Gastroenterology Flashcards
State the three stepwise process of progression of alcoholic liver disease?
- alcohol related fatty liver
- drinking –> fat build up
- can be reversed in two weeks - alcoholic hepatitis
- inflammation of liver sites - cirrhosis
- scar tissue replaces healthy liver tissue
- irreversible
What is the recommended alcohol consumption?
- men and women
- no more than 14 units per week
- spread over 3 or more days
The CAGE question can be used to quickly screen for harmful alcohol use:
C – CUT DOWN? Ever thought you should?
A – ANNOYED? Do you get annoyed at others commenting on your drinking?
G – GUILTY? Ever feel guilty about drinking?
E – EYE OPENER? Ever drink in the morning to help your hangover/nerves?
State 6 complications of alcohol
- Alcoholic liver disease
- Cirrhosis
- alcohol dependence and withdrawal
- Wernicke-korsakoff syndrome
- pancreatitis
- alcoholic cardiomyopathy
What are signs of liver disease?
9
- jaundice
- hepatomegaly
- spider naevi
- palmar erythema
- gynaecomastia
- bruising
- ascites
- caput medusae
- asterixis
What investigations might you do for an alcoholic liver disease patient?
BLOODs
- FBC - raised MCV?
- LFTs - raised ALT and AST, Gamma-GTT, low albumin, elevated bilirubin in cirrhosis
- Clotting - increased prothrombin time, due to reduced synthetic function of liver
- U&Es - deranged? hepatorenal syndrome
What might an USS of a patient with alcoholic liver disease show?
- increased echogenecity
- showing fatty changes
Complications of liver cirrhosis?
- portal hypertension
- varices
- ascites
- hepatic encephalopathy
stages of alcohol withdrawal
6 - 12hrs : tremor, sweating, headache, craving and anxiety
12 - 24hrs : hallucinations
24 - 48hrs : seizures
**48 - 72hrs : **delerium tremens
What is Delirium tremens?
- medical emergency
- associated with alcohol withdrawal
what receptors do alcohol stimulate in the brain?
- GABA receptors
- GABA receptors have relaxing effect on brain
Which receptors do alcohol inhibit?
- glutamate receptors
- inhibit electrical acitivity of the brain
what occurs to the GABA system with chronic alcohol use?
- GABA system becomes down-regulated
- Glutamate system becomes up regulated
How might alcohol withdrawal be managed?
- score patient on their withdrawal symptoms: CIWA-Ar tool
- Chlordiazepoxide (benzodiazapine)
- IV high dose B vitamins, followed by lower oral thiamine dose
How does alcohol excess affect thiamine (vitamin B1)
- leads to thiamine deficiency
- leads to Wernicke’s encephalopathy
- then Korsakoffs syndrome
Describe three features of Wernicke’s encephalopathy?
- confusion
- oculomotor disturbances
- ataxia
Describe features of Korsakoff’s syndrome?
- memory impairment (retrograde and anterograde)
2. behavioural changes
Fibrosis of the liver can lead to..
- affects structure and blood flow through liver
- causes increased resistance in the vessels
- portal hypertension
- caput medusae?
List 4 most common causes of liver cirrhosis?
- Alcoholic liver disease
- non-alcoholic fatty liver disease
- hepatitis B
- hepatitis C
Rarer causes of liver cirrhosis?
Autoimmune hepatitis
Primary biliary cirrhosis
Haemochromatosis
Wilsons Disease
Alpha-1 antitrypsin deficiency
Cystic fibrosis
Drugs (e.g. amiodarone, methotrexate, sodium valproate)
Asterixis is a sign of:
decompensated liver disease
A Cirrhosis ultrasound may show?
- nodularity of liver surface
- corkscrew appearance to arteries with increased flow as they compensate for reduced portal flow
- enlarged portal vein with reduced flow
- ascites
- splenomegaly
what scan is used to check the elasticity of the liver by sending high frequency sound waves into the liver?
fibroscan
What scoring system is used for liver Cirrhosis?
Child-Pugh score
features:
- bilirubin
- albumin
- INR
- ascites
- encephalopathy
portal vein is derived from the…
superior mesenteric vein and the splenic vein
delivers blood to liver
portal hypertension is:
- liver cirrhosis increases resistance of blood flow in the liver
- back pressure causes vessels to become swollen at tortuous
- at anastomoses sites
- known as varices
four common sites of varices?
- gastro-oesophageal junction
- ileocaecal junction
- rectum
- anterior abdominal wall via the umbilical vein (caput medusae)
three ways to treat stable varices?
