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Med Student Finals > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Diarrhoea

Most common causes (9)

A 
IBS 
Gastroenteritis 
Parasites 
Colorectal cancer 
Crohn's disease 
Ulcerative colitis 
Coeliac disease 
Thyrotoxicosis 
Antibiotics
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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)

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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

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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
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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

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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

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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

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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

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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

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10
Q

IBS

Definition (1)

A

A mixed group of abdominal symptoms for which no organic cause can be found

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11
Q

IBS

Prevalence (3)

A

10-20%
Age at onset <40
F:M 2:1

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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

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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

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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)
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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
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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

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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

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18
Q

Diverticular Disease

Prevalence (1)

A

30% of Westerners have diverticulosis by age 60 but the majority are asymptomatic

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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

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20
Q

Diverticular Disease

Complications (2)

A

Altered bowel habit +/- left sided colic relieved by defecation
Diverticulitis

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21
Q

Diverticular Disease

Treatment (3)

A

High fibre diet
Antispasmoidics eg. mebeverine
Surgical resection

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22
Q

Diverticulitis

Signs + Symptoms (4)

A

Bleeding
Pyrexia
Localised/general peritonism
Tender colon

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23
Q

Diverticulitis

Investigations (4)

A

High WCC
High CRP/ESR
Erect CXR + USS to detect perforation, free fluid and collections
CT with contrast

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24
Q

Diverticulitis

Treatment (4)

A

Mild attacks treated at home
IV fluids
IV antibiotics
Surgery if severe

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25
Q

Diverticulitis

Complications (4)

A

Perforation: ileus, peritonitis +/- shock, mortality 40%, laparotomy +/- Hartmann’s procedure
Haemorrhage (rectal)
Fistulae
Abscesses

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26
Q

Angiodysplasia

Definition (1)

A

Submucosal arteriovenous malformations that typically present as fresh PR bleeding in the elderly

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27
Q

Angiodysplasia

Pathology (1)

A

70-90% of lesions occur in right colon

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28
Q

Angiodysplasia

Investigations (4)

A

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

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29
Q

Angiodysplasia

Treatment (3)

A

Embolisation
Endoscopic laser electrocoagulation
Resection

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30
Q

Colorectal Cancer

Epidemiology (2)

A

Lifetime incidence 1:15 M and 1:19 in F

3rd most common cancer and 2nd most common cause of UK cancer death

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31
Q

Colorectal Cancer

Aetiology (1)

A

Adenocarcinoma

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32
Q

Colorectal Cancer

Location (1)

A

Rectum > sigmoid > ascending + caecum > transverse > descending

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33
Q 
Colorectal Cancer
Risk factors (7)
A 
Neoplastic polyps
IBD 
Genetics eg. FAP/HNPCC 
Diet (low fibre/high red + processed meat) 
Alcohol 
Smoking 
Previous cancer
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34
Q

Colorectal Cancer

Signs + symptoms (3)

A

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

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35
Q

Colorectal Cancer

Urgent referral criteria (4)

A

> 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

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36
Q

Colorectal Cancer

Investigations (5)

A

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

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37
Q

Colorectal Cancer

Spread (4)

A

Local
Lymphatic
Blood (liver, bone, lungs)
Transcoelomic

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38
Q

Colorectal Cancer

Dukes’ Classification (4)

A

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

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39
Q

Colorectal Cancer

Treatment of colon tumours (5)

A

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

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40
Q

Colorectal Cancer

Treatment of rectal tumours (3)

A

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

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41
Q

Colorectal Cancer

Principles of Resection (2)

A

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

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42
Q

Acute Mesenteric Ischaemia

Pathology (2)

A

Usually involves small bowel
Following superior mesenteric artery thrombosis/embolism or mesenteric vein thrombosis (less common but more likely in young)

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43
Q

Acute Mesenteric Ischaemia

Signs + symptoms (2)

A

Classic triad: acute severe abdominal pain, no abdo signs, rapid hypovolaemia –> shock
Pain tends to be constant, central or around RIF

