Gastro 9.5 Flashcards
(120 cards)
1
Q
Hydatid cysts - tapeworm parasite Echinococcus granulosis - outer fibrous capsule formed containing multiple small daughter cysts
- what type of reaction?
- clinical features?
- Ix?
- Rx?
A
- cysts are allergens -> type 1 hypersensitivity reaction
- 90% in liver & lungs, Sx if >5cm
- morbidity: cyst bursting, infection, organ dysfunction & anaphylaxis
- if rupture: biliary colic, jaundice, urticaria
- CT to differentiate hydatid vs amoebic vs pyogenic
- Surgery ( do not rupture cyst wall, sterilise contents first)
2
Q
Causes of acute pancreatitis
A
Gallstones
ETOH
Trauma
Steroids
Mumps, coxsackie B
Autoimmune (IgG4) eg PAN, Ascaris infection
Scorpion venom
Hypertriglyceridaemia, hyperchlyomicronaemia, hypercalcaemia, hypothermia
ERCP
Drugs: azathioprine, mesalazine, furosemide, bendroflumethiazide, valproate, pentamidine
3
Q
Achalasia = failure of LOS to relax & oesophageal peristalsis due to degenerative loss of ganglia from Auerbach’s plexus -> LOS contracts, oesophagus above dilates. Middle-age
Features?
Ix?
Rx?
A
- dysphagia solids & liquids, variation in severity, heartburn, regurgitation, malignant change in small number
- Dx = manometry: XS LOS tone doesn’t relax on swallow
- also barium swallow: fluid level, birds beak, corkscrew; CXR: wide mediastinum, fluid level
- Rx = intra-sphincteric injection of botulinum, Heller cardiomyotomy, balloon dilation
- Drugs to help lower oesophageal pressure = calcium channel blockers, nitrates
4
Q
Max dose of 1% lidocaine for a 66kg person?
Lidocaine = rapid onset of action, anaesthesia lasts 1h
- what is the max safe dose?
- and if mixed with adrenaline?
A
20ml of 1% or 10ml 2% lidocaine solution
- 3mg/kg
- adrenaline increases duration of action and reduces blood loss 2ry to vasoconstriction - NEVER use near extremities (ischaemia)
5
Q
What are the absorbable sutures? When do they disappear?
A
PDS
Dexon
Vicryl
- usually disappear after 7-10days
6
Q
What are the non-absorbable sutures? when are the usually removed?
A
Silk Novafil Prolene Ethilon - usually 7-14days face 3-5 scalp, limbs, chest 7-10 hand, foot, back 10-14
7
Q
3 types of colon cancer?
A
sporadic 95%
- series of genetic mutations; >50% show allelic loss of APC gene
- others inc activation of K-ras oncogene, p52 deletion & DCC tumour suppressor genes -> invasive car
HNPCC 5%
FAP <1%
8
Q
HNPCC 5% of bowel ca
= auto Dom, poorly diff, highly aggressive
- 7 mutations - genetics?
- amsterdam criteria?
A
- affect genes involved in DNA mismatch repair -> micro satellite instability
- MSH2 60%; MLH1 30%
- higher risk of other cancers e.g. endometrial
- at least 3 family members with colon ca
- cases span 2+ generations
- at least 1 case Dx before age 50
9
Q
FAP = A. dom bowel ca <1%
- hundreds of polyps by age 30-40 -> carcinoma
- genetics?
- Gardners syndrome?
A
- APC tumour supp gene mutation on chr 5
- analyse DNA from WBCs
- total colectomy with ileo-anal pitch in their 20s
- at risk of duodenal tumours
Gardners = FAP + osteomas of skull & mandible, retinal pigmentation, thyroid ca, epidermoid cysts of skin
10
Q
PBC = autoimmune damage to interlobular bile ducts due to chronic inflamm -> progressive cholestasis with may progress to cirrhosis - itching in middle aged F Ass? Dx? Rx? Complications?
A
- Sjogrens 80%, RA, systemic sclerosis, thyroid disease
- AMA M2 subtype 98%, smooth m Ab 30%, raised serum IgM
- cholestyramine for itch, fat-soluble vitamins, ursodeoxycholic acid, liver Tx if Bili >100 (graft recurrence can occur but not usually a problem)
- cirrhosis
- osteomalacia & osteoporosis
- significantly inc risk of HCC
11
Q
Budd-Chiari = hepatic vein thrombosis
Features?
Causes?
Ix?
A
- sudden onset severe abdo pain
- ascites
- tender hepatomegaly
- procoagulant: PRV, OCP, pregnancy, thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C&S deficiencies
Ix = Doppler flow studies
12
Q
Carcinoid syndrome usually occurs when mets in the liver release serotonin into systemic circulation
- may also occur with lung carcinomas as mediators aren’t ‘cleared’ by the liver
Features?
Ix?
Rx?
A
- flushing earliest, diarrhoea, bronchospasm, hypotension, right heart valvular stenosis (left can be affected in bronchial carcinoid)
- ACTH & GHRH eg Cushings
- pellagra rarely (dietary tryptophan -> serotonin)
Ix: urinary 5-HIAA, plasma chromogranin A y
Rx = somatostatin analogues eg octreotide, cyproheptadine may help diarrhoea
13
Q
Flushing earliest, diarrhoea, bronchospasm, hypotension, right heart valvular stenosis
Dx?
A
carcinoid syndrome
14
Q
Long Hx of diarrhoea with signs consistent of tricuspid regurgitation
- Dx?
- path findings of heart disease?
A
Carcinoid syndrome = paraneoplastic syndrome caused by endogenous secretion of serotonin
- endocardial plaques of fibrous tissue that may involve: tricuspid, pulmonary, cardiac chambers, venue cave, PA & coronary sinus
15
Q
Resuscitation in upper GI bleed?
