Gastroenterology Flashcards
1
Q
What are the causes of diarrhoea?
A
-
Acute
- Suspect gastroenteritis
- Travel, diet, contacts?
-
Chronic
- Diarrhoea alternating with constipation: IBS
- Anorexia, ↓wt., nocturnal diarrhoea: organic cause
-
Bloody
- Vascular: ischaemic colitis
- Infective: campylobacter, shigella, salmonella, E. coli, amoeba, pseudomembranous colitis
- Inflammatory: UC, Crohn’s
- Neoplastic: CRC, polyps
-
Mucus
- IBS, CRC, polyps
-
Pus
- IBD, diverticulitis, abscess
-
Assoc. c¯ medical disease
- ↑ T4
- Autonomic neuropathy (e.g. DM)
- Carcinoid
-
Assoc. c¯ drugs
- Abx
- PPI, cimetidine
- NSAIDs
- Digoxin
2
Q
What investigations would you perform in a patient presenting with diarrhoea?
A
-
Bloods
- FBC: ↑ WCC, anaemia
- U+E: ↓K+, dehydration
- ↑ESR: IBD, Ca
- ↑CRP: IBD, infection
- Coeliac serology: anti-TTG or anti-endomysial Abs
-
Stool
- MCS and C. diff toxin
3
Q
How would you manage a patient with diarrhoea?
A
- Treat cause
- Oral or IV rehydration
- Codeine phosphate or loperamide after each loose stool
- Anti-emetic if assoc. with n/v: e.g. prochlorperazine
- Abx (e.g. cipro) in infective diarrhoea → systemic illness
4
Q
What is the pathogen, epidemiology and risk factors for C. diff diarrhoea?
A
Pathogen
- Gm+ve spore-forming anaerobe
- Release enterotoxins A and B
- Spores are v. robust and can survive for >40d
Epidemiology
- Commonest cause (25%) of Abx assoc. diarrhoea
- 100% of Abx assoc. pseudomembranous colitis
- Stool carriage in 3% of healthy adults and 15-30% of hospital pts.
Risk Factors
- Abx: e.g. clindamycin, cefs, augmentin, quinolones
- ↑ age
- In hospital: ↑ c¯ length of stay, ↑ c¯ C. diff +ve contact
- PPIs
5
Q
How can C. diff infection present?
A
- Asymptomatic
- Mild diarrhoea
- Colitis w/o pseudomembranes
- Pseudomembranous colitis
- Fulminant colitis
- May occur up to 2mo after discontinuation of Abx
6
Q
What are the features of Pseudomembranous Colitis?
A
- Severe systemic symptoms: fever, dehydration
- Abdominal pain, bloody diarrhoea, mucus PR
- Pseudomembranes (yellow plaques) on flexi sig
- Complications
- Paralytic ileus
- Toxic dilatation → perforation
- Multi-organ failure
7
Q
What investigations would you perform in a patient presenting with suspected C. diff?
A
- Bloods: ↑↑CRP, ↑↑WCC, ↓albumin, dehydration
- CDT ELISA
- Stool culture
8
Q
What markers of severe disease are there for C. diff infection?
A
Severe Disease: ≥1 of
- WCC >15
- Cr >50% above baseline
- Temp >38.5
- Clinical / radiological evidence of severe colitis
9
Q
How would you manage a patient with C. diff infection?
A
General
- Stop causative Abx
- Avoid antidiarrhoeals and opiates
- Enteric precautions
Specific
- 1st line: Metronidazole 400mg TDS PO x 10-14d
-
2nd line: Vanc 125mg QDS PO x 10-14d
- Failed metro
-
Severe: Vanc 1st (may add metro IV)
- ↑ to 250mg QDS if no response (max 500mg)
- Urgent colectomy may be needed if
- Toxic megacolon
- ↑ LDH
- Deteriorating condition
-
Recurrence (15-30%)
- Reinfection or residual spores
- Repeat course of metro x 10-14d
- Vanc if further relapse (25%)
10
Q
What are the causes of constipation?
A
OPENED IT
-
Obstruction
- Mechanical: adhesions, hernia, Ca, inflamatory strictures, pelvic mass
- Pseudo-obstruction: post-op ileus
-
Pain
- Anal fissure
- Proctalgia fugax
-
Endocrine / Electrolytes
- Endo: ↓T4
- Electrolytes: ↓Ca, ↓K, uraemia
-
Neuro
- MS
- Myelopathy
- Cauda equina syndrome
- Elderly
- Diet / Dehydration
- IBS
-
Toxins
- Opioids
- Anti-mACh
11
Q
How would you manage a patient with constipation?
