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GI I Flashcards

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1
Q

Risk factors for a GORD

A 
Hiatus hernia
Smoking 
EtoH
Obesity 
Pregnancy 
Drugs
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2
Q

List the criteria for performing an OGD

A 
>55yrs 
Symptoms >4weeks 
Dysphagia
Persistently symptomatic despite treatment 
Wt loss
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3
Q

List the grading criteria of GORD

A

Los angeles classification

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4
Q

Management of GORD

A

Conservative

  • Loss weight
  • Small regular meals
  • Stop smoking and drink
  • Stop drugs ( NSAIDs, Steroids, CCBs)
Medical
- OTC antacids 
- Full dose PPI for 1-2 months 
Lansoprazole 30mg Od
- Double dose PPI 
- Add in H2RA 
Ranitidine 300mg nocte 
- Nissen Fundoplication
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5
Q

Classify the different types of hiatus hernia

A
  1. Sliding
  2. Rolling
  3. Mixed

Note rolling hernias should be repaired as it may strangulate

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6
Q

Name the scoring system to predict re bleeds and mortality in upper GI haemorrhage

A

Rockall score

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7
Q

Classify peptic ulcers

A

Acute: drugs or stress
Chronic: Drugs, H.Pylori, Increase Ca, Zollinger Ellions

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8
Q

List the complications of peptic ulcer disease

A
  1. Haemorrhage
  2. perforation
  3. Gastric outflow obstruction
  4. Malignancy
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9
Q

List the investigations you would carry out in patients with suspected peptic ulcer disease

A 
Bloods ( FBC< urea increase in haemorrhage
C13 breath test 
OCD
- stop PPIs 2 weeks before 
- CLO/ urease test 
- Take biopsies of all ulcers 
Gastrin levels in Zollinger Ellison
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10
Q

Outline the surgical options for patients with PUD

A

Vagotomy
Antrectomy with vagotomy
Subtotal gastrectomy

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11
Q

Complication of surgery for PUD

A

Physical

  • Stump leakage
  • Abdominal fullness
  • Reflux or billions vomiting
  • Stricture

Metabolic

  • Dumping syndrome (Early = osmotic hypovolaemia, late= reactive hypovolaemia)
  • Blind loop syndrome
  • malabsorption
  • Anaemia
  • Osteoporosis
  • Wt loss
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12
Q

Outline the pathophysiology of achalasia

A

Dengeneration of myenteric plexus (Auerbach’s)
Decreased peristalsis
LOS fails to relax

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13
Q

List the causes of achalasia

A

Idiopathic
Oesophageal Ca
Chagas disease (T.cruzii)

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14
Q

Investigations for achalasia

A

Barium swallow(Birds beak)
Manometry: failure of relaxation and decreased peristalsis
CXR: widened mediastinum
OGD: exclude malignancy

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15
Q

Treatment of achalasia

A
  1. Medical
    - CCB
    - Nitrates
  2. Interventional
    - Endoscopic ballon dilatation
  3. Surgical
    - Heller’s cardiomyotomy
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16
Q

Genetic links associated with coeliac disease

A

HLA-DQ2
HLADQ8
CD8+ mediated response to the gladden in gluten

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17
Q

Presentation of coeliac disease

A

GLIAD

  1. GI Malabsorption
    - fatigue
    - weakness
    - Carb (abdo distension)
    - Steatorrhoea
    - Hyperoxaluria
    - Protein losing enteropathy
    - anaemia
    - Bone pain, osteoporosis ( Vit D and Ca)
    - Increased INR (Vit K)
    - Angular stomatitis (b2)
    - Polyneuropathy (B1 and B6)
  2. Lymphoma and carcinoma
    - Enteropathy associated T cell lymphoma
    - Adenocarcinoma
  3. Immune associations
    - T1DM
    - PBC
  4. Anaemia
    - Increase or decrease MCV
    - Hyposplenism
  5. Dermatology
    - Dermatitis herpetiformis
    (symmetrical vesicles on extensor services_, granular deposits of IgA)
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18
Q

Name the antibodies you would look for in suspected coeliac disease

A

Antiendomyosial IgA
Anti TTG IgA
Anti gliadin IgG

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19
Q

Outline the appearance of the duodenum as seen on endoscopy in patients with coeliac

A

1/3 of the duodenum
Subtotal villous atrophy
Crypt hyperplasia
Intra epithelial lymphocytes

