GI Clinical 1 Flashcards
Diseases, treatments etc. (400 cards)
1
Q
What is oesophageal reflux?
A
Reflux of gastric acid into oesophagus
2
Q
What happens to the squamous epithelium with oesophageal reflux?
A
It thickens
3
Q
What are some of the things that can happen to the oesophagus with severe reflux?
A
Ulceration, fibrosis, stricture formation
4
Q
What can happen as a result of fibrosis of the oesophagus?
A
Stricture formation, impaired motility, oesophageal obstruction
5
Q
What is Barrett’s oesophagus?
A
Type of metaplasia
6
Q
What is metaplasia of the oesophagus (Barrett’s oesophagus)?
A
Transformation from squamous epithelium to mucin-secreting columnar epithelium
7
Q
Why can Barrett’s oesophagus be bad?
A
Pre-malignant condition
8
Q
What is the third most common cancer of the alimentary tract?
A
Oesophageal
9
Q
What are the two histological types of oesophageal cancer?
A
Squamous carcinoma
Adenocarcinoma
10
Q
Which histological type of cancer does Barrett’s oesophagus develop into?
A
Adenocarcinoma
11
Q
What are the risk factors for oesophageal squamous carcinoma?
A
Smoking, alcohol, dietary carcinogens
12
Q
What are the risk factors for oesophageal adenocarcinoma?
A
Barrett’s metaplasia, obesity
13
Q
What are some of the local effects of oesophageal cancer?
A
Obstruction, ulceration, perforation
14
Q
What is the spread of oesophageal cancer?
A
Direct - to surrounding structures
15
Q
What is the lymphatic spread of oesophageal cancer?
A
To regional lymph nodes
16
Q
Where does oesophageal cancer usually spread to via blood?
A
Liver
17
Q
What is the prognosis for oesophageal cancer over 5 years?
A
Very poor, less than 15%
18
Q
What are the three types of gastritis?
A
Autoimmune (type A) Bacterial (type B) Chemical injury (type C)
19
Q
What is autoimmune gastritis?
A
Autoantibodies to parietal cells and intrinsic factor
20
Q
How does autoimmune gastritis manifest?
A
Loss of specialised gastric epithelial cells -> decreased acid secretion and loss of intrinsic factor
21
Q
What effect does the loss of specialised gastric epithelial cells in autoimmune gastritis have on the stomach?
A
Decreased acid secretion and loss of intrinsic factor
22
Q
During autoimmune gastritis, what effect does loss of intrinsic factor have on the stomach?
A
Pernicious anaemia which causes vitamin B12 deficiency
23
Q
What is the most common cause of pernicious anaemia?
A
Vitamin B12 deficiency
24
Q
What is the most common type of gastritis?
A
Bacterial gastritis
25
What gram negative bacterium is bacterial gastritis related to?
Helicobacter pylori
26
Where is H.pylori found?
In gastric mucus on the surface of the gastric epithelium
27
What affects does H.pylori have?
Produces acute and chronic inflammatory response
| Increased acid production
28
What causes chemical gastritis?
Drugs (NSAIDS), alcohol, bile reflux
29
How does peptic ulceration occur?
An inbalance between acid secretion and the mucosal barrier
30
Where does peptic ulceration occur?
Lower oesophagus, body and antrum stomach, 1st and 2nd parts of duodenum
31
How is peptic ulceration associated with H.pylori?
Increased gastric acid
32
What are complications of peptic ulceration?
Bleeding (acute-haemorrhage, chronic-anaemia)
Perforation (peritonitis)
Healing by fibrosis (obstruction)
33
What is metaplasia?
Transformation of normal tissue type into another normal cell (is reversible)
34
What is the histology change of Barrett's oesophagus?
Squamous epithelium replaced with glandular epithelium
35
Why might obesity be a cause of oesophageal reflux?
Increased intra-abdominal pressure
36
What is the second commonest cancer of the alimentary tract?
Stomach cancer
37
What can be associated with previous H.pylori infection?
Stomach cancer
38
What is the histology of stomach cancer?
Adenocarcinoma
39
What is the spread of stomach cancer?
Direct - to surrounding structures
40
What is the lymphatic spread of stomach cancer?
To regional lymph nodes
41
What is the blood spread of stomach cancer?
Liver
42
What is the transcoelomic spread of stomach cancer?
Spread within peritoneal cavity
43
What is the prognosis for stomach cancer?
Very poor - 5 year survival rate <20%
44
What is dyspepsia?
Group of symptoms: pain or discomfort in upper abdomen, retrosternal pain, anorexia, nausea, vomiting, bloating, fullness, early satiety, heartburn
45
When do you refer someone to endoscopy? (mnemonic)
```
ALARMS or >55yo
A - anorexia
L - loss of weight
A - anaemia
R - recent onset of progressive symptoms
M - melaena/haematemesis or mass
S - swallowing problems (dysphagia)
```
46
Patient presents with dyspepsia, what do you do first?
History and examination
47
Patient presents with dyspepsia, what bloods do you order?
FBC, ferritin, LFTs, U+Es, calcium, glucose, coeliac serology/serum IgA
48
Patient presents with dyspepsia, what drugs in drug history are important?
NSAIDs, steroids, bisphosphonates, Ca antagonists, nitrates, theophyllines
49
If the patient is <55 and is positive for H.pylori, what is the next step?
Eradication therapy & symptomatic treatment with PPIs or H2R antagonists & lifestyle factors
50
Is H.pylori gram negative or gram positive?
Gram negative
51
Where does H.pylori colonise?
Gastric type mucosa
52
Where does H.pylori reside?
Resides in the surface mucous layer and does not penetrate the epithelial layer
53
What are the possible clinical outcomes of H.pylori infections?
Gastritis, chronic atrophic gastritis, intestinal metaplasia, gastric or duodenal ulcer, gastric cancer or MALT lymphoma
54
What are the possible consquences of antral predominant gastritis?
Increased acid production -> low risk stomach cancer, increased risk duodenal disease
55
What are the possible consequences of mild mixed gastritis (in both antrum and body)?
