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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 for 6 weeks prior

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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
what is the pathophysiology of Crohn's disease?
Transmural granulomatous inflammation of any part of GI tract => most common in terminal ileum and proximal colon. skip lesions - cobblestone appearance relapsing and remitting
26
what are 7 presentations of Crohn's?
Chronic diarrhoea weight loss Abdo pain blood in stool (less common than in UC) perianal disease mouth ulcers Obstructive symptoms
27
what can be seen on barium fluoroscopy in Crohn's?
Kantor's string sign - suggests strictures Rose thorn ulcers
28
what is classes as mild Crohn's ?
1st presentation 1st exacerbation in 12 months
29
what is classed as moderate Crohn's?
>2 exacerbations in 12 months Glucocorticoids cannot be tapered
30
what is severe Crohn's?
unresponsive to conventional therapy AND >1 symptom AND usually loose stools >3x per day
31
what is the management for inducing remission in Crohn's disease flare ups?
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
32
what medications are used in Crohn's to maintain remission?
1 - Azathioprine or mercaptopurine 2 - Methotrexate
33
what is IgG4 related sclerosing cholangitis?
Similar presentation to Primary sclerosing cholangitis but with raised IgG4 levels Responds well to steroids, associated with autoimmune pancreatitis
34
what are 6 indications for surgery in Crohn's?
Poor response to drug treatment Strictures Abscesses and fistulae Delayed growth Malignancy Obstruction/perforation
35
what are 5 surgeries that can be done for Crohn's?
ileocaecal resection partial R hemicolectomy Colectomy with ileostomy/ileo-rectal anastomosis panprotocolectomy and ileostomy Stricturoplasty
36
what are 6 complications of Crohn's disease?
Peri-anal abscess Anal fissure/fistula Strictures and obstruction Perforation Malignancy Osteoporosis
37
what is 1 important complication of azathioprine and mercaptopurine?
Myelosupression - check FBC weekly for 1st month then every 3 months
38
what is diverticulitis?
inflammation of diverticula diverticula = out pouching of the mucosa and submucosa through the muscular layer of the colonic wall
39
what is the main cause of diverticulitis?
low fibre diet
40
what are 5 risk factors for diverticulitis?
50+ low fibre diet obesity Smoking Genetics, connective tissue disorders
41
what part of the colon is diverticulitis most common in?
sigmoid colon
42
what is the pathophysiology of diverticulitis?
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
43
what are 5 presentations of diverticulitis?
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
44
what is the gold standard investigation for diverticulitis?
CT Ado/Pelvis with contrast - thickened bowel wall
45
what is the management for uncomplicated diverticulitis in primary care?
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
46
what is the management of complicated diverticulitis in hospital?
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
47
what are 5 complications of diverticulitis?
fistulae abscesses perforations peritonitis large haemorrhage ileus/obstruction
48
what is the management of diverticular diseae?
Increase fibre in diet Bulk forming laxatives - ispaghula husk - 1 sachet BD
49
what type of laxatives should be avoided in diverticular disease?
Stimulant laxatives
50
what system is used to classify severity of acute diverticulitis?
Hinchey classification
51
What is gastritis?
inflammation of the lining of the stomach associated with mucosal injury
52
what are 4 causes of gastritis?
NSAIDs alcohol H. Pylori infection Autoimmune
53
what are 3 risk factors for gastritis?
H. Pylori infection previous gastric surgery autoimmune disease
54
what are 5 presentations of gastritis?
dyspepsia/epigastric discomfort fever severe emesis (vomiting) nausea haematemesis/melaena
55
what are 3 investigations for gastritis?
H. Pylori urea breath test/ faecal antigen test endoscopy anti-IF/parietal cell antibodies
56
what are 3 differentials for gastritis?
peptic ulcer disease GORD non-ulcer dyspepsia
57
what is the management for gastritis?
H. pylori eradication PPIs antacids H2 antagonists
58
what are 3 complications of gastritis?
gastric carcinoma gastric lymphoma vitamin B12 deficiency
59
what are 6 risk factors for GORD?
FHx age hiatus hernias obesity Alcohol Smoking
60
what are 5 medications which may exacerbate GORD?
Tricyclics Anticholinergics Nitrates Calcium channel blockers Aspirin
61
what is the pathophysioogy of GORD?
Lower oesophageal sphinctr abnormalities and transient relaxation allow acid, bile, pepsin and pancreatic enzymes to reflux into oesophagus
62
what are 6 presentations of GORD?
Heart burn - chest pain/retrosternal pain Regurgitation + water brash Dyspepsia - upper GI dyscomfort (indigestion) Coughing/belching Hoarse voice - worse in morning Dysphagia
63
When should GORD be investigated with OGD?
>55 years symptoms >4 weeks Dysphagia Treatment resistance Relapsing symptoms weight loss excessive vomiting GI Bleeding/Anaemia Raised platelets
64
what is the gold standard investigation for GORD?
24 hour oesophageal pH monitoring
65
what is the management for GORD?
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
66
what is the gold standard surgery for severe refactory GORD?
Laproscopic fudoplication
67
what are 3 possible complications of PPI use?
Oesteoporosis Hypomagnesaemia - causes muscle twitching, tremor, vomiting, fatigue, loss of appetite C diff infection - due to decreased gastric acidity
68
what are 4 complications of GORD?
Barrett's oesophagus strictures oesophageal ulcer oesophagitis
69
what are 3 risk factors for IBS?
Female stress PTSD
70
what are the 3 different types of IBS?
IBS C - constipation IBS D - Diarrhoea IBS M - both
71
what are 3 key features of IBS?
IBS Intestinal discomfort Bowel habit abnormalities Stool abnormalities
72
what are 7 presentations of IBS?
abdo discomfort / bloating alteration of bowel habits normal abdo exam defecation urgency worse after eating improved by opening bowels
73
what is the diagnostic criteria for IBS?
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
74
what are 3 differentials for IBS?
IBD coeliac Ovarian cancer - in >50s
75
what lifestyle advice can be given for IBS?
drink enough fluids regular small meals adjust fiber intake limit caffeine, alcohol, fatty foods Low FODMAP diet Probiotics Reduce stress Regular exercise
76
what are 3 1st line medications for IBS?
Loperamide - diarrhoea Bulk forming laxatives (as lactulose can cause bloating) Antispasmodics - mebeverine, alverine, hyoscine butylbromide, peppermint oil
77
what is a specialist drug that can be initiated for IBS-C?
Linaclotide
78
what is a mallory Weiss tear?
mucosal tear at oesophageal gastric junction due to a sudden increase in intra-abdominal pressure => coughing/dry heaving causes haematesis, postural hypertension and dizziness
79
what are oesophageal varices?
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
80
what are 3 risk factors for oesophageal varices?
portal hypertension cirrhosis alcoholism
81
what are 6 presentations of oesophageal varices?
features of liver disease haematemesis melaena cirrhosis/liver disease abdo pain blood loss/shock symptoms Splenomegaly - portal hypertension
82
what are 3 investigations for oesophageal varices?
upper GI endoscopy - gold FBC - anaemia serum LFTs - deranged U+Es - raised urea in upper GI bleed causes protein meal
83
what investigation can be done for a suspected perforated peptic ulcer?
Erect CXR - pneumoperitoneum
84
what risk assessment can be done for those with upper GI bleed?
Glasgow Blatchford score
85
what blatchford score means patients can be discharged without endoscopy?
ZERO
86
How quickly should those eligible for endoscopy after upper GI bleed get it?
within 24 hours
87
what is the score than identifies patients at risk of adverse outcomes FOLLOWING endoscopic treatment of an upper GI bleed?
Rockall score
88
what is the management for non-bleeding oesophageal varices?
beta blockers - propanalol Endoscopic surveillance and variceal band ligation at 2 week intervals until eradicated
89
what is the management for bleeding oesophageal varices?
A-E assessment IV Fluids Blood products - PRBCs, Platelets (if <50), FFP Terlipressin - causes splanchnic vasoconstriction IV Abx - Quinolones - ciprofloxacin, levofloxacin Endoscopic variceal band ligation
90
what are 3 surgical procedures for upper GI bleed due to varices?
Endoscopic variceal band ligation - 1st line Sengstaken-blakemore tube - uncontrolled haemorrhage Transjugular intrahepatic portosystemic shunt - if all else fails
91
what is one important complication of Transjugular intrahepatic portosystemic shunt in bleeding varices?
exacerbates hepatic encephalopathy
92
what are 3 complications of oesophageal varices?
Rebleed encephalopathy infection - spontaneous bacterial peritonitis
93
why is urea raised in upper GI bleed?
Due to 'protein meal' of blood consumption
94
what 2 veins form the portal vein?
superior mesenteric and splenic veins
95
what is the normal pressure in the portal vein?
5-8 mmHg
96
what is a peptic ulcer?
A break in the mucosal lining of the stomach or duodenum more than 5 mm in diameter, with depth to the submucosa
97
what are 10 risk factors for peptic ulcers?
H. Pylori - disrupts mucus barrier NSAIDs - disrupts mucoid barrier SSRIs Corticosteroids Bisphosphonates Increase acid production: Smoking Alcohol Caffeine Stress Spicy food
98
what genetic condition is a rare cause of gastric ulcers?
Zollinger-ellison syndrome - leads to excessive gastrin secretion from gastrinoma
99
why does H. Pylori infection increase peptic ulcer risk?
