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Phase 4 > GI/Liver > Flashcards

GI/Liver Flashcards

1
Q

what is acute appendicitis?

A

an acute inflammation of the vermiform appendix

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2
Q

what age range is appendicitis most common in?

A

10-20 years

uncommon <4 years - usually present with perforation

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3
Q

what are 3 risk factors for appendicitis?

A

low dietary fibre
improved personal hygiene
smoking

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4
Q

what is the pathophysiology of appendicitis?

A

Lumen of appendix is obstructed => fills with mucus => increased pressure => bacteria multiply (bacteriodes fragilis and E.coli) => distension of lumen => inflammation, oedema, ischaemia, necrosis, perforation => nausea, vomiting, pain, reflex anorexia

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5
Q

what are 6 manifestations of appendicitis?

A

Acute abdomen pain localising to RLQ with guarding
anorexia
nausea + vomiting
tense rigid abdomen
low grade fever
Rovsing’s +ve
Rebound + percussion tenderness

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6
Q

where is McBurney’s point?

A

1/3rd of way from anterior superior iliac spine to umbilicus

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7
Q

what is the gold standard diagnosis for appendicitis?

A

CT abdomen

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8
Q

what are 2 investigations for appendicitis?

A

US abdo - also can check ovaries
Diagnostic laparoscopy

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9
Q

what are 5 key differentials for appendicitis?

A

ectopic pregnancy
Ovarian cyst/torsion
Meckle’s diverticulum
Mesenteric adenitis - usually in young children
Appendix mass

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10
Q

what are 3 complications of appendicitis?

A

Perforation
Peritonitis
Abscess formation

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11
Q

what are 5 complications of appendicectomy?

A

Bleeding, infection, pain, scars
Damage to bowel/bladder
Removal of normal appendix
anaesthetic risks
VTE

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12
Q

what is coeliac disease?

A

systemic autoimmune inflammatory disease affecting the small intestine triggered by dietary gluten peptides found in wheat, rye, barley, and related grains.

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13
Q

what are 4 histological features of coeliac disease?

A

villous atrophy
crypt hyperplasia

increase in intraepithelial lymphocytes
lamina propria lymphocyte infiltration

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14
Q

what is the trigger in coeliac disease?

A

prolamins found in gluten

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15
Q

what are 3 risk factors for coeliac disease?

A

FHx
IgA deficiency
autoimmune disease (T1DM)

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16
Q

what immune cell is coeliac gluten intolerance mediated by?

A

T cell

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17
Q

what are 4 presentations of coeliac disease?

A

Diarrhoea or steatorrhoea
abdominal bloating/discomfort
anaemia
indigestion
fatigue
Failure to thrive - children

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18
Q

What skin manifestation can be a sign of coeliac disease?

A

dermatitis herpetiformis - itchy blistering skin rash usually on abdomen

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19
Q

what are 3 neurological signs associated with celiac disease?

A

peripheral neuropathy
cerebellar ataxia
epilepsy

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20
Q

what are 6 conditions associated with coeliac?

A

T1DM
thyroid disease
autoimmune hepatitis
primary billiary cirrhosis
primary sclerosing cholangitis
downs syndrome

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21
Q

what are 2 serological investigations for coeliac disease?

A

1 - Tissue transglutaminase antibodies and total IgA - Anti-TTG

2 - endomysial antibodies - Anti-EMA

anti-casein antibodies

Must be on diet containing gluten

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22
Q

what are 9 complications of untreated coeliac disease?

A

vitamin deficiency
anaemia
Hyposplenism
subfertility
osteoporosis
ulcerative jenunitits
enteropathy associated t-cell lymphoma
non-Hodgkin lymphoma
small bowl adenocarcinoma

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23
Q

are males of females more likely to be affected by Crohn’s and coeliac disease?

A

females

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24
Q

what are 5 risk factors for Crohn’s disease?

A

HLA-B27
FHx
smoking
Ashekanazi jewish
caucasian

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25
Q

what is the pathophysiology of Crohn’s disease?

A

Transmural granulomatous inflammation of any part of GI tract => most common in terminal ileum and proximal colon.
skip lesions - cobblestone appearance
relapsing and remitting

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26
Q

what are 7 presentations of Crohn’s?

A

Chronic diarrhoea
weight loss
Abdo pain
blood in stool (less common than in UC)
perianal disease
mouth ulcers
Obstructive symptoms

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27
Q

what can be seen on barium fluoroscopy in Crohn’s?

A

Kantor’s string sign - suggests strictures
Rose thorn ulcers

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28
Q

what is classes as mild Crohn’s ?

A

1st presentation
1st exacerbation in 12 months

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29
Q

what is classed as moderate Crohn’s?

A

> 2 exacerbations in 12 months
Glucocorticoids cannot be tapered

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30
Q

what is severe Crohn’s?

A

unresponsive to conventional therapy
AND
>1 symptom
AND
usually loose stools >3x per day

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31
Q

what is the management for inducing remission in Crohn’s disease flare ups?

A

1st - Glucocorticoids (budenoside, prednisolone or IV hydrocortisone depending on severity)

1 - Elemental diet - in children when worries about steroid use

Immunosuppresion - azathioprine, mercaptopurine and methotrexate

Biologics - inflixibab
antibiotics for peri-anal disease

SURGERY

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32
Q

what medications are used in Crohn’s to maintain remission?

A

1 - Azathioprine or mecaptopurine

2 - Methotrexate

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33
Q

what is IgG4 related sclerosing cholangitis?

A

Similar presentation to Primary sclerosing cholangitis but with raised IgG4 levels

Responds well to steroids, associated with autoimmune pancreatitis

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34
Q

what are 6 indications for surgery in Crohn’s?

A

Poor response to drug treatment
Strictures
Abscesses and fistulae
Delayed growth
Malignancy
Obstruction/perforation

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35
Q

what are 5 surgeries that can be done for Crohn’s?

A

ileocaecal resection
partial R hemicolectomy
Colectomy with ileostomy/ileo-rectal anastomosis
panprotocolectomy and ileostomy
Stricturoplasty

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36
Q

what are 6 complications of Crohn’s disease?

A

Peri-anal abscess
Anal fissure/fistula
Strictures and obstruction
Perforation
Malignancy
Osteoporosis

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37
Q

what is 1 important complication of azathioprine and mercaptopurine?

A

Myelosupression - check FBC weekly for 1st month then every 3 months

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38
Q

what is diverticulitis?

A

inflammation of diverticula

diverticula = out pouching of the mucosa and submucosa through the muscular layer of the colonic wall

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39
Q

what is the main cause of diverticulitis?

A

low fibre diet

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40
Q

what are 5 risk factors for diverticulitis?

A

50+
low fibre diet
obesity
Smoking
Genetics, connective tissue disorders

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41
Q

what part of the colon is diverticulitis most common in?

A

sigmoid colon

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42
Q

what is the pathophysiology of diverticulitis?

A

Low fibre => increased intestinal transit time and straining on loo => increased intraintestinal pressure => diverticula herniations => foecal matter gets stuck => infection => inflammatory response => micro or macro perforations

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43
Q

what are 5 presentations of diverticulitis?

A

Severe L lower quadrant pain/guarding/tenderness
Nausea and Vom
Fever
Change in bowel habit
PR bleeding
Urinary symptoms - due to irritation of bladder by bowel

LLQ Mass - if abscess

Chronic - intermittent LIF pain, bloating, change in bowel habit

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44
Q

what is the gold standard for diverticulitis?

A

CT Ado/Pelvis with contrast - thickened bowel wall

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45
Q

what is the management for uncomplicated diverticulitis in primary care?

A

1 - Co-Amox 500/125 mg TDS PO 5 days

1 - Pen allergy
- Cefalexin 500mg TDS 5 days PO + metronidazole400mg TDS PO 5 days
- TRUE ALLERGY - Trimethoprim 200mg BD PO + Metronidazole 400mg TDS 5 days

Analgesia - paracetamol
Only take clear liquids till symptoms improve
Follow up in 2 days

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46
Q

what is the management of complicated diverticulitis in hospital?

A

1 - IV Co-amox 1.2g TDS

Pen Allergy
- Cefuroxime 750mg QDS + Metronidazole 500mg TDS
- TRUE ALLERGY - Ciprofloxacin 400mg TDS + Metronidazole 500g TDS

R/V in 48 hours

Analgesia
NBM/Clear fluids only
IV fluids
Urgent surgery if complications

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47
Q

what are 5 complications of diverticulitis?

A

fistulae
abscesses
perforations
peritonitis
large haemorrhage
ileus/obstruction

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48
Q

what is the management of diverticular diseae?

A

Increase fibre in diet
Bulk forming laxatives - ispaghula husk - 1 sachet BD

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49
Q

what type of laxatives should be avoided in diverticular disease?

A

Stimulant laxatives

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50
Q

what system is used to classify severity of acute diverticulitis?

A

Hinchey classification

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51
Q

What is gastritis?

A

inflammation of the lining of the stomach associated with mucosal injury

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52
Q

what are 4 causes of gastritis?

A

NSAIDs
alcohol
H. Pylori infection
Autoimmune

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53
Q

what are 3 risk factors for gastritis?

A

H. Pylori infection
previous gastric surgery
autoimmune disease

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54
Q

what are 5 presentations of gastritis?

A

dyspepsia/epigastric discomfort
fever
severe emesis (vomiting)
nausea
haematemesis/melaena

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55
Q

what are 3 investigations for gastritis?

A

H. Pylori urea breath test/ faecal antigen test
endoscopy
anti-IF/parietal cell antibodies

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56
Q

what are 3 differentials for gastritis?

A

peptic ulcer disease
GORD
non-ulcer dyspepsia

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57
Q

what is the management for gastritis?

A

H. pylori eradication
PPIs
antacids
H2 antagonists

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58
Q

what are 3 complications of gastritis?

A

gastric carcinoma
gastric lymphoma
vitamin B12 deficiency

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59
Q

what are 6 risk factors for GORD?

A

FHx
age
hiatus hernias
obesity
Alcohol
Smoking

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60
Q

what are 5 medications which may exacerbate GORD?

A

Tricyclics
Anticholinergics
Nitrates
Calcium channel blockers
Aspirin

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61
Q

what is the pathophysioogy of GORD?

A

Lower oesophageal sphinctr abnormalities and transient relaxation allow acid, bile, pepsin and pancreatic enzymes to reflux into oesophagus

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62
Q

what are 6 presentations of GORD?

A

Heart burn - chest pain/retrosternal pain
Regurgitation + water brash
Dyspepsia - upper GI dyscomfort (indigestion)
Coughing/belching
Hoarse voice - worse in morning
Dysphagia

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63
Q

When should GORD be investigated with OGD?

A

> 55 years
symptoms >4 weeks
Dysphagia
Treatment resistance
Relapsing symptoms
weight loss
excessive vomiting
GI Bleeding/Anaemia
Raised platelets

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64
Q

what is the gold standard investigation for GORD?

A

24 hour oesophageal pH monitoring

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65
Q

what is the management for GORD?

A

Lifestyle changes

Review medications

OTC antacids/alginates

1 - PPIs - Omeprazole 20mg OD, Lansoprazole 30mg OD - for 4 weeks then review

2 - H2 receptor antagonist - Famotidine 20-40mg BD< Ranitidine 150mg BD

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66
Q

what is the gold standard surgery for severe refactory GORD?

A

Laproscopic fudoplication

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67
Q

what are 3 possible complications of PPI use?

A

Oesteoporosis

Hypomagnesaemia - causes muscle twitching, tremor, vomiting, fatigue, loss of appetite

C diff infection - due to decreased gastric acidity

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68
Q

what are 4 complications of GORD?

A

Barrett’s oesophagus
strictures
oesophageal ulcer
oesophagitis

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69
Q

what are 3 risk factors for IBS?

A

Female
stress
PTSD

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70
Q

what are the 3 different types of IBS?

A

IBS C - constipation
IBS D - Diarrhoea
IBS M - both

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71
Q

what are 3 key features of IBS?

A

IBS

Intestinal discomfort
Bowel habit abnormalities
Stool abnormalities

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72
Q

what are 7 presentations of IBS?

