GI - LFTs, Biliary Disease and Upper GI Complaints Flashcards by Guy Kirkpatrick

Liver simplified functions

Synthetic Function:
Clotting
Albumin

Metabolic Function
Bilirubin
Oestrogens
Ammonia

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Diseased liver implications on functions

Decreased clotting factor –> Bruising
Decreased albumin –> Ascites and Leukonychia

Increased bilirubin –> Jaundice
Increased oestrogens –> Pamar erythema, spider naevi, gynaecomastia
Increased ammonia –> Confusion, asterixis

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True measures of liver function

Bilrubin
Albumin
INR (clotting factor production)

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Markers in acute liver injury

ALT
AST
ALP
GGT

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Liver injury markers

AST and ALT
AST:ALT ratio
–> Alcoholic liver disease: >2.5:1
–> Viral hepatitis: <1:1

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Biliary Duct injury markers

ALP and GGT
–> NB isolated GGT rise in acute alcohol intake

Cause: usually biliary tree obstruction

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Gallstones Risk factors

Fat 
Female
Fertile (pregnancy)
over Forty
FHx

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Gallstones Classic Presentation

Colicky right sided pain

Worse on eating fatty foods

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Gallstones Ix

LFTs:
Expect a raised ALP and GGT
Shouldn’t see direct liver injury

Ultrasound of biliary tree is gold standard.
Most gallstones are not radio-opaque.

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Gallstones Management

Location?

Common Bile duct:
Choecystectomy
Bile Duct Clearance

Gallbladder
Cholecystectomy

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Progression from gallstones

ASCENDING CHOLANGITIS
Common bile duct: Bile stasis –> Bacteria (Gut–>Bile ducts)

ACUTE CHOLECYSTITIS
Gallbladder/Cystic Duct:Bile stasis/Inflammation/Bacterial infection

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Acute Cholecystitis Presentation

Constant acute RUQ pain; radiates to R shoulder and scapula
Fever
Nausea and Vomiting
Jaundice
Rebound tenderness
Positive Murphy's sign

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Acute Cholecystitis Ix

FBC –> Raised WCC (Neutrophils)
LFTs –> Raised ALP and GGT
Ultrasound
CT/MRI

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Acute Cholecystitis Management

Cholecystectomy < 1 wk

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Charcot’s Cholangitis Triad

Jaundice
RUQ pain
Fever

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Acute Suppurative Cholangitis

Presence of pus in the biliary ducts may result in Reynold’s Pentad; Charcot’s Triad + Hypotension and Confusion.
(This is when bacteria enter the bloodstream)

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A 19-year-old male is admitted following an alcohol binge. His friends report he has vomited several times and fell over. You notice some bruises on his hands.

Which of the following is likely to be most elevated?

AST
ALT
GGT
ALP
All of the above

GGT

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A 42-year-old female is admitted with severe RUQ pain that is worse on eating fatty foods. After obtaining her LFTs, you notice a remarkably high ALP.

What is the most likely diagnosis?

Viral hepatitis
Alcoholic hepatitis
Short-term alcohol abuse
Biliary tract obstruction
Gilbert’s syndrome

Biliary tract obstruction

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A 45-year-old chronic alcoholic presents with jaundice, bruising and abdominal pain. His stools and urine are of normal colour. His bilirubin and AST are raised.

What other marker is likely to be abnormal?

ALT
Albumin
ALP
Haemoglobin
GGT

ALT

(but GGT as well
ALP can be normal or elevated in alcoholic liver disease.
Albumin and Hb would be low. So basically everything is abnormal - shit question sorry)

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Ascending Cholangitis Ix

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Basic obs (for sepsis)
FBC (raised WCC)
LFTs (raised ALP)
Ultrasound
ERCP

Ascending Cholangitis Management

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Manage symptoms - Fluids and Abx
Clear Ducts - ERCP suction and lithotripsy
Cholecystectomy

Autoimmune Biliary Disease classifications

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Primary Biliary Cholangitis (PBC)
Primary Sclerosing Cholangitis (PSC)

PBC: Destruction of small bile ducts –> intrahepatic cholestasis
PSC: Intra + Extrahepatic bile duct inflammation –> scarring –> narrowing. Stenosis and fibrosis around the bile ducts cause them to squeeze shut.

Primary Biliary Cholangitis Summary

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Autoimmune damage to small bile ducts –> intrahepatic cholestasis
Classic antibody - ANA
Diagnosis - Biopsy

Associated with:
RA
Thyroid disease
Sjogren’s

Primary Sclerosing Cholangitis Summary and Ix

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Antibody: p-anca
Diagnosis: ERCP (“beaded”)

Associated with UC

A 38-year old woman presents with vague, colicky right-sided abdominal pain. She reports it is got worse 6 hours ago after eating an Indian take-out. On examination her sclera appear icteric, and her abdomen is soft and non-tender. Select the investigation needed to confirm her diagnosis. ``` Liver function tests Ultrasound of the biliary tree Split bilirubin ratio ERCP Liver biopsy ```

Ultrasound of the biliary tree | First test is LFTs, but US is gold standard test

While waiting for her cholecystectomy, the same woman falls more unwell. She feels feverish, has vomited twice and reports that the pain initially felt colicky, but now is constant in her RUQ. She also feels dull pain in her right shoulder. On examination, she displays rebound tenderness in her RUQ and a positive Murphy’s sign. Select the likely diagnosis. ``` Biliary colic Primary Biliary Cholangitis Ascending Cholangitis Acute Cholecystitis Cholangiocarcinoma ```

