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Yr3 - General Medicine > Gastro > Flashcards

Gastro Flashcards

(130 cards)

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1
Q

Basic advice for a healthy diet

A

BMI - 18.5-25
Base meals on starch - slower release carbohydrates
5 fruit and veg a day
Eat food high in fat, salt or sugar infrequently
Eat some meat, fish, eggs and beans - 2 portions of fish a week and reduce intake of red or processed meat
Eat some milk and dairy products
Moderate alcohol - less than 14 units over 3 or more days

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2
Q

Advice for taking supplements

A

Scant evidence for those able to follow a balanced diet
Women attempting to conceive - 400mcg/day folic acid from pre-conception to 12wks
Vitamin D (10mcg/day) for breast-feeding, over 65yrs old, dark skinand those not exposed to sun

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3
Q

Risks of too much sugar

A 
Caries
Diabetes
Obesity 
- osteoarthritis
- cancer
- hypertension
- increased oxidative stress
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4
Q

Best approach for weight loss

A

Motivational therapy

  • referral to dietitian
  • exercise and diet strategies
  • targeted weight loss - psychotherapy
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5
Q

Treatment for obestiy

A

Primary prevention
Orlistat - lowers fat absorption
Surgery - potential for significant weight loss but also significant mortality

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6
Q

Define leucoplakia

A

Oral mucosal white patch that will not rub off and not attributable to other known disease
Premalignant lesion

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7
Q

Cause of oral hairy leucoplakia

A

Caused by EBV - seen in HIV

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8
Q

Define apthous ulcers

A

Shallow, painful ulcers on tongue or oral mucosa that heal without scarring

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9
Q

Causes of severe ulcers

A 
Crohn's disease
Coeliac disease
Behcet's
Trauma
Erythema multiforme
Lichen planus
Pemphigus
Pemphigoid
Infections - herpes simplex, syphilis
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10
Q

Treatment of minor ulcers

A

Avoid oral trauma - hard toothbrush and foods
Avoid acidic foods and drinks
Tetracycline or antimicrobial mouthwashes (chlorhexidine)
Topical steroids - triamcinolone gel
Topical analgesia

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11
Q

Treatment of severe ulcers

A

Systemic corticosteriods - oral prednisolone 30-60mg/d PO for a week
Thalidomide - contraindicated in pregnancy
Biopsy if not healing after 3wks to exclude malignancy

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12
Q

Features of oral candidiasis

A

White patches or erythema of the buccal mucosa

Patches hard to remove and may bleed if scraped

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13
Q

Risk factors for oral candidiasis

A

Extremes of age
DM
Antibiotics
Immunosuppression - long-term corticosteriods (inhalers), cytotoxics, malignancy, HIV

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14
Q

Treatment for oral candidiasis

A

Nystatin suspension 400 000u (4ml swill and swallow/6hr)

Fluconazole - for oropharyngeal thrush

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15
Q

Define cheilitis

A

Angular stomatitis

Fissuring of the mouth’s corners

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16
Q

Causes of cheilitis

A

Denture problems
Candidiasis
Deficiency or iron or riboflavin (vitamin D)

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17
Q

Define gingivitis

A

Gum inflammation +- hypertrophy

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18
Q

Causes of gingivitis

A 
Poor oral hygiene
Drugs - pheytoin, ciclosporin, nifedipine
Pregnancy
Vitamin C deficiency
Acute myeloid leukaemia
Vincent's angina
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19
Q

Define microstomia

A

Mouth is too small

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20
Q

Causes of microstomia

A

Thickening and tightening of perioral skin after burns
Epidermolysis bullosa - destructive skin and mucous membrane blisters +- ankyloglossia
Systemic sclerosis

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21
Q

Causes of oral pigmentation

A

Peutz-Jehers’ - perioral brown spots
Addisons’ disease - pigmentation anywhere in mouth
Malignant melanoma
Telangiectasia - systemic sclerosis
Fordyce glands - creamy yellow spots at the border of the oral mucosa and lip vermilion
Sebaceous cysts
Aspergillus niger - black tongue

