Gastroenterology Flashcards
(197 cards)
1
Q
What is biliary colic?
A
Biliary colic is crampy abdominal pain in the RUQ caused by a gallstone being intermittently stuck in the neck of the bladder/ cystic duct after gallbladder contraction
2
Q
What are the symptoms of biliary colic?
A
RUQ pain
Radiation to right shoulder and scapula
Nausea
Vomiting
Intolerance for fatty foods
3
Q
How is biliary colic diagnosed?
A
Liver function tests will be normal
Bloods will be normal
Ultrasound: shows gallstones in a thin walled gall bladder
4
Q
How does biliary colic often present?
A
Usually after eating a fatty meal: pain may start a few hours after finishing the meal. Patient will have had recurrent episodes of pain in the past
5
Q
How is biliary colic treated?
A
Analgesia, antiemetics, IV fluids
Elective laprascopic cholecystectomy
6
Q
What is the normal common bile duct diameter?
A
Less than 6mm
7
Q
What is acute cholecystitis?
A
Cholecystitis is inflammation of the gallbladder usually due to gallstones, however, it can also be caused by an infection, hypo perfusion and as a result of parenteral feeding
8
Q
What are the symptoms of acute cholecystitis?
A
RUQ pain
Pain on movement
Fever
Nausea
Vomiting
Jaundice: If stone is impacted in common bile duct
9
Q
Describe the bloods seen in acute cholecystitis?
A
Raised CRP
Raised WBC
Possibly raised ALP, BR, and GGT
10
Q
How do you treat acute cholecystitis?
A
Nil by mouth
IV fluids
IV antibiotics
Laprascopic cholecystectomy within 1 week of diagnosis
11
Q
What clinical signs can be elicited in acute cholecystitis?
A
Murphy sign: pressing on the RUQ and asking patient to inspire, will cause pain and halting of breathing
12
Q
What are some complications of acute cholecystitis?
A
Perforation
Gallbladder empyema
Gangrenous cholecystitis: necrosis and perforation of the gallbladder wall as a result of ischemia following progressive vascular insufficiency.
13
Q
What will an abdominal ultrasound show in cholecystitis?
A
Thickened gallbladder wall
Pericholecystic fluid
Gallstone in neck of gallbladder
Sludge
14
Q
What is ascending Cholangitis?
A
Infection of the common bile duct usually due to impacted gallstone
15
Q
What is the gold standard investigation and intervention for ascending Cholangitis?
A
ERCP
16
Q
What symptoms are seen in Cholangitis?
A
Chariots triad: jaundice, fever, RUQ pain
Nausea
Vomiting
Mental confusion
Hypotension
Tachycardia
17
Q
What imaging is done for Cholangitis?
A
Ultrasound
CT
MRCP
18
Q
How is Cholangitis treated?
A
ERCP +/- sphincterotomy: to remove stones from common bile duct
Stent insertion: strictures
Percutaneus transhepatic cholecystostomy: for patients who are unsuitable for ERCP or where ERCP has failed. Allows drainage of gallbladder contents to relieve symptoms.
19
Q
What are the most common organisms causing Cholangitis?
A
E.coli
Klebsiella
Enterococcus
20
Q
What is choledocholelithiasis?
A
Gallstones in the common bile duct
21
Q
How can choledocholelithiasis present if there is complete obstruction?
A
Abdominal pain
Jaundice
Itching
Pale stools
Dark urine
22
Q
Causes of obstructive jaundice?
A
Gallstones
Cholangiocarcinoma
Pancreatic head cancer
Pancreatitis causing strictures
23
Q
Why does primary biliary Cholangitis cause high cholesterol levels?
A
Cholesterol is one of the molecules found in bile. When the intrahepatic bile ducts become damaged, the flow of bile is reduced, resulting in back pressure. This results in the build up of cholesterol in the blood.
24
Q
What are the 2 main initial symptoms in primary biliary Cholangitis?
A
Fatigue
Pruritus (itch)
25
What symptoms aside from fatigue and itching, can be seen in primary biliary Cholangitis?
