Gastroenterology Flashcards
Cause of pancreatitis in pregnancy
Gallstones
Budd Chiari syndrome
Hepatic VEin thrombosis - seen in haem conditions
Assoc:
- Polycythaemia ruba vera
- Thrombohilia - PRotein C + S deficiency, antithrombin C deficiency, Portein C resistance
- Preg
- OCP
Ft:
- Sudden onset abdo pain
- Ascites
- Tender hepatomegaly
Inx:
- US doppler flow
Jejunal villous atrophy
Coeliac dx Whipples dx hypogammaglobulinaemia Tropical sprue Cows milk intolerance
Prophylaxis of variceal bleads
Propanolol - 1st line
Variceal band ligation + PPI cover whilst - ive very large
Bariatric surgery
Consider if BMI>40 or NMI >30 + Comoridities
Alla appropriate non surgical measures have failed fot >6/12
They are receiving or will receive specialist mx
fit for surgery
comitted to LT follow up
BMI 30 - 39 -> gastric banding
NMI>40 –> gastrectomy or sleeve.
Severity of Lover cirrhosis
PT time bilirubin Albumin Presence of ascites presence of encephalopathy
Hep B and pregnancy
Screen all preg women
BEbies born to chronically infected or acute infection during pregnancy –> complete vax + HEp B Ig
Vitamin deficiency in GAstric Bypass
NEarly all gastric bypass ops = bypass duodenum
dueodenum = IRon absorption
therefore all menstruating women likely Fe deficient
Secondary prophylacys of hepatic encephalopathy
Lactulose 1st line
2nd line - Rifaxamin
Liver abscess
tx - percut Drainage + abx
abx - Amox + cipro + metro
PBC associartions
Sjrogrens - most assoc.
Systemic sclerosis
RA
Thyroid dx
PAncreatic secretions 0- Exocrine and endocrine
Exocrine:
- Trypsinogen
- Chemotrypsinogen
- Pancreatic amylase
- lipase
Endo:
- Glucagon
- Insulin
- Somatostatin
- pancreatic polypeptide.
Gut hormones
Gastrin:
- S = G cells in Antrum of stomach
- Stim = AA + GAstric distension
- A= H+, pepsin, IF secretion
Cholecystokinin:
- S = Duodenum + Jej
- stim = AA + Fats + Peptides
- A = PAnreatic + GB secretions
Secretin:
- S= duodenum + Jej
- stim = H+ small bowel
- PAncreatin NaHCO3- & delay gastric emptying
Somatostatin:
- D cells of panceas
- Vagal + adrenergic
- inhibit gastric H+ & pancreatic secretions.
VIP:
- SI
- NEural
- Inhibits H+ & epsin –> increases pancreatic secretions
GIP:
- Duod + jej
- gluc fat AA
- inhib H+/increase insuli/decrease motility
Fe Metabolism
Absorption - upper SI
Bound to Transferrin as Fe 3*
Stored as ferritin
Causes of increase Fe:
- Vitamin C
- Gastric H+
Causes of decreased Fe:
- PPI
- Tetracycline
- Tannine - in tea
- Gastric Achlorydia
Folate metab
Foudn in leafy greens
abs in duod/jej
Drugs that stop metab:
- MTX
- Trimethoprim
- Pyrimethamine
Drugs that reduce reabs:
- Phenytoin
Causes of low Vit B12
PErnicoius anaemia
post gastrectomy
disorder of terminal ileum - CROHNS
VEgan/low protein diet
Features:
- MAcrocytic anaemia
- Sore tongue + kmouth
- Ataxia/mood
Mx:
- if neuro –> HYDROXOCABALAMIN
if folic A low - replace B12 1st to stop SCDC
Achalasia
adnormal peristalsis + Lack of relaxation of LOS
Ft:
- Dysphagia - both liquids + Solids
- Varies in severit
- Regurgitation
inx:
MANOMETRY - most important
- Ba swallow –> birds beak appearance
Mx:
- Botulinnum toxin inject
- Hellers cariomyotomy
- pneumatic ballon dilatation
Dyspepsia referral criteria
Urgent:
- Dysphagia
- Uppe abdo mass
- > 55 and - abdo pain/reflux/dspepsia
Non-urgent:
- Haematemesis
- > 55 w/ - tx resistant / upper abdo mass + low Hb/ high platelets and sx
Drug causes of dyspepsia
Direct causes:
- NSAIDs
- Steroids
- Bisphosphonates
Drugs causing relax of LOS:
- Nitrates
- CCB
- Theophyline
H.Pylori
Gram negative
assoc:
- PUD
- GAstric Ca
- B cell lymphoma of MALT
- Atrophic gastritis
Inx:
- Diagnosis - 13C urea breath test or stool culture:
- Erradication = Urea breath test
Mx 7/7:
- PPI + Amox + Clari
- PPI + Metro + Cari