A
ABCDE
- platelets if <50
- FFP if fibrinogen <1 or PT/APTT >1.5
- PCC if bleeding on warfarin
- OGD immediately if severe, otherwise within 24h
- PPIs AFTER OGD if non-variceal with bleed on ogd
- repeat OGD, IR/surgery if further bleed
- Pre-OGD consider terlipressin & proph Abx
- band ligation for oesophageal varices
- N-butyl-2-cyanoacrylate injections if gastric varices
- TIPS if varical bleeding not controlled
16
Q
Chronic pancreatitis affects exocrine & endocrine function
- causes?
- features?
- Ix?
- Rx?
A
- 80% ETOH, 20% unexplained
- genetic = CF, haemochromatosis
- ductal obstruction: tumours, stones, structural abnormalities inc pancreas divisum & annular pancreas
- pain worse after meal, steatorrhoea, diabetes
- AXR: pan calcification
- CT 85% spec 80% sens
- faecal elastase can assess exocrine function
Rx = enzymes, analgesia, antioxidants
17
Q
Aspirin in pts following upper GI bleed in whom haemostasis has been achieved?
A
Continue aspirin when it is being used for 2ry prevention of vascular events
18
Q
Coeliac disease: gluten enteropathy leading to villous atrophy -> malabsorption
- dermatitis herpetiformis, T1DM, AIhepatitis
Dx?
Ix?
A
Dx = immunology & jejunal Bx
- villous atrophy & immunology normally reverses on a gluten-free diet
- anti-TTG 1st choice most specific
- anti-endomyseal (but it is IgA)
- anti-gliadin (IgA/IgG) NOT recommended by NICE
- anti-casein found in some
Duodenal Bx: subtotal villous atrophy, crypt hyperplasia, increase in intraepithelial lymphocytes, lamina propria infiltration with lymphocytes
19
Q
Gilbert’s syndrome: autosomal rec of defective bilirubin conjugation due to deficiency of UDP glucuronosyltransferase in 1-2%
features?
Ix?
A
- unconjugated hyperbilirubinaemia (not in urine)
- jaundice in response to phys stress eg exercise, illness, fasting
- Rise in bilirubin following prolonged fasting or IV nicotinic acid
20
Q
33F 4 days increasing lethargy, reduced exercise tolerance, dark urine.
PMH: UC, started sulfasalazine recently for a flare, had been well controlled with no immunosuppressants
O/e conjunctival pallor, abdo DNT, resp/cardio/neuro normal except for a mild systolic murmur & sinus tachycardia. Rectal exam empty, no oral ulcers
Hb 89
MCV 85
Plts 356
WCC 12.1
CRP 30
LDH 2400
Blood film: Heinz bodies, reticulocytsosis
Most appropriate immediate Rx?
A
Stop Sulfasalazine
- Heinz bodies = small inclusion bodies in RBCs due to oxidative damage to Hb
- sulfasalazine, dapsone, ribavirin & paraquat ingestion poisoning leads to oxidation of Fe2+ to Fe3+, forming metHb
- when overwhelmed, RBCs undergo oxidative damage & cell death -> haemolysis -> raised LDH++
- metHb is converted to hemichromes & eventually precipitated to Heinz bodies
Rx of oxidative haemolytic anaemia = stop offending drug, bloods should normalise within weeks
(transfusion prior to stopping drug would result in further haemolysis)
21
Q
Wilsons disease = A recessive XS copper deposition in tissues -> increased copper absorption from small bowel & decreased hepatic copper excretion into bile
- defect in ATP7B gene on chr 13
- onset of Sx between 10-25yrs
- children: liver disease; young adults: neuro disease
Features?
Dx?
Rx?
A
- hepatitis, cirrhosis
- basal ganglia degeneration, speech, behavioural & psych problems, anxiety, chorea, dementia
- cornea: Kayser-Fleischer rings
- blue nails, haemolysis
- kidneys: RTA type 2
, Fanconi: aminoaciduria, glycosuria, phosphaturia - reduced serum caeruloplasmin, reduced serum copper, increased 24h urinary copper excretion
- Rx = Penicillamine (chelates copper) or TRIENTINE hydrochloride eg if penicillin allergy
- tetrathiomolybdate under Ix
22
Q
Extra-intestinal manifestations of IBD related to disease activity?
A
arthritis: pauciarticular
erythema nodosum
episcleritis (CD)
osteoporosis
23
Q
Extra-intestinal manifestations of IBD unrelated to disease activity?
A
arthritis: symmetric, polyarticular uveitis (UC) pyoderma gangrenosum clubbing PSC (UC)
24
Q
Pathology in UC?
Barium enema in UC?
A
- raw red mucosa that bleeds easily, no inflammation beyond submucosa unless fulminant
- widespread ulceration with preservation of adjacent mucosa (pseudo polyps)
- inflammatory cell infiltrate in lamina propria
- neutrophils migrate through walls of glands to form crypt abscesses
- goblet cell depletion & mucin from gland epithelium
Barium enema: loss of haustra, superficial ulcers/pseudopolyps, long standing disease: drainpipe short & narrow colon
Nb pts more likely to be pANCA +ve
25
```
Hepatic encephalopathy: XS ammonia & glutamine absorption from bacterial breakdown of proteins in gut
features?
grading?
precipitating factors?
Rx?
