Gastroenterology & Shock Flashcards

Question

What is considered a Mild GERD? Management? (4)

Answer 1

**GERD: Moderate to Severe** - Persistent symptoms, often daily, needing antacids regularly and not responding adequately to H2 receptor antagonists - Trial of a PPI – omeprazole, esomeprazole pantoprazole, rabreprazole or lansoprazole. - If inadequate response to 4 to 6 weeks treatment and symptoms recur - gastroscopy - Domperidone = increased gastric emptying

Answer 2

1. Assess for oesophagitis 2. Los Angeles Grading 3. ?Barrett’s present –biopsies 4. Any other pathology - helicobacter

Answer 3

PPIs increase beta-amyloid = dementia?

Answer 4

1. Peptic Ulcer (treat Helicobacter) 2. Erosive Oesophagitis 3. Chronic NSAID’s use 4. NSAID’s and anticoagulation – aspirin , clopidogrel, warfarin, new anticoagulants. Greater risk of GIT bleed with increasing age. 5. Barrett’s oesophagus THINK about cost and indications

Answer 5

- Mild reflux may resolve - Elderly- more likely severe oesophagitis and milder symptoms –don’t stop - Balance: PPI’s have changed management of severe reflux and oesophageal strictures. - Think about the indications and is it appropriate

Answer 6

pH AND MOTILITY STUDIES - Use pre surgery to confirm normal motility - If uncertain about reflux and symptoms – NERD but “sensitive “ oesophagus. Difficult clinical scenario. Mechanism poorly understood - Atypical chest pain - Motility disorders -achalasia

Answer 7

- Definition: The replacement of stratified squamous epithelium with specialised intestinal metaplastic columnar epithelium within the tubular oesophagus. - Associated with chronic GERD. - Increased risk of Oesophageal adenocarcinoma 30x the average population. - ABSOLUTE RISK IS LOW

Answer 8

1. Chronic reflux –GERD 2. Hiatus hernia 3. Males over 50 4. White 5. Smokers 6. Obese, high BMI, central obesity 7. Family history oesophageal cancer or BO

Answer 9

1. Control reflux – high dose PPI controls reflux but no current evidence prevents cancer 2. Careful follow up of high risk group with BE 3. Reflux surgery not shown to prevent risk of cancer. 4. Try and prevent progression from no dysplasia to HGD with endoscopic management

Answer 10

**Endoscopic follow up BE ** - Australian Cancer Council Guidelines Barrett’s Oesophagus 2015 - DYSPLASIA Seattle criteria 4 quadrant biopsies every 2cms and careful endoscopic assessment of mucosa. Biopsy any mucosal abnormality. - High grade dysplasia – need careful follow up and management as significant risk of adenocarcinoma - Improve endoscopic assessment with new techniques-high definition endoscopy, chromoendoscopy, NBI, confocal microscopy – almost a histological image but not readily available. These techniques allow more targeted biopsies.

Answer 11

* **Melissa** = Lifestyle factors: reduce alcohol, weight loss, ant-acid, H2 blocker = MILD * **Robert** = Moderate = Gastroscopy – waking at night, cough could give aspiration, worried about Barretts, also age, overweight = PPI * **Peggy** = Weight gain = raised intradbominal pressure – pt had ascites = ovarian cancer - REMEMBER PRESSURE/MASS CAUSES

Answer 12

Aetiology – not really known! But family hx important. Autoimmune?

Answer 13

**UC - Classify by:** 1. Disease extent: proctitis, left-sided disease, pancolitis 2. Severity 3. Colonic Mucosal Disease 4. Extraintestinal manifestations

Answer 14

Perianal disease much more common in Crohns vs. UC

Answer 15

Infections - C.Diff & UC – cytomegalovirus superimposed

Answer 16

**Faecal calprotectin** = stool marker for inflammation. Elevated faecal calprotectin indicates the migration of neutrophils (produced by neutrophils) to the intestinal mucosa, which occurs during intestinal inflammation, including inflammation caused by inflammatory bowel disease. - Faecal calprotectin is a very sensitive marker for inflammation in the gastrointestinal tract, and useful for the differentiation of inflammatory bowel disease (IBD) from irritable bowel syndrome (IBS). - Not PBS subsidised in WA.

