Hepatology Extras Flashcards
What is the definition of binge drinking?
this refers to drinking lots of alcohol in a short space of time
in the UK this is more than 8 units in a single session for men
and more than 6 units in a single session for women
What is the definition of a pack year?
one pack year is equivalent of smoking 20 cigarettes a day for 1 year
( number of cigarettes smoked per day / 20 ) x number of years smoked = number of pack years
e.g. smokes 40 cigarettes a day for 30 years
(40/20) = 2
2 x 30 = 60 pack year history
How do you calculate pack years when someone smokes tobacco?
- 25 grams (1 ounce) is equivalent to 50 cigarettes
- ask the patient how many ounces they smoke per week
- e.g. 1 oz per week is 50 cigarettes, divided by 7 is about 7 cigarettes per day
- e.g. 2 oz per week is 100 cigarettes, divided by 7 is about 14 cigarettes per day
What are the symptoms of gastrointestinal bleeding?
- vomiting blood
- blood in the stool
- small amounts of bleeding over a long time can cause iron-deficiency anaemia
- this leads to feeling tired or heart-related chest pain
- abdominal pain
- shortness of breath
- pale skin
- syncope (fainting)
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What are the most common causes of upper GI bleeding?
- peptic ulcer disease
- oesophageal varices due to liver cirrhosis & cancer
What are the most common causes of lower GI bleeds?
- haemorrhoids
- cancer
- inflammatory bowel disease
What is the boundary that determines whether a GI bleed is upper or lower?
How are the symptoms different?
the ligament of Treitz
- bright red blood in the stool indicates lower GI bleeding
- digested blood from the upper GI tract appears black/brown rather than red
this produces “coffee ground” vomit or melena
What is melena?
melena refers to black, tarry stools that are usually the result of upper GI bleeding
they tend to have an offensive smell and be difficult to flush
this is due to alteration and degradation of the blood by intestinal enzymes
What is the defintion of an upper GI bleed?
What are the 2 main symptoms associated with this?
upper GI bleeding is from a source between the pharynx and the ligament of Treitz
it is characterised by haematemesis (vomiting of blood)
and melena (tarry stools containing altered blood)
What medications are associated with causing upper GI bleeds?
- NSAIDs or COX-2 inhibitors increase the risk about fourfold
- SSRIs
- corticosteroids
- anticoagulants, such as dabigatran and warfarin
What is the definition of lower GI bleeding and what symptoms does it typically present with?
this is bleeding below the ligament of Treitz, typically from the colon, rectum or anus
this usually presents with the passage of fresh red blood rectally, especially in the absence of bloody vomiting
What is the definition of postural hypotension?
a condition in which a person’s blood pressure drops abnormally when they stand up after sitting or lying down
this can lead to dizziness, light-headedness, fainting and possible falls
also called orthostatic hypotension
By how much must someone’s blood pressure have to drop in order for them to be diagnosed with postural hypotension?
- there must be a fall in systolic blood pressure of at least 20 mmHg
- OR a fall in diastolic blood pressure of at least 10 mmHg
Why does postural hypotension occur?
- there is delayed (or absent) constriction of lower body blood vessels
- this is normally required to maintain adequate blood pressure when standing
- blood pools in the blood vessels of the legs for a longer period and less is returned to the heart
- this leads to reduced cardiac output and inadequate blood flow to the brain
What are the immediate signs of massive blood loss?
How is massive blood loss defined?
the immediate signs of massive blood loss include tachycardia, pallor and hypotension
this is defined as losing at least 750mls of blood
What are the 4 stages of blood loss according to the volume status assessment?
What symptoms would be present at each stage?
Stage I:
- 10 - 15% of volume is lost (750mls)
- there are no signs
Stage II:
- 15 - 30% of volume is lost (1.5L)
- there is postural hypotension and general vasoconstriction
Stage III:
- 30 - 40% of volume is lost (2L)
- there is hypotension, tachycardia and tachypnoea
Stage IV:
- there is > 40% volume loss
- all symptoms as above but patient may also be comatose
What is the difference between cholelithiasis and choledocholithiasis?
Cholelithiasis:
- this is the formation of gallstones
- there is a gallstone in the gallbladder but it is not causing an obstruction
Choledocholithiasis:
- this refers to the presence of gallstones in the common bile duct
- the gallstone begins obstructing the common bile duct, causing symptoms
What is the difference between cholangitis and cholecystitis?
