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GI Flashcards

1
Q

Signs and symptoms of an upper GI bleed ?

A

Epigastric pain
Haematemesis - red if active, coffee ground if settled
Melaena - black and foul smelling
Shock

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2
Q

Causes of an upper GI bleed ?

A

Peptic ulcer disease
Oesophagitis
Gastritis
Oesophageal or gastric varices
Upper GI cancer

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3
Q

Investigations for an Upper GI bleed ?

A

FBC
Check coagulation
U & E‘ s
LFT’s
Imaging - CXR, AXR, CT chest abdo

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4
Q

What is the ROCKALL full score ?

A

Performed post-endoscopy and considers age, shock, co-morbidities, endoscopic signs of acute bleeding and endoscopic diagnosis.
It assesses the risk of an Upper GI bleed.

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5
Q

Key questions to ask in a history if suspecting an Upper GI bleed ?

A

Any past GI bleeds ?
Dyspepsia ?
Any known ulcers ?
Liver diseases or known varices?
Dysphagia, vomiting, weight loss ?
Alcohol use ?
Any serious co-morbidities ?

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6
Q

What is the acute management of an upper GI bleed ?

A

Resuscitate and ABC
Give terlipressin ( ADH analogue ) or somatostatin plus prophylactic antibiotics.
Send for urgent endoscopic diagnosis and repair using clipping or thermal coagulation with adrenaline if non-variceal or band ligation if variceal.
PPI post endoscopy.

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7
Q

What is the pathophysiology of Crohn’s disease ?

A

Skip lesions anywhere from the mouth to the anus however the terminal ileum is the most common.
There is transmural granulomatous inflammation.

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8
Q

What is the prevalence of Crohn’s disease ?

A

1 in 600

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9
Q

Signs and symptoms of Crohn’s disease ?

A

Diarrhoea ( bloody in 25% )
Lower abdo pain
Weight loss
Fever
Fatigue
Right iliac fossa mass from inflammation
Perianal fistulas

Non-intestinal :
Ulcers
Clubbing
Entero-arthritis
Gallstones
Liver inflammation

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10
Q

Risk factors for Crohn’s disease ?

A

Smoking
Family history
White ethnicity

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11
Q

Investigations for Crohn’s disease ?

A

FBC
CRP
U & E’s
LFT ( check for hepatobiliary disease )
Stool culture ( rule out infection )
Faecal calprotectin
Presence of C diff marker ( poor prognosis )
Ileocolonscopy + biopsy
AXR
CT / MRI for info on extent of disease

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12
Q

Management for inducing remission after an attack of Crohn’s disease ?

A

IV hydrocortisone 100mg qds
If no improvement after 3-5 days escalate treatment and add biologics or surgery.

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13
Q

Management for maintaining remission in Crohn’s disease ?

A

Azathioprine or biologics are used as maintenance treatment .

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14
Q

What should be tested for before starting biologic treatment ?

A

Latent TB

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15
Q

Complications of Crohn’s disease ?

A

Small bowel obstruction ( bowel thickening and fibrosis can cause strictures )
Abscess
Fistulas
Colorectal carcinoma ( more common in UC )

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16
Q

What advice should be given to someone to help them stay in remission if they have Crohn’s disease ?

A

Smoking cessation

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17
Q

What are some key questions for taking a bowel habit history ?

A

How often do they go to the toilet ? And is this different from normal ?
Any changes in consistency ?
Are they waking up at night to open their bowels ?
Any blood present in stool ?
Do they have tenesmus ?
Do they have faecal incontinence or urgency ?

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18
Q

What are patients admitted with acute IBD at a high risk of having ?
What do they require to prevent this ?

A

A venous thromboembolism
Prophylactic heparin

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19
Q

What is the pathophysiology of UC ?

A

A continuous area of inflammation in the rectum +/- the colon.
There is an inflamed, friable mucosa with crypt changes. There are reduced goblet cells and pseudo polyps.
If severe there will be submucosal inflammation and ulceration.

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20
Q

What is the prevalence of UC ?

A

1 in 1000

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21
Q

Signs and symptoms of UC ?

