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Gastro Flashcards

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1
Q

Younger women with deranged LFTs and signs of liver disease. Differential?

A

Autoimmune hepatitis

Viral hepatitis

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2
Q

Is azathioprine safe to use in pregnancy?

A

Yes

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3
Q

Conditions associated with autoimmune hepatitis?

A

Hashimoto’s thyroiditis, RA, Grave’s, IBD, pleurisy, AIHA

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4
Q

Stepwise plan of autoimmune hepatitis

A
  1. Autoimmune profile –> ANA and SMA
  2. Protein electrophoresis –> high titres IgG suggestive
  3. Arrange other bloods –> FBC, LFTs
  4. Consider liver biopsy –> interface hepatitis + plasma cells +++
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5
Q

Approach for autoimmune hepatitis

A
  1. Watchful waiting –> asymptomatic, pre-cirrhotic
  2. Immunosuppression –> pred 40mg PO, taper and add azathioprine for long term
  3. Liver transplant in severe disease
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6
Q

How is remission of autoimmune hepatitis monitored?

A

Measuring AST/ALT and IgG levels post-therapy

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7
Q

What is primary biliary cirrhosis?

A

Chronic autoimmune disease characterised by progressive destruction of small intrahepatic bile ducts, resulting in cirrhosis

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8
Q

Clinical features of PBC?

A

Fatigue + pruritus = earliest

Jaundice = late

Other –> hepatosplenomegaly, facial hyperpigmentation, xanthelasma

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9
Q

How does PBC cause xanthelasma?

A

Dietary cholesterol metabolised in liver and excreted in bile. In PBC there is fibrosis of the biliary tracts causing cholestasis. Cholesterol accumulates and deposits around the eyes and tendons.

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10
Q

Stepwise plan for PBC?

A
  1. LFTs –> primary cholestatic picture
  2. Autoimmune profile + Ig electrophoresis
  3. Imaging –> exclude extrahepatic obstruction (US / MRI)
  4. Consider biopsy –> if unclear = lymphocytic infiltration with granulomatous changes
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11
Q

Management of PBC?

A
  1. Ursodeoxycholic acid
  2. Symptomatic treatment –> pruritus (cholestyramine), malabsorption (replace fat-soluble vitamins)
  3. Consider liver transplant
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12
Q

What is hereditary haemochromatosis?

A

An autosomal recessive genetic disorder characterised by excess iron deposition throughout the body

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13
Q

Early features of haemochromatosis

A

Non-specific = fatigue, abdo pain, arthralgia, ED

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14
Q

Late complications of haemochromatosis

A

Endocrine –> diabetes, hypogonadism

Cardiac –> arrhythmias, cardiomyopathy

Hepatic –> hepatomegaly, cirrhosis

MSK –> bronze skin, arthralgia

Neuro –> mood disturbances, memory impairment

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15
Q

What causes bronzing of skin in hereditary haemochromatosis?

A

Excess haemosiderin deposition + haemosiderin-induced melanocyte activation

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16
Q

What mutation causes haemochromatosis?

A

HFE gene on chromosome 6 –> regulates hepcidin

Hepcidin inhibits ferroportins in gut –> increased iron absorption

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17
Q

How do you manage haemochromatosis?

A
  1. Dietary advice –> low iron, avoid alcohol
  2. Regular venesection –> stimulate bone marrow to produce new RBCs and use up iron
  3. Chelation therapy –> IV desferrioxamine (if CI)
  4. Genetic counselling –> first degree
  5. Liver transplant –> end stage
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18
Q

What is hepatocellular carcinoma?

A

The commonest primary cancer arising from liver hepatocytes

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19
Q

Causes of HCC?

A

Chronic HBV and HCV

Cirrhosis –> ALD, HHC, PBC

Fungal infection –> Aspergillus

Misc –> PSC, androgenic steroids, COCP use

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20
Q

How would you investigate HCC?

A
  1. Imaging –> US for screening, otherwise CT / MRI
  2. Consider liver biopsy
  3. Tumour markers –> alpha-fetoprotein (6 month follow up)
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21
Q

How would you manage HCC?

A

Non-cirrhotic –> hepatic resection

Single nodule <5cm or <3 nodules <3 cm –> liver transplant

Consider RFA

Multinodular, intermediate –> trans-arterial chemoembolisation

Advanced –> chemotherapy (e.g. SORAFENIB)

Palliative care

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22
Q

What is the differential for a RIF mass?

A

Crohn’s disease, appendix mass / abscess, caecal carcinoma, ovarian/renal mass, TB

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23
Q

Clinical features of Crohn’s?

A

Diarrhoea, often not bloody

Abdo discomfort +/- weight loss

Aphthous ulcers, glossitis, fistulae

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24
Q

What are some extra-abdominal manifestations of Crohn’s?

