Gastro Flashcards
1
Q
What is the primary function of the oesophagus?
A
Acts as a conduit for food
2
Q
What is the average length of the oesophagus?
A
Approximately 25cm
3
Q
What is the gastro-oesophageal junction?
A
Transitional zone between the oesophagus and the stomach
4
Q
What is the ‘Z-line’?
A
Mucosal transition point at the gastro-oesophageal junction
5
Q
What type of epithelium replaces stratified squamous cells in Barrett’s oesophagus?
A
Simple columnar epithelium with goblet cells
6
Q
What is the role of the myenteric plexus?
A
Innervates predominantly smooth muscle for coordinated peristaltic waves
7
Q
What is the function of the lower oesophageal sphincter?
A
Prevents acid reflux and allows food boluses to enter the stomach
8
Q
What happens when the processes of oesophageal contractility fail?
A
Can lead to conditions such as achalasia and gastro-oesophageal reflux disease
9
Q
What are the main roles of the stomach?
A
Acts as a reservoir for food, produces hormones and proteins, assists with mechanical digestion
10
Q
What is the significance of hydrochloric acid in the stomach?
A
Key to digestion
11
Q
What is intrinsic factor (IF) and its role?
A
Binds to vitamin B12 and helps its absorption in the terminal ileum
12
Q
What are the primary substances absorbed in the stomach?
A
Water, alcohols, caffeine, some medications such as aspirin
13
Q
What regions of the stomach are involved in digestion?
A
Cardia, fundus, body, pylorus
14
Q
What is the purpose of the pyloric sphincter?
A
Separates the pylorus from the duodenum and regulates chyme passage
15
Q
What are the three muscular layers of the stomach?
A
Inner oblique layer
Middle circular layer
Outer longitudinal layer
16
Q
What is the histological structure of the stomach?
A
Mucosa with columnar epithelia, submucosa, muscularis layer, serosa
17
Q
What do Brunner’s glands do?
A
Secrete bicarbonate to alkalinate acidic chyme
18
Q
Which hormones are secreted by enteroendocrine cells in the stomach?
A
Gastrin
Intrinsic Factor
Pepsinogen
19
Q
What stimulates the secretion of gastrin?
A
Stretch of the fundus
20
Q
What is the primary function of cholecystokinin (CCK)?
A
Increases gall bladder contraction and pancreatic enzyme secretion
21
Q
What is the role of somatostatin in the stomach?
A
Decreases gastric acid production
22
Q
What does pepsin do?
A
Degrades amide bonds between amino acids in proteins
23
Q
What is the anatomical structure of the duodenum?
A
C-shaped structure approximately 30cm in length
24
Q
What is the role of the Ampulla of Vater?
A
Regulates the release of bile and pancreatic enzymes into the duodenum
25
What is the primary site of iron absorption?
Duodenum
26
What are the components of the pancreas?
*Head*
*Neck*
*Body*
*Tail*
27
What do alpha cells in the pancreas secrete?
Glucagon
28
What do beta cells in the pancreas secrete?
Insulin
29
What is the primary function of the jejunum?
Major site of nutrient absorption
30
What structures increase the surface area for absorption in the jejunum?
Villi and microvilli
31
What nutrients are primarily absorbed in the jejunum?
*Simple sugars*
*Amino acids*
*Vitamins*
*Glucose*
*Iron*
32
What is the primary site of vitamin B12 absorption?
Ileum
33
What is the role of the caecum?
Acts as a junction between the small intestine and colon
34
What are haustra in the colon?
Wide bulges of colon between taeniae coli
35
What is the major function of the colon?
Extract residual salt and water from luminal contents
36
What is the function of the sigmoid colon?
Connects the descending colon to the rectum
37
What is the primary function of the rectum?
Storage site for faeces prior to defecation
38
What is the function of the anal canal?
Provides controlled release of faeces during defecation
39
What histological changes occur in the anal canal?
Transition from simple columnar epithelium to stratified squamous epithelium
40
What is Sudak's point in relation to arterial blood supply?
Arterial blood supply changes from the inferior mesenteric artery supplying the sigmoid colon to the internal iliac artery
41
What is the function of the anal canal?
To provide muscular sphincter controlled release of faeces on defecation
42
What type of epithelium lines the first zone of the rectum?
Simple columnar epithelium
43
What type of epithelium is found at the pectinate line of the anal canal?
Stratified squamous epithelium
44
What does the anal verge represent?
The distinct line between anal tissue and external skin
45
What type of neural control governs the gastrointestinal tract?
Autonomic neural control
46
What is the role of peristalsis in the GIT?
Essential for mechanical digestion, delivery of nutrients to absorption sites, and elimination of waste products
47
What are interstitial cells of Cajal known for?
Acting as an 'internal pacemaker' to the small and large intestine
48
What embryonic layer does the entire gastrointestinal tract derive from?
Endoderm structures
49
What is Meckel's diverticulum?
A condition that persists when there is no retraction of the yolk sac attachment
50
What are the three divisions of the GIT during early fetal life?
* Foregut
* Midgut
* Hindgut
51
What role does the gut microbiome play?