A

Diarrhoea ( bloody in 75% ) and may contain mucus
Lower abdo cramps
Faecal urgency + tenesmus
Gradually occurs
Fever
Weight loss

Non-intestinal :
Entero-arthritis
Primary sclerosing Cholangitis
Liver disease

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22
Q

Risk factors for UC ?

A

Non-smokers
Family history
HLA-B27

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23
Q

Investigations for UC ?

A

FBC ( Hb, iron, B12, folate )
CRP ( also check albumin and platelets )
U & E’s ( Mg and Ca2+ )
LFT ( associated hepatobiliary disease )
Stool culture ( rule out infection )
Faecal calprotectin
Check for C. difficile ( poor prognosis )
Sigmoidoscopy
AXR

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24
Q

Management for inducing remission in UC ?

A

IV hydrocortisone
If not improving by day 3-5 consider adding :
Ciclosporin, biologics or surgery

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25
Management for maintaining remission in UC ?
Mesalazine is used for maintenance
26
Complications of UC ?
Perforation Toxic mega colon Colorectal carcinoma ( screen with colonoscopy every 3 years, consider removal if signs of dysplasia ) VTE
27
Pathophysiology of coeliac disease ?
It is an autoimmune disease response to the complex of gliadin and the enzyme tissue transglutaminase (tTG) resulting in intestinal damage.
28
What is the prevalence of Coeliac disease ?
1 in 100
29
Signs and symptoms of coeliac disease ?
Diarrhoea and steatorrhoea Abdominal pain Bloating Weight loss Anaemia - may cause fatigue Osteoporosis - calcium and vitamin D malabsorption Mouth ulcers + angular stomatitis
30
Risk factors for coeliac disease ?
Family history Other immune disorders such as T1DM IgA deficiency
31
Investigations for coeliac disease ?
Check levels of anti-tTG IgA plus total IgA too. Biopsy via upper endoscopy ( patients should remain on gluten while under investigations ) FBC ( Hb, iron, B12 or folate ) LFT ( raised transaminases ) Calcium and albumin levels
32
What screening should take place if someone is diagnosed with coeliac disease ?
1st degree relatives should be screened
33
Complications of coeliac disease ?
Osteoporosis Small increase in risk of small bowel adenocarcinoma
34
Management of coeliac disease ?
Long term gluten free diet Replace micronutrients
35
Causes of epigastric pain ?
Pancreatitis Gastritis or duodenitis peptic ulcers gallbladder disease Aortic aneurysm
36
Causes of left upper quadrant pain ?
Peptic ulcers Gastric or colonic cancer Splenic rupture
37
Causes of right upper quadrant pain ?
Cholecystitis Biliary colic Hepatitis Peptic ulcers Colonic cancer Renal colic
38
Causes of loin pain ?
Renal colic Pyelonephritis Renal tumour
39
Causes of left iliac fossa pain ?
Diverticulitis Volvulus Colon cancer IBD Renal colic UTI Ectopic pregnancy
40
Causes of right iliac fossa pain ?
Volvulus Colon cancer IBD Renal colic UTI Ectopic pregnancy Appendicitis Crohn’s ileitis
41
Causes of generalised abdominal pain ?
Gastroenteritis IBS Peritonitis Constipation
42
Causes of centralised pain ?
Mesenteric ischaemia Abdominal aneurysm Pancreatitis
43
Causes of haematemesis ?
Bleeds for the upper GI tract such as peptic ulceration, varices and oesophagitis
44
What is the more likely diagnoses if there is a large amount of fresh, red blood when vomiting with liver disease and alcohol abuse?
An active bleed from an oesophageal varices
45
What is the more likely diagnoses if there is a large amount of fresh, red blood when vomiting with abdominal pain and heartburn ?
Peptic ulceration GORD
46
What would small streaks of blood at the end of prolonged retching indicate ?
This would indicate minor oesophageal trauma at the gastro- oesophageal junction ( Mallory Weiss tear ).
47
What would be indicated if a patient was vomiting up coffee ground looking blood ?
This occurs as it has been altered by the stomach. It usually suggests the bleeding has ceased and that it is modest.
48
If someone has haematemesis what should you ask about ?
