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
stages of alcohol withdrawal
6-12 hrs
- insomnia/anxiety/agitation
- sweating/palpitations/tremor
- nausea/vomiting
12-24hrs
- hallucinations (visual/tactile/auditory)
typically ~36-72 hrs
- delirium tremens
> seizures
> psychosis
> confusionfeatures of pancreatitis
ACUTE PANCREATITIS - severe epigastric pain radiating to back - vomiting - possibly Cullen's/Gray-Turner's signs - rarely ischaemic retinopathy CHRONIC PANCREATITIS - steatorrhoea - epigastric pain, typically worse on eating, especially fatty foods - endocrine dysfunction (eg. T1DM)
investigations for pancreatitis
ACUTE - serum lipase - serum amylase - USS for cause (can have contrast CT) CHRONIC - CT/AXR for pancreatic calcification - faecal elastase for exocrine dysfunction - OGTT for T1DM lipase/amylase not typically raised in chronic
causes of acute pancreatitis
I GET SMASHED Idiopathic Gallstones Ethanol Trauma Steroids Mumps (other viruses include Coxsackie B) Autoimmune (e.g. polyarteritis nodosa) Scorpion venom Hypertriglyceridaemia, Hypercalcaemia ERCP Drugs (azathioprine, mesalazine, bendroflumethiazide, furosemide, sodium valproate)
management of acute pancreatitis
- fluid resuscitation
- analgesia
- surgery dependent on cause (eg. gallstone = cholecystectomy or ERCP)
- treat underlying cause, eg. alcoholism, nutrition, change meds
causes of chronic pancreatitis
- alcohol dependence
- genetic: CF, haemochromatosis
- ductal obstruction: gallstone, tumour
management of chronic pancreatitis
- treat underlying cause, eg. alcohol abstinence
- analgesia
- pancreatic enzyme supplements
- manage endocrine dysfunction if present, eg. give insulin
management of variceal bleeding
- ABCDE
- vit K, FFP, platelets
- terlipressin 2mg every 4-6 hrs until controlled (reduces portal hypertension)
- IV Abx broad spec eg. co-amox
- urgent endoscopy once haemodynamically stable (variceal banding done with endoscopy)
> regular endoscopy in those with cirrhosis - prophylactic propranolol
TIPS (trans-jugular intrahepatic portosystemic shunt) if recurrent, unresponsive)
Glasgow-Blatchford Score
stratifies upper GI bleeding patients who are “low-risk” and candidates for outpatient management
- score of 1+ = high risk
features of primary biliary cholangitis
autoimmune condition causing scarring and inflammation of the bile ducts, eventually leading to liver cirrhosis
- symptoms of biliary disease: jaundice, itch, fatigue
- anti-mitochondrial antibodies
- increased risk of hepatocellular carcinoma
- associated with other autoimmune conditions, particularly Sjogrens
causes of pre-hepatic jaundice
- conjugation disorders: Gilbert’s, Crigler-Naajjar
- haemolysis
- drugs: contrast, rifampicin
causes of intra-hepatic jaundice
- viruses (hepatitis, CMV, EBV)
- drugs: paracetamol overdose, valproate, statins, TB antibiotics
- cirrhosis
- liver abscess or malignancy
- haemochromatosis, Wilson’s disease
- autoimmune hepatitis
- alpha-1 antitrypsin deficiency
- Budd-Chiari syndrome
- failure to excrete conjugated bilirubin (Dubin-Johnson syndrome)
causes of post-hepatic jaundice
- cholestasis (dark urine, pale stools)
> primary biliary cholangitis
> primary sclerosing cholangitis
> gallstones - drugs: coamoxiclav, flucloxacillin, nitrofurantoin, steroids, sulfonylureas
- malignancy: pancreas adenocarcinoma, cholangiocarcinoma
features of primary sclerosing cholangitis
inflammation and fibrosis of intra and extra-hepatic bile ducts
- deranged LFTs
- hepatomegaly
- cholestatic jaundice
- p-ANCA
- multiple beaded biliary strictures seen on ERCP
- increased risk of cholangiocarcinoma
investigations for haemochromatosis
- bloods: deranged LFTs, raised serum ferritin and transferrin saturation
- genetic testing: HFE gene defects
- liver biopsy: increased iron stores
management of Barrett’s oesophagus
due to chronic GORD - squamous to columnar epithelium at lower oesophagus
- endoscopy classification:
> low-grade dysplasia = high dose PPI and 6 monthly endoscopy
