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Gastroenterology Flashcards

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1
Q

Management needlestick

A

High risk if significant exposure to blood or body fluids from source known to be HIV, HCV or HBV infected
Bloods baseline HIV / Hep B / Hep C serology
→ If starting HIV PEP also take FBC,U&E and LFTs
HIV PEP if high risk 1-72 hrs after exposure
Hep B vaccine if mod or high risk+ >1 year since last immunisation or whole course if never immunised if 0-7 days after exposure
Rpt bloods in 3 months

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2
Q

Risk of seroconversion from known positive needlestick injury

A

-HIV 0.3%
* HBV 30%
* HCV 1.8%

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3
Q

Admission criteria for abnormal LFTs

A

Admit if acutely unwell with:
-clinical evidence of liver disease.
-ALT higher than 250, ALP higher than 300, or bilirubin higher than 100.
Urgent hepatology if:
INR> 1.5
PT>18
plts< 100.
albumin< 35 + other abnormal LFTs.
Or well with:
clinical evidence of liver disease.
ALT> 250, ALP> 300, or bilirubin> 100.

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4
Q

8 causes RUQ pain

A

Biliary colic
Cholecystitis
Hepatitis/abscess
Congestive hepatomegaly
Pneumonia
PE
Renal colic
Pyelonephritis

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5
Q

4 causes epigastric pain

A

Pancreatitis
Gastritis/peptic ulcer
MI
Pericarditis

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6
Q

11 causes of RLQ pain

A

Appendicitis
Hernia
IBD
Ruptured AAA
Psoas abscess
testicular/ovarian torsion
Ectopic pregnancy
Endometriosis
PID/epididymitis
UTI
Renal colic

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7
Q

6 causes B12 deficiency

A

pernicious anaemia (75% of cases).
interference of B12 absorption from gastric or ileal disease:
Crohn’s disease.
gastrectomy.
ileal resection.
coeliac disease.
prolonged use of PPIs, metformin, COCP, colestyramine, methotrexate

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8
Q

When should you test for B12 deficiency?

A

Macrocytosis, pancytopaenia
Peripheral neuropathy, myelopathy, optic neuritis, cognitive change, dementia
If malabsorption suspected in Crohn’s, coeliac, pancreatic deficiency

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9
Q

What to do if B12 levels low

A

> 180 normal
130-180 low normal- advise OTC supplements
<130 with neuro symptoms/macrocytosis/anaemia then assess for pernicious anaemia (anti-gastric parietal cell Ab, anti-intrinsic antibodies) and malabsorption (anti-TTG IgA, faecal elastase)

If pernicious anaemia or macrocytosis or neuro deficit: IM for life (unless FBC not normalised in 8 weeks, then unlikely B12 deficiency)
If no to above, PO OTC 100mcg daily, recheck in 2 months
If suspected malabsorption- routine gastro ref

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10
Q

Red flags for bloating

A

Persistent and progressive distension- ascites, ovarian cancer
Rectal bleeding
Weight loss- ovarian, renal, colorectal ca
Onset age>50
Iron deficiency anaemia

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11
Q

IBS Ix

A

FBC, ferritin, B12, folate
TTG IgA (if +ve urgent gastro)
TFT, U+E, LFT, bone
CA-125 (if bloating)
Urinalysis/pregnancy test
Faecal calprotectin if chronic diarrhoea age<50 (If>150 urgent gastro ref)
C diff/molecular enterics (if diarrhoea)
USS (USC if raised CA-125)
CTAP if suspected ascites/older adults
HIV test if chronic diarrhoea

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12
Q

IBS management

A

Exclude bile salt malabsorption (eg post cholecystectomy), coeliac, IBD, cancer, lactose intolerance, wheat intolerance, infection, endometriosis, diverticulitis
Treat constipation
Treat diarrhoea
Avoid fizzy drinks, chewing gum, diet advice
Peppermint oil (OTC), mebeverine
Hyoscine butylbromide, amitriptyline 10mg ON or citalopram
Dietician? FODMAP
?probiotics
PMHSS/stress management

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13
Q

Definition of IBS

A

Recurrent abdominal pain or discomfort at least 1 day per month in the last 3 months, plus at least 2 of the following:
Relationship to defecation
Associated with change in frequency of stool
Associated with change in form (appearance) of stool
Symptom duration at least 6 months

