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67 Cards in this Set
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Manometric finding in achalasia?
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lower oesophageal resting pressure: HIGH
residual lower oesophageal sphincter pressure: LOW distal peristalsis: ABSENT (this is the hallmark) |
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what is Cowden's syndrome?
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one of the hamartotomatous polyposis syndromes
PTEN mutation |
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typical clinical features of Cowden's syndrome?
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oral papillomas
palmoplantar keratosis trichelemmomas (benign hair follicle tumor) |
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What investigation does the british society of gastroenterology suggest for finding of iron deficieny anaemia in adult men and postmenopausal women?
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everyone should be investigated
* minimal upper/lower GI tract (lower: barium enema is as good as colonoscopy for detection of Ca and can be used as substitute) * anti-endomysial antibodies for coeliac disease * urinalysis for haematuria - renal tract malignancy |
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What does british gastroenterology guidelines suggst for post menopausal women with IDA?
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if no warning signs, 3 month trial of iron substitutes and review and investigate if no improvement
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What constitutes a strong family history of colon Ca?
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either first degree relative <45 years
or two first degree relatives. |
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Management of acute ethanol related pancreatitis?
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60% O2
IV fluids if feeding required, then enteral via nasogastric tube abx - no consensus NSAIDS, abx, gabaxate not effective |
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How and when to assess for severity of pancreatitis to predict severe attack and patients that need high dependency unit?
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APACHE scoring at 24hours and 48 hours
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Brithish society of gastroenterology: in acoholics with established liver cirrhosis and varices - how to treat varices? When?
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if finding on endoscopy and C-P B or C then start propranolol if no contraindications to betablocker
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Main points of management of decompensated ALD
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* remove precipitants
* treat infection * purge bowels (laxatives, enemas) - aim for three soft stools./day * PPI for stress ulcer prophylaxis |
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jaundice in pregnancy - what are the possiblities?
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* 40% can be still viral hepatitis!!
* intrahepatic cholestasis of pregnancy * HELLP syndrome * acute fatty liver of pregnancy |
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is liver function generally impaired in pregnancy?
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no
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does pregnancy exacerbate liver disease?
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no
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what are the physiological changes in the liver during pregnancy?
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* proportion of cardiac output to liver falls therefore drug metabolism is affected
* ALP raises up to 4 times as it is released from the placenta * TG, cholesterol, caeruloplasmin, transferrin A1AT and fibrinogen levels rise due to increased synthesis * post partum hypercoaguble state (budd-chiari!) |
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how does hyperemesis gravidum change liver function?
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jaundice can occur but resolves when vomiting subsides
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What is intrahepatic cholestasis of pregnancy?
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condition of unknown etiology with a familial tendency presenting with pruritus alone in third trimester.
liver biochemistry shows cholestatic picture |
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Prognosis for intrahepatic cholestasis?
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good for mum, increased risk for fetus.
recurrency can occur with further pregnancies or contraceptive pill |
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what is the classical clinical features of pre-eclamsia?
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hypertension, proteinuria and oedema in second or third trimester
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what is acute fatty liver of pregnancy?
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rare serious condition of unknown etiology presenting in last trimester with symptoms of fulminant hepatitis
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what is the treatment for HELLP or AFLP?
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delivery
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acute variceal bleeding - what vasopressin analogue to use?
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terlipressin
in ischaemic heart disease it is contraindicated, and octreotide is used |
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what are the side effects the patient will complain if terlipressin is given?
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abdominal colic
defecate facial pallour (all due to general vasoconstriction) |
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when to use sengstaken-blakemore tube?
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if exsanguating bleeding and endoscopy not immediately available
if endoscopic/vasoconstrictor therapy failed |
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what is the prognosis after successful therapeutic endoscopy in terms of rebleeding?
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30% rebleed within 5 days
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what would be the next step if therapeutic endoscopy fails twice within 5 days?
