Gastroenterology Flashcards
1
Q
Diarrhoea
Most common causes (9)
A
IBS Gastroenteritis Parasites Colorectal cancer Crohn's disease Ulcerative colitis Coeliac disease Thyrotoxicosis Antibiotics
2
Q
Diarrhoea
Types (4)
A
Watery: osmotic, secretory or functional (typically IBS)
Laxative-induced: osmotic
Steatorrhoea (fat): increased gas, offensive smell (eg. coeliac disease)
Inflammatory: blood + pus (Crohn’s, UC, bacteria, parasites)
3
Q
Diarrhoea
Signs + Symptoms (7)
A
Acute- (<2 weeks) then suspect gastroenteritis/Chronic- suspect IBS, UC, Crohn’s
Bloody diarrhoea- suspect infection, UC, Crohn’s, colorectal cancer
Mucus- suspect IBS, colorectal cancer, polyps
Explosive- suspect cholera, giardia
Small bowel symptoms- periumbilical/RIF pain not relieved by defecation
Large bowel symptoms- watery stool +/- blood/mucus. pelvic pain relieved by defecation, tenesmus, urgency
Dehydration: dry mucus membranes, decreased skin turgor, cap refill <2s, shock
4
Q
Diarrhoea
Investigations (8)
A
FBC: reduced MCV/Fe deficiency (coeliac/Crohn's) ESR/CRP: raised in infection, Crohn's, UC, cancer U+E: reduced K in severe D+V TSH: look for thyrotoxicosis Coeliac serology Stool culture Rigid sigmoidoscopy Colonoscopy/barium enema
5
Q
Constipation
Definition (1)
A
<2 bowel actions/week, or less often than the person’s normal, or passed with difficulty/straining/pain, or with a sense of incomplete evacuation
6
Q
Constipation Rome Criteria (7)
A
Constipation= presence of >2 symptoms during bowel movements (BMs)
Straining for >25%
Lumpy/hard stools >25%
Sensation of incomlete evacuations >25%
Sensation of anorectal obstruction/blockage >25%
Manual manoeuvres to facilitate at least 25% of BMs
Fewer than 3 BMs per week
7
Q
Constipation
Investigations (4)
A
Indicated if >40, change in bowel habit, associated symptoms (weight loss, PR mucus/blood, tenesmus)
Bloosd: FBC, ESR, U&E, Ca, TFT
Sigmoidoscopy
Barium enema/colonoscopy if suspect colorectal malignancy
8
Q
Constipation
Causes (6)
A
General: poor diet/exercise/fluid intake/IBS/age
Anorectal disease: anal/colorectal cancer, fissures, rectal prolapse
Intestinal obstruction: colorectal cancer, strictures (eg. Crohn’s), pelvic mass (fibroids), diverticulosis
Metabolic/endocrine: increase Ca, hypothyroid, low K
Drugs: opiates, anticholinergics, iron
Neuromuscular: spinal/pelvic nerve injury
9
Q
Constipation
Treatment (5)
A
General: diet, fluid, exercise advice
Bulking agents: increase faecal mass to stimulate peristalsis
Stimulant laxatives: increase intestinal motility eg. Senna, glycerol suppositories
Stool softeners: help in painful anal conditions eg. fissure
Osmotic laxatives: retain fluid in the bowel eg. lactulose
10
Q
IBS
Definition (1)
A
A mixed group of abdominal symptoms for which no organic cause can be found
11
Q
IBS
Prevalence (3)
A
10-20%
Age at onset <40
F:M 2:1
12
Q
IBS
Signs + Symptoms (7)
A
Abdominal pain relieved by defecation or associated with altered stool form/bowel frequency (constipation and diarrhoea alternate
Incomplete evacuation
Abdo bloating/distension
PR mucus
Worsening symptoms after eating
Urgency
Exacerbated by stress, menstruation, gastroenteritis
13
Q
IBS
Investigations (3)
A
If classic history: FBC, ESR, CRP, LFT and coeliac serology
If >50 or any marker of organic disease: high temp, PR exam (blood), weight loss, colonoscopy
If diarrhoea is prominent: LFT, stool culture, B12/folate, TSH
14
Q
IBS Referral criteria (6)
A
Diagnosis unsure Changing symptoms in known IBS Rectal mucosal prolapse (surgeon) Food intolerance (dietician) Stress/depression (psycho/hypno-therapy) Cyclical pain/increased Ca-125 (gynae)
15
Q
IBS
Treatment (5)
A
General: high fibre diet Constipation: bisacodyl Diarrhoea: bulking agent Colic/bloating: oral antispasmoidics eg. mebeverine Psychological symptoms: CBT/hypno
16
Q
Diverticular Disease
Definition (4)
A
Diverticulum: outpouching of the gut wall, usually at sites of entry of perforating arteries
Diverticulosis: diverticula are present but asymptomatic
Diverticular disease: symptomatic diverticula
Diverticulitis: inflammation of diverticulum
17
Q
Diverticular Disease
Pathology (2)
A
Most occur in sigmoid colon with 95% of complications here
Lack of dietary fibres –> high intraluminal pressure –> mucosa herniates through muscle layers of the gut at weak points adjacent to penetrating vessels
18
Q
Diverticular Disease
Prevalence (1)
A
30% of Westerners have diverticulosis by age 60 but the majority are asymptomatic
19
Q
Diverticular Disease
Investigations (4)
A
Colonoscopy (usually incidental finding)
Barium enema
CT abdo to confirm cute diverticulitis (enema/colonoscopy can cause perforation acutely)
AXR: identify obstruction perforation or vesical fistulae
20
Q
Diverticular Disease
Complications (2)
A
Altered bowel habit +/- left sided colic relieved by defecation
Diverticulitis
21
Q
Diverticular Disease
Treatment (3)
A
High fibre diet
Antispasmoidics eg. mebeverine
Surgical resection
22
Q
Diverticulitis
Signs + Symptoms (4)
A
Bleeding
Pyrexia
Localised/general peritonism
Tender colon
23
Q
Diverticulitis
Investigations (4)
A
High WCC
High CRP/ESR
Erect CXR + USS to detect perforation, free fluid and collections
CT with contrast
24
Q
Diverticulitis
Treatment (4)
A
Mild attacks treated at home
IV fluids
IV antibiotics
Surgery if severe
25
Diverticulitis
| Complications (4)
Perforation: ileus, peritonitis +/- shock, mortality 40%, laparotomy +/- Hartmann's procedure
Haemorrhage (rectal)
Fistulae
Abscesses
26
Angiodysplasia
| Definition (1)
Submucosal arteriovenous malformations that typically present as fresh PR bleeding in the elderly
27
Angiodysplasia
| Pathology (1)
70-90% of lesions occur in right colon
28
Angiodysplasia
| Investigations (4)
PR examination
Colonoscopy to exclude other things
Mesenteric angiography shows early filling at lesion site (allows therapeutic embolisation during acute bleed)
CT angio for non invasive option
29
Angiodysplasia
| Treatment (3)
Embolisation
Endoscopic laser electrocoagulation
Resection
30
Colorectal Cancer
| Epidemiology (2)
