Gastro Flashcards
Define alcoholic liver disease
Stepwise progression of liver disease resulting from the long term effects of excessive alcohol consumption
Progression of alcoholic liver disease
Alcohol related fatty liver
Alcoholic hepatitis
Live cirrhosis
Complications of alcohol
Alcoholic liver disease
Cirrhosis
Hepatocellular carcinoma
Alcohol dependence
Wernicke-korsakoff syndrome
Pancreatitis
Alcoholic cardiomyopathy
Clinical signs of liver disease
Jaundice
Hepatomegaly
Spider naevi
Palmar erythema
Gynaecomastia
Bruising
Ascites
Caput medusae - engorged superficial epigastric veins
Asterixis a
Investigations in alcoholic liver disease
FBC - Raised MCV
LFTs - elevated transaminases, raised GGT. ALP raised in late disease. Bilirubin raised in cirrhosis
Clotting - raised pt
UE - hepatorenal syndrome
US - fatty changes
Endoscopy - varices
CT/MRI - fatty infiltration
Liver biopstu
Management of alcoholic liver disease
Stop drinking!
Detox?
Nutritional support
Steroids
Treat complications
Alcohol withdrawal times
6-12 hours - tremor, sweating, headache, craving and anxiety
12-24 - hallucinations
24-48 - seizure
24-72 - delirium tremens
Define delirium tremens
Medical emergency caused by alcohol withdrawal
Alcohol stimulates gaba and inhibits glutamate, as a result the glutamate is upregulated.
When removed glutamate overfunctions causing excess adrenergic activity
Presentation of delirium tremens
Acute confusion
Severe agitation
Delusions and hallucinations
Tremor
Tachycardia
Hypertension
Hyperthermia
Ataxia
Arrhythmias
Management of alcohol withdrawal
Chlordiazepoxide - benzo
Pabrinex - IV thiamine
Define wernicke-korsakoff syndrome
Encephalopathy caused by lack of thiamine.
Wernickes encephalopathy leads to kordakoff syndrome
Features of Wernicke’s encephalopathy
Confusoin
Oculomotor disturbance - movement
Ataxia - coordination
Features of Korsakoff’s syndrome
Memory impairment
Behavioural change
Often irreversible
Define liver cirrhosis
Damage to hepatocytes resulting in scar tissue forming. Results from chronic inflammation.
Common causes of liver cirrhosis
Alcoholic liver disease
Non alcoholic liver disease
Hepatitis B
Hepatitis C
(AI, PBC, Haemochromatosis, Wilsons, alph-1 antitrypsin, cystic fibrosis, drugs)
Clinical signs of liver cirrhosis
Jaundice
Hepatomegaly
Splenomegaly
Spider naevi
Palmar erythema
Gynaecomastia
Bruising
Ascites
Caput medusae
Aterixis
Investigations in liver cirrhosis
LFTS - often normal, maybe deranged
Albumin and PT useful markers of synthetic function
Hyponatraemia
Urea and creatinine deranged
Alpha-fetoprotein
Enhanced liver fibrosis blood test
US
Fibroscan
Endoscopy
CT/MRI
Biopsy
Tumour marker for hepatocellular carcinoma
Alph-fetoprotein
Scoring system for severity of Cirrhosis
Child-Pugh score
Bilirubin
Albumin
INR
Ascites
Encephalopathy
MELD score - 3 month mortality
Management of liver cirrhosis
US and alpha-fetoprotein every 6 months
Endoscopy every 3 years
High protein
Low sodium
MELD score every 6 months
Consideration of liver transplant
Managing complications
Common complications of liver cirrhosis
Malnutrition
Portal hypertension, varices and variceal bleeding
Ascites and SBP
Hepato-renal syndrome
Hepatic encephalopathy
Hepatocellular carcinoma
Define portal hypertension
Liver cirrhosis increases resistance to blood flow as a result there is increased back pressure in the portal system causing anastomoses with the systemic venous system. These can become swollen and tortuous - varices
Management of stable varices
Propranolol - reduce portal hypertension
Elastic band ligation
Injection of sclerosant
Trans jugular intra-hepatic portosystemic shunt
Management of bleeding oesophageal varices
Resus - vasopressing (vasoconstriction)
Vit K - Correct coagulopathy
Broard spectrum antibiotics - prophylactic
Intubation and ITU
Urgent endoscopy - ligation, sclerosant, sengstaken-blakemore tube
Define ascites
FLuid in the peritoneal cavity - Increases pressure on the portal system causes fluid to leak out of capillaries in the liver and bowel.
