GI Flashcards
GORD and hiatus hernia
Reflux of stomach contents acid + bile) causing into oesophagus or beyond
Can lead to oesophagitis, benign strictures, Barrett’s
Causes: hiatus hernia, systemic sclerosis (oesophageal dysmotility), obesity, drugs (tricyclics), H. pylori
Sx: heartburn (retrosternal discomfort), acid brash (acid regurg), odynophagia
cough, laryngitis (hoarse voice)
Complications: oesophagitis, benign stricture, IDA, Barrett’s (straified squamous to columnar)
Ix:
8wk PPI trial
OGD
ambulatory pH monitoring
Tx: weight loss, small regular meals PPI: Omeprazole (20mg), lansoprazole (30mg) Refractory: H2 antagonist: ranitidine Surgery: nissen fundoplication
Hiatus hernia
Upper GI bleeding
Sx: malaena, haematemesis
2 large bore IV cannulae (14-16G)
FBC, UEs (high urea, low Hb - upper GI bleed), LFTs, clotting, crossmatch
IV fluids
Catheter (>0.5ml/kg/hr)
CXR, ABG, ECG
Transfusion Hb<70
Clotting abnormalities: Vit K, FFP (if INR>1.5), platelets
If suspect varices: Terlipressin, broad spectrum IV abx
Rockall - mortality
Glasgow Blatchford - identify those who are low risk and can be managed outpt or high risk can require inpatient endoscopy)
Gastro-oesophagral varices:
Submucosal venous dilatation due to portal hypertension
Causes of portal HTN:
- Cirrhosis
- thrombosis (portal/splenic vein),
- schistosomiasis (most common worldwide)
- Budd Chiari syndrome (hepatic vein thrombosis by thrombosis/tumour causing ischaemia and hepatocyte damage. Sx: abdo pain, ascites, hepatomegaly)
Tx: Endoscopic banding
If endoscopy fails and still bleeding: Sengstaken- Blakemore tube
Prophylaxis: B-blockers (propranolol)
Resistant varices: TIPPS (trans intrahepatic porto-systemic shunt) - shunt between portal vein and hepatic vein
Peptic ulcer bleeds: Endoscopic haemostasis (clips, adrenaline), PPI, clear liquids 6 hr after endoscopy
Acute liver failure and chronic liver disease
Rapid decrease in liver function characterised by jaundice, coagulopathy (increased INR >1.5), hepatic encephalopathy
Causes: Acute viral hepatitis (A, B, C, E, CMV) Autoimmuine (ANA/SMA (PBC), LKM (AIH) Yellow fever Drugs: paracetamol overdose Budd Chiari
Signs: jaundice, hepatic encephalopathy (altered mood, sleep disturbance, confusion, liver flap), fetor hepaticus (breath smells like pear drops), asterixis
Tx: FBC (anaemia) LFTs (elevated ALT/AST, bilirubin) UEs (renal failure) Clotting (Increased PT/INR) Alcohol, Paracetamol levels ABG (metabolic acidosis - paracetamol) CXR, abdo US
Tx: NBM, Catheter
Glucose if hypoglycaemia
PPI (stress ulceration)
Haemodialysis (if renal failure develops)
Complications
Cerebral oedema (mannitol)
Ascites (restrict fluid, low salt diet, spironolactone (+ furosemide if poor response)
Bleeding: Vit K, FFP+bloods
Encephalopathy: Lactulose. Rifaximin (non absorable antibiotic decreases nitrogen forming bacteria)
Hepatotoxic drugs: paracetamol, methotrexate, amiodarone, isoniazid, azathioprine, oestrogen, 6-mercatopurine, salicylates, tetracycline
Hepatorenal syndrome
Cirrhosis, ascites, renal failure
Splanchnic and systemic vasodilation + renal vasoconstriction
Chronic liver disease and cirrhosis
Causes:
Chronic alcohol abuse (most common), Hep B/C, non-alcoholic liver disease (steatosis - steatohepatitis-NAFLD)
Signs: leuconychia (white nails) - due to hypoalbuminaemia, clubbing, palmar erythema, dupuytren’s conctracture, spider naevi, xanthelasma, gynaecomastia, hepatomegaly
Complications:
Hepatic failure: coagulopathy, encephalopathy, SBP
Portal HTN: Ascites, splenomegaly, oesophageal varices, caput madusae (enlarged periumbilical veins)
