gastro Flashcards
how does alcohol related fatty liver progress
alcohol related fatty liver (reverse in 2w if stop)->alcoholic hepatitis (reversible with permanent abstinence)-> cirrhosis=scar tissue, irreversible
signs liver disease
jaundice
hepatomegaly
spider naivi
palmar eryhthema
gynaecomastea
bruising
ascities
caput medusae (engorged superficial epigastric veins)
asterixis
ix alcoholic liver disease
FBC=increased MCV
LFTS=increased ALT, AST, GGT, low albumin
increased prothrombin time
deranged U+Es
USS=increased echogenicity
endoscopy for oesophageal varices
CT/MRI
biopsy
mx alcoholic liver disease
detox
thiamine
steroids: improve short term outcome
tx complications
liver transplant: requires 3m abstinence
alcohol withdrawal
6-12h: tremor, sweating, headache, craving, anxiety
12-24h: hallucinations
24-48h: seizures
24-72h: delerium tremens
delerium tremens pathophysiology
alcohol removed so GABA underfunctions and glutamate over functions = excitability and excessive adrenergic activity
features delierium tremens
confusion
agitation
delusion
tremor
increased HR and BP
temp
ataxia
arrhythmia
what does low thiamine cause
wernickes: confusion, occulomotor problem, ataxia
korsakoffs: amnesia, behavioural change
common causes cirrhosis
alcoholic liver disease
NAFLD
hep b and c
uncommon causes cirrhosis
AI hepatitis
primary biliary cirrhosis
haemochromatosis
wilsons
alpha1antitripsin deficiency
CF
drugs: amiodarone, methotrexate, sodium valproate
what does USS show in cirrhosis
nodular
corkscrew arteries
enlarged portal vein with decreased flow
ascites
splenomegaly
screen for HCC every 6m
what is a fibro-scan
assess degree cirrhosis
transient elastography
have every 2y
score to estimate cirrhosis severity
child pugh score
child pugh score
bilirubin: 1= <34, 2= 34-50, 3= >50
albumin: 1= >35, 2= 28-35, 3=<28
INR: 1= <1.7, 2=1.7-2.3, 3= >2.3
ascites: 1=none, 2=mild, 3=mod/sev
encephalopathy: 1=none, 2=mild, 3=mod/sev
mx liver cirrhosis
USS and alpha fetoprotein every 6m for HCC
endoscopy every 3y
high protein and low sodium diet
MELD score (bilirubin, creatinine, INR, Na) every 6m
consider transplant
complications cirrhosis
malnutrition
mortal HTN and varices
ascites
spontaneois bacterial peritonitis
hepatorenal syndrome
hepatic encephalopathy
malnutrition and cirrhosis
reduced ability of protein metabolism and glycogen storage
mx stable portal HTN and varices
propanolol
elastic band ligation
injection sclerosant
TIPS
mx bleeding/ unstable portal HTN and varices
vasopressin analogue (terlipressin)
vit k and fresh frozen plasma
broad spectrum abx
endoscopy and injection sclerosant/band ligation
sengstaken-blakemore tube if endoscopy fails
mx ascites
spironolactone
ascitic tap
ciprofloxacin
TIPS
features spontaneous bacterial peritonitis
fever
abdo pain
ileus
low BP
cause spontaneous bacterial peritonitis
e.coli
klebsiella pneumoniae
Staph
mx spontaneous bacterial peritonitis
ascitic culture
IV cefotaxime
hepatorenal syndrome
decreased blood flow to kidnet
need transplant within 1wk
what causes hepatic encephalopathy
build up of ammonia
features hepatic encephalopathy
LOC
confused
changes to personality/memory/mood
mx hepatic encephalopathy
laxatives
abx-rifaximin
nutritional support
progression NAFLD
NAFLD->non alcoholic steatohepatitis->fibrosis->cirrhosis
NAFLD fibrosis score
age
BMI
liver enzymes
platelets
alubmin
DM
fibroscan
ELF blood test
mx NAFLD
mx RF
if fibrosis: vit E or pioglitazone
non invasive liver screen
USS
hep B and C serology
auto Ab: ANA, SMA, AMA, LKM-1
immunoglobulins
coeruloplasmin
alpha 1 antitrypsin levels
ferritin and transferrin saturation
causes hepatitis
alcoholic
NAFLD
viral
AI
drug induced - paracetamol
hepatic picture LFTs
increased AST and ALT
smaller increase in ALP
Hep A spread
RNA virus
faeco oral
mx hep a
vaccine
analgesia
resolves 1-3m
hep b spread
DNA virus
blood or bodily fluids
mx hep b