Management of ascites
Low sodium diet
Anti-aldosterone diuretics - spironolactone
Paracentesis - tap or drain
Prophylactic abx - SBP
Consider TIPS
Consider transplant
Define spontaneous bacterial peritonitis
Infection developing in ascitic fluid and peritoneal lining without any clear causes - ie not secondary to perforation/drain.
Presentation of SBP
Fever
Abdo pain
Deranged bloods
Ileus
Hypotension
Management of SBP
Ascitic culture
IV Abx
Define hepatorenal syndrome
Hypertension in the portal system leads to dilation of blood vessels. Causes reduction in blood volume else where including kidneys. Rapid deterioration in kidney function and is fatal within a week
Management of hepatorenal syndrome
Liver transplant!
Define hepatic encephalopathy
Caused by build up of toxins within the brain - mainly ammonia which is produced by intestinal bacteria breaking down proteins. Liver metabolises into harmless waste product. If liver not working collects in blood. Colateral vessels created by portal hypertension allow ammonia to enter normal circulation.
Prevention of hepatic encephalopathy
Laxatives - clears ammonia from gut before absorption.
History of hepatic encephalopathy
Constipation
Electrolyte imballance
Infection
GI blees
High protein diet
Medication - sedatives
Liver cirrhosis
Management of hepatic encephalopathy
Laxatives - lactulose
Antibiotics - rifaximin
Nutritional support
Define non alcoholic fatty liver disease
Fat deposits in liver cells interfere with the functioning of the liver cells and can progress to hepatitis and cirrhosis
Part of the metabolic syndrome group of chronic health conditions relating to processing and storing energy that increase risk of heart disease
Stages of non alcoholic fatty liver disease
Non-alcoholic fatty liver disease
Non-alcoholic steatohepatitis
Fibrosis
Cirrhosis
Risk factors for NAFLD
30% of adults!
Obesity
Poor diet and low activity
TIIDM
High cholesterol
Middle age onwards
Smoking
High blood pressure
What is included in a liver screen
US liver
Hep B and C serology
Autoantibodies - hpetitis, pbc, psc
Immunoglobulins - AI hep, pbc
Ceruloplasmin - wilsons
Alpha 1 Anti-trypsin
Ferritin and transferrin
Coagulation
EBV
CMV
AMA, ASMA, Anti-LKM, ANA, p-ANCA
Investigations in NAFLD
Liver US
Enhanced liver fibrosis bloods - first line.
NAFLD fibrosis scores
Fibroscan
Management of NAFLD
Weight loss
Exercise
Stop smoking
Control diabetes
Avoid alcohol
Vit E
Pioglitazone
Define hepatitis
Inflammation of the liver
Common causes of hepatitis
Alcohol
NAFLD
Viral
Autoimmune
Drug induced
History of hepatitis
Abdo pain
Fatigue
Pruritis
Muscle and joing aches
Nausea and vomiting
Jaundice
Fever - viral
How are the hep viruses spreas
Hep A - Faeco-oral
Hep B - Blood
Hep C - Blood
Hep D - Blood
Hep E - Faeco-oral
Which hep viruses go together
A and E
B and D
Which hep biruses have vaccines
Hep A
Hep B
Which hep viruses are RNA
Hep A - RNA
Hep B - DNA
Hep C - RNA
Hep D - RNA
Management of Hep A
Self resolving in 1-3 months
Simple analgesia
Viral markers of Hep B
Surface antigen HBsAg - active infection
E antigen HBeAg - marker of viral repliaction - high infectivity
Core antibodies HBcAb - past infection
Surface antibodies HBsAb - vaccination or current infection
Hpatitis B virus DNA HBV DNA - direct count of the viral load
Management of Hep B
Screen for other viruses and HIV
Notify public health england
Stop smoking and alcohol
Test for complications
Antiviral meds can be used
Liver transplant
Management of hep c
Same as b
Direct acting antivirals
Which hep viruses are notifiable
All of them!
Define haemochromatosis
Iron storage disorder that results in excessive total iron and deposition of iron in tissues. The biggest cause in an autosomal recessive mutation in the HFE gene on chromosome 6
History of haemochromatosis
40 yo
Chronic tiredness
Joint pain
Pigmentation
Hair loss
Erectile dysfunction
Amenorrhoea
Cognitive symptoms
Investigations in haemochromatosis
Serum ferritin - raised in inflammation
Transferrin saturation - iron overload will be high - distinguish from inflammation
Genetic testing
(previously biopsy with perl’s stain)
CT abdo
MRI
Complications of haemochromatosis
Type 1 diabetes
Liver cirrhosis
Iron deposits in the pituitary - endocrine
Cardiomyopathy
Hepatocellular carcinoma
Hypothyroidism
Chronocalcinosis/pseudogout - calcium deposits in joint
Management of haemochromatosis
Venesection - therapeutic blood removal
Monitoring ferritin
Avoid alcohol
Genetic counselling
Monitoring and treatment of complications
Define Wilson’s disease
The excessive accumulation of copper in the body and tissues - caused by an autosomal recessive mutation in the wilson disease protein on chromosome 13.
