GI & Liver Flashcards
What is acute cholangitis & what are the common risk factors?
= inflammation & infection of the biliary tree which is a surgical emergency.
- Most common:
- Gallstones → obstructing bile outflow
- ERCP → infection introduced
What are the most common causative organisms for acute cholangitis?
- E.coli
- Klebsiella species
- Enterococcus species
How does acute cholangitis present?
- Charcot’s triad
- Fever
- RUQ pain
- Jaundice
- Pruritis
- Pale stools
- Dark urine
- Nausea & vomiting
What imaging is done for suspected acute cholangitis?
- Transabdominal USS → may show gallstones, common bile duct stones, and a dilated common bile duct.
- CT abdomen → used if USS negative and high clinical suspicion.
- Non-calcified stones will not be visible on CT
- If secondary to malignancy can be useful for assessing tumour.
- MRCP (Magnetic Resonance Cholangiopancreatography) → biliary specific MRI
- ERCP (endoscopic retrograde cholangiopancreatography)
- Gold standard investigation & intervention for acute cholangitis.
- Invasive & high risk → acute pancreatitis & severe haemorrhage are important risks.
- Several interventions can be done, including stone extraction and stent placement
What causes acute cholecystitis?
- Gallstones -> obstruction of bile flow
- Acalculous -> dysfunction of gallbladder emptying
How does acute cholecystitis present?
- Right upper quadrant pain
- Often begins as an attack of biliary colic, but it worsens over hours.
- As the parietal peritoneum around the gallbladder becomes inflamed, the pain becomes sharper, more localised, and is exacerbated by movement.
- Radiates to right shoulder → due to irritation of the phrenic nerve.
- Fever
- Nausea & vomiting
- Murphy’s Sign → absence of this does not rule out acute cholecystitis
- Tachycardic
- Voluntary guarding
What are the changes seen on abdominal USS during acute cholecystitis?
- Thick-walled gallbladder (>3mm)
- Impacted gallstones
- Pericholecystic fluid
How is acute cholecystitis managed?
- Hospital admission
- Conservative management
- Nil by mouth → clear oral fluids
- IV fluids
- Antibiotics
- Analgesia
- Interventions
- ERCP → if there are gallstones trapped in the common bile duct.
- Emergency cholecystostomy → within 72hrs of symptom onset
What increases the risk of developing gallstones?
- Increase in concentration of solutes
- High cholesterol or bilirubin levels
- Generalised overconcentration of bile due to dehydration
- Bile stasis
- Mechanical obstruction → stents, strictures, tumours
- Functional impairment → oestrogen & progesterone impair gallbladder emptying
- Infection causing bile pigment sludge
What is the gold-standard investigation for biliary colic, and what does it show?
Abdominal USS → gold standard, will show gallstones in a thin-walled gallbladder
How does biliary colic present?
- Sudden onset, severe RUQ or epigastric pain → can radiate to lower chest, back, or right shoulder
- Lasts about up to 6-8hrs
- Dull & constant, occasional waves of more intense pain.
- Triggered by fatty or spicy foods, with the pain starting a few hours after eating
- Autonomic symptoms → nausea, vomiting, sweating, palpitations
What advise/management is given for biliary colic?
- Self-limiting
- Analgesia & follow-up USS
- Sticking to clear fluids until symptoms resolve can reduce risk of spasms
- Lifestyle changes → low-fat diet, gradual weight loss, avoidance of trigger foods
- Elective laparoscopic cholecystectomy if severe or patient would like
What are the most common causes of chronic pancreatitis?
- Chronic alcohol excess (key one to remember)
- Cystic fibrosis
- Pancreatic cancer
What are the symptoms of chronic pancreatitis?
- Chronic epigastric pain → worse after eating fatty food (15-30mins after) and relieved by sitting forward.
- Bloating
- Weight loss
- Symptoms of exocrine dysfunction → malabsorption, steatorrhoea
- Symptoms of endocrine dysfunction → thirst, polyuria
How is chronic pancreatitis managed?
Conservative:
- Stop drinking alcohol & smoking
- Eat a healthy diet
Medical:
- Analgesia
- Replacement of pancreatic enzymes (Creon)
- Subcutaneous insulin regimes to treat diabetes
Surgical:
- ERCP with stenting
- Surgery if severe
What are the 3 most common causes of acute pancreatitis?
- gallstones
- alcohol
- post-ERCP
How does acute pancreatitis present?
Symptoms:
- Epigastric pain → sudden, severe, may radiate to back
- Nausea & vomiting
- Decreased appetite
- Abdominal tenderness
- Systemically unwell → low-grade fever, tachycardia
Signs:
- Epigastric tenderness
- Abdominal distension
- Reduced bowel sounds if an ileus has developed
- Evidence of systemic inflammatory response.
How is acute pancreatitis managed?
