Gastroenterology Flashcards
1
Q
Cause of Acute Liver failure ??
A
PCM overdose
Viral Hepatitis (A or B)
Alcohol
Acute Fatty Liver of Pregnancy
Look for the Following
- Jaundice. - Hypoalbuminaemia
- Coagulopathy: Raised PTT
- Hepatic encephalopathy
- Renal failure (Hepato-renal synd.)
2
Q
Most accurate test to assess the synthetic function of liver ??
A
Prothrombin time & Albumin level
(LFT do not always accurately reflect the synthetic function of liver)
3
Q
Causes of Hepatosplenomegaly ??
A
- Chr. Liver disease + Portal HTN
- Late stages of Cirrhosis are a/w small liver
- Infection: Glandular Fever, Malaria, Hepatitis
- Lymphoproliferative disorders
- Myeloproliferative disorders eg. CML
- Amyloidosis
4
Q
What are the main causes of cirrhosis ??
A
Alcohol; NAFLD; Viral Hepatitis (B & C)
Dx
Transient Elastography
- aka Fibroscan
- Uses 50 MHz wave, passes into the liver from a small transducer
- Measures ‘Stiffness’ of liver which is a proxy for fibrosis
- Acoustic Radiation force impulse imaging
5
Q
What screening test is done in NAFLD to rule out Cirrhosis ??
A
- Enhanced Liver Fibrosis Score is done to screen for pts. who need further testing
6
Q
What Ix are done in Cirrhosis ??
A
Transient Elastography is indicated in
- Hep. C infection
- Men takes > 50U of [-OH] per week
- Women takes > 35U [-OH] per week
- Diagnosed with [-OH] related disease
Upper GI Endoscopy (to check for varices in newly Dx pts.)
Liver USS every 6 months +/- AFP to check for HCC
7
Q
What scoring system is used in pts. with Cirrhosis ??
A
Child-Pugh was used before but now MELD- Model for End-Stage Liver Disease has been increasingly used
- MELD uses Bilirubin, Creatinine & INR to predict survival
MELD= 3.78[Bilirubin mg/dl] + 11.2[INR] + 9.57*[Cr mg/dl] + 6.43
8
Q
What is formulae to calculate MELD score
A
MELD =
3 months mortality based on MELD score
- >=40 : 71.3% mortality
- 30- 39 : 52.6%
- 20- 29 : 19.6%
- 10- 19 : 6%
- <9 : 1.9%
9
Q
Features of Autoimmune Hepatitis ??
A
Commonly seen in Young Females
- a/w Autoimmune disorders, Hypergammaglobulinaemia & HLA B8, DR3
- Signs of Chr. Liver Disease
- Acute Hepatitis: Fever, Jaundice (25% cases)
- Secondary AMENORRHOEA
- Liver Biopsy: Inflammation beyond limiting plate ‘Pincemeal Necrosis’, Bridging Necrosis
10
Q
Name the types of Autoimmune Hepatitis
A
Classified based on the Antibody-
Type 1:
- ANA & Anti-SMA (+)ve
- Affects BOTH Adults & Children
Type 2:
- Anti-Liver/Kidney Microsomal Type 1 antibody (LKM1)
- Affects ONLY Children
Type 3:
- Soluble Liver-Kidney Antigen
- Affects Adults in Middle-age
11
Q
What is Rx. for Autoimmune Hepatitis ??
A
- Steroids & other Immunosuppressants eg.- Azathioprine
- Liver Transplantation
12
Q
What is PSC ??
A
Biliary disease of unknown cause
- Inflammation & Fibrosis of INTRA- & EXTRA- Hepatic Bile duct
C/F
- Cholestasis: Jaundice, Pruritus
- Raised Bilirubin + ALP
- RUQ pain
- Fatigue
13
Q
Ix. & Complication of PSC ??
A
ERCP or MRCP: Multiple Biliary Strictures giving ‘Beaded’ appearance
pANCA may be (+)ve
Biopsy: Limited role, shows Fibrosis, Obliterative Cholangitis- ‘Onion skin’
Complications
- Cholangiocarcinoma (10% cases)
- Increased risk of COLORECTAL Ca
14
Q
What is PBC ??
A
Chr. liver disorder + Middle aged Females (9x MC than in men)
- Autoimmune cause
Chr. Inflammation => INTERLOBULAR Bile duct => Progressive Cholestasis => Cirrhosis
15
Q
C/F of PBC ??
A
Classic presentation: Itching + Middle aged woman
- Early: Asymptomatic (eg. raised ALP) or Fatigue, Pruritus
- CHOLESTATIC Jaundice
- Hyperpigmentation (at pressure points)
- RUQ pain (10% of cases)
- Xanthelasma, Xanthomata
- Clubbing, Hepatosplenomegaly
- Late: progress to Liver Failure
16
Q
How to Dx. PBC ??
A
AMA- M2 is (+)ve & is highly specific
SMA antibody (30% cases)
Raised S. IgM levels
Imaging
- USS (RUQ) or MRCP: Required before Dx. to exclude Extrahepatic Biliary obstruction
17
Q
Rx. & Complications of PBC ??
A
1st line: URSODEOXYCHOLIC Acid
- Slows disease progression & improves symptoms
Pruritus: CHOLESTYRAMINE
- Give Fat soluble Vit. supplements
Liver Transplantation
- If Bilirubin > 100
- Recurrence in graft can occur
COMPLICATIONS
- Cirrhosis => Portal HTN => Ascites, Variceal bleeds
- Osteomalacia & Osteoporosis
- HCC (20x increased risk)
18
Q
Mention the associations of
- PSC
- PBC
A
PSC
- UC : 4% pts., with UC have PSC, 80% of pts., with PSC have UC
- Crohn’s (less common than in UC)
- HIV
PBC
- Sjogren’s disease (upto 80% cases)
- RA. - Systemic Sclerosis
- Thyroid disease
19
Q
What is Alcoholic Liver Disease ??
A
ALD covers a spectrum of conditions
- Alcoholic Fatty Liver Disease
- Alcoholic Hepatitis
- Cirrhosis
Investigations:
- GGT is characteristically elevated
- AST : ALT of > 3 suggests Acute Alcoholic Hepatitis
20
Q
Rx. of Alcoholic Liver Disease ??
A
Acute episodes of Alcoholic hepatitis
- GCs (Prednisolone)
MADDREY’S Discriminant Func. (DF) is often used during Acute episodes to determine the benefits of GC therapy
- Calculated by using PCC & Bilirubin
PENTOXYPHYLLINE is also used
- Prednisolone improves survival at 28 days
- Pentoxyphylline doesn’t improve outcomes
21
Q
What is Alcoholic Ketoacidosis ??
A
Non-Diabetic Euglycaemic form of Ketoacidosis
- Binge drinks & Vomiting food => Starvation
- Malnourished => [-OH] binge => Fat breakdown => Ketones produced => Ketoacidosis
22
Q
C/F & Rx. of Alcoholic Ketoacidosis ??
A
Typically presents with
- Met. Acidosis
- Elevated Anion Gap
- Elevated S. Ketone levels
- Normal/ Low Glucose conc.
Treatment:
- Infusion of Saline & Thiamine
23
Q
What is NAFLD ??
A
Hepatic manifestation of Metabolic syndrome & Insulin resistance is thought to be the key machanism
MCC of Liver Disease in Developed world; largely caused by Obesity & the disease spectrum ranges from
- Steatosis: Fat in liver
- Steatohapatitis: Fat + Inflammation (NASH)
- Progressive disease may cause fibrosis & liver cirrhosis
24
Q
What is NASH ??
A
Describes the Liver changes similar to those seen in Alcoholic Hepatitis without H/o Alcohol abuse
- Progression of disease in pts. with NASH => previously known as CRYPTOGENIC Cirrhosis
25
Features & Ix. of NAFLD ??
Usually Asymptomatic
Hepatomegaly & ALT >>> AST
Increased Echogenicity or Incidental asymptomatic fatty changes on USS
- No screening tests
- Enhanced Liver Fibrosis (ELF) blood test to check for Advanced Fibrosis
26
How is NAFLD monitored ??
If ELF blood test was not available, Non-invasive tests used to assess severity of fibrosis
- FIB4 score or NAFLD fibrosis score
- Scores are used in combination with FibroScan (Excellent accuracy in predicting Fibrosis)
Advanced Fibrosis case, Refer to Liver Specialist
27
Rx. of NAFLD ??
LIFESTYLE Changes (specially Wt. loss)
Gastric banding & Insulin-sensitizing drugs (Metformin, Pioglitazone)
28
What is ELF Blood test ??
Enhanced Liver Fibrosis Blood Test
- Hyaluronic acid + Procollagen 3 + Tissue inhibitor of Metalloproteinase 1
29
What diseases are a/w NAFLD ??
Obesity
DM
Hyperlipidaemia
Jejunoileal Bypass
Sudden Wt. loss/ Starvation
30
What is Acute Fatty Liver of Pregnancy ??
Usually occurs in 3rd trimester or the period immediately following delivery
- Abd pain. - N & V. - Hypoglycaemia
- Headache - Jaundice
- Pre-eclampsia
ALT is typically elevated eg.- 500u/l
31
Rx. of AFLP ??
Supportive care
DELIVERY (after stabilising) is the definitive management
Gilbert's, Dubin-Johnson synd. may exacerbated during pregnancy
HELLP
32
What is Intrahepatic Cholestasis of Pregnancy ??
aka Obstetric Cholestasis; common in 3rd Trimester
- Pruritus, often Palms & Soles
- No rash (but Scratch marks seen)
- Raised Bilirubin
33
Rx. of Intrahepatic Cholestasis of Pregnancy ??
URSODEOXYCHOLIC Acid (Pruritus)
- Weekly LFT
Women are typically induced at 37 wks
34
Most common liver disease in Pregnancy ??
Intrahepatic Cholestasis of Pregnancy
35
Causes of SAAF < 11g/L ??
Hypoalbuminaemia
- Nephrotic
- Severe Malnutrition (eg Kwashiorkor)
Malignancy
- Peritoneal Carcinomatosis
Infections : Tubercular Peritonitis
Other Causes
- Pancreatitis
- Bowel obstruction
- Biliary ascites
- Post-op. lymphatic leak
- Serositis (Connective tissue disease)
36
How is Ascites classified ??
