Gastroenterology Flashcards
(224 cards)
1
Q
Why is lactulose used in the management of hepatic encephalopathy?
A
Reduce generation of ammonia by bacteria in the gut and reduce the absorbability of ammonia from the gut
2
Q
What is the optimum endoscopic therapy for bleeding oesophageal varicies?
A
VBL
3
Q
What are the clinical features of each grade of hepatic encephalopathy?
A
Grade 0 No abnormality
Grade 1 Alterations in behaviour, mild confusion, disordered sleep
Grade 2 Lethargy, moderate confusion, asterixis
Grade 3 Somnolent but can be roused
Grade 4 Coma
4
Q
What is the gold standard investigation for diagnosing coeliac disease?
A
Endoscopy with duodenal biopsy
To be performed after positive serology
5
Q
What is seen on duodenal biopsy in coeliac disease?
A
Villous atrophy
Crypt hyperplasia
Increase in intra-epithelial lymphocytes
6
Q
What are the first line serology investigations for coeliac disease?
A
Total IgA
IgA tissue transglutaminase (TTG)
7
Q
Does hepatitis A increase the risk of hepatocellular carcinoma?
A
No
8
Q
What is the treatment for Hep A?
A
Supportive, usually self limiting
9
Q
Features of Crohn’s disease
A
Affects anywhere from mouth to anus Skip lesions Inflamation is transmural Fissuring ulcers Lymphoid and neutrophil aggregates Non caseating granulomas Increased incidence in smokers
10
Q
Features of UC
A
Always affects the rectum, extends proximally Continuous Mucosa and sub mucosa inflammation only Crypt abscesses Decreased incidence in smokers
11
Q
What tests should be considered for patients with a change in bowel habit?
A
Blood tests - FBC (anaemia, raised platelet count), U&E (derrange electorlytes, AKI), CRP (inflmation, can indicate IBD)
Stool tests - culture (r/o infective collitis), faecal calprotectin (active IBD)
Simple imaging - AXR (proximal constipation, toxic megacolon)
Endoscopy - felxi sig (safest test in bloody diarrhoea), colonoscopy (to look for proximal disease), capsule endoscopy (visualise small bowel mucosa)
Cross sectional imaging - CT abdomen (acute compliactions), MRI enterography (small bowel crohn’s, fistulas), MRI rectum (perianal crohns)
12
Q
Why do patients with acute IBD need prophylactic heparin when staying in hospital?
A
High risk of VTE
13
Q
What are the rescue therapies in UC?
A
Ciclosporin
Biologics (e.g. Infliximab)
Surgery
14
Q
What are the rescue therapies for Crohns disease?
A
IV hyrdocortisone - first line
Biologics (e.g. Infliximab)
Surgery
15
Q
What is used to maintain remission in UC
A
Mesalazine (5-ASAs)
IF INEFFECTIVE
Sulfasalazine
Azathiprine and biologics (e.g. Infliximab)
16
Q
What drugs are used to maintain remission in Crohn’s disease?
A
Azithioprine
Biologics (e.g. Infliximab)
17
Q
What histological changes will be seen in UC?
A
Non-granulomatous inflammation of the mucosa and submucosa
Crypt abcesses
Goblet cell hypoplasia
Pseudopolyps
18
Q
What is the cardinal feature of UC?
A
Bloody diarrhoea
19
Q
Symptoms of UC
A
Proctitis, inflmmation confinded to the rectum only
Bloody diarrhoea
PR bleeing
Mucus discharge (PR)
Increased frequency and urgency of defecation
Tenesmus
Systemic symptoms: malaise, anorexia, low-grade pyrexia
20
Q
Features of severe UC
A
>6 bowel movements per day Visable Blood Pyrexia Tachycardia ESR>30 Anaemia
21
Q
Complications of UC
A
Toxic megacolon Colorectal carcinoma Osteoperosis Puchitis Bowel perforation
22
Q
What curative surgery can be used to manage UC?
A
Total proctocolectomy
23
Q
Why do patients with UC typically require segmental bowel resection, typically needing a subtotal colectomy defunctioning stoma?
