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Finals Bible: Medicine > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Acute causes of diarrhoea?

A

Gastroenteritis

Diverticulitis = LLQ and fever

Antibiotic therapy

Constipation causing overflow = Hx of alternating diarrhoea and constipation

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2
Q

Chronic causes of diarrhoea?

A

IBS = Abdo pain, bloating and change in bowel habit

UC = Bloody diarrhoea and crampy abdominal pain

Crohns = Cramby abdo pain + malabsorption, obstruction, mouth ulcers and perianal disease

Coeliacs

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3
Q

Staph aureus gastroenteritis typical Hx, incubation and management ?

A

Meat and eggs, no fever / abdo pain.
Severe vomiting

1-6 hours

Self limiting

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4
Q

B. Cereus gastroenteritis typical Hx, incubation and management ?

A

Rice.
vomiting or diarrhoea

6-12 hours

Self limiting

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5
Q

Salmonella gastroenteritis typical Hx, incubation and management ?

A

Source = pets or food
Nausea, fever and vomiting

12-48 hours

self-limiting, if persists = ciprofloxacin

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6
Q

E. Coli gastroenteritis typical Hx, incubation and management ?

A 
Travellers diarrhoea
Contaminated food
Watery stools and abdominal cramps
No fever
HUS....

12-48 hours

Avoid antibiotics

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7
Q

Listeria gastroenteritis typical Hx, incubation and management ?

A

Refrigerated food
Fever, watery diarrhoea and cramps

12-48 hours

Ampicillin

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8
Q

Shigella gastroenteritis typical Hx, incubation and management ?

A

Children at nursery
Water diarrhoea progressing to bloody mucoid diarrhoea
Vomiting and abdo pain

2-3 days

Avoid antibiotics, ciprofloxacin if needed

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9
Q

Campylobacter gastroenteritis typical Hx, incubation and management ?

A

Meat and dairy
Flu like prodrome, followed by severe abdominal pain and fever

2-3 days

Self limiting
Only treat if immunocompromised = Macrolide e.g. erythromycin
Complication = GBS

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10
Q

V. Cholera gastroenteritis typical Hx, incubation and management ?

A

Water and food with human faeces e.g. shell fish
Rice water stool

1 week

treat the fluid losses

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11
Q

Giardiasis gastroenteritis typical Hx, incubation and management ?

A

Endemic area travel = Eastern Europe, Africa and Asia
Prolonged non-bloody diarrhoea
Steatorrhoea
Flatulence and cramps, no fever

1 week

Metronidazole

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12
Q

Amoebiasis gastroenteritis typical Hx, incubation and management ?

A

Flask shaped ulcer
Gradual onset bloody diarrhoea and abdo pain. Can last weeks

1 week

Metronidazole and Paromomycin in luminal disease

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13
Q

Associated antibiotics with C. Diff diarrhoea?

A

Cephalosporins
Cipro
Clindamycin

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14
Q

Clinical features of C. Diff diarrhoea?

A

Mild diarrhoea

Pseudomembranous colitis
= severe systemic features, abdo pain and bloody diarrhoea

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15
Q

Management of C. Diff diarrhoea?

A

Stop causative antibiotics and fluids

Metronidazole 400mg TDS PO for 2 weeks

2nd line = Vancomycin 125mg QDS PO

If severe = vancomycin first then add metronidazole

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16
Q

What bowel histology do you see in laxative abuse?

A

Melanosis coli

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17
Q

What is IBS?

A

Chronic condition characterised by abdominal pain associated with bowel dysfunction, but no organic cause identified

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18
Q

Clinical features of IBS?

A

Abdo pain and bloating
Combo of diarrhoea and constipation
Worse on eating, relieved by defecation

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19
Q

What are the ROME criteria for IBS?

A

Abdo discomfort for >12 weeks, which has 2 of:

Relieved by defecation
Change in stool frequency
Change in stool form

Plus two of:

Urgency
Incomplete evacuation
Abdo bloating / distension
Mucous PR
Worsening symptoms after food
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20
Q

ROME exclusion criteria for IBS?

A 
>40
bloody stool
Anorexia
Weight loss
Diarrhoea at night
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21
Q

Management of IBS?

A

Exclude other diagnosis with investigations

Conservative = reassure and educate
Eliminate any triggers e.g. caffeine. Increase fibre
CBT

Medical:

Diarrhoea dominant = Loperamide 4mg PO OD

Constipation dominant = Lactulose

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22
Q

what is coeliacs?

Genetic associations

A

Genetic autoimmune condition caused by sensitivity to the protein gluten = immune activation in the small intestine

HLA- DQ2 and DQ8

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23
Q

What associated conditions also need screening for coeliacs?

A 
Autoimmune thyroid
Dermatitis herpetiformis
IBS
T1DM
1st degree relative with coeliacs
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24
Q

Clinical features of coeliacs?