Serum-ascites albumin gradient
SAAG > 11g/L (indicates Portal HTN)
- LIVER Disorders (MCC): Cirrhosis, ALD, Acute Liver Failure, Liver Metastases
- CARDIAC : Rt.HF, Constrictive Pericarditis
Other Causes:
- Budd-Chiari,
- Portal Vein thrombosis,
- Veno-occlusive disease,
- Myxoedama
SAAG < 11g/L
37
Rx. of Ascites ??
Reduce dietary Sodium
Fluid restriction (if Na+ < 125 mmol/L)
Aldosterone Antagonists
- Loop diuretics are often added
Therapeutic Abdominal Paracentesis
- Large volume paracentesis (> 5l) with Albumin cover
Prophylactic Antibiotics (to reduce SBP) : Oral Ciprofloxacin or Norflox for people with cirrhosis & ascites with an ascitic protein of <=15g/l until ascites resolves
TIPS (Transjugular Intrahepatic Portosystemic shunt)
38
What are the fea7026675582tures of SBP ??
Usually seen in pts. with ascites secondary to liver cirrhosis
- Ascites, Abdominal pain, Fever
Dx: Paracentesis- > 250 cells/ul
39
MC organism causing SBP
E coli
Rx
- IV Cefotaxime
Abx. prophylaxis is given to pts with ascites if
- H/o SBP
- Fluid protein < 15g/l + either Child-Pugh score of >=9 or Hepatorenal S
- Cirrhosis & ascites with an ascitic protein of <=15g/l until ascites has resolved
40
What is Hepatorenal Syndrome Pathophysiology ??
Vasoactive mediators => Splanchnic vasodilation => Reduces Systemic Vascular resistance => Kidney hypoperfusion => JG apparatus activates RAAS => Renal Vasoconstriction which is not enough to counterbalance the effects of splanchnic vasodilation
41
What are the types of HRS ??
Two types
TYPE 1 HRS
- Rapid progressive
- Doubling of S. Cr to > 221 umol/l (or) Halving of Cr Clearance to < 20ml/ min over a period of 2 wks
- Very poor prognosis
TYPE 2 HRS
- Slowly progressive
- Prognosis poor, but pts. may live longer
42
Why is Factor 8 paradoxically supra-normal in liver failure ??
Because Factor 8 is synthesized by ENDOTHELIAL Cells throughout the body; other Clotting factors are synthesized purely in Hepatic Endothelial cells.
Activated Factor 8 is usually rapidly cleared from blood stream, good hepatic function is required for this to occur, further leading to increase in circulating factor 8
43
Rx. of HRS ??
Vasopressin analogues
- Terlipressin => causes Splanchnic vasoconstriction
Volume Expansion with 20% Albumin
TIPS
44
Why are Liver Failure pts. are at increased risk of VTE ??
Supra-normal Factor 8
Reduced synthesis of purely hepatic derived natural anticoagulant
- Protein C & S (Vit. K dependent)
- Anti-thrombin (Non- Vit. K dependent)
PT & APTT are increased & Fibrinogen is decreased suggesting BLEEDING risk, but pts. with Chr. Liver Disease are NOT protected from VTE formation but are at an increased risk of thrombosis, in addition to bleeding
45
C/F of Hepatic Encephalopathy ??
Confusion & Altered GCS
Asterix: Liver flap, arrhythmic (-)ve myoclonus of 3- 5 Hz frequency
Constructional Apraxia: unable to draw a 5-pointed star
Triphasic Slow wave on EEG
Raised NH3 levels
46
What is Hepatic Encephalopathy ??
Excess absorption of NH3 & Glutamine from bacterial breakdown of protein in the gut
- a/w Acute Liver failure & also Chr. Liver failure
- TIPSS may ppt.
- Liver cirrhosis (minimal or covert encephalopathy)
47
Grading of Hepatic Encephalopathy ??
Grade 1: Irritability
Grade 2: Confusion, Inappropriate behaviour
Grade 3: Incoherent, Restless
Grade 4: Coma
48
Name a few precipitating factors of Hepatic Encephalopathy
- SBP. - GI Bleed. - Constipation
- Post TIPSS. - Hypokalaemia
- Renal Failure
- Increased diet Protein
- Drugs: Sedatives, Diuretics
49
Rx. of Hepatic Encephalopathy ??
Treat the underlying cause
- 1st line: Lactulose (Increases metabolism of NH3 by gut bacteria)
- Rifamixin (secondary prophylaxis of H Encephalopathy)- modulates the gut flora => decreased NH3 production
- Embolization of Portosystemic shunts
- Liver Transplantation
50
Name the antibodies seen in the following situations
- Previous Immunization
- Previous Hep. B (>6 months ago), NOT a carrier
- HBsAg
- Anti-HBc
- Anti-HBs (+)ve & all others are (-)ve
- Anti-HBc (+)ve, HBsAg (-)ve
- Ongoing infection: Acute or Chronic if present > 6 months
- Caught, ie. (-)ve if immunized
51
Important serological markers of Hep. B infection ??
HBsAg:
- 1st marker => causes synthesis of Anti-HBs
- Acute disease (1- 6 months)
- > 6 months : Chr. disease + Infective
Anti-HBs
- Implies Immunity (by exposure or immunization)
- (-)ve in Chr. disease
Anti-HBc
- Previous or Current infection
- IgM anti-HBc: Acute/ Recent infec.
- IgG anti-HBc: Chr. infec. >= 6months
HBeAg
- Results from breakdown of core antigen from infected liver cells
- Marker of Infectivity & HBV replication
52
Name the drugs that causes Hepatocellular picture
- PCM. - Alcohol
- Sodium valproate, Phenytoin
- Methyldopa. - MAOi
- Halothane. - Statins
- Isoniazid, Rifampicin, Pyrazinamide.
- Nitrofurantoin. - Amiodarone
53
What is Budd-Chiari syndrome ??
Hepatic Vein Thrombosis; seen due to an underlying Haematological disease or Procoagulant condition
Causes
Polycythaemia rubra vera
Thrombophilia:
- Activated Protein C resistance,
- Anti-thrombin 3 deficiency
- Protein C & S deficiency
Pregnancy; & COCPs use
54
How is Hep. B dealt during Pregnancy ??
All pregnant women: HBV screening
Chr. infected with HBV or Acute infection during pregnancy
- Baby should receive Complete vaccination course + Hep B IGs
- HBV is NOT transmitted via Breast feeding
- Lamivudine may be used in latter part of pregnancy
55
Features & Ix. done in Budd Chiari Syndrome
Triad of
- Abd. Pain: Sudden onset, Severe
- Ascites: Abd. distension
- Tender Hepatomagly
Investigations
- USS with Doppler flow studies
56
Name the drugs that causes Cholestasis (+/- Hepatitis) picture
- COCPs. - Sulfonylureas. - Fibrates.
- Anabolic Steroids & Testosterone
- Phenothiazines: Chlorpromazine, Prochlorperazine
- Nifedipine
Abx.- Flucloxacillin, Co-amoxiclav, Erythromycin
- Erythromycin Stearate has reduced risk
57
Name the drugs that cause Liver Cirrhosis
MTX
Methyldopa
Amiodarone
58
Name the drugs that Dyspepsia
NSAIDs, Bisphosphonates, Steroids
Due to reduced LOS pressure
- CCBs. - Nitrates. - Theophyllines
- CCBs & Nitrates can be used in Rx. of Achalasia
59
Hallmarks of Pyogenic Liver abscess ??
MC organisms isolated are
- Children: Staph. aureus
- Adults: E Coli
Treatment
- Percutaneous Drainage + Abx.
- Amoxicillin + Ciprofloxacin + Metronidazole (OR)
- Ciprofloxacin + Clindamycin (if Penicillin allergic)
60
Ix. & Rx. of Hydatid Cyst disease ??
1st line: USS
Best Ix.- CT (differentiates Hydatid cysts from Amoebic & Pyogenic cysts)
Serology: For Primary Dx. & Follow-up
Rx.-
- SURGERY (Cyst wall must not rupture during removal)
61
What is the Classic triad due to Biliary rupture in Hydatid cyst disease ??
Biliary colic + Jaundice + Urticaria
62
C/F of Hydatid Cysts ??
- Liver & Lung cysts
- Asymptomatic or Symptomatic if cysts > 5cm in diameter
Morbidity is due to
- Cyst bursting. - Organ dysfunction
- Infection. - Biliary, Bronchial, Renal & CSF outflow obstruction
63
Hallmarks of Hydatid Cysts
Endemic in Mediterranean & Middle Eastern countries
- Tapeworm Echinococcus granulosus
- Outer Fibrous Capsule: contains Multiple Small Daughter Cysts
- Cysts cause Type 1 HS reaction
64
What is Haemochromatosis ??
A R disorder of Iron absorption & metabolism => Iron accumulation
- HFE gene mutation on Chr 6
- Rare cases: Classic features seen but no HFE gene mutation
- 1 in 10 European descent carry a mutation
- Prevalence: 1 in 200 in European descent (more common than CF)
65
Which is the most sensitive & specific test for measuring liver iron content & for HCC screening ??
Liver Biopsy : PEARL'S Stain
- Assesses liver damage due to iron (ie. Fibrosis & Cirrhosis)
66
Ix. done is Haemochromatosis ??
GENERAL Population
- 1st line Ix: TRANSFERRIN Saturation
- Ferritin (but is NOT abnormal in early stages of disease)
FAMILY Members testing
- HFE mutation testing
MRI liver
Liver Biopsy: Perl's Stain
LFTs. Echocardiogram
Bone Densitometry
- Done in pts. with raised Ferritin
- May show Osteopenia (T score <-1 SD)/ Osteoporosis (T-score <-2.5 SD)
67
C/F of Haemochromatosis ??
- Initial C/F: Lethargy, Erectile dysfunction & Arthralgia (often of both hands)
- Bronze skin pigmentation
- DM. - Arthritis (specially Hands)
- Chondrocalcinosis
- Liver: Chr. Liver disease stigmata, Hepatomegaly, Cirrhosis, Hepatocellular deposition
- Cardiac Failure (secondary to DCM)
- Hypogonadism (secondary to Cirrhosis & Pituitary dysfunction)- Hypogonadotrophic hypogonadism
68
What are the Molecular genetic testing done in Haemochromatosis ??
Look for
- C282Y & H63D gene mutation
69
Rx. of Haemochromatosis ??