Answer 17

- Lots of cross over with rheumatology - Patients with IBD have an increased risk of DVT so should be put on VTE prophylaxis (eg. Clexane) if coming into hospital with an acute flare up. - Erythema Nodosum = round red raised nodules which are tender

Answer 18

IBD - Perianal Disease 1. Skin tags 2. Abscesses 3. Fistulas

Answer 19

5ASA - Mesalazine, also known as mesalamine or 5-aminosalicylic acid = not as useful in crohns (full thickness) because it is only topical

Answer 20

Steroids = really limit!

Answer 21

Must check drug metabolism enzyme level prior to commencing on azathioprine – pt might die

Answer 22

- Infliximab - Vedolizumab mostly affective on the gut so if lots of extraintestinal manifestions, wont be very useful - Humira = one of the most expensive drugs on the PBS in Australia - High risk of infections on these drugs – need to screen prior to commencing – eg. Quantiferon Gold for TB

Answer 23

Simplest drug to start with = Sulphasalazine or 5ASA drugs then Steroids – rectally - all ok during pregnancy. Pt should be well before getting pregnant.

Answer 24

- Rare in Japan, China, southern India but high in north. - Correlates with wheat based diet and HLA typing in population - May increase with western-style diets replacing rice based diets. Historically seasonal diarrhoea related to crops.

Answer 25

TTG = IgA antibodies so need to do that too because if your overall IgA is low its not accurate

Answer 26

Need to have at least one of HLA DQ2 or DQ8 (genes) to have coeliac but it’s not diagnostics.

Answer 27

The patient cant be on a gluten-free diet at this stage or your biopsies and antibody levels wont be.

Answer 28

1. Crohns disease 2. Eosinophilic gastroenteritis 3. **Giardiasis** 4. Lymphoma 5. Post gastroenteritis 6. Tropical sprue 7. Zollinger- Ellison syndrome 8. Autoimmune enteropathy 9. Cows milk intolerance (children) 10. Bacterial overgrowth 11. Drugs : Olmesartan, Mycophenolate

Answer 29

**Coealic & Infertility ** * Estimates of prevalence in women with unexplained infertility 2 to 6 % (compared to current population 1%) * Small studies and varying results * 2010 Swedish study reported 11,495 women with CD and the number of children born. Overall same a general population but reduced in the 2 years preceding diagnosis. * Results relate to mix of population.

Answer 30

- The adenoma-carcinoma sequence is a concept that envisages the evolution of carcinoma of the colon and rectum by way of an intermediate benign entity, the adenoma. - The adenoma-carcinoma sequence (ACS) is defined by a set of recurrent driver mutations in APC, KRAS, SMAD4, and TP53 genes, that accumulate during adenoma formation and progression to sporadic colorectal cancer (CRC), often correlating with specific stages of the developmental process.

Answer 31

Majority = sporadic

Answer 32

**CRC - Assessing Family History** - Number of relatives - Age of CRC diagnosis - Other cancers

Answer 33

Classic familial adenomatous polyposis, called FAP or classic FAP, is a genetic condition. It is diagnosed when a person develops more than 100 adenomatous colon polyps.

Answer 34

Lynch syndrome, also known as hereditary non-polyposis colorectal cancer (HNPCC), is the most common cause of hereditary colorectal (colon) cancer. People with Lynch syndrome are more likely to get colorectal cancer and other cancers, and at a younger age (before 50), including.

Answer 35

Blood losing indications are the most significant.