A

GLIAD

G – GI = malabsorption:
Carbs - weight loss, fatigue and distension
fat = steatorrhoea
haematinics - anaemic
vitamins - osteoporosis, B2 = angular stomatitis

L – Lymphoma enteropathy T-cell associated

I – Immune
IgA deficiency
T1DM

A – Anaemia

D - Derm = dermatitis herpetiformis = very itchy vesicles on extensor surface

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25
Q

Investigations for coeliacs?

A

Bloods - FBC, LFT’s, INR (don’t absorb Vit k), bone profile

Antibodies 1st line = anti-TTG (but low with exclusion diet or IgA deficiency)

Jejunal biopsy = sub-villous atrophy, crypt hyperplasia and intra-epithelial lymphocytes

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26
Q

Management of coeliacs?

A

Lifelong gluten avoidance
Ok = maize, corn and rice

Pneumovax as hyposplenism
Dermatitis herpetiformis = dapsone

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27
Q

Macroscopic features of UC?

A

Rectum to ileocaecal valve
Continuous
No strictures or fistulas

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28
Q

Macroscopic features of Crohns?

A

Mouth to anus, patchy

Strictures and fistulas

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29
Q

Microscopic features of UC?

A

Mucosal inflammation, not beyond the submucosa

Crypt abscesses

Broad shallow ulcers + pseudo-polyps

NO fibrosis

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30
Q

Microscopic features of Crohn’s?

A

Transmural = all layers

Goblet cells and granulomas

Deep and thin cobblestone ulcers

FIBROSIS

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31
Q

UC clinical features?

A

30’s, smoking protects

Diarrhoea with blood + mucous
LLQ pain
Anal symptoms = Tenesmus and faecal urgency

Extra-abdominal:

PSC + cholangiocarcinoma
Uveitis
Pyoderma gangrenosum

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32
Q

Crohns clinical features?

A

20’s, smoking increases risk

Non-bloody diarrhoea (commonest PC in adults)
Abdominal pain (commonest PC in kids)
RIF mass and obstruction

Extra-abdominal:

Mouth = apthous ulcers
Gallstones and renal stones
Perianal disease
Episcleritis

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33
Q

Complications of UC?

A

Toxic megacolon = >6cm
Bleeding
Malignancy = cholangiocarcinoma and colorectal

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34
Q

Complications of Crohns?

A

Fistula
Strictures = obstruction
Abscesses

Malabsortpion = Steatorrhoea, B12 - megaloblastic anaemia

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35
Q

Investigations in IBD?

A

FBC - anaemia, malabsorption = B12 and folate down

AXR = toxic megacolon

Stool microscopy to rule out infective causes

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36
Q

Crohns specific investigations?

A 
CROHNS:
Small bowel enema:
- Skip lesions
Strictures = Kantors string sign 
Proximal bowel dilation
Fistulae
Rose thorn ulcers and cobblestoning
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37
Q

UC specific investigations?

A

Barium enema:

Loss of haustrations
Superficial ulceration = pseudo polyps
Drainpipe colon

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38
Q

Truelove and Witts criteria for UC?

A

Mild = <4 stools ± blood. No systemic features

moderate = 4-6 stools with mild systemic disturbances

Severe = >6 stools, with blood. Systemic disturbance

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39
Q

Management of severe acute flair up of UC?

A

Admit
ABC
IV hydration and NBM

Medical:
IV hydrocortisone 100mg 6-hourly
If refractory = no response within 3 days = Ciclosporin IV

Still refractory = surgery

If improvement = switch to oral prednisolone

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40
Q

Inducing remission in UC?

A

For distal colitis = rectal mesalazine

1st line = Oral mesalazine

2nd line if refractory to mesalazine for 4 weeks = Oral prednisolone

3rd line if refractory to steroids for 4 weeks = Tacrolimus PO

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41
Q

Maintaining remission in UC?

A

Distal colitis = daily topical mesalazine ± oral mesalazine

1st line = mesalazine maintenance dose

2nd line:
if > 2 exacerbations in 1 year requiring steroids / mesalazine doesn’t maintain remission =
Azathioprine or mercaptopurine

3rd line = infliximab / adalimumab

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42
Q

Surgery in UC;

Emergency indications

Elective surgery indications

Surgery types

A

Emergency indications?

  • Toxic megacolon
  • Perforation
  • Massive haemorrhage

Elective indications?

  • Refractory to medical treatment
  • Malignancy

Surgeries:

SUBTOTAL COLECTOMY: (leaving the rectum) –> end ileostomy ± mucus pouch

Can later on carry out proctectomy removing the rectum and forming and ileo-anal pouch. Will leave a defunctioning loop ileostomy to allow anastomoses to heal

Will then do a third operation to heal the loop ileostomy

PANPROCTOCOLECTOMY:
Take out whole colon, rectum and anus. Permanent end ileostomy

rarely = Total colectomy leaving rectum and forming ileoanal anastomoses

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43
Q

Crohns acute attack management?

