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General gastro Flashcards

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1
Q

What is acute upper gastrointestinal bleeding most commonly due to

A

Peptic ulcer disease

Oeseophageal varices

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2
Q

Risk assessment in upper gastrointestinal bleeding

A

Use the blatchford score at first assessment(admission risk marker - patients with 0 may be considered for early discharge)

Full rockall score after endoscopy

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3
Q

Immediate management of acute GI bleed

A

A-E resus
Platelet transfusion if actively bleeding
FFP if low fibrinogen or APTT elevated
Immediate endoscopy after resuscitation within 24 hrs

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4
Q

Why should PPIs not be prescribed in an acute GI bleed

A

Should not be prescribed until post-endoscopy as they may mask the site of bleeding

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5
Q

Management of variceal bleeding

A

terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)

band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices

transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures

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6
Q

Symptoms and signs of giardiasis

A 
Asymptomatic 
Watery malodorous diarrhoea 
Abdominal cramps and distension 
Nausea 
Epigastric discomfort
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7
Q

What is giardiasis often accompanied by

A

Acquired lactose-intolerance

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8
Q

Transmission of giardiasis

A

Some trophozoites transform into environmentally resistant cysts that are spread by focal-oral route

Waterborne transmission is the major source of infection but transmission can occur from ingestion of contaminated food or direct person-to-person contact

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9
Q

Diagnosis of giardiasis

A

Enzyme immunoassay for antigen or molecular test for parasite DNA in stool

Microscopic examination of stool(characteristic trophozoites or cysts in stool are diagnostic)

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10
Q

Treatment for giardiasis

A

Metronidazole(warn to not drink alcohol to avoid disulfiram-like reaction)

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11
Q

What is Barrett’s oesophagus

A

Metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium

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12
Q

What type of cancer does Barrett’s oesophagus predispose to

A

Oesophageal adenocarcinoma

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13
Q

Risk factors for Barrett’s oesophagus

A

GORD is the single strongest risk factor
male gender (7:1 ratio)
smoking
central obesity

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14
Q

Mx of Barrett’s oesophagus

A

endoscopic surveillance with biopsies(recommended for patients with metaplasia every 3-5 yrs)

high-dose proton pump inhibitor

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15
Q

Options if dysplasia of any grade is identified in the oesophagus

A

Endoscopic mucosal resection

Radiofrequency ablation

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16
Q

Most common site for UC

A

Rectum(inflammation always starts there)

Never spreads beyond ileocaecal valve

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17
Q

Initial presentation of UC

A 
bloody diarrhoea
urgency
tenesmus
abdominal pain, particularly in the left lower quadrant
extra-intestinal features
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18
Q

Extra-intestinal features of UC

A 
Pauciarticular arthritis 
Asymmetric erythema nodosum 
Episcleritis 
Osteoporosis 
PSC
Uveitis
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19
Q

Pathology features of UC

A

red, raw mucosa, bleeds easily
no inflammation beyond submucosa (unless fulminant disease)

widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps

inflammatory cell infiltrate in lamina propria
neutrophils migrate through the walls of glands to form crypt abscesses

depletion of goblet cells and mucin from gland epithelium
granulomas are infrequent

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20
Q

What might a barium enema show in UC

A

loss of haustrations
superficial ulceration, ‘pseudopolyps’
long standing disease: colon is narrow and short -‘drainpipe colon’

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21
Q

Classification of UC

A

mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

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22
Q

What is proctitis

A

Inflammation of the rectum

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23
Q

Inducing remission in proctitis

A

topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior

if remission is not achieved within 4 weeks, add an oral aminosalicylate

if remission still not achieved add topical or oral corticosteroid

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24
Q

Inducing remission in proctosigmoiditis and left-sided ulcerative colitis

A

Topical aminosalicylate

If remission is not achieved within 4 weeks, an oral corticosteroid for 4 to 8 weeks in addition to the high-dose aminosalicylate should be offered.