H.pylori releases bacterial cytotoxins which disrupt gastric mucosa
100
what are 4 conditions that H. Pylori is associated with?
Peptic ulcers Gastric cancer B cell lymphoma of MALT tissue Atrophic gastritis
101
what is the management of H. pylori?
PPI (omeprazole 20-40mg BD 7 days) + Amoxicillin + Clarithromycin/Metronidazole 7 DAYS
102
what 2 investigations are used for H. pylori?
Urea breath test Stool antigen test
103
what is the management of H. Pylori in penicillin allergies?
PPI (omeprazole 20-40mg BD 7 days) + Metronidazole + Clarithromycin
104
what are 5 medications that increase risk of BLEEDING in peptic ulcers?
NSAIDs Aspirin Anticoagulant Steroids SSRIs
105
what are 5 presentations of peptic ulcer?
can be asymptomatic Epigastric discomfort Nausea and vomiting Dyspepsia Bleed - Haematemesis, coffee ground vomit, melaena, fall in Hb
106
when does pain worsen in a gastric ulcer?
after eating
107
when does pain worsen in duodenal ulcers?
2-3 hours post eating Pain is often relieved by eating and worse when hungry
108
what are 3 investigations for peptic ulcers?
upper GI endoscopy and biopsy - gold h. pylori breath/stool antigen FBC + U+e + LFTs
109
what are 3 complications of peptic ulcers?
gastroduodenal bleeding perforation Scaring and strictures - gastric outlet obstruction
110
what is the management of a bleeding peptic ulcer?
A-E Access, bloods, transfusions IV PPI - AFTER ENDOSCOPY! Endoscopy
111
what are 3 endoscopic interventions for gastric ulcer bleeding?
Mechanical clipping + adrenalin Thermal coagulation + adrenaline Sclerotherapy + adrenalin Surgery or interventional radiology embolization are saved for if these fail
112
what is the most common artery to bleed in peptic ulcers?
Gastroduodenal artery
113
is cronh's or ulcerative colitis more common?
UC
114
what are 4 risk factors for ulcerative colitis?
FHx HLA-B27 genes Caucasian Non-smoker NSAIDs can cause flare ups
115
what are 9 features of ulcerative colitis?
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
116
is crohns or UC most associated with blood in stool?
Ulcerative colitis
117
what are 5 presentations of ulcerative colitis?
Blood and mucus in stools Diarrhoea malnutrition and weight loss Abdo pain Urgency and tenesmus Extra-intestinal manifestations
118
what are 8 extraintestinal manifestations of IBD?
Erythema nodosum (bruise looking splotches on shins) Pyoderma gangrenosum Osteoporosis Axial arthritis Polyarticular arthritis Clubbing Episcleritis (C>UC) Uveitis (UC>C)
119
what is the most common extra-intestinal manifestation of IBD?
Pauci-articular arthritis <5 large joints affected asymmetrical, acute, self limiting often associated with enthesitis, tenosynovitis or dactylitis
120
what autoimmune condition is associated with ulcerative colitis?
primary sclerosing cholangitis
121
what autoimmune disease is associated with crohn's?
Autoimmune hepatitis
122
what is the gold standard investigation for UC?
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
123
what are other investigations that can be done in ulcerative colitis?
Abdo x-ray - for toxic megacolon Stool MCS Nutritional status CT abdo pelvis Serum antibodies - pANCA for UC Barium enema
124
what does UC look like on barium enema?
loss of haustrations widespread superficial ulceration and pseudopolyps LEAD PIPE COLON
125
what are the 4 different types of UC?
Proctitis - inflammation in rectum Proctosigmoiditis - rectum and sigmoid colon Left sided colitis - rectum to splenic flexure Pancolitis - whole colon
126
what system can be used to assess severity of UC flare?
Truelove and Witts' severity index
127
what system can be used to assess severity of UC flare in childre?
Paediatric ulcerative colitis activity index
128
what is a mild UC flare?
<4 bowel movements a day No blood/small amounts in stool HR <90 Apyrexial Not anaemic ESR <30
129
what is a moderate UC flare?
4-6 bowel movements a day Some blood in stool HR <90 Apyrexial not anemic ESR <30
130
what is a severe UC flare?
>6 bowel movements a day visible blood in stool HR >90 pyrexial anaemic ESR >30
131
what medications are used to induce remission in mild-moderate UC?
1 - Rectal aminosalicylate 2 - ADD high dose oral aminosalicylate 2 - ADD oral/rectal corticosteroid
132
what medications are used to induce remission in severe UC?
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)
133
what surgery can be done in severe UC?
panprotocolectomy and ileostomy/j pouch (ileo-anal anastomosis)
134
what medications can be used to maintain remission in mild-moderate UC?
Oral/rectal aminosalicylates
135
what medications can be used to maintain remission in severe UC?
Oral azathioprine OR Oral mercaptopurine
136
what are 2 examples of aminosalicylates?
Mesalazine Sulfasalazine
137
what are 4 complications of ulcerative colitis?
Toxic megacolon (most common cause of death) Bowel perforation colonic adenocarcinoma bowel obstruction
138
what is toxic megacolon?
Colonic distension >6cm in the presence of acute colitis
139
where is B12 absorbed?
distal ilium
140
where is folate (B9) absorbed?
proximal jejunum/duodenum
141
where is iron absorbed?
duodenum
142
where is intrinsic factor secreted from?
stomach - parietal cells
143
what is acute cholangitis?
an infection of the biliary tree, most commonly caused by obstruction with gall stones, may also be caused by ERCP
144
what are 5 causes of acute cholangitis?
Obstruction - gallstones, malignancy, strictures ERCP chronic pancreatitis
145
what are 4 risk factors for acute cholangitis?
50+ gall stones post procedure injury - ERCP Foreign travel - parasitic infection of liver flukes
146
what is the pathophysiology of acute cholangitis?
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
147
what are 5 symptoms of acute cholangitis?
RUQ pain/tenderness Fever Jaundice - pruritis, dark urine, pale stools Confusion nausea and vomiting
148
what is Charcot's triad?
Fever Jaundice RUQ Pain Seen in acute cholangitis
149
what is Reynolds pentad?
Jaundice Fever RUQ Pain Septic shock Mental confusion For acute cholangitis
150
what are 3 investigations for acute cholangitis?
1 - US Gallbladder ERCP - Gold - also for intervention MRCP + CT Gallbladder Bloods
151
what is the initial management of acute cholangitis?
NBM - for ERCP IV fluids Blood cultures IV Antibiotics - per guidelines - broad spectrum - Taz or Gent + Metro in allergy - 4-7 days Analgesia
152
what is the surgical management of acute cholangitis?
ERCP: sphincterotomy stone removal balloon dilation biliary stenting biopsy - diagnose obstructing lesions Percutaneous transhepatic cholangiogram - radiologically inserted drain cholecystectomy choledochotomy
153
what are 5 complications of acute cholangitis?
sepsis hepatic/biliary abscess acute pancreatitis AKI Recurrence Biliary necrosis
154
what are 3 bacteria that usually cause acute cholangitis?
E.Coli - gram negative bacili klebsiella species Enterococcus species
155
What s acute cholecystitis?
acute gallbladder inflammation typically due to obstruction with gallstones (cholelithiasis)
156
what are 5 risk factors for acute cholecystitis?
gallstones Obesity + physical inactivity Female Pregnancy low fibre intake
157
what are 4 causes of cholecystitis?
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
158
what is the pathophysiology of cholecystitis?
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
159
where is obstructed in acute cholecystitis?
gallbladder neck or cystic duct
160
what are 5 presentations of acute cholecystitis?
RUQ pain and tenderness (possible R shoulder tip pain) Fever and chills Nausea and Vomiting Anorexia palpable gall bladder
161
what examination sign is positive in cholecystitis?
Murphy's sign
162
what is the gold standard test for acute cholecystitis?
ultrasound gallbladder - thickened gallbladder wall, distended gallbladder, presence of stone or sludge, oedema around gallbladder
163
what is an investigation that can be done in acute cholecystitis 2nd line?
Cholescintigraphy HIDA scam - IV technetium labelled HIDA excreted in bile
164
what are 3 differentials for acute cholecystitis?
acute cholangitis pancreatitis peptic ulcer disease
165
what is the management for acute cholecystitis?
IV antibiotics - cefuroxime/Taz and metronidazole, Gent analgesia IV fluids 1 - Lap cholecystectomy within 72 hours is optimum, within 1 week required 2 - cholecystostomy
166
what are 4 complications of acute cholecystitis?
gallbladder gangrene gallbladder perforation emphysematous cholecystitis gallstone ileus
167
what is the management of gallbladder empyema?
Percutaneous cholecystostomy Lap cholecystectomy
168
what is acute liver failure?
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
169
what are 4 causes of acute liver failure?
Drugs - Paracetamol overdose viruses - Hep A/B/CMV Alcohol Acute fatty liver of pregnancy
170
what are 6 risk factors for acute liver failure?
chronic alcohol abuse poor nutritional status female pregnant Chronic Hep B Depression
171
what are 5 presentations of liver failure?
Jaundice signs of hepatic encephalopathy hepatomegaly RUQ tenderness bruising and GI bleeds (coagulopathy)
172
what is the treatment of acute liver failure?
ITU support treat underlying cause Liver transplant
173
what are 5 complications of acute liver failure?
