Gastro - general use this Flashcards
1
Q
Urgent referal for suspected GI cancer
A
Dysphagia lasting >3 weeks endoscopy to exclude malignant stricture
- Dysphagia
- Dyspepsia + 1 or more of
Weight loss
Proven anaemia
Pernicious anaemia
Vomiting
Jaundice
Upper abdomnal mass
Barrett’s oesophagus
Known dysplasia, atrophic gastritis, intestinal metaplasia
Peptic ucler surgery >20 years previously
FHx of UGI cancer in >2 first-degree relatives
- Dyspepsia >55 y/o + 1 or more of
Onset of dyspepsia <1 y previously
Continuous symptoms since onset
2
Q
Indications for endoscopy
A
- OGD
If pt presents for the first time 55 + there are warning signs or bleeding ulcer or ALARMS
Warning signs - >55 +
- Chronic blood loss
- Persistent vomiting
- Epigastric mass
- Unexplained, persistent, recent onset diarrhoea
- Previous peptic ulcer disease
- Previous gastric surgery
- Pernicious anaemia
- NSAID use
- FHx of gastric carcinoma
ALARMS Anorexia Loss of weight Anaemia (Fe deficiency) Rectal bleeding Melaena/Haematemesis Swallowing difficulty (progressive dysphagia) Suspicious barium meal
3
Q
Indications for emergency endoscopy
A
- Unstable patients, severe acute UGI bleeding immediately after resuscitation
- Continuing UGI bleed
- Glasgow-Blatchford score >6 (incl 6)
- Pt w aortic graft to exclude aorto-enteric fistula
- Suspiction of oesohageal varices due to chronic liver disease
4
Q
Why is constipation common after surgery
A
- Anaesthesia
- Opioid analgesia
- Electrolyte imbalances (hypokalaemia, hypomagnesaemia)
- Bowel manipulation
5
Q
How can we reduce the risk of post operative ileus
A
- Epidural/spinal anaesthesia
- Reduce use of opioids (more local anaesthetics)
- Reduce bowel manipulation during surgery
- Encourage early mobilisation
6
Q
Differentials for raised INR/PTT
A
- Liver failure (decreased hepatic production of coagulation factors)
- Vitamin K deficiency
- Cholestasis (decreased vitamin K absorption)
- DIC
7
Q
What kind of ischaemia does a strangulated hernia/volvulus cause
A
Ischaemic colitis/Colonic ischaemia(NOT acute/chronic mesenteric ischaemia)
8
Q
Which hepatitis viruses cause chronic infection?
A
HBV, HCV, HDV
9
Q
What does chronic hepatitis infection lead to?
A
chronic hepatitis
cirrhosis
hepatocellular carcinoma and eventually liver failure
HCC assosciated with HBV, HCV (most commonly with HCV)
10
Q
Causes of acute pancreatitis
A
I GET SMASHED Idiopathic Gallstones Ethanol Trauma Steroids Mumps/Coxsackie/HIV Autoimmune/Sjogren's syndrome/SLE/Coeliac disease Scorption bites Hyperlipidaemia/hypercalcaemia/hypothermia/hypertriglyceridaemia ERCP Drugs (Sodium valproate, steroids, thiazides, azathioprine)
11
Q
What is the hepatorenal syndrome?
A
Kidneys reduce their own blood flow distribution in response to the altered blood flow in the liver which causes extreme vasodilation and therefore decreases MAP
12
Q
Causes of UGIB
A
- Oesophageal tumour
- Mallory Weiss tear
- Oesophagitis
- Oesophageal varices
- Gastric carcinoma
- Gastritis
- Gastric ulcer
- Duodenal ulcer
- Angiodysplasia
look at diagram in epigastric pain
13
Q
What kind of cancer is the most common gastric cancer?
A
Adenocarcinoma
14
Q
Colon cancer screening
A
55 - FlexSig one off bowel scope screening test
60-74 - FOBT home testing kit every 2 years
15
Q
What kind of jaundice does Gilbert’s cause?
A
Pre-hepatic
Bilirubin is unconjugated
16
Q
Which enzyme is affected in Gilbert’s?
