Upper GI conditions

Question 1

How do you treat a variceal bleed?

Answer 1

1. Resuscitation - maintain pulse, blood pressure, antibiotics
2. Terlipressin - vasoconstrictor, predominantly splanchnic
3. Endoscopic variceal ligation (EVL)
4. sengtaken-blakemore tube- to delay until EVL, or delay until TIPS if EVL fails
5. TIPS

Secondary prophylaxis

• EVL
• BB (Propanolol)

Question 2

What is haemolytic uremic syndrome?

Answer 2

Condition where the small blood vessels in your kidneys become damaged and inflamed- this causes clots to form. The clots clog the filtering system in the kidneys and lead to kidney failure.

Question 3

What causes haemolytic uremic syndrome?

Answer 3

E Cloli, specifically EHEC

Question 4

What does haemolytic uremic syndrome present as?

Answer 4

Abdominal pain
Fever 
pallor
petechiae - tiny spots of bleeding under the skin or in the mucous membranes (mouth or eyelids)
Oliguria - pee less than usual 
Bloody diarrhoea

Question 5

What is seen in the blood count of a patient with haemolytic uremic syndrome?

Answer 5

High WBC 
Low platelets 
Low Hb 
RBC fragments 
LDH greater than 1.5x normal

Question 6

What is haemangioma

Answer 6

A benign liver lesion - single hypervascularised tumour

No treatment

Question 7

What is a focal nodular hyperplasia lesion?

Answer 7

A begnin nodule formation of normal liver tissue. There is a central scar containing a large artery and branches. There is a hyperplastic response to abnormal arterial flow. The cells in this lesion can be sinudoidal, kupffer, hepatocytes etc

Question 8

Do focal nodular hyperplasia cause pain?

Answer 8

Can cause pain but most are asymptomatic.

More common in young and middle aged women

Question 9

What is a hepatic adenoma lesion?

Answer 9

A benign neoplasm composed of normal hepatocytes (no portal tract, central veins or bile ducts). Associated with contraceptive pill

Far more common in women but men have a greater risk of malignancy

Question 10

Hoe does hepatic adenoma lesion present?

Answer 10

Asymptomatic
RUQ pain
rupture, haemorrhage
malignant transformation (rare)

Question 11

What is the treatment for hepatic adenoma lesion?

Answer 11

Women:
Stop contraceptive, weight loss
imaging after 6 months (<5cm = annual MRI, >5cm surgery)

Males:
Surgery irrespective of size

Question 12

What is a simple liver cyst? And what treatment is given

Answer 12

Liquid collection lined by an epithelium

None
imaging 3-6 months
can do surgical intervention

Question 13

What are some symptoms of a simple liver cyst?

Answer 13

asymptomatic (mostly)
intracystic haemorrhage 
infection 
rupture - rare
compression

Question 14

What is a hydatid cyst?

Answer 14

develop these cysts when ingest the eggs of the tapeworm Enchinococcus granulosus.

Presents as disseminated disease (throughout body) or erosion of cysts into adjacent structures

Question 15

How ids a hydatid cyst treated?

Answer 15

Albendazole (stops worms from absorbing sugar)
percutaneous drainage 
Surgery:
-opening and letting it drain 
-removing cyst/liver lobe

Question 16

What are some symptoms of polycystic liver disease?

Answer 16

Abdominal pain
Abdominal distension
Aytpical symptoms due to voluminous cysts resulting in compression of adjacent tissue or failure of the affected organ

Question 17

What are symptoms of a liver abcess (cyst filled with pus)

Answer 17

High fever 
leukocytosis 
abdominal pain 
complex liver lesion on imaging 
Hx of abdominal or biliary infection/dental procedure

Question 18

What is the management of liver abscess?

Answer 18

Amoxicillin, gentamycin, metronidazole
aspiration/ drainage
surgery if no improvement

Question 19

What is cholelithiasis?

Answer 19

Gallstones

Question 20

What are the different kind of gallstones?

Answer 20

Cholesterol gall stones
Pigment gallstones- excess of bilirubin
mixture gallstones

Question 21

What are some complications of gallstones?

