UKMLA: Gastroenterology

Alcohol Withdrawal: How do you manage the general symptoms?

Oral chlordiazepoxide

Alcohol Withdrawal: How do you manage delirium tremens?

Oral or IV lorazepam → reduces seizures and hallucinations that occur 3 days after withdrawal

Alcohol Withdrawal: What are the symptoms of the complication hepatic encephalitis?

• Personality changes

• Sleep-wake disturbances

• Confusion

Alcohol Withdrawal: How do you manage hepatic encephalitis?

Lactulose→ laxative drug to expel ammonia

NAFLD: What are the symptoms?

• Fatigue

• RUQ pain

• Hepatomegaly

• Obese patient

NAFLD: What are the expected serology findings?

ALT > AST in 2:1 ratio

NAFLD: What is the gold standard investigation?

Liver biopsy

NAFLD: Which tests are required every 6 months?

US and alpha fetoprotein test for hepatocellular carcinoma

NAFLD: What is the management?

Pioglitazone

NAFLD: Which imaging modalities are used?

• Liver biopsy (gold standard)

• US → shows hepatic echogenecity

• Elastography→ stiff liver

• Enhanced liver fibrosis test→ liver fibrosis

Coeliac Disease: What are the symptoms?

• Fatigue

• Diarrhoea

• Mouth ulcers

• Weight loss

• Dermatitis herpetiformis (itchy rash on elbows/knees/buttocks)

Coeliac Disease: What are the expected serological findings?

• Anti-TTG positive (check IgA deficiency if anti-TTG test is negative)

• Anti-EMA positive

Coeliac Disease: What is the gold standard investigation?

Gastroscopy and duodenal biopsy→ Howell—jolly bodies and duodenal villous atrophy

Coeliac Disease: What foods are gluten-free friendly?

“CPR”:

• Corn

• Potato

• Rice

Coeliac Disease: Which genes are associated?

• HLA-DQ2

• HLA-DQ8

GORD: What are the causes?

• Defective lower oesophageal sphincter

• Hiatus hernia

• Reduced oesophageal motility

GORD: What are the symptoms?

• Hoarse voice

• Reflux

• Dyspepsia

• Dysphagia

• Nausea/vomiting

GORD: What is the gold standard investigation?

OGD with carbon-13 urea breath test to rule out H.pylori

GORD: What is the management?

PPI (omeprazole)

Haemochromatosis: What is the epidemiology?

• White Europeans

• C282Y mutation

• Co-morbidities include erectile dysfunction, amenorrhoea, mood disturbance, HF, diabetes, dilated cardiomyopathy, testicular atrophy

Haemochromatosis: What are the symptoms?

• Over 40 years old

• Fatigue

• Joint pain

• Hepatomegaly

• Darkened skin

Haemochromatosis: What are the expected serological findings?

• Increased ferritin

• Increased transferritin saturation

• Decreased iron binding capacity

Haemochromatosis: What is the investigation?

1. Transferrin saturation over 45%

2. C282Y gene mutation test

3. H63D gene mutation test

4. Perl stain and liver biopsy

Haemochromatosis: What is the management?

• Venesection (removing blood, decreases iron levels)

• Desferrioxamine

Ascites: What is the pathophysiology?

Fluid leaks into the peritoneal cavity→ BP in kidneys decrease→ renin is activated→ aldosterone is secreted→ more H20 and Na is reabsorbed

Ascites: What is the management?

• Low sodium diet

• Spironolactone

• Ciprofloxacin

Autoimmune Hepatitis: What are the symptoms?

• Fatigue

• Pain

• Jaundice

• Malaise

• Hepatomegaly

• Previous history of autoimmune disease (personally or in first-degree relative)

Autoimmune Hepatitis: What are the different types?

• Type 1→ typically affects older adults→ anti-smooth muscle antibody (ANA) positive

• Type 2→ typically affects younger girls/teens→ anti-microsomial antibodies (AMA) positive, anti-liver cytosol antibodies (anti-LC1) positive

Autoimmune Hepatitis: What is the management?

• Initial management → prednisolone

• Maintenance management→ azithioprine

Hepatitis: What are the symptoms?

• Vomiting

• Severe abdominal pain

• Jaundice

• Pruitus

• Flu-like symptoms

• Signs of acute liver failure

• Dark urine

• Pale stools

Hepatitis: What is hepatitis A?

• Virus→ RNA piconovirus

• Incubation period→ 2-6 weeks

• Transmission→ faecal oral

• Vaccine available?→ yes

• Management→ supportive

Hepatitis: What is hepatitis B?

• Virus→ DNA hepadnivirdae

• Incubation period→ 3-5 weeks

• Transmission→ bodily fluids

• Vaccine available?→ yes

• Management→ supportive and anti-virals

• Key information→ only managed medically in the vulnerable + is a major risk factor for hepatocellular carcinoma

Hepatitis: What is hepatitis C?

• Virus→ RNA flaviviridae

• Incubation period→ 6-9 weeks

• Transmission→ blood

• Vaccine available?→ no

• Management→ anti-virals

Hepatitis: What is hepatitis D?

