Gastro Flashcards
chronic liver disease + transplant, colon cancer, haemochromatosis, IBD, coeliac, chronic pancreatitis , peptic ulcer disease , GORD
Causes of chronic liver disease
Fatty Liver
- Alcoholic
- Non-alcohol liver disease (NASH)
o DM/metabolic syndrome
o Pregnancy
o Idiopathic
Infectious
- Hepatitis : A – acute, B, C - chronic
- EBV
- CMV
Genetic
- Hereditary Hemochromatosis (AR)
o Increased intestinal iron absorption
- Wilson’s Disease (AR)
o Toxic accumulation of copper
- Alpha-1-antitrypsin deficiency (AR)
o Protease inhibitor (makes up most of alpha-1 globulin on protein electrophoresis)
Congestion
- Budd-Chiari Syndrome
- RHF/CHF
Autoimmune
- Autoimmune Hepatitis
o Ab against hepatocyte surface antigen
- Primary Biliary Cirrhosis
- Primary Sclerosing Cholangitis
Toxins/drugs
- Alcohol
- Paracetamol overdose
- Isoniazid, methotrexate, methyldopa, nitrofurantoin
Complications of chronic liver disease
- Portal Hypertension
- Hepatic Encephalopathy/Cerebral oedema
- Synthetic dysfunction causing coagulopathy, hypoalbuminaemia and feminization
- Hepatocellular Carcinoma
- Spontaneous bacterial peritonitis
- Hepatorenal syndrome
- Ascites
- Hypoglycaemia
Investigations for chronic liver disease - bloods and imaging + others
Bedside
- Fluid balance, weight
Bloods
- FBC, CRP (infection, GI bleed, leucopenia and thrombocytopenia suggest hypersplenism)
- Chemistry (urea synthesized in liver, creatinine for hepatorenal syndrome, CRP, ammonia for encephalopathy)
- Glucose
- Coags (↑ PT, ↑APTT, ↑Thrombin time)
- LFT’s (AST/ALT – hepatocellular, GGT/ALP –cholestatic, AST:ALT ration of>2 suggests alcoholic liver disease)
- Liver screen
o Viral serology (Hep B surface and core antigen, Hep C antibody, Hep A IgM, EBV, CMV)
o Autoantibodies
Autoimmune hep: ASMA, ALKM1, AMA
- PBiliaryC: AMA
- PSscleroC: ANA
o Caeruloplasmin, serum copper
o Ferritin
o Alpha-1 Antitrypsin (protein
electrophoresis 1 band) α
o Alpha fetoprotein - HCC
Imaging
- Abdo USS +/- portal vein Doppler (BC syndrome)
- Fibro scanning to diagnose cirrhosis
- MRCP
Other
- Ascitic tap
o High protein exudate
o Blood malignancy
o High cell count SBP
o Lactate SBP
o Amylase pancreatitis
Management of chronic liver disease
- non pharm, underlying cause, nutritional, ascites, varices, encephalopathy, pruitis, sbp
Non-Pharmacological
- Low salt diet, fluid restriction
- Alcohol abstinence
- Optimize nutrition
Pharmacological
- Treat underlying cause
o Hep B – entecavir od, sub cut PEG interferon
o Hep C – maviret 3 tab daily for 8, 12, 16 weeks
o Haemochromatosis – regular
venesection
o AIH – steroids
o NASH – weight loss, exercise, statins, Vit E in absence of DM
- Nutritional
o NG feeding if decompensated
o Vitamin B supplementation
o Glucose infusion if hypo - Ascites
o Bed rest and fluid restrict, low salt diet
o Spironolactone 100mg + Frusemide if response is poor
o Therapeutic paracentesis with concomitant albumin infusion can be tried - Varices
o If present, prophylactic treatment with B-blockers or if contraindicated variceal band ligation - SBP (spontaneous bacterial peritonitis)
o Antibiotics e.g. cefotaxime + metronidazole or Tazocin until sensitivities known.
