Gastroenterology Flash Cards
Achalasia (features, investigations, therapeutic options).
Impaired lower oesophageal sphincter relaxation and peristalsis in distal oesophagus.
Chronic, often constant, dysphagia for solids and liquids.
Weight loss unusual unless end-stage disease.
Increased risk of SCC x 10.
Investigations - barium swallow, endoscopy, oesophageal manometry.
Therapeutic options:
- calcium channel blockers, ISM.
- peroral endoscopic myotomy (POEM) * preferred.
- pneumatic dilatation (PD).
- oesophagectomy.
- endoscopic botox injection.
Eosinophilic Oesophagitis.
Younger patients; male > female.
- Food bolus obstruction.
- Chronic dysphagia solids > liquids.
- Refractory GORD.
Infiltration of eosinophils into oesophageal mucosa (15/hpf).
Therapeutic options:
1. PPI therapy - lack of evidence; usually high-dose for 8 weeks.
2. Swallowed topical steroids - eg budesonide 1mg orodispersive tablets.
3. Dietary elimination - difficult.
Barrett’s Oesophagus.
Risks: male, Caucasian, overweight, age, chronic heartburn, smoking, positive family history.
Precursor to oesophageal adenocarcinoma.
Risk of progression 0.38% per year.
Medical therapy: evidence to suggest combination PPI and aspirin therapy reduces risk of cancer development (AspECT trial).
Barrett’s Surveillance - confirmed LGD / HGD.
If LGD confirmed on 2 occasions 6 months apart by two expert pathologists -> endoscopic ablation therapy (or close surveillance).
If HGD confirmed, annual risk of progression to adenocarcinoma is 10%. Oesophagectomy vs. endoscopic resection preferred to ablative techniques.
Post-removal of HGD, need to treat the remainder of Barrett’s and RFA preferred.
Malignant and Benign Features of Dysphagia.
Malignant:
- Shorter duration.
- Solids > liquids.
- Constant and progressive.
- Older age.
- Accompanying alarm symptoms.
Benign:
1. Often long history.
2. Liquids + solids.
3. Intermittent/unpredictable.
4. Younger -> can have alarm symptoms e.g. weight loss, but this is often late in the clinical course.
(DDx: eosinophilic oesophagitis, achalasia, other dysmotility, benign stricture, globus hystericus).
Oesophageal Cancer Types.
- Squamous cell carcinoma.
- 90% oesophageal cancer worldwide.
- Male:female 1:1.
- Associations: smoking, alcohol, 10x more likely in achalasia.
- Most commonly in mid-oesophagus. - Adenocarcinoma.
- Most common oesophageal cancer in N. America and Europe.
- Male:female 3-4:1.
- Associations: GORD, obesity, no link to alcohol.
- Lower oesophageal distribution.
Endoscopic Features of Benign and Malignant Ulcers.
Benign:
- Round/oval/punched out, flat, smooth base.
- Smooth margins and normal surrounding mucosa.
- Majority <2cm.
- Normal adjoining rugal margins that extend to margins of the ulcer base.
Malignant:
- Irregular outline with necrotic or haemorrhagic base.
- Irregular raised margin.
- Anywhere.
- Any size.
- Prominent and oedematous rugal folds that usually do not extend to the margins.
H. pylori and disease.
<20% of those infected develop symptoms. PUD: ~10% of infected patients. Gastric Ca.: 1-3% of infected patients. MALT lymphoma: <0.1% infected patients. BUT - HP gastritis in 80% of patients with gastric cancer. - HP in 95% MALT lymphoma.
H. pylori and peptic ulcer disease.
75% of duodenal ulcers are associated with HP; eradication heals 95-98% compared with 85-95% with acid suppression alone.
HP infection associated with 70-80% gastric ulcers, 85% heal with HP eradication.
In upper GI bleeding from peptic ulcers, 27-37% will suffer a a re-bleed annually without HP eradication.
