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Flashcards in GI I Deck (98)
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1
Q

Risk factors for a GORD

A
Hiatus hernia
Smoking 
EtoH
Obesity 
Pregnancy 
Drugs
2
Q

List the criteria for performing an OGD

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

List the grading criteria of GORD

A

Los angeles classification

4
Q

Management of GORD

A

Conservative

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

Classify the different types of hiatus hernia

A
  1. Sliding
  2. Rolling
  3. Mixed

Note rolling hernias should be repaired as it may strangulate

6
Q

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

A

Rockall score

7
Q

Classify peptic ulcers

A

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

8
Q

List the complications of peptic ulcer disease

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

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

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

Outline the surgical options for patients with PUD

A

Vagotomy
Antrectomy with vagotomy
Subtotal gastrectomy

11
Q

Complication of surgery for PUD

A

Physical

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

Metabolic

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

Outline the pathophysiology of achalasia

A

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

13
Q

List the causes of achalasia

A

Idiopathic
Oesophageal Ca
Chagas disease (T.cruzii)

14
Q

Investigations for achalasia

A

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

15
Q

Treatment of achalasia

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

Genetic links associated with coeliac disease

A

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

17
Q

Presentation of coeliac disease

A

GLIAD

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

Name the antibodies you would look for in suspected coeliac disease

A

Antiendomyosial IgA
Anti TTG IgA
Anti gliadin IgG

19
Q

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

A

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

20
Q

Triad of symptoms seen in malabsorption

A

Diarrhoea
Weight loss
Lethargy

21
Q

List potential causes of malabsorption

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

Pathology of tropical sprue

A

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

23
Q

Treatment of tropical sprue

A

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

24
Q

Signs of UC on barium swallow

A
  1. Lead piping, no hausfrau
  2. Thumbprinting (mucosal thickening)
  3. Pseudopolyps
25
Q

Name the criteria used to grade the severity UC

A

Truelove and Witts criteria

26
Q

Maintenance therapy for patients with UC

A

1) 5 ASA (sulfasalazine)
2) Asathioprine
3) Infliximab

Achieving remission often requires a short course of prednisolone

27
Q

Outline the management of acute severe UC

A
  1. Resus
  2. Hydrocortisone
  3. Thromboprophylaxis
  4. Monitoring
28
Q

Signs of Crohns as seen on colonoscopy

A
  1. Skip lesions
  2. Rose thorn ulcers
  3. Cobblestone mucosa
  4. String sign of kantour
29
Q

List some of the complications of Crohn’s

A
  1. Fistuale
  2. Strictures
  3. Abscess
  4. Malabsorption
  5. Toxic megacolon
30
Q

Outline the criteria used to diagnosis IBS

A
ROME Criteria 
- Abdo discomfort for >12 weeks  with 2 of 
relieved by poking 
change in stool frequency 
change in stool form 

and two of

  • Urgency
  • Incomplete emptying
  • Bloating
  • Mucous PR
  • Worsening symptoms after food

Exclusion criteria

  • > 40yrs
  • Bloody stools
  • Anorexia
  • Wt loss
  • Diarrhoea
31
Q

List the causes of chronic pancreatitis

A
AGITS 
Alcohol 
Genetic 
- CF
- HH
Immune 
- Lymphoplasmacytic sclerosing pancreatitis ( increase in IgG4) 
Triglycerides increase 
Structural 
- Obstructed by a tumour
32
Q

Clinical features of chronic pancreatitis

A
Epigastric pain 
- relived by sitting back or with hot water bottle 
Steatorrhoea 
Wt loss
DM
33
Q

List the investigations you would do to confirm pancreatitis and what would they show

A
Increase glucose 
Decrease faecal elastase 
Us of the pancreas 
AXR speckled pancreatic calcifiction 
Ct pancreatic calcification
34
Q

Treatment of chronic pancreatitis

A

DRUGS

  • Analgesia ( may need coeliac plexus block
  • Creon
  • ADEK vitamins
  • DM Rx

DIET

  • No EtOH
  • Decrease in fat
  • Decrease in carbs

Surgery
- Pancreatectomy

35
Q

List the causes of acute pancreatitis

A
GET SMASHED 
Gallstones 
EtOH 
Trauma 
Steriods 
Mumps 
Autoimmune
Scorpion venom 
Hyperlipidaemia 
ERCP 
Drugs
36
Q

