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GI and liver Flashcards

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1
Q

what is acute appendicitis?

A

an acute inflammation of the vermiform appendix

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2
Q

what age range is appendicitis most common in?

A

10-20 years

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3
Q

what are 3 risk factors for appendicitis?

A

low dietary fibre
improved personal hygiene
smoking

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4
Q

what is the pathophysiology of appendicitis?

A

Lumen of appendix is obstructed => fills with mucus => increased pressure => bacteria multiply (bacteriodes fragilis and E.coli) => distension of lumen => inflammation, oedema, ischaemia, necrosis, perforation => nausea, vomiting, pain, reflex anorexia

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5
Q

what are 6 manifestations of appendicitis?

A 
acute abdomen pain localising to RLQ with guarding
anorexia 
nausea + vomiting 
tense rigid abdomen
low grade fever
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6
Q

what is the gold standard diagnosis for appendicitis?

A

CT abdomen

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7
Q

what are 3 investigations that can be done for appendicitis?

A

FBC - WBCs raised
CRP/ESR - raised
Urinalysis - pregnancy, renal colic excluded

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8
Q

what are 3 differentials for appendicitis?

A

ectopic pregnancy
UTI
Diverticulitis

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9
Q

what are 3 complications of appendicitis?

A

perforation
generalised peritonitis
appendicular mass

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10
Q

What is Barrett’s oesophagus?

A

a change (metaplasia) in the normal squamous epithelium of the oesophagus to specialised intestinal metaplasia (stratified squamous to simple columnar)

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11
Q

what are 4 causes for Barrett’s oesophagus?

A

GORD
Lower oesophageal sphincter hypotension
hiatus hernia
gastric acid hypersecretion

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12
Q

what are 3 risk factors for Barrett’s oesophagus?

A

smoking
obesity
male

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13
Q

what is the pathophysiology of Barrett’s oesophagus?

A

Reduced lower oesophageal sphincter mule tone => increased relaxation allowing reflux of gastric acid through the LOS => damage to squamous mucosa and eventual metaplasia to columnar cells

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14
Q

what are 4 clinical presentations of Barrett’s oesophagus?

A

heartburn
regurgitation
dysphasia
SOB/wheezing and belching

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15
Q

what is the investigation for Barrett’s oesophagus?

A

Upper Gi endoscopy + biopsy = gold

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16
Q

what are 3 differentials for Barrett’s oesophagus?

A

osephagitis
GORD
oesophageal carcinoma

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17
Q

what is the management of Barrett’s oesophagus?

A

1 - PPIs (omeprazole), lifestyle changes, radio frequency ablation

repeat endoscopic surveillance

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18
Q

what are 3 complications of Barrett’s oesophagus?

A

oesophageal adenocarcinoma
oesophageal strictures
quality of life deficit

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19
Q

what is coeliac disease?

A

systemic autoimmune inflammatory disease affecting the small intestine triggered by dietary gluten peptides found in wheat, rye, barley, and related grains.

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20
Q

what is the trigger in coeliac disease?

A

prolamins found in gluten

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21
Q

what are 3 risk factors for coeliac disease?

A 
FHx
IgA deficiency
autoimmune disease (T1DM)
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22
Q

what immune cell is coeliac gluten intolerance mediated by?

A

T cell

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23
Q

what are 5 presentations of coeliac disease?

A 
Diarrhoea or steatorrhoea 
abdominal bloating/discomfort
anaemia 
indigestion 
dermatitis herpetiformis
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24
Q

what are 3 serological investigations for coeliac disease?

A

1 - Tissue transglutaminase antibodies and total IgA
2 - endomysial antibodies
anti-casein antibodies

