GI Flashcards
Describe appendicitis
- Appendix is a small, thin tube of bowel sprouting from the caecum
- appendicitis is inflammation of the appendix
- results from obstruction of the appendix and subsequent infection and inflammation of the appendix
- peak incidence in ages 10-20
What are the symptoms of appendicitis?
- abdominal pain, typically central then settling in the right iliac fossa
- loss of appetite, N+V
What are the signs of appendicitis?
- tender to McBurney’s point
- guarding to RIF
- rebound tenderness and percussion tenderness indicate peritonitis
- rovsing’s sign positive
Describe the diagnosis of appendicitis
- mostly clinical based on signs and raised inflammatory markers
- CT can be useful in confirming diagnosis
- USS can be useful to exclude ovarian and gynae pathology
- if clinically appendicitis but tests negative, proceed to diagnostic laparoscopy
What are the common differential diagnoses for appedicitis?
- ectopic pregnancy
- ovarian cysts
- meckel’s diverticulitis
- mesenteric adenitis
What are the possible complications fo an appendicectomy?
- bleeding/ infection/ pain/ scars
- damage to bowel, bladder or other organs
- removal of normal appendix
- anaesthetic risk
- DVT/PE
Laparoscopic is associated with fewer risks and faster recovery
Describe the management of appendicitis
Appendicectomy is the definitive management for acute appendicitis.
Laparoscopic surgery is associated with fewer risks and faster recovery compared to laparotomy.
Define haemochromatosis
Haemochromatosis is an iron storage disorder that results in excessive total body iron and deposition of iron in tissues.
The human haemochromatosis protein (HFE) gene is located on chromosome 6.
Majority of cases are due to mutation in the HFE gene. Mutation is autosomal recessive.
What are the symptoms of haemochromatosis?
Usually presents after the age of 40 when the iron overload becomes symptomatic.
Chronic tiredness Joint pain Pigmentation Hair loss Erectile dysfunction Amenorrhoea Cognitive symptoms
What is the diagnosis of haemochromatosis?
Serum ferritin.
Ferritin is an acute phase reactant meaning that it goes up with inflammatory conditions such as infection.
Transferrin saturation is helpful in distinguishing between iron overload and other causes of high ferritin.
If both are high, do genetic testing to confirm.
What are the complications of haemochromatosis?
Type 1 DM
Liver cirrhosis
Iron deposits in the pituitary and gonads lead to endocrine and sexual problems
Cardiomyopathy
Hepatocellular carcinoma
Hypothyroidism
Chrondocalcinosis
What is the management of haemochromatosis?
Venesection Monitoring serum ferritin Avoid alcohol Genetic counselling Monitoring and treatment of complications
Define acute cholangitis
Acute cholangitis is infection and inflammation in the bile ducts.
What are the causes of acute cholangitis?
- Obstruction int he bile ducts stopping bile flow (i.e. gallstones in the common bile duct)
- Infection introduced during an ERCP procedure
What are the most common organisms that cause acute cholangitis?
- E. coli
- Klebsiella species
- Enterococcus species
Describe the presentation of acute cholangitis
charcot’s triad:
- RUQ pain
- Jaundice
- Fever
What is the management of patients with acute cholangitis?
Acute management of sepsis ad acute abdo:
- Nil by mouth
- IV fluids
- Blood culture
- IV antibiotics
Imaging to diagnose CBD stones and cholanditis:
- Abdo US
- CT
- MRCP
ERCP
Define acute pancreatitis
Pancreatitis refers to inflammation of the pancreas. Presents with rapid onset of symptoms
What are the key causes of pancreatitis?
- Gallstones
- Alcohol
- Post ERCP
What are the full list of causes of pancreatitis?
I GET SMASHED
Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting Hyperlipidaemia ERCP Drugs
Describe the presentation of acute pancreatitis
- Severe epigastric pain
- Radiating through to the back
- Associated vomiting
- Abdominal tenderness
- Systemically unwell
What are the investigations of acute pancreatitis?
