Flashcards in Gastroenterology Deck (249):
What are the two main types of infectious parasite?
Helminths = worms
Give an example of an infection with contiguous spread
Skin infection causing osteomyelitis
Give an example of an infection with haematogenous spread
Name an infection with vertical transmission
HIV (mother to child)
What are the main gram positive cocci?
Coagulase negative staphylococci
Alpha haemolytic strep (eg viridans)
Beta haemolytic strep (eg pyogenes)
What are the main gram positive bacilli?
What are the main gram negative cocci?
Neisseria meningitids and gonorrhoeae
What are the main gram negative bacilli?
A life threatening organ dysfunction caused be dysregulated host response to infection
What are the red flag signs of sepsis?
Resp rate at least 25
Urine output <0.5/ml/kg/hr or anuria for 18 hours
Mottled, ashen or acyanotic skin or a non-blanching rash
Heart rate at least 130bpm
VPU on AVPU
New need for oxygen to stay at or above 91%, or 88% in COPD
BP <90 or reduction be 50mmHg from normal
What are the common organisms involved in skin an soft tissue infections?
Staphylococci, including staph aureus
How should a staphylococcal skin infection be treated?
How should a streptococcal skin/soft tissue infection be treated?
Benzylpenicillin or flucloxacillin
How should a soft tissue/skin infection be treated if the patient is allergic to penicillin?
How should an MRSA skin/soft tissue infection be treated?
Use a glycopeptide eg vancomycin
How should musculoskeletal staph infections be treated?
Flucloxacillin or tetracycline if allergic
How should musculoskeletal strep infections be treated?
Benzylpenicillin/flucloxacillin or tetracyclin if allergic
How should diabetic foot infections be treated?
Often mixed organisms so broad spectrum penicillin eg tazocin + carbapenem
What four agents are used to treat TB?
How should streptococcal respiratory infections be treated?
Amoxicillin or co-amoxiclav
How should a respiratory haemophilus influenza infection be treated?
Amoxicillin or co-amoxiclav
What antibiotic is used to treat a legionella respiratory infection?
How should enterobacterial infections of the GI tract be treated?
Nothing unless severe then they should have ciprofloxacin, azithromycin, gentamycin or ceftriaxone
Which organisms are enterobacteriaceae?
E coli, proteus, klebsiella, salmonella
What is the treatment for a clostridium difficile infection?
PO metronidazole or vancomycin
In general, how are infections of the abdominal viscera treated?
Co-amoxiclav or ciprofloxacin
If severe or penicillins are contraindicated then carbapenem
How should enterobacterial infections of the GU tract be treated?
Coamoxiclav or ciprofloxacin
Trimethoprim or nitrofurantoin
How should a pseudomonas infection of the GU tract be treated?
Ciprofloxacin or gentamicin
How should resistant organisms of the GU tract be treated?
What is the treatment for gonorrhoea?
IM or IV cefriaxone
What is the treatment for chlamydia?
How should a streptococcal infection of the CNS be treated?
How should a CNS infection of neisseria be treated?
Ceftriaxone (+dexamethasone if bacterial meningitis)
How should a CNS infection of H influenzae be treated?
Ceftriaxone (+dexamethasone if bacterial meningitis)
How should a listeria infection of the CNS be treated?
Amoxicillin or meropenem
What is the treatment for herpes simplex encephalitis?
How should endocarditis be treated if it is caused by strep viridans?
Benzylpenicillin +/- gentamicin
How should endocarditis be treated if it is caused by enterobacteriaceae?
Flucloxacillin +/- gentamicin
How should endocarditis be treated if it is caused by staph aureus?
FLucloxacillin +/- gentamicin
How should endocarditis be treated if it is caused by MRSA?
What antibiotics are best for the use in line infections?
If staph then flucloxacillin
If strep then fluclox or benzylpenicillin
If MRSA then vancomycin
How should severe or multi-drug resistant hospital acquired infections be treated?
Tazocin or carbapenem
How should a hospital acquired enterbacteriaceae infection be treated?