• Virus→ RNA

• Transmission→ with hepatitis B

• Vaccine available?→ no

• Management→ pegylated interferon alpha

• Key information→ do a IgM, IgG test

Hepatitis: What is hepatitis E?

• Virus→ RNA

• Incubation period→ 2-9 weeks

• Transmission→ faecal-oral e.g. raw meat

• Vaccine available?→ no

• Management→ supportive

• Key information→ common in pregnant women leading to fulminate hepatitis (death!!!)

Hepatitis: What are the viral antibody and antigen markers?

• Surface antigen HBsAg→ active infection

• Surface antibodies HBsAb→ vaccination or past/current infection (immunity)

• E antigen HBeAg→ high infectivity and viral replication

• Core antibodies HBcAb→ past or current infection

• IgM anti-HBc positive→ acute infection

• IgG anti-HBc positive→ chronic infection

IBD: What are the symptoms of Crohn’s?

• Diarrhoea

• Abdominal pain

• Rectal bleeding

• Fatigue

• Weight loss

• Mouth ulcers

• Clubbing

• RLQ tenderness

IBD: What are the features of Crohn’s?

• N→ no blood

• E→ entire GI tract affected

• S→ skip lesions seen on endoscopy

• T→ terminal ileus and transmural inflammation

• S→smoking history

IBD: What are the risk factors?

• FH

• Smoking

• Poor diet

IBD: What is the onset?

• 15-40 years old + 60-80 years old→ Crohn’s

• 15-25 years old + 55-65 years old→ U.colitis

IBD: What are the dermatological signs?

• Pyoderma gangrenous

• Erythema nodosum (painful, on shins)

IBD: What are the ocular signs?

• Uveitis (painful, blurry, photophobic, red eye)

• Episcleritis (painless red eye)

IBD: What is the investigation?

Faecal calprotectin and endoscopy

IBD: What is the management?

1. Stop smoking

2. Oral prednisolone or IV hydrocortisone

3. Azithioprine or mecaptopurine → only prescribe after testing thiopurine methyltransferase levels first! (alternative is methotrexate)

4. Indiximab

IBD: What is the management of peri-anal abscess?

Incision and drainage

IBD: What is the management of peri-anal fistula?

1. IV ceftriaxone and metronidazole

2. Seton placement

IBD: What are the symptoms of ulcerative colitis?

• Tenesmus

• Weight loss

• Fever

• Anorexia

• Bloody diarrhoea

IBD: What are the features of ulcerative colitis?

• C→ continuous inflammation

• L→ limited to colon

• O→ only affects superficial mucosa

• S→ smoking is NOT a risk factor

• E→ excrete blood/mucus

• U→ use aminosalicylates

• P→primary sclerosing cholangitis

IBD: What are the expected histological findings for ulcerative colitis?

• Crypt abscesses

• Loss of goblet cells

• Inflammatory infiltrates

IBS: What are the symptoms?

• Intestinal discomfort worse after eating, improves after defecation

• Bowel habit abnormalities

• Stool abnormalities (watery, hard or mucusy)

IBS: What are the investigations?

To rule out differentials:

• FBC

• ESR

• CRP

• Anti-TTG

• CA125

• Faecal calprotectin→ if normal = IBS, if raised = IBD

IBS: What is the management?

• Diarrhoea→ loperamide

• Constipation→ 1) ispaghula husk 2) macrogol 3) chronic?= docusate

• Cramps→ mebeverine

• Anti-depressants→ amitriptyline

Hepatocellular Carcinoma: What are the symptoms?

• Jaundice

• Pain

• Ascites

• Encephalopathy

• Hepatomegaly

Hepatocellular Carcinoma: What conditions are associated?

• Liver cirrhosis

• Hepatitis B

• Do a 6-monthly US and AFP measurement

Hepatocellular Carcinoma: What is the management?

Surgical resection

Hepatocellular Carcinoma: What is the tumour marker?

Alpha fetoprotein

Liver Cirrhosis: What are the causes?

• Hepatitis B/C

• Alcohol liver disease

• Fatty liver disease

Liver Cirrhosis: What are the clinical signs?

• Hepatomegaly

• Splenomegaly

• Spider naevi

• Bruising

• Caput medusae (distended veins due to portal HTN)

• Leukonychia (white nails)

• Asterixis (flapping tremor)

• Jaundice

• Ascites

Liver Cirrhosis: What are the expected serological findings?

LFT:

• Increased bilirubin

• Increased ALT

• Increased AST

• Increased ALP

• Increased PT time

• Decreased platelets

• Decreased albumin

Liver Cirrhosis: What is the management of stable oesophageal varices?

Propanolol

Liver Cirrhosis: What is the management of unstable/bleeding oesophageal varices?

• Terlinpressin and ceftraxione

• TIPS

• Fresh frozen plasma

Liver Cirrhosis: What are the expected imaging findings?