GORD - indications for UGI endoscopy
- > 55
- sx >4/52 or tx resistant
- Dysphagia
- WL
- Relapsing/remitting
if neg endoscopy –> 24 hr oesophageal pH monitoring
Barretts
Squamous –> columnar
pre malignant
RF:
- GORD - greatest
- smoking
- Obesity
- Male
Mx;
- Endoscopic surveillance - 3-5 yrs
- high dose PPI
- if dysplasia –> ressection or ablation
Oesophageal Ca
Adenocarcinoma = most common
- can have sq cell
Majority effect MIDDLE 3rd of oesophagus
RF:
- GORD
- Barretts
- EtOH
- Achalasia
- plummer-Vinson syndrome - sq cell
- procssed meat - Sq cell
H.PYLORI NOT ASSOC - MAY BE PROTECTIVE
Inx:
UGI endoscopy
CT TAP for staging –> no mets –> endoscopic US
Peritoneal dx –> Laproscopy
Mx:
- Surgery + adjuvant chemo
Acute UGIB causes
Oesophageal:
- mallory weiss
- oesophagitis
- varices
- Ca
Gastric
- Gastritis
- Ca
- Dieulafoy lesion
- gastric ulcer
Duodenal:
- Posterior sited ulcer
Risk assessment in UGIB
glasgow blatchford score - pre endoscop --> >0 --> Mx Hb urea SBP Tachy Malena syncope hepatic dx or CFx
UGIB - Non variceal bleed
PPI post endoscopy
Further bleed –> rescope –> IR/Surgery
UGIB initial mx
A–> E
maj haem protocol
FFP if:
- fibrinogen <1
- INR >1.5x BL
Plt transfusion:
- Active bleed + plt <50
If taking warfarin –> PTCC
All PT –> endoscopy within 24 hrs
UGIB - variceal blled mx
Terlipressin + Abx
Endoscopy –> VBL (oesophageal) / N-butyl-2-cyanoacrylate inject (Gastric)
Fx of above – TIPSS
UGIB - idnications for surgery
> 60
fx of endoscopic intervention
rebleed
known CVD with poor tolerance for hypotension
Zollinger-Ellison syndrome
Increased gastrin production
Raised gastric acid - - > low b12 - - - > MACROCYTIC ANAEMIA
assoc w. Men type 1 ft: - Multiple P~Ud - diarrhoea - malasorption
Inx: Fasting gastrin levels
Gastric Ca
Epidemiology:
- affects 70-80 yrs
- JApanese/chinese/finland/columbia
- M>F
Histology –> SIGNET RING
Assox: Blood Group A H.pylori Polyps pericious anaemia smoking diet - Na / spicy / nitrates
Inx:
- Endoscopy + biopsy
- stagbg = Endo US or CT TAP
Mx: - PRooximl dx - 5 -10cm cm from G.O.jn --> subtotal gastrectomy - <5cm --> total gastrectomy - nodal disection adjuvant chemo
Gastroparesis
Causes:
- IDiopathic
- DB
- ANS
- Post vagotomy
Inx - Ba Swallow
Mx:
- dietary mod
- motility agents - DOMPERIDONE/ metoclop/erythromycin
- if severe or asp pnuemo –> feeding Jej
Dumping syndrome
complication of gastric surger & whipples
inapprop. metab response to eating:
- early syndrome = half hour
- late syndrome = 1-3 hrs
Sx:
- palpitations/headache/sweating/hypotension/light headed
Early dumping:
- rapid gastric emptying
- Mx = small frew high protein + fat meals
Late dumping:
- Hypogycaemia due to rebound hyperinsulinaemia.
- Mx - High carb meal.
acute Pancreatitis - causes
GETSMASHED
- AI = PAN
H = hypertriglycerides, hyperchylomicron, hypercalcaemia, hypothermia
Drugs - AZA, mesalazine, furosemide, bendroflumethazide, steroids, pentamidine, Na Valproate.
Acute PAncreatitis - inx + scoring
AMylase >3x ULN
US abdo –: G.stone dx
Scoring = glasgow Pao2 <8 Age >55 Neutrophils >15 Ca <2 Renal urea >16 Enzyme LDH >600/AST>2000 Alb <32 sugars >10
Score >3 –> SEVERE
CRP 150 = severe
PAncreatitis Mx
Feed –> decrease bacterial translocation
Analgesia
FLUID
G.stone obstructing biliary tree –> ERCP
Cholecystectomy
Infected necrosis –> drainage
Complicatuos f pancreatitis
pancreatic fluid collection - spont resolves
pseudocyst - observe 12/52 –> fx to resolve –> surgery
Necrosis –> if sterille = conservatibe/ if infected –> Drain
Abscess –> DRAIN
Haemorrhage
ARDS
Chronic oancreatitis
Main cause : EtOH
PThers:
- genetic - CF/haemochromatosis
- ductal obstruct - stones, tumour, structural
Px:
- Pain = 15-30 mins after meal
- 5 - 25yr olds - steatorhea
- > 20 yrs - DB
inx
- CT ABDO
- Faecal Elestase !!!!
