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3rd May 2022 [medicine] > Tuesday [24/5/22] > Flashcards

Tuesday [24/5/22] Flashcards

(100 cards)

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1
Q

What is Budd-Chiari? [1]

A

Budd-Chiari syndrome, or hepatic vein thrombosis, is usually seen in the context of underlying haematological disease or another procoagulant condition.

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2
Q

Causes of Budd-Chiari [4]

A

polycythaemia rubra vera
thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies
pregnancy
combined oral contraceptive pill: accounts for around 20% of cases

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3
Q

Features of Budd-Chiari [3]

A

abdominal pain: sudden onset, severe
ascites → abdominal distension
tender hepatomegaly

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4
Q

Ix for Budd-Chiari [1]

A

ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation

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5
Q

What is carcinoid syndrome? [2]

A

usually occurs when metastases are present in the liver and release serotonin into the systemic circulation
may also occur with lung carcinoid as mediators are not ‘cleared’ by the liver

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6
Q

Features of carcinoid tumours

A

flushing (often earliest symptom)
diarrhoea
bronchospasm
hypotension
right heart valvular stenosis (left heart can be affected in bronchial carcinoid)
other molecules such as ACTH and GHRH may also be secreted resulting in, for example, Cushing’s syndrome
pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour

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7
Q

Ix for carcinoid tumours [2]

A

urinary 5-HIAA

plasma chromogranin A y

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8
Q

Mx for carcinoid tumours [2]

A

somatostatin analogues e.g. octreotide

diarrhoea: cyproheptadine may help

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9
Q

How does cholestyramine work? [2]

A

Cholestyramine is a bile acid sequestrant used in the management of hyperlipidaemia. It decreases bile acid reabsorption in the small intestine, therefore upregulating the amount of cholesterol that is converted to bile acid. The main effect it has on the lipid profile is to reduce LDL cholesterol. It is also occasionally used in Crohn’s disease for treatment diarrhoea following bowel resection

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10
Q

Adverse effects of cholestyramine [4]

A

abdominal cramps and constipation
decreases absorption of fat-soluble vitamins
cholesterol gallstones
may raise level of triglycerides

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11
Q

Type of bug is C. diff

A

Clostridium difficile is a Gram positive rod often encountered in hospital practice.

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12
Q

Pathogenesis of C. diff

A

It produces an exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous colitis. Clostridium difficile develops when the normal gut flora are suppressed by broad-spectrum antibiotics

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13
Q

What typically causes C.diff? [3]

A

Clindamycin is historically associated with causing Clostridium difficile but the aetiology has evolved significantly over the past 10 years. Second and third generation cephalosporins are now the leading cause of Clostridium difficile.

Other than antibiotics, risk factors include:
proton pump inhibitors

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14
Q

Features of C.diff [4]

A 
Features
diarrhoea
abdominal pain
a raised white blood cell count (WCC) is characteristic
if severe toxic megacolon may develop
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15
Q

Mild C.diff [1]

A

Normal WCC

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16
Q

Moderate C.diff [2]

A

↑ WCC ( < 15 x 109/L)

Typically 3-5 loose stools per day

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17
Q

Severe C.diff [3]

A

↑ WCC ( > 15 x 109/L)
or an acutely ↑ creatinine (> 50% above baseline)
or a temperature > 38.5°C
or evidence of severe colitis(abdominal or radiological signs)

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18
Q

Life threatening C.diff [3]

A

Hypotension
Partial or complete ileus
Toxic megacolon, or CT evidence of severe disease

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19
Q

Dx of C.diff [2]

A

is made by detecting Clostridium difficile toxin (CDT) in the stool
Clostridium difficile antigen positivity only shows exposure to the bacteria, rather than current infection [2]

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20
Q

First-line Mx of C.diff [3]

A

First episode of Clostridium difficile infection

  • first-line therapy is oral vancomycin for 10 days
  • second-line therapy: oral fidaxomicin
  • third-line therapy: oral vancomycin +/- IV metronidazole
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21
Q

Recurrent episode of C.diff Mx [3]

A
  • recurrent infection occurs in around 20% of patients, increasing to 50% after their second episode
  • within 12 weeks of symptom resolution: oral fidaxomicin
  • after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin
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22
Q

Life-threatening C.diff Mx [2]

A

oral vancomycin AND IV metronidazole

specialist advice - surgery may be considered

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23
Q

Other therapies for C.diff [3]

A

bezlotoxumab is a monoclonal antibody which targets Clostridium difficile toxin B
NICE do not currently support its use to prevent recurrences as it is not cost-effective
faecal microbiota transplant
may be considered for patients who’ve had 2 or more previous episodes

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24
Q

Coeliac disease is an autoimmune condition to what?

