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LIVER and GI Flashcards

1
Q

what can acute and chronic liver injury lead to?

A

acute - liver failure or recovery
chronic - liver failure, cirrhosis or recovery

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2
Q

what is the differene in cells in acute vs chronic liver injury?

A

acute - cell damage/loss
chronic - fibrosis

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3
Q

what can cause acute liver injury?

A

viral (A,B, EBV)
drug
alcohol
Vascular
Obstruction
Congestion

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4
Q

what can cause chronic liver injury?

A

alcohol
viral (B,C)
autoimmune
metabolic (iron, copper)

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5
Q

what are the presentations of acute liver failure?

A

malaise - feeling ill/unwell
nausea
anorexia
jaundice

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6
Q

what are the presentations of chronic liver injury?

A

ascites
oedema
haematemesis (varices)
malaise
anorexia
wasting
easy bruising
itching
hepatomegaly
abnormal LFTs

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7
Q

what things do serum liver function tests measure?

A
  • Serum bilirubin, albumin, prothrombin time
  • Serum liver enzymes:
    cholestatic: alkaline phosphatase (ALP), gamma-GT (GGT)
    hepatocellular: transaminases (AST, ALT)- liver/muscle damage
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8
Q

what does elevated unconjucated billirubin show?

A

pre-hepatic

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9
Q

what does elevated conjucated bilirubin show?

A

post hepatic - bile duct obstruction

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10
Q

what can cause pre hepatic jaundice?

A

Haemolysis, Gilberts

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11
Q

what can cause hepatic jaundice?

A

Hepatitis: viral, drugs immune, alcohol
Ischaemia
Neoplasm
Congestion (CCF)

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12
Q

what can cause post hepatic jaundice?

A

Gallstones.
Surgical strictures.
Extra-hepatic malignancy - pancreatic
Pancreatitis.
Parasitic infection - inflammation

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13
Q

what does very high AST/ALT normally show?

A

liver damage- liver disease/hepatitis/injury

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14
Q

how is biliary obstruction shown on imaging?

A

dilated intrahepatic bile ducts on ultrasound

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15
Q

what are risk factors for gallstones?

A

female, fat, fertile
ileal disease
TPN- Total parenteral nutrition
clofibrate - drug lowers cholesterol

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16
Q

where do most gallstones form?

A

gallbladder

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17
Q

how do you distinguish gallstones in gallbladder vs bile duct?

A

gallbladder - cholecystitis
bile duct - cholangitis and/or pancreatitis, obstructive jaundice

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18
Q

how are gallbladder stones managed?

A
  • Laparoscopic cholecystectomy
  • Bile acid dissolution therapy (<1/3 success
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19
Q

how are bile duct stones managed?

A
  • ERCP with sphincterotomy and: removal (basket or balloon) crushing (mechanical, laser..) stent placement
    • Surgery (large stones)
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20
Q

what are the most common reason for drug induced acute liver failure?

A
  1. paracetamol
  2. idiosynchratic drug reaction - unpredicatable, uncommon reaction
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21
Q

what are the types of drug induced liver injury?

A

Hepatocellular - ALT >2 ULN, ALT/Alk Phos ≥ 5
Cholestatic - Alk Phos >2 ULN or ratio ≤ 2
Mixed - Ratio > 2 but < 5

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22
Q

what drugs cause DILI?

A
  • antibiotics - (Augmentin, Flucloxacillin, Erythromycin, Septrin, TB drugs)
  • CNS Drugs (Chlorpromazine, Carbamazepine Valproate, Paroxetine)
  • immunosupressants
  • Analgesics/musculskeletal (Diclofenac…)
  • Gastrointestinal Drugs (PPIs…)
  • Dietary Supplements
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23
Q

what drugs do not cause DILI?

A

Low dose Aspirin
NSAIDs other than Diclofenac
Beta Blockers
HRT
ACE Inhibitors
Thiazides
Calcium channel blockers

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24
Q

how is paracetamol induced fulminant hepatic failure managed?