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44
Q

Acute Mesenteric Ischaemia

Investigations (4)

A 
Hb high (due to plasma loss) 
WCC high 
Metabolic acidosis 
Abdo X-ray: 'gasless'
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45
Q

Acute Mesenteric Ischaemia

Treatment (4)

A

Fluid resuscitation
Antibiotics
Heparin
Surgery to remove dead bowel

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46
Q

Acute Mesenteric Ischaemia

Complications (2)

A

Septic peritonitis

Progression of a systemic inflammatory response syndrome (SIRS) into a multi-organ dysfunction syndrome (MODS)

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47
Q

Acute Mesenteric Ischaemia

Prognosis (2)

A

<40% survive arterial thrombosis and non-occlusive disease

Not as bad for venous and embolic ischaemia

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48
Q

Chronic Mesenteric Ischaemia (Intestinal Angina)

Pathology (1)

A

Often a history of vascular disease, 95% due to atherosclerotic disease in all 3 mesenteric arteries

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49
Q

Chronic Mesenteric Ischaemia (Intestinal Angina)

Signs + symptoms (6)

A 
Severe, colicky post-prandial abdo pain 
Weight loss (as eating hurts) 
Upper abdo bruit 
PR bleeding 
Malabsorption 
N+V
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50
Q

Chronic Mesenteric Ischaemia (Intestinal Angina)

Investigations (1)

A

CT angiography/contrast MR angiography

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51
Q

Chronic Mesenteric Ischaemia (Intestinal Angina)

Treatment (1)

A

Surgery: percutaneous transluminal angioplasty and stent insertion to allow revascularisation

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52
Q

Chronic Colonic Ischaemia (Ischaemic Colitis)

Pathology (2)

A

Usually follows low flow in the inferior mesenteric artery territory
Ranges from mild ischaemia to gangrenous colitis

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53
Q

Chronic Colonic Ischaemia (Ischaemic Colitis)

Signs + symptoms (2)

A

Lower left-sided abdominal pain

Bloody diarrhoea

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54
Q

Chronic Colonic Ischaemia (Ischaemic Colitis)

Investigations (2)

A 
Colonoscopy + biopsy 
Barium enema (submucosal swelling)
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55
Q

Chronic Colonic Ischaemia (Ischaemic Colitis)

Treatment (2)

A

Usually conservative: fluids + antibiotics

Gangrenous ischaemic colitis (presenting with peritonitis + hypovolaemic shock) requires resection and stoma

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56
Q

Ulcerative Colitis

Epidemiology (1)

A

Age 15-30

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57
Q

Ulcerative Colitis

Definitions (4)

A

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)

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58
Q 
Ulcerative Colitis
Protective factors (1)
A

Smoking, 3x more likely in non-smokers, symptoms may relapse on quitting

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59
Q

Ulcerative Colitis

Signs + symptoms (4)

A

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

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60
Q

Ulcerative Colitis

Investigations (4)

A

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

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61
Q

Ulcerative Colitis

Severity: Truelove + Witts Criteria (5)

A

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)

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62
Q

Ulcerative Colitis

Complications (5)

A 
Perforation 
Bleeding 
Toxic dilatation of colon 
Venous thrombosis 
Colonic cancer risk
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63
Q

Ulcerative Colitis

Treatment- Inducing remission (3)

A

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

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64
Q

Ulcerative Colitis

Treatment- Maintaining remission (3)

A

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

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65
Q

Crohn’s Disease

Definition (1)

A

Chronic inflammatory transmural disease affecting any part of the gut, unlike UC there is unaffected bowel between areas of active disease (skip lesions)

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66
Q

Crohn’s Disease

Epidemiology (1)

A

20-30 and 60-70

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67
Q

Crohn’s Disease

Signs + symptoms (10)

A 
Diarrhoea/urgency 
Abdo pain 
Weight loss 
Fever
Malaise 
Anorexia 
Apthous ulcerations 
Abdo mass 
Perianal abscess 
Extra-intestinal: clubbing, skin, joint + eye problems
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68
Q

