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GI Passmedicine Flashcards

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1
Q

What are the two most common causes of acute GI bleeds?

A

Peptic ulcers

Oesophageal varices

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2
Q

What risk assessment scores can you use to assess acute GI bleeds?

A

Blatchford score at first assessment

Full Rockall score after endoscopy

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3
Q

What features are assessed using the Blatchford score?

A 
Urea
Hb
Systolic BP
Pulse
Presentation with malaena
Presentation with syncope
Hepatic disease
Cardiac failure
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4
Q

Patients with what Blatchford score may be considered for early discharge?

A

0

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5
Q

What is involved in resus in acute GI bleed?

A

ABC, wide bore IV access

In some pts: FFP, platelets, prothrombin complex

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6
Q

What GI bleed pts would you give platelets to?

A

Those actively bleeding + with platelet count <50x10^9/l

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7
Q

What acute GI bleed pts would you give FFP to?

A

Fibrinogen level <1g/L or PT/APTT >1.5x normal

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8
Q

What acute GI bleed pts would you give prothrombin complex to?

A

Those actively bleeding and taking warfarin

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9
Q

What is the management of acute GI bleed?

A

Resus

Endoscopy

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10
Q

In what time period should those with an acute GI bleed have an endoscopy?

A

Within 24h

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11
Q

How is non-variceal acute GI bleed managed?

A

PPIs after endoscopy

If further bleeding - repeat endoscopy, interventional radiology and surgery

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12
Q

How is variceal acute GI bleeding managed at presentation?

A

Teripressin and prophylactic antibiotics

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13
Q

What is the treatment of oesophageal varices?

A

Band ligation

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14
Q

What is the treatment of gastric varices?

A

N-butyl-2-cyanoacrylate

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15
Q

Is band ligation/N-butyl-2-cyanoacrylate fails to control variceal bleeding what is the next measure implemented?

A

Transgular intrahepatic portosystemic shunts

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16
Q

What will you see on the blood results will you see in someone with an acute GI bleed?

A 
Raised urea (upper GI bleed)
Marginal normocytic anaemia
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17
Q

Why do patients with an acute upper GI bleed get a raised urea?

A

RBCs in the stomach are broken down into urea (blood acts as a protein meal)

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18
Q

What drugs can increase the risk of having a GI bleed?

A

NSAIDs without gastroprotection (peptic ulcers –> bleeding)
Prednisolone (upper GI bleed)
Alcohol excess

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19
Q

What receptor does metoclopramide act on?

A

D2 receptor antagonist

also a 5HT3 receptor antagonist/5HT4 receptor agonist

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20
Q

What is the main use of metoclopramide?

A

Anti-nausea drug

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21
Q

What are other causes of metoclopramide?

A

GORD
Prokinetic action useful in gastroparesis in diabetic neuropathy
Migraine (migraine –> gastroparesis which slows absorption of analgesics)

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22
Q

What adverse effects are associated with metoclopramide?

A

EPS: oculogyric crisis
Hyperprolactinaemia
Tardive dyskinesia
Parkinsonism

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23
Q

In which condition is metoclopramide CI?

A

Bowel obstruction

PD

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24
Q

Which group of patients are most at risk of developing extrapyramidal side effects from use of metoclopramide?

