GI Flashcards
(204 cards)
1
Q
Define Porphyria
A
A spectrum of disorders arising from abnormalities in haem synthesis pathway
Can be classified as acute or non-acute
2
Q
What are the most common examples of acute porphyrias?
A
Acute intermittent porphyria and variegate porphyria
3
Q
What are triggers for acute porphyrias?
A
- Abx = rifampicin, isoniazid, nitrofurantoin
- Anaesthetic agents = ketamine, etomidate
- Sulphonamides
- Barbiturates
- Antifungal agents
4
Q
Acute porphyria features
A
- Abdo pain
- Nausea
- Confusion
- Hypertension
- Seizures
- Purple/red urine
5
Q
Acute porphyria investigations
A
urinary porphobilinogen levels - make sure to protect the sample from light to prevent breakdown of the compound
6
Q
Acute porphyria management
A
Mainly supportive, but can give haem arginate IV to replenish haem levels and reduce disease severity
7
Q
Alcohol withdrawal features
A
Simple withdrawal (6-12 hours after last drink):
- Insomnia
-Tremor
- Anxiety
- Agitation
- N&V
- Sweating
- Palpitations
Alcohol hallucinosis (12-24 hours after last drink):
- Hallucinations of visual, tactile or auditory origins
Delirium tremens (72 hours after last drink)
- Delusions
- Confusion
- Seizures
- Tachycardia
- HTN
- Hyperthermia
8
Q
What are the indications for inpatient treatment of Alcohol withdrawal?
A
- Pt drinks >30 units per day
- Score >30 on SADQ score
- High risk of withdrawal seizures
- Concurrent withdrawal from benzo’s
- Psychiatric or medical comorbidities
- Vulnerable pt
- Pt under 18
9
Q
Alcohol withdrawal management
A
- Chlordiazepoxide in a reducing regimen
- Rapid acting benzo’s (e.g. IV lorazepam) for withdrawal seizures
- Pabrinex
- Oral lorazepam is 1st line for treating DT, w/ parenteral loraz/diazepam 2nd line
10
Q
What are the stages of Alcoholic liver disease?
A
1) Fatty liver disease = reversible w/ abstinence
2) Alcoholic hepatitis
3) Cirrhosis
11
Q
Alcoholic liver disease features
A
1) Fatty liver disease = asymptomatic, may have some hepatomegaly
2) Alcoholic hepatitis = jaundice, fever, tender hepatomegaly, N&V, malaise
3) Cirrhosis = jaundice, ascites, hepatic encephalopathy, bleeding tendencies, spider naevi, palmar erythema
12
Q
Alcoholic liver disease management
A
Conservative:
- Abstinence
- Nutritional support
Medical:
- Alcoholic hepatitis = 1-3 months of oral prednisolone for severe cases (Maddery’s DF > 32)
- Cirrhosis = manage complications
Surgical:
- Liver transplant for cirrhotic pts
13
Q
What is Maddrey’s discriminant function?
A
A function which predicts prognosis in alcoholic hepatitis and identifies pts who would benefit from treatment w/ steroids
Can be found online
14
Q
Alpha-1 antitrypsin deficiency definition
A
Genetic deficiency in the alpha-1 antitrypsin deficiency enzyme which usually inhibits neutrophil elastase
This results in emphysema and liver cirrhosis
15
Q
Alpha-1 antitrypsin deficiency features
A
- COPD in pts 30-40
- Neonatal jaundice
- Deranged LFTs in adults w/ no other identifiable cause and cirrhosis
16
Q
Alpha-1 antitrypsin deficiency investigations
A
- Spirometry shows obstructive picture
- Alpha-1 antitrypsin deficiency levels are low
- Genotyping
- CXR shows emphysema
- Liver biopsy = Periodic acid Schiff +ve globules
17
Q
Alpha-1 antitrypsin deficiency management
A
- Smoking cessation
- IV A1AT (not widely used due to cost)
- Liver transplant
18
Q
What causes of nausea is Cyclazine (H1 receptor antagonist) best for?
A
Vestibular disturbances
19
Q
What causes of nausea are Domperidone or metoclopramide (D2 receptor antagonist) best for?
A
Post-operative nausea, motion sickness (avoid in bowel obstruction as they also increase gut motility)
20
Q
What causes of nausea is Ondansetron (5HT3 receptor antagonist) best for?
A
Acute gastroenteritis, post-operative nausea, radiotherapy- or chemotherapy-induced
21
Q
What causes of nausea is Hyoscine hydrobromide (Anti-muscarinic) best for?
A
Vestibular disturbances, palliative care
22
Q
Ascites investigation
A
- Ascitic tap done under US guidance
- Serum ascites albumin gradient (SAAG)
- Bloods
- Imaging
23
Q
What is Serum ascites albumin gradient (SAAG)?
A
A calculation used to determine the cause of the ascites:
Serum albumin concentration - ascites albumin concentration
24
Q
What are causes of ascites with a high SAAG (>11 g/L)?
A
High SAAG suggests that the cause is due to raised portal pressure as water is being forced into the peritoneal cavity whilst albumin stays w/in the vessel - results in a higher difference between serum and ascites albumin concentrations
Causes:
- Cirrhosis
- RHF
- Budd-Chiari syndrome
- Constrictive pericarditis
- Liver failure
25
What are causes of ascites with a low SAAG (<11 g/L)?