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20
Q

Triad of symptoms seen in malabsorption

A

Diarrhoea
Weight loss
Lethargy

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21
Q

List potential causes of malabsorption

A 
Coeliac 
Crohn's 
Decrease in bile ( PBC, ileal resection)
Pancreatic insufficiency 
Small bowel resection 
Tropical sprue
Bacterial overgrowth 
Infection 
Hurry, post gastrectomy dumping
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22
Q

Pathology of tropical sprue

A

Vilious atrophy and malabsoprtion
Occurring the Far and Middle east
Cause is unknown

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23
Q

Treatment of tropical sprue

A

Tetracycline 250mg/6hr PO
Folic acid 15mg/d PO
Optimum nutrition

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24
Q

Signs of UC on barium swallow

A
  1. Lead piping, no hausfrau
  2. Thumbprinting (mucosal thickening)
  3. Pseudopolyps
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25
Name the criteria used to grade the severity UC
Truelove and Witts criteria
26
Maintenance therapy for patients with UC
1) 5 ASA (sulfasalazine) 2) Asathioprine 3) Infliximab Achieving remission often requires a short course of prednisolone
27
Outline the management of acute severe UC
1. Resus 2. Hydrocortisone 3. Thromboprophylaxis 4. Monitoring
28
Signs of Crohns as seen on colonoscopy
1. Skip lesions 2. Rose thorn ulcers 3. Cobblestone mucosa 4. String sign of kantour
29
List some of the complications of Crohn's
1. Fistuale 2. Strictures 3. Abscess 4. Malabsorption 5. Toxic megacolon
30
Outline the criteria used to diagnosis IBS
``` ROME Criteria - Abdo discomfort for >12 weeks with 2 of relieved by poking change in stool frequency change in stool form ``` and two of - Urgency - Incomplete emptying - Bloating - Mucous PR - Worsening symptoms after food Exclusion criteria - >40yrs - Bloody stools - Anorexia - Wt loss - Diarrhoea
31
List the causes of chronic pancreatitis
``` AGITS Alcohol Genetic - CF - HH Immune - Lymphoplasmacytic sclerosing pancreatitis ( increase in IgG4) Triglycerides increase Structural - Obstructed by a tumour ```
32
Clinical features of chronic pancreatitis
``` Epigastric pain - relived by sitting back or with hot water bottle Steatorrhoea Wt loss DM ```
33
List the investigations you would do to confirm pancreatitis and what would they show
``` Increase glucose Decrease faecal elastase Us of the pancreas AXR speckled pancreatic calcifiction Ct pancreatic calcification ```
34
Treatment of chronic pancreatitis
DRUGS - Analgesia ( may need coeliac plexus block - Creon - ADEK vitamins - DM Rx DIET - No EtOH - Decrease in fat - Decrease in carbs Surgery - Pancreatectomy
35
List the causes of acute pancreatitis
``` GET SMASHED Gallstones EtOH Trauma Steriods Mumps Autoimmune Scorpion venom Hyperlipidaemia ERCP Drugs ```
36
Clinical features seen in patients with acute pancreatitis
Jaundice Rigid abdomen Cullen's sign: periumbilical bruising Turner's sign: Bruising of the flanks
37
Outline the investigations and management plan you would initated in a patient presenting to A&E with acute pancreatitis
IX - Amylase >1000mL, levels will rise after the first 24-48 hours - Bloods - ABG, monitor acid base balance - AXR, no psoas shadow ( increase in retroperitoneal fluid) Sentinel loop (air filled dilatation) Treatment - NBM - IV fluid, catheter - Plan nutrition, no oral feeding for a week - Analgesic, morphine - Abx - Refer to ITU if detonation
38
What are the Glasgow Criteria and what is it used for?
``` Glasgow criteria used to determine the severity of the patients pancreatitis Consists of the following - PaO2 - Age -Neutrophilia - Calcium - Renal function - Enzymes - Albumin -Sugar ```
39
Discuss the pathology associated with diverticulitis
Stool or undigested food becomes trapped int he diverticulum Bacteria multiple Inflammatory response
40
List the potential complications of diverticulitis
Perforation Haemorrhage Fistula Abscess
41
Treatment of diverticulitis
``` Admit if unstable Give broad spec abs ( co-amoxiclav) Clear fluids only Surgery if - Faecal peritonitis - uncontrolled sepsis - fistula obstruction ```