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25
Management of mild-to-moderate ulcerative colitis that is extensive
A topical aminosalicylate and a high-dose oral aminosalicylate If remission is not achieved within 4 weeks, stop topical aminosalicylate treatment and offer a high-dose oral aminosalicylate and 4 to 8 weeks of an oral corticosteroid.
26
Treatment of acute severe ulcerative colitis
IV corticosteroids(hydrocortisone or methylpred) Assess need for surgery IV cyclosporin if corticosteroids are contra-indicated
27
Maintaining remission in mild, moderate or severe ulcerative colitis
maintenance therapy with an aminosalicylate is recommended in most patients. Corticosteroids are not suitable for maintenance treatment because of their side-effects.
28
Contra-indications of mesalazine
Blood clotting abnormalities
29
Side effects of aminosalicylates
Arthralgia GI discomfort Leucopenia Nausea
30
Which parameters should be monitored before starting an oral aminosalicylate
Renal function
31
Trigger factors for UC
Stress Medications(NSAIDs, antibiotics) Cessation of smoking
32
Area commonly affected by crohn's disease
Terminal ileum and colon
33
Complications of crohn's disease
``` Intestinal strictures Abscesses in the wall of intestine Fistulae Anaemia Malnutrition Colorectal and small bowel cancers ```
34
Extra-intestinal features of crohn's
``` Arthritis(pauciarticular) Asymmetric erythema nodosum Episcleritis(more common CD) Osteoporosis Mouth ulcers Perianal disease ```
35
Ix for Crohn's disease
raised inflammatory markers increased faecal calprotectin anaemia low vitamin B12 and vitamin D
36
Inducing remission in Crohn's disease
glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients Enteral feeding with an elemental diet
37
Second-line remission intervention in CD
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine
38
Useful addition in refractory and fistulating CD
infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on azathioprine or methotrexate
39
What can be used for isolated peri-anal disease in CD
Metronidazole
40
Maintaining remission in CD
Stopping smoking is a priority azathioprine or mercaptopurine is used first-line to maintain remission +TPMT activity should be assessed before starting methotrexate is used second-line
41
What type of bacterium is C.diff
Gram positive rod
42
What does C.diff cause
It produces an exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous colitis.
43
Risk factors for C.diff infection
Clindamycin Second and third gen cephalosporins PPIs
44
Features of pseudomembranous colitis
diarrhoea abdominal pain a raised white blood cell count (WCC) is characteristic if severe toxic megacolon may develop
45
Diagnosis of pseudomembranous colitis
Is made by detecting Clostridium difficile toxin (CDT) in the stool Clostridium difficile antigen positivity only shows exposure to the bacteria, rather than current infection
46
1st line antibiotic for c diff infection
Oral vancomycin
47
What is toxic megacolon
Nonobstructive dilation of the colon usually associated with systemic toxicity
48
Common causes of toxic megacolon
IBDs | Infections(C diff, salmonella, CMV)
49
Factors which precipitate toxic megacolon
Hypokalaemia Medications(anticholinergics, opioids, antidepressants) Barium enema Colonscopy and bowel preparations
50
Diagnosis of toxic megacolon
Radiographic evidence of the dilation of the colon greater than 6 cm ``` Fever Tachycardia Neutrophilic leukocytosis Anaemia Hypotension ```
51
Management of toxic megacolon
Supportive Abx(vancomycin and metronidazole) Treat underlying cause Surgical review
52
Surgical management of toxic megacolon
current surgical treatment of choice in acute toxic megacolon is subtotal colectomy with ileostomy and either a Hartmann pouch, sigmoidostomy, or rectostomy
53
What are pseudo polyps
Widespread ulceration in UC with preservation of adjacent mucosa which has the appearance of polyps
54
What is GORD
acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus Oesophagus has a squamous epithelial lining making it more sensitive to the effects of stomach acid. The stomach has a columnar epithelial lining that is more protected against stomach acid
55
GORD presentation
``` Heartburn Acid regurgitation Retrosternal or epigastric pain Bloating Nocturnal cough Hoarse voice ```
56
When should referral for endoscopy be made for GORD
``` Dysphagia (difficulty swallowing) at any age gets a two week wait referral Aged over 55 (this is generally the cut off for urgent versus routine referrals) Weight loss Upper abdominal pain / reflux Treatment resistant dyspepsia Nausea and vomiting Low haemoglobin Raised platelet count ```