A

Children, young adults

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25
What is the mechanism of action of metoclopramide in combating nausea?
Antagonism of D2 receptor in CTZ
26
What is the mechanism of action of ondansteron?
Antagonism of 5HT3 serotonin receptor
27
What is the most common acute abdominal condition requiring surgery?
Acute appendicitis
28
Describe the pain of acute appendicitis
Peri-umbilical --> RIF (migration of pain strong indicator of appendicitis)
29
What causes the peri-umbilical pain in acute appendicitis?
Visceral stretching of appendix lumen
30
What causes the RIF pain in acute appendicitis?
Localised parietal peritoneal inflammation
31
What may make the pain worse in acute appendicitis?
Cough, going over speed bumps
32
What are the clinical features of acute appendicitis?
``` Pain Vomiting (usually not persistent) Mild pyrexia Anorexia Diarrhoea rare ```
33
When might patients with acute appendicitis get generalised peritonitis?
If perforation has occurred/local peritonism
34
What sign may be seen in acute appendicitis?
Rovsing's sign
35
What is Rovsing's sign?
Palpation in LIF causes pain in RIF
36
What things justify an appendiectomy?
Typical raised inflammatory markers, with compatible hx and ex
37
What is the most common blood test finding found in appendicitis?
Neutrophil predominant leucocytosis
38
Why might you want to do urine analysis in a person presenting with suspected appendicitis?
Rule out pregnancy in women, renal colic and UTI
39
What urine analysis result may you find in someone with appendicitis?
Mild leucocytosis | NO nitrates
40
What US finding should raised your suspicion of acute appendicitis?
Free fluid | nb not always able to see appendix on USS
41
What are the two types of appendiectomy?
Laparoscopic (preferred) | Open
42
What should be given pre-operatively in an appendiectomy to reduce risk of wound infection?
IV prophylactic antibiotics
43
What does a perforated appendix often need?
Copious abdominal lavage
44
What is McBurneys point?
Site of maximum pain in appendicitis | It is one third of the distance from the ASIS to the umbilicus
45
What is the triad of symptoms seen in Plummer-Vinson syndrome?
Dysphagia (secondary to oesophageal webs) Glossitis Iron deficiency anaemia
46
What is the treatment of Plummer-Vinson syndrome?
Iron supplementation and dilation of webs
47
What is Mallory-weiss syndrome?
Severe vomiting --> painful mucosal lacerations in the gastro-oesphageal junction --> haematemesis
48
Who is Mallory-weiss syndrome most common in?
Alcoholics
49
What is Boerhaave sydnrome?
Severe vomiting --> oesophageal rupture
50
What is Gilbert's syndrome?
Autosomal recessive condition of defective bilirubin conjugation due to deficiency of UDP glucuronosyltrasnferase
51
What kind of hyperbilirubinaemia do you get in Gilbert's syndrome?
Unconjugated
52
What is the main feature of Gilbert's syndrome?
Jaundice during periods of intercurrent illness, exercise or fasting
53
How is Gilbert's syndrome investigated?
See rise in bilirubin after prolonged fasting/IV nicotonic acid
54
How is Gilbert's syndrome treated?
No treatment req.
55
What is the most common type of oesophageal cancer?
Adenocarcinoma
56
Patients with a history of what are more likely to get adenocarcinoma of the oesophagus?
GORD/Barrett's
57
Where are adenocarcinomas of the oesophagus most commonly found?
GO junction
58
Where are SSCs of the oesophagus most commonly found?
Middle third of oesophagus
59
What are RFs for oesophageal cancer?
``` Smoking Alcohol GORD Barrett's oesophagus Achalasia Plummer-Vinson syndrome SSC linked to diets rich in nitrosamines Rare: coeliac, scleroderma ```
60
What are the clinical features of oesophageal cancer?
Dysphagia Anorexia Wt loss Vomiting Others: odynophagia, hoarseness, melaena, cough
61
What is the most common presenting symptom of oesophageal cancer?
Dysphagia
62
What is the first line test for suspected oesophageal cancer?
Upper GI Endoscopy
63
How is oesophageal cancer staged?
CT chest, abdo, pelvis If overt mets --> further imaging unnecessary If no mets --> local stage assessed by endoscopic USS to assess for peritoneal disease PET CT performed if laparoscopy negative
64
How is oesophageal cancer managed?
Best if operable -resection | Adjuvant chemo
65
What is the biggest risk with resection for oesophageal cancer?
Anastomotic leak
66
How does the dysphagia from oesophageal cancer tend to present?
Progressive dysphagia - first solids then liquids (suggests growing obstruction)
67
How does achalasia tend to present?
Inability to swallow liquids and solids from onset
68
How to PPIs work?
Irreversibly block H+/K+ ATPase of the gastric parietal cells
69
Give 2 examples of PPIs
Omeprazole | Lansoprazole
70
What adverse effects are associated with PPIs?
Hyponatraemia, hypomagnasaemia (--> muscle weakness) Osteoporosis + inc. risk of fractures Microscopic colitis Increased risk of c. diff infectiosn
71
What is niacin AKA?
Vitamin B3
72
Is niacin water or fat soluble?
Water soluble
73
What is niacin a precursor to?
NAD+ and NADP+ It therefore plays an essential metabolic role in cells
74
What two conditions can lead to niacin deficiency?
Hartnup disease: hereditary disorder which reduces absorption of tryptophan Carcinoid syndrome: increased tryptophan metabolism into serotonin
75
What is niacin deficiency called?
Pellagra
76
What are the triad of symptoms in pellagra?
Dermatitis Dementia Diarrhoea Can lead to Death
77
What kind of bacteria is c. diff?
Gram +ve rod
78
What condition does c. diff cause?
Pseudomembranous colitis
79
How does c. diff cause pseudomembranous colitis?
By releasing an endotoxin
80
What drugs are associated with c. diff infections?
Antibiotics - the c's: cephalosporins, clindamycin etc. | PPIs
81
What are the clinical features of a c. diff infection?
Diarrhoea Ab pain Raised WCC
82
If you get a really severe c. diff infection what can result?
Toxic megacolon
83
How do you diagnose a c. diff infection?
Detecting c. diff toxin in the stool
84
Why can't you use c. diff antigen for diagnosis of a c. diff infection?
Antigen positively only indicates exposure to bacteria rather than infection
85
What is the pathophysiology of a c. diff infection?
Normal gut flora is suppressed, e.g. due to broad spectrum antibiotics
86
What is the first line management of c. diff infection?
Oral metronidazole 10-14d
87
If you have a severe c. diff infection or do not respond to metronidazole what antibiotic should be used?
Oral vancomycin
88
What is the 3rd line antibiotic for c. diff infections?
Fidaxomicin
89
How should life-threatening c. diff infections be treated?
Oral vancomycin + IV metronidazole
90
What is a pharyngeal pouch?
Posteromedial diverticulum through Killian's dehiscence
91
What is Hillian's dehiscence?
Triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles
92
In which gender is a pharyngeal pouch more common?
Men
93
In which age group is a pharyngeal pouch more common in?
Elderly patients
94
What are the features of a pharyngeal pouch?
``` Dysphagia Regurgitation Aspiration Neck swelling which gurgles on palpation Halitosis ```
95
How is pharyngeal pouch managed?
With surgery
96
What kind of cancers do carcinoid syndrome tend to occur with?
``` Liver mets (which release serotonin into systemic ciruclation) Lung carcinoid (as mediators are not cleared by the liver) ```
97
What are the features of carcinoid syndrome?
``` Flushing Diarrhoea Bronchospasm Hypotension Right heart valvular stenosis Other molecules, e.g. ACTH and GHRH can be secreted leading to cushings for e.g. Pellagra ```
98
Why can pellagra develop in carcinoid syndrome?
Dietary trytophan is diverted to serotonin by the tumour
99
What is usually the first symptom of carcinoid syndrome?
Flushing
100
What investigations should be done for suspected carcinoid syndrome?
Urinary 5-HIAA | Plasma chromogranin A y
101
How is carcinoid syndrome managed?
Somatostatin analogues, e.g. octreotide | Diarrhoea - cyproheptadine
102
What molecules can be released by carcinoid tumours?
Vasoactive amines - serotonin, noradrenaline, dopamine Peptides - e.g. bradykinin Prostaglandins
103
Why can you only get GI carcinoid syndrome with liver mets?
These vasoactive substances produced are inactived by the liver
104
What is the aetiology of autoimmune hepatitis?
Unknown
105
Who commonly gets autoimmune hepatitis?
Young females
106
What things are associated with autoimmune hepatitis?
Other autoimmune diseases Hypergammaglobulinaemia HLA B8, DR3
107
How many types of autoimmune hepatitis are there?
3
108
What are the types of autoimmune hepatitis?
1 2 3
109
Who does type 1 autoimmune hepatitis affect?
Adults + children
110
What antibodies are present in type 1 autoimmune hepatitis?
Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)
111
Who does type 2 autoimmune hepatitis affect?
Only children
112
What antibodies are present in type 2 autoimmune hepatitis?
Anti-liver/kidney microsomal type 1 antibodies (LKM1)
113
What antigen is present in type 3 autoimmune hepatitis?
Soluble liver-kidney antigen
114
Who does type 3 autoimmune hepatitis affect?
Adults in middle age
115
What are features of autoimmune hepatitis?
Signs of chronic liver disease Acute hepatitis: fever, jaundice etc. (25% present in this way) Amenorrhoea is common
116
What might you see in the liver biopsy of someone with autoimmune hepatitis?
Inflammation extending beyond limiting plate 'piecemeal necrosis' bridging necrosis
117
How is autoimmune hepatitis managed?
Steroids, immunosupressants, e.g. azathioprine | Liver Tx
118
What liver markers are most likely to be raised in autoimmune hepatitis?
ALT/AST
119
What are common symptoms of viral hepatitis?
N+V, anorexia Myalgia Lethargy RUQ pain
120
What are clues in a hx that someone may have viral hepatitis?
RFs e.g. IVDA, foreign travel
121
What is congestive hepatomegaly commonly a consequence of?
Congestive heart failure
122
What can occur in severe cases of congestive hepatomegaly?
Cirrhosis
123
How does biliary colic tend to present?
RUQ pain, intermittent usually begins abruptly and subsides gradually Nausea common
124
When do attacks of pain in biliary colic typically happen?
After eating
125
What patients are known to typically get biliary colic?
Female, fat, fair, forties
126
What causes the pain in biliary colic?
A gallstone temporarily blocking the bile duct
127
What is ascending cholangitis?
Infection of the bile ducts commonly secondary to gallstones
128
What is the triad of symptoms seen in ascending cholangitis?
Fever (+rigors) RUQ pain Juandice
129
What is gallstone ileus?
Small bowel obstruction due to impacted gallstone
130
What causes gallstone ileus?
Fistula develops between a gangrenous gallbladder + duodenum
131
What are common symptoms seen in gallstone ileus?
Ab pain, distension, vomiting
132
How does cholangiocarcinoma tend to present?
Persistent biliary colic, anorexia, jaundice, wt loss Palpable mass in RUQ Sister mary joseph nodes Virchow node
133
What is Courvoisier sign?
Palpable mass in RUQ
134
What are sister mary joseph nodes?
Periumbilical lymphadenopathy
135
What is a virchow node?
Left supraclavicular adenopathy
136
What tends to be the cause of acute pancreatitis?
Alcohol, gallstones
137
How does acute pancreatitis tend to present?
Severe epigastric pain | Vomiting
138
What might you see on Ex in acute pancreatitis?
Tenderness, ileus + low grade fever | Periumbilical discolouration, flank discolouration (rare)
139
What is Cullen's sign?
Periumbilical discolouration
140
What is Grey-Turner's sign?
Flank discolouration
141
What is the 'classical presentation' of pancreatic cancer?
Painless jaundice
142
What is another v. common symptom of pancreatic cancer?
Pain NB anorexia, wt loss are common too
143
What symptoms are associated with an amboeic liver abscess?
Malaise, anorexia, wt loss Mild RUQ pain Jaundice rare
144
How is Wilson's disease inherted?
AR
145
What is Wilson's disease?
Condition characterised by excessive copper deposition in tissues
146
Why is there increased copper in those with wilson's disease?
Metabolic abnormalities --> increased copper absorption from small intestine, decreased hepatic copper excretion
147
A mutation in what gene on what chromosome leads to wilson's disease?
ATP7B gene on chromosome 13
148
When is the onset of symptoms in wilson's disease usually?
10-25Y
149
How do children tend to present with wilson's disease?
Liver disease
150
