Gastro 3 Flashcards

Question

adverse effects of PPI?

Answer 1

hyponatraemia, hypomagnasaemia osteoporosis → increased risk of fractures microscopic colitis increased risk of C. difficile infections

Answer 2

A liver disease occurring in around 1% of pregnancies, typically in the third trimester.

Answer 3

* Pruritus, often in the palms and soles * No rash (skin changes may be present due to scratching) * Raised bilirubin

Answer 4

* Ursodeoxycholic acid for symptomatic relief * Weekly liver function tests * Induction at 37 weeks

Answer 5

Increased rate of stillbirth.

Answer 6

No, it is not generally associated with increased maternal morbidity.

Answer 7

A rare complication that may occur in the third trimester or immediately after delivery.

Answer 8

* Abdominal pain * Nausea & vomiting * Headache * Jaundice * Hypoglycaemia * Severe disease may result in pre-eclampsia

Answer 9

ALT is typically elevated, e.g., 500 u/l.

Answer 10

Support care and delivery once stabilized.

Answer 11

Gilbert's and Dubin-Johnson syndrome.

Answer 12

Haemolysis, Elevated Liver enzymes, Low Platelets.

Answer 13

Whipple's disease is a rare multi-system disorder caused by Tropheryma whippelii infection. It is more common in those who are HLA-B27 positive and in middle-aged men.

Answer 14

malabsorption: diarrhoea, weight loss large-joint arthralgia lymphadenopathy skin: hyperpigmentation and photosensitivity pleurisy, pericarditis neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus

Answer 15

jejunal biopsy shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules

Answer 16

guidelines vary: oral co-trimoxazole for a year is thought to have the lowest relapse rate, sometimes preceded by a course of IV penicillin

Answer 17

Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles. Although the polyps themselves don't have malignant potential, around 50% of patients will have died from another gastrointestinal tract cancer by the age of 60 years.

Answer 18

autosomal dominant responsible gene encodes serine threonine kinase LKB1 or STK11

Answer 19

hamartomatous polyps in the gastronintestinal tract (mainly small bowel) small bowel obstruction is a common presenting complaint, often due to intussusception gastrointestinal bleeding pigmented lesions on lips, oral mucosa, face, palms and soles

Answer 20

This condition is characterised by the presence of multiple white plaques or pseudomembranes on the gastrointestinal mucosa, typically as a result of overgrowth of the bacterium Clostridium difficile following antibiotic use.

Answer 21

The majority of adenocarcinomas are located near the gastroesophageal junction whereas squamous cell tumours are most commonly found in the upper two-thirds of the oesophagus.

Answer 22

dysphagia: the most common presenting symptom anorexia and weight loss vomiting other possible features include: odynophagia, hoarseness, melaena, cough

Answer 23

Upper GI endoscopy with biopsy is used for diagnosis Endoscopic ultrasound is the preferred method for locoregional staging CT scanning of the chest, abdomen and pelvis is used for initial staging FDG-PET CT may be used for detecting occult metastases if metastases are not seen on the initial staging CT scans. Laparoscopy is sometimes performed to detect occult peritoneal disease

Answer 24

The hepatic vein is cannulated percutaneously via the internal jugular vein, using a needle under radiological guidance. A connection is created and a stent is inserted through the liver from the hepatic to the portal vein, thereby reducing portal pressure and reducing the risk of a bleed. Encephalopathy is found in up to 25% of cases as blood normally detoxified in the liver, now bypasses this stage and toxins are delivered in greater quantity to the cerebral circulation.

Answer 25

usually asymptomatic hepatomegaly ALT is typically greater than AST increased echogenicity on ultrasound

Answer 26

Helicobacter pylori has 2 main mechanisms to survice in the acidic gastric environment: chemotaxis away from low pH areas, using its flagella to burrow into the mucous lining to reach the epithelial cells underneath secretes urease → urea converted to NH3 → alkalinization of acidic environment → increased bacterial survival pathogenesis mechanism: Helicobacter pylori releases bacterial cytotoxins (e.g. CagA toxin) → disruption of gastric mucosa

