ALIM Flashcards
what are the symptoms of GORD?
- heartburn
- regurgitation
- belching
- chronic cough
what is the first line investigation for GORD?
low dose PPI challenge
when would you do an endoscopy for GORD?
Patient is over 55 with alarm symptoms
what is grade A in the LA classification for oesophagitis used in GORD?
The mucosal breaks are confined to the mucosal folds, each no longer than 5mm
what is grade B in the LA classification for oesophagitis used in GORD?
at least one mucosal break longer than 5mm confined to the mucosal folds but not continuous between two folds
what is grade C in the LA classification for oesophagitis used in GORD?
mucosal breaks that are continuous between the tops of mucosal folds but not circumferential
what is grade D in the LA classification for oesophagitis used in GORD?
Grade D: extensive mucosal breaks engaging at least 75% oesophageal circumference.
what lifestyle changes should be advised in a patient with GORD?
Weight loss smoking cessatation small and regular meals less hot drinks reduce caffeine less alcohol less spicy food don't eat at least 3 hours before going to bed
what is the treatment chart for GORD?
- lifestyle advice
- OTC antiacids
- PPI such as omeprezale
- double PPI dose and make twice daily
- H2 receptor antagonist
what are the difference in effects of magnesium vs aluminium antacids?
Magnesium; tend to cause diarrhoea
Aluminium; tend to cause constipation
what are risk factors for GORD?
- obesity
- hiatus hernia
- pregnancy
- delayed gastric motility
- H.pylori
what drugs are a risk factor for gord?
anticholinergic agents
calcium channel blockers
nitrates
what are the two types of hiatus hernia?
80% sliding
15% paraoesophageal/ rolling
what type of hiatus hernia is more likely to cause gord?
sliding as the sphincter is no longer in tact
what is a sliding hiatus hernia?
The gastrooesophageal junction and part of the stomach slide up together into the chest
what is a rolling hiatus hernia?
The stomach squeezes through the hiatus landing next to the oesophagus in the chest
what is dyspepsia?
A term to describe a number of GI symptoms including heart burn, pain, nausea, belching.
how should you investigate dyspepsia?
endoscopy for patients over 55 or those with alarm symptoms
H pylori stool antigen test
what is the tissue change seen in Barrett’s oesophagus?
Squamous epithelium is replaced with metaplastic columnar mucosa
What is the management for low grade dysplasia in Barrett’s oesophagus?
repeat biopsy within 6 months. and give high dose PPI’s.
what is the management for high grade dysplasia in Barrett’s oesophagus?
High dose PPI’s are started and repeat biopsy in 3 months.
what is achalasia?
Impaired LOS relaxation causing foods and liquids to fail to reach the stomach
what is dysphagia?
Difficulty or painful swallowing often due to improper LOS function and aperistalsis
what are clinical features of peptic ulcers?
recurrent burning epigastric pain that is worse at night and when hungry
nausea
anorexia
back pain if posterior penetrating
how can you tell apart gastric and duodenal ulcers on clinical history?
Gastric: worse on eating
Duodenal: eating will relieve pain.The pain will be worse at night and vomiting is uncommon
what are the risk factors for peptic ulcer formation?
- H.pylori
- NSAIDS
- steroids
- zollinger Ellison
- smoking
- alcohol
why is H.pylori a risk factor for ulcer formation?
Secretes urease causing ammonia production weakening the mucosal barrier
why are NSAIDS a risk factor for ulcer formation?
inhibits COX meaning less PGE2 and PGI2
what is a cushings ulcer?
Intracranial disease causing increase in vagal stimulation leading to ulceration from increased acid secretion
A curling ulcer?
A type of duodenal ulcer due to trauma to the body such as burns
what possible tests are there to diagnose H.pylori?
- serological antibody test
- C urea breath test
- stool antigen test
- biopsy urease test
- CLO
- histology staining
how does the serological test for H pylori diagnosis work?
Detects IgG antibodies. Useful in diagnosis but not eradication
what is the C- urea breath test for H.pylori?
