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Gastroenterology Flashcards

1
Q

UGIB?

A

Bleeding from upper GI tract

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2
Q

Causes of UGIB?

A
  • peptic ulcers - gastro/duodenal
  • MW tear
  • oesophageal varices
  • stomach cancer
  • oesophagitis / GORD
  • AV malformation / aorto-enteric fistula
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3
Q

UGIB Px

A
  • haematemesis
  • coffee ground vomit
  • melaena
  • shock
  • abdo pain - ulcers
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4
Q

UGIB Ix?

A

Bloods
Haemoglobin (FBC)
Urea (U&Es)
Coagulation (INR and FBC for platelets)
Liver disease (LFTs)
Crossmatch 2 units of blood
Group and Save
VBG

Oesophago-gastro-duodenoscopy (OGD)

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5
Q

UGIB risk assessment tools?

A

Glasgow-Blatchford Score
>0 - high risk for GI bleed
- considers bloods, obs, symptoms and comorbidities

Rockall score post endoscopy
- considers age, shock, co-morbidities, endoscopic signs of acute bleeding and endoscopic diagnosis

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6
Q

UGIB MX?

A

unstable?
1. ABCDE - 2 large bore cannulas, O2, fluids and consider transfusion
2. stop anticoagulants / NSAIDs + reverse anticoagulation, eg vit K, PCC
3. keep nil by mouth and send for urgent endoscopic Dx

If variceal? give terlipression plus ABx
if non variceal? clipping or thermal coagulation or band ligation

Unsuccessful? consider surgery
NB can use Sengstaken-Blakemore tube with variceal bleed until surgery can be performed
NB PPI post endoscopy for PUD

Stable?
1. endoscopy within 24 hrs

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7
Q

peptic ulcer disease?

A

ulcer in mucosa of stomach / duodenum

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8
Q

PUD causes + their mechanism

A

disruption of mucosa: NSAIDs + H pylori

Overproduction of acid: stress
- alcohol, caffeine, smoking, spicy foods
- Zollinger-Ellison syndrome

Bleeding risk increased with
- NSAIDs, aspirin, anticoags, steroids, SSRIs

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9
Q

PUD Px?

A
  • epigastric discomfort / pain - gastric worsens pain, duodenal pain improves on eating, then worsens in 2-3hrs
  • wt loss
  • N+V
  • dyspepsia - beware ALARMS - anaemia, loss of weight, anorexia, recent onset sx, melaena, haematemesis, dysphagia
  • UGIB - haematemesis, coffee ground vomit, melaena, low Hb
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10
Q

PUD pain: gastric vs duodenal ulcer

A

gastric worsens pain
duodenal pain improves on eating, then worsens in 2-3hrs

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11
Q

PUD Ix?

A
  • FBC
  • OGD

H pylori Ix
- urea breath test
- stool antigen test
- rapid urease test - CLO test
- serological IgG test

  • biopsy
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12
Q

PUD and H pylori Mx

A
  • Stop NSAIDs / causes
  • PPIs - lansoprazole / omeprazole
  • H2 receptor antagonist - ranitidine / cimetidine
  • rpt OGD in 4-8wks to check healing

H pylori Mx
- PPI - lansoprazole
- 2 abx - amoxicillin + clari / met (clari + met if pen allergic)

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13
Q

Complications of PUD?

A
  • bleeding
  • perforation
  • acute pancreatitis
  • scarring, strictures -> gastric outlet obstruction
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14
Q

GORD?

A

Flow of acid from stomach through LOS into oesophagus

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15
Q

GORD causes?

A
  • Greasy and spicy foods
  • Coffee and tea
  • Alcohol
  • Non-steroidal anti-inflammatory drugs
  • Stress
  • Smoking
  • Obesity
  • Hiatus hernia
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16
Q

GORD Px?

A
  • dyspepsia
  • retrosternal / epigastric pain
  • bloating
  • nocturnal cough
  • hoarse voice
  • eased with burping
  • food / acid brash
  • water brash
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17
Q

GORD red flags - need 2ww for OGD

A
  • Dysphagia (at any age)
  • > 55
  • Weight loss
  • Upper abdo pain
  • Reflux
  • Tx-resistant
  • N+V
  • Upper abdo mass
  • Low Hb
  • Raised platelets

ALARMS
- anaemia
- loss of weight
- anorexia
- recent onset sx
- masses / melaena / haematemesis
- swallowing difficulty

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18
Q

GORD Ix?

A
  • OGD
  • barium swallow
  • H pylori Ix
  • 24hr oesophageal pH monitoring
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19
Q

GORD Mx

A
  • reduce tea, coffee, alcohol / wt loss / stop smoking / smaller meals
  • antacids - Gaviscon, rennie
  • PPIs - omeprazole, lansoprazole
  • H2 antagonist - ranitidine, famotidine
  • laparoscopic fundoplication
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20
Q

name 3 complications of GORD?

A

Barrett’s oesophagus
Peptic stricture
MW tear
Iron deficiency
Ulcers
oesophagitis

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21
Q

what is Barretts oesophagus? how can it be managed?

A

lower oesophageal epithelium changes from stratified squamous to simple columnar - premalignant for adenocarcinoma

Mx: PPI, ablation / resection, endoscopic monitoring

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22
Q

UC?

A

Relapsing / remitting inflammatory disorder of colonic mucosa

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23
Q

Pathophysiology of UC?

A

inappropriate immune response against colonic flora

C – Continuous inflammation
L – Limited to the colon and rectum
O – Only superficial mucosa affected
S – Smoking may be protective (ulcerative colitis is less common in smokers)
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary sclerosing cholangitis

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24
Q

UC Px?

