Gastroenterology Flashcards
Describe Hepatitis A
RNA virus
spread via faecal-oral or shellfish
endemic in Africa and south america
Presentation: Fever, malaise, anorexia, nausea, arthralgia, jaundice, hepatosplenomegaly, adenopathy
Rx: supportive, avoid alcohol. Rarely IFNa for life
Describe Hepatitis B, tests, and management, and complications.
DNA virus
spread: blood products, Sexual,
endemic in far east, africa and Mediterranean.
Presentation: Resemble Hep A, arthralgia and urticaria
Tests: PCR Viral Load, LFTs, HIV + Hep D (increased risk of HCC progression), Antibody screen
Management:
- Avoid alcohol. Immunise sexual contacts
- Chronic liver inflammation - PEG IFNa-2a, lamivudine, entecavir, adefovir (aim to clear HBsAG and prevent cirrhosis and HCC)
Complications: cirrhosis in 20%, HCC in 5-10%, fulminant hepatic failure, cholangiocarcinoma, cyroglobulinaemia.
Describe Hepatitis C, its management, and complications.
RNA favivirus,
spread: blood products, IVDU, Sexual, acupuncture
Presentation Early - mild/asymptomatic 85% silent chronic infection 25% cirrhosis in 20 yrs <4% HCC
Ix: LFT (AST:ALT <1:1), anti-HCV antibodies (exposure), HCV-PCR (ongoing infection/chronicity), liver biopsy
Management:
- quit alcohol
- Direct acting agents with specific regimes influences by the genotype (1, 2+3, 4+5+6)
- Protease inhibitors (doceprevir and telaprevir); PEG IFNa, Ribavarin, sofosbuvir
Complications: Cirrhosis, HCC, glomerulonephritis, cyroglobulinaemia, thyroiditis, autoimmune hepatitis, polyarteritis nodosa, polymyositis, porphyria cutanea tarda, non-Hodgkin’s lymphoma.
Describe Hepatitis D
incomplete RNA virus that needs HBV for assembly.
may cause acute liver failure/cirrhosis
Rx - liver transplant
Describe Hepatitis E
RNA virus similar to HAV common in indochina
Associated with pigs
Causes of hepatitis
Infection: Viral, CMV/EBV, Leptospirosis, malaria, Q fever, syphillis, yellow fever
Alcohol + drugs/toxins
Autoimmune hepatitis
Wilson’s.
Describe Mesenteric Ischaemia, its symptoms, and risk factors
Primarily caused by arterial embolism
Symptoms: presents with abdominal pain, diarrohoea, fever, rectal bleeding, metabolic acidosis, increased WBC
Risk factors: Atrial fibrillation, Increasing age, endocarditis, DVT, Cardiovascular disease, smoking, hypertension, diabetes
What are the inherited causes of unconjugated hyperbilirubinaemia?
Gilbert’s syndrome and Crigler-Najjar syndrome
What are the inherited causes of conjugated hyperbilirubinaemia?
Rotor’s syndrome and Dubin-Johnson syndrome
Describe Hepatocellular carcinoma and causes; Sx. Ix, Rx
Accounts for ~90% of primary liver tumours though 90% of all liver tumours are metastatic. It is common in China and Africa (40% of cancers) and 3 times more common in men
HBV is leading cause, HCV, autoimmune hepatitis, cirrhosis (alcohol, haemochromatosis, PBC), NAFLD, alfatoxin, anabolic steroids
Sx: fatigue, decreased appetite, weight loss, RUQ pain, jaundice, ascites
Ix:CT, MRI and biopsy, AFP,
Rx: Resecting solitary tumours (<3cm) Liver transplant (milan criteria for transplant is 1 nodule less than 5cm or 2-3 less than 3cm) tumour embolisation chemotherapy Percutaneous ablation
Describe Non-alcoholic fatty liver disease (NAFLD) and risk factors
Fatty liver entails steatosis +/- inflammation (steatohepatitis).
Consider if a patient presents with deranged LFT (typically raised ALT) or a fatty liver on ultrasound and drink less than 18u/wk.
It may progress to hepatic fibrosis +/- HCC.
Typically occurs in middle-aged obese females.
RF: DM, dyslipidaemia, parenteral feeding, jejuno-ileal bypass, wilson’s disease, drugs (amiodarone, methotrexate, tetracycline).
Describe Autoimmune Hepatitis; Sx, Ix and Mx
An inflammatory liver disease characterised by suppressor T-cell defects with autoantibodies against hepatocyte surface antigens. AIH predominantly affects young or middle-aged women.