```
```
- confusion, asterix (arrhythmic negative myoclonus 3-5Hz), constructional apraxia, triphasic slow waves on EEG, raised ammonia level
I irritable
II confusion, inappropriate
III incoherent, restless
IV coma
```
- infection eg SBP, GI bleed, post-TIPS, constipation, sedatives/diuretics, hypokalaemia, renal failure, increased dietary protein(uncommon)
- Rx the cause
- 1st = regular Lactulose: aim for 3 stools/day and continue for prevention of recurrent episodes
- +/- Rifaximin for 2ry prophylaxis: add-on for prevention of recurrent episodes after the 2nd episode
- lactulose: promotes ammonia excretion & increases metabolism of ammonia by gut bacteria; Rifaximin modulates gut flora -> decreased ammonia production
26
RUQ pain & malaena & jaundice after liver Bx
Dx?
how?
Haemobilia
- bleeding into biliary tree following connection between splanchnic circulation & intra/extrahepatic biliary system
- eg Bx needle hit splanchnic vein
27
3rd trimester itching & jaundice?
| Rx?
Intrahepatic cholestasis of pregnancy
- ursodeoxycholic acid for Sx relief, weekly LFTs, induction at 37/40
- inc rate of stillbirth
- there can be a prolonged PT & inc tendency to bleed
28
3rd trimester/immediate post-partum abdo pain, nausea/vomit, headache, jaundice, hypoglycaemia?
Acute fatty liver of pregnancy
- ALT >500
- if severe -> pre-eclampsia
- supportive care, delivery is definitive once stabilised
29
Causes of ascites with SAAG >11g/L
```
cirrhosis
ETOH hepatitis
cardiac
mixed
massive liver mets
fulminant hepatic failure
Budd-Chiari
portal vein thrombosis
vena-occlusive disease
myxoedema
fatty liver pregnancy
```
30
Causes of ascites with SAAG <11g/L
```
peritoneal carcinomatosis
TB peritonitis
pancreatic ascites
bowel obstruction
biliary ascites
post-op lymphatic leak
serositis in CT diseases
```
31
Rx of ascites?
- reduce dietary sodium
- fluid restrict if na <125
- AA eg spironolactone
- drain if tense (therapeutic abdo paracentesis)
- proph Abx to reduce risk of SBP: Ciprofloxacin/norfloxacin if ascitic protein 15 or less, until ascites has resolved
- consider TIPS in some
Nb paracentesis is not C/I in pts with abnormal clotting - most will have prolonged PT & some thrombocytopenia - but e.g. if severe thrombocytopenia, most would give platelets etc
32
Paracentesis induced circulatory dysfunction (PICD) - 2ry to fluid shifting after large volumes (>5L) paracentesis -> decreased circulating volume & renal dysfunction
Dx?
Prevention?
- increase of >50% of baseline plasma renin activity to >4ng/ml/h on day 5-6 post paracentesis
- limit volume of fluid removed to 5-6L at a time
- give albumin as a plasma expander if >5L ascitic fluid removed
33
Crohns disease: INDUCING remission:
- 1st line
- 2nd line
- Add on Rx
- if refractory/fistulating
- if isolated peri-anal disease
- 1st glucocorticoids (or budesonide)
- 2nd 5-ASA eg Mesalazine if steroids not effective
- Add-on Rx e.g. Azathioprine/Mercaptopurine/MTX (not monoRx)
- Infliximab if refractory/fistulating (& cont Azathioprine/mesalazine)
- Metronidazole if isolated peri-anal disease
- enteral feed with elemental diet can help
34
Crohns disease: MAINTAINING remission?
- stop smoking
- 1st Azathioprine/Mercaptopurine
- 2nd MTX
- consider 5-ASA e.g. mesalazine if pt has had previous surgery
- 80% eventually have surgery
35
Refeeding syndrome: metabolic abnormalities when feeding someone after a period of starvation - when extended period of catabolism ends abruptly with switching to carb metabolism
What are the metabolic consequences?
Who are considered high risk?
- low phosphate
- low K
- low Mg (torsades)
- abnormal fluid balance
- > organ failure
1+ of:
- BMI<16
- unintentional weight loss >15% over 3-6months
- little nutritional intake >10 days
- low K, phosphate, Mg before feeing
2+ of:
- BMI<18.5
- unintentional weight loss >10% over 3-6months
- little nutritional intake >5days
- Hx of ETOH abuse, drug Rx in insulin, chemo, diuretics, antacids
Nb:
if a pt hasn't eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days
36
```
Haemochromatosis: auto rec of iron absorption & metabolism -> ion accumulation - caused by inheritance of HFE gene on both copies of chr 6
- genetic testing of family members
- transferrin sat to screen general pop
Dx tests?
typical iron study profile?
Rx?
```
- molecular genetic testing: C282Y & H63D mutations
- liver B: Perl's stain
- transferrin sat >55% men or >50% women
- raised ferritin >500 & iron
- low TIBC
Venesection is 1st line - transferrin sat should be kept <50% and ferritin <50
- indicated in all with ferritin >1000
- typical initial regime is 400-500mls every 1-2weeks, then every 2-4months when levels fall to 50-100
37
Microscopic colitis = chronic inflammatory condition of gut - as common as classic IBD but different
Dx middle-age F>M
RFs?
Features?
RFs = smoking & drugs: NSAIDs, PPIs, SSRIs
- watery diarrhoea
- faecal urgency & incontinence
- abdominal pain
- constitutional Sx
- non-specific findings inc mild anaemia, raised inflame markers, autoAb e.g. RF & ANA
38
Bile acid malabsorption
- 1ry XS production
- 2ry reduced absorption: ill disease e.g. Crohns, cholecystectomy, coeliac disease, small bowel bacterial overgrowth
- steatorrhoea, vit A, D, E, K malabsorption
Ix?
Rx?
SeHCAT = Ix of choice
- nuclear medicine
- scans 7 days apart to assess retention/loss of radio labelled SeHCAT
Rx with bile acid sequestrates e.g. cholestyramine
39
Target HbA1c in chronic pancreatitis 2ry to resection?
