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Gastroenterology Flashcards

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1
Q

Cause of pancreatitis in pregnancy

A

Gallstones

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2
Q

Budd Chiari syndrome

A

Hepatic VEin thrombosis - seen in haem conditions

Assoc:

  • Polycythaemia ruba vera
  • Thrombohilia - PRotein C + S deficiency, antithrombin C deficiency, Portein C resistance
  • Preg
  • OCP

Ft:

  • Sudden onset abdo pain
  • Ascites
  • Tender hepatomegaly

Inx:
- US doppler flow

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3
Q

Jejunal villous atrophy

A 
Coeliac dx 
Whipples dx 
hypogammaglobulinaemia
Tropical sprue 
Cows milk intolerance
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4
Q

Prophylaxis of variceal bleads

A

Propanolol - 1st line

Variceal band ligation + PPI cover whilst - ive very large

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5
Q

Bariatric surgery

A

Consider if BMI>40 or NMI >30 + Comoridities

Alla appropriate non surgical measures have failed fot >6/12

They are receiving or will receive specialist mx

fit for surgery

comitted to LT follow up

BMI 30 - 39 -> gastric banding
NMI>40 –> gastrectomy or sleeve.

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6
Q

Severity of Lover cirrhosis

A 
PT time 
bilirubin 
Albumin
Presence of ascites 
presence of encephalopathy
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7
Q

Hep B and pregnancy

A

Screen all preg women

BEbies born to chronically infected or acute infection during pregnancy –> complete vax + HEp B Ig

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8
Q

Vitamin deficiency in GAstric Bypass

A

NEarly all gastric bypass ops = bypass duodenum

dueodenum = IRon absorption

therefore all menstruating women likely Fe deficient

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9
Q

Secondary prophylacys of hepatic encephalopathy

A

Lactulose 1st line

2nd line - Rifaxamin

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10
Q

Liver abscess

A

tx - percut Drainage + abx

abx - Amox + cipro + metro

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11
Q

PBC associartions

A

Sjrogrens - most assoc.
Systemic sclerosis
RA
Thyroid dx

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12
Q

PAncreatic secretions 0- Exocrine and endocrine

A

Exocrine:

  • Trypsinogen
  • Chemotrypsinogen
  • Pancreatic amylase
  • lipase

Endo:

  • Glucagon
  • Insulin
  • Somatostatin
  • pancreatic polypeptide.
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13
Q

Gut hormones

A

Gastrin:

  • S = G cells in Antrum of stomach
  • Stim = AA + GAstric distension
  • A= H+, pepsin, IF secretion

Cholecystokinin:

  • S = Duodenum + Jej
  • stim = AA + Fats + Peptides
  • A = PAnreatic + GB secretions

Secretin:

  • S= duodenum + Jej
  • stim = H+ small bowel
  • PAncreatin NaHCO3- & delay gastric emptying

Somatostatin:

  • D cells of panceas
  • Vagal + adrenergic
  • inhibit gastric H+ & pancreatic secretions.

VIP:

  • SI
  • NEural
  • Inhibits H+ & epsin –> increases pancreatic secretions

GIP:

  • Duod + jej
  • gluc fat AA
  • inhib H+/increase insuli/decrease motility
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14
Q

Fe Metabolism

A

Absorption - upper SI

Bound to Transferrin as Fe 3*
Stored as ferritin

Causes of increase Fe:

  • Vitamin C
  • Gastric H+

Causes of decreased Fe:

  • PPI
  • Tetracycline
  • Tannine - in tea
  • Gastric Achlorydia
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15
Q

Folate metab

A

Foudn in leafy greens

abs in duod/jej

Drugs that stop metab:

  • MTX
  • Trimethoprim
  • Pyrimethamine

Drugs that reduce reabs:
- Phenytoin

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16
Q

Causes of low Vit B12

A

PErnicoius anaemia
post gastrectomy
disorder of terminal ileum - CROHNS
VEgan/low protein diet

Features:

  • MAcrocytic anaemia
  • Sore tongue + kmouth
  • Ataxia/mood

Mx:
- if neuro –> HYDROXOCABALAMIN

if folic A low - replace B12 1st to stop SCDC

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17
Q

Achalasia

A

adnormal peristalsis + Lack of relaxation of LOS

Ft:

  • Dysphagia - both liquids + Solids
  • Varies in severit
  • Regurgitation

inx:
MANOMETRY - most important
- Ba swallow –> birds beak appearance

Mx:

  • Botulinnum toxin inject
  • Hellers cariomyotomy
  • pneumatic ballon dilatation
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18
Q

Dyspepsia referral criteria

A

Urgent:

  • Dysphagia
  • Uppe abdo mass
  • > 55 and - abdo pain/reflux/dspepsia

Non-urgent:

  • Haematemesis
  • > 55 w/ - tx resistant / upper abdo mass + low Hb/ high platelets and sx
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19
Q