Crohn’s Disease

Complications (5)

A 
Small bowel obstruction 
Toxic dilatation (colonic diameter >6cm but rarer than in UC) 
Abscess formation 
Fistulae 
Perforation
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69
Q

Crohn’s Disease

Investigations (6)

A

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

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70
Q

Crohn’s Disease

Treatment of mild attacks (2)

A

Optimise nutrition, TPN last resort

Oral prednisolone

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71
Q

Crohn’s Disease

Treatment of severe attack (5)

A

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%

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72
Q

Lower GI Bleeding

Aetiology (5)

A

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

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73
Q

Lower GI Bleeding

Investigations (5)

A

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

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74
Q

Lower GI Bleeding

Treatment (2)

A

Coiling/embolisation in angiodysplasia/identified vessel

Subtotal colectomy in UC

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75
Q

Intestinal Obstruction

Definitions (5)

A

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

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76
Q

Intestinal Obstruction

Aetiology (5)

A 
Small bowel: adhesions, hernias 
Large bowel: colon cancer, constipation, diverticular stricture, volvulus (sigmoid, caecal)  
Crohn's stricture 
Gallstone ileus 
Intussusception
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77
Q

Intestinal Obstruction

Pathology (3)

A

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

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78
Q

Intestinal Obstruction

Signs + symptoms (8)

A

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

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79
Q

Intestinal Obstruction

Investigations (9)

A

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

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80
Q

Intestinal Obstruction

Treatment (4)

A

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

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81
Q

GORD

Aetiology (10)

A 
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)
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82
Q

GORD

Signs + symptoms (7)

A

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)

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83
Q

GORD

Complications (5)

A 
Oesophagitis 
Ulcers 
Benign stricture 
Iron deficiency 
Barret's oesophagus (distal oesophageal epithelium undergoes metaplasia from squamous to columnar- pre malignant)
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84
Q

GORD

Investigations (3)

A

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

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85
Q

GORD

Treatment (5)

A

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

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86
Q

GORD

Los Angeles Classification (4)

A

1: >1 mucosal break <5mm long
2: mucosal break >5mm
3: <75% oesophageal circumference
4: >75% oesophageal circumference

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87
Q

Peptic Ulcer Disease

Definition (1)

A

A break in the inner lining of the stomach (elderly + lesser curvature) or duodenum (4x more common)

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88
Q

Peptic Ulcer Disease

Signs + symptoms (5)

A

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

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89
Q 
Peptic Ulcer Disease 
Risk factors (5)
A 
H.pylori (90% of duodenal and 80% of gastric) 
NSAIDs
Steroids 
SSRIs
Smoking (more for gastric)
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90
Q

Peptic Ulcer Disease

Investigations (2)

A

Urea breath test (H. pylori)

Upper GI endoscopy

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91
Q

Peptic Ulcer Disease

Treatment (4)

A

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

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92
Q

Peptic Ulcer Disease

Complications (5)

A 
Bleeding
Perforation 
Malignancy 
Reduced gastric outflow 
Pyloric stenosis (late complication due to scarring)
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93
Q 
Peptic Ulcer Disease 
Emergency treatment (3)
A

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

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94
Q

Gastric Cancer

Epidemiology (1)

A

2:1 M:F

95
Q

Gastric Cancer

Aetiology (1)

A

Adenocarcinoma

96
Q 
Gastric Cancer
Risk factors (6)
A 
Atrophic gastritis
Pernicious anaemia 
Blood group A
H. pylori 
Adenomatous polyps 
Smoking
97
Q

Gastric Cancer

Spread (4)

A

Direct –> pancreas
Lymphatic –> Virchow’s node
Haematogenous –> liver + lung
Transcoelemic –> ovaries

98
Q

Gastric Cancer

Signs + symptoms (7)

A 
Often non-specific 
Dyspepsia
Weight loss 
Vomiting 
Dysphagia 
Anaemia 
Suggesting incurable: mass, hepatomegaly, jaundice, ascites, Troisier's sign (enlarged Virchow's)
99
Q

