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Flashcards in Gastroenterology Deck (71)
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1

Common causes of steatorhoea

  • Chronic pancreatitis
  • Crohn's disease
  • Obstructed biliary flow
  • Coeliac disease

2

Acute mesenteric Ischaemia VS

Chronic mesenteric ischaemia VS

Acute on chronic mesenteric ischaemia VS

Acute pancreatitis VS

Chronic pancreatitis 

  • Acute mesenteric ischaemia: predisposing factors of ischaemia >> High amylase, abdominal pain, vomiting
  • Chronic mesenteric ischaemia: predisposing factors of ischaemia >> normal amylase, abdominal pain after meal for a long time
  • Acute on chronic mesenteric ischaemia: predisposing factors >> high amylase, acute abdominal pain, vomiting, abdominal pain after meal for a long time
  • Acute pancreatitis: Factors of GET SMASHED > Acute severe abdominal pain, raised amylase [-ve/absent factors for ischaemia]
  • Chronic pancreatitis: Mainly alcohol, other risk factors > steatorrhoea, weight loss, chronic pain, recent onset DM 

3

Mixed cryoglobinaemia (type 2 cryoglobinaemia) a/w HCV >>> C/F & Findings

  • C/F:
    • Meltzer's triad: 
      • Pulpable purpura (non-blancing rash)
      • Arthralgia (swelling, stiffness)
      • Myalgia
    • Livedo reticularis
    • Glomerulonephritis (MCGN/MPGN)
  • Dx: Histology
    • Low C4
    • RF +ve
    • Criculating cryoglobulin 
  • IOC: HCV serology

4

Hepatocellular carcinoma VS differentials

  • Raised AFP >>>>> rules out other hepatic cause
  • Absence of acute s/s >>> HCC;
    • Presence of acute S/S, jaundice, abdominal pain> may indicate acute HBV infection, alcoholism etc.
  • Weight loss >>> HCC
    • NO weight loss in chronic active hepatitis, Acute HBV, Alcoholism, and SBP
  •  Worsening ascites >>> HCC
    • Tender ascites + acute abdominal pain >>> SBP

5

Weight loss in colon cancer > cause

Anorexia

  •  In absence of anorexia > consider the following factors
    • Dysguesia (Loss of taste) > seen in cancer patients > very few weight loss
    • TNF (role in weight loss still unclear)
    • IL-6 (role in weight loss still unclear)

6

Cause of Dysguesia (taste changes) in cancer patients

  • Opioid analgesics
  • Cancer chemotherapy
  • Antibiotics
  • Radiation therapy to head, neck
  • Dry mouth
  • Dental problems
  • Mouth infection
  • Nausea, Vomiting 

7

Patient is on parenterial nutrition for UC >>> develops symptoms of deficiency >>> 

Most common feature of the following deficiencies:

1. Chromium deficiency

2. Copper deficiency

3. Magnesium deficiency 

4. Selenium deficiency 

5. Zinc deficiency

1. Chromium deficiency (RARE) >> glucose intolerence 

2. Copper deficiency (RARE) >> cardiac dysrrythmias, altered lipoprotein metabolism

3. Magnesium deficiency >> hypocalcaemia, neuromuscular excitability

4. Selenium deficiency (seen as "Keshan disease" in areas where soil has low selenium content) >> cardiomyopathy 

5. Zinc deficiency (IBD patients loose more amount of zinc from gut) >> dermatitis, alopecia

 

*** Parenteral nutrition has risk of low Mg

*** IBD has risk of low Zn

*** If IBD + Parenteral nutrition >>> decide by looking at 'presentations' 

8

Colonoscopy finds polyps in the gut:

Predict 'risks of malignant change' from 'features of polyp'

  • Low risk for malignant change:
    • Pedunculated (Stalked) polyp
    • Tubular architecture
    • Size <1.5cm
  • High risk for malignant change:
    • Sessile (flat) polyps
    • Villous architecture
    • Severe dysplasia
    • Squamous cell carcinoma
    • Size >1.5cm

*** If multiple polyps are found > do frequent colonoscopy

9

Drug-induced chronic hepatitis & other causes of chronic hepatits (figure)

