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Flashcards in Gastroenterology Deck (249):
1

What are the two main types of infectious parasite?

Helminths = worms
Protozoa

2

Give an example of an infection with contiguous spread

Skin infection causing osteomyelitis

3

Give an example of an infection with haematogenous spread

Endocarditis

4

Name an infection with vertical transmission

HIV (mother to child)

5

What are the main gram positive cocci?

Staph aureus
Coagulase negative staphylococci
Alpha haemolytic strep (eg viridans)
Beta haemolytic strep (eg pyogenes)

6

What are the main gram positive bacilli?

Listeria monocytogenes
Bacillus
Clostridium
Corynebacterium

7

What are the main gram negative cocci?

Neisseria meningitids and gonorrhoeae

8

What are the main gram negative bacilli?

Pseudomonas aeruginosa
Enterobacteriaceae
Haemophilus influenzae

9

Define sepsis

A life threatening organ dysfunction caused be dysregulated host response to infection

10

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

11

What are the common organisms involved in skin an soft tissue infections?

Staphylococci, including staph aureus
Streptococci

12

How should a staphylococcal skin infection be treated?

Flucloxacillin

13

How should a streptococcal skin/soft tissue infection be treated?

Benzylpenicillin or flucloxacillin

14

How should a soft tissue/skin infection be treated if the patient is allergic to penicillin?

Tetracyclin
Or cephalosporin/carbapenem

15

How should an MRSA skin/soft tissue infection be treated?

Use a glycopeptide eg vancomycin

16

How should musculoskeletal staph infections be treated?

Flucloxacillin or tetracycline if allergic

17

How should musculoskeletal strep infections be treated?

Benzylpenicillin/flucloxacillin or tetracyclin if allergic

18

How should diabetic foot infections be treated?

Often mixed organisms so broad spectrum penicillin eg tazocin + carbapenem

19

What four agents are used to treat TB?

Isoniazid
Ethambutol
Pyrazinamide
Rifampicin

20

How should streptococcal respiratory infections be treated?

Amoxicillin or co-amoxiclav

21

How should a respiratory haemophilus influenza infection be treated?

Amoxicillin or co-amoxiclav

22

What antibiotic is used to treat a legionella respiratory infection?

Doxycycline

23

How should enterobacterial infections of the GI tract be treated?

Nothing unless severe then they should have ciprofloxacin, azithromycin, gentamycin or ceftriaxone

24

Which organisms are enterobacteriaceae?

E coli, proteus, klebsiella, salmonella

25

What is the treatment for a clostridium difficile infection?

PO metronidazole or vancomycin

26

In general, how are infections of the abdominal viscera treated?

Co-amoxiclav or ciprofloxacin
If severe or penicillins are contraindicated then carbapenem

27

How should enterobacterial infections of the GU tract be treated?

Coamoxiclav or ciprofloxacin
Trimethoprim or nitrofurantoin

28

How should a pseudomonas infection of the GU tract be treated?

Ciprofloxacin or gentamicin

29

How should resistant organisms of the GU tract be treated?

Carbapenem

30

What is the treatment for gonorrhoea?

IM or IV cefriaxone

31

What is the treatment for chlamydia?

Azithromycin

32

How should a streptococcal infection of the CNS be treated?

IV cephalosporin

33

How should a CNS infection of neisseria be treated?

Ceftriaxone (+dexamethasone if bacterial meningitis)

34

How should a CNS infection of H influenzae be treated?

Ceftriaxone (+dexamethasone if bacterial meningitis)

35

How should a listeria infection of the CNS be treated?

Amoxicillin or meropenem

36

What is the treatment for herpes simplex encephalitis?

IV aciclovir

37

How should endocarditis be treated if it is caused by strep viridans?

Benzylpenicillin +/- gentamicin

38

How should endocarditis be treated if it is caused by enterobacteriaceae?

Flucloxacillin +/- gentamicin

39

How should endocarditis be treated if it is caused by staph aureus?

FLucloxacillin +/- gentamicin

40

How should endocarditis be treated if it is caused by MRSA?

Vancomycin

41

What antibiotics are best for the use in line infections?

If staph then flucloxacillin
If strep then fluclox or benzylpenicillin
If MRSA then vancomycin

42

How should severe or multi-drug resistant hospital acquired infections be treated?

