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Flashcards in GI Medicine Deck (143):
1

3 sources of ALP?

Liver
Bone
Placenta

2

Causes of an isolated ALP?

Pregnancy
Adolescence
Bone - tumour, Paget's disease, osteomalacia

3

Major causes of raised ALP + GGT?

Bile duct obstruction
PSC
Cholestasis - drug induced
Liver malignancy

4

3 causes of an isolated raised bilirubin?

Haemolytic anaemia
Gilbert's syndrome
Crigler-Najjar

5

5 broad areas of causes of acute abdomen?

Inflammation
Obstruction
Ischaemia
Perforation
Rupture

6

Inflammatory causes of acute abdomen?

'Itises' - appendicitis, diverticulitis, cholecystitis/angitis pancreatitis, salpingitis

7

Ischaemic causes of acute abdomen?

Strangulated hernia
Volvulus
Thromboembolism
Ovarian cyst torsion, testicular torsion

8

Perforation causes of acute abdomen?

Perforated ulcers, tumours etc
Diverticulum
Biliary pancreatitis
Bowel perforation (toxic megacolon)

9

Rupture causes of acute abdomen?

AAA
Ovarian cyst rupture
Ectopic pregnancy rupture

10

What are the 4 cardinal signs of GI obstruction?

Pain (colicky)
Vomiting
Bloating/distension
Absolute constipation

11

What symptoms does gastric outflow obstruction/upper GI obstruction cause?

Vomiting - undigested food

12

What symptoms does high small bowel obstruction cause?

Colicky pain
Vomiting, may be bilous if below ampulla of vater

13

Common cause of terminal ileal obstruction?

IBD - crohns

14

Symptoms of lower GI obstruction?

Central colicky pain
Vomiting - may be brown, feculent
Abdominal distension

15

What symptoms can sigmoid colon obstruction cause?

Colicky pain
Vomiting late feature
Distension
Absolute constipation

16

What normal anatomical feature can prevent perforation in end-colon obstruction?

Ileo-cecal valve incontinence

17

Underlying pathophysiology of GORD?

Incompetence of lower esophageal sphincter

18

Complications of GORD?

Oesophagitis
Ulcers
Strictures
Barretts oesophagus -> adenocarcinoma

19

What is Zollinger-Ellison syndrome?

Gastrin-secreting tumours leading to chronic or recurrent duodenal ulcers

20

What is the triad of tumours involved in MEN1!

Parathyroid
Pituitary
Gastrin-secreting - Zollinger Ellison

21

What common GI complaint can steroids cause?

GORD

22

2 rashes associated with IBD?

Erythema nodosum
Pyoderma gangrenosum

23

What effect does smoking have on UC?

Makes it better

24

What effect does smoking have on Crohn's disease?

Makes it worse

25

Which IBD does smoking make worse (ie quitting makes symptoms better)?

Crohns

26

What part of the GI tract does UC affect?

Universally rectum, ascends upwards but colon only

27

What does biopsy show in UC?

Intramural lesions - only part way through thickness of biopsy but all the way along

28

Where does crohns typically affect?

Ileo-colic (but anywhere from mouth to anus)

29

What does biopsy show on Crohn's disease?

Transmural skip lesions

30

What is a known complication of Crohn's disease which can result in vomiting, pain and abdominal distension?

Strictures - stenosis

31

In which IBD is surgery less helpful?

Crohn's

32

What immunology blood results are suggestive of autoimmune hepatitis?

Raised IgG
Raised ANA
Raised ASMA (anti-smooth muscle autoantibodies)

33

Typical sex and age of presentation for AIH?

Female 15-25 or 45-55

34

What liver enzymes are typically elevated in AIH?

Transaminases +/- ALP, GGT

35

What is the pathophysiological background of primary biliary cirrhosis (PBC)?

Autoimmune destruction of interlobular bile ducts (Herring canals) leading to intrahepatic cholestasis

36

What does the intrahepatic cholestasis in PBC cause?

Inflammation, scarring, fibrosis and cirrhosis

37

Common early symptoms of PBC?

TATT
Pruritis

38

What is an intrahepatic cholestatic picture of LFTs?