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14
Q

Diet advice IBS

A

Regular meals, eat slowly
Food diary
Consider lactose or wheat intolerance
Reduce fatty food, spicy food, caffeine, fizzy drinks, fruit juice, sorbitol and alcohol.
increase or decrease fibre depending on current bowel habit.
limit fresh fruit to 3 portions per day.
consider eating more oats (e.g. porridge) to help with wind and bloating.
have adequate fluid – 2L water

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15
Q

Treatment of IBS diarrhoea

A

Loperamide if no infection/IBD
Fybogel 1 sachet BD
If cholecystectomy, trial 4g colestyramine OD-BD for 2 weeks
Trial ondansetron 4-8mg BD-TDS 2 weeks

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16
Q

What are the high risk symptoms for bowel cancer?

A

Aged 40 years or older and with unexplained weight loss and abdominal pain
Aged 50 years or older with unexplained rectal bleeding
Aged 60 years or older with IDA or CIBH
Any adult with a rectal mass or abdominal mass
Younger than 50 years with rectal bleeding and abdominal pain, CIBH, weight loss, or IDA

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17
Q

Non infective causes of diarrhoea

A

IBS
Bile salt diarrhoea (post cholecystectomy)
Diet
Diverticulitis
Large or small bowel cancer
IBD
Coeliac disease
HIV, enteric sexually transmitted infections
Ischaemic colitis
Microscopic and collagenous colitis
Small bowel bacterial overgrowth
Lactose intolerance
Liver or pancreatic disease- Exocrine pancreatic insufficiency
Malabsorption syndromes
Post‑abdominal surgery
Gastrointestinal neuroendocrine tumours

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18
Q

C difficile treatment

A

Vancomycin 125mg QDS PO
2nd line fidaxomycin

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19
Q

Dermatitis herpetiformis

A

Inflammatory immunobullous disease of the skin and a cutaneous manifestation of coeliac disease

Symmetrical blisters to appear in clusters, resembling herpes simplex.

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20
Q

Describe colorectal polyp surveillance

A

low risk management for 1 to 2 small adenomas less than 1 cm:
<55 years or FHx of colorectal cancer, offer colonoscopy at five years.
>55 years + good bowel preparation, advise bowel screening programme.
intermediate risk management – for 3 to 4 small adenomas or at least one ≥ 1 cm offer colonoscopy at three years.
high risk management – for 5 or more small adenomas or ≥ 3 if at least one ≥ 1 cm offer colonoscopy at one year.

If hyperplastic polyps < 1cm in the rectum or sigmoid colon, no malignant potential, no surveillance

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21
Q

Which medications worsen constipation? (10)

A

Antacids
Antimuscarinics (hyoscine, oxybutynin)
Clozapine
Mebeverine
TCAs
Gabapentin
CCBs
Diuretics
Ondansetron
Iron + calcium
Opioids

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22
Q

When to refer USC colorectal without FIT test

A

Abdo or rectal mass
Anal mass or ulceration
Abdo pain with obstructive symptoms
IDA in men/post menopausal women
If vulnerable group (homeless, language barrier, elderly)

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23
Q

What medication should you avoid in anal fissures?

A

Nicorandil

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24
Q

Most common location anal fissure

A

Posterior midline of anus (6 oclock)
Sometimes after childbirth anterior midline
If elsewhere consider Crohn’s