Tazocin or carbapenem

43

How should a hospital acquired enterbacteriaceae infection be treated?

Co-amoxiclav

44

How should a hospital acquired pseudomonas infection be treated?

Ciprofloxacin or gentamicin

45

How many calories per gram are provided by fat, carbohydrates and protein?

Fat = 9kcal/gram
protein and carbs = 4/kcal/gram each

46

What is the basal metabolic rate?

Amount of energy expended by humans at rest, per day. (sufficient for vital organ function only)

47

What is dietary induced thermogenesis?

Additional energy required for the eating, absorption, metabolism and distribution of food

48

What are the daily calorie requirements for men and women?

men = 2200 per day
women =1800 per day

49

How are carbohydrates stored?

As gylcogen in the liver and muscle

50

What are the breakdown products of fat?

Fatty acids and glycerol

51

What is fat converted to in a state of starvation?

Ketones and glucose

52

What is a dietary source of vitamin B12?

Red meat

53

What is the daily requirement for sodium?

1-1.5mmol/kg/day

54

What is the daily requirement for potassium?

1mmol/kg/day

55

Name 3 causes for vitamin and trace element deficiency

Inborn error in metabolism/storage
Poor diet
Malabsorption
Food fads
Inadequate parenteral nutrition

56

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

57

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

58

What are some of the metabolic consequences of illness?

Increased catecholamines.
Massive muscle breakdown

59

What is sarcopenia?

Age-related muscle loss

60

What is the hierarchy of feeding?

Normal oral feeding
Oral supplementation
NG feeding
PEG of RIG (gastrostomy)
Naso-jejunal or PEG with jejunal extension
Parenteral
Total parenteral nutrition

61

What are the indications for nasogastric feeding?

Short-medium term solution
Bridge to either recovery or gastrostomy

62

What is a potential complication of NG feeding?

Gastric erosion

63

What are the indications for Percutaneous endoscopic gastroscopy? (PEG)

Medium - long term solution
Support in chronic disease, chemotherapy, radiotherapy, and palliative care

64

Name two disadvantages of PEG feeding

Doesn't protect from aspiration
Endoscopy required (intubation)

65

When is a radiologically inserted gastroscopy (RIG) done, rather than a PEG?

If the upper GI tract is inaccessible
If respiratory disease is present

66

Name disadvantage of RIG feeding

Easy to dislodge
Requires frequent changes

67

What nutrition is provided by NG, PEG and RIG feeding?

Around 1kcal/ml +/- supplementary water

68

When is parenteral nutrition used?

In intestinal failure
Inaccesible gut
Obstructed gut

69

What is a person's daily fluid requirement?

25mls/kg

70

How is the anion gap calculated?

(Na+K)-(HCO3+Cl)

71

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

72

What is parenteral nutrition?

Nutrition delivered with accessing or utilising the GI tract

73

How is parenteral nutrition delivered?

Intravenously, through a central venous catheter

74

What does parenteral feeding solution consist of?

Glucose
Water
Electrolytes
Vitamins
Trace elements
+/- lipids

75

What is a central venous catheter?

A long, flexible catheter tube with the tip sitting in a large vein

76

What are the three main types of complications of parenteral feeding?

Mechanical
Biochemical
Infectious

77

Name a mechanical complication of parenteral feeding

Line occlusion
Line fracture
Thrombosis
Air embolus
Pneumothorax

78

Name a biochemical complication of enteral feeding

Electrolyte abnormality
FLuid overload
Hyperglycaemia
Abnormal liver function (increased carbohydrates)

79

Name three clinical signs of anorexia nervosa

Lanugo hair
Low BMI
Muscle wasting
SKin changes
Pressure sores
Amenorrhoea
Knuckle calluses

80

Name three complications of anorexia nervosa

Severe malnutrition
Hypoglycaemia
Hypothermia
Liver failure
Osteoporosis
Fractures
Dehydration
Electrolyte imbalance
Micronutrient deficiency
Infections

81

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

82

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
Passing mucus
Symptoms worsened by eating
Abdominal bloating, distension, tension or hardness

83

What standard investigations should be done if IBS is suspected?