Raised ALP and GGT

39

What are 4 diagnostic blood test markers of PBC?

Anti-mitochondrial Abs (AMA)
Raised IgM
Cholestatic picture - raised GGT and ALP

40

Which of PBC/PSC is autoimmune?

PBC

41

What will PBC eventually lead to?

Liver cirrhosis

42

Early treatments of PBC?

UDCA
Questran

43

What vitamin supplementation can be given for PBC?

Fat-soluble (ADEK)

44

Underlying pathophysiology of PSC?

Intra - and extra-hepatic bile duct sclerosis, scarring and eventually cirrhosis

45

What other GI condition does PSC have a big link with?

UC

46

In whom is PSC more common?

Young males

47

Under what circumstances is PSC often diagnosed?

Often in the context of UC with deranged LFTs

48

What feature of early PSC may distinguish it from PBC?

Still have TATT, pruritis etc.
RUQ pain may be present

49

What 3 conditions may result from PSC?

Cholangiocarcinoma
Liver cirrhosis
Liver cancer

50

2 blood tests indicative of PSC?

ANCA
IgG

51

What can ERCP/MRCP show in PSC?

Beading of the bile ducts

52

What does disappearance of the psoas outlines on AXR indicate?

Bleed

53

What 2 veins converge to form the hepatic portal vein?

Splenic vein
Superior mesenteric vein

54

What 3 classic liver disease signs does portal hypertension cause?

Caput medusae (collateral vessels)
Varices (portocaval anastamoses)
Ascites

55

What 2 vessels converge to form the hepatic vein?

Hepatic portal vein
Hepatic artery

56

What signs are more indicative of someone being in acute than chronic liver failure?

RUQ pain
Nausea and vomiting
Fever
Encephalopathy
Clotting dysfunction - PT up to 100
Late on - jaundice

57

What is the spectrum of non-alcoholic fatty liver disease?

Fatty liver -> NASH -> NASH cirrhosis

58

What common antibiotic used for treatment of cellulitis can cause LFT derangement?

Flucloxacillin

59

What are 2 signs on examination that are more common in ALD than non-ALD?

Parotid megaly
Dupuytrens contracture

60

What is the underlying problem in pre-hepatic jaundice?

Increased bilirubin production - usually haemolysis

61

What type of bilirubin is high in pre-hepatic jaundice?

Unconjugated bilirubin

62

Describe the typical colour in pre-hepatic jaundice?

Lemon tinge jaundice

63

What are the urine and stools like in pre-hepatic jaundice?

Normal because unconjugated bilirubin is not water soluble so doesn't enter urine

64

What is the underlying pathophysiology of intrahepatic jaundice?

Altered excretion - liver causes e.g. Hepatitis, cirrhosis, cancers

65

Under what circumstances can you get pale stools and pruritis in intrahepatic jaundice?

If this is coexistent cellular cholestasis

66

What is the underlying pathology behind cholestatic jaundice?

Obstruction of bile ducts

67

What symptoms does obstructive jaundice typically yield?

Itching
Pale stools
Dark urine
Abdominal pain
Weight loss, fever, anorexia

68

What is the itching, pale stools and dark urine due to in obstructive jaundice?

Bile salts normally make stools dark but as they can't reach GI tract they get absorbed into the bloodstream (pale stools). They are also insoluble so get peed out making pee dark. They are also irritant so cause itching

69

Major causes of acute pancreatitis?

Gallstones
Drugs
Alcohol
Trauma

70

What are the symptoms of acute pancreatitis?

Severe epigastric pain radiating to back
Fever, anorexia, nausea and vomiting, tachycardia, sweating

71

What is elevated classically in acute pancreatitis but not necessarily in chronic?

Serum amylase

72

Management of acute pancreatitis?

Supportive - fluid, analgesia etc.
Get CT/USS or MRCP
ERCP particularly used to treat stones
Other surgery

73

What is the major cause of chronic pancreatitis?

Alcohol

74

What symptoms are more typical of chronic pancreatitis than acute?

Chronic or recurrent epigastric pain
Diarrhoea, weight loss
Malnutrition

75

What test is more suitable than serum amylase when looking for chronic pancreatitis?

