GI pathology Flashcards
What is constipation?
Retention of faecal material for long period of time.
What are symptoms associated with constipation?
Headaches
Nausea
Loss of appetite
Abdominal distension
What is diarrhoea?
The too frequent passing of liquid stool.
What are some causes of diarrhoea?
Entertoxigenic bacteria Stress Food Protozoans Nervousness Viruses Toxins
What are some examples of enterotoxigenic bacteria?
Vibrio cholerae
Escherichia coli
What is a possible treatment for diarrhoea?
Need to rehydrate so give patient a sodium/glucose solution to drive water absorption. The continued secretions then wash away the bacteria.
What is hepatitis?
Inflammation of the liver.
What are the differences between the different types go hepatitis?
Hepatitis A - usually no long term effects, contracted by consuming foods/water containing faecal matter. Not common. in UK.
Hepatitis B - blood borne virus usually spread from infected mother to baby. Common in Southeast Asia and Subsaharan Africa. If chronic may case cirrhosis and liver failure.
Hepatitis C - Blood borne virus. Common in uk and spread vis the sharing of needles. Creates flu like symptoms and may remain in body for years - cirrhosis and liver failure.
Hepatitis D - needs individual to be infected with hep B to survive. Blood borne or sexual contact. Chronic infection may cause cirrhosis and liver failure.
Hepatitis E - usually no long term effects. Causes acute hepatitis. Contracted by eating raw meat or shellfish.
What is fatty change?
Any abnormal accumulation of fat in parenchymal cells, usually related to excessive drinking or obesity.
What is pre-hepatic jaundice?
Excessive red blood cell breakdown within the spleen leaving the unconjugated bilirubin to remain in the bloodstream.
What is hepatic jaundice?
There is a dysfunction of the liver itself causing unconjugated and conjugated bilirubin to remain in blood.
What is post-hepatic jaundice?
There is an obstruction in the biliary tree that causes bilirubin to be reabsorbed and circulated in the enter-hepatic system.
What are the characteristics of Clostridium Difficile?
Gram positive spore forming bacteria.
Releases enterotoxins A &B.
Robust spores that can survive >40days.
Common cause of antibiotic associated diarrhoea.
What are the risk factors for c.diff diarrhoea?
Antibiotics - clindamycin,cefs, augmenting, quinolones.
Increasing age.
Hospitalisation.
Proton Pump Inhibitors.
How does c.diff diarrhoea present clinically?
Asymptomatic
Mild diarrhoea
Colitis with or without pseudomembranes.
Fulminant colitis (sudden/severe onset).
What is Pseudomembranous Colitis?
Colitis commonly caused by c.diff that has pseudomembranes (yellow plaques) and severe systemic symptoms.
How is c.diff diarrhoea treated?
Stop causative antibiotic
Avoid antidiarrhoeals and opiates.
Enteric precautions.
Metronidazole 400mg 1st line, 10-14 days.
Vancomycin 2nd line, 10-14days.
Vancomycin if severe.
Urgent colectomy if toxic megacolon, increased lactate dehydrogenase (LDH), deteriorating condition.
What is Lactate dehydrogenase?
LDH is an enzyme found in most tissues used to help convert sugar into energy. Levels are normally low within the blood but can become raised if there is tissue damage.
What is toxic megacolon?
Inflammation of the colon causing gas to become trapped. The colon becomes very enlarged and swollen with the risk of rupture. Complication of ulcerative colitis.
What are the causes of constipation?
OPENED IT
O- obstruction; adhesions, hernia, inflammatory strictures, pelvic mass.
P- pain; anal fissure, proctalgia fugax
E- endocrine/electrolytes; decreased T4 thyroid hormone, decreased calcium, decreased potassium, uraemia.
N- neuro; MS, myelopathy, cauda equina syndrome.
E- elderly
D- diet/dehydration
I- IBS
T- toxins; opioids, Anti-mACh.
How is constipation managed?
Drink more Increase dietary fibre Lactulose MgSO4 Liquid parafin softeners Phosphate enemas Glycerol suppository.
What is meant by IBS?
Irritable Bowel Syndrome is a group of disorders that present with bowel symptoms for which no organic cause can be found.
