Corrections - GI pt. 2 Flashcards by Esme Cosham

What are the 2 most common triggers for autonomic dysreflexia?

1) faecal impaction
2) urinary retention

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Who is autonomic dysreflexia seen in?

patients who have had a spinal cord injury at, or above T6 spinal level

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Notching of the inferior border of the ribs (due to collateral vessels) is seen in what condition?

Coarctation of the aorta (due to collateral vessels)

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What 3 categories can drug induced liver injury (DILI) be divided into?

1) hepatocellular
2) cholestatic
3) mixed

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What drugs tend to cause a hepatocellular picture?

paracetamol
sodium valproate, phenytoin
MAOIs
anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
statins
alcohol
amiodarone
methyldopa
nitrofurantoin

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What is hepatocellular liver injury characterised by?

Elevations in ALT and AST

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What is the pattern of liver injury seen in cholestasis?

Elevated ALP

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What drugs tend to cause a cholestatic picture (+/- hepatitis)?

COCP
Abx e.g. flucloxacillin, co-amoxiclav, erythromycin
anabolic steroids, testosterones
sulphonylureas

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What drugs can cause cirrhosis?

1) methotrexate
2) amiodarone
3) methyldopa

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What is the first serum marker to appear in Hep B?

surface antigen (HBsAg)

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What does HBsAg tend to imply in Hep B infection?

Acute disease (present 1-6 monhts)

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What type of liver injury does paracetamol overdose cause?

hepatocellular picture

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What is best to assess the synthetic function of the liver?

Albumin & prothrombin time.

Prothrombin time has a shorter half-life than albumin, making it a better measure of acute liver failure

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90% of women develop a benign liver cell adenoma in their 30s to 50s.

What is it linked to?

COCP

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What are widespread convulsions without conscious impairment likely to represent?

Pseudoseizure

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Which 3 Abx are associated with cholestasis?

1) flucloxacillin

2) co-amoxiclav

3) erythromycin

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What type of anaemia can alcohol cause?

Normoblastic macrocytic

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What would an isolated rise in GGT in the context of a macrocytic anaemia suggest?

Alcohol excess causing liver problems

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What is the best 1st line management of NAFLD?

Weight loss

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What would indicate an empyema over a malignancy with an exudative pleural fluid?

1) A very low pleural glucose concentration (<1.6 mmol/L) is indicative of empyema

2) as is a pleural fluid pH <7.3

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Management of an empyema?

prompt drainage alongside antibiotic therapy

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Who is autoimmune hepatitis most commonly seen in?

Young females

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What are the 3 types of autoimmune hepatitis? How are they characterised?

Type I
Type II
Type III

Characterised according to the types of circulating antibodies present.

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What Abs are present in type I autoimmune hepatitis?

Who does it affect?

Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)

Affects both adults & children

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What Abs are present in type II autoimmune hepatitis? Who does it affect?

Anti-liver/kidney microsomal type 1 antibodies (LKM1) Affects children only

What Abs are present in type III autoimmune hepatitis? Who does it affect?

Soluble liver-kidney antigen Affects adults in middle age

What malignancies can dermatomyositis be associated with?

typically ovarian, breast and lung cancer, found in 20-25% - more if patient older

What is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease?

Thrombocytopenia

Via what mechanism does alcohol cause polyuria?

Ethanol inhibits ADH secretion

What does SAAG stand for?

Serum-ascites albumin gradient (SAAG).

The cause of ascites can be be grouped into those with a SAAG <11 g/L or a gradient >11g/L. What SAAG indicates portal HTN?

>11 g/l

What are the most common causes of ascites with SAAG >11 g/l?

Liver disorders: - cirrhosis/alcoholic liver disease - acute liver failure - liver mets

How can pregnancy affect LFTs?

can cause raised ALP (due to production by placental tissue)

Surgical options in alpha-1 antitrypsin deficiency affecting the lungs?

lung reduction surgery

Can Alpha1-antitrypsin deficiency be diagnosed prenatally?

Yes - by chorionic villus sampling (CVS) or amniocentesis

What is the most common cause of hypopituitarism?

Non-secretory pituitary macroadenomas

Perinuclear antineutrophil cytoplasmic antibodies (pANCA) are most strongly associated with which condition?

eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

What is the characteristic iron study profile in haemochromatosis?

Raised ferritin Raised transferrin saturation Low TIBC

What are 3 early signs of haemochromatosis in males?

1) ED 2) Fatigue 3) Arthralgia

What is primary biliary cholangitis?

A chronic liver disorder typically seen in middle aged females. Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis which may eventually progress to cirrhosis.

Who primary biliary cholangitis primarily seen in?

middle-aged females

Classic presentation of primary biliary cholangitis?

