GI + Hepatology 27/7/20 Flashcards
(64 cards)
1
Q
stages of hepatic encephalopathy
A
1) . altered mood and behaviour, disturbance of sleep pattern and dyspraxia
2) . drowsiness, confusion, slurring of speech and personality change
3) . incoherency, restlessness, asterixis
4) . coma
2
Q
complications of liver failure
A
- infection
- cerebral oedema, hepatic encephalopathy
- bleeding
- hypoglycaemia (easily treated with glucose)
- multi-organ failure, hepatorenal syndrome.
- ascites, spontaneous bacterial peritonitis
- portal hypertension, variceal bleeding
3
Q
management of hepatic encephalopathy
A
- treat underlying cause
- lactulose (removes nitrogenous waste)
- IV mannitol to reduce cerebral oedema
4
Q
management of liver-related coagulopathy
A
- vitamin K
- FFP
5
Q
King’s college criteria for liver transplant (paracetamol overdose)
A
- arterial pH <7.3 24h after ingestion OR - pro-thrombin time >100s AND creatinine >300µmol/L AND grade III or IV encephalopathy
6
Q
King’s college criteria for liver transplant (NON-paracetamol overdose)
A
- prothrombin time >100s OR any three of: - drug-induced liver failure - age under 10 or over 40 years - 1 week from 1st jaundice to encephalopathy - prothrombin time >50s - bilirubin ≥300µmol/L
7
Q
causes of liver cirrhosis
A
- alcohol
- hepatitis B and C (+autoimmune hep)
- non-alcoholic fatty liver disease
- biliary: primary biliary cirrhosis, primary sclerosing cholangitis
- genetic: haemochromatosis, Wilson’s disease, alpha-1-antitrypsin deficiency
- drugs: methotrexate, amiodarone, isoniazid
- Budd-Chiari syndrome
- heart failure
8
Q
Child-Pugh score
A
used to assess severity of liver cirrhosis score - bilirubin (umol/l) - albumin (g/l) - prothrombin time (seconds prolonged) - encephalopathy - ascites
scores are added and the degree of cirrhosis is classified as
- A (<7 points)
- B (7-9 points)
- C (>9 points)
Model for End-Stage Liver Disease (MELD) used increasingly in recent years, especially when considering liver transplant
9
Q
management of ascites
A
- fluid restriction + low Na diet
- spironolactone (can add furosemide)
- drainage if tense
- albumin infusion may be required
- prophylactic Abx if at increased risk of SBP
10
Q
GI features of ulcerative colitis
A
- diarrhoea ± blood
- urgency/tenesmus
- abdominal pain, particularly in the left lower quadrant
- increased risk of colorectal cancer (UC higher risk than Crohn’s)
- lead pipe sign on AXR, loss of haustra with no skips in barium enema
11
Q
GI features of Crohn’s
A
- diarrhoea ± blood
- abdominal pain
- perianal disease: e.g. skin tags or ulcers
12
Q
extra-GI tract features of Crohn’s and UC
A
- weight loss + absorption problems
- arthritis
- erythema nodosum, pyoderma gangrenosum
- osteoporosis
- uveitis (UC more commonly)/episcleritis (Crohn’s more commonly)
- primary sclerosing cholangitis (UC more commonly)
- clubbing
13
Q
NICE classification of UC severity
A
- mild: < 4 stools/day, only a small amount of blood
- moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
- severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
14
Q
management of UC
A
MILD-MOD UC
- proctitis, proctosigmoiditis, left-sided UC = topical aminosalicylate (5-ASA eg. sulfasalazine), add oral 5-ASA if unresponsive after 4 wks/extensive
SEVERE UC
- inpatient management
- IV corticosteroids (IV ciclosporin if CI)
- surgery may be required (panproctocolectomy with permanent end ileostomy )
- following a severe relapse, PO azathioprine may be used for remission
15
Q
triggers for UC flares
A
- usually no identifiable trigger
- stress
- medications: NSAIDs, antibiotics
- cessation of smoking
16
Q
management of Crohn’s
A
- smoking cessation inducing remission: - prednisolone - 5-ASAs second line to glucocorticoids maintaining remission: - azathioprine - methotrexate second line surgery
17
Q
features of coeliac disease
A
- abdominal pain
- bloating
- nausea and vomiting
- diarrhoea
- steatorrhoea
- fatigue
- weight loss or failure to thrive in children
- dermatitis herpetiformis
18
Q
complications of coeliac and associated conditions
A
- anaemia (folate/B12/iron deficiency)
- osteoporosis
- enteropathy associated T-cell lymphoma
- autoimmune conditions: type 1 diabetes, thyroid disease eg. Graves’ disease or Hashimoto’s thyroiditis
19
Q
investigations for coeliac disease
A
- gluten diary
- stool culture to rule out infection
- serological markers
> anti-TTG IgA
> anti-endomysial antibody
> IgA to prevent false negatives due to deficiency - diagnostic OGD with biopsy
> histology shows: sub-total villous atrophy, crypt hyperplasia, intra-epithelial lymphocytes
20
Q
diagnostic criteria for IBS
A
Manning criteria:
- abdominal discomfort or pain that is relieved by defecation
- associated with altered bowel frequency or stool form (diarrhoea or constipation)
- bloating
- symptoms made worse by eating
- passage of mucus
21
Q
lifestyle advice for IBS
A
- regular mealtimes and take time to eat
- reduce caffeine, fizzy drinks, alcohol
- restrict fibre, porridge may be useful for people with wind/bloating
22
Q
pharmacological management of IBS
A
- IBS-C, laxative
- IBS-D, loperamide
- if ineffective, TCAs may be of use
23
Q
screening tools for alcohol dependence
A
- CAGE questionnaire
- AUDIT (alcohol use disorders identification test)
- SADQ (severity of alcohol dependence questionnaire)
also consider risk to others, eg. children, and associated psychosocial problems
24
Q
CAGE questionnaire
A
- have you ever felt you needed to CUT down on your drinking?