1st line
- VENESECTION
- Initially may need 1x/ week
Monitoring adequacy of Venesection
- Transferrin saturation: < 50%
- S. Ferritin conc.- < 50 ug/l
2nd line
- DESFERRIOXAMINE
70
Which is the 1st lab test to become abnormal in Haemochromatosis ??
Transferrin Saturation
71
Typical Iron study profile of Haemochromatosis ??
Raised Transferrin saturation
- > 45%
Raised Ferritin
- Men : > 300 ng/ml
- Women : > 200 ng/l
Raised Iron
LOW TIBC
72
List the Reversible & Irreversible Complications of Haemochromatosis ??
REVERSIBLE Complications
- Cardiomyopathy
- Skin Pigmentation
- Elevated LFTs & Hepatomegaly may be reversible
IRREVERSIBLE Complications
- Liver Cirrhosis
- DM
- Hypogonadotrophic Hypogonadism
- Arthropathy
73
What is Ferritin ??
Intracellular protein that binds Iron & Stores so that it can be released in a controlled fashion
74
What is increased Ferritin levels ??
Men/ Post-menopausal > 300 ug/l
Women > 200 ug/l
- It is an Acute phase protein & can therefore be falsely elevated in Inflammatory conditions
75
Causes of Increased Ferritin levels ??
WITHOUT Fe Overload (90% cases)
- Inflammation
- Alcohol excess
- Liver Disease. - CKD
- Malignancy
WITH Iron Overload
- Primary Iron Overload (Hereditary Haemochromatosis)
- Secondary Iron Overload (eg.- Repeated BTs)
76
Which is the best test to see whether Iron overload is present or not ??
TRANSFERRIN Saturation
77
Significance of Ferritin levels in IDA ??
Because Fe & Ferritin are bound, Total Body Ferritin levels may be decreased in cases of IDA
- S. Ferritin helps to determine whether an apparently Low Hb & Microcytosis is TRYLY caused by IDA state
78
What is Wilson's disease ??
A R disorder characterised by excessive Cu deposition in tissues
- Increased Cu absorption from SI
- Decreased Hepatic Cu excretion
ATP7B gene defect located on Chr 13
79
C/F of Wilson's disease ??
Onset is b/w 10- 25 yrs
- Children: Liver disease (1st sign)
- Adults: CNS disease (1st sign)
Excessive deposition of Cu in tissues; especially Brain, Liver, Cornea
Liver: Hepatitis, Cirrhosis
CNS:
- SPEECH, BEHAVIOUR & Psychiatric problems are often the 1st C/F
- Also Asterixis, Chorea, Dementia, Parkinsonism
Kayser-Fleisher rings
- Green-Brown rings in Iris periphery
- Cu deposition at Descemet's memb.
- Seen in 50% cases of Isolated Hepatic Wilson & 90% cases who have CNS involvement
Renal Tubular Acidosis (FANCONI'S)
- Haemolysis. - Blue nails
80
Ix. done in Wilson's disease ??
Slit lamp exam: for KF ring
REDUCED S. Caerulopalsmin
REDUCED total S. Cu (as 95% of Cu is carried by Caeruloplasmin)
- Free (Non-Caeruloplasmin bound) S. Cu is INCREASED
Increased 24hrs urinary Cu excretion
Dx. confirmed by ATP7B gene testing
81
Rx. of Wilson's disease ??
PENICILLAMINE (Chelates Cu)
TRIENTINE Hydrochloride
Tetrathiomolybdate (new drug under trials)
82
Hallmarks of HCC
3rd MCC of Cancer worldwide
- MCC in world: HBV
- MCC in Europe: HCV
Risk Factors (main RF is CIRRHOSIS secondary to HBV, HCV, [-OH], Haemochromatosis & PBC
- Wilson's is an exception
Other RF
- A1AT deficiency. - Male sex
- Hereditary Tyrosinosis
- Glycogen Storage disease
- COCPs, Anabolic steroids
- Aflatoxins. - Porphyria Cutanea T
- DM, Metabolic syndrome
83
Features of HCC ??
Presents late
Features of Cirrhosis/ Failure: Jaundice, Ascites, RUQ pain, Hepato-Spleno-megaly, Pruritus
Decompensation in pts. with CLD
Raised AFP
84
Who should be considered for screening of HCC ??
Screening with USS +/- AFP is considered in high risk people-
- Liver cirrhosis secondary to HBV/ HCV/ Haemochromatosis
- MEN with cirrhosis secondary to Alcohol
85
Rx. of HCC ??
Early disease: Surgical resection
Liver Transplantation
Radiofrequency ablation
Transarterial Chemoembolization
SORAFENIB: Multikinase inhibitor
86
List some CIs of Percutaneous Liver Biopsy
Deranged Clotting (eg INR > 1.4)
Low Platelets (< 60)
Anaemia
Extrahepatic Biliary Obstruction
Hydatid Cysts
Haemoangioma
Uncooperative pts.
Ascites
87
What are Carcinoid tumours ??
Occurs when metastases are present in the liver & release SEROTONIN into systemic circulation
- Can also occur with lung carcinoids as mediators are not 'cleared' by the liver.
88
C/F of Carcinoids ??
Earliest C/F: FLUSHING
- Diarrhoea. - Bronchospasm
- Hypotension
- RIGHT Heart Valve Stenosis (Lt. heart can be affected in Bronchial Carcinoids)
- ACTH, GNRH can also be secreted
- PELLAGRA: seen when dietary Tryptophan is diverted to Serotonin by the tumour
89
Ix. & Rx. of Carcinoid Tumours ??
Urinary 5-HIAA
Plasma Chromogranin A y
Rx.
- Somatostatin analogues (Octreotide)
- Diarrhoea: CYPROHEPTADINE
90
Hallmark features of Ischaemic Hepatitis.
Diffuse hepatic injury resulting from Acute Hypoperfusion ('Shock Liver')
- NOT an inflammatory process
- Elevated Aminotransferases (> 1000 IU/l or 50x the upper limit)
Often occur in conjugation with AKI (Tubular Necrosis) or Other End-organ dysfunction.
91
Name the breakdown products by the following enzymes
- Maltase
- Sucrase
- Lactase
- Disaccharide Maltose => Glucose + Glucose
- Sucrose => Fructose + Glucose
- Disaccharide Lactose => Glucose + Galactose
92
Hallmark features of Gall Stones
Prevalence F >> M
Maj. of Gall stones are a Mixed Composition (50%) & Pure Ch. stones being 20% of all cases
Cause of CBD stone
- West; due to migration to CBD
- East: De novo CBD stones
93
How small a duct size should not be explored ??
< 8 mm
- Small stones of < 5mm may be safely left & will pass spontaneously
94
Rx. of Gallstones
Asymptomatic + Stones in GB - No Rx.
CBD stones : Surgery (due to risk of Cholangitis or Pancreatitis)
Symptomatic Gallstones
- Laparoscopic Cholesystectomy
Very Frail pts.
- USS guided Cholecystectomy
During the operation, surgeons routinely perform either Intra Op. Cholangiography to confirm anatomy or to exclude CBD stones
- If stones (+) => ERCP in a day or 2 after Sx. (OR) Immediate Surgical Exploration of the B D
- Done via TRANS CYSTIC route (low morbidity & fast recovery. If this fails, formal CHOLEDOCHOTOMY is done
95
C/F & Ix. of Gallstones
Colicky RUQ pain that occurs Post-prandially
- C/F is worst after a Fatty meal (CCK levels are high => GB contraction is maximal)
Ix.
- USS abd & LFT
- When stones are suspected in Bile duct, the options lies b/w MRCP & Intraoperative imaging (determined by the skills & experience of Surgeon)
- If the Surgeon is not proceeding with BD Exploration: Pre-op MRCP
- If the Surgeon is willing to proceed with BD Exploration: Intraoperative Imaging >>> Pre-op. MRCP
96
Mention the risks involved with ERCP
- Bleeding : 0.9% (rises to 1.5% if Sphincterotomy performed)
- Duodenal Perforation : 0.4%
- Cholangitis : 1.1%
- Pancreatitis : 1.5%
97
What is Post-Cholecystectomy Syndrome ??
Is a recognised complication of Cholecystectomies
- Dyspepsia, Vomiting, Pain, Flatulence, Diarrhoea
Usually due to Remnant stones & Biliary injury
- Pain is due to
- Sphincter of Oddi dysfunction
- Development of Surgical Adhesions
98
What is Ascending Cholangitis ??
Bacterial infection (typically E Coli) of the BILIARY TREE
- MC predisposing factor is Gallstones
CHARCOT'S Triad (seen in 20- 50%)
- Fever (90%)
- RUQ pain (70%)
- Jaundice (60%)
Hypotension & Confusion (along with the above 3 => REYNOLD'S Pentad)
99
Rx. of Post- Cholecystectomy Synd.
- Low-Fat diet
- Bile acid sequestrants: Cholestramine
- PPIs
100
Ix. & Rx. of Ascending Cholangitis ??
Ix.
- 1st line: USS (look for Bile duct dilation & stones)
- Raised Inflammatory markers
Rx.
- IV Antibiotics
- ERCP after 24- 48 hrs to relieve any obstruction
101
Ix. for Bile-acid malabsorption ??
IoC : SeHCAT
- Uses Gamma-emitting Selenium molecules in Selenium Homocholic Acid Taurine or Tauroselcholic acid
- Scans are done 7 days apart to assess retention/ loss of radiolabelled (75)SeHCAT
Rx.
- CHOLESTYRAMINE
102
Features of Cholangiocarcinoma ??
aka Bile Duct Cancer
- PSC is a main risk factor
C/F
- Persistent Biliary Colic symptoms
- a/w Anorexia, Jaundice & Wt. loss
- Palpable mass in RUQ (Courvoisier sign)
- Periumbilical & Left Supraclavicular lymphadenopathy called Sister Mary Joseph & Virchow nodes.
- Raised CA 19-9 levels
103
S/E of Cholestyramine ??
- Abdominal cramps & Constipation
- Decrease absorption of Fat-soluble Vitamins
- CHOLESTEROL GallStones
- May RAISE levels of TGs
104
Features of Bile-Acid Malabsorption ??
Chronic Diarrhoea; due to
- Excessive synthesis of Bile acid
- reduced B A absorption
Steatorrhoea & Vit. A, D, E, K
Secondary causes
- Ileal diseases (Crohn's)
- Cholecystectomy
- Coeliac's. - SIBO
105
Features of Bile acid sequestrants
Used in the Rx of Hyperlipidaemia
- Decreases Bile acid reabsorption in S I => upregulates Ch conversion to Bile acid
- Reduces LDL Cholesterol
Also used in Crohn's disease for Rx of diarrhoea following Bowel resection
106
Features of Gilbert's Syndrome ??