A
In a flare of IBD primary anastomosis is not adivsed
24
Q
AXR features of UC flares
A
Mural thickening, thumbprinting, lead-pipe colon
25
What are some extra-intestinal manifestations of IBD?
MSK - enteropathic arthritis (large joints such as sacroilliac), clubbing (Crohns- metabolic bone disease)
Skin - erthema nodosum, (Crohn's, pyoderma gangrenosum)
Eyes - episcleritis, anterior uveitis, iritis
Hepatobillary - primary sclerosing cholangitis (more with UC), cholangiocarcinoma, gallstones
Renal - Renal stones in Crohn's disease
26
Which IBD has a cobblestone appearance?
Crohn's
27
What are the biggest risk factors for Crohn's disease?
Family history
| Smoking
28
How does Crohn's disease present?
Episodic abdominal pain
Diarrhoea, which may contain blood or muscous
Systemic symptoms: malaise, anorexia, low-grade fever
Malnourishment and malabsorption (failure to thrive in children)
Oral Apthous ulcers
Perianal disease including perianal abscess
29
Wha
30
Gold standard investigation for Crohns?
Colonoscopy
31
What score can be used to grade the severity of Crohn's disease?
Montreal score:
| Age, behaviour, location
32
How might CT imaging be usefull in Crohns?
Bowel obstruction from stricturing
Bowel perfoation
INtra abdominal collections
33
How is treatment in haemochromatosis monitored?
Ferritin and transferrin saturation
34
What triad does chronic mesenteric ischaemia often present with?
Severe, colicky post-prandial abdominal pain
Weight loss
Abdominal bruit
35
What will the acid base status of a patient with mesenteric ischemia be and why?
Metabolic acidosis
| Low bicarbonate
36
What triad may mesneteric ischemia present with?
CVD
Soft tender abdomen
High lactate
37
In hepatomegaly secondary to right sided heart failure, what is found on examination of RUQ?
Pulsatile, smooth, tender, liver edge
38
Why should colonoscopy be avoided in patients with severe colitis?
Risk of perforation
39
What may be seen on CT abdomen of a patient with pancreatic cancer?
Double duct sign - simultaneous dilatation of the common bile duct and pancreatic ducts
40
What kind of duct dilation will primary sclerosing cholangitis cause?
Intra-hepatic
41
In a patient with previous hepatitis B immunisation, what will be seen on serology?
anti-HBsAg positive
| All others negative
42
What will be positive on Hep B serology in patients who have had previous Hep C (>6months ago)?
anti-HBc
43
What will hep B serology show if a patient is carrying Hep B?
HBsAg positive
44
What anti-emetic should be avoided in bowel obstruction?
Avoid metoclopramide in bowel obstruction
45
What is the most common organism found on ascitic culture?
E coli
46
What is the ‘M rule’ in primary billary cholangitis?
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
47
In autoimmune hepatitis which antibodies and immunoglobins will be positive/raised?
Antinuclear antibody
Anti smooth muscle antibody
IgG
48
Clinical features of IBS?
```
Bloating
Change in bowel habit
Abdominal pain and distension, relieved by defecation
Mucus in stool
Back pain
Urinary symptoms
Fatigue
Symptoms made worse by eating
```
49
How should a suspected perianal fistula be investigated?
MRI pelvis
50
What iron study findings will be present in patients with untreated heriditory haemochromatosis?
Raised transferritin saturation
Raised ferritin
Low total iron binding capacity
51
Which part of the colon is most likely to be affected by ischemic colitis?
Splenic flexure
52
What is Wilson’s disease?
Wilson's disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues.
53
What liver pathology can arise secondary to Wilson’s disease?
Copper deposition leading to hepatitis or cirrhosis
54
What physical findings may be present in a patient with Wilson’s disease?
Kayser-Fleischer rings (green-brown rings in the periphery of the iris)
Blue nails
55
What psychiatric symptoms can Wilson’s disease cause?
Psychosis
56
Dysphagia equally to both solids and liquids from the outset is characteristic of what?
Achlasia
57
How may haematomochrosis present clinical features wise?