42
Causes of ischaemic colitis
Occlusion of the branches of the superior mesenteric artery or the inferior mesenteric artery New onset abdominal pain Bright red blood will be visible and the patient is likely to be in metabolic acidosis Risk is the translocation of intestinal bacteria across the lumen Systemic inflammatory response
43
List the potential complication of diverticulitis and the subsequent management
1. Septic peritonitis 2. Progression of systemic inflammatory response 3. Multi organ dysfunction syndrome 1. Resuscitation with fluids 2. Give abs 3. Give heparin 4. Post angiography give thrombolytics if needed
44
List the types of haemorrhoids
1. Internal haemorrhoids | 2. External haemorrhoids
45
Causes of haemorrhoids
``` Constapation Congestion Pregnancy CCF Portal hypertension ```
46
Treatment for haemarroids
1. Increase fluid and fibre Topical analgesics Stool softener 2. Non operative Rubber band ligation Infra red coagulation Cryotherapy
47
Describe a fistulae in ano
A track communicating between skin and anus Caused by Abscess, perianal sepsis, Crohns disease, Diverticulitis, TB. Will require a surgical repair.
48
Clinical features of bowel obstruction
``` Vomiting ( can be faecal) Colic pain Distension Constipation Tinkling/absent bowel sounds Rigid abdomen Sm ```
49
Types of bowel obstruction
Adhesive obstruction Hernia obstruction Volvulus Intessupation
50
Management of bowel obstruction
ABCDE patient Surgical management to relieve the obstruction NBM
51
Discuss the pattern of abdominal pain in acute appendicitis
Early inflammation - appendiceal irritation - not well localised - Pain referred to the dermatome corresponding to spinal cord entry level. Late inflammation - parietal peritoneum irritation - pain localised to the PIF
52
List the key signs seen with appendicitis
Guarding and tenderness @ McBurneys pt Rosing's sign: pressure in the LIF increase pain in the RIF Posts sign: pain on extending the hip Cope sign: Flexion and external rotation of the hip = pain
53
Classify the types of jaundice and give causes for each class
1. PRE HEPATIC Excess BR production Ineffective erythropoesis e.g. thallasaemia 2. HEPATIC * Unconjugated Decrease BR uptake (drugs) Decrease BR conjugation - Hypothyroidism - Gilberts - Criglers Najjar ``` *Conjugated Hepatocellular dysfunction - Congen: HH, Wilsons, - Infection: Hep a/b/c CMV, EBV - Toxins: EtOH - AI - Vascular: Budd Chiaria ``` Decrease Hepatic BR Excretion - Dublin-Johnson - Rotors ``` 3. POST HEPATIC Obstruction - Stones - Ca Pancreas - PSC - PBC - Drugs ```
54
List the causes of liver failure
``` Cirrhosis Acute - Infection - Toxins - Vascular (Budd Chiari) - Others (Wilsons, AIH) ```
55
Management of patients with liver failure
1. Manage in ITU 2. Rx underlying cause 3. Good nutrition via a NGT 4. Thaimine supplements 5. Prophylactic PPI MONITORING Fluids Bloods Glucose
56
List the complications of acute liver failure
``` Bleeding - Vit K, platelets, FFP Sepsis - Tazocin Ascites - Fluid restritction, spiro, fruse Hypoglycaemia - regular BM Encephalopathy - lactulose and enaemas Seizures - lorazepam Cerebral oedema - mannitol ```
57
Name the criteria used in acute liver failure for liver tx
``` Kings College Hospital Criteria *PARACETAMOL induced - pH <7.3 - All of PT>100s Cr >300uM Grade 3/4 encephalopathy ``` ``` *NON PARACETAMOL induced PT>100s 3/5 of drug induced Age <5 or >40 >1wk of jaundice Pt>50 BR> 300uM ```
58
Causes of cirrhosis
``` Chronic EtOH Chronic HCV NAFLD Genetic Autoimmune hepatitis Drugs Neoplasm Vascular; Budd Chiari, RHF, Constrictive pericarditis ```
59
Clinical features seen on examination of a patient with cirrohosis
Hands - Clubbing (+/- periostitis) - Leuconychai (decrease in albumin) - Terry's nails ( white proximally, red distally) - palmer erythema - Dupuytron's contractures Face - Pallor - Xanthelasma - Parotid enlargement Trunk - Spider naevi - Gynaecomastia - Loss of 2 sexual hair Abdo - Striae - Splenomegaly - Dilated superficial veins - Testicular atrophy
60
List the complications of cirrohosis
