Gastro Flashcards
(304 cards)
1
Q
definition of diarrhoea?
A
increased stool water
-> increased freq
2
Q
definition of steatorrhoea?
A
increased stool fat
-> pale, float, smelly
3
Q
Causes of bloody diarrhoea?
A
vascular: ischaemic colitis
infective: campylobacter, shigella, salmonella, e coli, c diff
Inflammatory: UC, crohns
Neoplastic: polyps, colorectal ca
4
Q
differential for pus w diarrhoea?
A
IBD
diverticulitis
abscess
5
Q
differential for mucus w diarrhoea?
A
IBD
colorectal ca
polyps
6
Q
diarrhoea due to systemic disease?
A
hyperthyroid
autonomic neuropathy
carcinoid
7
Q
diarrhoea assoc w drugs?
A
Abx
PPI, cimetidine
NSAIDs
digoxin
8
Q
Ix of Diarrhoea?
A
Bloods: anaemia, WCC, U+Es
ESR/CRP
coeliac serology: anti-TTG or anti-endomysial Abs
Stool culture: MCS and c diff toxin
9
Q
Mx of diarrhoea?
A
tx cause
oral or IV rehydration
codeine phosphate or loperamide after each loose stool
anti emetic if assoc w n+V: e.g. prochlorperazine
abx e.g. cipor in infective diarrhoea -> systemic illness
10
Q
risk factors for c diff pseudomembranous colitis?
A
abx use e.g. clindamycin, cephalosporins, augmentin, quinolones
increased age
in hospital: contact, length of stay
PPIs
11
Q
complications of pseudomembranous colitis?
A
paralytic ileus
toxic dilatation -> perforation
multi organ failure
12
Q
features of pseudomembranous colitis?
A
severe systemic features: fever, dehydration
Abdo pain, bloody diarrhoea, mucus PR
pseudomembranes (yellow plaques) seen on flexi sig
13
Q
Mx of C diff Pseudomembranous colitis?
A
General:
stop causative abx
avoid antidiarrhoeals and opiates
1st line: Metronidazole 400mg TDS Po 10-14d
2nd: Vanc 125 mg PO 10-14d
Urgent colectomy may be needed if toxic megacolon, deteriorating condition, raised LDH
14
Q
Mx of recurrence of C diff pseudomembranous colitis?
A
repeat course of metro 10-14d
if further relapses -> vanc
15
Q
Mx if extremely severe C dff colitis?
A
Vancomycin 1st line PO may add metro IV
16
Q
What determines severe pseudomembranous colitis?
A
WCC >15
Cr >50% above baseline
Temp >38.5
Clinical / radiological evidence of severe colitis
1 or more of the following
17
Q
definition of IBS?
A
disorders of enhanced visceral perception -> bowel symptoms for which no organic cause can be found
18
Q
Diagnosis of IBS?
A
ROME criteria
Abdo discomfort/ pain for ≥12 wks which has 2 of:
- relieved by defecation
- diarrhoea/ constipation
- change in stool form: pellets, mucus
+2 of:
- urgency
- incomplete evacuation
- abdo blating/ distension
- mucous PR
- worsening symptoms after food
Exclusion criteria:
>40yo, bloody stool, anorexia, weight loss, diarrhoea at night
19
Q
Ix of IBS?
A
Bloods: FBC, ESR, LFT, coeliac serology, TSH
Colonoscopy: if > 60 yo or any features of organic disease
20
Q
Mx of IBS?
A
Exclusion diets can be tried
Bulking agents for constipation and diarrhoea (e.g. fybogel)
antispasmodics for colic/ bloating e.g. mebeverine
Amitriptyline may be helpful
CBT
21
Q
definition of constipation?
A
Infrequent Bowel movements (≤ 3/wk) or passing BMs less often than normal or w difficulty, straining or pain.
22
Q
Causes of constipation?
A
Mechanical obstruction: adhesions, hernia, cancer, inflamm strictures
non-mechanical: post op ileus
pain: anal fissure
endocrine: hypothyroid, hypoCa/K, uraemia
Neuro: MS, myelopathy, cauda equina
elderly
diet/ dehydration
IBS
toxin: opioids, anti muscarinics
23
Q
Mx of constipation?
A
General: drink more, increase dietary fibre
Bulking agents to increase faecal mass -> increase peristalsis
e.g. bran, ispaghula husk (fybogel), methylcellulose
Osmotic agents to retain fluid in bowel
e.g. lactulose
Stimulant: increase intestinal motility and secretion
e.g. senna
Softeners e.g. liquid paraffin
enemas: e.g. phosphate enema (osmotic)
Suppositories: Glycerol (stimulant)
24
Q
When are bulking agents for constipation contraindicated?
A
fybogel (Ispaghula husk), bran, methylcellulose
obstruction, faecal impaction
25
when are stimulant laxatives contraindicated?
Obstruction
acute colitis
e.g. Senna, Bisacodyl, Docusate sodium
Glycerol suppositories
26
definition of dysphagia?
difficulty swallowing
27
Inflammatory causes of Dysphagia?
tonsillitis, pharyngitis
Oesophagitis: GORD, candida
Apthous ulcers
28
Mechanical causes of dysphagia?
Luminal:
large food bolus
Mural:
Benign stricture (plummer vinsoons, oesophagitis, trauma eg. OGD)
Malignant Stricture
Pharyngeal pouch
Extra mural:
Lung Ca, rolling hiatus hernia, mediastinal LNs, retrosternal goitre, thoracic aortic aneurysm
29
Causes of dysphagia?
inflammatory: inc infection
Mechanical block: luminal, mural, extramural
Motility: local, systemic
30
Motility disorders causing dysphagia?
local:
achalasia
diffuse oesophageal spasm
nutcracker oesophagus
bulbar/ pseudobulbar palsy (CVA/ MND)
systemic:
systemic sclerosis/ CREST
Myasthenia gravis
31
dysphagia for liquids and solids at start?
motility disorder
32
dysphagia for solids first then liquids?
stricture/ expanding mass
33
intermittent dysphagia for liquids and solids?
oesophageal spasm
34
dysphagia
neck bulges or gurgles on drinking?
pharyngeal pouch
35
odonophagia (pain) + dysphagia?
Ca, oesophageal ulcer, spasm
36
signs of dysphagia?
Cachexia
Anaemia
Virchows node
Neurology
Signs of systemic disease e.g. scleroderma
37
Ix of Dysphagia?
Bloods: FBC, U+E
CXR
OGD
Barium swallow
oesophageal manometry
38
Achalasia
birds beak sign on barium swallow
- dilated tapering oesophagus
39
Diffuse oesophageal spasm
Ba swallow shows corkscrew oesophagus
40
definition of dyspepsia?
non specific group of symptoms:
epigsatric pain, bloating, heartburn
41
ALARM symptoms of dyspepsia?
