Gastroenterology COPY Flashcards

Question

Management of constipation > 3 months?

Answer 1

> 3 months - Treat underlying cause - Diet + lifestyle advice (fibre and water) Medical laxatives - Bulk Laxatives (ispaghula) or methylcellulose. - 2nd line - Osmotic Laxatives (lactulose, macrogols, magnesium citrate) - 3rd line - Osmotic laxatives + diet + lifestyle + stimulant laxatives (senna or bisacodyl)

Answer 2

Increases faecal mass --> Increased peristalsis.

Answer 3

Obstruction or faecal impaction.

Answer 4

Bran Ispaghula husk (Fybogel) Methylcellulose

Answer 5

Lactulose | MgSO4 (rapid)

Answer 6

Retain fluid in the bowel

Answer 7

Senna Bisacodyl PO or PR (10mg) Sodium picosulphate

Answer 8

Docusate sodium (500mg daily)

Answer 9

Preparation for a flexible sigmoidoscopy | Constipation

Answer 10

Glycerol (stimulant)

Answer 11

- 1 hr before leaving home for day of examination - Place unopened enema bottle into jug of warm water for 5 mins. - Lie down on bed with knees to chest - Insert length of nozzle into your bottom, and squeeze bottle until it is empty. - Hold for 15 min until urge to open bowels.

Answer 12

Enhanced visceral perception giving bowel symptoms for which no organic cause can be found.

Answer 13

ROME criteria - At least 1 day per week in the last 3 months, with onset at least 6 months previously, of recurrent abdominal pain or discomfort. - Associated with 2 or more of the following: - 1) Improvement with defecation - 2) Onset associated with change in frequency of stool; - 3) Onset associated with a change in form of stool

Answer 14

Consider in anyone who has 6 months of: - Abdo pain - Bloating OR - Change in bowel habit. Diagnosis if a person has abdo pain which is: - related to defection - Associated with altered stool frequency (more or less) - Altered stool form or appearance.

Answer 15

``` >40 yrs Bloody stool Anorexia Weight loss Diarrhoea at night ```

Answer 16

- Bloods: FBC, ESR, LFTs, Coeliac serology, TSH | - Colonoscopy: if >60yrs or any features of organic disease.

Answer 17

- Exclusion diet can be tried (low FODMAP). Try to have regular meals, avoid missing meals, drink 8 cups of water, restrict tea + coffee to 3 cups a day. According to predominant symptom pain: antispasmodic agents (merebavine) constipation: laxatives but avoid lactulose (Linaclotide) diarrhoea: loperamide is first-line. An opioid receptor agonist which does not have systemic effects. 2nd line: - Amitriptyline may be helpful. (abdo pain) - CBT

Answer 18

Difficulty swallowing

Answer 19

``` Tonsilitis, pharyngitis, oesophagitis (GORD), Oral candidiasis, Aphthous ulcers. ```

Answer 20

Mechanical block: | - Luminal: (FB, Large food bolus),

Answer 21

Plummer-Vinson (Web), Oesophagitis Trauma (GORD) Pharyngeal pouch

Answer 22

Malignant stricture: 1) Pharynx 2) Oesphagus 3) Gastric

Answer 23

``` Lung Cancer Rolling hiatus hernia Mediastinal LN (Lymphoma) Retrosternal goitre Thoracic aortic aneurysm ```

Answer 24

Local: - Achalasia - Diffuse oesophageal spasm - Nutcracker oesophagus - Bulbar/pseudobulbar palsy (CVA, MND) Systemic: - Systemic sclerosis/CREST - MG

Answer 25

- Dysphagia for liquids and solids at start? Motility disorder - If not: solids > liquids: Stricture - Difficulty making swallowing: bulbar palsy - Odynophagia: Ca, oesphageal ulcer, spasm - Intermittent: oesophageal spasm - Constant and worsening: malignant stricture - Neck bulges or gurgles on drinking: pharyngeal pouch

Answer 26

``` Cachexia Anaemia Virchow's node (+ve = Troisier's sign) Neurology Signs of systemic disease ```

Answer 27

Bloods: FBC, U+E CXR OGD (Upper GI Endoscopy) - Stop PPI 2 weeks before an upper GI endoscopy. Barium Swallow ± Video fluroscopy

Answer 28

- Degeneration of the myenteric plexus (Auerbach's) - Decreased peristalsis - Lower oesophageal sphincter fails to relax

Answer 29

Primary/Idiopathic: commonest | Secondary: oesophageal Ca, Chagas' disease (T.cruzii)

Answer 30

Dysphagia: Liquids and solids at the same time Arching of neck/standing sitting up straight Regurgitations Substernal cramps Wt Loss

Answer 31

Chronic achalasia --> Oesophageal primary squamous cell carcinoma.

Answer 32

Bedside Obs: HR, O2, BP, RR. Bloods: FBC (Anaemia), U+E (Electrolytes), (TFTs) Barium swallow: See a dilated tapering oesophagus (Bird's Beak). Better in older patients. Manometry: Checking functioning of the oesophageal valve CXR: Widened mediastinum OGD: To exclude malignancy and is usually first line.

Answer 33

Intra-sphincteric injection of botulinum toxin First line: Pneumatic dilation - - Air inflated balloons are used to apply mechanical stretch to the lower oesophageal sphincter to tear its muscle fibres (Rigiflex or Witzel) - Surgical cardiomyotomy (open or endo) Poor surgical candidate? - Medical - CCB (nifedipine or verapamil) or nitrates. (to lower oesophageal sphincter pressure. - Botox - inhibits the release of acetylcholine from nerve terminals. Done endoscopically

Answer 34

Outpouching of the oesophagus - Between borders of cricopharyngeus and lower border of inferior constrictor of pharynx. - Weakness in muscle wall termed Killian's dehiscence Management is with Surgery

Answer 35

Defect usually posteriorly, but swelling usually bulges to left side of neck. Therefore food debris, then pouch expansion and dysphagia. Upper GI endoscopy is potentially hazardous and may result in iatrogenic perforation.

Answer 36

Intermittent dysphagia ± chest pain.

Answer 37

Ba Swallow shows corkscrew oesophagus.

Answer 38

Increase contraction of smooth muscle with normal peristalsis.

Answer 39

Non-specific group of symptoms: - Epigastric discomfort - Bloating - Heartburn

Answer 40

Urgent - All patients who've got dysphagia, all patients who have an upper abdo mass consistent with stomach cancer. Patients aged >55 years who've got weight loss, and any of the following: upper abdo pain, reflux, dyspepsia. Non-urgent: Patients with haematemesis Patients aged >= 55 years who've got: treatment-resistant dyspepsia or upper abdominal pain with low haemoglobin levels or raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain Managing patients who do not meet referral criteria: This can be summarised at a step-wise approach 1. Review medications for possible causes of dyspepsia 2. Lifestyle advice 3. Trial of full-dose proton pump inhibitor for one month OR a 'test and treat' approach for H. pylori Ensure you rule out coronary artery disease. Consider ECG, Serum Troponin, exercise stress testing. ``` ALARM: Anaemia/bleeding/Abdo Mass Loss of Weight Anorexia (Appetite) Recent onset progressive symptoms Melaena or haematemesis/vomiting Swallowing Difficulty ```

Answer 41

Inflammation: GORD, Gastritis, PUD Malignancy: Gastric or Oesophageal Functional: Non-ulcer dyspepsia

Answer 42

- OGD >60 or ALARMS - Consider conservative measures for 4 weeks - stopping NSAIDS/CCBs, stop smoking/ decrease ETOH, weight loss. Try OTC Antacids/Alginates (Gaviscon). 1st line: If no alarming features do breath test or stool test for H/Pylori. Breath test = drink C12, measure level of urea as it is broken down by H.pylori. Ensure patient has not had any antibiotics, no antisecretory drugs (PPI) in past 2 weeks. Other: Rapid urease test (CLO test) - biopsy with urea + pH indicator. Serum antibody: positive after eradication. Culture of gastric bipsy Gastric biopsy +ve H.Pylori = 7 day 2x daily Amoxicillin and Clarithromcyin or Metronidazole. -ve Result = PPI (Esomeprazole/Omeprazole/Lansoprazole

Answer 43

Lansoprazole 30mg, Omeprazole (20-40mg), Rabeprazole 20mg. - Full dose PPI 1 -2months. - Then, low dose PPI PRN. Adverse effects - Hyponatraemia - Osteoporosis - Microscopic Colitis - Increased risk of C.diff

Answer 44

- Full dose PPI for 1-2 months? What is that again? - H.pylori eradication if positive - Endoscopy to check for resolution if GU - Then, low-dose PPI PRN

Answer 45

PAC 500 (Penicillin) - PPI: Lansoprazole 30mg BD - Amoxicillin 1g BD - Clarithromycin 500mg BD Post eradication investigation is breath test.

Answer 46

- PPI: Lansoprazole 30mg BD - Metronidazole 400mg BD - Clarithromycin 250mg BD Note that PPIs cause hyponatraemia, osteoporosis (increased risk of fractures), microscopic colitis. Increased risk of C.diff infections.

Answer 47

95%. Failure due to poor compliance. Bismuth can be used for resistance to clarithromycin but gives stools tarry black colour.

Answer 48

Acute: Usually due to drugs (NSAIDs, Steroids) or Stress. Chronic: Drugs, H.pylori, Hypercalcaemia Zollinger-Ellison - 1/3 have MEN-1. Parathyroid, pituitary and pancreas. Zollinger-Ellison is too much gastrin - 30% have MEN-1. Causes multiple gastroduodenal ulcers, diarrhoea, malabsorption. Diagnosed with fasting gastrin and secretin.

Answer 49

Duodenal are 4x more common

Answer 50

First part of the duodenum (cap) | More common in males than females.

Answer 51

Lifestyle: ETOH, Smoking, increased gastric emptying (damage to duodenum) Infection: H.pylori (90%) Drugs: NSAIDS (COX-1 blocks prostaglandins needed for gastric mucosa), Steroids Also SSRI, steroids, bisphosphonates.

Answer 52

Epigastric pain: BEFORE meals, after meals and at NIGHT. Cause pen when hungry and are relieved by eating. Pyloric sphincter contracts when eating. Relieved by: eating or milk

Answer 53

- Lesser curve of gastric antrum (medial curve that is smaller) - Beware ulcers elsewhere (could be malignant)

Answer 54

- Lifestyle: Smoking, DECREASED gastric emptying - Infection: H.pylori - Drugs: NSAIDS, Steroids, SSRI, bisphosphonates - Stress: Cushing's Ulcer due to intracranial disease? Increased vagal stimulation, Increased stomach acid Curling's ulcer: Burns, Sepsis, Trauma (reduced plasma volume)

Answer 55

Worse ON eating Relieved by antacids Weight Loss

Answer 56

Start from ulcer: Bleeding --> Haemorrhage: - Haematemesis or melaena - Fe deficiency anaemia Duodenal ulcer bleeds from gastroduodenal artery. Even more? --> Perforation - Peritonitis Growing and blocking? --> Gastric Outflow obstruction - Vomiting, colic, distension Long term? Malignancy - Increased risk with H.pylori

Answer 57

- Obs: RR, HR, O2, BP - Bloods: FBC (anaemia/maleana), urea (increased in haemorrhage) - C13 breath test. - OGD (Stop PPIs >2 weeks before). Initially order if patient >60. Urease test for H.Pylori. Take biopsies to check for malignancy. - Gastrin (Hypergastrinaemia) levels if Zollinger-Ellison suspected. Forrest Score: on endoscopy - GBS - (Rockall is old) - Glasgow Blatchford.

Answer 58

- 1st line Endoscopy ± blood transfusion. PPI reduces rebleeding (omeprazole 80). Discontinue NSAIDs. Surgery is indicated in patients with ongoing acute bleeding despite repeated endoscopic therapy. - 2nd line: Surgery or embolisation

Answer 59

Conservative (Treat underlying cause) : Lose weight/Stop smoking + decrease ETOH. Avoid hot drinks + spicy food. Stop drugs such as NSAIDS, Steroids. + Medical: 1st line: Give PPI for 4 weeks (lansoprazole 15-30mg OD) 2nd line: H2 Antagonist (Ranitidine 150mg) For patients who need NSAIDS: Misoprostol 100-200microgram 4x OD.