FBC, LFTs, CRP, ESR
Endomysial antibody testing
Any abnormalities point towards other cause

84

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

85

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

86

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
Malignancy
Sepsis

87

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

88

Give 3 potentially fatal complications of acute liver failure

Raised intracranial pressure
Infection
Haemorrhage
Respiratory failure
AKI

89

What are the criteria for liver transplantation in paracetamol induced acute liver failure?

pH <7.3 24 hours after ingestion
Or all 3 of:
Creatinine >300micromol
Prothrombin time >100seconds
Grade 3 or 4 encephalopathy

90

What are the criteria for liver transplantation in non-paracetamol acute liver failure?

Prothrombin time>100seconds
Or 3 of:
Age <10 or >40
Bilirubin >300micromol
Prothombin time >50seconds
Drug induced
More than a week between first episode of jaundice and onset of encephalopathy

91

What are the potential bleeding sites for haematemesis?

Anywhere proximal to jejunum

92

What are the potential bleeding sites for malaena?

Anywhere proximal to caecum

93

Give 5 possible causes for an acute upper GI bleed

Peptic ulcer
Gastritis
Mallory weiss tear
Malignancy
Gastro-oesophageal varices
Duodenitis
Oesophagitis
Dieulafoy lesions
Hereditary haemorrhagic telangiectasia
Aorto-enteric fistula
Clotting defect
Meckel's diverticulum

94

What are the Rockall cut offs for the need for surgery?

If At least 3 pre-endoscopy or more than 6 post-endoscopy

95

What drug should be given to manage variceal bleeding?

Terlipressin

96

Which form of IBD is more likely to cause lower GI bleeding?

UC

97

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

98

What are the complications of acute total dysphagia?

Aspiration pneumonia
Distress

99

What is the commonest cause of total dysphagia acutely?

Impaction of food bolus on pre-existing lesion

100

How should acute total dysphagia be managed?

Reassurance and rehydration
Endoscopic removal of obstruction
Dilate stricture if possible
Enteral feeding tube

101

How can acute total dysphagia be avoided in oesophageal lesions?

Careful mastication
Avoid fibrous foods
Drink plenty, especially carbonated drinks
PPI if stricture

102

How does oesphageal rupture present?

Sudden severe central chest pain often after a provoking cause

103

How should an oesophageal rupture be investigated?

Rule out differentials:
ECG and cardiac enzymes
Amylase
Erect CXR
CT chest and abdomen
Gastrograffin swallow

104

What signs will there be on chest x ray in oesophageal rupture?

Surgical and mediastinal emphysema
Pleural effusion

105

What is the most common site for oesophageal rupture?

2-3 cm from oesophagogastric junction

106

Which food-borne organisms typically cause acute diarrhoea within 1-6 hours?

Bacillus cereus
Staph aureas

107

Which food-borne organisms typically cause acute diarrhoea within 8-18 hours?

E coli
Shigella
Campylobacter
Clostridium perfringens

108

Which food-borne organisms typically cause acute diarrhoea within 12-36 hours?

Clostridium botulinium salmonella

109

Name 3 drugs that can cause diarrhoea?

Propanolol
Digoxin
Laxatives
Antibiotics
PPI
Cytotoxics

110

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

111

What antibiotic should be used for salmonella?

Avoid where possible as cholestasis increases gallbladder carriage
Use ciprofloxacin or trimethoprim

112

What antibiotic should be used for shigella infection?

Ciprofloxacin

113

What antibiotic should be used for e coli infection?

Ciprofloxacin but risk of haemolytic uraemic syndrome

114

What antibiotic should be used for campylobacter infection?

Ciprofloxacin or erythromycin

115

What antibiotic should be used for clostridium difficule infection?

Oral metronidazole and vancomycin

116

What antibiotic should be used for giardia infection?

Metronidazole

117

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

118

What are the most common causes of small bowel obstruction?

Adhesions
Herniae
Malignancy

119

How should suspected bowel obstruction be investigated?

Bloods for FBC, U&Es, LFTs, ABG, Group and save
AXR
Erect CXR if ?perforation
CT to localise obstruction site

120

Give three causes of gastric outlet obstruction

Malignancy
Gastroparesis
Pyloric stenosis
Crohn's
Caustic injury
Bezoar
PEG tube migration
Gastric volvulus

121

What are the symptoms of gastroparesis?

Nausea and vomiting of undigested food
Early satiety
Bloating
Dyspepsia

122

How are apthous ulcers managed?