Gastric Cancer

Investigations (5)

A

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
Q

Gastric Cancer

Treatment (4)

A

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
Q

Gastric Cancer

Survival (2)

A

<10% 5y survival overall

Nearly 20% for patients undergoing radical surgery

102
Q

Upper GI Bleed

Aetiology (7)

A 
Peptic ulcers 35-50% 
Mallory-Weiss tear 15%
Oesophageal varices 
Gastritis/gastric erosions 
Drugs: NSAIDs, aspirin, steroids, anticoagulants
Oesophagitis/duodenitis 
Malignancy
103
Q

Upper GI Bleed

Rockall-Risk-Scoring Factors (3)

A

Age
Shock (systolic/pulse)
Comorbidity

104
Q

Upper GI Bleed

Signs + symptoms (7)

A 
Haematemesis/melaena
Dizziness + fainting 
Abdo pain 
Hypotension
Tachycardia 
Low JVP 
Low urine output
105
Q 
Upper GI Bleed
Acute treatment (6)
A

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
Q

Oesophageal Varices

Definition (2)

A

Extremely dilated submucosal veins in the lower 1/3 of oesophagus
Complication of portal hypertension, usually in the setting of cirrhosis

107
Q 
Oesophageal Varices
Risk factors (2)
A

Alcohol abuse

Cirrhosis

108
Q

Oesophageal Varices

Investigations (1)

A

Endoscopy

109
Q

Oesophageal Varices

Treatment (4)

A

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
Q

Oesophageal Cancer

Incidence (1)

A

<5/100,000/year

111
Q 
Oesophageal Cancer
Histological types (2)
A

Squamous carcinoma

Adenocarcinoma

112
Q 
Oesophageal Cancer
Risk factors (7)
A 
Diet 
Alcohol excess 
Smoking 
Achalasia 
Obesity 
Reflux oesophagitis +/- Barret's 
Male (5:1 M:F)
113
Q

Oesophageal Cancer

Site (3)

A

20% in upper part
50% in middle part
30% in lower part

114
Q

Oesophageal Cancer

Signs + symptoms (7)

A 
Progressive dysphagia 
Anorexia and weight loss 
Chest pain 
Cough 
Pneumonia 
Vocal cord paralysis 
Haematemesis
115
Q

Oesophageal Cancer

Sites of metastases (4)

A

Liver
Brain
Lungs
Bone

116
Q

Oesophageal Cancer

Investigations (3)

A

Oesophagoscopy with biopsy
EUS, CT/MRI for staging
Laparoscopy if significant infra-diaphragmatic component

117
Q

Oesophageal Cancer

Staging (6)

A 
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
Q

Oesophageal Cancer

Treatment (2)

A

T1/2- radical oesophagectomy +/- chemotherapy

Palliation with chemo/radio, stenting and laser

119
Q

Oesophageal Cancer

Prognosis (3)

A

40% 1 year survival
15% 5 year survival
>10% 10 year survival

120
Q

Barrett’s Oesophagus

Pathology (4)

A

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
Q

Barrett’s Oesophagus

Treatment (2)

A

If high grade oesophageal resection or mucosectomy if young + fit, for others do mucosal ablation
Annual endoscopic surveillance for low-grade

122
Q

Inguinal Hernias

Indirect vs direct (2)

A

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
Q 
Inguinal Hernias 
Risk factors (7)
A 
Males (8:1 M:F)
Chronic cough 
Constipation 
Urinary obstruction 
Heavy lifting 
Ascites 
Post abdominal surgery
124
Q

Inguinal Hernias

Anatomy (6)

A

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
Q

Inguinal Hernias

Contents of inguinal canal (3)

A

Ilioinguinal nerve
Round ligament in females
Spermatic cord in males

126
Q

Inguinal Hernias

Examination (4)

A

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
Q

Inguinal Hernias

Treatment(3)

A

Lose weight
Mesh repairs (mesh to reinforce posterior wall)
Laparoscopic repair

128
Q

Femoral Hernias

Pathology (4)

A

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
Q

Femoral Hernias

Anatomy (2)

