GI and Liver Flashcards

Question

what are Oesophago-gastric varices

Answer 1

Submucosal venous dilatations secondary to high portal pressures.

Answer 2

Bleeding can be brisk, particularly if underlying coagulopathy secondary to loss of hepatic synthesis of clotting factors.

Answer 3

Cirrhosis Thrombosis Parasitic infection

Answer 4

thrombosis (portal or splenic vein)

Answer 5

cirrhosis, schistosomiasis, sarcoid, myeloproliferative diseases, congenital hepatic fibrosis

Answer 6

Budd-Chiari syndrome, right heart failure, constrictive pericarditis, veno-occlusive disease

Answer 7

High portal pressure Variceal size Endoscopic features of the variceal wall and advanced liver disease

Answer 8

Only symptomatic if they bleed; Vomiting large amounts of blood Black, tarry or bloody stools Light headedness Loss of consciousness in severe cases

Answer 9

Don’t drink alcohol Healthy diet and weight Reduce risk of hepatitis – don’t share needles or have unprotected sex

Answer 10

Endoscopic banding or sclerotherapy

Answer 11

vomiting of blood. It may be bright red or look like coffee grounds.

Answer 12

black motions, often like tar, and has a characteristic smell of altered blood

Answer 13

Peptic ulcers Oesophageal varices Mallory-Weiss tear Gastritis/ oesophagitis Bleeding disorders Portal hypertensive gastropathy Meckel’s diverticulum

Answer 14

a tear in the mucous membrane where the oesophagus meets the stomach

Answer 15

Persistent vomiting/retching causes haematemesis via an oesophageal mucosal tear.

Answer 16

Endoscopy to stop the bleeding. Endoscopic haemostasis: 2 of clips, cautery, adrenaline.

Answer 17

Inflammation of the lining of the stomach.

Answer 18

Irritation due to excessive alcohol use, chronic vomiting, stress, or the use of certain medications such as aspirin. Helicobacter pylori Bile reflux: a backflow of bile into the stomach from the bile tract Infections caused by bacteria and viruses

Answer 19

Alcohol NSAIDs H.pylori Reflux hernia

Answer 20

Epigastric pain Vomiting Indigestion (dyspepsia) Abdominal bloating

Answer 21

Upper GI endoscopy Blood tests: anaemia and H.pylori infection Faecal occult blood tests – presence of blood in your stool.

Answer 22

H2 receptor antagonists e.g. ranitidine Proton pump inhibitors Avoid hot and spicy foods

Answer 23

A disease in which the small intestine is hypersensitive to gluten, leading to difficulty in digesting food.

Answer 24

T-cell responses to gluten in the small bowel causes villous atrophy and malabsorption.

Answer 25

Stinking stools/steatorrhea Diarrhoea Bloating Abdominal pain Nausea and vomiting Aphthous ulcers Angular stomatitis Weight loss, fatigue, weakness Dermatitis herpetiformis

Answer 26

Low Hb, B12 and ferritin Antibodies: anti-transglutaminase is single preferred test – check IgA levels to exclude subclass deficiency. Where serology positive or high index of suspicion proceed to duodenal biopsy while on a gluten-containing diet; expect subtotal villous atrophy

Answer 27

Lifelong gluten-free diet – rice, maize, soya, potatoes, and sugar are OK Limited consumption of oats may be tolerated in patients with mild disease. Gluten-free biscuits, flour, bread and pasta are prescribeable. Monitor response by symptoms and repeat serology.

Answer 28

Anaemia Dermatitis herpetiformis Osteopenia/ osteoporosis

Answer 29

The small intestine can’t absorb enough of certain nutrients and fluids. Malabsorption of protein, fat and carbohydrate leads to weight loss and malnutrition.

Answer 30

Coeliac disease – reduced surface area Chronic pancreatitis Crohn’s disease Pancreatic insufficiency – poor intraluminal digestion Infection – lymphatic obstruction

Answer 31

Diarrhoea Weight loss Lethargy Steatorrhea Bloating

Answer 32

Anaemia Bleeding disorders (low vit K) Oedema Metabolic bone disease

Answer 33

FBC: low Ca2+, Fe, B12 and folate Lipid profile: coeliac tests Stool: Sudan stain for fat globules

Answer 34

Correction of nutritional deficiencies Treatment of causative diseases

Answer 35

Inflammatory bowel disease is a term mainly used to describe two conditions: ulcerative colitis and Crohn’s disease. These are long term conditions that involve inflammation of the gut.

Answer 36

Crohn’s disease favours the ileum, but can occur anywhere along the intestinal tract. Ulcerative colitis affects the colon (large intestine) only.

Answer 37

A chronic inflammatory disease characterised by transmural granulomatous inflammation affecting any part of the gut from mouth to anus (especially terminal ileum).

Answer 38

unaffected bowel between areas of active disease (crohns)

Answer 39

An inappropriate immune response against the gut flora in a genetically susceptible individual. Smoking increases the risk.

Answer 40

Diarrhoea Abdominal pain Weight loss/failure to thrive Systemic symptoms: fatigue, fever, malaise, anorexia

Answer 41

Bowel ulceration Abdominal tenderness/mass Perianal abscess/fistulae/skin tags Anal strictures Clubbing, skin, joint and eye problems

Answer 42

Small bowel obstruction Toxic dilatation Abscess formation Fistulae Malnutrition

Answer 43

FBC: raised WCC, platelets, CRP&ESR, anaemia. Faecal calprotectin raised (indicates IBD). pANCA negative. Stool samples (rule out infection). LFTs: hypoalbuminemia. Low iron, vitamin B12 and folate (B9) levels.

