Gastrointestinal system Flashcards
1
Q
What is the stepwise progression of alcoholic liver disease?
A
- Alcohol related fatty liver (build up of fat in liver - reversible in 2 weeks)
- Alcoholic hepatitis (inflammation of liver - mild is reversible)
- Cirrhosis (scar tissue formation - irreversible)
2
Q
What is the recommended daily alcohol consumption?
A
14 units per week / 3 days (pregnant avoid completely)
3
Q
What are the CAGE questions to assess harmful alcohol use?
A
CUT DOWN ? Ever thought you should
ANNOYED? Annoyed at others comments?
GUILTY?
EYE OPENER?
4
Q
What is the AUDIT questionnaire?
A
Developed by the WHO to screen for people with harmful alcohol use - 10 questions (8 indicates harmful)
5
Q
What are some complications of alcohol dependency?
A
Alcoholic liver disease
Cirrosis (and hepatocellular carcinoma)
Alcohol dependence and withdrawal
Wernicke-Korsakoff Syndrome
Pancreatitis
Alcoholic cardiomyopathy
6
Q
What are some signs of liver disease?
A
Jaundice
Hepatomegaly
Spider Naevi
Palmar Erythema
Bruising due to abnormal clotting
Ascites
Capus medusae (engorged superficial epigastric veins)
Asterixis - “flapping tremor” in decompensated liver disease
7
Q
What blood tests can be used to assess alcoholic liver disease?
A
FBC - raised MCV
LFTs - elevated ALT and AST and gamma-GT low albumin due to reduced synthetic function of liver (ALP raised later in disease)
Low albumin (reduced synthetic function)
Clotting - elevated PT
U&Es may be deranged in hepatorenal syndrome
8
Q
What imaging can be used for alcoholic liver disease?
A
Ultrasound - showing fatty changes
Fibroscan - assessing degree of cirrhosis
Endoscopy - for oesophageal varices
CT/MRI - carcinoma, hepatosplenomegaly, ascites
Liver biopsy
9
Q
What is the general management of alcoholic liver disease?
A
Stop drinking (detox regime)
Nutritional support with vitamins (particularily thiamine)
Treat complications of cirrhosis (portal hypertension, varices, ascites and hepatic encephalopathy)
Referral for liver transplant (must abstain from alcohol for 3 months)
10
Q
What are some symptoms of alcohol withdrawal?
A
6-12 hrs: Tremor, sweating, headache, anxiety
12-24 hrs: Hallucinations
24-48 hrs: Seizures
24-72 hrs: Delerium Tremens
11
Q
What is delerium tremens, what happens?
A
Due to alcohol withdrawal (mortality 35% if untreated)
Alcohol stimulates GABA receptors in brain - relaxing it along with inhibiting glutamate
When alcohol is removed, to compensate long term alcohol use GABA underfunctions and glutamate overfunctions - causing extreme excitability in the brain
12
Q
How does delerium tremens present?
A
- Acute confusion
- Severe agitation
- Delusions and hallucinations
- Tremor
- Tachycardia
- HTN
- Hypertension
- Hyperthermia
- Ataxia (difficulty with coordination)
- Arrhythmias
13
Q
What should be given to manage alcohol withdrawal?
A
Chlordiazepoxide (benzo)
IV pabrinex (vit Bs) followed by low dose oral thiamine
14
Q
What vitamin deficiency do alcoholics typically have ?
A
B1 (thiamine)
15
Q
What can happen as a result of thiamine deficiency?
A
Wernicke-Korsakoff syndrome (Wernicke’s first)
16
Q
How does Wernicke’s encephalopathy present?
A
- Confusion
- Oculomotor disturbances
- Ataxia (no coordinated movements)
17
Q
What are some features of Korsakoff’s syndrome?
A
- Memory impairment
- Behavioural changes
18
Q
Is Korsakoff’s syndrome reversible?
A
No (require full time institutional care after)
19
Q
What are the 4 most common causes of cirrhosis?
A
Alcoholic liver disease
Non-alcoholic liver disease
Hep B
Hep C
20
Q
What are some rarer causes of cirrhosis?
A
- Autoimmune hepatits
- Primary biliary cirrhosis
- Haemochromatosis
- Wilsons disease
- Alpha-1 antitrypsin deficiency
- CF
- Drugs (e.g. amiodarone, methotrexate, sodium valporate)
21
Q
What are some signs of cirrhosis?
A
- Jaundice
- Hepatomegaly (liver then shrinks)
- Splenomegaly (due to portal hypertensio)
- Spider Naevi
- Palmar erythema
- Gynecomastia and testicular atrophy due to endocrine dysfunction
- Bruising (abnormal clotting)
- Ascites
- Caput medusae
- Asterixis - ‘flapping tremor’
22
Q
What are the blood results for cirrhosis?
