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Phase 2a Medicine > Liver and Friends > Flashcards

Liver and Friends Flashcards

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1
Q

What are the functions of the liver?

A
  1. Protein synthesis
  2. Glucose and fat metabolism
  3. Defence against infection
  4. Detoxification
  5. Excretion
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2
Q

What vitamins can the liver absorb?

A

A, D, E, K

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3
Q

What is needed to digest fat and absorb vitamins?

A

Bile

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4
Q

What is the function of Kupffer cells?

A

Remove senescent cells and particulates

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5
Q

What are the results of acute liver injury?

A
  1. Recovery

2. Liver failure

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6
Q

What are the results of chronic liver failure?

A
  1. Recovery
  2. Cirrhosis
  3. Liver failure
  4. Varices
  5. Hepatoma
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7
Q

What classifies chronic liver disease?

A

Persistent injury >6 months

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8
Q

What is the commonest cause of acute liver injury?

A

Inflammation

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9
Q

Give 4 causes of acute liver injury

A
  1. Viral e.g. Hep A
  2. Drugs
  3. Alcohol
  4. Obstruction
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10
Q

Give 4 causes of chronic liver injury

A
  1. Alcohol
  2. Viral e.g. Hep C
  3. Autoimmune
  4. Metabolic
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11
Q

Give 5 symptoms of acute liver injury

A
  1. Malaise
  2. Nausea
  3. Anorexia
  4. Jaundice
  5. Confusion
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12
Q

Give 5 symptoms of chronic liver injury

A
  1. Ascites
  2. Oedema
  3. Haematemesis
  4. Anorexia
  5. Itching
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13
Q

What is checked in LFTs?

A
  1. Serum bilirubin, albumin, prothrombin time

2. Serum liver enzymes

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14
Q

What enzymes are used as markers of liver injury?

A

AST and ALT

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15
Q

What causes jaundice?

A

Raised serum bilirubin

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16
Q

What can jaundice be classified into?

A
  1. Unconjugated (pre-hepatic)

2. Conjugated (hepatic and post-hepatic)

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17
Q

What can cause pre-hepatic jaundice?

A
  1. Haemolysis

2. Gilberts

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18
Q

What can cause hepatic jaundice?

A
  1. Hepatitis
  2. Ischaemia
  3. Neoplasm
  4. Congestion
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19
Q

What can cause post-hepatic jaundice?

A
  1. Gallstone

2. Stricture

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20
Q

How would a pre-hepatic pt. present?

A
  1. Normal urine
  2. Normal stools
  3. No itching
  4. Normal LFTs
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21
Q

How would a conjugated pt. present?

A
  1. Dark urine
  2. Pale stools
  3. Itching
  4. Abnormal LFTs
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22
Q

What other symptoms may be present in jaundice pt.?

A
  1. Biliary pain
  2. Rigors
  3. Abdomen swelling
  4. Weight loss
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23
Q

What tests are done in jaundice?

A
  1. LFT: high AST/ALT
  2. USS: dilated ducts
  3. CT
  4. MRCP
  5. ERCP
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24
Q

What are gallstones made of?