A

abdo discomfort / bloating
alteration of bowel habits
normal abdo exam
defecation urgency
worse after eating
improved by opening bowels

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73
Q

what is the diagnostic criteria for IBS?

A

6 months
At least one of
- Pain/discomfort relived by opening bowels
- Bowel habit abnormalities
- Stool abnormalities

2 of
- Straining, urgency or incomplete emptying
- Bloating
- Worse after eating
- passing mucus

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74
Q

what are 3 differentials for IBS?

A

IBD
coeliac
Ovarian cancer - in >50s

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75
Q

what lifestyle advice can be given for IBS?

A

drink enough fluids
regular small meals
adjust fiber intake
limit caffeine, alcohol, fatty foods
Low FODMAP diet
Probiotics
Reduce stress
Regular exercise

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76
Q

what are 3 1st line medications for IBS?

A

Loperamide - diarrhoea
Bulk forming laxatives (as lactulose can cause bloating)
Antispasmodics - mebeverine, alverine, hyoscine butylbromide, peppermint oil

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77
Q

what is a specialist drug that can be initiated for IBS-C?

A

Linaclotide

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78
Q

what is a mallory Weiss tear?

A

mucosal tear at oesophageal gastric junction due to a sudden increase in intra-abdominal pressure => coughing/dry heaving

causes haematesis, postural hypertension and dizziness

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79
Q

what are oesophageal varices?

A

abnormal, dilated veins in the lower 1/3rd of the oesophagus that occur at the lower end of the oesophagus; they account for 10-20% of upper GI bleeds. A complication of portal hypertension

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80
Q

what are 3 risk factors for oesophageal varices?

A

portal hypertension
cirrhosis
alcoholism

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81
Q

what are 6 presentations of oesophageal varices?

A

features of liver disease
haematemesis
melaena
cirrhosis/liver disease
abdo pain
blood loss/shock symptoms
Splenomegaly - portal hypertension

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82
Q

what are 3 investigations for oesophageal varices?

A

upper GI endoscopy - gold
FBC - anaemia
serum LFTs - deranged
U+Es - raised urea in upper GI bleed

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83
Q

what investigation can be done for a suspected perforated peptic ulcer?

A

Erect CXR - pneumoperitoneum

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84
Q

what risk assessment can be done for those with upper GI bleed?

A

Glasgow Blatchford score

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85
Q

what blatchford score means patients can be discharged without endoscopy?

A

ZERO

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86
Q

How quickly should those eligible for endoscopy after upper GI bleed get it?

A

within 24 hours

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87
Q

what is the score than identifies patients at risk of adverse outcomes FOLLOWING endoscopic treatment of an upper GI bleed?

A

Rockall score

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88
Q

what is the management for non-bleeding oesophageal varices?

A

beta blockers - propanalol
Endoscopic surveillance and variceal band ligation at 2 week intervals until eradicated

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89
Q

what is the management for bleeding oesophageal varices?

A

A-E assessment
IB Fluids
Blood products - PRBCs, Platelets (if <50), FFP

Terlipressin - causes splanchnic vasoconstriction
IV Abx - Quinolones - ciprofloxacin, levofloxacin

Endoscopic variceal band ligation

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90
Q

what are 3 surgical procedures for upper GI bleed due to varices?

A

Endoscopic variceal band ligation - 1st line

Sengstaken-blakemore tube - uncontrolled haemorrhage

Transjugular intrahepatic portosystemic shunt - if all else fails

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91
Q

what is one important complication of Transjugular intrahepatic portosystemic shunt in bleeding varices?

A

exacerbates hepatic encephalopathy

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92
Q

what are 3 complications of oesophageal varices?

A

Rebleed
encephalopathy
infection - spontaneous bacterial peritonitis

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93
Q

why is urea raised in upper GI bleed?

A

Due to ‘protein meal’ of blood consumption

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94
Q

what 2 veins form the portal vein?

A

superior mesenteric and splenic veins

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95
Q

what is the normal pressure in the portal vein?

A

5-8 mmHg

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96
Q

what is a peptic ulcer?

A

A break in the mucosal lining of the stomach or duodenum more than 5 mm in diameter, with depth to the submucosa

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97
Q

what are 10 risk factors for peptic ulcers?

A

H. Pylori - disrupts mucus barrier
NSAIDs - disrupts mucoid barrier
SSRIs
Corticosteroids
Bisphosphonates

Increase acid production:
Smoking
Alcohol
Caffeine
Stress
Spicy food

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98
Q

what genetic condition is a rare cause of gastric ulcers?

A

Zollinger-ellison syndrome - leads to excessive gastrin secretion from gastrinoma

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99
Q

why does H. Pylori infection increase peptic ulcer risk?

A

H.pylori releases bacterial cytotoxins which disrupt gastric mucosa

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100
Q

what are 4 conditions that H. Pylori is associated with?

A

Peptic ulcers
Gastric cancer
B cell lymphoma of MALT tissue
Atrophic gastritis

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101
Q

what is the management of H. pylori?

A

PPI (omeprazole 20-40mg BD 7 days)
+
Amoxicillin
+
Clarithromycin/Metronidazole

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102
Q

what 2 investigations are used for H. pylori?

A

Urea breath test
Stool antigen test

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103
Q

what is the management of H. Pylori in penicillin allergies?

A

PPI (omeprazole 20-40mg BD 7 days)
+
Metronidazole
+
Clarithromycin

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104
Q

what are 5 medications that increase risk of BLEEDING in peptic ulcers?

A

NSAIDs
Aspirin
Anticoagulant
Steroids
SSRIs

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105
Q

what are 5 presentations of peptic ulcer?

A

can be asymptomatic

Epigastric discomfort
Nausea and vomiting
Dyspepsia

Bleed - Haematemesis, coffee ground vomit, melaena, fall in Hb

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106
Q

when does pain worsen in a gastric ulcer?

A

after eating

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107
Q

when does pain worsen in duodenal ulcers?

A

2-3 hours post eating

Pain is often relieved by eating and worse when hungry

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108
Q

what are 3 investigations for peptic ulcers?

A

upper GI endoscopy and biopsy - gold

h. pylori breath/stool antigen
FBC + U+e + LFTs

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109
Q

what are 3 complications of peptic ulcers?

A

gastroduodenal bleeding
perforation
Scaring and strictures - gastric outlet obstruction

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110
Q

what is the management of a bleeding peptic ulcer?

A

A-E
Access, bloods, transfusions

IV PPI - AFTER ENDOSCOPY!
Endoscopy

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111
Q

what are 3 endoscopic interventions for gastric ulcer bleeding?

A

Mechanical clipping + adrenalin
Thermal coagulation + adrenaline
Sclerotherapy + adrenalin

Surgery or interventional radiology embolization are saved for if these fail

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112
Q

what is the most common artery to bleed in peptic ulcers?

A

Gastroduodenal artery

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113
Q

is cronh’s or ulcerative colitis more common?

A

UC

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114
Q

what are 4 risk factors for ulcerative colitis?

A

FHx
HLA-B27 genes
Caucasian
Non-smoker

NSAIDs can cause flare ups

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115
Q

what are 9 features of ulcerative colitis?

A

Arises in rectum
Affects only colon up to ileo-caecal valve
Continuous inflammation (no skip lesions)
Mucosa reddened, inflamed and bleeds easily
Ulcers and psueudopolyps in severe disease
Submucosal and mucosal inflammation (NOT transmural)
Depleted goblet cells
No granulomata
Increased crypt abscesses with neutrophil infiltration

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116
Q

is crohns or UC most associated with blood in stool?

A

Ulcerative colitis

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117
Q

what are 5 presentations of ulcerative colitis?

A

Blood and mucus in stools
Diarrhoea
malnutrition and weight loss
Abdo pain
Urgency and tenesmus
Extra-intestinal manifestations

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118
Q

what are 8 extraintestinal manifestations of IBD?

A

Erythema nodosum (bruise looking splotches on shins)
Pyoderma gangrenosum
Osteoporosis
Axial arthritis
Polyarticular arthritis
Clubbing
Episcleritis (C>UC)
Uveitis (UC>C)

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119
Q

what is the most common extra-intestinal manifestation of IBD?

A

Pauci-articular arthritis

<5 large joints affected
asymmetrical, acute, self limiting
often associated with enthesitis, tenosynovitis or dactylitis

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120
Q

what autoimmune condition is associated with ulcerative colitis?

A

primary sclerosing cholangitis

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121
Q

what autoimmune disease is associated with crohn’s?

A

Autoimmune hepatitis

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122
Q

what is the gold standard investigation for UC?

A

colonoscopy and biopsy

red raw mucosa with shallow ULCERS
No inflammation beyond submucosa
Lamina propria inflammatory cell infiltrates (neutrophil)
Pseudo-polyps
Crypt abscesses
Goblet cell depletion

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123
Q

what are other investigations that can be done in ulcerative colitis?

A

Abdo x-ray - for toxic megacolon
Stool MCS
Nutritional status
CT abdo pelvis
Serum antibodies - pANCA for UC
Barium enema

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124
Q

what does UC look like on barium enema?

A

loss of haustrations
widespread superficial ulceration and pseudopolyps

LEAD PIPE COLON

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125
Q

what are the 4 different types of UC?

A

Proctitis - inflammation in rectum
Proctosigmoiditis - rectum and sigmoid colon
Left sided colitis - rectum to splenic flexure
Pancolitis - whole colon

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126
Q

what system can be used to assess severity of UC flare?

A

Truelove and Witts’ severity index

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127
Q

what system can be used to assess severity of UC flare in childre?

A

Paediatric ulcerative colitis activity index

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128
Q

what is a mild UC flare?

A

<4 bowel movements a day
No blood/small amounts in stool
HR <90
Apyrexial
Not anaemic
ESR <30

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129
Q

what is a moderate UC flare?

A

4-6 bowel movements a day
Some blood in stool
HR <90
Apyrexial
not anemic
ESR <30

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130
Q

what is a severe UC flare?

A

> 6 bowel movements a day
visible blood in stool
HR >90
pyrexial
anaemic
ESR >30

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131
Q

what medications are used to induce remission in mild-moderate UC?

A

1 - Rectal aminosalicylate

2 - ADD high dose oral aminosalicylate
2 - ADD oral/rectal corticosteroid

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132
Q

what medications are used to induce remission in severe UC?

A

HOSPITALISATION

1 - IV hydrocortisone

2 - ADD IV Ciclosporin if no improvement in 72 hours

2 - IV infliximab if ciclosporin contraindicated

3 - Panprotocolectomy and ileostomy or ileo-anal anastamosis (j-pouch)

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133
Q

what surgery can be done in severe UC?

A

panprotocolectomy and ileostomy/j pouch (ileo-anal anastomosis)

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134
Q

what medications can be used to maintain remission in mild-moderate UC?

A

Oral/rectal aminosalicylates

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135
Q

what medications can be used to maintain remission in severe UC?

A

Oral azathioprine
OR
Oral mercaptopurine

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136
Q

what are 2 examples of aminosalicylates?

A

Mesalazine
Sulfasalazine

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137
Q

what are 4 complications of ulcerative colitis?

A

Toxic megacolon (most common cause of death)
Bowel perforation
colonic adenocarcinoma
bowel obstruction

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138
Q

where is B12 absorbed?

A

distal ilium

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139
Q

where is folate (B9) absorbed?

A

proximal jejunum/duodenum

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140
Q

where is iron absorbed?

A

duodenum

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141
Q

where is intrinsic factor secreted from?

A

stomach - parietal cells

needed for B12 absorptions

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142
Q

what is acute cholangitis?

A

an infection of the biliary tree, most commonly caused by obstruction with gall stones, may also be caused by ERCP

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143
Q

what are 5 causes of acute cholangitis?

A

Obstruction - gallstones, malignancy, strictures
ERCP
chronic pancreatitis

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144
Q

what are 4 risk factors for acute cholangitis?

A

50+
gall stones
post procedure injury - ERCP
Foreign travel - parasitic infection of liver flukes

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145
Q

what is the pathophysiology of acute cholangitis?