Anaemia
Loss of weight
Anorexia
Recent onset progressive symptoms
Melaena or haematemesis
Swallowing difficulty
42
Causes of dyspepsia?
Inflammation: GORD, gastritis, Peptic ulcer disease
Ca: oesophageal, gastric
Functional: non-ulcer dyspepsia
43
initial mx of new onset dyspepsia?
OGD if \>55 or ALARMS
try conservative measures for 4 wks:
stop drugs NSAIDs, CCBs (relax LOS)
Lose weight, stop smoking, less alcohol
avoid hot drinks, spicy food
OTC antacids, alginates (gaviscon)
44
mx of new onset dyspepsia if conservative measures dont work after 4 wks?
Test for H pylori if no improvement: breath or serology
+ve -\> eradication therapy
-ve -\> PPI trial for 4 wks
consider OGD if no improvement
45
Mx of proven GORD?
Full dose PPI e.g. omeprazole/ lansoprazole
(inhibits acid secretion) for 1-2 mo
then low dose PPI PRN
46
Mx of proven peptic ulcer disease?
Full dose PPI e.g. lansoprazole for 1-2mo
H pylori eradication if positive: Omeprazole, clari, amoxicillin
Endoscopy to check for resolution if gastric ulcer
then low dose PPI PRN
47
What is H Pylori eradication therapy?
note: PPIs and cimetidine -\> false -ve C13 breath tests -\> stop 2 wks before
7 days tx
PAC 500:
PPI lansoprazole 30mg BD, Amoxicillin 1g BD, Clarithromycin 500mg BD
or
PMC 250:
PPI lansoprazole 30mg BD, Metronidazole 400mg BD, Clarithromycin 250mg BD
95% success, failure due to poor compliance -\> add bismuth
48
what medications may cause False -ve C13 breath and antigen tests for H pylori?
PPI
cimetidine
49
Differentials for Haematemesis?
Vascular: Oesophageal varices, Angiodysplasia, Dieulafoy lesion (rupture of large arteriole in stomach)
Inflammation: PUD (DU most common cause), oesophago/ gastro/ duodenitis
Trauma: mallory-weiss tear, Boerhaave's Syndrome, Hereditary Haemorrhagic Telangiectasia (Osler-Weber-Rendu)
General bleeding diasthesis: Warfarin, thrombolytics, liver failure
50
Differential for Rectal Bleeding?
Vascular: Haemorrhoids, lower GI bleed, ischaemic colitis, HHT (osler weber rendu), angiodysplasia
Diverticulae
Infection: Campylobacter, Shigella, Salmonella, C diff, E col
Inflammation: UC, Crohns
Neoplasia
Polyps
51
When is jaundice visible?
at 3x Upper normal limit
50 uM
52
How is Hb converted to unconjugated Br?
by splenic macrophages
53
How is unconj Br converted to conj Br?
by BR-UDP-glucuronyl transferase in liver
54
what makes stools dark?
stercobilinogen (brown)
which was converted from urobilinogen
55
Causes of post hepatic jaundice?
Obstruction:
stones, ca of pancreas
drugs
PBC, PSC
biliary atresia
cholangioca
choledochal cyst
56
hepatic causes of jaundice?
decreased Br uptake:
drugs- contrast, rifampicin
CCF
decreased Br conjugation:
Gilberts (AD), Hypothyroidism, Crigler-Najjar (AR)
hepatocellular dysfunction:
- congenital: HH, Wilsons, a1ATD
- infection: Hep A/B/C, CMV, EBV
- toxin: alcohol, drugs
- Autoimmune hepatitis
- Neoplasia: mets, HCC
- Vasc: budd-chiari
decreased hepatic br excretion:
Dubin-Johnson
Rotors
57
Hepatic causes of jaundice?
due to hepatocellular dysfunction
- congenital: HH, Wilsons, a1ATD
- infection: Hep A/B/C, CMV, EBV
- toxin: alcohol, drugs
- Autoimmune hepatitis
- Neoplasia: mets, HCC
- Vasc: budd-chiari
58
What causes hepatic jaundice due to decrease br conjugation?
Gilberts (AD), Hypothyroidism, Crigler-Najjar (AR)
59
causes of pre-hepatic jaundice?
increased Br production
Haemolytic anaemia
ineffective erythropoiesis e.g. thalassaemia
60
What causes hepatic jaundice due to decreased br uptake?
drugs: contrast, rifampicin
CCF
61
What is Gilberts syndrome?
auto dom
partial UDP-GT deficiency
jaundice occurs during intercurrent illness
62
diagnosis of Gilberts?
increased unconj Br on fasting
normal LFTs
63
What is Crigler Najjar syndrome?
rare auto recessive
total UDP-GT deficiency
cant conjugate Br
- \> severe neonatal jaundice and kernicterus
tx: liver transplant
64
Mx of Crigler Najjar?
liver transplant
65
Drug induced jaundice
what drug causes haemolysis?
antimalarials e.g. dapsone
66
drug induced jaundice
what drugs cause hepatitis?
Paracetamol OD
Rifamp, Isoniazid, Pyrazinamide
Valproate
Statins
Halothane
67
drug induced hepatitis
what drugs cause cholestasis?
fluclox
co-amoxiclav
OCP
sulfonylureas
chlorpromazine, prochlorperazine
68
Ix of Jaundice
Post hepatic obstruction?
Pale stools, dark urine
Urine: high bilirubin, no urobilinogen
LFTs: high conj Br, high ALP (higher than raise in ALT/AST), high GGT
Abdo US: ducts \> 6mm, ERCP/ MRCP
Abs: anti-mitochondrial, ANCA, ANA
69
Ix of jaundice?
hepatic cause
Urine: high Br, high urobilinogen
LFTs: usually high conj Br,
high AST and ALT (if AST VV high -\> alcohol, if ALT vv high -\> viral)
GGT high
Function: low albumin, prolonged PT
FBC: anaemia
Abs: Anti-SMA, LKM, SLA, ANA
a1AT, ferritin, caeruloplasmin
Liver biopsy
70
Ix of jaundice?
pre hepatic cause
Urine: no Br, high urobilinogen, high Hb
LFTs: high unconj Br, LDH, AST
FBC and blood film
Coombs test
Hb electrophoresis
71
Causes of Liver Failure?
Cirrhosis
Acute:
infection- Hep A/B, CMV, EBV, leptospirosis
Toxin- alcohol, paracteamol, isoniazid, halothane
Vasc: budd chiari
Other- wilsons, autoimmune hepatitis
Obs- eclampsia, acute fatty liver of pregnancy
72
Signs of liver failure?
jaundice
oedema + ascites
bruising
encephalopathy - asterixis
fetor hepaticus
signs of cirrhosis/ chronic liver disease
73
Ix of Liver Failure?