- Cancer/mets in the peritoneum
- Infections = TB, peritonitis
- Pancreatitis
- Hypalbuminaemia = nephrotic syndrome, Kwashiorkor (severe protein malnutrition)
26
Ascites management
- Treat underlying cause
- High SAAG = salt-restricted diet and fluid restriction
- Spironolactone = 1st line treatment, add furosemide if it ineffective alone
- If pt is refractory to medical management - give regular paracentesis's
27
Define Spontaneous bacterial peritonitis
Bacterial infection of ascitic fluid - a serious complication of ascites
28
Spontaneous bacterial peritonitis investigations
Ascitic tap showing neutrophils >250
29
Spontaneous bacterial peritonitis management
Acute = IV Tazocin
Prophylactic = ciprofloxacin - given if ascitic protein is high
30
Classification of Autoimmune hepatitis
3 different types classified by antibodies:
1) ANA +ve w/ anti-smooth muscle abs
2) Anti-liver/kidney mitochondrial type 1 (LKM1) abs - more common in children
3) Anti soluble liver-kidney antigen
31
Autoimmune hepatitis features
Can present as acute hepatitis:
- Fever
- Jaundice
- Malaise
- Abdo pain
- Urticarial rash
- Polyarthritis
- Pulmonary infiltrates
- Glomerulonephritis
Can present as chronic liver disease:
- Ascites
- Jaundice
- Leukonychia
- Spider naevi
Other symptoms:
- Fatigue
- Anorexia
- Hepatomegaly
- Splenomegaly
32
Autoimmune hepatitis investigations
- Bloods = deranged LFTs showing a hepatic pattern - raised ALT and bilirubin, normal or mildly raised ALP
- IgG predominant hypergammaglobulinemia
- Specific antibody testing
33
Autoimmune hepatitis management
1st line = prednisolone for acute flairs and then maintenance w/ azathioprine
2nd line = other immunosuppressants
3rd line = liver transplant
34
Define Barrett's oesophagus
Metaplasia of the distal 1/3 oesophagus from the usual squamous epithelium to columnar epithelium - increases the risk of oesophageal adenocarcinoma 100-fold
Causes by long-term GORD
35
Barrett's oesophagus management
Conservative:
- Manage the GORD
- If there is a short-segment (<3cm) of Barrett's oesophagus w/out intestinal metaplasia then no further surveillance is required
Surveillance:
- Long-segment (>3cm) Barrett's oesophagus = repeat OGD every 2-3 years
- Short-segment Barrett's oesophagus w/ intestinal metaplasia = repeat OGD every 3-5 years
- Indefinite dysplasia = OGD every 6 months
Ablation:
- Pts w/ dysplasia are eligible for ablation therapy
1 1st line = endoscopic ablation of visualised lesions
36
Define Budd-Chiari syndrome
The obstruction of hepatic venous outflow, either due to thrombosis or compression of the hepatic veins and/or the IVC
This obstruction impedes the normal drainage of blood from the liver, leading to increased hepatic sinusoidal pressure causing congestion and ischaemia - eventually leads to fibrosis and cirrhosis
37
Budd-Chiari syndrome features
Range from asymptomatic to fulminant liver failure:
- RUQ pain
- Hepatomegaly
- Jaundice
- Ascites
- Peripheral oedema
- Splenomegaly
- Variceal bleeding
38
Budd-Chiari syndrome investigations
Bedside:
- Abdo exam
Bloods:
- LFTs
- FBCs and coagulation
- Serum albumin
- Ascitic tap showing high SAAG due to portal HTN
Imaging:
- Doppler USS = initial test to assess blood flow in the hepatic veins and IVC
- MRI or CT angiography = see extent of obstruction
- Hepatic venography = directly visualize veins and measure pressure
Invasive:
- Liver biopsy = assess degree of liver damage and fibrosis
39
Budd-Chiari syndrome management
- Anticoagulation depending on underlying cause
- Thrombolytic therapy
- Angioplasty and stenting
- Transjugular Intrahepatic Portosystemic Shunt = to reduce portal HTN and improve blood flow
- Liver transplant if liver failure
40
Define Carcinoid tumour
Slow-growing neuroendocrine tumours that typically originate in the appendix and small intestine
5-10% secrete serotonin
Have the potential to become malignant
41
Carcinoid tumour features
Symptoms usually only occur when the pts has liver mets which allow the serotonin to enter systemic circulation w/out undergoing metabolism - this is called carcinoid syndrome:
- Abdo pain
- Diarrhoea
- Flushing
- Wheezing
- Pulmonary stenosis
42
Carcinoid tumour investigations
- Urine 5-HIAA levels = breakdown product of serotonin
- Imaging = CT, MRI or octreotide scans
- Tissue biopsy = definitive diagnosis through histology
43
Carcinoid tumour management
- Octreotide = somatostatin analogue which blocks the production of hormones by the tumour
- Surgical resection
- Embolism, radio/chemotherapy based on the extent of disease
44
Cholera features
- Sudden onset watery diarrhoea
- Abdo cramps
- N&V
- Excessive thirst
- Dry mouth and mucus membranes
- Oliguria
- Drowsiness or lethergy
- Irritability
45
Cholera investigations
- Stool culture = gold standard
- Rapid diagnostic tests = can give results w/in hrs but less sensitive and specific than stool culture
46
Cholera management
- Aggressive fluid replacement
- Doxycycline or co-trimoxazole can decrease the volume of diarrhoea by 50% and is recommended in pts w/ moderate to severe dehydration
47
What are risk factors for developing C. diff?
- Abx = clindamycin, ciprofloxacin, 3rd gen cephalosporins (e.g. ceftriaxone), penicillins, Tazocin, carbapenems
- Long stay in healthcare setting
- > 65
- IBD, cancer r kidney disease
- Immunocompromised
- Taking a PPI
48
C. diff features
- Watery diarrhoea which can be bloody
- Painful abdo cramps
- Nausea
- Signs of dehydration
- Fever
- Anorexia
- Confusion
- Pseudomembranous colitis on XR
Classically has a raised WCC w/ little change in CRP
49
C. diff management
- Stop abx if possible
- Move to side room immedietly
- Abdo X-ray looking for megacolon
- PO vancomycin for first episode
- If recurrent or persistent - switch to PO fidaxomicin
- If severe (signs of shock) add IV metronidazole
50
Coeliac disease features
GI:
- Abdo pain
- Distention
- N&V
- Diarrhoea
- Steatorrhea
Systemic:
- Fatigue
- WL or failure to thrive in children
- Signs of vitamin deficiency = bruising (vit K)
- Dermatitis herpetiformis
51
Coeliac disease investigations
Serology = 1st line - Anti-TTG IgA antibodies and IgA levels, followed by anti-TTG IgG and anti-endomyseal antibodies
OGD and duodenal/jejunal biopsy is gold standard for diagnosis
Pt needs to have been eating gluten for 6 wks before the tests for them to be valid
52
Dermatitis herpetiformis management
Dapsone
53
What are the 2WW criteria for constipation?