A
-
General
- Drink more
- ↑ dietary fibre
-
Bulking: ↑ faecal mass → ↑ peristalsis
- CI: obstruction and faecal impaction
- Bran
- Ispaghula husk (Fybogel)
- Methylcellulose
-
Osmotic: retain fluid in the bowel
- Lactulose
- MgSO4 (rapid)
-
Stimulant: ↑ intestinal motility and secretion
- CI: obstruction, acute colitis
- SE: abdo cramps
- Bisacodyl PO or PR
- Senna
- Docusate sodium
- Sodium picosulphate (rapid)
-
Softeners
- Useful when managing painful anal conditions
- Liquid paraffin
-
Enemas
- Phosphate enema (osmotic)
-
Suppositories
- Glycerol (stimulant)
12
Q
What is the definition of IBS?
A
Disorders of enhanced visceral perception → bowel symptoms for which no organic cause can be found
13
Q
What are the diagnostic criteria for IBS?
A
ROME Criteria
- Abdo discomfort / pain for ≥ 12wks which has 2 of:
- Relieved by defecation
- Change in stool frequency (D or C)
- Change in stool form: pellets, mucus
- 2 of:
- Urgency
- Incomplete evacuation
- Abdo bloating / distension
- Mucous PR
- Worsening symptoms after food
- 2 of:
-
Exclusion criteria
- >40yrs
- Bloody stool
- Anorexia
- Wt. loss
- Diarrhoea at night
14
Q
How would you investigate and manage a patient with IBS?
A
Investigations
- Bloods: FBC, ESR, LFT, coeliac serology, TSH
- Colonoscopy: if >60yrs or any features of organic disease
Management
- Exclusion diets can be tried
- Bulking agents for constipation and diarrhoea (e.g.
- fybogel).
- Antispasmodics for colic/bloating (e.g. mebeverine)
- Amitriptyline may be helpful
- CBT
15
Q
What are the causes of dysphagia?
A
-
Inflammatory
- Tonsillitis, pharyngitis
- Oesophagitis: GORD, candida
- Oral candidiasis
- Aphthous ulcers
-
Mechanical Block
-
Luminal
- FB
- Large food bolus
-
Mural
- Benign stricture
- Web (e.g. Plummer-Vinson)
- Oesophagitis
- Trauma (e.g. OGD)
- Malignant stricture
- Pharynx, oesophagus, gastric
- Pharyngeal pouch
- Benign stricture
-
Extra-mural
- Lung Ca
- Rolling hiatus hernia
- Mediastinal LNs (e.g. lymphoma)
- Retrosternal goitre
- Thoracic aortic aneurysm
-
Luminal
-
Motility Disorders
-
Local
- Achalasia
- Diffuse oesophageal spasm
- Nutcracker oesophagus
- Bulbar / pseudobulbar palsy (CVA, MND)
-
Systemic
- Systemic sclerosis / CREST
- MG
-
Local
16
Q
What are the different ways in which dysphagia can present?
A
- Dysphagia for liquids and solids at start
- Yes: motility disorder
- No, solids > liquids: stricture
- Difficulty making swallowing movement: bulbar palsy
- Odonophagia: Ca, oesophageal ulcer, spasm
- Intermittent: oesophageal spasm
- Constant and worsening: malignant stricture
- Neck bulges or gurgles on drinking: pharyngeal pouch
17
Q
What clinical signs would you look for when examining a patient with dysphagia?
A
- Cachexia
- Anaemia
- Virchow’s node (+ve = Troisier’s sign)
- Neurology
- Signs of systemic disease (e.g. scleroderma)
18
Q
What investigations would you like to perform in a patient with dysphagia?
A
- Bloods: FBC, U+E
- CXR
- OGD
- Barium swallow ± video fluoroscopy
- Oesophageal manometrry
19
Q
What is the pathophysiology, cause, presentation and complication of achalasia?
A
-
Pathophysiology
- Degeneration of myenteric plexus (Auerbach’s)
- ↓ peristalsis
- LOS fails to relax
-
Cause
- 1O / idiopathic: commonest
- 2O: oesophageal Ca, Chagas’ disease (T. cruzii)
-
Presentation
- Dysphagia: liquids and solids at same time
- Regurgitation
- Substernal cramps
- Wt. loss
-
Comps
- Chronic achalasia → oesophageal SCC
20
Q
How would you investigate and manage a patient with achalasia?
A
-
Investigations
- Ba swallow: dilated tapering oesophagus (Bird’s beak)
- Manometry: failure of relaxation + ↓ peristalsis
- CXR: may show widended mediastinum
- OGD: exclude malignancy
-
Management
- Med: CCBs, nitrates
- Int: endoscopic balloon dilatation, botulinum toxin injection
- Surg: Heller’s cardiomyotomy (open or endo)
21
Q
What should you know about a pharyngeal pouch?
