Gastroenterology medicine block Flashcards
1
Q
How does someone present w IBD? Compare Crohn’s to UC
A
Px - change in bowel habits
Crohn’s - mouth to anus, skip lesions, full thickness, ulcers + fistulas, increased in smokers, non caseating granuloma
UC - rectum proximally, continuous, mucosal only, crypt abscess, decreased in smokers
2
Q
What are the ix into IBD?
A
- Bloods = FBC (ACD), CRP, U&E (derranged due to GI loss)
- AXR if toxic megacolon
- Stool culture or faecal calprotectin
- CT, MRI rectum
- Flexible sigmoidoscopy, colonscopy, capsule endoscopy
3
Q
What is the treatment of acute IBD?
A
- Any acute IBD presentation is at high risk of a VTE so need prophylactic heparin
- Normally IV hydrocortisone if in hospital
4
Q
What is IBD rescue therapy and when is it needed?
A
When a pt doesn’t improve w 3-5 days of IV hydrocortisone probs need escalation.
Rescue therapy - biologicals or surgery for UC + Crohn’s w the addition of ciclosporin for UC.
5
Q
What steroids are used in IBD and how do u maintain remission?
A
Steroids - oral prednisolone or budesonide, IV hydrocortisone, enemas or suppositories.
UC - mesalazine for remission or azathioprine/biologicals if doesn’t work.
Crohn’s - azathioprine or mercaptopurine
6
Q
What is the presentation of Coeliac’s disease?
A
- Loose stools, bloating
- Abdo cramps, flatulence
- Weight loss
- Dermatitis herpetiformis
- No sx and found incidentally when ix iron def anaemia or if FH
7
Q
What is dermatitis herpetiformis?
A
Blistering skin rash in Coeliac’s
8
Q
What happens if Coeliac’s is left untreated?
A
- Increase risk small bowel cancer and lymphoma
- Osteoporosis
- Gluten ataxia and neuropathy
9
Q
What are the ix into Coeliac’s?
A
- tTG - raised in most pt but not a diagnostic test in adults
- OGD and duodenal biopsy = diagnostic = villous atrophy and intra epithelial lymphocytosis
10
Q
What is the treatment of Coeliac’s?
A
Life long gluten free diet
11
Q
How do you treat dyspepsia without red flag symptoms?
A
PPI +/- test for H. pylori
12
Q
How do you manage dyspepsia w red flag sx? What are the red flag sx?
A
OGD needs to be considered.
Red flag - weight loss, older age, associated dysphagia
13
Q
What do you need to establish in a dysphagia hx?
A
- Is it difficulty swallowing or painful (odynophagia)
- Prob w oro pharyngeal phase - problem moving food out of mouth
- Prob w oesophageal dysphagia - moves food out of mouth but then it gets stuck
14
Q
What are the causes of oesophageal dysphagia?
A
- Neuromusc disorder - presbyoesophagus, achalasia, dysmotility
- Physical obstruction - tumour, benign strictures, oesophagitis
15
Q
Oesophageal dysphagia:
- Ix
- Treatment
A
- Ix - OGD, barium swallow
- Treat - surgery to remove cancer or dilation of stricture
16
Q
What are the causes of oropharyngeal dysphagia?
A
Problem w muscles that move food bolus to the back of the mouth eg. stroke
17
Q
Oropharyngeal dysphagia:
- Ix
- Treatment
A
Ix - CN exam, speech therapy assessment, video fluroscopy
Treatment - alt consistencies of food and fluid, if doesn’t work may need enteral feeding tube
18
Q
What are the important qs to ask in a hepatology history?
A
- Blood transfusion prior to 1990 in the UK
- IVDU
- What meds do they take?
- Any recent travel?
- Sexual exposure
- FH liver disease, DM, IBD
- Alcohol
- Obesity
- Surgery/vaccine w poor procedure
19
Q
What are the causes of acute vs chronic liver disease?
A
Acute - Hep A, E, drug induced liver disease, CMV, EBV
Chronic - Hep C, NASH, alcohol, autoimmune
20
Q
What might you find on an exam if someone had liver disease?
