Gastroenterology (Quesmed) Flashcards
What is Achalasia?
It is a condition of unknown cause which causes Failure of the Lower Oesophageal Sphincter
What are the 5 signs of Achalasia?
Remember 3 of them are LINKED directly
Dysphagia to both SOLIDS and LIQUIDS (which gradually increases over Months and Years)
Regurgitation of undigested foods
Aspiration
RETROSTERNAL Chest Pain/ Heartburn (which usually doesn’t respond to PPIs)
Weight Loss (often mild)
What investigations should be ordered in Achalasia?
Endoscopy (Dilated Oesophagus containing residual material)
GOLD STANDARD- Oesophageal Manometry (High Pressure and Incomplete Lower Oesophageal Sphincter Relaxation)
Barium Swallow (Bird’s Beak Appearance)
Chest Xray- Widened Mediastinum and Fluid Levels
What is the management of Achalasia?
FIRST LINE OPTION- BALLOON DILATATION
Surgery- Oesophageal Dilatation and Surgical Cleavage of the Lower Sphincter so that food can pass through (called !!!Heller’s Myomotomy)
!!!!Medical- Botox (if this fails or if they are not suitable for surgery, Calcium Channel Blockers/ Nitrates)
What are Porphyrias?
What are the signs and the management of Acute Intermittent Porphyria (Autosomal Dominant) (Porphyria caused by Triggers)?
NO DIARRHOEA, but may be constipation
Defects in Haem Synthesis due to alterations in Enzyme structure and function. This leads to the accumulation of PORPHYRINS
Signs-
1) Abdominal Pain and Vomiting
2) Motor Neuropathy
3) Hypertension and Tachycardia
4) Depression AND CONFUSIONNNNNNN
!!!!!5) ALSO Urine turns RED
Management
- Avoid the Triggers
- IV HAEM otherwise IV glucose
What are the 3 types of Acute Porphyrias?
Acute Intermittent Porphyria (Autosomal Dominant)
Variegate Porphyria (Autosomal Dominant)- suspect if SKIN is affected
ALA Deficiency (Autosomal RecessivE)
What are the medications that trigger Acute Porphyrias?
Antibiotics (Rifampicin, Isoniazid, Nitrofurantoin)
Anaesthetic Agents (Ketamide and Etomidate)
Sulfonamides
Barbiturates
Antifungal Agents
What are the signs of Acute Porphyria?
Suspect if Abdo pain, Confusion and recent Antibiotics/ Anaesthetics etc.
Remember CONFUSION
Generic Abdominal Symptoms
- Abdominal Pain
- Nausea
- Confusion
- Hypertension
What is needed for the diagnosis of Acute Porphyria?
What must you be careful about with the urine sample?
Measure Urinary Porphobilinogen levels which is a product of Haem Metabolism
Urine Samples needed to be protected from sunlight to prevent breakdown of PBG
What is the management of Acute Porphyria?
Largely supportive
IV Haem Arginate can be given to replenish Haem levels
What is Alpha 1 Antitrypsin Deficiency?
WHAT is the INHERITANCE PATTERN?
What Lobes of the lungs are affected in Alpha 1 vs COPD
What is the management?
It is an INHERITED AUTOSOMAL RECESSIVE condition that affects the Lungs, causing Emphysema- so this is a CAUSE of COPD in YOUNG PEOPLE/ NON SMOKERS
LOWER LOBES= Alpha 1, UPPER LOBES= COPD
It also affects the Liver which causes Cirrhosis and Hepatocellular Carcinoma
Without Alpha-1 Antitryptase, there is less defence against Neutrophil Elastase which destroys the Alveoli
This process is exacerbated in Smokers
Management-
1) Physiotherapy, Bronchodilators and Alpha 1 Antitrypsin
2) LUNG REDUCTION SURGERY
What is the presentation of Alpha 1 Antitrypsin Deficiency?
COPD presenting in a 30-40 year old
Neonatal JAUNDICE at Birth
Deranged LFTs in an adult with no other identifiable cause
What investigations should be ordered for Alpha 1 Antitrypsin Deficiency?
Test for Alpha 1 Antitrypsin Levels
Genotyping
Liver Biopsy (look for Periodic-acid-Schiff (PAS) positive globules)
What is the management of Alpha 1 Antitrypsin Deficiency?
Stop Smoking
Intravenous A1AT pooled from human donors is expensive and NOT widely used
If Decompensation, Liver Transplant may be needed
What is seen in patients who have been vomiting?
They appear dehydrated and unwell
There is Metabolic Hypochloraemic Alkalosis on a blood gas due to the loss of Stomach Acid when vomiting
What are the 4 types of Anti-Emetics?
H1 Receptor Antagonist
- Cyclizine
D2 Receptor Antagonist
- Domperidone, Metoclopramide (The ones with M at the start of their name) and Prochlorperazine
5HT3 Receptor Antagonist
- Ondansetron
Anti-Muscarinic
- Hyoscine hydrobromide
What is Ascites?
It is the accumulation of fluid within the Peritoneal Cavity
It may be seen in patients with Cirrhosis- though the mechanism is complex and not fully understood
It is thought to involve PORTAL HYPERTENSION causing an increased Hydrostatic Pressure which leads to the Transudation of Fluid
What is the Serum Ascites Albumin Gradient (SAAG)?
It can help determine the cause of Ascites
Subtract the Albumin concentration of the Ascites Fluid from the Serum Albumin Concentration (S-A)
What are the causes of a high (>1.1g/dL) SAAG?
2 organ failures plus 2 other conditions related to those organs plus 1 extra
Cause is Raised Portal Pressure
- Cirrhosis
- Heart Failure
- Budd Chiari Syndrome
- Constrictive Pericarditis
- Hepatic Failure
Increased Hydrostatic Pressure forces water into the Peritoneal Cavity whilst Albumin remains in the vessels
What are the causes of a low (<1.1g/dL) SAAG?
5 causes
- Cancer of the Peritoneum
- Tuberculosis and other infections
- Pancreatitis
- Hypoalbuminaemia- like Nephrotic Syndrome or Kwashiokor Malnutrition
- Bowel Obstruction
What is the management of Ascites?
SFSF Drain
- Address the underlying cause
- Salt-restricted diet
- Fluid Restriction (not recommended if Uncomplicated Ascites)
- Spironolactone
- Adjunctive Diuretic therapy like Furosemide may be needed if Spironolactone is insufficient
- Patients with Ascites refractory to Medical Management may require Regular Therapeutic Paracentesis, where the Fluid is drained from the abdomen
What is the main contraindication to Paracentesis (Ascites management)?
Signs of Disseminated Intravascular Coagulation
What are the signs of Autoimmune Hepatitis?
!!!!!THERE is AMENORRHOEA and FEVER AS WELL BTW
Remember the Arthralgia
Signs of OTHER AUTOIMMUNE CONDITIONS
!!!!!!AMENORRHOEA AND FEVER
Jaundice
Fatigue
Loss of Appetite
Hepatomegaly
Splenomegaly
Abdominal pain
Pruritus and Spider Naevi
Arthralgia in their Small Joints as well
What are the LFTs in Autoimmune Hepatitis?
What is the CRP like in Autoimmune Hepatitis?
What else is seen in Autoimmune Hepatitis in the blood that is raised?
Hepatic Pattern of Disease- Raised ALT and Bilirubin and Normal/ Mildly Raised ALP (by 10-20)- Significantly raised in Cholangitis
CRP is usually NOT raised
They may have IgG Predominant Hypergammaglobuminaemia
What are the 3 types of Autoimmune Hepatitis?
All have raised IgG levels
Type 1- Most common type- (Adults and Children)
- Anti Smooth Muscle Antibodies (80%) and Antinuclear Antibodies may also be raised (10%)
Type 2- Less common but often more severe (Children)
- Anti Liver/ Kidney Microsomal Antibodies Type 1
Type 3- Less common (Adults)
- Anti Soluble Liver-Kidney Antigen
Type 2 and 3 would be NEGATIVE for Anti Smooth Muscle Antibodies and Antinuclear Antibodies
What is the management of Autoimmune Hepatitis?
Depends on severity of symptoms and disease
- Prednisolone for induction and Azathioprine for maintenance
- Second Line- Other immunosuppressants
- Liver Transplant
What drugs can cause Hepatitis?
Methyldopa
Nitrofurantoin
Diclofenac
Phenytoin
What is Barret’s Oesophagus?
Chronic Acid Exposure (usually through GORD) changes distal oesophagus from Squamous Epithelium to Metaplastic Columnar Epithelium
It has a risk of progressing to Adenocarcinoma
What is the management of Barrett’s Oesophagus?
Identified through ENDOSCOPY
- If Low Grade Dysplasia- repeat in 6 months. If found in follow up and confirmed on at least 2 biopsies, offer them Endoscopic Ablation therapy- preferably with Radiofrequency Ablation. If not, check up on them every 6 months
- If High Grade Dysplasia or early Adenocarcinoma, Endoscopic Resection of Abnormal Areas- Radiofrequency Ablation, Photodynamic Ablation or Laser.
- If there is any grade of dysplasia then ablation!!!!!!
If they are fit for surgery, OESOPHAGECTOMY
-
What is Cholera?
In addition to dehydration, what 2 symptoms does it cause?
