Gastrointestinal - Level 2.3 Flashcards
1
Q
Definition of cirrhosis?
A
o Cirrhosis develops progressively as a result of damage to the liver
o Normal smooth liver surface becomes distorted, nodular and fibrosed
Distortion of hepatic vasculature, increased intrahepatic resistence and portal hypertension
Damaged hepatocytes cause less synthesis of clotting factors and metabolic detoxification
2
Q
Types of cirrhosis?
A
o Compensated – liver still functions effectively and no/few symptoms
o Decompensated – liver damaged where it cannot function adequately and clinical complications present (jaundice, ascites, variceal haemorrhage, hepatic encephalopathy)
3
Q
Epidemiology of cirrhosis?
A
- More common in urban areas, social deprivation
4
Q
Common risk factors of cirrhosis?
A
Alcohol misuse
Hepatitis B/C
Obesity (>30)
T2DM
5
Q
Less common risk factors of cirrhosis?
A
Autoimmune liver disease (AH, PBC, PSC)
Genetic (haemochromatosis, Wilson’s disease, alpha-1-antitrypsin deficiency, CF)
Methotrexate use
Budd-Chiari syndrome
Sarcoidosis
6
Q
Events causing decompensation in cirrhosis?
A
o Infection, portal vein thrombosis, surgery
7
Q
Symptoms of cirrhosis?q
A
o Asymptomatic o Malaise, fatigue, anorexia o Nausea o Weight loss o Muscle wasting o Abdominal pain o Oedema
8
Q
Signs of cirrhosis?
A
o Jaundice o Leuconychia o Palmar erythema o Dupuytren’s contracture o Scratch marks o Abnormal bruising o Keiser Fleischer rings o Hair loss o Gynaecomastia o Spider naevi o Caput Medusae o Hepatosplenomegaly o Peripheral oedema o Ascites o Sepsis o Variceal bleeding o Encephalopathy (asterixis – sudden involuntary flexion-extension movements of wrist and MCP joints when arms are extended and eyes closed)
9
Q
When to suspect cirrhosis?
A
o Clinical findings consistent
o Chronic liver disease with low platelets, raised AST:ALT ratio, high bilirubin, low albumin or increased INR/PT
10
Q
Diagnosing cirrhosis in primary care - when to perform transient elastography?
A
Transient elastography if:
Patient with Hep C infection
Men drinking >50 units per week for months
Women drinking >35 units per week for months
People diagnosed with alcohol-related liver disease
If not available, refer to hepatologist – liver biopsy
11
Q
Diagnosing cirrhosis in primary care - people with NAFLD?
A
o If NAFLD and advanced liver fibrosis (diagnosed with >10.51 on enhanced liver fibrosis test (ELF)):
Transient elastography or acoustic radiation force
12
Q
When to refer suspected cirrhosis to hepatologist/GI?
A
Hepatitis B PBC PSC Haemachromatosis Wilson’s disease
13
Q
Retesting in cirrhosis - if not diagnosed on initial testing?
A
If not diagnosed on initial testing – retest every 2 years in:
Alcohol-related liver disease, Hep C, NAFLD or advance liver fibrosis
14
Q
Tests to find cause in cirrhosis?
A
o Ferritin, iron/total iron binding capacity o Hepatitis serology o Autoantibodies (ANA, AMA, SMA) o AFP o Alpha-1 anti-trypsin
15
Q
Grading of cirrhosis?
A
o Child-Pugh grading and risk of variceal bleeding
16
Q
Management of cirrhosis - referral to secondary care?
A
Diagnosed on transient elastography
Decompensated liver disease
Misuse alcohol
End-stage liver disease requiring symptom or palliative care
17
Q
Management of cirrhosis - primary care - general advice?
A
- Diet
- Alcohol abstinence
- Smoking cessation
- Driving – notify DVLA, cannot drive if hepatic cirrhosis with chronic encephalopathy
- Seek medical advice before taking OTC drugs
18
Q
Management of cirrhosis - primary care - symptom management?
A
• Pruritus – colestyramine
19
Q
Management of cirrhosis - primary care - follow up?
A
- Review medications and change dose as required
* Ensure specialist follow up
20
Q
Management of cirrhosis - specialist care - management?
A
Upper GI endoscopy – detect varices
Liver transplant - Advanced cirrhosis due to:
Alcohol liver disease, hepatitis B&C, PBC, PSC, Wilson’s disease, alpha-1 antitrypsin deficiency
21
Q
Contraindications to liver transplant in cirrhosis?
