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Final year Medicine > Gastro > Flashcards

Gastro Flashcards

1
Q

Ix of Crohns

A

Bloods: FBC, U+E, LFT, CRP, ferritin, B12, folate, vitamin D

Stool: MC +S, c diff
Faecal calprotectin

Endoscopy - Colonoscopy and histology

Imaging -Small bowel enema, MRI, capsule
Pelvic MRI - perianal disease
CTAP - abscesses, fistulae,obstruction, AXR - dilation, obstruction

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2
Q

Mx crohns - inducing remission

A
  1. IV hydrocortisone 100mg oral,topical/iv
  2. 5 ASA
    • Azathioprine, Mercaptopurine, (check TPMT) methotrexate
  4. Infliximab, adalimumab, ustekinumab, vedolizumab.
  5. Surgery
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3
Q

Maintaining remission in crohns

A
  1. Stop smoking
  2. Azathioprine/mercaptopurine/
  3. methotrexate,
  4. 5 ASA (ifhadsurgery)
  5. Surgery - treat disease or complications
    - Ileocaecal resection
    - strictures -balloon dilatation
    - fistulae, perforation.
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4
Q

IX UC

A

Bloods: FBC, CRP, LFT, ferritin, vit D, folate, b12.

Stool: MC+S, c diff, faecal calprotectin

Endoscopy: colonoscopy (flexi sigmoidoscopy + biopsy if acute) and histology

Imaging - CT/MRI/AXR USS

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5
Q

MX UC inducing remission.

A

based on Severity (Mayo score) /extent.(endoscopy)

Mild/moderate: 
1. Topical 5ASA
4weeks not worked
2. Add oral 5ASA
3. switch/add topical steroid

Severe disease (but systemically well)

  1. Oral steroids 2 weeks
  2. Infliximab.

Surgery - incomplete response to medical treatment.
Dysplasia on surveillance colonoscopy.
Subtotal colectomy with end ileostomy.(preserve rectum)
->then ileoanal anastamosis/proctectomy + permanent ileostomy.

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6
Q

Assessing severity of UC

A

Mayo score
Mild: 1/2 more stools than normal, streaks of bood, erythema/mild friability.

Moderate: 3-4 more than normal, obvious blood most of the time, marked erythema, loss of vascular pattern, erosions.

Severe: 5/day more than normal, blood without stool, spontaneous bleeding/ulceration.

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7
Q

Maintenance therapy UC

A

Proctosigmoiditis: Topical ASA +/- oral ASA
Left sided UC - Oral ASA
consider Azathioprine/mercaptopurine if > 2 flares/year.

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8
Q

Assessing an acute flare of IBD

A

Truelove and Witt criteria

Mild: small amounts of blood in stool, bowel movements <4,
Moderate: , obvious blood in stool most of time, 4-6 stools per day,
Severe: Hb <105, Blood without stool, HR>90, BO >6x aday, CRP>30, Fever >37.8

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9
Q

Acute flare of IBD

Initial ix

A

FBC, CRP, U+E, LFTs,
Hep B/C, HIV, VZV, TB screen.
Stool MC+S, Cdiff,
Imaging - AXR, CT

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10
Q

Mx acute flare of IBD

A

A-E
1. NBM, iV fluids
Iv Hydrocortisone 100mg
LMWH

no improvement in 72h

2.IV infliximab (crohns)
Iv ciclosporin - not if HTN, Renal impairment (uc)

  1. Surgery. (colectomy)
    - failure of medical tx.
    - toxic dilation
    - haemorrhage
    - imminent perforation
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11
Q

Coeliac symptoms

A

Weight loss
variable bowel habit
oligomenorrhea

ddx: hyperthyroid, crohns.

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12
Q

Coeliac ix

A

Bloods:
low Hb,low iron, folate deficiency, b12
IgA tTG >7 iU/ml.

Referral for gastroscopy and duodenal biopsy. (before change diet)

Referral to dieticians for gluten free advice.

Referral for a bone density scan. (osteopenia)

First degree relative screening as 10% relatives will have/develop.