Jaundice
Xanthomata
Xanthelasma
Pale stools
Dark urine
Hyperpigmentation
Muscle and joint pain
Steatorrhoea
Peripheral oedema
Weight loss
26
Describe the typical presentation of PBC?
Middle aged (40-60) white woman presents with fatigue and itching. Bloods show raised ALP and positive AMA.
27
What is Primary biliary Cholangitis?
It is an autoimmune condition which causes chronic inflammation of the intrahepatic bile ducts. This results in destruction and cholestasis of bile. This eventually leads to liver scarring and eventually cirrhosis.
28
How is primary biliary Cholangitis diagnosed?
Bloods: raised ALP, cholesterol, IgM
Presence of Antimocrobial antiobodies
29
What percentage of patients with PBC test positive for anti microbial antibodies (AMA)
98%
30
What is the first line management for PBC?
Urodeoxycholic acid: non toxic hydrophilic bile acid. Protects cholangiocytes and makes bile less harmful to epithelial cells.
31
Aside from ursodeoxycholic acid what other treatment is available for PBC?
Colestyramine: for itching, reduces intestinal reabsorbtion of bile acids
Replacement of fat soluble vitamins
Bisphosphonates
Immunosuppression: with steroids
Liver transplant
32
What is PSC?
Primary sclerosing Cholangitis. It is the inflammation of both the intrahepatic and extrahepatic bile ducts, resulting in damage and sclerosis. This resulted in multi focal bile duct strictures resulting in the restriction of bile flow. Eventually leading to liver damage and cirrhosis.
33
Which auto immune conditions are associated with PSC?
Ulcerative colitis
Crohns
HIV
34
How does PSC present in the early stages?
Asymptomatic
Raised ALPs
35
What symptoms are seen in PSC?
RUQ pain
Jaundice
Pruritus
Fatigue
Weight loss
Hepatomegaly
Splenomegaly
36
What is the gold standard investigation for PSC?
MRCP: allows visualisation of biliary tree
37
What investigations are done for PSC?
MRCP
LFTs
P-Anca
Colonoscopy
Ultrasound
38
Describe the typical presentation of PSC?
White, middle aged male with existing UC, presents with itching and fatigue
39
How is PSC treated?
ERCP: ballon dilation and stunting
Liver transplant
UDCA
Cholestyramine
40
What lifestyle adjustments can be made to aid PSC treatment?
- Reducing alcohol intake
- fat soluble vitamin supplements
- osteoporosis screening
- calcium supplements, bisphosphonates
- monitor LFTs
41
What is the percentage risk for cholangiocarcinoma in PSC patients?
10-20%
42
What is the survival rate for liver transplant in PSC patients?
70% 10 year survival rate
43
What are the complications of PSC?
Acute bacterial Cholangitis
Cholangiocarcinoma
Cirrhosis: portal hypertension, oesophageal varies
Osteoporosis
44
What conditions are associated with PBC?
Sjögren’s syndrome
Rheumatoid arthritis
Thyroid disease
45
In a patient with PBC, when do you refer them for liver transplantation?
If bilirubin is > 100 micromils/ litre
46
What are the 5 types of viral hepatitis?
A
B
C
D
E
47
Which viral hepatitis is a DNA virus?
B
48
Which viral hepatitis is only possible in those with hepatitis B?
D
49
Which viral hepatitis is transmitted via the faecal oral route?
A and E
50
Which hepatitis viruses are notifiable diseases?
All of them
51
Who qualifies for hepatitis A vaccine?
- travelling
- men who have sex with men
- frequent injecting drug users
- chronic liver disease
- professions: sewage workers
52
How is Hepatitis A diagnosed?
LFTs: deranged
Viral screen for hepatitis A serology
- Anti- HAV IgM
- Anti- HAV Total
- PCR for Hepatitis A RNA
53
If Hepatitis A serology shows the following what does it indicate:
- positive anti-HAV IgM
- positive anti-HAV IgG
Acute hepatitis infection
54
What are the different phases of symptoms in hepatitis infection?
