Case 4 - Change In Bowel Habit

Question 1

Differential diagnosis of colitis

Answer 1

Infectious - bacterial i.e. E. coli, diverticulitis
Inflammatory - IBD, Ischaemic
Cancer?

Question 2

What is pancolitis?

Answer 2

Inflammation of the whole colon

Question 3

What is the most common cause of pancolitis?

Answer 3

Ulcerative colitis

Question 4

Pancolitis is usually caused by UC, what are other causes?

Answer 4

C. difficile, rheumatoid arthritis

Question 5

Ulcerative colitis VS Crohn’s disease

Which one has ‘skip’ lesions?

Answer 5

Crohn’s disease

UC has continuous segments

Question 6

Ulcerative colitis VS Crohn’s disease

Which one has ‘mucosal inflammation’

Answer 6

UC

Crohn’s has transmural inflammation

Question 7

Ulcerative colitis VS Crohn’s disease

Which one has ‘granulomas?’

Answer 7

Crohn’s - UC does not have granulomas

Question 8

Ulcerative colitis VS Crohn’s disease

Which one has ‘fistulae’?

Answer 8

Crohn’s has fistulae

Question 9

Ulcerative colitis VS Crohn’s disease

Which one is in colon only?

Answer 9

UC - Crohn’s disease is anywhere in GIT

Question 10

Fistulae is a common complication of what IBD?

Answer 10

Crohn’s

Question 11

How to treat a fistulae associated with Crohn’s

Answer 11

Treat any infection
Remove distal obstruction
Reduce flow
(Rehydrate)

Question 12

Management of Fistula mnemonic - SNAP

Answer 12

S = Sepsis - identify whether there is sepsis and it’s source, manage appropriately
N = Nutrition - optimise oral and/or enteral intake
Initiate parenteral nutrition if appropriate
A = Anatomical Mapping
P = Plan for potential surgical intervention

Question 13

Extraintestinal manifestations - aphthous ulcers - which IBD?

Answer 13

Crohn’s

Question 14

Pyoderma gangrenosum is a potential complication of both IBD types (more common in UC) - what is it?

Answer 14

Lesions in skin filled with pus, ulcer has indistinct edges and a unique purplish colour
Painful and slow to heal

Question 15

Erythema nodosum is a skin condition that most often affects people with …

Answer 15

Crohn’s disease

Question 16

What is this showing?

Answer 16

Erythema nodosum - an inflammatory condition characterised by inflammation of the fat cells under the skin, resulting in tender red nodules or lumps that are usually seen on both shins. Typically seen in Crohn’s (15% develop this), also idiopathic causes and some infections, medications, autoimmune disorders and potentially pregnancy

Question 17

What is episcleritis?

Answer 17

Persistent irritated red eye - discomfort, not severe pain
No visual change
Vessels mobile over sclera
Usually localised

Question 18

What is the most common eye manifestation of IBD?

Answer 18

Episcleritis - persistent red irritated eye, no vision loss, usually localised

Question 19

What is neutropenic sepsis?

Answer 19

Potentially life-threatening complication of neutropenia (low neutrophil count)
Complication of anti cancer or immunosuppressive drug treatment
Temp of greater than 38 and any symptoms/signs of sepsis, in a person with a neutrophil count of 0.5 x 10^9/L or lower

Question 20

Neutropenic sepsis is a complication of what treatments?

Answer 20

Immunosuppressive drugs and anti cancer treatment

Question 21

Define septic shock

Answer 21

Sepsis with hypotension not responsive to 20ml/kg or requiring vasopressors

Question 22

Define sepsis

Answer 22

Life-threatening organ dysfunction (medical emergency) caused by a dysregulated host response to infection

Question 23

Severe sepsis - define

Answer 23

Sepsis with Organ dysfunction or high lactate

Question 24

Sepsis 6

Answer 24

Take - blood cultures, lactate and Hb, urine output

Give - oxygen, antibiotics, fluid challenge

Question 25

Types of shock:

Answer 25

Cardio genie, hypovolaemic, obstructive, distributive (septic, anaphylactic, neurogenic)

Question 26

3 types of distributive shock

Answer 26

Septic, anaphylactic, neurogenic shock

Question 27

Neutropenic sepsis - what bacteria is it? And how do we treat?

Answer 27

Gram + or negative bacteria Broad spectrum antibiotics Anti-fungals +/-

Question 28

Primary sclerosing cholangitis is associated with …

Answer 28

Ulcerative colitis

Question 29

‘Beads on a string’ appearance is seen in a cholangiogram in what condition?

Answer 29

Primary sclerosing cholangitis

Question 30

What is a cholangiogram?

