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MSRA Content > Gastrointestinal - Level 2.2 > Flashcards

Gastrointestinal - Level 2.2 Flashcards

1
Q

Definition of inguinal hernia?

A
  • Protrusion of abdominal or pelvic contents into inguinal canal
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2
Q

Types of inguinal hernia?

A

o Indirect hernias (80%) pass through internal inguinal ring and out of external if large enough

o Direct hernias (20%) push through posterior wall of canal into Hesselbach’s triangle (medial to inferior epigastric and lateral to rectus abdominis)

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3
Q

Anatomy of inguinal canal?

A

o Deep ring – mid-point of inguinal ligament

o Superficial ring – split in EO aponeurosis superior and medial to pubic tubercle

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4
Q

Borders of inguinal canal?

A

o Floor – Inguinal ligament, lacunar ligament medially
o Roof – Transversalis and Internal oblique
o Anterior – External oblique aponeurosis + internal oblique for lateral 1/3
o Posterior – lateral – transversalis fascia, medial – conjoint tendon

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5
Q

Contents of inguinal canal?

A

o External spermatic fascia (from IO), cremasteric fascia (from TA), internal spermatic fascia (from TF) covers cord

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6
Q

Cord contents running through inguinal hernia?

A 
o	Vas deferens
o	Obliterated processus vaginalis
o	Arteries to vas, cremaster, testis
o	Genital branch of genitofemoral nerve/sympathetic
o	Ilioinguinal nerve
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7
Q

Epidemiology of inguinal hernia?

A
  • Most common hernia

- Men 8x more common

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8
Q

Risk factors of inguinal hernia?

A

o Male, older age, smoking, FHx, constipation, chronic cough, pregnancy, heavy lifting, obesity

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9
Q

Symptoms of inguinal hernia?

A

o Visible lump in groin
 Pain during strenuous exercise or heavy lifting
 Dragging sensation
 Inguinal = superomedial to pubic tubercle
 Femoral = inferolateral to pubic tubercle
o Worse on standing/coughing
o Sometimes reducible

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10
Q

Diagnostic examination of inguinal hernia?

A
  • Examination diagnostic usually
    o Done lying down and standing
    o Ask patient to reduce it and cough impulse
    o Palpate coughing impulse – insert finger through top of scrotum
    o Determining between direct and indirect hernia – reduce hernia and ask patient to cough, if not restrained and appears then direct hernia
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11
Q

Management of inguinal hernia - referral?

A

o If features of strangulation or obstruction – admit immediately
o If no features – refer urgently to surgeon if child and routine if adult (urgent if irreducible)

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12
Q

Management of inguinal hernia -general measures?

A

o Analgesia
o Fluids
o Stop smoking
o Weight loss

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13
Q

Management of inguinal hernia - if small and asymptomatic?

A

o Watchful waiting

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14
Q

Management of inguinal hernia - if large or symptomatic?

A 
o	Surgery
	Open/Laparoscopic surgery
•	Mesh repairs – Lichtenstein repair
•	Methods either transabdominal pre-peritoneal (TAPP) and totally extraperitoneal (TEP)
o	Prophylactic antibiotics
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15
Q

Management of inguinal hernia - if incarcerated or strangulated?

A

o Urgent surgical repair and prophylactic antibiotics

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16
Q

Definition of femoral hernia?

A
  • Bowel enters femoral canal presenting as mass in upper thigh or above inguinal ligament where it points down the leg
  • Likely irreducible and strangulated
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17
Q

Boundaries of femoral canal?

A

o Anterior – inguinal ligament
o Posterior – pectineus, pectineal ligament
o Medial – lacunar ligament
o Lateral – femoral vein, iliopsoas

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18
Q

Epidemiology of femoral hernia?

A
  • More in females

- Incidence increases with age

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19
Q

Aetiology of femoral hernia?

A

o Increased abdominal pressure
 Pregnancy, chronic cough, GI obstruction, straining
o Laxity of tissue
 Pregnancy, weight loss, previous repair

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20
Q

Symptoms of femoral hernia?

A 
o	Lump in groin
	Neck of hernia is inferior and lateral to pubic tubercle
	Worse on coughing and straining
	Reduces when supine
o	Dragging, aching feeling
o	May be asymptomatic
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21
Q

Diagnosis of femoral hernia?

A
  • Examination

- USS

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22
Q

Management of femoral hernia?

A
  • All Surgical – elective but within 2 weeks as risk of strangulation
    o Herniotomy – ligation and excision of sac
    o Herniorrhaphy – repair of hernial defect
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23
Q

Complications of femoral hernia?

A

o Strangulation

o Obstruction

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24
Q

Definition of incisional hernia?