Drug causes of dyspepsia

A

Direct causes:

  • NSAIDs
  • Steroids
  • Bisphosphonates

Drugs causing relax of LOS:

  • Nitrates
  • CCB
  • Theophyline
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20
Q

H.Pylori

A

Gram negative

assoc:

  • PUD
  • GAstric Ca
  • B cell lymphoma of MALT
  • Atrophic gastritis

Inx:

  • Diagnosis - 13C urea breath test or stool culture:
  • Erradication = Urea breath test

Mx 7/7:

  • PPI + Amox + Clari
  • PPI + Metro + Cari
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21
Q

GORD - indications for UGI endoscopy

A
  • > 55
  • sx >4/52 or tx resistant
  • Dysphagia
  • WL
  • Relapsing/remitting

if neg endoscopy –> 24 hr oesophageal pH monitoring

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22
Q

Barretts

A

Squamous –> columnar

pre malignant

RF:

  • GORD - greatest
  • smoking
  • Obesity
  • Male

Mx;

  • Endoscopic surveillance - 3-5 yrs
  • high dose PPI
  • if dysplasia –> ressection or ablation
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23
Q

Oesophageal Ca

A

Adenocarcinoma = most common
- can have sq cell

Majority effect MIDDLE 3rd of oesophagus

RF:

  • GORD
  • Barretts
  • EtOH
  • Achalasia
  • plummer-Vinson syndrome - sq cell
  • procssed meat - Sq cell

H.PYLORI NOT ASSOC - MAY BE PROTECTIVE

Inx:
UGI endoscopy
CT TAP for staging –> no mets –> endoscopic US
Peritoneal dx –> Laproscopy

Mx:
- Surgery + adjuvant chemo

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24
Q

Acute UGIB causes

A

Oesophageal:

