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Gastroenterology Flashcards

1
Q

Describe the progression of alcoholic liver disease

A

Alcohol-related fatty liver: reversible in 2 weeks

Alcoholic hepatitis: if mild, reversible with abstinence

Cirrhosis: liver made of scar tissue, irreversible, very poor prognosis if continue drinking

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2
Q

What are the CAGE questions

A

Cut down (ever thought you should)

Annoyed (if others comment on drinking)

Guilty

Eye-opener (drink in morning to help hangovers)

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3
Q

What are the AUDIT questions

A

Alcohol use disorders identification test

Developed by WHO

Screen for harmful alcohol use

> 8 = harmful

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4
Q

What are the complications of alcohol consumption

A

Alcoholic liver disease

Cirrhosis

Hepatocellular carcinoma

Alcohol dependence and withdrawal

Wernicke-Korsakoff syndrome

Pancreatitis

Alcoholic cardiomyopathy

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5
Q

What are the signs of liver disease

A

Jaundice

Hepatomegaly

Spider naevi

Palmar erythema

Gynaecomastia

Bruising

Ascites

Caput medusae

Flapping tremor

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6
Q

What investigations are needed for alcoholic liver disease

A

FBC, LFTs, clotting, U&Es

Ultrasound (fibroscan assesses elasticity of liver)

Endoscopy (oesophageal varices)

CT/MRI

Liver biopsy

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7
Q

What abnormalities would be seen in LFTs in alcoholic liver disease

A

High ALT and AST

High gamma-GT

High ALP later in disease

Low albumin

High bilirubin

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8
Q

What is the management for alcoholic liver disease

A

Permanently stop drinking

Consider detoxification regime

Nutritional support (thiamine, high protein)

Steroids

Treat complications of cirrhosis

Refer for liver transplant in severe disease (abstain for 3 months first)

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9
Q

Explain the timeframe of alcohol withdrawal

A

6 - 12 hrs: tremors, sweating, headaches, cravings, anxiety

12 - 24 hrs: hallucinations

24 - 48 hrs: seizures

24 - 72 hrs: delirium tremens

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10
Q

What is delirium tremens

A

Medical emergency

Due to alcohol withdrawal

Extreme excitability of brain, excess adrenergic activity

Presentation: acute confusion, severe agitation, delusions, hallucinations, tremors, tachycardia, hypertension, hyperthermia, ataxia, arrhythmias

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11
Q

How is alcohol withdrawal managed

A

High dose IV vitamin B

Then regular low dose thiamine

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12
Q

What is liver cirrhosis

A

Due to chronic inflammation of liver cells

Liver cells replaced by scar tissue

Nodules of scar form within liver

Increased resistance in vessels leading to liver (portal hypertension)

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13
Q

What are the common causes of liver cirrhosis

A

Alcoholic liver disease

Non-alcoholic fatty liver disease

Hepatitis B

Hepatitis C

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14
Q

What are the signs of liver cirrhosis

A

Jaundice

Hepatomegaly

Splenomegaly

Spider naevi

Palmar erythema

Gynaecomastia

Testicular atrophy

Bruising

Ascites

Caput medusae

Flapping tremor

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15
Q

What investigations are needed for liver cirrhosis

A

LFTs, clotting

Enhanced liver fibrosis blood test

Ultrasound (corkscrew arteries, enlarged portal veins, ascites, splenomegaly)

Fibroscan (if at risk, test every 2 years)

Endoscopy (oesophageal varices)