A
  • N acetyl Cysteine (NAC)
  • Supportive to correct:
    -coagulation defects
    - fluid electrolyte and acid base balance
    • renal failure
    • hypoglycaemia
    • encephalopathy
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25
Q

what are Paracetamol-induced liver failure severity indicators ?

A
  • Late presentation - (NAC less effective >24 hr)
  • Acidosis (pH <7.3)
  • Prothrommbin time > 70 sec
  • Serum creatinine ≥ 300 µmol/l
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26
Q

what causes ascites?

A
  • Chronic liver disease - cirrhosis (most)
    +/- Portal vein thrombosis
  • Neoplasia (ovary, uterus, pancreas…)
  • Pancreatitis
  • heart failure
  • kidney disease
  • TB
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27
Q

what is the pathogenesis of ascites?

A
  • increased intrahepatic resistance + systemic vasodilation
  • causes portal hypertension and secretion of RAAS, noradrenaline, vasopressin
  • causes fluid retention and ascites
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28
Q

what is the management of ascites?

A
  • fluid and salt restriction diet
  • diuretics - spironolactone +/- ferosemide
  • large-vol paracentesis (fluid drainage)
  • trans-jugular intrahepatic portosystemic shunt (TIPS)
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29
Q

what can mallorys hyalin with neurophils and fat suggest on a stain?

A

injured liver cells - fatty liver due to alcohol

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30
Q

what does fatty liver lead to?

A

alcoholic hepatitis/ cirrhosis
then acute decompensation

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31
Q

what causes portal hypertension?

A
  • cirrhosis
  • fibrosis
  • portal vein thrombosis
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32
Q

what is a complication of ascities (bacterial)?

A

Spontaneous bacterial peritonitis

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33
Q

how is Spontaneous bacterial peritonitis managed?

A
  • antibiotic prophylaxis
  • consider liver transplant
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34
Q

how is Spontaneous bacterial peritonitis
distinguished?

A
  • neutophils in ascitic fluid
  • often gram -ve stain - use blood culture bottles for this
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35
Q

what are some tests for encephalopathy?

A

Serial 7’s
WORLD backwards
Animal counting in 1 minute
Draw 5 point star
Number connection test

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36
Q

what are the causes of chronic liver disease?

A
  • alcohol
  • NASH
  • viral hepatitis - B, C
  • immune - autoimmune hepatitis, primary biliary cirrhosis, sclerosing cholangitis
  • metabolic - wilsons, haemochromatosis
  • vascular - Budd-Chiari
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37
Q

what do laborartory tests show when testing for autoimmune hepatitis?

A
  • Elevated liver enzymes (ALT, AST).
  • High serum globulin or gamma-globulin levels.
  • Presence of autoantibodies - eg ANA, ASMA, ALKM-1, SLA/LP
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38
Q

what is essential to diagnose autoimmune hepatitis?

A

liver biopsy
- Shows interface hepatitis, lymphoplasmacytic infiltration, rosette formation of hepatocytes, and, in chronic cases, fibrosis or cirrhosis

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39
Q

what are differential diagnosis of autoimmune hepatitis?

A
  • viral hepatitis
  • alcoholic liver disease
  • non-alcoholic fatty liver disease
  • drug-induced liver injury
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40
Q

how is autoimmune hepatitis treated?

A
  • corticosteroids - Prednisone or prednisolone
  • azathioprine in comination with above
  • immunosuppressants
  • liver transplant in liver failure
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41
Q

what are the clinical presentations/ laboratory tests for primary biliary cholangitis?

A
  • more common in females
  • fatigue and itching
  • abdo pain & jaundice
  • elvated ALP and GGT
  • +ve antimitochondrial antibody AMAs - 95% of cases
  • elevated serum bilirubin and liver enzymes in advanced disease
  • elevated IgM levels
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42
Q

what are the treatment options for Primary Biliary Cholangitis?