A

Admit, ABC, NBM and IV fluids

IV hydrocortisone and metronidazole
Refractory = methotrexate

Improvement = switch to oral prednisolone 40mg PO OD and taper

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44
Q

Inducing remission in Crohns?

A

STOP SMOKING
Medical:
1st line = prednisolone monotherapy

2nd line = sulfasalazine

3rd line = Mercatopurine / azathioprine - ADD ONS NOT MONOTHERAPY
If can’t tolerate consider methotrexate

4th line = Infliximab / adalimumab

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45
Q

Crohns maintaining remission?

A

STOP SMOKING

1st line = azathioprine / mercaptopurine as MONOTHERAPY

Consider methotrexate if it was needed for induction.

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46
Q

Surgery in Crohns:

Emergency and elective indications?

Procedures?

A

Emergency = obstruction, perforation or massive haemorrhage

Elective = refractory to medicine or malignancy
Abscess
Fistula

Options:

Limited resection
Stricturoplasty

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47
Q

Causes of constipation?

A

POINTED

Pain e.g. anal fissure

Obstruction:
Mechanical = Adhesions, strictures, hernia, malignancy
Pseudo-obstruction = post-op ileum

IBS

Neuro = MS, cauda equina

Toxins = opioids

Endocrine = hypothyroid, low calcium

Diet / dehydrated

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48
Q

Management of constipation - conservative?

A

Drink more and increase dietary fibre
Increase exercise and activity
Treat cause

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49
Q

Medical management of constipation?

A

1st line = bulk forming laxative e.g. isphagula. Must drink lots of fluids

2nd line = add osmotic laxative e.g. macrogol

If soft stool but difficult to pass add a stimulant laxative

Gradually reduce and stop laxatives until soft stool with no straining at least 3 times a week

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50
Q

Management of faecal loading / impaction?

A

If hard = high dose macrogol

Soft = Few days macrogol then stimulant

Poor response = suppository or enema

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51
Q

Causes of dysphagia?

A

Inflammatory = tonsillitis, GORD, oral candidiasis

Mechanical:
LUMINAL = food bolus
MURAL = Benign stricture e.g. Plummer vinson, malignant strictures and pharyngeal pouch
EXTRA-MURAL:
Lung cancer
Goitre
Aortic aneurysm

Motility disorders:
Achalasia
Systemic sclerosis
MND

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52
Q

Dysphagia + weight loss, anorexia and vomiting during eating.

PMHx of barrets / GORD / excess smoking and drinking

A

Oesophageal cancer

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53
Q

dysphagia + Hx of heartburn, odynophagia but no weight loss / systemic

A

GORD

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54
Q

Dysphagia + History of HIV / steroid use

A

Candidiasis

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55
Q

Dysphagia of both liquids and solids from the start.

Increased lower oesophageal sphincter pressure

A

Achalasia

Also get bird beak on barium swallow

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56
Q

Dysphagia in older man, midline lump that gurgles on palpation

A

Pharyngeal pouch

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57
Q

Dysphagia with telangiectasia and fat fingers?

A

CREST

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58
Q

Intermittent dysphagia ± chest pain.

Barium swallow = corkscrew

A

Diffuse oesophageal spasm

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59
Q

Dysphagia with solids > liquids at the start

A

Stricture

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60
Q

Dysphagia with iron deficiency anaemia and glossitis

A

Plummer vinson

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61
Q

What is achalasia?

A

Failure of both oesophageal peristalsis and relaxation of lower oesophageal sphincter due to degeneration of auerbachs plexus = LOS contracted = oesophagus dilates due to food backlog

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62
Q

Investigations in achalasia?

A

Manometry = increased LOS tone

Barium swallow = grossly expanded oesophagus, fluid level and birds beak

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63
Q

Management of achalasia?

A

intra-sphincteric injection of botulinum

Heller cardiomyotomy = laparoscopic procedure where oesophageal muscle is cut out, inner lining left intact

Balloon dilation

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64
Q

What is a pharyngeal pouch?

A

Outpouching of oesophagus between the upper border of cricopharynxgeus muscle and lower border of inferior constrictor of pharynx = Killians dehiscence

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65
Q

Management of pharyngeal pouch?

A

Surgical excision and endoscopic stapling

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66
Q

What is a peptic ulcer?

A

A break in the mucosal lining of the stomach / duodenum >5mm in diameter with depth to submucosa

Smaller than 5mm = erosion

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67
Q

Causes of peptic ulcers?

