Gastroenterology_Medicine Flashcards
(68 cards)
1
Q
What are the markets of liver synthetic dysfunction?
A
Bilirubin
Albumin - slow to change so gives good idea of chronic disease
Coagulation screen (APTT, PT, INR)
2
Q
Causes of hepatic decompensation in CLD? Key features of decompensation?
Dx & Mx of decompensated chronic liver disease?
A
Cause of hepatic decompensation in CLD:
- Hypokalaemia
- Constipation (given lactulose in hospital)
- Alcohol
- GI bleed (lots of protein (Hb) enters the bowel –>liver can’t cope)
- HCC
Decompensated CLD –> Ascites, jaundice & encephalopathy
- Severely scarred liver (cirrhosis) in CLD –> back pressure on portal vein –> PORTAL HTN = splenomegaly, ascites, varices - caput medusae, oesophageal & rectal
Ix:
-
Serum Ascites Albumin Gradient (SAAG) - serum albumin conc vs ascites conc - 11.1g/L
- <11.1g/L = exudative cause - peritonitis (infection), peritoneal malignancy OR n_ephrotic syndrome_ (pee out albumin so low serum albumin)
- Otherwise = transudative cause - cirrhosis, renal failure, HF
- >250 neutrophils = spontaneous bacterial peritonitis (SBP) –> Tazocin/3rd gen cephalosporin
- If protein conc <15g/L give prophylactic oral ciprofloxacin
Mx:
- Paracentesis (ascitic drain) –> post-paracentesis circulatory dysfunction (drops BP) SO if >5L drained give human albumin solution (HAS) 8g/L drained
- Spironolactone (2nd line - Furosemide) - to prevent fluid accumulation
- (Salt restrict)
- Hepatic encephalopathy (liver not dealing with toxins) - give Lactulose + Rifaximin to prevent
- Coagulopathy - OGD (check for varices) + vit K (needed for clotting)
3
Q
Gallstone disease - spectrum? RFs? Types of gallstone?
A
Spectrum:
-
Biliary colic - obstruction of gallbladder/bile duct (usually by stones)
- Sx: RUQ pain (after fatty meal) ± scapular pain
-
Cholecystitis - inflammation of gallbladder
- Sx: RUQ pain + FEVER
-
Ascending cholangitis - infection ascending biliary tract + entering systemic circulation
- Sx: Charcot’s triad = RUQ pain, fever + JAUNDICE
- Severe Sx: Reynold’s pentad = above + CONFUSION + SEPSIS
RFs (5Fs): Fat, Female, Fertile, Forty, Fair
Types of gallstone: mixed (80%), cholesterol (10%, bigger & smaller in #), pigment (10%, smaller & more numerous)
4
Q
Interpreting LFTs + causes
A
Liver - raised AST + ALT
- Causes: viral/alcoholic hepatitis, hepatotoxic drugs
- Most causes increase in ALT > increase in AST EXCEPT Alcoholic hepatitis - AST 2x > ALT
- AST also rises in muscle damage e.g. MI (normal ALT)
Biliary - raised GGT + ALP
- Causes: gallstones, cholecystitis, cholangitis, PSC/PBC
- NOTE: acute alcohol intake increases GGT
- NOTE: ALP can come from BONE (& placenta) - only biliary if GGT also raised
5
Q
Chronic liver disease
- Functions of liver? Outcome of failure?
- Causes? Ix?
- Important complication?
- Scoring?