Clinical features seen in patients with acute pancreatitis

A

Jaundice
Rigid abdomen
Cullen’s sign: periumbilical bruising
Turner’s sign: Bruising of the flanks

37
Q

Outline the investigations and management plan you would initated in a patient presenting to A&E with acute pancreatitis

A

IX
- Amylase >1000mL, levels will rise after the first 24-48 hours
- Bloods
- ABG, monitor acid base balance
- AXR, no psoas shadow ( increase in retroperitoneal fluid)
Sentinel loop (air filled dilatation)

Treatment

  • NBM
  • IV fluid, catheter
  • Plan nutrition, no oral feeding for a week
  • Analgesic, morphine
  • Abx
  • Refer to ITU if detonation
38
Q

What are the Glasgow Criteria and what is it used for?

A
Glasgow criteria used to determine the severity of the patients pancreatitis 
Consists of the following 
- PaO2
- Age
-Neutrophilia 
- Calcium 
- Renal function 
- Enzymes
- Albumin 
-Sugar
39
Q

Discuss the pathology associated with diverticulitis

A

Stool or undigested food becomes trapped int he diverticulum
Bacteria multiple
Inflammatory response

40
Q

List the potential complications of diverticulitis

A

Perforation
Haemorrhage
Fistula
Abscess

41
Q

Treatment of diverticulitis

A
Admit if unstable 
Give broad spec abs ( co-amoxiclav)
Clear fluids only 
Surgery if 
- Faecal peritonitis 
- uncontrolled sepsis
- fistula obstruction
42
Q

Causes of ischaemic colitis

A

Occlusion of the branches of the superior mesenteric artery or the inferior mesenteric artery
New onset abdominal pain
Bright red blood will be visible and the patient is likely to be in metabolic acidosis
Risk is the translocation of intestinal bacteria across the lumen
Systemic inflammatory response

43
Q

List the potential complication of diverticulitis and the subsequent management

A
  1. Septic peritonitis
  2. Progression of systemic inflammatory response
  3. Multi organ dysfunction syndrome
  4. Resuscitation with fluids
  5. Give abs
  6. Give heparin
  7. Post angiography give thrombolytics if needed
44
Q

List the types of haemorrhoids

A
  1. Internal haemorrhoids

2. External haemorrhoids

45
Q

Causes of haemorrhoids

A
Constapation 
Congestion 
Pregnancy 
CCF 
Portal hypertension
46
Q

Treatment for haemarroids

A
  1. Increase fluid and fibre
    Topical analgesics
    Stool softener
  2. Non operative
    Rubber band ligation
    Infra red coagulation
    Cryotherapy
47
Q

Describe a fistulae in ano

A

A track communicating between skin and anus
Caused by Abscess, perianal sepsis, Crohns disease, Diverticulitis, TB.
Will require a surgical repair.

48
Q

Clinical features of bowel obstruction

A
Vomiting ( can be faecal)
Colic pain
Distension 
Constipation 
Tinkling/absent bowel sounds 
Rigid abdomen 
Sm
49
Q

Types of bowel obstruction

A

Adhesive obstruction
Hernia obstruction
Volvulus
Intessupation

50
Q

Management of bowel obstruction

A

ABCDE patient
Surgical management to relieve the obstruction
NBM

51
Q

Discuss the pattern of abdominal pain in acute appendicitis

A

Early inflammation

  • appendiceal irritation
  • not well localised
  • Pain referred to the dermatome corresponding to spinal cord entry level.

Late inflammation

  • parietal peritoneum irritation
  • pain localised to the PIF
52
Q

List the key signs seen with appendicitis

A

Guarding and tenderness @ McBurneys pt
Rosing’s sign: pressure in the LIF increase pain in the RIF
Posts sign: pain on extending the hip
Cope sign: Flexion and external rotation of the hip = pain

53
Q

Classify the types of jaundice and give causes for each class

A
  1. PRE HEPATIC
    Excess BR production
    Ineffective erythropoesis e.g. thallasaemia
  2. HEPATIC
    * Unconjugated
    Decrease BR uptake (drugs)
    Decrease BR conjugation
    - Hypothyroidism
    - Gilberts
    - Criglers Najjar
*Conjugated 
Hepatocellular dysfunction 
- Congen: HH, Wilsons, 
- Infection: Hep a/b/c CMV, EBV 
- Toxins: EtOH 
- AI 
- Vascular: Budd Chiaria 