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25
what are 3 differentials for coeliac?
Crohn's disease peptic duodenitis giardiasis
26
what are 3 complications of coeliac disease?
osteoporosis risk increased risk of malignancy Anaemia
27
what is Crohn's disease?
a autoimmune inflammatory GI disorder characterised by transmural granulomatous inflammation of the GI tract from mouth to anus with skip lesions
28
are males of females more likely to be affected by Crohn's and coeliac disease?
females
29
what are 3 risk factors for Crohn's disease?
stress and depression FHx smoking
30
what is the pathophysiology of Crohn's disease?
Transmural granulomatous inflammation of any part of GI tract => most common in terminal ileum and proximal colon. skip lesions - cobblestone appearance relapsing and remitting
31
what are 6 presentations of Crohn's?
``` chronic diarrhoea weight loss Abdo pain (RLQ most common) blood in stool (less common than in UC) perianal lesions mouth ulcers ```
32
what are 3 blood tests for Crohn's disease?
CRP + ESR - raised FBC - anaemia (B12/iron/B9) U+Es
33
what are 3 differentials for Crohn's disease?
ulcerative colitis infectious cause coeliac disease
34
what is the management for Crohn's disease flare ups?
1st - Glucocorticoids (budenoside, prednisolone or hydrocortisone depending on severity) elemental diet Immunosuppresion - azathioprine, mercaptopurine and methotrexate Biologics - inflixibab antibiotics for peri-anal disease
35
what are 3 complications of Crohn's disease?
malignancy fistulae intestinal obstruction
36
what is diverticulitis?
inflammation of diverticula diverticula = out pouching of the mucosa and submucosa through the muscular layer of the colonic wall
37
what is the main cause of diverticulitis?
low fibre diet
38
what are 3 risk factors for diverticulitis?
50+ low fibre diet obesity
39
what part of the colon is diverticulitis most common in?
sigmoid colon
40
what is the pathophysiology of diverticulitis?
Low fibre => increased intestinal transit time and straining on loo => increased intraintestinal pressure => diverticula herniations => foecal matter gets stuck => infection => complications
41
what are 5 presentations of diverticulitis?
``` L lower quadrant pain/gaurding/tenderness blood on DRE fever diarrhoea/constipation palpable abdominal mass ```
42
what is the gold standard for diverticulitis?
Abdo CT with contrast
43
what are 3 blood tests for diverticulitis?
FBC - leukocytosis U+E+C - creatinine elevated, uraemia CRP - raised
44
what are 3 differentials for diverticulitis?
endometriosis colorectal cancer appendicitis
45
what is the management for diverticulitis?
dietary and lifestyle - fibre analgesia antibiotics - co-amoxiclav surgical intervention antispasmodics - dicycloverine
46
what are 3 complications of diverticulitis?
fistulae abscesses perforations
47
What is gastritis?
inflammation of the lining of the stomach associated with mucosal injury
48
what are 4 causes of gastritis?
NSAIDs alcohol H. Pylori infection Autoimmune
49
what are 3 risk factors for gastritis?
H. Pylori infection previous gastric surgery autoimmune disease
50
what are 5 presentations of gastritis?
``` dyspepsia/epigastric discomfort fever severe emesis (vomiting) nausea haematemesis/malaena ```
51
what are 3 investigations for gastritis?
H. Pylori urea breath test/ faecal antigen test endoscopy anti-IF/parietal cell antibodies
52
what are 3 differentials for gastritis?
peptic ulcer disease GORD non-ulcer dyspepsia
53
what is the management for gastritis?
H. pylori eradication PPIs antacids H2 antagonists
54
what are 3 complications of gastritis?
gastric carcinoma gastric lymphoma vitamin B12 deficiency
55
What is GORD?
the reflux of gastric contents into the oesophagus or beyond
56
what are 4 risk factors for GORD?
FHx age hiatus hernias obesity
57
what are 5 presentations of GORD?
``` heart burn regurgitation chest pain/retrosternal pain coughing/belching Water brash ```
58
what are 3 investigations for GORD?
PPI trial 24 hour pH monitoring endoscopy and biopsy
59
what are 3 differentials for GORD?
malignancy stable angina peptic ulcer disease
60
what are 4 managements of GORD?
PPIs - omeprazole antacids H2 receptor antagonist - ranitidine life style changes
61
what are 3 complications of GORD?
Barrett's oesophagus strictures oesophageal ulcer
62
what is IBS?
a chronic condition characterised by abdominal pain associated with bowel dysfunction where there is no structural abnormalities to explain the pain
63
what are 3 risk factors for IBS?
Female stress PTSD
64
what are the 3 different types of IBS?
IBS C - constipation IBS D - Diarrhoea IBS M - both
65
what are 5 presentations of IBS?
abdo discomfort / bloating alteration of bowel habits normal abdo exam defecation urgency
66
what are 4 general bowel tests that can be run?
Faecal calprotectin faecal occult blood tests coeliac serology foecal lactoferrin
67
what are 3 differentials for IBS?
crohn's coeliac ulcerative colitis
68
what are the 2 main types of oesophageal cancer?
squamous cell carcinoma (smoking) | adenocarcinoma (GORD)
69
what are 4 risk factors for oesophageal cancer?
Barrett's oesophagus male smoker Achalasia
70
what are 6 presentations of oesophageal cancer?
``` dysphagia (solids then liquids) pain on swallowing weight loss hoarse voice/cough melana lymphadenopathy ```
71
what are 3 investigations for oesophageal cancer?
oesophogastroduodenoscopy with biopsy - gold CT chest abdomen and pelvis Barium swallow
72
what are 3 differentials for oesophageal cancer?
benign stricture achalasia Barrett's oesophagus
73
what is the management of oesophageal cancer?
endoscopic resection oesophgectomy chemo - platinin based radiotherapy
74
what are 3 complications of oesophageal cancer?
postoperative pneumonia Prost-resection acid reflux trachea-oesophageal fistula
75
what is a mallory Weiss tear?
mucosal tear at oesophageal gastric junction due to a sudden increase in iata-abdominal pressure => coughing/dry heaving causes haematesis, postural hypertension and dizziness
76
what are oesophageal varices?
abnormal, dilated veins in the lower 1/3rd of the oesophagus that occur at the lower end of the oesophagus; they account for 10-20% of upper GI bleeds. A complication of portal hypertension
