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Phase 2a Medicine > Liver and Friends > Flashcards

Liver and Friends Flashcards

1
Q

What are the functions of the liver?

A
  1. Protein synthesis
  2. Glucose and fat metabolism
  3. Defence against infection
  4. Detoxification
  5. Excretion
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2
Q

What vitamins can the liver absorb?

A

A, D, E, K

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3
Q

What is needed to digest fat and absorb vitamins?

A

Bile

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4
Q

What is the function of Kupffer cells?

A

Remove senescent cells and particulates

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5
Q

What are the results of acute liver injury?

A
  1. Recovery

2. Liver failure

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6
Q

What are the results of chronic liver failure?

A
  1. Recovery
  2. Cirrhosis
  3. Liver failure
  4. Varices
  5. Hepatoma
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7
Q

What classifies chronic liver disease?

A

Persistent injury >6 months

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8
Q

What is the commonest cause of acute liver injury?

A

Inflammation

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9
Q

Give 4 causes of acute liver injury

A
  1. Viral e.g. Hep A
  2. Drugs
  3. Alcohol
  4. Obstruction
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10
Q

Give 4 causes of chronic liver injury

A
  1. Alcohol
  2. Viral e.g. Hep C
  3. Autoimmune
  4. Metabolic
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11
Q

Give 5 symptoms of acute liver injury

A
  1. Malaise
  2. Nausea
  3. Anorexia
  4. Jaundice
  5. Confusion
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12
Q

Give 5 symptoms of chronic liver injury

A
  1. Ascites
  2. Oedema
  3. Haematemesis
  4. Anorexia
  5. Itching
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13
Q

What is checked in LFTs?

A
  1. Serum bilirubin, albumin, prothrombin time

2. Serum liver enzymes

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14
Q

What enzymes are used as markers of liver injury?

A

AST and ALT

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15
Q

What causes jaundice?

A

Raised serum bilirubin

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16
Q

What can jaundice be classified into?

A
  1. Unconjugated (pre-hepatic)

2. Conjugated (hepatic and post-hepatic)

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17
Q

What can cause pre-hepatic jaundice?

A
  1. Haemolysis

2. Gilberts

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18
Q

What can cause hepatic jaundice?

A
  1. Hepatitis
  2. Ischaemia
  3. Neoplasm
  4. Congestion
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19
Q

What can cause post-hepatic jaundice?

A
  1. Gallstone

2. Stricture

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20
Q

How would a pre-hepatic pt. present?

A
  1. Normal urine
  2. Normal stools
  3. No itching
  4. Normal LFTs
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21
Q

How would a conjugated pt. present?

A
  1. Dark urine
  2. Pale stools
  3. Itching
  4. Abnormal LFTs
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22
Q

What other symptoms may be present in jaundice pt.?

A
  1. Biliary pain
  2. Rigors
  3. Abdomen swelling
  4. Weight loss
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23
Q

What tests are done in jaundice?

A
  1. LFT: high AST/ALT
  2. USS: dilated ducts
  3. CT
  4. MRCP
  5. ERCP
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24
Q

What are gallstones made of?

A

70% cholesterol, 30% pigment +/- Ca

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25
Q

What are the risk factors for gallstones?

A

4 Fs

  1. Female
  2. Fat
  3. Fertile
  4. 50
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26
Q

What are the classes of gallstone?

A
  1. Intrahepatic bile duct stones
  2. Extrahepatic bile duct stones
  3. Gallbladder stones
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27
Q

What is the presentation in gallbladder stones?

A
  1. Biliary pain
  2. Cholecystitis
  3. Obstructive jaundice
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28
Q

What is the presentation in bile duct stones?

A
  1. Biliary pain
  2. Obstructive jaundice
  3. Cholangitis
  4. Pancreatitis
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29
Q

What is the Rx for gallbladder stones?

A
  1. Laparoscopic cholecystectomy

2. Bile acid dissolution therapy

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30
Q

What is the Rx for bile duct stones?

A
  1. ERCP with sphincterotomy and removal crushing stent placement
  2. Surgery
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31
Q

What are the types of drug induced liver injury (DILI)?

A
  1. Hepatocellular
  2. Cholestatic
  3. Mixed
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32
Q

What is the onset time course in DILI?

A
  1. 1-12 weeks from starting
  2. Earlier is unusual
  3. May be several weeks after stopping
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33
Q

What is the resolution time course in DILI?

A
  1. 90% within 3m of stopping

2. 5-10% prolonged

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34
Q

What drugs often cause DILI?

A
  1. Antibiotics
  2. CNS drugs
  3. Immunosuppressants
  4. Analgesics/MSK
  5. GI drugs
  6. Dietary supplements
  7. Multiple drugs
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35
Q

What % of DILI cases are caused by paracetamol?

A

50%

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36
Q

What prevents toxic metabolites to be produced in paracetamol metabolism?

A

Glutathione conjugation

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37
Q

What is seen in paracetamol OD?

A
  1. Glutathione depletion
  2. Toxic metabolite increase
  3. Hepatocyte damage
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38
Q

What is the Rx for paracetamol induced fulminant hepatic failure?

A
  1. N acetyl cysteine

2. Supportive to correct

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39
Q

What are the complications of paracetamol OD?