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22
Q

Sign of lead poisoning

A

Blue line at gum-tooth margin

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23
Q

Causes of yellow-brown discolouration of teeth

A

Prenatal or childhood tetracycline exposure

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24
Q

Causes of furred or dry tongue

A

Dehydration
Drug therapy
After radiotherapy
Crohn’s disease

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25
Define glossitis
Smooth, red, sore tongue
26
Causes of glossitis
Iron, folate or B12 deficiency
27
Define macroglossia
Tongue is too big
28
Causes or macroglossia
Myxoedema Acromegaly Amyloid
29
Features of tongue cancer
Raised ulcer with firm edges
30
Risk factors of tongue cancer
Smoking | Alcohol
31
Pathway of spread of tongue cancer
Anterior 1/3 drains to submental node Middle 1/3 to submandibular nodes Posterior 1/3 to deep cervical nodes
32
Treatment for tongue cancer
Radiotherapy | Surgery
33
Causes of white intra-oral lesions
``` Idiopathic keratosis Leucoplakia Lichen planus Poor dental hygiene Candidiasis Squamous papilloma Carcinoma Hariy oral leucoplakia Lupus erythematosus Smoking Ahthous stomatitis Secondary syphilis ```
34
Indications for upper GI endoscopy
``` Diagnostic - haematemesis/malaena - dysphagia - dyspepsia - duodenal biopsy - persistent vomiting - iron deficiency Therapeutic - treatment of bleeding lesions - variceal banding and sclerotherapy - argon plasma coagulation for suspected vascular abnormality - stent insertion, laser therapy - stricture dilation, polyp resection ```
35
Pre-procedure for upper GI endoscopy
Stop PPIs 2wks prior Nil by mouth 6 hrs before Don't drive for 24hrs if sedation used
36
Upper GI endoscopy procedure
Sedation optional - midazolam 1-5mg slowly IV Nasal prong O2 - 2L/min + monitor sats Spray pharynx with local anaesthetic Continuous suction - prevent aspiration
37
Complications of upper GI endoscopy
Sore throat Amnesia - sedation Perforation Bleeding - aspirin, clopidogrel, warfarin or DOACs stopped if therapeutic
38
Uses of duodenal biopsy
Gold standard for coeliac disease Whipple's disease Giardiasis Lymphoma
39
Uses of sigmoidoscopy
Views rectum + distal colon - to splenic flexure Flexible has replaced rigid - 25% cancers still out of reach Therapeutic - decompression of sigmoid volvulus
40
Sigmoidoscopy procedure
Do PR exam first | Biopsies
41
Indications of colonscopy
``` Diagnostic - rectal bleeding - iron-deficiency anaemia - persistent diarrhoea - positive faecal occult blood test - assessment or suspicion of IBD - colon cancer surveillance Therapeutic - haemostasis - clipping vessels - bleeding angiodysplasia lesion - colonic stent deployment - volvulus decompression - pseudo-obstruction - polypectomy ```
42
Colonoscopy preparation
Stop iron 1wk prior | Discuss bowl preparation and diet required
43
Colonoscopy procedure
Do PR first | Sedation and analgesia
44
Complications of colonoscopy
Abdominal discomfort Incomplete examination Haemorrhage after biopsy or polypecotmy Perforation
45
Post-procedure of colonoscopy
No alcohol | No operating machinery for 24 hrs
46
Indications of video capsule endoscopy (VSE)
Evaluate obscure GI bleeding | Detect small bowel pathology
47
Pre-procedure for VSE
Small bowel imaging (contrast) or patency capsule test - if pt has abdo pain or symptoms suggesting obstruction Clear fluids only evening before Nill by mouth from morning till 4hr after capsule swallowed
48
VSE procedure
Capsule swallowed Transmits wirelessly to capture devise worn by pt Normal activities take place during day
49
Complications of VSE