77
what percentage of patients with cirrhosis have oesophageal varices?
50% at diagnosis
78
what are 3 risk factors for oesophageal varices?
portal hypertension cirrhosis alcoholism
79
what are 6 presentations of oesophageal varices?
``` features of liver disease haematemesis melaena cirrhosis/liver disease abdo pain blood loss/shock symptoms ```
80
what are 3 investigations for oesophageal varices?
upper GI endoscopy - gold FBC - anaemia serum LFTs - deranged U+Es - raised urea in upper GI bleed
81
what are 3 differentials for oesophageal varices?
hiatus hernia gastric varices mallory weiss tear
82
what is the management for non-bleeding oesophageal varices?
beta blockers | endoscopic ligation
83
what are 3 complications of oesophageal varices?
spontaneous bacterial peritonitis encephalopathy rebleed
84
what 2 veins form the portal. vein?
superior mesenteric and splenic veins
85
what is the normal pressure in the portal vein?
5-8 mmHg
86
what is a peptic ulcer?
A break in the mucosal lining of the stomach or duodenum more than 5 mm in diameter, with depth to the submucosa
87
what causes peptic ulcers?
Due to imbalance between factors promoting mucosal damage gastric acid, pepsin, helicobactor pylori, NSAIDs – and those promoting gastroduodenal defence – prostaglandins, mucins, bicarbonate, mucosal blood flow
88
what are 4 risk factors for peptic ulcers?
H. Pylori NSAIDs smoking FHx
89
why does H. Pylori infection increase peptic ulcer risk?
H.pylori => impaired somatostatin secretion => increased gastrin release => gastric acid hypersecretion
90
what are 5 presentations of peptic ulcer?
can be asymptomatic ``` abdo pain early satiety anorexia anaemia symptoms hypotension/shock - gastro bleeding ```
91
what are 3 investigations for peptic ulcers?
upper GI endoscopy and biopsy - gold h. pylori breath/stool antigen FBC + U+e + LFTs
92
what are 3 differentials for peptic ulcers?
oesophageal cancer GORD gastritis
93
what is the management of non H.Pylori peptic ulcers?
PPIs | H2 antagonist - nizatidine
94
what are 3 complications of peptic ulcers?
gastroduodenal bleeding perforation penetration
95
what is ulcerative colitis?
a type of relapsing remitting inflammatory bowel disease that characteristically involves the rectum and extends proximally to affect a variable length of the colon (colon mucosa)
96
is cronh's or ulcerative colitis more common?
UC
97
what are 3 risk factors for ulcerative colitis?
FHx HLA-B27 genes NSAIDs - flare ups
98
what is the pathophysiology of ulcerative colitis?
Arises in rectum, affects only colon up to ileo-caecal valve, continuous (no skip lesions), mucosa reddened, inflamed and bleeds easily, ulcers and psueudopolyps in severe disease, non-transmural inflammation, depleted goblet cells, no granulomata, increased crypt abscesses
99
what are 5 presentations of ulcerative colitis?
``` blood and mucus in stools diarrhoea malnutrition and weight loss fever - during attack arthritis/spondyloarthritis/uveitis ```
100
what is the gold standard investigation for UC?
colonoscopy and biopsy ``` red raw mucosa with shallow ULCERS lamina propria inflammatory cell infiltrates (neutrophil) pseudopolysps crypt abscesses goblet cell depletion ```
101
what are 3 differentials for UC?
Crohn's indeterminate collitis IBS
102
what are 3 complications of ulcerative colitis?
``` toxic megacolon (most common cause of death) colonic adenocarcinoma bowel obstruction ```
103
what is the treatment for mild ulcerative colitis?
1 - aminosalicylates - Sulfasalazine 2 - corticosteroids
104
where is B12 absorbed?
distal ilium
105
where is folate (B9) absorbed?
proximal jejunum/duodenum
106
where is iron absorbed?
duodenum
107
where is intrinsic factor secreted from?
stomach - parietal cells | needed for B12 absorptions
108
what is acute cholangitis?
an infection of the biliary tree, most commonly caused by obstruction.
109
what are 4 causes of acute cholangitis?
malignancies strictures cholethiasis (gallstones) chronic pancreatitis
110
what are 3 risk factors for acute cholangitis?
50+ gall stones post procedure injury
111
what is the pathophysiology of acute cholangitis?
Obstruction of bile duct results in bacteria in biliary tree, sludge forms providing a growth medium for bacteria, bile duct pressure increases => pressure gradient promotes extravasation of bacteria into blood stream => sepsis
112
what are 5 symptoms of acute cholangitis?
``` URQ pain/tenderness fever jaundice pruritis, dark urine, pale stools confusion ```
113
what are 3 investigations for acute cholangitis?
FBC - high WBCs CRP - raised ultrasound - 1st line MRCP - gold
114
what are 3 differentials for acute cholangitis?
acute cholecystitis peptic ulcer disease acute
115
what is the management of acute cholangitis?
``` IV Antibiotics - cefotaxime and metronidazole IV fluids Analgesia biliary decompression - ERCP surgical drainage ```
116
what are 3 complications of acute cholangitis?
sepsis hepatic abscess acute pancreatitis
117
what type of bacteria is acute cholangitis usually caused by?
gram negative bacili
118
What s acute cholecystitis?
acute gallbladder inflammation, and one of the major complications of cholelithiasis or gallstones.
119
who are gallstones most common in?
women over 50
120
what are 3 risk factors for acute cholecystitis?
gallstones physical inactivity low fibre intake
121
where is obstructed in acute cholecystitis?
gallbladder neck or cystic duct
122
what are 5 presentations of acute cholecystitis?
RUQ pain and tenderness (possible R shoulder pain) - Murphy's sign palpable mass fever, chills, tachycardia nausea and vomiting
123
what is the gold standard test for acute cholecystitis?
abdo ultrasound - thickened gallbladder wall, distended gallbladder, presence of stone
124
what are 3 investigations for acute cholecystitis?
ESR/CRP - raised FBC - WBCs raised LFTs - may be raised
125
what are 3 differentials for acute cholecystitis?
acute cholangitis pancreatitis peptic ulcer disease
126
what is the management for acute cholecystitis?
antibiotics - cefuroxime and metronidazole analgesia cholecystectomy
127