A
  • Protrusion of contents of a cavity through a previously made incision due to breakdown of muscle closure
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25
Q

Epidemiology of incisional hernia?

A
  • 10-20% occurrence after surgery

- More commonly following open surgery

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26
Q

Risk factors of incisional hernia?

A
  • Smoking
  • BMI >25
  • Midline incision
  • Infection
  • Increased abdominal pressure – pregnancy, coughing, straining, weight lifting
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27
Q

Symptoms of incisional hernia?

A

o Non-pulsatile reducible, soft and non-tender swelling at or near site of previous surgical wound
o If incarcerated – painful, tender, erythema

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28
Q

Signs of incisional hernia?

A

o Mass is palpable which may be reducible

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29
Q

Diagnosis of incisional hernia?

A
  • Clinical Examination

- USS or CT may help

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30
Q

Management of incisional hernia - asymptomatic?

A
  • If asymptomatic – can be managed conservatively
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31
Q

Management of incisional hernia symptomatic

A
  • Surgery
    o Reinforcing mesh repair
    o Sutures
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32
Q

Complications of incisional hernia?

A

o Incarceration
o Strangulation
o Bowel Obstruction

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33
Q

Definition of umbilical hernia??

A

Occur just above or below umbilicus – defect in anterior abdominal wall fascia that occurs when the umbilical ring fails to close
o Ring continues to close over time when occurs in childhood

Omentum or bowel herniates through the defect

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34
Q

Types of umbilical hernia??

A

o Adult Umbilical Hernia – 90% are acquired
o Congenital (omphalocele, gastroschisis)
o Infantile – associated with prematurity

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35
Q

Epidemiology of umbilical hernia??

A

10-30% of all hernias

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36
Q

Risk factors of umbilical hernia??

A

o Obesity
o Ascites
o Low birth weight
o Pregnancy

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37
Q

Symptoms of umbilical hernia??

A
  • Lump enlarges and may be multi-loculated
    o Easily reducible
  • Pain on coughing or straining
  • Ache or dragging sensation
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38
Q

Diagnosis of umbilical hernia??

A
  • Clinical Examination
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39
Q

Management of umbilical hernia??

A
  • Surgery (if large enough >1.5cm or child >5)

o Mayo repair – repair of rectus sheath

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40
Q

Definition of bile?

A
  • Bile contains cholesterol, bile pigments and phospholipids
  • Majority of biliary emergencies caused by gallstones – acute and chronic cholecystitis, biliary colic, ascending cholangitis
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41
Q

Definition of biliary colic?

Definition of acute cholecystitis?

A

o Temporary obstruction of cystic or CBD by stone

o Follow impaction of stone in cystic duct or neck of bladder

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42
Q

Definition of acute cholangitis?

A

o Infection of biliary tree and often secondary to CBD stones

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43
Q

Epidemiology of biliary tract infections?

A
  • 8% of those over 40 years

- 90% remain asymptomatic

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44
Q

Risk factors for biliary tract infection?

A 
o	Female
o	Fat
o	> Forty
o	Fair – Caucasian
o	Fertile – parity
o	Smoking
o	DM
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45
Q

Types of gallstones?

A

o Pigment stones (10%) – small friable and irregular – caused by hereditary spherocytosis, malaria and haemolytic anaemia
o Cholesterol stones (90%) – Large, often solitary – causes female, obesity, age
o Mixed stones – faceted

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46
Q

Symptoms of biliary colic?

A

o Short-lived recurrent episodes of epigastric/RUQ pain with radiation to back and right shoulder
o May have vomiting

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47
Q

Symptoms of acute cholecystitis?

A

 Continuous epigastric/RUQ pain radiating to right shoulder and back
 Fever, vomiting and local peritonism

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48
Q

Signs of acute cholecystitis?

A

 Fever, RUQ tenderness
 Murphy’s sign positive (pain and arrest of inspiration when palpating liver)
 May be palpable mass – suggestive of empyema and mucocele
 Septic shock

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49
Q

Symptoms of chronic cholecystitis?

A

 Chronic RUQ pain
 Flatulent dyspepsia
 Abdominal discomfort and distention
 Fat intolerance

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50
Q

Common bile duct stones can cause what>

A

o Acute pancreatitis
o Obstructive jaundice
 Symptoms
• Jaundice with pale stools and dark urine
• May have pain
• Courvoiser’s law – in presence of jaundice, if the gallbladder is palpable cause is likely to be a stone

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51
Q

Symptoms of acute cholangitis?

A
  • Charcot’s triad – RUQ pain, jaundice, fever/rigors
  • Shock
  • Urine dark and stools pale
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52
Q

Investigations in biliary colic?

