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Gastrointestinal Flashcards

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USMLE® Step 1 flashcards
1
Q

What is the description of dysphagia?

A

Difficulty in swallowing

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2
Q

What are some of the causes of dysphagia?

A

Mechanical block:

  • Malignant stricture (i.e. cancer of the pharynx, oesophagus and stomach)
  • Benign strictures
  • Pharyngeal pouch
  • External pressures (e.g. lung cancer, mediastinal lymph nodes)

Motility disorders:

  • Achalasia
  • Diffuse oesophageal spasm

Other:

  • Globus
  • Oesophagitis
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3
Q

What is the description of diffuse oesophageal spasm?

A

A condition characterised by uncoordinated contractions of the oesophagus

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4
Q

What are some signs and symptoms of diffuse oesophageal spasm?

A

Intermittent dysphagia

Atypical chest pain (similar to that of angina)

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5
Q

How do you diagnose diffuse oesophageal spasm?

A

Barium swallow - “Corkscrew” appearance

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6
Q

What is the treatment of diffuse oesophageal spasm?

A

Proton pump inhibitors
Calcium channel blockers
Anti-anxiety medication

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7
Q

What is the description of achalasia?

A

Coordinated peristalsis is lost and the lower oesophageal sphincter fails to relax.

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8
Q

What are some signs and symptoms of achalasia?

A

Dysphasia
Regurgitation of food
Weight loss

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9
Q

How do you diagnose achalasia?

A

Barium contrast swallow show dilated tapering oesophagus

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10
Q

What is the treatment of achalasia?

A

Endoscopic balloon dilatation

Then PPIs

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11
Q

What is the description of a benign oesophageal stricture?

A

A narrowing of the oesophagus

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12
Q

What is the causes of a benign oesophageal stricture?

A

GORD
Corrosives
Radiotherapy

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13
Q

What are some symptoms of a benign oesophageal structure?

A 
Difficult or painful swallowing
Weight loss
Regurgitation of food or liquids
Sensation of something stuck in the chest after you eat
Frequent burping or hiccups
Heartburn
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14
Q

How do you diagnose a benign oesophageal stricture?

A

Barium swallow

Endoscopy

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15
Q

What is the treatment of a benign oesophageal stricture?

A

Endoscopic balloon dilatation

Oesophageal stent

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16
Q

What is the description of a duodenal ulcer?

A

Ulcer in the duodenum.

4 times more common than a stomach ulcer.

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17
Q

What are some symptoms of a duodenal ulcer?

A

Epigastric pain (relieved with eating or antacids)
Reduced weight
Epigastric tenderness

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18
Q

How do you diagnose a duodenal ulcer?

A

Upper GI endoscopy

Test for H. pylori

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19
Q

What is the treatment for a duodenal ulcer?

A

Antibiotic treatment for H. Pylori
OR
Proton pump inhibitors

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20
Q

What is the description of a gastric ulcer?

A

An ulcer in the stomach.

Most likely in the elderly, on the lesser curve.

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21
Q

What are some risk factors for peptic ulcer disease?

A

H. pylori
NSAIDs
Smoking
Stress

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22
Q

What are some symptoms of a gastric ulcer?

A

Burning stomach pain
Heartburn
Nausea

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23
Q

How do you diagnose a gastric ulcer?

A

Upper GI endoscopy to rule out malignancy

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24
Q

What is the treatment of a gastric ulcer?

A

Eradicate H. pylori

PPIs

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25
Q

What is the description of gastritis?

A

An inflammation of the lining of the stomach.

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26
Q

What are some symptoms of gastritis?

A

Epigastric pain
Nausea
Vomiting

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27
Q

How do you diagnose gastritis?

A

Upper GI endoscopy, only if suspicious features arise

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28
Q

What is the treatment of gastritis?

A

PPIs

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29
Q

What is the description of gastro-oesophageal reflux disease (GORD)?

A

Reflux of the acid of the stomach up to the oesophagus.

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30
Q

What are some causes of GORD?

A

Oesophageal sphincter hypotension
Hiatus hernia
Obesity
Oesophageal dysmotility

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31
Q

What are some symptoms of GORD?

A

Oesophageal:

  • Heartburn
  • Belching
  • Dysphagia
  • Waterbrash (mouth fills with saliva)

Extra-oesophageal:

  • Nocturnal asthma
  • Chronic cough
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32
Q

What are some potential complications of GORD?

A

Oesophagitis
Barrett’s oesophagus
Oesophageal cancer

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33
Q

How do you diagnose GORD?

A

Endoscopy if dysphasia is a symptom

24h pH monitoring of the oesophagus if endoscopy is normal

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34
Q

What is the treatment of GORD?

A

Lifestyle - Weight loss, smoking cessation, small regular meals, reduce alcohol consumption
Drugs - Antacids or alginates. Can add a PPI
Surgery - Only consider in severe GORD when drugs are not working

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35
Q

What is the description of a Mallory-Weiss tear?

A

A tear in the oesophagus near the gastro-oesophageal junction.

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36
Q

What are some symptoms of a Mallory-Weiss tear?

A 
Haematemesis/ coffee-ground vomit
Malaena
Shortness of breath
Diarrhoea
Abdominal or chest pain that can radiate to the back
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37
Q

What are some of the causes of a Mallory-Weiss tear?

A

Violent coughing or vomiting
Hiatal hernia
Childbirth

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38
Q

How do you diagnose a Mallory-Weiss tear?

A

Presentation of symptoms
Check stool for blood/melaena
Endoscopy

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39
Q

What is the treatment of a Mallory-Weiss tear?

A

Most Mallory-Weiss tears will resolve on their own

Rarely, a clip will be places endoscopically to close the tear

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40
Q

What is the description of oesophageal varices?

