Gastrointestinal Flashcards
(88 cards)
1
Q
What are the distinguishing features of Chrohns vs UC?
A
- Chrohs:
- Cobblestone appearance
- Rosethorn ulcers
- Discontinuous/ skip lesions
- Transmural - Obstructucted bowel
- Narrowing of intestinal lumen
- Skip lesions and strictures
- Ileocaecal valve: RIF pain
- UC:
- Rectum mainly - LIF pain
- Continuous
- Crypt abscesses
- Submucosa and mucosa mainlt
- Loss of haustra > lead pipe colon
2
Q
What is UC?
A
- US is a relapsing and remitting IBD of the colonic mucosa.
- It may affect just the rectum
- Can extend to part of the colon (left-sided colitis) or the entire colon (pancolitis, in ~30%).
- ‘Never’ spreads proximal to the ileocaecal valve
3
Q
What is the pathophysiology of UC?
A
- Hyperaemic/haemorrhagic colonic mucosa ± pseudo-polyps formed by inflammation.
- Punctate ulcers deep into the lamina propria—
- Continuous inflammation of mucosa
- Mucosa and submucosa - NOT transmural
4
Q
What are some of the symptoms of UC?
A
- Episodic or chronic diarrhoea (± blood & mucus)
- Crampy abdominal discomfort
- Systemic symptoms: fever, malaise, anorexia, ↓weight.
5
Q
What are some of the extra intestinal signs of UC?
A
- Fingers: Clubbing
- Mouth: Aphthous oral ulcers
- Skin: Erythema nodosum, Pyoderma gangrenosum
- Eyes: Conjunctivitis; episcleritis; iritis
- Bones: Large joint arthritis; sacroiliitis; ankylosing spondylitis; psc (p[link]); nutritional deficits.
6
Q
What investigations are used to for diagnosing IBD?
A
- Blood tests: FBC (anaemia, leukocytosis, or thrombocytosis); UE (AKI due to GI losses); CRP; ESR, LFT
- Stools: stool cultures; faecal calprotectin (do not do in presence of blood); c. diff
- Simple imaging: AXR (less frequent but use for toxic megacolon): dilated loops with air-fluid level secondary to ileus; free air is consistent with perforation; in toxic megacolon, the transverse colon is dilated to ≥6 cm in diameter
- Endoscopy:
- Flexible sigmoidoscopy (safest in bloody diarrhoeah)
- Colonoscopy (proximal disease)
- Capsule endoscopy (small bowel mucosa:
- Biopsy
- Cross sectional imaging
- CT abdomen
- MRI enterography
- MRI rectum
7
Q
What are some of the complications of UC?
A
- Toxic dilatation of colon (toxic megacolon)
- Venous thromboembolism
- Colonic cancer
- Perforation
- Infection
- Stricture/ pseudopolyps
8
Q
How is IBD (maintaining remissions) treated?
A
- UC:
- Mesalazine 5-asa (PR or PO)
- Hydrocortisone: Topical steroid foams pr
- Chrohns:
- Azathioprine
- Biologics: Anti-tnfα infliximab and adalimumab; Anti-integrin etc.
9
Q
How is acute (moderate - severe) IBD managed?
A
- UC
- Moderate: oral prednisolone 40mg/d for 1wk; then maintain on mesalazine
- Severe: IV Hydrocortisone 100mg/6h; iv hydration/electrolyte replacement
- If symptoms dont improve 3-5 days: cyclosporin
- Or biologics: infliximab
- Then surgery
- Chrohns:
- Same as above
- Severe: IV Hydrocortisone 100mg/6h, NBM, metranidazole
- Biologics: Anti-TNFα; Anti-integrin
- Surgery: ~20% subtotal colectomy + terminal ileostomy
10
Q
What is Chrohns?
A
A chronic inflammatory disease characterized by transmural granulomatous inflammation affecting any part of the gut from mouth to anus
11
Q
What are some of the symptoms of Chrohns?