A
  • Insidious / intermittent sx
  • Bloody diarrhoea
  • Urgency
  • Tenesmus
  • Abdo pain
  • Fatigue, weight loss
  • Blood / mucus in stools
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25
Q

what conditions are associated with inflammatory bowel disease?

A
  • Erythema nodosum (tender, red nodules on the shins caused by inflammation of the subcutaneous fat)
  • Pyoderma gangrenosum (rapidly enlarging, painful skin ulcers)
  • Enteropathic arthritis (a type of inflammatory arthritis)
  • Primary sclerosing cholangitis (particularly with ulcerative colitis)
  • Red eye conditions (e.g., episcleritis, scleritis and anterior uveitis)
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26
Q

UC Ix?

A
  • FBC, CRP, U/E, LFT, TFTs
  • Stool MC+S
  • faecal calprotectin
  • colonoscopy + biopsy
  • CT / MRI
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27
Q

UC Mx?

A
  • aim to induce / maintain remission

Inducing Remission
Mild to moderate disease
* 1st line: aminosalicylate (e.g. mesalazine oral or rectal)
* 2nd line : corticosteroids (e.g. prednisolone)

Severe disease
* 1st line : IV corticosteroids (e.g. hydrocortisone)
* 2nd line : IV ciclosporin

Maintaining Remission
Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine

  • Surgery - colectomy, tx strictures/fistulas/abscess
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28
Q

UC Cx

A
  • colonic cancer
  • toxic dilatation of colon
  • perforation
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29
Q

Crohn’s

A

Chronic inflammatory disease characterised by transmural granulomatous inflammation

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30
Q

Crohn’s pathophysiology?

A
  • any part of gut affected
  • most commonly terminal ileum - site of B12 absorption
  • strictures / fistulas
  • transmural inflammation, goblet cells, granulomas, skip lesions, cobblestone appearance
    RFs
    smoking, NSAIDs, FHx
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31
Q

Crohns presentation?

A
  • Abdo pain
  • Diarrhoea
  • Weight loss
  • Fatigue, fever, malaise, anorexia
  • Inflammatory associations as above
  • Clubbing
  • Mouth ulcers
  • Blood / mucus less common
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32
Q

Crohn’s Ix?

A
  • Bloods - FBC, CRP, U/E, LFT, TFT, B12/folate
  • stool MC+S
  • faecal calprotectin
  • colonoscopy + biopsy
  • CT / MRI
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33
Q

Crohn’s Mx/

A

Induce remission
- oral prednisolone / IV hydrocortisone
- mesalazine
- azathioprine / mercaptopurine / methotrexate / infliximab / adalimumab

Maintain remission
- azathioprine / mercaptopurine
- methotrexate

Surgery
- resect distal ileum, tx strictures / fistulas / abscesses

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34
Q

coeliac disease

A
  • autoimmune inflammatory condition triggered by eating gluten
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35
Q

coeliac pathophysiology?

A
  • anti-TTG / anti-EMA ABs created in response to gluten - target epithelial cells in SI
  • jejunum particularly affected
  • crypt hypertrophy + villous atrophy -> malabsorption

Associations
- autoimmune thyroid disease
- T1DM
- dermatitis herpetiformis

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36
Q

Coeliac Px?

A
  • asym
  • failure to thrive (children)
  • diarrhoea
  • bloating
  • fatigue
  • wt loss
  • mouth ulcers
  • dermatitis herpetiformis - itchy, blistering skin rash - on abdo
  • anaemia
  • neuro sx - peripheral neuropathy, ataxia, epilepsy
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37
Q

Coeliac Ix?

A
  • Bloods - FBC, ferritin, haematinics, LFTs, anti-TTG, total IgA (to check for IgA deficiency)
  • endoscopy, biopsy (traditionally duodenum, but also jejunum)

NB can do anti-EMA as second line blood if in doubt

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38
Q

Coeliac Mx?

A

lifelong gluten free diet

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39
Q

IBS

A

Mixed group of abdo sx with no organic cause (functional)
- IBS-C/D/M - constipation/diarrhoea/mixed

  • disorder in brain-gut axis - abnormal smooth muscle activity
  • various causes
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40
Q

IBS Px

A
  • Abdo pain
  • Diarrhoea
  • Constipation
  • Change in bowel habit
  • Bloating
  • Worse after eating
  • Improved by opening bowels
  • Passing mucus
  • SYMPTOMS PRESENT FOR >6M
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41
Q

How many of these symptoms do patients need for and irritable bowel diagnosis?
* Straining, an urgent need to open bowels or incomplete emptying
* Bloating
* Worse after eating
* Passing mucus

A

at least 2

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42
Q

IBS - red flags to exclude!

A
  • Rectal bleeding / blood in stool
  • Weight loss
  • FHx bowel / ovarian cancer
  • > 60yo
  • Nocturnal sx
  • Anaemi
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43
Q

Irritable bowel syndrome Ix

A
  • Full blood count for anaemia
  • Inflammatory markers (e.g., ESR and CRP)
  • Coeliac serology (e.g., anti-TTG antibodies)
  • Faecal calprotectin for inflammatory bowel disease
  • CA125 for ovarian cancer
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44
Q

IBS Mx

A
  • fluids, fibre, limit caffeine/fatty foods, FODMAP, exercise
  • diarrhoea - loperamide
  • constipation - ispaghula husk / linaclotide
  • anti-spasmodics - mebeverine, buscopan, peppermint oil
  • low dose amitriptyline, SSRIs, CBT/hypnotherapy
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45
Q

Alcoholic liver disease (ALD)

A
  • liver disease from alcohol consumption

fatty liver -> alcoholic hepatitis -> alcoholic steatosis -> cirrhosis

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46
Q

ALD Patho

A

Fatty liver
- cells swollen with fat from alcohol metabolism, reversible

Alcoholic hepatitis
- inflammation, fatty change, leukocyte infiltration, necrosis, mallory bodies

Liver cirrhosis
- fibrosis, irreversibl

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47
Q

ALD Px?

