GIT/Liver (non surgical) Flashcards
Which is the most specific LFT test?
ALT
ALT> AST is most commonly related to liver disease NOT caused by alcohol
Also raised with biliary disease
If cirrhosis develops then AST > ALT
AST is present in liver, muscle, RBC, kidney, and heart.
-AST: ALT of > 2 suggests alcohol related liver causes
-AST: ALT > 5 suggests extrahepatic causes: rhabdo, MI
ALP is also present in the bone, (also WBC, small bone)
Causes for raised ALP and raised GGT?
ALP
-Mainly biliary pathology
-Also hepatocellular pathology
-High bone turnover: pagets disease, disease of bone, bony metastasis, hyperparathyroidism, hyperthyroidism)
-Normal pregnancy
GGT
- biliary disease
-any hepatocellular disease
-alcohol abuse
basically if GGT is not raised a single high ALP would indicate a bone issue
If GGT is raised alone, then alcohol abuse.
What investigations might you order for chronic diarrhoea?
Stool Cultures are expensive and unnecessary for every case of diarrhoea.
When should you consider ordering it?
Systemically unwell
* Fever over 38.5
* Duration > 3-4 days
* Severe diarrhoea leading to dehydration
* Blood or pus in stool
* Immunocompromised
Positive Exposure History e.g. recent overseas travel
High Transmission Risk e.g. child care attendance
What is the ROME 3 criterea?
It is to diagnose IBS
Abdominal pain or discomfort for at least 3 days of the month for at least 3 months and it is associated with at least 2 of the following
- Pain relieved with defecation
- Symptom onset occurs with change in bowel habits
- Onset with a change in stool appearance (loose, pellets, watery)
Initial investigations for IBS?
Since it is a diagnosis of exclusion you’ll need to exclude other pathology.
- EUC
- FBC
- Coeliac serology
- LFTs
- Faecal calprotectin
- CRP/ESR
- Stool MCS
- Consider Hydrogen breath testing for lactose intolerance , though might try elimination from the diet alone first. If doing this test it needs specific instruction.
After initial investigations for IBS, including possible hydrogen breathe testing, what can you suggest to a patient with IBS in terms of trialing elimination from the diet.
What can be eliminated?
- Fatty foods
- Caffiene
- Alcohol
- Fibres
- lactose
- Carbonated drinks
- Wheat/gluten
Fibre is an important dietary step in managing IBS as well as constipation, what is the recommended amount and what type of fibre is best?
Males 30grams/day
Females 25grams/day
Ideally you want SOLUBLE slowly fermented fibre such as psyllium husk and oats.
Also Insoluble - not fermented things like vegetable and fruit skins, nuts.
Plan
Start by gradually increasing fibre from fruit and vegetables, SLOWLY.
AVOID insoluble fibre that is SLOWLY fermented like wheat bran
Trial soluble fibre that is slowly fermented like psyllium (in metamucil)
Ensure adequate hydration
What medical options can be used for abdominal pain related to IBS?
(4)
peppermint oil 0.2ml/capsule. taking 1-2 capsules 30 minutes before food
Hyoscine Butylbromide (buscopan) 20mg, orally, When needed.Max 80mg / day
Mevebeverine 135mg PO PRN up to TDS (similar to buscopan, but not an antimuscuranic)
Herbal Iberogast can be used for mild abdominal pain
Options for treating the psychological component to IBS?
- CBT
- TCAs
Amitriptyline 5-10mg, PO, nocte - SSRIs
Citalopram 20mg, oral, daily
What drugs/oral supplements can cause constipation?
(6)
Opioids
Anticholinergic effects (oxybutynin, clozapine, olanzapine, TCAs, risperidone, quetiapine)
5-HT3 R antagonists (ondansetron)
Oral calcium supplements
Oral Iron supplements
Verapamil
In order of preference what tests are done for H.pylori?
- c13/14 breath test
- Faecal test
- Serology (too many false positives and false negatives)
Should people be screened for H.Pylori?
It is worthwhile in selected individuals
Eg.
Lower SES
Family members of someone with Gastric cancer
Older persons
Institutionalised persons
What does the patient need to know before a breath or fecal h.pylori test?
Before a breath or faecal antigen test, antibiotic therapy should not be taken for at least 4 weeks, and PPI therapy should be withheld for at least 1 week (and preferably 2 weeks), to minimise the chance of false-negative results
What are the two most common causes of peptic ulcers?
H.pylori
NSAIDs
What are red flag features of epigastric pain?
Signs of GI bleeding or anaemia
Weight loss
Vomiting
progression of symptoms
Dysphagia
Over 55
Fx of Gastric Carcinoma
Previous gastric surgery
What investigations can be useful for investigation of epigastric pain?
IF there are NO alarm symptoms.
Bloods
LFTs for biliary and liver causes - if concerned may need further viral hepatitis bloods or serum AFP. Abdominal U/S should help
Lipase/amylase. Can start with a U/S but will likely need a CT if these are raised
FBC/EUC
Breathe test - rule out H.Pylori
Ultrasound: can suggest pancreatitis, biliary disease, can usually visualize an aortic aneurysm
ECG- cardiac (if suspected)
CXR- if suspecting lower lobe pneumonia or pleurisy
What is triple therapy for H.pylori treatment?