A
- Diarrhoea (more mucus filled than blood unlike UC)
- Abdominal pain (RIF)
- Weight loss
- Systemic symptoms: fatigue, fever, malaise, anorexia.
12
Q
What are some of the intraintestinal signs of Chrohns?
A
- Bowel ulceration
- Abdominal tenderness/mass
- Perianal abscess/fistulae/skin tags
- Anal strictures
13
Q
What are some of the small bowel complications of Chrohn’s?
A
- Toxic dilatation of colon
- Abscess formation (abdominal, pelvic, or perianal)
- Fistulae: entero-enteric, colovesical (bladder), colovaginal, perianal
- Colon cancer
- Malnutrition.
14
Q
What tests should be performed for Crohns?
A
- Bloods: FBC (anaemia), ESR, CRP (elevated), U&E, LFT, INR, ferritin B12, folate - may be low (anaemia)
- Stool: faecal calprotectin, C.diff
- Imaging: plain abdo x ray, CT
- Specialist: colonoscopy, tissue biopsy, ?OGD (if disease extensive)
15
Q
What is Charcot’s triad?
A
RUQ, Fever, Jaundice
16
Q
What is Reynald’s Pentad?
A
- Charcots triad
- shock (tachycardia, hypotensive, shock)
- Indicated serious infection of biliary tree
17
Q
What is Mirizzi syndrome?
A
Obstructive jaundice from common bile duct compression by a gallstone impacted in the cystic duct, often associated with cholangitis
18
Q
How is Biliary Colic treated?
A
- Conservative: lifestyle, weight loss, reduced fat
- Pharmacological:
- Analgesia: morphine
- Anti emetic: metacloperamide?
- Surgery: elective lap cholecystectomy in 6 wks of presentation
19
Q
What is Calot’s triangle?
A
- Calot’s triangle (cystohepatic triangle) is a small anatomical space in the abdomen.
- It is located at the porta hepatis of the liver – where the hepatic ducts and neurovascular structures enter/exit the liver.
- The borders are as follows:
- Medial – common hepatic duct.
- Inferior – cystic duct.
- Superior – inferior surface of the liver.
20
Q
What is the surgical relevance of Calots triangle?
A
- Clinical importance during laparoscopic cholecystectomy
- Triangle is dissected by surgeon, and its contents and borders identified.
- Permits safe ligation and division of the cystic duct and cystic artery.
- Right hepatic artery is important – this must be identified by the surgeon prior to ligation of the cystic artery.
- If Calot’s triangle cannot be found ( e.g. inflammation), the surgeon may perform a subtotal cholecystectomy, or open surgery.
21
Q
What is Coeliac disese?
A
- Immunological response to the Gladin fraction of gluten
- Immune activation in the small intestine leads to villous atrophy, hypertrophy of the intestinal crypts, and increased numbers of lymphocytes in the epithelium and lamina propria
- Suspect this if diarrhoea + weight loss or anaemia (esp. if iron or b12 ↓)
22
Q
What is the prevalence of Coeliac?
A
- 1 in 100–300 (commoner if Irish).
- Peaks in childhood and 50–60yrs ♀:♂ >1:1.
- Risk in 1st-degree relatives
23
Q
What are the symptoms of Coeliacs?
A
- Stinking stools/steatorrhoea
- Diarrhoea
- Abdominal pain
- Bloating; nausea + vomiting
- Mouth: Aphthous ulcers and angular stomatitis
- ↓weight
- Fatigue
- Weakness
- Bones: Osteomalacia
24
Q
What are some of the complications of Coeliac?
A
- Anaemia
- Dermatitis herpetiformis
- Osteopenia/osteoporosis
- GI t-cell lymphoma
- ↓weight
- ↑risk of malignancy (lymphoma, gastric, oesophageal, colorectal)
- Neuropathies
25
How is Coeliac diagnosed?
