Gastrointestinal Flashcards

Question

What are some complications of Barrett's Oesophagus?

Answer 1

- Associated with a 50-100 fold increased risk of oesophageal adenocarcinoma. - Endoscopic complications: oesophageal rupture, or stricture development

Answer 2

Gastro-oesophageal reflux disease is where there is reflux of stomach content into oesophagus.

Answer 3

- Lower oesophageal hypotension - Oesophageal dysmotility - Gastric acid hypersecretion

Answer 4

- High BMI - Genetics - Pregnancy - Smoking - NSAIDs, Caffeine, Alcohol - Hiatus hernia - Scleroderma - Zollinger-Ellison syndrome - Medications that lower LOS pressure - Antihistamines - CCBs - Antidepressants - Benzodiazepines - Glucocorticoids

Answer 5

- Heartburn (worse when lying down after eating) - Regurgitation - Dyspepsia - Chest pain - Bloating - Dysphagia - Odynophagia - Nausea - Water brash - Cough - Hoarse voice

Answer 6

- Can be diagnosed based on clinical presentation and based on whether PPI trial would resolve the symptoms. - if patient displays red flags then do the following: - 24-hour pH monitoring - Endoscopy

Answer 7

Used for the classification of GORD; - Grade A: ≥1 mucosal break, each ≤ 5mm - Grade B: ≥1 mucosal break > 5mm. Not continuous between top of mucosal folds. - Grade C: ≥1 mucosal break, continuous between top of mucosal folds, not circumferential - Grade D: mucosal breaks involving more than three quarters of luminal circumference.

Answer 8

From worse to best: - Erosive oesophagitis - Non-erosive oesophagitis - Acid hypertensive oesophagitis - Functional heartburn

Answer 9

- Functional heartburn - Achalasia (failed relaxation of LOS) - Eosinophilic oesophagitis - Peptic ulcer disease - Non-ulcer dyspepsia - Malignancy - Pericarditis - Ischaemic heart disease

Answer 10

- Typical reflux syndrome - Reflux chest-pain syndrome - Reflux oesophagitis - Reflux stricture - Barrett's oesophagus - Oesophageal adenocarcinoma

Answer 11

- Reflux cough syndrome - Reflux laryngitis syndrome - Reflux asthma syndrome - Reflux dental erosion syndrome

Answer 12

- PPI: prevent acid production within the stomach through inhibition of H+/K+ ATPases in parietal cells. - H2 receptor antagonist e.g. ranitidine: reduces stomach acid - Antacids e.g. Gaviscon: neutralise stomach acid - Nissen fundoplication: wrapping the fundus of the stomach around the lower oesophagus to tighten the sphincter

Answer 13

- Weight loss - Smoking cessation - Dietary modification: Smaller meals. Reduce tea, coffee, alcohol, spicy foods, fizzy drinks, chocolate - Patients should avoid eating within two hours of sleep - Patients should elevate the head of the bed

Answer 14

- Leiomyomas are most common - Papillomas - Fibrovascular polyps - Haemangiomas - Lipomas

Answer 15

- Usually asymptomatic, found incidentally on barium swallow - Dysphagia - Retrosternal pain - Food regurgitation - Recurrent chest infections

Answer 16

- Endoscopy and biopsy: to rule out malignancy - Barium swallow

Answer 17

- Endoscopic removal - Surgical removal of larger tumours

Answer 18

Oesophageal cancer is when malignant or cancerous cells arise in the oesophagus. It is divided into adenocarcinoma and squamous cell carcinoma.

Answer 19

- Small cell carcinoma - Adenocarcinoma

Answer 20

- Age >60 - Barrett's Oesophagus - Obesity - Male - Smoking - Rarer -> Coeliac disease and scleroderma

Answer 21

- Age >60 - Smoking - Alcohol - Achalasia - Plummer-Vinson syndrome - Palmoplantar keratoderma - Hot beverages - Nitrosamines (dietary) - Caustic strictures

Answer 22

- Lymphadenopathy - Vocal cord paralysis - Melaena on digital rectal examination: due to bleeding oesophageal cancer

Answer 23

- Progressive dysphagia (solids then liquids): most common feature - Regurgitation - Pyrosis (heartburn) - Pain in chest or back - Odynophagia - Weight loss and anorexia - Hoarseness: with recurrent laryngeal nerve involvement - Vomiting

Answer 24

Upper GI endoscopy (OGD) and biopsy: first-line investigation and allows for visualisation of masses and biopsy

Answer 25

- Barium swallow - CT of the chest - Endoscopic ultrasound - Staging laparoscopy - PET CT - HER2 testing

Answer 26

- Endoscopic mucosal resection - Ivor Lewis oesophagectomy - McKeown oesophagectomy - Transhiatal oesophagectomy - Chemotherapy

Answer 27

Radical chemoradiotherapy: localised SCC can be treated with curative chemoradiotherapy, although surgical resection may be offered

Answer 28

- Palliation: stenting for dysphagia - Chemotherapy or chemoradiotherapy: platinum-based agents - Trastuzumab (Herceptin): for HER2 positive metastatic oesophageal cancer, in combination with chemotherapy

Answer 29

- Tracheo-oesophageal or broncho-oesophageal fistula - Aspiration pneumonia - Metastasis

Answer 30

Mallory-Weiss tear (MWT) refers to longitudinal lacerations limited to the mucosa and submucosa, at the border of the gastro-oesophageal junction.

Answer 31

- Age → 30-50 years - Any condition that predisposes to retching or vomiting: such as gastroenteritis, bulimia, hyperemesis gravidarum - Alcoholism - Chronic cough - Hiatus hernia - Gastro-oesophageal reflux disease - Trauma to chest or abdomen - Transoesophageal echocardiography - Heavy lifting or straining

Answer 32

The classic history of a Mallory Weiss tear is a patient with a background of alcohol excess presenting with episodes of violent retching or vomiting, followed by vomiting a small or moderate amount of fresh blood.

Answer 33

- Melaena on rectal examination: an uncommon feature - Features of shock: an uncommon feature

Answer 34

- Preceding retching and vomiting - Vomiting blood: usually a small to moderate volume of bright red blood, which is self-limiting - Melaena: rare - Epigastric pain

Answer 35

- Upper GI endoscopy: gold-standard - FBC - U&Es - Coagulation profile - LFTs - Erect CXR

Answer 36

Risk stratify patients with an upper GI bleed. Those with a score of 0 can be discharged and return for an outpatient endoscopy. If the score is more than 0, patients require admission for inpatient endoscopy.

Answer 37

- Haemoglobin - Urea - Initial systolic blood pressure - Gender - Heart rate (tachycardia) - Melaena - History of syncope - Hepatic disease history - Cardiac failure present

Answer 38

Calculated after endoscopy, with the score including age, blood pressure, comorbidities, and endoscopic findings. It is used to identify patients at risk of adverse outcomes following endoscopic treatment of an upper GI bleed.

Answer 39

- Boerhaave’s syndrome - Gastroenteritis - Peptic ulcer - Varices - Cancer

Answer 40

- Upper GI endoscopy - Clipping - Thermal coagulation with adrenaline - Sclerotherapy with adrenaline - Variceal band ligation - High dose IV proton pump inhibitor - Manage contributing factors

Answer 41

Surgical repair or interventional radiology: only performed if endoscopic haemostasis has failed or transmural oesophageal perforation is present; this is very rarely needed for MWT

Answer 42

- Re-bleeding - Hypovolaemic shock - Oesophageal perforation

Answer 43

Oesophageal varices are abnormal, dilated veins that occur at the lower end of the oesophagus; they account for 10-20% of upper GI bleeds. They develop as a consequence of portal hypertension.

Answer 44

- Portal hypertension - Cirrhosis - Alcoholism - Schistosomiasis infection Risk factors for bleeding: - Large varices - Decompensated liver cirrhosis

Answer 45

- Features of chronic liver disease - Features of decompensated liver disease - Splenomegaly due to portal hypertension - Hypotension - Tachycardia - Pallor

Answer 46

Patients can present as asymptomatic if varices aren’t bleeding. - Haematemesis and melaena (dark sticky faeces) - Abdominal pain - Symptoms of blood loss (shock) - Light-headedness - Dyspnoea - Chest pain - Syncope

Answer 47

- Upper GI endoscopy: gold standard - FBC - LFTs - Coagulation profile - Venous blood gas - Crossmatch/group and save - Erect CXR

Answer 48

- Gastric varices - Mallory-Weiss tear - Peptic ulcer disease - Hiatal hernia

Answer 49

It is recommended patients undergo endoscopic surveillance and are commenced on a beta-blocker

Answer 50

- ABDCE - IV fluids - Blood products - Terlipressin - Prophylatic antibiotics - Balloon tamponade - Oesophageal varices: endoscopic variceal band ligation is first line and is superior to sclerotherapy

Answer 51

- Re-bleed - Encephalopathy - Infection

Answer 52

Achalasia is an oesophageal motor disorder characterised by a loss of oesophageal peristalsis and failure of the lower oesophageal sphincter to relax in response to swallowing.

Answer 53

- Dysphagia. - Heart burn. - Weight loss (eating less). - Coughing while lying horizontally.

Answer 54

- Barium swallow X-ray - Oesophageal endoscopy with or without ultrasound - Endoscopic biopsy

Answer 55

- Calcium channel blockers for mild to moderate disease. - Nitrates effective before dilation occurs. - PPIs (after surgery to prevent reflux damage) - Surgery - Laparoscopic Heller myotomy. - Endoscopic myotomy.

Answer 56

Gastritis refers to inflammation of the lining of the stomach associated with mucosal injury.

Answer 57

Gastropathy refers to epithelial cell damage and regeneration WITHOUT inflammation - commonest cause is mucosal damage associated with Aspirin/NSAIDs

Answer 58

- Helicobacter pylori infection - Autoimmune gastritis - Duodenogastric reflux - Crohn's disease - Mucosal ischemia - Increased acid - Aspirin and NSAIDs - Alcohol, smoking, caffeine - Viruses e.g. cytomegalovirus and herpes simplex

Answer 59

- Alcohol - NSAIDs - H.pylori - CMV and herpes - Infectious: crowding and poor sanitation - Autoimmune: HLA-DR3 and B8 - Reflux/hiatus hernia - Granulomas e.g. in Crohn's - Zollinger-Ellison syndrome - Menetrier's disease

Answer 60

- Nausea or recurrent upset stomach - Vomiting - Abdominal bloating - Epigastric pain - Indigestion - Haematemesis/ malaena

Answer 61

- Endoscopy - will be able to see it - Biopsy - Test for H. pylori - Clo test - H.pylori urea breath test - H.pylori stool antigen test - Autoimmune gastritis - Anti-IF antibody

Answer 62

- Peptic ulcer disease (PUD) - GORD - Non-ulcer dyspepsia - Gastric lymphoma - Gastric carcinoma

Answer 63

- Remove causative agents such as alcohol/NSAIDs - Reduce stress - H2 antagonists e.g. ranitidine or cimetidine - to reduce acid release - PPIs e.g. lansoprazole or omeprazole - Antacids

Answer 64

Same as before but also: Triple therapy - PPI for acid suppression e.g. lansoprazole or omeprazole - Plus two of: metranidazole, clarithromycin, amoxicillin, tetracycline, bismuth - Quinolones e.g. ciprofloxacin, furozolidone and rifabutin are used when standard regimens have failed as ‘rescue therapy’

Answer 65

- Gastric cancers - Achlorydria: lack of HCl in stomach - Vitamin B12 deficiency

Answer 66

A break in the mucosal lining of the stomach or duodenum more than 5 mm in diameter. Duodenal ulcers are more common than gastric ulcers.