  • mallory weiss
  • oesophagitis
  • varices
  • Ca

Gastric

  • Gastritis
  • Ca
  • Dieulafoy lesion
  • gastric ulcer

Duodenal:
- Posterior sited ulcer

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25
Risk assessment in UGIB
``` glasgow blatchford score - pre endoscop --> >0 --> Mx Hb urea SBP Tachy Malena syncope hepatic dx or CFx ```
26
UGIB - Non variceal bleed
PPI post endoscopy | Further bleed --> rescope --> IR/Surgery
27
UGIB initial mx
A--> E maj haem protocol FFP if: - fibrinogen <1 - INR >1.5x BL Plt transfusion: - Active bleed + plt <50 If taking warfarin --> PTCC All PT --> endoscopy within 24 hrs
28
UGIB - variceal blled mx
Terlipressin + Abx Endoscopy --> VBL (oesophageal) / N-butyl-2-cyanoacrylate inject (Gastric) Fx of above -- TIPSS
29
UGIB - idnications for surgery
>60 fx of endoscopic intervention rebleed known CVD with poor tolerance for hypotension
30
Zollinger-Ellison syndrome
Increased gastrin production Raised gastric acid - - > low b12 - - - > MACROCYTIC ANAEMIA ``` assoc w. Men type 1 ft: - Multiple P~Ud - diarrhoea - malasorption ``` Inx: Fasting gastrin levels
31
Gastric Ca
Epidemiology: - affects 70-80 yrs - JApanese/chinese/finland/columbia - M>F Histology --> SIGNET RING ``` Assox: Blood Group A H.pylori Polyps pericious anaemia smoking diet - Na / spicy / nitrates ``` Inx: - Endoscopy + biopsy - stagbg = Endo US or CT TAP ``` Mx: - PRooximl dx - 5 -10cm cm from G.O.jn --> subtotal gastrectomy - <5cm --> total gastrectomy - nodal disection adjuvant chemo ```
32
Gastroparesis
Causes: - IDiopathic - DB - ANS - Post vagotomy Inx - Ba Swallow Mx: - dietary mod - motility agents - DOMPERIDONE/ metoclop/erythromycin - if severe or asp pnuemo --> feeding Jej
33
Dumping syndrome
complication of gastric surger & whipples inapprop. metab response to eating: - early syndrome = half hour - late syndrome = 1-3 hrs Sx: - palpitations/headache/sweating/hypotension/light headed Early dumping: - rapid gastric emptying - Mx = small frew high protein + fat meals Late dumping: - Hypogycaemia due to rebound hyperinsulinaemia. - Mx - High carb meal.
34
acute Pancreatitis - causes
GETSMASHED - AI = PAN H = hypertriglycerides, hyperchylomicron, hypercalcaemia, hypothermia Drugs - AZA, mesalazine, furosemide, bendroflumethazide, steroids, pentamidine, Na Valproate.
35
Acute PAncreatitis - inx + scoring
AMylase >3x ULN US abdo --: G.stone dx ``` Scoring = glasgow Pao2 <8 Age >55 Neutrophils >15 Ca <2 Renal urea >16 Enzyme LDH >600/AST>2000 Alb <32 sugars >10 ``` Score >3 --> SEVERE CRP 150 = severe
36
PAncreatitis Mx
Feed --> decrease bacterial translocation Analgesia FLUID G.stone obstructing biliary tree --> ERCP Cholecystectomy Infected necrosis --> drainage
37
Complicatuos f pancreatitis
pancreatic fluid collection - spont resolves pseudocyst - observe 12/52 --> fx to resolve --> surgery Necrosis --> if sterille = conservatibe/ if infected --> Drain Abscess --> DRAIN Haemorrhage ARDS
38
Chronic oancreatitis
Main cause : EtOH PThers: - genetic - CF/haemochromatosis - ductal obstruct - stones, tumour, structural Px: - Pain = 15-30 mins after meal - 5 - 25yr olds - steatorhea - >20 yrs - DB inx - CT ABDO - Faecal Elestase !!!! Mx: - Creon - Vit ACE - Analgesia - DB - insulin - abstinence form alcohol
39
Pancreatic Ca
``` Assoc: - Age smoking -DB - Chronic pancreatitis HNPCC - MEN - BRCA2 ``` Px: - painless jaundice - courvoissser's lae - trousseaus sign inx - high res CT Mx: - <20 % resectable - Whipples procedure + adjuvant chemo - Palliative ERCP Stenting
40
sulphasalazine side effects
Diarrhoea skin rash male infertility agranulocytosis
41
melanosis coli
pigment laden macrophages assoc with laxative abuse
42
Insulinoma
px: - early am and premeal hypoglycaemia - raised insulin - raised C-peptide - reaised pre-insulin:insulin inx: 0 supervised prologed fasting - CT pancrease Mx: - surggery - if not a candidate Diazoxide + Somatostatin
43
colorectal Ca screening PPV
5 - 15%
44
VIPoma
VIP produce in SI + Pancrease --> increases pancreatic + Interstinal secretions. It inhibits H+/pepsinogen Ft: - LOADS OF DIARRHOEA - WL - Dehydration - low CL-
45
Glucagonoma
alpha cells Ft - charcetristic rash = migratory neccrolytic erythema - WL - Glucose intolerance - DB
46
Somatostatinoma
Secreted by D cells Ft: - DB - GB dx - Diarrhoea - WL - Steatorhea - hypochlorydia
