Gastroenterology Flashcards
(26 cards)
Acute liver disease:
- Definition
- Causes (4)
Describe paracetamol overdose
- Symptoms
- Signs
- Investigations
- Management
- Kings college hospital criteria for liver transplant
Acute liver disease:
- Definition: resolves in 6 months
- Causes (4): paracetamol overdose, alcohol, viral hepatitis a/b, acute fatty liver in pregnancy
- Symptoms: jaundice, ruq pain, hypoglycemia, inc PR, hypoalbumin, hepatic encephalopathy, renal failure (hepatorenal syndrome)
- Describe paracetamol overdose: normally NAC is precursor of glutathione which then conjugates with toxic NAPQI
- Risk factors: phenytoin, carbamezapine, malnourished, inc risk hepatotoxiciy if malnourished/chronic alc intake/liver inducing enzymes
- Symptoms: n+v, jaundice, ruq pain, hypoglycemia signs
- Signs: asterixis, bruising, oligouria, tachycardia, hypotension
- Investigations: lfts (inc alp, dec albumin), clotting (inc inr), u+es, paracetamol levels, vbg (met acidosis), cbg
- Management
1. if <1 hour activated charcoal reduces absorption
2. use normogram (a 21hour regime which looks at levels at 1/4/16 hours) - give acetylcysteine if >100mg/l at 4 hours at >15mg/l at 15 hours, give if staggered overdose, if present within 8-24 hours taking over 150mg/kg, >24 hours and tender/jaundiced/ or inc ALT
Infusion can cause non ige mediated mast cell release anaphylactoid reaction 30% so slow rate
Discharge when inr <1.3, ALT<2x upper limit, self harm assessment low
- criteria: abg<7.3 24 hours after ingestion, pr>100s, creatinine >300, grad 3/4 encephalopathy
Functions of the liver (4)
- Risk factors in history to ask for (9)
- Anatomy of liver including lobes and ligaments
functions:
storage: glycogen, fe, cu, vit adek
synthesis: glucose, bile, clotting factors, albumin
metabolism: bilirubin, drugs, alcohol
immune: kupfer cells
Chronic liver disease (cirrhosis):
- Causes (drug, infection, deposition and autoimmune causes)
- Symptoms (5)
- Signs (10)
- Investigations
- Management
- Complications (6)
Chronic liver disease (cirrhosis):
- Causes
drugs: paracetamol, maois, alcohol, statins, methotrexate, methyldopa, amiodarone
infection: hep b/c
deposition: hereditary haemochromatosis, nafld (obesity + diabetes leads to inc insulin resistance hence steatosis -> steatohepatitis -> cirrhosis, needs ELF blood test), wilsons
autoimmune causes: hepatitis (ASMA/ANA), primary biliary cholangitis, primary sclerosing cholangitis
- Symptoms (5): bruising, confusion, fatigue, weight loss, pruritus, n+V
- Signs (10): jaundice, ascites (portal htn + hypo albumin), hepatomegaly, spider naevi, palmar erythema, gynaecomastia, caput medusa, splenomegaly, asterixis
- Investigations: fbc (thrombocytopenia), lfts (dec albumin), INR (inc), u+es, liver screen. USS (nodules, ascites, splenomeg, enlarged portal vein), fibroscan, endoscopy every 3 years, liver biopsy, dexa
iron screen: hep b/c serology, iron studies, AMA/SMA ab, coeliac, a antitrypsin, caeuruloplasmin - Management: high protein, low na, check afp + liver uss every 6 months, spironolactone if ascites (if large drain then iv human albumin solution
- Complications (6): hepatic encephalopathy, SBP (ecoli, needs IV cefotaxime, can give prophylactic oral cipro)), varices oesophageal/rectal/umbilical as portal shunts via anastomoses, malnutrition (dec metabolic proteins + ability to store glucose), hepatorenal syndrome (splanchnic vasodilaton means hypovolaemia pre renal causing increased RAAS hence vasoconstriction and damage to kidneys - needs terlipressin, TIPSS)
Hepatic encephalopathy:
- Definition:
- precipitating factors
- grades
- mx