How do young adults tend to present with wilson's disease?
Neurological disease
151
Where is copper especially deposited in wilson's disease?
Brain Liver Cornea
152
Deposition of copper in the liver in wilson's disease leads to what?
Hepatitis | Cirrhosis
153
Deposition of copper in the brain in wilson's disease leads to what?
Basal ganglia degeneration Speech, behavioural, psychiatric problems Asterixis, chorea, dementia, parkinsonism
154
What can you often see in the cornea of those with wilson's disease?
Kayser-Fleischer rings (due to deposition of copper in cornea)
155
What are other features (not liver, neuro, cornea) of wilson's disease?
Renal tubular acidosis (esp. Fanconi syndrome) Haemolysis Blue nails
156
How do you diagnose Wilson's disease?
Reduced serum caeruloplasmin Reduced serum copper Inc. 24h urinary copper excretion
157
Why does copper deposition in tissues lead to damage to the tissues?
Copper reacts with hydrogen peroxide to produce free radicals which can damage the tissues
158
How is wilson's disease managed?
Penicillamine
159
How does penicillamine work for Wilson's disease?
Chelates copper
160
What is an alternative treatment option for wilson's disease?
Trientine hydrochloride
161
Define refeeding syndrome
Metabolic abnormalities which occur on feeding a person following a period of starvation
162
When can refeeding syndrome occur?
After an extended period of catabolism ends abruptly switching to carb metabolism
163
What are the metabolic consequences of refeeding syndrome?
Hypophosphataemia Hypokalaemia Hypomagnesaemia Abnormal fluid balance
164
What can hypomagnesaemia predispose to?
Torsades de pointes
165
What can the metabolic abnormalities in refeeding syndrome lead to?
Organ failure
166
Patients are considered at high risk of refeeding syndrome if they have 1+ of the following:
BMI <16 Unintentional wt loss >15% over 3-6m Little nutritional intake >10d Hypokalaemia, hypophosphataemia, or hypomagnesaemia prior to feeding
167
Patients are considered at high risk of refeeding syndrome if they have 2+ of the following:
BMI <18.5 Unintentional wt loss >10% over 3-6m Little nutritional intake >5d Hx: alcohol abuse, drug therapy incl. insulin, chemotherapy, diuretics, antacids
168
How do you avoid refeeding syndrome?
If a patient has not eaten for >5 days aim to re-feed at no more than 50% of requirements for the first 2 days
169
Define diarrhoea
>3 loose/watery stools per day
170
Define acute diarrhoea
<14 days
171
Define chronic diarrhoea
>14 days
172
What symptoms are classical of diverticulitis?
LLQ pain, diarrhoea, fever
173
What would be a typical history of a patient with constipation causing overflow diarrhoea?
Hx of alternating diarrhoea + constipation
174
What are the most common features of IBS?
Abdominal pain Bloating Change in bowel habit
175
What are the two types of IBS?
Constipation predominant | Diarrhoea predominant
176
What additional features may be seen in IBS?
Lethargy Nausea Backache Bladder symptoms
177
What are the clinical features of UC?
``` Bloody diarrhoea Crampy abdominal pain Wet loss Faecal urgency Tenesmus ```
178
What are the clinical features of CD?
``` Cramp ab pain + diarrhoea Malabsorption, wt loss, lethargy Mouth ulcers Perianal disease (skin tags, ulcers) Intestinal obstruction ```
179
What symptoms can you get with colorectal cancer?
``` Depends on site of lesion Diarrhoea Rectal bleeding Anaemia Constitutional symptoms, e.g. wt loss, anorexia ```
180
What are clinical features of coeliac disease in children?
FTT Diarrhoea Abdominal distension
181
What are clinical features of coeliac disease in adults?
Lethargy Anaemia Diarrhoea Wt loss Other autoimmune dx may be present
182
What conditions may be associated with diarrhoea?
Thyrotoxicosis Laxative abuse Appendicitis Radiation enteritis
183
What is diverticulosis?
Multiple out pouchings of the bowel
184
Where is the most common places to get diverticulae in diverticulosis?
Sigmoid colon
185
What is the difference between diverticulosis and diverticular disease?
Diverticulosis = diverticula present | Diverticular disease = symptomatic disease
186
What are risk factors for diverticulosis?
Increasing age | Diet low in fibre
187
What is the two ways in which diverticulosis can present?
Painful diverticular disease | Diverticulitis
188
How does painful diverticular disease present?
Altered bowel habit, colicky left sided ab pain
189
What is the recommended management of painful diverticular disease?
Diet high in fibre to minimise symptoms
190
What is diverticulitis?
A diverticula becomes infected
191
What is the classical presentation of diverticulitis?
Left iliac fossa pain, tenderness Anorexia, nausea, vomiting Diarrhoea Features of infection - pyrexia, raised WCC, CRP
192
How are mild attacks of diverticulitis managed?
Oral antibiotics
193
How are more severe episodes of diverticulitis managed?
In hospital | Nil by mouth, IV fluids, IV antibiotics
194
What IV antibiotics are given for more severe episodes of diverticulitis?
Cephalosporin + metronidazole
195
What are complications of diverticulitis?
Abscess formation Perionitis Obstruction Perforation
196
Where is the most common place to get diseased bowel in CD?
Terminal ileum
197
What inflammatory marker correlates well with disease activity in CD?
CRP
198
What is the investigation of choice in CD?
Colonscopy
199
What features may you see during colonscopy in CD?
Deep ulcers | Skip lesions
200
What can you see on histology in CD?
Transmural inflammation Goblet cells Granulomas
201
What sign might you see on small bowel enema in CD?
Kantor string sign (from strictures in terminal ileum so it appears narrow)
202
What signs may you see on barium enema in someone with CD?
``` Strictures Proximal bowel dilatation Rose thorn ulcers Fistulae Crypt abscesses ```
203
In what patients is spontaneous bacterial peritonitis seen in?
Usually those with ascites secondary to liver cirrhosis
204
What are the clinical features of spontaneous bacterial peritonitis?
Ascites Abdominal pain Fever
205
What is a common finding with spontaneous bacterial peritonitis on paracentesis?
Neutrophil count >150cells/ul
206
What is the most common organism found in the ascitic fluid in spontaneous bacterial peritonitis?
E. coli
207
How is spontaneous bacterial peritonitis managed?
IV cefotaxime
208
What patients with ascites should be given prophylaxis for spontaneous bacterial peritonitis?
Those who: Have had a prev. SBP With fluid protien <15g/l + either Child Pugh score 9+ or hepatorenal syndrome
209
What antibiotic is given for prophylaxis in spontaneous bacterial peritonitis?
Oral ciprofloxacin or norfloxacin
210
What medications should be withheld in c. diff infections (besides the offending antibiotic)?
Antimotility + antiperistalsis medications, e.g. opioids
211
Why should antimotility/antiperistalsis medications be withheld in c. diff infections?
By slowing clearance of c. diff infection they predispose to toxic megacolon
212
What is Barrett's oesophagus?
Metaplasia of the lower oesophageal mucosa (with normal squamous epithelium being replaced with columnar)
213
What does Barrett's oesophagus carry an increased risk of?
Oesophageal adenocarcinoma
214
What is the screening programme for Barrett's oesophagus?
There is not one
215
What are the two subtypes of Barrett's oesophagus?
Short <3cm | Long >3cm
216
What does the length of the affected segment in Barrett's oesophagus correlate with?
The chances of identifying metaplasia
217
What is the strongest RF for developing Barrett's oesophagus?
GORD
218
What are other RFs for Barrett's oesophagus?
Male gender Smoking Central obesity
219
Is alcohol consumption a RF for Barrett's oesophagus?
It is not an independent RF, although it is associated with oesophageal cancer and GORD
220
What are the clinical features of Barrett's oesophagus?
Barrett's oesophagus itself is asymptomatic but clearly pt will have sx of GORD
221
How is Barrett's oesophagus investigated?
Endoscopic surveillance + biopsies | pH and manometry
222
How is Barrett's oesophagus managed?
PPIs | Endoscopic surveillance to monitor if metaplasia is occurring
223
For patients with metaplasia (but no dysplasia) how often is endoscopic surveillance recommended?
Every 3-5y
224
Once in Barrett's oesophagus the metaplasia --> dysplasia what treatment is offered?
Endoscopic mucosal resection | Radiofrequency ablation
225
What is melanosis coli?
Disorder of pigmentation of the bowel
226
What do you see on histology in melanosis coli?
Pigment laden macrophages
227
What is melanosis coli associated with?
Laxative abuse esp. anthraquinone compounds e.g. senna
228
Ischaemia to the lower GI tract can lead to a variety of conditions. What re the 3 main conditions it can cause?
Acute mesenteric ischaemia Chronic mesenteric ischaemia Ischaemic colitis
229
What are common predisposing factors for ischaemia to the lower GI tract?
``` Increased age AF (esp. mesenteric ishcaemia) Emboli: endocarditis, malignancy CV RFs: smoking, HTN, DM Cocaine (ischaemic colitis sometimes seen in young people after cocaine use) ```
230
What are some common features that can be seen following ischaemia to the lower GIT?
``` Ab pain Rectal bleeding Diarrhoea Fever Elevated WCC and lactic acidosis ```
231
What is the investigation of choice in ischaemia to the lower GIT to reach a diagnosis?
CT
232
What tends to cause acute mesenteric ischaemia?
Embolism resulting in occlusion of an artery that supplies the small bowel, e.g. SMA
233
Patients with acute mesenteric ischaemia classically have what condition?
AF
234
What is typical of the abdominal pain experienced in acute mesenteric ischaemia?
It is very severe, of sudden onset and out of keeping with physical signs
235
How is acute mesenteric ischaemia managed?
Urgent surgery
236
What is the prognosis of acute mesenteric ischaemia?
Very poor
237
What is chronic mesenteric ischaemia?
Intestinal angina
238
What is the pain in chronic mesenteric ischaemia like?
Colicky, intermittent
239
What is ischaemic colitis?
Acute transient compromise in blood flow to the large bowel which may lead to inflammation, ulceration and haemorrhage
240
Where are the most common places for ischaemic colitis?
Watershed areas, e.g. splenic flexure (where borders of territory are supplied by the IMA and SMA)
241
What might you see on AXR in ischaemic colitis?
Thumbprinting due to mucosal oedema/haemorrhage
242
How is ischaemic colitis managed?
Usually supportive | Surgery if conservative measures fail, or generalised peritonitis, perforation or ongoing haemorrhage
243
What pattern do you see on ABG in ischaemia of the lower GIT?
LACTIC ACIDOSIS
244
Where does the inflammation in UC always start?
Rectum
245
Where is UC said never to spread past?
Ileocaecal valve
246
Is UC continuous or are there skip lesions?
Disease usually continuous
247
What is the peak age for developing UC?
15-25y second peak at 55-65y
248
What symptoms do you tend to get in UC?
``` Bloody diarrhoea Urgency Tenesmus Ab pain (esp LLQ) Extra-intestinal features ```
249
What are extra-intestinal features of IBD?
``` Arthritis - CD + UC Episcleritis - UC Erythema nosodum Osteoporosis Uveitis - UC PSC - UC Clubbing ```
250
What layers of the bowel are affected by UC?
Mucosa only
251
What does UC look like on endoscopy?
Pseudopolyps Red, raw mucosa, contact bleeding Wide spread ulceration Neutrophils migrate through walls of glands to form crypt abscesses Depeleted goblet cells + mucin from gland epihelium
252
What can you see on barium enema in UC?
Loss of haustrations Superficial ulceration, pseudopoyps Long standing disease - drainpipe colon (colon narrow + short)
253
Are crypt abscesses seen more commonly in UC or CD?
CD
254
What is coeliac disease?
Autoimmune condition caused by sensitivity to protein gluten
255
What is the prevalence of coeliac disease?
1%
256
Why do you get malabsorption in coeliac disease?
Repeated exposure to gluten leads to vilous atrophy
257
What conditions are associated with coeliac disease?
Dermatitis herpetiformis | Autoimmune dx e.g. T1DM, autoimmune hepatitis
258
What is dermatitis herpetiformis?
A vesicular, pruritic skin eruption
259
What HLA allele is coeliac disease associated with?
HLA-DQ2 and HLA-DQ8
260
Patients with what conditions should be screened for coeliac disease?
``` Autoimmune thyroid disease Dermatitis herpetiformis Irritable bowel syndrome T1DM First degree relatives with coeliac disease ```
261
What symptoms/signs may lead to you test for coeliac disease?