A
o Extrahepatic malignancy, severe cardiopulmonary disease, sepsis, HIV, non-compliance with drug therapy
22
Q
Monitoring cirrhosis in secondary care?
A
Calculate Model for end-stage liver disease (MELD) score every 6 months for compensated cirrhosis – 12 or more high risk
US + AFP every 6 months for HCC
Upper GI endoscopy every 3 year
23
Q
Managing complications of cirrhosis?
A
1o prevention of bleeding - Endoscopic variceal band ligation
If upper GI bleeding – prophylactic antibiotics
Refractory Ascites - Transjugular intrahepatic portosystemic shunt
Cirrhosis with ascites with protein level <15 until resolved - Prophylactic oral ciprofloxacin
24
Q
Prognosis of cirrhosis?
A
o Irreversible – usually progresses over number of years
o Prognosis depends on cause, lifestyle, complications and hospital admissions
25
Complications of cirrhosis?
```
o Portal hypertension
o Ascites
o Hepatic Encephalopathy
o Oesophageal varices (haemorrhage)
o Infection
o Hepatorenal syndrome
o HCC
o Portal vein thrombosis
o Portal hypertensive gastropathy
o Anaemia, coagulopathy
```
26
Description of hepatic encephalopathy?
Dysfunction of brain due to liver insufficiency and related to nitrogenous waste products (ammonia and glutamine) in brain
Present with cognitive and behavioural changes, sleep disturbance, motor problems and altered consciousness
Predisposed by constipation, dehydration, infection, GI bleed, drugs (opiates, benzodiazepines, diuretics)
27
What is hepatorenal syndrome?
Changes to circulation due to cirrhosis with water and sodium retention and renal vasoconstriction
Decrease renal blood flow and reduced glomerular filtration rate
28
Definition of autoimmune hepatitis?
- Chronic disease with continuing hepatocellular inflammation and necrosis which progresses to cirrhosis
- HLA implicated
29
Types of autoimmune hepatitis?
o 1 – presence of ASMA or ANA
| o 2 – presence of anti-LKM-1 or anti-liver cytosolic 1 antibodies
30
Epidemiology of autoimmune hepatitis?
- Young/Middle Aged women but can occur in anybody
31
Associated conditions of autoimmune hepatitis?
- Associated disease: pernicious anaemia, UC, thyroiditis, T1DM, PSC, RA, glomerulonephritis
32
Symptoms of autoimmune hepatitis?
o Often insidious onset
o Fatigue, myalgia, pruritus, nausea
o Upper abdominal pain, anorexia, diarrhoea
33
Signs of autoimmune hepatitis?
Same as cirrhosis
34
Investigations of autoimmune hepatitis?
Bloods
o FBC - Normochromic anaemia
o LFTs - Raised ALT and AST
o Hypergammaglobulinaemia
Autoantibodies
o ANA, ASMA, ALKM1, ALC1
35
Diagnostic investigation of autoimmune hepatitis?
Liver biopsy - diagnostic
o Chronic hepatitis
o Mononuclear infiltrates
36
Management of autoimmune hepatitis?
Immunosuppression
o Prednisolone 30mg for 1 month and then decrease by 5mg each month to maintenance dose
o Azathioprine
Liver transplant
o If decompensated cirrhosis or failure to respond to medication, recurrence may occur
37
Definition of primary sclerosing cholangitis?
- Progressive cholestasis with bile duct inflammation and structures
38
Associated diseases of primary sclerosing cholangitis?
- Associated with males, HLA, AIH, IBD
39
Symptoms of primary sclerosing cholangitis?
o Asymptomatic
o Jaundice
o Pruritus
o If advanced – ascending cholangitis, cirrhosis and hepatic failure
40
Investigations of primary sclerosing cholangitis?
Bloods
o LFT – elevated ALP, GGT, bilirubin
o Abnormal albumin or PT if disease progressed
o Raised ANCA, aCL, ANA
US
o Bile duct dilatation and liver changes
MRCP to visualise the duct
Liver biopsy - staging
41
Management of primary sclerosing cholangitis - surveillance?
- Risk of bile duct, gall bladder, liver and colon cancer so:
o Yearly colonoscopy + US
42
Management of primary sclerosing cholangitis - Symptomatic control?
- Pruritus – colestyramine
- Nutrition – Fat-soluable vitamins – ADEK
- Prevent progression – ursodeoxycholic acid, avoid alcohol
- Stricture – ERCP balloon dilatation
43
Management of primary sclerosing cholangitis - end-stage liver disease?