o Prophylaxis in high risk patients - Encephalopathy
o Remove precipitating factors
Enemas to rid gut of blood
Low protein diet
Attack urea splitting organisms with lactulose or
antibiotics like neomycin or metronidazole
o Lorazepam for seizures
o Mannitol in cerebral oedema - Pruritus – treat with cholestyramine
- Bleeding – vitamin K
- Avoid
o Gentamicin
o Naltrexone
o NSAIDS, opiates
o Sedatives
Different Hepatitis - ABCD as well as interpretation of serology
Hep A
Acute infection
Faecal oral transmission, more common from overseas travel, also body fluid-sex and drugs
- Anti-HAV IgM (recent infection)/ IgG (past infection/immunisation)
Has vaccine
Hep B
Most common, acute or chronic
Transmit by body fluid e.g. sex, IV drug use
- Hep B surface antigen: active infection
- Anti-hepB surface antigen - recovery from hep B or vaccination
- anti hep B core antigen - past or ongoing infection. - IgM core -acute
Vaccine routinely
More kids get chronic
Hep C
Chronic can lead to cirrhosis
Transmit through blood e.g. iv drug, blood transfusion pre 1992
- anti HCV core- exposure
- HCV RNA - active infection
Invasive treatment and hccancer screening for chronic liver disease and in those after liver transplant
Invasive
- TIPSS (trans jugular intrahepatic
portosystemic shunt)
- Liver transplant
Screening
- abdo USS +/-alpha -fetoprotein every 6 months to screen for HCC (esp if cirrhosis from Hep B or Hep C)
OR annual MRI for HCC in pt with recurrent viral hep or hx of hcc (in transplant)
Risk factors, examination, screening for colon cancer
Screening
- Faecal occult blood home testing kits - + result requires colonoscopy
- High risk pt require more routine colonoscopy eg. IBD, adematous polyps, colorectal ca, fam hx of colorectal ca
Lynch syndrome: HNPCC have increased risk of CRC but also increased risk of other cancers of stomach, small intestine, liver, gall bladder, upper
urinary tract, skin +/- ovaries & endometrium. May have benign polyps.
Risk factors
- Polyps
- Family hx: colon cancer, familial adenomatous polyposis (FAP), hereditary
non-polyposis colon cancer (HNPCC).
- Inflammatory bowel disease
- Previous cancer
- Smoking
- Diet – low fibre, high red meat
- Alcohol
EXAMINATION
- Anaemia or jaundice
- Abdo – masses, radio skin changes, scars
- Ask for PR exam results
- Lymph nodes
- Skin lesions and mucosal pigmentation
Investigations and management for colon cancer (surgical, rads, chemo)
INVESTIGATIONS
Bloods
- FBC (microcytic anaemia)
- LFT
- CEA to monitor disease and effectiveness of treatment
- Faecal occult blood (if screening)
Imaging
- Colonoscopy or CT colonography
- Liver USS
Other
- If polyposis or HNPCC in family, refer for genetic testing once > 15 years.
- aspirin can be used as prevention to inhibit polyp growth in those high risk
MANAGEMENT
Surgery
- R hemi –> caecal, ascending and proximal transverse colon tumours
- L hemi –> distal transverse or descending colon
- Sigmoid colectomy sigmoid tumours
- Anterior resection low sigmoid or high rectal tumours
- Abdomino-perineal (A-P) resection with permanent colostomy and removal or anus and rectum +/- reconstruction tumours low in rectum (< 8 cm from anus)
- Hartmann’s procedure emergency bowel obstruction
- If metastatic, not for resection unless isolated liver met only.
Endoscopic
- Transanal microsurgery local excision in those unfit for surgery
Stenting palliation in malignant
obstruction or bridging to acute surgery
Radiotherapy
- usually pre-op for rectal tumours or to
downstage irresectable tumours
Chemotherapy
- 5-fluorouracil +/- others for involvement of regional lymph nodes
Dukes classification for staging colon cancer
A: 90% 5yr tx survival -confined to beneath the muscularis mucosa
B: 65% - extension through the
muscularis mucosa
C: 30% Involvement of regional
lymph nodes
D: <10% Distant metastases
the post transplant complications of liver transplant and treatment/ monitoring (7)
Hypertension - due to CNI use
- Self monitoring for first 6 months every week and GP every month, w/out HTN then every 6mo
- Ca blocker (avoid first gen as interact with CNI
- Cardioselective BB (meto)
DM
- Fasting plasma glucose or HbA1c every 6 months and annual retinal screening in patients with dm
Renal disease
- eGFR every 2-3 months for first year , then eGFR + Cr every 3-6 months
- Urinalysis annually for microalbuminuria
Gout/Hyperuricaemia – both CNIs decrease uric acid excretion
- Acute attack treated with colchicine, then prednisone. NSAIDS avoided.