Linked to many disease states, particularly autoimmune conditions
52
What is faecal transplantation?
An emerging therapeutic field with a high cure rate for C. difficile infection
53
What is the most common cause of Gastrooesophageal Reflux Disease (GORD)?
Transient lower oesophageal relaxation
54
What lifestyle factors predispose to lower resting lower oesophageal sphincter tone?
* Alcohol
* Caffeine
* Smoking
* Fat-rich diets
55
How is GORD diagnosed?
Endoscopic assessment of the oesophagus
56
What does the LA Classification assess in GORD?
Length of inflammation and mucosal breaks with the degree of the circumference affected
57
What are complications of GORD?
* Oesophageal metaplasia
* Ulceration
* Strictures
* Chronic cough
58
What is the role of Proton Pump Inhibitors in GORD management?
Reduce acid production and symptoms
59
What is Barrett's Oesophagus?
Oesophageal metaplasia at the lower oesophageal junction
60
What is the progression rate of Barrett's Oesophagus to oesophageal adenocarcinoma?
0.2% per year
61
What are the risk factors for Barrett's Oesophagus?
* Duration of GORD
* Alcohol
* Smoking
* Obesity
* Male
* Caucasian
62
What is Eosinophilic Oesophagitis?
A form of allergic response presenting symptoms similar to GORD
63
What is the characteristic feature of Eosinophilic Oesophagitis on biopsy?
Eosinophil infiltration of oesophageal tissue
64
What is the initial treatment for Eosinophilic Oesophagitis?
PPI therapy followed by repeated endoscopy and histological assessment
65
What is the key pathological abnormality in Achalasia?
Failure of smooth muscle relaxation of the lower oesophageal sphincter
66
What diagnostic tests are used for Achalasia?
* Oesophageal Manometry
* Barium Swallow
67
What is the most common and safest surgical treatment for Achalasia?
Modified Heller Myotomy
68
What is H. Pylori?
A gram-negative, flagellated bacterium that colonizes the stomach
69
What are common symptoms of H. Pylori infection?
* Gastritis
* Abdominal pain
* Ulceration
70
What are the protective factors against peptic ulcer disease?
Regular PPI therapy
71
What is the gold standard for diagnosing H. Pylori?
Gastric biopsy and staining for H pylori organisms
72
What is the treatment regimen for H. Pylori eradication?
* Proton Pump Inhibitors
* Antibiotic therapy
73
What are the common causes of Vitamin B12 deficiency?
* Vegan diet
* Pernicious anaemia
* Atrophic gastritis
* Gastrectomy
* Terminal ileum disease
74
What is pernicious anaemia?
Autoimmune destruction of parietal cells by autoantibodies
75
What is the consequence of Vitamin B12 deficiency?
* Megaloblastic anaemia
* Neurological issues
* Oral manifestations
76
What is the significance of the Schilling's Test?
To diagnose pernicious anaemia and absorption disorders
77
What are common clinical presentations of malabsorption syndromes?
* Iron deficiency
* Folate deficiency
* Vitamin B12 and ADEK deficiencies
78
What is the cause of pernicious anemia if B12 elimination corrects with Intrinsic Factor supplementation?
Pernicious anemia
79
What condition is indicated if B12 elimination corrects with antibiotics?
Small bowel bacterial overgrowth
80
What is the cause of B12 elimination correction with a gluten-free diet?
Coeliac disease
81
What can malabsorption of nutrients lead to?
Deficiencies
82
Common clinical presentations of malabsorption include deficiencies in which nutrients?
* Iron
* Folate
* Vitamin B12
* ADEK vitamins
83
What can occur following ileitis or ileal resection in Crohn's Disease?
Malabsorption of Vitamin B12, fat-soluble ADEK vitamins, and bile acids
84
What is a consequence of impaired ileal reabsorption of bile acids?
Increased gallstone production and passive oxalate absorption leading to nephrolithiasis
85
What factors contribute to the pathophysiology of Coeliac disease?
* Genetic factors
* Environmental factors
* Autoantibody formation
86
What are common symptoms of Coeliac disease?
* Diarrhoea
* Abdominal cramps
* Bloating
87
What HLA predispositions are associated with Coeliac disease?
* HLA-DQ2
* HLA-DQ8
88
Coeliac disease is associated with which other autoimmune disorders?
* Type 1 Diabetes Mellitus
* Thyroid disorders
* IgA deficiency
* Vitiligo
89
What is the gold standard for diagnosing Coeliac disease?
Endoscopy and small bowel biopsy
90
What should be assessed when testing for Anti-TTG or Anti-Endomysial antibodies?
Total IgA levels
91
What does histology of Coeliac disease show?
* Increased intraepithelial lymphocytes
* Villous atrophy
* Crypt hyperplasia
92
What is the mainstay treatment for Coeliac disease?
Complete abstinence from gluten-containing diets
93
What is a rare complication in Coeliac disease that requires exclusion of alternative causes?
Refractory disease
94
What is the most common cause of pancreatitis?
Alcohol excess or biliary tree obstruction
95
What is the most common genetic mutation associated with inherited pancreatitis?
