Gastroenterology Flashcards
liver cirrhosis: causes
alcohol
NAFLD
Hepatitis B or C
Metabolic liver disease (Wilson’s, haemochromatosis)
liver cirrhosis: most sensitive investigation
FBC - thrombocytopenia
liver cirrhosis: complications
- UGIB
- sepsis
- spontaneous bacterial peritonitis
- hypoglycaemia
- hepatocellular carcinoma
- hepatorenal syndrome
liver cirrhosis: monitoring for hepatocellular carcinoma
6 monthly USS
Alpha fetoprotein
decompensated liver disease: triggers
- alcohol
- Hepatitis A or E
- infection
- dehydration
- constipation
- UGIB
acute hepatitis: causes
- Alcohol
- Hepatitis A or E
- Autoimmmune
- Toxicity (e.g. paracetamol)
autoimmune hepatitis: types and serology
Type 1 - ANA, anti-SMA
Type 2 - anti-LMK1
primary sclerosing cholangitis: distribution
intra- and extra-hepatic bile ducts
primary biliary sclerosis: distribution
intra-hepatic bile ducts
primary sclerosing cholangitis: associations
ulcerative colitis (in 70% cases)
primary sclerosing cholangitis: presentation
intermittent jaundice and pruritis, classically younger people
primary biliary sclerosis: associations
- Sjogren’s syndrome
- Raynaud’s phenomenon
- arthritis
- autoimmune thyroid disease
primary biliary sclerosis: presentation
insidious onset of fatigue, weight loss, pruritis, classically in middle aged women
primary sclerosing cholangitis: investigations
pANCA in 70% cases (also: ASM, ANA)
ERCP shows stricturing
primary biliary sclerosis: investigations
AMA
primary sclerosing cholangitis: management
No curative treatment
Consider cholestyramine (pruritis), ERCP stenting or balloon dilation, liver transplant for end-stage disease
primary biliary sclerosis: management
Ursodeoxycholic acid
Consider cholestyramine (pruritis), liver transplant for end-stage disease
primary sclerosing cholangitis: complications
- recurrence
- biliary cirrhosis
- Cholangiocarcinoma
- colorectal cancer
- portal hypertension
- malabsorption (metabolic bone disease)
primary biliary sclerosis: complications
- cirrhosis
- Hepatocellular carcinoma
- malabsorption (metabolic bone disease)
ulcerative colitis: distribution
large bowel +/- ‘backwash ileitis’, continuous distribution
ulcerative colitis: associations
pANCA
Primary Sclerosing Cholangitis
ulcerative colitis: presentation
Violent, bloody, mucousy diarrhoea and abdominal pain, systemic malaise.
ulcerative colitis: extra-intestinal manifestations
eyes - uveitis
joints - AS, arthropathy, sacroilitis
skin - erythema nodosum
ulcerative colitis: management of acute flairs
- topical aminosalicylate (sulfasalazine, mesalazine)
- oral aminosalicylate
- topical or oral steroid
ulcerative colitis: maintenance therapy
- topical or oral aminosalicylate
- add azathioprine or cyclosporine
- trial anti-TNF (infliximab, adalibumab)
ulcerative colitis: complications
- toxic megacolon
- primary sclerosing cholangitis
- colonic cancer
Crohn’s disease: distribution
can affect any part of the GIT, commonly affects the terminal ileum, see skip lesions
Crohn’s disease: risk factors
smoking
Crohn’s disease: presentation
diarrhoea which may be bloody, steatorrhoea, crampy abdominal pain and systemic malaise
see mouth ulcers and perianal disease (skin tags, fistulae, abscesses)
Crohn’s disease: extra-intestinal manifestations
eyes - uveitis, episcleritis
joints - AS, arthropathy
skin - erythema nodosum
ulcerative colitis: investigations
- stool culture
- fecal calprotectin
- barium contrast studies
- flexible sigmoidoscopy
Avoid barium studies and endoscopy during acute flair due to risk of perforation
Crohn’s disease: investigations
- stool culture
- fecal calprotectin
- barium contrast studies
- colonoscopy +/- OGD
- haematinics
Crohn’s disease: management of acute flair
- Oral corticosteroid
- Azathioprine or mercaptopurine
- Anti-TNF (infliximab, adalimumab)
Crohn’s disease: maintenance therapy
Azathioprine or mercaptopurine
Crohn’s disease: complications
- strictures
- perforation
- fistulae
- abscesses
- malabsorption
- carcinoma
- bile duct stones
splenomegaly: causes
- malaria
- visceral leishmaniasis
- CML
- myelofibrosis
hyposplenism: causes
- iatrogenic
- trauma
- Sickle Cell Disease
- Coeliac Disease
- Hepatic Disease
- Grave’s Disease
- SLE
- Amyloid
- Thrombosis
Hepatitis A: course
Acute hepatitis, typically following 3-6wk prodrome of malaise, anorexia, fever, N&V
Hepatitis E: course
Acute hepatitis, typically following 3-6wk prodrome of malaise, anorexia, fever, N&V
Acute viral hepatitis: serology
IgM = acute illness
IgG = past infection
Hepatitis A: spread
faeco-oral
Hepatitis E: spread
faeco-oral (Pork and Shellfish)
Hepatitis C: course
Chronic infection, typically without acute illness. Usually found incidentally.