- have people ANNOYED you by criticising your drinking?
- have you felt GUILTY about your drinking?
- have you ever felt you needed a drink first thing in the morning (EYE OPENER) to get rid of a hangover or steady your nerves?
2+ = likely alcohol dependence
25
management of alcohol withdrawal
- CBT if appropriate (mild dependence/problem drinking)
- assisted withdrawal required if >20 score in AUDIT or over 15units daily
> pabrinex
> chlordiazepoxide
> acamprosate or naltrexone
> PO lorazepam if delirium tremens
26
stages of alcohol withdrawal
```
6-12 hrs
- insomnia/anxiety/agitation
- sweating/palpitations/tremor
- nausea/vomiting
12-24hrs
- hallucinations (visual/tactile/auditory)
typically ~36-72 hrs
- delirium tremens
> seizures
> psychosis
> confusion
```
27
features of pancreatitis
```
ACUTE PANCREATITIS
- severe epigastric pain radiating to back
- vomiting
- possibly Cullen's/Gray-Turner's signs
- rarely ischaemic retinopathy
CHRONIC PANCREATITIS
- steatorrhoea
- epigastric pain, typically worse on eating, especially fatty foods
- endocrine dysfunction (eg. T1DM)
```
28
investigations for pancreatitis
```
ACUTE
- serum lipase
- serum amylase
- USS for cause (can have contrast CT)
CHRONIC
- CT/AXR for pancreatic calcification
- faecal elastase for exocrine dysfunction
- OGTT for T1DM
lipase/amylase not typically raised in chronic
```
29
causes of acute pancreatitis
```
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa)
Scorpion venom
Hypertriglyceridaemia, Hypercalcaemia
ERCP
Drugs (azathioprine, mesalazine, bendroflumethiazide, furosemide, sodium valproate)
```
30
management of acute pancreatitis
- fluid resuscitation
- analgesia
- surgery dependent on cause (eg. gallstone = cholecystectomy or ERCP)
- treat underlying cause, eg. alcoholism, nutrition, change meds
31
causes of chronic pancreatitis
- alcohol dependence
- genetic: CF, haemochromatosis
- ductal obstruction: gallstone, tumour
32
management of chronic pancreatitis
- treat underlying cause, eg. alcohol abstinence
- analgesia
- pancreatic enzyme supplements
- manage endocrine dysfunction if present, eg. give insulin
33
management of variceal bleeding
- ABCDE
- vit K, FFP, platelets
- terlipressin 2mg every 4-6 hrs until controlled (reduces portal hypertension)
- IV Abx broad spec eg. co-amox
- urgent endoscopy once haemodynamically stable (variceal banding done with endoscopy)
> regular endoscopy in those with cirrhosis
- prophylactic propranolol
TIPS (trans-jugular intrahepatic portosystemic shunt) if recurrent, unresponsive)
34
Glasgow-Blatchford Score
stratifies upper GI bleeding patients who are “low-risk” and candidates for outpatient management
- score of 1+ = high risk
35
features of primary biliary cholangitis
autoimmune condition causing scarring and inflammation of the bile ducts, eventually leading to liver cirrhosis
- symptoms of biliary disease: jaundice, itch, fatigue
- anti-mitochondrial antibodies
- increased risk of hepatocellular carcinoma
- associated with other autoimmune conditions, particularly Sjogrens
36
causes of pre-hepatic jaundice
- conjugation disorders: Gilbert's, Crigler-Naajjar
- haemolysis
- drugs: contrast, rifampicin
37
causes of intra-hepatic jaundice
- viruses (hepatitis, CMV, EBV)
- drugs: paracetamol overdose, valproate, statins, TB antibiotics
- cirrhosis
- liver abscess or malignancy
- haemochromatosis, Wilson's disease
- autoimmune hepatitis
- alpha-1 antitrypsin deficiency
- Budd-Chiari syndrome
- failure to excrete conjugated bilirubin (Dubin-Johnson syndrome)
38
causes of post-hepatic jaundice
- cholestasis (dark urine, pale stools)
> primary biliary cholangitis
> primary sclerosing cholangitis
> gallstones
- drugs: coamoxiclav, flucloxacillin, nitrofurantoin, steroids, sulfonylureas
- malignancy: pancreas adenocarcinoma, cholangiocarcinoma
39
features of primary sclerosing cholangitis
inflammation and fibrosis of intra and extra-hepatic bile ducts
- deranged LFTs
- hepatomegaly
- cholestatic jaundice
- p-ANCA
- multiple beaded biliary strictures seen on ERCP
- increased risk of cholangiocarcinoma
40
investigations for haemochromatosis
- bloods: deranged LFTs, raised serum ferritin and transferrin saturation
- genetic testing: HFE gene defects
- liver biopsy: increased iron stores
41
