Gastro Flashcards
(80 cards)
1
Q
Prehepatic causes of portal hypertension?
A
portal or splenic vein thrombosis, arteriovenous thrombosis
2
Q
Hepatic causes of portal hypertension?
A
presinusoidal: Primary biliary cirrhosis. sinusoidal: cirrhosis, idopathic. post-sinusoidal: veno-occlusive disease
3
Q
Posthepatic causes of portal hypertension?
A
Budd-Chiari syndrome, congestive heart failure, constrictive pericarditis
4
Q
Clinical signs of chronic liver disease (general, hands, face, chest and abdomen)?
A
- General: cachexia, icterus, excoriation and bruising
- Hands: leuconychia, clubbing, Dupuytren’s contractues, palmar erythema
- Face: xanthelasma, parotid swelling, fetor hepaticus
- Chest and abdomen: spider naevi and caput medusa, reduced body hair, gynaecomastia and testicular atrophy
- Trou: Red.
5
Q
Signs of hepatomegaly?
A
- Palpation/percussion: mass in RUQ that moves with respiration, smooth if malignancy, craggy/nodular if cirrhosis, pulsatile (TR in CCF)
- Auscultation: bruit over liver (hepatocellular carcinoma)
6
Q
Underlying cause of hepatomegaly suggested by: tattoos and needle marks, slate-grey pigmentation, cachexia, mid-line sternotomy?
A
- infectious hepatitis
- haemochromatosis
- malignancy
- CCF
7
Q
3 As suggesting decompensation of chronic liver disease?
A
Ascites (shifting dullness), asterixis, altered consciousness (encephalopathy)
8
Q
Big 3 Cs causing hepatomegaly? 3 Is that might cause?
A
- Cirrhosis (Alcohol)
- Congestive cardiac failure
- Carcinoma (secondaries)
- Infectious (HBV and HCV)
- Immune (PBC, PSC, AIH)
- Infiltrative (amyloid and myeloproliferative disorders)
9
Q
Important investigations for chronic liver disease/hepatomegaly?
A
- Bloods: FBC, clotting, U&E, LFT and glucose
- Ultrasound scan of abdomen
- Tap ascites
10
Q
Tests to order if cirrhotic?
A
Liver screen bloods:
- autoantibodies and immunoglobulins (PBC, PSC, AIH)
- Hepatitis B and C serology
- Ferritin (haemochromatosis)
- Caeruloplasmin (Wilson’s disease)
- alpha-1 antitrypsin
- AFP (hepatocellular carcinoma)
Hepatic synthetic function: INR (acute) and albumin (chronic)
Liver biopsy (diagnosis and staging)
ERCP (diagnose/eclude ERCP)
11
Q
Tests to order if suspecting malignancy?
A
- Imaging: CXR and CT abdomen/chest
- Colonoscopy/gastroscopy
- Biopsy
12
Q
Complications of cirrhosis?
A
- Variceal haemorrhage due to portal hypertension
- Hepatic encephalopathy
- Spontaenous bacterial peritonitis
13
Q
Scoring system used to classify cirrhosis?
A
Child Pugh classification
- Prognostic score based of: bilirubin/albumin/INR/ascites/encephalopathy
14
Q
3 Cs for causes of ascites?
A
- Cirrhosis (80%)
- Carcinomatosis
- CCF
15
Q
Treatment of ascites in cirrhotics?
A
- Abstinence from alcohol
- Salt restriction
- Diuretics (aim: 1kg weight loss/day)
- Liver transplantation
16
Q
Causes of palmar erythema?
A
- Cirrhosis
- Hyperthyroidism
- Rheumatoid arthritis
- Pregnancy
- Polycythaemia
17
Q
Causes of gynaecomastia?
A
- Physiological: puberty and senility
- Kleinfelter’s syndrome
- Cirrhosis
- Drugs, e.g. spironolactone and digoxin
- Testicular tumour/orchidectomy
- Endocrinopathy, e.g. hyper/hypothyroidism and Addison’s
18
Q
Autoantibody in PBC?