It is an Acute Secretory Diarrhoea caused by an infection with Vibrio Cholera of the O1 and O139 subgroup. It is ENDEMIC in many countries
It causes RICE WATER DIARRHOEA and HYPOGLYCAEMIA
What are the signs of Cholera?
Tummy Ache and Loss of Fluids Through Diarrhoea and Vomiting
Watery Diarrhoea that begins suddenly
Abdominal Cramps (just like Clostridium Difficile)
Nausea and Vomiting
Excessive Thirst and Oliguria (cos of all the water they’re losing through the diarrhoea)
Dry Skin and Mouth
Drowsiness and Irritability
What is the management of Cholera?
What are the 3 antibiotics that can be given?
Aggressive fluid Replacement- Effective Therapy that can decrease mortality from over 50% to less than 0.2%
Antibiotics (Doxycycline or Co-trimoxazole or Ciprofloxacin)
What are the causes of Chronic Pancreatitis?
- 80% of patients- Chronic Alcohol Excess
- Less Common Causes- Genetic (Cystic Fibrosis),
Obstructive Causes (Pancreatic Cancer) and Metabolic Causes (Raised Triacylglycerides)
What are the signs of Chronic Pancreatitis?
Epigastric Pain- Worse after eating Fatty Food and Relieved by Sitting Forward
Exocrine Dysfunction- Malabsorption and Steatorrhoea (occurs after YEARS as well)
Endocrine Dysfunction- Type 1 Diabetes Mellitus- Polyuria and Polydipsia (occurs after 20 YEARS of symptom onset)
Check for signs of Chronic Liver Disease
What Investigations should be ordered in Chronic Pancreatitis?
Is it worth checking Amylase and Lipase in Chronic Pancreatitis?
Structural Investigations
- CT- Pancreatic Calcification (this is preferred)
- Abdominal Xray- Calcification
Functional Investigations
- Exocrine Dysfunction- FAECAL ELASTASE
- Endocrine Dysfunction- FASTING GLUCOSE/ OGTT
- Serum Amylase and Lipase are NOT TYPICALLY RAISED- unlike Acute
What is the management of Chronic Pancreatitis
What is the general life advice, 3 medication options and then if all else fails- 2 things that can be done?
Conservative- Ethanol Abstinence and a Good Diet
Medical-
- Pain control with !!!!!!!Analgesia
- Manage the Endocrine Dysfunction with Insulin
- Manage the Exocrine Dysfunction with Pancreatic Enzyme Replacement
If the above management options fail- !!!!!!!Coeliac Plexus Block and Pancreatectomy
What are the complications of Chronic Pancreatitis?
May be Local- Pseudocysts (observe for 12 weeks first then surgery) or Pancreatic Cancer
May be Systemic- Endocrine (Diabetes) and Exocrine Dysfunction (Malabsorption and Steatorrhoea)
What is Clostridium Difficile (D for Diarrhoea)?
Which 2 drugs increase the risk of it occurring?
What are the signs?
What is used to diagnose it?
What is the management?
It is a gram-positive bacteria that causes Pseudomembranous Colitis
It is seen in people who have been on a course of BROAD SPECTRUM ANTIBIOTICS (usually Clindamycin) and PROTEIN PUMP INHIBITORS
The microorganism produces Toxins that cause Inflammation, Diarrhoea and the development of a Pseudomembrane in the Large Bowel
Signs-
- Abdominal Pain, Diarrhoea, RAISED WCC (which is used to determine the severity)
Diagnosis-
C.Diff TOXIN- not the antigen as the antigen indicates a PAST INFECTION as well
Management
- Oral Vancomycin
- Then Oral Fidaxomicin (Fedex)
- Then Oral Vancomycin and IV Metronidazole (use this ASAP if Hypotension/ Toxic Megacolon)
What are the Risk Factors for Clostridium Difficile?
Broad Spectrum Antibiotics (Clindamycin, Ciprofloxacin, Cephalosporins, Penicillins)
Have been in healthcare settings (hospital or care home) for a long time
> 65 years old
Weak Immune System
Other Conditions- IBD, Cancer or Kidney Disease
Are on a PPI
What are the signs of Clostridium Difficile?
Suspect if on Broad Spectrum Antibiotics/ Long healthcare stay (hospital or care home)
Remember CONFUSION and signs of DEHYDRATION
May be asymptomatic but usually-
- Watery diarrhoea (may be bloody)
- Painful Abdominal Cramps
- Nausea
- Dehydration- Tachycardia, Oliguria, Dry mucous membranes
- FEVER
- Loss of Appetite and Weight Loss
- Confusion
What is the management of Clostridium Difficile?
What is the extra management that can help and what 2 things should the patient avoid?
What 3 things define a LIFE-THREATENING PRESENTATION?
PO Vancomycin (add IV Metronidazole if Severe- hypotension or toxic megacolon or ILEUS)
If Vancomycin is ineffective- Fidaxomicin
If Recurrent Infections= FAECAL TRANSPLANT can help
Avoid Anti-diarrhoeal Agents and minimise Narcotic Use as the Anti-peristaltic effects and Toxin entrapment can predispose to Toxic Megacolon
Replacing Fluid and Electrolyte losses is indicated as needed
What are the Severe Complications of Clostridium Difficile?
Massive Colonic Inflammation characterised by a Pseudomembrane of Immune Cells (Raised Yellow Plaques), Mucus and Necrotic Tissue. Pseudomembranous Colitis represents and advanced stage of disease is diagnostic of CDI
Colonic Distension- Toxic Megacolon
Systemic Toxicity and manifestations of the Systemic Inflammatory Response Syndrome (Leucocytes>35, Lactate>5, Hypotension requiring Vasopressor Therapy, Acute Renal Failure and Respiratory Distress)
What are the Strong and Weak Risk factors for Colorectal Cancer?
Strong
- Age
- Alcohol
- Tobacco
- Obesity
- Processed meat
- IBD
- Radiation Exposure
Weak
- Lack of Dietary Fibre
- Limited Physical Activity
- Asbestos Exposure
- Red Meat
What is the TNM staging of Colorectal cancer?
Tumour, Node, Metastasis
T-
- Tis (in situ)
- T1- extends through mucosa into submucosa
- T2- extends through submucosa into muscularis
- T3- extends through muscularis into subserosa
- T4- extends into Neighbouring Organs or Tissues
N-
- N0- No regional lymph node involvement
- N1- Metastasis to 1-3 regional lymph nodes
- N2- Metastasis to 4 or more regional lymph nodes
M-
- M0- No Distant Metastasis
- M1- Distant Metastasis
What are the current NHS Screening programmes for Colorectal Cancer?
Faecal Immunochemical Test (FIT) every 2 years for men and women aged 60-74. If positive, patients are referred for Colonoscopy
What would warrant the 2 week wait referral for Colorectal Cancer?
You can FIT test even if they do not meet the criteria but are close to doing so btw!!
Generally- unexplained rectal bleeding, unexplained mass
1) >40 years old with Unexplained Weight Loss AND Abdominal Pain
2) >50 years old with Unexplained Rectal Bleeding
3) > 60 with either Iron Deficiency Anaemia or Changes to Bowel Habit
4) Faecal Occult Blood Testing
5) Rectal or Abdominal Mass
6) <50 with Rectal Bleeding AND Abdominal Pain, Change in Bowel Habit, Weight Loss, Iron Deficiency Anaemia
What investigations should be ordered if Colorectal Cancer is suspected?
First Step= Colonoscopy
If it can not be performed, CT Colonoscopy is a suitable option but it does not allow for biopsy
AFTER Histological Diagnosis- CTAP should be performed to STAGE the disease so an appropriate intervention can be made
In Rectal Disease, Pelvic MRI or Endorectal US are preferred over CT scan
Carcinoembryonic Antigen (CEA) is NOT diagnostic but can be used to monitor therapeutic response to interventions
What is the management of Colorectal Cancer?
Colon Cancer-
- Stage 1-3 (no metastasis)= Surgical Resection and Post-operative Chemotherapy (If stage 3 (lymph node involvement)). Add Preoperative Chemotherapy if Stage 4 (Metastasis)
Rectal Cancer-
- Anterior Resection if >8cm from Anal Canal. Abdomino-perineal Resection if <8cm from the Anal Canal
Resections-
- Caecal, Ascending or Proximal Transverse Colon- Left hemicolonectomy
- Distal Transverse, Descending- Right hemicolonectomy
- Rectum- Anterior Resection
- Anal Verge- Abdomino-perineal Excision of the Rectum
What are 3 types of genetic Colorectal Cancer and their symptoms?
All of them are Autosomal Dominant
Hereditary Non-Polyposis Colorectal Cancer/ Lynch Syndrome (MOST COMMON)
- Autosomal Dominant
- 80% chance of getting Colorectal Cancer by their 30s
- Endoscopic Surveillance
Familial-Adenomatous Polyposis
- Autosomal Dominant
- Adenomatous Polyps in their Teens and they are GUARANTEED to get Colorectal Cancer unless that have Proctocolectomy
Peutz-Jeghers Syndrome
- Autosomal Dominant
- Mucocutaneous Pigmentation (pigmented spots on the skin or the mouth) and Hamartomatous Polyps in their Teens
- The risk of Neoplastic Transformation of their Hamartomatous Polyps is low but they need Endoscopic Surveillance anyway
What are the Bristol Stool Classifications?