47
Coeliac dx
Assoc w/ HLA DQ2 & DR8 anti-TTG = 1st line anti endomysial Ab both IgA - when tested for need to be on gluten for at least 6/52 Biopsy: - Villous trophy - lymphocyte infiltration of lamina propria - increased intraepthelial lymphocytes TTG used to assess compliance to gluten free diet;
48
coeliac dx complications
``` anaemia - Folate >B12 hyposplenism osteoperosis/osteopaenia lactose intoerance enteropathy assoc. lymphoma decreased fertility. ```
49
Brush border enzymes and their products
Maltase - Gluc + gluc sucrase - Gluc + fructose lactase - Gluc + galactose
50
carcinoid syndrome
mets --> liver Ft: - 1st sign = flushing - diarrhoea - bronchospasm - hypotension - R sided heart valve complications inx: - Urinary catecholamines = Urinary 5-HIAA Mx: - Octeotride - somatostatin analgue - s.e --> Gallstones Diarrhoe = Cryoheptadine
51
Whipples dx
Remeber the @old man with the whip in the rave pixorise vide ``` G+ PAS + Foamy Mac Steatorhea - golden butts Cardiac psigns - heart shaped couches neuro signs - old man wearing helmet ``` Inx = Jejunal biopsy MX: IV penicillin --> co-trimoxazole for 12/12
52
Angiodysplasia
Vascular malformation - seen in elderly -A-ngiodysplasia is assoc withj -A-ortic stenosis Inx: - colonoscopy - acute bleed = mesenteric angio mx - endoscopic cautery or argon laser. - TXA - Oestrogen
53
Refeeding syndrome
Metabolic derangement when someone in previous catabolic stateis fed abruptly sudden switch to anabolic --> surge in insulin --> Increase uptake of gluc, mg, po4-,K+ --> low levels in blood Mx if not eaten for 5days or more --> reefed at 50% og required daily intake for 2/7
54
refeeding syndrome RF - High risk
One of : - BMI<16 - WL >15% (3-6/12) - low intake >10 days - already low electolytes 2 of: - BMI <16.5 - WL >10% - not eaten > 5 days - EtOH/Insulin/ chemo/.steroids/ diuretucs
55
Malnutrition
Definition BM( <18.5 or unintentional WL >10% NMI <20 + WL >5% Acreen - MUST Mx: - Dietician --> FOOD FIRST PLAN --< fx --> PO nutritional supplement.
56
Vitamins
B6 - pyridoxine - Caused - Inz - peripheral neuropathy / sideroblastic anaemia B1 - Thiamine - EtOH, Malnutrtion - W-K encephalopathy - Dry + wet beri beir B3 - Niacin - Hartnups dx, Carcinoid - Pellagra = dermatitis, dementia, diarrhoea B2 - Riboflavin - Angular chellitis B12 - Pernicious anaemia/ post gastrectomy/ crohns/vegan/metformin - Peripheral neuropathy, ataxia, neuro-psychm macrocytic anemia, sore tongue _+ mouth C - scurvy - poor wound healing/bleeding gums/haematuria/epistaxis - gen malaise
57
SB bacterial overgrowth syndrome
RF: - Congenital abnormalities - Scleroderma - DB Ft: - IBS like picture - diarrhoea, bloating, flatulence Inx: _ HYDROGEN BREATH TEST Mx: - Tx underlying - RIFAXIMIN
58
Crohns - Px/Inx
Mouth --> anus patchy inflamm of all layers = "cobblestone" Histology - all layers - increased goblet cells - granulomas Px: most common on adult = diarrhoea, most common in child = Abdo pain ``` inx: - faecal calprotectin - CRP relates to DX ACTIVITY - Colonoscopy + Biopsy SB enema --> strings of Kantor + Rose thorn Ulcers ``` Complication: - SB cancer osteoporosis colorectal Ca
59
Crohns mx
General - stop smoking - decrease NSAIDs Indicing remission: - 1) Steroids +/- enteral 2) Mesalazine 3) MTX/AZA or mecatopurine 4) Infliximab NB - Use inflix if fistula. need to check TPMT activity before Aza and mecatopurine Mainaining: 1) Aza or metacopurine 2) ASA (prev surgery) or MTX Surgery - if stricture or fistula
60
UC Px/ Inx
More likely to px with bloody diarrhoea and tenesmus + LLQ pain Pathology: - limited to submucosa - decreased goblet cells - don't get granulomas - Crypt abscess - inflamm cell infiltrate of LP Inx: - Colonoscopy + biops - SB enema - Loss of hgaustra --> V sev --> LEAD PIPE COLON Severity: - Mild - <4 stools/day w/ little blood - Mod - 4-6 stools/day - no systemic upset - Sev - > 6 stools/day w/ systemic upset.
61
UC Mx - inducinf remission
Mild -- Mod procttiis: 1) rectal Mesalasine 2) PO mesalazine 3) PO/topical steroid Mild- mod proctosigmoiditis + L side Dx: 1) Rectal Mesalasine 2) PO mesalasin 3) PO Mesalazine + topical steroid 4) PO Mesalazine + PO steroid Mild - mod - extensive dx: 1) PO + Topical meselazine 2) PO Mesalazine + PO steroid Sev colitis: 1) IV STEROID or CICLOSPORIN 2) not resolved in 72 hrs --> +Ciclosporin or go to surgery.
