Gastroenterology Flashcards
(212 cards)
1
Q
Acute causes of diarrhoea?
A
Gastroenteritis
Diverticulitis = LLQ and fever
Antibiotic therapy
Constipation causing overflow = Hx of alternating diarrhoea and constipation
2
Q
Chronic causes of diarrhoea?
A
IBS = Abdo pain, bloating and change in bowel habit
UC = Bloody diarrhoea and crampy abdominal pain
Crohns = Cramby abdo pain + malabsorption, obstruction, mouth ulcers and perianal disease
Coeliacs
3
Q
Staph aureus gastroenteritis typical Hx, incubation and management ?
A
Meat and eggs, no fever / abdo pain.
Severe vomiting
1-6 hours
Self limiting
4
Q
B. Cereus gastroenteritis typical Hx, incubation and management ?
A
Rice.
vomiting or diarrhoea
6-12 hours
Self limiting
5
Q
Salmonella gastroenteritis typical Hx, incubation and management ?
A
Source = pets or food
Nausea, fever and vomiting
12-48 hours
self-limiting, if persists = ciprofloxacin
6
Q
E. Coli gastroenteritis typical Hx, incubation and management ?
A
Travellers diarrhoea Contaminated food Watery stools and abdominal cramps No fever HUS....
12-48 hours
Avoid antibiotics
7
Q
Listeria gastroenteritis typical Hx, incubation and management ?
A
Refrigerated food
Fever, watery diarrhoea and cramps
12-48 hours
Ampicillin
8
Q
Shigella gastroenteritis typical Hx, incubation and management ?
A
Children at nursery
Water diarrhoea progressing to bloody mucoid diarrhoea
Vomiting and abdo pain
2-3 days
Avoid antibiotics, ciprofloxacin if needed
9
Q
Campylobacter gastroenteritis typical Hx, incubation and management ?
A
Meat and dairy
Flu like prodrome, followed by severe abdominal pain and fever
2-3 days
Self limiting
Only treat if immunocompromised = Macrolide e.g. erythromycin
Complication = GBS
10
Q
V. Cholera gastroenteritis typical Hx, incubation and management ?
A
Water and food with human faeces e.g. shell fish
Rice water stool
1 week
treat the fluid losses
11
Q
Giardiasis gastroenteritis typical Hx, incubation and management ?
A
Endemic area travel = Eastern Europe, Africa and Asia
Prolonged non-bloody diarrhoea
Steatorrhoea
Flatulence and cramps, no fever
1 week
Metronidazole
12
Q
Amoebiasis gastroenteritis typical Hx, incubation and management ?
A
Flask shaped ulcer
Gradual onset bloody diarrhoea and abdo pain. Can last weeks
1 week
Metronidazole and Paromomycin in luminal disease
13
Q
Associated antibiotics with C. Diff diarrhoea?
A
Cephalosporins
Cipro
Clindamycin
14
Q
Clinical features of C. Diff diarrhoea?
A
Mild diarrhoea
Pseudomembranous colitis
= severe systemic features, abdo pain and bloody diarrhoea
15
Q
Management of C. Diff diarrhoea?
A
Stop causative antibiotics and fluids
Metronidazole 400mg TDS PO for 2 weeks
2nd line = Vancomycin 125mg QDS PO
If severe = vancomycin first then add metronidazole
16
Q
What bowel histology do you see in laxative abuse?
A
Melanosis coli
17
Q
What is IBS?
A
Chronic condition characterised by abdominal pain associated with bowel dysfunction, but no organic cause identified
18
Q
Clinical features of IBS?
A
Abdo pain and bloating
Combo of diarrhoea and constipation
Worse on eating, relieved by defecation
19
Q
What are the ROME criteria for IBS?
A
Abdo discomfort for >12 weeks, which has 2 of:
Relieved by defecation
Change in stool frequency
Change in stool form
Plus two of:
Urgency Incomplete evacuation Abdo bloating / distension Mucous PR Worsening symptoms after food
20
Q
ROME exclusion criteria for IBS?
A
>40 bloody stool Anorexia Weight loss Diarrhoea at night
21
Q
Management of IBS?
A
Exclude other diagnosis with investigations
Conservative = reassure and educate
Eliminate any triggers e.g. caffeine. Increase fibre
CBT
Medical:
Diarrhoea dominant = Loperamide 4mg PO OD
Constipation dominant = Lactulose
22
Q
what is coeliacs?
