Revision Flashcards
(265 cards)
1
Q
Where does digestion take place?
A
Stomach
2
Q
Which cells produce Hcl?
A
Parietal cells
3
Q
What is the role of Hcl in digestion?
A
Activates pepsinogen to form pepsin which hydrolyses proteins
4
Q
Where in the GI tract does absorption occur?
A
Small intestine
5
Q
Name the 4 distinct layers of the alimentary canal
A
Mucosa
Submucosa
Muscularis externa
Serosa/adventitia
6
Q
What nerve plexus lies between the mucosa and submucosa?
A
Submucosal plexus
7
Q
What is the mucosa composed of?
A
Epithelium
Lamina propria
Muscularis mucosae
8
Q
Which nerve plexus lies between the inner and outer layer of the muscular externa?
A
Myenteric plexus
9
Q
What type of epithelium is present in the oesophagus?
A
Non-keratinised stratified squamous
10
Q
What type of epithelium is present in the anal canal?
A
Non-keratinised stratified squamous
11
Q
What type of epithelium is present in the tongue?
A
Keratinised stratified squamous
12
Q
What type of epithelium is present in the small intestine?
A
Simple columnar
13
Q
What type of epithelium is present in the stomach?
A
Simple columnar
14
Q
What is the lamina propria?
A
A loose connective tissue layer that lies below the epithelium
15
Q
What type of fibres are carried in the submucosal plexus (Meissner’s plexus)?
A
Parasympathetic
16
Q
Which segment of the small intestine contains payer’s patches?
A
Submucosa of the ileum
17
Q
Which tunic of the GI tract contains blood, lymph and glands?
A
Submucosa
18
Q
Which nerves carry parasympathetic innervation to the gut?
A
Vagus nerve (CN X)
19
Q
Which nerves carry sympathetic innervation to the gut?
A
Splanchnic nerve
20
Q
What effect would increasing parasympathetic innervation to the gut have?
A
Increases activity of enteric nervous system:
Increased gut motility
Increased gastric secretions (parietal cells and G cells)
21
Q
What substance do G cells secrete?
A
Gastrin
22
Q
What effect would increasing sympathetic innervation to the gut have?
A
Decreases activity of enteric nervous system:
Decreased gut motility
Inhibits gastric secretions
23
Q
Name 3 monosaccharides
A
Glucose
Galactose
Fructose
24
Q
Glucose + Glucose =
A
Maltose
25
Glucose + Galactose =
Lactose
26
Glucose + Fructose =
Sucrose
27
Where, in the GI tract, are disaccharides broken down to form monosaccharides?
In small intestine by brush border enzymes
28
What is the action of proteases?
Hydrolyse peptide bonds
29
What is the action of peptidases?
Reduce peptides to amino acids
30
Where is intrinsic factor produced and what does it bind to?
Parietal cells
| Binds to Vitamin B12 to form complex
31
Where is vitamin B12 absorbed?
Distal ileum
32
Which protein does iron bind to when it is being stored intracellularly?
Ferritin
33
Which plasma protein does iron bind to?
Transferrin
34
Anaemia is caused by a lack of which iron binding protein?
Ferritin
35
What effect would increased parasympathetic innervation have on salivary secretion?
Profuse watery secretions
36
What effect would increased sympathetic innervation have on salivary secretion?
Small volume of serous saliva
| High mucus & amylase content
37
Which type of muscle makes up the upper 1/3 of the muscular externa of the oesophagus?
Skeletal muscle
38
Which type of muscle makes up the lower 1/3 of the muscular externa of the oesophagus?
Smooth muscle
39
Which type of cells in the muscular is externa control peristaltic rhythm?
Pacemaker cells
40
What is the normal frequency of peristalsis in the stomach?
3 waves per minute
41
Which region of the stomach is mainly responsible for mixing/grinding ingested material?
Antrum
42
Which region of the stomach is mainly responsible for producing gastric secretions?
Body
43
What do chief cells secrete?
Pepsinogen
44
What do parietal cells secrete?
Hcl and intrinsic factor
45
Which cells secrete mucus?
Mucus neck cells
46
Where are enterogastrones secreted from?