Cerebral oedema Haemorrhage - due to coagulopathy Infection Hepatorenal failure Metabolic dysfunction
174
what are the 10 causes of acute pancreatitis? (mnemonic)
I GET SMASHED Idiopathic/Infection Gallstones (50-60%) Ethanol (25-30%) Trauma Steroids Mumps Autoimmune Scorpion venom Hyperlipidaemia, Hypercalcaemia, Hypothermia ECRP Drugs
175
How does alcohol cause acute pancreatitis?
alcohol is directly toxic to pancreatic cells resulting in inflammation
176
what are 8 medications that can cause acute pancreatitis?
azathioprine mesalazine didanosine bendroflumethiazide furosemisde pentamidine steroids sodium valporate
177
What are 3 risk factors for acute pancreatitis?
Older age Obesity T2DM
178
what is the pathophysiology of acute pancreatitis?
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
179
what are 3 acute local and 3 late local complications of acute pancreatitis?
Acute - vascular damage and retroperitoneal haemorrhage - reactive ascites - portal venous thrombosis Late - Pancreatic necrosis - Pancreatic pseudocyst
180
what are 4 systemic complications of acute pancreatitis?
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
181
what are 3 metabolic complications of acute pancreatitis?
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
182
what are 6 presentations of acute pancreatitis?
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
183
what are 3 investigations for acute pancreatitis?
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
184
what score is used to assess severity of acute pancreatitis?
Glasgow score
185
what does the scoring of the Glasgow score mean?
0-1 - mild pancreatitis 2 - moderate 3+ severe
186
What are the criteria for the Glasgow score?
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
187
What are 6 conditions other than pancreatitis that can cause a raised amylase?
Upper GI perforation Mesnteric/bowel ischaemia Renal failure retroperitoneal haematoma Intra-abdo ectopic Inflammation/obstruction of salivary glands
188
what is the management of acute pancreatitis?
ABCDE + Supportive IV Fluids Catheterisation Opiate Analgesia Antiemetics Tx of gallstones - ERCP, Cholecystectomy Abx- if evidence of infection
189
What are the 3 stages of alcoholic liver disease?
1 - fatty liver (hepatic steatosis) - reversible 2 - alcoholic hepatitis (inflammation and necrosis) 3 - Cirrhosis
190
what are 5 risk factors for alcoholic liver disease?
prolonged alcoholism Obesity Smoking Other liver disease Poor nutritional status
191
how is alcohol metabolised?
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
192
what 4 things can alcohol in early pregnancy lead to?
Miscarriage Small for dates preterm delivery foetal alcohol syndrome
193
what are 9 signs o/e of alcoholic liver disease?
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
194
what is the 1st line screening tool for alcohol misuse?
AUDIT - alcohol use disorders identification test 10 questions, >8 indicated harmful use
195
what is the AST:ALT ratio usually suggest alcoholic liver disease?
>1.5-2
196
what non-transaminase liver enzyme is usually raised in alcoholic liver disease?
Gamma GT (GGT) Bilirubin raised in cirrhosis
197
what 2 blood tests suggest reduced synthetic function of liver?
Low albumin Raised Prothrombin time (PT)
198
why can U+Es be deranged in liver cirrhosis?
hepatorenal syndrome
199
what are 4 investigations for liver fibrosis/cirrhosis?
Liver US Transient elastography (fibro scan) CT/MRI Liver biopsy
200
what is the gold standard investigation for chronic liver disease (alcohol/nonA)?
liver biopsy
201
what is the management of alcoholic liver disease?
Alcohol abstinence Nutritional support - B1 and high protein Glucocorticoids - predisolone - reduce inflammation Tx complications Liver transplant - after 6 months of abstinence
202
what are 5 complications of alcoholic liver disease?
hepatocellular carcinoma peptic ulcers Oesophageal varices +/- haemorrhage Wernicke-korsakoff syndrome Hepato-renal syndrome
203
what is ascites?
a pathological collection of fluid in the peritoneal cavity.
204
what is the most common cause of ascites?
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
205
what are 4 manifestations of ascites?
Abdominal distension fluid on exam with shifting dullness shortness of breath fatigue
206
what protein level in ascites indicates liver cirrhosis, heart failure or other causes of portal hypertension?
>11 g/L
207
what protein level in ascites indicates Hypalbuminaemia, malignancy and infections?
<11 g/L
208
what are 2 causes of hypoalbuminaemia?
Nephrotic syndrome severe malnutrition - kwashiorkor
209
what is the management for ascites?
treat underlying cause limit sodium Aldosterone antagonists - spironolactone Loop diuretics - furosemide Fluid restriction Paracentesis Prophylactic Abx Trans jugular intrahepatic portosystemic shunt Liver transplant
210
when and what prophylactic Abx are given in ascites?
when <15 g/L protein in ascetic fluid or Child-pugh score >9 or hepatorenal syndrome Ciprofloxacin, norfloxacin
211
what are the stages of ascites?
1 – detectable only after careful exam 2 – easily detectable but small volume 3 – obvious but not tense 4 – tense
212
What is cholelithiasis?
gallstones
213
what are gallstones usually made out of in the developed world?
cholesterol - 90%
214
what are 5% of gallstones made out of?
polymerised calcium billirubinate - black pigment stones
215
what are the risk factors for cholelithiasis?
4Fs Female Fat Forties Fair (white) Also- DM, Rapid weight loss, COCP
216
what is the pathophysiology of cholelithiasis?
Bile is super saturated by cholesterol from liver Precipitates crystals which aggregate into stones Stones migrate into ducts causing biliary colic
217
what hormone is triggers gallbladder contraction?
Cholecystokinin (CCK) Released post prandially
218
what are 4 presentations of cholelithiasis?
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
219
what are 3 investigations for cholelithiasis?
1 + GOLD - US gallbladder LFTs - Raised Alk phos is biliary obstruction MRCP ERCP - mainly to clear stones from bile ducts
220
what is the management of gall stones?
Observation and life style management + analgesia Laparoscopic cholecystectomy ECRP
221
what are 5 complications of cholelithiasis?
cholecystitis cholangitis pancreatitis gall stone ileus post-cholecystectomy syndrome
222
What is post-cholecystectomy syndrome?
Due to changes in bile flow after cholecystectomy Diarrhoea, indigestion, epigastric and RUQ pain, nausea, intolerance of fatty foods, flatulence
223
what is gallstone ileus?
Gall stone eroded though gallbladder into duodenum and causes constipation
224
What is chronic pancreatitis?
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
225
what are 3 causes of chronic pancreatitis?
Alcohol - most common Autoimmune - raised IgG4 Cystic Fibrosis
226
what are 4 risk factors for chronic pancreatitis?
Alcohol Smoking FHx and genetics (CF) Ductal obstruction - gallstones, tumours, structural abnormalities
227
what are 4 manifestations of chronic pancreatitis?
Epigastric pain radiating to back - usually worse following a meal Steatorrhea and diarrhoea Weight loss and fatigue Diabetes Mellitus
228
what investigations are used for chronic pancreatitis?
1 - US pancreas CT abdo MRI Abdo faecal elastase serum lipse/amylase, LFTs, HbA1c, triglycerides, FBC
229
what are 3 differential diagnosis of chronic pancreatitis?
pancreatic cancer acute pancreatitis biliary colic
230
what is the management of chronic pancreatitis?
Diet and lifestyle modification Analgesia - NSAIDs and paracetamol Pancreatic enzyme replacement - Creon SC insulin if needed ERCP with stenting pancreatectomy
231
what are 3 complications of chronic pancreatitis?
malabsorption pancreatic pseudocystitis pancreatic cancer
232
what is recurrent acute pancreatitis?
identifiable cause of chronic pancreatitis that doesn’t lead to chronic
233
what are the 3 most common causes of liver cirrhosis?
alcohol related liver disease non-alcoholic fatty liver disease chronic viral hepatitis (B+C)
234
what are 7 rare causes of liver cirrhosis?
Autoimmune hepatitis primary biliary cirrhosis haemochromatosis Wilsons disease Alpha-1 antitrypsin deficiency Cystic fibrosis Drugs - amiodarone, methotrexate, sodium valproate
235
what are 3 risk factors for cirrhosis?
alcohol missuse IVDU unprotected sex
236
what is the pathophysiology of liver cirrhosis?
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
237
what are 14 presentations of liver cirrhosis o/e?
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
238
what is included in a non-invasive liver screen?
Us liver Hep B+C serology Autoantibodies - ANA, SMA, AMA, LKM-1 Immunoglobulins Ceruloplasmin - Wilsons Alpha-1 antitrypsin levels Ferritin and transferrin saturations (haemochromatosis)
239
what electrolyte abnormality can be seen in liver cirrhosis and why?.
Hyponatraemia - due to increases fluid retention in severe disease
240
what is the 1st line investigation for cirrhosis?
Transient elastography - fibro scan
241
what is the gold standard investigation for cirrhosis?
liver biopsy
242
who should be offered a fibro scan?
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
243
How often should people with liver cirrhosis get an US liver?
every 6 months check for hepatocellular carcinoma
244
How does fatty liver appear on USS?
Increased echogenicity
245
what are 5 manifestations of liver cirrhosis on US?
Nodularity of liver surface corkscrew appearance of hepatic arteries enlarged poral vein with reduced flow Ascites splenomegaly
246
what score can be used to estimate 3 month mortality in end stage liver disease?