A
Functions of the liver –> failure:
- Albumin (plasma oncotic pressure) –> oedema
- Bilirubin metabolism –> jaundice
- Clotting factors –> coagulopathy
- Detoxification –> encephalopathy
Causes:
- Common - alcoholic liver disease, viral hepatitis, NASH (non-alcoholic steatohepatitis)
- Less common - AI hepatitis, PSC/PBC, HF, alpha1-antitrypsin def, haemochromatosis, Wilson’s disease
Ix:
- Alcohol history
- Hep B/C serology
- Ferritin, transferrin, A1AT, ceruloplasmin (Wilson’s)
- Ig, auto-abs (ANA in AI hep, AMA in PBC)
Important complication = VARICES
- Normal venous return: GI tract –hepatic portal vein –> liver –> hepatic vein –> systemic circulation
- Physiological hepatosystemic anastomoses (connection of portal vein to systemic circulation) sites - oesophagus, spleen, umbilicus, rectum
- MEMORY AID: BUTT, GUT, CAPUT
- Pathological process:
- In the case of cirrhosis - nodules impede flow of blood through the liver to the hepatic vein –> reducing blood flow to the systemic circulation
- Backflow of blood to the hepatic portal vein = increased –> backflow to hepatosystemic anastomoses:
- Oesophagus –> Oesophageal varices
- Spleen –> Splenomegaly
- Umbilicus –> Caput Medusae
- Only from portal HTN if running from below umbilicus up
- Rectum –> Rectal varices
Score for prognosis & need for liver transplant = Child-pugh score (A = 5-6; B = 7-9; C = 10-15 –> C is most severe)
6
Q
Jaundice breakdown & causes by type & Ix to differentiate
A
Pre-hepatic - unconjugated bilirubin comes from breakdown of RBCs
- Haemolysis related-causes (excess prod) - AIHA, SCD, G6PD def, malaria
- Ix:
- Bloods: excess unconjugated bilirubin (exceeds capacity of liver to conjugate it)
- Urine: normal (unconjugated bilirubin is insoluble)
- Stool: normal as liver functioning normally
Hepatic - bilirubin absorbed into liver –> conjugated –> excreted via biliary tract into duodenum
- Liver disease related-causes - cirrhosis, hepatitis, Gilbert’s syndrome, drugs
- Ix:
- Bloods: high unconjugated (liver less able to conjugate quickly) & conjugated bilirubin (leakage of conjugated bilirubin into circulation)
- Urine: dark (leaked conjugated bilirubin is soluble)
- Stool: slightly pale (reduced conjugated bilirubin to GI tract)
Post-hepatic - conjugated bilirubin –> soluble urobilingogen (yellow): 1) Absorbed into circulation –> excreted via kidneys 2) Remaining –oxidised–> stercobilin (brown)
- Biliary disease related-causes (prevent bile outflow) - gallstones, head of pancreas tumour, cholangiocarcinoma, PSC/PBC
- Ix:
- Bloods: high conjugated bilirubin (backlog as obstruction at biliary tree so can’t reach duodenum and instead leaks into blood)
- Urine: dark (leaked conjugated bilirubin is soluble)
- Stool: very pale (no conjugated bilirubin reaches GI tract –> no stercobilin generated)
7
Q
Chronic diarrhoea - ddx? Sx? Distribution? Histology? Ix? Mx?
A
IBD
- Truelove & Witts’ severity index = severity criteria for IBD
-
Crohn’s disease
- Sx: RIF pain (terminal ileum), failure to thrive (incl. between attacks)
- Distribution: mouth to anus (esp. terminal ileum), skip lesions
- Histology: transmural, non-caseating granuloma (also in sarcoidosis)
-
Ix:
- OGD/colonoscopy/capsule endoscopy
- Gastografin follow-through
-
Mx:
- Induction:
- Steroids (induce remission)
- 5-ASA (mesalazine)
- Maintenance:
- Steroid-sparing agents (methotrexate, azathioprine, mercaptopurine)
- Biologics e.g. Anti-TNF (infliximab)
- Induction:
-
Ulcerative colitis
- Sx: gen. abdo pain, PR blood & mucus
- Distribution: ONLY rectum & colon, continuous
- Histology: mucosa & submucosa, mucosal ulcers, crypt abscesses
-
Ix:
- Flexible sigmoidoscopy/colonoscopy
-
Mx:
- Induction:
- 5-ASA
- Steroids
- Maintenance:
- 5-ASA (mesalazine)
- Steroid-sparing agents (azathioprine)
- Biologics (infliximab)
- Surgery (proctocolectomy, IJ pouch)
- Induction:
Coeliac disease
-
Def: inflammatory response to gluten (immune reaction to gliadin)
- DQ2/8 (on HLA typing)
-
Sx: abdo Sx (steatorrhoea, diarrhoea, bloating), failure to thrive
- Exam: blistering rash on both knees. aphthous mouth ulcers
- Assoc: T1DM
- Distribution: duodenum
- Histology: subtotal villous atrophy with crypt hyperplasia
-
Ix: (maintain normal diet - eat gluten for 6wks before testing)
- Haematinics - macrocytic anaemia, low Fe, B12/folate
- Serological testing:
- Screening: Anti-TTG & total IgA (check for selective IgA def in case this caused false ‘-ve’ anti-tTg abs)
- If weakly +ve –> anti-endomysial abs (more sensitive & specific)
- OGD & duodenal biopsy
- Histology: sub-total villous atrophy with crypt hyperplasia
- Mx: gluten avoidance
Irritable bowel syndrome - Dx of exclusion
-
Sx: bloating, related to stress, diarrhoea/constipation, relieved by defecation
- “Pellet-like stools”
- Ix: faecal calprotectin (an inflammatory marker of GI tract = less likely to be IBS, more likely IBD)
- Mx: dietary changes, stress Mx, anti-spasmodics, probiotics, laxatives/loperamide, anti-depressants
8
Q
Mesenteric ischemia:
- What is the blood supply to the GI tract?