- Maintenance is allopurinol 1.5mg x eGFR (max 100)
Metabolic bone disease
- DEXA scan prior to transplantation and every second year after
Screening for skin and non-skin malignancy
- Annual physical exam – +oropharynx + full body
- PSA annual
-PAP + mammography annual
- Colon screening as per national schedule
- Liver screening
Smoking cessation + sunblock
Infection risk
- CMV screening
- live vaccines given pre LT + vaccines for Hep A B
What are differentials for dyspepsia (epigastric pain related to food, bloating,heartburn, early satiety, postprandial fullness). What are the red flags symptoms indicating need for gastroscopy, and points to get on exam
= GORD/Oesophagitis,
- peptic ulcer disease: gastric ulcers and duodenal
ulcer,
- gastritis,
- gastric malignancy, functional/non-ulcer dyspepsia
- chronic pancreatitis/ cancer
- biliary pain
- intestinal angina (chronic mesenteric ischaemia
- crohns disease
Red flags
Anaemia (iron deficiency), Losing weight, Anorexia,
Recent onset of progressive symptoms, Melaena, Swallowing difficulty)
others
-Duodenal ulcers are typically relieved by eating and gastric ulcers worsened
- NSAID use, smoking, fam hx
Exam
- Abdominal examination
- Usually tender in epigastrium
- Don’t forget to check (L supraclavicular node indicative of gastric Ca metastasis)
- Look for signs of anaemia
- Check for mass in abdomen (cancer)
What are the investigations ordered for dyspepsia ; how does it change if you have over 55/ have alarm symptoms
- FBC (check for anaemia from ulcer bleeding)
- Urease breath test (for H. Pylori) OR faecal antigen test (stop PPI for 2 weeks)
OGD - with biopsy and histology of these these samples
If alarm symptom or if onset >55yo, or if no improvement after medications then Gastroscopy with biopsy
If under 55 + no ALARM symptoms, then you can just treat with PPIs and H pylori
eradication without the need for a scope.
- CXR (look for free air under diaphragm = perforation)
- Barium swallow – hiatus hernia or poor LOS function
- 24h oesophageal pH monitoring if endoscopy is normal
what is the management of dyspesia due to peptic ulcer + complications
Lifestyle
- Avoid food that worsens symptoms,
- stop smoking (slows healing of ulcers).
Pharm
- H. Pylori triple eradication therapy : (omeprazole, clarithromycin, and
metronidazole/amoxicillin) for 7 days if present
- Acid reduction with PPIs (omeprazole 40mg od/bd) for 4 weeks (DU) or 8 weeks (GU).
Can also use H2 antagonists (ranitidine PRN) but not as effective.
- Stop NSAIDs and steroids or
- May require lifelong PPIs if require long term NSAIDs for
another condition.
SURGICAL
- Gastric surgery if severe bleeding or perforation.
- All patients should be followed up after treatment with another gastroscopy to confirm healing.
Complications
- perforation, bleeding,
malignancy
What are the discerning features of GORD on hx and exam, investigations
- Heartburn (retrosternal burning pain related to meals and lying down)
- Acid regurgitation
- Odynophagia, Hoarse voice
- Chronic cough
- Nocturnal asthma
- Risk factors = hiatus hernia, smoking, alcohol, obesity, LOS dysfunction, pregnancy, drugs (TCA’s and nitrates)
Examination
-Abdominal, also look at throat and look for signs of anaemia
Investigations
- Barium swallow (looking for hiatus hernia and assess LOS function)
- Scope to look for cobble stoning.
Specific management for GORD
- ppis better than h2 antagonists
Lifestyle
- Avoid foods that trigger symptoms, lose weight, decrease alcohol, stop smoking
Acid reduction = first try antacids (Mylanta and Gaviscon), then PPI’s (omeprazole), then H2 antagonists (ranitidine).