A
UDP glucuronyl transferase
reduced activity –> higher unconjugated blirubin –> tightly bound to albumin –> does not enter urine
17
Q
What can you use to evaluate liver function
Most representative test for liver function
A
Albumin
Bilirubin
Clotting factors
Prothrombin time
(clotting factor synthesis affected more quickly than albumin)
18
Q
Aetiology of appendicitis
A
Gut organisms invade appendix wall after lumen obstruction
Becomes inflamed + infected
This leads to oedema, ischaemic necrosis and perforation
Infected + faecal matter escape into the peritoneal cavity producing life threatening peritonitis
Lumen can be obstructed by stool, foreign object, faecolith, infective organisms
19
Q
What is the difference between
diverticulum
diverticulosis
diverticulitis
diverticular disease
A
- Diverticulum – herniation of mucosa and submucosa through the muscular layer of the colonic wall
- Diverticulosis – presence of diverticulae outpouchings of the colonic mucosa + submucosa through the muscular wall of the large bowel, asymptomatic
- Diverticulitis – acute inflammation and infection of diverticulae
- Diverticular disease - the complications from diverticulosis
20
Q
Most common site of diverticula
A
Sigmoid colon
Descending colon
i.e. L hand side
21
Q
What is the Hinchey classificaiton?
A
Assessment of periotneal contamination in the context of acute diverticulitis
I pericolic or mesenteric abscess
II walled off pelvic abscess
III perforation with generalised purulent peritonitis
IV generalised faecal peritonitis
22
Q
A feverish 65-year-old is brought to the local A&E department by her daughter. She complains about nausea, LIF pain and vomiting. The attending doctor takes a full history and performs an abdominal examination and subsequently makes a diagnosis of acute diverticulitis with some associated signs of peritonism. A erect AXR is taken which shows some air under the diaphragm. What is the most appropriate surgical procedure?
Hartmann’s procedure Primary anastomosis Colectomy and end-ileostomy formation Delorme’s procedure Whipple’s procedure
A
Hartmann’s procedure
if presentation is ACUTE because the bowel needs to rest + inflammation needs to go down before primary anastomosis
Diverticular disease surgical management
Primary anastomosis
- One stage resection of affected bowel + anastomosis
- Proximal loop ileostomy (diverts contents before they pass via primary anastomosis - protects the primary anastomosis)
Hartmann’s procedure - if presentation is ACUTE because the bowel needs to rest + inflammation needs to go down before primary anastomosis
- Proctosigmoidectomy + Formation of an end colostomy with anorectal stump
- Used when primary anastomosis is not possible due to e.g. inflammation
Delorme’s procedure – rectal prolapse
Whipple’s procedure - ca of head of pancreas
Whipple procedure (pancreaticoduodenectomy) is an operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct.
23
Q
How to differentiate bn Inguinal hernias + femoral hernias
A
o Reduce hernia
o Place finger over femoral canal
o Ask patient to cough
o Inguinal hernia – will reppear, Femoral hernia – will stay reduced
24
Q
How to differentiate bn direct + indirectInguinal hernias
A
Reduce the hernia and put your hand over the deep inguinal ring
Get patient to cough - if the hernia reappears then it means it is direct (through the abdominal wall)
if it doesnt reappear it means it’s indirect (through the deep inguinal ring which you are blocking with your hands)
deep inguinal ring:
• Midpoint of inguinal ligament
• 1.5cm above midpoint
• Opening in transversalis fascia
25
Inguinal vs femoral hernia
Inguinal
Superior and medial to pubic tubercle
Still more common in F than femoral
often contain bowel
```
Femoral
Inferior and lateral to pubic tubercle
F>M
Higher risk of stangulation than inguinal because it has a narrower neck
Often contain omentum
```
26
Direct vs indirect inguinal hernia
Direct
Superior and medial to pubic tubercle
Through the abdominal wall
Medial to deep inferior epigastric artery
Through Hesselbach's triangle
Doesn't usually extend into scrotum
Cough impulse - will expand outwards (through the defect in the posterior wall of the inguinal canal)
Lower risk of strangulation than indirect hernias
greater tendency for spontaneous reduction
Indirect
More common than direct
Superior and medial to pubic tubercle
Through the deep inguinal ring
Lateral to deep inferior epigastric artery
lateral to Hesselbach's triangle
More likely to extend into scrotum
Cough impulse - will expand in an inferomedial direction (along the length of the inguinal canal)
Higher risk of strangulation than direct hernias
deep inferior epigastric artery lies medial to the deep inguinal ring
27
Which is the most common hernia?
