Corrections - GI pt. 2 Flashcards
What are the 2 most common triggers for autonomic dysreflexia?
1) faecal impaction
2) urinary retention
Who is autonomic dysreflexia seen in?
patients who have had a spinal cord injury at, or above T6 spinal level
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)
What 3 categories can drug induced liver injury (DILI) be divided into?
1) hepatocellular
2) cholestatic
3) mixed
What drugs tend to cause a hepatocellular picture?
- paracetamol
- sodium valproate, phenytoin
- MAOIs
- anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
- statins
- alcohol
- amiodarone
- methyldopa
- nitrofurantoin
What is hepatocellular liver injury characterised by?
Elevations in ALT and AST
What is the pattern of liver injury seen in cholestasis?
Elevated ALP
What drugs tend to cause a cholestatic picture (+/- hepatitis)?
- COCP
- Abx e.g. flucloxacillin, co-amoxiclav, erythromycin
- anabolic steroids, testosterones
- sulphonylureas
What drugs can cause cirrhosis?
1) methotrexate
2) amiodarone
3) methyldopa
What is the first serum marker to appear in Hep B?
surface antigen (HBsAg)
What does HBsAg tend to imply in Hep B infection?
Acute disease (present 1-6 monhts)
What type of liver injury does paracetamol overdose cause?
hepatocellular picture
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
90% of women develop a benign liver cell adenoma in their 30s to 50s.
What is it linked to?
COCP
What are widespread convulsions without conscious impairment likely to represent?
Pseudoseizure
Which 3 Abx are associated with cholestasis?
1) flucloxacillin
2) co-amoxiclav
3) erythromycin
What type of anaemia can alcohol cause?
Normoblastic macrocytic
What would an isolated rise in GGT in the context of a macrocytic anaemia suggest?
Alcohol excess causing liver problems
What is the best 1st line management of NAFLD?
Weight loss
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
Management of an empyema?
prompt drainage alongside antibiotic therapy
Who is autoimmune hepatitis most commonly seen in?
Young females
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.
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
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?
UC
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)