Chronic/intermittent diarrhoea FFT/faltering growth in kids Persistent/unexplained GI symptoms (incl. NV) Prolonged fatigue Recurrent ab pain, cramping, distension Sudden/unexplained wt loss Unexplained iron deficiency anaemia/other anaemia
262
What are complications of coeliac disease?
``` Anaemia (Fe, folate, B12) Hyposplenism Osteoporosis, osteomalacia Lactose intolerance Subfertility Rare: oesophageal cancer, other malignancies ```
263
What malignancy is associated with coeliac disease?
Enteropathy-associated T cell lymphoma of small intestine
264
What is primary sclerosing cholangitis?
Biliary disease of unknown aetiology characterised by inflammation and fibrosis of the intra and extra-hepatic bile ducts
265
Which condition has the strongest association with PSC?
UC
266
What other conditions are associated with PSC?
CD | HIV
267
What are the clinical features of PSC?
Cholestasis - jaundice, pruritus RUQ pain Fatigue
268
What investigations are diagnostic in PSC?
ERCP or MRCP
269
What do you see on ERCP/MRCP in PSC?
Multiple biliary strictures giving a beaded appearance
270
What does ERCP stand for?
Endoscopic retrograde cholangiopancreatography
271
What does MRCP stand for?
Magnetic resonance cholangiopancreatography
272
There is a limited role for liver biopsy in PSC but what might you see if you do it?
Fibrous obliterative cholangitis ('onion skin')
273
What are complications of PSC?
``` Acute bacterial cholangitis Cholangiocarcinoma Increased risk of colorectal cancer Cirrhosis + liver failure Deficiencies in fat soluble vitamins ```
274
What antibody may be +ve in PSC?
pANCA | ANA and and aCL can also be up
275
What is the function of the bile ducts?
Taking the bile from where its made in the liver into the small intestine
276
What is meant by a stricture?
Narrowing
277
What is meant by fibrosis?
Hardening
278
What does the stricturing + fibrosis of the bile ducts in PSC lead to?
Obstruction of bile --> back pressure of bile --> liver --> inflammation (hepatitis) --> fibrosis of liver --> cirrhosis
279
What might you see on the LFTs of someone with PSC?
Cholestatic picture - high ALP, bilirubin and GGT | Then other ALT and AST will become more derranged as disease progresses to cirrhosis
280
What is the only definitive management of PSC?
Liver transplant
281
What is the management of PSC if liver transplant cannot be done?
ERCP - dilate and stent strictures Ursodeoxycholic acid Colestryamine - bile acid sequestrate (reduces pruritus)
282
What does ERCP involve?
Inserting camera into duodenum, through sphincter of Oddi, ampulla of vater Can dilate and stent stricture if find any
283
What is Budd-Chiari also known as?
Hepatic vein thrombosis
284
Where is Budd-Chiari usually seen in the context of?
Underlying haematological disease or other procoagulant conditions
285
What are causes of Budd-Chiari syndrome?
Polycythaemia rubra vera Thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C and S deficiencies Pregnancy COCP
286
What is the classic triad of clinical features seen in Budd-Chiari syndrome?
Ab pain - sudden, severe Ascites Tender hepatomegaly
287
How is Budd-Chiari syndrome diagnosed?
USS with doppler flow studies
288
Does Budd-Chiari syndrome cause portal hypertension?
Yes
289
What SAAG indicates portal hypertension is the cause of an ascites?
>11g/L
290
What are the three types of colon cancer?
Sporadic 95% HNPCC FAP
291
What does HNPCC stand for?
Hereditary non-polyposis colorectal cancer
292
What does FAP stand for?
Familial adenomatous polyposis
293
What is thought to cause sporadic colon cancer?
A series of genetic mutations E.g. loss of APC gene, then activation of a K-ras oncogene or deletion of p53/DCC tumour supressor genes to lead to an invasive carcinoma
294
What is the mode of inheritance of HNPCC?
AD
295
Where is the commonest place to develop colon cancer in HNPCC?
Proximal colon
296
Do the colon cancers in HNPCC tend to be aggressive or slow growing?
Aggressive
297
What % of people with HNPCC will develop a colon cancer?
90%
298
Currently ___ mutations causing HNPCC have been identified, which can affect genes involved in ________ leading to _______.
7 | Genes involved in DNA mismatch repair leading to microsatellite instability
299
What are the two most common genes involved in HNPCC?
MSH2 and MLH1
300
What is the second most common cancer after colon cancer for people with HNPCC to get?
Endometrial cancer
301
What criteria is used to aid the diagnosis of HNPCC?
Amsterdam critera
302
What is the amsterdam criteria?
At least 3 family members with colon cancer Cases span at least 2 generations At least 1 case diagnosed before age 50
303
What is FAP?
AD condition which leads to the formation of hundreds of polyps before age 30-40
304
Do patients with FAP tend to go on to develop carcinoma?
Yes
305
What is FAP due to?
Mutation in tumour supressor gene called adenomatous polyposis coli gene located on chromosome 5
306
How can FAP be diagnosed?
Via genetic testing by analysis DNA from a pts WBCs
307
What tends to be the management for FAP?
Total colectomy with ileo-anal pouch formation
308
A variant of FAP is Gardener's syndrome which also features what?
Osteomas of the skull and mandible Retinal pigmentation Thyroid carcinoma Epidermioid cysts on the skin
309
What are patients with FAP also at risk of?
Duodenal tumours
310
What is the most common inheritable form of colorectal cancer?
HNPCC
311
Define malnutrition
BMI <18.5 OR Unintentional wt loss >10% within last 3-6m OR BMI <20 and unintentional wt loss >5% in last 3-6m
312
What is the best screening tool for malnutrition?
MUST
313
When should MUST screening be used?
On admission to care/nursing homes and hospital or if there is concern
314
If a pt is high risk of malnutrition what i the management?
Dietician input Food-first approach with clear instructions rather than just prescribing for e.g. ensure Oral nutritional supplements should be taken between meals rather than instead of meals
315
What is achalasia?
Failure of oesophageal peristalsis + relaxation of lower oesophageal sphincter due to degenerative loss of ganglia from Auerbach's plexus
316
At what age does achalasia tend to occur?
Middle age
317
What are the clinical features of achalasia?
Dysphagia of SOLIDS and LIQUIDS from the start Variation in severity of symptoms Heartburn Regurg (may lead to aspiration pneumonias)
318
How is achalasia investigated?
Oesophageal manometry | Barium swallow
319
What do you see on oesophageal manometry in achalasia?
Excessive LOS tone which doesn't relax on swallowing
320
What do you see on barium swallow in achalasia?
Grossly expanded oesophagus, fluid level , bird's beak appearance (due to narrowing of LOS)
321
What are the treatment options for achalasia?
Intra-sphincteric injection of botox Heller cardiomyotomy Pneumatic (balloon) dilation
322
Name 3 of the commonest causes of hepatomegaly
Cirrhosis Malignancy R heart failure
323
What does a cirrhotic liver feel like?
Non-tender, firm liver Remember later liver decreases in size
324
What does a malignant liver feel like?
Hard, irregular liver edge
325
What does hepatomegaly due to R heart failure feel like?
Firm, smooth, tender liver edge | Pulstaile
326
What are other causes of hepatomegaly?
``` Viral hepatitis Glandular fever Malaria Abscess - pyogenic/amoebic Hydatid disease Haematological malignancies Haemochromatosis PBC Sarcoidosis, amyloidosis ```
327
Why can hepatomegaly due to R heart failure be pulsatile?
Due to back up of blood in liver
328
Who tends to be at more risk of pernicious anaemia?
Elderly females
329
What is the pathophysiology of pernicious anaemia?
Autoimmune disease caused by antibodies to the gastric parietal cells/intrinsic factors
330
Pernicious anaemia is a deficiency in...
B12
331
What conditions are associated with pernicious anaemia?
Thyroid disease, DM, Addison's, RA, vitiligo
332
What can pernicious anaemia predispose to?
Gastric carcinoma
333
What are the features of pernicious anaemia?
Lethargy, weakness Dyspnoea Paraesthesia (loss of vibration sense in feet) Mild jaundice (LEMON TINGE), diarrhoea, sore tongue
334
What are possible signs of pernicious anaemia?
Retinal haemorrhages, mild splenomegaly, retrobulbar neuritis
335
How is pernicious anaemia managed?
3mnthly injections of B12 | Folic acid supplements may also be req.
336
What causes a lemon tinge in pernicious anaemia?
Pallor (anaemia) + mild jaundice (due to haemolysis)
337
Over 80% of pancreatic cancers are...
Adenocarcinomas
338
Where do pancreatic cancers tend to occur?
Head of pancreas
339
What things are associated with pancreatic cancer?
``` Increased age Smoking DM Chronic pancreatitis HNPCC MEN BRCA2 mutation ```
340
How does pancreatic cancer classically present?
Painless jaundice
341
What is Courvoisier's law?
In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
342
How do a majority of patients with pancreatic cancer actually present?
Non-specific symptoms, e.g. anorexia, wt loss, epigastric pain ``` May have loss of exocrine function - steatorrhoea, loss of endocrine function - DM, atypical backpain often seen Migratory thrombophlebitis (Trousseau sign) ```
343
What is the investigation of choice for diagnosing pancreatic cancer?
High resolution CT
344
What sign might you see on imaging in pancreatic cancer?
Double duct sign - presence of simultaneous dilatation of common bile duct and pancreatic ducts
345
What procedure is performed for resectable pancreatic cancer?
Whipple'sresection (pancreaticoduodenectomy) + adjuvant chemo
346
What are side effects of Whipple's procedure?
Dumping syndrome and peptic ulcer disease
347
What procedure can be used for palliation in pancreatic cancer?
ERCP with stenting
348
How is UC usually classified?
Mild Moderate Severe
349
Define mild UC
<4 stools/day, only a small amount of blood
350
Define moderate UC
4-6 stools/day, varying amounts of blood, no systemic upset
351
Define severe UC
>6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
352
How do you induce remission in mild-to-moderate UC proctitis?
Topical (rectal) aminosalicylate (mesalazine) No remission in 4w - add oral aminosalicylate If no remission still - add topical/oral corticosteroid
353
How do you induce remission in someone with mild-to-moderate UC proctosigmoiditis + left sided UC?
Topical (rectal) aminosalicylate No remission in 4w - add high dose oral aminosalicylate OR switch to high dose oral aminosalicylate + topical corticosteroids No remission still - stop topical treatments and offer oral aminosalicylate + oral corticosteroid
354
How put EXTENSIVE mild-to-moderate UC into remission?
Topical (rectal) aminosalicylate + high dose oral aminosalicylate No remission in 4w - stop topical treatments and offer high dose oral aminosalicylate + oral corticosteroid
355
Should you admit someone with a severe flare UC?
Yes
356
What is the first line treatment for severe flare of UC?
IV steroids | If steroids CI - IV ciclosporin
357
If you admit someone with a severe flare of UC to hospital and give IV steroids and this does not cause improvement within 72h what should you do?
Consider adding IV ciclosporin to IV corticosteroids OR consider surgery
358
How do you maintain remission following a mild to moderate UC flare in someone who had proctitis or proctosigmoiditis?
Rectal aminosalicylate alone OR oral + reacl aminosalicylate OR oral aminosalicylate alone Treatment can be daily or intermittent
359
How do you maintain remission following a mild to moderate UC flare in someone who had left sided or extensive UC?
Low dose of oral aminosalicylate
360
What therapy is given to someone who has had a severe relapse of UC or >= 2 exacerbation in the last year?
Oral azathioprine or oral mercaptopurine
361
What kinds of drugs are azathioprine and mercaptopurine?
Thiopurines
362
What are the most common organisms causing pyogenic liver abscesses in kids?
Staph aureus
363
What are the most common organisms causing pyogenic liver abscesses in adults?
E. coli
364
What is the management of a pyogenic liver abscess?
Drainage + antibiotics
365
What kind of drainage is usually done for pyogenic liver abscesses?
Imaged guoded percutaneous
366
What antibiotics are usually given for pyogenic liver abscesses?
Amoxicillin + ciprofloxacin + metronidazole | if penicillin allergic: ciprofloxacin + clindamycin
367
At what age is there a peak of gastric cancers?
70-80yos
368
What cells might you see in a gastric cancer?
Signet ring cells
369
