GI Flashcards
What are the main causes Of liver cirrhosis
Alcohol related liver disease
NAFLD
Hep B
Hep C
Autoimmune hep
Wilsons/ haemochromatosis
Primary Hillary cirrhosis
What is in a non invasive liver screen
USS liver
Hep B/C serology
Autoanitbodies (ANA, SMA, AMA)
Immunoglobulins
Caeruloplasmin
Alpha-1 antitrypsin def
Ferritin and transferritin
What investigations are used to diagnose liver cirrhosis
USS - NAFLD- fatty changes= increased echo
Fibroscan- transient elastrography
What is the scoring system for cirrhosis
Child Pugh Score
Minimum score 5 max is 15
ABCDE
Albumin, bilirubin, clotting INR, dilation (ascites), encephalopathy
Do MELD score every 6 months for end stage liver disease in compensated liver cirrhosis
What is the management of bleeding oesophageal varices
Prevention- non selective bet a blockers or variecal band ligation
Bleeding varices- blood transfusion (major Haemoglobin protocol), FFP,vasopressin, somatostatin, broad spectrum abx, urgent endoscopy with vatical band ligation
What infection can occur in patients with ascites and how is it managed
Spontaneous bacterial peritonitis
Caused by E.Coli or Klebsiella pneumonia
Sample ascitic fluid for culture before giving abx
IV broad spectrum abx0 piperacillin with tazobactam
What are the stages of alcoholic liver disease
- Alcoholic fatty liver- hepatic steatosis - reversible with abstinence
2.Alcoholic hepatitis
- Cirrhosis
What is the main issue with alcohol withdrawal
Delerium tremens- under functioning GABA and over functioning glutamate - extreme brain excitability
Management: Chlorodiazepoxide- bento with dose reduced over 5-7 days
High dose B vitamins IM or IV and long term thiamine
What is Kernicke Korsakoff Syndrome
Thiamine deficiency causes confusion, ataxia etc
How do you diagnose NAFLD
1ST LINE- enhanced liver fibrosis (ELF) blood test - 10.51 or < = advanced fibrosis
ALT:AST <0.8
liver biopsy = gold standard but painful
How do you get Hep A
RNA- faecal oral route- contaminated water etc
Vaccine available
How do you get Hep b
DNA
Blood contact/ body fluids
Most recover, some will be chronic carriers
what are the different Hep B antibodies and what do they mean
HBsAG- surface antigen- active infection
HBeAg- infectivity
HBcAb- core antibodies- previous infection
IgM= active infection
IgG= past infection
HBsAb= antibody= vaccination
HBV DNA- direct viral load count
How do you get Hep C and what is it associated with
RNA, spread blood and body fluids
Curable with antiviral meds but no vaccine
Associated with liver cirrhosis and hepatic cellular carcinoma
What are the two types of autoimmune hepatitis and how is it diagnosed ?
Type 1- women in later 40s/50s around menopause- fatigue and liver disease
Type 2- children and young people
Investigations
Liver biopsy will show interface hepatitis and plasma cell infiltration
High ALT and AST no change in ALP
Raised IgG
ANA, anti-smooth muscle ab and anti-soluble liver antigen
Treat with steroids and immunosuppressants
What is haemochromatosis and how is it treated
Autosomal recessive -Chr 6
Diagnosed
Serum ferritin and transferrin saturation
Genetic testing
Liver biopsy with perls stain
Management
Venesection
Monitoring serum ferritin and complications
What is Wilson’s disease ?
Autosomal recessive - Chr 13
Teens/ young adults- liver neuro, psych, anaemia
Diagnosis
Serum caeuloplasmin screening test (if low Wilson’s)
24 hr urine copper assay- high urinary copper
Liver biopsy
Genetic testing
Management
Copper chelation
Penicillamine
Trientine
What is alpha-1 antitrypsin deficiency
Affects lungs- COPD and liver fibrosis
-Autosomal codominant Chr 14
-Alpha-1 antitrypsin made in liver - builds up in hepatocytes when mutated - fibrosis , lack of it also causes neutrophils to attack elastin in lungs
Describe the pathology of primary biliary cholangitis
Autoimmune system attacks small bile ducts in liver- obstructive jaundice and liver disease (intrahepatic)
Blocked flow of bile acids (itching), bilirubin (jaundice) and cholesterol (xanthelasma)
Women 40-60
Auto-antibodies - anti-mitochondrial antibodies most specific
What is the treatment for primary biliary cholangitis
Ursodeoxycholic acid (a bile acid)
Colestyramine (bile acid sequestrate to stop itching)
Replace fat soluble vitamins
Immunosuppression
Liver transplant
Describe the pathophysiology of Primary Sclerosing Cholangitis
Intra and extra hepatic bile ducts become inflamed and blocked and obstruct bile flow
Risk factors- male., aged 30-40, ULCERATIVE COLITIS, family history
Antibodies not as helpful in diagnosis but p-ANCA antibody may help
Need an MRCP to show bile duct strictures
Colonoscopy if UC suspected
What is the management of primary sclerosis cholangitis
ERCP for big strictures
Cholesytamine for itching
liver transplant if needed
What are the risk factors for hepatocellular carcinoma
