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Phase 4 Question Knowledge > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

UGIB

A

Bleeding from upper GI tract

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2
Q

UGIB causes

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

  • VBG, FBC, U/E, LFTs, CRP, coag, G+S, crossmatch

Glasgow-Blatchford Score

> 0 - high risk for GI bleed

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5
Q

UGIB Mx

A
  • ABCDE
  • 2x large bore IV access
  • Blood transfusion / MHP
  • stop anticoagulants / NSAIDs
  • reverse anticoagulation, eg vit K, PCC
  • variceal - terlipressin, abx
  • OGD - clips / thermal coagulation / variceal band ligation
  • Rockall score
  • Sengstaken-Blakemore tube
  • PPI post-OGD
  • consider IR / surgery

Varices prophylaxis

  • propranalol
  • variceal band ligation
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6
Q

Peptic ulcer disease (PUD)

A

ulcer in mucosa of stomach / duodenum

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7
Q

PUD causes

A
  • NSAIDs
  • H pylori
  • Ischaemia of gastric cells
  • 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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8
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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9
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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10
Q

PUD 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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11
Q

PUD Cx

A
  • bleeding
  • perforation
  • acute pancreatitis
  • scarring, strictures -> gastric outlet obstruction
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12
Q

GORD

A

Flow of acid from stomach through LOS into oesophagus

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13
Q

GORD Causes

A
  • LOS hypotension
  • hiatus hernia - sliding / rolling
  • SSc, achalasia
  • obesity
  • overeating, greasy/spicy foods, coffee/tea
  • smoking, alcohol, pregnancy
  • TCAs, anticholinergics, nitrates, NSAIDs
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14
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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15
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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16
Q

GORD Ix

A
  • OGD
  • barium swallow
  • H pylori Ix
  • 24hr oesophageal pH monitoring
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17
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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18
Q

GORD Cx

A

Barrett’s oesophagus
- lower oesophageal epithelium changes from stratified squamous to simple columnar - premalignant for adenocarcinoma
- Mx - endoscopic monitoring, PPI, ablation / resection

Peptic stricture
- narrowing
- Px - intermittent dysphagia, worsening
- Mx - endoscopic dilatation, long term PPI

MW tear
Iron deficiency
Ulcers
Oesophagitis

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19
Q

UC

A

Relapsing / remitting inflammatory disorder of colonic mucosa

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20
Q

UC Patho

A
  • inappropriate immune response against colonic flora
  • only mucosal, crypt abscesses, goblet cell mucin depleted, continuous inflammation, starts at rectum, looks like polyps
  • smoking protective

Associations

  • PSC, erythema nodosum, pyoderma gangrenosum, enteropathic arthritis, episcleritis, scleritis, anterior uveitis
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21
Q

UC Px

A
  • Insidious / intermittent sx
  • Bloody diarrhoea
  • Urgency
  • Tenesmus
  • Abdo pain
  • Fatigue, weight loss
  • Blood / mucus in stools
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22
Q

UC flares

A
  • worsening of sx
  • eg from stress, meds, cessation of smoking

Mild

  • <4 stools/d
  • no systemic disturbance
  • normal ESR / CRP

Moderate

  • 4-6 stools/d
  • minimal systemic disturbance

Severe

  • > 6 stools/d
  • fever, tachy, abdo tenderness/distention, anaemia, hypoalbuminaemia
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23
Q

UC Ix

A
  • FBC, CRP, U/E, LFT, TFTs
  • Stool MC+S
  • faecal calprotectin
  • colonoscopy + biopsy
  • CT / MRI
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24
Q

UC Mx

A
  • aim to induce / maintain remission

Mild

  • mesalazine - rectal, then oral
  • steroids - prednisolone - oral / rectal

Moderate

  • oral prednisolone
  • continue mesalazine

Severe

  • admit
  • IV fluids
  • IV hydrocortisone
  • azathioprine, mercaptopurine, ciclosporin, MAbs
  • Surgery - colectomy, tx strictures/fistulas/abscess
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25
Q

UC Cx

A
  • colonic cancer
  • toxic dilatation of colon
  • perforation
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26
Q

Crohn’s

A

Chronic inflammatory disease characterised by transmural granulomatous inflammation

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27
Q

Crohn’s patho

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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28
Q

Crohn’s Px

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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29
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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30
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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31
Q

Coeliac disease

A
  • autoimmune inflammatory condition triggered by eating gluten
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32
Q

Coeliac disease patho

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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33
Q

Coeliac disease 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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34
Q