How should a hospital acquired pseudomonas infection be treated?
Ciprofloxacin or gentamicin
How many calories per gram are provided by fat, carbohydrates and protein?
Fat = 9kcal/gram
protein and carbs = 4/kcal/gram each
What is the basal metabolic rate?
Amount of energy expended by humans at rest, per day. (sufficient for vital organ function only)
What is dietary induced thermogenesis?
Additional energy required for the eating, absorption, metabolism and distribution of food
What are the daily calorie requirements for men and women?
men = 2200 per day
women =1800 per day
How are carbohydrates stored?
As gylcogen in the liver and muscle
What are the breakdown products of fat?
Fatty acids and glycerol
What is fat converted to in a state of starvation?
Ketones and glucose
What is a dietary source of vitamin B12?
What is the daily requirement for sodium?
What is the daily requirement for potassium?
Name 3 causes for vitamin and trace element deficiency
Inborn error in metabolism/storage
Inadequate parenteral nutrition
How does the weight loss of starvation and illness differ?
In starvation, adaptations are made and fat is lost. In illness, adaptations are not made and muscle is lost
What are some of the metabolic consequences of starvation?
Glycogenolysis and reduced insulin and catecholamines
Reduced basal metabolic rate and increased level of hormone sensitive lipase
Gluconeogenesis from fat and amino acids
Ketogenesis from fat
What are some of the metabolic consequences of illness?
Massive muscle breakdown
What is sarcopenia?
Age-related muscle loss
What is the hierarchy of feeding?
Normal oral feeding
PEG of RIG (gastrostomy)
Naso-jejunal or PEG with jejunal extension
Total parenteral nutrition
What are the indications for nasogastric feeding?
Short-medium term solution
Bridge to either recovery or gastrostomy
What is a potential complication of NG feeding?
What are the indications for Percutaneous endoscopic gastroscopy? (PEG)
Medium - long term solution
Support in chronic disease, chemotherapy, radiotherapy, and palliative care
Name two disadvantages of PEG feeding
Doesn't protect from aspiration
Endoscopy required (intubation)
When is a radiologically inserted gastroscopy (RIG) done, rather than a PEG?
If the upper GI tract is inaccessible
If respiratory disease is present
Name disadvantage of RIG feeding
Easy to dislodge
Requires frequent changes
What nutrition is provided by NG, PEG and RIG feeding?
Around 1kcal/ml +/- supplementary water
When is parenteral nutrition used?
In intestinal failure
What is a person's daily fluid requirement?
How is the anion gap calculated?
What is the risk of giving too much normal saline, and how does this occur?
Risk of hyperchloraemic acidosis. Chloride and sodium given in equal quantities but chloride is normally at a lower concentration in the plasma.
Proportionally, chloride is increased in the blood.
Body compensated by increasing HCO3 loss and increasing H+ levels, leading to acidosis
What is parenteral nutrition?
Nutrition delivered with accessing or utilising the GI tract
How is parenteral nutrition delivered?
Intravenously, through a central venous catheter
What does parenteral feeding solution consist of?
What is a central venous catheter?
A long, flexible catheter tube with the tip sitting in a large vein
What are the three main types of complications of parenteral feeding?
Name a mechanical complication of parenteral feeding
Name a biochemical complication of enteral feeding
Abnormal liver function (increased carbohydrates)
Name three clinical signs of anorexia nervosa
Name three complications of anorexia nervosa
Explain the physiological processes involved in refeeding syndrome
After a period of starvation, if feeding takes place there is insulin secretion.
THis Increases uptake of glucose, phosphate, magnesium and potassium
Thiamine use is increased
This leads to hypophosphataemia, hypokalaemia, hypomagnesaemia, thiamine deficiency and sodium and water retention
What is the diagnostic criteria for irritable bowel syndrome?
Abdominal discomfort or pain that's relieved by defecation OR associated with altered bowel frequency or stool form
AND at least 2 of:
Altered stool passage
Symptoms worsened by eating
Abdominal bloating, distension, tension or hardness
What standard investigations should be done if IBS is suspected?
