Gastroenterology 2 🚽 Flashcards
Oesophageal varices investigation
Gastroscopy
Medication for prophylaxis for oesophageal varices
Beta blocker (propanolol)
Medications when oesophageal varices ruptured
Ocreotide first, Terlipressin second. Abx
Endoscopic management for esophageal varices. Consider portal HTN too
Band ligation. Balloon Tamponade if bleeding. TIPS to decrease portal hypertension
Mallory-Weiss management
Treat like every upper GI bleed. Can-do epinephrine, thermal therapy, sclerosant therapy in endoscopy. Gastric artery ligation 2nd. Antibiotics. If bleeding stops can just give PPI.
Boerhaave Invx
If suspect, do contrast oesophagram with gastrographin
Treatment for boerhave
Broad-spectrum antibiotics, repair the tear, mediastinal wash, fluids, NPO
Some main investigations for lower GI bleed
Colonoscopy/push enteroscopy/Cam. Vascular studies is a second line. Open laparoscopy last line
Diverticulosis management
High fibre meals high water intake
Diverticulitis management
Antibiotics and if perforation do surgery and peritoneal lavage
Investigations for diverticulitis/diverticulosis
Colonoscopy (not for itis) or CT. Chest x-ray if perforation
Stages 1–4 for haemorrhoids
One – not visible, two – returns itself, three – returns with finger, four – doesn’t return
First line management ideas for haemorrhoids
High fibre, exercise, stool softener, topical steroids
Aside from Conservative management, haemorrhoids grade one – two can both be managed with which intervention
Sclerotherapy
Aside from Conservative management, haemorrhoids grade 2 and 3 can both be managed with which intervention
Rubber band ligation or haemorrhoidopexy
Grade 4 haemorrhoids usually need what Treatment
Haemorrhoidectomy
General GI bleed management
ABC, two bore needles, crossmatch, take bloods, IV saline, catheter and urine output, ECG, chest x-ray, terlipressin if suspect varices, antibiotics. If upper bleed do endoscopy within 24 hours
GERD investigations in a patient less than 40
PPI trial for one month
GERD investigations for a patient more than 40 years old or has dysphasia or has a ALARMS symptoms
Endoscopy and 24 hour pH monitoring
First line therapy for GERD
Lifestyle modifications, antacids if mild, PPI if more severe
Indications for Nissen fundoplication
GERD refractory to medical therapy or has complications
Los Angeles classification grade A
GERD. One or more mucosal erosions confined to mucosal folds. Do not exceed 5 mm
Los Angeles classification grade B
Mucosal breaks confined to mucosal folds. Do exceed 5 mm
Los Angeles classification grade C
Mucosal breaks beyond mucosal folds
Los Angeles classification D
75% or more of the circumference of the oesophagus is eroded
Two potential investigations for hiatal hernia
Endoscopy (to rule out other pathology). CT plus IV contrast diagnose is it
Treatment for most cases of hiatal hernia
Conservative. Decrease weight. PPI
Indications for surgery in hiatal hernia
Medications did not work, or complicated case
Barretts oesophagus endoscopic surveillance, if no dysplasia
Every 3 to 5 years
Barretts oesophagus surveillance, if dysplasia present
Endoscopy every 6 to 12 months
How to manage Barretts in young patients or patients with high-grade dysplasia
Perform in oesophagectomy
Eosinophilic oesophagitis management
Corticosteroids and avoid trigger in diet
Investigation of choice for oesophageal cancer
Endoscopy. Then for metastasis do CT, Laparoscopy to check for partner your maths, and consider endoscopic ultrasound
Treatment for oesophageal cancer in the initial stages (mucosa in submucosal invasion)
Ablation, endoscopic resection, or oesophagectomy
Advanced oesophageal cancer treatment
Iver Lewis and chemotherapy
For late stages of oesophageal cancer patients may get dysphasia, how can we manage this
Stent placement
Investigations for acute/general gastritis
H. pylori test (either urea breath or stool antigen), B12, endoscopy and biopsy
General treatment for acute gastritis/ulcers
PPIs and treat cause
Treatment for H. pylori
Triple therapy (PPI, clarithromycin, amoxicillin or metronidazole) can also add bismuth
Bleeding peptic ulcer management
PPI, tranexamic acid, somatostatin analog, do endoscopy if active bleeding
Investigations for peptic ulcer disease
Endoscopy is the gold standard, and should biopsy to rule out malignancy. Chest x-ray if suspect perforation. Order urea breath test, full blood count, Gastro
Management of gastric cancer (local versus extensive)
If local can do endoscopic resection. If extensive should do gastrectomy and lymph node ectomy
Peritonitis investigations
Supine and upright abdomen x-ray (in case of perforation), CT, paracentesis undo SAAG