Answer 27

peptic ulcer disease 95% of duodenal ulcers 75% of gastric ulcers gastric cancer B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of patients) atrophic gastritis ## Footnote The role of H pylori in Gastro-oesophageal reflux disease (GORD) is unclear - there is currently no role in GORD for the eradication of H pylori

Answer 28

eradication may be achieved with a 7-day course of a proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole) if penicillin-allergic: a proton pump inhibitor + metronidazole + clarithromycin

Answer 29

Ig**M** anti-**M**itochondrial antibodies, **M**2 subtype **M**iddle aged females

Answer 30

tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE endomyseal antibody (IgA) needed to look for selective IgA deficiency, which would give a false negative coeliac result anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE anti-casein antibodies are also found in some patients

Answer 31

the 'gold standard' for diagnosis - this should be performed in all patients with suspected coeliac disease to confirm or exclude the diagnosis traditionally done in the duodenum but jejunal biopsies are also sometimes performed findings supportive of coeliac disease: villous atrophy crypt hyperplasia increase in intraepithelial lymphocytes lamina propria infiltration with lymphocytes

Answer 32

many side-effects are due to the sulphapyridine moiety: rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis other side-effects are common to 5-ASA drugs (see mesalazine)

Answer 33

ulphapyridine side-effects seen in patients taking sulphasalazine are avoided mesalazine is still however associated with side-effects such as GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis ## Footnote *pancreatitis is 7 times more common in patients taking mesalazine than sulfasalazine

Answer 34

Hepatocellular carcinoma hepatitis B most common cause worldwide hepatitis C most common cause in Europe

Answer 35

drainage (typically percutaneous) and antibiotics amoxicillin + ciprofloxacin + metronidazole if penicillin allergic: ciprofloxacin + clindamycin

Answer 36

the only recommended test for H. pylori post-eradication therapy, is urea breath test. The others are either too invasive, remain positive, or are not sensitive and specific enough.

Answer 37

age > 55 years hypocalcaemia hyperglycaemia hypoxia neutrophilia elevated LDH and AST

Answer 38

Triad of: dysphagia (secondary to oesophageal webs) glossitis iron-deficiency anaemia Treatment includes iron supplementation and dilation of the webs

Answer 39

We can split the causes of increased ferritin levels into 2 distinct categories The best test to see whether iron overload is present is transferrin saturation. Typically, normal values of < 45% in females and < 50% in males exclude iron overload.

Answer 40

First-line pharmacological treatment - according to predominant symptom pain: antispasmodic agents constipation: laxatives but avoid lactulose diarrhoea: loperamide is first-line Second-line pharmacological treatment low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors psychological interventions - if symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS), consider referring for cognitive behavioural therapy, hypnotherapy or psychological therapy

Answer 41

have regular meals and take time to eat avoid missing meals or leaving long gaps between eating drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas restrict tea and coffee to 3 cups per day reduce intake of alcohol and fizzy drinks consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice) reduce intake of 'resistant starch' often found in processed foods limit fresh fruit to 3 portions per day for diarrhoea, avoid sorbitol for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).

Answer 42

increasing age smoking diabetes chronic pancreatitis (alcohol does not appear an independent risk factor though) hereditary non-polyposis colorectal carcinoma multiple endocrine neoplasia BRCA2 gene KRAS gene mutation

Answer 43

classically painless jaundice pale stools, dark urine, and pruritus cholestatic liver function tests the following abdominal masses may be found (in decreasing order of frequency) hepatomegaly: due to metastases gallbladder: Courvoisier's law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones epigastric mass: from the primary tumour many patients present in a non-specific way with anorexia, weight loss, epigastric pain loss of exocrine function (e.g. steatorrhoea) loss of endocrine function (e.g. diabetes mellitus) atypical back pain is often seen migratory thrombophlebitis (Trousseau sign) is more common than with other cancers

Answer 44

ultrasound has a sensitivity of around 60-90% high-resolution CT scanning is the investigation of choice if the diagnosis is suspected imaging may demonstrate the 'double duct' sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts

Answer 45

less than 20% are suitable for surgery at diagnosis a Whipple's resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple's include dumping syndrome and peptic ulcer disease adjuvant chemotherapy is usually given following surgery ERCP with stenting is often used for palliation

Answer 46

Urea breath test

Answer 47

Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women.