The amount and nature of blood Previous bleeding episodes, treatment and outcome Cigarette smoking Use of : - NSAIDs - Warfarin - Clopidogrel Red flags for malignancy
49
What questions should be asked if there is PR bleeding ?
The amount of blood The nature of blood Mixed into the stool or on it ? Is it spattered over the pan, with the stool or only seen on the paper ? Any other features such as mucus which could indicate IBD or colonic cancer ?
50
What is melaena ?
It is a jet-black, tar-like and pungent smelling stool representing blood from the upper GI tract that has been altered by passage through the gut.
51
What are some causes of a lower GI bleed ?
Haemorrhoids Anal fissure Diverticular disease Colorectal carcinoma IBD
52
What is jaundice ?
A yellow pigmentation of the skin, sclera and mucosae caused by excess bilirubin in the tissue.
53
What features occur when there is an interference in the normal metabolism of bilirubin ?
Dark urine - renal excretion of conjugated bilirubin Pale stool Abdominal pain Jaundice
54
If jaundice is present what are some key questions to ask about in the history ?
Previous blood transfusions Past history of jaundice, hepatitis, pancreatitis or biliary surgery Drugs - NSAIDs, antibiotics IV drug use Sexual history Any liver disease Alcohol consumption
55
Causes of pre-hepatic jaundice ?
Haemolysis Ineffective erythropoiesis Impaired hepatic breakdown - drugs
56
Causes of hepatic jaundice ?
Viral hepatitis Alcohol Alpha 1 antitrypsin deficiency Drug induced hepatitis
57
What should be asked about if someone is presenting with diarrhoea ?
Colour consistency Offensive smell Ease of flushing Duration Does it disturb the patient’s sleep ? Is there blood, mucus or pus ? Associated pain or colic ? Urgency ? Any associated vomiting , nausea or weight loss ? Foreign travel ?
58
Definition of diarrhoea ?
Increase in stool volume, frequency and change in consistency to semi-formed or liquid stool.
59
Causes of diarrhoea ?
Malabsorption Increased intestinal motility - hyperthyroidism, IBD Crohn’s disease UC Osmotic such as lactose intolerance Secretory such as infection Drugs Laxatives
60
Define nausea ?
A feeling of sickness - inclination to vomit Usually occurs in waves May be associated with retching or heaving Varies in duration
61
Define vomiting ?
The forceful expulsion of the gastric contents by reflex contractions of the thoracic and abdominal muscles. Usually follows nausea
62
What conditions are indicated in an acute setting of nausea and vomiting ?
Cholecystitis Gastroenteritis Recreational drug use Pancreatitis
63
What conditions may be indicated in a chronic setting of nausea and vomiting ?
Metabolic disorders GORD Pregnancy Medications
64
If nausea and vomiting occurs before breakfast what could be indicated ?
Pregnancy Uraemia Alcohol Raised ICP
65
If nausea and vomiting occurs after eating what could be indicated ?
Psychiatric causes Peptic ulcers Pyloric stenosis
66
If nausea and vomiting occurs continuously what could be indicated ?
Depression
67
If the nature of vomitus is undigested food what is indicated ?
Achalasia Diverticulum Strictures
68
If the nature of vomitus is partially digested food what is indicated ?
Gastric outlet obstruction Gastroparesis
69
If the nature of vomitus is undigested food what is indicated ?
Proximal small bowel obstruction
70
If the nature of vomitus is faeculent what is indicated ?
Fistula Obstruction
71
What would you be concerned of if there was nausea and vomiting with weight loss ?
Malignancy
72
What would you be concerned of if there was nausea and vomiting with diarrhoea, myalgia, malaise and headaches ?
Viral infection
73
What would you be concerned of if there was nausea and vomiting with headaches, neck stiffness and vertigo ?
Central neurological problem
74
What does undigested food without bile in vomit suggest ?
A lack of connection between the stomach and the small intestine ( pyloric obstruction )
75
When assessing someone’s nutritional status what should be asked about in the history ?
Appetite Diet history Any changes in oral intake Changes in weight