Gland cells in duodenal mucosa
47
What occurs during the cephalic phase of gastric acid secretion?
Food is tasted/smelt
Increased vagus nerve activity
This stimulates G cells to produce gastrin
Gastrin stimulates parietal cells to produce Hcl
48
What is the role of gastrin in digestion?
Stimulates parietal cells to produce Hcl
| Stimulates muscle contraction
49
During gastric phase of gastric acid secretion, distension of the stomach causes?
Vagal/enteric parasympathetic nerve to release Acetylchoine
Acetylcholine stimulates parietal cells to produce Hcl
50
During gastric phase of gastric acid secretion, peptides in the lumen causes?
Stimulation of G cells to produce Gastrin
Gastrin stimulates parietal cells to produce Hcl and intrinsic factor
51
During the intestinal phase of digestion once acid, fatty acids and monoglycerides reach the duodenum, which hormones are released?
Enterogastrones:
CCK
Secretin
GIP
52
What stimulates the release of secretin?
Acid in duodenum
53
What stimulates the release of CCK?
Fatty acids in duodenum
54
What is the role of CCK?
Decreases gastric emptying
Increases pancreatic enzyme secretion
Gallbladder contraction
Relaxes sphincter of oddi
55
What is the role of secretin?
Decreases gastric emptying
Decreases gastric acid secretion
Increases pancreatic HCO3 secretion
Increases digestive enzyme secretion
56
What switches off the production of secretin?
When pH rises back to normal
57
What is the role of gastric mucus?
Protects cells from corrosion by Hcl (acts as a buffer)
58
Which cells secrete pepsinogen?
Chief cells
59
Pepsinogen is the inactive precursor of what?
Pepsin
60
What stimulates pepsinogen activation?
Low pH produced by Hcl (from parietal cells)
61
What do pancreatic duct cells secrete?
Bicarbonate
62
What do pancreatic acinar cells secrete?
Digestive enzymes
63
Name the components of bile
```
Bile acids
Lecithin
Cholesterol
Bilirubin
Toxic metals
Bicarbonate
```
64
Which cells secrete bile acids?
Hepatocytes of the liver
65
Which cells secrete the bilirubin component of bile?
Hepatocytes of the liver
66
Which cells secrete the bicarbonate component of bile?
Duct cells of the pancreas
67
What is bilirubin derived from?
Breakdown products of haemoglobin
68
Which amino acids are bile acids conjugated with to form bile salts?
Taurine or Glycine
69
What is the purpose of conjugating bile acids with amino acids?
To improve solubility
70
Which duct(s) does excess bile drain from the liver to the gall bladder?
Common hepatic duct then cystic duct
71
Which tunic layer is absent in the gallbladder?
Submucosa
72
How does bile move from the gall bladder to the duodenum?
It is ejected by contraction of muscular externa of gall bladder
It then moves down cystic duct and common bile duct to sphincter of oddi
73
What is the function of the gallbladder?
Stores and concentrates bile by removing water and sodium
74
What is the function of the spinchter of oddi?
Controls release of pancreatic juice and bile into duodenum
75
What hormone is responsible for relaxing the sphincter of oddi?
CCK
76
What happens when the sphincter of oddi is contracted?
Bile is forced back into gallbladder
77
Where does iron absorption occur?
Duodenum
78
Where does the majority of nutrient absorption occur?
Jejenum of small intestine
79
What is the function of crypts in the small intestine?
Active secretion of Cl
| Osmotic secretion of water - keeps chyme in liquid state
80
Why are digestive enzymes produces in an inactive form? (zymogens)
Prevents enzymes from digesting the cells which secrete them
81
Whilst absorption is occurring in the small intestine, which muscle layer is acting to produce segmentation of chyme?
Longitudinal muscle layer of muscular externa
82
When does peristalsis occur?
After absorption has occurred
83
What triggers the end of peristalsis and beginning of segmentation?
Arrival of food
84
What determines the frequency of segmentation?
Basal electrical rhythm (BER)
85
What is the purpose of segmentation in small intestine?