MELD score - assess every 6 months Bilirubin, creatinine, INR, sodium, dialysis
247
what score assesses severity of liver cirrhosis and prognosis?.
Child-pugh score ABCDE Albumin Bilirubin Clotting - INR Dilation (ascites) Encephalopathy
248
what are 3 differentials for liver cirrhosis?
Budd-chiari syndrome portal vein thrombosis splenic vein thrombosis
249
what is Budd chiari syndrome?
rare condition of hepatic vein occlusion (clot) causing triad of sudden onset abdo pain, ascites and tender hepatomegally
250
what is the management of cirrhosis?
Tx underlying Monitor for and manage complication Liver transplant
251
what are 4 features of decompensated liver disease?
AHOY Ascites Hepatic encephalopathy Oesophageal varices bleeding Yellow - Jaundiced
252
what are 6 complications of cirrhosis?
Malnutrition Portal hypertension, oesophageal varices and upper GI bleeds Ascites and spontaneous bacterial peritonitis Hepatorenal syndrome Hepatic encephalopathy Hepatocellular carcinoma
253
what nutritional advice should cirrhosis patients be given?
Regular meals High protein and calories Low sodium intake Avoid alcohol
254
what is the management of hepatorenal syndrome?
Vasopressin analogues - terlipressin Volume expansion with albumin LIVER TRANSPLANT
255
what is spontaneous bacterial peritonitis?
in 10-20% of patients with ascites Infection of ascitic fluid and peritoneal lining without clear source of infection
256
what can be seen on paracentesis in spontaneous bacterial peritonitis?
Neutrophil count >250 cells/uL
257
what are the 2 most common organisms present in spontaneous bacterial peritonitis?
1- E. Coli Klebsiella pneumoniae
258
what is the management of spontaneous bacterial peritonitis?
Paracentesis and culture - also therapeutic Broad spectrum Abx - pip/taz. or cefotaxime
259
who with ascites should be given prophylactic Abx and what ABx?
prev. spontaneous bacterial peritonitis paracentesis <15 g/l protein and either child-pugh >9 or hepatorenal syndrome Oral ciprofloxacin or norfloxacin
260
what is hepatorenal syndrome?
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
261
what are the 2 different types of hepatorenal syndrome?
type 1 - rapidly progressive, doubling creatinine in <2 weeks type 2 - slowly progressive, poor prognosis but live longer
262
which is the only DNA Hepatitis virus?
Hep B Virus
263
what type of viruses are hepatitis A, C, D, E?
RNA virus
264
which two hepatitis viruses have faecal oral transmission?
A and E
265
what is the transmission route for Hepatitis B?
Blood Bodily fluids vertical transmission - high rates
266
what is the most infectious blood borne virus?
1 - Hepatitis B 2 - Hepatitis C 3 - HIV
267
what is the needlestick transmission rates of Hep B, Hep C and HIV?
Alphabetical order Hep B - 30% Hep C - 3% HIV - 0.3%
268
what is the transmission route for hepatitis C?
Blood Some low risk of vertical transmission
269
what is the presentation of all of the hepatitis viruses?
Mild flu like symptoms Jaundice Anorexia nausea + vom abdo discomfort fever hepatomegaly splenomegaly ascites
270
what are the 5 different immunoglobulins?
GAMED IgG IgA IgM IgE IgD
271
what immunoglobulin is seen in acute infection?
IgM MA! - acute
272
what immunoglobulin is seen on chronic/previous infection?
IgG GP - non-acute
273
who should be vaccinated against hep A? 6
Travellers to areas of high prevalence People with chronic liver disease People with haemophilia MSM IVDU High occupational risk
274
what is the serology for Hepatitis A virus?
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
275
how quickly is Hep A usually cleared?
3-6 months
276
what are 4 complications of hepatitis A?
fulminant hepatitis - acute liver failure Relapsing hepatitis reactive arthritis pancreatitis
277
what are 4 differentials for hepatitis viruses?
other acute hep virus Wilsons disease autoimmune hepatitis alcoholic liver disease
278
what hepatitis virus do you need to be infected with in order to get infected with hepatitis D?
Hepatitis B - chronic in 5%
279
what is hepatitis B?
the most common liver infection May result in self-limiting disease requiring no treatment or in chronically infected state (more likely in children)
280
what are the investigations for hepatitis B?
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
281
what are 6 complications of hepatitis B infection?
Chronic hepatitis Fulminant liver failure hepatocellular carcinoma glomerulonephritis polyarteritis nodosa Cypglobulimaemia
282
what is the management of babies born to hepatitis B +ve mothers?
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
283
can hepatitis B +ve mother breast feed?
YES if babies are properly vaccinated
284
what is the management of hepatitis B?
Monitoring for disease and complications Anti-virals - peginterferon alfa 2a, entecavir, tenofovir
285
when are children vaccinated against Hep B?
8 weeks 12 weeks 16 weeks
286
what fraction of Hepatitis C Virus patients progress to chronic?
55-85%
287
what are the investigations for Hepatitis C?
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
288
what is the management for Hepatitis C?
8-12 weeks oral direct acting antivirals tailored to virus genotype - daclatasvir, sofosbuvir, simeprevir, ribavirin
289
what is the management of hepatitis C in children?
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
290
what hepatitis c treatment is teratogenic?
Ribavirin - should not become pregnant within 6 months of discontinuing
291
what are 5 complications of hepatitis C virus?
Cirrhosis Hepatocellular carcinoma Cryoglobulinemia Rheum problems - arthralgia, arthritis Sjorgren's syndrome
292
what are 4 risk factors for hepatitis A/E?
contaminated water poor sanitation ingestion of undercooked meat/shellfish travel to endemic areas
293
what group of people is Hep E worst in?
pregnant - 10-30% mortality 1% in general pop
294
is Hepatitis E usually self limiting or not?
usually self limiting
295
what percentage of immunocompetent adults with HBV achieve seroconversion without treatment?
95%
296
What plasma bilirubin level is considered jaundiced?
>21 umol/L May not become clinically apparent until >51 umol/L
297
How is bilirubin produced and cleared?
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
298
what are 3 causes of prehepatic jaundice?
increase bilirubin production increased RBC destruction (haemolytic anaemia, medications) increased unconjugated bilirubin (Gilbert's syndrome)
299
what so the stools and urine look like in prehepatic jaundice?
normal stools and urine
300
what are 7 causes of intrahepatic jaundice?
Hepatitis viruses HIV/parasitic infections toxins - alcohol NAFLD Autoimmune hepatitis genetics - Wilsons disease, haemochromatosis Hepatic Malignancy
301
what is are 6 causes of post hepatic jaundice?
Post operative stricture Gallstones Ascending cholangitis Pancreatitis Extra-hepatic malignancy
302
what does the urine and stools look like in intrahepatic jaundice?
urine - dark due to conjugated bilirubin being directly excreted in urine stools - normal
303
what does the urine and stools look like in post hepatic jaundice?
urine - dark - due to conjugated bilirubin being directly excreted in the urine stools - pale - due to obstruction => lack of stercobilin being excreted in stool
304
what are 5 manifestations of jaundice?
yellowing of skin, sclera and mucosa pruritus anorexia nausea and vomiting RUQ pain
305
what are 7 initial investigations of jaundice?
FBC - ?haemolysis U+E LFTs Clotting Amylase - ?pancreatitis Viral hepatitis screen Urine dip for bilirubin
306
what are red flags in jaundice?
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
307
what is the most common cause of liver disease in the west?
non-alcoholic fatty liver disease 25% of adults estimated
308
what are the 4 stages of non-alcoholic fatty liver disease?
Non-alcoholic fatty liver disease Non-alcoholic steatohepatitis (NASH) Fibrosis Cirrhosis
309
what are 8 risk factors for Non-alcoholic fatty liver disease?
obesity T2DM hyperlipidaemia hypertension Smoking Poor diet and activity Middle aged and older Sudden weight loss/starvation/Gastric bypass surgery
310
what is thought to be the key mechanism of Non-alcoholic fatty liver disease?
insulin resistance leading to excessive accumulation of triglycerides in liver thought to be hepatic manifestation of metabolic syndrome
311
what are 5 presentation of NAFLD?
Usually asymptomatic Abdo discomfort Hepatomegaly Liver signs - palmar erythema, Dupuytren's contracture, jaundice, ascites, spider naevi, hepatic encephalopathy, caput medusae, haematemesis
312
what is usually seen on LFTs in Non-alcoholic fatty liver disease?
Raised ALT greater than AST AST:ALT ratio <1
313
what is seen on US in Non-alcoholic fatty liver disease?
increased echogenicity
314
what is included in the enhanced liver fibrosis bloods?
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
315
what score on enhanced liver fibrosis bloods indicates advanced fibrosis?
>10.5 Recheck every 3 years if <10.5 (indicates unlikely advanced fibrosis)
316
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?
NAFLD Fibrosis score - Age, DM, BMI, AST, ALT, platelets, albumin Fibrosis-4 score (FIB-4) - Age, AST, ALT, platelets
317
what is the gold standard investigation for Non-alcoholic fatty liver disease?
liver biopsy
318
what is the treatment for NAFLD?
lifestyle modifications - weight loss, healthy eating, exercise, limit alcohol, stop smoking and monitoring Diabetes control Specialist - vitamin E, pioglitazone, bariatric surgery, liver transplant
319
what are 6 complications of NAFLD?
ascites Variceal haemorrhage hepatocellular carcinoma Hepatic encephalopathy Hepatorenal syndrome Hepatopulmonary syndrome
320
What is primary biliary cholangitis?