A

70% cholesterol, 30% pigment +/- Ca

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25
What are the risk factors for gallstones?
4 Fs 1. Female 2. Fat 3. Fertile 4. 50
26
What are the classes of gallstone?
1. Intrahepatic bile duct stones 2. Extrahepatic bile duct stones 3. Gallbladder stones
27
What is the presentation in gallbladder stones?
1. Biliary pain 2. Cholecystitis 3. Obstructive jaundice
28
What is the presentation in bile duct stones?
1. Biliary pain 2. Obstructive jaundice 3. Cholangitis 4. Pancreatitis
29
What is the Rx for gallbladder stones?
1. Laparoscopic cholecystectomy | 2. Bile acid dissolution therapy
30
What is the Rx for bile duct stones?
1. ERCP with sphincterotomy and removal crushing stent placement 2. Surgery
31
What are the types of drug induced liver injury (DILI)?
1. Hepatocellular 2. Cholestatic 3. Mixed
32
What is the onset time course in DILI?
1. 1-12 weeks from starting 2. Earlier is unusual 3. May be several weeks after stopping
33
What is the resolution time course in DILI?
1. 90% within 3m of stopping | 2. 5-10% prolonged
34
What drugs often cause DILI?
1. Antibiotics 2. CNS drugs 3. Immunosuppressants 4. Analgesics/MSK 5. GI drugs 6. Dietary supplements 7. Multiple drugs
35
What % of DILI cases are caused by paracetamol?
50%
36
What prevents toxic metabolites to be produced in paracetamol metabolism?
Glutathione conjugation
37
What is seen in paracetamol OD?
1. Glutathione depletion 2. Toxic metabolite increase 3. Hepatocyte damage
38
What is the Rx for paracetamol induced fulminant hepatic failure?
1. N acetyl cysteine | 2. Supportive to correct
39
What are the complications of paracetamol OD?
1. Coagulation defects 2. Fluid electrolyte and acid base balance 3. Renal failure 4. Hypoglycaemia 5. Encephalopathy
40
What are the severity indicators for paracetamol induced liver failure?
1. Late presentation 2. Acidosis 3. Prothrombin time >70s 4. Serum creatinine >300 umol/L
41
What are the causes of ascites?
1. Chronic liver disease 2. Neoplasia 3. Pancreatitis 4. Cardiac causes
42
What can present with chronic liver disease to cause ascites?
1. Portal vein thrombosis 2. Hepatoma 3. TB
43
What causes portal HTN?
1. Increased intrahepatic resistance | 2. Systemic vasodilation
44
What can cause ascites?
1. Portal HTN | 2. Low serum albumin
45
What can systemic vasodilation result in?
1. Secretion of renin-angiotensin, NA, vasopressin | 2. Fluid retention
46
What is Rx for ascites?
1. Fluid and salt retention 2. Diuretics 3. Large volume paracentesis and albumin 4. Trans-jugular intrahepatic portosystemic shunt
47
What does acute alcohol-related injury cause?
Hepatocyte ballooning mediated by neutrophils
48
What is steatosis?
Fat accumulation within hepatocytes
49
What can fatty liver cause?
1. Alcoholic hepatitis | 2. Cirrhosis
50
What is the main cause of liver death in UK?
Alcoholic liver disease (ALD)
51
What is the prognosis for ALD?
10 year survival 25%
52
What is the Rx for ALD?
1. Spironolactone 2. Gastroscopy and rubber bands on varices 3. Terlipressin
53
What are the consequences of ALD?
1. Haematemesis 2. Blood/plasma resuscitation 3. Varices
54
What causes portal HTN?
1. Cirrhosis 2. Fibrosis 3. Portal vein thrombosis
55
What is the pathophysiology of portal HTN?
1. Increased hepatic resistance | 2. Increased splanchnic blood flow
56
What are the consequences of portal HTN?
1. Varices | 2. Splenomegaly
57
What is the Rx for alcohol withdrawal?
Lorazepam
58
Why do pt. with chronic liver disease deteriorate?
1. Constipation 2. Drugs 3. GI bleed 4. Infection 5. High ion count 6. Alcohol withdrawal
59
Why are liver pt. vulnerable to infection?
1. Impaired reticuloendothelial function 2. Reduced opsonic activity 3. Leucocyte function 4. Permeable gut wall
60
What sites do infections commonly occur in liver pt.?
1. Spontaneous bacterial peritonitis 2. Septicaemia 3. Pneumonia 4. Skin 5. Urinary tract
61
What is the commonest serious infection in cirrhosis?
Spontaneous bacterial peritonitis
62
What is the Rx for spontaneous bacterial peritonitis?
1. Abx prophylaxis | 2. Consider liver transplant