Mixes partially digested food and digestive juices
| Brings chyme into contact with intestinal wall to aid absorption
86
The law of intestine states that if intestinal smooth muscle is distended by a bolus of chyme, smooth muscle on the oral side of the bolus will:
Contract
87
The law of intestine states that if intestinal smooth muscle is distended by a bolus of chyme, smooth muscle on the anal side of the bolus will:
Relax
88
Which layer of the muscular externa is incomplete in the large intestine?
Longitudinal layer
89
What forms the teniae coli of the large intestine?
3 bands of longitudinal muscle
90
What forms the haustra of the large intestine?
Contraction of teniae coli
91
What type of epithelium is present in the mucosa of the large intestine?
Simple columnar
92
What type of muscle is present at the external anal sphincter?
Skeletal
93
What type of muscle is present at the internal anal sphincter?
Smooth
94
What is odonphagia?
Painful swallowing
95
What are some of the main causes of dysphagia?
```
Malignancy
Mobility disorders
Benign stricture
Eosionophilic oesophagus
Extrinsic compression e.g. lung tumour
```
96
Name some substances that can reduce LOS pressure and lead to reflux
Nicotine
Alcohol
Dietary xanthines
97
What is the chronic form of reflux called?
GORD
98
What are the main symptoms of GORD?
```
Heartburn
Water brash
Sleep disturbance
Cough
Dysphagia
```
99
If a patient presents with GORD symptoms what investigations would you carry out?
If under 55 and no ALARM symptoms begin treatment
| If over 55 or ALARM symptoms give upper GI endoscopy and manometry
100
What are ALARM symptoms?
Symptoms suggestive of malignancy
```
Anaemia
Loss of weight
Anorexia
Recent onset
Malena
Swallowing difficulty
```
101
What is the gold standard test for GORD?
pH monitoring
102
What treatment can be given for GORD?
```
Lifestyle changes
Pharmacological
- Alaginates (Gaviscon)
- H2RA
- PPI (omneprazole)
Anti reflux surgery
```
103
What is Barrett's oesophagus?
Metaplasia in the oesophagus caused by repeated acid exposure as a result of GORD
104
In Barrett's oesophagus, what epithelial cell change occurs?
Squamous cells become columnar
105
What type of cancer is likely to occur as a result of Barrett's oesophagus?
Adenocarcinoma
| Squamous cell carcinoma is more linked to tobacco smoke
106
What treatment can be given for Barrett's oesophagus?
Radiofrequency ablation
| Endoscopic mucosal resection
107
Barrett's oesophagus is most likely to lead to cancer in which part of the oesophagus? (Proximal, Middle or Distal)
Distal 1/3
108
Squamous cell carcinoma is most likely to occur in which part of the oesophagus?
Proximal and Middle 1/3
109
What are the common symptoms of oesophageal cancer?
PROGRESSIVE DYSPHAGIA
Stridor
Weight loss
110
What are the common metastatic sites for oesophageal cancer?
Liver
Brain
Lungs
Bone
111
How is oesophageal cancer diagnosed?
Endoscopy and biopsy
| CT for distant metastases
112
What are the 3 types of oesophageal motility disorder?
Hypermotility
Hypomotility
Achalasia
113
What condition is oesophageal hyper motility often mistaken for?
Angina
114
How is oesophageal hyper motility diagnosed?
Corkscrew appearance on barium swallow
| Manometry
115
How is oesophageal hyper motility treated?
Smooth muscle relaxants
116
What is achalasia?
Degeneration of LOS neurons in myenteric plexus
| Prevents LOS from relaxing
117
How is achalasia diagnosed?
```
Manometry
Barium swallow (shows dilated distal oesophagus)
```
118
What complication are achalasia patients at risk of?
Squamous cell carcinoma due to toxins building up in oesophagus
119
What are the risks of endoscopy?
Person must be fasted - if not aspiration can occur
Perforation (1/2000)
Bleeding - must come off anticoagulants
120
When is manometry indicated?
Investigation of dysphagia following endoscopy
| When motility disorder is suspected
121
What does manometry check?
Spinchter tonicity
Relaxation of sphincters
Oesophageal muscle contractions
122
What are the 2 types of hiatus hernia that can occur?