62
UC maintaining remission
Mild - mod proctitis: - Meslazine - PO or topical or combo Mild to mod L side dx - PO Mesalazine Sev relapse or >2 exac in a yr: - Aza or mercaptopurine - TMPT activity
63
IBD 0 extraintestinal dx
Related to dx activity: - arthritis - puaciarticular - episcleritis - Erythema Nodosum - osteoporosis ``` Unrelated to sx activity - periarticular arthritis - uveitis - pyoderma gangrenosum clubbinf PSC ```
64
UC and colorecyal Ca
``` High risk: - Dx > 10yrs Px < 15yr sold - pancolitis - unremitting dx - poor complains ``` Suveillance: Low riks - 5 yrs - no complicated L side dx - no inflamm on endo or histo Med risk - 3 yrs: - Ext dx w/ mild inflamm - Fhx of colorectal Ca >50 High =1yr: - Mod--> sev inflamm - FHx <50 yrs - Complications - strictures, dysplasia, PSC
65
C.Diff
Produces and exotoxin --> pseudomembranous colitris RF: - Cephlasporin > Clindamycin - PPI inx: - Cdiff toxin in stool Mx: - PO metronidazole - if sev or Fx 1st line --> PO Vanc or Fidaoxamicin - life threatening ---> IV metro + PO Vanc Ft of life threatentingL - WCC>15.0 - Cr > 1.5X BL - Temp > 38 - Sev colitis on radiology
66
Peutz - Jeghers syndrome
AD Harmatomas Ft: - harmatomatous polyps in GIT - Pigmented lesions on lips, oral muco, palms,Intestinal obstruct - GI malignancy Mx = conservative
67
Coagulopathy of liver dx
Factor 8 is paradoxically increased. This is because it is made in endothelial cells all around body, not just liver !! Also it is cleared by the liver therefore it is not cleared !!! As a result despite increase bleed risk, CLD pt tstill at risk of VTE
68
Colorectal Ca
SPoradic 95% HNPCC 5% - AD - PRoximal colon, poorly differentiated + VV agressive - Amsterdam critea >3 family members, cross 2 generations or >1 diagnosed < 50yrs FAP<1% - AD - APC gene on chromsome 5 - Multiple polyps - Gardners syndrome - FAP + OSteomas + retinal pigmentation + thyroid Ca + epidermal Cysts
69
Colorectal Ca screening
Every 2 yrs 60-74 UK 50-74 scotlnd FIT - better than FOB - only 1 sample and only detects human Hb. 5-15% of + tests --> colorectal Ca Flexsig- one of test - @55 yrs - can opt in until 60 in addition to above - offer FOBT if: - >50 + abdo mass or WL - >60 + anaemia.
70
Colorectal Ca referral
Ugent: - =/>40 + Abdo pin + WL - =/>50 + Rectal bleed - =/> 60 w/ IDA or chaneg in bowel habit - + FOBT Consider: - Rectal/abdo mass - anal mass/ulceration - < 50 + rectal bleed + one other sx.
71
IBS
Diagnosis: - 6/12 ``` Abdo pain - relief on defecation or assoc with change in bowel habit and 2/4 of: - Bloating - alt stool passing - sx worse on eating - Passing mucus ``` inx - FBC/ESR/Coeliac screen Mx - 1st line: - Diet advice - avoif high fibre - Diarrhoea - loperamide - Constipation - LAxatives --> fx --> Lincosamie - pain - antispasmodic Mx: 2nd line: - Lincosamide - TCA - CBT
72
GI Infections
1 - 6hrs: - Staph A - projectile vomit - Bacillus cerus - Rice - <6hr = vomit >6hrs diarrhoea ``` 12-48 hrs: + Salmonella - G- nacillus - pea soup diarrhoea - rose spots - usueal SL --> Fx --> Cipro ``` +E.coli - Traveller diarrhoea = watery 48-72 hours: + Shigella: - BLOODY diarrhoea - useually SL --> if sev --> Cipro + Campylobacter: - Non bloody diarrhoea - FLU-LIKE PRODROME - GBS/ reiters - Usually SL --> sev --> Clarithromycin or Cipro >7/7: + Giardiasis: - non-blood diarrhoea --> malabsorption/lactose intolerance - Mx = metronidazole + Amoebiasis: - Prolonged BLOODY diarrhoea - HOT STOOL MICROSCOPY - get amoebic liver abscess - mx = Metro + Luminal amoebicide (If invasivve dx)
73
Pre - hepatic jaundice
Increased RBC BD: G6PD deficiency: - AR --> decreased glutathiazone --> increase susceptble to O2 stress. - NEONATAL jaundice - HEINZ BODIES + SPLENOMEGALU HEreditary spherocytosis: - RBC BD in microcirculation --> destryed in SPLEEN - Fx to thrive - SPLENOMEGALY Congenital hyperbilirubinaemia: Gilberts - relative loss of UDP GT --> decreased conjugation - Jaundice worse in INTERCURRENT ILLNESS OR EX - inx - prolonged fasting --> measure Bili Criggler - NAjjar - More severe than gilberst --> ABSOLUTE LOSS of UDP GT - dont survive long - 2 types, tpe 1 is more sev. than type 2
74
Hepatic jaundice