Answer 67

- Gender → Male > Female - More common with increasing age - More common in developing countries due to H. pylori infection

Answer 68

- Evidence of bleeding - Hypotension and tachycardia (shock) - Melaena on rectal examination - Epigastric tenderness - Pallor, if anaemic

Answer 69

- ‘Burning’ epigastric pain - Pain relieved by eating and worse when hungry: duodenal ulcer - Pain worsened by eating: gastric ulcer - Nausea and vomiting - Haematemesis or melaena - Dyspepsia (indigestion) - Reduced appetite and weight loss - Anaemia: due to bleeding - Fatigue

Answer 70

- ‘Burning’ epigastric pain - Pain relieved by eating and worse when hungry: duodenal ulcer - Pain worsened by eating: gastric ulcer - Nausea and vomiting - Haematemesis or melaena - Dyspepsia (indigestion) - Reduced appetite and weight loss - Anaemia: due to bleeding - Fatigue

Answer 71

H. pylori breath test and/or stool antigen with an upper GI endoscopy and biopsy is gold standard and used for diagnosis.

Answer 72

Same as non-bleeding but also: - FBC - U&Es - LFTs - Venous blood gas - Erect CXR

Answer 73

- Gastric malignancy - GORD - Non-ulcer dyspepsia - Gastritis

Answer 74

First line: - Conservative: treat risk factors - H. pylori negative: proton pump inhibitor (PPI) - omeprazole - H. pylori positive: triple eradication therapy Second line: - Switch to alternative strategy

Answer 75

First line: - IV crystalloid - Blood transfusion - Upper GI endoscopy - Mechanical therapy - Thermal coagulation with adrenaline - Sclerotherapy with adrenaline - High dose IC PPI Second line: - Surgery or embolisation by intravenous radiology

Answer 76

- Perforation - Gastric outlet obstruction / pyloric stenosis

Answer 77

Gastroenteritis is inflammation all the way from the stomach to the intestines and presents with nausea, vomiting and diarrhoea.

Answer 78

- Rotavirus - Norovirus - Adenovirus - Astrovirus

Answer 79

- Campylobacter jejuni (most common) - E. coli (children) - Salmonella (children) - Shigella spp. (children) - Bacillus cereus - Yersinia enterocolitica - Vibrio cholerae

Answer 80

- Giardia lamblia - most common - Entamoeba histolytica - Cryptosporidium

Answer 81

- Foreign travel - PPI or H2 antagonist use - Crowded area - Poor hygiene - Risk factors for pseudomembranous colitis?

Answer 82

- Bloody diarrhoea - associated with bacterial infection (salmonella, shigella, e.coli) - Vomiting - Abdominal cramping - Some causes (especially viral) present with: - Fever, fatigue, headache, muscle pain

Answer 83

- FBC - ESR/CRP - U&Es - Stoll MCS - Abdominal X-ray - Sigmoidoscopy

Answer 84

- Appendicitis - Volvulus - IBD - UTI - Diabetes mellitus - Pancreatic insufficiency - Short bowel syndrome - Coeliac disease - Laxative abuse

Answer 85

- Isolate patient - Good hygiene - Treat causes - IV fluids if severely dehydrated - Oral rehydration and avoid high-sugar drinks in children (increases diarrhoea) - Antibiotics, where appropriate - Anti-motility agents e.g Loperamide - Anti-emetics - treat vomiting e.g. Metoclopramide

Answer 86

- Metronidazole - Oral vancomycin - Rifampicin/Rifaximin - Stop C antibiotic - Stool transplant - for recurrent disease - Urgent colectomy if toxic megacolon

Answer 87

Haematemesis is simply defined as “vomiting blood”. It is caused by bleeding from part of the upper portion of the gastrointestinal tract. It may be bright red or look like coffee grounds.

Answer 88

- Rapid ABCDE assessment - High flow O2 - Insert 2 large bore IV cannulae and take blood for FBC, LFT, U&E, clotting and crossmatch. - Start fluid resuscitation if needed - Insert urinary catheter to monitor and guide fluid replacement. Consider CVP line for monitoring fluid replacement - Transfuse if significant Hb drop - Correct clotting abnormalities - Vit K, fresh frozen plasma, platelets

Answer 89

- FBC - LFTs - U&Es - Group and save - Oesophagogastroduodenoscopy (OGD) - Erect CXR - Ct abdomen

Answer 90

- Gastric adenocarcinoma - Lymphoma - Carcinoid tumour - Leiomyosarcoma

Answer 91

- H. pylori infection: commonest cause, - Smoking - Alcohol - Diet: smoked and preserved foods, nitrosamines; salty and spicy foods - Obesity

Answer 92

- Male gender - Increasing age - Family history - Pernicious anaemia - Blood type A - Gastric adenomatous polyps - Lynch syndrome II - Autoimmune gastritis - Achlorhydria

Answer 93

- Iron deficiency anaemia - Palpable mass - Melena - Acanthosis nigricans - Troisier's sign - Leser-Trelat sign - Polyarteritis nodosa - Trousseau syndrome

Answer 94

- Malaise - Loss of appetite - Anorexia and weight loss - Dyspepsia - Abdominal pain - Difficulty swallowing - Early satiety - Nausea and vomiting - May be malaena and haematamesis

Answer 95

Upper GI endoscopy and biopsy: ulcer with heaped-up edges is a common presentation

Answer 96

- CT of the chest - PET - Staging laparoscopy - Endoscopic ultrasound - HER2 testing

Answer 97

Siewert's classification is for gastro-oesophageal tumours.

Answer 98

- Peptic ulcer disease - Oesophageal cancer - Achalasia

Answer 99

- Oesophagogastrectomy - Total gastrectomy - Sub-total gastrectomy - Endoscopic submucosal resection - D2 lymph node dissection - Chemotherapy

Answer 100

- Chemotherapy or chemoradiotherapy: usually a combination of a platinum compound and fluorouracil - Palliative gastrectomy - Trastuzumab (Herceptin): for HER2 positive metastatic gastric cancer, in combination with chemotherapy

Answer 101

Coeliac disease is a systemic autoimmune disorder that affects the small intestine and is triggered by the ingestion of gluten peptides found in wheat, barley, rye and other related grains. Malabsorption is the hallmark of coeliac disease.

Answer 102

- Family history of coeliac disease - HLA-DQ2 and HLA-DQ8: 95% of patients have HLA-DQ2, and 80% have HLA-DQ8 - Autoimmunity: type 1 diabetes, autoimmune thyroid disease and autoimmune hepatitis - IgA deficiency: allows increased gluten peptides to circulate in the submucosa - Down’s syndrome - Turner’s syndrome

Answer 103

- Persistent abdominal symptoms: - Indigestion - Diarrhoea (watery) or steatorrhoea (pale, floating stools) - Abdominal bloating or discomfort - Constipation - Prolonged fatigue - Unexpected weight loss - Failure to thrive in children - Severe or persistent mouth ulcers - Dermatitis herpetiformis: itchy vesicular skin eruption caused by IgA antibodies attacking tTG in the epidermis. - Anaemia secondary to iron, B12 or folate deficiency

Answer 104

- FIRST LINE - Tissue transglutaminase antibodies (tTG) - SECOND LINE - Anti-tTG, endomysial, or gliadin (IgG) antibodies - Anti-casein can also be measured - GOLD STANDARD - Small bowel biopsy. - FBC

Answer 105

- Gluten free diet - Dietary supplements - folate, B12, vitamin D, iron, calcium. - Vaccinations - Referral to specialist

Answer 106

- Dermatitis herpetiformis - Malignancy - small bowel adenocarcinoma - Malabsorption related - Osteoporosis - Calcium / Vitamin D deficiency - Anaemia - Peripheral neuropathy - Infection - Lactose intolerance - Ulcerative jejunitis - Coeliac crisis

Answer 107

Crohn’s disease is a form of inflammatory bowel disease characterised by transmural inflammation of the gastrointestinal tract (anywhere from mouth to anus), with the terminal ileum and colon most commonly affected.

Answer 108

- Gender → Female > Male - Family History - Smoking - NSAIDs may exacerbate - Stress and depression

Answer 109

- Abdominal tenderness - Fever - Rectal examination: blood, skin tags, erythema, fissures, fistulas, ulceration - Aphthous mouth ulcers

Answer 110

- Cutaenous - Erythema nodosum - inflammatory disorder affecting subcutaneous fat. - Pyoderma gangrenosum - rapidly enlarging, very painful ulcer. - Musculoskeletal - Pauci-articular arthritis: asymmetrical - Osteoporosis - Axial arthritis - Polyarticular arthritis: symmetrical - Clubbing - Sacroiliitis - Ankylosing spondylitis - Eyes - Episcleritis - inflammation of your episclera - Uveitis - eye inflammation - Conjunctivitis - Hepatobiliary - Primary sclerosing cholangitis - Autoimmune hepatitis - Gallstones - Other - Calcium oxalate renal stones

Answer 111

- Diarrhoea - Abdominal pain (most commonly in RLQ where the ileum is) - Bloody stools: more common in ulcerative colitis - Delayed puberty and failure to thrive: in children - Weight loss - Systemic symptoms: - Anorexia - Fever - Malaise - Lethargy

Answer 112

- Diagnostic - Colonoscopy - Faecal calprotectin - FBC - CRP and ESR - LFTs - U&Es - Assess for anaemia

Answer 113

- Ulcerative colitis - Alternative causes of diarrhoea should be excluded e.g. Salmonella spp, Giardia intestinalis and rotavirus - Chronic diarrhoea

Answer 114

- FIRST LINE - Glucocorticoids - Mild attacks - budesonide - Moderate/Severe attacks - Prednisolone - Severe - IV hydrocortisone - Add immunosuppressants if no remission induced - Azathioprine - Mercaptopurine - Methotrexate - Add biologics for refractory period - Infliximab - Adalimumab - Antibiotics can also be used in peri-anal disease - Metronidazole - Ciprofloxacin

Answer 115

- 1st line: Azathioprine or Mercaptopurine - 2nd line: Methotrexate, Infliximab, Adalimumab - Post-surgery: consider azathioprine, with or without methotrexate Patients can either have no treatment, or pharmacological therapy depending on their risk of relapse. Glucocorticoids should not be offered

Answer 116

- Ileocecal resection - Partial right hemicolectomy - Colectomy with ileostomy - Colectomy with ileo-rectal anastomosis - Panproctocolectomy - Stricturoplasy - Abscess drainage - Resection of bowel where fistulae have formed - Perianal fistula drainage

Answer 117

- Ulcerative colitis (UC) is a type of inflammatory bowel disease that characteristically involves the rectum and extends proximally to affect a variable length of the colon. - It never spreads proximally beyond the ileocecal valve and is, therefore, confined to the large bowel. It does not affect the anus.

