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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
UC Cx
- colonic cancer - toxic dilatation of colon - perforation
26
Crohn's
Chronic inflammatory disease characterised by transmural granulomatous inflammation
27
Crohn's patho
- 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
28
Crohn's Px
- Abdo pain - Diarrhoea - Weight loss - Fatigue, fever, malaise, anorexia - Inflammatory associations as above - Clubbing - Mouth ulcers - Blood / mucus less common
29
Crohn's Ix
- Bloods - FBC, CRP, U/E, LFT, TFT, B12/folate - stool MC+S - faecal calprotectin - colonoscopy + biopsy - CT / MRI
30
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
31
Coeliac disease
- autoimmune inflammatory condition triggered by eating gluten
32
Coeliac disease patho
- 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
33
Coeliac disease 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
34
Coeliac disease Ix
- Bloods - FBC, ferritin, haematinics, LFTs, anti-TTG, total IgA - endoscopy, biopsy (traditionally duodenum, but also jejunum)
35
Coeliac disease Mx
- lifelong gluten diet - immunisations - eg pneumococcal due to functional hyposplenism
36
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
37
IBS Px
- Abdo pain - Diarrhoea - Constipation - Change in bowel habit - Bloating - Worse after eating - Improved by opening bowels - Passing mucus - Sx >6mo for dx
38
IBS - red flags to exclude
- Rectal bleeding / blood in stool - Weight loss - FHx bowel / ovarian cancer - >60yo - Nocturnal sx - Anaemia
39
IBS Ix
- Bloods - FBC, CRP/ESR, anti-TTG, CA125 (ovarian ca) - faecal calprotectin
40
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
41
Alcoholic liver disease (ALD)
- liver disease from alcohol consumption fatty liver -> alcoholic hepatitis -> alcoholic steatosis -> cirrhosis
42
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, irreversible
43
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
44
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
45
ALD Mx
- stop drinking - CBT / motivational interviewing - tx cx - eg thiamine, detox - prednisolone - liver transplant
46
Non-alcoholic fatty liver disease (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
47
NAFLD Px
- asym - hepatomegaly
48
NAFLD Ix
- bloods - LFTs, enhanced liver fibrosis (ELF) test - USS - increased echogenicity - NAFLD fibrosis score - FIB-4 score - Fibroscan - liver biopsy
49
NAFLD Mx
- diet, weight, stop smoking - specialist mx - vit E, pioglitazone, bariatric surgery, liver transplant
50
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
51
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
52
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
53
Acute liver failure Mx
- tx cause - liver transplant
54
Liver cirrhosis
- fibrosis of liver from chronic inflammation - collagen deposition + scarring
55
Liver cirrhosis causes
- Alcohol liver disease - NAFLD - Hep B/C - Autoimmune hepatitis - Primary biliary cirrhosis - Haemochromatosis, Wilson's, A1AT deficiency - CF - Drugs - amiodarone, methotrexate, sodium valproate
56
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
57
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
58
Liver cirrhosis Mx
- tx cause - monitor cx - 6mo US/AFP, 3yrly OGD - ascites - fluid restrict, spironolactone, furosemide, paracentesis - liver transplant
59
Liver cirrhosis Cx
- malnutrition - varices - portal HTN - ascites - SBP - hepatorenal syndrome - hepatic encephalopathy
60
Portal HTN
- high pressure in hepatic portal vein from liver cirrhosis, increased resistance - leads to ascites, splenomegaly, varices, caput medusae, collateral vessel formation
61
Portal HTN causes
Pre-hepatic - portal vein thrombosis intra-hepatic - cirrhosis - schistosomiasis - sarcoidosis Post-hepatic - RHF - constrictive pericarditis - IVC obstruction - Budd-Chiari syndrome
62
Portal HTN Px
- Splenomegaly - Caput medusae - Ascites - Sx of liver disease / other cx - Sx of varices
63
Portal HTN Ix
- for liver disease - bloods, biopsy, CT/MRI etc - Abdo US / doppler US - hepatic venous pressure gradient - vascular imaging
64
Portal HTN Mx
- tx cause, liver transplant - BBs / nitrates - TIPS - salt restriction, diuretics
65
Ascites
free fluid in peritoneal cavity
66
Ascites causes
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
67
Ascites classification
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
68
Ascites Px
- Abdo swelling - Distention - Shifting dullness - Peripheral oedema - Weight gain - Abdo pain - Difficulty breathing - Sx of liver disease