Trypsinogen gene PRSS1 mutation
96
What is the role of smoking cessation in relation to pancreatic cancer?
It reduces the risk of pancreatic cancer
97
What enzyme is inadequately functioning in Gilbert Syndrome?
Glucuronyltransferase
98
What happens when the glucuronyltransferase system becomes saturated?
Excess unconjugated bilirubin is excreted back into the bloodstream
99
What can cause a rise in unconjugated bilirubin in Gilbert Syndrome patients?
Drugs that impair metabolic enzymes, like Erythromycin
100
What does the term 'colitis' refer to?
Inflammation of the colon from any etiology
101
What are common symptoms of colitis?
* Abdominal discomfort
* Diarrhoea
* Mucous stool
* Rectal bleeding
102
What are the differential diagnoses of colitis?
* Infectious
* Inflammatory
* Vascular
* Drug-related
* Microscopic colitis
103
What is the most common cause of acute colitis?
Infectious colitis
104
What is the most common viral cause of colitis?
Viral colitis
105
What are the two major inflammatory bowel diseases causing colitis?
* Crohn's Disease
* Ulcerative Colitis
106
What is the surgical emergency related to ischaemic colitis?
Ischaemic colitis
107
What is the management for acute ischaemic colitis?
Urgent bowel resection
108
What are the symptoms of microscopic colitis?
* Chronic, profuse, watery, non-bloody diarrhoea
* Bloating
* Abdominal discomfort
* Faecal incontinence
109
What are the two forms of microscopic colitis?
* Lymphocytic
* Collagenous
110
What is the first-line treatment for microscopic colitis?
Withdrawal of potentially causative drugs
111
What dietary modification can help manage IBS?
Low FODMAP diet
112
What are the sub-classifications of IBS based on symptoms?
* IBS-C (constipation predominant)
* IBS-D (diarrhoea predominant)
* IBS-M (mixed symptoms)
113
What are common risk factors for Clostridium Difficile infection?
* Older age
* Hospitalisation
* Recent antibiotic use
* Proton pump inhibitor therapy
114
What is the first-line treatment for acute Clostridium Difficile infection?
Oral Metronidazole
115
What common symptom is associated with constipation?
Infrequent bowel movements
116
What are common underlying causes of constipation?
* Idiopathic dysmotility disorders
* Hypothyroidism
* Autonomic dysfunction
* Obstructive lesions
* Drug-related causes
117
What is the multifocal approach to treating constipation?
* Adequate hydration
* Fibre-enhanced diet
* Exercise
* Aperients
118
What is the role of saline in combination therapy?
Saline is used as a route of administration in combination therapy
## Footnote
Saline can help with hydration and electrolyte balance.
119
Name two types of stimulants used in constipation treatment.
* Senna
* Bisacodyl
120
What is the mechanism of action of surfactants in treating constipation?
Surfactants enable more water in stool
121
What is the time frame for oral administration of polyethylene glycol?
2-72 hours
122
What complications can arise from constipation?
* Anal fissures
* Haemorrhoids
* Rectal prolapse
123
What might faecal impaction require for resolution?
Manual or surgical disimpaction
124
What is Crohn's Disease (CD)?
An inflammatory bowel disease characterized by transmural inflammation of the GI tract
125
What is the peak onset age for Crohn's Disease?
2nd-3rd decade of life
126
What genetic mutation is associated with Crohn's Disease?
NOD2/CARD15 gene mutation
127
List two risk factors for Crohn's Disease.
* Smoking
* NSAID use
128
What is the increased risk associated with Crohn's Disease after 8 years?
Increased risk of colorectal cancer
129
What type of inflammation is primarily seen in Crohn's Disease?
Transmural inflammation
130
What is a common presentation of ileitis in Crohn's Disease?
Right lower quadrant pain
131
What systemic symptoms indicate more severe Crohn's Disease?
* Fever
* Weight loss
* Fatigue
132
What is the Crohn's Disease Activity Index (CDAI)?
A scoring system to determine disease severity based on stools/day, pain score, and other factors
133
What ocular manifestations can occur with Crohn's Disease?
* Uveitis
* Episcleritis
134
What is the significance of ASCA positivity in blood tests?
Specific for Crohn's Disease
135
What is the most widely used tool for assessing Crohn's Disease?
Colonoscopy
136
What type of lesions are typically seen in the colon during colonoscopy for Crohn's Disease?
* Patchy skip lesions
* Focal ulcerations
* Cobblestone appearance
137
What is the treatment approach for mild to moderate Crohn's Disease?
Induction with corticosteroids followed by maintenance therapies
138
What are TNF-a inhibitors used for in Crohn's Disease?
Effective for acute CD and maintenance therapy
139
What is the risk associated with TNF-a inhibitors?
Risk of tuberculosis reactivation
140
What is the main mechanism of action for azathioprine?
Immunosuppression via T cell apoptosis
141
What is Ulcerative Colitis (UC)?
An autoimmune condition characterized by inflammation limited to the mucosa of the colon
142
How does UC typically progress through the colon?
Begins at the rectum and spreads retrograde without skip lesions
143
What are common symptoms of Ulcerative Colitis?