Answer 48

dysphagia of BOTH liquids and solids typically variation in severity of symptoms heartburn regurgitation of food may lead to cough, aspiration pneumonia etc malignant change in small number of patients

Answer 49

oesophageal manometry excessive LOS tone which doesn't relax on swallowing considered the most important diagnostic test barium swallow shows grossly expanded oesophagus, fluid level 'bird's beak' appearance chest x-ray wide mediastinum fluid level

Answer 50

pneumatic (balloon) dilation is increasingly the preferred first-line option less invasive and quicker recovery time than surgery patients should be a low surgical risk as surgery may be required if complications occur surgical intervention with a Heller cardiomyotomy should be considered if recurrent or persistent symptoms intra-sphincteric injection of botulinum toxin is sometimes used in patients who are a high surgical risk drug therapy (e.g. nitrates, calcium channel blockers) has a role but is limited by side-effects

Answer 51

Serum amylase Serum lipase (more sensitive and specific) USS Contast CT

Answer 52

Rare features associated with pancreatitis: ischaemic (Purtscher) retinopathy - may cause temporary or permanent blindness

Answer 53

autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis

Answer 54

Cholestyramine is a bile acid sequestrant used in the management of hyperlipidaemia. It decreases bile acid reabsorption in the small intestine, therefore upregulating the amount of cholesterol that is converted to bile acid. The main effect it has on the lipid profile is to reduce LDL cholesterol. It is also occasionally used in Crohn's disease for treatment diarrhoea following bowel resection.

Answer 55

Adverse effects abdominal cramps and constipation decreases absorption of fat-soluble vitamins cholesterol gallstones may raise level of triglycerides

Answer 56

abdominal pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings rectal bleeding diarrhoea fever bloods typically show an elevated white blood cell count associated with a lactic acidosis

Answer 57

increasing age atrial fibrillation - particularly for mesenteric ischaemia other causes of emboli: endocarditis, malignancy cardiovascular disease risk factors: smoking, hypertension, diabetes cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use

Answer 58

epigastric pain radiates to the back typically worse 15 to 30 minutes following a meal may be relieved by sitting forward steatorrhoea: symptoms of pancreatic insufficiency usually develop between 5 and 25 years after the onset of pain diabetes mellitus develops in the majority of patients. It typically occurs more than 20 years after symptom begin

Answer 59

Overview associated with H. pylori infection in 95% of cases good prognosis if low grade then 80% respond to H. pylori eradication Features paraproteinaemia may be present

Answer 60

Causes of hepatosplenomegaly chronic liver disease - with portal hypertension infections: glandular fever, malaria, hepatitis lymphoproliferative disorders myeloproliferative disorders e.g. CML amyloidosis

Answer 61

Indications for upper GI endoscopy: age > 55 years symptoms > 4 weeks or persistent symptoms despite treatment dysphagia relapsing symptoms weight loss If endoscopy is negative consider 24-hr oesophageal pH monitoring (the gold standard test for diagnosis)

Answer 62

Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6*. It is often asymptomatic in early disease and initial symptoms often non-specific e.g. lethargy and arthralgia

Answer 63

early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands) 'bronze' skin pigmentation diabetes mellitus liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition) cardiac failure (2nd to dilated cardiomyopathy) hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism) arthritis (especially of the hands)

Answer 64

bloody diarrhoea urgency tenesmus abdominal pain, particularly in the left lower quadrant extra-intestinal features - arthritis, erythema nodosum, episcleritis, pyoderma gangrenosum, clubbing, primary sclerosing cholangitis

Answer 65

red, raw mucosa, bleeds easily no inflammation beyond submucosa (unless fulminant disease) widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps ('pseudopolyps') inflammatory cell infiltrate in lamina propria neutrophils migrate through the walls of glands to form crypt abscesses depletion of goblet cells and mucin from gland epithelium granulomas are infrequent

Answer 66

loss of haustrations superficial ulceration, 'pseudopolyps' long standing disease: colon is narrow and short -'drainpipe colon'