Immediate:
- Hospital admission
- A-E assessment for initial resuscitation.
- IV fluids
- Nil by mouth until pain improves
- Analgesia → IV paracetamol & opioids
- Anti-emetics
- Control of BMs
NB → do not routinely give antibiotics unless there is a specific indication.
Manage Underlying Cause:
- Gallstones
- ERCP
- Cholecystectomy
- Alcohol
- Patients withdrawing from alcohol should be managed according to severity scores, such as CIWA.
What are the risk factors for peptic ulcers?
- Disruption to mucus barrier
- H.pylori
- NSAIDs
- Increase stomach acid
- Stress
- Alcohol
- Caffeine
- Smoking
- Spicy foods
How does the pain differ on presentation of gastric vs duodenal ulcers?
- Epigastric discomfort or pain
- Gastric ulcers → pain worse on eating
- Duodenal ulcers → pain improves on eating, followed by pain 2-3 hours later
How are peptic ulcers diagnosed?
- Diagnosed on endoscopy
- Rapid urease test can be performed to check for H.pylori.
- Biopsy is considered to exclude malignancy
How does pancreatic cancer present?
- Painless obstructive jaundice → usually due to a tumour in the head or neck of the pancreas compressing the common bile duct.
- Yellowing of skin or sclera
- Dark urine
- Pale stools
- Generalised itching
- Non-specific upper abdominal or back pain
- Unintentional weight loss
- Change in bowel habit
- New-onset diabetes or worsening of type 2 diabetes.
What is a specific blood test used for suspected pancreatic cancer?
CA19-9
How will hepatitis present on LFTs?
- LFTs will show a hepatic picture
- High transaminases → AST/ALT
- Proportionately less of a rise in ALP
- Bilirubin may rise due to inflammation of the liver cells.
What is Primary Biliary Cholangitis?
= an autoimmune condition where the intrahepatic bile ducts are attacked, resulting in obstructive jaundice & liver disease.
How does someone present with primary biliary cholangitis?
- Typical patient is a caucasian woman aged 40-60 years.
- Often patients are asymptomatic at diagnosis, and picked up on LFT testing.
- Fatigue
- Pruritis → accumulation of bile acids
- GI symptoms & abdominal pain → due to lack of bile acids helping with fat digestion.
- Jaundice
- Pale, greasy stools → malabsorption of fat
- Dark urine
What is the key investigation to remember when suspecting primary biliary cholangitis?
Anti-mitochondrial antibodies (AMA) are positive in >90% of individuals
How is primary biliary cholangitis managed?
- Ursodeoxycholic acid → non-toxic, hydrophilic bile acid that protects cholangiocytes from inflammation and damage.
- Slows disease progression & improves outcomes
- Key treatment.
- Colestyramine → for symptoms of pruritis, reduces intestinal absorption of bile acids
- Immunosuppression in some patients.
What is primary sclerosing cholangitis?
= a condition where the intrahepatic & extrahepatic bile ducts become inflamed & damaged, developing strictures that obstruct bile flow out of the liver.
- Chronic bile obstruction eventually leads to liver inflammation, fibrosis, and cirrhosis.
What are 4 risk factors for primary sclerosing cholangitis?
- Male
- Aged 30-40
- Ulcerative colitis → strong association, with 70% of cases occuring in people with UC.
- Family history
If symptomatic, how does primary sclerosing cholangitis present?
- Abdominal pain in RUQ
- Fatigue
- Jaundice
- Hepatomegaly
- Splenomegaly
What is the diagnostic investigation for primary sclerosing cholangitis?
What other investigations are done?
- MRCP → diagnostic imaging investigation, shows bile duct strictures
- LFTs cholestatic pattern → raised ALP
- No autoantibodies are helpful for diagnosis.
- Colonoscopy → should be performed for UC
- Liver biopsy → not usually required, but useful if there is diagnostic uncertainty.
How is primary sclerosing cholangitis managed?
- No proven effective treatments.
- ERCP → dilation of dominant strictures, and stents can be inserted.
- Colestyramine → for pruritis
- Replacement of fat-soluble vitamins
- Liver transplant in advanced disease
- Monitoring for complications → cholangiocarcinoma, cirrhosis, oesophageal varices.
What are the risk factors for diverticulitis?
- Older age
- Low fibre diet
- Smoking
- Obesity
- Medication → NSAIDs & opioids
How is uncomplicated diverticulitis managed?
- Oral co-amoxiclav
- Analgesia
- Only taking clear fluids until symptoms improve → usually in 2-3 days
- Follow-up
How is complicated diverticulitis managed?
- Hospital admission
- IV fluids
- IV antibiotics
- Nil by mouth
- Analgesia
- Urgent CT scan
- If fistula or persistent abscess → laparoscopic resection
- If faeculant peritonitis → colonic resection
What are some causes of hernias?