FBC
U+Es: hepatorenal syndrome
LFTs: low albumin
Clotting: raised INR
Glucose
ABG: metabolic acidosis
Cause: ferritin, a1AT, caeruloplasmin, Abs, paracetamol levels
Hepatitis viral serology
Blood and urine culture
ascites tap for MCS + clinical chemistry
Imaging: CXR, Abdo US + portal vein duplex
74
what is hepatorenal syndrome?
renal failure in pts w advanced chronic liver failure
diagnosis of exclusion
cirrhosis -\> splanchnic arterial vasodilation -\> effective circulatory vol -\> RAS activation -\> renal arterial vasoconstriction
persistent underfilling of renal circ -\> failure
75
Classification of Hepatorenal syndrome?
Type 1: rapidly progressive deterioration (survival \<2 wks)
Type 2: steady deterioration (survival 6 mo)
76
Mx of Hepatorenal syndrome?
IV albumin + splanchnic vasoconstrictors (terlipressin)
Haemodialysis as supportive mx
Liver transplant
77
Mx of Liver Failure?
Manage in ITU
tx underlying cause
good nutrition - via NGT w high carbs
thiamine supplements
prophylactic PPIs vs stress ulcers
78
Monitoring in Liver Failure?
Fluids: urinary and central venous catheters
Bloods: daily FBC, U+E, LFT, INR
Glucose: 1-4 hrly + 10% dextrose IV 1L /12h
79
Complications of liver failure?
Bleeding: Vit K, platelets, FFP, blood
Sepsis: tazocin
Ascites: fluid+salt restrict, spiro, fruse, tap, daily weight
Hypoglycaemia: regular BMs, IV glucose if \<2 mM
Encephalopathy: avoid sedatives, lactulose
Seizures: lorazepam
Cerebral oedema: mannitol
80
prescribing in liver failure?
what to avoid
avoid: opiates, oral hypoglycaemics, Na-containing IVI
warfarin effects increase
hepatotoxic drugs: paracetamol, methotrexate, isoniazid, salicylates, tetracycline
81
Poor prognostic factors in liver failure?
grade 3/4 hepatic encephalopathy
age \>40
albumin\<30g/L
raised INR
drug induced liver failure
82
Criteria for Liver Transplant in Paracetamol induced liver failure?
pH\< 7.3 24h after ingestion
or all of:
PT\>100s
Cr \>300
Grade 3/4 encephalopathy
83
Kings College Hospital Criteria for liver transplant in non-paracetamol induced liver failure?
PT\> 100s
or 3 out of 5 of:
- drug induced
- age \<10 or \>40
- \>1 wk from jaundice to encephalopathy
PT\> 50s
BR\>300
84
causes of cirrhosis?
Common:
chronic Alcohol
chronic Hep C and hep B
Non-alcoholic fatty liver disease/ NASH
Other:
genetic: wilsons, a1ATD, HH, CF
AI: AIH, PBC, PSC
Drugs: methotrexate, amiodarone
neoplasm: HCC, mets
Vasc: budd chiari, RHF, constrictive pericarditis
85
signs of cirrhosis in hands?
clubbing
leuconychia (hypoalbumin)
Terry's nails (white proximally, red distally)
Palmar erythema
Dupuytrens contracture
86
Signs of cirrhosis in the face?
Pallor: ACD
Xanthelasma: PBC
Parotid enlargement: alcohol excess
87
signs of cirrhosis in the trunk?
spider naevi (\>5, fill from the centre)
gynaecomastia
loss of secondary sexual hair
88
signs of cirrhosis in the abdomen?
striae
hepatomegaly (may be small in late disease)
splenomegaly (portal HTN)
dilated superficial veins (caput medusae)
testicular atrophy
89
signs of chronic liver disease?
palmar erythema
dupuytrens contracture
gynaecomastia
spider naevi
clubbing
90
signs of decompensation -\> liver failure?
jaundice
encephalopathy: asterixis
hypoalbuminaemia -\> oedema + ascites
coagulopathy -\> bruising
91
signs of portal HTN?
splenomegaly
ascites
varices: oesophageal varices, caput medusa
92
complications of cirrhosis?
decompensation -\> liver failure
(jaundice, encephalopathy, oedema, bruising)
Portal HTN: splenomegaly, ascites, varices
spontaneous bacterial peritonitis
increased risk of HCC
93
Ix of cirrhosis?
Bloods:
FBC: low WCC, low Pl indicate hypersplenism
LFTs
Prolonged INR
low Albumin
find cause:
alcohol: high MCV, GGT
NASH: hyperlipidaemia, high glucose
infection: hepatitis, EBV, CMV serology
Genetic: ferritin, a1AT, caeruloplasmin (low in wilsons)
Autoimmune: Abs
Ca: alpha-fetoprotein
Abdo US + Portal Vein Duplex
Ascitic Tap + MCS
Liver Biopsy
94
what tumour marker is assoc w HCC?
Alpha fetoprotein
95
what may you see on abdo US + portal vein duplex in cirrhosis?
small/ large liver
focal lesions
reversed portal vein flow
ascites
96
Ascitic tap + MCS in cirrhosis?
PMN \> 250 mm3 indicated SBP
97
general mx of cirrhosis?
good nutrition
alcohol abstinence: baclofen can help reduce cravings
colestyramine for pruritus
screening for HCC: US and AFP & oesophageal varices: endoscopy
98
tx of wilsons?
penicillamine
99
tx of PBC?
ursodeoxycholic acid
100
tx of Hep C virus -\> Cirrhosis?
IFNa
101
Monitoring for varices in cirrhosis?
OGD screening + banding
102
Monitoring for HCC in cirrhosis?
US + AFP every 3-6 mo
103
Mx of ascites in cirrhosis?
fluid and salt restrict
spironolactone
frusemide
ascitic tap
daily weights
104
Mx of coagulopathy in cirrhosis?
Vit K
platelets
FFP
blood
105
Mx of encephalopathy in cirrhosis?
avoid sedatives, lactulose+/- enemas, rifaximin
106
Mx of hepatorenal syndrome in cirrhosis?
IV albumin + terlipressin
107
Mx of Spontaneous bacterial peritonitis in cirrhosis?
Tazocin
108
What is Child-Pugh Grading of cirrhosis?
predicts risk of bleeding, mortality and need for tx
Graded A-C using severity of 5 factors
Albumin
Bilirubin
Clotting
Distension: ascites
Encephalopathy
Score \>8 = significant risk of variceal banding
109
110
Causes of Portal HTN?
Pre-hepatic:
portal vein thrombosis e.g. pancreatitis
Hepatic:
cirrhosis (most common), schisto (most common worldwide), sarcoidosis
Post Hepatic: Budd Chiari, constrictive pericarditis, congestive HF -\> congestive splenomegaly
111
Where are the likely locations for porto-systemic anastamoses?