- both alpha & beta cells removed in pancreatectomy
- reducing intensity of any counter regulatory response to hypoglycaemia
- impacts on prospects of recovery & increases severity of individual events
- so more lax HbA1c target instigated
- eg HbA1c 53
40
What drug enhances the effects and increases the toxicity of azathioprine?
Allopurinol
| - reduce dose of Azathioprine to 1/4 but significant & v specialist
41
Gastric cancer
- histology?
- Ass?
- features?
- Ix?
- intestinal metaplasia -> dysplasia -> cancer
- TNM staging, risk of LN involvement is related to size & depth of invasion; early cancers confined to submucosa have a 20% incidence of LN metastasis
- signet ring cells: large vacuole of mucin which displaces nucleus to one side, higher numbers = worse prognosis
- H. pylori, blood group A, gastric adenomatous polyps, pernicious anaemia, smoking, diet
- dyspepsia, nausea & vomiting, anorexia & weight loss, dysphagia
```
Dx = endoscopy & Bx
staging = CT or endoscopic US (eUS superior to CT)
```
42
Gastric ca tumours of GOJ classification?
type 1 - true oesophageal cancers, may be ass with Barretts
type 2 - carcinoma of cardia, arising from cardiac type epithelium or short segments with intestinal metaplasia at the OGJ
type 3 - subcardial cancers that spread across the junction, involve similar nodal stations to gastric ca
43
Staging & Rx of gastric ca?
- CT CAP routine 1st line
- laparoscopy to identify occult peritoneal disease
- PET CT esp for junctional tumours
- Subtotal gastrectomy for proximally sited disease 5-10cm from OGJ
- Total gastrectomy if tumour <5cm from OGJ
- Oesophagogastrectomy for type 2 junctional tumours extending into oesophagus
- Endoscopic submucosal resection in early gastric cancer confined to mucosa/submucosa
- Lymphadenectomy/D2 nodal dissection
- Most receive chemo pre/post op
44
Colorectal ca in UC
- lesions can be multifocal
- factors that increase risk?
- colonoscopy surveillance?
- disease duration >10years, pts with punctilios, onset before 15yrs old, unremitting disease, poor compliance to Rx
Low risk = 5yr colonoscopy
- extensive colitis with no active endoscopic/histological inflammation
- or left-sided colitis
- or Crohns colitis <50% of colon
Intermediate = 3yr colonoscopy
- extensive colitis with mild active inflammation
- or post-inflammatory polyps
- or FHx colorectal ca in 1st degree relative aged 50+
Higher risk = annual colonoscopy
- extensive colitis with mod/severe inflame
- or stricture in last 5yrs
- or dysplasia in last 5yrs declining surgery
- or PSC/Tx for PSC
- or FHx colorectal ca in 1st degree relative <50yrs
45
UC severity?
Mild - <4stools/day small amount blood
Mod 4-6stools/day varying blood, no systemic upset
Severe >6stools/day + features of systemic upset e.g. fever, tachycardia, anaemia, raised inflammatory markers
46
UC Rx INDUCING remission?
- Distal/Rectal colitis: Topical aminosalicylates or steroids
- Oral aminosalicylates
- Oral prednisolone 2nd line if aminosalicylates fail - wait 4wks before deciding
IV steroids 1st line for severe colitis
- assess response after 3-5days
- rescue therapy = Infliximab or cyclosporin if disease remains severely active
- if inadequate response of infliximab at day 5-7 then consider colectomy
47
UC Rx MAINTAINING remission?
- oral aminosaicylate eg mesalazine
- azathioprine & mercaptopurine
- some evidence probiotics may prevent relapse
48
C diff = gram +ve rod - produces exotoxin which causes bowel damage leading to pseudomembranous colitis
RFs = Abx, PPIs
Features = diarrhoea, abdo pain, raised WBC, toxic megacolon if severe
Dx = CD toxin in stool
Rx?
- oral metronidazole
- oral van if not responding or severe
- fidaxomicin if not responding or multiple comorbidities
- oral vanc + IV metronidazole for life-threatening infections
- Bezlotoxumab is a mAb which targets C diff toxin B
colonoscopy: yellow membranes in an inflamed colon suggests pseudomembranous colitis
49
Laparoscopy complications?
- GA risk
- vasovagal reaction e.g. bradycardia in response to abdo distension
- extra-peritoneal gas insufflation: surgical emphysema
- injury to GI tract
- injury to blood vessels e.g. common iliac, deep inferior epigastric artery
50
Volvulus = torsion of colon around its mesenteric axis -> compromised blood flow & closed loop obstruction
- 80% sigmoid 20% caecum (retroperitoneal in most so not at risk of twisting but in 20% there's developmental failure of peritoneal fixation of proximal bowel)
Features?
Dx?
Rx?
- constipation, abdo bloating/distension, abdo pain, nausea/vomiting
- AXR
- Sigmoid: LBO + coffee bean sign
- Caecal: SBO
Sigmoid -> rigid sigmoidoscopy with rectal tube insertion
Caecal -> operative, often right hemicolectomy
51
Post-gastrectomy syndromes?
(Roux en Y reconstruction gives best functional outcomes; where a gastrojejunostomy is performed as reconstruction following distal gastrectomy, the gastric emptying is generally better if the jejunal limbs are tunneled in the retrocolic plane)
```
small capacity (early satiety)
dumping syndrome
bile gastritis
afferent loop syndrome
efferent loop syndrome
anaemia/B12 deficiency
metabolic bone disease
```
52
Postprandial hypoglycaemia after gastric bypass or bariatric surgery?
Late dumping syndrome = postprandial hyperinsulinemic hypoglycaemia, presents months-years post-op, managed with diet changes
(Early dumping syndrome = rapid emptying of food into the small bowel-> colicky abdominal pain, diarrhoea & nausea = much more common complication of bariatric surgery)
53
Prophylaxis of variceal bleed?