what are 3 complications of acute cholecystitis?
obstructive jaundice gallbladder empyema galstone ileus
128
what is acute liver failure?
a rapid decline in hepatic function characterised by jaundice, coagulopathy (INR >1.5), and hepatic encephalopathy in patients with no evidence of prior liver disease
129
what are 3 causes of acute liver failure?
Drugs - Paracetamol overdose viruses - Hep A/B/CMV autoimmune hepititis
130
what are 4 risk factors for acute liver failure?
chronic alcohol abuse poor nutritional status female pregnant
131
what are 5 presentations of liver failure?
``` jaundice signs of hepatic encephalopathy hepatomegaly bruising and GI bleeds (coagulopathy) RUQ pain nausea and vomiting ```
132
what are 3 blood tests for acute liver failure?
LFTs - deranged including prothrombin time and INR U+E - low urea and high creatinine blood glucose - low
133
what are 3 differentials for acute liver failure?
severe acute hepatitis cholestasis haemolysis
134
what is the treatment of acute liver failure?
treat underlying good nutrition - thiamine and folate
135
what are 3 complications of acute liver failure?
Sepsis AKI haemorrhage
136
what are the 10 causes of acute pancreatitis? (mnemonic)
I GET SMASHED ``` idiopathic (or infections) Gallstones (50-60%) Ethanol (25-30%) Trauma Steroids Mumps autoimmune scorpion venom hyperlipidaemia ECRP Drugs ```
137
what are 3 risk factor for acute pancreatitis?
obesity Diet T2DM
138
what is the pathophysiology of acute pancreatitis?
The destructive effect of premature activation of pancreatic enzymes which cause self-perpetuating pancreatic inflammation by enzyme mediated autodigestion.
139
what are 6 presentations of acute pancreatitis?
``` severe epigastric pain radiating to back nausea and vomiting signs of hypovolaemia jaundice and steatorrhoea poor urinary output ```
140
what are 3 investigations for acute pancreatitis?
serum lipase/amylase - >3x normal - gold FBC with differential - leukocytosis haematocrit >44% CRP - elevated
141
What are the 3 stages of alcoholic liver disease?
fatty liver (steatosis), alcoholic hepatitis (inflammation and necrosis), and alcoholic liver cirrhosis
142
what are 3 risk factors for alcoholic liver disease?
prolonged alcoholism female hepatitis C
143
how is alcohol metabolised?
in liver by alcohol dehydrogenase and cytochrome P-450 2E1 => chronic alcohol use causes cytochrome P-450 to produce more free radicals and alcohol dehydrogenase when converted to NADH inhibits gluconeogenesis and increases fatty acid oxidation
144
what are 7 signs of alcoholic liver disease?
``` caput medusa splenomegaly palmar erythema Dupuytren's contracture - thick palmar fascia - flexed fingers leuconychia - white lines on nails gynaecomastia spider naevi ```
145
what are 4 biochemical investigations for alcoholic liver disease?
LFTs - aminotransferase (AST) and alanine aminotransferase (ALT) elevated FBCs - thrombocytopenia serum bilirubin - elevated serum albumin - low
146
what is the gold standard investigation for chronic liver disease (alcohol/nonA)?
liver biopsy - may show Mallory bodies, large mitochondria, neutrophil infiltrate, hepatocyte allowing, fibrosis and cholestasis
147
what are 3 differentials for alcoholic liver disease?
hepatitis A/B/C cholecystitis hepatic vein thrombosis
148
what is the management of alcoholic liver disease?
``` alcohol abstinence hydration nutrition steroids - predisolone - cirrhosis reduce salt avoid liver metabolised drugs liver transplant ```
149
what are 3 complications of alcoholic liver disease?
hepatocellular carcinoma peptic ulcers varices
150
what is ascites?
a pathological collection of fluid in the peritoneal cavity.
151
what is the most common cause of ascites?
cirrhosis - 75%
152
what are 4 manifestations of ascites?
Abdominal distension fluid on exam with shifting dullness shortness of breath fatigue
153
what are 3 differentials for ascites?
Hep C alcoholic liver disease congestive heart failure
154
what is the management for ascites?
treat underlying cause limit sodium diuretics - spironolactone paracentesis
155
what are the stages of ascites?
1 – detectable only after careful exam 2 – easily detectable but small volume 3 – obvious but not tense 4 – tense
156
What is cholelithiasis?
gallstones | the presence of solid concretions in the gallbladder. They may exit into the bile ducts in choledocholithiasis.
157
what are gallstones usually made out of n the developed world?
cholesterol - 90%
158
what are 5% of gallstones made out of?
polymerised calcium billirubinate - black pigment stones
159
what are the risk factors for cholelithiasis?
``` Female Fat Forties Fertile Fair (white) ```
160
what is the pathophysiology of cholelithiasis?
=> bile is super saturated by cholesterol from liver => nucleating factors precipitate in the gallbladder where hypomotility provides time for stone growth
161
what are 4 presentations of cholelithiasis?
RUQ pain - biliary colic jaundice fever dietary upset/nausea
162
what are 3 investigations for cholelithiasis?
LFTs CRP abdo ultrasound - gold
163
what are 3 differentials for cholelithiasis?
peptic ulcers gallbladder cancer gallbladder polyps
164
what is the management of cholelithiasis?
``` laparoscopic cholecystectomy analgesia observation and life style management - lower cholesterol diet, stop smoking ECRP radiological drain cholecystectomy ```
165
what are 3 complications of cholelithiasis?
cholecystitis cholangitis pacreatitis
166
what is gallstone ileus?
Gall stone eroded though gallbladder into duodenum and causes constipation
167
What is chronic pancreatitis?
Debilitating continuing inflammatory process of the pancreas resulting in progressive loss of exocrine pancreatic tissue which is replaced by fibrosis
168
what are 4 causes of chronic pancreatitis?
alcohol - 60-70% CKD hereditary - defects in trypsinogen, CF autoimmune - raised IgG4
169
what are 3 risk factors for chronic pancreatitis?
alcohol smoking FHx
170
what is the pathogenesis of chronic pancreatitis?
Obstruction/reduction in bicarb secretion leading to activation of trypsinogen to trypsin in the pancreas as pH rises leading to pancreatic tissue necrosis and eventual fibrosis.