Features of Wilson’s disease
Hepatic problems - Chronic hepatitis, Cirrhosis
Neurological problems - dysarthria, dystonia, parkinsonism.
Psychiatric problems - depression, psychosis
Kayser fleischer rings
Haemolytic anaemia
Renal tubular damage - renal tubular acidosis
Osteopenia
Investigations in Wilson’s disease
Serum caeruloplasmin - will be low i wilson
Liver biopsy - gold standard
24 hr urine copper assay
MRI brain
Management of wilsons disease
Penicillamine
Trientene
(copper chelation)
Define alpha-1 antitrypsin deficiency
Condition caused by an abnormality in the gene for protease inhibitor called alpha-1 antitrypsin.
Autosomal recessive condiont affecting chromosome 14
Main organs affected by A1AT
Liver - cirrhosis
Lung - bronchiectasis and emphysema
Investigations in A1AT
DSerum levels
Liver biopsy
Genetic testing
High resolution CT thorax
Management of A1AT
Stop smoking
Symptomatic management
Don’t replace
Organ transplant
Monitor complications
Define primary biliary cirrhosis
A condition where the immune system attacks the small bile ducts within the liver. It first affects the interlobar ducts obstructing the outflow of bile (cholestasis). Back pressure of bile and the disease process leads to fibrosis and cirrhosis and liver failure.
History of primary biliary cirrhosis
Fatigue
Pruritus
GI disturbance Jaundice
Pale stool
Xanthelasma - cholesterol deposits in the skin
Signs of cirrhosis
Risk factors for primary biliary cirrhosis
Middle aged
Other auto immune conditions
Rheumatoid conditions
Investigations in primary biliary cirrhosis
LFTs - raised alp
Autoantibodies - antimitochondrial, ANA
Raised ESR
Raised IgM
Liver biopsy - staging
Management of primary biliary cirrhosis
Ursodeoxycholic acid
Cholestyramine -
Liver transplant
Immunosuppression
Define primary sclerosing cholangitis
Condition where the intra/extra hepatic ducts become strictured and fibrotic. This causes obstruction tot eh flow of bile out of the liver and into the intestines. Leading to inflammation fibrosis and cirrhosis
Risk factors for primary sclerosing cholangitis
Male
Age 30-40
Ulcerative colitis
FH
History of primary sclerosing cholangitis
Jaunice
Chronic right upper quadrant pain
Pruritus
Fatigue
Hepatomegaly
Investigations in primary sclerosing cholangitis
LFTs - cholestatic pucture - ALP most deranged
Autoantibodies - pANCA, ANA, aCL
MRCP - gold standard diagnostic
Complicaions of primary sclerosing cholangitis
Acute bacterial cholangitis
Cholangiocarcinoma
Colorectal cancer
Cirrhosis and liver failure
Biliary strictures
Fat soluble vitamin deficiencies
Management of primary sclerosing cholangitis
ERCP - dilate strictures
Cholestyramine
Monitoring
Transplant
What are the main types of liver cancer
Hepatocellular carcinoma (80%)
Cholangiocarcinoma (20%)
(metastases)
Risk factors for hepatocellular carcinoma
Cirrhosis - hepatitis B,C, Alcohol, NAFLD
Risk factors for cholangiocarcinoma
Primary sclerosing cholangitis
History of liver carncer
Weight loss
Abdo pain
Anorexia
Nausea and vomiting
Jaundice
Pruritus
Cholangiocarcinoma - painless jaundice
Investigations in liver cancer
Alpha-fetoprotein - hepatocellular carcinoma
CA19-9 - cholangiocarcinoma
US
CT/MRI
ERCP
Management of hepatocellular carcinoma
Resection in early disease
Transplant
Kinase inhibitors - something-nib
Not chemo and radio
Management of cholangiocarcinoma
ERCP
Early surgical resection
Not chemo and radio
Define haemangioma
Common benign tumour of the liver - often found incidentally.
No symptoms and no threat of becoming cancerous
Define focal nodular hyperplasia
Benign tumour made of fibrotic tissue - found incidentally.
Asymptomatic and no malignant potential.