Answer 118

- Family history - HLA-B27 - Caucasian - Non-smoker → 3x more common - NSAIDs → associated with flares - Chronic stress and depression → associated with flares

Answer 119

- Abdominal tenderness - Fever - in acute UC - Tachycardia - in acute severe UC - Fresh blood on rectal examination

Answer 120

- Diarrhoea - Blood and mucus in stool - Urgency and tenesmus (cramping rectal pain) - Abdominal pain: particularly in left lower quadrant - Weight loss and malnutrition - Fever and malaise during attacks

Answer 121

- Fulminant refers to an abrupt and severe onset of a UC flare - Suggested by one of the following: - >10 bowel movements per day - Continuous bleeding - Abdominal tenderness and distention - Toxicity - Colonic dilation - The need for blood transfusion

Answer 122

- Cutaenous - Erythema nodosum - inflammatory disorder affecting subcutaneous fat. - Pyoderma gangrenosum - rapidly enlarging, very painful ulcer. - Musculoskeletal - Pauci-articular arthritis: asymmetrical - Osteoporosis - Axial arthritis - Polyarticular arthritis: symmetrical - Clubbing - Sacroiliitis - Ankylosing spondylitis - Eyes - Episcleritis - inflammation of your episclera - Uveitis - eye inflammation - Conjunctivitis - Hepatobiliary - Primary sclerosing cholangitis - Autoimmune hepatitis - Other - Cholangiocarcinoma - Aphthous oral ulcer - Nutritional deficits

Answer 123

N - No blood of mucus. E - Entire GI tract S - Skip lesions on endoscopy T - Terminal ilium most affected and Transmural inflammation S - Smoking is a risk factor

Answer 124

C - Continuous inflammation L - Limited to the colon and rectum O - Only superficial mucosa affected S - Smoking is protective E - Excrete blood and mucus U - Use aminosalicylates P - Primary sclerosing cholangitis

Answer 125

- GOLD STANDARD - Colonoscopy / Biopsy - Faecal calprotectin - FBC - LFTs - CRP and ESR

Answer 126

- Chron's disease - Other causes of diarrhoea

Answer 127

- Mild = 1st line aminosalicylate and 2nd line corticosteroids - Severe = 1st line IV corticosteroid and 2nd line IV ciclosporin - Colectomy may be required: leaves patient with J-pouch (can be reversed) or ileostomy. - J- pouch: ileoanal anastomosis, colon removed and rectum fused to ileum - Ileostomy: colon and rectum are removed and the ileum brought out on to the abdominal wall as a stoma - Maintenance with aminosalicylate, azathioprine, mercaptopurine.

Answer 128

- Toxic megacolon. - Perforation - Colonic adenocarcinoma - Strictures and obstruction - Extra-intestinal manifestations

Answer 129

- An inflammatory condition of the colon characterized by elevated yellow-white plaques that come together to form pseudomembranes on the mucosa. - C. diff can replace the normal gut flora resulting in dangerous diarrhoea.

Answer 130

- Diarrhoea - Abdominal pain - Leucocytosis - History of recent antibiotic use

Answer 131

- FBC - Leucocytosis - Faecal occult blood test - Stool PCR - Abdominal X-Ray

Answer 132

- Oral fidaxomicin - OR vancomycin - OR metronidazole

Answer 133

- Irritable bowel syndrome (IBS) is a chronic condition characterised by abdominal pain associated with bowel dysfunction. It is a functional bowel disorder (there is no identifiable organic disease underlying the symptoms). - IBS-C → with constipation. - IBS-D → with diarrhoea. - IBS-M → with constipation and diarrhoea.

Answer 134

- Gender -> Women > Men - Worsens symptoms: - Stress - Menstruation - Acute gastroenteritis

Answer 135

- General abdominal tenderness may be felt. - Fluctuating bowel habit - Diarrhoea - Constipation - Incomplete evacuation - Urgency - Mucus PR - Abdominal pain - Pain worse after eating - Improved by opening bowels - Bloating If for more than 6 months -> Chronic

Answer 136

- Crohn's disease - Ulcerative colitis - Coeliac disease - Malignancies

Answer 137

- Abdominal pain / discomfort: - Relieved on opening bowels, or - Associated with a change in bowel habit - AND 2 of: - Abnormal stool passage - Bloating - Worse symptoms after eating - PR mucus

Answer 138

- Normal FBC, ESR and CRP blood tests - Faecal calprotectin - raised in IBD not IBS. - Negative coeliac disease serology - Colonoscopy to rule out cancer

Answer 139

- Loperamide for diarrhoea - Laxatives for constipation. - Avoid lactulose as it can cause bloating. - Linaclotide is a specialist laxative for patients with IBS not responding to first-line laxatives - Antispasmodics for cramps e.g. hyoscine butylbromide (Buscopan)

Answer 140

- SECOND LINE - Tricyclic antidepressants (i.e. amitriptyline 5-10mg at night) - THIRD - SSRIs antidepressants

Answer 141

Acute appendicitis is an acute inflammation of the vermiform appendix, most likely due to obstruction of the lumen of the appendix.

Answer 142

- Young age: the highest incidence is between 10-20 years of age - Gender → Male > Female - Frequent antibiotic use: causes an imbalance in gut flora and a modified response to subsequent infection which may trigger appendicitis - Smoking

Answer 143

Central abdominal pain which migrates to the right iliac fossa, low-grade pyrexia and anorexia. 50% of patients present with this characteristic history.

Answer 144

- Right iliac fossa tenderness - Guarding - Tachycardia - Rovsing's sign - Psoas sign - Obturator sign - Digital rectal examination

Answer 145

- Periumbilical pain - Low-grade fever - Reduced appetite - Nausea and vomiting - Diarrhoea

Answer 146

The Alvarado score is used to predict the likelihood of appendicitis. A score of ≥7 is predictive of acute appendicitis. A score of 5 or 6 may warrant an ultrasound or CT but this should be considered on a case-by-case basis. - Migratory right iliac fossa pain (1) - Anorexia (1) - Nausea and Vomiting (1) - Right iliac fossa tenderness (2) - Fever (1) - High white blood cell count (2) - Leukocyte left shit - 75% neutrophils (1)

Answer 147

- FBC - CRP and ESR - U&Es - Urinalysis - Abdominal ultrasound - CT of abdomen with contrast - Diagnostic laparoscopy -> done to confirm diagnosis and then proceed to appendectomy in the same procedure.

Answer 148

- Ectopic Pregnancy - Ovarian cyst - Meckel's diverticulum - Mesenteric adenitis - UTI - Diverticulitis - Perforated ulcer - Food poisoning - Acute terminal ileitis

Answer 149

- Initial management - Fluids - Analgesia - Antiemetics - Preoperative IV antibiotics - Appendectomy - Postoperative antibiotics

Answer 150

- Perforation - Appendix mass - Abscess

Answer 151

Diverticulitis: where diverticula become inflamed and infected, typically causing severe lower abdominal pain, fever, general malaise, and occasionally rectal bleeding

Answer 152

- Diverticulosis: the presence of diverticula (out-pouching) in an asymptomatic patient - Diverticular disease: where diverticula cause symptoms, such as intermittent lower abdominal pain, without inflammation and infection

Answer 153

- Increasing age: > 50 years; peak age is 50-70 years old - Low dietary fibre - Obesity: particularly in younger people - Sedentary lifestyle - Smoking increase risk - NSAIDs increase risk

Answer 154

- Pyrexia - Left lower quadrant or iliac fossa tenderness and guarding - Left iliac fossa tender mass - Rigidity, guarding, rebound or percussion tenderness - Tachycardia and hypotension

Answer 155

- Left lower quadrant pain - Fresh rectal bleeding and mucus - Constipation - Urinary symptoms - Nausea and vomiting - Flatulence - Erratic bowel habits

Answer 156

- FBC - U&Es - CRP and ESR - Venous Blood Gas - Blood cultures - CT of the abdomen with contrast - Group and Save crossmatch

Answer 157

- FIRST LINE - dietary and lifestyle changes - Analgesics - Antispasmodic

Answer 158

- Conservative management - Could give bulk forming laxatives - Tell patient to increase fibre

Answer 159

- Oral antibiotics - Analgesia - Antispasmodic - Low residue or liquid diet

Answer 160

- Supportive management - IV fluids, analgesia - IV antibiotics - Co-amoxiclav - Surgery if bleeding is not controlled

Answer 161

- Radiological drainage.

Answer 162

- Elective colonic resection

Answer 163

- Fistulae - Abscess - Perforation - Structures - Haemorrhage

Answer 164

- Most common congenital abnormality of the small bowel. - Diverticulum projects from the wall of the ileum.

Answer 165

- FBC - Meckel's scan - technetium-99m pertechnetate scan. - CT of abdomen and pelvis - Ultrasound

Answer 166

Laparoscopic surgery to straighten the twisted bowel and removal of the diverticula.

Answer 167

- Small bowel obstruction (SBO) is a mechanical or functional obstruction of the small intestine that prevents the normal passage of digestive contents. - It can be partial or complete.

Answer 168

- Abdominal tenderness and distension - Tinkling bowel sounds in mechanical obstruction - Absent bowel sounds may be present in functional obstruction - Empty rectal passage - Tachycardia and hypotension

Answer 169

- Colicky, central or generalised abdominal pain. - Nausea and vomiting - Abdominal bloating - Constipation - Anorexia

Answer 170

- GOLD STANDARD - CT abdomen and pelvis with contrast. - FIRST LINE - Abdominal X-ray - Bloods - FBC - U&Es - CRP and ESR - Group and save crossmatch - VBG

Answer 171

- IV resuscitation - Nasogastric tube - IV antibiotics - Analgesia and anti-emetics

Answer 172

- Emergency laparotomy - Adhesiolysis

Answer 173

Large bowel obstruction (LBO) occurs due to mechanical or functional obstruction of the large intestine that prevents the normal passage of contents.

Answer 174

- Increasing age - >65 years old. - Volvulus - Colorectal cancer - Stricture

Answer 175

- Abdominal tenderness and distention - Tinkling bowel sounds early on, absent later - Rectal examination: empty rectum, hard stools and blood - Tachycardia and hypotension - Third-spacing of fluid - Significant hypotension may indicate ischaemia, perforation or sepsis

Answer 176

- Colicky, generalised abdominal pain - Pain is constant in LBO compared to SBO - Bloating - Constipation (may be absolute in distal obstruction): no passing of faeces or flatus - Occurs earlier in LBO than in small bowel obstruction - Vomiting: - May be faeculent in nature - A late symptom in LBO, occurs earlier in small bowel obstruction Symptoms of LBO present later and slower than that of SBO due to the LB being able to distant much greater → has a larger lumen as well as circular and longitudinal muscles.

Answer 177

- GOLD STANDARD - CT abdomen and pelvis with contrast. - FIRST LINE - Abdominal X-ray - Bloods - FBC - U&Es - CRP and ESR - Group and save crossmatch - VBG

Answer 178

- IV resuscitation - Nasogastric tube - IV antibiotics - Analgesia and anti-emetics - Further -> surgery for underlying cause.

Answer 179

- Bowel ischemia - Sepsis - Aspiration pneumonia - Dehydration

Answer 180

- Bowel ischemia - Sepsis - Aspiration pneumonia - Dehydration

Answer 181

- Clinical picture mimicking colonic obstruction but with no mechanical cause. - Also known as Ogilvie syndrome.

Answer 182

- Patients present with rapid and progressive abdominal distension and pain - Similar presentation to mechanical obstruction

Answer 183

X-ray shows gas filled large bowel

Answer 184

- Treat underlying problem e.g. withdrawal of opiate analgesia - Correct U&E - IV Neostigmine - a cholinesterase inhibitor, may be given to encourage motility. - Endoscopic colonic decompression can be used in those failing to respond. - Those at increasing risk of or who have developed complications (e.g. necrosis, perforation) will typically need surgical management, if appropriate.

Answer 185

Colorectal carcinoma is a neoplastic growth in the colon or rectum. The majority are adenocarcinomas.

Answer 186

TNM and Dukes' staging used.

Answer 187

- Gender → Male > Female - Increasing age - Smoking - Obesity - Red or processed meats - Diet low in fibre - Inflammatory bowel disease - Polyps - Hereditary conditions: FAP, HNPCC, Peutz-Jeghers syndrome

Answer 188

Right-sided tumours are often asymptomatic, with the majority of patients presenting with incidental iron-deficiency anaemia. In contrast, left-sided tumours are particularly associated with a change in bowel habit and have higher rates of rectal bleeding and large bowel obstruction.

