HPB Flashcards
ALT/ALP ratio of less than 2 suggests what pattern of liver injury?
Cholestatic
ALT/ALP ratio of more than 5 suggests what pattern of liver injury?
Hepatocellular
Bile is produced by which cells?
Hepatocytes
What cells are responsible for recycling haemoglobin?
Kupffer cells
What cells store vitamin A?
Stellate cells
What is the function of GGT?
Transport of amino acids and peptides to the liver
ALP is found mainly in the cells lining what structure?
Bile duct
What are the four most common causes of liver cirrhosis?
Alcohol related liver disease- non-alcoholic fatty liver, hepatitis B, hepatitis C
High levels of ammonia can cause what serious condition?
Hepatic encephalopathy
Why is the RAAS system activated in liver failure?
Cirrhosis causes resistance in blood flow of the liver. Increased portal hypertension. Arterial vasodilation to compensate for poor perfusion, triggering the RAAS system.
Deficiency in what ion can increase the risk of decompensation in liver failure and why?
Sodium, it’s how the astrocytes compensate for excess glutamine.
Where is IgA mainly found?
Mucosal cells lining the lungs and GI tract
Which hepatitis viruses are transmitted via faecal-oral route?
A and E
Which hepatitis viruses are transmitted via blood and semen?
B and C
Which hepatitis virus is most concerning for a mother-baby transmission during childbirth?
B
Which hepatitis virus can be transmitted through undercooked pork meat?
E
Reduced plasma protein binding, caused by hypalbuminaemia, has what effect on drug pharmacokinetics?
Increased gradient, free-drug movement into tissues, increased Vd, reduced plasma concentration.
First pass metabolism may be decreased in liver cirrhosis, what affect does this have?
Bypasses functional liver cells, less first-pass effect on oral drugs, increased bioavailability.
What mainly affects the clearance rate of drugs with a high extraction ratio, such as propranolol?
Blood flow
Morphine is a flow limited drug. Decreased hepatic blood flow, caused by cirrhosis, results in what bioavailability of this drug?
Increased bioavailability due to reduced hepatic clearance.
Drugs with a low extraction ratio are also called what? What limits the metabolism in these drugs?
Capacity limited drugs.
Protein binding and intrinsic clearance.
Hepatobiliary cycling may be reduced in what pathology?
Biliary obstruction
How does N-acetylcysteine prevent liver damage in paracetamol overdose?
Replenishes availability of glutathione which reacts with reactive metabolite of paracetamol to form an inactive metabolite that can be excreted in the urine.
Describe the structure of haem
Molecule consisting of single inorganic Fe ion bound to by 4 pyrrole rings.
Haem has what four chains?
2 alpha and 2 beta chains
What does the lower oesophageal sphincter (LOS) prevent in normal conditions?
It prevents significant acid reflux into the oesophagus.
What other antireflux mechanisms are involved in preventing acid reflux into the oesophagus?
The intraabdominal section of the oesophagus, diaphragmatic crura, and folds of gastric mucosa.
What happens in gastro-oesophageal reflux disease (GORD)?
These antireflux mechanisms fail, allowing acid reflux into the oesophagus.
Why might the presentation of GORD be difficult to distinguish from angina?
GORD can include nonspecific ECG changes, and atypical symptoms such as nocturnal asthma or laryngeal discomfort.
What can severe oesophagitis in GORD lead to?
Occult and/or overt gastrointestinal bleeding and iron-deficiency anaemia.
When is endoscopy indicated in patients with GORD?
In those older than 55, with symptoms lasting more than 4 weeks, dysphagia, abdominal mass, weight loss, or persistent symptoms despite testing and treatment.
How long should antacid treatment be stopped before endoscopy in suspected GORD?
At least 2 weeks.
What lifestyle modifications are recommended in the management of GORD?
Avoid precipitating dietary factors, eat smaller meals, raise the head of the bed, avoid eating 3-4 hours before bed, encourage weight loss, smoking cessation, reduce stress, and avoid drugs that reduce lower oesophageal sphincter pressure.
What is the first-line treatment for GORD?
Lifestyle modifications and full-dose proton pump inhibitor (PPI) therapy for 4 weeks.
What medications are considered for patients with nocturnal symptoms of GORD?
Histamine (H2)-receptor antagonists, such as famotidine.
What is the treatment for patients with a positive H. pylori test?
A 7-day course of PPI and amoxicillin with clarithromycin or metronidazole.