What is peptic ulcer disease?
Having 1 or more ulcers within the stomach (gastric ulcers) or duodenum (duodenal ulcers).
Ulcers are small round punched out looking sores which are a break in the membrane.
What are some causes of Peptic Ulcers?
Helicobacter Pylori - most common cause. It is a gram negative bacteria that releases adhesions and proteases which damage the mucosa and eventually lead to ulceration.
NSAIDs - inhibit enzyme cyclooxygenase which is involved in the synthesis of prostaglandins. The prolonged decrease of prostaglandins makes the mucosa susceptible to damage.
Zollinger-Ellison syndrome - caused by the tumour, Gastrinoma. Creates abnormal gastrin levels which in turn create excess HCl levels which damage mucosa.
What are some complications of Peptic ulcers?
Perforation - Ulcer erodes all the way through the wall of the stomach/duodenum.
Gastric contents then enters into the peritoneal space. Air collects under the diaphragm which irritates the phrenic nerve and can present as referred shoulder pain.
Haemorrhage
Obstruction of pyloric sphincter.
How do peptic ulcers present?
Epigastric pain - gastric ulcers pain gets worse on eating. Duodenal ulcer pain gets better when eating.
Gastric ulcers are associated with weight loss. Duodenal ulcers are associated with weight gain.
Bloating
Belching
Vomitng
What are the investigations for peptic ulcer diagnosis?
Bloods - FBC, urea
C13 breath test.
Upper endoscopy
Biopsy.
What are the management options for Peptic ulcers?
Conservative - lose weight, stop smoking, avoid hot drinks/spicy food, stop NSAIDs and steroids.
Medical- Antacids e.g Gaviscon, Mg trisilicate.
Full dose acid suppression for 1-2 months using PPIs e.g Iansoprazole or H2RAs e.g ranitidine
Surgery in extreme cases.
Antrectomy
Vagotomy
Subtotal gastrectomy
What is GORD?
Gastro-oesophageal Reflux Disease is when acid leaks from the stomach up tiny the oesophagus usually as a result of lower oesophageal sphincter dysfunction.
What are the risk factors for GORD?
Hiatus hernia Smoking Alcohol Obesity Pregnancy Drugs - anti-AChm, nitrates, CCBs, TCAs.
What are the symptoms for GORD?
Heartburn Belching Acid/water brash (heartburn) Odynophagia (pain on swallowing). Can also get nocturnal asthma, chronic cough, laryngitis or sinusitis.
What are some complications of GORD?
Ulceration
Benign stricture
Barrett’s oesophagus
Oesophageal adenocarcinoma.
What are the investigations of GORD?
Endoscopy Barium swallow or meal 24hr pH monitoring Manometry Blood tests
What are the treatment options for GORD?
Conservative - Lose weight, raise head of bed, small regular meals, stop smoking and decrease alcohol, avoid hot drinks and spicy food, stop NSAIDs, steroids, CCBs and nitrates.
Medical - OTC Antacids e.g Gaviscon, Mg trsilicate.
1st line - full-dose PPI for 1-2months e.g Lansoprazole.
2nd line - Double dose of PPI.
3rd line - add an H2RA e.g ranitidine.
Surgical - Nissen Fundoplication. Mobilises gastric fundus and wraps it around lower oesophagus. Closes any hiatuses.
What is a Hiatus Hernia?
When abdominal organs slip through the diaphragm innate the chest cavity.
What are the different types of hiatus hernia?
Sliding (80%) - gastro-oesophageal junction slides up into chest. More common in GORD.
Rolling (15%) - gastro-oesophageal junction remains in abdomen but bulge of stomach rolls into chest. Can lead to strangulation.
What are the investigations for a hiatus hernia?
Chest x-ray - gas bubbles and fluid in chest.
Barium swallow - diagnostic.
Gastroscopy.
24hr pH and manometry - to exclude dysmotility or achalasia.
What is Achalasia?
Muscles of the oesophagus don’t contract properly and the LOS doesn’t open properly or at all. Causes difficulty/pain when swallowing.
What is the treatment for Hiatus Hernia?
Lose weight
Treat reflux
Surgery if intractable symptoms despite medical treatment - should always surgically repair rolling hernias as they can cause strangulation.