63
What can cause renal failure in liver disease?
1. Drugs 2. Infection 3. GI bleed 4. Myoglobinuria 5. Renal tract obstruction
64
What can cause coma in pt. with chronic liver disease?
1. Hepatic encephalopathy 2. Hyponatraemia 3. Hypoglycaemia 4. Intracranial event
65
What are the bedside tests for encephalopathy?
1. Serial 7s 2. WORLD backwards 3. Animal counting in 1 min 4. Draw 5 point star 5. No. connection test
66
Give 5 consequences of liver dysfunction
1. Malnutrition 2. Impaired coagulation 3. Vit K deficiency 4. Amenorrhoea 5. Hypoglycaemia
67
What are the consequences of liver disease?
1. Malnutrition 2. Variceal bleeding 3. Encephalopathy 4. Ascites 5. Infections
68
How is malnutrition treated?
Nasogastric feeding
69
How is variceal bleeding treated?
1. Endoscopic banding 2. Propranolol 3. Terlipressin
70
How is encephalopathy treated?
Lactulose
71
How is ascites treated?
1. Salt/fluid restriction 2. Diuretics 3. Paracentesis
72
What are 5 causes of chronic liver disease?
1. Alcohol 2. Non-alcoholic steatohepatitis (NASH) 3. Viral hepatitis (B, C) 4. Wilson's disease 5. Primary biliary cirrhosis
73
What must be asked in PMx in chronic liver disease pt.?
1. Alcohol problems 2. Biliary surgery 3. Autoimmune disease 4. Blood products
74
What is the investigations for chronic liver disease?
1. Viral serology 2. Autoantibodies 3. Immunoglobulins 4. USS 5. CT 6. MRI 7. Biochemistry
75
What is the DDx for hepatitis?
1. Viral 2. Drug-induced 3. Autoimmune 4. Alcoholic
76
What are the hepatitis investigations?
1. Acute viral serology 2. Iron studies 3. Immunology 4. Liver biopsy
77
What is seen in autoimmune hepatitis liver biopsy?
1. Interface hepatitis 2. Inflammation (plasma cells/lymphocytes) 3. No cirrhosis 4. No increase iron stain
78
What % of autoimmune hepatitis have cirrhosis at presentation?
30%
79
What is Rx for autoimmune hepatitis?
Prednisolone +/- azathioprine
80
Where is the damage in primary biliary cirrhosis?
Small bile ducts
81
What is the prevalence of primary biliary cirrhosis?
1 in 1000
82
What is the investigation for primary biliary cirrhosis?
+ve AMA
83
What is the clinical presentation in primary biliary cirrhosis (PBC)?
1. Itching 2. Fatigue 3. Dry eyes 4. Joint pain 5. Variceal bleeding 6. Liver failure
84
What is the Rx for cholestatic itch?
1. Cholestyramine 2. Rifampicin 3. Opiate antagonists
85
What is the Rx for fatigue and PBC?
Modafinil
86
Give 3 disease associated with PBC
1. Sjögrens 2. Thyroiditis 3. Rheumatoid arthritis
87
What is the benefit of using ursodeoxycholic acid in PBC?
1. Improves bilirubin 2. Reduces inflammation 3. Reduces portal pressure 4. Reduces variceal development
88
How does primary sclerosing cholangitis present (PSC)?
1. Itching 2. Pain 3. Rigors 4. Jaundice
89
What is the Dx for PSC?
1. Raised alkaline phosphorylate | 2. Raised GGT
90
What stains ferric iron blue?
Perl's stain
91
What can cause excess iron?
1. Haemochromatosis 2. Multiple blood transfusions 2. Haemolysis 3. Alcoholic liver disease
92
What gene is mutated in haemochromatosis?
HFE gene
93
What is the pathophysiology of haemochromatosis?
Uncontrolled intestinal iron absorption with deposition in liver, heart and pancreas
94
What is the Dx for haemochromatosis?
1. Raised ferritin 2. Transferrin saturation 3. HFE genotyping 4. Liver biopsy
95
What is at higher risk if haemochromatosis is present with cirrhosis?
Hepatocellular carcinoma
96
What is the Rx for haemochromatosis?
Iron removal
97
Give 5 symptoms of haemochromatosis
1. Cirrhosis 2. White nails 3. Joint pain 4. Chronic fatigue 5. Dry skin
98
What is the pathophysiology of a1-antitrypsin deficiency?
Inability to export a1-antitrypsin from liver
99
What can a1-antitrypsin deficiency result in?
1. Liver disease | 2. Emphysema
100
How may a1-antitrypsin deficiency present?
1. Neonatal jaundice | 2. Chronic liver disease in adults
101
What is the Rx for a1-antitrypsin deficiency?
No Rx
102
What are the risk factors for hepatocellular carcinoma?
1. Hepatitis B, C 2. Haemochromatosis 3. Cirrhosis from alcohol 4. Autoimmune disease 5. Male