Prodromal phase: flu like symptoms (3-10 days)
- nausea
- vomiting
- headaches
- muscle pain, malaise, fever, fatigue
Icteric phase: 1- 12 weeks
- jaundice, itching, pale stools, dark urine, helatomegaly, splenomegaly,
Convalescent phase: up to 6 months
- Malaise, anorexia, muscle weakness
55
How is Hepatitis A treated?
Hepatitis A should resolve on its own within 1-6 months
Supportive treatment: rest, hydration
Antiemetics: metoclopramide
Analgesia: paracetamol, ibuprofen, codeine (in mild liver impairment)
Itching: loose clothing, avoid hot showers, cool environment, chlorphenamine
56
How is hepatitis B transmitted?
Blood and bodily fluids
57
How is hepatitis B diagnosed?
LFTs
Liver ultrasound
Liver biopsy
Hepatitis B serology
HBV-DNA
58
How do you manage acute hepatitis B?
Same as Hepatitis A
Repeat Hepatitis serology after 6 months to check if it’s chronic
59
How is chronic hepatitis B treated?
Regular review by liver specialist:
- screen for HCC
- monitor serology
- pegylated interferon Alpha
Tenofovir/ entecavir
60
What type of hepatitis B infection does the following results indicate?
HBsAg: Positive
Anti-HBs: negative
HBeAg: positive
Anti-HBe: negative
Anti-HBc IgM: negative
HBV-DNA: positive
Chronic hepatitis B: Active
61
When is HBeAg positive?
It is positive in acute and chronic (active) infection
62
What is HBeAg a marker of?
Active viral replication and increased transmissibility
63
When are babies given the hepatitis b vaccine? What happens if mother is hepatitis B positive?
6 in 1 vaccine at 8,12 and 16 weeks
Hep b positive mother: additional doses at 24hrs, 4 weeks and 12 months
64
Which type of hepatitis is curable?
C
65
How is hepatitis c diagnosed?
Anti-HCV
Hepatitis C RNA
66
What does positive hepatitis RNA indicate?
Current hepatitis C infection
67
How is hepatitis c treated?
Supportive treatment
Direct acting antivirals: treatment dependant on genotype
68
What is the aim of treatment in hepatitis c?
Sustained viral response: undetectable viral load 6 months after completion of therapy
69
How many genotypes of hepatitis c are there? Which are the most common?
11
1,2,3
70
What is co infection and superinfection? (Hepatitis B)
Co- infection: infected with both hepatitis B and D at the same time
Superinfection: hepatitis B patient is subsequently infected with Hepatitis D
71
Can hepatitis E become chronic?
Very rarely and only in immunocompromised patients/ organ transplant patients
72
What is the most common hepatitis in the UK?
E
73
What group of people have the highest mortality rate with hepatitis E?
Pregnant women
74
What is pancreatitis?
Inflammation of the pancreas
75
What are some causes of pancreatitis?
Idiopathic, steroids, ERCP, gallstones, hyperlipidaemia, alcohol
76
How is pancreatitis diagnosed?
Serum lipase/ amylase: 3x upper limit
Characteristic symptoms
77
What imaging is done for pancreatitis?
Ultrasound
CT: complications
78
How is pancreatitis treated?
- Aggressive fluid resuscitation
- IV analgesia
- nutrional support
- oxygen
- antibiotics: sepsis, Cholangitis
Surgical:
- ERCP
- percutaneus/ endoscopic drainage
79
What are the complications of pancreatitis?
Pseudocysts
Pancreatic abscess
Pancreatic necrosis
80
What is a pancreatic pseudocyst? How is it treated?
A pancreatic pseudocyst is a collection of pancreatic fluid surrounded by granulation tissue. These can often be asymptomatic and if symptomatic can resolve on their own. However, they can also become infected and would therefore need drainage. Treatment is cystogastroscopy (endoscopic drainage of cysts)
81
What are complications of pancreatic pseudocysts?