Answer 60

- Eradication therapy (triple = PPI, Clari, Amox or Metro) (Quad = PPI, Tetracycline, Metronidaole, bismuth)

Answer 61

Rarely used today. - Vagotomy: Truncal (must be included with a pyloroplasty (open opening to duodenum) or gastroenterostomy) - Selective: Vagus nerve only denervates where it supplies lower oesophagus. (Nerves of Laterjet)

Answer 62

Removal of the distal half of stomach + anastomosis: - Directly added to duodenum: Biliroth 1 - To small bowel loop with duodenal stump oversewn: Biliroth 2 or Polya.

Answer 63

Sometimes performed for Zollinger-Ellison

Answer 64

Physical complications - Duodenal stump leakage - Abdominal fullness - Reflux or bilious vomiting (improves with time) - Stricture formation

Answer 65

Dumping syndrome - Abdominal pain, flushing + N/V - Early pain (10-30 mins) = Osmotic hypovolaemia - Late: (2-3 hrs) Reactive hypoglycaemia due to rapid increase in insulin due to excess sugar in intestine. Also during gastric surgery. Blind loop syndrome --> Malabsorption, Diarrhoea - Overgrowth of bacteria in duodenal stump - Anaemia: FB + B12 - Osteoporosis Weight loss: Malabsorption of decreased calories intake

Answer 66

Blind loop syndrome --> Malabsorption, Diarrhoea - Overgrowth of bacteria in duodenal stump - Anaemia: FB + B12 - Osteoporosis

Answer 67

Dysfunction of the lower oesophageal sphincter --> leading to stomach acid reflux up the oesophagus --> oesophagitis.

Answer 68

``` Lifestyle: Smoking, ETOH, Obesity Physiological: Pregnancy Anatomical: Hiatus Hernia Iatrogenic: drugs (nitrates, CCB, TCA, anti-ACHm. Surgical: Heller's Myotomy ```

Answer 69

- Heart burn that is related to meals, lying down, and gets better with antacids. - Belching - Acid Brash (salivation due to excess acid) - Odynophagia

Answer 70

- Chronic cough - Laryngitis, sinusitis - Nocturnal asthma (chest tightness, SOB, Wheeze)

Answer 71

- From excess acid = Oesophagitis - Oesophagitis can cause ulceration - Chronic oesophagitis can cause strictures + dysphagia - Furthermore, Barrett's oesophagus and oesophageal adenocarcinoma. GORD is single strongest risk factor for development of Barrett's oesophagus.

Answer 72

- Other causes of oesophagitis: Infection, IBD, burns. - PUD - Oesophageal cancer

Answer 73

- If isolated no need for further investigations --> trial of PPI - Bloods: FBC - CXR: Hiatus Hernia may be seen. - OGD if: >55 yrs old, symptoms >4 weeks, Dysphagia, persistent symptoms, Weight Loss. - Barium Swallow (rule out other causes): Hiatus hernia or dysmotility - 24 pH testing ± manometry (pH <4 for > 4hrs). Pre-operative workup for patients. Measures pressures within the lower oesophageal sphincter and helps with diagnosis.

Answer 74

Grade A = One or more mucosal breaks < 5mm in maximal length. Grade B = Breaks >5 mm but without continuity across mucosal folds. Grade C = Mucosal breaks between >2 mucosal folds = less than 75% of oesophageal circumference. Grade D = Involving more than 75% of oesophageal circumference.

Answer 75

- Lose weight - Raise head of bed - Small regular meals at least 3hrs before bed - Stop smoking + decreased alcohol intake - Avoid hot/spicy food - Stop drugs: NSAIDs, Steroids, CCBs, Nitrates.

Answer 76

- OTC: Gaviscon, Mg Trisilicate - First line: Full dose PPI for 1-2 months (omeprazole 20mg/lansoprazole 30mg OD) - Second line: If no response double dose of PPI BD. - Third line: If no response: add H2RA such as ranitidine 300mg ON.

Answer 77

Nissen Fundoplication - Indications: Need all 3 of - Severe symptoms - Refractory to medical therapy - Confirmed reflux (pH monitoring)

Answer 78

Aim: prevent reflux, repair diaphragm. - Normally laparoscopic - Mobilise gastric fundus + wrap around lower oesophagus. - Close any diaphragmatic hiatus - Complications: Gas-bloat syndrome: inability to belch/vomit. - Dysphagia if wrap too tight.

Answer 79

1) Sliding (80%) - Gasto-oesophageal junction SLIDES up into chest. Associated with GORD. 2) Rolling (15%) - Gasto-oesophageal junction remains in abdomen, but a bulge of stomach rolls into chest alongside the oesophagus. LOS remains in abdomen therefore little GORD. Can become strangulated. 3) Mixed

Answer 80

Bloods: FBC, U+E CXR: Gas bubble + fluid level within the chest cavity. Ba Swallow: Diagnosis OGD: Can help visualise the mucosa but is not diagnostic. 24hr pH + manometry: exclude dysmotility or achalasia

Answer 81

Conservative: Lose weight Medical: Management of reflux? Surgical: Only if medical treatment is unmanageable. - NB should repair a rolling hernia as it can strangulate.

Answer 82

- VINTAGE - Varices - Inflammation: (Oesophagus, stomach or duodenum). - PUD (DU is most common) - Neoplasia (Oesphageal or gastric Ca) - Trauma: Mallory-Weiss because of vomiting. - Boerhaave's Syndrome - Full thickness tear 2cm proximal to LOS. - Angiodysplasia + other vascular anomalies Angiodysplasia (vascular malformation), HHT or Osler-Weber-Rendu (hereditary haemorrhagic telangiectasia, Dieulafoy lesion: rupture of large arteriole in stomach or other bowel. - Generalised bleeding diathesis Warfarin, thrombolytics CRF (chronic renal failure) - Epistaxis

Answer 83

``` DHIPING ARSE - Diverticulae - Haemorrhoid - Infection: Campy Shigella E.coli C.diff Amoebic dysentery - Polyps - Inflammation (Crohn's, UC) - Neoplasia - Gastric-Upper Bowel Bleeding - Angio (Ischaemic colitis, HHT, Angiodysplasia) ```

Answer 84

- May have had previous bleeds - Known ulcers or dyspepsia - Dysphagia/Weight loss - Liver disease or known varices - Drugs and EtOH - Co-morbidities If there is an iron deficiency anaemia - Check FBC - Then if low Hb and low MCV in non-pregnnacy person check the ferritin. Ferritin can be elevated in disease malignancy etc. - If this is the case consider iron, TIBC, transferrin. Once confirmed as iron deficiency anaemia = serum ferritin less than 15mcg/L.

Answer 85

- CLD (jaundice, ascites, encephalopathy, clubbing, spider naevi, Dupuytren's) - PR: Melaena - Signs of Shock Clammy, cool, CRT >2s Decreased BP (<100) or postural hypotension (>20 drop) Decreased urine output (<30ml/h) Tachycardia Decreased GCS.

Answer 86

1) PUD: 40% (mostly DU) 2) Gastritis/Erosions: 20% 3) Mallory-Weiss tear: 10% 4) Varices: 5% 5) Oesophagitis: 5% 6) Ca Stomach/oesophagus 7) Boerhaave's

Answer 87

- Prediction of re-bleeding and mortality - 40% of rebleeders die - Initial score pre-endosocopy --> Age (60-79 = +1) (>=80 = +2) Shock: BP (SBP <100=1) , Pulse (tachy = 1) , Comorbidities (any = +2, if it is renal, liver or malignancy = +3) Diagnosis: Malignancy = +2, All other diagnoses = +1) Final score post-endoscopy - Final Dx + evidence of recent haemorrhage: Active bleeding, Visible vessel, Adherent clot. - Initial score >3 or final >6 are indications for surgery.

Answer 88

Upper GI bleeding source distal to pylorus.

Answer 89

More for PUD and makes variceal bleed less likely.

Answer 90

Boerhaave's syndrome.

Answer 91

Fresh blood through the anus, in or with stools. | Different to melaena which is black. More associated with LGIB than UGIB.

Answer 92

- Resuscitate - (consider blood/terlipressin) - Maintenance - Urgent Endoscopy - Management after endoscopy

Answer 93

- Head down - 100% O2, protect airway 2 x 14G cannulae + IV crystalloid infusion up to 1L (orange/Grey)

Answer 94

Blood Group specific or O- until Xmatched.

Answer 95

- Terlipressin IV (splanchnic vasoperssor | - Prophylactic Abx: e.g ciprofloxacin 1g/24hr

Answer 96

- Crystalloid IV, with transfusion if necessary - Catheter + consider CVP (aim for >5cm H20) (central venous pressure) - Correct coagulopathy: vit K, FFP, platelets - Pabrinex if EtOH - Notify surgeons

Answer 97

Urgent Endoscopy: All patients with suspected Upper GI bleed require an endoscopy within 24hrs of admission. ``` - Haemostasis of vessel or ulcer: Adrenaline injection Thermal/laser coagulation Fibrin glue Endoclips ``` - Variceal bleeding : 2 of: 1st line banding, 2nd line sclerotherapy, adrenaline, coagulation Balloon tamponade with Sengstaken-Blakemore tube - Only used if exsanguinating haemorrhage endoscopic therapy failure. - TIPPS if bleeding can't be stopped endoscopically. Transjugular intrahepatic portosystemic shunt - TIPS procedure connects the hepatic vein and the portal vein.

Answer 98

- Omeprazole IV + continuation PO (decreased re-bleeding). Do not do it before as it may mask the bleeding. - Offer Vit K - Antibiotic - Keep NBM for 24hr --> Clear fluid --> light diet @ 48hr - Daily bloods: FBC, U+E, LFTs, Clotting - H.pylori testing and eradication - Stop NSAIDs, Steroids etc.

Answer 99

- Rebleeding - Bleeding despite transfusing 6U - Uncontrollable bleeding at endoscopy - Initial Rockall score >3 or final >6.

Answer 100

Uncompensated liver disease (makes ascites worse). | - Use blood or albumin for resus and 5% dextrose for maintenance.

Answer 101

Portal HTN --> Dilated veins @ sites of porto-systemic anastomosis --> L.gastric and inferior oesophageal veins. - 30-50% with portal HTN will bleed from varices. - Overall mortality 25%: increased severity of liver disease.

Answer 102

Pre-hepatic: Portal vein thrombosis Hepatic: cirrhosis (80% in UK), schisto (worldwide), sarcoidosis Post-hepatic: Budd-Chiari (occlusion of hepatic vein), RHF, constrict pericarditis

Answer 103

Betablockers (propranolol), repeat endoscopic banding

Answer 104

Betablockers (propranolol), repeat banding, TIPSS.

Answer 105

Transjugular Intrahepatic Porto-Systemic Shunt

Answer 106

Can increase effect of warfarin

Answer 107

First assessment score (candidates for outpatient management) - Haemoglobin <100 = 6 points. - Blood urea (think about protein meal) - Systolic blood pressure = <90 = 3 points. - Pulse >100/min = 1 point. - Presentation with melaena = 1 point. - Presentation with syncope = 2 points. - Hepatic disease = 2 points - Cardiac failure = 2 points. - Sex

Answer 108

- IR creates an artificial channel between hepatic vein and portal vein --> Decreased portal pressure - Colapinto needle creates tract through liver parenchyma, expand using a balloon and maintained by placement of a stent. - Used prophylactically or acutely if endoscopic therapy fails to control variceal bleeding.

Answer 109

- Normal bilirubin = 3-17

Answer 110

50uM (3x upper limit of normal)

Answer 111

Splenic macrophages

Answer 112

BR-UDP-glucuronyl transferase in the liver.

Answer 113

Into the bile, where it becomes urobilinogen (colourless)

Answer 114

- Reabsorbed, returned to the liver, and back into the bile - Excreted in the urine - into the GIT, converted to sterobilin (brown).

Answer 115

- Pre-hepatic - Hepatic - Post-hepatic

Answer 116

- Excess bilirubin production - -> Haemolytic anaemia - - >Ineffective erythropoiesis (thalassaemia, sickle cell, G6PD)

Answer 117

Unconjugated? - Decreased BR uptake due to using up liver's ability to take it up. 1) Drugs: contrast, Rifampycin 2) Congestive cardiac failure - Decreased bilirubin conjugation 1) Hypothyroidism (decreased movement + conjugation) 2) Gilbert's (AD) 3) Crigler-Najjar (AR) Neonatal jaundice is both increased production and reduced conjugation.