Answer 30

X-ray of bile ducts

Question 31

Abnormal LFTS - Hepatitic vs cholestatic

Answer 31

``` Hepatitic = very high ALT/AST, slightly high ASP/bilirubin/GGT Cholestatic = very high ALP/bilirubin/GGT, slightly high ALT/AST ```

Question 32

``` … = very high ALT/AST, slightly high ASP/bilirubin/GGT … = very high ALP/bilirubin/GGT, slightly high ALT/AST ```

Answer 32

``` Hepatitic = very high ALT/AST, slightly high ASP/bilirubin/GGT Cholestatic = very high ALP/bilirubin/GGT, slightly high ALT/AST ```

Question 33

ALT>AST is associated with what?

Answer 33

Chronic liver disease

Question 34

AST>ALT is associated with … and …

Answer 34

Cirrhosis and acute alcoholic hepatitis

Question 35

Common causes of acute hepatocellular injury (3)

Answer 35

Poisoning i.e. paracetamol overdose Infection (Hep A/B) Liver Ischaemia

Question 36

Common causes of chronic hepatocellular injury (3)

Answer 36

Alcoholic fatty liver disease Non-alcoholic fatty liver disease Chronic infection (Hep B/C) Primary biliary cirrhosis

Question 37

What is prothrombin time? (PT)

Answer 37

Prothrombin time is a measure of the blood’s coagulation tendency, specifically assessing the extrinsic pathway. In the absence of other secondary causes such as anticoagulant drug use and vitamin K deficiency, an increased PT can indicate liver disease and dysfunction. The liver is responsible for the synthesis of clotting factors, therefore hepatic pathology can impair this process resulting in increased prothrombin time

Question 38

Albumin levels can fall due to:

Answer 38

Liver disease resulting in a decreased production of albumin (e.g. cirrhosis) Inflammation triggering an acute phase response which temporarily decreases the liver’s production of albumin Excessive lots of albumin due to protein-losing enteropathies or nephrotic syndrome

Question 39

Bilirubin is a breakdown product of what?

Answer 39

Haemoglobin

Question 40

Jaundice usually occurs when bilirubin levels are …

Answer 40

>60umol/L

Question 41

Darker urine indicates the patient has … hyperbilirubinaemia

Answer 41

Conjugated - as this can pass into the urine as urobilinogen

Question 42

The stool colour can help to differentiate the causes of jaundice - if bile and pancreatic lipases are not able to reach the bowel due to blockage, fat is not absorbed, meaning the stool is …

Answer 42

Pale, bulky and more difficult to flush

Question 43

Normal stools + normal urine = … hepatic cause of jaundice

Answer 43

Pre hepatic cause

Question 44

Normal stools + dark urine = … hepatic cause of jaundice

Answer 44

Hepatic cause

Question 45

Pale stools + dark urine = … hepatic cause of jaundice

Answer 45

Post-hepatic cause (obstructive)

Question 46

Causes of unconjugated hyperbilirubinaemia include:

Answer 46

Haemolytic (e.g. haemolytic anaemia) Impaired hepatic uptake (E.g. drugs, congestive cardiac failure) Impaired conjugation (e.g. Gilbert’s syndrome)

Question 47

Causes of conjugated hyperbilirubinaemia include:

Answer 47

Hepatocellular injury | Cholestasis

Question 48

The liver’s main functions are … (4)

Answer 48

Conjugation and elimination of bilirubin Synthesis of albumin Synthesis of clotting factors Gluconeogenesis

Question 49

If the patient is jaundiced but ALT and ALP levels are normal - it is suggestive of a … cause of jaundice

Answer 49

Pre-hepatic

Question 50

Causes of an isolated rise in bilirubin include:

Answer 50

Gilbert’s syndrome: the most common cause | Haemolysis - check a blood film, full blood count, reticulocyte count, haptoglobin and LDH levels to confirm

Question 51

A greater than 10-fold increase in ALT and a less than 3-fold increase in ALP suggests a predominantly … injury

Answer 51

Hepatocellular injury

Question 52

A less than 10-fold increase in ALT and a more than 3-fold increase in ALP suggests …

Answer 52

Cholestasis

Question 53

Is it possible to have a mixed picture of hepatocellular injury and Cholestasis?

Answer 53

Yes

Question 54

If there is a rise in ALP, it is important to review the level of GGT also - why?

Answer 54

A raised GGT can be suggestive of biliary epithelial damage and bile flow obstruction. It can also be raised in response to alcohol and drugs such as phenytoin. A markedly raised ALP with a raised GGT is highly suggestive of Cholestasis.

Question 55

A markedly raised ALP with a raised GGT is highly suggestive of …

Answer 55

Cholestasis

Question 56

Causes of an isolated rise in ALP include:

Answer 56

Bony metastases or primary bone tumours Vitamin D deficiency Recent bone fractures Renal osteodystrophy

Question 57

… is found in high concentrations within hepatocytes and enters the blood following hepatocellular injury.

Answer 57

ALT

Question 58

… is particularly concentrated in the liver, bile duct and bone tissues. It is often raised in liver pathology due to increased synthesis in response to Cholestasis.

Answer 58

ALP - so it is a useful indirect marker of Cholestasis

Question 59

If the ALT is raised decide if this is a more than a … fold rise of less than a … fold rise

Answer 59

10 fold (more or less)

Question 60

If the ALP is raised decide if this is a more than a … fold rise of less than a … fold rise

Answer 60

3 fold rise (more or less)

Question 61

ALT, AST, ALP and GGT are used to distinguish between … damage and ….

Answer 61

hepatocellular damage and Cholestasis

Question 62

Bilirubin, albumin and PT are used to assess what?

Answer 62

Livers synthetic function

Question 63

What blood tests are used to assess liver function?

Answer 63