A
Stigmata of liver disease:
- Spider nevi
- Ascites
- Palmar erythema
- Clubbing
21
Q
What are the grades of hepatic encephalopathy?
A
Grade 1 - reversed sleep pattern, psychomotor slowing, poor memory, apraxia
Grade 2 - agitation, lethargy, disorientation, liver flap
Grade 3 - drowsy
Grade 4 - coma
22
Q
What are the blood tests for liver disease and what do they indicate?
A
- ALT = damage to hepatocytes
- ALP = damage to ducts
- Bilirubin, albumin and PT = synthetic func tests, concerning if deranged in acute liver disease
- AST:ALT 2:1 = alcoholic hepatitis
23
Q
What are the causes of hepatitic liver disease >500 ALT?
A
- Viral
- Ischaemia
- Toxic eg. paracetamol
- Autoimmune
24
Q
What are the causes of hepatitic liver disease 100-200 ALT?
A
- NASH
- Autoimmune hepatitis
- Chronic viral hepatitis
- Drug induced liver injury
25
What are the causes of cholestatic liver disease w dilated ducts?
- Malignancy
| - Gall stones
26
What are the causes of cholestatic liver disease w/o dilated ducts?
- Alcoholic hepatitis
- Cirrhosis
- Drug induced liver injury
27
What is included in the liver screen?
- Hep B+C serology
- Fe
- AutoAb
- Caeuruloplasmin <30yo
- Coeliac serology
- TFT, lipids, glucose
28
What are the causes of chronic liver disease dependent on demographic?
- Women > men = primary biliary cholangitis, autoimmune hepatitis
- Men > women = haemachromatoma earlier, primary sclerosing cholangitis
- Only in young adults = Wilson's
29
How do you treat chronic liver disease?
Remove underlying cause eg. stop drinking, venesection, antivirals, lose weight to prevent further damage and progression to cirrhosis.
30
When should cirrhosis be suspected?
- Thrombocytopenia
- Varices seen on endoscopy
- Stigmata of liver disease
31
What are the ix into cirrhosis?
- Imaging but not very good
- Fibro scan
- If cirrhosis, DEXA as increased risk osteoporosis
32
What cancer does cirrhosis increase the risk of?
Hepatocellular carcinoma - screen all CLD/cirrhosis pt w a fetoprotein and USS every 6 months.
33
What is the treatment of ascites?
- Spironolactone
| - If tense - paracentesis
34
What does every pt admitted to hospital w ascites need? What is being looked for?
Diagnostic tap - exclude spontaneous bacterial peritonitis
35
What is involved in a nutritional assessment?
- Hx - diet, appetite, changes in oral intake, changes in weight
- Malnutrition universal screening tool (MUST) - BMI, % of weight loss, ill and >5 days no food
36
What is involved in nutritional support?
- Encourage high cal options and fortify food to help
- Don't interrupt meal times
- Supplement - fortisips
- Offer assistance w eating, correct teeth and cutlery
37
Describe NG tube use and the risks
- Is a short term solution, can provide all requirements or supplements on top of diet
- Have to aspirate pH every time use to make sure tip in the stomach not the lungs, can be skewed by PPI use so need CXR to check
- Stops pt aspirating food but can still aspirate saliva
- Pt has to mobilise w a drip stand
38
What are the tubes called that directly access the GI system? What are the risks of their use?
PEG and RIG - access stomach and PEGJ and RIGJ straight into small bowel.
Longer term use. Pt can still aspirate saliva though and have to puncture stomach.
39
Describe parentral nutrition and the risks associated
Nutrition and fluid directly into a patients veins through PICC/Hickman line. Indicated when GI blocked or not working.
Risks - sepsis and liver dysfunction
40
How do you assess GI bleeding?
- Hx - need to establish what passing blood means = haemetemesis, malaena, fresh PR bleed, coffee ground vomit
- Pt RF - use of NSAIDs, anticoag, anti platelet, CLD, varices, stigmata of CLD
- ROCKALL score = chance of dying from GI bleed
- Blatchford score = need for intervention and admission
41
What are the ix into GI bleeding?