H. pylori therapy.
Increased clarithromycin resistance.
Triple therapy should not be prescribed unless H. pylori clarithromycin resistance rates are known to be <15%.
If clarithromycin resistance rates are not known, do not use triple therapy.
First-line if clarithromycin resistance >15% or unknown:
- Quadruple therapy with clarithromycin + metronidazole + amoxicillin + PPI.
- Treatment duration: 14 days.
Post-eradication H. pylori testing.
Everyone.
No sooner than 4 weeks after completion of treatment.
If repeat endoscopy is clinically unnecessary - urea breath test or faecal antigen testing is acceptable.
Pre-breath test: withhold antibiotics for >28 days, withhold PPI for 7-14 days.
Pre-faecal antigen test: withhold PPI 14 days.
Guidelines on anti-platelet agents in high-risk patient with GI bleed.
Restart APA on day 3 post-endoscopy -> relook gastroscopy up to discretion of endoscopist.
If DAPT -> continue aspirin; clopidogrel/ticagrelor continuation/resumption decided on case-by-case basis with cardiologist. If low-risk stigmata, single or DAPT can continue.
Warfarin and GI Bleed.
Scope when INR = 2.5.
Don’t delay to correct coagulopathy.
If INR supra-therapeutic - no evidence. Therefore, partial or complete reversal indicated in cases of serious/life threatening bleeding.
If risk of reversal very high and bleed not severe - delaying endoscopy may be reasonable option.
DOAC and GI Bleed.
If patient stable/responds to resuscitation, reasonable to delay 12-24 hours.
If persistently hypotensive:
a) Dabigatran -> Idarucizumab.
b) Xa inhibitors
- Andexanet alpha (US).
- Combination of clotting factors have been used (PCC/4F PCC).
Resumption same as warfarin.
Coeliac Testing.
Anti-TTG
- Test of choice provided patient consuming gluten-containing diet and sufficient IgA.
If anti-TTG IgA weakly positive, anti-endomysial IgA.
- Very specific but technically difficult test.
In IgA deficiency -> use IgG tests.
** must always test for IgA deficiency.
Refractory Coeliac Disease (subtypes).
Type 1 (85%)
- Lymphocyte infiltrate is the same as that in untreated CD.
- Steroids +/- steroid-sparing agents e.g. azathioprine.
- ?budesonide, ?mesalazine.
Type 2 (15%)
- CD3 intra-epithelial T cells with abnormal surface markers /- oligoclonal T cell expansion.
- Less favourable prognosis.
- Malnutrition can be profound, may need TPN.
- Multitude of therapies tried -> best evidence for Cladribine (chemotherapy used in haematological malignancies).
Whipple’s Disease.
Triad: weight loss, chronic diarrhoea (which can be bloody), arthralgia.
+ prolonged fever and peripheral lymphadenopathy.
SB biopsy shows PAS-positive macrophages in sub-mucosa.
Jaundice (DDx).
- Elevated haeme load.
- Haemolysis.
- Inadequate erythropoiesis.
- Haematoma. - Hepatocellular dysfunction.
- Hepatitis.
- Hepatic failure.
- Cirrhosis.
- Drug injury. - Biliary obstruction.
- Malignant.
- Parasitic.
- Stone disease.
- Extrinsic compression.
Screening for HCC in Cirrhosis.
USS + AFP 6-monthly.
Cutaneous and extremity manifestations of cirrhosis.
Increase in estradiol:
- spider angiomas.
- gynecomastia.
- feminization: inversion of male pubic hair pattern, loss of axillary or chest hair.
- palmar erythema (central palmar sparing).
- testicular atrophy.
Jaundice.
Nail changes: terry nails, muehrchke nails, clubbing.
Hypertrophic osteoarthropathy.
Dupytren’s contractures.
Physical Findings of Cirrhosis.
Parotid gland enlargement (alcohol). Fetor hepaticus. Ascites. Caput medusae. Splenomegaly. Cruveilhier-Baumgarten murmur. Asterixis.