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25
Treatment of anal fissure
Xyloproct ointment before bowel movement If no improvement after 1 week: GTN ointment 0.4% BD 6 weeks (SE headaches, use alongside docusate) Review in 6 weeks, can rpt GTN if helped but not fully healed If not healing ?cancer
26
Risk factors and management of anorectal abscess
Risk factors: smoking, diabetes/immunosuppression, IBD Admit for drainage
27
Treatment acute diverticulitis
If clinically unwell- admit Co-amoxiclav 625mg TDS PO 5 days Or cipro + metro Or cotrimox + metro Clear fluids, paracetamol
28
Treatment haemorrhoids
Adequate fluid + fibre, toileting position, avoid straining Fybogel 1st line, laxido/lactulose 2nd line, senna 3rd line Anusol 1st line, Anusol plus HC/germaloid 2nd line
29
Risk factors for gallstones
Older age, female, FHx, obesity, rapid weight loss, ileal resection, T2DM, pregnancy, COCP, crohn's, haemolysis
30
Management gallstones
Admit if obstructive jaundice or suspected pancreatitis/cholangitis Routine ref cholecystectomy if symptommatic, stones in CBD or calcified porcelain gallbladder or prev jaundice/pancreatitis Low fat diet, weight reduction, smoking cessation, reduce alcohol
31
Referral criteria hernias
Admit: severe abdominal pain or vomiting with an irreducible hernia. suspected strangulation, incarceration, or obstruction of any hernia. Routine ref groin hernia if: history of incarceration, difficulty in reducing hernia increased risk of strangulation (femoral hernias) inguino-scrotal hernia progressive increase in size (month to month) significant pain causing functional impairment symptomatic hernia of any kind with significant impact on activities of daily living. recurrence of hernia or post‑operative painless swelling which lasts 3 months or more
32
Red flags sarcoma
Soft tissue lump: >5cm in diameter. Deep to fascia (fixed) and any size. Growing (especially observed rapid growth). Painful. Recurring after a previous sarcoma excision. Then USC USS
33
GORD red flags
Dysphagia Weight loss age>55 Patient aged 55 years or older with: treatment-resistant dyspepsia. upper abdominal pain with low haemoglobin levels raised platelet count with any nausea, vomiting, weight loss, reflux, dyspepsia, or upper abdominal pain. nausea or vomiting with reflux, dyspepsia, or upper abdominal pain.
34
Which medications can exacerbate dyspepsia? (10)
Beta-blockers Aspirin Bisphosphonates CCBs Steroids Nitrates NSAIDs SSRIs, TCAs Theophylline
35
Ix for dyspepsia
Bloods if age>55 H pylori (in dyspepsia, not in GORD) - no PPI for 2 weeks
36
Initial management GORD
Smaller meals and not eating for at least 3 to 4 hours before bed Sleeping with the head of the bed raised Weight reduction Smoking cessation Limiting alcohol Avoiding triggers – can include spicy, acidic or fatty foods, peppermint, fizzy drinks, coffee, chocolate Stop NSAIDs/bisphosphonates Omeprazole 20mg OD 4 weeks (30 mins before breakfast) If inadequate response famotidine 20mg BD
37
Define treatment resistant dyspepsia
Upper abdominal pain or discomfort, heartburn, acid reflux, nausea and/or vomiting with no response to omeprazole 20mg OD for 4 weeks or famotidine/ranitidine or lifestyle advice If age>55 yrs arrange direct access OGD, if<55 routine gastro referral Note: treatment resistant heartburn/GORD is different, can try 6 months double dose PPI or full dose + famotidine/ranitidine before routine upper GI surg referral for ?fundoplication
38
What is odynophagia? Main causes
Pain on swallowing, usually caused by irritation of the oesophageal mucosa. Causes include: Infections -candida, HSV, CMV. Chemical- drug induced, radiation, Crohn's disease, dermatological causes, severe reflux. Xerostomia (dry mouth) – check medication causes (e.g., antidepressants, antihypertensives, antipsychotics, diuretics), Sjogren's syndrome. Oesophageal malignancy.
39
What is globus?
Non painful lump or fullness in the throat with unimpaired food bolus transport. Alleviated by eating and/or drinking fluid. Most noticeable with swallowing saliva.
40
Causes of oropharyngeal dysphagia
often neuro- Parkinson disease, MS, Stroke, motor neurone disease may be caused by a local tumour in the pharynx.
41
Relevant hx for faecal incontinence
Obstetric hx (episiotomy, shoulder dystocia, perineal tears) Prev surgery Chronic constipation and straining Chronic diarrhoea IBD, IBS MS, spinal injury, cauda equina, stroke, dementia Rectocele/cystocele/pelvic floor laxity
42
Referral criteria for faecal incontinence