Bowel obstruction
Vessel obstruction
Rupture
Infection
82
Describe the process of pancreatic necrosis?
Extra ducal release of pancreatic enzymes causing auto digestion as well as hypovolemia (SIRS) resulting in poor perfusion and tissue death. This necrotic tissue can become infective and spread to other organs in the body. Treatment is required once complications or infection have developed. Treatment involves debridement and drainage.
83
What additional symptoms are seen in chronic pancreatitis?
- pain worse after eating
- steatorrhoea
- diabetes Mellitus
- Weight loss
84
In chronic pancreatitis, what can be seen on an x ray?
Multiple small calcification foci
85
Which medications can cause pancreatitis?
Azathioprine
Mesalazine
Furosemide
Sodium valproate
86
What is the preferred investigation for chronic pancreatitis?
CT: 85% specificity
87
How is chronic pancreatitis treated?
Lifestyle:
- quit smoking
- reduce alcohol intake
- high calorie, high protein diet
Medical:
- pancreatic enzyme supplementation (croon)
- vitamin supplementation
- analgesia
- insulin regimens
- ERCP: strictures, biliary obstruction
- pancreatic resection
88
Why do cholesterol levels increase in cholestasis?
Bile is the normal excretory pathway for cholesterol. If there is reduced flow of bile, cholesterol degradation and secretion is impaired. As a result cholesterol levels build up in the blood.
89
Explain the pathogenesis in appendicitis?
Obstruction results in increased luminal pressure. This compromises lymphatic and venous drainage. This results in hypoxia and tissue ischaemia. Obstruction also creates an environment that promotes bacterial growth allowing invasion of bacteria into the appendix. This results in an inflammatory response. This can lead to necrosis and ultimately perforation.
90
What is the proposed function of the appendix?
Lymphatic drainage
Production and maintenance of good bacteria
91
What symptoms are seen in acute appendicitis?
Umbilical pain moving to RIF
Nausea
Vomiting
Anorexia: loss of appetite
Pain worse on coughing
92
What are the possible causes of appendicitis?
Faecoliths
Lymphoid hyperplasia
Foreign body
Malignancy
Direct bacterial invasion
93
What are some differentials for appendicitis?
Ovarian cyst
Ectopic pregnancy
Meckels diverticulitis
Testicular torsion
UTI
Pelvic inflammatory disease
Crohns
94
What investigations are done for suspected appendicitis?
FBC (neutrophils)
CRP
Urinalysis: HCG
Ultrasound: gynaecological pathology
95
How is uncomplicated appendicitis treated?
Appendicectomy: ideally laparoscopic
IV fluids
IV antibiotics
96
What is an appendix mass?
This is when the surrounding omentum sticks to the inflamed appendix, forming a mass in the RIF. Initially managed with analgesia and antibiotics. Once resolved an appendicectomy can be performed. Ultrasound and CT
97
If patient presents clinically with appendicitis but investigations are negative, what can be done?
Observation: monitor patient and see if there is any improvement, give antibiotics and fluids.
Diagnostic laparoscopy
98
What are some complications of appendicitis?
Appendix mass
Abscess formation
Phlegmon
99
What are the 2 types of IBD?
Crohns
Ulcerative colitis
100
What symptoms are seen in Crohns?
Chronic diarrhoea
Weight loss
Fatigue
Nausea
Vomiting
Abdominal pain: typically right iliac fossa
Mouth ulcers
Perinatal disease: itch, pain, fissures
101
What extraintestinal symptoms can be seen in Crohns?
Uveitis: pain on eye movement, photophobia, blurry vision
Erythema nodosum
Pyoderma gangrenosum
Gallstones
Renal stones
Arthritis
102
Explain how Crohns causes fistula formation? What is the most common?
Crohns causes chronic inflammation of most frequently the intestine. The inflammation is transmural and affects the whole intestinal wall. This results in tracts forming between the intestinal lumen/ anal canal and nearby structures. This allows the movement of bacteria, air and faeces to enter surrounding structures causing infection resulting in abscess.
