GI 3 Flashcards
(102 cards)
1
Q
What are the investigations into stools?
A
FOB testing
Stool culture
Faecal calprotectin
Faecal elastase – investigation of pancreatic insufficiency/malabsorption
2
Q
How do you screen the liver?
A
hep B/C serology autoantibodies (ANA, AMA), immunoglobulin Ferritin Alpha 1 antitrypsin Caeuloplasmin, copper Alpha fetoprotine
3
Q
What is coeliac serology?
A
Tissue transglutaminase
Endomysial antibody
Check IgA levels
4
Q
How do you manage a patient with low risk features with rectal bleeding?
A
Wait and watch for 6 weeks
Then review + refer if deteriorated or persistent
5
Q
How do you manage a patient with high risk features with rectal bleeding?
A
Refer
Investigate
6
Q
How do you investigate bleeding?
A
Endoscopy (+ biopsy if suspicious) Contrast imaging CT MRI >Whatever is most appropriate
7
Q
What is important for success in bowel anastomosis?
A
Tension free Well perfused Well oxygenated Clean surgical site Acceptable systemic state
8
Q
What are the complications of bowel surgery?
A
Anaesthetic related Bleeding Sepsis VTE Anastomotic breakdown Small bowel obstruction Wound hernia
9
Q
What is the acute abdomen?
A
A combination of symptoms and signs, including abdominal pain,
>which results in a patient being referred for an urgent general surgical opinion
10
Q
What are the most common causes for acute abdomen?
A
Non-specific pain Acute appendicitis Acute cholecystitis Peptic ulcer perforation Urinary retention
11
Q
What are the routes of infection of the peritoneum? (causing peritonitis)
A
Perforation of GI/ biliary tract
Female genital tract
Penetration of abdominal wall
Haematogenous spread
12
Q
When does generalised peritonitis occur?
A
It means localisation has failed and occurs when:
Contamination too rapid
Contamination persists
Abscess ruptures
13
Q
What are the symptoms of intestinal obstruction?
A
Pain Vomiting Distension Constipation Borborygmi
14
Q
What are the types of abdominal pain? (character)
A
Visceral
Somatic
Referred
15
Q
If pain comes and goes, what should you consider?
A
Peritonitic pain
Colic
Body wall pain
16
Q
What are the aims of resus in regards to acute abdomen?
A
Restore circulating volume Ensure tissue is perfused Enhance tissue oxygenation Treat sepsis Decompress gut Ensure adequate pain relief
17
Q
What are the types of viral hepatitis?
A
A and E (self limiting)
B, C and D are parenteral (cause chronic disease)
18
Q
How is Hep A transmissible?
A
Transmission through fecal-oral route, sexual, or blood bourne
19
Q
What are the features of Hep A?
A
5-14 commonenst (children affected for shorter, but more common)
Sporadic infection of epidemic
Diagnosed acutely with IgM antibodies
20
Q
Who is advised to get the Hep A vaccine?
A
Travellers Patients with chronic liver disease (HBV or HCV especially!) Haemophiliacs Occupational exposure Men who have sex with men
21
Q
What is the structure of HBV?
A
Has a surface antigen coat
Inner coat with DNA polymerase
Inside with the core antigen
22
Q
How does HBV avoid the immune system?
A
Creates a host of empty cells of surface antigens to confuse body (no inner core)
Sits in liver, but sends decoy antigen into blood (E antigen – HbeAg)
Difference between E antigen and core antigen is the lack of Pre C in code, what allows it to travel into the blood
23
Q
What do the different HBV antigens indicate? Surface antigen E antigen Core antigen HBV DNA
A
Surface antigen – presence of virus
Presence of E antigen in blood indicates acute infection (active replication)
Core antigen – active replication (not detectable in blood)
HBV DNA (active replication)
24
Q
What do the different HBV antibodies indicate? Anti-HBs IgM anti HBc IgG anti HBc Anti HBe
A
Anti-HBs - protection
IgM anti HBc – acute infection
IgG anti HBc – chronic infection/exposure
Anti HBe – inactive virus
25
What is the approach to HBV infection?
If HBsAG negative – no active infection, vaccinate
Positive – check if clinical evidence of acute infection
If no evidence, of no IgM anti-HBc then chronic infection
If clinical evidence and IgM anti HBc – acute infection
As acute infection clears in 90% of patients in 6 months, no treatment
Chronic – evaluate for ongoing monitoring and treatment
(Not all patients have chronic disease)
26
How do you treat chronic HBV?
If the HBV DNA IU/mL >2000, treatment indicated
Normally Tenofovir used, as low rates of resilience, works in HIV co-infected, high potency, category B in pregnancy. However, renal toxicity
27
What are the other potential agents used for HBV infection?