Treatment for peritonitis
Third generation cephalosporin, consider albumin infusion if suspected liver cause, laparoscopic surgery if perforation case
Infectious diarrhoea treatment Generally
Oral fluids is best, but IV fluids if vomiting or situation severe. Empiric antibiotics only if suspect infectious bacterial diarrhoea
C diff antibiotics
Fidoximicin or oral vancomycin for mild
Fidoximicin or oral vancomycin for more severe
Fulminant cases, oral vancomycin and IV metronidazole are best
Pneumoperitoneum investigation and management
Chest x-ray, supine abdominal x-ray, CT. And laparoscopy to fix
Investigation for C. difficile
Toxin A and B to check in stool, PCR is also okay.: colonoscopy can be done
Investigations/diagnosis of Crohn’s
Endoscopy and biopsy. Blood tests are important to
Treatment overview for Crohn’s
Steroids for flares. Mesalazine is the best initial maintenance therapy, reserved for mild diseases. Azathioprine and MTX reserved for moderate disease. TNF alphas for late
Colon cancer surveillance for Crohn’s patients
Start eight years after diagnosis. Do every 1 to 3 years
Investigations for ulcerative colitis
Stool culture to rule out infection. Bloods are important. Radiograph to rule out megacolon, colonoscopy and biopsy is diagnostic
Management overview for ulcerative Colitis
🥲
Acute: mesalamine for mild, CSs for moderate, IV steroids for severe
Maintenance: mesalamine for mild, other biologicals for step up
Last line colectomy
Diagnosis/investigations for appendicitis
Dx by Clinical diagnosis and imaging. Ultrasound can be done first and is the main stay in kids and pregnancy. CT with contrast is the best however. MRI for preg and children is an alternative.
Management for appendicitis. Consider non-ruptured, ruptured, ruptured but stable
Antibiotics and appendectomy. Appendectomy should be done within 12 hours of diagnosis. If that is perforation appendectomy should be done immediately. If perforated but patient is still stable can do IV antibiotics, drainage of any abscess, and a rescue appendectomy
Diagnosis and investigations for small bowel obstruction
Best initial test is abdominal x-ray. CT is best to find the cause (diagnostic). Do ABG, full blood count, lactate et cetera also
What investigation can be done for patients who do not respond to Conservative treatment for SBO, and can potentially rule out the need for surgery
Small bowel follow through with Gastrografin
Nonsurgical/Conservative treatment for SBO
Fluids, NPO, NG decompression, attempt to treat underlying cause
Indications for surgery for SBO
Peritonitis, acidosis, continuous pain, systemic symptoms, or need to lyse adhesions. Or Conservative therapy does not work for 24 hours
Patient has fever and paralytic ileus 5–7 days after bowel surgery. What is happening
Anastomotic leak
Patient has closed loop large bowel obstruction. How to manage according to GI surgeon guy
Do Hartmanns procedure and anastomosis later
Management of large bowel obstruction (general)
Hospitalised, Xray and CT, Gastrografin enema, Colonoscopy. Surgery usually required
When do you not do surgery in SBO
If abdomen soft non-tender. Or if partial SBO
Stage 1234 colorectal cancer
Stage one is mucosal. Stage two is muscularis. Stage three is lymph nodes. Stage four is distant metastasis.
How to manage a stage one colo rectal cancer
Resect locally
How to manage a stage 2 colorectal cancer
Partial colectomy and lymph node ectomy
How to manage a stage three colorectal cancer
Partial colectomy and lymph node ectomy And chemotherapy
How to manage a stage 4 colorectal cancer
Partial colectomy and lymph node ectomy And chemotherapy. Consider full colectomy
Patient with lynch syndrome. Went to screen for colorectal cancer
Start a 20 and do every one year
When to start screening for colorectal cancer in FAP
Start at 10 years old
Management of toxic megacolon
Broad-spectrum antibiotics and corticosteroids. NG decompression, fluids. It doesn’t improve after 48 hours colectomy
Ischaemic colitis best initial test. And then best test overall
CTA without contrast, endoscopy and biopsy respectively (needed for Dx)
Management of mild colonic ischaemia
Bed rest and observe. NGT if Ileus
Management of moderate colonic ischaemia
Antibiotics
Management of severe colonic ischaemia
Exploratory laparotomy. May need to resect the necrotic bowel. Indicated if you see peritonitis, gangrene , pneumatosis
Best initial investigation and best overall investigation for acute mesenteric ischaemia
CTA (non invasive), mesenteric angiography (invasive) respectively. Angio needed to confirm Dx
When to invx penetrative retroperitoneal trauma? and blunt trauma?