Alcohol related liver disease, NAFLD, Hep B/C, Primary sclerosis cholangitis
What are the investigations in liver cancer
Liver USS- first line imagine
Alpha-fetoprotein
CT and MRI
Biopsy
What are the main features of a cholangiocarcinoma
Cancer of the bile ducts
Mainly adenocarcinoma
Perihilar region most commonly affected- where ducts meet to become common hepatic duct
Associated with primary sclerosing cholangitis
Obstructive jaundice is a key feature, CA19-9 tumour marker
What are the features of GORD and what are it’s main causes
Acid from stomach flows through lower sphincter into oesophagus
Greasy/spicy foods,
tea/ coffee
alcohol/NSAIDs, stress, smoking, obesity, hiatus hernia
What are the main red flag features related to GORD
Dysphagia at any age
Over 55
Weight loss
Upper abdo pain
Reflux
Treatment resistant dyspepsia
N&V
Upper abdo mass on palp
Low Hb
Raised plt count
Urgent 2 week wait endoscopy
What are the main investigations for H.Pylori
H.Pylori test given to anyone with dyspepsia - need 2 weeks without a PPI before testing
Stool antigen test
Urea breath test
H.Pylori antibody test
Rapid urease test- small stomach biopsy during endoscopy
What is the treatment for H.Pylori and a peptic ulcer
Triple therapy with a PPI- Omeprazole and 2 abx- amoxicillin and clarithromycin for 7 days
Ulcer treatment
Stop NSAIDs, treat H.Pylori, PPIS and repeat endoscopy in 4-8 weeks
What is the procedure for barrels oesophagus monitoring
Metaplasia- lower oesophageal epithelium changes from squamous to columnar epithelium - pre malignant and high risk for oesophageal adenocarcinoma
Endoscopic monitoring for progression
PPI
Endoscopic ablation to destroy columnar epithelial cells
What is Zollinger Ellison syndrome
Duodenal or pancreatic tumour secretes excessive gastrin that stimulates excessive acid secretion
Associated with MEN1
What are the risk factors for peptic ulcers and risk of bleeding ulcers
H.Pylori
NSAIDs
Bleeding
NSAID’s
Aspirin
DOACS
Steroids
SSRIs
How to tell the difference between a gastric and peptic ulcer
Eating will worsen a gastric ulcer -more associated with weight loss
Eating will improve a duodenal ulcer
What are the main causes of an upper GI bleed
Peptic ulcers
Mallory Weiss tear
Oesophageal varices
Stomach cancers
What scores are taken into account in an upper GI bleed
Glasgow-Blatchford bleeding score - anything over 0 is high risk
Rockall Score - after endoscopy assesses risk of re-bleed
What is the management of an upper GI bleed
ABATED
ABCDE
Bloods- FBC, U&E, Coag, LFTs, crossmatch
2 large bore cannula
Tranfusions
Endoscopy
Drugs- Stop NSAIDs and Anticoags
Transfusion
In massive bleed - blood, plus and FFP (clotting factors)
In active bleeding -Plt
In active bleeding and taking warfarin - prothrombin complex
What are specific steps to manage oesophageal varices
Terlipressin and broad spectrum abx
OGD needed to treat source of bleeding and vatical band ligation
What are the main features of Crohn’s
NESTS
No blood or mucus
Entire GI tract affected
Skip lesions
Terminal ileum most affected
Smoking is a risk factor
Fistulas and strictures associated
What are the main features of Ulcerative Colitis
CLOSEUP
Continuous inflammation
Limited to colon and rectum
Only superficial mucosa
Smoking protective
Excrete blood and mucus
Use aminosalicylates
Primary sclerosis cholangitis
Also associated with eye issues
What investigations are needed for iBD diagnosis
Stool microscopy to exclude infection
Faecal calprotectin 90% sensitive and specific for IBD before endoscopy
Colonoscopy with multiple intestinal biopsies
What is the management plan of Ulcerative colitis
1st line Aminosalicylates (mesalazine)
2nd line steroids (pred)
IV steroids if severe (IV hydro)
Maintaining remission
Aminosalicylate
Azathioprine (Immunosurpressant)
Mercaptopurine
What are the management steps for Crohn’s
Induce remission
1.Steroids
Nutrition if needed
Can also use
Inflicimab and adalimumab - biologics
Maintaining remission
Azathioprine
Mercaptopurine
Methotrexate can also be used
Surgical options
Resect distal ileum
Treat strictures
Treat fistulas
What is the criteria for an IBS diagnosis
6 months of abdo pain/ discomfort and 1 of
1. Pain relieved by posing
2. Bowel habit abnormalities
3. Stool abnormalities
And 2 of
Straining, urgent need to open bowels or incomplete emptying
Bloating
Worse after eating
Passing mucus
What is the management for IBS
Lifestyle management
FODMAP diet
Medications
Loperamide for diarrhoea
Bulk forming laxatives (avoid lactulose causes bloating)
Antispasmodics for cramps
CBT, SRRIs if needed
What are the main antibodies in coeliac disease
Anti-TTG - main one
Anti-EMA
Anti-DGP
For features * think malabsorption*
What will endoscopy show in coeliac
Jejunum particularly affected
Crypt hyperplasia
Villous atrophy