Fecal elastase

76

3 risk factors for pancreatic cancer?

Smoking
Alcohol
Chronic pancreatitis

77

What is the typical picture of cancer of the head of the pancreas?

Obstructive jaundice - painless jaundice and itching
In the context of weight loss, TATT, deranged LFTs

78

What can be inserted via ERCP to improve bile flow in blocked or obstructed ducts?

Biliary stents

79

What is Murphys sign?

Acute pain on inspiration when palpating just under gallbladder
Positive in acute cholecystitis

80

Is jaundice likely in acute cholecystitis?

No as no bile duct involvement

81

What is cholangitis?

Inflammation of the common bile duct normally due to gallstones

82

What is ascending cholangitis/biliary sepsis?

Sepsis as a result of bacteraemia which is ascendant from GI tract via ampulla of vater. Stone blockage of CBD allows bacteria to pass through wall into blood

83

Charcot's triad of cholangitis?

Fever
Obstructive Jaundice
RUQ pain

84

Management of cholangitis?

ERCP to remove stones
Later cholecystectomy particularly if recurrent

85

What does a cholangiocarcinoma typically cause?

Painless jaundice and deranged LFTs

86

What tumour marker is raised in cholangiocarcinoma?

Ca19-9

87

What condition can give rise to silver stools?

Peri-amullary carcinoma - tumour causes obstructive jaundice (pale stools) and also melena (black stools)

88

What are the 3 types of gallstone?

Cholesterol
Pigment stones
Mixed

89

What types of gallstones are radiographically visible?

Mixed/pigment stones with high calcium

90

What is the relationship between eating fatty foods and cholecystitis?

Eating fatty foods causes pain due to increased bile and stone blockage

91

Differentiating factors between cholecystitis and cholangitis?

Murphys sign positive in cholecystitis
Jaundice in cholangitis only

92

What is a gallstone ileus?

Complication of chronic cholecystitis whereby a gallstone gets into small intestine and causes obstruction, usually at ileocecal valve

93

History suggestive of gallstone ileus?

Recurrent RUQ pain as indicative of chronic cholecystitis
Followed by acute abdomen - signs of lower GI obstruction

94

Where does the majority of intussusception occur in kids? What symptoms does this cause?

Ileo-coecal
So causes lower GI obstruction Sx

95

At what ages does intussusception typically occur?

5-12 months

96

What is the most common type of intussusception?

Simple telescoping I.e. Non-pathological lead point

97

What 2 signs on examination are suggestive of intussusception?

Palpable sausage-shaped mass in RUQ
Dances sign - no bowel in RLQ

98

What stool is typical of intussusception?

Mucoid, Redcurrant diarrhoea

99

Typical USS sign of intussusception?

Target/donut sign

100

What investigation is first line for intussusception?

Abdominal US

101

Why is GORD so common in kids?

Functional immaturity of the lower esophageal sphincter

102

When does childhood GORD normally resolve by?

1 year

103

Symptoms of childhood GORD?

Recurrent regurgitation and non-forceful vomiting
Abdo pain presenting as crying, non-feeding, FTT, behavioural problems

104

What constitutes an apparent life threatening event in kids in the context of GORD?

Cyanosis, apnoea, floppy baby (decreased tone), choking/gagging

105

Complications of childhood GORD?

Sandifer syndrome
Oesophagitis -> herniae, strictures
Aspiration pneumonia, wheeze, cough etc.

106

Initial management of childhood GORD?

Conservative - food thickeners, postural changes, high frequency low volume feeds

107

What is a common differential for GORD in kids?

Cows milk protein allergy

108

3 causes of unconjugated jaundice in young kids?

Rhesus haemolytic disease of newborn
Breast milk jaundice
Hypothyroidism

109

What is physiological jaundice in young kids?

Occurs after 24 hours due to breakdown of fetal Hb, poor bilirubin metabolism and short lifespan of neonatal rbcs. Peaks at 3-4 days and is settled by 2 weeks

110

What is the importance of physiological jaundice?

Unconjugated bilirubin is lipid soluble so can end up crossing BBB and depositing in basal ganglia, causing kernicterus

111

What is kernicterus?

