Gastroenterology Flashcards
What are the CAGE questions?
C - Ever thought you should Cut down
A - Do you get annoyed at others commenting on your drinking?
G - Ever feel guilty about drinking?
E - Eye opener? Ever drink in the morning to help your hangover
When to admit to hospital with alcohol withdrawal?
High risk of delirium tremens or seizures
Vulnerable groups - frail, lack social support, learning difficulties, <18y
Time-frame after last drink leading to delirium tremens?
- 6-12 hours – tremor, sweating, headache, craving, anxiety
- 12-24 hours – Hallucinations
- 24-48 hours – Seizures
- 24-72 hours – Delirium tremens
Acute alcohol withdrawal Mx?
Benzodiazepines (chlordiazepoxide) or Carbamazepine
+ thiamine
Delirium tremens Mx?
Oral lorazepam
Parenteral lorazepam or haloperidol
Wernicke’s triad?
Confusion
Oculomotor disturbances
Ataxia
Features of Korsakoff syndrome?
Untreated Wernicke’s -> Korsakoff syndrome
Memory impairment (anterograde and retrograde)
Behavioural changes
Confabulation
Korsakoff syndrome is irreversible -> Full time carer needed
Stepwise progression of alcohol liver disease?
- Alcohol related fatty liver
- Alcoholic hepatitis
- Cirrhosis
Alcohol-related liver disease Ix finidngs?
- FBC – raised MCV
- LFTS – elevated ALT, AST and raised gGT
- Clotting – elevated prothrombin time
Ix to assess degree of cirrhosis?
Fibroscan
Every 2 years in patients at risk of cirrhosis
Diagnostic test of alcohol-related hepatitis or cirrhosis?
Liver biopsy
Px of delirium tremens?
Acute confusion
Severe agitation
Delusions and hallucinations
Tremor
Tachycardia
Hypertension
Hyperthermia
Ataxia (difficulties with coordinated movements)
Arrhythmias
What tool is used to score a patient of their withdrawal symptoms and guide mx?
CIWA-Ar
Clinical Institute Withdrawal Assessment – Alcohol revised
Mx of alcohol-related hepatis?
Stop drinking alcohol + nutritional support
Mx complications of cirrhosis
Severe alcoholic hepatitis -> steroids
Liver transplant referral but must abstain from alcohol for 3 months prior to referral
Cirrhosis complications? (5)
Portal hypertension
Varices
Ascites
Hepatorenal syndrome
Hepatic encephalopathy
Most common causes of liver cirrhosis? (4)
Alcoholic liver disease
NAFLD
Hepatitis B
Hepatitis C
Investigation findings of cirrhosis?
LFTS - if decompensated, all abnormal
Synthetic function - low albumin and high pro-thrombin time = worse-off
U&Es - hyponatraemia
Hepatocellular carcinoma monitoring in liver cirrhosis?
Every 6 months?
- Alpha-fetoprotein (tumour marker) is measured
- Ultrasound
What scoring systems for cirrhosis?
Child-Pugh score - severity of cirrhosis
MELD score - 3 month mortality of cirrhosis (guides liver transplant)
Prophylaxis of variceal haemorrhage?
Propranolol
Medium to large varices -> band ligation
TIPSS if other measures unsuccessful
Mx of bleeding varices?
ABC
Correct clotting - VitK & fresh frozen plasma
Before endoscopy:
- Vasoactive agents - terlipressin
- Prophylactic IV antibiotics - quinolones
Endoscopic band ligation or sclerosant injection
Uncontrolled -> Sengstaken-Blakemore tube
Mx of cirrhosis -> ascites?
Low sodium diet
Anti-aldosterone diuretics - spironolactone
Paracentesis - ascitic tap or ascitic drain
Prophylactic antibiotics against spontaneous bacterial peritonitis (ciprofloxacin or norfloxacin) in patients with less than 15g/litre of protein in the ascitic fluid
If refractory ascites -> consider TIPs or transplant
Px of spontaneous bacterial peritonitis?
Fever
Abdo pain
Deranged bloods
Ileus
Hypotension
Most common causative agent of SBP?
E. coli
Klebsiella pneumoniae
GM+ve coccit
Mx of spontaneous bacterial peritonitis?
Ascitic culture
Cefotaxime
What is hepatorenal syndrome?
When Cirrhosis -> portal hypertension -> dilatation of portal blood vessels
This leads to blood being moved away from other areas of the body such as the kidneys -> rapidly deteriorating kidney function
What is hepatic encephalopathy?
Liver doesn’t metabolise toxins properly -> build-up of toxin
(especially ammonia)
Mx of hepatic encephalopathy?