Indirect inguinal hernias
28
Difference bn obstructed + strangulated hernia
Obstructed hernia – refers mainly to hernias containing bowel, where the contents of the hernia are compressed to the extent the the bowel lumen is no longer patent and causes bowel obstruction
Strangulated hernia – the compression around the hernia prevents blood flow into the hernial contents causing ischaemia to the tissues and pain
29
Pathophysiology of acute pancreatitis
inflammatory condition of the exocrine pancreas in which activated pancreatic enzymes are released and begin to autodigest the gland
30
Hypercalcaemia
Hypocalcaemia
How do they relate to pancreatitis?
Hypercalcaemia causes pancreatitis
Hypocalcaemia is caused by pancreatitis
31
Large bowel obstruction commonly due to
| Small bowel obstruction commonly due to
large
Malignancy
+ hernias, feacal impaction
small
adhesions, hernias
32
4 causes of acute mesenteric ischaemia
```
Arterial emoblism (e.g. AF)
Arterial thrombosis (e.g. atheroscleorsis)
Venous thrombosis (e.g. hypercoaguable states, malignancy)
Non-occlusive disease (e.g. hypotension, cocaine)
```
33
Causes of chronic mesenteric ischaemia
* Chronic atherosclerotic disease of the vessels supplying the intestine
* Also known as intestinal angina
* All 3 major mesenteric arteries are involved
Combination of a
Low-flow state (e.g. HF)
Atherosclerotic disease
More common in females
34
Bacteria that cause bloody diarrhoea (dysentry)
```
CCHESS
Campylobacter
Clostrodium difficile
Haemorrahgic E coli (E0157)
Entoameoba histolytica
Salmonella
Shigella
```
35
Which organism caused the diarrhoea (not bloody)? Clues in hx
- Milk, cheese
- >70 yo, past C. diff, use of antibiotics, antiperistaltic drugs
- food, 1-6 hours after eating, short lived
- rice water diarrhoea, poor sanitation, shock
- leafy vegetables
- reheated rice, can cause cerebral abscess
- eggs, poultry may present with constipation, multiplies in Payer’s patches of the intestine
- sudden onset diarrhoea a few hours after a wedding reception
- A university student with watery diarrhoea a few days after a barbeque
- Listeria monocytogenes
- C diff
- Staph aureus
- Vibrio cholera
- E. Coli
- Bacillus cereus
- Salmonella
- sudden presentation that lasts less than 24h - because of a toxin in food (food poisoning) - Staph aureus, Bacillus cereus = bacteria that grow on warm food + produce toxins that result in rapid-onset diarrhoea
- campylobacter jejuni
36
Which organism caused the dysentery (bloody diarrhoea)? Clues in hx
- uncooked poultry (e.g. after a bbq)
- leafy vegetables
- poor sanitation, tropical places, MSM
- person-to-person contact, poor sanitation, MSM
- eggs
Campylobacter (salmonella is most commonly assosciated with raw eggs)
Haemorrhagic E.coli - Bloody diarrhoea followed by haemolytic uraemic syndrome
Entamobea histolytica
Shigella
Salmonella
37
Most common hepatitis in pregnant women
Hep E
38
Hepatitis buzzwords
Hep A - shellfish, faeco-oral, sexual, acute
Hep B - Baby making (sexual), Blood (transfusions, contaminated needles), Birthing (antenatal exposure), adults clear it (less likley to result in chronic infection and HCC than HCV), children stay carriers, risk of HCCC
Hep C - blood transmission(contaminated medical equipemnt, needles) raised afp (higher risk of HCC than with HBV), adults stay carriers, children clear it, asymptomatic, flu like symptoms, more common than HBV more likely to cause chronic infection thatn HBV therefore more likely to cause HCC
Hep D - only in individuals suffering with HBV, blood transmission
Hep E - Expectant mothers, Emmunocompromised, acute, faeco oral, self-limiting
39
Which abx is the first line treatment for C. difficile infection?
Which class of abx is responsible for the infection?
ORAL Metronidazole
or oral vancomycin (2nd line)
Caused by 3rd generation cephalosporins
40
How to maintain remission in UC?
- Low dose oral ASA (e.g. melsalazine)
| - Second line - oral azathioprine/mercaptopurine
41
Types of hepatitis that cause chronic liver disease vs acute hepatitis
Chronic - B,C - can cause cirrhosis and HCC
| Acute - A, D, E
42
Congenital/genetic causes of chronic liver disease
Wilson's
Haemochromatosis
A1 antitrypsin deficiency
all are AR
43
What are the causes of tranaminits in the 1000s?