* **Bloods:** General:**↓Hb↓b12, ↓ferritin,** consider blood smear
* **Antibodies**:
* **IgA-tTG** - not a diagnostic test in adult patients - *above normal*
* **Endomysial antibody**
* **Imaging:**
* **Endoscopy and duodenal biopsy** *while on a gluten-containing diet:*
* Subtotal villous atrophy
* ↑Intra-epithelial wbcs
* Crypt hyperplasia
* **Others**: HLA, skin biopsy *(dermatitis* *herpetiformis),* gluten challenge
26
How is Coeliac disease treated ?
* Gluten free diet
* **Bisphosphonates** for osteoporosis
* **Pneumococcal** vaccine + booster every 5 years + influenza on a case by case basis
27
What is dysphagia?
Dysphagia is difficulty in swallowing and should prompt urgent investigation to exclude malignancy
28
What are some of the causes of dysphagia?
Oral, pharyngeal, or oesophageal? Mechanical or motility related?
29
What are the key history questions to ask re dysphagia?
1. Was there difficulty swallowing solids + liquids from the start?
* **Yes: motility** disorder (eg achalasia, cns, or pharyngeal causes).
* **No:** Solids then liquids: **stricture** (benign or malignant).
2. Is it difficult to initiate a swallowing movement?
* **Yes:** bulbar palsy, especially if patient coughs on swallowing
3. Is swallowing painful (odynophagia)?
* Yes: **ulceration** (malignancy, oesophagitis, viral infection or Candida in immunocompromised, or poor steroid inhaler technique) / **spasm**.
4. Is the dysphagia intermittent or is it constant and getting worse?
* **Intermittent:** oesophageal spasm.
* **Constant and worsening**: suspect **malignant stricture**
5. Does the neck bulge or gurgle on drinking?
* **Yes:** Suspect a **pharyngeal pouch**
30
What are some of the signs of dysphagia?
* Is the patient cachectic or anaemic?
* Examine the mouth
* Feel for left Virchow’s node—intra-abdominal malignancy)
* Signs of systemic disease eg systemic sclerosis
31
What are some of the tests for dysphagia?
Bloods: FBC (anaemia); U+E (dehydration).
1. **OGD** ± biopsy
2. **Barium swallow** - pharyngeal pouch
3. **Oesophageal manometry** - dysmotility.
(Video fluoroscopy may help identify neurogenic causes)
32
What are the symptoms and investigations for diffuse oesophageal spasm?
* Sx: intermittent dysphagia ± chest pain.
* Contrast swallow/manometry: abnormal contractions
33
What is Achalasia?
Achalasia is an oesophageal motor disorder of unknown aetiology, characterised by oesophageal aperistalsis and insufficient lower oesophageal sphincter (LOS) relaxation in response to swallowing
34
What are the sx of achalasia?
* Dysphagia
* Regurgitation
* ↓Weight
* Retrosternal pressure and pain
35
How is achalasia investigated and what is found?
* **Upper GI endoscopy**: *mucosa obscured by retained saliva with frothy appearance; in advanced cases oesophagus may be dilated and tortuous and contain food debris (sigmoid oesophagus)*
* **Manometry**: *incomplete relaxation of LOS with wet swallows and oesophageal aperistalsis; typically high resting lower oesophageal pressure*
* **Barium swallow:** *bird beak-like narrowing at the gastro-oesophageal junction*
*
36
How is achalasia treated?
* Pharmacological:
* **PPIs**
* **CCBs**: nifedepine
* **Nitrates**: isosorbide dinitrate
* Surgical:
* **Botulinum** toxin injection (non-invasive procedure)
* **Endoscopic pneumatic balloon dilatation**
* **Laparoscopic Heller's cardiomyotomy**
37
When should dyspepsia be referred?
* Dysphagia OR
* \>55 yo + persistent symptoms OR
* ALARM signs
38
What are the alarm's symptoms?
* **A**naemia
* **L**oss of weight
* **A**norexia
* **R**ecent onset/ progressive symptoms
* **M**alaena/ haematemesis
* **S**wallowing/ difficulty
39
In addition to ALARMS, what are the other symptoms experienced?