A
antimitochondrial antibody (M2 subtype) in 98% increased IgM
19
Q
Autoantibody in PSC?
A
ANA, anti-smooth muscle may be positive
20
Q
Antibodies in autoimmune hepatitis?
A
anti-smooth muscle, anti-liver/kidney microsomal typ 1 (LKM1) and occasionally ANA may be positive
21
Q
Cinical signs of haemochromatosis?
A
- slate-grey skin
- stigamata of chronic liver disease
- hepatomegaly
22
Q
Scars to look for in patient with haemochromatosis?
A
Venesection, liver biopsy, joint replacement, abdominal rooftop incision
23
Q
Evidence of complications in haemochromatosis?
A
- Endocrine: ‘bronze diabetes’, hypogonadism, testicular atrophy
- Cardiac: congestive cardiac failure
- Joints: arthropathy (pseudo-gout)
24
Q
How is haemochromatosis inherited?
A
- Autosomal recessive on chromosome 6
- HFE gene mutation: regulator of gut iron absorption
- Homozygous prevalence 1:300, carrier rate 1:10
- Males affected at an earlier age than females- protected by menstrual iron losses
25
How does haemochromatosis present?
* Fatigue and arthritis
* Chronic liver disease
* Incidental diagnosis or family screening
26
Investigation to order for haemochromatosis?
* Raised serum ferritin
* Raised transferrin saturation
* Liver biopsy (diagnosis + staging)
* Genotyping positive
* Consider: blood glucose (diabetes), ECG/CXR/ECHO (cardiac failure), liver ultrasound/alpha fetoprotein (HCC)
27
Treatment for haemochromatosis?
* Regular venesection (1 unit/week) until deficient, then venesect 1 unit, 3-4 times/ year
* Avoid alcohol
* Surveillance for HCC
28
Which family members are screened if patient has haemochromatosis?
Iron studies (ferritin and TSAT) done in 1st degree relatives aged \>20 years. If positive: liver biopsy, genotype analysis
29
Prognosis of haemochromatosis?
* 200 x increased risk of HCC if cirrhotic
* Reduced life expectancy if cirrhotic
* Normal life expectancy without cirrhosis + effective treatment
30
General clinical signs of splenomegaly?
Anaemia, lymphadenopathy (axillae, cervical and inguinal areas), purpura
31
Abdominal clinical signs of splenomegaly?
LUQ mass that moves inferomedially with respiration, has a notch, is dull to percussion and cannot get above/ballot. Estimate size and check for hepatomegaly.
32
Underlying cause of splenomegaly suggested by
1. lymphadenopathy
2. stigmata of chronic liver disease
3. splinter haemorrhages, murmur etc.
4. rheumatoid hands
1. Haematological and infective
2. Cirrhosis with portal hypertension
3. Bacterial endocarditis
4. Felty's syndrome
33
Causes of massive splenomegaly?
Myeloproliferative disorders: CML and myelofibrosis
Tropical infections: malaria, visceral leishmaniasis: kala-azar
34
Causes of moderate splenomegaly?
* Myelo/lymphoproliferative disorders
* Infiltration: Gaucher's and amyloidosis
35
Causes of Tip splenomegaly (\<4cm)?
* Myelo/lymphoproliferative disorders
* Portal hypertension
* Infections (EBV, infective endocarditis and infective hepatitis)
* Haemolytic anaemia
36
Investigations to order for splenomegaly?
* Ultrasound abdomen
* Haematological: FBC and film, CT chest and abdomen, bone marrow aspirate and trephine, lymph node biopsy.
* Infectious: thick and thin films (malaria), viral serology
37
Indications for splenectomy?
Rupture (trauma), haematological (ITP and hereditary spherocytosis)
38
Splenectomy workup?
* Vaccination: pneumococcus, meningococcus, haemophilus
* Prophylactic penicillin (lifelong)
* Medic alert bracelet
39
Peripheral clinical signs associated with renal enlargement?
