Medicine Finals > GI > Flashcards

GI Flashcards

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1
Q

What are the 3 layers of the GI tract?

A
  • Mucosa
  • Submucosa (includes submucosal auerbach plexus)
  • Muscularis externa (muscle layers and myenteric plexus)
  • Serosa
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2
Q

What to foveolar cells produce?

A

mucus

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3
Q

What cells release pepsinogen?

A

chief cells

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4
Q

What are the stages of gastric acid production?

A
  • Cephalic phase (thought of food) Ach vagal mediated (increases acid)
  • Gastric phase (in stomahc) gastrin and histomine mediated (increases acid)
  • Duodenal phase (secretin + cck) reduces acid
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5
Q

Name some function of the GI tract

A
  • Digestion and storage
  • Enzyme activation
  • Antimicrobial
  • IF secretion
  • Lubrication (salivary glands)
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6
Q

Name the salivary glands

A
  • Parotid
  • Sublingual
  • Submandibular
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7
Q

What are the 2 types of IBD?

A

Crohn’s
Ulcerative colitis

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8
Q

Describe risk factors for Crohn’s

A
  • transmural inflammation of any part of the GI tract
  • associated with family history
  • smoking
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9
Q

What gene is coeliac mostly from?

A

HLA DQ2 - 90%
HLA DQ8

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10
Q

Inestigations for coeliac disease

A
  • IgA anti-TTG
  • Jejunal biopsy (Venous atrophy and crypt hyperplasia)
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11
Q

What vaccines are offerend to those diagnosed with coeliac disease?

A
  • Pneumococcal
  • Annual flu / influenza
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12
Q

Peak age occurance of appendicitis

A

10-20 years old

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13
Q

Where does the appendix arise from?

A

The caecum of the large bowel, at the point where 3 teniae coli meet

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14
Q

What are tenaie coli?

A

longitudinal muscles that run the length of the large intestine

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15
Q

What causes appendicitis?

A

Pathogens getting trapped in the appendix (dead end) causing inflammation and potentially gangrene and rupture

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16
Q

How could appendicitis cause peritonitis?

A
  • Rupture of appendix
  • Faecal contents and infective material released into the peritoneal cavity
  • Leads to inflammation of the peritoneal lining
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17
Q

What kind of abdo pain is described in appendicitis?

A

central abdo pain that moves down to the right ileac fossa within the first 24 hours

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18
Q

Where is McBurney’s point and what is it?

A

It is 1/3 of the distance from the anterior superior ileac spine to the umbilicus

On palpation of McBurney’s point there is tenderness = appendicitis

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19
Q

Name some classic features of appendicitis

A
  • loss of appetitie (anorexia)
  • n+v
  • fever
  • Rosvig’s sign
  • guarding
  • rebound tenderness
  • percussion tenderness
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20
Q

How is appendicitis diagnosed?

A
  • clinical presentation
  • raised inflammatory markers
  • CTAP (CT abdo pelvis)
  • diagnostic laparoscopy (appendectomy in same procedure if indicated)
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21
Q

Key differentials of appendicitis symptoms / acute abdomen

A
  • ectopic pregnancy
  • ovarian cysts / torsion / rupture
  • meckel’s diverticulum
  • mesenteric adenitis
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22
Q

What is ileus?

A

normal peristalsis stops temporarily (in small bowel)

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23
Q

What is pseudo-obstruction?

A

functional obstruction of the large bowel, patient presents with clinical signs, but there’s no mechanical explanation