Cirrhosis - increased portal pressure (splenomegaly) - portosystemic shunting (oesophageal varices, encephlopathy) - vasodilation - increased RAAS, catecholamines to compensate - renal vasoconstriction (hepato-renal syndrome)
Ix:
LFTs (ALT>AST in chronic liver disease, except alcoholic),
later: increased bilirubin, PT, decreased albumin
Alcohol (Gamma GT)
Viral (Hep B,C) - Hep C leading cause chronic viral infection in Western world
Autoimmune (AMA (PBC), ANA/SMA (PSC), LKM (AIH)
Serum caeuroplasmin (Wilson’s)
Ferritin (HH)
a1 anti-trypsin
alpha-feto protein (HCC)
Decreased platelets, WCC (hyersplenism)
Liver US
Liver biospy
Tx: Avoid NSAIDs, sedatives, opiates Colestyramine - itch Ursodeoxycholic acid Penicillamine (Wilson's)
Ascites (spironolactone, or spironolactone+furosemide, paracentesis (+albumin): (cell count, albumin, protein, cytology). Most common: E.coli, Klebsiella, Strepcocci. SAAG (serum albumin ascites gradient >11, low protein: cirrhosis leading to portal HTN (or alcohol hepatitis, Budd-Chiari)
SAAG <11: bowel obstruction, post-op lymphatic leak
Liver transplant
Decompensated cirrhosis: cirrhosis with acute deterioration of liver function jaundice, ascites, HE, GI bleeding, hepatorenal syndrome, sepsis
Causes:
GI bleeding, infection/sepsis, alcohol, drugs, dehydration, constipation
Acute alcohol withdrawal
Withdrawal starts 10-72h after last drink.
Signs: Increased HR, decreased BP, tremor, confusion, hallucinations (delirum tremens)
GMWAS (glasgow modified alcohol withdrawal scale) High risk (liver disease, co-morbidities e.g. COPD, pneumonia, reduced GCS)
Diazepam 20mg 6 hrly oral
Lorazapam
Severe withdrawal:
IV diazemul
Assess Wernicke’s encephalopathy
- Confusion, nystagmus, ataxia, hypotension/hypothermia
IV Pabrinex 2 vials 3x/day (contains Vit C, B1 (thiamine), B2 (riboflavin), B3 (nicotinamide), B6 (pyroxidine)
Change to oral thiamine (day 6) 4x/day (Vit B1)
Prevention: Alcohol free beers Group therapy (AA) Acamproste (helps anxiety, craving) Disulfarim (chronic alcohol dependence) - causes flushing, headache, palpitations upon alcohol ingestion
Screening
CAGE
Ever felt like Cutting down?
Do you get Annoyed by people asking you to cut down?
Ever felt Guilty about your drinking?
Do you need an Eye-opener (drink in the morning)?
>2 - may be exhibiting dependency
Gastritis/Duodenitis
Gastric mucosal inflammation
Causes: H.Pylori, NSAIDs, alcohol, autoimmune gastritis
Sx: dyspepsia/epigastric discomfort, N+V, loss of appetite
Ix: H.Pylori urea breathe test H.pylori fecal antigen test OGC (>60 yrs or with alarm features: weight loss, anaemia, dysphagia, vomiting) Gastric mucosal biopsy
Tx:
H.pylori: triple therapy - Amox(or met)+Clary+omeprazole
Autoimmune gastritis: B12
Oesophageal varices
Dilated collateral blood vessels in oesophagus which develop due to portal HTN, usually due to cirrhosis
Size of varices is most important predictor of variceal haemorrhage
Sx:
cirrhosis, ascites, spider naevi, caput madusa, jaundice, hepatic encephalopathy
Ix: Hepatic venous pressure gradient ( >12 = bleeding risk) FBC (anaemia, thrombocytopenia) Coagulation profile (increased INR) LFTs (increased bilirubin, AST/ALT) UEs (Low Na+ due to fluid overload) OGD
Tx:
1st line: Terlipressin + Endoscopic ligation
Prophylactic Abx
If 1st line fails: TIPSS (trans intrahepatic portosystemic shunt)
PBC and PSC
Primary biliary cholangitis
Intralobular bile ducts damaged due to granulomatous inflammation causing cholestasis (decrease in bile flow) leading to fibrosis, cirrhosis and PTN
Risk fx: family hx, recurrent UTIs, smoking, increased use of nail/hair dye
Anti-mitochondrial antibodies
Sx: asymptomatic. Increased ALk Phos.
