Gastro Flashcards
Councilman bodies on liver post mortem
Yellow fever
The three classical causes of ALT in the 1000s
Acute hepatitis
Ischaemia
Drug tox ( paracetamol, anaesthetic agents, alcohol, labetalol)
right upper quadrant pain, evidence of upper GI bleeding and jaundice after liver biopsy
Haemobilia
- bleeding into the biliary tree following connection between splanchnic circulation and either the intrahepatic or extrahepatic biliary system
Endoscopy only diagnostic in 12%
MRI with cholangiopancreatographic may help
Angiography is diagnostic and then embolisation of the lesion
Patient presents with drop in Hb. Colonoscopy and OGD normal two years ago. What investigation is more likely to contribute to diagnosis
Capsule endoscopy
?angiodysplasia - second leading cause of lower GI bleeding in >60yr
Treated with sclerotherapy,angioembolisatiob or selective resection
Capsule endoscopy used to identify the source of occult GIB when an OGD/colonoscopy N
How many bloody stools in a day is severe in UC
More than 6
<4 and 4-6 are mild and moderate
Patient with Crohn’s or coeliac disease, started on sertraline…what may develop?
Lymphocytic colitis
Lymphocytic infiltrates on biopsy
Patient presents with two years of Abdo pain and loose stool.
They then develop cognitive decline , and eye exam reveals upgaze palsy, and pendular oscillations of both eyes. With each eye movement there is concurrent movement of the jaw
Diagnosis
Whipple’s
Eye involvement is only in 20% but pathognomonic
Diagnose with jejunal biopsy
Eye features of Whipple’s disease occur in 20% but are thought to be pathognomonic. What are they?
upgaze palsy, and pendular oscillations of both eyes. With each eye movement there is concurrent movement of the jaw
Diagnose with jejunal biopsy
Patient with diabetes presents with chronic diarrhoea
Found to have low vitamin B 12 and high folate levels
Small bowel bacterial overgrowth syndrome
Investigation for suspected Bile acid malabsorption
SeHCAT test - a form of nuclear imaging test
Mx: bile acid sequestrants e.g. cholestyramine
Combined oral contraceptive pill use + acute abdominal pain/distension
ascites and deranged liver function tests
Diagnosis
?Budd-Chiari syndrome
Aka hepatic being thrombosis
Triad of sudden onset abdominal pain, ascites, and tender hepatomegaly
What is budd chiari
Hepatic vein thrombosis
…sudden onset abdominal pain, ascites, and tender hepatomegaly
Spontaneous bacterial peritonitis is diagnosed with….
neutrophil count > 250 cells / mm^3
Variceal uncontrolled haemorrhage, not resolved by banding in endoscopy
Sengstaken-Blakemore tube
If that fails then TIPSS (connects hepatic vein to portal vein, can exacerbate hep enceph)
UC flare marker of need for surgery
At day three CRP >45 mg/l or a stool freq of >8/day predicts the need for surgery in 85% of cases.
Jejunal biopsy shows deposition of macrophages containing PAS-positive granules
Whipple’s
Patient with Barrett’s management
Endoscopic surveillance w biopsy and high dose PPI
If metaplasia then Endoscopy 3-5y
If dysplasia then Endoscopic mucosal resection , radiofreq ablation
Risk of cancer for Crohn’s
Small bowel standard incidence ratio 40
Colorectal standard incidence ratio 2 (less than in UC)
Pt has varices so has TIPS. 2 months later develops breathless and reduced ET. No other symptoms.
Pulmonary hypertension is known complication
Causes an increased cardiac preload by diverting blood past cirrhotic liver, increasing peripheral resistance
Colonic Adenoma surveillance
Low risk:
1or 2 adenomas, less than 10mm….. 5y colonoscopy
Intermediate
3 or 4 small, or 1-2 w one >10mn……3y colonoscopy
High
5 or more smaller, or 3 / more but larger…….1y colo
What topical disease has mega-oesophagus? -dilated on barium
Chronic phase of Chagas disease
Trypanosoma cruzi
Can also have mega colon,CHF and Arrhythmia
Management of primary biliary cirrhosis
Ursodeoxycholine acid
AMA antibodies
Management for achalasia
pneumatic (balloon) dilation first line
Nifedipine , lowers oesoph pressure
Absolute contraindications for transjugular intrahepatic portosystemic shunt TIPPS
Severe and progressive liver failure (Child-Pugh score >12)
Uncontrolled hepatic enceph (commonly makes it worse)
R HF
Uncontrolled sepsis
Unrelieved biliary obstruction
What is TIPPS procedure
transjugular intrahepatic portosystemic shunt
percutaneous creation of a tract between the intrahepatic portal vein and the hepatic vein.