A
AKA Zenker’s Diverticulum
- Outpouching of oesophagus between upper boarder of cricopharyngeus muscle and lower boarder of inferior constrictor of pharynx
- Weak area called Killian’s dehiscence.
- Defect usually occurs posteriorly but swelling usually bulges to left side of neck.
- Food debris → pouch expansion → oesophageal compression → dysphagia.
- Pres: regurgitation, halitosis, gurgling sounds
- Rx: excision, endoscopic stapling
22
Q
What is diffuse oesophageal spasm?
A
- Intermittent dysphagia ± chest pain
- Ba swallow shows corkscrew oesophagus
23
Q
What is nutcracker oesophagus?
A
↑ contraction pressure with normal peristalsis
24
Q
What worrying associated features might there be with dyspepsia?
A
ALARM Symptoms
- Anaemia
- Loss of wt.
- Anorexia
- Recent onset progressive symptoms
- Melaena or haematemesis
- Swallowing difficulty
25
What are the causes of dyspepsia?
* **Inflammation**: GORD, gastritis, PUD
* **Ca**: oesophageal, gastric
* **Functional**: non-ulcer dyspepsia
26
How would you manage a patient with new onset dyspepsia?
* OGD if \>55 or ALARMS
* Try conservative measures for 4 wks
* Stop drugs: NSAIDs, CCBs (relax LOS)
* Lose wt., stop smoking, ↓ EtOH
* Avoid hot drinks and spicy food
* OTC
* Antacids: magnesium trisilicate
* Alginates: gaviscon advance
* Test for H. pylori if no improvement: breath or serology
* +ve → eradication therapy
* Consider OGD if no improvement
* -ve → PPI trial for 4wks
* Consider OGD if no improvement
* PPIs can be used intermittently to control symptoms.
* **Proven GORD**
* Full dose PPI for 1-2mo
* Then, low-dose PPI PRN
* **Proven PUD**
* Full dose PPI for 1-2mo
* H. pylori eradication if positive
* Endoscopy to check for resolution if GU
* Then, low-dose PPI PRN
27
What is H. pylori eradication therapy?
* 7 days Rx
* NB. PPIs and cimetidine → false –ve C13 breath tests and antigen tests so stop \>2wks before.
* PAC 500
* PPI: lansoprazole 30mg BD
* Amoxicillin 1g BD
* Clarithromycin 500mg BD
* PMC 250
* PPI: lansoprazole 30mg BD
* Metronidazole 400mg BD
* Clarithromycin 250mg BD
* Failure
* 95% success
* Mostly due to poor compliance
* Add bismuth
* Stools become tarry black
28
What are the causes of peptic ulcer disease?
* **Acute**: usually due to drugs (NSAIDs, steroids) or “stress”
* **Chronic**: drugs, H. pylori, ↑Ca, Zollinger-Ellison
29
What are the features of duodenal ulcers?
* Pathology
* 4x commoner than GU
* 1st part of duodenum (cap)
* M\>F
* Risk factors
* H. pylori (90%)
* Drugs: NSAIDs, steroids
* Smoking
* EtOH
* ↑ gastric emptying
* Blood group O
* Presentation
* Epigastric pain:
* Before meals and at night
* Relieved by eating or milk
30
What are the features of gastric ulcers?
* Pathology
* Lesser curve of gastric antrum
* Beware ulcers elsewhere (often malignant)
* Risk factors
* H. pylori (80%)
* Smoking
* Drugs
* Delayed gastric emptying
* Stress
* **Cushing’s**: intracranial disease
* **Curling’s**: burns, sepsis, trauma
* Presentation
* Epigastric pain:
* Worse on eating
* Relieved by antacids
* Wt. loss
31
What are the complications of peptic ulcer disease?
* **Haemorrhage**
* Haematemeis or melaena
* Fe deficiency anaemia
* **Perforation**
* Peritonitis
* **Gastric Outflow Obstruction**
* Vomiting, colic, distension
* **Malignancy**
* ↑ risk c¯ H. pylori
32
How would you investigate a patient with peptic ulcer disease?
* **Bloods**: FBC, urea (↑ in haemorrhage)
* C13 breath test
* OGD (stop PPIs \>2wks before)
* CLO / urease test for H. pylori
* Always take biopsies of ulcers to check for Ca
* Gastrin levels if Zollinger-Ellison suspected
33
What are the conservative and medical management options for peptic ulcer disease?
* **Conservative**
* Lose wt.