management of Barrett's oesophagus
due to chronic GORD - squamous to columnar epithelium at lower oesophagus
- endoscopy classification:
> low-grade dysplasia = high dose PPI and 6 monthly endoscopy
> high-grade dysplasia = endoscopic resection
42
management of H. pylori
- triple therapy: amoxicillin (metronidazole if allergy), clarithromycin and a PPI twice daily for seven days
- untreated H. pylori can lead to:
> peptic ulcers
> gastric cancer
> B cell lymphoma of MALT tissue
43
management of gastroenteritis
- fluid replacement/oral rehydration sachets
- Abx if systemic disease/immunocompromised
> salmonella and shigella = ciprofloxacin
> campylobacter = erythromycin
> cholera = tetracycline
food poisoning is a notifiable disease
44
antibiotics with increased risk of facilitating Clostridium dificile infection
- clindamycin
- ciprofloxacin
- cephalosporins
- penicillins
45
management of Clostridium dificile infection
- PO metronidazole
- PO vancomycin if severe
- supportive treatment
- faecal transplant in recurrence
46
investigations for achalasia
- oesophageal manometry: excessive LOS tone which doesn't relax on swallowing
- barium swallow: bird's beak appearance
47
management of achalasia
- pneumatic balloon dilation (if low surgical risk - due to possible complications of procedure)
- botox injection of LOS if high surgical risk
- nitrates/CCBs
48
features of achalasia
- dysphagia of BOTH liquids and solids
- heartburn
- regurgitation
- may lead to cough, aspiration pneumonia etc
- malignant change in small number of patients
49
features of pharyngeal pouch
typically in elderly men
- dysphagia
- regurgitation
- aspiration
- neck swelling which gurgles on palpation
- halitosis
50
features of oesophageal stricture
- longer history of dysphagia, often not progressive
- GORD
- lack of systemic features seen with malignancy
51
features of oesophageal cancer
```
BOTH
- progressive dysphagia
- weight loss
ADENOCARCINOMA
- may have previous symptoms of GORD or Barrett's oesophagus
SQUAMOUS CELL CARCINOMA
- usually no GORD history
- more linked with weight loss
```
52
alcohol picture of LFTs
- raised GGT
| - AST:ALT > 2
53
features of Budd-Chiari syndrome
```
triad of:
- abdominal pain: sudden onset, severe
- ascites
- tender hepatomegaly
doppler US diagnostic
```
54
features of ascending cholangitis
```
usually follow gallstone obstruction/biliary stricture = severely septic and unwell
Charcot's triad:
- fever
- jaundice
- right upper quadrant pain
typically E. coli
```
55
management of ascending cholangitis
- fluid resuscitation
- IV Abx
- ERCP
56
Hep B antigen testing
HBsAg = ongoing infection, either acute or chronic if present > 6 months
anti-HBc = caught, i.e. negative if immunized
57
screening for hepatocellular carcinoma
USS and alpha fetoprotein in at risk groups, eg. current cirrhosis
58
metabolic features of refeeding syndrome
- hypophosphataemia
- hypokalaemia
- hypomagnesaemia: may predispose to torsades de pointes
- abnormal fluid balance
these may lead to organ failure
59
management of SBP
ABCDE
- IV cefotaxime
> most common organism is E. coli
- prophylactic ciprofloxacin in those with ascites and cirrhosis
60
features of Whipple's disease
```
Tropheryma whippelii
- malabsorption: diarrhoea, weight loss
- arthralgia
- lymphadenopathy
- skin: hyperpigmentation and photosensitivity
treatment with PO co-trimoxazole
```
61
features of Wilson's disease
increased copper deposition, particularly in liver, brain and cornea
- hepatitis/cirrhosis
- basal ganglia degeneration (behaviour, speech, psychiatric features, later parkinsonism, dementia)
- Kayser-Fleischer rings
- Fanconi syndrome
62
management of primary biliary cholangitis
- ursodeoxycholic acid: slows disease progression and improves symptoms
- pruritus: cholestyramine
- fat-soluble vitamin supplementation (ADEK)
- liver transplantation
no definitive treatment for primary SCLEROSING cholangitis besides liver transplant
63
management of alcoholic liver disease
alongside pabrinex, alcohol withdrawal pathway, etc.
| - prednisolone + NAC
64
management of haemorrhoids
- soften stools: increase dietary fibre and fluid intake
- topical local anaesthetics and steroids
- rubber band ligation
- surgery is reserved for non-responsive, large, symptomatic haemorrhoids