Decrease Hepatic BR Excretion

  • Dublin-Johnson
  • Rotors
3. POST HEPATIC 
Obstruction 
- Stones 
- Ca Pancreas
- PSC 
- PBC
- Drugs
54
Q

List the causes of liver failure

A
Cirrhosis 
Acute 
- Infection 
- Toxins 
- Vascular (Budd Chiari)
- Others (Wilsons, AIH)
55
Q

Management of patients with liver failure

A
  1. Manage in ITU
  2. Rx underlying cause
  3. Good nutrition via a NGT
  4. Thaimine supplements
  5. Prophylactic PPI

MONITORING
Fluids
Bloods
Glucose

56
Q

List the complications of acute liver failure

A
Bleeding - Vit K, platelets, FFP 
Sepsis - Tazocin
Ascites - Fluid restritction, spiro, fruse
Hypoglycaemia - regular BM 
Encephalopathy - lactulose and enaemas 
Seizures - lorazepam 
Cerebral oedema - mannitol
57
Q

Name the criteria used in acute liver failure for liver tx

A
Kings College Hospital Criteria
*PARACETAMOL induced 
- pH <7.3 
- All of PT>100s
Cr >300uM
Grade 3/4 encephalopathy 
*NON PARACETAMOL induced 
PT>100s
3/5 of drug induced 
Age <5 or >40 
>1wk of jaundice 
Pt>50
BR> 300uM
58
Q

Causes of cirrhosis

A
Chronic EtOH 
Chronic HCV 
NAFLD
Genetic 
Autoimmune hepatitis 
Drugs 
Neoplasm 
Vascular; Budd Chiari, RHF, Constrictive pericarditis
59
Q

Clinical features seen on examination of a patient with cirrohosis

A

Hands

  • Clubbing (+/- periostitis)
  • Leuconychai (decrease in albumin)
  • Terry’s nails ( white proximally, red distally)
  • palmer erythema
  • Dupuytron’s contractures

Face

  • Pallor
  • Xanthelasma
  • Parotid enlargement

Trunk

  • Spider naevi
  • Gynaecomastia
  • Loss of 2 sexual hair

Abdo

  • Striae
  • Splenomegaly
  • Dilated superficial veins
  • Testicular atrophy
60
Q

List the complications of cirrohosis

A
  1. Decompensation resulting in hepatic failure
    - Jaundice
    - Encephalopathy
    - Hypoalbuminaemia, oedema, ascites
    - Coagulopathy
    - Hypoglycaemia
  2. Spontaneous Bacterial Peritonitis
3. Portal HTN (SAVE) 
Splenomegaly 
Ascites 
Varies 
- Oesophageal varices 
- Caput medusa 
- Worsening existing piles 
Encephalopathy 
  1. Increase risk of HCC
61
Q

The following conditions are associated with the presence of certain abs. Please list the abs associated with each condition

  1. AIH
  2. PBC
  3. PSC
  4. Ca
A

AIH

  • SMA
  • SLA
  • LKM
  • ANA
  • High IgG

PBC

  • AMA
  • High IgM

PSC

  • ANCA
  • ANA

CA
- Alpha-fetoprotein

62
Q

Causes of portal HTN

A

PRE HEPATIC
- Portal vein thrombosis

HEPATIC

  • Cirrohosis
  • Schisto
  • Sarcoidosis

POST HEPATIC

  • Budd chiari
  • RHF
  • Constrictive pericarditis
63
Q

Describe the pathophysiology of encephalopathy

A
  1. Decreased hepatic metabolic function
  2. Diversion of the toxins from the liver directly into systemic system
  3. Ammonia accumulates and pass to brain where astrocytes clear it causing conversion of glutamate to glutamine
  4. Increase in glutamine
  5. Osmotic imbalance
  6. Cerebral oedema
64
Q

Classification of encephalopathy

A
  1. Confusion: irritable, mild confusion, sleep inversion
  2. Drowsy: Increased disorientation, slurred speech, asterixis
  3. Stupor: rousable, incoherence
  4. Coma: Unrousable +/- extensor plantars
65
Q