Answer 189

- Iron deficiency anaemia: koilonychia, pallor, angular cheilitis - May be very large without evident symptoms or signs

Answer 190

- Progressive change in bowel habit: diarrhoea or constipation; more prominent in left-sided tumours - Abdominal discomfort - Symptoms of large bowel obstruction: more common in left-sided tumours - Constitutional symptoms e.g. weight loss - Dyspnoea and fatigue

Answer 191

- Rectal mass - Anaemia is rare

Answer 192

- Progressive change in bowel habit: diarrhoea or constipation; more prominent in left-sided tumours - Abdominal discomfort - Symptoms of large bowel obstruction: more common in left-sided tumours - Obstruction causes colicky abdominal pain, constipation, blood-streaked stools if stool is passed, abdominal distension, vomiting (faeculent) - Constitutional symptoms e.g. weight loss - Rectal bleeding and tenesmus

Answer 193

- GOLD STANDARD - Colonoscopy with biopsy - CT colonography - SECOND LINE alternative - FBC - LFTs - U&Es - CT chest, abdomen and pelvis if biopsy is diagnostic of malignancy

Answer 194

- IBS - Ulcerative colitis - Crohn's disease - Haemorrhoids - Anal fissure - Diverticular disease

Answer 195

- NHS home screening test to detect traces of blood in stool - The two types of test are the Faecal Occult Blood (FOB) test and Faecal Immunochemical Test (FIT) - Screening sigmoidoscopy - Colonoscopy may be offered based on findings

Answer 196

- Initial - Iron replacement - Elective - Colon cancer - chemotherapy - Rectal cancer - radiotherapy or chemoradiotherapy - For all stages -> surgical resection including mets (FIRST LINE)

Answer 197

- Cancer related - Metastasis - Large bowel obstruction - Treatment related - Surgical complications

Answer 198

- A colonic polyp is an abnormal growth of tissue projecting from the colonic mucosa. - Polyps range from a few millimetres to several centimetres and are single or multiple

Answer 199

- Most polyps are asymptomatic and found by chance - Polyps in the rectum or sigmoid colon often present with bleeding

Answer 200

Polyps are removed at colonoscopy to reduce development into cancer risk

Answer 201

- Familial Adenomatous Polyposis - Autosomal dominant condition due to APC gene mutation. - Adenomas develop at 16 y/o and the cancer develops at 39 y/o.

Answer 202

- Hereditary Non-Polyposis Colon Cancer - HNPCC - Polyps formed in the colon and can rapidly develop to colon cancer. - Autosomal dominant condition in DNA mismatch repair genes → hMSH2 or hMSH1. - These genes maintain DNA stability in replication a defect causes micro satellites (just short repeated DNA sequences). - The gene mutation causes more DNA damage and thus colorectal carcinoma can develop. - Thus the cancer can develop much quicker.

Answer 203

- Bowel ischaemia which affects the large bowel. This is mainly due to pathology in the inferior mesenteric artery territory and can range from mild ischaemia to gangrenous colitis. - Also known as chronic colonic ischaemia.

Answer 204

- Older age - Peripheral vascular disease - Infective endocarditis - Atrial fibrillation - Atherosclerosis - Previous MI - Coagulation disorders - Cocaine use - Vasculitis - Hydroperfusion

Answer 205

- Abdominal tenderness - Peritonism - Haemodynamic instability - Pyrexia - shock - Tachycardia - shock

Answer 206

- Lower left side abdominal pain (may be crampy in nature) - Diarrhoea +/- blood - Haematochezia - passage of fresh blood through the anus - Fever - There is a spectrum of disease from mild self-limiting insults to necrosis and bowel perforation.

Answer 207

- GI endoscopy - GOLD STANDARD - Abdominal X-ray - CT of abdomen with contrast - Bloods - FBC - U&Es - VBG - Coagulation screen

Answer 208

- Other causes of acute colitis e.g. IBD.

Answer 209

- IV fluid resuscitation - Broad spectrum antibiotics - IV unfractionated heparin / LMW heparin

Answer 210

- Embolectomy - Thrombolysis - Mesenteric angioplasty and stenting - Laparotomy and resection of ischaemic/ necrotic segments - Stoma formation

Answer 211

- Bowel infarction and perforation - Systemic inflammatory response syndrome (SIRS) - Strictures

Answer 212

Bowel ischemia which affects the small bowel. It refers to pathology affecting the superior mesenteric artery.

Answer 213

- Age -> typically over 40 - Gender → Female > Male - Atrial fibrillation - Atherosclerosis - Previous MI - Hypercoagulable state - Infective endocarditis - Vasculitis - Hypoperfusion

Answer 214

- Often no abdominal signs and pain is out of proportion to clinical findings - Absence of bowel sounds as motility decreases: late sign - Epigastric bruit on auscultation: in chronic ischaemia - Rectal exam: bleeding - Hypotensive and tachycardic - shock due to hypovolaemia

Answer 215

- Abdominal pain - Acute ischaemia: severe, out of proportion to abdominal signs - Chronic ischaemia: colicky, intermittent, post-prandial and described as ‘intestinal angina’ - Nausea and vomiting - Diarrhoea - Fever - Weight loss: may be present with chronic ischaemia

Answer 216

- ECG - CT angiography - diagnostic test - CXR - Bloods - FBC - U&Es - VBG - Coagulation screen

Answer 217

- Bowel rest: nil-by-mouth and NG tube - IV fluids - IV broad antibiotics - IV heparin: anti-coagulation - Prompt laparotomy

Answer 218

- Endovascular revascularisation - Embolisation - Angioplasty - Laparotomy - Embolectomy - Arterial bypass - Resection of necrotic bowel

Answer 219

- Bowel infarction - Systemic inflammatory response syndrome (SIRS) - Short bowel syndrome - Strictures

Answer 220

The protrusion of a viscus/ part of a viscus through a defect of the wall of its containing cavity into an abnormal position.

Answer 221

- Irreducible - contents cannot be pushed back into place. - Obstructed - bowel contents cannot pass as the intestine is obstructed. - Strangulated - ischaemia occurs as blood supply of the sac is cut off - this requires urgent surgery. - Incarceration - contents of the hernial sac are stuck inside by adhesions.

Answer 222

- The protrusion of abdominal contents through the inguinal canal. - Commonest type of hernia in both men and women. Account for 70% of all abdominal hernias.

Answer 223

- Gender → Male > Female - Chronic cough - Constipation - Urinary obstruction - Heavy lifting - Ascites - Past abdominal surgery

Answer 224

- Bulging associated with coughing or straining (bowel movement, heavy lifting) - Appearance of lump - Rarely painful - If painful then indicates strangulation - Patient can usually reduce the hernia themselves

Answer 225

- Look for lump and previous scars, check for cough impulse (swelling expands when coughing) - compare to the other side. - Examine external genitalia

Answer 226

- Femoral hernia - Epididymitis - Testicular torsion - Groin abscess - Aneurysm - Hydrocele - Undescended testes

Answer 227

- Use truss to contain and prevent further progression of hernia. - Pre-op - diet and stop smoking - Herniotomy, Herniorrhaphy, or Hernioplasty.

Answer 228

- Bowel enters the femoral canal (presenting as a mass in upper medial thigh) or above the inguinal ligament (points down the leg). - Likely to be irreducible and to strangulate due to the rigidity of the canal’s borders.

Answer 229

- Gender → Female > Male. - More common in middle-age and elderly.

Answer 230

The neck of the hernia is felt inferior and lateral to the pubic tubercle.

Answer 231

- Inguinal hernia - Saphena varix (dilation of saphenous vein at junction of femoral vein in groin) - Enlarged cloquet's node - Lipoma - Femoral artery aneurysm - Psoas abscess

Answer 232

- Surgical repair - Herniotomy - ligation and excision of the sac - Herniorrhaphy - repair of the hernial defect

Answer 233

A type of paediatric hernia affecting 3% of life births.

Answer 234

- Low birth weight (<1500g). - African ancestry.

Answer 235

Rarely needed, most resolve by the age of 3.

Answer 236

All are uncommon - Post-operative → Infection and bleeding. - Incarceration. - Strangulation. - Rupture.

Answer 237

- Occurs when tissue protrudes through a surgical scar that is weak - They are a complication of abdominal surgery but can occur anywhere where there is an incision and follows a breakdown of muscle closure after surgery

Answer 238

- Emergency surgery. - Wound infection post operation. - Persistent coughing and heavy lifting. - Poor nutrition.

Answer 239

- Repair is more difficult in those that are obese - Mesh repair - reduced recurrence but associated with high levels of infection

Answer 240

Pass through the linea alba above the umbilicus

Answer 241

- Pain - Tenderness - Redness - Impulse on cough

Answer 242

- Investigations - Ultrasound - CT - Management - Surgery

Answer 243

- Protrusion of intra-abdominal contents into the thoracic cavity though an enlarged oesophageal hiatus of the diaphragm. - 2 subtypes: - Sliding hiatus hernia (80%). - Paraesophageal hernia (rolling hiatus hernia) (20%).

Answer 244

- Small hernias - asymptomatic - Large hernias - GORD (50%)

Answer 245

- Upper GI endoscopy - to visualise the mucosa, but cannot exclude hiatus hernia. - Barium swallow to confirm diagnosis.

Answer 246

- Weight loss - Treatment of GORD - Surgical treatment, if: - High risk of strangulation - Intractable symptoms despite medical therapy - Complications

Answer 247

The abnormal passage of loose or liquid stool more than 3 times daily

Answer 248

Acute diarrhoea is defined as that lasting less than 2 weeks

Answer 249

- Stool MCS - establish the causative organism and antibiotic sensitivities. - Flexible sigmoidoscopy with colonic biopsy is performed if symptoms persist and no diagnosis has been made

Answer 250

Treatment is symptomatic to maintain hydration with anti-diarrhoeal agents (Loperamide) for short-term relief and antibiotics for specific indications.

Answer 251

Chronic diarrhoea is defined as lasting more than 2 weeks.

Answer 252

- Faecal markers - U&Es - Stool MCS - Sigmoidoscopy with biopsy - CRP and ESR - Other bloods

Answer 253

- Treat cause - Oral rehydration - Anti-diarrhoeal e.g. loperamide or codeine phosphate

Answer 254

- Painful tear in squamous lining of lower anal canal, distal to the dentate line resulting in pain on defecation. - Can be acute: <4-6 weeks - Or chronic: >6 weeks

Answer 255

- Extreme pain - especially on defecation - Bleeding - Faecal impaction and constipation due to avoidance of toileting - If chronic, there may be skin tags: - At distal end of the fissure, the tag is called a sentinel pile - At the proximal end of the fissure, the tag is called a hypertrophied anal papillae.

Answer 256

- Can usually be made on history alone - Confirmed on perianal inspection - Rectal examination (sometimes not possible due to pain and sphincter spasm) - Individuals with rectal bleeding or an atypical location of the fissure should get further evaluation, including anoscopy, colonoscopy, or sigmoidoscopy to exclude secondary causes of an anal fissure or an alternative diagnosis like haemorrhoids.

Answer 257

- Increase dietary fibre and fluids - Use of stool softeners - Hygiene advice - FIRST LINE - Lidocaine ointment + GTN ointment or topical diltiazem - SECOND LINE - Botulinum toxin injection (botox) and topical diltiazem - Surgery if medication fails: lateral partial internal sphincterotomy (the internal sphincter is divided to lower its resting pressure, which helps improve blood supply to the fissure and allows faster healing).

Answer 258

An abnormal connection between the epithelial surface of the anal canal and skin - it is essentially a track that communicates between the skin and anal canal/rectum.

Answer 259

- Pain - Usually intermittent and during defecation, during sitting or activity. - Malodorous discharge (bloody or mucus) - Pruritus ani (itchy bottom) - Perianal skin may be excoriated and inflamed - Systemic abscess if it becomes infected

Answer 260

- In some cases, the internal opening can be palpated on digital rectal exam. - MRI: - To exclude sepsis - To detect associated conditions e.g. Crohn’s or TB - Imaging will show air or contrast material in the fistula - Endoanal ultrasound: - To determine tracks location and underlying causes

Answer 261

- Surgical - Fistulotomy and excision - Treat with antibiotics if infected

Answer 262

- Haemorrhoids are normal spongy vascular structures in the anal canal that act as cushions for the stool as it passes through. - Hemorrhoidal disease (simply know as haemorrhoids) is when haemorrhoids get disrupted, swollen and inflamed.