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
321
what are 3 risk factors for primary biliary cholangitis?
female Other autoimmune conditions - sjorgrens, RA, systemic sclerosis, thyroid disease FHx
322
what is the pathophysiology of primary biliary cholangitis?
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
323
what are 5 presentations of primary biliary cholangitis?
Pruritus fatigue and weight loss skin hyperpigmentation clubbing mild heptosplenomegaly jaundice xanthelasma and xatholamata
324
what are 6 investigations for primary biliary cholangitis?
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
325
what antibodies are most specific for Primary biliary cholangitis?
Anti-mitochondrial antibodies (AMA) ANA may also be present
326
what are 3 differentials for primary biliary cholangitis?
obstructive bile duct lesions primary sclerosis cholangitis malignancy
327
what its the 1st line management of primary biliary cholangitis?
1 - Ursodeoxycholic acid 12-14mg/kg/day in 3 divided doses initially - bile acid analogue 2 - Obeticholic acid - ursodeoxycholic acid not tolerated
328
what is the ongoing management of Primary biliary cholangitis?
Colestyramine 4-8g OD - for pruritus Replacement of fat soluble vitamins Immunosuppression Liver transplant at end stage
329
what are 6 complications of primary biliary cholangitis?
cirrhosis Hepatocellular carcinoma Hyperlipidaemia osteroporosis Sjogrens and systemic sclerosis thyroid disease
330
what is primary sclerosing cholangitis?
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
331
what are 4 risk factors for primary sclerosing cholangitis?
Male Age 30-40 Ulcerative colitis FHx
332
what is the pathophysiology of primary sclerosing cholangitis?
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
333
what are 6 manifestations of primary sclerosing cholangitis?
Often asymptomatic RUQ pain Jaundice and pruritus Fatigue and weight loss Hepato/splenomegaly Steatorrhea Cirrhosis symptoms
334
what are 3 investigations for primary sclerosing cholangitis?
LFTs - raised Alk phos initially (obstructive picture), other deranged LFTs as progresses MRCP/ERCP - gold - bead shaped appearance Colonoscopy for ulcerative colitis
335
what are 3 autoantibodies that may be positive in Primary sclerosing cholangitis?
Perinuclear antineutrophil cytoplasmic antibody - (p-ANCA) Antinuclear antibodies - (ANA) Anti-smooth muscle antibodies - (anti-SMA) Not sensitive or specific
336
what are 3 differentials for primary sclerosing cholangitis?
secondary sclerosing cholangitis IgG4 cholangitis immune hepatitis
337
what is the management for primary sclerosing cholangitis?
ERCP may be used to treat strictures and insert biliary stents Liver transplant Colestyramine - bile acid sequestrant - for pruritus Replacement of fat soluble vitamins
338
what are 6 complications of primary sclerosing cholangitis?
Biliary strictures Acute cholangitis cholangiocarcinoma osteoporosis Cirrhosis and complications Fat soluble vitamin deficiency
339
what is the gold standard investigation for Crohn's?
colonoscopy + biopsy transmural inflammation, deep ulcers, skip lesions, cobblestone mucosa, granulomas, goblet cells
340
what does foecal calprotectin help differentiate between?
IBS and IBD - raised in IBD - marker of bowel inflammation
341
what disease in pANCA most associated with?
ulcerative colitis
342
what disease is ASCA more associated with?
Crohn's disease
343
where is crohn's most common?
terminal ileum
344
what is Rovsing's sign?
in appendicitis - pain in the R iliac fossa worsened by pressing on the left iliac fossa
345
what is psoas sign?
appendicitis pain worsened in extending hip
346
what is obturator sign?
appendicitis pain worsened by flexing and internally rotating hip
347
what is the most common cause of small bowel obstruction?
adhesions
348
what are 4 causes of adhesion?
Pelvic/abdo surgery Peritonitis Abdo/pelvic infections endometriosis
349
what is the most common cause of large bowel obstruction?
malignancy
350
what is volvulus?
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.
351
what are the 2 main types of volvulus?
Sigmoid volvulus - most common Caecal volvulus
352
what is sigmoid volvulus?
volvulus affecting the sigmoid colon - more common in older patients caused by chronic constipation and lengthening of sigmoid mesentery
353
what is the management of sigmoid volvulus?
Endoscopic decompression using flexible/rigid sigmoidoscopy with rectal/flatus tube insertion
354
what are 6 risk factors for volvulus?
Neuropsychiatric disorders - Parkinson's Nursing home residents Chronic constipation High dietary fibre Pregnancy Adhesions
355
what can be seen on abdo x-ray in sigmoid volvulus?
coffee bean sign
356
what are 8 causes of small bowel obstruction?
Adhesions Tumours Crohn's Hernias Volvulus Intussusception Gallstone ileus Bezoars
357
what are 5 manifestations of small bowel obstruction?
abdominal pain and distension tinkling/absent bowel sounds empty rectum early vomiting (usually bilious) and nausea Absolute constipation
358
what is the 1st line management of bowel obstruction?
IV fluids (drip) NG tube (suck) IV antibiotics analgesia and anti-emetics
359
what is the surgical management of bowel obstruction?
if complete obstruction, strangulation, peritonitis, ischaemia or no improvement in 48-72 hours Adhesiolysis Bowel resection Bowel stenting in cancers
360
what are 3 complications of bowel obstruction?
Bowel ischaemia, perforation and peritnonitis Sepsis Hypovolaemic shock
361
is large or small bowel obstruction more common?
small
362
what are 5 manifestations of large bowel obstruction?
abdo pain and distension tinkling sounds early on absent later empty rectum bloating and constipation (early) vomiting - late sign Hypotension and tachycardia
363
what is the diameter of small bowel, colon, and caecum on abdo x-ray?
small = 3cm Large = 6cm Caecum = 9cm
364
do lines go all the way across in small or large bowel x-ray?
SMALL valculae connivents which are mucosal folds in small bowel
365
do lines go fully or partial across large bowel x-ray?
partially Haustrations - pouches formed by muscles in large bowel
366
what imaging is used 1st line for bowel perforation?
erect chest x-ray
367
what imaging is usually used to confirm intestinal obstruction?
Contrast abdo CT
368
what symptoms point to an infective cause of diarrhoea?
sudden onset | cramps abdominal pain and fever
369
how long does acute diarrhoea last?
<2 weeks
370
name 1 anti-diarrhoeal agent?
loperamide
371
what is contained in the foregut?
stomach, duodenum to sphincter of odd, biliary system, liver, pancreas
372
what is the blood supply of the foregut?
coeliac artery
373
what is contained in the midgut?
duodenum to 1st half of transverse colon
374
what is the blood supply of the midgut?
superior mesenteric artery
375
what is the blood supply of the hindgut?
inferior mesenteric artery
376
how long is the anus?
3-4 cm
377
what is the name of the line separating the histologically different parts of the anal canal?
the (pectinate) dentate line
378
what is hyper acute liver failure?
hepatic encephalopathy <7 days of noticing jaundice
379
what is hyperacute liver failure?
hepatic encephalopathy within 7 days of noticing jaundice
380
what is classed as acute liver failure?
hepatic encephalopathy within 8-28 weeks of noticing jaundice
381
what is fulminant hepatic failure?
clinical syndrome resulting from massive necrosis of liver cells leading to sever impairment of liver function
382
what are the signs of hepatic encephalopathy?
altered mental status confusion apraxia - difficulty motor planning asterisks - flapping
383
what is the grading system for heptic encephalopathy called?
the west haven criteria
384
what are 4 functions of the liver?
storage breakdown synthesis immune function
385
what are 5 signs of decompensated liver disease?
encephalopathy ascites jaundice GI bleeding coagulopathy
386
what are black pigment gallstones and when do they occur?
stones of billirubinate - occur in patients with increased haemolysis (haemolytic anaemias)
387
what are brown pigment gallstones and when do they occur?
calcium bilrubinate and calcium salts of fatty acids associated with infection and cholecystectomy
388
what is Murphy's sign?
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
389
what does ERCP stand for?
endoscopic retrograde cholangiopancreatography
390
what is Cullen's sign?
for pancreatitis - periumbilical bleeding
391
what is Grey Turner's syndrome?
flank bleeding secondary to retopritoneal haemorrhage in pancreatitis
392
what are 3 complications of pancreatitis?
pancreatic abscess haemorrhage necrotising pancreatitis
393
what is the treatment for pruitus?
cholestyramine
394
what is the treatment for ascites?
fluid restriction and reduced salt intake Spironolactone
395
what score is used to grade liver cirrhosis?
child-pugh score
396
what are 3 complications of liver cirrhosis?
coaglopathy encephalopathy hepatocellular carcinoma
397
what are 2 causes of pre-hepatic portal hypertension?
portal vein thrombosis | splenic vein thrombosis
398
what are 4 causes of intra-hepatic portal hypertension?
cirrhosis - most common UK schistosomiasis - most common worldwide sarcoidosis congenital hepatic fibrosis
399
what are 4 cause of post hepatic portal hypertension?
R Heart failure budd-chiari syndrome constrictive pericarditis veno-occlusive disease
400
where can hepatic varices form?