A
- LFTs often normal (unless decompensated cirrhosis then ALT, AST, ALP and bilirubin becomes deranged - all the markers)
- Albumin drops and PT time increases for synthetic function
- Hyponatraemia indicates fluid retention
- Urea and creatinin become deranged in hepatorenal syndrome
- AFP for hepatocellular carcinoma
23
Q
What is the first line investigation for patients with potential non-alcoholic fatty liver disease?
A
Enhanced liver fibrosis (can’t be used for cirrhosis of other causes)
24
Q
What is the imaging for cirrhosis? What are you looking for?
A
Ultrasound (nodularity of the surface, corkscrew arteries, enlarged portal vein, ascites, splenomegaly)
Fibroscan (look at elasticity of liver)
Endoscopy (look for and treat oesophageal varices)
CT and MRI (hepatocellular carcinoma, hepatosplenomegaly, abnormal blood vessels)
Liver biopsy (to confirm diagnosis of cirrhosis)
25
What is used as a screening tool for hepatocellular carcinoma in patients with cirrhosis?
**Ultrasound** every **6 months**
26
Who is at **risk of cirrhosis** and thus needs a **fibroscan every 2 years**?
- Hep B/C
- Heavy drinkers
- Diagnosed ALD
- Non-alcoholic fatty liver disease
27
What **scoring system** is used for **cirrhosis**?
**Child-Pugh** score
28
What does the **MELD score** tell you? When is it used?
**Estimated 3 month mortality,** helping guide referral for liver transplant
Used every **6 month** in patients with compensated cirrhosis
29
What is the **general management** for **cirrhosis**?
**Ultrasound** and **AFP every 6 months** for HC carcinoma
**Endoscopy** every **3 years** for **varices**
High protein, low sodium diet
MELD score every 6 months
30
What are some complications of cirrhosis?
- **Malnutrition**
- Portal hypertension, **varices**
- **Ascites**
- **Hepato-renal syndrome**
- Hepatic **Encephalopathy**
- Hepatocellular **carcinoma**
31
How can **malnutrition** caused by alcoholism be treated?
**Regular meals** (every 2-3 hours)
**Low sodium** (minimise fluid retention)
**High protein** and **high calorie** diet
32
What combines to form the portal vein?
Superior mesenteric vein and splenic vein
33
Where does the portal system anastamose with the systemic venous system (where **varices occur**)?
**Gastro-oesophageal** junction
**Ileocaecal** junction
**Rectum**
**Anterior abdo wall** (caput medusae)
34
What does exsanguinate mean? When can it happen?
Bleed out
Bleeding oesophageal varices
35
How are **stable varices treated**?
Propanolol
Elastic band ligation of varices
**Injection** of **sclerosant**
36
What is TIPS used for? How does it work?
**Transjugular intra-hepatic portosystemic shunt** (wire into jugular vein, vena cava and into liver via hepatic vein)
If **other treatment of stable varices fails**
Connection made between **hepatic vein and portal vein**
37
What does TIPS stand for?
Transjugular intra-hepatic porto-systemic shunt
38
What is used for treatment of bleeding oesophageal varices?
**- Terlipressin** (vasopressin anologue) cause vasoconstriction
- **Vit K** and **FFP**
- Broad spectrum **A****bx**
- Intubation and intensive care
39
What intervention can be used for bleeding varices?
Injecting **sclerosant** into varices (during endoscopy)
Elastic band ligation
**Sengstaken-Blakemore Tube** is an inflatable tube inserted into oesophagus to tamponade bleeding (after endoscopy fails)
40
What causes ascites?
Increased pressure in porto-systemic system
41
Why is ascites aggrevated?
Kidneys sense a lower circulating volume and so secrete **renin**
42
What type of ascites is caused by cirrhosis? How is ascites managed?
**Transudate** (low protein)
- Low sodium diet
- Anti-aldosterone diuretic (spironolactone)
- Paracentesis (ascites tap/drain)
- TIPS in refractory ascites
43
When can spontaneous bacterial peritonitis occur?
Spontaneous infection in ascitic fluid (10% of patients with ascites)
44
How does **spontaneous bacterial peritonitis present**?
- Fever
- Abdo pain
- Deranged bloods (raised WBC, CRP, creatinine)
- Ileus
- Hypotension
Can be **asymptomatic**
45
What are the most common organisms for **SBP**?
E. Coli
Klebsiella
Gram positive cocci (staph/enterococcus)
46
How is **SBP managed**?
Ascitic culture
- IV cefotaxime (cephalosporin)
47
What causes **hepatorenal syndrome**? Is it fatal?