Genetic associations
A
Genetic autoimmune condition caused by sensitivity to the protein gluten = immune activation in the small intestine
HLA- DQ2 and DQ8
23
Q
What associated conditions also need screening for coeliacs?
A
Autoimmune thyroid Dermatitis herpetiformis IBS T1DM 1st degree relative with coeliacs
24
Q
Clinical features of coeliacs?
A
GLIAD
G – GI = malabsorption:
Carbs - weight loss, fatigue and distension
fat = steatorrhoea
haematinics - anaemic
vitamins - osteoporosis, B2 = angular stomatitis
L – Lymphoma enteropathy T-cell associated
I – Immune
IgA deficiency
T1DM
A – Anaemia
D - Derm = dermatitis herpetiformis = very itchy vesicles on extensor surface
25
Investigations for coeliacs?
Bloods - FBC, LFT's, INR (don't absorb Vit k), bone profile
Antibodies 1st line = anti-TTG (but low with exclusion diet or IgA deficiency)
Jejunal biopsy = sub-villous atrophy, crypt hyperplasia and intra-epithelial lymphocytes
26
Management of coeliacs?
Lifelong gluten avoidance
Ok = maize, corn and rice
Pneumovax as hyposplenism
Dermatitis herpetiformis = dapsone
27
Macroscopic features of UC?
Rectum to ileocaecal valve
Continuous
No strictures or fistulas
28
Macroscopic features of Crohns?
Mouth to anus, patchy
| Strictures and fistulas
29
Microscopic features of UC?
Mucosal inflammation, not beyond the submucosa
Crypt abscesses
Broad shallow ulcers + pseudo-polyps
NO fibrosis
30
Microscopic features of Crohn's?
Transmural = all layers
Goblet cells and granulomas
Deep and thin cobblestone ulcers
FIBROSIS
31
UC clinical features?
30's, smoking protects
Diarrhoea with blood + mucous
LLQ pain
Anal symptoms = Tenesmus and faecal urgency
Extra-abdominal:
PSC + cholangiocarcinoma
Uveitis
Pyoderma gangrenosum
32
Crohns clinical features?
20's, smoking increases risk
```
Non-bloody diarrhoea (commonest PC in adults)
Abdominal pain (commonest PC in kids)
RIF mass and obstruction
```
Extra-abdominal:
Mouth = apthous ulcers
Gallstones and renal stones
Perianal disease
Episcleritis
33
Complications of UC?
Toxic megacolon = >6cm
Bleeding
Malignancy = cholangiocarcinoma and colorectal
34
Complications of Crohns?
Fistula
Strictures = obstruction
Abscesses
Malabsortpion = Steatorrhoea, B12 - megaloblastic anaemia
35
Investigations in IBD?
FBC - anaemia, malabsorption = B12 and folate down
AXR = toxic megacolon
Stool microscopy to rule out infective causes
36
Crohns specific investigations?
```
CROHNS:
Small bowel enema:
- Skip lesions
Strictures = Kantors string sign
Proximal bowel dilation
Fistulae
Rose thorn ulcers and cobblestoning
```
37
UC specific investigations?
Barium enema:
Loss of haustrations
Superficial ulceration = pseudo polyps
Drainpipe colon
38
Truelove and Witts criteria for UC?
Mild = <4 stools ± blood. No systemic features
moderate = 4-6 stools with mild systemic disturbances
Severe = >6 stools, with blood. Systemic disturbance
39
Management of severe acute flair up of UC?
Admit
ABC
IV hydration and NBM
Medical:
IV hydrocortisone 100mg 6-hourly
If refractory = no response within 3 days = Ciclosporin IV
Still refractory = surgery
If improvement = switch to oral prednisolone
40
Inducing remission in UC?
For distal colitis = rectal mesalazine
1st line = Oral mesalazine
2nd line if refractory to mesalazine for 4 weeks = Oral prednisolone
3rd line if refractory to steroids for 4 weeks = Tacrolimus PO
41
Maintaining remission in UC?
Distal colitis = daily topical mesalazine ± oral mesalazine
1st line = mesalazine maintenance dose
2nd line:
if > 2 exacerbations in 1 year requiring steroids / mesalazine doesn't maintain remission =
Azathioprine or mercaptopurine
3rd line = infliximab / adalimumab
42
Surgery in UC;
Emergency indications
Elective surgery indications
Surgery types
Emergency indications?
- Toxic megacolon
- Perforation
- Massive haemorrhage
Elective indications?