A

Obstruction of bile duct results in bacteria in biliary tree, sludge forms providing a growth medium for bacteria, bile duct pressure increases => pressure gradient promotes extravasation of bacteria into blood stream => sepsis

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146
Q

what are 5 symptoms of acute cholangitis?

A

RUQ pain/tenderness
Fever
Jaundice - pruritis, dark urine, pale stools
Confusion
nausea and vomiting

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147
Q

what is Charcot’s triad?

A

Fever
Jaundice
RUQ Pain

Seen in acute cholangitis

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148
Q

what is Reynolds pentad?

A

Jaundice
Fever
RUQ Pain
Septic shock
Mental confusion

For acute cholangitis

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149
Q

what are 3 investigations for acute cholangitis?

A

1 - US Gallbladder

ERCP - Gold - also for intervention

MRCP + CT Gallbladder

Bloods

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150
Q

what is the initial management of acute cholangitis?

A

NBM - for ERCP
IV fluids
Blood cultures
IV Antibiotics - per guidelines - broad spectrum - Taz or Gent + Metro in allergy - 4-7 days
Analgesia

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151
Q

what is the surgical management of acute cholangitis?

A

ERCP:
sphincterotomy
stone removal
balloon dilation
biliary stenting
biopsy - diagnose obstructing lesions

Percutaneous transhepatic cholangiogram - radiologically inserted drain

cholecystectomy
choledochotomy

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152
Q

what are 5 complications of acute cholangitis?

A

sepsis
hepatic/biliary abscess
acute pancreatitis
AKI
Recurrence
Biliary necrosis

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153
Q

what are 3 bacteria that usually cause acute cholangitis?

A

E.Coli - gram negative bacili
klebsiella species
Enterococcus species

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154
Q

What s acute cholecystitis?

A

acute gallbladder inflammation typically due to obstruction with gallstones (cholelithiasis)

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155
Q

what are 5 risk factors for acute cholecystitis?

A

gallstones
Obesity + physical inactivity
Female
Pregnancy
low fibre intake

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156
Q

what are 4 causes of cholecystitis?

A

Gallstones
Ascending bacterial infection
Acalculous cholecystitis - critically ill patients, on TPN or long fast due to lack of gallbladder stimulation and emptying
Vascular insufficiency - ischaemia or infarction of gall bladder

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157
Q

what is the pathophysiology of cholecystitis?

A

There is obstruction to outflow leading to increased pressure in gall bladder
There is inflammation leading to neutrophil infiltration into gallbladder wall
Stagnant bile causes infection

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158
Q

where is obstructed in acute cholecystitis?

A

gallbladder neck or cystic duct

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159
Q

what are 5 presentations of acute cholecystitis?

A

RUQ pain and tenderness (possible R shoulder tip pain)
Fever and chills
Nausea and Vomiting
Anorexia
palpable gall bladder

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160
Q

what examination sign is positive in cholecystitis?

A

Murphy’s sign

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161
Q

what is the gold standard test for acute cholecystitis?

A

ultrasound gallbladder - thickened gallbladder wall, distended gallbladder, presence of stone or sludge, oedema around gallbladder

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162
Q

what is an investigation that can be done in acute cholecystitis 2nd line?

A

Cholescintigraphy HIDA scam - IV technetium labelled HIDA excreted in bile

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163
Q

what are 3 differentials for acute cholecystitis?

A

acute cholangitis
pancreatitis
peptic ulcer disease

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164
Q

what is the management for acute cholecystitis?

A

IV antibiotics - cefuroxime/Taz and metronidazole, Gent (

analgesia

IV fluids

1 - Lap cholecystectomy within 72 hours is optimum, within 1 week required

2 - cholecystostomy

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165
Q

what are 4 complications of acute cholecystitis?

A

gallbladder gangrene
gallbladder perforation
emphysematous cholecystitis
gallstone ileus

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166
Q

what is the management of gallbladder empyema?

A

Percutaneous cholecystostomy

Lap cholecystectomy

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167
Q

what is acute liver failure?

A

a rapid decline in hepatic function characterised by jaundice, coagulopathy (INR >1.5), hepatic encephalopathy, hepatorenal syndrome in patients with no evidence of prior liver disease

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168
Q

what are 4 causes of acute liver failure?

A

Drugs - Paracetamol overdose
viruses - Hep A/B/CMV
Alcohol
Acute fatty liver of pregnancy

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169
Q

what are 6 risk factors for acute liver failure?

A

chronic alcohol abuse
poor nutritional status
female
pregnant
Chronic Hep B
Depression

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170
Q

what are 5 presentations of liver failure?

A

Jaundice
signs of hepatic encephalopathy
hepatomegaly
RUQ tenderness
bruising and GI bleeds (coagulopathy)

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171
Q

what is the treatment of acute liver failure?

A

ITU support

treat underlying cause

Liver transplant

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172
Q

what are 5 complications of acute liver failure?

A

Cerebral oedema
Haemorrhage - due to coagulopathy
Infection
Hepatorenal failure
Metabolic dysfunction

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173
Q

what are the 10 causes of acute pancreatitis? (mnemonic)

A

I GET SMASHED

Idiopathic/Infection

Gallstones (50-60%)
Ethanol (25-30%)
Trauma

Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia, Hypercalcaemia, Hypothermia
ECRP
Drugs

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174
Q

How does alcohol cause acute pancreatitis?

A

alcohol is directly toxic to pancreatic cells resulting in inflammation

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175
Q

what are 8 medications that can cause acute pancreatitis?

A

azathioprine
mesalazine
didanosine
bendroflumethiazide
furosemisde
pentamidine
steroids
sodium valporate

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176
Q

What are 3 risk factors for acute pancreatitis?

A

Older age
Obesity
T2DM

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177
Q

what is the pathophysiology of acute pancreatitis?

A

There is obstruction of exocrine enzyme release
Pancreatic proenzymes are prematurely activated - trypsinogen/trypsin
Pancreatic enzymes are released into circulation
Inflammation and Autodigestion of blood vessels and fats

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178
Q

what are 3 acute local and 3 late local complications of acute pancreatitis?

A

Acute
- vascular damage and retroperitoneal haemorrhage
- reactive ascites
- portal venous thrombosis

Late
- Pancreatic necrosis
- Pancreatic pseudocyst

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179
Q

what are 4 systemic complications of acute pancreatitis?

A

Systemic inflammatory response, vasodilation and cardiovascular shock
Inflammation in lungs - interstitial oedema and ARDS
Reactive inflammation of pleura - pleural oedema
Systemic inflammation leading to DIC

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180
Q

what are 3 metabolic complications of acute pancreatitis?

A

Hyperglycaemia due to islet cell destruction
Acute hypocalcaemia due to free fatty acids sequestering calcium after lipase lysis
Malabsorption - due to loss of exocrine pancreatic tissue

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181
Q

what are 6 presentations of acute pancreatitis?

A

Severe epigastric pain radiating to back
Nausea + vom
Jaundice + steatorrhoea - due to gallstones cause
Systemically unwell - fever, tachy, hypovolaemic
Grey-tuner’s sign
Cullen’s sign

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182
Q

what are 3 investigations for acute pancreatitis?

A

serum lipase/amylase - >3x normal - gold

FBC, U+E, LFTs, CRP, ABG (glucose and paO2)
Calcium
USS to assess for gallstones
CT abdo with contrast for complications

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183
Q

what score is used to assess severity of acute pancreatitis?

A

Glasgow score

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184
Q

what does the scoring of the Glasgow score mean?

A

0-1 - mild pancreatitis
2 - moderate
3+ severe

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185
Q

What are the criteria for the Glasgow score?

A

PANCREAS

PaO2 <8KPa
Age >55
Neutrophils (WBC >15)
Calcium <2
R - uRea >16
Enzymes - LDH >600 or AST/ALT >200
Albumin <32
Sugar - glucose >10

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186
Q

What are 6 conditions that can cause a raised amylase?

A

Upper GI perforation
Mesnteric/bowel ischaemia
Renal failure
retroperitoneal haematoma
Intra-abdo ectopic
Inflammation/obstruction of salivary glands

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187
Q

what is the management of acute pancreatitis?

A

ABCDE + Supportive

IV Fluids
Catheterisation
Opiate Analgesia
Antiemetics
Tx of gallstones - ERCP, Cholecystectomy
Abx- if evidence of infection

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188
Q

What are the 3 stages of alcoholic liver disease?

A

1 - fatty liver (hepatic steatosis) - reversible
2 - alcoholic hepatitis (inflammation and necrosis)
3 - Cirrhosis

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189
Q

what are 5 risk factors for alcoholic liver disease?

A

prolonged alcoholism
Obesity
Smoking
Other liver disease
Poor nutritional status

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190
Q

how is alcohol metabolised?

A

in liver by alcohol dehydrogenase and cytochrome P-450 2E1 => chronic alcohol use causes cytochrome P-450 to produce more free radicals and alcohol dehydrogenase when converted to NADH inhibits gluconeogenesis and increases fatty acid oxidation

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191
Q

what 4 things can alcohol in early pregnancy lead to?

A

Miscarriage
Small for dates
preterm delivery
foetal alcohol syndrome

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192
Q

what are 9 signs o/e of alcoholic liver disease?

A

Hands - palmar erythema, dupuytren’s contracture

Jaundice

Ascites

Spider navi - telangiectasia

Confusion and asterixis - hepatic encephalopathy

hepatosplenomegaly

Caput medusae

Feminisation - gynaecomastia, hypogonadism

Hepatic mass

Haematemesis

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193
Q

what is the 1st line screening tool for alcohol misuse?

A

AUDIT - alcohol use disorders identification test

10 questions, >8 indicated harmful use

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194
Q

what is the AST:ALT ratio usually suggest alcoholic liver disease?

A

> 1.5-2

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195
Q

what non-transaminase liver enzyme is usually raised in alcoholic liver disease?

A

Gamma GT (GGT)

Bilirubin raised in cirrhosis

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196
Q

what 2 blood tests suggest reduced synthetic function of liver?

A

Low albumin

Raised Prothrombin time (PT)

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197
Q

why can U+Es be deranged in liver cirrhosis?

A

hepatorenal syndrome

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198
Q

what are 4 investigations for liver fibrosis/cirrhosis?

A

Liver US
Transient elastography (fibro scan)
CT/MRI
Liver biopsy

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199
Q

what is the gold standard investigation for chronic liver disease (alcohol/nonA)?

A

liver biopsy

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200
Q

what is the management of alcoholic liver disease?

A

Alcohol abstinence
Nutritional support - B1 and high protein
Glucocorticoids - predisolone - reduce inflammation
Tx complications

Liver transplant - after 6 months of abstinence

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201
Q

what are 5 complications of alcoholic liver disease?

A

hepatocellular carcinoma
peptic ulcers
Oesophageal varices +/- haemorrhage
Wernicke-korsakoff syndrome
Hepato-renal syndrome

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202
Q

what is ascites?

A

a pathological collection of fluid in the peritoneal cavity.

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203
Q

what is the most common cause of ascites?

A

cirrhosis - 75%

portal HTN causes fluid to leak out of capillaries and into peritoneal cavity => lower circulating volume => kidneys activate RAAS system => increased reabsorption of fluid and sodium

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204
Q

what are 4 manifestations of ascites?

A

Abdominal distension
fluid on exam with shifting dullness
shortness of breath
fatigue

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205
Q

what protein level in ascites indicates liver cirrhosis, heart failure or other causes of portal hypertension?

A

> 11 g/L

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206
Q

what protein level in ascites indicates Hypalbuminaemia, malignancy and infections?

A

<11 g/L

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207
Q

what are 2 causes of hypoalbuminaemia?

A

Nephrotic syndrome
severe malnutrition - kwashiorkor

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208
Q

what is the management for ascites?

A

treat underlying cause
limit sodium
Aldosterone antagonists - spironolactone
Loop diuretics - furosemide
Fluid restriction
Paracentesis
Prophylactic Abx
Trans jugular intrahepatic portosystemic shunt

Liver transplant

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209
Q

when and what prophylactic Abx are given in ascites?