Mx:
- Creon
- Vit ACE
- Analgesia
- DB - insulin
- abstinence form alcohol
Pancreatic Ca
Assoc: - Age smoking -DB - Chronic pancreatitis HNPCC - MEN - BRCA2
Px:
- painless jaundice
- courvoissser’s lae
- trousseaus sign
inx - high res CT
Mx:
- <20 % resectable
- Whipples procedure + adjuvant chemo
- Palliative ERCP Stenting
sulphasalazine side effects
Diarrhoea
skin rash
male infertility
agranulocytosis
melanosis coli
pigment laden macrophages
assoc with laxative abuse
Insulinoma
px:
- early am and premeal hypoglycaemia
- raised insulin
- raised C-peptide
- reaised pre-insulin:insulin
inx:
0 supervised prologed fasting
- CT pancrease
Mx:
- surggery
- if not a candidate Diazoxide + Somatostatin
colorectal Ca screening PPV
5 - 15%
VIPoma
VIP produce in SI + Pancrease –> increases pancreatic + Interstinal secretions.
It inhibits H+/pepsinogen
Ft:
- LOADS OF DIARRHOEA
- WL
- Dehydration
- low CL-
Glucagonoma
alpha cells
Ft
- charcetristic rash = migratory neccrolytic erythema
- WL
- Glucose intolerance
- DB
Somatostatinoma
Secreted by D cells
Ft:
- DB
- GB dx
- Diarrhoea
- WL
- Steatorhea
- hypochlorydia
Coeliac dx
Assoc w/ HLA DQ2 & DR8
anti-TTG = 1st line
anti endomysial Ab
both IgA - when tested for need to be on gluten for at least 6/52
Biopsy:
- Villous trophy
- lymphocyte infiltration of lamina propria
- increased intraepthelial lymphocytes
TTG used to assess compliance to gluten free diet;
coeliac dx complications
anaemia - Folate >B12 hyposplenism osteoperosis/osteopaenia lactose intoerance enteropathy assoc. lymphoma decreased fertility.
Brush border enzymes and their products
Maltase - Gluc + gluc
sucrase - Gluc + fructose
lactase - Gluc + galactose
carcinoid syndrome
mets –> liver
Ft:
- 1st sign = flushing
- diarrhoea
- bronchospasm
- hypotension
- R sided heart valve complications
inx:
- Urinary catecholamines = Urinary 5-HIAA
Mx:
- Octeotride - somatostatin analgue - s.e –> Gallstones
Diarrhoe = Cryoheptadine
Whipples dx
Remeber the @old man with the whip in the rave pixorise vide
G+ PAS + Foamy Mac Steatorhea - golden butts Cardiac psigns - heart shaped couches neuro signs - old man wearing helmet
Inx = Jejunal biopsy
MX:
IV penicillin –> co-trimoxazole for 12/12
Angiodysplasia
Vascular malformation - seen in elderly
-A-ngiodysplasia is assoc withj -A-ortic stenosis
Inx:
- colonoscopy
- acute bleed = mesenteric angio
mx
- endoscopic cautery or argon laser.
- TXA
- Oestrogen
Refeeding syndrome
Metabolic derangement when someone in previous catabolic stateis fed abruptly
sudden switch to anabolic –> surge in insulin –> Increase uptake of gluc, mg, po4-,K+ –> low levels in blood
Mx if not eaten for 5days or more –> reefed at 50% og required daily intake for 2/7
refeeding syndrome RF - High risk
One of :
- BMI<16
- WL >15% (3-6/12)
- low intake >10 days
- already low electolytes
2 of:
- BMI <16.5
- WL >10%
- not eaten > 5 days
- EtOH/Insulin/ chemo/.steroids/ diuretucs
Malnutrition
Definition
BM( <18.5 or unintentional WL >10%
NMI <20 + WL >5%
Acreen - MUST
Mx:
- Dietician –> FOOD FIRST PLAN –< fx –> PO nutritional supplement.