10

Drug induced hepatitis VS Differentials

  • Drug induced hepatitis (DIH) vs Autoimmune hepatitis
    • Both: More in Female, Anti-LKM Ab +ve, deranged LFTs, Jaundice, hepatomegaly
    • DIH has short history; Autoimmune hepatitis has long history
    • DIH has causative drug; Autoimmune doesn't have
  • DIH vs PBC
    • DIH has very high ALT, AST ::::: PBC has very high ALP + relatively normal ALT, AST
    • DIH has anti-LKM Ab +ve ::::: PBC has AMA Ab +ve
  • DIH vs PSC
    • DIH has very high ALT, AST ::::: PSC has very high ALP + relatively normal ALT, AST
    • DIH has anti-LKM Ab +ve ::::: PSC has ANCA +ve
  • DIH vs Gallstones
    • DIH has very high ALT, AST ::::: Gallstones has very high ALP + relatively normal ALT, AST
    • DIH has anti-LKM Ab +ve ::::: Gallstone has no such Ab
  • Drug-induced hepatitis, hepatitis B, C vs Drug-induced cholestasis +/- hepatitis
    • Hepatittis has normal ALP ::::: Cholestasis has very high ALP
    • Then, look into drugs of each category of hepatitis, cholestasis and cirrhosis 

11

NAFLD vs Differentials

*** If obesity, DM, GDM + high ALT >>> consider NAFLD (since it has very high prevalence ~25% in general population

*** ALT >> AST is a criteria for NALFD, however, if only ALT is given >>> consider very high ALT

  • NAFLD vs Autoimmune hepatitis
    • NAFLD has no positive auto-ab; Autoimmune hepatitis has positive auto-antibody
  • NAFLD vs PBC
    • NAFLD is asymptomatic; PBC has pruritus, lethargy
    • NAFLD has no auto-Ab; PBC has AMA positive
  • NAFLD vs Gallstone
    • NAFLD is asymptomatic; Gallstone has abdominal pain
  • NAFLD vs Cirrhosis
    • NAFLD has normal bilirubin, PT, Platelet count; Cirrhosis has high bilirubin, high PT, and low Platelet count

12

Crohn's disease:

Epidemiology

  • 6-10% of individuals with IBD have one or more affected relatives
  • High co-efficient of heritability for Crohn's disease.
    • high heritability co-efficient suggests how phenotype in an individuals is due to genetic defects among the individuals of a community
    • High heritability suggests > variation is due to genetics
    • Low heritabiltiy suggests > variation is due to environmental factors
  • CD is more in female slightly (M:F = 1:1.2)
  • CD occurs at more early median age in females than males
  • CD is more in Jews >>> than non-jews; and Ashkenazi jews >>> Sephradic jews
  • NO proven link between CD and TB 

13

Chronic diarrhoea + scleroderma/systemic /CREST syndrome > Dx > Tx

(= Intermittent bloating, diarrhoea + above)

Small Bowel Bacterial Overgrowth (SBBOS)

TOC: Metronidazole

If not available, Rifaximine

14

Chronic diarrhoea + Diverticulosis > Dx > Tx

Small Bowel Bacterial Overgrowth (SBBOS)

TOC: Metronidazole

If not available, Rifaximine

15

Chronic diarrhoea + Neonates with congenital GI abnormalities > Dx > Tx

Small Bowel Bacterial Overgrowth (SBBOS)

TOC: Metronidazole

If not available, Rifaximine

(SBBOS can later cause bile acid diarrhoea type -3)

16

Chronic diarrhoea + IBD (UC or CD) + steatorrhoea, flatulence, Low vitamin B12 (+/- its features)  > Dx > Tx

Small Bowel Bacterial Overgrowth (SBBOS)

TOC: Metronidazole

If not available, Rifaximine

 SBBOS can later cause bile acid darrhoea

17

Chronic diarrhoea + any of:

(Metformin intake/

DM patients taking multiple meds/

Ileal resection/

Cholecystectomy/)

or SeHCAT test +ve

> Dx > Ix > Tx

Dx: Bila acid diarrhoea

Ix: SeHCAT test

Tx: Cholestyramine

18

Chronic diarrhoea + crohn's disease > D/D > Tx

  • If steatorrhoea, flatulence, low vitamin B12 > Dx: SBBOS > TOC: Rifaximin, Metronidazole (SBBOS can cause type-3 bile acid diarrhoea)
  • If absence of such > Dx: Type-1 bile acid diarrhoea (bile acid malabsorption) > TOC: Cholestyramine

19

Barrett's oesophagus VS differentials

  • Pathognomic signs:
    • Gastric looking mucosa spreading to lower oesophageal sphicter
    • Columnar metaplasia 
    • New velvet-like mucosa of lower oesophagus
  •  Barrett's VS Achalasia
    •  Barrett's have above findings ::::: Achalasia: Absence of above findings + hiypertensive (high tone) of LES
    • Achalasia is a oesophageal motility disorder
  • Barrett's VS Erosive oesophagitis
    • Both may have heart burn, dyspepsia, regurgitation, mucosal change
    • In the lower oesophagus, Barett's > gastric mucosa, velvety-like mucosa ::::: Erosive oesophagitis > erosion of oesophageal own mucosa itself
    • In the lower oesophagus, Barett's > Columnar epithelium ::::: Erosive oesophagitis > Squamous epithelium 