A

when <15 g/L protein in ascetic fluid or Child-pugh score >9 or hepatorenal syndrome

Ciprofloxacin, norfloxacin

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210
Q

what are the stages of ascites?

A

1 – detectable only after careful exam
2 – easily detectable but small volume
3 – obvious but not tense
4 – tense

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211
Q

What is cholelithiasis?

A

gallstones

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212
Q

what are gallstones usually made out of in the developed world?

A

cholesterol - 90%

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213
Q

what are 5% of gallstones made out of?

A

polymerised calcium billirubinate - black pigment stones

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214
Q

what are the risk factors for cholelithiasis?

A

4Fs

Female
Fat
Forties
Fair (white)

Also- DM, Rapid weight loss, COCP

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215
Q

what is the pathophysiology of cholelithiasis?

A

Bile is super saturated by cholesterol from liver Precipitates crystals which aggregate into stones
Stones migrate into ducts causing biliary colic

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216
Q

what hormone is triggers gallbladder contraction?

A

Cholecystokinin (CCK)

Released post prandially

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217
Q

what are 4 presentations of cholelithiasis?

A

Sudden onset RUQ pain - biliary colic - may radiate to R shoulder or scapula
Typically occurs after fatty meal
30 mins to 8 hours
Complications - cholecystitis, cholangitis, pancreatitis, obstructive jaundice

May have nausea, vomiting, diaphoresis, bloating

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218
Q

what are 3 investigations for cholelithiasis?

A

1 + GOLD - US gallbladder

LFTs - Raised Alk phos is biliary obstruction
MRCP
ERCP - mainly to clear stones from bile ducts

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219
Q

what is the management of gall stones?

A

Observation and life style management + analgesia

Laparoscopic cholecystectomy
ECRP

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220
Q

what are 5 complications of cholelithiasis?

A

cholecystitis
cholangitis
pancreatitis
gall stone ileus
post-cholecystectomy syndrome

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221
Q

What is post-cholecystectomy syndrome?

A

Due to changes in bile flow after cholecystectomy

Diarrhoea, indigestion, epigastric and RUQ pain, nausea, intolerance of fatty foods, flatulence

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222
Q

what is gallstone ileus?

A

Gall stone eroded though gallbladder into duodenum and causes constipation

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223
Q

What is chronic pancreatitis?

A

Debilitating continuing inflammatory process of the pancreas resulting in progressive loss of pancreatic tissue which is replaced by fibrosis leading to exocrine and endocrine dysfunction

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224
Q

what are 3 causes of chronic pancreatitis?

A

Alcohol - most common
Autoimmune - raised IgG4
Cystic Fibrosis

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225
Q

what are 4 risk factors for chronic pancreatitis?

A

Alcohol
Smoking
FHx and genetics (CF)
Ductal obstruction - gallstones, tumours, structural abnormalities

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226
Q

what are 4 manifestations of chronic pancreatitis?

A

Epigastric pain radiating to back - usually worse following a meal

Steatorrhea and diarrhoea

Weight loss and fatigue

Diabetes Mellitus

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227
Q

what investigations are used for chronic pancreatitis?

A

1 - US pancreas

CT abdo
MRI Abdo

faecal elastase
serum lipse/amylase, LFTs, HbA1c, triglycerides, FBC

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228
Q

what are 3 differential diagnosis of chronic pancreatitis?

A

pancreatic cancer
acute pancreatitis
biliary colic

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229
Q

what is the management of chronic pancreatitis?

A

Diet and lifestyle modification
Analgesia - NSAIDs and paracetamol
Pancreatic enzyme replacement - Creon
SC insulin if needed
ERCP with stenting

pancreatectomy

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230
Q

what are 3 complications of chronic pancreatitis?

A

malabsorption
pancreatic pseudocystitis
pancreatic cancer

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231
Q

what is recurrent acute pancreatitis?

A

dentifiable cause of chronic pancreatitis that doesn’t lead to chronic

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232
Q

what are the 3 most common causes of liver cirrhosis?

A

alcohol related liver disease
non-alcoholic fatty liver disease
chronic viral hepatitis (B+C)

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233
Q

what are 7 rare causes of liver cirrhosis?

A

Autoimmune hepatitis
primary biliary cirrhosis
haemochromatosis
Wilsons disease
Alpha-1 antitrypsin deficiency
Cystic fibrosis
Drugs - amiodarone, methotrexate, sodium valproate

234
Q

what are 3 risk factors for cirrhosis?

A

alcohol missuse
IVDU
unprotected sex

235
Q

what is the pathophysiology of liver cirrhosis?

A

Hepatic fibrosis due to activation of hepatic stellate cells and kupfer cells leading to accumulation of type I+III collagen in hepatic parenchyma and space of disse => sinusoids lose characteristic fenestration => altered exchange between plasma and hepatocytes

236
Q

what are 14 presentations of liver cirrhosis o/e?

A

Cachexia
Jaundice
Hepatomegaly
Small nodular liver
splenomegaly (due to portal HTN)
Spider naevi
Palmar erythema
Gynaecomastia and testicular atrophy
Bruising
excoriations
ascites
caput medusae
leukonychia - white fingernails
asterixis - decompensated

237
Q

what is included in a non-invasive liver screen?

A

Us liver
Hep B+C serology
Autoantibodies - ANA, SMA, AMA, LKM-1
Immunoglobulins
Ceruloplasmin - Wilsons
Alpha-1 antitrypsin levels
Ferritin and transferrin saturations (haemochromatosis)

238
Q

what electrolyte abnormality can be seen in liver cirrhosis and why?.

A

Hyponatraemia - due to increases fluid retention in severe disease

239
Q

what is the 1st line investigation for cirrhosis?

A

Transient elastography - fibro scan

240
Q

what is the gold standard investigation for cirrhosis?

A

liver biopsy

241
Q

who should be offered a fibro scan?

A

people with hep C
Men who drink >50 units per week
Women who drink >35 units per week
People dx with alcohol related liver disease

242
Q

How often should people with liver cirrhosis get an US liver?

A

every 6 months

check for hepatocellular carcinoma

243
Q

How does fatty liver appear on USS?

A

Increased echogenicity

244
Q

what are 5 manifestations of liver cirrhosis on US?

A

Nodularity of liver surface
corkscrew appearance of hepatic arteries
enlarged poral vein with reduced flow
Ascites
splenomegaly

245
Q

what score can be used to estimate 3 month mortality in end stage liver disease?

A

MELD score - assess every 6 months

Bilirubin, creatinine, INR, sodium, dialysis

246
Q

what score assesses severity of liver cirrhosis and prognosis?.

A

Child-pugh score

ABCDE
Albumin
Bilirubin
Clotting - INR
Dilation (ascites)
Encephalopathy

247
Q

what are 3 differentials for liver cirrhosis?

A

Budd-chiari syndrome
portal vein thrombosis
splenic vein thrombosis

248
Q

what is Budd chiari syndrome?

A

rare condition of hepatic vein occlusion

249
Q

what is the management of cirrhosis?

A

Tx underlying
Monitor for and manage complication

Liver transplant

250
Q

what are 4 features of decompensated liver disease?

A

AHOY

Ascites
Hepatic encephalopathy
Oesophageal varices bleeding
Yellow - Jaundiced

251
Q

what are 6 complications of cirrhosis?

A

Malnutrition
Portal hypertension, oesophageal varices and upper GI bleeds
Ascites and spontaneous bacterial peritonitis
Hepatorenal syndrome
Hepatic encephalopathy
Hepatocellular carcinoma

252
Q

what nutritional advice should cirrhosis patients be given?

A

Regular meals
High protein and calories
Low sodium intake
Avoid alcohol

253
Q

what is the management of hepatorenal syndrome?

A

Vasopressin analogues - terlipressin
Volume expansion with albumin

LIVER TRANSPLANT

254
Q

what is spontaneous bacterial peritonitis?

A

in 10-20% of patients with ascites

Infection of ascitic fluid and peritoneal lining without clear source of infection

255
Q

what can be seen on paracentesis in spontaneous bacterial peritonitis?

A

Neutrophil count >200 cells/uL

256
Q

what are the 2 most common organisms present in spontaneous bacterial peritonitis?

A

E. Coli
Klebsiella pneumoniae

257
Q

what is the management of spontaneous bacterial peritonitis?

A

Paracentesis and culture - also therapeutic

Broad spectrum Abx - pip/taz

258
Q

what is hepatorenal syndrome?

A

Portal hypertension (in liver cirrhosis) causes portal vessels to release vasodilators which cause vasodilation in splanchnic circulation leading to reduced blood pressure to abdominal organs leading to reduced blood flow to kidneys despite activation of RAAS system

259
Q

which is the only DNA Hepatitis virus?

A

Hep B Virus

260
Q

what type of viruses are hepatitis A, C, D, E?

A

RNA virus

261
Q

which two hepatitis viruses have faecal oral transmission?

A

A and E

262
Q

what is the transmission route for Hepatitis B?

A

Blood
Bodily fluids
vertical transmission - high rates

263
Q

what is the most infectious blood borne virus?

A

1 - Hepatitis B
2 - Hepatitis C
3 - HIV

264
Q

what is the needlestick transmission rates of Hep B, Hep C and HIV?

A

Alphabetical order

Hep B - 30%
Hep C - 3%
HIV - 0.3%

265
Q

what is the transmission route for hepatitis C?

A

Blood

Some low risk of vertical transmission

266
Q

what is the presentation of all of the hepatitis viruses?

A

Mild flu like symptoms
Jaundice
Anorexia
nausea + vom
abdo discomfort
fever
hepatomegaly
splenomegaly
ascites

267
Q

what are the 5 different immunoglobulins?

A

GAMED

IgG
IgA
IgM
IgE
IgD

268
Q

what immunoglobulin is seen in acute infection?

A

IgM

MA! - acute

269
Q

what immunoglobulin is seen on chronic/previous infection?

A

IgG

GP - non-acute

270
Q

who should be vaccinated against hep A? 6

A

Travellers to areas of high prevalence
People with chronic liver disease
People with haemophilia
MSM
IVDU
High occupational risk

271
Q

what is the serology for Hepatitis A virus?

A

HAV IgM + IgG - +ve

IgM positive soon after symptoms and for a few months

IgG positive 5-10 days post symptoms and for rest of life - recovery OR vaccination

272
Q

how quickly is Hep A usually cleared?

A

3-6 months

273
Q

what are 4 complications of hepatitis A?

A

fulminant hepatitis - acute liver failure
Relapsing hepatitis
reactive arthritis
pancreatitis

274
Q

what are 4 differentials for hepatitis viruses?

A

other acute hep virus
Wilsons disease
autoimmune hepatitis
alcoholic liver disease

275
Q

what hepatitis virus do you need to be infected with in order to get infected with hepatitis D?

A

Hepatitis B - chronic in 5%

276
Q

what is hepatitis B?

A

the most common liver infection

May result in self-limiting disease requiring no treatment or in chronically infected state (more likely in children)

277
Q

what are the investigations for hepatitis B?

A

HBsAg – infection acute or chronic

HBeAg – active viral replication => active infection acute or chronic, infectious

Anti-HBs – immunity to HBV => natural or vaccine

Anti-HBc IgG– recovered or chronic infection

Ant-HBc IgM – recent/current infection (last 6 months)

Anti-HBc – past or chronic infection

Anti-HBe – implies seroconversion and is present for life

278
Q

what are 6 complications of hepatitis B infection?

A

Chronic hepatitis
Fulminant liver failure
hepatocellular carcinoma
glomerulonephritis
polyarteritis nodosa
Cypglobulimaemia

279
Q

what is the management of babies born to hepatitis B +ve mothers?

A

At birth -
Hepatitis B vaccination
Hepatitis B immunoglobulin infusion

Hepatitis B vaccination at 1 and 12 months as well as in normal vaccination schedule

Tested for HBsAg at 12 months - to see if they have contracted hepatitis B

280
Q

can hepatitis B +ve mother breast feed?

A

YES if babies are properly vaccinated

281
Q

what is the management of hepatitis B?

A

Monitoring for disease and complications

Anti-virals - peginterferon alfa 2a, entecavir, tenofovir

282
Q

when are children vaccinated against Hep B?