- Liver transplant for end-stage liver disease
44
Definition of primary biliary cirrhosis?
- Progressive autoimmune disease of biliary system
- Destruction of interlobular bile ducts (canals of Hering) causing intrahepatic cholestasis which damages cells, leading to scarring, fibrosis and cirrhosis
- Women 10x
45
Causes of primary biliary cirrhosis?
- Causes by anti-mitochondrial antibody (AMA)
46
Symptoms of primary biliary cirrhosis?
- Asymptomatic
- Fatigue
- Pruritus
- RUQ pain
- Later stages – dark urine, pale stools
47
Investigations of primary biliary cirrhosis - bloods?
```
Bloods
o FBC (ESR raised)
o LFTs
ALP raised
o Late stage – raised bilirubin, PT and albumin
```
Antibodies (AMA present)
48
Investigations of primary biliary cirrhosis - imaging?
- US of liver
49
Investigations of primary biliary cirrhosis - diagnosis?
Liver biopsy
| o AMA with cholestatic liver biochemistry
50
Stages of primary biliary cirrhosis?
o Portal stage – portal inflammation and bile duct abnormalities
o Periportal stage – periportal fibrosis
o Septal – septal fibrosis and inflammation
o Cirrhotic – nodules with inflammation
51
Management of primary biliary cirrhosis - symptomatic?
```
o Pruritus – colestyramine
o Diarrhoea – codeine phosphate
o Fat-soluble vitamin ADEK
o Ursodeoxycholic acid
o Liver transplant for end-stage or intractable pruritus
```
52
Monitoring of primary biliary cirrhosis?
o Regular LFTs, AFP and liver US
53
Definition of hereditary haemochromatosis?
- Autosomal recessive deficiency of iron regulating hormone hepcidin
- Causes increased intestinal absorption of iron leading to accumulation in tissues, especially the liver, and organ damage (joints, liver, heart, pancreas, pituitary, adrenals, skin)
54
Causes of hereditary haemochromatosis?
- Caused by mutation on HFE gene on chromosome 6
| - Penetrance varies
55
Symptoms & signs of hereditary haemochromatosis?
- Symptoms start in 40-60 in men and post-menopausal women
- Fatigue
- Weakness, arthralgia
- Erectile dysfunction, decreased libido
- Amenorrhoea, hypogonadism
- Diabetes mellitus
- Arrhythmias, dilated cardiomyopathy
- Cirrhosis
- Impaired memory, mood swings and depression
- Slate-grey skin
56
Investigations if Northern European and features of hereditary haemochromatosis?
- If Northern European and features of HH:
| o FBC, LFTs, ferritin, transferrin saturation
57
Investigations if raised ferritin and transferrin with normal FBC in hereditary haemochromatosis?
- If raised ferritin and transferrin (>300 and 50% males, >200 and 40% females) with normal FBC:
o Genetic testing
58
Further investigations of hereditary haemochromatosis?
- MRI to defect and quantify hepatic iron excess
| - Biopsy not usually needed – by if so, Perl’s stain for iron
59
Investigations to family members in case of hereditary haemochromatosis?
- Offer lab testing to family members – FBC, LFTs, ferritin, transferrin and genetic testing
60
Management of hereditary haemochromatosis - when to refer?
- If serum ferritin >1000mcg/L and raised transaminases:
| o Refer to hepatologist for fibrosis assessment
61
Management of hereditary haemochromatosis - specialist management
```
- Venesection - weekly
o 400-500ml blood
o Aim for SF 20-30 and Tsat <50%
o Monitor FBC and SF/Tsat
o Maintenance every 2-3 months
```
- Desferrioxamine if intolerant to venesection
Liver Transplant
62
Management of hereditary haemochromatosis - monitoring?
o AFP and US every 6 months
63
Complications of hereditary haemochromatosis ?
- Liver fibrosis
- Cirrhosis
- HCC
64
Definition of Wilson's Disease?
- Inherited disorder of biliary copper excretion with excess copper in liver and CNS
o ATPase mutation prevents movement of copper across intracellular membranes and supports excretion of copper in bile
65
Causes of Wilson's Disease?
- Caused by autosomal recessive mutation in ATP7B, on chromosome 13
- Onset during 20-30s
66
Symptoms of Wilson's Disease?
- Young people with liver disease (hepatitis, cirrhosis, fulminant liver failure)
67
Signs of Wilson's Disease - neurological?