Answer 67

Terlipressin - method of action = constriction of the splanchnic vessels

Answer 68

- hypophosphataemia (this is the hallmark of refeeding syndrome - may result in heart failure and respiratory failure) - hypokalaemia -hypomagnesaemia

Answer 69

Shift from Fat to Carbohydrate Metabolism: In refeeding syndrome, the reintroduction of carbohydrates leads to a shift from fat to carbohydrate metabolism. This switch activates insulin secretion, which in turn increases cellular uptake of glucose. Intracellular Movement of Phosphate: Insulin and increased glucose uptake stimulate the intracellular movement of phosphate, which is used in the synthesis of ATP and 2,3-diphosphoglycerate in erythrocytes. This intracellular shift reduces serum phosphate levels. Decreased Phosphate Stores: Patients with chronic malnutrition often have depleted phosphate stores, although their serum phosphate levels may initially be normal. When refeeding starts, the sudden demand for phosphate in anabolic processes exceeds the supply, leading to hypophosphatemia.

Answer 70

- cardiac dysfunction 0 can impair myocardial contractility - resp failure (Phosphate is essential for ATP production, necessary for respiratory muscle function) - Neurological complications - confusion/seizure.coma - attributable to disturbed ATP metabolism in the central nervous system - haematological effects - Reduced 2,3-diphosphoglycerate levels in erythrocytes affect oxygen release from haemoglobin, leading to tissue hypoxia. Hypophosphatemia can also result in hemolysis. - rhabdo - Phosphate depletion impairs ATP production in muscles, which can lead to muscle breakdown and rhabdomyolysis.

Answer 71

Patients are considered high-risk if one or more of the following: BMI < 16 kg/m2 unintentional weight loss >15% over 3-6 months little nutritional intake > 10 days hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high) If two or more of the following: BMI < 18.5 kg/m2 unintentional weight loss > 10% over 3-6 months little nutritional intake > 5 days history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids

Answer 72

The MSH2 gene is involved in the process of DNA mismatch repair, which is essential for maintaining genomic stability.

Answer 73

Bezlotoxumab This is a drug that acts as a monoclonal antibody which targets Clostridium difficile toxin B. It is listed as an option in the BNF as an option for prevention of the recurrence of Clostridium difficile in those at high risk of recurrence but has not yet received NICE approval.

Answer 74

surface antigen (HBsAg) is the first marker to appear and causes the production of anti-HBs

Answer 75

HBsAg normally implies acute disease (present for 1-6 months) if HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective)

Answer 76

Anti-HBs implies immunity (either exposure or immunisation). It is negative in chronic disease

Answer 77

Anti-HBc implies previous (or current) infection. IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months. IgG anti-HBc persists

Answer 78

HbeAg results from breakdown of core antigen from infected liver cells as is, therefore, a marker of infectivity. Marker of HBV replication and infectivity

Answer 79

previous immunisation: anti-HBs positive, all others negative previous hepatitis B (> 6 months ago), not a carrier: anti-HBc positive, HBsAg negative previous hepatitis B, now a carrier: anti-HBc positive, HBsAg positive ## Footnote HBsAg = ongoing infection, either acute or chronic if present > 6 months anti-HBc = caught, i.e. negative if immunized

Answer 80

maltase: cleaves disaccharide maltose to glucose + glucose sucrase: cleaves sucrose to fructose and glucose lactase: cleaves disaccharide lactose to glucose + galactose

Answer 81

Sjogren's syndrome (seen in up to 80% of patients)

Answer 82

Dubin-Johnson syndrome is a benign autosomal recessive disorder resulting in hyperbilirubinaemia (conjugated, therefore present in urine). It is due to a defect in the canillicular multispecific organic anion transporter (cMOAT) protein. This causes defective hepatic bilirubin excretion ## Footnote Dubin-Johnson syndrome results in a conjugated hyperbilirubinaemia

Answer 83

VIP (vasoactive intestinal peptide) source: small intestine, pancreas stimulation: neural actions: stimulates secretion by pancreas and intestines, inhibits acid and pepsinogen secretion VIPoma 90% arise from pancreas large volume diarrhoea weight loss dehydration hypokalaemia, hypochlorhydia f

Gastro 3 Flashcards

(107 cards)