103
How may hepatocellular carcinoma present?
1. Decompensation of liver disease 2. Weight loss 3. Ascites 4. Abdo pain
104
What are the Rx for hepatocellular carcinoma?
1. Transplant 2. Resection 3. Local ablation 4. Sorafenib
105
What is produced in 50% of hepatocellular carcinoma pt.?
Alpha fetoprotein
106
What are the risk factors for non-alcoholic fatty liver disease (NAFLD)?
1. Obesity 2. Diabetes 3. Hyperlipidaemia
107
What are the symptoms for NALFD?
1. Asymptomatic | 2. Liver ache
108
What is the investigation for NAFLD?
1. High LFT 2. ALT 3. Biopsy
109
What is seen in NASH?
Fatty liver, sometimes with inflammation and fibrosis
110
What does NASH cause?
Cryptogenic cirrhosis
111
What is the Rx for NAFLD?
Weight loss
112
What are the causes of hepatic vein occlusion?
1. Thrombosis 2. Membrane obstruction 3. Veno-occlusive disease
113
How may hepatic vein occlusion present?
1. Abnormal LFTs 2. Ascites 3. Acute liver failure
114
What is the Rx for hepatic vein occlusion?
1. Anticoagulation 2. Transjufular intrahepatic portosystemic shunt 3. Liver transplant
115
What is hepatitis?
Inflammation of the liver
116
What are the symptoms of acute hepatitis?
1. Malaise 2. GI upset 3. Jaundice 4. Pale stools 5. Dark urine
117
What are the signs of acute hepatitis?
1. Tender hepatomegaly 2. Bleeding 3. Ascites 4. Encephalopathy
118
What is seen in bloods for acute hepatitis?
1. Raised transaminases (ALT/AST) | 2. Raised bilirubin
119
Give 3 non-viral infections that cause acute hepatitis?
1. M. tuberculosis 2. Bartonella 3. Syphilis
120
Give 4 non-infective causes of acute hepatitis
1. Drugs 2. Alcohol 3. NAFLD 4. Pregnancy
121
What signs are seen in chronic hepatitis?
1. Clubbing 2. Palmar erythema 3. Dupuytren's contracture 4. Spider naevi
122
What is seen in decompensated chronic hepatitis?
1. Coagulopathy 2. Jaundice 3. Low albumin 4. Ascites 5. Encephalopathy
123
What are the complications of chronic hepatitis?
1. Hepatocellular carcinoma 2. Varices 3. Bleeding
124
What are the viral causes of chronic hepatitis?
Hepatitis B (+D), C
125
How is hepatitis A transmitted?
Faeco-oral transmission
126
What are the risk factors for hepatitis A?
1. Travel 2. Household contact 3. Sexual contact 4. IVDU
127
What is the incubation period for hepatitis A?
15 to 50 days
128
What are the pre-icteric symptoms in hepatitis A?
1. Constitutional symptoms | 2. Abdo pain
129
What is the immunity rate after hepatitis A infection?
100%
130
What is the serology for acute hepatitis A?
Anti-HAV IgM
131
What is the serology past infection for hepatitis A?
Anti-HAV IgG
132
What is the Rx for hepatitis A?
1. Supportive 2. Monitor liver function 3. Manage close contacts 4. Vaccination
133
What is the transmission methods for hepatitis E GT1 and GT2?
Contaminated food and water
134
What is the transmission methods for hepatitis E GT3 and GT4?
1. Zoonotic reservoir (pig) | 2. Undercooked meat products
135
Where is hepatitis E found?
GT1: Africa and Asia GT2: Mexico ad West Africa GT3: High income countries GT4: China and SE Asia
136
What are some consequences of acute hepatitis E?
1. Fulminant hepatitis 2. Acute-on-chronic liver failure 3. Chronic infection
137
What is the serology for acute hepatitis E?
Anti-HEV IgM
138
What is the serology past infection for hepatitis E?
Anti-HEV IgG
139
What must be done in serology in immunocompromised Hep E pt.?
Measure and monitor HEV RNA +/- stool
140
What is the Rx for acute hep E?
1. Supportive 2. Monitor for complications 3. Consider ribavirin
141
What is the Rx for chronic Hep E?
1. Reverse immunosuppression | 2. Ribavirin
142
How is hepatitis B transmitted?
Blood-borne virus
143
What is the serology for acute hepatitis E?
Anti-HB core IGM
144
When might anti-HB core IgG be seen?
1. Exposure to HBV infection | 2. Current chronic HBV infection
145
What confirms chronic hep B?
Hepatitis B surface antigen
146
What is the incubation period for hepatitis B?
30 to 180 days
147
What is the management of hepatitis B?
1. Supportive 2. Monitor liver function 3. Tenofovir/entecavir 4. Manage close contacts
148