Acute Cholecystitis

A 48-year old obese man presents to AandE in agony. He is shivering visibly, clutching his right upper quadrant. You notice his hands are yellow and there are excoriations on his arms. His bloods show a raised white cell count and CRP. Select the likely diagnosis. ``` Biliary colic Primary Sclerosing Cholangitis Primary Biliary Cholangitis Viral hepatitis Ascending Cholangitis ```

Ascending Cholangitis

Mallory-Weiss tear

Tear in the mucosal layer of the oesophagus Follows episode of severe vomiting; e.g. due to alcohol, bulimia Usually seen as blood streaked in vomit Vomiting always precedes bleeding Resolves within 24-48hrs Tears happen at the gastro-oesophageal junction

Boerhaave Syndrome Summary and Ix

Severe Mallory-Weiss tear Rare Complete rupture of oesophageal wall Diagnosis: CXR and CT - pneumomediastinum

Oesophageal Varices Summary of Causes

Liver Cirrhosis: Decreased clotting factors --> Increased bleed risk --> ruptured oesophageal varices Increased extrahepatic blood shunting --> Portal hypertension --> ruptured oesophageal varices Continued alcohol use --> Oesophageal irritation --> ruptured oesophageal varices

Oesophageal Varices Presentation

Background of cirrhosis Chronic alc. use Fresh, large-volume blood

Oesophageal Varices Ix

FBC: microcytic anaemia LFTs: Raised ALT/ALP/AST Raised Bilirubin Decreased Albumin UandE's: Increased urea

Oesophageal Varices Management

ABCDE approach Fluids, regular monitoring Reduce portal HTN - terlipressin Endoscopy - band ligation is first line

Ruptured peptic ulcer presentation

Background of PUD - NSAIDs/ ? H.Pylori Coffee ground emesis Melaena

Ruptured peptic ulcer Ix

Obs: Decreased BP | FBC and LFTs normal

Ruptured peptic ulcer Management

1. Endoscopy - IM adrenaline at site of ulcer 2. Omeprazole 3. Triple therapy if H. Pylori

Dysphagia DDx

Functional/Structural vs High/Low severity Functional/High: Stroke Parkinson's disease Functional/Low: Achalasia Oesophageal spasm CREST Structural/High: Pharyngeal pouch ``` Structural/Low: Cancer Benign stricture Plummer-Vinson Ortner's Syndrome ```

Dysphagia Ix and Indication

Barium Swallow: High dysphagia - avoid risky endoscopy Low dysphagia - if suspecting achalasia Endoscopy: often first line for low dysphagia Videofluoroscopy: Functional, High dysphagia Manometry: Differentiate between motility disorders

Oesophageal Cancers

Middle third - squamous cell carcinoma | Lower third - adenocarcinoma

Achalasia pathophysiology

Absence of (inhibitory) ganglion cells in myenteric plexus. No relaxation of lower sphincter Aperistalsis 'Bird's Beak' appearance

Oesophageal Cancer vs Achalasia

``` OC: Structural dysphagia Middle-aged to elderly New-onset Progressive FLAWS High or low Ix: OGD ``` ``` Achalasia: Functional dysphagia Young people Long-term onset Intermittent No FLAWS Low Ix: Barium swallow and manometry ```

A 76-year old retired greengrocer visits her GP with difficulty swallowing solids. She says this has been getting progressively worse over 1 month. There is no coughing, choking or heartburn. She reports food getting “stuck” 2-3 seconds after swallowing. She attributes her weight loss to not eating properly, and also thinks this has caused loose, brown-black stools. Bloods show a microcytic anaemia. Select the likely diagnosis: ``` Stroke Oesophageal cancer Pharyngeal pouch Plummer-Vinson syndrome Benign stricture ```

Oesophageal Cancer

A 27-year old lawyer presents with a 2-year history of mild dysphagia to both solids and liquids. She has no weight loss. She has symptoms of heartburn and nocturnal cough, but PPIs and bronchodilators haven’t helped. She is systemically well, and her examination is unremarkable. A “bird’s beak” appearance is noted on barium swallow. Select the diagnosis: ``` Achalasia Benign stricture Plummer-Vinson syndrome Oesophageal spasm Stroke ```

Achalasia

A 45-year old man presents with a 6-week history of dysphagia. This is associated with pain in his fingers, with him noting that he sees the colour vary from red, to white, to blue. He also has several red, vascular marks on his face. Select the diagnosis: ``` Plummer-Vinson syndrome Ortner’s syndrome Pharyngeal pouch Limited cutaneous scleroderma Oesophageal spasm ```

Limited cutaneous sleroderma

Neurological Dysphagia

Due to stroke or Parkinson's disease Other symptoms present in history Coughing: immediately on swallow. Choking: also implies problem with swallow. Slow eating Early dysphagia for liquids

Pharyngeal pouch

Coughing up food (late) Halitosis Gurgling/dysphonia Barium swallow

Plummer-Vinson syndrome

Iron deficiency anaemia Oesophageal webs Dysphagia

Limited Cutaneous Scleroderma (CREST syndrome)

``` CREST: Calcinosis Raynaud's Esophageal dysmotility Sclerodactyly Telangiectasia ``` Antibodies: ANA and anti-centromere

GI - LFTs, Biliary Disease and Upper GI Complaints Flashcards

(48 cards)