* Stop smoking and ↓ EtOH
* Avoid hot drinks and spicy food
* Stop drugs: NSAIDs, steroids
* OTC antacids
* **Medical**
* OTC antacids: Gaviscon, Mg trisilicate
* H. pylori eradication: PAC500 or PMC250
* Full-dose acid suppression for 1-2mo
* PPIs: lansoprazole 30mg OD
* H2RAs: ranitidine 300mg nocte
* Low-dose acid suppression PRN
34
What are the surgical management options for peptic ulcer disease?
* **Concepts**
* No acid → no ulcer
* Secretion stimulated by gastrin and vagus N.
* **Vagotomy**
* **Truncal**: ↓ acid secretion but prevents pyloric sphincter relaxation so must be combined with pyloroplasty or gastroenterostomy.
* **Selective**: vagus nerve only denervated where it supplies lower oesophagus and stomach
* Nerves of Laterjet (supply pylorus) left intact
* **Antrectomy with vagotomy**
* Distal half of stomach removed + anastomosis:
* Directly to duodenum: Billroth 1
* To small bowel loop with duodenal stump oversewn: Billroth 2 or Polya
* **Subtotal gastrectomy with Roux-en-Y**
* Occasionally performed for Zollinger-Ellison
35
What complications can there be following surgical management for peptic ulcer disease?
* **Physical**
* **S**tump leakage
* **A**bdominal fullness
* **R**eflux or bilious vomiting (improves c¯ time)
* **S**tricture
* **Metabolic**
* Dumping syndrome
* Abdo distension, flushing, n/v
* Early: osmotic hypovolaemia
* Late: reactive hypoglycaemia
* Blind loop syndrome → malabsorption, diarrhoea
* Overgrowth of bacteria in duodenal stump
* Anaemia: Fe + B12
* Osteoporosis
* Wt. loss: malabsorption of ↓ calories intake
36
What are the risk factors for GORD?
* Hiatus hernia
* Smoking
* EtOH
* Obesity
* Pregnancy
* Drugs: anti-AChM, nitrates, CCB, TCAs
* Iatrogenic: Heller’s myotomy
37
What are the symptoms of GORD?
* **Oesophageal**
* Heartburn
* Related to meals
* Worse lying down / stooping
* Relieved by antacids
* Belching
* Acid brash, water brash
* Odonophagia
* **Extra-oesophageal**
* Nocturnal asthma
* Chronic cough
* Laryngitis, sinusitis
38
What complications can occur with GORD?
* Oesophagitis: heartburn
* Ulceration: rarely → haematemesis, melaena, ↓Fe
* Benign stricture: dysphagia
* Barrett’s oesophagus
* Intestinal metaplasia of squamous epithelium
* Metaplasia → dysplasia → adenocarcinoma
* Oesophageal adenocarcinoma
39
What is the differential diagnosis for GORD?
* Oesophagitis
* Infection: CMV, candida
* IBD
* Caustic substances / burns
* PUD
* Oesophageal Ca
40
What investigations would you order for a patient presenting with GORD?
* Isolated symptoms don’t need Ix
* **Bloods**: FBC
* **CXR**: hiatus hernia may be seen
* **OGD** if:
* \>55yrs
* Symptoms \>4wks
* Dysphagia
* Persistent symptoms despite Rx
* Wt. loss
* OGD allows grading by **Los Angeles** **Classification**
* **Ba swallow**: hiatus hernia, dysmotility
* 24h pH testing ± manometry
* pH \<4 for \>4hrs
41
What are the conservative treatment options for GORD?
* Lose wt.
* Raise head of bed
* Small regular meals ≥ 3h before bed
* Stop smoking and ↓ EtOH
* Avoid hot drinks and spicy food
* Stop drugs: NSAIDs, steroids, CCBs, nitrates
42
What are medical and surgical treatment options for GORD?
* **Medical**
* OTC antacids: Gaviscon, Mg trisilicate
* 1: Full-dose PPI for 1-2mo
* Lansoprazole 30mg OD
* 2: No response → double dose PPI BD
* 3: No response: add an H2RA
* Ranitidine 300mg nocte
* Control: low-dose acid suppression PRN
* **Surgical**: Nissen Fundoplication
* Indications: all 3 of:
* Severe symptoms
* Refractory to medical therapy
* Confirmed reflux (pH monitoring)
43
What is a Nissen Fundoplication?
* **Aim**: prevent reflux, repair diaphragm
* Usually laparoscopic approach
* Mobilise gastric fundus and wrap around lower oesophagus
* Close any diaphragmatic hiatus
* **Complications**:
* Gas-bloat syn.: inability to belch / vomit
* Dysphagia if wrap too tight
44
How are hiatus hernias classified?
* **Sliding (80%)**
* Gastro-oesophageal junction slides up into chest
* Often assoc. with GORD
* **Rolling (15%)**
* Gastro-oesophageal junction remains in abdomen but a bulge of stomach rolls into chest alongside the oesophagus
* LOS remains intact so GORD uncommon
* Can → strangulation
* **Mixed (5%)**
45
What investigations would you order for a patient with a suspected hiatus hernia?