How many acute hepatitis B cases become chronic?
5%
149
What can chronic hepatitis B cause?
1. Cirrhosis | 2. Hepatocellular carcinoma
150
Which chronic hepatitis B pt. are treated?
High HBV DNA associated with high ALT
151
What drugs can treat hepatitis B?
1. Pegylated interferon-a 2a | 2. Oral nucleoside analogues
152
What are the SE of pegylated interferon-a 2a?
1. Myalgia 2. Flue-like symptoms 3. Thyroiditis 4. Low blood counts 5. Depression
153
Name an oral nucleoside analogue
Entecavir
154
What is the prevention for hepatitis B?
1. Antenatal screening of pregnant mothers 2. Screening +/- immunisation of contacts 3. Childhood immunisation 4. Screening of blood products 5. Sterilise equipment 6. Immunise HCPs and at-risk groups
155
What does hepatitis D need to replicate?
HBsAg
156
How is hepatitis D transmitted?
Blood and body fluids
157
What is the consequence of acquiring Hep D simultaneously with HBV?
Fulminant hepatitis in acute infection
158
What are the consequences of acquiring Hep D after HBV?
1. Acute on chronic hepatitis | 2. Accelerated progression to liver fibrosis
159
What is the Dx for Hep D?
Hep D antibody followed by HDV RNA
160
What is the Rx for Hep D?
Pegylated interferon-a
161
How many acute hepatitis C infections become chronic?
70%
162
How many chronic HCV pt. develop cirrhosis?
10-40%
163
Which groups are at risk for hepatitis C?
1. PWID 2. Prison inmates 3. Blood transfusions prior 1991 4. MSM 5. Tattoo/piercing 6. MTCT
164
What is the test for hepatitis C?
1. Capillary blood sample - antibody and RNA 2. Mouth swab 3. Rapid antibody test
165
What is the Rx for hep C?
Directly acting antivirals (DAAs) +/- ribavirin
166
Name 2 DAAs
1. Ledipasvir | 2. Sofosbuvir
167
What is the prevention for hep C?
1. Screening blood products 2. Precautions handling bodily fluids 3. Needle exchanges 4. Rx of transmitters e.g. PWID
168
What are the functions of gut bacteria?
1. Aid reabsorption back across intestinal wall 2. Digestion of fibre 3. Metabolism of vit K 4. Synthesis vitamin B12, folic acid and thiamine 5. Prevent infection
169
How does normal flora discourage infection?
1. Inhibit overgrowth of endogenous pathogens | 2. Prevent colonisation by exogenous pathogens
170
What occurs if gut barriers are breached by bacteria?
Peritonitis
171
What kills most swallowed pathogens?
Gastric acid
172
What can increase risk of intraluminal infection?
1. Less gastric acid | 2. Broad spectrum Abx
173
How does disruption to normal flora by Abx cause infection by external pathogens?
1. Pathogen bypasses stomach acid 2. Secretes spores in lower gut which has no protection 3. Damage mucosa
174
What is the Rx for intraluminal infection?
1. Different Abx | 2. Faecal transplant
175
What is diarrhoea?
3+ loose liquid stools in 24hrs
176
Give 4 causes of diarrhoea
1. Campylobacter 2. Salmonella 3. Bacterial dysentery 4. Cholera
177
What causes chronic diarrhoea?
Parasites and non-infectious causes e.g. cancer
178
What animals can cause diarrhoea?
1. Puppies - salmonella | 2. Reptiles - campylobacter
179
How many cases of diarrhoea are caused by viruses?
50-70%
180
Which viruses often cause diarrhoea?
1. Rotavirus (children) | 2. Norovirus
181
How do viruses cause diarrhoea?
1. Shorten and damage villi 2. Hyperplasia of crypts 3. Inflammatory exudate
182
How does enterotoxin-mediated diarrhoea occur? e.g. E. coli
1. Bacteria in upper bowel produce enterotoxins 2. Increase IC AMP 3. Mucosal cells secrete fluid 4. Watery voluminous diarrhoea
183
Where does invasive bacterial diarrhoea affect?
1. Colon (shigella/campylobacter) | 2. Lower ileum (salmonella)
184
What causes bloody mucoid stools in invasive bacterial diarrhoea?
Penetration of intestinal mucosa
185
How does cholera spread?
Faecal-oral transmission
186
What does cholera diarrhoea look like?
Profuse watery 'rice water' diarrhoea, vomiting and rapid dehydration
187
What is the faecal output daily in cholera?
15-20L
188
What is the Rx for cholera?
Doxycycline and fluids
189
What is the leading bacterial cause of diarrhoea in children?
EnteroToxigenic E. coli (ETEC)
190