Always invx penetrative. blunt only if zone 1
Treatment of gallstone ileus
Laparotomy to extract stone, close to fistula, cholecystectomy
Diagnosis of gallstone ileus
X-ray of the abdomen first, to see small bowel obstruction and pneumobilia. This usually confirms the diagnosis. Can do upper GI barium contrast
Suspect cholelithiasis , How to investigate
Ultrasound, and MRCP/ERCP if US equivocal
Management of incidental asymptomatic gallstones in GB
No treatment needed.
Investigations for choledocolithiasis
Right upper quadrant ultrasound first, then either MRCP (middle risk of choledoc), or ERCP (if high-risk of choledoc)
Management of biliary colic (consider when to do Sx)
Analgesia, rehydration. And an elective cholecystectomy If severe symptoms, porcelain, Empyema , pancreatitis. This is not choledocolithiasis remember
Management for choledocho lithiasis
 ERCP, it’s both diagnostic and therapeutic. After 72 hours after ERCP should do cholecystectomy
Investigations for ascending cholangitis
Right upper quadrant ultrasound first. Then either an ERCP or MRCP.
Management of ascending cholangitis
Acutely managed. Empiric antibiotics (ceftriaxone ) and ERCP. Cholecystectomy after. Percutaneous drainage performed if ERCP did not work or cannot be done
Investigations for cholecystitis
Right upper quadrant sound first. If findings are equivocal and suspicion is strong can do HIDA scan
How to manage cholecystitis
Supportive care (analgesia and fluids), nonemergent cases do cholecystectomy in less than 72 hours. Emergent cases (perforation, gangrene) do cholecystectomy right away
Investigations for primary biliary cirrhosis
Antimitochondrial antibodies, LFTs, ultrasound of the liver. Biopsy only if suspicion high and AMA is negative
Treatment for primary biliary cirrhosis
Ursodeoxycholic acid. Consider cholestyramine. Transplant in cirrhosis
Investigations for primary sclerosing cholangitis
MRCP is first line. ERCP similar to MRCP but is considered a gold standard. LFTs needed. Biopsy if inconclusive. P-ANCA not needed
Treatment of primary sclerosing cholangitis
Ursodeoxycholic acid. Can do stenting and balloon dilation. Liver transplant may be needed
investigation ideas for ischaemic hepatitis
rule out hepatitis from viruses and medication/paracetamol. Do LFTs of course
Treatment for ischaemic hepatitis
Resus and treat underlying cause
Investigation for autoimmune hepatitis
Rule out viruses and paracetamol. LFTs. Anti-smooth-muscle antibody. Biopsy usually needed And is most accurate
Treatment for a autoimmune hepatitis
Corticosteroids. Plus or minus Azathioprine. If fails do liver transplant
Grade one, two, three, four hepatic encephalopathy
Grade 1 is irritable. Grade 2 is confused and inappropriate. Grade 3 is incoherent and restless. Great 4 is coma (IIIC)
Investigations for hepatic encephalopathy
Clinical diagnosis. Ammonia and urea measurements. Consider CT or MRI
Type A versus B versus C hepatic encephalopathy 
Type A is Acute liver failure. Type B is Bypass shunt. Type C is Cirrhosis
Management of hepatic encephalopathy
Lactulose and rifaximin
Investigations for Budd-Chiari
Ultrasound with Doppler is first line. Arteriography is gold standard
Management of Budd-Chiari
Anticoagulant and diuretics (for ascites). Consider TIPS. Consider thrombolysis
Management for the fatty liver disease
Lifestyle
Wilson’s disease investigations
Non invasive first: 24 urinary copper excretion, ceruloplasmin and serum copper, slitlamp exam. Liver biopsy not always needed, can do genetic testing
Treatment for Wilson’s
Penicilamine and oral zinc is first line. Transplant if medication fails
 Main investigations for acute pancreatitis
Bloods as usual (especially amylase). Ultrasound first (check stones), CT best
Management of acute pancreatitis