Vitamins
B6 - pyridoxine
- Caused - Inz
- peripheral neuropathy / sideroblastic anaemia
B1 - Thiamine
- EtOH, Malnutrtion
- W-K encephalopathy
- Dry + wet beri beir
B3 - Niacin
- Hartnups dx, Carcinoid
- Pellagra = dermatitis, dementia, diarrhoea
B2 - Riboflavin
- Angular chellitis
B12
- Pernicious anaemia/ post gastrectomy/ crohns/vegan/metformin
- Peripheral neuropathy, ataxia, neuro-psychm macrocytic anemia, sore tongue _+ mouth
C
- scurvy
- poor wound healing/bleeding gums/haematuria/epistaxis
- gen malaise
SB bacterial overgrowth syndrome
RF:
- Congenital abnormalities
- Scleroderma
- DB
Ft:
- IBS like picture - diarrhoea, bloating, flatulence
Inx: _ HYDROGEN BREATH TEST
Mx:
- Tx underlying
- RIFAXIMIN
Crohns - Px/Inx
Mouth –> anus patchy inflamm of all layers = “cobblestone”
Histology
- all layers
- increased goblet cells
- granulomas
Px: most common on adult = diarrhoea, most common in child = Abdo pain
inx: - faecal calprotectin - CRP relates to DX ACTIVITY - Colonoscopy + Biopsy SB enema --> strings of Kantor + Rose thorn Ulcers
Complication:
- SB cancer
osteoporosis
colorectal Ca
Crohns mx
General
- stop smoking
- decrease NSAIDs
Indicing remission:
- 1) Steroids +/- enteral
2) Mesalazine
3) MTX/AZA or mecatopurine
4) Infliximab
NB - Use inflix if fistula. need to check TPMT activity before Aza and mecatopurine
Mainaining:
1) Aza or metacopurine
2) ASA (prev surgery) or MTX
Surgery - if stricture or fistula
UC Px/ Inx
More likely to px with bloody diarrhoea and tenesmus + LLQ pain
Pathology:
- limited to submucosa
- decreased goblet cells
- don’t get granulomas
- Crypt abscess
- inflamm cell infiltrate of LP
Inx:
- Colonoscopy + biops
- SB enema - Loss of hgaustra –> V sev –> LEAD PIPE COLON
Severity:
- Mild - <4 stools/day w/ little blood
- Mod - 4-6 stools/day - no systemic upset
- Sev - > 6 stools/day w/ systemic upset.
UC Mx - inducinf remission
Mild – Mod procttiis:
1) rectal Mesalasine
2) PO mesalazine
3) PO/topical steroid
Mild- mod proctosigmoiditis + L side Dx:
1) Rectal Mesalasine
2) PO mesalasin
3) PO Mesalazine + topical steroid
4) PO Mesalazine + PO steroid
Mild - mod - extensive dx:
1) PO + Topical meselazine
2) PO Mesalazine + PO steroid
Sev colitis:
1) IV STEROID or CICLOSPORIN
2) not resolved in 72 hrs –> +Ciclosporin or go to surgery.
UC maintaining remission
Mild - mod proctitis:
- Meslazine - PO or topical or combo
Mild to mod L side dx
- PO Mesalazine
Sev relapse or >2 exac in a yr:
- Aza or mercaptopurine - TMPT activity
IBD 0 extraintestinal dx
Related to dx activity:
- arthritis - puaciarticular
- episcleritis
- Erythema Nodosum
- osteoporosis
Unrelated to sx activity - periarticular arthritis - uveitis - pyoderma gangrenosum clubbinf PSC
UC and colorecyal Ca
High risk: - Dx > 10yrs Px < 15yr sold - pancolitis - unremitting dx - poor complains
Suveillance:
Low riks - 5 yrs
- no complicated L side dx
- no inflamm on endo or histo
Med risk - 3 yrs:
- Ext dx w/ mild inflamm
- Fhx of colorectal Ca >50
High =1yr:
- Mod–> sev inflamm
- FHx <50 yrs
- Complications - strictures, dysplasia, PSC
C.Diff
Produces and exotoxin –> pseudomembranous colitris
RF:
- Cephlasporin > Clindamycin
- PPI
inx:
- Cdiff toxin in stool
Mx:
- PO metronidazole
- if sev or Fx 1st line –> PO Vanc or Fidaoxamicin
- life threatening —> IV metro + PO Vanc
Ft of life threatentingL
- WCC>15.0
- Cr > 1.5X BL
- Temp > 38
- Sev colitis on radiology
Peutz - Jeghers syndrome
AD
Harmatomas
Ft:
- harmatomatous polyps in GIT
- Pigmented lesions on lips, oral muco, palms,Intestinal obstruct
- GI malignancy
Mx = conservative
Coagulopathy of liver dx
Factor 8 is paradoxically increased.
This is because it is made in endothelial cells all around body, not just liver !!
Also it is cleared by the liver therefore it is not cleared !!!
As a result despite increase bleed risk, CLD pt tstill at risk of VTE
Colorectal Ca
SPoradic 95%
HNPCC 5%
- AD
- PRoximal colon, poorly differentiated + VV agressive
- Amsterdam critea >3 family members, cross 2 generations or >1 diagnosed < 50yrs
FAP<1%
- AD - APC gene on chromsome 5
- Multiple polyps
- Gardners syndrome - FAP + OSteomas + retinal pigmentation + thyroid Ca + epidermal Cysts
Colorectal Ca screening
Every 2 yrs
60-74 UK
50-74 scotlnd
FIT - better than FOB - only 1 sample and only detects human Hb.