```
Bronze appearance of the skin
Hepatomegaly
Bilateral joint pain due to chondrocalcinosis of the joints
Weakness
Hyperglycaemia
```
58
What is used to screen for Wilson’s disease?
Serum Caeruloplasmin
| reduced
59
Best measure of acute liver failure?
Prothrombin time
60
What does a high SAGG indicate
Portal hypertension
61
What is the acute management of severe alcoholic hepatitis?
corticosteroids
62
What is Peutz-Jeghers syndrome
Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract
63
What drugs tend to cause drug induced cholestasis?
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
64
What kind of GI bleed does a high urea suggest?
Lower GI bleed
65
What is the The Mackler triad for Boerhaave syndrome?
Subcutaneous emphysema
Thoracic pain
Vommting
(Oesophageal rupture)
66
Why are anti-motility drugs like loperamide, sometimes used to treat diahorrea, contraindicated in patients with Crohns during a flare up?
Anti-motility drugs, such as loperamide, should be avoided in acute attacks, as these can precipitate toxic megacolon.
67
Why should colonoscopic surveillance be offered to people with Crohns, and under what circumstance?
Due to increased risk of colorectal malignancy, colonoscopic surveillance is offered to people who have had the disease for over ten years and have over one bowel segment affected.
68
When is surgical management indicated in Crohn's?
Failed medical management
Strictures
Perforation
Surgeons will take a bowel sparing approach
69
What surgeries may be performed to manage Crohns?
Ileocaecal resection
Small or large bowel resection
Surgery for peri-anal disease (I&D, laying open of fistulae, seton insertion)
Stricturoplasty
70
Complication of Crohn's disease?
```
Fistula (enterovesical, enterocutaneous, rectovaginal)
Stricture formation
Recurrent perianal fistulae
GI mallignancy
Malabsorption
Osteoperosis
Gallstones
Renal stones
```
71
What is the stepwise progression of alcoholic liver disease?
1. Alcohol related fatty liver
2. Alcoholic hepatitis
3. Cirrhosis
72
How long does it take to reverse alcohol related fatty liver after alcohol cessation?
2 weeks
73
Is alcoholic hepatitis reversable?
With permanent abstinence
74
Is alcoholic liver cirrhosis reversable?
No but alcohol cessation will prevent further damage
75
What is the reccomended limit of alcohol consumption?
14 units a week, over 3+ days
| No more than 5 units in one day
76
What is the CAGE question used to screen for alcohol missuse?
Cut down
Annoyed
Guilty
Eye opener
77
What score on the AUDIT questionaire indicated harmful alcohol use?
8 or more
78
What are the complications of alcohol abuse?
```
Alcoholic liver disease
Cirrhosis
Hepatocellular carcinoma (2* to cirrhosis)
Dependence, withdrawal
WKS, wernicke korsakoff syndrome
Pancreatitis
Alcoholic cardiomyopathy
Clotting problems
```
79
What may be found on examination of a patient with liver disease?
```
Jaundice
Hepatomegaly
Spider naevi
Palmar erythema
Gynaecomastia
Brusing (abnormal clotting)
Ascites
Capur meduase (engoged superficial epigastric veins)
Asterixis
```
80
What may be seen on LFTs in alcoholic liver disease?
Elevated transaminases (AST, ALT) with abnormal AST:ALT ratio
Particularly raised gamma-GT
Low albumin
Elevated bilirubin
81
In liver disease, what does low albumin indicate?
Reduced synthetic function of the liver
82
What AST:ALT is indicative of alcoholic liver disease?
>2
| ie. AST is twice that of ALT
83
What might be abnormal in the FBC of a patient with alcoholic liver disease?
Raised MCV
84
Why may U&Es be derranged in a patient with alcoholic liver disease?
Hepatorenal syndrome
85
Why are CT and MRI useful in liver disease?
Look for fatty infiltration of the liver, hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessel changes, ascities
86
When is liver biopsy reccomended in patients with alcoholic liver disease?
When steroid treatment is being considered
87
What is the role of endoscopy in suspected portal hypertension?
Assess for and treat oesophogeal varicies
88
What scan can be used to check the elasticity of the liver and assess the degree of cirrhosis?