In liver **cirrhosis** blood pools in the portal venous system (due to dilatation), causing **hypotension** in the kidney and activation of **RAAS** and vasoconstiction in kidney and then failure
Fatal within a week without liver transplant
48
What **toxin** builds up in liver cirrhosis causing **hepatic encephalopathy**?
Ammonia
49
Why does ammonia build up in cirrhosis?
**Functional impairment** of the **liver cells prevent metabolism of ammonia**
Also shunting of blood to the systemic circulation means that **blood isnt filtered**
50
What can precipitate hepatic encephalopathy?
Constipation
Electrolyte disturbance
Infection
GI bleed
High protein diet
Medications (particularly sedative)
51
How is **hepatic encephalopathy managed**?
**Laxatives** e.g. lactulose promotes **excretion of ammonia**
**Antibiotics** (i.e. rifaximin - poorly absorbed, stays in GI tract) reducing number of intestinal bacteria producing ammonia
Nutritional support
52
What are the stages of **non-alcoholic fatty liver disease**?
- Non-alcoholic fatty liver disease
- Non-alcoholic steatohepatits
**- Fibrosis**
**- Cirrhosis**
53
What are the **risk factors for NAFLD**?
- Obesity
- Poor diet / low activity levels
- Type 2 diabetes
- High cholesterol
- Middle age onwards
- Smoking
- High blood pressure
54
When a patient presents with abnormal LFTs without a clear underlying cause what can be used?
**Non-invasive liver screen**
55
What forms the non-invasive liver screen?
**Ultrasound Liver**
**Hepatitis B** and **C** serology
**Autoantibodies** (autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis)
**Immunoglobulins** (autoimmune hepatitis and primary biliary cirrhosis)
**Caeruloplasmin** (Wilsons disease)
**Alpha 1 Anti-trypsin levels** (alpha 1 anti-trypsin deficiency)
**Ferritin and Transferrin Saturation** (hereditary haemochromatosis)
56
What are some **liver autoantibodies**?
Antinuclear antibody (**ANA**)
Smooth muscle antibody (**SMA**)
Antimitochondrial antibody (**AMA**)
57
What can be used to **diagnose fatty liver**?
**Liver ultrasound** (doesnt indicate severity/if fibrosis)
58
What can be used to assess fibrosis?
**Enhanced liver fibrosis blood test**
59
What is the **second line assessment for liver fibrosis**?
**NAFLD** fibrosis score (algorithm of age, liver enzymes, platelets, albumin)
60
What is the **third line investigation for fibrosis**?
**Fibroscan** (type of ultrasound)
61
What is the management of NAFLD?
- Weight loss
- Exercise
- Stop smoking
- Control diabetes, blood pressure, cholesterol
- Avoid alcohol
Refer patients with **liver fibrosis** to a liver specialist where they may treat with **vitamin E** or **pioglitazone**
62
What is hepatitis?
**Inflammation** of the liver
63
What are some **causes of hepatitis**?
- **Alcoholic hepatitis**
- **NAFLD**
- **Viral** hepatitis
- **Autoimmune** hepatitis
- **Drug induced** hepatitis (e.g. paracetamol overdose)
64
How does **hepatitis present**?
**- Abdo pain**
**- Fatigue**
**- Pruritis** (itching)
- Muscle and joint aches
- Nausea and vomiting
**- Jaundice**
**- Fever** (viral hepatitis)
65
How are the **LFTs** in **hepatitis**?
High **AST/ALT** proportionally less of a rise of ALP = "**hepatic picture**"
66
Is hep A common in the UK?
No ~1000 cases in 2017 (most common viral hepatitis worldwide)
67
How is Hep A transmitted?
Faecal-oral route
68
How does Hep A present?
**Nausea**
**Vomiting**
**Anorexia**
**Jaundice**
**Cholestasis** (dark urine / pale stools)
69
Does Hep A resolve?
Yes, without treatment in 1-3 months
70
How is hep A managed?
Basic analgesia
71
Is there a vaccination for Hep A?
Yes
72
Is **Hep A a notifiable disease**?
Yes
73
What kind of virus is Hep A?
RNA virus
74
What kind of virus is Hep B?
DNA virus
75
How is hep B transmitted?
Blood / bodily fluids
Sex, IVDU, mother to child
76
What percentage of people go on to **get chronic hepatitis after Hep B infection**?
10%
77
What do the **following markers mean:**
Surface antigen (HBsAg)
E antigen (HBeAg)
Core antibodies (HBcAb)
Surface antibody (HBsAb)
Hepatitis B virus DNA (HBV DNA)
**Surface antigen (HBsAg)** – active infection
**E antigen (HBeAg)** – marker of viral replication and implies high infectivity
**Core antibodies (HBcAb)** – implies past or current infection
**Surface antibody (HBsAb)** – implies vaccination or past or current infection
**Hepatitis B virus DNA** (HBV DNA) – this is a direct count of the viral load
78
For HBcAb how is past or current infection distinguished?