Constipation (or diarrhoea) w/ WL in pts 60+
Consider urgent CT/US to rule out pancreatic cancer
54
Give an example of a bulk forming laxative, explain how they work and the common side effects
Ispaghula husk
Works by increasing faecal mass to stimulate peristalsis
SE = Bloating and flatulence
55
Give an example of a stimulant laxative, explain how they work and the common side effects
Senna
Increases intestinal motility for short-term relief
SE = cramps
56
Give an example of a stool softening laxative, explain how they work and the common side effects
Macrogol, sodium docusate
Increases water and fat absorbance in the stool to soften it and make it easier to pass
SE = flatulence, nausea
57
Give an example of an osmotic laxative, explain how they work and the common side effects
Lactulose
Pulls water into the stool, or stops it being drawn out
SE = abdo discomfort, flatulence, diarrhoea, electrolyte imbalances
1st line in hepatic encephalopathy due to its inhibition of ammonia-forming microorganisms
58
How do Phosphate enemas work?
Increases the fluid in the small bowel and causes a motion w/in 1-5 minutes
59
Crohn's features
GI Symptoms:
- Crampy abdo pain
- Non-bloody diarrhoea
- Perianal disease
- WL
- Fever
Dermatological:
- Erythema nodosum
- Pyoderma gangrenosum
Ocular:
- Anterior uveitis
- Episcleritis
MSK:
- Enteropathic arthropathy (symmetrically, non-deforming)
- Axial spondyloarthropathies
Hepatobiliary:
- Gallstones due to reduced bile acid reabsorption and increased Ca loss
Haematological:
- AA amyloidosis
- Renal stones
Signs:
- Anaemic
- Clubbing
- Aphthous ulcers in the mouth
- RLQ tenderness, RIF mass
- PR = skin tags, fistulae, perianal abscess
60
Crohn's investigations
Bedside:
- Stool culture to exclude infection
- Faecal calprotectin (antigen produced by neutrophils - will be raised)
Bloods:
- Raised WCC, CRP, ESR
- Thrombocytosis
- Anaemia
- Low albumin (malabsorption)
Imaging:
- Endoscopy required for diagnosis - will show skip lesions, cobblestone mucosa, transmural inflammation and non-caseating granulomas
61
Crohn's management
Inducing remission (treating flares):
- Monotherapy w/ steroids = oral pred or IV hydrocortisone (if 1st presentation and severe enough to require admission)
- Biologics
Maintaining remission:
- Azathioprine or mercaptopurine if 2 or more flares in 12 month period, or the steroid cannot be tapered
- Methotrexate can be used/added in pts who are intolerant to or uncontrolled on the above drugs
- Biologics (infliximab or adalimumab) in severe cases unresponsive to dual therapy
Surgical:
- Used to control fistulae, resect strictures or rest/defunction the bowel
62
Perianal fistulae management
High (trans-sphincter) fistula = drainage seton
Low (submucosal) fistula = fistulotomy (dissecting the superficial tissue and opening the tract)
Cant do a fistulotomy in a high fistula as you cant cut the sphincter
63
Perianal abscess management
- IV ceftriaxone + metronidazole
- Incision and drainage under GA - wound heals by secondary intention (edges not brought together)
64
Which drugs are Cytochrome P450 inducers?
CRAP GPS induces rage:
- Carbamazepine
- Rifampicin
- Alcohol
- Phenytoin
- Griseofulvin
- Phenobarbitone
- Sulphonylureas
65
Which drugs are Cytochrome P450 inhibitors?
SICKFACE.COM:
- Sodium valproate
- Isoniazid
- Cimetidine
- Ketoconazole
- Fluconazole
- Alcohol and grapefruit juice
- Chloramphenicol
- Erythromycin
- Sulphonamides
- Ciprofloxacin
- Omeprazole
- Metronidazole
66
What common drugs are metabolised by Cytochrome P450 enzymes?
Clopidogrel, statins, warfarin, OCP
There doses need to be reduced if taking inhibitors, and increased when taking inducers
67
Define Dyspepsia
A constellation of upper GI symptoms, such as epigastric pain, bloating, belching, early satiety and nausea, w/out evidence of structural or biochemical abnormalities
It requires assessment for ALARM symptoms
68
What are ALARM symptoms in dyspepsia?
- Anaemia
- Loss of weight
- Anorexia
- Recent onset of symptoms
- Melaena/haematemesis
- Swallowing difficulties
69
Dyspepsia management
Conservative:
- Smoking cessation
- WL
- Avoiding trigger foods
- Smaller meals
Medical:
- Stop offending medications = alpha/beta blockers, anticholinergics, aspirin, CCBs, corticosteroids, NSAIDs, TCA's, bisphosphonates
Medical:
- PPI trial for 1 month
70
What are the causes of Dysphagia?