Para-oesophageal
| Sliding
123
How is achalasia treated?
Pharmacological (Nitrates)
Endoscopic (Botox, Balloon dilation)
Surgical (Myotomy)
124
How is staging of oesophageal cancer carried out?
Endoscopy + biopsy (T/N stage)
| CT of chest and abdomen (M stage)
125
What are the treatment options for an individual diagnosed with oesophageal cancer who is deemed terminal?
Stenting to improve dysphagia
Radiotherapy to improve dysphagia
Palliative chemotherapy
126
What are the treatment options for an individual diagnosed with oesophageal cancer who is deemed fit for surgery?
Neoadjuvant Chemotherapy + oesophagectomy
127
What are the treatment options for an individual diagnosed with oesophageal cancer who is deemed unfit for surgery?
Radiotherapy + chemotherapy
128
What are the risks involved in an oesophagectomy?
5-10% mortality risk
Lung needs to be collapsed so surgeon can get into oesophagus
Long recovery period
129
When is anti reflux surgery indicated?
When GORD is occurring as result of hiatus hernia
130
What is the most common type of anti reflux surgery?
Fundoplication
| Carried out laparoscopically - top of stomach is wrapped round oesophagus
131
What complications are associated with fundoplication?
Dysphagia
Difficulty belching/vomiting
Gas bloating
132
What are the indications for bariatric surgery?
Life threatening obesity
BMI >40 or BMI >35 in patients with hypertension or diabetes
Or if weight loss is needed before life saving surgery
133
What are the common symptoms of dyspepsia?
Epigastric pain
Belching
Nausea
Low appetite
134
How should a dyspepsic patient be assessed?
History - drugs and lifestyle
If they are >55 or have alarm symptoms - upper Gi endoscopy
If they are <55 test for H.pylori
135
What are the common tests used to diagnose H.pylori infection?
Non invasive tests:
- Serology IgG
- Urea breath test
- Stool antigen test
Invasive tests:
- Endoscopy + gastric biopsy
136
What are the outcomes of an infection with H.pylori?
80% are asymptomatic
15-20% develop ulcers or metaplasia
<1% develop gastric cancer
137
What treatment is given for H.pylori infection?
Triple therapy for 7 days:
Clarithromycin
Amoxicillin
PPI
138
Where does H.pylori colonise?
Gastric mucosal epithelium
139
What is the most common cause of peptic ulcers?
H.pylori
140
What are the common symptoms of peptic ulcers?
```
Epigastric pain (often worse at night or when hungry)
Epigastric tenderness
Nausea
Weight loss
Bleeding (haematemesis/malena/anaemia)
```
141
How are peptic ulcers treated?
Stop NSAIDs
Triple therapy for H.pylori infection
PPIs/H2RA
Surgery in complicated cases
142
What are the complications of peptic ulcers?
Acute bleeding (haematemesis/malaena)
Chronic bleeding (anaemia)
Perforation (peritonitis)
Strictures
143
How can peptic ulcers eventually lead to gastric outlet obstruction?
Stricture formation due to healing by fibrosis can cause outlet to become obstructed
144
What are the common symptoms of gastric outlet obstruction?
Vomit lacking bile and containing fermented food
Dehydration due to lack of absorption
Abdominal distension
Early satiety
145
If gastric outlet obstruction is suspected, how should it be investigated?
UGIE to identify cause
146
What are the main causes of gastric outlet obstruction?
Stricture formation due to ulcers
| Cancer
147
What is the pathophysiology behind the formation of peptic ulcers?
Imbalance between acid secretion and mucosal barrier
148
What is gastritis?
Inflammation of the gastric mucosa
149
What are the main causes of gastritis?
Autoimmune
Bacterial (H.pylori) - most common
Chemical (NSAIDs, alcohol)
150
Which type of cancer is most commonly found in gastric mucosa?
Adenocarcinoma
151
If you suspected someone may have gastric cancer, which investigations would you carry out?
UGIE + biopsy
| CT chest and abdomen
152
Autoimmune gastritis is caused by autoantibodies to which cells?