Hepatic Encephalopathy (staging, features).
Reversible neuropsychiatric abnormalities associated with liver dysfunction and/or portosystemic shunting.
Staging:
- Minimal.
- Grade 1: sleep/wake reversal, change in behaviour, mild confusion..
- Grade 2: lethargy, moderate confusion.
- Grade 3: stupor, arousable, incoherent.
- Grade 4: unresponsive to pain, intubate.
Hyperreflexia, bradykinesia, myoclonus, rigidity, nystagmus, decerebrate posturing, focal neurological defects.
NB: caused by ammonia penetration into the CNS. A healthy liver clears ammonia by conversion to glutamine. Measurement of venous ammonia is often not helpful. Not useful prognostically.
Causes of Hepatic Encephalopathy.
Infection.
Bleeding.
Medication - anticholinergics, narcotics/benzodiazepines.
Metabolic derangement - alkalosis, hypokalaemia, hyponatraemia.
Hypovolaemia/hypoxia.
Constipation.
Treatment of Hepatic Encephalopathy.
Lactulose.
- decrease GI transit time.
- decrease pH of gut lumen, trapping NH4.
- alternative metabolic substance for gut bacteria - less ammonia production.
- 30-45mL 2-4 times per day.
- goal is 2-3 soft stools per day.
Rifaximin.
- 400mg tds or 550mg bd.
- novel antibiotic - decontamination of the gut.
Ascites and Albumin-Gradient.
High gradient = portal hypertension.
- Serum albumin to ascites gradient >/= 11g/L.
- Not specific for cirrhosis.
- Alcoholic hepatitis, heart failure, massive hepatic metastases, Budd-Chiari, portal vein thrombosis, portal fibrosis, schistosomiasis.
Low gradient = leaky capillaries/tumour.
- Serum albumin to ascites albumin gradient <11g/L.
- Peritoneal carcinomatosis, peritoneal tuberculosis, pancreatitis, serositis, nephrotic syndrome.
Ascitic Fluid Analysis.
Cell count and differential is the single most useful test to perform on ascites fluid.
>500WBC is abnormal.
>250/mm3 neutrophils is consistent with peritonitis.
Total protein - values <10g/L indicate high-risk for SBP.
LDH increased in infection.
Consider perforation if 2 out of 3 present:
1. Total protein >10.
2. Glucose <2.8.
3. LDH > ULN for serum.
Spontaneous Bacterial Peritonitis.
Infection in the ascitic fluid in the absence of a surgical source.
>/=250 PMNs/mm3.
Empiric treatment with fever (T 37.8, abdominal pain, altered mental status, positive paracentesis).
Gut bacteria: E. coli, Klebsiella common pathogens.
Use broad-spectrum antibiotics without nephrotoxicity for five days: Cefotaxime 2g 8 hourly.
Discontinue non-selective beta-blockers. These are associated with 58% increase in mortality.
** NB: IV Albumin in patients with SBP (1.5g/kg) at diagnosis and 1gm/kg on Day 3.
SBP Prophylaxis.
History of SBP:
- Prolonged/indefinite use of TMP/SMX or daily Fluoroquinolone.
- Inpatients with ascites fluid total protein <10 or 15 -> antibiotics during the hospitalisation.
Cirrhosis with GI bleeding:
- Ceftriaxone 1g daily, followed by TMP/SMX twice a day or Ciprofloxacin 500mg bd for seven days.
Gastrooesophageal Varices Treatment.
Pre-primary prophylaxis: treat underlying liver disease (HCV, HBV, NASH).
Primary prophylaxis (varices present, but never bleed): screening endoscopy every 1-3 years, non-selective beta blocker (nadolol or propranolol) or Carvedilol or endoscopic variceal ligation.
Secondary prophylaxis: endoscopic variceal ligation and NSBB.
Acutely:
- Resuscitation.
