gastro 4 Flashcards
what causes splenic rupture?
usually secondary to abdominal trauma
a minority of cases are iatrogenic or secondary due to splenomegaly from haematological malignancy or infective causes
what are the clinical features of spLenic rupture?
abdominal pain
hypovolemic shock
LUQ tenderness
radiating left shoulder pain caused by free blood irritating the diaphragm
what investigations would you perform for splenic rupture?
immediate laparotomy if they are hemodynamically unstable
if they are hemodynamically stable - urgent CT chest abdo pelvis with IV contrast
what scale is used for splenic injury ?
The American Association for the Surgery of Trauma (AAST) splenic injury scale is the most commonly used system for grading splenic trauma.
what is splenic infarct?
A splenic infarct is caused by occlusion of the splenic artery or one of its branches, resulting in tissue necrosis.
As the spleen is supplied by the splenic artery (from the coeliac axis) and the short gastric arteries (from left gastroepiploic artery), infarction is often not complete due to collateral circulation.
what can cause splenic infarct?
Haematological disorders* such as lymphoma, myelofibrosis, Sickle Cell Disease, Chronic Myeloid Leukaemia, Polycythaemia Rubra Vera, or hypercoagulable states
Embolic disorders such as endocarditis, atrial fibrillation, infected aneurysm grafts, or post-MI mural thrombus
other causes include vasculitis, trauma, collagen tissue disease
what are the clinical features of splenic infarct?
LUQ abdominal pain which may radiate to the left shoulder
other symptoms include - fever, nausea, vomiting, pleuritic chest pain
many people will be completely asymptomatic
what investigations would you perform for splenic infarct?
CT abdomen with IV contrast
routine bloods
how is splenic infarct managed?
analgesia
hydration
treat underlying condition
what is bile acid malabsorption?
Bile-acid malabsorption is a cause of chronic diarrhoea. This may be primary, due to excessive production of bile acid, or secondary to an underlying gastrointestinal disorder causing reduced bile acid absorption. It can lead to steatorrhoea and vitamin A, D, E, K malabsorption.
what investigations would you perform for bile-acid malabsorption?
the test of choice is SeHCAT
nuclear medicine test using a gamma-emitting selenium molecule in selenium homocholic acid taurine or tauroselcholic acid (SeHCAT)
scans are done 7 days apart to assess the retention/loss of radiolabelled 75SeHCAT
how do you manage bile acid malabsorption?
bile acid sequestrants e.g. cholestyramine
what is budd-chiari syndorme?
aka hepatic vein thrombosis
s usually seen in the context of underlying haematological disease or another procoagulant condition.
what are the causes of budd-chiari syndrome?
polycythaemia rubra vera
thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies
pregnancy
combined oral contraceptive pill: accounts for around 20% of cases
what are the features of budd-chiari syndrome?
The features are classically a triad of:
abdominal pain: sudden onset, severe
ascites → abdominal distension
tender hepatomegaly
what investigations would you perform for budd-chiari syndrome?
ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation
what is gilbert’s syndrome?
Gilbert’s syndrome is an autosomal recessive condition of defective bilirubin conjugation due to a deficiency of UDP glucuronosyltransferase.
what are the features of Gilbert’s syndrome?
unconjugated hyperbilirubinaemia (i.e. not in urine) jaundice may only be seen during an intercurrent illness, exercise or fasting
what are the investigations and management of Gilbert’s syndrome?
investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid
no treatment required
what is Meckel’s diverticulum?
Meckel’s diverticulum is a congenital diverticulum of the small intestine. It is a remnant of the omphalomesenteric duct (also called the vitellointestinal duct) and contains ectopic ileal, gastric or pancreatic mucosa
what is the rule of 2’s in Meckel’s diverticulum?
occurs in 2% of the population
is 2 feet from the ileocaecal valve
is 2 inches long
how does meckel’s diverticulum present?
usually asymptomatic abdominal pain which mimics appendicitis rectal bleeding (common cause of painless massive GI bleed requiring transfusion in children between the ages of 1 and 2) intestinal obstruction secondary to a volvulus
what investigations would you perform for suspected meckel’s diverticulum ?
FBC technetium-99 pertechnetate scan (meckel's scan) plain abdo xray CT scan USS
How is Meckel’s diverticulum managed?
if incidental finding - no treatment requires
if symptomatic - excision of the diverticulum and opposing region of ileum
what can cause acute liver failure?
paracetamol overdose
alcohol
viral hepatitis (usually A or B)
acute fatty liver of pregnancy
what are the features of acute liver failure ?
jaundice
coagulopathy: raised prothrombin time
hypoalbuminaemia
hepatic encephalopathy
renal failure is common ('hepatorenal syndrome')what tests would you perform to look at the synthetic function of the liver?
liver function tests’ do not always accurately reflect the synthetic function of the liver. This is best assessed by looking at the prothrombin time and albumin level.
what is non alcoholic fatty liver disease?
part of the “metabolic syndrome” group of chronic health conditions relating to processing and storing energy that increase risk of heart disease, stroke and diabetes.