> high-grade dysplasia = endoscopic resection
management of H. pylori
- triple therapy: amoxicillin (metronidazole if allergy), clarithromycin and a PPI twice daily for seven days
- untreated H. pylori can lead to:
> peptic ulcers
> gastric cancer
> B cell lymphoma of MALT tissue
management of gastroenteritis
- fluid replacement/oral rehydration sachets
- Abx if systemic disease/immunocompromised
> salmonella and shigella = ciprofloxacin
> campylobacter = erythromycin
> cholera = tetracycline
food poisoning is a notifiable disease
antibiotics with increased risk of facilitating Clostridium dificile infection
- clindamycin
- ciprofloxacin
- cephalosporins
- penicillins
management of Clostridium dificile infection
- PO metronidazole
- PO vancomycin if severe
- supportive treatment
- faecal transplant in recurrence
investigations for achalasia
- oesophageal manometry: excessive LOS tone which doesn’t relax on swallowing
- barium swallow: bird’s beak appearance
management of achalasia
- pneumatic balloon dilation (if low surgical risk - due to possible complications of procedure)
- botox injection of LOS if high surgical risk
- nitrates/CCBs
features of achalasia
- dysphagia of BOTH liquids and solids
- heartburn
- regurgitation
- may lead to cough, aspiration pneumonia etc
- malignant change in small number of patients
features of pharyngeal pouch
typically in elderly men
- dysphagia
- regurgitation
- aspiration
- neck swelling which gurgles on palpation
- halitosis
features of oesophageal stricture
- longer history of dysphagia, often not progressive
- GORD
- lack of systemic features seen with malignancy
features of oesophageal cancer
BOTH - progressive dysphagia - weight loss ADENOCARCINOMA - may have previous symptoms of GORD or Barrett's oesophagus SQUAMOUS CELL CARCINOMA - usually no GORD history - more linked with weight loss
alcohol picture of LFTs
- raised GGT
- AST:ALT > 2
features of Budd-Chiari syndrome
triad of: - abdominal pain: sudden onset, severe - ascites - tender hepatomegaly doppler US diagnostic
features of ascending cholangitis
usually follow gallstone obstruction/biliary stricture = severely septic and unwell Charcot's triad: - fever - jaundice - right upper quadrant pain typically E. coli
management of ascending cholangitis
- fluid resuscitation
- IV Abx
- ERCP
Hep B antigen testing
HBsAg = ongoing infection, either acute or chronic if present > 6 months
anti-HBc = caught, i.e. negative if immunized
screening for hepatocellular carcinoma
USS and alpha fetoprotein in at risk groups, eg. current cirrhosis
metabolic features of refeeding syndrome
- hypophosphataemia
- hypokalaemia
- hypomagnesaemia: may predispose to torsades de pointes
- abnormal fluid balance
these may lead to organ failure
management of SBP
ABCDE
- IV cefotaxime
> most common organism is E. coli
- prophylactic ciprofloxacin in those with ascites and cirrhosis
features of Whipple’s disease
Tropheryma whippelii - malabsorption: diarrhoea, weight loss - arthralgia - lymphadenopathy - skin: hyperpigmentation and photosensitivity treatment with PO co-trimoxazole
features of Wilson’s disease
increased copper deposition, particularly in liver, brain and cornea
- hepatitis/cirrhosis
- basal ganglia degeneration (behaviour, speech, psychiatric features, later parkinsonism, dementia)
- Kayser-Fleischer rings
- Fanconi syndrome
management of primary biliary cholangitis
- ursodeoxycholic acid: slows disease progression and improves symptoms
- pruritus: cholestyramine
- fat-soluble vitamin supplementation (ADEK)
- liver transplantation
no definitive treatment for primary SCLEROSING cholangitis besides liver transplant
management of alcoholic liver disease
alongside pabrinex, alcohol withdrawal pathway, etc.
- prednisolone + NAC
management of haemorrhoids
- soften stools: increase dietary fibre and fluid intake
- topical local anaesthetics and steroids
- rubber band ligation
- surgery is reserved for non-responsive, large, symptomatic haemorrhoids