Laxatives - increase excretion of ammonia
Antibiotics (rifamixin)
Nutritional support
NAFLD stages?
- Non-alcoholic Fatty Liver Disease
- Non-Alcoholic Steatohepatitis (NASH)
- Fibrosis
- Cirrhosis
Ix for hepatic steatosis?
Liver ultrasound
Ix for assessing liver fibrosis?
- Enhanced liver fibrosis (ELF)
- NAFLD fibrosis score
- Fibroscan
Mx for NAFLD?
Lifestyle
Vitamin E
Pioglitazone
Mx of hepatitis A?
Supportive with analgesia
Resolves in 1-3 months
Hepatitis A spread?
Faecal-oral route
Hepatitis B spread?
Direct contact with blood or bodily fluids
- PWID, tattoos
What doe antibodies HBsAg, HBcAG, HBsAb mean?
HBsAg - active infection
HBcAb - past or current infection
HBsAb - implies vaccination or past or current infection
IgM and IgG of HBcAb indicate?
IgM implies active infection
- High titre indicates acute infection
- Low titre indicates chronic infection
IgG indicates a past infection
What does HBeAg indicate?
HBeAg is a marker of viral replication and implies high infectivity
Higher HBeAg = Greater infectivity
Hepatitis C spread?
Spread by blood and bodily fluids
What hepatitis is an RNA virus and DNA virus?
Hepatitis B is a DNA virus
Hepatitis C is an RNA virus
Ix for Hep C?
Screening - hepatitis C antibody
Diagnositc - hepatitis C RNA testing
Ix of autoimmune hepatitis?
Antibodies
Type 1:
- ANA
- Anti-smooth muscle antibodies (anti-actin)
- Anti-soluble liver antigen
Type 2:
- Anti-liver kidney microsomes-1 (anti-LKM1)
- Anti-liver cytosol antigen type 1 (anti-LC1)
Dx - liver biopsy
Mx of autoimmune hepatitis?
High dose steroids (prednisolone) followed by azathioprine
What is haemochromatosis?
Iron storage disorder -> excess rotal body iron and deposition of iron in tissues
Px of haemochromatosis?
Typically over 40y
Chronic tiredness
Joint pain
Pigmentation
Hair loss
Erectile dysfunction / amenorrhoea
Cognitive symptoms
Dx of haemochromatosis?
- High serum ferritin and high transferrin
Dx - Genetic testing
Mx of haemochromatosis?
Venesection
+ monitoring serum ferritin & avoid alcohol
What is Wilson’s disease?
Excessive accumulation of copper in the body and tissues
Inheritance of haemochromatosis and Wilson’s disease?
Autosomal recessive
Px of Wilson’s disease?
Hepatic - chronic hepatitis -> cirrhosis
Neurological - dysarthia, dystonia, parkinsonism
- Asymmetrical motor symptoms
Psychiatric - depression, psychosis
Kayser-fleischer rings a sign of?
Wilson disease
Dx of Wilson’s disease?
Ix - serum caeruloplasmin
Low suggests wilson’s disease
Dx - liver biopsy or 24-hour urine copper assay
Mx of Wilson’s disease?
Penicillamine
Trientene
Px of alpha 1 antitrypsin deficiency?
Liver cirrhosis after 50y
Bronchiectasis and emphysema in lungs after 30y
Ix of alpha-1-antitrypsin deficiency?
Screening - low serum-alpha-1-antitrypsin
Liver biopsy shows cirrhosis and acid-Schiff-positive staining globules in hepatocytes
What is PBC and PSC?
PBC - small intrahepatic ducts
PSC - medium to large extrahepatic and intrahepatic ducts
PBC or PSC correlated with IBD?
PSC
Bloods & Autoantibodies associated with PBC?
Anti-mitochondrial antibodies
Anti-nuclear antibodies (35%)
ESR and IgM raised
Mx of PBC?
For pruritis:
- Ursodeoxycholic acid
- Colestryamine
Consider immunosuppression and transplant
Autoantibodies associated with PSC?
p-ANCA (94%)
ANA (77%&
Anticardiolipin antibodies (aCL) in up to 63%
Dx of PSC?
MRCP
Mx of PSC?
ERCP to dilate and stent bile ducts
Pruritis -> consider colestramine
Consider liver transplant
What is MRCP and ERCP?
MRCP - MRI scan of lover, bile ducts and pancreas
ERCP - endoscopy + x-rays & contrast to identify abnormalities
Px of PSC & PBC?
PSC:
Jaundice
Chronic right upper quadrant pain
Pruritus
Fatigue
Hepatomegaly
PBC specific - Xanthoma and xanthelasma
- Raised papules or bumps on trunks, arms or legs (skin coloured, pink or yellow)
Types of liver cancer?