1. Decompensation resulting in hepatic failure - Jaundice - Encephalopathy - Hypoalbuminaemia, oedema, ascites - Coagulopathy - Hypoglycaemia 2. Spontaneous Bacterial Peritonitis ``` 3. Portal HTN (SAVE) Splenomegaly Ascites Varies - Oesophageal varices - Caput medusa - Worsening existing piles Encephalopathy ``` 4. Increase risk of HCC
61
The following conditions are associated with the presence of certain abs. Please list the abs associated with each condition 1. AIH 2. PBC 3. PSC 4. Ca
AIH - SMA - SLA - LKM - ANA - High IgG PBC - AMA - High IgM PSC - ANCA - ANA CA - Alpha-fetoprotein
62
Causes of portal HTN
PRE HEPATIC - Portal vein thrombosis HEPATIC - Cirrohosis - Schisto - Sarcoidosis POST HEPATIC - Budd chiari - RHF - Constrictive pericarditis
63
Describe the pathophysiology of encephalopathy
1. Decreased hepatic metabolic function 2. Diversion of the toxins from the liver directly into systemic system 3. Ammonia accumulates and pass to brain where astrocytes clear it causing conversion of glutamate to glutamine 4. Increase in glutamine 5. Osmotic imbalance 6. Cerebral oedema
64
Classification of encephalopathy
1. Confusion: irritable, mild confusion, sleep inversion 2. Drowsy: Increased disorientation, slurred speech, asterixis 3. Stupor: rousable, incoherence 4. Coma: Unrousable +/- extensor plantars
65
Presentation of encephalopathy
``` Asterixis Confusion Dysarthria Constructional apraxia Seizures ```
66
List the possible precipitants of encephalopathy
``` HEPATICS Haemorrhages Electrolytes Posions Alcohol Tumour (HCC) Infection Constipation Sugar ```
67
What liver enzymes will be raised in alcoholics
1. AST 2. ALT 3. GGT
68
What is the triad of Wernicke's encephalopathy
Confusion Opthalmoplegia Ataxia Korsakoff's: amnesia to confabulation
69
A patient presents with anorexia, D/V, and a jaundiced look about them On examination you note ascites, tender hepatomegaly. On questioning the patient reveals to you the have been drinking 100 units a week of vodka for the past five years 1. List your working diagnosis 2. What investigations will you do and what do you expect them to show 3. Outline the management plan for this patient
1. Alcoholic hepatitis 2. Bloods - Increase MCV - GGT, AST,ALT - Ratio of AST:ALT will be > 2 3. Plan - Stop EtOH - Withdrawal treatment Tapering regimen of chlordiazepoxide PO/ Lorazepam IM - Give parbinex - Optimise nutrition - Daily weights and bloods - Alcohol cessation support
70
List the different types of hepatitis and the mode of transmission associated with each one
``` A: Orally spread, seafood B: IV, blood, body fluids, vertically babies C: IV, Blood D: IV, Prior infection with HBV E: PO, Developing world ```
71
Hepatitis generally develops over three phases. List the phases and the symptoms associated with each one
PRODROMAL PHASE HAV,HVB Flu like, arthralgia ``` ICTERIC PHASE Acute jaundice Hepatitis - abdo pain - hepatomegaly - cholestasis Extra hepatic features (due to immune complexes) - Cryoglobulinaemia - PAN -GN - Arthritis ``` CHRONIC PHASE - HCV - Cirrhosis Mainly supportive care Anti-virals in chronic disease
72
Outline the pathology ad risk factors associated with NAFLD
Cause of hepatitis and cirrhosis associated with insulin resistance and metabolic syndrome Non alcoholic steatohepatitis is most extreme ``` RF Obesity HTN T2DM Hyperlipidaemia ```
73
What are the components of metabolic syndrome
``` Central obesity +2 of - Increased triglycerides - Decreased HDL - HTN - Hyperglycaemia (DM,IGT,IFG) ``` Note: patients will generally have increased transaminases AST:ALT <1
74
Causes of Budd-Chiari syndrome
1. Hypercoagulable state - Myeloproliferative disorders - PNH - anti-phospholipid - OCP 2. Local tumour - HCC 3. Congenital - Membraneous obstruction of IVC
75
What is the triad associated with Budd Chiari syndrome
1. RUQ pain 2. Hepatomegaly 3. Ascites SAAg >1.1g/dL Jaundice may be present Do the JAK2 mutation analysis CD55 CD59
76
Management of a patient with newly diagnosed Budd Chiari syndrome
``` Anticoagulate unless +ve varices Ascites: fluid and salt restirctionm spiro, fruse Thrombolysis Angioplasty TIPSS ```
77
Describe the pathophysiology of alpha-1 antitrypsin deficiency
Sorption involved in the control of the inflammatory cascade by inhibiting neutrophil disease Synthesised in the liver