A
  1. Coagulation defects
  2. Fluid electrolyte and acid base balance
  3. Renal failure
  4. Hypoglycaemia
  5. Encephalopathy
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40
Q

What are the severity indicators for paracetamol induced liver failure?

A
  1. Late presentation
  2. Acidosis
  3. Prothrombin time >70s
  4. Serum creatinine >300 umol/L
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41
Q

What are the causes of ascites?

A
  1. Chronic liver disease
  2. Neoplasia
  3. Pancreatitis
  4. Cardiac causes
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42
Q

What can present with chronic liver disease to cause ascites?

A
  1. Portal vein thrombosis
  2. Hepatoma
  3. TB
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43
Q

What causes portal HTN?

A
  1. Increased intrahepatic resistance

2. Systemic vasodilation

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44
Q

What can cause ascites?

A
  1. Portal HTN

2. Low serum albumin

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45
Q

What can systemic vasodilation result in?

A
  1. Secretion of renin-angiotensin, NA, vasopressin

2. Fluid retention

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46
Q

What is Rx for ascites?

A
  1. Fluid and salt retention
  2. Diuretics
  3. Large volume paracentesis and albumin
  4. Trans-jugular intrahepatic portosystemic shunt
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47
Q

What does acute alcohol-related injury cause?

A

Hepatocyte ballooning mediated by neutrophils

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48
Q

What is steatosis?

A

Fat accumulation within hepatocytes

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49
Q

What can fatty liver cause?

A
  1. Alcoholic hepatitis

2. Cirrhosis

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50
Q

What is the main cause of liver death in UK?

A

Alcoholic liver disease (ALD)

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51
Q

What is the prognosis for ALD?

A

10 year survival 25%

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52
Q

What is the Rx for ALD?

A
  1. Spironolactone
  2. Gastroscopy and rubber bands on varices
  3. Terlipressin
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53
Q

What are the consequences of ALD?

A
  1. Haematemesis
  2. Blood/plasma resuscitation
  3. Varices
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54
Q

What causes portal HTN?

A
  1. Cirrhosis
  2. Fibrosis
  3. Portal vein thrombosis
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55
Q

What is the pathophysiology of portal HTN?

A
  1. Increased hepatic resistance

2. Increased splanchnic blood flow

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56
Q

What are the consequences of portal HTN?

A
  1. Varices

2. Splenomegaly

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57
Q

What is the Rx for alcohol withdrawal?

A

Lorazepam

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58
Q

Why do pt. with chronic liver disease deteriorate?

A
  1. Constipation
  2. Drugs
  3. GI bleed
  4. Infection
  5. High ion count
  6. Alcohol withdrawal
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59
Q

Why are liver pt. vulnerable to infection?

A
  1. Impaired reticuloendothelial function
  2. Reduced opsonic activity
  3. Leucocyte function
  4. Permeable gut wall
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60
Q

What sites do infections commonly occur in liver pt.?

A
  1. Spontaneous bacterial peritonitis
  2. Septicaemia
  3. Pneumonia
  4. Skin
  5. Urinary tract
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61
Q

What is the commonest serious infection in cirrhosis?

A

Spontaneous bacterial peritonitis

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62
Q

What is the Rx for spontaneous bacterial peritonitis?

A
  1. Abx prophylaxis

2. Consider liver transplant

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63
Q

What can cause renal failure in liver disease?

A
  1. Drugs
  2. Infection
  3. GI bleed
  4. Myoglobinuria
  5. Renal tract obstruction
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64
Q

What can cause coma in pt. with chronic liver disease?

A
  1. Hepatic encephalopathy
  2. Hyponatraemia
  3. Hypoglycaemia
  4. Intracranial event
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65
Q

What are the bedside tests for encephalopathy?

A
  1. Serial 7s
  2. WORLD backwards
  3. Animal counting in 1 min
  4. Draw 5 point star
  5. No. connection test
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66
Q

Give 5 consequences of liver dysfunction

A
  1. Malnutrition
  2. Impaired coagulation
  3. Vit K deficiency
  4. Amenorrhoea
  5. Hypoglycaemia
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67
Q

What are the consequences of liver disease?

A
  1. Malnutrition
  2. Variceal bleeding
  3. Encephalopathy
  4. Ascites
  5. Infections
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68
Q

How is malnutrition treated?

A

Nasogastric feeding

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69
Q

How is variceal bleeding treated?

A
  1. Endoscopic banding
  2. Propranolol
  3. Terlipressin
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70
Q

How is encephalopathy treated?

A

Lactulose

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71
Q

How is ascites treated?

A
  1. Salt/fluid restriction
  2. Diuretics
  3. Paracentesis
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72
Q

What are 5 causes of chronic liver disease?

A
  1. Alcohol
  2. Non-alcoholic steatohepatitis (NASH)
  3. Viral hepatitis (B, C)
  4. Wilson’s disease
  5. Primary biliary cirrhosis
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73
Q

What must be asked in PMx in chronic liver disease pt.?

A
  1. Alcohol problems
  2. Biliary surgery
  3. Autoimmune disease
  4. Blood products
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74
Q

What is the investigations for chronic liver disease?

