Gastrointestinal - Level 2.2 Flashcards
1
Q
Definition of inguinal hernia?
A
- Protrusion of abdominal or pelvic contents into inguinal canal
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)
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
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
5
Q
Contents of inguinal canal?
A
o External spermatic fascia (from IO), cremasteric fascia (from TA), internal spermatic fascia (from TF) covers cord
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
7
Q
Epidemiology of inguinal hernia?
A
- Most common hernia
- Men 8x more common
8
Q
Risk factors of inguinal hernia?
A
o Male, older age, smoking, FHx, constipation, chronic cough, pregnancy, heavy lifting, obesity
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
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
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)
12
Q
Management of inguinal hernia -general measures?
A
o Analgesia
o Fluids
o Stop smoking
o Weight loss
13
Q
Management of inguinal hernia - if small and asymptomatic?
A
o Watchful waiting
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
15
Q
Management of inguinal hernia - if incarcerated or strangulated?
A
o Urgent surgical repair and prophylactic antibiotics
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
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
18
Q
Epidemiology of femoral hernia?
A
- More in females
- Incidence increases with age
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
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
21
Q
Diagnosis of femoral hernia?
A
- Examination
- USS
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
23
Q
Complications of femoral hernia?
A
o Strangulation
o Obstruction
24
Q
Definition of incisional hernia?
A
- Protrusion of contents of a cavity through a previously made incision due to breakdown of muscle closure
25
Epidemiology of incisional hernia?
- 10-20% occurrence after surgery
| - More commonly following open surgery
26
Risk factors of incisional hernia?
- Smoking
- BMI >25
- Midline incision
- Infection
- Increased abdominal pressure – pregnancy, coughing, straining, weight lifting
27
Symptoms of incisional hernia?
o Non-pulsatile reducible, soft and non-tender swelling at or near site of previous surgical wound
o If incarcerated – painful, tender, erythema
28
Signs of incisional hernia?
o Mass is palpable which may be reducible
29
Diagnosis of incisional hernia?
- Clinical Examination
| - USS or CT may help
30
Management of incisional hernia - asymptomatic?
- If asymptomatic – can be managed conservatively
31
Management of incisional hernia symptomatic
- Surgery
o Reinforcing mesh repair
o Sutures
32
Complications of incisional hernia?
o Incarceration
o Strangulation
o Bowel Obstruction
33
Definition of umbilical hernia??
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
34
Types of umbilical hernia??
o Adult Umbilical Hernia – 90% are acquired
o Congenital (omphalocele, gastroschisis)
o Infantile – associated with prematurity
35
Epidemiology of umbilical hernia??
10-30% of all hernias
36
Risk factors of umbilical hernia??
o Obesity
o Ascites
o Low birth weight
o Pregnancy
37
Symptoms of umbilical hernia??
- Lump enlarges and may be multi-loculated
o Easily reducible
- Pain on coughing or straining
- Ache or dragging sensation
38
Diagnosis of umbilical hernia??
- Clinical Examination
39
Management of umbilical hernia??
- Surgery (if large enough >1.5cm or child >5)
| o Mayo repair – repair of rectus sheath
40
Definition of bile?
- Bile contains cholesterol, bile pigments and phospholipids
- Majority of biliary emergencies caused by gallstones – acute and chronic cholecystitis, biliary colic, ascending cholangitis
41
Definition of biliary colic?
Definition of acute cholecystitis?
o Temporary obstruction of cystic or CBD by stone
o Follow impaction of stone in cystic duct or neck of bladder
42
Definition of acute cholangitis?
o Infection of biliary tree and often secondary to CBD stones
43
Epidemiology of biliary tract infections?
- 8% of those over 40 years
| - 90% remain asymptomatic
44
Risk factors for biliary tract infection?
```
o Female
o Fat
o > Forty
o Fair – Caucasian
o Fertile – parity
o Smoking
o DM
```
45
Types of gallstones?