Propranolol
= non-cardioselective beta blocker - works by producing splanchnic vasoconstriction & reducing portal venous inflow, limiting blood flow to the hepatic varices and reduces the pressure causing a smaller chance of bleeding
EVL: endoscopic variceal band ligation at 2weekly intervals until all varies eradicated with PPI cover to prevent EVL induced ulceration
54
Rx of vatical bleed?
ABCDE, correct clotting with FFP, vit K
- vasoactive agents: Terlipressin benefits initial haemostasis & prevents rebleeding (also octreotide)
- prophylactic Abx in pts with cirrhosis e.g. quinolone
- OGD: endoscopic band ligation
- Sengstaken-Blakemore tube if uncontrolled haemorrhage
- TIPSS if above all fail
55
Chronic diarrhoea with a v large stool volume maintained whilst fasting - Dx?
VIPoma
- suggested by a secretory diarrhoea (not osmotic)
- VIP hormone stimulates secretion & inhibits absorption of sodium, chloride, potassium & water within small bowel & increases bowel motility
- secretory diarrhoea, hypokalaemia, dehydration
56
```
Barretts = metaplasia of lower oesophageal mucosa: squamous -> columnar that resembles cardiac stomach region or small bowel (with goblet cells, brush border)
- inc risk adenoca
RFs?
Rx?
Endoscopic surveillance?
Rx?
```
- GORD strongest RF
- male, smoking, central obesity
- Rx = high-dose PPI, endoscopic surveillance with biopsies
- surveillance for pts with metaplasia (but not dysplasia) recommended every 3-5years
- intervention offered if there is ANY grade of DYSPLASIA i.e. endoscopic mucosal resection or radio frequency ablation
57
Pseudomyxoma peritonei = rare mutinous tumour most commonly arising from appendix
- characterised by accumulation of large amounts of mutinous material in abdominal cavity
Rx?
- surgical: cytoreductive surgery +/- peritonectomy, combined with intra-peritoneal chemo with mitomycin C
58
```
Small bowel overgrowth syndrome = XS amounts of bacteria in small bowel -> GI Sx
RFs?
Features?
Dx?
Rx?
```
- neonates with GI abn, scleroderma, DM
- chronic diarrhoea, bloating, flatulence, abdo pain, weight loss, it B12 malabsorption, impaired absorption of fat-soluble vitamins
Dx: hydrogen breath test, small bowel aspirate & culture but invasive - sometimes Abx given as a Dx trial
Rx: correct underlying disorder, Abx = Rifaximin
59
Best Rx for alcoholic hepatitis that improves survival at 28 days?
Prednisolone
60
MDS score in alcoholic hepatitis?
>32 ass with 50% mortality within 2months indicating need for Rx
- give vitamin replenishment & nutritional support & PREDNISOLONE
(Pentoxifylline may reduce mortality in presence of hepatorenal syndrome)
61
Common drugs causing cholestatic jaundice?
| +/- hepatitis
- Flucloxacillin, Co-amoxiclav, Erythromycin
- Sulfonylureas
- Fibrates
- Chlorpromazine, prochlorperazine
- OCP
- Anabolic steroids, testosterone
62
Drugs that cause hepatocellular picture?
- paracetamol
- sodium valproate, phenytoin
- amiodarone
- nitrofurantoin (chronic use: hepatic necrosis)
- methyldopa
- MAO-Is
- anti-TB RIP
- statins
- ETOH
- halothane
63
Drugs that can cause cirrhosis?
MTX
Amiodarone
Methyldopa
64
Thiamine = water soluble vitamin B complex
- TTP = one of its phosphate derivatives that is a coenzyme in the enzymatic reactions:
- pyruvate dehydrogenase complex
- pyruvate decarboxylase in ETOH fermentation
- alpha-ketoglutarate dehydrogenase complex
- branched-chain amino acid dehydrogenase complex
- 2-hydroxyphytanoyl-CoA lyase
- transketolase
Therefore is important in catabolism of sugars & AAs -> so consequences of thiamine deficiency are seen 1st in highly aerobic tissues e.g. brain & heart
Causes?
Conditions ass with thiamine deficiency?
- XS ETOH & malnutrition
- Wernicke's encephalopathy: nystagmus, ophthalmoplegia, ataxia
- Korsakoff's: amnesia, confabulation
- Dry beri beri: peripheral neuropathy, muscle pain
- Wet beri beri: dilated cardiomyopathy
Nb clinical ass between hyperemesis gravidarum & thiamine deficiency esp when prolonged and dietary intake compromised
65
SBP: ascites, abdo pain, fever
Dx?
Rx?
Abx prophylaxis?
What else has been shown to reduce mortality?
- paracentesis neutrophil count >250cells
- commonest organism = E. coli on ascitic tap
- Rx = IV Cefotaxime
Abx prophylaxis should be given to pts with ascites if:
- they have had an ep of SBP
- fluid protein <15 of Child-Pugh 9+ or hepatorenal syndrome
- NICE: offer proph oral Cipro or norfloxacin for people with cirrhosis & ascites with an ascitic protein 15 or less until ascites has resolved
- HAS to rehydrate inc cirrhosis with SBP
66
Decompensated liver disease:
- causes?
- signs?
- Rx?
infection: pneumonia, SBP, hep B/C
drugs: paracetamol, anaesthetic agents
toxins: etoh, Amanita phalloides mushroom
vascular: Budd-chiari syndrome, veno-occlusive disease
haemorrhage: upper GI bleed
constipation
- asterixis
- jaundice
- hepatic encephalopathy
- constructional apraxia
Rx the cause etc
- enhace nitrate clearance with phosphate enemas aiming for minimum 3 loose stools/day & lactulose to enhance binding of nitrate in intestine
67
Someone decompensated with ascites treated for SBP
- lab calls and says ascitic tap is mixed growth
Most likely cause?