Answer 118

Problems with the liver/Hepatocellular dysfunction? - Congenital - Infection - Autoimmune - Neoplastia - Vascular

Answer 119

- Hereditary Haemochromatosis - Wilson's - a1ATD

Answer 120

- CMV - Hep A/B/C - EBV

Answer 121

- EtOH | - Drugs

Answer 122

AI: AIH Neoplasia: HCC, Mets Vascular: Budd-Chiari

Answer 123

- Dubin-Johnson (black liver due to melanin deposits) | - Rotors

Answer 124

``` - Obstruction Stones Ca Pancreas Drugs PBC PSC Biliary Atresia Choledochal Cyst Cholangio carcinoma ```

Answer 125

Antimalarials - Dapsone

Answer 126

- Paracetamol OD - RMP, INH, PZA - Valproate - Statins - Halothane - MAOIs --> Monoamine oxidase

Answer 127

- Flucloxacillin (weeks after Rx) - Co-amoxiclav - OCP - Sulphonylureas - Chlopromazine, prochlorperazine (antipsychotic)

Answer 128

- Autosomal dominant UDP-GT deficiency - 2% of the population - Jaundice occurs during intercurrent illness - Dx: increase in uBR on fasting, normal LFTs.

Answer 129

Rare auto rec total UDP-GT deficiency - Severe neonatal jaundice and kernicterus Rx: liver Tx

Answer 130

Urine: No Bilirubin, increased urobilinogen, increased Hb if intravascular haemolysis LFTs: increased uBR, increased AST, increased LDH Others: FBC and film, Coombs Test, Hb Electrophoresis

Answer 131

Do a PR for melaena Urine: Increased bilirubin, increased urobilinogen LFTs: Increased conjugated bilirubin, increased AST:ALT - If >2 = ETOH if < 1 = Viral - Increased GGT (EtoH, Obstruction) - Increased ALP - Function: decreased albumin, increased PT. - Others: FBC = Anaemia Anti-SMA (AIH), LKM (AIH), SLA (Chronic Hep C), ANA a1AT, ferritin, caeruloplasmin, Liver biopsy.

Answer 132

- Urine: Increased BR ++, no urobilinogen - LFTs: Increased CBR, Increased AST, increased ALT, Increased ALP, Increased GGT. - Other: Abdo US - Ducts >6mm, ERCP, MRCP, Anti-AMA, ANCA (PSC), ANA.

Answer 133

1) Cirrhosis 2) Acute failure due to: - Infection: Hep A/B, CMV, EBV, Leptospirosis - Toxin: EtOH, Paracetamol, Isoniazid, halothane - Vascular: Budd-Chiari - Other: Wilson's, AIH - Obs: Eclampsia, Acute Fatty Liver of pregnancy.

Answer 134

Jaundice Oedema + ascites Bruising Encephalopathy - normally in acute liver failure. - Aterixis, Constructional apraxia Fetor hepaticus (sweet breath/thiols pass into lungs) Signs of cirrhosis/chronic liver disease

Answer 135

Bloods: - FBC: infection, GI bleed, decreased MCV (ETOH) - U+E: Decreased urea, increased creatinine: Hepatorenal syndrome (urea synthesised in liver so poor test of renal function). - LFT: AST:ALT >2 = ETOH AST:ALT <1 = Viral Albumin: decreased in chronic liver failure ``` PT: Increased in acute liver failure. - Clotting: Increased INR - Glucose - ABG: Metabolic acidosis Causes: Ferritin, a1AT, caeruloplasmin, Abs, paracetamol lvls. ```

Answer 136

Cholestatic: Bili, ALP, GGT Hepatocellular: Bili, AST, ALT.

Answer 137

- Hep, CMV, EBV serology - Blood and urine culture - Ascites MCS + SAAG

Answer 138

- CXR - Abdo US + portal vein duplex. (US is preffered). - For patients with suspected cholangitis, cholecystitis, pancreatitis = CT study.

Answer 139

- Renal failure in patients with advanced CLF. | - Diagnosis of exclusion

Answer 140

- Cirrhosis --> Splanchnic arterial vasodilation --> effective hypovolaemia circulatory volume --> RAS activation --> Renal arterial vasoconstriction. - This persistent underfilling of renal circulation --> failure. Systemic trop in PVR causes activation of sympathetic system and vasocontrictiors.

Answer 141

Type 1: Rapidly deteriorating (survival <2 weeks) | Type 2: Steady deteriorating (survival ~6 months)

Answer 142

- IV albumin + splanchnic vasoconstrictors (terlipressin) - Haemodialysis as supportive management - Liver Transplant is management of choice

Answer 143

- Manage in ITU - Rx of underlying cause: NAC in paracetamol OD - Good nutrition: e.g. via NGT with high carbs. - Thiamine supplements - prophylactic PPI vs stress ulcers

Answer 144

Fluids: urinary and central venous catheters. Bloods: Daily FBC, U+E, LFTs, INR Glucose: 1-4hrly + 10% dextrose IV 1L/12hrs.

Answer 145

- Bleeding: Vit K, platelets, FFP, Blood. - Sepsis: Tazocin (avoid gen: nephrotoxicity) - Ascites: fluid + salt restriction, spironolactone (K+ sparing), furosemide, tap, daily weight. Hypoglycaemia: Regular BMs, IV glucose if <2mM - Encephalopathy: avoid sedatives, lactulose ± enemas, rifaximin. Seizures: lorazempam Cerebral oedema: mannitol

Answer 146

- Avoid: Opiates, oral hypoglycaemics, Na-containing IVI. Effect of warfarin effects increased. - Hepatotoxic drugs: paracetamol, methotrexate, isoniazid, salicylate, tetracycline.

Answer 147

- Grade 3/4 hepatic encephalopathy - >40 yrs old - Albumin <30g/L - Increased INR - Drug-induced liver failure

Answer 148

- Cadaveric: heart-beating or non-heart beating | - Live: right lobe

Answer 149

``` Paracetamol-induced - pH <7.3 24hr after ingestion. Or all of: PT >100s Cr >300uM Grade 3/4 encephalopathy ``` ``` Non-paracetamol PT >100s Or 3 out of 5 of: - Drug-induced - Age <10 or >40 - >1 week from jaundice to encephalopathy - PT >50s - BR >300uM ```

Answer 150

Chronic ETOH Chronic HCV NAFLD/NASH

Answer 151

Genetic: Wilson's, a1ATD, HH, CF AI: AH, PBC, PSC Drugs: Methotrexate, amiodarone, Methylodopa, INH Neoplasm: HCC, Mets Vasc: Budd-Chiari, RHF, constrictive pericarditis

Answer 152

- Clubbing (± periostitis) - Leuconychia (decreased albumin) - Terry's nails (white proximally, red distally) - Palmar erythema - Dupuytron's contracture

Answer 153

Pallor: ACD Xanthelasma: PBC Parotid enlargement: espc with ETOH

Answer 154

- Spider naevi (>5 fill from centre) - Gynaecomastia (low albumin - altered sex hormone metabolism - Loss of 2ndry sexual hair

Answer 155

- Striae - Hepatomegaly (may be small in late disease) - Splenomegaly - Dilated superficial veins (caput medusa) - Testicular atrophy

Answer 156

1. Decompensation --> Hepatic Failure - Jaundice (conjugated) - Encephalopathy - Hypoalbuminaemia --> oedema + ascites - Coagulopathy --> bruising - Hypoglycaemia 2. Spontaneous Bacterial Peritonitis 3. Portal Hypertension 4. Increasing risk HCC

Answer 157

SAVE - Splenomegaly - Ascites - Varices (Oesophageal varices, caput medusa, worsens existing piles) - Encephalopathy

Answer 158

Bloods: - FBC: decreased WCC, decreased platelets indicate hypersplenism. Thrombocytopenia is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with liver disease. - Increased LFTs (2.5 increase ratio of AST to ALT). Urea should go down. - Increased INR - Decreased Albumin

Answer 159

EToH: increased MCV, increased GGT

Answer 160

Hyperlipidaemia, increased glucose.

Answer 161

Hep C, Hep B, CMV, EBV serology

Answer 162

Ferritin (Haemachromatosis), a1AT, caeruloplasmin (decreased in Wilson's)

Answer 163

AIH: SMA, SLA, LKM, ANA

Answer 164

Increased IgG = AIH | Increased IgM = PBC

Answer 165

Transient elastography and acoustic radiation force (for patients with NAFLD, enhanced liver fibrosis). This is fibroscan. Measures the stiffness of the liver. Abdo US + Portal Vein Duplex - Small liver, nodularity, splenomegaly, increased diameter of the portal vein. - Reversed portal vein flow - Ascites - Also liver biopsy

Answer 166

PMN > 250mm indicates SBP, whether or not culture has grown. Most common organism = E.coli

Answer 167

- Frequently encountered bacterial infection in patients with cirrhosis, most commonly seen in patients with end-stage liver disease. - Key symptoms = abdo pain, fever, vomiting, altered mental status and GI bleeding. However can also present asymptomatically.

Answer 168

- General - Good nutrition, - ETOH abstinence: baclofen helps decreasing cravings - Colestyramine for pruritus - Screening: HCC -US and AFP every 6 months. - Oesophageal varices: endoscopy.

Answer 169

- Interferon-a/Oral antiviral = Sofosbuvir, Elbasvir

Answer 170

- IV Cefotaxime 2g every 8-12 hrs + Vancomycin 500-1000mg - Prophylaxis given to patient who have had an episode of SBP - Patients with fluid protein <15 and either a Child-Pugh score of at least 9 or hepatorenal syndrome. - Offer oral cipro or norfoxacin prophylaxis for people with cirrhosis + ascites.

Answer 171

Primary Biliary Cholangitis - Disease of small intrahepatic bile ducts (and eventual loss) occuring in the context of chronic portal tract inflammation. Develops fibrosis, then bile acids remain in the liver, resulting in cirrhosis.

Answer 172

- Bile acid analogues - ursodeoxycholic acid. - Prednisolone: 20-30mg - Antipruritic: colestyramine

Answer 173

AR disease - copper accumulation due to enzyme defect in biliary excretion of copper. Hx: Hepatitis, cirrhosis, hepatic decompensation, psychiatric disorder. Ix: - Reduced serum caeruloplasmin - Reduced serum copper (95% of plasma copper is carried by ceruloplasmin - Increased 24hr urinary copper excretion - slit lamp examination, liver biopsy.

Answer 174

The Nazer score is a triage tool on deciding who should receive a liver transplant and those who should receive anti-copper medical therapy. It is based on the severity of abnormality for each of: - Serum AST - Bilirubin - Prothrombin time 0 = Bili <100, AST <100, PT <4 10-12 should be transplanted. 1 - 6 = Medical treatement 7-9 = Evaluated by clinical judgement

Answer 175

penicillamine (chelates copper) has been the traditional first-line treatment Trientine and Zinc 4-6 months.

Answer 176

Ascites: fluid and salt restrict, 1st line: spiro 2nd line: fruse, tap, daily weights. Coagulopathy: vit K, platelets, FFP, blood. Encephalopathy: avoid sedatives, lactulose ± enemas, rifaximin (used to reduce the recurrence of episodes of overt hepatic encephalopathy - use if refractory to lactulose). Neomycin is another medication licensed for use in hepatic encephalopathy. Sepsis/SBP: Tazocin? Cefotaxime + Vanc Hepatorenal syndrome: IV albumin + terlipressin

Answer 177

Predicts risk of bleeding, mortality and need for Tx - Graded A-C using severity of 5 factors. - Albumin - 1,2 or 3 points for each. - Bilirubin - - Clotting - - Distension: Ascites - Encephalopathy . Class A = 5-6 points (1yr survival 100%) Class B = 7-9 points Class C = 10-15 points (45%)

Answer 178

Pre-hepatic - portal vein thrombosis (pancreatitis) Hepatic - cirrhosis or schisto (worldwide) Post-hepatic - Budd-Chiari, RHF, constrictive pericarditis, TR

Answer 179

Oesophageal varices = Portal - Left and short gastric veins. Systemic = Inf. oesophageal veins. Caput medusae = Peri-umbilical vein. Superficial abdo wall veins. Haemorrhoid = Super rectal veins. Inferior and middle rectal veins.