What do signet ring cells look like?
Large vacuole of mucin which displaces the nucleus to one side
370
In gastric cancer a higher number of signet cells is associated with what?
A worse prognosis
371
What things are associated with gastric cancer?
``` H. pylori infection Blood group A Gastric adenomatous polyps Pernicious anaemia Smoking Diet - salty, spicy, nitrates Maybe be negatively associated with duodenal ulcer ```
372
What are features of gastric cancer?
Dyspepsia NV Anorexia, wt loss Dysphagia
373
How do you diagnose gastric cancer?
Endoscopy with biopsy
374
How do you stage a gastric cancer?
1st line: CT chest, abdo, pelvis Laparoscopy to identify occult peritoneal disease PET CT
375
What staging system is used to stage gastric cancer?
TNM staging
376
How many types of cancers of the gastro-oesophageal junction are there?
3
377
What is type 1 gastro-oesophageal cancer?
True oesophageal cancer (may be assoc. with Barrett's)
378
What is type 2 gastro-oesophageal cancer?
Carcinoma of the cardia, arising from cardiac type epithelium or short segments with intestinal metaplasia at the oesophagogastric junction
379
What is type 3 gastro-oesophageal cancer?
Subcardial cancers that spread across the junction
380
What are the options for treatment of gastric cancer?
``` Subtotal/total gastrectomy Oesophagogastrectomy Endoscopic submucosal resection Lymphadenectomy Pre/post-op chemo for most pts ```
381
What patients may receive a subtotal gastrectomy for their gastric cancer?
If they have proximally sited disease greater than 5-10cm from OG junction
382
What patients may receive a total gastrectomy for their gastric cancer?
If the tumour is <5cm from OG junction
383
What patients may receive a oesphagogastrectomy for their gastric cancer?
Type 2 junctional tumours (extending into oesophagus)
384
What patients may receive endoscopic submucosal resection for their gastric cancer?
If they have an early gastric cancer confined to the mucosa
385
What is the cause of hepatic encephalopathy?
Liver disease
386
What is the aetiology of hepatic encephalopathy?
Excess absorption of ammonia and glutamine from bacterial breakdown of proteins in the gut
387
How might the presentation of hepatic encephalopathy differ in acute vs chronic liver failure?
In chronic may develop subtle symptoms (e.g. MCI) first
388
What are features of hepatic encephalopathy?
``` Confusion, altered GCS Asterix Constructional apraxia Raised ammonia level Triphasic slow waves on EEG ```
389
What is asterix?
Liver flap | Arrythmic negative clonus
390
What is constructional apraxia?
Inability/difficult to build, assemble or draw objects | E.g. unable to draw 5 pointed star when asked
391
What are the grades of hepatic encephalopathy?
1 - irritability 2 - confusion, inappropriate behaviour 3 - incoherent, restless 4 - coma
392
What factors may precipitate hepatic encephalopathy?
``` Infection, e.g. SBP GI bleed Post transgular intrahepatic portosystemic shunt Constipation Drugs, e.g. sedatives, diuretics Hypokalaemia Renal failure Increased dietary protein ```
393
How do you manage hepatic encephalopathy?
Rx underlying cause | 1st line: lactulose + rifaximin for 2ndary prophylaxis of HE
394
How does lactulose work in treating hepatic encephalopathy?
Promotes excretion of ammonia and inhibits production of ammonia in the intestine
395
How does rifaximin work in treating hepatic encephalopathy?
Antibiotics like rifaximin modulate gut bacteria resulting in decreased ammonia production
396
What advice should be given to patients with crohn's disease re their lifestyle?
Stop smoking
397
How do you induce remission in CD?
Glucocorticoids/budesonide Enteral feeding with an elemental diet can be used in children 2nd line: 5ASA Azathiopurine/mercaptopurine may be used as add on therapies but not alone Methorexate can be used instead of azathioprine Infliximab useful in refractory disease + fistulating CD Metronidazole often used for isolated peri-anal disease
398
What drugs are used first line in CD to maintain remission?
Azathioprine/mercaptopurine
399
What drug are used second line in CD to maintain remission?
Methorexate | Consider 5ASA if pt has had prev. surgery
400
Around what % of CD patients will eventually have surgery?
80%
401
What is the commonest pattern of CD?
Stricturing terminal ileal disease
402
What surgical treatments may be offered to those with CD?
Segmental resections | Stricturoplasty
403
CD is notorious for forming fistulae - where might these form?
Between rectum + skin (perianal), or small bowel + skin or between loops of bowel
404
What can fistulae in CD result in?
Bacterial overgrowth + malabsorption
405
What conditions are patients with CD at more risk of?
Small bowel cancer Colorectal cancer Osteoporosis
406
What MUST you do before offering azathioprine/mercarptopurine?
Assess thiopurine methyltransferase activity | Those with TMPT deficiency may get severe SEs from conventional doses of thiopurines
407
List some foods in which vitamin C is found
``` Citrus fruits Tomatoes Potatoes Brussel sprouts Cauliflower Broccoli Cabbage Spinach ```
408
What is vitamin C deficiency AKA?
Scurvy
409
What does scurvy lead to?
Impaired collagen synthesis + disordered connective tissue
410
Why does vitamin C deficiency lead to impaired collagen synthesis?
Absorbic acid is a cofactor for enzymes used in the production of proline and lysine
411
Who is prone to scurvy?
Those with severe malnutrition, drug/alcohol abuse, living in poverty
412
What are signs/symptoms of scurvy?
Follicular hyperkeratosis + perifollicular haemorrhage Ecchymosis, easy bruising Poor wound healing Gingivitis with bleeding and receding gums Sjogren's syndrome Oedema Arthalgia Impaired wound healing Generalised symptoms, e.g. weakness, malaise, anorexia, depression
413
Should you always endoscopy someone with new onset dysphasia?
Yes - this is a red flag symptom
414
What would be a typical history of someone with oesophageal cancer?
Dysphagia + wt loss, anorexia, vomiting whilst eating | PMH Barrett's, GORD, excessive smoking/alcohol use
415
What would be a typical history of someone with oesophagitis?
Hx heartburn | Odynophagia, no wt loss + systemically well
416
What would be a typical history of someone with oesophageal candidiasis?
Hx HIV/other RF e.g. steroid inhaler use
417
What would be a typical history of someone with achalasia?
Dysphagia of solids + liquids from the start Heartburn Regurg of food (may lead to cough/aspiration pneumonia etc.)
418
What are typical symptoms in pharyngeal pouch?
Dysphagia, regurg, aspiration, chronic cough | Halitosis
419
What are the features of CREST syndrome?
``` Calcinosis Raynauds Oesophageal dysmotility (+ LOS pressure is decreased) Scleroderma Telangiectasia ```
420
What would be a typical history of myasthenia gravis presenting with dysphagia?
Other symptoms like extraocular muscle weakness/ptosis | Dysphagia with liquids + solids
421
What would be a typical history of someone with globus hystericus?
Hx anxiety Sx intermittent + relieved by swallowing Usually painless
422
What is a good way to image oesophageal motility disorders?
Barium swallow
423
What study may be used in the investigation of GORD/achalasia?
pH and manometry studies
424
What are neurological causes of dysphagia?
``` CVA PD MS Brainstem pathology Myasthenia gravis ```
425
What is the classical triad of symptoms experienced in intestinal angina?
Severe, colicky, post-prandial abdominal pain Wt loss Abdominal bruit
426
What is the commonest cause of intestinal angina?
Atherosclerotic disease in the arteries supplying the GIT
427
What is the most common cause of HCC (hepatocellular carcinoma) worldwide?
Chronic Hep B
428
What is the most common cause of HCC (hepatocellular carcinoma) in Europe?
Chronic Hep C
429
What is the main risk factor for HCC?
Liver cirrhosis, e.g. secondary to hep B/C, alcohol, haemachromatosis, PBC
430
What are other RFs for HCC?
``` Alpha-1-antitrypsin deficiency Hereditary tyrosinosis Glycogen storage disease Aflatoxin COCP, anabolic steroids Pophyria cutanea tarda Male DM, metabolic syndrome ```
431
Does HCC tend to present early or late?
Late
432
What are the features of HCC?
Features of liver cirrhosis/failure | May present as a decompensation in pt with chronic liver disease
433
What are features of liver cirrhosis/failure?
Jaundice, ascites, RUQ pain, hepatomegaly, pruritus, splenomegaly
434
What screening is done for high risk groups for HCC?
USS +/- AFP
435
What groups are considered at high risk of HCC?
Pts with liver cirrhosis secondary to hep B and C/haemachromatosis Men with liver cirrhosis secondary to alcohol
436
What are management options for HCC?
``` Early disease - resection Liver Tx Radiofrequency ablation Transarterial chemoembolisation Sorafenib (multikinase inhibitor) ```
437
What is AFP more used for in HCC?
To monitor for recurrence
438
What are the criteria for a mild flare of UC?
<4 stools a day w/wo blood No systemic disturbance Normal ESR/CRP
439
What are the criteria for a moderate flare of UC?
4-6 stools a day | Minimal systemic disturbance
440
What are the criteria for a severe flare of UC?
>6 bloody stools a day Systemic disturbance, e.g. fever, tachycardia, abdominal tenderness, distension, reduced bowel sounds, anaemia, hypoalbuminaemia
441
What is the pattern of inheritance of haemochromatosis?
AR
442
What is haemachromatosis?
Disorder of iron absorption and metabolism leading to iron accumulation
443
Where is the mutation in haemochromatosis?
HFE gene on both copies of chromosome 6
444
How should you screen for haemochromatosis in the general population?
Transferrin saturation + ferritin (but ferritin usually normal in early stages)
445
How should you screen for haemochromatosis in those with affected family members?
Genetic testing for HFE mutation
446
What are the diagnostic tests for haemachromatosis?
MOlecular genetic testing for C282Y and H63D mutations | Liver biopsy - Perl's stain
447
What is the typical iron study profile in a pt with haemochromatosis?
Transferrin saturation > 55% in men or > 50% in women Raised ferritin (e.g. > 500 ug/l) and iron Low TIBC
448
What is the first line treatment of haemachromatosis?
Venesection
449
How should people with haemochromatosis on venesection monitor their treatment?
Transferrin sat should be kept below 50% | Serum ferritin conc below 50microg/L
450
What might you see if you X-ray the joints of someone with haemochromatosis?
Chrondocalcinosis
451
Is h. pylori gram positive or negative?
Negative
452
What is h. pylori principally associated with?
Peptic ulcer disease
453
Is h. pylori infection associated with duodenal or gastric ulcers more?
Duodenal
454
What other associations does h. pylori have?
Gastric cancer B cell lymphoma of MALT tissue Atrophic gastritis
455
How do you eradicate h. pylori?
PPI + amoxicillin + clarithromycin OR PPI + metronidazole + clarithromycin
456
How is the cause of ascites categorised?
SAAG <11g/L or >11g/L
457
What does a SAAG >11g/L indicate in ascites?
Portal hypertension
458
What are causes of ascites with a SAAG <11g/L?
``` Cirrhosis Alcoholic hepatitis Cardiac ascites Mixed ascites Massive liver mets Fulminant hepatic failure Budd-Chiairi syndrome Portal vein thrombosis Veno-occlusive disease Myxoedema Fatty liver of pregnancy ```
459
What are causes of ascites with a SAAG >11g/L?
``` Peritoneal carcinomatosis Tuberculous peritonitis Pancreatic ascites Bowel obstruction Biliary ascites Post-op lymphatic leak Serositis in connective tissue diseases ```
460
How do you manage ascites?
``` Reduce dietary Na ?Fluid restrict Aldosterone antagonist, e.g. spirnolactone +/- loop diuretic ?Drainage Prophylactic antibiotic TIPS in some patients ```
461
What patients with ascites may need to fluid restrict?
If the sodium is <125mmol/L
462
What kind of ascites may you need to drain?
Tense ascites
463
What 'cover' does large volume paracentesis require?
Albumin to reduce risk of paracentesis induced circulatory dysfunction
464
What can paracentesis induced circulatory dysfunction cause?
Hepatorenal syndrome, dilutional hyponatraemia | There is a high mortality rate
465
Why do you offer patients with ascites prophylactic antibiotics?
To reduce risk of spontaneous bacterial peritonitis
466
What does TIPS stand for?
Transjugular intrahepatic portosystemic shunt
467
What is alcoholic ketoacidosis?
Non-diabetic euglycaemic form of ketoacidosis that occurs in people who drink large volumes of alcohol
468
Why can alcoholics go into ketoacidosis?