A

Abnormal, enlarged veins in the oesophagus that can often tear and bleed.

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41
Q

What is the cause of oesophageal varices?

A

Blood flow to the liver is compromised by cirrhosis or a blockage, so angiogenesis takes place.

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42
Q

What are some symptoms of oesophageal varices?

A

Vomiting large amounts of blood
Melaena
Pre-syncope
Syncope in severe cases

Also signs of liver disease:
Jaundice
Ascites

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43
Q

How do you diagnose oesophageal varices?

A

Endoscopy

Doppler ultrasound to detect presence of liver disease

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44
Q

What is the treatment of oesophageal varices?

A 
Beta-blockers to reduce portal hypertension
Variceal banding (using elastic bands to "tie off" the oesophageal varices)
Balloon tamponade (inflating a ballon to put pressure on the bleeding temporarily - usually 24h)
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45
Q

What is the description of oesophagitis?

A

Inflammation of the epithelial lining of the oesophagus

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46
Q

What are some causes of oesophagitis?

A

GORD

Ingestion of chemicals

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47
Q

What are some symptoms of oesophagitis?

A 
Heartburn
Bloating
Belching
Dysphasia
Persistent cough at night
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48
Q

How do you diagnose oesophagitis?

A

Presentation of symptoms
Endoscopy
Barium swallow

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49
Q

What are some potential complications of oesophagitis?

A

Barrett’s oesophagus

Cancer

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50
Q

What is the treatment for oesophagitis?

A

Drugs - Antacids or alginates. Can add a PPI

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51
Q

What is the description of Barrett’s oesophagus?

A

The change of stratified squamous epithelium in the oesophagus to simple columnar epithelium with the presence of goblet cells .

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52
Q

What is the cause of Barrett’s oesophagus?

A

Chronic GORD or oesophagitis

Risk factors include:

  • Being male
  • Being overweight/obese
  • Smoking
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53
Q

What is Barrett’s oesophagus associated with a higher risk for?

A

Oesophageal cancer

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54
Q

What are some symptoms of Barrett’s oesophagus?

A

Dysphagia
Chest pain
Heartburn

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55
Q

How do you diagnose Barrett’s oesophagus?

A

Presentation of symptoms
Endoscopy
Biopsy will be diagnostic

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56
Q

What is the treatment for Barrett’s oesophagus?

A

Lifestyle - Weight loss, smoking cessation, small regular meals, reduce alcohol consumption
Drugs - Antacids or alginates. Can add a PPI
Monitoring - Regular endoscopies to monitor disease

If dysplasia is found:

  • Cryotherapy
  • Surgery
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57
Q

What is the description of diverticulitis?

A

Inflammation of the diverticula (out-pouches in the colon).

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58
Q

What is the cause of diverticulitis?

A

Diverticula usually develop when naturally weak places in the colon give way under pressure.
Diverticulitis occurs when diverticula tear, resulting in inflammation or infection or both.

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59
Q

What are some symptoms of diverticulitis?

A 
Pain, which may be constant and persist for several days in the LLQ
Nausea and vomiting
Fever
Abdominal tenderness
Constipation or diarrhoea
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60
Q

How do you diagnose diverticulitis?

A

FBC and U&E => to check for signs of infection.
Stool culture => rule out infection in patients with diarrhoea
LFTs => to rule our liver-related causes
CT scan => diagnostic

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61
Q

What is the treatment for diverticulitis?

A

IV antibiotics
Pain relief

Potential surgery - bowel resection may be necessary

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62
Q

What is the description for Meckel’s diverticulum?

A

A congenital diverticulum, left over from the umbilical cord.

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63
Q

What are some symptoms of Meckel’s diverticulum?

A 
Gastrointestinal bleeding 
Abdominal pain and cramping
Tenderness near the belly button
Obstruction of the bowels
Diverticulitis
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64
Q

What causes Meckel’s diverticulum?

A

The vitilline duct is not fully absorbed in the 7th week of foetal development.

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65
Q

How is Meckel’s diverticulum diagnosed?

A

Presentation of symptoms
Colonoscopy
Wireless capsule endoscopy

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66
Q

What is the treatment for Meckel’s diverticulum?

A

Surgery - resection of part of bowel and anastomoses

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67
Q

What is the description of Peutz-Jeghers syndrome?

A

A disorder characterised by the development of hamartomatous polyps.

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68
Q

What are some symptoms of Peutz-Jeghers syndrome?

A 
Dark coloured spots around the mouth
Bowel obstruction 
Abdominal pain
Nausea
GI bleeding
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69
Q

What is the cause of Peutz-Jeghers syndrome?

A

Mutation in the STK11 gene.

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70
Q

How do you diagnose Peutz-Jeghers syndrome?

A

Presentation of symptoms
Check family history for history of polyps
Genetic testing

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71
Q

What is the management of Peutz-Jeghers syndrome?

A

Colonoscopy for removal of polyps

Continue monitoring for possibility of cancer development

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72
Q

What is the description of Lynch syndrome?

A

An inherited condition which causes multiple polyps and increases risk of multiple cancers e.g. bowel, uterus, breast

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73
Q

What is the cause of Lynch syndrome?

A

MMR mutation

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74
Q

How do you diagnose Lynch syndrome?

A

Genetic screening

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75
Q

What is the management of Lynch syndrome?

A

Currently there are no treatments

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76
Q

What is the description of gastroenteritis?

A

A disease characterised by diarrhoea and vomiting due to enteric infection (with viruses, bacteria or parasites).

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77
Q

What are some symptoms of gastroenteritis?

A 
Acute diarrhoea (3 or more episodes of water stool for less than 14 days)
Blood in the stool
Nausea and vomiting
Abdominal pain
Fever
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78
Q

What are the different types of diarrhoea?