CT/MRI

Liver biopsy

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16
Q

What is the Child-Pugh score

A

Assesses progression of cirrhosis

Takes into account: bilirubin, albumin, INR, ascites, encephalopathy

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17
Q

What is the MELD score

A

Use every 6 months in patients with compensated cirrhosis

Gives estimated 3 month mortality

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18
Q

What is the management for liver cirrhosis

A

Ultrasound and aFP every 6 months

Endoscopy every 3 years

High protein, low sodium diet

MELD score every 6 months

Consider liver transplant

Manage complications

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19
Q

What are the complications of liver cirrhosis

A

Malnutrition

Portal hypertension

Varices and variceal bleeds

Ascites

Spontaneous bacterial peritonitis

Hepato-renal syndrome

Hepatic encephalopathy

Hepatocellular carcinoma

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20
Q

What are the stages of non-alcoholic fatty liver disease

A

Non-alcoholic fatty liver disease

Non-alcoholic steatohepatitis

Fibrosis

Cirrhosis

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21
Q

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

A

Obesity

Poor diet

Low activity levels

Type 2 diabetes

High cholesterol

Middle age or above

Smoking

Hypertension

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22
Q

What are the investigations for non-alcoholic fatty liver disease

A

Non-invasive liver screen: ultrasound, hep B and C serology, autoantibodies, immunoglobulins, alpha 1 antitrypsin levels, ferritin and transferrin saturation

Enhanced liver fibrosis blood test: first line for fibrosis, based on markers, gives severity of fibrosis

NAFLD fibrosis score: based on age, BMI, liver enzymes, platelets, albumin, diabetes