What is the differential diagnosis for haematemesis (vomiting blood)?
VINTAGE
V- varices
I - inflammation - ulcers/itis
N- neoplasia - oesophageal/gastric cancer
T - trauma - mallory-weirs tear, Boerhaave’s syndrome.
A - angiodysplasia
G- Generalised bleeding diathesis - warfarin. thrombolytics, CRF.
E- epistaxis.
What is a Mallory Weiss tear?
Tear in the lining of the upper gastrointestinal tract. The tear usually occurs at the gastro-oesophageal junction or within the lining of the fundus.
What are the causes of a Mallory-Weiss tear?
Anything that causes a sudden rise in pressure , either in the stomach or lower part of the oesophagus.
- Repeated vomiting
- Violent coughing
- Excessive straining
- Idiopathic.
What are the risk factors for a Mallory-Weiss tear?
Hiatus hernia
Alcohol
Pregnancy
Bulimia nervosa.
What are the symptoms of a Mallor-Weiss tear?
Bright red blood in vomit (haematemesis)
Melena
Epigastric pain
What investigations would you carry out for a Mallory-Weiss tear?
Gastroscopy.
Bloods - anaemia, clotting factors.
Angiography.
What is the treatment for a Mallory-Weiss tear?
May resolves by itself.
Treat reflux, anaemia, coagulation.
if still bleeding may surgically treat via endoscope - haemoclipping, ligation, adrenaline injection.
What is Boerhaave’s Syndrome?
Full thickness tear of the oesophagus 2cm proximal to the LOS.
Usually caused by the forceful ejection of gastric contents against a closed glottis.
What are the symptoms of Boerhaave’s Syndrome?
Haematemesis Chest pain Subcutaneous emphysema Epigastric pain Back pain Dyspnoea Shock
What are the investigations and treatment used in Boerhaave’s syndrome?
CXR
Fluroscopy
CT
Surgery is gold standard but oesophageal stunting may be used as a conservative method.
What is Angiodysplasia?
Vascular abnormality where there is a formation of artery-venous malformations. Usually presents as a small tuft of dilated vessels. Can be acquired or congenital.
How does Angiodysplasia present?
Angiodysplasia can affect anywhere along the GI tract so symptoms vary depending on location of bleed.
Haematemesis Rectal bleeding Anaemia Asymptomatic Melena
What investigations would you carry out for Angiodysplasia?
FBC U&Es LFTs Clotting factors Endoscopy Colonoscopy Angiography
What is the treatment for Angiodysplasia?
Endoscopic Ablation therapy.
Mesenteric angiography - catheterisation and embolisation of vessel.
Surgery.
What is Hereditary Haemorrhagic Telangiectasia (HHT)?
Inherited genetic recessive disorder where your blood vessels don’t develop properly, making them susceptible to bleed. Symptoms usually start in child/teen years.
What are the symptoms of HHT?
Nose bleeds Visible red spots across body. Anaemia. Haematemesis Rectal bleeding
What is the treatment for HHT?
No cure but good prognosis with management.
Iron supplements.
Laser treatment.
Embolisation.
Radiotherapy.
Treatment depends on the location of the bleed.
What is Dieulafoy lesion?
Rupture of a large arteriole in the stomach or other bowel.
What is epistaxis?
Nosebleed.
What is the differential diagnosis of rectal bleeding?
DRIPING A
D- Diverticulae R- rectal haemorrhoids I- Infection P- polyps I- inflammation - UC/Crohn's N - neoplasia G - gastric-upper bleed A - angio - HHT, ischaemic colitis, Angiodysplasia.
What is Diverticular disease?
Development of diverticula = small bulge for pockets that develop within the lining of the bowel.
What is diverticulitis?
Inflamed or infected diverticula.
What are the symptoms of diverticular disease and diverticulitis?
Usually asymptomatic Lower left flank pain - gets worse during/just after eating. Bloating Constipation Diarrhoea Mucus in stool Rectal bleeding Pyrexia Nausea Vomiting Fatigue Malaise
What are the investigations for diverticular disease and diverticulitis?
Need to rule out IBS, coeliac, bowel cancer.