Lifetime incidence 1:15 M and 1:19 in F
| 3rd most common cancer and 2nd most common cause of UK cancer death
31
Colorectal Cancer
| Aetiology (1)
Adenocarcinoma
32
Colorectal Cancer
| Location (1)
Rectum > sigmoid > ascending + caecum > transverse > descending
33
```
Colorectal Cancer
Risk factors (7)
```
```
Neoplastic polyps
IBD
Genetics eg. FAP/HNPCC
Diet (low fibre/high red + processed meat)
Alcohol
Smoking
Previous cancer
```
34
Colorectal Cancer
| Signs + symptoms (3)
Left-sided: bleeding/mucus PR, altered bowel habit, obstruction, tenesmus, mass PR
Right-sided: weight loss, low Hb, abdo pain (obstruction less likely)
Either/both: abdo mass, perforation, haemorrhage, fistula
35
Colorectal Cancer
| Urgent referral criteria (4)
>40 with unexplained weight loss + abdo pain
>50 with unexplained rectal bleeding
>60 with iron-deficiency anaemia or changes in bowel habit
Blood in FOB test
36
Colorectal Cancer
| Investigations (5)
FBC: microcytic anaemia
FOB: screening every 2 years ages 60-75
Colonoscopy + biopsy: diagnostic
CT/MRI and LFT: staging especially for liver mets
CEA (carcinoembryonic antigen): disease monitoring
37
Colorectal Cancer
| Spread (4)
Local
Lymphatic
Blood (liver, bone, lungs)
Transcoelomic
38
Colorectal Cancer
| Dukes' Classification (4)
A: limited to muscularis mucosae, 93% 5 year survival
B: extension through muscularis mucosae, 77% 5 year survival
C: involvement of regional lymph nodes, 48% 5 year survival
D: distant mets, 6.6% 5 year survival
39
Colorectal Cancer
| Treatment of colon tumours (5)
Surgery +/- adjuvant chemo (FOLFOX: 5-FU, folinic acid,oxaliplatin)
Right hemicolectomy: caecal/ascending/proximal transverse tumours
Left hemicolectomy: distal transverse/descending tumours
Sigmoid colectomy
Hartmann's procedure: acute obstruction
40
Colorectal Cancer
| Treatment of rectal tumours (3)
Surgery +/- neoadjuvant radio (however, radio mainly for palliation)
Ant. resection: low sigmoid/high rectal tumours
Abdominal-perineal (AP) resection: low rectal tumours or sphincter involvement
41
Colorectal Cancer
| Principles of Resection (2)
Anastamosis can only be performed if adequate blood supply, mucosal apposition and no tissue tension
End stoma formed if criteria not met for anastamosis, sepsis or unstable
42
Acute Mesenteric Ischaemia
| Pathology (2)
Usually involves small bowel
Following superior mesenteric artery thrombosis/embolism or mesenteric vein thrombosis (less common but more likely in young)
43
Acute Mesenteric Ischaemia
| Signs + symptoms (2)
Classic triad: acute severe abdominal pain, no abdo signs, rapid hypovolaemia --> shock
Pain tends to be constant, central or around RIF
44
Acute Mesenteric Ischaemia
| Investigations (4)
```
Hb high (due to plasma loss)
WCC high
Metabolic acidosis
Abdo X-ray: 'gasless'
```
45
Acute Mesenteric Ischaemia
| Treatment (4)
Fluid resuscitation
Antibiotics
Heparin
Surgery to remove dead bowel
46
Acute Mesenteric Ischaemia
| Complications (2)
Septic peritonitis
| Progression of a systemic inflammatory response syndrome (SIRS) into a multi-organ dysfunction syndrome (MODS)
47
Acute Mesenteric Ischaemia
| Prognosis (2)
<40% survive arterial thrombosis and non-occlusive disease
| Not as bad for venous and embolic ischaemia
48
Chronic Mesenteric Ischaemia (Intestinal Angina)
| Pathology (1)
Often a history of vascular disease, 95% due to atherosclerotic disease in all 3 mesenteric arteries
49
Chronic Mesenteric Ischaemia (Intestinal Angina)
| Signs + symptoms (6)
```
Severe, colicky post-prandial abdo pain
Weight loss (as eating hurts)
Upper abdo bruit
PR bleeding
Malabsorption
N+V
```
50
Chronic Mesenteric Ischaemia (Intestinal Angina)
| Investigations (1)
CT angiography/contrast MR angiography
51
Chronic Mesenteric Ischaemia (Intestinal Angina)
| Treatment (1)
Surgery: percutaneous transluminal angioplasty and stent insertion to allow revascularisation
52
Chronic Colonic Ischaemia (Ischaemic Colitis)
| Pathology (2)
Usually follows low flow in the inferior mesenteric artery territory
Ranges from mild ischaemia to gangrenous colitis
53
Chronic Colonic Ischaemia (Ischaemic Colitis)
| Signs + symptoms (2)
Lower left-sided abdominal pain
| Bloody diarrhoea
54
Chronic Colonic Ischaemia (Ischaemic Colitis)
| Investigations (2)
```
Colonoscopy + biopsy
Barium enema (submucosal swelling)
```
55
Chronic Colonic Ischaemia (Ischaemic Colitis)
| Treatment (2)
Usually conservative: fluids + antibiotics
| Gangrenous ischaemic colitis (presenting with peritonitis + hypovolaemic shock) requires resection and stoma
56
Ulcerative Colitis
| Epidemiology (1)
Age 15-30
57
Ulcerative Colitis
| Definitions (4)
Relapsing + remitting inflammatory disorder of the colonic mucosa
Proctitis affects just the rectum (~50% cases)
Left-sided colitis is when it extends to involve part of the colon (~30% of cases)
Pancolitis is involvement of entire colon (~20% of cases)
58
```
Ulcerative Colitis
Protective factors (1)
```
Smoking, 3x more likely in non-smokers, symptoms may relapse on quitting
59
Ulcerative Colitis
| Signs + symptoms (4)
Episodic/chronic diarrhoea +/- blood + mucus
Crampy abdominal discomfort
Systemic: fever, malaise, anorexia, weight loss, tender distended abdomen, tachycardia
Extraintestinal: clubbing, apthous oral ulcers, erythema nodosum, conjunctivitis, large joint arthritis
60
Ulcerative Colitis
| Investigations (4)
Blood: FBC, ESR, CRP, U&E, LFT, culture
Stool culture
Abdo X-ray: no faecal shadows, mucosal thickening, colonic dilatation
Colonoscopy + biopsy: inflammatory infiltrate, goblet cell depletion, glandular distortion, mucosal ulcers
61
Ulcerative Colitis
| Severity: Truelove + Witts Criteria (5)
Motions per day: mild (<4), moderate (4-6), severe (>6)
Rectal bleeding: mild (small), moderate (moderate), severe (large)
Temperature: mild (apyrexial), moderate (37.1-37.8), severe (>37.8)
Pulse: mild (<70), moderate (70-90), severe (>90)
Hb: mild (>110), moderate (105-110), severe (<105)
62
Ulcerative Colitis
| Complications (5)
```
Perforation
Bleeding
Toxic dilatation of colon
Venous thrombosis