Fibroscan: elasticity of liver

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23
Q

What is the management for non-alcoholic fatty liver disease

A

Weight loss

Exercise

Smoking cessation

Control co-morbidities

Avoid alcohol

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24
Q

What are the different types of hepatitis

A

Alcoholic

Non-alcoholic fatty liver disease

Viral

Autoimmune

Drug induced

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25
How might hepatitis present
Abdominal pain Fatigue Pruritis Muscle and joint aches Nausea and vomiting Jaundice Fever
26
How are LFTs deranged in hepatitis
AST and ALT high Bilirubin high
27
Give an overview of hepatitis A
RNA virus Faecal-oral route Presentation: nausea vomiting, anorexia, jaundice, cholestasis, hepatomegaly Resolves in 1-3 months Management: basic analgesia Vaccine available Notifiable disease
28
Give an overview of hepatitis B
DNA virus Direct contact with blood/bodily fluids, vertical transmission Most recover in 2 months, 10% become chronic Use viral markers to test Vaccine available Management: low threshold for screening, screen for other blood-borne infections and STIs, notify public health, smoking cessation, stop alcohol, test for complications, antiviral medication, liver transplant
29
Give an overview of hepatitis C
RNA virus Spreads through bodily fluids No vaccine Curable through 8-12 weeks of direct antivirals 3/4 become chronic Antibody testing for screening, RNA testing for diagnosis Management: low threshold for screening, screen for other blood-borne infections and STIs, notify public health, stop smoking, stop drinking alcohol, educate, inform risky contacts, test for complications, liver transplant
30
Give an overview of hepatitis D
RNA virus Only found alongside hep B Notifiable disease
31
Give an overview of hepatitis E
RNA virus Faecal-oral transmission Normally clears within a few months No treatment required Rarely progresses to chronic hepatitis/liver failure No vaccine Notifiable disease
32
Give an overview of autoimmune hepatitis
Genetic predisposition, viral infection triggers Type 1 in adults: autoantibodies - ANA, anti-actin, anti-SLA/LP Type 2 in children: autoantibodies - anti-LKM1, anti-LC1 Diagnosis - liver biopsy Treatment: high dose prednisolone, immunosuppressants
33
What is haemochromatosis
Iron storage disorder Excessive total body iron Iron depletion in tissues Autosomal recessive
34
What are the symptoms of haemochromatosis
Presents in > 40s (finally become symptomatic) Chronic tiredness Joint pains Pigmentation Hair loss Erectile dysfunction Amenorrhoea Memory and mood issues
35
How is haemochromatosis diagnosed
Serum ferritin levels Transferrin saturation Liver biopsy (iron in parenchymal cells) CT abdomen MRI (iron deposits in liver)
36
What is the management for haemochromatosis
Venesection Monitor serum ferritin Avoid alcohol Genetic counselling Monitor compliance
37
What are the complications of haemochromatosis
Type 1 diabetes (iron affects pancreas) Liver cirrhosis Endocrine and sexual problems Cardiomegaly Hepatocellular carcinoma Hypothyroidism Arthritis
38
What is Wilson's disease
Excessive accumulation of copper Autosomal recessive
39
What are the clinical features of Wilson's disease
Chronic hepatitis Cirrhosis Neurological problems Psychiatric problems Kayser-Fleischer rings in cornea Haemolytic anaemia Renal tubular acidosis Osteopenia
40
How is Wilson's disease diagnosed
Serum caeruloplasmin (low) Liver biopsy (gold standard) 24-hour urine copper assay MRI brain (non-specific changes)
41
What is the management for Wilson's disease
Copper chelation (penicillamine, trientine)
42
What is alpha 1 antitrypsin deficiency
Autosomal recessive Inhibition of neutrophil elastase enzyme Live: cirrhosis, hepatocellular carcinoma Lungs: bronchiectasis, emphysema
43
How is alpha 1 antitrypsin deficiency diagnosed
Low serum alpha 1 antitrypsin Liver biopsy Genetic testing High resolution CT thorax
44
What is the management for alpha 1 antitrypsin deficiency
Smoking cessation Symptomatic management Organ transplant Monitor for hepatocellular carcinoma
45
What is primary biliary cirrhosis
Immune system attacks small bile duct of liver Initially affects intralobar ducts (Canal of Hering) Obstruction to outflow of bile, causing cholestasis Ultimately get: fibrosis, cirrhosis, liver failure F>M
46
How might primary biliary cirrhosis present
Fatigue Itching Jaundice Xanthelasma GI disturbance Pale stools Signs of cirrhosis and liver failure (ascites, splenomegaly, spider naevi)
47
How is primary biliary cirrhosis diagnosed