Often alcoholics will not eat regularly + vomit food --> periods of starvation Once they become malnourished, after an alcohol binge the body breaks down fat producing ketones
469
What do you see on ABG in a alcoholic ketoacidosis?
Elevated anion gap metabolic acidosis
470
What do you see on testing the blood/urine of someone in an alcoholic ketoacidosis?
Elevated serum ketones | Normal/low glucose conc.
471
How is alcoholic ketoacidosis managed?
Infusion of saline + thiamine
472
Why are patients with alcoholic ketoacidosis given thiamine?
To prevent Wernicke's/Korsakoffs
473
Lists drugs that are toxic to the liver
``` Paracetamol Na valproate, phenytoin MAOIs Halothane Anti-TB antibiotics Statins Alcohol Amiodarone Methyldopa Nitrofuratoin ```
474
What drugs can cause cholestasis (+/- hepatitis)?
COCP Antibiotics - flucloxacillin, co-amoxiclav, erythromycin Anabolic steroids, testosterones Phenothiazines: chlorpromazine, prochlorperazine SUs Fibrates Nifedipine
475
What drugs are linked with liver cirrhosis?
Methotrexate Methyldopa Amiodarone
476
What tests can be used to test for H. pylori infection?
``` Urea breath test Rapid urease test (CLO test) Serum antibody Culture of gastric biopsy Gastric biopsy Stool antigen test ```
477
The urea breath test involves drinking what?
Urea with carbon isotope 13
478
Why does the urea breath test work?
Urea is broken down by H. pylori
479
What are the four regions of the stomach?
Fundus Cardia Body Pylorus
480
What are the two parts of the pylorus?
Antrum | Pyloric canal
481
What are the four layers of the stomach?
Mucosa Submucosa Muscularis Serosa
482
What are the three layers of the mucosa of the stomach?
Epithelial layer Lamina propria Muscularis mucosa
483
What does the epithelial layer of the stomach do?
Absorbs and secretes mucus and digestive enzymes
484
What does the lamina propria of the stomach contain?
Blood + lymph vessels
485
The epithelium of the stomach extends down into the lamina propria to create what?
Gastric pits
486
What do the foveolar cells in the stomach produce?
Mucus
487
What is the role of mucus lining the epithelium of the stomach?
Protects it from digestive enzymes and hydrochloric enzymes
488
What do parietal cells secrete?
HCl | Intrinsic factor
489
What do chief cells in the stomach secrete?
Pepsinogen to help digest proteins
490
What do G cells in the stomach secrete?
Gastrin
491
How does h. pylori protect itself from the harsh acidic environment of the stomach?
It has urease an enzyme which breaks urea down into CO2 and ammonia which can neutralise the stomach acid
492
What symptoms might someone with a H. pylori infection get?
Usually asymptomatic Heartburn, SoB, loss of apetite, pain in abdomen Chronic infection --> chronic anaemia (bacteria eat iron)
493
How is a urea breath test conducted?
Patient consumes urea with carbon isotope 13 After 30m exhales into gas tube Mass spectrometry analysis calculates amount of 13C CO2
494
When can a urea breath test not be conducted?
Within 4 weeks of an antibiotic/anti-secretory drug, e.g. PPI
495
What is the only test to check for h. pylori eradication?
Urea breath test
496
How does a rapid urease test work?
Biopsy sample mixed with urea + pH indicator | Colour change if H. pylori urease activity
497
How is coeliac disease diagnosed?
Immunological tests + duodenal biopsy
498
Does vilous atrophy/immunology reverse on a gluten free diet in coeliac disease?
Yes | Patients should be asked to reintroduce gluten 6 w before testing
499
What is the first choice immunological test for coeliac disease?
Serum TTG and IgA
500
What other immunological tests might you do in coeliac disease?
Endomyseal antibody (IgA) - needed to look for selective IgA deficiency which would given false negative coeliac result
501
What do you see on duodenal biopsy in coeliac disease?
Villous atrophy Crypt hyperplasia Increase in intraepithelial lymphocytes Lamina propria infiltration with lymphocytes
502
What are early symptoms of haemochromatosis?
Fatigue Erectile dysfunction Arthalgia (often hands)
503
What are later features of haemochromatosis?
Bronze skin pigmentation DM Liver - stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition Cardiac failure (2ndary to dilated cardiomyopathy) Hypogonadism (2ndary to cirrhosis and pituitary dysfunction)
504
What features of haemochromatosis are reversible with treatment?
Liver cirrhosis DM Hypogonadotrophic hypogonadism Arthropathy
505
Define GORD
Symptoms of oesophagitis secondary to refluxed gastric contents
506
How should endoscopically proven oesophagitis be treated?
Full dose PPI 1-2m If response - low dose Rx as req. No response double PPI for 1m
507
How should endoscopically negative reflux disease be treated?
Full dose PPI 1m If response offer low dose Rx possuble as req. No response - H2RA or prokinetic for 1m
508
What are complications of GORD?
``` Oeosphagitis Ulcers Anaemia Benign strictures Barrett's oesophagus Oesophageal carcinoma ```
509
What heart problems does carcinoid syndrome cause?
Pulmonary stensis | Tricuspid insufficiency
510
What is Zollinger-Ellison syndrome?
Condition characterised by excessive levels of gastrin, usually from a gastrin secreting tumour in the duodenum/pancreas
511
What condition is associated with Zollinger-Ellison syndrome?
MEN 1
512
What are the features of Zollinger-Ellison syndrome?
Multiple duodenal ulcers Diarrhoea Malabsorption
513
What is the best screening test for Zollinger-Ellison syndrome?
Fasting gastrin levels
514
What other test can you do to diagnose Zollinger-Ellison syndrome?
Secretin stimulation test
515
What drug is used to control the symptoms of Zollinger-Ellison syndrome?
PPIs
516
What are the features of MEN 1?
Hyperparathyroidism Pituitary adenomas Pancreatic tumours - insulinomas, gastrinoma Also - adrenal/thyroid tumours
517
What is the action of the hormone gastrin?
Stimulates secretion of HCl by parietal cells | Aids in gastric motility
518
What is small bowel bacterial overgrowth syndrome?
Disorder characterised by excessive amounts of bacteria in teh small bowel --> GI symptoms
519
What are risk factors for SBBOS?
Neonates with congenital GI abnormalities Scleroderma DM
520
What are the features of SBBOS?
Chronic diarrhoea Bloating, flatulence Abdominal pain
521
What tests are used to diagnose SBBOS?
Hydrogen breath test Small bowel aspiration + culture Trail of antibiotics
522
How do you manage SBBOS?
Correct underlying disorder | Antibiotics - rifaximin (alt: co-amoxiclav, metronidazole)
523
What group of drugs are first line to treat pain in IBS?
Antispasmodics
524
What group of drugs are first line to treat constipation in IBS?
Laxatives
525
What laxative should you avoid in IBS?
Lactulose
526
What drug is first line to treat diarrhoea in IBS?
Loperamide
527
If IBS patients are not responding to conventional laxatives what can you try?
Linaclotide (consider if optimal/max dose of prev. laxatives from diff classes haven't worked or if they have had constipation >12m)
528
What other group of drugs may be useful (2nd line) in the treatment of IBS?
Low dose TCAs
529
What psychological therapies may be useful in IBS?
CBT, hypnotherapy, psychological therapy
530
What IBS patients might you consider referring for psychological therapies?
Those not responding to pharmacological therapy after 12m and who develop a continuing symptom profile
531
What advice should you give re eating habits to someone with IBS?
Have regular meals Take time to eat Avoid missing meals/having long gaps between eating Limit high fibre foods Reduce intake of resistant starch (found in processed foods) Limit fresh fruit to 3 portions/day Increase intake oats/linseeds
532
What advice should you give re drinking habits to someone with IBS?
At least 8 cups fluid/day Restrict tea/coffee to 3 cups/day Reduce alcohol and fizzy drink intake
533
For those with IBS-d what product should you advise them to avoid?
Sorbitol
534
Is ferritin raised or decreased in inflammatory disorders?
Raised
535
What kind of anaemia do you get in anaemia of chronic disease?
Normochromic/hypochromic normocytic anaemia Reduced TIBC Normal/raised ferritin
536
What is the recommended treatment of severe alcoholic hepatitis?
Prednisone 40mg
537
What are common causes of liver cirrhosis?
Alcoholism NAFLD Viral hepatitis (B and C)
538
How did we used to diagnose cirrhosis?
Liver biopsy
539
How is liver cirrhosis usually diagnosed now?
Transient elastography or acoustic radiation force impulse imaging
540
What is the brand name for transient elastography?
FibroScan
541
What does a fibroscan involve?
50MHz wave passed into liver from small transducer on end of a USS probe Measures stiffness of liver which is a proxy for fibrosis
542
Who should be offered a fibroscan?
People with Hep C infection Men drinking >50 units/wk, women drinking >35units/week for several months People diagnosed with ARLD
543
What investigations should be done in those diagnosed with cirrhosis?
At time of diagnosis - UGIE to check for varices | Liver USS every 6m (+/- AFP) to check for hepatocellular cancer
544
What are RFs for peptic ulcers?
H. pylori infection Drugs - NSAIDs, SSRIs, corticosteroids, bisphosphonates Zollinger-Ellison syndrome
545
What are features of peptic ulcers common to both gastric and duodenal ulcers?
Epigastric pain | Nausea
546
What are features specific to gastric ulcers?
Epigastric pain worsened by eating
547
What are features specific to duodenal ulcers?
Epigastric pain when hungry and relieved by eating
548
What investigation should you do in peptic ulcer disease?
Urea breath test/stool antigen test to check for h. pylori
549
How do you manage peptic ulcer disease?
H. pylori +ve --> H. pylori erradication therapy H. pylori -ve --> PPIs until ulcer has healed
550
Is there any benefit from differentiating gastric ulcers from duodenal ulcers?
Yes, gastric ulcers are more likely to be malignant
551
What is the incubation period of Hep A?
2-4 weeks
552
What is a typical hx of hep A infection?
Flu like prodrome Nausea, arthalgia Can progress to hepatosplenomegaly + jaundice Seafood consumption
553
How is hep A spread?
Faecal oral
554
What kind of virus is hep D?
Single stranded RNA virus
555
How is hep D transmitted?
Parenterally
556
What does D require to complete its replication + transmission cyle
Hep B surface antigen
557
In relation to hep D terminology: | What does co-infection mean?
Hep B and D infection at the same time
558
In relation to hep D terminology: | What does superinfection mean?
Hep B surface antigen +ve patient subsequently develops a hep D infection
559
What is Hep D superinfection associated with?
High risk of fulminant hepatitis, chronic hepatitis status and cirrhosis
560
How do you diagnose a hep D infection?
Reverse polymerase chain reaction of hep D RNA
561
How do you treat hep D infection?
Interferon
562
What is the characteristic iron study profile in haemochromatosis?
Raised transferrin saturation, and ferritin and low TIBC
563
What is transferrin?
The main protein iron binds to for transport in the blood
564
What is ferritin?
Intracellular storage of iron, with a small amount usually found in blood
565
What is TIBC a measure of?
Available binding sites on transferrin
566
Why is TIBC low in haemochromatosis?
Lots of irons take up the binding sites on transferrin so there is less capacity to bind more
567
What is the recommended alcohol consumption for women?
Do not exceed >14 units a week
568
What is the recommended alcohol consumption for men?
Do not exceed >14 units a week
569
If you decide to drink 14 units a week, what is the recommendation regarding spreading it over a certain no of days?
Spread evenly over 3 days or more
570
What advice is giving to pregnant women re drinking?
Avoid
571
One unit of alcohol is = ____ml pure ethanol.
10
572
How is the strength of an alcoholic drink determined?
Alcohol by volume (ABV)
573
What is 1 unit in spirits?
25ml single measure
574
What is 1 unit in beer?
1/3rd pint
575
What is 1 unit in wine?
Half of a 175ml (standard) glass of red wine *ABV 12%)
576
How can you calculate the number of units in a drink?
No of ml x ABV/1000
577
How is Peutz-Jeghers syndrome inhertied?
AD
578
What is Peutz-Jeghers syndrome characterised by?
Numerous hamartomatous polyps in the GI tract Pigmented freckles on lips, face, palms and soles (Others: intestinal obstruction, e.g. intussception, GI bleeding)
579
Do the polyps in Peutz-Jeghers syndrome have malignant potential?
