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Clinical Practice > Gastroenterology and Hepatology > Flashcards

Gastroenterology and Hepatology Flashcards

1
Q

what are the causes of transudative ascites?

A 
right sided heart failure
constrictive pericarditis
nephrotic syndrome
IVCO
Budd-Chiari syndrome
veno-occlusive disease
cirrhosis
liver tumour
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2
Q

what are the causes of exudative ascites?

A 
peritonitis
TB
SBP
pancreatitis
bile peritonitis
ovarian carcinoma
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3
Q

what is the management of acute hepatitis A?

A

supportive
isolation
contact public health department
avoid alcohol while infected

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4
Q

define serum ascites albumin gradient

A

serum albumin - ascitic fluid albumin

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5
Q

what is the treatment of ascites?

A

salt restriction (2g/day)
spironolactone 100mg/day, increase as required
therapeutic paracentesis
give 1 unit of 4.5% albumin for every 2L drained
treat underlying disorder

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6
Q

describe the method of toxicity in paracetamol overdose

A

a small portion of paracetamol is converted into NABQI then conjugated with glutathione which is converted to mercapturate then excreted (normal)
in overdose, more NABQI is produced and glutathione is exhausted

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7
Q

define acute liver failure

A

hepatocellular jaundice
increased transaminases
increased PT

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8
Q

describe fulminant liver failure

A

acute liver failure complicated by hepatic encephalopathy

may be acute, hyper acute or subacute

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9
Q

describe the clinical features of acute liver failure

A 
encephalopathy
cerebral oedema
jaundice
ascites
coagulopathy
hypotension
hepatopulmonary syndrome
renal dysfunction
metabolic and electrolyte disturbances
sepsis
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10
Q

what are the features and treatment of raised intracranial pressure?

A

increased BP
decreased HR
increased tone

avoid venous jugular compression
bed at 20-30o tilt
mannitol 1g/kg of 20% solution rapidly IV
thiopentone
maintain CPP at >60mmHg
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11
Q

what is the treatment of hypoglycaemia?

A

dextrose infusion 5-10% with boluses as required

give thiamine if malnourished/alcoholic

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12
Q

what is the treatment of haemorrhagic diathesis?

A

vitamin K 10mg IV

PPI to cover against upper GI bleeding

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13
Q

describe hepatorenal syndrome

A

uraemia, hyponatraemia, oliguria
no other obvious renal disease
urine sodium <5mmol/L

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14
Q

what is the pathology and treatment of hepatorenal syndrome?

A

sodium retention
possible imbalance of prostaglandins/thromboxane in the kidney

terlipressin

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15
Q

describe the pathology and treatment of hepatopulmonary syndrome

A

intrapulmonary arterio-venous shunting

treat hypoxia
intubation if grade III or IV coma
avoid ventilation with PEEP; increases ICP

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16
Q

what are the symptoms of IBD?

A 
diarrhoea
blood/mucous in stools
anaemia
malaise
weight loss
mass +/- RIF
crampy abdominal pain
local peritonitis
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17
Q

what is the treatment of IBD?

A

sulphasalazine/mesalazine
systemic/topical corticosteroids
azathioprine/methotrexate/infliximab

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18
Q

describe ulcerative colitis

A

relapsing and remitting inflammatory disorder of the colonic mucosa
always involves the rectum
involving just the rectum (proctitis) or the whole bowel (pan colitis)
does not spread proximal to the ileocaecal valve
more common in non-smokers

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19
Q

what are the symptoms and signs of ulcerative colitis?

A 
episodic/chronic diarrhoea
crampy abdominal pain
urgency
tenesmus
fever
malaise
weight loss
clubbing
aphthous oral ulcers
erythema nodosum
episcleritis/iritis
large joint arthritis
sclerosing cholangitis
pyoderma gangrenosum
amyloidosis
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20
Q

what are the symptoms of an acute severe attack of ulcerative colitis?

A

fever
tachycardia
tender distended abdomen

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21
Q

what are the complications of ulcerative colitis?

A 
bleeding
toxic dilatation of colon
iron deficiency anaemia
venous thrombosis
PBC, PSC, chronic active hepatitis
colonic cancer
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22
Q

what is the treatment of ulcerative colitis?

A

steroids, sulphasalazine, mesalazine (mild)

prednisolone 40mg 7 days then reducing course with steroid enemas (moderate)

hospital admission, NBM, IVF, IV hydrocortisone 100mg 6hrly, monitor bloods, daily axr assess (severe)
after improvement prednisolone with a 5-ASA to maintain remission
or rescue therapy with cyclosporin or infliximab

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23
Q

what are the indications for and the types of surgery in ulcerative colitis?

A

perforation
massive haemorrhage
toxic dilatation
failed medical therapy

proctocolectomy + terminal ileostomy; retain ileocaecal valve and reduce fluid loss
colectomy with ileoanal pouch later

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24
Q

what drugs are considered in immunomodulation with ulcerative colitis?

A 
azathioprine
methotrexate
infliximab
adalimumab
calcineurin inhibitors
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25
Q

describe Crohn’s disease and its risk factors

A

transmural granulomatous inflammation
commonly affects terminal ileum and proximal colon

NOD2/CARD15 mutation
smoking
NSAIDs

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26
Q

describe the histology of Crohn’s disease

A 
granulomas containing multinucleate giant cells
transmural inflammation
neutrophil infiltrates
skip lesion
wall thickening
discrete deep ulcers
cobblestone mucosa
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27
Q

what are the symptoms and signs of Crohn’s disease?