1- Nuts
2- Lumpy Sausage
3- Cracked Sausage
4- Smooth Sausage
5- Blobs with Clear cut edges
6- Mushy Fluffy pieces with Ragged Edges
7- Watery (no solid pieces)
Constipation is Type 1 or 2
Diarrhoea is Type 6 or 7
Lacking Fibre= Type 5
What drugs can cause Constipation?
COAA
Calcium Channel Blockers
Opiates
Some Antipsychotics
Anticholinergics (like Amitriptylline)
What is the age of onset for Crohn’s?
15-40 years old
and 60-80 years old
Usually in Caucasians
What are the signs of Crohn’s Disease?
GI Symptoms- Crampy Abdominal Pain and Diarrhoea
Systemic Symptoms- Weight Loss and !!!!!!!!FEVER
- Generally may be Cachectic and Pale due to Anaemia
- There may be CLUBBING
- Aphthous Ulcers in the Mouth
- !!!!!!!Abdominal/ Right Lower Quadrant Tenderness and a RIGHT ILIAC FOSSA MASS
- PR Exam for Perianal Skin Tags, Fistulae or Perianal Abscess
Dermatological manifestations-
1) Erythema Nodosum (usually on shins)
2) Pyoderma Gangrenosum (well defined ulcer with Purple Overhanging Edge)
Ocular Manifestations-
1) Anterior Uveitis (Painful red eye with blurred vision and photophobia)
2) Episcleritis (Painless red eye)
MSK Manifestations-
1) Arthritis (ASYMMETRICAL and non-deforming)
2) Sacro-iliitis (similar to Ankylosing Spondylitis)
3) Osteoporosis
Hepatobiliary Manifestations-
1) Gallstones (more common in Crohn’s than in Ulcerative Colitis)
Haematological and Renal Manifestations-
1) Amyloidosis and Renal Stones (more common in Crohn’s than in Ulcerative Colitis)
What investigations should be ordered in Crohn’s?
What will the blood tests and imaging show?
Remember Fistulae and Proximal Bowel Dilatation
What is the definitive diagnosis?
Blood Tests-
1) HIGH CRP and ESR and WCC (always raised even in flare up)
2) Thrombocytopaenia
3) Low Albumin
4) Anaemia
Stool Culture is necessary to exclude infection
Faecal Calprotectin (an antigen produced by Neutrophils) will be RAISED (helps distinguish IBD from IBS)
COLONOSCOPY with Imaging is needed for Diagnosis
EXAMINING SMALL BOWEL is DEFINITIVE
Colonoscopy may show
1) Deep Ulcers
2) Skip Lesions
3) Fistulae
4) Proximal Bowel Dilatation
5) STRING of KANTOUR
6) Rose Thorn Ulcers
7) Non-Caseating Granulomas
8) Cobblestone Mucosa
Histology may show
1) Goblet Cells
2) Granulomas
What are the Colonoscopy findings of Crohn’s?
- Intermittent Inflammation- Skip Lesions
- Cobblestone Mucosa- due to Ulcerations and Mural Oedema
- Rose-thorn Ulcers (due to transmural inflammation) +/- Fistula or Abscesses
- Non-caseating Granulomas
What is the Medical Management of Crohn’s?
Induce Remission
1) Glucocorticoid Monotherapy (Prednisolone or IV Hydrocortisone)
1a) Enteral Nutrition may be considered as an alternative in children (as steroids suppress growth)
2) Azathioprine or Mercaptopurine may be added if there are 2 or more Exacerbations within a year or if Glucocorticoids can not be tapered.
ASSESS TPMT before giving Azathioprine or Mercaptopurine
2a) If TPMT deficient- Methotrexate can be given next
3) If severe- Infliximab or Adalimumab
4) MRI then Metronidazole for Perianal Fistulae Disease
What is given to Maintain Remission in Crohn’s?
(Just Step 2 from the Medical Management for Inducing Remission)
1) Azathioprine or Mercaptopurine
1a) Otherwise Methotrexate
What is the management of Peri-Anal Fistulae in Crohn’s?
Drainage Seton for HIGH FISTULAE (Trans-sphincteric- so passes through muscle layers and is complex)
Fistulotomy for LOW FISTULAE (Submucosal)
What is the management of Peri-Anal Abscess in Crohn’s?
IV Antibiotics- Ceftriaxone and Metronidazole
They also require Examination under Anaesthetic and Incision and Drainage. An Incision is made in the affected region and the pus is broken up
What is the method of action of Imitinib?
It Inhibits Tyrosine Kinase
What is a significant side effect of Metronidazole?
Peripheral Neuropathy
What are the histological signs of Crohn’s?
Does not extend beyond submucosa (So only Submucosal Fibrosis)- Cobblestone Mucosa
Goblet cell depletion
Crypt Abscesses (collections of Neutrophils in Crypts)
What is a complication of Terminal Ileum Resection (done for Crohn’s Disease) and what are the signs?
Bile Acid Malabsorption
Presents as Diarrhoea and Fatty Stools
Where are Cytochrome P450 Enzymes found?
They are metabolised in the Liver
What are the 7 Cytochrome P450 enzyme Inducers and 9 Inhibitors?
Inducers (Avoid in Oral Contraceptives)
1) Alcohol (Chronic) and smoking
2) Phenytoin
3) Phenobarbitone
!!!!4) Rifampicin
!!!!5) Carbamazepine
6) Griseofulvin
7) St. John’s Wort
Inhibitors (INCREASEs INR and increases STATIN concentration) (OG DEVICES)
1) Omeprazole
2) Grapefruit Juice
3) Disulfiram
4) Erythromycin
5) Valproate
6) Isoniazid
7) Ciprofloxacin
8) Ethanol (Acute Intoxication)
9) Sulphonamides
When should patients be checked for Upper GI cancer in Peptic Ulcer Disease? (ENDOSCOPY within 2 weeks)?
Over 55 or ALARM signs
- Anaemia
- Loss of Weight
- Anorexia
- Recent onset of Symptoms
- Melaena
- Swallowing Difficulties (Dysphagia)
What are the signs of Peptic Ulcer Disease?
In addition to the pain what other symptom is there?
Epigastric pain, worse when hungry and relieved by eating if duodenal (common) or worse after eating if gastric (less common)
!!! NAUSEA in PEPTIC ULCER DISEASE
Nausea
Intolerance of Fatty Acids
What is the management of patients who are not over 55 or have ALARMS signs for Peptic Ulcer Disease?
What 2 medication types should they avoid?
!!!!!!!Lifestyle Changes, Medication changes (avoid NSAIDs and Steroids) and give Antacids
If symptoms do not improve, test for H Pylori
(breath or Stool Antigen) (but they should not have taken Antibiotics or Bismuth for 4 weeks and PPI for 2 weeks before the test)
- If positive- TRIPLE THERAPY= PPI, Clarithromycin and Amoxicillin (Metronidazole if allergic to Penicillin)
- If negative- PPI or H2 antagonist
6-8 weeks later, do another Endoscopy
What are the differentials for Dysphagia?
- Neurovascular Disease- Cerebrovascular Disease, Parkinson’s, Motor Neurone Disease, Bulbar Palsy
- Motility Disorder- Achalasia, Diffuse Oesophageal Spasm, Systemic Sclerosis (SOLIDS and LIQUIDS affected from the start and other features of CREST)
- Mechanical/ Obstructive Disorders- Strictures, Malignancy, Pharyngeal Pouch, Extrinsic Pressure from LUNG CANCER, Mediastinal Lymph Nodes, Retrosternal Goitre
1) Odynophagia suggests Candida Infection (suspect if HIV), Malignancy, Ulcer or Spasm
2) Halitosis, Gurgling, Bulging neck on swallowing suggests Pharyngeal Pouch
3) Iron Deficiency, Glossitis and Angular Stomatitis suggests Plummer-Vinson Syndrome- also OESOPHAGEAL WEBS
4) Odynophagia with no weight loss or vomiting- Oesophagitis
5) Difficulty in making the swallowing motion suggests Neurological cause
What are the Hepatobiliary causes of Malabsorption?
Primary Biliary Cirrhosis (autoimmune bile duct degradation) and Ileal Resection (failure of Bile acid absorption at Terminal Ileum)
What are the Pancreatic Causes of Malabsorption?
Chronic Pancreatitis
Pancreatic Cancer
Cystic Fibrosis
What are the Small Bowel Causes of Malabsorption?
Coeliac Disease
Crohn’s Disease
Small Bowel Resection
What are the Typical Symptoms of GORD which suggest a diagnosis?
Dyspepsia (Heartburn)
Sensation of Acid Regurgitation
What are the Atypical Symptoms of GORD?
Look at the G and the O of GORD
Epigastric Pain (worse when lying down and after eating)
Nausea
Bloating and Belching (so acid is refluxed)
Globus (lump in your throat)
Laryngitis
Tooth Erosion
What Investigations should be ordered in GORD? (3) POO
1) Give them a trial of PPI
2) OGD if there are Alarm symptoms (like Peptic Ulcer Disease) (anaemia, weight loss, melaena, Dysphagia etc.) or if Atypical or Recurrent symptoms
3) Oesophageal Manometry (like Achalasia)
What is the management of GORD?
Conservative, 2 drugs, surgery
Lifestyle Interventions- weight loss, dietary changes, elevation of head at night, avoidance of late-night eating
PPI Therapy
Antacids for symptomatic relief
If Refractory- Anti-reflux Surgery
What are the 3 complications of GORD?