Normal acid -> no significant disease
56
What are the possible consequences of corpus (body) predominant gastritis?
Decreased acid -> gastric atrophy, gastric cancer
57
What are non-invasive diagnostic tests for H.pylori?
Serology (IgG against H.pylori), urea breath test, stool antigen test
58
What are invasive diagnostic tests for H.pylori?
Endoscopy, biopsy, rapid slide urease test (CLOtest)
59
Why a rapid slide urease test (CLOtest) to test for H.pylori?
H.pylori secretes the urease enzyme which catalyses the conversion of urea to ammonia and carbon dioxide
60
What are the majority of peptic ulcers caused by?
H.pylori infection
61
What are more common: duodenal ulcers or peptic ulcers?
Duodenal ulcers
62
What are the symptoms of a peptic ulcer?
Epigastric pain/tenderness, nocturnal/hunger pain (more DU), back pain, N&V, weight loss, anorexia, haematemesis, meleana, anaemia
63
Why might a patient with a peptic ulcer have back pain?
May be penetration of posterior DU
64
If a peptic ulcer bleeds, how may the patient present?
Haematemesis and/or melaena, or anemia
65
How are ulcers caused by H.pylori treated?
Triple therapy eradication therapy for 7 days to get rid of bacteria --> clarithromycin, amoxycillin and antacid medication e.g. proton pump inhibitors or H2 receptor antagonists
66
What is an example of a proton pump inhibitor used to treat peptic ulcers?
Omeprazole
67
What is an example of a H2 receptor antagonist used to treat peptic ulcers?
Ranitidine
68
How many days triple therapy for H.pylori infection?
7 days
69
What are the complications of a peptic ulcer?
Acute bleeding, chronic bleeding, perforation, fibrotic stricture, gastric outlet obstruction
70
What are the signs and symptoms of gastric outlet obstruction?
Vomiting (lacks bile/fermented foodstuff), early satiety, abdominal distention, weight loss, gastric splash, dehydration, loss of H+ and CL- in vomit, metabolic alkalosis
71
What would the blood results be for gastric outlet obstruction and what would the implications be?
Low Cl, low Na, low K
| Renal impairment
72
How would you diagnosis a gastric outlet obstruction?
UGIE
73
How is a gastric outlet obstruction treated?
Endoscopic balloon dilation or surgery
74
How do patients with gastric cancer present?
Dyspepsia, early satiety, N&V, weight loss, GI bleeding, iron deficiency anaemia, gastric outlet obstruction
75
What are the genes associated with heritable gastric cancer syndromes?
HDGC (autosomal dominant)
| CDH-1 gene (E-cadherin)
76
How do you manage a patient with gastric cancer?
Histological diagnosis - endoscopy and biopsy
Staging investigations - CT chest/abdo
MDT discussion
Treatment - surgical and chemo
77
What are the functions of the colon and rectum?
Fluid and electrolyte balance, waste management, continence, microbe related
78
The colon has more anaerobes than the small intestine: true or false?
True
79
What do patients with colon or rectal problems complain of?
Change in bowel habit/continence, bleeding, pain, non-intestinal manifestations
80
What is visceral pain?
Pain receptors in smooth muscle, afferent impulses running with sympathetic fibres, is poorly localised
81
Visceral pain is: well localised or poorly localised?
Poorly localised
82
What are the low risk features of rectal bleeding?
Transient symptoms (<6wks) of rectal bleeding with anal symptoms, patient is <40yo
83
What are the high risk features of rectal bleeding?
Persistent change in bowel habit (>6wks)
Persistent rectal bleeding without anal symptoms
Right sided abdominal mass
Palpable rectal mass
Unexplained iron deficiency anaemia
Patients in whom there is no clinical doubt
84
What is the protocol for managing patients who have low risk features for rectal bleeding?
Wait and watch (6wks):
| Assessment and review, patient agreement, appropriate info/councelling
85
What is the protocol for managing patients who have high risk features for rectal bleeding?
Refer for visualisation of the large bowel:
Colonoscopy
Flexible/rigid sigmoidoscopy +/- barium enema
CT colongraphy
86
What are the investigations for CRC?
Endoscopy, colonscopy, biopsy, contrast imaging (barium enema), CT/CT colonography, MRI
87
What is important for success of bowel anastomosis?
Tension free, well perfused, well oxygenated, clean surgical site, acceptable systemic state
88
What is faecal diversion?
Creation of an ileostomy or colostomy - a new path for waste material to leave the body
89
What are some complications of bowel surgery?
```
Anaesthetic related
Bleeding
Sepsis
VTE
Anastomotic breakdown
Small bowel obstruction
Would hernia
```
90
What are the symptoms of oesophageal disease?
```
Heartburn
Retrosternal discomfort or burning
Waterbrash
Cough
Dysphagia
Odynophagia
```
91
What is water brash?
Acid mixes with the excess saliva during reflux
92
What are some of the causes of oesophageal dysphagia?
```
Benign stricture
Malignant stricture
Eosinophilic oesophagitis
Motility disorders e.g. achalasia, presbyoesophagus
Extrinsic compression e.g. lung cancer
```
93
What are some investigations for oesophageal disease?
```
Endoscopy:
Oesophago-gastro-duodenoscopy (OGD)
Upper GI endoscopy (UGIE)
Barium swallow (contrast radiography)
Oesophageal pH and manometry
```
94
What does hypermotility of the oesophagus look like on a barium swallow?
Corkscrew appearance
95
What are the symptoms of hypermotility of the oesophagus?
Severe, episodic chest pain +/- dysphagia
96
What is the treatment for hypermotility of the oesophagus?
Smooth muscle relaxants
97
What does manometry investigation show for hypermotility of the oesophagus?
Exaggerated, uncoordinated, hypertonic contractions of the oesophagus
98
What is hypomotility of the oesophagus associated with?
Connective tissue disease, diabetes, neuropathy
99
What causes hypomotility of the oesophagus?
Failure of LOS mechanism
100
What causes achalasia?
Functional loss of myenteric plexus ganglion cells in the distal oesophagus and LOS = failure of LOS to relax
101
What are the functional consequences of achalasia?