A R condition
- Defective Bilirubin Conjugation
- UDP Glucuronosyltransferase defeciency
C/F
- Unconjugated Hyperbilirubinaemia (Not in urine)
- Jaundice: during Intercurrent illness, Exercise or Fasting
NO Treatment required
107
Name the inherited causes of Jaundice
Un-Conjugated Hyperbilirubinaemia
- Gilbert's
- Crigler-Najjar (Type 1 & 2)
Conjugated Hyperbilirubinaemia
- Dubin-Johnson
- Rotor
108
Ix. done in Gilbert's syndrome ??
Rise in Bilirubin after
- Prolonged Fasting or
- IV Nicotinic Acid
109
Features of Dubin Johnson Synd. ??
Benign A R disorder
- Conjugated Hyperbiliorubinaemia
- Present in Urine)
Common among Iranian Jews
Mutation in ABCC2 gene => codes for
Canalicular Multidrug Resistance Protein 2 (MRP2) => defective hepatic excretion of Bilirubin. out of liver cells
- Grossly BLACK Liver
110
Features of Crigler-Najjar Syndrome
A R inheritance & Unconjugated Hyperbilirubinaemia
Type 1
- Absolute deficiency of UDP-Glucuronosyl transferase
- Do NOT survive to Adulthood
Type 2
- More common than Type 1
- Is less severe than Type 1
- May improve with PHENOBARBITAL
111
What is Rotor Syndrome ??
Benign A R condition
Defect in the hepatic Uptake & Storage of Bilirubin
112
Hallmark features of Acute Pancreatitis ??
MCC is Alcohol or Gallstones
AUTODIGESTION of Pancreatic tissue by pancreatic enzymes => Necrosis
Clinical Features
- Severe Epigastric pain; radiates to back
- Vomiting
- Epigastric tenderness, Ileus & Low grade fever
- Cullen's Sign (Periumbilical) & Grey-Turnes sign (Flanks) discolouration
- PURTSCHER Retinopathy: Ischaemic, may cause temporary or permanent blindness
113
Name the conditions where S. Amylase are raised
Acute Pancreatitis
Pancreatic Pseudocyst
Mesenteric Infarct
Perforated Viscus
Acute Cholecystitis
DKA
114
Ix. done in Acute Pancreatitis ??
S. AMYLASE
- Raised in 75% of pts.- > 3x the upper limit of normal
- Levels do not correlate with disease severity
S. LIPASE
- More sensitive & specific
- Longer 1/2 life than amylase
- Useful in late presentations > 24hrs
IMAGING (Early USS & CECT)
- Dx. can be made without imaging if Typical Pain + Amylase/ Lipase > 3x normal levels
115
Scoring system used in Acute Pancreatitis >>
Ranson score, Glasgow score & APACHE II
Common factors that indicate severe pancreatitis are
- Age > 55 yrs
- Hypo Ca2+
- Hyperglycaemia
- Hypoxia
- Neutrophilia
- Elevated LDH & AST
Amylase is not of Prognostic value
116
Name the Local & Systemic complications of Acute Pancreatitis
Peripancreatic fluid (25% cases)
Pseudocysts
Pancreatic abscess
Pancreatic Necrosis
Haemorrhage
ARDS (high mortality rate of 20%)
117
Hallmark of Chronic Pancreatitis
Inflammatory process which eventually affects Exocrine & Endocrine pancreatic functions
- 80% due to Alcohol excess
- 20% due to unexplained
Other causes are
- Genetic: CF, Haemochromatosis
- Ductal obstruction: Tumours, Stones, Str. abnormalities- Pancreatic divisum & Annular pancreas
118
C/F of Chronic Pancreatitis
- PAIN- typically worse 15- 30 min after food
- Steatorrhoea (develops b/w 5- 25 yrs. after onset of pain)
- DM: Seen > 20 yrs after symptoms start
119
Ix. & Rx. of Chronic Pancreatitis ??
- Abd. X-ray : Pancreatic Calcifications (30% cases)
- CT is more sensitive for calcification
Functional tests
- Faecal Elastase: to assess Exocrine function IF imaging inconclusive
Rx.
- Pancreatic enzyme supplemantation
- Analgesia.
- Antioxidants (may benefit in early disease)
120
Biliary & Pancreatic diseases a/w HIV ??
Sclerosing Cholangitis due to
- CMV, Cryptosporidium & Microsporidia
Pancreatitis may be due to
- ART Rx. (specially DIDANOSINE)
- Opportunistic infection eg- CMV
121
Features of Pancreatic Cancer
Often Dx. late & presents in a Non-specific way
- 80% are ADENOCARCINOMA
- MC site: Head of Pancreas
Associations
- Increasing age
- Smoking. - DM
- Chr. Pancreatitis (-OH is not an independent risk factor)
- HNPCC. - MEN
- BRCA2. - KRAS mutation
122
C/F of Pancreatic Cancer
PAINLESS JAUNDICE
- Pale stools, Dark urine, Pruritus
- Cholestatic LFTs
Courvoisier's Law: Painless obstructive jaundice + Palpable GB is unlikely due to Gallstones
Anorexia, Wt. loss, Epigastric pain
Loss of Exocrine func. (Steatorrhoea)
Loss of Endocrine func. (DM)
Atypical Backpain
MIGRATORY Thrombophlebitis (Trousseau sign)
123
Ix. & Rx. of Pancreatic Cancer
IoC is HRCT
USS is sensitive around 60- 90%
'DOUBLE Duct' sign : Simultaneous dilatation of the CBD & Pancreatic ducts
Rx.
- < 20% are suitable for Sx
- Resectable lesions of Head of pancreas : Whipple's Sx (Pancreatico-duodenectomy)
- Adjuvant Chemotherapy (after Sx.)
- ERCP with Stenting: PALLIATION
124
Name a few unusual & medical causes of abdominal pain
Acute Coronary Syndrome
DKA
Pneumonia
Acute Intermittent Porphyria
Lead Poisoning
125
What is Killian's Dehiscence ??
Triangular area in the wall of the pharynx b/w the Thyropharyngeus & Cricopharyngeus muscles
- Zenker's diverticulum is a Posteromedial Diverticulum through this
126
What is Plummer-Vinson Syndrome ??
- Dysphagia (secondary to Oesophageal webs)
- Glossitis
- IDA
Rx: Iron supplementation & Dilation of webs
127
S/E of Whipple's Procedure ??
Dumping Syndrome
Peptic Ulcer Disease
128
Features of Pharyngeal Pouch ??
MC in older pts., 5x MC in Men
- Dysphagia. - Regurgitation
- Aspiration. - Halitosis
- Neck swelling which gurgles on palpation
Ix.- Barium Swallow with Dynamic Video Fluoroscopy
Rx
- Surgery
129
What is Mallory Weiss syndrome ??
Severe vomiting => Painful Mucosal Lacerations at GEJ => Haematemesis
- Common in Alcoholics
130
What is Boerhaave syndrome ??
Severe vomiting => Oesophageal Rupture
131
What are the Indications of Upper GI Endoscopy in GORD ??
- Age > 55 yrs
- Symptoms > 4 wks or persistent symptom despite Rx.
- Dysphagia
- Relapsing symptoms
- Wt. loss
If Endoscopy (-)ve, => 24hr Oesophageal pH monitoring (Gold std. test for Dx.)
132
Features of Barrett's Esophagus
METAPLASIA of Lower Oesophageal mucosa
- Increased risk of Adenocarcinoma by 50- 100 folds
Barrett's can be subdivided into
- Short < 3cm
- Long > 3cm
The length of affected segment correlates strongly with the chances of identifying metaplasia
133
Histology features of Barrett's ??
Squamous epithelium is replaced by COLUMNAR Epithelium (resembles that of Cardia of stomach or Small Intestine eg- Goblet cells, brush borders)
134
Risk Factors for Barrett's Oesophagus ??
- GORD : single strongest RF
- Male (7x). - Smoking. - Obesity.
- Alcohol is NOT an independent RF; but is a/w GORD & Oesophageal Ca
Endoscopic Surveillance
- Metaplasia & No Dysplasia: 3- 5 yrs
- Dysplasia of any grade, endoscopic intervention is offered
---- Endoscopic Mucosal Resection
---- Radiofrequency ablation
135
Rx. of Barrett's Oesophagus ??
Endoscopic Surveillance with Biopsy
High-dose PPIs
136
What is Achalasia ??
Failure of Oesophageal peristalsis & LOS contracted (due to degenerative loss of ganglia from Auerbach's plexus) & Oesophagus above is dilated
- Middle aged; M=F
137
C/F of Achalasia ??
- Dysphagia to BOTH liquids & Solids
- Heartburn. - Regurgitation of food (Cough, aspiration pneumonia)
Malignant changes in a few pts.
Investigations
- Oesophageal Manometry (Dx. test)- Excessive LOS tone => no relaxation
- Barium Swallow- Bird Beak appearance
CXR - Wide Mediastinum
Fluid level
138
C/F of Acute GI bleed ??
MCC are Oesohageal varices or Peptic ulcer disease
Haematemesis (MC presenting c/f)
- Bright red or Coffee ground colour
MALENA
- Altered blood passage in stools
- Black or Tarry in colour
Raised Urea ('Protein meal' of blood)
Features a/w the particular disease
139
Rx. of Achalasia ??
1st line: Pneumatic Balloon Dilation
Recurrent/Persistent C/F : Heller Cardiomyotomy
High Surgical Risk pts.- Intra-sphincteric injection of Botox
Drug therapy
- Nitrates, CCBs
140
Blatchford Score
- Pts. with 0 can be considered for Early discharge
UREA in mmol/l
- 6.5- 8 = 2. - 8- 10 = 3
- 10- 25 = 4. - > 25 = 6
HAEMOGLOBIN g/L
Men Women
- 12- 13 = 1 - 10- 12 = 1
- 10- 12 = 2 - < 10 = 6
- < 10 = 6
SBP mmHg
- 100- 109 = 1
- 90- 99 = 2
- < 90 = 3
Pulse >= 100/min = 1
Presentation with Malena = 1
Presentation with Syncope = 2
Hepatic Disease = 2
Cardiac Failure = 2
141
What is Dieulafoy lesion ??