A
  1. Viral serology
  2. Autoantibodies
  3. Immunoglobulins
  4. USS
  5. CT
  6. MRI
  7. Biochemistry
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75
Q

What is the DDx for hepatitis?

A
  1. Viral
  2. Drug-induced
  3. Autoimmune
  4. Alcoholic
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76
Q

What are the hepatitis investigations?

A
  1. Acute viral serology
  2. Iron studies
  3. Immunology
  4. Liver biopsy
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77
Q

What is seen in autoimmune hepatitis liver biopsy?

A
  1. Interface hepatitis
  2. Inflammation (plasma cells/lymphocytes)
  3. No cirrhosis
  4. No increase iron stain
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78
Q

What % of autoimmune hepatitis have cirrhosis at presentation?

A

30%

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79
Q

What is Rx for autoimmune hepatitis?

A

Prednisolone +/- azathioprine

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80
Q

Where is the damage in primary biliary cirrhosis?

A

Small bile ducts

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81
Q

What is the prevalence of primary biliary cirrhosis?

A

1 in 1000

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82
Q

What is the investigation for primary biliary cirrhosis?

A

+ve AMA

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83
Q

What is the clinical presentation in primary biliary cirrhosis (PBC)?

A
  1. Itching
  2. Fatigue
  3. Dry eyes
  4. Joint pain
  5. Variceal bleeding
  6. Liver failure
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84
Q

What is the Rx for cholestatic itch?

A
  1. Cholestyramine
  2. Rifampicin
  3. Opiate antagonists
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85
Q

What is the Rx for fatigue and PBC?

A

Modafinil

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86
Q

Give 3 disease associated with PBC

A
  1. Sjögrens
  2. Thyroiditis
  3. Rheumatoid arthritis
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87
Q

What is the benefit of using ursodeoxycholic acid in PBC?

A
  1. Improves bilirubin
  2. Reduces inflammation
  3. Reduces portal pressure
  4. Reduces variceal development
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88
Q

How does primary sclerosing cholangitis present (PSC)?

A
  1. Itching
  2. Pain
  3. Rigors
  4. Jaundice
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89
Q

What is the Dx for PSC?

A
  1. Raised alkaline phosphorylate

2. Raised GGT

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90
Q

What stains ferric iron blue?

A

Perl’s stain

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91
Q

What can cause excess iron?

A
  1. Haemochromatosis
  2. Multiple blood transfusions
  3. Haemolysis
  4. Alcoholic liver disease
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92
Q

What gene is mutated in haemochromatosis?

A

HFE gene

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93
Q

What is the pathophysiology of haemochromatosis?

A

Uncontrolled intestinal iron absorption with deposition in liver, heart and pancreas

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94
Q

What is the Dx for haemochromatosis?

A
  1. Raised ferritin
  2. Transferrin saturation
  3. HFE genotyping
  4. Liver biopsy
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95
Q

What is at higher risk if haemochromatosis is present with cirrhosis?

A

Hepatocellular carcinoma

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96
Q

What is the Rx for haemochromatosis?

A

Iron removal

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97
Q

Give 5 symptoms of haemochromatosis

A
  1. Cirrhosis
  2. White nails
  3. Joint pain
  4. Chronic fatigue
  5. Dry skin
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98
Q

What is the pathophysiology of a1-antitrypsin deficiency?

A

Inability to export a1-antitrypsin from liver

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99
Q

What can a1-antitrypsin deficiency result in?

A
  1. Liver disease

2. Emphysema

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100
Q

How may a1-antitrypsin deficiency present?

A
  1. Neonatal jaundice

2. Chronic liver disease in adults

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101
Q

What is the Rx for a1-antitrypsin deficiency?

A

No Rx

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102
Q

What are the risk factors for hepatocellular carcinoma?

A
  1. Hepatitis B, C
  2. Haemochromatosis
  3. Cirrhosis from alcohol
  4. Autoimmune disease
  5. Male
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103
Q

How may hepatocellular carcinoma present?

A
  1. Decompensation of liver disease
  2. Weight loss
  3. Ascites
  4. Abdo pain
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104
Q

What are the Rx for hepatocellular carcinoma?

A
  1. Transplant
  2. Resection
  3. Local ablation
  4. Sorafenib
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105
Q

What is produced in 50% of hepatocellular carcinoma pt.?

A

Alpha fetoprotein

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106
Q

What are the risk factors for non-alcoholic fatty liver disease (NAFLD)?

A
  1. Obesity
  2. Diabetes
  3. Hyperlipidaemia
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107
Q

What are the symptoms for NALFD?

A
  1. Asymptomatic

2. Liver ache

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108
Q

What is the investigation for NAFLD?

A
  1. High LFT
  2. ALT
  3. Biopsy
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109
Q

What is seen in NASH?

A

Fatty liver, sometimes with inflammation and fibrosis

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110
Q

What does NASH cause?

A

Cryptogenic cirrhosis

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111
Q

What is the Rx for NAFLD?

A

Weight loss

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112
Q

What are the causes of hepatic vein occlusion?

A
  1. Thrombosis
  2. Membrane obstruction
  3. Veno-occlusive disease
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113
Q

How may hepatic vein occlusion present?