Answer 44

Quit smoking Optimise nutrition

Answer 45

Prednisolone PO, plan maintenance therapy Azathioprine Biologics Nutrition Surgery

Answer 46

Admit for IV hydration/ electrolyte replacement; IV steroids e.g. hydrocortisone Monitor pulse, BP, temperature, record stool frequency/character Physical examination daily, and FBC, ESR, CRP, AXR Consider need for blood transfusion

Answer 47

A relapsing and remitting inflammatory disorder of the colonic mucosa. It may affect just the rectum or extend to involve part of the colon or the entire colon.

Answer 48

Inappropriate mucosal immune response to luminal bacteria. Smoking appears to decrease the risk of UC.

Answer 49

Hyperaemic/ haemorrhagic colonic mucosa +/- pseudopolyps formed by inflammation.

Answer 50

Episodic or chronic diarrhoea Crampy abdominal discomfort Bowel frequency relates to severity Urgency/tenesmus – proctitis Systemic symptoms: fever, malaise, anorexia, weight loss

Answer 51

May be none Acute, severe UC – fever, tachycardia, tender distended abdomen Extra-intestinal signs: Clubbing Aphthous oral ulcers Conjunctivitis

Answer 52

Blood: FBC, ESR, CRP, U&E, LFT, blood culture Stool: to exclude Campylobacter, C.difficile Faecal calprotectin: a simple, non-invasive test for GI inflammation with high sensitivity.

Answer 53

Toxic dilatation of colon with risk of perforation Venous thromboembolism

Answer 54

Colonic cancer Neoplasms in mucosa

Answer 55

Mesalamine is the mainstay for remission-induction/maintenance Prednisolone

Answer 56

Induce remission oral prednisolone

Answer 57

IV hydration/ electrolyte replacement Monitor pulse, BP, temperature, record stool frequency/character Physical examination daily, and FBC, ESR, CRP, AXR

Answer 58

Irritable bowel syndrome A mixed group of abdominal symptoms for which no organic cause can be found. Most are probably due to disorders of intestinal motility, enhanced visceral perception or microbial dysbiosis.

Answer 59

Urgency Abdominal bloating/distension Worsening of symptoms after food Symptoms are chronic >6 months and often exacerbated by stress, menstruation or gastroenteritis. Examination may be normal but general abdominal tenderness is common

Answer 60

FBC, CRP, ESR, U&E Coeliac screen Faecal calprotectin

Answer 61

Only diagnose IBS if recurrent abdominal pain associated with at least 2 of: Relief by defecation Altered stool form Altered bowel frequency (constipation/diarrhoea)

Answer 62

Colonic cancer Inflammatory bowel disease – Crohn’s, UC Coeliac disease

Answer 63

Should focus on controlling symptoms, initially using lifestyle/dietary measures, then cognitive therapy or pharmacotherapy if required

Answer 64

ensure adequate water and fibre intake and promote physical activity.

Answer 65

avoid sorbitol sweeteners, alcohol and caffeine. Reduce dietary fibre content, encourage patients to identify their own trigger foods.

Answer 66

oral antispasmodics. Combination probiotics in sufficient doses may help flatulence or bloating. Less alcohol intake.

Answer 67

emphasize the positive. Sinister pathology has been excluded and symptoms tend to improve over time. Consider CBT and hypnosis.

Answer 68

diarrhoea +/- vomiting due to enteric infection with viruses, bacteria or parasites.

Answer 69

Single-stranded RNA virus. Highly infectious. Transmission by contact with infected people, environment, food. Most common cause of infectious GI disease in England. Presents 12-48hr after exposure, lasting 24-72h.

Answer 70

Acute-onset vomiting, watery diarrhoea, cramps, nausea.

Answer 71

clinical, stool sample reverse transcriptase PCR

Answer 72

supportive, anti-motility agents, usually self-limiting.

Answer 73

Double-stranded RNA virus. Commonest cause of gastroenteritis in children.

Answer 74

incubation 2day. Watery diarrhoea and vomiting for 3-8d, fever, abdominal pain

Answer 75

clinical, antigen in stool

Answer 76

supportive. Routine vaccination in UK

Answer 77

Gram -ve anaerobe Disease due to heat-stable or heat labile toxin which stimulates Na+, Cl- and water efflux into gut lumen

Answer 78

incubation 1-3days. Watery diarrhoea, cramps lasts 3-4 days

Answer 79

clinical, identification of toxin from stool culture.

Answer 80

supportive, self-limiting

Answer 81

boil water, cool thoroughly, peel fruit and vegetables. Avoid ice, salads, shellfish. Drink with a straw.

Answer 82

watery diarrhoea preceded by cramps and nausea

Answer 83

upper GI symptoms e.g. bloating, belching

Answer 84

colitic symptoms, urgency, cramps.

Answer 85

3 or more unformed stools per day plus one of the following: Abdominal pain Cramps Nausea Vomiting Dysentery

Answer 86

Oral rehydration. Clear fluid or oral rehydration salts. Antimotility agents e.g. loperamide Antibiotics

Answer 87

3 episodes partially formed or watery stool/day for <14d

Answer 88

infectious gastroenteritis with bloody diarrhoea

Answer 89

acutely starting diarrhoea lasting >14d

Answer 90

Traveller’s diarrhoea: starting during, or shortly after, foreign travel

Answer 91

disease caused by consumption of food/wate

Answer 92

Gram -ve, spiral-shaped rod

Answer 93

Rotavirus/norovirus most common in the UK Campylobacter Shigella Salmonella S.aureus E.coli C.diff

Answer 94

incubation 1-10d. Bloody diarrhoea, pain, fever, headache.

Answer 95

bacteraemia, hepatitis, pancreatitis, miscarriage, reactive arthritis

Answer 96

stool culture. PCR/enzyme immunoassay.

Answer 97

supportive. Antibiotics only in invasive cases, refer to local sensitivities.

