Gastroenterology Flashcards
Chronic Liver Disease
What are the causes of cirrhosis?
- Alcohol
- NAFLD
- Autoimmune/Metabolic: PBC, PSC, AIH, Haemochromatosis, Wilson’s disease, CF, a1-AT deficiency
- Drugs: Methorexate, Isoniazid, Amiodarone
Chronic Liver Disease
What are the complications of cirrhosis?
>Consequences of liver syntheteic dysfunction: -Hypoalbuminaemia -Coagulopathy -Encephalopathy >Consequences of portal hypertension: -Oesophageal varices & bleeding -Gastric varices -Asites & SBP -Hypersplenism & thrombocytopaenia >Hepatocellular carcinoma
Chronic Liver Disease
How do you classify the severity of hepatic encephalopathy?
> West Haven Criteria:
- I: Insomnia, Reversal of day night sleep pattern
- II: Lethargy, Disorientation
- III: Confusion, Somnolence
- IV: Coma
Chronic Liver Disease
What are the components of Childs-Pugh classification?
How do you assess the severity of cirrhosis?
> Components
- Bili, albumin, INR, ascites, encephalopathy
Child A 5-6 (90% 5 yr survival), Child B 7-9 (80% 5 yr survival), Child C >10 (33% 1 yr motality).
-Bilirubin: <35, 35-50, >50
-Albumin: >35, 28-35, <28
-INR: <1.7, 1.7-2.2, >2.2
-Ascites: Nil, Diuretic responsive, Diuretic refractory
-Encephalopathy: Nil, Grad I/II, Grade II/IV
Ascites
How do you classify ascites?
-Ascites is classified using the Serum Ascites Albumin Gradient (SAAG)
-SAAG = Serum Albumin - Ascitic Fluid Albumin
-SAAG > 11 = Portal hypertensive ascites.
=> Cirrhosis, Heart failure, Budd-Chiari syndrome.
-SAAG < 11 = Non-portal hypertensive ascites.
=> Infection, Pancreatitis, Malignancy
Splenomegaly
What are the causes of splenomegaly?
- Portal hypertension
- Haematological malignancy
- Infection e.g. HIV, Endocarditis
- Congestion e.g. CCF
- Primary splenic disease e.g. splenic vein thrombosis
Massive: CML, Myelofibrosis, Malaria, AIDS
Moderate: Portal hypertension, Lymphoma, Leukaemia, Thalassaemia, Glycogen storage disorders
Mild: PRV, EBV, IE, RA, SLE, Amyloid, Sarcoid
Splenomegaly
What are the causes of Hyposplenism?
- Splenic infarction (sickle cell anaemia, vasculitis)
- Splenic artery thrombosis
- Autoimmune disease
- Infiltrative conditions (amyloidosis, sarcoidosis)
- Coeliac disease
Hepatomegaly
What are the causes of tender hepatomegaly?
- Infectious e.g. viral hepatitis
- Alcohol hepatitis
- Malignancy e.g. HCC
- Hepatic congestion e.g. CCF
- Vascular liver disease e.g. Budd-Chiari syndrome
Hepatomegaly
What are the causes of hepatomegaly (without splenomegaly)?
- Malignancy (primary or secondary)
- Cirrhosis (alcoholic, NAFLD)
- Hepatic congestion (RHF, constrictive pericarditis, restrictive cardiomyopathy)
- Infectious (viral hepatitis, liver abscess)
- Infiltrative (amyloidosis, sarcoidosis, glycogen storage disorders)
- Vascular liver disease (Budd-Chiari syndrome)
- Polycystic liver disease
A Renal Abdomen
What are the major causes of chronic renal disease in developed countries?
- Diabetes
- Hypertension
- Glomerulonephritis
- Polycystic kidney disease
- Reflux nephropathy
- Analgesic nephropathy
Polycystic Kidneys
What are the causes of bilateral renal cysts?
- Polycystic kidney disease
- Von Hippel Lindau syndrome
- Tuberous sclerosis
- Multiple simple cysts
A Renal Abdomen
What are the indications for dialysis?
Mnemonic: AEIOU
- E. (EUC’s) Hyperkalaemia refractory to medical treatment
- A. Acidosis refractory to medical treatment
- O. Fluid overload refractory to medical treatment
- U. Uraemic complications e.g. encephalopathy, pericarditis, bleeding diathesis
- I. (Intox) Removal of dialyseable toxins e.g. lithium, salicylates
A Renal Abdomen
What are the complications of chronic renal disease?
- Electrolyte disturbances (hyperkalaemia, hyperphosphataemia)
- Metabolic acidosis
- Fluid overload
- Anaemia due to EPO deficiency
- Renal osteodystrophy (osteitis fibrosa, osteomalacia, adynamic bone disease)
Polycystic Kidneys
What are the causes of renal enlargement?
- Polycystic kidney disease
- Hydronephrosis
- Renal cell carcinoma
- Hypertrophy of single functioning kidney
- Simple renal cysts
What are the investigations in cirrhosis? (For monitoring and etiology?)