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24
Q

Causes of ileus

A
  • injury
  • handling during surgery (usually open)
  • inflammation / infection near bowel
  • electrolyte imbalances (hypokalaemia / hyponatraemia)
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25
Signs and symptoms of ileus
- vomiting (green bilious) - abdo distention - absolute constipation - lack of flactulance - absent bowel sounds
26
Management of ileus
Treat underlying cause Supportive care: - Nil by mouth - NG tube if vomiting - IV fluids - Mobilisation - Total parenteral nutrition (TPN)
27
What is volvulus?
Bowel twists around itself and the mesentery it's attached to
28
What is the mesentery?
membranous peritoneal tissue that creates a connection between the bowel and the posterior abdominal wall
29
Where does the bowel get it's blood supply?
mesenteric arteries
30
Volvulus is a ____-_____ obstruction. This cuts off blood supply leading to ___ , ____ , and ________.
- closed-loop - ischaemia - necrosis - perforation
31
Types of volvulus
- Sigmoid (more common, elderly, chronic constipation, excessive use of laxiatives too) - Caecal (less common, younger patients)
32
Risk factors for volvulus
- neuropsychiatric disorders (e.g. parkinsons) - nursing home residents - chronic constipation - high fibre diet - pregnancy - intestinal adhesions
33
Coffee bean sign shows ______
volvulus
34
What is a Hartmann's procedure?
done for a sigmoid volvulus removal of the rectosigmoidal colon and formation of a colostomy
35
What is a right hemicolectomy / ileocaecal resection?
removing bowel affected by the volvulus
36
What is ascites?
abnormal build up of fluid in the peritoneal cavity (>25ml)
37
Name the areas of the peritoneum
- parietal (anterior wall) - visceral (around organs) - retroperitoneum (posterior / against spine)
38
What does ascitic fluid contain?
- proteins (albumin) - lipids - bile acids - wbcs
39
What is SAAG?
Serum ascites albumin gradient Tells you if it is caused by a hydrostatic or oncotic pressure gradient
40
How do you calculate the SAAG?
albumin in serum (conc) - albumin in ascitic fluid (conc)
41
What is considered a high or low SAAG?
High = >1.1mg/dL Low = < 1.1mg/dL
42
Explain the pathophysiology in ascites with a high SAAG
Fluid pushed out of circulation, causing increased albumin in the serum Albumin normally too big to pass through peritoneum Concentration of albumin in the ascitic fluid is low So caused by a hydrostatic pressure gradient
43
Explain the pathophysiology in ascites with a low SAAG
albumin in the serum and ascitic fluid are similar, so the peritoneum must be more permeable than usual oncotic pressure gradient
44
Name some causes of high SAAG ascites
- Portal hypertention - Cirrhosis - Heart failure - Budd-Chiari syndrome - Portal vein thrombosis
45
Name some causes of low SAAG ascites
- Nephrotic syndrome - Pancreatitis - Infection (TB) - Peritoneal malignancy
46
What investogations would you order if seeing a newly presenting patient with ascites?
- FBC - LFTs - Coagulation screen - USS (visualise organs, estimate volume of ascites, estimate PV pressure) - Paracentesis and calculate SAAG
47
When performing paracentesis on an ascites patient, what adjunct would you give and why?
Often an albumin infusion is given at the same time to avoid the sacites quickly reforming
48
What is a TIPS procedure?
transjugular intrahepatic portosystemic shunt
49
Which SAAG (high or low) does NOT respond well to diuretics?
Low SAAG ascites
50
What cells are in the pancreas?
Acinar cells
51
52
What is the name of the node found in advanced malignancy of a gastric adenocarcinoma? Describe it
Sister Mary Joseph's node Palpable nidule in the umbilicus due to mets of malignant cancer within the pelvis or abdomen
53
What is Virchow's node?
enlarged left supraclavicular lymph node
54
What is Peabody's sign?
found in patients with a deep vein thrombosis (DVT) and a positive test indicated by calf muscle spasm occurring on elevation and foot extension of the affected leg
55
Signs of viral hepatitis
- n+v - myalgia - lethargy - RUQ pain
56
What is Boerhaave syndrome?
spontaneous rupture of the oesophagus, usually due to recent episode of vomiting
57
Symptoms of Boerhaave syndrome
- Severe chest pain - Shock - Creps on palpation of the chest wall
58
What sign is highly indicative of pancreatic head carcinoma?
the 'double act sign' : dilation of both the common bile duct and the pacreatic duct + epigastric mass
59
What complications does being on long term PPIs expose you to?