* Diarrhoea
* Frank bleeding
* Abdominal pain
144
What can severe bleeding in Ulcerative Colitis lead to?
Severe iron deficiency anaemia and hypovolaemic shock
145
What increases the risk of colorectal carcinoma in Ulcerative Colitis?
Long-term disease duration
146
What is the importance of monitoring TPMT activity in patients on azathioprine?
Underactive TPMT can cause high 6-TG levels leading to bone marrow suppression
147
What is the typical treatment for severe Crohn's Disease?
* Bowel rest
* Intravenous corticosteroids
* Intravenous antibiotics
148
What is the recommended action if a patient has low 6-TG levels on azathioprine?
Consider allopurinol to increase drug activity
149
What is a common radiological assessment for ulcerative colitis (UC)?
There is no standardised radiological assessment for UC
## Footnote
'Thumb-printing' may be seen on abdominal X-Ray
150
When is Computed Tomography (CT) indicated for UC?
For acute presentations concerning for bowel perforation
## Footnote
CT is rarely used for known UC surveillance
151
What is the purpose of Flexible Sigmoidoscopy in UC assessment?
To assess the mucosa within the rectum and sigmoid colon, up to the splenic flexure
## Footnote
Biopsies can still be taken during this procedure
152
What are the luminal appearances generally associated with UC?
Continuous mucosal friability extending from the rectum
* No skip lesions
* No focal ulcerations
153
What is indicated for biopsies of abnormal mucosa in UC?
To assess the degree of inflammation and exclude other diagnoses
154
What is the goal of random mucosal biopsy during UC treatment surveillance?
To ensure 'histological remission'
## Footnote
This reduces exacerbations, surgery requirement, and bowel cancer risk
155
What technique is used in chromoendoscopy for UC?
Uses blue dye to detect flat dysplasia on the mucosal surface
156
What histological changes are seen in active UC?
Inflammation of crypts with neutrophil infiltration and crypt abscesses
* Distortion of crypt architecture
* Increased inflammatory cells, typically lymphocytes and plasma cells
157
Does smoking cessation improve outcomes in UC?
No, smoking cessation does not improve outcomes in UC, but is recommended due to adverse effects of smoking
158
What is the first line treatment for proctitis in UC?
Topical 5-Aminosalicylic Acid (s-ASA, Mesalazine) - suppository or rectal enema/foams
159
What is a common treatment for mild-moderate left-sided or pan-colitis?
Intravenous steroids to induce remission
* Combination of oral and rectal 5-ASA therapies for maintenance
160
What treatment is indicated for fulminant colitis?
Intravenous fluid resuscitation
* Intravenous corticosteroids
* Red blood cell transfusion
* Intravenous antibiotic therapy
161
What is the role of 6-mercaptopurine, azathioprine, and methotrexate in UC?
Very limited role in UC
162
What are TNF-a inhibitors used for in UC?
Very effective in fulminant colitis and treatment-resistant disease
## Footnote
Examples include Infliximab and Adalimumab
163
What is the function of a4/b7-Integrin Inhibitors in UC treatment?
Blocks lymphocyte trafficking proteins to reduce lymphocyte infiltration to inflammatory lesions
## Footnote
Example includes Vedolizumab
164
What is the risk associated with IL-12 and IL-23 Inhibitor therapy in UC?
Increased risk of infections, including tuberculosis reactivation
165
What surgical procedure is most commonly performed for UC?
Total colectomy and the formation of a J-pouch from ileum
## Footnote
A remnant cuff of rectum remains in situ and is still at risk of rectal cancer
166
What is pouchitis and how is it treated?
Infection of the formed J-pouch, treated with antibiotics such as Ciprofloxacin
167
What is the risk of colorectal cancer in UC patients?
Significantly increased risk, further increased with involvement proximal to the splenic flexure and uncontrolled disease
168
What should guide treatment in UC to reduce cancer risk?
Histological remission
169
What is the second most common cancer diagnosis in Australia?
Colorectal cancer
170
Approximately how many new cases of colorectal cancer are diagnosed per year in Australia?
17,000 new cases per year
171
What is the median age at diagnosis for colorectal cancer?
Approximately 75 years
172
What is the average 5-year survival rate for colorectal cancer?
70-96%
173
What percentage of cancer deaths in Australia is attributed to colorectal cancer?
8%
174
What is the trend in the rate of colorectal cancer diagnosis over the past 30 years?
Stable
175
What is the significance of COX-2 in colorectal cancer?
90% of colorectal cancers overexpress COX-2 on the cell surface
176
What has been shown to be effective in the prevention of COX-2 expressing colorectal cancer?
Aspirin
177
At what age should colorectal carcinoma be suspected in patients?
Over 50 years of age
178
What are significant symptoms that may indicate colorectal carcinoma?
* Significant change in bowel habit
* Rectal bleeding
* Unexplained weight loss
179
What common condition should trigger investigation for colorectal cancer?
Iron deficiency anaemia
180
What type of blood cultures are associated with colorectal cancer?
