Gastrointestinal (1) Flashcards
What is achalasia?
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus
What is the epidemiology of achalasia?
Typically presents in middle-age and is equally common in men and women
What is the aetiology of achalasia?
1.Degenerative loss of ganglia from Auerbach’s (myenteric) plexus in the oesophagus
2. This leads to failure of the LOS to relax
What are the clinical features of achalasia?
- Dysphagia of BOTH liquids and solids
- Typically variation in severity of symptoms
- Heartburn
- Regurgitation of food
- May lead to cough, aspiration pneumonia
- Malignant change in small number of patients
What are the investigations for achalasia?
- Oesophageal manometry
- Barium swallow
- Chest x-ray
What is the most important diagnostic test for achalasia?
Oesophageal manometry
Shows excessive LOS tone which doesn’t relax on swallowing
What are the findings of achalasia on barium swallow and chest x-ray?
Barium swallow:
1. shows grossly expanded oesophagus, fluid level
2. ‘bird’s beak’ appearance
Chest x-ray
1. wide mediastinum
2. fluid level
What are the management options for achalasia?
- Pneumatic (balloon) dilation
- Surgical intervention with a Heller cardiomyotomy - considered if recurrent or persistent symptoms
- Itra-sphincteric injection of botulinum toxin - for high surgical risk patients
- Dug therapy (e.g. nitrates, calcium channel blockers) has a role but is limited by side-effects
What is the preferred management for achalasia?
Pneumatic (balloon) dilation
Less invasive and quicker recovery time than surgery
Patients should be a low surgical risk as surgery may be required if complications occur
What are some of the complications of achalasia?
Aspiration pneumonia
Malnutrition
Weight loss
What is acute cholangitis?
A bacterial infection of the biliary tree
The most common predisposing factor is gallstones
What is the most common bacterial infection in acute cholangitis?
E.coli, most commonly predisposed by gallstones
What is the main difference between acute cholangitis and acute cholecystitis?
Cholangitis = inflammation (and infection) of the biliary tree
Cholecystitis = the gallbladder
What is the triad in acute cholangitis and what is it known as?
Charcot’s triad:
1. Right upper quadrant pain
2. Fever/ riggers
3. Jaundice
Occurs in 20-50% of patients
What are the features of acute cholangitis?
Charcot’s triad: fever, jaundice and RUQ pain
Hypotension
Confusion
Together these five are known as Reynolds’ pentad
What are the appropriate investigations for acute cholangitis?
Ultrasound is first choice:
1. Bile duct dilatation
2. Bile duct stones (from gallstones)
Also see raised inflammatory markers
What is the management for acute cholangitis?
- IV antibiotics
- Endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
What are the complications of acute cholangitis?
Acute pancreatitis (from ERCP?)
Inadequate biliary drainage from intervention
Hepatic abscess
What is the difference between laparotomy and laparoscopy?
Laparoscopy: ‘keyhole’/ minimally invasive
Laparotomy: open
What is alcohol withdrawal?
A patient who is alcohol dependent and has stopped or reduced their alcohol intake within hours or days of presentation
What is the mechanism of alcohol withdrawal?
- Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
- Alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
What is alcohol dependence?
Characterized by three or more of:
. Withdrawal on cessation of alcohol
. Tolerance
. Compulsion to drink, difficulty controlling termination or the levels of use
. Persistent desire to cut down or control use
. Time is spent obtaining, using, or recovering from alcohol
. Neglect of other interests (social, occupational, or recreational)
. Continued use despite physical and psychological problems
What are the features of alcohol withdrawal?
Symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
Peak incidence of seizures at 36 hours
Peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
What are the presenting symptoms of alcohol withdrawal?
HAD A PINT
Headache
Anxiety/ agitation
Depression
Anorexia
Palpitations
Insomnia
Nausea
Tremor
What are the signs of chronic alcohol misuse?