FIbroscan (USS)
89
What scan can be used to check the elasticity of the liver and assess the degree of cirrhosis?
FIbroscan (USS)
90
How will fatty changes in the liver be visable on USS?
Increased echogenicity
91
What is the general management of alcoholic liver disease?
Immediate alcohol cessation
Consider a detoxication regime
Nutritional support with vitamins (particulary thiamine) and a high protein diet
Steroids improve short term outcomes (over 1 month) in severe alcholic hepaitits
Treat infection and GI bleeding
Treat complications of cirrhosis (portal HTN, varices, ascities, hepatic encephalopathy)
3 months after cessation of alcohol liver transplant can be considered
92
What are the symptoms of alochol withdrawal and at what point to they occur?
6-12 hours: tremor, sweating, headache, craving an anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: delirium termens
93
What drug is used in portal HTN?
Propanolol
94
What is delirium tremens?
Medical emergency associateds with alcohol withdrawal
95
How does delirium tremens present?
```
Acute confusion
Severe agitation
Delusions and hallucinations
Tremor
Tachycardia
HTN
Hyperthermia
Ataxia
Arrythmias
```
96
What is the pathophysiology of delerium tremens?
1. Alcohol use: Inhibition of the electrical activity of the brain
This is due to stimulation of GABA receptors and inhibition of NMDA (glutamate) receptors
2. Chronic alcohol use - GABA system down regulated, glutamate system upregulated to balance the effects of alcohol
3. When alcohol is removed from the system GABA under functions and glutamate over functions, cuasing an extreme excitability of the brain with excess adrenergic activity.
97
In particular what vitamin needs to be replaced in alocholics?
Thiamine (vit B1)
Given as pabrinex IV in alcohol withdrawal. ( B1, B2, B6, nicotinamide, vitamin C and glucose)
Given as oral suplimentation at a lower dose afterwards
98
What complications can arise from vitamin B1 (thiamine) deficiency?
Wernicke-Korsakoff Syndrome (WKS)
1. Wernicke's encephalopathy
2. Korsakoff syndrome
99
What benzodiazapine is given as first line to combat alcohol withdrawal?
Chlordiazepoxide
| Given over 5-7 days, titrated down
100
Clinical features of Wernicke's encephalopathy?
Confusion
OCulomotor disturbances
Ataxia
Medical emergency, high mortality rate if left untreated
101
Clinical features of Korsakoffs syndrome?
```
Memeory impairment (retrograde and aterograde)
Behavioural change
```
Often irreversable
102
What are the most common causes of liver pathology where ALT>500
Viral (consider hep A and E)
Ischemia
Toxicity (usually paracetomol)
Autoimmune
103
What are the most common causes of liver pathology where ALT 100-200?
Non-alcoholic steatohepaititis
Autoimmune hepaitits
CHronic viral hepatitis
Drug induced liver injury
104
What cholestatic pathologies cause duct dilations?
Gallstones
| Mallignanacy
105
What cholestatic pathologies cause non-dilated ducts?
Alcoholic hepaititis
Cirrhosis - PBC, PSC, Alcohol
Drug induced liver injury (antibioitics - co-amoixclav)
106
What is included in the liver screen?
Hepatitis B&C serology (+A and E in acute disease with marked ALT rise)
Iron studies (ferritin and transferrin saturation)
Autoantibodies (AMA&SMA) and immunoglobins
Consider caeuruloplasmin if under 30 years
Alpha-a-antityrpsin
Coeliac serology
TFTs, lipids, glucose
107
What are the symptoms of coeliac disease?
```
Loose stools
Bloating
Wind
Abdominal cramps
Weight loss
Dermatitis herpetiformis
```
108
What are the potential complications of coeliac disease?
```
Small bowel cancer
Small bowel lymphoma
Osteoperosis
Gluten Ataxia
Gluten neuropathy
```
109
What enzyme is raised in the bloods of most patients with coeliac disease (although not diagnostic in adult patients)
tTG (tissue transglutaminase)
110
What is histologically seen in coeliac disease?