A 
diarrhoea
urgency
abdominal pain
weight loss
fever
PR blood
malaise
anal/perianal/oral lesions
skin tags
fissure
fistula
anal disease
adhesions
strictures
perforation
fatty liver
renal stones
malnutrition
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28
Q

what are the complications of Crohn’s disease?

A 
small bowel obstruction
toxic dilatation
abscess formation
fistula
rectal haemorrhage
colonic carcinoma
B12 deficiency
iron deficiency anaemia
venous thromboembolism
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29
Q

what is the treatment of Crohn’s disease?

A

reducing course prednisolone (mild)

hospital admission, NBM, IVF, hydrocortisone 100mg IV 6hrly (severe)
antibiotics
daily bloods and axr

after improvement start oral prednisolone
if no improvement consider infliximab/adalimumab

perianal disease - local surgery with seton insertion

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30
Q

what is the long-term treatment of Crohn’s disease?

A

PENTASA reduces recurrent disease post-op
azathioprine
methotrexate
TNF alpha inhibitors

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31
Q

describe the pathology of oesophageal cancer

A

squamous tumours - mid thoracic portion

adenocarcinomas - lower oesophagus or on a background of barrett’s oesophagus

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32
Q

what are the risk factors for oesophageal cancer?

A 
smoking
alcohol
barrett's oesophagus
chronic reflux
obesity
Chinese/russian ethnicity
achalasia
tylosis
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33
Q

what are the symptoms of oesophageal cancer?

A 
asymptomatic
dyspepsia
progressive dysphagia
vomiting
weight loss
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34
Q

what is the treatment of oesophageal cancer?

A

surgery
oesophageal stenting
radical radiotherapy
chemotherapy

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35
Q

what are the risk factors for gastric cancer?

A 
Japanese
hypo/achlorydia
male
high salts and nitrates
gastric polyps
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36
Q

what are the symptoms of gastric cancer?

A 
dyspepsia
epigastric pain
anorexia
early satiety
iron deficiency anaemia
haematemesis
melaena
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37
Q

what are the risk factors for colorectal cancer?

A 
male
FHx
IBD (especially ulcerative colitis)
familial polyposis coli
diet low in fibre, fruit and vegetables
diet high in red meat and fat
obesity
cholecystectomy
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38
Q

what are the signs of a right-sided colon cancer?

A

iron deficiency anaemia
abdominal pain
abdominal mass

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39
Q

what are the signs of a left-sided colon cancer?

A

blood per rectum
altered bowel habit
abdominal mass

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40
Q

what are the signs of a rectal cancer?

A

tenesmus
obstruction
blood per rectum

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41
Q

what is the treatment of colorectal cancer?

A

adjuvant chemotherapy and radiotherapy
serial monitoring of CEA marker to detect recurrence
isolated hepatic metastases of a single liver lobe can be resected

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42
Q

what are the signs, symptoms and risk factors of pancreatic cancer?

A 
abdominal pain radiating through to the back
obstructive jaundice
weight loss
pruritus
double duct sign at ERCP
small bowel obstruction
CA19-9

increased risk in diabetes and smokers

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43
Q

what are the risk factors for hepatocellular cancer?

A 
africa, asia and japan
hepatitis B and C
cirrhosis
long-term OCP use
aflatoxin
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44
Q

what is the treatment of hepatocellular cancer?

A

resection
transplant
chemo/ethanol injection not tumour/embolisation (palliative)

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45
Q

what are the signs, risk factors and treatment of cholangiocarcinoma?

A

obstructive jaundice

PSC
liver fluke infection
choledochal cyst
caroli’s disease

transplant
resection

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46
Q

what are the symptoms and risk factors for benign hepatic adenoma?

A

OCP >5 years
anabolic steroids

asymptomatic
intraperitoneal bleeding
RUQ pain

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47
Q

what are the causes of changes in the bowel habit?

A 
coeliac
Crohn's
diverticulitis
IBS
IBD
thyroid disorders
antibiotics
laxatives
cancers
nerve damage (stroke)
spinal cord injury
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48
Q

what are the specific investigations for suspected IBD?

A 
faecal calprotectin
stool O&S
barium enema
sigmoidoscopy
serum iron, B12, folate, albumin
AXR
colonoscopy & biopsy
CT small bowel
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49
Q

define significant weight loss

A

5% over 3-6 months

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50
Q

what are the causes of intentional weight loss?

A

exercise/dieting
bariatric surgery
anorexia nervosa/eating disorder

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51
Q

what are the causes of unintentional weight loss with normal intake?

A

hyperthyroidism
increased exercise (marathon runner)
malabsorption (pancreatic, bowel)
DM

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52
Q

what are the causes of unintentional weight loss with decreased intake?

A

malignancy
GI disease
psychological
endocrine

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53
Q

what features of weight loss suggest malignancy?

A

nocturnal symptoms
progressive symptoms
FHx

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54
Q

what are the consequences of sepsis?

A

increased BMR
negative nitrogen balance
increased gluconeogenesis
increased production of acute phase proteins

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55
Q

what are the consequences of starvation and sepsis?