Bloods
Colonoscopy
CT
What is the treatment for Diverticular disease?
High fibre diet (30g per day for an adult).
Paracetamol, aspirin or ibuprofen to ease pain.
Colectomy if very severe.
What is the treatment for diverticulitis?
Fluid only diet for a few days as symptoms recover.
Gradually build fibre back into diet until 30g per day is achieved.
Paracetamol - NO aspirin or ibuprofen as they can cause stomach upsets.
Antibiotics.
Colectomy if severe.
What are some common organisms that cause infection of the bowel and subsequently rectal bleeding?
Campylobacter Shigella, E.coli C.diff Amoebic dysentry.
What are polyps?
Small growths on the inner lining of the GI tract. Most commonly in bowel and rectum.
What is ischaemic colitis?
Acute transient compromise in blood flow, below what is required metabolically by the colon.
Leads to mucosal ulceration, inflammation and haemorrhage.
What are some causes of ischaemic colitis?
Systemic - heart failure, atherosclerosis.
Embolic - AF
Thrombotic - malignancy or haematological disorders.
Drugs - NSAIDs, chemo, statins, immunosuppressive drugs, diuretics etc.
Iatrogenic - AAA surgery, colonoscopy.
What are the symptoms of ischaemic colitis?
Diarrhoea Rectal bleeding Colicky abdominal pain Guarding on examination Symptoms come on in a few hours and continue to worsen.
What investigations would you carry out for ischaemic colitis?
CT within first few hours Colonoscopy within 48hrs. Clotting factor Haemoglobin level C reactive protein and neutrophil count may be raised.
What is the treatment for Ischaemic colitis?
IV fluids and general management.
Anticoagulation
Lifestyle changes e.g smoking cessation.
Drug monitoring - often patients are on medications for ischaemic heart disease which disrupt colonic BF.
What are the common causes of upper GI bleeding?
Peptic ulcer disease Acute erosions/gastritis Mallory-Weiss tears Varices Oesophagitis Cancer
What is the management plan for upper GI bleeding?
1- Resuscitate - head down, secure airway, bloods, cannulate.
2- Blood transfusion if still in shock.
3- IV terlipressin if variceal bleed and prophylactic antibiotics (ciptofloxacin).
4- Maintenance - correct coagulopathy, notify surgeons if severe.
5- Urgent endoscopy.
Use 2 methods to stop bleed if variceal.
6- Omeprazole IV, Nil by mouth of 24hrs, stop NSAIDs and steroids, daily bloods and H.pylori testing.
7 - Surgery.
What is jaundice?
Yellowing of the skin and sclera due to excess circulating bilirubin which is a byproduct of ahem metabolism.
At what level is jaundice detectable?
When total plasma bilirubin levels > 34umol/L
What are the different classifications of jaundice?
Pre-hepatic
Hepatic
Post -hepatic
What are the characteristics of Pre-hepatic jaundice?
Unconjugated - bilirubin is bound to albumin.
There is an increased quantity of bilirubin and impaired transport of it.
Patient will have history of anaemia and normal urine colour.
They will be pallor and have splenomegaly on examination.
What are the characteristics of hepatic jaundice?
Conjugated
Defective uptake, conjugation or excretion of bilirubin.
Will have risk factors for chronic liver disease e.g ascites, variceal bleeds, drug intake, spider naevi, gynaecomastia, asterixis (fine tremor).
What are the characteristics post-hepatic jaundice?
Conjugated Defective transport of bilirubin by biliary ducts. Abdominal pain Coloured urine Pruritus Pale stool Palpable gallbladder
What investigations would you carry out for jaundice?
Liver screen of blood:
- bilirubin levels
- hep B&C serology
- Autoantibody profile
- Serum immunoglobulins
- Ferritin and Transferritin saturation
- Alpha 1 anti trypsin
- Fasting glucose and lipid profile
Ultrasound of Abdomen.
What is Liver failure?
The loss of the liver’s ability to regenerate or repair itself. Decompensation occurs instead.
What are some causes of Liver failure?
Toxins - Alcohol, Paracetamol, Drug abuse etc.
Infections - Viral hepatitis, Epsen-Barr virus, Adenovirus etc.