* **Epigastric pain** often related to hunger
* Specific foods, or time of day,
* **Fullness** after meals
* **Heartburn** (**retrosternal** pain)
* **Tender** epigastrium.
40
One of the most common causes of dyspepsia, is H.Pylori. How is this tested and treated?
* **2 abx + PPI** -
* **Lansoprazole** 30mg/12h po
* **Clarithromycin** 250mg/12h po
* **Amoxicillin** 1g/12h po for 1wk.
* Refer for urgent endoscopy - dysphagia, + ≳55 with alarm symptoms / with treatment-refractory dyspepsia
41
What is the incidence of duodenal vs peptic ulcer?
4-fold commoner than GU
42
What are the major minor RFs for duodenal ulcers?
* **Major:** H.pylori (90%); drugs (nsaids; steroids; ssri).
* **Major**: ↑Gastric acid secretion; ↑gastric emptying (↓duodenal pH); blood group o; smoking.
43
What are the signs/ symptoms of duodenal vs gastric ulcers?
* Gastric: eating **exacerbates** rather than relieves pain
* Duodenal: pain is **relieved** by food but occurs 2-3 hr after a meal
44
What is the diagnosis for duodenal ulcer?
* **Upper gi endoscopy.**
* Test for H.pylori
* Measure gastrin concentrations when off ppis - Zollinger–Ellison syndrome
45
Where and to whom to gastric ulcers occur?
* Stomach - lesser curve.
* Elderly
* Ulcers elsewhere are more often malignant.
46
What are the risk factors for gastric ulcers?
* H.pylori (~80%)
* Smoking
* NSAIDs
* Reflux of duodenal contents
* Delayed gastric emptying
* Stress, eg neurosurgery or burns (Cushing’s or Curling’s ulcers).
47
How are gastric ulcers diagnosed?
* **Upper gi endoscopy** to exclude malignancy
* **Multiple biopsies** from ulcer rim and base (histology, H.pylori).
* **Repeat endoscopy** after 6–8 weeks to confirm healing and exclude malignancy.
48
What are the functions of the liver?
49
What is Wernicke's encephalopathy?
* Caused by B1 (thiamine) deficiency secondary to alcohol miuse
* Presents: confusion, ataxia, nystagmus
50
What are the risk factors to be asked for patients with liver disease?
* Blood transfusions \<1990 UK
* Ops/ Vaccinations
* IVDU
* Sexual exposure
* Medications
* FH (liver disease, diabetes, IBD)
* Obesity
* Alcohol
* Foreign travel
51
When do acute and chronic liver disease arise?
Acute:
* No existing liver condition
* Resolves in 6 months: Hep A, E, CMV, EBV, DILI
Chronic:
* Starts with acute
* Effects beyond 6mo
* Cirrhosis and complications: alcohol, Hep C, NASH, autoimmune (PBC,PSC, AIH)
52
What are the signs of chronic liver diease?
* Spider naevi
* Finger clubbing
* Palmer erythema
* Ascites
* Hepato/splenomegaly
* Hepatic encephalopathy
* Coagulopathy
* Jaundice
* Hepatic flap
* Aphraxia
53
What investigations are used in liver disease and what do they look for?
* Bloods: FBC, UE, coagulopathy( **thrombocytopenia),** Bilirubin/ Albumin, glucose, paracetemol, Hep ABC, CMV + EBV serology, ferritin, a1 anti trypsin deficiency, LFT:
* **îALT:** Hepatocytes
* **îALP: + îGGT** - Bile ducts disease + some liver conditions **(post hepatic)**
* **îALP alone -** bone disease
* **îLFT** showing **cholestatic** abnormality --\> **USS** (dilated ducts/ cirrhosis)
* Microbiology: urine and blood cultures, ascitic tap (SBP)
* Imaging: CXR, USS, doppler of veins
54
What is included in the liver screen?
* Hepatitis BC
* IRON: ferritin/ transferring
* AutoABs (AMA/SMA), Ig
* CAEROPLASMIN
* Alpha-a-antitrypsin
* Coeliac
* TFT, lipids, glucose
55
How do you manage liver failure?