57
Lifestyle advice for GORD
``` Reduce tea, coffee and alcohol Weight loss Avoid smoking Smaller, lighter meals Avoid heavy meals before bed time Stay upright after meals rather than lying flat ```
58
Mx of GORD
Gaviscon/Rennie Omeprazole Ranitidine as alternative to PPI
59
Surgical mx of GORD
Surgery for reflux is called laparoscopic fundoplication. This involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.
60
Diagnosis of haemorrhoids
Bright red, painless rectal bleeding(on toilet paper/in toilet bowel) Anal itching/irritation Feeling of rectal fullness or incomplete evacuation on bowel movements Soiling Pain(not in internal)
61
When should patients with haemorrhoids be admitted
Extreme pain | Internal haemorrhoids which have prolapsed
62
Lifestyle advice to aid healing of the haemorrhoid
Advise on the importance of correct anal hygiene. The anal region should be kept clean and dry to aid healing and reduce irritation and itching. Recommend careful perianal cleansing and to pat (rather than rub) the area dry. Avoid still withholding
63
Mx of haemorrhoids
Simple analgesia | Topical haemorrhoids preparation(corticosteroids)
64
Secondary care medical treatments for haemorrhoids
Rubber band ligation Injection sclerotherapy Infrared coagulation/photocoagulation
65
Indications for liver transplant
acute liver failure or chronic liver failure. hepatocellular carcinoma.
66
Factors suggesting unsuitability for liver transplant
Significant co-morbidities (e.g., severe kidney, lung or heart disease) Current illicit drug use Continuing alcohol misuse (generally 6 months of abstinence is required) Untreated HIV Current or previous cancer (except certain liver cancers)
67
Scar associated with liver transplant
“rooftop” or “Mercedes Benz” incision along the lower costal margin for open surgery
68
Post-transplant care
``` Lifelong immunosuppression Avoid alcohol and smoking Treating opportunistic infections Monitoring for disease recurrence (i.e. of hepatitis or primary biliary cirrhosis) Monitoring for cancer ```
69
Stages of non-alcoholic fatty liver disease
Non-alcoholic Fatty Liver Disease Non-Alcoholic Steatohepatitis (NASH) Fibrosis Cirrhosis
70
Risk factors for NAFLD
``` Obesity Poor diet and low activity levels Type 2 diabetes High cholesterol Middle age onwards Smoking High blood pressure ```
71
Diagnosis of NAFLD
Liver ultrasound
72
1st line recommended ix for assessing fibrosis in NAFLD
Enhanced liver fibrosis blood test (ELF) Otherwise NAFLD fibrosis score Then fibroscan
73
Mx of NAFLD
``` Weight loss Exercise Stop smoking Control of diabetes, blood pressure and cholesterol Avoid alcohol ```
74
Stages of alcoholic liver disease
Alcohol related fatty liver - build up of fat from drinking Alcoholic hepatitis - usually reversible with permanent abstinence Cirrhosis
75
Complications of alcohol
``` Alcoholic Liver Disease Cirrhosis and HCC Alcohol Dependence and Withdrawal Wernicke-Korsakoff Syndrome (WKS) Pancreatitis Alcoholic Cardiomyopathy ```
76
IX in alcoholic liver disease
FBC - raised MCV LFTs - elevated ALT and AST, low albumin Clotting - elevated prothrombin time U&Es - deranged in hepatorenal syndrome
77
Imaging ix in alcoholic liver disease
Fibroscan - assess degree of cirrhosis Endoscopy CT/MRI Liver biopsy
78
General mx of alcoholic liver disease
``` Alcohol cessation Detox regime Thiamine and high protein diet Steroids Liver transplant ```
79
Alcohol withdrawal symptoms 6-12 hrs
tremor, sweating, headache, craving and anxiety
80
Alcohol withdrawal symptoms 12-24 hrs
Hallucinations
81
Alcohol withdrawal symptoms 24-48 hrs
Seizures
82
Alcohol withdrawal symptoms 24-72 hrs
Delirium tremens
83
Delirium tremens presentation
``` Acute confusion Hypertension Hyperthermia Tachycardia Delusions and hallucinations Tremor ```
84
Which tool can be used to guide treatment in alcohol withdrawal
CIWA-Ar (Clinical Institute Withdrawal Assessment – Alcohol revised) tool
85
Mx of effects of alcohol withdrawal
Chlordiazepoxide IX high-dose B vitamins(pabrinex) followed by regular lower dose oral thiamine
86
Features of wercicke's encephalopathy
Confusion Oculomotor disturbances (disturbances of eye movements) Ataxia (difficulties with coordinated movements)
87
Features of korsakoffs syndrome
``` Memory impairment (retrograde and anterograde) Behavioural changes ```

Gen surg (24 decks)

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