Quick and reliable
Ingest C13 urea then measure carbon dioxide levels.
sensitivity affected if taken PPIs/ antibiotics
what is the stool antigen test for H.pylori?
monoclonal antibodies are used for qualititative detection of H.pylori antigen.
Useful for both diagnosis and eradication
Patients should be off PPI’s but can continue H2 antags
what is the invasive biopsy urease test for H.pylori?
antral biopsies are added to urease and phenol red. if there is H.pylori colour change from yellow to red
cant be on antibiotics or PPI’s
what cancer is h.pylori infection associated with?
- gastric adenocarcinoma (distal)
- B cell MALT lymphoma
what is often included in an eradication regime for H pylori?
Two antibiotics with a PPI
what antibiotics can be used in a H.Pylori eradication regime?
Metronidazole
clarithromycin
amoxicillin
tetracycline
what is the medical management of a peptic ulcer?
- if the patient is on an NSAID stop taking it
- give a PPI
at what bilirubin level is jaundice detectable?
3mg/Dl
why is there jaundice in pre-hepatic causes?
An excess amount of bilirubin is presented to the liver due to increased haemolysis
what levels will be in the serum of someone with pre-hepatic jaundice?
Elevated unconjugated bilirubin
why is there jaundic in hepatic causes?
Due to impaired uptake, faulty conjugation or abnormal secretion of bilirubin by the liver cell
what levels will be high in someone with hepatic cause of jaundice?
Both conjugated and unconjugated
what is a cause of pre-hepatic jaundice?
Haemolysis
what are some causes of hepatic jaundice?
Viral hepatitis Cirrhosis Drugs Cholangitis Pregnancy Cholestasis
why is there jaundice in post hepatic causes?
Impaired excretion of conjugated billirubin due to mechanical obstruction
what levels are high in the serum of someone with jaundice due to a post hepatic cause?
Conjugated billirubin
what are some causes of post hepatic jaundice?
- common duct stones
- carcinoma
- biliary sstricture
- sclerosing cholangitis
- pancreatic pseudocyst
how is the urine, stool and skin change in pre- hepatic jaundice?
Normal urine and stool
No pruritis
how is the urine, stool and skin change in hepatic jaundice?
Dark urine, normal stool and no pruritis
how is the urine, stool and skin change in post hepatic jaundice?
Dark urine, acholic pale poop, pruritis
what oher clinical signs can be seen in haemolyic (pre hepatic jaundice)?
- anaemia
- jaundice
- splenomegaly
- leg ulcers
why is there high levels of unconjugated billirubin in gilberts syndrome?
A mutation means reduced levels of UDP glucuronosyl transferase activity. This normally conjugates billirubin
what investigations would you do in someone with jaundice?
- viral markers
- USS
- liver biochemistry
when is AST raised?
acute phase of cellular necrosis
what is disadvantage of suing AST for liver damage?
Non organ specific
what is a raised ALP associated with?
biliary obstruction with cholestasis
what liver function tests are associated with a cholestatic pattern?
billirubin, ALP, GGT
what LFT’s are associated with an inflammatory pattern?
ALT
what is the main route of transmission of Hep A?
Faecal Oral route
what is the main route of transmission of Hep B?
Blood products
Sexual intercourse
Vertical transmission
what is the main transmission of Hep C?
Blood products
Saliva
what is the main route of transmission of hep D?
Blood products mainly
what is the main route of transmission of hep E?
faeco-oral
Large water borne outbreaks
what are complications of chronic hepatitis B or C infection?
- hepatocellular caricnoma
- liver cirrhosis
- liver fibrosis
what are indications for Hep B vaccination?
- healthcare personnel
- haemophilia patients
- CKD
- dialysis
- long term travellers
- MSM
- bisexual men
- more than 1 sexual partner
- sex worker
- IVDU
- diabetics
Why does the increased NADH in alcohol liver disease lead to increased damage?
Due to lactate and malate build up
why does increased NADH in alcohol liver disease lead to an increase in lactate?