Gastro-oesophageal junction rectum left renal vein diaphragm the anterior abdominal wall via the umbilical vein
401
what is the management for bleeding oesophageal varices?
ABCDE IV fluids Blood transfusion Terlipressin - ADH analogue prophylactic antibiotic balloon tamponade
402
how long does acute hepatitis last?
< 6 months
403
what are 5 infective causes of acute hepatitis?
Hep A/E Herpes viruses leptospirosis toxoplasmosis Coxiella
404
what are 4 causes of non-infective hepatitis?
Alcoholic hepatitis Non-alcoholic steatohepatitis (NAFLD) Autoimmune hepatitis Drug induced hepatitis
405
what LFTs are raised in acute hepatitis?
AST and ALP +/- bilirubin
406
what are 2 infective causes of chronic hepatitis?
Hep B +/- D Hep C virus
407
is hepatits A chronic?
NO
408
are hepatitis viruses notifiable?
YES
409
which hep viruses have vaccines?
A and B
410
what is the incubation period of Hep B?
1-6 months
411
what is necesary for hepatitis D infection?
Concurrent hepatitis B infection Hep D binds to hep B surface antigen to complete replication and transmission
412
what are the serological investigations for Hep D?
IgM anti-HD IgG anti-HD HDAg - neg in chronic HDV RNA
413
what is the treatment for hep D?
interferon alpha
414
what are 3 investigations for Hepatitis E virus?
serology - IgM = active, IgG = recovery HEV PCR LFTs - elevated AST and ALT
415
what are 3 risk factors for autoimmune hepatitis?
Female Age - children or 40-50s Autoimmune conditions - coeliac, hashimotos, primary biliary cirrhosis
416
who does type 1 autoimmune hepatitis usually affect?
women in late 40s or 50s presents with features of liver disease - less acute course than type 2 Can often cause amenorrhoea
417
who does type 2 autoimmune hepatitis usually affect?
children and young people - more commonly girls Presents with acute hepatitis with high transaminases (ALT and AST) and jaundice
418
what 3 autoantibodies are associated with type 1 autoimmune hepatitis?
anti-nuclear antibodies - ANA Anti-smooth muscle antibodies - anti-actin Anti-soluble liver antigen - anti-SLA/LP
419
what are 2 autoantibodies seen in type 2 autoimmune hepatitis?
Anti-liver kidney microsomes-1 (anti-LKM1) Anti-liver cytosol antigen type 1 (anti-LC1)
420
what immunoglobulin is often raised in autoimmune hepatitis?
IgG
421
what is found on liver biopsy in autoimmune hepatitis?
interface hepatitis plasma cell infiltration piecemeal necrosis
422
what is the treatment for autoimmune hepatitis?
immunosuppression: 1 - high dose prednisolone AND azathioprine Hep A+B vaccination Liver transplant
423
what are 4 complications of autoimmune hepatitis?
Cirrhosis osteoporosis - steroids Cushings - steroids Hepatocellular carcinoma
424
what is the definition of travellers diarrhoea?
at least 3 loose to watery stool in 24 hours with or without abdo cramps, fever, nausea, vomiting or blood in stool
425
what is the main cause of travellers diarrhoea?
enterotoxigenic E. coli
426
what toxins does E. coli 0157 produce?
shiga toxins
427
what is one complication of shiga toxin gastroenteritis?
Haemolytic uraemic syndrome
428
what is seen in shigella gastroenteritis?
blood diarrhoea vomiting and abdo pain usually resolves within 1 week
429
what are 4 viral causes of infective diarrhoea?
rotavirus - most common in children norovirus - most common in adults adenoviruses astroviruses
430
what is the incubation period for S. aureus and B. cereus food poisoning?
1-6 hours
431
what is the presentation of b. cereus infection?
assciated with rice vomiting within 6 hours diarrhoea after 6 hours resolves witin 24 hours
432
what is the most common bacterial cause of diarrhoea?
campylobacter jejuni
433
what are 3 causes of campylobacter jejuni?
raw or undercooked poultry Untreated water unpasteurised milk
434
what is the management of campylobacter?
1 - clarithromycin 2 - ciprofloxacin
435
what are 2 antibiotics which can cause c. difficile?
Clindamycin Cephalosporins
436
what is one non-abx medication that increases risk of C. diff?
PPIs
437
what are 4 features of c. diff infection?
Diarrhoea abdo pain raised WCC toxic megacolon may develop
438
what is mild c. diff infection?
symptoms but normal WCC
439
what is a moderate C. diff infection?
WCC raised but <15 3-5 loose stools per day
440
what is severe c. diff infection?
WCC >15 OR AKI OR Temp >38.5 OR evidence of severe colitis
441
what is a life threatening c. diff infection?
Hypotension Partial or complete ileus Toxic megacolon, or CT evidence of severe disease
442
what test is used to diagnose C. diff?
C. diff stool toxin test Testing for antigen only shows exposure to bacteria not current infection
443
what is the management of C. difficile infection?
1 - Vancomycin 10 days PO 2 - Oral fidaxomicin 3 - oral vancomycin +/- IV metronidazole
444
what is the management of recurrent C. diff?
< 12 weeks of symptom resolution - Oral fidaxomicin >12 weeks of symptom resolution - oral Vancomycin or fidaxomicin
445
what is the management of life threatening c. diff?
oral vancomycin AND IV metronidazole
446
what bacteria can cause diarrhoea after eating undercooked pork?
yersinia enterocolitica
447
what bacteria produced rice water stools?
vibrio cholerae
448
what antibiotics cause diarrhoea?
rule of Cs clindamycin ciprofloxacin (quinolones) Co-amoxiclav (penicillins) cephalosporins
449
what is the most common parasitic cause of diarrhoea?
giardia lamblia
450
what is the presentation of giardia infection?
prolonged non-blood diarrhoea - incubation can be up to 7 days
451
what is the management of giardiasis?
Tinidazole Metrondazole
452
what is the presentation of ameobiasis diarrheoa?
gradual onset of blood diarrhoea, abdo pain and tenderness which may last several weeks
453
what is the presentation of typhoid?
headache, High fever, arthralgia bradycardia abdo pain, distension Diarrhoea/constipation (more common) Rose spots on trunk - appear over 1st week
454
what in the Ix for typhoid?
Blood cultures
455
what bacteria causes typhoid/paratyphoid?
Salmonella typhi/paratyphi Gram negative bacilli (red/pink rods)
456
what is the tx of typhoid?
Abx - ceftriaxone
457
what are 5 complication of typhoid?
Osteomyelitis GI bleeding/perforation meningitis cholecystitis chronic typhoid carrier
458
what are 4 risk factors for pseudomembranous colitis?
elderly antibiotics long hospital stay immunocompromised
459
what is haemochromatosis?
multisystem disorder of dysregulated dietary iron absorption and increased iron release from macrophages.
460
what causes haemochromatosis?
Autosomal recessive HFE gene mutation on chromosome 6 chronic transfusions high iron intake alcoholism
461
what protein from the liver controls iron levels?
Hepcidin
462
what are 7 manifestations of haemochromatosis?
Bronze skin Diabetes Liver stigmata of disease Dilated cardiomyopathy - CHF Hypogonadism Arthritis Present - fatige, ED, arthralgia
463
what investigations do you of for haemochromatosis?
serum ferritin - high Transferrin saturations - high Serum iron - high Total binding capacity - low Genetic testing for HFE mutation
464
what is the treatment for haemochromatosis?
venesection - draining small amounts of blood maintenance phlebotomy low iron diet
465
what are 4 complications of haemochromatosis?
cirrhosis hepatocellular carcinoma DM congestive HF
466
what is wilsons disease?
genetic condition leading to excessive copper deposits in tissues due to metabolic abnormalities of increased copper absorption and decreased excretion
467
what is the inheritance pattern of Wilson's disease?
autosomal recessive chromosome 13
468
what is the 1st line investigation for wilson's disease?
Serum caeruloplasmin
469
what investigations are done in wilsons disease?
Slit lamp for kayser-fleischer rings Reduced serum caeruloplasmin reduced total serum copper (carried by caeruloplasmin) Increased 24 hour urinary copper excretion
470
what are 5 presentations of wilson's disease?
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
471
what is the 1st line treatment for Wilsons disease?
Copper chelation - D-penicillamine
472
what condition is the double panda sign on MRI seen?
wilsons disease
473
what is alpha-1-antitrypsin deficiency?
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)
474
what is alpha-1 antitrypsin?
a protease inhibitor which inhibits the action of neutrophil elastase (a protease enzyme secreted by neutrophils to digest elastin)
475
what is the inheritance of alpha-1-antitrypsin deficiency?
autosomal recessive/co-dominant Disease severity depends on combination of both copies of gene
476
what does alpha-1-antitrypsin deficiency cause?
early onset COPD liver cirrhosis and hepatocellular carcinoma
477
what are 2 1st line investigations for alpha-1 antitrypsin deficiency?
1 - low serum alpha-1 antitrypsin (screening test) Genetic testing
478
what can be seen on liver biopsy in alpha-1-antitrypsin deficiency?
periodic acid-Schiff positive staining globules in hepatocytes => build up of mutant alpha-1-antitrypsin protein
479
what is the management of alpha-1-antitrypsin deficiency?
Stop smoking Symptomatic management Organ transplant Lung volume reduction surgery Monitor for complications Screening of family members
480
what are 10 causes of peritonitis? (mnemonic)
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.