* NG tube/ cathetar
* Nutritional supplements: **thiamine** + **folate**
* Steroids
* 10% **glucose** to avoid hypoglycaemia
* Treat the cause: e.g. paracetemol - ***N-acetylcysteine***
* Ascites: **furosemide** + **spironolactone**
* Bleeding: **vitamin** **K**
* Encephalopathy: **lactulose** 30–50mL/8h(aim for 2–4 soft stools/d + **Rifaximin**
* Seizures (+alcohol withdrawal): **diazepam** + **lorazepam**
* **Liver transplant**
56
What criteria is used for determining liver transplantation
King College Criteria for Liver Transplantatio
57
Which conditions lead to chronic liver disease which could lead to cirrhosis. Which ones are more common in men and females?
* Non alcoholic steatohepatis hepatitis
* Viral hepatitis B+C
* **Women:** PBC, autoimmune hepatitis
* **Men:** PSC, associated with IBD, haemachromatosis
* **Adolescents/ young adults:** Wilsons, anti LKM autoimmune hepatitis
58
What is liver Cirrhosis?
* Cirrhosis is the pathological end-stage of any chronic liver disease and most commonly results from chronic hepatitis B and C, alcohol-related liver disease, and non-alcoholic fatty liver disease
* Irreversible liver damage.
* Histologically: fibrosis and conversion of normal liver architecture to structurally abnormal nodules known as regenerative nodules
59
What are some of the signs of liver cirrhosis?
* Leuconychia: white nails with lunulae undemarcated, from hypo-albuminaemia
* Hands: Palmar erythema, Dupuytren’s contracture; spider naevi
* Xanthelasma
* Gynaecomastia
* Atrophic testes
* Loss of body hair
* Parotid enlargement
* Portal hypertension: Hepato (small in late liver)/ splenomegaly, Ascites
60
Who should you suspect liver cirrhosis for?
* Patients with **thrombocytopenia**
* **Clinical stigmata of chronic liver disease**
61
What investigations are used for Cirrhosis
* **Imaging**: - splenomegaly, course texture, nodularity
* **Fibroscan:** quicker and more specific
* **Endoscopy**: for varices
62
What are the complications of Cirrhosis and how are they investigated and treated?
* **Oesophageal varices:** Endoscopy: *Primary prophylaxis*
* **Splenomegaly, liver fibrosis, nodules, sclerosis, hepatomagaly:** USS: (+fibroscan, liver biopsy)
* **Ascites:** *Spirinolactone \> paracentesis*
* **Spontaneous bacterial peritonitis:** Ascitic tap
* **Hepatocellular carcinoma: alpha-fetoprotein, USS** every 6 months
63
What questions should be asked when nutritional assessment is considered
* Appetite
* Diet history
* Changes in oral intake
* Changes in weight
* **MUST** tool - Malnutrition Universal Screening tool
64
How do you provide nutritional support conservatively?
* Food and encouragement
* Avoid interruptions
* Encourage high quality options
* Assist with eating
* Provide appropriate cutlery
* Teeth
* Dietitician - nutritional supplements
65
What options provide nutrition when they have a non functioning GI tract or unsafe swallow?
* NG tube
* PEG/ RIG?PEGJ/RIGJ
* Paraenteral nutrition
66
What is an NG tube and what are its benefits?
* Short term access and provide all of the nutritional and fluid requirements
* On top of pt oral intake
* Check pH to ensure tip is in stomach (not lungs) - pH can be affected by PPI
* Use CXR to confirm position
* Can \< risk of aspiration, but they can still aspirate through saliva
67
What is an PEG/RIG/PEGJ/RIGJ and what are its benefits?
* Provide **longer term** enteral access than an NG tube
* **Stomach** - PEG and RIG
* **Small bowel** - PEG-J or PEG-J
* Must be placed **endoscopically** (PEG) or **radiologically** (RIG)
* Do not prevent aspiration as patients may aspirate through their saliva.