```
o Tremor
o Dysarthria
o Dysphagia
o Dyskinesia
o Dystonia
o Dementia
o Parkinsonism
o Ataxia
```
68
Signs of Wilson's Disease - mood?
o Depression, mania, labile emotions, decreased/increased libido, personality change
69
Signs of Wilson's Disease - cognition?
o Memory impairment, slow to solve problems, low IQ, delusions
70
Signs of Wilson's Disease -other?
- Kayser-Fleischer ring in iris
- Blue nails, arthritis, grey skin
- Cardiomyopathy, pancreatitis, infertility
71
Investigations of Wilson's Disease?
- Urine – 24h copper excretion is high (>100mcg/24h)
- Bloods (LFTs raised)
- Serum copper – typically <11
- Serum caeruloplasmin - <200mg/L (<140 is pathognomonic)
o Falsely low – nephrotic, protein deficient, chronic liver disease
o Falsely high – inflammation, infection, pregnancy
72
Diagnostic investigations of Wilson's Disease?
- Slit Lamp – Kayser-Fleischer rings in iris
- Liver biopsy – increased hepatic copper
- MRI
73
Management of Wilson's Disease - if family member diagnosed?
o Genetic testing of ATP7B gene
74
Management of Wilson's Disease - general advice?
Avoid alcohol
| Avoid eating food with high copper (liver, chocolate, nuts, mushrooms, legumes, shellfish)
75
Management of Wilson's Disease - drugs?
Lifelong penicillamine (500mg every 8 hours for 1y then maintenance of 0.75-1g/d)
• Chelating agent – excretes copper in urine
Zinc
Trientine dihydrochloride
o Liver transplant if severe liver disease
76
Management of Wilson's Disease - monitoring?
U&E, FBC, clotting
| Annual slit lamp study
77
Management of Wilson's Disease - follow up?
Lifelong follow-up
78
Definition of Budd-Chiari syndrome?
- Hepatic vein obstruction causes congestive ischaemia and hepatocytes damage
79
Causes of Budd-Chiari syndrome?
o Haematological – PCV, thrombophilia, antiphospholipid syndrome, PNH
o Blood flow – RHF, contractive pericarditis, right atrial myxoma
o Obstetric – during or postpartum
o Drugs – COCP, HRT
o Infection – amoebic abscess, aspillergosis, syphilis, TB
o Inflammations – IBD, sarcoid, SLE, Sjogrens
o Malignancy – HCC, RCC, Wilm’s tumour, adrenal carcinoma
o Trauma or surgery
80
Symptoms and signs of Budd-Chiari syndrome?
- RUQ pain
- Ascites
- Hepatomegaly
- Jaundice
- AKI
- Dilated abdominal wall veins
81
Investigations of Budd-Chiari syndrome?
- LFTs raised
- Ascitic tap – high in protein
- Doppler USS
- MRI/CT
82
Management of Budd-Chiari syndrome?
- Treat ascites
- Surgical
o Angioplasty
o Transjugular intrahepatic porto-systemic shunt
o Surgical shunt
- Anticoagulation lifelong
- Liver transplant if fulminant hepatic necrosis or cirrhosis
83
Physiology of alpha-1-antitrypsin?
o Glycoprotein produced in liver, serine protease inhibitor
| o Function – balance action of neutrophil-protease enzymes in lungs (neutrophil elastase)
84
Pathology of alpha-1-antitrypsin deficiency?
o Autosomal recessive deficiency means protein cannot pass out of liver and accumulates, leading to hepatocyte damage
o Deficiency leads to elastase breakdown of lungs alveolar walls and emphysema
85
Mutation of alpha-1-antitrypsin deficiency?
- Mutation on SERPINA1 gene on chromosome 14 – common amongst white people
86
Symptoms in lung of alpha-1-antitrypsin deficiency?
o Smokers develop earlier
| o COPD symptoms – diffuse emphysema – SOB, wheeze, cough
87
Symptoms in liver of alpha-1-antitrypsin deficiency?
o Hepatitis
o Cirrhosis
o Liver failure
88
Investigations of alpha-1-antitrypsin deficiency?
- LFTs abnormal
- Serum alpha1-antitrypsin levels low
- Liver biopsy
o Periodic acid Schiff (PAS) positive
o Diastase resistant globules
- Phenotype
- CXR, spirometry and CT for lung involvement
89
Management of alpha-1-antitrypsin deficiency -general measures??