Streptococcus bovis or Streptococcus gallolyticus
181
What percentage of colorectal cancer diagnoses are made in patients with no genetic risk?
90%
182
List classical risk factors for colorectal cancer.
* Older age
* Male
* Higher intake of alcohol
* Cigarette smoking
* Processed and red meat intake
* Sedentary lifestyle
183
What increased risk factors are associated with colorectal cancer?
* Inflammatory Bowel Disease
* Genetic predisposition
184
Which inflammatory bowel diseases increase the risk of colorectal carcinoma?
* Crohn's Disease
* Ulcerative Colitis
185
What is the risk of colorectal cancer in patients with Ulcerative Colitis after 30 years?
Approaches 20%
186
What is the lifetime risk of colorectal cancer for patients with Hereditary Non Polyposis Colorectal Cancer (HNPCC)?
80%
187
What is the median age of diagnosis for HNPCC?
44 years of age
188
What are the cancers associated with HNPCC in order of risk?
* Right-sided (proximal) colorectal cancer
* Endometrial cancer
* Stomach cancer
* Ovarian cancer
* Ureteric and bladder cancers
189
What genetic mutations are associated with HNPCC?
* MSH2 (60%)
* MLH1 (30%)
* MSH6
* PMS2
* EPCAM
190
What criteria are used to identify patients for HNPCC testing?
* Three or more family members with colorectal cancer
* Two successive generations
* One person diagnosed younger than 50 years of age
* Exclusion of FAP
191
What screening is indicated for patients with HNPCC?
* Colonoscopy every 1-2 years from age 20
* Annual pelvic examination and transvaginal ultrasound from age 30
* Endoscopic screening and H. pylori testing from age 30
* Annual urinalysis and cytology from age 30
192
What should be done if colorectal cancer is diagnosed in a patient with HNPCC?
Total colectomy
193
What are the three major forms of Familial Adenomatosis Polyposis (FAP)?
* FAP
* Attenuated FAP
* Autosomal recessive FAP
194
What gene mutation is responsible for classical FAP?
APC gene
195
What is the median age for colorectal cancer in patients with classical FAP?
39 years of age
196
What is the lifetime risk of colorectal cancer in patients with attenuated FAP?
70%
197
At what age should colonoscopy be performed for early detection of polyps in FAP?
Annually from age 10
198
What is the main principle behind colorectal cancer screening guidelines?
Colorectal cancer arises from benign polyps (adenomas) progressing to carcinoma
199
What type of polyps have the highest malignant potential?
Villous adenomas
200
What screening test is recommended for average risk for colon cancer in asymptomatic patients at age 50?
FOBT (Fecal Occult Blood Test)
201
What is the recommendation if the FOBT is positive?
Colonoscopy is indicated
202
What should be done if life expectancy is less than 10 years regarding colorectal cancer screening?
Stop screening
203
What are the indications for adjuvant chemotherapy in colorectal cancer?
* Stage III disease with nodal involvement
* Stage IV disease with palliative intent
204
What is the recommended chemotherapy regimen for colorectal cancer?
Oxaliplatin-based chemotherapy for 6 cycles over 6 months
205
What is the 5-year survival rate for Stage IV colorectal cancer?
<20%
206
What is the normal liver span?
13-15 cm
207
What are the two blood supplies to the liver?
* Hepatic artery
* Portal vein
208
What role does the liver play in metabolism?
* Nutrient absorption
* Drug metabolism
* Bilirubin breakdown
* Toxin breakdown
209
What is the pharmacokinetics of ethanol regarding oral bioavailability?
>80%
210
What is the metabolic process of ethanol in the liver?
* Ethanol is converted to acetaldehyde by alcohol dehydrogenase
* Acetaldehyde is converted to acetate by acetaldehyde dehydrogenase
211
What is the time frame for circulating levels to occur post ingestion?
Approximately 60 minutes post ingestion
212
What can cause a delay in peak dosing?
Delayed gastric emptying, commonly related to food intake
213
What is the volume of distribution for the drug?
0.5 L/kg
214
Does the drug bind to plasma proteins?
No plasma protein binding
215
Can the drug cross the blood-brain barrier?
Yes, it does cross the blood-brain barrier
216
Where is the drug metabolized?
Virtually all of the drug is metabolized in the liver
217
What are the two steps in the metabolism process of ethanol?
* Ethanol is converted to acetaldehyde by alcohol dehydrogenase
* Acetaldehyde is converted to acetate by acetaldehyde dehydrogenase
218
What type of kinetics does the metabolism of ethanol follow?
Zero-order kinetics
219
What is the rate limiting step in ethanol metabolism?
The first reaction via alcohol dehydrogenase
220
What percentage of ethanol is exhaled or passed unchanged in urine?
Only 5-10%
221
How much ethanol is in one standard drink?
10g of ethanol
222
What are examples of one standard drink?
* 1 bottle (375ml) of mid-strength beer
* 1 pot (280ml) of full-strength beer
* 1 glass (100ml) of red or white wine or champagne
* 1 shot (30ml) of 40% w/w spirit
223
What are some gastrointestinal adverse effects of alcohol?