Neuro:
- Cerebrovascular disease
- Parkinson's disease
- MND
- Myasthenia gravis
- Bulbar palsy
Motility disorders:
- Achalasia
- Diffuse oesophageal spasms
- Systemic sclerosis
Mechanical causes:
- Benign strictures
- Malignancy
- Pharyngeal pouch
- Lung cancer
- Mediastinal lymph nodes
- Retrosternal goitre
Other:
- Oesophagitis
- Globus
- Plummer-Vinson syndrome
71
Define Plummer-Vinson syndrome
A complication of long-term iron def anaemia where there are small web-like growths of tissue which partially block the oesophagus
Causes dysphagia
72
Define Enteric fever
Infection w/ salmonella typhi or salmonella paratyphi
Symptoms appear 6-30 days after exposure
73
Enteric fever features
- High fever
- Weakness
- Myalgia
- Relative bradycardia
- Abdo pain
- Constipation
- Headaches
- Vomiting (not usually severe)
- Skin rash w/ rose-coloured spots
- Confusion (if severe)
74
Enteric fever management
- A-E for acutely unwell pts
- Azithromycin or ceftriaxone
- Typhoid is a notifiable disease
75
GORD management
- For Pts <40 w/ typical symptoms and no red flags = 8 wks of PPI + lifestyle changes
76
Campylobacter gastroenteritis summary
From contaminated food
Incubation period = 16-48hrs
Causes bloody diarrhoea
Treated w/ macrolides e.g. clarithromycin
77
E.coli gastroenteritis summary
Most common cause of travellers diarrhoea
From improperly cooked meat
Treated w/ fluids
78
Salmonella gastroenteritis summary
From contaminated poulty, eggs and milk
Incubation period = 16-48 hrs
Causes bloody diarrhoea
Treated w/ fluids
79
Shigella gastroenteritis summary
Faecal-oral route
Incubation period = 1-4 days
Causes severe bloody diarrhoea
80
Bacillus cereus gastroenteritis summary
From contaminated foods - usually reheated rice
Causes vomiting and diarrhoea due to 2 toxins
Incubation period = 0.5-6 hours for vomiting and 8-16 hours for diarrhoea
81
Staph aureus gastroenteritis summary
Causes profuse vomiting w/ mild diarrhoea and abdo pain
Incubation period = <6 hrs
82
Which parasites cause gastroenteritis, and how do they present?
- Cryptosporidium = prolonged GI symptoms
- Entamoeba histolytica = ranges from mild-severe dysentery
- Giardia = explosive watery diarrhoea, constitutional symptoms and bloating - may last a long time
These can be treated w/ metronidazole
83
Define Gastroparesis
A chronic medical condition characterised by delayed gastric emptying w/out any mechanical obstruction in the stomach
It arises due to impaired activity of the stomach muscles which causes the stomach to take longer than usual to empty its contents
84
What are the causes of Gastroparesis?
Most common = autonomic neuropathy in DM
Other causes = post-surgical complication, meds, Parkinson's, MS
85
Gastroparesis features
- N&V
- Early satiety
- Abdo pain
- Bloating
Can lead to poor glucose level management in diabetics due to delayed absorption of food
86
Gastroparesis investigations
Solid meal gastric scintigraphy (AKA radionucleotide study of gastric emptying)
This allows for visualisation of gastric emptying
87
Gastroparesis management
- Dietary modifications = low fibre diet, smaller but more frequent meals, consumption of pureed food
- Medical = Prokinetic meds - Metoclopramide (1st line), domperidone or erythromycin
88
Which cause of gastroenteritis can lead to lactose intolerance?
Giardiasis
89
Define Gilbert's syndrome
An autosomal recessive disorder where there is decreased activity of the enzyme that conjugates bilirubin
90
Gilbert's syndrome features
intermittent episodes of mild unconjugated jaundice triggered by stress, fasting injections or exercise
91
H. pylori investigations
1st line = stool test or carbon-13 urea breath test
If having an OGD, rapid urease test (CLO) can be done
92
How do the different Hepatitis viruses present?
Hep A and E = acute hepatitis:
- Prodromal viral illness
- RUQ pain
- Jaundice
- Tender hepatosplenomegaly (due to swelling of the liver capsule)
Hep B or C = chronic hepatitis:
- Jaundice
- Ascites
- Coagulopathy
- Hepatic encephalopathy
Hep D can only occur in individuals who are infected with hep B
93
What is the incubation time of Hepatitis A?
2-6 weeks
94
What does Hepatitis B surface antigen indicate?
Current infection - can persist for up to 6 months
95
What does anti-hep B surface antigen indicate?
Immunity from past infection or vaccination
96
What does Hepatitis B e antigen indicate?
Acute active viral replication
97
What does Hepatitis B e antibody indicate?
Lower viral replication due to seroconversion
98
What does Hepatitis B core antibody indicate?
IgM indicates acute infection
IgG indicates past infection or vaccination
99
Hep B investigations
- Hep B antigen testing
- Biopsy = ground glass hepatocytes
100
Hep B management
- 1st line = Pegylated interferon alpha-2a (doesn't cure the infection, but stops liver disease)
- 2nd line = tenofovir and entecavir (antivirals)
101
What additional symptoms can occur in Hep C other than chronic liver disease?
- arthralgia/arthritis
- Sjogren's syndrome
- Cryoglobulinemia
- Porphyria cutanea tarda
- Membranoproliferative glomerulonephritis
102
Hep C management
- Nucleoside anologues = sofosbuvir + daclatasvir
- Antivirals
103
Risk factors for Hepatocellular carcinoma
Chronic liver disease and cirrhosis
104
Hepatocellular carcinoma features
- Abdo pain
- WL
- Jaundice
- Ascites
- Hepatomegaly w/ a craggy liver edge on examination
- Encephalopathy
105
Hepatocellular carcinoma investigations
- Increased alpha-fetoprotein (AFP) = tumour marker
- Abdo USS is 1st line imaging
- Liver biopsy is gold standard for diagnosis
- CT CAP +/- PET for staging
Pts w/ liver cirrhosis have 6 monthly HCC screening AFPs +/- USS
106
Hepatocellular carcinoma management
- Radical resection if lesion < 3cm
- Percutaneous radiofrequency ablation and tumour embolisation
- Liver transplant
- Palliative for advanced disease
107
Define Hereditary haemochromatosis
A genetic disorder of iron metabolism which leads to excessive iron deposition in the heart, liver, joints, pituitary, pancreas and skin
108
Hereditary haemochromatosis features
- Bronze skin
- T2DM
- Fatigue
- Joint pain
- Liver disease/cirrhosis features
- Adrenal insufficiency
- Testicular atrophy
- Dilated cardiomyopathy
109
Hereditary haemochromatosis investigations
Iron studies:
- Raised transferrin saturation (>55% in women, >50% in men)
- Raised ferritin
- Raised iron
- Low total iron binding capacity
Genetic testing
MRI brain and heart to look for iron deposition
Liver biopsy to confirm iron overload
110
Hereditary haemochromatosis management
- Venesection = stimulates erythropoiesis and mobilises iron from parenchymal cells and other storage sites - target transferrin <50%
- Desferrioxamine = iron chelating agent
111
Define Hiatus hernia
Where abdominal contents protrude through an enlarged oesophageal hiatus in the diaphragm
112
What are the 2 types of Hiatus hernia?