Remove offending agent, opioids, fluids, electrolyte, bowel rest, NG decompression, IV antibiotics. ERCP if gallstone pancreatitis, surgical debride meant if necrosis
Investigations for chronic pancreatitis
Bloods as usual. CT first and best (MRCP good also), and/or proof of insufficiency such as faecal fat, elastase tests
Modified Glasgow criteria for acute pancreatitis
PANCREAS. PA02 below 8, age above 55, neutrophils above 15, calcium below 2, renal function with a urea above 16, enzymes with LGH above 600 and AST above 2000, albumin below 32 and sugar above 10
Management for a chronic pancreatitis patient
CREON, low-fat, vitamin ADEK, PPI, insulin if needed, opiate or NSAIDs, stop alcohol and smoking
Stage one, two, three, four for pancreatic cancer
Stage one is less than 2 cm. Stage two is 2 cm or more. Stage three is spread to neighboring tissue. Stage four is distant metastasis
First imaging modality for pancreatic cancer suspicion. Consider if jaundice present or not present
If you want this present do ultrasound first, if jaundice not present do CT first
When is an ERCP used in the investigations of pancreatic cancer
If both CT an ultrasound or unequivocal
Aside from imaging which investigations should be done for pancreatic cancer
CA 19–9, lipase, LFTs
Surgical procedure for pancreatic head cancer
Whipples (pancreatoduodenectomy)
Patient has dysphasia. Only to solid food and is intermittent. What is the differential
Can be webs, rings, stricture. Eosinophilic oesophagitis
Patient has dysphasia to solid foods. And has been progressive… may start to impede liquids too
Can be peptic stricture (young good patient). Or oesophageal cancer
Patient has dysphasia to both solids and liquids and is intermittent. Patient has chest pain in these periods
Diffuse oesophageal spasm
Patient has dysphasia. Has been progressive. And is to solids and liquids (was to both initially and equally). What are two differentials
Scleroderma or achalasia
Patient has dysphasia, specifically an issue initiating swallowing. Is this oesophageal or oropharyngeal
Oropharyngeal
Hepatic angioma, investigation/diagnosis. Any CI’s?
Contrast enhanced imaging. Likely done by ultrasound or CT. Do not biopsy
Hydatid cyst diagnosis/investigation
Imaging (usually ultrasound), with a follow-up with CT. Alongside an ELISA.
Diagnosis/investigations for hepatocellular cancer
LFTs, CT or ultrasound, AFP, biopsy only if diagnosis uncertain.
definition of chronic diarrhea
Abnormal passage of 3 or more loose stools/day for more than 1 month
what is ROME criteria used for?
IBS
assymptomatic gall stones in biliary tree vs gall bladder (mx of both?)
in GB? Do reassurance. In tree? Do cholecystectomy and bile duct clearance
GB empyema Tx?
percutaneous cholecystotomy
H pylori Mx
PPI+amoxicillin+clarithromycin for 7 days
Mx of mild to moderate UC… whether in acute flare or not (doesnt matter)
oral 5-aminosalicylic acid (5-ASA) medications and 5-ASA enemas. Not CSs
Prior to Nissen fundoplication, what needs to be done
24 hr pH monitoring with a pH of 4 or less
Dyspepsia Mx…. algorithm ideas
Clinically Dx (incl urea breath test), then preemptively Tx (PPI/triple therapy etc.) and see if gets better. EGD only if doesn’t improve (confirmatory)
Tx of NSAID-induced PUD
stop NSAID use and introduce proton pump inhibitor (PPI) use
which peritonitis types are pauci-bacillary and which are polymicrobial
pauci = Primary spont. bac (only cocci can cross barrier
poly = secondary causes (perforation)
main cause of dialysis associated peritonitis
staph epidermidis
definition of acute and persistent diarrhea
acute = less than 2 weeks
persistent = 2-4 weeks
ABx coverage in gastroenteritis?
o Most bacteria are gram –ive bacteria
Cephalosporin (3rd gen)
Quinolones (ciprofloxacin)
o Anaerobic coverage
Metronidazole
o Clostridium infection
Metronidazole IV or vancomycin PO (IV maybe)
Is peritonitis a CI for anastomosis?
