Gastro Flashcards
1
Q
Primary Sclerosing Cholangitis
what is it
A
the intrahepatic or extrahepatic ducts become strictured + fibrotic
2
Q
Primary Sclerosing Cholangitis
pathophysiology
A
strictured + fibrotic intrahepatic or extrahepatic ducts
obstruction to flow of bile out liver and into intestines
chronic bile obstruction leads to hepatitis, fibrosis and cirrhosis
3
Q
Primary Sclerosing Cholangitis
what does sclerosis refer to
A
stiffening and hardening of the bile ducts
4
Q
Primary Sclerosing Cholangitis
what does cholangitis refer to
A
inflammation of the bile ducts
5
Q
Primary Sclerosing Cholangitis
what condition is it associated with
A
ulcerative colitis
6
Q
Primary Sclerosing Cholangitis
cause
A
unclear but probs a combination of:
- genetic
- autoimmune
- intestinal microbiome
- environmental factors
7
Q
Primary Sclerosing Cholangitis
RFs (4)
A
- male
- aged 30-40
- ulcerative colitis
- FH
8
Q
Primary Sclerosing Cholangitis
presentation (5)
A
- jaundice
- chronic RUQ pain
- pruritis
- fatigue
- hepatomegaly
9
Q
Primary Sclerosing Cholangitis
what will LFTs show
A
a ‘cholestatic’ picture
ALP is the most deranged
10
Q
Primary Sclerosing Cholangitis
LFTs: why may there be a rise in bilirubin
A
as the strictures become more severe and prevents bilirubin from being excreted through the bile duct
11
Q
Primary Sclerosing Cholangitis
LFTs: why may other LFTs apart from ALP be deranged
A
as the disease progresses to hepatitis
12
Q
Primary Sclerosing Cholangitis
are there any antibodies which are highly sensitive or specific to PSC
A
no but can indicate where there is an autoimmune element that may respond to immunosuppression
13
Q
Primary Sclerosing Cholangitis
which autoantibodies may be present
A
p-ANCA (94%)
ANA (77%)
aCL (63%) - anticardiolipid
14
Q
Primary Sclerosing Cholangitis
gold standard inx for dx
A
MRCP - magnetic resonance cholangiopancreatography (MRI scan of the liver, bile ducts and pancreas)
15
Q
Primary Sclerosing Cholangitis
what will the MRCP show
A
may show bile duct lesions or strictures
16
Q
Primary Sclerosing Cholangitis
associations and complications
A
- acute bacterial cholangitis
- cholangiocarcinoma
- colorectal cancer
- cirrhosis and liver failure
- biliary strictures
- fat soluble vitamin deficiencies
17
Q
Primary Sclerosing Cholangitis
mnx
A
- liver transplant
- ERCP
- Colestyramine
18
Q
Primary Sclerosing Cholangitis
mnx: what is ERCP
A
endoscopic retrograde cholangio-pancreatography
insert camera through throat through to bile ducts.
Use X-rays and injecting contrast to identify any strictures
stented
19
Q
Primary Sclerosing Cholangitis
mnx: what is colestyramine
A
a bile acid sequestrate: binds to bile acids to prevent absorption in the gut
can help with pruritus due to raised bile acids
20
Q
Primary Biliary Cirrhosis
what is it
A
the immune system attacks the small bile ducts within the liver
21
Q
Primary Biliary Cirrhosis
how does it lead to fibrosis, cirrhosis and liver failure
A
immune system attacks the intralobar ducts (aka Canals of Hering)
this causes obstruction of the outflow of bile (cholestasis)
back pressure of bile obstruction leads to fibrosis
22
Q
Primary Biliary Cirrhosis
what causes itching
A
obstruction to the outflow of bile acids so they build up in the blood as they are not being excreted
23
Q
Primary Biliary Cirrhosis
what causes jaundice
A
obstruction to the outflow of biliruibin so they build up in the blood as they are not being excreted
24
Q
Primary Biliary Cirrhosis
what causes raised cholesterol
A
obstruction to the outflow of cholesterol so they build up in the blood as they are not being excreted
25
Primary Biliary Cirrhosis
what is the name for cholesterol deposits in the skin
xanthelasma
26
Primary Biliary Cirrhosis
why is there increased risk of CVD
cholesterol deposits in blood vessels
27
Primary Biliary Cirrhosis
why are there greasy stools
lack of bile acids --> fat not digested
28
Primary Biliary Cirrhosis
why are there pale stools
lack of biliruibin
biliruibin normally causes the dark colour of stool
29
Primary Biliary Cirrhosis
presentation
- fatigue
- pruritis
- GI disturbance + abdo pain
- jaundice
- pale stools
- xanthoma + xanthelasma
- signs of cirrhosis + failure (ascites, splenomegaly, spider naevi)
30
Primary Biliary Cirrhosis
what is xanthoma
larger nodular cholesterol deposits in the skin or tendons
31
Primary Biliary Cirrhosis
associations (3)
- middle aged women
- autoimmune disease (thyroid, coeliac)
- rheumatoid conditions (systemic sclerosis, Sjogrens + RA)
32
Primary Biliary Cirrhosis
LFT result
cholestatic picture
ALP raised first, then others + biliruibin raised in later disease
33
Primary Biliary Cirrhosis
what it the most specific autoantibody to PBC and forms part of the diagnostic criteria
anti-mitochondrial antibodies
34
Primary Biliary Cirrhosis
autoantibodies
anti-mitochondrial antibodies (most specific)
ANA (35%)
35
Primary Biliary Cirrhosis
what inx is used for diagnosis and staging
liver biopsy
36
Primary Biliary Cirrhosis
what will other blood tests show (apart from LFTs)
- raised ESR
| - raised IgM
37
Primary Biliary Cirrhosis
mnx
- ursodeoxycholic acid
- colestyramine
- liver transplant (end stage liver disease)
- immunosuppression with steroids is considered in some
38
Primary Biliary Cirrhosis
mnx: how does ursodeoxycholic acid work
reduces the intestinal absorption of cholesterol
39
Primary Biliary Cirrhosis
mnx: how does colestyramine work
a bile acid sequestrate: binds to bile acids to prevent absorption in the gut
and can help with pruritis due to raised bile acids
40
Primary Biliary Cirrhosis
what are the most important end results of this disease
- advanced liver cirrhosis
| - portal HTN
41
Primary Biliary Cirrhosis
complications
- distal renal tubular acidosis
- hypothyroidism
- osteoporosis
- hepatocellular carcinoma
42
Alpha 1 Antitrypsin Deficiency
what is it
a condition caused by an abnormality in the gene for a protease inhibitor called alpha-1-antitrypsin
43
Alpha 1 Antitrypsin Deficiency
what enzyme is secreted from neutrophils
elastase
44
Alpha 1 Antitrypsin Deficiency
what does the enzyme, elastase do?