AV malformation characterised by tortuous, enlarged submucosal artery that can erode the mucosa & cause Haematemesis & Malena
142
How do we do Risk Assessment in Acute GI Bleed cases ??
GLASGOW-BLATCHFORD Score
- 1st assessment when pt. arrives
- Helps to decide whether the pt. can be managed as OP or IP
The ROCKALL Score
- Used after Endoscopy)
- Provides %age risk of Rebleeding & Mortality
- Age, C/F of Shock, Co-morbidities, Etiology of Bleeding, Endoscopic stigmata of recent bleeding
143
Rx. of Acute GI Bleed
- ABC, Wide-bore IV access * 2
- Plt. Transfusion if Active bleed + Plt < 50
- FFPs (if Fibrinogen < 1g/L or PTT or APTT is > 1.5x normal
- PT Complex (if pt. is on Warfarin + Active Bleeding)
ENDOSCOPY
- Done soon after Resuscitation in pts. with Severe bleed
- ALL pts. should have endoscopy within 24 hrs
144
Rx. of a Non-variceal bleed ??
- No PPIs before Endoscopy
- PPIs should be given in Non-variceal bleed + Recent Haemorrhage seen on endoscopy
- Further bleeding: Repeat Endoscopy , Interventional radiology & Surgery
145
How is Variceal Bleeding managed ??
1) ABC
2) Correct clotting: FFPs, Vit. K
3) Vasoactive agents
- TERLIPRESSIN (Initial haemostasis & prevents Re-bleeding)
- Octreotide can be used but Terlipressin reduces mortality
4) Prophylactic IV Antibiotics
- QUINOLONES are typically used
5) ENDOSCOPY
- Band ligation >>> Sclerotherapy
6) Sengstaken-Blakemore tube if uncontrolled bleed
7) TIPSS: if above measure fails
- Connects Hepatic vein==>Portal vein
- Exacerbation of H Encephalopathy is a common complication
146
Hallmark & C/F of Oesophageal Cancer
MC type in UK/US : Adenocarcinoma
MC type in Developing world
- Squamous Cell Cancer
C/F
- Dysphagia (MC presenting c/f)
- Anorexia & Wt. loss
- Vomiting
- Other possible features: Cough, Odynophagia, Hoarseness, malena
147
Prophylaxis for Variceal Bleeding ??
Propranolol
- Reduce Rebleeding & Mortality
Endoscopic Variceal Band ligation >>> Endoscopic Sclerotherapy
- Performed at 2 weekly intervals until all varices are eradicated
- PPIs cover to prevent EVL-induced Ulceration
148
Features of Oesophageal Cancer ??
Adenocarcinoma
- Site: LOWER 1/3rd; near GEJ
RFs
- GORD. - Barrett's
- Smoking. - Achalasia
- Obesity
SQUAMOUS CELL Cancer
- Site: Upper 1/3rd of oesophagus
RFs
- Smoking. - Alcohol
- Nitrosamines - Achalasia
- Plummer-Vinson syndrome
149
Dx. of Oesophageal Cancer ??
Dx.- Upper GI Endoscopy + Biopsy
Locoregional staging: Endoscopic USS
Initial Staging: CT Chest, Abd. & Pelvis
If initial CT (-)ve for metastases
- FDG-PET CT can be used to detect occult metastases
Laparoscopy: to detect Occult Peritoneal disease
150
Rx. of Oesophageal Cancer ??
Surgical Resection
- Done for Operable disease
- Ivor-Lewis type of Oesophagectomy
Followed by Adjuvant Chemotherapy
151
Biggest surgical challenge after Resection in Oesophageal Ca ??
Anastomotic Leak
152
Hallmark of H pylori infection ??
Gram (-)ve Bacteria
2 main survival mechanisms in acidic environment
Chemotaxis away from Low pH area
- Uses Flagella => Burrows into mucosal lining => reach epithelial cells underneath
- Secretes Urease => Urea converted to NH3 => Alkalinization of acidic pH => Increased Bacterial growth
Pathogenesis mechanism
- H pylori release bacterial cytotoxins (eg. CagA toxins)=>disrupts G mucosa
153
Diseases a/w H pylori infection ??
PUD
- Duodenal ulcers (95%)
- Gastric ulcers (75%)
Gastric Cancers
B-cell Lymphoma of MALT tissue (Eradication of H pylori results causes regression in 80% of pts.)
There is NO ROLE of H pylori in GORD
154
Ix. done in H pylori infection ??
UREA BREATH Test
- NOT performed within 4 wks of Rx with Abx. or within 2 wks of an Antisecretory drug
- Used to check Eradication
RAPID UREASE Test (eg.- CLO test)
Serum Antibody
- Remains (+)ve after eradication
- Sensitivity: 90-95%
- Specificity: 95-98%
GASTRIC BIOPSY Culture
- Check for Abx. Sensitivity
- Sensitivity: 70% Specificity: 80%
GASTRIC BIOPSY
- Only HP analysis
- Sensitivity & Specificity: 95- 99%
STOOL ANTIGEN TEST
- 90% sensitive & 95% specificity
155
Rx. of H pylori infection ??
7 days course of
- PPI + Amoxicillin + Clarithromycin/ Metronidazole
- PPI + Clarithromycin + Metronidazole (if Penicillin allergic)
156
Hallmark of Gastric Cancer
Cancer of Older people (1/2 pts. are > 75yrs) & Male 2x common
RFs
- H pylori => Mucosal inflammation => Atrophy & Intestinal & Metaplasia
- Atrophic Gastritis
- Smoking. - A blood grp.
- Diet (Salt & salt preserved food; Nitrates)
157
Ix. done in Gastric Cancer ??
Dx.- Endoscopy & Biopsy
- Signet Ring cells (Large vacuole of mucin, displaces nucleus to one side
- Higher in no. => Worse prognosis
Staging: CT scan
158
Rx. of gastric Ca. ??
Surgical Resection depends on the extent & side but include
- Endoscopic Mucosal Resection
- Partial Gastrectomy
- Total Gastrectomy
Chemotherapy
159
C/F of Gastric Ca ??
Abdominal Pain
- Vague, epigastric pain
- Dyspepsia
Wt. loss & Anorexia. - N & V
Dysphagia: Particularly if Ca arises in PROXIMAL stomach
Overt GI bleed (minority cases)
Virchow's & Sister Mary Joseph nodes
160
Features of Gastric MALT lymphoma ??
- a/w H pylori infection in 95% cases
- Good prognosis
- If low grade, 80% respond to H pylori eradication
- Paraproteinaemia can be present
161
What is Zollinger Ellison Syndrome ??
Excessive levels of GASTRIN usually from a Gastrin producing tumour
- Site: Duodenum or Pancreas
- 30% cases occur as part of MEN 1
Gastrinoma => Increased Gastrin secretion => (+) Parietal cells to produce excess Gastric Acid => Peptic ulcer
162
Features & Dx. of ZE Syndrome ??
Multiple gastroduodenal ulcers
Diarrhoea
Malabsorption
Dx.
- Fasting Gastrin Levels (single best screening test)
- Secretin stimulation test
163
Features of PPIs ??
MoA: Irreversible blockade of H+/K+ ATPase of Gastric Parietal cells
S/E
- Hypo Na+, Hypo Mg2+
- Osteoporosis => increased risk of #
- Microscopic colitis
- Increased risk of C Difficile infections
164
RFs of Anal Cancer ??
2x MC in Males
Average presenting age is 85-89 yrs
- HPV 16 or 18 a/w SSCs
- MSM & high no. of sexual partners
- HIV + on Immunosuppression
- H/o Cervical Ca or CIN
- Immunosuppresants used in transplanr recipients
- Smoking
165
Causes of Jejunal villous atrophy ??
- Coeliac's disease (Classic cause)
- Tropical sprue
- Hypogammaglobulinaemia
- Gastrointestinal Lymphoma
- Whipple's disease
- Cow's milk intolerance
166
Hallmarks of Anal Cancer
80% are SQUAMOUS Cell CAs
Other types include
- Melanomas, Lymphomas & Adenocarcinomas
Anal margin tumour: spreads to Inguinal LNs
Tumours more to margins: spreads to Pelvic LNs
167
C/F of Anal Cancers ??
Typically present with a subacute onset
- Perianal Pain &/or Bleeding
- Palpable lesion
- Faecal Incontinence
- Neglected tumour in a Female may present with a Rectovaginal Fistula
168
Ix. done in Anal Cancer
T stage assessment
- DRE, Anoscopic examination + Biopsy, Inguinal LN palpation
CT, MRI, Endo-anal USS & PET
Tested for relevant infection including HIV
169
T staging of Anal Cancer
TX: Primary tumour can't be assessed
T0: No eivdence of Primary tumour
Tis: Carcinoma insitu
T1: <= 2cm in greatest dimension
T2: 2 to 5 cm in greatest dimension
T3: > 5cm in greatest dimension
T4: Any size tumour + Invades adjacent organs
- Vagina, Urethra, Bladder
- The following are NOT classified as T4: Direct invasion to Rectal wall, Perirectal skin, Subcutaneous tissue or Sphincter muscles
170
What is a VIPoma ??
Vasoactive Intestinal Peptide
- Source: Small Intestine, Pancreas
- Actions: (+) srcretions by Pancreas & Intestines & (-) Acid & Pepsinogen
90% of VIPomas arise in PANCREAS
- Large volume diarrhoea
- Wt. loss. - Dehydration
- Hypo K+ & Hypochlorhydria
171
Features of Angiodysplasia ??
Vascular deformity of GIT which predisposes to Bleeding & IDA
- a/w AORTIC Stenosis
- Common in Elderly pts.
172
What is Villous Adenoma ??
COLONIC Polyps with the potential for Malignant transformation
- Secrete large amounts of Mucous => Electrolyte disturbances
C/F (vast maj. are asymptomatic)
- Non-specific lower GI symptoms
- Secretory Diarrhoea
- Microcytic Anaemia
- Hypo K+
173
Ix. & Rx. of Angiodysplasia
Dx.
- Colonoscopy
- Mesentric Angiography (if acute bleed)
Rx.-
- Endoscopic Cautery or Argon Plasma Coagulation
- Antifybrinolytics (Tranexemic acid)
- Oestrogens may also be used
174
What is Hirschsprung's disease ??