A 
increased glucose demand
glycogen stores rapidly used
increased gluconeogenesis
protein oxidation
muscle loss
increasingly negative nitrogen balance
less oral intake
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56
Q

describe the mechanism of acute phase protein production in sepsis

A 
increased proteolysis and increased protein synthesis
->
increased free amino acid pool
->
increased acute phase protein
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57
Q

describe nitrogen balance

A

the equilibrium between protein intake and losses

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58
Q

describe cachexia

A 
general muscle wasting from
famine
reduced oral intake
malabsorption
increased catabolism
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59
Q

how do you assess a patient’s nutritional status?

A 
reported recent weight loss
food diary
behavioural patterns
BMI
biochemical markers
MUST assessment
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60
Q

what are the requirements for maintaining adequate nutrition?

A

intact GI tract
ability to absorb nutrients
adequate diet

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61
Q

what are the signs and symptoms of diabetes?

A 
polyuria
polydipsia
genital thrush
unexplained weight loss (mostly T1DM)
visual blurring
lethargy
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62
Q

how does weight loss occur in diabetes?

A

glucose cannot get into the cells due to a lack of insulin and so the body breaks down fat and muscle to use for energy
the glucose remains in the blood and the kidneys excrete it, causing frequent urination and weight loss due to dehydration and loss of calories

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63
Q

what are the symptoms of thyrotoxicosis?

A 
diarrhoea
weight loss
increased appetite
sweating
heat intolerance
palpitations
tremor
irritability
oligomenorrhoea
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64
Q

what are the signs of thyrotoxicosis?

A 
tachycardia
goitre
warm moist skin
tremor
lid lag and retraction
thin hair
palmar erythema
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65
Q

what are the signs of Grave’s disease?

A 
exopthalmos
ophthalmoplegia
oedematous swellings above lateral malleolus
clubbing
painful finger and toe swelling
periosteal reaction in limb bones
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66
Q

what will investigations show in thyrotoxicosis?

A 
TSH suppressed
increased T3 and T4
mild normocytic anaemia
mild neutropenia
increased ESR, Ca, LFT
thyroid autoantibodies
isotope scan
eye exam
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67
Q

describe the pathology of Grave’s disease

A

circulating IgG autoantibodies binding to and activating G-protein-coupled TSH receptors, causing smooth thyroid enlargement and increased hormone production

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68
Q

what are the causes of thyrotoxicosis?

A 
Grave's disease
toxic multi nodular goitre
toxic adenoma
ectopic thyroid tissue
iodine excess
levothyroxine excess
contrast media
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69
Q

what is the treatment of thyrotoxicosis?

A

beta blockers (symptomatic)
titration Carbimazole 20-40mg/24hr for 4 weeks
Carbimazole and thyroxine simultaneously (block & replace)
radioiodine (contraindicated in pregnancy and worsens eye disease)
thyroidectomy (risk of recurrent laryngeal nerve damage and hypoparathyroidism)

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70
Q

what are the side effects of Carbimazole?

A

agranulocytosis

must stop if suspected infection

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71
Q

what are the complications of thyrotoxicosis?

A 
HF (thyrotoxic cardiomyopathy)
angina
AF
osteoporosis
ophthalmopathy
gynaecomastia
thyroid storm
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72
Q

what are the symptoms and signs of malabsorption?

A 
diarrhoea
weight loss
steatorrhoea
bloating
lethargy
anaemia (B12, folate, iron)
bleeding disorders (low vitamin K)
oedema (low protein)
metabolic bone disease (low vitamin D)
neuropathy
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73
Q

describe coeliac disease

A

T cell mediated
protamine intolerance causes villous atrophy and malabsorption
HLA DQ2

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74
Q

what are the symptoms and complications of coeliac disease?

A 
diarrhoea
weight loss
anaemia
bloating
abdominal pain
mouth ulcers
steatorrhoea

GI T-cell lymphoma
malignancy
osteoporosis
neuropathy

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75
Q

what are the symptoms and causes of chronic pancreatitis?

A 
epigastric pain that radiates to the back
relieved by sitting forward
steatorrhoea
weight loss
bloating
brittle diabetes

alcohol
cystic fibrosis
haemochromatosis
duct obstruction

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76
Q

what is the treatment and complications of chronic pancreatitis?

A 
analgesia
lipase
fat soluble vitamins
insulin
surgery

pseudocyst
diabetes
biliary obstruction
pancreatic cancer

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77
Q

what are the symptoms of Crohn’s disease?

A 
diarrhoea
urgency
PR bleeding
weight loss
aphthous ulcers
perianal abscess/fistulae/strictures
clubbing
skin/joint/eye involvement
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78
Q

what is the treatment and complications of Crohn’s disease?

A

DMARDs
immunosuppression
surgery in severe cases

SBO
toxic dilatation
abscess
fistulae
colon cancer
rectal haemorrhage
PSC
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79
Q

what are the signs and symptoms of malignancy?

A 
nausea
vomiting
change in bowel habit
melena
dysphagia
odynophagia
abdominal pain
jaundice
masses/raised lymph nodes
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80
Q

describe refeeding syndrome

A

must be considered in feeding with inadequate oral intake for >5 days
surges in insulin
large intracellular shifts in potassium, phosphate and magnesium
resulting in low plasma levels

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81
Q

what are the consequences of refeeding syndrome?

A 
cardiac instability/arrhythmias
seizures
delirium
parasthesia
myopathy
haemolysis
paralysis
oedema
respiratory and cardiac failure
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82
Q

what symptoms require a red flag referral for GORD?