481
what are 5 risk factors for peritonitis?
peritoneal dialysis GI perforation abdo surgery/trauma cirrhosis with ascites PID
482
what are 9 features of peritonitis?
Abdo pain Nausea and vom bloating anorexia abdo tenderness guarding rigidity rebound tenderness fever
483
what are 6 complications of peritonitis?
Sepsis Abscess formation bowel obstruction/ileus AKI Adhesions and chronic pain multiple organ dysfunction syndrome
484
what bacteria most commonly causes peritonitis in people with peritoneal dialysis?
Staphylococcus epidermis and other coagulase -ve staph
485
what is the management for bleeding varices?
IV terlipressin
486
what is the treatment for bleeding varicose in someone with ischaemic heart disease?
IV somatostatin
487
What is Reynolds pentad?
For acute cholangitis Charcot’s triad - RUQ pain, Fever, Jaundice Plus - hypotension and confusion
488
What 2 autoantibodies are present in primary biliary cholangitis?
Antimitochondrial antibodies (AMA) - most specific Anti-nuclear antibodies (ANA) - less specific
489
what is a hiatus hernia?
protrusion of part of the stomach through the diaphragmatic hiatus into the thoracic cavity
490
what are the 4 different types of hiatus hernia?
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
491
What are 6 risk factors for hiatus hernia?
Older age Female FHx Lifestyle - obesity, smoking Mechanical stressors - heavy lifting, straining Iatrogenic - surgery
492
what are 5 presentations of hiatus hernia?
GORD symptoms Chest pain Resp symptoms Dyspepsia Anaemia Oesophagtis and complications
493
what is the 1st line investigation for hiatus hernia?
Barium swallow
494
what is the gold standard for diagnosing hiatus hernia?
OGD endoscopy
495
what is the management for hiatus hernia?
Lifestyle modifications PPIs - Omeprazole 20mg OD, Lansoprazole 30mg OD H2RA - Famotidine 20-40mg BD, Ranatidine 150mg BD Surgery - lapraroscopic fudoplication
496
what are 6 complications of hiatus hernia?
Gastric volvulus Hernia incarceration Hernia strangulation Oesophagitis Barrett's oesophagus Oesophageal adenocarcinoma
497
what are the 4 types of acute mesenteric ischaemia?
Arterial embolism - most common - usually cardiac origin Arterial thrombosis Venous thrombosis Non-occlusive mesenteric ischaemia (caused by arterial dissection or vasculitises)
498
what is the blood supply to the foregut?
Foregut = stomach, part of duodenum, biliary system, liver, pancreas, spleen COELIAC ARTERY
499
what is the blood supply to the midgut?
Midgut - distal duodenum to 1st half of transverse colon SUPERIOR MESENTERIC ARTERY
500
what is the blood supply to the hindgut?
Hindgut = 2nd half of transverse colon to rectum INFERIOR MESENTERIC ARTERY
501
what are risk factors for acute mesenteric ischaemia?
AF or recent MI Infective endocarditis Risk factors for atherosclerosis - smoking, HTN, >60 Profound splanchnic vasoconstriction - non-occlusive mesenteric ischaemia
502
What are 5 presentations of acute mesenteric ischaemia?
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
503
what is the investigation for acute mesenteric ischaemia?
Bloods and ABG CT mesenteric angiogram
504
what is the initial manegment of acute mesenteric ischaemia?
Bowel rest - NBM, NG decompression IV fluids IV Abx - e.g. ceftriaxone + metronidazole IV unfractioned heparin Laparotomy
505
what is the definitive management of acute mesenteric ischaemia?
Endovascular revascularisation - embolectomy, angioplasty Laparotomy - open embolectomy, arterial bypass, resection of necrotic bowel
506
what are 4 complications of acute mesenteric ischaemia?
bowel infarction and perforation Short bowel syndrome Strictures Sepsis
507
what is chronic mesenteric ischaemia?
intestinal angina due to narrowing of mesenteric blood vessels due to atherosclerosis
508
what is the classic triad of chronic mesenteric ischaemia?
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
509
what is the diagnostic investigation of chronic mesenteric ischaemia?
CT angiogram
510
What can be seen on CT in intestinal ischaemia?
Pneumatosis intestinalis - gas in intestinal wall Pneumatosis portalis - gas in portal vein or mesenteric vein pneumoperitoneum - bowel perforation free fluid
511
what is the management of chronic mesenteric ischaemia?
Reduce modifiable risk factors Secondary prevention - Statins, antiplatelets Revascularisation - PC mesenteric artery stenting, open endarterectomy
512
what is the difference between mesenteric ischaemia and ischaemic colitis ?
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
513
what are anal fissures?
small tears or cuts in anal canal - longitudinal tears of anoderm
514
What are 4 causes of primary anal fissures?
Idiopathic Increases anal resting pressure Trauma Constipation and straining
515
what are 4 causes of secondary anal fissures?
IBD - inflammation in rectum Infectious causes - STIs Malignancy Other - proctitis, trauma, iatrogenic
516
what is classed as chronic anal fissures?
>6 weeks
517
what is the presentation of anal fissures?
Pain Rectal bleeding - bright red on toilet paper or in bowl Pruritus ani Discharge of mucus Constipation - avoidance behaviour
518
what is the management of acute anal fissure?
Dietary advice - high fibre, high fluid 1 - Bulk forming laxatives 2 - Lactulose Lubricants before defecation topical anaesthetics analgesia
519
what is the management of chronic anal fissures?
Acute plus 1 - Topical glyceryl trinitrate 2 - Surgery - lateral internal sphincterotomy
520
what are 7 risk factors for anal fissure?
chronic constipation persistent diarrhoea straining during bowel movements passing hard or large stools anal intercourse IBD pregnancy and childbirth
521
what are 3 complications of anal fissures?
Failure to heal/reoccurrence Abscess or fistula formation Incontinence
522
what are haemorrhoids?
enlarged anal vascular cushions often associated with constipation and straining
523
what are the anal cushions?
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
524
where are the anal cushions usually located?
3, 7 , 11 o'clock with patient on back
525
what is the classification of haemarrhoids?
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
526
what is the presentation of haemorrhoids?
Bright red bleeding on toilet tissue Sore/itchy anus lump in anus
527
what can be used to visualise haemarrhoids?
protoscopy
528
what is the topical management of haemorrhoids?
Anusol - astringents Anusol HC - astringents + hydrocortisone Germaloids cream - lidocaine Proctosedyl ointment - cinchocaine and hydrocortisone
529
what are 4 non-surgical management options of haemorrhoids?
Rubber band ligation injection sclerotherapy infra-red coagulopathy bipolar diathermy
530
what are 3 surgical management options for haemorrhoids?
Haemorrhoid artery ligation Haemorrhoidectomy - may result in faecal incontinence Stapled haemorrhoidectomy
531
what line determines whether a haemorrhoid is internal or external?
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
532
what are 5 complications of haemorrhoids?
perianal thrombosis ulceration incarceration of prolapsed haemerrhoidal tissue Anal stenosis anaemia
533
what do thrombosed haemorrhoids appear like?
purplish very tender swollen lumps around anus PR impossible due to pain resolve with time
534
what is paralytic ileus?
reduced motility of the GI tract due to failure of peristalsis leading to functional bowel obstruction
535
what are 6 causes of paralytic ileus?
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
536
what are 5 presentations of ileus?
Nausea and Vomiting - green bilious Abdo distension diffuse abdo pain absolute constipation and lack of flatulence Absent bowel sounds
537
what 2 electrolyte abnormalities affect bowel smooth muscle function?
Hyponatraemia Hypocalcaemia can cause paralytic ileus
538
what is the gold standard investigation for paralytic ileus?
CT scan
539
what is the management of paralytic ileus?
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
540
What is mesenteric adenitis?
inflammation of the mesenteric lymph nodes in the abdomen primarily affecting children and teens which causes an appendicitis like presentation
541
what usually precedes presentation with mesenteric adenitis?
viral infection
542
what are 4 presentations of mesenteric adenitis?
Abdo pain - RIF GI symptoms Systemic features Tender lymph nodes in RIF
543
what is a hernia?
Protrusion of part or whole of an organ or tissue through the wall of the cavity that normally contains it
544
what is hernia incarceration?
hernia cannot be reduced - can lead to bowel obstruction and strangulation
545
what is hernia stranguation?
non-reducible hernia with reduced/absent blood supply leading to ischemia and significant pain
546
what is richter's hernia?
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
547
what is the anatomy of a direct inguinal hernia?
protrudes through weakness in abdo wall (Hesselbach's triangle) passing medial to inferior epigastric artery, above inguinal ligament into the inguinal canal Usually do not enter scrotum and are acquired later in life
548
what are the boundaries of Hesselbach's triangle?
RIP Rectus abdominis - medial Inferior epigastric vessels - superior/lateral border Poupart's (inguinal) ligament - inferior border
549
what is the anatomy of an indirect inguinal hernia?
more common Bowel herniates through deep inguinal canal (ring) lateral to the inferior epigastric artery due to failure of processes vaginalis to close - can travel into scrotum
550
what examination can be done to differentiate between direct and indirect inguinal hernia?
hernia remains reduced when pressure is applied to deep inguinal ring (mid-point from anterior superior iliac spine and pubic tubercle) = direct inguinal hernia
551
what are 5 risk factors for inguinal hernia?