The most common being enterovesical (UTI) and perianal (abscess)
103
What signs can be seen on examination in Crohns?
- tenderness in RIF or generalised
- erythema nodosum
- absent bowel sounds
Clubbing
Pallor
Red eye
Perinatal tenderness, reddened skin, abscess
104
What investigations should be done in suspected Crohns ?
FBC
CRP
ESR
LFTs
Iron profile/ haematinics
Anti-TTG
Stool sample: culture and fecal cal protection
Colonoscopy + biopsy
MRI/ CT
105
What will colonoscopy show in Crohns?
Skip lesions
Cobble stoning
Ulcers
106
What will CT show in Crohn’s disease?
Fistulas
Abscesses
Strictures
Bowel wall thickness
107
How is Crohns remission induced?
First line: corticosteroids: IV hydrocortisone, prednisone
- If ileocaecal disease/ corticosteroid not tolerated and contraindicated offer budesonide
Second line: single exarcerbation in 12 months/ first presentation and unable to tolerate glucocorticoids offer an aminosalicylate (mesalazine/ sulfasalazine)
Third line: If patient has had 2 or more exarcerbation within the last 12 months/ glucocorticoid cannot be tapered add on a thiopurine (azathioprine) or methotrexate
Fourth line: Biologics (infliximab) severe Crohn’s disease
108
What must be assessed before starting a thiopurine?
TPMT: thiopurine methyltransferase activity
109
What is the first line and second line medication for remission maintenance in Crohns?
Azathioprine
Methotrexate
110
What surgical options are available for Crohns?
Resection of distal ileum
Segmental bowel resections
ERCP stricture ballooning
Abscess drainage
Fistula removal
111
What should patients with Crohns be advised to do first and foremost?
QUIT SMOKING
112
What type of drug is infliximab?
Anti- tumour necrosis factor alpha
113
When should budenoside be offered instead of a corticosteroid for Crohns?
If it’s the patients first presentation or they have had a single exarcerbation in the last 12 months
And
Unable to tolerate/ contraindicated to glucocorticosteroids?
114
What should be first line treatment in children and adolescents with Crohns exarcerbation? Why?
Enteral nutrition. This is due to concerns about growth or side effects
115
How is a mild to moderate exarcerbation of ulcerative colitis treated?
First line: topical aminosalicylate (mesalazine), if remission not induced within 4 weeks change to oral
Second line: If remission still not induced add oral or topical corticosteroid
116
How is severe a exarcerbation of ulcerative colitis treated?
First line: IV corticosteroid (hydrocortisone)
If steroid is not tolerated or contraindicated give IV ciclosporin
Second line: If within 72 hours no improvement add IV ciclosporin
Third line: Surgery-
117
How is remission maintained in mild, moderate and severe ulcerative colitis?
Mild to moderate:
First line: Aminosalicyclate (topical) or both oral and topical aminosalicylate
Severe: oral azathioprine (methotrexate)
118
How does ulcerative colitis show on colonoscopy?
Uniformed ulceration of the mucosa
Granulation
Pseudopolyps
119
How does ulcerative colitis present on biopsy?
Crypt abscesses
Crypt distortion
Inflammation extending to submucosa only
120
What are the complications of ulcerative colitis?
Toxic mega colon
Perforation
Colorectal cancer
121
How often should patients with ulcerative colitis have a colonoscopy?
Everyone should have one 10 years after the first onset of symptoms. After that it is dependant on the extent of disease
122
What symptoms are seen in coeliac disease?
Abdominal pain
Abdominal cramping
Weight loss
Fatigue
Inability to thrive
Bloating
Diarrhoea steatorrhoea
Nausea
Vomiting
123
What investigations are done for suspected coeliac?
Anti-ttg
Anti-EMA
Serum IgA
Duodenal biopsy
124
Why is serum IgA needed in coeliac investigations?
A low serum IgA can give a false negative for anti-ttG antibodies
125
What does a biopsy show in coeliac disease?