Failure of LOS to relax = distal obstruction of the oesophagus
102
What are the symptoms of achalasia?
Progressive dysphagia, weightless, chest pain, regurgitation and chest infection
103
What is the treatment for achalasia?
Pharmacological: nitrates, Ca+ channel blockers,
Endoscopic: botox, pneumatic balloon dilation
Radiological: pneumatic balloon dilation
Surgical: myotomy
104
What are the complications of achalasia?
Pneumonia, lung disease, increased risk of squamous cell oesophageal carcinoma
105
Which can lead to GORD: hypermotility or hypomotility?
Hypomotility
106
What are some of the causes of GORD?
Pregnancy, smoking, obesity, alcoholism, hypomotility, drugs lowering LOS pressure
107
What are some of the symptoms of GORD?
Heartburn, sleeping disturbance, water brash, cough
108
What is GORD pathologically?
Acid (and bile) exposure in the lower oesophagus
109
When should endoscopy be performed for GORD?
In presence of ALARM features for malignancy e.g. vomiting, dysphagia, weight loss
110
What are some of the causes of GORD without abnormal anatomy?
```
Increased transient relaxation of LOS
Hypotensive LOS
Delayed gastric emptying
Delayed oesophageal emptying
Decreased oesophageal acid clearance
Decreased tissue resistance to acid/bile
```
111
What are the two main types of hiatus hernia?
Sliding
| Para-oesophageal
112
What predisposes a person to a hiatus hernia?
Age (>50)
| Obesity
113
What are some of the complications of GORD?
Stricure
Ulceration
Glandular metaplasia (Barrett's oesophagus)
Carcinoma
114
What are the treatments for Barrett's oesophagus?
Endoscopic mucosal resection (EMR)
Radio-frequency ablation (RFA)
Oesophagectomy
115
What are the treatment options for GORD?
Lifestyle measures
Pharmacological: Alginates (Gaviscon), H2RA (Ranitidine), PPI (Omeprazole, Lansoprazole)
Anti-reflux surgery: fundoplication
116
What are some of the symptoms of oesophageal cancer?
Progressive dysphagia, weight loss and anorexia, odynophagia, chest pain, cough, haematemesis (vomiting blood), pneumonia, vocal cord paralysis
117
Which oesophageal cancer type most commonly affects the distal oesophagus?
Adenocarcinoma
118
Which oesophageal cancer type most commonly affects the proximal and middle 1/3 of the oesophagus?
Squamous cell carcinoma
119
What are the common metastases for oesophageal cancer?
Liver, bone, brain, lungs
120
What are the investigations for oesophageal cancer?
Endoscopy, biopsy
121
What are the staging investigations for oesophageal cancer?
CT scan
Endoscopic ultrasound
PET scan
Bone scan
122
What are the treatment options for oesophageal cancer?
Only potential cure: surgical oesophagectomy +/- adjuvant or neoadjuvant chemotherapy
Combined chemo and radiotherapy for longer term survival
Symptom palliation: endoscopic (stent, PEG), chemotherapy, radiotherapy, brachytherapy
123
What is eosinophilic oesophagitis?
A chronic, allergic inflammatory disease of the oesophagus
124
What is the cause of eosinophilic oesophagitis?
Eosinophil (WBC) infiltration into the epithelial lining of the oesophagus and initiates and inflammatory response
125
What are the symptoms of eosinophilic oesophagitis?
Dysphagia and food bolus obstruction
126
What are the treatment options for eosinophilic oesophagitis?
Topical/swallowed corticosteroids
Dietary elimination - if allergen suspected
Endoscopic dilatation
127
What is the investigation to work out the T/N stage for oesophageal cancer?
Endoscopic ultrasound (EUS)
128
What is the investigation to work out the M stage for oesophageal cancer?
PET CT
129
What conduits can be used for an oesophagectomy?
Stomach or colon
130
What are the modifiable risk factors for stomach cancer?
Alcohol, smoking, infection with h.pylori virus, excessive consumption of salted fish, pickled vegetables and cured meats
131
What are the investigations for stomach cancer?
Endoscopy
| Constrast meal
132
What are the staging investigations for stomach cancer?
CT chest/abdomen, laparoscopy
133
What are the possible surgeries for gastric cancer?
Subtotal gastrectomy
| Total gastrectomy and Roux en Y reconstruction (oesophago-jejunostomy)
134
What are the two options for operating for gastrectomy?
Laparoscopic distal gastrectomy
| Open gastrectomy
135
What is pancolitis?
A form of ulcerative colitis which affects the entire large bowel
136
What are the two main diseases of inflammatory bowel disease?
Ulcerative colitis
| Crohn's disease
137
Where does ulcerative colitis affect?
Large bowel only
138
How does ulcerative colitis usually spread?
Rectum to proximal
139
What are some of the histological features of ulcerative colitis?
```
No granulomas!
Mucosa inflammation
Cryptitis
Crypt abscesses
Mucosal atrophy
Ulceration
Submucosal fibrosis
Limited mainly to mucosa and submucosa
```
140
What is reactive atypia?
Changes due to inflammation or injury without neoplastic change
141
What type of UC becomes a risk for developing cancer?
Pancolitis
142
What are other complications of UC?
Haemorrhage
Perforation
Toxic dilatation
143
Does Crohn's affect more females or males?
Females
144
Where does Crohn's disease affect?
Any level of GIT from mouth to anus
145
When are the peaks of age for Crohn's disease?
20-30yrs
| 60-70yrs
146
What ethnic populations are most affected by Crohn's disease?
Caucasians and Jewish populations
147
Where does Crohn's mostly affect?
Small intestine
148
What are some pathological features of Crohn's disease?
Wall thick
Narrowing of lumen
Skip lesions
Cobblestone appearance - ulcerations
149
What causes skip lesions in Crohn's disease?
Sharp demarcation between diseased segments and adjacent normal tissue
150
What are some of the histological features of Crohn's disease?
```
Non-caseating granulomas!
Cryptitis and crypt abscesses
Ulceration - deep
Transmural inflammation - chain of pearls
Fibrosis
Paneth cell metaplasia
```
151
Which has non-caveating granulomas on histological examination: ulcerative colitis or Crohn's disease?