Colonic cancer risk
```
63
Ulcerative Colitis
| Treatment- Inducing remission (3)
Mild: 5-ASA (aminosalicylates eg. sulphasalazine) +/- steroid
Moderate: 5-ASA + steroid + twice daily steroid enemas
Severe: admit for nil by mouth + IV fluids + IV hydrocortisone, if no improvement after 3 days, need rescue therapy (infliximab/ciclosporin) or colectomy
64
Ulcerative Colitis
| Treatment- Maintaining remission (3)
5-ASAs reduce relapse rate from 80% to 20%
Immunomodulation: azathioprine, methotrexate, infliximab, adalimumab if failure to induce remission with steroids or prolonged use required
Surgery required in ~20% eg. proctocolectomy + terminal ileostomy
65
Crohn's Disease
| Definition (1)
Chronic inflammatory transmural disease affecting any part of the gut, unlike UC there is unaffected bowel between areas of active disease (skip lesions)
66
Crohn's Disease
| Epidemiology (1)
20-30 and 60-70
67
Crohn's Disease
| Signs + symptoms (10)
```
Diarrhoea/urgency
Abdo pain
Weight loss
Fever
Malaise
Anorexia
Apthous ulcerations
Abdo mass
Perianal abscess
Extra-intestinal: clubbing, skin, joint + eye problems
```
68
Crohn's Disease
| Complications (5)
```
Small bowel obstruction
Toxic dilatation (colonic diameter >6cm but rarer than in UC)
Abscess formation
Fistulae
Perforation
```
69
Crohn's Disease
| Investigations (6)
Blood: FBC, ESR, CRP, U&E, LFT, ferritin, B12, folate
Stool culture
Colonoscopy + rectal biopsy
Small bowel enema to detect ileal disease
MRI to assess disease extent and site of strictures
Upper GI endoscopy
70
Crohn's Disease
| Treatment of mild attacks (2)
Optimise nutrition, TPN last resort
| Oral prednisolone
71
Crohn's Disease
| Treatment of severe attack (5)
IV steroids
Metronidazole
Infliximab and adalimumab if no improvement
Azathioprine can be used as steroid sparer if multiple/rapid relapses
Surgery needed in 50-80%
72
Lower GI Bleeding
| Aetiology (5)
Colitis: bleeding brisk in advanced cases, usually have diarrhoea, AXR shows featureless colon
Acute diverticulitis: often settle spontaneously within 24-48h, bleeding often dark and of large volume
Cancer: not usually major bleeding but first signs of disease
Haemorrhoids: bleeding bright red post defecation
Angiodysplasia: massive bleeding without other symptoms
73
Lower GI Bleeding
| Investigations (5)
Bloods: FBC, LFT, U&E, creatinine, clotting, amylase (always rule out pancreatitis), crossmatch
AXR
Haemorrhoidal bleeding: proctosigmoidoscopy
Haemodynamically stable: elective colonoscopy
Haemodynamically unstable: CT/percutaneous angiography to identify angiodysplasia +/- coiling or surgery eg. embolisation
74
Lower GI Bleeding
| Treatment (2)
Coiling/embolisation in angiodysplasia/identified vessel
| Subtotal colectomy in UC
75
Intestinal Obstruction
| Definitions (5)
Failure of downward passage of intestinal contents
Simple obstruction: one obstructing point and no vascular compromise
Closed loop: obstruction at 2 points forming a loop of grossly distended bowel at risk of perforation eg. volvulus, obstructed hernia
Strangulation: blood supply is compromised and patient more ill than you'd expect, localised pain +/- peritonism
Sigmoid volvulus: bowel twists on its mesentery, producing severe strangulated obstruction
76
Intestinal Obstruction
| Aetiology (5)
```
Small bowel: adhesions, hernias
Large bowel: colon cancer, constipation, diverticular stricture, volvulus (sigmoid, caecal)
Crohn's stricture
Gallstone ileus
Intussusception
```
77
Intestinal Obstruction
| Pathology (3)
Above the obstruction there is early increased peristalsis and distension with air, later peristalsis ceases as the bowel becomes flaccid
Below the obstruction the intestine collapses and becomes paralysed and pale
Dehydration occurs because of vomiting and the failure of absorption of GI secretions in the bowel proximal to the obstruction
78
Intestinal Obstruction
| Signs + symptoms (8)
Vomiting (may even be faeculent)
Nausea
Anorexia
Colic (occurs early, most likely in small bowel)
Constipation (most likely in large bowel)
Abdominal distension (most likely in large bowel and progresses)
Silent abdomen on auscultation
Empty rectum/faecal impaction/tumour on PR exam
79
Intestinal Obstruction
| Investigations (9)
FBC: leucocytosis in peritonitis/strangulation
U&E + creatinine: electrolyte disturbance in small bowel obstruction
LFT: checking for liver mets in large bowel obstruction
Clotting: abnormal in sepsis due to strangulation/peritonitis
Erect CXR: pneumoperitoneum (free air under diaphragm) indicates perforation
AXR: small bowel - dilated small bowel loops with fluid levels, large bowel- peripheral gas shadows proximal to the blockage
Gastrograffin follow through: indicates non-surgical resolution if contrast visible in large bowel
Gastrograffin enema: identifies level of obstruction in large bowel
CT abdo: confirms and identifies level
80
Intestinal Obstruction
| Treatment (4)
Strangulation and large bowel obstruction require surgery
Ileus + incomplete small bowel obstruction can be treated conservatively
Immediate: 'drip and suck' (NG tube and fluid resuscitation)
Surgery: laparotomy/laparoscopy if cause is identified, if obstructed hernia then reduce viable bowel into abdo and resect eh non-viable
81
GORD
| Aetiology (10)
```
Lower oesophageal sphincter hypotension
Hiatus hernia (gastro-oesophageal junction slides up into the chest)
Abdominal obesity
Gastric acid hypersecretion
Slow gastric emptying
Over eating
Smoking
Alcohol
Pregnancy
Drugs (tricyclics, anticholinergics, nitrates)
```
82
GORD
| Signs + symptoms (7)
Heartburn (burning, retrosternal discomfort after meals, lying or straining, relieved by antacids)
Belching
Acid brash (acid/bile regurgitation)
Water brash (lots of salivation)
Odynophagia (painful swallowing eg. oesophagitis/ulceration)
Chronic cough
Laryngitis (hoarseness, throat clearing)
83
GORD
| Complications (5)
```
Oesophagitis
Ulcers
Benign stricture
Iron deficiency
Barret's oesophagus (distal oesophageal epithelium undergoes metaplasia from squamous to columnar- pre malignant)