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13
Q

Coeiliac not improving on gluten free diet?

A

Repeat IgA tTG
Re refer to dieticians for dietary advice.

if still neg, fecal calprotectin - IBD screen, fecal elastase for pancreatic exocrine insufficiency.

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14
Q

Iron deficiency anaemia ix

A

Colonoscopy
gastroscopy
Coeliac serology

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15
Q

Duodenal ulcer mx

A

a proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole)

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16
Q

Gastric ulcer mx

A

Ix: biopsy + CLO test.
Urea breath test
HP stool antigen

PPI, amoxicillin, clari/metronidazole

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17
Q

Blatchford score

A 
Urea,
Hb
Systolic BP
sex
HR
melaena
recent syncope
hepatic disease
cardiac failure.
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18
Q

initial Mx Upper GI bleed (unstable)

A

ABCDE
2222/major haemorrhage if drowsy, airway/blood loss +++.
IV access, urinary catheter
Fluids STAT
Cross match 6 units, transfuse 2 units o neg.
optimise clotting ?plts, vit k, FFP.

Monitor vital signs every 15 mins, put on cardiac monitor.
Monitor fluid balance.

Blatchford score
NBM

Call surgeons/gastro requires urgent endoscopy once stable.
Then IV omeprazole 80mg STAT

If variceal - endoscopy in 4h -banding/sclerotherapy.
Terlipressin 2mg IV QDS
Tazocin IV
Sengstaken-Blakemore tube if life threatening.

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19
Q

Post OGD tx (heater probe and clip applied) mx

A 
IV PPI 72h, 8mg/h
Rpt Hb and clotting 
can eat next day
eradicate H.pylori if CLO+ve or not done. 
Home after 72h if well

6weeks PPI, then stop
lifestyle advice
avoid NSAIDs.

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20
Q

Variceal management

A

ABC
Fluids
cross match 4 units transfuse 2 immediately
optimise clotting, vit K 10mg Iv, FFP, asperwt PT
Terlipressin 2mg
OGd within 4h if active bleeding.

Not stopped -> sengstaken blakemore tube. , further OGD, TIPPS/ surgery.

Then terlipressin for 48-72h
Rpt hb and clotting and correct
IV abx (augmenting, ciprofloxacin)
consider lactulose if encephalopathic

Non cardioselective beta blockers are 1st line for prevention of variceal bleeding.
if not poss, regular endoscopy and variceal band ligation.

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21
Q

Blood volume loss Classes

A

Class1: 0-750ml
0-15%, HR<100, normal Bp/CRt/Urine output >30
RR normal. Restless.

Class 2: 750-1500ml
15-30% lost. increased DBP. CRT >2s. 20-30ml/h UO.
increased RR
pale extremities.
anxious/aggressive. 
Class 3: 1500 -2000ml
30-40%
HR>120
reduced BP
CRT>2
UO 5-15 ml/h
RR>20
pale, confused, agresive
Class 4: >2000
>40% lost.
Very low BP
undetectable CRT
anuric
RR>20
pale, clammy, cold. confused, lethargic, unconscious.
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22
Q

melaena ix:

A 
ABCDE
IV fluids
Further hx.
DRE
FBC, U+E, clotting. 
erect CXR

hb<70
cross matched if stable.
tranfuse 2 units immediately

OGD.
if not show bleeding site + blood in stomach site -> mesenteric angiography.

Melaena but not blood on ogd -> Colonoscopy.

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23
Q

Ix haematemesis

A

FBC, U+E, LFTs clotting, cross match, blood glucose (marker of liver synthetic function)

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24
Q

Autoimmune hepatitis ix

A

Sx: Jaundice, hepatomegaly,
fever, amenorrheoa

FBC,
LFTs
viral serology
total protein, serum globulins
ANA 
anti SMA
ANti LKMA
liver biopsy - inflam plasma cells, spilling over portal tract -> hepatocytes. submassive piecemeal necrosis
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25
Q

Mx AI hepatitis

A

High dose prednisolone 30mg
then taper.
then add azathioprine
(check TPMT before) - can continue in pregnancy.

treat for 2 years after blood tests normalised.
Biopsy before stopping therapy.