- Refractory to medical treatment
- Malignancy
Surgeries:
SUBTOTAL COLECTOMY: (leaving the rectum) --> end ileostomy ± mucus pouch
Can later on carry out proctectomy removing the rectum and forming and ileo-anal pouch. Will leave a defunctioning loop ileostomy to allow anastomoses to heal
Will then do a third operation to heal the loop ileostomy
PANPROCTOCOLECTOMY:
Take out whole colon, rectum and anus. Permanent end ileostomy
rarely = Total colectomy leaving rectum and forming ileoanal anastomoses
43
Crohns acute attack management?
Admit, ABC, NBM and IV fluids
IV hydrocortisone and metronidazole
Refractory = methotrexate
Improvement = switch to oral prednisolone 40mg PO OD and taper
44
Inducing remission in Crohns?
STOP SMOKING
Medical:
1st line = prednisolone monotherapy
2nd line = sulfasalazine
3rd line = Mercatopurine / azathioprine - ADD ONS NOT MONOTHERAPY
If can't tolerate consider methotrexate
4th line = Infliximab / adalimumab
45
Crohns maintaining remission?
STOP SMOKING
1st line = azathioprine / mercaptopurine as MONOTHERAPY
Consider methotrexate if it was needed for induction.
46
Surgery in Crohns:
Emergency and elective indications?
Procedures?
Emergency = obstruction, perforation or massive haemorrhage
Elective = refractory to medicine or malignancy
Abscess
Fistula
Options:
Limited resection
Stricturoplasty
47
Causes of constipation?
POINTED
Pain e.g. anal fissure
Obstruction:
Mechanical = Adhesions, strictures, hernia, malignancy
Pseudo-obstruction = post-op ileum
IBS
Neuro = MS, cauda equina
Toxins = opioids
Endocrine = hypothyroid, low calcium
Diet / dehydrated
48
Management of constipation - conservative?
Drink more and increase dietary fibre
Increase exercise and activity
Treat cause
49
Medical management of constipation?
1st line = bulk forming laxative e.g. isphagula. Must drink lots of fluids
2nd line = add osmotic laxative e.g. macrogol
If soft stool but difficult to pass add a stimulant laxative
Gradually reduce and stop laxatives until soft stool with no straining at least 3 times a week
50
Management of faecal loading / impaction?
If hard = high dose macrogol
Soft = Few days macrogol then stimulant
Poor response = suppository or enema
51
Causes of dysphagia?
Inflammatory = tonsillitis, GORD, oral candidiasis
```
Mechanical:
LUMINAL = food bolus
MURAL = Benign stricture e.g. Plummer vinson, malignant strictures and pharyngeal pouch
EXTRA-MURAL:
Lung cancer
Goitre
Aortic aneurysm
```
Motility disorders:
Achalasia
Systemic sclerosis
MND
52
Dysphagia + weight loss, anorexia and vomiting during eating.
PMHx of barrets / GORD / excess smoking and drinking
Oesophageal cancer
53
dysphagia + Hx of heartburn, odynophagia but no weight loss / systemic
GORD
54
Dysphagia + History of HIV / steroid use
Candidiasis
55
Dysphagia of both liquids and solids from the start.
| Increased lower oesophageal sphincter pressure
Achalasia
Also get bird beak on barium swallow
56
Dysphagia in older man, midline lump that gurgles on palpation
Pharyngeal pouch
57
Dysphagia with telangiectasia and fat fingers?
CREST
58
Intermittent dysphagia ± chest pain.
| Barium swallow = corkscrew
Diffuse oesophageal spasm
59
Dysphagia with solids > liquids at the start
Stricture
60
Dysphagia with iron deficiency anaemia and glossitis
Plummer vinson
61
What is achalasia?
Failure of both oesophageal peristalsis and relaxation of lower oesophageal sphincter due to degeneration of auerbachs plexus = LOS contracted = oesophagus dilates due to food backlog
62
Investigations in achalasia?
Manometry = increased LOS tone
Barium swallow = grossly expanded oesophagus, fluid level and birds beak
63
Management of achalasia?
intra-sphincteric injection of botulinum
Heller cardiomyotomy = laparoscopic procedure where oesophageal muscle is cut out, inner lining left intact
Balloon dilation
64
What is a pharyngeal pouch?
Outpouching of oesophagus between the upper border of cricopharynxgeus muscle and lower border of inferior constrictor of pharynx = Killians dehiscence
65
Management of pharyngeal pouch?
Surgical excision and endoscopic stapling
66
What is a peptic ulcer?