A

Fatty liver
- asym
- N+V, diarrhoea
- hepatomegaly

Hepatitis
- jaundice, ascites, abdo pain, fever, hepatomegaly
- sx of chronic disease

Cirrhosis
- chronic disease - ascites, bruising, Dupuytren’s etc

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48
Q

ALD Ix?

A
  • Bloods - FBC, LFT (raised ALT/AST, raised GGT, later raised ALP, raised bilirubin in cirrhosis, low albumin), coag, U/E
  • liver USS - fatty changes / cirrhosis
  • transient elastography (Fibroscan)
  • CT / MRI
  • liver biopsy
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49
Q

ALD Mx?

A
  • stop drinking
  • CBT / motivational interviewing
  • tx cx - eg thiamine, detox
  • prednisolone
  • liver transplant
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50
Q

Non alcoholic fatty liver (NAFLD?)

A
  • excessive fat in liver

Patho
- steatosis - fat liver
- Non-alcoholic steatohepatitis (NASH) - fat with inflammation
- fibrosis/cirrhosis later on

RFs
- older, obesity, poor diet, sedentary, T2DM, high cholesterol, HTN, smoking

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51
Q

NAFLD Px?

A
  • asymptomatic
  • hepatomegaly
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52
Q

NAFLD Ix

A
  • bloods - LFTs, enhanced liver fibrosis (ELF) test
  • USS - increased echogenicity
  • NAFLD fibrosis score
  • FIB-4 score
  • Fibroscan
  • liver biopsy
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53
Q

NAFLD Mx?

A
  • diet, weight, stop smoking
  • specialist mx - vit E, pioglitazone, bariatric surgery, liver transplant
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54
Q

acute liver failure?

A
  • acute deterioration in liver function

Patho
- hepatic encephalopathy
- coagulopathy
- ascites
- jaundice

Causes
- paracetamol OD
- alcohol
- viral hepatitis
- acute fatty liver of pregnancy
- HCC, Wilson’s, A1AT deficiency

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55
Q

acute liver failure Px

A
  • jaundice
  • coagulopathy - bleeding, bruising
  • hypoalbuminaemia - ascites
  • hepatic encephalopathy - confusion, coma, asterixis, drowsiness, slurred speech, behaviour change, apraxia
  • renal failure
  • fever, vomiting
  • fetor hepaticus
  • maybe sx of chronic disease
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56
Q

acute liver failure Ix

A
  • Bloods - inc LFTs, PTT, albumin, coag, FBC, U/E, culture, viral serology
  • USS, CT/MRI, CT head
  • avoid liver biopsy if coagulation derranged
  • EEG - encephalopathy
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57
Q

acute liver failure Mx

A
  • tx cause
  • liver transplan
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58
Q

liver cirrhosis

A
  • fibrosis of liver from chronic inflammation
  • collagen deposition + scarring
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59
Q

causes of liver cirrhosis?

A
  • Alcohol liver disease
  • NAFLD
  • Hep B/C
  • Autoimmune hepatitis
  • Primary biliary cirrhosis
  • Haemochromatosis, Wilson’s, A1AT deficiency
  • CF
  • Drugs - amiodarone, methotrexate, sodium valproate
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60
Q

liver cirrhosis Px?

A
  • leukonychia
  • finger clubbing
  • palmar erythema
  • Dupuytren’s contracture
  • spider naevi >5
  • xanthelasma
  • loss of body hair
  • jaundice
  • HSM
  • bruising
  • ankle swelling, oedema, ascites
  • caput medusae
  • cachexia
  • gynaecomastia, testicular atrophy
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61
Q

Liver cirrhosis Ix?

A
  • bloods - LFTs, coag, FBC, U/E, AFP (HCC)
  • NILS
  • US liver
  • enhanced liver fibrosis test
  • fibroscan
  • CT / MRI
  • liver biopsy
  • Model for End-Stage liver disease (MELD) score
  • Child Pugh score
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62
Q

liver cirrhosis Mx?

A
  • tx cause
  • monitor cx - 6mo US/AFP, 3yrly OGD
  • ascites - fluid restrict, spironolactone, furosemide, paracentesis
  • liver transplant
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63
Q

liver cirrhosis Cx?

A
  • malnutrition
  • varices
  • portal HTN
  • ascites
  • SBP
  • hepatorenal syndrome
  • hepatic encephalopathy
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64
Q

portal HTN?

A
  • high pressure in hepatic portal vein from liver cirrhosis, increased resistance
  • leads to ascites, splenomegaly, varices, caput medusae, collateral vessel formation
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65
Q

portal HTN causes?

A

Pre-hepatic
- portal vein thrombosis

intra-hepatic
- cirrhosis
- schistosomiasis
- sarcoidosis

Post-hepatic
- RHF
- constrictive pericarditis
- IVC obstruction
- Budd-Chiari syndrome

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66
Q

Portal HTN Px?

A
  • Splenomegaly
  • Caput medusae
  • Ascites
  • Sx of liver disease / other cx
  • Sx of varices
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67
Q

Portal HTN Ix?

A
  • for liver disease - bloods, biopsy, CT/MRI etc
  • Abdo US / doppler US
  • hepatic venous pressure gradient
  • vascular imaging
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68
Q

portal HTN Mx?