Encephalopathy secondary due unconjugated jaundice, may result from 'physiological' jaundice in kids

112

What is opisthotonos?

Back arching secondary to kernicterus

113

Causes of early jaundice (less than 24 hours)?

Acute intravascular haemolysis - rhesus disease, ABO, G6PD, spherocytosis

114

What is TPN jaundice?

Jaundice as a result of TPN, resulting in stodgy enterohepatic circulation and raised bilirubin

115

What is Crigler-Najjar?

Glucoronyl transferase deficiency -> massive unconjugated bilirubin so pre-hepatic jaundice

116

When and in whom does pyloric stenosis present?

Boys with a family history
At 2-7 weeks birth age regardless of gestational age

117

Clinical features of pyloric stenosis?

Vomiting - increasing frequency over time eventually becoming projectile
Hunger post-vomiting
Faltering growth

118

Diagnosing pyloric stenosis?

Test feed: look for olive-like mass in RUQ and visible gastric peristalsis

119

What is the definitive management of pyloric stenosis?

Pyloromyotomy

120

What is Meckels Diverticulum?

Ileal remnant of vitello-intestinal duct which can contain ectopic gastric mucosa

121

If symptomatic, how can Meckels Diverticulum present?

Severe rectal bleeding
As intussusception (pathological lead point), diverticulitis or volvulus

122

Investigation for Meckel Diverticulum?

Technetium scan (shows ectopic gastric mucosa)

123

What is malrotation/volvulus?

Improper attachment of gut mesentery, predisposing to malrotation of gut

124

2 ways that malrotation can present?

Obstruction (bilous vomiting, abdo pain, distension)
Ischaemic bowel if blood supply compromised

125

Major RFs for NEC?

Prematurity
Low birth weight
PDA

126

When does NEC typically present?

3-10 days after birth, although can be up to 3 months

127

Early signs of NEC?

Non-specific (feeding problems, vomiting, abdo distension, sepsis)

128

GI Sx of NEC?

Abdo distension, erythema, visible abdo loops
Altered stool pattern (blood Mucoid) and bilous vomiting
Decreased bowel sounds

129

What investigation is diagnostic and must be done urgently if suspecting NEC?

AXR - pneumatosis intestinalis (gas in bowel wall)

130

Clinical features of duodenal ulcers?

Burning 'right' epigastric pain
Pain is often 2-3 hours after eating but initially relieved by food
Nocturnal pain

131

Which form of peptic ulcer is worse when hungry and relived by eating? Why?

Duodenal ulcer, because eating makes pyloric sphincter close and so gastric juices stop emptying down

132

Clinical features of gastric ulcers?

Burning 'left' epigastric pain worse within 1 hr of food
Often related to anorexia, weight loss

133

What is Dubin Johnson syndrome?

Isolated raised conjugated bilirubin (no LFT derangement)

134

4 RFs for diverticular disease?

Age (>50)
Smoking
Obesity
Low dietary fibre

135

Describe the pain associated with diverticular disease?

Non-specific LLQ pain, worse on eating and eased by flatus and passing stool

136

What is the difference in diverticular disease presentation between Asian and non-Asian populations?

RLQ more common in Asians

137

Symptoms of diverticulitis?

CIBH - usually diarrhoea, bloody, may be frank haemorrhage
LLQ pain and pseudo-obstruction
Fever, tachycardia
Anorexia, nausea, vomiting

138

Most common complication of diverticulitis? When is it most likely to occur?

Abscess formation; most likely after 1st acute presentation

139

Common fistulae associated with diverticular disease?

Colovesicular
Colovaginal

140

Appropriate investigation for diverticulitis? What should be avoided in the acute phase?

CT
Avoid endoscopy (do as OP) but do flexisig if bleeding

141

What defines prolonged jaundice? Causes?

Lasts over 14 days (/21 if preterm)
Common causes are breast milk, hepatitis, Galactosaemia, UTI, biliary atresia, TPN related, hypothyroidism, haematoma (instrumental delivery), Criggler Najjar etc.

142

When has physiological jaundice usually settled down by?

10-14 days - any longer consider prolonged jaundice

143

Rash associated with coeliac disease?

Dermatitis herpetiformis