Gastro Flashcards
Which liver zone is most susceptible to ischaemia and which to viral hepatitis?
Zone 1 = viral hepatitis
Zone 3 = Alcohol, ischaemia =
Differentiate between acute and chronic hepatitis?
Acute = parenchymal liver damage caused by poison, viral, non-viral, drugs, alcohol Chronic = lasting > 6 months caused by autoimmune, drugs, viral (commonest), hereditary
Define Autoimmune Hepatitis
Chronic Hepatitis w autoimmune features: auto-antibodies, hyperglobulinaemia
2 causes of AIH
- Genetics
2. Decrease regulatory T cell function
Explain genetics
Susceptible individuals express antigens following environmental stimulus –> T cell mediated autoimmune attack against hepatocytes –> necroinflammation –> fibrosis –> cirrhosis
Define 3 features of type I AIH
ANA, anti-actin, anti-SLA
1 feature of Type II AIH
anti-liver/kidney microsomal Ab (anti-LKM)
Type I or Type II AIH more prevalent? and which gender group more likely?
Type I and mostly young women
Define alcoholic hepatitis
inflammatory liver injury caused by heavy alcohol intake
Different name for Zone 3?
Centrilobular
Describe progression of alcoholic hep from fatty change to alcoholic cirrhosis
1 it causes reversible steatosis of hepatocytes which increases with heavy alcohol use however is reversible –> this does not cause liver dmg itself
2 it causes perivenular fibrosis by converting stellate cells into collagen producing myofibroblast cells
3 fibrosis causes inflammation (alcoholic hepatitis) which causes infiltration by polymorphonuclear leucocytes at zone 3 and hepatic necrosis. Histopathology is characterised by Mallory bodies + giant mitochondria
4 eventually alcoholic hepatitis can progress to alcoholic cirrhosis
Presentation of a patient suffering from alcoholic fatty liver disease (AFLD)
Usually asymptomatic and no signs
Presentation of a patient suffering from alcoholic hep?
Can be from asymptomatic to severe
What will the FBC show in a person with alcoholic hepatitis?
v Hb, v Platelets ^ MCV, ^ WCC LFTs: ^ALT, ^AST, ^ALP, ^ GGT ^bilirubin ^PT time, v albumin v urea, and v K+
3 complications of alcoholic liver disease (hepatitis)
- Hepatocellular Carcinoma
- Hepatorenal Syndrome
- Acute Liver Failure
- Cirrhosis
Name the RFs for NAFLD?
Metabolic syndrome basically so: HTN TIIDM Hyperlipidaemia Obesity Soft drinks - increased lvls of sugar in such drinks can cause central fat deposition
Management of NAFLD?
- there is no pharmacological agent specifically for the disease however we can use pharmacological agents to control the metabolic components/ risk factors
2 Control RFs = Control Progression - Bariatric Surgery may help (particularly to control obesity - help with weight loss)
- Regular follow up
Define biliary colic and explain its difference with acute cholecystitis?
Biliary colic is the term used to describe the pain associated with temporary obstruction of the cystic or common bile duct by a stone usually migrating from the GB.
Acute cholecystitis is a complication of biliary colic in which there is inflammation of the gallbladder following GB distention as a result of increased glandular secretion –> progressive GB distention –> inflammation –> 2ndary infection. The main difference is the inflammatory component present in acute cholecystitis (elevated WCC, fever, local peritonism) and the absence of these in biliary colic.
Which are the types of gallstones?
Mixed, pure cholesterol, bile pigmented
What are the RFs for cholesterol stones?
Increased age, FHx, F>M, multiparity, diet(high in fat and low in fibre), DM, Obesity, Rapid Weight Loss, Metabolic Syndrome
Presentation of biliary colic?
Sudden onset, crescendo RUQ or epigastric pain, radiating to right shoulder and sub-scapular region, +- nausea and vomiting
On examination:
tender epigastrium or RUQ
Presentation of acute cholecystitis?
Similar to biliary colic presentation but with marked inflammatory markers
Murphys sign
possible phlegmon
tenderness and muscle guarding due to localized parietal peritoneum
fever
tachycardia
Presentation of ascending cholangitis?
Charcot’s triad: RUQ pain, jaundice, rigors
if +hypotension, and confusion = Reynold’s pentad
potential pyrexia
Management of biliary colic?
IF MILD: conservative, avoid high fat diets. Ongoing debate on whether we should do prophylactic cholecystectomy on patients with asymptomatic gallstones IF SEVERE (HIGHLY SYMPTOMATIC): IV fluids, antibiotics, anti-emetics, analgesia (opioids), NBM --> if symptoms fail to go down --> drain (percutaneously or cholesystostomy) because there would probably be a localised abscess. Then CHOLECYSTECTOMY is the endpoint.
Management of acute cholecystitis?