Sliding (80%):
- Where the gastro-oesophageal junction slides up into the chest
- This results in a less competent sphincter and consequent acid reflux
Rolling (20%):
- Where the gastro-oesophageal junction stays in the abdomen, but a part of the stomach protrudes into the chest alongside the oesophagus
- Requires more urgent treatment since volvulus can occur and lead to ischaemia
113
Hiatus hernia features
- Dysphagia
- Regurgitation
- Odynophagia
- Dyspepsia
- SOB
- Chronic cough
- Chest pain
114
Hiatus hernia investigations
- Barium swallow is most sensitive
- Endoscopy
- Oesophageal manometry
115
Hiatus hernia management
Conservative:
- WL
- Elevating head of the bed
- Avoidance of alcohol and acidic foods
- Smoking cessation (nicotine relaxes the lower oesophageal sphincter)
Medical = PPI's for 4-8 weeks before assessing response
Surgical = Nissen's fundoplication (closing defect by tightening the crura and wrapping the gastric fundus around the LOS)
116
Which drugs most commonly cause iatrogenic diarrhoea?
- Magnesium
- Abx - esp penicillins
- Chemo agents
- PPIs
- H2 blockers = cimetidine and ranitidine
- NSAIDs
- Metformin
117
Which drugs most commonly cause iatrogenic constipation?
- Anti-depressants
- Anti-psychotics
- Levodopa
- Aluminium-based antacids
- Iron supplements
- Opiates
118
What are the Manning criteria for diagnosis of IBS?
Abdo discomfort or pain relieved by defecation OR associated w/ altered bowel frequency or stool form
AND at least 2 of the following:
- altered stool passage (e.g. straining or urgency)
- Abdo bloating
- Symptoms worsened by eating
- Passage of mucus
119
IBS investigations
Rule out organic diseases w/:
- Faecal calprotectin
- FBC, ESR/CRP
- Coeliac serology
120
IBS management
Conservative:
- Exercise
- Stress management
- Dietary changes (e.g low-FODMAP diet)
Medical:
- Mebeverine (antispasmodic)
- Laxatives
- Imodium
- Low dose TCA (2nd line)
121
What are the causes of Jaundice?
Pre-hepatic:
- Conjugation disorders = Gilbert's, Crigler-Naajjar
- Haemolysis
- Drugs = contrast, rifampicin
Hepatic (hepatocellular dysfunction):
- Viruses
- Drugs = paracetamol OD, nitrofurantoin, halothane, valproate, statins, TB treatment
- Alcohol
- Cirrhosis
- Liver mass (abscess or malignancy)
- Haemochromatosis
- AI hepatitis
- Alpha-1 antitrypsin deficiency
- Budd-Chiari
- Wilson's disease
Post-hepatic:
- PBC
- PSC
- Gallstones in CBD
- Drugs = coamox, flucloxacillin, steroids, sulfonylureas
- Pancreatic malignancy
- Cholangiocarcinoma
- Biliary atresia
122
Jaundice investigations
Bedside:
- Urine dip for urobilinogen levels - raised in pre-/hepatic jaundice, but decreased in obstructive jaundice
Bloods:
- FBCs, U&Es, LFTs, split bilirubin
- Synthetic liver function tests (albumin, coag screen)
Imaging:
1st = abdo USS to look for duct dilation
2nd = MRCP
- Liver biopsy may be done
123
Define Liver Cirrhosis
Irreversible scarring of the liver w/ loss of normal hepatic architecture
124
What are the causes of Liver Cirrhosis?
Common:
- Alcohol
- Hep B and C
- MAFLD
AI:
- AI hepatitis
- PBC
- PSC
- Sarcoid
Genetic:
- Haemochromatosis
- Wilson's
- A1AT
Drugs:
- Methotrexate
- Amiodarone
- isoniazid
Other:
- Budd-Chiari
- Heart failure
- Tertiary syphilis
125
Liver Cirrhosis features
Compensated cirrhosis:
- Fatigue
- Anorexia and cachexia
- Nausea and abdo pain
- Spider naevi
- Gynaecomastia
- Clubbing
- Leukonychia
- Dupuytren's contracture
- Caput medusae
- Splenomegaly
Decompensated cirrhosis:
- Above features
- Ascites and oedema
- Jaundice
- Pruritus
- Palmar erythema
- testicular atrophy
- Easy bruising
- Hepatic encephalopathy
- Liver flap
126
How is Liver Cirrhosis severity calculated?
Charles-Pugh score - is a predictor of mortality and transplant need
127
Liver Cirrhosis management
Conservative:
- Good nutrition and no alcohol
- Avoid NSAIDs, sedatives and opiates
- 6 monthly USS and serum AFP to monitor for hepatocellular cardinoma
- OGD for varices every 3 years
Medical:
- Cholestyramine for itching
- Ascites management
- Prophylactic lactulose and rifaximin for encephalopathy
- Prophylactic abx in those at risk of spontaneous bacterial peritonitis
Surgical:
- Liver transplant
128
Define Liver failure
The loss of liver function and the development of complications including jaundice, coagulopathy or encephalopathy
It can be:
- Hyperacute = onset <7 days
- Acute = onset 8-21 days
- Subacute = onset 4-26 weeks
- Chronic = on a background of cirrhosis
128
What is the pathology of hepatic encephalopathy?