69
Ascites Ix
- abdo exam, shifting dullness - Bloods - USS / CT / MRI - Ascitic tap - SAAG, raised WCC, culture, cytology, amylase
70
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
71
Spontaneous bacterial peritonitis (SBP)
- infection of ascitic fluid (from liver cirrhosis) - commonly E coli / Klebsiella
72
SBP Px
- asym - ascites - abdo pain - fever - ileus - hypotension - guarding - abdo distention
73
SBP Ix
- paracentesis - raised WCC - bloods - raised WCC
74
SBP Mx
- broad spec abx - IV cefotaxime / met, maybe tazocin
75
Hepatorenal syndrome
- impaired kidney function from changes in blood flow to kidneys - relating to cirrhosis / portal HTN Mx - Terlipressin - albumin - TIPS - liver transplant
76
Hepatic encephalopathy
- neurological dysfunction from build up of ammonia - Grade I-IV
77
Hepatic encephalopathy Px
-irritable - confused, inappropriate behaviour - incoherent, restless - coma - asterixis, drowsiness, dyspraxia, slurred speech, apraxia (unable to draw 5-pointed star)
78
Hepatic encephalopathy Ix
- as for liver failure - EEG - triphasic slow waves
79
Hepatic encephalopathy Mx
- lactulose - rifaximin (neomycin / met alternatives) - tx liver disease
80
Viral hepatitis
- inflammation of liver - <6mo acute, >6mo chronic
81
Hepatitis causes
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
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
83
Viral hepatitis Ix
- LFTs - hepatitis picture - high AST/ALT, greater than ALP, high bilirubin ...
84
Hepatitis A
- RNA virus, faeco-oral transmission - 2-6wk incubation - usually self-limiting - Vaccine to prevent
85
Hep A Px
- pre-icteric - 1wk before jaundice - abdo pain, fever, anorexia, arthralgia, N+V - icteric - jaundice - HSM, RUQ pain
86
Hep A Ix
- Bloods - LFTs, FBC - HAV ABs - IgM / IgG
87
Hep A Mx
- supportive - fluids, antiemetics - vaccine to prevent / for contacts
88
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
89
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
90
Hep B Px
- as for viral hepatitis - HSM etc
91
Hep B Ix
- serology - LFTs - screen for other viral infections - HIV, hep A, C, D
92
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
93
Hep B screening
- test for anti-HBc (previous infection) and HBsAg (active infection) - if positive, test for HBeAg and HBV DNA for infectivity
94
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+
95
Hep B Mx
- vaccine to prevent - contact tracing - antivirals - pegylated interferon-alpha, tenofovir - liver transplant if liver failure
96
Hep B Cx
- chronic hepatitis - liver failure - HCC
97
Hep 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
98
Hep 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
99
Autoimmune hepatitis
- 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
Autoimmune hepatitis Px
- liver disease - hepatitis, HSM, ascites, encephalopathy, abdo pain, jaundice - fever, malaise, urticarial rash, polyarthritis, pleurisy, pulm infiltration, glomerulonephritis - amenorrhoea
101
Autoimmune hepatitis Ix
- Bloods - LFTs, IgG, auto-ABs - liver biopsy
102
Autoimmune hepatitis Mx
- immunosuppressants - pred, azathioprine - liver transplant
103
Hereditary haemochromatosis (HHC)
- autosomal recessive - increased intestinal iron absorption - iron deposits in liver, joints, heart, pancreas, pituitary, adrenals -> fibrosis, liver cirrhosis
104
HHC Px
- fatigue, arthralgia, hypogonadism (erectile dysfunction, testicular atrophy, amenorrhoea) - chronic liver disease, hepatomegaly, HF, arrhythmias, osteoporosis, DM, memory/mood disturbance - bronze skin pigmentation
105
HHC Ix
- iron study - raised ferritin, transferrin, serum iron, low TIBC - LFTs - genetic testing - MRI - liver biopsy - ECG / ECHO
106
HHC Mx
- low dietary iron - venesection - desferrioxamine - liver transplant - tx cx - eg DM, testosterone
107
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
108
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
109
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
110
Wilson's Mx
- penicillamine / trientine - zinc salts - liver transplant
111
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
112
A1AT deficiency Px
Lungs - adults, resp sx, SOB etc Liver - children, hepatitis, cirrhosis, jaundice
113
A1AT deficiency Ix
- low serum A1AT - genetic testing - CXR, HRCT, pulm function tests - liver biopsy
114
A1AT deficiency Mx
- stop smoking - Mx of COPD - lung volume reduction surgery - liver / lung transplant
115
Primary biliary cholangitis (PBC)