Liver transplant
Increased risk of HCC. regular screening.

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26
Q

Drug for food poisoning

A

Ciprofloxacin - good against salmonellae/c.jej.

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27
Q

Quinolon cautions

A 
Pts >60yo -> tendon damge.
Aortic aneurysm
Epilepsy - lower seizure threshold. 
Children - skeletal deformities. 
Pregnancy.
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28
Q

C.Diff mx

A

Admit to hosp
Request 3x stool culture for CDT
Start oral metronidazole.

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29
Q

Contraindications for loperamide

A 
Bloody diarrhoea
IBD
Bacterial enterocolitis (e.coli)
avoid for C.diff.
High temperature.
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30
Q

Metronidazole cautions

A

Alcohol - Disulfiram like effect

flushing, abdo pain, hypotension. up to 3 days after tx.

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31
Q

Toxic megacolon

A

dilation of colon >10cm

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32
Q

Ix Progressive dysphagia

A

OGD + biopsy

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33
Q

Mx benign peptic stricture

A

Balloon dilatation - complication - perforation (chest pain, SOB, mediastinitis, palpable surgical emphysema )
Tx of underlying GORD with PPIs.
Refractory - Oesophageal stent

34
Q

post balloon dilatation perforation ix

A

CT scan oral contrast.

35
Q

Extra gi manifestations UC related to activity

A 
Erythema nodosum
apthous ulcers
episcleritis
anterior uveitis
acute arthropathy

Not related to activity

  • sacroileitis,ank spond -> HLA b27, Lower back and SI XRays.
  • PSC
36
Q

Child Pugh score cirrhosis mortality

A

Bilirubin +1 <34.2umol/L, +2 34.2-51.3, +3 >51.3
Albumin +1 >35g/L, +2 28-35, +3 <28

INR +1 <1.7, 1.7-2.2 +2, >2.2 +3
ascites absent, slight, moderate +3
encephalopathy. none, grade 1/2, grade 3/4

> 8 = high risk of variceal bleed.

37
Q

RFs variceal bleed

A

High portal pressures (>12mmhg)
Large varices
abnormal variceal wall at endoscopy (e.g. haemocystic spots)
High child pugh score

38
Q

Cirrhosis signs

A 
Clubbing
Parotid enlargement
Dupuytrens contracture
gynaecomastia
testicular atrophy
HCC - USS, CT, afp
39
Q

Liver biopsy complications

A

Abdo pain/shoulder tip pain
Bleeding. (risk if severe cirrhosis, clotting disorder, extensive ascities, uncooperative)
Bowel perf, biliary peritonitis, renal laceration.
Pneumothorax.

40
Q

Tx Alcohol withdrawal

A
  1. IV pabrinex slow. >10mins for 5 days.
  2. 4 hourly observations
  3. Glasgow modified alcohol withdrawal score/CIWA-Ar score.
  4. Oral benzodiazepine based on score.
  5. Arrange Gastro review.
41
Q

serum ascites albumin gradiet

A

> 1.1g/dL = portal hypertension. could be cirrhosis, alcoholic hepatitis, portal venous thrombosis, HF, massive hepatic mets.

low SAAG <1.1g/dL
=peritoneal cause.
malignancy, infections (TB), pancreatitis, nephrotic syndrome, serositis including lymphoma.

42
Q

what should you send ascitic tap off for?

A 
Culture and sensitivity
LDH
Cytology
total Protein
albumin conc
Cell count and differential
GLucose
43
Q

Ix pancreatic cancer

A

CT CAP

44
Q

Mx pancreatic cancer

A

> 3cm , liver mets.

Percutaneous, endoscopic biliary stent insertion, brush cytology.