Antiseptic mouthwash usually sufficient. If not then topical salicyclate or steroid

123

Give three infective causes of oral ulceration

Herpes simplex
Candidiasis
Vincent's angina

124

What is the most common type of cancer of the oral cavity?

Squamous cell carcinoma

125

Name three risk factors for the development of oral cancer

Smoking
Malnutrition
Betel nut chewing
Alcohol excess

126

How is oral cancer treated?

Preferably by radical radiotherapy
Surgery (+/- radiotherapy and chemotherapy)

127

What is the appearance of oral crohn's?

Multifocal, firm painless lumps
or ulceration

128

What hereditary pattern is found in hereditary haemorrhagic telangiectasia?

Autosomal dominant

129

What is gardner syndrome?

Autosomal dominant disorder causing intestinal polyposis (subset of FAP) with extensive oral involvement

130

What are the oral finding s in Gardner syndrome?

Unerupted teeth
Jaw osteomas
Jay enostoses

131

What is Peutz-Jegher's syndrome?

Autosomal dominant disorder of hamartomatous intestinal polyps and increased risk of all cancers

132

What mechanisms normally prevent gastro oesophageal reflux?

Angle of Hiss
Lower oesophageal sphincter
Oesophageal contractions

133

Give 5 causes of GORD

Hiatus hernia
Gastroparesis
Pregnancy
Obesity
Chronic cough
Smoking
Rich diet
NSAIDs
Binge drinking
Tight clothes
Systemic sclerosis
TCAs
Anticholinergics
Calcium channel blockers
Nitrates

134

When should an endoscopy be performed in someone with dyspepsia/heart burn?

If >55 years
Symptoms for over 4 weeks
Dysphagia
Symptoms refractory to treatment
Relapsing symptoms
Weight loss

135

When should dyspepsia be referred for 2ww?

If with:
Weight loss
Anaemia
Vomiting
Continuous symptoms in over 55s
Positive upper GI history in >2 first degree relatives
Barrett's oesophagus
Pernicious anaemia
Peptic ulcer surgery over 20 years ago
Dysplasia
Atrophic gastritis
Jaundice
Upper abdominal mass

136

What is the pharmacological management of GORD?

Full dose PPI for 1 month or 2 months if confirmed on endoscopy

137

How should a patient prepare for an endoscopy investigating GORD?

Stop any PPIs/H2 antagonists 2 weeks before procedure

138

What is the surgical option for GORD?

Laparascopic fundoplication

139

What are the findings on oesophageal manometry in achalasia?

Absent peristalsis
Increased resting cardia pressure
Incomplete relaxation on swallowing

140

How is achalasia managed?

Heller's myotomy or pneumatic dilatation
Or Botulinum injection
Nitrates/calcium channel blockers

141

What's the most common type of oesophageal malignancy?

Adenocarcinoma

142

What is a pharyngeal pouch?

A posteromedial diverticulum through pharyngeal wall in between crycopharyngeus and thryopharyngeus

143

What are the features of a pharyngeal pouch?

Regurgitation
Halitosis
Gurgling
Night time cough
Dysphagia
Aspiration

144

What is a mallory-weiss tear?

A tear through the mucosa of the oesophagogastric junction

145

What is eosinophilic oesophagitis?

Eosinophilic infiltration of the oesophageal mucosa causing dysphagia/vomiting

146

What are the features of plummer-vinson syndrome?

Dysphagia from oesophageal web
Iron deficiency anaemia
Glossitis

147

What are haemorrhoids?

The abnormal swelling of vascular anal mucosal cushions

148

What positions do anal vascular cushions sit in?

3 7 and 11

149

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

150

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

151

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

152

How should anal fissures be managed?

Avoid/correct constipation
Simple analgesia +/- regular hot baths if long lasting pain
Topical lidocaine if extreme pain on defecation
GTN ointment
Botox injections

153

Give 5 risk factors for the development of polonidal sinus

Male
Young adulthood
Caucasian
Sedentary lifestyle
Obesity
Hirsuitism
Deep natal cleft
Family history
Hidradenitis suppurativa

154

How is a pilonidal abscess managed?