171
what are 5 manifestations of chronic pancreatitis?
``` epigastric pain radiating to back steatorrhoea and diarrhoea weight loss and fatigue diabetes melitus nausea and vomiting ```
172
what are 3 differential diagnosis of chronic pancreatitis?
pancreatic cancer acute pancreatitis biliary colic
173
what is the management of chronic pancreatitis?
diet and lifestyle modification analgesia - NSAIDs and paracetamol pancreatic enzyme replacement pancreatectomy
174
what are 3 complications of chronic pancreatitis?
malabsorption pancreatic pseudocystitis pancreatic cancer
175
what is recurrent acute pancreatitis?
dentifiable cause of chronic pancreatitis that doesn’t lead to chronic
176
what is cirrhosis?
The pathological end-stage of any chronic liver disease characterised by fibrosis and conversion of normal liver architecture to structurally abnormal nodules known as regenerative nodules.
177
what are 4 causes of liver cirrhosis?
alcohol related liver disease non-alcoholic fatty liver disease chronic viral hepatitis Budd-Chiari syndrome
178
what are 3 risk factors for cirrhosis?
alcohol missuse IVDU unprotected sex
179
what is the pathophysiology of liver cirrhosis?
Hepatic fibrosis due to activation of hepatic stellate cells and kupfer cells leading to accumulation of type I+III collagen in hepatic parenchyma and space of disse => sinusoids lose characteristic fenestration => altered exchange between plasma and hepatocytes
180
what are 8 presentations of liver cirrhosis?
``` hepatosplenomegaly palmar erythema and spider naevi and bruising Dupuytren's contracture leuconychia and clubbing oedema loss of body hair and gynaecomastia ```
181
what are 3 investigations of liver cirrhosis?
liver biopsy - gold LFT - deranged ultrasound and duplex
182
what are 3 differentials for liver cirrhosis?
Budd-chiari syndrome portal vein thrombosis splenic vein thrombosis
183
what is Budd chiari syndrome?
rare condition of hepatic vein occlusion
184
what is the treatment of cirrhosis?
``` treat underlying disease monitor for complications sodium restriction and diuretics liver transplant trans jugular intrahepatic portosystemic shunt ```
185
what are 3 complications of cirrhosis?
ascites visceral haemorrhage jaundice
186
what are the 4 clinical stages of cirrhosis?
- Stage 1 o Patient without GO varices or ascites - Stage 2 o Patient with GO varisces (but no bleeding) and no ascites - Stage 3 o Patient with ascites but with or without GO varices but no bleeding - Stage 4 o Patients with GI bleeding due to portal hypertension with or without ascites
187
which is the only Hepatitis virus that is DNA?
HBV
188
which two hepatitis viruses are faecal oral transmission?
A and E
189
which 3 hepatitis viruses are blood-blood/sexual transmission?
B, C, D
190
what is the pathophysiology of Hepatitis viruses?
travels through mesenteric veins to liver => enters hepatocytes => replication
191
what are 6 manifestation of hepatitis?
``` fever malaise myalgia nausea + vomiting (GI upset) jaundice hepatomegaly + RUQ pain ```
192
what is the serology for HAV?
HAV IgM + IgG - +ve IgM positive soon after symptoms and for a few months IgG positive 5-10 days post symptoms and for rest of life - recovery OR vaccination
193
what are 3 differentials for | Hepatitis viruses?
other acute hep virus Wilsons disease autoimmune hepatitis alcoholic liver disease
194
what is the management for HAV?
hep A vaccines and or immunoglobulins supportive care liver transplant
195
what are 5 complications of hepatitis viruses?
``` prolonged cholestasis acute pancreatitis hepatocellular carcinoma cirrhosis rheumatological complications ```
196
what hepatitis virus do you need to be infected with in order to get infected with hepatitis D?
Hepatitis B - chronic in 5%
197
what is hepatitis B?
the most common liver infection | May result in self-limiting disease requiring no treatment or in chronically infected state (more likely in children)
198
what are 3 risk factors for hepatitis B/C/D?
perinatal exposure high risk sexual behaviours IVDU
199
what are the investigations for hepatitis B?
HBsAg – infection acute or chronic HBeAg – active viral replication => active infection acute or chronic Anti-HBs – immunity to HBV => natural or vaccine Anti-HBc IgG– recovered or chronic infection Ant-HBc IgM – recent infection (last 6 months) Anti-HBc – past or chronic infection Anti-HBe – implies seroconversion and is present for life
200
what fraction of HCV patients present with an acute illness and progress to chronic?
1/3
201
what are the investigations for HCV?
hepatitis C PCR - gold, current/active infection (chronic or acute) Hep C virus antibody enzyme immunoassay - implies current or previous infection LFTs - raised AST and ALT
202
what is the management for HCV?
oral direct acting antivirals - ending -ASVIR or -BUVIR
203
what are 4 risk factors for hepatitis A/E?
contaminated water poor sanitation ingestion of undercooked meat/shellfish travel to endemic areas
204
what group of people is HEV worst in?
pregnant - 10-30% mortality | 1% in general pop
205
is HEV usually self limiting or not?
usually self limiting
206
what percentage of immunocompetent adults with HBV achieve seroconversion without treatment?
95%
207
what is jaundice?
the result of accumulation of bilirubin in the bloodstream and subsequent deposition in the skin, sclera, and mucous membranes
208
describe the breakdown of bilirubin
heam is broken down by macrophages to biliverdin then to lipid soluble unconjugated bilirubin => enters blood bound to albumin unconjugated B taken up by hepatocytes + conjugated with glucuronic acid conjugated B is water soluble and excreted in bile gut bacteria convert bilirubin to urobilogen and stercobillinogen => excreted in urine and stool respectively
209
what are 3 broad causes of prehepatic jaundice?
increase bilirubin production increased RBC destruction increased unconjuated bilirubin
210
what are 2 conditions that can cause prehepatic jaundice?
haemolysis | Gilbert's syndrome
211
what so the stools and urine look like in prehepatic jaundice?
normal stools and urine
212
what are 4 causes of intrahepatic jaundice?