To use up the NADH pyruvate is converted to lactate.
why does increased NADH in alcohol liver disease lead to an increase in malate?
Using up the NADH by converting oxacoacetate to malate
why are patients with alcoholic liver disease at risk of hypoglycaemia?
They use up pyruvate and oxaloacetate to get rid of the NADH. This means less gluconeogenesis can take place
why can alcooholic liver disease lead to fatty liver?
- more ehtnaol means more acetate which is broken down to form malonyl CoA Which is a TG precursor
removal of NADH using DHAP leading to glycerol 3 phosphate formation
what two TG precursors are produced in alcoholic liver disease?
malonyl COA
Glycerol 3 phosphate
Why is thiamine deficiency an issue?
There are thiamine dependant enzymes;
- transketolase
- pyruvate dehydrogenase
- alpha ketogluterate
In wernickes there is thiamine deficiency meaning pyruvate dehydrogenase can’t work what does this cause?
A build up of lactate
what is the triad seen in wernickes?
Ataxia
Opthalmoplegia
Nystagmus
As well as thiamine deficiency what other defieincy is often seen in alcoholics?
vit B3
alcoholics can get vit B3 deficienncy how does this present?
Pallega
Redness and swelling of the mouth, tongue.
Skin rash
diarrhoea
what are the stages of alcoholic liver disease?
Fatty iver
Alcoholic hepatitis
Alcoholic cirrhosis
what is the pathology in alcoholic hepatitis?
Fatty change
infiltration of leucocytes and hepatocellular necrosis in zone 3
Mallory bodies
Giant mitochondria
In alcoholic hepatitis mallory bodies are visible what are these?
dense cytoplasmic inclusions suggesting damage
what are the clinical manifestations of fatty liver?
Often no symptoms
Can have nausea and vomiting
what drugs can cause acute hepatitis?
Alcohol Rifampicin Isoniziad Methyldopa Atenolol
what drugs can cause chronic hepatitis??
- methyldopa
- nitrofurantoin
- isoniazid
- fenofibrate
How does paracetomal cause acute hepatotoxicity?
Normally paracetomal is metabolised by glucoronidation and sulfation. Also a little by N hydroxylation forming toxic NAPQI. this is the conjugatied with glutathione to be non toxic
In OD gltathione is saturated and toxic NAPQI builds up
what does the west haven criteria assess?
Impaired mental status mainly for HE
What is your west haven criteria score based on?
impairment in consciousness
intellectual function
behaviour
what is grade 1 in the west haven criteria?
- trivial lack of awareness
shortened attention span
impaired addition
what is grade 2 on the west haven criteria?
ethargy
minimal disorientation in place/time
personality change
inappropriate behaviour
what is grade 3 in the west haven criteria?
- semi stupir but can respond to verbal stimuli
confusion
gross disorientation
what are the three main factors underlying the pathogenesis of ascites?
Low serum albumin
Portal nHypertension
Sodium and water retention
what are causes of straw coloured ascitic fluid?
malignancy cirrhosis TB hepatic vein obstruction chronic pancreatitis constrictive pericarditis nephrotic syndrome
what are causes of chylous coloured ascitic fluid?
obstruction of the main lymphatic duct
cirrhosis
what are causes of haemmorhagic ascites?
malignancy
ruptured ectopic pregnancy
abdo trauma
acute pancreatitis
where in the bowel does crohns affect?
Any part from the mouth to anus
where in the bowel does uc AFFECT?
Starts at the rectum and works up
in what pattern does crohns affect tissue?
Patchy and discontinious
In what pattern does uc affect tissue?
Continious
What layers does inflammation in crohns affect?
transmural
What layer of tissue is affected in UC?
just mucosal
what is the management of UC?
- Proctitis and proctosigmoiditis you give an aminosalicylate
- corticosteroids
- prednisolone
what is the management of crohns?
- monotherapy with prednisolone or hydrocortisone
- can add azathioprine/ mercaptopurine
- consider methotrexate