What other conditions can E. coli cause?
1. UTI 2. Neonatal meningitis 3. Gram -ve sepsis
191
What are the symptoms of haemolytic uraemia syndrome (HUS)?
1. Bloody diarrhoea 2. Haemolysis 3. Renal failure 4. Abdo pain
192
What causes HUS?
EnteroHaemorrhagic E. coli (EHEC)
193
Which E. coli causes a dysentery like illness?
EnteroInvasive E. coli (EIEC)
194
Which infections are immunosuppressed more susceptible to?
1. Cryptosporidium 2. Mycobacteria 3. Microsporidia 4. CMV 5. HSV
195
What symptoms accompany diarrhoea in traveller's diarrhoea?
1. Fever 2. Nausea 3. Vomiting 4. Cramps 5. Bloody stools
196
What causes most travellers diarrhoea?
ETEC
197
What are the investigations for diarrhoea?
1. Bloods - inflammatory markers, blood cultures | 2. Stool tests - microscopy, culture, ova, cysts, parasites, toxin detection
198
What is the prevention for diarrhoea pt.?
Barrier nursing (side room, PPE, PHE notified)
199
What is the Rx for diarrhoea?
1. Fluids 2. Electrolyte replacement 3. Antiemetics 4. Antimotility agents
200
When are antimotility agents not used?
Inflammatory diarrhoea
201
What are the red flags for diarrhoea?
1. Dehydration 2. Electrolyte imbalance 3. Renal failure 4. Immunocompromised 5. Severe abdo pain
202
What are the cancer red flags for diarrhoea?
1. Over 50 2. Chronic diarrhoea 3. Weight loss 4. Blood in stool 5. FHx cancer
203
What causes peptic ulcer disease?
Helicobacter pylori
204
How does H. pylori cause peptic ulcer disease?
Releases ureas which produces ammonia which neutralises stomach acid and damages epithelial cells
205
What are the symptoms for peptic ulcers?
1. Dyspepsia 2. Epigastric pain 3. Loss of appetite
206
What is the Dx for peptic ulcer disease?
1. Stool antigen test 2. Urease breath test 3. Bloods for antibodies 4. Endoscopy with biopsy
207
What is the Rx for peptic ulcer disease?
Triple therapy 1. Omeprazole (PPI) 2. Clarithromycin 3. Amoxicillin
208
What is ascending cholangitis?
Bacterial infection of biliary tract as a result of obstruction
209
What are the RF for gallstones?
Four Fs 1. Fair (Caucasian) 2. Female 3. Fat 4. Fertile
210
What is the diagnosis for ascending cholangitis?
Charcot's triad 1. Jaundice 2. RUQ pain 3. Fever
211
What is the DDx for colicky RUQ pain?
1. Biliary colic | 2. Cholecystitis
212
What is the management for ascending cholangitis?
1. IV Abx 2. Fluids 3. ERCP
213
What bacteria can cause liver abscess?
1. E. coli | 2. Klebsiella spp
214
What are the symptoms for bacterial liver abscess?
1. RUQ pain 2. Fever 3. PUO
215
What is the Dx for bacterial liver abscess?
USS or CT
216
What is the Rx for bacterial liver abscess?
Abx and drainage
217
What are the symptoms for hydatid liver abscess?
Insidious RUQ pain, eosinophilia
218
What is the Rx for hydatid liver abscess?
1. Albendazole | 2. PAIR (percutaneous aspiration, injection, reaspiration)
219
How do typhoid and paratyphoid spread?
Faecal-oral
220
What causes typhoid and paratyphoid?
Types of salmonella
221
What are the symptoms for enteric fever?
1. Generalised/RLQ pain 2. High fever 3. Bradycardia 4. Headache 5. Rose spots 6. Constipation/green diarrhoea
222
What is the Dx for enteric fever?
1. Blood culture | 2. Bone marrow aspiration
223
What are the complications of enteric fever?
1. GI bleed 2. Perforation/peritonitis 3. Myocarditis 4. Abscesses
224
What is the Rx for enteric fever?
1. Emergency surgery 2. IV ceftriaxone 3. Typhoid vaccine
225
What are the parts of the peritoneal cavity?
1. Visceral peritoneum | 2. Parietal peritoneum
226
What is the function of the peritoneum in health?
1. Visceral lubrication | 2. Fluid and particulate absorption
227
What is the function of the peritoneum in disease?
1. Pain perception 2. Inflammatory and immune responses 3. Fibrinolytic activity
228
What is peritonitis?
Inflammation of the peritoneum
229
What is the most common type of peritonitis?
Acute bacterial peritonitis
230
What can cause peritoneal infection with an example?
1. GI perforation e.g. appendicitis 2. Transmural translocation e.g. pancreatitis 3. Exogenous contamination e.g. open surgery 4. Female genital tract infection e.g. pelvic inflammatory disease 5. Haematogenous spread e.g. septicaemia