Answer 180

- A lot more common than caput medusa. - Blood flow down below towards legs: portal HTN. - Blood flow towards the head: IVC obstruction.

Answer 181

- Decreased hepatic metabolic function - Diversion of toxins from liver directly into systemic system. - Ammonia accumulates and pass to brain where astrocytes clear it causing glutamate --> Glutamine - Increased glutamine --> osmotic imbalance --> cerebral oedema.

Answer 182

1: Confused - irritable, mild confusion, sleep inversion 2: Drowsy - Increased disorientated, slurred speech, asterixis 3: Stupor - rousable, incoherence 4: Coma - unrousable, ± extensor plantars

Answer 183

Constipation (commonest cause - due to excessive nitrogen load and can lead to Liver decompensation. HEPATICS - Hepatic encephalopathy - Haemorrhage: e.g varices - Electrolytes: decreased K, decreased Na - Poisons: diuretics, sedatives, anaesthetics - Alcohol - Tumour: HCC - Infection: SBP, pneumonia, UTI, HDV - Constipation (commonest cause - due to excessive nitrogen load - Sugar (glucose) decrease: e.g low calorie diet.

Answer 184

- Excessive nitrogen loading - Electrolyte or metabolic disturbances - Drugs and medication - Infection (pneumonia)

Answer 185

increased plasma NH4

Answer 186

- Nurse 20 degrees head up - Correct any precipitants - Avoid sedatives - Lactulose ± PO4 enemas to decreased nitrogen-forming bowel bacteria --> 2-4 soft stools/d - Consider rifaximin PO to kill intestinal microflora.

Answer 187

- back-pressure --> Fluid exudation - decreased effective circulating volume --> RAS activation - (in cirrhosis): decreased albumin --> Decreased plasma oncotic pressure and aldosterone metabolism impaired.

Answer 188

- Distension --> abdo discomfort and anorexia - Dyspnoea - decreased venous return

Answer 189

Serum Ascites Albumin Gradient (SAAG) = Serum albumin - ascitic albumin - SAAG >=1.1g/L = Portal HTN. (pre, hepatic, post), Cirrhosis in 80%. - SAAG <1.1g/dL = other causes. = Neoplasia: peritoneal or visceral = Inflammation: e.g pancreatitis = Nephrotic syndrome = Infection: TB peritonitis

Answer 190

- Bloods: FBC, U+E, LFTs, INR, chronic hepatitis screen. - US: confirm ascites, liver echogenicity, PV duplex - Ascitic tap: MCS and AFB Cytology - Chemistry: albumin, LDH, glucose, protein - SAAG = Serum albumin - ascites albumin - Liver biopsy

Answer 191

- Daily weight aiming for <0.5kg/d reduction - Fluid restrict <1.5L/d and low Na diet ( - Spironolactone + frusemide - Therapeutic paracentesis with albumin infusion) 100ml 20%/L drained. - Respiratory compromise, pain/discomfort, renal impairment. Need to give albumin - To avoid PICD - Paracentesis-Induced Circulatory Dysfunction - Refractory ascites?: TIPSS.

Answer 192

- Patient with ascites and peritonitic abdomen - Caused by E.co.i, Klebsiella, Streps - Complicated by hepatorenal syndrome in 30% - Ix: Ascites PMN > 250mm + MCS - Rx: Tazocin or cefotaxime/vancomycin until sensitivities known

Answer 193

Splenic congestion - Hypersplenism: decreased WCC, decreased platelets. Massive splenomegaly - CML, Myelofibrosis, Visceral leishmaniasis, Malaria. Mild: Infections: IE, EBV, CMV, amyloidosis, sarcoidosis, SLE, RA(Felty's).

Answer 194

Hepatic: Fatty liver --> hepatitis--> cirrhosis AST: ALT >2, increased GGT.

Answer 195

- Gastritis, erosions - PUD - Varices - Pancreatitis - Carcinoma

Answer 196

- Poor memory/cognition - Peripheral polyneuropathy (mainly sensory) - Wernicke's encephalopathy: confusion, ophthalmoplegia (nystagmus, LR (6th nerve palsy - eye cannot turn outwards, looking in slightly), ataxia. --> Mamillary bodies. - Korsakoff's: amnesia --> Confabulation - Fits, Falls

Answer 197

Arrhythmias: e.g AF Dilated cardiomyopathy (completely reversible) Increased BP

Answer 198

Increased MCV | Folate deficiency --> anaemia

Answer 199

CAGE - Cut Down? - Annoyed by people's criticisms? - Guilty about drinking? - Eye opener?

Answer 200

10-72hrs after last drink - Consider in new ward pt (<3 days) with acute confusion - Signs = increased HR, decreased BP, tremor = Confusion, fits, hallucinations: esp formication (DTs).

Answer 201

- Tapering regime of chlordiazepoxide PO 50-100mg /lorazepam IM - Thiamine

Answer 202

- Serum urea (in case it is renal) - Serum Creatinine - Liver function (hepatic dysfunction) - Electrolytes (Na/K)

Answer 203

Group therapy or self-help AA - Naltrexone (50-100mg) OD: patients still drinking + Decreased pleasure. - Acamprosate: 666mg TDS. Decreases cravings - Disulfiram (500mg orally for 1 week then 250mg) : aversion therapy - Baclofen: decreased cravings

Answer 204

- Anorexia - Diarrhoea, vomiting, - Tender hepatomegaly, - Ascites - If severe = Jaundice, varices, encephalopathy

Answer 205

- Bloods: increased MCV, Increased GGT, AST: ALT >2, elevated bilirubin, decreased albumin, INR prolonged - Ascitic tap - Abdo US + PV duplex - fatty liver, hepatomegaly, cirrhosis

Answer 206

- Stop ETOH - Management of withdrawal - High Dose B vitamins: Pabrinex - Optimise nutrition (BCAA) - Immunisation - Pneumo, influenza, Hep A/B. - Daily weights, LFTs, U+E, INR - Mx complications of liver failure - Corticosteroids for severe alcoholic hepatitis. HDF valve >32.

Answer 207

Maddrey score - Looks at Prothrombin, thrombin and bilirubin. - Mild: 0-5% 30 day mortality - Severe: 50% 30d mortality - 1yr after admission: 40% mortality

Answer 208

Type A = Faeco-Or, by seafood (especialyl abroad). Type B = IV, from blood, body fluids, babies (vertical) Type C = IV, mainly blood, less vertical. Type D, IV = Dependent on prior Hep B infection Type E = FO - Developing world.

Answer 209

Seen in Hep A and B - Flu-like, malaise, arthralgia, nausea. - Distaste for cigarettes in Hep A. - Ranged between 5-7 days.

Answer 210

- Acute jaundice in A>B>C (99, 75, 25%) | - Hepatitis (abdo pain, hepatomegaly, cholestasis: Dark urine, pale stools.

Answer 211

- Splenomegaly - Right upper quadrant pain - Posterior cervical adenopathy - Bradycardia

Answer 212

Hep B has extrahepatic features (serum sickness syndrome): - Urticaria or vasculitis rash - Cryoglobulinaemia - PAN (polyarteritis nodosa) - GN (glomerulonephritis) - Arthritis

Answer 213

Hepatitis C and Childhood Hep B | - Can lead to cirrhosis and increased risk of HCC.

Answer 214

Carriers = 10%. HBsAg +ve > 6 months. - Chronic hepatitis: 10% Cirrhosis: 5%

Answer 215

Carrier: 80% - HCV RNA+ve > 6 months. Chronic hepatitis: 80% Cirrhosis: 20%

Answer 216

- FBC, - LFTs (Raised ALT/AST), Alk phos, - HBsAg for more than >6 months = chronic HBV infection. Implies ongoing infection - either acute or chronic if present >6 months. - Serum anti-HBs = Provides life-long immunity, suggests resolved infection and is also detectable in those immunised with HBV vaccine. Therefore positive HBs and negative anti-HBs means no immunity and hence means that patient is chronically infected. - Serum anti-HBc = IgM anti-HBc may be only way of diagnosing acute HBV infection. Anti IgM is acute. - Serum anti-HBc (IgM + IgG) = IgM anti-HBc appears during acute or recent hep B and present for 6 months. Positive in acute infection, chronic infection. Single best test for screening household contacts of HBV infection. - Serum HBeAg = indicates high likelihood of developing chronic HBV infection with HIGH viral replication. - clotting Ground glass appearance of the cytoplasm of hepatocytes.

Answer 217

- Enzyme immunoassay or Hep C antibodies (Exposure to Hep C) - NAATs (active infection) - Viral genotyping (predicts response to antiviral therapy)

Answer 218

Acute HBV infection? - Supportive care - Some patient suitable for antiviral (Lamivudine, entecavir) Chronic HBV infection: - Entecavir, tenofovir, peginterferon alpha.

Answer 219

Acute HCV - Monitor or decide to start treatment Chronic infection - Ribavirin, NS3 protease inhibitor, sofosbuvir.

Answer 220

Non-alcoholic Fatty Liver Disease

Answer 221

- Cryptogenic cause of hepatitis and cirrhosis associated with insulin resistance and the metabolic syndrome. - Non-alcoholic steatohepatitis is most extreme form and --> cirrhosis in 10%.

Answer 222

- Typically asymptomatic - Obesity, insulin, diabetes, hyperlipidaemia, HTN, metabolic syndrome. - Absence of alcohol use - Fatigue and malaise - Hepatosplenomegaly - truncal obesity - Right upper quadrant abdo discomfort

Answer 223

Hepatitis B presentation

Answer 224

A 60-year-old man presents with several months of gradually worsening abdominal swelling, intermittent haematemesis, and dark stool. He denies chest pain or difficulty breathing. Past medical and family history are not contributory. Past surgical history is significant for back surgery requiring blood transfusion in 1990. Social history is significant for occasional alcohol use. BP is 110/80 mmHg. Physical examination is significant for spider angiomata on the upper chest, gynaecomastia, caput medusae, and a fluid wave of the abdomen. The rest of the examination is normal. A 62-year-old man presents for a routine initial visit in New York. He has occasional arthralgia or myalgia, and takes an ACE inhibitor and a thiazide diuretic for hypertension. A retired accountant and non-smoker, he drinks 1 or 2 beers per week and denies current drug use. Physical examination is normal except for being overweight. Routine blood chemistries are normal, but a screening hepatitis C virus (HCV) antibody test is positive. At follow-up, the patient is concerned about whether he will develop liver problems. He had heard on television that new oral medications are easier to take than older regimens that used injections and asks about the next diagnostic and treatment steps.

Answer 225

- Central obesity (increased waist circumference) and two of: - Increased triglycerides - Decreased HDL - HTN - Hyperglycaemia: DM, IGT, IFG

Answer 226

``` BMI Liver profile: increased (AST: ALT <1) Glucose Fasting lipids Liver biopsy ``` In patients with incidental finding of NAFLD - typically asymptomatic fatty changes on liver US. Liver Fibrosis blood test should be performed to assess for more severe liver disease. - Hyaluronic acid + procollagen III + tissue inhibitor of metaloproteinase 1. Associated with obesity, T2DM, hyperlipidaemia, jejunoileal bypass. Sudden weight loss/starvation.

Answer 227

- Diet + Exercise - Control HTN, DM, Lipids - Consider surgery (Roux en Y)

Answer 228

Hepatic vein obstruction (from level of small hepatic veins to inferior vena cava) --> ischaemia and hepatocyte damage --> Liver failure or insidious cirrhosis

Answer 229

- Hypercoagulable state - - Myeloproliferative disorders (PV most common), PNH, anti-phospholipid, OCP. Local Tumour: HCC Congenital: membranous obstruction of IVC

Answer 230

Triad - RUQ pain: stretching of Glisson's capsule - Hepatomegaly - Ascites: SAAG >1.1g/dL Jaundice (and other features)

Answer 231

Bloods: FBC, clotting (prolonged prothrombin), LFTs US + hepatic vein Doppler. Very sensitive and is radiological investigation. Ascitic Tap: increased protein (>2.5g/dL), with increased SAAG (>1.1g/dL) Other: JAK2 mutation analysis, RBC, CD55 and CD59 (PND)

Answer 232

- Treat underlying disease - Anticoagulate: unless varices present - Ascites: fluid and salt restrict, spiro, frusemide, tap, daily weights - Other options: Thrombolysis, angioplasty, TIPSS - Transplant if fulminant hepatic failure or cirrhosis

Answer 233

- Prevalence: 1/3,000; 10% are carriers | - Age of onset - 40-60 years (women later due to menses)

Answer 234

``` Autosomal recessive: HFE gene (High FE) on chromosome 6 (C282Y) ```

Answer 235

Inherited, mutisystem disorder resulting from abnormal iron metabolism Increased intestinal Fe absoprtion (increased enterocyte DMT + decreased hepatocyte hepcidin) -> deposition in multiple organs

Answer 236

Early signs: Fatigue, erectile dysfunction and arthralgia. iron MEALS -Myocardial:restricted then dilated cardiomyopathy, arrhythmia - Endocrine: - Pancreas (DM), - pituitary (hypogonadism -> amenorrohea, infertility), - parathyroid (hypocalcaemia, osteoporosis) The menses delay presentation due to reducing iron. - Arthritis: 2nd and 3rd MCP joints, knees and shoulders - Liver: Chronic liver disease -> cirrhosis -> HCC and hepatomegaly - Skin: slate grey discolouration - tan + cirrhosis + pseudogout + RCM/DCM + hypogonadism + DM.