- FBC - reduced Hb and platelets (need replacing, reduced in CLD)
- U&E - increased urea = bleed
- G&S in case need transfusion
- Clot - need to correct if abnormal
- Venous blood gas - quickest way to find out Hb
42
What is the presentation of variceal bleeding? How is it managed?
Haemetemesis and malaena.
- IV access, fluid resus if haemodynamically compromised and then blood
- IV terlipressin and IV abx, need upper GI endoscopy
- Oesophageal banding, TIPPS
43
What are the causes of non variceal bleeding?
Peptic ulcer disease and angiodysplasia
44
What is the treatment of non variceal bleeding?
- IV access, fluid resus then blood
- Need to be haemodynamically stable before endoscopy
- Can stop bleeding in endoscopy, by embolisation or surgery
- PPI after endoscopy to treat ulcer
45
Give differentials for haemetemesis
- Mallory Weiss tear
- Oesophageal varices rupture
- Peptic ulcer eroding blood vessel
- Gastric malignancy
- Oesophagitis
46
Give differentials for melaena
- Upper GI bleed - gastric ulcer
- Variceal bleed
- Upper GI malignancy if ulcerating
- Gastritis/oesophagitis
- Mallory Weiss tear, less common
47
Give differentials for jaundice
- CLD, ALD, hepatitis
- Biliary colic, cholangitis, cholecystitis, pancreatitis.
- HPB cancer
- Haemolytic anaemia
- Haemachromatosis
48
Give differentials for diarrhoea
- IBD, IBS, Coeliac's disease
- Gastroenteritis, viral or bacterial
- Acute appendicitis
- Colorectal cancer
- Drugs
49
Give differentials for N+V
- Gastritis, peptic ulcer disease, acute gastroentertitis, GORD
- Post op and chemo induced
- Gastro paresis
- DKA
- IBD
50
What are the clinical features of a paracetamol overdose?
- Asymptomatic
- N+V
- Loin pain/RUQ pain
- Haematuria, proteinuria
- Jaundice
- Coma and severe met acidosis
51
What is the pathophysiology of a paracetamol overdose?
Metabolism of paracetemol = NAPQI, normally inactivated by glutathione but stores decrease in overdose so NAPQI builds up - causes liver and kidney damage.
52
What is the management of a paracetamol overdose?
- <1 hour = activated charcoal
- Staggered overdose or >15 hours ago = N-acetylcysteine
- <4 hours ago wait for 4 hours then start N-acetylcysteine based one level
53
What patients are at increased risk of toxicity after a paracetamol overdose?
- Pt on long term enzyme inducers
- Reg alcohol excess
- Pre existing liver disease
- Glutathione depleted = eating disorder, malnutrition, HIV
54
What are the common causes of viral hepatitis?
- Hep B
- Hep C
- CMV
- EBV
55
What are the clinical features of viral hepatitis?
- Malaise and fatigue
- N+V
- RUQ pain
- Diarrhoea - pale stools and dark urine, jaundice
- Hepatomegaly, splenomegaly, lymphadenopathy
56
Hep B:
- Transmission
- Clinical features
- Management
Transmission - intercourse, transfusion, vertical
Features - most children develop chronic disease, lower risk in adults
Management - only if HbsAg +ve, compensated liver disease or pregnant will have treatment
57
What is the serology of Hep B?
- HBsAg - acute/chronic infection
- HBeAg - highly infectious
- HBsAb - previous vaccination/infection
58
Hep C:
- Transmission
- Features
Transmission - IVDU, blood transfusion, haemodialysis, sex, needlestick injuries
Features - most pt asymptomatic and will become chronic -> cirrhosis, high LFTs, hepatocellular carcinoma, liver fail
59
What are the ix into Hep C?
- Anti HCV serology - 90% +ve 3 months after infection
| - HCV RNA - positive for more than 2 months = need treatment
60
What is the management of Hep C?