It is characterised by fat deposited in liver cells. These fat deposits can interfered with the functioning of the liver cells. NAFLD does not cause problems initially, however it can progress to hepatitis and cirrhosis.
what are the stages of non alcoholic fatty liver disease?
- Non-alcoholic Fatty Liver Disease
- Non-Alcoholic Steatohepatitis (NASH)
- Fibrosis
- Cirrhosis
risk factors for non-aloholic fatty liver disease?
Obesity Poor diet and low activity levels Type 2 diabetes High cholesterol Middle age onwards Smoking High blood pressure
what is a non-invasive liver screen?
Ultrasound Liver
Hepatitis B and C serology
Autoantibodies (autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis)
Immunoglobulins (autoimmune hepatitis and primary biliary cirrhosis)
Caeruloplasmin (Wilsons disease)
Alpha 1 Anti-trypsin levels (alpha 1 anti-trypsin deficiency)
Ferritin and Transferrin Saturation (hereditary haemochromatosis)
what investigations would you perform for non-alcoholic fatty liver?
Liver USS
Enhanced liver fibrosis blood test
fibroscan
how would you manage non-alcoholic fatty liver?
Weight loss
Exercise
Stop smoking
Control of diabetes, blood pressure and cholesterol
Avoid alcohol
Refer patients with liver fibrosis to a liver specialist where they may treat with vitamin E or pioglitazone.
what is liver failure>
Hepatic failure occurs when the liver loses the ability to regenerate or repair, so that decompensation occurs. It is marked by:
- hepatic encephalopathy
- abnormal bleeding
- ascites
- jaundice
how can liver failure be classified?
> Fulminant hepatic failure (FHF) occurs when the failure takes place within eight weeks of the onset of the underlying illness.
> Late-onset hepatic failure (also called subacute FHF) occurs when there has been a gap of 8-26 weeks. The difference may not immediately be obvious, as the underlying disease may have been present for a long time but undiagnosed.
> Chronic decompensated hepatic failure occurs when the latent period is over six months.
what are causes of liver failure?
Toxins (chronic alcohol abuse, paracetamol poisoning, illicit drugs, reye’s syndrome)
Infections (viral hepatitis, adenovirus, EBV, CMV)
neoplastic (hepatocellular, metastatic carcinoma)
Metabolic (wilson’s disease, alpha-1antitrypsin deficiency)
Vascular - ischaemia or veno-occlusive disease, budd-chiari syndrome
autoimmune liver disease
what may you find on examination of someone with liver failure?
mental state may show drowsiness and confusion
jaundice
hyperdynamic circulation with multiple organ failure may mimic septic shock
abdominal distension (ascites, hepatomegaly, splenomegaly)
cerebral oedema with increased ICP may produce papilloedema, HTN and bradycardia)
hepatic flap
hepatic encephalopathy
what investigations would you perform for liver failure?
FBC INR transaminases bilirubin ammonia glucose ABG viral serolgy test for specific condition (wilsons and paracetamol) dopple USS CT/MRI head imaging
how is liver failure managed?
manage specific underlying condition
lactulose with neomycin to reduce ammonia production
mannitol may reduce raised ICP
AKI may require hemodialysis
glucose monitoring - large amounts of IV glucose may be required
Fresh-frozen plasma, platelet concentrates, antifibrinolytic drugs, prothrombin complex concentrates and recombinant activated factor VII are often used to treat or prevent abnormal bleeding .
liver transplant - may be life saving
what are the complications of liver failure?
infection - spontaneous peritonitis common, opportunistic pneumonia may occur
cerebral oedema and raised ICP
haemorrhage, oesophageal varacies
what is hepatic encecphalopathy?
Hepatic encephalopathy is defined as a spectrum of neuropsychiatric abnormalities in patients with liver failure
what are some common precipitants of hepatic encephalopathy?
Acute kidney injury. Electrolyte imbalance. Gastrointestinal bleeding. Infection. Constipation. Sedative drugs - eg, opiates, benzodiazepines, antidepressants and antipsychotic drugs. Diuretics. High protein intake.
how does hepatic encephalopathy present?
mood disturbances (euphoria or depression) sleep disturbance (insomnia or hypersomnia) motor disturbance - ataxia, extrapyramidal symptoms (muscle rigidity, bradykinesia, hypokinesia, slow monotonous speech, parkinsonian like tremor)