- Family members investigated
| - Stop smoking
90
Management of alpha-1-antitrypsin deficiency - lung disease?
o COPD managed as COPD
o Lung transplant
o Pneumococcal and yearly influenza vaccines
91
Management of alpha-1-antitrypsin deficiency - liver disease?
o LFTs monitored
o Treat cirrhosis
o 6-monthly AFP and US – HCC
o Liver transplant
92
Definition of primary NAFLD?
Excess fat accumulation in liver (steatosis), where hepatocytes contain >5% of triglycerides which is not due to alcohol or secondary causes
o Spectrum of liver disease – associated with insulin resistance
o Ranges from hepatic steatosis, through to non-alcoholic steatohepatitis (NASH) which may progress to liver fibrosis and cirrhosis
o NASH is liver expression of metabolic syndrome
93
Definition of secondary NAFLD?
caused by drugs, Hep C and endocrine conditions
94
Epidemiology of NAFLD?
- NAFLD commonest cause of abnormal LFT
- Commonest cause of liver disease in western countries
- Prevalence highest in males aged 40-60
- Doubled in last 20 years
95
Cause of NAFLD?
o Thought to be due to insulin resistance, obesity and metabolic syndrome
o Also, oxidative stress and blood flow compromise
96
Risk factors of NAFLD?
```
o Metabolic – central obesity, T2DM, hypertension, hyperlipidaemia
o Obstructive sleep apnoea
o Polycystic ovary disease
o Hypothyroidism
o FHx of NAFLD
o Hispanic or Asian people
o Drugs – NSAIDs, amiodarone, corticosteroids, diltiazem, methotrexate and tamoxifen
o Hepatits C, Wilsons disease
```
97
Symptoms of NAFLD?
- Asymptomatic
- Mild fatigue, malaise
- RUQ abdominal discomfort
98
When to suspect NAFLD?
o Risk factors (T2DM, metabolic syndrome)
o Persistent elevation of LFT for >3 months – typically ALT 3x upper limit of normal and >AST
o Upper abdominal US – fatty changes (increased echogenicity)
• LFTs and US may be normal in NAFLD
99
Assessment of alcohol in NAFLD?
- Alcohol intake: <2.5 units per day for women and <3.75 units per day for men a cut-off
o If above this value then alcoholic fatty liver disease
100
Bloods to test in NAFLD - if indicated?
```
o LFT
o FBC
o Clotting
o Hep B&C serology
o Auto-antibodies
o Ferritin
o Serum caeruloplasmin
o Alpha-1-antitrypsin deficiency
o HbA1c
o Lipids
o U&E
o TFTs
o IgA TTG
```
101
Assessing risk of NAFLD?
Enhanced liver fibrosis test (ELF)
If >10.51 then advanced
Algorithm measuring hyaluronic acid, amino-terminal propeptide of type 3 procollagen (PIIINP) and tissue inhibitor of metalloproteinase 1 (TIMP-1)
NAFLD Fibrosis Score (intermediate or high score suggests fibrosis)
Fibrosis (FIB)-4 Score
102
When to diagnose advanced liver disease and refer to hepatology in NAFLD?
o NAFLD and ELF >10.51
103
How to investigate children <18 years old for NAFLD?
o Offer US if have T2DM or metabolic syndrome and do not misuse alcohol
o Refer all children suspected
o Diagnosed if US shows fatty liver and other causes ruled out
o Retest every 3 years if T2DM or metabolic syndrome and normal US
104
Management of NAFLD - general advice?
o Regular physical exercise
o Healthy diet
o Weight loss – 10% in 6 months
o Do not exceed weekly alcohol limits
105
Management of NAFLD - statins?
o Keep taking generally
| o Stop statins if liver enzyme doubles within 3 months of starting statins
106
Management of NAFLD - follow up in primary care?
o Annual – U&E, HbA1c, Lipids
| o 3-yearly – assess risk of liver fibrosis – ELF test
107
Management of NAFLD - referral to hepatology?
o High risk of advanced liver fibrosis – ELF>10.51
o Signs of advanced liver fibrosis
o Uncertainty
108
Management of NAFLD - secondary care investigations?
o Transient elastography (Fibroscan)
| o Liver biopsy
109
Management of NAFLD - secondary care - surveillance?
US and AFP every 6 months
110
Management of NAFLD - secondary care - drug treatments?
o Drug treatments – pioglitazone or vitamin E
| Re-test ELF after 2 years to see if effective – if risen then stop drug and switch
111
Management of NAFLD - secondary care - definitive treatment?
o Liver transplant
112
Prognosis of NAFLD?
o Depends on stage of disease and co-morbidities
Overweight, obese and T2DM at more risk or progression
o If simple steatosis – cirrhosis develops in only 0-4% of people over 10-20 years
o NASH has increased risk of HCC, cirrhosis and fibrosis
113
Complications of NAFLD?