digests connective tissue
45
Alpha 1 Antitrypsin Deficiency
where is Alpha 1 Antitrypsin mainly produced
in the liver
46
Alpha 1 Antitrypsin Deficiency
how does alpha-1-antitrypsin protect the body
travels around the body and inhibits the neutrophil elastase enzyme
47
Alpha 1 Antitrypsin Deficiency
what chromosome is A1AT coded for on
14
48
Alpha 1 Antitrypsin Deficiency
what is the inheritance pattern
autosomal recessive
49
Alpha 1 Antitrypsin Deficiency
what are the 2 main organs it affects
liver and lungs
50
Alpha 1 Antitrypsin Deficiency
what does it lead to after 30 years old
bronchiectasis and emphysema in the lungs
51
Alpha 1 Antitrypsin Deficiency
what does it lead to after 50 years old
liver cirrhosis
52
Alpha 1 Antitrypsin Deficiency
how does it cause liver cirrhosis and hepatocellular carcinoma
a mutant version of A1AT protein is created in the liver
gets trapped and builds up and causes liver damage
the liver damage progresses to cirrhosis over time and can lead to HCC
53
Alpha 1 Antitrypsin Deficiency
how does it cause bronchiectasis and emphysema
lack of normal A1AT leads to excess protease enzymes that attack the connective tissue in the lungs
54
Alpha 1 Antitrypsin Deficiency
what is the screening test of choice
serum-alpha-1-antitrypsin (low)
55
Alpha 1 Antitrypsin Deficiency
what would liver biopsy show
cirrhosis and
acid-Schiff-positive staining globules in hepatocytes
(this stain highlights the mutant alpha-1-antitrypsin proteins)
56
Alpha 1 Antitrypsin Deficiency
what gene are you looking for in genetic testing
A1AT gene
57
Alpha 1 Antitrypsin Deficiency
how to diagnose bronchiectasis and emphysema
high resolution CT thorax
58
Alpha 1 Antitrypsin Deficiency
mnx
- stop smoking
- symptomatic mnx
- organ transplant for end stage liver or lung disease
- moniter complications (HCC)
- NICE do not recommend replacement A1AT
59
Upper GI bleed
where is the bleeding from
the oesophagus, stomach or duodenum
60
Upper GI bleed
DDx
- oesophageal varices
- Mallory-Weiss tear
- ulcers (stomach or duodenum)
- cancers of the stomach or duodenum
61
Upper GI bleed
presentation
- haematemesis (vomiting blood)
- coffee ground vomit
- melaena
- haemodynamic instability if large blood loss
62
Upper GI bleed
what is coffee ground vomit
vomiting digested blood that looks like coffee grounds
63
Upper GI bleed
what is melaena
tar like, black, greasy and offensive stools caused by digested blood
64
Upper GI bleed
how would haemodynamic instability present
- low BP
- tachycardia
- signs of shock
65
Upper GI bleed
how would a peptic ulcer present as
epigastric pain and dyspepsia
66
Upper GI bleed
how would a pt with liver disease with oesophageal varices present with
jaundice or ascites
67
Upper GI bleed
what scoring system is used to establish their risk of having an upper GI bleed
Glasgow-Blatchford Score
68
Upper GI bleed
what does the Glasgow-Blatchford score take into account
- drop in Hb
- Rise in urea
- BP
- HR
- Melaena
- Syncope
69
Upper GI bleed
what indicates a high risk in the Glasgow-Blatchford score
>0
70
Upper GI bleed
why does the urea rise
the blood in the GI tract gets broken down by the acid and digestive enzymes
one of the breakdown products is urea which is absorbed in the intestines
71
Upper GI bleed
which scoring system is used for pts that have had an endoscopy to calculate their risk of rebleeding and overall mortality
Rockall Score
72
Upper GI bleed
what features does the Rockall Score take into account
- age
- features of shock (tachycardia or hypotension)
- co-morbidities
- cause of bleeding
- endoscopic stigmata of recent haemorrhage e.g. clots or visible bleeding vessels
73
Upper GI bleed
mnx
ABATED
```
ABCDE
Bloods
Access (2 large bore cannula)
Transfuse
Endoscopy (within 24hrs)
Drugs (stop anticoagulants + NSAIDs)
```
74
Upper GI bleed
what bloods should you send for
- Haemoglobin (FBC)
- Urea (U&Es)
- Coagulation (INR, FBC for platelets)
- Liver disease (LFTs)
- Crossmatch 2 units of blood
75
Upper GI bleed
what's the difference between 'Group & Save' and 'Crossmatch'
“Group and save”: lab checks the pt's blood group and keeps a sample of their blood saved in case they need to match blood to it.
“Crossmatch”: lab finds blood, tests that it is compatible and keeps it ready in the fridge to be used if necessary
76
Upper GI bleed
what do you transfuse to pts with massive haemorrhage
blood, platelets and clotting factors (fresh frozen plasma)
77
Upper GI bleed
when should platelets be given
in active bleeding and thrombocytopenia (platelets<50)
78
Upper GI bleed
what can be given to pts taking warfarin that are actively bleeding
prothrombin complex concentrate
79
Upper GI bleed
what can be given if suspecting oesophageal varices (in pts with a hx of chronic liver disease)
- Terlipressin
| - prophylactic broad spectrum abx
80
Upper GI bleed
definitive trx
oesophagogastroduodenoscopy (OGD)
to provide interventions that stop the bleeding e.g. banding of varices or cauterisation of the bleeding vessel.
81
Upper GI bleed
should you use PPI prior to endoscopy
NICE recommend against using a PPI but some senior doctors do this.
82
Haemochromatosis
what is it
an iron storage disorder that results in excessive total body iron and deposition of iron in tissues
83
Haemochromatosis
what gene is affected
the human haemochromatosis protein (HFE) gene
84
Haemochromatosis
where is the HFE gene located
Ch6
85
Haemochromatosis
what is the inheritance pattern
autosomal recessive
86
Haemochromatosis
what does the HFE gene do
regulate iron metabolism
87
Haemochromatosis
when does it usually present
after the age of 40 when the iron overload becomes symptomatic
88
Haemochromatosis
why does it present later in females
due to the menstruation acting to regularly eliminate iron from the body
89
Haemochromatosis
symptoms
- memory + mood disturbance
- hair loss
- chronic tiredness
- bronze skin pigmentation
- erectile dysfunction
- amenorrhoea
- joint pain
90
Haemochromatosis
main diagnostic inx
serum ferritin
91
Haemochromatosis
what does it mean when it says ferritin is an acute phase reactant
ferritin levels go up with inflammatory conditions such as infection
92
Haemochromatosis
what inx to perform to distinguish between high ferritin caused by iron overload vs other causes like inflammation or nonalcoholic fatty liver disease
transferrin saturation
high in haemochromatosis
93
Haemochromatosis
high serum ferritin, high transferrin saturation, what inx next?
genetic testing
94
Haemochromatosis
what used to be the gold standard inx but has been surpassed by genetic testing
liver biopsy with Perl's stain to establish iron conc in the parenchymal cells
95
Haemochromatosis
what inx to show a non-specific increase in attenuation of the liver
CT abdo
96
Haemochromatosis
what inx to give a more detailed pic of liver deposits of iron and iron deposits in the heart
MRI
97
Haemochromatosis
complications
- T1DM
- liver cirrhosis
- hypogonadism, impotence, amenorrhea, infertility
- cardiomyopathy
- HCC
- hypothyroidism
- chondrocalcinosis/pseudogout
98
Haemochromatosis
why is T1DM a complication
iron affects the functioning of the pancreas
99
Haemochromatosis
why is hypogonadism, impotence, amenorrhea, infertility a complication
iron deposits in the pituitary and gonads leads to endocrine and sexual problems
100
Haemochromatosis
why is cardiomyopathy a complication
iron deposits in the heart
101
Haemochromatosis
why is hypothyroidism a complication
iron deposits in the thyroid
102
Haemochromatosis
why is Chrondocalcinosis / pseudogout a complication
calcium deposits in joints causing arthritis
103
Haemochromatosis
mnx
- Venesection
- moniter serum ferritin
- avoid alcohol
- genetic counselling
- moniter and trx of complications
104
Haemochromatosis
mnx: what is venesection
a weekly protocol of removing blood to decrease total iron
105
what is Zollinger Ellison Syndrome
a condition where there is excess acid production leading to peptic ulcers
106
what is Zollinger Ellison Syndrome caused by
a gastinoma which is a neuroendocrine tumour secreting the hormone, gastrin
107
what is Gilbert's syndrome
an autosomal recessive* condition of defective bilirubin conjugation caused by deficiency of UDP glucuronosyltransferase
108
signs of Gilbert's syndrome
- unconjugated hyperbilirubinaemia (i.e. not in urine)
| - jaundice may only be seen during an intercurrent illness, exercise or fasting
109
Gilbert's syndrome
Inx
rise in bilirubin following prolonged fasting or IV nicotinic acid
110
Gilbert's syndrome
trx
none
111
what is the 1st line trx for ascites in liver disease
spironolactone
112
what are 3 defining features of acute liver failure
- INR>1.5
- encephalopathy
- jaundice
113
what is a marker of HCC
alpha-fetoprotein
114
what is definitive mnx for a perforated peptic ulcer
laparotomy
115
IBD
features of Crohn's
crows NESTS
No blood or mucus
Entire GI tract
Skip lesions on endoscopy
Terminal ileum most affected + Transmural inflammation
Smoking is a RF (don't set the nest on fire)
weight loss, strictures, fistulas
116
IBD
features of Ulcerative Colitis
U-C-CLOSEUP
```
Continuous inflammation
Limited to colon + rectum
Only superficial mucosa affected
Smoking is protective
Excrete blood + mucus
Use aminosalicylates
Primary Sclerosing Cholangitis
```
117
IBD
presentation (4)
- diarrhoea
- abdo pain
- passing blood
- weight loss
118
IBD
screening test
faecal calprotectin
119
IBD
why is faecal calprotectin raised
released by the intestines when inflamed
120
IBD
diagnostic inx?