* Hypertension
* AV fistulae, tunneled dialysis line
* Immunosuppressant stigmata eg. Cushingoid habitus due to steroids, gum hypertrophy with ciclosporin
40
Abdominal clinical signs associated with renal enlargement?
* Palpable kidney
* Polycystic kidney
* Iliac fossae: scar with or without transplanted kidney
* Urine dip: proteinuria and haematuria
* Examine genitalia: varicocele in males
41
What could the following suggest if present with renal enlargement?
1. hepatomegaly
2. indwelling catheter
1. polycystic kidney disease
2. obstructive nephropathy with hydronephrosis
42
Causes of unilateral renal enlargement?
* Polycystic kidney disease
* Renal cell carcinoma
* Simple cysts
* Hydronephrosis
43
Causes of bilateral renal enlargement?
* Polycystic kidney disease
* Bilateral renal cell carcinoma
* Bilateral hydronephrosis
* Tuberous sclerosis
* Amyloidosis
44
Investigations to order if renal enlargement present?
* U&E
* Urine cytology
* Ultrasound abdomen +/- biopsy
* IVU
* CT if carcinoma is suspected
* Genetic studies (ADPKD)
45
What is autosomal dominant polycystic kidney disease?
Progressive replacement of normal kidnye tissue by cysts leading to renal enlargement and renal failure (5% of end-stage renal failure in UK)
46
Genetics of ADPKD?
* 85% ADPKD1 mutation on chormosome 16
* 15% ADPKD2 on chromosome 4
47
How does ADPKD present?
* Hypertension, recurrent UTIs, abdo pain, haematuria
* Other organ involvement: hepatic cysts/hepatomegaly, Berry aneurysms, mitral valve prolapse
48
Treatment of ADPKD?
nephrectomy for recurrent bleeds/infection/size, dialysis and renal transplantation
49
What are each of these scars and what transplants are they each for?
1. Mercedes-Benz scar or roof-top scar for liver transplant
2. Iliac fossa scar for kidney transplant
50
What clinical signs may be present in a renal transplant patient?
* Palpable transplanted kidney beneath scar
* Unilateral/bilateral palpable native kidneys (ADPKD)
* Other scars: nephrectomy, CAPD catheter and tunneled neck lines
* AV fistulae
51
What condition would the following suggest as the reason for a liver transplant?
1. Pigmentation
2. Other autoimmune diseae
3. Tattoos and needle marks
1. Haemochromatosis
2. PBC
3. Hepatitis B, C
52
Clinical signs present with use of the following immunosuppressants?
1. ciclosporin
2. steroids
1. gum hypertrophy and hypertension
2. cushingoid appearance, thin skin, ecchymoses etc.
53
What skin signs (malignancy or infective) could be present in a transplant patient due to immunosuppression?
* Malignancy: dysplastic change (actinic keratoses), squamous cell carcinoma, basal cell carcinoma/malignant melanoma
* Infection: viral warts, cellulitis
54
Top 3 causes of renal transplantation?
* Glomerulonephritis
* Diabetic nephropathy
* ADPKD
55
Top 3 causes for liver transplantations?
* Cirrhosis
* Acute hepatic failure (hepatitis A and B , paracetamol overdose)
* Hepatic malignancy
56
Problems following transplantation?
* Rejection: acute or chronic
* Infection secondary to immunosuppression: PCP, CMV
* Increased risk of other pathologies: skin malignancy, post-transplant lymphoproliferative disease, hypertension and hyperlipidaemia causing CVD
* Immunosuppressant drug side effects/toxicity: ciclosporin nephrotoxicity
* Recurrence of original disease
* Chronic graft dysfunction
* Psychological
57
How high are survival rates (1 year and 5 year) for:
1. renal transplantation
2. liver transplantation
1. 90% 1 year, 50% 5 year
2. 80% 1 year, 70% 5 year
58
Signs of renal bone diseae in patients with chronic renal failure due to:
1. hyperparathyroidism
2. osteomalacia
3. extraskeletal calcification
1. bone resorption, osteoporosis, telescopic shortening of phalanges, parathyroidectomy scar
2. proximal myopathy
3. calciphylaxis, periarticular soft tissues, red-eyes
59
Causes of gum hypertrophy?