suspected cauda equina- admit ED Persistent symptoms- refer Pelvic Health Hub. Routine colorectal surgery referral if: external rectal prolapse. rectovaginal fistula. previous sphincter repair or sacral nerve stimulator and ongoing issues. If the patient has a suspected neurological cause, or symptoms are exacerbated by an existing neurological condition, request routine
43
Name 7 extraintestinal manifestations of IBD
Skin, e.g. erythema nodosum, pyoderma gangrenosum Arthropathy Eye, e.g. episcleritis, iritis Mouth ulcers Night sweats Primary sclerosing cholangitis (PSC)
44
Relationship between smoking and IBD
Smoking increases the risk of developing Crohn's disease. Smoking reduces the risk of ulcerative colitis. Smoking cessation can precipitate ulcerative colitis
45
What Ix results suggest IBD?
Anaemia, leucocytosis, thrombocytosis, raised CRP/ESR, or faecal calprotectin greater than 150 microgram/g. An acute infection, e.g. campylobacter can cause elevated calprotectin. Confirm faecal infective screen is negative before refer urgent gastro for colonoscopy
46
Main treatments of IBD
Mesalazine- risk blood dyscrasia, stop and check FBC if sore throat/bleeding/bruising/purpura. Monitor u+e before starting, 3m then yearly Pred, budesonide (+ adcal d3 BD) Azathioprine+ 6mercaptopurine. Myelo and immune suppression. Avoid allopurinol. Methotrexate- stop if sore throat/bleeding/bruising/SOB, once weekly dose, contraception during + 6m after
47
Main causes of iron deficiency anaemia
Excessive blood loss: GI blood loss-NSAIDs, cancer, ulcer Menstrual blood loss (menorrhagia) Recurrent epistaxis Renal tract malignancy Regular blood donation After major surgery with inadequate replacement Dietary inadequacy especially in elderly and vegetarians Malabsorption (coeliac disease), after gastric surgery, medications (PPI, antacids, calcium) Excessive requirements, e.g. pregnancy
48
Patterns to notice in abnormal LFTs
Relatively greater increase in ALT and AST compared to ALP and GGT – problem with hepatocytes. Relatively greater increase in ALP and GGT compared to ALT and AST (cholestatic pattern) – suggests biliary obstruction. Abnormal synthetic function- raised bilirubin, elevated INR and PT, and low albumin. Portal hypertension- low plts-> pancytopenia if advanced.
49
Name 9 commonly prescribed drugs that can cause abnormal LFTs
Statins, methotrexate, azathioprine, 6MP, anticonvulsants, flucloxacillin, erythromycin, co-amox, nitrofurantoin.
50
Clinical features of acute hepatitis
Fever GI – abdo pain, anorexia, nausea, vomiting Icteric features- jaundice, dark urine, pale faeces Enlarged tender liver or spleen Urticaria, and joint pains (particularly in hepatitis A and B)
51
Signs of cirrhosis
Jaundice Leuconychia Spider naevi Palmar erythema Gynaecomastia Muscle wasting Liver enlargement Shrunken liver Hardened liver edge Ascites Splenomegaly
52
Causes isolated raised ALP
Growth in childhood and adolescence Third trimester and postpartum Transient hyperphosphataemia Right‑sided heart failure Paget's disease Bone malignancy- osteosarcoma, multiple myeloma, mets Hyperparathyroidism Osteomalacia
53
What to do with isolated rise in bilirubin
Conjugated:unconjugated bilirubin FBC, Blood film Reticulocyte count Haptoglobins, LDH Haemolysis if: predominant unconjugated bilirubin. anaemia with reticulocytosis. reduced haptoglobins. If predominant unconjugated, other tests normal and bili<85 then Gilbert's
54
Raised ALP predominant causes
Cholestatic: Abscess, cancer Stones in CBD post‑operative stricture Inflammatory strictures from chronic pancreatitis Amyloidosis, sarcoidosis Drugs: Flucloxacillin and co-amox, COCP Pregnancy Primary sclerosing cholangitis Primary biliary cirrhosis
55
Causes of ALT predominant abnormal LFTs
NAFLD Alcohol liver disease Coeliac disease Hepatitis A, B, C, CMV, EBV Medications Haemochromatosis Wilson's disease Alpha-1 antitrypsin deficiency
56
If abnormal LFTs thought to be NAFLD and low fib-4 score, what would your management be?
Alcohol cessation Weight loss CV + diabetes risk reduction Reassess in 4 years
57
Management if ALT predominant abnormal LFTs
Rpt ALT in 3m if<100, 1m if 100-300, immediately if 300+ If still abnormal, Fib-4 + liver aetiology screen
58
Management if ALP predominant abnormal LFTs
Imaging + liver aetiology screen
59
NAFLD assessment
LFT (AST and ALT), FBC, prothrombin time (PT), albumin, HbA1c, and lipids. FIB-4 socre >1.3 refer routine hepatology
60
Symptoms and signs of pancreatic cancer
Pain epigastric-> back New unexpected onset diabetes New alcohol intolerance Painless jaundice Dark 'tea' urine Weight loss Nausea/vomiting Anorexia Pale buoyant stool Ascending cholangitis

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