Presentation of encephalopathy

A
Asterixis 
Confusion 
Dysarthria 
Constructional apraxia 
Seizures
66
Q

List the possible precipitants of encephalopathy

A
HEPATICS 
Haemorrhages
Electrolytes
Posions
Alcohol 
Tumour (HCC)
Infection 
Constipation 
Sugar
67
Q

What liver enzymes will be raised in alcoholics

A
  1. AST
  2. ALT
  3. GGT
68
Q

What is the triad of Wernicke’s encephalopathy

A

Confusion
Opthalmoplegia
Ataxia

Korsakoff’s: amnesia to confabulation

69
Q

A patient presents with anorexia, D/V, and a jaundiced look about them
On examination you note ascites, tender hepatomegaly.
On questioning the patient reveals to you the have been drinking 100 units a week of vodka for the past five years
1. List your working diagnosis
2. What investigations will you do and what do you expect them to show
3. Outline the management plan for this patient

A
  1. Alcoholic hepatitis
  2. Bloods
    - Increase MCV
    - GGT, AST,ALT
    - Ratio of AST:ALT will be > 2
  3. Plan
    - Stop EtOH
    - Withdrawal treatment
    Tapering regimen of chlordiazepoxide PO/ Lorazepam IM
    - Give parbinex
    - Optimise nutrition
    - Daily weights and bloods
    - Alcohol cessation support
70
Q

List the different types of hepatitis and the mode of transmission associated with each one

A
A: Orally spread, seafood 
B: IV, blood, body fluids, vertically babies
C: IV, Blood 
D: IV, Prior infection with HBV
E: PO, Developing world
71
Q

Hepatitis generally develops over three phases. List the phases and the symptoms associated with each one

A

PRODROMAL PHASE
HAV,HVB
Flu like, arthralgia

ICTERIC PHASE 
Acute jaundice 
Hepatitis 
- abdo pain
- hepatomegaly 
- cholestasis 
Extra hepatic features (due to immune complexes)
- Cryoglobulinaemia 
- PAN 
-GN
- Arthritis 

CHRONIC PHASE

  • HCV
  • Cirrhosis

Mainly supportive care
Anti-virals in chronic disease

72
Q

Outline the pathology ad risk factors associated with NAFLD

A

Cause of hepatitis and cirrhosis associated with insulin resistance and metabolic syndrome
Non alcoholic steatohepatitis is most extreme

RF 
Obesity 
HTN
T2DM
Hyperlipidaemia
73
Q

What are the components of metabolic syndrome

A
Central obesity 
\+2 of 
- Increased triglycerides 
- Decreased HDL
- HTN 
- Hyperglycaemia (DM,IGT,IFG)

Note: patients will generally have increased transaminases
AST:ALT <1

74
Q

Causes of Budd-Chiari syndrome

A
  1. Hypercoagulable state
    - Myeloproliferative disorders
    - PNH
    - anti-phospholipid
    - OCP
  2. Local tumour
    - HCC
  3. Congenital
    - Membraneous obstruction of IVC
75
Q

What is the triad associated with Budd Chiari syndrome

A
  1. RUQ pain
  2. Hepatomegaly
  3. Ascites SAAg >1.1g/dL

Jaundice may be present
Do the JAK2 mutation analysis
CD55
CD59

76
Q

Management of a patient with newly diagnosed Budd Chiari syndrome

A
Anticoagulate unless +ve varices 
Ascites: fluid and salt restirctionm spiro, fruse
Thrombolysis 
Angioplasty 
TIPSS
77
Q

Describe the pathophysiology of alpha-1 antitrypsin deficiency

A

Sorption involved in the control of the inflammatory cascade by inhibiting neutrophil disease
Synthesised in the liver

78
Q

List the investigations you would request if you suspect a patient had alpha-1 antitrypsin deficiency and what they would show

A

Bloods: decrease in serum a1AT
Liver biopsy: PAS +ve, diastase-resistant globules
CXR: Emphysematous change
Spirometry: Obstructive defect

79
Q

Describe the pathophysiology of hereditry haemochromatosis

A

Autosommal recessive genetic disorder
Abnormal iron metabolism
Increase FE absorption
Increase deposition in multiple organs