Dupuytrens contracture
Palmar erythema
Bruising
Spider naevi
Telangiectasia- widened venules cause threadlike red lines or patterns on the skin
Bilateral parotid enlargement
Gynaecomastia
Smell of alcohol
What are the appropriate investigations for alcohol withdrawal?
A to E approach
VBG: respiratory alkalosis with delirium tremens
Bloods: Increased MCV, thrombocytopenia, hypomagnesaemia, hypokalaemia, hypophosphataemia, elevated AST, ALT, and GGT
Coagulation studies: prolonged INR and prothrombin time
Drug screen: barbiturates, paracetamol
What is the management plan for a patient with alcohol withdrawal?
First-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam (lorazepam may be preferable in patients with hepatic failure) with a reducing dose protocol
B1 thiamine, pabrinex
Carbamazepine also effective in treatment of alcohol withdrawal
Patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
What are the possible complications of alcohol withdrawal?
Seizures (generalised tonic-clonic) - cause of fatality
Delirium tremens
What are the complications of chronic alcohol use?
Cerebral atrophy and dementia
Cerebellar degeneration
Optic atrophy
Peripheral neuropathy
Myopathy
Indirect effects include hepatic encephalopathy, thiamine deficiency, causing Wernickes encephalopathy or Korsakoffs psychosis
What is the prognosis for patients with alcohol withdrawal?
Depends on complications.
Alcoholic fatty liver is reversible on abstinence from alcohol
In general, 5-year survival rates in those with alcoholic cirrhosis who stop drinking are 60–75%, but < 40% in those who continue
What is Wernicke’s encephalopathy?
A neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics
What is the triad seen in Wernicke’s encephalopathy?
- Oculomotor dysfunction: nystagmus (the most common ocular sign) or ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy
- Gait ataxia
- Encephalopathy: confusion, disorientation, indifference, and inattentiveness
(May also see peripheral sensory neuropathy)
What are the appropriate investigations for Wernicke’s encephalopathy?
- Bloods: decreased red cell transketolase
- MRI
What is the treatment for Wernicke’s encephalopathy?
Urgent replacement of thiamine
What are the complications of not treating Wernicke’s encephalopathy with thiamine?
Development of Korsakoff’s syndrome:
Triad of ataxia, oculomotor dysfunction and encephalopathy plus antero- and retrograde amnesia and confabulation (creation of false memories)
What is the aetiology of Wernicke- Korsakoff syndrome?
- Untreated thiamine deficiency
- This causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus
- Therefore inability to acquire new memories (anterograde) and retrograde amnesia plus confabulation
What is alcoholic liver disease?
A spectrum of conditions:
1. Alcoholic fatty liver disease
2. Alcoholic hepatitis
3. Cirrhosis
What is Alcoholic hepatitis?
Inflammatory liver injury and necrosis caused by chronic heavy intake of alcohol
What is the aetiology of alcoholic hepatitis?
The middle stage between fatty liver disease and liver cirrhosis
Inflammatory liver injury with:
1. Centrilobal ballooning degeneration
2. Necrosis of hepatocytes
3. Steatosis: abnormal retention of lipids
4. Neutrophilic inflammation
5. Cholestasis: impaired secretion of bile
What is the epidemiology of alcoholic hepatitis?
10-35% of heavy drinkers develop this stage of liver disease
What are some of the features of alcoholic hepatitis?
Signs of alcohol liver disease: palmar erythema, telangiectasia, parotid enlargement, spider navei, gynaecomastia, bruising
More severe signs: hepatomegaly, encephalopathy, ascites
What are the most important investigations in alcoholic hepatitis?
LFTs:
1. gamma-GT (GGT) is characteristically elevated
2. Ratio of AST:ALT of > 3 is strongly suggestive of acute alcoholic hepatitis (>2 is normal)
What are some other investigations for alcoholic hepatitis?
FBC: macrocytic anaemia
Impaired renal and liver function tests including raised bilirubin and abnormal clotting: Prolonged PT
Ultrasounds to exclude other causes of liver impairment e.g. malignancy
What is the general management for alcoholic hepatitis?