Oesophageal varices:
left and short gastric veins + inf oesophageal veins
Caput Medusae:
Peri umbilical veins + superficial abdo wall veins
rectal (haemorrhoids):
Superior rectal veins + inf and mid rectal veins
112
difference between caput medusae and prominent abdo veins?
blood flow down below the umbilicus: portal HTN
blood flows up below the umbilicus: IVC obstruction
113
Caput Medusae
114
pathophysiology of hepatic encephalopathy?
decreased hepatic metabolic function -\> diversion of toxins from liver directly into systemic system
ammonia accumulates and pass to brain where astrocytes clear it causing glutamate -\> glutamine
high glutamine -\> osmotic imbalance -\> cerebral oedema
115
classification of hepatic encephalopathy?
1. Confused - irritable, mild confusion, sleep inversion
2. Drowsy - disoriented, slurred speech, asterixis
3. Stupor - rousable, incoherent
4. Coma - unrousable, upgoing plantars
116
presentation of hepatic encephalopathy?
Asterixis, ataxia
confusion
dysarthria
constructional apraxia
seizures
117
precipitants of hepatic encephalopathy?
Haemorrhage: varices
Electrolytes: low K/Na
Poisons: diuretics, sedatives, anaesthetics
Alcohol
Tumour: HCC
Infection: SBP, pneumonia, UTI
Constipation (commonest cause)
Sugar (glucose) e.g. low calorie diet
118
Ix of hepatic encephalopathy?
raised plasma NH4
119
Mx of hepatic encephalopathy?
Nurse 20o head up
correct any precipitants
avoid sedatives
**Lactulose** +/- PO4 enemas to decrease Nitrogen-forming bowel bacteria
Consider rifaximin PO to kill intestinal microflora
120
pathophysiology of ascites?
back pressure -\> fluid exudation
decrease in effective circulating vol -\> RAS activation
In cirrhosis: low albumin -\> low plasma oncotic pressure
all lead to fluid within abdominal space
121
symptoms of ascites?
distension -\> abdo discomfort and nausea
dyspnoea
decreased venous return
122
differential of ascites?
according to Serum Ascites Albumin Gradient (SAAG)
**SAAG \>/= 1.1g/dL = Portal HTN (97% accuracy)**
- pre, hepatic and post
- 80% due to cirrhosis
**SAAG \< 1.1g /dL = other causes**
Neoplasia: peritoneal, ovarian
Inflammation e.g. pancreatitis
Nephrotic syndrome
Infection: TB peritonitis
123
Ix of ascites?
Bloods: FBC, U+E, LFTs, INR, chronic hepatitis screen
US: confirm ascites, liver echogenicity, PV duplex
Ascitic tap: MCS, Cytology, chemistry, SAAG = serum albumin - ascites albumin
Liver biopsy
124
Mx of ascites?
daily weight aiming for = 0.5kg/d reduction
fluid restrict \<1.5L /d and low Na diet
spironolactone + frusemide (if response poor)
therapeutic paracentesis w albumin infusion (100ml 20% albumin/ L drained)
Refractory: TIPSS
125
prophylaxis against spont bacterial peritonitis if high recurrence?
ciprofloxacin long term
126
features of splenomegaly?
splenic congestion
hypersplenism: overactive spleen, removes blood cells too early and too quickly (low WCC, low Pl)
127
alcoholism effects on the body?
**Liver:**
fatty liver -\> hepatitis -\> cirrhosis
AST:ALT\>2, raised GGT
**GIT:**
gastritis, erosions
PUD
varices
pancreatitis
carcinoma
**CNS:**
poor memory/ cognition
peripheral neuropathy (mainly sensory)
\*Wernickes encephalopathy: confusion, ataxia, ophthalmoplegia
Korsakoffs: amnesia -\> confabulation
Fits, falls
**Heart**:
arrhythmias e.g. AF
dilated cardiomyopathy
high BP
**Blood:**
raised MCV
folate / B12 deficiency -\> macrocytic anaemia
128
Features of alcohol withdrawal?
10-72h after last drink
raised HR, low BP, tremor
confusion, fits, hallucinations esp formication (DTs)
129
Mx of alcohol withdrawal acutely?
Tapering regimen of chlordiazepoxide PO
/ lorazepam IM
thiamine - Pabrinex
130
Mx of alcohol withdrawal long term?
Group therapy (AA) or self help
Baclofen: reduce cravings
Acamprosate: reduce cravings
Disulfiram: aversion therapy
131
presentation of alcoholic hepatitis?
anorexia
D/V
tender hepatomegaly
ascites
severe: jaundice, bleeding, encephalopathy
132
Ix of alcoholic hepatitis?
Bloods: high MCV, GGT, AST:ALT\>2
ascitic tap
abdo US + PV duplex
133
Mx of alcoholic hepatitis?
1. corticosteroids (mx of severe alcoholic hepatitis)
stop alcohol
tx withdrawal
Pabrinex
optimise nutritiion
daily weight, LFT, U+E, INR
mx complications of liver failure
134
cause of Hep D infection?
prior Hep B infection
135
presentation of viral hepatitis?
_prodromal phase: seen in Hep A/ B_
flu-like, malaise, arthralgia, nausea
distaste for cigarettes in Hep A
_icteric phase:_
Acute jaundice in A\>B\>C (99, 75, 25%)
hepatitis - abdo pain, hepatomegaly, cholestasis: dark urine, pale stools
Extraheparic features due to complexes (esp Hep B):
urticaria, vasculitic rash
cryoglobulinaemia
PAN
GN
Arthritis
136
Ix that confirms dx of chronic Hep B?
HBsAg +ve \> 6mo
137
Ix that confirms dx of chronic Hep C?
HCV RNA +ve \> 6mo
138
Which viral hepatitis is more likely to develop into chronic hepatitis?
Hep C: 80%
-\> 20% develop cirrhosis
Hep B: 10%
-\> 5% develop cirrhosis
139
Ix of viral hepatitis?
FBC, LFTs, clotting
Hep A/B/C serology
140
Mx of acute viral hepatitis?
supportive:
no alcohol, avoid hepatotoxic drugs e.g aspirin
141
Mx of chronic Hep B?
PEG-IFN alpha, IFN alpha 2a
antivirals e.g tenoforvir, lamivudine
142
Mx of chronic Hep C?
PEG-IFN
+ ribavarin
US surveillance for HCC
143
what is non alcoholic fatty liver disease?
hepatitis and cirrhosis assoc w insulin resistance and metabolic syndrome
NASH is most extreme form and -\> cirrhosis in 10%
144
risk factors of Non alcoholic fatty liver disease?
obesity
HTN
T2DM
hyperlipidaemia
145
presentation of NAFLD?
mostly asymptomatic
hepatomegaly and RUQ discomfort may be present
metabolic syndrome: central obesity
146
what is metabolic syndrome?
central obesity (high waist circumference) + 2 of:
high triglycerides
low HDL
HTN
hyperlipidaemia: DM, IGT, IFG
147
Ix of NAFLD?