20

Chronic pancreatitis VS differentials

  • Key features:
    • Alcohol is the most common cause in adults
    • Weight loss is important for diagnosis
    • Serum amylase can be normal
    • Other imporant features: Pain worse fater a meal, chronic diarrhoea
  • C.P vs Acute pancreatitis:
    • Both > Alcohol, epigastric pain
    • C.P > Chronic pain ::::: A.P > Acute severe pain
    • C.P > Chronic diarrhoea ::: A.P > Acute/absent diarrhoea
    • C.P > weight loss ::::: A.P > absent weight loss
    • C.P > pain worse after a meal ::::: A.P > rare
    • C.P. > often normal amylase ::::: A.P > always raised amylase
  • C.P vs PUD
    • Both > Chronic abdominal pain, weight loss
    • C.P. > Diarrhoea ::::: PUD > Absent
  • C.P vs Coeliac disease
    • Both > Diarrhoea, weight loss
    • C.P > Abdominal pain ::::: Coeliac disease > NO abdominal pain
  • C.P vs Cirrhosis of liver
    • Both > Alcohol history
    • C.P > Diarrhoea, epigastric pain, weight loss ::::: Cirrhosis > Absent those + Ascites 

21

Lactose intolerence VS differentials

  1. A change of diet (from Easi-Asian or African diet to European diet/Western diet) or
  2. Taking more European/Western diet (which is dairy-rich)
  3. Intake of dairy-rich diet
  4. Any 'change of diet' due to recent travel to 'anywhere'
  5. Recent Giardia infection (/given its Tx Tinidazole)
  • After any of above 6 > if intermittent diarrhoea, bloating >>> Dx: Lactose intolerence 
  • Lactose intolerance VS IBS
    • Both > Intermittent diarrhoea, bloating +/- abd. pain
    • L.I. > Above history/recent GI infection :::: IBS: Absent of above such history
  • Lactose intolerence VS Coeliac disease
    • Both > possible diarrhoea, cramping, pain, bloating distension etc,
    • L.I. > Above history/recent GI infection ::::: Coeliac disease > Absent of such history
    • L.I. > more in people of Africa or East-Asia origin ::::: Coeliac > more in western, europe, ireland origin people
  • Lactose intolerance VS Chronic pancreatitis
    • L.I. > Intermittent diarrhoea, bloating ::::: C.P. > Chronic diarrhoea

22

Cause of gynaecomastia in cirrhosis

  • 1st cause: Altered oestrogen metabolism >>> high level of oestrogen 
  • 2nd cause: If we started on 'spironolactone (aldosterone antagonist' >>> Side-effect

23

Facts on Gamma-glutamyl tranferase (GGT)

  • GGT in raised in fatty liver disease
  • In hepatic metastasis >>> high GGT + high ALP (not alone GGT)
  • A rise does NOT always indicate liver pathology; Phenytoin and alcohol mildly increase GGT
  • It can be high in pancreatic carcinoma suggesting liver pathology (consider if pain radiates to back, high viscosity etc. pacreatic features)
  • Raised transaminases (ALT, AST) indicate infectious liver disease; Raised GGT indicates cholestasis
  • GGT is present in many tissues, including liver
  • In pregnancy > GGT is normal; ALP is elevated (due to placental source)

24

Venesection is a useful treatment for - ?

Cardiomyopathy (/cardiac failure) a/w Haemochromatosis

  •  upto 2 times per week >>> improve symptoms and reduce the need of diuretic therapy  

25

TOC for Gastric MALT (Mucosa associated Lymphoid Tissue)

  • H. pylori eradication therapy
    • As 95% cases of MALT lymphoma are A/W H. pylori

26

Vitamin C is essential for which process of collagen synthesis ?

Hydroxylation of procollagen priline and lysine

27

Organ that comes in direct contact with lef kidney (not seperated by visceral peritoneum) >> so, has more risk in nepherectomy

  • Pancreas
  • Left supra-renal gland
  • Colon

*** Add left-colonic flexure in the section of left kidney (with peritoneum in between)

*** Distal part of small intestine includes jejunum

*** Kidneys are retroperitoneal organ between T12 to L3 vertebrae

*** Right is placed superiorly than left kidney

 

28

Limited haematemesis + stable patient + O/E: normal + Hb normal + H/OO aspirin intake > Dx

Gastric erosion

29

Mechanism of action of lactulose

30

Altered bowel habit + blood in the stool + polyp in the descending colon at Duke A stage >>> further approach/ time interval of colonoscopy