* **CXR**: gas bubble and fluid level in chest
* **Ba swallow**: diagnostic
* **OGD**: visualises the mucosa but can’t exclude hernia
* **24h pH + manometry**: exclude dysmotility or achalsia
46
What are the management options for a hiatus hernia?
* Lose wt.
* Rx reflux
* Surgery if intractable symptoms despite medical Rx.
* Should **repair rolling hernia** (even if asympto) as it may strangulate.
47
What is the differential diagnosis for haematemesis?
**VINTAGE**
* **Varices**
* **Inflammation**
* Oesophago-gastro-duodenitis
* PUD: DU is commonest cause
* **Neoplasia**
* Oesophageal or gastric Ca
* **Trauma**
* Mallory-Weiss Tear
* Mucosal tear due to vomiting
* Boerhaave’s Syndrome
* Full-thickness tear
* 2cm proximal to LOS
* **Angiodysplasia + other vascular anomalies**
* Angiodysplasia
* HHT
* Dieulafoy lesion: rupture of large arteriole in stomach or other bowel
* **Generalised bleeding diathesis**
* Warfarin, thrombolytics
* CRF
* **Epistaxis**
48
What is the differential diagnosis for rectal bleeding?
**DRIPING Arse**
* **Diverticulae**
* **Rectal**
* Haemorrhoids
* **Infection**
* Campylobacter, shigella, E. coli, C. diff, amoebic dysentery
* **Polyps**
* **Inflammation**
* UC, Crohn’s
* **Neoplasia**
* **Gastic-upper bowel bleeding**
* **Angio**
* Ischaemic colitis
* HHT
* Angiodysplasia
49
What important points should you ask in the history for a patient presenting with an upper GI bleed?
* Previous bleeds
* Dyspepsia, known ulcers
* Liver disease or oesophageal varices
* Dysphagia, wt. loss
* Drugs and EtOH
* Co-morbidities
50
What should you look for in your examination of a patient presenting with an upper GI bleed?
* Signs of CLD
* PR:melaena
* Shock?
* Cool, clammy, CRT\>2s
* ↓BP (\<100) or postural hypotension (\>20 drop)
* ↓ urine output (\<30ml/h)
* Tachycardia
* ↓GCS
51
What are the common causes of an upper GI bleed?
* **PUD**: 40% (DU commonly)
* Acute erosions / gastritis:20%
* Mallory-Weiss tear: 10%
* Varices: 5%
* Oesophagitis: 5%
* Ca Stomach / oesophagus:\<3%
52
What is the Rockall score?
**Rockall Score**: (Prof T Rockall, St. Mary’s)
* Prediction of re-bleeding and mortality
* 40% of re-bleeders die
* Initial score pre-endoscopy
* Age
* Shock: BP, pulse
* Comorbidities
* Final score post-endoscopy
* Final Dx + evidence of recent haemorrhage
* Active bleeding
* Visible vessel
* Adherent clot
* Initial score ≥3 or final \>6 are indications for surgery
53
What is the pathophysiology and prognosis of oesophageal varicies?
* Portal HTN → dilated veins @ sites of porto-systemic anastomosis: L. gastric and inferior oesophageal veins
* 30-50% with portal HTN will bleed from varices
* Overall mortality 25%: ↑ with severity of liver disease.
54
What are the causes of protal HTN?
* **Pre-hepatic**: portal vein thrombosis
* **Hepatic**: cirrhosis (80% in UK), schistosomasis (commonest worldwide), sarcoidosis.
* **Post-hepatic**: Budd-Chiari, RHF, constrictive pericarditis
55
What treatment is used to try and prevent oesophageal varicial bleeds?
* **1º**: β-B, repeat endoscopic banding
* **2º**: β-B, repeat banding, TIPSS
## Footnote
**Transjugular Intrahepatic Porto-Systemic Shunt (TIPSS)**
* IR creates artificial channel between hepatic vein and portal vein → ↓ portal pressure.
* Colapinto needle creates tract through liver parenchyma which is expand using a balloon and maintained by placement of a stent.
* Used prophylactically or acutely if endoscopic therapy fails to control variceal bleeding.
56
What is the acute management of an upper GI bleed?
* **Resuscitate**
* Head-down
* 100% O2, protect airway
* 2 x 14G cannulae + IV crystalloid infusion up to 1L.