A

Derm –> erythema nodosum, pyoderma gangrenosum

Eyes –> anterior uveitis, episcleritis

MSK –> arthritis, AnkSpond

Liver –> gallstones

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25
How would you investigate Crohn's?
1. Bloods --> FBCs, LFTs, haematinics 2. Stool testing --> MC&S (exclude infection), faecal calprotectin 3. Imaging --> AXR +/- erect CXR, MRI pelvis, capsule endoscopy 4. Endoscopy --> ileocolonoscopy + biopsy
26
Describe the management of Crohn's in terms of inducing remission.
1. First line = oral/IV corticosteroids 2. Consider budesonide or 5-ASA therapy in some situations 3. Add-on in resistive (2+ exacerbations/year) cases --> azathioprine or 6-MP (or methotrexate if CI) 4. Consider biologics --> e.g. infliximab, adalimumab 5. Consider surgery
27
Describe the management of Crohn's in terms of maintaining remission.
1. Stop smoking + lifestyle advice 2. First-line = azathioprine or 6-MP (never use long-term steroids) 3. Alternative = MTX 4. Stricture management --> balloon dilatation via colonoscopy, otherwise surgery 5. Monitoring --> assess osteopenia/-porosis, colonoscopy surveillance for colorectal Ca if >10 years since symptom onset
28
Describe the management of Crohn's in terms of managing perianal disease.
1. Consider oral ABx --> e.g. metro / cipro 2. Consider immunosuppression --> azathioprine +/- infliximab 3. Consider surgery
29
What are some major features of oesophageal disorders?
Dysphagia --> slow progressive + heartburn = peptic stricture; rapid = malignancy; to both liquid and solid progressive = achalasia Odynophagia --> oesophagitis, e.g. reflux/infection Substernal discomfort --> reflux of gastric contents into oesophagus, worse when lying Regurgitation
30
What is the main sign of oesophageal disease?
Weight loss due to decreased intake of food
31
Which test is used to assess H. pylori post-eradication therapy?
Urea breath test
32
Most common organisms in pyogenic liver abscesses?
Children = S. aureus Adults = E. Coli
33
Management of pyogenic liver abscess?
Image-guided drainage + IV antibiotics Amoxicillin + ciprofloxacin + metronidazole Allergic --> ciprofloxacin + clindamycin
34
Diagnostic marker of choice for carcinoid syndrome?
5-HIAA
35
What is the name of the stain used in biopsy for HHC?
Perl's
36
Typical iron study in patient with HHC
Transferrin sat >55% or >50% Raised ferritin and iron Low TIBC
37
What markers of iron study are aimed for in venesection for HHC?
Transferrin <50% Ferritin <50
38
Which gastro drug can cause hypomagnesaemia?
Omeprazole
39
List some adverse effects of PPIs
Hyponatraemia, hypomagnesaemia Osteoporosis Microscopic colitis Inc. risk C. Diff
40
Single most important investigation for patient with severe flare of UC?
AXR --> exclude toxic megacolon
41
What is coeliac disease?
An autoimmune disorder triggered by gluten consumption, resulting in small bowel inflammation and subsequent malabsorption.
42
Which HLA is coeliac disease associated with?
HLA-DQ2
43
What should be assessed before starting therapy with azathioprine or mercaptopurine?
Thiopurine methyltransferase (TPMT) activity
44
What constitutes a MILD flare of UC?
< 4 stools daily +/- blood No systemic disturbance Normal ESR and CRP
45
What constitutes a MODERATE flare of UC?
4 - 6 stools a day Minimal systemic disturbance
46
What constitutes a SEVERE flare of UC?
> 6 stools a day Evidence of systemic disturbance
47
What are some systemic disturbances that can be caused by a severe UC flare?
Fever, tachycardia Acute abdomen Anaemia Hypoalbuminaemia
48
Causes of pancreatitis
GET SMASHED ``` Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion venom Hypercalcaemia, hypothermia ERCP Drugs ```
49
What drugs can cause pancreatitis?
``` Azathioprine Mesalazine Bendroflumethiazide Furosemide Steroids Sodium Valproate ```
50
Antibodies for autoimmune hepatitis type I?
ANA and SMA
51
Antibodies for autoimmune hepatitis type II?
anti-LKM1
52
Antibodies for autoimmune hepatitis type III?
soluble liver-kidney antigen
53
Melanosis coli
Laxative abuse
54
Treatment for Wilson's disease
Penicillamine
55
Wilson's disease mutation
ATP7B gene on Chr 13
56
Clinical presentation of coeliac disease.
GI --> malabsorption, unexplained weight loss Metabolic --> IDA, B12/folate deficiency, hypocalcaemia, faltering growth Derm --> dermatitis herpetiformis, severe aphthous oral ulcers Misc --> autoimmune conditions, lymphoma
57
Most common inherited colorectal cancer
HNPCC
58
What is SAAG used for?
SAAG usually < 11 SAAG > 11 implies portal hypertension
59
What is the most specific and sensitive marker of cirrhosis in chronic liver disease?
Thrombocytopenia (< 150)
60
What neutrophil count in ascitic tap is diagnostic of SBP?
> 250
61
Management of SBP?
IV cefotaxime
62
MoA of loperamide?
Loperamide is a μ-opioid receptor agonist which does not have systemic effects as it is not absorbed through the gut
63
Epigastric pain + diarrhoea
Zollinger-Ellison syndrome
64
Triad of intestinal angina?
Colicky post-prandial abdo pain Weight loss Abdominal bruits
65
Most common site of diverticula?
Sigmoid colon
66
Unruptured sigmoid volvulus ---> Rx?
rigid sigmoidoscopy + flatus tube insertion
67
The hepatic portal vein is formed by the union of _ + _ ?
Superior mesenteric and splenic veins
68
Tumour marker for cholangiocarcinoma?
CA 19-9
69
dyspepsia and over 55?
endoscopy
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