US:

• Liver modularity

• Corkscrew artery appearance

• Enlarged portal vein

Liver Cirrhosis: Which scoring system is used for classification?

Child-Pugh cirrhosis severity score:

A→ albumin (increased)

B→ bilirubin (increased)

C→ clotting (decreased)

D→ dilation (ascites)

E→ encephalopathy

Liver Transplant: Which scoring system is used for eligibility?

Kings College Criteria→ PT time over 100 OR any 3 of the following:

• <10 years old or >40 years old

• 1 week presentation

• PT time over 50

• Bilirubin over 300

• Cr over 300

• Grade 3 or 4 encephalopathy (incoherent, restless, asterixis)

Liver Transplant: What is the criteria in patients with paracetamol overdose?

PH < 7.3 after 24 hours

Liver Transplant: What is the management of acute transplant rejection?

High dose IV methylprednisolone

Liver Transplant: What is the management of hyper-acute transplant rejection?

Remove graft

Peptic Ulcers: What are the symptoms?

• Dyspepsia

• Relieved by eating

• Pain restarts 2-3 hours after eating

• Nausea

• Vomiting

• Epigastric pain

• Usually duodenal

Peptic Ulcers: What are the causes of peptic ulcer bleeds?

• H.pylori

• NSAIDS

• SSRI’s

• Aspirin

• DOAC’s

Peptic Ulcers: What are the symptoms of peptic ulcer bleeding?

• Haematemesis

• Coffee ground vomit

• Malaena

• Increased urea

• Decreased Hb

Peptic Ulcers: Which scoring system is used for classification of peptic ulcer bleeds?

Glasgow-blatchford GI bleed score

Peptic Ulcers: What are the investigations?

• Over 55 y/o, weight loss and dyspepsia→ 2 week referral for OGD

• C-13 urea breath test for H.pylori

Peptic Ulcers: What is the management?

• PPI

• Stop smoking

• Improve diet

Primary Biliary Cholangitis: What are the symptoms?

• 40-60 y/o white woman (autoimmune condition)

• Fatigue

• Cholesterol deposits

• Pale, greasy stools

• Pruitus

Primary Biliary Cholangitis: What are the expected serological findings?

• Increased ALP

• Increased IgM

• AMA positive

Primary Biliary Cholangitis: What is the management?

Ursodeoxycholic acid and colestyramine for pruitus

Primary Sclerosing Cholangitis: Which condition is it associated with?

Ulcerative colitis

Primary Sclerosing Cholangitis: What are the risk factors?

• Male

• 30-40 y/o

• Ulcerative colitis

• Family history

Primary Sclerosing Cholangitis: What are the symptoms?

• RUQ pain

• Fatigue

• Pruitus

• Hepatomegaly

• Splenomegaly

Primary Sclerosing Cholangitis: What are the investigations?

• Increased ALP

• MRI scan (reveals hepatic strictures)

Wilson’s Disease: What is the pathophysiology?

• Autosomal recessive ATP7B gene mutation

• Causes accumulation of copper in the liver and brain

Wilson’s Disease: What are the symptoms?

• Haemolytic uraemia

• Jaundice

• Ataxia

• Drooling

• Psychiatric manifestations

• Kaiser-fleischer rings

Wilson’s Disease: What are the investigations?

1. Serum caeruloplasmin (<140mg)

2. 24 hour urine collection

3. ATP7B gene test

4. MRI (shows ganglia deterioration)

5. Biopsy

Wilson’s Disease: What is the management?

• Diet: no nuts or chocolate

• D-penicillamine

• Liver transplant

• Zinc salts

Pyloric Stenosis: What is the pathophysiology?

Pyloric sphincter hypertrophy causes obstruction

Pyloric Stenosis: What are the symptoms?

• Projectile vomiting

• Palpable abdominal mass

• Persistent hunger

• Weight loss

Pyloric Stenosis: What is the epidemiology?

Common in:

• Infants aged 6-8 weeks

• White males

• Premature babies

Pyloric Stenosis: What are the investigations?

• US→ 16mm length, 3-4mm thickness

• Low K+

• Low Cl-

• Metabolic alkalosis

Pyloric Stenosis: What is the management?

• NBM

• IV fluids

• Ramstead’s pylorotomy

Hirschsprung’s Disease: What is the pathophysiology?

Absent ganglion cells in the myenteric and submucosal plexuses→ obstruction

Hirschsprung’s Disease: What are the symptoms?

• No meconium

• Delayed meconium (>48 hours)

• Distended bowel

• Vomiting

• Constipation

• Poor weight gain

• Failure to thrive

Hirschsprung’s Disease: What is the management?

Rectal biopsy to confirm absence of ganglion cells→ remove this section

Intussusception: What is the pathophysiology?

Ileum folds onto the caecum→ obstruction

Intussusception: What are the symptoms?

• < 2 y/o infant

• Severe, colicky abdominal pain

• Green vomit

• Red-currant jelly stool

• Sausage shaped mass on palpation

• US→ donut or target sign

Intussusception: What is the management?

• Enema

• Bowel resection