45
Q

Risk factors for pancreatic cancer

A 
Smoking
alcohol
diabetes
60% in head, 15% tail, 25% body. 
median survival <6months. 
Can present with acute pancreatitis 
Ca19-9 is non specific.
46
Q

PBC presentation

A 
Lethargy
Pruritus
AST ALP
GGT
middle aged woman
Jaundice (late)
xanthelasma
Spider naevi
Splenomegaly

progressive inflammation and destruction of interlobular bile ducts, fibrosis, cholestasis -> cirrhosis.

47
Q

PBC ix

A

USS upper abdomen - exlude biliary dilatation, assess liver parenchyma, +/- biopsy.

viral hep serology

ANA, Anti mitonchondial Ab

serum lipids

Blood clotting profile

48
Q

Contraindication for liver biopsy

A 
Platelets <100
INR >1.3
hb <100
Acute confused.
Extensive ascites - drain them first.
49
Q

complications of PBC

A 
Malabsorption 
Osteoporosis
HCC
Liver failure
Haematemesis
Hypothyroidism
50
Q

Mx PBC

A

Ursodeoxycholic acid - prevents progression.
Cholestyramine - alleviates pruritus. (give 2h apart from UDCA)
Fat soluble vitamin prophylaxis.
Liver transplant.

51
Q

Alcoholic hepatitis ix

A

GGT elevated

AST:ALT >2

52
Q

Mx alcoholic hepatitis

A

Prednisolone.
(using maddreys discriminant function)

Pentoxyphylline

53
Q

Ascites mx

A 
Reduce sodium intake
Fluid restrict if na <125
spironolactone
drainage - if tense
Ciprofloxacin if protein <15
TIPS
54
Q

Mx hepatic encephalopathy

A

Tx cause (infection, gi vleed, Post TIPS) constipation, drugs, hypokalaemia, renal failure, protein.

Lactulose - excrete ammonia.
rifaximin
embolise shunts
liver transplant

55
Q 
64M 
Intermittent epigastric pain - boring to back. 
diarrhoea (steatorrhoea)
recent diabetes
wt loss
prev Etoh/smoking hx.
A

Chronic pancreatitis

56
Q

Ix Chronic pancreatitis

A 
Amylase
LFTs
Serum albumin/corrected ca
FBC
AXR - calcification in pancreatic area.
CT - calcification, atrophy, duct dilatation. pancreatic pseudocysts. 
MRCP
57
Q

Complications of chronic pancreatitis

A 
Carcinoma 2-3%
Intractable pain - opiate addiction
Pseudocyst 
Malabsorption
Diabetes
58
Q

pt comes in after outbreak of food poisoning in hotel - what actions?

A

Ensure side room gloves aprons

inform local health protection consultant even if out of hours.

59
Q

drug induced liver damage ix

A

differential WCC - e.g. eosinophils = allergic response to drug

USS - exclude Causes of intra/extrahepatic obstruction

Serology for hepatitis

60
Q

Hepatotoxic drugs

A 
statins
macrolides
paracetamol
roziglitazone
flucloxacillin
61
Q

Haemochromatosis features

A 
Hfe gene on chr 6
increased fe absorption 
 MEALS
Myocardial - dilated cardiomyopathy
arrythmias

Endocrine - DM, pituitary hypogonadism, amenorrheoa, infertility
Parathyroid- hypocalcemia, osteoporosis

Arthritis-2nd and 3rd MCPs, joints, knees, shoulders

Liver - CLD, cirrhosis, HCC
hepatomegaly

Skin - slate grey

62
Q

Ix Haemochromatosis

A 
LFTs
Ferritin increased
FE increased
TIBC decreased
glucose
blood genotype
XR - chondrocalcinosis
ECG, Echom 
Liver biopsy - pearls stain
MRI - loading
63
Q

Mx Haemochromatosis

A

Regular venesection
Analgeisa
Refer diabetologist
screen 1st relatives.