A

8 weeks
12 weeks
16 weeks

283
Q

what fraction of Hepatitis C Virus patients progress to chronic?

A

55-85%

284
Q

what are the investigations for Hepatitis C?

A

hepatitis C PCR - gold, current/active infection (chronic or acute)

Hep C virus antibody enzyme immunoassay - implies current or previous infection

LFTs - raised AST and ALT

285
Q

what is the management for Hepatitis C?

A

8-12 weeks oral direct acting antivirals tailored to virus genotype - daclatasvir, sofosbuvir, simeprevir, ribavirin

286
Q

what is the management of hepatitis C in children?

A

test at 18 months for children of HCV +ve mothers

> 3 years tx with pegylated interferon and ribavirin

Often wait until adulthood for treatment as more effective

287
Q

what hepatitis c treatment is teratogenic?

A

Ribavirin - should not become pregnant within 6 months of discontinuing

288
Q

what are 5 complications of hepatitis C virus?

A

Cirrhosis
Hepatocellular carcinoma
Cryoglobulinemia
Rheum problems - arthralgia, arthritis
Sjorgren’s syndrome

289
Q

what are 4 risk factors for hepatitis A/E?

A

contaminated water
poor sanitation
ingestion of undercooked meat/shellfish
travel to endemic areas

290
Q

what group of people is HEV worst in?

A

pregnant - 10-30% mortality
1% in general pop

291
Q

is Hepatitis E usually self limiting or not?

A

usually self limiting

292
Q

what percentage of immunocompetent adults with HBV achieve seroconversion without treatment?

A

95%

293
Q

What plasma bilirubin level is considered jaundiced?

A

> 21 umol/L

May not become clinically apparent until >51 umol/L

294
Q

How is bilirubin produced and cleared?

A

Pre-hepatic - heam is broken down by macrophages in liver, spleen, kidneys, skin etc. to biliverdin then to lipid soluble unconjugated bilirubin. It enters the blood bound to albumin and is transported to liver.

Intra-hepatic - unconjugated Bilirubin is taken up by hepatocytes + conjugated with glucuronic acid to become water soluble. Is excreted in bile.

Post-hepatic - Transported in bile to intestines where gut bacteria convert bilirubin to urobilinogen and stercobilinogen => excreted in urine and stool respectively

295
Q

what are 3 causes of prehepatic jaundice?

A

increase bilirubin production
increased RBC destruction (haemolytic anaemia, medications)
increased unconjugated bilirubin (Gilbert’s syndrome)

296
Q

what so the stools and urine look like in prehepatic jaundice?

A

normal stools and urine

297
Q

what are 7 causes of intrahepatic jaundice?

A

Hepatitis viruses
HIV/parasitic infections
toxins - alcohol
NAFLD
Autoimmune hepatitis
genetics - Wilsons disease, haemochromatosis
Hepatic Malignancy

298
Q

what is are 6 causes of post hepatic jaundice?

A

Post operative stricture
Gallstones
Ascending cholangitis
Pancreatitis
Extra-hepatic malignancy

299
Q

what does the urine and stools look like in intrahepatic jaundice?

A

urine - dark due to conjugated bilirubin being directly excreted in urine

stools - normal

300
Q

what does the urine and stools look like in post hepatic jaundice?

A

urine - dark - due to conjugated bilirubin being directly excreted in the urine

stools - pale - due to obstruction => lack of stercobilin being excreted in stool

301
Q

what are 5 manifestations of jaundice?

A

yellowing of skin, sclera and mucosa
pruritus
anorexia
nausea and vomiting
RUQ pain

302
Q

what are 7 initial investigations of jaundice?

A

FBC - ?haemolysis
U+E
LFTs
Clotting
Amylase - ?pancreatitis
Viral hepatitis screen
Urine dip for bilirubin

303
Q

what are red flags in jaundice?

A

Hepatic encephalopathy signs
Signs associated with severe hepatic dysfunction
Haematemesis or melaena
Sepsis
Ascending cholangitis (charcot’s triad)
Marked abdo pain
Vomiting
Suspected paracetamol overdose

304
Q

what is the most common cause of liver disease in the west?

A

non-alcoholic fatty liver disease

25% of adults estimated

305
Q

what are the 4 stages of non-alcoholic fatty liver disease?

A

Non-alcoholic fatty liver disease
Non-alcoholic steatohepatitis (NASH)
Fibrosis
Cirrhosis

306
Q

what are 8 risk factors for Non-alcoholic fatty liver disease?

A

obesity
T2DM
hyperlipidaemia
hypertension
Smoking
Poor diet and activity
Middle aged and older
Sudden weight loss/starvation/Gastric bypass surgery

307
Q

what is thought to be the key mechanism of Non-alcoholic fatty liver disease?

A

insulin resistance leading to excessive accumulation of triglycerides in liver

thought to be hepatic manifestation of metabolic syndrome

308
Q

what are 5 presentation of NAFLD?

A

Usually asymptomatic

Abdo discomfort
Hepatomegaly

Liver signs - palmar erythema, Dupuytren’s contracture, jaundice, ascites, spider naevi, hepatic encephalopathy, caput medusae, haematemesis

309
Q

what is usually seen on LFTs in Non-alcoholic fatty liver disease?

A

Raised ALT greater than AST

AST:ALT ratio <1

310
Q

what is seen on US in Non-alcoholic fatty liver disease?

A

increased echogenicity

311
Q

what is included in the enhanced liver fibrosis bloods?

A

Hyaluronic acid (HA)
Procollagen III (PIIINP)
Tissue inhibitor of Metalloproteinase 1 (TIMP-1)

Uses an algorithm to indicate whether there is advanced fibrosis of the liver

312
Q

what score on enhanced liver fibrosis bloods indicates advanced fibrosis?

A

> 10.5

Recheck every 3 years if <10.5 (indicates unlikely advanced fibrosis)

313
Q

what 2 scoring systems can be used in combination with a transient elastography (fibroscan) to assess risk of advanced fibrosis where ELF bloods are not available?

A

NAFLD Fibrosis score - Age, DM, BMI, AST, ALT, platelets, albumin

Fibrosis-4 score (FIB-4) - Age, AST, ALT, platelets

314
Q

what is the gold standard investigation for Non-alcoholic fatty liver disease?

A

liver biopsy

315
Q

what is the treatment for NAFLD?

A

lifestyle modifications - weight loss, healthy eating, exercise, limit alcohol, stop smoking and monitoring

Diabetes control

Specialist - vitamin E, pioglitazone, bariatric surgery, liver transplant

316
Q

what are 6 complications of NAFLD?

A

ascites
Variceal haemorrhage
hepatocellular carcinoma
Hepatic encephalopathy
Hepatorenal syndrome
Hepatopulmonary syndrome

317
Q

What is primary biliary cholangitis?

A

chronic granulomatous autoimmune disease causing progressive small intrahepatic bile duct damage (and eventual loss) of the intrahepatic bile ducts as well as back pressure leading to liver fibrosis, cirrhosis and failure

318
Q

what are 3 risk factors for primary biliary cholangitis?

A

female
Other autoimmune conditions - sjorgrens, RA, systemic sclerosis, thyroid disease
FHx

319
Q

what is the pathophysiology of primary biliary cholangitis?

A

Progressive destruction of biliary epithelial cells (cholangiocytes) lining the small intrahepatic bile ducts => obstruction of bile flow => cholestasis and backflow => fibrosis => cirrhosis

AMA antibodies present

320
Q

what are 5 presentations of primary biliary cholangitis?

A

Pruritus
fatigue and weight loss
skin hyperpigmentation
clubbing
mild heptosplenomegaly
jaundice
xanthelasma and xatholamata

321
Q

what are 6 investigations for primary biliary cholangitis?

A

LFTs - raised Alk phos initially - other derangements as progresses

IgM may be non-specifically raised
USS - exclude other pathologies
Liver biopsy for dx and staging

322
Q

what antibodies are most specific for Primary biliary cholangitis?

A

Anti-mitochondrial antibodies (AMA)

ANA may also be present

323
Q

what are 3 differentials for primary biliary cholangitis?

A

obstructive bile duct lesions
primary sclerosis cholangitis
malignancy

324
Q

what its the 1st line management of primary biliary cholangitis?

A

1 - Ursodeoxycholic acid 12-14mg/kg/day in 3 divided doses initially - bile acid analogue

2 - Obeticholic acid - ursodeoxycholic acid not tolerated

325
Q

what is the ongoing management of Primary biliary cholangitis?

A

Colestyramine 4-8g OD - for pruritus
Replacement of fat soluble vitamins
Immunosuppression
Liver transplant at end stage

326
Q

what are 6 complications of primary biliary cholangitis?

A

cirrhosis
Hepatocellular carcinoma
Hyperlipidaemia
osteroporosis
Sjogrens and systemic sclerosis
thyroid disease

327
Q

what is primary sclerosing cholangitis?

A

A chronic progressive cholestatic liver disease, characterised by inflammation and fibrosis of the intrahepatic and/or extrahepatic bile ducts, resulting in stricture formation which obstructs flow of bile

328
Q

what are 4 risk factors for primary sclerosing cholangitis?

A

Male
Age 30-40
Ulcerative colitis
FHx

329
Q

what is the pathophysiology of primary sclerosing cholangitis?

A

Inflammation of medium/large bile ducts => fibrosis and strictures form => bile stasis => bile stones and retained bile salts => increased hepatic pressure => jaundice, pruritus, biliary cirrhosis => end stage liver disease

330
Q

what are 6 manifestations of primary sclerosing cholangitis?

A

Often asymptomatic

RUQ pain
Jaundice and pruritus
Fatigue and weight loss
Hepato/splenomegaly
Steatorrhea
Cirrhosis symptoms

331
Q

what are 3 investigations for primary sclerosing cholangitis?

A

LFTs - raised Alk phos initially (obstructive picture), other deranged LFTs as progresses

MRCP/ERCP - gold - bead shaped appearance

Colonoscopy for ulcerative colitis

332
Q

what are 3 autoantibodies that may be positive in Primary sclerosing cholangitis?

A

Perinuclear antineutrophil cytoplasmic antibody - (p-ANCA)
Antinuclear antibodies - (ANA)
Anti-smooth muscle antibodies - (anti-SMA)

Not sensitive or specific

333
Q

what are 3 differentials for primary sclerosing cholangitis?

A

secondary sclerosing cholangitis
IgG4 cholangitis
immune hepatitis

334
Q

what is the management for primary sclerosing cholangitis?

A

ERCP may be used to treat strictures and insert biliary stents

Liver transplant

Colestyramine - bile acid sequestrant - for pruritus
Replacement of fat soluble vitamins

335
Q

what are 6 complications of primary sclerosing cholangitis?

A

Biliary strictures
Acute cholangitis
cholangiocarcinoma
osteoporosis
Cirrhosis and complications
Fat soluble vitamin deficiency

336
Q

what is the gold standard investigation for Crohn’s?

A

colonoscopy + biopsy

transmural inflammation, deep ulcers, skip lesions, cobblestone mucosa, granulomas, goblet cells

337
Q

what does foecal calprotectin help differentiate between?

A

IBS and IBD - raised in IBD - marker of bowel inflammation

338
Q

what disease in pANCA most associated with?

A

ulcerative colitis

339
Q

what disease is ASCA more associated with?

A

Crohn’s disease

340
Q

where is crohn’s most common?

A

terminal ileum

341
Q

what is Rovsing’s sign?

A

in appendicitis - pain in the R iliac fossa worsened by pressing on the left iliac fossa

342
Q

what is posoas sign?

A

appendicitis pain worsened in extending hip

343
Q

what is obturator sign?

A

appendicitis pain worsened by flexing and internally rotating hip

344
Q

what is the most common cause of small bowel obstruction?

A

postoperative adhesions

345
Q

what is the most common cause of large bowel obstruction?

A

Volvulus

346
Q

what is volvulus?

A

where colon twists around itself and mesentery reducing blood supply to the intestines and causing a closed-loop bowel obstruction. Can lead to bowel ischaemia and necrosis and bowel perforation.