Answer 36

**Anatomy of the Liver** - Right and left lobe – separated by falciform ligament - 8 segments - 2 blood supplies: Hepatic artery & Portal vein. - Hepatic artery – 20% of hepatic inflow, 50% of oxygen. - Origin coeliac artery. Branches into right gastric artery, gastroduodenal and proper hepatic. - Portal vein – 80% of hepatic inflow, 50% of oxygen - Origin at the confluence of splenic and SMV. Branches to right and left portal vein

Answer 37

**Bilirubin** - End product of haemoglobin degradation - Porphyrin portion of haemoglobin molecule is converted by macrophages into bilirubin and released into blood - Unconjugated (insoluble) bilirubin is taken up by the liver and conjugated to be excreted in stool and urine - In healthy individuals, majority of bilirubin should be unconjugated

Answer 38

- ALT found predominantly in the liver in the cytosol of hepatocytes - AST less specific for liver disease, is a liver mitochondrial enzyme, and can be also found in cardiac/skeletal muscles, red blood cells and kidney - Damage to hepatocytes results in release of ALT and AST = “Hepatitic picture” - Ratio can be useful in alcoholic hepatitis or fibrosis – AST:ALT ratio of >2:1 - Not useful as a prognostic factor – can have normal ALT/AST in chronic liver disease as not many hepatocytes left

Answer 39

**ALP** - Present in liver cells and bile duct cells - Raised in cholestasis or bile duct damage = "Obstructive picture” reflecting biliary obstruction - Also produced in other parts of the body – bone, intestine, placenta - Will see it in other diseases e.g. osteomalacia, Paget’s disease, bone mets - Retained bile acids prompt increased production of ALP - ALP also reduces secretory functions of biliary epithelium and promotes cholestatisis - Needs to be interpreted in combination with GGT and bilirubin - “Cholestatic” pattern

Answer 40

**GGT** - Located in the biliary pole of hepatocytes and bile duct cells - Suggestive of cholestasis/obstruction or biliary epithelial damage - Raised in response to alcohol and medications (phenytoin, warfarin, rifampicin) - Raised in fatty liver disease - Raised in biliary obstruction - “Cholestatic picture”

Answer 41

**Albumin** - Most abundant circulating protein in plasma - Synthesized by hepatocytes and rapidly excreted into plasma - Half life of 20 days - Helps to maintain oncotic pressure and also acts as a transporter - Low albumin can reflect liver disease but non specific - May also be low in pregnancy, poor nutritional state, chronic inflammation, sepsis, renal disease - Can be replaced but short lived

Answer 42

- Liver impairment can result in reduced production of clotting factor - Obstructive jaundice results in reduction of bile acids in intestine. - Reduced absorption of vitamin K which is essential for producing clotting factors II,VII, IX and X - Complex picture – an elevated coagulation test time (INR, APTT) - Acute disease – increased bleeding tendence due to reduced clotting factors - Chronic disease – increased thrombotic tendency due to reduced effects of thrombomodulin

Answer 43

1. Infective causes 2. Drugs 3. Vascular 4. Autoimmune 5. Malignancy 6. Metabolic 7. Pregnancy related

Answer 44

**Other viruses that can cause Acute Liver Failure:** 1. Herpes simplex virus 2. Ebstein barr virus 3. Cytomegalovirus 4. Parvovirus

Answer 45

- Predictable (dose dependent, well known) vs idiosyncractic (unpredictable) - Can present with a hepatitic or cholestatic injury - History is key to identifying timing of drug exposure - Drug discontinuation generally leads to improvement in liver injury (gradual) - 5-10% will develop chronic liver injury - Increasing number of herbal supplements causing liver injury – green tea extract, garcinia cambognia

Answer 46

**Alcohol** - Excessive consumption can result in steatosis, alcoholic hepatitis and eventually cirrhosis. - Alcohol is metabolised in the liver, resulting in formation of toxic acetaldehyde and free radicals. - Characterised by jaundice within 60 days of heavy alcohol consumption for a minimum of 6 months, AST:ALT ratio of 2:1. - Supportive treatment with cessation of alcohol use and thiamine - Steroid therapy if Maddrey score >32. - Lille score at 1 week to assess response. If adequate response, continue steroids for 28 days. If inadequate response, cease

