GIT Flashcards
1
Q
What is the referral criteria for non-urgent direct access for endoscopy to investigate for oesophageal/stomach cancer?
A
> 55 with treatment resistant dyspepsia (chronic GORD) but are H.Pyori -ve.
2
Q
What is the criteria for an urgent referral (2WW) for an endoscopy to investigate for oesophageal/stomach cancer?
A
Dysphagia OR >55 with weight loss and one of the following: upper abdo pain, reflux, dyspepsia.
3
Q
Barrett’s oesophagus is metaplasia of what cells? What is this caused by?
A
squamous epithelium transforms into columnar epithelium alongside presence of goblet cells.
Caused by chronic GORD.
4
Q
What does Barrett’s oesophagus put someone at increased risk of? How do we manage high grade dysplasia?
A
- Adenocarcinoma in the distal 1/3 of the oesophagus
- High grade can be managed with endoscopic ablation
5
Q
A patient >50 with an extensive smoking history and a PMHx of Barrett’s oesophagus presenting with weight loss and worsening dysphagia is likely what?
A
Adenocarcinoma of the oesophagus.
6
Q
What is the most common malignancy of the oesophagus? What are common risk factors?
A
SCC (often upper 2/3).
RFs: excessive smoking and drinking, and HPV
7
Q
What is Plummer-Vinson Syndrome? How might it present? What is it a RF for?
A
- Triad of post cricoid dysphagia, iron deficiency, and upper oesophageal web.
- bulge in neck on swallowing, odynophagia, halitosis, glossitis, angular stomatitis, and pallor.
- RF for SCC
8
Q
Someone with a bleeding gastric ulcer who is -ve for H.Pylori after endoscopy should managed how 6 weeks later?
A
Endoscopy 6-8 weeks later, these are high risk for malignancy.
9
Q
How might someone with a left sided colonic cancer present?
A
- microcytic anaemia
- bowel obstruction (due to firm stool here)
- fresh rectal bleeding
- tenesmus
- mass in the LIF/rectum
10
Q
How might someone with a right sided bowel cancer present?
A
- microcytic anaemia
- occult bleeding
- change in bowel habit
- increased mucus in stool
- weight loss
- DRE clinically normal
11
Q
Ca19-9 is associated with what cancer? How might this present?
A
Pancreatic.
Upper abdo mass, weight loss, painless jaundice.
12
Q
Which strand of HPV is most commonly associated with oropharyngeal cancers?
A
HPV-16
13
Q
What is Zollinger-Ellison Syndrome?
A
Gastrinoma releasing excessive gastrin cause severe ulcerations in stomach and duodenum.
14
Q
What type of colonic adenomas are most likely to become cancerous?
A
Flat colonic adenomas
15
Q
Villous polyps are associated with malignancy where? What electrolyte abnormality are they associated with?
A
Colorectal cancer, hypokalaemia
16
Q
Where does colorectal cancer most commonly metastasize to?
A
Liver because of the portal-venous drainage system.
17
Q
What characteristics are seen on a biopsy of someone with UC?
A
- Surface inflammation: mucosa to submucosa
- goblet cell depletion
- crypt abscesses (containing collections of neutrophils)
- mucin depletion
- mucosal atrophy
- basal plasmacytosis
- continuous disease
18
Q
How do we categorise the severity UC? What are the components of a severe episode?
A
Truelove and Witts criteria.
Severe:
- bowel movements /day ( >6)
- visible blood in stool
- pyrexia (>37.8)
- pulse (>90)
- anaemia (<105)
- ESR (>30)
19
Q
What is 1st line for management of mild-moderate UC?
A
Aminosalicylates (mesalazine, sulfasalazine)
20
Q
What is first line management for severe UC?
A
Steroids
21
Q
What characteristics are seen on biopsy for crohn’s disease?
A
- Deeper inflammation: mucosa to serosa
- goblet cell INCREASE
- granulomas
22
Q
Why might someone with Crohn’s be B12 defficient?