endoscopy (OGD + colonoscopy) with biopsy
121
IBD
inx to look for complications such as fistulas, abscesses + strictures
imaging w/ US, CT + MRI
122
IBD
what inx indicates inflammation and active disease
CRP
123
IBD
1st line to induce remission in Crohn's
steroids (PO prednisolone or IV hydrocortisone)
124
IBD
Crohn's: if steroids don't work to induce remission, what do you consider adding?
immunosuppressants:
- Azathioprine
- Mercaptopurine
- Methotrexate
- Infliximab
- Adalimumab
125
IBD
Crohn's: maintaining remission 1st line
- Azathioprine
| - Mercaptopurine
126
IBD
Crohn's: when is it possible to surgically resect
when the disease only affects the distal ileum
127
IBD
UC: inducing remission in mild to moderate disease
1st line: aminosalicylate (e.g. PO mesalazine or rectal)
2nd line: corticosteroids (prednisolone)
128
IBD
UC: inducing remission in severe disease
1st line: IV corticosteroids (hydrocortisone)
2nd line: IV ciclosporin
129
IBD
UC: maintaining remission
AMINOSALICYLATE (e.g. mesalazine PO or rectal)
azathioprine
mercaptopurine
130
IBD
what does UC typically only affect
the colon and rectum
131
IBD
UC: what surgery will remove the disease
panproctocolectomy (removal of colon and rectum)
132
IBD
after a panproctocolectomy, what is left?
either a permanent ileostomy or an ileo-anal anastomosis (J-pouch)
133
IBD
what is an ileo-anal anastomosis (J-pouch)
the ileum is folded back in itself and fashioned into a larger pouch that functions a bit like a rectum.
This “J-pouch” which is then attached to the anus and collects stools prior to the person passing the motion.
134
what is Melanosis coli
colonoscopy shows dark brown pigmented areas in the lamina propria usually asssociated with chronic laxative abuse (Senna)
135
Liver Cancer
what is primary liver cancer
cancer that originates in the liver
136
Liver Cancer
what are the 2 main types of primary liver cancer
hepatocellular carcinoma (80%)
cholangiocarcinoma (20%).
137
Liver Cancer
what is secondary liver cancer
cancer that originates outside the liver and metastasises to the liver
138
Liver Cancer
the main RF for HCC is liver cirrhosis due to?
- Viral hepatitis (B and C)
- Alcohol
- Non alcoholic fatty liver disease
- Other chronic liver disease
139
Liver Cancer
Cholangiocarcinoma is associated with what condition
primary sclerosing cholangitis
140
Liver Cancer
why is there a poor prognosis
often remains asymptomatic for a long time and then presents late
141
Liver Cancer
presentation
- Weight loss
- Abdominal pain
- Anorexia
- Nausea and vomiting
- Jaundice
- Pruritus
142
Liver Cancer
how do cholangiocarcinomas present similarly to pancreatic cancer
painless jaundice
143
Liver Cancer
what is the tumour marker for HCC
Alpha-fetoprotein
144
Liver Cancer
what is the tumour marker for cholangiocarcinoma
CA19-9
145
Liver Cancer
what inx to diagnose and stage
CT and MRI
146
Liver Cancer
initial inx
liver US
147
Liver Cancer
which inx to take biopsies or brushings to diagnose cholangiocarcinoma
ERCP
148
Liver Cancer
what mnx options can be curative in HCC
- Resection of early disease in a resectable area of the liver
- Liver transplant when the HCC is isolated to the liver
149
Liver Cancer
what medical trx is licensed for HCC
several kinase inhibitors: sorafenib, regorafenib and lenvatinib
150
Liver Cancer
How do kinase inhibitors work in treating HCC
inhibit the proliferation of cancer cells.
can potentially extend life by months.
151
Liver Cancer
is chemo or radio used in HCC or cholangiocarcinomas
No, both are generally considered resistant to chemo and radiotherapy.
152
Liver Cancer
early disease of cholangiocarcinoma can be cured how?
potentially be cured with surgical resection.
153
Liver Cancer
mnx of cholangiocarcinoma
ERCP: stent in bile duct where the cholangiocarcinoma is compressing the duct.
allows drainage of bile and usually improves symptoms.
154
Liver Cancer
what is a haemangioma
common benign tumours of the liver
often found incidentally
no sx no potential to become cancerous.
no trx or monitoring required
155
Liver Cancer
what is Focal nodular hyperplasia
a benign liver tumour made of fibrotic tissue
often found incidentally
usually asymptomatic and has no malignant potential
156
Liver Cancer
whom is focal nodular hyperplasia more common in
often related to oestrogen and is therefore more common in women and those on the OCP
157
Alcoholic Liver Disease
what is the stepwise progression of alcoholic liver disease
1. alcohol related fatty liver
2. alcoholic hepatitis
3. cirrhosis
158
Alcoholic Liver Disease
recommended alcohol consumption
14 units/week for both men and women
spread evenly over 3≥ days and not >5 units/day
159
Alcoholic Liver Disease
which questions can be used to quickly screen for harmful alcohol use
CAGE questions
160
Alcoholic Liver Disease
what are the CAGE questions
Cut down - ever thought you should?
Annoyed - at others commenting on your drinking
Guilty - ever feel guilty about drinking
Eye opener - ever drink in the morning to help your hangover/nerves
161
Alcoholic Liver Disease
what is the AUDIT questionnaire
Alcohol Use Disorders Identification Test to screen people for harmful alcohol use.
10Q's with MCA
162
Alcoholic Liver Disease
what score on the AUDIT questionnaire indicates harmful use
≥8
163
Alcoholic Liver Disease
complications of alcohol
- alcoholic liver disease
- cirrhosis --> HCC
- alcohol dependence + withdrawal
- Wernicke-Korsakoff Syndrome
- Pancreatitis
- alcoholic cardiomyopathy
164
Alcoholic Liver Disease
signs of liver disease
- jaundice
- hepatomegaly
- spider naevi
- palmar erythema
- gynaecomastia
- bruising
- ascites
- caput medusae - engorged superficial epigastric veins
- asterixis - 'flapping tremor' in decompensated liver disease
165
Alcoholic Liver Disease
what would FBC show
raised MCV
166
Alcoholic Liver Disease
what would LFTs show
RAISED GGT
elevated ALT, AST
low albumin due to reduced synthetic function
elevated ALP later in the disease
elevated bilirubin in cirrhosis
167
Alcoholic Liver Disease
what would the bloods in clotting show
elevated PTT due to reduced synthetics function of the liver
168
Alcoholic Liver Disease
when may U+E's be deranged
hepatorenal syndrome
169
Alcoholic Liver Disease
what may US show
“increased echogenicity” - fatty changes
170
Alcoholic Liver Disease
what is a FibroScan
checks the elasticity of the liver by sending high frequency sound waves into the liver
helps assess the degree of cirrhosis
171
Alcoholic Liver Disease
diagnosis of alcohol-related hepatitis or cirrhosis
liver biopsy
172
Alcoholic Liver Disease
general mnx
- stop drinking
- consider detoxification regime
- thiamine + high protein diet
- short term steroids
173
Alcoholic Liver Disease
alcohol withdrawal sx 6-12h after alcohol consumption ceases
- tremor
- sweating
- headache
- craving + anxiety
174
Alcoholic Liver Disease
alcohol withdrawal sx 12-24h after alcohol consumption ceases
hallucinations
175
Alcoholic Liver Disease
alcohol withdrawal sx 24-48h after alcohol consumption ceases
seizures
176
Alcoholic Liver Disease
alcohol withdrawal sx 24-72h after alcohol consumption ceases
delirium tremens
177
Alcoholic Liver Disease
pathophysiology of delirium tremens
alcohol stimulates GABA receptors in brain --> relaxing effect
alcohol inhibits glutamate (NMDA) receptors --> inhibitory effect on electrical activity on brain
chronic alcohol use --> GABA system becomes down regulated and glutamate system becomes up regulated
alcohol removed --> GABA under functions and glutamate over functions -- > excess adrenergic activity
178
Alcoholic Liver Disease
presentation of delirium tremens
- Acute confusion
- Severe agitation
- Delusions and hallucinations
- Tremor
- Tachycardia
- Hypertension
- Hyperthermia
- Ataxia (difficulties with coordinated movements)
- Arrhythmias
179
Alcoholic Liver Disease
what can be used to score the patient on their withdrawal symptoms and guide treatment.