A

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
Q

Acute Abdomen

Right upper quadrant pain (3)

A

Acute cholecystitis
Duodenal ulcer
Appendicitis

131
Q 
Acute Abdomen
Epigastric pain (5)
A 
Pancreatitis 
MI 
Peptic ulcer 
Acute cholecystitis 
Perforated oesophagus
132
Q

Acute Abdomen

Left upper quadrant pain (4)

A

Ruptured spleen
Gastric ulcer
Aortic aneurysm
Perforated colon

133
Q 
Acute Abdomen
Umbilical pain (5)
A 
Intestinal obstruction 
Acute pancreatitis 
Early appendicitis 
Aortic aneurysm
Diverticulitis
134
Q

Acute Abdomen

Right lower quadrant pain (6)

A 
Appendicitis 
Ruptured ectopic pregnancy 
Renal/ureteric stone 
Strangulated hernia 
Crohn's disease 
Perforated caecum
135
Q

Acute Abdomen

Left lower quadrant pain (7)

A 
Sigmoid diverticulitis 
Ruptured ectopic 
Strangulated hernia 
Perforated colon 
Crohn's disease 
UC 
Renal/ureteric stones
136
Q

Acute Abdomen

Investigations (3)

A 
Bloods: U&amp;E, FBC, amylase, LFT, CRP 
ABG: check for mesenteric ischaemia 
Urinalysis 
Erect CXR
AXR
Laparoscopy 
CT
USS: identify perforation/free fluid
137
Q

Acute Abdomen

Syndromes requiring laparotomy (2)

A

Organ rupture: spleen, aorta, ectopic pregnancy

Peritonitis: perforated peptic ulcer, duodenal ulcer, diverticulum, appendix, bowel or gallbladder

138
Q

Acute Abdomen

Syndromes not requiring laparotomy (2)

A

Local peritonitis: diverticulitis, cholecystitis, salpingitis, appendicitis
Colic: gut, ureter, uterus, bile duct, gallbladder

139
Q

Acute Appendicitis

Pathology (3)

A

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
Q

Acute Appendicitis

Signs + symptoms (9)

A 
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
Q

Acute Appendicitis

Investigations (4)

A

FBC: neutrophil leucocytosis
CRP: elevated
USS
CT

142
Q 
Acute Appendicitis 
Differential diagnoses (7)
A 
Ectopic pregnancy 
UTI 
Cystitis 
Cholecystitis 
Diverticulitis 
Perforated ulcer 
Food poisoning
143
Q

Acute Appendicitis

Treatment (2)

A

Appendicectomy

Antibiotics: metronidazole + cefuroxime pre-op (give longer course if suspect perforation)

144
Q

Gallstones

Pathology (2)

A

Bile contains cholesterol, bile pigments (from broken down Hb) and phospholipids
If concentrations vary, different stones may form

145
Q

Gallstones

Types (3)

A

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
Q

Gallstones

Prevalence (2)

A

8% of those >40

90% remain asymptomatic

147
Q

Gallstones

Complications (3)

A

In gallbladder + cystic duct: biliary colic, acute + chronic cholecystitis, empyema
In bile duct: obstructive jaundice, cholangitis, pancreatitis
In gut: gallstone ileus

148
Q

Biliary Colic

Definition (2)

A

Gallstones are symptomatic with cystic duct obstruction

RUQ pain radiates to the back +/- jaundice (if it move to CBD)

149
Q

Biliary Colic

Treatment (2)

A

Analgesia

Elective laparoscopic cholecystectomy

150
Q

Acute Cholecystitis

Definition (1)

A

Follows stone or sludge impaction in the neck of the gallbladder

151
Q

Acute Cholecystitis

Signs + symptoms (7)

A

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
Q

Acute Cholecystitis

Investigations (2)

A

High WCC

Ultrasound: thick-walled shrunken gallbladder, fluid, stones, dilated CBD

153
Q

Acute Cholecystitis

Treatment (6)

A

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
Q

Cholangitis

Definition (1)

