Gastroenterology Flashcards
1
Q
UGIB?
A
Bleeding from upper GI tract
2
Q
Causes of UGIB?
A
- peptic ulcers - gastro/duodenal
- MW tear
- oesophageal varices
- stomach cancer
- oesophagitis / GORD
- AV malformation / aorto-enteric fistula
3
Q
UGIB Px
A
- haematemesis
- coffee ground vomit
- melaena
- shock
- abdo pain - ulcers
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)
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
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
7
Q
peptic ulcer disease?
A
ulcer in mucosa of stomach / duodenum
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
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
10
Q
PUD pain: gastric vs duodenal ulcer
A
gastric worsens pain
duodenal pain improves on eating, then worsens in 2-3hrs
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
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)
13
Q
Complications of PUD?
A
- bleeding
- perforation
- acute pancreatitis
- scarring, strictures -> gastric outlet obstruction
14
Q
GORD?
A
Flow of acid from stomach through LOS into oesophagus
15
Q
GORD causes?
A
- Greasy and spicy foods
- Coffee and tea
- Alcohol
- Non-steroidal anti-inflammatory drugs
- Stress
- Smoking
- Obesity
- Hiatus hernia
16
Q
GORD Px?
A
- dyspepsia
- retrosternal / epigastric pain
- bloating
- nocturnal cough
- hoarse voice
- eased with burping
- food / acid brash
- water brash
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
18
Q
GORD Ix?
A
- OGD
- barium swallow
- H pylori Ix
- 24hr oesophageal pH monitoring
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
20
Q
name 3 complications of GORD?
A
Barrett’s oesophagus
Peptic stricture
MW tear
Iron deficiency
Ulcers
oesophagitis
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
22
Q
UC?
A
Relapsing / remitting inflammatory disorder of colonic mucosa
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
24
Q
UC Px?
A
- Insidious / intermittent sx
- Bloody diarrhoea
- Urgency
- Tenesmus
- Abdo pain
- Fatigue, weight loss
- Blood / mucus in stools
25
what conditions are associated with inflammatory bowel disease?
* 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)
26
UC Ix?
- FBC, CRP, U/E, LFT, TFTs
- Stool MC+S
- faecal calprotectin
- colonoscopy + biopsy
- CT / MRI
27
UC Mx?
- 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
28
UC Cx
- colonic cancer
- toxic dilatation of colon
- perforation
29
Crohn's
Chronic inflammatory disease characterised by transmural granulomatous inflammation
30
Crohn's pathophysiology?
- 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
31
Crohns presentation?
- Abdo pain
- Diarrhoea
- Weight loss
- Fatigue, fever, malaise, anorexia
- Inflammatory associations as above
- Clubbing
- Mouth ulcers
- Blood / mucus less common
32
Crohn's Ix?
- Bloods - FBC, CRP, U/E, LFT, TFT, B12/folate
- stool MC+S
- faecal calprotectin
- colonoscopy + biopsy
- CT / MRI
33
Crohn's Mx/
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
34
coeliac disease
- autoimmune inflammatory condition triggered by eating gluten
35
coeliac pathophysiology?
- 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
36
Coeliac Px?
- 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
37
Coeliac Ix?
- 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
38
Coeliac Mx?
lifelong gluten free diet
39
IBS
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
40
IBS Px
- Abdo pain
- Diarrhoea
- Constipation
- Change in bowel habit
- Bloating
- Worse after eating
- Improved by opening bowels
- Passing mucus
- SYMPTOMS PRESENT FOR >6M
41
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
at least 2
42
IBS - red flags to exclude!
- Rectal bleeding / blood in stool
- Weight loss
- FHx bowel / ovarian cancer
- >60yo
- Nocturnal sx
- Anaemi
43
Irritable bowel syndrome Ix
- 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
44
IBS Mx
- 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
45
Alcoholic liver disease (ALD)
- liver disease from alcohol consumption
fatty liver -> alcoholic hepatitis -> alcoholic steatosis -> cirrhosis
46
ALD Patho
Fatty liver
- cells swollen with fat from alcohol metabolism, reversible
Alcoholic hepatitis
- inflammation, fatty change, leukocyte infiltration, necrosis, mallory bodies
Liver cirrhosis
- fibrosis, irreversibl
47
ALD Px?