FBC, LFTs, CRP, ESR
Endomysial antibody testing
Any abnormalities point towards other cause
What are the main pharmacological ways of managing IBS?
If there is cramping pain, give an anti-spasmodic if mebeverine
If there is constipation, then a bulk forming laxative eg ispaghula
If there is diarrhoea then an antimotility agent eg loperamide
If none of these work, then consider a TCA eg amitriptylline for the pain
What is acute liver failure?
An acute failure of the metabolic and synthetic functions of the liver in the presence of encephalopathy and the absence of pre-existing liver disease
Name 3 causes of acute liver failure
Drugs eg paracetamol
Infection eg Hep B, CMV
Vascular disease, eg right heart failure, budd-chiari syndrome
Metabolic eg wilson's disease
What are the 4 grades of encephalopathy?
Grade 1 = altered mood, behaviour and sleep patterns. (tremor and apraxia)
Grade 2 = Increasing drowsiness, confusion, slurred speech, disorientation and inappropriate behavious. ( asterixis and hyporeflexia)
Grade 3 = Stupor, incoherence and restlessness with significant confusion. (asterixis and hyperreflexia)
Grade 4 = coma with decerebration
Give 3 potentially fatal complications of acute liver failure
Raised intracranial pressure
What are the criteria for liver transplantation in paracetamol induced acute liver failure?
pH <7.3 24 hours after ingestion
Or all 3 of:
Prothrombin time >100seconds
Grade 3 or 4 encephalopathy
What are the criteria for liver transplantation in non-paracetamol acute liver failure?
Or 3 of:
Age <10 or >40
Prothombin time >50seconds
More than a week between first episode of jaundice and onset of encephalopathy
What are the potential bleeding sites for haematemesis?
Anywhere proximal to jejunum
What are the potential bleeding sites for malaena?
Anywhere proximal to caecum
Give 5 possible causes for an acute upper GI bleed
Mallory weiss tear
Hereditary haemorrhagic telangiectasia
What are the Rockall cut offs for the need for surgery?
If At least 3 pre-endoscopy or more than 6 post-endoscopy
What drug should be given to manage variceal bleeding?
Which form of IBD is more likely to cause lower GI bleeding?
How should lower GI bleeding be investigated?
Bloods for FBC, U&E, LFTs and clotting
If haemorrhoids suspected then proctosigmoidoscopy
If fresh blood then flexible sigmoidoscopy
If darker blood then colonoscopy
If unstable/heavy bleeding then mesenteric angiography
If still unknown, then repeat colonsocopy then barium enema then capsule endoscopy
Laparotomy with on-table colonoscopy
What are the complications of acute total dysphagia?
What is the commonest cause of total dysphagia acutely?
Impaction of food bolus on pre-existing lesion
How should acute total dysphagia be managed?
Reassurance and rehydration
Endoscopic removal of obstruction
Dilate stricture if possible
Enteral feeding tube
How can acute total dysphagia be avoided in oesophageal lesions?
Avoid fibrous foods
Drink plenty, especially carbonated drinks
PPI if stricture
How does oesphageal rupture present?
Sudden severe central chest pain often after a provoking cause
How should an oesophageal rupture be investigated?
Rule out differentials:
ECG and cardiac enzymes
CT chest and abdomen
What signs will there be on chest x ray in oesophageal rupture?
Surgical and mediastinal emphysema
What is the most common site for oesophageal rupture?
2-3 cm from oesophagogastric junction
Which food-borne organisms typically cause acute diarrhoea within 1-6 hours?
Which food-borne organisms typically cause acute diarrhoea within 8-18 hours?
Which food-borne organisms typically cause acute diarrhoea within 12-36 hours?
Clostridium botulinium salmonella
Name 3 drugs that can cause diarrhoea?
How should acute diarrhoea be managed?
Replace fluid loss orally if possible
IV fluids if bloody diarrhoea or dehydration
Anti-diarrhoeal drugs eg loperamide if not bloody and only use with caution
Antibiotics if infective cause found
What antibiotic should be used for salmonella?