Crypt hyperplasia
Villus atrophy
126
When should anti-EMA be done for coeliac?
If the anti-tTG antibodies come back equivocal or slightly raised
127
If serum IgA is low what test should be done for coeliac disease?
IgG anti-tTg, anti-SMA or anti-DGP
128
What is the mainstay of treatment for coeliac disease?
Gluten free diet
129
What monitoring should be done for coeliac?
Children: BMI, growth and nutritional status
DEXA scan: osteoporosis
Annually:
- coeliac serology to check adherence
- thyroid function tests
- micronutrients
- type 1 diabetes
130
Which cancers are coeliac patients at an increased risk of?
Enteropathy-associated t-cell lymphoma (EATL): rare, aggressive non Hodgkin lymphoma, associated with refractory coeliac disease.
Small bowel adenocarcinoma
131
Which 2 genes are associated with coeliac disease?
HLA-DQ2
HLA-DQ8
132
In how many cases is coeliac often asymptomatic?
1/3rd
133
What extraintestinal symptoms are seen in coeliac disease?
- osteoporosis
- subfertility and miscarriages
- anaemia
- dermatitis herpetiformis
- angular stomatitis
134
What is the mechanism behind osteoporosis in coeliac disease?
Low calcium and vitamin D absorption resulting in compensatory secondary hyperparathyroidism
135
What is IBS?
Irritable bowel syndrome
It is a functional disorder due to a disruption in the brain gut connection resulting in abnormal gastrointestinal motility and visceral hypersensitivity
136
When should a diagnosis of IBS be considered?
If patient has had 6 months of the one of the following:
- abdominal pain
- Abdominal bloating
- altered bowel habits
137
When can a positive diagnosis of IBS be made in primary care?
If patient has abdominal pain/ discomfort for 6 months that is either relieved on defecation or is associated with altered bowel frequency or stool form, and 2 of the following:
- stool urgency, straining, incomplete evacuation
- mucus
- abdominal bloating, hardness, distension
- worse on eating
138
What is the ROME IV criteria for IBS diagnosis in secondary care?
Patient must have recurrent abdominal pain at least once a week I. The last 3 months, with symptom onset being 6 months ago, associated with 2 or more of the following:
- pain related to defecation
- change in frequency of stool
- change in consistency of stool
139
What are some extra intestinal symptoms that can be seen in IBS?
Lethargy
Nausea
Back pain
Headache
140
What are some common triggers for IBS?
Caffeine
Alcohol
Diet
Stress
Anxiety
Depression
Medications (opioids
141
What investigations are done for IBS?
IBS is a diagnosis by exclusion.
FBC: anaemia
CRP
ESR
Coeliac serology
Faecal cal protection
Ca125
Measure patient BMI and diet
142
How is IBS managed initially?
Lifestyle advice:
- Exercise
- balanced diet
- reduce caffeine
- reduce stress
- reduce alcohol
- regulate fibre intake
- drink plenty of fluid
If unsuccessful refer patient to dietician for specialised dietary advice : Low fodmap
143
What is first line pharmacological treatment for IBS symptoms? When should efficacy be reviewed?
Constipation: bulk forming laxatives
Diarrhoea: loperamide
Pain: antispasmodic agents (peppermint oil, mebeverine hydrocjloride)
Efficacy should be reviewed after 3 months
144
If IBS symptom of constipation persists after 12 months despite maximal dose of laxatives, what medication should be given and when should the patient be reviewed?
Linaclotide, review after 12 weeks
145
What second line treatment is available for IBS?
TCA: amitriptyline
SSRI: citaprolam, fluoxetine
CBT: if refractory
146
What are the 4 classifications of IBS? What are the classifications based on?
IBS- C
IBS- D
IBS- M
IBS- U
Based on Bristol stool chart
147
What are the red flag symptoms in suspected GORD that should be referred for 2 week wait OGD?
Dysphagia
Persistent symptoms despite treatment
Age > 55
Weight loss
Excessive nausea and vomiting
GI bleeding ( malaena/ coffee ground)
Symptoms > 4 weeks
148
How is how should uninvestigated GORD symptoms be treated?
