GI - LFTs, Biliary Disease and Upper GI Complaints Flashcards
Liver simplified functions
Synthetic Function:
Clotting
Albumin
Metabolic Function
Bilirubin
Oestrogens
Ammonia
Diseased liver implications on functions
Decreased clotting factor –> Bruising
Decreased albumin –> Ascites and Leukonychia
Increased bilirubin –> Jaundice
Increased oestrogens –> Pamar erythema, spider naevi, gynaecomastia
Increased ammonia –> Confusion, asterixis
True measures of liver function
Bilrubin
Albumin
INR (clotting factor production)
Markers in acute liver injury
ALT
AST
ALP
GGT
Liver injury markers
AST and ALT
AST:ALT ratio
–> Alcoholic liver disease: >2.5:1
–> Viral hepatitis: <1:1
Biliary Duct injury markers
ALP and GGT
–> NB isolated GGT rise in acute alcohol intake
Cause: usually biliary tree obstruction
Gallstones Risk factors
Fat Female Fertile (pregnancy) over Forty FHx
Gallstones Classic Presentation
Colicky right sided pain
Worse on eating fatty foods
Gallstones Ix
LFTs:
Expect a raised ALP and GGT
Shouldn’t see direct liver injury
Ultrasound of biliary tree is gold standard.
Most gallstones are not radio-opaque.
Gallstones Management
Location?
Common Bile duct:
Choecystectomy
Bile Duct Clearance
Gallbladder
Cholecystectomy
Progression from gallstones
ASCENDING CHOLANGITIS
Common bile duct: Bile stasis –> Bacteria (Gut–>Bile ducts)
ACUTE CHOLECYSTITIS
Gallbladder/Cystic Duct:Bile stasis/Inflammation/Bacterial infection
Acute Cholecystitis Presentation
Constant acute RUQ pain; radiates to R shoulder and scapula Fever Nausea and Vomiting Jaundice Rebound tenderness Positive Murphy's sign
Acute Cholecystitis Ix
FBC –> Raised WCC (Neutrophils)
LFTs –> Raised ALP and GGT
Ultrasound
CT/MRI
Acute Cholecystitis Management
Cholecystectomy < 1 wk
Charcot’s Cholangitis Triad
Jaundice
RUQ pain
Fever
Acute Suppurative Cholangitis
Presence of pus in the biliary ducts may result in Reynold’s Pentad; Charcot’s Triad + Hypotension and Confusion.
(This is when bacteria enter the bloodstream)
A 19-year-old male is admitted following an alcohol binge. His friends report he has vomited several times and fell over. You notice some bruises on his hands.
Which of the following is likely to be most elevated?
AST ALT GGT ALP All of the above
GGT
A 42-year-old female is admitted with severe RUQ pain that is worse on eating fatty foods. After obtaining her LFTs, you notice a remarkably high ALP.
What is the most likely diagnosis?
Viral hepatitis Alcoholic hepatitis Short-term alcohol abuse Biliary tract obstruction Gilbert’s syndrome
Biliary tract obstruction
A 45-year-old chronic alcoholic presents with jaundice, bruising and abdominal pain. His stools and urine are of normal colour. His bilirubin and AST are raised.
What other marker is likely to be abnormal?
ALT Albumin ALP Haemoglobin GGT
ALT
(but GGT as well
ALP can be normal or elevated in alcoholic liver disease.
Albumin and Hb would be low. So basically everything is abnormal - shit question sorry)
Ascending Cholangitis Ix
Basic obs (for sepsis) FBC (raised WCC) LFTs (raised ALP) Ultrasound ERCP
Ascending Cholangitis Management
- Manage symptoms - Fluids and Abx
- Clear Ducts - ERCP suction and lithotripsy
- Cholecystectomy
Autoimmune Biliary Disease classifications
Primary Biliary Cholangitis (PBC)
Primary Sclerosing Cholangitis (PSC)
PBC: Destruction of small bile ducts –> intrahepatic cholestasis
PSC: Intra + Extrahepatic bile duct inflammation –> scarring –> narrowing. Stenosis and fibrosis around the bile ducts cause them to squeeze shut.
Primary Biliary Cholangitis Summary
Autoimmune damage to small bile ducts –> intrahepatic cholestasis
Classic antibody - ANA
Diagnosis - Biopsy
Associated with:
RA
Thyroid disease
Sjogren’s
Primary Sclerosing Cholangitis Summary and Ix
Antibody: p-anca
Diagnosis: ERCP (“beaded”)
Associated with UC
A 38-year old woman presents with vague, colicky right-sided abdominal pain. She reports it is got worse 6 hours ago after eating an Indian take-out. On examination her sclera appear icteric, and her abdomen is soft and non-tender.
Select the investigation needed to confirm her diagnosis.
Liver function tests Ultrasound of the biliary tree Split bilirubin ratio ERCP Liver biopsy
Ultrasound of the biliary tree
First test is LFTs, but US is gold standard test
While waiting for her cholecystectomy, the same woman falls more unwell. She feels feverish, has vomited twice and reports that the pain initially felt colicky, but now is constant in her RUQ. She also feels dull pain in her right shoulder. On examination, she displays rebound tenderness in her RUQ and a positive Murphy’s sign.
Select the likely diagnosis.