Hepatitis viruses HIV/parasitic infections toxins genetics - Wilsons disease
213
what is are 6 causes of post hepatic jaundice?
``` post operative stricture cholelithiasis (gallstones) ascending cholangitis IgG4 cholangiopathy infections malignancy ```
214
what does the urine and stools look like in intrahepatic jaundice?
urine - dark | stools - normal
215
what does the urine and stools look like in post hepatic jaundice?
urine - dark | stools - pale
216
what are 5 manifestations of jaundice?
``` yellowing pruritus anorexia nausea and vomiting RUQ pain ```
217
what are 3 investigations of jaundice?
Prothrombin time and INR serum LFTs liver ultrasound
218
What is non-alcoholic fatty liver disease?
a spectrum of conditions characterised histologically by macrovesicular hepatic steatosis in those who do not consume alcohol in amounts generally considered harmful to the liver.
219
what is the most common cause of liver disease in the west?
non-alcoholic fatty liver disease
220
what are 4 risk factors for NAFLD?
obesity T2DM hyperlipidaemia hypertension
221
what are 5 presentation of NAFLD?
``` RUQ discomfort pruritus + jaundice spider angiograms, palmar erythema and caput medusa bruising, petechiae, melaena peripheral oedema and ascites ```
222
what are 3 investigations for NAFLD?
LFTs - AST, ALT, APT, bilirubin raised FBC - anaemia/thrombocytopenia prothrombin time + INR - elevated
223
what are 3 differentials for NAFLD?
alcoholic liver disease autoimmune/viral hepatitis Wilsons disease
224
what is the treatment for NAFLD?
lifestyle modifications liver transplant vitamin E insulin sensitiser (metformin) lipid lowering therapy (statin) weight loss surgery/pharmacy
225
what are 3 complications of NAFLD?
ascites vatical haemorrhage hepatocellular carcinoma
226
What is primary biliary cholangitis?
chronic granulomatous autoimmune disease of small intrahepatic bile ducts that is characterised by progressive bile duct damage (and eventual loss) occurring in the context of chronic portal tract inflammation
227
what are 3 risk factors for primary biliary cholangitis?
female autoimmune conditions FHx
228
what is the pathophysiology of primary biliary cholangitis?
Progressive destruction of biliary epithelial cells lining the small intrahepatic bile ducts => precipitated by cholestasis => fibrosis => cirrhosis AMA antibodies present
229
what are 5 presentations of primary biliary cholangitis?
``` pruritus fatigue and weight loss skin hyperpigmentation clubbing mild heptosplenomegaly ```
230
what are 3 investigations for primary biliary cholangitis?
antimitochondrial antibodies (AMA - most specific) or antinuclear antibodies (ANA) serum cholesterol - raised LFTs - raised ALP, GGT and bilirubin
231
what are 3 differentials for primary biliary cholangitis?
obstructive bile duct lesions primary sclerosis cholangitis malignancy
232
what its the treatment of primary biliary cholangitis?
bile acid analogue - ursodeoxycholic acid fat soluble vitamin supplements Cholestyramine - anti-pruritus codine and bisphosphonates Liver transplant
233
what are 3 complications of primary biliary cholangitis?
cirrhosis hypercholesterolaemia osteroporosis
234
what is primary sclerosing cholangitis?
A chronic progressive cholestatic liver disease, characterised by inflammation and fibrosis of the intrahepatic and/or extrahepatic bile ducts, resulting in stricture formation
235
what is the epidemiology of primary sclerosing cholangitis?
young and middle aged men often with underlying IBD relatively rare
236
what is the pathophysiology of primary sclerosing cholagitis?
Inflammation of medium/large bile ducts => fibrosis and strictures => bile stasis => bile stones and retained bile slats => jaundice, pruritus, biliary cirrhosis => end stage liver disease
237
what are 5 manifestations of primary sclerosing cholangitis?
may be asymptomatic ``` jaundice and pruritus abdo pain fatigue and weight loss steatorrhoea ascites/encephalopathy ```
238
what are 4 investigations for primary sclerosing cholangitis?
LFTs - raised ALP, bilirubin, GGT, ALT and AST MRCP/ERCP - gold - bead shaped appearance antibodies screening - may be pANCA +ve, AMA -VE!, may be ANA +ve
239
what are 3 differentials for primary sclerosing cholangitis?
secondary sclerosing cholangitis IgG4 cholangitis immune hepatitis
240
what is the management for primary sclerosing cholangitis?
liver transplant - only non-symptom treatment observations and lifestyle cholestyramine - pruritus relief fat souble Vitamin replacement
241
what are 3 complications of primary sclerosing cholangitis?
cholangitis cholangiocarcinoma osteoporosis
242
what are 2 stool tests for Crohn's?
Feacal calprotectin - raised in inflammation | stool microscopy and culture
243
what is the gold standard for Crohn's?
colonoscopy + biopsy transmural inflammation, deep ulcers, skip lesions, cobblestone mucosa, granulomas, goblet cells
244
what is the management for crohn's in remission?
1 - azathioprine or mercaptopurine 2 - methotrexate, infliximab, adalimumab
245
what are 4 surgeries can be offered in Crohn's?
ileocaecal resection partial hemicolectomy colectomy with ileostomy resection of bowel
246
what does faecal calprotectin help differentiate between?
IBS and IBD - raised in IBD
247
what is the treatment for severe UC?
1 - IV corticosteroids 2 - IV ciclosporin surgery - J pouch or ileostomy
248
what does UC look like on barium enema?
loos of haustrations widespread superficial ulceration and pseudopolyps LEAD PIPE COLON
249
what disease in pANCA most associated with?
ulcerative colitis
250
what disease is ASCA more associated with?
Crohn's disease
251
what scoring system is used for the severity of UC?
Truelove and Witt's severity index
252
where is crohn's most common?
terminal ileum
253
what are 4 histological features of coeliac disease?
villous atrophy crypt hyperplasia increase in intraepithelial lymphocytes lamina propria lymphocyte infiltration
254
what is the most common gastric/intestinal cancer?
adenocarcinoma
255
where in the world is gastric cancer most common?
Japan
256
what are 5 manifestations of gastric cancer?
``` iron deficiency anaemia mass melaena weight loss and malaise early satiety ```
257