Other agents – Telbivudine
Entecavir
Adefovir
Lamivudine
28
What is the natural history of HCV?
```
Rarely causes acute liver failure
Most asymptomatic until chirrotic
May have normal LFTs
10% report acute jaundice
An RNA virus – so uses DNA-RNA transcriptase which mutates rapidly (deliberately)
HIV/alcohol speed up disease
```
29
What are the drugs available for HCV?
sofosbuvir + ledipasvir
30
What is HDV?
A small RNA virus that doess not code for own protein coat, enveloped by HBsAg
Co infection or superinfection with HBV (same transmission)
Very resistant to treatment
Parasite of HBV
31
What is HEV?
Commonest cause of acute hepatitis in Grampian
Self-limiting
No specific treatment
No vaccine
Tropical Zoonotic virus (transmitted by animals, E - via pigs)
32
What does non-alcoholic liver disease encompass?
Simple steatosis
Non alcoholic steatohepatitis
Fibrosis and cirrhosis
33
What is NAFLD associated with?
```
Diabetes mellitus
Obesity
Hypertriglyceridemia
Hypertension
Age
Ethnicity (Hispanics)
Genetics (PNPLA3 gene)
```
34
What is the progression of NAFLD?
Normal
- -> steatosis
- -> NASH +/- fibrosis
- -> cirrhosis
35
How do you diagnose NAFLD?
```
AST/A:T ratio
USS
Fibroscan
Liver biopsy
NAFLD tool on website
```
36
How do you treat NAFLD?
Diet and weight reduction (+/- surgery)
Exercise
Insulin sensitisers
Glucagon-like peptide 1 (GLP1) analogues (Liraglutide)
Farnesoid X nuclear receptor ligand (obeticholic acid)
Vitamin E
37
What are the autoimmune diseases of the liver/biliary tract?
```
Autoimmune hepatitis
Primary biliary cholangitis (PBC)
Primary sclerosing cholangitis (PSC)
Overlap syndromes
Autoimmune cholangiopathy
IgG 4 disease
```
38
What is autoimmune hepatitis?
```
Female predominant
Elevated IgG
Diagnosed by liver biopsy
Responds well to steroids
Long term azathioprine
3 types of antibodies; Type 1 – ANA, SMA. Type 2: LKM1. Type 3 SLA
```
39
Who is eligible for a liver transplant?
Chronic liver diseases with poor predictive survival or poor quality of life
Hepatocellular carcinoma
Acute liver failure
Genetic diseases – primary oxaluria, tyrosemia
40
What are the contraindications for liver transplant?
Active extrahepatic malignancy
Hepatic malignancy with macrovascular or diffuse tumour invasion
Active and uncontrolled infection outside of hepatobiliary system
Active substance or alcohol abuse
Severe cardiopulmonary or other comorbid conditions
Psychosocial factors that would preclude recovery
Technical/anatomical barriers
Brain death
41
How is liver transplant prioritised in cirrhosis?
Child’s Pugh scoring A, B, C
MELD score (Bilirubin, Creatinine and INR)
UKELD( Bilirubin, Sodium, Creatinine and INR)
42
What is the post op treatment for a liver transplant?
Post operative ICU care
Multidisciplinary care
Prophylactic antibiotics and anti-fungal drugs
Anti-rejection drugs: Steroids, Azathioprine, Tacrolimus/Cyclosporine
43
What can cause acute liver injury?
Hepatitis
| Bile duct obstruction
44
What is the pathophysiology of jaundice?
Increased circulation of bilirubin
Caused by altered metabolism on bilirubin
Pathway can be pre hepatic, hepatic, or post hepatic
45
What is prehepatic metabolism (bilirubin pathway)?
Breakdown of haemoglobin in spleen to form haem and globin
Haem converted to bilirubin
Release of bilirubin into circulation
46
What is hepatic metabolism of bilirubin?
Uptake of bilirubin by hepatocytes
Conjugation of bilirubin hepatocytes
Excretion of conjugated bilirubin into biliary system
47
What is post hepatic metabolism of bilirubin?
Transport of conjugated bilirubin in biliary system
Breakdown of bilirubin conjugate in intestine
Re-absorption bilirubin – entero-hepatic circulation of bilirubin
48
What causes prehepatic jaundice?
increased release of haemoglobin from red cells – haemolysis
49
What causes hepatic jaundice?
cholestasis (accumulation of bile within hepatocytes or bile canaliculi)
Intra-hepatic bile duct obstruction
50
What causes post-hepatic jaundice?
cholelithiasis
Disease of gall bladder
Extra hepatic duct obstruction
What are the causes of cholestasis
51
What are the causes of cholestasis?
Viral hepatitis
Alcoholic hepatitis
Liver failure
Drugs – therapeutic/recreational predictable v unpredictable (dose vs other factors)
52
What are the causes of intra-hepatic bile duct obstruction?