Hepatitis ALD Wislons dx Drugs: - Phenobarbital - Amoxicillin - other abx Rotor syndrome: - AR - defect in hepatc uptale + storage Dubllin Johnson sndrome: - iranian jews - MDRP2 - Decrease hepatic excreton --> GROSSLY BLACK LIVER Liver Cirrhosis Hepatic MEts Cardiac fx
75
Wilsons dx
AR increase DI absorbtion of Cu + decreased HEpatic excretion of Cu --> deposits in tissuess Px 10-25 yrs - 1sst sign in children = liver dx - 1st sign in adults = neur-psych - he fx - KAiser - flaischer rings - RTA - BLue nails Inx: - low serum Cu + Caeruloplasmin - Increased 24 hr urinary Cu excretion MX: - PENICILLAMINE
76
post-hepatic JAundice - Gallstones
Female/fair/fat/forty/fertile Mx: - Asx and G stone in GB --> dont need to tx - ASx and Gstone in CBD --> Tx Complications: - Biliary colic --> US --. LAp CHole - Cholecystitis --> Abx --> choecystitis within 48hrs - GB Abscess --> drain - Chokangitis - Charcots triad or reynalds pentad - G stone ileus --> SBO --> lap - Acalculous Cholecysttiis -- cholecystectomy - Acute pancreatitis
77
Post HEpatic JAundice - other causes
PAncreatic Ca PBC: - AMA M2/ASMA/ IgM - mx : UDA, Cholecystyramine, Vitamins - If Bili >100 --> ?liver transplant - Complications - osteomalacia/osteoperosis, Cirrhosis, Heptocellular Ca PSC: - Assoc UC - Inx - ERCP/MRCP, ANCA + - ncreased risk of Cholangiocarcinoma + colrectal Ca LN
78
Liver cirrhosis - liver biopsy features
Alcohol steatohepatitis: -Macrovesicular fatty change with giant mitochondria, spotty necrosis and fibrosisi Liver cirrhosis: - Xs collagen and extracellular matrix deposition in periportal and pericentral zones leading to the formation of regenerative nodules.
79
What decreases accuracy of 13C-urea breath test
No abx or 4/52 No PPI 2/52
80
HELLP vs AFLP
HELLP: - HAemolysis - Elevated LFT - Low Platelet Alcoholic fatty liver of preg: - No haemolysis on blood fim - ALT >500 - Hypoglycaemia
81
Acute UGIB caused by a duodenal ulcer - what artery is likely to be affected?
Gastroduodenal artery posterior site DU
82
IF you ?ischaemic bowe in the Q what may they give you in the Q stem on bloods?
Raised LActate low pH on Acidosis high RR and Low HCO3- - compensation of metabolic acidosis
83
Ascites
``` TransudaTE (saag >11) - CHfx - Hep CV thrombosis - Cirrhosis EtOH - Mixed - Hep Fx - Budd-chiari _ Veno-occlusive dx -Fatty liver of preg ``` Exudate (SAAG <11) - Malignancy - Infection - TB - Pancreatitis - Bowel obstruction Mx: - Fluid srestric + Na rresitrict - Catheter - UO - Daily wait - Spironolactone - Prophylactic Ciprofloxacin - TAP --> S.e ++ Panncreatic circulatory dysfn - therefore if large vol, give albumin cover. - TIPSS
84
Hepatorenal syndrome
pathophysiology = complex - thought to ?> be splanchnic VD --> decrerase renal perf --> RAAS --> Renal VC 2 Types: - Type 1 - V rapid onsetr + agress - 2 x Cr BL or 1.5 x Cr Clx in 2/52 - Type 2 - slower + better prognosis Mx: - Terlipressin - 20 albumin --> vol expansion - TIPSS
85
SBP
Paracentesis --> neutrophil count > 250 Mx : IV cefotaxime in pt with ascites give prophylaxis if: - =>1 episode of SBP - Fluid proten <15g/L or CHild pugh >9 or HRS
86
Hepatitis A
``` Hep A - Faecal oral - RNA - Flu-like prodrome - Mx = supportive Vax = yes ```
87
Hep B serology
HBsAg = acute dx = 1-6/12 or chronic if present >6/12 anti-HBsAg = immunity anti-HBc Ag = infection - previous or current HBeAG = marker of infectivity
88
Hep B
Hep B - Chronic: - Blood bourne - DNA - Jaundice/ fever . transaminases - Mx = pegylate ifn-alpha +/- tenofovir.entecavir/talbivudir - complications - 50% --> Chronic Hep = ground glass hepatocytes - Complications: fulminante hep Fx/ Hepatocellular Ca/ GN/PAN - VAX -= YEss - all children in UK + Occupational risk
89
Hep C
CHRONIC Blood borne/sexual RNA Acute hepatitis less sever the A + B Inx = HCV RNA Chronicity 55-70%: - Complications - Rheumatic dx - Sjrogrens - Cirrhosis - Hepatocellular Ca - membranoprolif GN - Porphyria Mx: - Protease inhibitor (-navir-) +/- Ribavirin - used to be ifn alpga S.e of ribavirin: - Haemolytic anaemia - Cannot become pregnant <6/12 after stopping IFN-alpha: - flu like - depression - fatigue - leukopaenia - thrombocytropenia
90
Hep D
Exacerbated HEp B no chronicitiy of itself no vax blood-borne
91
Hep E
faecal -oral RNA - Acute self limiting HIGH MORTALITY during PREH no vax
92
AI Hepatitis