The CIWA-Ar (Clinical Institute Withdrawal Assessment – Alcohol revised) tool
180
Alcoholic Liver Disease
mnx of alcohol withdrawal
Chlordiazepoxide (“Librium”)
(a benzodiazepine)
IV high-dose B vitamins (pabrinex)
followed by a regular lower dose PO thiamine
181
Alcoholic Liver Disease
how is chlordiazepoxide given
orally as a reducing regime titrated to the required dose based on the local alcohol withdrawal protocol (e.g. 10 – 40 mg every 1 – 4 hours).
continued for 5-7 days.
182
Alcoholic Liver Disease
why does it lead to thiamine (Vit B1) deficiency
- thiamine is poorly absorbed in the presence of alcohol
| - alcoholics tend to have poor diets and rely on the alcohol for their calories
183
Alcoholic Liver Disease
features of Wernicke's encephalopathy
- confusion
- oculomotor disturbances
- ataxia
184
Alcoholic Liver Disease
what comes after Wernicke's encephalopathy
Korsakoff's syndrome (often irreversible)
185
Volvulus
what is it
bowel twists around itself and the mesentery that it is attached to
186
Volvulus
what are the 2 main types
- sigmoid volvulus
| - caecal volvulus
187
Volvulus
which type is more common and tends to affect older patients
sigmoid volvulus
188
Volvulus
what is a key cause of sigmoid volvulus (2)
chronic constipation
lengthening of the mesentery attached to the sigmoid colon
189
Volvulus
what are sigmoid volvulus' associate with (2)
- high fibre diet
- excessive use of laxatives
the sigmoid colon becomes overloaded with faeces. causing it to sink down causing a twist
190
Volvulus
who does caecal volvulus tend to affect
younger patients and less common
191
Volvulus
risk factors (6)
- high fibre diet
- chronic constipation
- adhesions
- neuropsychiatric disorders (e.g. Parkinson's)
- nursing home residents
- pregnancy
192
Volvulus
presentation
akin to bowel obstruction, with:
- Vomiting (particularly green bilious vomiting)
- Abdominal distention
- Diffuse abdominal pain
- Absolute constipation and lack of flatulence
193
Volvulus
what will the abdo x-ray show in sigmoid volvulus
'coffee bean' sign
194
Volvulus
what is the diagnostic inx
contrast CT scan
195
Volvulus
initial mnx
same as with bowel obstruction
- nil by mouth
- NG tube
- IV fluids
196
Volvulus
conservative mnx for sigmoid volvulus
- endoscopic decompression (without peritonitis)
197
Volvulus
what happens in endoscopic decompression
- flexible sigmoidoscope is inserted carefully,
- patient in the left lateral position, resulting in a correction of the volvulus.
- A flatus tube / rectal tube is left in place temporarily to help decompress the bowel and is later removed.
198
Volvulus
what surgical procedure is appropriate for a sigmoid volvulus
Hartmann’s procedure
- removal of the rectosigmoid colon and formation of a colostomy
laparotomy
199
Volvulus
what surgical procedure is appropriate for a caecal volvulus
Ileocaecal resection or right hemicolectomy
200
Liver Cirrhosis
what is it
the result of chronic inflammation and damage to liver cells
when the liver cells are damaged they are replaced with scar tissue (fibrosis) and nodules of scar tissue form within the liver
201
Liver Cirrhosis
what causes portal hypertension
fibrosis affects the structure and blood flow through the liver
which causes increased resistance in the vessels leading in to the liver
202
Liver Cirrhosis
most common causes
1. alcoholic liver disease
2. non alcoholic fatty liver disease
3. Hep B
4. Hep C
203
Liver Cirrhosis
rarer causes
- autoimmune hepatitis
- primary biliary cirrhosis
- haemochromatosis
- Wilson's disease
- alpha-1 antitrypsin deficiency
- cystic fibrosis
- drugs (amiodarone, methotrexate, sodium valproate)
204
Liver Cirrhosis
signs of cirrhosis
- jaundice
- hepatomegaly
- splenomegaly
- spider naevi
- palmar erythema
- gynaecomastia and testicular atrophy in males
- bruising
- ascites
- caput medusae
- asterixis
205
Liver Cirrhosis
inx
- bloods
- US
- Fibroscan
- Endoscopy
- CT/MRI
- liver biopsy
206
Liver Cirrhosis
what will LFTs show
often normal
but in decompensated cirrhosis ALT, AST, ALP and bilirubin become deranged
207
Liver Cirrhosis
what happens to albumin and PTT (markers of 'synthetic function' of the liver) as the synthetic function becomes worse
- albumin drops
| - PTT increases
208
Liver Cirrhosis
what does hyponatraemia indicate
fluid retention in severe liver disease
209
Liver Cirrhosis
what becomes deranged in hepatorenal syndrome
urea and creatinine
210
Liver Cirrhosis
what is a tumour marker for HCC and can be checked every 6m as a screening test in patients with cirrhosis along with ultrasound.
Alpha-fetoprotein
211
Liver Cirrhosis
what is the 1st line inx for assessing fibrosis in non-alcoholic fatty liver disease
Enhanced Liver Fibrosis (ELF) blood test
212
Liver Cirrhosis
what does the enhanced liver fibrosis (ELF) blood test measure
3 markers (HA, PIIINP and TIMP-1)
uses an algorithm to provide a result that indicates the fibrosis of the liver:
213
Liver Cirrhosis
what does the enhanced liver fibrosis (ELF) blood test of <7.7 indicate
none to mild fibrosis
214
Liver Cirrhosis
what does the enhanced liver fibrosis (ELF) blood test of ≥ 7.7 to 9.8 indicate
moderate fibrosis
215
Liver Cirrhosis
what does the enhanced liver fibrosis (ELF) blood test of ≥9.8 indicate
severe fibrosis
216
Liver Cirrhosis
what may US show
- nodules on surface
- 'corkscrew' arteries: increased flow was they compensate for reduced portal flow
- enlarged portal vein with reduced flow
- ascites
- splenomegaly
217
Liver Cirrhosis
what is a 'FibroScan' used for
to check the elasticity of the liver by sending high frequency sound waves into the liver.
helps assess the degree of cirrhosis.
This is called “transient elastography” and should be used to test for cirrhosis.