- Antibiotic prophylaxis.
- Lower the portal pressure:
- octreotide/terlipressin.
- avoid over-transfusion (goal Hb 70-80).
- TIPSS.
** an INR >3 in a patient with cirrhosis does not indicate an increased risk for bleeding due to rebalanced haemostasis in CLD.
Management of Haemostatic Abnormalities in Liver Disease with Bleeding.
Vitamin K.
Treat infection.
Consider DIC (diminished factor VIII level).
Cryoprecipitate - given for hypofibrinogenaemia or dysfibrinogenaemia.
PCC and recombinant activated factor VII expensive and not proven to improve outcomes.
Avoid FFP due to large volume.
Transfuse platelets to keep count >50,000.
Hepatorenal Syndrome.
Progressive rise in creatinine >150mg/L. Absence of shock. Urine Na <10. Cirrhosis with ascites. No response to two days of volume expansion and withdrawal of diuretics. No nephrotoxic drugs.
Type 1:
- Twofold increase in creatinine to >250mg/L during a period of less than 2 weeks.
- Median survival is a few weeks without treatment.
- Always fix the volume -> albumen 1g/kg/d up to 100g/d.
- Terlipressin 1-2m g IV every 4-6 hours with albumen 25-50g/day.
- norepinephrine and albumen in the critically ill.
- dialysis only as a bridge to transplant or acute injury recovery.
Type 2:
- Diuretic-resistant ascites.
- Slow increase in Cr >150mg/L.
- Median survival 6 months.
Causes of Cholestatic Liver Disease.
A. Non-obstructive.
- PBC.
- Drugs.
- Pregnancy/oestrogens.
- CF.
B. Obstructive.
- PSC.
- Tumours.
- Cholelithiasis.
- Biliary cysts.
- Pancreatic disease.
Primary Biliary Cholangitis.
95% women; usually 30-65 years. Half asymptomatic at time of diagnosis. Fatigue and pruritus most common symptoms - itching worse at night. 25-50% have hyperpigmentation. Elevated ALP. GGT and 5'Nucleotidase elevation. Eosinophilia early.
Anti-mitochondrial antibodies (M2 subtype) present in 95% of patients with PBC. Specificity of 98%. Titre of 1:40 or higher.
Associated: ANA +ve in 70%, high incidence of other autoimmune disease (Sjogren’s, autoimmune thyroid disease, RA).
Treatment:
- Ursodeoxycholic acid (13-15mg/kg/day).
- improved LFTs, reduced disease progression, no effect on pruritus or fatigue.
Monitoring:
- LFTs every 3-6 months; TFTs annually.
- BMD every 2-4 years.
- Monitor vitamin A, D, K annually if Br >20.
- Appropriate monitoring of cirrhosis if present.
Primary Sclerosing Cholangitis.
Inflammation, fibrosis and stricturing of the medium and large bile ducts.
Majority have UC (90%).
Only 5% of patients with UC have PSC.
Half asymptomatic, pruritus common.
Atypical P-ANCA 30-80%; hypergammaglobulinaemia in 30%.
May be positive for ANA, ASMA, RF.
Diagnosis:
- MRCP first test of choice.
- ERCP allows therapeutics.
IgG4-associated cholangitis (usually associated with autoimmune pancreatitis) is steroid-responsive and indistinguishable from PSC. Always measure IgG4 in new dx. of PSC.
Complications: cholangiocarcinoma (10-15% risk); gallbladder cancer (screening recommended); cirrhosis/portal hypertension; fat soluble vitamin deficiency/steatorrhoea; colon cancer; metabolic bone disease; cholangitis.
Treatment:
- Endoscopic treatment of dominant biliary strictures may be beneficial in highly select patients.
- Screening.
- Liver transplantation (85% 5-year survival; 20% will have recurrent disease).
Fulminant Hepatic Failure.
- Acute liver injury.
- Hepatic encephalopathy.
- Elevated PT/INR.