some have chronic sx
vaccine
antivirals
transplant if end stage
HBsAg
surface antigen
=active infection
HBeAg
E Ag
=marker viral replication, high infectivity
HBcAb
core Ab
=past or current infection
HBcAb
surface Ab
=vaccination or past or current infection
HBV DNA
viral load
Hep C spread
RNA virus
blood and bodily fluids
hep c mx
no vaccine
direct acting antiviral meds
hep c compliations
cirrhosis
HCC
hep D spread
RNA virus
cant survive without Hep B
what does hep D do
increase complications and severity hep b
hep E spread
RNA virus
faeco oral
mx hep E
no vaccine
supportibe - usually mild
features type 1 AI hep
adults 40-50y: fatigue and liver sx, ANA, anti-actin, anti-SLA/LP
feaures AI hep type 2
children - teens, acute hep and jaundice. anti-LKM1, anti-LC1
mx AI hep
pred
azathioprine
usually tx for life
haemochromatosis
excessive iron deposition
autosomal recessive - chrom 6 HFE gene
sx haemochromatosis
tired
joint pain
bronze
hair loss
erectile dysfunction
amenorrhoea
memory/mood
ix haemochromatosis
serum ferritin
transferrin saturation
liver biopsy with pearls stain
mx haemochromatosis
venesection
complications haemochromatosis
T1DM
cirrhosis
cardiomyopathy
HCC
hypothyroid
arthritis-chondrocalcinosis
wilsons disease
genetic
excess copper
sx wilsons disease
cirrhosis
neuro: dyasrthria, dystoia, parkinsonism
psych: depression, psychosis
kayser-fleischer rings
haemolytic anaemia
renal tubular acidosis
osteopenia
ix wilsons disease
serum coeruloplasmin
liver biopsy
24h urine copper assay
mx wilsons disease
copper chelation (penicilamine, trientene)
alpha 1 antitrypsin deficiency
autoromal recessive
leads to excess protease enzymes->liver cirrhosis and pulmonary basal emohysema
ix alpha 1 antitrypsin deficiency
serum alpha 1 antitrypsin
liver biopsy with acid-schiff positive staining globules
genetocs
CT thorax
mx alpha 1 antitrypsin deficiency
transplant
primary biliary cirrhosis
immune system attacks small bile ducts in liver
sx primary biliary cirrhosis
fatigue
pruritis
abdo pain
jaundice
pale and greasy stool
xanthoma
xanthelasma
cirrhosis
ix primary biliary cirrhosis
increased ALP, AMA, ANA, increased ESR, increased IgM
biopsy
mx primary biliary cirrhosis
ursodeoxycholic acid, colestyramine +/- steroids +/- transplant
associations with primary biliary cirrhosus
middle aged
F
other AI
rheum
complications primary biliary cirrhosis
steatorrhoea
distal renal tubular acidosis
hypothyroid
osteoporosis
HCC
primary sclerosisng cholangitis
intrahepatic or extrahepatic ducts strictured and fibrotic therefore obstruct bile outflow leading to liver cirrhosis
RF primary sclerosisng cholangitis
UC
M
sx primary sclerosing cholangitis
jaundice
RUQ pain
pruritis
fatigue
hepatomegaly
ix primary sclerosing cholangitis
cholestatic bloods=increased ALP
p-ANCA, ANA, aCP
MRCP
mx primary sclerosing cholangitis
ERCP
ursodeoxycholic acid
colestyramine
transplant
complocations primaru sclerosing cholangitis
bacterial cholangitis
cholangiocarcinoma
colorectal ca
fat sol vitamin deficiency
liver cancers
HCC
cholangiocarcinoma
haemangioma
focal nodular hyperplasia
RF HCC
cirrhosis
marker for HCC
alpha fetoprotein
mx HCC
resection
transplant
kinase i e.g. scrafenib
marker for cholangiocarcinoma
CA19-9
mx cholangiocarcinoma
resection
ERCP
features haemangioma
no sx
benign
features focal nodular hyperplasia
benign
asx
related to oestrogen
who is unsuitable for liver transplant
malnourished
active hep b/c
end stage HIV
active alcohol use
meds post liver transplant
steroids and azathioprine for life
features GORD
heartburn, acid regurg, epigastric pain, bloating, nocturnal cough, hoarse voice
mx GORD
lifestyle
gaviscon/rennie
PPI=omeprazole (reduces acid secretion)
H2 antagonist=ranitidine
when to 2ww for endoscopy
dysphagia
>55 and wt loss, upper ando pain and reflux, resistant dyspepsia, N+V, low Hb, high platelets
link between h.pylori and GORD