Parietal cells - causes decreased acid secretion and loss of intrinsic factor
153
Define functional bowel disorders
Disorder of bowel function where structure remains normal
154
Name some examples of functional bowel disorders
IBS
Non ulcer dyspepsia
Drug related effects
155
How are functional bowel disorders such as IBS diagnosed?
1. History
2. Examination
3. Refer for endoscopy/colonoscopy if alarm symptoms present
4. Bloods (FBC, blood glucose, thyroid status)
5. Coeliac serology
156
What are the clinical features of IBS?
```
Abdominal pain/discomfort relieved by defecting
Bloating
Altered stool passage
Symptoms worse after eating
Mucus in stool
```
157
If you suspected someone may have IBS, what investigations would you carry out?
1. History
2. Examination
3. FBC/blood analysis
4. Stool culture
5. Calprotectin
Mainly you are trying to rule out other causes
158
How is IBS treated?
```
FODMAP
Antispasmodics
Probiotics
Anti motility agents
Laxitives
```
159
Name some of the functional causes of vomiting
```
Drugs
Alcohol
Pregnancy
Migraine
Functional bowel disorder
```
160
Define structural bowel disorders
Disorders of the small bowel which have detectable pathology
161
What are the clinical signs of small bowel structural disorders?
Symptoms of malabsorption:
Decreased BMI
Vitamin deficiencies
Iron deficiency
162
What are some of the non-specific signs associated with small bowel structural disorders?
Clubbing
Scleroderma
Mouth ulcers
Dermatitis herpetiformis
163
Name some of the causes of small bowel malabsorption
Inflammation (coeliac)
Infection (Giardia, HIV, Whipples)
Impaired motility
164
What is the pathophysiology of coeliac disease?
Gliadin fraction of gluten gets through mucosal barrier and is activated by tissue transglutaminase
Certain genotypes sensitise due to MHCII which leads to inflammation
165
How is coeliac disease diagnosed?
Serology:
Anti-tissue transglutaminase antibody
Anti-gliadin in children
Distal duodenal biopsy - gold standard if serology positive
166
What is refractory coeliac disease?
When symptoms persist even after antigen (gluten) is removed from diet
167
What is dermatitis herpetiformis?
A cutaneous manifestation of coeliac disease due to IgA deposits in skin which causes blistering of scalp, elbows and knees
168
If small bowel malabsorption is found to be due to Giardia, how is this treated?
Metronidazole
169
If a patient presents with small intestinal malabsorption, after completing blood tests and stool tests what other investigations can be carried out?
```
Endoscopy + biopsy
MRI enterography
White cell scan
CT scan
Capsule enterography
```
170
Vitamin C malabsorption can cause?
Scurvy
171
Vitamin A malabsorption can cause?
Night blindness
172
Vitamin K malabsorption can cause?
Raised prothrombin time
173
Niacin malabsorption can cause?
Unexplained heart failure
174
Name some types of inflammatory bowel disorder
Ulcerative colitis
Crohns
Indeterminate colitis
Microscopic colitis (collagenous and lymphocytic)
175
Compare ulcérative colitis and crohn's disease
UC affects females more, Crohn's M=F
UC only affects colon, Crohn's affects mouth to anus
UC has no skip lesions, Crohn's has skip lesions
UC peak incidence is 20-40 years, Crohn's peak incidence is 20-40 years and >60 years
176
What are the common presenting symptoms of ulcerative colitis?
Bloody diarrhoea
Weight loss
Abdominal pain
177
What are the common presenting symptoms of Crohn's disease?
```
Diarrhoea
Abdominal pain
Weight loss
Malabsorption
Mouth ulcers
```
Depends largely on which areas are affected
178
If you suspected someone may have inflammatory bowel disease, which investigations would you carry out?
```
Bloods:
ESR and CRP
Increased platelets
Increased white cell count
Low haemoglobin
Low albumin
```
Colonscopy with biopsy - gold standard
179
What are the complications associated with inflammatory bowel disease?
Ulcerative colitis:
Colonic carcinoma
Sclerosing cholangitis
Toxic megacolon
Crohn's:
Strictures
Fistulas
180
What is primary sclerosis cholangitis?