Coeliac disease Ix

A
  • Bloods - FBC, ferritin, haematinics, LFTs, anti-TTG, total IgA
  • endoscopy, biopsy (traditionally duodenum, but also jejunum)
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35
Q

Coeliac disease Mx

A
  • lifelong gluten diet
  • immunisations - eg pneumococcal due to functional hyposplenism
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36
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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37
Q

IBS Px

A
  • Abdo pain
  • Diarrhoea
  • Constipation
  • Change in bowel habit
  • Bloating
  • Worse after eating
  • Improved by opening bowels
  • Passing mucus
  • Sx >6mo for dx
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38
Q

IBS - red flags to exclude

A
  • Rectal bleeding / blood in stool
  • Weight loss
  • FHx bowel / ovarian cancer
  • > 60yo
  • Nocturnal sx
  • Anaemia
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39
Q

IBS Ix

A
  • Bloods - FBC, CRP/ESR, anti-TTG, CA125 (ovarian ca)
  • faecal calprotectin
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40
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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41
Q

Alcoholic liver disease (ALD)

A
  • liver disease from alcohol consumption

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

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42
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, irreversible
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43
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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44
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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45
Q

ALD Mx

A
  • stop drinking
  • CBT / motivational interviewing
  • tx cx - eg thiamine, detox
  • prednisolone
  • liver transplant
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46
Q

Non-alcoholic fatty liver disease (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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47
Q

NAFLD Px

A
  • asym
  • hepatomegaly
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48
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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49
Q

NAFLD Mx

A
  • diet, weight, stop smoking
  • specialist mx - vit E, pioglitazone, bariatric surgery, liver transplant
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50
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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51
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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52
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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53
Q

Acute liver failure Mx

A
  • tx cause
  • liver transplant
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54
Q

Liver cirrhosis

A
  • fibrosis of liver from chronic inflammation
  • collagen deposition + scarring
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55
Q

Liver cirrhosis causes

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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56
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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57
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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58
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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59
Q

Liver cirrhosis Cx

A
  • malnutrition
  • varices
  • portal HTN
  • ascites
  • SBP
  • hepatorenal syndrome
  • hepatic encephalopathy
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60
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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61
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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62
Q

Portal HTN Px

A
  • Splenomegaly
  • Caput medusae
  • Ascites
  • Sx of liver disease / other cx
  • Sx of varices
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63
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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64
Q

Portal HTN Mx

A
  • tx cause, liver transplant
  • BBs / nitrates
  • TIPS
  • salt restriction, diuretics
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65
Q

Ascites

A

free fluid in peritoneal cavity

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66
Q

Ascites causes

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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67
Q

Ascites classification

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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68
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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69
Q

Ascites Ix

A
  • abdo exam, shifting dullness
  • Bloods
  • USS / CT / MRI
  • Ascitic tap - SAAG, raised WCC, culture, cytology, amylase
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70
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
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71
Q

Spontaneous bacterial peritonitis (SBP)

A
  • infection of ascitic fluid (from liver cirrhosis)
  • commonly E coli / Klebsiella
72
Q

SBP Px

A
  • asym
  • ascites
  • abdo pain
  • fever
  • ileus
  • hypotension
  • guarding
  • abdo distention
73
Q

SBP Ix

A
  • paracentesis - raised WCC
  • bloods - raised WCC
74
Q

SBP Mx

A
  • broad spec abx - IV cefotaxime / met, maybe tazocin
75
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
76
Q

Hepatic encephalopathy

A
  • neurological dysfunction from build up of ammonia
  • Grade I-IV
77
Q

Hepatic encephalopathy Px

A

-irritable
- confused, inappropriate behaviour
- incoherent, restless
- coma

  • asterixis, drowsiness, dyspraxia, slurred speech, apraxia (unable to draw 5-pointed star)
78
Q

Hepatic encephalopathy Ix

A
  • as for liver failure
  • EEG - triphasic slow waves
79
Q

Hepatic encephalopathy Mx

A
  • lactulose
  • rifaximin (neomycin / met alternatives)
  • tx liver disease
80
Q

Viral hepatitis

A
  • inflammation of liver
  • <6mo acute, >6mo chronic
81
Q

Hepatitis causes

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
82
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
83
Q

Viral hepatitis Ix

A
  • LFTs - hepatitis picture - high AST/ALT, greater than ALP, high bilirubin
    …
84
Q

Hepatitis A

A
  • RNA virus, faeco-oral transmission
  • 2-6wk incubation
  • usually self-limiting
  • Vaccine to prevent
85
Q

Hep A Px

A
  • pre-icteric - 1wk before jaundice - abdo pain, fever, anorexia, arthralgia, N+V
  • icteric - jaundice
  • HSM, RUQ pain
86
Q