ammonia released damages epithelial cells
ix h.pylori GORD
urea breath test
stool Ag
rapid urease test in endoscopy
mx h.pylori GORD
7d PPI (omeprazole) and 2 abx (amoxicillin and clarithromycin)
test eradication=urea breath
barrets oesophagus
lower oesophageal epithelium changes from squamous to columnar
precursor adenocarcinoma
mx barrets oesophagus
PPI +/- ablation
peptic ulcer cause
due to breakdown of wall - h.pylori or nsaids
increased acid - stress, alcohol, smoking, caffeine, spice
sx peptic ulcer
epigastric pain
N+V
dyspepsia
bleeding=haematemesis
low iron=anaemia
what type of peptic ulcer worsens with food
gastric
what type of peptic ulcer is worse when hungry/improves with food
duodenal
ix peptic ulcer
endoscopy
check for h.pylori-urea breath test, rapid urease test in endoscopy
mx peptic ulcer
PPI
if perforates ->peritonitis->surgery
causes upper GI bleed
oesophageal varices
mallory-weis tear
ulcers-stomach/duodenum
cancer - stomach/duodenum
features upper GI bleed
haematemesis (vom blood)
melaena (black stool due to blood)
pain
mx upper GI bleed
A-E
bloods: Hb, urea (U+E), coag (INR), LFTs, crossmatch 2 units
access
transfuse if needed
endoscopy within 24h
stop anticoags and nsaids
definitive mx: OGD to intervene/stop bleeding
what is glascow-blatchford score for
risk upper GI bleed
components glascow blatchford score
Hb
urea
BP
HR
melaena
syncope
what is rockall score for
risk re-bleed after endoscopy
components rockall score
age
shock (HR and BP)
co-morbidities
cause
endoscopic stigmata
features crohns
entire GI tract
skip lesions
transmural thickness
wt loss
strictures
smoking is a RF
less common for blood/mucus
features UC
continuous inflamamtion superficial mucosa
colon and rectum only
blood and mucus excreted
smoking is protective
ix IBD
increased CRP
faecal calprotectin
endoscopy and biopsy
inducing remission in crohns
steroids: oral pred, IV hydrocortisone
+/- azathioprine, inlfiximab, methotrexate
maintenance in crohns
nothing
azathioprine
mercaptopurine
methotrexate
surgical options crohn
resect distal ileum
tx strictures and fistulas
inducing remission UC
mild/mod: aminosalicylate e.g. mesalazine or pred
sev: IV hydrocortisone, IV ciclosporin
maintenance in UC
mesalazine
azathioprine
surgical option sUC
remove colon and rectum leaving with ileostomy or j-pouch
IBS diagnosis
exclude other pathology: FBC, ESR, CRP, faecal calprotectin, anti-TTG Ab
sx of abdo pain relieved on defecation or associated wth change in bowels
+2 of: abnormal stool passage, bloating, worse after eating, mucus
mx IBS
lifestyle: reduce caffeien and alcohol, FODMAP, probiotics
1st line: loperamide if diarrhoea, laxatives if constipated, antispasmodic=buscapan
2nd line=amitryptiline
3rd line =SSRI
CBT
pathophysiology coeliac
anti-TTG and anti-EMA target epithelial cells
sx coeliac disease
asx
FTT
diarrhoea
aneamia
dermatitis herpetiformis
peripheral neuropathy
genes associated with coeliac disease
HLA-DQ2
HLA-DQ8
auto ab associated with coeliac disease
anti-TTG
anti-EMA
anti-DGP
diagnosis coeliac disease
exclude IgA deficiency
icreased anti-TTG or EMA
endoscopy=crypt hypertrophy, villous atrophy
conditions associated with coeliac disease
AI-T1DM, thyroid, AI hep, primary biliary cirhhosis, primary sclerosing cholangitis
complications coeliac disease
vit deficiencies
anaemia
osteoporosis
ulcerative jejunitis
enteropathy associated T cell lymphoma
NHL
small bowel adenocarcinoma
positive serology acute hep B infection
HBsAg
HBeAg
Anti-HBc IgM
HBV DNA
plus elevated transaminases
positive serology active chronic hep b infection
HBsAg
(HBeAg
Anti-HBc IgG
HBV DNA
plus elevated transaminases
positive serology inactive hep b infection/carrier
HBsAg
anti-HBe
HBc IgG
HBV DNA - low
positive serology hep b Immunity (following acute infection)
anti-HBs
anti-HBe
Anti-HBc IgG
positiver serology hep b Immunity (following vaccination)
anti-HBs