Crohn's disease
152
What are the long term pathological features of Crohn's disease?
```
Malabsorption
Strictures
Fistulas and abscesses
Perforation
Increased risk of cancer
```
153
Which has transmural inflammation: ulcerative colitis or Crohn's disease?
Crohn's disease
154
Which has inflammation which is limited to the mucosa: ulcerative colitis or Crohn's disease?
Ulcerative colitis
155
Which has granulomas: ulcerative colitis or Crohn's disease?
Crohn's disease
156
How does ischaemic enteritis occur?
Acute occlusion of 1 of the 3 major supply vessels to the bowel
157
What some predisposing conditions for ischaemic enteritis?
Arterial thrombosis: atherolsclerosis, vasculitis, dissecting aneurysm, oral contraceptives
Arterial embolism: cholesterol embolism, acute atheroembolism
Non-occlusive ischaemia: cardiac failure, shock/dehydration, vasoconstrictive drugs (propranolol)
158
Where in the colon is vulnerable to acute ischaemia?
Splenic flexure
159
What are some of the histological features of acute ischaemia?
```
Oedema
Interstitial haemorrhages
Sloughing necrosis of mucosa = ghost outlines
Nuclei indistinct
Vascular dilation
Initial absence of inflammation
```
160
What are some of the features of chronic ischaemia of the bowel?
```
Mucosal inflammation
Ulceration
Submucosal inflammation
Fibrosis
Stricture
```
161
What is radiation colitis?
Abdominal irradiation can impair the normal proliferative activity of the small and large bowel epithelium
162
What are the symptoms of radiation colitis?
Anorexia, abdominal cramps, diarrhoea, malabsorption
163
Which type of radiation is most likely to result in radiation colitis?
Rectum-pelvic radiotherapy
164
What are some of the histological features of radiation colitis?
```
Bizarre cellular changes
Inflammation - crypt abscesses and eosinophils
Ulceration
Necrosis
Haemorrhage
Perforation
```
165
How long is the average appendix?
6-7cm
166
What happens in appendicitis?
Acute inflammation
167
What are some of the histological features of appendicitis?
Macro: exudate, perforation, abscess
Micro: acute suppurative inflammation in wall and pus in lumen, acute gangrenous full thickness necrosis +/- perforation
168
What are the two subtypes of dysplasia?
Low grade
| High grade
169
What are three types of adenoma?
Tubular
Villous
Tubulovillous
170
How would low grade dysplasia be described histologically?
Increased nuclear numbers
Increased nuclear size
Reduced mucin
171
How would high grade dysplasia be described histologically?
Carcinoma in situ
Crowded
Very irregular
Not yet invasive
172
What type of cancer/dysplasia are most colorectal carcinomas?
Adenocarcinoma
173
What are some risk factors for colorectal carcinoma?
Lifestyle
FH
IBD - UC and Crohn's disease
Genetics - FAP, HNPCC
174
What are the features of right-sided colorectal adenocarcinoma?
```
Exophytic/polypoid
Anaemia
Vague pain
Weakness
Obstruction
```
175
What are the features of left-sided colorectal adenocarcinoma?
Annular - napkin ring lesion
Bleeding
Altered bowel habit
Obstruction
176
Where does upper GI bleeding occur?
From oesophagus, stomach or duodenum
| Proximal to ligament of Trietz
177
Where does lower GI bleeding occur?
Distal to duodenum (jejunum, ileum, colon)
| Distal to ligament of Trietz
178
What is the landmark us to separate lower and upper GI bleeding?
Ligament of Trietz
179
What could present as upper GI bleeding?
Haematemesis
| Melaena
180
What marker could indicate upper GI bleeding?
Elevated urea (digested blood: haem->urea)
181
What symptoms is upper GI bleeding associated with?
Dyspepsia, reflux, epigastric pain
182
Which class of drugs may cause upper GI bleeding?
NSAIDs
183
What are signs of lower GI bleeding?
Fresh blood/clots, magenta stools
184
What symptoms are lower GI bleeding associated with?
Typically painless
185
What will the urea levels be like for lower GI bleeding?
Normal urea (rarely elevated if proximal small bowel origin)
186
What is melena?
Dark black, tarry faeces associated with upper GI bleeding
187
53yo male reports passing black, loose, sticky bowel motions for preceding 24hrs. What might be the cause?
Upper GI bleeding
188
What are some causes of oesophageal bleeding?
```
Oesophageal ulcer
Oesophagitis
Oesophageal varices
Mallory Weiss tear
Oesophageal malignancy
```
189
What are some causes of gastric bleeding?
```
Gastric ulcer
Gastritis
Gastric varices
Portal hypertensive gastropathy
Gastric malignancy
Dieulafoy's lesion
Angiodysplasia
```
190
What are some causes of duodenal bleeding?
Duodenal ulcer
Duodenitis
Angiodysplasia
191
What is a Mallory Weiss tear?
Bleeding from a laceration in the mucosa at the junction of the stomach and oesophagus
192
What is dieulofoy's lesion?
Large tortuous arteriole (most commonly in stomach wall) which erodes and bleeds
193
What usually causes a Mallory Weiss tear?
Severe vomiting e.g. alcoholism, bulimia
194
What are two damaging forces to gastric mucosa?
Gastric acidity
| Peptic enzymes
195
What substances can injure the gastric mucosa?
```
H. pylori infection
NSAIDs
Aspirin
Smoking
Alochol
Gastric hyperacidity
Duodenal-gastric reflux
```
196
What can lead to peptic ulceration?
```
Increasing damaging substances
Impaired defences (damaged gastric mucosa)
```
197
Which are the most common: gastric ulcers or duodenal ulcers?
Duodenal ulcers
198
What are the risk factors for peptic ulcers?
H.pylori
NSAIDs/aspirin
Alcohol excess
Systemic illness = stress ulcers
199
How is H.pylori a risk factor for peptic ulcers?
Produces urease -> ammonia produced -> buffers gastric acid locally = increased acid production
200
How do NSAIDs/aspirin cause peptic ulcers?