BMI
Glucose, fasting lipids
raised transaminases: AST:ALT\<1
liver biopsy
148
mx of NAFLD?
lose weight
control HTN, DM, lipids
149
what is Budd Chiari syndrome?
hepatic vein obstruction -\> ischaemia and hepatocyte damage -\> liver failure or insidious cirrhosis
150
Causes of Budd Chiari Syndrome?
hypercoagulable states: myeloproliferative disorders (PV = commonest cause), PNH, anti phospholipid, OCP
Local tumour: HCC
Congenital: membranous obstruction of IVC
151
presentation of Budd chiari syndrome?
RUQ pain: stretching of Glissons capsule
Hepatomegaly
Ascites: SAAG \>/= 1.1g/dL
Jaundice + other features of liver failure
152
Ix of budd chiari syndrome?
Bloods: FBC, clotting, LFTs
**US + hepatic vein doppler**
Ascitic tap: high protein + high SAAG
JAK2 mutation analysis, RBC CD55/59
153
Mx of Budd Chiari syndrome?
**anticoagulate** unless varices present
**ascites**: fluid/ salt restrict, spiro, fruse, tap, daily weight
consider thrombolysis, angioplasty, TIPSS
transplant if fulminant hepatic failure or cirrhosis
tx underlying cause
154
haemochromatosis inheritance?
auto recessive
155
what gene is involved in haemochromatosis?
HFE gene
156
what organs are involved in haemochromatosis?
liver (cirrhosis)
heart (cardiomyopathy), skin (bronzed pigmentation/ slate grey), pancreas (diabetes)
gonads (atrophy and impotence)
parathyroid (hypoCa, osteoporosis)
arthritis
157
Perl's Prussian blue stain +ve
haemochromatosis
158
pathophysiology of hereditary haemochromatosis?
inherited, multisystem disorder resulting from abnormal iron metabolism
increased intestinal Fe absorption -\> deposition in multiple organs
e.g. liver, heart, pancreas, pituitary, skin, parathyroids
159
Ix of hereditary haemochromatosis?
Bloods: ↑LFT, ↑ferritin, ↑Fe, ↓TIBC, glucose, genotype
Xray: chondrocalcinosis
ECG, Echo: arrhythmias, cardiomyopathy
Liver biopsy: Perls stain to quantify Fe and severity
MRI: can estimate iron loading
160
Mx of hereditary haemochromatosis?
Iron removal:
venesection - aim for Hct \<0.5
Desferrioxamine 2nd line
General:
monitor DM
Low Fe diet
Screening:
Se ferritin and genotype
Screen 1st degree relatives
transplant in cirrhosis (cirrhotic pts have \>10% risk of HCC)
161
emphysema in lungs and cirrhosis - deficiency in?
alpha1- antitypsin
lack of inhibition of neutrophil proteases -\> destruction of tissues
162
what gene is implicated in Wilsons?
ATP7B gene
163
Mutation in ATP7B gene
Wilsons disease
164
inheritance in wilson's
autosomal recessive
165
features of Wilsons
multi-organ copper accumulation
-\> cirrhosis, behavioural changes, depression, psychosis,
parkinsonism, seizures and dementia
cardiomyopathy
166
kayser- Fleischer rings
wilsons
167
pathophysiology of a1-antitrypsin deficiency?
a1AT inhibits neutrophil elastase
- \> emphysema in lungs
- \> hepatitis and cirrhosis in liver
168
presentation of a1AT deficiency?
variable
- neonatal and childhood hepatitis
- cirrhosis
75% of adults have emphysema esp smokers
169
Ix of a1AT deficiency?
Blood: low serum a1AT levels
Liver Biopsy: **Periodic Acid Schiff+ve**
CXR: emphysematous changes
Spirometry: obstructive defect
Prenatal diagnosis: possible by CVS
170
Mx of a1AT deficiency?
mostly supportive for pulmonary and hepatic complications
quit smoking
can consider a1AT therapy from pooled donors
171
what organs are affected in Wilsons disease?
Eyes: Kayser-Flesicher rings
Liver: acute hepatitis, fulminant necrosis -\> cirrhosis
CNS: Parkinsonism, depression, psychosis
Joints: chrondrocalcinosis, osteoporosis
Kidney: osteomalacia
Haemolytic anaemia: coombs -ve
172
Kayser Fleischer Rings
- Wilsons
173
When does wilsons disease present?
between childhood and 30
174
Ix of Wilson's Disease?
Bloods: low Cu, low Caeruloplasmin
high 24h urinary Cu
Liver biopsy: high hepatic copper
MRI: basal ganglia degeneration
175
Mx of Wilsons Disease?
Diet: avoid high Cu foods: liver, chocolate, nuts
Penicillamine lifelong (Cu chelator)
Liver transplant if severe liver disease
genetic testing
176
Types of autoimmune hepatitis?
Type 1: adults. SMA+ (smooth muscle Ab) in 80%, ANA + (10%), high IgG
Type 2: Young, LKM+ (Anti-Liver-Kidney Microsomal)
Type 3: Adult SLA+ (anti soluble liver antigen)
177
presentation of autoimmune hepatitis?
teens and early 20s:
fatigue, fever, malaise
hepatitis
cushingoid: hirsute, acne, striae
polyarthritis
pulmonary infiltration
hepatosplenomegaly
Post/ peri-menopausal
- present insidiously w chronic liver disease
178
assoc conditions of autoimmune hepatitis?
autoimmune thyroiditis
DM
pernicious anaemia
PSC
UC
GN
AIHA (coombs +ve)
179
Anti-smooth muscle ab?
Autoimmune Hepatitis
Type 1
180
IX of autoimmune hepatitis?
LFTs, ↑IgG
Auto Abs: SMA, LKM, SLA, ANA
↓WCC and ↓Platelets = hypersplenism
Liver biopsy
181
Anti-Liver Kidney Microsomal Ab?
Autoimmune hepatitis
kids
Type 2
182
Mx of autoimmune hepatitis?
Immunosuppression
- Prednisolone
- Azathioprine
Liver transplant
183
pathophysiology of primary sclerosing cholangitis?
inflammation, fibrosis and strictures in intra and extra hepatic ducts
chronic biliary obstruction -\> secondary biliary cirrhosis -\> liver failure
184
Primary Sclerosing Cholangitis
M\>F 2:1
may present asymptomatically
or
with jaundice, pruritus, fatigue, abdo pain
185
signs of primary sclerosing cholangitis?
Hepatosplenomegaly
Obstructive Jaundice: dark urine, pale stools
186
Complications of primary sclerosing cholangitis?
Bacterial cholangitis
increased risk of cholangiocarcinoma
increased risk colorectal cancer
187
What is primary sclerosing cholangitis assoc w?
UC
3% of those w UC have PSC
80-100% of those w PSC have UC/ Crohns
188
Ix of Primary sclerosing cholangitis?