Answer 98

Onset/duration Characteristics of stool Food/drink Travel Fresh water/ swimming Medications

Answer 99

Acute – viral/bacterial Chronic – parasites and non-infectious causes

Answer 100

Floating: fat content – malabsorption, coeliac Blood or mucus: inflammatory/invasive infection/ cancer Watery: small bowel infection

Answer 101

Meat – campylobacter Rice – bacillus cereus Poultry – salmonella Shellfish – norovirus, v.parahaemolyticus

Answer 102

No cholera in the UK – traveller’s diarrhoea

Answer 103

crypto, giardia, aeromonas

Answer 104

Recent antibiotics – C.diff or side effects

Answer 105

Over 50 Chronic diarrhoea Weight loss Blood in stool

Answer 106

Stool tests Blood tests Lower GI endoscopy

Answer 107

Microscopy Culture Ova, cysts and parasites Toxin detection

Answer 108

Blood culture Inflammatory markers ESR/ CRP

Answer 109

non-inflammatory (enterotoxin or superficial adherence/invasion)

Answer 110

inflammatory (invasion/cytotoxin)

Answer 111

proximal small bowel

Answer 112

vibrio cholerae e.coli (ETEC) c.diff bacillus cereus s.aureus

Answer 113

shigella e.coli (EIEC,EHEC) Salmomella enteritidis v.parahaemolyticus c.diff campylobacter jejuni

Answer 114

rotavirus norovirus

Answer 115

giardia cryptosporidium

Answer 116

entamoeba histolytica

Answer 117

Treat cause. Food handlers – no work until stool samples are -ve. If a hospital outbreak, wards may need closing Oral rehydration is better than IV, but if sustained diarrhoea/vomiting then IV fluids with electrolytes may be needed. Avoid antibiotics unless infective diarrhoea is causing systemic upset.

Answer 118

The cause of pseudomembranous colitis. Gram positive spore forming bacteria.

Answer 119

rule of Cs Clindamycin Ciprofloxacin Co-amoxiclav Cephalosporins

Answer 120

Increased temperature Diarrhoea with systemic upset High CRP, WCC and low albumin

Answer 121

Urgent testing of suspicious stool (characteristic smell) Two-stage process with rapid screening test for C.diff protein followed by specific ELISA for toxins.

Answer 122

Stop causative antibiotic. Barrier nursing

Answer 123

Dysphagia Weight loss Retrosternal chest pain

Answer 124

Oesophagoscopy with biopsy Endoscopic ultrasound CT/ MRI for staging

Answer 125

T1 – invading lamina propria/ submucosa T2 – invading Muscularis propria T3 – invading adventitia T4 – invasion of adjacent structures

Answer 126

N0 – no nodal spread N1 – regional node metastases M0 – no distant metastases spread M1 – distal metastases

Answer 127

Localised T1/T2 disease – radical curative oesophagectomy may be tried Pre-op chemo – cisplatin Chemoradiotherapy Palliation aims to restore swallowing with chemo/radiotherapy, stenting and laser use

Answer 128

Often non-specific Dyspepsia Weight loss Vomiting Dysphagia Anaemia

Answer 129

Epigastric mass Hepatomegaly Jaundice Ascites

Answer 130

Gastroscopy and multiple ulcer edge biopsies EUS (endoscopic ultrasound) CT/ MRI for staging

Answer 131

Partial gastrectomy for distal tumours Total gastrectomy if more proximal Combination chemo Surgical palliation for obstruction, pain or haemorrhage

Answer 132

Bleeding/ mucus PR Altered bowel habit or obstruction Tenesmus PR mass

Answer 133

Weight-loss Low Hb Abdominal pain Obstruction less likely

Answer 134

Abdominal mass Perforation Haemorrhage Fistula

Answer 135

Over 40 with PR bleeding and bowel habit change Any age with right lower abdominal mass Palpable rectal mass Men/non-menstruating women with unexplained iron-deficiency anaemia

Answer 136

FBC – microcytic anaemia Faecal occult blood – used for UK screening programme Sigmoidoscopy Barium enema or colonoscopy – or CT Liver USS

Answer 137

Aims to cure and increases survival by up to 50% Different types of surgery done for different sites of cancer

Answer 138

Used in palliation for colonic cancer Occasionally used pre-op to allow resection

Answer 139

Adjuvant chemo helpful Chemo is also used in palliation of metastatic disease

Answer 140

Fever Malaise Anorexia Weight loss RUQ pain

Answer 141

Hepatomegaly Signs of chronic liver disease and evidence of decompensation Feel for an abdominal mass Bruit over liver

Answer 142

Blood: FBC, clotting, LFT, hepatitis serology, α-fetoprotein Imaging: US/ CT to identify lesions. MRI distinguishes malignant and benign lesions Biopsy: find primary e.g. CXR, endoscopy

Answer 143

Primary hepatocyte neoplasia accounts for 90% of primary liver tumours

Answer 144

Fatigue Appetite loss RUQ pain Weight loss Jaundice Ascites

Answer 145

HBV – main cause Autoimmune hepatitis Cirrhosis – alcohol, hemochromatosis, PBC Non-alcoholic fatty liver

Answer 146

3 phase CT MRI Biopsy

Answer 147

Resecting solitary tumours Liver transplant Percutaneous ablation

Answer 148

Biliary tree cancer.

Answer 149

Fever Abdominal pain and ascites Malaise Elevated bilirubin

Answer 150

Most tumours are inoperable at presentation. Most operated on recur. Post-op complications include liver failure, bile leak and GI bleeds Stenting of an obstructed extrahepatic biliary tree, percutaneously or via ERCP

Answer 151

collection of small blood vessels incidental finding on US or CT No treatment required Avoid biopsy

Answer 152

anabolic steroids, oral contraceptives, pregnancy

Answer 153

Only treat if symptomatic or >5cm.