A

Acute diarrhoea - 3 or more episodes of water stool for less than 14 days
Dysentery - bloody diarrhoea
Persistent - diarrhoea lasting > 14 days
Traveller’s diarrhoea - starting during or shortly after foreign travel
Food poisoning - caused by consumption of food

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79
Q

What is the full description of Norovirus infection?

include symptoms, diagnosis and treatment in your answer

A

Causes gastroenteritis.
Single-stranded RNA virus, which is highly infectious.
Symptoms - diarrhoea, cramps, vomiting
Diagnosis - stool sample reverse transcriptase PCR
Treatment - usually self-limiting, anti-motility drugs

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80
Q

What is the full description of Rotavirus infection?

include symptoms, diagnosis and treatment in your answer

A

Causes gastroenteritis.
Double-stranded RNA virus, commonest cause of gastroenteritis in children.
Symptoms - watery diarrhoea, vomiting, fever
Diagnosis - antigen in stool
Treatment - supportive + routine vaccination

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81
Q

What is the full description of Campylobacter infection?

include symptoms, diagnosis and treatment in your answer

A

Commonest cause of food poisoning.
Grave -ve spiral shaped rod.
Symptoms - Bloody diarrhoea, abdominal pain, fever, headache
Diagnosis - Stool culture
Treatment - Supportive. Antibiotics only in invasive cases

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82
Q

What is the description of irritable bowel syndrome?

A

A mixed group of abdominal symptoms for which no cause can be found.
Often triggered by factors such as stress or mental health issues.

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83
Q

What are some symptoms of irritable bowel syndrome?

A
  • Abdominal pain, cramping or bloating that is typically relieved by passing a bowel movement
  • Excess gas
  • Diarrhoea or constipation
  • Mucus in the stool
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84
Q

How do you diagnose irritable bowel syndrome?

A

Patient must have abdominal pain associated with 2 others:

  • relief by defecation
  • altered stool form
  • altered bowel frequency (diarrhoea and constipation alternating)

Then do FBC, CRP, Coeliac serology to confirm positive diagnosis

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85
Q

What is the treatment for irritable bowel syndrome?

A

Symptom control:

  • Constipation => Ensure adequate water and fibre intake, simple laxatives e.g. Imodium
  • Diarrhoea => Avoid sorbitol sweeteners, alcohol and caffeine. Avoid trigger foods. Add a bulking agent and loperamide
  • Colic/bloating => oral antispasmodics e.g. mebeverine
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86
Q

What is the prevalence of irritable bowel syndrome?

A

10-20% of people
2:1 female:male ratio
People under 50

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87
Q

What is the description of anal fissure?

A

A tear in the mucosa of the anus

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88
Q

What are some symptoms of anal fissure?

A
  • Pain (can be severe) during bowel movements
  • Bright red blood on stool or paper
  • A visible crack around the anus
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89
Q

What are some of the causes of anal fissures?

A
  • Passing large or hard stools
  • Constipation or chronic diarrhoea
  • Anal intercourse (more common in gay men)
  • Anal cancer
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90
Q

How do you diagnose an anal fissure?

A
  • PR exam tends to be enough

- Otherwise => Flexible sigmoidoscopy

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91
Q

What is the treatment for an anal fissure?

A

Medications:

  • Externally applied nitroglycerin (Rectiv), to help increase blood flow to the fissure and promote healing. May cause headache.
  • Topical anaesthetic creams such as lidocaine hydrochloride for pain relief.
  • Diltiazem can help relax the anal sphincter.

Surgery:
- For chronic anal fissures or severe symptoms, consider surgery

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92
Q

What is the description of rectal prolapse?

A

A condition where the rectum protrudes out of the anus

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93
Q

What are some symptoms of rectal prolapse?

A
  • Feeling of a lump coming out of anus after bowel movement
  • Difficulty controlling bowel movements
  • Bright red blood or slimy mucus coming out of rectum
  • Discomfort or pain
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94
Q

What causes rectal prolapse?

A
  • Chronic constipation

- Weakened pelvic floor muscles

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95
Q

How do you diagnose rectal prolapse?

A
  • Presentation of symptoms
  • PR exam (usually diagnostic)
  • Barium enema
  • Colonoscopy may be needed
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96
Q

What is the description of ileus?

A

A temporary and often painful lack of peristalsis (or any movement) of the intestines.

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97
Q

What are some potential causes of ileus?

A

Post surgery

Opioid drugs, calcium channel blockers and anticholinergics may affect the intestines

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98
Q

What are some symptoms of ileus?

A
  • Abdominal cramps and pain
  • Bloating
  • Nausea and vomiting
  • Constipation and inability to pass gas
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99
Q

How do you diagnose ileus?

A
  • Presentation of symptoms
  • Medication history may suggest ileus
  • Abdominal exam => absent or excessive bowel sounds
  • AXR
  • CT scan
  • Ultrasound
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100
Q

What is the treatment for ileus?

A

Pain relief
Dietary changes
Surgery is an option if the above don’t work.

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101
Q

What is the description of volvulus?

A

Twisting of part of the small or large intestine which may cut off blood supply to the bowel.

102
Q

What are some of the potential causes of volvulus?

A
  • Malrotation in infants

- Chronic constipation, an enlarged colon, abdominal adhesions and pregnancy in adults

103
Q

What are some of the symptoms of volvulus?

A
  • Abdominal pain and tenderness
  • Vomiting green bile
  • Nausea
  • Distended abdomen
  • Constipation
104
Q

How do you diagnose volvulus?

A
  • Presentation of symptoms
  • Abdominal exam
  • Barium x-rays
  • CT scan
105
Q

What is the treatment for volvulus?

A

Urgent surgery

106
Q

What are the different types of intestinal failure?