* Drugs: ciclosporin, phenytoin, nifedipine
* Scurvy
* Acute myelomonocytic leukaemia
* Pregnancy
* Familial
60
How might chronic liver disease present (4)?
1. Jaundice
2. Abdominal pain
3. Fatigue
4. Abdominal swelling
61
What are the features of reduced oestrogen breakdown due to chronic liver disease (5)?
1. Palmar erythema
2. Spider naevi (5 or more)
3. Gynaecomastia
4. Reduced axillary and genital hair
5. Testicular atrophy
62
What are the features of reduced liver synthetic function due to chronic liver disease (3)?
1. Cachexia
2. Leukonychia
3. Bruising
63
5 features of chronic liver disease decompensation?
1. Hepatic encephalopathy (liver flap, drowsiness, confusion)
2. Ascites (shifting dullness, fluid thrill, drain/tap marks, tazocin)
3. Easy bleeding (bruising)
4. Jaundice
5. Fluid overload: peripheral perfusion, pulse, mucous membranes, JVP, peripheral oedema
64
Specific signs of alcoholic liver disease? (2)
1. Dupuytrens contracture
2. Enlarged parotids
65
Specific signs of Hepatitis B/C (2)?
1. Tattoos
2. Track marks
66
Specific signs of hereditary haemochromatosis? (3)
1. Finger prick marks from BM testing
2. arthropathy
3. Bronze pigmentation
67
Specific signs of primary biliary cirrhosis (5)?
1. Middle aged female
2. Xanthelasma
3. Excoriation marks
4. Easy bruising
5. Hepatosplenomegaly
68
Specific signs of autoimmune hepatitis (2)?
1. Vitiligo
2. Scar from previous thyroidectomy
69
Differentials for chronic liver disease?
* Toxic
* Metabolic
* Infective
* Autoimmune
* Hereditary
* Toxic: lacohol, methotrexate, amiodarone, isoniazid
* Metabolic: NASH
* Infective: hepatitis B and C
* Autoimmune: PBC, PSC, autoimmune hepatitis, sarcoidosis
* Hereditary: haemochromatosis, alpha-1-anti-trypsin defciency, Wilson's disease, glycogen storage disease
70
Further investigations for chronic liver disease?
* Bedside (2)
* Bloods (4)
* Imaging (2)
* Special tests (8)
Bedside
1. Urine dip: leukocytes, nitrates, pregnancy test
2. Ascitic tap: fluid cell count and differential, protein, albumin, culture in aerobic/anaerobic blood culture bottles
Bloods
1. FBC: anaemia, thrombocytopaenia, leukopenia
2. Clotting
3. U&Es: deranged electrolytes as a risk for decompensation, monitoring diuretics, risk of hepatorenal syndrome
4. LFTs: albumin, SAAG, enzyme derangement
5. Glucose: hypoglycaemia, diabetes
Imaging
1. USS abdomen: liver/spleen size, cirrhosis, liver masses, ascites, portal pressures
2. MRCP could be done prior to ERCP if features on obstruction on USS
Special tests
1. If cirrhotic liver screen incl. HBV/HCV,
2. Autoimmune screen incl. ANA, AMA
3. Immunoglobulins
4. caeruloplasmin
5. ferritin
6. alpha-1-antri trypsin
7. oesophageo-gastro-duodenoscopy (surveillance for varices)
8. liver biopsy and/or ERCP
71
Aetiology of IBD?
* Genetic: NOD2 gene on chromosome 16
* Environmental incl.: smoking improves UC but worsens CD, NSAIDs, psychosocial, OCP
* Immune response
* Host microbiome
72
Differences between UC and CD?
* CD affects anywhere from mouth to anus- skip lesions. UC progresses from rectum to sigmoid or can affect the whole colon with backwash ileitis/
* CD is transmural (involving all layers), UC affects mucosal layer.
* Strictures, fisutlae, granulomas form in CD but not as common in UC.