**IgM and IgG is measured**
**IgM** implies active infection
**IgG** indicates a past infection when HBsAg is negative
79
Is **vaccination** available for **hep B**?
**Yes** - injecting the hep B surface antigen
80
How is Hep B managed?
- Screen for other BBV and STIs (hep A, B and HIV)
- Refer to gastro, hepatology / infectious diseases
- Notify Public Health
- Educate about transmission
- Test for complications: fibroscan for cirrhosis and ultrasound for hepatocellular carcinoma
81
What kind of virus is Hep C?
RNA
82
Is there a cure for Hep C?
**Yes** (no vaccine)
83
What percentage of patients with Hep C become chronic?
What are the complications?
3 in 4
**Liver cirrhosis** and **hepatocellular carcinoma**
84
What is the **screening test for Hep C**?
What can confirm diagnosis?
**Hep C antibody** is the screening test
## Footnote
**Hep C RNA testing**
85
What is the **management of Hep C**?
- Screen for other BBV and STIs
- Refer to gastro
- Notify Public health
- Stop smoking and alcohol
- Educate about reducing transmission
- **Fibroscan** and ultrasound
- Antiviral treatment with **direct acting antivirals**
86
What is **hepatitis D**?
**RNA virus** - can only survive in patients who have Hep B
Increases complications and disease severity of hep B
**No specific treatment**
87
What type of virus is hepatits A-E
A = RNA
B = DNA
C = RNA
D = RNA
E = RNA
88
How is hepatitis E spread?
Faecal-oral
89
How does Hep E present?
Mild illness, clears in a month.
No vaccination.
Notifiable disease
Rarely progresses to chronic hepatitis and liver failure (more in immunocompromised)
90
What causes **autoimmune hepatitis**? What are the two types?
We are not sure (could be genetic predisposition and triggered by environmental factors e.g. viral infection causing T-cell mediated response against liver cells)
Type 1 = adults (women in late 40s / 50s)
Type 2 = Children
91
What will LFTs and immune screening show for auto-immune hepatitis?
Raised ALT and AST
Raised IgG
92
What autoantibodies are raised in type 1 hepatitis?
Anti-nuclear antibodies (ANA)
Anti-smooth muscle antibodies (anti-actin)
93
How is autoimmune hepatitis diagnosed?
Liver biopsy
94
What is the treatment of auto-immune hepatitis?
High dose steroids **e.g. prednisolone** initially then tapered as:
Then immunosuppressants e.g. **azathioprine**
95
Can autoimmune hepatitis reoccur in transplanted patients?
YES
96
What is **haemochromatosis**?
**Iron storage disease** leading to excessive iron and deposition of iron in tissues
97
What is the mode of inheritance of haemochromatosis?
Autosomal recessive
98
How does haemochromatosis present?
\> 40 years old due to accumulation of iron (later in females as menstruation helps)
- Chronic **tiredness**
- **Joint pain**
- **Pigmentation** (bronze)
- **Hair loss**
- **Erectile dysfunction / amenorrhea**
- Memory and mood disturbance
99
How is **haemochromatosis diagnosed**?
**Serum ferritin** levels (main diagnostic method)
**Transferrin saturation** can be used to distinguish if this has gone up because ferritin is an acute phase reactant (e.g. inflammation NAFLD)
**Genetic testing confirms diagnosis**
100
What are some **complications of haemochromatosis**?
- **Type 1 diabetes** (liver affects functioning of the pancreas)
- **Liver cirrhosis**
- **Cardiomyopathy**
- **Hepatocellular carcinoma**
- **Hypothyroidism** (iron deposits in the thyroid)
- **Hypogonadism/ impotence/ amenorrhea** (deposits in the pituitary gland)
- **Chrondocalcinosis** / **pseudogout** (calcium deposits in joints) causing arthritis
101
What is the **management of haemochromatosis**?
Venesection
Monitoring serum ferritin
Avoid alcohol
Genetic counselling
Monitoring and treating complications
102
What is Wilson's disease?
Accumulation of copper in the body and tissues
Mutation on chromosome 13
103
What is the genetic inheritance of Wilson's disease?
**Autosomal recessive**
104
How do patients with Wilson's disease present?
**Hepatic problems** (chronic hepatitis then cirrhosis)
**Neurological problems** (concentration difficulties and dysarthria - speech difficulty, dystonia - abnormal muscle tone, copper in basal ganglia causes parkinsonism)
**Asymmetrical motor symptoms**
105
What are the **psychiatric problems in Wilson's disease?**
Mild depression to full psychosis
106
What can be seen in the **eyes of patients with Wilson's disease**?