```
o Morbidity from CVD and liver disease
Liver
• Portal hypertension
• Variceal haemorrhage
• Liver failure
• HCC
• Sepsis
Metabolic
• Hypertension, CKD, T2DM
CVD
• AF, MI, CVA
```
114
Definition of ascites?
- Fluid within peritoneal cavity
115
Pathology of ascites?
o Portal hypertension
o Secondary to salt and water retention
o Low Albumin
116
Definition and grading of uncomplicated ascites?
Not infected and not associated with hepatorenal syndrome
Graded:
1 (mild) – only detectable by USS
2 (moderate) – moderate symmetrical distention of abdomen
3 (severe) – marked abdominal distention
117
Definition and groups of refractory ascites?
Ascites that cannot be mobilised or early recurrence of which cannot be satisfactorily prevented by medical therapy
Groups:
Diuretic-resistant – refectory to diuretics and salt restriction
Diuretic-intractable – development of diuretic complications that preclude use
118
Causes of ascites - transudate?
```
Cirrhosis
Hepatic Outflow obstruction
Budd Chiari syndrome
Heart Failure
Constrictive pericarditis
Malignancy
Meig’s syndrome
```
119
Causes of ascites - exudate?
Peritoneal carcinomatosis/TB
Pancreatitis
Nephrotic syndrome
Lymph obstruction
120
Symptoms and signs of ascites?
- Discomfort
- Nausea and appetite suppression
- Fullness in flanks
- Fluid may push out umbilical hernias
- Shifting dullness, fluid thrill
- May be pleural effusion and peripheral oedema
121
Bloods to perform in ascites?
```
o FBC
o U&E
o LFTs
o Clotting (Prothrombin time)
o TFTs
```
122
Imaging to perform in ascites?
Abdominal USS
123
Diagnostic test in ascites?
- Diagnostic Paracentesis of 10-20ml of ascitic fluid
o Albumin (>11g/L in transudate, <11g/L in exudate)
o Neutrophil count (>250 SPB)
o Culture
o Amylase if suggestion of pancreatitis
o Cytology if suggestion of malignancy
124
Management of ascites - salt?
- Salt Restriction
o No-added salt diet, 5.2g salt/day
- If sodium <120mmol/L stop diuretics, caution when <135mmol/L
125
Management of ascites - drug therapy?
o Spironolactone from 100mg/day to 400mg/day
Add furosemide from 40mg/day up to 160mg/day if fails to resolve
Aim for weight loss <0.5kg/day
126
Management of ascites - further management?
- Therapeutic paracentesis (first line in large or refractory ascites)
o If <5 litres – plasma expander given
o If >5 litres – volume expander given using 8g albumin/litre of ascites removed
- Transjugular Intraheptic Portosystemic Shunt
o Used for treatment refractory ascites requiring frequent therapeutic paracentesis
- Liver transplant in cirrhotic ascites
127
Complications of ascites?
o Hyponatraemia
o Spontaneous Bacterial Peritonitis
o Hepatorenal syndrome
128
Definition of spontaneous bacterial peritonitis?
Ascitic neutrophil count of >250cells/mm3
| Commonly E.coli & Kleisiella
129
Symptoms of spontaneous bacterial peritonitis?
Symptoms – tender abdomen, fever, vomiting, deterioration, asymptomatic
130
Treatment of spontaneous bacterial peritonitis?
* Empirical Abx – Cefotaxime
* Prophylactic Abx – Norflaxacin 400mg/day
* Consider for liver transplant
* Albumin if renal impairment developing
131
Prognosis of ascites?
o 50% mortality over 2 years
| o Ascites signifies need to consider liver transplant
132
Definition of ulcerative colitis?
- Along with Crohn’s disease known as inflammatory bowel disease
- Chronic, relapsing-remitting, non-infectious inflammatory disease of GI tract
- Mucosa of rectum and colon affected
- Probable autoimmune condition triggered by environmental factors causing inflammation
133
Pathology of ulcerative colitis - macroscopic?
Begins in rectum and extends proximally
Continuous
Red mucosa, ulcers and pseudopolyps
Backwash ileitis
134
Pathology of ulcerative colitis - microscopic?
Mucosal inflammation
No granulomas
Goblet cell depletion
Crypt abscesses
135
Epidemiology of ulcerative colitis?