Avoid where possible as cholestasis increases gallbladder carriage
Use ciprofloxacin or trimethoprim
What antibiotic should be used for shigella infection?
What antibiotic should be used for e coli infection?
Ciprofloxacin but risk of haemolytic uraemic syndrome
What antibiotic should be used for campylobacter infection?
Ciprofloxacin or erythromycin
What antibiotic should be used for clostridium difficule infection?
Oral metronidazole and vancomycin
What antibiotic should be used for giardia infection?
When should antibiotics be given in acute diarrhoea?
If infective cause and systemic effects eg temperature >39, bloody diarrhoea for over 2 weeks or signs of dehydration
What are the most common causes of small bowel obstruction?
How should suspected bowel obstruction be investigated?
Bloods for FBC, U&Es, LFTs, ABG, Group and save
Erect CXR if ?perforation
CT to localise obstruction site
Give three causes of gastric outlet obstruction
PEG tube migration
What are the symptoms of gastroparesis?
Nausea and vomiting of undigested food
How are apthous ulcers managed?
Antiseptic mouthwash usually sufficient. If not then topical salicyclate or steroid
Give three infective causes of oral ulceration
What is the most common type of cancer of the oral cavity?
Squamous cell carcinoma
Name three risk factors for the development of oral cancer
Betel nut chewing
How is oral cancer treated?
Preferably by radical radiotherapy
Surgery (+/- radiotherapy and chemotherapy)
What is the appearance of oral crohn's?
Multifocal, firm painless lumps
What hereditary pattern is found in hereditary haemorrhagic telangiectasia?
What is gardner syndrome?
Autosomal dominant disorder causing intestinal polyposis (subset of FAP) with extensive oral involvement
What are the oral finding s in Gardner syndrome?
What is Peutz-Jegher's syndrome?
Autosomal dominant disorder of hamartomatous intestinal polyps and increased risk of all cancers
What mechanisms normally prevent gastro oesophageal reflux?
Angle of Hiss
Lower oesophageal sphincter
Give 5 causes of GORD
Calcium channel blockers
When should an endoscopy be performed in someone with dyspepsia/heart burn?
If >55 years
Symptoms for over 4 weeks
Symptoms refractory to treatment
When should dyspepsia be referred for 2ww?
Continuous symptoms in over 55s
Positive upper GI history in >2 first degree relatives
Peptic ulcer surgery over 20 years ago
Upper abdominal mass
What is the pharmacological management of GORD?
Full dose PPI for 1 month or 2 months if confirmed on endoscopy
How should a patient prepare for an endoscopy investigating GORD?
Stop any PPIs/H2 antagonists 2 weeks before procedure
What is the surgical option for GORD?
What are the findings on oesophageal manometry in achalasia?
Increased resting cardia pressure
Incomplete relaxation on swallowing
How is achalasia managed?
Heller's myotomy or pneumatic dilatation
Or Botulinum injection
Nitrates/calcium channel blockers
What's the most common type of oesophageal malignancy?
What is a pharyngeal pouch?
A posteromedial diverticulum through pharyngeal wall in between crycopharyngeus and thryopharyngeus
What are the features of a pharyngeal pouch?
Night time cough
What is a mallory-weiss tear?
A tear through the mucosa of the oesophagogastric junction
What is eosinophilic oesophagitis?
Eosinophilic infiltration of the oesophageal mucosa causing dysphagia/vomiting
What are the features of plummer-vinson syndrome?
Dysphagia from oesophageal web
Iron deficiency anaemia
What are haemorrhoids?
The abnormal swelling of vascular anal mucosal cushions
What positions do anal vascular cushions sit in?
3 7 and 11
How are internal haemorrhoids classified?
1st degree = don't prolapse outside anal canal
2nd degree = prolapse on straining but reduce spontaneously
3rd degree = prolapse and require manual reduction
4th degree = cannot be reduced
How should haemorrhoids be managed?
Conservative = avoid constipation and promote anal hygiene
Topical preparations to reduce pain and increase lubrication.