In persons without pre-existing liver disease.
Viral and drug-induced injury are the major causes.
Cerebral oedema common in hyperacute and acute disease. PT/INR the best lab to monitor status.
Early transplant evaluation.
? N-AC for all.
King’s College Criteria for Liver Transplant Referral.
Acetaminophen-induced liver failure with:
a) Arterial pH <7.30 or
b) Grade 3 or 4 encephalopathy with PT >100s and Cr >340 mg/L.
Non-acetaminophen-induced liver failure with:
a) PT >100s or
b) Any three of:
- Age <10 or >40.
- Non-A and non-B viral hepatitis, idiosyncratic drug reaction, Wilson’s disease.
- Jaundice >7 days prior to encephalopathy.
- PT >50s.
- Br >180mg/L.
Hepatitis B Serology Interpretation.
HBsAg -> hallmark of active infection.
(anti-HBsAb persists after -> recovery/immunity).
anti-HBcAb (IgM) -> acute infection.
anti-HBcAb (IgG) -> recovery/chronic.
HBeAg -> indicated replication/infectivity (~DNA).
Immune-tolerant phase (baby) -> living with virus.
- +ve HBeAg; +ve HBV DNA; ALT normal.
Immune-active phase: immune system turns on against HBV around 30 yrs of age.
- +ve/-ve HBeAg; reduced HBV DNA; elevated ALT.
Inactive chronic hep B phase: virus goes into hiding.
- -ve HBeAg; reduced HBV DNA; normal ALT.
Immune reactivation: virus attempts domination.
- -ve HBeAg; increased HBV DNA; increased ALT.
Hepatitis B Treatment.
Indications:
- Acute infection only if: fulminant hepatic failure, severe or protracted illness (>4 weeks).
- Anyone with cirrhosis.
- Immune active chronic HBV with:
a) HBeAg +ve (immune active) if >20,000 IU DNA and ALT >2x ULN.
b) HBeAg -ve if >2000 IU DNA, ALT >2x ULN. Consider liver biopsy if ALT <2x ULN and DNA >2000.
4. Presence of HCC.
Treatment NOT indicated in:
a) Immune-tolerant phase (HBeAg +ve; high DNA; normal ALT).
b) Inactive carrier phase (low or no DNA, normal transaminase).
c) Latent HBV infection (DNA without HBsAg).
Options:
- Interferon (young patients with well-compensated liver disease).
- Entecavir (rare resistance; can’t use if resistant to Lamivudine).
- Tenofovir.
- Lamivudine (safe in pregnancy; high resistance).
- Adefovir.
- Telbivudine.
Extra-hepatic manifestations of HCV.
Lichen planus:
- 19% with lichen planus will have HCV.
- 6x risk for HCV in persons with lichen planus.
Porphyria cutanea tarda (50%).
Necrolytic acral erythema (erythematous papules most commonly on dorsal aspect of feet; all cases will have HCV).
Essential mixed cryoglobulinaemia.
- 50% will have cryoglobulins.
- arthralgias, MPGN, neurologic disease, peripheral neuropathy, leukocytoclastic vasculitis.
Lymphoma (10x increased risk). Sjogren's syndrome/sicca syndrome. ITP. Diabetes. Thyroid disease. Autoantibodies - ANA, ASMA, RF in up to 65%.
HCV Therapeutics.
NS3 (serine protease) -> “previrs”
NS5A (RNA binding site) -> “asvirs”
NS5B (RNA-dependent RNA polymerase) -> “buvirs”
Maviret (Gecaprevir/pibrentasvir)
- All genotypes.
- Expect a >90% SVR with current regimens.
- SVR at 12 weeks = cure.
Alcoholic hepatitis.
Rule out HAV, HBV flair, acute HCV, biliary obstruction and Budd-Chiari.
Discriminant function: (4.6 x PT elevation) + Br (mg/dL)
If >32, high short-term mortality, consider steroids.