Answer 154

Mostly ductal adenocarcinoma – metastasise early, present late A few arise in ampulla of Vater or pancreatic islet cells (insulinoma, gastrinoma, glucagonomas, somatostinomas, VIPomas

Answer 155

Tumours in the head of the pancreas present with painless obstructive jaundice 75% of tumours in the body and tail present with epigastric pain – radiates to back, relieved by sitting forward

Answer 156

anorexia, weight loss, diabetes, acute pancreatitis

Answer 157

Jaundice + palpable gallbladder Epigastric mass Hepatomegaly Splenomegaly Lymphadenopathy Ascites

Answer 158

Blood: cholestatic jaundice. Ca19-9 elevated – non-specific, but helps assess prognosis Imaging US or CT show pancreatic mass +/- dilated biliary tree +/- hepatic metastases Guide biopsy and help staging prior to surgery

Answer 159

Surgery – considering pancreaticoduodenectomy if fit and with no metastases Post-op morbidity is high Laparoscopic excision Post-op chemotherapy to delay disease progression Palliation of jaundice Endoscopic or percutaneous stent insertion may help jaundice and anorexia Pain – opiates or radiotherapy

Answer 160

Blockage to the lumen of the gut. Commonly refers to blockage of intra-abdominal part of the intestine.

Answer 161

a twist/rotation of segment of bowel

Answer 162

sticking together (abdominal structures to one another, bowel loops or omentum, other solid organs, abdominal wall)

Answer 163

Mechanical (intraluminal)/ true (extraluminal) Paralytic (pseudo obstruction)

Answer 164

Simple Closed loop Strangulation Intussusception

Answer 165

Adhesions (previous surgery) Hernia Rarer; Crohn’s, Malignancy, Volvulus, Intussusception

Answer 166

the inversion of one portion of the intestine within another.

Answer 167

Colon carcinoma Constipation Diverticular stricture Volvulus - Sigmoid

Answer 168

occurs when the bowel twists on its mesentery, which can produce severe, rapid, strangulated obstruction.

Answer 169

Anorexia Nausea Vomiting: Nature – forceful/ regurgitation Content – bilious, feculent Distension Abdominal pain Altered bowel habits: Constipation Obstipation

Answer 170

Tissue death – blood supply can be cut off to part of the intestine Infection – peritonitis.

Answer 171

cause, site, speed of onset, and completeness of obstruction determine definitive therapy. Strangulation and large bowel obstruction require surgery; ileus and conservatively, at least initially.

Answer 172

NGT and IV fluids to rehydrate and correct electrolyte imbalance.

Answer 173

CT to establish the cause of obstruction.

Answer 174

strangulation needs emergency surgery.

Answer 175

the protrusion of a viscus part or part of a viscus through a defect of the walls of its containing cavity into an abnormal position.

Answer 176

contents cannot be pushed back into place

Answer 177

bowel contents cannot pass – features of intestinal obstruction

Answer 178

ischaemia occurs – the patient requires urgent surgery

Answer 179

contents of the hernial sac are stuck inside by adhesions

Answer 180

Usually presents as lump and pain

Answer 181

Bowel enters the femoral canal, presenting as a mass in the upper medial thigh or above the inguinal ligament where it points down the leg, unlike an inguinal hernia which points to the groin.

Answer 182

Occur more often in women, middle age and elderly Irreducible and strangulate

Answer 183

surgical repair

Answer 184

Follow breakdown of muscle closure after surgery If obese, repair is not easy Mesh repair – less recurrence but more infections compared to sutures

Answer 185

Indirect hernias pass through the internal inguinal ring and out through the external inguinal ring Direct hernias push their way directly forward through the posterior wall of the inguinal canal, into a defect in the abdominal wall

Answer 186

Male sex Chronic cough Urinary obstruction Past abdominal surgery

Answer 187

Is lump visible? Ensure it is not a scrotal lump Ask patient to cough – should appear above and medial to pubic tubercle

Answer 188

Indirect hernias

Answer 189

Lose weight and stop smoking pre-op Hernias may recur Mesh techniques – polypropylene mesh reinforces posterior wall

Answer 190

Inflammation and injury of the large intestine resulting from inadequate blood supply.

Answer 191

Usually follows low flow in the inferior mesenteric artery territory and it ranges from mild to gangrenous.

Answer 192

Lower left-sided abdominal pain May have bloody diarrhoea

Answer 193

CT may be helpful but lower GI colonoscopy is gold-standard.

Answer 194

Treatment – usually conservative with fluid replacement and antibiotics Most recover but subsequent development of ischaemic strictures is common Gangrenous ischaemic colitis requires prompt resuscitation followed by resection of the affected bowel and stoma formation. Mortality is high.

Answer 195

Injury to the small intestine occurs due to inadequate blood supply.

Answer 196

Superior mesenteric artery thrombosis/embolism Mesenteric vein thrombosis Non-occlusive disease Trauma, vasculitis, radiotherapy strangulation.

Answer 197

Acute severe abdominal pain No/minimal abdominal signs Rapid hypovolaemia – shock

Answer 198

tends to be constant, central or around the right iliac fossa (RIF)

Answer 199

High Hb due to plasma loss High WCC, modestly raised plasma amylase Persistent metabolic acidosis Abdominal X-ray shows a gasless abdomen Laparotomy – nasty, necrotic bowel

Answer 200

Septic peritonitis Progression of a systemic inflammatory response syndrome to multi-organ failure.

Answer 201

Resuscitation with fluid, antibiotics and LMW heparin are required. If arteriography is done, thrombolytics may be attempted on potentially viable bowel.

Answer 202

Typically brought about through a combination of a low-flow state with atheroma.

Answer 203

Severe, colicky post-prandial abdominal pain Weight loss (painful to eat) Upper abdominal bruit may be present

Answer 204

CT angiography and contrast-enhanced MR angiography

Answer 205

Once diagnosis is confirmed, surgery should be considered due to the ongoing risk of acute infarction. Percutaneous transluminal angioplasty and stent insertion has replaced open revascularisation

Answer 206

Inflamed and painful appendix. It is the most common surgical emergency.