A

Gluten

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25
How common is coeliac disease in the UK? [1]
1%
26
How can coeliac disease lead to malabsoprtion? [1]
Repeated exposure to gluten leads to villous atrophy which in turn causes malabsoprtion
27
Conditions associated with coeliac disease
Dermatitis herpetiformis [a vesicular, pruritic skin eruption] and autoimmune disorders [T1DM and autoimmune hepatitis] Strongly associated with HLA-DQ2 [95% of patients] and HLA-DQ8 [80%]
28
Complications associated with coeliac disease [7]
1. Anaemia: iron, folate, B12 deficiency 2. Hyposplenism 3. OP, osteomalacia 4. Lactose intolerance 5. Enteropathy-associated T-cell lymphoma of small intestine 6. Subfertiliy, unfavourable pregnancy outcomes 7. Rare: oesophageal cancer, other malignancies
29
How is coeliac disease diagnosed? [2]
Combination of serology and endoscopic intestinal biopsy
30
When should patients be reintroduced to gluten for Dx? [1]
At least 6w prior to testing should have gluten
31
Serology seen in coeliac disease [2]
Tissue transglutaminase [TTG] antibodies and antibodies [IgA] are the first-choice according to NICE
32
Which type of IgA antibodies are seen in coeliac disease? [1]
Endomyseal antibodies [IgA]
33
Which is the gold standard for coeliac disease Dx and what findings would there be? [5]
Endoscopic intestinal biopsy is the gold standard. Traditionally done in the duodenum but jejunal biopsies sometimes done. - villous atrophy - crypt hyperplasia - increase in intraepithelial lymphocytes - lamina propria infiltration with lymphocytes
34
Gluten-containing foods [4]
Wheat, barley, rye, oats
35
Gluten-free food [3]
Rice, potatoes, corn
36
What are coeliac disease patients offered and why? [2]
Pneumococcal vaccine and has a booster every 5y. | - they have functional hyposplenism
37
What do patients with HNPCC have a higher risk of? [1]
Endometrial cancer
38
What is HNPCC also known as? [1]
Lynch syndrome. The most common cause of inherited colon cancer.
39
Amsterdam criteria for Lynch syndrome [3]
at least 3 family members with colon cancer the cases span at least two generations at least one case diagnosed before the age of 50 years
40
What is FAp and how can it develop into Gardner's syndrome? [2]
FAP is a rare autosomal dominant condition which leads to the formation of hundreds of polyps by the age of 30-40 years. Patients inevitably develop carcinoma Patients with FAP are also at risk from duodenal tumours. A variant of FAP called Gardner's syndrome can also feature osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin
41
Define constipation [3]
It may be defined as defecation that is unsatisfactory because of infrequent stools (< 3 times weekly), difficult stool passage (with straining or discomfort), or seemingly incomplete defecation.
42
Crohn's disease presentation [4]
- non-specific symptoms like weight loss and lethargy - diarrhoea - abdominal pain - perianal disease e.g. skin tags and ulcers - extra-intestinal features more common patients with colitis and perianal disease
43
When does Crohn's usually present? [1]
Late adolescence or early adulthood
44
most prominent symptom of Crohn's in adults [1]
diarrhoea
45
most prominent symptom of Crohn's in adults [1]
abdominal pain
46
What may cause bloody diarrhoea in Crohn's? [1]
Crohn's colitis
47
Ix findings for CD [4]
Raised inflammatory markers Increased faecal calprotectin Anaemia Low vitamin B12 and vitamin D
48
Sx common to both CD and UC related to disease activity [4]
Arthritis: pauciarticular, asymmetric Erythema nodosum Episcleritis Osteoporosis
49
Sx common to both CD and UC unrelated to disease activity [4]
``` Arthritis: polyarticular, symmetric Uveitis Pyoderma gangrenosum Clubbing Primary sclerosing cholangitis ```
50
Which is the most common extra-intestinal feature in both CD and UC? [1]
Arthritis is the most common extra-intestinal feature in both CD and UC
51
Which condition more common UC than CD? [1]
PSC
52
Which condition more common CD than UC? [1]
Episcleritis
53
Which part of the bowel does CD commonly affect? [1]
Crohn's disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus
54
Bloods in CD [1]
CRP raised
55
Endoscopy in CD [1]
colonoscopy is the investigation of choice | features suggest of Crohn's include deep ulcers, skip lesions
56
Histology for CD [3]
inflammation in all layers from mucosa to serosa goblet cells granulomas
57
What has high sensitivity and specificity for examination of the terminal ileum in CD? [1]
Small bowel enema
58
What could a small bowel enema show in CD? [4]
strictures: 'Kantor's string sign' proximal bowel dilation 'rose thorn' ulcers fistulae
59
What should patients be strongly advised against in CD? [1]
patients should be strongly advised to stop smoking
60
Which drug is used first-line to induce remission in CD? [1]
glucocorticoids (oral, topical or intravenous) are generally used to induce remission.
61
Alternative to glucocorticoids for first-line remisssion for CD [1]
Budesonide
62
feeding in CD [2]
enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children)
63
2nd- line Tx CD if glucocorticoids not effective [1]
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective
64
Add-on therapy to induce remission CD [2]
azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine
65
