Acute Cholangitis, Alc Hep, Anal Fissure, Appendicitis, Autoimmune hep, Barret's

Question 1

What is Charcot’s Triad?

Answer 1

Fever, Jaundice, RUQ pain

Question 2

What are the most common causes?

Answer 2

Choledocholithiasis (stones in the biliary tree) and benign + malignant strictures

Question 3

What are some diagnostic factors?

Answer 3

RUQ pain/tenderness
Jaundice
Pruritus
Pale stools
Hypotension
Mental status changes

Question 4

What are risk factors for AC?

Answer 4

Age >50
Cholelithiasis
Strictures

Question 5

What are 1st investigations for AC?

Answer 5

Serum urea, creatinine, ABG (acidosis suspecting sepsis), FBC

Consider abdominal CT with IV contrast/MRCP/Percutanrous transhepatic cholangiography

Question 6

What is treatment for AC?

Answer 6

1. IV antibiotics + intensive medical management
2. Biliary decompression via ERCP if patient is worsening
   PTC if poor candidate for ERCP (e.g., status post-Roux-en-Y gastric bypass, presence of oesophageal stricture)
3. Biliary decompression surgically with laparoscopic choledochotomy with T-tube placement or cholecystectomy with common bile duct exploration

Question 7

What drug is used as an alcohol detox in hospital?

Answer 7

Chlordiazepoxide to help withdrawal (generously first 3 days and then wean off over a week)

Question 8

What drugs can be used to prevent alcohol relapse?

Answer 8

Acamprosate and metronidazole - cause acetaldehyde buildup so any alcohol ingestion will cause unpleasant side effects like headaches, flushing, palpitations.

Question 9

What are the CAGE questions?

Answer 9

C: Ever felt like cutting down on drinking?
A: Have people annoyed you by criticising your drinking?
G: Have you ever felt guilty about your drinking?
E: Ever had an eye-opener in the morning?

Question 10

How would a patient with alcoholic hepatitis present?

Answer 10

With malaise, increased TPR, AST:ALT>2, tender hepatomegaly and jaundice, low WBC and platelets due to toxicity/hypersplenism

Question 11

How is alcoholic hepatitis treated?

Answer 11

1. If ascites, ascitic tap, screen for infection and SBP
2. Stop alcohol
3. Maddrey discriminant factor takes patient’s PT and bilirubin into account - if over 31 and encephalopthy present, give prednisolone
4. Vitamin K and thiamine

Question 12

What indicates anal fissure?

Answer 12

Fresh red blood on wiping
Tearing sensation on passing stool
Sentinel pile present
Visible fissure

Question 13

How are anal fissures treated?

Answer 13

Glyceryl trinitrate topically or diltiazem
If resistant/chronic:
Botulinum toxin A
Surgical sphincterectomy/anal advancement flap

Question 14

How does appendicitis usually present?

Answer 14

Acute abdominal pain starting in the mid-abdomen and later localising to the right lower quadrant. Associated with fever, anorexia, nausea, vomiting, and elevation of the neutrophil count.

Question 15

What is appendicitis usually caused by?

Answer 15

Obstruction of the lumen of the appendix (by faecolith, normal stool, infective agents, or lymphoid hyperplasia)

Question 16

How is uncomplicated appendicitis in adults managed?

Answer 16

Supportive treatment: Keep patient nil by mouth with maintenance fluids if surgery being considered + paracetamol/morphine sulfate
Prophylactic antibiotics with laparoscopic appendicectomy within 24 hours

Question 17

What are potential complications of appendicitis?

Answer 17

Perforation, acutely unwell, abscess/phlegmon

Question 18

What are symptoms of autoimmune hepatitis?

Answer 18

Fever, malaise, urticarial rash, polyarthritis, glomerulonephritis

Question 19

What are risk factors of autoimmune hepatitis?

Answer 19

Female sex, Genetic predisposition, immune dysregulation

Question 20

What would tests indicate in autoimmune hepatitis?

Answer 20

Elevated LFTs, hypergammaglobulinaemia, positive autoantibodies, liver biopsy shows mononuclear infiltrates of portal and periportal areas
MRCP helps exclude PSC if ALP disproportionately elevated

Question 21

What are the 2 types of autoimmune hepatitis?

Answer 21

Type 1: ASMA (anti smooth muscle antibody) + ANA (antinuclear antibody) positive with good response to immunosuppression and presenting with cirrhosis
Type 2: LKM1 antibody positive (anti-liver/kidney microsomal type 1) with ASMA and ANA negative - more common in children and worse prognosis

Question 22

What is the definition of severe AIH and how is it treated?

Answer 22

Acute severe AIH as patients presenting with jaundice, international normalised ratio >1.5 to <2, no encephalopathy, and no previously recognised liver disease.

60mg prednisolone OD and taper as per response