A disease of the bile ducts of the liver due to multiple strictures, can eventually lead to cirrhosis
181
How is IBD treated?
First aim is to induce remission, this can be done using steroids
1. 5ASAs - anti inflammatory used to induce and maintain remission (1st line in UC)
2. Corticosteroids
3. Azathioprine (steroid sparing anti inflammatory but with significant side effects)
182
What are some of the risks involved with taking Azathioprine?
```
Increased lymphoma risk
Leukopenia
Hepatotoxicity
Pancreatitis
Intolerance
```
183
What is acute pancreatitis?
Inflammation of the pancreas with biochemical associations (increased amylase, increased lipase)
184
What are the main causative agents of acute pancreatitis?
```
Gallstones
Ethanol (most common)
Trauma
Others: Mumps, HIV, Autoimmune, Carcinoma
Idiopathic (10%)
```
185
What is the pathogenesis of acute pancreatitis?
Primary insult e.g. alcohol causes release of activated pancreatic enzymes (remember pancreatic enzymes are normally released as inactive zymogens)
This causes auto digestion of own pancreas: oedema, inflammation, haemorrhage etc
186
What are the symptoms of acute pancreatitis?
Epigastric pain
Anorexia
Nausea/vomiting
Flank bruising
187
If you suspect someone may have acute pancreatitis, what investigations would you carry out?
1. Serum amylase and lipase - This confirms pancreatic inflammation
2. FBC, urea and electrolytes, Glucose, CRP to indicate prognosis
Now need to determine cause:
3. Abdominal ultrasound (gallstones)
4. AXR (excludes pleural effusion)
5. ERCP
6. CT
188
What does ERCP image?
Allows X-rays to be taken of ducts of pancreas, liver and gallbladder
189
What scoring system is used to determine severity of acute pancreatitis?
Glasgow Prognosis Score (3 or more is severe)
190
How would you treat a patient with acute pancreatitis?
Initial management:
Analgesia
IV fluids
Oxygen
Then treat underlying cause
191
How would you treat acute pancreatitis caused by gallstones?
Consider ERCP or cholecystectomy
192
Name some of the complications of acute pancreatitis
Pancreatic necrosis
Abscess
Pseudocyst
193
Define chronic pancreatitis
Structural integrity of pancreas is permanently altered as a direct result of chronic inflammation
Characterised by glandular destruction
194
What is the pathology of chronic pancreatitis?
Glandular atrophy
Fibrous tissue formation
Dilation of ducts - eventually become strictures
Secretions may calcify
195
What are the main causes of chronic pancreatitis?
Alcohol (80%)
Cystic fibrosis (2%)
Congenital abnormalities
Hereditary pancreatitis
196
Name some of the genes associated with hereditary pancreatitis
CFTR (cystic fibrosis)
PRSS1
SPINK1
197
What are the main signs of chronic pancreatitis?
```
Early disease may be asymptomatic
Main symptom is pain! Exacerbated by food and alcohol, may be relieved by sitting forward
Weight loss
Steatorrhoea
Portal hypertension, jaundice
```
198
If you suspected a patient may have chronic pancreatitis, what investigations would you carry out?
```
1. Bloods
Serum amylase - usually normal unless acute on chronic attack
FBC
LFTs
Blood glucose
HbA1C
```
2. Secretin test (does pancreas respond to secretin?)
3. Ultrasound
4. Plain xray or CT (shows calcification)
199
If a patient was diagnosed with chronic pancreatitis, how would you manage them?
1. Pain management
Avoid alcohol
Opiate analgesia
2. Exocrine and endocrine management
Low fat diet
Pancreatic enzyme supplements
Insulin for diabetes
200
What are the clinical signs of pancreatic carcinoma?
```
Epigastric pain (body and tail tumours)
Painless obstructive jaundice (head tumours)
Weight loss
Steatorrhoea
Portal hypertensio/ascites
Abdominal mass
Abdominal tenderness
```
201
What % of patients that present with pancreatic carcinoma are operable?
<10%
202
If a patient with pancreatic carcinoma is deemed to be operable, what radical surgery is carried out?