- What area of GI tract is vulnerable to ischaemia?
- Breakdown of mesenteric ischemia? Sx? Ix? Mx?
What is the difference between Mesenteric ischemia & ischemic colitis? Sx? Ix?
A
Blood supply
- Coeliac axis - oesophagus, stomach, start of small intestine
- Superior mesenteric artery (SMA) - most of the small intestines up to 2/3 transverse colon
- Inferior mesenteric artery (IMA) - from 2/3 along transverse colon down to rectym
- NOTE: area 2/3 along transverse colon @splenic flexure = WATERSHED ZONE (limited supply from superior & inferior mesenteric arteries) –> vulnerable to ischaemia!!
__Mesenteric ischemia
-
Acute - occlusion of SMA by thrombus/embolus
- Sx: severe abdo pain, normal abdo exam, shock
-
Ix:
- AXR (gasless abdo)
- VBG (lactic acidosis)
-
CT abdo with contrast (if suspect mesenteric ischaemia)/CT angiogram (if LA)
- If not primary surgery –> followed by mesenteric angiography (Dx non-occlusive mesenteric ischaemia)
- Mx: resus + CCOT + NBM
- Empirical abx
- Bypass ± bowel resection
- Heparin post-op
-
Chronic - narrowing of SMA by atherosclerosis (stable angina of bowel)
- Sx: colicky post-prandial abdo pain (more work for bowel to do –> pain, just like in stable angina & exercise)
- Ix: as above
- Mx: medical optimisation + bypass (angioplasty + stent if not suitable for surgery)
Ischemic colitis
- Occlusion of inferior mesenteric artery (IMA) by thrombus/embolus
- Sx: abdo pain, PR bleeding
- Ix: sigmoidoscopy/colonoscopy
- Mx: seek GI & surgical input (can develop chr ulcerating IC)
- Mild - conservative (IV abx, fluids, bowel rest, DM control)
- Prophylactic LMWH
- Segmental resection + stoma
- Mild - conservative (IV abx, fluids, bowel rest, DM control)
9
Q
Most common reason to do AXR? Most common causes of this reason by type?
AXR interpretation?
Key volvulus signs on AXR?
A
Reason to do AXR: worried about bowel obstruction (small/large bowel)
Small bowel obstruction on AXR:
- valvulae conniventes (from one wall to other)
- Central to image
- >3cm distension
- Causes: adhesions (surgery, sepsis), hernia, neoplasm, volvulus, IBD
Large bowel obstruction on AXR:
- Haustra (Not full width of bowel)
- Outsides of image
- >6cm distension
- Causes: neoplasm, diverticular disease, volvulus, faecal impaction
NOTE: 3/6/9 rule = upper limits of normal for bowel (small = 3cm, large = 6cm, caecum = 9cm)
Volvulus signs (twisting of loop of bowel on mesentery –> balloon animal):
- Coffee bean sign - sigmoid volvulus (large bowel just before rectum)
- Embryo sign - caecal volvulus (large bowel just after small bowel)
10
Q
Acute abdo DDx lower quadrants
A
RLQ:
- Appendicitis
- Salpingitis (can be bilateral) - ascending inf from vagina into fallopian tubes
LLQ:
- Sigmoid volvulus
- Sigmoid diverticulitis - outpouching of mucosal tissue in sigmoid colon
Diffuse/either:
- Ectopic pregnancy
- Ovarian torsion
- Renal calculi
- Pyelonephritis (ascending lower UTI)
11
Q
Acute abdo DDx upper quadrants
A
RUQ:
- Biliary cholic, cholecystitis, ascending cholangitis
- Perforated duodenal ulcer
- Acute hepatitis (e.g. viral)
LUQ:
- Splenic rupture
- IBS (complication - splenic flexure syndrome)
12
Q
Acute abdo DDx epigastric & diffuse
A
Epigastric:
- Peptic ulcer disease (PUD) - worse after eating (increased HCL), nocturnal (RFs: NSAIDs, H. pylori inf)
- Pancreatitis - radiates (to back), N&V ± Cullen’s/Turner’s
- Aortic dissection - tearing, radiates (to back)
- MI - crushing, radiates (carotids & arms)
Diffuse:
- Peritonitis - distension & guarding, caused by haemorrhage/perforation
- Bowel obstruction, bowel strangulation
- Acute hepatitis
13
Q
Why do patients with chronic liver disease get oedematous?