Villous atrophy
| Intra-epithelial lymphocytosis
111
When red flag symptoms or atypical symptoms are associated with dysphagia/weight loss/new onset at older age what investigation is indicated?
OGD should be considered
112
What causes oesphageal dysphagia?
Physical obstruction
| Neuromuscular problem
113
Neuromuscular causes of oesophageal dysphagia
Achalasia
Dysmotility
Prebyoesophagus
114
Obstructive causes of oesophageal dysphagia?
Tumor
Benign (peptic) stricture
Inflmattion from oesophagitis
115
What is used to exclude obstrcutive causes of oesophageal dysphagia?
OGD
116
What investigations will identify neuromuscular causes of oesophageal dysphagia?
Barium swallow
| Oesophageal manometry
117
What is the medical term for a painful swallow?
Odynophagia
118
How are benign oesophogeal stricture treated?
Dilatation
119
How are oesophogeal cancers managed definitively?
Stenting
| Surgical resection
120
What is oro-pharangeal dysphagia?
Difficulty getting the food to mouth
121
What usually causes oro-pharyngeal dysphagia?
Problems coordinating the muscles that move the food bolus to the back of the mouth, as the result of a neurological disease such as a stroke
122
What should be examined/investigated in a patient with oro-pharangeal dysphagia?
Cranial nerve examination
SALT assesment
A video-fluroscopy
123
What are the functions of the liver?
```
Stores glycogen
Releases glucose
Absorbs fats, fat soluble vitamins & iron
Manufactures cholesterol
Dissolves dietary fats
Breakdown product of haemoglobin
Manufactures most clotting products
Drug excretion (/activation)
Alcohol breakdown
Kupfer cells engulf antigens
Albumin and binding protin manufacture
```
124
Risk factors for liver disease
```
Blood transfusions (prior to 1990 in the UK)
IVDU
Operations/vaccinations with dubious sterile procedures
Sexual exposure
Medication (prescribed/self prescribed)
FH of liver disease, diabetes, IBD
Obesity
Features of metabolic syndrom
Alcohol dependency/abuse
Forigen travel
```
125
Examples of causes of acute liver disease (resolves within 6 months)
```
Hep A
Hep E
CMV
EBV
Drug induced liver injury
```
126
What is thrombocytopenia (in liver pathology) a sensitive marker for?
Liver fibrosis
127
USS findings that suggest liver cirrhosis?
Coarse tecture
Nodularity
Splenomegaly
Ascites
128
Most common causes of chronic liver disease?
Alcoholic liver disease
Non-alcoholic steatohepatitis
Viral hepatitis (B&C)
129
Less common but important causes of chronic liver disease?
```
Autoimmune hepatitis
Primary bililary cholangitis
Primary sclerosing cholangitis
Haemachromatosis
Wilsons disease and anti LKM autoimmune hepatitis (both in adolescents and young adults)
```
130
How does familial adenomatosis polyposis coli present?
Often seen on endoscopy with the formation of hundreds of polyps within the colon
Patients will inveitibly develop carcinoma
131
What is the presence of varicies on endocsopy in a patient with chronic liver disease also diagnostic of?
Liver cirrhosis
132
Primary prophylaxis for patients with varices?
Beta blockers
| Oesophageal variceal ligation for medium/large varices
133
How is ascites treated pharmacologically?
Sprinolactone
134
How can tense ascites be treated?
Paracentesis
135
Other conditions which patients with liver cirrhosis are at risk of, and what screening can be performed?
Osteoperosis, dexascan
| Hepatocellular carcinoma, alpha-fetoprotein and USS every 6 months
136
Other conditions which patients with liver cirrhosis are at risk of, and what screening can be performed?
Osteoperosis, dexascan
| Hepatocellular carcinoma, alpha-fetoprotein and USS every 6 months
137
What is performed in a diagnostic ascitic tap (to look for SBP)?
Cell count and MC&S
138
What are the factors used to calculate a MUST score, for screening for malnutrition?
BMI (18.5-20 = 1. <18.5 = 2)
Unexplained weight loss in past 3-6 months (5-10% = 1, >10% = 2)
If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days (2)
139
What MUST score indicated medium risk?
1
140
What MUST score indicates high risk?