- Increased intra-abdominal pressure:
- Chronic cough → COPD, bronchiectasis, cystic fibrosis
- Abdominal distension → pregnancy, obesity
- Straining → chronic constipation, heavy lifting during work or exercise
- Weakened tissues
- Trauma → such as surgery
- Ageing
- Chronic malnutrition
- Collagen disorders
- Congenital defects
What are the two types of inguinal hernia?
- Indirect → where bowel herniates through the inguinal canal
- Normally after the testes descend through the inguinal canal, the deep inguinal ring closes, however sometimes this ring remains patent, leaving a tunnel.
- Direct → due to weakness in the abdominal wall at Hesselbach’s triangle.
How are the common hernias managed?
Inguinal, umbilical, epigastric - low risk of complications:
- If small & unbothersome then leave alone → low risk of obstruction or strangulation
- Mesh repair → gold standard.
Femoral:
- Always repaired due to high risk
- Laparoscopic mesh repair
What is a hiatus hernia and how is it managed?
= herniation of the stomach up through the diaphragm.
- Medical → for GORD
- Surgical → laparoscopic fundoplication
How does an anal fissure present?
- Anal pain always occurs when passing stool
- Severe, sharp, often followed by deep burning pain that lasts several hours.
- Bleeding with defecation → seen on stool or toilet paper
- Tearing sensation on passing stool
- Can be acute or chronic
- Acute → <6 weeks
- Chronic → > 6 weeks
- If presenting acutely with an abscess → rapid onset of perianal pain & swelling, often with systemic features such as fever or tachycardia.
What is the most common type of colorectal cancer?
Adenocarcinoma
How is suspected colorectal cancer investigated?
- FIT
- Faecal immunochemical tests
- Looks for human Hb in the stool
- Can be used as a test in primary care for those who do not meet the criteria for a 2 week referral.
- Used in the bowel cancer screening programme.
- CEA
- Carcinoembryonic antigen
- Not used for screening or testing, more for monitoring treatment & disease progression
- Colonoscopy
- Gold standard investigation
- Any suspicious lesions are biopsied
- CT colonography
- CT scan with bowel prep & contrast to visualise the colon in more detail
- Used if patient isn’t fit for colonoscopy but means you can’t biopsy any lesions.
- Staging CT CAP
How is Barrett’s Oesophagus managed?
- Endoscopic surveillance for signs of progression.
- PPIs → high dose, long term
- Endoscopic ablation
How does oesophageal cancer present?
- Progressive dysphagia → initially for solids, later for liquids
- Occurs when there is obstruction of 2/3s of the lumen
- Hoarseness if local invasion of recurrent laryngeal nerve.
- Appetite loss
- Weight loss
- Dyspepsia → treatment resistant
- Reflux
- Haematemesis
What are the risk factors for oesophageal cancer?
- Smoking
- High alcohol intake
- Obesity
- GORD → Barrett’s Oesophagus
- Achalasia
- High intake of hot beverages
What antibodies are tested for in coeliac disease?
- Anti-tissue transglutaminase antibodies (Anti-TTG)
- Total IgA level → to exclude IgA deficiency giving a false negative
How does peritonitis present?
- Severe abdominal pain → lying still as movement worsens the pain
- Systemic signs of illness → fever, haemodynamic instability
- Nausea & vomiting
- Abdominal rigidity/involuntary abdominal guarding → involuntary tensing of abs in response to pressure on the abdomen
- Rebound tenderness → pressure on the abdomen elicits less pain than releasing the hand
What is the standard order in which laxatives are advised for constipation?
- Bulk-forming laxative
- Macrogol (laxido) → add or switch to if still symptomatic
- Stimulant laxative if stools are soft but difficult to pass, or feeling of incomplete emptying (short term use)
What is the drug name of a bulking agent used for constipation? How does it work, and what are the contraindications?
Ispaghula husk.
- helpful in people unable to increase dietary fibre.
- need to increase fluid intake to reduce risk of obstruction.
- Increases faecal mass with soluble fibre, which stimulates peristalsis.
- Contraindicated: Faecal impaction, intestinal obstruction, reduced gut motility
How do haemorrhoids present?
- Painless, bright red bleeding → seen on toilet paper
- Can become painful if the haemorrhoid thromboses.
- Palpable lump in or around the anus
- Peri-anal itch
- Often with associated constipation & straining.
- Tenesmus → feeling of fullness or incomplete defaecation
What is Rigler’s Sign?
When gas is seen on both sides of the bowel wall on abdominal x-ray, indicating a pneumoperitoneum.
What medication is given for diarrhoea in those with IBS?
Loperamide
What medication is given for constipation in those with IBS?
Bulk-forming laxative - ispaghula husk
How does an ileus present?