Answer 237

- Bloods: increased LFT, ferritin (>55) , iron, LOW TIBC, glucose, genotype Transferrin = protein that iron binds to for transport. INcreased iron so more available to bind to transferrin so saturation goes up. Ferritin is the intracellular storage form of iron therefore going up. TIBC - binding sites on transferrin - less capacity so low. - XR - chondrocalcinosis (cartilage calcification) - ECG, ECHO (heart failure) - Liver biopsy - Pearl's stain to quantify Fe and severity - MRI liver- can estimate iron loading Screening - General population: transferrin saturation > ferritin Family members: HFE genetic testing

Answer 238

- Iron removal : venesection - aim for Hct <0.5, (transferrin <50) Desferrioxamine is 2nd line - General: Monitor DM, low Fe diet - Joint x-ray = Chondrocalcinosis - Screening: Se ferritin and genotype, screen 1st degree relatives - Transplant in cirrhosis

Answer 239

- Venesection returns life expectancy to normal if non-cirrhotic and non-diabetic - Cirrhotic patients have >10% chance of HCC

Answer 240

- Prevalence: 1/4,000; 10% are carriers

Answer 241

Autosomal recessive, Chromosome 14 | Homozygotes have PiZZ phenotype

Answer 242

alpha1-Antitrypsin (a1AT) is a serpin involved in control of inflammatory cascade inhibiting neutrophil elastase a1AT is synthesised in liver and comprises 90% of sea10globulin on electrophoresis

Answer 243

Variable - Neonatal and childhood hepatitis - 15% adults develop cirrhosis by 50 Y - 75% adults have emphysema (especially smokers)

Answer 244

- Blood - reduced serum a1AT levels - Liver biopsy: PAS+ve, diastase-resistant globules - CXR: emphysematous changes - Spirometry: obstructive defect - Prenatal Dx: possibly by CVS

Answer 245

Mostly supportive for pulmonary and hepatic complications - Quit smoking - Can consider a1AT therapy from pooled donors

Answer 246

Prevalence: 3/100,000 Age: presents between childhood and 30 (never >56) Genetics: AR, ATP7B gene on Chr 13

Answer 247

- Mutations of the Cu transporting ATPase - Impaired hepatocyte incorporation of Cu into caeruoloplasmin and excretion into bile - Cu accumulation in the liver and in other organs

Answer 248

- Cornea - Kayser Fleischer rings (70% may need slit-lamp) - Liver disease - Children present with acute hepatitis with necrosis/ cirrhosis - Arthritis Chondrocalcinosis/Osteoporosis - Neurology - Parkinsonism = Bradykinesia, tremor, chorea, tics. Ataxia + depression, dementia, psychosis. - Kidney - Fanconi's syndrome (T2 RTA) type 2 renal tubular acidosis loss of bicarbonate) Osteomalacia - Abortions - Haemolytic Anaemia

Answer 249

CLANKAH - Cornea - Liver - Arthritis - Neurology - Kidney - Fanconi's syndtome - Abortions - Haemolytic anaemia - Coombs negative

Answer 250

- Bloods: decreased copper, decreased caeruloplasmin. Caeruloplasmin is an acute-phase protein + may be high during infection. May be low protein states: nephrotic syndrome or malabsorption - Increased 24hr urinary copper - Liver Biopsy: increased hepatic copper - MRI: basal-ganglia degeneration

Answer 251

- Conservative: Diet = Avoid high Cu foods: liver, chocolate, nuts. - Medical: Penicillamine lifelong (Cu Chelator). SE: Nausea, rash, decreased WCC, decreased Hb, decreased plats, lupus haematuria. Monitor FBC and urinary Cu excretion. - Liver Tx if severe liver disease - Screen siblings

Answer 252

- Inflammatory disease of unknown cause characterised by Abs directed vs hepatocyte surface antigens - Predominately young and middle-aged women - Classified according to Abs T1 = Adult, SMA+ (80%), ANA+ (10%), Increased IgG T2 = Young, LKM+ T3 = Adult, SLA+

Answer 253

Teens and early 20s (25%) - Constitutional: fatigue, fever, malaise - Cushingoid: hirsute, acne, striae - Hepatitis - HSM (hepatosplenomegaly) - Fever - Amenorrhoea - Polyarthritis - Pulmonary infiltration - Pleurisy Post/peri-menopausal - Present insidiously with chronic liver disease

Answer 254

- Autoimmune thyroiditis - DM - Pernicious anaemia - PSC - UC - GN - AIHA (Coombs +ve)

Answer 255

- Increased LFTs - Increased IgG - Auto Abs: SMA, LKM, SLA, ANA - Decreased WCC + decreased platelets due to hypersplenism - Liver Biopsy

Answer 256

Immunosuppression - Prednisolone - Azathioprine as steroid-sparer Liver Transplant (disease may recur)

Answer 257

- Remission in 80% of patients | - 10yr survival 80%

Answer 258

Intrahepatic bile duct destruction by chronic granulomatous inflammation --> cirrhosis

Answer 259

Prev: <4/100,000 Sex: F>>M = 9.1 (90% womeN) Age: 50 Middle age woman with liver failure - signs of rheum/autoimmune conditions.

Answer 260

THe M rule of Primary Biliary Cholangitis - Anti-Mitochondrial antibodies, middle aged females, IgM. - Often asymptomatic and Dx incidentally (Increased ALP) - Jaundice occurs LATE - Pruritis and fatigue - occurs first. - Pigmentation of face - Bones: osteoporosis, osteomalacia (decreased VIt D) - Big organism: hepatosplenomegaly - Cirrhosis and coagulopathy (decreased Vit K) - Cholesterol increased: xanthalasma, xanthomata - Steatorrhoea

Answer 261

- Thyroid - RA, Sjogrens, scleroderma - Coeliac - Renal tubular acidosis - Membranous GN

Answer 262

LFTs: very high ALP, very high GGT, moderately high AST/ALT. ``` Abs: AMA + (98%) Increased IgM Increased Cholesterol ± Increased TSH US to exclude extra-hepatic cholestasis Liver biopsy: non-caseating granulomatous inflammation ```

Answer 263

Symptomatic: - pruritis: cholestyramine, naltrexone - Diarrhoea: Codeine phosphate - Osteoporosis: bisphosphonates Specific - ADEK vitamins - Ursodeoxycholic acid: decreased LFTs but no effect on mortality or need for transplant - Immunomodulatory therapy: Prednisolone 20-30mg orally once daily intially. Can consider azathioprine or mycophenolate mofetil. Liver transplant - End stage disease or intractable pruritis - Recurrence occurs in 20% but doesn't usually lead to graft failure.

Answer 264

Inflammation, fibrosis of strictures and intra- and extra-hepatic ducts. Chronic biliary obstruction --> 2ndry biliary cirrhosis --> liver failure

Answer 265

Epidemiology - Age: 30-50yr - Sex: M>F = 2: 1

Answer 266

May be asyptomatic and diagnosis incidentally (increased ALP).

Answer 267

- Jaundice - Pruritus - Fatigue - Abdo pain

Answer 268

- Jaundice: dark urine, pale stools | - Hepatosplenomegaly

Answer 269

- Bacterial cholangitis - Increased cholangiocarcinoma - Increased risk of colorectal carcinoma

Answer 270

- 3% of those with UC have PSC - 80-100% of those with PSC have UC/Crohns - Crohns much raiser - AIH - HIV

Answer 271

- LFTs: increased ALP initially, then increased BR - Abs: pANCA, ANA and SMA may be +ve - MRCP: beaded appearance of ducts (beads on string) is standard to diagnose primary sclerosing cholangitis. - Can use ERCP if MRCP is contra-indicated. They are the investigation of choice for diagnosing PSC. Biopsy: fibrous, obliterative cholangitis

Answer 272

- No curative medical therapy: transplant needed - Symptomatic: Pruritus: colestyramine, naltrexone Diarrhoea: codeine phosphate - Specific ADEK vitamins Ursodeoxycholic acid improves cholestasis only Abs - Screening Cholangiocarcinoma: US + Ca19-9 CRC: colonoscopy Transplant - Recurrence occurs in 30% High risk

Answer 273

90% are 2ndry mets -primary in men: stomach, lung colon. - primary in women: breast, colon, stomach, uterus - Less common: pancreas, leukaemia, lymphoma 90% of primary tumours are HCC - Benign tumours: haemangiomas = reddish purple hypervascular lesion. Hyperechoic on US. - Liver adenomas = Linked to OCP. Solitary lesion sharply demarcated. Mixed echoity, hypodense. cyst.

Answer 274

- Benign tumours usually asymptomatic - Systemic: fever, malaise, weight loss, anorexia - RUQ pain: stretching of Glisson's capsule - Jaundice is often late except in cholangiocarcinoma - May rupture --> intraperitoneal haemorrhage

Answer 275

- Hepatomgealy: smooth, hard or irregular - Signs of chronic liver disease - Abdominal mass - hepatic bruit (HCC)

Answer 276

Bloods: LFTs, Hepatitis serology, AFP (HCC) Imaging: US or CT/MRI ± guided diagnostic biopsy ERCP + biopsy in suspected cholangiocarcinoma - Biopsy (seeding may occur along tract) - Find primary e.g colonoscopy, mammography

Answer 277

- Rx and prognosis vary with type and extent of primary - Small solitary CRC mets may be resectable - Advanced disease therefore prognosis < 6months.

Answer 278

- Rare in west, common in china and sub-saharan africa

Answer 279

- Viral hepatitis Hepatitis B most common cause in world Hepatitis C most common cause in Europe - Screening with ultrasound (+/- alpha-fetoprotein) for high risk groups. - Patients liver cirrhosis secondary to hepatitis B and C or haemochromatosis. - Men with liver cirrhosis secondary to alcohol - Cirrhosis: EtOH, HH, PBC - Aflatoxins (produced bu aspergillus

Answer 280

- Resection of solitary tumours improves prognosis (13--> 59%), but 50% have recurrence - Also: Chemo, percutaneous ablation and embolisation (transarterial chemoembolisation). Sorafenib: mutlikinase inhibitor.

Answer 281

Staging = Liver MRI, chest abdo and pelvic CT. Check testes. BCLC - 0A, B, C,D. A = Liver transplantation alongside TACE (transarterial chemo-embolisation and/or radiofrequency ablation bridging therapy. B = TACE + percutaneous ablation C = sorafenib or lenvatinib - oral multikinase inhibitors. D = Hospice care (± liver transplant)

Answer 282

- Biliary tree malignancy

Answer 283

- Flukes (clonorchis) - PSC - Congenital biliary cysts - UC (intrahepatic from cirrhosis + Hep B + C.

Answer 284

Fever, malaise Abdo pain, ascites, jaundice Increased bilirubin, increased ALP Diagnosis - Obstructive picture with liver function tests- - Ca 19-9^^, CEa, CA125 - CT/MRI and MRCP

Answer 285

30% resectable - Consider neoadjuvant chemo or chemoradiotherapy. - Palliative stenting: percutaneous or ERCP

Answer 286

- Cadaveric: heart-beating or non-heart beating | - Live - right lobe

Answer 287

- Advanced cirrhosis - HCC - Cholangiocarcinoma - Alpha-1 antitrypsin deficiency.