76
What bedside tool can be used to assess nutrional status ?
The Malnutrition Universal Screening Tool (MUST) screening tool
77
What are the 3 things assessed on in the MUST tool ?
BMI Unplanned weight loss in the past 3-6 months If the patient is acutely unwell or if they are likely to have no nutritional intake for more than 5 days
78
What is the first step in managing malnutrition ?
Using food and encouragement. Make sure mealtimes aren’t interrupted and high calorie options are encouraged.
79
What is an NG tube used for ?
Short term access and may provide all of the nutritional and fluid requirements. It may also be used on top of the patients oral intake as supplementary feeding.
80
What should be checked before feeding someone using an NG tube ?
pH to ensure the tip is in the stomach and not in the lungs
81
What is a risk of feeding someone orally with a swallowing impairment ?
Aspiration
82
What is parenteral nutrition ?
This provides nutrition and fluid directly into a patient’s veins. It is indicated when the GI tract is either not accessible or not working.
83
What are the risks of parenteral nutrition ?
The nutrition and fluid is given via a dedicated PICC or Hickman lune so there are risks of sepsis and liver dysfunction.
84
What is a PEG / RIG / PEGJ / RIGJ tube ?
These tubes provide long term enteral access. They may feed into the stomach ( PEG or RIG ). They may also go into the small bowel ( PEGJ or RIGJ ). PEG and PEGJ are placed in via endoscopy and RIG and RIGJ are placed in radiologically. All these tubes require puncture into the stomach.
85
What are some conditions associated with malnutrition ?
Any very ill patients Malignancy Metabolic disorders GI disease Sepsis Trauma Depression Post-surgery
86
Define malnutrition ?
Malnutrition includes under nutrition ( wasting, stunting, underweight ), inadequate vitamins or minerals, obesity, overweight and resulting diet-related non communicable diseases.
87
Define acute liver failure ?
Hepatocellular dysfunction causing coagulopathy and encephalopathy in someone without a known liver disease.
88
What can cause acute liver failure ?
Paracetamol overdose Viral hepatitis usually hep A or B Drugs - phenytoin, sodium valproate, isoniazid, nitrofurantoin, sulfonamides and co-amoxiclav Ischaemic hepatitis Pregnancy
89
Signs and symptoms of acute liver failure
Fatigue Nausea Anorexia Weight loss Abdominal or RUQ pain Jaundice Hepatic encephalopathy
90
Investigations when suspecting acute liver failure ?
General bloods : LFT INR FBC ABG U & E Cause specific tests : Paracetamol levels Viral serology Auto-antibodies Imaging - abdo USS,
91
Complications of acute liver failure ?
Cerebral oedema Sepsis Shock AKI
92
What should you be check for in a patient with liver failure ?
Sepsis Hypoglycaemia GI bleeds / varices Encephalopathy
93
Management of acute liver disease ?
Protect the airway with intubation and place an NG tube. Monitor Obs and bloods Give glucose to prevent hypoglycaemia Treat the underlying cause. If seizing treat with lorazepam. Give PPI as prophylaxis against stress ulcers
94
How to treat cerebral oedema ?
On ITU : Give 20% mannitol IV
95
How to treat ascites ?
Restrict fluids Low salt diet Give diuretics
96
What are some risk factors for acute liver failure ?
Chronic alcohol misuse Poor nutritional status Age above 40 Female
97
What signs and symptoms are present in paracetamol overdose ?
Non initially but may have vomiting or RUQ pain Later : jaundice and encephalopathy from liver damage + acute kidney injury
98
What is the pathophysiology of a paracetamol overdose ?
The usual paracetamol metabolism pathways become rapidly saturated. This causes the other pathway to be used via cytochrome P450 enzymes which generates a toxic metabolite NAPQI. The body can only detoxify a small amount with endogenous glutathione. This causes NAPQI to accumulate.
99
Investigations for paracetamol overdose ?
FBC LFT U & E’s Albumin levels Serum paracetamol levels ABG
100
Management of paracetamol overdose ?