A break in the mucosal lining of the stomach / duodenum >5mm in diameter with depth to submucosa
Smaller than 5mm = erosion
67
Causes of peptic ulcers?
```
Dudodenal = H. Pylori
Stomach = NSAID use
```
Rarer causes = Zollinger Ellison = gastric acid secretion due to a gastrin secreting neuroendocrine tumour
68
Clinical features of gastric vs duodenal ulcer?
Gastric = pain worse on eating, relieved by antacids. Weight loss
Duodenal = pain is before meals and at night. Relived by eating / milk
69
Complications of peptic ulcer disease?
Upper GI bleed = Haematemesis of malaena.
Ulcer erodes through gasproduodenal vessel
Perforation = erosion through wall into peritoneal cavity.
Generally in elderly taking NSAIDS.
Shock and peritonitis
Gastric outflow obstruction = due to pyloric stenosis after ulcer healing with scarring.
70
Management of peptic ulcer disease?
Conservative = stop causative drugs, smoking and drinking. lose weight
Medical:
If H.Pylori - eradication
No H Pylori = 20mg omeprazole PO BD for 2 months
2nd line = ranitidine 300mg
71
What is GORD?
Symptoms or complications secondary to reflux of the gastric contents into the oesophagus
72
RF's for GORD?
```
Smoking, alcohol
Obesity
Hiatus hernia
Hellers cardiomyotomy
Pregnancy
```
73
Complications of GORD?
Ulcers
Benign stricture
Barrett's oesophagus = intestinal metaplasia of squamous epithelium.
Metaplasia to dysplasia to adenocarcinoma in power 3rd of the oesophagus
74
GORD management?
Conservative = lose weight, stop smoking and drinking
Medical:
Full dose PPI for 2 months = omeprazole 20mg PO OD
2nd line = double dose BD
3rd line = ranitidine
75
Surgical options for GORD?
Nissen fundoplication:
Indications = severe symptoms refractory
Laparoscopic
Mobilise the gastric fungus, wrap it around the lower oesophagus. Whilst closing any diaphragmatic hernias
76
What is a hiatus hernia and the types?
Herniation of part of the stomach through the diaphragm
Sliding = 95% = GOJ moves above the diaphragm
Rolling = 5% = GOJ remains below the diaphragm but a separate part of the stomach herniates through the oesophageal hiatus
77
Investigations and management of hiatus hernia?
CXR = gas bubble and fluid level
Barium swallow = diagnostic
Lose weight, manage the GORD
If refractory = repair the hernia
Repair rolling hernia even if asymptomatic as risk of strangulation
78
Differentials of haematemesis?
OESOPHAGEAL:
```
Varices
Oesophagitis
Mallory-Weiss
Boerhaaves
Malignancy
```
GASTRIC:
PUD
Dieulafoys lesions
Gastric tumours
79
Large fresh haematemesis, chronic liver disease / alcoholic
Varices
80
What causes varices?
Portal HTN causes dilated veins at site of porto-systemic anastomoses - often the left gastric and inferior oesophageal
81
Portal HTN causes?
Pre-hepatic = portal vein thrombosis
Hepatic = Cirrhosis and schistosomiasis
Post-hepatic = budd chiari
82
Small amount of fresh blood, sometimes streaks vomit. Heartburn. No other features
Oesophagitis
83
Haematemesis following vomiting, small amount of blood
Mallory-Weiss tear
Mucosal tear, often ceases spontaneously
84
Large haematemesis following vomiting
Boerhaave's
Full mucosal tear
2cm proximal to LOS
85
Small amount of blood with dysphagia, weight loss
Malignancy
86
Investigations for haematemesis?
Admit, X-match blood and clotting
All need OGD within 24 hours
Blatchford score at first assessment
Rockall score after endoscopy for risk of re-bleeding
87
What criteria are in the blatchford score?
Urea, Hb, systolic BP and others
Score of 0 = early discharge
88
Management of varices?
ACUTELY:
Terlipressin and prophylactic antibiotics
2nd line = banded ligation if oesophageal.
Glue (N-butyl-2-cyanoacrylate) for gastric
3rd line:
Sengstaken-Blakemore tube
If still cannot stop bleeding insert trans jugular intrahepatic portosystemic shunt TIPS
= artificial channel between hepatic and portal vein = reduced portal pressure
PROPHYLAXIS = propranolol and band ligation
89
Management of non-variceal bleed?