* **Bloods**: FBC, U+E (↑ urea), LFTs, clotting, x-match 6u, ABG, glucose
* **Blood if remains shocked**
* Group specific or O- until X-matched
* **Variceal Bleed**
* Terlipressin IV (splanchnic vasopressor)
* Prophylactic Abx: e.g. ciprofloxacin 1g/24h
* **Maintenance**
* Crystalloid IVI, transfuse if necessary (keep Hb≥10)
* Catheter + consider CVP (aim for \>5cm H2O)
* Correct coagulopathy: vit K, FFP, platelets
* Thiamine if EtOH
* Notify surgeons of severe bleeds
* **Urgent Endoscopy**
57
What is the endoscopic management of an acute upper GI bleed?
* **Haemostasis of vessel or ulcer:**
* Adrenaline injection
* Thermal / laser coagulation
* Fibrin glue
* Endoclips
* **Variceal bleeding:**
* 2 of: banding, sclerotherapy, adrenaline, coagulation
* Balloon tamponade with Sengstaken-Blakemore tube
* Only used if exsanguinating haemorrhage or failure of endoscopic therapy
* TIPSS if bleeding can’t be stopped endoscopically
* **After endoscopy**
* Omeprazole IV + continuation PO (↓s re-bleeding)
* Keep NBM for 24h → clear fluids → light diet @ 48h
* Daily bloods: FBC, U+E, LFT, clotting
* H. pylori testing and eradication
* Stop NSAIDs, steroids et.c.
58
What are the indications for surgery for an acute upper GI bleed?
* Re-bleeding
* Bleeding despite transfusing 6u
* Uncontrollable bleeding at endoscopy
* Initial Rockall score ≥3, or final \>6
Open stomach, find bleeder and underrun vessel.
59
What type of fluid replacement should be used for an upper GI bleed in a patient with uncompensated liver disease?
Avoid 0.9% NS in uncompensated liver disease (worsens ascites). Use blood or albumin for resus and 5% dex for maintenance.
60
What is the normal bilirubin physiology?
* Normal BR = 3-17uM
* Jaundice visible @ 50uM (3 x ULN)
* Hb → unconjugated BR by splenic macrophages
* uBR → cBR by BR-UDP-glucuronyl transferase in liver
* Secreted in bile then cBR → urobilinogen (colourless)
* Some urobilinogen is reabsorbed, returned to liver and re-excreted into bile.
* Some reabsorbed urobilinogen is excreted into the urine
* The urobilinogen that remains in the GIT is converted to stercobilin (brown) and excreted.
61
What are the causes of jaundice?
* **Pre-Hepatic**
* **Excess BR production**
* Haemolytic anaemia
* Ineffective erythropoiesis e.g. thalassaemia
* **Hepatic**
* **Unconjugated**
* **↓ BR Uptake**
* Drugs: contrast, RMP
* CCF
* **↓ BR Conjugation**
* Hypothyroidism
* Gilbert’s (AD)
* Crigler-Najjar (AR)
* Neonatal jaundice is both ↑ production + ↓ conjug.
* **Conjugated**
* **Hepatocellular Dysfunction**
* Congen: HH, Wilson’s, α1ATD
* Infection: Hep A/B/C, CMV, EBV
* Toxin: EtOH, drugs
* AI: AIH
* Neoplasia: HCC, mets
* Vasc: Budd-Chiari
* **↓ Hepatic BR Excretion**
* Dubin-Johnson
* Rotor’s
* **Post-Hepatic**
* **Obstruction**
* **Stones**
* **Ca pancreas**
* Drugs
* PBC
* PSC
* Biliary atresia
* Choledochal cyst
* Cholangio Ca
62
What drugs can cause jaundice and by what different mechanisms?
* **Haemolysis**
* Antimalarials (e.g. dapsone)
* **Hepatitis**
* Paracetamol OD
* RMP, INH, PZA
* Valproate
* Statins
* Halothane
* MOAIs
* **Cholestasis**
* Fluclox (may be wks after Rx)
* Co-amoxiclav
* OCP
* Sulfonylureas
* Chlopromazine, prochlorperazine
63
What are Gilbert's and Crigler-Najjar?
* **Gilbert’s**
* Autosomal dominant partial UDP-GT deficiency
* 2% of the population
* Jaundice occurs during intercurrent illness
* **Dx**: ↑ uBR on fasting, normal LFTs
* **Crigler-Najjar**
* Rare autosomal recessive total UDP-GT deficiency
* Severe neonatal jaundice and kernicterus
* **Rx**: liver Tx
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What investigations would you do for a patient with suspected pre-hepatic jaundice?
* **Urine**
* No BR (acholuric)
* ↑ urobilinogen
* ↑Hb if intravascular haemolysis
* **LFTs**
* ↑ uBR
* ↑ AST
* ↑ LDH
* **Other**
* FBC and film
* Coombs Test
* Hb electrophoresis
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What investigations would you do for a patient with suspected hepatic jaundice?