Male- >75 FHx - Marfans, EDS Previous R lower abdo incisions Premature babies Chronic coughing, straining, heavy lifting
552
what is the presentation of strangulated hernia?
Pain groin discomfort irreducible groin mass tender distended abdomen, lack of bowel sounds nausea and vomiting constipation
553
what is the management of hernias?
conservative watchful waiting if low risk Endoscopic mesh repair - tension free repair Tension repair - suture hole back together
554
what are femoral hernias at high risk of?
strangulation obstruction incarceration
555
what are femoral hernia?
herniation of abdominal contents through femoral canal BELOW inguinal ligament and lateral to pubic tubercle
556
are femoral hernias more common in males or females?
FEMALES
557
what are the boundaries of the femoral canal?
FLIP Femoral vein - lateral Lacunar ligament - medial Inguinal ligament - anteriorly Pectineal ligament - posteriorly
558
what are the borders of the the femoral triangle?
SAIL Sartorius - lateral Adductor longus - medial Inguinal Ligament - superior
559
what is the management of femoral hernias?
need surgical repair due to high risk of strangulation
560
what is a spigelian hernia?
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
561
what is diastasis recti?
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
562
what is an obturator hernia?
abdomen contents herniate through obturator foramen at bottom of pelvis due to defect in pelvic floor
563
what is hepatic encephalopathy?
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
564
what are 5 features of hepatic encephalopathy?
confusion and altered GCS Asterixis Constructional apraxia - unable to draw 5 pointed star Triphasic slow waves of EEG Raised ammonia levels
565
what is the grading of hepatic encephalopathy?
1 - irritable 2 - confusion, inappropriate behaviour 3 - incoherent, restless 4 - coma
566
what are 7 factors that can worsen hepatic encephalopathy?
constipation dehydration electrolyte disturbance infection GI bleed high protein diet medications - sedatives
567
what is the management of hepatic encephalopathy?
1 - Lactulose 30-50ml TDS 1 - Abx - Rifaximin - modulates gut bacteria to decrease ammonia production Liver transplant
568
How does lactulose treat hepatic encephalopathy?
speeds up gut transit time - clears ammonia before absorption Promotes bacterial uptake of ammonia Changes pH of intestine - more acidic - kills ammonia producing bacteria
569
what are 5 contraindications to liver transplant?
Significant co-morbidities Current illicit drug use Continuing alcohol misuse - in last 6 months Untreated HIV Current or previous cancers - except some liver cancers
570
what are 4 signs of liver transplant rejection?
Abnormal LFTs Fatigue Fever jaundice
571
what is Gilbert's syndrome?
An inherited condition (AR usually) causing mild intermittent elevation of unconjugated bilirubin due to defective conjugating enzymes in the liver
572
what are 2 features of Gilbert's syndrome?
Unconjugated hyperbilirubinaemia - not in urine => normal colour Mild jaundice brought on by illness, exercise, fasting, stress
573
what is the management of Gilbert's syndrome?
avoid triggers No lasting complications associated
574
what is bile acid malabsorption?
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
575
what are the fat soluble vitamins?
ADEK
576
what investigation is used in bile acid malabsorption?
SeHCAT - nuclear medicine test done 7 days apart to see radiolabelled SeHCAT
577
what is the management of bile acid malabsorption?
Bile acid sequestrants - Cholestyramine
578
what are 9 complications of malabsorption?
weakened immune system Delayed wound healing Generalised weakness Growth failure impaired intellectual development Rickets osteoporosis Reduced fertility Hypothermia
579
what is malabsorption?
the umbrella term for inability to absorb nutrients from ingested food
580
what is the NICE definition of malnutrition?
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
581
what is malnutrition?
a deficiency, excess or imbalance of macronutrients or micronutrients
582
what scoring system can be used to screen for malnutrition?
MUST (malnutrition universal screening tool) Score
583
what are the 3 broad causes of malnutrition?
Inadequate intake Impaired absorption Increased nutritional demands
584
what ae 9 risk factors for malnutrition?
>65 years Low socioeconomic status institutionalisation Drug/alcohol abuse chronic conditions Diseases causing malabsorption Diseases affecting dentition, smell/taste, swallow Cognitive impairment Mental illness
585
what is the management of malnutrition?
Dietician support if high risk Food-first approach over supplements Oral nutritional supplements (ensure) inbetween meals NOT instead of
586
what 2 presentations can be caused by macronutrient deficiency?
Kwashiorkor Marasmus
587
what is marasmus?
severe malnutrition due to inadequate intake of all macronutrients. Most common <1 year olds and causes muscle wasting and loss of subcutaneous fat
588
what is kwashiorkor?
Severe malnutrition due to protein deficiency but with adequate energy intake. Leads to muscle atrophy, oedema, ascites and enlarged liver with fatty infiltrates
589
what are 3 electrolyte abnormalities that can be caused by reefeeding?
Hypophosphatemia Hypokalaemia Hypomagnesaemia
590
what are 2 clinical manifestations of vitamin A deficiency?
night blindness immunodeficiency
591
what are 4 manifestations of zinc deficiency?
Delayed wound healing impaired taste hair loss immune deficiency
592
what is the other name for vitamin C?
Ascorbic acid
593
what is the presentation of vitamin C deficiency?
Fatigue Weakness Joint pain Bleeding - gums, petechiae, hemarthrosis, bruising Follicular hyperkeratosis - swollen hair follicles with keratin plugs leading to goosebumps or corkscrew hairs
594
what are 4 key functions of the spleen?
Activation of lymphocytes Removal of damaged RBCs from circulation Sequestration of platelets In utero - haematopoiesis
595
what are 7 causes of hyposplenism?
Post-splenectomy Sickle cell Coeliac disease - functional hyposplenism Grave's disease SLE Amyloidosis Liver cirrhosis - causes portal HTN and disrupted splenic blood flow
596
what are 3 complications of hyposplenism?
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
597
what can be seen on peripheral blood smear in hyposplenism?
Howell-Jolly bodies Siderocytes (pitted red cells)
598
what is the management of hyposplenism?
Immunisations - N. meningitidis, HIB, S. pneumoniae, flu Daily prophylactic Abx - penicillin V/macrolides Patient education
599
what is the vaccination schedule post splenectomy?
Men C and Hib 2 weeks post MenACWY one month post <2 years old may need further booster at 2 years pneumococcal vaccines
600
what is classed as constipation?
Defecation <3 times per week usually with difficult stool passage or seeming incomplete defecation
601
what are 5 medications that can cause constipation?
Opioids Calcium channel blockers Antipsychotic and tricyclic antidepressants Antispasmodics Antimuscarinics
602
what are 3 metabolic disturbances that can cause constipation?
Hypothyroidism Hypercalcaemia Diabetes
603
what are 3 neurological conditions that can cause constipation?
Parkinsons Spinal cord lesions MS
604
what is lifestyle advice for someone with constipation?
Increase daily fibre intake Increase exercise/movement Increase fluid intake
605
what is the 1st line management of constipation?
LIFESTYLE ADVICE
606
what is the pharmacological management of constipation in adults?
1 - Bulk forming laxative - Ispaghula husk 1 sachet BD 2 - switch to Osmotic - Macrogol (2 sachets) or lactulose (15ml) (if macrogol not tolerated)
607
what laxative should be used in soft stools that are difficult to pass or associated with incomplete emptying?
Stimulant - Sena
608
what laxatives should be used in opioid induced constipation?
Osmotic - Macrogol Stimulant - Senna NOT BULK FORMING
609
what are 5 complications of constipation?
Overflow diarrhoea Haemorrhoids/anal fissures Bowel obstruction, perforation or ulceration Urinary retention Delirium
610
what laxative can be used after 6 months of 2 other different classed laxatives have failed?
Prucalopride - prokinetic Trial for 4 weeks
611
what is the management of faecal loading?
1 - High dose oral macrogol 2 - ADD Stimulant laxative - senna
612
what is the management of faecal loading if initial treatment fails/is too slow?
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
613
How long classes as chronic constipation?
>3 months
614
what are the 4 different types of laxatives?
Bulk forming osmotic stimulat Softening
615
what are 2 examples of bulk forming laxatives?
fybrogel - ispaghula methylcellulose take a few days to work
616
what are 3 examples of osmotic laxitives
Lactulose macrogol Polyethylene glycol take a few days to work
617
what are 3 stimulant laxatives?
Bisacodyl senna sodium picosulfate take 6-12 hours to work
618
what is faecal loading?
retention of faeces to the extent that spontaneous evacuation is unlikely
619
what are 7 contraindications to laxatives?
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
620
what advice should be given to people taking bulk forming laxatives?
Need adequate fluid intake to avoid obstruction
621
what drug class is prucalopride?
5HT4 receptor agonist - prokinetic laxative
622
what are 4 presentations of perianal abscess?
Pain around anus worse on sitting hard tissue in anal region pus like discharge from anus Systemic infection symtpoms
623
what is the most common bacterial pathogen in perianal abcess?
e. coli
624
what is the gold standard imaging modality in perianal abscess?
MRI
625
what are 3 risk factors for perianal abscess?
IBD Diabetes Underlying malignancy
626
what is the management of perianal abscess?
Incision and drainage under local anaesthetic
627
what antiemetic should be avoided in bowel obstruction?
Metoclopramide - has prokinetic qualities

Phase 4 (22 decks)

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