Answer 288

- Extra-hepatic malignancy - Severe cardiorespiratory disease - Systemic sepsis - HIV infection - Non-compliance with drug therapy

Answer 289

- 12-24hr on ITU - Immunosuppression : Ciclosporin/Tacrolimus + Azathioprine/Mycophenolate Mofetil + Prednisolone

Answer 290

``` - Acute rejection (T-cell mediated) 50% @ 5-10 days Pyrexia, tender hepatomegaly increased or change immunosuppressants - Sepsis - Hepatic artery thrombosis - CMV infection - Chronic rejection (6-9 months): shrinking bile ducts - Disease recurrence (e.g HBV) ```

Answer 291

Depends on disease aetiology | 60-90% 5 yrs.

Answer 292

``` UC = 100-200/100,000 Crohns = 50-100/100,000. ```

Answer 293

``` Crohns = 20s UC = 30s ```

Answer 294

UC is protective | Crohns increased risk

Answer 295

``` UC = TH2 mediated Crohns = Th1/Th17 mediated ```

Answer 296

Rectum + colon + backwash ileitus

Answer 297

Mouth to anus esp terminal ileum

Answer 298

Contiguous

Answer 299

Skip lesions

Answer 300

Mucosal | Crypt Abscesses

Answer 301

transmural - Granulomas - Increased goblet cells

Answer 302

Shallow and broad

Answer 303

Deep, thin, serpiginous --> Cobblestone mucosa

Answer 304

Ulcerative Colitis

Answer 305

Fever Malaise Anorexia Weight Loss

Answer 306

- Diarrhoea - Blood ± mucus PR - Abdominal discomfort - Tenesmus, faecal urgency (more rectally) Nocturnal diarrhoea and incontinence are typical features of IBD.

Answer 307

- Diarrhoea (not bloody mostly) - Abdominal pain - Weight loss more prominent - Extra-intestinal signs

Answer 308

- Fever | - Tender, distended abdomen

Answer 309

- Aphthous ulcers - glossitis - Abdominal tenderness - RIF mass - Perianal abscesses, fistulae, tags - Anal/rectal stricture

Answer 310

Skin - Clubbing - Erythema nodosum - Pyoderma gangrenosum (not related to disease activity) Perianal skin tags in Crohns

Answer 311

Eyes - Iritis - Episcleritis - Conjunctivitis

Answer 312

- Arthritis (non-deforming, asymm) (related to disease activity - if asymmetrical) - Sacroiliitis - Ank Spondylitis - Osteoporosis (related to disease activity) HPB - PSC + cholangiocarcinoma (mainly UC). UC has PSC - (not related to disease activity) Primary sclerosing cholangitis - Gallstones (esp. Crohn's) - Fatty liver Other - Amyloidosis - Oxalate renal stones (esp. Crohns)- due to reduced bile acid reabsorption

Answer 313

- Toxic megacolon = Diameter >6cm - Risk of perforation - Bleeding - Malignancy : CRC in 15% with pancolitis for 20yrs : cholangiocarcinoma - Strictures --> obstruction - Venous thrombosis

Answer 314

Fistulae - Entero-enteric/colonic --> diarrhoea - Enterocutaneous = intestine to skin (high or low) output. Can be duodenal/jejunal fistulae which excoriates skin. Colo-cutaneous fistulae leak faeculent material. - Enterovesical --> frequency as it goes to bladder. Investigate with Pelvic MRI to categorise course of fistula. Management - Heal provided no underlying IBD. - When skin involvement = protect underlying skin with stoma bag. - Nutritional complications may require need for TPN. - Crohns perianal fistula requires drainage through use of setons. ``` UTI - Enterovaginal - Perianal --> Pepperpot anus. Abscesses - Abdominal, anorectal Malaborption - Fat --> Steatorrhoea, gallstones - B12 --> megaloblastic anaemia - Vit D --> osteomalacia - Protein --> Oedema ``` Toxic megacolon and Ca may occur (< cf UC)

Answer 315

``` Ix - Bloods: FBC: decreased Hb, Increased WCC LFTs: decreased albumin Increased CRP/ESR (>30 suggestive of a severe flare up) ``` Faecal calprotectin.- NICE advise the use of faecal calprotectin to differentiate IBS from IBD. Blood cultures

Answer 316

MCS: exclude campy, shigella, salmonella CDT: C.diff may complicate or mimic

Answer 317

AXR: megacolon (>6cm) wall thickening (also caused by C.diff, ameobosis) CXR: Perforation CT Ba/gastrograffin enema - Lead-pipe: no haustra - Thumbprinting: mucosal thickening - Pseudopolyp: regenerating mucosal island - Ileocolonoscopy + regional biopsy: Baron Score = Minimum of two biopsies from at least 5 sites along the colon, including the rectum and terminal ileum. During acute flares endoscopic examination should be limited to flexible sigmoidoscopy without bowel prep, due to increased risk of perforation.

Answer 318

Truelove and Witts Criteria - Motions (<4), (4-6), <6 - PR bleed (small, moderate, large) - Temp (aprexic) or (>37.8) - HR (>70), >90 - Hb (>11) (<10.5) - ESR <30 >30

Answer 319

- Resus: Admit, IV hydration, NBM - Hydrocortisone: IV 100mg QDS + PR. (IV ciclosporin can be used if steroids are contraindicated). If after 72hrs no improvement, consider ciclosporin IV + steroids or surgery. - Transfuse if required - Thromboprophylaxis: LMWH - Monitoring Bloods: FBC, ESR, CRP, U+E Vitals + stool chart Twice daily examination ± AXR

Answer 320

- Perforation - Bleeding - Toxic Megacolon (>6cm) - VTE Later on - DALM lesion can lead to metasitic disease.

Answer 321

- Switch to oral pred + a 5-ASA | - Taper pred after full remission

Answer 322

Rescue therapy? - On day 3: Stool frequency >8, or CRP >45: Predicts 85% chance of needing a colectomy during the admission. - Discussion between patient, physician and surgeon. Medical: cyclosporin, infliximab, visiliuzumab (anti-T) Surgical

Answer 323

Oral - 1st line: 5-ASAs (mesalazine) - 1000mg once daily at bedtime for 3-6 weeks. 2nd line: prednisolone (30-40mg)

Answer 324

- Mainly for left sided disease For Mild-to-moderate - Proctitis: suppositories. Topical, rectal aminosalicylates. For distal colitis rectal masalazine is better. If not improving add oral aminosalicylates. If still not improving give oral steroids. - More proximal disease: (proctosigmoiditis + left-sided ulcerative colitis) Rectal 5-ASA ± steroids (prednisolone or budesonide) If not working switch to high dose oral aminosalicylate or aminosalicylate + steroid. Extensive (left, transverse and right) - rectal Aminosalicylate + high-dose oral aminosalicylate.

Answer 325

1st line: 5-ASA PO- sulfasalazine or mesalazine. Can lead to Mesalazine > Sulfasalazine in terms of pancreatitis. (Topical Rx may be used in proctitis) 2nd line - beclometasone dipropionate.

Answer 326

1st line = Mercaptopurine (2-2.5mg/kg) / Azathioprine 2nd line - TNF-alpha inhibitor = infliximab, adalimumab 3rd line - vedolizumab or tofacitinib (Janus Kinase inhibitor) 4th line - Ciclosporin 5th line - Colectomy

Answer 327

- 20% need surgery - Toxic megacolon - Perforation - Extensive haemorrhage - Failure to respond to medicine

Answer 328

Emergency presentation - Subtotal colectomy. This is because removal of the rectum is not always conducted in an emergency setting. End ileostomy is created and rectum is stapled off or left in situ. Elective = Curative - proctocolectomy with permanent ileostomy - proctocolectomy with continent ileostomy restorative option - ileal-pouch anal anastomosis (IPAA) ( J pouch) = restorative option. Only when rectum is in situ and cannot usually be underaken - Panproctocolectomy + permanent end ileostomy (removal of entire colon, rectum and anal canal)

Answer 329

- Chronic symptoms despite medical therapy | - Carcinoma or high-grade dysplasia

Answer 330

- Panproctocolectomy with end ileostomy or IPAA (J pouch) | - Total colectomy with IRA

Answer 331

Abdominal - Small bowel obstruction - Anastomotic stricture - Pelvic Abscess ``` Stoma complications: Retraction, stenosis, prolapse, dermatitis Pouch - Pouchitis (50%): - metronidazole + ciprofloxacin - Decreased female fertility - faecal leakage ```

Answer 332

Bloods (top 3 are severity markers) - FBC: decreased Hb, increased WCC - LFTs: decreased albumin - increased CRP/ESR - Haematinics: Fe, B12, Folate - Blood cultures Stools - MCS: exclude Campy, Shigella, Salmonella - CDT: C.diff may complicate or mimic Imaging - AXR: obstruction, sacroileitis - CXR: perforation - MRI: assess pelvic disease and fistula. Assess disease severity - Small bowel follow-through or enteroclysis (liquid passing through) Shows: Skip lesions, rose thorn ulcers, cobblestoning: ulceration + mural oedema - String sign of kantor Endoscopy - Ileocolonoscopy + regional biopsy: Ix of choice - Wireless capsule endoscopy - Small bowel enteroscopy

Answer 333

- Increased temp, increased HR, increased ESR, increased CRP, increased WCC, decreased albumin

Answer 334

- Resus: Admit, NBM, IV hydration - Hydrocortisone: IV + PR if rectal disease. Budesonide is an alternative if cannot be tolerated. 5ASA - Mesalazine is second line. - Azathioprine + mercaptopurine is add-on. If 5 days without improvement - add: - Infliximab as refractory disease. - Abx: metronidazole PO or IV Thromboprophylaxis: LMWH ``` - Dietician Review Elemental diet: liquid prep of amino acids, glucose and fatty acids. Consider parenteral nutrition. - Monitoring Vitals + stool chart Daily examination ```

Answer 335

- Switch to oral pred (40mg/d)

Answer 336

- Discuss with patient physician and surgeon - Medical: methotrexate ± infliximab - Surgical

Answer 337

OPD treatment | - Supportive = High fibre diet, vitamin supplements.

Answer 338

- 1st line ileocaecal = budesonide - 1st line colitis = sulfasalazine - 2nd line: prednisolone (tapering) (or with methotrexate) - 3rd line: methotrexate - 4th line: infliximab or adalimumab

Answer 339

``` Occurs in ~50% Ix: MRI + EUA Rx - Oral antibiotics: metronidazole - Immunosuppression ± infliximab - Local Surgery ± seton insertion ```

Answer 340

1st line: azathioprine or mercaptopurine. Ensure you check the thiopurine methyltransferase activity. Leads to greater risk fo severe side effects. 2nd line: methotrexate 3rd line: infliximab/adalimumab

Answer 341

50-80% need >1 operation in their life Never curative Should be as conservative as possible

Answer 342

Disease pattern in Crohns ends in terminal ileal disease - ileocaecal resection. Emergency - Failure to respond to medical management - intestinal obstruction or perforation - Massive haemorrhage Elective - Abscess or fistula - Perianal disease - Chronic ill health - Carcinoma

Answer 343

Primary remove most of the bowel as Crohns can recur if just segmental. Surgery is NOT a cure. Severe perianal or rectal = proctectomy (pouch not recommended) - Limited resection: e.g ileocaecal. Extensive small bowel resections may result in short bowel syndrome and localised stricturoplasty may allow preservation of intestinal length.