A

Bile duct infection

155
Q

Cholangitis

Signs + symptoms (1)

A

Charcot’s triad: RUQ pain + jaundice + rigors (fever and high WCC)

156
Q

Cholangitis

Treatment (1)

A

IV cefuroxime + metronidazole

157
Q

Cholangiocarcinoma

Aetiology (2)

A

Adenocarcinoma

Primary sclerosing cholagnitis

158
Q

Cholangiocarcinoma

Signs + symptoms (6)

A 
Fever 
Abdo pain 
Ascites 
Malaise 
Obstructive jaundice 
Virchow node lymphadenopathy
159
Q

Cholangiocarcinoma

Investigations (5)

A 
High alk phos
High bilirubin 
Abdo USS 
CT
MRCP
160
Q

Cholangiocarcinoma

Treatment (1)

A

Surgical resection only curative option but 80% are inoperable so palliate with biliary stents/chemo

161
Q

Cholangiocarcinoma

Prognosis (2)

A

5 year survival ~30% if early stage

Overall ~ 5 months

162
Q

Acute Pancreatitis

Aetiology (10)

A 
Gallstones 
Ethanol 
Trauma 
Steroids 
Mumps 
Autoimmune 
Scorpion venom 
Hyperlipidaemia/Hypothermia/Hypercalcaemia
ERCP/Embolii
Drugs (steroids, azathioprine, diuretics)
163
Q

Acute Pancreatitis

Pathology (3)

A

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
Q

Acute Pancreatitis

Signs + symptoms (7)

A

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
Q

Acute Pancreatitis

Investigations (9)

A

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
Q

Acute Pancreatitis

Glasgow Criteria of Severity (9)

A 
>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
Q

Acute Pancreatitis

Treatment (5)

A 
NG tube (reduce pancreatic stimulation) 
IV fluids 
Analgesia 
Antibiotics in severe disease 
ERCP + gallstones removal if progressive jaundice
168
Q 
Acute Pancreatitis
Early complications (6)
A 
Shock 
ARDS
Renal failure 
Sepsis
Hypocalcaemia 
High glucose
169
Q 
Acute Pancreatitis
Late complications (6)
A 
Pancreatic necrosis 
Pseudocyst 
Abscess 
Bleeding 
Thrombosis 
Fistulae
170
Q

Chronic Pancreatitis

Aetiology (6)

A 
Alcohol 
Cystic fibrosis 
Haemochromatosis 
Pancreatic duct obstruction (stones/tumour) 
High PTH 
Familial
171
Q

Chronic Pancreatitis

Signs + symptoms (6)

A 
Epigastric pain which radiates to the back 
Bloating 
Exocrine insufficiency --> steatorrhoea
Endocrine insufficiency --> diabetes
Weight loss 
Relapsing and worsening symptoms
172
Q

Chronic Pancreatitis

Investigations (3)

A

Ultrasound +/- CT (pancreatic calcifications confirm diagnosis)
AXR: speckled calcification
Glucose increased

173
Q

Chronic Pancreatitis

Treatment (3)

A

Drugs: analgesia (eg. coeliac plexus block), pancreatic enzyme supplements, insulin
Diet: no alcohol
Surgery for unremitting pain and weight loss eg. pancreatectomy

174
Q

Chronic Pancreatitis

Complications (6)

A 
Pseudocyst 
Diabetes
Biliary obstruction 
Local arterial aneurysm 
Splenic vein thrombosis
Pancreatic carcinoma
175
Q

Pancreatic Cancer

Epidemiology (2)

A

<2% of malignancy

Typically male >60

176
Q 
Pancreatic Cancer
Risk factors (5)
A 
Smoking 
Alcohol 
Diabetes 
Chronic pancreatitis 
Increased waist circumference (ie. central adiposity)
177
Q

Pancreatic Cancer

Pathology (3)

A

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
Q

Pancreatic Cancer

Signs + symptoms (12)

A 
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
Q

Pancreatic Cancer

Investigations (2)