Surgical excision and drainage
Analgesia
Meticulous perianal hygiene

155

Give 5 risk factors for the development of anal carcinoma

HIV positive
HPV positive
Engaging in anoreceptive sex
Immunosuppression
Syphilis
Prior perianal crohn's or fistulae
Prior pelvic irradiation
SMoking

156

How might anal carcinoma present?

Fresh rectal bleeding and discomfort
Anal discharge

157

What are the 4 main types of anorectal abscesses?

Intersphincteric
Ischiorectal
Perianal
Supralevator

158

Which are the most common anorectal abscesses?

Perianal
Ischiorectal

159

How are anorectal abscesses managed?

Antiobiotics
Surgical drainage
Pus swab and culture
Packing and drain insertion in ischiorectal

160

How do perianal abscesses develop?

Infection spreads downwards from intersphincteric space to the anal verge

161

How do ischiorectal abscesses develop?

Infection spreads outwards from intersphincteric space into the ischiorectal fossa, where it can quickly enlarge

162

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

163

How are anal fistulae managed?

Fistulotomy surgery
Perianal excision and colostomy formation if severe

164

Give three pre-hepatic causes of jaundice

Haemolytic anaemia
Gilbert's syndrome
Malaria
Drugs eg sulfasalazine
Crigler-najjar syndrome

165

Give three post-hepatic causes of jaundice

Gallstones
Extra-hepatic malignancy
Surgical strictures
Pancreatitis
Parasitic infection eg fasciola

166

Give three hepatic causes of jaundice

Viral infection
Alcohol
Non-alcoholic fatty liver disease
Autoimmune disease eg schlerosing cholangitis
Haemachromatosis
Wilson's disease
Biliary malignancy
Drugs eg paracetamol/TB drugs

167

How are oesophageal varices graded?

Grade 1 - collapse on inflation of oesophagus with air
Grade 3 - occlue lumen
Grade 2 - between the two

168

How is portal hypertension confirmed?

Measure portal pressure gradient (difference between portal and hepatic vein)
If >12 mmHg then there is portal hypertension

169

Give 3 consequences of portal hypertension

Collateral vessel formation
Ascites
Increased risk of hepatorenal syndrome
Hepatic encephalopathy
Splenomegaly

170

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

171

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

172

How is the underlying cause of ascites determined?

History
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

173

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
?antibiotics

174

Why may antibiotics be given in ascites?

Because of risk of spontaneous bacterial peritonitis

175

Which patients are most at risk of spontaneous bacterial peritonitis?

Ascitic albumin concentration <0.1g/l
Previous SBP
Cirrhosis with bleeding varices
Fluid protein <15g/l with either impaired renal function or child-pugh score of 9 or more

176

What are the most common causative organisms of spontaneous bacterial peritonitis?

E coli
Streptococcus

177

How is spontaneous bacterial peritonitis managed?

IV tazocin
IV albumin
Long term ciprofloxacin

178

What does bloody ascitic fluid indicate?

Trauma
Malignancy
Haemorrhagic pancreatitis
Perforated peptic ulcer

179

What does turbid ascitic fluid indicate?

Spontaneous bacterial peritonitis
Perforated viscus

180

What does chylous ascitic fluid indicate?

Malignancy
Lymphoma
TB
Parasitic infection

181

What are the features of hepatic encephalopathy?

Altered GCS
Hepatic flap
Constructional apraxia
Triphasic slow waves on EEG

182

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

183

What are the main precipitants of hepatic encephalopathy?

Increase serum ammonia
Neurotoxins
Disturbance of blood-brain barrier

184

How is hepatic encephalopathy managed?

Correct any precipitants
Lactulose for 3-4 loose stools a day
Reduce dietary protein
Consider transplantation

185

What is hepatorenal syndrome?

An acute, potentially reversible oliguric renal failure in liver disease with intense renal vasoconstriction in otherwise normal kidneys

186

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

187

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%

188

What criteria must be met for a diagnosis of hepatorenal syndrome in cirrhosis

No mesenchymal kidney disease
Creatinine >133
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

189

How is hepatorenal syndrome managed?

Treat any infection
Withdraw any nephrotoxins
Terlipressin
Albumin volume expansion
TIPSS
Liver transplantation

190

Name the CYP450 inhibitors

Cimetidine
Ritonavir
Amiodarone
Ciprofloxacin
Ketoconazole
Acute alcohol
Macrolides
Isoniazid
Grapefruit juice
Omeprazole
Sulfonamides
Sodium valproate

191

Name the main CYP450 inducers

Carbamazepine
Rifampcin
Alcohol chronically
Phenytoin
Sulphonylureas
St John's wort

192

At what dose of paracetmaol do serious adverse effects start to be seen?