A
  1. Abnormal LFTs
  2. Ascites
  3. Acute liver failure
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114
Q

What is the Rx for hepatic vein occlusion?

A
  1. Anticoagulation
  2. Transjufular intrahepatic portosystemic shunt
  3. Liver transplant
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115
Q

What is hepatitis?

A

Inflammation of the liver

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116
Q

What are the symptoms of acute hepatitis?

A
  1. Malaise
  2. GI upset
  3. Jaundice
  4. Pale stools
  5. Dark urine
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117
Q

What are the signs of acute hepatitis?

A
  1. Tender hepatomegaly
  2. Bleeding
  3. Ascites
  4. Encephalopathy
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118
Q

What is seen in bloods for acute hepatitis?

A
  1. Raised transaminases (ALT/AST)

2. Raised bilirubin

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119
Q

Give 3 non-viral infections that cause acute hepatitis?

A
  1. M. tuberculosis
  2. Bartonella
  3. Syphilis
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120
Q

Give 4 non-infective causes of acute hepatitis

A
  1. Drugs
  2. Alcohol
  3. NAFLD
  4. Pregnancy
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121
Q

What signs are seen in chronic hepatitis?

A
  1. Clubbing
  2. Palmar erythema
  3. Dupuytren’s contracture
  4. Spider naevi
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122
Q

What is seen in decompensated chronic hepatitis?

A
  1. Coagulopathy
  2. Jaundice
  3. Low albumin
  4. Ascites
  5. Encephalopathy
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123
Q

What are the complications of chronic hepatitis?

A
  1. Hepatocellular carcinoma
  2. Varices
  3. Bleeding
124
Q

What are the viral causes of chronic hepatitis?

A

Hepatitis B (+D), C

125
Q

How is hepatitis A transmitted?

A

Faeco-oral transmission

126
Q

What are the risk factors for hepatitis A?

A
  1. Travel
  2. Household contact
  3. Sexual contact
  4. IVDU
127
Q

What is the incubation period for hepatitis A?

A

15 to 50 days

128
Q

What are the pre-icteric symptoms in hepatitis A?

A
  1. Constitutional symptoms

2. Abdo pain

129
Q

What is the immunity rate after hepatitis A infection?

130
Q

What is the serology for acute hepatitis A?

A

Anti-HAV IgM

131
Q

What is the serology past infection for hepatitis A?

A

Anti-HAV IgG

132
Q

What is the Rx for hepatitis A?

A
  1. Supportive
  2. Monitor liver function
  3. Manage close contacts
  4. Vaccination
133
Q

What is the transmission methods for hepatitis E GT1 and GT2?

A

Contaminated food and water

134
Q

What is the transmission methods for hepatitis E GT3 and GT4?

A
  1. Zoonotic reservoir (pig)

2. Undercooked meat products

135
Q

Where is hepatitis E found?

A

GT1: Africa and Asia
GT2: Mexico ad West Africa
GT3: High income countries
GT4: China and SE Asia

136
Q

What are some consequences of acute hepatitis E?

A
  1. Fulminant hepatitis
  2. Acute-on-chronic liver failure
  3. Chronic infection
137
Q

What is the serology for acute hepatitis E?

A

Anti-HEV IgM

138
Q

What is the serology past infection for hepatitis E?

A

Anti-HEV IgG

139
Q

What must be done in serology in immunocompromised Hep E pt.?

A

Measure and monitor HEV RNA +/- stool

140
Q

What is the Rx for acute hep E?

A
  1. Supportive
  2. Monitor for complications
  3. Consider ribavirin
141
Q

What is the Rx for chronic Hep E?

A
  1. Reverse immunosuppression

2. Ribavirin

142
Q

How is hepatitis B transmitted?

A

Blood-borne virus

143
Q

What is the serology for acute hepatitis E?

A

Anti-HB core IGM

144
Q

When might anti-HB core IgG be seen?

A
  1. Exposure to HBV infection

2. Current chronic HBV infection

145
Q

What confirms chronic hep B?

A

Hepatitis B surface antigen

146
Q

What is the incubation period for hepatitis B?

A

30 to 180 days

147
Q

What is the management of hepatitis B?

A
  1. Supportive
  2. Monitor liver function
  3. Tenofovir/entecavir
  4. Manage close contacts
148
Q

How many acute hepatitis B cases become chronic?

149
Q

What can chronic hepatitis B cause?

A
  1. Cirrhosis

2. Hepatocellular carcinoma

150
Q

Which chronic hepatitis B pt. are treated?

A

High HBV DNA associated with high ALT

151
Q

What drugs can treat hepatitis B?

A
  1. Pegylated interferon-a 2a

2. Oral nucleoside analogues

152
Q

What are the SE of pegylated interferon-a 2a?

A
  1. Myalgia
  2. Flue-like symptoms
  3. Thyroiditis
  4. Low blood counts
  5. Depression
153
Q

Name an oral nucleoside analogue

154
Q

What is the prevention for hepatitis B?

A
  1. Antenatal screening of pregnant mothers
  2. Screening +/- immunisation of contacts
  3. Childhood immunisation
  4. Screening of blood products
  5. Sterilise equipment
  6. Immunise HCPs and at-risk groups
155
Q

What does hepatitis D need to replicate?