A

o If pain gone and no asymptomatic – discharge and rearrange GP follow-up

o If symptoms – LFTs (raised ALP and bilirubin) and USS shows stones
 MRCP if US not detected stones but bile duct dilated and/or LFT abnormal

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53
Q

Initial investigations in cholecystitis?

A

o Abdominal USS
o Bloods
 FBC (Raised WCC, ALP and bilirubin), U&Es, glucose, amylase, LFTs (post hepatic – raised ALP, bilirubin)

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54
Q

Management of gallstones - if asymptomatic?

A

NONE

 If asymptomatic common bile duct stones – offer bile duct clearance and laparoscopic cholecystectomy

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55
Q

Management of gallstones - if symptomatic?

A

 General Advice
• Avoid food and drink which trigger symptoms
• Low fat diet
 Analgesia
 Elective laparoscopic cholecystectomy
• +/- bile duct clearance (if common bile duct stones)

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56
Q

Management of acute cholecystitis?

A

o NBM
o IV analgesia (diclofenac75mg IM if severe) and antiemetic
o IV Fluids if needed
o Bloods – FBC (Raised WCC, ALP and bilirubin), U&Es, glucose, amylase, LFTs (post hepatic – raised ALP, bilirubin)
o CXR, ECG (atypical MI)
o USS confirm diagnosis (tenderness on pressing USS transducer over area of thickened gallbladder containing stones called ultrasonic Murphy’s sign)
o IV Abx (co-amoxiclav + metronidazole)
o Refer to surgery
 Laparoscopic cholecystectomy (within 1 week or after acute episode subsided - 4 weeks)

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57
Q

Management of chronic cholecystitis?

A

o USS – small shrunken gall bladder, measure CBD diameter
o Cholecystectomy if dilated CBD with stones
o If symptoms persist then consider other causes

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58
Q

Management of acute cholangitis?

A 
o	NBM
o	IV analgesia and antiemetic
o	IV fluids
o	Bloods – FBC (Increased WCC), LFTs (Raised bilirubin, ALP)
o	USS – dilated CBD
o	IV Abx (Co-amoxiclav and Metronidazole)
o	ERCP – biopsy, drainage, stenting
o	May need laparoscopic cholecystectomy
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59
Q

Complications of biliary tract infections?

A 
o	Mucocele
o	Empyema
o	Carcinoma
o	Mirizzis’s Syndrome
	Stone on GB presses on bile duct causing jaundice
o	Pancreatitis
o	Gallstone Ileus
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60
Q

Definition of portal hypertension?

A
  • Abnormally high pressure in hepatic portal vein

- Hepatic venous pressure gradient >10mmHg

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61
Q

Pathophysiology of portal hypertension?

A

o Increased vascular resistance in portal venous system contributes to abnormal blood flow patterns
o Increased blood flow in portal veins – vasodilatation
o Raised pressure opens up collateral vessels:
 GOJ – producing varices
 Anterior abdominal wall – via umbilical vein – caput medusae
o Hypervolaemia and salt and water retention

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62
Q

Causes of portal hypertension - pre-hepatic?

A

 Thrombosis (portal or splenic vein)

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63
Q

Causes of portal hypertension - intra-hepatic?

A 
	Cirrhosis (80%)
	Schistosomiasis
	Sarcoid
	Myeloproliferative diseases
	Congenital hepatic fibrosis
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64
Q

Causes of portal hypertension - post-hepatic?

A

 Budd-Chiari syndrome
 RHF
 Constrictive pericarditis
 Veno-occlusive disease

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65
Q

Symptoms of portal hypertension?

A

o Dilated veins in anterior abdominal wall – caput medusae
o Splenomegaly
o Ascites

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66
Q

Signs of liver failure?

A 
o	Jaundice
o	Spider naevi
o	Palmar erythema
o	Liver flap
o	Fetor hepaticus
o	Low BP
o	Enlarged liver
o	Gynaecomastia
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67
Q

Complications of portal hypertension?

A

o Haematemesis – bleeding varices
o Lethargy, irritability – encephalopathy
o Increased weight, abdomen – ascites
o Abdominal pain and fever - SBP

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68
Q

Investigations of portal hypertension?

A 
o	LFT
o	U&E
o	Glucose
o	FBC
o	Clotting 
o	If liver disease not known – ferritin, hepatitis serology, autoantibodies, alha-1-antitrypsin, ceruloplasmin
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69
Q

Imaging of portal hypertension?