A 
Dudodenal = H. Pylori
Stomach = NSAID use

Rarer causes = Zollinger Ellison = gastric acid secretion due to a gastrin secreting neuroendocrine tumour

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68
Q

Clinical features of gastric vs duodenal ulcer?

A

Gastric = pain worse on eating, relieved by antacids. Weight loss

Duodenal = pain is before meals and at night. Relived by eating / milk

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69
Q

Complications of peptic ulcer disease?

A

Upper GI bleed = Haematemesis of malaena.
Ulcer erodes through gasproduodenal vessel

Perforation = erosion through wall into peritoneal cavity.
Generally in elderly taking NSAIDS.
Shock and peritonitis

Gastric outflow obstruction = due to pyloric stenosis after ulcer healing with scarring.

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70
Q

Management of peptic ulcer disease?

A

Conservative = stop causative drugs, smoking and drinking. lose weight

Medical:
If H.Pylori - eradication

No H Pylori = 20mg omeprazole PO BD for 2 months

2nd line = ranitidine 300mg

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71
Q

What is GORD?

A

Symptoms or complications secondary to reflux of the gastric contents into the oesophagus

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72
Q

RF’s for GORD?

A 
Smoking, alcohol
Obesity
Hiatus hernia
Hellers cardiomyotomy
Pregnancy
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73
Q

Complications of GORD?

A

Ulcers

Benign stricture

Barrett’s oesophagus = intestinal metaplasia of squamous epithelium.
Metaplasia to dysplasia to adenocarcinoma in power 3rd of the oesophagus

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74
Q

GORD management?

A

Conservative = lose weight, stop smoking and drinking

Medical:
Full dose PPI for 2 months = omeprazole 20mg PO OD

2nd line = double dose BD

3rd line = ranitidine

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75
Q

Surgical options for GORD?

A

Nissen fundoplication:

Indications = severe symptoms refractory

Laparoscopic

Mobilise the gastric fungus, wrap it around the lower oesophagus. Whilst closing any diaphragmatic hernias

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76
Q

What is a hiatus hernia and the types?

A

Herniation of part of the stomach through the diaphragm

Sliding = 95% = GOJ moves above the diaphragm

Rolling = 5% = GOJ remains below the diaphragm but a separate part of the stomach herniates through the oesophageal hiatus

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77
Q

Investigations and management of hiatus hernia?

A

CXR = gas bubble and fluid level
Barium swallow = diagnostic

Lose weight, manage the GORD

If refractory = repair the hernia

Repair rolling hernia even if asymptomatic as risk of strangulation

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78
Q

Differentials of haematemesis?

A

OESOPHAGEAL:

Varices
Oesophagitis
Mallory-Weiss
Boerhaaves
Malignancy

GASTRIC:
PUD
Dieulafoys lesions
Gastric tumours

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79
Q

Large fresh haematemesis, chronic liver disease / alcoholic

A

Varices

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80
Q

What causes varices?

A

Portal HTN causes dilated veins at site of porto-systemic anastomoses - often the left gastric and inferior oesophageal

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81
Q

Portal HTN causes?

A

Pre-hepatic = portal vein thrombosis

Hepatic = Cirrhosis and schistosomiasis

Post-hepatic = budd chiari

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82
Q

Small amount of fresh blood, sometimes streaks vomit. Heartburn. No other features

A

Oesophagitis

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83
Q

Haematemesis following vomiting, small amount of blood

A

Mallory-Weiss tear

Mucosal tear, often ceases spontaneously

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84
Q

Large haematemesis following vomiting

A

Boerhaave’s

Full mucosal tear
2cm proximal to LOS

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85
Q

Small amount of blood with dysphagia, weight loss

A

Malignancy

86
Q

Investigations for haematemesis?

A

Admit, X-match blood and clotting

All need OGD within 24 hours

Blatchford score at first assessment

Rockall score after endoscopy for risk of re-bleeding

87
Q

What criteria are in the blatchford score?

A

Urea, Hb, systolic BP and others

Score of 0 = early discharge

88
Q

Management of varices?

A

ACUTELY:

Terlipressin and prophylactic antibiotics

2nd line = banded ligation if oesophageal.
Glue (N-butyl-2-cyanoacrylate) for gastric

3rd line:
Sengstaken-Blakemore tube
If still cannot stop bleeding insert trans jugular intrahepatic portosystemic shunt TIPS
= artificial channel between hepatic and portal vein = reduced portal pressure

PROPHYLAXIS = propranolol and band ligation

89
Q

Management of non-variceal bleed?

A

Inject adrenaline to bleeding points and thermal coagulation / mechanical clips

90
Q

What is jaundice?

A

Accumulation of bilirubin in the bloodstream and subsequent deposition in the skin, sclera and mucous membranes

91
Q

What is the mechanism of bilirubin production?