**Kayser-Fleischer rings** in cornea - brown circles surrounding the iris
107
What are some 'other features' of Wilson's ?
**Haemolytic anaemia**
Renal tubular damage leading to **renal tubular acidosis**
**Osteopenia** (loss of bone mineral density)
108
How is Wilson's disease diagnosed?
Serum Caeruloplasmin (low is suggestive of Wilsons)
It is the **protein that carries copper in the blood**
109
What is the **gold standard test** for Wilson's disease?
Liver biopsy for copper contents (diagnosis can also be established if 24-hour urine copper assay is sufficiently elevated)
110
How is haemochromatosis managed?
**Copper Chelation** (penicillamine /trientene)
111
What is **alpha 1 antitrypsin deficiency**?
**Inherited deficiency of a protease inhibitor** (leading to an excess of protease enzymes)
112
What enzyme is inhibited by alpha 1-antitrypsin?
**Neutrophil elastase**
113
What is the mode of inheritance of A1AT?
Autosomal recessive
114
What is the result of A1AT deficiency?
**Liver cirrhosis**
Pulmonary **emphysema** and **bronchiectasis**
115
What is the screening for A1AT deficiency?
Levels of **serum alpha 1 antitrypsin** (would be low)
**Liver biopsy for cirrhosis** and **acid-Schiff-positive staining globules**
**Genetic testing** for A1AT gene
**High resolultion CT thorax** diagnoses bronchiectasis and emphysema
116
What is the treatment of A1AT deficiency?
- **Stop smoking**
- **Symptomatic** management
- **Organ transplant** for end stage liver / lung disease
- Monitor for **complications** e.g. hepatocellular carcinoma
(NICE recommend against replacement of alpha-1-antitrypsin - debate ongoing)
117
What is primary biliary cirrhosis?
Autoimmune condition targetting the
118
What is the result of the inflammation from primary bilary cirrhosis?
**Cholestasis and back pressure** leading to fibrosis, cirrhosis and liver failure
119
What is normally excreted through the bile ducts and into the liver?
**Bile acids, bilirubin and cholesterol**
120
What is a result of the increase in bile acids in blood?
**Itching**
121
What is the result of increased cholesterol in the blood?
**Xanthelasma** (or **xanthoma** if they are larger, nodular deposits)
122
How do stools appear in Primary Biliary Cirhosis?
**Greasy** (lack of bile) and **pale** (lack of bilirubin)
123
What are the **presentations** of **primary biliary cirrhosis**?
- **Fatigue**
- **Pruritus**
- **GI** disturbances
- **Jaundice**
- **Pale stool**
- **Xanthoma / xanthelasma**
- **Signs of cirrhosis and failure** (e.g. ascites, splenomegaly, spider naevi)
124
What are some associations of primary biliary cirrhosis?
Middle aged women
Other autoimmune conditions
Rheumatoid conditiosn (systemic sclerosis, Sjogrens, RA)
125
How is primary bilary cirrhosis diagnosed?
**LFTs** = ALP first to rise
**Autoantibodies = Anti-mitochondrial antibodies,** Antinuclear antibodies
**ESR raised**, IgM raised
**Liver** biopsy for diagnosing
126
What is used in the **management** of **primary biliary cirrhosis**?
**Ursodeoxycholic acid** - reduces intestinal absorption of cholesterol
**Colestyamine** - bile acid sequestrate
Liver transplant
**Immunosuppression** e.g. with steroids considered in some patients
127
What are the end results of Primary Biliary Cirrhosis?
**- Advanced liver cirrhosis**
**- Portal hypertension**
- Systemic pruritus, fatigue, steatorrhoea, distal renal tubular acidosis, hypothyroidism, osteoporosis, hepatocellular carcinoma
128
What is primary sclerosing cholangitis?
Condition where intra/extrahepatic ducts become **strictured and fibrotic**
129
What is the cause of Primary Sclerosing Cholangitis?
Mostly unclear although established link between **UC and PSC** (70% alongside)
130
What are some **risk factors** for **primary sclerosing cholangitis**?
- **Male**
- Aged **30-40**
- **UC**
- **FH**
131
How does primary sclerosing cholangitis present?
- Jaundice
- Chronic right upper quadrant **pain**
- Pruritis
- Fatigue
- Hepatomegaly
132
What would the LFTs show for primary sclerosing cholangitis?
"**Cholestatic**" picture meaning ALP is the most deranged LFT
133
Are there any specific antibodies for PSC?
Not really (maybe pANCA, ANA)
Helpful in **indicating an autoimmune element** to disease that may **respond to immunosuppression**
134
What is the **gold standard** for diagnosis of PSC?