* Gastritis and peptic ulcer disease
* Alteration of gut microbiome
224
What hepatic complications arise from alcohol use?
* Direct cellular toxicity
* Accumulation of lipids resulting in steatosis
* Progression to liver cirrhosis and liver failure
225
What are central nervous system complications associated with alcohol use?
* Direct cellular effects, particularly on the cerebellum
* Alcohol is a carcinogen linked to pancreatic, bowel, and gastric cancers
226
True or False: Alcohol is a potent teratogen during pregnancy.
True
227
What are some social complications of alcohol use?
* Loss of inhibition leading to violent behavior
* Strong associations with domestic violence
* Increased motor vehicle accidents due to loss of coordination
228
What is alcoholic neuropathy?
Typically affects the motor nerves of the lower limb, causing instability on mobilization and foot drop
229
What are the clinical signs of cerebellar toxicity due to alcohol?
* Gait ataxia
* Nystagmus
* Dysmetria
* Dysdiadochokinesis
230
What is Wernicke's Encephalopathy (WE)?
Exhaustion of Vitamin B1 (thiamine) reserves leading to neurological symptoms
231
What is the classical clinical triad of Wernicke's Encephalopathy?
* Ataxia
* Confusion
* Ophthalmoplegia
232
How can Wernicke's Encephalopathy potentially be reversed?
With aggressive thiamine supplementation
233
What is the significance of providing intravenous thiamine in WE?
It must be given before glucose solutions to prevent exacerbation of the condition
234
What characterizes Korsakoff's Syndrome?
* Amnesia
* Confusion
* Personality change
* Confabulation
235
What is the management for Wernicke's Encephalopathy?
High dose, parenteral thiamine initially, followed by indefinite oral thiamine
236
What is alcoholic fatty liver disease?
A common side effect of chronic alcohol abuse characterized by triglyceride accumulation
237
What is the Maddrey Score used for?
To predict prognosis from acute alcoholic hepatitis
238
What Maddrey Score indicates a 30-day mortality rate of >40%?
Maddrey Score >32
239
What is the first line treatment for Hepatitis B?
* Tenofovir
* Entecavir
240
What is the goal of treatment for Hepatitis B?
Sustained virological response (SVR) with no detectable circulating DNA
241
What is the primary cause of acute liver failure in developed countries?
Paracetamol overdose
242
What is N-acetylcysteine (NAC) used for in paracetamol overdose?
To replace depleted glutathione stores and overcome ROS
243
What are the key features of management for acute paracetamol overdose?
* Acute resuscitation
* Risk assessment
* Management of overdose depending on time from ingestion
244
What is the King's College Criteria used for?
To assess eligibility for acute liver transplantation in paracetamol toxicity
245
What are the genotypes of Hepatitis C most common in Australia?
* Genotype 1
* Genotype 3
246
What is the aim of treatment for Hepatitis C?
To achieve sustained virological response (SVR) at the end of the course
247
What are the complications of Hepatitis C?
* Hepatitis, cirrhosis, liver failure
* Cryoglobulinaemia
* Glomerulonephritis
* Lymphoproliferative disorders
* Dermatological issues
248
What is the presence of cirrhosis an indication for?
Longer treatment
## Footnote
Treatment duration may vary based on the presence of cirrhosis.
249
What must be excluded before treatment for Hepatitis C?
The presence of Hepatocellular Carcinoma (HCC)
## Footnote
Treatment is contraindicated in patients with current or previous HCC due to risks of reactivation.
250
What is the aim of treatment for Hepatitis C?
To achieve SVR (Sustained Virologic Response) at the end of the course
## Footnote
SVR has been shown to be sustained lifelong.
251
What are the SVR rates for Genotype 1 and Genotype 3 Hepatitis C?
Genotype 1: >90%, Genotype 3: >85%
## Footnote
These rates reflect treatment effectiveness.
252
What are the typical treatment durations for Hepatitis C?
12 weeks without cirrhosis, 24 weeks with cirrhosis
253
What is required during the final course of treatment for Hepatitis C?
Measurement of Hepatitis C RNA
## Footnote
Ongoing presence of Hepatitis C RNA indicates the need for further treatment.
254
What improvements have studies shown with Hepatitis C treatment?
Improvement in liver histology, reduced rate of liver failure, reduced rate of HCC, improvement in mortality
255
What is the cost of a typical 12-week course of treatment for Hepatitis C?
Approximately $60,000
256
What are examples of Direct-Acting Antivirals (DAAs)?
* Nucleoside polymerase inhibitor - Sofosbuvir
* Non-Nucleoside polymerase inhibitor - Dasabuvir
* Serine Protease Inhibitors
* NSSA Inhibitors - Daclatasvir, Ledipasvir
257
What is the most prescribed treatment for Hepatitis C in Australia?
Sofosbuvir/Ledipasvir (Harvoni)
## Footnote
Effective for Genotypes 1 and 3.
258
Which medications are contraindicated with Direct-Acting Antivirals?
Statins and amiodarone
259
What is the prevalence of Non-Alcoholic Fatty Liver Disease (NAFLD) in Australia?
Approximately 10% of the adult population
260
How is NAFLD commonly detected?