5-15% of + tests –> colorectal Ca
Flexsig- one of test
- @55 yrs
- can opt in until 60
in addition to above - offer FOBT if:
- > 50 + abdo mass or WL
- > 60 + anaemia.
Colorectal Ca referral
Ugent:
- =/>40 + Abdo pin + WL
- =/>50 + Rectal bleed
- =/> 60 w/ IDA or chaneg in bowel habit
- FOBT
Consider:
- Rectal/abdo mass
- anal mass/ulceration
- < 50 + rectal bleed + one other sx.
IBS
Diagnosis: - 6/12
Abdo pain - relief on defecation or assoc with change in bowel habit and 2/4 of: - Bloating - alt stool passing - sx worse on eating - Passing mucus
inx - FBC/ESR/Coeliac screen
Mx - 1st line:
- Diet advice - avoif high fibre
- Diarrhoea - loperamide
- Constipation - LAxatives –> fx –> Lincosamie
- pain - antispasmodic
Mx: 2nd line:
- Lincosamide
- TCA
- CBT
GI Infections
1 - 6hrs:
- Staph A - projectile vomit
- Bacillus cerus - Rice - <6hr = vomit >6hrs diarrhoea
12-48 hrs: \+ Salmonella - G- nacillus - pea soup diarrhoea - rose spots - usueal SL --> Fx --> Cipro
+E.coli
- Traveller diarrhoea = watery
48-72 hours:
+ Shigella:
- BLOODY diarrhoea
- useually SL –> if sev –> Cipro
+ Campylobacter:
- Non bloody diarrhoea
- FLU-LIKE PRODROME
- GBS/ reiters
- Usually SL –> sev –> Clarithromycin or Cipro
> 7/7:
+ Giardiasis:
- non-blood diarrhoea –> malabsorption/lactose intolerance
- Mx = metronidazole
+ Amoebiasis:
- Prolonged BLOODY diarrhoea
- HOT STOOL MICROSCOPY
- get amoebic liver abscess
- mx = Metro + Luminal amoebicide (If invasivve dx)
Pre - hepatic jaundice
Increased RBC BD:
G6PD deficiency:
- AR –> decreased glutathiazone –> increase susceptble to O2 stress.
- NEONATAL jaundice
- HEINZ BODIES + SPLENOMEGALU
HEreditary spherocytosis:
- RBC BD in microcirculation –> destryed in SPLEEN
- Fx to thrive
- SPLENOMEGALY
Congenital hyperbilirubinaemia:
Gilberts
- relative loss of UDP GT –> decreased conjugation
- Jaundice worse in INTERCURRENT ILLNESS OR EX
- inx - prolonged fasting –> measure Bili
Criggler - NAjjar
- More severe than gilberst –> ABSOLUTE LOSS of UDP GT
- dont survive long
- 2 types, tpe 1 is more sev. than type 2
Hepatic jaundice
Hepatitis
ALD
Wislons dx
Drugs:
- Phenobarbital
- Amoxicillin
- other abx
Rotor syndrome:
- AR
- defect in hepatc uptale + storage
Dubllin Johnson sndrome:
- iranian jews
- MDRP2
- Decrease hepatic excreton –> GROSSLY BLACK LIVER
Liver Cirrhosis
Hepatic MEts
Cardiac fx
Wilsons dx
AR
increase DI absorbtion of Cu + decreased HEpatic excretion of Cu –> deposits in tissuess
Px 10-25 yrs
- 1sst sign in children = liver dx
- 1st sign in adults = neur-psych
- he fx
- KAiser - flaischer rings
- RTA
- BLue nails
Inx:
- low serum Cu + Caeruloplasmin
- Increased 24 hr urinary Cu excretion
MX:
- PENICILLAMINE
post-hepatic JAundice - Gallstones
Female/fair/fat/forty/fertile
Mx:
- Asx and G stone in GB –> dont need to tx
- ASx and Gstone in CBD –> Tx
Complications:
- Biliary colic –> US –. LAp CHole
- Cholecystitis –> Abx –> choecystitis within 48hrs
- GB Abscess –> drain
- Chokangitis - Charcots triad or reynalds pentad
- G stone ileus –> SBO –> lap
- Acalculous Cholecysttiis – cholecystectomy
- Acute pancreatitis
Post HEpatic JAundice - other causes
PAncreatic Ca
PBC:
- AMA M2/ASMA/ IgM
- mx : UDA, Cholecystyramine, Vitamins
- If Bili >100 –> ?liver transplant
- Complications - osteomalacia/osteoperosis, Cirrhosis, Heptocellular Ca
PSC:
- Assoc UC
- Inx - ERCP/MRCP, ANCA +
- ncreased risk of Cholangiocarcinoma + colrectal Ca
LN
Liver cirrhosis - liver biopsy features
Alcohol steatohepatitis:
-Macrovesicular fatty change with giant mitochondria, spotty necrosis and fibrosisi
Liver cirrhosis:
- Xs collagen and extracellular matrix deposition in periportal and pericentral zones leading to the formation of regenerative nodules.