* **Urine**
* ↑BR
* ↑ urobilinogen
* **LFTs**
* ↑ cBR (usually)
* ↑AST:↑ALT
* \> 2 = EtOH
* \< 1 = Viral
* ↑ GGT (EtOH, obstruction)
* ↑ ALP
* Function: ↓ albumin, ↑ PT
* **Other**
* FBC: anaemia
* Anti- SMA, LKM, SLA, ANA
* α1AT, ferritin, caeruloplasmin
* Liver biopsy
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What investigations would you do for a patient with suspected post-hepatic jaundice?
* **Urine**
* ↑↑ BR
* No urobilinogen
* **LFTs**
* ↑↑ cBR
* ↑ AST, ↑ ALT
* ↑↑ ALP
* ↑ GGT
* **Other**
* Abdo US: ducts \>6mm
* ERCP, MRCP
* Anti- AMA, ANCA, ANA
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What are the causes of liver failure?
* **Acute**
* **Infection**: Hep A/B, CMV, EBV, leptospirosis
* **Toxin**: EtOH, paracetamol, isoniazid, halothane
* **Vasc**: Budd-Chiari
* **Other**: Wilson’s, AIH
* **Obs**: eclampsia, acute fatty liver of pregnancy
* **Cirrhosis**
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What are the signs of liver failure?
* Jaundice
* Oedema + ascites
* Bruising
* Encephalopathy
* Aterixis
* Constructional apraxia (5-pointed star)
* Fetor hepaticus
* Signs of cirrhosis / chronic liver disease
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What investigations should you do for a patient with suspected liver failure?
* **Blood**
* **FBC**: infection, GI bleed, ↓ MCV (EtOH)
* **U+E**
* ↓U, ↑Cr: hepatorenal syndrome
* Urea synth in liver thus poor test of renal function
* **LFT**
* AST:ALT \> 2 = EtOH
* AST:ALT \< 1 = Viral
* Albumin: ↓ in chronic liver failure
* PT: ↑ in acute liver failure
* **Clotting**: ↑INR
* **Glucose**
* **ABG**: metabolic acidosis
* **Cause**: Ferritin, α1AT, caeruloplasmin, Abs, paracetamol levels
* **Microbiology**
* Hep, CMV, EBV serology
* Blood and urine culture
* Ascites MCS + SAAG
* **Radiology**
* CXR
* Abdo US + portal vein duplex
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What is the pathophysiology, classification and treatment for hepatorenal syndrome?
* **Hepatorenal syndrome**
* Renal failure in pts. with advanced CLF
* Dx of exclusion
* **Pathophysiology**: “Underfill theory”
* Cirrhosis → splanchnic arterial vasodilatation → effective circulatory volume → RAS activation → renal arterial vasoconstriction.
* Persistent underfilling of renal circulation → failure
* **Classification**
* **Type 1:** rapidly progressive deterioration (survival \<2wks)
* **Type 2:** steady deterioration (survival ~6mo)
* **Rx**
* IV albumin + splanchnic vasoconstrictors (terlipressin)
* Haemodialysis as supportive Rx
* Liver Tx is Rx of choice
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How do you manage liver failure generally and what should be monitored?
* **Management**
* Manage in ITU
* Rx underlying cause: e.g. NAC in paracetamol OD
* Good nutrition: e.g. via NGT with high carbs
* Thiamine supplements
* Prophylactic PPIs vs. stress ulcers
* **Monitoring**
* **Fluids**: urinary and central venous catheters
* **Bloods**: daily FBC, U+E, LFT, INR
* **Glucose**: 1-4hrly + 10% dextrose IV 1L/12h
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What complications can occur in patients with liver failure and how shoud they be managed?
* **Bleeding**: Vit K, platelets, FFP, blood
* **Sepsis**: tazocin (avoid gent: nephrotoxicity)
* **Ascites**: fluid and salt restrict, spiro, fruse, tap, daily weight
* **Hypoglycaemia**: regular BMs, IV glucose if \<2mM
* **Encephalopathy**: avoid sedatives, lactulose ± enemas, rifaximin
* **Seizures**: lorazepam
* **Cerebral oedema**: mannitol
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What do you need to remember when prescribing in liver failure?
* **Avoid**:
* opiates
* oral hypoglycaemics
* Na-containing IVI
* **Warfarin effects ↑**
* **Hepatotoxic drugs**:
* paracetamol
* methotrexate
* isoniazid
* salicylates
* tetracycline
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What are poor prognostic factors in liver failure?
* Grade 3/4 hepatic encephalopathy
* Age \>40yrs
* Albumin \<30g/L
* ↑INR
* Drug-induced liver failure
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What types of liver transplant are there and what are the criteria?