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
48
ALD Ix?
- 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
49
ALD Mx?
- stop drinking
- CBT / motivational interviewing
- tx cx - eg thiamine, detox
- prednisolone
- liver transplant
50
Non alcoholic fatty liver (NAFLD?)
- 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
51
NAFLD Px?
- asymptomatic
- hepatomegaly
52
NAFLD Ix
- bloods - LFTs, enhanced liver fibrosis (ELF) test
- USS - increased echogenicity
- NAFLD fibrosis score
- FIB-4 score
- Fibroscan
- liver biopsy
53
NAFLD Mx?
- diet, weight, stop smoking
- specialist mx - vit E, pioglitazone, bariatric surgery, liver transplant
54
acute liver failure?
- 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
55
acute liver failure Px
- 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
56
acute liver failure Ix
- 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
57
acute liver failure Mx
- tx cause
- liver transplan
58
liver cirrhosis
- fibrosis of liver from chronic inflammation
- collagen deposition + scarring
59
causes of liver cirrhosis?
- Alcohol liver disease
- NAFLD
- Hep B/C
- Autoimmune hepatitis
- Primary biliary cirrhosis
- Haemochromatosis, Wilson's, A1AT deficiency
- CF
- Drugs - amiodarone, methotrexate, sodium valproate
60
liver cirrhosis Px?
- 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
61
Liver cirrhosis Ix?
- 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
62
liver cirrhosis Mx?
- tx cause
- monitor cx - 6mo US/AFP, 3yrly OGD
- ascites - fluid restrict, spironolactone, furosemide, paracentesis
- liver transplant
63
liver cirrhosis Cx?
- malnutrition
- varices
- portal HTN
- ascites
- SBP
- hepatorenal syndrome
- hepatic encephalopathy
64
portal HTN?
- high pressure in hepatic portal vein from liver cirrhosis, increased resistance
- leads to ascites, splenomegaly, varices, caput medusae, collateral vessel formation
65
portal HTN causes?
Pre-hepatic
- portal vein thrombosis
intra-hepatic
- cirrhosis
- schistosomiasis
- sarcoidosis
Post-hepatic
- RHF
- constrictive pericarditis
- IVC obstruction
- Budd-Chiari syndrome
66
Portal HTN Px?
- Splenomegaly
- Caput medusae
- Ascites
- Sx of liver disease / other cx
- Sx of varices
67
Portal HTN Ix?
- for liver disease - bloods, biopsy, CT/MRI etc
- Abdo US / doppler US
- hepatic venous pressure gradient
- vascular imaging
68
portal HTN Mx?
- tx cause, liver transplant
- BBs / nitrates
- TIPS
- salt restriction, diuretics
69
ascites?
free fluid in peritoneal cavity
70
causes of ascites?
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
71
How to classify ascites?
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
72
ascites Px?
- Abdo swelling
- Distention
- Shifting dullness
- Peripheral oedema
- Weight gain
- Abdo pain
- Difficulty breathing
- Sx of liver disease
73
ascites Ix?
- abdo exam, shifting dullness
- Bloods
- USS / CT / MRI
- Ascitic tap - SAAG, raised WCC, culture, cytology, amylase
74
ascites mx?
- 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
Spontaneous bacterial peritonitis (SBP)?
- infection of ascitic fluid (from liver cirrhosis)
- commonly E coli / Klebsiella
76
SBP Px
- asymptomatic
- ascites
- abdo pain
- fever
- ileus
- hypotension
- guarding
- abdo distention
77
SBP Ix?
- paracentesis - raised WCC
- bloods - raised WCC
78
SBP Mx?
- broad spec abx - IV cefotaxime / met, maybe tazocin
79
hepatorenal syndrome
- impaired kidney function from changes in blood flow to kidneys - relating to cirrhosis / portal HTN
Mx
- Terlipressin
- albumin
- TIPS
- liver transplant
80
hepatic encephalopathy
- neurological dysfunction from build up of ammonia
- grade I-IV
81
hepatic encephalopathy Px?
- irritable
- confused, inappropriate behaviour
- incoherent, restless
- coma
- asterixis, drowsiness, dyspraxia, slurred speech, apraxia (unable to draw 5-pointed star)
82
hepatic encephalopathy Ix?