- A to E approach
- Thiamine and other vitamins
- Treat encephalopathy with oral lactulose and phosphate enemas
- Treat ascites with diuretics (spironolactone ± furosemide)
What is the specific management of alcoholic hepatitis?
- Glucocorticoids e.g. prednisolone used during acute episodes
- Pentoxyphylline is sometimes used
What are the complications of alcoholic hepatitis?
- Acute liver decompensation
- Hepatorenal syndrome: renal failure secondary to advanced liver disease
- Cirrhosis
What are the two types of hepatorenal syndrome?
- Rapidly progressive, doubling of serum creatinine to > 221, ver poor prognosis
- Slow progression, patients may live for longer
What is the management for hepatorenal syndrome?
Ideal treatment = liver transplantation
1. Vasopressin analogues by causing vasoconstriction of the splanchnic circulation
2. 20% albumin
3. Transjugular intrahepatic portosystemic shunt
What are the two prognostic scores used in alcoholic hepatitis?
- Maddrey’s discriminant function (DF):
- used during acute episodes
- determines who would benefit from steroid therapy
- calculated using prothrombin time and bilirubin concentration - Glasgow alcoholic hepatitis score:
- looks at age, white cell count, urea, PT ratio and bilirubin
- >9 indicates >50% 30-day mortality
What is the prognosis for patients with alcoholic hepatitis?
Mortality in the first month = 10%
Mortality in the first year = 40%
If alcohol intake continues → most progress to cirrhosis within 1-3 years
What is amyloidosis?
A (heterogenous) group of diseases characterised by extracellular deposition of insoluble amyloid fibrils
What are the two types of amyloidosis?
- AL amyloid = primary, immunoglobulin light chain amyloidosis, associated with Myeloma
- AA amyloid = secondary, non-familial and familial
2a. Non- familial AA = Inflammatory polyarthropathies account for 60% of cases, then chronic infections, IBD
2b. Familial AA = familial periodic Mediterranean fever syndrome
What are the risk factors for amyloidosis?
PMH of inflammatory conditions (AA)
Chronic infections (AA)
Positive FH
What are the features of primary amyloidosis (AL)?
Dependent on organ involvement:
1. Kidneys: glomerular lesions—proteinuria and nephrotic syndrome
2. Heart: restrictive cardiomyopathy (looks ‘sparkling’ on echo), arrhythmias, angina
3. Nerves: peripheral and autonomic neuropathy; carpal tunnel syndrome
4. GI: macroglossia (big tongue), malabsorption/weight, perforation, haemorrhage, obstruction, and hepatomegaly
5. Vascular: purpura, especially periorbital—a characteristic feature
What are the features of secondary non-familial amyloidosis (AA)?
PMH of chronic inflammation (e.g. RA/ IBD) or chronic infection (e.g. TB)
Affects the kidneys, liver, and spleen, and may present with proteinuria, nephrotic syndrome, or hepatosplenomegaly
Macroglossia is not seen; cardiac involvement is rare
What are the appropriate investigations for amyloidosis?
Diagnosis made with biopsy of affected tissue: positive Congo Red staining with apple-green birefringence under polarized light microscopy
The rectum or subcutaneous fat are relatively non-invasive sites for biopsy and are positive in 80%
Can also use serum amyloid precursor (SAP) scan
What is the management of amyloidosis?
AL: optimize nutrition; PO melphalan + prednisolone extends survival
High-dose IV melphalan with autologous stem cell transplantation may be better
AA: manage the underlying condition optimally
What is the prognosis of patients with amyloidosis?
Median survival is 1–2 years
Patients with myeloma and amyloidosis have a shorter survival than those with myeloma alone
What is an anal fissure?
Longitudinal or elliptical tears of the squamous lining of the distal anal canal
What are the characteristic features of anal fissures?
- Pain on defecation
- Rectal bleeding
How can anal fissures be categorised?