What decreases accuracy of 13C-urea breath test
No abx or 4/52
No PPI 2/52
HELLP vs AFLP
HELLP:
- HAemolysis
- Elevated LFT
- Low Platelet
Alcoholic fatty liver of preg:
- No haemolysis on blood fim
- ALT >500
- Hypoglycaemia
Acute UGIB caused by a duodenal ulcer - what artery is likely to be affected?
Gastroduodenal artery
posterior site DU
IF you ?ischaemic bowe in the Q what may they give you in the Q stem on bloods?
Raised LActate
low pH on Acidosis
high RR and Low HCO3- - compensation of metabolic acidosis
Ascites
TransudaTE (saag >11) - CHfx - Hep CV thrombosis - Cirrhosis EtOH - Mixed - Hep Fx - Budd-chiari _ Veno-occlusive dx -Fatty liver of preg
Exudate (SAAG <11)
- Malignancy
- Infection
- TB
- Pancreatitis
- Bowel obstruction
Mx:
- Fluid srestric + Na rresitrict
- Catheter - UO
- Daily wait
- Spironolactone
- Prophylactic Ciprofloxacin
- TAP –> S.e ++ Panncreatic circulatory dysfn - therefore if large vol, give albumin cover.
- TIPSS
Hepatorenal syndrome
pathophysiology = complex - thought to ?> be splanchnic VD –> decrerase renal perf –> RAAS –> Renal VC
2 Types:
- Type 1 - V rapid onsetr + agress - 2 x Cr BL or 1.5 x Cr Clx in 2/52
- Type 2 - slower + better prognosis
Mx:
- Terlipressin
- 20 albumin –> vol expansion
- TIPSS
SBP
Paracentesis –> neutrophil count > 250
Mx : IV cefotaxime
in pt with ascites give prophylaxis if:
- =>1 episode of SBP
- Fluid proten <15g/L or CHild pugh >9 or HRS
Hepatitis A
Hep A - Faecal oral - RNA - Flu-like prodrome - Mx = supportive Vax = yes
Hep B serology
HBsAg = acute dx = 1-6/12 or chronic if present >6/12
anti-HBsAg = immunity
anti-HBc Ag = infection - previous or current
HBeAG = marker of infectivity
Hep B
Hep B - Chronic:
- Blood bourne
- DNA
- Jaundice/ fever . transaminases
- Mx = pegylate ifn-alpha +/- tenofovir.entecavir/talbivudir
- complications - 50% –> Chronic Hep = ground glass hepatocytes
- Complications: fulminante hep Fx/ Hepatocellular Ca/ GN/PAN
- VAX -= YEss - all children in UK + Occupational risk
Hep C
CHRONIC
Blood borne/sexual
RNA
Acute hepatitis less sever the A + B
Inx = HCV RNA
Complications
- Rheumatic dx
- Sjrogrens
- Cirrhosis
- Hepatocellular Ca
- membranoprolif GN
- Porphyria
Mx:
- Protease inhibitor (-navir-) +/- Ribavirin
- used to be ifn alpga
S.e of ribavirin:
- Haemolytic anaemia
- Cannot become pregnant <6/12 after stopping
IFN-alpha:
- flu like
- depression
- fatigue
- leukopaenia
- thrombocytropenia
Hep D
Exacerbated HEp B
no chronicitiy of itself
no vax
blood-borne
Hep E
faecal -oral
RNA
- Acute self limiting
HIGH MORTALITY during PREH
no vax
AI Hepatitis
assoc w/ other AI conditions/hypogammaglobulinaemia/ HLAB8/DR3
Type 1 - ANA/ASMA - affects both adult and child
Typ II = LKM1 - Kids
Type III - Soluble liver-kidney Ag - Adults
Inx:
- CLD signs
Amennorhea
- ANA/ASMA/LKM1/IgM !!!!!!!
- liver buiopsy –> Necxrosis = piecemeal or bridging
Mx:
- IS/Steroids
- Liver transplant
Drug induced hepatitis
Cholestatic
- Fluclox
- Erythromycin
- OCP
- Anabolic steroids
True hep
- Statin
- Anti-TB - Inz
- Ketoconaxole
- I.s.