- Symptomatic early on
- Antivirals benefit all pt irrespctive of amount of cirrhosis eg. sofobuvir = undetectable viral loads
- Manage underlying cirrhosis
61
What is hereditary haemochromatosis?
Disordered Fe met = too much Fe in body and deposited in liver, heart, joints, pit, pancreas, skin
62
What are the clinical features of hereditary haemochromatosis?
- Bronze skin
- T2DM
- Fatigue, joint pain
- Liver cirrhosis
- Adrenal insufficiency
63
What are the Ix into hereditary haemochromatosis?
- Bloods - derranged LFTs, raised serum ferritin and transferrin
- Genetic testing
- MRI brain and heart = Fe deposition
- Liver biopsy = increased Fe
64
What is the management of hereditary haemochromatosis?
- Therapeutic venesection
| - Desforrioxamine = iron chelating agent
65
What is the pathophysiology of alcoholic liver disease?
Hepatic ethanol breakdown = increased triglyceride synthesis in the liver and chronic inflam = steatohepatitis which causes fibrosis and sclerosis = portal hypertension and cirrhosis.
66
What are the clinical features/stages of ALD?
- Alcoholic fatty liver = asymptomatic, hepatomegaly, regresses after alcohol stopped
- Alcoholic hepatitis = reversible if mild, get nausea, loss of appetite, weight loss, low grade fever, hepatomegaly, jaundice, splenomegaly, ascites, variceal bleeding
- Alcohol related cirrhosis = final stage ALD
67
How do you diagnose ALD?
- Lab tests = increased AST, ALT, ALP, GGT, bilirubin, PT time, reduced albumin, anaemia
- Imaging = alcoholic fatty liver/cirrhosis, hepatomegaly
- Confirm cirrhosis on biopsy
68
How do you treat ALD?
- Immediate cessation of alcohol
| - Glucocorticoids eg. prednisolone in severe disease
69
What is acute liver failure?
Rapid decrease in hepatic func:
- Jaundice
- Coagulopathy
- Hepatic encephalopathy
70
What are the signs of hepatic encephalopathy?
Nervous system problems:
- Confusion
- Memory loss
- Change in personality+behaviour
- Inappropriate action
- Irritable and uninterested
71
What are the symptoms of acute liver failure?
- Pain in RUQ
- Ascites
- N+V, malaise
- Disorientation+drowsy
- Breath = musty/sweet smell
72
What are the causes of acute liver failure?
- Paracetamol overdose and other drugs eg. Abx, NSAIDs, anticonvulsants
- Hepatitis, autoimmune diseae
- Clot in hepatic venous system
- Metabolic disease eg. Wilson's
- Malignancy
- Sepsis
- Heat stroke
73
How do you manage acute liver failure?
- Treat underlying cause
- IV fluid resus
- May need ICU and airway management
74
What is NAFLD and NASH?
Non alcoholic fatty liver disease and non alcoholic steatohepatitis = fatty and inflammation.
75
What are the RF of NAFLD?
- Obesity and metabolic syndrome
| - T2DM
76
What is the treatment of NAFLD?
Weight loss = reduces fat, inflam and fibrosis. Healthy diet also helps.
77
List some RF for GI bleed
- Drugs = NSAIDs, anticoag, antiplatelet, SSRIs
- Alcohol and smoking
- Peptic ulcer disease, H.pylori infection
- CLD and varices
- Chronic vom
78
Decompensated vs compensated liver disease
Compensated cirrhosis - no varices or ascites
| Decompensated cirrhosis - varices and bleeding, ascites, encephalopathy
79
What are the criteria for liver transplant in paracetamol overdose? What is it called?
King's college criteria:
pH <7.3 24 hours after overdose
or all of the following three: prothrombin time >100 secs or INR >6.5, grade 3 or 4 hepatic encephalopathy, creatinine >300
80
How do you treat hepatic encephalopathy and what causes it?
Caused by build up of ammonia secondary to liver cirrhosis.
1st line - lactulose, inhibits ammonia production
2nd line - rifaximin, liver transplant