Answer 207

Gut organisms invade the appendix wall after lumen obstruction by lymphoid hyperplasia, faecolith or filarial worms. This leads to oedema, ischaemic necrosis and perforation.

Answer 208

Classic periumbilical pain that moves to the right iliac fossa. Tachycardia Fever Percussion tenderness in RIF Pain on the right during PR examination suggests an inflamed, low lying pelvic appendix

Answer 209

Rovsing’s sign: greater pain in the RIF than the LIF when the LIF is pressed Psoas sign: pain on extending hip if retrocaecal appendix. Cope sign: pain on flexion and internal rotation of right hip if appendix in close relation to obturator internus.

Answer 210

UTI Mesenteric adenitis Diverticulitis/ cholecystitis/ cystitis Food poisoning Crohn’s disease

Answer 211

Blood tests may reveal neutrophil leucocytosis and elevated CRP Ultrasound may help, but appendix not always visualised CT has high diagnosis accuracy and is useful if diagnosis is unclear

Answer 212

Prompt appendicectomy Antibiotics: piperacillin Laparoscopy: diagnostic and therapeutic advantages. Not recommended with suspected gangrenous perforation – rate of abscess formation is higher.

Answer 213

Perforation Appendix mass – occurs when inflamed appendix becomes covered with omentum Appendix abscess – if an appendix mass enlarges.

Answer 214

Bile contains cholesterol, bile pigments and phospholipids. If concentrations vary, different stones may form.

Answer 215

small, friable and irregular.

Answer 216

large, often solitary.

Answer 217

faceted (calcium salts, pigment and cholesterol).

Answer 218

Fair Forty Fertile Fat Female

Answer 219

Biliary pain Cholecystitis maybe Obstructive jaundice

Answer 220

Biliary pain Obstructive jaundice Cholangitis Pancreatitis

Answer 221

Laparoscopic cholecystectomy Bile acid dissolution therapy Bile duct stones: ERCP with sphincterotomy and removal (balloon)/ crushing (laser)/ stent placement Surgery (large stones)

Answer 222

Biliary colic Acute and chronic cholecystitis Carcinoma Mirizzi’s syndrome

Answer 223

Obstructive jaundice Cholangitis Pancreatitis

Answer 224

when a gallstone erodes through the gallbladder into the ileum, causing complications

Answer 225

Gallstones are symptomatic with cystic duct obstruction or if passed into the common bile duct. RUQ pain radiating to the back Possible jaundice

Answer 226

urinalysis, CXR and ECG

Answer 227

analgesia, rehydrate. Elective laparoscopic cholecystectomy

Answer 228

inflammation of gallbladder Follows stone or sludge impaction in the neck of the gallbladder, which may cause continuous epigastric or RUQ pain, vomiting, fever, local peritonism or a GB mass. High WCC (differs it from biliary colic) If the stone moves to the CBD, obstructive jaundice and cholangitis may occur.

Answer 229

high WCC ultrasound – thick-walled, shrunken GB, pericholecystic fluid. Plain AXR only shows 10% of gallstones.

Answer 230

- NBM, pain relief, IVI and antibiotics e.g. co-amoxiclav.

Answer 231

Vague abdominal discomfort Distension Nausea Flatulence Fat intolerance (fat stimulates cholecystokinin release and GB contraction)

Answer 232

Ultrasound to image stones and assess CBD diameter. MRCP is used to find CBD stones.

Answer 233

cholecystectomy.

Answer 234

Pancreatitis is characterised by self-perpetuating pancreatic enzyme-mediated autodigestion; oedema and fluid shifts cause hypovolaemia, as extracellular fluid is trapped in the gut, peritoneum and retroperitoneum.

Answer 235

Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion venom Hyperlipidaemia/ hypothermia/ hypercalcaemia ERCP and emboli Drugs

Answer 236

Gradual or sudden severe epigastric or central abdominal pain. Vomiting prominent. Pain radiates to back, sitting forward may relieve.

Answer 237

High heart rate Fever Jaundice Shock Rigid abdomen with local/general tenderness Periumbilical bruising (Cullen’s) or flanks (Grey Turner’s) from blood vessel autodigestion

Answer 238

Raised serum amylase – excreted renally so renal failure will increase levels. Serum lipase is more sensitive and specific for pancreatitis – rises earlier and falls later. CT: assess severity and complications

Answer 239

Nil by mouth Analgesia Hourly pulse, BP and urine output: daily FBC, U&E, Ca2+, glucose, amylase ERCP and gallstone removal Repeat imaging is performed to monitor progress

Answer 240

Shock Renal failure Sepsis

Answer 241

Pancreatic necrosis and pseudocyst Bleeding from elastase eroding a major vessel Thrombosis may occur in splenic arteries causing bowel necrosis

Answer 242

A chronic inflammatory process of the pancreas, leading to irreversibly low pancreatic function.

Answer 243

Chronic inflammation in the pancreas leads to the replacement of functional pancreatic tissue by fibrous scar tissue.

Answer 244

Alcohol Smoking Autoimmune Pancreatic duct obstruction

Answer 245

Persistent upper abdominal pain and weight loss Radiates to the back and is relieved by sitting forward or hot water bottles on epigastrium/back Steatorrhea and diabetes mellitus occur late once most of the gland is destroyed Brittle diabetes

Answer 246

Ultrasound and CT scan: pancreatic calcifications confirm the diagnosis. MRCP, AXR – speckled calcification

Answer 247

Drugs: give analgesia and fat-soluble vitamins Diet: no alcohol, low fat may help Surgery: e.g. pancreatectomy for unremitting pain/ weight loss

Answer 248

Diabetes Biliary obstruction Local arterial aneurysm Gastric varices

Answer 249

Loss of the liver’s ability to regenerate or repair. Liver failure may be recognised by the development of coagulopathy and encephalopathy. This may occur suddenly in the previously healthy liver (acute liver failure), but it more often occurs on a background of cirrhosis (chronic liver failure).