156
Q

How is hepatitis D transmitted?

A

Blood and body fluids

157
Q

What is the consequence of acquiring Hep D simultaneously with HBV?

A

Fulminant hepatitis in acute infection

158
Q

What are the consequences of acquiring Hep D after HBV?

A
  1. Acute on chronic hepatitis

2. Accelerated progression to liver fibrosis

159
Q

What is the Dx for Hep D?

A

Hep D antibody followed by HDV RNA

160
Q

What is the Rx for Hep D?

A

Pegylated interferon-a

161
Q

How many acute hepatitis C infections become chronic?

162
Q

How many chronic HCV pt. develop cirrhosis?

163
Q

Which groups are at risk for hepatitis C?

A
  1. PWID
  2. Prison inmates
  3. Blood transfusions prior 1991
  4. MSM
  5. Tattoo/piercing
  6. MTCT
164
Q

What is the test for hepatitis C?

A
  1. Capillary blood sample - antibody and RNA
  2. Mouth swab
  3. Rapid antibody test
165
Q

What is the Rx for hep C?

A

Directly acting antivirals (DAAs) +/- ribavirin

166
Q

Name 2 DAAs

A
  1. Ledipasvir

2. Sofosbuvir

167
Q

What is the prevention for hep C?

A
  1. Screening blood products
  2. Precautions handling bodily fluids
  3. Needle exchanges
  4. Rx of transmitters e.g. PWID
168
Q

What are the functions of gut bacteria?

A
  1. Aid reabsorption back across intestinal wall
  2. Digestion of fibre
  3. Metabolism of vit K
  4. Synthesis vitamin B12, folic acid and thiamine
  5. Prevent infection
169
Q

How does normal flora discourage infection?

A
  1. Inhibit overgrowth of endogenous pathogens

2. Prevent colonisation by exogenous pathogens

170
Q

What occurs if gut barriers are breached by bacteria?

A

Peritonitis

171
Q

What kills most swallowed pathogens?

A

Gastric acid

172
Q

What can increase risk of intraluminal infection?

A
  1. Less gastric acid

2. Broad spectrum Abx

173
Q

How does disruption to normal flora by Abx cause infection by external pathogens?

A
  1. Pathogen bypasses stomach acid
  2. Secretes spores in lower gut which has no protection
  3. Damage mucosa
174
Q

What is the Rx for intraluminal infection?

A
  1. Different Abx

2. Faecal transplant

175
Q

What is diarrhoea?

A

3+ loose liquid stools in 24hrs

176
Q

Give 4 causes of diarrhoea

A
  1. Campylobacter
  2. Salmonella
  3. Bacterial dysentery
  4. Cholera
177
Q

What causes chronic diarrhoea?

A

Parasites and non-infectious causes e.g. cancer

178
Q

What animals can cause diarrhoea?

A
  1. Puppies - salmonella

2. Reptiles - campylobacter

179
Q

How many cases of diarrhoea are caused by viruses?

180
Q

Which viruses often cause diarrhoea?

A
  1. Rotavirus (children)

2. Norovirus

181
Q

How do viruses cause diarrhoea?

A
  1. Shorten and damage villi
  2. Hyperplasia of crypts
  3. Inflammatory exudate
182
Q

How does enterotoxin-mediated diarrhoea occur? e.g. E. coli

A
  1. Bacteria in upper bowel produce enterotoxins
  2. Increase IC AMP
  3. Mucosal cells secrete fluid
  4. Watery voluminous diarrhoea
183
Q

Where does invasive bacterial diarrhoea affect?

A
  1. Colon (shigella/campylobacter)

2. Lower ileum (salmonella)

184
Q

What causes bloody mucoid stools in invasive bacterial diarrhoea?

A

Penetration of intestinal mucosa

185
Q

How does cholera spread?

A

Faecal-oral transmission

186
Q

What does cholera diarrhoea look like?

A

Profuse watery ‘rice water’ diarrhoea, vomiting and rapid dehydration

187
Q

What is the faecal output daily in cholera?

188
Q

What is the Rx for cholera?

A

Doxycycline and fluids

189
Q

What is the leading bacterial cause of diarrhoea in children?

A

EnteroToxigenic E. coli (ETEC)

190
Q

What other conditions can E. coli cause?

A
  1. UTI
  2. Neonatal meningitis
  3. Gram -ve sepsis
191
Q

What are the symptoms of haemolytic uraemia syndrome (HUS)?

A
  1. Bloody diarrhoea
  2. Haemolysis
  3. Renal failure
  4. Abdo pain
192
Q

What causes HUS?

A

EnteroHaemorrhagic E. coli (EHEC)

193
Q

Which E. coli causes a dysentery like illness?

A

EnteroInvasive E. coli (EIEC)

194
Q

Which infections are immunosuppressed more susceptible to?

A
  1. Cryptosporidium
  2. Mycobacteria
  3. Microsporidia
  4. CMV
  5. HSV
195
Q

What symptoms accompany diarrhoea in traveller’s diarrhoea?

A
  1. Fever
  2. Nausea
  3. Vomiting
  4. Cramps
  5. Bloody stools
196
Q

What causes most travellers diarrhoea?

197
Q

What are the investigations for diarrhoea?