Acute: present for less than 6 weeks
Chronic: present for more than 6 weeks
What are the risk factors for anal fissures?
- Constipation
- Inflammatory bowel disease
- STIs, e.g. HIV, syphilis, herpes
What are the features of anal fissures?
- Painful, bright red rectal bleeding
- Around 90% of anal fissures occur on the posterior midline (if alternative location consider Crohn’s disease)
How are anal fissures investigated?
Usually clinical diagnosis
If resistant fissures: anal manometry = low resting pressure
If suspected anal sphincter deficits = anal ultrasound
How is the management for anal fissures divided?
Split into acute anal fissure and chronic
What is the management of an acute anal fissure (<1 week)?
- Soften stool: high fibre diet with bulk-forming laxatives (lactulose is 2nd line)
- Lubricants e.g. petroleum jelly
- Topical anaesthetics
- Analgesia
What is the management of a chronic anal fissure?
- High fibre diet + bulk forming laxatives
- Lubricants
- Topical anaesthetics
- Analgesia
PLUS: - First line = Topical glyceryl trinitrate (GTN)
If not effective after 8 weeks = secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
What are the complications of anal fissures?
Most acute anal fissures heal spontaneously
A proportion if untreated can become chronic
Recurrence is more likely is a patient stops treatment too early
Risk of incontinence after surgical management?
What is the prognosis of anal fissures?
Around 60% of patients will heal after 6-8 weeks
What is an Appendicectomy?
The removal of the appendix either laparoscopically (mainly) or open surgery with general anaesthesia
What are the indications for an Appendicectomy?
- Appendicitis: indicated in all cases of suspected nonperforated appendicitis
- Carcinoid tumors are the most common malignancy of the appendix; most of these are small (<1 cm)
What are the possible complications of an Appendicectomy?
- Wound infection- prophylactic antibiotics may be given
- Haematoma
- Scarring
- Abscess
- Hernia – at the site of incision
- Bowel obstruction
What advancement in surgery has shown to decrease the risk of complications in an appendicectomy?
Laparoscopic appendicectomy
What is appendicitis?
An acute inflammation of the vermiform appendix, most likely due to obstruction of the lumen of the appendix
What is the pathophysiology of appendicitis?
- Lymphoid hyperplasia or a faecolith
- Obstruction of appendiceal lumen
- Gut organisms invading the appendix wall
- Resulting in oedema, ischaemia +/- perforation
What is the epidemiology of appendicitis?
Can occur at any age but is most common in young people aged 10-20 years
What are the main features of appendicitis?
- Abdominal pain:
- Peri-umbilical pain radiating to the RIF due to localised parietal peritoneal inflammation
- Often worse on coughing or going over speed bumps - Vomiting (only once or twice)
- Mild pyrexia (higher temperatures are more typical of mesenteric adenitis)
- Anorexia
What are the signs of appendicitis on examination?
- If perforated or localised peritonism:
1a. Generalised peritonitis
1b. Rebound and percussion tenderness
1c. Guarding and rigidity - If retrocaecal appendicitis: psoas sign = pain on extending hip
- Rovsing’s sign = palpation in the LIF causes pain in the RIF
- DRE: may reveal boggy sensation if pelvic abscess is present, or even right-sided tenderness with a pelvic appendix
What are the investigations for appendicitis?
- Bloods:
- Raised inflammatory markers coupled with compatible history and examination findings
- Neutrophil- predominant leucocytosis - Urine analysis: exclude pregnancy, renal colic and UTI
- Imaging:
- Ultrasound is useful in females to exclude pelvic pathology
- Not always needed depending on patient’s age, body habitus and the likelihood of appendicitis
What is the management for appendicitis?
- Appendicectomy: laparoscopic is now treatment of choice
- Prophylactic IV antibiotics
- If peroration = require copious abdominal lavage
- Be wary in older patients who may have either an underlying caecal malignancy or perforated sigmoid diverticular disease
How does the management for appendicitis differ without peritonitis?