!!!!2 of them start with OESOPHAGUS
1) Oesophageal Ulcer
2/3) Barrett’s Oesophagus and therefore Adenocarcinoma of the Oesophagus
4) Oesophageal Stricture
What are the signs of Gastroparesis?
Nausea and Vomiting
Feeling of Fullness after a few bites
!!!!Abdominal Pain and BLOATING
Constipation
!!! ABDOMINAL PAIN and ERRATIC GLUCOSE CONTROL in GASTROPARESIS
Also POOR GLUCOSE TOLERANCE in Diabetes Patients due to lack of absorption of Ingested Food
What is needed for the diagnosis of Gastorparessis?
Solid Meal Gastric Scintigraphy (Radionuclide Studies of Gastric Emptying)
What is the management of Gastroparesis?
Diet and 3 meds
1) Dietary Modification- Low fibre, Smaller/ more frequent meals, Pureed/ mashed food
2) Domperidone- Dopamine Receptor Antagonist (unless QT Prolongation or Heart Failure)
3) Metoclopramide or Erythromycin (Motility Agents)
What is Giardiasis?
It is a type of Gastroenteritis caused by the parasite Giardia Lamblia
It is spread via the Faecal-Oral Route so a history of Contaminated water, Uncooked Fruit or Vegetables or a Lack of Hand Hygiene are key
What are the 4 signs of Giardiasis?
How long is the incubation period?
Bloating and Non-bloody Steatorrhoea
The incubation of the disease is ONE to THREE WEEKS
1) Explosive, Watery, Non-bloody (unlike Salmonella) Steatorrhoea (Foul Smelling and Difficult to Flush)
2) Bloating and Flatulence (unlike Cholera), Nausea
!!!!!!!!!!!!!!3) Weight Loss and Anorexia
4) NEW ONSET LACTOSE INTOLERANCE for up to SIX WEEKS can also occur
What is the diagnosis of Giardiasis?
Stool Microscopy for Trophozoites and Cysts is conducted THREE TIMES on THREE SEPARATE days
Other tests= Stool antigen tests (Greater Sensitivity), Stool PCR
Duodenal Aspirates and Biopsies are invasive and only used in Indeterminate Cases
What is the management of Giardiasis?
Without treatment, the disease can persist for MONTHS
Treatment is with Antibiotics like METRONIDAZOLE
What is Gilbert’s Syndrome?
What is the Inheritance Pattern?
Doesn’t require treatment as it is benign
It is an Autosomal Recessive condition where there is decreased activity of the UDP enzyme that conjugates bilirubin due to a mutation in the UGT1A1 gene
so Lack of Conjugation
What are the signs of Gilbert’s Syndrome?
Doesn’t require treatment as it is benign
Intermittent Mild Jaundice in relation to Chest, Fasting, Infection or Exercise
There will be a NORMAL FBC but mildly raised Unconjugated Bilirubin, other LFTS will be NORMAL
What is Henoch-Schonlein Purpura?
What typically occurs before it?
What is seen on Skin Biopsy?
It is the most common type of Vasculitis seen in children aged 3-15 years old. This occurs due to the DEPOSITION of IgA Immune Complexes in the affected organs
So it is associated with IgA Nephropathy as well
Skin Biopsies of the affected regions show Neutrophils and Monocytes- also use the biopsy for Immunofluorescence of C3/IgA which is DEFINITIVE DIAGNOSIS
It is typically seen after an Upper Respiratory Tract Infection
What are the signs of Henoch-Schonlein Purpura?
Remember PANA
TETRAD
1) Purpuric Rash over Buttocks and Extensor Surfaces
2) Abdominal Pain
3) Arthralgia/ Arthritis
4) Renal Disease presenting as Asymptomatic Microscopic Haematuria or Isolated Proteinuria (Nephritis)
How is Henoch-Schonlein Purpura diagnosed?
What 3 things are high and what is the gold standard for diagnosis?
High ESR/CRP
!!!!!High IgA (complexes are depositing)
!!!!!!HIGH Creatinine (if Renal Involvement)
Skin/ Renal Biopsy with Immunoflourescence for IgA/ C3 is GOLD STANDARD
What is the management of Henoch-Scholein Purpura?
What should you look for if the abdominal pain is Severe?
Most cases resolve Spontaneously and don’t need treatment
!!!!!Analgesia and Supportive measures
Corticosteroids for Renal Disease
Severe Abdominal Pain- Check for possible Intussusception or Bowel Infarction
Referral to renal specialist for further Immunosuppression or Dialysis
What are the signs of a Hepatitis infection? (3,2,2)
Four signs of Liver Failure
1) Malaise and Fatigue
2) Nausea and Vomiting
3) Lymphadenopathy
!!!!!1) Right Upper Quadrant Pain
!!!!!2) Hepatomegaly and Splenomegaly
1) Diarrhoea (may be Pale Stools and Dark Urine)
2) Jaundice
Liver Failure- Hepatic Encephalopathy, Jaundice, Ascites, Abnormal Clotting
What type of Virus is Hepatitis A and how is it transmitted?
It is an RNA Picornavirus, transmitted through a FECAL-ORAL ROUTE (occasionally through Food Sources or through Anal Sex)
What is the Epidemiology of Hepatitis A and B?
What is the incubation period?
Which one of these is the most common cause of Hepatitis Worldwide?
Hepatitis A
- Prevalence is high in Developing countries
- Immunize Travellers and those at Risk
- Faeco-Oral Route
- Incubation= 2-4 weeks
Hepatitis B
- Most common cause of Hepatitis World-wide
- High prevalence in Africa, Asia and Pacific Islands
- Blood/ Body Fluid
- Incubation period is 2-3 months
What is the presentation of Hepatitis A?
3 symptoms
What is the management?
1) Flu-like Symptoms
2) Jaundice (Abnormal LFTs)
3) RUQ Pain and Hepatomegaly
4) Complete recovery can take 6 months (management is supportive)
What are the investigations of Hepatitis A?
IgM and IgG Antibodies to Hepatitis A
What type of Virus is Hepatitis B and how is it transmitted?
dsDNA
It is transmitted via Blood or Body Fluids
- Vaginal/ Anal Intercourse
- Transfusion
- Vertical Transmission to Babies from Moms
What are the signs of Hepatitis B? (think standard hepatitis signs)
What is the risk of Chronic Disease in adults and children?
Only 5% of Children have Jaundice. The majority get Chronic Disease
50% of Adults have Jaundice, Fever, Malaise, Darkening of Urine and Pale Stools. The risk of Chronic Disease is Low
What is the Serology of Hepatitis B?
1) HbsAg means the infection is still going on. >6 months means Chronic. If it is positive but the infection is over symptomatically then it means they are a carrier
2) AntiHbs means they have a previous or current infection or a vaccination
3) Anti-Hbc means the patients have a previous or current INFECTION (not a vaccination basically). IgM implies Acute, IgG implies Chronic
4) HbeAg is a marker of virus replication so a high amount of this means the patient is very infectious. Anti-HbeAg implies they are least infectious
What is the management of Hepatitis B?
Only for adults who are:
- HBsAg Positive
- Compensated Liver Disease
- Pregnant
Peg
/////
Ten
Ent
First Line- Peginterferon Alfa 2
Second Line- Tenofovir, Entecavir
What type of virus is Hepatitis C and how is it transmitted?
RNA Virus of the Flaviviridae Family (Type 1 and 3 are the most common)
Blood and Bodily Fluid-
- IV Drug Use
- Blood Transfusion
- Haemodialysis (rare in UK)
- Sexual Transmission (rare)
- Needlestick Transmission
- Perinatal infection from Mother to Baby
Incubation Period= 2-3 Months
What are the signs of Acute and Chronic Hepatitis C? (Most are ASYMPTOMATIC)
What are the 3 complications?
Chronic Hepatitis has Arthritis and Sjogren’s as well
Most infections are Asymptomatic- 55-85% go on to develop Chronic Infection
Signs (seen in 1/3 of patients)- Arthralgia, Jaundice, Fatigue
Chronic Infection= Persistently High LFTs, Cirrhosis develops in 20-30% of patients
1-2% develop Hepatocellular Carcinoma, 2-5% develop Liver Failure
THREE COMPLICATIONS
- Cryoglobuminaemia
- Cirrhosis
- Hepatocellular Carcinoma
What investigations should be ordered in Hepatitis C?
Remember there are NO Vaccinations for Hep C
After how long of HCV RNA does the disease need to be treated?
Anti-HCV Serology- 90% are positive 3 MONTHS after infection
HCV RNA- If positive for more than 2 MONTHS then need to be treated
What is the management of Hepatitis C?
What are the side effects of Ribavirin?
S-virs with or without RIBAVIRIN
Symptomatic Treatment in the Early Stages of the Disease
Drug Therapy should be considered for ALL PATIENTS. Nucleoside Analogs are preferred (daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with or without Ribavirin but they lead to Undetectable Viral Loads
Ribavirin side effects-
- Haemolytic Anaemia
- Cough
- Teratogenicity (don’t get pregnant for 6 months after stopping)
Antivirals are beneficial in all patients
What is the management of Hepatitis C?
Symptomatic Treatment in the Early Stages of the Disease
Drug Therapy should be considered for ALL PATIENTS. Nucleoside Analogs are preferred- SOFOSBUVIR- but they lead to Undetectable Viral Loads
Antivirals are beneficial in all patients
What are the risk factors for Hepatocellular Carcinoma?