```
84
GORD
| Investigations (3)
Endoscopy if symptoms >4 weeks, persistent vomiting, GI bleeding/Fe deficiency, palpable mass, >55, treatment not helping, weight loss
Barium swallow for hiatus hernia
24h oesophageal pH monitoring +/- manometry if endoscopy normal
85
GORD
| Treatment (5)
General: raise bed head, reduce weight, stop smoking, food avoidance (alcohol, citrus, fitzzy, caffeine), drug avoidance (nitrates, anticholinergics, CCBs, NSAIDs)
Antacids
Alginates eg. Gaviscon
PPI for oesophagitis
Surgery to increase lower oesophageal sphincter pressure eg. fundoplication
86
GORD
| Los Angeles Classification (4)
1: >1 mucosal break <5mm long
2: mucosal break >5mm
3: <75% oesophageal circumference
4: >75% oesophageal circumference
87
Peptic Ulcer Disease
| Definition (1)
A break in the inner lining of the stomach (elderly + lesser curvature) or duodenum (4x more common)
88
Peptic Ulcer Disease
| Signs + symptoms (5)
Epigastric pain often related to hunger, specific foods or time of day
Bloating
Heartburn
Tender epigastrum
ALARMS: Anaemia, Loss of weight, Anorexia, Recent onset, Malaena/haematemesis, Swallowing difficulties
89
```
Peptic Ulcer Disease
Risk factors (5)
```
```
H.pylori (90% of duodenal and 80% of gastric)
NSAIDs
Steroids
SSRIs
Smoking (more for gastric)
```
90
Peptic Ulcer Disease
| Investigations (2)
Urea breath test (H. pylori)
| Upper GI endoscopy
91
Peptic Ulcer Disease
| Treatment (4)
General: reduce stress, reduce alcohol, stop smoking, avoid aggravating foods
H. pylori eradication: triple therapy- amoxicillin + clarithromycin + PPI (eg. omeprazole/lansoprazole)
Drug to reduce acid: PPI/H2 blockers
Surgery: vagotomy
92
Peptic Ulcer Disease
| Complications (5)
```
Bleeding
Perforation
Malignancy
Reduced gastric outflow
Pyloric stenosis (late complication due to scarring)
```
93
```
Peptic Ulcer Disease
Emergency treatment (3)
```
Haemorrhagic: adrenaline injection, diathermy, laser coagulation
Perforation: laparoscopic repair followed by H. pylori eradication
Pyloric stenosis: endoscopic balloon dilatation followed by maximal acid suppression, drainage procedure +/- vagotomy if it fails
94
Gastric Cancer
| Epidemiology (1)
2:1 M:F
95
Gastric Cancer
| Aetiology (1)
Adenocarcinoma
96
```
Gastric Cancer
Risk factors (6)
```
```
Atrophic gastritis
Pernicious anaemia
Blood group A
H. pylori
Adenomatous polyps
Smoking
```
97
Gastric Cancer
| Spread (4)
Direct --> pancreas
Lymphatic --> Virchow's node
Haematogenous --> liver + lung
Transcoelemic --> ovaries
98
Gastric Cancer
| Signs + symptoms (7)
```
Often non-specific
Dyspepsia
Weight loss
Vomiting
Dysphagia
Anaemia
Suggesting incurable: mass, hepatomegaly, jaundice, ascites, Troisier's sign (enlarged Virchow's)
```
99
Gastric Cancer
| Investigations (5)
Gastroscopy + multiple biopsies
Endoscopic ultrasound can evaluate depth of invasion
CT/MRI for staging
Staging laparoscopy for locally advanced tumours
Bloods: FBC (anaemia), LFTs
100
Gastric Cancer
| Treatment (4)
Chemotherapy as pre-op or palliation
Gastrectomy/partial gastrectomy
Endoscopic mucosal resection for early tumours confined to mucosa
Surgical palliation for obstruction, pain, haemorrhage
101
Gastric Cancer
| Survival (2)
<10% 5y survival overall
| Nearly 20% for patients undergoing radical surgery
102
Upper GI Bleed
| Aetiology (7)
```
Peptic ulcers 35-50%
Mallory-Weiss tear 15%
Oesophageal varices
Gastritis/gastric erosions
Drugs: NSAIDs, aspirin, steroids, anticoagulants
Oesophagitis/duodenitis
Malignancy
```
103
Upper GI Bleed
| Rockall-Risk-Scoring Factors (3)
Age
Shock (systolic/pulse)
Comorbidity
104
Upper GI Bleed
| Signs + symptoms (7)
```
Haematemesis/melaena
Dizziness + fainting
Abdo pain
Hypotension
Tachycardia
Low JVP
Low urine output
```
105
```
Upper GI Bleed
Acute treatment (6)
```
IV fluids
Transfusion
Correct clotting abnormalities (vit K, FFP, platelets)
Omeprazole
Endoscopic haemostasis (within 4h of suspected variceal bleeding or 24h if ongoing bleeding)
Surgery
106
Oesophageal Varices
| Definition (2)
Extremely dilated submucosal veins in the lower 1/3 of oesophagus
Complication of portal hypertension, usually in the setting of cirrhosis
107
```
Oesophageal Varices
Risk factors (2)
```
Alcohol abuse
| Cirrhosis
108
Oesophageal Varices
| Investigations (1)
Endoscopy
109
Oesophageal Varices
| Treatment (4)
B-blocker as prophylaxis
Endoscopic variceal band ligation as prophylaxis
Transjugular intrahepatic porto-systemic shunt (TIPS) for varices resistant to banding
For acute bleed-endoscopic banding (but may be impossible due to limited visualisation) or sclerotherapy
110
Oesophageal Cancer
| Incidence (1)
<5/100,000/year
111
```
Oesophageal Cancer
Histological types (2)
```
Squamous carcinoma
| Adenocarcinoma
112
```
Oesophageal Cancer
Risk factors (7)
```
```
Diet
Alcohol excess
Smoking
Achalasia
Obesity
Reflux oesophagitis +/- Barret's
Male (5:1 M:F)
```
113
Oesophageal Cancer
| Site (3)
20% in upper part
50% in middle part
30% in lower part
114
Oesophageal Cancer
| Signs + symptoms (7)
```
Progressive dysphagia
Anorexia and weight loss
Chest pain
Cough
Pneumonia
Vocal cord paralysis
Haematemesis
```
115
Oesophageal Cancer
| Sites of metastases (4)
Liver
Brain
Lungs
Bone
116
Oesophageal Cancer
| Investigations (3)
Oesophagoscopy with biopsy
EUS, CT/MRI for staging
Laparoscopy if significant infra-diaphragmatic component
117
Oesophageal Cancer
| Staging (6)
```
T1- tumour invades lamina propria or submucosa
T2- tumour invades muscularis propria
T3- tumour invades adventitia
T4- tumour invades adjacent structures
N1- regional lymph node metastases
M1- distant metastases
```
118
Oesophageal Cancer
| Treatment (2)
T1/2- radical oesophagectomy +/- chemotherapy
| Palliation with chemo/radio, stenting and laser
119
Oesophageal Cancer
| Prognosis (3)
40% 1 year survival
15% 5 year survival
>10% 10 year survival
120
Barrett's Oesophagus
| Pathology (4)
Results from prolonged exposure of normal oesophageal squamous epithelium to the refluxate of GORD
Causes mucosal inflammation and erosion