Inject adrenaline to bleeding points and thermal coagulation / mechanical clips
90
What is jaundice?
Accumulation of bilirubin in the bloodstream and subsequent deposition in the skin, sclera and mucous membranes
91
What is the mechanism of bilirubin production?
Made in reticuloendothelial cells, released and travel in the blood to liver, bound by albumin
Enter hepatocytes and conjugated by glucoronyl transferase
Conjugated bilirubin is the secreted in the bile = urobilinogen
- some reabsorbed by liver
- some excreted in urine
- Some stays in GIT = stercobilinogen = brown stool
92
Causes of jaundice?
PREHEPATIC:
Gilberts
Haemolysis e.g. haemolytic anaemias and anitmalarials
HEPATIC:
Unconjugated = Hypothyroid, gilberts, Crigler-Najjar
Conjugated = Viral/alcoholic hepatitis, NAFLD, cirrhosis, Wilsons
POST-HEPATIC:
Gallstones and pancreatic cancer.
+ PBC, PSC, cholangiocarcinoma
93
Jaundice + episode of colicky pain, obstructive picture
Gallstones
94
Obstructive jaundice + RUQ pain, fever
Ascending cholangitis
95
FHx of jaundice, worse with fasting. Unconjugated
Gilberts
96
Jaundice with alcohol abuse. AST and ALT high
Alcoholic hepatitis
97
Jaundice + fevers, chills and splenomegaly
Haemolytic anaemias
98
Pre-hepatic jaundice biochem?
Unconjugated bili, urobilinogen and normal enzymes
99
Heaptic jaundice biochem?
Unconjugated / conjugated and urobilinogen present
AST:ALT > 2 = alcohol
AST:ALT < 1 = viral
100
Post hepatic jaundice biochem?
Conjugated bilirubin very high with no urobilinogen
ALP very high
101
How does alcohol affect the liver?
| GI affects?
Fatty liver = hepatitis = cirrhosis
PUD
Varices
Pancreatitis
102
What is the triad of Wernicke's encephalopathy, and what features emerge in Korsakoff's?
Confusion, ophthalmoplegia and ataxia
Korsakoffs = Amnesia and confabulation
103
Features of alcohol withdrawal?
Management?
6-12 hours = tremors, sweating, tachycardia and anxiety
36 hours = seizures
48-72 hours = delirium tremens:
Coarse tremor, confusion, delusions, auditory hallucinations
Mx = Chlordiazepoxide
104
Management of alcoholism?
Conservative = group therapy
Medical:
Baclofen reduces cravings
Acamprosate reduces cravings
Disulfiram = aversion therapy
105
What is alcoholic hepatitis?
Follow on from fatty liver disease. Chronic alcohol use causes deficiency in anti-oxidants so oxidative stress causes hepatic necrosis and apoptosis
106
Clinical features of alcoholic hepatitis?
Alcohol Hx
Abdominal pain
Weight loss and malnutrition
Severe = jaundice, hepatomegaly
107
AST:ALT >2?
Alcoholic hepatitis
Also raised GGT, microcytic anaemia
108
Management of alcoholic hepatitis?
Conservative = alcohol abstinence and withdrawal advice
Medical:
Multivitamins and pabrinex
Immunisations = Influenza and one off pneumovax
Manage failures
109
What is NAFLD?
It is a spectrum of disease.
Steatosis = fatty liver
Steaohepatitis = Fat with inflammation (NASH)
Progressive disease = fibrosis and liver cirrhosis
110
Investigations for NAFLD?
BMI and glucose - often see insulin resistance in metabolic syndrome
LFT's
Enhanced liver fibrosis (ELF) = If find NAFLD do this test for advanced fibrosis
111
Management of NAFLD?
Lose weight, dietary modifications
Control co-morbdities
112
What is hepatitis A?
RNA virus, not associated with chronic liver disease. Self limiting
113
Hep A transmission?
Faceo-oral
114
Ig picture in Hep A?
Acutely IgM peaks, with rise in ALT
post infection = IgG
115
When should you get a Hep A vaccine?
```
Travelling to endemic area
Chronic liver disease
Haemophillia
MSM
IVDU's
```
116
How is hepatitis B spread?
Exposure to blood / fluids
| Can also get vertical transmission
117
Serology of hepatitis B?
Hep B surface antigen appears first causing anti-HBs production
If HBsAg = acute infection
Anti-HBs = immunity or exposure. Negative in chronic disease
Anti-HBc means previous or current infection. At about 30 weeks it divides into IgM and IgG.
