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One-2-One Medicine Clinical Case Masterclass > Case 4 - Change In Bowel Habit > Flashcards

Case 4 - Change In Bowel Habit Flashcards

1
Q

Differential diagnosis of colitis

A

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

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2
Q

What is pancolitis?

A

Inflammation of the whole colon

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3
Q

What is the most common cause of pancolitis?

A

Ulcerative colitis

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4
Q

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

A

C. difficile, rheumatoid arthritis

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5
Q

Ulcerative colitis VS Crohn’s disease

Which one has ‘skip’ lesions?

A

Crohn’s disease

UC has continuous segments

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6
Q

Ulcerative colitis VS Crohn’s disease

Which one has ‘mucosal inflammation’

A

UC

Crohn’s has transmural inflammation

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7
Q

Ulcerative colitis VS Crohn’s disease

Which one has ‘granulomas?’

A

Crohn’s - UC does not have granulomas

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8
Q

Ulcerative colitis VS Crohn’s disease

Which one has ‘fistulae’?

A

Crohn’s has fistulae

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9
Q

Ulcerative colitis VS Crohn’s disease

Which one is in colon only?

A

UC - Crohn’s disease is anywhere in GIT

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10
Q

Fistulae is a common complication of what IBD?

A

Crohn’s

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11
Q

How to treat a fistulae associated with Crohn’s

A

Treat any infection
Remove distal obstruction
Reduce flow
(Rehydrate)

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12
Q

Management of Fistula mnemonic - SNAP

A

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

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13
Q

Extraintestinal manifestations - aphthous ulcers - which IBD?

A

Crohn’s

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14
Q

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

A

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

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15
Q

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

A

Crohn’s disease

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16
Q

What is this showing?

A

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

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17
Q

What is episcleritis?

A

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

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18
Q

What is the most common eye manifestation of IBD?

A

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

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19
Q

What is neutropenic sepsis?

A

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

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20
Q

Neutropenic sepsis is a complication of what treatments?

A

Immunosuppressive drugs and anti cancer treatment

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21
Q

Define septic shock

A

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

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22
Q

Define sepsis

A

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

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23
Q

Severe sepsis - define

A

Sepsis with Organ dysfunction or high lactate

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24
Q

Sepsis 6

A

Take - blood cultures, lactate and Hb, urine output

Give - oxygen, antibiotics, fluid challenge

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25
Q

Types of shock:

A

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

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26
Q

3 types of distributive shock

A

Septic, anaphylactic, neurogenic shock

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27
Q

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

A

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

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28
Q

Primary sclerosing cholangitis is associated with …

A

Ulcerative colitis

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29
Q

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

A

Primary sclerosing cholangitis

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30
Q

What is a cholangiogram?

A

X-ray of bile ducts

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31
Q

Abnormal LFTS - Hepatitic vs cholestatic

A 
Hepatitic = very high ALT/AST, slightly high ASP/bilirubin/GGT
Cholestatic = very high ALP/bilirubin/GGT, slightly high ALT/AST
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32
Q 
… = very high ALT/AST, slightly high ASP/bilirubin/GGT
… = very high ALP/bilirubin/GGT, slightly high ALT/AST
A 
Hepatitic = very high ALT/AST, slightly high ASP/bilirubin/GGT
Cholestatic = very high ALP/bilirubin/GGT, slightly high ALT/AST
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33
Q

ALT>AST is associated with what?

A

Chronic liver disease

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34
Q

AST>ALT is associated with … and …

A

Cirrhosis and acute alcoholic hepatitis

35
Q

Common causes of acute hepatocellular injury (3)

A

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

36
Q

Common causes of chronic hepatocellular injury (3)

A

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

37
Q

What is prothrombin time? (PT)

A

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

38
Q

Albumin levels can fall due to:

A

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

39
Q

Bilirubin is a breakdown product of what?

A

Haemoglobin

40
Q

Jaundice usually occurs when bilirubin levels are …

A

> 60umol/L

41
Q

Darker urine indicates the patient has … hyperbilirubinaemia

A

Conjugated - as this can pass into the urine as urobilinogen

42
Q

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 …

A

Pale, bulky and more difficult to flush

43
Q

Normal stools + normal urine = … hepatic cause of jaundice

A

Pre hepatic cause

44
Q

Normal stools + dark urine = … hepatic cause of jaundice

A

Hepatic cause

45
Q

Pale stools + dark urine = … hepatic cause of jaundice

A

Post-hepatic cause (obstructive)

46
Q

Causes of unconjugated hyperbilirubinaemia include:

A

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

47
Q

Causes of conjugated hyperbilirubinaemia include:

A

Hepatocellular injury

Cholestasis

48
Q

The liver’s main functions are … (4)

A

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

49
Q

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

A

Pre-hepatic

50
Q

Causes of an isolated rise in bilirubin include:

A

Gilbert’s syndrome: the most common cause

Haemolysis - check a blood film, full blood count, reticulocyte count, haptoglobin and LDH levels to confirm

51
Q

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

A

Hepatocellular injury

52
Q

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

A

Cholestasis

53
Q

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

A

Yes

54
Q

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

A

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.

55
Q

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

A

Cholestasis

56
Q

Causes of an isolated rise in ALP include:

A

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

57
Q

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

A

ALT

58
Q

… 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.

A

ALP - so it is a useful indirect marker of Cholestasis

59
Q

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

A

10 fold (more or less)

60
Q

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

A

3 fold rise (more or less)

61
Q

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

A

hepatocellular damage and Cholestasis

62
Q

Bilirubin, albumin and PT are used to assess what?

A

Livers synthetic function

63
Q

What blood tests are used to assess liver function?

A 
ALT
AST
ALP
GGT
Bilirubin
Albumin
Prothrombin time (PT)
64
Q

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

A

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

65
Q

Hepatocellular jaundice - dysfunction of hepatic cells - bilirubin is …

A

Mixed - both conjugated and unconjugated

66
Q

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

A

Conjugated hyperbilirubinaemia

67
Q

Differential diagnosis of abnormal LFTS (hepatitic)

A

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

68
Q

Differential diagnosis of abnormal LFTS (cholestatic)

A 
Gallstones
Drugs
Primary sclerosing cholangitis
Primary biliary cirrhosis
Cancer
69
Q

What is primary biliary cirrhosis (cholangitis)?

A

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.

70
Q

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

A

Typically female sex, age 45-60years

71
Q

Which condition is largely associated with IBD?

- Primary sclerosing cholangitis? Or Primary biliary cirrhosis?

A

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

72
Q

Primary biliary cholangitis vs primary sclerosing cholangitis - key diagnostic factors

A

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

73
Q

Will people with primary biliary cholangitis have a normal cholangiogram?

A

Usually it is normal but hard to distinguish from intrahepatic PSC

74
Q

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

A

Antimitochondrial autoantibody is present in 95% of cases

75
Q

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

A

Primary sclerosing cholangitis

76
Q

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

A

Crohn’s with ileitis and malabsorption

77
Q

Neutrophil count of 0.1 is suggestive of …

A

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

78
Q

‘Onion skin’ fibrosis =

A

Cirrhosis due to PSC

79
Q

Tender brushes on skin - usually shins indicates …

A

Erythema nodosum

80
Q

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

A

Crohn’s disease

81
Q

Positive antimitochondrial antibody =

A

Primary biliary cirrhosis

82
Q

‘Beads on a string’ appearance on ERCP =

A

Primary sclerosing cholangitis

83
Q

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

A

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

84
Q

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

A

Bile drainage

One-2-One Medicine Clinical Case Masterclass (25 decks)

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