LFTs: ↑ALP initially then ↑Br
Abs: pANCA (80%), ANA and SMA may be +Ve
ERCP/MRCP: beaded appearance of ducts
biopsy: fibrous, obliterative cholangitis
189
ERCP/MRCP: beaded appearance of ducts
primary sclerosing cholangitis
190
what Ab is assoc w PSC?
pANCA
also ANA, SMA
191
Mx of primary sclerosing cholangitis?
No curative medical therapy -\> transplant needed
Symptomatic tx:
**pruritus**: colestyramine, naltrexone
**diarrhoea:** codeine phosphate
**Vit ADEK**
Ursodeoxycholic acid - improves cholestasis
Abx for cholangitis
Interventional: Endoscopic stenting for dominant strictures
Liver transplant
Screening:
for cholangiocarcinoma: US + CA19-9
Colorectal Ca: colonoscopy
192
what cancers are assoc w PSC?
due to increased risk
Cholangiocarcinoma
Colorectal Ca
193
Pathophysiology of Primary Biliary Cirrhosis?
intrahepatic bile duct destruction by chronic granulomatous inflammation -\> cirrhosis
194
presentation of primary biliary cirrhosis?
F:M\>\>9
often asympto + diagnose incidentally
**P**ruritus, fatigue, **p**igmentation of face
**B**ones: osteoporosis, osteomalacia
Hepatosplenomegaly
**C**irrhosis and **c**oaugulopathy
**C**holesterol: xanthelasma, xanthomata
Steatorrhoea
Jaundice occurs late
195
What conditions are assoc w PBC?
Thyroid disease
RA, Sjogrens, scleroderma
Coeliac disease
196
Ix of PBC?
LFTs: ↑↑ALP, ↑↑GGT, ↑AST/ALT
Abs: AMA +ve
↑IgM
↑cholesterol
+/-↑TSH
US to exclude extra-hepatic cholestasis
Liver biopsy: non-caseating granulomatous inflammation
197
What ab is assoc w PBC?
Anti mitochondrial Ab
198
Mx of PBC?
symptomatic:
pruritus- colestyramine, naltrexone
Diarrhoea- codeine phosphate
Osteoporosis- bisphosphonates
ADEK vitamins
Ursodeoxycholic acid - improves cholestasis
Liver transplant: end stage disease or intractable pruritus
199
anti mitochondrial Ab?
PBC
200
most common type of primary liver tumour?
90% HCC
201
what are the most common type of tumour in liver?
90% of liver tumours are 2O metastases
202
Symptoms of Liver Tumour?
Benign tumours are usually asymptomatic
Systemic: FLAW
RUQ pain: stretching of Glisson’s capsule
Jaundice is often late, except in cholangiocarcinoma
May rupture → intraperitoneal haemorrhage
203
Signs of liver tumour
Hepatomegaly: smooth or hard and irregular
Signs of chronic liver disease
Abdominal mass
Hepatic bruit (HCC)
204
Ix of liver tumour?
Bloods: LFTs, hepatitis serology, AFP
Imaging:
* US or CT / MRI ± guided diagnostic biopsy
* ERCP + biopsy in suspected cholangiocarcinoma
Biopsy (seeding may occur along tract)
Find primary: e.g. colonoscopy, mammography
205
Causes of HCC?
\*common in China and sub saharan Africa
Viral hepatitis (B/C/D)
Cirrhosis: ETOH, HH, PBC
Aflatoxins (produced by Aspergillus)
206
Mx of HCC?
Resection of solitary tumours improves prognosis (13 → 59%), but 50% have recurrence.
Also: chemo, percutaneous ablation and embolization
207
Causes of cholangiocarcinoma?
Flukes (Clonorchis)
PSC
Congenital biliary cysts
UC
208
presentation of Cholangiocarcinoma?
Fever, malaise
Abdominal pain, ascites, jaundice
↑BR, ↑↑ALP
209
Mx of cholangiocarcinoma?
30% resectable
Palliative stenting: percutaneous or ERCP
210
Indications for Liver Transplant?
Advanced cirrhosis
HCC
211
Contraindications of Liver Transplant?
Extra-hepatic malignancy
Severe cardiorespiratory disease
Systemic sepsis
HIV infection
Non-compliance w drug therapy
212
Complications of Liver Transplant?
_Acute rejection (T-cell mediated)_
* 50% @ 5-10 days
* Pyrexia, tender hepatomegaly
* ↑ or change immunosuppressants
Sepsis
Hepatic artery thrombosis
CMV infection
Chronic rejection (6-9mo): shrinking bile ducts
Disease recurrence (e.g. HBV)
213
What immunosuppression therapy would be required post op in Liver Transplant?
Ciclosporin / Tacrolimus +
Azathioprine / Mycophenolate Mofetil +
Prednisolone
214
Smoking in UC / crohns?
protective in UC
increases risk in crohns
215
symptoms of Crohns vs UC?
UC:
usually bloody + mucus
tenesmus, faecal urgency
216
Skin manifestations of IBD?
```
erythema nodosum
Pyoderma gangrenosum (esp UC)
```
clubbing
217
Abdominal Mass in IBD?
V rare in UC
common in Crohns: commonly RIF
but can affect anywhere in the tract
218
Complications of Crohns?
Fistulae
- enterocolonic, enterovesical, enterovaginal, perianal
Strictures -\> obstruction
Abscesses: abdo, anorectal
Malabsorption of
- fat -\> steatorrhoea, gallstones
- B12 -\> megaloblastic anaemia
- Vit D -\> osteomalacia
- protein -\> oedema
219
Complications of UC?
Toxic megacolon -\> perforation
Bleeding
malignancy: CRC, cholangiocarcinoma
strictures -\> obstruction
venous thrombosis
220
Complications of stoma?
retraction
stenosis
prolapse
dermatitis
high output
221
Complications of the Pouch after surgery for Crohns/ UC?
Pouchitis 50%: metro + cipro
decreased female fertility
Faecal leakage
222
Colonoscopy shows
skip lesions, rose thorn ulcers, cobblestoning, String sign of Kantor?
Crohns
String sign of Kantor: narrow terminal ileum
223
Pathophysiology of Coeliac Disease?
HLA-DQ2 (95%) and DQ8
CD8+ mediated response to gliadin in gluten
224
Presentation of Coeliac Disease?
GI Malabsorption: fatigue, weakness, abdo distension + colic, Steatorrhoea, weight loss
Anaemia
Dermatitis herpetiformis, aphtous ulcers
increased risk of EATL, adenocarcinoma of small bowel
Immune assoc: IgA deficiency, T1DM, PBC
225
what immune conditions are assoc w coeliac?
IgA deficiency, T1DM, PBC
226
why are coeliac disease pts at higher risk of Renal stones?
Hyperoxaluria due to malabsorption of fat
227
What Cancers are coeliac assoc w?