A 
dysphagia
weight loss
haematemesis
melena
persistent vomiting
iron deficiency anaemia
epigastric mass
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83
Q

what is the treatment of GORD?

A

PPI full-dose for 4-8 weeks (lansoprazole 30mg OD)
oesophageal stricture dilatation; remain on full-dose long-term therapy (lansoprazole 30mg OD)

continuous/recurring symptoms - lowest dose PPI or H2RA therapy (ranitidine)

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84
Q

what is the management of Barrett’s oesophagus?

A

offer laparoscopic fundoplication for those who respond to PPI but do not want to continue long-term
antacid and/or alginate therapy

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85
Q

what are the features of oropharyngeal dysphagia?

A

delay in swallow initiation
postnasal regurgitation when swallowing
cough when swallowing
repetitive swallowing required

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86
Q

what are the causes of oropharyngeal dysphagia?

A 
CVA
Parkinson's
MS
MND
ALS
MG
pharyngeal pouch
head and neck malignancies
enlarged thyroid
anticholinergics
opiates
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87
Q

what are the causes of oesophageal dysphagia?

A 
foreign body (acute)
tumour
peptic stricture
oesophageal rings and webs
eosinophilic oesophagitis
chemical injury
radiation
infectious oesophagi's (herpes, candida)
achalasia
dysmotility disorders
scleroderma
mixed CT diseases
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88
Q

what are the causes of oesophageal dysphagia with solid food?

A 
stricture
oesophagitis
cancer
oesophageal rings, webs
eosinophilic oesophagitis
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89
Q

what are the causes of oesophageal dysphagia with liquids?

A

scleroderma
absent contractility
achalasia
distal oesophageal spasm

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90
Q

what is the treatment of a benign stricture?

A 
high dose PPI
inject steroid and dilate
stents
self-dilatation
surgery
91
Q

how is eosinophilic oesophagitis diagnosed?

A

food impaction
>15 eosinophils per HPF
lack of response to high dose PPI
normal pH monitoring

92
Q

what is the treatment of eosinophilic oesophagitis?

A

topical steroids
dilatation
elimination diet (paeds)

93
Q

what is the treatment of achalasia?

A

botox
balloon dilatation
heller myotomy

94
Q

describe functional dysphagia

A

sense of food sticking or passing abnormally through the oesophagus
no oesophageal, mucosal or structural abnormality
no GORD or EoE
no major oesophageal motor disorders

95
Q

what is the treatment of oesophageal hypersensitivity?

A

high dose PPI

SSRI (fluoxetine) or TCA (amitriptyline)

96
Q

what are the symptoms and signs of anaemia?

A 
dyspnoea
lethargy
chest pain
tinnitus
headache
palpitations
pallor
tachycardia
flow murmur ESM
cardiac enlargement 
ankle swelling (CF)
97
Q

what are the causes of microcytic anaemia?

A 
haematological defect
IDA
sideroblastic; lead poisoning
globin defect
thalassaemia
98
Q

what are the causes of normocytic anaemia?

A

blood loss
bone marrow failure
renal failure
pregnancy (increased plasma volume)

99
Q

what are the causes of macrocytic megaloblastic anaemia?

A

vitamin B12 or folate deficiency
anti-folate drugs (phenytoin, methotrexate)
cytotoxic (hydroxycarbamide)

100
Q

what are the causes of macrocytic non-megaloblastic anaemia?

A

reticulocytosis
alcohol or liver disease
hypothyroidism
myelodysplasia

101
Q

what are the signs of haemolytic anaemia?

A 
reticulocytosis
mild macrocytosis
haptoglobin reduced
increased bilirubin
increased urobilinogen
mild jaundice
102
Q

what are the causes of haemosiderosis?

A

endocrine, liver and cardiac damage

103
Q

what are the causes and treatment of sideroblastic anaemia?

A 
congenital
acquired
myelodysplastic/proliferative disease
chemotherapy
anti-TB drugs
lead

remove cause
pyridoxine
transfusion for severe anaemia

104
Q

what is the pathophysiology of thalassemia?

A

unbalanced production of globin chains
haemolytic while still in the bone marrow and removal by the spleen
autosomal recessive inheritance

105
Q

what are the features of beta thalassemia major?

A 
severe anaemia
jaundice
failure to thrive
extra medullary erythropoiesis
frontal bossing
maxillary overgrowth
hepatosplenomegaly
haemochromatosis >10yrs
106
Q

what are the causes of iron deficiency anaemia?

A 
menorrhagia
GI bleeding
poor diet
coeliac disease
Crohn's disease
107
Q

what is the treatment of iron deficiency anaemia?

A

oral or IV iron

108
Q

what are the causes of haematemesis?

A 
varices
oesophago-gastro-duodenitis
PUD/DU
oesophageal or gastric cancer
mallory-weiss tear
mucosal tear
angiodysplasia
HHT
large arteriole rupture in stomach or bowel
warfarin
thrombolytics
epistaxis
109
Q

what are the causes of rectal bleeding?

A 
diverticular disease
rectal haemorrhoids
camplyobacter
shigella
E. coli
C. diff
amoebic dysentery
polyps
UC
Crohn's
neoplasia
gastric/upper bowel bleeding
ischaemic colitis
HHT
angiodysplasia
110
Q

what are the signs of an upper GI bleed?

A 
tachycardia
chronic liver disease
melena PR
hypotension/postural hypotension
reduced urine output
reduced GCS
111
Q

what are the causes of upper GI bleeding?