A
Backflow of blood into the hepatic portal vein –> increased hydrostatic pressure –> more fluid leaking out into interstitium
Less albumin produced by liver –> less oncotic pressure
Overall net fluid movement into interstitium
14
Q
Decompensated chronic liver disease - what is it? what is the physical presentation?
A
CLD can be stable but insults such as alcohol/infection –> decompensation (liver failing to carry out normal function)
Presentation: ASCITES (+ worsening jaundice/coagulopathy/asterixis/hypoglycaemia)
15
Q
At the end of abdo exam what do you offer to do?
A
GOR(D)
- external Genitalia
- hernial Orificies
- digital Rectal
16
Q
Structures in each region of abdomen?
A
17
Q
Exposure in abdo exam?
A
Ideally nipples to knees but in this case, I will do nipples to the groin due to possible patient discomfort
18
Q
diarrhoea with profound hyperkalaemia + persists with fasting
what is the diagnosis?
A
VIPoma - neuroendocrine tumour (starts in pancreas)
19
Q
IBS presentation
A
- Chr abdo pain + bloating + altered bowel habit but improves with defecation
- Dx of exclusion
20
Q
WHat is inclusion bodies (owl eyes) associated with?
A
CMV colitis
21
Q
IBD - UC Vs Crohn’s (epidemiology, pattern, histology)
A
Smoking: protects UC, worsens Crohn’s
Site: rectum (colon) in UC, terminal ileum (entire GI tract) in Crohn’s
Pattern: continuous (worse distally) in UC, skip lesions (patchy) in Crohn’s
Histology: mucosa - crypt abscesses in UC, trans-mural - non-cas granuloma in Crohn’s
22
Q
Erythema nodosum is associated with which conditions?
A
IBD (also pyoderma gangrenosum),
Sarcoidosis
TB
Meds (OCP, sulphonamides, aspirin/NSAIDs)
23
Q
What is the severity index score for acute colitis (e.g. IBD)?
A
Truelove & Witts’ severity index
24
Q
Extra-intestinal signs of IBD
A
A PIE SAC
- APHTHOUS - MOUTH ULCERS (CROHNS)
- PYODERMA GANGRENOSUM
- I (EYE)- IRITIS, UVEITIS, EPISCLERITIS (CROHNS)
- ERYTHEMA NODOSUM
- SCLEROSING CHOLANGITIS (PRIAMRY- UC)
- ARTHRITIS
- CLUBBING FINGERS (CD> UC)
25
Peptic/duodenal ulcer - Ix? Mx? Key DDx?
Duodenal \> gastric ulcers
Key Investigation:
* Stool antigen test (urea breath test not done due to COVID) to test for H. pylori
Triple therapy- 1 week
* PPI
* Clarithromycin
* Amoxicillin OR Metronidazole
DDx: **Zollinger-Ellison syndrome** (very rare cause): Gastrin secreting neuroendocrine tumour in pancreas - gastrinoma
* Would have FHx: MEN + multiple ulcers post-treatment
26
Sign most commonly suggestive of bowel obstruction
Tinkling bowel sounds
27
Primary Sclerosis Cholangitis (PSC) vs Primary Biliary Cholangitis (PBC)
* Associations? Ix? Tx?
* **PSC** - intrahepatic & extrahepatic (horrible & progressive disease, obstructive jaundice)
* **Associations:** _UC_ (10% but 80% PSC have UC), _Cholangiocarcinoma_
* **Ix:** MRCP, pANCA
* 'Beads on string' on ERCP
* **Tx:** supportive, liver transplant
* **PBC** - intrahepatic only (benign condition - middle-aged female, intractable itching)
* **Associations:** _AI diseases_ (RA, Sjogren's, hypothyroidism)
* **Sicca syndrome** (70%) - dry eyes & mouth (like Sjogren's syndrome)
* Fat malabsorption w/ steatorrhoea (incl vitamins ADEK):
* Low vit D can cause _osteomalacia & proximal myopathy_ *e.g. difficulty climbing stairs & pain in lower back*
* Low vit K can cause coagulopathy
* **Ix:** _anti-mitochondrial Ab (AMA)_, high cholesterol
* **Tx:** ursodeoxycholic acid (prognostic benefit)
28
AI hepatitis - RFs? Ix? Mx? Complications?
RFs:
* Immune dysregulation (thyroiditis, T1DM, UC, Coeliac, RA)
* Genetic predisposition:
* For T1 AIH - HLA-DR3/4
* For T2 AIH - HLA-DQB1/DRB1
Ix:
* Anti-smooth muscle Ab (SMA), ANA
* T1: Anti-soluble liver antigen or liver/pancreas (SLA/LP), pANCA
* T2: anti-LKM1
Mx: high-dose prednisolone + long-term azathioprine
Complications:
* Cirrhosis in 40%, relapse high if stop IS
29
How do you tell between spleen & kidney on examination?