A

Type 1 - short-term, self-limiting and often perioperative in nature.
Type 2 - more long term, in metabolically unstable patients. Requires parenteral nutrition and careful monitoring to prevent it from developing into type 3 IF. Can be reversed with surgery.
Type 3 - Irreversible, chronic IF. Long term parenteral feeding is required (therefore Home Parenteral feeding).

107
Q

What is the description of pseudo-obstruction?

A

A condition with symptoms that resemble those caused by an obstruction of the intestines, but no blockage exists. Instead, the symptoms are due to nerve or muscle problems that affect the movement of food, fluid, and air.

108
Q

What are the causes of pseudo-obstruction?

A
  • Abdominal or pelvic surgery
  • Lupus erythematous and Parkinson’s disease
  • Medications, such as opiates and antidepressants
109
Q

What are some symptoms of pseudo-obstruction?

A
  • Abdominal distension
  • Abdominal pain
  • Nausea and vomiting
  • Constipation
  • Diarrhoea
110
Q

How do you diagnose a pseudo-obstruction?

A
  • Presentation of symptoms
  • Abdominal examination
  • Abdominal X-ray
  • CT scan
111
Q

What is the treatment of pseudo-obstruction?

A
  • Enteral Nutrition
  • Medications such as laxatives
  • Surgery in severe cases
112
Q

What is the description of ulcerative colitis?

A

A relapsing and remitting inflammatory disorder of the colonic mucosa.

113
Q

What is the cause of ulcerative colitis?

A

Inappropriate immune response against colonic flora in genetically susceptible individuals.

114
Q

What are some symptoms of ulcerative colitis?

A
  • Episodic or chronic diarrhoea
  • Abdominal cramps
  • Tenesmus
  • Fever
  • Malaise
115
Q

What are some signs of ulcerative colitis?

A
  • Clubbing
  • Erythema nodosum
  • Pyoderma gangrenosum
116
Q

How do you diagnose ulcerative colitis?

A
  • Presentation of symptoms

- FBC, CRP, U&E, stool culture to eliminate gastroenteritis

117
Q

What is the treatment for ulcerative colitis?

A

Mild UC - Mesalazine, given PR for distal disease and PO for extensive disease. Prednisolone 20mg as well.

Moderate UC - 40mg of prednisolone that taper by 5mg over 7 weeks. Maintain with mesalazine.

Severe UC - IV steroids, thromboembolism prophylaxis

118
Q

What is the description of Crohn’s disease?

A

A chronic inflammatory disease characterised by transmural granulomatous inflammation affecting any part of the gut from mouth to anus.

119
Q

What is the cause of Crohn’s disease?

A

Inappropriate immune response against colonic flora in genetically susceptible individuals.

120
Q

What are some symptoms of Crohn’s disease?

A
  • Diarrhoea, which is bloody
  • Abdominal pain
  • Weight loss, failure to thrive
  • Fatigue, fever, malaise
121
Q

What are some signs of Crohn’s disease?

A
  • Bowel ulceration
  • Abdominal tenderness
  • Peri-anal abscess/fistulae
  • Clubbing
122
Q

How do you diagnose Crohn’s disease?

A
  • Presentation of symptoms
  • Abdominal and PR exams
  • FBC, CRP, U&E, stool culture
  • Colonoscopy and biopsy
123
Q

What is the treatment of Crohn’s disease?

A

Mild/moderate: Azathioprine, 40mg of prednisolone/day for 1 week, then taper by 5mg for 7 weeks.

Severe: IV steroids, thromboembolism prophylaxis

Perianal disease: oral antibiotics, immunosuppressant therapy, local surgery and seton insertion

124
Q

What is the description of gastrointestinal malabsorption?

A

Malabsorption refers to decreased intestinal absorption of carbohydrate, protein, fat, minerals or vitamins.

125
Q

What are some causes of gastrointestinal malabsorption?

A
  • Coeliac disease
  • Chronic pancreatitis
  • Crohn’s disease
  • Primary biliary cholangitis
126
Q

What are some symptoms of gastrointestinal malabsorption?

A
  • Diarrhoea
  • Reduced weight
  • Lethargy
  • Steatorrhoea
  • Bloating
127
Q

How do you diagnose gastrointestinal malabsorption?

A
  • FBC
  • Stool culture
  • Endoscopy and small bowel biopsy
128
Q

What is the description of coeliac disease?

A

A common digestive condition where the small intestine becomes inflamed and unable to absorb nutrients due to the ingestion of gluten.

129
Q

What is the cause of coeliac disease?

A

T-cell responses to gluten in the small bowel causes villous atrophy and malabsorption.

130
Q

What are some symptoms of coeliac disease?

A
  • Stinking stools
  • Diarrhoea
  • Abdominal pain
  • Bloating
131
Q

How do you diagnose coeliac disease?

A
  • Presentation of symptoms
  • Antibodies
  • Biopsy
132
Q

What is the treatment of coeliac disease?

A

A gluten free diet

133
Q

What is the full description of scurvy?

cause, signs, diagnosis, treatment

A
  • Due to a lack of vitamin C
  • Signs: anorexia, gingivitis, bleeding from gums, muscle pain, oedema
  • Diagnosis: WBC, lowered ascorbic acid
  • Treatment: dietary education and ascorbic acid
134
Q

What is the description of chronic pancreatitis?

A

Long term inflammation of the pancreas that alters its normal structure and function.

135
Q

What are some causes of chronic pancreatitis?

A
  • Alcohol
  • Smoking
  • Autoimmune
  • Sometimes can be familial
136
Q

What are some symptoms of chronic pancreatitis?

A
  • Epigastric pain, which can be relieved by sitting forward or hot water bottles on epigastrium. Pain may worsen when eating or drinking alcohol.
  • Nausea and vomiting
  • Steatorrhea
137
Q

How do you diagnose chronic pancreatitis?