A 
PUD/DU
mallory-weiss tear
acute erosions/gastritis
varices
oesophagitis
stomach/oesophageal cancer
112
Q

what are the components of the Rockall score?

A 
age
shock (BP, HR, co-morbidities)
final diagnosis
evidence of recent haemorrhage
active bleeding
visible vessel
adhered clot
113
Q

what is the treatment of oesophageal varices?

A 
variceal banding
Sengstaken-Blakemore tube
beta blockers
broad spectrum antibiotics
IV terlipressin
repeat endoscopic banding
TIPSS
114
Q

what are the signs of lower GI bleeding?

A 
pale and cold extremities
sweating
pulse volume
bruises
mouth and nose bleeding
abdominal tenderness +/- peritonism
masses
signs of chronic liver disease
blood, melon, palpable mass, haemorrhoids (PR)
115
Q

what are the causes of lower GI bleeding?

A 
diverticular bleeds
angiodysplasia
colorectal cancer
ischaemic colitis
Meckel's diverticulum
infectious colitis
IBD
haemorrhoids
radiation proctitis
aorta-enteric fistula
116
Q

what is the treatment of lower GI bleeding?

A

surgical resection
colonoscopic haemostasis
radiological embolisation
may be upper GI

117
Q

what is the treatment of GI bleeding?

A 
resuscitate and stabilise
IV fluids
group and crossmatch
ABG and bloods
correct clotting factors
oxygen if hypoxic
IV PPI
urgent endoscopy
inform surgeons incase need for surgery/embolisation
118
Q

what are the causes of folate deficiency?

A 
reduced intake
increased demand (pregnancy, haemolytic, malignancy)
coeliac
Crohn's
phenytoin
methotrexate
trimethoprim
119
Q

what are the causes of B12 deficiency?

A 
decreased meat, fish and dairy intake
decreased intrinsic factor
pernicious anaemia
post-gastrectomy
ileal resection
bacterial overgrow
congenital metabolic errors
120
Q

what are the symptoms of B12 deficiency?

A 
anaemia
pallor and mild jaundice
glossitis
parasthesia
peripheral neuropathy
depression
dementia
optic atrophy
subacute combined degeneration of the cord
121
Q

describe pernicious anaemia

A

most common cause of macrocytic anaemia
autoimmune attack against gastric parietal cells that secrete intrinsic factor and acid
= achlorhydria and lack of gastric intrinsic factor secretion
>40yrs
associated with thyroid disease, vitiligo and addison’s

122
Q

describe the diagnosis and treatment of pernicious anaemia

A

presence of intrinsic factor and parietal cell antibodies in serum
lifelong quarterly hydroxocobalamin B12 injections

123
Q

define delirium

A

an acute mental disturbance characterised by confused thinking and disrupted attention usually accompanied by disordered speech and hallucinations
usually develops over 1-2 days

124
Q

describe hyperactive delirium

A

heightened arousal, restless, agitated and aggressive

125
Q

describe hypoactive delirium

A

withdrawn, quiet and sleepy

can be more difficult to recognise

126
Q

what are the signs of delirium?

A 
disordered thinking
euphoric, fearful, depressed, or angry
language impaired
delusions
reversal of sleep/awake cycle
inattention
disorientated
memory deficits
127
Q

what are the risk factors for delirium?

A 
>65yrs
dementia
severe illness
surgery
infection
impaired hearing/vision
poly pharmacy (including alcohol)
dislocation to an unfamiliar environment
sleep deprivation
immbolisation
CNS damage
previous CVA
128
Q

what are the warning signs in delirium?

A

head injury + warfarin
focal neurology
reduced GCS
high NEWS score

129
Q

what is the treatment of delirium?

A 
reduce distress
encourage family to sit with patient
moderately lit quiet room
improve orientation to time and place
verbal de-escalation
hearing aids and glasses
avoid physical restraints
haloperidol
lorazepam (alternative in Parkinson's or QTC prolongation)
130
Q

define stroke

A

rapid onset, focal neurological deficit due to a vascular lesion lasting >24hrs
infarction due to ischaemia (80%) or intracerebral haemorrhage (20%)

131
Q

what are the risk factors for stroke?

A 
smoking
hypertension
diabetes
high lipids
FHx
AF
cardiac valve disease
peripheral vascular disease
Hx
ethnicity
OCP
132
Q

what are the symptoms of a stroke?

A 
facial drop
weakness in arms or legs
dysarthria/dysphagia
sudden loss/blurring of vision
dizziness
confusion
balance and co-ordination problems
sudden/severe headache
loss of consciousness
133
Q

describe a total anterior circulation stroke

A 
hemiplegia (contralateral)
homonymous hemianopia (contralateral)
higher cortical dysfunction
134
Q

describe an anterior cerebral artery stroke

A

contralateral motor/sensory loss in the legs>arms

face is spared

135
Q

describe a middle cerebral artery stroke

A

contralateral motor/sensory loss in face and arms>legs
contralateral homonymous hemianopia
cognitive changes

136
Q

describe a posterior cerebral artery stroke

A

contralateral homonymous hemianopia with macula sparing

137
Q

describe locked-in syndrome

A

patient aware and cognitively intact but completely paralysed except for the eye muscles

ventral pons infarction (basilar artery)
central pontine myelinolysis
rapid correction of hyponatraemia

138
Q

what is the treatment of a stroke?