Aganglionic segment of Bowel due to a developmental failure of the PARASYMPATHETIC Auerbach & Meissner plexuses
- Parasym. Neuroblasts fail to migrate from Neural crest to distal colon => Devt. failure of Parasym. Auerbach & Meissner plexuses => Uncoordinated peristalis => Functional Obstruction
175
Ix. & Rx. of Hirschsprung's Disease ??
RECTAL BIOPSY (Gold std.)
Abd. X-Ray
Rx.-
- Initial: Rectal washout/ Bowel irrigation
- Defenitive: Surgery of affected segment of colon
176
Hallmark of Hirschsprung's disease ??
3x more common in MALES
Down's syndrome
Presentations
- Neonates: Failure/ Delay to pass Meconium
- Older kids: Constipation, Abdominal
distension
177
What is Anal Fissure ??
Longitudinal or Elliptical tears of Squamous lining of Distal Anal Canal
- Acute: < 6 wks
- Chronic: > 6 wks
RFs
- Constipation. - IBD
- STIs (HIV, Syphilis, Herpes)
178
Features of Anal fissure ??
PAINFUL, Bright Red, Rectal bleed
- Site: Posterior Midline (90% cases)
- If fissures are located in alternative locations, then other causes should be considered eg.- Crohn's
179
Rx. of Anal Fissures ??
Acute Anal Fissure (< 1 wk)
Soften stool
- Diet: High fibre & Fluid
- 1st line: Bulk Laxatives
- 2nd line: Lactulose
Lubricants, Topical anaesthetics
Analgesics
CHRONIC Anal Fissure
- Above mentioned technique
- 1st line: Topical GTN
- Surgery (Sphincterotomy) or Botox- If Topical GTN not effectice after 8 wks
180
Types of Laxatives ??
OSMOTIC Laxatives
- Lactulose, Macrogols, Rectal phosphates
STIMULANT Laxatives
- Senna, Docusate, Bisacodyl, Glycerol
- Co-danthramer: Only considered in Palliative pts as it is carcinogenic
BULK-FORMING Laxatives
- Ispaghula Husk, Methylcellulose
FAECAL Softners
- Arachis Oil Enemas
- Not commonly used
181
What is Melanosis Coli ??
Pigmentation of Bowel Wall
- Laxative abuse: Anthracycline compounds such as Senna
HP: Pigment laden Macrophages
182
Causes of Diarrhoea in Children ??
Gastroenteritis
- MCC is Rotavirus (a/w Fever & Vomiting for 1st 2 days)
- Severe Dehydration
- Diarrhoea can last for a week
CHRONIC Diarrhoea
- MCC in developed world: Cow milk intolerance
- Toddler Diarrhoea: Stools vary in consistency + contains Undigested food
- Coeliac's disease
- Post-GE Lactose Intolerance
183
Causes of Malabsorption ??
INTESTINAL Causes
- Coeliac's. - Crohn's. - Giardiasis
- Tropical sprue. - Whipple's
- Brush border enzyme deficiency (eg. Lactase insufficiency)
PANCREATIC Causes
- Chr. Pancreatitis. - Cystic Fibrosis
- Pancreatic Ca
BILIARY Causes
- Biliary Obstruction. - PBC
OTHER Causes
- Bacterial Overgrowth (eg SSc, Diverticulae, Blind loop)
- Short Bowel Synd. - Lymphoma
184
185
Amount of Calories in 1 gram of
- Carbohydrate ??
- Protein ??
- Fats ??
- 4 kcal
- 4 kcal
- 9 kcal
186
Hallmarks of Pyloric Stenosis
Presents at 2- 4 wks of life & can rarely present at up to 4 months
- Hypertrophy of CIRCULAR muscles of the Pylorus.
- 4x more common in MALE
- 1st born is MC affected
187
Features of Pyloric Stenosis ??
Projectile vomiting 30min after food
Constipation & Dehydration
Palpable mass in the upper abdomen
Hypochloraemic HypoKalaemic Alkalosis (due to persistent vomiting)
Dx.- USS abd.
Rx.- Ramstedt Pyloromyotomy
188
Hallmark of Pernicious anaemia ??
Autoimmune disorder affecting the gastric mucosa => B12 deficiency
- Antibodies to IF
- Antibodies to Parietal cells => Reduced Acid production & Atrophic gastritis
B12 is important for RBC production & Myelination of nerves
Increased risk of Gastric Cancer
189
Features of Pernicious Anaemia ??
MC in Females + Middle to old age
a/w other autoimmune disorders
- Thyroid, Type1 DM, Addison's, RA, Vitiligo
Lethargy, Pallor & Dyspnoea
Peripheral Neuropathy (Symmetrical, pins & needles, legs & arms)
SCD of S Cord: Progressive weakness, ataxia & paresthesias may progress to Spasticity & Paraplegia
Memory loss, Poor conc., Confusion, Depression, Irritability
Mild Jaundice + Pallor=> LEMON tinge
Glossitis: Sore tongue
190
Ix. done in Pernicious Anaemia ??
1) FBC
- Macrocytosis, Hypersegmented Polymorphs, Low WBCs & Plt.
2) B12 & Folate levels
- B12 of > 200 is normal
3) Anti IF antibodies (highly specific)
4) Anti-G Parietal cell antibodies
- highly sensitive but low specificity
5) Schilling test is NO longer routinely done
191
Rx. of Pernicious anaemia ??
B12 replacement
- IM form
- No CNS features: 3 injections/ wk. for 2 wks., then 3 monthly Rx of B12 injections
- More frequent doses if CNS c/f (+)ve
Folic acid supplementation may also be needed
192
Hallmarks of Coeliac's disease ??
Due to Sensitivity to Protein GLUTEN
- Repeated exposure => Villous Atrophy => Malabsorption
- a/w HLA-DQ2 (95% pts.) & HLA-DQ8 (80% pts.)
- a/w other Autoimmune disorders (T1DM, Autoimmune Hepatitis)
193
Features of Coeliac's disease ??
- Chr./ Intermittent Diarrhoea
- F to T or Faltering growth
- Persistent/ Unexplained GI symptoms including N & V
- Prolonged Fatigue
- Recurrent Abd. pain, Cramping, distension
- Sudden, unexplained Wt. loss
- Unexplained Anaemia
DERMATITIS Herpetiformis
- Vesicular, Pruritic skin eruptions
Irritable Bowel Syndrome
1st degree relative with Coeliac's
194
Ix. done in Coeliac's disease ??
Dx. by a combination of
- Serology + Endoscopic Biopsy
If pt. is already on Gluten free diet,
- Gluten should be reintroduced for >= 6 wks prior to testing
SEROLOGY
- 1st line: TTG IgA antibodies
- EMA IgA: In Selective IgA deficiency will give a FN result
- Anti-Casein antibody (+)ve in some
- Anti-Gliadin IgA/ IgG NOT done now
ENDOSCOPIC Biopsy is Gold std.
- Done in ALL suspected pts.
- DUODENUM >>>> Jejunum
Rectal Gluten Challenge
- Not widely used
195
Complications seen in Coeliac's disease ??
- Anaemia (IFA, Folate & B12)
- HYPOSPELENISM
- Osteoporosis, Osteomalacia
- Lactose Intolerance
- Enteropathy associated T-cell Lymphoma of Small Intestine
- Subfertility
- Oseophageal Ca & Other malignancy
196
Biopsy Hallmarks of Coeliac's disease ??
Duodenal Biopsy
- Villous Atrophy. - Flat mucosa
- Crypt Hyperplasia
- Intraepithelial LYMPHOCYTOSIS
- Dense Cellular Infiltration in Lamina Propria
- Vacuolated Superficial Epithelial Cells
Villous atrophy & Immunology REVERSES on Gluten free diet
197
Rx. of Coeliac's disease ??
GLUTEN-FREE Diet
Foods that are Gluten free are
- Rice, Potatoes, Corn (maize)
Immunization
- Due to Functional Hyposplenism
- Pneumococcal vaccine + Booster doses every 5 years
- Influenza vaccine given on an individual basis
198
Which anaemia is MC in Coeliac's ??
Which antibody is tested to check the compliance to Gluten free diet ??
- Folate deficiency is MC than B12
- TTG IgA antibodies
199
Name some Gluten rich foods ??
Wheat: Bread, Pasta, Pastry
Barley: Beer
- Whisky is made from malted beer => Distillation process => Removes Gluten => SAFE in Coeliac's
Rye
Oats (some pts. DO Tolerate oats)
200
What is Small Bowel Bacterial Overgrowth Syndrome (SBBOS) ??
Characterized by Excess amounts of Bacteria in S I => GI symptoms
RFs
- Neonates with Congenital GI abnormalities
- Scleroderma. - DM
C/F (Many features overlap with IBS)
- Chronic Diarrhoea
- Bloating, Flatulence
- Abdominal Pain
201
Dx. & Rx. of SBBOS ??
HYDROGEN Breath Test
Small Bowel Aspiration & Culture
Course of Abx. as a diagnostic trial
Rx.
- Correct the Underlying disorder
- RIFAMIXIN (ToC)
- 2nd line: Co-Amoxiclav or Metronidazole
202
Hallmarks of Whipple's disease ??
Rare, Multisystem disorder caused by TROPHERYMA WHIPPELII infection
- more common in HLA-B27 (+)ve
- Middle aged MEN
C/F (GIT, Joints, CNS, Skin, LNs)
- Malabsorption: Diarrhoea, Wt, loss
- Large joint Arthralgia
- Lymphadenopathy
- Hyperpigmentation, Photosensitivity
- Pleurisy, Pericarditis
- CNS: Ophthalmoplegia, Dementia, Seizures, Ataxia, Myoclonus
203
Ix. & Rx. of Whipple's disease ??
JEJUNAL Biopsy
- Macrophages with PAS (+)ve Granules
Rx.
- IV penicillin followed by
- Oral Co-Trimoxazole for 1 year
204
Hallmark features of Irritable Bowel Syndrome ??
Dx. of IBS is considered if a pt. has had the following for at least 6 m
- Abdominal pain &/or
- Bloating &/or
- Change in Bowel habit
RED FLAGS features are
- Rectal Bleeding
- Unintentional Wt. loss
- FHx of Bowel or Ovarian Ca
- Onset at >= 60 yrs
205
Symptoms of IBS ??
Abd. pain relieved on pooping (OR) a/w Altered Bowel frequency Stool form in addition to 2 of 4 c/f:
- Altered Stool passage (straining, urgency, Incomplete evacuation)
- Abd. Bloating (MC in F than M)
- C/F worse on eating
- Passage of Mucus
Lethargy, Nausea, Backache & Bladder symptoms supports Dx.