A
Crohn’s is associated with terminal ileitis which is where B12 is absorbed meaning the inflammation prevents efficient absorption.
23
Q
Crohn’s is associated with perianal fistulas due to chronic inflammation in the anal canal. What is gold standard for investigating these?
A
MRI pelvis.
24
Q
What is first line for inducing remission inan acute crohn’s flare?
A
Steroids (predisolone or IV hydrocortisone)
25
What is first line to maintain remission in a flare of crohn's?
Azathioprine or mercaptopurine
26
What is a Hartmann's procedure?
Removal of sigmoid colon and formation of a COLONOSTOMY.
27
How do anal fissures present? How are they managed?
Pain on defecation, fresh blood in bowl and on paper from wiping.
Topical diltiazem (CCN) and topical vasodilator (GTN).
28
How Coeliac disease present?
- N+V
- abdo pain
- diarrhoea
- steatorrhea
- fatigue
- weight loss
- dermatitis herpetiformis (papulovesicular rash on buttocks, arms, legs, abdo)
29
How do you investigate for coeliac disease? What are the findings?
Gold standard is duodenal or jejunal biopsy - villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis, lamina propria inflammation.
Can do serum anti-TTG to help guide diagnosis.
30
What is removed in a Right Hemicolectomy? How can it be extended? Why is it used?
Removal from ileum to hepatic flexure.
Extended = up to splenic flexure.
Used for right sided bowel cancers.
31
What is removed in a left hemi-colectomy?
From splenic flexure to proximal sigmoid.
32
What is removed in...
- AP resection.
- High and Low anterior resecetion.
- AP is sigmoid, rectum, and anus.
- High is sigmoid.
- Low is sigmoid and rectum.
33
What is a panproctocolectony?
Removal of the entire colon, rectum, and anal canal.
Requires formation of an end ileostomy.
34
What is done in a Hartmann's Procedure? Why is it done?
Rectosigmoid removal, closure of anal stump, formation of end colostomy.
More emergent cases e.g., diverticular perforation.
35
Why does D+V cause a raised anion gap metabolic acidosis?
Loss of bicarbonate
36
What is the most common cause of D+V in children?
Rotavirus - causes acute onset of D+V, reduced oral intake, lethargy, etc.
37
What is pseudomembranous colitis? What is it a complication of?
Raised yellow plaques (2-10mm) along mucosa of colon.
Complication of C.Diff.
38
How can we diagnose a H.Pylori infection in:
a) someone presenting with chronic GORD?
b) someone presenting with a gastric or duodenal ulcer?
a) stool sample or carbon13 breath test
b) rapid urease test on gastric biopsy taken from endoscopy
39
How do you manage a H.pylori infection?
- Amoxicillin (metro in penicillin allergic), clarithromycin, PPI for 7 days
- Re-test
- If still present swap clarithromycin for metro and do another 7 days of triple therapy (if pen allergic then do a tetracycline or quinolone)
40
What is Whipple's disease? What are the symptoms?
Tropheryma whipplei infection (gram +ve bacteria) causing D+V, abdo pain, joint pain, malabsorption, and systemic features.
41
How do we diagnose and treat Whipple's disease?
Invx - Jejunal biopsy (positove acid-schiff macrophages invading lamina propria).
Mx - 2-4 weeks of IV abx (ceftriaxone or penicillin).
42
What is 1st line for C.Diff infection? What about in recurrence?
For mild-moderate cases oral vancomycin 125mg QDS.
If it recurs within 12 weeks use oral fidaxomicin 200 mg BD.
43
How does mesenteric adenitis present? What will USS or CT show?
diffuse abdo pain, low-grade fever, and abdo generalised tenderness often following URTI.
USS or CT will show a normal appendix with pronounced lymph nodes.
44
What is the most common causative organism of mesenteric adenitis?