- FBC
- U+E
- LFT
- Calcium
- ABG
- Amylase if raised more than 3 times upper limit, it is acute pancreatitis
- CRP
- USS
- CT abdo
What is the glasgow score in terms of pancreatitis?
Used to determine severity of pancreatitis:
0-1 mild
2 moderate
3 or more severe
PANCREAS PaO2 <60 Age >55 Neutrophils >15 Calcium <2 uRea >16 Enzymes (LDH>600 or AST/ALT>200) Albumin <32 Sugar (glucose>10)
What is the management of acute pancreatitis?
ABCDE IV fluids Nil by mouth Analgesia Monitor
Tx of gallstones: ERCP/cholecystectomy
Abs for infection
Tx of complications
What are the complications of acute pancreatitis?
Necrosis of the pancreas Infection in a necrotic area Abscess formation Acute peripancreatic fluid collection Pseudocysts Chronic pancreatitis
What is the stepwise progression of alcoholic liver diease?
- Alcohol related fatty liver
drinking leads to build up of fat in the liver. Can be reversed in 2 weeks with abstinence. - Alcoholic hepatitis
Drinking over a long period causes inflammation in the liver sites. Mild hepatitis can be reversed, - Cirrhosis
Liver is made up of scar tissue rather than healthy tissue. Irreversible.
What are the signs of liver disease?
Jaundice Hepatosplenomegaly Spider Naevi Palmer erythema Gynaecomastia Bruising Ascites Caput Medusae Asterixis
What are the investigations and findings in alcoholic liver disease?
Bloods:
- FBC: raised MCV
- LFTs: High ALT+AST+GGT. ALP will be raised later. Low albumin and high bilirubin
- Clotting: elevated PT
- U+Es: deranged
USS: show early changes and fibroscan to check elasticity of liver to assess degree of cirrhosis.
Endoscopy:
assess for and treat oesophageal varices when portal hypertension is suspected
CT and MRI can look for fatty infiltration of the liver
Liver Biopsy to confirm diagnosis of alcohol related hepatitis or cirrhosis.
What is the general management of alcoholic liver disease?
Stop drinking
Consider detoxification
Nutritional support
Steroids improve short term outcomes
What is portal hypertension?
Result of resistance in the vessels in the liver due to fibrosis affecting the structure and blood flow
What are the most common causes of liver cirrhosis?
Alcoholic liver disease
Non-alcoholic fatty liver disease
Hep B
Hep C
What are the investigations and findings in liver cirrhosis?
Liver biochemistry often normal but in decompensated cirrhosis, all markers deranged
Albumin drops and prothrombin time increases
Hyponatramia
Urea and creatinine deranged
USS: nodullarity, corkscrew appearance, enlarged portal vein
What are the markers for synthetic function of the liver?
Albumin and prothrombin time
What is the first line investigation for assessing fibrosis in non-alcoholic fatty liver disease?
Enhanced liver fibrosis blood test.
Measures HA, PIIINP and TIMP-1
What is a fibroscan?
Can be used to check the elasticity of the liver. Retest every 2 years in patients at risk of cirrhosis:
- Hep C
- heavy alcoholics
- diagnosed alcoholic liver disease
- non-alcoholic liver disease
- chronic hep B
What is the diagnostic test for liver cirrhosis?
Liver biopsy
What score is used to measure severity and prognosis of cirrhosis?
Child-pugh score
Which score is used to give estimated 3 month mortality and help guide referral for liver transplant?
MELD score
What is the general management of cirrhosis?
US and alpha fetoprotein every 6 months for hepatocellular carcinoma
Endoscopy every 3 years in patients with varices
High protein, low sodium diet
MELD score every 6 months
Consideration of a liver transplant
What is the treatment of stable varices?
- propanolol reduces portal hypertension
- elastic band ligation of varices
- injection of scllerosant
- TIPS
What are the non-invasive liver screens and what do they look for?
US liver
Hep B and C serology
Autoantibodies (autoimmune hep, primary biliary cirrhosis and primary sclerosing cholangitis)
Immunoglobulins (autoimmune hep and primary biliary cirrhosis)
Caerulopllasmin (wilsons disease)
Alpha 1 anti-trypsin levels (alpha 1 anti-trypsin deficiency)
Ferritin and transferrin saturation (hereditary haemochromatosis)
What are the investigations in non-alcoholic fatty liver disease?
