GI + Hepatology 27/7/20 Flashcards
stages of hepatic encephalopathy
1) . altered mood and behaviour, disturbance of sleep pattern and dyspraxia
2) . drowsiness, confusion, slurring of speech and personality change
3) . incoherency, restlessness, asterixis
4) . coma
complications of liver failure
- infection
- cerebral oedema, hepatic encephalopathy
- bleeding
- hypoglycaemia (easily treated with glucose)
- multi-organ failure, hepatorenal syndrome.
- ascites, spontaneous bacterial peritonitis
- portal hypertension, variceal bleeding
management of hepatic encephalopathy
- treat underlying cause
- lactulose (removes nitrogenous waste)
- IV mannitol to reduce cerebral oedema
management of liver-related coagulopathy
- vitamin K
- FFP
King’s college criteria for liver transplant (paracetamol overdose)
- arterial pH <7.3 24h after ingestion OR - pro-thrombin time >100s AND creatinine >300µmol/L AND grade III or IV encephalopathy
King’s college criteria for liver transplant (NON-paracetamol overdose)
- prothrombin time >100s OR any three of: - drug-induced liver failure - age under 10 or over 40 years - 1 week from 1st jaundice to encephalopathy - prothrombin time >50s - bilirubin ≥300µmol/L
causes of liver cirrhosis
- alcohol
- hepatitis B and C (+autoimmune hep)
- non-alcoholic fatty liver disease
- biliary: primary biliary cirrhosis, primary sclerosing cholangitis
- genetic: haemochromatosis, Wilson’s disease, alpha-1-antitrypsin deficiency
- drugs: methotrexate, amiodarone, isoniazid
- Budd-Chiari syndrome
- heart failure
Child-Pugh score
used to assess severity of liver cirrhosis score - bilirubin (umol/l) - albumin (g/l) - prothrombin time (seconds prolonged) - encephalopathy - ascites
scores are added and the degree of cirrhosis is classified as
- A (<7 points)
- B (7-9 points)
- C (>9 points)
Model for End-Stage Liver Disease (MELD) used increasingly in recent years, especially when considering liver transplant
management of ascites
- fluid restriction + low Na diet
- spironolactone (can add furosemide)
- drainage if tense
- albumin infusion may be required
- prophylactic Abx if at increased risk of SBP
GI features of ulcerative colitis
- diarrhoea ± blood
- urgency/tenesmus
- abdominal pain, particularly in the left lower quadrant
- increased risk of colorectal cancer (UC higher risk than Crohn’s)
- lead pipe sign on AXR, loss of haustra with no skips in barium enema
GI features of Crohn’s
- diarrhoea ± blood
- abdominal pain
- perianal disease: e.g. skin tags or ulcers
extra-GI tract features of Crohn’s and UC
- weight loss + absorption problems
- arthritis
- erythema nodosum, pyoderma gangrenosum
- osteoporosis
- uveitis (UC more commonly)/episcleritis (Crohn’s more commonly)
- primary sclerosing cholangitis (UC more commonly)
- clubbing
NICE classification of UC severity
- mild: < 4 stools/day, only a small amount of blood
- moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
- severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
management of UC
MILD-MOD UC
- proctitis, proctosigmoiditis, left-sided UC = topical aminosalicylate (5-ASA eg. sulfasalazine), add oral 5-ASA if unresponsive after 4 wks/extensive
SEVERE UC
- inpatient management
- IV corticosteroids (IV ciclosporin if CI)
- surgery may be required (panproctocolectomy with permanent end ileostomy )
- following a severe relapse, PO azathioprine may be used for remission
triggers for UC flares
- usually no identifiable trigger
- stress
- medications: NSAIDs, antibiotics
- cessation of smoking
management of Crohn’s
- smoking cessation inducing remission: - prednisolone - 5-ASAs second line to glucocorticoids maintaining remission: - azathioprine - methotrexate second line surgery
features of coeliac disease
- abdominal pain
- bloating
- nausea and vomiting
- diarrhoea
- steatorrhoea
- fatigue
- weight loss or failure to thrive in children
- dermatitis herpetiformis
complications of coeliac and associated conditions
- anaemia (folate/B12/iron deficiency)
- osteoporosis
- enteropathy associated T-cell lymphoma
- autoimmune conditions: type 1 diabetes, thyroid disease eg. Graves’ disease or Hashimoto’s thyroiditis
investigations for coeliac disease
- gluten diary
- stool culture to rule out infection
- serological markers
> anti-TTG IgA
> anti-endomysial antibody
> IgA to prevent false negatives due to deficiency - diagnostic OGD with biopsy
> histology shows: sub-total villous atrophy, crypt hyperplasia, intra-epithelial lymphocytes
diagnostic criteria for IBS
Manning criteria:
- abdominal discomfort or pain that is relieved by defecation
- associated with altered bowel frequency or stool form (diarrhoea or constipation)
- bloating
- symptoms made worse by eating
- passage of mucus
lifestyle advice for IBS
- regular mealtimes and take time to eat
- reduce caffeine, fizzy drinks, alcohol
- restrict fibre, porridge may be useful for people with wind/bloating
pharmacological management of IBS
- IBS-C, laxative
- IBS-D, loperamide
- if ineffective, TCAs may be of use
screening tools for alcohol dependence
- CAGE questionnaire
- AUDIT (alcohol use disorders identification test)
- SADQ (severity of alcohol dependence questionnaire)
also consider risk to others, eg. children, and associated psychosocial problems
CAGE questionnaire
- have you ever felt you needed to CUT down on your drinking?
- have people ANNOYED you by criticising your drinking?
- have you felt GUILTY about your drinking?
- have you ever felt you needed a drink first thing in the morning (EYE OPENER) to get rid of a hangover or steady your nerves?
2+ = likely alcohol dependence
management of alcohol withdrawal
- CBT if appropriate (mild dependence/problem drinking)
- assisted withdrawal required if >20 score in AUDIT or over 15units daily
> pabrinex
> chlordiazepoxide
> acamprosate or naltrexone
> PO lorazepam if delirium tremens