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TIPS
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most sensitive test for pancreatic exocrine function?
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secretin test
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how to interpret the secretin test?
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volume normal and bicarb <80 (pancreatic exocrine failure)
volume low (pancreatic duct obstruction ?tumor) |
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when is a colon considered a toxic megacolon?
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>5.5 cm
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trulove criteria for severe ulcerative colitis flare up?
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>6motions
T >37.8 on 2/4 days HR >90 ESR >30 Hb <10 |
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how can wilson's disease present?
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neuropsychiatric symptoms
extrapyramidal signs liver disease (asymptomatic hepatomegaly, deranged LFTs) |
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how does PSC present?
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* intermittent episodes of jaundice with dark urine
* FUO with night sweats * abdominal pain weight loss *cholestatic LFTs |
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how can PSC be treated?
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dilation of strictures/placement of endoprothesis at ERCP
dietary replacement of Vit A, D, E, K liver transplantation |
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how does behcet's present?
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oral and genital ulcers
eye disease skin disease pathergy |
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how does budd chiari present?
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triad: abdo pain, ascites, hepatomegaly
ascites has high protein content. |
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RUQ pain and fever, deranged LFTs in HIV pos patient?
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AIDS cholangiopathy
CMV and cryptosporidium associated disease |
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How to calculate SAAG?
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subtract ascitic albumin from serum albumin
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What does SAAG >1.1g/L mean? Which conditions is it associated with and what to look at to distinguish?
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"high albumin gradient ascites" -> portal hypertension
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protein >2.5 heart failure
protein <2.5 cirrhosis, budd-chiari |
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What does a SAAG <1.1 mean? What conditions is it associated with?
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"low albumin gradient ascites" -> normal portal venous pressure
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nephrotic syndrome, tuberculosis, cancer, pancreatic duct leak
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ascites due to pancreatitis
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amylase about 2000
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ascites with infection
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WBC about >500 or neutrophils >250 diagnostic
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ranson criteria at 24hours and 48hours
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at 24h
age >55 WCC >16 fasting glucose >11 LDH >350 AST >250 |
at 48h
hb decrease by 10% pO2 <8 serum Ca <2 BUN increase >1.8 Base deficit >4 fluid sequestration >6 litres |
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what serological markers favor crohn's over ulcerative colitis
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pANCA -ve
ASCA +-ve (anti-saccharomyces cervisiae) crohn - corona - beer!!! |
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cysts in pancreas? how to manage?
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pancreatic pseudocyst
serous cystadenoma mucinous cystadenoma von hippel lindau, polycystic kidney disease |
pseudocyst aspirated if >6cm
serous cystadenoma - annual follow up mucinous cystadenoma - can become malignant - resection von hippel lindau/polycystic - annual follow up for 4 years |
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how to confirm diagnosis of gilberts syndrome?
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non-haemolytic unconjugated hyperbilirubinaemia:
normal rest of LFTs no haemolysis (ret, haptaglobin) persistent high unconjugated bili (6 months) |
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gardners syndrome?
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polyps in colon with tumors outside
extracolonic tumors include osteomas, thyroid cancer, epidermoid custs, fibromas, sebaceaous cysts. |
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peutz-jeghers syndrome
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hamartomatous polyps in GI tract and hyperpigmented macules in lips and oral mucosa.