A 
ensure patent airway
NBM until swallowing assessed
don't over hydrate
monitoring (glucose 4-11, BP <185/110)
urgent CT/MRI
thrombolysis with tPA
clot retrieval if large vessel occluded
antiplatelets
refer to stroke unit
DVT prophylaxis
surgery
carotid endarterectomy
139
Q

what is the secondary prevention of a stroke?

A

start statin after 48hr
aspirin/clopidogrel 300mg 2weeks after then reduce dose
warfarin for cardiac thromboembolism 2 weeks post-stroke

140
Q

define transient ischaemic attack

A

sudden onset focal neurology lasting <24hr due to temporary occlusion of part of the cerebral circulation

141
Q

what are the causes of a TIA?

A

atherothromboembolism from carotids
cardioembolism (post-MI, AF, valve disease)
hyper viscosity (polycythaemia, myeloma)

142
Q

what are the signs of a TIA?

A

carotid bruits
murmur
AF
HTN

143
Q

what is the treatment of a TIA?

A

aspirin or clopidogrel 300mg OD 2 weeks then 75mg after
BP, lipids, smoking, DM, exercise, diet control
ABCD2 score (assess risk)
score >4, refer within 24hrs
score <4, refer within 7 days

144
Q

what are the components of the ABCD2 score?

A

age >60
BP >140/90
clinical features (unilateral weakness, speech disturbance without weakness)
duration of symptoms (>1hr, 10-59 minutes)
diabetes

145
Q

what are the symptoms of a sagittal sinus thrombosis?

A 
headache
vomiting
seizures
reduced vision
papilloedema
146
Q

what are the symptoms of a transverse sinus thrombosis?

A

headache +/- mastoid pain
focal neuro
seizures
papilloedema

147
Q

what are the symptoms of a sigmoid sinus thrombosis?

A

cerebellar signs

lower CN palsies

148
Q

what are the symptoms of an inferior petrosal sinus thrombosis?

A

5th and 6th CN palsies

149
Q

what are the symptoms of a cavernous sinus thrombosis?

A 
spread from facial pustules or folliculitis
headache
chemosis
eyelid oedema
proptosis
painful ophthalmoplegia
fever
150
Q

what are the symptoms of a cortical vein thrombosis?

A

venous infarcts with stroke-like focal symptoms

evolve over days

151
Q

what are the causes of intracranial venous sinus thrombosis?

A 
pregnancy/puerperium
OCP
head injury
dehydration
intra/extracranial malignancy
thrombophilia
152
Q

what are the treatment of intracranial venous sinus thrombosis?

A

LMWH -> warfarin (INR 2-3)

fibrinolytics (streptokinase)

153
Q

describe the spinal cord

A

extends from the cranio-cervical junction at the top of C1 to the conus medullaris opposite the bottom of L1

154
Q

describe the motor and sensory pathways of the spinal cord

A

the principle descending motor pathway is the corticospinal tract that crosses in the midbrain
the two principal ascending sensory pathways are the dorsal columns (carry vibration and joint position sense ) and spinothalamic tracts (carries pain and temperature)

155
Q

describe a complete transection of the cord

A

due to trauma or severe inflammation
complete loss of all modalities distal to the transection
including motor, sensory and sphincter function

156
Q

describe a hemisection of the cord

A

brown-sequard syndrome
due to trauma, glioma, MS
loss of motor function and dorsal column sensation ipsilateral to the hemisection
contralateral loss of pain and temperature

157
Q

describe a central cord lesion

A

due to syringomyelia, intramedullary tumour, trauma, central necrosis
syringomyelia - cervical and thoracic region leading to dissociated sensory loss (preserved dorsal column function) and LMN weakness, atrophy and fasciculations

158
Q

what are the symptoms and causes of cord compression?

A

back pain
lower limb; weakness, numbness, sensory changes, reflex loss

metastases in spine
abscess
haematoma
disc prolapse
intrinsic cord tumour
159
Q

what is the treatment of cord compression?

A 
treat the cause
dexamethasone 8mg IV BD
radiotherapy
chemotherapy
surgical drainage of abscess and antibiotics
decompressive laminectomy
160
Q

what are the symptoms of conus medullaris lesions?

A

mixed UMN/LMN weakness
early constipation and retention
back pain
sacral sensory disturbance

161
Q

what are the symptoms of caudal equina lesions?

A 
saddle anaesthesia
back pain
radicular pain down legs
bilaterally flaccid, areflexic lower limb weakness
incontinence/faeces/urine retention
poor anal tone
162
Q

what are the symptoms of cervical spondylitis?

A

usually asymptomatic
neck stiffness +/- crepitus
stabbing/dull arm pain (brachialgia)
upper limb motor and sensory disturbances according to compression levels (often C7)
myelopathy with quadraparesis and sphincter dysfunction

163
Q

what are the treatment of cervical spondylitis?

A 
stiff collar
analgesia
transforaminal steroid injection
decompression
laminectomy or laminoplasty
164
Q

what are the symptoms and signs of lumbar spondylitis?

A 
most commonly compression by L4/5, L5/S1 discs
severe pain on sneezing/coughing
lumbago
sciatica
limited spinal flexion
pain on straight-leg raise
165
Q

what is the treatment of lumbar spondylitis?

A 
rest
analgesia
mobilisation/physiotherapy
transforaminal steroid injection
diseconomy or laminectomy may be considered with continuing pain or muscle weakness
166
Q

what are the symptoms of spinal stenosis?