- Chronic Viral Hepatitis (B or C)
- Cirrhosis
- Primary Biliary Cirrhosis
- Non-alcoholic Fatty Liver Disease (but Alcohol can cause it still)
- Alcohol Misuse
- Obesity
- Type 2 Diabetes
- Inherited Metabolic Diseases
- Rare Diseases= Wilson’s Disease, Porphyria cutanea tarda, Alpha-1Anti-trypsin
What investigations should be ordered in Hepatocellular Carcinoma?
What warrants screening?
Bloods- FBC, U/E, CRP, LFTs
Liver Screen including Hepatitis Screen
!!!!!!Abdominal Ultrasound and AFP is used for SCREENING if:
1) CIRRHOSIS occurs due to (3) Alcohol, Hep B/C, Haemochromatosis
AFP marker (but only abnormal in 50% of cases) (if Normal, it could be liver metastasis which is more common than liver cancer)
CTAP and PET Scan
What is the management of Hepatocellular Carcinoma?
Hepatic RESECTION
Liver Transplant
Radiofrequency Ablation
Sorafenib
What are the signs of Hepatocellular carcinoma?
DISTENSION/ ASCITES and GI HAEMORRHAGE, and Fever
Abdominal Discomfort (pain) and DISTENSION
JAUNDICE
Weight Loss
GI HAEMORRHAGE
Pruritus
Fever
Nausea or Vomiting
Following Alcoholic Liver Disease/ Cirrhosis/ Hepatitis B or C
What is Hereditary Haemochromatosis?
What is the inheritance pattern?
It is an Autosomal Recessive Disorder of Iron Metabolism where there is excessive Iron Accumulation and Deposition across the skin, joints and organs
This occurs due to the HFE Protein
What are the signs of Hereditary Haemochromatosis?
Suspect in Diabetics with Joint Pain and Deranged LFTs (or Cirrhosis)
!!!!What are the first 3 symptoms?
FIRST THREE SYMPTOMS ARE Fatigue, Erectile Dysfunction and Arthralgia
Depositing in the Pancreas, Liver, Joints, Heart and Adrenal Glands
1) BRONZE Skin
2) Type 2 Diabetes Mellitus due to Pancreatic Deposition
1) Liver Cirrhosis and Adrenal Insufficiency
2) Hepatomegaly and Chronic Liver Disease
1) Dilated Cardiomyopathy due to Myocardial Deposition
2) Joint Pain due to Joint Deposition
What tests should be ordered for the diagnosis of Hereditary Haemochromatosis?
Bloods
- Deranged LFTs (as well as Biopsy)
- Raised Serum Ferritin
- Raised Transferritin Saturation (MOST IMPORTANT TEST)
- (Also LOW TIBC)
Genetic Testing can reveal HFE gene defects
MRI Imaging of the brain and heart may show evidence of Iron Deposition
Liver Biopsies will also show Increased Iron Stores
What are the Complications of Hereditary Haemochromatosis?
Things that affect the Liver are unchanged by Phlebotomy
Liver Fibrosis
Cirrhosis
Hepatocellular Carcinoma
Skin Hyperpigmentation (which decreases after Phlebotomy)
Diabetes Mellitus (often unchanged by Phlebotomy)
!!!!!!!!!!Severe Myocardial Siderosis which leads to cardiac dysfunction (Dyspnoea, Orthopnoea or Arrhythmia- improves after Iron Depletion)
- Restrictive and Dilated Cardiomyopathy (improves after Venesection)
Arthropathy
What is the management of Hereditary Haemochromatosis?
What should patients avoid?
Aim is to normalise body iron stores and prevent iron-mediated tissue injury and organ dysfunction
Primary therapy- Phlebotomy/ Venesection as this Stimulates Erythropoeisis
!!!!Another option is Desferrioxime
AVOID FRUIT JUICES- Especially Vitamin C
What are the 2 types of Hiatus Hernia?
Sliding (80%)
- The Gastro-oesophageal Junction slides up into the Chest. A less competent sphincter results in Acid Reflux. Treatment is similar as for GORD
Rolling (20%)
- The Gastro-oesophageal Junction remains in the Abdomen but part of the stomach protrudes into the chest along the Oesophagus. This needs more URGENT treatment as Volvulus (twisting) can result in Ischaemia and Necrosis
What are the signs of Hiatus Hernia?
Heartburn
Dysphagia
Regurgitation
Odynophagia
!!!!!Shortness of Breath
Chronic COUGH and Chest Pain (Heart Burn)
What is needed for the diagnosis of Hiatus Hernia?
Barium Swallow (Upper GI Series)
Otherwise
- Endoscopy and Manometry
What is the management of Hiatus Hernia?
What 3 medications should they avoid?
Conservative
- Lose weight
- Elevate the head of the bed
- Avoid Large Meals and eat 3-4 hours before bed
- Avoid Alcohol and Acidic Food
- Avoid Smoking, Chocolate, Caffeine
!!!!!!Calcium Channel Blockers, Beta Blockers and Nitrates can worsen symptoms
Medical-
- PPI for 6 weeks
Surgical-
- Nissel’s Fundoplication if medications dont work or if patient prefers it (majority do not need this)
What is seen on Xray of Hiatus Hernia?
A Retrocardiac Round Structure and a Stomach Bubble
Which drugs cause Diarrhoea?
CM MACORN/E
Chemotherapy
Magnesium
Metformin
Antibiotics (Penicillin)
Cimetidine
Omeprazole
Ranitidine
NSAIDs
Also ENTERAL FEEDING
What drugs cause Constipation?
AI ALOA
Antidepressants (Amitriptyline)
Iron
Antipsychotics
Levodopa
Opiates
Aluminium
What should be done in Overflow Diarrhoea?
Do NOT REDUCE LAXATIVES even though they have diarrhoea
instead do Rectal Exam
What type of Laxative is Microgol?
Osmotive Laxative
What is TIPS? And when is it indicated?
An Artificial channel between the inflow portal vein and the outflow hepatic vein
(Transjugular Intrahepatic Portosystemic Shunt)
1) Secondary Prophylaxis for Oesophageal Variceal Bleeding
2) Treatment for Refractory Ascites
3) Treatment for Portal Hypertension in Budd Chiari
What is the side effect of TIPSS?
Hepatic Encephalopathy
What is the Manning Criteria for the diagnosis of IBS?
Abdominal Discomfort relieved by Defecation or Discomfort associated with changed Bowel Habits AND
- At least 2 OF:
!!!!!!1) Altered stool passage (Straining or Urgency)
!!!!!2) Abdominal Bloating
3) Symptoms made worse by Eating
4) Passage of Mucus
There may also be Lethargy and Nausea but this is normal
What are the symptoms in IBS that can indicate a different disease?
Pain or Diarrhoea that disturbs sleep
PR BLEEDING
Weight Loss
FEVER
What investigations should be conducted to rule out other diseases in IBS?
Faecal Calprotectin (raised in IBD, not IBS)
FBC, ESR/CRP- (raised in IBD, not IBS)
Coeliac Serology
Which investigations are NOT required in IBS?
Only really need to test for other diseases- Faecal Calprotectin/ Anti TTg/ FBC, ESR, CRP for IBD, Coeliac etc.
No Need for Imaging/ H Pylori/ Infection
Abdominal Ultrasound
Sigmoidoscopy and Colonoscopy
TFTs
FOBT- detects whether there is blood in the stool
Faecal Ova and Parasites
Hydrogen Breath Test
When is Bilirubin Present in URINALYSIS? In Prehepatic, Hepatic and Posthepatic Jaundice?
Absent in Prehepatic
Present in Hepatic and Posthepatic
When is Urobilinogen Present in Urinalysis? In Prehepatic, Hepatic and Posthepatic Jaundice?
Present in Normal
Increased in Prehepatic and Hepatic
Decreased or Absent in Posthepatic
What are the 3 causes of Prehepatic Jaundice?
1) Conjugation Disorders- Gilbert’s Syndrome and Crigler-Najjar
2) Haemolysis- Malaria and Haemolytic Anaemia
3) Drugs- Contrast or Rifampicin
What are the 11 causes of Hepatic Jaundice?
4, 4, 3
Alcohol
Budd Chiari
Cirrhosis
Drugs (V PHATS- Valproate, Paracetamol, Halothane, Antibiotics for Tuberculosis, Statins)
!!!!Liver Mass (could also be post hepatic jaundice though)
Autoimmune Hepatitis
Viral Hepatitis
Alpha-1-Antitrypsin Deficiency
Wilson’s Disease
Haemochromatosis
Failure to excrete Conjugated Bilirubin (Rotor and Dubin-Johnson Syndrome- Autosomal Recessive- both Benign)
What are the drug causes of Hepatic Jaundice?
V PHATS
Valproate
Paracetamol Overdose
Halothane
Antibiotics (Tuberculosis)
Statins
What are the causes of Posthepatic Jaundice?
The 3 P_Cs/ Stones/ Drugs/ Malignancies/ 2 extra
Primary Biliary Cirrhosis/ Primary Biliary Cholangitis/ Primary Sclerosing Cholangitis (seen in UC with signs of Jaundice/ raised ALP)
Common Bile Duct Stones or Mirizzi’s Syndrome
Drugs (CCFNSS- Coamoxiclav, Chlorpromazine, Flucloxacillin, Nitrofurantoin, Steroids, Sulphonylureas)
Malignancies- Head of Pancreas Adenocarcinoma, Cholangioacarcinoma
Caroli’s Disease
Biliary Atresia
What are the signs of Mirizzi’s Syndrome?