A
  • tx cause, liver transplant
  • BBs / nitrates
  • TIPS
  • salt restriction, diuretics
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69
Q

ascites?

A

free fluid in peritoneal cavity

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70
Q

causes of ascites?

A

Inflammation
- peritonitis
- infection, TB
- abdo cancer, ovarian
- intra-abdo surgery

Low protein
- hypoalbuminaemia
- nephrotic syndrome
- malnutrition

Low flow
- cirrhosis, portal HTN
- Budd Chiari syndrome
- Cardiac failure
- constrictive pericarditis

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71
Q

How to classify ascites?

A

Serum ascitic albumin gradient (SAAG) = serum albumin - ascitic fluid albumin

High SAAG >1.1g/dL - transudate
- Cirrhosis, portal HTN
- Acute liver failure
- Budd Chiari syndrome
- Portal vein thrombosis
- Cardiac failure
- Constrictive pericarditis

Low SAAG <1.1g/dL - exudate
- Malignancy
- Infection
- Pancreatitis
- Nephrotic syndrome
- Peritoneal TB

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72
Q

ascites Px?

A
  • Abdo swelling
  • Distention
  • Shifting dullness
  • Peripheral oedema
  • Weight gain
  • Abdo pain
  • Difficulty breathing
  • Sx of liver disease
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73
Q

ascites Ix?

A
  • abdo exam, shifting dullness
  • Bloods
  • USS / CT / MRI
  • Ascitic tap - SAAG, raised WCC, culture, cytology, amylase
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74
Q

ascites mx?

A
  • tx cause
  • low Na diet, fluid restriction
  • oral spironolactone
  • add furosemide
  • paracentesis - ascitic tap / drain
  • human albumin solution
  • prophylactic abx - eg oral cipro
  • TIPS
  • liver transplant
75
Q

Spontaneous bacterial peritonitis (SBP)?

A
  • infection of ascitic fluid (from liver cirrhosis)
  • commonly E coli / Klebsiella
76
Q

SBP Px

A
  • asymptomatic
  • ascites
  • abdo pain
  • fever
  • ileus
  • hypotension
  • guarding
  • abdo distention
77
Q

SBP Ix?

A
  • paracentesis - raised WCC
  • bloods - raised WCC
78
Q

SBP Mx?

A
  • broad spec abx - IV cefotaxime / met, maybe tazocin
79
Q

hepatorenal syndrome

A
  • impaired kidney function from changes in blood flow to kidneys - relating to cirrhosis / portal HTN

Mx
- Terlipressin
- albumin
- TIPS
- liver transplant

80
Q

hepatic encephalopathy

A
  • neurological dysfunction from build up of ammonia
  • grade I-IV
81
Q

hepatic encephalopathy Px?

A
  • irritable
  • confused, inappropriate behaviour
  • incoherent, restless
  • coma
  • asterixis, drowsiness, dyspraxia, slurred speech, apraxia (unable to draw 5-pointed star)
82
Q

hepatic encephalopathy Ix?

A
  • as for liver failure
  • EEG - triphasic slow waves
83
Q

hepatic encephalopathy Mx?

A
  • lactulose
  • rifaximin (neomycin / met alternatives)
  • tx liver disease
84
Q

viral hepatitis

A
  • inflammation of liver
  • <6mo acute, >6mo chronic
85
Q

Causes of hepatitis?

A

Viral
- Hep A, E, C, B/D
- Herpes viruses – EBV, CMV, VZV

Non-viral
- Leptospirosis
- Toxoplasmosis
- Coxiella
- TB

Non-infective
- Drugs / toxins
- NAFLD / NASH
- Pregnancy
- Autoimmune
- Hereditary metabolic causes

86
Q

viral hepatitis Px?

A
  • Abdo pain
  • Fatigue
  • Flu-like illness
  • Jaundice
  • Pruritis
  • Myalgia
  • N+V
  • Acute liver failure - bleeding, ascites, encephalopathy
  • If chronic, signs of cirrhosis / chronic liver disease
87
Q

viral hepatitis Ix?

A
  • LFTs - hepatitis picture - high AST/ALT, greater than ALP, high bilirubin
88
Q

hepatitis A?

A
  • RNA virus, faeco-oral transmission
  • 2-6wk incubation
  • usually self-limiting
  • Vaccine to prevent
89
Q

hepatitis A Px?

A
  • pre-icteric - 1wk before jaundice - abdo pain, fever, anorexia, arthralgia, N+V
  • icteric - jaundice
  • HSM, RUQ pain
90
Q

hepatits A Ix?

A
  • Bloods - LFTs, FBC
  • HAV ABs - IgM / IgG
91
Q

hepatitis A Mx?

A
  • supportive - fluids, antiemetics
  • vaccine to prevent / for contacts
92
Q

hepatitis E?

A
  • RNA virus, similar to hep A
  • faeco-oral transmission, 2-9wk transmission

Px
- as hep A
- >95% asym
- maybe neuro sx

Ix
- LFTs
- viral serology

Mx
- supportive
- ribavirin
- hygiene / sanitation to prevent

93
Q

hepatitis B?

A
  • DNA virus
  • blood-borne, bodily fluid transmission, vertical transmission
  • 1-6mo incubation
  • 5% develop chronic hep B - risk of HCC, cirrhosis, liver failure - virus DNA integrates into cell nucleus
94
Q

Hep B Px?

A
  • can be asymptomatic
  • jaundice
  • dark urine
  • hepatosplenomegaly
95
Q

hep B Ix?

A
  • serology
  • LFTs
  • screen for other viral infections - HIV, hep A, C, D
96
Q

hep B serology?