Non surgical = rubber band ligation, injection sclerotherapy, infrared coagulation or diathermy
Surgical = open or staple haemorrhoidectomy
Haemorrhoidal artery ligation
What are the differences in appearance of acute and chronic anal fissures?
Acute are superficial and well-demarcated
Chronic can be deep with visible muscle fibres. Wider and deeper with swollen edges. May be a sentinel skin tag
How should anal fissures be managed?
Simple analgesia +/- regular hot baths if long lasting pain
Topical lidocaine if extreme pain on defecation
Give 5 risk factors for the development of polonidal sinus
Deep natal cleft
How is a pilonidal abscess managed?
Surgical excision and drainage
Meticulous perianal hygiene
Give 5 risk factors for the development of anal carcinoma
Engaging in anoreceptive sex
Prior perianal crohn's or fistulae
Prior pelvic irradiation
How might anal carcinoma present?
Fresh rectal bleeding and discomfort
What are the 4 main types of anorectal abscesses?
Which are the most common anorectal abscesses?
How are anorectal abscesses managed?
Pus swab and culture
Packing and drain insertion in ischiorectal
How do perianal abscesses develop?
Infection spreads downwards from intersphincteric space to the anal verge
How do ischiorectal abscesses develop?
Infection spreads outwards from intersphincteric space into the ischiorectal fossa, where it can quickly enlarge
What is an anal fistula?
Abnormal connection between anus roughly at dentate line, through the site of a pervious abscess out to the perianal skin
How are anal fistulae managed?
Perianal excision and colostomy formation if severe
Give three pre-hepatic causes of jaundice
Drugs eg sulfasalazine
Give three post-hepatic causes of jaundice
Parasitic infection eg fasciola
Give three hepatic causes of jaundice
Non-alcoholic fatty liver disease
Autoimmune disease eg schlerosing cholangitis
Drugs eg paracetamol/TB drugs
How are oesophageal varices graded?
Grade 1 - collapse on inflation of oesophagus with air
Grade 3 - occlue lumen
Grade 2 - between the two
How is portal hypertension confirmed?
Measure portal pressure gradient (difference between portal and hepatic vein)
If >12 mmHg then there is portal hypertension
Give 3 consequences of portal hypertension
Collateral vessel formation
Increased risk of hepatorenal syndrome
How does hypersplenism in liver disease develop?
Portal hypertension causes splenomegaly. Enlargement leads to sequestration of red blood cells, white blood cells and platelets so there is apparent pancytopenia
What is the difference between transudate and exudate?
Transudate has a low protein content and is due to either high hydrostatic pressure eg from hypertension, or low oncotic pressure, eg hypoalbuminaemia
Exudate has high protein content and is due to eg either inflammation or malignancy
How is the underlying cause of ascites determined?
Serum ascites albumin gradient: (serum albumin - ascites albumin concentrations)
If >11g.l then is due to portal hypertension
If <11g/l then is due to another cause
Can also due bloods, USS and ascitis tap
How is ascites managed?
Optimise nutritional status to try and increase albumin and correct any underlying condition
Aim for weight loss of no more than 0.5kg/day
Spironolactone and add furosemide if necessary
Paracentesis if causing discomfort + IV albumin
Transjugular intrahepatic portosystemic shunt if refractory
Why may antibiotics be given in ascites?
Because of risk of spontaneous bacterial peritonitis
Which patients are most at risk of spontaneous bacterial peritonitis?
Ascitic albumin concentration <0.1g/l
Cirrhosis with bleeding varices
Fluid protein <15g/l with either impaired renal function or child-pugh score of 9 or more
What are the most common causative organisms of spontaneous bacterial peritonitis?
How is spontaneous bacterial peritonitis managed?
Long term ciprofloxacin
What does bloody ascitic fluid indicate?
Perforated peptic ulcer
What does turbid ascitic fluid indicate?
Spontaneous bacterial peritonitis
What does chylous ascitic fluid indicate?
What are the features of hepatic encephalopathy?