150mg/kg so in 9g in a 60kg person

193

Give three factors that increase the risk of toxicity in paracetamol overdose

On enzyme inducing drugs
Malnutrition
HIV positive
Genetics
Liver disease
Excess alcohol

194

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

195

What are the criteria for liver transplantation in paracetamol overdose?

pH<7.3 24 hours post-ingestion
or all three of:
PT >100secs
Creatinine >300
Grade 3 or 4 encephalopathy

196

What are the plasma concentration limits of paracetmaol needed to give acetylcysteine?

>100mg/l at 4 hours
>15mg/l at 15 hours

197

Give three causes of haemochromatosis

Autosomal dominant mutation
Thalassaemia major
Dietary iron
Parenteral iron from repeated transfusions
End stage alcoholic cirrhosis

198

Give 5 clinical features of haemochromatosis

Dilated cardiomyopathy
Arrhythmias
Diabetes mellitus
Hypogonadism
Hypocalcaemia
Osteoporosis
Arthritis
Cirrhosis
Hepatomegaly
Slate grey skin discolouration

199

How is hereditary haemochromatosis managed?

Lifelong venesection. May not be necessary in menstruating females.

200

What abnormalities may be seen on x ray in someone with haemochromatosis?

Chondrocalcinosis
Destructive arthropathy

201

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

202

How is wilson's disease managed?

Lifelong penicillamine
Reduced dietary copper

203

How does antitrypsin deficiency cause liver disease?

Abnormal alpha1AT accumulates in the liver and causes cellular injury

204

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

205

What is the most common location for gastric ulcers?

The lesser curve

206

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

207

What drugs are used to eradicate h pylori?

PPI eg lanzoprazole
Clarithromycin
Amoxicillin or metronidazole

208

Give 2 complications of peptic ulcer disease?

Perforation
Haemorrhage
Gastric outlet obstruction
Malignancy

209

What autoantibodies are implicated in autoimmune hepatitis?

ANA/SMA in type 1
Anti liver/kidney microsome in type 2
Raised IgG

210

What are the common clinical features of autoimmune hepatitis?

Amenorrhoea
Fever
Jaundice
Fatigue

211

How is autoimmune hepatitis managed?

High dose corticosteroids +/- immunosuppressant

212

Give three ways in which alcohol causes damage to the liver?

Increases iron levels
Causes mitochondrial damage
Reduces number of antioxidants
Alters intracellular signalling

213

What is the spectrum of conditions in alcoholic liver disease?

Fatty liver - alcoholic hepatitis - cirrhosis

214

How is alcoholic liver disease managed/

Abstinence
Supportive measures eg optimise nutrition
B vitamin supplements
Treat withdrawal
Liver transplantation after 6 months abstinence

215

What marker is used to identify hepatocellular carcinoma?

AFP

216

Which cancers commonly metastasise to the liver?

Stomach
Colon
Uterus
Breast
Lung

217

Other than liver, what other cancer can cause raised AFP?

Testicular

218

How is hepatocellular carcinoma managed?

Surgical resection
Ablation
Palliative chemo/radiotherapy

219

Name two conditions that predispose to developing cholangiocarcinoma

Ulcerative colitis
Primary sclerosing cholangitis
Typhoid
Liver flukes

220

What blood abnormalities are found in cholangiocarcinoma?

Obstructive picture on LFTs
Raised CA19-9, CA125 and CEA

221

How is cholangiocarcinoma managed?

Surgical resection
Palliative stenting

222

What organisms commonly cause pyogenic liver abscesses?

E coli
Staph aureus

223

Give three contraindications to liver transplantation?

Extra-hepatic malignancy
Sepsis
Advanced cardiopulmonary disease
Active alcohol/drug use
Non-compliance with drug therapy

224

What are the criteria for carrying out liver transplantation in someone with chronic liver disease?

3 of:
<10 or >40 years old
PT>50s
Bilirubin >300
Jaundice present for >7 days before encephalopathy
Cause is either: Non-A or B hepatitis
Idiosyncratic drug reaction
Halothane hepatitis

225

How can the prognosis of someone with cirrhosis be assessed?