Neoplastic - Hepatocellular carcinoma
Metabolic - Wilson’s disease, Alpha-1 antitrypsin deficiency
Vascular - Ischamia, Budd-Chiari syndrome
Other - Autoimmune liver disease, idiopathic.
How does liver failure present?
Hepatic encephalopathy
Abnormal bleeding
Ascites
Jaundice
What are the investigations for liver failure?
Liver function tests and blood cultures.
Ultrasound
CT
How is liver failure managed?
Usually within the ITU. Treat underlying cause. Good nutrition via NG tube Thiamine supplements Prophylactic PPIs Blood, glucose and fluid monitoring. Avoid opiates, oral hypoglycaemic, Na containing IVIs, hepatotoxic drugs e.g. paracetamol, methotrexate isoniazid, salicylates, tetracycline.
Liver transplant.
What is cirrhosis?
The scarring of liver tissue due to long term liver damage. Scarring prevents the liver working properly.
What are the causes of cirrhosis?
Chronic Alcoholism Chronic Hepatitis C and B virus. Non-alcoholic Fatty liver disease (NAFLD) Non-Alcoholic Steatohepatitis (NASH) Other - vascular, neoplasia, drugs etc.
What are the symptoms of cirrhosis?
Fatigue Lethargy Nausea Loss of appetite Loss of sex drive Haematemesis Itchy skin (pruritus) Melena Bruising Oedema Ascites
What are the signs of cirrhosis when examining the hands?
Finger clubbing Leuconychia (decreased albumin) Terry's nails (white proximally red distally) Palmar erythema Dupuytron's contracture
What are the signs of cirrhosis when examining the face?
Pallor
Xanthelasma
Parotid enlargement
What are the signs of cirrhosis when examining the trunk?
Spider naevi
Gynaecomastia
Loss of hair
What are the signs of cirrhosis when examining the abdomen?
Striae Hepatomegaly Splenomegaly Caput medusa Testicular atrophy
What investigations would you carry out for cirrhosis?
Bloods - FBC, LFTs, INR, albumin etc. Ultrasound CT Liver biopsy Endoscopy to look for varices which are a sign of cirrhosis. Ascitic tap.
What is the management for cirrhosis?
General - good nutrition, Baclofen to help with alcohol withdrawals, Colestyramine for pruritus.
Specific treatment depending on the cause, e.g. Interferon-alpha for HCV. Penicillamine for Wilson’s.
What is the management for decompensation?
Ascites - fluid and salt restriction, spironolactone, frusemide.
Coagulopathy - Vitamin K, platelets, FFP, blood.
Encephalopathy - Avoid sedatives, lactulose, rifaximin.
Sepsis - tazocin (avoid gentamicin).
Hepatorenal syndrome - IV albumin and terlipressin.
What is Portal hypertension?
Increased pressure within the portal vein as a consequence of chronic liver disease.
What are some causes of portal hypertension?
Pre-hepatic - Portal vein thrombosis.
Hepatic - cirrhosis, schistosomiasis, sarcoidosis.
Post-hepatic - Budd-chiari, Right Heart Failure, constrictive pericarditis, TR.
What is the sequelae (after-effect) of Portal Hypertension?
SAVE
S- Splenomegaly
A- Ascites
V- Varices
E- Encephalopathy
What is TIPSS?
Transjugular Intrahepatic Portal Systemic Shunt.
Shunt treatment method used to treat oesophageal varices and portal hypertension.
Metal tube is passed across liver to allow the blood in the portal vein to bypass the resistance of the liver and go straight to the hepatic vein.
What is a complication of TIPSS?
Encephalopathy - toxins bypass liver and can effect the electrical activity of the brain.
How is portal hypertension measured?
Hepatic Venous Pressure Gradient (HVPG).
Normal HVPG values are <5mmHg.
HVPG >10mmHg predicts oesophageal varices.
What is the treatment for Portal Hypertension?
Need to treat underlying cause and manage consequences.
Non-Selective beta -blockers e.g carvedilol
Nitrates
Vasoactive drugs e.g Terlipressin, octreotide.
What GI conditions can alcoholism cause?
Fatty liver - hepatitis - cirrhosis. Gastritis Peptic ulcer disease Varices Pancreatitis Carcinoma
What key questions do you ask someone you suspect is an alcoholic?