``` ALT AST ALP GGT Bilirubin Albumin Prothrombin time (PT) ```

Question 64

In pre-hepatic jaundice, there is excessive red blood cell breakdown which leads to what?

Answer 64

Overwhelms the livers ability to conjugate bilirubin - causing an unconjugated hyperbilirubinaemia

Question 65

Hepatocellular jaundice - dysfunction of hepatic cells - bilirubin is …

Answer 65

Mixed - both conjugated and unconjugated

Question 66

Post-hepatic jaundice refers to obstruction of biliary drainage - so the result is ..

Answer 66

Conjugated hyperbilirubinaemia

Question 67

Differential diagnosis of abnormal LFTS (hepatitic)

Answer 67

Alcoholic fatty liver disease Non alcoholic fatty liver disease Viral hepatitis Paracetamol overdose

Question 68

Differential diagnosis of abnormal LFTS (cholestatic)

Answer 68

``` Gallstones Drugs Primary sclerosing cholangitis Primary biliary cirrhosis Cancer ```

Question 69

What is primary biliary cirrhosis (cholangitis)?

Answer 69

A chronic disease of the small intrahepatic bile ducts that is characterised by progressive bile duct damage (and eventual loss) occurring in the context of chronic portal tract inflammation. Fibrosis develops as a consequence of the original insult and the secondary effects of toxic bile acids retained in the liver, resulting ultimately in cirrhosis. The almost universal presence of autoantibodies in PBC patients (classically anti-mitochondrial antibodies) has led to the widely held view that the disease has an autoimmune component to its aetiology.

Question 70

Key diagnostic factors in primary biliary cirrhosis (cholangitis) - age and sex

Answer 70

Typically female sex, age 45-60years

Question 71

Which condition is largely associated with IBD? | - Primary sclerosing cholangitis? Or Primary biliary cirrhosis?

Answer 71

Primary sclerosing cholangitis - usually have a history of IBD, male sex more common, age in 40s/50s

Question 72

Primary biliary cholangitis vs primary sclerosing cholangitis - key diagnostic factors

Answer 72

Primary biliary cholangitis predominantly affects middle-aged women and is not associated with IBD, whereas primary sclerosing cholangitis typically in men and with people with a history of IBD

Question 73

Will people with primary biliary cholangitis have a normal cholangiogram?

Answer 73

Usually it is normal but hard to distinguish from intrahepatic PSC

Question 74

What autoantibody is present in 95% of those with primary biliary cholangitis?

Answer 74

Antimitochondrial autoantibody is present in 95% of cases

Question 75

The classic histopathological finding of … is presence of periductal concentric “onion skin” fibrosis

Answer 75

Primary sclerosing cholangitis

Question 76

Someone that is thin, but not cachectic is less likely to have what?

Answer 76

Crohn’s with ileitis and malabsorption

Question 77

Neutrophil count of 0.1 is suggestive of …

Answer 77

Agranulocytosis- can be due to side effects of immunosuppressive drugs or anti cancer therapy

Question 78

‘Onion skin’ fibrosis =

Answer 78

Cirrhosis due to PSC

Question 79

Tender brushes on skin - usually shins indicates …

Answer 79

Erythema nodosum

Question 80

‘Skip lesions’ on colonoscopy and transmural inflammation with granulomas =

Answer 80

Crohn’s disease

Question 81

Positive antimitochondrial antibody =

Answer 81

Primary biliary cirrhosis

Question 82

‘Beads on a string’ appearance on ERCP =

Answer 82

Primary sclerosing cholangitis

Question 83

Abdominal distension in acute colitis - important to do an abdominal X-ray to look for what?

Answer 83

Toxic mega colon - dilated transverse colon - it is life-threatening

Question 84

Ursodeoxycholic acid is used to help … drainage in patients with PSC and PBS

Answer 84

Bile drainage