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
46
Symptoms of biliary colic?
o Short-lived recurrent episodes of epigastric/RUQ pain with radiation to back and right shoulder
o May have vomiting
47
Symptoms of acute cholecystitis?
Continuous epigastric/RUQ pain radiating to right shoulder and back
Fever, vomiting and local peritonism
48
Signs of acute cholecystitis?
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
49
Symptoms of chronic cholecystitis?
Chronic RUQ pain
Flatulent dyspepsia
Abdominal discomfort and distention
Fat intolerance
50
Common bile duct stones can cause what>
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
51
Symptoms of acute cholangitis?
* Charcot’s triad – RUQ pain, jaundice, fever/rigors
* Shock
* Urine dark and stools pale
52
Investigations in biliary colic?
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
53
Initial investigations in cholecystitis?
o Abdominal USS
o Bloods
FBC (Raised WCC, ALP and bilirubin), U&Es, glucose, amylase, LFTs (post hepatic – raised ALP, bilirubin)
54
Management of gallstones - if asymptomatic?
NONE
If asymptomatic common bile duct stones – offer bile duct clearance and laparoscopic cholecystectomy
55
Management of gallstones - if symptomatic?
General Advice
• Avoid food and drink which trigger symptoms
• Low fat diet
Analgesia
Elective laparoscopic cholecystectomy
• +/- bile duct clearance (if common bile duct stones)
56
Management of acute cholecystitis?
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)
57
Management of chronic cholecystitis?
o USS – small shrunken gall bladder, measure CBD diameter
o Cholecystectomy if dilated CBD with stones
o If symptoms persist then consider other causes
58
Management of acute cholangitis?
```
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
```
59
Complications of biliary tract infections?
```
o Mucocele
o Empyema
o Carcinoma
o Mirizzis’s Syndrome
Stone on GB presses on bile duct causing jaundice
o Pancreatitis
o Gallstone Ileus
```
60
Definition of portal hypertension?
- Abnormally high pressure in hepatic portal vein
| - Hepatic venous pressure gradient >10mmHg
61
Pathophysiology of portal hypertension?
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
62
Causes of portal hypertension - pre-hepatic?
Thrombosis (portal or splenic vein)
63
Causes of portal hypertension - intra-hepatic?
```
Cirrhosis (80%)
Schistosomiasis
Sarcoid
Myeloproliferative diseases
Congenital hepatic fibrosis
```
64
Causes of portal hypertension - post-hepatic?
Budd-Chiari syndrome
RHF
Constrictive pericarditis
Veno-occlusive disease
65
Symptoms of portal hypertension?
o Dilated veins in anterior abdominal wall – caput medusae
o Splenomegaly
o Ascites
66
Signs of liver failure?
```
o Jaundice
o Spider naevi
o Palmar erythema
o Liver flap
o Fetor hepaticus
o Low BP
o Enlarged liver
o Gynaecomastia
```
67
Complications of portal hypertension?
o Haematemesis – bleeding varices
o Lethargy, irritability – encephalopathy
o Increased weight, abdomen – ascites
o Abdominal pain and fever - SBP
68
Investigations of portal hypertension?
```
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
```
69
Imaging of portal hypertension?
o Abdominal USS
o Doppler US
o Spiral CT scan if US inconclusive
- Endoscopy – for oesophageal varices
- Portal pressure by hepatic venous pressure gradient
70
Management of portal hypertension - drug treatment?
o Beta-blockers
o Nitrates
o Terlipressin and octreotide – acute variceal bleeding
71
Management of portal hypertension - endoscopy?
- Endoscopic procedures:
| o Vein ligation – prevent varices bleeding
72
Management of portal hypertension - shunting?
- 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
Management of portal hypertension - surgical?
o Portosystemic shunt
| o Gastro-oesophageal devascularisation
74
Complications of portal hypertension?
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
What is Hepatitis A?
- Hepatitis A: Single-stranded RNA Picornavirus
| - Replicates in hepatocytes interfering with cell function and causing inflammation
76
Clinical phases of Hepatitis A?
o Incubation (28-30 days)
o Prodromal
o Icteric
o Convalescent
77
Spread of Hepatitis 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
Epidemiology of Hepatitis A?