- as for liver failure
- EEG - triphasic slow waves
83
hepatic encephalopathy Mx?
- lactulose
- rifaximin (neomycin / met alternatives)
- tx liver disease
84
viral hepatitis
- inflammation of liver
- <6mo acute, >6mo chronic
85
Causes of hepatitis?
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
viral hepatitis Px?
- 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
viral hepatitis Ix?
- LFTs - hepatitis picture - high AST/ALT, greater than ALP, high bilirubin
88
hepatitis A?
- RNA virus, faeco-oral transmission
- 2-6wk incubation
- usually self-limiting
- Vaccine to prevent
89
hepatitis A Px?
- pre-icteric - 1wk before jaundice - abdo pain, fever, anorexia, arthralgia, N+V
- icteric - jaundice
- HSM, RUQ pain
90
hepatits A Ix?
- Bloods - LFTs, FBC
- HAV ABs - IgM / IgG
91
hepatitis A Mx?
- supportive - fluids, antiemetics
- vaccine to prevent / for contacts
92
hepatitis E?
- 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
hepatitis B?
- 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
Hep B Px?
- can be asymptomatic
- jaundice
- dark urine
- hepatosplenomegaly
95
hep B Ix?
- serology
- LFTs
- screen for other viral infections - HIV, hep A, C, D
96
hep B serology?
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
Hep B screening?
- test for anti-HBc (previous infection) and HBsAg (active infection)
- if positive, test for HBeAg and HBV DNA for infectivity
98
hep B serology interpretation?
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
hep B Mx?
- vaccine to prevent
- contact tracing
- antivirals - pegylated interferon-alpha, tenofovir
- liver transplant if liver failure
100
hep B Cx?
- chronic hepatitis
- liver failure
- HCC
101
hepatitis D?
- 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
hepatitis C?
- 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
autoimmune hepatitis?
- 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
autoimmune hepatitis Px?
- liver disease - hepatitis, HSM, ascites, encephalopathy, abdo pain, jaundice
- fever, malaise, urticarial rash, polyarthritis, pleurisy, pulm infiltration, glomerulonephritis
- amenorrhoea
105
autoimmune hepatitis Ix?
- Bloods - LFTs, IgG, auto-ABs
- liver biopsy
106
autoimmune hepatitis Mx?
- immunosuppressants - pred, azathioprine
- liver transplant
107
hereditary haemochromatosis (HHC)
- autosomal recessive - increased intestinal iron absorption
- iron deposits in liver, joints, heart, pancreas, pituitary, adrenals -> fibrosis, liver cirrhosis
108
HHC Px?
- fatigue, arthralgia, hypogonadism (erectile dysfunction, testicular atrophy, amenorrhoea)
- chronic liver disease, hepatomegaly, HF, arrhythmias, osteoporosis, DM, memory/mood disturbance
- bronze skin pigmentation
109
HHC Ix?
- iron study - raised ferritin, transferrin, serum iron, low TIBC
- LFTs
- genetic testing
- MRI
- liver biopsy
- ECG / ECHO
110
HHC Mx?
- low dietary iron
- venesection
- desferrioxamine
- liver transplant
- tx cx - eg DM, testosterone
111
Wilson's disease?
- autosomal recessive - excess copper accumulation in body
- error in copper metabolism - not bound to caeruloplasmin - deposited in liver, basal ganglia, cornea, kidneys, bones
112
Wilson's Px?
- 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
Wilson's Ix?
- 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
Wilson's Mx?
- penicillamine / trientine
- zinc salts
- liver transplan
115
A1AT deficiency?
- 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
A1AT deficiency Px?
Lungs - adults, resp sx, SOB etc
Liver - children, hepatitis, cirrhosis, jaundice
117
A1AT deficiency Ix?
- low serum A1AT
- genetic testing
- CXR, HRCT, pulm function tests
- liver biopsy
118
A1AT deficiency Mx?
- stop smoking
- Mx of COPD
- lung volume reduction surgery
- liver / lung transplant
119
primary biliary cholangitis?
- autoimmune granulomatous inflammation of small bile ducts in liver
- obstructive jaundice + liver disease
- anti-mitochondrial ABs (AMA)
120
primary biliary cholangitis Px?