2 or more
141
First step in managing malnutrition?
High calorie options
Reduced mealtime interruptions
Food fortification
Dietitian referral
142
Options to feed patients with an unsafe swallow?
NG Tube
PEG/RIG/PEGJ/RIGJ
Parenteral Nutrition (macronutrients and micronutrients given via PICC or Hickman line)
143
Risks of TPN?
Sepsis
| Liver dysfunction
144
How can you ensure that you have correctly placed an NG tube?
Test pH of aspirate
| CXR
145
How can you ensure that you have correctly placed an NG tube?
Test pH of aspirate
| CXR
146
Which tubes can be used for longer-term enteral feeding into the stomach?
PEG
| RIG
147
Which tubes can be used for longer-term enteral feeding into the small bowel?
PEG-J
| RIG-J
148
What is important to clarify in a history from a patient with a GI bleed?
Is it haematemesis? (fresh blood, vomited)
Coffee ground vomit (?altered blood)
Melaena (black, tarry sticky stool)
Fresh PR bleeding (lower GI bleed, or brisk upper GI bleed in a very haemodynamically unstable patient?
149
Risk factors for an upper GI bleed?
```
Varices
Chronic liver disease (/stigmata of)
NSAIDs
Antiplatelets
Anticoagulants
```
150
What scores can be used to assess GI bleeding?
ROCKALL score
| Blatchford score
151
What score is used to predict the need for intervention in a GI bleed (such as blood transfusion, therapeutic endoscopy)?
The Blatchford score
152
What score is used to predict the need for intervention in a GI bleed (such as blood transfusion, therapeutic endoscopy)?
The Blatchford score
153
What investigations may be helpful in a GI bleed?
FBC (Hb, platelet count (thrombocytopenia in liver disease))
U&Es - a raised urea supports a diagnosis of upper GI bleeding
Clotting - abnormal clotting
Group and Save (Cross match if haemodynamically unstable) in case blood transfusion required
LFTs - chronic liver disease (but normal does not rule out)
154
What is the quickest way to get a haemoglobin result in a haemodynamically unstable?
Venous Blood Gas
155
How is Variceal bleeding managed?
Fluid resuscitation followed by blood if heamodynamically unstable (note that systolic BP is often low in pts with cirrhosis)
IV Terlipression
IVAbx
Endocscopy with band ligation (or Liton tube or TIPSS if unsucsessful)
156
What does TIPSS stand for?
trans-jugular, intrahepatic porto-systemic shunt
157
Is there evidence for giving PPI before an endoscopy?
Not in a non-variceal bleed
158
How might paracetamol overdose present?
```
Asymptomatic
N&V
Loin pain
Haematuria and proteinuria
Jaundice
Abdominal pain
Coma
Severe metabolic acidosis
```
158
How might paracetamol overdose present?
```
Asymptomatic
N&V
Loin pain
Haematuria and proteinuria
Jaundice
Abdominal pain
Coma
Severe metabolic acidosis
```
159
What is the name of the toxic symptoms that builds up during a paracetamol overdose?
NAPQI
| N-acetyl-p-benzoquinone-imine
160
How is paracetamol overdose managed when ingestion was less than one hour ago and the dose was over >150mg/kg
Activated charcoal
161
How is paracetamol overdose managed when the ingestion was staggered, or when ingestion was over 15 hours ago?
Start N-acetylcysteine immediatley
162
How is paracetamol overdose managed when ingestion was less than 4 hours ago?
At FOUR HOURS take a level and treat with N-acetylcysteine based on level
163
How is paracetamol overdose managed when ingestion was 4-15 hours ago?
Take immediate level and treat based on level
164
What bloods should be obtained in paracetamol overdose?
```
Paracetamol level
FBC
U&Es
INR
VBG
```
165
How should an anyphlactoid reaction to NAC be managed?
Stopping the infusion temporarily, restarting at a lower rate
(Not a true anaphylactic reaction)
166
In which patients, due to their increased risk of paracetamol overdose toxicity, be given NAC immediately?
Patients on long-term enzyme inducers
Regular alcohol excess
Pre-existing liver disease
Glutathione-deplete states: eating disorders, malnutrition, HIV
167
What is the triple therapy for H-pylroi erradication?