Yersinia enterocolitica
45
What is Cullen's Sign? What is it a sign of?
Bruising around the umbilicus indicating retroperitoneal haemorrhage, may be seen in pancreatitis.
46
What is grey-turner's signs?
Bruising down the flanks, indicating intra-abdominal haemorrhage, may be seen in pancreatitis.
47
How can you differentiate acute from chronic pancreatitis?
Acute: amylase/lipase significantly raised (amylase 3x upper limit)
Chronic: presence of pseudocysts of USS, relapsing episodes, associated with alcohol excess (investigate with faecal elastase).
48
How can you remember the drug causes of pancreatitis?
FATSHEEP
- furosemide
- azathioprine
- thiazides
- sulfasalazine/statins/sodium valproate
- hydrochlorothiazide
- estrogens (COCP)
- ethanol
- protease inhibitors/nucleotide reverse transcriptase inhibitors
49
How can you remember the causes of Pancreatitis?
GET SMASHED
- gallstones
- ethanol
- trauma
- steroids
- mumps
- autoimmune
- scorpion sting
- hypercalcaemia
- ERCP
- drugs
50
How do we measure the severity of pancreatitis?
Glasgow-Imrie Score (PANCREAS)
- paO2<8
- age >55
- neutrophils >15
- calcium <8
- renal function (urea >16)
- enzymes (LDH >600 or AST >200)
- albumin <32
- sugar (BM>10)
Severe = 3 or more (HDU management)
51
What % of pts develop ARDS as a complication of pancreatitis?
10-20% develop ARDS (hypoxia, bilateral lung infiltrates, diffuse alveolar damage, hyaline membrane formation.
52
What is Peutz-jeghers syndrome? What is the complication of them in the GIT?
Hamartomas throughout the body, can cause bowel obstructions when in the GIT.
53
What are Howell-Jolly bodies? What might then indicate?
Nuclear remnants of RBCs, indicate splenic dysfunction, or, absence (present after removal)
54
A pt presenting with RUQ pain and a positive murphy's sign is indicative of what? How is it managed?
Acute cholecystitis - stone blocking the CBD
Abx, fluids, analgesia, may opt to perform a cholecystectomy once sx has settled.
55
What is Charcot's Triad and Reynold's pentad for ascending cholangits? How is it managed?
Triad: RUQ pain, fever, jaundice.
Pentad: triad + hypotension and confusion
IV Abx, fluids, biliary drainage (ERCP stenting, percutaneous drainage, or surgical drainage), and management of underlying cause (gallstones, malignancy, etc)
56
What is Pneumobilia? What does it indicate?
Air within the biliary tree,
Gallstone ileus - Gallstones causing intestinal obstruction.
57
What is Zenker's Diverticulum? How does it present?
Pharyngeal diverticulum:
- Gurgling sound at the back of the throat,
- Halitosis,
- Food regurgitation.
58
How does a hiatal hernia present on CXR? What are the RFs?
Rounded, retrocardiac structure with a gastric bubble.
RFs: Obesity, increased abdominal pressure (chronic cough), and prior hiatal surgery.
59
Someone with a splenectomy are more at risk from which type of organism? Give 3 examples.
Encapsulated bacteria: strep pneumoniae, nessisseria meningitidis, haemophilus influenza.
60
Necrosis and apoptosis in the large bowel caused by chronic senna use is what? What is seenon the biopsy?
Melanosis coli: dark brown discolouration of macrophages in lamina propria of the colon.
61
What are signs of melanosis coli?
Chronic constipation, anorexia, nausea, abdominal discomfort, weight loss
62
What is Hirschsprung's disease? Where do you biopsy for diagnosis?
Congenital abnormality caused by absence of ganglion cells and thick, non-myelinated nerves in the distal colon.
Causes difficulty passing stool.
Biopsy 1.5cm above pectinate line for diagnosis.