Lifestyle changes
Drugs:
- 4 week course of PPI
- If symptoms return offer low dose of PPI for 1-2months
- If no response offer H2 receptor antagonist
149
How should confirmed GORD be treated?
- 4-8 week course of full dose PPI
- offer h2RA if PPI inadequate
- 8 week course if severe oesophagitis ( if fails then high dose of PPI)
- if symptoms recur then offer PPI at low dose long- term/ as needed
Severe oesophagitis offer full dose PPI long term
-
150
What can h.pylori infection cause?
Peptic ulcers
Gastritis
Increased risk of gastric cancer
Functional dyspepsia
151
What tests are done for h.pylori?
Stool antigen test
Urea breath test
Rapid urease tests.pylori serum antibody test
Gastric biopsy culture
152
Which tests for h.pylori are first line?
Stool antigen
Urea breath test
153
How is h.pylori managed first line?
Triple therapy, 7 day course of:
NPA: PPI + amoxicillin + clarithromycin/ metronidazole
PA: PPI + clarithromycin + metronidazole
154
How long after initial therapy should you retest for h.pylori?
If poor compliance to first line therapy retest for h.pylori 4-8 weeks after
155
How long must a patient with suspected coeliac be eating gluten for before serology testing?
6 weeks
156
What are the risk factors for Barrett’s oesophagus?
Smoking
GORD
Central obesity
Male
157
How is Barrett’s oesophagus treated?
High dose PPI
Endoscopic surveillance
If dysplasia is found: endoscopic ablation or endoscopic mucosal resection
158
Which cancer does Barrett’s oesophagus increase the risk for?
Oesophageal adenocarcinoma
159
What is the most common cause of peptic ulcers?
H. Pylori
160
What are the symptoms of peptic ulcers?
Nausea
Epigastric pain (radiate to back)
Haematemesis
Dyspepsia
Pain relieved or worsened by eating
161
Which type of peptic ulcer is worse on eating?
Gastric ulcer
162
What investigations are done for suspected peptic ulcer?
FBC: microcytic anaemia
Urea breath test
Stool antigen test
Endoscopy: if red flag symptoms
163
What are the complications for peptic ulcers?
Perforation
Bleeding
164
What are some causes of an upper GI bleed?
Mallory Weiss tear
Oesophagitis
Oesophageal varies
Peptic ulcers
Gastric cancer
165
What are the symptoms of an upper GI bleed?
Haematemesis
Malaena
166
How should an upper GI bleed be treated?
Risk assessment: blatchford
Resuscitation: oxygen, fluids
Blood transfusion: do not offer if not actively bleeding/ haemodynamically stable
Platelet transfusion: if platelet count below 50L
Fresh frozen plasma: If INF 1.5x normal
Prothrombin complex concentrate: offer to patients on warfarin and actively bleeding
Endoscopy within 24 hours: treatment based on cause
167
How should a oesophageal variceal bleed be treated?
Terlipressin
Prophylactic antibiotic
Band ligation
Transhugukar I translated portosystemic shunt (TIPS): if not controlled by band ligation
168
How do you treat a non variceal upper GI bleed?
PPI only after endoscopy
Mechanical clips
Thermal coagulation with adrenaline
169
Why is there an increase in urea in an upper GI bleed?
Acid and enzymes break down blood from bleed. Breakdown produces proteins which are absorbed in the GI tract, there is adequate time due to it being an upper GI bleed. Protein is then metabolised in the liver producing urea.
170
What are the 3 stages to alcoholic liver disease?
Fatty liver
Hepatitis
Cirrhosis
171
What tests are done for suspected alcoholic liver disease?
FBC
LFTs
U&Es
Haematinics
Viral hepatitis serology
Ultrasound
AMA
Liver biopsy
Endoscopy
172
What clinical signs can be seen in alcoholic liver disease?