Prostaglandin production -> reduced mucus and bicarbonate excretion -> reduced physical defences
201
Where might be a hidden place to find a gastric carcinoma?
Under a gastric ulcer
202
What causes recurrent poor healing duodenal ulcers?
Zollinger-Ellison syndrome
203
What is Zollinger-Ellison syndrome?
A gastrin-secreting pancreatic tumour
204
What does Zollinger-Ellison syndrome result in?
Overproduction of gastrin which causes ulcers
205
When might gastritis or duodentitis cause bleeding?
Impaired coagulation causes by:
Medical conditions
Anti-coagulants
Anti-platelets
206
When might oesophagitis cause bleeding?
```
Reflux oseophagitis
Hiatus hernia
Alcohol
Biphosphonates
Systemic illness
```
207
What are examples of anti-platelets that are likely to cause upper GI bleeding?
Clopidogrel
| Ticagrelor
208
What are examples of anti-coagulants that are likely to cause upper GI bleeding?
Warfarin
Rivaroxaban
Apixaban
Dabigatran
209
An injecting drug user presents to A+E with fresh haematemesis and collapse. On examination you notice a mass in his left upper quadrant. What is the most likely diagnosis?
Liver cirrhosis (secondary to chronic hep C)
210
An injecting drug user presents to A+E with fresh haematemesis and collapse. On examination you notice a mass in his left upper quadrant. What is the most likely cause of the LUQ mass?
Enlarged spleen due to portal hypertension
| Portal hypertension is cause of varies which have cause haematemesis
211
What are varices usually due to?
Secondary to portal hypertension (due to liver cirrhosis)
212
What are the most common type of varices?
Oesophageal
213
What malignancies might you think of for upper GI bleeding?
Oesophageal cancer
| Gastric cancer
214
What is angiodysplasia?
Vascular malformation which can occur anywhere in the GIT
215
What is angiodysplasia often associated with?
Chronic conditions including heart valve replacement
216
For GI bleeding, when should UGIE be performed?
Within 24hrs, sooner if unstable
217
24you female, constipation, presenting with 24hr history of painless fresh red bleeding per rectum which occurred following a period of straining. What is the diagnosis?
Haemorrhoids
218
What are some colonic causes of lower GI bleeding?
```
Diverticular disease
Haemorrhoids
Vascular malformations (angiodysplasia)
Neoplasia (carcinoma or polyps)
Ischaemic colitis
Radiation enteropathy/proctitis
IBD
```
219
What are the lower GI bleeding diagnostic investigations?
Flexible sigmoidoscopy
Full colonoscopy
CT angiography
220
What is diverticular disease?
Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
221
What is the difference between diverticulosis and diverticulitis?
```
Diverticulosis = presence of pouches
Diverticulitis = inflammation of pouches
```
222
What are haemorrhoids?
Enlarged vascular cushions around anal canal
223
What are haemorrhoids associated with?
Straining
Constipation
Low fibre diet
224
What is the treatment of haemorrhoids?
Elective surgical intervention
225
How is angiodysplasia treated?
Argon phototherapy
| Medication incl. tranexamic acid, thalidomide
226
What symptoms does ischaemic colitis present with?
Crampy abdominal pain and sudden bleeding
227
What are complications of ischaemic colitis?
Gangrene and perforation
228
What might someone have a PMH of if they have radiation proctitis?
Radiotherapy - cervical/prostate
229
What is the treatment for radiation proctitis?
Argon plasma coagulation (APC)
Sulcrafate enemas
Hyperbaric oxygen
230
What are small bowel causes of acute lower GI bleeding?
Meckel's diverticulum
Small bowel angiodysplasia
Small bowel tumour/GIST (gastro-intestinal stromal tumour)
Small bowel ulceration
Aortoentero fistulation (following AAA repair)
231
What are small bowel investigations for acute lower GI bleeding?
CT angiogram
Meckel's scan (scintigraphy)
Capsule endoscopy
Double balloon enteroscopy
232
What is Meckel's diverticulum?
A true congenital diverticulum
| Slight bulge in the small intestine and a remnant of the yolk sac
233
What is the management of GI bleeding?
ABCDE
Circulation: IV fluids, blood transfusion if Hb<7g/dl, blood samples to lab
Catheter
234
What is shock?
Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypo perfusion and tissue hypoxia
235
What are the signs for haemorrhagic shock?
```
High RR (tachypnoea)
Rapid pulse (tachycardia)
Anxiety or confusion
Cool clammy skin
Low urine output (oliguria)
Low BP (hypotension)
```
236
What are the two scoring systems used in risk stratification of UGIB?
Rockall Score
| Blatchford Score
237
In the Blatchford scoring system for UGIB, what factors are looked at for the pre-endoscopy score?
Blood urea
Haemoglobin
Systolic BP
Other markers: hepatic disease/cardiac failure
238
What score in the Blatchford scoring system for UGIB is associated with a greater than 50% risk of needing an intervention?
>6
239
What are improved factors for patients who are admitted to dedicated GI bleeding units?
```
Improved mortality
Improved outcome
Prompt resus
Close medical and surgical liaison
Protocolised care
```
240
What is the management for peptic ulcers?
PPI
Endoscopy with endotherapy
Angiography with embolisation
Laparotomy
241
What is the management of varices?
```
Endotherapy:
Oesophageal - band ligation/glue injection
Gastric or rectal - glue injection
IV terlipressin
IV BS antiobiotics
Correct coagulopathy
```
242
What does IV terlipressin due in varices treatment?
Vasoconstricts splanchnic blood supply and reduces blood flow to portal vein, reducing portal pressures
243
Where do magenta stools typically come from?
Right colon or distal small bowel
244
What is haemotochezia?
Passage of fresh or altered blood per rectum - may be upper or lower GI
245
What is an acute abdomen?
A combination of signs and symptoms, including abdominal pain, which results in a patient being referred for an urgent general surgical opinion
246
What three things to consider for an acute abdomen diagnosis?
Peritonitis
Intestinal obstruction
Abdominal pain
247
What are the routes of infection for peritonitis?