A
  1. Bloods - inflammatory markers, blood cultures

2. Stool tests - microscopy, culture, ova, cysts, parasites, toxin detection

198
Q

What is the prevention for diarrhoea pt.?

A

Barrier nursing (side room, PPE, PHE notified)

199
Q

What is the Rx for diarrhoea?

A
  1. Fluids
  2. Electrolyte replacement
  3. Antiemetics
  4. Antimotility agents
200
Q

When are antimotility agents not used?

A

Inflammatory diarrhoea

201
Q

What are the red flags for diarrhoea?

A
  1. Dehydration
  2. Electrolyte imbalance
  3. Renal failure
  4. Immunocompromised
  5. Severe abdo pain
202
Q

What are the cancer red flags for diarrhoea?

A
  1. Over 50
  2. Chronic diarrhoea
  3. Weight loss
  4. Blood in stool
  5. FHx cancer
203
Q

What causes peptic ulcer disease?

A

Helicobacter pylori

204
Q

How does H. pylori cause peptic ulcer disease?

A

Releases ureas which produces ammonia which neutralises stomach acid and damages epithelial cells

205
Q

What are the symptoms for peptic ulcers?

A
  1. Dyspepsia
  2. Epigastric pain
  3. Loss of appetite
206
Q

What is the Dx for peptic ulcer disease?

A
  1. Stool antigen test
  2. Urease breath test
  3. Bloods for antibodies
  4. Endoscopy with biopsy
207
Q

What is the Rx for peptic ulcer disease?

A

Triple therapy

  1. Omeprazole (PPI)
  2. Clarithromycin
  3. Amoxicillin
208
Q

What is ascending cholangitis?

A

Bacterial infection of biliary tract as a result of obstruction

209
Q

What are the RF for gallstones?

A

Four Fs

  1. Fair (Caucasian)
  2. Female
  3. Fat
  4. Fertile
210
Q

What is the diagnosis for ascending cholangitis?

A

Charcot’s triad

  1. Jaundice
  2. RUQ pain
  3. Fever
211
Q

What is the DDx for colicky RUQ pain?

A
  1. Biliary colic

2. Cholecystitis

212
Q

What is the management for ascending cholangitis?

A
  1. IV Abx
  2. Fluids
  3. ERCP
213
Q

What bacteria can cause liver abscess?

A
  1. E. coli

2. Klebsiella spp

214
Q

What are the symptoms for bacterial liver abscess?

A
  1. RUQ pain
  2. Fever
  3. PUO
215
Q

What is the Dx for bacterial liver abscess?

216
Q

What is the Rx for bacterial liver abscess?

A

Abx and drainage

217
Q

What are the symptoms for hydatid liver abscess?

A

Insidious RUQ pain, eosinophilia

218
Q

What is the Rx for hydatid liver abscess?

A
  1. Albendazole

2. PAIR (percutaneous aspiration, injection, reaspiration)

219
Q

How do typhoid and paratyphoid spread?

A

Faecal-oral

220
Q

What causes typhoid and paratyphoid?

A

Types of salmonella

221
Q

What are the symptoms for enteric fever?

A
  1. Generalised/RLQ pain
  2. High fever
  3. Bradycardia
  4. Headache
  5. Rose spots
  6. Constipation/green diarrhoea
222
Q

What is the Dx for enteric fever?

A
  1. Blood culture

2. Bone marrow aspiration

223
Q

What are the complications of enteric fever?

A
  1. GI bleed
  2. Perforation/peritonitis
  3. Myocarditis
  4. Abscesses
224
Q

What is the Rx for enteric fever?

A
  1. Emergency surgery
  2. IV ceftriaxone
  3. Typhoid vaccine
225
Q

What are the parts of the peritoneal cavity?

A
  1. Visceral peritoneum

2. Parietal peritoneum

226
Q

What is the function of the peritoneum in health?

A
  1. Visceral lubrication

2. Fluid and particulate absorption

227
Q

What is the function of the peritoneum in disease?

A
  1. Pain perception
  2. Inflammatory and immune responses
  3. Fibrinolytic activity
228
Q

What is peritonitis?

A

Inflammation of the peritoneum

229
Q

What is the most common type of peritonitis?

A

Acute bacterial peritonitis

230
Q

What can cause peritoneal infection with an example?

A
  1. GI perforation e.g. appendicitis
  2. Transmural translocation e.g. pancreatitis
  3. Exogenous contamination e.g. open surgery
  4. Female genital tract infection e.g. pelvic inflammatory disease
  5. Haematogenous spread e.g. septicaemia
231
Q

What are the main microorganisms in peritonitis?

A
  1. E. coli
  2. Streptococci
  3. Enterococci
232
Q

Give 5 clinical features of localised peritonitis

A
  1. Anorexia
  2. Pain
  3. Nausea/vomiting
  4. Fever
  5. Tachycardia
233
Q

What are the early features of diffuse peritonitis?

A
  1. Abdominal pain
  2. Tenderness
  3. Generalised guarding
  4. Infrequent bowel sounds
  5. Fever
234
Q

What are the late features of diffuse peritonitis?

A
  1. Generalised rigidity
  2. Destension
  3. Absent bowel sounds
  4. Circulatory failure
  5. Thready irregular pulse
235
Q

What are the investigations for peritonitis?