A

HBsAg - surface antigen - active infection

Anti-HBs / HBsAb - surface antibody - vaccination or past/current infection - immune response

Anti-HBc / HBcAb - core antibodies - past/current infection - in response to core antigen - IgM / IgG

HBeAg - envelope antigen - marker of viral replication / infectivity

Anti-HBe / HBeAb - antibodies to envelope antigen - if positive with negative HBeAg -> replication phase has passed, chronic infection is inactive

HBV DNA - hep B virus DNA - direct count of viral load

97
Q

Hep B screening?

A
  • test for anti-HBc (previous infection) and HBsAg (active infection)
  • if positive, test for HBeAg and HBV DNA for infectivity
98
Q

hep B serology interpretation?

A

Active infection
HBsAg+, HBeAg+, anti-HBc IgM+, HBV DNA+

Chronic infection (active)
HBsAg+, HBeAg+, anti-HBc IgG+, HBV DNA+ (high)

Chronic infection (inactive, carrier)
HBsAg+, anti-HBe+, anti-HBc IgG+, HBV DNA+ (low)

Immunity (after acute infection)
HBsAb+, anti-HBe+, anti-HBc IgG+

Immunity (after vaccine)
HBsAb+

99
Q

hep B Mx?

A
  • vaccine to prevent
  • contact tracing
  • antivirals - pegylated interferon-alpha, tenofovir
  • liver transplant if liver failure
100
Q

hep B Cx?

A
  • chronic hepatitis
  • liver failure
  • HCC
101
Q

hepatitis D?

A
  • incomplete RNA virus, needs hep B to manifest
  • blood-borne

Px
- as hep B

Ix
- as HBV
- hep D ABs, HDV RNA (PCR)

Mx
- pegylated interferon alpha

102
Q

hepatitis C?

A
  • RNA virus
  • blood-borne, bodily fluids
  • 70% develop chronic infection -> cirrhosis, liver failure, HCC, rheum issues, cryoglobulinaemia
    Px
  • most acute infections asym
  • flu-like sx
  • jaundice
    Ix
  • LFTs
  • POCTs
  • hep C AB
  • hep C RNA testing
    Mx
  • pegylated interferon alpha / ribavirin
  • supportive
  • no vaccine
    Cx
  • HCC, cirrhosis, liver failure
103
Q

autoimmune hepatitis?

A
  • chronic autoimmune inflammatory liver disease

Type 1
- 80%, F in late 40/50s
- ANA, anti-actin, anti-SLA/LP

Type 2
- children
- anti-LMK1, anti-LC1

Type 3
- adults middle aged
- soluble liver kidney Ag

104
Q

autoimmune hepatitis Px?

A
  • liver disease - hepatitis, HSM, ascites, encephalopathy, abdo pain, jaundice
  • fever, malaise, urticarial rash, polyarthritis, pleurisy, pulm infiltration, glomerulonephritis
  • amenorrhoea
105
Q

autoimmune hepatitis Ix?

A
  • Bloods - LFTs, IgG, auto-ABs
  • liver biopsy
106
Q

autoimmune hepatitis Mx?

A
  • immunosuppressants - pred, azathioprine
  • liver transplant
107
Q

hereditary haemochromatosis (HHC)

A
  • autosomal recessive - increased intestinal iron absorption
  • iron deposits in liver, joints, heart, pancreas, pituitary, adrenals -> fibrosis, liver cirrhosis
108
Q

HHC Px?

A
  • fatigue, arthralgia, hypogonadism (erectile dysfunction, testicular atrophy, amenorrhoea)
  • chronic liver disease, hepatomegaly, HF, arrhythmias, osteoporosis, DM, memory/mood disturbance
  • bronze skin pigmentation
109
Q

HHC Ix?

A
  • iron study - raised ferritin, transferrin, serum iron, low TIBC
  • LFTs
  • genetic testing
  • MRI
  • liver biopsy
  • ECG / ECHO
110
Q

HHC Mx?

A
  • low dietary iron
  • venesection
  • desferrioxamine
  • liver transplant
  • tx cx - eg DM, testosterone
111
Q

Wilson’s disease?

A
  • autosomal recessive - excess copper accumulation in body
  • error in copper metabolism - not bound to caeruloplasmin - deposited in liver, basal ganglia, cornea, kidneys, bones
112
Q

Wilson’s Px?

A
  • Liver - acute / chronic hepatitis, cirrhosis
  • Neuro - tremor, dysarthria, dystonia, Parkinsonism
  • Psych - abnormal behaviour, depression, cognitive impairment, psychosis
  • Kaiser-Fleischer rings
  • osteopenia
  • renal tubular acidosis
  • haemolytic anaemia
113
Q

Wilson’s Ix?

A
  • Bloods - low serum caeruloplasmin, low total serum copper, low Hb, negative Coombs
  • 24hr urine copper assay
  • liver biopsy
  • Slit-lamp
  • MRI brain
  • genetic testing
114
Q

Wilson’s Mx?

A
  • penicillamine / trientine
  • zinc salts
  • liver transplan
115
Q

A1AT deficiency?

A
  • genetic condition - low alpha-1 antitrypsin
  • no inhibition of neutrophil elastase -> attacks connective tissue in lungs
  • abnormal variant of A1AT builds up in hepatocytes -> inflammation, fibrosis
116
Q

A1AT deficiency Px?

A

Lungs - adults, resp sx, SOB etc
Liver - children, hepatitis, cirrhosis, jaundice

117
Q

A1AT deficiency Ix?

A
  • low serum A1AT
  • genetic testing
  • CXR, HRCT, pulm function tests
  • liver biopsy
118
Q

A1AT deficiency Mx?