Which drug is used in refractory disease in CD if fistulating? [2]
infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on azathioprine or methotrexate
66
Which drug used for isolated peri-anal disease? [1]
Metronidazole
67
How to maintain remission in CD? [2]
- as above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis) - azathioprine or mercaptopurine is used first-line to maintain remission
68
What should be assessed before starting azathioprine/mercaptopurine? [1]
TPMT activity should be assessed before starting
69
Which drug is used second line to maintain remission? [1] - assuming that's fucking UC
MTX
70
How common is surgery in CD? [1]
around 80% of patients will have it
71
Mx for stricturing terminal ileal disease [1]
Ileocaecal resection
72
Other types of surgeries in CD [5]
- stricturing terminal ileal disease → ileocaecal resection - segmental small bowel resections - stricturoplasty - perianal fistulae draining seton - perianal abscess incision and draining
73
What is the Ix for perianal fistulae? [1]
MRI
74
What are patients with Sx perianal fistulae usually given? [1]
Oral metronidazole
75
What is put in place for a complex fistulae? []1
draining seton - surgical thread piece that's left in the fistula to keep it open. Stops abscess formation.
76
Mx perinala abscess in CD [1]
incision, draining, Abx therapy
77
Cx of CD [3]
small bowel cancer [standard incidence ratio = 40] colorectal cancer [standard ratio =2] OP
78
Define acute diarrhoea [1]
Over 3 loose or watery stools peer day
79
Acute diarrhoea [1]
Under 14d
80
Chronic diarrhoea [1]
Over 14d
81
Diverticulitis Sx [1]
Typically LLQ pain, diarrhoea, fever
82
Constipation with overflow Sx [1]
A history of alternating diarrhoea and constipation may be given May lead to faecal incontinence in the elderly
83
IBS symptoms [3]
Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those with constipation-predominant IBS. Features such as lethargy, nausea, backache and bladder symptoms may also be present
84
Coeliac disease Sx [3]
In children may present with failure to thrive, diarrhoea and abdominal distension In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may coexist
85
Conditions associated with diarrhoea [4]
thyrotoxicosis laxative abuse appendicitis radiation enteritis
86
RFs for diverticulosis [2]
Increasing age, low-fibre diet
87
Presentation of diverticulitis [4]
left iliac fossa pain and tenderness anorexia, nausea and vomiting diarrhoea features of infection (pyrexia, raised WBC and CRP)
88
Mx of mild vs severe diverticulitis [2]
mild attacks can be treated with oral antibiotics more significant episodes are managed in hospital. Patients are made nil by mouth, intravenous fluids and intravenous antibiotics (typical a cephalosporin + metronidazole) are given
89
Cx of diverticulitis [4]
abscess formation peritonitis obstruction perforation
90
How can drug-induced liver disease by divided? [1]
Hepatocellular, cholestatic, mixed.
91
Drugs causing a hepatocellular picture [5]
``` paracetamol sodium valproate, phenytoin MAOIs halothane anti-tuberculosis: isoniazid, rifampicin, pyrazinamide statins alcohol amiodarone methyldopa nitrofurantoin ```
92
Drugs causing a cholestasis [+/- hepatitis] picture [5]
combined oral contraceptive pill antibiotics: flucloxacillin, co-amoxiclav, erythromycin* anabolic steroids, testosterones phenothiazines: chlorpromazine, prochlorperazine sulphonylureas fibrates rare reported causes: nifedipine
93
Which drugs can cause liver cirrhosis? [3]
MTX methyldopa amiodarone
94
Urgent referral for dyspepsia and endoscopy [i.e. within 2w] [3]
All patients who've got dysphagia All patients who've got an upper abdominal mass consistent with stomach cancer Patients aged >= 55 years who've got weight loss, AND any of the following: - upper abdominal pain - reflux - dyspepsia
95
Non-urgent referral for dyspepsia [2]
Patients with haematemesis Patients aged >= 55 years who've got: - treatment-resistant dyspepsia or - upper abdominal pain with low haemoglobin levels or - raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain - nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain
96
Managing patients who do not meet the referral for undiagnosed dyspepsia [3]
1. Review medications for possible causes of dyspepsia 2. Lifestyle advice 3. Trial of full-dose proton pump inhibitor for one month OR a 'test and treat' approach for H. pylori - if symptoms persist after either of the above approaches then the alternative approach should be tried
97
What is the initial Dx for H.pylori? [1]
initial diagnosis: NICE recommend using a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology 'where its performance has been locally validated'
98
Test of cure for H/pylori eradication [2]
- there is no need to check for H. pylori eradication if symptoms have resolved following test and treat - however, if repeat testing is required then a carbon-13 urea breath test should be used
99
What is a red flag Sx of dysphagia [1]
New onset dysphagia and requires urgent endoscopy, regardless of age or other Sx [100]
100
Sx of oesophageal Ca [2]
Dysphagia may be associated with weight loss, anorexia or vomiting during eating Past history may include Barrett's oesophagus, GORD, excessive smoking or alcohol use

3rd May 2022 [medicine] (3 decks)

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