CAGE
C - Cut down?
A - Annoyed at criticism from other people?
G- Guilty about drinking?
E- Eye opener need in the morning?
What are the signs of withdrawal?
Signs may occur 10-72hrs after last drink. Increased heart rate Decreased blood pressure Tremor Confusion Fits Hallucinations
What is the treatment for withdrawals?
Tapering regimen of chlordiazepoxide and lorazepam.
Thiamine.
Group therapy and sell-help (AA).
Baclofen / Acamprosate to decrease cravings.
What FAST score indicates a FAST positive?
> or = 3.
Need to continue onto an AUDIT score.
What are the values of an AUDIT score that indicate concern?
8-15 = increasing risk of dependency 16-9 = high risk of dependency 20+ = possible dependence.
What is hepatic encephalopathy?
Altered brain function and consciousness due to chronic liver failure.
How does hepatic encephalopathy occur?
1- Various precipitants cause a decrease in metabolic function of the liver.
2- Diversion of toxins into the systemic system.
3- Ammonia accumulates and passes into the brain.
4- Astrocytes clear ammonia by converting glutamate into glutamine.
5- Increased levels of glutamine lead to osmotic imbalance which in turn causes cerebral oedema.
How is Hepatic encephalopathy graded?
Grade 1 = Mild confusion with irritability and sleep inversion.
Grade 2 = Drowiness with disorientation, slurred speech and tremor.
Grade 3 = Stupor - rousable but incoherent.
Grade 4 = Coma - unrousable +/- extensor plantar reflex.
What are causes of Hepatic Encephalopathy?
HEPATICS
H - Haemorrhage E- Electrolytes (decreased K/Na). P - Poisons (sedatives, diuretics, anaesthetics) A - Alcohol T - Tumour (HCC) I - Infection (SBP, UTI, Pneumonia, HDV) C - Constipation S - sugar (glucose)
What is the treatment for Hepatic Encephalopathy?
Correct any causes
Lactulose
Phosphate enemas
Rifaximin - to kill intestinal microflora.
What is Alcoholic Hepatitis?
Inflammation of the liver caused by excessive consumption of alcohol.
What are the investigations for alcoholic hepatitis?
Bilirubin - raised Gamma Glutamyl transferase - raised AST:ALT ratio >2 Alcohol history Ascitic tap Abdominal ultrasound
What is the treatment for Alcoholic hepatitis?
Stop alcohol and treat withdrawals.
Thiamine - improves neuro function.
Steroids if very severe - don’t use in milder cases as they can cause GI bleeding/infection.
Frequent feeds - patients often malnourished.
What is Non-Alcoholic Fatty Liver Disease (NAFLD)?
Umbrella term that covers simple steatosis (fatty liver) , NASH (Non-Alcoholic Steatohepatitis) and Cirrhosis.
Not caused by alcohol.
Very similar presentation.
What is NAFLD associated with?
Diabetes mellitus
Obesity
Hypertriglyceridaemia
Hypertension
What are some risk factors for NAFLD?
Ethnicity - more common in hispanics.
Increasing Age
Genetics - PNPLA3 gene
What is Hereditary Haemochromatosis (HHC)?
Autosomal recessive disorders related to the deficiency of iron regulatory hormone Hepcidin. Results in increased intestinal reabsorption of iron which leads to iron accumulation in tissues, esp. Liver.
What are the clinical features of HHC?
Iron MEALS
M - Myocardium - Dilated cardiomyopathy, arrhythmias.
E - Endocrine - DM, hypogonadism, hypocalcaemia, osteoporosis.
A - Arthritis
L - Liver - chronic liver disease - cirrhosis.
S- Skin - slate grey discolouration.
What investigations would you carry out for HHC?
Serum Ferritin LFTs Liver biopsy MRI - pearl's staining Gene testing ECG/ECHO - for heart complications. X-ray
What is the treatment for HHC?
Phlebotomy - frequent blood removal to reduce iron levels.
Chelation - medication to lower iron content if taking blood regularly is an issue.
Liver transplant in severe cirrhosis cases.
Avoid iron/vitaminC supplements/supplemented foods e.g cereals.