Leads to replacement of the mucosa with metaplastic columnar epithelium
Risk of progression to adenocarcinoma
121
Barrett's Oesophagus
| Treatment (2)
If high grade oesophageal resection or mucosectomy if young + fit, for others do mucosal ablation
Annual endoscopic surveillance for low-grade
122
Inguinal Hernias
| Indirect vs direct (2)
Indirect: pass through the internal inguinal ring and, if large ,out through the external ring, very common and can strangulate
Direct: push directly forward through the posterior wall of the inguinal canal, into a defect in the abdominal wall (Hessellbach's triangle- medial to the inferior epigastric vessels and lateral to the rectus abdominis), reduce easily
123
```
Inguinal Hernias
Risk factors (7)
```
```
Males (8:1 M:F)
Chronic cough
Constipation
Urinary obstruction
Heavy lifting
Ascites
Post abdominal surgery
```
124
Inguinal Hernias
| Anatomy (6)
Deep ring: midpoint of inguinal ligament, ~1/2cm above femoral pulse
Superficial ring: split in the external oblique aponeurosis just superior and medial to the pubic tubercle (which is the medial attachment of the inguinal ligament)
Floor: inguinal ligament + lacunar ligament medially
Roof: transversalis + internal oblique
Anterior: external oblique and internal oblique
Posterior: transversalis fascia laterally, conjoint tendon medially
125
Inguinal Hernias
| Contents of inguinal canal (3)
Ilioinguinal nerve
Round ligament in females
Spermatic cord in males
126
Inguinal Hernias
| Examination (4)
Try reducing it
If no lump visible, feel for cough impulse
Repeat examination standing
Distinguishing direct from indirect: reduce hernia and occlude deep ring with 2 fingers and ask patient to cough and if it's restrained it's indirect, if not it's direct
127
Inguinal Hernias
| Treatment(3)
Lose weight
Mesh repairs (mesh to reinforce posterior wall)
Laparoscopic repair
128
Femoral Hernias
| Pathology (4)
Bowel enters femoral canal presenting as a mass in the upper medial thigh or above the inguinal ligament where it points down the leg (inguinal hernias point to the groin)
Occur more often in women
Likely to be irriducible
Strangulation (ischaemia occurs) is common due to the rigidity of the canal's borders
129
Femoral Hernias
| Anatomy (2)
Neck of hernia felt inferior and lateral to the pubic tubercle
Boundaries of the femoral canal: anterior- inguinal ligament, medially- lacunar ligament, laterally- femoral vein, posteriorly- pectineus
130
Acute Abdomen
| Right upper quadrant pain (3)
Acute cholecystitis
Duodenal ulcer
Appendicitis
131
```
Acute Abdomen
Epigastric pain (5)
```
```
Pancreatitis
MI
Peptic ulcer
Acute cholecystitis
Perforated oesophagus
```
132
Acute Abdomen
| Left upper quadrant pain (4)
Ruptured spleen
Gastric ulcer
Aortic aneurysm
Perforated colon
133
```
Acute Abdomen
Umbilical pain (5)
```
```
Intestinal obstruction
Acute pancreatitis
Early appendicitis
Aortic aneurysm
Diverticulitis
```
134
Acute Abdomen
| Right lower quadrant pain (6)
```
Appendicitis
Ruptured ectopic pregnancy
Renal/ureteric stone
Strangulated hernia
Crohn's disease
Perforated caecum
```
135
Acute Abdomen
| Left lower quadrant pain (7)
```
Sigmoid diverticulitis
Ruptured ectopic
Strangulated hernia
Perforated colon
Crohn's disease
UC
Renal/ureteric stones
```
136
Acute Abdomen
| Investigations (3)
```
Bloods: U&E, FBC, amylase, LFT, CRP
ABG: check for mesenteric ischaemia
Urinalysis
Erect CXR
AXR
Laparoscopy
CT
USS: identify perforation/free fluid
```
137
Acute Abdomen
| Syndromes requiring laparotomy (2)
Organ rupture: spleen, aorta, ectopic pregnancy
| Peritonitis: perforated peptic ulcer, duodenal ulcer, diverticulum, appendix, bowel or gallbladder
138
Acute Abdomen
| Syndromes not requiring laparotomy (2)
Local peritonitis: diverticulitis, cholecystitis, salpingitis, appendicitis
Colic: gut, ureter, uterus, bile duct, gallbladder
139
Acute Appendicitis
| Pathology (3)
Faecal material becomes lodged in appendix
Smooth muscle tries to expel it by contracting (causing general periumbilical pain)
Pus then builds up causing serosal inflammation, this rubs against the peritoneum to cause the localised pain at McBurney's point
140
Acute Appendicitis
| Signs + symptoms (9)
```
Periumbilical pain that moves to RIF
Anorexia
Constipation
Tachycardia
Fever
Shallow breaths
Guarding
Rebound and percussive tenderness
Psoas sign- pain on extending hip if retrocaecal appendix
```
141
Acute Appendicitis
| Investigations (4)
FBC: neutrophil leucocytosis
CRP: elevated
USS
CT
142
```
Acute Appendicitis
Differential diagnoses (7)
```
```
Ectopic pregnancy
UTI
Cystitis
Cholecystitis
Diverticulitis
Perforated ulcer
Food poisoning
```
143
Acute Appendicitis
| Treatment (2)
Appendicectomy
| Antibiotics: metronidazole + cefuroxime pre-op (give longer course if suspect perforation)
144
Gallstones
| Pathology (2)
Bile contains cholesterol, bile pigments (from broken down Hb) and phospholipids
If concentrations vary, different stones may form
145
Gallstones
| Types (3)
Pigment stones: <10%, small, friable + irregular, caused by haemolysis
Cholesterol stones: large, often solitary, female, age + obesity are risk factors
Mixed stones: faceted (calcium salts, pigment and cholesterol)
146
Gallstones
| Prevalence (2)
8% of those >40
| 90% remain asymptomatic
147
Gallstones
| Complications (3)
In gallbladder + cystic duct: biliary colic, acute + chronic cholecystitis, empyema
In bile duct: obstructive jaundice, cholangitis, pancreatitis
In gut: gallstone ileus
148
Biliary Colic
| Definition (2)
Gallstones are symptomatic with cystic duct obstruction
| RUQ pain radiates to the back +/- jaundice (if it move to CBD)
149
Biliary Colic
| Treatment (2)
Analgesia
| Elective laparoscopic cholecystectomy
150
Acute Cholecystitis
| Definition (1)
Follows stone or sludge impaction in the neck of the gallbladder
151
Acute Cholecystitis
| Signs + symptoms (7)
Continuous epigastric/RUQ pain which may be referred to the right shoulder
Vomiting
Fever
Local peritonism
Mass
Obstructive jaundice and cholangitis may occur if stone moves to the CBD