347
Q

what are the 2 main types of volvulus?

A

Sigmoid volvulus - most common
Caecal volvulus

348
Q

what is sigmoid volvulus?

A

volvulus affecting the sigmoid colon - more common in older patients caused by chronic constipation and lengthening of sigmoid mesentery

349
Q

what are 6 risk factors for volvulus?

A

Neuropsychiatric disorders - Parkinson’s
Nursing home residents
Chronic constipation
High dietary fibre
Pregnancy
Adhesions

350
Q

what can be seen on abdo x-ray in sigmoid volvulus?

A

coffee bean sign

351
Q

what are 5 manifestations of small bowel obstruction?

A 
abdominal pain and distension 
tinkling/absent bowel sounds 
empty rectum
early vomiting and nausea
constipation
352
Q

what is the 1st line imaging investigation for bowel obstruction?

A

abdominal X-ray

small - dilated small bowel and fluid level
Large - coffee bean sign (sigmoid volvulus)

353
Q

what is the 1st line management of bowel obstruction?

A

IV fluids
NG tube (suck)
IV antibiotics
analgesia and anti-emetics

354
Q

what are 3 complications of bowel obstruction?

A

ischaemia and perforation
sepsis
aspiration pneumonia

355
Q

is large or small bowel obstruction more common?

A

small

356
Q

what is Hirschsprung’s disease?

A

neonates born without complete innervation of colon and rectum causing large bowel obstruction

357
Q

what are 5 manifestations of large bowel obstruction?

A 
abdo pain and distension
tinkling sounds early on absent later 
empty rectum 
bloating and constipation (early)
vomiting - late
358
Q

what symptoms point to an infective cause of diarrhoea?

A

sudden onset

cramps abdominal pain and fever

359
Q

how long does acute diarrhoea last?

A

<2 weeks

360
Q

name 1 anti-diarrhoeal agent?

A

loperamide

361
Q

what is contained in the foregut?

A

stomach, duodenum to sphincter of odd, biliary system, liver, pancreas

362
Q

what is the blood supply of the foregut?

A

coeliac artery

363
Q

what is contained in the midgut?

A

duodenum to 1st half of transverse colon

364
Q

what is the blood supply of the midgut?

A

superior mesenteric artery

365
Q

what is the blood supply of the hindgut?

A

inferior mesenteric artery

366
Q

how long is the anus?

A

3-4 cm

367
Q

what is the name of the line separating the histologically different parts of the anal canal?

A

the (pectinate) dentate line

368
Q

what is hyper acute liver failure?

A

hepatic encephalopathy <7 days of noticing jaundice

369
Q

what is hyperacute liver failure?

A

hepatic encephalopathy within 7 days of noticing jaundice

370
Q

what is classed as acute liver failure?

A

hepatic encephalopathy within 8-28 weeks of noticing jaundice

371
Q

what is fulminant hepatic failure?

A

clinical syndrome resulting from massive necrosis of liver cells leading to sever impairment of liver function

372
Q

what are the signs of hepatic encephalopathy?

A

altered mental status
confusion
apraxia - difficulty motor planning
asterisks - flapping

373
Q

what is the grading system for heptic encephalopathy called?

A

the west haven criteria

374
Q

what are 4 functions of the liver?

A

storage
breakdown
synthesis
immune function

375
Q

what are 5 signs of decompensated liver disease?

A 
encephalopathy
ascites
jaundice
GI bleeding 
coagulopathy
376
Q

what are black pigment gallstones and when do they occur?

A

stones of billirubinate - occur in patients with increased haemolysis (haemolytic anaemias)

377
Q

what are brown pigment stones and when do they occur?

A

calcium bilrubinate and calcium salts of fatty acids

associated with infection and cholecystectomy

378
Q

what is Murphy’s sign?

A

As the patient breathes out, place your hand below the right costal margin. As the patient breathes in an inflamed gallbladder moves inferiorly, the patient catches their breath. To be considered positive, it should be absent on the left side. => acute cholecystitis

379
Q

what does ERCP stand for?

A

endoscopic retrograde cholangiopancreatography

380
Q

what is Cullen’s sign?

A

for pancreatitis - periumbilical bleeding

381
Q

what is Grey Turner’s syndrome?

A

flank bleeding secondary to retopritoneal haemorrhage in pancreatitis

382
Q

what is the management of acute pancreatitis?

A 
IV fluids
catherterisation 
O2 
opiate analgesia 
early nutritional support
383
Q

what are 3 complications of pancreatitis?

A

pancreatic abscess
haemorrhage
necrotising pancreatitis

384
Q

what is the treatment for pruitus?

A

cholestyramine

385
Q

what is the treatment for ascites?

A

fluid restriction and reduced salt intake

spironolactone

386
Q

what score is used to grade liver cirrhosis?

A

child-pugh score

387
Q

what are 3 complications of liver cirrhosis?

A

coaglopathy
encephalopathy
hepatocellular carcinoma

388
Q

what are 2 causes of pre-hepatic portal hypertension?

A

portal vein thrombosis

splenic vein thrombosis

389
Q

what are 4 causes of intra-hepatic portal hypertension?

A

cirrhosis - most common UK
schistosomiasis - most common worldwide
sarcoidosis
congenital hepatic fibrosis

390
Q

what are 4 cause of post hepatic portal hypertension?

A

R Heart failure
budd-chiari syndrome
constrictive pericarditis
veno-occlusive disease

391
Q

where can hepatic varices form?

A 
gastro-oesophageal junction
rectum
left renal vein
diaphragm
 the anterior abdominal wall via the umbilical vein
392
Q

what is the management for bleeding oesophageal varices?

A 
ABCDE 
IV fluids
Blood transfusion
Terlipressin - ADH analogue
prophylactic antibiotic 
balloon tamponade
393
Q

how long does acute hepatitis last?

A

< 6 months

394
Q

what are 5 infective causes of acute hepatitis?

A

Hep A/E
Herpes viruses
leptospirosis
toxoplasmosis
Coxiella

395
Q

what are 4 causes of non-infective hepatitis?

A

Alcoholic hepatitis
Non-alcoholic steatohepatitis (NAFLD)
Autoimmune hepatitis
Drug induced hepatitis

396
Q

what LFTs are raised in acute hepatitis?

A

AST and ALP +/- bilirubin

397
Q

what are 2 infective causes of chronic hepatitis?

A

Hep B +/- D
Hep C virus

398
Q

is hepatits A chronic?

A

NO

399
Q

are hepatitis viruses notifiable?

A

YES

400
Q

which hep viruses have vaccines?

A

A and B

401
Q

what is the incubation period of Hep B?

A

1-6 months

402
Q

what is necesary for hepatitis D infection?

A

Concurrent hepatitis B infection

Hep D binds to hep B surface antigen to complete replication and transmission

403
Q

what are the serological investigations for Hep D?

A

IgM anti-HD
IgG anti-HD
HDAg - neg in chronic
HDV RNA

404
Q

what is the treatment for hep D?

A

interferon alpha

405
Q

what are 3 investigations for Hepatitis E virus?

A

serology - IgM = active, IgG = recovery
HEV PCR
LFTs - elevated AST and ALT

406
Q

what are 3 risk factors for autoimmune hepatitis?

A

Female
Age - children or 40-50s
Autoimmune conditions - coeliac, hashimotos, primary biliary cirrhosis

407
Q

who does type 1 autoimmune hepatitis usually affect?

A

women in late 40s or 50s

presents with features of liver disease - less acute course than type 2

Can often cause amenorrhoea

408
Q

who does type 2 autoimmune hepatitis usually affect?

A

children and young people - more commonly girls

Presents with acute hepatitis with high transaminases (ALT and AST) and jaundice

409
Q

what 3 autoantibodies are associated with type 1 autoimmune hepatitis?

A

anti-nuclear antibodies - ANA

Anti-smooth muscle antibodies - anti-actin

Anti-soluble liver antigen - anti-SLA/LP

410
Q

what are 2 autoantibodies seen in type 2 autoimmune hepatitis?

A

Anti-liver kidney microsomes-1 (anti-LKM1)

Anti-liver cytosol antigen type 1 (anti-LC1)

411
Q

what immunoglobulin is often raised in autoimmune hepatitis?

A

IgG

412
Q

what is found on liver biopsy in autoimmune hepatitis?

A

interface hepatitis
plasma cell infiltration

piecemeal necrosis

413
Q

what is the treatment for autoimmune hepatitis?

A

immunosuppression: 1 - high dose prednisolone AND
azathioprine

Hep A+B vaccination

Liver transplant

414
Q

what are 4 complications of autoimmune hepatitis?

A

Cirrhosis
osteoporosis - steroids
Cushings - steroids
Hepatocellular carcinoma

415
Q

what is the main cause of travellers diarrhoea?

A

enterotoxigenic E. coli

416
Q

what toxins does E. coli produce?

A

shiva toxins

417
Q

what are 4 viral causes of infective diarrhoea?

A

rotavirus - most common in children
norovirus - most common in adults
adenoviruses
astroviruses

418
Q

what is the most common bacterial cause of diarrhoea?

A

campylobacter jejuni - associated with poultry

419
Q

what bacteria can cause diarrhoea after eating undercooked pork?

A

yersinia enterocolitica

420
Q

what bacteria produced rice water stools?

A

vibrio cholerae

421
Q

what antibiotics cause diarrhoea?

A

rule of Cs

clindamycin
ciprofloxacin (quinolones)
Co-amoxiclav (penicillins)
cephalosporins

422
Q

what is the most common parasitic cause of diarrhoea?

A

giardia lamblia

423
Q

what are 4 risk factors for pseudomembranous colitis?

A

elderly
antibiotics
long hospital stay
immunocompromised

424
Q

name an anti-emetic?

A

metoclopramide

425
Q

what is haemochromatosis?

A

multisystem disorder of dysregulated dietary iron absorption and increased iron release from macrophages.

426
Q

what causes haemochromatosis?

A

Autosomal recessive HFE gene mutation on chromosome 6

chronic transfusions
high iron intake
alcoholism

427
Q

what protein from the liver controls iron levels?

A

Hepcidin

428
Q

what are 7 manifestations of haemochromatosis?

A 
skin hyperpigmentation - bronze 
arthritic joints 
testicular atrophy hepatomegaly 
congestive cardiac failure 
osteoporosis 
T1DM
429
Q

what investigations do you of for haemochromatosis?

A

serum ferritin - high

seum transferritin - high, more specific

430
Q

what is the treatment for haemochromatosis?

A

venesection - draining small amounts of blood
maintenance phlebotomy
low iron diet

431
Q

what are 4 complications of haemochromatosis?

A

cirrhosis
hepatocellular carcinoma
DM
congestive HF

432
Q

what is wilsons disease?

A

genetic condition leading to excessive copper deposits in tissues due to metabolic abnormalities of increased copper absorption and decreased excretion

433
Q

what is the inheritance pattern of Wilson’s disease?

A

autosomal recessive

chromosome 13

434
Q

what is the 1st line investigation for wilson’s disease?

A

Serum caeruloplasmin

435
Q

what investigations are done in wilsons disease?

A

Slit lamp for kayser-fleischer rings
Reduced serum caeruloplasmin
reduced total serum copper (carried by caeruloplasmin)
Increased 24 hour urinary copper excretion

436
Q

what are 5 presentations of wilson’s disease?

A

Liver - hepatitis, cirrhosis
Neuro -
Basal ganglia degeneration - where most copper is deposited
Speech, behaviour and psychiatric problems
Asterixis, chorea, dementia, parkisonism
Kayser-fleischer rings
Renal tubular acidosis
Haemolysis
Blue nails

437
Q

what is the 1st line treatment for Wilsons disease?

A

Copper chelation - D-penicillamine

438
Q

what condition is the double panda sign on MRI seen?

A

wilsons disease

439
Q

what is alpha-1-antitrypsin deficiency?

A

genetic disorder causing a reduction or mutation in production of alph-1 antitrypsin in the liver leading to COPD and bronchiectasis in the lungs and dysfunction, fibrosis and, cirrhosis in the liver (genotype depending)

440
Q

what is alpha-1 antitrypsin?