IgM is only there for the acute phase (6 months) , IgG persists
HBeAg is from breakdown of core antigen = marker of infectivity
118
Hep C transmission?
Blood and fluids.
| Vertical too
119
Complications of Hep B?
10% get chronic
5% get cirrhosis
Hepatocellular carcinoma
120
Immunisation for Hep B?
Contains HBsAg in three doses
Anti-HBs levels:
>100 = adequate responder
10-100 = suboptimal, need one more vaccine
<10 = non-responder. Check for past/current infection and repeat course
121
PEP for Hep B?
If known responder to HB vaccine give a booster
Non-responder needs HBIG and vaccine course
In process of being vaccinated = accelerated course and HBIG
122
Management of Hep B?
Pegylated IFN alpha
123
Complications of Hep C?
60-80% get chronic hepatitis = persistence of HCV-RNA > 6 months
HCC
124
Management of Hep C?
Combination of protease inhbitors = Daclatasvir + sofosbuvir ± ribavirin
125
PEP for Hep C?
Monthly PCR.
If seroconversion = IFN ± ribavirin
126
Hep D transmission?
Bodily fluids
127
Classification of Hep D?
Co-infection = Hep B and D at the same time
Super-infection = HBsAg positive patient, who then develops Hep D
High risk of fulminant hepatitis
128
What is autoimmune hepatitis?
Chronic inflammatory liver disease with unknown aetiology
Characterised by presence of circulating auto-Ab's
129
Who is commonly affected by AI hepatitis?
Young females
130
Types of AI hepatitis?
Type 1 = ANA/SMA, children and adults
Type 2 = LKM1, children
Type 3 = soluble liver-kidney antigen, adults in middle age
131
Clinical features of AI hepatitis?
Acute hepatitis
Ammenorrhoea is common
Associated AI diseases
132
Classic liver biopsy finding in AI hepatitis?
Inflammation extending beyond limiting plates = piecemeal necrosis
133
Management of AI hepatitis?
Prednisolone 40mg. PO OD
| 2nd line = azathioprine
134
Definition of cirrhosis?
Inflammatory condition which must involve the whole liver.
Must be presence of fibrosis, nodules of regenerating hepatocytes and contain distorted vasculature of the liver
135
Causes of cirrhosis?
Chronic Hep B and C
Alcohol
NAFLD
136
Clinical features of chronic stable liver disease?
Multiple spider naevi
Dupuytrens
Palmar erythema
Gynaecomastia
137
Clinical features of decompensated liver failure?
Jaundice
Encephalopathy
Hypoalbumin = oedema and ascites
Coagulopathy = bruising
138
Features of portal HTN?
SAVE
```
Splenomegaly
Ascites
Varices:
- 90% oesophageal = haematemesis
- Caput medusa
Encephalopathy
```
139
What is the Child-Pugh-Turcotte score?
Determines the severity of cirrhosis
Uses - Bilirubin, albumin, PT, encephalopathy and ascites
A = score<7, well compensated
B = 7-9 = significant functional compromise
C = >9 = decompensated
140
Investigations in cirrhosis?
Bloods = LFT's albumin and PT
Find cause = serology, macrocytic anaemia for alcohol, BMI and glucose for NAFLD
Offer transient elastography screen for cirrhosis to:
- People with Hep C
- men who drink >50units a week, women > 35
- People diagnosed with alcohol related liver disease
If newly diagnosed cirrhosis = OGD for varices
141
Follow up for cirrhosis?
Twice yearly USS for HCC
142
What is portal HTN?
HTN in the portal system, drains from the intestines to the liver
143
Causes of portal HTN?
Pre-hepatic:
Portal vein thrombosis e.g. pancreatitis
Hepatic:
Cirrhosis and schistosomiasis
Post-hepatic:
Budd-Chiari, RHF, tricuspid regurgitation.
144
Why do you get ascites in portal HTN?
Back pressure = fluid exudation
145
What is the SAAG?
Serum ascite albumin gradient
>1.1 = portal HTN
<1.1 = Malignancy, nephrotic syndrome, TB peritonitis
146
Management of ascites?
Daily weight reduction <0.5kg
Fluid restrict and low sodium diet
Spironolactone and furosemide if refractory
If do a therapeutic paracentesis = Albumin infusion 100ml 20% albumin / litre drained
147
What is SBP?
Peritonitis seen secondary to ascites due to liver cirrhosis
148
Common organism for SBP?