Patients may receive broad-spectrum antibiotics and consideration for an interval appendicectomy around 6 weeks later
What are the complications of appendicitis?
- Perforation → generalised peritonitis
- Appendicular mass (usually due to delay in medical treatment)
- Appendicular abscess: usually occurs as a progression of the disease process, particularly after perforation
- Surgical wound infection
What is autoimmune hepatitis?
A chronic inflammatory disease of the liver of unknown aetiology, which is most commonly seen in young females
What are some associations of autoimmune hepatitis?
- Other autoimmune disorders
- Hypergammaglobulinaemia
- HLA B8, DR3
What is the aetiology of autoimmune hepatitis?
- Unknown
- Genetically predisposed person exposed to an environmental agent e.g. virus/ drug → hepatocyte expression of HLA agents
- T-cell mediated autoimmune attack
- Chronic inflammatory changes are similar to those seen in chronic viral hepatitis:
- lymphoid infiltration of the portal tracts and hepatocyte necrosis, leading to fibrosis and, eventually, cirrhosis
What are the three types of autoimmune hepatitis?
Type 1: Anti-nucelar and/or anti-smooth muscle antibodies (ANA and/or SMA), affects both adults and children
Type 2: Anti-liver/kidney microsomal type 1 antibodies (LKM1), affects children only
Type 3: Soluble liver-kidney antigen, affects adults in middle-age
What are the features of autoimmune hepatitis?
- may present with signs of chronic liver disease
- Acute hepatitis: fever, jaundice etc (only 25% present in this way)
- Amenorrhoea (common)
- On investigation = ANA/SMA/LKM1 antibodies, raised IgG levels
- On liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
What are some of the common symptoms of autoimmune hepatitis?
Fatigue/ malaise
Anorexia
Pruritus
Arthralgia
Nausea
Fever
Amenorrhoea
What signs might you seen on examination in autoimmune hepatitis?
Hepatomegaly
Signs of chronic liver disease
Jaundice and fever
Spider angioma: dilation of vessels below the skin
What is the management of autoimmune hepatitis?
- Steroids
- Immunosuppressants such as azathioprine
- Liver transplantation
What are the causes of raised GGT levels?
- Alcohol abuse
- Intra or extra hepatic cholestasis and biliary obstruction
- Hepatocellular disease e.g. malignancy
What are the causes of raised Alk Phosphate?
Intra or extra hepatic cholestasis
Bone diseases e.g. fracture, paget’s
Placenta e.g. last trimester of pregnancy
What are the causes of low albumin?
- Most forms of chronic liver disease, especially cirrhosis
- Nephrotic syndrome
- Malnutrition/ malabsorption
- Chronic infection
- Loss from bloodstream: haemorrhage, burns
What is bariatric surgery?
A management option for obesity in patients who fail to lose wight with lifestyle and drug interventions
What are the NICE recommendations for bariatric surgery?
Very obese patients (e.g. BMI 40-50 kg/m^2 etc) should be referred early for bariatric surgery
This is particularly if they have other conditions that may be caused by it (e.g. type 2 DM, HTN), rather than it being a ‘last resort’
What are the different types of bariatric surgery?
Divided into:
1. Primarily restrictive operations
2. Primarily malabsorptive operations
3. Mixed operations
What are the primarily restrictive operations in bariatric surgery?
- Laparoscopic-adjustable gastric banding (LAGB)
- normally the first-line intervention in patients with a BMI of 30-39kg/m^2
- produces less weight loss than malabsorptive or mixed procedures but has fewer complications - Sleeve gastrectomy= stomach is reduced to about 15% of its original size
- Intragastric balloon = balloon can be left in the stomach for a maximum of 6 months
What are the primarily malabsorptive operations in bariatric surgery?
Biliopancreatic diversion with duodenal switch
Usually reserved for very obese patients (e.g. BMI > 60 kg/m^2)
What are the mixed operations in bariatric surgery?