- Most common form of IBD
- Around 1 in 1000 prevalence
- Peak between 15-25 and 55-65 years
136
Risk factors of ulcerative colitis?
o Family History
o OCP
o NOT smoking
o Stress
137
Symptoms of ulcerative colitis?
```
o Episodic or chronic diarrhoea +/- blood/mucous
o Crampy abdominal discomfort
o Increased bowel frequency
o Urgency/Tenesmus = Rectal UC
o Fever/Malaise/Weight loss
```
138
Signs of ulcerative colitis?
```
o In acute UC – fever, tachycardia, tenderness
o Clubbing
o Aphthous Ulcers
o Erythema Nodosum
o Pyoderma gangrenosum
o Conjunctivitis/Episcleritis/Iritis
o Arthritis
```
139
Bloods if ulcerative colitis suspected?
Bloods
FBC (anaemia, low B12), ferritin, ESR, CRP, U&E, LFTs (raised platelets, abnormal LFTs), blood culture (if needed), TTG, Faecal calprotectin (sign of inflammation)
140
Cultures if ulcerative colitis suspected?
o Stool Culture
| M, C & S for C. diff, campylobacter, E.coli
141
Imaging to perform in ulcerative colitis?
o Colonoscopy
Allows biopsy and confirmation
o Barium Enema
Detects ileal disease
o AXR, Erect CXR – acute colitis
142
Severity assessment of ulcerative colitis?
Truelove and Witts Criteria
Based on bloody stools per day, pulse, temperature, Hb, ESR, CRP
143
Management of ulcerative colitis - referral?
- Urgent referral to gastroenterology
144
Management of ulcerative colitis - specialist investigations?
o Colonoscopy and biopsy – inflammation extending from rectum proximally, erythema, granulomas, ulceration, crypt abscesses
o CT scan to stage UC
145
Management of ulcerative colitis - surveillance?
Offer when symptoms started 10 years ago and have UC or Crohn’s colitis
Baseline colonoscopy with chromoscopy and targeted biopsy of any abnormal areas to determine risk
Low risk – colonoscopy at 5 years
Intermediate risk - colonoscopy at 3 years
High risk – colonoscopy at 1 year
146
Management of ulcerative colitis - symptoms management?
o Diarrhoea – bulk-forming laxative (ispaghula husk)
o Fistula – long term antibiotics (metronidazole or ciprofloxacin), surgery
o Abdominal pain – paracetamol 1st line, avoid NSAIDs when possible, chronic pain service
147
Management of ulcerative colitis - medical - inducing remission - mild-to-moderate proctitis/proctosigmoiditis/extensive UC?
5-ASA (sulfasalazine, mesalazine, olsalazine) OD topical dose
If no remission in 4 weeks – oral aminosalicylate
If further treatment needed - Oral or PR prednisolone for 2 weeks and decrease
148
Management of ulcerative colitis - medical - inducing remission - moderate to severe UC?
5-ASA (sulfasalazine, mesalazine, olsalazine) OD topical dose
If no remission in 4 weeks – oral aminosalicylate
If further treatment needed - Oral or PR prednisolone for 2 weeks and decrease
Tofacitinib
149
Management of ulcerative colitis - inducing remission - acute severe UC?
* MDT Management
* Assess likelihood of needing surgery (stool frequency >8/day, pyrexia, tachycardia, colonic dilation, low albumin, low Hb, high platelet, >CRP)
* NBM and IV fluids
* Prophylactic heparin
• Hydrocortisone IV
o IV Ciclosporin if cannot take IV steroids or not improvement within 72 hours
o Infliximab if ciclosporin contraindicated
• Surgery
o Indicated in perforation, haemorrhage, toxic dilatation, failed medical therapy
o Sub-total colectomy with rectal preservation
o Total proctocolectomy with ileostomy curative
• Daily bloods and X-rays
150
Management of ulcerative colitis - maintaining remission - proctitis or proctosigmoiditis?
• Topical ASA alone +/- oral ASA
151
Management of ulcerative colitis - maintaining remission - left sided and extensive UC?
• Low dose oral ASA
152
Management of ulcerative colitis - maintaining remission - other options?
• Oral azathioprine or mercaptopurine
| o If 2 or more inflammatory exacerbations in 12 months needing systemic corticosteroids
153
Management of ulcerative colitis - monitoring?
o Bloods – Vitamin B12, folate, calcium and vitamin D
154
Prognosis of UC?
o Lifelong relapses and remissions
| o May need colectomy, 1 in 10 after 10 years
155
Complications of UC?