Answer 250

a clinical syndrome resulting from massive necrosis of liver cells leading to severe impairment of liver function.

Answer 251

viral hepatitis, yellow fever, leptospirosis

Answer 252

paracetamol overdose, halothane, isoniazid

Answer 253

Carbon tetrachloride, Amanita phalloides mushroom

Answer 254

Budd-Chiari syndrome, veno-occlusive disease

Answer 255

alcoholic fatty liver disease, primary biliary cholangitis, primary sclerosing cholangitis, haemochromatosis, autoimmune hepatitis, metabolic causes, malignancy.

Answer 256

hepatic vein obstruction by thrombosis or tumour causes congestive ischaemia and hepatocyte damage.

Answer 257

Destruction of hepatocytes Development of fibrosis in response to chronic inflammation Destruction of the architecture of the nodules of the liver removes the ability of the liver to adequately perform functions, repair and regenerate

Answer 258

Abnormal bleeding Ascites Jaundice Hepatic encephalopathy Fetor hepaticus (sweet and musty breath) Constructional apraxia Mental state drowsiness and confusion, due to cerebral oedema

Answer 259

Blood: FBC – LFTs, clotting, hepatitis, paracetamol level, ferritin Raised bilirubin Glucose low – no glycogenesis Microbiology: blood culture, urine culture, neutrophils >250/mm3 indicates spontaneous bacterial peritonitis Radiology: CXR, abdominal US, Doppler flow studies of the portal vein

Answer 260

Beware of sepsis, hypoglycaemia, GI bleeds/ varices, encephalopathy. Protect airway with intubation and insert a tube to avoid aspiration and remove any blood from the stomach Insert urinary and central venous catheters to help assess fluid status Treat the cause Treat seizures with phenytoin Hemofiltration/ haemodialysis Avoid sedatives/ other drugs with hepatic metabolism LIVER TRANSPLANT

Answer 261

Cerebral oedema, bleeding, encephalopathy, ascites

Answer 262

Can be asymptomatic General malaise Myalgia GI upset Abdominal pain +/- jaundice (pale stools, dark urine) Tender hepatomegaly

Answer 263

hepatitis A,B,C,D,E, herpes virus

Answer 264

Spirochaetes Mycobacteria Parasites Bacteria

Answer 265

Alcohol Toxins/poisoning Autoimmune

Answer 266

Dupuytren’s contracture Spider naevi LFTs can be normal Compensated – liver function maintained

Answer 267

Dupuytren’s contracture Spider naevi LFTs can be normal jaundice ascites low albumin coagulopathy encephalopathy

Answer 268

faecal-oral or shellfish

Answer 269

Fever Malaise Anorexia Nausea Arthralgia

Answer 270

AST and ALT rise 22-40d after exposure, returning to normal over 5-20wks IgM rises due to recent infection IgG is detectable for life

Answer 271

Supportive Monitor liver function Fulminant hepatitis failure/ acute liver failure

Answer 272

blood borne, IV drug abusers, sexual, direct contact

Answer 273

IV drug abusers and their sexual partners/carers, health workers, haemophiliacs, sexually promiscuous

Answer 274

Incubation: 1-6 months

Answer 275

Resemble hepatitis A but arthralgia and urticaria are commoner

Answer 276

HBsAg (surface antigen) is present 1-6months after exposure Antibodies imply past infection

Answer 277

high risk groups vaccinated passive immunisation may be given to non-immune contacts after high-risk exposure also prevents HDV

Answer 278

Fulminant hepatic failure Cirrhosis Membranous nephropathy

Answer 279

Avoid alcohol Immunise sexual contacts Antivirals Supportive

Answer 280

blood transfusion, IV drug abuse, sexual contact

Answer 281

male, older, higher viral load, use of alcohol, HIV

Answer 282

LFTs Anti-HCV antibodies confirms exposure

Answer 283

Non-structural viral protein inhibitors. Quit alcohol Directly acting antivirals

Answer 284

Glomerulonephritis Thyroiditis Autoimmune hepatitis

Answer 285

via blood and bodily fluids.

Answer 286

anti-HDV antibody

Answer 287

pegylated interferon-alpha. If limited success – liver transplant.

Answer 288

via faecal-oral route (food, contaminated water, undercooked seafood and pork)

Answer 289

Fever, malaise, nausea + vomiting, jaundice, hepatomegaly

Answer 290

Serum ALT and AST raised, bilirubin raised, ESR raised HEV serology: HEV IgM antibodies = active infection. HEV IgG antibodies = recovery. HEV RNA = current infection

Answer 291

1st line – no treatment. Very mild illness which is self-limiting within a month. It is a notifiable disease. No vaccine available.

Answer 292

Complications Chronic hepatitis, liver failure (especially in pregnant women), cirrhosis, hepatocellular carcinoma

Answer 293

Cirrhosis implies irreversible liver damage. Histologically, there is loss of normal hepatic architecture with bridging fibrosis and nodular regeneration.

Answer 294

Most common: Alcoholic liver disease, non-alcoholic fatty liver disease, hepatitis B, hepatitis C Rarer: haemochromatosis, Wilson’s disease, alpha 1 trypsin deficiency

Answer 295

Leukonychia: white nails with lunulae undermarcated, from hypoalbuminemia Ectasias Palmar erythema (red palms) Hyperdynamic circulation Hepatomegaly

Answer 296

Coagulopathy (failure of hepatic synthesis of clotting factors) Encephalopathy Hypoalbuminaemia Sepsis Spontaneous bacterial peritonitis

Answer 297

Ascites Splenomegaly Portosystemic shunt including oesophageal varices

Answer 298

Blood: LFT – increased bilirubin, AST, ALT, ALP Low albumin Low WCC and platelets indicate hypersplenism Liver ultrasound – may show a small liver or hepatomegaly, splenomegaly MRI – increased caudate lobe size

Answer 299

General: Good nutrition is vital Alcohol abstinence Ascites: Fluid restriction, low-salt diet Transplant

Answer 300

Autoimmune disease of the liver. Results from a slow, progressive destruction of the small bile ducts of the liver, causing bile and other toxins to build up in the liver (cholestasis).