LFTs (ALP high initially, then bilirubin raised) Autoantibodies (anti-mitrochondrial, anti-nuclear) High ESR High IgM Liver biopsy
48
What is the management for primary biliary cirrhosis
Ursodeoxycholic acid (reduces intestinal absorption of cholesterol) Colestyramine (bile acid sequestrant) Liver transplant Immunosuppression
49
What are the complications of primary biliary cirrhosis
Advanced liver cirrhosis Portal hypertension Symptomatic pruritus Fatigue Steatorrhoea Distal renal tubular acidosis Hypothyroidism Osteoporosis Hepatocellular carcinoma
50
What is primary sclerosing cholangitis
Intrahepatic/extrahepatic ducts become strictured and fibrosed Obstruction to outflow of bile Eventually leads to hepatitis, fibrosis, cirrhosis Associated with ulcerative colitis
51
What are the risk factors for primary sclerosing cholangitis
M>F 30 - 40 Ulcerative colitis Family history
52
How might primary sclerosing cholangitis present
Jaundice Chronic right upper quadrant pain Pruritus Fatigue Hepatomegaly
53
What are the investigations for primary sclerosing cholangitis
LFTs (ALP very deranges, bilirubin high) Autoantibodies (p-ANCA, ANA, aCL)
54
How is primary sclerosing cholangitis diagnosed
Magnetic resonance cholangiopancreatography (MRCP)
55
What is the management for primary sclerosing cholangitis
ERCP (dilate and stent strictures) Ursodeoxycholic acid (slow disease progression) Cholestyramine (bile sequestrant) Liver transplant
56
What are the complications of primary sclerosing cholangitis
Acute bacterial cholangitis Cholangiocarcinoma Colorectal cancer Cirrhosis Liver failure Biliary strictures Fat soluble vitamin deficiency
57
What are the 2 main types of liver cancer
Hepatocellular carcinoma Cholangiocarcinoma
58
What are haemangiomas/focal nodular hyperplasias
Benign tumours of liver
59
What are the risk factors for liver cancer
Hepatocellular carcinoma: cirrhosis Cholangiocarcinoma: primary sclerosing cholangitis
60
How might liver cancer present
Weight loss Abdominal pain Anorexia Nausea and vomiting Jaundice Pruritus Painless jaundice (cholangiocarcinoma)
61
What are the investigations for liver cancer
Alpha-fetoprotein (hepatocellular carcinoma) Ca19-9 (cholangiocarcinoma) Liver ultrasound CT/MRI for staging ERCP (biopsy)
62
What is the management for hepatocellular carcinoma
Poor prognosis unless picked up very early Resection Liver transplant Kinase inhibitors (sorafenib, regorafenib, lenvatinib) Usually resistant to chemotherapy and radiotherapy
63
What is the management for cholangiocarcinoma
Poor prognosis unless picked up very early Resection ERCP (stenting) Usually resistant to chemotherapy and radiotherapy
64
Which patients would be unsuitable for a liver transplant
Significant co-morbidities Excessive weight loss and malnutrition Active hep B/C End stage HIV Active alcohol use
65
What is involved in post liver transplant care
Lifelong immunosuppressants Avoid alcohol Avoid smoking Monitor for disease recurrence Monitor for cancer Monitor for rejection (abnormal LFTs, fatigue, fevers, jaundice)
66
What is GORD
Stomach acid refluxes through lower oesophageal sphincter and irritates lining of oesophagus Oesophagus - squamous cell carcinoma Stomach - columnar epithelium
67
How might GORD present
Heartburn Acid regurgitation Retrosternal/epigastric pain Bloating Nocturnal cough Hoarse voice
68
What would be red flags in GORD
Dysphagia (2ww) Age (>55 2ww) Weight loss Upper abdominal pain Reflux Treatment-resistant dyspepsia Nausea and vomiting Low Hb Raised platelets
69
What is the management for GORD
Lifestyle advice (weight loss, smaller meals, stay upright) Acid-neutralising medications: gaviscon, rennie PPIs: omeprazole, lansoprazole Ranitidine: H2 receptor antagonist Surgery (laparoscopic fundoplication - tie fundus around lower oesophagus)
70
Give an overview of H pylori
Gram negative aerobic Causes gastritis and ulcers Produces ammonia (neutralises stomach acid, damages epithelial cells) Testing: 2 weeks without PPI, urea breath test, stool antigen test Eradication: PPI + 2 antibiotics (7 days)
71
What is Barrett's oesophagus
Metaplasia of lower oesophageal epithelium Can develop into adenocarcinoma Treat with PPIs and ablation
72
Where can peptic ulcers be found
Stomach Duodenum
73
What can cause peptic ulcers
Medications (steroids, NSAIDs) H pylori Stress Alcohol Smoking Spicy food
74
How does eating relate to peptic ulcers
Worsens pain in gastric ulcers Improves pain in duodenal ulcers
75
How might peptic ulcers present
Epigastric pain Nausea and vomiting Dyspepsia Haematemesis Melena Iron deficiency anaemia