Clarithromycin 500mg, orally, 12 hourly for 7 days
PLUS
Esomeprazole 20mg, orally, 12 hourly for 7 days
PLUS
Amoxicillin 1g, orally, 12 hourly for 7 days
What specifically needs to be done after finishing eradication therapy for H.pylori ?
Breath test 4 weeks after completion of antibiotics. And withholding PPI for at least 7 days (if not 2 weeks) prior to the test.
DO NOT use serology to confirm treatment response as antibodies will be positive for it only tests IgG
What is needed to diagnose a first episode of diverticulitis?
CT abdomen with contrast
What is the main aspects of management for UNCOMPLICATED diverticulitis?
(6)
Technically uncomplicated diverticulitis is Diverticulitis without perforation, peritonitis, sepsis or septic shock, or an abscess larger than 5 cm in diameter.
- no need for imaging if there has been a previous diagnosis
- Judicious use of antibiotics
- Low fibre until resolved
- Analgesia
- bed rest with a clear liquid diet
- Follow up with safety netting
What are signs on examination that would alert you to complicated diverticulitis?
(4)
High fever
Severe or worsening abdominal pain
Signs of peritonitis
Vomiting
In uncomplicated diverticulitis, severe disease is differentiated from moderate disease by evidence of systemic infection, peritonitis, inability to tolerate oral intake or failure of outpatient management. Other signs of severe disease include persistent fever or leukocytosis, or worsening pain after two to three days.
What is the antibiotic treatment if deemed necssary?
amoxicillin+clavulanate 875+125 mg orally, 12-hourly for 5 days
uncomplicated diverticulitis does not need antibiotics.
What 3 features might make you think to prescribe an antibiotic?
Persistent pain >72 hours
Right sided pain
Immunocomproise
What is the mainstay of management for long term diverticular disease?
(5)
- Adequate fibre
- Adequate hydration
- Knowing how to manage constipation
- Education including lack of evidence for avoiding corn and seeds
- when to seek care if there is an exacerbation
For patients with a confirmed history of diverticulitis, and mild symptoms typical of recurrence, what investigation is needed?
(1)
none
if it is a first episode, or a severe episode (peritonitic symptoms, fever, worsening pain) then you need a CT abdo to either diagnose diverticular disease/itis or complicated diverticulitis respectively. But in the case of mild recurrence that is typical of previous episodes and a known diverticular disease a repeat scan is not indicated.
Lifestyle advice for the management of GORD?
(7)
Weight loss. Can improve symptoms in most people
Recommend diet changes to avoid foods that exacerbate symptoms: spice, coffee, chocolate, citrus fruits, tomato, high fat meals, alcohol and carbonated beverages.
Eat smaller meals
Drink fluid between meals rather than with
Avoid eating 2-3 hours before bed or before exercise
Stop smoking!
Elevate the head at night
Red flag features when evaluating GORD? Or features that would warrant an endoscopy?
alarm symptoms
-anaemia
-dysphagia (difficulty swallowing) or odynophagia (painful swallowing)
-haematemesis and/or melaena
-vomiting
-weight loss
new symptoms in an older person (>50)
changing symptoms
severe or frequent symptoms
inadequate response to treatment
diagnostic clarification of symptoms
Treatment (medical) options for MILD and intermittent GORD?
PRN antacid plus alignate preparation 10-20ml or magnesium hydroxide plus aluminium hydroxide preparation 10 to 20 mL orally, as required.
H2 receptor blocker e.g: ranitidine 150mg PO once or twice daily PRN
PRN PPI can be used but unsure how effective it is . If so then dose it 60 minutes before a meal.
For severe or persistent GORD symptoms, what medication can you start?
PPI
Specifically
Pantoprazole 40mg, oral, daily
or
Esomeprazole 20mg, oral, daily
What is pernicious anaemia and what causes it?
Lack of absorbing B12
Due to an autoimmune process that reduces the amount of intrinsic factor (IF). IF is needed to absorb B12 from the stomach
Causes for UNconjugated hyperbilirubemia?
Gilberts Disease
Haemolysis
Drug toxicity (rifamicipin, probenacid)
Extra hepatic causes of conjugated hyperbilirubemia?
(7)
Intrinsic to the ductal system:
-Gallstones
-Surgical strictures
-Infection (cytomegalovirus, Cryptosporidium infection in patients with acquired immunodeficiency syndrome)
-Intrahepatic malignancy
-Cholangiocarcinoma
Extrinsic to the ductal system:
-Extrahepatic malignancy (pancreas, lymphoma)
-Pancreatitis
Intrahepatic causes of conjugated hyperbilirubemia?
(12) - at least name the first 3.
Likelihood is that you’ll be aware of intrahepatic injury by looking at transaminases.
Hepatocellular disease:
1. Viral infections (hepatitis A, B, and C)
2. Chronic alcohol use
3. Autoimmune disorders
Drugs
Pregnancy
Parenteral nutrition
Sarcoidosis
Dubin-Johnson syndrome
Rotor’s syndrome
Primary biliary cirrhosis
Primary sclerosing cholangitis