What is Alpha-1-Antitrypsin (A1AT)?
Glycoprotein largely produced in the liver. It helps to control the inflammatory response by inhibiting neutrophil elastase.
What happens when there is a deficiency in A1AT?
Elastase can breakdown elastin unchecked. This means in the lung there is destruction of alveolar cells and emphysematous damage.
The conformational change which causes this deficiency means that A1AT is trapped within the liver cells which can lead to liver damage - cirrhosis.
What are the symptoms for A1AT deficiency?
Cough Wheeze Dyspnoea Emphysema Liver failure signs at late stage.
What investigations would you carry out for A1AT deficiency?
Serum A1AT
LFTs
CXR
CT
What is the treatment for A1AT deficiency?
Mostly supportive of pulmonary and hepatic complications.
Quit smoking
Consider A1AT therapy from pooled donors.
What is Wilson’s disease?
Autosomal recessive genetic disorder that causes the build up of copper within the body.
Overload of copper can lead to liver damage as well as brain, kidney and cornea damage.
ATP7B gene mutation.
What are the liver symptoms for Wilson’s disease?
Jaundice Nausea Vomiting Abdominal pain Cirrhosis
What are the investigations for Wilson’s disease?
Bloods - Caeruloplasmin, Copper levels
24hr urinary copper.
Liver biopsy
MRI
What is the treatment for Wilson’s disease?
Diet - avoid foods high in copper e.g. chocolate, liver, nuts.
Penicillamine - removes copper via urine. Life long treatment.
Trientine is an alternative to Penicillamine.
Zinc - blocks copper from being absorbed, has less side effects than Penicillamine.
What is Autoimmune hepatitis?
Inflammatory disease in which the antibodies and WBCs attack the hepatocyte surface antigens.
Idiopathic.
Predominantly young/middle aged women.
What are the symptoms of Autoimmune hepatitis?
Fatigue Malaise Fever Nausea Joint/muscle pain Abdominal pain Jaundice.
What are some examples of diseases that are associated with autoimmune hepatitis?
Diabetes mellitus Primary sclerosis cholangitis (PSC) Glomerular nephritis (GN) Pernicious anaemia Ulcerative colitis (UC) Autoimmune thyroiditis.
What investigations would you carry out for Autoimmune hepatitis?
LFTs IgG levels Autoimmune antibodies Blood count Liver biopsy Ultrasound.
What is the treatment for Autoimmune hepatitis?
Immunosuppression - Prednisolone.
Azathioprine (steroid spacer usually used alongside prednisolone)
Avoid alcohol.
Liver transplant if severe.
What is Primary Biliary Cholangitis/Cirrhosis?
Intrahepatic destruction of bile ducts by chronic granulomatous inflammation. Progressively gets worse and eventually leads to cirrhosis.
What are the symptoms of Primary biliary cholangitis?
Can be asymptomatic Pruritus Pigmentation of face Bone/joint aches Big organs - heaptosplenomegaly. Coagulopathy Cholesterol levels increased. Steatorrhoea Late presentation of jaundice.
What are the investigations for Primary Biliary Cholangitis?
LFTs Antibodies IgM Cholesterol Thyroid hormones (hypothyroidism associated disease) Ultrasound Liver biopsy
What is the treatment for primary biliary cholangitis?
Symptomatic:
Pruritus - colestyramine, naltrexone.
Diarrhoea - codeine phosphate.
Osteoporosis - Bisphosphonates.
Specific:
ADEK vitamins
Ursodeoxycholic acid - delay liver damage.
Liver transplant.
What is Primary Sclerosing Cholangitis?
Intra AND extra hepatic bile duct decrease in size due to inflammation and fibrosis.
Leads to cirrhosis and liver failure.
M>F 2:1
What other diseases are associated with Primary Sclerosing Cholangitis?
IBD - especially UC.
Hepatobiliary malignancies
Colorectal cancer.
What are the symptoms of Primary Sclerosing Cholangitis?
Asymptomatic Jaundice Pruritus Fatigue Upper right quadrant abdominal pain. Hepatosplenomegaly.
What investigations would you carry out for Primary Sclerosing Cholangitis?
LFTs - ALP is usually raised first.