218
Liver Cirrhosis
how often should you test patients at risk of cirrhosis with a FibroScan
every 2 years
219
Liver Cirrhosis
at risk patients of cirrhosis
- hep C
- heavy alcohol drinkers (M>50U, W>35U/week)
- diagnosed alcoholic liver disease
- non alcoholic fatty liver disease + evidence of fibrosis on ELF blood test
- chronic hep B
220
Liver Cirrhosis
when can endoscopy be used
to assess for and treat oesophageal varices when portal hypertension is suspected
221
Liver Cirrhosis
when can CT/MRI be used
to look for HCC, hepatosplenomegaly, abnormal blood vessel changes and ascites
222
Liver Cirrhosis
which inx can be used to confirm the dx of cirrhosis
liver biopsy
223
Liver Cirrhosis
which scoring system indicates the severity of cirrhosis and the prognosis
Child-Pugh Score for Cirrhosis
224
Liver Cirrhosis
what features are used in the Child-Pugh Score for Cirrhosis
1. Bilirubin
2. Albumin
3. INR
4. Ascites
5. Encephalopathy
225
Liver Cirrhosis
which scoring system is recommended by NICE to be used every 6 months in patients with compensated cirrhosis
MELD score
gives a % estimated 3m mortality and helps guide referral for liver transplant
226
Liver Cirrhosis
what features does the MELD score take into account
- biliruibin
- creatinine
- INR
- sodium
227
Liver Cirrhosis
general mnx
- US + alpha fetoprotein every 6m for HCC
- endoscopy every 3y in pts with known varices
- high protein, low Na diet
- MELD score every 6m
- consideration of liver transplant
- managing complicatiions
228
Liver Cirrhosis
complications
- malnutrition
- portal hypertension, varices + variceal bleeding
- ascites + SBP
- hepato-renal syndrome
- hepatic encephalopathy
- HCC
229
Liver Cirrhosis
why does it cause malnutrition + muscle wasting
- metabolism of proteins in liver affected and reduces the amount of protein
- disrupts livers ability to store glucose as glycogen
- results in body using muscle tissue as fuel leading to muscle wasting and weight loss
230
Liver Cirrhosis
mnx of muscles wasting and malnutrition
- regular meals (every 2-3h)
- low Na (to minimise fluid retention)
- high protein + high calorie diet
- avoid alcohol
231
Liver Cirrhosis
where does the portal vein come from
the superior mesenteric vein and the splenic vein
232
Liver Cirrhosis
how does it cause portal hypertension
liver cirrhosis increases the resistance of blood flow in to the liver
increased back-pressure into the portal system
233
Liver Cirrhosis
how does portal hypertension cause varices
back-pressure causes the vessels at the sites where the portal system anastomoses with the systemic venous system to become swollen and tortuous
234
Liver Cirrhosis
which locations do the varices occur
- gastro oesophageal junction
- ileocaecal junction
- rectum
- Anterior abdominal wall via the umbilical vein (caput medusae)
235
Liver Cirrhosis
trx of stable varices
- propranolol (reduced portal HTN)
- elastic band ligation of varices
- injection of sclerosant (less effective)
- last line: TIPS
236
Liver Cirrhosis
what is TIPS procedure
Transjugular Intra-hepatic Portosystemic Shunt
- wire into jugular vein, down the vena cava, hepatic vein into the liver
- make connection through the liver tissue between the hepatic vein and portal vein and put a stent in place
- allows blood to flow directly from the portal vein to the hepatic vein and relieves the pressure in the portal system and varices
237
Liver Cirrhosis
mnx for bleeding oesophageal varices
Resus
- terlipressin
- correct any coagulopathy: vit K + FFP
- prophylactic broad spectrum abx
- consider intubation
urgent endoscopy
- injection of sclerosant into the varices can be used to cause “inflammatory obliteration” of the vessel
- elastic band ligation of varices
238
Liver Cirrhosis
what is used when endoscopy fails for the trx of bleeding oesophageal varices
Sengstaken-Blakemore Tube:
- an inflatable tube inserted into the oesophagus to tamponade the bleeding varices
239
Liver Cirrhosis
how does it cause ascites
The increased pressure in the portal system causes fluid to leak out of the capillaries in the liver and bowel and in to the peritoneal cavity
240
Liver Cirrhosis
why is there high fluid and sodium in ascites
- drop in circulating volume
- reduction in BP entering the kidneys
- kidney senses lower pressure
- renin released
- increased aldosterone secretion via the renin-angiotensin-aldosterone system
241
Liver Cirrhosis
cirrhosis causes what kind of ascites
transudative (low protein content)
242
Liver Cirrhosis
mnx of ascites
- low Na diet
- spironolactone
- paracentesis
- prophylactic abx against SBP if <15g/L protein in ascitic fluid
- consider TIPS in refractory ascites
- consider transplantation
243
Liver Cirrhosis
cause of Spontaneous Bacterial Peritonitis (SBP)
cirrhosis --> ascites --> 10% develop SBP
infection developing in the ascitic fluid and peritoneal lining without any clear cause
244
Liver Cirrhosis
presentation of Spontaneous Bacterial Peritonitis (SBP)
- asymptomatic
- fever
- abdo pain
- raised WBC, CRP, creatinine or metabolic acidosis
- ileus
- hypotension
245
Liver Cirrhosis
most common organisms causing Spontaneous Bacterial Peritonitis (SBP)
- e.coli
- Klebsiella pnuemoniae
- Gram positive cocci (staphylococcus and enterococcus)
246
Liver Cirrhosis
mnx of SBP
- ascitic culture prior to giving abx
| - IV cefotaxime
247
Liver Cirrhosis
pathophysiology of Hepatorenal Syndrome
- Portal HTN
- dilation of portal blood vessels, stretched by large amounts of blood pooling there
- loss of blood volume in kidneys
- hypotension in kidneys
- activation of RAAS
- renal vasoconstriction + low circular volume --> starvation of blood to the kidney
- rapid deteriorating kidney function
248
Liver Cirrhosis
why does ammonia build up in the blood in pts with cirrhosis
- functional impairment of liver cells prevent them metabolising the ammonia into harmless waste products
- collateral vessels between the portal and systemic circulation mean that the ammonia bypasses liver altogether and enters the systemic system directly
249
Liver Cirrhosis
what is hepatic encephalopathy
build up of toxins (ammonia) that affect the brain
250
Liver Cirrhosis
what produces ammonia
intestinal bacteria
251
Liver Cirrhosis
hepatic encephalopathy mnx
- laxatives (PO)
- Rifaximin (abx)
- nutritional support
252
Liver Cirrhosis
why is laxatives used to treat hepatic encephalopathy
help clear the ammonia from the gut before it is absorbed
253
Liver Cirrhosis
why is Rifaximin used to treat hepatic encephalopathy
reduces the number of intestinal bacteria producing ammonia
Rifaximin is poorly absorbed and so stays in the GI tract
254
Liver Cirrhosis
presentation of hepatic encephalopathy
Acute
- reduced consciousness
- confusion
Chronic
- changes to personality, memory, mood
255
Non Alcoholic Fatty Liver Disease
stages
1. Non-alcoholic Fatty Liver Disease
2. Non-Alcoholic Steatohepatitis (NASH)
3. Fibrosis
4. Cirrhosis
256
Non Alcoholic Fatty Liver Disease
RFs
shares the same RFs for CVD:
- Obesity
- Poor diet and low activity levels
- Type 2 diabetes
- High cholesterol
- Middle age onwards
- Smoking
- HTN
257
pt presents with abnormal LFTs without a clear cause. What do you perform
a non-invasive liver screen
258
what is involved in a non-invasive liver screen
- US liver
- hep B+C serology
- autoantibodies (PBC, PSC)
- Ig (autoimmune hepatitis, PBC)
- Caeruloplasmin (Wilson's disease)
- alpha 1 anti-trypsin levels
- ferritin + transferrin saturation (hereditary haemochromatosis)
259
Non Alcoholic Fatty Liver Disease
what can confirm the dx of hepatic steatosis (fatty liver)
liver US
260
Non Alcoholic Fatty Liver Disease
what is the 1st line inx for assessing fibrosis
Enhanced Liver Fibrosis (ELF) blood test
261
Non Alcoholic Fatty Liver Disease
what is the 2nd line inx for assessing fibrosis where the ELF test is not available
NAFLD fibrosis score
262
Non Alcoholic Fatty Liver Disease
what is the NAFLD fibrosis score based on
an algorithm of:
- age
- BMI
- liver enzymes
- platelets
- albumin
- diabetes
helpful in ruling out fibrosis but not assessing the severity
263
Non Alcoholic Fatty Liver Disease
what is the 3rd line inx
Fibroscan
performed if the ELF blood test or NAFLD fibrosis score indicates fibrosis.
264
Non Alcoholic Fatty Liver Disease
conservative mnx
- weight loss
- Exercise
- Stop smoking
- Control of diabetes, blood pressure and cholesterol
- Avoid alcohol
265
Non Alcoholic Fatty Liver Disease
medical trx by specialist
vitamin E or pioglitazone
266
Hepatitis
causes
- Alcoholic hepatitis
- Non alcoholic fatty liver disease
- Viral hepatitis
- Autoimmune hepatitis
- Drug induced hepatitis (e.g. paracetamol overdose)
267
Hepatitis
presentation
- Abdominal pain
- Fatigue
- Pruritis (itching)
- Muscle and joint aches
- Nausea and vomiting
- Jaundice
- Fever (viral hepatitis)
268
Hepatitis
typical biochemical findings
'hepatic picture'
- high AST, ALT
- less of a rise in ALP
- high bilirubin
269
Hepatitis
what are transaminases
AST, ALT
liver enzymes released into blood due to inflammation of liver cells
270
Hepatitis
why does bilirubin rise
inflammation of liver cells
271
what is the most common Hepatitis in the world
Hep A
but rare in UK
272
Hepatitis A
what kind of virus is it
RNA
273
Hepatitis A
how is it transmitted
faecal-oral route
usually contaminated water or food
274
Hepatitis A
how does it present
- N+V
- anorexia
- jaundice
- cholestasis: dark urine + pale stools
- moderate hepatomegaly
275
Hepatitis A
what is cholestasis
slowing of bile flow through the biliary system
276
Hepatitis A
mnx
basic analgesia
it resolves without trx in around 1-3m
277
Hepatitis A
is vaccination available
yes
278
Hepatitis A
who needs to be notified
Public Health
279
Hepatitis B
what kind of virus is it
DNA
280
Hepatitis B
how is it transmitted
- direct contact with blood or bodily fluids
e. g. sex or sharing needles
- vertical transmission from mother to child
281
Hepatitis B
prognosis
most fully recover within 2m
10% become chronic hep B carriers
282
Hepatitis B
what is a chronic hep B carrier
In these patients the virus DNA has integrated into their own DNA and so they will continue to produce the viral proteins.