Hep A Ix

A
  • Bloods - LFTs, FBC
  • HAV ABs - IgM / IgG
87
Q

Hep A Mx

A
  • supportive - fluids, antiemetics
  • vaccine to prevent / for contacts
88
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
89
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
90
Q

Hep B Px

A
  • as for viral hepatitis
  • HSM etc
91
Q

Hep B Ix

A
  • serology
  • LFTs
  • screen for other viral infections - HIV, hep A, C, D
92
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

93
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
94
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+

95
Q

Hep B Mx

A
  • vaccine to prevent
  • contact tracing
  • antivirals - pegylated interferon-alpha, tenofovir
  • liver transplant if liver failure
96
Q

Hep B Cx

A
  • chronic hepatitis
  • liver failure
  • HCC
97
Q

Hep 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
98
Q

Hep 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
99
Q

Autoimmune hepatitis

A
  • chronic autoimmune inflammatory liver disease

Typically seen in young females

Type 1

  • 80%, F in late 40/50s
  • ANA, SMA

Adults and children

Type 2

  • children
  • anti-LMK1, anti-LC1

Type 3

  • adults middle aged
  • soluble liver kidney Ag
100
Q

Autoimmune hepatitis Px

A
  • liver disease - hepatitis, HSM, ascites, encephalopathy, abdo pain, jaundice
  • fever, malaise, urticarial rash, polyarthritis, pleurisy, pulm infiltration, glomerulonephritis
  • amenorrhoea
101
Q

Autoimmune hepatitis Ix

A
  • Bloods - LFTs, IgG, auto-ABs
  • liver biopsy
102
Q

Autoimmune hepatitis Mx

A
  • immunosuppressants - pred, azathioprine
  • liver transplant
103
Q

Hereditary haemochromatosis (HHC)

A
  • autosomal recessive - increased intestinal iron absorption
  • iron deposits in liver, joints, heart, pancreas, pituitary, adrenals -> fibrosis, liver cirrhosis
104
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
105
Q

HHC Ix

A
  • iron study - raised ferritin, transferrin, serum iron, low TIBC
  • LFTs
  • genetic testing
  • MRI
  • liver biopsy
  • ECG / ECHO
106
Q

HHC Mx

A
  • low dietary iron
  • venesection
  • desferrioxamine
  • liver transplant
  • tx cx - eg DM, testosterone
107
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
108
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
109
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
110
Q

Wilson’s Mx

A
  • penicillamine / trientine
  • zinc salts
  • liver transplant
111
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
112
Q

A1AT deficiency Px

A

Lungs - adults, resp sx, SOB etc

Liver - children, hepatitis, cirrhosis, jaundice

113
Q

A1AT deficiency Ix

A
  • low serum A1AT
  • genetic testing
  • CXR, HRCT, pulm function tests
  • liver biopsy
114
Q

A1AT deficiency Mx

A
  • stop smoking
  • Mx of COPD
  • lung volume reduction surgery
  • liver / lung transplant
115
Q

Primary biliary cholangitis (PBC)

A
  • autoimmune granulomatous inflammation of small bile ducts in liver
  • obstructive jaundice + liver disease
  • anti-mitochondrial ABs (AMA)
116
Q

PBC Px

A
  • asym
  • fatigue, pruritis, GI sx, RUQ abdo pain, jaundice, pale greasy stools, dark urine, xanthelasma, hepatomegaly
  • Cx - cirrhosis, portal HTN, HCC, ADEK malabsorption - coagulopathy, osteopenia/porosis
117
Q

PBC Ix

A
  • LFTs - raised ALP
  • Auto-ABs - AMA, also ANA
  • raised IgM
  • US liver / biliary tract / MRCP
  • Liver biopsy
118
Q

PBC Mx

A
  • ursodeoxycholic acid
  • colestyramine
  • bisphosphonates
  • vit ADEK
  • steroids
  • liver transplant
119
Q

PBC Cx

A
  • Liver cirrhosis, portal HTN, HCC
  • Renal tubular acidosis
  • Hypothyroidism / thyroid disease
  • Fat malabsorption, ADEK deficiency
  • Osteoporosis
  • Hyperlipidaemia
  • Sjogren’s syndrome, systemic sclerosis, RA
120
Q

Primary sclerosing cholangitis (PSC)

A
  • inflammation / sclerosis of intra/extrahepatic bile ducts - obstruct bile flow - liver inflammation / cirrhosis
  • UC association
121
Q