- autoimmune granulomatous inflammation of small bile ducts in liver - obstructive jaundice + liver disease - anti-mitochondrial ABs (AMA)
116
PBC Px
- 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
PBC Ix
- LFTs - raised ALP - Auto-ABs - AMA, also ANA - raised IgM - US liver / biliary tract / MRCP - Liver biopsy
118
PBC Mx
- ursodeoxycholic acid - colestyramine - bisphosphonates - vit ADEK - steroids - liver transplant
119
PBC Cx
- Liver cirrhosis, portal HTN, HCC - Renal tubular acidosis - Hypothyroidism / thyroid disease - Fat malabsorption, ADEK deficiency - Osteoporosis - Hyperlipidaemia - Sjogren's syndrome, systemic sclerosis, RA
120
Primary sclerosing cholangitis (PSC)
- inflammation / sclerosis of intra/extrahepatic bile ducts - obstruct bile flow - liver inflammation / cirrhosis - UC association
121
PSC Px
- asym - RUQ pain, pruritis, fatigue, jaundice, HSM, sx of cirrhosis
122
PSC Mx
- ERCP - stent strictures - liver transplant - colestyramine - vit ADEK
123
PSC Ix
- LFTs - raised ALP - Auto-ABs (less helpful) - p-ANCA, ANA, anti-SMA - MRCP - colonoscopy (UC) - liver biopsy
124
PSC Cx
- Cirrhosis - Cholangiocarcinoma - develops in 10-20% - Acute bacterial cholangitis - ADEK deficiency - Osteoporosis
125
Hepatocellular carcinoma (HCC)
- primary liver cancer - secondary more common - mets to lymph nodes, bones, lungs, brain
126
HCC RFs
- liver cirrhosis - from NAFLD, ALD, hep B/C, PSC - pts with liver cirrhosis - screen for HCC - 6monthly USS, AFP
127
HCC Px
- asym - presents late - liver cirrhosis / failure - wt loss - abdo pain - anorexia - N+V - jaundice - pruritis - upper abdo mass
128
HCC Ix
- AFP - raised - Liver USS - CT / MRI - biopsy
129
HCC Mx
- surgical resection - liver transplant - radiofrequency / microwave ablation - transarterial chemoembolisation - radiotherapy - targeted drugs - kinase inhibitors, MAbs
130
Benign liver tumours
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
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
132
Achalasia
- failure of oesophageal peristalsis and impaired relaxation of LOS - due to degeneration of ganglia from Auerbach's plexus
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Achalasia Px
- dysphagia - both solids + liquids - variation in sx severity - dyspepsia - regurg of foods -> cough, asp pneumonia - malignant change (in small no)
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Achalasia Ix
- oesophageal manometry - barium swallow - CXR - CT / OGD
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Achalasia Mx
- balloon dilatation - surgery - Heller cardiomyotomy - botox injection into sphincter - nitrates, CCBs
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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
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Angiodysplasia
- vascular deformity of GI tract Px - iron-deficiency anaemia - GI bleed Ix - colonoscopy - mesenteric angiography Mx - endoscopic cautery - TXA - oestrogens
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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
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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
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Ischaemic hepatitis
- diffuse hepatic injury from acute hypoperfusion - shocked liver - massive increases in AST / ALT - often other end-organ dysfunction, eg AKI
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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
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C diff causes
- clindamycin - cephalosporins - co-amox - carbapenems - ciprofloxacin - PPIs
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C diff Px
- diarrhoea - abdo pain - nausea - dehydration - fever if severe
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C diff Ix
- stool sample - C diff Ag / A/B toxins - FBC - raised WCC - C diff Ag - serum - see notes for categories
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C diff Mx
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
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C diff Cx
- pseudomembranous colitis - yellow/white plaques - toxic megacolon - bowel perforation - sepsis
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Gastroenteritis (GE)
inflammation / infection of gastrointestinal tract Diarrhoea - >3 loose/watery motions/d, chronic >14d Causes - travellers diarrhoea - acute food poisoning - Viruses - rotavirus, norovirus, adenovirus - Bacterial
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GE - E coli