* **Types**
* **Cadaveric**: heart-beating or non-heart beating
* **Live**: right lobe
* **Kings College Hospital Criteria in Acute Failure**
* **Paracetamol-induced**
* pH\< 7.3 24h after ingestion
* Or all of:
* PT \> 100s
* Cr \> 300uM
* Grade 3/4 encephalopathy
* **Non-paracetamol**
* PT \> 100s
* Or 3 out of 5 of:
* Drug-induced
* Age \<10 or \>40
* \>1wk from jaundice to encephalopathy
* PT \> 50s
* BR ≥ 300uM
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What are the causes of cirrhosis?
* **Common**
* Chronic EtOH
* Chronic HCV (and HBV)
* Non-alcoholic fatty liver disease / Non-alcoholic steatohepatitis
* **Other**
* **Genetic**: Wilson’s, α1ATD, HH, CF
* **AI**: AH, PBC, PSC
* **Drugs**: Methotrexate, amiodarone, methyldopa, INH
* **Neoplasm**: HCC, mets
* **Vasc**: Budd-Chiari, RHF, constrictive pericarditis
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What are the clinical signs of cirrhosis?
* **Hands**
* Clubbing (± periostitis)
* Leuconychia (↓ albumin)
* Terry’s nails (white proximally, red distally)
* Palmer erythema
* Dupuytron’s contracture
* **Face**
* Pallor: ACD
* Xanthelasma: PBC
* Parotid enlargement (esp. c¯ EtOH)
* **Trunk**
* Spider naevi (\>5, fill from centre)
* Gynaecomastia
* Loss of 2º sexual hair
* **Abdo**
* Striae
* Hepatomegaly (may be small in late disease)
* Splenomegaly
* Dilated superficial veins (Caput medusa)
* Testicular atrophy
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What complications can occur with cirrhosis?
* **Decompensation → Hepatic Failure**
* Jaundice (conjugated)
* Encephalopathy
* Hypoalbuminaemia → oedema + ascites
* Coagulopathy → bruising
* Hypoglycaemia
* **SBP** (spontaneous bacterial peritonitis)
* **Portal Hypertension: SAVE**
* **S**plenomegaly
* **A**scites
* **V**arices
* Oesophageal varices (90% of cirrhotics)
* Caput medusa
* Worsens existing piles
* **E**ncephalopathy
* **↑ risk of HCC**
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What investigations would you order for a patient with cirrhosis?
* **Bloods**
* FBC: ↓WCC and ↓ plats indicate hypersplenism
* ↑LFTs
* ↑INR
* ↓Albumin
* **Find Cause**
* **EtOH**: ↑MCV, ↑GGT
* **NASH**: hyperlipidaemia, ↑ glucose
* **Infection**: Hep, CMV, EBV serology
* **Genetic**: Ferritin, α1AT, caeruloplasmin (↓ in Wilson’s)
* **Autoimmune**: Abs (there is lots of cross-over)
* **AIH**: SMA, SLA, LKM, ANA
* **PBC**: AMA
* **PSC**: ANCA, ANA
* **Ig**: ↑IgG – AIH, ↑IgM – PBC
* **Ca**: α-fetoprotein
* **Abdo US + PV Duplex**
* Small / large liver
* Focal lesions
* Reversed portal vein flow
* Ascites
* **Ascitic Tap + MCS**
* PMN \>250mm3 indicates SBP
* **Liver biopsy**
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How should a patient with cirrhosis be managed?
* **General**
* Good nutrition
* EtOH abstinence: baclofen helps ↓ cravings
* Colestyramine for pruritus
* Screening
* HCC: US and AFP
* Oesophageal varices: endoscopy
* **Specific**
* **HCV**: Interferon-α
* **PBC**: Ursodeoxycholic acid
* **Wilson’s**: Penicillamine
* **Complications**
* **Varices**: OGD screening + banding
* **HCC**: US + AFP every 3-6mo
* **Decompensation**
* **Ascites**: fluid and salt restrict, spiro, fruse, tap, daily wt
* **Coagulopathy**: Vit K, platelets, FFP, blood
* **Encephalopathy**: avoid sedatives, lactulose ± enemas, rifaximin
* **Sepsis / SBP**: tazocin (avoid gent: nephrotoxicity)
* **Hepatorenal syndrome**: IV albumin + terlipressin
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What grading system is used for cirrhosis?
**Child-Pugh Grading of Cirrhosis**
* Predicts risk of bleeding, mortality and need for Tx
* Graded A-C using severity of 5 factors
* **A**lbumin
* **B**ilirubin
* **C**lotting
* **D**istension: Ascites
* **E**ncephalopathy
* Score \>8 = significant risk of variceal bleeding
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