A
  • stop smoking
  • Mx of COPD
  • lung volume reduction surgery
  • liver / lung transplant
119
Q

primary biliary cholangitis?

A
  • autoimmune granulomatous inflammation of small bile ducts in liver
  • obstructive jaundice + liver disease
  • anti-mitochondrial ABs (AMA)
120
Q

primary biliary cholangitis Px?

A
  • autoimmune granulomatous inflammation of small bile ducts in liver
  • obstructive jaundice + liver disease
  • anti-mitochondrial ABs (AMA)
121
Q

primary biliary cholangitis Ix?

A
  • LFTs - raised ALP
  • Auto-ABs - AMA, also ANA
  • raised IgM
  • US liver / biliary tract / MRCP
  • Liver biopsy
122
Q

primary biliary cholangitis Mx?

A
  • LFTs - raised ALP
  • Auto-ABs - AMA, also ANA
  • raised IgM
  • US liver / biliary tract / MRCP
  • Liver biopsy
123
Q

primary biliary cholangitis complications?

A
  • Liver cirrhosis, portal HTN, HCC
  • Renal tubular acidosis
  • Hypothyroidism / thyroid disease
  • Fat malabsorption, ADEK deficiency
  • Osteoporosis
  • Hyperlipidaemia
  • Sjogren’s syndrome, systemic sclerosis, RA
124
Q

primary sclerosing cholangitis?

A
  • inflammation / sclerosis of intra/extrahepatic bile ducts - obstruct bile flow - liver inflammation / cirrhosis
  • UC association
125
Q

primary sclerosing cholangitis Px?

A
  • asym
  • RUQ pain, pruritis, fatigue, jaundice, HSM, sx of cirrhosis
126
Q

primary sclerosing cholangitis Mx?

A
  • ERCP - stent strictures
  • liver transplant
  • colestyramine
  • vit ADEK
127
Q

primary sclerosing cholangitis Ix?

A
  • LFTs - raised ALP
  • Auto-ABs (less helpful) - p-ANCA, ANA, anti-SMA
  • MRCP
  • colonoscopy (UC)
  • liver biopsy
128
Q

primary sclerosing cholangitis complications?

A
  • Cirrhosis
  • Cholangiocarcinoma - develops in 10-20%
  • Acute bacterial cholangitis
  • ADEK deficiency
  • Osteoporosis
129
Q

hepatocellular carcinoma (HCC)

A
  • primary liver cancer
  • secondary more common
  • mets to lymph nodes, bones, lungs, brain
130
Q

HCC risk factors?

A
  • liver cirrhosis - from NAFLD, ALD, hep B/C, PSC
  • pts with liver cirrhosis - screen for HCC - 6monthly USS, AFP
131
Q

HCC Px?

A
  • asym - presents late
  • liver cirrhosis / failure
  • wt loss
  • abdo pain
  • anorexia
  • N+V
  • jaundice
  • pruritis
  • upper abdo mass
132
Q

HCC Ix?

A
  • AFP - raised
  • Liver USS
  • CT / MRI
  • biopsy
133
Q

HCC Mx?

A
  • surgical resection
  • liver transplant
  • radiofrequency / microwave ablation
  • transarterial chemoembolisation
  • radiotherapy
  • targeted drugs - kinase inhibitors, MAbs
134
Q

describe 3 types of benign liver tumour?

A

Haemangioma
- most common benign liver tumour
- US / CT / MRI
- no tx

Hepatic adenoma
- common - cOCP, anabolic steroids, pregnancy association
- abdo pain, intraperitoneal bleeding
- surgical resection if sx

Focal nodular hyperplasia
- benign liver tumour of fibrotic tissue, related to oestrogen, OCP
- asym
- no tx / monitorin

135
Q

Zollinger-Ellison syndrome

A
  • duodenal / pancreatic tumour secretes excess gastrin -> stimulates acid secretion in stomach -> dyspepsia, diarrhoea, peptic ulcers

Dx
- fasting gastrin levels / secretin stimulation test

Gastrinomas associated with MEN 1

136
Q

achalasia?

A
  • failure of oesophageal peristalsis and impaired relaxation of LOS
  • due to degeneration of ganglia from Auerbach’s plexus
137
Q

achalasia Px?

A
  • dysphagia - both solids + liquids
  • variation in sx severity
  • dyspepsia
  • regurg of foods -> cough, asp pneumonia
  • malignant change (in small no)
138
Q

achalasia Ix?

A
  • oesophageal manometry
  • barium swallow
  • CXR
  • CT / OGD
139
Q

achalasia Mx?

A
  • balloon dilatation
  • surgery - Heller cardiomyotomy
  • botox injection into sphincter
  • nitrates, CCBs
140
Q

alcoholic ketoacidosis

A
  • non-diabetic euglycaemic ketoacidosis
  • binge drinkers -> malnourished, starved
  • metabolic acidosis, elevated anion gap, elevated serum ketones, normal/low glucose

Mx
- IV fluids, thiamine

141
Q

angiodysplasia?

A
  • vascular deformity of GI tract

Px
- iron-deficiency anaemia
- GI bleed

Ix
- colonoscopy
- mesenteric angiography

Mx
- endoscopic cautery
- TXA
- oestrogens

142
Q

Budd-chiari syndrome?

