Gastrointestinal Flashcards
Presentation chronic liver disease
Swelling of feet/abdomen Fatigue, nausea Jaundice, pruritis Bruising Haematemis Confusion
Risk factors chronic liver disease
Alcohol
Hepatitis/jaundice
Drugs
Diabetes, cardiac failure
Causes of chronic liver disease
FIGCAT
Fatty liver
Infectious
Genetic (haemochromotosis, alpha-1-antitrypsin deficiency)
Congestion (RHF)
Autoimmune (primary biliary cirrhosis or primary sclerosing cholangitis)
Toxins
Complications of chronic liver disease
Portal hypertension Hepatitic encephalopathy Coagulopathy Hepatocellular carcinoma Spontaneous bacterial peritonitis Hepatorenal syndrome Ascites Hypoglycaemia
Bloods for chronic liver disease
FBC, CRP, urea, ammonia Coags Lfts Full liver screen: viral serology, autoantibodies, serum copper, ferritin Alpha-1 antitrypsin Alpha fetoprotein
investigations for chronic liver disease
Bloods Abdo USS +- portal vein doppler Fibroscanning MRCP Ascitic tap Liver biopsy Paracetamol levels
Criteria for child-pugh score
Encephalopathy Ascites Bilirubin Albumin Prothrombin time
Pharmacological treatment for chronic liver disease
Depends on underlying cause: Hep B: interferon Hep C: ribavirin Autoimmune hepatitis: steroids Fatty: weight loss, statins Nutritional support
How to treat ascites
Bed rest and fluid restrict Low salt diet Spironolcatone Frusemide Therapeutic paracentesis
How to treat varices
Prophylactic treatment with beta blockers or variceal band ligation
Encephalopathy treatment
Enemas to rid gut of blood Low protein diet Lactulose or antibiotics like metronidazole Mannitol Lorazepam for seizures
End line liver treatment
TIPS (transjugular intrahepatic portosystemic shunt) which connects portal vein to hepatic vein
Liver transplant
Screening in liver disease
USS +/- alpha fetoprotein every 6 months for HCC
Indications for liver transplant
Advanced cirrhosis caused by; alcohol, hepatitis, primary biliary cirrhosis, wilson’s, A1-antitrypsin, primary sclerosing cholangitis, HCC
Contraindications for liver transplant
Extra hepatic malignancy Multiple hepatic tumours Severe cardioresp disease Sepsis HIV Non compliance with medications
Kings college criteria for liver transplant
Non-paracetamol induced PT 100s/INR >6 or 3/5 of not hepatitis Age <10 or >40 >1 week from first jaundice to encephalopathy PT >50s/INR >3.5 Bilirubin >0.3mmol/L Paracetamol induced pH <7.3 or INR >6 Cr >300 Grade 3 or 4 encephalopathy
which drugs are needed for immunosuppression in liver transplant?
Ciclosporin and tacrolimus or
Tacrolimus and azathioprine or mycophenolate and prednisone
Complications of liver transplant
Rejection
Sepsis
1 year 80% success
How does the presentation of colon cancer change with position?
Left: PR bleeding/ altered bowel habit/ tenesmus/ mass on PR
Right: Weight loss/anaemia
Either: abdominal mass, haemorrhage, perforation, fistula
Riak Factors colon cancer
Polyps Family History IBD Previous cancer Smoking Diet Alcohol
Investigations colon cancer
FBC (microcytic anemia) LFT CEA Faecal occult blood (if screening) Colonoscopy Liver USS If polyposis in family refer for genetic testing once every 15 years
Management of colon cancer
Hemicolectomy, sigmoid colectomy, anterior resection, hartmann’s procedure
Stenting (palliative)
Radiotherapy and chemotherapy
Key things to ask in dyspepsia history
When symptoms occur NSAID use Progressive Previous ulcer/reflux Dysphagia Maleana Losing weight
Investigations for dyspepsia
FBC Urease breath test and stool antigen (H.pylori) Gastroscopy with biopsy CXR Barium swallow 24hr esophageal pH monitoring-GERD
Differential diagnosis for dyspepsia
GORD Gastritis Gastric cancer Pancreatitis/pancreatic cancer Ulcer Chronic mesenteric ischaemia
How do we kill H pylori
Triple therapy with omeprazole, clarithromycin and metronidazole
Management of dyspepsia
H pylori eradication
Stop NSAIDS and steroids
PPIs/H2 antagonists
Ulcers should be biopsied to ensure not cancer
Presenting symptoms of IBD
Diarrhoea Blood Mucous Abdo pain Urgency/tenesmus
Complications of UC
Toxic megacolon Strictures/fistulae Carcinoma of colon Primary sclerosing cholangitis Cirrhosis Erythema nodosum
Complications of Crohn’s
Fissures/fistulas/abscesses
Obstruction
Carcinoma of colon and small bowel
Gallstones
Investigations for IBD
FBC ESR, CRP U and E LFTs Testing p-ANCA and ASCA Stool sample-fecal calprotectin AXR Sigmoidoscopy Biopsy CT
Treatment ladder for UC
mesalazine/sulfazine
prednisolone (oral or rectal)
azothioprine/cyclosporin/infliximab
proctocolectomy
Treatment ladder to Crohn’s
prednisolone IV/rectal hydrocortisone Metronidazole Azathioprine/infliximab Surgery-limited resection
Presentation of haemochromatosis
Tiredness Arthralgia Grey-skin Hepatomegaly cardiomyopathy Diabetes pituitary dysfunction
Investigations haemochromatosis
Raised LFT, raised sFerritin Transferrin sat HFE genotype XRAY Liver MRI Biopsy
Management of haemochromatosis
venesection
Monitor
What causes haemochromatosis
Defect in activation of hepcidin normally triggered by iron excess
Investigations for coeliac disease?
Anti-tTG
Duodenal biopsy
Complications of coeliac disease?
Anaemia, lactose intolerance, T cell lymphoma, GI malignancies, myopathies
Difference between cushing’s syndrome and cushings disease
Syndrome: any other cause of high cortisol
Disease: ACTH secreting pituitary
Difference between Boorhave’s syndrome and Mallory weiss?
Boorhave’s: perforation of the esophagus
Mallory weiss: damage to the mucus membrane of the gastroesophageal junction
How do AST and ALT change in alcohol?
AST/ALT ratio of greater than 2 indicates alcoholic liver disease
Which score is used to assess pre endoscopy for bleeding risk?
Rockall score
Acute management of upper GI bleedig
ABCDE Nil by mouth Obtain IV access Give normal saline Check hb, LFTS, clotting factors If Hb low, transfuse (dont over transfuse because of risk of bleeding) Give omeprazole and IV antibiotics and ocreotide plus terlipressin post op (if varices) Calculate rockall score Call endoscopist
Causes of hypoglycemia
Exogenous Pituitary insufficiency Liver failure Addison's Islet cell tumours Naughty-alcohol
How to tell if this lump is the spleen?
Can’t get over it
Splenic notch
Dull to percussion
Comes down on inspiration