A

Made in reticuloendothelial cells, released and travel in the blood to liver, bound by albumin

Enter hepatocytes and conjugated by glucoronyl transferase

Conjugated bilirubin is the secreted in the bile = urobilinogen

  • some reabsorbed by liver
  • some excreted in urine
  • Some stays in GIT = stercobilinogen = brown stool
92
Q

Causes of jaundice?

A

PREHEPATIC:
Gilberts
Haemolysis e.g. haemolytic anaemias and anitmalarials

HEPATIC:
Unconjugated = Hypothyroid, gilberts, Crigler-Najjar

Conjugated = Viral/alcoholic hepatitis, NAFLD, cirrhosis, Wilsons

POST-HEPATIC:
Gallstones and pancreatic cancer.
+ PBC, PSC, cholangiocarcinoma

93
Q

Jaundice + episode of colicky pain, obstructive picture

A

Gallstones

94
Q

Obstructive jaundice + RUQ pain, fever

A

Ascending cholangitis

95
Q

FHx of jaundice, worse with fasting. Unconjugated

96
Q

Jaundice with alcohol abuse. AST and ALT high

A

Alcoholic hepatitis

97
Q

Jaundice + fevers, chills and splenomegaly

A

Haemolytic anaemias

98
Q

Pre-hepatic jaundice biochem?

A

Unconjugated bili, urobilinogen and normal enzymes

99
Q

Heaptic jaundice biochem?

A

Unconjugated / conjugated and urobilinogen present

AST:ALT > 2 = alcohol
AST:ALT < 1 = viral

100
Q

Post hepatic jaundice biochem?

A

Conjugated bilirubin very high with no urobilinogen

ALP very high

101
Q

How does alcohol affect the liver?

GI affects?

A

Fatty liver = hepatitis = cirrhosis

PUD
Varices
Pancreatitis

102
Q

What is the triad of Wernicke’s encephalopathy, and what features emerge in Korsakoff’s?

A

Confusion, ophthalmoplegia and ataxia

Korsakoffs = Amnesia and confabulation

103
Q

Features of alcohol withdrawal?

Management?

A

6-12 hours = tremors, sweating, tachycardia and anxiety

36 hours = seizures

48-72 hours = delirium tremens:
Coarse tremor, confusion, delusions, auditory hallucinations

Mx = Chlordiazepoxide

104
Q

Management of alcoholism?

A

Conservative = group therapy

Medical:

Baclofen reduces cravings
Acamprosate reduces cravings
Disulfiram = aversion therapy

105
Q

What is alcoholic hepatitis?

A

Follow on from fatty liver disease. Chronic alcohol use causes deficiency in anti-oxidants so oxidative stress causes hepatic necrosis and apoptosis

106
Q

Clinical features of alcoholic hepatitis?

A

Alcohol Hx
Abdominal pain
Weight loss and malnutrition
Severe = jaundice, hepatomegaly

107
Q

AST:ALT >2?

A

Alcoholic hepatitis

Also raised GGT, microcytic anaemia

108
Q

Management of alcoholic hepatitis?

A

Conservative = alcohol abstinence and withdrawal advice

Medical:
Multivitamins and pabrinex
Immunisations = Influenza and one off pneumovax

Manage failures

109
Q

What is NAFLD?

A

It is a spectrum of disease.

Steatosis = fatty liver
Steaohepatitis = Fat with inflammation (NASH)
Progressive disease = fibrosis and liver cirrhosis

110
Q

Investigations for NAFLD?

A

BMI and glucose - often see insulin resistance in metabolic syndrome
LFT’s

Enhanced liver fibrosis (ELF) = If find NAFLD do this test for advanced fibrosis

111
Q

Management of NAFLD?

A

Lose weight, dietary modifications

Control co-morbdities

112
Q

What is hepatitis A?

A

RNA virus, not associated with chronic liver disease. Self limiting

113
Q

Hep A transmission?

A

Faceo-oral

114
Q

Ig picture in Hep A?

A

Acutely IgM peaks, with rise in ALT

post infection = IgG

115
Q

When should you get a Hep A vaccine?

A 
Travelling to endemic area
Chronic liver disease
Haemophillia
MSM
IVDU's
116
Q

How is hepatitis B spread?

A

Exposure to blood / fluids

Can also get vertical transmission

117
Q

Serology of hepatitis B?

A

Hep B surface antigen appears first causing anti-HBs production
If HBsAg = acute infection

Anti-HBs = immunity or exposure. Negative in chronic disease

Anti-HBc means previous or current infection. At about 30 weeks it divides into IgM and IgG.
IgM is only there for the acute phase (6 months) , IgG persists

HBeAg is from breakdown of core antigen = marker of infectivity

118
Q

Hep C transmission?

A

Blood and fluids.

Vertical too

119
Q

Complications of Hep B?