Hands:
Palmar erythema
Dupuytrures contracture
Clubbing
Chest:
Spider naevi
Gynecomastia
Ascites
Hepatomegaly
Splenomegaly
Loss of hair
Reduced libido
173
How is alcoholic liver disease managed?
Alcohol abstinence
Weight loss
Nutrition: high protein diet
Vaccinations
Corticosteroids
Treatment for oesophageal varices and ascites
174
How is ascites treated?
Low sodium diet
Reduce fluid intake if sodium is less than 125
Spironolactone
Prophylactic antibiotics (citaprolam)
Drainage
175
What is the time frame for alcohol withdrawal symptoms?
6-12 hrs: sweating, tremor, headache, nausea
12-24hrs: hallucinations
24-48: seizures (tonic-clonic)
48-72hrs: delirium tremens
176
What is delirium tremens?
Medical emergency due to alcohol withdrawal. GABA under-functions and glutamate over-functions due to sudden alcohol withdrawal. Can lead to wernicke-korsakoff syndrome
177
How is alcohol withdrawal managed?
benzodiazepines (diazepam/ chlordiazepoxide)
Carbamazepine as alternative
Pabrinex (IV or IM)
Long term thiamine
178
What increases risk of wernicke- Korsakoff’s syndrome?
Malnourished
Risk of malnourishment
Existing liver disease
179
What is encephalopathy?
Disturbance to brain function due to infection/ injury
180
In patients with delirium tremens what medication should they be given?
Lorazepam first line
Haloperidol/ IV lorazepam second line
181
What are the side effects for metoclopramide?
Diarrhoea
Dystonia: involuntary muscle contraction
Dyskinesia: involuntary body movement
Avoid in bowel obstruction
182
What are the risk factors for clostridium difficile?
Antibiotics
PPI
183
What symptoms are seen in clostridium difficile infection?
Diarrhoea
Abdominal pain
Toxic mega colon
Fever
184
How is c.difficile diagnosed?
Stool culture to detect the c.difficile toxin
185
How is c.difficile treated?
First line: oral vancomycin for 10 days
Second line: oral fidaxomicin
Third line: oral vancomycin + IV metronidazole
186
How is oesophageal variceal haemorrhage prevented?
Propranolol
Endoscopical variceal band ligation + PPI (to prevent ulcers)
TIPS
187
If a patient presents with ongoing symptoms within 12 weeks of c.diff treatment what antibiotic should they be given?
Oral fidaxomicin
188
Which gene is responsible for haemochromatosis?
HFE gene : chromosome 6
189
What auto antibodies are associated with autoimmune hepatitis?
ANA
Anti-SMA
P-ANCA
LC-1
LKM-1
190
How is autoimmune hepatitis treated?
Moderate to severe: immunosuppressive with prednisolone or azathioprine
Vaccinations against hep b and c
Yearly dexa scan
Calcium and vitamin d supplements
191
What are possible causes of a serum albumin gradient (SAAG) greater than 11g/L?
Portal hypertension causes:
Cirrhosis
Alcoholic liver disease
Liver metastasis
Right heart failure
192
What are the adverse effects of PPIs?
Hypomagnesia
Hyponatraemia
Osteoporosis
Increased risk of c.difficile infection
193
What blood results are indicative of haemochromatosis?
High transferritin
Raised or normal ferritin
Low total iron binding capacity
194
What are some symptoms of haemochromatosis?
Bronze skin
Diabetes mellitus
Hepatomegaly
Cirrhosis
Heart failure
Arthritis
Fatigue
Erectile dysfunction
195
How is autoimmune hepatitis diagnosed?
Diagnosis is via liver biopsy showing hepatocyte swelling, interface hepatitis, plasma cell infiltration and necrosis
196
In which 2 locations are coeliac biopsy’s done? Which is more common?
Jejunum and duodenum
Duodenum is more common
197
What are the symptoms seen in autoimmune hepatitis?
asymptomatic
Jaundice
Fatigue
Cirrhosis
Anorexia
Weight loss
Ammenorrhoea
Pruritus
Pyrexia