**MRCP**
magnetic resonance cholangiopancreatography (bile duct lesions/strictures)
135
What are some associations and complications of PSC?
- Acute bacterial cholangitis
- Cholangiocarcinoma
- Colorectal cancer
- Cirrhosis and liver failure
- Biliary strictures
- Fat soluble vitamin deficiencies
136
What is the **management** for **primary sclerosing cholangitis**?
**- Liver transplant**
- **ERCP** to dilate and stent any strictures
**- Ursodeoxycholic acid**
**- Colestryamine** - bile acid sequestrate (prevents absorption in gut)
- Monitor for **complications** (cholangiocarcinoma, cirrhosis, oesophageal varices)
137
How can strictures from PSC be treated?
**ERCP** (endoscopic retrograde cholangio pancreatography) using a camera through throat, oesophagus, stomach and duodenum, through **sphincter of Oddi** and into ampulla of vater into bile ducts
**Stenting** the strictures
138
What are the two main **types** of **primary liver cancer**?
**Hepatocellular**(80%) and **cholangiocarcinoma**
139
What is the main risk factor for **hepatocellular carcinoma**?
Liver cirrhosis due to:
- **Viral Hep B/C**
- **Alcohol**
- **NAFLD**
- Other **chronic liver disease**
140
What is cholangiocarcinoma typically associated with?
Primary Sclerosing Cholangitis
141
How does liver cancer present?
(often asymptomatic for long time)
- Weight loss
- Abdo pain
- Anorexia
- N&V
- Jaundice
- Pruritus
142
What are some **investigations** for **liver cancer**?
**AFP** for HCC
**CA19-9** for cholangiocarcinoma (tumour markers)
**Liver ultrasound** for tumours
**CT and MRI** for diagnosis
**ERCP** - take biopsies / brushings to diagnose cholangiocarcinoma
143
What is the mainstay of **treatment** for **hepatocellular carcinoma**?
- **Liver resection and / liver transplant**
- Kinase inhibitors (inhibit proliferation of cancer cells) e.g. **sorafenib**, **regorafenib** and **lenvatinib** to extend life by months
- Generally considered **resistant to chemo / RT**
144
What is the **treatment** of **cholangiocarcinoma**?
Very **poor prognosis unless diagnosed early** (potentially cured with surgical resection)
**ERCP** for stenting and improving symptoms
**Resistant** to chemo / RT
145
What is a **haemangioma**? What is the treatment?
Common **benign tumour** of the liver, found incidentally, no symptoms / potential to become cancerous
No treatment / monitoring required
146
What is **focal nodular hyperplasia**?
**Benign** liver tumour made of **fibrotic tissue** found incidentally (usually asymptomatic and no malignant potential)
Often **related to oestrogen** and so more common in women / COCP
No treatment / monitoring required
147
What is the term for an **entire** liver transplanted from a desceased patient?
What is a **living donor transplant**?
**Orthotopic transplant** (if you split into two = **split donation**)
**Living donor transplant** = take a portion of organ from a living donor - both regenerate
148
What **causes acute liver failure**? (requires immediate transplant - chronic liver failure can wait for 5 months)
Acute viral hepatitis
Paracetamol overdose
149
What **factors** suggest **unsuitability** for a **liver transplant**?
- Significant **co-morbidities** e.g. severe kidney / heart disease
- **Excessive weight loss** and malnutrition
- Active hep B, hep C or other infection
- End stage **HIV**
- Active **alcohol** use (6 months abstinence required)
150
What **incision** is used in a **liver transplant**?
"rooftop" or "Mercedes Benz"
151
What medications are involved in post-transplant care?
**Lifelong immunosuppression**
Steroids
Azathioprine
Tacrolimus
152
What is the lifestyle advise for transplant patients?
- Avoid alcohol and smoking
- Treat oppurtunistic infections
- Monitor for disease reccurence (i.e. of hepatitis / primary biliary cirrhosis)
- **Monitor for cancer** higher risk in immunosuppression
153
What may suggest **liver transplant rejection**?
Abnormal **LFTs**
Fatigue
Fever
Jaundice
154
What is the **lining** of the **oesophagus** / **stomach**?
**Oesophagus** = squamous epithelial lining (more sensitive to stomach acid)
**Stomach** = columnar epithelial lining
155
How does GORD present?
**Dyspepsia** (indigestion)
- Heartburn
- Acid regurg
- Retrosternal pain
- Bloating
- Nocturnal cough
- Hoarse voice
156
When is an endoscopy used in clinical practise?
Assess:
- Peptic **ulcers**
- Oesophageal/gastric **malignancy**/maleana
157
What are the key red flag symptoms for endoscopy referral?