Necrosis:
- Tetrahydrochloride ingestion
- Paracetamol OD
Liver Cirrhosis
Inx of choice = TRANSIENT ELASTOGRAPGY
- Fibroscan = measures stiffness
Endoscopy - varices
Screemomg - Liver US +/- AFP
- Hep C
- EtOH intake - >50 for M and > 35 units for F
- ALD
Scoring =
MELD - Bili/Cr/INR
Child pugh score - Bili Alb PTT Enceph Ascites
child pugh score
BIli:
- <34 = 1
- 34 - 50 = 2
- > 50 = 3
Alb
>35 = 1
28 - 35 = 2
<28 = 3
PTT:
<4 = 1
4-6 =2
>6 = 3
Enceph AND ascites
none = 1
mod = 2
marked = 3
Severtity
A = <7
B = 7-9
C = >9
Prtal HTN - causes
causes:
- cirrhosis
-Portal V thrombosis - budd - chairi
- R HFx
Vholangio-carcinoma/hepatocellular Ca - Constrictive pericarditis
- Splemic V Thrombosi s
prophylaxis form Variceal bleed
1) Propanolol
2) VBL>Sclerotherapy (cover w/ PPI)
VBL used 1st line if Cirrhosis + med/lrg varices
Hepatic Encephalopathy
Ft:
- GCS change
- Asterix - 3-5hz
- construcytional apraxia
Inx:
- Raised ammonia
- EEG - Transient slow waves
PRecipitants:
- Infection
- GIB
- TIPSS
- CONSTIP{ATION
- Drugs - sedatives/diuretics
- hypokalaemia
- Renal Fx
- High protein diet
Mx:
- Tx precipitant
- !st line = Lactulose
- 2nd line = + Rifaximin
Hep encephalopathy - GCS grades
grade 1: irritable
grade 2 0- confusion/inappropriate
grad 3 - incoherent/relestless
grade 4 - coma
PBC complications
Osteomalacia/osteoporosis
- Sjrogrens
portal HTN
Hepatocellular Ca - 20 x risk increase.
Haemochromatosis
HFE gene on chromosome 6
Ft:
- Fatigue / erectile dysfn/ arthralgia = early
- Bronnze skin
- CLD
- DB
- Cardiomyopathy
- Hypogonadism = hypogonadotrophic = Pit dysfn
Inx:
- general population transferrin saturation +/- ferritin
- FHx +ve –> HFE gene
- Tranferrin > 55% in M or >50% F
- ferritin >500
- Fe Raised
- TIBC reduced
Mx:
- Venesectuin - aim to keep trasnferin saturation <50% and Feritin <50
Which complications of haemochromatosis = reversible>
Skin pigmentation
Cardiomyopahty
Paracytic liver ingections
Hytadid dx: - ingestion -dog taperowmr - larvae --> blood --> liver cysts Mx = surgical + bendazole
Schistomiasis:
- Parasite penetrates skin when in infected H2O
Schistom HAematobium –> Renal –> bladder clac/haematuria - Mx = Praziquantel
-Schistoma Mansonium/japonicum –> Liver Cirrhoss
VAriceal Dx
- Schistoma intercalatum/mekongi —> intestinal dx
Liver abscess
Pyogernic:
- Drain + IV ABx = Amoc + cipro + metro
- pen allergy = Cipro + clinda
Amoebic:
- Anchovy paster
- Prodrome of diarrhoeal illness
- Mx = metro
hepatocellular carcinoimna
Rf: - Liver citrrhosis - any cause - Alpha-1 antitrypsin - Heriditary tyronsinosis - glycogen storage dx - Alfatoxin Drugs = OCP/ Anabolic steroids - male
Screening:
- US +/- AFP
- cirrhosis secondary to hep B/C/haemochromatosis
- men with ALD
Mx: - Early = resection - Albumin Sorafenib = multikinase inhibitor - Transarterial chemoembolisattion - liver transplant
Cholangiocarcinoma - features
Biliary colic
post-hep jaundice
Courvosers sign = palpable mass inRUQ + jaundice
sister mary joseph nodule = periumbilical LN
Virchows node
Mx:
- v.few suitable for surgery
- palliative stenting
NAFLD
Insulin resistance
spectrum disorder:
- steatosis
- steatohepatitis
- steatohepatis (NASH) = Same changes as ALD
Assoc
- obesity
- DB2
- lipids
- jujenoileal bypass
- sudden WL ot starvations
Inx:
- Liver screen ALT > AST rise
- Enhanced lifer fibrosis blood tersts
Fibroscan + FIB4 score
Mx:
- WL
- Adv dx –> specialit
Ascites and protein concentration <15 but no bacteria yet…… what should be done re abx
Give prophylaxis ciprofloxacin or norfloxacin
PSC investigation of choice?
ERCP - - > bead like appearance
Most common organism. In SBP
E. Coli
Contraindications to liver biopsy
- extrahepatic biliary obstruct - as use ERCP/MRCP
- deranged clotting - INR>1.4
- Low platelets - <60
- anaemia
- hytadid cyst
- haemangioma
- uncooperative pt
- ascites
Gastric MALT
Feature of dysoepsia and weight loss
Lymohima cekls pressnt on bioosy
Most conmonky assoc h. Pylori,.