Triphasic slow waves on EEG
How is encephalopathy graded?
Grade 1 = irritability and apraxia
Grade 2 = Confusion, inappropriate behaviour, dysarthria and ataxia
Grade 3 = Incoherence and restlessness and asterixis
Grade 4 = coma and decerebration
What are the main precipitants of hepatic encephalopathy?
Increase serum ammonia
Disturbance of blood-brain barrier
How is hepatic encephalopathy managed?
Correct any precipitants
Lactulose for 3-4 loose stools a day
Reduce dietary protein
What is hepatorenal syndrome?
An acute, potentially reversible oliguric renal failure in liver disease with intense renal vasoconstriction in otherwise normal kidneys
What is the pathology in hepatorenal syndrome?
Vasoactive mediators cause splanchnic vasodilation, reducing blood flow to kidneys, with activate the RAAS system, causing renal vasoconstriction.
Also gross cardiovascular alterations and sympathetic overactivity
Result in sodium and water retention and vasoconstriction
What are the main differences between the two types of hepatorenal syndrome?
Type 1 is rapidly progressive with creatinine >226
Associated with cardiac and liver impairment and encephalopathy. 3 month survival in 10%
Type 2 is slowly progressive with creatinine 133-226
Associated with refractory ascites
3 month survival is 70%
What criteria must be met for a diagnosis of hepatorenal syndrome in cirrhosis
No mesenchymal kidney disease
No improvement in creatinine after 2 days of diuretic withdrawal and volume expansion
No current or recent nephrotoxic drugs
Absence of shock
Cirrhosis with ascites
How is hepatorenal syndrome managed?
Treat any infection
Withdraw any nephrotoxins
Albumin volume expansion
Name the CYP450 inhibitors
Name the main CYP450 inducers
St John's wort
At what dose of paracetmaol do serious adverse effects start to be seen?
150mg/kg so in 9g in a 60kg person
Give three factors that increase the risk of toxicity in paracetamol overdose
On enzyme inducing drugs
How should a paracetamol overdose be managed?
If within 1 hr then activated charcoal
If staggered or ingestion time unknown or above limit then give n-acetylcysteine
Transplantation if meets King's criteria
What are the criteria for liver transplantation in paracetamol overdose?
pH<7.3 24 hours post-ingestion
or all three of:
Grade 3 or 4 encephalopathy
What are the plasma concentration limits of paracetmaol needed to give acetylcysteine?
>100mg/l at 4 hours
>15mg/l at 15 hours
Give three causes of haemochromatosis
Autosomal dominant mutation
Parenteral iron from repeated transfusions
End stage alcoholic cirrhosis
Give 5 clinical features of haemochromatosis
Slate grey skin discolouration
How is hereditary haemochromatosis managed?
Lifelong venesection. May not be necessary in menstruating females.
What abnormalities may be seen on x ray in someone with haemochromatosis?
What is the pathophysiology of wilson's disease?
Defect in copper excretion so it can't bind to caeruloplasmin and so can't be excreted in bile and accumulates in the liver, and later in other tissues
How is wilson's disease managed?
Reduced dietary copper
How does antitrypsin deficiency cause liver disease?
Abnormal alpha1AT accumulates in the liver and causes cellular injury
What is the difference in the presentation of epigastric pain of the different types of peptic ulcers?
Gastric ulcers are aggravated by food and relieved by antacids
Duodenal ulcers cause hunger and nocturnal pain and is relieved by eating and milk
What is the most common location for gastric ulcers?
The lesser curve
How are peptic ulcers managed medically?
1-2 months of full dose PPI
If H pylori proven then eradication therapy after PPI therapy stops, followed by repeat endoscopy
What drugs are used to eradicate h pylori?
PPI eg lanzoprazole
Amoxicillin or metronidazole
Give 2 complications of peptic ulcer disease?
Gastric outlet obstruction
What autoantibodies are implicated in autoimmune hepatitis?
ANA/SMA in type 1
Anti liver/kidney microsome in type 2
What are the common clinical features of autoimmune hepatitis?