what are 3 differentials for gastric cancer?
peptic ulcer oesophageal stricture achalasia
258
what are 2 risk factors for small intestine cancer?
coeliac disease | Crohn's disease
259
what staging is used in colorectal cancer?
Duke's staging
260
what 3 inherited conditions can cause colorectal cancer?
familial adenomatous polypososis Hereditary non-polyposis colon cancer Peutz-Jeghers syndrome
261
what is the inheritance pattern for FAP and HNPCC?
autosomal dominant
262
what part of the colon is most affected in familial adenomatous polyposis?
left colon and rectum
263
what part of the colon is most affected in Hereditary non-polyposis colon cancer?
right colon
264
what are 4 risk factors for colorectal cancer?
increased age red and processed meats low dietary fibre hereditary conditions
265
what are 5 presentations of R sided colorectal cancer?
often asymptomatic ``` iron deficiency anaemia progressive change in bowel habit large bowel obstruction weight loss and fatigue abdo discomfort ```
266
what are 5 presentations of L sided colorectal cancer?
``` rectal mass progressive change in bowel habit abdo discomfort large bowel obstruction weight loss and fatigue ```
267
what are 3 investigations for colorectal cancer?
colonoscopy and biospy - gold FBC and U+E fecal occult blood test
268
what is the pain like in a duodenal ulcer?
worse when hungry or a few hours after eating, relieved by eating
269
what is the pain like in a gastric ulcer?
made worse by eating
270
what is the management of H. Pylori peptic ulcers?
omeprazole, clarithromycin and amoxicillin (metronidazole if allergic)
271
what is Rovsing's sign?
in appendicitis - pain in the R iliac fossa worsened by pressing on the left iliac fossa
272
what is posoas sign?
appendicitis pain worsened in extending hip
273
what is obturator sign?
appendicitis pain worsened by flexing and internally rotating hip
274
what is the most common cause of small bowel obstruction?
postoperative adhesions
275
what is the most common cause of large bowel obstruction?
Volvulus
276
what are 5 manifestations of small bowel obstruction?
``` abdominal pain and distension tinkling/absent bowel sounds empty rectum early vomiting and nausea constipation ```
277
what is the 1st line imaging investigation for bowel obstruction?
abdominal X-ray small - dilated small bowel and fluid level Large - coffee bean sign (sigmoid volvulus)
278
what is the 1st line management of bowel obstruction?
IV fluids NG tube (suck) IV antibiotics analgesia and anti-emetics
279
what are 3 complications of bowel obstruction?
ischaemia and perforation sepsis aspiration pneumonia
280
is large or small bowel obstruction more common?
small
281
what is Hirschsprung's disease?
neonates born without complete innervation of colon and rectum causing large bowel obstruction
282
what are 5 manifestations of large bowel obstruction?
``` abdo pain and distension tinkling sounds early on absent later empty rectum bloating and constipation (early) vomiting - late ```
283
what symptoms point to an infective cause of diarrhoea?
sudden onset | cramps abdominal pain and fever
284
how long does acute diarrhoea last?
<2 weeks
285
name 1 anti-diarrhoeal agent?
loperamide
286
what is contained in the foregut?
stomach, duodenum to sphincter of odd, biliary system, liver, pancreas
287
what is the blood supply of the foregut?
coeliac artery
288
what is contained in the midgut?
duodenum to 1st half of transverse colon
289
what is the blood supply of the midgut?
superior mesenteric artery
290
what is the blood supply of the hindgut?
inferior mesenteric artery
291
how long is the anus?
3-4 cm
292
what is the name of the line separating the histologically different parts of the anal canal?
the (pectinate) dentate line
293
what is hyper acute liver failure?
hepatic encephalopathy <7 days of noticing jaundice
294
what is subacute live failure?
hepatic encephalopathy within 5-12 weeks of noticing jaundice worst prognosis - usually associated with shrunken liver
295
what is classed as acute liver failure?
hepatic encephalopathy within 8-28 weeks of noticing jaundice
296
what is fulminant hepatic failure?
clinical syndrome resulting from massive necrosis of liver cells leading to sever impairment of liver function
297
what are the signs of hepatic encephalopathy?
altered mental status confusion apraxia - difficulty motor planning asterisks - flapping
298
what is the grading system for heptic encephalopathy called?
the west haven criteria
299
what are 4 functions of the liver?
storage breakdown synthesis immune function
300
what are 5 signs of decompensated liver disease?
``` encephalopathy ascites jaundice GI bleeding coagulopathy ```
301
what is the treatment for hepatic encephalopathy?
1 - laxatives (lactulose) 2 - antibiotics (rifaximin) long term
302
what are black pigment gallstones and when do they occur?
stones of billirubinate - occur in patients with increased haemolysis (haemolytic anaemias)
303
what are brown pigment stones and when do they occur?
calcium bilrubinate and calcium salts of fatty acids associated with infection and cholecystectomy
304
what is Murphy's sign?
As the patient breathes out, place your hand below the right costal margin. As the patient breathes in an inflamed gallbladder moves inferiorly, the patient catches their breath. To be considered positive, it should be absent on the left side. => acute cholecystitis
305
what does ERCP stand for?
endoscopic retrograde cholangiopancreatography
306
what is Charcot's triad?
for ascending cholangitis RUQ pain jaundice fever
307
what is Cullen's sign?
for pancreatitis - periumbilical bleeding
308
what is Grey Turner's syndrome?
flank bleeding secondary to retopritoneal haemorrhage in pancreatitis
309
what is the management of acute pancreatitis?
``` IV fluids catherterisation O2 opiate analgesia early nutritional support ```
310
what are 3 complications of pancreatitis?
pancreatic abscess haemorrhage necrotising pancreatitis
311
what is the treatment for pruitus?
cholestyramine
312
what is the treatment for ascites?
fluid restriction and reduced salt intake | spironolactone
313
what is the treatment for hepatic encephalopathy?
prophylactic lactulose and rifaximin
