Gastroenterology Flashcards
Describe the progression of alcoholic liver disease
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
What are the CAGE questions
Cut down (ever thought you should)
Annoyed (if others comment on drinking)
Guilty
Eye-opener (drink in morning to help hangovers)
What are the AUDIT questions
Alcohol use disorders identification test
Developed by WHO
Screen for harmful alcohol use
> 8 = harmful
What are the complications of alcohol consumption
Alcoholic liver disease
Cirrhosis
Hepatocellular carcinoma
Alcohol dependence and withdrawal
Wernicke-Korsakoff syndrome
Pancreatitis
Alcoholic cardiomyopathy
What are the signs of liver disease
Jaundice
Hepatomegaly
Spider naevi
Palmar erythema
Gynaecomastia
Bruising
Ascites
Caput medusae
Flapping tremor
What investigations are needed for alcoholic liver disease
FBC, LFTs, clotting, U&Es
Ultrasound (fibroscan assesses elasticity of liver)
Endoscopy (oesophageal varices)
CT/MRI
Liver biopsy
What abnormalities would be seen in LFTs in alcoholic liver disease
High ALT and AST
High gamma-GT
High ALP later in disease
Low albumin
High bilirubin
What is the management for alcoholic liver disease
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)
Explain the timeframe of alcohol withdrawal
6 - 12 hrs: tremors, sweating, headaches, cravings, anxiety
12 - 24 hrs: hallucinations
24 - 48 hrs: seizures
24 - 72 hrs: delirium tremens
What is delirium tremens
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
How is alcohol withdrawal managed
High dose IV vitamin B
Then regular low dose thiamine
What is liver cirrhosis
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)
What are the common causes of liver cirrhosis
Alcoholic liver disease
Non-alcoholic fatty liver disease
Hepatitis B
Hepatitis C
What are the signs of liver cirrhosis
Jaundice
Hepatomegaly
Splenomegaly
Spider naevi
Palmar erythema
Gynaecomastia
Testicular atrophy
Bruising
Ascites
Caput medusae
Flapping tremor
What investigations are needed for liver cirrhosis
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
What is the Child-Pugh score
Assesses progression of cirrhosis
Takes into account: bilirubin, albumin, INR, ascites, encephalopathy
What is the MELD score
Use every 6 months in patients with compensated cirrhosis
Gives estimated 3 month mortality
What is the management for liver cirrhosis
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
What are the complications of liver cirrhosis
Malnutrition
Portal hypertension
Varices and variceal bleeds
Ascites
Spontaneous bacterial peritonitis
Hepato-renal syndrome
Hepatic encephalopathy
Hepatocellular carcinoma
What are the stages of non-alcoholic fatty liver disease
Non-alcoholic fatty liver disease
Non-alcoholic steatohepatitis
Fibrosis
Cirrhosis
What are the risk factors for non-alcoholic fatty liver disease
Obesity
Poor diet
Low activity levels
Type 2 diabetes
High cholesterol
Middle age or above
Smoking
Hypertension
What are the investigations for non-alcoholic fatty liver disease
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
What is the management for non-alcoholic fatty liver disease
Weight loss
Exercise
Smoking cessation
Control co-morbidities
Avoid alcohol
What are the different types of hepatitis
Alcoholic
Non-alcoholic fatty liver disease
Viral
Autoimmune
Drug induced
How might hepatitis present
Abdominal pain
Fatigue
Pruritis
Muscle and joint aches
Nausea and vomiting
Jaundice
Fever
How are LFTs deranged in hepatitis
AST and ALT high
Bilirubin high
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
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
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
Give an overview of hepatitis D
RNA virus
Only found alongside hep B
Notifiable disease
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
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
What is haemochromatosis
Iron storage disorder
Excessive total body iron
Iron depletion in tissues
Autosomal recessive
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
How is haemochromatosis diagnosed
Serum ferritin levels
Transferrin saturation
Liver biopsy (iron in parenchymal cells)
CT abdomen
MRI (iron deposits in liver)
What is the management for haemochromatosis
Venesection
Monitor serum ferritin
Avoid alcohol
Genetic counselling
Monitor compliance
What are the complications of haemochromatosis
Type 1 diabetes (iron affects pancreas)
Liver cirrhosis
Endocrine and sexual problems
Cardiomegaly
Hepatocellular carcinoma
Hypothyroidism
Arthritis
What is Wilson’s disease
Excessive accumulation of copper
Autosomal recessive
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
How is Wilson’s disease diagnosed
Serum caeruloplasmin (low)
Liver biopsy (gold standard)
24-hour urine copper assay
MRI brain (non-specific changes)
What is the management for Wilson’s disease
Copper chelation (penicillamine, trientine)
What is alpha 1 antitrypsin deficiency
Autosomal recessive
Inhibition of neutrophil elastase enzyme
Live: cirrhosis, hepatocellular carcinoma
Lungs: bronchiectasis, emphysema
How is alpha 1 antitrypsin deficiency diagnosed
Low serum alpha 1 antitrypsin
Liver biopsy
Genetic testing
High resolution CT thorax
What is the management for alpha 1 antitrypsin deficiency
Smoking cessation
Symptomatic management
Organ transplant
Monitor for hepatocellular carcinoma
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
How might primary biliary cirrhosis present
Fatigue
Itching
Jaundice
Xanthelasma
GI disturbance
Pale stools
Signs of cirrhosis and liver failure (ascites, splenomegaly, spider naevi)
How is primary biliary cirrhosis diagnosed