A 
spinal claudication
aching or heavy buttock and lower limbs pain on walking
parathesia/numbness
pain eased by leaning forward
pain on spine extension
167
Q

what is the treatment of spinal stenosis?

A

NSAIDs
epidural steroid injection
canal decompression surgery

168
Q

what are the symptoms and causes of subacute combined degeneration of the cord?

A 
symmetrical dysaesthesiae
loss of posterior column sensory modalities
spastic para or quaraparaesis
brisk knee jerks
absent ankle jerks
extensor plantas
B12 deficiency (treatment is parenteral B12 replacement)
seen alongside pernicious anaemia, severe malnutrition, nitrous oxide abuse
169
Q

describe the pathology and causes of Lhermitte’s sign

A

transit short-lasting sensation at the back of the neck, lower back after neck flexion
electric-like, tingling, buzzing
disappears on normal posture

MS
spondylosis
vitamin B12
adulation myelopathy

170
Q

describe the pathology and treatment of Guillian-Barre syndrome

A

acute inflammatory demyelinating polyneuropathy
post infectious (campylobacter, EBV, zoster)
symmetrical ascending weakness
antibodies attack nerves
can advance quickly and causes paralysis
can affect respiratory muscles

IV immunoglobulins

171
Q

what is the treatment of a coma?

A 
antibiotics with IV acyclovir if CNS infection suspected
respiratory support
haemodynamic support
fluid and electrolyte balance
VTE prophylaxis
acid-base balance
172
Q

what makes up the portal triad?

A

bile duct
branch of the hepatic artery
branch of the portal vein

173
Q

what are the causes of transaminase derangement?

A 
hepatocyte damage
alcohol
viral hepatitis
paracetamol
ischaemia
174
Q

what are the causes of ALP/GGT derangement?

A 
cholestasis
biliary disease
primary biliary cholangitis
drugs
fatty liver
175
Q

describe acute liver disease and its causes

A

<2-3 months

paracetamol
alcohol
viral hepatitis

176
Q

describe chronic liver disease and its causes

A

> 6 months
progression to fibrosis

caused by
fatty liver disease
alcohol
viral hepatitis
autoimmune liver disease
metabolic
177
Q

what are the causes of jaundice?

A

prehepatic - haemolysis, thalassemia, haemoglobinpoathies, Gilbert’s syndrome
hepatic - viral hepatitis, drugs, cirrhosis, tumours
post hepatic - gallstones, cancer of bile duct, pancreatic carcinoma, lymph node enlargement in portal vein

178
Q

what are the complications of liver cirrhosis?

A 
jaundice
hepatic encephalopathy
coagulopathy
portal hypertension
liver cancer
179
Q

what are the symptoms and signs of hepatocellular carcinoma?

A

RUQ pain
weight loss
decompensated disease
AFP

predominately in patients with cirrhosis
single lesion or diffuse growth

180
Q

what is the treatment of hepatocellular carcinoma?

A 
resection
transplant (CLT/LDLT)
RF/PEI
TACE
sorafenib
supportive care
181
Q

what are the signs of chronic liver disease?

A 
jaundice
ascites
hepatomegaly
cirrhosis
caput medusae
gynaecomastica
palmar erythema
spider naevi
bruising
leukonychia
asterixis
finger clubbing
fetor hepaticus
xanthelasma
parotid enlargement
xanthoma
hepatic flap
182
Q

what are the markers of liver inflammation?

A

AST
ALT
GGT
ALP

183
Q

what are the tests that measure synthetic liver function?

A

bilirubin
albumin
PT

184
Q

what causes an increase in AST and ALT?

A 
infection (hepatotropic viruses)
alcohol
autoimmune disease
paracetamol
statins
anaesthetics
haemochromatosis
Wilson's disease
vascular insult
185
Q

what can cause AST>ALT and GGT increase?

A

alcohol

186
Q

what can cause ALT>AST, GGT and ferritin increase?

A

fatty liver disease

187
Q

what causes an increased GGT and ALP?

A

biliary obstruction (stones, slide, strictures)
primary and secondary biliary cholangitis
primary sclerosing cholangitis
ischaemia
heart failure
fibrosis

188
Q

what are the components of the GMAWS?

A 
agitation
hallucination
orientation
sweating
tremor
189
Q

what is the mechanism by which ascites accumulates in liver disease?

A

portal hypertension -> reduced albumin -> reduced oncotic pressure -> transudation of fluid
reduced aldosterone metabolism ->RAAS activation -> reduced renal blood flow -> salt and water retention

190
Q

what is the management of a patient with chronic liver disease?

A

alcohol withdrawal
IV thiamine (pabrinex) twin vials 3x daily
oral/IV benzodiazepines

determine mortality using GAHS and Maddrey’s discriminant function (corticosteroids if >32)

191
Q

describe the mechanism and the components of the Lille score

A

prediction of mortality in patients with severe alcoholic hepatitis who have been treated with corticosteroids

age 
renal insufficiency
albumin 
PT
bilirubin
evolution of bilirubin at day 7
192
Q

what is the treatment of alcoholic hepatitis?

A 
if infection, treat with antibiotics
prednisolone 40mg daily x7 days
at day 7 assess using Lille score
<0.45 continue for 28 days (responder)
>0.56 stop (non-responder)
alcohol abstinence
nutrition
193
Q

what is the management of uncomplicated ascites?