Hepatitis B: course
Chronic infection, usually heralded by acute illness and hepatitis which follows 3-6mo incubation period
Hepatitis C: serology
IgM = acute infection
IgG = chronic infection
Hepatitis C: management
(IFN-alpha and ribavirin)
Sofosbuvir
Hepatitis B: serology
HbsAg = any exposure
HbcAg = chronic exposure
Anti-HbcAg IgM = acute infection
Anti-HbcAg IgG = chronic or cleared infection
Anti-HbsAg = in isolation indicates vaccination
Hepatitis B: management
Acutely, supportive care
Chronic carriage, tenofovir or IFN-alpha
Hepatitis D: course
Chronic, superinfects Hep B carriers and causes more rapid progression to liver failure
Hepatitis B: vaccination criteria
- MSM
- IVDU
- occupational risk
Hepatitis A: vaccination cirteria
- travellers
- people with chronic liver disease
- haemophiliacs
- MSM
- IVDU
- occupational risk
acute viral hepatitis: management
supportive
hepatorenal syndrome: presentation
- cirrhosis
- ascites
- renal failure
hepatorenal syndrome: management
terlipressin
ascitic tap
- MC&S
- Cytology - neutrophils >250 in SBP
- SAG ratio: >11 = transudate; <11 = exudate
causes of transudative ascites
- liver disease
- heart failure
causes of exudative ascites
- pancreatitis
- malignancy
- nephrotic syndrome
- TB
spontaneous bacterial peritonitis: diagnostic criteria
Ascitic tap neutrophils > 250
variceal bleed: management
terlipressin
broad spectrum antibiotics
endocscopy (banding or sclerotherapy)
In an emergency, consider Sengstaken-Blakemore tube.
If resistance, consider TIPS
peptic ulcer: first-line management
oral PPI
H pylori stool antigen (breath test if known previous infection)
peptic ulcer: management in H pylori infection
eradication therapy:
PPI + amoxicillin + clarithromycin
peptic ulcer: management of associated UGIB
endoscopic haemostasis (adrenaline injection)
clipping or ablation
UGIB: scoring systems pre- and post-endoscopy
Pre: Glasgow Blatchford Score
Post: Rockall Score
peptic ulcer: risk factors
- H pylori infection
- Drugs (NSAIDs, SSRIs, steroids, bisphosphonates)
- smoking
- alcohol
- Zollinger-Ellison syndrome
peptic ulcer: complications
- UGIB
- perforation
- malignancy
acute pancreatitis: causes
I GET SMASHED
- idiopathic
- gallstones
- ethanol
- trauma
- steroids
- mumps (or other viruses)
- autoimmune
- scorpion stings
- hypercalcaemia or hypertriglyceridaemia
- ERCP
- drugs (azathioprine, mesalazine, bendroflumethiazide, furosemide, valproate)
also: smoking
acute pancreatitis: most sensitive and specific investigation
serum lipase
acute pancreatitis: differentials for a raised amylase
- acute pancreatitis
- pseudocyst
- mesenteric infarct
- perforated viscus
- acute cholecystitis
- DKA
acute pancreatitis: diagnostic criteria
- Typical history
- Amylase or lipase elevated above 3x ULN
- Imaging to rule-out gallstones (USS) or perforation (CTAP)
2/3 is diagnostic
acute pancreatitis: assessment for severe pancreatitis
Glasgow Criteria
- PaO2 < 7.9kPa
- Age > 55
- Neutrophils (WCC > 15)
- Calcium < 2
- Renal dysfunction (urea >16)
- Enzymes (LDH > 600)
- Albumin < 32
- Sugar (Glucose > 10)
3+ = high risk
acute pancreatitis: management
supportive (fluids, analgesia, managed nutrition)
acute pancreatitis: complications
- peripancreatic fluid collection
- pseudocyst (4wks post-attack, raised amylase, if asymptomatic monitor 12wks)
- pancreatic necrosis (+/- infection)
- pancreatic abscess (secondary to infected pseudocyst)
- haemorrhage
- sepsis
- ARDS
chronic pancreatitis: causes
- alcohol [common]
- recurrent acute pancreatitis
- haemochromatosis
- CF
- hypercalcaemia
- smoking
- CKD
- ductal obstruction (e.g. tumour, stones, annular pancreas)
chronic pancreatitis: management
- enzyme supplements
- analgesia