A

10% get chronic
5% get cirrhosis
Hepatocellular carcinoma

120
Q

Immunisation for Hep B?

A

Contains HBsAg in three doses

Anti-HBs levels:
>100 = adequate responder

10-100 = suboptimal, need one more vaccine

<10 = non-responder. Check for past/current infection and repeat course

121
Q

PEP for Hep B?

A

If known responder to HB vaccine give a booster

Non-responder needs HBIG and vaccine course

In process of being vaccinated = accelerated course and HBIG

122
Q

Management of Hep B?

A

Pegylated IFN alpha

123
Q

Complications of Hep C?

A

60-80% get chronic hepatitis = persistence of HCV-RNA > 6 months

HCC

124
Q

Management of Hep C?

A

Combination of protease inhbitors = Daclatasvir + sofosbuvir ± ribavirin

125
Q

PEP for Hep C?

A

Monthly PCR.

If seroconversion = IFN ± ribavirin

126
Q

Hep D transmission?

A

Bodily fluids

127
Q

Classification of Hep D?

A

Co-infection = Hep B and D at the same time

Super-infection = HBsAg positive patient, who then develops Hep D
High risk of fulminant hepatitis

128
Q

What is autoimmune hepatitis?

A

Chronic inflammatory liver disease with unknown aetiology

Characterised by presence of circulating auto-Ab’s

129
Q

Who is commonly affected by AI hepatitis?

A

Young females

130
Q

Types of AI hepatitis?

A

Type 1 = ANA/SMA, children and adults

Type 2 = LKM1, children

Type 3 = soluble liver-kidney antigen, adults in middle age

131
Q

Clinical features of AI hepatitis?

A

Acute hepatitis
Ammenorrhoea is common
Associated AI diseases

132
Q

Classic liver biopsy finding in AI hepatitis?

A

Inflammation extending beyond limiting plates = piecemeal necrosis

133
Q

Management of AI hepatitis?

A

Prednisolone 40mg. PO OD

2nd line = azathioprine

134
Q

Definition of cirrhosis?

A

Inflammatory condition which must involve the whole liver.

Must be presence of fibrosis, nodules of regenerating hepatocytes and contain distorted vasculature of the liver

135
Q

Causes of cirrhosis?

A

Chronic Hep B and C
Alcohol
NAFLD

136
Q

Clinical features of chronic stable liver disease?

A

Multiple spider naevi
Dupuytrens
Palmar erythema
Gynaecomastia

137
Q

Clinical features of decompensated liver failure?

A

Jaundice
Encephalopathy
Hypoalbumin = oedema and ascites
Coagulopathy = bruising

138
Q

Features of portal HTN?

A

SAVE

Splenomegaly
Ascites
Varices:
- 90% oesophageal = haematemesis
- Caput medusa
Encephalopathy
139
Q

What is the Child-Pugh-Turcotte score?

A

Determines the severity of cirrhosis

Uses - Bilirubin, albumin, PT, encephalopathy and ascites

A = score<7, well compensated

B = 7-9 = significant functional compromise

C = >9 = decompensated

140
Q

Investigations in cirrhosis?

A

Bloods = LFT’s albumin and PT

Find cause = serology, macrocytic anaemia for alcohol, BMI and glucose for NAFLD

Offer transient elastography screen for cirrhosis to:

  • People with Hep C
  • men who drink >50units a week, women > 35
  • People diagnosed with alcohol related liver disease

If newly diagnosed cirrhosis = OGD for varices

141
Q

Follow up for cirrhosis?

A

Twice yearly USS for HCC

142
Q

What is portal HTN?

A

HTN in the portal system, drains from the intestines to the liver

143
Q

Causes of portal HTN?

A

Pre-hepatic:
Portal vein thrombosis e.g. pancreatitis

Hepatic:
Cirrhosis and schistosomiasis

Post-hepatic:
Budd-Chiari, RHF, tricuspid regurgitation.

144
Q

Why do you get ascites in portal HTN?

A

Back pressure = fluid exudation

145
Q

What is the SAAG?

A

Serum ascite albumin gradient

> 1.1 = portal HTN

<1.1 = Malignancy, nephrotic syndrome, TB peritonitis

146
Q

Management of ascites?

A

Daily weight reduction <0.5kg

Fluid restrict and low sodium diet
Spironolactone and furosemide if refractory

If do a therapeutic paracentesis = Albumin infusion 100ml 20% albumin / litre drained

147
Q

What is SBP?

A

Peritonitis seen secondary to ascites due to liver cirrhosis

148
Q

Common organism for SBP?

A

E. coli, klebsiella and strep

149
Q

Investigations for SBP?

A

Paracentesis = neutrophil count > 250cells / uL

150
Q

Management of SBP?