Primary biliary cholangitis
Primary sclerosing cholangitis
Tumours of liver – hepatocellular carcinoma, tumours of intra-hepatic bile ducts and metastatic tumours
53
What is primary biliary cholangitis?
Organ specific auto immune disease (mainly females)
Anti-mitochondrial antibodies in serum
Raised serum alkaline phosphates
Granulomatous inflammation involving bile ducts
Loss of intra-hepatic bile ducts
Progression to cirrhosis
54
What is primary sclerosing cholangitis?
```
Chronic inflammation and fibrous obliteration of bile ducts
Loss of intra-hepatic bile ducts
Assoc. w/ inflammatory bowel disease
Progression to cirrhosis
Increased risk of developing cholangiocatcinoma
Male predominant
Recurrant cholangitis, Jaundice
Liver Tx, Biliary stents to treat
```
55
What are the causes of cirrhosis?
```
Alcohol
Hepatitis B, C
Immune mediated liver disease
>Auto-immune hepatitis
>Primary biliary cholangitis
Metabolic disorders (excess iron - primary haemochromatosis
>Excess copper – wilsons disease
Obesity – diabetes mellitus
```
56
What is the pathology of cirrhosis?
Involves whole liver – loss of normal liver structure
| Replaced by nodules of hepatocytes and fibrous tissue
57
What complications can arise from cirrhosis?
altered liver function so failure
Abnormal blood flow – portal hypertension
Increased risk of hepatocellular carcinoma
58
What are the risk factors for gallstones?
```
obesity,
diabetes,
female
Cholesterol
Parity + OCP
Bile infection
```
59
What is the pathology of gallstones?
Caused by inflammation (acute/chronic cholecystitis)
Acute – empyema (perforation of gall bladder, biliary peritonitis)
May lead to chronic – causes fibrosis as well as inflammation
60
What leads to bileduct obstruction?
Gallstones
Bile duct tumours
Benign stricture
External compression – tumours
61
What are teh effects of bilestone obstruction?
Jaundice
No bile in duodenum
Infection of bile proximal to obstruction (ascending cholangitis)
Secondary biliary cirrhosis if obstruction prolonged)
62
What is the presentation of gallstones?
```
Majority asymptomatic
Dyspeptic symptoms
Biliary colic
Acute cholecytitis
Empyema
Perforation
Jaundice
Gallstone ileus
```
63
What is choledocho-iliasis, what can it lead to?
Blockage of bile duct
Can lead to obstructive jaundice (painful)
Can lead to acute pancreatitis
Can lead to ascending cholangitis
64
How do you investigate suspected gallstones?
```
Blood tests – amylase, lipase, WCC, LFTs: AST/ALT,ALP
USS, EUS
Oral cholecystography
CT scan, radio-isotope scan
IV cholangiography
MRCP/ERCP
PTC
```
65
How do you manage gallstones?
Asymptomatic – do nothing
Non-operative treatment – dissolution, lithotripsy
Operative
>Cholecystectomy - remove gallbladder, laproscopic gold standard
66
What are the causes of benign biliary tract disease?
Congenital:
>biliary atresia
>Choledochal cysts
Benign biliary stricture
67
What tumours can cause jaundice?
Cholangiocarcinoma (intra or extrahepatic, gallbladder, ampullary)
Cancer of head of pancreas
68
What are the tisks of cholangiocarcinoma?
```
(Bileduct cancer)
PSC (strong association)
Congenital cystic disease
Biliary-enteric drainage
Thorotrast (contrast)
Hepatolithiasis
Carcinigens: aflatoxins, etc.
```
69
What is the presentation of cholangiocarcinoma?
Obstructive jaundice
Itching
Non-specific symptoms
70
What are the three types oc cholangiocarcinoma?
Mass forming (blockage)
Peri-ductal (both sides)
Intra-ductal (one side)
71
How do you manage cholagiocarcinoma?
Surgical – only potential cure
```
Palliative –
surgical bypass
Stenting
Radiotherapy
Chemo
PDT
```
72
How do you treat an ampullary tumour?
```
Depends if adenoma or adenocarcinoma
Treatment:
Endoscopic excision
Trans-duodenal excision
Pancreatico-duodenectomy
```
73
What are the liver function tests?
```
Bilirubin
Aminotransferases
Alkaline phosphatase
Gamma GT
Albumin
Prothombin time
Creatine
Platelet count
```
74
What are aminotransferases?
enzymes in hepatocytes –
>ALT more specific than AST.
>AST/ALT ratio points towards ALD
>suggests parenchymal involvement)
75
What is alkaline phosphatase (ALP)?
enzyme in bile ducts,
elevated with obstruction or liver infiltration.