- Uncommon in UK
- Endemic in low income countries (India, Pakistan, Bangladesh, Nepal, Africa, Far East, Middle East, Central and South America)
79
Risk factors of Hepatitis A?
o Travellers to high prevalent areas
o MSM/risk sexual practices
o IVDU
o Occupation – care homes, sewage work, primates
80
Symptoms of prodromal phase of Hepatitis A?
o Flu-like (fatigue, malaise, arthralgia, myalgia, low-grade fever)
o N&V, RUQ pain
o Headache, diarrhoea/constipation, itch
81
Symptoms of icteric phase of Hepatitis A?
o Jaundice, pale stool, dark urine if cholestasis
o Pruritus
o Fatigue, anorexia, N&V
o Hepatomegaly, splenomegaly
82
Symptoms of convalescent phase of Hepatitis A?
Malaise, anorexia, muscle weakness and hepatic tenderness
83
Bloods to perform in Hepatitis A?
o LFTs – elevated ALT/AST, raised bilirubin
| o Raised PT
84
Serology testing in Hepatitis 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
Interpretation of serology testing in Hepatitis 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
Diagnosis of Hepatitis 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
Management of Hepatitis A - prevention - who to vaccinate?
Travellers to prevalent area (at least at 2 weeks before departure), clotting factor disorder, chronic liver disease, MSM, sex workers, IVDU, occupational risk
88
Management of Hepatitis A - prevention - when to perform pre-vaccination serology?
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
Management of Hepatitis A - prevention - what is the vaccine?
Monovalent hepatitis A vaccine – single dose then booster dose 6-12 months later if remains at long-term risk of contracting hepatitis A
90
Management of Hepatitis A - prevention - general advice?
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
Management of Hepatitis A - when to admit?
systemically unwell
92
Management of Hepatitis A - general advice?
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
Management of Hepatitis A - notification?
o Notify Health Protection Unit (HPU)
94
Management of Hepatitis A - follow up?
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
Management of Hepatitis A -person in contact with Hep A?
o Contact HPU – advise on management (includes vaccine, human normal Ig)
96
Prognosis of Hepatitis A?
- Self-limiting which lasts <2 months, complete recovery may take up to 6 months
- Result in lifelong immunity
- No chronic sequelae
97
Complications of hepatitis A?
- Relapse in 15%
- Cholestasis which resolves
- Rarely, fulminant liver disease (severe vomiting, irritability, confusion, encephalopathy & coagulopathy)
98
Description of Hepatitis B?
```
- Hepatitis B = enveloped DNA virus
o Consists of core antigen surrounded by surface antigen
o 8 (A-H) genotypes
```
99
Definition of acute hepatitis B?
o Usually self-limiting
| o HBV penetrates hepatocytes and immune response causes inflammation
100
Definition of chronic hepatitis B?
o Occurs when failure to clear virus, causing persistent HBsAg for >6 months
o Can lead to cirrhosis and HCC
101
Transmission of Hepatitis B?
```
Blood-to-blood contact
Sharing needles
Needlestick injury
Blood transfusion
Tattoo, body piercings, acupuncture
Sharing razors
```
Sexual transmission
Vertical transmission
102
Epidemiology of Hepatitis B?
- Most common viral hepatitis
| - Prevalent most in Africa, Asia and Pacific Islands
103
High risk of Hepatitis B?
```
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
Symptoms of Hepatitis B?
```
- Prodromal illness
o Fever, arthralgia, rash
- Fatigue, fever, nausea, anorexia
- RUQ pain
- Jaundice, pale stools, black urine
```
105
Signs of Hepatitis B?
o Hepatosplenomegaly
| o Signs of chronic liver disease
106
When to test serology of HepB?
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
How to test Hep B serology?
o Serological testing of HBsAg, HBeAg, Anti-Hbe, anti-HBc, anti-HBs, anti-Hbc IgG, IgM anti-HBc, HBV DNA
108
What initial serology tests should be perform in Hep B?
