalbuminaemia, hyperbilirubinaemia
- INR looking for elevation due to decreased clotting factors
- CRP, ESR looking for inflammation
Other blood tests for underlying cause:
- ETOH
- HBV, HCV serology
- ANA/AMA, ANCA for autoimmune causes
- iron studies, copper caeruloplasmin for metabolic causes

Radiology:

  • abdominal ultrasound looking for cirrhosis (small liver, coarsened, nodules), portal HTN (enlarged spleen, ascites), HCC (mass in liver)
  • AXR

Other:

  • liver biopsy to grade and stage cirrhosis
  • FibroScan
  • gastroscopy for complications e.g. varices
23
Q

What is the management of chronic liver disease?

A
  1. Treat the cause
    - alcohol, viral, metabolic, autoimmune, etc.
  2. Manage and prevent complications
  3. Consider liver transplant
24
Q

What are the complications of chronic liver disease?

A 
Hepatorenal syndrome: renal failure due to CLD
Hepatocellular carcinoma (HCC)
Metabolic failure
Osteoporosis
Malnutrition
25
Q

What are the causes of acute pancreatitis?

A 
Remember I GET SMASHED:
Idiopathic
Gallstones
EtOH
Trauma
Steroids
Mumps
Autoimmune
Scorpion stings or spider bites
Hyperlipidaemia/calcaemia/parathyroidism (metabolic causes)
ERCP
Drugs
26
Q

What are the causes of jaundice?

A 
Post-hepatic causes (most common)
- gallstones
- pancreatic cancer
- cholangiocarcinoma
- PSC
- pancreatitis
- metastatic malignancy > enlarged LN
Hepatic causes:
- viral hepatitis
- Gilbert's
- cirrhosis
- liver failure
Pre-hepatic
- sickle cell anaemia
- malaria 
- DIC
- major trauma
27
Q

What questions do you ask when taking a history of a patient with jaundice?

A

Associated symptoms:

  • pain
  • pale stools
  • dark urine
  • pruritus
  • fever
  • weight loss, anorexia, night sweats, fatigue (malignancy)
  • vomiting, nausea, distension (gastric outlet obstruction)

Risk factors:

  • alcohol
  • drugs
  • travel
  • IVDU
  • tattoos
  • medication
  • vaccinations
  • sexual history
  • transfusions

PMHx:

  • liver disease
  • surgery Hx
  • IBD (PSC)
28
Q

What signs are you looking for on examination of a patient presenting with jaundice?

A

General inspection:

  • jaundice if bilirubin > 2x normal
  • scleral icterus
  • scratch marks from pruritis
  • cachexia (malignancy)
  • stigmata of CLD

Vital signs:
- febrile (infection)

Abdominal exam:

  • ascites
  • RUQ tenderness
  • hepatomegaly
  • pancreatic mass
  • palpable gallbladder
29
Q

What is Courvoisier’s Law?

A

Courvoisier’s law states that in the presence of a palpably enlarged gallbladder which is nontender and accompanied with mild painless jaundice, the cause is unlikely to be gallstones (rather carcinoma of the pancreas or the lower biliary tree is more likely).

30
Q

What is Murphy’s sign?

A

A positive Murphy’s sign is seen in acute cholecystitis. It is elicited by firmly placing a hand at the costal margin in the right upper abdominal quadrant and asking the patient to breathe deeply.

31
Q

What investigations would you order for a patient with jaundice?

A

Bloods:

  • LFTs, bilirubin
  • FBE for anaemia
  • blood films for haemolysis
  • INR for hepatic synthetic function
  • electrolytes
  • tumour markers CA19.9

Imaging:

  • US for gallstones
  • constrast CT
  • CT cholangiography
  • MRI/MRCP
  • ERCP

Others (depending on LFTs)

  • Hep serology
  • autoimmune serology
  • liver biopsy
32
Q

What is hepatorenal syndrome?

A

Hepatorenal syndrome is the development of renal failure in patients with severe liver disease (acute or chronic) in the absence of any other identifiable cause of renal pathology.

33
Q

What are the four phases of Hepatitis B infection?

A
  1. Immune tolerance - minimal inflammation, if any (replicative phase)
  2. Immune clearance - immune system starts to attack liver cells that express the virus, causes scar tissue
  3. Immune control - viral levels low, damage to liver is low
  4. Immune escape - virus escape immune system, becomes active again

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