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Gastro Flashcards

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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
Mx AI hepatitis
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.
26
Drug for food poisoning
Ciprofloxacin - good against salmonellae/c.jej.
27
Quinolon cautions
``` Pts >60yo -> tendon damge. Aortic aneurysm Epilepsy - lower seizure threshold. Children - skeletal deformities. Pregnancy. ```
28
C.Diff mx
Admit to hosp Request 3x stool culture for CDT Start oral metronidazole.
29
Contraindications for loperamide
``` Bloody diarrhoea IBD Bacterial enterocolitis (e.coli) avoid for C.diff. High temperature. ```
30
Metronidazole cautions
Alcohol - Disulfiram like effect | flushing, abdo pain, hypotension. up to 3 days after tx.
31
Toxic megacolon
dilation of colon >10cm
32
Ix Progressive dysphagia
OGD + biopsy
33
Mx benign peptic stricture
Balloon dilatation - complication - perforation (chest pain, SOB, mediastinitis, palpable surgical emphysema ) Tx of underlying GORD with PPIs. Refractory - Oesophageal stent
34
post balloon dilatation perforation ix
CT scan oral contrast.
35
Extra gi manifestations UC related to activity
``` 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
Child Pugh score cirrhosis mortality
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
RFs variceal bleed
High portal pressures (>12mmhg) Large varices abnormal variceal wall at endoscopy (e.g. haemocystic spots) High child pugh score
38
Cirrhosis signs
``` Clubbing Parotid enlargement Dupuytrens contracture gynaecomastia testicular atrophy HCC - USS, CT, afp ```
39
Liver biopsy complications
Abdo pain/shoulder tip pain Bleeding. (risk if severe cirrhosis, clotting disorder, extensive ascities, uncooperative) Bowel perf, biliary peritonitis, renal laceration. Pneumothorax.
40
Tx Alcohol withdrawal
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
serum ascites albumin gradiet
>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
what should you send ascitic tap off for?
``` Culture and sensitivity LDH Cytology total Protein albumin conc Cell count and differential GLucose ```
43
Ix pancreatic cancer
CT CAP
44
Mx pancreatic cancer
>3cm , liver mets. | Percutaneous, endoscopic biliary stent insertion, brush cytology.
45
Risk factors for pancreatic cancer
``` Smoking alcohol diabetes 60% in head, 15% tail, 25% body. median survival <6months. Can present with acute pancreatitis Ca19-9 is non specific. ```
46
PBC presentation
``` 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
PBC ix
USS upper abdomen - exlude biliary dilatation, assess liver parenchyma, +/- biopsy. viral hep serology ANA, Anti mitonchondial Ab serum lipids Blood clotting profile
48
Contraindication for liver biopsy
``` Platelets <100 INR >1.3 hb <100 Acute confused. Extensive ascites - drain them first. ```
49
complications of PBC
``` Malabsorption Osteoporosis HCC Liver failure Haematemesis Hypothyroidism ```
50
Mx PBC
Ursodeoxycholic acid - prevents progression. Cholestyramine - alleviates pruritus. (give 2h apart from UDCA) Fat soluble vitamin prophylaxis. Liver transplant.
51
Alcoholic hepatitis ix
GGT elevated | AST:ALT >2
52
Mx alcoholic hepatitis
Prednisolone. (using maddreys discriminant function) Pentoxyphylline
53
Ascites mx
``` Reduce sodium intake Fluid restrict if na <125 spironolactone drainage - if tense Ciprofloxacin if protein <15 TIPS ```
54
Mx hepatic encephalopathy
Tx cause (infection, gi vleed, Post TIPS) constipation, drugs, hypokalaemia, renal failure, protein. Lactulose - excrete ammonia. rifaximin embolise shunts liver transplant
55
``` 64M Intermittent epigastric pain - boring to back. diarrhoea (steatorrhoea) recent diabetes wt loss prev Etoh/smoking hx. ```
Chronic pancreatitis
56
Ix Chronic pancreatitis
``` Amylase LFTs Serum albumin/corrected ca FBC AXR - calcification in pancreatic area. CT - calcification, atrophy, duct dilatation. pancreatic pseudocysts. MRCP ```
57
Complications of chronic pancreatitis
``` Carcinoma 2-3% Intractable pain - opiate addiction Pseudocyst Malabsorption Diabetes ```
58
pt comes in after outbreak of food poisoning in hotel - what actions?
Ensure side room gloves aprons | inform local health protection consultant even if out of hours.
59
drug induced liver damage ix
differential WCC - e.g. eosinophils = allergic response to drug USS - exclude Causes of intra/extrahepatic obstruction Serology for hepatitis
60
Hepatotoxic drugs
``` statins macrolides paracetamol roziglitazone flucloxacillin ```
61
Haemochromatosis features
``` 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
Ix Haemochromatosis
``` LFTs Ferritin increased FE increased TIBC decreased glucose blood genotype XR - chondrocalcinosis ECG, Echom Liver biopsy - pearls stain MRI - loading ```
63
Mx Haemochromatosis
Regular venesection Analgeisa Refer diabetologist screen 1st relatives.
64
Hepatorenal syndrome tx
IV albumin Terlipressin haemodialysis liver transplant
65
Mx Liver cirrhosis
``` Nutrition etoh abstinence Cholestyramine - pruritus Screening 6m for HCC AFP/USS endoscopy ``` Treat cause - HCV - interferon a, PBC UDCA, wilsons - penicillamine tx decompensation
66
Tx decompensated liver cirrhosis
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
Wilsons features
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
Ix wilsons
24h urinary cu | caerulopasmin reduced, copper reducedd
69
Mx wilsons
diet- avoid chocolate, liver, nuts Penicillamine - lifelong. SE: nausea, rash, leukopenia, anaemia, plats, Monitor FBC, cu extretion Liver
70
PBC
``` 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
PSC
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
Carcinoid tumours
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
HCC features
``` Tender hepatomegaly Jaundice weight loss ascites cachexia ```
74
HCC ix
``` AFP glucose clotting Calcium/albumin CXR USS Hepatitis serology CT ```
75
HCC rfs
Male Alcoho HBV/HCV Haemochromatosis
76
Mode of transmission of hepatitis
``` 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
Rate of transmission of hep / hiv from needlesticks
hep B 1in3 hep c 1in 30 hiv 1 in 300
78
complications of hepc
Cirrhosis HCC mesangiocapillary glomerulonephritis - nephritic syndrome
79
Hep C mx
Genotype and viral load pre tx viral RNA level monitor response to tx DAA regimen
80
Glasgow criteria for severity of pancreatitis
``` 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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