Perforation of GI/biliary tract
Female genital tract
Abdominal wall penetration
Haemotogenous spread
248
What are the bacteria in the upper GI tract normally?
Aerobes
249
What are the bacteria in the lower GI tract normally?
Anaerobes
250
What is the main bacteria in the peritoneum normally?
Aerobes
251
What are the cardinal features of intestinal obstruction?
```
Pain
Vomiting
Distention
Constipation
Borborygmi
```
252
What is borborygmi?
A rumbling or gurgling noise made by the movement of fluid and gas in the intestine
253
What do the features of intestinal obstruction depend on?
Site of blockage - distal or proximal
254
What are the three main character types of pain?
Visceral - diffuse, difficult to localise, internal organs e.g. deep, squeezing, dull
Somatic - located in skin/deep tissues, well localised e.g. aching, throbbing
Referred - pain perceived at a location other than the site of the painful stimulus
255
Where are the pain receptors for visceral pain?
In smooth muscle
256
How do the afferent impulses run for visceral pain?
With sympathetic fibres accompanying segmental vessels e.g. CP, SMA, IMA
257
Where are the pain receptors for somatic and referred pain?
In parietal peritoneum or abdominal wall
258
How do the afferent impulses run for somatic and referred pain?
With segmental nerves
259
What are the effects of peritonitis and intestinal obstruction?
Fluid loss, sepsis -> circulatory collapse -> death
260
What would the patient be like if they had peritonitis pain?
Lying still, sore to move
261
What would a patient be like if they had body wall pain?
Sore to touch
262
What would a patient be like if they had colic pain?
Look like 'a woman in childbirth'
263
What is the management procedure for an acute abdomen?
Assess (+ resuscitate)
Investigate
Observe
Treat
264
In your assessment of an acute abdomen, what questions should you ask?
What is the problem?
What are its effects?
What should I do?
265
What investigations would you do for an acute abdomen?
Ward: urine
Lab: FBC, U+E, LFT
Radiology: Plain XR, US, axial CT
266
What are you trying to do when resuscitating an acute abdomen?
```
Restore circulating fluid volume
Ensure tissue perforation
Enhance tissue oxygenation
Treat sepsis
Decompress gut
Ensure adequate pain relief
```
267
What are the general treatments for an acute abdomen?
Pain relief
Antibiotics
Definitive intervention e.g. surgery
268
What are the five main types of viral hepatitis?
A, B, C, D + E
269
Which of the hepatitic viruses are enteric?
A+E
270
Which of hepatitic viruses are parenteral?
B,C+D
271
Which of the hepatitic viruses are self-limiting acute infections?
A+E
272
Which of the hepatitic viruses are chronic diseases?
B,C+D
273
Which immunoglobulin increases with hepatitis A?
IgG
274
Which immunoglobulin increases with acute infection with hepatitis A?
IgM
275
Which enzyme is elevated in hepatitis A?
ALT
276
What do patients with chronic hepatitis B have a risk of developing?
Cirrhosis of the liver
277
What do patients with cirrhosis of the liver have a risk of developing?
HCC (hepatocellular carcinoma)
| ESLD (end stage liver disease)
278
What are the treatment options for HBV?
Antiviral drugs
Pegylated inferon
Treatment of symptoms
279
What are examples of antiviral drugs used for treatment of HBV?
Lamiduvine
Entecavir
Adefovir
280
What is the usual transmission of HCV?
Blood
| Mother to child (vertical transmission)
281
What is the main treatment used nowadays for HCV?
Direct-acting antivirals (DAA)
282
Which hepatitis infection is very resistant to treatment?
Hepatitis D virus
283
What is the commonest hepatitis virus to cause acute hepatitis in Grampian?
Hepatitis E
284
What is the treatment for hepatitis E?
No specific treatment, self-limiting
285
What does non-alcoholic fatty liver disease (NAFLD) encompass?
Simple steatosis
Non alcoholic steatohepatitis
Fibrosis and cirrhosis
286
What conditions is NAFLD associated with?
Diabetes mellitus
Obesity
Hypertriglyceridemia
Hypertension
287
What are the risk factors for NAFLD?
Conditions associated e.g. DM, HT, obesity
Age
Ethnicity (Hispanics)
Genetic factors
288
What is the natural history of progression for NAFLD?
Normal liver -> steatosis -> NASH +/- fibrosis -> cirrhosis
289
What does NASH stand for?
Non-alcoholic steatohepatitis
290
What diagnostic tests are there for NAFLD?
```
Biochemical tests: AST/ALT ratio
Enhanced liver fibrosis (ELF) panel
Cytokeratin-18
Ultrasound
Fibroscan
MRI/CT
MR spectroscopy
Liver biopsy
```
291
What does the NAFLD score do?
Estimates amount of scarring to liver to evaluate progression/stabilisation
292
What are the treatment options for NAFLD?
Diet and weight reduction
Exercise
Weight reduction surgeries
Insulin sensitizers e.g. Metformin, Pioglitazone
Glucagon-peptide-1 (GLP-1) analogues e.g. Liraglutide
Farnesoid X nuclear receptor ligand e.g. Obeticholic acid
Vitamin E
293
What are some examples of autoimmune liver disease?
Autoimmune hepatitis
Primary biliary cholangitis (PBS)
Primary sclerosing cholangitis (PSC)
294
Which autoimmune liver diseases are female predominant?
Autoimune hepatitis
| PBC
295
Which autoimmune liver disease is male predominant?
PSC
296
Who qualifies for a liver transplant?
Chronic liver disease with poor predicted survival
Chronic liver disease with associated poor quality of life
HCC
Acute liver failure
Genetic diseases e.g. primary oxaluria, tyrosemia
297
What are some contraindications for a liver transplant?
Active extra hepatic malignancy
Hepatic malignancy with microvascular or diffuse tumour invasion
Active substance or alcohol abuse
Active and uncontrolled infection outside of hepatobiliary system
Severe cardiopulmonary or other comorbid condition
Psychosocial problems that would preclude recovery
Brain death
298
What scoring systems are used to prioritise cirrhosis?