Roux-en-Y gastric bypass surgery = both restrictive and malabsorptive in action
What are the complications of bariatric surgery?
Acid reflux
Chronic nausea and vomiting
Dilation of oesophagus
Infection
Obstruction of stomach
Weight gain/ failure to lose weight
What is barrels oesophagus?
Metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium
What is the aetiology of Barrett’s oesophagus?
The single strongest risk factor is gastro-oesophageal reflux disease (GORD)
What are the risk factors for barret’s oesophagus?
1st = GORD
Male gender (7:1)
Smoking
Central obesity
What is the role of alcohol in Barret’s oesophagus?
Alcohol is not an independent risk factor for barrels oesophagus but is associated with GORD and oesophageal cancer
What are the features of Barret’s oesophagus?
Symptoms of GORD: heartburn, nocturnal cough
Nausea
Chest pain
Dysphagia: difficulty swallowing
What is the investigation of choice for Barret’s oesophagus?
OGD and biopsy
Abnormal epithelium proximal to the gastro-oesophageal junction
Send for histology
What are the histological features of Barret’s oesophagus?
Columnar epithelium may resemble that of either the cardiac region of the stomach or that of the small intestine (e.g. with goblet cells, brush border)
What is the management for Barret’s oesophagus?
- High dose proton pump inhibitor
- Endoscopic surveillance with biopsies for patient with metaplasia every 3-5 years
- If dysplasia of any grade = identified endoscopic intervention
- 1st line: Radiofrequency ablation for low-grade
- Endoscopic mucosal resection
What is the difference between metaplasia and dysplasia?
Metaplasia: transforms a cell from one form to another- can be reversible
Dysplasia: transforms a cell into an abnormal version of itself- is not reversible
What is barret’s oesophagus?
Replacement of squamous epithelium by metaplastic columnar epithelium, usually from chronic GORD
What are the complications of Barret’s oesophagus?
- Oesophageal stricture (abnormal narrowing)
- Dysplasia and adenocarcinoma
(and effect of quality of life)
What is the role of proton pump inhibitors in Barret’s oesophagus?
Commonly used to treat symptoms of GORD but does not lead to regression of barret’s oesophagus
What is the prognosis of Barret’s oesophagus?
Patients are at a greater risk of developing adenocarcinoma
Anti-reflux (and surgery) lower the risk of progression to cancer
What are cholangiocardinomas?
Cancer of the bile ducts
How can cholangiocarcinomas be divided?
On their location in the biliary tree:
1. Intrahepatic
2. Extrahepatic (perihilar or distal)
What is the main risk factor for cholangiocarcinoma?
Primary sclerosing cholangitis
What are some of the other risk factors for cholangiocarcinomas?
Main is primary sclerosis cholangitis
Worm infections
Liver cirrhosis
What is Primary sclerosing cholangitis?
Biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts
Closely associated with Ulcerative Colitis
What are the risk factors for Cholangiocarcinoma other than PSC?
Age > 50 years
Cholangitis
Choledocholithiasis (gall stones)
Structural disorders of the biliary tract e.g. bile duct adenoma
Ulcerative colitis
Non-specific cirrhosis
Alcoholic liver disease
HIV
Hepatitis B and C
What are the features of cholangiocarcinoma?
- Persistent biliary colic symptoms
- Associated with anorexia, jaundice and weight loss
- A palpable mass in the right upper quadrant (Courvoisier sign)
- Periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen
- Obstructive jaundice = dark urine and pale stools
What is the triad seen in Acute Cholangitis?
Charcot’s triad:
Fever, jaundice and right upper quadrant pain
What are the appropriate investigations for cholangiocarcinomas?
- Raised CA 19-9 levels (often used for detecting cholangiocarcinoma in patients with PSC)
- Bloods e.g. bilirubin, LFTs
- Abdominal USS: intrahepatic cholangiocarcinoma may be seen as a mass lesion
- ERCP: filling defect or area of narrowing will be seen if a tumour is present