Capsule retention - endoscopic or surgical removal Obstruction Incomplete exam - slow transit, achalasia
50
Problems with VSE
No therapeutic options Poor localisation of lesions May miss more subtle lesions
51
Routes for liver biopsy
Percutaneous - if INR in range | Transjugular - with FFP
52
Indications for liver biopsy
Increased LFTs of unknown origin Assessment of fibrosis in chronic liver disease Suspected cirrhosis Suspected hepatic lesions/cancer
53
Pre-op for liver biopsy
Nil by mouth for 8 hr INR < 1.5 Platelets > 50x10^9/L
54
Liver biopsy procedure
Sedation and analgesia may be given Do under US/CT guidance Liver borders percussed Lidocaine 2% infiltrated down to the liver capsule Breathing rehearsed and needle biopsy taken with breath held in expiration Lie on right hand side for 2hr Stay in bed for 4 hr Check BP and pulse every 15 mins for 1 hr then 30 mins for 2 hrs then hourly Discharge 4 hr post op
55
Complications of liver biopsy
Local pain Pneumothorax Bleeding Death
56
Define dysphagia
Difficulty swallowing
57
Key questions to ask with dysphagia
``` Difficulty swallowing solids and liquids from the start - y - motility disorder - n - stricture - benign or malignant Difficult to initiate swallowing - y - bulbar palsy Swallowing painful - y - ulceration - malignancy, oesophagitis, viral infection, Candida Dysphagia intermittent - intermittent - oesophageal spasm - constant and worsening - malignant stricutre Neck buldge or gurgle - y - pharyngeal pouch ```
58
Signs associated with dysphagia
``` Cachectic Anaemic Examine mouth Feel for supra-clavicular nodes Systemic disease - sclerosis, CNS ```
59
Investigations for dysphagia
``` FBC - anaemia U&Es - dehydration Upper GI endoscopy +- biopsy Contrast swallow - pharyngeal pouch Video fluroscopy - neurogenic causes Oesophageal manometry - dysmotility ```
60
Findings in vomit
Coffee grounds - upper GI bleed Recognisable food - gastric stasis Feculent - small bowel obstruction
61
Timing of vomit
Morning - pregnancy or raised ICP 1hr post food - gastric stasis/gastroparesis Relieves pain - peptic ulcer Preceded by loud gurgling - GI obstruction
62
Investigations for vomiting
Bloods - FBC, U&Es, LFTs, Ca2+, glucose, amylase ABG - metabolic alkalosis from loss of gastric contents indicates severe vomiting - pH > 7.45, increased HCO3- Plain AXR - if suspected bowel obstruction Upper GI endoscopy - bleed or persistent vomitting¬
63
Treatment for N+V
Identify and treat underlying causes Symptomatic relief - oral route first anti-emetic, IV fluids with K+ replacement Monitor fluid and electrolyte balance
64
H1 receptor antagonists antiemetics
Cyclizine - 50mg/8h PO/IV/IM - GI causes | Cinnarizine - 30mg/8hr PO - vestibular disorders
65
D2 receptor antagonists antiemetics
Metoclopramide - 10mg/8h PO/IV/IM - GI causes + prokinetic Domperidone - 60mg/12h PR, 20mg/6hr PO - prokinetic Prochlorperazine - 12.5 mg IM, 5mg/8h PO - vestibular + GI causes Haloperidol - 1.5mg/12h PO - chemical causes (opioids)
66
5HT3 receptor antagonist antiemetics
Ondansetron - 4-8mg/8hr IV slowly - doses can be higher for chemo
67
Other antiemetics
Hyoscine hydrobromide - 200-600mcg SC/IM - antimuscarinic, antispasmodic and antisecretory - don’t prescribe with prokinetic Dexamethasone - 6-10mg/d PO/SC - unknown MOA, adjuvant Midazolam - 2-4mg/d SC (syringe driver) - unknown MOA, anti-emetic effect outlasts sedative effect
68
Mechanical causes of dysphagia
``` Malignant stricture - pharyngeal cancer - oesophageal cancer - gastric cancer Benign strictures - oesophageal web or ring - peptic stricture Extrinsic pressure - lung cancer - mediastinal lymph nodes - retrosternal goitre - AAA - left atrial enlargement Pharyngeal pouch ```