Lethargy, pruritus, jaundice
Signs: jaundice, skin pigmentation, xanthelasma, heptosplenomegaly
Complications: cirrhosis, OP, osteomalacia and coagulopathy (due to malabsorption of fat soluble vitamins (A, D, E, K), HCC
Ix:
Raised Alk phos, Gamma GT, mild AST/ALT. Late: increased bilirubin, PT, decreased albumin
AMA
IgM (increased)
US abdo
Biopsy (not usually required) - granulomas around bile ducts+ cirrhosis
Tx:
Ursodeoycholic acid. Increases bile flow by decreasing hepatic synthesis of cholesterol, allowing it be solubulised from gallstones
SE: nausea, weight gain
Colestyramine: for itch
Liver transplant: MELD score (model for end-stage liver disease) predicts risk of death
Primary sclerosing cholangitis
Progressive cholestasis with bile duct inflammation and strictures
Sx: pruritus + fatigue
HLA-DR3 (assoc. with autoimmune hepatitis)
Assoc. with UC.
Increased risk of colorectal Ca, bile duct/gallbladder, liver Ca
Yearly colonscopy + US
Ix: Increased Alk phos, bilirubin AMA -ve, but ANA, SMA, ANCA may +ve IgM (increased) ERCP/MCRP (strictures) Biopsy: fibrous, oblierative cholangitis
Tx: Liver transplant
Abx for bacterial cholangitis
NAFLD
Commonest liver disorder in Western countries
Patho:
Steatosis - non-alcoholic steatohepatitis - NAFLD
Steatosis (macrovesicular steatosis with lipid vacuole filling hepatocyte cytoplasm)
Steatohepatitis (neutrophils+lymphocytes surrounding hepatocytes with mallory hyaline
NAFLD cirrhosis (fibrosis. Distortion of architecture and nodules)
Assoc with metabolic diseases: obesity, dyslipidaemia, diabetes, HTN
Tx: lifestyle modification e.g. weight loss
bariatric surgery e.g. Roux en Y gastric bypass (top of stomach separated (30mL). Small bowel attached directly to small pouch of stomach. This causes pt to feel fuller sooner, and less absorption.
Complications: dumping syndrome (increased HR, sweat, diarrhoea due to body flooding intestines with gastric acid due to sugary foods), anastomotic leak, anastamotic ulcer
Hereditary causes chronic liver failure
Wilson’s disease
Excess copper
Autosomal recessive in copper transporting ATPase
In liver, copper is carried by caeuroplasmin.
In Wilson’s, the linkage of copper with caeruloplasmin impaired, and excretion into bile
Copper deposits into liver and other organs
Sx: liver disease+CNS signs (tremor, dysarthria), mood (depression, mania)
Signs: Kayser Fleischer rings (copper in iris), blue nails, arthritis
Ix:
Low serum caeruloplasmin
Low serum copper
Urine: 24 hr copper excretion
Tx:
Penicillamine
Liver transplant
HH
Autosomal recessive: Increased intestinal absorption of iron leads to deposition of iron in joints, liver, heart, pancreas, skil
HFE gene
Sx: fatigue, arthralgia, decreased libido, grey skin, signs of chronic liver disease, diabetes (iron deposition in pancreas)
Ix:
Ferritin, transferrin increased, TIBC low (as all taken up by iron)
HFE genotyping
Tx: venesection
Alpha 1 anti-trypsin deficiency
Inherited disorder affects lung (emphysema) and liver (cirrhosis, HCC)
A1AT is a serine protease inhibitor
Lung A1AT protects against damage from neutrophil elastase
Sx: dyspnoea, cirrhosis, cholestatic jaundice
Ix:
Serum A1T1 levels low
Lung function (obstructive)
Liver biospy
Tx:
Smoking cessation, vaccinations
IV alpha 1 proteinase inhibitor (A1AT) from pooled human plasma
IBS
Recurrent abdo pain assoc. with bowel dysfunction
Sx: recurrent abdo pain (lower/middle) change in bowel habits (diarrhoea, constipation) abdo distention (no nausea/vomiting) and relieved by defecation/flatus
Ix: FBC (if anaemia - then not IBS)
Stool culture
Anti-endomysial, TTG (exclude coeliac)
Flex sigmoidscopy (abnormal mucosa)
Tx: Lifestyle: add fibre, avoid caffiene Lactulose Linaclotide Anti-sposmodics e.g. hyoscyamine
Dyspepsia
Sx: epigastric pain, heartburn (retrosternal pain)
ALARMS sx: Anaemia, Loss weight, Anorexia, Recent/progressive onset, Melaena/haematemesis, Swallowing difficulty
Dysphagia or >55yrs with ALARMS sx:
Upper GI endoscopy
If not:
Stop NSAIDs, life style changes
Antacids, review after 4 weeks
Trial PPI (4wks) or test and treat H. Pylori
Malunutrition
A Body Mass Index (BMI) < 18.5
Unintentional weight loss greater than 10% within the last 3-6 months
BMI < 20 and unintentional weight loss greater than 5% within the last 3-6 months
