Gastrointestinal

Question 1

Causes of Cirrhosis

Answer 1

Alcohol
Viral:
Hep B or C
Autoimmune:
Primary biliary cirrhosis
Primary sclerosing cholangitis
Autoimmune hepatitis
Metabolic
MALFD
Haemochromatosis
Alpha-1-antitrypsin deficiency
WIlson’s Disease
Cystic fibrosis
Drugs:
Methotrexate
Amiodarone
Isoniazid
Phenytoin

Question 2

Childs Pugh Scoring?

Answer 2

Bilirubin
Albumin
INR
Ascites
Encephalopathy

> 10 is C. 33% 1 year mortality

Question 3

Management of Cirrhosis:

Answer 3

1) slow or reverse underlying cause
- abstain from ETOH
- Antiviral therapy
- immunosuppression

2)Prevent superimposed liver damage
- ETOH, immunisation for hep A and B, flu, pneumococcal

3) Prevent complications (HCC, Varices, ascites)
- 6 monthly US and AFP for HCC
- Surveillance endoscopy for varicies
- beta-blocker for bleeding prophylaxis
- prophylactic antibiotics for SPB after first episode

4) Liver Transplantation:
- Consider eligibility for transplantation

Question 4

Causes of ascites:

Answer 4

Cirrhosis (75%)
Malignancy (10%)
Heart Failure (3%)
TB
Pancreatitis

Question 5

Investigation of ascites:

Answer 5

Diagnostic paracentesis
- Albumin, MCS, cytology
- Serum Ascites Albumin Gradient (SAAG > 11 = transudate)

Abdomen US
- malignancy: liver or intra-abdominal mass
- splenomegaly (PH)
- hepatic and portal vein doppler (thrombosis)

Blood tests:
- LFTs
- INR, PT, Albumin
- FBC

Question 6

Management of Ascites:

Answer 6

Non-Pharm:
- Dietary Sodium restriction
- Fluid restriction

Pharm:
- MRA Spironolactone to achieve naturesis followed by loop diuretic to improve diuresis.

Question 7

Causes of Hepatomegaly:

Answer 7

Malignancy - Primary or Secondary
Cirrhosis - ALD, MALFD, PBC
Hepatic Congestion - RHF
Hepatitis - alcoholic
Infectious - Viral, toxoplasmosis, hydatid disease, liver abscess
Infiltrative - amyloidosis, sarcoidosis
Vascular liver disease - BC syndrome, sickle cell
Polycystic liver disease
Syphillis

Question 8

Cancers that metastasise to the liver

Answer 8

CRC most common
Other GI - oesophageal, gastric
Lung, Breast, renal, endometrial, bone

Question 9

Budd Chiari Syndrome

Answer 9

Hepatic outflow obstruction usually due to thrombosis

Usually an underlying cause is found that causes prothrombotic state:
- Malignancy
- thrombophilia

Can present acutely with jaundice, encephalopathy abdominal pain, hepatomegaly, ascites.

Diagnosis - doppler US

Management
- anticoagulation
- medial management of ascites
- If liver failure consider thrombolysis, angioplasty, transplantation.

Question 10

Causes of splenomegaly:

Answer 10

Portal Hypertension

Haematological Malignancy (CML, myelofibrosis, lymphoma, leukaemia)

Infection - HIV, endocarditis, malaria, visceral leishmaniasis

Haemolytic anaemia
Thalassaemia

Autoimmune - RA (Felty syndrome), SLE

Infiltrative (amyloidosis, sarcoidosis)

Which ones are likely to cause isolated splenomegaly:
- Primary splenic lesions like abscess or thrombosis
- Auto-immune like RA or SLE