Toxins - Paracetamol overdose
Viral - Acute viral hepatitis (not B)
Ischaemia
44
Ratio of transaminits in alcoholic hepatitis
AST:ALT 2:1
45
Pathophysiology of Wilson's disease
ATP7B mutation on Chr 13
codes for transporters that excrete copper form liver into bile
• ATP7B encourages:
o Production of the ferroxidase caeruloplasmin (in which copper is incorporated)
o Excretion of copper into bile
46
Presentation of Wilson's disease in
Children, adolescents
vs
Young adults
* Usually presents as liver disease in children + adolescents - acute hepatitis - cirrhosis - liver failure
* Usually presents as a neuropsychiatric illness in young adults
47
Pathophysiology of haemochromatosis
Deficiency of hepcidin HFE gene mutations on the short arm of Chr 6
Known mutations of the HFE gene are C282Y and H63D (must be homozygous)
Increased intestnal absorption of iron causes accumulation in tissues , esp liver
Increased iron release from macrophages
This can lead to organ damage
Deposits in liver, pancreas, pituitary gland
iron in enterocytes wants to be released into the hepatic portal system
ferroprotin is responsible for transferring the iron out of the cells into the blood
Hepcidin inhibits ferrportin --> iron stays in enterocytes, is not released into the blood and is excreted
Hepcidin mutation means ferroportin is uninhibited --> increased release of iron from entercytes to blood
48
Difference bn PBC and PSC
PBC
Autoimmune
T cell mediated destruction of the biliary tracts
Pathology of intra-hepatic bile ducts by antibodies
Anit-mitochondrial antibody 95%
ANA 35%
Females
Assosciated with other autoimmune conditions (thyroid, sjogrens syndrome, systemic sclerosis, coeliac disease, RA)
“Buzzwords” – Hypercholestrolaemia: tendon xanthomata, xanthelasma peri-ocular, post-hepatic jaundice (intrahepatic obstruction)
PSC
Pathology of intra+extra hepatic bile ducts
MRCP - beads on a string
Males
Assosciated with IBD (UC specifically)
“Buzzwords” – UC, cholangiocarcinoma
post-hepatic jaundice (extrahepatic obstruction)
49
Which patients are likely to develop cholangiocarcinoma?
Pt w UC who develop PSC
50
Commonest abscesses in developed world vs worldwide
* Developed countries – pyogenic (bacterial) abscesses most common
* Worldwide – amoebae most common
51
Liver cyst vs liver abscess
Liver cyst - not infetious
Lined with biliary-type epithelium but cyst fluid does not contain bile
F>M
```
Liver abscess - infectious
Mass filled with pus in liver
Pyogenic = polymicrobial (80%)
Amoebic = Entamoeba histolytica (10%)
Fungal = Candida (10%)
```
52
What is the difference between a sliding hiatus hernia and a para-oesophageal (rolling) hiaus hernia?
* Sliding hiatus hernia [85-95%] – the gastro-oesophageal junction slides up into the thoracic cavity
* Para-oesophageal (rolling) hiatus hernia [5-15%] – the gastro-oesophageal junction remains in place but part of the stomach (or colon, spleen, pancreas, small intestine) herniates into the chest next to the oesophagus
53
Which class of drugs increases risk of bleeding form diverticular disease?
NSAIDs
54
Norovirus buzzwords
devloped nations
residential homes
cruise ships
55
Zollinger Ellison syndrome pathophysiology
Ix
Mx
Pancreatic tumour producing gastrin (gastrinoma) as part of MEN1
Hypergastrinaemia
Hypertrophy of gastric mucosa & stimulation acid secreting cells
Damaged mucosa & Ulceration, abdominal pain, vomiting
+ Malabsorption due to damage of GI mucosa
+ inactivation pancreatic enzymes
consider if FHx of MEN, or if multiple ulcers refractory to treatment --> measure fasting serum gastrin
PPIs or surgical resection
56
Peptic ulcer disease RF
H.Pylori - developing countries
NSAIDs - developed countries (iburofen, aspirin, naproxen) - Look out for conditions that may have lead to long term NSAID use, e.g. MI and Stroke for aspirin, long standing hx of headaches
Bisphosphonates
Smoking
Burns - curling ulcer
Head Trauma - cushing ulcer
Zollinger Ellison syndrome (part of MEN 1)
NSAIDs related more to gastric ulcers
H. pylori related more to duodenal ulcers
57
Two types of oseophageal cancer and what are the RF
Squamous cell carcinoma - smoking, alcohol [middle third of the oesophagus]
Adenocarcinoma - GORD, Barret's oesophagus, obesity [lower third of the oesophagus] - most common
58
Define oesophageal varices
Extremely dilated submucosal veins in the lower third of the oesophagus due to portal hypertension as a result of cirrhosis
59
```
A 62yr old gentleman is brought to A&E by his wife who suspects that her husband has been drinking. It is clear that the gentleman is disoriented, and he has a particularly unsteady gate. On examination, you note: spider naevi, gynaecomastia, nystagmus on lateral gaze and mild peripheral neuropathy. His blood results are as follows:
FBC:
Hb: 12.5g/dL (13.5-17.5g/dL)
MCV: 105fL (80-96)
HCT: 0.35 (0.4-0.5)
Platelet: 200*10^9/L (150-400*10^9)
WBC: 8,000/mL (4,000-10,000)
U&E: Normal
CRP: Normal
INR: 0.7 (<1.1)
```
What is the most likely diagnosis?
```
A. Hepatic Encephalopathy
B. Wernicke’s Encephalopathy
C. Encephalitis
D. Normal Pressure Hydrocepahlus
E. Delirium tremens
```
B. Wernicke’s Encephalopathy
(triad of CAN – confusion, ataxia, nystagmus)
In Wernicke’s clotting is not affected
Hepatic encephalopathy denotes liver failure – clotting would be affected
Acute-med lecture
60
epithelium above + below dentate/pectinate line
| innervation
Squamous epithelium below dentate/pectinate line (lower 1/3 of anal canal), somatic innervation, usually visible on inspection
Columnar epithelium above dentate/pectinate line (upper 2/3 of anal canal), visceral innervation, not visible on inspection
61
What kind of cancer is the most common colon cancer?
adenocarcinoma
62
Colon cancer screening program
```
FlexiSig at 56yrs
Screening FIT (faecal immunological test) from 60-74yrs every 2yrs
```
63
Where in the large intestine is colon cancer most commonly found
rectum>sigmoid>ascending colon> transverse colon>descending colon
64
UC complications
Toxic megacolon
| Colonic adenocarcinoma, PSC, cholangiocarcinoma
65
Define coeliac disease
T cell mediated autoimmune reaction to dietary gluten that leads to small bowel + systemic disease
66
Alleles assosciated with coeliac disease
HLA DQ 2/8
67
Malignancy assosciated with coeliac disease
- EATL - Enteropathy assosciated T cell lymphoma - quite specific to coeliac, only increased risk if untreated
- NHL HL
- other small bowel adenocarcinomas
68
DDx for coeliac
Ddx for coeliac is IBD/crohns so if antibody test negative do faecal calprotectin
69
High SAAG meaning
SAAG = serum albumin ascites gradient
[serum albumin]-[ascites albumin]
High value = >11g/L
means low albumin in ascites = Transudative ascites
```
therefore can be
heart failure
constrictive pericarditis
portal hypertenison
cirrhosis
Budd chiari
Hepatic vein obstruction
```
70
Low SAAG meaning
SAAG = serum albumin ascites gradient
[serum albumin]-[ascites albumin]
Low value = <11g/L
means high albumin in ascites or low albumin in serum = exhudative ascites
```
therefore can be
infection
bowel obstruction
pancreatitis
malignancy
nephrotic syndrome (causes hypoalbuminaemia)
```
71
Both liver disease + blocked CBD (obstructive jaundice) can cause patients to have prolonged blood clotting times - how to differentiate?
• Administering parenteral vitamin K will only correct the problem in obstructive jaundice and not in liver disease
72
Consequence of a cholecystoduodenal fistula formation as a result of gallstones
Stone passes to small intestine - can get stuck in the terminal ileum (narrowest part of the intestinal tract)
Mechanical obstruction --> gallstone ileus
73
GI causes of clubbing
IBD
Liver cirrhosis
PBC
Achalasia
74
A1 antitrypsin deficiency
what does it cause
how does it present
inheritance
- Emphysema
- Asthma
- Chronic liver disease
- HCC
- Gallstones
- Pancreatitis
- Wegener's granulomatosis
presentation
- SOB
- Liver cirrhosis
- Cholestatic jaundice
AR
75
Typical offending organisms in ascending cholangitis
E. coli
| Klebsiella
76
Duodenal ulcers vs gastric ulcers
* Duodenal ulcer more common than gastric ulcer!
* All gastric ulcers should be biopsied due to their potential for malignant change (unlike duodenal ulcers)
* Chronic gastric ulcers --> RF for adenocarcinoma
77
Pseudomembranous colitis
what is it and what is it assosciated with
overgrowth of c difficile
occurs post abx therapy
assosciated with broad spectrum abx but cephalosporins are the high risk group e.g. cefotaxime
78
Bacterium implicated in ascites + SBP (spontaneous bacterial peritonitis)
E. coli
(Klebsiella)
SPB = ascites neutrophils > 250 cells/mm3
IV abx – cefotaxime, ceftriaxone, peperacillin/tanzobactam (tanzocin)
If they had a previous episode/ if they are considered high risk – prophylactic oral abx – norfloxacin, ciprofloxacin
79
SPB (spontaneous bacterial peritonitis) definition
Why is it dangerous?
SPB = ascites neutrophils > 250 cells/mm3
Can led to rapid decompensation of liver disease --> hepatic encephalopathy + death
80
Chronic alcohol dependence
Abdominal pain
Weight loss
Stools that are difficult to flush
What are you suspecting?
Next ix?
Chronic pancreatitis
| CT abdo to look for panceratic calcifications
81
Similarities + differences between cholecystitis + ascending cholangitis
Both present with RUQ pain + fever
Ascending cholangitis also presents with jaundice
Ascending cholangitis might also present with hypotention, altered mental status (part of Reynold's pentad along with RUQ pain, fever, jaundice)
Acute cholecysitis presents with RUQ pain, fever, increased WCC
ix
Cholecystitis - US
Ascending cholangitis - ERCP
Mx
Cholecystitis - NMB IVF Abx
NSAIDs, cholecystectomy
Ascending cholangitis - NMB IVF Abx
Opioids, ERCP
82
AAA monitoring + mx
Normal diameter of aorta - 2cm
<4 cm - annual US
4-5.5cm - US every 3 months
>5.5cm - elective intervention
```
Early intervention
rapidly expanding (>1cm/year)
tender
symptomatic
suspected rupture
```
83
Duke's classification
A - confined to the bowel wall
B - invades the bowel wall but no lymph node involvement (beyond muscularis propria)
C - invades the bowel wall + spreads to the lymph nodes
C1 - apical lymph node not involved
C2 - apical lymph node involved
D - distant metastases present
grading of colorectal cancer
84
Autoimmune hepatitis antibodies
Type 1 autoimmune hepatitis
Type 2 autoimmune hepatitis
Type 3 autoimmune hepatitis
Type 1 autoimmune hepatitis – ANA, ASMA, anti-soluble liver antigen or liver/pancreas (anti-SLA/LP), pANCA
Type 2 autoimmune hepatitis – anti-liver-kidney microsomal – 1 ab (anti-LKM-1), anti-liver cytosol 1 (anti-LC1)
Type 3 autoimmune hepatitis – anti-soluble liver antigen or liver/pancreas (anti-SLA/LP)
85
How can we tell that the increased bilirubin in Gilbert's is not due to haemolysis?
Reticulocyte count is normal in Gilbert's whereas in haemolytic anaemia it is increased
Haptoglobin is decreased in heamolysis whereas in Gilbert's it's normal
86
Drugs known to cause cholestasis
```
Clavulanic acid
Penicillin
Co-amoxiclav
Erythromycin
Chlorpromazine
Oestrogens
```
87
GI causes of finger clubbing
```
Coeliac disease
IBD
UC
PBC
Liver cirrhosis
Achalasia
```
88
where is the absorption of
```
Calcium, iron
vitamins:
B2, C
B3, D
B12
```
taking palce
```
Calcium, iron - duodenum
vitamins:
B2, C - proximal ileum
B3, D - jejunum
B12 - termianal ileum
```
89
Transaminins in the 1000s
```
Paracetamol overdose
Ishchaemic hit
Viral hepatitis (except B)
```