Hepatic encephalopathy:
- Definition: build up of toxins like ammonia + glutamine as liver can’t metabolise it
- precipitating factors: infection, gi bleed, TIPSS, constipation, hypokal, renal failure
- Grades
1. irritable, constructional apraxia, poor memory, reversed sleep pattern
2. confused, lethargic, asterixis
3. incoherent, drowsy
4. coma - mx: lactulose + rifaximin
Nutrition:
- What tool is used for nutritional assessment and what does it include
- refeeding syndrome
- MUST: bmi, acute illness/nbm 5 days, % weight loss - 2 or more is high risk
- refeeding syndrome: sudden insulin surge causes hypophosphataemia (muscle weakness, impairs heart contractibility, resp failure, rhabdomyolysis), hypokalaemia, hypomagnesia (torsades de pointes). Feed no more than 50% requirements for first 2 days
Differentials for dyspepsia/reflux (3)
Red flag symptoms (4)
- mx
- referral
- mx: review meds, lifestule, full dose ppi triall, h pylori test
- referral: 2ww if: dysphagia, upper abdo mass, >55 + weight loss + either (abdo pain, reflux, dyspepsia)
Peptic ulcer disease:
- Definition + pathophysiology
- Causes (5)
- Symptoms (5)
- Investigations
- Complications (3)
- Management
Peptic ulcer disease:
- Definition + pathophysiology: breakdown in muscularis mucosa in mostly duodenum or lesser curve
- Causes (5): hpylori, meds (nsaids, steroids, ssris, bisphosphonates), malig, smoking, stress
- Symptoms (5): epigastric pain worse when eating if gastric and worse 2 hours later when duodenum and initially relieved when eating, n+v, early satiety, decreased weight, melena/haematemesis
- Investigations: urea breath test/ stool ag test, ogd
- Complications (3): perforation, haemorrhage (gastroduodenal artery if duodenal, splenic artery if gastric), pyloric stenosis via scar tissue
- Management: dec weight/smoking/meds, 4-8 weeks high dose ppi until ulcer has healed (if h pylori then eradication treatment).
If bleed (gastroduodenal artery) - iv ppi + adrenaline + endoscopy cautery. If fails then angiography with transarterial embolisation or surgery
if suspect perforated then erect cxr
Gastro-oesophageal reflux disease:
- Definition
- Risk factors (3)
- Symptoms (6)
- Indic for OGD
- Management
- ppi mech action + SE
- Complications (4)
Gastro-oesophageal reflux disease:
- Definition: reflux of contents through LOS causing irritation
- Risk factors (3): hiatal hernia, overweight, preg
- Symptoms (6): metallic taste, heartburn retrosternal, hoarse voice, dry cough worse night , N+V, waterbrash
- Indic: >55, >4 weeks symptoms despite treatment, dysphagia, relapsing, weight loss. If endoscopy neg 24 hour oesoph ph monitoring is gold standard
- Management: dec weight/caffeine/alc, antacids, if endoscopy shows oesophagitis: ppi full dose 1 month (if response switch to low dose, if none double dose for 1 month) annual review). If endoscopy neg then full dose ppi 1 month, if none then h2 rec antag 1 month
- PPI SE: block H/k/atpase of gastric parietal cell - hyponat/hypomag/osteoporosis, microscopic colitis, inc risk c diff
- Complications (4): barretts (sq -> columnar) (high dose ppi, endoscop surveillance 3-5 years, ablation if dysplasia), oesophagitis, strictures, ulcer, anaemia
Dysphagia:
- Odynophagia definition
- Oesophageal dysphagia DD + investigations
- Oro-pharyngeal dysphagia DD + investigations
- Describe swallowing process
Dysphagia:
- Odynophagia definition: painful swallowing
- Oesophageal dysphagia DD + investigations: tumour, stricture, oesophagitis, achalasia, systemic sclerosis, MG, pharyngeal pouhc (diverticulum through killians dihiscence so need barium swallow + fluroscopy and surgery to corrrect) - needs ogd + barium swallow