Incidentally by blood tests or imaging
261
What is a typical enzyme pattern in NAFLD?
AST > ALT predominant rise in liver enzymes
262
What is the strong link associated with NAFLD?
Metabolic syndrome
## Footnote
Includes obesity, insulin resistance, hyperlipidaemia, hypertension.
263
What characterizes Non-Alcoholic Steatohepatitis (NASH)?
Inflammation present in the context of steatosis
264
What is the gold standard for diagnosing NAFLD?
Liver biopsy
265
What are histology findings in NAFLD?
* Macrovesicular steatosis
* Evidence of portal inflammation, hepatocellular injury, and necrosis indicate NASH
* Fibrosis indicates progression to early cirrhosis
266
What is the key to management in NAFLD?
Lifestyle changes, including weight loss and exercise
267
What is the role of pharmacotherapy in NAFLD/NASH?
No medication has proven hepatic or mortality benefit
268
What is the prevalence of Primary Biliary Cirrhosis (PBC)?
1 in 5,000 in developed countries
269
What is a common presenting complaint in PBC?
Itch
270
What blood test results are common in PBC?
Cholestatic liver enzyme derangement (ALP, GGT)
## Footnote
Bilirubin may also be elevated.
271
What antibodies are positive in Primary Biliary Cirrhosis?
Anti-mitochondrial antibodies (AMA)
272
What is the first-line treatment for PBC?
Ursodeoxycholic acid
273
What is a common complication of PBC?
Cirrhosis and liver failure tend to occur within 2 years
274
What is the prevalence of Primary Sclerosing Cholangitis (PSC)?
Approximately 1 in 100,000 population
275
What is a common association with PSC?
Inflammatory Bowel Disease, particularly Ulcerative Colitis
276
What is a common presenting complaint in PSC?
Itch
277
What is the characteristic finding in liver biopsy for PSC?
Periductal concentric fibrosis of interlobular bile ducts
278
What is the mainstay of treatment for Hemochromatosis?
Phlebotomy
279
What is the classical triad of symptoms in Hemochromatosis?
Skin bronzing, liver cirrhosis, diabetes mellitus
280
What is the genetic mutation associated with Wilson's Disease?
ATP7B gene on chromosome 13
281
What are common signs of Wilson's Disease?
* Liver disease
* Neuropsychiatric disease
* Kayser-Fleischer Rings
282
What is the first-line treatment for Wilson's Disease?
Copper chelation with Penicillamine
283
What is the epidemiology of Autoimmune Hepatitis?
Affects approximately 1 in 10,000 people, more common in females
284
What is the common age group for Autoimmune Hepatitis (AIH) prevalence?
Young females
## Footnote
AIH can occur at any age but is most common in young females.
285
Which conditions are related to Autoimmune Hepatitis?
* Coeliac disease
* Type 1 diabetes mellitus
* Thyroid disorders
* Vasculitis
## Footnote
These conditions often co-exist with AIH.
286
What is the exact cause of Autoimmune Hepatitis (AIH)?
Unknown
## Footnote
There are strong correlations to autoantibody formation, but the role of these antibodies remains unclear.
287
What are the common symptoms of Autoimmune Hepatitis?
* Fatigue
* Right upper quadrant pain
* Weight loss
* Anorexia
* Itch
* Jaundice
* Arthralgia
## Footnote
These symptoms are typical signs of hepatitis.
288
What initial blood tests indicate in Autoimmune Hepatitis?
Predominant elevation in transaminases (ALT, AST)
## Footnote
These tests are crucial for diagnosing AIH.
289
What does histology show in Autoimmune Hepatitis?
Interface hepatitis with lymphoplasmacytic infiltrate causing hepatic necrosis
## Footnote
This finding is characteristic of AIH.
290
What is the first-line treatment for Autoimmune Hepatitis?
Prednisolone
## Footnote
It is used to induce remission but not for long-term high-dose use due to adverse effects.
291
What are the steroid-sparing immunosuppressive agents used in Autoimmune Hepatitis?
* Azathioprine
* Mycophenylate
* Cyclosporine
* Tacrolimus
* Methotrexate
## Footnote
These agents are used when Prednisolone is not suitable for long-term use.
292
What is the common genetic mutation associated with Alpha 1-Antitrypsin Deficiency?
Mutation in SERPINA1 gene on chromosome 14
## Footnote
More than 120 known mutations exist, with PIZZ being the most pathogenic.
293
What are the two most common clinical presentations of Alpha 1-Antitrypsin Deficiency?
* COPD
* Liver Cirrhosis
## Footnote
These conditions arise due to the accumulation of abnormal a1-AT protein.
294
What is the primary treatment for lung-affected patients with Alpha 1-Antitrypsin Deficiency?
Intravenous a1-AT protein replacement
## Footnote
This treatment is aimed at managing lung complications.
295
What are the common aetiologies of Drug-Induced Liver Disease?
* Alcohol
* Paracetamol
## Footnote
These substances are the most frequently involved in liver damage.
296
What is the risk associated with statin therapy regarding liver function?
Transient elevation in transaminases
## Footnote
This is considered rare and usually resolves after discontinuation.