63
What is the difference between diverticulosis and diverticulitis?
losis: small out pouches along the colon
litis: becomes symptomatic (lower abdo pain, diarrhoea or constipation, bloating) and bloods show raised inflammatory markers and microcytic anaemia.
64
Why does ileal resection put you at an increased risk of cholecystitis?
Bile salts are reabsorbed in terminal ileum so without this they build up.
65
What is angiodysplasia? How can it be managed?
Dilated, small blood vessels of the mucosa and submucosa in the GIT causing painless, chronic, intermittent, lower GI bleeding leading to anaemia and its sx (fatigue, SOB, weakness).
Managed with interventional colonoscopy (band ligation, embolization, etc)
66
What is 1st line to manage gastroparesis?
Domperidone.
67
What causes gastroparesis? What are the causes?
Delayed gastric emptying caused by impaired activity of the stomach muscles.
Commonly associated with diabetes, others include post-surgical complications, certain medications, and some neurological disorders such as Parkinson's and MS.
68
What is the triad of Boerhaave syndrome? What is it caused by? What is the Hamman sign? Do you get haemoptysis?
Ripping chest pain which radiates to the back, vomiting, and subcutaneous emphysema.
Caused by repeated retching/vomiting.
Hamman sign is a crackling between S1 and S2 which is air in the subcutaneous space.
NOT associated with haemoptysis.
69
What is a Mallory-Weiss tear?
Tear of lower oesophagus causing haemoptysis, due to repeated retching/vomiting.
70
Do GI bleeds cause a high or low urea?
High - gut bacteria breaks down blood causing it to be elevated. Similar can happen in a high protein diet.
71
What is the acute pharmacological management for variceal bleeds? How does it work?
Terlipressin: vasopressin analogue that reduced portal venous pressure by vasoconstricting vessels to reduce bleeding.
72
How do you manage oesophageal variceal bleeds prophylactically?
Beta blockers
73
What is Rigler's sign on abdo XR?
Air on both sides of intestine (luminal and peritoneal) caused by perforation of viscera.
74
Which electrolyte abnormalities are caused by refeeding syndrome?
Hypophosphatemia (cells start to respire again and use up all ATP), hypokalaemia, hypomagnesaemia, hyponatraemia, hyperglycaemia.
75
What are the 4 Ds of pellagra? What is it? How is it managed?
Dementia, diarrhoea, dermatitis, and death of not treated.
Vitamin B3 deficiency - manage with nicotinamide.
76
A pt presenting with acute severe, generalised abdo pain and tenderness, vomiting, and raised lactate should raise suspicion for what?
Acute mesenteric ischaemia.
77
What artery is most commonly affected by acute mesenteric ischaemia?
SMA
78
A pt presenting with acute onset abdo pain, distension, bilious vomiting, tympanic high-pitched bowel sounds, fever and fluid depletion should raise suspicions for what?
SBO - most commonly caused by adhesions.
79
A pt presenting with absolute constipation, cramping, bloating, and vomiting much later on should raise suspicions for what? What is it most commonly caused by?
LBO - caused by malignancies, strictures, volvulus, hernias.
80
What medications can hep to reduce the secretions from GIT in the context of a bowel obstruction to help reduce vomiting?
Buscopan and octreotide can dry up some of the GIT secretions to reduce vomiting.
81
Severe abdo pain, PR bleeding, pyrexia, and tender mass in the LIF is likely what?
Diverticular abscess.
82
What are the signs of GI malabsorption?
Diarrhoea, steatorrhea, and weight loss.
83
What is a sigmoid volvulus? What sign do you get on AXR?
Portion of sigmoid bowel twists/rotates causing an obstruction and interruption of the blood supply.
You get the coffee bean sign of AXR.
84
What happens in toxic megacolon? What do you see by scanning them?
Often a complication of IBD - excessive NO release due to inflammation,
AXR- bowel dilates (>6cm), and you get a loss of haustra.
85
What is Rovsing's Sign?
Pressure on the LIF elicits pain in the RIF - sign of peritonitis.