A
  • blockage of hepatic vein, obstructing liver outflow
  • primary - thrombosis
  • secondary - external - eg tumour
    Causes
  • polycythaemia
  • thrombophilia
  • pregnancy
  • cOCP
    Px
  • abdo pain, sudden onset, severe
  • ascites, abdo distension
  • tender hepatomegaly
  • liver failure sx
    Ix
  • deranged LFTs, coag
  • USS, doppler flow studies
  • CT / MRI
    Mx
  • tx cause
  • anticoagulate - warfarin / DOAC
  • shunt - TIPS
  • liver transplant if failure
143
Q

Gilbert’s syndrome?

A
  • autosomal recessive condition of defective bilirubin conjugation (glucuronyl transferase deficiency)
    Px
  • jaundice - eg when ill, exercising, fasting
  • no stool / urine change
    Ix
  • high bilirubin - after fasting / IV nicotinic acid
    Mx
  • none
144
Q

ischaemic hepatitis?

A
  • autosomal recessive condition of defective bilirubin conjugation (glucuronyl transferase deficiency)
    Px
  • jaundice - eg when ill, exercising, fasting
  • no stool / urine change
    Ix
  • high bilirubin - after fasting / IV nicotinic acid
    Mx
  • none
145
Q

clostridium difficile?

A
  • G+ rod, anaerobic
  • develops when normal gut flora suppressed by broad spec abx
  • exotoxin damages intestine (epithelial/inflammatory cells) -> colitis
  • faeco-oral transmission
146
Q

c diff causes?

A
  • clindamycin
  • cephalosporins
  • co-amox
  • carbapenems
  • ciprofloxacin
  • PPIs
147
Q

c diff presentation?

A
  • diarrhoea
  • abdo pain
  • nausea
  • dehydration
  • fever if severe
148
Q

c. diff Ix?

A
  • stool sample - C diff Ag / A/B toxins
  • FBC - raised WCC
  • C diff Ag - serum
149
Q

c diff Mx?

A

First episode
- oral vancomycin
- oral fidaxomicin
- oral vanc +/- IV met

Recurrent
- <12wks of sx resolution - oral fidaxomicin
- >12wks - oral vancomycin / fidaxomicin

Life-threatening
- oral vancomycin + IV met
- surgery
- bezlotoxumab
- faecal microbiota transplant

150
Q

c diff complications?

A
  • pseudomembranous colitis - yellow/white plaques
  • toxic megacolon
  • bowel perforation
  • sepsis
151
Q

gastroenteritis

A

inflammation / infection of gastrointestinal tract
Diarrhoea - >3 loose/watery motions/d, chronic >14d

Causes
- travellers diarrhoea
- acute food poisoning
- Viruses - rotavirus, norovirus, adenovirus
- Bacterial

152
Q

gastroenteritis –> E. coli

A
  • Travellers, watery stools, abdo cramps, nausea
  • E coli -157 - Shiga toxin -> HUS
  • Abx increase HUS risk - avoid in E coli GE
  • self limiting
153
Q

gastroenteritis –> giardiasis

A
  • Prolonged, non-bloody diarrhoea
  • Microscopic parasite, faeco-oral transmission
  • metronidazole
154
Q

gastroenteritis - cholera

A

Profuse watery diarrhoea, severe dehydration, wt loss, not common in travellers
- doxycycline/ ciprofloxacin

155
Q

gastroenteritis - shigella

A
  • Bloody diarrhoea, vomiting, abdo pain
  • Faeces / contaminated food/drink
  • Shiga toxin -> HUS
  • ciprofloxacin / azithromycin
156
Q

gastroenteritis - staph aureus

A
  • Severe vomiting - short incubation period
  • Caused by enterotoxin from bacteria
  • self limiting
157
Q

gastroenteritis - campylobacter

A
  • Flu-like prodrome, crampy abdo pain, fever, diarrhoea +/- blood, GBS cx
  • Most common cause travellers diarrhoea
  • Untreated water, unpasteurised milk, poultry
  • clarithromycin / azithro / cipro
158
Q

gastroenteritis - bacillus cereus

A
  • Vomiting in 6hrs (eg rice) / watery diarrhoea after 6hrs
  • self limiting or vancomycin
159
Q

gastroenteritis amoebiasis

A
  • Gradual onset bloody diarrhoea, abdo pain, tenderness
  • metronidazole + diloxanide furoate
160
Q

gastroenteritis - salmonella

A
  • Sudden onset abdo pain, diarrhoea +/- blood, nausea, vomiting, sometimes constipation
  • Food contamination / raw eggs / chicken
  • treat with ABx if severe e.g. cipro
161
Q

gastroenteritis incubation periods?

A
  • Sudden onset abdo pain, diarrhoea +/- blood, nausea, vomiting, sometimes constipation
  • Food contamination / raw eggs / chicken
162
Q

gastroenteritis presentation?

A
  • Nausea
  • Vomiting
  • Diarrhoea
  • Abdo pain
  • Fever
  • Blood in stools
  • Dehydration
163
Q

diarrhoea Ddx

A

Acute
- GE
- Diverticulitis
- Abx therapy
- Overflow incontinence – constipation

Chronic
- IBS
- IBD
- Colorectal cancer
- Coeliac disease

Other conditions
- Thyrotoxicosis
- Laxative abuse
- appendicitis

164
Q

gastroenteritis Ix

A
  • Stool sample - MC+S
  • monitor dehydration
165
Q

gastroenteritis Mx?

A
  • hydrate
  • oral rehydration salts - dioralyte
  • IV fluids
  • avoid loperamide / antiemetics
  • off school/work for 48hrs after sx
  • abx - if bloody diarrhoea, immunocompromised, typhoid, elderly, severe sx
166
Q

complications of gastroenteritis?

A
  • Lactose intolerance
  • IBS
  • ReA
  • GBS
  • HUS
167
Q

constipation?