A

o Abdominal USS
o Doppler US
o Spiral CT scan if US inconclusive

  • Endoscopy – for oesophageal varices
  • Portal pressure by hepatic venous pressure gradient
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70
Q

Management of portal hypertension - drug treatment?

A

o Beta-blockers
o Nitrates
o Terlipressin and octreotide – acute variceal bleeding

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71
Q

Management of portal hypertension - endoscopy?

A
  • Endoscopic procedures:

o Vein ligation – prevent varices bleeding

72
Q

Management of portal hypertension - shunting?

A
  • Transjugular intrahepatic portosystemic shunt (TIPS)
    o Connecting portal and hepatic veins using stent to reduce pressure
    o Useful in ascites, varices if refractory to treatment
73
Q

Management of portal hypertension - surgical?

A

o Portosystemic shunt

o Gastro-oesophageal devascularisation

74
Q

Complications of portal hypertension?

A

o Ascites – SBP
o Hepatorenal syndrome – impaired renal function with cirrhosis
o Portopulmonary hypertension
o Hepatopulmonary syndrome – triad of hepatic dysfunction, hypoxaemia and extreme vasodilation in form of intrapulmonary vascular dilations
o Liver failure
o Hepatic encephalopathy

75
Q

What is Hepatitis A?

A
  • Hepatitis A: Single-stranded RNA Picornavirus

- Replicates in hepatocytes interfering with cell function and causing inflammation

76
Q

Clinical phases of Hepatitis A?

A

o Incubation (28-30 days)
o Prodromal
o Icteric
o Convalescent

77
Q

Spread of Hepatitis A?

A
  • Spread by faecal-oral route by ingestion of contaminate food (shellfish), water
    o Shed in faeces for 2 weeks before and 1 week after onset of jaundice
78
Q

Epidemiology of Hepatitis A?

A
  • Uncommon in UK
  • Endemic in low income countries (India, Pakistan, Bangladesh, Nepal, Africa, Far East, Middle East, Central and South America)
79
Q

Risk factors of Hepatitis A?

A

o Travellers to high prevalent areas
o MSM/risk sexual practices
o IVDU
o Occupation – care homes, sewage work, primates

80
Q

Symptoms of prodromal phase of Hepatitis A?

A

o Flu-like (fatigue, malaise, arthralgia, myalgia, low-grade fever)
o N&V, RUQ pain
o Headache, diarrhoea/constipation, itch

81
Q

Symptoms of icteric phase of Hepatitis A?

A

o Jaundice, pale stool, dark urine if cholestasis
o Pruritus
o Fatigue, anorexia, N&V
o Hepatomegaly, splenomegaly

82
Q

Symptoms of convalescent phase of Hepatitis A?

A

Malaise, anorexia, muscle weakness and hepatic tenderness

83
Q

Bloods to perform in Hepatitis A?

A

o LFTs – elevated ALT/AST, raised bilirubin

o Raised PT

84
Q

Serology testing in Hepatitis A?

A

o HAV-specific IgM
 Positive = acute infection (detectable after 3 weeks)

o HAV-IgG
 Positive = current or past hepatitis A infection or immunity from vaccination

85
Q

Interpretation of serology testing in Hepatitis A?

A

o Interpretation
 Positive HAV-IgM and HAV-IgG = acute hepatitis A
 High IgG reactivity and moderate level of IgM = hepatitis A infection in recent past
 Positive HAV-IgM and negative HAV-IgG = may be false positive
 Negative HAV-IgM and positive HAV-IgG = past hepatitis A infection of immunity from past vaccination

o If taken within 10 days of symptoms, repeat after 1-2 weeks later

86
Q

Diagnosis of Hepatitis A?

A

o Clinical case – acute illness, and jaundice or elevated serum aminotransferase levels
o Confirmed case – meets clinical case definition and has IgM and IgG antibodies to hepatitis A

87
Q

Management of Hepatitis A - prevention - who to vaccinate?

A

 Travellers to prevalent area (at least at 2 weeks before departure), clotting factor disorder, chronic liver disease, MSM, sex workers, IVDU, occupational risk

88
Q

Management of Hepatitis A - prevention - when to perform pre-vaccination serology?

A

Pre-vaccination serology for HAV-IgG
 People from highly endemic areas, prior history of hepatitis or jaundice and MSM
 If not immune then vaccinate (2 doses of monovalent Hepatitis A vaccine at 0 and 6-12 months)

89
Q

Management of Hepatitis A - prevention - what is the vaccine?

A

 Monovalent hepatitis A vaccine – single dose then booster dose 6-12 months later if remains at long-term risk of contracting hepatitis A

90
Q

Management of Hepatitis A - prevention - general advice?