Answer 344

Stoma complications Enterocutaneous fistulae Anastomotic leak or stricture

Answer 345

``` <1-2m small bowel - Features: Steatorrhoea, ADEK and B12 malabsorption Bile acid depletion --> gallstones -Hyperoxaluria --> renal stones ``` Rx - Dieticians - Supplements or TPN - Loperamide

Answer 346

Prev: 0.5-1% Age: any, bimodal: infancy and 50-60yr Sex: F>M Geo: Increased in Ireland and N.Africa

Answer 347

HLA-DQ2 and DQ8 | CD8+ mediated response to gliadin in gluten

Answer 348

GI malabsorption: fatigue, weakness - Carbs: N/V/D. Abdo distention + colic, Flatus, weight loss. - Fat: Steatorrhoea, hyperoxaluria --> Renal stones - Protein: protein-losing enteropathy - Haematinic: decreased folate and fe --> Anaemia - Vitamins: Vit D and ca --> bone pain, osteoporosis Vit K --> Petechiae and increased INR B2 (riboflavin)--> angular stomatitis B1 and B6 --> Polyneuropathy

Answer 349

Lymphoma and carcinoma - Enteropathy - associated T cell lymphoma - Adenocarcinoma of small bowel Other Ca: breast, bladder Immune Associated - IgA deficiency - T1DM - PBC Anaemia - Increased or decreased MCV - Hyposplenism: Howell-Jolly bodies, target cells ``` Dermatological - Dermatitis herpetiformis: Everyone: Symmetrical vesicles, extensor surfaces - Esp elbows V.itchy responds to gluten-free diet or dapsone Biopsy: granular deposition of IgA Aphthous ulcers ```

Answer 350

- Bloods: FBC, LFTs (decreased albumin), INR, VitD and bone, red cell folate, serum B12. Iron in proximal, Then folate in jejunum, and then B12 in the terminal ileum. Likely to be deficient in iron, folate, V12. - Ab: Anti-endomysial IgA (95% specificity) 1st line: Anti-TTG IgA - Both above decreased with exclusion diet Anti-Gliadin IgG persists with exclusion diet. Patient must eat gluten for at least 6 weeks before they are tested. IgA increased in most but may have IgA deficiency. Need to look for selective IgA deficiency, which would give a false negative coeliac result. Cannot interpret TTG without looking for IgA total. Stools - Stool cysts and antibody: exclude Giardia OGD and duodenal biopsy - Subtotal villous atrophy - Crypt hyperplasia - Intra-epithelial lymphocytes

Answer 351

``` Lifelong gluten free diet, - Avoid barley, rye, oats, wheat - OK: Maize, soya, rice - Verify diet by endomysial Ab test Pneumovax for HYPOSPLENISM Dermatitis herpetiformis: dapsone ``` Annual blood test - FBC, Ferritin, TFTs, LFTs, B12, Folate.

Answer 352

- Diarrhoea/Steatorrhoea - Weight loss - Lethargy

Answer 353

- Common in UK: Coeliac, Chronic pancreatitis, Crohn's (3 Cs) - Rarer: decreased bile: PBC, ileal resection, colestyramine Pancreatic insufficiency: ca, CF, chronic pancreatitis - Small bowel: resection, tropical sprue, metformin - Bacterial overgrowth: spontaneous, post-op, blind loops, DM, PPIs Infection: Giardia, Strongyloides, Cryptoparvum, Whipples (Fever, arthritis + steatorrhoea. PAS Positive macrophages. T.whipplei Hurry: post-gastrectomy dumping

Answer 354

``` Coeliac Tests Stool Microscopy Faecal elastase Hydrogen breath test MRI/CT ERCP (chronic pancreatitis ) Small bowel endoscopy ``` ELEVATED FOLATE - bacterial overgrowth.

Answer 355

SINED - Smoking - Inflammation: chronic pancreatitis - Nutrition (high fat diet) - EtOH - DM - HNPCC - MEN - BRCA2

Answer 356

- Mostly ductal adenocarcinoma - Metastasis early, present late - 60% head - 25% body - 15% tail - Endocrine tumours are rare

Answer 357

``` Typically male >60 Head: painless obstructive jaundice - with dark urine + pale stools Body/Tail: epigastric pain - Radiates to back, relieved sitting forward Anorexia and weight loss Acute pancreatitis Sudden onset DM in the elderly ```

Answer 358

- Epigastric mass - Jaundice - Palpable gallbladder - Thrombophlebitis migrans (Trousseau Sign) - episodes of vessel inflammation due to blood clot - Splenomegaly: PV thrombosis --> Portal HTN - Ascites

Answer 359

- Bloods: cholestatic LFTs, increased Ca19-9, increased Ca. - Imaging: US: pancreatic mass, dilated ducts, hepatic mets allow biopsy - Can consider CT - HRCT for diagnosis EUS: better than CT/MRI for staging ERCP - Shows anatomy. Allows Stenting.

Answer 360

Surgery: - Fit, no mets, tumour <3cm (<10% of patients) - Whipple's pancreatoduodenectomy - Post-op chemo delays progression - 5yrs = 5-14% Palliation - Endoscopic/percutaneous stenting of CBD - Palliative bypass surgery - Pain relief: may need coeliac plexus block

Answer 361

Mean survival <6 months | 5yrs = <2 %.

Answer 362

AGITS - Alcohol - Genetic (CF, HH, Hereditary pancreatitis) - Immune (Lymphoplasmacytic sclerosing pancreatitis (increased IgG4) - Triglycerides increased - Structural (Obstruction by tumour or Pancreas divisum)

Answer 363

- Epigastric pain (bores through to back, relieved by sitting back or hot water bottle --> Erythema ab igne) - exacerbated by fatty food ot EToH. - Steatorrhoea - Weight loss - DM - Epigastric mass: pseudocyst

Answer 364

``` increased glucose decreased faecal elastase US: pseudocyst AXR: speckled pancreatic calcification CT: pancreatic calcification ```

Answer 365

Drugs - Analgesia: may need coeliac plexus block - Creon (Enxymes) /Pancreatin - ADEK vitamins - DM management Diet - no ETOH - decreased fat, increased carb Surgery - Ind: Unremitting pain, weight loss - Pancreatectomy

Answer 366

- Pseudocyst - DM - Pancreatic cancer - Biliary obstruction - Splenic vein thrombosis - splenomegaly

Answer 367

Neuroendocrine tumours of enterochromaffin cell origin capable of producing 5HT. - May secrete 5-HT, VIP, gastrin, glucagon, insulin, ACTH. - Carcinoid syndrome suggest bypass of first-pass metabolism and strongly assoc with metastatic disease. - 10% part of MEN1 - Sites :Appendix: 45%, Ileum 30%, Colorectum 20%, Stomach 10%, Elsewhere in GIT and bronchus. Consider all as malignant.

Answer 368

- Appendicitis - Intussusception or obstruction - Abdo pain

Answer 369

- Flushing: Paroxysmal, upper body ± wheals - Intestinal: diarrhoea - Valve fibrosis: tricuspid regurg and pulmonary stenosis --> affected the right side of the heart. - Wheeze: Bronchoconstriction - Hepatic involvement: bypassed 1st pass metabolism therefore only when liver mets have occured will you get serotinin syndrome. - Tryptophan deficiency --> Pellagra (3Ds) May also present with some classic Cushingoid features - moon-face, central fat accumulation and bruising. Cortisol causes hypokalaemia and hypernatraemia.

Answer 370

- Increased urine 5- hydroxindoleacetic acid - Increased chromogranin A - CT/MRI: find primary

Answer 371

Symptoms: octreotide or loperamide Curative: Resection (tumours are v.yellow, give octreotide to avoid carcinoid crisis)

Answer 372

Tumour outgrows blood supply or is handled too much --> massive mediator release - Vasodilator, hypotension, bronchoconstriction, hyperglycaemia - Management: High-dose octreotide

Answer 373

- Median survival is 5-8yrs (~3 yrs if mets present)

Answer 374

- Xerophthalmia - Dry conjunctivae, develop spots (Bitots spots) - Corneas become cloudy then ulcerated - Night blindness --> total blindness Taken in excess can be teratogenic

Answer 375

Beri Beri - Wet: heart failure + oedema - Dry: Polyneuropathy - Wernicke's: ophthalmoplegia, ataxia, confusion

Answer 376

Pellagra - Think about Vegans - Diarrhoea, Dermatitis, Dementia. Leads to sunburn-like dermatitis rash. - Also, neuropathy, depression, ataxia - Causes: dietary, isoniazid, carcinoid syndrome

Answer 377

Peripheral sensory neuropathy | - Causes: PZA

Answer 378

Glossitis --> Sore tongue Peripheral neuropathy - Paraesthesia - Early loss of vibration and proprioception --> ataxia SCDC (subacute cord degeneration) - Dorsal and corticospinal tracts - Sensory loss and UMN weakness OVerall mixed UMN and LMN signs with sensory disturbance - Extensor plantars + absent knee and ankle jerks.

Answer 379

Scurvy - Gingivitis - Bleeding: gums, nose, hair follicles (petechial) - Muscle pain/weakness - Oedema - Corkscrew hairs

Answer 380

Bone pain + fractures

Answer 381

Decreased factors 2,7,9, 10 C and S - Bruising: petechiae - Bleeding: e.g epistaxis, menorrhagia

Answer 382

Coeliac's - Villous atrophy = malabsorption - Associated with dermatitis herpetiformis (vesicular, pruritic skin eruption and AI disorders T1DM and Hepatitis). Associated with HLA-DQ2 Complications of Coeliac's - Anaemia = Iron, folate, Vit B12. - Hyposplenism - Osteoporosis - EATL - Subfertility

Answer 383

Courvoisier's law states that painless, enlarged gallbladder unlikely to be gallstones. Pancreatic Cancer - RF = Age, Smoking, Diabetes, Chronic Pancreatitis, HNPCC, BRCA2 - Classically painless jaundice, loss of exocrine function (steatorrhoea), loss of endocrine function, Trousseau's sign = migratory thrombophlebitis - Investigations = US, High resolution CT Management - Whipple's resection (pancreaticoduodenectomy) - Adjuvant chemo - ERCP with stenting

Answer 384

``` A - Albumin B - Bilirubin C - Clotting - Prothrombin D - Ascites E - Encephalopahty ``` MELD - Combination of patient's bilirubin, creatinine, and INR gives mortality 3 month score. - Model end stage liver disease - Takes into account aetiology

Answer 385

- Acute mesenteric ischaemia (sudden, sharp pain from mostly likely superior mesenteric artery, with a history of AF) - Chronic mesenteric ischaemia - ischaemic colitis - Mesenteric ischaemia (small bowel, embolism, sudden onset, urgent surgery, high mortality). - Ischaemic colitis (Large bowel, multifactorial, less severe symptoms, bloody diarrhoea, thumbprinting, conservative management. Will see high lactate and metabolic acidosis with low bicarb. - Ischaemic colitis = acute but transcient compromise in blood flow to large bowel. More likely to occur in watershed areas, such as splenic flexure. Located at the borders of the territory supplied by superior and inferior mesenteric arteries. See Thumbprinting on AXR. Surgery in a minority of cases if conservative measures fail.

Answer 386

Diffuse hepatic injury resulting in acute hypoperfusion (shock liver). Usually has a inciting event + marked increased ALT levels 50x normal. Associated with AKI

Answer 387

Liver transplant | Whipples

Answer 388

Hockeystick scar | - Kidney Surgery

Answer 389

1Hz. Need 30 second to check for liver flap.

Answer 390

Mr J has evidence of fingernail clubbing conjunctival jaundice, palmar erythema and evidence of digital clubbing. The jugular venous pressure was elevated and there were mutliple spider naevi in the distribution of the SVC. The abdomen is distended with dilated veins which fills away from the umbilicus suggestive of caput medusae. I noted 8 finger breadth of smooth-non tender heptaomgealy extending below the right costal margin, There is no associated splenomegaly. He has a distended abdomen with shifting dullness in keeping with ascites which is non-tense. There is peripheral oedema likely from hypoalbuminaemia. These finding would be most consistent with a diagnosis of cirrhosis liver disease with some evidence of decompensation. To complete my examination - Examine the CVS system to look for underlying valvular heart disease. - Perform a urine dip to look for glucosuria, as diabetes is a risk factor for NASH - examine external genitalia looking for loss of secondary sexual characteristics Perform a DRE to look for melaena as a sign of decompensation Request a URine dip Neuro exam for cerebellar ataxia and peripheral neuropathy.