Perforation
- Ascites is normally sterile so any growth of organisms is indicative of infective pathology
- mixed growth suggests large communication of microbes into abdo cavity, which makes perforation most likely cause
(- Spontaneous peritonitis occurs with bacterial translocation across the bowel - usually a single species of normal gut flora as a pathogen)
68
5-ASA is released in colon and not absorbed -> acts locally as anti-inflammatory, may inhibit prostaglandin synthesis
Sulfasalazine side-effects?
Mesalazine side-effects?
Sulfasalazine has combo with sulphonamide
- rash, oligospermia, headache, heinz body anaemia, megaloblastic anaemia, lung fibrosis
- + others common to 5-ASAs
Mesalazine = delayed release form of 5-ASA
- GI upset, headache, agranulocytosis, interstitial nephritis, pancreatitis
69
C/Is to percutaneous liver Bx?
- deranged clotting INR>1.4
- low platelets <60
- anaemia
- extrahepatic biliary obstructioni.e. cholestasis (can be bile leak leading to 2ry peritonitis)
- hydatid cyst/malignant lesion - Bx can seed the lesion causing sepsis/dissemination
- haemangioma
- uncooperative pt
- ascites
70
H. pylori eradication Rx?
- PPI + Amoxicillin + Clarithromycin
| metronidazole if pen allergic
71
GI parasite: Enterobiasis
- common cause of pruritus anti
- Dx?
- Rx?
```
Dx = scotch tape at anus to trap eggs and view microscopically
Rx = Mebendazole
```
72
GI parasite: Ancylostoma duodenale = hookworm that anchors in proximal small bowel, mostly aSx or IDA
Dx?
Rx?
- larvae may be found in stools left at ambient temp, otherwise difficult to Dx
- infection occurs as a result of cutaneous penetration, migrates to lungs, coughed up & then swallowed
Rx = mebendazole
73
GI parasite: Ascariasis = roundworm infection that starts in the gut after ingestion, then penetrates duodenal wall t migrate to lungs, coughed up & swallowed, cycle begins again
Dx?
Rx?
```
Dx = identification of worm/eggs within faeces
Rx = Mebendazole
```
74
GI Parasite: strongyloidiasis (rare in west) - nematode living in duodenum of host
infection?
Dx?
Rx?
- initial infection via skin penetration -> migrate to lungs coughed up & swallowed -> mature in small bowel -> excreted & cycle begins again
- auto-infective cycle also recognised where larvae will penetrate colonic wall
- can be aSx, may have rest disease & skin lesions
```
Dx = stool microscopy
Rx = mebendazole in UK
```
75
GI parasite: Cryptosporidium = protozoal infection where organisms produce cysts which are excreted & produce new infections
Sx?
Dx?
Rx?
- diarrhoea & crampy abdo pain, worse in immunocompromised
Dx = cysts in stool
Rx = Metronidazole
76
GI parasite: Giardiasis = protozoal diarrhoeal infection as a result of ingestion of cysts
Sx?
Dx?
Rx?
= GI abdo pain, bloating, soft/loose stools
Dx = serology or stool microscopy
Rx = Metronidazole 1st line
77
Autoimmune hepatitis
- features?
- associations?
- Rx?
- may present with signs of chronic liver disease
- acute hepatitis in 25%
- amenorrhoea common
- ANA/SMA/LKM1 Ab, raised IgG
- Bx: interface hepatitis: inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis
- other AI disorders, hypergammaglobulinaemia, HLA B8, DR3
Rx = steroids, other immunosuppressants e.g. azathioprine, liver Tx
78
Autoimmune hepatitis types?
Type I - ANA/anti-SMA, affects adults & kids
Type II - anti-LKM1, affects kids only
Type III - soluble liver-kidney Ag, affects middle aged adults
79
Hepatitis D = ssRNA transmitted parenterally, requiring hep B sAg to complete its replication & transmission cycle
Dx?
co-infection?
super-infection?
- reverse PCR of hepatitis D RNA
- confection is hep B & D at the same time
- superinfection is when a hep B sAg +ve pt develops hep D - ass with high risk fulminant hepatitis, chronic hepatitis status & cirrhosis
80
Acute severe UC flare:
At day 3 a CRP>45 mg/l or a stool frequency of >8/day predicts the need for surgery in 85% of cases
- benefit of steroids?
- if no improvement?
- IV steroids for 5 days with no additional benefit beyond 7 days
- if no improvement seen after 72h of IV steroid or if pt deteriorates then URGENT surgical R/v and add Cyclosporin 2mg/kg/day
(infliximab if C/I)
81
Causes of raised faecal calprotectin?
```
IBD (highly spec & sens in adults, can be used to monitor response to Rx)
bowel ca
coeliac disease
infectious colitis
NSAIDs
```
82
PPIs MoA & adverse effects?
- H+/K+ ATPase of gastric parietal cell
- low Na, Mg
- osteoporosis
- microscopic colitis
- increased risk C diff
83
In Crohns, Anti-TNF agents used in combination with immunomodulating agents are more effective at maintaining steroid-free clinical remission than when used as mono-therapy - what is the increased risk?
Non-melanoma skin cancer and others
84
Ix to identify source of occult GI bleed when an OGD & colonoscopy have failed to show a cause - esp useful for pathology in the ileum?
Capsule endoscopy
85
WHipple's disease: Tropheryma whippelii infection rare multi-system disorder, more common in HLA-B27 +ve middle-aged men
Features?
Ix?
Rx?