- **Dysphagia** (difficulty swallowing)
- Weight loss
- Upper abdo pain / reflux
- Treatment resistant dyspepsia
- N&V
- Low Hb
- Raised platelet count
EVIDENCE OF **GI BLEED** (meleana / coffee ground vomit) need admission / **urgent endoscopy**
158
What is the **management of GORD**?
**Lifestyle**: Reduce tea, coffee, alcohol, weight loss, avoid smoking, smaller meals, avoid heavy meals before bed, stay upright after meals rather than flat
**Acid neutralising medication**: Gaviscon, rennie
**PPI**: Omeprazole, lansoprazole
**Ranitidine**: H2 receptor antagonist (alt to PPI), H2 receptor antagonist (antihistamine)
Surgery - laparoscopic fundoplication
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What is **Helicobacter Pylori**?
**Gram negative aerobic bacteria** which lives in stomach and damages it causing gastritis, ulcers and increasing risk of stomach cancer
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What does a H/ Pylori infection result in?
- **Gastritis**
- **Ulcers**
- Increasing risk of **stomach cancer**
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What does H. Pylori produce?
**Ammonia** - neutralises stomach acid
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What are the different **tests** for **H. Pylori**?
**Urea breath test**
**Stool antigen test**
**Rapid Urease test** (CLO- campylobacter like organism - test stomach biopsy from endoscopy taken and added to urea - if H. Pylori is present it will produce urease to convert urea to ammonia - giving the solution an alkali pH)
MUST BE **OFF PPI FOR 2 WEEKS** BEFORE ANY TESTING
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What is the **triple therapy** for **H. Pylori**? How long is it usually taken for?
**PPI**
Amoxicillin
Clarithromycin
**7 days**
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What happens during **Barrett's oesophagus**?
**Metaplasia** from **squamous** to **columnar epithelium** in lower oesophagus
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What happens to to **GORD symptoms** after Barett's oesophagus?
**Inprovement** in reflux symptoms
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What is the risk factor with Barrett's ?
Adenocarcinoma
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What is the treatment of Barrett's oesophagus?
PPIs
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What can the protective layer in the stomach be broken down by?
Steroids/ NSAIDs
Helicobacter pylori
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What can **increased stomach acid result from**?
- Stress
- Alcohol
- Caffeine
- Smoking
- Spicy foods
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How do **peptic ulcers present**?
Epigastric discomfort / pain
N&V
Dyspepsia
Coffee ground vomit
Iron deficiency anaemia (due to constant bleeding)
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**Which ulcers** does **eating improve/worsen** symptoms?
**Worsens** gastric ulcers
**Improves** duodenal ulcers
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How are **peptic ulcers diagnosed**?
**Endoscopy** (CLO test also performed for H. pylori, biopsies for cancer)
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What is the treatment of Peptic Ulcers?
PPIs (endoscopy to monitor ulcer and ensure healing)
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What are the **complications** of **peptic ulcers**?
**Bleeding**
**Perforation** resulting in peritonitis and acute abdomen
**Scarring and strictures** of muscle and mucosa
**Pyloric stenosis**
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What are some causes of upper GI bleeds?
- Oesophageal varices
- Mallory-Weiss tear
- Stomach ulcers
- Cancers of stomach
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How do **upper GI bleeds present**?
- **Haematemesis**
- **"Coffee ground" vomit** (digested blood)
- **Melaena**, tar like, black, greasy and offensive stool
- Haemodynamic instability (causes low blood pressure, tachycardia and other signs of shock)
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What is used as a **scoring system for risk of upper GI bleeds**?
**Glasgow-Blatchford Score** (\>0 indicates high risk)
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Why does urea raise in upper GI bleeds?
Digested product of blood in GI tract (then absorbed in intestines)
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What is the **Rockall score** used for?
Risk of **rebleeding/mortality** in **patients** who have had an endoscope
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What is the **management of an upper GI bleed**?
**ABATED**
**A**-E
**B**loods
**A**ccess (2 large bore cannulas)
**T**ransfuse
**E**ndoscopy (within 24 hrs)
**D**rugs (stop anticoagulants / NSAIDs)
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What should be checked in **upper GI bloods**?
**Haemoglobin** (FBC)
**Urea** (U&Es)
**Coagulation** (INR, FBC for platelets)
**Liver disease** (LFTs)
**Cross match** 2 units of blood
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What are the **additional steps** of treatment for **oesophageal** **varices**?
**Terlipressin**
Prophylactic **broad spectrum** abx
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What is the definitive treatment of upper GI bleeds?
**OGD** - for interventions e.g. banding of varices / cauterisation
(NICE recommend against PPI prior to endoscopy - some senior doctors do this)
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What are the features of Crohn's?