Amoxicillin, clarithromycin and a PPI twice daily for seven days
168
Why do patients with CLD often have excorations?
Excorations as a result of scratching secondary to pruritis associated with raised serum bilirubin, generally preceeds jaundice
169
What can be used to reduce pruritus in chronic liver disease?
Colestyramine, a bile acid sequestriant, to reduce raised serum bilirubin
170
What are the two main causes of high urea - ‘protein meal’?
The 2 major causes of this includes a high-protein diet or an upper
gastrointestinal bleed, the latter occurring as a result of gut bacteria breaking down blood proteins.
171
What blood markers are indicative of refeeding syndrome?
Low phosphate
Low magnesium
Low potassium
Hyperglycaemia
172
How is refeeding syndrome managed?
Slow introduction of food
| Thiamine replacement
173
What electrolyte imbalance can severe vomiting cause?
Metabolic alkalosis (by product of increased acid secretion in the stomach)
Hypokalaemia (due to increased potassium wasting in the kidneys in exhcnage for proton retention to combat the alkalosis)
Hypochloraemia (due to loss of chloride in the vomit)
174
How do you calculate units of alcohol?
Strength (ABV) x Volume (ml)
175
Where is vitamin B12 absorbed?
Terminal ileum
176
Where is folic acid, nicotinamide and vitamin D absorbed?
Jejunum
177
Clinical signs indicative of portal HTN?
Caput medusae
| Splenomegaly
178
What is Budd-Chiari Syndrome?
Hepatic vein obstruction
Classic triad: severe abdominal pain, ascites, tender hepatomegaly
Primary if there is hepatic vein thrombosis
Often seen in pts with haematological conditions (e.g polycythaemia ruba vera), or pro-coagulable states
Secondary if there is external compression of hepatic vein (secondary to a liver, renal, or adrenal tumour)
179
Gold standard for diagnosis of Budd-Chiari Syndrome?
Diagnosis is an abdnominal USS with Doppler studies?
180
Common electrolyte distrubance in Crohn's disease?
Hypomagnesia due to malabsorption and diahorrea
181
Why can re-feeding syndrome lead to arrythmias, diarrhoea and seizures?
Hypomagnesaemia
| Severe hypophosphatemia
182
What is the
183
What is gastroparesis?
Syndrome of delayed gastric emptying in the absence of mechanical obstruction.
184
Features of gastroperisis?
```
Post-prandial fullness
Nausea
Vomiting,
Bloating
Abdominal pain
```
185
Causes of gastroperisis?
Poorly controlled diabetes leading to longer period of hyperglycemia, causing automonic neuropathy - which can affect the gastric system and caused delayed gastric emptying
Post bariatric surgery
Parkinson's disease
Scleroderma
185
Causes of gastroperisis?
Poorly controlled diabetes leading to longer period of hyperglycemia, causing automonic neuropathy - which can affect the gastric system and caused delayed gastric emptying
Post bariatric surgery
Parkinson's disease
Scleroderma
186
What is toxic megacolon?
Toxic megacolon occurs when a section of the colon becomes inflamed and damaged, resulting in a breakdown of the mucosa and exposure of the muscular component of the bowel wall. As a result, there is a loss of tone and motility in the affected section that can result in a build-up of faecal matter and consequently complications such as infection and perforation.
187
What type of infective gastroenteritis is associated with profuse vomiting and short incubation period?
Staphylococcus aureus gastroenteritis
188
Pain from gastric ulcers
Pain from gastric ulcers is classically exacerbated by food, and maximal within 30 minutes to an hour of eating a meal
189
Diagnosis of gastric ulcers?
OGD
190
First line management of staggered paracetmol overdose?
In patients who have taken a staggered overdose first line treatment is with N-acetylcysteine regardless of the time from ingestion.
191
When is it appropriate to take blood paracetamol level and wait for result before initiating treatment in a pt with paracetomol overdose?
This is the correct course of action in patients with an overdose of <150mg/kg that has been ingested within a 1 hour period - not staggered,
192
When should activated charcol be given in paracetmol overdosE?