A

 Wash hands after toilet and before food prep
 Good personal hygiene
 Practice safe sex
 Avoid reusing injecting equipment
 Vaccinate against Hep B too
 Travellers – avoid water and food contaminated with faeces (salads, shellfish)

91
Q

Management of Hepatitis A - when to admit?

A

systemically unwell

92
Q

Management of Hepatitis A - general advice?

A

 Avoid alcohol during illness

 Avoid work/school/nursery until 7 days after onset of jaundice or symptoms

 Hand washing, good hygiene, avoid food handling

 Avoid UPSI (including oro-anal and oro-genital contact until no longer infectious

 Avoid needle sharing

 Symptomatic Care
• Pain – PRN paracetamol (if bilirubin >300 or PT>3 seconds reduce dosage to maximum of 1 gram BDS/TDS), ibuprofen
• Nausea – metoclopramide or cyclizine
• Itch – cool environment, avoid hot baths/showers, chlorphenamine

93
Q

Management of Hepatitis A - notification?

A

o Notify Health Protection Unit (HPU)

94
Q

Management of Hepatitis A - follow up?

A

 Every 1-2 weeks
 LFT – 3-5 days after diagnosis and weekly until improvement, then monthly until normal
• If jaundice or symptoms – twice a week
• If significantly abnormal LFTs – every 1-2 days

95
Q

Management of Hepatitis A -person in contact with Hep A?

A

o Contact HPU – advise on management (includes vaccine, human normal Ig)

96
Q

Prognosis of Hepatitis A?

A
  • Self-limiting which lasts <2 months, complete recovery may take up to 6 months
  • Result in lifelong immunity
  • No chronic sequelae
97
Q

Complications of hepatitis A?

A
  • Relapse in 15%
  • Cholestasis which resolves
  • Rarely, fulminant liver disease (severe vomiting, irritability, confusion, encephalopathy & coagulopathy)
98
Q

Description of Hepatitis B?

A 
-	Hepatitis B = enveloped DNA virus
o	Consists of core antigen surrounded by surface antigen
o	8 (A-H) genotypes
99
Q

Definition of acute hepatitis B?

A

o Usually self-limiting

o HBV penetrates hepatocytes and immune response causes inflammation

100
Q

Definition of chronic hepatitis B?

A

o Occurs when failure to clear virus, causing persistent HBsAg for >6 months
o Can lead to cirrhosis and HCC

101
Q

Transmission of Hepatitis B?

A 
Blood-to-blood contact
	Sharing needles
	Needlestick injury
	Blood transfusion
	Tattoo, body piercings, acupuncture
	Sharing razors

Sexual transmission

Vertical transmission

102
Q

Epidemiology of Hepatitis B?

A
  • Most common viral hepatitis

- Prevalent most in Africa, Asia and Pacific Islands

103
Q

High risk of Hepatitis B?

A 
o	IVDU
o	MSM/Many sexual partners
o	Travellers to high prevalence areas
o	Sex workers
o	Household contacts of people with Hepatitis B
o	Regular blood products
o	CKD, chronic liver disease
104
Q

Symptoms of Hepatitis B?

A 
-	Prodromal illness
o	Fever, arthralgia, rash
-	Fatigue, fever, nausea, anorexia
-	RUQ pain
-	Jaundice, pale stools, black urine
105
Q

Signs of Hepatitis B?

A

o Hepatosplenomegaly

o Signs of chronic liver disease

106
Q

When to test serology of HepB?

A

o Asymptomatic and in high risk group
 IVDU, MSM, sex workers, sexual assault, needlestick injury, HIV-positive, CKD/cirrhosis

o Clinical Features of acute or chronic infection

o Abnormal LFTs
 Raised AST/ALT, raised bilirubin, PT prolonged

107
Q

How to test Hep B serology?

A

o Serological testing of HBsAg, HBeAg, Anti-Hbe, anti-HBc, anti-HBs, anti-Hbc IgG, IgM anti-HBc, HBV DNA

108
Q

What initial serology tests should be perform in Hep B?

A

 Initially at least – HbsAg and anti-HBc

 Further tests may be required depending on findings

109
Q

Interpretation of HBsAg and anti-HBc IgM?

A

 Positive HBsAg and anti-HBc IgM = acute infection

 Positive HBsAg and negative anti-HBc IgM = chornic infection

110
Q

Markers of Hep B serology?

A
  • HBsAg – present for 1-6 months after exposure and remains in chronic
  • HBeAg & HBV-DNA – detectable around same time as HBsAg, high infectivity and chance of chronic progression
  • IgM Anti-HBc – first antibody to rise – infection within 6 months, appear within 1 month of HBsAg, reduces gradually
  • IgG Anti-HBc – persists for life, past infection
  • Anti-HBs – recovery or vaccination
111
Q

Interpretation of serology - susceptible?