EATL
Adenoca of small bowel
228
Dermatitis herpetiformis
Symmetrical vesicles, extensor surfaces
Esp. elbows
Very itchy
Responds to gluten-free diet or dapsone
Biopsy: granular deposition of IgA
229
what skin rash is assoc w coeliac disease?
Dermatitis herpetiformis
230
Mx of coeliac disease?
Lifelong gluten-free diet
- Avoid: barley, rye, oats, wheat
OK: Maize, soya, rice
Verify diet by endomysial Ab tests
Pneumovax as hyposplenic
Dermatitis herpetiformis: dapsone
231
Ix of Coeliac Disease?
Bloods: FBC, LFTs (↓alb), INR, Vit D and bone, red cell folate, serum B12
Abs : Anti-endomysial IgA (95% specificity), Anti-TTG IgA
Both ↓ w exclusion diet
Anti-gliadin IgG persist w exclusion diet)
IgA ↑ in most but may have IgA deficiency
Stools: Stool cysts and antibody: exclude Giardia
OGD and duodenal biopsy: Subtotal villous atrophy, Crypt hyperplasia, Intra-epithelial lymphocytes
232
What is seen on OGD and biopsy in Coeliac Disease?
Subtotal villous atrophy, Crypt hyperplasia, Intra-epithelial lymphocytes
233
What is the most specific ab for coeliac?
anti-endomysial IgA antibody
234
causes of malabsorption?
**Common in UK**: Coeliac, Chronic pancreatitis, Crohn’s
**Rarer**
* ↓Bile: PBC, ileal resection, colestyramine
* Pancreatic insufficiency: Ca, CF, chronic panc
* Small bowel: resection, tropical sprue, metformin
* Bacterial overgrowth: spontaneous, post-op blind loops, DM, PPIs
* Infection: Giardia, Strongyloides, Crypto parvum
* post-gastrectomy dumping
235
presentation of malabsorption?
Diarrhoea / Steatorrhoea
Wt. loss
Lethargy
236
Risk factors for Pancreatic Cancer?
Smoking
Inflammation: chronic pancreatitis
Nutrition: ↑fat diet
EtOH
DM
237
Most common type of pancreatic cancer?
which site?
Ductal Adenoca
head
238
presentation of pancreatic cancer in the head?
Typically male \>60yrs
painless obstructive jaundice w dark urine + pale stools
Anorexia and wt. loss
Acute pancreatitis
Sudden onset DM in the elderly
239
Presentation of pancreatic cancer in the tail/ body of pancreas?
Typically male \>60yrs
epigastric pain -Radiates to back, relieved sitting forward
Anorexia and wt. loss
Acute pancreatitis
Sudden onset DM in the elderly
240
Signs of pancreatic cancer?
Epigastric mass
Jaundice
Palpable gallbladder
Thrombophlebitis migrans (Trousseau Sign)
Splenomegaly: PV thrombosis → portal HTN
Ascites
241
Ix of pancreatic cancer?
**Bloods**: cholestatic LFTs, ↑Ca19-9, ↑Ca
**Imaging**
US: pancreatic mass, dilated ducts, hepatic mets, allows biopsy
Endoscopic US: better than CT/MRI for staging
**ERCP** -\> Shows anatomy + Allows stenting
242
Mx of Pancreatic Cancer?
**Surgery**
* Fit, no mets, tumour ≤3cm (≤10% of pts)
* Whipple’s pancreatoduodenectomy
* Post-op chemo delays progression
**Palliation**
* Endoscopic / percutaneous stenting of CBD
* Palliative bypass surgery
* Pain relief: may need coeliac plexus block
243
what is the main surgery for pancreatic cancer in pts fit for surgery, tumour \<3cm?
Whipples procedure
aka
pancreatiduodenectomy
- take out gallbladder, head of pancreas, duodenum
stitch remain pancreas, end of stomach and bile duct directly to small intestine
244
What pain relief is best for pts with Pancreatic cancer?
Coeliac plexus block
245
Causes of Chronic Pancreatitis?
**most common: Alcohol**
Genetic; CF, HH, Hereditary pancreatitis
Immune: Lymphoplasmacytic sclerosing pancreatitis (↑IgG4)
Triglycerides ↑
Structural: Obstruction by tumour, Pancreas divisum
246
Presentation of chronic pancreatitis?
Epigastric pain:
radiates through to back
Relieved by sitting back or hot water bottle → erythema ab igne
Exacerbated by fatty food or EtOH
Steatorrhoea
Wt. loss
DM
Epigastric mass: pseudocyst
247
Ix of chronic pancreatitis?
↑ glucose
↓ faecal elastase
US: pseudocyst
AXR: speckled pancreatic calcifications
CT: pancreatic calcifications
248
mx of chronic pancreatitis?
Medical:
Analgesia: may need coeliac plexus block
Creon - pancreatic enzyme replacement therapy
ADEK vitamins
DM Rx
Diet: No EtOH, ↓ fat, ↑ carb
Surgery:
Ind: unremitting pain, wt. loss
Pancreatectomy
249
Complications of Chronic Pancreatitis?
Pseudocyst
DM
Pancreatic Ca
Biliary obstruction
Splenic vein thrombosis → splenomegaly
250
Dry conjunctivae, develop spots (Bitots spots)
Corneas become cloudy then ulcerate
Night blindness → total blindness
What Vitamin is deficient?
Vit A -\> xerophthalmia
251
Diarrhoea, Dermatitis, Dementia
Also: neuropathy, depression, ataxia
which vitamin is deficient?
Vit B3 Niacin -\> Pellagra
Causes: dietary, isoniazid, carcinoid syndrome
252
Features of Pellagra?
Diarrhoea, dermatitis, dementia
| (Niacin B3 deficiency)
253
Features of Thiamine deficiency?
Wet Beri Beri: heart failure + oedema
Dry Beri Beri: polyneuropathy
Wernicke's: ophthalmoplegia, ataxia, confusion
254
↓ factors: 2, 7, 9, 10, C and S
Bruising, petechiae
Bleeding: e.g. epistaxis, menorrhagia
which vitamin is deficient?
Vit K
255
Gingivitis
Bleeding: gums, nose, hair follicles (petechial)
Muscle pain / weakness
Oedema
Corkscrew hairs
which vitamin is deficient?
scurvy
vitamin c deficient
256
Features of B12 deficiency?
Glossitis → sore tongue
**Peripheral neuropathy:** Paraesthesia, Early loss of vibration and proprioception → ataxia
**SCDC:** Dorsal and corticospinal tracts
Sensory loss and UMN weakness
Overall mixed UMN and LMN signs w sensory disturbance
Extensor plantars + absent knee and ankle jerks
257
Which tracts are affected in subacute combined degeneration of cord?
Dorsal columns
+ corticospinal tracts
-\> sensory loss and UMN weakness
258
Why are there mixed UMN and LMN signs w sensory disturbance in B12 deficiency?