Answer 263

- Grade I: no protrusion outside the anal canal. - Grade II: protrusion outside the anus during bowel movement, but they retract spontaneously. - Grade III: prolapsed haemorrhoids that don’t retract spontaneously, but they can be pushed back in manually. - Grade IV: prolapsed haemorrhoids that cannot be manually pushed back in.

Answer 264

Internal haemorrhoids are ones above the dentate line, and external haemorrhoids are ones below the dentate line.

Answer 265

- Obesity - Old age

Answer 266

- Usually asymptomatic but can: - Get inflamed - Cause itching, burning, vague discomfort - Cause painless passage of bright red blood with a bowel movement

Answer 267

- Painful, especially when associated with thrombosed haemorrhoids - Thrombosed external haemorrhoids are tender and have a purplish hue - Swelling in the affected area - Mucus discharge - Itching

Answer 268

- Abdominal examination to rule out other diseases - Rectal exam - Proctoscopy for internal haemorrhoids. - Further testing with flexible sigmoidoscopy or colonoscopy to exclude proximal pathology if >50 years old

Answer 269

- Perianal haematoma - Anal fissure - Abscess - Tumour - Proctalgia fugax: anal pain that doesn't have a specific cause

Answer 270

- Increase fibre and fluid intake - Stool softeners - Topical analgesia - Topical steroids for short periods

Answer 271

- Rubber band ligation - Sclerotherapy: injection of drugs causes coagulation - Infrared coagulation - Bipolar diathermy and direct current electrotherapy: local heat causes coagulation

Answer 272

- Excisional haemorrhoidectomy - Stapled haemorrhoidopexy

Answer 273

- Analgesia - Ice packs - Stool softeners

Answer 274

Hair follicles get stuck under the skin in the natal cleft (butt crack) ~6cm above the anus, resulting in irritation and inflammation leading to small tracks which can become infected (abscess)

Answer 275

- Gender → Male > Female - Commonly present between 20-30 years old. - Obese Caucasians and those from Asia, Middle East and Mediterranean are at increased risk - Large amount of body hair - Having deep gluteal clefts - Sedentary job - Family history

Answer 276

- Painful swelling over days - Pus filled with foul smell from abscess - Systemic signs of infection

Answer 277

- Associated mucoid, purulent, or bloody drainage. - 4 in 10 have repeated recurrent pilonidal sinus - Infection never clears completely

Answer 278

- Clinical examination detection.

Answer 279

- Acute pilonidal abscess requires incision and drainage - Chronic pilonidal disease and recurrent abscesses require: - Surgical excision and pus drainage - Pre-op antibiotics - Complex tracks can be laid open and packed individually - Skin flaps can be used to cover defect - Hygiene and hair removal advice (near sinus)

Answer 280

- A genetic syndrome of mild unconjugated hyperbilirubinaemia. - Defined by concentration of <102 micromol/L. - The liver is otherwise functionally normal.

Answer 281

- Family History - Post-pubertal age. - Mutation in the UGT1A1 gene.

Answer 282

- Asymptomatic - Mild jaundice (icterus) seen in times of fasting or physiological stress

Answer 283

- LFTs - normal - FBC - normal - Unconjugated bilirubin - Elevated - Liver biopsy is not needed but may be done to exclude other diagnosis

Answer 284

- Doesn’t need treating as there isn’t any liver damage - Patient education - Avoidance or reversal of inciting agents

Answer 285

- Acute pancreatitis refers to an acute inflammatory process involving the pancreas. - The 2 main causes of acute pancreatitis are gallstones and alcohol. - In the UK, around 50% of cases are caused by gallstones, 25% by alcohol, and 25% by other factors.

Answer 286

- Incidence increases with age.

Answer 287

- Acute pancreatitis should be suspected in any person with: - Acute upper or generalised abdominal pain, particularly if they have a history or clinical features of gallstones or alcohol misuse.

Answer 288

- Abdominal tenderness and guarding - Abdominal distention - Tachycardic and/or hypotensive - pt may be in shock - Jaundice - Cullen's sign - Grey Turner's syndrome - Fox's sign

Answer 289

- Severe upper abdominal pain: epigastric, RUQ or LUQ pain which may radiate to the back - Nausea, vomiting and anorexia - Steatorrhoea: excess fat in faeces in acute-on-chronic pancreatitis - Poor urinary output

Answer 290

- FBC - U&Es - LFTs - ABG - Serum glucose - Serum LDH - Serum calcium - CRP

Answer 291

Patients with a score of 3 points or more within the first 48 hours should be considered for referral to high-dependency care for acute pancreatitis. P - pO2 (<8kPa) A - Age (>55 years) N - Neutrophils (WCC>15x10^9/L) C - Calcium (<2mmol/L) R - Renal function (Urea >16mmol/L) E - Enzymes (AST >200U?L OR LDH >600U/L) A - Albumin (<32g/L) S - Sugar (Blood glucose >10mmol/L)

Answer 292

FIRST LINE management is supportive - IV fluid resuscitation - Catheterisation - Oxygen supplementation - Opiate analgesia - Early nutritional support - Antibiotics

Answer 293

- Endoscopic Retrograde Cholangiopancreatography (ERCP) - Cholecystectomy - Alcohol cessation and withdrawal management (alcohol)

Answer 294

Chronic pancreatitis refers to inflammation of the pancreas. Unlike acute pancreatitis, chronic pancreatitis is irreversible. It is characterised by structural changes e.g. fibrosis, calcification and atrophy which leads to a decline in function of the pancreas.

Answer 295

- Gender → Male > Female - Alcohol excess - Smoking - Family history - Ductal obstruction e.g. gallstones, tumours, structural abnormalities - Genetic - cystic fibrosis and haemochromatosis

Answer 296

- Epigastric tenderness - Signs of liver disease due to alcohol excess e.g. jaundice and ascites - Skin nodules (rare) - pancreatic lipase leaks into circulation and causes fat necrosis in soft tissue

Answer 297

- Diarrhoea - Foul-smelling stools which are hard to flush. Stool contains fat as pancreatic function declines and food isn't digested properly - Nausea and vomiting - Weight loss and fatigue - Features of diabetes e.g. polyuria and polydipsia

Answer 298

- Epigastric pain radiating to the back - Steatorrhea - Malnutrition - Diabetes mellitus

Answer 299

- FIRST LINE - CT or MRI - NICE FIRST LINE - Transabdominal ultrasound

Answer 300

- MRCP - Faecal elastase - LFTs - HbA1c - IgG4 - ERCP - Amylase and Lipase serum levels

Answer 301

- FIRST LINE - Lifestyle modification - smoking and alcohol cessation - Diet modification - Analgesia - Pancreatic enzyme replacement

Answer 302

- Intervention procedures - Endoscopic stenting - Coeliac plexus nerve blocks - Drainage - Pancreatectomy

Answer 303

- Malabsorption - Duct obstruction - Pseudocyst - Diabetes - Pancreatic cancer - Local vascular complications - Gastric varices - Metabolic bone disease

Answer 304

'Pancreatic cancer' refers to primary pancreatic ductal adenocarcinoma, which accounts for >85% of all pancreatic neoplasms. These adenocarcinomas usually affect the head of the pancreas, but sometimes the body and tail. Some are multifocal.

Answer 305

- Male - Family history - Smoking - Alcohol - Obesity - Diet high in red meat - Diabetes: a risk factor and a potential consequence of pancreatic cancer - Chronic pancreatitis - Genetic: hereditary non-polyposis colorectal carcinoma, BRCA1 and BRCA2 mutations, Peutz-Jeghers syndrome - Multiple endocrine neoplasia

Answer 306

- Positive Courvoisier’s sign: In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones - Trousseau sign of malignancy: migratory thrombophlebitis (blood clots felt as small lumps under skin)

Answer 307

- Non-specific symptoms: - Epigastric or atypical back pain, anorexia, weight loss; these features are common - New-onset diabetes: - Thirst, polyuria, nocturia, weight loss - Due to the loss of endocrine function - Nausea and vomiting - Steatorrhoea: due to loss of exocrine function fats are not digested - Dark urine and pale stools: due to obstructive jaundice - Cancer related anorexia - Acute pancreatitis

Answer 308

- Painless obstructive jaundice.

Answer 309

- Abdominal ultrasound - FIRST LINE - LFTs - Coagulation profile - CA 19-9 - CT chest of abdomen and pelvis - PET CT if CT is inconclusive (NICE)

Answer 310

- Surgical resection (Whipple's resection or laparoscopic excision) - Adjuvant chemotherapy after surgery - Neoadjuvant therapy before surgery may be offered

Answer 311

- Palliative management: - ERCP with stenting: for symptomatic relief of obstructive jaundice in patients with unresectable and metastatic tumours - Chemotherapy/chemoradiotherapy: offered if patients are able to tolerate it - Management of pain: opiates or radiotherapy

Answer 312

- Cancer related - VTE - New-onset diabetes mellitus - Cholangitis - Surgery related - Early dumping syndrome - Late dumping syndrome

Answer 313

Cholelithiasis (gallstones) refers to the development of a solid deposit or ‘stone’ within the gallbladder.

Answer 314

- Risk factors - Female - 2-3 x higher - Fat - Forties - Fertile - pregnancy

Answer 315

- Genetic predisposition - Diabetes - Rapid weight loss / fasting - Medications - Chron's disease - Haemolytic conditions - Diet high in fat and refined carbohydrates

Answer 316

- Gallstones are normally asymptomatic - Biliary colic - Acute cholecystitis - Acute cholangitis - Acute pancreatitis - Mucocele/Empyema - Mirizzi's syndrome - Obstructive jaundice - Gallstone ileus - Gallbladder cancer

Answer 317

- Biliary colic refers to a pain in the RUQ/epigastrium caused by gallstones. - Though termed a 'colic' the pain is normally constant lasting from 30 minutes to 6 hours.

Answer 318

- Nausea and vomiting - Right upper quadrant pain - Epigastric pain - Pain may radiate to right shoulder or interscapular region - Episodes typically last 30 minutes - 6 hours. Often worse after ingestion of fatty foods. - Note: there are no signs on abdominal examination. Murphy's sign negative.

Answer 319

- FIRST LINE - abdominal ultrasound - LFTs - FBC - CRP and ESR - Amylase level

Answer 320

- Cholecystitis - Ascending cholangitis - Common bile duct stone - Gastritis - Peptic ulcer disease - IBS - Carcinoma on right side of colon - Renal colic - Pancreatitis

Answer 321

- Symptomatic management - Analgesia - Paracetamol and NSAIDS - Diet modification - low fat - Surgical management - MRCP +/- ERCP for confirmation - On table cholangiogram - Elective laparoscopic cholecystectomy

Answer 322

- Obstructive jaundice - Cholecystitis - Ascending cholangitis - Acute pancreatitis - Gallbladder empyema - Gallstone ileus - Gallbladder cancer

Answer 323

- Acute cholecystitis refers to inflammation of the gallbladder most commonly occurring due to impacted gallstones (calculous cholecystitis) - Relatively rarely acute cholecystitis occurs in the absence of gallstones (acalculous cholecystitis).

Answer 324

- Acute cholecystitis refers to inflammation of the gallbladder most commonly occurring due to impacted gallstones (calculous cholecystitis) - Relatively rarely acute cholecystitis occurs in the absence of gallstones (acalculous cholecystitis).