Bloods: LFT, albumin, FBC, creat, coags Imaging: U/S, CT abdo, fibroscan Hepatitis serology Anti-mitochondrial Ab: PBC ANA, smooth muscle Ab, Anti-LKM1 pANCA: PSC in assoc with UC Iron studies Caeruloplasmin Alpha-1 AT CMV Ascitic tap Liver biopsy
Treatment for hepatitis C?
Genotype 1a/b: sufosbovir + daclatasvir 2: sufosbovir + ribavarin 3: sufosbovir + daclatasvir 4,5,6: sufosbovir + PEG-IFN + ribavarin
12 weeks of treatment naive
12-24 if treatment experienced, cirrhosis
What are the criteria for listing for liver transplant?
End stage CLD with decompensation:
- Childs > 6 (I.e B or C)
- variceal bleeding
- SBP
- encephalopathy
- MELD >10 (INR, Bili, creat)
What are the CI to liver transplant?
- hepatorenal syndrome
- coagulopathy
- metastatic malignancy
- sepsis
- cholangiocarcinoma
- HIV
- hepatopulmonary syndrome
What are clinical features of hemochromatosis?
- cirrhosis
- bronze pigmentation
- arthropathy of 2nd, 3rd MCP
- dilated cardiomyopathy
- glycosuria (“bronze diabetes”)
What are the peripheral signs of chronic liver disease?
- clubbing
- leuconychia
- palmar erythema
- dupuytren contracture
- jaundice, scleralicterus
- spider naevi
- gynecomastia
How to distinguish a spleen from kidney?
- no palpable upper border of spleen
- spleen moves inferomedially on inspiration
- spleen not ballotable
- splenic notch
- dull to percussion over splenic mass
What are the differences between UC and CD?
UC: - colon only - mucosal inflammation - usually acute onset CD: - anywhere in GI tract - transmural inflammation - usually indolent onset
What are extra colonic features of ulcerative colitis?
- arthritis
- ankylosing spondylitis
- uveitis
- oral ulcers
- anaemia
- liver: PSC
- bowel cancer
- skin: erythema nodosum, pyoderma gangrenosum
What are the causes of cirrhosis?
- Alcohol
- Viral hepatitis
- NASH
- Drugs: MTX, Isoniazid
- Autoimmune hepatitis
- Haemochromatosis and Wilson’s
- PSC
- PBC
What is approach to management of chronic liver disease/cirrhosis?
Hepatocellular failure: - diet - ascites: diuretics, low salt diet, paracentesis - encephalopathy: treat infection, give lactulose, rifaximin Portal HTN: - band varices, propanolol - TIPS procedure Transplant
What are findings on colonoscopy in CD vs UC?
CD: cobblestone appearance, skip lesions, ileitis may be crohns
UC: continuous, crypt abscesses
What investigations for inflammatory bowel disease?
- bloods: FBC, ESR/CRP, pANCA (often UC), ASCA (often CD), nutritional, LFT
- stool culture
- AXR, CT
- Colonoscopy
How would you manage CD?
GENERAL: - stop smoking LOW RISK DISEASE: - colonic disease: 5ASA - SB disease: oral budesonide - if refractory, add AZA HIGH RISK DISEASE: - steroid+AZA or MTX - if no response, add infliximab - if no response to infliximab, add adalimumab or vedolizumab SURGERY: - indicated if: fistula with abscess, intestinal obstruction
How would you manage UC?
- PO or PR 5ASA
- PO or PR Steroid
- severe: cyclosporin (rapid within a week), TNF-i (infliximab, golimumab or adalimumab) or Vedolizumab (less systemic immunosuppression)
- Maintenance: AZA, 6MP; (no evidence for MTX in UC unlike CD)
- surgery is curative: though liver, ank spond, pyoderma still happen
What are indications for colectomy in UC?
- severe disease not responding within 7-10 days
- perforation, bleeding
- high risk of carcinoma(high grade dysplasia)
How to monitor for CRC recurrence?
- CEA q3-6m
- CT C/A/P yearly
- colonoscopy every 3 years
What is you differential for jaundice?
Pre hepatic: hemolytic anemia
Hepatic: hepatitis, CLD
Post hepatic: obstructive jaundice, PBC, gallstones, cholangitis
What are the onset of action of immunomodulators in IBD?
Which are safe in pregnancy?
> Thiopurines - azathioprine, mercaptopurine (6MP)
-Slow onset may take up to 3 to 6 months for remission
-TPMT (thiopurine methyltransferase) before starting
-Safe in pregnancy and breast feeding
-Small increase in skin cancers and lymphoma
-3 monthly FBC and LFTs; Sun screen, annual skin checks.
Methotrexate absolutely contraindicated in pregnancy and breastfeeding
- Both women/men should delay pregnancy 3 to 6 months after stopping the drug (effective contraception must be given due to risk of birth defects)
- Use if intolerant or refractory to thiopurines.
-5 mg of folic acid on the non-methotrexate days
-3 monthly FBC and LFTs.
How to screen for CRC?
- FOBT annually (in people with no Hx)
- colonoscopy: age 50, then q10yr; if high risk (1’ relative)
What are the criteria for liver transplant in HCC?
- x1 liver lesion