Itching in a middle aged female

Clinical features of primary biliary cholangitis?

- early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus - cholestatic jaundice - hyperpigmentation, especially over pressure points - around 10% of patients have right upper quadrant pain - xanthelasmas, xanthomata - also: clubbing, hepatosplenomegaly - late: may progress to liver failure

What are 2 measurements used to monitor treatment in haemochromatosis?

1) ferritin 2) transferrin saturation

is haemochromatosis a risk factor for gout?

yes

How does hep A present?

- flu like symptoms - RUQ pain - tender hepatomegaly - deranged LFTs: raised bilirubin, raised ALT/AST, normal or slightly raised ALP

What is acute intermittent porphyria (AIP)?

A rare autosomal dominant condition caused by a defect in porphobilinogen deaminase, an enzyme involved in the biosynthesis of haem. The results in the toxic accumulation of delta aminolaevulinic acid and porphobilinogen.

How does AIP classically present?

Combo of abdo, neuro & psych symptoms in 20-40 year olds: - abdo: pain & vomiting - neuro: motor neuropathy - psych: depression - HTN & tachycardia common

What can cause obstructive jaundice post cholecystectomy?

Common bile duct gallstones --> Around 15% of patients are found to have gallstones in the common bile duct (choledocholithiasis) at the time of cholecystectomy

Investigation of choice for suspected perianal fistulae in patients with Crohn's?

MRI

Are pseudopolyps more commonly seen in UC or Crohn's disease?

1st line in maintain remission in ulcerative colitis patients with proctitis and proctosigmoiditis?

A topical (rectal) aminosalicylate +/- an oral aminosalicylate

1st line in a a mild-moderate flare of ulcerative colitis extending past the left-sided colon?

oral aminosalicylates should be added to rectal aminosalicylates

What condition does diarrhoea + fatigue + osteomalacia indicate?

Coeliac disease

Blood results in osteomalacia?

Low calcium, low phosphate, low vit D, high PTH

What is carcinoid syndrome?

Usually occurs when metastases are present in the liver and release serotonin into the systemic circulation.

What hormone is released in carcinoid syndrome?

Serotonin

What is often the earliest symptom of carcinoid syndrome?

Flushing

1st line investigation in carcinoid syndrome?

urinary 5-HIAA

What is 5-HIAA?

A breakdown product of serotonin

What is the AST/ALT ratio in alcoholic hepatitis?

normally > 2, a ratio of > 3 is strongly suggestive of acute alcoholic hepatitis

What is the most common symptom of Crohn's disease in children?

Abdo pain

How does Coeliac disease cause osteomalacia?

Due to decreased absorption of Vitamin D that occurs, in turn, because of improper functionality of the small intestine.

What are the top 3 genetic diseases that cause liver cirrhosis?

1) A1AT deficiency 2) Wilson's disease 3) Haemochromatosis

What scoring system is used at the initial presentation in suspected upper GI bleeding?

Glasgow Blatchford

What is the diagnostic imaging investigation for primary sclerosing cholangitis?

Magnetic resonance cholangiopancreatography (MRCP)

What antibodies are most specific to primary biliary cholangitis and form part of the diagnostic criteria?

Anti-mitochondrial antibodies (AMA)

What is seen on a liver biopsy in alpha-1 antitrypsin deficiency?

Periodic acid-Schiff positive staining globules in hepatocytes

What scoring system is used to assess the severity of liver cirrhosis and the prognosis?

Child-Pugh score

What 2 scoring systems are available to estimate the degree of liver fibrosis in patients with non-alcoholic fatty liver disease?

1) NAFLD fibrosis score (NFS) 2) Fibrosis 4 (FIB-4) score

What is the inheritance pattern of Wilson’s disease? What gene is affected?

Autosomal recessive Wilson disease protein gene on chromosome 13 (ATP7B copper-binding protein)

What hormone may contribute to the development of focal nodular hyperplasia in the liver?

Oestrogen

How long should the symptoms of irritable bowel syndrome be present before establishing the diagnosis?

At least 6 months

What is seen on examination of jejunal biopsies in coeliac disease? (2)

1) crypt hyperplasia 2) villous atrophy

What 4 features indicate decompensated liver disease (as opposed to compensated)?

1) ascites 2) hepatic encephalopathy 3) bleeding oesophageal varices 4) jaundice

What type of laxative is the first line for constipation in irritable bowel syndrome?

Bulk forming e.g. ispaghula husk

What condition involves duodenal or pancreatic tumour secretes excessive quantities of gastrin, resulting in excessive acid production in the stomach?

Zollinger Ellison syndrome

What genetic condition is associated with developing gastrin-secreting tumours?

Multiple endocrine neoplasia type 1 (MEN1)