How is autoimmune hepatitis managed?
High dose corticosteroids +/- immunosuppressant
Give three ways in which alcohol causes damage to the liver?
Increases iron levels
Causes mitochondrial damage
Reduces number of antioxidants
Alters intracellular signalling
What is the spectrum of conditions in alcoholic liver disease?
Fatty liver - alcoholic hepatitis - cirrhosis
How is alcoholic liver disease managed/
Supportive measures eg optimise nutrition
B vitamin supplements
Liver transplantation after 6 months abstinence
What marker is used to identify hepatocellular carcinoma?
Which cancers commonly metastasise to the liver?
Other than liver, what other cancer can cause raised AFP?
How is hepatocellular carcinoma managed?
Name two conditions that predispose to developing cholangiocarcinoma
Primary sclerosing cholangitis
What blood abnormalities are found in cholangiocarcinoma?
Obstructive picture on LFTs
Raised CA19-9, CA125 and CEA
How is cholangiocarcinoma managed?
What organisms commonly cause pyogenic liver abscesses?
Give three contraindications to liver transplantation?
Advanced cardiopulmonary disease
Active alcohol/drug use
Non-compliance with drug therapy
What are the criteria for carrying out liver transplantation in someone with chronic liver disease?
<10 or >40 years old
Jaundice present for >7 days before encephalopathy
Cause is either: Non-A or B hepatitis
Idiosyncratic drug reaction
How can the prognosis of someone with cirrhosis be assessed?
Use the Child-Pugh criteria, which looks at:
INR, encephalopathy, ascites, serum albumin, bilirubin
What immunosuppresion therapy are transplant patients on?
Either tacrolimus or ciclosporin
High dose prednisolone
Azathioprine of mycophenolate mofetil
Give 5 potential complications of liver transplantation
Hepatic artery or portal vein thrombosis
Increased cancer risk
Bone marrow disease
Give three side effects of the calcineurin inhibitors?
Gingival hyperplasia with ciclosporin
What is the acute rejection that occurs in liver transplantation?
Occurs within 6 months, but usually within 2 weeks and is a t cell mediated infiltration of mononuclear cells, causing sepsis and tender hepatomegaly
What is primary sclerosing cholangitis?
Progressive liver disease with inflammation and fibrosis of bile ducts leading to stricturing
Give three clinical features of primary sclerosing cholangitis
Reduced fat soluble vitamin absorption
What abnormalities are found on investigation in primary sclerosing cholangitis?
Raised ALP, GGT, bilirubin (+ALT/AST)
Raised IgG and IgM
Bile duct dilatation on USS
How is primary sclerosing cholangitis managed?
Colestyramine for pruritis
Cholangiocarcinoma and colorectal cancer surveillance
Baloon dilatation of bile ducts
Give 3 complications of primary sclerosing cholangitis
What conditions are associated with primary sclerosing cholangitis?
What are the 4 stages of primary sclerosing cholangitis?
Destruction and inflammatory cell infiltration and scarring of bile duct epithelia
Fibrosis and reduction in number of bile ductules. with hepatocyte necrosis
Disappearance of bile ducts and periportal cholestasis.
What is primary biliary cholangitis?
Slowly progressive autoimmune destruction of intrahepatic bile duct epithelia causing intrahepatic cholestasis
Give 3 clinical features of primary biliary cholangitis?
Signs of cirrhosis
Give three conditions associated with primary biliary cholangitis
What abnormalities are found on blood tests in primary biliary cholangitis?
What imaging should be done in primary biliary cholangitis?
What is found on liver biopsy in primary biliary cholangitis?
Chronic, non-suppurative cholangitis
How is primary biliary cholangitis managed?
Colestyramine for puritis
Give three complications of primary biliary cholangitis
Renal tubular acidosis
What are the general features of intestinal malabsorption?
Give 5 causes of malabsoprtion
IBD esp crohn's
What are the biopsy findings in coeliac disease?
Villous atrophy with crypt hyperplasia
What antibodies are associated with coeliac disease?
Ig A tissue transglutaminase