68
What is paraenteral nutrition and what are its benefits?
* Provides nutrition and fluid directly into patients **veins**
* When GI tract is not accessible (blocked) or not working (short, leaking or diseased)
* Mix of fluids, micro and macronutritients
* Dedicated **central line required: PICC or Hickman line**
* Risks: **sepsis, liver dysfunction**
69
What other questions should be asked in a GI bleed history?
* What do they mean by **passing blood**
* **Haematemesis** (fresh vomited blood) ?
* **Coffee ground vomit** (altered blood but anything that has been in the stomach)
* **Malaena** (black tarry sticky stool)
* **Fresh PR bleeding** (lower GI or in a haemodynamically unstable pt it can be upper GI)
* **Risk factors:** chronic liver disease, stigmata of chronic liver disease, NSAIDs, anti patelets or anticoagulants?
70
What are some of the common causes of an upper GI bleed?
* Peptic ulcers
* Mallory-Weiss tear
* Oesophageal varices
* Gastritis/gastric erosions
* Drugs (NSAIDS, aspirin, steroids, thrombolytics, anticoagulants)
* Oesophagitis
* Duodenitis
* Malignancy
* No obvious cause
71
What are some of the rarer causes of upper GI bleeding?
* Bleeding disorders
* Portal hypertensive gastropathy
* Aorto-enteric fistula10
* Angiodysplasia
* Haemobilia
* Dieulafoy lesion11
* Meckel’s diverticulum
* Peutz-Jeghers’ syndrome
* Osler-Weber-Rendu syndrome.
72
What signs indicate an upper GI bleed?
* Malaena
* Haematemesis
73
How would you manage an acute upper GI bleed?
* ABCDE!
* A- Protect airway
* B- High flow o2
* C **- IV access,** 2 wide bore cannulae, take bloods (FBC, UE, LFT, clotting, cross match, group and save);
* **IV fluids:** If haemodynamically, give group O Rh−ve blood. Avoid saline if cirrhotic/varices
* **Transfuse** (with crossmatched blood if needed) if significant Hb drop (\<70g/L).
* **Urinary cathetar:** Urine Output
* Consider **CVP line** to monitor and guide fluid replacement
* CXR, ECG, ABG
* Correct clotting abnormalities (vitamin k, ffp, platelets)
* Specific management: **varices** - **terlipressin iv eg 1–2mg/6h for ≤3d +** broad-spectrum iv antibiotic cover.
* Monitor pulse, bp, and cvp (keep \>5cmH2O) at least hourly until stable.
* **OGD**
* If endoscopic control fails, surgery or emergency mesenteric angiography, varices: **Sengstaken–Blakemore tube** - *uses balloons to decompress the varices*
74
What tests are used for evaluating Upper GI bleeds?
* **Rockall** - risk of death by upper GI bleeds and re bleeding
* **Glasgow Blatchford** - predicts need for intervention. Spec blood tests required
75
What are the specific management techniques for oesophageal varices?
1. **IV access** and **fluid resuscitation**
2. **IV Prophylactic AB** (broad spectrum)
3. **Telipressin** (if no ischaemic HD/ PVD) + somatostatin analogues
4. Refer for **Upper GI endoscopy.**
5. **Surgery**
1. Endoscopic **banding**
2. **Sengstaken–Blakemore tube -** uses balloons to decompress the varices. Used to buy time.
3. **TIPPS** (trans jugular intra hepatic porto systemic shunt) - connects portal + hepatic vein.
76
How do you specifically manage Peptic Ulcer?
* Adrenaline, cauterisation, IV PPI omeprazole 80mg
* H Pylori eraditcation (clarithromycin, amoxicillin, PPI)
* Urgent upper GI endoscopy
* Emergency mesenteric embolisation/ Angioembolisation
77
What will blood tests reveal to you in an upper GI bleed?