231
What are the main microorganisms in peritonitis?
1. E. coli 2. Streptococci 3. Enterococci
232
Give 5 clinical features of localised peritonitis
1. Anorexia 2. Pain 3. Nausea/vomiting 4. Fever 5. Tachycardia
233
What are the early features of diffuse peritonitis?
1. Abdominal pain 2. Tenderness 3. Generalised guarding 4. Infrequent bowel sounds 5. Fever
234
What are the late features of diffuse peritonitis?
1. Generalised rigidity 2. Destension 3. Absent bowel sounds 4. Circulatory failure 5. Thready irregular pulse
235
What are the investigations for peritonitis?
1. Urine dipstick 2. ECG 3. Bloods (U&E, FBC) 4. Serum amylase 5. CT, CXR, USS
236
What is the management of peritonitis?
1. Fluids 2. Urinary catheterisation 3. Abx 4. Analgesia 5. Treat underlying cause
237
Name 3 special forms of peritonitis?
1. Bile peritonitis 2. Tuberculosis peritonitis 3. Familial Mediterranean fever
238
What is ascites?
An accumulation of excess serous fluid within peritoneal cavity
239
What determines the exchange of fluid between capillaries and peritoneal fluid?
Balanced effects of plasma and peritoneal colloid osmotic and hydrostatic pressures
240
What are the causes of ascites?
1. Cirrhosis 2. Gynaecological malignancy 3. Heart failure 4. TB
241
What are the symptoms of ascites?
1. Abdominal distension 2. Nausea 3. Constipation 4. Cachexia 5. Pain
242
What are the signs of ascites?
1. Abdominal distension 2. Jaundice 3. Puddle sign 4. Shifting dullness 5. Flanks fullness
243
What are the investigations for ascites?
1. X-ray 2. US 3. CT abdo 4. Ascitic aspiration (culture the fluid)
244
What is the Rx for ascites?
1. Sodium restriction 2. Diuretics 3. Paracentesis 4. Indwelling drain 5. Peritoneovenous shunting
245
Where is most bile reabsorbed?
Terminal ileum
246
What is bile made of?
Bile acids, phospholipids and cholesterol
247
What is the function of bile?
Absorption of fat, cholesterol and vitamins ADEK by forming micelles
248
What is cholestasis?
Obstruction of bile secretion
249
Give 3 causes of cholestasis
1. Pancreatitis 2. Cholelithiasis (stones) 3. Tumours
250
What are the signs of cholestasis?
1. Jaundice 2. Itching 3. Intermittent RUQ pain 4. Dark brown urine 5. Pale stool
251
What are the tests for cholestasis?
1. LFT, U&E, CRP, gamma T 2. USS 3. MRCP 4. CT 5. EUS
252
What causes cholelithiasis (gallstones)?
Increased cholesterol which precipitates to form stones
253
What can form gallstones (GS)?
1. Cholesterol | 2. Calcium bilirubinate (pigment)
254
What are the risks for cholesterol GS?
1. Rapid weight loss 2. Age 3. OCP/pregnancy 4. Crohn's
255
What are the risks for pigment GS?
1. Sickle cells 2. Chronic haemolysis anaemia 3. Chronic biliary tract infection
256
What are the symptoms of GS?
1. Epigastric pain to RUQ 2. RQU to shoulder/scapula 3. Nocturnal 4. Asymptomatic (70%)
257
What is the Rx for GS?
1. Cholecystectomy | 2. Bile salt therapy - ursodeoxycholic acid
258
What is acute cholecystitis?
Inflammation of gall bladder
259
What is the presentation of acute cholecystitis?
1. Biliary pain progressive 2. Sepsis signs 3. Hx of previous attacks 4. GB palpable 5. Jaundice
260
What does positive Murphy's sign indicate?
Acute cholecystitis
261
What does negative Murphy's sign indicate?
Biliary colic disease
262
What is the investigations for acute cholecystitis?
1. WCC, CRP 2. Bilirubin and alkaline phosphatase 3. USS 4. MRI
263
What is the DDx for biliary colic/acute cholecystitis?
1. Pancreatitis 2. Appendicitis 3. Peptic ulcer disease 4. Liver abscess 5. Pneumonia
264
Give 4 complications of acute cholecystitis
1. Gangrene 2. Empyema 3. Cholangitis 4. Porcelain gall bladder
265
What is the Rx for acute cholecystitis?
1. Treat sepsis with Abx | 2. Cholecystectomy
266
What is choledocholithiasis?
Common bile duct stone
267
What is the main symptom of choledocholithiasis?
Painful jaundice
268
What is cholangitis?
Infection if bile duct going upwards
269
What does Charcot's triad indicate?
Obstructive jaundice
270
What is Charcot's triad?