283
Hepatitis B
what does Surface antigen (HBsAg) indicate
active infection
284
Hepatitis B
what does E antigen (HBeAg) indicate
marker of viral replication and implies high infectivity
285
Hepatitis B
what do Core antibodies (HBcAb) indicate
implies past or current infection
286
Hepatitis B
what does surface antibody (HBsAb) indicate
implies vaccination or past or current infection
287
Hepatitis B
what is Hepatitis B virus DNA (HBV DNA)
a direct count of the viral load
288
Hepatitis B
what does high titres of the IgM version of the HBcAb indicate
active acute infection
289
Hepatitis B
what do low titres of the IgM version of the HBcAb indicate
chronic infection
290
Hepatitis B
what does an IgG of the HBcAb indicate where the HBsAg is negative
a past infection
291
Hepatitis B
what does Hepatitis B e antigen (HBeAg) indicate
the patient is in an acute phase of the infection where the virus is actively replicating
If the HBeAg is higher, they are highly infectious to others
292
Hepatitis B
what does it imply if the HBeAg is negative but the HBeAb is positive
they have been through a phase where the virus was replicating
but the virus has now stopped replicating and they are less infectious
293
Hepatitis B
is vaccination available
yes
3 doses
part of the UK routine vaccination schedule (as part of the 6 in 1 vaccine)
294
Hepatitis B
what is injected in the vaccine
the hepatitis B surface antigen
295
Hepatitis B
who do you notify
Public Health
296
Hepatitis B
medical/surgical mnx
Antiviral medication can be used to slow the progression of the disease and reduce infectivity
Liver transplantation for end-stage liver disease
297
Hepatitis B
general mnx
- low threshold for at risk pts
- screen for hep A, B, HIV, STIs
- refer to gastro/infectious diseases
- stop smoking + alcohol
- education about reducing transmission
- fibroscan for cirrhosis
- US for HCC
298
Hepatitis C
what type of virus is it
RNA
299
Hepatitis C
how is it spread
blood and bodily fluids
300
Hepatitis C
is a vaccine available
no
301
Hepatitis C
mnx
curable with direct acting antiviral medications.
302
Hepatitis C
disease course
- 1/4 make a full recovery
| - 3/4 become chronic
303
Hepatitis C
complications
liver cirrhosis
HCC
304
Hepatitis C
what is the screening test
Hep C antibody
305
Hepatitis C
what test is used to confirm the diagnosis
Hepatitis C RNA testing
306
Hepatitis C
mnx
same as Hep B mnx but
| - direct acting antivirals (DAAs) tailored to the specific viral genotype (cure!)
307
Hepatitis D
what virus is it
RNA virus
308
Hepatitis D
which patients get it
it can only survive in patients who also have a hepatitis B infection
attaches itself to the HBsAg to survive and cannot survive without this protein
309
Hepatitis D
specific trx
none
310
Hepatitis D
is it notifiable
yes
311
Hepatitis E
what virus is it
RNA
312
Hepatitis E
how is it transmitted
by the faecal oral route
313
Hepatitis E
how does it present
- mild illness
| - cleared within a month
314
Hepatitis E
trx
none usually
Rarely it can progress to chronic hepatitis and liver failure, more so in patients that are immunocompromised.
315
Hepatitis E
is there a vaccination
no
316
Hepatitis E
is it notifiable
yes
317
Autoimmune hepatitis
what are the types and who do they occur in
type 1: adults
type 2: children
318
woman in late 40s/50s
perimenopause
fatigue, features of liver disease on exam. Less acute. WHat is it
type 1 autoimmune hepatitis
319
teenager/early 20s presents with acute hepatitis w/ high transaminases + jaundice. What is it
type 2 autoimmune hepatitis
320
Autoimmune hepatitis
what autoantibodies are associated with type 1
- Anti-nuclear antibodies (ANA)
- Anti-smooth muscle antibodies (anti-actin)
- Anti-soluble liver antigen (anti-SLA/LP)
321
Autoimmune hepatitis
what autoantibodies are associated with type 2 associated with
- Anti-liver kidney microsomes-1 (anti-LKM1)
| - Anti-liver cytosol antigen type 1 (anti-LC1)
322
Autoimmune hepatitis
diagnostic inx
liver biopsy
323
Autoimmune hepatitis
trx
high dose steroids (prednisolone) that are tapered over time
as other immunosuppressants, particularly azathioprine, are introduced
life long
324
Autoimmune hepatitis
liver transplant?
may be required in end stage liver disease, however the autoimmune hepatitis can recur in transplanted livers
325
Autoimmune hepatitis
cause
unknown
could be associated with a genetic predisposition and triggered by environmental factors such as a viral infection that causes a T cell-mediated response against the liver cells.
326
Wilsons Disease
what is it
the excessive accumulation of copper in the body and tissues.
327
Wilsons Disease
cause
mutation in the “Wilson disease protein” on chromosome 13
aka “ATP7B copper-binding protein”
328
Wilsons Disease
what is the “ATP7B copper-binding protein” or Wilson disease protein responsible for
the removal of excess copper in the liver
329
Wilsons Disease
genetic inheritance
autosomal recessive
330
Wilsons Disease
presentation
- hepatic problems
- neuro problems
- psychiatric problems
331
Wilsons Disease
why does it cause hepatic, neuro and psych problems
Copper deposition in the liver leads to chronic hepatitis and eventually liver cirrhosis
Copper deposition in the CNS
332
Wilsons Disease
what neuro sx may be present
- concentration + coodination problems
- dysarthria (speech)
- dystonia
- Parkininsonism (if in basal ganglia)
333
Wilsons Disease
are motor neuro sx often symmetrical or asymmetrical
asymmetrical
334
Wilsons Disease
how can psych sx present as
vary from mild depression to full psychosis
335
Wilsons Disease
findings on slit lamp examination
- Kayser-Fleischer rings in cornea (deposition of copper in Descemet’s corneal membrane)
brownish circles surrounding the iris
336
Wilsons Disease
other features apart from neuro, psych + liver problems
- Haemolytic anaemia
- Renal tubular damage leading to renal tubular acidosis
- Osteopenia (loss of bone mineral density)
337
Wilsons Disease
initial inx of choice and result
low serum caeruloplasmin
338
Wilsons Disease
what is caeruloplasmin
the protein that carries copper in the blood
339
Wilsons Disease
what is wrong with using serum caeruloplasmin
- can be falsely normal or elevated in cancer or inflammatory conditions.
- not specific to Wilson disease
340
Wilsons Disease
what is the definitive gold standard test for dx
Liver biopsy for liver copper content
341
Wilsons Disease
what other inx (apart from biopsy) can be used to diagnose it
sufficiently elevated 24-hour urine copper assay is
or scoring systems
342
Wilsons Disease
other inx apart from caeruloplasmin, biopsy, urine
- Low serum copper
- Kayser-Fleischer rings
- MRI brain shows nonspecific changes
343
Wilsons Disease
mnx
copper chelation using:
- penicillamine
- trientene
344
Liver Transplant
name for when an entire liver is transplanted from a deceased patient to a recipient
orthotopic transplant
345
Liver Transplant
what is a living donor transplant
taking a portion of the organ from a living donor, transplant it into a patient and have both regenerate to become two fully functioning organs
because the liver can regenerate as an organ
346
Liver Transplant
what is the name when you split the organ of a deceased person into two and transplant it into two patients and have them regenerate to their normal size in each recipient
split donation.
347
Liver Transplant
indications
acute liver failure:
- acute viral hepatitis
- paracetamol overdose
chronic liver failure
348
Liver Transplant
factors suggesting unsuitability for liver transplantation
- Significant co-morbidities (e.g. severe kidney or heart disease)
- Excessive weight loss and malnutrition
- Active hep B, C or other infection
- End-stage HIV
- Active alcohol use (generally 6m of abstinence required)
349
Liver Transplant
what kind of incisions is required for open surgery
- rooftop
| - Mercedes Benz
350
Liver Transplant
post-transplantation meds
lifelong immunosuppression (e.g. steroids, azathioprine and tacrolimus)
351
Liver Transplant
how would you monitor for evidence of transplant rejections
- Abnormal LFTs
- Fatigue
- Fever
- Jaundice
352
Liver Transplant
post-transplantation care
- Avoid alcohol and smoking
- Treat opportunistic infections
- Monitoring for disease recurrence (i.e. of hepatitis or primary biliary cirrhosis)
- Monitoring for cancer as there is a significantly higher risk in immunosuppressed patients
353
Gastro-Oesophageal Reflux Disease
what is it
acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus.