Initially at least – HbsAg and anti-HBc
| Further tests may be required depending on findings
109
Interpretation of HBsAg and anti-HBc IgM?
Positive HBsAg and anti-HBc IgM = acute infection
| Positive HBsAg and negative anti-HBc IgM = chornic infection
110
Markers of Hep B serology?
* 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
Interpretation of serology - susceptible?
o All negative
112
Interpretation of serology - active infection?
o Positive for HBsAg, HBeAg, anti-HBc, IgM anti-HBc, HBV DNA
| o Negative for Anti-HBs, Anti-HBe
113
Interpretation of serology - immunity following infection?
o Positive for Anti-HBs, Anti-HBc
114
Interpretation of serology - immunity following vaccination?
o Positive for Anti-HBs
115
Interpretation of serology - chronic Hep B infection?
Positive for HBsAg, Anti-HBc, HBV-DNA
116
Other tests to perform in Hep B?
```
Hepatitis B screen, C screen, A screen
HIV test
LFTs
FBC
Prothrombin time
AFP
Liver US
```
117
Management of Hepatitis B - prevention - immunisation?
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
Management of Hepatitis B - when to admit?
o Admit if systemically unwell
119
Management of Hepatitis B - notification?
o Notify Health Protection Unit
120
Management of Hepatitis B - general advice?
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
Management of Hepatitis B -symptomatic management?
Pain – PRN paracetamol, ibuprofen
Nausea – metoclopramide or cyclizine
Itch – cool environment, avoid hot baths/showers, chlorphenamine
122
Management of Hepatitis B - follow up?
Hepatitis serology repeated at 6 months (HBsAg after 6 months indicates chronic infection)
Regular liver specialist review
123
Management of Hepatitis B - Referral?
- Refer ALL with positive HBsAg to hepatologist/GI/ID for further treatment (pregnant women within 6 weeks)
124
Management of Hepatitis B - assessment in secondary care?
```
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
Management of Hepatitis B - when to offer antivirals?
>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
Management of Hepatitis B - when to monitor if antiviral not indicated?
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
Management of Hepatitis B - antiviral therapy - pregnant women?
Tenofovir (if HBV DNA >10 in 3rd trimester), stop 4-12 weeks after birth
128
Management of Hepatitis B - antiviral therapy - children?
48 week course of peginterferon alfa-2a
129
Management of Hepatitis B - antiviral therapy - immunosuppressed?
Entecavir or tenofovir if HBsAg positive or HBV DNA >2000
130
Management of Hepatitis B - antiviral therapy - compensated Hep B??
Peginterferon alfa-2a 48-week course
131
Management of Hepatitis B - antiviral therapy - decompensated Hep B?
Entecavir and liver transplant
132
Management of Hepatitis B - antiviral therapy - co-infection with Hep C?
peginterferon alfa & ribavirin
133
Management of Hepatitis B - antiviral therapy - co-infectin with Hep D?
48-week peginterferon alfa-2a
134
Monitoring of decompensated Hep B?
• FBC, LFT, U&E, phosphate, clotting, HBV DNA and HBeAg before and weekly
135
Monitoring of compensated Hep B?
* Review injection technique and effects weekly for 1 month
| * FBC, LFT, U&E, TFT, HBV DNA, HBsAg, HBeAg – before and 48 weeks
136
HCC surveillance in Hep B?
6-montly liver US and AFP test in fibrosis or cirrhosis, OR if >40 with FHx and HBV DNA >20,000
137
Complications of Hep B?
o Both - glomerulonephritis, vasculitis, polyarteritis
o Acute - Fulminant hepatitis 1%
o Chronic – liver fibrosis, cirrhosis (15%), HCC
138
Definition of Hepatitis C?
- Slow, progressive disease of liver caused by Hep C
| - Blood-borne virus
139
Types of Hepatitis C?
- 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
Causes of Hepatitis C?
o Blood-borne RNA virus (Flaviviridae, Hepacivirius)
| o 6 different strains of HepC
141
Risk factors of Hepatitis C?