Answer 391

``` Verapamil Cimetidine Spironolactone Digoxin Cannabis Conns ```

Answer 392

``` Tatoos/IVDU - viral Xanthelasma - PBC - Tan - haemachromatosis Parotid swelling, neuropathy, gout, cerebellar - alcohol - BM Stix - NASH - Afro-caribbean = Sarcoidosis - Dysarthria, tremor - Wilson's Female, vitilgo - autoimmune - Barrel chest, urse lip breathing ```

Answer 393

Cachexia Organ failure - Bruising from coagulopathy - Peripheral oedema (hypoalbuminuria) - Fetor hepaticus (portosystemic shunting - varices) - Portal HTN - splenomegaly, ascites, caput medusa + varices.

Answer 394

AScites, jaundice, encephalopathy Alcohol Sedatives: Benzos and opiates NSAIDS - worsen renal failure - Excess diuretics - Hypokalaemia - results in decreased renal ammonia. Excess diuretics - Hypokalaemia - results in decreased renal ammmonia Constipation - Any source of increased protein/nitrogen: GI bleed, renal failure. Infections: SBP (E.coli is commonest)

Answer 395

Diural sleeping pattern disturbance Asterixis Bradykinesia Decerebrate then coma

Answer 396

Hepatitis C

Answer 397

``` Achalasia Neurological plexus damage Gastroparesis Constipation Diarrhoea Gallstones NASH ```

Answer 398

Until recent times oesophageal cancer was most commonly due to a squamous cell carcinoma but the incidence of adenocarcinoma is rising rapidly. Adenocarcinoma is now the most common type of oesophageal cancer and is more likely to develop in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett's. Diagnosis - Upper GI endoscopy is the first line test. Gold standard to take biopsy. - Contrast swallow may be of benefit in classifying benign motility disorders but has no place in the assessment of tumours - Staging is initially undertaken with CT scanning of the chest, abdomen and pelvis. If overt metastatic disease is identified using this modality then further complex imaging is unnecessary - If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound - Staging laparoscopy is performed to detect occult peritoneal disease. PET CT is performed in those with negative laparoscopy. Thoracoscopy is not routinely performed. Management - Operable disease is best managed by surgical resection. The most standard procedure is an Ivor- Lewis type oesophagectomy. This procedure involves the mobilisation of the stomach and division of the oesophageal hiatus. The abdomen is closed and a right sided thoracotomy performed. The stomach is brought into the chest and the oesophagus mobilised further. An intrathoracic oesophagogastric anastomosis is constructed. - Alternative surgical strategies include a transhiatal resection (for distal lesions), a left thoraco-abdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis. - The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality. The McKeown technique has an intrinsically lower systemic insult in the event of anastomotic leakage. In addition to surgical resection many patients will be treated with adjuvant chemotherapy.

Answer 399

- History of anxiety - Intermittent and relieved by swallowing - Persistent sensation of having a 'lump in the throat' when there is none. - Usually painless - presence of pain should warrant further investigation.

Answer 400

- Colicky post-prandial abdominal pain - Weight loss - Abdominal bruit

Answer 401

Tortuous arteriole - located in the upper stomach, which causes an upper GI bleed. Approximately 6 cm from OG junction.

Answer 402

Associated with H.pylori, blood group A: gAstric cancer Pernicious anaemia (lemon tinge and parasthesia) Gastric adenomatous polyps Smoking Path: Signet ring cells Features - - Dyspepsia - Nausea - Anorexia - Dysphagia

Answer 403

BMI <18.5 Weight loss >10% within last 3-6 months unintentially BMI <20 and unintentional weight loss >5% within 3-6 months. Screening with the MUST (Malnutrition Universal Screen Tool). - Done on admission or if there is concern - pressure sores. - Takes into account BMI - Categorises patients into low, medium and high risk.

Answer 404

Patients with malignancies in the peritoneum which lead to ascites, via increased production of peritoneal fluid + concurrent decreased resorption.

Answer 405

Dopamine antagonist which may worsen symptoms in patients with Parkinson's. Metoclopramide is a D2 receptor antagonist* mainly used in the management of nausea. Other uses include: gastro-oesophageal reflux disease prokinetic action is useful in gastroparesis secondary to diabetic neuropathy often combined with analgesics for the treatment of migraine (migraine attacks result in gastroparesis, slowing the absorption of analgesics) ``` Adverse effects extrapyramidal effects: oculogyric crisis. This is particularly a problem in children and young adults hyperprolactinaemia tardive dyskinesia parkinsonism ``` Metoclopramide should be avoided in bowel obstruction, but may be helpful in paralytic ileus.

Answer 406

Alcohol units = volume x ABV/1,000.

Answer 407

Hydatid cysts are endemic in Mediterranean and Middle Eastern countries. They are caused by the tapeworm parasite Echinococcus granulosus. An outer fibrous capsule is formed containing multiple small daughter cysts. These cysts are allergens which precipitate a type 1 hypersensitivity reaction. Clinical features are as follows: Up to 90% cysts occur in the liver and lungs Can be asymtomatic, or symptomatic if cysts > 5cm in diameter Morbidity caused by cyst bursting, infection and organ dysfunction (biliary, bronchial, renal and cerebrospinal fluid outflow obstruction) In biliary ruputure there may be the classical triad of; biliary colic, jaundice, and urticaria CT is the best investigation to differentiate hydatid cysts from amoebic and pyogenic cysts. Surgery is the mainstay of treatment (the cyst walls must not be ruptured during removal and the contents sterilised first).

Answer 408

- paracetamol - sodium valproate, phenytoin - MAOIs - halothane - anti-tuberculosis: isoniazid, rifampicin, pyrazinamide - statins - alcohol - amiodarone - methyldopa - nitrofurantoin

Answer 409

- combined oral contraceptive pill - antibiotics: flucloxacillin, co-- amoxiclav, erythromycin* - anabolic steroids, - testosterones - phenothiazines: - chlorpromazine, - prochlorperazine - sulphonylureas fibrates rare reported causes: nifedipine

Answer 410

Methotrexate Methyldopa Amiodarone

Answer 411

Giardia causes fat malabsorption, therefore greasy stool can occur. Resistant to chlorination, hence risk of transfer in swimming pool. Floats in water therefore steatorrhea.

Answer 412

- Cirrhosis: if early disease, later liver decreases in size. Associated with a non-tender, firm liver - Malignancy: metastatic spread or primary hepatoma. Associated with a hard, irregular. liver edge - Right heart failure: firm, smooth, tender liver edge. May be pulsatile - viral hepatitis - glandular fever - malaria - abscess: pyogenic, amoebic - hydatid disease - haematological malignancies - haemochromatosis - primary biliary cirrhosis - sarcoidosis, amyloidosis

Answer 413

Metaplasia of the lower oesophagus mucosa - squamous being replaced with columnar epithelium. - Increased risk of adenocarcinoma. Barrett's can be subdivided into short (<3cm) and long (>3cm). Management - Endoscopic surveillance with biopsies - High dose PPI: whilst this is commonly used in patients with Barrett's the evidence . Endoscopic surveillance - Metaplasia endoscopy is recommended every 3-5 years If dysplasia of any grade is identified endoscopic intervention is offered - Endoscopic mucosal resection - Radiofrequency ablation

Answer 414

Incision under right subcostal margin e.g. Cholecystectomy (open)

Answer 415

Upper abdomen access for Whipple's

Answer 416

Groin incision e.g. Emergency repair strangulated femoral hernia - NOW OBSOLETE

Answer 417

Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation.

Answer 418

Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically acceptable than Lanz

Answer 419

- Refeeding syndrome describes the metabolic abnormalities which occur on feeding a person following a period of starvation. It occurs when an extended period of catabolism ends abruptly with switching to carbohydrate metabolism. The metabolic consequences include: - hypophosphataemia - hypokalaemia - hypomagnesaemia: may predispose to torsades de pointes - abnormal fluid balance Patients are considered high-risk if one or more of the following: BMI < 16 kg/m2 unintentional weight loss >15% over 3-6 months little nutritional intake > 10 days hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high) Levels are already depleted due to malnutrition. Carbohydrate ingestion causes insulin release which causes rapid intracellular shift of potassium, magnesium and phosphate

Answer 420

Histamine H1 receptor antagonist

Answer 421

5HT-3 serotonin receptor

Answer 422

Dopaminergic receptors, used as antipsychotic agents.

Answer 423

Sulphapyridine and 5-ASA Many side-effect are due to the sulphapyridine moiety: rashs, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis. Other side-effects are common to 5-ASA drugs.

Answer 424

A delayed released forms of 5-ASA mesalazine is still however associated with side-effects such as GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis

Answer 425

Risk factors for SBBOS - Neonates with congenital gastrointestinal abnormalities - Scleroderma - Diabetes Mellitus Presents with chronic diarrhoea, bloating, flatulence, abdominal pain Diagnosis - Hydrogen breath test - Small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce - Clinicians may sometimes give a course of antibiotics as a diagnostic trial. Rifaximin is now treatment of choice.

Answer 426

MElanosis Coli is a disorder of pigmentation of the bowel wall. Histology demonstrates pigment-laden macrophages. Associated with laxative abuse, especially senna.

Answer 427

Concerns about bowel malignancy

Answer 428

Gut inflammation as part of workup for inflammatory bowel disease.

Answer 429

Think about Hep B patient with IVDU. Superinfecetion: A hep B surface antigen positive patient subsequently develops Hep D. LEads to fulminant hepatitis, chronic hep status and cirrhosis.

Answer 430

Alcoholic ketoacidosis is a non-diabetic euglycaemic form of ketoacidosis. It occurs in people who regularly drink large amounts of alcohol. Often alcoholics will not eat regularly and may vomit food that they do eat, leading to episodes of starvation. Once the person becomes malnourished, after an alcohol binge the body can start to break down body fat, producing ketones. Hence the patient develops a ketoacidosis. ``` It typically presents with a pattern of: Metabolic acidosis Elevated anion gap Elevated serum ketone levels Normal or low glucose concentration ``` The most appropriate treatment is an infusion of saline & thiamine. Thiamine is required to avoid Wernicke encephalopathy or Korsakoff psychosis.

Answer 431

Biliary sepsis is a major predisposing factor Structures drained by the portal venous system form the second largest source Common symptoms include fever, right upper quadrant pain. Jaundice may be seen in 50% Ultrasound will usually show a fluid filled cavity, hyperechoic walls may be seen in chronic abscesses

Answer 432

Entamoeba Histolytica Liver abscess is the most common extra-intestinal manifestation of amoebiasis Between 75 and 90% lesions occur in the right lobe Presenting complaints typically include fever and right upper quadrant pain. - profuse, bloody diarrhoea there may be a long incubation period stool microscopy may show trophozoites if examined within 15 minutes or kept warm (known as a 'hot stool') treatment is with metronidazole Ultrasonography will usually show a fluid filled structure with poorly defined boundaries Aspiration yield sterile odourless fluid which has an anchovy paste consistency Treatment is with metronidazole

Answer 433

Seen in cases of Echinococcus infection - A parasitic Tapeworm. Typically an intense fibrotic reaction occurs around sites of infection The cyst has no epithelial lining Cysts are commonly unilocular and may grow to 20cm in size. The cyst wall is thick and has an external laminated hilar membrane and an internal enucleated germinal layer Typically presents with malaise and right upper quadrant pain. Secondary bacterial infection occurs in 10%. Liver function tests are usually abnormal and eosinophilia is present in 33% cases Ultrasound may show septa and hyatid sand or daughter cysts. CT is best to investigate hydatid cyst. Percutaneous aspiration is contra indicated = this is due to risk of anaphylaxis and seeding of daughter cysts through abdomen. Treatment is by sterilisation of the cyst with mebendazole and may be followed by surgical resection. Hypertonic swabs are packed around the cysts during surgery

Answer 434

Hypocalcaemia = saponification of fats. As lipase leaks out of damaged pancreas = breaks down fat into triglyceride + fatty acid. These combine with calcium to make soap. Amylase does not correlate with disease severity. Serum lipase is more sensitive and specific. Assessment of severity - Glasgow, Ranson scoring systems and APACHE II ``` Predicts severe attack with 48hrs = Clinical impression of severity - Body mass index >30 - Pleural effusion - APACHE score >8 ``` ``` 24hrs = Clinical impression of severity APACHE II >8 Glasgow score of 3 or more Persisting multiple organ failure CRP>150 ``` 48hr = Glasgow Score of >3 CRP >150 Persisting or progressive organ failure - Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy. - Patients with obstructed biliary system due to stones should undergo early ERCP. - Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement, fine needle aspiration is still used by some. - Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise.