Gastro (Medicine) Flashcards by Roshan Patel

What could cause acute liver failure?

paracetamol OD
alcohol 
hepatitis (A&B)
acute fatty liver of pregnancy
Wilson's
Malignancy
Budd-Chiari

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How would acute liver failure present? Including investigation results

Jaundice
Prolonged PT
Hypoalbuminaemia 
Renal failure (hepatorenal syndrome)
Encephalopathy - flap and constructional apraxia

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What tests would be most useful in looking for acute liver failure and why?

PT and albumin

LFTs don’t necessarily reflect the synthetic function of the liver

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What is the pathophysiology of hepatic encephalopathy?

There is excess ammonia and glutamine absorption from protein breakdown in the gut

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What could precipitate hepatic encephalopathy?

Infection
Hypokalaemia
GI bleed
Sedative drugs

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How would hepatic encephalopathy present? (Grades)

All grades: liver flap and constructive apraxia
1 - irritable
2 - confused
3 - incoherent 
4 - coma

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How would you manage hepatic encephalopathy? What do these drugs do?

Lactulose: increased excretion
Rifaximin: reduced production

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What are the most common causes of chronic liver failure?

Alcohol

Hepatitis

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What are the signs and symptoms of chronic liver failure?

Clubbing, leukonychia, palmar erythema, asterixis (flap)

Spider nevi, gynaecomastia, caput medusae

Hepatomegaly, ascites

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What could you find on examination of someone with portal hypertension?

Caput medusae
Oesophageal varices
haemorrhoids (painless)

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Describe the pathophysiology of palmar erythema and leukonychia

palmar erythema: reduced breakdown of sex hormones

leukonychia: hypoalbuminaemia

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What screening would you want to carry out in someone with cirrhosis

Upper endoscopy on diagnosis: varices?

6 monthly USS and a-feto-protein: cancer?

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What investigation would you use to screen for cirrhosis

Transient elastography

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What investigations would suggest alcoholic liver disease?

Raised gamma-GT

AST:ALT ratio >2

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How is alcoholic liver disease managed?

Steroids (often prednisolone)

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How would you assess the severity of alcoholic liver disease?

Maddrey’s discriminant function

It looks at PT and bilirubin

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What drugs would cause a hepatocellular liver disease and which would cause a cholestatic?

Hepatocellular:
paracetemol, alcohol, TB drugs, psychotics, statins

Cholestatic:
COCP, antibiotics eg co-amox, sulphonylurea

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What is thought to be the mechanism behind non-alcoholic fatty liver disease? Therefore what are the risk factors/causes?

Insulin resistance

Obesity, T2DM, hyperlipidaemia
Also sudden weight loss/starvation

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What blood results do you get in non-alcoholic fatty liver disease?

ALT > AST

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How is non-alcoholic liver disease managed?

Weight loss

+/- drugs like metformin

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What is the model for end stage liver disease (MELD) and what factors determine a patients score?

It predicts survival in end stage liver disease

INR, creatinine and bilirubin

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How would autoimmune hepatitis present? Including investigation results

As acute liver failure: fever, jaundice
As chronic liver failure
Amenorrhoea (very common)
ANA or SMA or LKM1 antibodies and raised IgG

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How is autoimmune hepatitis treated?

Steroids +/- other immunosuppressants

Liver transplant

What is the pathophysiology of a raised serum-ascites albumin gradient (SAAG)?

certain disease cause a raised hydrostatic pressure in the circulation = fluid leaves circulation and enters peritoneum (ascites) = circulation is now more concentrated = raised serum albumin compared to ascites.

What would cause ascites with a raised SAAG?

PORTAL HYPERTENTION Liver disease: alcohol, cirrhosis, metastasis Budd-Chiari Right heart failure and constrictive pericarditis

What would causes ascites with a normal SAAG?

Hypoalbuminaemia: Nephrotic syndrome, Kwashiokor Pancreatitis Bowel obstruction Peritoneal cancer

How is ascites managed?

Reduce dietary sodium Fluid restrict (if sodium is <125) Spironolactone +/- loop Drainage with paracentesis

What is a complication of paracentesis? What can this lead to? How is it managed?

paracentesis induced circulatory failure leads to: recurrence of ascites, hepatorenal syndrome and dilutional hyponatraemia management: give prophylactic albumin cover

Causes of hepatomegaly?