yes
Overview of management for chronic mesenteric ischaemia
NGT decomp, fluids and NPO. Vasodilator, anticoag Tx
Lynch syndrome Amsterdam criteria
3 fam members, 2 generations, 1 less than 50 yo
Sepsis Mx
ABCDEFG
AIRWAY = maintain airway (and check for patency)
BREATHING = give O2 and aim for SpO2 >95%
CIRCULATION – 2 large bore IV lines Get IV access, collect blood and check blood
Bloods for culture (x2 at 2 different sites)
FBC, EUC, CRP, LFT, Glucose, Calcitonin
IV fluid for resuscitation (250-500ml NaCl 0.9% bolus)
Administration of IV broad spectrum Abx.
Early antibiotic use with empiric broad spectrum, depending on where you think the infection is coming from
Add vasopressors if fluid not enough and allow for Mean arterial presser >65mmHg (use adrenalin)
DISABILITY = GCS
EXAMINE
Swab, Culture, Chest X-ray, Check skin for infection or cutaneous manifestations such as rash
FLUID BALANCE
GLUCOSE LEVEL
Monitor for signs of deterioration (maintain charts, and look at the trends)
Decreased consciousness
Increased tachypnea or tachycardia
Decrease urine output (fluid balance)
Increased serum lactate
What is post cholecystectomy Sy
Post cholecystectomy syndrome
occurs after a cholecystectomy:
presents with right upper quadrant pain, bowel habit changes, reflux, increased AST/ALT and alkaline phosphatase
Lynch syndrome Amsterdam criteria
3 fam members, 2 generations, 1 less than 50 yo
Gold standard to Dx Hep C acute infx
HCV RNA test (gold standard) – identified current acute or chronic infection
on US and CT, you see cirrhosis…. one nodule is above 10 mm… are you concerned?
Yes, above 10mm nodule is concerning for HCC
Main difference between Invx in acute and chronic pancreatitis
acute = lipase/amylase is needed (CT not always)
chronic = CT is gold
Hepatic angioma…. when to be conservative, and what to do
If assymp and less than 5cm…. then lifestyle mod, remove OCP, do MRI in 6mo. If in 6 mo, size increased…. resect
Hepatic angioma, when to do conservative therapy. What do we do
Assymp, and less than 5cm. remove OCP, and weight loss, then repeat MRI in 6 mo. If still grown, resect.
Hydatid cyst Tx
Albendazole, then aspirate or resect
When to leave a hepatic angioma and when to do follow up? (clue: size wise)
Less than 5mm, leave it
Anal pain = sign of what?
anal cancer
how to mx thrombosed hemorrhoid
general anesthesia prior to examination…
blood hits water basin…. sign of what?
hemorrhoid
blood mixed in with stool, potentially what? thus invx how?
sign of sigmoidal cancer, do sigmoidoscopy.
Mx of perianal abscess
general anesthesia (lidocaine wont work) and emergency drainage. Check for Crohns after
Perianal fistula Mx
examine under GA. Insert probe through to assess anatomy. If doesnt involve anal muscles = do fistulotomy. If does, insert sling, and do MRI 3 weeks later.
Pilonidal abcess/cyst Mx
GA, incision and drainage… allow to heal by secondary intention (leave it open)
Bascom and Karydakis are used to Mx what
pilonidal cyst/abcess
First line Mx for anal fissure
fiber, stool softener, lidocaine, CCB ointment
Botox in sphincter and sphincterotomy last line
peritonitis and bacteria only cocci (no bacilli), means what cause
primary spont. bac peritonitis
peritonitis and bacteria mainly gram +
proximal visceral rupture
peritonitis and bacteria mainly gram -
distil vicseral rupture
Option for testing in IgA def patients for celiacs
for patients with IgA deficiency, deamidated gliadin peptide (DGP) IgG testing is available
Overview of management for acute mesenteric ischaemia
NGT decomp, fluids and NPO. Angioplasty or thrombolysis, and emergency laparotomy if signs of necrosis or peritonitis
When is peritoneal lavage done in the setting of intraabdominal hemorrhage
When unstable and bedside ultrasound results are questionable .