354
Gastro-Oesophageal Reflux Disease
what cells line the oesophagus
squamous epithelial lining
355
Gastro-Oesophageal Reflux Disease
what cells line the stomach
columnar epithelial lining
356
Gastro-Oesophageal Reflux Disease
which cell lining is more sensitive to stomach acid
squamous epithelial (oesophagus)
357
Gastro-Oesophageal Reflux Disease
what is dyspepsia
a non-specific term used to describe indigestion.
358
Gastro-Oesophageal Reflux Disease
sx
- Heartburn
- Acid regurgitation
- Retrosternal or epigastric pain
- Bloating
- Nocturnal cough
- Hoarse voice
359
Gastro-Oesophageal Reflux Disease
what are the key red flag features indicating an urgent referral
- dysphagia (swallowing)
- aged>55y
- weight loss
- upper abdo pain/reflux
- Treatment resistant dyspepsia
- Nausea and vomiting
- Low haemoglobin
- Raised platelet count
360
Gastro-Oesophageal Reflux Disease
mnx
- lifestyle advice
- acid neutralising meds PRN
- PPIs
- Ranitidine
- surgery
361
Gastro-Oesophageal Reflux Disease
what lifestyle advice would you give
- Reduce tea, coffee and alcohol
- Weight loss
- Avoid smoking
- Smaller, lighter meals
- Avoid heavy meals before bed time
- Stay upright after meals rather than lying flat
362
Gastro-Oesophageal Reflux Disease
name some acid neutralising meds
- Gaviscon
| - Rennie
363
Gastro-Oesophageal Reflux Disease
what is Ranitidine
- an alternative to PPIs
- H2 receptor antagonist (antihistamine)
- Reduces stomach acid
364
Gastro-Oesophageal Reflux Disease
what is the surgery for reflux called
laparoscopic fundoplication
tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter
365
Gastro-Oesophageal Reflux Disease
what kind of bacteria is H.pylori
a gram negative aerobic bacteria.
366
Gastro-Oesophageal Reflux Disease
how can H.pylori damage the epithelial cells in the stomach, causing gastritis
- breaks into the gastric mucosa
- epithelial cells underneath are exposed to acid
- also produces ammonia which neutralises the acid and directly damages the epithelial cells
367
Gastro-Oesophageal Reflux Disease
who is offered a test for H.pylori
anyone with dyspepsia.
They need 2 weeks without using a PPI before testing for H. pylori for an accurate result.
368
Gastro-Oesophageal Reflux Disease
what 3 tests can be used to test for H.pylori
- Urea breath test using radiolabelled carbon 13
- Stool antigen test
- Rapid urease test can be performed during endoscopy.
369
Gastro-Oesophageal Reflux Disease
what is a rapid urease test aka
CLO test (Campylobacter-like organism test)
370
Gastro-Oesophageal Reflux Disease
what does the rapid urease test involve
- performed during endoscopy
- biopsy from stomach mucosa
- add urea to sample
371
Gastro-Oesophageal Reflux Disease
if H,pylori are present in the rapid urease test, what result will you get and why
- positive: alkali solution
- H.pyloria produce urease enzymes
- which convert urea to ammonia
- making solution alkali
372
Gastro-Oesophageal Reflux Disease
how to eradicate H.pylori
triple therapy:
1. PPI
2. amoxicillin
3. clarithromycin
7d
373
Gastro-Oesophageal Reflux Disease
what is Barretts Oesophagus
lower oesophageal squamous cells change to columnar epithelium cells
in a process called metaplasia
due to constant reflux of acid
374
Gastro-Oesophageal Reflux Disease
how may patients with Barretts oesophagus present
improvement in reflux symptoms
375
Gastro-Oesophageal Reflux Disease
what is Barretts oesophagus a RF for developing
adenocarcinoma of the oesophagus
376
Gastro-Oesophageal Reflux Disease
monitoring for pts with Barretts oesophagus
regular endoscopy to monitor for adenocarcinomas
377
Gastro-Oesophageal Reflux Disease
progression of Barrett's oesophagus
squamous cell --> columnar epithelium, no dysplasia --> low grade dysplasia --> high grade dysplasia --> adenocarcinoma
378
Gastro-Oesophageal Reflux Disease
trx of Barretts oesophagus
PPIs
new evidence but not in guidelines: regular aspirin
379
Gastro-Oesophageal Reflux Disease
trx for pts with Barretts oesophagus with low or high grade dysplasia
Ablation treatment during endoscopy using photodynamic therapy, laser therapy or cryotherapy
destroys the epithelium so that it is replaced with normal cells
380
Peptic Ulcers
what are they
ulceration of the mucosa of the stomach (gastric ulcer) or the duodenum (duodenal ulcer).
381
Peptic Ulcers
which kind are more common
duodenal ulcers
382
Peptic Ulcers
when is the stomach mucosa prone to ucleration
- Breakdown of the protective layer of the stomach and duodenum
- Increase in stomach acid
383
Peptic Ulcers
what is the protective layer in the stomach comprised of
mucus + bicarbonate
secreted by the stomach mucosa
384
Peptic Ulcers
what can the protective later be broken down by
- Medications (e.g. steroids or NSAIDs)
| - Helicobacter pylori
385
Peptic Ulcers
what can increased acid result from
- Stress
- Alcohol
- Caffeine
- Smoking
- Spicy foods
386
Peptic Ulcers
presentation
- Epigastric discomfort or pain
- N+V
- Dyspepsia
- “coffee ground” vomiting and melaena
- Iron deficiency anaemia (due to constant bleeding)
387
Peptic Ulcers
how are they diagnosed
endoscopy
388
Peptic Ulcers
what should be done during endoscopy
rapid urease test (CLO test) can be performed to check for H. pylori during it
biopsy to exclude malignancy
389
Peptic Ulcers
medical trx
high dose PPI
390
Peptic Ulcers
complications
- bleeding
- perforation
- scarring + strictures --> pyloric stenosis
391
Peptic Ulcers
how does pyloric stenosis present
upper abdominal pain
distention
nausea and vomiting, particularly after eating
392
Peptic Ulcers
eating typically worsens the pain
which type of ulcer is it
gastric ulcer
393
Peptic Ulcers
eating typically improves the pain
which type of ulcer is it
duodenal ulcers
394
Irritable Bowel Syndrome
why is it a 'functional bowel disorder'
there is no identifiable organic disease underlying the symptoms
395
Irritable Bowel Syndrome
sx
- Diarrhoea
- Constipation
- Fluctuating bowel habit
- Abdominal pain
- Bloating
- Worse after eating
- Improved by opening bowels
396
Irritable Bowel Syndrome
NICE criteria for dx
- other pathology excluded
| - sx should suggest IBS
397
Irritable Bowel Syndrome
NICE criteria: other pathology excluded
- Normal FBC, ESR and CRP
- Faecal calprotectin negative to exclude IBD
- Negative coeliac disease serology (anti-TTG antibodies)
- Cancer is not suspected or excluded if suspected
398
Irritable Bowel Syndrome
NICE criteria: sx should suggest IBS
Abdominal pain / discomfort:
- Relieved on opening bowels, or
- Associated with a change in bowel habit
AND 2 of:
- Abnormal stool passage
- Bloating
- Worse symptoms after eating
- PR mucus
399
Irritable Bowel Syndrome
General healthy diet and exercise advice
- Adequate fluid intake
- Regular small meals
- Reduced processed foods
- Limit caffeine and alcohol
- Low “FODMAP” diet (ideally with dietician guidance)
- Trial of probiotic supplements for 4w
400
Irritable Bowel Syndrome
1st line medications: diarrhoea
loperamide
401
Irritable Bowel Syndrome
1st line medications: constipation
laxatives
| avoid lactulose as can cause bloating
402
Irritable Bowel Syndrome
what is a specialist laxative for patients with IBS not responding to first-line laxatives
Linaclotide
403
Irritable Bowel Syndrome
1st line medications: cramps
Antispasmodics
e.g. hyoscine butylbromide (Buscopan)
404
Irritable Bowel Syndrome
2nd line medication
Tricyclic antidepressants (i.e. amitriptyline 5-10mg at night)
405
Irritable Bowel Syndrome
3rd line medication
SSRIs
406
Irritable Bowel Syndrome
mnx option to help patients psychologically manage the condition and reduce distress associated with symptoms.