IV fluids, antibiotics, anti-emetics, NBM, analgesia, ±drain, early laparoscopic cholecystectomy (~72hours) (we used to wait for the inflammation to settle 6-12 weeks, but evidence shows that early cholecystectomy has fewer complications)
Biliary Colic Complications?
Stones in GB can cause: recurrent biliary colic, chronic/acute cholecystitis, GB empyema, carcinoma (rare)
Stones outside GB (e.g. cystic duct) can cause: obstructive jaundice, pancreatitis, ascending cholangitis, Mirizzi’s syndrome
Complications of cholecystectomy?
biliary leak from biliary bed or cystic duct
post-cholecystectomy syndrome = RUQ pain of biliary nature, identical to biliary colic pain due: colonic spasm @ hepatic flexure, left stones @ CBD, HTN of sphincter of Oddi
List the Investigations you would do on a patient with jaundice (8)
- Blood tests (Coombs, Serum Bilirubin, malaria parasites, reticulocyte count)
- Urine (CB? Urobilin?)
- LFTs - ^AST - Viral hep
- Microbiology cultures (Hep A,B,C & leptospirosis)
- USS
- ERCP
- Liver Biopsy
- CT (for suspected malignancy)
(9) Genetic tests for Dubin Johnson
Risk Factors for appendicitis? (4)
Male
FMHx
10-20
Low fibre diet
Symptoms (2) & signs (6-7) of appendicitis?
- Initial periumbilical pain –> tranferred to RIF (2/3 umbilicus + ASIS = McBurneys point)
- ±Vomiting/Constipation
- Rovisigns Sign
- guarding
- rebound and percussion tenderness
- fever
- tachycardic
- coughing pain
- ±Psoas sign
ΔΔ in a suspected appendicitis (5)?
- Ectopic pregnancy
- UTI
- Cystitis
- Diverticulitis
- CD
- Food Poisoning
Investigations in cholecystitis (4)
- Bloods (^WCC, ^CRP)
- USS - 90% specificity
- HIDA - shows cystic duct obstruction but does not consider other causes
- Plain AXR
Management of cholecystitis? (4)
- NBM
- Antibiotics, Analgesia, ± Anti-emetics
- cholecystectomy (open if perforation, laparoscopic if well + GA tolerable)
- cholecystotomy is unwell or acalculous cholecystitis – cholecystectomy can always be performed at a later date although evidence seems to suggest that it is better asap.
Complications of cholecystitis (5)?
- Perforation
- Acute pancreatitis
- Cholangitis
- Mirizzi’s syndrome
- Gallstone ileus
DIAGNOSTIC Indications for an ERCP (5)
It is rarely used purely from a diagnostic standpoint and when so it is because other methods have failed to show diagnosis.
1) Biliary strictures
2) Biliary tumors
3) Gallstones
4) Sphincter of Oddi dysfunction
5) Obstructive Jaundice
THERAPEUTIC Indications for an ERCP (4)
1) Biliary stricture dilatation
2) Removal of gallstones
3) Insertion/Removal of stent
4) Sphincterectomy
Complications of an ERCP (4-5)
- Pancreatitis
- Intestinal perforation
- Bleeding
- Cholangitis
- Allergies to contrast
Indications for diagnostic upper GI endoscopy (5)
- Haematemesis
- Persistent Vomiting
- Dyspepsia,
- Duodenal or Gastric biopsy
- Iron deficiency anaemia
Therapeutic indications of upper GI endoscopy (4)
- treatment of bleeding
- stent insertion
- sphincterectomy
- stricture dilatation
complications of upper GI endoscopy (4)?
- Bleeding - particularly with sphincterectomy
- sore throat
- Amnesia after sedation
- perforation
Therapeutic Colonoscopy Indications (4)
- Polypectomy
- Volvulus untwisting
- stents
- bleeding haemostasis
diagnostic indications for colonoscopy (5)?
- Assessment or suspicion of IBD
- Assessment of cancer
- Rectal Bleeding
- Iron deficiency anaemia
- persistent diarrhoea
RFs for coeliac disease (5)
- FMHx
- HLA DQ2 or DQ8
- Type I DM
- Autoimmune Thyroid Disease
- IgA deficiency
Other factors that have been implicated in the aetiology include: timing of exposure to gluten, GI infection = gluten mimicry
Presentation of coeliac disease (6)
- Anaemia (usually B12 + Iron deficiency)
- Weight Loss
- Diarrhoea
- Abdominal Pain
- Stinky poo/Steatorrhoea
- Aphthous ulcers
1/3 are asymptomatic
Investigations for coeliac disease (5)
- Endoscopy (macroscopic + microscopic)
- Bloods (v Hb, v Ferritin, v B12)
- Antibodies –> a-gliadin, transglutaminase
- HLA Typing (DQ2, DQ8)
- Poo microscopy to exclude other causes
Complications of coeliac disease (5)
- Anaemia
- 2o lactose intolerance
- ^ risk of malignancy
- GI lymphoma
- osteoporosis