**Spleen (vs kidney):**
* Moves down with inspiration
* You can’t get above it
* Has a notch
* Dull to percussion & not ballotable
30
Causes of hepatomegaly, splenomegaly & enlarged kidney(s)?
**Hepatomegaly causes:**
* _Hepatitis (infective and non-infective)_
* _Hepatocellular carcinoma/hepatic mets_
* Wilson’s disease, Haemochromatosis
* Primary biliary cirrhosis
* Leukaemia, Myeloma, haemolytic anaemia
* Glandular fever
* Tricuspid regurgitation
**Splenomegaly causes:**
* _Portal HTN secondary to liver cirrhosis_
* Splenic mets
* Haemolytic anaemia, Congestive HF, Glandular fever
**Large kidney causes:**
* Bilaterally enlarged: _polycystic kidney disease, amyloidosis_
* Unilaterally enlarged: _renal tumour_
31
What are signs of chronic stable liver disease? Some specific signs for the cause of the CLD?
Spider naevi (≥5), palmar erythema, gynecomastia, Dupuytren's contracture (alcoholic liver disease), clubbing
NOTE - Spider naevi:
* SVC distribution (above nipples)
* Press on them and flush from inside out
Specific signs:
* Needle marks/tattoos - hep C
* Parotid swelling - alcohol-related liver disease
* Bronzed complexion/insulin injection signs - haemochromatosis
* Obesity/DM - non-alcoholic fatty liver disease
* Xanthelasma - cholestatic disorder
32
Different kinds of erythema?
Nodosum - pain over shins
Multiforme - target lesions (life-threatening = Steven's Johnson Syndrome)
Ab igne - hot water bottle (chr heat exposure)
Marginatum - acute rheumatic fever
Chronicum migrans - lyme disease
33
Findings on abdo exam general inspection?
34
IBD complications?
Crohn's: strictures, obstruction, fistulae
UC: toxic megacolon, colonic carcinoma, PSC
35
Abdo examination differentiating observations from inspection
* Distended abdo - CLD, hepato-splenomegaly, PCKD
* AV-fistula - renal failure on dialysis, renal transplant
* Stoma - IBD, surgical
36
Chr diarrhoea, bloating, PMH scleroderma - Dx?
Small bowel bacterial overgrowth
37
Suspected bile acid malabsorption - test?
SeHCAT test
38
Barley, wheat & rye - should be avoided when?
coeliac disease (rice, maize, soya ok)
39
Middle-aged women with non-specific bloating - Dx? Mx?
Possible ovarian cancer --\> 2WW + CA125
40
When to admit UC case? Mx?
Severe UC (if does not meet --\> managed in outpatients):
* 6+ bowel move/day
* Frank blood
* Temp ≥37.8, HR ≥90, anaemia, ESR ≥30
41
IBD Hx, asymmetrical joint swelling, HLA-B27 - Dx?
Enteropathic arthritis
42
Alcoholic liver disease - presentation? Bloods? Decompensated Mx?
Presentation: peripheral neuropathy, cerebellar, Wernicke's, gout, parotitis, Dupuytren's contracture
Bloods: AST \> ALT (2:1)
Decompensated Mx:
* _Discrimination function_ calculated (PT/INR + bilirubin):
* \<32/Inf/upper GI bleed --\> no steroids
* Otherwise --\> steroids
43
Pan-acinar emphysema, young-onset liver disease, PiZZ phenotype - Dx?
Alpha-1-antitrypsin def
44
Raised transferrin saturation, tanned, DM - Dx?
Hereditary haemochromatosis
45
Hep B Serology reading?
* Active hepatitis requires HbsAg
* Anti-HBs – vaccinated or previous infection
* Anti-HBc – must have cleared infection/had in past
* Acute inf Anti-HBc IgM
* Chronic inf Anti-HBc IgG
* HBeAg +ve = high infectivity
46
Hep C Serology reading?
* HCV-RNA = acute
* Anti-HCV = previous infection
* Both = chronic infection
47
Hep B + HIV co-inf Tx?
Tenofovir
48
Needle-stick injury from hep B patient + no prev vaccine - Tx?
Accelerated hep B vaccination
49
Raised BMI, raised ALT/AST - Dx?
Non-alcoholic fatty liver disease
50
Abdo exam - don't forget what?