```
o Bleeding
o Toxic Megacolon
o Colorectal cancer
o VTE
o Osteoporosis
```
156
Definition of Crohn's disease?
- Chronic inflammatory, relapsing and remitting inflammatory disease of GI tract
- Known with UC collectively as inflammatory bowel disease
- Inflammation involves discrete parts of the GI tract, anywhere from mouth to anus (called skip lesions)
- Full thickness of intestinal wall is inflamed
157
Pathology of Crohn's disease - macroscopic?
Affects all GI
Oral and perianal disease
Skip lesions
Deep ulcers and fissure in mucosa – cobblestone
158
Pathology of Crohn's disease - microscopic?
Transmural inflammation
| Non-caseating granulomas with Langerhans– 50%
159
Epidemiology of Crohn's disease?
- Mostly in terminal ileum
- 1 in 10000 incidences
- Peak 20-40 years
160
Aetiology of Crohn's disease?
Cause unknown
161
Risk factors of Crohn's disease?
```
o Familial
o Genetic
NOD2 and CARD15 genes confer risk
o Smoking
o Stress
o Gastroenteritis
o NSAIDs
```
162
Symptoms of Crohn's disease?
```
o Diarrhoea
o Urgency
o Abdominal Pain
o Weight Loss
o Fever/Malaise/Anorexia
o Nausea and Vomiting
```
163
Signs of Crohn's disease?
```
o Clubbing
o Aphthous ulcers
o Perianal abscesses/fistula/stricture
o Erythema nodosum
o Pyoderma gangrenosum
o Conjunctivitis/Episcleritis/Iritis
o Arthritis
o Ankylosing Spondylitis
```
164
Investigations of Crohn's disease?
- Bloods
o FBC (anaemia), CRP, ESR, U&E, LFTs (low albumin), ferritin, B12, coeliac screen,
o Faecal calprotectin (differentiate between IBD and IBS)
- Stool Sample
o M, C & S – for C. diff, Campylobacter, E. coli
- Colonoscopy and biopsy
- Barium Enema
165
Management of Crohn's disease - referral?
- If Crohn’s disease suspected, urgent referral to gastroenterologist for confirmation of diagnosis and treatment
166
Management of Crohn's disease - specialist investigations?
o Colonoscopy with histology – discontinuous colonic inflammation or ulceration, cobblestone appearance and rectal sparing
o CT used to stage Crohn’s disease
167
Management of Crohn's disease - education?
o Stop smoking
168
Management of Crohn's disease - symptom management?
o Diarrhoea – loperamide, bulk-forming laxative (ispaghula husk)
o Fistula – long term antibiotics (metronidazole or ciprofloxacin), surgery
o Abdominal pain – paracetamol 1st line, avoid NSAIDs when possible, chronic pain service
169
Management of Crohn's disease - inducing remision - stepwise approach?
Prednisolone/methylprednisolone/IV hydrocortisone – 12 months
• Consider aminosalicylate if prednisolone CI
Add azathioprine or mercaptopurine
• If 2 or more inflammatory exacerbations in 12 month period or steroids not tolerated
Add methotrexate
• If 2 or more inflammatory exacerbations in 12 month period or steroids not tolerated
Add Infliximab or adalimumab
170
Management of Crohn's disease - maintaining remission?
* Azathioprine or mercaptopurine
* Methotrexate
* Sulfasalazine
* Infliximab
* DO NOT GIVE STEROIDS
171
Managing complications of Crohn's disease?
Strictures – balloon dilation
| Fistula – plug insertion or ablation
172
Management of Crohn's disease - acute attack = mild?
• Prednisolone PO for 5 weeks
173
Management of Crohn's disease - acute attack - severe?
* Admit
* NBM, IV fluids
* IV & PR hydrocortisone
* Metronidazole
* Daily bloods and imaging
* If not improving, consider infliximab and adalimumab
174
Management of Crohn's disease - surgery?
o 50% need >1 operation
| o Aims to rest distal disease (pouch), resection (short-bowel syndrome)
175
Monitoring of Crohn's disease?
o Bloods – Vitamin B12, folate, calcium and vitamin
| d
176
Prognosis of Crohn's disease?
o Around 50% people need surgery
o Slightly higher mortality
o Poor prognosis with early, severe disease
177
Complications of Crohn's disease?
```
o Psychological impact
o Toxic dilatation
o Haemorrhage
o Abscesses, strictures, fistulas
o Anaemia, malnutrition
o Colorectal and small bowel cancer
o Osteopenia
```