Right heart failure Cirrhosis Malignancy

What is ischaemic hepatitis and what blood results would you expect?

Due to acute hypoperfusion eg after arrest ALT is +++++ Can also get AKI picture on bloods

How does Gilberts syndrome present? Signs and bloods

Jaundice in times of stress eg ill, drunk, dehydrated | unconjugated hyperbilirubinemia

What is budd-chiari syndrome?

Hepatic vein thrombosis leading to: - Tender Hepatomegaly - Ascites - abdo distension - Abdominal pain - severe sudden onset

What causes Budd-chiari syndrome?

Polycythaemia rubra vera Thrombophilia's - antithrombin III deficiency, protein C and S deficiency COCP Pregnancy

How is Budd-Chiari investigated and managed?

Doppler US Radiological - angioplasty or shunt Surgery - shunt or liver transplant

Which vessels are affected by portal hypertension to lead to varices, caput medusa and haemorrhoids?

Varices - Normally left gastric --> oesophageal vein Caput medusa - normally para-umbilical --> small epigastric vein Haemorrhoids - normally superior rectal --> inferior rectal

What are the scoring systems for liver cirrhosis?

``` MELD Child-Pugh: - bilirubin - albumin - PT - ascites - encephalopathy ```

What is spontaneous bacterial peritonitis? How does it present?

Seen in patients with ascites secondary to liver cirrhosis Present: - abdo pain - fever - ascites

How is spontaneous bacterial peritonitis investigated and managed?

Ix - paracentesis - neut >250. Commonly E. Coli Mx - IV Cefotaxime

When is Abx prophylaxis given for spontaneous bacterial peritonitis?

Had an episode of spontaneous bacterial peritonitis Fluid protein <15 and child-pugh score >9 or hepatorenal syndrome Give oral ciprofloxacin or norfloxacin

What blood result abnormalities are seen in alcoholic liver disease?

Macrocytic anaemia | Thrombocytopaenia

State the ABG results seen in alcoholic ketoacidosis

metabolic acidosis with raised anion gap raised ketones normal to low glucose

How is alcohol ketoacidosis managed?

saline and thiamine

What antibodies are associated with the 3 types of autoimmune hepatitis?

Raised IgG in all Type 1: ANA and SMA antibodies Type 2 (children): LKM1 antibodies Type 3: soluble liver kidney antigen

How does autoimmune hepatitis present?

Often as chronic liver failure picture Can present as acute hepatitis with fever and jaundice Amenorrhoea

How is autoimmune hepatitis managed?

steroids

What blood test results indicate hepatorenal syndrome?

Huge rise in creatinine and decline in creatinine clearance within a space of 2 weeks

What is the management of hepatorenal syndrome?

``` Ideally liver transplant but most patients are too unwell for this Vasopressin analogues (pathophysiology is thought to be splanchnic vasodilation leading to underperfused kideny) ```

What are the risk factors for non-alcoholic fatty liver disease?

Anything that causes insulin resistance: - obesity - T2DM - hyperlipidaemia - starvation

What LFTs are seen in non-alcoholic fatty liver disease? | What does the liver look like on USS?

ALT typically >AST | Echogenic on USS

What is the management of non-alcoholic fatty liver disease?

weight loss

Who is at risk of re-feeding syndrome?

Low BMI ++ unintentional weight loss Severely reduced intake over past 5-10 days Pre-existing electrolyte abnormalities

What are the characteristic investigation findings of refeeding syndrome?

Low phosphate, K and Mg Can get Torsades as a result of low Mg Abnormal fluid balance

What is Wilsons disease?

autosomal recessive disorder of abnormal copper deposition in tissues

What are the features of Wilsons disease?

LIVER: hepatitis and cirrhosis BRAIN: psych symptoms, speech difficulty, chorea, asterixis, dementia, parkinsonism CORNEA: Kayser-Fleischer rings NAILS: blue

What blood test results indicate Wilsons disease?

Low serum caeruloplasmin Low total serum copper (as it's bound to caeruloplasmin) Raised free non-bound copper

What is the management of Wilsons disease?

Penicillamine