- malabsorption diarrhoea & weight loss, large-joint arthralgia, lymphadenopathy, skin: hyper pigmentation & photosensitivity, pleurisy, pericarditis, neuro Sx (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus
Ix = jejunal Bx showing deposition of macrophages containing PAS granules
Rx eg oral co-trimoxazole for a year
86
Metoclopramide = D2 receptor antagonist mainly used for nausea, also GORD, pro kinetic action in gastroparesis, combined with analgesics for Rx of migraine
Adverse effects?
- EPSEs: oculogyric crisis esp in children & young adults
- hyperPRL
- tardive dyskinesia
- parkinsonism
- avoid inbowel obstruction, may be helpful in paralytic ileus
87
Rx oculogyric crisis
1st line Procyclidine = rapidly acting anticholinergic, with BZDs & anticholinergic antihistamines
88
Rec acute pancreatitis with new diabetes & steatorrhoea, develops acute abdominal pain with normal amylase?
Acute on chronic pancreatitis
| - amylase may not be raised if there is significantly poor residual pancreatic function
89
Gastrectomy complications?
- vit B12 deficiency, IDA, weight loss, early satiety, osteoporosis/osteomalacia
- inc risk gallstones & gastric ca
- dumping syndromes:
early = food of high osmotic potential moves into small bowel causing fluid shift -> osmotic diarrhoea, small bowel distension, abdo pain, intravascular depletion
late = rebound hypoglycaemia
90
Colorectal ca Dukes classification & survival?
```
A = confined to mucosa & submucosa 95% M 100% F
B = extends through the muscular propria >80% M 90% F
C = regional LNs involved 65% M 65% F
D = distant spread >5% M 10% F
```
91
Commonest organisms of pyogenic liver abscess?
| Rx?
kids staph aureus
adults E coli
Rx = Amoxicillin + Ciprofloxacin + Metronidazole
If pen allergic = Ciprofloxacin + Clindamycin
92
Recent appendicitis -> deranged LFTs, abdo pain, tenderness, raised inflame markers, febrile, palpable mass Dx?
Liver abscess
93
Associated factors with NAFLD?
| features?
obesity, T2DM, hyperlipidaemia, jejunoileal bypass, sudden weight loss/starvation
- aSx, hepatomegaly, ALT>AST, increased echogenicity on US
94
If incidental NAFLD on US what is recommended?
ELF: enhanced liver fibrosis blood test to check for advanced fibrosis
- combo of hyaluronic acid + pro collagen III + tissue inhibitor of metalloproteinase 1
- if not available, can use the FIB4 score of NAFLD fibrosis score in combo with Fibroscan (liver stiffness measurement assessed with transient elastography)
95
Liver abscess: rusty brown pus drained, microbiology for parasites -> Entamoeba histolytica
Rx?
Metronidazole
| Diloxanide furoate should begin after to kill remaining amoeba in gut
96
Increased stool frequency, urgency, incontinence and nocturnal seepage following ileal pouch-anal anastomosis after total colectomy in UC - Dx? Rx?
Pouchitis
- metronidazole/ciprofloxacin
- can become chronic leading to pouch failure and requiring pouch excision
97
Vitamin B6 = pyridoxine, water-soluble b vitamin, converted to PLP (pyridoxal phosphate) = cofactor for many reactions inc transamination, deamination & decarboxylation
causes & consequences of deficiency?
Isoniazid Rx
- peripheral neuropathy
- sideroblastic anaemia
98
In pts with known cirrhosis, what is the management of varices?
No varices -> rescope in 2-3yrs
Grade 1 varices -> rescope in 1 year
grade 2/3 varices or signs of bleeding -> non cardio selective beta blocker
99
Anti-Saccharomyces cerevisiae antibodies are more likely to be positive in which IBD?
Crohn's
100
Dysphagia 2ry to oesophageal webs + glossitis + IDA
| Dx? Rx?
Plummer-Vinson syndrome
rx = iron supplementation & dilation of webs
- the webs are premalignant for oesophageal SCC & pharyngeal SCC
101
Hyperemesis gravidarum = extreme nausea & vomit in pregnancy, related to raised beta-hCG, most common between 8-12/40 but may persist to 20/40
Dx?
Ass?
Rx?
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
- multiple pregnancies, trophoblastic disease, hyperthyroid, nulliparity, obesity
- 1st line antihistamines e.g. promethazine, or also cyclizine
- 2nd line ondansetron & metoclopramide
- may need admission for IV hydration
- Wernicke's (Give THIAMINE)
- Mallord-Weiss tear
- cnetral pontine myelinolysis
- acute tubular necrosis
- fetal: small for gestational age, pre-term
102
What marker is most useful in determining his risk for developing cirrhosis from hepatitis B
hepatitis B DNA levels
| - will determine viral load and quantify the level of infection
103
```
Lysosomal storage disorder of alpha-galactosidase-A
-> accumulation of creamed trihexoside
- angiokeratomas
- peripheral neuropathy of extremities
- renal failurw
Dx?
```
Fabry disease
104
Commonest lysosomal storage disorder, of beta-glucocerebrosidase, resulting in accumulation of glucocerebrosidase in brain, liver, spleen
- hepatosplenomegaly
- aseptic necrosis of femur
Gaucher's disease
105
Lysosomal storage disease of Hexosaminidase A leading to accumulation go GM2 ganglioside within lysosomes
- developmental delay, cherry red spot on macula, liver & spleen normal size
Dx?
Tay-Sachs disease
106
Glycogen storage disease of myophosphorylase/glycogen phosphorylase leading to skeletal muscle glycogen accumulation
- myalgia
- myoglobinuria with exercise
McArdle's disease type V
107
Recurrent cholecystitis, pneumobilia, SBO, abdo pain, distension
- Dx?