E. coli, klebsiella and strep
149
Investigations for SBP?
Paracentesis = neutrophil count > 250cells / uL
150
Management of SBP?
IV cefotaxime
Prophylaxis oral cipro if:
Previous SBP
Fluid protein >15g/L or Child-Pugh Score >9
Hepatorenal syndrome
151
What is encephalopathy?
Due to hepatic metabolic dysfunction = toxin build up systemically = ammonia builds up in brain and astrocytes clear it producing glutamate
Glutamate increase = cerebral oedema
152
Classification of encephalopathy?
```
1 = Irritability
2 = Confusion and disinhibited
3 = Incoherent and restless
4 = Coma
```
153
Clinical features of encephalopathy?
Confusion
Asterixes
Constructional apraxia = can't draw 5-pointed star
EED = triphasic slow waves
154
Management of encephalopathy?
Treat cause
| Lactulose = increased ammonia secretion from gut + rifamixin = modulate gut flora producing ammonia
155
What is liver failure?
The inability of the liver to perform its synthetic and metabolic function
Chronic - cirrhosis
Acute = Infection e.g. hepatitis, Toxins e.g. alcohol or paracetamol, Budd Chiari and Wilsons
156
What is hepatorenal syndrome?
Development of acute renal failure In patients with severe liver disease
Cirrhosis = splanchial artery dilation = RAS activation = Renal artery vasoconstriction
157
Type of hepatorenal syndrome?
Type 1 = rapid deterioration, survival 2 weeks. Creatine doubles or >221
Type 2 = 6-month survival
158
Management of hepatorenal syndrome?
IV terlipressin and albumin
Liver transplant
159
Is liver cancer usually primary or metastatic?
95% = metastatic
Most common primary = HCC and cholangiocarcinoma
160
RF's for HCC?
Cirrhosis or Hep B
161
Management of HCC?
Surgical resection. Often opt for whole resection and transplantation as livers are cirrhotic and high risk
Not chemo / radio sensitive
162
Where do cholangiocarcinomas occur?
Bile ducts
80% extra hepatic
163
Main RF for cholangiocarcinoma?
Investigations?
PSC
LFT's obstructive picture
CT/MRI
164
Management of cholangiocarcinoma?
Resection
Peri-hilar tumours are problematic and coupled with lobar atrophy = no surgery
Can palliate the jaundice, but avoid metal stents if planning resection
165
Types of liver transplant?
Indications?
Cadaveric
Live - donating a lobe
Cirrhosis and HCC
166
Contraindications to liver transplant?
Extra-hepatic malignancy
Systemic sepsis
HIV
Non-compliance with drug therapy
167
What is hereditary haemochromatosis?
Autosomal recessive disorder of iron metabolism and absorption = iron accumulation
Reduced duodenal absorption due to low hepcidin
Low hepcidin causes macrophages to release iron
168
Clinical features of heamochromatosis?
Non specific - fatigue, erectile dysfunction and arthralgia
Skin pigmentation = bronzing of the skin
Liver disease
Diabetes
169
Investigations of haemochromatosis?
Bloods = Iron and ferritin raised
TIBC low
Transferrin sats > 45%
Liver biopsy = Perls stain = raised iron content
glucose
170
Management of haemochromatosis?
Transferrin saturation should be below 50%, and serum ferritin below 50ug/L
Conservative = Hep A and B vaccines
Vit C supplementation
Avoid alcohol
Medical if symptomatic:
Venesection = stimulates more blood production with iron stores
2nd line = desferrioxamine IV
171
What is A1AT deficiency?
Inherited condition caused by a lack of protease inhibitor from the liver which usually protects cells from enzymes = damage to liver and lungs
172
Clinical features of A1AT deficiency?
Lung = productive cough, SOB, smoker
- LOWER LOBE pan-acinar emphysema
Liver = cirrhosis and HCC
173
Investigations and management in A1AT deficiency?
A1AT levels low. CXR = basal emphysema.
LFT's
Mx:
Stop smoking, Hep A/B vaccines
Medical:
standard COPD patient, IV A1AT
174
What is Wilsons disease?
Autosomal receive disorder characterised by excessive copper deposition in tissue
175
Clinical features of Wilsons?
Liver = cirrhosis
Neuro = basal ganglia degeneration = speech / behavioural problems
Kaiser Fleischer rings
176
Investigations for Wilsons?
Bloods = copper and caeruloplasmin low
(caeruloplasmin is an acute phase protein so may be high during infection)
Increased urinary 24 hour excretion
177
Management of Wilsons?