Use the Child-Pugh criteria, which looks at:
INR, encephalopathy, ascites, serum albumin, bilirubin

226

What immunosuppresion therapy are transplant patients on?

Either tacrolimus or ciclosporin
High dose prednisolone
Azathioprine of mycophenolate mofetil

227

Give 5 potential complications of liver transplantation

Acute rejection
Chronic rejection
Diabetes mellitus
Sepsis
Hepatic artery or portal vein thrombosis
CMV
Disease recurrence
Increased cancer risk
Hypertension
Renal dysfunction
Hyperlipidaemia
Bone marrow disease

228

Give three side effects of the calcineurin inhibitors?

Headache
Tremor
Nephrotoxicity
Hypertension
Gingival hyperplasia with ciclosporin

229

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

230

What is primary sclerosing cholangitis?

Progressive liver disease with inflammation and fibrosis of bile ducts leading to stricturing

231

Give three clinical features of primary sclerosing cholangitis

RUQ pain
Jaundice
Pruritis
Steatorrhoea
Fatigue
Weight loss
Reduced fat soluble vitamin absorption
Xanthoma
Hepatomegaly

232

What abnormalities are found on investigation in primary sclerosing cholangitis?

Raised ALP, GGT, bilirubin (+ALT/AST)
Raised PTT
Raised IgG and IgM
Positive ANCA
Bile duct dilatation on USS

233

How is primary sclerosing cholangitis managed?

Colestyramine for pruritis
Vitamin supplementation
Cholangiocarcinoma and colorectal cancer surveillance
Baloon dilatation of bile ducts

234

Give 3 complications of primary sclerosing cholangitis

Cirrhosis
Bacterial cholangitis
Biliary obstruction
Cholaniocarcinoma
Colorectal cancer

235

What conditions are associated with primary sclerosing cholangitis?

UC
Crohn's
HIV

236

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.
Cirrhosis

237

What is primary biliary cholangitis?

Slowly progressive autoimmune destruction of intrahepatic bile duct epithelia causing intrahepatic cholestasis

238

Give 3 clinical features of primary biliary cholangitis?

Fatigue
Pruritis
RUQ pain
Cutaneous hyperpigmentation
Hepatosplenomegaly
Jaundice
Xanthelasma
Signs of cirrhosis

239

Give three conditions associated with primary biliary cholangitis

Sjogren's
Thyroid disease
Seronegative arthritis
Seropositive arthritis
Systemic sclerosis
Coeliac disease
Gallstones
Hepatocellular carcinoma

240

What abnormalities are found on blood tests in primary biliary cholangitis?

Raised ESR
Raised ALP
AMA
Raised IgM
SMA

241

What imaging should be done in primary biliary cholangitis?

USS
CHolangiography
Transient elastography

242

What is found on liver biopsy in primary biliary cholangitis?

Chronic, non-suppurative cholangitis

243

How is primary biliary cholangitis managed?

Ursodeoxycholic acid
Colestyramine for puritis
Vitamin supplementation
Transplantation

244

Give three complications of primary biliary cholangitis

Renal tubular acidosis
Hepatocellular carcinoma
Hypothyroidism
CIrrhosis
Fat malabsorption

245

What are the general features of intestinal malabsorption?

Diarrhoea (steatorrhoea)
Weight loss
Fatigue
Anaemia
Increased bleeding
Oedema

246

Give 5 causes of malabsoprtion

Coeliac
IBD esp crohn's
Lactose intolerance
Infection
Diverticulae
Cystic fibrosis
Chronic pancreatitis
Pancreatic carcinoma
Drugs
Intestinal hurry
Fistulae
Amyloidosis
THyroid disease
Parathyroid disease
Addison's
Diabetes mellitus
Eating disorders
Laxative abuse

247

What are the biopsy findings in coeliac disease?

Villous atrophy with crypt hyperplasia

248

What antibodies are associated with coeliac disease?

Ig A tissue transglutaminase
Anti-endomysial antibodies

249

Give 3 complications of coeliac disease

Anaemia
Lactose intolerance
Osteoporosis
Hyposplenism
Increased malignancy risk
Myopathy
Neuropathy