Sx: acute hepatitis (fever, jaundice, RUQ pain) and signs of autoimmune disease e.g. fever, malaise, urticarial rash, polyarthritis, pleurisy, pulmonary infiltration or glomerulonephritis, amenorrhoea,
Ix: serum bilirubin, AST, ALT and ALP are usually raised, hypergammaglobulinaemia, +ve autoantibodies (e.g. Antismooth muscle antibodies, ANA).
Mx: Prednisolone or azathioprine (steroid sparing)
What are some causes of Constipation?
- General e.g. Poor diet, lack of exercise, poor fluid intake, IBS, old age, hospital environment
- Anorectal disease (especially if painful) e.g. Anal or colorectal cancer, fissures, strictures, rectal prolapse, proctaglia fugax, mucosal ulceration, pelvic muscle dysfunction
- Intestinal obstruction e.g. Colorectal carcinoma, strictures (crohn’s), pelvic mass, diverticulosis, pseudo-obstruction.
- Metabolic/endocrine e.g. Hypercalcaemia, Hypokalaemia, porphyria, lead poisoning.
- Drugs e.g. Opiates, anticholinergics, iron, diuretics, calcium channel blockers.
- Neuromuscular e.g. Spinal or pelvic nerve injury, aganglionosis, diabetic neuropathy
- Other e.g. Psychological, anorexia nervosa, depression, child abuse.
Describe Crohn’s Disease; presentation, Ix, Mx
A chronic inflammatory GI disease characterised by transmural granulomatous inflammation affecting any part of the gut from mouth to anus (especially terminal ileum). Skip lesions present.
Usually presents between 20-40yrs. Smoking increased risk and NSAIDs may exacerbate disease.
Presentation: Diarrhoea/urgency, abdominal pain, weight loss, fever, malaise, anorexia. Other signs include aphthous ulcerations, abdominal tenderness, perianal abscess/fistulae/skin tags. Clubbing, joint and eye problems also occur.
Ix
- Bloods FBC, ESR, CRP, LFT, INR, Ferritin, B12.
- Colonoscsopy + rectal biopsy.
Mx:
- Prednisolone for mild attacks/remission
- azothioprine as steroid sparing agent.
- sever attacks require IV hydrocortisone, and metronidazole.
- perianal disease: PO antibiotics, immunosuppresant therapy +/- infliximab and local surgery
Additional therapy
Conservative: elemental diets
Medical: Azathioprine, sulfasalazine, methotrexate, TNFa inhibitors (infliximab, adalimumab)
Biological: Vedolizumab (a4b7 integrin inhibitor), ustekinumab(IL23 inhibitor)
Surgical - if failure to respond to drugs, intestinal obstruction, perforation, fistulae, abscess
- small bowel: stricturoplasty/resection
- large bowel: panproctocolectomy + ileostomy/ subtotal colectomy + ileorectal anastomosis
Describe Ascending Cholangitis; symptoms and management
A bacterial infection of the biliary tree. Most common predisposing factor is gallstones.
Symptoms: Charcot triad of RUQ pain, fever and jaundice occurs in about 20-50% of patients. Fever is most common followed by RUQ and then jaundice. May also be hypotensive and/or confused.
Mx: -IV antibiotics e.g. Cefuroxime and Metronidazole
-ERCP after 24-48hrs to relieve any obstruction
Describe Hereditary Haemorrhagic Telangiectasia and its symptoms.
Also known as Osler-Weber-Rendu disease, it’s a rare autosomal dominant disorder that affects blood vessels and results in a tendency for bleeding.
Symptoms: Telangiectasia, Epistaxis, visceral lesions, strong family history. GI bleeds, Arteriovenous malformations.
Describe Peutz-Jeghers syndrome
Autosomal Dominant disorder
Geraldine mutations of tumour suppressor gene STK11
cause mucocutaneous dark freckles on lips, oral mucosa, palms and soles, + multiple GI polyps (hamartomas), causing obstruction, intussception, or bleeds.
15-fold increase risk of developing GI cancer
Perform colonoscopy (from age 18) and OGD (from age 25) every 3yrs
Describe Bowel Obstructions; Symptoms and management
Types:
- Small Bowel Obstruction: Vomiting present earlier, distension is less, and pain is higher in the abdomen. AXR shows central gas shadows with valvulae conniventes that completely cross the lumen and no gas in the large bowel.
- Large Bowel Obstruction: Pain is more constant, more distension. AXR shows dilated large bowel with Haustra peripherally arranged.
Symptoms: Vomiting, Colicky pain, constipation, distension,
Mx: -Drip and Suck, NGT and IV fluids
- Consider CT to look for cause of obstruction
- if strangulated emergency surgery is needed.