In liver failure, ammonia accumulates in the circulation
It can cross the BBB, and once in the cerebral circulation it is detoxified by astrocytes which form glutamine
The excess glutamine disrupts the oncotic balance and the astrocytes begin to swell, causing cerebral oedema
129
What are the 4 stages of hepatic encephalopathy?
1) Altered mood and behaviour, disturbance of sleep pattern and dyspraxia
2) Drowsiness, confusion, slurring of speech and personality changes
3) Incoherency, restlessness, asterixis
4) Coma
130
Management of Hepatic encephalopathy
- Grade the encephalopathy
- Give lactulose = increases ammonia loss through bowels
- Rifaximin = abx which reduces nitrogen forming organisms in the gut
- IV mannitol can reduce the cerebral oedema
131
Define Hepatorenal syndrome
A triad of cirrhosis, ascites and renal failure
Occurs due to portal HTN which leads to release of vasoactive mediators and splanchnic vasodilation - this reduces renal perfusion, causing a pre-renal AKI
2 types:
1) Rapidly progressive - treated w/ terlipressin 2
2) Slowly progressive - treated w/ midodrine (alpha agonist)
132
Define Malnutrition
- BMI < 18.5
- Unintentional WL >10% w/in 3-6 months
- BMI <20 and unintentional WL >5% w/in 3-6 months
133
Malnutrition classification
Undernutrition:
- Marasmus = deficiency in carbs, fats and proteins - causes visible wasting of fat and muscles under the skin
- Kwashiorkor = deficiency in protein - causes bilateral swelling of the extremities and abdomen
- Vitamin deficiencies
Overnutrition:
- Metabolic syndrome
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Define Metabolic syndrome
A group of conditions that together increase a persons risk of CVD, T2DM and stroke.
These are:
- Excessive abdo fat - waist circumference > 40 inches in men or > 35 inches in women
- Hypertriglyceridemia (>150 mg/dl)
- Low HDL levels
- Raised fasting plasma glucose (>6.1)
- Raised BP - systolic > 135, diastolic > 85
135
Define Melanosis coli
A histological condition associated w/ chronic stimulant laxative abuse (esp Senna)
Characterised by the presence of dark brown pigmentation (necrosis and apoptosis) of the macrophages in the lamina propria of the colon - detected by colonoscopy
Not typically harmful, but a useful sign of laxative abuse
136
Define Mucosa-associated lymphoid tissue (MALT)
A NHL that usually occurs in the stomach and is associated with H. pylori infection and chronic inflammation
137
Mucosa-associated lymphoid tissue (MALT) features
- Abdo pain
- N&V
- Anaemia
- WL
138
Mucosa-associated lymphoid tissue (MALT) investigations
- Endoscopy and biopsy
- Immunohistochemistry to identify B cell linage
- Staging CT/PET
139
Mucosa-associated lymphoid tissue (MALT) management
- H pulori eradication
- Chemo/radioT if that didnt cure, or if H. pylori -ve
- Can add rituximab in severe cases
140
What are the stages of Metabolic associated fatty liver disease (MAFLD)?
1) Simple steatosis
2) Metabolic associated steatohepatitis (MASH)
3) Fibrosis ad cirrhosis
141
What are the causes of MAFLD?
- Metabolic syndrome
- Rapid WL or prolonged starvation
- PCOS
- Hypothyroidism
- OSA
142
MAFLD investigations
- Bloods = LFTs, FBC, fasting glucose and lipids, tests to exclude other pathologies
- Imaging = USS (1st line), Elastography (AKA FibroScan - measures liver stiffness to ass fibrosis), Enhanced liver fibrosis test (blood test assessing markers of fibrosis)
- Liver biopsy (gold standard)
143
MAFLD management
Conservative:
- Lifestyle mods = WL, exercise dietary changes
- Avoid hepatotoxic drugs
Medical:
- Metabolic management = control DM, hyperlipidaemia and HTN
Monitoring:
- Screen for hepatocellular carcinoma in cirrhotic pts
144
Causes of portal hypertension
- Cirrhosis or fibrosis
- Portal vein thrombosis
- Schistosomiasis
145
Oesophageal varices features
Asymptomatic till they bleed
- Haematemesis
- Melena
- Palpitations
-Syncope
- Hypotension
- Raised urea (digestion of blood)
146
Oesophageal and gastric varices management
Acute:-
Resuscitation
- Terlipressin = vasopressin analogue which reduces portal pressure and bleeding
- Broad spectrum abx to reduce the risk of bacteraemia and spontaneous bacterial peritonitis
- Variceal band ligation via endoscopy for oesophageal
- Sclerotherapy for gastric
- For uncontrolled bleeding - insert a Sengstaken-Blakemore tube (NG-like tube which has a balloon which can be inflated to tamponade the bleeding)
Prevention:
- Non-selective beta blockers and band ligation
- If these don't work, transjugular intrahepatic portosystemic shunt (TIPS)
147
What are the causes of Oesophagitis?
- GORD
- NSAIDs
- Infections e.g. candida
- Allergens = eosinophilic oesophagitis
148
Oesophagitis management
PPI for 1 month
149
Oral candida management
1st line = oral nystatin
Fluconazole can be given if there is oropharyngeal involvement
150
Define Hairy leucoplakia
A benign condition triggered by EBV and is suggestive of underlying HIV
Causes white patches on the tongue which may look hairy and cannot be scraped off
Is a pre-malignant condition
151
Aphthous ulcer management
1st line = chlorohexidine mouth wash
If not healing after 3 wks - biopsy and referral to oral surgeon to rule out malignancy
152
Oral candida features
- White patches in the mouth which can be scraped off
- Friable mucosa underneath
- Satellite lesions
153
Paracetamol OD features
- <24 hrs = asymptomatic, or N&V
- 24-72 hrs = RUQ pain, hypotension
- 72-96 hrs = liver and renal failure, metabolic acidosis, encephalopathy, coagulopathy, confusion, drowsiness, oliguria, loin pain, jaundice, bleeding diathesis
154
Paracetamol OD medical management
- Ingestion less than 1 hr ago + dose >150mg/kg = activated charcoal
- Ingestion 1-4 hrs ago = wait until 4 hrs to take a level and treat w/ N-acetylcysteine (NAC) based on level
- Ingestion w/in 4-8 hrs + dose >150 mg/kg = NAC immediately if there is going to be a delay of >8 hrs in obtaining paracetamol level, otherwise weight for level and treat if high
- Ingestion w/in 8-24 hrs + dose >150 mg/kgs = NAC immediately
- Ingestion >24 hrs ago = NAC immediately if pt has jaundice, RUQ, elevated ALT, INR >1.3 or if paracetamol conc detectable
- Staggered OD = NAC immediately
155
How is N-acetylcysteine given?