A
  • Presentation of symptoms
  • Ultrasound (pancreatic calcifications confirm the diagnosis)
  • CT
138
Q

What is the treatment for chronic pancreatitis?

A

Drugs - Give analgesics for pain
Diet - no alcohol, low fat diet
Surgery - for unremitting pain

139
Q

What are some potential complications of chronic pancreatitis?

A
  • Pseudocyst
  • Diabetes
  • Biliary obstruction
140
Q

What is the description of pancreatic carcinoma?

A

Cancer can present in 3 parts of the pancreas; the head, the body and the tail.

141
Q

What is the presentation of pancreatic carcinoma?

A

Head of the pancreas - Painless jaundice
Body and tail - epigastric pain and jaundice

Patients also present with:

  • Weight loss
  • Acute pancreatitis
142
Q

What are some signs of pancreatic carcinoma?

A
  • Jaundice
  • Palpable epigastric mass
  • Hepatomegaly
  • Splenomegaly
143
Q

What is the epidemiology of pancreatic carcinoma?

A
  • 3% of all malignancies
  • More common in males
  • > 70 years old
  • 95% of patients have mutations in the KRAS2 gene
144
Q

How do you diagnose pancreatic carcinoma?

A
  • Blood tests - show cholestatic jaundice
  • Ultrasound and CT can show a pancreatic mass
  • Biopsy
145
Q

What is the treatment of pancreatic carcinoma?

A
  • 20% of pancreatic carcinomas are suitable for radical surgery (pancreatoduodenectomy - Whipple procedure)
  • Most patients also get adjuvant chemotherapy
146
Q

What is the prognosis of pancreatic carcinoma?

A

Mean survival < 6 months
5 year survival < 3 %
5 year survival after Whipple - 5-14%

147
Q

What is the description of carcinoid tumours?

A

A group of tumours capable of producing 5HT.

148
Q

Where do carcinoid tumours occur?

A

Common sites include the appendix, ileum, rectum, ovaries and testes

149
Q

What are some symptoms of carcinoid tumours?

A

GI tumours can cause:

  • Appendicitis
  • Intussusception
  • Intestinal obstruction
150
Q

What is carcinoid syndrome and some of its symptoms?

A

Paraneoplastic syndrome
Occurs in 5% of patients with carcinoid tumours

Symptoms include:

  • Bronchoconstriction
  • Flushing
  • Diarrhoea
  • Congestive cardiac failure
151
Q

How do you diagnose a carcinoid tumour?

A
  • CXR and CT to locate tumours

- increased 24h urine 5HIAA (5HT metabolite)

152
Q

What is the treatment for carcinoid tumours?

A
  • Resection is the only cure for carcinoid tumours
153
Q

What is the treatment for carcinoid syndrome?

A
  • Octreotide => blocks the release of tumour mediators and counters peripheral effects
154
Q

What is the description of jaundice?

A

The yellowing of skin, sclera and mucosa due to increased plasma bilirubin

155
Q

How is jaundice classified?

A

In two ways:

a) By the site of the problem i.e. pre-hepatic, hepatocellular, cholestatic
b) By the type of circulating bilirubin i.e. conjugated or unconjugated.

156
Q

What is the description of unconjugated hyperbilirubinaemia?

A

As unconjugated bilirubin is water-insoluble, it does not enter urine.

157
Q

What are some of the potential causes of unconjugated hyperbilirubinaemia?

A
  • Overproduction e.g. Haemolysis
  • Impaired hepatic uptake e.g. Drugs
  • Impaired conjugation e.g. Gilbert’s syndrome
  • Physiological neonatal jaundice
158
Q

What is the description of conjugated hyperbilirubinaemia?

A

Conjugated bilirubin is water-soluble, so it enters urine and makes it dark. Less conjugated bilirubin enters the intestine and makes stool pale.

159
Q

What causes jaundice when the patient has normal urine and normal stool?

A

Pre-hepatic cause

160
Q

What is the cause of jaundice when the patient has dark urine and normal stool?

A

Hepatic cause

161
Q

What is the cause of jaundice when the patient has dark urine and pale stool?

A

Cholestatic cause/ obstructive cause

162
Q

What are some pre-hepatic causes of jaundice?

A
  • Haemolysis
  • Malaria
  • Sickle-cell anaemia
  • Thalassemia
163
Q

What are some hepatic causes of jaundice?

A
  • Liver cirrhosis
  • Viral hepatitis
  • Liver cancer
  • Alcoholic hepatitis
  • Primary biliary cirrhosis
164
Q

What are some cholestatic causes of jaundice?

A
  • Cholelithiasis (gall stones)
  • Pancreatic carcinoma
  • Pancreatitis
  • Cholangiocarcinoma
165
Q

How do you diagnose the type of jaundice a patient is presenting with?

A
  • Blood tests - look for haemolysis
  • Urine analysis - only conjugated jaundice presents with bilirubin in the urine
  • Ask patient about IV drug use, blood transfusions, tattoos, sexual activity, travelling abroad, alcohol use etc.
166
Q

Which raised LFT’s show hepatic pathology?

A

AST and ALT

  • if AST > ALT, then it indicates acute liver disease or cirrhosis
  • if ALT > AST, then it indicated chronic liver disease
167
Q

Which raised LFT’s show cholestatic pathology?

A

ALP and GGT

  • A more than 3-fold increase in ALP suggests cholestasis
  • A raised GGT is indicative of biliary epithelial damage and bile flow obstruction
168
Q

What does an isolated raised ALP indicate?

A
  • Bony metastases / primary bone tumours (e.g. sarcoma)
  • Vitamin D deficiency
  • Recent bone fractures
169
Q

What does an isolated decreased albumin indicate?

A
  • Cirrhosis

- Inflammation affecting the liver

170
Q

What does an isolated raised bilirubin indicate?