Liver US
Enhanced liver firbosis blood test (first line)
NAFLD fibrosis score (2nd line)
Fibroscan (3rd line)
What is the management of non-alcoholic fatty liver disease?
Weight loss Exercise Stop smoking Control of diabetes, BP and cholesterol Avoid alcohol
What are the causes of hepatitis?
Alcoholic hep Non-alcoholic fatty liver disease Viral hep Autoimmune hep Drug induced hep
What is the presentation of hepatitis?
Abdo pain Fatigue Puritis Muscle and joint aches Nausea and vomiting Jaundice Fever (viral hep)
What is hep A and how is it transmitted?
It is an RNA virus. Transmitted via faecal-oral route
How does hep A present?
Nausea Vomiting Anorexia Jaundice Cholestasis - dark urine and pale stools Hepatomegaly
What is the management for hep A?
Resolves without treatment in 1-3 months
What is hep B and how is it transmitted?
DNA virus. Transmitted by direct contact with blood or bodily fluids
What percentage of people go onto get chronic hep B?
Most people recover within 2 months but 10% go onto become chronic hep B carriers
What are the viral markers and their meaning for hep B?
Surface antigen (HBsAg) - active infection
E antigen (HBeAg) - high infectivitiy
Core antibodies (HBcAb) - past or current infection
Surface antibody (HBsAb) - vaccination or past or current infection
Hep B virus DNA (HBV DNA) - direct count of viral load
What is hep c and give the transmission?
RNA virus
Spread by blood and bodily fluids
What is the disease course of hep c?
25% full recovery
75% becomes chronic
What are the complications of hep c?
Liver cirrhosis and hepatocellular carcinoma
What is the test for hep c?
Hep C antibody is the screening test
Hep C RNA testing is used to confirm diagnosis of hep C
What is the management of hep c?
direct acting antivirals are tailored and successfully cure the infection in over 90% of patients
What is hep D and E?
can only get hep d if you have hep b as well
Hep e is faecal oral route and v rare in the UK
Who does type 1 autoimmune hepatitis affect and what are the associated anitbodies?
Occurs in adults
Women
Around or after menopause
Less acute than type 2
Anti-nuclear antibodies
Anti-smooth muscle antibodies
Anti-soluble liver antigen
Who does type 2 autoimmune hepatitis affect and what are the associated anitbodies?
Teenagers or early twenties with acute hep with high transaminases and jaundice
Anti-liver kidney microsome-1 (anti-LKM1)
Anti-livre cytosol antigen type 1 (anti-LC1)
What are the treatments for autoimmune hepatitis?
High dose steroids (prednisolone) tapered over with other immunosuppressants
What is wilson’s disease?
Excessive accumulation of copper in the body caused by a mutation in the wilsons disease protein on chromosome 13
Describe the presentation of Wilson’s disease?
Hepatic problems (cirrhosis) Neurological problems Psychiatric problems Kayser-Fleischer rings Haemolytic anaemia Renal tubular acidosis Osteopenia
What is the diagnosis of Wilson’s disease?
Initial investigation: Serum caeruloplasmin low = Wilson’s
Diagnostic investigation: liver biopsy
Other:
24hr urine copper
Low serum copper
Kayser-Fleischer rings
What is the management of Wilson’s disease?
Copper chelation with:
Penicillamine
Trientene
What is primary biliary cirrhosis?
Where the immune system attacks the small bile ducts. This causes obstruction of the outflow of bile (cholestasis) leading to bile acids, billilrubin and cholesterol building up in the body
Describe the presentation of primary biliary cirrhosis
Fatigue Pruritus GI disturbance and abdo pain Jaundice Pale stools Xanthoma and xanthelasma Signs of cirrhosis and failure
What is primary biliary cirrhosis associated with?