69
Motility disorders causing dysphagia
``` Achalasia Diffue oesophageal spasm Systemic sclerosis Neurological bulbar palsy - pseudobulbar palsy - Wilson's or Parkinson's disease - syringobulbia - bulbar poliomyelitis - Chagas's disease - Myasthenia gravis ```
70
Other causes of dysphagia
Oesophagitis | Globus
71
Symptoms of dyspepsia
Epigastric pain often related to hunger, specific foods or time of day Fullness after meals Heartburn (retrosternal pain) Tender epigastrium
72
Red flags of dyspepsia
``` Anaemia - iron deficiency Loss of weight Anorexia Recent onset/progressive Melaena/haematemsis Swallowing difficulty ```
73
Treatment for H.pylori
PPI + 2 antibiotics for 1 week - Lansoprazole 30mg/12hr PO - Clarithromycin 250mg/12hr PO - Amoxicillin 1g/12hr PO
74
Risk factors for a peptic ulcer
``` H.pylori Drugs - NSAIDs, steriods, SSRI Increased gastric acid secretion Increased gastric emptying - lowers duodenal pH Blood group O Smoking Stress ```
75
Symptoms and signs of a peptic ulcer
Asymptomatic or epigastric pain +- weight loss Epigastric tenderness
76
Risk factors for gastritis
``` Alcohol NSAIDs H.pylori Reflux/hiatus hernia Atrophic gastritis Granulomas - Crohn's, sarcoidosis CMV Zollinger-Ellison syndrome ```
77
Symptoms of gastritis
Epigastric pain | Vomiting
78
Complications of peptic ulcer disease
Bleeding Perforation Malignancy Reduced gastric outflow
79
Treatment of functional dyspepsia
H.pylori eradication PPIs and psychotherapy Low-dose amitriptyline - 10-20mg each night PO
80
H.pylori tests
``` CLO test Histology Culture 13C breath test - most accurate non-invasive Stool antigen Serology ```
81
Differential diagnosis of dyspepsia
``` Non-ulcer dyspepsia Duodenal/gastric ulcer Duodenitis Oesophagitis/GORD Gastric malignancy Gastritis ```
82
Causes of GORD
``` Lower oesophageal spinchter hypotension Hiatus hernia Oesophageal dysmotility Obesity Gastric acid hypersecretion Delayed gastric emptying Smoking Alcohol Pregnancy Drugs - tricyclics, anticholinergics, nitrates ```
83
Symptoms of GORD
``` Oesophageal - heartburn - belching - acid brash - waterbrash - odynophagia Extra-oesophageal - nocturnal asthma - chronic cough - laryngitis - sinusitis ```
84
Complications of GORD
``` Oesophagitis Ulcers Benign strictures Iron-deficiency Barrett's oesphagus ```
85
Treatment of GORD
``` Lifestyle - weight loss - smoking cessation - small regular meals - reduce hot drinks, alcohol, citrus fruits, onions, fizzy drinks, spicy foods, caffeine, chocolate - avoid eating 3 hrs before bed Drugs - antacids relieve symptoms - PPI Surgery ```
86
Describe a sliding hiatus hernia
Gastro-oesophageal junction slides up into the chest | Acid reflux occurs as LOS becomes less competent
87
Describe a paraoesophageal hernia
Gastro-oesophageal junction remains in abdomne but buldge of stomach herniates up into chest alongside oesophagus
88
Clinical features of hiatus hernia
Common - 30% > 50yrs, esp obese women | Large hernias -> GORD
89
Imaging of hiatus hernia
Upper GI endoscopy visualises mucosa but cannot exclude hitatus hernia
90
Treatment of hiatus hernia
Weight loss Treat GORD Surgery
91
Surgical indications for hiatus hernia
Intractable symptoms despite aggressive medical therapy | Complications
92
Define haematemesis
Vomiting of blood - may be bright red or like coffee grounds - indicates upper GI bleed
93
Define malaena
Black stools due to altered blood | - indicates upper GI bleed
94
Stages of a GI bleed history
``` Past GI bleeds Dyspepsia/known ulcers Known liver or oesophageal varices Dysphagia Vomiting Weight loss Drugs - antiplatelets, anticoagulants, NSAIDs Alcohol use Co-morbidities - liver disease ```