Pancreatoduodectomy
203
A Pancreatoduodectomy involves removal of which organs?
```
Head of pancreas
Gall bladder
Part of duodenum
Pylorus
Lymph nodes near head of pancreas
```
204
If a patient with pancreatic carcinoma is deemed inoperable, what treatments can be given to them to improve symptoms?
Stent - improves jaundice
| Opiates for pain control
205
What do raised ALT and AST indicate?
Acute liver injury
206
Which enzyme is more specific to liver damage, AST or ALT?
ALT
207
An AST:ALT ratio of 2:1 suggests?
Alcoholic liver disease
208
Raised albumin is suggestive of?
Chronic liver injury
209
Prothrombin time is a measurement of?
Time taken for blood to clot
210
Raised prothrombin indicates what?
Liver dysfunction
| Reduced blood clotting
211
What is the definition of liver failure?
Not enough functioning hepatocytes to keep up with liver function
212
What is the most likely outcome of infection with hepatitis C?
Chronic liver failure
213
What are the outcomes of infection with hepatitis A?
Acute failure or resolution
214
What are the outcomes of infection with hepatitis B?
Acute failure or chronic failure
215
What is alcoholic hepatitis?
Alcohol causes fat to accumulate in hepatocytes which causes inflammatory response in liver
216
If a patient has continued episodes of alcoholic hepatitis what is the likely outcome?
Liver cirrhosis
217
What is the pathology of liver cirrhosis?
Loss of hepatocytes
| Hepatocytes replaced by fibrous tissue
218
Name some of the causes of liver cirrhosis
```
Alcohol
Hepatitis B or C
Autoimmune hepatitis
Primary biliary cholangitis
Idiopathic (>50%)
```
219
What is jaundice?
An accumulation of bilirubin
220
What level of bilirubin needs to be present in the serum before jaundice becomes apparent?
Around 35umol/L
221
What are the 3 types of jaundice?
Pre hepatic
Hepatic
Post hepatic
222
Name a pre hepatic cause of jaundice
Hemolytic anaemia (abnormal breakdown of RBCs)
223
Which component of haemoglobin is used to form bilirubin?
Heme
224
In hepatocytes, bilirubin is conjugated with what to make it water soluble?
Glucuronic acid
225
Name 2 hepatic causes of jaundice
Cholestasis
| Intrahepatic bile duct obstruction
226
Name 3 causes of intrahepatic bile duct obstruction
Primary biliary cholangitis
Primary sclerosis cholangitis
Liver tumours
227
What is cholestasis?
Accumulation of bile in hepatocytes of bile calculi
228
What are the causes of cholestasis?
Viral hepatitis
Alcoholic hepatitis
Drugs
229
What are the main differences between primary biliary cholangitis and primary sclerosing cholangitis?
Primary billiary is an organ specific autoimmune disease
Primary sclerosing is associated with IBD
Primary biliary affects females more than males
Primary sclerosing affects males more than females
Primary biliary is associated with granulomatous inflammation
Primary sclerosing is associated with stricture formation
Both lead to destruction of bile ducts but primary sclerosing leads to cirrhosis quicker
230
A cholangiocarcinoma is a tumour of which tissue?
Bile duct epithelium
231
Name the 2 main post hepatic causes of jaundice
Gallstones
| Common bile duct obstruction
232
What are the risk factors for developing gallstones?
Obesity
| Diabetes
233
What is acute cholecystitis?
Acute inflammation of the gallbladder
234
What is the main cause of acute cholecystitis?
Gallstone blocking the cystic duct
235
If a patient has acute cholecystitis, which complication are you most concerned about?
Perforation of the gallbladder which can cause empyema
236
What is chronic cholecystitis?
Gallbladder damage due to repeated attacks of inflammation - healing and fibrosis occurs
Thickened wall makes it hard to expel bile
237
What are the causes of common bile duct obstruction?
Gallstones
Bile duct tumours (cholangiocarcinoma)
Extrinsic tumour compression
Benign stricture
238
If levels of conjugated bilirubin are elevated, what does this suggest?