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diagnosis of toxic megacolon
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>6cm
signs of toxaemia at least 3: fever, HR >120, neutrophilia, anaemia |
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emergency treatment of toxic megacolon
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nasojejunal tube
manoevre to promote farting IV antibiotics |
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emergency treatment of AFLP
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FFP, correct hypoglycaemia, prompt c-section
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acute diarrhoe - bloody
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campylobacter
e.coli (0157) enteromoeba shighella latent UC |
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acute diarrhoe - non-bloody
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viral
cryptosporidium amoebia dysentery giardiasis latent crohn's, coeliac |
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chronic diarrhoe
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coeliac - bloating, mouth ulcer, low Fe, low Ca
bacterial overgrowth - low VB12, high folate chronic pancreatitis - steatorrhoe whipples - pleuritic pain, migratory arthritis, pericarditis, pigmentation, neuro sx carcinoid - fllushing, wheeze, hepatomegaly, TR/TS giardiasis - steatorrhoe HIV enteropathy - worse with milk lactose intolerance - worse with milk |
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familial colon cancer syndromes
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FAP
HNPCC - right sided colon cancer peutz-jegher's - mucocutaneous pigmentation, hamartomas gardner's - osteomas turcot's - medulloblastoma cowden's - orofacial papules/papillomas, macrocephaly, thyroid |
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crohn's disease treatment
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stop smoking (as effective as any other treatment)
steroids azathioprine nutritinal therapy 5ASA - NOT AS NEARLY AS EFFECTIVE surgery |
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azathioprine in crohn's
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steroid dependent, severe relapse, frequent relapses
flue like sx, muscle aches, nausea leukopenia opportunistic infections (VZV, CMV) safe in pregnancy |
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infliximab in crohn's
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contraindicated in active infections/malignancy. Rule out TB
infusion reactions |
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medical rx for acute severe UC flare up
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5ASA no role in acute severe UC!!!!
hydrocortisone IV rectal hydrocortisone enemas IV fluids + KCH heparin metronidazole if febrile/pos cultures normal E+D |
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indications for surgery in acute UC
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toxic megacolon if not resolving after 24-48hrs of intensive medical Rx
development of toxic megacolon during medical therapy perforation, massive bleeding patients failing to improve on day 3 (CRP >45, stool >8) should be discussed with surgeons |
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reye's syndrome
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potentially fatal disease causing damage to brain, liver and causing hypoglycaemia
mitochondrial damage due to aspirin in children <16 taking with viral infections fatty liver infiltration leading to hepatomegaly, minimal infiltration no jaundice cerebral: oedema, encephalopathy |
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entamoeba abscess
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entamoeba histolytica
cysts in food (destroyed by heat/freezing) travels from guts to portal vein, thus may cause bloody diarrhoe and then liver disease RUQ pain, tenderness, sepsis but no jaundice RLL effusion/consolidation, atelectasis |
USS/CT to visualise abscess
stool test (amoeba, pus, antigen) serology (to rule out only) Rx: metronidazole and diloxanide |
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schistosomiasis
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asia, africa, south america
frehswater snails - human: skin penetration, lung, portal vein hepatomegaly, portal hypertension, ALP elevated |
stool exam for eggs, best repeated as eggs can be missed on one only
rectal biopsy if negative Rx: praziquantel, antimony, castor oil. |
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child pugh score
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Ascites 1 none 2 mild 3 severe
Encephalopathy 1 none 2 mild 3 severe Bilirubin 1: <34 2: 34 -50 3: >50 Albumin 1: >35 2:35-28 3:<38 PT: 1:<4 2:4-6 3:>6 B C |
A <7 life expetancy 15-20 years
B 7-9 C 10+ life expectancy 1-3 years |
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management of cirrhosis
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6 monthly USS and AFP
reduced dietary salt, otherwise normal diet avoid NSAIDs/aspirin avoid EtOH, although small amounts okay in non-alcoholic cirrhosis |
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portal hypertension
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pressure exeeds 10-12mmHg
gastro-oesophageal junction, rectum, left renal vein, abdominal wall prehepatic, hepatic, posthepatic |
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posthepatic causes of portal hypertension
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prolonged congestive heart failure and TR, constrictive pericarditis
veno-occlusive disease |
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intrahepatic causes of portal hypertension (except cirrhosis)
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schistosomiasis
non-cirrhotic portal hypertension |
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how can you confirm acute upper GI bleed without OGD?
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aspiration of stomach with NGT
NOT SERIAL HB, NOT UREA |
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