A

IV cefotaxime

Prophylaxis oral cipro if:
Previous SBP
Fluid protein >15g/L or Child-Pugh Score >9
Hepatorenal syndrome

151
Q

What is encephalopathy?

A

Due to hepatic metabolic dysfunction = toxin build up systemically = ammonia builds up in brain and astrocytes clear it producing glutamate

Glutamate increase = cerebral oedema

152
Q

Classification of encephalopathy?

A 
1 = Irritability
2 = Confusion and disinhibited
3 = Incoherent and restless
4 = Coma
153
Q

Clinical features of encephalopathy?

A

Confusion
Asterixes
Constructional apraxia = can’t draw 5-pointed star
EED = triphasic slow waves

154
Q

Management of encephalopathy?

A

Treat cause

Lactulose = increased ammonia secretion from gut + rifamixin = modulate gut flora producing ammonia

155
Q

What is liver failure?

A

The inability of the liver to perform its synthetic and metabolic function

Chronic - cirrhosis

Acute = Infection e.g. hepatitis, Toxins e.g. alcohol or paracetamol, Budd Chiari and Wilsons

156
Q

What is hepatorenal syndrome?

A

Development of acute renal failure In patients with severe liver disease

Cirrhosis = splanchial artery dilation = RAS activation = Renal artery vasoconstriction

157
Q

Type of hepatorenal syndrome?

A

Type 1 = rapid deterioration, survival 2 weeks. Creatine doubles or >221

Type 2 = 6-month survival

158
Q

Management of hepatorenal syndrome?

A

IV terlipressin and albumin

Liver transplant

159
Q

Is liver cancer usually primary or metastatic?

A

95% = metastatic

Most common primary = HCC and cholangiocarcinoma

160
Q

RF’s for HCC?

A

Cirrhosis or Hep B

161
Q

Management of HCC?

A

Surgical resection. Often opt for whole resection and transplantation as livers are cirrhotic and high risk

Not chemo / radio sensitive

162
Q

Where do cholangiocarcinomas occur?

A

Bile ducts

80% extra hepatic

163
Q

Main RF for cholangiocarcinoma?

Investigations?

A

PSC

LFT’s obstructive picture
CT/MRI

164
Q

Management of cholangiocarcinoma?

A

Resection

Peri-hilar tumours are problematic and coupled with lobar atrophy = no surgery

Can palliate the jaundice, but avoid metal stents if planning resection

165
Q

Types of liver transplant?

Indications?

A

Cadaveric

Live - donating a lobe

Cirrhosis and HCC

166
Q

Contraindications to liver transplant?

A

Extra-hepatic malignancy
Systemic sepsis
HIV
Non-compliance with drug therapy

167
Q

What is hereditary haemochromatosis?

A

Autosomal recessive disorder of iron metabolism and absorption = iron accumulation

Reduced duodenal absorption due to low hepcidin
Low hepcidin causes macrophages to release iron

168
Q

Clinical features of heamochromatosis?

A

Non specific - fatigue, erectile dysfunction and arthralgia

Skin pigmentation = bronzing of the skin

Liver disease

Diabetes

169
Q

Investigations of haemochromatosis?

A

Bloods = Iron and ferritin raised
TIBC low
Transferrin sats > 45%

Liver biopsy = Perls stain = raised iron content

glucose

170
Q

Management of haemochromatosis?

A

Transferrin saturation should be below 50%, and serum ferritin below 50ug/L

Conservative = Hep A and B vaccines
Vit C supplementation
Avoid alcohol

Medical if symptomatic:
Venesection = stimulates more blood production with iron stores
2nd line = desferrioxamine IV

171
Q

What is A1AT deficiency?

A

Inherited condition caused by a lack of protease inhibitor from the liver which usually protects cells from enzymes = damage to liver and lungs

172
Q

Clinical features of A1AT deficiency?

A

Lung = productive cough, SOB, smoker
- LOWER LOBE pan-acinar emphysema

Liver = cirrhosis and HCC

173
Q

Investigations and management in A1AT deficiency?

A

A1AT levels low. CXR = basal emphysema.
LFT’s

Mx:
Stop smoking, Hep A/B vaccines
Medical:
standard COPD patient, IV A1AT

174
Q

What is Wilsons disease?

A

Autosomal receive disorder characterised by excessive copper deposition in tissue

175
Q

Clinical features of Wilsons?

A

Liver = cirrhosis

Neuro = basal ganglia degeneration = speech / behavioural problems

Kaiser Fleischer rings

176
Q

Investigations for Wilsons?

A

Bloods = copper and caeruloplasmin low

(caeruloplasmin is an acute phase protein so may be high during infection)

Increased urinary 24 hour excretion

177
Q

Management of Wilsons?

A

Conservative = avoid high copper foods, screen family

Medical = Penicillamine lifelong

178
Q

What is primary billiary cirrhosis / cholangitis?

