Case 4 - Change In Bowel Habit Flashcards
Differential diagnosis of colitis
Infectious - bacterial i.e. E. coli, diverticulitis
Inflammatory - IBD, Ischaemic
Cancer?
What is pancolitis?
Inflammation of the whole colon
What is the most common cause of pancolitis?
Ulcerative colitis
Pancolitis is usually caused by UC, what are other causes?
C. difficile, rheumatoid arthritis
Ulcerative colitis VS Crohn’s disease
Which one has ‘skip’ lesions?
Crohn’s disease
UC has continuous segments
Ulcerative colitis VS Crohn’s disease
Which one has ‘mucosal inflammation’
UC
Crohn’s has transmural inflammation
Ulcerative colitis VS Crohn’s disease
Which one has ‘granulomas?’
Crohn’s - UC does not have granulomas
Ulcerative colitis VS Crohn’s disease
Which one has ‘fistulae’?
Crohn’s has fistulae
Ulcerative colitis VS Crohn’s disease
Which one is in colon only?
UC - Crohn’s disease is anywhere in GIT
Fistulae is a common complication of what IBD?
Crohn’s
How to treat a fistulae associated with Crohn’s
Treat any infection
Remove distal obstruction
Reduce flow
(Rehydrate)
Management of Fistula mnemonic - SNAP
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
Extraintestinal manifestations - aphthous ulcers - which IBD?
Crohn’s
Pyoderma gangrenosum is a potential complication of both IBD types (more common in UC) - what is it?
Lesions in skin filled with pus, ulcer has indistinct edges and a unique purplish colour
Painful and slow to heal
Erythema nodosum is a skin condition that most often affects people with …
Crohn’s disease
What is this showing?
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
What is episcleritis?
Persistent irritated red eye - discomfort, not severe pain
No visual change
Vessels mobile over sclera
Usually localised
What is the most common eye manifestation of IBD?
Episcleritis - persistent red irritated eye, no vision loss, usually localised
What is neutropenic sepsis?
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
Neutropenic sepsis is a complication of what treatments?
Immunosuppressive drugs and anti cancer treatment
Define septic shock
Sepsis with hypotension not responsive to 20ml/kg or requiring vasopressors
Define sepsis
Life-threatening organ dysfunction (medical emergency) caused by a dysregulated host response to infection
Severe sepsis - define
Sepsis with Organ dysfunction or high lactate
Sepsis 6
Take - blood cultures, lactate and Hb, urine output
Give - oxygen, antibiotics, fluid challenge
Types of shock:
Cardio genie, hypovolaemic, obstructive, distributive (septic, anaphylactic, neurogenic)
3 types of distributive shock
Septic, anaphylactic, neurogenic shock
Neutropenic sepsis - what bacteria is it? And how do we treat?
Gram + or negative bacteria
Broad spectrum antibiotics
Anti-fungals +/-
Primary sclerosing cholangitis is associated with …
Ulcerative colitis
‘Beads on a string’ appearance is seen in a cholangiogram in what condition?
Primary sclerosing cholangitis
What is a cholangiogram?
X-ray of bile ducts
Abnormal LFTS - Hepatitic vs cholestatic
Hepatitic = very high ALT/AST, slightly high ASP/bilirubin/GGT Cholestatic = very high ALP/bilirubin/GGT, slightly high ALT/AST
… = very high ALT/AST, slightly high ASP/bilirubin/GGT … = very high ALP/bilirubin/GGT, slightly high ALT/AST
Hepatitic = very high ALT/AST, slightly high ASP/bilirubin/GGT Cholestatic = very high ALP/bilirubin/GGT, slightly high ALT/AST
ALT>AST is associated with what?
Chronic liver disease
AST>ALT is associated with … and …
Cirrhosis and acute alcoholic hepatitis
Common causes of acute hepatocellular injury (3)
Poisoning i.e. paracetamol overdose
Infection (Hep A/B)
Liver Ischaemia
Common causes of chronic hepatocellular injury (3)
Alcoholic fatty liver disease
Non-alcoholic fatty liver disease
Chronic infection (Hep B/C)
Primary biliary cirrhosis
What is prothrombin time? (PT)
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
Albumin levels can fall due to:
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
Bilirubin is a breakdown product of what?