A

Pre-hepatic cause of jaundice i.e. haemolysis or Gilbert’s syndrome

171
Q

What can an increased prothrombin time indicate?

A

Hepatic pathology

172
Q

What is the description of liver failure?

A

Loss of function to the liver. This may be recognised by the development of coagulopathy or encephalopathy.

It may occur acutely or chronically.

173
Q

What are some of the causes of liver failure?

A
  • Infections e.g. viral hepatitis and yellow fever
  • Drugs e.g. paracetamol overdose and isoniazid
  • Toxins e.g. mushrooms
  • Vascular
  • Other e.g. alcohol, fatty liver disease
174
Q

What are some signs of liver failure?

A
  • Jaundice
  • Hepatic encephalopathy
  • Liver flap
  • Fetor hepaticus (smells like pear drops)
  • Ascites
175
Q

How do you diagnose liver failure?

A

FBC, LFTs, U&E, clotting, urine culture, abdominal ultrasound etc.

176
Q

What is the management of liver failure?

A
  • Treat the cause if known
  • Treat any seizures with phenytoin
  • If malnourished, give dietary supplements
  • Haemofiltration or haemodialysis
  • Treat ascites with diuretics
  • Avoid drugs with hepatic metabolism
177
Q

What is the description of cirrhosis?

A

Loss of normal hepatic architecture with fibrosis and nodular regeneration. It implies irreversible liver damage.

178
Q

What are some of the causes of cirrhosis?

A
  • Chronic alcohol abuse
  • HBV or HCV infection
  • Haemochromatosis
179
Q

What are some signs of cirrhosis?

A
  • Leuconychia
  • Clubbing
  • Palmar erythema
  • Spider navei
  • Xanthelasma
  • Gynecomastia
180
Q

How do you diagnose cirrhosis?

A
  • FBC and LFTs
  • Liver ultrasound and duplex
  • MRI
  • Ascitic tap
  • Liver biopsy (diagnostic)
181
Q

What is the management of cirrhosis?

A
  • Good nutrition
  • No alcohol and avoid NSAIDs, opiates and sedatives
  • Liver transplantation is the only effective treatment for cirrhosis
182
Q

What is the prognosis of cirrhosis?

A

5 year survival is about 50%

183
Q

What is the description of viral hepatitis A?

A

An RNA virus with a faecal-oral spread (or shellfish) and an incubation period of 2-6 weeks.
Most infections usually occur in childhood.

184
Q

What are some symptoms of viral hepatitis A?

A
  • Fever
  • Malaise
  • Anorexia
  • Nausea
  • Arthralgia (pain in a joint)

Then:

  • Jaundice
  • Hepatosplenomegaly
  • Adenopathy
185
Q

How do you diagnose viral hepatitis A?

A
  • AST and ALT rise for 22-40 days after exposure and return to normal after 5-20 weeks
  • IgM rises from day 25 and means recent infection
  • IgG is detectable for life
186
Q

What is the treatment of viral hepatitis A?

A
  • Supportive care, as disease is usually self-limiting and not chronic
  • Avoid alcohol
  • Active immunisation is important => with inactivated viral protein, 1 dose gives immunity for 1 year (20 years if further booster is given at 6-12 months.
187
Q

What is the description of viral hepatitis B?

A

A DNA virus with spread through blood products, IV drug users and sexual and direct contact. It has an incubation period of 1-6 months.

188
Q

What are some of the risk factors for viral hepatitis B?

A
  • Being an IV drug user
  • Sexual partners/ carers of IV drug users
  • Health workers
  • Haemophiliacs
  • Men who have sex with men
  • Haemodialysis
  • Sex workers
  • Babies of affected mothers
189
Q

What are some of the symptoms of viral hepatitis B?

A
  • Fever
  • Malaise
  • Anorexia
  • Nausea
  • Arthralgia (pain in a joint)
  • Urticaria (hives)
  • Jaundice
  • Hepatosplenomegaly
190
Q

How do you diagnose viral hepatitis B?

A
  • HBsAg - present 1-6 months after exposure
  • HBsAg - persisting for >6 months defines carrier status
  • HBeAg - present 1.5- 3 months after acute illness (implies high infectivity)
  • Antibodies to HBcAg imply past infection
  • Antibodies to HBsAg alone imply vaccination
191
Q

What is the vaccination for viral hepatitis B?

A
  • Passive immunisation may be given to non-immune contacts after high-risk exposure
  • Use hepatitis B vaccine 1ml into deltoid and repeat at 1&6 months
192
Q

What are some potential complications of viral hepatitis B?

A
  • Hepatic failure
  • Cirrhosis
  • Cholangiocarcinoma
193
Q

What is the treatment for viral hepatitis B?

A
  • Avoid alcohol
  • Immunise sexual contacts
  • Any patients with chronic liver inflammation or cirrhosis refer for antivirals:
    • PEG interferon alfa-2a for 48 weeks
      or better tolerated
    • Long-term nucleotide analogues e.g. tenofovir, entecavir
194
Q

What is the description of viral hepatitis C?

A

An RNA flavivirus with spread through blood, transfusions, IV drug abuse and sexual contact. The incubation period is 2 weeks to 3 months (after which its considered chronic).

195
Q

What are the symptoms of a viral hepatitis C infection?

A
  • Early infection is often asymptomatic
  • 85% develop silence chronic infection
  • 25% will get cirrhosis in 20 years of which 4% get hepatocellular cancer
196
Q

Who is at higher risk for progression of a viral hepatitis C infection?

A
  • Male
  • Older
  • Higher viral load
  • Use of alcohol
  • HIV
  • Hepatitis B virus
197
Q

How do you diagnose a viral hepatitis C infection?