* FBC - Hg + platelet count - **thrombocytopenia** - **chronic liver disease**
* UE - Î **urea**
* **Clotting** - abnormal clotting
* **Group + save**
* **LFTs** - normal LFTs do not exclude _chronic liver disease_
* **Venous blood gas** - **Hg** result
78
What are the important things to consider when managing non variceal bleeding?
* Causes: ulcer disease, vascular malformations: angiodysplasia
* More likely to stop bleeding on their own than variceal bleeds
* Ensure pt is haemadynamically stable before endoscopy
79
How would you immediately manage managing non variceal bleeding?
* **IV access**
* **Fluid resuscitation**
* Prescription: PPI possible post endoscopy
* Discuss with GI team.
* Endoscopy
* If bleeding does not stop by endoscopy, radiological embolization or surgery may be possible
* PPI to treat ulcers (maybe)
80
What things should you check with Upper GI bleeding?
* **Peripherally cool/clammy**; capillary refill time \>2s; urine output \<0.5mL/kg/h
* **↓GCS** (tricky to assess in **decompensated liver disease**) or **encephalopathy**
* **Tachycardia** (pulse \>100bpm)
* **Systolic BP** \<100mmHg; postural drop \>20mmHg.
* Calculate the **Rockall score**
81
What are some of the complications of cirrhosis?
* **Hepatic failure:** coagulopathy, encephalopathy, hypoalbuminaemia (oedema, leuconychia), liver flap, SBP, hypoglycaemia
* **Portal hypertension:** ascites, splenomegaly, oesophageal varices, caput meducae
* **Increased risk of HCC**
82
How would you manage liver cirrhosis?
* **Conservative**: stop drinking and smoking, lose weight, avoid NSAIDs, opiates and other hepatotoxic drugs
* **Pharmacological**: symptomatic management
* **Alcohol abstinence:** **diazepam** and **chlordiazepoxide**
* Pruritis: **colestyramine**
* Ascites: **spironolactone** + **furosemide**
* Wilsons disease: **pennicillamine**
* SBP: **tazocin**
* **Monitor for complications:** USS + alpha feotoprotein (HCC) + variceal monitoring
* **Surgery**: liver transplant - only definitive management
83
What are the causes of liver cirrhosis?
* Chronic alcohol abuse
* **Infection**: HBV + HCV
* Genetic disorders: hemachromatosis, wilsons disease, a1 anti trypsin deficiency
* **Vascular**: budd chiari
* **Autoimmune**: autoimmune hepatitis PBC, PSC
* **Drugs**: amiodorone, methotrexate, rifampacin, methyldopa
* NASH
84
What grading systems are used for liver cirrhosis?
Child Pugh Grading System or cirrhosis and risk of variceal bleeding.
85
What is the diagnostic criteria for IBS?
The diagnosis of IBS should be considered if the patient has had the following for at least **6 month**s:
* Abdominal pain, and/or
* Bloating, and/or
* Change in bowel habit
86
How is IBS managed?
* **Constipation**: ensure adequate water and fibre intake and promote physical activity
* Simple laxatives
* **Diarrhoea**: avoid sorbitol sweeteners, alcohol, and caffeine; reduce dietary fibre content; encourage patients to identify their own ‘trigger’ foods
* Bulking agent ± **loperamide 2mg** after each loose stool.
* Bloating: **oral antispasmodics: mebeverine** 135mg/8h or **hyoscine butylbromide** 10mg/8h (over the counter)
* **Psychological symptoms/visceral hypersensitivity:** CBT, hypnosis, and tricyclics, eg **amitriptyline** 10–20mg at night
87
What classification system is used for GORD/ oesphagitis?
**Los Angeles Classification**
1. 1 mucosal break. \<5mm
2. mucosal break \>5mm
3. Mucosal break \<75% of oesophageal circumference
4. Mucosal break \>75% of oesophageal circumference
88
If referring for an upper GI endoscopy, what should be done before hand?
* NBM 4 h before
* PPI stopped 2 wks before
* Dont drive for 24ht if sedation used
* Sedation: **midazolam**, **propofol** (if stronger needed)
* Give **continuous suction**