95
Signs of a GI bleed
``` Peripherally cool/clammy Capillary refil >2s Urine output <0.5mL/kg/h Reduced GCS Tachycardic - pulse > 100bpm Systolic BP <100mmHg ```
96
Investigations for upper GI bleed
FBC - anaemia and platelet count - thrombocytopenia suggestive of chronic liver disease U&Es - raised urea Clotting Group and save - may need blood transfusion LFTs Venous blood gas - quick haemoglobin result
97
Acute management of upper GI bleeed
2 large-bore (14-16g) IV cannulae - give IV fluids if haemodynamically compromised - give O Rh- blood Correct clotting - FFP, vitamin K, platelets If suspicion of varices - IV Terlipressin and IV antibiotics Arrange urgent upper GI endoscopy Monitor hourly
98
Rockall risk-scoring for upper GI bleeds
Age - <60, 60-79, >80 Cormorbidity - No, Heart failure or IHD, Renal or liver failure, Metastases Shock - No shock, Tachycardia, Hypotension Source of bleeding - M-W tear, all other diagnosis, malignancy Stigmata of recent bleeding - None, blood in upper GI tract visible of spurting vessel
99
Blatchford score
Admission risk markers - blood urea - haemoglobin - systolic BP - others
100
Features of Crohn's disease
``` Mouth to anus Skip lesions Transmural inflammation Fissuring ulcers Lymphoid and neutrophil aggregates Non-caseating granulomas Increased incidence in smokers ```
101
Features of UC
``` Rectum then proximally Continuous Mucosal and submucosa inflammation Crypt abscesses Decreased incidence in smokers ```
102
IBD investigations
``` Blood tests - FBC - anaemia or raised platelets - U&Es - deranged electrolytes of AKI - CRP - inflammatory marker Stool tests - cultures - exclude infection colitis - Faecal calprotectin - raised in active disease Imaging - AXR - proximal constipation - CT - acute complications - MRI enterography - small bowel Crohn's - MRI rectum - perianal Crohn's Endoscopy - flexible sigmoidoscopy - safest in bloody diarrhoea - colonoscopy - proximal disease - capsule endoscopy - small bowel mucosa ```
103
What are patients admitted to hospital with acute IBD at high risk of?
VTE - need prophylactic heparin
104
IBD steriod treatment
Acute flare ups - topically - suppositories, enemas - orally - prednisolone or budesonide in small bowel disease - IV - hydrocortisone (100mg qds for 3-5 days)
105
UC treatment
``` Maintain remision - Mesalazine Rescue therapy - ciclosporin - biologics - surgery ```
106
Crohn's treatment
``` Maintain remission - azathioprine - biologics - perianal or fistulating Rescue therapy - biologics - surgery ```
107
Presentation of coeliac disease
``` Loose stools Bloating Wind Abdo cramps Weight loss Dermatitis herpetiformis ```
108
Complications of untreated coeliac disease
Small bowel lymphoma Small bowel cancer Osteoporosis Gluten ataxia and neuropathy
109
How to diagnose coeliac disease
Continue normal diet Tissue transglutaminae - raised OGD and duodenal biopsies - villous atrophy and intra-epithelial lymphocytosis
110
Treatment of coeliac disease
Gluten free diet - barley - wheat - oats - rye
111
Functions of the liver
``` Nutrition - stores glycogen - releases glucose - absorbs fats, fat soluble vitamins and iron - manufactures cholesterol Bile salts dissolve dietary fats Breakdown of haemoglobin to haemoglobin Manufactures clotting factors Detoxification - drug excretion - alcohol breakdown Kupfer cells engulf antigens Manufactures proteins - albumin - binding proteins ```
112
Risk factors of liver disease
``` Blood transfusion prior to 1999 in UK IVDU Operations/vaccinations with dubious sterile procedures Sexual exposure Medications FH of liver disease, diabetes, IBD Obesity Alcohol Foreign travel ```
113
Features of acute liver disease