When is surgery considered in GORD management?
Rarely, only if symptoms are severe despite maximum medical management and evidence of active acid reflux during symptomatic episodes.
What is a benign oesophageal stricture and how is it managed?
It is a narrowing of the oesophagus that occurs in older patients, causing intermittent dysphagia. It is managed with endoscopic dilation.
What is a hiatus hernia?
The herniation of part of the stomach into the chest cavity, often associated with acid reflux.
What are the two types of hiatus hernia?
Sliding hiatus hernia and rolling (paraoesophageal) hiatus hernia.
What is a sliding hiatus hernia?
The gastro-oesophageal junction slides through the oesophageal hiatus into the thorax, accounting for 80% of hiatus hernias.
What is a rolling (paraoesophageal) hiatus hernia?
Part of the stomach rolls into the chest next to the oesophagus while the lower oesophageal sphincter remains below the diaphragm. This can lead to gastric volvulus.
What is Barrett’s oesophagus?
Intestinal metaplasia from squamous to columnar epithelium following long-standing acid reflux, which is premalignant for oesophageal adenocarcinoma.
What is eosinophilic oesophagitis?
A hypersensitive inflammatory condition of the oesophagus, often associated with allergies.
What are the main treatments for eosinophilic oesophagitis?
Allergy testing, allergen avoidance, swallowed liquid cortisone, and possibly PPIs.
What are oesophageal motility disorders?
Conditions that affect the movement of the oesophagus, causing symptoms like dysphagia and pain.
What is achalasia?
A condition where there is failure of relaxation of the distal oesophagus due to neuromuscular problems, causing progressive dilatation and incoordination of peristalsis.
How is achalasia diagnosed?
Diagnosis is made with a barium swallow, endoscopy, and oesophageal manometry.
What are the treatment options for achalasia?
Botulinum toxin, endoscopic balloon dilatation, or surgery (Heller cardiomyotomy).
What is oesophageal cancer commonly associated with?
Heavy drinking, smoking, and certain predisposing conditions like Plummer-Vinson syndrome and achalasia.
What are the common types of oesophageal cancer?
Squamous cell carcinoma (more common in the upper/mid oesophagus) and adenocarcinoma (typically arises in columnar epithelium of the lower oesophagus).
What is the general prognosis for oesophageal cancer?
The 5-year survival rate is poor, especially in advanced stages (around 4%).
What diagnostic methods are used for oesophageal cancer?
Endoscopy with biopsy, barium swallow, CT/MRI scanning, and staging laparoscopy.
What is the treatment for oesophageal cancer?
Surgery (gastrectomy), chemotherapy, radiotherapy, and palliative care. Surgery is the only curative option.
What are the main causes of peptic ulcer disease?
H. pylori infection and NSAID use.
What complications are common with peptic ulcer disease?
Bleeding, perforation, and pyloric stenosis.
How do duodenal ulcers typically present?
Pain before meals or at night, relieved by eating.
How do gastric ulcers typically present?
Pain related to meals, relieved by antacids.
What is the first-line investigation for peptic ulcer disease?
Endoscopy.
How is H. pylori testing performed?
Biopsy specimens from endoscopy, or breath/stool tests.
What is the treatment for H. pylori infection in peptic ulcer disease?
A PPI with amoxicillin and either clarithromycin or metronidazole for 7 days.
What are the signs of upper gastrointestinal bleeding?
Haematemesis (vomiting blood) and melaena (black, tarry stools).
How is immediate management of upper GI bleeding initiated?
With the ABCDE approach, ensuring airway protection, establishing IV access, fluid resuscitation, and correction of clotting.
What role does endoscopy play in managing upper GI bleeding?
It is both diagnostic and therapeutic, helping identify the source and treat the bleed.
How is variceal bleeding managed?
With vasoconstrictor therapy (terlipressin) and prophylactic antibiotics. Endoscopic therapy may involve banding or sclerotherapy.
What is the mortality rate for first-time variceal bleeding?
Approximately 20%.
What is gastric cancer’s most common presentation?
Dyspepsia, nausea, vomiting, dysphagia, GI bleeding, and iron-deficiency anaemia.
What is the 5-year survival rate for advanced gastric cancer?
Around 5%.
What is the most common type of gastric cancer?
Adenocarcinoma.
What is a gastrointestinal stromal tumour (GIST)?
A mesenchymal tumour of the GI tract, often benign, but can be malignant.