Describe Diverticular Disease; symptoms. complications, management
Outpouching of gut wall, which may become inflamed. They can be congenital or more commonly acquired through age
Symptoms: There may be later altered bowel habit plus left-sided colic relieved by defecation. Nausea and flatulence. Diarrhoea may occur if inflamed.
Complications
- perforation
- haemorrhage usual cause of big rectal bleeds
- fistulae
- abscess
Mx referral for colonoscopy to exclude bowel cancer -high fibre diet -mebeverine (anti-spasmodic) -Abx if fever and diarrhoea
chronic pancreatitis -causes, symptoms, investigations, management, complications
Causes:Alcohol mostly Gallstones Rarely: - familial - CF, haemochromatosis, - Pancreatic duct obstruction - Hyperparathyroidism - Congenital.
Epigastric pain ‘bores’ through to back, relieved by sitting forward or hot water bottles on epigastrium, also bloating, steatorrhoea, weight loss, brittle diabetes.
Erythema ab igne
Ix: US +/- CT looking for pancreatic calcification. MRCP + ERCP AXR Signs of pancreatic insuff: - Increase glucose (brittle diabete) - Low faecal elastase - do breath tests
Mx:Conservative: diet - no alcohol,low fat, medium chain triglycerides
Medical: Analgesia, lipase (e.g. creon), fat soluble vitamins, insulin
Surgery: - for unremitting pain, narcotic abuse, weight loss Pancreatectomy or pancreaticojejunostomy
Complications
Pseudocysts, diabetes, biliary obstruction, local arterial aneurysms, splenic vein thrombosis, gastric varices, pancreatic carcinoma
Describe Zollinger-Ellison Syndrome; symptoms, Ix, Mx
Gastrin-secreting tumour, which cause multiple refractory and recurrent peptic ulcers. Can present as MEN1 Autosomal dominant disorder
Symptoms: Epigastric pain, diarrhoea, weight loss, GI bleeding. Treatment resistant dyspepsia.
Ix -FBC: IDA, Ferritin may be low Parathyroid hyperplasia is a common feature of MEN1, Calcium may be elevated. H.Pylori testing, endoscopy if severe or red-flags fasting Gastrin levels prolactin levels CT for staging
Mx: -ABCDE approach if GI bleeding.
- Oral PPIs
- Surgical resection of primary tumour.
Describe Irritable Bowel Syndrome; Sx, red flags, Mx
A group of abdominal symptoms for which no organic cause can be found. Most are likely due to disorders of interstitial motility or enhanced visceral perception. Faecal calprotectin can exclude IBD.
Sx: Abdominal pain relieved by defecation or associated with altered stool form and at least 2 of urgency, incomplete evacuation, abdominal bloating, worsening symptoms after food. Symptoms are chronic and exacerbated by stress, menstruation.
Red Flags: age over 40yrs, history less than 6 months, anorexia, weight loss, waking at night with pain/diarrhoea, mouth ulcers, abnormal CRP, ESR, Hb, coeliac serology. Investigate PR bleeding urgently.
Mx: -Ensure healthy diet
- Fibre, lactose, fructose, wheat, starch, caffeine, sorbitol, alcohol, fizzy drinks can worsen symptoms try modifying diet to balance symptoms.
- anti-spasmodic S e.g. Mebeverine may help
- Psychological wellbeing +/- CBT amitryptilline can help.
What is acute cholecystitis; symptoms, Mx
Follows stone or sludge impaction in the neck of the gallbladder.
Symptoms: Colicky pain but more severe and persistent, it may radiate to the back or right shoulder. Patient may be pyrexial and Murphy’s sign positive I.e. Arrest of inspiration on palpation of RUQ.
Mx: -NBM, pain relief, Cefuroxime.
-laparoscopic cholecystectomy is treatment of choice for all patients fit for GA.
Causes of acute pancreatitis; symptoms, management
Cause: GET SMASHED, Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion venom, Hypertriglyceridaemia + Hypercalcemia + Hypothermia, ERCP, Drugs e.g. Azothioprine, mesalazine, Bendroflumethiazide, steroids, sodium valproate.
Sx: Severe epigastric pain or central abdominal radiating to back, sitting forward may relieve, vomiting, low-grade fever, abdominal tenderness, ileus, peri umbilical discolouration (Cullen’s sign) and flank discolouration (grey-turners signs).
Mx: -serum amylase/lipase, CRP
- assess using Glasgow, Ranson scoring systems.
- NBM, plenty of saline.
- hourly pulse, BP, UO, daily FBC U+E Ca glucose, amylase, ABG.