A

dietary restriction of sodium (80-120mmol/day or 4.6-6.9g)
anti-mineralocorticoid drugs
furosemide (no response to anti-mineralocorticoids or hyperkalaemia develops)
torasemide (weak response to furosemide)

194
Q

what are the features of diverticulitis

A

presents in older ages

pain in the left iliac fossa

195
Q

describe the liver lobules

A

blood flows from the portal triad to the central vein in the branches of the portal vein and hepatic artery
bile flows from the centre to the portal triad in the bile duct
surrounded by hepatocytes

196
Q

what are the functions of the liver

A 
digestion; bile production
coagulation
metabolism
immune function
storage of vitamins, minerals and glucose
197
Q

what would the LFTs look like in hepatocyte damage due to alcohol?

A

AST/ALT
GGT (+MCV, IgA, ferritin)
approx 2-300

198
Q

what are the causes of transaminases >1000?

A

viral hepatitis
drugs; paracetamol
ischaemia

199
Q

what are the causes of deranged ALP/GGT?

A 
cholestasis
biliary disease; deranged LFTs and pain 90% gallstones
primary biliary cholangitis
drugs
fatty liver
200
Q

describe fibroscan

A

assess liver stiffness
non-invasive
quick
safe

201
Q

what are the complications of liver cirrhosis?

A

liver dysfunction; jaundice, hepatic encephalopathy, coagulopathy
portal hypertension
liver cancer

202
Q

describe the indications and components of the child Pugh score

A 
shows the estimated 1 and 2 year survival of cirrhosis
encephalopathy
ascites
bilirubin
albumin
PT; seconds prolonged, INR
203
Q

what are the components of portal hypertension?

A 
increased hepatic vascular resistance
increased portal blood inflow
formation of portosystemic collaterals
20-60% mortality
pressure = resistance (liver) x blood flow
204
Q

what are the surveillance techniques used to detect hepatocellular carcinoma?

A

6 monthly
USS
AFP; rises with exacerbation of underlying disease

205
Q

what is the function of AST & ALT?

A

elevated in response to liver parenchymal injury

206
Q

what is the function of ALP & GGT?

A

found in cells lining bile ducts and elevated in cholestatic diseases

207
Q

what questions should be asked in a jaundice history?

A

symptoms; pain, urine colour, stool colour, itch
risk factors; alcohol, viral hepatitis, drugs, FHx
past medical history; NAFLD, pancreatitis, gallstones, malignancy

208
Q

what investigations should be done to diagnose liver disease?

A 
U&E
blood glucose
coagulation screen
liver screening panel
CXR
USS
diagnostic peritoneal tap
OGD
209
Q

what tests are done in a liver screening pan?

A 
hepatitis screen; acute viruses, viruses leading to chronic  disease
autoimmune
coeliac
IgG
ferritin & % saturation
copper & caeruloplasmin
A1-anti trypsin levels
210
Q

what are the components of the GAHS?

A 
age
WCC
urea
PT ratio or INR
bilirubin
211
Q

define maddrey’s discriminant function

A

a disease specific prognostic score of alcoholic hepatitis
4.6 x bilirubin + (patients PT - control PT)
>32; 30-50% mortality in 1 month

212
Q

what is the lifestyle management of liver disease?

A

alcohol abstinence
ascites management
nutrition

213
Q

what are the infective causes of liver failure?

A

viral hepatitis (B, C, CMV)
yellow fever
leptospirosis

214
Q

what are the drug related causes of liver failure?

A

paracetamol overdose
halothane
isonazid

215
Q

what are the vascular causes of liver failure?

A

Budd Chiari syndrome

veno-occlusive disease

216
Q

what are the other causes of liver failure?

A 
AFLD
NAFLD
PBC
haemochromatosis
autoimmune hepatitis
alpha-1 antitrypsin deficiency
Wilsons disease
HELLP
fatty liver of pregnancy
malignancy
217
Q

what are the signs of liver failure?

A 
jauncide
asymptomatic
hepatic encephalopathy
fetor hepaticus
asterixis/flap
constructional apraxia
ascites
218
Q

what are the signs of chronic liver disease?

A 
leukonychia
malnourishment
IVDU
finger clubbing
palmar erythema
hyperdynamic circulation
Dupuytren’s
spider naevi
xanthelasma
gynaecomastica
atrophic testes
reduced body hair
parotid swelling
hepatomegaly
shrunken liver
lethargy
bruising
thin skin
219
Q

what are the signs of portal hypertension?

A

splenomegaly
caput medusa
oesophageal varices
ascites

220
Q

what is the treatment of portal hypertension?

A

band varices
prophylactic beta blockers
TIPPS procedure

221
Q

what are the complications of chronic liver disease?

A 
portal hypertension
upper GI haemorrhage
ascites
spontaneous bacterial peritonitis
hepatic encephalopathy
hepatopulmonary syndrome
hepatorenal syndrome
222
Q

what is the management of chronic liver disease?

A 
essential monitoring
treat the underlying cause
nutrition (thiamine and folate)
cholestryamine
reduced alcohol intake

be mindful of sepsis, GI bleeds/varices, hypoglycaemia, encephalopathy

223
Q

what medications should be reviewed when GORD is diagnosed/suspected?

A 
NSAIDs
bisphosphonates
calcium antagonists
nitrates
theophylline
corticosteroids

Clinical Practice (14 decks)

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