Cholangitis:
- this is inflammation of the gallbladder and biliary system (bile duct system)
Cholecystitis:
- this is inflammation of the gallbladder
What is the classical triad of symptoms associated with cholangitis?
- fever
- jaundice
- right upper quadrant pain
What is ideal blood pressure and what is determined to be high blood pressure?
- ideal blood pressure is considered to be between 90/60 mmHg and 120/80 mmHg
- high blood pressure is considered to be 140/90 mmHg or higher
- a reading between 120/80mmHg and 140/90mmHg means the patient is at risk of developing high blood pressure if they do not take steps to keep it under control
If someone has a high blood pressure reading at the GP, what is usually recommended to them to find out whether they have high blood pressure?
ambulatory (24-hour) blood pressure monitoring
- having raised BP in 1 test does not necessarily mean someone has high BP
- the 24-hour monitor will check the blood pressure throughout the day to determine whether blood pressure is consistently high
What is the main difference between a lower respiratory tract infection and pneumonia?
- pneumonia is a radiological diagnosis
there must be consolidation present on chest X-ray in the right clinical context
- it is a LRTI if the patient has all the right symptoms, but there is no evidence of consolidation on CXR
What are the 9 main causes of chronic liver disease?
- chronic alcohol abuse
- hepatitis b
- hepatitis c
- non-alcoholic fatty liver disease
- autoimmune hepatitis
- other autoimmune conditions
- primary biliary cholangitis
- primary sclerosing cholangitis
- haemochromatosis
- Wilson’s disease
- a1-antitrypsin deficiency
What are the clinical signs of chronic liver disease?
- jaundice
- palmar erythema
- hepatic flap (asterixis)
- ascites
- leukonychia
- Keyser-Fleisher rings under slit-lamp
- spider naevi
- Dupuytren’s contracture
- gynaecomastia
- caput medusae
- testicular atrophy
- loss of pubic hair / axillary hair
- pedal oedema (not specific to liver disease)
What is meant by microcytic anaemia?
the presence of small, often hypochromic, red blood cells
it is usually characterised by a low MCV
when the MCV is <80 fL, the red cells are described as microcytic
the MCV is the average red blood cell size
What is macrocytic anaemia?
this occurs when there are abnormally large red blood cells
the MCV is >100
What is the aetiology of iron deficiency anaemia?
-
blood loss
- GI bleeding (peptic ulcer, diverticulitis)
- menorrhagia
- poor diet
- malabsorption
What are the clinical features of iron deficiency anaemia?
- brittle hair and nails
- atrophic glossitis
- angular stomatitis
- koilonychia
What is involved in the investigations for iron deficiency anaemia?
- there will be reduced Hb and MCV
- there will be reduced ferritin
- there will be reduced serum iron
- there will be an increase in TIBC
What is TIBC and what does it measure?
total iron binding capacity
this is a test that measures the blood’s capacity to bind iron with transferrin
transferrin can bind iron with high affinity to transport it in the blood
Why is TIBC raised in iron-deficiency anaemia?
- the concentration of iron in the blood is low
- transferrin and TIBC is high as the liver produces more transferrin
it does this to try at maximise the use of the little iron that is present
- percentage transferrin saturation is low as there is insufficient iron
What is involved in the management of iron deficiency anaemia?
- treat the underlying cause
-
oral iron in the form of ferrous sulphate
- this causes constipation as a side effect
What diseases are associated with anaemia of chronic disease?
- infection
- vascular disease
- rheumatoid arthritis
- malignancy
- renal failure
- chronic inflammatory disease (e.g. Crohn’s)
- tuberculosis
- endocarditis
What is the aetiology involved in anaemia of chronic disease?
- all conditions associated with it produce elevation of interleukin-6
- this stimulates hepcidin production and release from the liver
- this shuts down ferroportin, a protein that controls export of iron from the gut and from iron-storing cells (e.g. macrophages)
- circulating iron levels are reduced
What type of anaemia is present in anaemia of chronic disease?
it is usually normocytic and normochromic
it can also be microcytic
What will investigations show in anaemia of chronic disease?
- reduced serum iron levels
- reduced serum iron binding capacity
- raised or normal serum ferritin
What is the treatment for anaemia of chronic disease?
- treat the underlying cause
- if it is due to renal failure, then anaemia is partly due to erythropoietin deficiency
recombinant erythropoietin is useful