>Also present in bone, placenta and intestines
76
What is Gamma GT?
A non specific liver test
Elevated in alcohol, however
>Useful to confirm ALP result
77
What does low albumin indicate?
suggest chronic liver disease,
| >can be low in kidney disorders and malnutrition
78
Why is prothrombin time important?
Tells extent of liver damage
79
Why is creatine important as a liver test?
It is essentially kidney function
| >Used to determine survival from liver disease
80
Why is platlet count a liver test? What do low levels indicate?
liver produces thromboprotein
>cirrhosis in splenomegaly
Platelets low in cirrhotic patients (hypersplenism) >Indirect marker of portal hypertension
81
What are the symptoms of liver failure?
Jaundice,
ascites,
variceal bleeding,
hepatic encephalopathy
82
What are the clues for pre-hepatic jaundice?
Clinical:
Pallor
Splenomegaly
History:
anaemia (fatigue, dyspnoea, chest pain), acholuric jaundice
83
What are the clues for hepatic jaundice?
```
Clinical:
Ascities,
asterixis,
stigmata of CLD
>(spider naevi, gynaecomastia)
```
```
History:
risk factors for liver disease
>(IVDU, drug intake),
decompensation
>(ascities, variceal bleed, encephalopathy)
```
84
What are the clues for post-hepatic jaundice?
Clinical:
palpable gall bladder (courvoisier’s sign)
History:
abdominal pain,
cholestasis
>(puritus, pale stools, con. Urine)
85
What can therapeutic ERCP be used for?
Dilated biliary tree (w/ or w/o visible stones/tumour)
Acute gallstone pancreatits
Stenting of biliary tract obstruction
Post-op biliary complications
86
What complications can arise from ERCP?
```
Sedation related
Procedure related
>pancreatitis,
>cholangitis,
>sphincterotomy -
>bleed/ perforation
```
87
What is chronic liver disease?
```
Liver disease lasting more than 6 months:
Chronic hepatitis
Chronic cholestasis
Fibrosis and cirrhosis
Others – steatosis
Liver tumours
```
88
How does compensated chronic liver disease present?
Routinely detected on screening tests
| Abnormality of liver function tests
89
How does decompensated liver disease present?
Ascites
Variceal bleeding
Hepatic encephalopathy
90
What are the clinical features of ascites?
```
Physical exam reveals dullness in flanks and shifting dullness
Can be confirmed by U/S
Corroborating evidence
>JVP elevation
>Spiders,
>palmar erythema,
>abdominal veins,
>fetor hepaticus
>Unbilical nodule
>Flank haematoma
```
91
How do you confirm ascites?
Protein and albumin concentration
Cell count and differential
Routine – cell count, protein, albumin
92
What does a SAAG score of >1.1 mean?
SAAG (serum ascites albumin gradient) >1.1g/dl portal HTN related
93
What does a SAAG score of <1.1 mean?
<1.1g/dl nonportal HTN causes (both 97% acc)
94
What are the causes of a SAAG score >1.1g/Dl
```
Portal hypertension
CHF
Constrictive pericarditis
Budd Chiarri
Myxedema
Massive liver metastases
```
95
What are the causes of a SAAG score <1.1g/Dl
```
Malignancy
Tuberculosis
Chylous ascites
Pancreatic
Biliary ascites
Nephrotic syndrome
Serositis
```
96
How do you treat ascites?
```
Diuretics
Large volume paracentesis
TIPS
Aquaretics
Liver transplant
```
97
What is variceal haemorrhage?
```
When an acites bleeds due to portal hypertension.
Occur at porto-systemic anastomoses
Skin – caput medusa
Oesophageal and gastric
Rectal
Posterior abdominal wall
Stomal
A medical emergency!
```
98
How do you treat variceal haemorrhage?
```
Resuscitate patient
Good IV access
Blood transfusion as required
Emergency endoscopy
- Band ligation
Add terlipressin for control
Sengstaken-blakemore tube for uncontrolledbleeding
TIPSS for rebleeding after banding
```
99
What is hpatic encephalopathy?
Confusion due to liver disease
| Graded 1-4: confusion to coma
100
How does hepatocellular carcinoma present?
```
Decompensation of liver disease
Abdominal mass
Abdominal pain
Weight loss
Bleeding from tumour
```
101
How do you diagnose hepatocellular carcinoma?
Tumour markers – AFP
Radiological tests – U/S, CT, MRI
Liver biopsy rarely
102
How do you treat hepatocellular carcinoma?
```
Hepatic resection
Liver transplant
Chemo – locally delivered or systemic
Locally ablative treatmetns – alcohol injection, radiofrequency ablation
Sorafenib (tyrosinase kinase inhibitor)
Hormonal therapy – tamoxifen
```