80
Q

Clinical features associated with HH

A

(iron) MEALS
Myocardial: dilated cardiomyopathy
arrhythmias

Endocrine: DM, hypogondaism, hypocalcaemia

Arthritis

Liver: HCC, cirrohosis

Skin: slate grey discolouration

81
Q

A patient presents and tells you his mother had HH. He asks about the inheritance pattern.
What investigations would you do if you suspect he had HH and what would they show

A

Inheritance pattern: Autosommal recessive

Bloods

  • abnormal LFTs
  • Increase ferritin
  • Increase Fe
  • Decrease TIBC

Genotype

Liver biopsy: pearls stain to quantify the FE and severity

82
Q

Describe the pathophysiology of Wilson’s disease

A

Mutation of Cu transporting ATPase
Imparied hepatocyte incorporation of Cu into caeruloplasmin and exertion into bile
Cu accummulation in liver and other organs

83
Q

List the clinical features of Wilson’s disease

A
Cornea: Kayser Fleischer rings 
Cirrhosis 
Chondrocalcinosis
Parkinsonism 
Fanconii's syn (T2 RTA)
Haemolytic anaemia, coomb's negative
84
Q

Treatment of Wilson’s disease

A
Avoid high Cu foods 
Penicillamine lifelong (Cu chelator)
85
Q

Clinical features associated with PBC

A
Pruritus 
Pigmentation of the face 
Bones, osteoporosis, osteomalacia 
Big organs, HSM 
Cirrhosis and coagulopathy 
Cholesterol 
Steatohorrea
86
Q

What will be seen on liver biopsy in patients with PBC

A

Non caesating granulomatous inflammation

87
Q

Management of PBC

A
  1. General
    - Pruritis (colestyamine)
    - Diarrhoea (Codeine phosphate)
    - Osteoporosis (Bisphosphanates)
  2. Specific
    - ADEK vitamins
    - Urodeoxcholic acid
  3. Liver transplant
88
Q

A patient is refer from his GP with symptoms of pruritus, on going abdo pain and episodes of pale stools and dark urine
His most recent LFT’s are included in the referral and show a raised ALP and BR as well as positive ANA and pANCA antibodies.
What is your working diagnosis?
What other investigation would you order and what would it show?
How would you treat the pruritus?

A
  1. Primary sclerosing cholangitis
  2. Endoscopic retrograde cholangiopancreatography, beaded appearance of the ducts
  3. Colestryamine
89
Q

List the five symptoms seen in Reynolds pentad present in cholangitis

A
Mental confusion 
Shock 
Fever 
Jaundice 
Abdo pain
90
Q

What makes up chariot’s triad

A

Right upper quadrant pain
Intermittent fever
Jaundice

91
Q

Common causing organism seen in cholangitis

A

Klebsiella
E.coli
Enterobacter

92
Q

List the investigations you would order in a case of suspected cholangitis

A
LFT
FBC 
WCC
Inflammatory markers 
U&amp;Es
Blood cultures 

Imaging

  • Abdo xr ( includes KUB)
  • Contrast enhanced CT
  • MR cholangiopanreatography
93
Q

List the different types of stones seen in biliary colic

A

Cholesterol stones: large, solitary and radiolucent
Black pigment stones: small, friable. irregular and radiolucent
Mixed stones: calcium salts and cholesterol
Brown stones: stasis and infection

94
Q

List the imaging done to dx cholecyctisis

A

Ultrasound

ERCP

95
Q

Outline the differences between cholecystitis and binary colic

A
RUQ pain 
Vomiting 
Fever 
Local peritonism 
GB mass 

Difference: Inflammatory component ( fever, raised white cell count)

Note Murphy’s sign
Two fingers over the RUQ and ask the patient to inhale , inspiration causes pain

96
Q

List the management of binary colic/cholecystitis

A
  1. Analgesic such as opioids
  2. Abx ( must be IV in hospital)
  3. Surgical
    - Early cholecystectomy
    - Laparoscopic cholecystectomy
97
Q

Treatment of H.pylori

A

7/7 Rx
Lansoprazole 30mg BD
Amoxicillin 1g BD
Clarithromycin 500mg BD

98
Q

Name the immunosupressants used in liver transplant patients

A
Ciclosporin or Tacrolimus 
\+
Azathioprine or Mycophenolate 
\+ 
Prednisolone