Often related to oestrogen - COCP
Define gastro oesophageal reflux disease
GORD is where acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus
History of GORD
Heart burn
Acid regurgitation
Bloating
Nocturnal cough
Hoarse voice
Red flags of GORD
Dysphagia
Aged >55
Weight loss
Upper abdo pain
Treatment resistant
Nausea and vomiting
Low haemoglobin
Raised platelet count
Management of GORD
Reduce tea, coffee and alcohol
Weight loss
Avoid smoking
Smaller lighter meals
Stay upright
Gaviscon/rennie
Omeprazole
Ranitidine
Laparoscopic fundoplication
How does h.pylori cause GORD
Bacteria tries to avoid acidic environment so forces way into mucosa breaking it and exposing epithelial cells. Also produces ammonia that damages cells - breath test
Investigations for h.pylori
Urea breath test
Tool antigen tests
Rapid urease test on endoscopy
Management of h.pylor
Tripple therapy with ppi and 2 abx
Amox and clari and omeprazole
Define barrets oedophagus
Metaplasia of the squamous epithilium lining the oesophagus to columnar (like the stomach) after repeat exposure to acid.
Management of barretts oesohagus
PPI
Regular aspirin?
Ablation therapy
Define peptic ulcers
Ulceration of the mucosa of the stomach, or duodenum.
History of peptic ulcers
Epigastric discomfort
Nausea and vomiting
Dyspepsia
Bleeding causing haematemesis - coffee ground vomiting
Melaena
Iron deficiency anaemia
Management of peptic ulcers
PPIs
Endoscopy to monitor?
Complications of peptic ulcers
Bleeding
Perforation
Scarring - pyloric stenosis
Commo causes of upper GI bleeds
Oesophageal varices
Mallory-Weiss tear
Ulcers
Cancers
History of upper gi bleed
Haematemesis - coffee ground vomit
Melaena
Haemodynamic instability
Epigastric pain
Jaundice
What scoring system is used to assess the risk of having an upper GI bleed
Glasgow-Blatchford score
Drop in Hb
Rise in urea
Blood pressure
HR
Melaena
Syncope
What score is used to assess the risk of rebleeding and overall mortality of upper gi bleeds
Rockall score - after endoscopy
Age
Features of shock (tachycardia or hypotension)
Co-morbidities
Cause of bleed
Endoscopic stigmata of recent haemorrhage
Management of upper GI bleed
ABATED
ABCDE
Bloods
Access
Transfuse
Endoscopy
Drugs
Investigations in upper gi bleed
Haemaglobin
Urea
Coagulation
Liver disease
Crossmatch
Define inflammatory bowel disease
The umbrella term for two main diseases causing inflammation to the GI tract
What are the conditions that make up inflammatory bowel disease
Ulcerative colitis
Crohn’s
Features of Crohn’s disease
NESTS
No blood or mucus - less common
Entire GI tract
Skip lesions on endoscopy
Terminal ileum most commonly affected
Transmural - full thickness
Smoking is risk factor - don’t set the nest on fire
Features of ulcerative colitis
UC-CLOSEUP
Continuous inflammation
Limited to colon and rectum
Only superficial mucosa
Smoking is protective
Excrete blood and mucus
Use aminosalicylates
Primary sclerosing cholangitis
History of inflammatory bowel disease
DIarrhoea
Abdo pain
Passing blood
Weight loss
Investigations in IBD
Routine bloods - anaemia, infection, thyroid, kidney and liver function
CRP
Faecal calprotectin
Endoscopy
US, CT, MRI
Management of Crohn’s disease
Induce remission - steroids
Consider adding immunosuppression - azathioprine
Maintaining remission - azathioprine, mercaptopurine (methotrexate, infliximab, adalimumab)
Surgery - if only affecting distal ileum can be removed.
Management of ulcerative collitis
Induce remission - aminosalicylate (mesalazine)
2nd line 0 corticosteroids
Maintain remission - mesalazine, azathioprine, mercaptopurine
Surgery - ileostomy
Define coeliac disease
Auto immune condition where gluten causes inflammation to the small bowel. Particularly affects the jejunum where it causes intestinal villi atrophy leading to malabsorption.
History of coeliac disease
Failure to thrive - young!
Diarrhoea
Fatigue
Weight loss
Mouth ulcers
Anaemia - iron, b12 or folate deficiency
Dermatitis herpetiformis
Neurological signs - neuropathy, ataxia and epilepsy
Very linked to TIDM
Investigations in coeliac disease
Must be carried out whilst eating a gluten containing diet
anti-TTG
antiEMA
Endoscopy
What will be seen on endoscopy in coeliac disease
Crypt hypertrophy
Villous atrophy
What conditions are often associated with coeliac disease
Autoimmune conditions
TIDM
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Complications of coeliac disease
Vitamin deficinecy
Anaemia
Osteoporosis
Ulcerative jejunitits
Enteropathy associated t cell lymphoma
Non hodgkin lymphoma
Small bowel adenocarcinoma