A

a protease inhibitor which inhibits the action of neutrophil elastase (a protease enzyme secreted by neutrophils to digest elastin)

441
Q

what is the inheritance of alpha-1-antitrypsin deficiency?

A

autosomal recessive/co-dominant

Disease severity depends on combination of both copies of gene

442
Q

what does alpha-1-antitrypsin deficiency cause?

A

early onset COPD

liver cirrhosis and hepatocellular carcinoma

443
Q

what are 2 1st line investigations for alpha-1 antitrypsin deficiency?

A

1 - low serum alpha-1 antitrypsin (screening test)

Genetic testing

444
Q

what can be seen on liver biopsy in alpha-1-antitrypsin deficiency?

A

periodic acid-Schiff positive staining globules in hepatocytes => build up of mutant alpha-1-antitrypsin protein

445
Q

what is the management of alpha-1-antitrypsin deficiency?

A

Stop smoking
Symptomatic management

Organ transplant
Lung volume reduction surgery
Monitor for complications
Screening of family members

446
Q

what are the causes of peritonitis/ (mnemonic)

A

ACUTE ABDOMEN

AAA
Collapsed inferior vena cava
Ulcer (perforated viscus)
Trauma 
Ectopic pregnancy
Appendicitis 
Biliary tract
Distended bowel loop
Obstructive uropathy 
Men: testicular torsion
Women: ovarian torsion.
447
Q

what is the management for bleeding varices?

A

IV terlipressin

448
Q

what is the treatment for bleeding varicose in someone with ischaemic heart disease?

A

IV somatostatin

449
Q

What is Reynolds pentad?

A

For acute cholangitis

Charcot’s triad - RUQ pain, Fever, Jaundice

Plus - hypotension and confusion

450
Q

What is Reynolds pentad?

A

For acute cholangitis

Charcot’s triad - RUQ pain, Fever, Jaundice

Plus - hypotension and confusion

451
Q

What 2 autoantibodies are present in primary biliary cholangitis?

A

Antimitochondrial antibodies (AMA) - most specific
Anti-nuclear antibodies (ANA) - less specific

452
Q

What 2 autoantibodies are present in primary biliary cholangitis?

A

Antimitochondrial antibodies (AMA) - most specific
Anti-nuclear antibodies (ANA) - less specific

453
Q

what is a hiatus hernia?

A

protrusion of part of the stomach through the diaphragmatic hiatus into the thoracic cavity

454
Q

what are the 4 different types of hiatus hernia?

A

Sliding - most common - gastrooesophageal junction slides above diaphragm alongside portion of stomach

Paraoesophageal - gastroesophageal junction remains in place and stomach herniates through hiatus beside it

Mixed

complex/giant paraoesophageal - herniation of other organs through oesophageal hiatus

455
Q

What are 6 risk factors for hiatus hernia?

A

Older age
Female
FHx
Lifestyle - obesity, smoking
Mechanical stressors - heavy lifting, straining
Iatrogenic - surgery

456
Q

what are 5 presentations of hiatus hernia?

A

GORD symptoms
Chest pain
Resp symptoms
Dyspepsia
Anaemia
Oesophagtis and complications

457
Q

what is the 1st line investigation for hiatus hernia?

A

Barium swallow

458
Q

what is the gold standard for diagnosing hiatus hernia?

A

OGD endoscopy

459
Q

what is the management for hiatus hernia?

A

Lifestyle modifications

PPIs - Omeprazole 20mg OD, Lansoprazole 30mg OD

H2RA - Famotidine 20-40mg BD, Ranatidine 150mg BD

Surgery - lapraroscopic fudoplication

460
Q

what are 6 complications of hiatus hernia?

A

Gastric volvulus
Hernia incarceration
Hernia strangulation
Oesophagitis
Barrett’s oesophagus
Oesophageal adenocarcinoma

461
Q

what are the 4 types of acute mesenteric ischaemia?

A

Arterial embolism - most common - usually cardiac origin
Arterial thrombosis
Venous thrombosis
Non-occlusive mesenteric ischaemia (caused by arterial dissection or vasculitises)

462
Q

what is the blood supply to the foregut?

A

Foregut = stomach, part of duodenum, biliary system, liver, pancreas, spleen

COELIAC ARTERY

463
Q

what is the blood supply to the midgut?

A

Midgut - distal duodenum to 1st half of transverse colon

SUPERIOR MESENTERIC ARTERY

464
Q

what is the blood supply to the hindgut?

A

Hindgut = 2nd half of transverse colon to rectum

INFERIOR MESENTERIC ARTERY

465
Q

what are risk factors for acute mesenteric ischaemia?

A

AF or recent MI
Infective endocarditis
Risk factors for atherosclerosis - smoking, HTN, >60
Profound splanchnic vasoconstriction - non-occlusive mesenteric ischaemia

466
Q

What are 5 presentations of acute mesenteric ischaemia?

A

Abdo pain - severe, sharp, out of proportion to investigation findings
GI symptoms - nausea vom, diarrhoea
Peritoneal - peritonitis, guarding, rebound tenderness
Vitals - tachycardia, hypotension
Labs - leucocytosis, raised lactate

467
Q

what is the investigation for acute mesenteric ischaemia?

A

Bloods and ABG

CT mesenteric angiogram

468
Q

what is the initial manegment of acute mesenteric ischaemia?

A

Bowel rest - NBM, NG decompression
IV fluids
IV Abx - e.g. ceftriaxone + metronidazole
IV unfractioned heparin
Laparotomy

469
Q

what is the definitive management of acute mesenteric ischaemia?

A

Endovascular revascularisation - embolectomy, angioplasty
Laparotomy - open embolectomy, arterial bypass, resection of necrotic bowel

470
Q

what are 4 complications of acute mesenteric ischaemia?

A

bowel infarction and perforation
Short bowel syndrome
Strictures
Sepsis

471
Q

what is chronic mesenteric ischaemia?

A

intestinal angina due to narrowing of mesenteric blood vessels due to atherosclerosis

472
Q

what is the classic triad of chronic mesenteric ischaemia?

A

central colicky abdominal pain after eating - starting 30 mins after eating, lasting 1-2 hours

Weight loss - due to food avoidance

Abdominal bruit on auscultation

Also can have bloating and abdo distension, nausea and vomiting, diarrhoea, malabsorption

473
Q

what is the diagnostic investigation of chronic mesenteric ischaemia?

A

CT angiogram

474
Q

what is the management of chronic mesenteric ischaemia?

A

Reduce modifiable risk factors
Secondary prevention - Statins, antiplatelets

Revascularisation - PC mesenteric artery stenting, open endarterectomy

475
Q

what is the difference between mesenteric ischaemia and ischaemic colitis ?

A

Mesenteric - small bowel
ischaemic colitis - large bowel

ischaemic colitis typically occurs in ‘watershed’ areas e.g. splenic flexure and is typically transient and less severe

476
Q

what are anal fissures?

A

small tears or cuts in anal canal - longitudinal tears of anoderm

477
Q

What are 4 causes of primary anal fissures?

A

Idiopathic
Increases anal resting pressure
Trauma
Constipation and straining

478
Q

what are 4 causes of secondary anal fissures?

A

IBD - inflammation in rectum
Infectious causes - STIs
Malignancy
Other - proctitis, trauma, iatrogenic

479
Q

what is classed as chronic anal fissures?

A

> 6 weeks

480
Q

what is the presentation of anal fissures?

A

Pain
Rectal bleeding - bright red on toilet paper or in bowl
Pruritus ani
Discharge of mucus
Constipation - avoidance behaviour

481
Q

what is the management of acute anal fissure?

A

Dietary advice - high fibre, high fluid

1 - Bulk forming laxatives
2 - Lactulose

Lubricants before defecation
topical anaesthetics
analgesia

482
Q

what is the management of chronic anal fissures?

A

Acute plus

1 - Topical glyceryl trinitrate

2 - Surgery - lateral internal sphincterotomy

483
Q

what are 7 risk factors for anal fissure?

A

chronic constipation
persistent diarrhoea
straining during bowel movements
passing hard or large stools
anal intercourse
IBD
pregnancy and childbirth

484
Q

what are 3 complications of anal fissures?

A

Failure to heal/reoccurrence
Abscess or fistula formation
Incontinence

485
Q

what are haemorrhoids?

A

enlarged anal vascular cushions often associated with constipation and straining

486
Q

what are the anal cushions?

A

specialised submucosal tissues that contain connections between arteries and veins. Supported by smooth muscles they help control anal continence along with the internal and external sphincters

487
Q

where are the anal cushions usually located?

A

3, 7 , 11 o’clock with patient on back

488
Q

what is the classification of haemarrhoids?

A

1st degree - no prolapse
2nd degree - prolapse when straining, return on relaxation
3rd - prolapse when straining, can be pushed back into place
4th - prolapsed permanently

489
Q

what is the presentation of haemorrhoids?

A

Bright red bleeding on toilet tissue
Sore/itchy anus
lump in anus

490
Q

what can be used to visualise haemarrhoids?

A

protoscopy

491
Q

what is the topical management of haemorrhoids?

A

Anusol - astringents
Anusol HC - astringents + hydrocortisone
Germaloids cream - lidocaine
Proctosedyl ointment - cinchocaine and hydrocortisone

492
Q

what are 4 non-surgical management options of haemorrhoids?

A

Rubber band ligation
injection sclerotherapy
infra-red coagulopathy
bipolar diathermy

493
Q

what are 3 surgical management options for haemorrhoids?

A

Haemorrhoid artery ligation
Haemorrhoidectomy - may result in faecal incontinence
Stapled haemorrhoidectomy

494
Q

what line determines whether a haemorrhoid is internal or external?

A

Dentate (pectinante) line - 2cm from anal verge

Above dentate line from embryonic hindgut
below dentate line from ectoderm or the proctodeum => different vascular and nerve supply

495
Q

what are 5 complications of haemorrhoids?

A

perianal thrombosis
ulceration
incarceration of prolapsed haemerrhoidal tissue
Anal stenosis
anaemia

496
Q

what do thrombosed haemorrhoids appear like?

A

purplish very tender swollen lumps around anus

PR impossible due to pain

resolve with time

497
Q

what is paralytic ileus?

A

reduced motility of the GI tract due to failure of peristalsis leading to functional bowel obstruction

498
Q

what are 6 causes of paralytic ileus?

A

postoperative - most common - due to handling of bowel during surgery
Medication - opioids, anticholinergics, muscle relaxants
Metabolic/electrolyte abnormalities
Systemic medical conditions - sepsis, MI, pneumonia
Neuro conditions - parkinsons, spinal cord injury
Intra-abdominal conditions - reflex reduction in bowel motility

499
Q

what are 5 presentations of ileus?

A

Nausea and Vomiting - green bilious
Abdo distension
diffuse abdo pain
absolute constipation and lack of flatulence
Absent bowel sounds

500
Q

what 2 electrolyte abnormalities affect bowel smooth muscle function?

A

Hyponatraemia
Hypocalcaemia

can cause paralytic ileus

501
Q

what is the gold standard investigation for paralytic ileus?

A

CT scan

502
Q

what is the management of paralytic ileus?

A

NBM - bowel rest
NG decompression if vomiting
IV fluids - prevent dehydration and correct electolyte imbalance
Mobilisation - helps peristalsis
TPN - may be required whilst waiting for bowel to regain function

503
Q

What is mesenteric adenitis?

A

inflammation of the mesenteric lymph nodes in the abdomen primarily affecting children and teens which causes an appendicitis like presentation

504
Q

what usually precedes presentation with mesenteric adenitis?

A

viral infection

505
Q

what are 4 presentations of mesenteric adenitis?

A

Abdo pain - RIF
GI symptoms
Systemic features
Tender lymph nodes in RIF

506
Q

what is hernia incarceration?

A

hernia cannot be reduced - can lead to bowel obstruction and strangulation

507
Q

what is hernia stranguation?

A

non-reducible hernia with reduced/absent blood supply leading to ischemia and significant pain

508
Q

what is richter’s hernia?