Child's Pugh scoring A, B and C
MELD score (bilirubin, creatinine and INR)
UKELD (bilirubin, sodium, creatinine and INR)
299
What can liver failure be a result of?
Acute liver injury
| Chronic liver injury e.g. cirrhosis
300
What can acute liver injury be a result of?
Hepatitis - viruses, alcohol, drugs
| Bile duct obstruction
301
What is the pathology of viral hepatitis?
Inflammation of the liver
| Liver cell damage and death of individual liver cells
302
What happens in alcoholic liver disease?
Response of liver to excess alcohol
Fatty change and alcoholic hepatitis: acute inflammation -> liver cell death -> liver failure
Progress to cirrhosis
303
What is jaundice caused by?
Increased levels of circulating bilirubin caused by altered metabolism of bilirubin
304
What is pathway of bilirubin metabolism?
Pre-hepatic: breakdown of haemoglobin in spleen to haem and globin, haem is converted to bilirubin, release of bilirubin into circulation
Hepatic: uptake of bilirubin by hepatocytes, conjugation of bilirubin in hepatocytes, excretion of conjugated bilirubin into biliary system
Post-hepatic: transport of conjugated bilirubin in biliary system, breakdown of bilirubin conjugate in intestine, re-absorption of bilirubin
305
What are the three classifications of jaundice?
Pre-hepatic
Hepatic
Post-hepatic
306
What are the causes of pre-hepatic jaundice?
Increased release of haemoglobin from red cells + therefore increased quantity of bilirubin (haemolysis)
Impaired transport
307
What are the hepatic causes of jaundice?
Cholestasis - reduction/stoppage of bile flow
| Intra-hepatic bile duct obstruction
308
What is cholestasis?
A reduction or stoppage of bile flow resulting in an accumulation of bile within hepatocytes or bile canaliculi
309
What are some causes of cholestasis?
Viral hepatitis
Alcoholic hepatitis
Liver failure
Drugs: therapeutic or recreational
310
What is meant by predictable vs unpredictable drug-induced cholestasis?
```
Predictable = dose related
Unpredictable = not dose related
```
311
What are some causes of intra-hepatic bile duct obstruction?
Primary biliary cholangitis (PBC)
Primary sclerosing cholangitis (PSC)
Tumours of the liver e.g. HCC, tumours of intra-hepatic bile ducts, metastatic tumours
312
What is cholangiocarcinoma?
Malignant tumour of bile duct epithelium
313
What is the pathology of primary biliary cholangitis?
Granulomatous inflammation involving bile ducts, loss of intra-hepatic bile ducts, progression to cirrhosis
314
What is the pathology of primary sclerosing cholangitis?
Chronic inflammation and fibrous obliteration of bile ducts, loss of intra-hepatic bile ducts
315
What disease is primary sclerosing cholangitis often associated with?
Inflammatory bowel disease (IBD)
316
What are you of increased risk of with primary sclerosing cholangitis?
Cholangiocarcinoma
317
What are some of the causes of cirrhosis?
```
Alcohol
Hepatitis B/C
Immune mediated liver disease
Metabolic disorders e.g. excess iron or copper
Obesity
Cryptogenic
```
318
What is the pathology of cirrhosis?
Diffuse process involving whole liver, loss of liver structure as replaced by nodules of hepatocytes and fibrous tissue
319
What are some complications of liver cirrhosis?
Altered liver function - failure
Abnormal blood flow - portal hypertension
Increased risk of HCC
320
What are some of the causes of post-hepatic jaundice?
Cholelithiasis
Diseases of gall bladder
Extra-hepatic duct obstruction - defective transport of bilirubin by biliary ducts
321
What are the risk factors for gallstones?
Obesity, diabetes
322
What are some diseases of the gall bladder that can cause post-hepatic jaundice?
Inflammation e.g. acute or chronic cholecystitis
323
What is acute cholecystitis?
Acute inflammation of the gall bladder
324
What are some complications of acute cholecystitis?
Empyema - perforation of the gall bladder or biliary peritonitis
325
What is chronic cholecystitis?
Chronic inflammation and fibrosis of the gall bladder
326
What are some causes of common bile duct obstruction?
Gallstones
Bile duct tumours
Benign stricture
External compression e.g. tumours
327
What are the effects of common bile duct obstruction?
Jaundice
No bile excreted into duodenum
Infection of bile proximal to obstruction - ascending cholangitis
Secondary biliary cirrhosis if obstruction prolonged
328
What are the detoxification functions of the liver?
Urea produced from ammonia
Detoxification of drugs
Bilirubin metabolism
Breakdown of insulin and hormones
329
What are the immune functions of the liver?
Combating infections
Clearing the blood of particles and infections, including bacteria
Neutralising and destroying all drugs and toxins
330
What are the storage functions of the liver?
Stores glycogen
Stores vitamin A, D, B12 and K
Stores copper and iron
331
What is bilirubin a product of?
Haem metabolism
332
What is bilirubin initially bound to in its unconjugated form?
Albumin
333
What is bilirubin pre-hepatically elevated due to?
Haemolysis
334
What is bilirubin hepatically elevated due to?
Parenchymal damage
335
What is bilirubin post-hepatically elevated due to?
Obstruction
336
What are aminotransferases and where are they found?
Enzymes present in hepatocytes
337
Which is more specific ALT or AST?
ALT
338
What does ALT stand for?
Alanine transaminase
339
What does AST stand for?
Aspartate transaminase
340
What does an AST/ALT ratio greater than 2:1 point towards?
Alcoholic liver disease (ALD)
341
What is alkaline phosphatase and where is it found?
Enzymes present in bile ducts
342
When is alkaline phosphatase (ALP) elevated?
With obstruction or liver infiltration
343
Where is alkaline phosphatase (ALP) also found?
Bone, placenta, intestines
344
What is gamma GT?
Non specific liver enzyme
345
When is gamma GT elevated?
Alcohol use
346
What is gamma GT used for?
To confirm source of ALP
347
What else can raise gamma GT levels?
Drugs e.g. NSAIDs
348
What is albumin an important test for?
Synthetic function of the liver
349
What do low levels of albumin suggest?
