Laz Gastro

Question 1

What are the three main causes of chronic liver disease

Answer 1

alcoholic liver disease
NAFLD
viral hep

Question 2

what are secondary causes of CLD

Answer 2

haemochromatosis (accumulation of iron)
Wilson’s disease (accumulation of copper)
CF
alpha-1 antitrypsin deficiency

Question 3

link the functions of the liver to what occurs in liver failure

Answer 3

• albumin production > oedema, leuconychia
• bilirubin metabolism > jaundice
• clotting factors > coagulopathy (easy bruising)
• detox > encepalopathy

Question 4

explain how blood arrives to the liver in a normal physiological state

Answer 4

blood from the GI system (so dirty, with lots of toxins) travels to liver via HEPATIC PORTAL VEIN

Question 5

Explain what happens to blood arriving to liver in CLD and how this causes signs

Answer 5

there is increased resistance from the liver
due to nodules and fibrosis

This puts backpressure onto the portal system (portal hypertension)

this leads to formation of portosystemic anastamoses

Question 6

what portosystemic anastamoses are formed by CLD backpressure onto the portal system?

Answer 6

• oesophageal varices
• hypersplenism
• caput medusae
• rectal varices

Question 7

why does oedema occur in liverfailure

Answer 7

hypoalbumniaemia –> drop of oncotic pressure and increase in hydrostatic pressure intravascularly

Question 8

What two indices are important in someone with ascites

Answer 8

SAAG

neutrophil count

Question 9

What is SAAG

Answer 9

Serum Ascites Albumin Gradient

SAAG = serum albumin - ascites albumin

Question 10

what is the boundary in SAAG

Answer 10

11.1g/L

Question 11

what does a HIGH SAAG indicate

Answer 11

> 11.1g/L = TRANSUDATIVE -> the albumin in ascites > albumin in blood
* due to portal HTN (also CLD, HF, RF)
* Raised hydrostatic pressure in hepatic portal system forces water into peritoneum while albumin (which is too big to travel through membrane) stays intravascular

Question 12

what does a LOW SAAG indicate

Answer 12

<11.1g/L =-EXUDATIVE

• albumin is being created in the peritoneum, and the fluid is due to a peritonitic problem e.g. infection, inflammation (pancreatitis, malignancy (pancreatic cancer) or nephrotic syndrome

Question 13

what is jaundice caused by

Answer 13

accumulation of bilirubin in blood

Question 14

explain the process of producing and moving bilirubin

Answer 14

RBC are broken down in bloodstream to produce bilirubin
bilirubin travells to the liver, where it is conjugated
then it is moved to gallbladder and stored
then via biliary tract it is ejected when necessary into the GI tract
in the GI tract it becomes urobilinogen
urobilinogen that is kept in GI tract becomes stercobilin > secreted in poo
some urobilinogen leaves circulation > travels to kidneys > excreted out

Question 15

What are PREHEPATIC causes of jaundice

Answer 15

issues with increased RBC breakdown

• AIHA
• sickle cell disease
• G6PD deficiency
• Malaria

Question 16

What are HEPATIC causes of jaundice

Answer 16

issues with liver conjugation of bili

• liver disease
• hepatitis
• Gilbert’s
• drugs

Question 17

what are POST HEP causes of jaundice

Answer 17

Biliary disease

• gallstones
• PSC / PBC
• Cholangiocarcinoma

Pancreatic cancer

Question 18

what will parameters be like in pre-hep jaundice

Answer 18

RAISED unconjugated bilirubin (as there is too much bili for the liver to conjugate and excrete, while the bili that the liver is able to conjugate is excreted normally)
Urine normal (as unconjugate bilirubin is insoluble so does not reach the urine) 
Stool normal (same but for stool)

Question 19

What are parameters like in hep jaundice

Answer 19

RAISED unconj and conj bilirubin (as liver cannot dispose of bilirubin well and cannot conj it well)

Urine dark (raised urobilinogen)
Stool normal / silghtly pale

Question 20

what are parameters like in post-hepatic / obstructive jaundice

Answer 20

RAISED conjugated bilirtubin as it leaks from the bililary tree (it cannot drain normally due to the obstruction)

urine is DARK (as all this conj bilii is drained by kidneys)

stool is very PALE (as due to obstruction the bilirubin can no longer reach the intestine)

Question 21

what should you do in acute abdomen in a female of child bearing age

Answer 21

PREGNANCY TEST IS MANDATORY (EVEN IF THEY SAY THEYRE NOT ACTIVE)

Question 22

what kind of drug is orlistat

p

Answer 22

inhibits pancreatic and gastric lipase –> prevent digestion of fat

Question 23

causes of gastroentreitis and infctious colitis

Answer 23

• viral: rotavirus (children), norovirus (adults)
• bacteria: campylobacter jejuni, e.coli, salmonella
• protozoa: entamoeba histolytica

Question 24

investigations for gastroenteritis and infectious colitis

Answer 24

• ASSESS HYDRATION STATUS (postural hypotension, dry tongu, tachycardia, weakness, , reduced urine output
• Bloods: FBC, blood culture, U&Es (dehydration), C diff = raised WCC
• Stool sample: faecal microscopy and analysis for toxins (C. difficile toxin causes pseudomembranous colitis)
• AXR or ultrasound: exclude other causes of abdominal pain (e.g. bowel perforation)

Question 25

management of gastroenteritis

Answer 25

Conservative - **Bed rest** – stay at home until D+V gone for 48h - **Fluid and electrolyte replacement** (oral rehydration solution = contains glucose and salt) - Most infections are **self-limiting** - Regular handwashing, use separate towels - Admit if patient **cannot retain oral fluids (severe vomiting), signs of severe shock or severe dehydration** --> **IV rehydration** - Abx only used if severe or if infective agent has been identified