NO | But 50% of pts will have died of another GI cancer by age 60
580
Mutations in what genes are responsible for Peutz-Jeghers syndrome?
Serine threonine kinase LKB1 or STK11
581
How is Peutz-Jeghers syndrome managed?
Conservatively | Manage complications
582
List indications for an UGIE in GORD
``` Age >55 Symptoms >4w or persistent symptoms despite Rx Dysphagia Relapsing symptoms Wt loss ```
583
If endoscopy in GORD is negative what is the next step?
Consider 24hr oesophageal pH monitor (which is actually the gold standard test for diagnosis)
584
What drugs (if any) should be stopped before an UGIE and why?
PPIs (2w before) so pathology can be identified during the procedure
585
How does cholangiocarcinoma present?
Jaundice, wt loss, pruritus, persistent biliary symptoms
586
What is hepatorenal syndrome?
Thedevelopment of renal failure in those with severe liver disease in the absence of any other identifiable cause of renal pathology
587
What is the pathophysiology of HRS?
Vasoactive mediators --> splanchnic vasodilation --> reduced SVR --> underfilling of hte kidneys Juxtaglomerular apparatus then activates RAAS --> renal constriction which is not enough to counterbalance the effects of splanchnic vasodilation
588
How many types of HRS are there?
2
589
What is type 1 HRS?
Rapidly progresssive Doubling of serum creatinine to >221micromol/L/having creatinine clearance to less than 20ml/min over <2 weeks V poor prognosis
590
What is type 2 HRS?
Slowly progressive | Poor prognosis but pts live for longer
591
What are management options for HRS?
Vasopressin analogues, e.g. terlipressin Volume expansion with 20% albumin TIPS
592
How do vaspressin analogues work in treating HRS?
They cause vasoconstriction of the splanchnic circulation
593
List red flag symptoms for gastric cancer that merit an UGIE
``` New onset dyspepsia in >55y Unexplained persistent vomiting Unexplained wt loss Progressively worsening dysphagia/odynophagia Epigastric pain ```
594
A transjugular intrahepatic portosystemic shunt procedure connects which two vessels?
Portal vein and hepatic vein
595
What is the main aim of a TIPS procedure?
Treat portal hypertension by making a route for blood to flow from the portal to the systemic circulation bypassing the liver
596
How do you manage an acute variceal haemorrhage?
``` ABC Correct clotting (FFP, vit K) Vasoactive agents Prophylactic anibiotics Endoscopy with band ligation Sengstaken Blakemore tube if uncontrolled haemorrhage TIPSS if all above fails ```
597
What vasoactive agent is licensed for variceal haemorrhage?
Terlipressin
598
What prophylactic antibiotics are generally given for variceal haemorrhage?
Quinolones
599
What is involved in the prophylaxis of variceal haemorrhage?
Propanolol | Endoscopic variceal band ligation
600
How should endoscopic variceal band ligation be done?
Every 2 weeks until all varices have been erradicated
601
What drug should be given whilst a patient is getting endoscopic variceal band ligation and why?
PPI cover to reduce risk of EVL-induced ulceration
602
Carcinoid tumours usually produce bradykinin and serotonin. What other hormones can they produce?
Pituitary hormones, e.g. ACTH --> cushingoid features
603
Define increased ferritin level
>300microg/L in men/postmenopausal women | >200microg/L in premenopausal women
604
What is the issue with interpreting a raised ferritin level?
Ferritin is an acute phase protein + may be synthesised in increased quantities in infalmmation
605
How can we split the causes of increased ferritin?
Without iron overload | With iron overload
606
What are causes of increased ferritin without iron overload?
``` Inflammation Alcohol excess Liver disease CKD Malignancy ```
607
What are causes of increased ferritin with iron overload?
Primary iron overload - haemochromatosis | Secondary iron overload - repeated transfusions
608
What is the best test to see whether iron overload is present?
Transferrin saturation
609
What values of transferrin saturation rule out iron overload?
<45% in F | <50% in M
610
What test can be used to differentiate between IBS and IBD in primary care?
Faecal calprotectin
611
Where is calprotectin released from?
Inflamed bowel
612
What does a positive faecal calprotectin mean?
Doesn't indicate definite IBD but patients should be referred to secondary care for further investigation
613
Do c. diff patients need to be isolated?
Yes until the diarrhoea has been resolved for at least 48h
614
What does HBsAg indicate?
First marker to appear Causes production of anti-HBs Implies acute disease (present for 1-6m) If present >6m implies chronic disease
615
What does anti-HBs indicate?
Immunity (either exposure/vaccination)
616
What does anti-HBc indicate?
Previous/current infection IgM anti-HBc appears during acute or recent hep B infection + is present for about 6m IgG anti-HBc persists HBc = Caught
617
What is HbeAg?
Results from breakdown of core antigen in infected liver cells
618
What does HbeAg indicate?
Infectivity
619
Is vitamin B6 water or fat soluble?
Water
620
What is vitamin B6 converted to in the body?
Pyridoxal phosphate (PLP)
621
What is PLP a cofactor for?
Many reactions inclyding transmination, deamination, decarboxylation
622
What are causes of B6 deficiency?
Isoniazid therapy
623
What are consequences of B6 deficiency?
Peripheral neuropathy | Sideroblastic anaemia
624
What drug is usually co-prescribed with isoniazid to prevent B6 deficiency?
Pyridoxine hydrochloride
625
Which vitamin if taken in high doses can be teratogenic?
Vitamin A Pregnant women should be advised to avoid it and foods high in it, e.g. liver
626
Is vitamin A fat or water soluble?
Fat
627
What are the functions of vitamin A?
Converted into retinal, an important visual pigment Important in epithelial cell differentiation Antioxidant
628
When should biologic therapy be considered for treatment of an acute flare of CD?
When symptoms don't improve after 5 days of IV hydrocortisone
629
What biologics may be used in CD?
Anti-TNFa agents, e.g. infliximab or adalimumab
630
All patients with suspected upper GI bleed should have what within 24h of admission?
Endoscopy
631
Which patients with dyspepsia should have an urgent referral (i.e. within 2 weeks) for endoscopy?
Those with: Dysphagia Upper abdominal mass consistent with stomach cancer Those 55+ with wt loss + any of: upper abdominal pain, reflux, dyspepsia
632
Which patients with dyspepsia should have an non-urgent referral for endoscopy?
Those with haematemesis Those 55y+ with treatment resistant dyspepsia or upper abdominal pain with low Hb levels or raised platelet count + any of: N, V, wt loss, reflux, dyspepsia, upper abdominal pain NV + any of: wt loss, reflex, dyspepsia, upper abdominal pain
633
How do you manage patients who don't the criteria for referral for dyspepsia?
Review medications for causes of dyspepsia Lifestyle advice Trail full dose PPI 1m or test + treat for h. pylori
634
What structures do you transverse in a midline incision?
Linea alba, transversalis fascia, extraperitoneal fat, peritoneum
635
What is a paramedial incision?
Parallel to the midline (about 3-4cm)
636
Where is Kocher's incision?
Incision under right subcostal margin
637
What operation uses a Kocher's incision?
Open cholecystectomy
638
Where is a Lanz incision?
Incision in RIF, e.g. for appendiectomy
639
Where is a Gridiron incision?
Oblique incision over McBurneys point (less cosmetically acceptable than Lanz)
640
What is a gable incision?
Rooftop incision
641
Where is a Pfannenstiel incision?
Transverse suprapubic (used for pelvic surgery)
642
Where is a McEvedy's incision?
Groin incision, e.g. for emergency repair of a strangulated femoral hernia
643
Where is a Rutherford Morrison incision?
Extraperitoneal approach to LLQ/RLQ
644
What does a Rutherford Morrison incision give really good access to?
Iliac vessels
645
What is the incision of choice for first time renal transplantation?
Rutherford Morrison incision
646
What kin of incision is used for a pancreatectomy?
Rooftop
647
What kind of incision is used for an emergency c-section?
Pfannensteil
648
What would your investigations in CD show?
Raised inflammatory markers Increased faecal calprotectin Anaemia Low vit B12 and vitamin D
649
What is the most common symptom of CD in kids?
Abdominal pain
650
What is the most common symptom of CD in adults?
Diarrhoea
651
What is the most common type of gallstone?
Mixed
652
What is the most common cause of a CBD stone in the western world?
Migration
653
What are the classical symptoms of gallstones ('biliary colic')?
Colicky RUQ pain occuring post-prandially | Worse following fatty meals
654
Why is the pain of gallstones worse following a fatty meal?
Cholecystokinin levels are higher so gallbladder contraction is maximal
655
What is the diagnostic work up of gallstones?
Abdominal USS | LFTs
656
What imaging should be done for suspected CBD stone?
MRCP and intraoperative imaging
657
How is biliary colic managed?
If imaging shows gallstones --> laparoscopic cholecystectomy
658
What is a typical presentation of acute cholecystitis?
RUQ pain Fever Murphys sign May have derranged LFTs
659
How is acute cholecystitis managed?
USS imaging and cholecystectomy (within 48h presentation)
660
How does a gallbladder abscess tend to present?
Prodromal illness RUQ pain Swinging pyrexia Systemically unwell
661
How should you image a suspected gallbladder abscess?
USS +/- CT
662
How is a gallbladder abscess managed?
Subtotal cholecystectomy may be req. if Calot's triangle is hostile If unfit - percutaneous drainage may be considered
663
What is cholangitis?
Infection of the biliary tree
664
How does cholangitis tend to present?
Patient septic and v. unwell Jaundice RUQ pain
665
How is cholangitis managed?
Fluid resus Broad spectrum IV antibiotics Correct coagulopathies Early ERCP
666
How is gallstone ileus managed?
Laparotomy, removal of gallstone from small bowel | Do not interfere with fistula between duodenum and gallbladder
667
What is acalculous cholecystitis?
Inflammation of the gallbladder without gallstones/cystic duct obstruction
668
Who does acalculous cholecystitis tend to occur in?
Those with intercurrent illness, e.g. DM, organ failure
669
How should acalculous cholecystitis be managed?
Fit - cholecystectomy | Unfit - percutaneous cholecystostomy (drainage of gallbladder)
670
Should asymptomatic gallbladder stones be treated?
No
671
Should asymptomatic stones in the CBD be managed?
Consider it as there is a risk of cholangitis/pancreatitis
672
How should you treat symptomatic gallstones?
Cholecystectomy via laparoscopic route
673
In a very frail patient with symptomatic gallstones what other treatment should be considered?
US guided cholecystostomy
674
What are risks of ERCP?
Bleeding Duodenal perforation Cholangitis Pancreatitis
675
What are RFs for developing gallstones?
``` Increasing age Family history Sudden wt loss Loss of bile salts, e.g. ileal resection/terminal ileitis DM Oral contraception ```
676
What are opioid agonist antidiarrhoea agents?
Loperamide | Diphenoxylate
677
How does loperamide work in treating diarrhoea?
u-opioid receptor agonist which does not have systemic effects as it is not absorbed through the gut It reduces peristalsis of the intestines
678
What is the initial investigation that should be done in a case of suspected gallstones?
USS
679
What does type 1 HRS typically follow?
An acute event, e.g. upper GI bleed
680
What is type 2 HRS generalyl associated with?
Refractory ascites
681
What do you typically see on a plain AXR in gallstone ileus?
Small bowel obstruction and air in the biliary tree
682
Achalasia increases the risk of SCC or adenocarcinoma of hte oesophagus?
SCC
683
Barrett's/GORD increases the risk of SSC or adenocarcinoma of the oesophagus?
Adenocarcinoma
684
What sections of the oesophagus are associated with adenocarcinoma + what sections are associated with SCC?
Upper 2/3rd --> SCC | Lower 1/3rd --> adenocarcinoma
685
What is acute liver failure?
Rapid onset of hepatocellular dsyfunction leading to a variety of systemic complications
686
What are causes of acute liver failure?
Paracetamol OD Alcohol Viral hep (usually A or B) Acute fatty liver of pregnancy
687
What are the features of acute liver failure?
``` Jaundice Fetor hepaticus (sweet faecal breath) Coagulopathy (prolonged PT) Hypoalbuminaemia Hepatic encephalopathy Renal failure (HRS) ```
688
What is the commonest causes of acute liver failure in the UK?
Paracetamol OD