Prednisone 40mg daily for 28 days; 16 day taper.
Pentoxifylline 400mg tds as an alternative.
Discontinue non-selective beta blockers.
Autoimmune hepatitis.
AST >10x or AST >5x with 2 x gamma globulin level.
Type 1 AIH:
- SMA and ANA.
- atypical p-ANCA (useful if other antibodies negative).
- anti-mitochondrial antibody.
Type 2 AIH:
- Anti-LKM1.
- Specificity 99%.
Liver biopsy.
Treatment not required in asymptomatic patients with normal or minimally elevated transaminases and gamma globulin levels and minimal necroinflammatory activity on biopsy.
Monotherapy -> prednisone 60, 40, 30, 30, 20, indefinitely.
Combination -> prednisone 30, 20, 15, 15, 10, 5…. azathioprine 50mg daily (or 1-2mg/kg/day).
Normalisation of labs and histology usually takes over 12 months.
Haemochromatosis.
Most related to HFE gene mutations (C282Y or H63D).
Transferrin saturation >45%.
Ferritin >200 in men or >150 in women.
Liver biopsy is only needed in select cases.
Response to phlebotomy.
Extrahepatic manifestations:
- diabetes (50%).
- arthropathy.
- cardiomyopathy.
- hypogonadism (secondary).
Wilson’s disease.
Autosomal recessive. >500 mutations found of ATP7B (ATPase).
Serum copper is typically low (decreased caeruloplasmin).
24-hour baseline urinary copper excretion (usually 2-3 x normal).
24-hour urine after 500mg D-penicillamine (>1600microgr copper diagnostic).
Manifestations:
a) Liver disease -> steatosis, fulminant hepatic failure with Coombs-negative haemolytic anaemia, cirrhosis. Only 50% have Kayser-Fleischer rings.
b) Neurologic disease -> behaviour deterioration, difficulty writing, tremor, speech change, Parkinsonism, dysarthria, dystonia. 98% will have Kayser-Fleischer rings. MR mays show basal ganglia hyperintensity on T2-weighted images.
c) Psychiatric - psychosis, depression, anxiety.
Treatment: - copper removal. Chelators - usually 6-12 months to remove excess copper. D-penicillamine (30% cannot tolerate). Trientine (expensive). Tetrathiomolybdate (being studied). - low copper diet. - oral zinc -> interferes with copper absorption.
Acute liver failure in Wilson’s Disease.
Clues: family history, AST/ALT >2.2, ALP/Br <4, low Hb, Copper >200 microgr/dL.
Early liver transplant evaluation.
Rapid removal of copper.
- Haemodialysis, peritoneal dialysis, haemofiltration.
- Plasmapheresis, plasma exchange.
Liver transplant is curative.
Nonalcoholic fatty liver disease.
Hepatic steatosis in the absence of an identifiable cause.
Prevalence in the Asia-Pacific region is 5-30%.
NAFLD -> NAFL, NASH.
Associated with metabolic syndrome: obesity, hypertension, dyslipidaemia, insulin resistance or diabetes.
Transaminases may be normal or up to 5x ULN.
Liver biopsy only modality to distinguish NAFL from NASH and determine severity of disease.
Management:
- Weight loss/exercise.
- Vitamin E (antioxidant).
- Thiazolidinediones -> improve liver histology and labs; weight gain, swollen legs and heart failure.
- Vaccinate for HAV and HBV.
Indications for Liver Transplantation.
Acute liver failure (Kings College criteria previous). Cirrhosis with complications or MELD >/= 15. Neoplasm involving the liver -> HCC single lesion = 5cm or three or less lesions = 3cm. Liver-based metabolic disease. Complications due to liver disease: - Recurrent cholangitis in PSC. - Intractable pruritis. - Hepatopulmonary syndrome. - Primary hyperoxaluria. - Refractory ascites. - Recurrent variceal bleeding. - Refractory hepatic encephalopathy.