314
what score is used to grade liver cirrhosis?
child-pugh score
315
what are 3 complications of liver cirrhosis?
coaglopathy encephalopathy hepatocellular carcinoma
316
what are 2 causes of pre-hepatic portal hypertension?
portal vein thrombosis | splenic vein thrombosis
317
what are 4 causes of intra-hepatic portal hypertension?
cirrhosis - most common UK schistosomiasis - most common worldwide sarcoidosis congenital hepatic fibrosis
318
what are 4 cause of post hepatic portal hypertension?
R Heart failure budd-chiari syndrome constrictive pericarditis veno-occlusive disease
319
where can hepatic varices form?
``` gastro-oesophageal junction rectum left renal vein diaphragm the anterior abdominal wall via the umbilical vein ```
320
what is the management for bleeding oesophageal varices?
``` ABCDE IV fluids Blood transfusion Terlipressin - ADH analogue prophylactic antibiotic balloon tamponade ```
321
how long does acute hepatitis last?
< 6 months
322
what are 5 infective causes of acute hepatitis?
``` Hep A/E Herpes viruses leptospirosis toxoplasmosis coxiella ```
323
what are 6 causes of non-infective acute hepatitis?
``` alcohol drugs toxins/poison pregnancy autoimmune hereditary ```
324
what LFTs are raised in acute hepatitis?
AST and ALP +/- bilirubin
325
what are 2 infective causes of chronic hepatitis?
Hep B +/- D | Hep C virus
326
what are 4 non-infective causes of chronic hepatitis?
alcohol drugs autoimmune hereditary
327
is hepatits A chronic?
NO
328
are hepatitis viruses notifiable?
YES
329
which hep viruses have vaccines?
A and B
330
what is the incubation period of HBV?
1-6 months
331
what are the serological investigations for Hep D?
IgM anti-HD IgG anti-HD HDAg - neg in chronic HDV RNA
332
what is the treatment for hep D?
interferon alpha
333
what are 3 investigations for HEV?
serology - IgM = active, IgG = recovery HEV PCR LFTs - elevated AST and ALT
334
what are 3 antibodies that are associated with autoimmune hepatitis?
Antinuclear (ANA) anti-smooth muscle - ASMA anti-SLA/LP
335
what is the treatment for autoimmune hepatitis?
immunosuppression - prednisolone and azathioprine
336
what is the main cause of travellers diarrhoea?
enterotoxigenic E. coli
337
what toxins does E. coli produce?
shiva toxins
338
what are 4 viral causes of infective diarrhoea?
rotavirus - most common in children norovirus - most common in adults adenoviruses astroviruses
339
what is the most common bacterial cause of diarrhoea?
campylobacter jejuni - associated with poultry
340
what bacteria can cause diarrhoea after eating undercooked pork?
yersinia enterocolitica
341
what bacteria produced rice water stools?
vibrio cholerae
342
what antibiotics cause diarrhoea?
rule of Cs clindamycin ciprofloxacin (quinolones) Co-amoxiclav (penicillins) cephalosporins
343
what is the most common parasitic cause of diarrhoea?
giardia lamblia
344
what are 4 risk factors for pseudomembranous colitis?
elderly antibiotics long hospital stay immunocompromised
345
name an anti-emetic?
metoclopramide
346
what is haemochromatosis?
multisystem disorder of dysregulated dietary iron absorption and increased iron release from macrophages.
347
what causes haemochromatosis?
Autosomal recessive HFE gene mutation on chromosome 6 chronic transfusions high iron intake alcoholism
348
what protein from the liver controls iron levels?
Hepcidin
349
what are 7 manifestations of haemochromatosis?
``` skin hyperpigmentation - bronze arthritic joints testicular atrophy hepatomegaly congestive cardiac failure osteoporosis T1DM ```
350
what investigations do you of for haemochromatosis?
serum ferritin - high | seum transferritin - high, more specific
351
what is the treatment for haemochromatosis?
venesection - draining small amounts of blood maintenance phlebotomy low iron diet
352
what are 4 complications of haemochromatosis?
cirrhosis hepatocellular carcinoma DM congestive HF
353
what is the inheritance pattern of Wilson's disease?
autosomal recessive
354
what is the gold standard test for Wilson's disease?
liver biopsy - test for copper contents
355
what is the 1st line treatment for Wilsons disease?
Copper chelation - D-penicillamine
356
what is alpha-1-antitrypsin deficiency?
autosomal recessive disorder causing liver and pulmonary disease
357
what does alpha-1-antutrypsin deficiency cause?
early onset COPD | liver cirrhosis and hepatocellular carcinoma
358
what is the most common primary liver cancer?
hepatocellular carcinoma
359
what can cause liver adenomas?
anabolic steroids, oral contraceptive pill, pregnancy
360
what part of the pancreas is usually affected in pancreatic cancer?
the head
361
what are 6 symptoms of pancreatic cancer?
``` painless jaundice non-specific symptoms new onset diabetes nausea and vomiting steatorrhoea dark urine and pale stools ```
362
what is Whipple's resection?
pancreaticoduodenectomy for resectable lesions of the head of the pancreas. This removes the antrum of the stomach, proximal duodenum, head of the pancreas, common bile duct and gallbladder => pancreatic cancer
363
what is a hernia?
the protrusion of an organ through a defect in the wall of it's cavity into an abnormal position
364
what are 3 risk factors for inguinal hernia?
male chronic cough constipation
365
how much paracetamol can be fatal in adults?
24 x 12g tablets | 150 mg/Kg
366
what is the management for paracetamol overdose?
``` activated charcoal (within 1 hour) N-Acetylcysteine ```
367
what are 3 complications of paracetamol overdose?
acute liver failure acute kidney injury anaphylactoid reaction
368
what are the 2 antibodies present in coeliac disease?
IgA tissue transglutaminase | IgA anti-endomysial
369
what are the causes of peritonitis/ (mnemonic)
ACUTE ABDOMEN ``` AAA Collapsed inferior vena cava Ulcer (perforated viscus) Trauma Ectopic pregnancy ``` ``` Appendicitis Biliary tract Distended bowel loop Obstructive uropathy Men: testicular torsion Women: ovarian torsion. ```
370
what is the management for bleeding varices?
IV terlipressin
371
what is the treatment for bleeding varicose in someone with ischaemic heart disease?
IV somatostatin

Phase 2A :!: (14 decks)

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