```
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
Symptoms of Hepatitis C?
o Malaise (flu-like, fatigue, myalgia, anxiety, poor concentration)
o N&V
o RUQ pain
o Jaundice
143
Signs of Hepatitis C?
o Signs of chronic liver disease
144
When to screen people for Hepatitis C?
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
How to test in GP for people of Hepatitis C?
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
Management of Hepatitis C - primary care referral?
* Same-day assessment - acute hepatitis C infection
| * Urgent referral – chronic hepatitis C infection
147
Management of Hepatitis C - primary care general measures?
```
• Notify local Health Protection Team
Arrange baseline investigations:
o Hep C RNA and genotyping
o FBC, U&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
Management of Hepatitis C - primary care follow up?
• Regular reviews under GI
149
Management of Hepatitis C - specialist investigations?
Blood – viral load, clotting, autoantibodies
Transient elastography
Liver US
Liver biopsy
150
Management of Hepatitis C - specialist treatments?
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
Management of Hepatitis C - surveillance?
o If established cirrhosis – 6-monthly US and AFP testing
152
Management of Hepatitis C - screening?
o Annual tests for hepatitis C if risk factors
153
Prognosis of HepatitisC?
o 25-50% clear virus without treatment
| o 50% will develop chronic Hepatitis C
154
Complications of Hepatitis C?
```
o Acute – fulminant hepatitis (<1%)
o Chronic
Cirrhosis
HCC
Decompensated liver disease
```
155
Definition of Hepatitis D?
- Defective, single-stranded RNA virus
- Requires presence of HBV to replicate (HBsAg) in hepatocytes
- Transmitted by infected blood or blood products
156
Risk groups of Hepatitis D?
```
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
Symptoms of Hepatitis D?
```
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
Symptoms of Hepatitis D if co-infected with Hep B?
```
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
Investigations of Hepatitis D?
Anti-HDV antibodies
```
Other:
o Hepatitis B screen, C screen, A screen
o HIV test
o LFTs
o FBC
o Prothrombin time
```
160
Management of Hepatitis D - drug treatment?
- Pegylated interferon alpha
| - Liver transplant
161
Management of Hepatitis D - prevention of Hep B infection?
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
Definition of Hepatitis E?
- RNA virus
- Faecal-oral route – contaminated water supplies
- HEV genotype 3 and 4 infects human and can be caught from pigs
163
Epidemiology of Hepatitis E?
- Indian, Central and Southeast Asia, Middle East, Africa
| - Mortality is high in pregnancy
164
Route of infection of Hepatitis E?
o Contaminated drinking water
o Person-to-person
o From pigs, cows, primates
165
Symptoms of prodromal phase of Hepatitis E?
o Flu-like (fatigue, malaise, arthralgia, myalgia, fever)
o N&V, RUQ pain
o Headache, diarrhoea/constipation, itch
166
Symptoms of icteric phase of Hepatitis E?
o Jaundice, pale stool, dark urine if cholestasis
o Pruritus
o Fatigue, anorexia, N&V
o Hepatomegaly, splenomegaly
167
Symptoms of convalescent phase of Hepatitis E?
o Malaise, anorexia, muscle weakness
168
Investigations of Hepatitis E?
- Hepatitis serology
| - IgM and IgG to anti-HEV in serum
169
Supportive management of Hepatitis E?
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
Prevention of Hepatitis E?
o Good hand hygiene, sanitation
| o Avoid tap-water in high-risk areas
171
Prognosis of Hep E?
- Usually self-limiting
| - Mortality low but increased in pregnant women (25%)
172
What is gallstone ileus in gallstones?
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
What is Mirizzi's syndrome in gallstones?
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
What is Bouveret syndrome in gallstones?
Gastric outlet obstruction secondary to impaction of a gallstone in the pylorus or proximal duodenum
175
What is Riglers triad in gallstone?
Bowel obstruction, pneumobilia, and an ectopic gallstone
176
What is porcelain gallbladder?
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