- Repeated C.Diff infections - Hypomagnaesmia - Hyponatraemia - Osteoporosis --> fractures - Microscopic colitis
60
How frequent is surveillance of Barrett's oesophagus in cases with no dysplasia?
every 3-5 years
61
Management of Barrett's oesophagus
- High dose PPI - Endoscopic surverillance with biopsies
62
What is the difference between dysplasia and metaplasia?
Dysplasia = pre-cancerous cell change Metaplasia = benign change
63
Drugs used in management of UC
Aminosalicylates (Mesalazine, Sulfasalazine) Oral corticosteroids (Prednisolone) Immunosuppressants (Azathioprine)
64
What are the severities of UC?
Mild = < 4 stools a day, small amount of blood Moderate = 4-6 stools , varying blood Severe = >6 bloody stools a day + features of systemic upset (pyrexia, tachycardia, anaemia, rasied inflammatory markers)
65
How many weeks is generally aimed for when achieving remission of a UC flare?
4 weeks
66
How many types of viral hepatitis are there?
5
67
How is HepA transmitted?
- Fecal oral route (common in traveller's)
68
Name the 2 types of viral hepatitis that are transmitted through the fecal oral route
HepA (more from meats) HepE (more undercooked seafood)
69
How is HepC transmitted?
Via the bloood - Childbirth - Sex - IV drug use
70
How is HepC diagnosed?
- HCV RNA test *** GS - Enzyme immunoassay (IgG) - Recombinant immunoblot assay
71
How is HepB transmitted?
Via the bloood - Childbirth - Sex - IV drug use
72
Which type of viral hepatitis are likely to go chronic after an acute infection?
- Hep C - Hep B (only 20% of cases, but more likely to go chronic in young children)
73
HBsAg indicates ________
HepB surface antigen indicates active infection (either acute or chronic)
74
Anti-HBs indicates _________
anti-Hepb surface antigen indicates immunity
75
HBeAg is present in _______
HepB 'e' antigen is present in viral replication and infectivity, so positive in acute infection
76
IgM anti-HBc indicates _______
IgM anti-HepB (core) indicates current or recent hepatitis B infection and is present for around 6 months; therefore this is positive in acute infection
77
What is the most commonly affected area of the bowel in Crohn's?
Ileum
78
In pernicious anaemia, autoantibodies are made against _______
intrinsic factor
79
What deficiency causes angular chelitis?
Iron, B12 or B2 (riboflavin)
80
What is the first line treatment for alcoholic ketoacisosis?
IV thiamine and 0.9% saline
81
Name some causes of hyperferritinaemia
- Alcohol excess - Haemochromatosis - Excessive excerise (mildly elevates) - Liver disease - CKD - MAlignancy - Repeated transfusions
82
What is a 'protein meal'?
When blood is digested in the stomach, urea from the breakdown of the red blood cells is absorbed causing a raised urea
83
What is the Rockall scale and when is it used?
Provides a percentage risk of vleeding and mortality in a GI bleed (age, shock features, co-morbidities, aetiology of bleeding and edoscopic evidence of recent bleed) After endoscopy
84
Who typically gets spontaneuos bacterial peritonitis?
Patients with known: - Cirrhosis - Ascites - Alcoholic liver disease - Hep B / C - NAFLD
85
How does spontaneous bacterial peritonitis usually present?
- Fever - Abdo tenderness - Abdo distention - Vomiting - Altered mental state
86
Long term management of high SAAG ascites
- low socium diet - diuretics - reduce / abstain from alcohol - Propanolo for preimary prevention of oespophageal variceal bleeding
87
What management is used for large volume tense ascites?`
large volume paracentesis
88
Which vitamin if taken in high amounts can be teratogenic in pregnancy?
vitamin A
89
What is commonly the diagnosis in a type 2 diabetic with abnormal LFTs?
NAFLD
90
Name some medications that can cause hyponatraemia (low Na+)
- Diuretics (especially thiazides) - PPIs - Antidepressants (SSRIs, TCAs) - Antipsychotics - Anticonvulsants (Carbamezapine) - Opioids - ACE inhibitors
91
What blood tests are requested in coeliac and why?
- anti-TTG - anti-EMA (less so) - IgA (look for deficiency, low IgA may mean they have coeliac but false negative autoantibodies as they are made from IgA)
92
What medication should be avoided in bowel obstruction?
Metoclopramide It is a pro-kinetic anti-emetic so could cause a perforation in bowel obstruction
93
Chronic UC management
- Aminosalicylates (topical) - Aminosalicylates (oral) - Corticosteroids (topical --> oral) - Biologics to maintain remission (Inflixamab, Adalibumab) - JAK inhibitors
94
Chronic Crohn's disease management