Hands/arms:
* Leukonychia (hypoalbuminaemia in liver cirrhosis), Koilonychia (IDA), clubbing (IBD, cirrhosis, coeliac), palmar erythema (liver disease/pregnant)
* Liver flap
* Feel for HR/RR
Neck/chest: **lymphadenopathy** (incl Virchow's node), inspect back/chest for spider naevi (\>5 sign), gynecomastia, loss of axillary hair etc.
Abdo: distension (fluid, fat, foetus, flatus, faeces)
* Hepatomegaly - mets/HCC, cirrhosis, hepatitis, RVF, haem (leukaemia/lymphoma)
* Splenomegaly - portal HTN, haem (lymphoma/leukaemia/myelofibrosis), malaria
* Check for Murphy's/Rovsing's if relevant
* Spleen vs kidney - can't get above spleen, spleen notched, spleen not ballotable, spleen moves down on inspiration
* AAA palpation (expansile = AAA)
* Bowel sounds (tinkling = obstruction, absent = paralytic ileus/peritonitis)
Other: ankle oedema = hypoalbuminaemia (liver disease)
51
Upper GI bleed - scoring for need for intervention? Mx?
**Blatchford score**
Variceal bleed
* Massive haemorrhage --\> balloon tamponade
* A-E assessment --\> IV fluids, blood transfusion
* F1 Essentials:
* 2x large bore cannula
* VBG
* G&S/X-match
* Bleep the bleed reg
* Drugs with prognostic benefit:
* IV Terlipressin (ADH analogue --\> vasoconstriction)/Somatostatin (used for same reason)
* Prophylactic abx - Ceftriaxone/Norfloxacin (abx)
* Intervention (discuss with on-call bleed registrar) --\> endoscopic band ligation
52
Viral hepatitis
**Hep A:** faecal-oral --\> acute
**Hep B:** blood-borne --\> acute/chronic --\> serology
* Contains: Core Ag (cAg), E Ag (eAg), DS-DNA, surface antigens (sAg)
* eAg present if active & infective
* Infection response --\> generate sAb (surface) + cAb (core)
* Vaccination gives sAg (no reproductive capacity) --\> develop sAb (but not cAb)
* Serology:
* HB**sAg**/HB**eAg** - actively infecte
* IgM = acute; IgG = chronic
* _eAg = highly infective_
* HB**sAb** - protective (cleared/vaccinated)
* HB**cAb** - only if previously cleared
* Can be assoc with Polyarteritis Nodosa (vasculitic rash) & mononeuritis multiplex
* Tx: IFN-alpha & lamivudine
**Hep C:** blood-borne --\> _chronic_ --\> HCV RNA
* More likely to become chronic than Hep B
* Assoc w/ _mixed cryoglobulinaemia_ (purpuric skin lesions, Raynaud's phenomenon)
* RF +ve, low C4, normal C3
* Can have +ve anti-LKM1 ab (also in AI hep)
* Tx: PEG-IFN alpha & ribavirin
Hep D: blood-borne --\> co/superinfection w/ Hep B virus
Hep E: faecal-oral --\> acute, pregnancy
53
Very high BMI (± T2DM) + high ALT - Dx?
Non-alcoholic fatty liver disease
54
Persistent dysphagia that comes and goes for fluid/food - Dx?
Achalasia
55
Peptic ulcer disease - RFs? Types? What artery is most likely to bleed in duodenal ulcer?
Presentation? Ix? Mx? Scoring to evaluate risk of re-bleed/death?
