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MedEd GKP/AB/VP > GI - LFTs, Biliary Disease and Upper GI Complaints > Flashcards

GI - LFTs, Biliary Disease and Upper GI Complaints Flashcards

1
Q

Liver simplified functions

A

Synthetic Function:
Clotting
Albumin

Metabolic Function
Bilirubin
Oestrogens
Ammonia

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2
Q

Diseased liver implications on functions

A

Decreased clotting factor –> Bruising
Decreased albumin –> Ascites and Leukonychia

Increased bilirubin –> Jaundice
Increased oestrogens –> Pamar erythema, spider naevi, gynaecomastia
Increased ammonia –> Confusion, asterixis

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3
Q

True measures of liver function

A

Bilrubin
Albumin
INR (clotting factor production)

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4
Q

Markers in acute liver injury

A

ALT
AST
ALP
GGT

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5
Q

Liver injury markers

A

AST and ALT
AST:ALT ratio
–> Alcoholic liver disease: >2.5:1
–> Viral hepatitis: <1:1

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6
Q

Biliary Duct injury markers

A

ALP and GGT
–> NB isolated GGT rise in acute alcohol intake

Cause: usually biliary tree obstruction

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7
Q

Gallstones Risk factors

A 
Fat 
Female
Fertile (pregnancy)
over Forty
FHx
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8
Q

Gallstones Classic Presentation

A

Colicky right sided pain

Worse on eating fatty foods

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9
Q

Gallstones Ix

A

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.

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10
Q

Gallstones Management

A

Location?

Common Bile duct:
Choecystectomy
Bile Duct Clearance

Gallbladder
Cholecystectomy

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11
Q

Progression from gallstones

A

ASCENDING CHOLANGITIS
Common bile duct: Bile stasis –> Bacteria (Gut–>Bile ducts)

ACUTE CHOLECYSTITIS
Gallbladder/Cystic Duct:Bile stasis/Inflammation/Bacterial infection

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12
Q

Acute Cholecystitis Presentation

A 
Constant acute RUQ pain; radiates to R shoulder and scapula
Fever
Nausea and Vomiting
Jaundice
Rebound tenderness
Positive Murphy's sign
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13
Q

Acute Cholecystitis Ix

A

FBC –> Raised WCC (Neutrophils)
LFTs –> Raised ALP and GGT
Ultrasound
CT/MRI

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14
Q

Acute Cholecystitis Management

A

Cholecystectomy < 1 wk

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15
Q

Charcot’s Cholangitis Triad

A

Jaundice
RUQ pain
Fever

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16
Q

Acute Suppurative Cholangitis

A

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)

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17
Q

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
A

GGT

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18
Q

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
A

Biliary tract obstruction

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19
Q

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
A

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)

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20
Q

Ascending Cholangitis Ix

A 
Basic obs (for sepsis)
FBC (raised WCC)
LFTs (raised ALP)
Ultrasound
ERCP
21
Q

Ascending Cholangitis Management

A
  1. Manage symptoms - Fluids and Abx
  2. Clear Ducts - ERCP suction and lithotripsy
  3. Cholecystectomy
22
Q

Autoimmune Biliary Disease classifications

A

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.

23
Q

Primary Biliary Cholangitis Summary

A

Autoimmune damage to small bile ducts –> intrahepatic cholestasis
Classic antibody - ANA
Diagnosis - Biopsy

Associated with:
RA
Thyroid disease
Sjogren’s

24
Q

Primary Sclerosing Cholangitis Summary and Ix

A

Antibody: p-anca
Diagnosis: ERCP (“beaded”)

Associated with UC

25
Q

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
A

Ultrasound of the biliary tree

First test is LFTs, but US is gold standard test

26
Q

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
A

Acute Cholecystitis

27
Q

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
A

Ascending Cholangitis

28
Q

Mallory-Weiss tear

A

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

29
Q

Boerhaave Syndrome Summary and Ix

A

Severe Mallory-Weiss tear
Rare
Complete rupture of oesophageal wall

Diagnosis: CXR and CT - pneumomediastinum

30
Q

Oesophageal Varices Summary of Causes

A

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

31
Q

Oesophageal Varices Presentation

A

Background of cirrhosis
Chronic alc. use
Fresh, large-volume blood

32
Q

Oesophageal Varices Ix

A

FBC: microcytic anaemia

LFTs:
Raised ALT/ALP/AST
Raised Bilirubin
Decreased Albumin

UandE’s: Increased urea

33
Q

Oesophageal Varices Management

A

ABCDE approach
Fluids, regular monitoring
Reduce portal HTN - terlipressin
Endoscopy - band ligation is first line

34
Q

Ruptured peptic ulcer presentation

A

Background of PUD - NSAIDs/ ? H.Pylori
Coffee ground emesis
Melaena

35
Q

Ruptured peptic ulcer Ix

A

Obs: Decreased BP

FBC and LFTs normal

36
Q

Ruptured peptic ulcer Management

A
  1. Endoscopy - IM adrenaline at site of ulcer
  2. Omeprazole
  3. Triple therapy if H. Pylori
37
Q

Dysphagia DDx

A

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
38
Q

Dysphagia Ix and Indication

A

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

39
Q

Oesophageal Cancers

A

Middle third - squamous cell carcinoma

Lower third - adenocarcinoma

40
Q

Achalasia pathophysiology

A

Absence of (inhibitory) ganglion cells in myenteric plexus.
No relaxation of lower sphincter
Aperistalsis

‘Bird’s Beak’ appearance

41
Q

Oesophageal Cancer vs Achalasia

A 
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
42
Q

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
A

Oesophageal Cancer

43
Q

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
A

Achalasia

44
Q

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
A

Limited cutaneous sleroderma

45
Q

Neurological Dysphagia

A

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

46
Q

Pharyngeal pouch

A

Coughing up food (late)
Halitosis
Gurgling/dysphonia
Barium swallow

47
Q

Plummer-Vinson syndrome

A

Iron deficiency anaemia
Oesophageal webs
Dysphagia

48
Q

Limited Cutaneous Scleroderma (CREST syndrome)

A 
CREST:
Calcinosis
Raynaud's
Esophageal dysmotility
Sclerodactyly
Telangiectasia

Antibodies: ANA and anti-centromere

MedEd GKP/AB/VP (28 decks)

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