- propranolol to reduce portal hypertension
- elastic band ligation of varices
- injection of sclerosant
What is a trans jugular intra-hepatic Porto-systemic shunt (TIPS)
- interventional radiologist inserts wire into jugular vein
- down vena cava
- via hepatic vein into liver
- makes connection
- through hepatic vein and portal vein tissue
- puts stent in place
- allows blood to flow directly from portal vein to hepatic vein, relieving the pressure in portal system and varices
Management of bleeding oesophageal varices?
- RESUSCITATION
- urgent endoscopy
- sengstaken-blakemore tube
Management of bleeding oesophageal varices?
Describe the process of resuscitation?
- vasopressin analogue (causes v.constriction and slow bleeding in varices)
- vitamin K to correct coagulopathy and fresh frozen full of clotting factor plasma
- prophylactic broad spectrum antibiotics
- intubation and ICU consideration
What is a sengstaken-blakemore tube?
- inflatable tube
- inserted into oesophagus to tamponade the bleeding varices
Cirrhosis causes what type of ascites?
- transudative
- low protein content
management of ascites?
- low sodium diet
- aldosterone antagonist diruetics (spironolactone)
- paracentesis
What is spontaneous bacterial peritonitis?
- infection developing in ascitic fluid and peritoneal lining
- without clear cause
most common organisms causing spontaneous bacterial peritonitis?
- E.coli
- klebsiella pneumoniae
- gram positive cocci
presentation of patient with spontaneous bacterial peritonitis?
- fever
- abdominal pain
- deranged bloods
- ileus
- hypotenion
what is an ileus?
complete or partial non mechanical blockage of small and/or large intestine
management of spontaneous bacterial peritonits?
- take an ascitic culture prior to giving antibiotics
- usually treated with IV cephalosporin
- such as cefotaxime
What is hepatorenal syndrome?
- occurs in liver cirrhosis
- hypertension in portal system leads to dilation of portal blood vessels
- loss of blood volume in other areas of circulation, like kidneys
- hypotension in kidneys
- activation of RAAS
- renal v.constriction
- this with reduced circulation volume leads to starvation of blood to the kidneys
- leads to rapid deteriorating kidney function
fatality of hepatorenal syndrome
- fatal within a week
- unless liver transplant is performed
give an example of a toxin that builds up causing hepatic encephalopathy?
- ammonia
- produced from intesitnal gut bacteria
- laxatives can help clear ammonia from gut before it is absorbed.
- antibiotics can reduce the amount of ammonia producing bacteria
management of patient with hepatic encephalopathy?
- laxatives (lactulose) to promote excretion of ammonia
- antibiotics (rifaximin)
rifaximin is useful as it is poorly absorbed and so stays in the GI tract
stages of NAFLD
- non alcoholic fatty liver disease: fat deposits
- non alcoholic steatohepatitis
- fibrosis
- cirrhosis
patients with liver fibrosis as a result of NAFLD may be treated with
vitamin E
or
pioglitazone
Most common viral hepatitis world wide
hep A
Hep A is what type of virus
RNA virus
Hep A presents with what symptoms
- nausea
- vomiting
- anorexia
- jaundice
management of Hep A
- basic analgesia
- should resolve within 1-3 months
Hep B is what type of virus
DNA virus
How is Hep B transmitted
- direct contact with blood or bodily fluids
- IVDU
- vertical transmission
Hep A transmitted via
faecal oral route
Describe recovery time for hep A?
usually within 2 months
10% patients become chronic hep B carriers
virus DNA integrated into their own DNA
Surface antigen (HBsAg) indicates
active infection
Surface antigen (HBsAg) indicates
- marker of viral replication
- high infectivity
Core antibodies (HBcAb)
- past or current infection
Surface antibody (HBsAb)
- implies vaccination or past or current infection
Hepatitis B virus DNA (HBV DNA)
this is a direct count of the viral load
Hep C is what type of virus
RNA virus
How is hep C spread
blood and bodily fluids
no vaccine available
curable via direct actng antiviral medications
Hepatitis D is what type of virus
RNA virus
can only survive in patients who also have hep B infection
Hepatitis E is what type of virus
RNA virus
Hep E transmitted via
faecal oral route
usually produced mild illness
no vaccination
type 1 autoimmune hepatitis
- occurs in adults
- less acute than type 2
Type 1 autoimmune hepatitis autoantibodies
- anti-nuclear antibodies
- anti-smooth muscle antibodies
- anti-soluble liver antigen
Type 2 autoimmune hepatitis autoantibodies
- anti-liver kidney microsomes-1
- anti-liver cytosol antigen type 1
treatment of autoimmune hepatitis
- high dose steroids (prednisolone)
- azathioprine
Haemochromatosis is…
- iron storage disorder
- results in excessive total body iron
mutations in what gene on chromosome 6 are linked to haemochromatosis?
