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Hark and Paul's clinical review > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Chronic Liver Disease

What are the causes of cirrhosis?

A
  • Alcohol
  • NAFLD
  • Autoimmune/Metabolic: PBC, PSC, AIH, Haemochromatosis, Wilson’s disease, CF, a1-AT deficiency
  • Drugs: Methorexate, Isoniazid, Amiodarone
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2
Q

Chronic Liver Disease

What are the complications of cirrhosis?

A 
>Consequences of liver syntheteic dysfunction:
-Hypoalbuminaemia
-Coagulopathy
-Encephalopathy
>Consequences of portal hypertension:
-Oesophageal varices & bleeding
-Gastric varices
-Asites & SBP
-Hypersplenism & thrombocytopaenia
>Hepatocellular carcinoma
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3
Q

Chronic Liver Disease

How do you classify the severity of hepatic encephalopathy?

A

> West Haven Criteria:

  • I: Insomnia, Reversal of day night sleep pattern
  • II: Lethargy, Disorientation
  • III: Confusion, Somnolence
  • IV: Coma
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4
Q

Chronic Liver Disease

What are the components of Childs-Pugh classification?

How do you assess the severity of cirrhosis?

A

> 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

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5
Q

Ascites

How do you classify ascites?

A

-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

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6
Q

Splenomegaly

What are the causes of splenomegaly?

A
  • 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

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7
Q

Splenomegaly

What are the causes of Hyposplenism?

A
  • Splenic infarction (sickle cell anaemia, vasculitis)
  • Splenic artery thrombosis
  • Autoimmune disease
  • Infiltrative conditions (amyloidosis, sarcoidosis)
  • Coeliac disease
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8
Q

Hepatomegaly

What are the causes of tender hepatomegaly?

A
  • Infectious e.g. viral hepatitis
  • Alcohol hepatitis
  • Malignancy e.g. HCC
  • Hepatic congestion e.g. CCF
  • Vascular liver disease e.g. Budd-Chiari syndrome
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9
Q

Hepatomegaly

What are the causes of hepatomegaly (without splenomegaly)?

A
  • 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
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10
Q

A Renal Abdomen

What are the major causes of chronic renal disease in developed countries?

A
  • Diabetes
  • Hypertension
  • Glomerulonephritis
  • Polycystic kidney disease
  • Reflux nephropathy
  • Analgesic nephropathy
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11
Q

Polycystic Kidneys

What are the causes of bilateral renal cysts?

A
  • Polycystic kidney disease
  • Von Hippel Lindau syndrome
  • Tuberous sclerosis
  • Multiple simple cysts
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12
Q

A Renal Abdomen

What are the indications for dialysis?

A

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
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13
Q

A Renal Abdomen

What are the complications of chronic renal disease?

A
  • Electrolyte disturbances (hyperkalaemia, hyperphosphataemia)
  • Metabolic acidosis
  • Fluid overload
  • Anaemia due to EPO deficiency
  • Renal osteodystrophy (osteitis fibrosa, osteomalacia, adynamic bone disease)
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14
Q

Polycystic Kidneys

What are the causes of renal enlargement?

A
  • Polycystic kidney disease
  • Hydronephrosis
  • Renal cell carcinoma
  • Hypertrophy of single functioning kidney
  • Simple renal cysts
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15
Q

What are the investigations in cirrhosis? (For monitoring and etiology?)

A 
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
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16
Q

Treatment for hepatitis C?

A 
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

17
Q

What are the criteria for listing for liver transplant?

A

End stage CLD with decompensation:

  • Childs > 6 (I.e B or C)
  • variceal bleeding
  • SBP
  • encephalopathy
  • MELD >10 (INR, Bili, creat)
18
Q

What are the CI to liver transplant?

A
  • hepatorenal syndrome
  • coagulopathy
  • metastatic malignancy
  • sepsis
  • cholangiocarcinoma
  • HIV
  • hepatopulmonary syndrome
19
Q

What are clinical features of hemochromatosis?

A
  • cirrhosis
  • bronze pigmentation
  • arthropathy of 2nd, 3rd MCP
  • dilated cardiomyopathy
  • glycosuria (“bronze diabetes”)
20
Q

What are the peripheral signs of chronic liver disease?

A
  • clubbing
  • leuconychia
  • palmar erythema
  • dupuytren contracture
  • jaundice, scleralicterus
  • spider naevi
  • gynecomastia
21
Q

How to distinguish a spleen from kidney?

A
  • no palpable upper border of spleen
  • spleen moves inferomedially on inspiration
  • spleen not ballotable
  • splenic notch
  • dull to percussion over splenic mass
22
Q

What are the differences between UC and CD?

A 
UC:
- colon only
- mucosal inflammation 
- usually acute onset 
CD:
- anywhere in GI tract
- transmural inflammation
- usually indolent onset
23
Q

What are extra colonic features of ulcerative colitis?

A
  • arthritis
  • ankylosing spondylitis
  • uveitis
  • oral ulcers
  • anaemia
  • liver: PSC
  • bowel cancer
  • skin: erythema nodosum, pyoderma gangrenosum
24
Q

What are the causes of cirrhosis?

A
  1. Alcohol
  2. Viral hepatitis
  3. NASH
  4. Drugs: MTX, Isoniazid
  5. Autoimmune hepatitis
  6. Haemochromatosis and Wilson’s
  7. PSC
  8. PBC
25
Q

What is approach to management of chronic liver disease/cirrhosis?

A 
Hepatocellular failure:
- diet
- ascites: diuretics, low salt diet, paracentesis
- encephalopathy: treat infection, give lactulose, rifaximin
Portal HTN:
- band varices, propanolol
- TIPS procedure
Transplant
26
Q

What are findings on colonoscopy in CD vs UC?

A

CD: cobblestone appearance, skip lesions, ileitis may be crohns
UC: continuous, crypt abscesses

27
Q

What investigations for inflammatory bowel disease?

A
  • bloods: FBC, ESR/CRP, pANCA (often UC), ASCA (often CD), nutritional, LFT
  • stool culture
  • AXR, CT
  • Colonoscopy
28
Q

How would you manage CD?

A 
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
29
Q

How would you manage UC?

A
  • 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
30
Q

What are indications for colectomy in UC?

A
  • severe disease not responding within 7-10 days
  • perforation, bleeding
  • high risk of carcinoma(high grade dysplasia)
31
Q

How to monitor for CRC recurrence?

A
  • CEA q3-6m
  • CT C/A/P yearly
  • colonoscopy every 3 years
32
Q

What is you differential for jaundice?

A

Pre hepatic: hemolytic anemia
Hepatic: hepatitis, CLD
Post hepatic: obstructive jaundice, PBC, gallstones, cholangitis

33
Q

What are the onset of action of immunomodulators in IBD?

Which are safe in pregnancy?

A

> 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.

34
Q

How to screen for CRC?

A
  • FOBT annually (in people with no Hx)

- colonoscopy: age 50, then q10yr; if high risk (1’ relative)

35
Q

What are the criteria for liver transplant in HCC?

A
  • x1 liver lesion

Hark and Paul's clinical review (12 decks)

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