A
  1. Urine dipstick
  2. ECG
  3. Bloods (U&E, FBC)
  4. Serum amylase
  5. CT, CXR, USS
236
Q

What is the management of peritonitis?

A
  1. Fluids
  2. Urinary catheterisation
  3. Abx
  4. Analgesia
  5. Treat underlying cause
237
Q

Name 3 special forms of peritonitis?

A
  1. Bile peritonitis
  2. Tuberculosis peritonitis
  3. Familial Mediterranean fever
238
Q

What is ascites?

A

An accumulation of excess serous fluid within peritoneal cavity

239
Q

What determines the exchange of fluid between capillaries and peritoneal fluid?

A

Balanced effects of plasma and peritoneal colloid osmotic and hydrostatic pressures

240
Q

What are the causes of ascites?

A
  1. Cirrhosis
  2. Gynaecological malignancy
  3. Heart failure
  4. TB
241
Q

What are the symptoms of ascites?

A
  1. Abdominal distension
  2. Nausea
  3. Constipation
  4. Cachexia
  5. Pain
242
Q

What are the signs of ascites?

A
  1. Abdominal distension
  2. Jaundice
  3. Puddle sign
  4. Shifting dullness
  5. Flanks fullness
243
Q

What are the investigations for ascites?

A
  1. X-ray
  2. US
  3. CT abdo
  4. Ascitic aspiration (culture the fluid)
244
Q

What is the Rx for ascites?

A
  1. Sodium restriction
  2. Diuretics
  3. Paracentesis
  4. Indwelling drain
  5. Peritoneovenous shunting
245
Q

Where is most bile reabsorbed?

A

Terminal ileum

246
Q

What is bile made of?

A

Bile acids, phospholipids and cholesterol

247
Q

What is the function of bile?

A

Absorption of fat, cholesterol and vitamins ADEK by forming micelles

248
Q

What is cholestasis?

A

Obstruction of bile secretion

249
Q

Give 3 causes of cholestasis

A
  1. Pancreatitis
  2. Cholelithiasis (stones)
  3. Tumours
250
Q

What are the signs of cholestasis?

A
  1. Jaundice
  2. Itching
  3. Intermittent RUQ pain
  4. Dark brown urine
  5. Pale stool
251
Q

What are the tests for cholestasis?

A
  1. LFT, U&E, CRP, gamma T
  2. USS
  3. MRCP
  4. CT
  5. EUS
252
Q

What causes cholelithiasis (gallstones)?

A

Increased cholesterol which precipitates to form stones

253
Q

What can form gallstones (GS)?

A
  1. Cholesterol

2. Calcium bilirubinate (pigment)

254
Q

What are the risks for cholesterol GS?

A
  1. Rapid weight loss
  2. Age
  3. OCP/pregnancy
  4. Crohn’s
255
Q

What are the risks for pigment GS?

A
  1. Sickle cells
  2. Chronic haemolysis anaemia
  3. Chronic biliary tract infection
256
Q

What are the symptoms of GS?

A
  1. Epigastric pain to RUQ
  2. RQU to shoulder/scapula
  3. Nocturnal
  4. Asymptomatic (70%)
257
Q

What is the Rx for GS?

A
  1. Cholecystectomy

2. Bile salt therapy - ursodeoxycholic acid

258
Q

What is acute cholecystitis?

A

Inflammation of gall bladder

259
Q

What is the presentation of acute cholecystitis?

A
  1. Biliary pain progressive
  2. Sepsis signs
  3. Hx of previous attacks
  4. GB palpable
  5. Jaundice
260
Q

What does positive Murphy’s sign indicate?

A

Acute cholecystitis

261
Q

What does negative Murphy’s sign indicate?

A

Biliary colic disease

262
Q

What is the investigations for acute cholecystitis?

A
  1. WCC, CRP
  2. Bilirubin and alkaline phosphatase
  3. USS
  4. MRI
263
Q

What is the DDx for biliary colic/acute cholecystitis?

A
  1. Pancreatitis
  2. Appendicitis
  3. Peptic ulcer disease
  4. Liver abscess
  5. Pneumonia
264
Q

Give 4 complications of acute cholecystitis

A
  1. Gangrene
  2. Empyema
  3. Cholangitis
  4. Porcelain gall bladder
265
Q

What is the Rx for acute cholecystitis?

A
  1. Treat sepsis with Abx

2. Cholecystectomy

266
Q

What is choledocholithiasis?

A

Common bile duct stone

267
Q

What is the main symptom of choledocholithiasis?

A

Painful jaundice

268
Q

What is cholangitis?

A

Infection if bile duct going upwards

269
Q

What does Charcot’s triad indicate?

A

Obstructive jaundice

270
Q

What is Charcot’s triad?

A
  1. Fever
  2. Jaundice
  3. RUQ pain
271
Q

What is the Rx for choledocholithiasis and cholangitis?

A
  1. ERCP to remove stone
  2. Cholecystectomy
  3. Inoperative cholangiogram
  4. IV Abx
272
Q

What are the risks of primary sclerosing cholangitis?

A
  1. Ulcerative colitis

2. Colon cancer

273
Q

What is the presentation of primary sclerosing cholangitis?