CBT
407
Coeliac Disease
what is it
an autoimmune condition where exposure to gluten causes an autoimmune reaction that causes inflammation in the small bowel
408
Coeliac Disease
when does it usually develop
in early childhood but can start at any age
409
Coeliac Disease
pathophysiology
- auto-antibodies target epithelial cells of the intestine in response to gluten
- leads to inflammation
410
Coeliac Disease
what are the autoantibodies
- anti-tissue transglutaminase (anti-TTG)
- anti-endomysial (anti-EMA)
- Deaminated gliadin peptides antibodies (anti-DGPs)
411
Coeliac Disease
which area of bowel does it affect
small bowel, esp the jejunum
412
Coeliac Disease
what does it cause to the intestinal villi
- villous atrophy
| - crypt hypertrophy
413
Coeliac Disease
presentation
often asymptomatic
- Failure to thrive in young children
- Diarrhoea
- Fatigue
- Weight loss
- Mouth ulcers
- Anaemia secondary to iron, B12 or folate deficiency
- Dermatitis herpetiformis
414
Coeliac Disease
what is dermatitis herpetiformis
an itchy blistering skin rash typically on the abdomen
415
Coeliac Disease
rarely it can present with neuro problems. What are they
- Peripheral neuropathy
- Cerebellar ataxia
- Epilepsy
416
all new cases of T1DM are also tested for what
coeliac disease as they are often linked
417
Coeliac Disease
genetic associations
HLA-DQ2 gene (90%)
| HLA-DQ8 gene
418
Coeliac Disease
Anti-TTG and anti-EMA antibodies are types of which Ig?
IgA
419
Coeliac Disease
what do you need to test before you test for Anti-TTG and anti-EMA antibodies and why
total IgA levels as some pts have an IgA deficiency
if total IgA is low because they have an IgA deficiency then the coeliac test will be negative even when they have coeliacs
420
Coeliac Disease
how do you test for coeliac if they have IgA deficiency
test for the IgG version of anti-TTG or anti-EMA antibodies
or endoscopy with biopsies
421
Coeliac Disease
what to tell pt before checking their IgA and anti-TTG
patient must be on a diet containing gluten
422
Coeliac Disease
what will endoscopy and intestinal biopsy show
“Crypt hypertrophy”
| “Villous atrophy”
423
Coeliac Disease
what other autoimmune conditions is it associated with
- Type 1 Diabetes
- Thyroid disease
- Autoimmune hepatitis
- PBC
- PSC
424
Coeliac Disease
complications of untreated coeliac disease
- Vitamin deficiency
- Anaemia
- Osteoporosis
- Ulcerative jejunitis
- Enteropathy-associated T-cell lymphoma (EATL) of the intestine
- Non-Hodgkin lymphoma (NHL)
- Small bowel adenocarcinoma (rare)
425
Coeliac Disease
trx
Lifelong gluten-free diet
426
Spontaneous bacterial peritonitis with increased serum creatinine should be also prescribed what?
human albumin solution because it reduces the risk of developing renal impairment
427
what is achalasia
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS)
428
cause of achalasia
degenerative loss of ganglia from Auerbach's plexus
429
what are the clinical features of achalasia
- dysphagia of BOTH liquids and solids
- heartburn
- regurgitation of food
430
what is the diagnostic test for achalasia
oesophageal manometry
431
what will oesophageal manometry show if they have achalasia
excessive lower oesophageal sphincter tone which doesn't relax on swallowing
432
what will the barium swallow show if they have achalasia
a dilated oesophagus with a fluid level (described as a "bird's beak" appearance)
433
trx of achalasia
- pneumatic (balloon) dilation
- surgery: Heller cardiomyotomy
- intra-sphincteric injection of botulinum toxin
434
man presents with dermatitis, dementia and diarrhoea. what is it
Vitamin B3 deficiency (pellagra)
trx with nicotinamide (vitamin B3)
435
what is gastric paresis
delayed gastric emptying
436
which condition is gastric paresis commonly associated with
DM
437
what causes gastric paresis
decreased activity of the stomach muscles, causing food to be held in the stomach for a longer period than usual
438
sx of gastric paresis
- Nausea
- Vomiting
- Feeling of fullness after a few bites
- Abdominal pain
- Bloating
439
how is diagnosis of gastric paresis made
solid meal gastric scintigraphy (Radionuclide studies of gastric emptying)
440
mnx of gastric paresis
- Dietary modification - low fibre, smaller/more frequent meals, pureed/mashed food
- Domperidone - dopamine receptor antagonist
- Metoclopramide or Erythromycin (motility agents)
441
pt develops gastroenteritis after eating rice. Which organism is responsible
Bacillus cereus
442
which drug is known to cause drug-induced cholestasis
co-amoxiclav
443
child presents with low platelets, an acute kidney injury and a haemolytic anaemia. What is it
haemolytic uraemic syndrome, the most common cause of which is E Coli 0157
444
which condition is Pellagra (vit b3 deficiency) associated with
carcinoid syndrome
445
abx trx for Gram negative curved rods with a seagull shaped appearance
Azithromycin
treatment for Campylobacter
446
which drug is avoided in hepatic encephalopathy
morphine as it can worsen it
447
what can be used to find the cause of ascites
The serum ascites albumin gradient (SAAG)
448
how is the serum ascites albumin gradient (SAAG) calculated
serum albumin con - albumin conc of ascitic fluid
449
what does a high SAAG (>1.1g/dL) suggest
```
the cause of the ascites is due to raised portal pressure
Cirrhosis
Heart failure
Budd Chiari syndrome
Constrictive pericarditis
Hepatic failure
```
450
what does a low SAAG (<1.1g/dL) suggest
Cancer of the peritoneum
Tuberculosis and other infections
Pancreatitis
Nephrotic syndrome
451
what is an absolute contraindication to performing paracentesis
disseminated intravascular coagulation:
- Bleeding from gums
- raised d-dimer
- low fibrinogen
452
what is Whipple's disease
a rare, systemic condition caused by Tropheryma whipplei.
453
presentation of Whipple's disease
diarrhoea, abdominal pain and joint pain,
454
Gold standard for the diagnosis of Whipple's disease
Jejunal biopsy: presence of acid-Schiff (PAS)-positive macrophages
455
mnx of Whipple's disease
co-trimoxazole.
456
how would Plummer-Vinson syndrome present as
Triad of:
- dysphagia (secondary to oesophageal webs)
- glossitis
- iron-deficiency anaemia
457
dysphagia: liquids and solids being equally affected from the start
what could it be
motility disorders
458
dysphagia: Progressive dysphagia of solids and then liquids
what could it be
a benign or malignant stricture
459
what is Budd-Chiari syndrome caused by
obstruction of the hepatic veins (often by thrombosis)
460
what is the classic triad of Budd-chiari syndrome
1. abdominal pain
2. ascites
3. hepatomegaly
461
what may patients develop after being treated for Giardiasis with abx such as metronidazole
lactose intolerance
462
why shold CCBs be avoided in reflux
they can relax the lower oesophageal sphincter, thus increasing reflux
463
difference between right and left sided colonic cancer
left:
- present earlier
- stool more formed
- fresh rectal bleeding
- tenesmus
right
- presents later
- more insidious in manner with occult bleeding and anaemia
- semi-liquid stool
464
how to calculate units of alcohol
strength (ABV) x volume (ml) ÷ 1000
465
mnx of c.difficile infection
1. stop abx causing it
2. PO vancomycin for 10d
2nd line therapy: PO fidaxomicin
3rd line therapy: PO vancomycin +/- IV metronidazole
466
what other drugs apart from abx can cause c.difficile
PPIs
steroids
chemo
467
pt has constipation. what would you be excluding in a upright chest x-ray
bowel perforation
468
pt has constipation. what would you be excluding in a abdominal chest x-ray
bowel obstruction
469
4 drugs classes which cause constipation
- opioids
- CCBs
- antipsychotics
- anticholinergics
470
why does crohn's increase the risk of gallstones
increase in loss of bile salts