assoc w/ other AI conditions/hypogammaglobulinaemia/ HLAB8/DR3 Type 1 - ANA/ASMA - affects both adult and child Typ II = LKM1 - Kids Type III - Soluble liver-kidney Ag - Adults Inx: - CLD signs Amennorhea - ANA/ASMA/LKM1/IgM !!!!!!! - liver buiopsy --> Necxrosis = piecemeal or bridging Mx: - IS/Steroids - Liver transplant
93
Drug induced hepatitis
Cholestatic - Fluclox - Erythromycin - OCP - Anabolic steroids True hep - Statin - Anti-TB - Inz - Ketoconaxole - I.s. Necrosis: - Tetrahydrochloride ingestion - Paracetamol OD
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Liver Cirrhosis
Inx of choice = TRANSIENT ELASTOGRAPGY - Fibroscan = measures stiffness Endoscopy - varices Screemomg - Liver US +/- AFP - Hep C - EtOH intake - >50 for M and > 35 units for F - ALD Scoring = MELD - Bili/Cr/INR ``` Child pugh score - Bili Alb PTT Enceph Ascites ```
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child pugh score
BIli: - <34 = 1 - 34 - 50 = 2 - >50 = 3 Alb >35 = 1 28 - 35 = 2 <28 = 3 PTT: <4 = 1 4-6 =2 >6 = 3 Enceph AND ascites none = 1 mod = 2 marked = 3 Severtity A = <7 B = 7-9 C = >9
96
Prtal HTN - causes
causes: - cirrhosis -Portal V thrombosis - budd - chairi - R HFx Vholangio-carcinoma/hepatocellular Ca - Constrictive pericarditis - Splemic V Thrombosi s
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prophylaxis form Variceal bleed
1) Propanolol 2) VBL>Sclerotherapy (cover w/ PPI) VBL used 1st line if Cirrhosis + med/lrg varices
98
Hepatic Encephalopathy
Ft: - GCS change - Asterix - 3-5hz - construcytional apraxia Inx: - Raised ammonia - EEG - Transient slow waves PRecipitants: - Infection - GIB - TIPSS - CONSTIP{ATION - Drugs - sedatives/diuretics - hypokalaemia - Renal Fx - High protein diet Mx: - Tx precipitant - !st line = Lactulose - 2nd line = + Rifaximin
99
Hep encephalopathy - GCS grades
grade 1: irritable grade 2 0- confusion/inappropriate grad 3 - incoherent/relestless grade 4 - coma
100
PBC complications
Osteomalacia/osteoporosis - Sjrogrens portal HTN Hepatocellular Ca - 20 x risk increase.
101
Haemochromatosis
HFE gene on chromosome 6 Ft: - Fatigue / erectile dysfn/ arthralgia = early - Bronnze skin - CLD - DB - Cardiomyopathy - Hypogonadism = hypogonadotrophic = Pit dysfn Inx: - general population transferrin saturation +/- ferritin - FHx +ve --> HFE gene - Tranferrin > 55% in M or >50% F - ferritin >500 - Fe Raised - TIBC reduced Mx: - Venesectuin - aim to keep trasnferin saturation <50% and Feritin <50
102
Which complications of haemochromatosis = reversible>
Skin pigmentation Cardiomyopahty
103
Paracytic liver ingections
``` Hytadid dx: - ingestion -dog taperowmr - larvae --> blood --> liver cysts Mx = surgical + bendazole ``` Schistomiasis: - Parasite penetrates skin when in infected H2O Schistom HAematobium --> Renal --> bladder clac/haematuria - Mx = Praziquantel -Schistoma Mansonium/japonicum --> Liver Cirrhoss VAriceal Dx - Schistoma intercalatum/mekongi ---> intestinal dx
104
Liver abscess
Pyogernic: - Drain + IV ABx = Amoc + cipro + metro - pen allergy = Cipro + clinda Amoebic: - Anchovy paster - Prodrome of diarrhoeal illness - Mx = metro
105
hepatocellular carcinoimna
``` Rf: - Liver citrrhosis - any cause - Alpha-1 antitrypsin - Heriditary tyronsinosis - glycogen storage dx - Alfatoxin Drugs = OCP/ Anabolic steroids - male ``` Screening: - US +/- AFP - cirrhosis secondary to hep B/C/haemochromatosis - men with ALD ``` Mx: - Early = resection - Albumin Sorafenib = multikinase inhibitor - Transarterial chemoembolisattion - liver transplant ```
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Cholangiocarcinoma - features
Biliary colic post-hep jaundice Courvosers sign = palpable mass inRUQ + jaundice sister mary joseph nodule = periumbilical LN Virchows node Mx: - v.few suitable for surgery - palliative stenting
107
NAFLD
Insulin resistance spectrum disorder: - steatosis - steatohepatitis - steatohepatis (NASH) = Same changes as ALD Assoc - obesity - DB2 - lipids - jujenoileal bypass - sudden WL ot starvations Inx: - Liver screen ALT > AST rise - Enhanced lifer fibrosis blood tersts Fibroscan + FIB4 score Mx: - WL - Adv dx --> specialit
108
Ascites and protein concentration <15 but no bacteria yet...... what should be done re abx
Give prophylaxis ciprofloxacin or norfloxacin
109
PSC investigation of choice?
ERCP - - > bead like appearance
110
Most common organism. In SBP
E. Coli