Given IV over 2 12 hr infusions
If pt still has deranged LFTs, clotting or renal function, continue infusions and discuss for urgent transplant
156
What are the criteria for urgent liver transplant in paracetamol OD?
- INR >3 at 48 hrs, or >4.5 at any time
- Oliguric or creatinine > 200
- pH < 7.3 despite fluid resus
- Hypotension (systolic < 80)
- Severe thrombocytopenia
- Encephalopathy
157
Which type of peptic ulcer is more common?
Duodenal are 4x higher
158
What are the causes of duodenal ulcers?
- Primarily H. pylori
- NSAIDs
- Chronic steroid use
- SSRI's
- Increased secretion of gastric acid
- Smoking
- Blood group O
- Accelerated gastric emptying
159
What are the causes of gastric ulcers?
- NSAIDs
- H. pylori
- Smoking
- Delayed gastric emptying
- Severe stress
160
Peptic ulcer features
Both:
- Abdo pain
- N&V
- Anorexia
- Unexplained WL
- Coffee ground vomiting
Gastric = pain worse on eating (increased gastric acid)
Duodenal = pain relieved by eating (pyloric sphincter closes so less acid)
161
Peptic ulcer management
Conservative:
- Smoking cessation
- Smaller meals, avoid spicy/fatty foods and coffee
- Stress management
- Avoid NSAIDs, steroids, bisphosphonates, K supplements, SSRIs
Medical (H. pylori +ve):
- Associated w/ NSAID use = 8 wks PPI followed by triple eradication therapy for 7 days
- Not NSAID associated = triple therapy for 7 days
Gastric ulcers require a repeat OGD 6-8 wks following PPI treatment to ensure healing and rule out malignancy
Surgical:
- Underrunning of ulcer
- Fixation of perforation
162
Pernicious anaemia pathophysiology
1) AI attack = destruction of gastric parietal cells leads to reduced intrinsic factor
2) Intrinsic factor deficiency = leads to impaired B12 absorption
3) B12 deficiency
4) Megaloblastic changes = impaired DNA synthesis in RBC, results in larger RBC which are less effective at at carrying O2 and thus anaemia occurs
5) Haemolysis (sometimes)
163
B12 Deficiency features
- Fatigue
- Pallor
- Glossitis
- Subacute combined degeneration of the cord
- Jaundice (haemolysis)
- Cognitive impairment = memory problems, confusion and mood changes
164
Pernicious anaemia management
Life long B12 replacement via 3 monthly hydroxocobalamin injections
165
What are the long-term complications of Pernicious anaemia?
Increased risk of gastric cancer and carcinoid tumours
166
Define Pharyngeal pouch
AKA Zenker's diverticulum - a herniation of the pharyngeal mucosa that occurs through a weak point between the thyropharyngeus and cricopharyngeus muscles in the inferior constrictor of the pharynx
167
Pharyngeal pouch features
- Dysphagia
- Regurgitation of undigested food resulting in halitosis
- Aspiration
- Chronic cough
- WL
168
Pharyngeal pouch investigations
Barium swallow test - shows a residual pool of contrast w/in the pouch
AVOID OGD as this can cause perforation
169
Pharyngeal pouch management
- If small and asymptomatic - no treatment required
- Surgical resection of the diverticulum
- Incision of the cricopharyngeus
170
Define Primary biliary cholangitis
AI scarring and inflammation of the bile ducts
171
Primary biliary cholangitis features
- Asymptomatic
- Extreme fatigue
- Pruritus
- Dry skin (xerosis)
- Sicca syndrome (dry eyes)
- RUQ pain
- Xanthelasma
- Clubbing
- Jaundice
- Late signs = sequalae of chronic liver disease
172
What cancer are pts w/ Primary biliary cholangitis at risk of?
Hepatocellular carcinoma
173
Primary biliary cholangitis investigations
- Derranged LFTs w/ a cholestatic picture
- +ve AMA
- Raised IgM
- USS to rule out obstruction
- MRCP
- Liver biopsy gold standard for diagnosis = granulomatous inflammation around the bile ducts
174
Primary biliary cholangitis management
- Ursodeoxycholic acid to slow disease progression by promoting bile flow
- Cholestyramine for pruritus
- Vitamin supplements
- Liver transplant once bilirubin > 100 (PBC may reoccur)
175
Primary sclerosing cholangitis definition
AI mediated chronic inflammation and fibrosis of the intra and extrahepatic bile ducts
Results in lots of strictures
176
Primary sclerosing cholangitis features
- Hepatomegaly
- Jaundice
- RUQ pain
- Fatigue
- WL
- Fevers
- Sweats
- Associated w/ UC
177
Primary sclerosing cholangitis investigations
- Deranged LFTs w/ a cholestatic picture
- +ve anti-smooth muscle antibodies, +ve pANCA
- MRCP/ERCP = multiple beaded strictures seen
- Biopsy if diagnosis unclear = fibrosis and obliterative cholangitis (onion skin appearance)
178
Primary sclerosing cholangitis management
- Alcohol avoidance
- Cholestyramine for pruritus
- Vit ADEK replacement
- Strictures may be dilated via ERCP
- Liver transplant in chronic liver disease or malignancy
179
What cancer are pts w/ Primary sclerosing cholangitis at risk of?