Haemoglobin
Jaundice usually occurs when bilirubin levels are …
> 60umol/L
Darker urine indicates the patient has … hyperbilirubinaemia
Conjugated - as this can pass into the urine as urobilinogen
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 …
Pale, bulky and more difficult to flush
Normal stools + normal urine = … hepatic cause of jaundice
Pre hepatic cause
Normal stools + dark urine = … hepatic cause of jaundice
Hepatic cause
Pale stools + dark urine = … hepatic cause of jaundice
Post-hepatic cause (obstructive)
Causes of unconjugated hyperbilirubinaemia include:
Haemolytic (e.g. haemolytic anaemia)
Impaired hepatic uptake (E.g. drugs, congestive cardiac failure)
Impaired conjugation (e.g. Gilbert’s syndrome)
Causes of conjugated hyperbilirubinaemia include:
Hepatocellular injury
Cholestasis
The liver’s main functions are … (4)
Conjugation and elimination of bilirubin
Synthesis of albumin
Synthesis of clotting factors
Gluconeogenesis
If the patient is jaundiced but ALT and ALP levels are normal - it is suggestive of a … cause of jaundice
Pre-hepatic
Causes of an isolated rise in bilirubin include:
Gilbert’s syndrome: the most common cause
Haemolysis - check a blood film, full blood count, reticulocyte count, haptoglobin and LDH levels to confirm
A greater than 10-fold increase in ALT and a less than 3-fold increase in ALP suggests a predominantly … injury
Hepatocellular injury
A less than 10-fold increase in ALT and a more than 3-fold increase in ALP suggests …
Cholestasis
Is it possible to have a mixed picture of hepatocellular injury and Cholestasis?
Yes
If there is a rise in ALP, it is important to review the level of GGT also - why?
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.
A markedly raised ALP with a raised GGT is highly suggestive of …
Cholestasis
Causes of an isolated rise in ALP include:
Bony metastases or primary bone tumours
Vitamin D deficiency
Recent bone fractures
Renal osteodystrophy
… is found in high concentrations within hepatocytes and enters the blood following hepatocellular injury.
ALT
… 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.
ALP - so it is a useful indirect marker of Cholestasis
If the ALT is raised decide if this is a more than a … fold rise of less than a … fold rise
10 fold (more or less)
If the ALP is raised decide if this is a more than a … fold rise of less than a … fold rise
3 fold rise (more or less)
ALT, AST, ALP and GGT are used to distinguish between … damage and ….
hepatocellular damage and Cholestasis
Bilirubin, albumin and PT are used to assess what?
Livers synthetic function
What blood tests are used to assess liver function?
ALT AST ALP GGT Bilirubin Albumin Prothrombin time (PT)
In pre-hepatic jaundice, there is excessive red blood cell breakdown which leads to what?
Overwhelms the livers ability to conjugate bilirubin - causing an unconjugated hyperbilirubinaemia
Hepatocellular jaundice - dysfunction of hepatic cells - bilirubin is …
Mixed - both conjugated and unconjugated
Post-hepatic jaundice refers to obstruction of biliary drainage - so the result is ..
Conjugated hyperbilirubinaemia
Differential diagnosis of abnormal LFTS (hepatitic)
Alcoholic fatty liver disease
Non alcoholic fatty liver disease
Viral hepatitis
Paracetamol overdose
Differential diagnosis of abnormal LFTS (cholestatic)
Gallstones Drugs Primary sclerosing cholangitis Primary biliary cirrhosis Cancer
What is primary biliary cirrhosis (cholangitis)?
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.
Key diagnostic factors in primary biliary cirrhosis (cholangitis) - age and sex
Typically female sex, age 45-60years
Which condition is largely associated with IBD?
- Primary sclerosing cholangitis? Or Primary biliary cirrhosis?
Primary sclerosing cholangitis - usually have a history of IBD, male sex more common, age in 40s/50s
Primary biliary cholangitis vs primary sclerosing cholangitis - key diagnostic factors
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
Will people with primary biliary cholangitis have a normal cholangiogram?
Usually it is normal but hard to distinguish from intrahepatic PSC
What autoantibody is present in 95% of those with primary biliary cholangitis?
Antimitochondrial autoantibody is present in 95% of cases
The classic histopathological finding of … is presence of periductal concentric “onion skin” fibrosis
Primary sclerosing cholangitis
Someone that is thin, but not cachectic is less likely to have what?
Crohn’s with ileitis and malabsorption
Neutrophil count of 0.1 is suggestive of …
Agranulocytosis- can be due to side effects of immunosuppressive drugs or anti cancer therapy
‘Onion skin’ fibrosis =
Cirrhosis due to PSC
Tender brushes on skin - usually shins indicates …
Erythema nodosum
‘Skip lesions’ on colonoscopy and transmural inflammation with granulomas =
Crohn’s disease
Positive antimitochondrial antibody =
Primary biliary cirrhosis
‘Beads on a string’ appearance on ERCP =
Primary sclerosing cholangitis
Abdominal distension in acute colitis - important to do an abdominal X-ray to look for what?
Toxic mega colon - dilated transverse colon - it is life-threatening
Ursodeoxycholic acid is used to help … drainage in patients with PSC and PBS
Bile drainage
