Gastroenterology Flashcards
How many units of alcohol is the recommendation?
Men and women should drink no more than 14 units of alcohol per week!
If you do drink as much as 14 units per week, it is best to spread this evenly over 3 days or more
If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum.
What is the commonest cause of hepatocellular carcinoma?
Chronic hepatitis B is the most common cause of HCC worldwide with chronic hepatitis C being the most common cause in Europe.
The main risk factor for developing HCC is liver cirrhosis, for example secondary to hepatitis B & C, Alcohol, Haemochromatosis and Primary Biliary Cirrhosis. Other risk factors include:
- alpha-1 antitrypsin deficiency
- hereditary tyrosinosis
- glycogen storage disease
- aflatoxin
- drugs: oral contraceptive pill, anabolic steroids
- porphyria cutanea tarda
- male sex
- diabetes mellitus, metabolic syndrome
Signs and symptoms of HCC?
Features of liver cirrhosis or failure may be seen:
- Jaundice
- Ascites,
- RUQ pain
- Hepatomegaly
- Pruritus
- Splenomegaly
Possible presentation is decompensation in a patient with chronic liver disease.
- Raised AFP
- Tends to present late
What is the acute treatment for variceal haemorrhage?
Acute treatment of variceal haemorrhage:
- ABC: patients should ideally be resuscitated prior to endoscopy
- Correct clotting: FFP, vitamin K
- Vasoactive agents:
- Terlipressin is currently the only licensed vasoactive agent. Benefit in initial haemostasis and preventing rebleeding.
- Octreotide may also be used although there is some evidence that Terlipressin has a greater effect on reducing mortality. - Prophylactic antibiotics. Quinolones are typically used. Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper GI bleeding.
- Endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation
- Sengstaken-Blakemore tube if uncontrolled haemorrhage
- Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
- connects the hepatic vein to the portal vein
- exacerbation of hepatic encephalopathy is a common complication
What drug is given for prophylaxis of variceal haemorrhage?
Propranolol: reduced rebleeding and mortality compared to placebo
What is Wilson disease? Mode of inheritance?
Wilson’s disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion.
The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease
Signs and symptoms of wilson disease?
Features result from excessive copper deposition in the tissues, especially the BRAIN, LIVER and CORNEA:
- Liver: hepatitis, cirrhosis
- Neurological:
- basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia
- Speech, behavioural and psychiatric problems are often the first manifestations
- also: asterixis, chorea, dementia, parkinsonism
- Kayser-Fleischer rings
green-brown rings in the periphery of the iris
due to copper accumulation in Descemet membrane - renal tubular acidosis (esp. Fanconi syndrome)
- haemolysis
- blue nails
How is Wilsons disease investigated?
- Slit lamp examination for Kayser-Fleischer rings
- Reduced serum caeruloplasmin
- Reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin). Free (non-ceruloplasmin-bound) serum copper is increased
- Increased 24hr urinary copper excretion
Which drug is given in management of Wilsons disease?
Penicillamine (chelates copper) has been the traditional first-line treatment.
Trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future
What are the associated factors for NAFLD?
Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of liver disease in the developed world. It is largely caused by obesity and describes a spectrum of disease ranging from:
- steatosis - fat in the liver
- steatohepatitis - fat with inflammation, non-alcoholic steatohepatitis (NASH)
- progressive disease may cause fibrosis and liver cirrhosis
Associated factors:
- obesity
- type 2 diabetes mellitus
- hyperlipidaemia
- jejunoileal bypass
- sudden weight loss/starvation
Investigations for NAFLD?
(Incidental finding of NAFLD - typically asymptomatic fatty changes on liver ultrasound)
in these patients, NICE recommends the use of the Enhanced Liver Fibrosis (ELF) blood test to check for advanced fibrosis.
if the ELF blood test was not available:
Non-invasive tests may be used to assess the severity of fibrosis.
These include the FIB4 score or NALFD fibrosis score
these scores may be used in combination with a FibroScan (liver stiffness measurement assessed with transient elastography).
This combination has been shown to have excellent accuracy in predicting fibrosis
Management for NAFLD?
Management:
The mainstay of treatment is lifestyle changes (particularly weight loss) and monitoring.
there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g. metformin, pioglitazone)
Anti-smooth muscle antibodies (SMA) is associated with which condition?
Autoimmune hepatitis
What is the main stay of coeliac disease management?
The management of coeliac disease involves a GLUTEN-FREE DIET. Gluten-containing cereals include:
- wheat: bread, pasta, pastry
- barley: beer
- rye
- oats
Some notable foods which are gluten-free include:
- rice
- potatoes
- corn (maize)
What antibody is checked to check for compliance to a gluten-free diet?
Tissue transglutaminase antibodies
Diarrhea, the stool floats in the toilet water, but there is no blood. What is the most likely causative organism?
Giardia lamblia causes fat malabsorption, therefore greasy stool can occur
What is the first line pharmacological treatment for IBS?
First-line pharmacological treatment - according to predominant symptom:
Pain: antispasmodic agents
Constipation: laxatives but avoid lactulose
Diarrhoea: Loperamide is first-line
General dietary advice:
- have regular meals and take time to eat
- avoid missing meals or leaving long gaps between eating
- drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas
- restrict tea and coffee to 3 cups per day
- reduce intake of alcohol and fizzy drinks
- consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)
- reduce intake of ‘resistant starch’ often found in processed foods
- limit fresh fruit to 3 portions per day
- for diarrhoea, avoid sorbitol
- for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).
What are the features of hepatic encephalopathy?
Hepatic encephalopathy is largely believed to occur from accumulation of ammonia in the blood stream due to the livers decreased ability to detoxify ammonia that is produced and transported from the gastrointestinal tract.