What is the treatment for GIST?
Surgical excision and possibly targeted therapy with tyrosine kinase inhibitors like imatinib.
What is the 2-year survival rate for advanced GIST with targeted therapy?
80%.
What are common symptoms of GIST?
Nausea, pain, and occult bleeding.
What is the association of GIST with neurofibromatosis?
GIST is more common in patients with neurofibromatosis type I.
What is the typical location of GISTs?
They can occur anywhere in the GI tract but are most commonly solitary.
What is the role of HLA-DQ in coeliac disease?
Coeliac disease is associated with the HLA-DQ protein, particularly the DQ2 and DQ8 isoforms, which are present in more than 95% of cases.
Name some clinical features of coeliac disease.
Diarrhoea, steatorrhoea, abdominal discomfort, weight loss, mouth ulcers, anaemia, failure to thrive (children), osteomalacia, and neuropathies.
What autoimmune diseases are coeliac disease patients at increased risk of developing?
Coeliac disease patients are at increased risk of developing thyroid disease, insulin-dependent diabetes, and small bowel lymphomas and adenocarcinomas.
What is dermatitis herpetiformis?
Dermatitis herpetiformis is a chronic subepidermal blistering skin disorder associated with coeliac disease.
What serological tests are first-line in diagnosing coeliac disease?
Total immunoglobulin A (IgA) and IgA tissue transglutaminase (tTG) tests.
What is the role of a duodenal biopsy in coeliac disease diagnosis?
A duodenal biopsy showing villous atrophy and chronic inflammation is needed for the diagnosis of coeliac disease.
What is the primary treatment for coeliac disease?
The primary treatment is a lifelong gluten-free diet and nutrient replacement (e.g., vitamin D).
What is bacterial overgrowth in the context of gastrointestinal diseases?
Bacterial overgrowth occurs when bacteria proliferate in the small intestine, leading to steatorrhoea and vitamin B12 deficiency.
How is bacterial overgrowth treated?
Treatment involves correcting the underlying disorder and vitamin replacement. Broad-spectrum antibiotics, including anaerobic cover with metronidazole, are also used if necessary.
What is tropical sprue?
Tropical sprue is a severe malabsorption disease occurring in tropical regions, usually associated with diarrhoea and malnutrition.
What is Whipple’s disease?
Whipple’s disease is a rare cause of malabsorption characterized by symptoms like steatorrhoea, fever, chronic cough, and weight loss. It is caused by Tropheryma whippelii.
What is carcinoid syndrome?
Carcinoid syndrome is a paraneoplastic syndrome associated with carcinoid tumours, characterized by flushing, abdominal pain, diarrhoea, bronchospasm, and oedema.
How is carcinoid syndrome diagnosed?
Diagnosis is made by measuring 5-hydroxyindoleacetic acid (5HIAA) in a 24-hour urine collection and plasma chromogranin A levels.
What is the treatment for carcinoid syndrome?
Management includes avoiding precipitants, surgical removal of localized tumours, and drugs like octreotide for symptom relief.
What is a gastrinoma?
A gastrinoma is a gastrin-secreting pancreatic tumour that causes Zollinger–Ellison syndrome, leading to recurrent ulcers and excessive acid production.
What are the symptoms of an insulinoma?
Symptoms include recurrent fasting hypoglycaemia, which may manifest as bizarre behavior, epilepsy, or confusion.
What is the treatment for insulinomas?
Surgical excision is the primary treatment. If surgery isn’t feasible, diazoxide or octreotide can be used.
What is a VIPoma?
A VIPoma is a tumour that secretes vasoactive intestinal peptide (VIP), causing watery diarrhoea, hypokalaemia, and sometimes achlorhydria.
What is the treatment for glucagonomas?
Treatment includes surgery to remove the tumour, with octreotide used to control symptoms such as diarrhoea and hyperglycaemia.
What is the most common type of colorectal cancer?
The vast majority of colorectal cancers are adenocarcinomas.
What are the risk factors for colorectal cancer?
Risk factors include high red and processed meat intake, alcohol consumption, smoking, low-fibre diet, high BMI, family history, and inflammatory bowel disease (IBD).
What is the role of colonoscopy in colorectal cancer diagnosis?
Colonoscopy is the gold standard for diagnosing colorectal cancer and allows for biopsy.
What is Lynch syndrome?
Lynch syndrome (hereditary nonpolyposis colorectal cancer) is a dominantly inherited mutation of DNA mismatch repair genes, leading to early-onset right-sided colorectal cancers.