Middle aged women
Other autoimmune diseases
Rheumatoid conditions
What is the diagnosis of primary biliary cirrhosis/
ALP raised first
Bilirubin and others raised later
Diagnostic: Anti-mitochondrial antibodies
Anti-nuclear antibodies
ESR raised
IgM raised
Livery biopsy
What is the treatment for primary biliary cirrhosis?
Ursodeoxycholic acid
Colestyramine
Liver transplant
immunosuppression
What is primary sclerosing cholangitis?
Where the intrahepatic and extrahepatic ducts become strictured and fibrotic. Causes an obstruction to the flow of bile out of the liver
What are the risk factors for primary sclerosing cholangitis
Male
Aged 30-40
UC
Family history
What is the presentation of primary sclerosing cholangitis?
Jaundice Chronic RUQ pain Pruritus Fatigue Hepatomegaly
What is the diagnosis of primary sclerosing cholangitis?
Gold standard: MRCP
High ALP
p-ANCA
ANA
aCL
What is the management of primary sclerosing cholangitis?
Liver transplant can be curative
ERCP
Ursodeoxycholic acid
Colestyramine
What is the test for H. pylori
Need to not use PPI for 2 weeks before
Urea breath test
Stool antigen test
Rapid urease test
What is the eradication regime for H. pylori?
Triple therapy with PPI + 2 antibiotics for 7 days
What is the presentation of peptic ulcers?
Epigastric discomfort or pain N+V Dyspepsia Bleeding "coffee ground" vomit and melaena Iron deficiency anaemia
Eating worsens pain = gastric ulcers
Eating improves pain = duodenal ulcers
What are the features of crohns?
Crows NESTS
No blood or mucus Entire GI tract Skip lesions on endoscopy Terminal ileum most affected Transmural inflammation Smoking is a risk factor
What are the features of ulcerative colitis?
U-C- CLOSEUP
Continuous inflammation Limited to colon and rectum Only superficial mucosa affected Smoking is protective Excrete blood and mucus Use aminosalicylates Primary sclerosing cholangitis
What is the test for inflammatory bowel disease?
1st line: Stool microscopy
Faecal calprotectin is a useful screening test
Endoscopy with biopsy is diagnostic
What is the management of crohns?
First line: steroids
± immunosuppressant
Maintaining:
First line: Azathiprine or mercaptopurine
Surgery if it only affects the distal ileum
What is the management of UC?
Inducing remission mild to moderate:
First line: aminosalicylate e.g. mesalazine
Second line: corticosteroids
Inducing remission severe:
First line: IV corticosteroids
Second line: IV ciclosporin
Maintaining remission:
aminosalicylate, azathioprine or mercaptopurine
Surgery
What is the diagnosis of coeliac disease?
Must be carried out when they are still on gluten diet.
Raised anti-TTG
Raised EMAs
Endoscopy and intestinal biopsy shows:
crypt hypertrophy
villous atrophy
What is necrotising enterocolitis?
Disorder affecting premature neonates where part of the bowel becomes necrotic.
What is the presentation of necrotising enterocolitis?
Intolerance to feeds Vomiting with green bile Generally unwell Distended, tender abdomen Absent bowel sounds Blood in stools
What is the diagnosis of necrotising enterocolitis?
Abdominal xray: diagnostic
- dilated loops of bowel
- bowel wall oedema
- pneumatosis intestinalis
- Pneumoperitoneum
- gas in portal veins
What is Budd-Chiari syndrome?
Obstruction of the hepatic venous outflow
What is the presentation of Budd-Chiari syndrome?
Sudden onset abdominal pain
Ascites
Tender hepatomegaly
What condition increases plasma urea levels?
Gastric ulcer
Relapsing coeliac disease that initially settled with gluten free diet could mean which condition?
T-cell lymphoma
ABG of obstructive sleep apnoea
Compensated respiratory acidosis
Which is the most sensitive blood test for acute pancreatitis?
Lipase
What is the triad for acute liver failure presentation?
Encephalitis
Coagulopathy
Jaundice
History of PSC and painless jaundice = which cancer?
Cholangiocarcinoma
Which dermatological condition is linked with IBD?
Erythema nodosum