So blood can bypass the liver and lowers portal pressure
Barrett’s w low grade dysplasia. Management
PPI, repeat colonoscopy in 6m
If there is still dysplasia, then enoscopic ablation
Progression rate of low grade dysplasia in barrett’s oesoph
9%/yr to high grade or oesoph Ca
Cancer surveillance for Crohn’s
1y scope in moderate/severe or PSC/fam hx in under 50/dysplasia/structure
3yr if mild, or fam hx over 50/postinflam polyps
colorectal carcinoma w liver mets management
staged surgical resection of carcinoma and liver lesions - 5-year survival rate of up to 30%
biopsy is not an option as would seed the tumour
when do you get acalculous cholecystitis ?
Typically occurs in the very ill patient on the intensive care unit, or after extensive burns
what is a succussion splash?
AKA gastric splash
sloshing sound heard through a stethoscope during sudden movement of the pt on abdo auscultation
- gas and fluid in an obstructed organ, as in gastric outlet obstruction or gastroparesis
Pt w ulcerative proctitis on oral mesalazine 2g BD presents w flare:
inflamed distal 7 cm of rectum, with normal mucosa above…. Management
Topical treatment with mesalazine suppositories is the most appropriate first-line measure for a proctitis flare.
already on a high dose of oral 5-aminosalicylic acid
regurge of undigested food and halotosis
zenker’s diverticulum
diagnosed w barium swallow
pt presents with change in bowel habit, PR bleeding, and history of Osteomas of the skull and mandible
diagnosis
Gardner’s syndrome
variant of FAP
w osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin
features of Gardner’s syndrome
variant of FAP
w colorectal Ca, osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin
mx of hepatic encephalopathy
treat any underlying cause
Lactulose and Rifaximin
MOA of Rifaximin and lactulose in hep encephalopathy
rifaxmin decreases ammonia production
Lactulose promotes excretion of ammonia and increasing the metabolism of ammonia by gut bacteria
diagnosis of autoimmune pancreatitis
imaging and raised serum IgG4
Classic presentation of graft Vs host disease post liver transplant
15 days post, abnormal LFTs jaundice hepatomegaly
Macpap rash on palms and soles
Diarrhoea
Urgent USS and Doppler
Pt w UC
anorexia, jaundice, RUQ pain and weight loss over 6m
cholangiocarcinoma (in 10% of Primary sclerosing cholangitis)
east africa, eosinophiilia, liver failure, varices
Schistosoma mansoni and Schistosoma japonicum
most common autoimmune hepatitis
type 1
Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (ASMA)
scoring system for autoimmune hepatitis
revised original AIH score
tx of autoimmune hep
induce remission w pred,
then taper and add azathioprine
if IgG, ALT normalise then can stop treatment completely (40% req lifelong)
Chronic Hepatitis C complication
Membranoproliferative glomerulonephritis
Hepatocellular Cancer
Cryoglobulinaemia: typically type II (mixed monoclonal and polyclonal)
sjogrens
immunocompromised pt develops watery diarrhoea
Management
Cryptosporidium
Largely supportive
Nitazoxanide is licensed in the US for immunocompetent patients
confused after transjugular intrahepatic portosystemic shunt TIPPS
Hepatic encephalopathy
TIPPS precipitates it in 25%
increased portosystemic passage of nitrogen from the gut
in well-man check, patient has Ferritin 15, MCV 76, Hb 132
iron deficiency (without anaemia)
Endoscopy if postmenopausal women and men >50yr,
which immunoglobulin is classically raised in autoimmune hepatitis?
IgG
Single most important factor to indicate the need for a liver transplant post paracetamol overdose
pH < 7.3 , 24hr after ingestion
Or all of:
PT>100
Cr >300
Grade 3 or 4 enceph
(King’s College Hospital criteria for liver transplantation)
Which autoimmune hepatitis has highest rate of cirrhosis?
Type 2 (82%) --Soluble liver-kidney antigen
T3 (75%)
T1 (45%)
Which autoimmune hepatitis has best response to steroids
3
indication of alcoholic liver disease rather than non-alcoholic fatty liver
AST : ALT ratio > 2
Normal GGT can exclude alcohol only
Newly diagnoses coeliac disease , responded to gluten exclusion. Now asymptomatic. Abnormal transaminases, why?
Hepatic steatosis is common finding at diagnosis or within a yr of treatment
Usually returns to normal
Auto immune hep tends to be middle aged women, chronic fatigue & pruritis
sudden onset bilat red eyes in history of IBD. Mx?
Episcleritis (more common in Crohn’s)
Topical corticosteroids
what do you measure to determine cause of ascites?
serum-ascites albumin gradient (SAAG)
Serum albumin / ascitic albumin
>11g/L indicates portal hypertension