A

only part of the bowel wall and lumen herniate through and become strangulated with the other side of that section of bowel remaining in the abdominal cavity. This leads to rapid ischaemia and necrosis

509
Q

what is the anatomy of a direct inguinal hernia?

A

protrudes through weakness in abdo wall (Hesselbach’s triangle) passing medial to inferior epigastric artery, above inguinal ligament

Usually do not enter scrotum and are acquired later in life

510
Q

what are the boundaries of Hesselbach’s triangle?

A

RIP

Rectus abdominis - medial
Inferior epigastric vessels - superior/lateral border
Poupart’s (inguinal) ligament - inferior border

511
Q

what is the anatomy of an indirect inguinal hernia?

A

more common

Bowel herniates through inguinal canal (ring) lateral to the inferior epigastric artery due to failure of processus vaginalis to close - can travel into scrotum

512
Q

what examination can be done to differentiate between direct and indirect inguinal hernia?

A

hernia remains reduced when pressure is applied to deep inguinal ring (mid-point from anterior superior iliac spine and pubic tubercle)

513
Q

what are 5 risk factors for inguinal hernia?

A

Male- >75
FHx - Marfans, EDS
Previous R lower abdo incisions
Premature babies
Chronic coughing, straining, heavy lifting

514
Q

what is the presentation of strangulated hernia?

A

Pain
groin discomfort
irreducible groin mass
tender distended abdomen, lack of bowel sounds
nausea and vomiting
constipation

515
Q

what is the management of hernias?

A

conservative watchful waiting if low risk

Endoscopic mesh repair - tension free repair

Tension repair - suture hole back together

516
Q

what are femoral hernias at high risk of?

A

strangulation
obstruction
incarceration

517
Q

what are femoral hernia?

A

herniation of abdominal contents through femoral canal BELOW inguinal ligament and lateral to pubic tubercle

518
Q

are femoral hernias more common in males or females?

A

FEMALES

519
Q

what are the boundaries of the femoral canal?

A

FLIP

Femoral vein - lateral
Lacunar ligament - medial
Inguinal ligament - anteriorly
Pectineal ligament - posteriorly

520
Q

what are the borders of the the femoral triangle?

A

SAIL

Sartorius - lateral
Adductor longus - medial
Inguinal Ligament - superior

521
Q

what is the management of femoral hernias?

A

need surgical repair due to high risk of strangulation

522
Q

what is a spigelian hernia?

A

between lateral border of rectus abdominis and linear semilunaris usually in lower abdomen

not always palpable lump may be diagnosed on US

high risk strangulation

523
Q

what is diastasis recti?

A

widening of linea alba in the middle of the abdomen leading to bulge especially when lift head lying down

Common post pregnancy or in obesity

524
Q

what is an obturator hernia?

A

abdomen contents herniate through obturator foramen at bottom of pelvis due to defect in pelvic floor

525
Q

what is hepatic encephalopathy?

A

encephalopathy thought to be caused by build up of toxins in brain primarily ammonia

Usually in acute liver failure but can occur in chronic liver disease

526
Q

what are 5 features of hepatic encephalopathy?

A

confusion and altered GCS
Asterixis
Constructional apraxia - unable to draw 5 pointed star
Triphasic slow waves of EEG
Raised ammonia levels

527
Q

what is the grading of hepatic encephalopathy?

A

1 - irritable
2 - confusion, inappropriate behaviour
3 - incoherent, restless
4 - coma

528
Q

what are 7 factors that can worsen hepatic encephalopathy?

A

constipation
dehydration
electrolyte disturbance
infection
GI bleed
high protein diet
medications - sedatives

529
Q

what is the management of hepatic encephalopathy?

A

1 - Lactulose 30-50ml TDS

1 - Abx - Rifaximin - modulates gut bacteria to decrease ammonia production

Liver transplant

530
Q

How does lactulose treat hepatic encephalopathy?

A

speeds up gut transit time - clears ammonia before absorption
Promotes bacterial uptake of ammonia
Changes pH of intestine - more acidic - kills ammonia producing bacteria

531
Q

what are 5 contraindications to liver transplant?

A

Significant co-morbidities
Current illicit drug use
Continuing alcohol misuse - in last 6 months
Untreated HIV
Current or previous cancers - except some liver cancers

532
Q

what are 4 signs of liver transplant rejection?

A

Abnormal LFTs
Fatigue
Fever
jaundice

533
Q

what is Gilbert’s syndrome?

A

An inherited condition (AR usually) causing mild intermittent elevation of unconjugated bilirubin due to defective conjugating enzymes in the liver

534
Q

what are 2 features of Gilbert’s syndrome?

A

Unconjugated hyperbilirubinaemia - not in urine => normal colour
Mild jaundice brought on by illness, exercise, fasting, stress

535
Q

what is the management of Gilbert’s syndrome?

A

avoid triggers

No lasting complications associated

536
Q

what is bile acid malabsorption?

A

can be primary or due to an excessive production of bile acids or associated with another condition (crohn’s, coeliac, cholecystectomy, small intestinal bacterial overgrowth)

Leads to steatorrhea and fat soluble vitamin deficiencies

537
Q

what are the fat soluble vitamins?

A

ADEK

538
Q

what investigation is used in bile acid malabsorption?

A

SeHCAT - nuclear medicine test done 7 days apart to see radiolabelled SeHCAT

539
Q

what is the management of bile acid malabsorption?

A

Bile acid sequestrants - Cholestyramine

540
Q

what are 9 complications of malabsorption?

A

weakened immune system
Delayed wound healing
Generalised weakness
Growth failure
impaired intellectual development
Rickets
osteoporosis
Reduced fertility
Hypothermia

541
Q

what is malabsorption?

A

the umbrella term for inability to absorb nutrients from ingested food

542
Q

what is the NICE definition of malnutrition?

A

BMI <18.5
OR
Unintentional weight loss greater than 10% within last 3-6 months
OR
BMI <20 and unintentional wt loss >5% in last 3-6 months

543
Q

what is malnutrition?

A

a deficiency, excess or imbalance of macronutrients or micronutrients

544
Q

what scoring system can be used to screen for malnutrition?

A

MUST (malnutrition universal screening tool) Score

545
Q

what are the 3 broad causes of malnutrition?

A

Inadequate intake
Impaired absorption
Increased nutritional demands

546
Q

what ae 9 risk factors for malnutrition?

A

> 65 years
Low socioeconomic status
institutionalisation
Drug/alcohol abuse
chronic conditions
Diseases causing malabsorption
Diseases affecting dentition, smell/taste, swallow
Cognitive impairment
Mental illness

547
Q

what is the management of malnutrition?

A

Dietician support if high risk
Food-first approach over supplements

Oral nutritional supplements (ensure) inbetween meals NOT instead of

548
Q

what 2 presentations can be caused by macronutrient deficiency?

A

Kwashiorkor
Marasmus

549
Q

what is marasmus?

A

severe malnutrition due to inadequate intake of all macronutrients.

Most common <1 year olds and causes muscle wasting and loss of subcutaneous fat

550
Q

what is kwashiorkor?

A

Severe malnutrition due to protein deficiency but with adequate energy intake.

Leads to muscle atrophy, oedema, ascites and enlarged liver with fatty infiltrates

551
Q

what are 3 electrolyte abnormalities that can be caused by reefeeding?

A

Hypophosphatemia
Hypokalaemia
Hypomagnesaemia

552
Q

what are 2 clinical manifestations of vitamin A deficiency?

A

night blindness
immunodeficiency

553
Q

what are 4 manifestations of zinc deficiency?

A

Delayed wound healing
impaired taste
hair loss
immune deficiency

554
Q

what is the other name for vitamin C?

A

Ascorbic acid

555
Q

what is the presentation of vitamin C deficiency?

A

Fatigue
Weakness
Joint pain
Bleeding - gums, petechiae, hemarthrosis, bruising
Follicular hyperkeratosis - swollen hair follicles with keratin plugs leading to goosebumps or corkscrew hairs

556
Q

what are 4 key functions of the spleen?

A

Activation of lymphocytes
Removal of damaged RBCs from circulation
Sequestration of platelets
In utero - haematopoiesis

557
Q

what are 7 causes of hyposplenism?

A

Post-splenectomy
Sickle cell
Coeliac disease - functional hyposplenism
Grave’s disease
SLE
Amyloidosis
Liver cirrhosis - causes portal HTN and disrupted splenic blood flow

558
Q

what are 3 complications of hyposplenism?

A

Increased risk of life threatening bacterial infections - N. Meningitidis, H. Influenzae, S. Pneumoniae

Increased risk of severe falciparum malaria infection

Possible increased risk of thrombotic events

559
Q

what can be seen on peripheral blood smear in hyposplenism?

A

Howell-Jolly bodies
Siderocytes (pitted red cells)

560
Q

what is the management of hyposplenism?

A

Immunisations - N. meningitidis, HIB, S. pneumoniae, flu

Daily prophylactic Abx - penicillins/macrolides

Patient education

561
Q

what is classed as cconstipation?

A

Defecation <3 times per week usually with difficult stool passage or seeming incomplete defecation

562
Q

what are 5 medications that can cause constipation?

A

Opioids
Calcium channel blockers
Antipsychotic and tricyclic antidepressants
Antispasmodics
Antimuscarinics

563
Q

what are 3 metabolic disturbances that can cause constipation?

A

Hypothyroidism
Hypercalcaemia
Diabetes

564
Q

what are 3 neurological conditions that can cause constipation?

A

Parkinsons
Spinal cord lesions
MS

565
Q

what is lifestyle advice for someone with constipation?

A

Increase daily fibre intake
Increase exercise/movement
Increase fluid intake

566
Q

what is the 1st line management of constipation?

A

LIFESTYLE ADVICE

567
Q

what is the pharmacological management of constipation in adults?

A

1 - Bulk forming laxative - Ispaghula husk 1 sachet BD

2 - switch to Osmotic - Macrogol (2 sachets) or lactulose (15ml) (if macrogol not tolerated)

568
Q

what laxative should be used in soft stools that are difficult to pass or associated with incomplete emptying?

A

Stimulant - Sena

569
Q

what laxatives should be used in opioid induced constipation?

A

Osmotic - Macrogol
Stimulant - Senna

NOT BULK FORMING

570
Q

what are 5 complications of constipation?

A

Overflow diarrhoea
Haemorrhoids/anal fissures
Bowel obstruction, perforation or ulceration
Urinary retention
Delirium

571
Q

what laxative can be used after 6 months of 2 other different classed laxatives have failed?

A

Prucalopride - prokinetic
Trial for 4 weeks

572
Q

what is the management of faecal loading?

A

1 - High dose oral macrogol

2 - ADD Stimulant laxative - senna

573
Q

what is the management of faecal loading if initial treatment fails/is too slow?

A

1-
Bisacodyl suppository for soft stools
Glycerol +/- bisacodyl suppositories for hard stools
Docusate enema
Sodium citrate enema

2 -
Sodium phosphate or arachis oil retention enema

574
Q

How long classes as chronic constipation?

A

> 3 months

575
Q

what are the 4 different types of laxatives?

A

Bulk forming
osmotic
stimulat
Softening

576
Q

what are 2 examples of bulk forming laxatives?

A

fybrogel - ispaghula
methylcellulose

take a few days to work

577
Q

what are 3 examples of osmotic laxitives

A

Lactulose
macrogol
Polyethylene glycol

take a few days to work

578
Q

what are 3 stimulant laxitives?

A

Bisacodyl
senna
sodium picosulfate

take 6-12 hours to work

579
Q

what is faecal loading?

A

retention of faeces to the extent that spontaneous evacuation is unlikely

580
Q

what are 7 contraindications to laxatives?

A

Intestinal obstruction/perforation
Paralytic ileus
Bulk forming - colonic atony/faecal impaction
Crohns and UC
Toxic megacolon
Bisacodyl - severe dehydration
Lactulose - Galactosaemia
Peanut allergy - arachis oil

581
Q

what advice should be given to people taking bulk forming laxatives?

A

Need adequate fluid intake to avoid obstruction

582
Q

what drug class is prucalopride?

A

5HT4 receptor agonist - prokinetic laxative

Phase 4 (22 decks)

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