Answer 47

**Paracetamol** - Accidental vs intentional - Acute vs chronic - Gastric decontamination no longer recommended - Predisposing factors may increase risk of toxicity at lower dosages - N-acetyl cysteine works by increasing hepatic gluthathione stores to allow more conjugation of NAPQI. - Important to consider and address factors which led to overdose – psych review, webster pack for elderly patients with dementia.

Answer 48

**Ischaemic / Vascular causes of Acute Liver Injury** 1. Budd Chiari syndrome 2. Portal vein thrombosis 3. Hypotension secondary to shock/hypovolemia/ circulatory failure 4. Thrombotic state – pregnancy, OCP, polycythemia rubra vera

Answer 49

**Autoimmune causes of Acute Liver Injury** 1. Autoimmune hepatitis 2. Primary biliary cholangitis 3. Primary sclerosing cholangitis - May be asymptomatic so can present late in the disease with cirrhosis - Diagnosed based on blood tests (ANA, AMA, anti-LKM, SMA), imaging (MRCP) and liver biopsy - Management with steroids/ursodeoxycholic acid

Answer 50

- Primary vs metastatic - Incidence of hepatocellular carcinoma is increasing = 7th most common cancer - Poor prognosis with 5 year survival of 20% - Risk factors: cirrhosis, hepatitis B, alcohol - Treated with surgery, locoregional therapies, immunotherapy, chemotherapy or transplant

Answer 51

**Metabolic Causes of Acute Liver Injury** 1. **Metabolic associated fatty liver disease** 2. **Haemochromatosis** 3. **Alpha 1 anti-trypsin:** Autosomal dominant lung disease, Genetic testing and alpha 1 levels 4. **Wilson’s disease:** Neurologic symptoms, Family history, Kayser-Fleischer rings, Low caeruloplasmin and 24h urinary copper, Liver biopsy

Answer 52

**Symptoms of acute liver failure** 1. Abdominal pain 2. Abdominal distention 3. Confusion 3. Jaundice 4. Dark urine 5. Pale stools 6. Pruritis 7. Bleeding 8. Anorexia

Answer 53

1. Jaundice 2. Scleral icterus 3. Mental state and cognition 4. Asterixis 5. Ecchymoses or petechiae 6. Hepatomegaly 7. Ascites 8. Pedal oedema 9. Pleural effusion

Answer 54

1. Treat underlying cause and prevent further insult if possible 2. Transfer to a centre with ICU/transplant centre 3. Monitor coagulation but do not correct if no acute bleeding (good prognostic value) 4. Maintain normotension and normovolemia 5. PPI prophylaxis for stress ulcer prevention 6. Dialysis for renal failure 7. Monitor for cerebral oedema 8. Maintain nutrition 9. Monitor for infection 10. Correct metabolic abnormalities 11. Consider transplant if not improving and meets criteria

Answer 55

**PATTERNS OF ABNORMALITY** 1. Isolated GGT 2. Hepatitic – ALT or AST elevation 3. Cholestatic - bilirubin, ALP, GGT 4. Mixed

Answer 56

1. Hepatitis serology (A/B/C) 2. Epstein-Barr Virus (EBV) 3. Cytomegalovirus (CMV) 4. Anti-mitochondrial antibody (AMA) 5. Anti-smooth muscle antibody (ASMA) 6. Anti-liver/kidney microsomal antibodies (Anti-LKM) 7. Anti-nuclear antibody (ANA) 8. p-ANCA 9. Immunoglobulins – IgM/IgG 10. Alpha-1 Antitrypsin (to rule out alpha-1 antitrypsin deficiency) 11. Serum Copper (to rule out Wilson’s disease) 12. Ceruloplasmin (to rule out Wilson’s disease) 13. Ferritin (to rule out haemochromatosis)

Answer 57

**Model for End-stage Liver Disease score:** A model used to predict mortality in patients with liver cirrhosis and to stratify patients awaiting liver transplantation. Takes into account renal function, bilirubin, INR, and plasma sodium.