A

o All negative

112
Q

Interpretation of serology - active infection?

A

o Positive for HBsAg, HBeAg, anti-HBc, IgM anti-HBc, HBV DNA

o Negative for Anti-HBs, Anti-HBe

113
Q

Interpretation of serology - immunity following infection?

A

o Positive for Anti-HBs, Anti-HBc

114
Q

Interpretation of serology - immunity following vaccination?

A

o Positive for Anti-HBs

115
Q

Interpretation of serology - chronic Hep B infection?

A

Positive for HBsAg, Anti-HBc, HBV-DNA

116
Q

Other tests to perform in Hep B?

A 
	Hepatitis B screen, C screen, A screen
	HIV test
	LFTs
	FBC
	Prothrombin time
	AFP
	Liver US
117
Q

Management of Hepatitis B - prevention - immunisation?

A

o Immunisation (HBsAg) and serology testing
 Babies born to infected mothers – 0, 1, 2 months
 Needlestick injury, imminent travel – over 21 days
 Others, not rapid protection – 0, 1 and six months
• If serology demonstrates immunity then do not give other doses

o Immunoglobulin prophylaxis with vaccinations if exposed to infected blood or body fluids (IM within 48 hours of exposure and at same time as vaccine)

118
Q

Management of Hepatitis B - when to admit?

A

o Admit if systemically unwell

119
Q

Management of Hepatitis B - notification?

A

o Notify Health Protection Unit

120
Q

Management of Hepatitis B - general advice?

A

 Avoid sharing razors, scissors, UPSI until non-infectious, needle sharing
 Do not donate blood or carry organ donor card
 Avoid alcohol
o Chronic Hepatitis B – vaccinate against Hepatitis A

121
Q

Management of Hepatitis B -symptomatic management?

A

 Pain – PRN paracetamol, ibuprofen
 Nausea – metoclopramide or cyclizine
 Itch – cool environment, avoid hot baths/showers, chlorphenamine

122
Q

Management of Hepatitis B - follow up?

A

 Hepatitis serology repeated at 6 months (HBsAg after 6 months indicates chronic infection)
 Regular liver specialist review

123
Q

Management of Hepatitis B - Referral?

A
  • Refer ALL with positive HBsAg to hepatologist/GI/ID for further treatment (pregnant women within 6 weeks)
124
Q

Management of Hepatitis B - assessment in secondary care?

A 
Transient Elastography
•	<6kPa
o	Liver biopsy (if <30, HBV DNA >2000 and ALT >30 (19F) on 2 consecutive tests 3 months apart)
•	6-10kPa
o	Liver biopsy
•	>10kPa
o	Offer antiviral treatment

Annual elastography if no antivirals

125
Q

Management of Hepatitis B - when to offer antivirals?

A

 >30 with HBV DNA >2000 and ALT > 30M (19F) on 2 consecutive tests 3 months apart

 <30 with HBV DNA >2000 and ALT > 30M (19F) on 2 consecutive tests 3 months apart if evidence of fibrosis/necroinflammation on liver biopsy or elastography >6kPa

 Adults HBV DNA >20,000 and ALT > 30M (19F) on 2 consecutive tests 3 months apart regardless of age

 Transient Elastography >10kPa

126
Q

Management of Hepatitis B - when to monitor if antiviral not indicated?

A

 Children – ALT every 6 months if HBeAg positive (annually if HBeAg negative) and no fibrosis, every 3 months if abnormal ALT or HBV DNA

 Adults with HBeAg positive – every 6 months (every 3 months if increase in ALT)

 Adults with HBeAg negative, HBVDNA<2000, ALT <30(19) – every 48 weekss ALT and HBV DNA

127
Q

Management of Hepatitis B - antiviral therapy - pregnant women?

A

Tenofovir (if HBV DNA >10 in 3rd trimester), stop 4-12 weeks after birth

128
Q

Management of Hepatitis B - antiviral therapy - children?

A

48 week course of peginterferon alfa-2a

129
Q

Management of Hepatitis B - antiviral therapy - immunosuppressed?

A

Entecavir or tenofovir if HBsAg positive or HBV DNA >2000

130
Q

Management of Hepatitis B - antiviral therapy - compensated Hep B??

A

Peginterferon alfa-2a 48-week course

131
Q

Management of Hepatitis B - antiviral therapy - decompensated Hep B?

A

Entecavir and liver transplant

132
Q

Management of Hepatitis B - antiviral therapy - co-infection with Hep C?