Conservative = avoid high copper foods, screen family
Medical = Penicillamine lifelong
178
What is primary billiary cirrhosis / cholangitis?
Chronic liver disorder characterised by progressive damage to the intra-lobular bile ducts = cholestasis = cirrhosis
179
Rule of M's in PBC?
IgM
Anti- Mitochondrial Ab's
Middle aged itchy female
180
PBC associations?
Sjogrens = patient may have dry eyes and mouth
RA
CREST
181
Investigations in PBC?
LFT's raised
98% = AMA +ve
Raised serum IgG
182
Management of PBC?
Symptomatic:
Itching = Cholestyramine 4g PO BD
Osteoporosis = bisphosphonates
Specific = ADEK
Ursodeoxycholic acid
End stage = liver transplant if bilirubin >100
183
What is primary sclerosing cholangitis?
Inflammation and fibrosis of the intra and extra hepatic ducts = diffuse multi-focal stricture complications
middle aged male
184
PSC associated conditions?
UC
185
Clinical features of PSC?
RUQ pain, obstructive jaundice
186
Complications of PSC?
Liver cirrhosis and failure
HCC
ADEK down
Gall stones
187
Investigations for PSC?
ANCA
LFT's raised
ERCP gold standard = multiple biliary strictures = BEADED APPEARANCE
188
Management of PSC?
Symptomatic = cholestyramine 4g PO BD
Specific = ADEK, ursodeoxycholic acid
Stenting if dominant strictures
Regular screening for malignancy
189
What is chronic pancreatitis?
Recurrent or persistent abdominal pain with progressive injury to pancreas and surrounding structures
190
Investigations pancreatitis?
Exocrine low = low faecal elastase
Endocrine low = no insulin = raised glucose
Abdo x-ray = calcifications
CT more specific
191
Management of chronic pancreatitis?
Stop alcohol, reduce fatty foods
Medical = CREON
Vitamin ADEK
Analgesia
192
Complications of chronic pancreatitis?
Diabetes
Steatorrhoea
Pseudocyst
193
Where does pancreatic cancer occur?
60% head
25% body
15% tail
194
RF's for pancreatic cancer?
Smoking
FHx
Diabetes
Chronic pancreatitis
195
Painless jaundice, obstructive picture and weight loss?
Pancreatic cancer
196
Investigations in pancreatic cancer =
Obstructive LFT's, Ca 19-9
| USS = Pancreatic mass, dilated bile ducts, liver mets
197
Management of pancreatic cancer?
Stage 1/2 = resectable = Whipple's (pancreaticoduodenectomy)
SE's = dumping syndrome and PUD
Unresectable = stenting, chemo.
CREON for both
198
What is carcinoid syndrome?
Occurs due to the release of vasoactive peptides and serotonin from a carcinoid tumoiur
199
Where does carcinoid syndrome occur?
30% = midgut (duodenum = proximal 2/3rds of transverse colon)
5% = bronchial
1% = Pancreatic
200
Clinical features of carcinoid syndrome?
Diarrhoea
Flushing, hypotension
Bronchospasm
Right sided valvular fibrosis
Pellegra
201
Investigations for carcinoid syndrome?
Urinary 5-HIAA raised
Plasma chromogranin ! increased
CT/MRI for primary
202
Management of carcinoid syndrome?
Octreotide
Curative = resection
Tumours very yellow
Give high dose octreotide as overwhelming release of vasoactive peptides due to manipulation of tumour
203
Vitamin deficiency:
Dry conjunctiva, ulcerated cornea
Night blindness
Vitamin A
204
Vitamin:
Heart failure and oedema or polyneuropathy
Can also see wernickes
B1 = thiamine = Beri Beri
205
Vitamin:
Diarrhoea, dermatitis and dementia
Pellegra B3
206
Vitamin:
Peripheral sensory neuropathy
B6 / pyridoxine
207
Vitamin:
Dermatitis and sebborhoea
Biotin / B7
208
Vitamin:
Megaloblastic anaemia, neural tube defects in pregnancy
Folic acid / B9
209
Vitamin:
Glossitis, peripheral neuropathy, SACD
B12 / cyanocobalamin
210
Vitamin:
Gingivitis
Bleeding gums
Corkscrew hairs
C = scurvy
211
Vitamin:
Bone pain and fractures
D = osteomalacia
212
Vitamin
Bruising and petechiae
Bleeding / epistaxis
K
| 2,7,9,10