A
  • LFTs
  • Anti-HVC antibodies confirms exposure
  • HVC-PCR confirms ongoing infection
  • Liver biopsy
198
Q

What is the treatment for a viral hepatitis C infection?

A
  • Quit alcohol

- Ledipasvir & sofosbuvir

199
Q

What is the full description of a viral hepatitis D infection?

(description, complications, diagnosis, treatment)

A
  • An incomplete RNA virus (need hep B virus for its completion).
  • Hep B vaccination prevents Hep D infection.
  • Complications: can cause liver failure or cirrhosis
  • Diagnosis: Anti-HDV antibody (only ask for it if HBsAg positive)
  • Treatment: Interferon alfa has limited success so liver transplantation may be needed
200
Q

What is the full description of a viral hepatitis E infection?

(description, epidemiology, diagnosis, treatment)

A
  • RNA virus, incubation period of 2-10 weeks
  • Common in Indochina, and commoner than Hep A in the UK
  • Mortality high in pregnancy
  • Vaccine is available in China (not Europe)
  • Diagnosis: Serology
  • Treatment: Ribavirin
201
Q

When do patient who suffer from alcoholism start to experience withdrawal symptoms?

A

10-72 hours after last drink

202
Q

What are some of the signs and symptoms of alcohol withdrawal?

A
  • Increased pulse
  • Decreased BP
  • Tremor
  • Confusion
  • Fits
  • Hallucinations
203
Q

What is the relapse rate for alcoholism?

A

About 50%

204
Q

What is the description of fatty liver disease?

A

A condition in which fat levels build up in the liver. There’s two types; alcoholic fatty liver disease and non-alcoholic fatty liver disease.

205
Q

What is the description of non-alcoholic fatty liver disease?

A

A type of fatty liver disease that is not associated with heavy alcohol use. There are two types; simply fatty liver (no inflammation, no liver damage) and non-alcoholic steatohepatitis (NASH) (inflammation and liver damage).

206
Q

What are some risk factors for non-alcoholic fatty liver disease?

A
  • Type 2 diabetes, pre-diabetes
  • Obesity
  • Middle-aged or older
  • Hypertension
  • Hyperlipidaemia and hypercholesterolaemia
  • Hep C exposure
  • Too rapid weight loss
207
Q

What are some of the symptoms of fatty liver disease?

A

Usually silent with barely any symptoms

208
Q

How do you diagnose fatty liver disease?

A
  • LFTs
  • Ultrasound
  • CT
  • Liver biopsy
209
Q

What is the treatment for fatty liver disease?

A

Control risk factors - including obesity - weight loss can help
Avoid alcohol consumption
Vitamin E may improve histology of fibrosis

210
Q

What is the description of alcoholic hepatitis?

A

Inflammation of the liver caused by heavy consumption of alcohol.

211
Q

What are some symptoms of alcoholic hepatitis?

A
  • Jaundice
  • Loss of appetite
  • Nausea and vomiting
  • Fever, low grade
  • Abdominal tenderness
  • Fatigue and weakness
212
Q

What are some potential complications of alcoholic hepatitis?

A
  • Varices
  • Ascites
  • Hepatic encephalopathy
  • Cirrhosis
  • Kidney failure
213
Q

How do you diagnose alcoholic hepatitis?

A
  • LFTs
  • FBC
  • Ultrasound or CT
  • Liver biopsy
214
Q

What is the treatment of alcoholic hepatitis?

A
  • Quit alcohol consumption
  • Corticosteroids for inflammation
  • Liver transplant may be an option
215
Q

What is the description of primary biliary cholangitis?

A

Bile ducts are damaged by chronic autoimmune granulomatous inflammation.

216
Q

What is the cause of primary biliary cholangitis?

A
  • Unknown environmental triggers (pollutants, xenobiotics)

- Possible genetic predisposition

217
Q

What are some of the signs and symptoms of primary biliary cholangitis?

A
  • Lethargy
  • Pruritus
  • Jaundice
  • Xanthelasma
  • Hepatosplenomegaly
218
Q

What are some of the potential complications of primary biliary cholangitis?

A
  • Cirrhosis

- Osteoporosis

219
Q

How do you diagnose primary biliary cholangitis?

A
  • Blood => increased ALP, GGT and mildly increased ALT and AST.
  • Ultrasound
  • Biopsy (not usually needed)
220
Q

What is the treatment for primary biliary cholangitis?

A
  • Treat symptoms
  • Monitor LFTs
  • Consider high-dose ursodeoxycholic acid (UDCA)
  • Liver transplantation
221
Q

What is the description of primary sclerosing cholangitis?

A

Progressive cholestasis (inability for bile to flow from the bile duct to the duodenum) with bile duct inflammation and strictures.

222
Q

What are some of the symptoms of primary sclerosing cholangitis?

A
  • Pruritus
  • Fatigue
  • Ascending cholangitis
  • Cirrhosis
  • Hepatic failure

Also causes increased risk of bile duct, gall bladder, liver and colon cancer.

223
Q

How do you diagnose primary sclerosing cholangitis?

A
  • LFTs => Increased ALP and then increased bilirubin
  • ERCP or MRCP
  • Livery biopsy shows a fibrous, obliterative cholangitis
224
Q

What is the treatment for primary sclerosing cholangitis?

A
  • Liver transplantation is the mainstay for end-stage disease
  • Ursodeoxycholic acid may improve LFT
  • Colestyramine for prutirus
225
Q

What is the description for autoimmune hepatitis?

A

Autoimmune liver inflammation. Characterised by abnormal T-cell function and autoantibodies directed against hepatocyte surface antigens.

226
Q

What are some of the symptoms of autoimmune hepatitis?

A
  • Fatigue
  • Abdominal discomfort
  • Jaundice
  • Hepatomegaly
  • Spider naevi
  • Rashes
  • Joint pain
227
Q

How do you diagnose autoimmune hepatitis?