Murphy's sign: 2 fingers over RUQ, patient breathes in, causes pain and arrest of inspiration
152
Acute Cholecystitis
| Investigations (2)
High WCC
| Ultrasound: thick-walled shrunken gallbladder, fluid, stones, dilated CBD
153
Acute Cholecystitis
| Treatment (6)
Analgesia
Fluids
IV cefuroxime
Lapaorscopic cholecystectomy (acute or delayed)
Open surgery if perforation
Bile duct stones: suggested if RUQ pain post-op (do MRCP to confirm), clear surgically at time of laparoscopy or ERCP
154
Cholangitis
| Definition (1)
Bile duct infection
155
Cholangitis
| Signs + symptoms (1)
Charcot's triad: RUQ pain + jaundice + rigors (fever and high WCC)
156
Cholangitis
| Treatment (1)
IV cefuroxime + metronidazole
157
Cholangiocarcinoma
| Aetiology (2)
Adenocarcinoma
| Primary sclerosing cholagnitis
158
Cholangiocarcinoma
| Signs + symptoms (6)
```
Fever
Abdo pain
Ascites
Malaise
Obstructive jaundice
Virchow node lymphadenopathy
```
159
Cholangiocarcinoma
| Investigations (5)
```
High alk phos
High bilirubin
Abdo USS
CT
MRCP
```
160
Cholangiocarcinoma
| Treatment (1)
Surgical resection only curative option but 80% are inoperable so palliate with biliary stents/chemo
161
Cholangiocarcinoma
| Prognosis (2)
5 year survival ~30% if early stage
| Overall ~ 5 months
162
Acute Pancreatitis
| Aetiology (10)
```
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia/Hypothermia/Hypercalcaemia
ERCP/Embolii
Drugs (steroids, azathioprine, diuretics)
```
163
Acute Pancreatitis
| Pathology (3)
Self-perpetuating pancreatic inflammation by enzyme-mediated autodigestion
Oedema and fluid shifts causing hypovolaemia as extracellular fluid is trapped in the gut, peritoneum and retroperitoneum
Progression may be rapid from mild oedema to necrotising fasciitis
164
Acute Pancreatitis
| Signs + symptoms (7)
Gradual/sudden severe epigastric or central abdominal pain (radiates to back, sitting forward may relieve)
Vomiting
Tachycardia
Fever
Jaundice
Rigid abdomen +/- local/general tenderness
Shock
165
Acute Pancreatitis
| Investigations (9)
Serum amylase (>1000 or 3x normal, degree of elevation not related to severity)
Serum lipase
ABG to monitor oxygenation + acid-base balance
AXR: no psoas shadow (increased retroperitoneal fluid)
Erect CXR: excludes other causes, eg. perforation
CT: assess severity and complications
US: if gallstones
ERCP: if LFTs worsen
High CRP: indicates severe pancreatitis
166
Acute Pancreatitis
| Glasgow Criteria of Severity (9)
```
>3 +ve factors within 48h suggests severe pancreatitis (transfer to ITU/HDU)
PaO2 <8
Age >55
Neutrophilia
Calcium <2
Renal function (urea >16)
Enzymes (LDH >600)
Albumin (<32)
Sugar (glucose >10)
```
167
Acute Pancreatitis
| Treatment (5)
```
NG tube (reduce pancreatic stimulation)
IV fluids
Analgesia
Antibiotics in severe disease
ERCP + gallstones removal if progressive jaundice
```
168
```
Acute Pancreatitis
Early complications (6)
```
```
Shock
ARDS
Renal failure
Sepsis
Hypocalcaemia
High glucose
```
169
```
Acute Pancreatitis
Late complications (6)
```
```
Pancreatic necrosis
Pseudocyst
Abscess
Bleeding
Thrombosis
Fistulae
```
170
Chronic Pancreatitis
| Aetiology (6)
```
Alcohol
Cystic fibrosis
Haemochromatosis
Pancreatic duct obstruction (stones/tumour)
High PTH
Familial
```
171
Chronic Pancreatitis
| Signs + symptoms (6)
```
Epigastric pain which radiates to the back
Bloating
Exocrine insufficiency --> steatorrhoea
Endocrine insufficiency --> diabetes
Weight loss
Relapsing and worsening symptoms
```
172
Chronic Pancreatitis
| Investigations (3)
Ultrasound +/- CT (pancreatic calcifications confirm diagnosis)
AXR: speckled calcification
Glucose increased
173
Chronic Pancreatitis
| Treatment (3)
Drugs: analgesia (eg. coeliac plexus block), pancreatic enzyme supplements, insulin
Diet: no alcohol
Surgery for unremitting pain and weight loss eg. pancreatectomy
174
Chronic Pancreatitis
| Complications (6)
```
Pseudocyst
Diabetes
Biliary obstruction
Local arterial aneurysm
Splenic vein thrombosis
Pancreatic carcinoma
```
175
Pancreatic Cancer
| Epidemiology (2)
<2% of malignancy
| Typically male >60
176
```
Pancreatic Cancer
Risk factors (5)
```
```
Smoking
Alcohol
Diabetes
Chronic pancreatitis
Increased waist circumference (ie. central adiposity)
```
177
Pancreatic Cancer
| Pathology (3)
Mostly ductal adenocarcinoma (metastasise early and present late)
60% arise in the pancreas head, 2% in body, 15% in tail
~95% have mutations in the KRAS2 gene
178
Pancreatic Cancer
| Signs + symptoms (12)
```
Painless obstructive jaundice is how tumours in the head present
Most body + tail tumours present with epigastric pain
Anorexia
Weight loss
Diabetes
Acute pancreatitis
Jaundice
Palpable gallbladder/epigastric mass
Hepatomegaly
Splenomegaly
Ascites
Lymphadenopathy
```
179
Pancreatic Cancer
| Investigations (2)
US/CT show pancreatic mass+/- dilated biliary tree +/- hepatic metastases
ERCP for biliary tree anatomy and may localise site of obstruction
180
Pancreatic Cancer
| Prognosis (2)
Mean survival <6 months
| 5 year survival 3%
181
Liver Function Tests
| Bilirubin (3)
Byproduct of haeme metabolism
Liver solubises it
Elevated in haemolysis, parenchymal damage and obstruction
182
Liver Function Tests
| Aminotransferases (2)
Enzymes present in hepatocytes
| Suggests parenchymal involvement
183
```
Liver Function Tests
Alkaline phosphatase (3)
```
Enzyme present in bile ducts
Elevated with obstruction or liver infiltration
Also present in bone, placenta and intestines
184
```
Liver Function Tests
Gamma GT (3)
```
Nonspecific liver enzyme
Elevated with alcohol and NSAID use
Useful to confirm liver source of ALP
185
Liver Function Tests
| Albumin (3)
Important test for synthetic function of liver
Low level suggests chronic liver disease
Can be low in kidney disorders and malnutrition
186
Liver Function Tests
| Creatinine (3)
Essentially kidney function
Determines survival from liver disease
Critical assessment for need of transplant
187
Liver Function Tests
| Distinguishing between liver damage and cholestasis (3)
```