Answer 325

- Female - 2-3 x higher - Fat - Forties - Fertile - pregnancy - Genetic predisposition - Diabetes - Rapid weight loss / fasting - Medications - Chron's disease - Haemolytic conditions - Diet high in fat and refined carbohydrates

Answer 326

- RUQ abdominal tenderness - Murphy’s sign positive: palpating the RUQ whilst the patient breathes in deeply causes pain - Abdominal mass - Due to distended gallbladder (present in 30-40%) - Pyrexia - Tachycardia - Hypotension (in severe cases)

Answer 327

- Nausea and vomiting - Fever - Right upper quadrant abdominal pain - Severe and lasting >30 minutes - Preceding history of biliary colic - Referred right shoulder tip pain - Note: jaundice should not be present. If jaundiced, this may suggest Mirizzi syndrome, CBD stone or ascending cholangitis.

Answer 328

- FIRST LINE - Transabdominal ultrasound - GOLD STANDARD - Abdominal ultrasound - FBC - LFTs - U&Es - Coagulation profile - VBG - Inflammatory markers

Answer 329

- Pancreatitis - Peptic ulcer disease - Cholangitis - Appendicitis - Basal pneumonia

Answer 330

- ABC and sepsis 6 - IV antibiotics - cefuroxime and metronidazole - IV fluids and analgesia - Nil by mouth - Note: before cholecystectomy, CBD stones should be checked for: MRCP or on-table cholangiogram. - Early laparoscopic cholecystectomy

Answer 331

- Urgent cholecystostomy

Answer 332

- Gallbladder empyema - Gallstone ileus - Acute cholangitis - Obstructive jaundice - Procedure-related - bile duct injury

Answer 333

Chronic inflammation of the gallbladder +/- colic.

Answer 334

- Flatulent dyspepsia - Abdominal discomfort - RUQ pain (esp after meal) - Distension - Nausea - Fat intolerance (fat stimulates cholecystokinin release and gallbladder contraction)

Answer 335

- Ultrasound - to image stone and assess CBD diameter - MRCP - used to find CBD stones - X-ray - may show porcelain gallbladder

Answer 336

- If symptoms persist post-treatment, consider: - Hiatus hernia - IBS - Peptic ulcer - Chronic pancreatitis - Tumour

Answer 337

- Cholecystectomy - ERCP + sphincterotomy prior to surgery

Answer 338

Acute cholangitis refers to infection of the biliary tree characteristically resulting in pain, jaundice and fevers.

Answer 339

- Gallstones: the most common predisposing factor - Stricture of the biliary tree: benign or malignant - Post-procedure injury of the bile ducts e.g. post-ERCP - Age → > 50 years old.

Answer 340

- Right upper quadrant (RUQ) abdominal pain, jaundice, and fever is known as Charcot’s triad and suggests a diagnosis of ascending cholangitis. It is seen in 20-50% of patients. - The addition of hypotension and change in mental state/ confusion (shock) is known as Reynolds’ pentad and is associated with biliary sepsis.

Answer 341

- RUQ tenderness - Scleral icterus - Pyrexia - Hypotension: part of Reynold’s pentad

Answer 342

- RUQ abdominal pain - Jaundice - Fever: the most common feature - Nausea and vomiting - Malaise - Pruritis - Dark urine and pale stool (cholestasis) - Confusion: part of Reynold’s pentad

Answer 343

- FIRST LINE - Transabdominal ultrasound - MRCP - GOLD STANDARD for diagnosis - FBC - LFTs - U&Es - CRP and ESR - VBG - Blood cultures - Inflammatory markers

Answer 344

- Acute cholecystitis - Peptic ulcer disease - Pancreatitis - Hepatic abscess - Appendicitis - Biliary colic

Answer 345

- ABC with sepsis 6 - IV antibiotics e.g. cefotaxime and metronidazole for 4-7 days - IV fluids - Analgesia

Answer 346

- Biliary decompression - ERCP - Percutaneous trans-hepatic cholangiography - Surgical drainage - Elective cholecystectomy

Answer 347

- Biliary sepsis - Acute pancreatitis - Hepatic abscess - Risk of ERCP

Answer 348

Biliary tree cancer. Makes up 10% of the primary liver cancers.

Answer 349

- Inflammatory bowel disease - HBV - HCV - Infection with parasitic worms (flukes)

Answer 350

- Palpation - enlarged, irregular, tender liver may be felt - Signs of chronic liver disease - Signs of decompensation - jaundice, ascites - Listen for bruit - murmur over the liver

Answer 351

- Fever - Weight loss - Abdominal pain +/- ascites - Malaise

Answer 352

- CT and ultrasound - MRI - staging - Biopsy - FBC - Clotting profile - Hepatitis serology - LFT - Serum alpha-fetoprotein - Bilirubin levels - ALP levels

Answer 353

- Surgery (not possible in 70% of patients at presentation) - Intrahepatic then FIRST LINE is partial liver resection - Extrahepatic then surgical excision - Liver transplantation - Chemotherapy, Radiotherapy, Immunotherapy - high resistance

Answer 354

- Normal portal vein pressures range from 5–10 mm Hg. The term portal hypertension refers to elevated pressures in the portal venous system. Venous pressure more than 5 mm Hg greater than the inferior vena cava pressure is defined as portal hypertension. - Portal vein is formed by the union of the superior mesenteric and splenic veins

Answer 355

- Cirrhosis - Alcohol - Congestive heart failure - Hyper-coagulable state

Answer 356

- Features of chronic liver disease - Leukonychia (white discolouration on nails) - Palmar erythema - Spider telangiectasia - Gynecomastia - Features of decompensated liver disease - Encephalopathy - Jaundice - Ascites - Splenomegaly due to portal hypertension - Variceal bleeding

Answer 357

- Abdominal ultrasound - dilated portal vein - Doppler ultrasound - slow velocity and dilated portal vein - Endoscopy - for presence of oesophageal varices

Answer 358

- Treat underlying cause - Salt reduction and diuretics - Beta-blockers and nitrate to reduce blood pressure

Answer 359

- Varices and variceal haemorrhage - Ascites - Hepatopulmonary syndrome - Liver failure - Hepatic encephalopathy - Cirrhotic cardiomyopathy

Answer 360

- Chronic liver disease is caused by repeated insults to the liver, which can result in inflammation, fibrosis and ultimately cirrhosis. - CLD is generally defined as progressive liver dysfunction for six months or longer. The end result of chronic liver disease is cirrhosis, which describes irreversible liver remodelling.

Answer 361

- Non-specific signs: - Anorexia, lethargy - Weight loss - Hepatomegaly - Nausea - Disturbed sleep pattern.

Answer 362

- Caput medusa - Splenomegaly - Palmar erythema - Dupuytren's contracture - Leukonychia - Gynecomastia - Spider naevi

Answer 363

- Encephalopathy - Ascites - Jaundice - GI bleeding - Coagulopathy

Answer 364

- GOLD STANDARD - Liver biopsy - LFTs - FBC - Hyperbilirubinemia - Transient elastography - USS - CT or MRI - Non-invasive liver screen

Answer 365

- Treat underlying pathology - Transplantation - based upon UKELD score - Hepatic encephalopathy - FIRST LINE - laxatives - Ascites - aldosterone agonist e.g. spironolactone - GI bleeding - beta blockers and variceal band ligation - Spontaneous bacterial peritonitis - antibiotics

Answer 366

- Hepatic encephalopathy - Ascites - Gastrointestinal bleeding (i.e. variceal bleed) - Bacterial infections (i.e. SBP) - Acute kidney injury - Hepatorenal syndrome - Hepatopulmonary syndrome - Hepatocellular carcinoma - Acute-on-chronic liver failure

Answer 367

- HCC - 6-monthly surveillance

Answer 368

Alcoholic liver disease (ALD) has 3 stages of liver damage: fatty liver (steatosis), alcoholic hepatitis (inflammation and necrosis), and alcoholic liver cirrhosis. All are caused by chronic heavy alcohol ingestion.

Answer 369

- Prolonged and heavy alcohol consumption - Hepatitis C - increased risk of cirrhosis - Female sex - ALD develops more rapidly and occurs at lower drinking levels in women than in men. However, most patients with ALD are male. - Genetic predisposition - Increasing age >65 - Obesity

Answer 370

- Often, no symptoms or signs - Vague abdominal symptoms of nausea, vomiting, diarrhoea are due to the more general effects of alcohol on the GI tract - Hepatomegaly, sometimes huge, can occur together with other features of chronic liver disease

Answer 371

- Mild jaundice may occur - Signs of chronic liver disease (ascites, bruising, clubbing, Dupuytren’s contracture) - Anorexia - Asterixis - Diarrhoea and vomiting - High temperature, pulse and respiration - Abdominal pain in severe cases - Deep jaundice, hepatomegaly and ascites in severe cases

Answer 372

- Patients can be very well with few symptoms - On examination there are usually signs of chronic liver disease - ascites, bruising, clubbing and Dupuytren’s contracture - There are features of alcohol dependency

Answer 373

- Hepatomegaly - Abdominal pain - Haematemesis - Venous collaterals - engorged para-umbilical veins (caput medusae), present in advanced alcoholic liver disease. - Splenomegaly - Jaundice - Palmar erythema - Asterixis - Ascites - Weight loss - Fatigue - Confusion - Pruritis - Fever - Nausea and vomiting - Finger clubbing - Dupuytren's contracture - Bruising - coagulopathy - Withdrawal symptoms - high pulse, low BP, tremor, confusion, fits, hallucinations

Answer 374

A combination of clinical features and laboratory findings are used to make a diagnosis. A liver biopsy is usually reserved for severe case. It helps to assess severity, look for underlying cirrhosis and exclude alternative causes of liver disease.

Answer 375

- FBC - U&Es - LFTs - Bone profile - CRP - Magnesium levels - INR - Non-invasive liver screen - Liver ultrasound - Liver biopsy

Answer 376

- FBC - U&Es - LFTs - Bone profile - CRP - Magnesium levels - INR - Non-invasive liver screen - Liver ultrasound - Liver biopsy

Answer 377

- C – CUT DOWN? Ever thought you should? - A – ANNOYED? Do you get annoyed at others commenting on your drinking? - G – GUILTY? Ever feel guilty about drinking? - E – EYE OPENER? Ever drink in the morning to help your hangover/nerves?

Answer 378

- Maddrey discriminant function (DF) - used to assess the severity of alcoholic hepatitis. It is based on serum bilirubin and prothrombin time. - Model for End-stage liver disease (MELD) - assesses severity - Glasgow alcoholic hepatitis score (GAH) - predicts mortality among patients with alcoholic hepatitis. It is a slightly more complex score based on age, white blood cell count, urea, bilirubin and prothrombin time.