- Oro-pharyngeal dysphagia DD + investigations: stroke - fluoroscopy
- Describe swallowing process
Inflammatory bowel disease:
- Clinical features (6)
- Risk factors (4)
- Microscopic UC + Crohns
- Macroscopic UC + crohns
- Extra intestinal features (6)
- Complications (6)
- Investigations
- Management
Inflammatory bowel disease:
- Clinical features (6): blood, mucus, change bowel habits, tenesmus, abdo pain
- Risk factors (4): smoking (UC), fx, abx
- Microscopic UC + Crohns: in UC crypt cell abscesses/ goblet cell hypoplasia/ non granulomatous inflamm in mucosa/submucosa. In Crohns non caseating granulomas + transmural + goblet cells
- Macroscopic UC + crohns: in UC contin, granular appearance + loss haustra. In crohns cobblestone, skip lesions and anywhere in GI
- Extra intestinal features (6): arthritis, episcleritis, erythema nodosum, osteoporosis - these related to disease activity. Ant uveitis, pyoderma gangrenoosum, clubbing, prim sclerosing cholangitis - not related to activity
- Complications (6): toxic megacolon, colorectal cancer, osteoporosis, fistulas/strictures
- Investigations: culture stool, faec calp, fbc/crp, colonoscopy/endo, crohns small bowel enema strictures (kantor string sign) and rose thorn ulcers, for uc barium enema shows loss haustra, superficial ulceration, long standing disease ‘drainpipe colon’
- Management
Severity of UC:
- mild: <4 stools day
- mod: 4-6
- sev: >6 bloody + systemic upset
Coeliac disease:
- Definition
- Symptoms
- Complications (6)
- Investigations
- Management
Coeliac disease:
- Definition: immunological response to gluten / gliaden fraction which leads to damage of villi, hypertrophy of crypts + lymphocytes leading to malabsorption. Strongly associated with HLADQ2 + DQ8
- Symptoms: loose stools, bloating, wind, cramps, weight loss, dermatitis herpetiformis
- Complications (6): small bowel t cell lymphoma/ca, osteoporosis, b12 deficiency, anaemia, hyposplenism, lactose intolerance, subfertility
- Investigations: 6 weeks gluten prior, endomyseal igA levels, tissue transglutaminase, fbc, ogd + duodenal biopsy
- Management: avoidance, pneumococcal and booster every 5 years
Salivation:
- Composition (5)
- Functions
- Name 3 salivary glands
- How is it made
- water, K, bicarb, mucins, amylase/lingual lipase, IgA, lactoferrin, lysozyme
- lubrication for speech/swallow, dental hygiene, germs, initial digestion, taste molecules dissolved in it
- Submandibular mixed (facial), parotid serous (glossopharyngeal), sublingual mucous (facial)
- Initial saliva made in acinus, then travels into ductal cells and Na/cl secreted out and K/HCO3 in. At rest this is very slow making it v hypotonic as longer time for electrolytes to be removed. At high flow rate its more hypertonic
H pylori infection:
- pathophysiology
- complications
- ix
- mx
- path: gram - survive in acid via chemotaxis burrying in mucosa then secretes urease which alkalises the environment. In atrum causes overactivity of g cells inc gastrin hence inc acid contents. In body causes atrophy via parietal cells via producing toxins which damages mucosa cag A, ammonia, mucinase, vacuolating toxin a
- causes: pud, gastric cancer, atrophic gastritis, b cell lymphoma MALT
- ix: urea breath test (13c urea drink and measure after 13c in co2 after 30 mins - no abx 4 weeks before and no ppi 2 weeks before), clo test via biopsy (colour changes if change in ph and urease presence), serum ab (but present after eradication), stool ag
- mx: ppi, clarithromycin/metro, amoxicillin 7 days. urea breath test post treatment if recurrence symptoms.