Answer 58

1. Portal hypertension due to cirrhosis 2. Loss of function 3. Liver cancer – hepatocellular carcinoma (85%) and cholangiocarcinoma (15%) - Cirrhosis (alcohol, viral hepatitis, fatty liver disease) - Noncirrhotic (fatty liver disease)

Answer 59

**LIVER REGENERATION** - Two pathways by which adult liver can regenerate: 1. **Hepatocyte mediated**: mature hepatocytes divide to replenish lost liver mass - Acute injury (a.k.a Zeus) 2. **Progenitor cell mediated:** hepatocyte replicative arrest; adult liver progenitor cells proliferate, migrate and differentiate into mature hepatocytes and biliary epithelium = Chronic injury

Answer 60

**NAFLD** = Commonest liver condition in Western world in children and adults **NAFLD IN ADOLESCENTS WA DATA** ◼ 15% of 16 yo have NAFLD (US Dx) ◼ More common in females ◼ 21% have other features of metabolic syndrome ◼ 60% of obese have NAFLD, 30% of overweight have NAFLD, 8% normal weight have NAFLD ◼ 80% of NAFLD have normal ALT

Answer 61

◼ NAFLD less common in children exclusively breast fed for at least 6 months ◼ More common in those who are obese and who consume increased fructose ◼ Female NAFLD more likely if maternal obesity and early – mid gestational weight gain > 6 kg ◼ Male NAFLD associated with lower family SES

Answer 62

1. Augmentin 1 in 2350 patients (22%) 2. Diclofenac 1 in 9480 patients (6%) 3. Azathioprine 1 in 133 patients (4%) 4. Infliximab 1 in 148 patients (4%) 5. Nitrofurantoin 1 in 1369 patients (4%)

Answer 63

Antiglobulin testing, also known as the **Coombs** test, is an immunology laboratory procedure used to detect the presence of antibodies against circulating red blood cells (RBCs) in the body, which then induce hemolysis.

Answer 64

Pneumothorax refers to the presence of air in the pleural space, leading to lung collapse.

Answer 65

Pneumothorax refers to the presence of air in the pleural space, leading to lung collapse.

Answer 66

Intubation refers to the placement of a tube into the trachea to establish a secure airway and facilitate mechanical ventilation.

Answer 67

Impending respiratory failure refers to a critical condition in which a patient's respiratory function is deteriorating, and there is an imminent risk of respiratory system failure.

Answer 68

Transfer to higher care units, such as the intensive care unit (ICU), is typically considered when a patient's condition requires a higher level of monitoring, specialized interventions, and multidisciplinary care.

Answer 69

The evaluation and treatment of ventricular tachycardia (VT) involve a systematic approach to assess the patient's hemodynamic stability, identify the underlying cause, and determine the appropriate management strategy.

Answer 70

The evaluation and treatment of ventricular fibrillation (VF) require prompt intervention due to its life-threatening nature. VF is characterized by disorganized and chaotic electrical activity in the ventricles, leading to a loss of effective cardiac contractions and cardiac output.

Answer 71

Hypertensive emergency refers to a severe elevation in blood pressure (hypertension) that requires immediate medical intervention to prevent organ damage. It is a medical emergency that requires prompt evaluation and treatment to reduce blood pressure and protect vital organs from potential complications. Hypertensive emergency typically presents with significantly high blood pressure levels (systolic blood pressure >180 mmHg and/or diastolic blood pressure >120 mmHg) along with signs of acute end-organ damage.

Gastroenterology & Shock Flashcards

(172 cards)