A
  • Defecation that is unsatisfactory - can be infrequent, difficult passage (straining / discomfort), incomplete defecation
  • Chronic >3mo
168
Q

causes of constipation?

A

Faecal impaction
Functional / primary
Organic / secondary
- drugs - opioids, anticholinergics, calcium salts, iron salts, CCBs
- medical - bowel obstruction, IBS, cancer, diverticular disease, dehydration, hypothyroid, neuromuscular, anorexia, pregnancy

169
Q

constipation Px?

A
  • Not opening bowels
  • Infrequent
  • Hard stools
  • Maybe droppings
  • Overflow incontinence
170
Q

constipation assessment

A
  • normal bowel habit
  • abdo / rectal / urinary sx
  • abdo exam, PR
  • bloods - FBC, U/E, LFTs, Ca, TFTs
  • specialist - sigmoidoscopy / colonoscopy, CT colon, AXR
171
Q

constipation red flags?

A
  • Persistent unexplained change in bowel habits
  • Palpable mass in RLQ / pelvis
  • Persistent PR bleed w/o anal sx
  • Narrowing of stool calibre
  • FHx colon cancer / IBD
  • Unexplained weight loss, iron deficiency anaemia, fever, nocturnal sx
  • Severe, persistent constipation
172
Q

constipation management?

A

red flags - gastro / surgery referral
- continence service / dietician
- increase fibre, fluids, activity

General mx
1st - ispaghula husk
2nd - macrogols +/- senna/bisacodyl
3rd - prucalopride / linaclotide

173
Q

management of faecal impaction?

A

1st - macrogols +/- senna/bisacodyl
2nd - suppositories - bisacodyl +/- glycerol
3rd - micro-enema - docusate sodium / sodium citrate
4th - retention enema - sodium phosphate enema / arachis oil enema

174
Q

management of opioid induced constipation?

A

1st - senna/bisacodyl +/- macrogols (also prophylaxis)
2nd - docusate sodium / sodium picosulfate
3rd - methylnaltrexone SC / naloxegol tabs

175
Q

management of ibs associated constipation

A

antispasmodic - mebeverine / peppermint oil

176
Q

constipation complications?

A
  • overflow diarrhoea
  • acute urinary retention
  • haemorrhoids
177
Q

paracetamol overdose?

A
  • peak conc at 4hrs
  • inactivated by liver conjugation, then renally excreted
  • in OD, normal pathway saturated, so metabolised by alt pathway - toxic NAPQI produced - normally deactivated by glutathione - but stores of this depleted - NAPQI builds up -> necrosis in liver/kidney
178
Q

types of paracetamol OD?

A

Acute ingestion
- taken within <1hr
- >150mg/kg can be fatal

Staggered
- over >1hr

Unknown time
- tx as staggered

Delayed presentation
- start tx empirically whilst awaiting tx

Unintentional
- no self-harm intention
- >4g/24hrs

179
Q

paracetamol OD Px?

A

<24hrs
- May be asymptomatic
- N+V, abdo pain

> 24hrs-72hrs
- RUQ pain, jaundice, acute liver failure
- Hepatic encephalopathy, confusion
- Hypoglycaemia
- Coagulopathy, bruising
- Asterixis
- Oliguria, renal failure ~72hrs
- Lactic acidosis
- Coma

180
Q

paracetamol OD Ix?

A

Bloods
- FBC, U/E, LFTs (ALT most important), bone profile, gas, BM, coag, phosph
- paracetamol levels >4hrs post-ingestion - use nomogram
- salicylate levels

Assess
- dose ingested, time since last dose, weight, pregnancy, suicide risk

Indications for hospital admission
- Symptomatic
- >75mg/kg over <1hr
- >75mg/kg, time uncertain
- Staggered OD
- >4g/24hrs
- Self-harm

181
Q

paracetamol OD Mx?

A
  • activated charcoal <1hr post-ingestion
  • N-acetylcysteine (NAC) - beware anaphylactoid reaction
  • liver transplant
  • liaison psychiatry
182
Q

NAC indications?

A
  • plasma paracetamol conc above tx line 4-15hrs post-ingestion
  • staggered OD
  • presenting 8-24hrs post-ingestion of >150mg/kg dose
  • presenting >24hrs - jaundiced / hepatic tenderness / ALT deranged
183
Q

Paracetamol OD Mx timeline - very long flashcard!

A

<1hr post-ingestion
- Activated charcoal

<8hrs post-ingestion
- Take paracetamol level >4hrs after last ingestion
- Plot level on nomogram
- Start NAC if - plasma conc levels greater than nomogram line / evidence of hepatic injury / results not available within 8hrs ingestion

8-24hrs post-ingestion
- Take urgent paracetamol level on admission
- Start NAC immediately if >150mg/kg ingested
- Plot plasma level on nomogram
- If below line, asymptomatic, normal bloods – can stop NAC

> 24hrs post-ingestion
- Take urgent paracetamol level on admission
- Start NAC immediately if jaundiced / hepatic tenderness
- Tx with NAC if ALT raised / INR >1.3 / paracetamol level still detected
- No NAC if asym, normal bloods, no paracetamol detected

Staggered OD
- Start NAC immediately
- Take paracetamol level >4hrs after last ingestion
- Stop NAC if – >4hrs after last ingestion AND paracetamol <10mg/L, ALT normal, no signs hepatic damage
- Continue NAC if – sx of hepatic damage, paracetamol >10 / raised ALR / INR >1.3

184
Q

what happens to urea after a UGIB?

A

Acid and digestive enzymes break down blood in the upper GI tract. One of the breakdown products is urea, which is then absorbed in the intestines, causing a rise in blood urea

finals (19 decks)

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