Answer 21

Acute cholecystitis 
Chronic cholecystitis 
Mucocoele (build up of mucous as blocked)
Empyema - mucous sac infected
Carcinoma 
Asecinding cholangitis 
Obstructive jaundice 
Gallstone ileus 
Acute pancreatitis 
Chronic pancreatitis

Question 22

What is the treatment of gallstones?

Answer 22

Cholecystectomy
Ursodexycholic acid (dissolves stones but should only be used in patients with small stones and unimpaired gallbladder)
Buprenorphine/pethidine (analgesia for biliary colic)
Atropine/GTN for biliary spasm

Question 23

What is biliary colic?

Answer 23

Waxing/waining postprandial epigastric/RUQ pain due to transient cystic duct obstruction by gallstones

Question 24

What are some symptoms of biliary colic?

Answer 24

RUQ pain that radiates to the back
4-6/8hrs pain duration, settles on its own
No fever, no leukocytosis, raised ALP

Question 25

What ttreatment is given in biliary colic?

Answer 25

Analgesics - not morphine low fat diet consider cholecystectomy if recurrent

Question 26

What is cholecystitis?

Answer 26

Inflammation of the gallbladder

Question 27

What pathogenesis occurs in acute cholecystitis?

Answer 27

GB wall distension, inflammation and oedema due to the obstruction - initialy sterile then will become infected due to bacteria. Can cause adhesions, empyema, rupture, peritonitis

Question 28

What signs are expected in acute cholecystitis?

Answer 28

RUQ pain >24hrs +/- fever tender in RUQ Murphy's sign - if you press below R costal margin, the patient won't be able to breath in elevated WBC expected but not reliable

Question 29

What is the Tokyo guidelines?

Answer 29

Grading for acute cholecystitis Grade 1 - mild inflammation Grade 2- inflammation Grade 3 - organ dysfunction

Question 30

What investigations are carried out in acute cholecystitis?

Answer 30

US (1st line) Nuclear HIDA scan - dye in biliary system and no filling of GB MRCP

Question 31

What will be seen on an ultrasound in acute cholecystitis?

Answer 31

Distended gallbladder increased wall thickness peri-cholecystic fluid - fluid around GB Positive sonographic Murphy's sign

Question 32

What treatment is given in acute cholecystitis?

Answer 32

- Early cholecystectomy for acute 48-72hrs - elective cholecystectomy for acute >72hrs and chronic - if patient too sick then cholecystostomy (drain GB)

Question 33

What is Choledocholithiasis?

Answer 33

Presence of gallstones in the CBD

Question 34

What is the treatment for choledocholithiasis?

Answer 34

ERCP - for stone extraction | Eary/interval cholecystectomy is considered after recovery from ERCP

Question 35

What is Cholangitis?

Answer 35

Inflammation of the bile duct due to obstruction in the CBD. Can be due to stones or strictures. Can lead to sepsis and septic shock

Question 36

What are symptoms/signs of cholangitis

Answer 36

Charcot's triad: persistant RUQ pain, fever, jaundice Raised WBC Obstructive LFTS (high bilirubin and ALP) For suppurative - hepatic encephalopathy and hypotension

Question 37

What is the treatment for cholangitis?

Answer 37

``` IV fluids IV antibiotics If emergency decompression is required: -ERCP -Percutaneous transhepatic drainage ```

Question 38

What is gallstone pancreatitis?

Answer 38

Acute inflammation of the pancreas due to gallstones- reflux of bile into pancreatic duct or obstruction of ampulla of Vater by stone

Question 39

What LFT is commonly high in gallstone pancreatiits?

Answer 39

ALT >150 (3x normal value)

Question 40

What is the treatment for gallstone pancreatitis?

Answer 40

IV fluids, light diet, analgesia Once resolving ERCP and stone extraction Mild cases - cholecystectomy on adomission Severe - cholecystectomy within 4 weeks

Question 41

What are some DDs of RUQ pain?

Answer 41

``` Biliary disease -Acute/chronic cholecytits -CBD stone -Cholangitis Inflammed/perforated peptic ulcer Pancreatitis Hepatitis Rule out: -appendicitis -renal colic -pneumonia -pleurisy -AAA ```