In a non-staggered overdose presenting within an hour when the GCS is 8 or higher
193
What is type of anaemia does iron def cause?
Iron deficiency causes a microcytic, hypochromic anaemia.
194
What type of anaemia does B12 def cause?
B12 deficiency can cause a macrocytic anaemia.
195
Anaemia in malnourished pts?
In patients with marked generalised malnutrition (as is clear from this patient's history) a normocytic anaemia can prevail. This is due to mixed effects of iron deficiency (which normally causes a microcytic anaemia) and B12 +/- folate deficiency (which normally causes a macrocytic anaemia).
196
How long before testing must a pt be eating gluten when investigating coeliac disease?
Patients must eat gluten for at least 6 weeks before they are tested
197
What landmark determines upper vs lower gi bleed
The definition of an Upper GI Bleed is a haemorrhage with an origin proximal to the ligament of Treitz
198
Histology in coeliac
Villous atrophy
Crypt hyperplasia
Intraepithelial lymphocytes
199
Rash in coealiac?
Dermititis herpetiformis
200
Second line treatment of hepatic enchephalopathy?
Rifaximin
Embolisation of portosytemic shunts
Liver transplant
201
Precipiates of heptatic enchepaholopathy
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Bleeding (upper GI)
Infection
Constipation
Electrolyte imbalance
Protein intake
Sedation
Renal failure
```
202
Anaemia in coeliac disease?
1. Anaemia of chronic disease (microcytic)
2. B12 def (macrocytic)
3. Folate def (macrocytic)
Therefore pts will have either microcytic anaemia (iron def dominates) or normocytic (due to mixture of all 3)
203
What does vitamin B1 (thiamine) deficiency cause?
Cognative impairment
204
Causes of koilonychia (spoon shaped nails)
Iron deficiency anaemia (e.g. Crohn’s disease)
Lichen planus
Rheumatic fever
205
Causes of leukonychia (whitening of nails)
Nailbed trauma
Hypoalbuminaemia (e.g. end-stage liver disease, protein-losing enteropathy)
Chemotherapy
206
What is seen on bariam swallow in achlasia?
Birds beak appearance
207
What antibodies can cause pernicious anaemia?
Anti-intrinsic factor antibodies - bind to intrinsic factor made by parietal cells in gastric fundus so Vitamin b12 reduced absorption in terminal illeum
208
What gastroenterology condition is associated with anti-microbial antibodies?
PBC
209
What gastroenterology condition is associated with intrinsic factor antibodies?
Pernicious anemia
210
What gastroenterology condition is associated with anti-glandin antibodies?
Coeliac
211
What gastroenterology condition is associated with anti smooth muscle antiboides?
Autoimmune hepaitis
212
How to assess if alcohol intake is problematic?
CAGE
Felt need to Cut down
Do you get Annoyed by people critising your drinking
Do you ever feel Guilty about drinking
Do you ever need a drink Early in the morning
213
Macrocytosis?
Loss of central hollowness on blood film
| RBC appear higher
214
Causes of macrocytosis?
B12 def
Folate def
Liver disease
215
Which liver enzymes are most associated with alochol liver diesase?
Gamma GT
| ALT
216
Alchol withdrawal timeline?
1. 8 hours - anxiety, nauseua, insomina abdopain
2. Days 1-3 High blood presuure increase body temp
3. 1 week Hallucination fever seizures and agidtation
217
Gilbert syndrome
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Autosomal recessibe
20-60 bilirubin
Associated flares with stress
Jaundice with no other abnormality
Reassure and discharge
```
218
Secondary prophylaxis of hepatic encephalopathy?
Lactulose and rifaximin
219
Globus pharygis
Globus pharyngis (also known as globus hystericus) is the persistent sensation of having a 'lump in the throat', when there is none
220
What is pellagra?
Def of vit B3 (nican)
| Dementia, dermatitis, death
221
If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given what?
either oral azathioprine or oral mercaptopurine to maintain remission
222
Urine dip where Urobilinogen is absent. Bilirubin is strongly positive?
Conjugated bilirubin only = post hepatic jaundice