**NESTS**
**No** blood or mucus
**E**ntire GI tract with **skip lesions**
**S**kip lesions on endoscopy
**Terminal ileum** usually affect with **t**ransmural inflammation
**Smoking** is a **risk** factor
Associated with weight loss, strictures and fistulas
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What are the **features of UC**?
**U-C-CLOSE UP**
**C**ontinuous inflammation from the colon/rectum
**L**imited to colon and rectum
**O**nly superficial mucosa affected
**S**moking is protective
**E**xcrete blood and musus
**U**se **amiosalicylates**
**P**SC associated
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How does **IBD present**?
Diarrhoea
Abdo pain
Passing blood
Weight loss
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How is **IBD diagnosed**?
**Bloods:** anaemia, infection, thyroid, kidney and liver function
**CRP** for inflammation and active disease
Faecal **calprotectin**
**Endoscopy with biopsy is diagnostic** (OGD and colonoscopy)
**Imaging** to look for fistulas, abscesses and strictures
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What **medications** are used to induce **remission / maintain Crohn's**?
**Induce** = Steroids (oral pred / IV hydrocortisone)
May add immunosuppressants:
Azathioprine/mercaptopurine/methotrexate/infliximab/adalimumab
**Remission** (reasonable to not take anything) OR:
First line: azathioprine, mercaptopurine
Second line: methotrexate, infliximab, adalimumab
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What is used to induce remission in UC?
**Aminosalicylates** (mesalazine)
Second line e.g. corticosteroids - prednisolone
In severe disease IV corticosteroids e.g. hydrocortisone or IV ciclosporin may be used
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What is used 2nd line to induce remission in UC?
What is used to maintain?
**2nd line in acute** = cortocosteroids
**Maintaining** = Aminosalicylates (mesalazine) or azathioprine or mercaptopurine
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What **surgery can patients with UC have**?
**Panproctocolectomy** (removing colon and rectum - typically only affects here)
Left with **ileostomy** or **ileo-anal anastomosis** (J pouch)
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What are some symptoms of IBS?
- Diarrhoea
- Constipation
- Fluctuating bowel habit
- Abdo pain
- Bloating
- Worse after eating and improved by opening bowels
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What is the **NICE** criteria for **diagnosis** of **IBS**?
**Other pathology should be excluded**:
* Normal FBC, ESR and CRP blood tests
* **Faecal calprotectin** negative
* **Negative** coeliac disease serology (anti-TTG antibodies)
* **Cancer not suspected** / excluded
**Symptoms should suggest**:
* Abdo pain / discomfort: relieved by opening bowels / associated with change in bowel habit AND
* 2 of: abnormal stool passage, bloating, worse symptoms after eating, PR mucus
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What are some general treatments for IBS?
- Ensure **adequate fluid intake**
- Regular **small meals**
- **Reduce processed food**
- Limit caffeine and alcohol
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What is the first line medication for diarrhoea in IBS?
Second line
Third line?
**_First line_**
**Loperamide**
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)
**_Second line_**
TCA e.g. amitriptyline 5-10mg at night
**_Third line_**
SSRI antidepressant
**CBT** is another option of help patients manage condition
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What happens in coeliacs?
Auto-antibodies in response to exposure to gluten targetting **epithelial cells** of intestine and lead to inflammation
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What are the antibodies in Coeliacs?
Anti tissue transflutaminase (**Anti-TTG**)
Anti-endomysial (**anti-EMA**)
Rise with disease activity
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Where is inflammation in Coeliacs typically?
Small intestine - **Jejunum**
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What happens to the bowel wall in Coeliacs?
Atrophy of intestinal villi
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What is the presentation of Coeliacs?
- **Failure to thrive** in young children
- Diarrhoea
- Fatigue
- Weight loss
- Mouth ulcers
- Anaemia second to iron, B12 or folate deficiency
- **Dermatitis herpetiformis** (itchy blistering rash typically on abdomen)
- **Neuro symptoms**: peripheral neuropathy, cerebellar ataxia, epilepsy
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How is Coeliacs diagnosed?
Diagnosed when patient is on a diet containing gluten
- Exlude IgA deficiency before testing for:
**Anti-TTG antibodies**
**Anti-endomyseal antibodies**
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What will intestinal biopsy show for coeliacs?
**Crypt hypertrophy**
**Villous atrophy**
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What are some associations of Coeliacs?
- Type 1 diabetes
- Thyroid disease
- Autoimmune hepatitis
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
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What are some complications of untreated Coeliacs diease?
- Vitamin deficiency
- Anaemia
- Osteoporosis
- Ulcerative jejunitis
- Enteropathy-associated T-cell lymphoma (EATL) of intestine
- Non-hodgkin lymphoma (NHL)
- Small bowel adenocarcinoma (rare)
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What is the treatment of Coeliacs?
**Gluten free diet** (lifelong)
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