- autoimmune granulomatous inflammation of small bile ducts in liver
- obstructive jaundice + liver disease
- anti-mitochondrial ABs (AMA)
121
primary biliary cholangitis Ix?
- LFTs - raised ALP
- Auto-ABs - AMA, also ANA
- raised IgM
- US liver / biliary tract / MRCP
- Liver biopsy
122
primary biliary cholangitis Mx?
- LFTs - raised ALP
- Auto-ABs - AMA, also ANA
- raised IgM
- US liver / biliary tract / MRCP
- Liver biopsy
123
primary biliary cholangitis complications?
- Liver cirrhosis, portal HTN, HCC
- Renal tubular acidosis
- Hypothyroidism / thyroid disease
- Fat malabsorption, ADEK deficiency
- Osteoporosis
- Hyperlipidaemia
- Sjogren's syndrome, systemic sclerosis, RA
124
primary sclerosing cholangitis?
- inflammation / sclerosis of intra/extrahepatic bile ducts - obstruct bile flow - liver inflammation / cirrhosis
- UC association
125
primary sclerosing cholangitis Px?
- asym
- RUQ pain, pruritis, fatigue, jaundice, HSM, sx of cirrhosis
126
primary sclerosing cholangitis Mx?
- ERCP - stent strictures
- liver transplant
- colestyramine
- vit ADEK
127
primary sclerosing cholangitis Ix?
- LFTs - raised ALP
- Auto-ABs (less helpful) - p-ANCA, ANA, anti-SMA
- MRCP
- colonoscopy (UC)
- liver biopsy
128
primary sclerosing cholangitis complications?
- Cirrhosis
- Cholangiocarcinoma - develops in 10-20%
- Acute bacterial cholangitis
- ADEK deficiency
- Osteoporosis
129
hepatocellular carcinoma (HCC)
- primary liver cancer
- secondary more common
- mets to lymph nodes, bones, lungs, brain
130
HCC risk factors?
- liver cirrhosis - from NAFLD, ALD, hep B/C, PSC
- pts with liver cirrhosis - screen for HCC - 6monthly USS, AFP
131
HCC Px?
- asym - presents late
- liver cirrhosis / failure
- wt loss
- abdo pain
- anorexia
- N+V
- jaundice
- pruritis
- upper abdo mass
132
HCC Ix?
- AFP - raised
- Liver USS
- CT / MRI
- biopsy
133
HCC Mx?
- surgical resection
- liver transplant
- radiofrequency / microwave ablation
- transarterial chemoembolisation
- radiotherapy
- targeted drugs - kinase inhibitors, MAbs
134
describe 3 types of benign liver tumour?
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
Zollinger-Ellison syndrome
- 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
achalasia?
- failure of oesophageal peristalsis and impaired relaxation of LOS
- due to degeneration of ganglia from Auerbach's plexus
137
achalasia Px?
- dysphagia - both solids + liquids
- variation in sx severity
- dyspepsia
- regurg of foods -> cough, asp pneumonia
- malignant change (in small no)
138
achalasia Ix?
- oesophageal manometry
- barium swallow
- CXR
- CT / OGD
139
achalasia Mx?
- balloon dilatation
- surgery - Heller cardiomyotomy
- botox injection into sphincter
- nitrates, CCBs
140
alcoholic ketoacidosis
- non-diabetic euglycaemic ketoacidosis
- binge drinkers -> malnourished, starved
- metabolic acidosis, elevated anion gap, elevated serum ketones, normal/low glucose
Mx
- IV fluids, thiamine
141
angiodysplasia?
- vascular deformity of GI tract
Px
- iron-deficiency anaemia
- GI bleed
Ix
- colonoscopy
- mesenteric angiography
Mx
- endoscopic cautery
- TXA
- oestrogens
142
Budd-chiari syndrome?
- 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
Gilbert's syndrome?
- 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
ischaemic hepatitis?
- 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
clostridium difficile?
- G+ rod, anaerobic
- develops when normal gut flora suppressed by broad spec abx
- exotoxin damages intestine (epithelial/inflammatory cells) -> colitis
- faeco-oral transmission
146
c diff causes?
- clindamycin
- cephalosporins
- co-amox
- carbapenems
- ciprofloxacin
- PPIs
147
c diff presentation?