What are common clinical features of colorectal cancer?
Symptoms include weight loss, anorexia, abdominal pain, altered bowel habit, bowel obstruction, rectal bleeding, and iron-deficiency anaemia.
How is colorectal cancer staged?
Colorectal cancer is staged using the modified Duke classification, with stages ranging from A (confined to bowel wall) to D (distant metastasis). Contrast-enhanced CT is used for staging.
What is the normal function of the lower oesophageal sphincter (LOS)?
It prevents significant acid reflux into the oesophagus.
What other mechanisms help prevent acid reflux in the oesophagus?
Intraabdominal section of the oesophagus, diaphragmatic crura, and gastric mucosa folds.
What is the primary condition when these anti-reflux mechanisms fail?
Gastro-oesophageal reflux disease (GORD).
What are common clinical features of GORD?
Dyspepsia, possible symptoms similar to angina, and nocturnal asthma or laryngeal discomfort.
When is endoscopy recommended in GORD patients?
In those older than 55 years, with symptoms lasting more than 4 weeks, or in those with weight loss, dysphagia, or persistent symptoms despite treatment.
What is the first-line treatment for GORD?
Lifestyle modifications and full-dose proton pump inhibitors (PPIs) for 4 weeks.
What lifestyle changes are recommended for managing GORD?
Smaller meals, avoid eating 3-4 hours before bed, weight loss, smoking cessation, and stress reduction.
What medication can be prescribed for nocturnal GORD symptoms?
Histamine (H2) receptor antagonists like famotidine.
What surgical intervention may be used for severe GORD?
Nissen fundoplication (fundus of the stomach wrapped around the LOS).
What is a benign oesophageal stricture, and how is it treated?
A narrowing of the oesophagus often in patients over 60; treated by endoscopic dilation and pharmacologic control of acid secretion.
What is a hiatus hernia?
Herniation of part of the stomach into the chest cavity.
What are the two main types of hiatus hernia?
Sliding hiatus hernia and rolling (paraoesophageal) hiatus hernia.
What is a sliding hiatus hernia?
The gastro-oesophageal junction slides into the thorax.
What is a rolling (paraoesophageal) hiatus hernia?
Part of the stomach rolls up into the chest next to the oesophagus while the LOS stays below the diaphragm.
What is Barrett’s oesophagus?
Intestinal metaplasia of the oesophagus, where squamous epithelium changes to columnar epithelium, often due to long-term acid reflux.
What is the significance of Barrett’s oesophagus?
It is premalignant and increases the risk of oesophageal adenocarcinoma.
What is eosinophilic oesophagitis?
A hypersensitive inflammatory condition often seen in children and young adults, causing dysphagia and food impaction.
How is eosinophilic oesophagitis treated?
Allergy testing, allergen avoidance, swallowed liquid cortisone, and PPIs.
What is achalasia?
A condition where the lower oesophagus fails to relax due to neuromuscular problems, leading to dysphagia and oesophageal dilatation.
How is achalasia diagnosed?
Barium swallow, endoscopy, and oesophageal manometry.
What is the treatment for achalasia?
Botulinum toxin injection, endoscopic balloon dilatation, or surgery (Heller cardiomyotomy).
What are the two types of oesophageal cancer?
Squamous cell carcinoma and adenocarcinoma.
What are risk factors for oesophageal cancer?
Heavy drinking, smoking, Plummer-Vinson syndrome, achalasia, and Barrett’s oesophagus.
What are common symptoms of oesophageal cancer?
Dysphagia, weight loss, anorexia, and retrosternal pain.
How is oesophageal cancer investigated?
Endoscopy with biopsy, barium swallow, CT/MRI scans, and staging laparoscopy.
What is the management of oesophageal cancer?
Surgery, chemotherapy, radiotherapy, and palliative care.
What is gastroduodenitis and peptic ulcer disease commonly caused by?
H. pylori infection, NSAIDs, alcohol, smoking, and severe stress.
What is the most common site for peptic ulcers?
Duodenum, followed by the stomach.
What is the cause of carcinoid tumours in the small bowel?
They originate from enterochromaffin cells and secrete hormones like gastrin, glucagon, and VIP.
What is carcinoid syndrome?
A paraneoplastic syndrome due to hormone release from carcinoid tumours, causing symptoms like flushing, abdominal pain, diarrhoea, and bronchospasm.