A
  1. Fatigue
  2. Pruritis
  3. Anorexia
  4. Indigestion
  5. Jaundice
274
Q

What are the investigations for primary sclerosing cholangitis?

A
  1. Alk phos rise
  2. Bilirubin rise
  3. MRCP
  4. Liver biopsy
275
Q

What is the Rx for primary sclerosing cholangitis?

A
  1. Balloon dilation
  2. Resection
  3. Liver transplant
276
Q

What are the complications for primary sclerosing cholangitis?

A
  1. Cholangiocarcinoma
  2. Gallstones
  3. Gallbladder polyps
  4. Gallbladder cancer
277
Q

What are the risk factors for biliary dyskinesia?

A
  1. Female
  2. > 50
  3. OW
  4. Fatty foods
278
Q

What is the Dx for biliary dyskinesia?

A
  1. HIDA scan

2. Hepatobiliary function scan

279
Q

What is the Rx for biliary dyskinesia?

A
  1. Cholecystectomy
280
Q

What are the causes of acute pancreatitis?

A
  1. Alcohol
  2. Gallstones
  3. Ductal obstruction
  4. Acinar cell injury
281
Q

What is the Dx for acute pancreatitis?

A
  1. Typical Hx
  2. Elevated amylase
  3. Imaging consistent (CT, MRI, USS)
282
Q

What is SIRS?

A

Systemic inflammatory response syndrome

283
Q

What are the symptoms of acute pancreatitis?

A
  1. Abdominal pain
  2. Fever
  3. Nausea
  4. Tachycardia
  5. Tender abdomen
284
Q

What is the diagnostic criteria for SIRS?

A

2 or more of

  1. Temp <36 or >38
  2. HR > 90 bpm
  3. RR > 20/min
  4. WBC changes
285
Q

What is the Rx for acute pancreatitis?

A
  1. Opiates
  2. IV fluids
  3. Insulin
  4. Ca correction
286
Q

What must be checked for in acute pancreatitis?

287
Q

What is the pathophysiology of chronic pancreatitis?

A

Irreversible fibrosis of pancreatic parenchyma, accompanied by calcification and dilatation of pancreatic ducts

288
Q

What are the risk factors for chronic pancreatitis?

A
  1. Alcohol
  2. Smoking
  3. Drugs e.g. azathioprine
  4. Genetics
289
Q

What are the complications of chronic pancreatitis?

A
  1. Pain
  2. Bile duct strictures
  3. Nutrition
  4. Low insulin
  5. Steatorrhoea
290
Q

What is the management for chronic pancreatitis?

A
  1. Stop alcohol/smoking
  2. Steroids
  3. Pancreatic enzyme replacement therapy
  4. Nutrition/diet
291
Q

What is the 5 year survival for pancreatic cancer?

292
Q

What are the symptoms of pancreatic cancer?

A
  1. Jaundice
  2. Painless
  3. Upper abdomen pain
  4. New onset DM in >60
293
Q

What is the investigations for pancreatic cancer?

A
  1. CT
  2. PET CT
  3. Ca19-9 marker
294
Q

What is the Rx for pancreatic cancer?

A
  1. ERCP
  2. Whipple’s surgery
  3. Distal surgery
  4. Palliative chemo
295
Q

What is the pathophysiology of cirrhosis?

A
  1. Encapsulation of injured tissue by a collagenous scar

2. Connective tissue production and deposition

296
Q

What are the symptoms of cirrhosis?

A
  1. Fatigue
  2. Anorexia
  3. Itchiness
  4. N&V
  5. Tenderness around liver
297
Q

What is the Ix for cirrhosis?

A
  1. CT
  2. USS
  3. MRI
  4. Biopsy liver
298
Q

What is the Rx for cirrhosis?

A
  1. Lifestyle change
  2. Low salt diet
  3. Diuretics
  4. ACEI
  5. Liver transplant
299
Q

What is Wilson’s disease?

A

Genetic disorder in which excess copper builds up in body

300
Q

What are the Wilson’s disease symptoms?

A
  1. Fatigue
  2. Abdominal pain
  3. Jaundice
  4. Kayser-Fleischer rings
  5. Oedema peripheral
301
Q

What is the Ix for Wilson’s disease?

A
  1. Ceruloplasmin level
  2. Copper level
  3. Liver biopsy
  4. Slit lamp exam for KF rings
  5. LFTs
302
Q

What is the Rx for Wilson’s disease?

A
  1. Trientine
  2. Zinc
  3. Liver transplant
303
Q

What gene mutation is a risk factor for Wilson’s disease?

304
Q

What are varices?

A

Abnormally dilated vessel with tortuous course

305
Q

What are the symptoms of varices?

A
  1. Haematemesis
  2. Black, tarry stools
  3. Vertigo
  4. LOC
306
Q

What are the Ix for varices?

A
  1. CT abdomen
  2. Doppler US
  3. Transient elastography
  4. Hepatic venous pressure gradient
  5. Endoscopy
307
Q

What is the Rx for varices?

A
  1. BB
  2. Endoscopic ligation
  3. Vasoactive drug
  4. Somatostatin
  5. Transjugular shunt

Phase 2a Medicine (15 decks)

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