- diarrhoea
- abdo pain
- nausea
- dehydration
- fever if severe
148
c. diff Ix?
- stool sample - C diff Ag / A/B toxins
- FBC - raised WCC
- C diff Ag - serum
149
c diff Mx?
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
c diff complications?
- pseudomembranous colitis - yellow/white plaques
- toxic megacolon
- bowel perforation
- sepsis
151
gastroenteritis
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
gastroenteritis --> E. coli
- Travellers, watery stools, abdo cramps, nausea
- E coli -157 - Shiga toxin -> HUS
- Abx increase HUS risk - avoid in E coli GE
- self limiting
153
gastroenteritis --> giardiasis
- Prolonged, non-bloody diarrhoea
- Microscopic parasite, faeco-oral transmission
- metronidazole
154
gastroenteritis - cholera
Profuse watery diarrhoea, severe dehydration, wt loss, not common in travellers
- doxycycline/ ciprofloxacin
155
gastroenteritis - shigella
- Bloody diarrhoea, vomiting, abdo pain
- Faeces / contaminated food/drink
- Shiga toxin -> HUS
- ciprofloxacin / azithromycin
156
gastroenteritis - staph aureus
- Severe vomiting - short incubation period
- Caused by enterotoxin from bacteria
- self limiting
157
gastroenteritis - campylobacter
- 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
gastroenteritis - bacillus cereus
- Vomiting in 6hrs (eg rice) / watery diarrhoea after 6hrs
- self limiting or vancomycin
159
gastroenteritis amoebiasis
- Gradual onset bloody diarrhoea, abdo pain, tenderness
- metronidazole + diloxanide furoate
160
gastroenteritis - salmonella
- Sudden onset abdo pain, diarrhoea +/- blood, nausea, vomiting, sometimes constipation
- Food contamination / raw eggs / chicken
- treat with ABx if severe e.g. cipro
161
gastroenteritis incubation periods?
- Sudden onset abdo pain, diarrhoea +/- blood, nausea, vomiting, sometimes constipation
- Food contamination / raw eggs / chicken
162
gastroenteritis presentation?
- Nausea
- Vomiting
- Diarrhoea
- Abdo pain
- Fever
- Blood in stools
- Dehydration
163
diarrhoea Ddx
Acute
- GE
- Diverticulitis
- Abx therapy
- Overflow incontinence – constipation
Chronic
- IBS
- IBD
- Colorectal cancer
- Coeliac disease
Other conditions
- Thyrotoxicosis
- Laxative abuse
- appendicitis
164
gastroenteritis Ix
- Stool sample - MC+S
- monitor dehydration
165
gastroenteritis Mx?
- 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
complications of gastroenteritis?
- Lactose intolerance
- IBS
- ReA
- GBS
- HUS
167
constipation?
- Defecation that is unsatisfactory - can be infrequent, difficult passage (straining / discomfort), incomplete defecation
- Chronic >3mo
168
causes of constipation?
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
constipation Px?
- Not opening bowels
- Infrequent
- Hard stools
- Maybe droppings
- Overflow incontinence
170
constipation assessment
- normal bowel habit
- abdo / rectal / urinary sx
- abdo exam, PR
- bloods - FBC, U/E, LFTs, Ca, TFTs
- specialist - sigmoidoscopy / colonoscopy, CT colon, AXR
171
constipation red flags?
- 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
constipation management?
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
management of faecal impaction?
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
management of opioid induced constipation?
1st - senna/bisacodyl +/- macrogols (also prophylaxis)
2nd - docusate sodium / sodium picosulfate
3rd - methylnaltrexone SC / naloxegol tabs
175
management of ibs associated constipation
antispasmodic - mebeverine / peppermint oil
176
constipation complications?
- overflow diarrhoea
- acute urinary retention
- haemorrhoids
177
paracetamol overdose?
- 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
types of paracetamol OD?
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
paracetamol OD Px?
<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
paracetamol OD Ix?
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
paracetamol OD Mx?
- activated charcoal <1hr post-ingestion
- N-acetylcysteine (NAC) - beware anaphylactoid reaction
- liver transplant
- liaison psychiatry
182
NAC indications?
- 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
Paracetamol OD Mx timeline - very long flashcard!
<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
what happens to urea after a UGIB?
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