Obstructive Jaundice
Two week history of Jaundice (yellowing of the skin and sclera)- Dark Urine and Pale Stools
Due to CBD Stone
!!!!Also Fever, Nausea and Vomiting may be seen
How are the LFTs different in different Jaundices?
What are the readings like for Hepatic, Prehepatic and Posthepatic Jaundice?
What does Low Albumin Suggest?
What is the most common cause for high GGT?
How should the synthetic function of the liver be measured?
Prehepatic- AST/ALT would NOT be markedly elevated
Hepatic- Bilirubin would be raised. ALP is raised but NOT MARKEDLY RAISED. Also LOW ALBUMIN, which also suggests Chronic
Posthepatic- ALP is MARKEDLY raised. High Bilirubin.
AST is 2x higher or more than ALT= Alcoholic Hepatitis. High GGT is also present.
ALT is higher if Paracetamol Overdose
In Hepatitis A- ALT>1,000
Non-Alcoholic Fatty Liver Disease- Obesity, Diabetes, Hypercholesterolaemia
Remember that ‘liver function tests’ do not always accurately reflect the synthetic function of the liver. This is best assessed by looking at the prothrombin time and albumin level.
What are the signs of Compensated and Decompensated Cirrhosis?
Compensated (FANGS)
- Fatigue and Anergia
- Anorexia and Cachexia
- Nausea or Abdominal Pain
- Gynaecomastia
- Spider Naevi
Decompensated (GEPJAP)
- Gynaecomastia/ Testicular Atrophy
- Early Bruising
- Pruritus
- Jaundice
- Ascites and Oedema
- Palmar Erythema
What are the causes of Cirrhosis?
Memorise the first 3 and the drugs, read the rest
Usually-
- Alcohol
- Hepatitis B and C
- Non-Alcoholic Fatty Liver Disease
Autoimmune
- Autoimmune Hepatitis
- Primary Biliary Cirrhosis
- Primary Sclerosing Cholangitis
- Sarcoid
Genetic
- Haemochromatosis
- Wilson’s Disease
- Alpha 1 Antitrypsin Deficiency
DRUGS
- I am
- Isoniazid
- Amiodarone
- Methotrexate
Heart Failure, Budd-Chiari Syndrome
What blood tests should be ordered in Cirrhosis?
Check the Liver, check the 3 blood cells and 1 other
LFTs
- AST, ALT, ALP, GGT
- Albumin
- Bilirubin
FBC (3 blood cells)
- Leucocytosis (possible Infective Cause)
- Thrombocytopaenia (Chronic Liver Disease)
- Anaemia (Normocytic= Wilson’s Disease or GI Bleed from Oesophageal Varices)
- Macrocytic- Folate or B12 Deficiency in Alcohol Excess
Urea and Electrolytes
- look for hepatorenal syndrome or any Electrolyte Abnormality
What 5 Investigations should be ordered in Cirrhosis to rule out other conditions?
!!!!!Cytomegalovirus Serology (Viral Infection)
Iron Studies (Haemochromatosis)
Alpha 1 Antitrypsin (A1AT Deficiency)
Caeruloplasmin (Wilson’s Disease)
Autoantibodies (Autoimmune Hepatitis, Primary Biliary Cirrhosis, Primary Sclerosing Cholangitis)
What 4 Imaging and Invasive Investigations should be conducted in Cirrhosis?
TRANSIENT ELASTOGRAPHY is the most important one for CIRRHOSIS, although a LIVER BIOPSY can also be done
!!!If Ascites- Peritoneal Tap for Bacterial Peritonitis (if Neutrophils>250)
!!!!!!!Doppler Ultrasound for identifying Budd Chiari
Transient Elastography or Acoustic Radiation Force Impulse for Non-Alcoholic Fatty Liver Disease
If Still in doubt- Liver Biopsy (only if INR<1.5)
What is the management of Decompensated Liver Disease (GEPJAP symptoms)?
What 4 things should be avoided?
What should they be screened for regularly? What is given for the Pruritus? What should be given for Encephalopathy? What 3 things indicate a high risk of Bacterial Peritonitis? And what is the ultimate treatment?
1) Avoid NSAIDs, Alcohol, Sedatives, Opiates
2) Ultrasound scan and Serum AFP every 6 months to detect development of Hepatocellular Carcinoma
3) Pruritus- Cholestyramine (bile acid sequestrant)
4) Manage Ascites with Fluid Restriction (<1.5L per day) and a Low Salt Diet. Spironolactone and Furosemide if necessary. If severe- Paracentesis with Albumin Infusions
5) Recurrent Episodes of Encephalopathy can be reduced with Prophylactic Lactulose and Rifaximin
6) If High Risk of Bacterial Peritonitis (Low Albumin, High INR, Low Ascitic Albumin)- give Prophylactic Antibiotics
7) Ultimate treatment- Liver Transplant
What are the signs of Alpha 1 Antitrypsin Deficiency?
Early onset COPD and Cirrhosis- do SPIROMETRY as INVESTIGATION
What is the first test to be done on ANY Drowsy Patient with a suspected Liver Condition?
Blood Glucose (Capillary)
as they are at HIGH RISK of Hypoglycaemia
What is an Indication for Vitamin K delivery?
PT>14
What is Chronic Liver Failure?
Liver Failure on the background of Cirrhosis
What are the signs of Liver Failure?
(Similar to Decompensated Liver dIsease)
Hepatic Encephalopathy
Abnormal Bleeding
Ascites
Jaundice
Cerebral Oedema (so may be signs of Raised ICP)
What is the pathophysiology of Hepatic Encephalopathy in Liver Failure?
Ammonia accumulates in the circulation
This crosses the blood brain barrier and is detoxified by Astrocytes- this forms Glutamine which disrupts the Osmotic Balance
This causes Cerebral Oedema
What are the Investigations that should be ordered in Liver Failure?
!!!First 2 are the same as Cirrhosis
Doppler Ultrasound if Budd Chiari is suspected
Ascites= Peritoneal Tap for Bacterial Peritonitis
Abdominal Ultrasound
Blood Tests- FBC/ CRP/ U&Es/ Albumin/ Clotting Screen
What 5 Blood Tests should be ordered in Liver Failure?
Very Very similar to cirrhosis
2, 3 and 4 are the same
1) INR to look for coagulopathy and establish a diagnosis of liver failure
2) Liver Function Tests including albumin to check liver enzymes, bilirubin levels and to further assess synthetic function of the liver
3) Full blood count to look for leucocytosis (possible infective cause), thrombocytopaenia (in chronic liver disease) and anaemia (normocytic could indicate haemolytic anaemia as in Wilson’s or a GI bleed from oesophageal varices, macrocytic could indicate B12 and folate deficiency as in alcohol excess)
4) Urea and electrolytes to establish baseline renal function and to look for hepato-renal syndrome or any electrolyte abnormalities (such as hypokalaemia which can worsen encephalopathy and should be corrected)
5) Tests to determine cause such as:
- Paracetamol level (paracetamol overdose)
- Hepatitis
- Epstein-Barr virus
- Cytomegalovirus serology (viral infection)
- Iron studies (haemochromatosis)
- α-1 anti-trypsin (α-1 antitrypsin deficiency)
- Caeruloplasmin level (Wilson’s disease)
- Iron studies (hereditary haemochromatosis)
- Auto-antibodies (autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis)
What are the main complications of Liver Failure?
!!!INFECTION (happens in almost all patients)
Also
- Cerebral Oedema
- Bleeding (where there is a source- like introduction of new ICP monitors)
- Hypoglycaemia (TREAT with GLUCOSE)
- Multiorgan Failure
What are the 6 complications of Cirrhosis?
1) Ascites
2) Spontaneous bacterial peritonitis
3) Hepatic encephalopathy
4) Portal hypertension
5) Variceal bleeding
6) Hepatorenal syndrome
What is the management of Liver Failure?
What should be monitored in these patients?
Treat the underlying cause
MONITOR their BLOOD GLUCOSE
- Encephalopathy- ORAL Lactulose and IV Mannitol to prevent Cerebral Oedema
- Coagulopathy- give Vitamin K and Fresh Frozen Plasma if they are bleeding
- Spontaneous Bacterial Peritonitis- Broad Spectrum Antibiotics (Ceftriaxone)
- Renal Dysfunction- Haemofiltration may be needed. Give them Human Albumin solution rather than Crystalloid if they need resuscitation
- Liver Transplantation may be needed
What is the criteria for Liver Transplant?
Paracetamol Induced
- Acidic Arterial Blood after 1 day OR
1) PT>100 AND Creatinine>300 AND Grade 3 or 4 Encephalopathy (Asterixis, Coma, Restlessness)
Non Paracetamol Induced
- PT>100 OR any THREE of
1) Drug Induced Liver Failure
2) <10 years old or >40 years old
3) 1 week from first Jaundice to Encephalopathy
4) PT>50
5) Bilirubin >300
What is Melanosis Coli?
It is the Dark Brown Pigmentations of Macrophages in the Lamina Propria found on Colonoscopy
This is due to Chronic Laxative Excess (like Senna)- and is reversed by stopping these
What is Mucosa-associated Lymphoid Tissue (MALT)?