* CD 'cobblestone' ulceration, UC shallow
73
Extra-intestinal manifestations of IBD in:
1. Skin
2. Joints
3. Hepato-biliary
4. Eyes
5. Other
1. Clubbing, erythema nodosum, pyoderma gangrenosum
2. Arthritis (non-deforming, \<5 joints, asymmetric), sacroilitis, ankylosing spondylitis
3. PSC + cholangiocarcinoma (esp. UC), gallstones (esp. CD), fatty liver
4. Iritis, scleritis, episcleritis, conjunctivitis
5. Amyloidosis, oxalate renal stones
74
Clinical features of Crohn's?
* Major symptoms: diarrhoea (80%, sometimes bloody), abdominal pain (can be acute RIF pain), weight loss
* Constitutional symptoms: malaise, lethargy, anorexia, nausea, vomiting, low grade fever
* In children: reduced growth velocity and delayed puberty
* Relapsing and remitting symptoms
* Symptoms depend on portion of bowel affected, abdominal pain may be colicky suggesting obstruction
* 25% present with anal/perianal complications e.g. fissure, haemorrhoids, skin tags, abscess, fistulae
* 20-40% present with enteric fistulae to bladder, vagina, abdominal wall
75
Clinical signs of Crohn's?
* Weight loss and malnutrition
* Apthous ulceration
* Abdo exam often normal, may be tenderness/RIF mass
* Examine anus for skin tags, fissures, abscesses
* Extraintestinal features
76
Investigations to order for Crohn's?
* Bloods
* Stool tests
* Imaging
* Monitoring
Bloods
* Normocytic, normochromic anaemia of chronic disease
* Raised ESR/CRP
* Hypoalbuminaemia
* Liver biochemistry may be abnormal
* Blood cultures if septicaemia suspected
* Serological tests: negative p-ANCA, positive ASCA
Stool tests
* C. diff assay
* Microscopy for parasites
* Faecal calprotectin and lactoferrin raised in active intestinal disease
Imaging
* Colonoscopy: varies from mild, patchy, superficial ulceration to widespread, larger, deeper ulcers with cobblestoning. ENDOSCOPIC ASSESSMENT of terminal ileum ESSENTIAL- two biopsies performed in 5 areas including rectum and terminal iluem
* Upper GI endoscopy: exclude oesophageal/gastroduodenal disease in patients with relevant symptoms, also to diagnose/define extent of disease
* Small bowel imaging: mandatory in patients with CD. CT scan wih oral contrast, small bowel ultrasound or MRI enteroclysis.
* Ultrasound scanning can be performed
* Perianal MRI or endoanal ultrasound to assess perianal disease
* Capsule endoscopy
* Radionulide scans
Monitoring
* Haemoglobin, WCC, ESR/CRP/platelets, serum albumin
* Faecal calprotectin or lactoferrin has potential
77
Alternative causes for symptoms to exclude before managing Crohn's?
* Gastroenteritis
* Extraintestinal sepsis
* Stricture formation
* Functional GI disease
* Bile salt malabsorption
78
Management of Crohn's?
* Conservative
* Medical (induction and maintenance)
* Surgical
Conservative
* If mild symptoms/no evidence of extensive disease then symptomatic treatment
* Stop smoking, replace B12/folate/iron if anaemic
Medical
* Induction of remission: glucocorticoids, aminosalicylates, antibiotics if infection, exclusive enteral nutrition. If conventional methods fail anti-TNF agents
* Maintenance of remission: conventional (azathioprine, mercaptopurine, methotrexate), anti-TNF (infliximab, adalimumab, certolizumab pegol).
Surgical
* If medical therapy fails, complications present, growth failure despite treatment, perianal sepsis
* Subtotal colectomy + ileorectal anastamosis: CD affecting entire colon with rectum spared
* Panproctocolectomy with end ileostomy: entire colon and rectum involved
79
Complications of Crohn's?
* Psychosocial
* Intestinal: strictures, fistulas, perianal disease, acute dilatation and perforation, significant haemorrhage
* Anaemia
* Malnutrition
* Cancer
80