RFs:
* H. pylori exposure
* Aspirin/NSAID use
Types:
* Gastric - pain worsened by meal (pain 30m-1hr after meal), loose weight, vomiting, assoc w/ _NSAIDs_
* Duodenal - MORE COMMON, pain relieved by meal (pain 2-3hrs after meal), assoc w/ _H. pylori_, worse by stress/at night --\> radiates to back, put weight on, malaena
* Gastroduodenal artery - runs posterior to 1st/2nd parts of duodenum --\> likely cause of bleeding in PUD
Presentation:
* Chr/recurrent upper abdo pain - related to eating & nocturnal
* Can be severe/radiate to back in Duodenal ulcers if ulcers penetrates pancreas
* Pointing sign on exam - show where pain is with 1-finger
* NOTE: 'Coffee grounds' vomiting = upper GI bleed (mostly due to PUD \> gastric erosions)
Ix:
* **OGD endoscopy** = gold-standard
* Immediately if dyspepsia + upper GI bleed
* Within 2wks if ≥55yrs + weight loss + dyspepsia/reflux/upper abdo pain --\> exclude malignancy
* Repeat within 6-8wks to ensure ulcer healing/rule out malignancy
* **H. pylori stool antigen**/breath test (2wk wash out period after PPI or 4wks after abx, retest 6-8wks after starting Tx)
* Bloods - FBC
Mx: consider **STOPPING NSAIDs**
* Active bleed:
* Urgent evaluation (A-E + **Blatchford score**) + blood transfusion
* **OGD endoscopy** (Dx & Tx) --\> high-dose IV PPI afterwards (continue oral PPI for 6wks)
* **Rockall score** (for risk of rebleed/death) --\> if re-bleed --\> repeat endoscopy & Tx endoscopically/emergency surgery
* If H. pylori +ve:
* **H. pylori eradication - triple therapy for 7 days** (**PPI** + 2 abx = **Amox** + **clari**/metro) --\> retest 6-8wks after starting Tx (leave washout 2wks after PPI, 4wks after abx)
* If pen allergic --\> PPI + Clari + Metro
* If long-term NSAID/aspirin use:
* Consider stopping NSAIDs/aspirin
* Ulcer healing Tx - full-dose PPI/H2 antagonist for 8wks --\> H. pylori eradication afterwards
* If H. pylori -ve: treat underlying cause + PPI (4-8wks, 2nd line = H2 antagonist)
* If recurrent/refractory ulcers --\> long-term PPI/H2 antagonist
56
* Joint pain in both knees, XR shows chondrocalcinosis
* Wakes at night frequently to urinate, PMHx T2DM, low albumen on blood
Dx? Classification? Presentation? Ix? Mx?
Dx: haemochromatosis
* Risk of HCC (hepatocellular carcinoma)
Classification:
* Hereditary - AR, gene on chr6 (carried by 1:10 Europeans)
* Secondary e.g. from frequent blood transfusions (SCD)
Presentation - from Fe-deposition in various tissues:
* Arthritis (esp hands), bronze DM (tan), cirrhosis
* Hypogonadism (accumulates in testis)
* Dilated cardiomyopathy (accumulates in heart)
* XR - chondrocalcinosis is assoc w/ pseudogout & haemochromatosis
Ix:
* Blood iron profile:
* **TF saturation high** (\>55% men, \>50% women)
* Ferritin normal/slightly high (\>500)
* Low TIBC (as all transferrin saturated)
Mx:
* **Venesection** (until transferrin saturation normal)
* **Desferrioxamine** (iron chelator to prevent recurring)
* Monitoring ; TF saturation \<50% & serum ferritin \<50ug/l
57
abdominal discomfort and bloating, worse after eating foods containing milk
stools have a foul smell and tend to float
recently returned from a backpacking trip in Thailand
Dx? Ix?
Giardiasis
Ix: stool microscopy for OCP (trophozoite, cysts) - 65% sensitive
* Stool antigen detection assay has greater sensitivity and faster turn-around time
58
What 2 things can make ALT go \>1000? What are some more weird causes of slightly high ALT?
**Ischaemic liver**
**Massive paracetamol overdose**
Very rarely: fulminant hepatitis (B/C)
Weird causes of slightly raised ALT: Addison's coeliac, anorexia
59
Young female with unilateral leg tremor
* Psychiatric issues
* Exam: tremor, bradykinesia, dark circles round iris
Dx? Ix? Mx?
Dx: Wilson's disease (AR)
* Neuropsych issues + liver involvement (no increased risk of HCC unlike haemochromatosis)
* Basal ganglia degeneration - movement disorders, dysarthria
Ix:
* Conservative:
* Urinalysis - elevated urinary copper
* _Kayser-Fleischer rings_ on slit-lamp exam
* Bloods: hepatic bloods, **reduced serum ceruloplasmin**
* Genetic testing (trinucleotide repeat) - condition appears earlier & earlier each generation
Mx: **chelation w/ penicillamine**
60
Sewage worker, RUQ pain, fever
* Bloods --\> renal failure + hepatitis
Dx?
**Weil's disease** aka Leptospirosis
* Rodent vectors (sewage worker)
* Causes _renal & liver failure_
61
Mouth ulcer causes?
Aphthous ulcers: stress, Behcet's disease (vasculitis), Crohn's, Fe/B12/folate def
Oral leukoplakia = white coating/lacing
* Hairy leukoplakia in EBV (lateral tongue)
62
Case:
* 57yrs, burning pain after eating & lying flat, improved with cold drinks, high BMI, smokes, drinks alcohol, occasional bitter taste in back of the mouth
* Difficulty swallowing in recent months
Dx? Presentation? Ix? Mx? Complication?