A

peginterferon alfa & ribavirin

133
Q

Management of Hepatitis B - antiviral therapy - co-infectin with Hep D?

A

48-week peginterferon alfa-2a

134
Q

Monitoring of decompensated Hep B?

A

• FBC, LFT, U&E, phosphate, clotting, HBV DNA and HBeAg before and weekly

135
Q

Monitoring of compensated Hep B?

A
  • Review injection technique and effects weekly for 1 month

* FBC, LFT, U&E, TFT, HBV DNA, HBsAg, HBeAg – before and 48 weeks

136
Q

HCC surveillance in Hep B?

A

 6-montly liver US and AFP test in fibrosis or cirrhosis, OR if >40 with FHx and HBV DNA >20,000

137
Q

Complications of Hep B?

A

o Both - glomerulonephritis, vasculitis, polyarteritis
o Acute - Fulminant hepatitis 1%
o Chronic – liver fibrosis, cirrhosis (15%), HCC

138
Q

Definition of Hepatitis C?

A
  • Slow, progressive disease of liver caused by Hep C

- Blood-borne virus

139
Q

Types of Hepatitis C?

A
  • Acute = HCV immediately following incubation (2-6 weeks) to within 6 months of acquiring infection
  • Chronic = following acute Hepatitis C, presence of HCV >6 months after acquiring infection
140
Q

Causes of Hepatitis C?

A

o Blood-borne RNA virus (Flaviviridae, Hepacivirius)

o 6 different strains of HepC

141
Q

Risk factors of Hepatitis C?

A 
o	IVDU
o	Blood transfusions, blood products
o	Tattoos or body piercing
o	Sharing razors
o	Needlestick injuries
o	Mother-to-baby transmission
o	Sexual – anal, traumatic sex
o	Travelling to Egypt, Pakistan, China
142
Q

Symptoms of Hepatitis C?

A

o Malaise (flu-like, fatigue, myalgia, anxiety, poor concentration)
o N&V
o RUQ pain
o Jaundice

143
Q

Signs of Hepatitis C?

A

o Signs of chronic liver disease

144
Q

When to screen people for Hepatitis C?

A

Screening high risk people
 IVDU, blood or organ recipients, babies born to infected mothers, healthcare workers (at risk of transmitted), tattoo/body piercing where unsterilized equipment, positive for Hepatitis B

Clinical features of hepatitis

Abnormal LFTs (ALT >10x raised)

145
Q

How to test in GP for people of Hepatitis C?

A

Clotted blood sample for HCV antibodies
 If positive – second sample for confirmation
 If negative – repeat if high risk (>3 months after exposure)

HCV RNA and genotype analysis (if HCV positive or immunocompromised)
 If positive – repeat
 If negative – repeat after 6 months

146
Q

Management of Hepatitis C - primary care referral?

A
  • Same-day assessment - acute hepatitis C infection

* Urgent referral – chronic hepatitis C infection

147
Q

Management of Hepatitis C - primary care general measures?

A 
•	Notify local Health Protection Team
Arrange baseline investigations:
o	Hep C RNA and genotyping
o	FBC, U&amp;E, LFTs, clotting, HbA1c, TFTs, ferritin
o	HBsAg, anti-HBc, HAV-IgM
o	HIV

Stop alcohol intake

Stop smoking

Maintain healthy body weight

Safe sex advice

Hep A & B vaccines

148
Q

Management of Hepatitis C - primary care follow up?

A

• Regular reviews under GI

149
Q

Management of Hepatitis C - specialist investigations?

A

 Blood – viral load, clotting, autoantibodies
 Transient elastography
 Liver US
 Liver biopsy

150
Q

Management of Hepatitis C - specialist treatments?

A

Antivirals
• All people with chronic HCV infection
• SC pegylated-interferon alpha + daily oral ribivirin
• Regular blood tests

Liver transplant with end-stage liver disease

151
Q

Management of Hepatitis C - surveillance?

A

o If established cirrhosis – 6-monthly US and AFP testing

152
Q

Management of Hepatitis C - screening?

A

o Annual tests for hepatitis C if risk factors

153
Q

Prognosis of HepatitisC?

A

o 25-50% clear virus without treatment

o 50% will develop chronic Hepatitis C

154
Q

Complications of Hepatitis C?

A 
o	Acute – fulminant hepatitis (<1%)
o	Chronic
	Cirrhosis
	HCC
	Decompensated liver disease
155
Q

Definition of Hepatitis D?

A
  • Defective, single-stranded RNA virus
  • Requires presence of HBV to replicate (HBsAg) in hepatocytes
  • Transmitted by infected blood or blood products
156
Q

Risk groups of Hepatitis D?