111
Contraindications to liver biopsy
- extrahepatic biliary obstruct - as use ERCP/MRCP - deranged clotting - INR>1.4 - Low platelets - <60 - anaemia - hytadid cyst - haemangioma - uncooperative pt - ascites
112
Gastric MALT
Feature of dysoepsia and weight loss Lymohima cekls pressnt on bioosy Most conmonky assoc h. Pylori,. 1st ljne management is HPYLORI ERADICATION
113
Bile. Acid Malabsorption
Bile acid is absorbed in the terminal. Ileum Therefore seen jn those with Ileal resection or diseass (CHRONS) Px is chronic diarrhoea ans burning sensatiom on passing faeces Management is cholecystyramine
114
Bile. Acid Malabsorption
Bile acid is absorbed in the terminal. Ileum Therefore seen jn those with Ileal resection or diseass (CHRONS) Px is chronic diarrhoea ans burning sensatiom on passing faeces Management is cholecystyramine
115
Heo B most important factor for determining progression to cirrhosis
HBV DNA titre
116
PBC - The M ruke
Ig-M- Anti-M-itochondrial Ab -M-iddle. Aged female Lft - - > raised alp and gamma-GT Mx: Puritus - cholecystyramine Uro acid
117
PBC criteria for liver transplant
Bili > 100
118
Diagnosis of SBP
Paracentesis--"> netrophil vount >250 Most common organism = E. Coli
119
Diagnosis of SBP
Paracentesis--"> netrophil vount >250 Most common organism = E. Coli
120
Management of scute severe alcohokic hepatitis
Prednisolone
121
Gilbert's sybdrome
Unconjugated hyperbilirubinaemia Jaundice on intervurrent illness Investigatiin: Rise in bilirubin followinf orolonged fasting or nicotinic acid
122
Heoatorenall syndrome
Type 1 rapidly orgressive Typd 2 slower Mexhanizm - splanchnic vasodilation . Mx Terlipressin Volume expansion wuth 20% albumin TIPSS
123
Menetriers disease
Characterised by massiv gastric folds in the fundus Histology - hypertrophy of gastric pits, gkand atrophy amf increase overall. Mucosal thickness Ft: Epigastric paib Diarrhoea Hypoalbuminaemia
124
Extra-intestina manifestations of IBD - A PIE SAC
Arthritis, ankylosing spsondylitis PSC, Pyoderma gangrenosum, pleuritis, pancreatitis, perianal skin tag, psoriasis I = eyes = iritis, uveitis, episcleritis, conjunctivitis E = eryhema nodosum Sacroilitis Apthous ulcers Clubbinc, cholelithiasis renal calculi
125
Carcinoid syndrome - False + on Urinary HIAA
Diet high in veg/nuts, therefore --> test after diet restriction
126
Hepatic adenoma
benign lesion of liver seen in women of childbearing age assoc with OCP
127
Immunoglobulin in gastro
IgA - A-lcohol IgM - PBC - anti M-itochondrial Ab IgG - AIH
128
Hepatitis E
Rna . Faecak. Oral Severe ilness and death in pr-E-gnant women in yhe 3 (for E) trimester
129
Colonoscopy surveillance
Low risk - 1 or.2 adenomas - 5rs Med - 3 or 4 adenomas or. One >1cm - 3yrly High - 5 or more.... Or at keazt 3 with one >1cm
130
Peutz jegher
Mucosa pigmentation Gu bleed Chromosme 19 - AD
131
Pathognomic finding of chronic oancreatitis
PANCREATIC CALC - Xray (alsp kn ERCP)
132
What drug causes crohns like Enterocolitis in transplant patient
Mycophenelate mofetil
133
Colonoscopy for dukaes A tumour
Colonoscopy annually for 2 years. Yhen 3 years
134
Treatment of whipples of disease
Amoxicillin
135
Most common cause of small bowel overgrowht
Radiation enteritis
136
Travis or oxford criteria for UC
At day 3:. Stool freq >8 Crp >45 85% need surgery Theaes - INFLIXIMAB OR CICLOSPORIN
137
Drug mimics of IBD
NSAIDs Mycophenlate mofetil Nicorandil
138
If symptoms of Coeliac dx, but endomysial test neg, but still dignosis is coeliac
Coeliac dx - assoc IgA however in Q stem if tehy state past histry of allerges, this may be indicating an IgA deficiency --> therefore endomysial = IgA test wil be negative !
139
Pyoderma gangrenosum
If severe - topical tacrolimus Ciclosporun if this fails (only available parenteral) Can use topivle beclometasone if mild
140
Hereditary haemochromatosis inheritance
Pseudo-dominant
141
How to distinguish between protein losing enteropathy and nephrotic sydnrome
LOW TOTAL CHOLESTEROL nephrotic syndrome loses proteins dependent on weight and charge. Cholesterol too big --> therefore not lost. Investigation - Faecal alpha-1 antitrypsin
142
Chronic Hep B carrier marker of infectivity
HBe antigen if present --> high infectivit | IF negative --> low infectivity

MRCP (20 decks)

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