A
  • LFTs (bilirubin, AST, ALT and ALP all usually increased)
  • Liver biopsy
  • MRCP

Sometimes diagnosis is a challenge as there is overlap with other conditions.

228
Q

What is the treatment for autoimmune hepatitis?

A
  • Immunosuppressant therapy with prednisolone

- Liver transplantation

229
Q

What is the description of Wilson’s disease?

A

A rare, inherited autosomal recessive disorder of copper excretion with excess deposition in liver and CNS.

230
Q

What are some signs and symptoms of Wilson’s disease in children?

A

Begin with liver disease:

  • Hepatitis
  • Cirrhosis
  • Liver failure
231
Q

What are some signs and symptoms of Wilson’s disease in adults?

A

Begin with CNS disease:

  • Tremor
  • Dysphagia
  • Dyskinesia
  • Demetia
232
Q

What are some general signs and symptoms of Wilson’s disease?

A
  • Mood => depression, mania, personality change
  • Cognition => worse memory, slow to solve problems, decreased IQ
  • Kayser-Sleischer rings => Copper in iris
  • Haemolysis
233
Q

How do you diagnose Wilson’s disease?

A
  • Urine: 24h copper excretion is high
  • Increased LFTs
  • Serum copper: very high
  • Liver biopsy: increased hepatic copper
234
Q

What is the management of Wilson’s disease?

A
  • Diet: avoid foods with high copper content
  • Check water sources for copper
  • Drugs: lifelong penicillamine
  • If severe: liver transplantation

Also screen siblings.

235
Q

What is the description of hereditary haemochromatosis?

A

An inherited disorder of iron metabolism in which increased intestinal iron absorption leads to iron deposition in joints, liver, heart, pancreas, adrenals and skin.

236
Q

What are some symptoms of hereditary haemochromatosis?

A

Early on:

  • Tiredness
  • Arthralgia

Later:

  • Slate-Grey skin pigmentation
  • Signs of chronic liver disease
  • Hepatomegaly
  • Cirrhosis
  • Dilated cardiomyopathy
237
Q

How do you diagnose hereditary haemochromatosis?

A
  • LFTs - increased
  • Increased ferritin
  • HFE genotyping
  • Liver and cardiac MRI - Fe overload
  • Liver biopsy
238
Q

What is the treatment of hereditary haemochromatosis?

A
  • Venesect for life (consider desferrioxamine if intolerant of this)
  • Monitor LFTs
  • Diet: a well-balanced diet should be encouraged. Avoid alcohol, avoid uncooked seafood.
239
Q

What is the description of alpha-1-antitrypsin (A1AT) deficiency?

A

An inherited disorder affecting lung (emphysema) and liver (cirrhosis and HCC).
A1AT is a glycoprotein made in the liver that controls inflammatory cascades.
A1AT deficiency is the chief genetic cause of liver disease in children.

240
Q

What some of the symptoms of A1AT deficiency?

A
  • Dyspnoea from emphysema
  • Cirrhosis
  • Cholestatic jaundice
241
Q

How do you diagnose A1AT deficiency?

A
  • Serum alpha-1-antitrypsin levels low
  • Lung function testing => shows reduction in FEV1 with obstructive pattern
  • Liver biopsy
  • Phenotyping

Can also make a pre-natal diagnosis which is possible by DNA analysis of chorionic villus samples.

242
Q

What is the treatment of A1AT deficiency?

A
  • Smoking cessation
  • Prompt treatment/ preventative vaccinations for lung infections
  • Liver transplantation and lung transplantation may be needed
243
Q

What is the description of liver tumours?

A

Tumours of the liver. Usually they are metastases as primary hepatic tumours are much less common.

244
Q

What are some of the symptoms of liver tumours?

A
  • Fever
  • Malaise
  • Anorexia
  • Weight loss
  • RUQ pain
  • Jaundice (usually late)
245
Q

What are some signs of liver tumours?

A
  • Hepatomegaly
  • Cirrhosis
  • Jaundice
  • Ascites
246
Q

How do you diagnose liver tumours?

A
  • Blood tests: FBC, clotting, LFTs, hepatitis serology
  • Imaging: Ultrasound, CT
  • Liver biopsy for histological diagnosis
247
Q

What is the full description of liver metastases?

A
  • Typically signify advanced disease
  • Treatment and prognosis vary on type and extent of the primary tumour (but prognosis is typically < 6 months)
  • Chemotherapy may be effective (e.g. lymphomas)
  • Small, solitary metastases may be amenable to resection
248
Q

What is the full description of hepatocellular carcinoma?

A
  • Primary hepatocyte neoplasia which accounts for 90% of primary liver cancers.
  • Symptoms: Fatigue, reduced appetite, RUQ pain, weight loss, jaundice, ascites.
  • Causes: Hepatitis B infection is the leading cause worldwide
  • Diagnosis: 3-phase CT, MRI, liver biopsy
  • Treatment: Resecting solitary tumours increased survival. Liver transplant
249
Q

What is the full description of cholangiocarcinoma?

A
  • Billiary tree cancer
  • Causes: Flukes, primary sclerosing cholangitis, biliary cysts
  • Symptoms: Fever, abdominal pain, ascites, high bilirubin and high ALP
  • Pathology: Usually slow growing
  • Management: 70% inoperable at presentation
  • Prognosis: about 5 months
250
Q

What is the full description of benign liver tumours?

A
  • Haemangiomas: commonest benign liver tumours. They are often an incidental finding on ultrasound or CT. They don’t require treatment. Avoid biopsy
  • Adenomas: Common. Causes include anabolic steroids, oral contraceptive pill and pregnancy. Only treat if symptomatic, or >5cm.

Medical Conditions (3 decks)

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