Biliary colic Primary Biliary Cholangitis Ascending Cholangitis Acute Cholecystitis Cholangiocarcinoma
Acute Cholecystitis
A 48-year old obese man presents to AandE in agony. He is shivering visibly, clutching his right upper quadrant. You notice his hands are yellow and there are excoriations on his arms. His bloods show a raised white cell count and CRP.
Select the likely diagnosis.
Biliary colic Primary Sclerosing Cholangitis Primary Biliary Cholangitis Viral hepatitis Ascending Cholangitis
Ascending Cholangitis
Mallory-Weiss tear
Tear in the mucosal layer of the oesophagus
Follows episode of severe vomiting; e.g. due to alcohol, bulimia
Usually seen as blood streaked in vomit
Vomiting always precedes bleeding
Resolves within 24-48hrs
Tears happen at the gastro-oesophageal junction
Boerhaave Syndrome Summary and Ix
Severe Mallory-Weiss tear
Rare
Complete rupture of oesophageal wall
Diagnosis: CXR and CT - pneumomediastinum
Oesophageal Varices Summary of Causes
Liver Cirrhosis:
Decreased clotting factors –> Increased bleed risk –> ruptured oesophageal varices
Increased extrahepatic blood shunting –> Portal hypertension –> ruptured oesophageal varices
Continued alcohol use –> Oesophageal irritation –> ruptured oesophageal varices
Oesophageal Varices Presentation
Background of cirrhosis
Chronic alc. use
Fresh, large-volume blood
Oesophageal Varices Ix
FBC: microcytic anaemia
LFTs:
Raised ALT/ALP/AST
Raised Bilirubin
Decreased Albumin
UandE’s: Increased urea
Oesophageal Varices Management
ABCDE approach
Fluids, regular monitoring
Reduce portal HTN - terlipressin
Endoscopy - band ligation is first line
Ruptured peptic ulcer presentation
Background of PUD - NSAIDs/ ? H.Pylori
Coffee ground emesis
Melaena
Ruptured peptic ulcer Ix
Obs: Decreased BP
FBC and LFTs normal
Ruptured peptic ulcer Management
- Endoscopy - IM adrenaline at site of ulcer
- Omeprazole
- Triple therapy if H. Pylori
Dysphagia DDx
Functional/Structural vs High/Low severity
Functional/High:
Stroke
Parkinson’s disease
Functional/Low:
Achalasia
Oesophageal spasm
CREST
Structural/High:
Pharyngeal pouch
Structural/Low: Cancer Benign stricture Plummer-Vinson Ortner's Syndrome
Dysphagia Ix and Indication
Barium Swallow:
High dysphagia - avoid risky endoscopy
Low dysphagia - if suspecting achalasia
Endoscopy: often first line for low dysphagia
Videofluoroscopy: Functional, High dysphagia
Manometry: Differentiate between motility disorders
Oesophageal Cancers
Middle third - squamous cell carcinoma
Lower third - adenocarcinoma
Achalasia pathophysiology
Absence of (inhibitory) ganglion cells in myenteric plexus.
No relaxation of lower sphincter
Aperistalsis
‘Bird’s Beak’ appearance
Oesophageal Cancer vs Achalasia
OC: Structural dysphagia Middle-aged to elderly New-onset Progressive FLAWS High or low Ix: OGD
Achalasia: Functional dysphagia Young people Long-term onset Intermittent No FLAWS Low Ix: Barium swallow and manometry
A 76-year old retired greengrocer visits her GP with difficulty swallowing solids. She says this has been getting progressively worse over 1 month. There is no coughing, choking or heartburn. She reports food getting “stuck” 2-3 seconds after swallowing. She attributes her weight loss to not eating properly, and also thinks this has caused loose, brown-black stools. Bloods show a microcytic anaemia.
Select the likely diagnosis:
Stroke Oesophageal cancer Pharyngeal pouch Plummer-Vinson syndrome Benign stricture
Oesophageal Cancer
A 27-year old lawyer presents with a 2-year history of mild dysphagia to both solids and liquids. She has no weight loss. She has symptoms of heartburn
and nocturnal cough, but PPIs and bronchodilators haven’t helped. She is systemically well, and her examination is unremarkable. A “bird’s beak” appearance is noted on barium swallow.
Select the diagnosis:
Achalasia Benign stricture Plummer-Vinson syndrome Oesophageal spasm Stroke
Achalasia
A 45-year old man presents with a 6-week history of dysphagia. This is associated with pain in his fingers, with him noting that he sees the colour vary from red, to white, to blue. He also has several red, vascular marks on his face.
Select the diagnosis:
Plummer-Vinson syndrome Ortner’s syndrome Pharyngeal pouch Limited cutaneous scleroderma Oesophageal spasm
Limited cutaneous sleroderma
Neurological Dysphagia
Due to stroke or Parkinson’s disease
Other symptoms present in history
Coughing: immediately on swallow.
Choking: also implies problem with swallow.
Slow eating
Early dysphagia for liquids
Pharyngeal pouch
Coughing up food (late)
Halitosis
Gurgling/dysphonia
Barium swallow
Plummer-Vinson syndrome
Iron deficiency anaemia
Oesophageal webs
Dysphagia
Limited Cutaneous Scleroderma (CREST syndrome)
CREST: Calcinosis Raynaud's Esophageal dysmotility Sclerodactyly Telangiectasia
Antibodies: ANA and anti-centromere