Hepatocellular carcinoma (80%)
Cholangiocarcinoma (20%)
Metastatic liver cancer
CA19-9 a tumour marker for?
Cholangiocarcinoma
Alpha-fetoprotein a tumour marker for?
Hepatocellular carcinoma
Mx of hepatocellular carcnioma?
Resection
Tyrosine kinase inhibitors - sorafenic, regorafenib and lenvatinib
Resistant to chemotherapy + radiotherapy
What is a haemangioma?
Common benign tumour of the liver
What is focual nodular hyperplasia?
Benign liver tumour made of fibrotic tissue
- Asymptomatic and no malignant potential
- Related to oestrogen
Most common causes of acute liver failure?
Acute viral hepatitis
Paracetamol overdose
What is the cell-makeup of the oesophagus and the stomach?
Oesophagus - squamous
Stomach - columnar
Red flags for endoscopy?
Dysphagia
Aged over 55 (urgent > routine referrals)
Weight loss
Upper abdominal pain / reflux
Treatment resistant dyspepsia
Nausea and vomiting
Low haemoglobin
Raised platelet count
-> 2 week referral
Mx of GORD?
- Lifestyle + acid neutralising mx (gaviscon, rennie)
- PPI - omeprazole, lansoprazole
- Ranitidine (H2 receptor antagonist)
What kind of bacteria is H. Pylori?
Gram negative aerobic bacteria
Test for H.pyloria?
Urea breath test
Stool antigen test
During endoscopy -> rapid urease test
Mx of H. Pylori?
PPI + 2 antibiotics (amoxicillin & clarithromycin) for 7 days
What is Barrett’s Oesophagus?
Metaplasia from squamous to columnar epithelium in lower oesophageal epithelium
How does eating affect gastric and duodenal ulcers?
Eating;
- Worsens pain from gastric ulcers
- Improves pain from duodenal ulcers
Mx of peptic ulcer?
Endoscopy + rapid urease test - exclude malignancy
Mx - PPI
What is pyloric stenosis?
Narrow pylorus causing difficulty in emptying stomach content
Can be a complication of peptic ulcer -> strictures
Crohn’s mnemonic?
NESTS
N – No blood or mucus (less common)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
Ulcerative colitis mnemonic?
CLOSEUP
C – Continuous inflammation
L – Limited to colon and rectum
O – Only superficial mucosa affected
S – Smoking is protective
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary Sclerosing Cholangitis
Screening test for IBD?
Faecal calprotectin
Dx of IBD?
Endoscopy (OGD and colonoscopy) with biopsy
IBD associaitons?
Crohn’s - Wight loss, strictures, fistulas
UC - PSC
Mx of Crohn’s?
Induce remission - steroids
Maintain remission - Azathioprine or Mercaptopurine
Only distal ileum affected -> consider surgery
Mx of inducing remission in UC?
Mild-moderate:
1. Aminosalicylate (PR or Oral Mesalazine)
2. Prednisolone
Severe disease:
1. IV corticosteroids
2. IV Ciclosporin
Mx of maintaining remission of UC?
Aminosalicylate (mesalazine oral or rectal)
Alternatives:
- Azathioprine
- Mercaptopurine
Surgery option for UC?
Panproctocolectomy
->
Ileostomy
J-Pouch
When to consider IBS?
> 6 months of:
A - Abdominal pain
B - Bloating
C - Change in bowel habit
Lifestyle advice of IBS?
Adequate fluid intake
Regular small meals
Reduced processed foods
Limit caffeine and alcohol
Low “FODMAP” diet (ideally with dietician guidance)
Trial of probiotic supplements for 4 weeks
Initial Mx of IBS?
Diarrhoea -> Loperamide
Constipation -> Laxatives but avoid lactulose
Pain (cramps) -> anti-spasmodic (hyoscine butylbromide - Buscopan)
2nd and 3rd line Mx of IBS?
- Tricyclic antidepressants (amitriptyline)
- SSRIs
+/- CBT
Dx of IBS?
Abdo pain:
- Relieved by defecation
- Associated with altered bowel habit
+ 2 of:
- Altered stool passage
- Bloating
- PR mucus
- Worse symptoms after eating
Anti-bodies in Coeliac disease?
Anti-TTG
Anti-endomysial (Anti-EMA)
Where does coeliac affects?
Small bowel, particularly jejunum
Ix of Coeliac disease?
Total IgA + anti-TTG + anti-EMA
What does endoscopy of Coeliac disease show?
Crypt hypertrophy
Villous atrophy
