GI Flashcards
PBC features, criteria
Middle aged female
AI, destruction of intrahepatic bile ducts
Chronic progressive cholestatic disease of liver
Criteria (2 out of 3 is probable)
- AMA (M2 AMA)
- Increase ALP, GGT for >6m
- Histological features consistent with Dx
Tx of PBC
Specific therapy
- Ursodeoxycholic acid (UDCA)
Mx of Pruritus
- Cholestyramine
- Rifampicin
- Opioid antagonist (uncommonly used)
- Liver transplant
Mx of cholestasis Cx
- Vit D, Ca, Bisphosphonate for metabolic bone disease
- Statin for HL
- Medium chain triglycerides for lipid malabsorption
- Vit deficiency (Vit D; Vit K if increase PT)
Anti-smooth muscle Abs
For AI hepatitis
Alcoholic liver disease Dx
Hx of alcohol use (M:30 g/day; F:20 g/day)
PE for signs of CLD
Staging of severity with liver chemistry, CBC, PT
AutoAbs for AIH
Type 1:
Anti-smooth muscle Ab
ANA (Anti nuclear Ab)
Elevated IgG
Type 2: Anti-liver-kidney microsomal Ab (Anti-LKM Ab)
Type 3: Ab to soluble liver Ag (Anti-SLA)
MELD score (Model for end stage liver disease)
BICE
Bilirubin
INR
Creatinine
Etiology
Child-Pugh score
ABCDE
Albumin Bilirubin PT Ascites (distension) Encephalopathy
A - 5-6 (compensated, normal liver function)
B - 7-9 –> can go for transplant
C - 10-15
*5-15 score
Acute liver failure
What score for liver transplant?
King’s college criteria
- Panadol induced or not
Causes of Chronic diarrhea
- Osmotic (Lactase deficiency)
- Malabsorption
- Secretory (Endocrine tumors, BS malabsorption)
- Inflammatory (IBD)
- Motility (IBS)
- Chronic infection (uncommon in HK)
HP - Urea breath test, stool Ag ELISA affected by
RB
PPI
ABX
Bismuth
But not affected by H2 blocker / antacids
Post-tx do test 4 wk later
Ab test not used after tx as it will be positive for 6-12m
ELISA
Enzyme-linked immunosorbent assay
3 categories of GERD
RB
- Non-erosive reflux disease (Sx but OGD normal)
- Erosive esophagitis (OGD abnormal)
- Extra-esophageal disease
RF for GERD
RB
- Obesity (high BMI)
- Smoking
- Alcohol
- FH
Dx of GERD
RB
- Symptom questionnaires
- OGD
- Ambulatory 24h esophageal pH monitoring
- PPI testing
Tx of GERD
RB
- Dietary and lifestyle modification
- Medical: Antacids, H2 blocker, PPI
- Endoscopic: Fundal plication
Ix for HBV cirrhosis patient with ascites
RB
- CBC - degree of hypersplenism; anemia
- LFT
- Albumin: chronic liver disease
- Globulin: increased in cirrhosis
- Bilirubin: only high when late stage of cirrhosis
- AST/ALT does not reflect degree of cirrhosis
- ALP/GGT also should be normal unless SOL - Clotting: Prolong PT = liver dysfunction
- AFP
- HB serology
- HBsAg tested annually, - 1-1% annual rate of seroconversion
- HBeAg / anti-HBe
- HBV DNA - Diagnostic paracentesis for ascites
- WCC w/ D to r/o SBP
- Protein level - tend to be low in cirrhosis
- Malignant cytology - RFT: as baseline before starting diuretics
- USG liver every 6m to detect HCC
When to start antiviral for HBV
RB
HBV DNA viral load is high
ALT 1.5-2x ULN
HBV vs HCV in causing HCC
HBV is directly oncogenic
20% HCC from HBV does not have cirrhosis (80% has)
but 100% of HCC from HCV has cirrhosis
TACE
Transcatheter arterial chemoembolization
Mx of HE
RB
- Identify and treat precipitating factor
- Normal protein diet
- IV 10% dextrose to provide adequate calorie intake (to prevent protein breakdown)
- Lactulose as enema and orally (to induce bowel movements 2-4 times/day)
?Rifaximin as abx
S/S of Crohn’s disease
Inflammation (abd pain, diarrhea, LOW)
Obstruction (cramp, V, distension)
Fistulization
S/S of UC
Bloody diarrhea
Abd pain
Tenesmus, urge
Fever, LOW
Anti-Saccharomyces cerevisiae Abs (ASCA)
Anti-neutrophil cytoplasmic Abs (ANCA)
ASCA more for Crohn’s
ANCA more for UC
Cx of UC
- Toxic megacolon
- Perforation
- Cancer
Extraintestinal manifestations of IBD
- Arthritis: Large joints, AS, sacroilitis
- Uveitis, iritis, episcleritis
- Erythema nodosum, pyoderma gangrenosum
- Primary sclerosing cholangitis (PSC)
- Bone loss, osteoporosis
- Vit B12 deficiency
Tx of IBD
Mild:
- 5-ASA (aka Mesalazine)
- ABX for acute
Moderate to severe
- Steroid for acute flares
- Immunosuppressants
- Azathioprine, 6MP (Purine analog to inhibit T cell fx)
- Infliximab (TNF-inhibitor)
Precipitating factors for HE
RB
- Increased protein intake
Decreased blood supply
- GIB (high protein content in blood in the gut + decreased blood to already cirrhotic liver)
- Over-diuresis (with dehydration, electrolytes disturbances)
CNS disturbance (GABA)
- Constipation (bacteria produce bacteria?)
- Infection, esp SBP, HBV, HCV
- Hynoptics
- Alcohol
- Shunting procedures, e.g. TIPS
- Inappropriate paracentesis (w/o adequate albumin infusion)
SBP usu which organism
Gram neg E coli, Klebsiella (or Streptococci from skin) Tx = 3rd gen cephalosporin Long term: Norfloxacin (FQ)
Complications of Cirrhosis
- Ascites
- SBP (Spontaneous bacterial peritonitis)
- Hepatorenal syndrome
- Variceal bleeding
- Hepatic encephalopathy
- HCC
TIPS
Transjugular intrahepatic portosystemic shunt
For recurrent variceal bleeding
Quadruple therapy for HP
PPI Bismuth Metronidazole Tetracycline for 7 days
Budd-Chiari syndrome
Abd pain
Ascites
Hepatomegaly
Caused by occlusion of hepatic vein (mainly thrombosis, can also be compression by tumor)