Answer 301

Interlobular bile ducts are damaged by chronic autoimmune granulomatous inflammation causing cholestasis (may lead to fibrosis, cirrhosis and portal hypertension).

Answer 302

Unknown environmental triggers (possibly pollutants, xenobiotics) and a genetic predisposition leading to loss of immune tolerance to self-mitochondrial proteins.

Answer 303

Often asymptomatic and diagnosed after incidental finding high ALP. Lethargy, sleepiness and pruritus (skin itching) may precede jaundice. Jaundice Skin pigmentation Hepatosplenomegaly

Answer 304

Blood: high ALP, mildly high AST and ALT. High bilirubin and low albumin Ultrasound; excludes extrahepatic cholestasis Biopsy: not usually needed but can be used to look for granulomas around bile ducts.

Answer 305

For symptomatic patients try cholestyramine. Fat-soluble vitamin prophylaxis Monitoring: regular LFT and ultrasound twice yearly Liver transplantation: end-stage disease

Answer 306

Liver disease due to excessive alcohol consumption, including fatty liver, alcoholic hepatitis, and chronic hepatitis with liver fibrosis or cirrhosis.

Answer 307

Alcohol metabolism in the liver generates high levels of NADH which stimulates fatty acid synthesis and production of triglycerides, leading to steatosis. Oxidative stress from metabolism of alcohol leads to hepatocyte injury and necro-inflammatory activity (ASH – alcoholic steatohepatitis). Ongoing, this causes liver fibrosis which may progress to cirrhosis

Answer 308

Steatosis (fatty liver cells which disturbs metabolism) and mild ASH are usually asymptomatic but are a common cause of mildly abnormal LFTs. Severe alcohol hepatitis following binge drinking causes malaise and fever. Jaundice Complications of cirrhosis e.g. ascites or ruptured oesophageal varices

Answer 309

Fatty liver – acute/reversible, but can progress to cirrhosis Alcoholic hepatitis – can progress to cirrhosis Cirrhosis – irreversible liver damage

Answer 310

self neglect, decreased memory function, cortical atrophy

Answer 311

obesity, peptic ulcers, varices, pancreatitis, cancer

Answer 312

high MCV, anaemia from marrow depression and GI bleeding

Answer 313

arrhythmias, high BP, cardiomyopathy

Answer 314

testicular atrophy

Answer 315

Blood: high WCC, low platelets, high MCV, high urea

Answer 316

PREVENTION – CAGE questions ALCOHOL WITHDRAWAL – alcohol free beers may be helpful to patients with addiction to alcohol Acamprosate may help intense anxiety, insomnia and craving after alcohol withdrawal.

Answer 317

Ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticising your drinking? Ever felt Guilty about your drinking? Ever had an Eye-opener in the morning?

Answer 318

An inherited disorder of copper metabolism, leading to the accumulation of toxic levels of copper in the liver and brain.

Answer 319

Possession of two mutated ATP7B alleles on chromosome 13 causes disruption of normal copper transport and accumulation of toxic levels of copper in hepatocytes and basal ganglia.

Answer 320

Most present in childhood or early adulthood with chronic liver disease or cirrhosis. A small proportion of patients present in hepatic failure About half of patients also develop neuropsychiatric symptoms due to copper accumulation in the brain CNS signs Kayser-Fleischer (KF) rings: copper in iris

Answer 321

Tremor Dysarthria (unclear articulation of speech) Dysphagia Parkinson’s

Answer 322

Urine: 24h copper excretion is high (>100mcg, normal is <40mcg) High LFT Serum copper - <11μmol/L Molecular genetic testing can confirm the diagnosis Slit lamp exam: KF rings seen in iris Liver biopsy: raised hepatic copper

Answer 323

Diet: avoid foods with high copper content e.g. chocolate, nuts, mushrooms. Drugs: lifelong penicillamine Liver transplant in severe liver failure Screen siblings – asymptomatic homozygotes need treating.

Answer 324

nausea, rash, low WCC, Hb and platelets

Answer 325

An inherited disorder characterised by increased intestinal absorption of iron, leading to iron overload in multiple organs, particularly the liver and sometimes leading to organ damage

Answer 326

Hepcidin controls plasma iron concentrations by inhibiting iron export by ferroportin from duodenal enterocytes and macrophages. Deficiency of hepcidin results in raised plasma iron concentrations and accumulation in multiple organs, including the liver, pancreas, heart, joints and pituitary.

Answer 327

Early symptoms are non-specific e.g. fatigue and arthropathy Later symptoms; Skin pigmentation (slate-grey) Cirrhosis Hypogonadism Cardiac failure Diabetes mellitus

Answer 328

Blood: high LFT and ferritin levels are raised Images: chondrocalcinosis (haemochromatosis causes stressed joints to deteriorate faster than resting joints, and this is visible on X-rays). Liver and cardiac MRI Liver biopsy: Perl’s stain quantifies iron loading and assesses severity of disease

Answer 329

Venesection (removal of accumulating iron) until ferritin <50mcg/L. Iron will continue to accumulate, so maintenance venesection will be needed for life. Diet: a well-balanced diet should be encouraged, avoiding alcohol but no need to avoid iron-rich foods. Avoid uncooked seafood. Screening: serum ferritin, transferrin saturation.

Answer 330

An inherited disorder affecting the lungs (emphysema) and the liver (cirrhosis).

Answer 331

Lung A1At protects against tissue damage from neutrophil elastase. Deficiency means there is no protection and leads to emphysema in adults and liver disease in children. It is also one of a family of serine protease inhibitors made in the liver, that control inflammatory cascades.