``` No pre-existing liver disease Resolves in 6 months Causes - viral - Hep A, Hep E, CMV, EBV - drug-induced liver injury (DILI) ```
114
Features of chronic liver disease
``` Starts with acute liver disease On-going effects beyond 6 months May lead to cirrhosis and its complications Causes - alcohol - Hep C - Non-alcoholic steatohepatitis - autoimmune (PBC, PSC, AIH) ```
115
Grading of hepatic encephalopathy
``` Grade 1 - psychomotor slowing - constructional apraxia - poor memory - reversed sleep pattern Grade 2 - lethargy - disorientation - agitation/irritability - asterixis Grade 3 - drowsy Grade 4 - coma ```
116
Investigations for liver disease
``` Thrombocytopenia - liver fibrosis LFTs - ALT - hepatocytes - ALP - ducts Bilirubin, Albumin and Prothrombin time - synthetic function USS - cirrhosis ```
117
Hepatic causes of deranged LFTs
``` ALT > 500 - viral - ischaemia - toxic - paracetamol - autoimmune ALT 100-200 - non-alcoholic steatohepatitis - autoimmune hepatitis - chronic viral hepatitis - drug induced liver injury ```
118
Cholestatic causes of deranged LFTs
``` Dilated ducts - gallstones - malignancy Non-dilated ducts - alcoholic hepatitis - cirrhosis - PBC, PSC, alcohol - drug-induced liver injury - antibiotics ```
119
Components of the liver screen
``` Hepatitis B&C serology Iron studies - ferritin and atransferrin saturation Autoantibodies and immunoglobulins Caeuruloplasmin - under 30 yrs Alpha-a-antitrypsin Coeliac serolgy TFTs, lipids and glucose ```
120
Commonest causes of chronic liver disease
Alcoholic liver disease Non-alcoholic steatohepatitis Viral hepatitis - B+C
121
Less common causes of chronic liver disease
``` Women - autoimmune hepatitis - PBC Men - PSC - associated with IBD - haemachromatosis Adolescents - Wilsons disease - anti LKM autoimmune hepatitis ```
122
Treatment of chronic liver disease
Removing underlying aetiology to prevent further damage and progression to cirrhosis - stop drinking - weight loss - antivirals - venesection
123
Diagnosis of cirrhosis
Chronic liver disease pts with thrombocytopenia or clinical stigmata of chronic liver diease Imaging - splenomegaly, coarse texture and nodularity Fibroscan - quicker
124
Management of cirrhosis
Screen for varices Spironolactone - ascites DEXA scan for osteoporosis Alpha-fetoprotein and USS every 6 months - hepatocellular carcinoma
125
What should be performed on all patients admitted with ascites?
Diagnositc ascitic tap - cell count and MC&S | - look for spontaneous bacterial peritonitis
126
Components of nutritional assessment
``` Appetite Diet history Changes in oral intake Changes in weight Malnutrition Universal Screening Tool (MUST) ```
127
Steps of nutritional support
``` Food and encouragement - protected mealtimes - high calorie options encouraged - food fortification Nutritional supplements - large calories but small volumes NG tube PEG Parenteral ```
128
NG tube
Short term Supplementary feeding or solo Get in way and attached to drip Do on eliminated aspiration - pts aspirate on saliva
129
PEG
``` Longer term access to - Stomach - PEG - Small bowel - PEG-J Placed endoscopically (PEG) or Radiologically - (RIG) Indicated - feeding difficulty - need to provide supplementary feeding Do on eliminated aspiration - pts aspirate on saliva ```
130
Parenteral nutrition
Nutrition and fluid directly into patients veins Indicated when - GI tract not accessible - blocked - GI tract not working - short, leaking, diseased Mix of fluid, marco and micronutrients Given via dedicated central line Risks of line sepsis and liver dysfunction

Yr3 - General Medicine (9 decks)

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