- human haemochromatosis protein (HFE) gene
describe some symptoms of haemochromatosis?
- chronic tiredness
- joint pain
- pigmentation
- hair loss
- erectile dysfunction
- amenorrhoea
- memory and mood disturbance
management of haemochromatosis?
- monitor serum ferritin
- venesection (removing blood to decrease total iron)
- avoid alcohol
- genetic counselling
Wilson’s disease
excessive accumulation of copper in body and tissues
caused by mutation in wilsons disease protein on chromosome 13
autosoma recessive
describe the three main ranges of symptoms of patients with Wilson’s disease?
- hepatic problems
- neurological problems
- psychiatric problems
neurologic symptoms in Wilsons disease
- dysarthria (speech difficulties)
- dystonia
- copper deposition in basal ganglia leads to parkinsonism
parkinsonism characterised by what three signs
- tremor
- bradykinesia
- rigidity
initial investigation of choice for Wilson’s disease
serum caeruloplasmin
low [serum caeruloplasmin] characteristic of Wilson’s
management of Wilsons disease
Copper chelation using:
- penicillamine
- trientene
briefly summarise the pathophys of alpha 1 antitrypsin deficiency
- neutrophils secrete elastase
- elastase enzyme digests connective tissues
- liver produces A1T1 inhibits elastase
- offers protection
two main organs affected by alpha-1-antitrypsin deficiency are
- Liver : cirrhosis
2. Lungs : bronchiectasis and emphysema in lungs
why does bronchiectasis and emphysema occur over time in lungs of patients with A1T1 deficiency ?
- lack of a1t1
- excess of protease enzymes
- attack connective tissue lining of lung
management for a1t1 deficiency
- smoking cessation to decelerate emphysema
- symptomatic management
- organ transplant
primary biliary cirrhosis is a condition where..
- immune system attacks
- small bile ducts within the liver
presentation of primary biliary cirrhosis?
- fatigue
- pruritis
- GI disturbance and abdominal pain
- jaundice
- pale stools
- xanthoma
- signs of cirrhosis and failure (e.g. ascites, splenomegaly and spider naevi)
what is primary biliary cirrhosis associated with?
- other autoimmune diseases (thyroid, coeliac)
- rheumatoid conditions (e.g. systematic sclerosis, sjogrens and rheumatoid arthritis)
which autoantibodies are specific to primary biliary cirrhosis?
- anti-mitochondrial antibodies (most specific to PBC)
- anti-nuclear antibodies (present in 35% of patients)
treatment of primary biliary cirrhosis?
- ursodeoxycholic acid (reduces intestinal absorption of cholesterol)
- cholestyramine
- liver transplant in end stage liver disease
- immunosuppresion?
what is primary sclerosing cholangitis?
- where intrahepatic or extrahepatic ducts become strictured and fibrotic
- sclerosis: stiffening and hardening
- cholangitis : inflammation of bile ducts
5 key features of presentation of patient with primary sclerosing cholangitis?
- jaundice
- chronic RUQ pain
- pruritus
- fatigue
- hepatomegaly
gold standard investigation for diagnosis of primary sclerosing cholangitis?
MRCP
magnetic resonance cholangiopancreatography
MRI : liver , bile ducts, pancreas
management of primary sclerosing cholangitis?
Liver transplant?
- ERCP to dilate and stent any structures
- ursodeoxycholic acid
- cholestryamine (bile acid sequestrate)
primary sclerosing cholangitis is heavily associated with
ulcerative colitis
what are the two types of primary liver cancer?
primary liver cancer originates in the liver
two main types: hepatocellular carcinoma, cholangiocarcinoma
secondary liver cancer is…
- cancer that originates outside the liver and metastasises to the liver
main risk factors for hepatocellular carcinoma is liver cirrhosis due to:
- viral hepatitis B and C
- alcohol
- NAFLD
- chronic liver disease
Liver cancer often remains asymptomatic for a long time and then presents late making prognosis poor.
what is a tumour marker for hepatocellular carcinoma?
- alpha-fetoprotein
what is a tumour marker for cholangiocarcinoma?
- CA19-9
treatment of hepatocellular carcinoma?