Answer 332

Symptomatic patients usually have the PiZZ genotype ( both parents carriers): Dyspnoea from emphysema Cirrhosis Cholestatic jaundice

Answer 333

Serum α1-antitrypsin levels low Lung function testing: reductions in FEV1 with obstructive pattern Liver biopsy: periodic acid Schiff (PAS) Phenotyping: distinguish between SZ and ZZ phenotypes

Answer 334

Smoking cessation Prompt treatment/ preventative vaccination for lung infections. Liver transplanted – needed in decompensated cirrhosis Lung transplant – improves survival

Answer 335

Effusion and accumulation of serous fluid (protein-containing) in the abdominal cavity.

Answer 336

Stage 1 detectable only after careful examination/ ultrasound scan (mild) Stage 2 easily detectable but of relatively small volume Stage 3 obvious, not tense ascites (moderate) Stage 4 tense ascites (large)

Answer 337

A state of sodium water imbalance Interplay of various neurohormonal agents – renin, aldosterone, sympathetic nervous system, nitric oxide Over filling – inappropriate Na + H2O retention – no volume depletion – hypervolemia

Answer 338

Malignancy Cardiac failure Nephrotic syndrome

Answer 339

Abdominal surgery/ trauma, malignancy, radiation, congenital

Answer 340

Cirrhosis Malignancy Heart failure TB Pancreatitis

Answer 341

Abdominal distension – clothes getting tighter Nausea, loss of appetite Constipation Weight loss

Answer 342

Flanks fullness Fluid thrill Shifting dullness

Answer 343

Naked eye assessment – swollen stomach Chemistry: proteins and amylase Ultrasound scan and abdominal CT

Answer 344

Treat underlying cause Diuretics – spironolactone, metolazone Salt and fluid restriction

Answer 345

Can lead to spontaneous bacterial peritonitis.

Answer 346

Inflammation of the peritoneum.

Answer 347

tensing muscles to prevent movement of peritoneum.

Answer 348

Cholecystitis Pancreatitis Appendicitis Diverticulitis AEIOU

Answer 349

appendicitis, ectopic pregnancy, infection (TB), obstruction, ulcer.

Answer 350

inflamed organs, air, pus, faeces, luminal contents and blood.

Answer 351

Medical causes – spontaneous bacterial peritonitis, pelvic inflammatory disease, dialysis related, TB Surgical causes – perforation of GIT e.g. trauma, appendicitis, cancer Sterile – pancreatitis, familial Mediterranean fever Perforation of peptic/duodenal ulcer

Answer 352

Abdominal pain Diarrhoea Swelling Swinging fever Prostration Shock Tenderness + rebound/percussion pain Board-like abdominal rigidity

Answer 353

Appendicitis Angioedema

Answer 354

Ultrasound/ CT scan Ascitic tap: Raised WCC (neutropil) Erect CXR may show gas under diaphragm

Answer 355

Sepsis Multi-organ failure CV events (MI, stroke) Respiratory complications (pneumonia, pulmonary embolus) Surgical complications

Answer 356

Laparotomy Laparoscopy Treat problem – patch hole, remove organ/cause Wash out infection

Answer 357

Surgery Intensive care Support of kidneys Physio/early mobilisation

Answer 358

an outpouching of the gut wall, usually at sites of entry of perforating arteries.

Answer 359

refers to inflammation of a diverticulum.

Answer 360

symptomatic diverticula

Answer 361

A diet low in fibre and high in meat is the strongest risk factor.

Answer 362

Firm stools require higher intraluminal pressures to propel High intraluminal pressure forces pouches of the colonic mucosa through an anatomical weak point in the muscular layer where blood vessels pass through to supply the mucosal layer.

Answer 363

Intermittent abdominal pain, altered bowel habit, iron deficiency anaemia Acute inflammation in a diverticulum presents with severe left iliac fossa pain Occasionally, erosion of a large submucosal vessel can cause severe rectal bleeding.

Answer 364

Diverticula are a common incidental finding at colonoscopy CT abdomen is best to confirm acute diverticulitis and can identify extent of disease and any complications Colonoscopy risk perforation in acute setting AXR may identify obstruction or free air

Answer 365

Try antispasmodics e.g. mebeverine Surgical resection occasionally needed

Answer 366

Mild attacks can be treated at home with bowel rest (fluids only) and antibiotics Most attacks settle but complications include abscess formation or perforation.

Answer 367

Abnormally dilated and prolapsed anal cushions Extremely common Thought to be due to disruption of the normal suspensory mechanisms caused by chronic straining at stool

Answer 368

Cause bright red rectal bleeding and discomfort

Answer 369

Polypoid projections of the anal mucosa and submucosa

Answer 370

Excised haemorrhoids examined microscopically contain large dilated blood vessels, which may show evidence of thrombosis, with an overlying hyperplastic squamous epithelium.

Answer 371

Microscopically composed of a fibrovascular core covered by squamous epithelium. The fibrovascular core lacks the typically ecstatic vessels of haemorrhoids

Answer 372

A tear in the mucosa of the lower anal canal which is most always located posteriorly in the midline

Answer 373

Cause is unclear, but chronic infection may lead to loss of the normal elasticity of the mucosa, such that passage of hard faeces may precipitate the tear

Answer 374

A collection of pus within deep perianal tissue A complication of infection within a deep anal gland

Answer 375

perianal erythema, swelling and pain

Answer 376

An abnormal epithelial-line tract connecting the anal canal to the perianal skin Usually the result of infection in an anal gland tracking to the skin surface

Answer 377

Uncommon and invariably associated with HPV infection

Answer 378

Vast majority are squamous cell carcinomas which arise from areas of squamous dysplasia known as anal intraepithelial neoplasia which is graded 1-3.

Answer 379

Colonoscopy and biopsy (granulomatous transmural inflammation. Skip lesions, cobblestone appearance. Strictures “string sign”)