A

US/CT show pancreatic mass+/- dilated biliary tree +/- hepatic metastases
ERCP for biliary tree anatomy and may localise site of obstruction

180
Q

Pancreatic Cancer

Prognosis (2)

A

Mean survival <6 months

5 year survival 3%

181
Q

Liver Function Tests

Bilirubin (3)

A

Byproduct of haeme metabolism
Liver solubises it
Elevated in haemolysis, parenchymal damage and obstruction

182
Q

Liver Function Tests

Aminotransferases (2)

A

Enzymes present in hepatocytes

Suggests parenchymal involvement

183
Q 
Liver Function Tests
Alkaline phosphatase (3)
A

Enzyme present in bile ducts
Elevated with obstruction or liver infiltration
Also present in bone, placenta and intestines

184
Q 
Liver Function Tests
Gamma GT (3)
A

Nonspecific liver enzyme
Elevated with alcohol and NSAID use
Useful to confirm liver source of ALP

185
Q

Liver Function Tests

Albumin (3)

A

Important test for synthetic function of liver
Low level suggests chronic liver disease
Can be low in kidney disorders and malnutrition

186
Q

Liver Function Tests

Creatinine (3)

A

Essentially kidney function
Determines survival from liver disease
Critical assessment for need of transplant

187
Q

Liver Function Tests

Distinguishing between liver damage and cholestasis (3)

A 
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
Q

Liver Function Tests

Assessing synthetic liver function (4)

A 
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
Q

Liver Function Tests

Common patterns of deranged LFTs (3)

A

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
Q

Liver Cirrhosis

Aetiology (4)

A

Chronic alcohol abuse
Hep B/C
Genetic: haemochromatosis, alpha-1-antitrypsin deficiency
Drugs: amiodarone, methotrexate

191
Q

Liver Cirrhosis

Pathology (1)

A

Necrosis of hepatic parenchyma causes connective tissue proliferation and nodular regeneration

192
Q

Liver Cirrhosis

Signs + symptoms (11)

A 
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
Q

Liver Cirrhosis

Investigations (8)

A 
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
Q

Liver Cirrhosis

Complications (3)

A

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
Q

Liver Cirrhosis

Child-Pugh Grading of Cirrhosis and Risk of Variceal Bleeding (7)

A 
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
Q

Liver Cirrhosis

Treatment (3)

A

Alcohol abstinence
Ascites: bed rest, fluid restriction, spironolactone
Liver transplant

197
Q

Hepatic Encephalopathy

Pathology (2)

A

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
Q

Hepatic Encephalopathy

Grading (4)

A

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
Q

Hepatic Encephalopathy

Precipitants (4)

A

Constipation
Haemorrhage
Infection
Electrolyte imbalance (hyponatraemia, hypokalaemia)

200
Q

Hepatic Encephalopathy

Treatment (2)

A

Treat cirrhosis

Lactulose +/- phosphate enema

201
Q

Portal Hypertension

Aetiology (3)

A

Pre-hepatic: thrombosis (portal/splenic vein)
Intra-hepatic: cirrhosis, Schistosomiasis
Post-hepatic: Budd-Chiari, right heart failure

202
Q

Portal Hypertension

Pathology (4)

A

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
Q

Liver Failure

Aetiology (2)

A

Acute, eg. alcohol, paracetamol overdose, hep A/B

Decompensation ie. any cause of cirrhosis

204
Q

Liver Failure

Signs + symptoms (5)

A 
Jaundice 
Hepatic encephalopathy 
Fetor hepaticus (smells of pear drops) 
Liver flap 
Signs of cirrhosis/chronic liver disease
205
Q

Liver Failure

Investigations (11)

A 
FBC (infection, GI bleed) 
U&amp;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
Q

Liver Failure

Treatment (7)

A 
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
Q

Alcoholic Liver Disease

Pathology (1)

A

Steatosis (fatty acids replaced by alcohol products in the Krebs cycle promoting glycogenolysis) to hepatitis (inflammation + necrosis) and cirrhosis (fibrosis of necrotic tissue)

208
Q

Alcoholic Liver Disease

Signs + symptoms (8)