76
What is the management for peptic ulcers
Endoscopy (rapid urease test, biopsy) High dose PPI
77
What are the complications of peptic ulcers
Bleeding from ulcer Perforation (acute abdomen, peritonitis) Scarring and strictures (pyloric stenosis)
78
What are the causes of upper GI bleeds
Oesophageal varices Mallory-Weiss tears Peptic ulcers Cancer in upper GI tract
79
How might upper GI bleeds present
Haematemesis Coffee ground vomit Melaena Haemodynamic instability Symptoms of underlying pathology (epigastric pain in peptic ulcers, jaundice in liver disease)
80
Explain the Glasgow-Blatchford score
> 0 = high risk of upper GI bleed Drop in Hb Rise in urea Blood pressure Heart rate Melaena Syncope
81
What is the Rockall score
Risk of rebleeding and mortality after endoscopy Age Features of shock Co-morbidities Cause of bleeding Endoscopic stigmata of recent haemorrhage
82
What is the management for upper GI bleeds
ABATED ABCDE Bloods (Hb, U&Rs, coag, liver screen, crossmatch) Access (2 large bore canulae) Transfuse Endoscopy (urgent, within 24 hrs) Drugs (stop anticoagulants and NSAIDs) Definitive management: oesophagogastroduodenoscopy (banding, cauterisation)
83
What are the features of Crohn's disease
Crow's NEST No blood/mucus Entire GI tract Skip lesions on endoscopy Terminal ileum most affected, transmural (full thickness) Smoking is a risk factor
84
What are the features of ulcerative colitis
UC CLOSEUP Continuous inflammation Limited to colon and rectum Only superficial mucosa affected Smoking is protective Excrete blood and mucus Use aminosalicylates Primary sclerosing cholangitis
85
How might inflammatory bowel disease present
Diarrhoea Abdominal pain Passing blood Weight loss
86
What are the investigations for inflammatory bowel disease
Routine bloods Faecal calprotectin Stool culture Endoscopy with biopsy Ultrasound/CT/MRI (look for complications)
87
What are acute admissions of IBD at high risk of
VTE Need prophylactic heparin
88
What is the management for Crohn's disease
Induce remission: steroids, immunosuppressants (azathioprine, methotrexate, infliximab) Maintain remission: use some combination of same drugs Surgery: only if affecting distal ileum
89
What is the management for ulcerative colitis
Induce remission: aminosalicylate, corticosteroids, IV corticosteroids Maintain remission: aminosalicylate, azathioprine Surgery: remove colon and rectum, left with permanent ileostomy
90
What is irritable bowel syndrome
Functional bowel disorder Diagnosis of exclusion
91
What are the symptoms of irritable bowel syndrome
Diarrhoea Constipation Fluctuating bowel habits Abdominal pain Bloating Worse after eating Improved by opening bowels
92
What is the NICE diagnostic criteria for irritable bowel syndrome
Excluded other pathologies Abdominal pain and discomfort plus to of: abnormal stool, bloating, worse after eating, PR mucus
93
What is the management for irritable bowel syndrome
Diet and exercise advise First line: loperamide (diarrhoea), laxatives (constipation, but avoid lactulose), antispasmodics (cramps) Second line: tricyclic antidepressants Third line: SSRI CBT
94
What is coeliac disease
Autoimmune condition Exposure to gluten causes inflammation of small bowel Especially jejunum Get atrophy of intestinal villi Malabsorption of nutrients Genetic associations: HLA-DQ2, HLA-DQ8
95
Which antibodies are associated with coeliac disease
Anti-tissue transglutaminase (anti-TTG) Anti-endomysial (anti-EMA)
96
How might coeliac disease present
Failure to thrive (children) Diarrhoea Fatigue Weight loss Mouth ulcers Anaemia Dermatitis herpetiformis Neurological symptoms (peripheral neuropathy, cerebral ataxia, epilepsy)
97
How is coeliac disease diagnosed
Investigate while still eating gluten Check total IgA Check antibodies (anti-TTG, anti-EMA) Endoscopy (crypt hypertrophy, villous atrophy)
98
Which conditions are associated with coeliac disease
Type 1 diabetes Thyroid disease Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis
99
What is the treatment for coeliac disease
Lifelong gluten-free diet
100
What are the complications of coeliac disease
Vitamin deficiency Anaemia Osteoporosis Ulcerative colitis Lymphoma of intestines Small bowel adenocarcinoma Neurological complications (gluten ataxia, neuropathy)
101
What does a liver screen include
Hep B and C serology Iron studies (ferritin and transferrin saturation) Autoantibodies (AMA, SMA) Immunoglobulins Ceruloplasmin (if >30) Alpha 1 antitrypsin Coeliac serology Thyroid function tests Lipids Glucose

Medicine (9 decks)

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