- poor prognosis unless diagnosed early
- kinase inhibitors inhibiting proliferation of cancer cells
- HCC resistant to chemo
treatment of cholangiocarcinoma?
- very poor prognosis unless diagnosed very early
- ERCP . can be used to place stent in bile duct
- allows drainage of bile and usually improves symptoms
what is an haemangioma
benign tumour of liver
often find incidentally
what is a focal nodular hyperplasia
- benign liver tumour made of fibrotic tissue
most common causes of acute liver failure?
- acute viral hepatitis
- paracetamol overdose
symptoms of GORD
dyspepsia: indigestion
- heartburn
- acid regurgitation
- retrosternal or epigastric pain
- bloating
- nocturnal cough
- hoarse voice
what are key red flag features which would indicate two week wait referral for endoscopy?
- dysphagia
- aged > 55
- weight loss
- upper abdominal pain / reflux
- treatment resistant dyspepsia
- nausea and vomiting
- low haemoglobin
- raised platelet count
management of GORD
Lifestyle advice
acid neutralising medication
PPI
ranitidine
surgery for laparoscopic fundoplication
what is ranitidine ?
- alternative to PPIs
- H2 receptor antagonist (antihistamine)
- reduces stomach acid
describe the process of laparoscopic fundoplication?
- tying funds of stomach
- around lower oesophagus
- to narrow the lower oesophageal sphincter
What class of bacteria is Heliobacter Pylori
gram negative
Tests for H.pylori
- urea breath test
- stool antigen test
- rapid urease test (involves biopsy during endoscopy)
Eradication regime for H.Pylori
triple therapy
with PPI and two antibiotics (e.g. amoxicillin and clarithromycin)
Barretts oesophagus
metaplasia from squamous to columnar epithelium
treatment for Barretts oesophagus
PPI
ablation treatment
- during endoscopy
eating typically worsens the pain of what ulcers
gastric ulcers
management of peptic ulcers
- endoscopy
- urease test to check for H.pylori
- high dose PPI
State some causes of upper GI bleed
- oesophageal varices
- mallory-weiss tear
- ulcers of stomach or duodenum
- cancers of stomach or duodenum
presentation of upper GI bleed
- haematemesis
- ‘coffee ground’ vomit
- Melaena
- low BP, haemodynamic instability, t.cardia, shock=
management for upper GI bleed
ABCDE
Bloods
Access (2 large bore cannula)
Transfuse
Endoscopy within 24hrs
Drugs
ABATED
definitive treatment for upper GI bleed
oesophagogastroduodenoscopy
banding of varices, or cauterisation
features of Crohn’s disease
NESTS
N - no blood or mucus
E - entire GI tract
S - skip lesions on endoscopy
T - terminal ileum, transmural
S - smoking risk factor
Ulcerative colitis features
CLOSE UP
C - continuous inflammation
L - limited to colon and rectum
O - only superficial mucosa
S - smoking is protective
E - excrete blood and mucus
U - use aminosalicylates
marker of bowel inflammation?
faecal calprotectin
management of Crohn’s
first line: steroids (oral prednisolone, or IV hydrocortisone)
consider adding immunosuppressant: azathioprine
management of mild moderate ulcerative colitis
first line: amino salicylate (e.g. mesalazine)
second line: corticosteroids (e.g. prednisolone)
management of severe ulcerative colitis
first line: IV corticosteroids (e.g. hydrocortisone)
second line: IV ciclosporin
criteria for diagnosis of irritable bowel syndrome?
- Normal FBC, ESR and CRP blood tests
- faecal calprotectin negative to exclude IBD
- negative coeliac disease serology (anti-TTG antibodies)
management of irritable bowel syndrome?
- fluids
- regular small meals
- reduced processed foods
- limit caffeine and alcohol
- low ‘FODMAP’
- probiotics?
first line medication for irritable bowel syndrome?
- loperamide for diarrhoea
- laxative for constipation , avoid lactulose
- antispasmodics for cramps e.g. hyoscine butylbromide
second line medication for irritable bowel syndrome?
tricyclic antidepressants
i.e. amitriptyline
what is coeliac disease?
- autoimmune
- exposure to gluten causes inflammation in small bowel
- auto-antibodies created in response to gluten
two antibodies in coeliacs disease
anti-TTG
anti-EMA
describe what occurs to the small bowel in coeliacs disease?
- villous atrophy
- crypt hypertrophy
- malabsorption of nutrients
what is the rash that occurs in some coeliac patients?
dermatitis herpetiformis
- itchy, blistering rash
genetic associations in coeliac disease
HLA-DQ2
HLA-DQ8