206
Ix. done in IBS ??
FBC, ESR/ CRP
Coeliac disease screen (TTG IgA)
Rx.-
1st line DRUG Rx (according to predominant c/f)
- Pain: Antispasmodics
- Constipation: Laxatives (AVOID Lactulose)
- Diarrhoea: Loperamide (1st line)
2nd line DRUG Rx
- Low dose TCAs (Amitriptyline 5-10mg) preferred over SSRIs
Non Pharmacological Rx.
207
When is the laxative Linaclotide considered ??
- When optimal or maximum tolerated doses of previous laxatives from different class have NOT helped
- Constipation for at lease 12 months
208
When is Non-pharmacological Rx for IBS used ??
Psychological Interventions
- If C/F do NOT respond to drug Rx for 12 months & who develop a continuing symptom profile (Refractory IBS)
- CBT, Hypnotherapy or Psychological Therapy
NO Acupuncture or Reflexology is helpful in IBS
209
Hallmark features of UC ??
Inflammation starts at RECTUM (MC site) & NEVER spreads beyond Ileo-caecal valve
- CONTINUOUS lesions
- Peak age: 15- 25 & 55- 65 yrs
C/F (Insidious & Intermittent)
- BLOODY Diarrhoea
- Urgency - Tenesmus.
- Abd. Pain (LEFT Lower Quad.)
- Extra-intestinal features
210
Dx. of UC ??
ENDOSCOPY
- Colonoscopy + Biopsy
- Flexible Sigmoidoscopy : In severe colitis, to avoid risk of Perforation
Findings
- Red, raw mucosa, Bleeds easily
- No inflamm. beyond Submucosa
- Pseudopolyps: Ulceration with preserved adjacent mucosa
- Lamina Propria inflammatory cells infiltrate
- CRYPT Abscess: Neutrophils migrate through the walls of gland
- Depleted Goblet cells & Mucin
- NO Granuloma formed
BARIUM Enema
- Loss of Haustrations
- Superficial ulcerations, Pseudopolyp
- Long term disease: Narrowed Colon (Drainpipe colon)
211
Name the following Extra-intestinal features of IBD which are
- Related to disease activity
- NOT Related to diseases activity
PAUCIarticular, Asymmetric Arthritis (MC Extra-I feature)
Erythema Nodosum
Episcleritis (MC in Crohn's)
Osteoporosis
POLYarticular, Symmetric Arthritis
Uveitis (MC in UC)
Pyoderma gangrenosum
Clubbing
PSC (MC in UC)
212
Features of UC Flares
Stress, Medications (NSAIDs, Abx.), Smoking cessation
TYPES
Mild:
- < 4x stools +/- Blood
- NO systemic disturbance
- Normal ESR & CRP
Moderate:
- 4 to 6x stools + Minimal systemic c/f
Severe:
- > 6x stools with Blood
- Fever. - Tachycardia
- Abd. tenderness, Distension
- Reduced Bowel Sounds
- Anaemia. - Hypoalbuminaemia
213
Types of UC
Proctitis
Proctosigmoiditis
Distal Colitis
Extensive Colitis
Pancolitis
214
Rx. of Mild- Moderate UC ??
INDUCING REMISSION
PROCTITIS :
- Topical (rectal) Aminosalicylates (AS)
- Distal Colitis: Rectal Mesalazine
- No remission in 4 wks.: + Oral AS
- Still NO Remission : + Topical or Oral Corticosteroids
ProctoSigmoiditis & Lt. Sided UC
- Topical (Rectal) AS
- No remission in 4 wks.: + High-dose Oral AS (OR) switch to High-dose Oral AS + Topical Corticosteroids
- Still NO remission: Stop topical Rx & give Oral AS + Oral CS
EXTENSIVE Disease
- Topical AS + High-dose Oral AS
- No remission in 4 wks.: Stop Topical Rx. & give High-dose Oral AS +Oral CS
215
Rx. of Severe Colitis ??
Treated in Hospital
1st line: IV Steroids
IV Ciclosporin used if steroids CI
Ciclosporin & Thiopurines started together
- Ciclosporin induce remission & acts as a bridge until Thiopurine starts to act over next few wks.
After 72hrs + No improvement
- Add IV Ciclosporin to IV CS (OR)
- Do Surgery (Sub total Colectomy)
216
Rx. to Maintain Remission in UC ??
After Mild-Moderate UC flare
PROCTITIS & PROCTOSIGMOIDITIS
- Topical (Rectal) AS (daily/ intermittent) (OR)
- Oral AS + Topical (Rectal) AS (daily/intermittent) (OR)
- Only Oral AS (not effective)
Lt. Sided & Extensive Colitis
- Low Maintenance dose of Oral AS
217
Rx. in cases of Severe Relapse or >= 2 exacerbations in the past year ??
Oral AZATHIOPRINE or
Oral MERCAPTOPURINE
MTX is not used in UC
Probiotics can prevent relapse in Mild to moderate disease
218
Hallmark features of Crohn's disease ??
MC site: Terminal Ileum & Colon
- Can occur anywhere from mouth to anus
- Late Adolescence or Young Adults
Strong Genetic Susceptibility seen
Transmural inflammation => Strictures, Fistula & Adhesions
219
Features of CD ??
Wt. loss, Lethargy
Most prominent symptom in
- Adults: Diarrhoea
- Children: Abdominal Pain
Perianal disease: Skin tag, ulcers
Extra-intestinal manifestation are MC in pts. with Colitis or Perianal disease
- Pauciarticular, assymetric arthritis
- Episcleritis
- Others, see in UC flash cards
220
Ix. done in CD ??
Endoscopy: Colonoscopy is IoC
Raised Inflammatory markers
Increased FAECAL Calprotectin
Anaemia & Low B12 & Vit. D
CRP correlates with disease activity
HP:
- Transmural inflammation
- Goblet cells. - Granulomas (+)
Small Bowel Barium ENEMA
221
Barium Enema features of CD ??
Terminal Ileum (best spot)
- Narrowed terminal Ilium in a 'string like' configuration in keeping with a ling stricture segment termed Kantor's String sign
- Proximal Bowel Dilation
- Rose thorn ulcers.
- Fistulas
222
Rx for Inducing Remission in CD ??
- Oral/Topical/IV GCs
- Budesonide is an alternative
ENTERAL Feeding
- Used in addition to drugs (OR) used instead of drugs due to concerns with GCs S/E (Young Children)
2nd line
- 5-ASA (Mesalazine)
- Azathioprine/MTX or MCP used as ADD-ON but not as monotherapy
223
Levels of what activity should be checked before starting Azathioprine or MCP ??
TMPT activity
224
Mention the Rx. for the following
- Refractory Fistulating CD ??
- Isolated Peri-anal disease ??
- INFLIXIMAB
- Metronidazole
225
How to Maintain Remission in CD ??
STOP Smoking (is a priority)
1st line: Azathioprine or MCP
2nd line: MTX
226
Surgical Rx. for CD ??
80% of CD will eventually have Sx.
1) Stricturing Terminal Ileal disease
- Ileocaecal resection
2) Segmental Small Bowel Resection
3) Stricturoplasty
PERIANAL Fistulae
- Inflam. tract b/w Anal canal & Perianal skin
- 1st line: Metronidazole
- Anti-TNF: Infliximab (effective in closing & maintaining closure)
- Complex fistula: Draining Seton
PERIANAL ABSCESS
- I & D + Abx. therapy
227
IoC for suspected Perianal Fistulae ??
MRI
228
Feature more common in
- CD than in UC ??
- UC than in CD ??
- Non-Bloody Diarrhoea
- Wt. loss. - Abd. Pain
- Bowel Obstruction. - Skip lesions
- Transmural inflammation
- Goblet cell hyperplasia
- Granulomas. - Fistulae
- STOP Smoking
- Cobble-stone
- Bloody Diarrhoea
- PSC. - Uveitis. - Colorectal Ca
- Continuous disease
- Crypt abscess. - Pseudopolyp
- No inflam. beyond Submucosa
- Smoking Protective
229
Which Aminosalicylate drug is a/w Pancreatitis ??
7x more common with MESALAZINE than with Sulfasazine
230
Hallmark features of Acute Appendicitis ??
MC in Young people aged 10- 20 yrs
Lymphoid Hyperplasia or Faecolith => Appendiceal lumen obstructed => Gut organisma invade the appendix wall => Oedema, Ischaemia +/- Perforation
Migration of pain from Periumbilicus (Visceral stretching of appendix lumen & it is a MIDGUT str.) => RIF (localised Parietal peritoneal inflammation) is a strong indicator
231
Features of Acute Appendicitis ??
Abd. Pain
- Peri-umbilical ==> RIF
Vomit (1x or 2x)
Diarrhoea (is RARE but)
- Pelvic appendicitis can cause local rectal irritation => diarrhoea
- Pelvic abscess
Mild Pyrexia (37.5 to 38 C)
- Higher temp. is more typical in other conditions- Mesentric adenitis
ANOREXIA (very common)
232
Examination features of Acute Appendicitis ??
1)Generalised Peritonitis if perforated or Localised Peritonism
- Rebound & Percussion tenderness
- Gaurding & Rigidity
2) RETROCAECAL Appendicitis will have very few signs
3) DRE
- Boggy sensation if Pelvic abscess
- Rt. sided tenderness if Pelvic appendix
4) ROVSING's Sign: LIF palpation causes RIF pain
5) PSOAS Sign: Pain on extending hip if RETROCAECAL appendix
233
Dx. of A Appendicitis ??
Inflammatory markers & Neutrophil predominant Leukocytosis
History & Examination
USS:
- Useful in Females where Pelvic organ pathology is suspected
- Presence of Free fluid (always pathological in males) should raise suspicion
CT Scans
234
Rx. of A Appendicitis ??
Lap. Appendicectomy + Prophylactic Abx.
Perforated Appendicitis: Copious Abdominal Lavage
Appendix mass + No Peritonitis
- Broad Spectrum Abx. & Interval Appendicectomy
235
Hallmark of Appendicitis is Children ??