- Travellers, watery stools, abdo cramps, nausea - E coli -157 - Shiga toxin -> HUS - Abx increase HUS risk - avoid in E coli GE
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GE - giardiasis
- Prolonged, non-bloody diarrhoea - Microscopic parasite, faeco-oral transmission
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GE - cholera
Profuse watery diarrhoea, severe dehydration, wt loss, not common in travellers
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GE - shigella
- Bloody diarrhoea, vomiting, abdo pain - Faeces / contaminated food/drink - Shiga toxin -> HUS
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GE - S aureus
- Severe vomiting - short incubation period - Caused by enterotoxin from bacteria
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GE - Campylobacter
- Flu-like prodrome, crampy abdo pain, fever, diarrhoea +/- blood, GBS cx - Most common cause travellers diarrhoea - Untreated water, unpasteurised milk, poultry
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GE - Bacillus cereus
- Vomiting in 6hrs (eg rice) / watery diarrhoea after 6hrs
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GE - Amoebiasis
- Gradual onset bloody diarrhoea, abdo pain, tenderness
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GE - Salmonella
- Sudden onset abdo pain, diarrhoea +/- blood, nausea, vomiting, sometimes constipation - Food contamination / raw eggs / chicken
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GE Incubation periods
1-6hrs – S aureus, bacillus cereus (vomiting) 12-48hrs – salmonella, E coli 48-72hrs – shigella, campylobacter >7d – giardiasis, amoebiasis
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GE Px
- Nausea - Vomiting - Diarrhoea - Abdo pain - Fever - Blood in stools - Dehydration
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Diarrhoea DDx
Acute - GE - Diverticulitis - Abx therapy - Overflow incontinence – constipation Chronic - IBS - IBD - Colorectal cancer - Coeliac disease Other conditions - Thyrotoxicosis - Laxative abuse - Appendicitis
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GE Ix
- Stool sample - MC+S - monitor dehydration
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GE Mx
- 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
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GE Cx
- Lactose intolerance - IBS - ReA - GBS - HUS
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Constipation
- Defecation that is unsatisfactory - can be infrequent, difficult passage (straining / discomfort), incomplete defecation - Chronic >3mo
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Constipation causes
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
Constipation Px
- Not opening bowels - Infrequent - Hard stools - Maybe droppings - Overflow incontinence
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Constipation assessment
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
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Constipation Mx
- 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
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Constipation cx
- overflow diarrhoea - acute urinary retention - haemorrhoids
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Paracetamol OD
- 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
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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
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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
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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
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Paracetamol OD Mx
- activated charcoal <1hr post-ingestion - N-acetylcysteine (NAC) - beware anaphylactoid reaction - liver transplant - liaison psychiatry
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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
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Paracetamol OD Mx timeline
<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
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King's College hospital criteria for liver transplant
Arterial pH <7.3, 24hrs post-ingestion Lactate >3, OR All of: - INR >6.5 - Creatinine >300 - Grade III/IV encephalopathy
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Pernicious anaemia?
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 (36 decks)

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