What is it associated with?
It is a rare Low-grade Non-Hodgkin’s Lymphoma that presents in the stomach
It develops from B Lymphocytes in the Marginal Zone
It is strongly associated with H Pylori Infections
What are the signs and management of MALT?
Abdominal Pain, Nausea
ANAEMIC Symptoms and Weight Loss
There may be paraproteins in the blood
Management-
- H-Pylori Eradication Therapy
- If this doesn’t work- chemotherapy and radiotherapy
What are Candida?
White patches at the mouth caused by the fungus Candida- Leukoplakia describes the white patches
It can occur due to
- Old Age
- Diabetes, Immunosuppression, Corticosteroids
- Malignancy
- Antibiotics
Management- FLUCONAZOLE
What is Hairy Leukoplakia?
Benign Condition that does not need treatment
It is caused by EBV and suggests underlying HIV
What are Oral Ulcers?
Caused by
- Iron, B12, Folate Deficiencies
- Crohn’s Disease
What are the mouth signs of Iron Deficiency Anaemia?
Glossitis
Angular Cheilitis/ Stomatitis
Post-cricoid webs
What are the signs of Pancreatic Cancer?
Early Disease- Non specific- Malaise, Abdominal Pain, Nausea, Weight Loss
Advanced Disease
1) Courvoisier’s sign- Blockage of Common Bile Duct from the tumour- Obstructive Jaundice and a Painless Palpable Gallbladder
2) Diabetes- suspect in Old Patient with NEW Diabetes and is ALSO LOSING WEIGHT
3) Pancreatitis Signs
4) Paraneoplastic Syndromes. Trosseau’s Syndrome- Thrombophlebitis affecting Extremities- veins are swollen and rigid
5) Disseminated Intravascular Coagulation
It metastasises to LUNG, LIVER and BOWEL (haemoptysis, jaundice and constipation)
What investigations should be ordered in Pancreatic Cancer?
Associated with BRCA 2 gene and HNPCC cancer
Suspect in Painless Obstructive Jaundice
1) Always do this- High Clinical Suspicion- HIGH RESOLUTION CT FIRST- may show DOUBLE DUCT SIGN
2) Ultrasound - look for liver metastasis and CBD dilatation. BUT NORMAL ULTRASOUND does not rule out Pancreatic Cancer
3) MRCP shows info about the bile ducts
4) Endoscopic Ultrasound can detect small lesions as well or ERCP can be used for biopsy
What is the treatment of Pancreatic Cancer?
What are the side effects of the procedure?
Resect with Pancreaticoduodenectomy (Kausch-Whipple Procedure aka Whipple Resection) if
1) No evidence of involvement of the Superior Mesenteric Arteres or Coeliac Arteries
2) No Evidence of Distant Metastasis
Side effect of Whipple’s- Peptic Ulcer Disease and Dumping Syndrome
What are the risk factors for Duodenal Ulcers?
NSAIDs
Steroids
SSRIs
Smoking
Increase in Gastric Acid Secretion/ Increased Gastric Emptying- MORE ACID in Duodenum
Blood Group O
What is the management of Peptic Ulcers if H Pylori Negative?
6 weeks of PPI and Lifestyle Advice
What are the signs of Peritonitis?
Abdominal Guarding
Rebound Tenderness (Pressing hurts less than letting go)
Also Fever, Vomiting, Tachycardia, Hypotension
Suspect if ABDOMINAL PAIN AND FEVER in LIVER DISEASE
What is seen in Abdominal Xray of Peritonitis? and Chest Xray?
Rigler Sign
Air is on Both Sides of the Intestine (Luminal and Peritoneal Sides of the Bowel Wall)
Also Air Under Diaphragm on CXR
What is Pernicious Anaemia?
Suspect if other Autoimmune diseases are present
It is a deficiency in Red Blood Cells caused by the Lack of B12
This is usually due to the AUTOIMMUNE reaction to INTRINSIC FACTOR PRODUCTION
What are the causes of B12 Deficiency?
TUBERCULOSIS
METFORMIN
!!!!!!!Any cause of Pancreatic Insufficiency
Zollinger-Ellison Syndrome
!!!!Small Bowel Bacterial Growth (since bacteria use B12)
Gastric Causes- Pernicious Anaemia, Chronic Severe Atrophic Gastritis
What are the Blood Results for Pernicious Anaemia?
What is the Reticulocyte count?
What is seen on Blood Smear?
What is Pernicious Anaemia associated with?
Low Hb
High MCV
High MCH
Normal MCHC
LOW B12
Low or Normal Folic Acid
Low Reticulocyte (immature red blood cells)
Large/ Oval RBCs in Blood Smear
Antibodies against Intrinsic Factor and Parietal Cells
Pernicious Anaemia is associated with Atrophic Body Gastritis
What is the management of Pernicious Anaemia?
What should they be warned about developing?
Lifelong replacement therapy with Cobalamin
And warn them that they are at risk of Gastric Cancer and Carcinoids
What are the signs of a Pharyngeal Pouch?
Dysphagia
Regurgitation of Undigested Food
Aspiration
Chronic Cough
!!!!!Weight Loss
LUMP in NECK with HALITOSIS
What investigations should be ordered in a Pharyngeal Pouch?
What should NOT be done?
Avoid Endoscopy due to the risk of perforating the Lesion
BARIUM SWALLOW shows a Residual pool of Contrast within the pouch (BLACK POUCH)
What is the management of a Pharyngeal Pouch?
If asymptomatic- no treatment needed
Otherwise- Diverticular Resection and Incision of the Cricopharyngeus Muscle
What are the signs of Plummer-Vinson Syndrome?
What disease is it associated with?
Upper Oesophageal Web
Post Cricoid Dysphagia
Iron Deficiency Anaemia
It is associated with Squamous Carcinoma of the Oesophagus
What is Primary Biliary Cholangitis?
What 2 conditions can it lead to?
It is an Autoimmune Condition where the Bile Ducts are inflamed
This leads to LIVER CIRRHOSIS
They are also at higher risk of Hepatocellular Carcinoma
What are the signs of Primary Biliary Cholangitis?
Fatigue
Itching (Pruritus)
Dry Eyes and Dry Skin
Jaundice
What investigations should be ordered in Primary Biliary Cholangitis?
1) Abnormal LFTs
2) Positive Antimicrobial Antibodies
3) Abdominal Ultrasound
4) Liver Biopsy- which shows Inflammation and Scarring and GRANULOMAS around the Bile Ducts
5) RAISED IgM
What is the management of Primary Biliary Cholangitis?
Largely Supportive but includes
1) Ursodeoxycholic Acid
2) Cholestryamine (for itching)
3) Vitamin Supplements
4) Liver transplantation (may recur after transplant)
What is Primary Sclerosing Cholangitis associated with typically?
Young Males with IBD
(Primary Biliary Cholangitis mainly affects women)
What are the signs of Primary Sclerosing Cholangitis?
Can be Asymptomatic with Abnormal LFTs or Hepatomegaly
Jaundice
RUQ pain
Fatigue, Weight Loss and Sweats (B Symptoms- so paints picture of RUQ cancer)
Associated with Ulcerative Colitis
What investigations should be ordered in Primary Sclerosing Cholangitis?
Deranged LFTs- that show a Cholestatic Picture
Positive (3) (may not be all of them)
1) Anti-Smooth Muscle
2) Antinuclear Antibodies
3) ANCA Antibodies
Multiple Beaded Biliary Strictures seen on MRCP/ ERCP
What are patients with Primary Sclerosing Cholangitis at risk of?
Cholangiocarcinoma
And Colorectal Cancer if existing IBD
What is the management of Primary Sclerosing Cholangitis?
Avoid Alcohol
Cholestyramine for Pruritus
Give Vitamin ADEK
Dilate Strictures with ERCP
Liver Transplant may be indicated in cases complicated by Chronic Liver Disease/ Malignancies
What are the signs of Vitamin C deficiency?
Bleeding and Bruising
Gingival swelling and teeth loss
Coiled hair
What is the main risk of Vitamin C deficiency?
Intracerebral or Endocardial Haemorrhage
(bleeding in heart or brain)
What are the signs of Vitamin B1 Deficiency?
Wernicke’s Encephalopathy (Confusion, Ataxia, Ocular Abnormalities)
Wet Beriberi (High Output Cardiac Failure)
Dry Beriberi (Peripheral Neuropathy)
What are the signs of Vitamin B3 Deficiency?
(if Diet= Corn/Maize)
Diarrhoea, Dementia, Dermatitis
What is the management of Vitamin B3 Deficiency?
Nicotinamide (B3)
What are the signs of Vitamin A Deficiency?
Night Blindness and Xerophthalmia (Corneal Ulcers)
As Vitamin A is needed by Rhodopsin
What are the causes of RIF Pain?
Gastrointestinal Causes
- Acute Appendicitis
- Mesenteric Adenitis
- Inflamed Meckel’s Diverticulum
- Diverticulitis (although more common on the left)
- Inflammatory Bowel’s Disease (Specifically Crohn’s)
Gynaecological Causes
- Ectopic Pregnancy
- Ovarian Torsion/ Cyst Torsion
- Ovarian Cyst Rupture
- Pelvic Inflammatory Disease
Urological Causes
- Pyelonephritis
- Ureteric Colic
What are the signs of Typhoid Fever?
