Gastroenterology Flashcards
HBsAg pos
Anti-HBc pos
IgM Anti-HBcore Negative
Anti-HBs Negative
What is this?
Chronic hepatitis B
HBsAg neg
Anti-HBc neg
Anti-HBs pos
What is this?
Vaccinated
HBsAg neg
Anti-HBc pos
Anti-HBs pos
What is this
Resolved HepB infection
HBsAg pos
Anti-HBc pos
IgM Anti-HBcore pos
Anti-HBs Negative
What is this?
Acute Hep B infection
Stages of Chronic Hepatitis B infection (just the stages)
Phase 1: Immune tolerance
Phase 2: Immune clearance
Phase 3: Immune control
Phase 4: Immune escape
Stages of Chronic Hepatitis B infection (Description of stages- tests)
Immune tolerance
- Viral load HIGH
- LFTs Normal
- HBeAg pos
–> monitor 6-12 monthly
Immune clearance
- Viral load HIGH
- LFTs deranged
- HBeAg pos
–> refer for treatment
Immune control
- Low viral load
- LFTs normal
- Anti- HBeAg
–> monitor 6-12 monthly
Immune escape
- Viral load HIGH
- LFTS deranged
- Anti- HBeAg
—> refer for treatment
HCC surveillance (indications, and what)
- LIVER US +/- AFP
Chronic heb B PLUS
- Cirrhosis
- Without cirrhosis but:
African >20
ASTI >50
Asian men >40
Asian women >50
Family hx HCC
Chronic Hep B monitoring
Viral load
Iron supplementation counselling
- Constipation
- GI upset: nausea
- 3 months then retest
- Take on empty stomach
- Dark stools
- Take with vitamin C
Chronic Heb B management (on antivirals)
- Quarterly viral load
- annual HbsAg and Anti-Hbs (for seroconversion- therefore cessation of treatment)
- HCC surveillance
- Condoms with new partners
- etOH
Aspirin advice for bowel cancer prevention
100mg daily for at least 2.5 years (from 50-70 years)
Immediate emergency management of haematemesis (shock symptoms)
- Call ambulance for urgent transfer to tertiary centre
- Insert 2x large bore IV cannulae in cubital fossa
- Normal saline 0.9% bolus (500ml-1000ml)
- IV pantoprazole 40-80mg stat ** don’t forget
- Keep NBM
- Monitor vitals
Clinical signs for haemachromatosis
- Bronzed skin
- Joint swelling/tenderness
Then think liver disease signs
- Hepatomegaly, spider naevi
Then think heart failure
- Peripheral pitting oedema, elevated JVP
General causes for LFT derrangement (young, without cancer risk factors)
- Alcoholic hepatits/fatty liver diseae
- Hepatic steatosis
- Hepatitis A,B,C
- Autoimmune hepatitis
- Haemochromatosis
- Rare: Wilson’s, alpha 1 anti-trypsin deficiency
Non alcoholic fatty liver disease- new name
MAFLD
Metabolic (dysfunction) associated fatty liver disease
Management of MALFD
- Weight loss 7-10% (referral to AEP)
- Mediterranean diet
- Atorvastatin 10mg
- No alchohol
- arrange Fibroscan to assess for fibrosis
- Discuss HepA&B vaccination
- Aggressive management of CVD risk factors
Screening for HCC in cirrhosis
AFP (alphafetoprotein) every 6 months
Liver US every 6 months
Differentials for dyspepsia
- GORD
- H.pylori gastritis
- PUD
- Medication induced Gastritis
- EtOH induced gastritis
- Functional dyspepsia
- Biliary colic
- Gastric or oesophageal ca
- pancreatitis
- Gastroparesis
PUD management
(Plus indications for prolonged acid suppression & repeat gastroscopy)
- Pantoprazole 40mg**
- Smoking cessation
- Consider repeat gastroscopy 8-12 weeks to check resolution ***
**
Giant ulcer >2cm
Other issue needing ongoing NSAIDs (eg stroke prevention)
>2 in a year
Persistent on repeat endoscopy
Giant >2cm
persistent symptoms despite PPI
evidence of bleeding
features of malignancy
LFTs: ALP >200 and ALP 3x ALT
- Cholestasis or HC damage
Cholestasis
LFTs: ALT >200 and ALT 3x ALP
- Cholestasis or HC damage
HC Damage
Causes of Cholestasis picture on bloods
1) Pregnancy
2) Biliary obstruction:
- Gallstone
- Head of pancreas carcinoma
- Cholangiocarcinoma
3) Drugs: erythromycin, oestrogen, flucloxcillin
4) Primary biliary cirrhosis
5) Primary sclerosing cholangitis
> 60 & weight loss
PLUS and
- Diarrhoea
- Vomiting
- Abdominal pain
- Change in bowels,
- New onset diabetes
a) What are you concerned about?
b) what test
Pancreatic carcinoma
CT abdomen
Traveller’s Diarrhoea Pharmacology management
Azithromycin 1g single dose
Distal Oesophageal Spasm pharmacology
- Trial PPI
- GTN 400mcg spray
or if disabling - Diltiazem MR 180mg daily
Hepatitis B non responder (someone who received childhood vaccines but then titre <10)
Booster plan?
One today (=4th dose) then if titre in 4 weeks then if negative then for 2 further doses 1 month apart
IBS non-pharmacological management
- Use food diary to identify triggers to avoid
- Refer to dietician for low FODMAP diet
- Referral to psychologist for CBT
- Advise on meal portion control
- Regular meal times
Anal fissure treatment (hint: topical)
GTN 0.2% ointment up to QID
Anal fissure non-pharmacological management
- High fibre diet to achieve soft bowel motions
- Sitz bath or warm salt bath after opening bowels
TRIPLE THERAPY for H Pylori
Esomeprazole 20mg BD 7-14 days
AMoxicillin 1g PO BD 7-14 dyas
Clarythromycin 500mg PO BD 7-14 days
GORD treatment duration (inital)
4-8 weeks
IBS differentials (vague bloating and pain)
- SIBO
- Coeliac
- IBD
- lactose/gluten/fructose intolerance
SIgns of severity for diverticulitis
Signs of peritonitis
- severe pain
- rebound tenderness or guarding
Sepsis
- SBP <90
- Hypoxaemia
Bowel obstruciton
- distension
- obstipation
Non-pharmacological bowel cancer prevention
- Avoid smoking
- <2 std /day etOH (1 for women)
- Increased cereal fibre
- Healthy BMI
- 30-60 mins exercise per day
Hepatitis C treatment medication contraindications
- Statins
- PPIs
Test for screening for cirrhosis
Fibroscan
or
AST to platelet Ratio Index (APRI) - if fibroscan not available
Plus INR (sensitive)
When to tests for success of HCV treatment?
12 weeks post test HCV RNA level
(Antibody will stay positive life long)
Tests to consider at time of diagnosis of Coeliac disease
- TSH
- LFTs
- B12, Folate, Vit D
- BMD
Also
- Join coeliac australia
Jaundice differentials (also with weight loss) (HINT cancer and non-cancerous causes)
- Pancreatic carcinoma of the pancreas
- Cholangiocarcinoma
- Hepatocellular carcinoma
- Liver metastases
NON CANCER:
- Alcoholic hepatitis
- Viral hepatitis eg HCV
- Choledocolithiasis
- Primary biliary cirrhosis