PSC Px

A
  • asym
  • RUQ pain, pruritis, fatigue, jaundice, HSM, sx of cirrhosis
122
Q

PSC Mx

A
  • ERCP - stent strictures
  • liver transplant
  • colestyramine
  • vit ADEK
123
Q

PSC Ix

A
  • LFTs - raised ALP
  • Auto-ABs (less helpful) - p-ANCA, ANA, anti-SMA
  • MRCP
  • colonoscopy (UC)
  • liver biopsy
124
Q

PSC Cx

A
  • Cirrhosis
  • Cholangiocarcinoma - develops in 10-20%
  • Acute bacterial cholangitis
  • ADEK deficiency
  • Osteoporosis
125
Q

Hepatocellular carcinoma (HCC)

A
  • primary liver cancer
  • secondary more common
  • mets to lymph nodes, bones, lungs, brain
126
Q

HCC RFs

A
  • liver cirrhosis - from NAFLD, ALD, hep B/C, PSC
  • pts with liver cirrhosis - screen for HCC - 6monthly USS, AFP
127
Q

HCC Px

A
  • asym - presents late
  • liver cirrhosis / failure
  • wt loss
  • abdo pain
  • anorexia
  • N+V
  • jaundice
  • pruritis
  • upper abdo mass
128
Q

HCC Ix

A
  • AFP - raised
  • Liver USS
  • CT / MRI
  • biopsy
129
Q

HCC Mx

A
  • surgical resection
  • liver transplant
  • radiofrequency / microwave ablation
  • transarterial chemoembolisation
  • radiotherapy
  • targeted drugs - kinase inhibitors, MAbs
130
Q

Benign liver tumours

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 / monitoring
131
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

132
Q

Achalasia

A
  • failure of oesophageal peristalsis and impaired relaxation of LOS
  • due to degeneration of ganglia from Auerbach’s plexus
133
Q

Achalasia Px

A
  • dysphagia - both solids + liquids
  • variation in sx severity
  • dyspepsia
  • regurg of foods -> cough, asp pneumonia
  • malignant change (in small no)
134
Q

Achalasia Ix

A
  • oesophageal manometry
  • barium swallow
  • CXR
  • CT / OGD
135
Q

Achalasia Mx

A
  • balloon dilatation
  • surgery - Heller cardiomyotomy
  • botox injection into sphincter
  • nitrates, CCBs
136
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
137
Q

Angiodysplasia

A
  • vascular deformity of GI tract

Px

  • iron-deficiency anaemia
  • GI bleed

Ix

  • colonoscopy
  • mesenteric angiography

Mx

  • endoscopic cautery
  • TXA
  • oestrogens
138
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
139
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
140
Q

Ischaemic hepatitis

A
  • diffuse hepatic injury from acute hypoperfusion - shocked liver
  • massive increases in AST / ALT
  • often other end-organ dysfunction, eg AKI
141
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
142
Q

C diff causes

A
  • clindamycin
  • cephalosporins
  • co-amox
  • carbapenems
  • ciprofloxacin
  • PPIs
143
Q

C diff Px

A
  • diarrhoea
  • abdo pain
  • nausea
  • dehydration
  • fever if severe
144
Q

C diff Ix

A
  • stool sample - C diff Ag / A/B toxins
  • FBC - raised WCC
  • C diff Ag - serum
  • see notes for categories
145
Q

C diff Mx

A

First episode

1st- oral vancomycin

2nd- oral fidaxomicin

3rd- 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
146
Q

C diff Cx

A
  • pseudomembranous colitis - yellow/white plaques
  • toxic megacolon
  • bowel perforation
  • sepsis
147
Q

Gastroenteritis (GE)

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
148
Q

GE - E coli

A
  • Travellers, watery stools, abdo cramps, nausea
  • E coli -157 - Shiga toxin -> HUS
  • Abx increase HUS risk - avoid in E coli GE
149
Q

GE - giardiasis

A
  • Prolonged, non-bloody diarrhoea
  • Microscopic parasite, faeco-oral transmission
150
Q

GE - cholera

A

Profuse watery diarrhoea, severe dehydration, wt loss, not common in travellers

151
Q

GE - shigella

A
  • Bloody diarrhoea, vomiting, abdo pain
  • Faeces / contaminated food/drink
  • Shiga toxin -> HUS
152
Q

GE - S aureus

A
  • Severe vomiting - short incubation period
  • Caused by enterotoxin from bacteria
153
Q

GE - Campylobacter

A
  • Flu-like prodrome, crampy abdo pain, fever, diarrhoea +/- blood, GBS cx
  • Most common cause travellers diarrhoea
  • Untreated water, unpasteurised milk, poultry
154
Q

