Advanced GI, Liver Disease and Advanced Neurology Flashcards Preview

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Flashcards in Advanced GI, Liver Disease and Advanced Neurology Deck (27)
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Where is the most common place for a tablet to get stuck?

The Vuleculinc Space (behind the epiglottis)


Briefly explain the FOUR stages of swallowing

Oral Preparatory --> Senses stimulated by sight and smell, producing saliva. This is where chewing occurs and the bolus is formed


Oral Stage --> When the tongue propels the bolus towards the back of the throat. The soft pallate shuts off the nose


Pharyngeal Stage --> 'Wave like movement that occurs when swallowing' The airway closes and throat muscles contract to send the bolus into the oesophagus


Oesophageal Stage --> The time in which the bolus enters the oesophagus until in enters the stomach. Lasts between 8-20 seconds


What is the neuronal control of swallowing?

Sensory stimulation of receptors are sent to the 'swallow centre' in the medulla via afferent well as recieving input from supramedullary structures


Information is then sent back to the muscles via the efferent fibres




What are the THREE possible causes of Dysphagia?

Neurological --> Eg, strokes, MS, MND and Dementia


Structural --> Tumour of the neck, strictures, mouth ulcers and scarcopenic muscles changes (during natural ageing)


Mechanical --> Trachostomy tube in place, denture problems, infections (eg, thrush), learning disabilites and epilepsy


What are the 5 different types of Enteral tubes that can be put in?

Nasogastric --> Wide bore (cant be used for feeding) or fine bore. These are short term tubes and can be blocked easily


Post-Pyloric --> Through the nose, stomach, pyloric sphincter and small bowel. Used for patients with impaired gastric emptying (normally in ICU). These are very difficult to put in


Gastrostromy (PEG/RIG) --> Endoscope (or barium) into the stomach to allow a hole to be punched through and the tube placed. Can be used for overnight feeding and is more discrete, however more care is needed


Jejunostomy --> Surgically inserted into the jejunum (part of the small intestine) to prevent TPN use, but very easy to block and patients feel very bloated


Gastrojejunostomy --> A PEG tube is inserted into the jejenum. Easier to place than a jejunostomy, but still hard and can be blocked easily


What is Liver Cirrhosis?

Functional hepatocytes become non-functional stellate cells that make collagen


What are the 5 main LFTs?

Alanine Transaminase (ALT) --> Liver specific!


Aspartate Transaminase (AST) --> Found in the liver, heart, skeletal muscle pancreas and muscle (so not very specific)

Both released from heaptocytes when damaged however


Alkaline Phosphatase (ALP) --> Indicates biliary tract involvement....also found in the liver, bone, intestine and placenta


Gamma-Glutamyl Transferase (GGT) --> Increased by enzyme induction (eg, alcohol and cancers). Also found all over the body


Billirubin --> Indicates billary tract involvement. A product of RBC breakdown that is conjugated, beocming water-soluble and excreted via the bile into the intestines and urine. Will cause yellow skin


In Chronic Liver Disease, what effect is there on Albumin levels?


And what effect will this have on specific drugs?

Lower concentration


So higher free drug concentration of highly bound drugs like phenytoin


In liver impairment, what ADME effects are there?

Absorption --> Decreased hepatic blood flow, so decreased first pass effect (increased dose of normal drugs, less for pro-drugs)


Distribution --> Increased V of water soluble drugs due to ascites, so increased concentrations

Low albumin will cause an increase active drug for highly bound drugs


Metabolism --> Accumulation of drug (especially pro-drugs) due to decreased enzymatic activity


Elimination --> Cholestasis causes a decrease in elimination of drugs via the bile, causing reduced enterohepatic circulation


What effect does alcohol have on the liver?

An increase in fat production (steatosis), potentially causing fatty liver disease

Then causes destruction of hepatocytes by neutrophillic infiltration


Why should tramadol be avoided in Liver Cirrhosis?

Half life doubles

Lowers the seziure threshold


What are the TWO types of Stroke?

Ischemic Stroke --> A clot in the brain

Becomes a TIA if symptoms present for less than 24hrs


Haemorrhagic Stroke --> Bleed in the brain


Explain what Thrombolysis is and what a Thrombectomy is 

Thrombolysis --> Dissolving the plot using Alteplase (t-PA) a clot busting drug that breaks down plasminogen to plasmin. Should be done ASAP and regardless of if thrombectomy occurs or not


Thrombectomy --> A thin tube is inserted into a vein (via the groin) and into the brain that grabs the clot

The procedure must be done within 6 hours of the stroke occuring


What are the TWO types of Haemorrhagic Stroke?


And what are their treatments?

Subarachnoid (SAH) --> Surgical intervention needed, and often nimodipine


Intracranial (ICH) --> Symptomatically managed... so BP below 160mmHg within 6 hours and 140mmHg for 7 days


What are the THREE types of MS?


And how is the condition managed?


Primary progressive

Progressive relapsing


Sympomatically managed to prevent spasms, fatigue, actue flares and disease progression


If the gut is affected by a disease, nutritionally what is likely to occur?

Digestion and absorption will change


Pain may also present due to the large nerve supply


Can cause incontinence due to the gut pushing things further down the colon


What is the ERAS Protocol in terms of nutrition and surgery?

Enhanced Recovery After Surgery (ERAS)


Where glucose is taken just before surgery to prevent insulin resistance (speeding up gut recovery)


Avoid prolonged fasting pre-op also


What type of liquids will somebody with a stoma require?


And why?



This is because normal liquids (hypotonic) cause sodium to be pulled into the small intestine (and so draw water with it), causing dehydration


What is PERT?


(In terms of nutrition)

Parcreatic Enzyme Replacement Therapy (PERT) such as Creon and Nutrizym


This should be titrated to demand, with yellow/oily stools suggesting that they are being underdosed




What are the 4 main complications that can occur due to enteral feeding?






What is the basic reason for why psychosis occurs?

Increased dopamine levels in the mesolimbic pathway


What is Clozapine?

Drug used for when anti-psychotics just don't work


Licenced for 'Treatment resistent schizophrenia'


Major burden = side effects


What is a major interaction with clozapine?



If a patient stops smoking on treatment then dose reviews will be needed


Why is anticoagulation contraindicated in haemorrhagic strokes?

As it is a bleed on the you don't want to thin the blood any more!


If it present then you may need to use reversal agents


What is the major potential adverse effect of thrombolysis with Alteplase tPA?

Haemorrhagic transformation


Need to check for significant bleeding risks when assesing the patient


What is the first line DOAC for AF secondary prevention?



When would IPC (intermittent pneumatic compression) devices be used?

For VTE prophylaxis in stoke patients when there are no contradictions to them



Leg ulcers

Peripheral vascular disease

Severe oedema/heart faliure

Exisiting VTE