Gallstone ileus
- rare complication of chronic cholecystitis when a gallstone passes through a fistula between GB & small bowel before becoming impacted at the ileocaecal valve
108
```
Pancreatic cancer - 80% are adenocarcinomas typically at head of pancreas
Associations?
Features?
Ix?
Rx?
```
- age, smoking, diabetes, chronic pancreatitis, HNPCC, MEN, BRCA2 gene
- painless jaundice, non-specific constitutional Sx, loss of exocrine Sx, loss of endocrine Sx, atypical back pain, migratory thrombophlebitis
- Ix: US sens 60-90%, high-res CT is Ix of choice
Rx: <20% suitable for surgery at Dx
- Whipple's resection (pancreaticoduodenectomy) performed for resectable lesions at head of pancreas - side-effects inc dumping syndrome & peptic ulcer disease
- adjuvant chemo
- ERCP with stunting for palliation
109
```
Pancreatic cancer - 80% are adenocarcinomas typically at head of pancreas
Associations?
Features?
Ix?
Rx?
```
- age, smoking, diabetes, chronic pancreatitis, HNPCC, MEN, BRCA2 gene
- painless jaundice, non-specific constitutional Sx, loss of exocrine Sx, loss of endocrine Sx, atypical back pain, migratory thrombophlebitis
- Ix: US sens 60-90%, high-res CT is Ix of choice
Rx: <20% suitable for surgery at Dx
- Whipple's resection (pancreaticoduodenectomy) performed for resectable lesions at head of pancreas - side-effects inc dumping syndrome & peptic ulcer disease
- adjuvant chemo
- ERCP with stunting for palliation
110
Dx of liver cirrhosis??
Screening?
- traditionally liver Bx
- others inc transient elastography & acoustic radiation force impulse imaging
- or enhanced liver fibrosis score to screen for pts who need further testing with nafld
Transient elastography = Fibroscan - uses 50MHz wave into liver from a small transducer on end of US probe
- measures stiffness of liver
Screening: transient elastography in:
- people with hep C
- men who drink >50units, F>30units/week
- people with ETOH-related liver disease
- upper OGD to check for varies in new Dx of cirrhosis
- liver US every 6months +/- AFP to check HCC
111
Screening Hep cell ca in high risk?
- liver US every 6months +/- AFP to check HCC
112
IBS med Rx?
Depends on predominant Sx
- antispasmodic if pain
- laxative (not lactulose) if constipation - if not responding can consider Linaclotide if persisted 12months and optimal/maximum tolerated doses from different classes not helped
- loperamide if diarrhoea
2nd line pharm = TCAs low dose e.g. amitriptyline
113
Clostridium difficile infections that don't respond to metronidazole/vancomycin
Fidaxomicin
114
Pernicious anaemia pathphys & features?
- Ab to gastric parietal cells or intrinsic factor -> vit B12 deficiency
- ass with thyroid disease, diabetes, Addisons, rheum, vitiligo
- predisposes to gastric carcinoma
- lethargy, weakness, dyspnoea, paraesthesia, mild jaundice, diarrhoea, sore tongue, retinal haemorrhages, mild splenomegaly, retrobulbar neuritis
115
Dold standard diagnostic test for small bowel bacterial overgrowth?
Jejunal aspirate
116
```
iron metabolism:
absorption?
transport?
storage?
excretion?
```
- absorbed in upper small bowel, 10% dietary absorbed, Fe2+ better absorbed, regulated by boys need, increased by it C & gastric acid
- decreased by PPIs, tetracycline, gastric achlorhydria, tannin
- transported in plasma as Fe3+ bound to transferrin
- stored as ferritin in tissues
- excreted via intestinal tract following desquamation
117
Angiodysplasia is a vascular deformity of GI tract which predisposes to bleeding & IDA
- ass with aortic stenosis
Dx?
Rx?
- colonoscopy
- mesenteric angiography is acutely bleeding
- endoscopic cautery or argon plasma coagulation
- antifibrinolytics eg TXE
- oestrogen may be used
118
TIPSS = percutaneous creation of a low-pressure tract between the intrahepatic portal vein & hepatic vein, allowing blood to bypass the liver & lower portal pressure
- 1ry indications?
- absolute C/I?
- relative C/I?
- uncontrolled vatical bleed, refractory ascites & hepatic pleural effusion are main indications for TIPSS
Absolute C/I = severe & progressive liver failure (Child-Pugh >12), uncontrolled hepatic encephalopathy, right heart failure, uncontrolled sepsis, unrelieved biliary obstruction
Relative = severe uncorrectable coagulopathy, thrombocytopenia, portal & hepatic vein thrombosis, pulm HTN, central hepatoma
119
```
Gastric MALT lymphoma
- ass with H pylori
- good Px
- if low grade then 80% respond to triple Rx
Features?
```
paraproteinaemia
- ogd Biopsy of this area is reported as having large number of lymphocytes that have irregular nuclear contours with abundant cytoplasm
120
```
Oesophageal ca (adenoca commonest) - majority in middle 1/3 of oesophagus
RFs?
Features?
Dx?
Rx?
```
- smoking, ETOH, GORD, Barrets, achalasia, Plummer-Vinson, SCC linked to diets rich in nitrosamines
- dysphagia, anorexia, weight loss, vomiting etc
- OGD
- contrast swallow can help classify benign motility disorders but no place in assessment of tumours
- staging CT - if negative then eUS for local staging
- staging laparoscopy to detect occult peritoneal disease
- PET CT if negative laparoscopy
- Surgery: Ivor-Lewis oesophagectomy commonest
- biggest surgical challenge is anastomotic leak, with intrathoracic anastomosis that will result in medistinitis with high mortality
- adjuvant chemo