A

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
Q

Alcoholic Liver Disease

Wernicke’s Encephalopathy (2)

A

Thiamine deficiency

Triad of nystagmus, opthalmoplegia and ataxia with confusion + altered GCS

210
Q

Alcoholic Liver Disease

Korsakoff’s Syndrome (1)

A

Anterograde + retrograde amnesia

211
Q 
Alcoholic Liver Disease
CAGE Screening (4)
A

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
Q

Alcoholic Liver Disease

Investigations (6)

A 
FBC (macrocytic anaemia, thrombocytopenia) 
Folate deficient 
LFT (AST> ALT with high GGT) 
Prolonged INR 
U&amp;E (hypomagnesaemia) 
Cirrhosis investigations
213
Q

Alcoholic Liver Disease

Treatment (4)

A

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
Q

Alcoholic Hepatitis

Definition (2)

A

Acute inflammation due to alcohol consumption

80% proceed to cirrhosis, 10% to liver failure

215
Q

Alcoholic Hepatitis

Signs + symptoms (8)

A 
Fever 
Nausea 
Diarrhoea 
Vomiting 
Tender hepatomegaly 
Jaundice 
Ascites 
Encephalopathy
216
Q

Alcoholic Hepatitis

Investigations (6)

A 
FBC: High WCC, low platelets 
INR: high 
AST: high 
MCV: high 
Urea: high 
Cirrhosis investigations
217
Q

Alcoholic Hepatitis

Treatment (4)

A

Treat withdrawal
Vit K
Thiamine (pabrinex)
Prednisolone tapered dose for >3 weeks

218
Q

Non-Alcoholic Fatty Liver Disease

Definition (1)

A

Increased fat in hepatocytes (steatosis) +/- inflammation (Steatohepatitis)

219
Q 
Non-Alcoholic Fatty Liver Disease
Risk factors (5)
A 
Obesity 
Hypertension 
Type 2 diabetes 
Dyslipidaemia 
Typical patient is middle aged obese female
220
Q

Non-Alcoholic Fatty Liver Disease

Treatment (2)

A

Control risk factors

Bariatric surgery

221
Q

Budd-Chiari Syndrome

Aetiology (2)

A 
Hypercoagulable states (eg. the pill, pregnancy, malignancy, polycythaemia, thrombophilia) 
Liver/renal/adrenal tumour
222
Q

Budd-Chiari Syndrome

Pathology (1)

A

Hepatic vein obstruction by thrombosis or tumour causes congestive ischaemia and hepatocyte damage

223
Q

Budd-Chiari Syndrome

Signs + symptoms (3)

A

Abdo pain
Hepatomegaly
Ascites

224
Q

Budd-Chiari Syndrome

Investigations (4)

A

ALT: high
USS + hepatic vein doppler
LFTs
Ascitic tap

225
Q

Budd-Chiari Syndrome

Treatment (2)

A

Anticoagulation (unless varices)

May require angioplasty, TIPSS procedure (transjugular intrahepatic porto-systemic shunt)

226
Q

Hereditary Haemochromatosis

Definition (2)

A

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
Q

Hereditary Haemochromatosis

Signs + symptoms (3)

A

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
Q

Hereditary Haemochromatosis

Investigations (4)

A

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
Q

Hereditary Haemochromatosis

Treatment (3)

A

Iron removal via venesection (lifelong)
Monitor for and treat diabetes
Screen 1st degree relatives

230
Q

Autoimmune Hepatitis

Definition (2)

A

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
Q

Autoimmune Hepatitis

Signs + symptoms (8)

A 
Many present with acute hepatitis and signs of autoimmune disease 
Fever
Malaise 
Urticarial rash 
Polyarthritis 
Glomerulonephritis 
Gradual jaundice 
Amenorrhoea
232
Q

Autoimmune Hepatitis

Investigations (5)

A

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
Q

Autoimmune Hepatitis

Treatment (2)

A

Prednisolone/azathioprine as steroid-sparing

Liver transplant

Med Student Finals (23 decks)

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