Answer 379

- Alcohol cessation - Diazepam and/or IV thiamine to prevent Wernicke-Korsakoff encephalopathy. - Hydration - Nutrition

Answer 380

- Nutrition must be maintained with enteral feeding (high protein diet) and if necessary vitamin supplementation e.g. Vit K - Steroids show short-term benefit e.g. prednisolone. Given to patients who score high on Maddrey Discriminant Factor scoring system. - Screen for infections (ascitic fluid tap) and treat spontaneous bacterial peritonitis

Answer 381

- Reduce salt intake - Avoid aspirin and NSAIDs - Liver transplantation

Answer 382

- Liver failure, hepatocellular carcinoma - CNS complications etc - Obesity, diarrhoea, vomiting etc - Arrhythmias, hypertension, cardiomyopathy, sudden death - Coagulopathy, thrombocytopaenia, anaemia, folate deficiency, haemolysis

Answer 383

- Non-Alcoholic Fatty Liver Disease - NAFLD refers to a fatty liver that cannot be attributed to alcohol or viral causes - Spectrum of disease - steatosis, steatohepatitis, fibrosis, cirrhosis (least to most severe)

Answer 384

- Older age - Obesity - Hypertension - Diabetes - Hypertriglyceridemia - Hyperlipidemia

Answer 385

*May be asymptomatic even at advanced stages* - Sometimes symptoms may be vague - Fatigue - Malaise - Sufficient damage present with: - Hepatomegaly - Pain in RUQ - Jaundice - Ascites - Bruising - Pruritis

Answer 386

- Enhanced liver fibrosis scan - FIRST LINE - NAFLD fibrosis score - SECOND LINE - Fibroscan - THIRD LINE - Serum AST and ALT - LFTs - FBC - Imaging - US, CT, MRI - Liver biopsy - GOLD STANDARD

Answer 387

- Alcoholic liver disease - Autoimmune hepatitis - Hepatitis B and C - Hemochromatosis - DILI - Primary biliary cholangitis - Primary sclerosing cholangitis - Wilson's disease - Alpha-1 antitrypsin deficiency

Answer 388

- Steatosis and steatohepatitis is reversible if underlying cause is addressed. Cirrhosis is not reversible. - Avoid alcohol consumption - Reverse factors that contribute to insulin resistance - Healthy diet - Active lifestyle - Medication to control blood glucose - Control risk factors e.g. bariatric surgery for obesity - Address cardiovascular risk (commonest cause of death) - Vitamin E may improve histology of fibrosis

Answer 389

- Ascites - Varices and variceal haemorrhage - Encephalopathy - Hepatocellular carcinoma - Hepatorenal syndrome - renal disease secondary to liver failure - Hepatopulmonary syndrome - shortness of breath and hypoxemia caused by vasodilation in the lungs of patients with liver disease.

Answer 390

- Cirrhosis is a diffuse pathological process, characterised by fibrosis and conversion of normal liver architecture to structurally abnormal nodules known as regenerative nodules, surrounded by fibrotic tissue. - It can arise from a variety of causes (chronic alcohol use or viral attack) and is the final stage of any chronic liver disease. It can lead to portal hypertension, liver failure, and hepatocellular carcinoma. In general, it is considered to be irreversible in its advanced stages, although there can be significant recovery if the underlying cause is treated.

Answer 391

- Alcohol misuse - IV drug use - Obesity

Answer 392

- Leukonychia - white discolouration's on nails due to hypoalbuminaemia - Clubbing - Palmar erythema - Dupuytren’s contracture - Spider naevi - Xanthelasma - yellow fat deposits under skin usually around eyelids - Gynaecomastia - Loss of body hair - Hepatomegaly - Splenomegaly - Bruising - Ankle swelling and oedema - Abdominal pain due to ascites

Answer 393

- Liver biopsy - GOLD STANDARD - LFTs - FBC - Ascitic tap - Imaging - MRI or Ultrasound

Answer 394

- Constrictive pericarditis - Budd-Chiari syndrome - Portal vein thrombosis - Splenic vein thrombosis - Schistosomiasis - Sarcoidosis - Inferior vena cava obstruction

Answer 395

- Treatment of underlying condition - FIRST LINE - Promote change in diet and lifestyle - Liver transplant - SECOND LINE - Trans-jugular intrahepatic portosystemic shunt - SECOND LINE

Answer 396

- Coagulopathy - Encephalopathy - Hypoalbuminaemia - Hepatocellular carcinoma - Spontaneous bacterial peritonitis - Acute kidney injury - Portal hypertension

Answer 397

- The severity of cirrhosis can be graded using the Child-Pugh score. - The different classes reflect the severity of cirrhosis and provide an estimated one year survival. - Class A: mild disease, one year survival 100% - Class B: moderate disease, one year survival 80% - Class C: severe disease, one year survival 45%

Answer 398

- Yellow discolouration of the skin due to raised serum bilirubin. - Occurs at bilirubin levels greater than 51µmol/L or 3mg/dL.

Answer 399

- Pre-hepatic - Intra-hepatic or Hepatocellular - Post-hepatic

Answer 400

- Haemolytic anaemia - Gilbert’s syndrome - Criggler-Najjar syndrome

Answer 401

- Alcoholic Liver Disease - Viral hepatitis - Iatrogenic Hereditary Haemochromatosis - Autoimmune Hepatitis - Primary Sclerosing Cholangitis - Primary Biliary Cirrhosis - Hepatocellular Carcinoma

Answer 402

- Intra-luminal cause → Gallstones - Mural: cholangiocarcinoma, strictures, drug-induced cholestasis - Extra-mural: pancreatic cancer, abdominal masses

Answer 403

- Usually based on history and clinical observation of yellow discolouration. - LFTs - Coagulation tests - FBC - Ultrasound - looking for biliary obstruction

Answer 404

- Based on the underlying cause.

Answer 405

Primary biliary cholangitis (PBC), previously known as primary biliary cirrhosis, is an autoimmune condition characterised by granulomatous destruction of the intrahepatic biliary ducts, leading to cholestasis and subsequent leakage of bile into the circulation.

Answer 406

- Gender → Female > Male (x10 more) - Autoimmune conditions - Family history - Past pregnancy - Smoking - Excessive use of nail polish and hair dye - Chronic urinary tract infection

Answer 407

The classic presentation of PBC is with significant itching in a middle-aged female. Some patients may be asymptomatic and be simply diagnosed on a routine blood test demonstrating abnormal LFTs (e.g. raised ALP).

Answer 408

- Skin hyperpigmentation: due to increased melanin - Clubbing - Mild hepatosplenomegaly - Xanthelasma and xanthomata (late sign) - due to leakage of cholesterol - Scleral icterus (late sign)

Answer 409

- Pruritis (itchy skin) - leakage of bile salts - Fatigue and weight loss - Dry eyes and dry mouth - Sjögren's syndrome - Obstructive jaundice (late sign) - due to leakage of bile and conjugated bilirubin - Icteric - Pale stool and dark urine

Answer 410

- Antimitochondrial antibodies (AMA) - DIAGNOSTIC - Antinuclear antibodies (ANA) - Smooth muscle antibodies - Raised serum cholesterol - LFTs - Coagulation profile - Serum immunoglobulin - IgM - Transabdominal ultrasound

Answer 411

- Primary sclerosing cholangitis - AMA would not be found - Obstructive bile duct lesion - Drug induced cholestasis - can do liver biopsy

Answer 412

- Bile acid analogue e.g. ursodeoxycholic acid - FIRST LINE - Fat soluble vitamin supplementation (A, D, E, and K) - Cholestyramine - Codeine phosphate - Bisphosphonates - Liver transplant - ONLY FOR END-STANG LIVER DISEASE

Answer 413

- Malabsorption of fat soluble vitamins (A, D, E, and K) - Hypercholesterolaemia - Liver cirrhosis - Hepatocellular carcinoma - Metabolic bone disease

Answer 414

Primary sclerosing cholangitis (PSC) is an immune-mediated chronic liver disease that is characterised by inflammation, fibrosis and destruction of intrahepatic and/or extrahepatic bile ducts.

Answer 415

- Male - History of inflammatory bowel disease: usually ulcerative colitis (UC); 4% of patients with UC have PSC, 80% of patients with PSC have UC - Family history - Some association with HLA-A1, B8 and DR3

Answer 416

- Jaundice - Signs of complications: - Ascending Cholangitis: Charcot’s triad - Chronic liver disease: rare at first presentation, e.g. ascites or encephalopathy

Answer 417

- Pruritis - Fatigue - RUQ/ epigastric abdominal pain - Symptoms of underlying bowel disease: bloody stools, tenesmus, diarrhoea, steatorrhea

Answer 418

Charcot's triad, a classic presentation seen in 50% of patients with acute cholangitis, is characterized by fever, jaundice, and right upper quadrant pain.

Answer 419

- MRCP - Magnetic resonance cholangiopancreatography - GOLD STANDARD - LFTs (ALP, bilirubin, GGT, ALT, albumin, AST) - Viral hepatitis screen - Antibodies screen - pANCA (anti-neutrophil cytoplasmic antibodies) - Antimitochondrial antibodies - not present - ANA - Anticardiolipin antibodies - Abdominal ultrasound

Answer 420

- Observation and lifestyle change - FIRST LINE - Cholestyramine - pruritus relief - Fat soluble vitamin supplementation (A, D, E, and K) - Ursodeoxycholic acid - may improve LFTs - Antibiotics - for bacterial cholangitis - Liver transplant - FOR END STANGE LIVER DISEASE ONLY

Answer 421

- Cholangitis - Biliary strictures - Choledocholithiasis - Metabolic bone disease - End-stage liver disease - Cholangiocarcinoma - Hepatocellular carcinoma - Colorectal carcinoma

Answer 422

- PBC - more common in middle-aged women - PSC - More common in middle-aged men

Answer 423

- PBC - Progressive destruction of only intrahepatic small and medium sized bile ducts. - PSC - Progressive chronic inflammation of intra-hepatic and/or extra-hepatic bile ducts.

Answer 424

- PBC - Sjorgen syndrome (25%), Raynauds syndrome (25%), Autoimmune thyroid disease(25%). - PSC - Inflammatory bowel disease (75%) - particularly ulcerative cholangitis.

Answer 425

- PBC - Often asymptomatic, fatigue and pruritis, Jaundice, Hepatomegaly - PSC - Similar to PBC, Symptoms of IBD, Charcot's triad

Answer 426

- PBC - Increased ALP, GGT and conjugated bilirubin. Anti-mitochondrial antibodies. - PSC - Increased ALP, GGT, pANCA

Answer 427

- PBC - Cholestatic LFTs, History, Examination, abdominal ultrasound - PSC - Cholestatic LFTs, History, MRCP

Answer 428

- PBC - Ursodeoxycholic acid, Cholestyramine, Fat soluble vitamins (ADEK) - PSC - Observation and lifestyle, Cholestyramine, Fat soluble vitamins (ADEK) - Liver transplant for both - AT END STAGE ONLY

Answer 429

Autoimmune hepatitis (AIH) is a chronic inflammatory disease of the liver of unknown aetiology. It is characterised by the presence of circulating auto-antibodies with a high serum globulin concentration, inflammatory changes on liver histology, and a favourable response to immunosuppressive treatment.

Answer 430

- Gender → Female > Male (4:1) - Age → Type 1 = Adults, Type 2 = Children - Associated with other autoimmune conditions such as, Hashimoto's thyroiditis and primary biliary cholangitis - HLA-DR3 and HLA-DR4 association

Answer 431

- Evidence of chronic liver disease: - Jaundice - Spider telangiectasia - Gynaecomastia - Splenomegaly - Evidence of acute liver failure (less common): - Jaundice - Ascites - Variceal bleed - Encephalopathy

Answer 432

- Fatigue - Fever - Malaise - Urticarial rash - Arthralgia - Weight loss - Nausea - Amenorrhoea - 25% of cases are asymptomatic and patients may be asymptomatic even if their disease has progressed to cirrhosis. If symptoms are present, most cases present with non-specific symptoms.

Answer 433

- LFTs (ALT and AST elevated, bilirubin may be raised) - FBCs - Immunoglobulins - Liver biopsy - Viral screen - Autoimmune screen (ANA, anti-SMA, anti-SLA/LP, anti-LKM1, anti-LC1) - Hereditary screen

Answer 434

- High dose corticosteroids - FIRST LINE e.g. methylprednisolone or prednisolone - Liver transplant - Hepatitis A and B vaccines

Answer 435

- Immunosuppression e.g. prednisolone and azathioprine - FIRST LINE - High dose corticosteroids e.g. methylprednisolone or prednisolone - Hepatitis A and B vaccines - Liver transplant in severe cases

Answer 436

- Cirrhosis - Hepatocellular carcinoma - Iatrogenic - osteoporosis, Cushing's syndrome (long term steroid use)

Answer 437

Wilson's disease is an autosomal-recessive disease of copper accumulation and copper toxicity caused by mutations in the ATP7B gene, which is part of the biliary excretion of copper pathway.