Could indicate perforated appendicitis.
86
Where is a inguinal hernia located?
Superomedial to the pubic tubercule.
87
Where is a femoral hernia?
Inferolateral to pubic tubercule.
88
Where is a Spigelian hernia?
passes through linea semilunaris, around the rectus abdominis muscle.
89
What is Courvoisier's Sign? What are the exceptions?
Painless jaundice with dilated GB = neoplasm (usually pancreatic or hepatocellular) EXCEPTIONS:
- double impaction (chronic disease meaning stones don’t cause it to dilate because it has fibrosed and cannot dilate)
- when tumour is above common hepatic duct (won’t have a palpable GB).
90
What are the signs of cholecystitis on USS?
- Thickened GB wall
- May get hypoechoic shadows from stones
91
What is the incubation period of salmonella typhi?
24-48 hours
92
What is the incubation period of camplobacter?
48-72 hours
93
What scores can be used to assess a GI bleed?
- Glasgow Blatchford (pre endoscopy)
- Rockall (pre and post endoscopy)
94
What do you see on a jejunal biopsy for Whipple's disease?
Periodic acid-schiff positive macrophages invading lamina propria.
95
What might you see on blood film of someone with coeliac?
Target cells and howell-jolly bodies.
96
How does campylobacter jejuni gram stain?
Gram -ve curved rod, which is +ve for urease and oxidase tests.
97
What complication can occur for up to 6 weeks following giardiasis treatment that can cause diarrhoea, bloating, and flatulence?
Lactose intolerance
98
What is the management for acute pancreatitis?
Aggressive fluid resus (IV crystalloid 4-6 hourly, check fluid balance between bags), supportive management, and address underlying cause.
99
What is the most common surgical management of rectal cancer?
Low anterior resection: removal of rectum and sigmoid with anastomoses of remaining colon to anus.
100
Why can pts with coeliac disease develop nyctalopia (night blindness)?
Less absorption of fat soluble vitamins, including A which results in nyctalopia.
101
What are the signs of a vitamin c deficiency (scurvy)?
- Atraumatic bleeding and bruising
- Gingival hypertrophy
- Teeth loss
- Coiled hairs
102
How does someone with an obturator hernia present?
- Paraesthesia down medial thigh
- Tender mass per rectum
- Small bowel obstruction (abdo distension, pain, N+V)
103
What immune cell mediates the inflammatory autoimmune process in Coeliac Disease?
T cells
104
What is 1st line for giardiasis? What appearance is seen on stool culture?
- Metronidazole PO
- Rose petal appearance
105
How often are patients with Barrett's Oesophagus to attend Surveillance?
- < 3cm and no dysplasia = 3-5 yearly
- > 3cm and no dysplasia = 2-3 yearly
- Low grade dysplasia = 6 monthly
- High grade dysplasia after ablation = 3 monthly up to 1 year then yearly.
106
Which gene mutation is associated with FAP?
APC gene mutation.
107
What is the incubation period for staph aureus gastroenteritis? What foods is it associated with?
1-6 hours.
Dairy products.
108
What is used to treat chronic diarrhoea caused by excessive bile acid after cholecystectomy?
Cholestyramine: binds bile salts to reduce quantity in the GIT which can cause chronic diarrhoea.
109
Which antibiotic is useful for treating peri-anal disease in Crohn's pts?
Metronidazole
110
What are the management steps for someone with suspected diverticular perforation or abcess?
1) Treat for sepsis until confirmed (abx)
2) USS or CT abdo
3) Perforation = Hartmann's/LPL
Abscess = drainage
111
Where around the anal canal are fissures more commonly seen? Why?
Posterior midline as reduced blood supply slows healing.
112
When would you do a 'hot' vs delayed cholecystectomy in cholecystitis?
Hot = <1 week if mild-moderate.
Delayed = after symptoms have cleared in severe (organ dysfunction).
113