Gastritis:
acute:
- def
- causes
chronic:
- patho
- causes
Gastritis:
acute:
- def: inflamm of mucosa
- causes: nsaids, chemo, bile reflux, alcohol
chronic:
- patho: lymphocytes, glandular atrophy, fibrosis
- causes: h pylori, autoimmune (ab to parietal cells dec IF production hence b12 absorption hence megaloblastic anaemia and neuropathy as there is no longer myelination of nerves)
Achalasia:
- definition
- symptoms
- ix
- mx
Achalasia:
- definition: failure of oesophageal peristalsis and relaxation of loss due to degenerative loss of ganglia from auerbach’s plexus
- symptoms: dysphagia of both solids + liqs, heartburn, regurg
- ix: oesophageal manometry (excessive los tone), barium swallow (birds beak - dilatation oesophagus), cxr (wide mediastinum)
- mx: pneumatic balloon dilatation, surgery heller cardiomyotomy, botulin injection in sphincter if high risk patient
Constipation:
- definition
- secondary causes
- mx
- complications
Constipation:
- definition: <3 week, difficultly, hard stools
- causes: lack fibre, crohns, hypothyroid, parkinsons, hypercalc, drugs
- mx: fluids/ex/fibre, bulk forming laxative ispaghula, osmotic laxative/ softening macrogol
- complications: fecal impaction, haemorrhoids, urinary retention
IBS:
- symptoms
- ix
- mx
IBS:
- symptoms: >6 months of abdo pain + bloating + change in bowels, mucus
- ix: fbc/crp, coeliac screen, stool cultures
- mx: antispasmodics (hyoscine butylbromide), laxatives or loperamide, amitriptyline 2nd line, cbt if >12 months
Scurvy:
- definition
- symptoms
Scurvy:
- definition: vit c def leads to impaired collagen synthesis and connective tissue issues
- symptoms: easy bruising, poor wound healing, gingivitis, sjogrens, arthralgia, bleeding gums
Alcoholic liver disease:
- types
- ix
- mx
Alcoholic liver disease:
- types: alcoholic fatty liver, alcoholic hepatitis, cirrhosis
- ix: lfts (inc yGT, inc AST:ALT)
- mx: pred if hepatitis, pentoxyphylline
Budd chiari sndrome:
- definition
- causes
- symptoms
- ix
Budd chiari sndrome:
- definition: hepatic vein thrombosis
- causes: polycythaemia vera, preg, thrombophilia, cocp
- symptoms : abdo pain, ascites, tender hepatomegaly
- ix: doppler uss
- mx: anticoag, thrombolysis/angioplasty, TIPPs, liver transplant
Hereditory haemochromatosis:
- definition
- symptoms
- complications
- ix
- mx
Hereditory haemochromatosis:
- definition: auto recessive iron absorption disorder where accumulates - HFE gene. Inc risk of hepatocellular ca
- symptoms: early there is fatigue/ ED, arthralgia. Then bronze skin (reversible), diab, liver cirrhosis signs, hypogonadism, dilated cardiomyopathy (reversible)
- ix: transferrin sats (inc), genetic testing, ferritin (inc), lfts, total iron binding capacity (low)
- mx: venesection and keep sats <50%, desferrioxamine 2nd line
Wilsons disease:
- definition
- symptoms
- ix
- mx
Wilsons disease:
- definition: auto recessive causes excessive copper deposition in tissues - atp78 gene
- symptoms: liver cirrhosis signs, neurolog speech/psych issues, kayser fleischer rings in iris, renal tubular acidosis, blue nails
- ix: slit lamp, serum caeruloplasmin (carrier so dec levels), total serum copper reduced, inc 24 hour urin excretion copper, gene testing
- mx: penicillamine (chelator)
Ascites:
- saag >11g/l
- saag <11g/l
- mx
> 11 (means portal htn): liver cirrhosis, liver mets, right hf, budd chairi
<11: hypo albumin (malnut, nephrotic syndrome), peritoneal malig, tb peritonitis, pancreatitis, bowel obstruuction
- mx: reduce salt, fluid restrict, spironolactone, abdo paracentesis, oral cipro prophylactic
Primary biliary cirrhosis/cholangitis
- definition
- symptoms
- ix
- mx
- complications
Primary biliary cirrhosis:
- definition: mostly F, immune system attacks small interlobular bile ducts in liver causing obstruction hence cholestasis and back pressure hence liver cirrhosis. caused decreased excretion of bile acids, bilirubin and cholesterol. Associated with sjogrens, ra, systemic sclerosis, thyroid
- symptoms: bile acids - pruritis, jaundice, pale stools - inc bilirubin, xanthelasma - inc cholest, malabsorption of fats, liver cirrhosis
- ix: lfts (inc alp/bili), ama ab, esr (inc), igm, liver biopsy diagnostic
- mx: ursodeoxycholic acid slows progression, cholestyramine for itching (bile acid sequestrant reducng absorption but can cause abdo cramps/gallstones), fat sol vitamins, liver transplant, immunosuppressant
- complications: steatorrhoea, hypothyroidism, osteoporosis, hepatocellular carcinoma