Features:
- Confusion, altered GCS
- Asterix: ‘liver flap’, arrhythmic negative myoclonus with a frequency of 3-5 Hz
- Constructional apraxia: inability to draw a 5-pointed star
- Triphasic slow waves on EEG
- Raised ammonia level (not commonly measured anymore)
What is the first line treatment for hepatic encephalopathy?
Management:
- Treat any underlying precipitating cause
- NICE recommend LACTULOSE first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy
- lactulose is thought to work by promoting the excretion of ammonia and increasing the metabolism of ammonia by gut bacteria - Antibiotics such as rifaximin are thought to modulate the gut flora resulting in decreased ammonia production
- other options include embolisation of portosystemic shunts and liver transplantation in selected patients
What is the investigation of choice for crohn’s disease? What is usually seen?
Crohn’s disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus.
Bloods:
C-reactive protein correlates well with disease activity
Colonoscopy is the investigation of choice!
- features suggestive of Crohn’s include deep ulcers, skip lesions
Histology
- inflammation in all layers from mucosa to serosa
- goblet cells, granulomas
Small bowel enema
- high sensitivity and specificity for examination of the terminal ileum
- strictures: ‘Kantor’s string sign’
- proximal bowel dilation
- ‘rose thorn’ ulcers
- fistulae
Commonest organism found in ascitic culture of spontaneous bacterial peritonitis?
Spontaneous bacterial peritonitis (SBP) is a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.
Features:
Ascites
Abdominal pain
Fever
Diagnosis:
- Paracentesis: neutrophil count > 250 cells/ul
- The most common organism found on ascitic fluid culture is E. coli
What is the antibiotic given for SBP? What is the prophylaxis?
Management of SBP:
Intravenous Cefotaxime
Antibiotic prophylaxis should be given to patients with ascites if:
- Patients who have had an episode of SBP
- Patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
- Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved’
What is Courvoisir’s law?
Courvoisier’s law states that in the presence of a palpably enlarged gallbladder and accompanied with mild jaundice, the cause is unlikely to be gallstones.
Signs and symptoms of pancreatic cancer?
- Classically painless jaundice
- Pale stools, dark urine, and pruritus
- Cholestatic liver function tests
- Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
- However, patients typically present in a non-specific way with anorexia, weight loss, epigastric pain
- Loss of exocrine function (e.g. steatorrhoea)
- Loss of endocrine function (e.g. diabetes mellitus)
- Atypical back pain is often seen
migratory thrombophlebitis (Trousseau sign) is more common than with other cancers
Investigation of choice for suspecte pancreatic cancer?
- Ultrasound has a sensitivity of around 60-90%
- High-resolution CT scanning is the investigation of choice if the diagnosis is suspected!
- Imaging may demonstrate the ‘double duct’ sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts
What procedure is done for pancreatic ca?
- less than 20% are suitable for surgery at diagnosis
- A Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas.
- Side-effects of a Whipple’s include dumping syndrome and peptic ulcer disease
- Adjuvant chemotherapy is usually given following surgery. ERCP with stenting is often used for palliation
What is the management for haemochromatosis?
- Venesection is the first-line treatment
monitoring adequacy of venesection: transferrin saturation should be kept below 50% and the serum ferritin concentration below 50 ug/l - Desferrioxamine may be used second-line
Which drugs are given in Crohn’s to induce and maintain remission?
Patients should be strongly advised to stop smoking!
Inducing remission:
- Glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients.
- 5-ASA drugs (e.g. Mesalazine) are used second-line to glucocorticoids but are not as effective
- Azathioprine or mercaptopurine may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine
- Infliximab is useful in refractory disease and fistulating Crohn’s. Patients typically continue on azathioprine or methotrexate
- metronidazole is often used for isolated peri-anal disease
Maintaining remission:
- As above, stopping smoking is a priority (remember: smoking makes Crohn’s worse, but may help ulcerative colitis)
- Azathioprine or mercaptopurine is used first-line to maintain remission
- Methotrexate is used second-line
- 5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery
Surgery:
- around 80% of patients with Crohn’s disease will eventually have surgery
Crohn’s disease is notorious for the developmental of intestinal fistulae; these may form between the rectum and skin (perianal) or the small bowel and skin. Fistulation between loops of bowel may also occur and result in bacterial overgrowth and malabsorption. Management of enterocutaneous fistulae involves controlling sepsis, optimising nutrition, imaging the disease and planning definitive surgical management.
What are the symptoms and signs of haemochromatosis?
Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation.
Presenting features:
- Early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands)
- ‘bronze’ skin pigmentation
- diabetes mellitus
- liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition)
- Cardiac failure (2nd to dilated cardiomyopathy)
- Hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism)
- Arthritis (especially of the hands)
Signs and symptoms of acute appendicitis?
Abdominal pain is seen in the vast majority of patients:
- Peri-umbilical abdominal pain (visceral stretching of appendix lumen and appendix is midgut structure) radiating to the right iliac fossa (RIF) due to localised parietal peritoneal inflammation.
- The migration of the pain from the centre to the RIF has been shown to be one of the strongest indicators of appendicitis. patients often report the pain being worse on coughing or going over speed bumps. Children typically can’t hop on the right leg due to the pain.
Other features:
- Vomit once or twice but marked and persistent vomiting is unusual
- Diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation of some loose stools. A pelvic abscess may also cause diarrhoea
- Mild pyrexia is common - temperature is usually 37.5-38oC. Higher temperatures are more typical of conditions like mesenteric adenitis
- Anorexia is very common. It is very unusual for patients with appendicitis to be hungry
- Around 50% of patients have the typical symptoms of anorexia, peri-umbilical pain and nausea followed by more localised right lower quadrant pain
