Gastro Flashcards
what are some stigmata of chronic liver disease
spider naevi
gynacomastia
ascites
caput medusa
palmar erythema
jaundice
splenomegaly
what are some precipitants of hepatic encephalopathy
UGIB
alcohol ingestion
portal vein thrombosis
SBP
what
what are some differentials for confusion and low GCS
alcoholic encephalopathy
alcohol/drug intoxication
electrolyte disturbanc eg hyponatremia
endocrine eg hypoglycaemia
head injury eg SDH
what are the 5 components of Child-Pigh score for ALD
BAAIE
ascities
albumin
INR
encephalopathy
bilirubin
name some things than can exacerbate chronic liver disease plus how you would test
- SBP - ascitic tap
- GI bleed - PR
- head trauma - CT
- alcohol - serum alcohol
- drug ingestion - UDS
- hypo - BSL
- hepatic vein thrombosis - US
what are the management step for suspected button battery ingestion?
- NBM
- X ray neck (lateral) chest and abdo to look for battery
- hx to obtain likelihood and number of batteries
- assess patient for signs of complications eg resp distress, stridor, SOB, haematemesis abdo pain etc
with button battery ingestion what the indications for immediate endoscopy?
what conditions need to be met for conservative management?
discharge advice?
endoscopy:
* symptomatic
* magnet co-ingestion
* battery lodged in oesophagus
Conservative
* asymptomatic
* battery under 12mm
* single battery
* no pre-existing oesophageal disease
* reliable caregiver
* proximity to hospital
advice’
* avoid laxitives
* immediate return if GI/resp sx
* regular diet and encourage activity
* examine stool to look for it
* return if not passed in 10-14 days
what two factors affect whether attempt to resite PEG
time since PEG placement
Ig under 4 weeks may not have matured and risk of tube misplacement
Time since peg removal
should be within 24 hours
major bleeding
peritonitis
tract closure
what can be used as alternative to PEG
what can be used to confirm placement
large gauge foley catether
imaging eg water soluble imaging contrast via tube and CT
What are some PEG complications that can present to ED
- accidental removal
- bleeding
- leaking
- blockage
- pneumoperitomeum
- gastric ulceration
- gastric outflow obstruction
- ileus
- aspiration
describe and interpret key abnormalities
- hepatic failure with non obstructive pattern
- hypoglycaemia
- impaired synthetic function with low albumin and high INR
- ?hepatic encephalopathy as drowsy
Potential causes?
- toxins eg paracetamol
- alcoholic liver cirrhosis
- viral hepatitis
- ischaemic liver injury
- budd chiari
- wilsons
- malignancy
- autoimmune
list and justify potential investigations to work out cause
- VBG – assess for acidosis
- Xmatch – risk of bleeding if coagulopathic & may need FFP
- U&E – correct electrolyte abnormalities & assess for renal failure
- FBC – look for anaemia & thrombocytopenia
- Ammonia level – look for hepatic encephalopathy
- Paracetamol level – consider need for NAC
- Drug screen – assess possible ingestions/overdoses
- Hepatitis serology – look for aetiological cause for liver failure
- Autoimmune markers – look for aetiological cause for liver failure
- CXR – look for complications such as pleural effusions.
- CT Abdo – assess cause of liver failure such as hepatic vein thrombosis, malignancy,
- ischaemia, cirrhosis.
- CT Brain – look for signs of cerebral oedema
Interpret and justify
- unconjugated hyperbilirubinaemia
- heptatocellular pattern as ALT/AST >ALP/GGT - likely hepatitis
- low albumin likely from impaired synthetic function of liver
non infective cause of hepatitis
malignancy
tox - paracemtaol
wilsons
budd chiary
autoimmune
NAFLD
alcoholc ciirrhosis
what investigations would you perform in suspected variceal bleed?
VBG - degree of hypoperfusion/lactate/HB
HB - guide RBC replacement
Coags - guide replacement
BSL - likely in liver failure and can replace
CT tri phasic - degree of bleeding
what haematological parameters do you target in management of variceal bleed?
HB>70
INR<1.6
PLT>50
Fibrinogen >1
ionised Ca normal range
what is the initial management of variceal bleed?
- fluid resis and blood replacement
- urgent endoscopy for variceal banding
- ocreotide 50mcg bolus
- IV abx
- ?AWC
what are the US findings consistent with cholecystitis?
GB wall >3mm
gallstones
sonographic murphys sign
pericholycystic fluid
what is the normal diameter of CBD?
under 8mm
causes of extrhepatic biliary obstruction
Complications?
- pancreatic mass
- cholangiocarcinoma
- choledocholithiasis
Complications:
cholangitis
reduced absorption of vit K
what is the key finding?
What complications can arise?
rectal FB with no obvious perforation
Complications:
* rectal mucosa laceration and bleeding
* perforation
what are the anaesthesia options for removal in ED?
Non anaesthesia
Anaesthesia:
* regional anaesthesia - perianal block
* procedural sedation eg fent/prop
Non anaesthesia
* valsalva with lubricant
* gentle traction with lubricant
* foley catheter wth 50ml balloon and lubricant
aortoenteric fistula
supratherapeutc anticoagulation
embolic mesenteric iscahamia
what can be used to reverse dabigatran
Idarucizumab
what organisms can cause vascular prosthetic infection?
s.aureus
e.coli
enterococcus
salmonella
q-fever
two possible causes?
List three further tests and rationale
- bone mets
- pagets disease
Tests
* FBC - ?anaemia in malignancy
* calcium - hypercalcaemia in malignancy
* PSA - ?prostate ca
what cancers common metastasize to bone
prostate -NB SCLEROTIC
breast
bladder
lung
thyroid
kidney