689
What is haematochezia?
Passage of fresh blood per rectum | Usually occurs in a lower GI bleed
690
What 2 scores are used to assess the severity of liver cirrhosis?
Child-Pugh | MELD (Model for End-Stage Liver Disease)
691
What parameters does the Child-Pugh score take into account?
``` Bilirubin Albumin PT prolonged by Encephalopathy Ascites ```
692
How are Child-Pugh scores graded?
A, B or C based on summation of scores
693
What is Child-Pugh score A?
<7
694
What is Child-Pugh score B?
7-9
695
What is Child-Pugh score C?
>9
696
What factors does MELD take into account?
Bilirubin, creatinine, INR | It uses a formula to predict create a score that correlates with mortality
697
What is a typical history of traveller's diarrhoea?
Diarrhoea, abdominal cramps, nausea following travel
698
What is the most common cause of traveller's diarrhoea?
Enterotoxigenic E. coli
699
Should PPIs be given in an acute GI bleed prior to endoscopy?
No as they can mask the site of leeding
700
How is coeliac disease managed?
Gluten free diet
701
What foods contain gluten?
Wheat - bread, pasta, pastry Beer Rye Oats
702
What are good carbs for coeliac patients to eat that are gluten free?
Potatoes Corn Rice
703
What blood test can be used to check compliance with a gluten free diet in coeliac disease?
Tissue transglutaminase (TTG)
704
Why do patients with coeliac disease require extra vaccinations?
They have a degree of functional hyposplenism
705
What vaccines are those with coeliac disease advised to recieve?
Pneumococcal vaccine with booster every 5 years | Annual flu vaccine
706
What is the gold standard procedure for diagnosing PSC?
MRCP | ERCP only if unable to tolerate MRI e.g. metal implants
707
When should a diagnosis of IBS be suspected?
In a patient with the following for at least 6 months: - Ab pain +/or - Bloating +/or - Change in bowel habit
708
When should a positive diagnosis of IBS be made?
If patient has abdominal pain relieved by defaecation or associated with altered bowel frequency or stool form + 2 of: - Altered stool passage (straining, urgency, incomplete evacuation)
709
When should a positive diagnosis of IBS be made?
If patient has abdominal pain relieved by defaecation or associated with altered bowel frequency or stool form + 2 of: - Altered stool passage (straining, urgency, incomplete evacuation) - Ab bloating, distension, tension, hardness - Symptoms made worse by eating - Passage of mucus
710
What are red flag symptoms in IBS that should be enquired about?
Rectal bleeding Unexplained/unintentioanl wt loss FH of bowel/ovarian cancer Onset >60y
711
What are suggested primary are investigations for suspected IBS?
FBC ESR/CRP Coeliac disease screen (TTG Abs + IgA)
712
Which of UC and CD carry a higher risk of colorectal cancer?
UC
713
Which of UC and CD carry a higher risk of obstruction and fistula formation?
CD
714
In which of UC and CD do you see increased goblet cells?
CD
715
In which of UC and CD do you more commonly see crypt abscesses?
UC
716
In which of UC and CD do you more commonly see granulomas?
CD
717
What do you see on endoscopy in CD?
Deep ulcers | Skip lesions - cobblestone appearance
718
What do you see on endoscopy in UC?
Widespread ulceration with preservation of adjacent mucosa --> pseudopolyps
719
What do you see on small bowel enema in CD?
Strictures --> Kantor's string sign Proximal bowel dilatation Rose thorn ulcers Fistulae
720
What do you see on barium enema in UC?
Loss of haustrations Pseudopolyps Long standing disease - colon is narrow + short (drainpipe colon)
721
What is the second most common causative organism causing SBP?
Klebsiella
722
What organisms commonly cause a gram positive SBP?
Strep pneumoniae Strep viridians Staph
723
What is PBC?
Chronic disease of the small intrahepatic bile ducts that is characterised by progressive bile duct damage, cholestasis and may eventually lead to cirrhosis
724
What is the aetiology of PBC?
Autoimmune
725
Who is PBC typically seen in?
Middle aged women
726
What is the classical presentation of PBC?
Itching in a middle aged woman
727
What are some early features of PBC?
May be asymptomatic (e.g. raised ALP on routine LFTs) | Or fatigue, pruritus
728
What are some later features of PBC?
``` Cholestatic jaundice Hyperpigmentation, esp. over pressure joints May have RUQ pain Xanthelasmas, xanthomata Clubbing, hepatomegaly ```
729
What are complications of PBC?
Malabsorption - osteomalacia, coagulopathy Sicca syndrome Portal HTN - ascites, variceal haemorrhage Hepatocellular cancer
730
By how much does PBC increase your risk of hepatocellular cancer?
20x
731
What conditions is PBC associated with?
Sjogren's syndrome (80%) RA Systemic sclerosis Thyroid disease
732
What factors are used to help diagnose PBC?
AMA M2 subtype present in 98% SMA Raised serum IgM
733
What drug is used to help itching in PBC?
Cholestyramine
734
Apart from cholestyramine, what else is involved in the management of PBC?
Fat soluble vit supplements Ursodeoxycholic acid Liver transplant, e.g. if bilirubin >100
735
Name 3 aminosalicylate drugs
Sulphasalazine Mesalazine Olsalazine
736
Where is 5ASA released from in the body and what is its action?
The colon | It is not absorbed but it has anti-inflammatory actions (may inhibit prostaglandin synthesis)
737
What is sulphasalazine a combination of?
Sulphapyridine (a sulphonamide) and 5ASA
738
What are SEs of sulphasalazine?
``` Rashes Oligospermia Headache Heinz body anaemia Megaloblastic anaemia Lung fibrosis + SEs of mesalazine ```
739
What is mesalazine?
Delayed release form of 5ASA
740
What are the SEs of mesalazine?
GI upset, headache, agranulocytosis, pancreatitis, interstitial nephritis
741
What is the structure of olsalazine?
2 molecules of 5ASA linked by a diazo bond which is broken by colonic bacteria
742
Is pancreatitic more common in mesalazine or sulphasalazine?
Mesalazine
743
What is the first line serological test for coeliac disease?
TTG Abs
744
What are infective causes of acute abdomen?
``` Gastroenteritis Appendicitis Diverticulitis Pyelonephritis Cholecystitis Cholangitis PID Hepatitis Pneumonia ```
745
What are inflammatory causes of acute abdomen?
Pancreatitis | Peptic ulcer disease
746
What are vascular causes of acute abdomen?
Ruptured abdominal aortic aneurysm Mesenteric ischaemia MI
747
What are traumatic causes of acute abdomen?
``` Ruptured spleen Perforated viscus (e.g. oesophagus, stomach, bowel) ```
748
What are metabolic causes of acute abdomen?
Renal/ureteric stone | DKA
749
How can you differentiate biliary colic from acute cholecystitis?
No fever | Normal inflammatory markers
750
What is acute cholecystitis?
Inflammation/infection of the gallbladder secondary to impacted gallstones
751
What is Murphy's sign?
Arrest of inspiration on palpation of the RUQ
752
Where is the pain in biliary colic?
RUQ
753
Where is the pain in acute cholecystitis?
RUQ
754
What is ascending cholangitis?
Bacterial infection of the biliary tree
755
What is the most common predisposing factor for ascending cholangitis?
Gallstones
756
What triad of symptoms do you see in ascending cholangitis?
Charcot's triad: RUQ pain Fever Jaundice
757
What are the two most common causes of acute pancreatitis?
Alcohol, gallstones
758
Where is the pain in acute cholangitis?
RUQ
759
Where is the pain of acute pancreatitis?
Epigastrium May radiate through to back Very severe!!
760
What do you often see on examination in acute pancreatitis?
Tenderness, ileus and low grade fever
761
Where is the pain in acute diverticulitis? What is the character of the pain in acute diverticulitis?
Colicky LLQ
762
What do you see on the bloods in acute diverticulitis?
Raised inflammatory markers and WCC
763
Apart from pain what are other symptoms of diverticulitis?
Fever | Diarrhoea (sometimes bloody)
764
Where is the pain of intestinal obstruction?
Central
765
What might you hear if you listened to the abdomen of someone with intestinal obstruction?
Tinkering bowel sounds
766
What are features of bowel obstruction?
Absolute constipation | Vomiting
767
What are urological causes of acute abdomen?
Renal colic Acute pyelonephritis Urinary retention
768
Where is the pain of renal colic? What is the character of the pain?
Loin to groin pain | Intermittent but severe
769
What other feature may you see (despite the pain) in renal colic?
Visible/non-visible haematuria
770
Where is the pain of acute pyelonephritis?
Loin pain
771
What are the features of acute pyelonephritis?
Fever, rigors, vomiting | Loin pain
772
Where is the pain from urinary retention?
Suprapubic
773
What should all women of reproductive age who present with abdominal pain be considered until proven otherwise?
Pregnant
774
Where is the pain of an ectopic pregnancy?
R or LIF
775
How does ectopic pregnancy typically present?
Pain + Hx of amenorrhoea for past 6-9 weeks | Vaginal bleeding may be present
776
What are vascular causes of acute abdomen?
Ruptured AAA | Mesenteric ischaemia
777
Where is the pain in ruptured AAA?
Central abdominal radiating to the back
778
How can ruptured AAA present?
Sudden collapse or persistent central abdominal pain with developing shock (hypotension, tachycardic) Hx CVdx
779
Where is the pain of mesenteric ischaemia?
Central
780
What are other features of mesenteric ischaemia?
Hx AF/CVdx Diarrhoea, rectal bleeding may be seen Metabolic acidosis due to dying tissue
781
When should you diagnose toxic megacolon?
When the transverse colon is >6cm diameter and the patient is systemically unwell
782
How is toxic megacolon managed?
Aggressive medical therapy for 24-72h, if no signs of improvement then colectomy
783
Which of UC or CD is more likely to have a palpable mass in the RIF?
CD
784
What should be used instead of ferritin as a marker of iron stored in the body during an acute infection?
Transferrin saturation
785
What is the first line treatment for NAFLD?
Weight loss
786
What part of the bowel is most affected by UC?
Rectum
787
What is the most sensitive and specific lab finding for diagnosing liver cirrhosis in those with chronic liver disease?
Thrombocytopenia
788
What examination should you always do in a male with acute abdomen and why?
Scrotal examination to rule out testicular problems, e.g. torsion
789
What features of a c. diff infection would indicate it is severe and hence requires treatment first line with vancomycin?
ITU admission Shock WCC >15 Acutely rising blood creatinine (e.g. >50% increase above baseline) Temperature >38.5°C Evidence of severe colitis (abdominal signs, radiology)
790
Who should be offered serological testing for coeliac disease?
Persistent unexplained abominal/GI symptoms Faltering growth Prolonged fatigue Unexplained wt loss Severe/persistent mouth ulcers Unexplained iron, vit B12, folate deficiency T1DM at diagnosis Autoimmune thyroid disease at diagnosis IBS in adults First degree relatives of those with coeliac disease
791
From what vertebral level does the IMA arise from?
L3
792
Where does the IMA supply?
Hindgut
793
What is a typical history of acute fatty liver of pregnancy?
Jaundice following abdominal pain and pruritus in pregnancy
794
What is the normal LFT pattern in hepatocellular disease?
ALT raised at least 2x ALP normal ALP/ALP 5+ normal
795
What is the normal LFT pattern in cholestatic disease?
ALT normal ALP raised at least 2x ALP/ALP <2
796
What is the normal LFT pattern in mixed disease?
ALT and ALP raised at least 2x | ALT/ALP 2-5
797
What triad of symptoms are seen in acute liver failure?
Encephalopathy Jaundice Coagulopathy
798
What is ischaemic hepatitis?
Diffuse hepatic injury resulting from acute hypoperfusion (liver shock)
799
How do you diagnose ischaemic hepatitis?
In the presence of an initiating event (e.g. cardiac arrest) + marked increases in aminotransferase levels
800
What does ischaemic hepatitis often occur in conjuction with?
AKI (tubular necrosis) or other end organ dysfunction
801
Bilirubin is a breakdown product of what?
Heme
802
Describe how heme --> bilirubin
Heme is processed in macrophages and oxidised to form biliverdin + iron Biliverdin reduced to form unconjugated bilirubin which enters the blood stream
803
What is UC bilirubin carried by in the blood? Where does it end up?
Albumin | Hepatocytes
804
Where is UC bilirubin conjugated?
Hepatocytes
805
What is the key difference between conjugated and unconjugated bilirubin?
Conjugated bilirubin is water soluble unconjugated is not

GI (8 decks)

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