297
What adverse effects can high-dose methotrexate cause?
Acute and severe elevations in transaminases
## Footnote
Chronic use may lead to fatty liver disease and potential progression to cirrhosis.
298
What is a major risk factor for liver injury when using Rifampicin?
Age
## Footnote
Older patients have a higher risk of liver injury when treated with Rifampicin.
299
What is the pathophysiology of liver cirrhosis?
Irreversible liver damage leading to fibrosis and impaired blood flow
## Footnote
This results in portal hypertension and associated complications.
300
How is the severity of cirrhosis classified?
Using the Child-Pugh Status
## Footnote
This classification considers parameters like bilirubin, INR, and encephalopathy.
301
What does the Model for End-Stage Liver Disease (MELD) Score predict?
3-month mortality and need for liver transplantation
## Footnote
It uses bilirubin, INR, and creatinine in its calculation.
302
What is a common complication of portal hypertension?
Splenomegaly
## Footnote
Increased pressure in the portal vein leads to vascular congestion in the spleen.
303
What is the primary treatment for ascites due to cirrhosis?
Dietary salt restriction
## Footnote
This initial treatment is critical for managing fluid balance.
304
What does the Serum-Ascites Albumin Gradient (SAAG) indicate?
Differentiates between transudative and exudative ascites
## Footnote
A SAAG > 1.1 indicates transudates, while < 1.1 indicates exudates.
305
What is Lactulose used for in hepatic encephalopathy?
Reduces ammonia production and absorption
## Footnote
It is the first-line treatment for preventing hepatic encephalopathy.
306
What are the treatment options for esophageal varices?
* Propranolol
* Variceal banding
## Footnote
Propranolol reduces portal flow, while banding treats active varices.
307
What is the purpose of the Transjugular Intrahepatic Portosystemic Shunt (TIPS)?
Decompress portal vein by shunting flow
## Footnote
TIPS is used in selected patients and can bridge to transplant or provide palliation.
308
What is the threshold for decompensated liver failure?
>16mmHg
309
What indicates a high risk of mortality in decompensated liver failure?
»22mmHg
310
What is the initial treatment for ascites?
Dietary salt restriction
311
Why is dietary salt restriction critical in cirrhosis?
It reduces the effect of RAAS
312
What pharmacotherapy is effective in interrupting RAAS?
Diuretics
313
Which two diuretics are used together to ameliorate RAAS effects?
* Frusemide
* Spironolactone
314
What is the purpose of abdominal paracentesis?
Diagnostic or therapeutic purposes
315
What complications can arise from repeated abdominal paracentesis?
* SBP
* Bleeding events
* Fistula tracts
316
What is required during large volume paracentesis?
Intravenous supplementation of albumin
317
What condition can precipitate due to fluid shift during paracentesis?
Hepatorenal syndrome (HRS)
318
What characterizes Type 1 Hepatorenal Syndrome?
Rapid progression in renal failure
319
What is the prognosis for Type 1 HRS?
Mortality rates exceeding 50%
320
What adjunctive therapies are indicated for Type 1 HRS?
* Somatostatin analogues
* Alpha-receptor agonists
321
What defines Type 2 Hepatorenal Syndrome?
Chronic impairment of renal function in cirrhosis
322
What is a common symptom of Spontaneous Bacterial Peritonitis (SBP)?
Fever
323
What is the first line treatment for SBP?
Intravenous broad spectrum antibiotics
324
What is a typical finding in diagnostic abdominal paracentesis for SBP?
Cell count >500
325
What is hepatic hydrothorax associated with?
Severe liver disease
326
What is a common treatment option for hepatic hydrothorax?
Therapeutic pleural drainage
327
What defines Portopulmonary Hypertension (PPH)?
Coexistence of pulmonary and portal hypertension
328
What is the best long-term treatment for PPH?
Liver transplant
329
What symptoms do patients with Hepatopulmonary Syndrome (HPS) present?
* Shortness of breath
* Hypoxaemia
330
What is the only beneficial treatment for HPS?
Liver transplantation
331
What type of cancer is Hepatocellular Carcinoma (HCC)?
Most common type of primary liver cancer
332
What are major risk factors for HCC?
* Hepatitis B
* Hepatitis C
* Haemochromatosis
* a1-AT deficiency
333
What is the recommended screening for early detection of HCC?
6-monthly abdominal ultrasound and AFP tumour markers
334
What imaging findings are characteristic of HCC?
* Circumferential, well delineated tumour
* Arterial phase enhancement
* Rapid venous washout phase
335
What is the first line treatment for HCC if criteria are met?
Liver Resection
336
What is the role of Radiofrequency Ablation (RFA) in HCC treatment?
Typically not curative treatment
337
What does Transarterial Chemoembolisation (TACE) involve?
Injection of embolising beads +/- chemotherapy
338
What systemic therapy is used for advanced HCC?
Sorafenib
339
What is the prognosis for patients with Child Pugh C cirrhosis not amenable to liver transplant?
Palliative care
340
What is the role of chemotherapy and radiotherapy in HCC management?
Little role in Australian management