1. Fever 2. Jaundice 3. RUQ pain
271
What is the Rx for choledocholithiasis and cholangitis?
1. ERCP to remove stone 2. Cholecystectomy 3. Inoperative cholangiogram 4. IV Abx
272
What are the risks of primary sclerosing cholangitis?
1. Ulcerative colitis | 2. Colon cancer
273
What is the presentation of primary sclerosing cholangitis?
1. Fatigue 2. Pruritis 3. Anorexia 4. Indigestion 5. Jaundice
274
What are the investigations for primary sclerosing cholangitis?
1. Alk phos rise 2. Bilirubin rise 3. MRCP 4. Liver biopsy
275
What is the Rx for primary sclerosing cholangitis?
1. Balloon dilation 2. Resection 3. Liver transplant
276
What are the complications for primary sclerosing cholangitis?
1. Cholangiocarcinoma 2. Gallstones 3. Gallbladder polyps 4. Gallbladder cancer
277
What are the risk factors for biliary dyskinesia?
1. Female 2. >50 3. OW 4. Fatty foods
278
What is the Dx for biliary dyskinesia?
1. HIDA scan | 2. Hepatobiliary function scan
279
What is the Rx for biliary dyskinesia?
1. Cholecystectomy
280
What are the causes of acute pancreatitis?
1. Alcohol 2. Gallstones 3. Ductal obstruction 4. Acinar cell injury
281
What is the Dx for acute pancreatitis?
1. Typical Hx 2. Elevated amylase 3. Imaging consistent (CT, MRI, USS)
282
What is SIRS?
Systemic inflammatory response syndrome
283
What are the symptoms of acute pancreatitis?
1. Abdominal pain 2. Fever 3. Nausea 4. Tachycardia 5. Tender abdomen
284
What is the diagnostic criteria for SIRS?
2 or more of 1. Temp <36 or >38 2. HR > 90 bpm 3. RR > 20/min 4. WBC changes
285
What is the Rx for acute pancreatitis?
1. Opiates 2. IV fluids 3. Insulin 4. Ca correction
286
What must be checked for in acute pancreatitis?
Necrosis
287
What is the pathophysiology of chronic pancreatitis?
Irreversible fibrosis of pancreatic parenchyma, accompanied by calcification and dilatation of pancreatic ducts
288
What are the risk factors for chronic pancreatitis?
1. Alcohol 2. Smoking 3. Drugs e.g. azathioprine 4. Genetics
289
What are the complications of chronic pancreatitis?
1. Pain 2. Bile duct strictures 3. Nutrition 4. Low insulin 5. Steatorrhoea
290
What is the management for chronic pancreatitis?
1. Stop alcohol/smoking 2. Steroids 3. Pancreatic enzyme replacement therapy 4. Nutrition/diet
291
What is the 5 year survival for pancreatic cancer?
3%
292
What are the symptoms of pancreatic cancer?
1. Jaundice 2. Painless 3. Upper abdomen pain 4. New onset DM in >60
293
What is the investigations for pancreatic cancer?
1. CT 2. PET CT 3. Ca19-9 marker
294
What is the Rx for pancreatic cancer?
1. ERCP 2. Whipple's surgery 3. Distal surgery 4. Palliative chemo
295
What is the pathophysiology of cirrhosis?
1. Encapsulation of injured tissue by a collagenous scar | 2. Connective tissue production and deposition
296
What are the symptoms of cirrhosis?
1. Fatigue 2. Anorexia 3. Itchiness 4. N&V 5. Tenderness around liver
297
What is the Ix for cirrhosis?
1. CT 2. USS 3. MRI 4. Biopsy liver
298
What is the Rx for cirrhosis?
1. Lifestyle change 2. Low salt diet 3. Diuretics 4. ACEI 5. Liver transplant
299
What is Wilson's disease?
Genetic disorder in which excess copper builds up in body
300
What are the Wilson's disease symptoms?
1. Fatigue 2. Abdominal pain 3. Jaundice 4. Kayser-Fleischer rings 5. Oedema peripheral
301
What is the Ix for Wilson's disease?
1. Ceruloplasmin level 2. Copper level 3. Liver biopsy 4. Slit lamp exam for KF rings 5. LFTs
302
What is the Rx for Wilson's disease?
1. Trientine 2. Zinc 3. Liver transplant
303
What gene mutation is a risk factor for Wilson's disease?
ATP7B
304
What are varices?
Abnormally dilated vessel with tortuous course
305
What are the symptoms of varices?
1. Haematemesis 2. Black, tarry stools 3. Vertigo 4. LOC
306
What are the Ix for varices?
1. CT abdomen 2. Doppler US 3. Transient elastography 4. Hepatic venous pressure gradient 5. Endoscopy
307
What is the Rx for varices?
1. BB 2. Endoscopic ligation 3. Vasoactive drug 4. Somatostatin 5. Transjugular shunt

Phase 2a Medicine (15 decks)

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