A 
o	IVDU
o	MSM/Many sexual partners
o	Travellers to high prevalence areas
o	Sex workers
o	Household contacts of people with Hepatitis B
o	Regular blood products
o	CKD, chronic liver disease
157
Q

Symptoms of Hepatitis D?

A 
o	Prodromal illness
	Fever, arthralgia, rash
o	Fatigue, fever, nausea, anorexia
o	RUQ pain
o	Jaundice, pale stools, black urine
o	Signs
	Hepatosplenomegaly
	Signs of chronic liver disease
158
Q

Symptoms of Hepatitis D if co-infected with Hep B?

A 
o	Prodromal illness
	Fever, arthralgia, rash
o	Fatigue, fever, nausea, anorexia
o	RUQ pain
o	Jaundice, pale stools, black urine
o	Signs
	Hepatosplenomegaly
	Signs of chronic liver disease
159
Q

Investigations of Hepatitis D?

A

Anti-HDV antibodies

Other:
o	Hepatitis B screen, C screen, A screen
o	HIV test
o	LFTs
o	FBC
o	Prothrombin time
160
Q

Management of Hepatitis D - drug treatment?

A
  • Pegylated interferon alpha

- Liver transplant

161
Q

Management of Hepatitis D - prevention of Hep B infection?

A

Immunisation (HBsAg) and serology testing
 Babies born to infected mothers – 0, 1, 2 months
 Needlestick injury, imminent travel – over 21 days
 Others, not rapid protection – 0, 1 and six months
• If serology demonstrates immunity then do not give other doses

Immunoglobulin prophylaxis with vaccinations if exposed to infected blood or body fluids (IM within 48 hours of exposure and at same time as vaccine

162
Q

Definition of Hepatitis E?

A
  • RNA virus
  • Faecal-oral route – contaminated water supplies
  • HEV genotype 3 and 4 infects human and can be caught from pigs
163
Q

Epidemiology of Hepatitis E?

A
  • Indian, Central and Southeast Asia, Middle East, Africa

- Mortality is high in pregnancy

164
Q

Route of infection of Hepatitis E?

A

o Contaminated drinking water
o Person-to-person
o From pigs, cows, primates

165
Q

Symptoms of prodromal phase of Hepatitis E?

A

o Flu-like (fatigue, malaise, arthralgia, myalgia, fever)
o N&V, RUQ pain
o Headache, diarrhoea/constipation, itch

166
Q

Symptoms of icteric phase of Hepatitis E?

A

o Jaundice, pale stool, dark urine if cholestasis
o Pruritus
o Fatigue, anorexia, N&V
o Hepatomegaly, splenomegaly

167
Q

Symptoms of convalescent phase of Hepatitis E?

A

o Malaise, anorexia, muscle weakness

168
Q

Investigations of Hepatitis E?

A
  • Hepatitis serology

- IgM and IgG to anti-HEV in serum

169
Q

Supportive management of Hepatitis E?

A

o Avoid alcohol during illness
o Avoid work/school/nursery until 7 days after onset of jaundice or symptoms
o Hand washing, good hygiene, avoid food handling
o Avoid UPSI (including oro-anal and oro-genital contact until no longer infectious
o Avoid needle sharing
o Symptomatic Care
 Pain – PRN paracetamol, ibuprofen
 Nausea – metoclopramide or cyclizine
 Itch – cool environment, avoid hot baths/showers, chlorphenamine
o Notify Health Protection Unit (HPU)

170
Q

Prevention of Hepatitis E?

A

o Good hand hygiene, sanitation

o Avoid tap-water in high-risk areas

171
Q

Prognosis of Hep E?

A
  • Usually self-limiting

- Mortality low but increased in pregnant women (25%)

172
Q

What is gallstone ileus in gallstones?

A

Rare form of small bowel obstruction due to impaction of a gallstone within lumen of the small intestine

Gallstone enters the bowel via a cholecysto-enteric fistula

Most commonly at distal ileum, proximal to the ileocecal valve

173
Q

What is Mirizzi’s syndrome in gallstones?

A

Gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common hepatic duct, resulting in obstruction and jaundic

174
Q

What is Bouveret syndrome in gallstones?

A

Gastric outlet obstruction secondary to impaction of a gallstone in the pylorus or proximal duodenum

175
Q

What is Riglers triad in gallstone?

A

Bowel obstruction, pneumobilia, and an ectopic gallstone

176
Q

What is porcelain gallbladder?

A

A calcification of the gallbladder believed to be brought on by excessive gallstones in chronic cholecystitis

50% malignancy risk of cholangiocarcinoma - need to remove gall bladder

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