CHARD’S VC
ROSE COLOURED SPOTS
Abdominal Pain and Constipation
Diarrhoea is less common
May be Splenomegaly
Headaches commonly Occur
Vomiting (not severe)
Weakness
If Severe- CONFUSION
What is the diagnosis of Typhoid?
What’s seen on the blood tests?
Through Culture or detecting the bacterial DNA in the blood, stool or bone marrow
Bloods show
- Raised Transaminases
!!!!!- Neutropenia
What is the treatment of Typhoid?
Antibiotics- Fluoroquionolones (Floxacins) or Cephalosporins (Ceftriaxone)
When does Ulcerative Colitis present usually?
15-25 years AND 55-65 years old
What are the signs of Ulcerative Colitis?
Abdominal Distension/ Tenderness on Palpation
Bloody/ Mucosal Diarrhoea
WEIGHT LOSS AND FEVER
1) Pallor due to Secondary Anaemia
2) LEFT ILIAC FOSSA (usually) Pain
3) Clubbing
4) Tenesmus or Urgency
EXTRA INTESTINAL FEATUREs
What are the Extra-Intestinal Features of Ulcerative Colitis?
Dermatological
- Erythema Nodosum, Pyoderma Gangrenosum
Ocular
- Anterior Uveitis
- Episcleritis
- Conjunctivitis
Musculoskeletal
- Clubbing
- ASYMMETRICAL Arthritis
- Sacroiliitis
Hepatobiliary
- Primary Sclerosing Cholangitis (more common in UC than Crohn’s)
AA Amyloidosis may also be present- secondary to chronic inflammation
What investigations should be ordered in Ulceraive Colitis?
Blood Tests
- FBC- ANAEMIA and HIGH WCC
- ESR/CRP- Raised
- LFTs- LOW ALBUMIN- as there is malabsorption
Microbiological Investigations- Exclude Infective Colitis (C. DIFFICILE)
FAECAL CALPROTECTIN IS RAISED
Also Endoscopy
What are the Imaging Findings of Ulcerative Colitis?
Colonoscopy- (3) Continuous Inflammation with an Erythema Mucosa, LOSS OF HAUSTRAL MARKINGS and PSEUDOPOLYPS
Biopsy reveals= Loss of Goblet Cells, Crypt Abscesses and Inflammatory Cells (Lymphocytes)
Barium Enema- (3) Lead-Piping Inflammation (lack of haustral markings), Thumb Printing (marker of Bowel Inflammation), Pseudopolyps (due to areas of Ulcerating Mucosa adjacent to areas of Regenerating Mucosa)
There will be NO Noncaseating GRANULOMAs (this is only in Crohn’s)
What Imaging should be ordered in Ulcerative Colitis?
In Acute Setting, do NOT order Colonoscopy or Bowel Enema due to risk of Perforation.
CT is more suitable
Abdominal Xray and Chest Xray can exclude Toxic Megacolon
What determines if Ulcerative Colitis is SEVERE?
6TAPE
1) 6 or More Bowel Movements per day
2) ESR> 30
3) Temperature>37.8C
4) Pulse> 90
5) Anaemia
What is the management of Mild-Moderate Ulcerative Colitis?
Proctitis and Proctosigmoiditis
1) Topical or Oral ASA (Aminosalicylate) (-SALAZINES)
2) Add Prednisolone after 4 Weeks
3) Ass Oral Tacrolimus after weeks
Left sided or Extensive Disease
1) High Dose Oral ASA
2) Add Prednisolone after 4 Weeks
3) Ass Oral Tacrolimus after weeks
What is the management of Severe Ulcerative Colitis?
1) IV Corticosteroids (otherwise IV Ciclosporin)
2) If no Improvement after 5 days, Add IV Ciclosporin (or INFLIXIMAB if not) and consider Surgery
What are the indications for Emergency Surgery in Ulcerative Colitis?
1) Acute Fulminant (Severe and Sudden Onset) Ulcerative Colitis
2) Toxic Megacolon with no improvement at 5 days of IV Steroids
3) IV Steroids do not help with symptoms
What should be given to maintain remission in Mild-Moderate Ulcerative Colitis?
Proctitis
1) Topical ASA and/or Oral ASA
Left Sided and Extensive Ulcerative Colitis
1) Oral ASA
2) Azathioprine or Mercaptopurine
3) Biologic (Infliximab, Adalimumab, Vedolizumab, Tofacitinib)
What are the surgical options for the management of Ulcerative Colitis?
1) Panprotocolectomy with Permanent End-Ileostomy
2) Colectomy with Temporary End Ileostomy (Can be reversed 3 Months Later with an Ileorectal Anastomosis)
3) Complete Proctectomy with a Permanent End Ileostomy or Ileal Pouch Anal Anastomosis
What are the complications of Ulcerative Colitis?
Toxic Megacolon
!!!!!Massive Lower GI Haemorrhage
Colorectal Cancer
!!!!!Cholangiocarcinoma
Colonic Strictures
PRIMARY SCLEROSING CHOLANGITIS
What are the causes of Variceal Bleeds?
Varices arise due to Portal Hypertension (usually because of Cirrhosis)
So Cirrhosis can kill patients through Variceal Bleeds and Patients with Cirrhosis should undergo endoscopy to look for Varices (every 2-3 Years)
What is the management of Variceal Bleeding?
1) DRABCDE
2) Resuscitate and ensure they are Haemodynamically Stable
3) They may need BLOOD TRANSFUSION is large bleed
4) Vitamin K, FFP and Platelet Transfusion to correct clotting abnormalities
5) TERLIPRESSIN (before Endoscopy) is a vasopressin analogue that causes Splanchnic Vasoconstriction which reduces Portal Pressure and Bleeding
6) Broad Spectrum Antibiotics (before Endoscopy) reduce risk of Bactraemia and Spontaneous Bacterial Peritonitis
7) Do endoscopy as soon as they are haemodynamically stable- VARICEAL BAND LIGATION is the Treatment of CHOICE
8) If Bleeding is uncontrolled- a Sengstaken-Blakemore tube can be inserted
How can Variceal Bleeds be Prevented?
1) Non Selective Beta Blockers like PROPANOLOL and ENDOSCOPIC Variceal Band Ligation
2) If this fails, patients may be referred for TIPSS
What are the signs of Schistosomiasis?
It is a cause of PORTAL HYPERTENSION
1) Ascites/ Caput Medusae
2) Genitourinary Symptoms (Frequency, Haematuria, Urinary Tract Obstruction)
3) Other GI Symptoms (GI Bleed, Diarrhoea, Abdominal Pain)
What are the Dietary Sources of Vitamin D?
Oily Fish
Red Meat and Liver
Egg yolks
What is Whipple’s Disease? What are the signs?
It is a rare systemic condition caused by Tropheryma Whipplei
Signs
1) Diarrhoea and Abdominal Pain
2) Joint Pain as well but can affect other systems as well (Cardiac and Nervous Systems)
3) Weight Loss may be present
4) HYPERPIGMENTATION and PHOTOSENSITIVTY
What investigations should be ordered in Whipple’s Disease and what is the management?
It is more common in MALES
Diagnosis
- Small Bowel Biopsy look for Acid-Schiff Positive Macrophages (PAS Macrophages)- which contains bacteria
Management-
- CO-TRIMOXAZOLE
What causes Wilson’s Disease?
A defective ATP7B protein product
Characterised by Impaired Copper Metabolism and Copper Build up in tissues
What are the signs of Wilson’s Disease?
What are the 3 groups of signs and the Ocular Manifestations?
May be Asymptomatic
May be HEPATIC, NEUROLOGICAL or PSYCHIATRIC
Liver
- Asymptomatic with TRANSAMINASE ALT/AST ELEVATION
- Acute Hepatitis
- Acute-on-chronic Liver Failure
- Cirrhosis
- There will be COOMB’s NEGATIVE HAEMOLYTIC ANAEMIA- with episodes of Low Grade Haemolysis and Jaundice
Neurological
- Akinetic-Rigidity like Parkinson’s
- Pseudosclerosis dominated by a Tremor
- Ataxia
- Dystonic Syndrome- which leads to Contractures
Other findings- Drooling, Spasticity, Chorea, Athetosis, Myoclonus, Dysarthria, Dyslalia
Psychiatric Abnormalities- Personality changes, Decreased Academic Performance, depression etc.
Ocular Manifestations- Kayser-Fleischer ring and Sunflower Cataracts
What investigations should be ordered in Wilson’s Disease?
1) Serum Caeruloplasmin and Copper are usually LOW due to the Copper Deposits in Tissue (but they MAY be normal)
2) Urinary Copper is HIGH and a 24 hour urine collection is the INVESTIGATION of CHOICE
!!!!!!3) Diagnosis is CONFIRMED by Genetic Analysis of ATP7B gene
What is the management of Wilson’s Disease?
The pencil trident
SXREENING in WILSON’S
1) D-Penicillamine and Trientine
2) Zinc Salts act as Inductors of Methallothioneins
3) SCREEN FIRST and SECOND DEGREE RELATIVES
What is Zollinger-Ellison Syndrome?
It is the development of Severe Ulcerations in the stomach and duodenum due to the uncontrolled release of Gastrin from a Gastrinoma
This usually occurs in the PANCREAS but can happen in the DUODENUM