Antibodies - pANCA
ERCP/MRCP
Liver biopsy.
What is the treatment for Primary Sclerosing Cholangitis?
No curative therapy so transplant will be needed.
Symptomatic;
Pruritus - colestyramine, naltrexone
Diarrhoea - codeine phosphate.
Specific: ADEK vitamins Antibiotics for cholangitis Endoscopic stenting Ursodeoxycholic acid.
What are the different antibodies involved in the different types of autoimmune hepatitis?
Type 1 = ANA, SMA.
Type 2 = LKM1
Type 3 = SLA
What is Hepatocellular Carcinoma (HCC)?
Primary liver tumour usually in patients with existing Cirrhosis and liver failure.
Common in sub-Saharan Africa and Asia.
M>F
What are the symptoms of HCC?
Pruritus Hepatosplenomegaly Weight loss Oesophageal varices Jaundice Hepatic encephalopathy Ascites Right Upper quadrant pain.
What are the investigations for HCC?
Ultrasound Alpha-fetoprotein (AFP) CT Fine needle aspiration/biopsy LFTs.
What is the treatment for HCC?
Resection of solitary tumours. Chemotherapy. Percutaneous ablation therapy. Embolisation. Symptomatic treatment.
What is Cholangiocarcinoma?
Carcinomas anywhere within the biliary tree.
What are some causes of Cholangiocarcinoma?
Flukes - live in liver and feed on bile.
Primary Sclerosing Cholangitis.
Congenital Biliary Cysts.
Ulcerative Colitis.
What are the symptoms of Cholangiocarcinoma?
Fever Malaise RUQ abdo pain Weight loss Steatorrhoea Ascites Jaundice
What investigations would you carry out for Cholangiocarcinoma?
LFTs - raised bilirubin/ALP. CT/MRI Biopsy Fine-needle aspiration. ERCP/MRCP.
TNM staging.
What is the treatment for cholangiocarcinoma?
Palliative stenting
Resection (30% cases)
Chemo/radiotherapy.
What is the first line treatment for ulcerative colitis?
5ASAs (aminosalicylates).
Work to reduce inflammation.
e.g. Mesalazine
Balsalazide
Olzalazine
Sulfasalazine
What is the first line treatment for Crohn’s disease?
Budesonide if ileocaecal
Sulfasalazine if colitis
What is the second line treatment for both Ulcerative colitis and Crohn’s disease?
Prednisolone - 40mg per day is optimal dose.
What are add on medications that help with Ulcerative colitis and Crohn’s disease?
Thiopurines - immunosuppressive drugs e.g Azathioprine, used as steroid spacers.
Methotrexate - immunosuppressant used only in Crohn’s. Maintains remission.
Biologics - anti-TNFalpha antibodies e.g Infliximab, Adulimumab. Alpha 4b7 intern blockers e.g Vedolizumab.
Antibiotics - metronidazole for Crohn’s perianal disease or small bowel bacterial overgrowth.
What are the surgical options for ulcerative colitis and Crohn’s disease?
UC - total colectomy, ileostomy and rectal preservation. Pouch surgery.
CD - Want to take away as little as possible.
What is Coeliac Disease?
Common digestive condition where the small intestine becomes inflamed and can’t absorb nutrients. Adverse reaction to gluten- a dietary protein found in wheat, barley and rye. Autoimmune.
What are the symptoms of Coeliac disease?
Diarrhoea Foul smelling faeces Abdominal pain Bloating Flatulence Indigestion Constipation Dermatitis herpetiformis Problems getting pregnant Ataxia.
What is the pathology of coeliacs disease?
Immune system mistakes substances within gluten as a threat and attacks them - damages surface of intestine - reduced absorption.
What investigations would you carry out for Coeliacs disease?
Bloods - autoimmune antibodies, anaemia Endoscopy Biopsy MRI DXA scan of bones Genes (HLA-DQ2/DQ8)
What are some conditions associated with coeliacs?
Type 1 diabetes Down's syndrome Close relatives with coeliacs Turner's syndrome Autoimmune conditions
What is the treatment for Coeliac’s disease?
Gluten-free diet for life.
Vitamin supplements for 6 months to replace deficiency.