Dx: GORD
* Decreased lower oesophageal sphincter (LOS) pressure:
* Drugs - nitrates, CCBs (smooth muscle relaxation)
* Alcohol, smoking
* Hiatus hernia
Presentation: RFs (above), heartburn (worse lying down/at night), reflux incl bitter taste in mouth (after meals)
Ix:
* 8wk PPI trial
* If dyspepsia consider _OGD_ for: **anaemia, weight loss, dysphagia, \>55yrs**
* Oesophageal pH study (\<4 for \>4% of time = GORD)
Mx:
* Conservative: weight loss, smoking cessation, head of bed elevation/avoid eating late at night, reduce alcohol
* Medical:
* Standard-dose PPI (20mg omeprazole) - continued long-term (if Sx continue after stopping/erosive oesophagitis/Barrett's oesophagus)
* H2 antagonist (e.g. cimetidine)
* Surgery (only if PPIs work but don't want long-term medical Tx) e.g. laparoscopic fundoplication
Complication: Barrett's oesophagus --\> oesophageal adenocarcinoma
63
Zollinger-Ellison syndrome - def? presentation?
Other causes of poorly healing peptic ulcers?
Gastrinoma (pancreatic islet-cell tumour)
* Multiple peptic ulcers & relapses
* _Diarrhoea_
* NOTE: can be good for OSCE - PUD presentation + diarrhoea
ZE syndrome - is one cause of poorly healing gastric ulcers, others:
* Crohn's, gastric Ca
* Bisphosphonates
* TB, CMV
64
Causes of peptic ulcers?
Stress ulcers:
* Cushing's ulcers - severe head trauma, stress, raised ICP
* Increased vagal tone --\> increased acid prod
* Curling's ulcers - severe burns
Drugs: CSs, NSAIDs, bisphosphonates, SSRIs
* Bisphosphonates (30mins before food & stand for 30mins after taking)
65
Anal fissure - def? RFs? Presentation? Ix? Mx?
Def: tears of the squamous lining of the distal anal canal
* \<6 weeks = acute, ≥6wks = chronic
* 90% @posterior midline
RFs: constipation, IBD, STIs (HIV, syphilis, herpes)
Presentation: painful, bright red, rectal bleeding
Ix: PR exam
Mx:
* Acute \<1wk:
* Soften stool - high-fibre diet + high fluid intake, fybogel (2nd - lactulose)
* Lubricants (for passing stool), topical anaesthetic, analgesia
* Chronic: maintain above + topical GTN
* After 8wks (if above not effective) --\> GI referral for sphincterotomy (or botulinum toxin)
66
Portal HTN - Def? Causes?
**Portal hypertension** - increase in the pressure within portal vein, which carries blood from the digestive organs to the liver
* Hepatic venous pressure gradient (HPVG) = gold standard for assessing severity and a pressure \>= 5mmg
Causes:
* Pre-hepatic – Portal/splenic vein thrombosis, congenital atresia of portal vein
* Hepatic – Cirrhosis, Schistosomiasis, hepatic mets
* Post-hepatic – Budd-Chiari Syndrome, Veno-occlusive disease, constrictive pericarditis
67
Dysphagia DDx? Ix?
Dysphagia - difficulty swallowing
* vs Odynophagia - painful swallowing
* vs Globus sensation - lump in throat, no pain
Oropharyngeal - difficulty initiating swallowing (± cough, choking, aspirating, _regurgitation_) - pressure in throat
* Oral:
* mastication (CN 5,7,11) e.g. CVA
* Low saliva e.g. Sjogren's syndrome
* Pharyngeal:
* Neuromuscular - CVA, Myasthenia Gravis, Parkinson's
* Upper oesophageal sphincter - decreased relaxation
Oesophageal - difficulty after swallowing - pressure in chest
* Solids & liquids - motor
* Intermittent: oesophageal dysmotility
* Progressive (solids --\> both): achalasia, systemic sclerosis
* Solids only - obstructive
* Non-progressive: lower oesophageal rings/webs, oesophagitis
* Progressive: stricture, cancer
Ix:
* Barium swallow if possible proximal oesophageal lesion
* Upper endoscopy ± biopsy
* If affects solids & liquids --\> manometry
68
Haemorrhoids - presentation, grading, Ix, Mx?
Presentation: rectal bleeding & perianal pain
Grading:
* 1 - prominent BVs (no prolapse)
* 2 - prolapse on bearing down + _spontaneous reduction_
* 3 - _manual reduction_
* 4 - _can't be manually reduced_
Ix:
* Bedside: Anoscopic exam, stool (occult haem)
* Bloods: FBC
* Imaging: Colonoscopy/flex sigmoidoscopy
Mx:
* Conservative - fibre, fluids
* Medical = **G1** - topical CS
* Surgical:
* **G2/3**: band ligation
* **G4**: surgical haemorrhoidectomy