Induce remission: - Corticosteroids - Budesonide - Aminosalicylates Add ons: - Mercaptopurine - Azathioprine - Methotrexate
95
In a suspected GI bleed, what is the management before having endoscopy?
- Fasting (6-8 hours) - Limited clear fluids (up to 2 hours before) - Adjust / stop certain medications (blood thinners)
96
What is budd chiari syndrome?
Blood outflow from the top of the liver is blocked, casues blood to back up in the liver and leads to backflow into the portal vein / complications
97
Liver anatomy
Portal vein in through bottom of liver Righ, left, middle hepatic veins out the top and flow into the inferior vena cava
98
What is in the portal triad?
arteriole, venule, bile duct
99
What causes budd-chiari syndrome? (pathophysiology)
Blood clot in one of the hepatic veins (hepatic vein thrombosis) Post hepatic obstruction of blood flow = less blood into the vena cava Primary = thrombosis Secondary = compression (from tumour for example)
100
What is in Virchow's triad?
- endothelial damage - increased coagualopathy - slow blood flow / stasis
101
Causes of Budd-Chiari syndrome (conditions)
- Primary polycythemia vera ** most common - OCP * - Pregnancy - PNH (primary nocturnal haemoglobinurea) - Lupus pro-coags - Liver cancer - Compression by tumour
102
Investigation findings in budd-chiari
- USS - cenral lobular necrosis - ischaemia and peripheral fatty change - porto systemic shunt 'nutmeg liver'
103
Symptoms of budd-chiari syndrome
- ascites - abdo pain - painful liver on palpation
104
What does the portal vein arise from?
- superior mesenteric vein - splenic vein
105
Examination findings in patient with budd-chiari
- ascites - splenomegaly - hepatomegaly - caput medusae - oesphageal varices - haemorrhoids
106
What is hepato-renal syndrome?
107
Management options for budd-chiari syndrome
Conservative: salt reduction Medical: anticoagulants, diuretics Surgical: TIPS procedure,
108
Prognosis of chiari syndrome
Not great
109
What is achalasia?
failure of oesophageal peristalsis and relaxation of the lower oesophageal sphincter (LOS) due to degenerative lossof ganglia from the myenteric plexus (auerbach's)
110
Clinical features of achalasia
- dysphagia of both solids and liquids - variation of severity of symptoms - heartburn - regurgitation of food (could lead to cough and aspiration pneumonia) - malignant change in small number of patients
111
What are the investigations for achalasia?
Oesophageal manometry *** - excessive LOS tone which doesn't relax on swallowing - considered the most important diagnostic test Barium swallow - grossly expanded oesophagus - fluid level - 'birds beak' appearance - bit like a seagull's head) CXR - widened mediastinum, fluid level
112
Treatment for achalasia
- Pneumatic balloon dilation - Intra-sphincteric injection of botox - Heller cardiomyotomy (surgical) - Drug therapy: nitrates, ccbs
113
Inguinal hernias are more common in _____
males
114
Where is an inguinal hernia?
Groin lump Superior and medial to the pubic tubercle
115
Surgical options for inguinal hernia
- Hernia truss - Mesh repair
116
Which inguinal hernias are repaired open or laparoscopically?
- unilateral = open - bilateral and recurrent = laparoscopy
117
Name some complications of hernia repair
Immediate (intra-op to 24 hours) : - Bleeding - Nerve injury (ilioinguinal most common) - Vas deferens injury - Bowel injury - Bladder perforation
118
Where would the patient have numbness in an injury to the ilioinguinal nerve?
Numbness / tingling over the superomedial thigh, base of penis or anterior scrotum / labia
119
Variceal haemorrhage management (pre-endoscopy)
A-E assessment - Rescucitation - Blood trnasfusion - Correct clotting (FFP, vitK, platelets) Vasoactive agents: - Terlipressin - Octreotide Prophylactic antibiotics IV - usually quinalones
120
Management of oesophageal variceal bleed (endoscopy onwards)
- Endoscopy - Band ligation - Sengstaken-Blakemore tube if uncontrolled haemorrhage - TIPSS procedure (transjugular intrahepatic portosystemic shunt, connects portal vein to hepatic vein)
121
Prophylaxis of variceal haemorrhage
- Non-selective beta blockers (Carvedilol chosen in patients with compensated cirrhosis) - Band ligation - TIPSS
122
If a patient taking aminosalicylates (e.g. masalazine) presents with a fever, sore throat, fatigue or bleeding gums what should you be concerned about?
Agranulocytosis Aminosalicylates are associated with a variety of haematological adverse effects, including agranulocytosis - FBC is a key investigation
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