Cholangiocarcinoma and colorectal cancer
180
Define Upper GI bleed
Any haemorrhage of the GI tract between the oesophagus and the duodenum at the ligament of Treitz
181
What are the causes of Upper GI bleeds?
Oesophageal:
- Varices
- Oesophagitis
- Malloy-Weiss tear = tear after severe retching/vomiting
- Oesophgeal cancer
Stomach:
- Peptic ulcers
- Gastric varices
- Gastritis
- Gastic cancer
- Vascular malfortmation = Dieulafoy lesiona dilated submucosal artery that erodes into the GI mucosa resulting in massive bleeding
Duodenum:
= Peptic ulcers
- Aortoenteric fistula
182
What scoring systems are used in Upper GI bleeds?
Glasgow-Blatchford score is used on initial assessment to determine how urgently endoscopy is indicated = score of 0 means low risk and can have outpatient OGD
Rockall score is used post-endoscopy to help w/ risk stratification
183
Upper GI bleed features
- Haematemesis
- Melaena
- Light-headedness
- Syncope
- Abdo pain
- Anaemia in subacute/chronic bleeds
- Signs of hypovolaemic shock
184
Upper GI bleed investigations
Bedside:
- VBG = for urgent haemoglobin levels
- ECG = cardiac ischaemia can occur in large bleeds
Bloods:
- FBC
- U&Es
- LFTs
- Coagulation
- Group and save
- Cross-match
Imaging:
- OGD
- CXR
185
Upper GI bleed management
- Resuscitate as per major haemorrhage protocol
- In suspected variceal bleeds - Terlipressin and prophylactic abx
- Immediate endoscopy = non-variceal bleeding can be clipped w/ thermal coagulation or fibrin/thrombin, variceal bleeding treated w/ band ligation, gastric variceal treated w/ sclerotherapy
186
Define Backwash ileitis
Inflammation of the terminal small bowel in UC when inflammatory mediators are washed passed the ileocecal valve
187
Ulcerative colitis features
GI:
- Diarrhoea containing blood or mucus
- Tenesemus or urgency
- Crampy LIF pain
Systemic:
- WL
- Fever
- Malaise
- Anorexia
Extra-intestinal:
- Derm = erythema nodosum, pyoderma gangrenosum
- Ocular = anterior uveitis, episcleritis, conjunctivitis
- MSK = clubbing, enteric arthritis, sacroiliitis
- Hepatobiliary = PSC
- AA amyloidosis
188
Ulcerative colitis investigations
- Faecal calprotectin (raised)
- Abdo and erect CXR in acute settings to exclude toxic megacolon and perforations
- Colonoscopy + biopsy + barium enema (diagnostic) - will show continuous inflammation starting at the rectum that does not invade beyond the submucosa, there may be loss of haustral markings, crypt abscesses and pseudopolyps, barium enema will show lead pipe inflammation
189
How is the severity of acute exacerbations of UC assessed?
Using Truelove and Witt's criteria:
Mild:
- <4 bowel movements a day
- Small amount of blood in stool
- No temp, tachycardia or anaemia
- ESR < 30
Moderate:
- 4-6 stools a day
- Mild-severe blood in stool
- No temp, tachycardia or anaemia
- ESR < 30
Severe:
- 6 or more stools per day
- Visible blood in stool
- At least one of; temp, tachycardia or anaemia
- ESR > 30
190
Ulcerative colitis acute management
Mild-moderate disease:
- Proctitis or proctosigmoiditis = topical ASA (mesalazine or sulfasalazine) for 4 weeks, of that doesn't induce remission then escalate to oral ASA, then add oral prednisolone, then add oral tacrolimus
- Left sided or extensive disease = high dose oral ASA for 4 weeks, then add oral prednisolone, then add oral tacrolimus
Severe disease:
Step 1) IV corticosteroids (ciclosporin if contraindicated)
Step2) If no improvement w/in 72 hrs, add IV ciclosporin or consider surgery
Step 3) Trial of etrasimod (selective S1p receptor modulator)
191
What are the surgical options in UC?
- Panproctocolectomy w/ permanent end ileostomy
- Total colectomy w/ ileorectal anastomosis
192
Scurvy features
Causes impaired collagen synthesis resulting in:
- Spontaneous bleeding and bruising (fragile vessels)
- Gingival swelling
- Coiled hairs
- Teeth loss
- Increased risk of intracranial and endocardial haemorrhages
193
Thiamine deficiency features
- Wernicke's encephalopathy
- Korsakoff's syndrome
- Wet beriberi = HF and cardiomegaly
- Dry beriberi = peripheral neuropathy (mimics GBS)
194
Pellagra (B3 deficiency) features
3 D's:
- Diarrhoea
- Dermatitis
- Dementia
Treated w/ nicotinamide (vit B3)
195
Vitamin A deficiency features
- Night blindness
- Xerophthalmia (dry eyes)
- Complete blindness if severe
196
Define Wipple's disease
A rare disorder caused by the bacterium Tropheryma whipplei
Can affect any part of the body, but most commonly impacts the GI system, joints and nervous system
197
Wipple's disease features
- Chronic diarrhoea
- Abdo pain
- Joint pain
- WL
- HF
- Neurological issues
198
Wipple's disease investigations
Small bowel biopsy = shows acid-Schiff +ve macrophages
199
Wipple's disease management
Long-term course of co-trimoxazole
200
Define Zollinger Ellison syndrome
A gastrinoma of the pancreas or duodenum
It uncontrollably releases gastrin resulting in multiple peptic ulcerations
Associated w/ MEN-1
201
Zollinger Ellison syndrome features
- Epigastric pain
- Diarrhoea
- GI bleedings
- Non-responsive to PPI's
202
Zollinger Ellison syndrome investigations
- Gastrin levels
- Diagnostic = secretin administration causing extreme gastrin release
- Somatostatin receptor scintigraphy = imaging choice as CT can miss the tumours
203
Zollinger Ellison syndrome management
- Surgical resection of the tumour
- PPI's