A

Chronic liver disorder characterised by progressive damage to the intra-lobular bile ducts = cholestasis = cirrhosis

179
Q

Rule of M’s in PBC?

A

IgM

Anti- Mitochondrial Ab’s

Middle aged itchy female

180
Q

PBC associations?

A

Sjogrens = patient may have dry eyes and mouth

RA

CREST

181
Q

Investigations in PBC?

A

LFT’s raised
98% = AMA +ve
Raised serum IgG

182
Q

Management of PBC?

A

Symptomatic:
Itching = Cholestyramine 4g PO BD
Osteoporosis = bisphosphonates

Specific = ADEK
Ursodeoxycholic acid

End stage = liver transplant if bilirubin >100

183
Q

What is primary sclerosing cholangitis?

A

Inflammation and fibrosis of the intra and extra hepatic ducts = diffuse multi-focal stricture complications

middle aged male

184
Q

PSC associated conditions?

185
Q

Clinical features of PSC?

A

RUQ pain, obstructive jaundice

186
Q

Complications of PSC?

A

Liver cirrhosis and failure
HCC
ADEK down
Gall stones

187
Q

Investigations for PSC?

A

ANCA
LFT’s raised
ERCP gold standard = multiple biliary strictures = BEADED APPEARANCE

188
Q

Management of PSC?

A

Symptomatic = cholestyramine 4g PO BD

Specific = ADEK, ursodeoxycholic acid
Stenting if dominant strictures

Regular screening for malignancy

189
Q

What is chronic pancreatitis?

A

Recurrent or persistent abdominal pain with progressive injury to pancreas and surrounding structures

190
Q

Investigations pancreatitis?

A

Exocrine low = low faecal elastase
Endocrine low = no insulin = raised glucose

Abdo x-ray = calcifications
CT more specific

191
Q

Management of chronic pancreatitis?

A

Stop alcohol, reduce fatty foods

Medical = CREON
Vitamin ADEK
Analgesia

192
Q

Complications of chronic pancreatitis?

A

Diabetes
Steatorrhoea
Pseudocyst

193
Q

Where does pancreatic cancer occur?

A

60% head
25% body
15% tail

194
Q

RF’s for pancreatic cancer?

A

Smoking
FHx
Diabetes
Chronic pancreatitis

195
Q

Painless jaundice, obstructive picture and weight loss?

A

Pancreatic cancer

196
Q

Investigations in pancreatic cancer =

A

Obstructive LFT’s, Ca 19-9

USS = Pancreatic mass, dilated bile ducts, liver mets

197
Q

Management of pancreatic cancer?

A

Stage 1/2 = resectable = Whipple’s (pancreaticoduodenectomy)
SE’s = dumping syndrome and PUD

Unresectable = stenting, chemo.

CREON for both

198
Q

What is carcinoid syndrome?

A

Occurs due to the release of vasoactive peptides and serotonin from a carcinoid tumoiur

199
Q

Where does carcinoid syndrome occur?

A

30% = midgut (duodenum = proximal 2/3rds of transverse colon)

5% = bronchial

1% = Pancreatic

200
Q

Clinical features of carcinoid syndrome?

A

Diarrhoea
Flushing, hypotension
Bronchospasm
Right sided valvular fibrosis

Pellegra

201
Q

Investigations for carcinoid syndrome?

A

Urinary 5-HIAA raised
Plasma chromogranin ! increased

CT/MRI for primary

202
Q

Management of carcinoid syndrome?

A

Octreotide

Curative = resection
Tumours very yellow
Give high dose octreotide as overwhelming release of vasoactive peptides due to manipulation of tumour

203
Q

Vitamin deficiency:
Dry conjunctiva, ulcerated cornea
Night blindness

204
Q

Vitamin:

Heart failure and oedema or polyneuropathy

Can also see wernickes

A

B1 = thiamine = Beri Beri

205
Q

Vitamin:

Diarrhoea, dermatitis and dementia

A

Pellegra B3

206
Q

Vitamin:

Peripheral sensory neuropathy

A

B6 / pyridoxine

207
Q

Vitamin:

Dermatitis and sebborhoea

A

Biotin / B7

208
Q

Vitamin:

Megaloblastic anaemia, neural tube defects in pregnancy

A

Folic acid / B9

209
Q

Vitamin:

Glossitis, peripheral neuropathy, SACD

A

B12 / cyanocobalamin

210
Q

Vitamin:

Gingivitis
Bleeding gums
Corkscrew hairs

A

C = scurvy

211
Q

Vitamin:

Bone pain and fractures

A

D = osteomalacia

212
Q

Vitamin

Bruising and petechiae
Bleeding / epistaxis

A

K

2,7,9,10

Finals Bible: Medicine (6 decks)

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