Does the screening regime for colonoscopy change if patient had hyperplastic polyps
No no no
What is the screening regime if patient has first degree relative with CRCA les than 60. Or if they find an adenoma in the previous scope
5 year and 1 year respectively
Intuss Dx into Mx
Clinical and US. diagnosis confirmed with air enema and this is the Tx also. Can do surgery if enema didn’t work
What is the initial Invx for necr ent? What are some of the beginning signs. What are the main risk factors
Abdominal X-ray. Apnoea and bradycardia episodes, abdominal distension…. Very general. So look, out for the RFs: premat, low birth weight, enteral feeding
Which bacteria are prevalent in
How does C diff present (main symptom)
Persistent watery diarrhoea
Role of NG suction in GI bleed
Nasogastric tubes may be used to differentiate between upper and lower sources of gastrointestinal bleeding, to detect ongoing bleeding (red blood in lavage), and to remove particulate matter, or blood clots to facilitate endoscopy.
Dx and Mx of rectovag fistula
Diagnosis is typically clinical and based on visualization of a posterior vaginal defect; for patients with an unclear presentation, imaging may be performed (Fistulography, Diagnostic studies! Magnetic resonance imaging, Endosonography)
. Treatment is with surgical repair.
Name causes of rectovag fistula
- Pelvic radiation
• Obstetric trauma
• Pelvic surgery
• Colon cancer
• Diverticulitis
• Crohn disease
Appearance seen in rectovag fistula
Velvety lesion (rectal mucosa). And tan brown smelly discharge
Immunocomp and have dysphagia or odyno… can give prophlx what before EGD
azole for Candida
First step in Tx of Eosinophilic esophagitis
PPI and avoid cause.
Oral CS is a step up
Main difference between nutcracker oesophagus and DES
DES leads to regurgitate, whereas Nutcracker does not
Other than our CCB, TCA, nitrate… what can be done for DES
Endoscopic myotomy. Novel Tx
Barrett’s Max
- no dysplasia
- indeterminate
- dysplasia or insitu
EGD every few years
EGD every few months
Endoscopic resection
Angiodysplasia Mx. Consider if symptomatic or assymp
Assymp: no mx
Symp: cautery is best
Boerhaave Dx’ic test
Contrast esophogram
Main age in dyspepsia’s where you EGD
Above 60. Whereas GERD is above 50. Not sure how legit this is
Valproate tox Tx
L carnitine
Tx for AI hep
CS +- Azathioprine
Acute liver failure Dx trio
LFTS above 1000, hep enceph, INR >1.5
Platypneoa and orthodeoxia seen where
Hepato pulmonary syndrome
NAFLD Tx (consider if NASH)
Decrease weight, good diet, (Vit E and glitazone for NASH)
Alvarado score of what or more, should we do CT and further evaluate appendicitis Patient
4
Hepatic bemangiona below what? We can leave
5mm… like stones
Red flags on imaging for a pancreatic cyst. And thus needing ultrasound guided biopsy.
Large (above 3 cm), solid, calcified, main duct involved, a irregular wall
 Where is xylose absorbed. Consider the xylose test
Duodenal. Therefore it could be due to coeliac‘s if it’s low, not terminal Ileal disease
If everything points to iron deficiency anaemia. The Gwak stool test is negative, is that enough to rule out doing a scope
No
Psychical vomiting syndrome. Is associated with which maternal condition
Migraines
Patient with large abdominal aortic aneurysm. Gets left lower quadrant pain and bloody diarrhoea. Thickening of the colon at the rectosigmoid junction on CT
Ischaemic colitis
Giardia Mechanism of action of causing diarrhoea
Disrupts tight junctions causing epithelial disruption
Main way to differentiate post op alias and small bowel obstruction
Small bowel obstruction will have a fluid levels and a clear area of decompression. Ilias won’t necessarily have these two components. But it still might have no gas or bowel movement.
Young patient, recent viral infection. Sudden abdomen pain, low blood pressure, anaemia, free fluid
Splenic rupture.
If we get a bloody abdominal paracentesis, why do we do another one
You may just get an incidental bit of blood from the trauma
When do we advise breastfeeding to last up until
At least six months
Why might a postmenopausal woman only just start to get signs of hereditary haemochromatosis
Menses may have hidden the syndrome.
Recap on requirements to diagnose acute liver failure
ALT AST above 1000. Signs of hepatic in cattle apathy. And proof of synthetic liver dysfunction (INR are above 1.5, low albumin)
Plural effusion draining green turbid fluid, secondary trauma. What’s the cause
Oesophageal perforation