Alanine transaminase (ALT): high concentration in hepatocytes, enters blood following hepatocellular injury (high ALT low ALP = hepatocellular)
Alklaline phosphatase (ALP): high conc. in liver, bile duct and bone tissues, increased synthesis suggests cholestasis (high ALP low ALT high GGT = cholestasis, high ALP, low ALT normal GGT = non-biliary pathology eg. tumour/mets)
Gamma glutamyl transferase (GGT): biliary epithelial damage, bile flow obstruction
```
188
Liver Function Tests
| Assessing synthetic liver function (4)
```
Bilirubin (conjugated is raised in hepatocellular injury/cholestasis)
Albumin (decreased in cirrhosis + inflammation)
Prothrombin time (decreased in cirrhosis + inflamation)
Prothrombin time (INR) (increased in hepatic pathology)
ALT/AST ratio: ALT>AST = chronic liver disease, AST>ALT = cirrhosis
```
189
Liver Function Tests
| Common patterns of deranged LFTs (3)
Acute hepatocellular damage: v high ALT, normal/raised ALP, normal/raised GGT, high/v. high bilirubin (paracetamol overdose, hep A/B, liver ischaemia)
Chronic hepatocellular damage: ALT normal/high, ALP normal/high, GGT normal/high, bilirubin normal/high (alcoholic liver disease, hep B/C, alpha 1 antitrypsin deficiency)
Cholestasis: ALT normal/high, ALP v. high, GGT v. high, bilirubin v. high
190
Liver Cirrhosis
| Aetiology (4)
Chronic alcohol abuse
Hep B/C
Genetic: haemochromatosis, alpha-1-antitrypsin deficiency
Drugs: amiodarone, methotrexate
191
Liver Cirrhosis
| Pathology (1)
Necrosis of hepatic parenchyma causes connective tissue proliferation and nodular regeneration
192
Liver Cirrhosis
| Signs + symptoms (11)
```
May be none and just high LFTs
Leuconychia due to hypoalbuminaemia
Clubbing
Palmar erythema
Dupuytren's contracture
Spider naevi
Xanthelasma
Gynaecomastia
Loss of body hair
Hepatomegaly (or a small liver in late disease)
Ascites
```
193
Liver Cirrhosis
| Investigations (8)
```
LFTs: ALT normal/high, ALP normal/high, GGT normal/high
Synthetic function: bilirubin normal/high, albumin normal/high
FBC: thrombocytopenia
Hepatitis serology
Liver ultrasound and duplex
MRI
Ascitic tap
Liver biopsy
```
194
Liver Cirrhosis
| Complications (3)
Hepatic failure: coagulopathy (low factors II, VII, IX, X causes high INR), encephalopathy, hypoalbuminaemia, sepsis
Spontaneous bacterial peritonitis
Portal hypertension: ascites, splenomegaly, portosystemic shunt including oesophageal varices and caput medusae (enlarged superficial periumbilical veins)
195
Liver Cirrhosis
| Child-Pugh Grading of Cirrhosis and Risk of Variceal Bleeding (7)
```
Grade A= 5-6, grade B= 7-9, C= >10
Risk of variceal bleeding higher if score >8
Bilirubin
Albumin
Prothrombin time
Ascites
Encephalopathy
```
196
Liver Cirrhosis
| Treatment (3)
Alcohol abstinence
Ascites: bed rest, fluid restriction, spironolactone
Liver transplant
197
Hepatic Encephalopathy
| Pathology (2)
Reduced hepatic metabolic function causes conversion of liver toxins directly into systemic circulation with ammonia accumulation and transfer over the blood-brain barrier
In the brain it is converted to glutamate and then glutamine causing osmotic imbalance and cerebral oedem
198
Hepatic Encephalopathy
| Grading (4)
I: confused, irritable, mild confusion, sleep inversion, dyspraxia
II: drowsy, confusion, slurred speech +/- liver flap, inappropriate behaviour/personality change
III: incoherent, restless, liver flap
IV: coma
199
Hepatic Encephalopathy
| Precipitants (4)
Constipation
Haemorrhage
Infection
Electrolyte imbalance (hyponatraemia, hypokalaemia)
200
Hepatic Encephalopathy
| Treatment (2)
Treat cirrhosis
| Lactulose +/- phosphate enema
201
Portal Hypertension
| Aetiology (3)
Pre-hepatic: thrombosis (portal/splenic vein)
Intra-hepatic: cirrhosis, Schistosomiasis
Post-hepatic: Budd-Chiari, right heart failure
202
Portal Hypertension
| Pathology (4)
Increased intrahepatic pressure causes increased hepatic portal pressure, when >12 collateral circulation forms between portal and systemic
Oesophageal and gastric varices: portal gastric veins anastomose with systemic inferior oesophageal veins
Caput medusae: portal periumbilical veins anastomose with superior abdominal wall veins
Haemorrhoids: portal superior rectal veins anastomose with systemic middle and inferior rectal veins
203
Liver Failure
| Aetiology (2)
Acute, eg. alcohol, paracetamol overdose, hep A/B
| Decompensation ie. any cause of cirrhosis
204
Liver Failure
| Signs + symptoms (5)
```
Jaundice
Hepatic encephalopathy
Fetor hepaticus (smells of pear drops)
Liver flap
Signs of cirrhosis/chronic liver disease
```
205
Liver Failure
| Investigations (11)
```
FBC (infection, GI bleed)
U&E + creatinine
LFTs
Clotting (increased PT/INR)
Glucose
Paracetamol level
Hepatitis/CMV/EBV serology
Blood + urine culture
Ascitic tap for culture and serology to investigate spontaneous bacterial peritonitis
CXR
Abdo ultrasound
```
206
Liver Failure
| Treatment (7)
```
ITU admission
IV glucose to avoid hypoglycaemia
Treat the cause
Thiamine + folate supplements
Haemodialysis if renal failure develops
PPI as prophylaxis against ulceration
Liver transplant
```
207
Alcoholic Liver Disease
| Pathology (1)
Steatosis (fatty acids replaced by alcohol products in the Krebs cycle promoting glycogenolysis) to hepatitis (inflammation + necrosis) and cirrhosis (fibrosis of necrotic tissue)
208
Alcoholic Liver Disease
| Signs + symptoms (8)
Hepatic: alcoholic hepatitis, cirrhosis
GI: gastritis, erosions, peptic ulcers,varices, pancreatitis
CNS: poor memory + cognition, peripheral polyneuropathy, fits, falls, Wernicke's, Korsakoff's
CVS: dilated cardiomyopathy, AF, high BP
Haematology: anaemia, thrombocytopenia
Features of dependency- CAGE
Signs of withdrawal on stopping eg. DTs, tremor, delusions, hallucinations
Cravings
209
Alcoholic Liver Disease
| Wernicke's Encephalopathy (2)
Thiamine deficiency
| Triad of nystagmus, opthalmoplegia and ataxia with confusion + altered GCS
210
Alcoholic Liver Disease
| Korsakoff's Syndrome (1)
Anterograde + retrograde amnesia
211
```
Alcoholic Liver Disease
CAGE Screening (4)
```
do you feel you should Cut down?