LFTs (ALP high initially, then bilirubin raised)
Autoantibodies (anti-mitrochondrial, anti-nuclear)
High ESR
High IgM
Liver biopsy
What is the management for primary biliary cirrhosis
Ursodeoxycholic acid (reduces intestinal absorption of cholesterol)
Colestyramine (bile acid sequestrant)
Liver transplant
Immunosuppression
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
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
What are the risk factors for primary sclerosing cholangitis
M>F
30 - 40
Ulcerative colitis
Family history
How might primary sclerosing cholangitis present
Jaundice
Chronic right upper quadrant pain
Pruritus
Fatigue
Hepatomegaly
What are the investigations for primary sclerosing cholangitis
LFTs (ALP very deranges, bilirubin high)
Autoantibodies (p-ANCA, ANA, aCL)
How is primary sclerosing cholangitis diagnosed
Magnetic resonance cholangiopancreatography (MRCP)
What is the management for primary sclerosing cholangitis
ERCP (dilate and stent strictures)
Ursodeoxycholic acid (slow disease progression)
Cholestyramine (bile sequestrant)
Liver transplant
What are the complications of primary sclerosing cholangitis
Acute bacterial cholangitis
Cholangiocarcinoma
Colorectal cancer
Cirrhosis
Liver failure
Biliary strictures
Fat soluble vitamin deficiency
What are the 2 main types of liver cancer
Hepatocellular carcinoma
Cholangiocarcinoma
What are haemangiomas/focal nodular hyperplasias
Benign tumours of liver
What are the risk factors for liver cancer
Hepatocellular carcinoma: cirrhosis
Cholangiocarcinoma: primary sclerosing cholangitis
How might liver cancer present
Weight loss
Abdominal pain
Anorexia
Nausea and vomiting
Jaundice
Pruritus
Painless jaundice (cholangiocarcinoma)
What are the investigations for liver cancer
Alpha-fetoprotein (hepatocellular carcinoma)
Ca19-9 (cholangiocarcinoma)
Liver ultrasound
CT/MRI for staging
ERCP (biopsy)
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
What is the management for cholangiocarcinoma
Poor prognosis unless picked up very early
Resection
ERCP (stenting)
Usually resistant to chemotherapy and radiotherapy
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
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)
What is GORD
Stomach acid refluxes through lower oesophageal sphincter and irritates lining of oesophagus
Oesophagus - squamous cell carcinoma
Stomach - columnar epithelium
How might GORD present
Heartburn
Acid regurgitation
Retrosternal/epigastric pain
Bloating
Nocturnal cough
Hoarse voice
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
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)
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)
What is Barrett’s oesophagus
Metaplasia of lower oesophageal epithelium
Can develop into adenocarcinoma
Treat with PPIs and ablation
Where can peptic ulcers be found
Stomach
Duodenum
What can cause peptic ulcers
Medications (steroids, NSAIDs)
H pylori
Stress
Alcohol
Smoking
Spicy food
How does eating relate to peptic ulcers
Worsens pain in gastric ulcers
Improves pain in duodenal ulcers
How might peptic ulcers present
Epigastric pain
Nausea and vomiting
Dyspepsia
Haematemesis
Melena
Iron deficiency anaemia
What is the management for peptic ulcers
Endoscopy (rapid urease test, biopsy)
High dose PPI
What are the complications of peptic ulcers
Bleeding from ulcer
Perforation (acute abdomen, peritonitis)
Scarring and strictures (pyloric stenosis)
What are the causes of upper GI bleeds
Oesophageal varices
Mallory-Weiss tears
Peptic ulcers
Cancer in upper GI tract
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)
Explain the Glasgow-Blatchford score
> 0 = high risk of upper GI bleed
Drop in Hb
Rise in urea
Blood pressure
Heart rate
Melaena
Syncope
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
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)
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
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
How might inflammatory bowel disease present
Diarrhoea
Abdominal pain
Passing blood
Weight loss
What are the investigations for inflammatory bowel disease
Routine bloods
Faecal calprotectin
Stool culture
Endoscopy with biopsy
Ultrasound/CT/MRI (look for complications)
What are acute admissions of IBD at high risk of
VTE
Need prophylactic heparin
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
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
What is irritable bowel syndrome
Functional bowel disorder
Diagnosis of exclusion
What are the symptoms of irritable bowel syndrome
Diarrhoea
Constipation
Fluctuating bowel habits
Abdominal pain
Bloating
Worse after eating
Improved by opening bowels
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
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
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
Which antibodies are associated with coeliac disease
Anti-tissue transglutaminase (anti-TTG)
Anti-endomysial (anti-EMA)
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)
How is coeliac disease diagnosed
Investigate while still eating gluten
Check total IgA
Check antibodies (anti-TTG, anti-EMA)
Endoscopy (crypt hypertrophy, villous atrophy)
Which conditions are associated with coeliac disease
Type 1 diabetes
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
What is the treatment for coeliac disease
Lifelong gluten-free diet
What are the complications of coeliac disease
Vitamin deficiency
Anaemia
Osteoporosis
Ulcerative colitis
Lymphoma of intestines
Small bowel adenocarcinoma
Neurological complications (gluten ataxia, neuropathy)
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