64
Q

Hepatorenal syndrome tx

A

IV albumin
Terlipressin
haemodialysis
liver transplant

65
Q

Mx Liver cirrhosis

A 
Nutrition
etoh abstinence
Cholestyramine - pruritus
Screening 6m for HCC AFP/USS
endoscopy

Treat cause - HCV - interferon a, PBC UDCA, wilsons - penicillamine

tx decompensation

66
Q

Tx decompensated liver cirrhosis

A

Ascites - fluid and salt restrict, spironolactone, frusemide, tap, daily wts, tipps HAS.

coagulopathy - vit K, FFP, plts, blood

Encephalopathy - avoid sedatives, lactulose + enemas
rifaximin

sepsis SBP - tazocin

Hepatorenal syndrome - iV albumin, terlipressin

67
Q

Wilsons features

A

cu transport ATPase mutation = hepatocyte cant put cu into cerulopasmin
cu sequestered into tissues

CLANKAH

Cornea - kayser fleischer rings

Liver disease- acute hep - cirrhosis

Arthritis

Neuro - parkinsonism, psychosis, ataxia

kidney - Fanconis syndrome - osteomalacia

abortions

Haemolytic anaemia

68
Q

Ix wilsons

A

24h urinary cu

caerulopasmin reduced, copper reducedd

69
Q

Mx wilsons

A

diet- avoid chocolate, liver, nuts

Penicillamine - lifelong. SE: nausea, rash, leukopenia, anaemia, plats,
Monitor FBC, cu extretion
Liver

70
Q

PBC

A 
F>M
50s
intrahepatic bile duct destruction, granulomas
ALP raised
Pruritus, fatigue
Pigmentation of face
osteoporosis, osteomalacia (vit Ddef)
Cirrhosis, coagulopathy
Cholesterol, xanthelasma
Steatorrhoea
Ix: LFTs, ALP, GGT, late BR, PT, albumin
abs - AMA 
IgM
cholesterol
TSH
US
Liver biopsy
tx: cholestyrmaine
diarrhoea - codeine
bisphosphonates
ADEK vits
UDCA - 
Liver transplant

jaundice -> survival <2y

71
Q

PSC

A

intra and extrahepatic duct fibrosis, strictures, M>F

jaundice, pruritus fatigeu
complications: cholangiocarcinoma, CRC, bacterial cholangitis
ASw UC
ALP -> BR
 pANCA
ANA, SMA
MRCP - beaded ducts
biopsy

mx - cholestyramine, codeine, ADEK vits, UCDA, abx, endoscopic stenting,
Transplant

72
Q

Carcinoid tumours

A

neuroendocrine -> 5HT, etc.
Sites: appendix, ileium, colorectum, stomach,

-appendicitis, intussusseption, abdo pain.

FIVE HT
Flushing
diarrhoea
valve fibrosis
wheeze
hepatic
pellagra

Ix: Increased urine 5 hdroxyindoleacetic acid, increased plasma chromogranin A
CT
tx: octreotide, loperamide
resectjkn

73
Q

HCC features

A 
Tender hepatomegaly
Jaundice
weight loss
ascites
cachexia
74
Q

HCC ix

A 
AFP
glucose
clotting
Calcium/albumin
CXR
USS
Hepatitis serology
CT
75
Q

HCC rfs

A

Male
Alcoho
HBV/HCV
Haemochromatosis

76
Q

Mode of transmission of hepatitis

A 
Hep A feaco oral
Hep B Blood borne, vertical, std
Hep C blood borne, vertical, std
Hep D co infection w hep b
hep E faeco oral
77
Q

Rate of transmission of hep / hiv from needlesticks

A

hep B 1in3
hep c 1in 30
hiv 1 in 300

78
Q

complications of hepc

A

Cirrhosis
HCC
mesangiocapillary glomerulonephritis - nephritic syndrome

79
Q

Hep C mx

A

Genotype and viral load pre tx
viral RNA level monitor response to tx
DAA regimen

80
Q

Glasgow criteria for severity of pancreatitis

A 
WCC >15
Glucose >10
LDH >600
AST >200
urea >15
Ca <2
Albumin <32
pO2 <8

Final year Medicine (18 decks)

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