MC acute surgical problems facing Children
Dx is difficult as they do NOT present with Classic History of
- Central Abd. pain later radiates to RIF
- Low grade pyrexia. - Minimal Vomit
Younger Children/ Retrocaecal/Pelvic appendix presents in Atypical ways
236
Hallmark Features of C Difficile
Gram (+)ve Rods => Produce EXOtoxins =>Intestine damage => PM Colitis
- Develops when normal gut flora is suppressed by broad spectrum Abx.
- Diarrhoea. - Abd. Pain
- Raised WBCs.
- Toxic Megacolon in severe cases
237
Dx. of PM Colitis ??
C Difficile Toxin (CDT) in Stool
CD antigen (+)ve only shows exposure to bacteria rather than current infection
238
Severity scale used in PM Colitis ??
MILD : Normal WBC
MODERATE
- Increased WBCs but < 15* 109/l
- 3- 5 loose stools per day
SEVERE
- WCC > 15. or - Temp. > 38.5 C or
- Acutely increased Cr >50% above baseline or
- Evidence of Severe Colitis
LIFE Threatening
- Hypotension
- Partial/ Complete Ileus
- Toxic Megacolon or CT evdence of Severe disease
239
Hallmark features of Diverticulosis ??
Multiple outpouchings of bowel wall
- Site: SIGMOID Colon
Diverticular disease means a pt. with diverticula has become symptomatic
RFs: Increasing Age, Low fibre diet
Complications
- Abscess formation. - Peritonitis
- Obstruction. - Perforation
240
How can Diverticulosis present ??
It can present as
Painful Diverticular Disease
- Altered Bowel Habit
- Colicky LEFT sided pain
- High fibre diet is recommended
DIVERTICULITIS (infected Diverticula)
- LIF pain & Tenderness
- Anorexia. - N & V. - Diarrhoea
- Features of Infection (Pyrexia, Raised WBCs & CRP)
241
Rx. of Diverticular disease ??
Mild attack : Oral Abx.
More severe attacks
- Hospital admission
- NPO. - IV Fluids
- IV [Cephalosporins + Metronidazole]
241
Name the conditions caused by Ischaemia of Lower GIT
Acute Mesentric Ischaemia
Chronic Mesentric Ischaemia (Intestinal Angina)
- Colicky, Intermittent pain
Ischaemic Colitis
241
List some common features of Bowel Ischaemia
RFs
- Aging. - AF (MC in Mesenteric I)
- Other causes of Emboli (Malignancy, Endocarditis)
- Smoking - HTN. - DM
- Cocaine (Ischaemic C in Young)
Elevated WBCs + Lactic Acidosis
IoC : CT Scan
241
Features of Acute Mesenteric I ??
Typically due to an EMBOLI [AF mcc]
- Sudden onset, severe Pain & Pain out of proportion to exam findings
- Diarrhoea. - Fever. - Rectal Bleed
WBCs elevated + Lactic Acidosis
Rx
- URGENT Surgery
242
Features of Ischaemic Colitis ??
Acute but Transient compromise in the blood flow to large intestine => Inflammation, Ulceration & Bleeding
- More likely to affect WATER-SHED areas like SPLENIC Flexure
Ix.
- Abd. X-ray: Thumbprinting (mucosal oedema/ Haemorrhage)
Rx.-
Usually Supportive
Surgery if
- Conservative measures fail or
- Generalised Peritonitis
- Perforation
- Ongoing Bleeding
243
To which vein does Oesophageal varices drain ??
Azygous vein
- This subsequently drains to SVC
244
Vitamins a/w decreased risk of Colon Ca ??
Vit D (reduces initiation & Progression)
Vit B6 (Pyridoxine)
[Vit. E can increase Prostate Ca risk]
244
Drugs use for CD in pregnancy ??
Azathioprine
Ciclosporin
- LBW babies seen but its of to continue during pred.
245
Cause of Gynaecomastia in CLD ??
Decreased Androstenedione Catabolism (liver dysfunction => decreased catabolism => Peripheral conversion to Estrogen)
- Obesity & Alcoholism => Increase AROMATASE activity
246
Difference b/w Type 1 & 2 Autoimmune hepatitis ??
Type 1
- Fatigue + PM women
- Anti SM & ANA
Type 2
- Acute episode of Jaundice + Young women
- Anti LKM1 activity
247
Non-invasive screening test for IBD ??
Fecal Calprotectin (indicates migration of neutrophils to intestinal mucosa)
- Normal test makes IBD unlikely
248
Optimal way to confirm H pylori eradication ??
IoC : Urea Breath Test
Stool antigen test can also be used
249
Pre-menopausal women + unexplained IDA
- Which test should be done ??
Anti-TTG IgA antibody
250
Why does Ascites necessitates reduction in PCM dose ??
Ascites implies the presence of Cirrhosis
- PCM is metabolized in Liver
Ibuprofen is not used in CLD
251
Ideal initial Ix for Pancreatic insufficiency ??
Faecal Elastase
- Elastase is produced by exocrine pancreas
- Levels > 200 mg/g = Normal
- 100- 200 mg/g = Mild-Moderate insufficiency
- < 100 mg/g = Severe Exocrine Pancreas Insufficiency
252
Constituents of Bile ??
Water (97%) & Organic Salts
Organic Salts include
- Bile salts (largest component- 60g/l)
- 2 primary bile acids (Cholic acid- most abundant & Chenodeoxycholic acid)
- These 2 acids are conjugated with 2 amino acids to form 8 possible salts, which are more soluble than bile acids
Bile salts acts as detergents => emulsify fat into smaller droplets => increase surface area of lipids to be broken down by Duodenal lipase
- Bile salts are Amphipathic str. (have both Hydrophobic lipid soluble end & hydrophilic water soluble end)
Bilirubin 3g/l
Cholesterol 3- 9g/l
Lecithin 3g/l
253
Most appropriate Ix to Dx. PSC ??
MRCP
- Inflammation & Fibrosis of Intra & Extra hepatic bile ducts
- Shows Bile duct stricture with both duct dilatation & stenosis
Antibody testing is more useful in PBC (AMA antibodies)
254
What is Meckel's Diverticulum ??
Congenital True Diverticulum of S I
- remnant of Vitellointestinal or Omphalomesentric duct
- Contains: ectopic Ilial, gastric or pancreatic mucosa
Rule of 2
- 2% population. - 2 inch long
- 2 ft. from Ileocaecal valve
255
Features of Meckel's Diverticulum ??
Usually Asymptomatic
Abd. pain mimicking appendicitis
Rectal Bleeding
- MCC of painless massive GI bleed requiring BT in 1- 2 yrs old kids
Intestinal obstruction
Secondary to Omphalomesenteric band (MC), Volvulus, Intussusception
256
Ix. & Rx. of Meckel's Diverticulum
Meckel's Scan
- Must be haemodynamically stable with less severe or intermittent bleed
- Uses 99m Tc Pertechnetate
Mesenteric Angiography
- Used in more severe cases (eg.- pts. needing BT)
Rx.-
- Wedge excision or Formal Small Bowel Resection if Narrow neck or Symptomatic
257
Pathophysiology of Meckel's Diverticulum ??
Normally, in fetus there is a connection b/w VI duct & Yolk sac, which disappears by 6 wks
- The tip is free in maj. of cases
- a/w Enterocystomas, Umbilical sinuses & Omphaloileal fistulas
- Artery supply: Omphalo-Mesenteric Artery
- If lined by gastric mucosa => Peptic ulceration
258
Hallmark features of Colorectal Ca ??
3rd MC type of Ca in the UK & 2nd MCC of Ca deaths
SITE-
- Rectal (40%). - Sigmoid (30%)
- Ascending colon & Caecum (15%)
- Transverse Colon (10%)
- Descending Colon (5%)
TYPES-
- Sporadic (95%). - HNPCC (5%)
- Familial A Polyposis (<1%)
259
Genetic mutations a/w Colorectal Ca ??
Sporadic Ca is due to mutations-
- > 1/2 of cases: Allelic loss of APC
- K-ras oncogene Activation
- Deletion of p53 & DCC tumour suppressor gene => Invasive Ca
260
Features of HNPCC or Lynch Syndrome ??
A D condition & MC form of Inherited Colon Ca
- > 90% develop Ca; Proximal colon
- Poorly differentiated & Highly aggressive
- Mutations involved in DNA mismatch repair => Microsatellite instability
MC genes involved are
- MSH2 (60% cases)
- MSH1 (30% cases)
261
What is The Amsterdam Criteria ??
Which cancers are a/w HNPCC ??
Helps in the Dx. of HNPCC
- >= 3 Family members with Colon Ca
- In 2 generation
- At least 1 case Dx. before 50 yrs age
MC associated Ca with HNPCC
- Colon Cancer
- Endometrial Ca
262
Features of FAP ??
A D condition leads to formation of 100s of polyps by 30- 40 yrs
- Pt. inevitably develops CA
- Are also at risk of Duodenal tumour
Mutation: APC tumour suppressor gene on Chr. 5
Dx.- DNA analysis of WBCs
Rx.- Total Colectomy with Ileo-anal pouch formation in 20s
263
What is Gardner's syndrome ??
Its a variant of FAP & the following features can be seen
- Osteomas of skull & mandible
- Retinal Pigmentation
- Thyroid CA
- Epidermoid Cysts on Skin
264
What are the Referral Guidelines for Colorectal Ca ??
URGENT Referral (in < 2 wks)
- >= 40yrs + Unexplained Wt. loss & Abd. Pain
- > 50 yrs + Unexplained Rectal bleed
- >= 60 yrs + IDA (OR) Change in Bowel Habits
- Test shows occult Blood in faeces
URGENT Referral is 'Considered' if-
- Rectal or Abdominal mass
- Change in Bowel Habits
- Wt. loss
- IDA
265
Screening test for Colorectal Ca ??
Most Ca develops from Adenomatous Polyps
Home based Faecal Immunochemical Test (FIT) screening in Elderly
NHS offers Screening test for
- England: 60- 74 yrs every 2 yrs once
- Scotland: 50- 74 yrs every 2 yrs once
- > 74 yrs may Request screening
266
Features of FIT ??
A type of Faecal Occult Blood test which uses antibodies that specifically recognise human Hb
- It can also quantify the amount of blood in a single stool sample
- It does't identify Animal Hb ingested in our diet
- Just 1 stool test is enough
Pts. with Abnormal FIT are offered Colonoscopy
267
Statistics of Colonoscopy
5 out of 10 will have Normal results
4 of 10 will be found to have polyps which may be removed due to their Premalignant potential
1 of 10 will be Dx. with Cancer
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