GE - Bacillus cereus

A
  • Vomiting in 6hrs (eg rice) / watery diarrhoea after 6hrs
155
Q

GE - Amoebiasis

A
  • Gradual onset bloody diarrhoea, abdo pain, tenderness
156
Q

GE - Salmonella

A
  • Sudden onset abdo pain, diarrhoea +/- blood, nausea, vomiting, sometimes constipation
  • Food contamination / raw eggs / chicken
157
Q

GE Incubation periods

A

1-6hrs – S aureus, bacillus cereus (vomiting)

12-48hrs – salmonella, E coli

48-72hrs – shigella, campylobacter

> 7d – giardiasis, amoebiasis

158
Q

GE Px

A
  • Nausea
  • Vomiting
  • Diarrhoea
  • Abdo pain
  • Fever
  • Blood in stools
  • Dehydration
159
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
160
Q

GE Ix

A
  • Stool sample - MC+S
  • monitor dehydration
161
Q

GE Mx

A
  • hydrate
  • oral rehydration salts - dioralyte
  • IV fluids
  • avoid loperamide / antiemetics
  • off school/work for 48hrs after sx
  • abx

Abx

  • if bloody diarrhoea (except E coli 0157), immunocompromised, typhoid fever, elderly, severe sx
  • follow culture sensitivities
  • E coli – self-limiting
  • Giardiasis – metronidazole
  • Cholera – doxycycline / ciprofloxacin
  • Shigella – ciprofloxacin / azithromycin
  • S aureus – self-limiting
  • Campylobacter – clarithromycin / azithromycin / ciprofloxacin
  • Bacillus – self-limiting / vancomycin
  • Amoebiasis – metronidazole + diloxanide furoate (intraluminal agent)
  • Salmonella – if severe – eg ciprofloxacin
162
Q

GE Cx

A
  • Lactose intolerance
  • IBS
  • ReA
  • GBS
  • HUS
163
Q

Constipation

A
  • Defecation that is unsatisfactory - can be infrequent, difficult passage (straining / discomfort), incomplete defecation
  • Chronic >3mo
164
Q

Constipation causes

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

165
Q

Constipation Px

A
  • Not opening bowels
  • Infrequent
  • Hard stools
  • Maybe droppings
  • Overflow incontinence
166
Q

Constipation assessment

A

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
  • normal bowel habit
  • abdo / rectal / urinary sx
  • abdo exam, PR
  • bloods - FBC, U/E, LFTs, Ca, TFTs
  • specialist - sigmoidoscopy / colonoscopy, CT colon, AXR
167
Q

Constipation Mx

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

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

Opioid induced

1st - senna/bisacodyl +/- macrogols (also prophylaxis)

2nd - docusate sodium / sodium picosulfate

3rd - methylnaltrexone SC / naloxegol tabs

IBS

antispasmodic - mebeverine / peppermint oil

Pregnancy

1st - bulk forming

2nd - lactulose

3rd - senna

168
Q

Constipation cx

A
  • overflow diarrhoea
  • acute urinary retention
  • haemorrhoids
169
Q

Paracetamol OD

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
170
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
171
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
172
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
173
Q

Paracetamol OD Mx

A
  • activated charcoal <1hr post-ingestion
  • N-acetylcysteine (NAC) - beware anaphylactoid reaction
  • liver transplant
  • liaison psychiatry
174
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
175
Q

Paracetamol OD Mx timeline

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
176
Q

King’s College hospital criteria for liver transplant

A

Arterial pH <7.3, 24hrs post-ingestion
Lactate >3, OR
All of:
- INR >6.5
- Creatinine >300
- Grade III/IV encephalopathy

177
Q

Pernicious anaemia?

A

Autoimmune disorder affecting the gastric mucosa that results in vitamin B12 deficiency

Antibodies to intrinsic factor +/- gastric parietal cells- B12 important in production of blood cells and myelination of nerves- megaloblastic anaemia and neuropathy

Associated with other autoimmune conditions

Features-
Anaemia features- lethargy, pallor dyspnoea
Neurological features- peripheral neuropathy, subacute combined degeneration of the spinal cord
Neuropsychiatric features- memory loss, poor concentration, confusion, depression, irritability

Mild jaundice, atrophic glossitis

Investigation-
FBC- macrocytic anaemia, hypersegmented polymorphs

Low B12 and folate levels

Antibodies- anti intrinsic factor, anti gastric parietal cell antibodies

Management-
Vit B12 replacement
3 injections per week for 2 weeks, 3 monthly treatment of B12 inejctions

Increased risk of gastric cancer

Phase 4 Question Knowledge (30 decks)

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