1st ljne management is HPYLORI ERADICATION
Bile. Acid Malabsorption
Bile acid is absorbed in the terminal. Ileum
Therefore seen jn those with Ileal resection or diseass (CHRONS)
Px is chronic diarrhoea ans burning sensatiom on passing faeces
Management is cholecystyramine
Bile. Acid Malabsorption
Bile acid is absorbed in the terminal. Ileum
Therefore seen jn those with Ileal resection or diseass (CHRONS)
Px is chronic diarrhoea ans burning sensatiom on passing faeces
Management is cholecystyramine
Heo B most important factor for determining progression to cirrhosis
HBV DNA titre
PBC - The M ruke
Ig-M-
Anti-M-itochondrial Ab
-M-iddle. Aged female
Lft - - > raised alp and gamma-GT
Mx:
Puritus - cholecystyramine
Uro acid
PBC criteria for liver transplant
Bili > 100
Diagnosis of SBP
Paracentesis–”> netrophil vount >250
Most common organism = E. Coli
Diagnosis of SBP
Paracentesis–”> netrophil vount >250
Most common organism = E. Coli
Management of scute severe alcohokic hepatitis
Prednisolone
Gilbert’s sybdrome
Unconjugated hyperbilirubinaemia
Jaundice on intervurrent illness
Investigatiin:
Rise in bilirubin followinf orolonged fasting or nicotinic acid
Heoatorenall syndrome
Type 1 rapidly orgressive
Typd 2 slower
Mexhanizm - splanchnic vasodilation
. Mx
Terlipressin
Volume expansion wuth 20% albumin
TIPSS
Menetriers disease
Characterised by massiv gastric folds in the fundus
Histology - hypertrophy of gastric pits, gkand atrophy amf increase overall. Mucosal thickness
Ft:
Epigastric paib
Diarrhoea
Hypoalbuminaemia
Extra-intestina manifestations of IBD
- A PIE SAC
Arthritis, ankylosing spsondylitis
PSC, Pyoderma gangrenosum, pleuritis, pancreatitis, perianal skin tag, psoriasis
I = eyes = iritis, uveitis, episcleritis, conjunctivitis
E = eryhema nodosum
Sacroilitis
Apthous ulcers
Clubbinc, cholelithiasis
renal calculi
Carcinoid syndrome - False + on Urinary HIAA
Diet high in veg/nuts, therefore –> test after diet restriction
Hepatic adenoma
benign lesion of liver seen in women of childbearing age assoc with OCP
Immunoglobulin in gastro
IgA - A-lcohol
IgM - PBC - anti M-itochondrial Ab
IgG - AIH
Hepatitis E
Rna
. Faecak. Oral
Severe ilness and death in pr-E-gnant women in yhe 3 (for E) trimester
Colonoscopy surveillance
Low risk - 1 or.2 adenomas - 5rs
Med - 3 or 4 adenomas or. One >1cm - 3yrly
High - 5 or more…. Or at keazt 3 with one >1cm
Peutz jegher
Mucosa pigmentation
Gu bleed
Chromosme 19 - AD
Pathognomic finding of chronic oancreatitis
PANCREATIC CALC - Xray (alsp kn ERCP)
What drug causes crohns like Enterocolitis in transplant patient
Mycophenelate mofetil
Colonoscopy for dukaes A tumour
Colonoscopy annually for 2 years. Yhen 3 years
Treatment of whipples of disease
Amoxicillin
Most common cause of small bowel overgrowht
Radiation enteritis
Travis or oxford criteria for UC
At day 3:.
Stool freq >8
Crp >45
85% need surgery
Theaes - INFLIXIMAB OR CICLOSPORIN
Drug mimics of IBD
NSAIDs
Mycophenlate mofetil
Nicorandil
If symptoms of Coeliac dx, but endomysial test neg, but still dignosis is coeliac
Coeliac dx - assoc IgA
however in Q stem if tehy state past histry of allerges, this may be indicating an IgA deficiency –> therefore endomysial = IgA test wil be negative !
Pyoderma gangrenosum
If severe - topical tacrolimus
Ciclosporun if this fails (only available parenteral)
Can use topivle beclometasone if mild
Hereditary haemochromatosis inheritance
Pseudo-dominant
How to distinguish between protein losing enteropathy and nephrotic sydnrome
LOW TOTAL CHOLESTEROL
nephrotic syndrome loses proteins dependent on weight and charge. Cholesterol too big –> therefore not lost.
Investigation - Faecal alpha-1 antitrypsin
Chronic Hep B carrier marker of infectivity
HBe antigen if present –> high infectivit
IF negative –> low infectivity