Chronic liver disease
350
What can albumin also be low in (apart from chronic liver disease)?
Kidneys disorders, malnutrition
351
What does prothrombin time (PT) indict?
Degree of liver dysfunction
352
What is prothrombin time used to calculate?
Scores to decide stage of liver disease/who needs liver transplant/who gets liver transplant
353
What does creatinine test?
Kidney function
354
What is platelet count an indirect marker of?
Portal hypertension
355
Why is platelet count low in cirrhotic subjects?
Cirrhosis results in splenomegaly (hypersplenism)
356
What does splenomegaly and caput medusae suggest?
Portal hypertension
357
At was plasma bilirubin level is jaundice detectable?
Over 34μmol/L
358
Which classification of jaundice is conjugated?
Pre-hepatic
359
Which classification of jaundice is unconjugated?
Hepatic and post-hepatic
360
What are clues on history of pre-hepatic jaundice?
Fatigue, dysponea, chest pain, history of anaemia, acholuric jaundice
361
What are the clues on history of hepatic jaundice?
Risk factors for liver disease e.g. IVDU, drug intake
| Decompensation (ascites, varicella bleed, encephalopathy)
362
What are the clues on history of post-hepatic jaundice?
Abdominal pain
| Cholestasis (pruritus, pale stools, high coloured urine)
363
What are the clues on clinical examination of pre-hepatic jaundice?
Pallor, splenomegaly
364
What are the clues on clinical examination of hepatic jaundice?
Stigmata of CLD (spider naevi, gynaecomastia)
Ascites
Asterixis - liver flap
365
What are the clues on clinical examination of post-hepatic jaundice?
Palpable gall bladder (Courvoisier's sign)
366
What are the investigations after diagnosis of jaundice?
Liver screen: hep B+C serology, autoantibody profile, serum immunoglobulins, ceruloplasmin and copper, ferritin and transferrin saturation, alpha-1 anti-tyrpsin, fasting glucose and lipid profile
US of abdomen
367
What is ERCP?
Endoscopic retrograde cholangio-pancreatography
368
What is MRCP?
Magnetic resonance cholangio-pancreatography
369
What are the complications of ERCP?
Sedation required
Pancreatitis
Cholangitis
Sphincterotomy - bleeding/perforation
370
What is PTC imaging modality?
Percutaenous transhepatic cholangiogram (PTC)
371
What is endoscopic ultrasound (EUS) used for?
Characterising pancreatic masses
Staging of tumours
Fine need aspirate (FNA) of tumours and cysts
Excluding biliary microcalculi
372
How long does liver disease last before it is chronic?
6 months
373
What does physical examination reveal if ascites?
Dullness in flanks and shifting dullness
374
What is the corroborating evidence on examination for ascites?
Spider naevi, palmar erythema, abdominal veins, fetor hepaticus
Umbilical nodule
JVP elevation
Flank haematoma
375
What is measured in ascitic fluid on diagnostic paracentesis?
Protein and albumin concentration
Cell count and differential
SAAG (serum-ascites albumin gradient)
376
What level of SAAG would indicate portal hypertension?
>1.1g/dl
377
What does high gradient SAAG indicate?
Portal hypertension
378
What does low gradient SAAG indicate?
```
Malignancy
TB
Chylous ascites
Pancreatitis
Biliary ascites
Nephrotic syndrome
Serositis
```
379
Apart from portal hypertension, what could high gradient SAAG indicate?
```
Chronic heart failure
Constrictive pericarditis
Budd Chiarri syndrome
Myxedema
Massive liver mets
```
380
What are the treatment options for ascites?
```
Diuretics
Large volume paracentesis
TIPS - transjugular intrahepatic portosystemic shunt
Aquaretics
Liver transplant
```
381
What causes varices?
Portal hypertension
382
Where do varices typically occur?
```
Porto-systemic anastomoses:
Skin - caput medusae
Oesophageal and gastric
Rectal
Posterior abdominal wall
Stomal
```
383
What is the management for varices?
Resuscitation
Good IV access
Blood transfusion as required
Emergency endoscopy
384
What is hepatic encephalopathy?
Confusion or altered level of consciousness due to liver failure
385
What clinical signs might indicate hepatic encephalopathy?
Liver flap and fetor hepaticus
386
What are the investigations for HCC?
Tumour markers: AFP
Ultrasound
CT
MRI
387
What scoring systems are used for alcohol screening tests?
FAST and AUDIT
388
Regarding alcoholism, what does the acronym CAGE remind you to ask when doing a history?
Have you ever felt the need to CUT down?
Have you ever felt ANNOYED by criticism of your drinking?
Have you ever felt GUILTY about your drinking?
Do you need an EYEOPENER
389
In the grading of hepatic encephalopathy what is 1?
Mild confusion
390
In the grading of hepatic encephalopathy what is 4?
Coma
391
What are the symptoms and signs of spontaneous bacterial peritonitis?
Abdominal pain, fever, rigors, renal impairment, signs of sepsis, tachycardia, pyrexia
392
An ascitic tap for spontaneous bacterial peritonitis, what are you looking at?
Fluid protein and glucose levels
Cultures
White cell count
393
What would the neutrophil count be above in spontaneous bacterial peritonitis?
>0.25x10^9/L
394
What would the protein be below in spontaneous bacterial peritonitis?
<25g/L
395
What is the treatment for spontaneous bacterial peritonitis?
IV antibiotics
Ascitic fluid drainage
IV albumin infusion
396
What investigations results would help the diagnosis of alcoholic hepatitis?
Raised bilirubin
Raised GGT and ALP
Alcohol history
397
What is the treatment for alcoholic hepatitis?
```
Supportive
Treat infection
Treat encephalopathy
Treat alcohol withdrawal
Protect against GI bleeding
Airway protection
```
398
When do you give steroids for alcoholic hepatitis?
Only if grading severe e.g. Glasgow Alcoholic Hepatitis Score >9
399
What scoring system is used to determine the prognosis of alcoholic hepatitis and whether to use steroids?
Modified Maddrey's discriminant function
400
Which nutrient are alcoholic hepatitis patients often lacking?
Thiamine