Answer 438

Family history: suggests inherited mutations in the ATP7B gene

Answer 439

- Hepatic issues - Neurological issues - Psychiatric issues

Answer 440

- Behavioural and psychiatric issues: such as depression and delusions, often the first presentation. Also, loss of libido and bad memory. - Parkinsonism: half of patients present with a tremor - Asterixis - Chorea - Dysarthria - Dystonia - Dementia - Hepatosplenomegaly - Hepatitis and cirrhosis - Jaundice - Ascites - Asterixis and encephalopathy - Renal tubular acidosis - Fanconi syndrome - Kayser-Fleischer rings: copper ring in iris. - Haemolytic anaemia - Blue nails - Arthritis - Grey skin - Hypermobile joints

Answer 441

- Copper studies - serum ceruloplasmin - LFTs - increase in AST and ALT - Genetic testing: ATP7B mutation - Liver biopsy - GOLD STANDARD - MRI of the brain

Answer 442

- Copper chelation e.g. Penicillamine or Trientene - Lifestyle advice - Liver transplantation

Answer 443

- Liver failure - Renal stones - Renal failure - Side effects of medication

Answer 444

- Haemochromatosis is a multisystem disorder of dysregulated dietary iron absorption and increased iron release from macrophages. - Type 1 (HFE-related) hereditary haemochromatosis most commonly occurs in individuals of northern European descent (1 in 10 people carry a mutation).

Answer 445

- Family history - Alcoholism - History of chronic transfusion: only relevant in acquired haemochromatosis, for example in patients with thalassaemia

Answer 446

- Skin hyperpigmentation (bronze skin) - Arthritic joints - Testicular atrophy - Features of chronic liver disease e.g. hepatomegaly - Features of congestive cardiac failure e.g. peripheral oedema due to dilated cardiomyopathy - Signs of osteoporosis

Answer 447

- Patients are usually asymptomatic, especially in early stages. - Early symptoms: lethargy, arthralgia (often in hands) and erectile dysfunction - Loss of libido: hypogonadism due to cirrhosis and pituitary dysfunction - Polyuria and polydipsia due to T1DM

Answer 448

- Serum ferratin levels - FIRST LINE - Serum transferrin saturation - LFTs - Genetic testing - Liver biopsy - CT or MRI

Answer 449

- Venesection - FIRST LINE - Iron chelation - SECOND LINE - Avoid alcohol - Low iron diet - Genetic counselling

Answer 450

- Cirrhosis - Hepatocellular carcinoma - Diabetes Mellitus - Hypogonadism - Dilated cardiomyopathy - Congestive HF - Pseudogout - Osteoporosis - Skin hyperpigmentation

Answer 451

- Alpha-1 antitrypsin deficiency is a rare autosomal recessive disorder that causes liver and pulmonary disease. - A1AT is a type of serine protease inhibitor. Deficiency is called serinopathy.

Answer 452

Family history: there may be a family history of early-onset COPD and/or AAT deficiency

Answer 453

Early onset of COPD

Answer 454

- Jaundice - Hepatomegaly - Ascites - Inability to make coagulation factors - Build-up of toxins leading to hepatic encephalopathy - Portal hypertension and consequent complications - Dyspnoea and productive cough - Prolonged expiratory phase and wheeze with pursed-lip breathing - Weight loss - Barrel chested due to hyperexpanded lungs

Answer 455

- Plasma AAT level - FIRST LINE - High resolution chest CT - Lung function test - Liver biopsy - Genetic tests: allows identification of the mutated allele and the patient’s genotype, e.g. PiZZ

Answer 456

- Asthma - COPD - Bronchiectasis - Viral hepatitis - Alcoholic liver disease

Answer 457

- Smoking cessation and pollution avoidance - FIRST LINE - Alcohol avoidance - FIRST LINE - COPD treatment - A1AT augmentation - Hepatitis A and B vaccinations - Organ transplant - END STAGE management

Answer 458

- Respiratory failure - Cirrhosis and hepatocellular carcinoma - Cholestasis

Answer 459

- Sometimes called portosystemic encephalopathy. - Hepatic encephalopathy is a neuropsychiatric syndrome caused by acute or chronic advanced hepatic insufficiency. - Characterised by confusion and drowsiness as well as other more worse symptoms.

Answer 460

- Cirrhosis - Acute hepatic failure - Portocaval shunt

Answer 461

- Symptoms vary in severity from mildly altered mental state to coma but is often reversible with treatment. - Mood disturbances - euphoria or depression. - Sleep disturbances - insomnia or hypersomnia. - Motor disturbances - muscle rigidity, bradykinesia, hypokinesia, slow monotonous speech, tremor. - Advanced neurological deficits - hyper-reflexia, nystagmus, clonus. - Acutely it presents with reduced consciousness and confusion, but chronically is more changes to personality, memory and mood.

Answer 462

- Constipation - Electrolyte disturbance - Infection - GI bleed - High protein diet - Mediations such as sedatives

Answer 463

- I - Altered mood/behaviour, sleep disturbance, dyspraxia - II - Increasing drowsiness, confusion, slurred speech +/- liver flap, inappropriate behaviour/personality change - III - Incoherent, restless, liver flap, stupor - IV - Coma

Answer 464

- Laxatives e.g. lactulose - Aim for 2-3 soft motions daily - Antibiotics e.g. Rifaximin - Reduce number of intestinal bacteria making ammonia - Nutritional support → NG tube maybe

Answer 465

- Cavernous haemangioma - Nodal Nodular Hyperplasia - Hepatic adenoma

Answer 466

Primary hepatocyte neoplasia. Accounts for 90% of primary liver cancers.

Answer 467

- Gender → Male > Female - HBV - HCV - Cirrhosis

Answer 468

- Palpation - enlarged, irregular, tender liver may be felt - Signs of chronic liver disease - Signs of decompensation - jaundice (will appear late), ascites - Listen for bruit - murmur over the liver

Answer 469

- Fever - Malaise - Fatigue - Loss of appetite - Weight loss - RUQ pain - Jaundice - Ascites - Haemobilia - bleeding into biliary tree

Answer 470

- Alpha-fetoprotein - tumour marker for HCC - Live ultrasound - CT and MRI scans - Biopsy - LFTs

Answer 471

- Resect solidary tumours - FIRST LINE - Liver transplant - Percutaneous ablation - Kinase inhibitors in advanced disease - HCC is considered resistant to chemotherapy and radiotherapy

Answer 472

- A toxic overdose is defined as ingestion of paracetamol >75mg/kg. - 12g/ 24 tablets or 150mg/kg in adults may be fatal

Answer 473

- Jaundice - Encephalopathy - reduced GCS - consciousness - Tachycardia/ hypotension - Evidence of self-harm

Answer 474

- Abdominal pain - Right upper quadrant pain - Nausea or vomiting - Confusion or coma

Answer 475

- Serum paracetamol - LFTs - Clotting screen - U&Es - Arterial blood gas

Answer 476

- Supportive care - FIRST LINE - Active charcoal - IV N-acetylcysteine (NAC) - Anti-emetics - Liver transplantation - Psychiatric output

Answer 477

- Acute liver failure - Acute kidney injury - Anaphylactoid reaction

Answer 478

The Hepatitis A virus is a non-enveloped single-stranded RNA virus.

Answer 479

Hepatitis B is caused by the hepatitis B virus (HBV). It is an enveloped DNA virus that belongs to the Hepadnaviridae family and can cause acute or chronic hepatitis:

Answer 480

Acute: can occur at any age. Majority of patients have a subclinical or anicteric (no evidence of jaundice) illness. In adults and older children, usually a self-limiting illness. In young children, more likely to develop chronic infection.

Answer 481

Chronic: failure to clear the virus after acute infection. Defined as persistence of hepatitis B surface antigen (HBsAg) for >6 months. HBsAg is a viral protein that can be measured in the blood. Chronic hepatitis B (CHB) can lead to cirrhosis and hepatocellular carcinoma (HCC).

Answer 482

- Hepatitis C virus (HCV) is an infectious, hepatotropic virus belonging to the Flavivirus family. Infection may be acute and chronic. - Spread by blood transfusions, IV drug abuse, and sexual contact. Vertical transmission is rare.

Answer 483

- Hepatitis D virus (HDV) is a unique RNA virus that can only establish infection in the human liver with the help of Hepatitis B virus (HBV). HDV has an outer envelope that contains the HBV surface antigen (HBsAg). Therefore, it can only establish infection in HBsAg-positive patients.

Answer 484

- Hepatitis E is a small, non-enveloped RNA virus that can lead to acute and chronic hepatitis. - Now recognised as the most common cause of acute viral hepatitis in many countries. - HEV is spread via the faeco-oral route.

Answer 485

- Fever - Malaise - Nausea - Hepatomegaly - RUQ pain

Answer 486

- Raised ALT and AST on LFTs - Atypical lymphocytosis - Jaundice - Increased urobilinogen in urine

Answer 487

A is Acquired by mouth from Anus, is Always cleared Acutely and only ever Appears once E is Even in England and can be Eaten (found in pigs), if not always beaten B is Blood-Borne and if not Beaten can be Bad B and D is DastarDly C is usually Chronic but Can be Cured - at a Cost

Answer 488

- Acute liver failure is a syndrome of acute liver dysfunction without underlying chronic liver disease. - ALF is characterised by coagulopathy (derangement in clotting) of hepatic origin and altered levels of consciousness due to hepatic encephalopathy (HE).

Answer 489

- Hyperacute: HE within 7 days of noticing jaundice. Best prognosis as much better chance of survival and spontaneous recovery. - Acute: HE within 8-28 days of noticing jaundice - Subacute: HE within 5-12 weeks of noticing jaundice (ALF may be defined up to 28 weeks). Worst prognosis as usually associated with shrunken liver and limited chance of recovery.

Answer 490

Jaundice and hepatic encephalopathy

Answer 491

- Hepatic encephalopathy - Raised intracranial pressure - Fetor hepaticus - Jaundice - RUQ pain - Hepatomegaly - Ascites - Bruising - GI bleeding - Hypotension - Signs of chronic liver disease

Answer 492

The severity of HE can be graded using the West Haven criteria: - Grade I: change in behaviour with minimal change in level of consciousness. May have mild asterixis or tremor. - Grade II: gross disorientation, drowsiness, asterixis and inappropriate behaviour - Grade III: marked confusion, incoherent speech, sleeping most of the time but rousable to verbal stimuli. Asterixis less noticeable, elements of rigidity. - Grade IV: coma that is unresponsive to verbal or painful stimuli. Evidence of decorticate or decerebrate posturing.

Answer 493

- FBC - U&Es - LFTs - Blood glucose - Arterial ammonia - ABG - Coagulation - Lactate dehydrogenase - Lipase/amylase - Blood cultures

Answer 494

- Paracetamol serum level - Alpha-1 antitrypsin levels - Caeruloplasmin levels - Ferritin levels - Autoimmune markers: ANA, autoantibodies, immunoglobulins, ANCA - Toxicology screen: serum/urine - Ascitic tap - Viral screen: blood and urine culture

Answer 495

- Ultrasound - Doppler ultrasound - Chest X-ray - CT abdomen and pelvis

Answer 496

- Treat underlying cause - Intensive care management - Fluid resuscitation - Intubation and ventilation - NG feeding - Metabolic → blood glucose levels, acisosis, electrolyte balance - Renal → AKI common, renal replacement therapy or haemodialysis - Coagulopathy → blood products (FFP) - Liver transplant

Answer 497

- Acute kidney injury/ hepatorenal syndrome - Metabolic disturbance - Hypoglycaemia - Haemorrhage (e.g. GI Bleeding) - Cerebral dysfunction (e.g. seizures, irreversible brain injury). - Patients are at risk of high output cardiac failure due to low vascular resistance from the widespread inflammatory response. - Sepsis

Gastrointestinal Flashcards

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