Symptoms:
- Vomiting → green bilious vomiting
- Abdominal distention
- Absolute constipation & lack of flatulence
Signs
- Absent bowel sounds → opposed to the tinkling bowel sounds of mechanical obstruction
- Diffuse abdominal pain
How is an ileus managed?
- NBM or limiting sips of water
- IV fluids
- NG tube if vomiting
- Mobilisation to help stimulate peristalsis
- Use non-opioid analgesia
What is liver cirrhosis?
= liver disease that is the result of chronic inflammation & damage to hepatocytes. There is widespread disruption of normal liver structure, which becomes distorted with regenerative nodules surrounded by diffuse fibrosis.
What is decompensated liver cirrhosis?
- the largely symptomatic phase of cirrhosis when the liver is damaged, affecting its function, with potentially life-threatening complications such as jaundice, ascites, hepatic encephalopathy, and variceal bleeding.
- Due to portal hypertension and/or hepatocellular dysfunction.
What are the 4 common causes of liver cirrhosis?
- Alcohol-related liver disease
- > 50 units of alcohol per week in men, >35 in women, for at least several months.
- Non-alcoholic fatty liver disease
- Hepatitis B
- Hepatitis C
What changes are seen in cirrhosis during a liver ultrasound scan?
nodularity of surface, corkscrew appearance of hepatic arteries (with increased flow as they compensate for reduced portal flow), enlarged portal vein, Ascites, Splenomegaly
What are the complications of liver cirrhosis?
- Malnutrition
- Portal hypertension & varices
- Ascites & spontaneous bacterial peritonitis
- Hepatorenal syndrome
- Hepatic encephalopathy
- Hepatocellular carcinoma
What is given prophylactically for oesophageal varices?
- Propranolol → first line, non-selective beta-blocker
- Variceal band ligation → if propranolol contraindicated
How are bleeding oesophageal varices managed?
- 2222, major haemorrhage protocol
- Vasopressin analogue → terlipressin, causes vasoconstriction
- Prophylactic broad spectrum antibiotics
- Urgent endoscopy with variceal band ligation
- Sengstaken-blackemore tube
- Consider intubation & intensive care
How are ascites due to liver cirrhosis managed?
- Low sodium diet
- Aldosterone antagonists → spironolactone
- Paracentesis
- Prophylactic antibiotics
How is hepatic encephalopathy managed?
- Lactulose → reduces the intestinal production & absorption of ammonia. Aim for 2-3 soft stools daily
- Antibiotics → reduce the number of intestinal bacterial producing ammonia
- Nutritional support
What are the stages of alcohol-related liver disease?
- Hepatic Steatosis → drinking leads to the build up of fat in the liver. This is reversible with abstinence
- Alcoholic Hepatitis → drinking over a long period or binge drinking causes inflammation in the liver cells. Mild hepatitis is usually reversible with permanent abstinence.
- Cirrhosis → where functional liver tissue is replaced with scar tissue, this is irreversible. Abstinence can prevent further damage.
What are the stages of NAFLD?
- Non-alcoholic fatty liver disease
- Non-alcoholic steatohepatitis
- Fibrosis
- Cirrhosis
What are the key investigations in NAFLD?
- Raised ALT → often the first indication that a patient has NAFLD
- Liver USS → confirms diagnosis of hepatic steatosis, seen as increased echogenicity
- Enhanced liver fibrosis blood test → first line investigation for assessing fibrosis in NAFLD
- Liver biopsy- confirms diagnosis & excludes other causes of liver disease
What does a coffee bean sign on abdominal x-ray indicate?
Sigmoid volvulus
What are the 4 key symptoms in bowel obstruction?
- Vomiting → green bilious
- Abdominal distention
- Diffuse abdominal pain → severe, colicky
- Absolute constipation & lack of flatulence
How is a volvulus managed?
- NBM, NG tube, IV fluids
- Conservative → endoscopic decompression
- Surgical → laparotomy, Hartmann’s, hemicolectomy
What are the 3 most common causes of bowel obstruction?
- Adhesions
- Hernias
- Malignancy
What are the differing features of UC & Crohns on endoscopy & histology
Crohns:
- Entire GI tract affected, most commonly in the terminal ileum.
- Skip lesions on endoscopy, transmural inflammation
Ulcerative Colitis:
- Limited to the colon & rectum
- Continuous inflammation, only affecting the superficial mucosa. Crypt abscess
How is Crohn’s Disease managed?
- Inducing remission
- Steroids → prednisolone (1st line)
- Enteral nutrition → particularly when there are concerns about steroids affecting growth.
- If steroids inadequate, other medications can be considered → azathioprine, methotrexate
- Maintaining remission
- Azathioprine or mercaptopurine (1st line)
- Methotrexate
- Surgery → resection of distal ileum if disease isolated to this area, treat strictures & fistulas