N-acetylcysteine IV - most effective within 8 hours Methionine PO is second line. Give activated charcoal if less than 1 hour from ingestion.
101
What are some poor prognostic indicators in a paracetamol overdose ?
High or increased PT Low pH High lactate High creatinine
102
What is N-acetylcysteine ?
A glutathione precursor allowing detoxification of NAPQI. It completely prevents ALF if given before 8 hours in paracetamol overdose.
103
Causes of cirrhosis ?
Chronic alcohol abuse Chronic HPV or HCV infection Haemochromatosis Alpha 1 antitrypsin deficiency Wilson’s disease Non-alcoholic steatohepatitis ( NASH ) Autoimmunity Drugs
104
Signs and symptoms of chronic liver disease ?
Leuconychia Clubbing Palmar erythema Dupuytren’s contracture Spider naevi Xanthelasma Gynaecomastia Hepatomegaly
105
Complications of chronic liver disease ?
Hepatic failure : coagulopathy, encephalopathy Portal hypertension : Caput medusae, oesophageal varices
106
What is assessed in LFT’s ?
Albumin ALT AST ALP Bilirubin
107
What is seen on LFT’s in pre-hepatic jaundice ?
Raised serum unconjugated bilirubin Raised urobilinogen in urine
108
What is seen on LFT’s in hepatocellular damage ?
Raised ALT Raised AST Raised conjugated and unconjugated bilirubin Low albumin
109
What is seen on LFT’s in post hepatic jaundice ?
Raised conjugated levels Low urobilinogen Raised ALP Raised amylase
110
What is a concern about high levels of unconjugated bilirubin ?
It can cross the blood brain barrier
111
Management of alcoholic liver disease ?
Reduce and stop alcohol intake. Benzodiazepine to help with withdrawal. Give disulfiram to prevent relapse on alcohol Liver transplant after 3 months away from alcohol.
112
What is the management of non-alcoholic fatty liver disease ?
Control risk factors Bariatric surgery helps Monitor LFT’s and glucose levels
113
Management for viral hepatitis ?
If hep A or B notify public health england. Screen and vaccinate contacts Supportive treatment Antiviral medications
114
Management for haemochromatosis ?
Lifestyle changes : avoid iron and vitamin C Have a hep A or hep B vaccine Venesection
115
Management of Autoimmune liver disease ?
Immunosuppression Prednisolone Azathioprine
116
What are some causes of chronic liver disease ?
Alcoholic liver disease Obesity Hep B and C EBV Autoimmune hepatitis Hereditary haemochromatosis Wilson’s disease Drugs - methotrexate, amiodarone
117
Signs and symptoms of chronic liver disease ?
May be asymptomatic Jaundice Pruritis Bleeding varices Ascites Hepatic encephalopathy Anorexia Weight loss Fatigue
118
What can be found on examination in chronic liver disease ?
Organomegaly - Early on - hepatomegaly but then shrinks, splenomegaly due to portal hypertension. Hands - leuconychia, clubbing, dupuytren’s contracture Xanthelamsa Spider naevi
119
Investigations for chronic liver disease ?
LFT’s FBC U & E Viral serology Check ferritin And ceruloplasmin Imaging - USS Biopsy
120
Management of chronic liver disease ?
Treat aetiology - stop drinking - weight loss - antivirals - venesection
121
Complications of chronic liver disease ?
Cirrhosis Portal hypertension Ascites and spontaneous bacterial peritonitis Hepatorenal syndrome Hepatocellular carcinoma
122
Pathophysiology of portal hypertension ?
Cirrhosis causes an increased resistance in the portal vein.
123
Complications of portal hypertension ?
Varices Splenomegaly Caput medusae
124
How do varices form ?
Cirrhosis causes a back up in the blood flow to the liver. This causes blood flow to be diverted through smaller systemic veins causing them to dilate forming varices.
125
What are the main signs of portal hypertension seen in patients ?
GI bleeding Ascites Encephalopathy Low platelets, red blood cells and white blood cells
126
Investigations of portal hypertension ?
Endoscopy Measure the pressure in the hepatic vein Imaging - USS Blood tests
127
Management of portal hypertension ?
Beta blockers Banding or sclerotherapy for varices Also treatment for associated features

Medicine Block (4 decks)

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