have you felt Annoyed when criticised about drinking?
do you feel Guilt?
do you need an Eye opener?
212
Alcoholic Liver Disease
| Investigations (6)
```
FBC (macrocytic anaemia, thrombocytopenia)
Folate deficient
LFT (AST> ALT with high GGT)
Prolonged INR
U&E (hypomagnesaemia)
Cirrhosis investigations
```
213
Alcoholic Liver Disease
| Treatment (4)
Disulphram: promotes abstinence by inhibiting acetylaldehyde dehydrogenase which causes a severe reaction if you drink alcohol
Acamprosate: reduces cravings as a weak NMDA antagonist
Benzo/carbamazepine for withdrawal
Pabrinex: for thiamine deficiency
214
Alcoholic Hepatitis
| Definition (2)
Acute inflammation due to alcohol consumption
| 80% proceed to cirrhosis, 10% to liver failure
215
Alcoholic Hepatitis
| Signs + symptoms (8)
```
Fever
Nausea
Diarrhoea
Vomiting
Tender hepatomegaly
Jaundice
Ascites
Encephalopathy
```
216
Alcoholic Hepatitis
| Investigations (6)
```
FBC: High WCC, low platelets
INR: high
AST: high
MCV: high
Urea: high
Cirrhosis investigations
```
217
Alcoholic Hepatitis
| Treatment (4)
Treat withdrawal
Vit K
Thiamine (pabrinex)
Prednisolone tapered dose for >3 weeks
218
Non-Alcoholic Fatty Liver Disease
| Definition (1)
Increased fat in hepatocytes (steatosis) +/- inflammation (Steatohepatitis)
219
```
Non-Alcoholic Fatty Liver Disease
Risk factors (5)
```
```
Obesity
Hypertension
Type 2 diabetes
Dyslipidaemia
Typical patient is middle aged obese female
```
220
Non-Alcoholic Fatty Liver Disease
| Treatment (2)
Control risk factors
| Bariatric surgery
221
Budd-Chiari Syndrome
| Aetiology (2)
```
Hypercoagulable states (eg. the pill, pregnancy, malignancy, polycythaemia, thrombophilia)
Liver/renal/adrenal tumour
```
222
Budd-Chiari Syndrome
| Pathology (1)
Hepatic vein obstruction by thrombosis or tumour causes congestive ischaemia and hepatocyte damage
223
Budd-Chiari Syndrome
| Signs + symptoms (3)
Abdo pain
Hepatomegaly
Ascites
224
Budd-Chiari Syndrome
| Investigations (4)
ALT: high
USS + hepatic vein doppler
LFTs
Ascitic tap
225
Budd-Chiari Syndrome
| Treatment (2)
Anticoagulation (unless varices)
| May require angioplasty, TIPSS procedure (transjugular intrahepatic porto-systemic shunt)
226
Hereditary Haemochromatosis
| Definition (2)
Inherited (autosomal recessive mutation in HFE gene on chromosome 7) disorder of iron metabolism in which there is increased intestinal iron absorption
Leads to iron deposition in joints, liver, heart, pancreas, pituitary, adrenals and skin
227
Hereditary Haemochromatosis
| Signs + symptoms (3)
Early on: nil or tiredness/arthralgia/fewer erections
Later: slate-grey skin pigmentations, signs of chronic liver disease (cirrhosis, hepatomegaly), dilated cardiomyopathy, osteoporosis
Endocrine: DM (diabetes in pancreas), hypergonadism (pituitary dysfunction)
228
Hereditary Haemochromatosis
| Investigations (4)
Bloods: high LFT, high serum ferritin, iron, reduced total iron binding capacity
Liver MRI: chondrocalcinosis, Fe overload
Liver biopsy to quantify iron loading
ECG/echo: cardiomyopathy
229
Hereditary Haemochromatosis
| Treatment (3)
Iron removal via venesection (lifelong)
Monitor for and treat diabetes
Screen 1st degree relatives
230
Autoimmune Hepatitis
| Definition (2)
Inflammatory liver disease of unknown cause, characterised by suppressor T cell defects with autoantibodies directed against hepatocyte surface antigens
Effects young + middle-aged women
231
Autoimmune Hepatitis
| Signs + symptoms (8)
```
Many present with acute hepatitis and signs of autoimmune disease
Fever
Malaise
Urticarial rash
Polyarthritis
Glomerulonephritis
Gradual jaundice
Amenorrhoea
```
232
Autoimmune Hepatitis
| Investigations (5)
Serum bilirubin, AST, ALT and alk phos all usually increased
Hypergammaglobulinaemia (especially IgG)
Autoantibodies: antismooth muscle antibodies (ASMA), ANA, IgG
Anaemia, low WCC, low platelets indicate hypersplenism
Liver biopdy
233
Autoimmune Hepatitis
| Treatment (2)
Prednisolone/azathioprine as steroid-sparing
| Liver transplant