78
List the investigations you would request if you suspect a patient had alpha-1 antitrypsin deficiency and what they would show
Bloods: decrease in serum a1AT Liver biopsy: PAS +ve, diastase-resistant globules CXR: Emphysematous change Spirometry: Obstructive defect
79
Describe the pathophysiology of hereditry haemochromatosis
Autosommal recessive genetic disorder Abnormal iron metabolism Increase FE absorption Increase deposition in multiple organs
80
Clinical features associated with HH
(iron) MEALS Myocardial: dilated cardiomyopathy arrhythmias Endocrine: DM, hypogondaism, hypocalcaemia Arthritis Liver: HCC, cirrohosis Skin: slate grey discolouration
81
A patient presents and tells you his mother had HH. He asks about the inheritance pattern. What investigations would you do if you suspect he had HH and what would they show
Inheritance pattern: Autosommal recessive Bloods - abnormal LFTs - Increase ferritin - Increase Fe - Decrease TIBC Genotype Liver biopsy: pearls stain to quantify the FE and severity
82
Describe the pathophysiology of Wilson's disease
Mutation of Cu transporting ATPase Imparied hepatocyte incorporation of Cu into caeruloplasmin and exertion into bile Cu accummulation in liver and other organs
83
List the clinical features of Wilson's disease
``` Cornea: Kayser Fleischer rings Cirrhosis Chondrocalcinosis Parkinsonism Fanconii's syn (T2 RTA) Haemolytic anaemia, coomb's negative ```
84
Treatment of Wilson's disease
``` Avoid high Cu foods Penicillamine lifelong (Cu chelator) ```
85
Clinical features associated with PBC
``` Pruritus Pigmentation of the face Bones, osteoporosis, osteomalacia Big organs, HSM Cirrhosis and coagulopathy Cholesterol Steatohorrea ```
86
What will be seen on liver biopsy in patients with PBC
Non caesating granulomatous inflammation
87
Management of PBC
1. General - Pruritis (colestyamine) - Diarrhoea (Codeine phosphate) - Osteoporosis (Bisphosphanates) 2. Specific - ADEK vitamins - Urodeoxcholic acid 3. Liver transplant
88
A patient is refer from his GP with symptoms of pruritus, on going abdo pain and episodes of pale stools and dark urine His most recent LFT's are included in the referral and show a raised ALP and BR as well as positive ANA and pANCA antibodies. What is your working diagnosis? What other investigation would you order and what would it show? How would you treat the pruritus?
1. Primary sclerosing cholangitis 2. Endoscopic retrograde cholangiopancreatography, beaded appearance of the ducts 3. Colestryamine
89
List the five symptoms seen in Reynolds pentad present in cholangitis
``` Mental confusion Shock Fever Jaundice Abdo pain ```
90
What makes up chariot's triad
Right upper quadrant pain Intermittent fever Jaundice
91
Common causing organism seen in cholangitis
Klebsiella E.coli Enterobacter
92
List the investigations you would order in a case of suspected cholangitis
``` LFT FBC WCC Inflammatory markers U&Es Blood cultures ``` Imaging - Abdo xr ( includes KUB) - Contrast enhanced CT - MR cholangiopanreatography
93
List the different types of stones seen in biliary colic
Cholesterol stones: large, solitary and radiolucent Black pigment stones: small, friable. irregular and radiolucent Mixed stones: calcium salts and cholesterol Brown stones: stasis and infection
94
List the imaging done to dx cholecyctisis
Ultrasound | ERCP
95
Outline the differences between cholecystitis and binary colic
``` RUQ pain Vomiting Fever Local peritonism GB mass ``` Difference: Inflammatory component ( fever, raised white cell count) Note Murphy's sign Two fingers over the RUQ and ask the patient to inhale , inspiration causes pain
96
List the management of binary colic/cholecystitis
1. Analgesic such as opioids 2. Abx ( must be IV in hospital) 3. Surgical - Early cholecystectomy - Laparoscopic cholecystectomy
97
Treatment of H.pylori
7/7 Rx Lansoprazole 30mg BD Amoxicillin 1g BD Clarithromycin 500mg BD
98
Name the immunosupressants used in liver transplant patients
``` Ciclosporin or Tacrolimus + Azathioprine or Mycophenolate + Prednisolone ```

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