SCDC: loss of corticospinal tracts -\> UMN weakness
Peripheral neuropathy -\> LMN signs
259
Features of B6 Pyridoxine neuropathy?
peripheral sensory neuropathy
260
Flushing: paroxysmal, upper body ± wheals
Intestinal: diarrhoea
Valve fibrosis: tricuspid regurg and pulmonary stenosis
whEEze: bronchoconstriction
Hepatic involvement: bypassed 1st pass metabolism
Tryptophan deficiency → pellagra (3Ds)
Carcinoid Syndrome
261
Ix of carcinoid syndrome?
↑ urine 5-hydroxyindoleacetic acid
↑ plasma chromogranin A
CT/MRI: find primary
262
Mx of Carcinoid Syndrome?
Symptoms: octreotide or loperamide
**Curative**
* Resection: tumours are v. yellow
* Give octreotide to avoid carcinoid crisis
Carcinoid Crisis Rx: high-dose octreotide
263
Mx of carcinoid crisis?
high dose octreotide
264
where are most of the oesophageal cancers found?
in the middle third of the oesophagus.
265
most common type of oesophageal cancer?
adenocarcinoma
| (esp w hx of GORD/ Barrett's)
266
1st line Ix of Oesophageal carcinoma?
Upper GI endoscopy
267
Oesophageal ca
Barium swallow - 5cm irregular narrowing of the mid-thoracic oesophagus with proximal shouldering
268
Oesophageal carcinoma
Fluoroscopy - a region of fixed, irregular stricturing is seen in the distal oesophagus
269
biggest surgical challenge in oesophageal cancer?
anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality.
270
A transjugular intrahepatic portosystemic shunt procedure connects which two vessels?
hepatic vein to the portal vein
aims to treat portal hypertension by making route for blood to flow from the portal circulation to the systemic circulation, bypassing the liver.
271
Prophylaxis of variceal haemorrhage?
propranolol: reduced rebleeding and mortality compared to placebo
endoscopic variceal band ligation (EVL)
Proton pump inhibitor cover is given to prevent EVL-induced ulceration.
272
Why do patients with coeliac disease require regular immunisations?
Patients with coeliac disease often have a degree of **functional hyposplenism**. For this reason all patients with coeliac disease are offered the pneumococcal vaccine.
273
SAAG value in ascites?
a high SAAG gradient indicates a transudate rather than exudate
A high SAAG (\>11 g/L) is an indication of portal hypertension.
274
Barium study is shown from a patient with worsening **Crohn's disease.** Long segment of narrowed terminal ileum in a 'string like' configuration in keeping with a long stricture segment. Termed 'Kantor's string sign'.
275
what blood result correlates well w crohns disease activity?
CRP
276
By which mechanism does loperamide act through to slow down bowel movements?
stimulation of μ-opioid receptors in the submucosal neural plexus of the intestinal wall. This, in turn, reduces peristalsis of the intestines decreasing gastric motility.
277
What cardiac abnormalities are associated with carcinoid syndrome?
tricuspid insufficiency and pulmonary stenosis
(TIPS)
278
what drugs predispose a pt to duodenal ulcers?
NSAIDs, steroids and selective serotonin reuptake inhibitors (SSRI)
279
advice regarding alcohol intake?
men and women should drink no more than 14 units of alcohol per week
'if you do drink as much as 14 units per week, it is best to spread this evenly over 3 days or more'
280
Complications of primary biliary cirrhosis?
malabsorption: osteomalacia, coagulopathy
sjogrens syndrome occurs in 70% of cases
portal hypertension: ascites, variceal haemorrhage
hepatocellular cancer (20-fold increased risk)
281
At what vertebral level does the inf mesenteric artery branch from the aorta?
L3 vertebra.
282
Risks of ERCP?
Bleeding 0.9% (rises to 1.5% if sphincterotomy performed)
Duodenal perforation 0.4%
Cholangitis 1.1%
Pancreatitis 1.5%
283
most common familial cause of colorectal ca?
HNPCC
284
diagnostic test for Primary sclerosing cholangitis?
ERCP is the standard diagnostic tool, showing multiple biliary strictures giving a 'beaded' appearance
285
ix of pt for coeliac disease if on gluten free diet?
if possible, to reintroduce gluten for at least 6 weeks prior to testing.
286
first-line treatment of hereditary haemochromatosis?
venesection
287
What is the main benefit of prescribing albumin when treating large volume ascites'?
to reduce paracentesis-induced circulatory dysfunction and mortality
288
definition of barrett's oesophagus?
Metaplasia of squamous cells in lower 1/3 of oesophagus to column cells
289
findings of inflammatory infiltrates coupled with mucosal ulcers, goblet cell depletion and crypt abscesses
Ulcerative colitis
290
transmural, non-caseating granulomatous inflammation, coupled with fissuring ulcers, lymphoid aggregates and neutrophil infiltrates
Crohns
291
if pt w ascites needs prophylaxis against spontaneous bacterial peritonitis, what abx should be used?
oral ciprofloxacin or norfloxacin
292
Grading of hepatic encephalopathy?
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
293
Mx of hepatic encephalopathy?
treat any underlying precipitating cause
1st line: lactulose
+/- rifaximin for secondary prophylaxis
Lactulose works to inhibit production of ammonia in the intestine-\> decrease hyperammonaemia
294
Precipitating factors of hepatic encephalopathy?
infection e.g. spontaneous bacterial peritonitis
GI bleed
post transjugular intrahepatic portosystemic shunt
constipation
drugs: sedatives, diuretics
hypokalaemia
renal failure
increased dietary protein (uncommon)
295
What type of oesophageal ca does achalasia increase the risk of?
Squamous Cell Carcinoma
296
What is considered in treatment of an acute flare of Crohn's disease when symptoms don't improve after 5 days of IV hydrocortisone?
Biologic therapy e.g. Infliximab
297
Triad of Plummer Vinson Syndrome?
dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia
298
mx of hepatorenal syndrome?
vasopressin analogues, e.g. terlipressin
- vasoconstriction of the splanchnic circulation -\> increase kidney filling
volume expansion with 20% albumin
transjugular intrahepatic portosystemic shunt
299
histology showing signet ring sells?
gastric adenocarcinoma
300
Mx of gastric tumour \<5 cm from oesophagogastric junction?
total gastrectomy
if 5-10 cm away: sub total gastrectomy
+ lymphadenectomy
+/- chemo
301
what is the most sensitive and specific lab finding indicating liver cirrhosis in the setting of patients with chronic liver disease?
Thrombocytopenia (platelet count \<150,000 mm^3)
302
most common organism found in pyogenic liver abscesses?
in adults
in children
adults: E coli
children: staph aureus
give abx and US guided perc drainage
303
mx of dysplasia in Barrett's oesophagus? but no carcinoma
endoscopic mucosal resection
or
radiofrequency ablation
304
Ix fo choice to detect Liver cirrhosis in hep C?
transient elastography
measures the 'stiffness' of the liver which is a proxy for fibrosis