Hepatic or post hepatic cause of jaundice
239
If a patient appears with pain in upper right quadrant and jaundice, what liver function tests would you carry out?
ALT:AST
ALP and Gamma GT
Conjugated bilirubin
Prothrombin time
240
What does raised ALP indicate?
ALP is an enzyme found in bile ducts and it becomes raised when they are obstructed, however it is not specific so should be measured alongside gamma GT o confirm liver source
241
Would you expect an elevated or lowered platelet count in a patient with cirrhosis?
Low
| Cirrhosis causes splenomegaly which causes the spleen to destroy platelets
242
If a patient appears with jaundice and upper right quadrant pain, which investigations would you carry out?
```
LFTs
Abdominal ultrasound (shows site and cause of obstruction)
Hep B and C serology
Copper test (Wilson's)
ERCP
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243
What is ascites?
Fluid in peritoneal space
244
How would you investigate a patient with ascites?
Examination shows swiftness dullness (>1.5L)
Abdominal ultrasound (100ml)
Diagnostic removal of ascitic fluid for testing
245
How is ascites treated?
Paracentesis - needle removal
Shunt
Diuretics
Liver transplant
246
If ascites has a serum albumin gradient of more than 1.1g/dL what does that suggest?
Shows portal hypertension so ascites is being caused by cirrhosis and other conditions which cause portal hypertension
247
Define varices
Abnormally dilated vessels at porto-systemic anastomoses
248
If varices are present and rupture, how is this dealt with?
This is a medical emergency
1. Resuscitate
2. Blood transfusion
3. Emergency endoscopic band ligation
249
What are the 3 stages of alcoholic liver disease?
1. Alcoholic fatty liver disease - reversible (fat in liver cells)
2. Alcoholic hepatitis
3. Alcoholic cirrhosis
250
How is alcoholic fatty liver disease diagnosed?
AST:ALT >2:1
Raised gamma GT
Low platelet count
Abdominal ultrasound can show fatty liver
251
What are the common presentations of alcoholic hepatitis?
Jaundice (cholestasis - intrahepatic cause)
| Encephalopathy
252
If you suspect someone may have alcoholic hepatitis, what investigations would you carry out and what results would you expect?
1. History - alcohol
2. Bloods
Raised ALP and Gamma GT
Raised prothrombin time
Hep B/C screen to rule out viral hepatitis
253
How is alcoholic hepatitis managed?
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Support alcohol withdrawal
Treat infections
Treat encephalopathy
Nutritional help
Oral steroids if hepatitis score is more than 9
```
254
How is hepatic encephalopathy treated?
Laxitives and antibiotics
255
What is hepatic encephalopathy often preceded by?
Constipation or infection
256
What is spontaneous bacterial peritonitis?
Infection of fluid in abdomen
257
What are the symptoms of spontaneous bacterial peritonitis?
Patient with ascites becomes feverish and has signs of sepsis
258
How would you diagnose spontaneous bacterial peritonitis?
Do ascitic tap and check for:
decreased fluid
Increased white cell count
259
What 3 conditions come under the term 'non alcoholic fatty liver disease'?
Simple steatosis
Non alcoholic steatohepatitis
Fibrosis and cirrhosis
260
You suspect a patient has fatty liver disease but you are unsure if it is caused by alcohol or not, what test can you do to determine the answer?
AST:ALT
If >2:1 it is alcohol related
If <1:1 is is non alcohol related
261
What are the main causes of non-alcoholic fatty liver disease?
Obesity
Diabetes
Hypertension
262
How is non-alcoholic fatty liver disease diagnosed?
1. AST:ALT
2. Ultrasound to look for fat
3. Fibroscan
4. MR spectroscopy (quantifies fat)
263
How is non alcoholic fatty liver disease managed?
Diet and weight reduction
Exercise
Insulin sensitisers e.g. Metformin
Weight reduction surgery
264
What are the indications for liver transplantation?
Chronic disease with poor predicted outcome or poor quality of life
Hepatocellular carcinoma
Acute liver failure
265
What scoring criteria is used to determine a patient's eligibility for liver transplantation?
Child's pugh score
| MELD score