A
  • Ursodeoxycholic Acid (UDCA) - improves survival
  • Obeticholic Acid (OCA) - if above is not tolerated
  • Cholestyramine for pruritus
  • liver transplant
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43
Q

what are the treatment options for Primary sclerosing Cholangitis?

A
  • Ursodeoxycholic Acid (UDCA) - improves LFTs, not survival
  • Cholestyramine for pruritus
  • liver transplant
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44
Q

what condition is Primary Sclerosing Cholangitis linked to?

A

IBD usually ulcerative colitis

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45
Q

what condition is Primary biliary Cholangitis linked to?

A

sjogren syndrome
rheumatoid artharitis
systemic sclerosis

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46
Q

what is inflammed in Primary Biliary Cholangitis (PBC) vs Primary Sclerosing Cholangitis (PSC)?

A

PBC - intrahepatic bile duct
PSC - intra and extrahepatic bile duct

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47
Q

what does Primary Sclerosing Cholangitis present with?

A
  • itching
  • pain +/- rigors
  • cholangitis
  • raised ALP and GGT
  • more common in males than females
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48
Q

how is Primary Sclerosing Cholangitis diagnosed?

A

blood tests - raised ALP, AST/ALT
antibodies - anti-smooth muscle, anti-nulcear, PANCA
MRCP - gold standard - “beads on a string”

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49
Q

what is Haemochromatosis?

A

genetic disorder characterized by excessive absorption and accumulation of iron in the body

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50
Q

what is the most common gene mutation in Haemochromatosis?

A

C282Y
H63D
- autosomal recessive

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51
Q

how is a diagnosis made for Haemochromatosis?

A
  • suggested by raised ferritin and transferrin levels
  • confirmed by genotyping and liver biopsy
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52
Q

what can alpha1-antitrypsin deficiency lead to?

A

liver disease
emphysema - protein deficiency in blood

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53
Q

what do 50% of cases with hepatcellular carcinoma produce?

A

alpha fetoprotein

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54
Q

what are risk factor for non-alcoholic fatty liver?

A
  • obesity
  • diabetes
  • hyperlipidaemia
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55
Q

what are the LFTs in non-alcoholic fatty liver?

A

mildly elevated

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56
Q

what is NASH?

A

Nonalcoholic Steatohepatitis
- advanced form of fatty liver disease - also includes inflammation and liver cell damage aswell as fat
- may progress to cirrhosis or hepatocellular carcinoma

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57
Q

what may hepatic vein occlusion be caused by and be treated with?

A

caused by thrombosis, membrane obstruction, veno-occlusive disease

treated by: anticoagulants, TIPS - shunt

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58
Q

what are the main causes of diarrhoea?

A

infections - bacteria/viruses
inflammation - chrons
loss of absorptive area - coeliac
Pancreatic disease
Drugs - antibiotics
colon cancer
IBS

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59
Q

what is the main difference in causes of acute/chronic diarrhoea?

A

acute - viral/bacteria
chronic - parasites or non infectious

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60
Q

what pathogens cause watery diarrhoea?

A

cholera
staph aureus
rotavirus
norovirus
giardia
(non-inflammatory)

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61
Q

what pathogens cause bloody, mucoid diarrhea?

A

shingella
e.coli
salmonella
c.diff
campylobacter jejuni
(inflammatory)

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62
Q

whats the most common cause for travellers diarrhoea?

A

Enterotoxigenic e.coli

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63
Q

what does ETEC, EHEC, EIEC cause?

A

ETEC - non invasive watery diarrhoea - LT and ST entertoxins
EHEC - Shiga-like toxin. Can cause Haemolytic Uraemic Syndrome (HUS)
EIEC - similar to shingella

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64
Q

what are symptoms of cholera infection and how is it treated?

A
  • “rice water” diarrhoea, vomiting, dehydration
  • doxycyline and fluids
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65
Q

what bacteria causes peptic ulcers?

A

helicobacter pylori

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66
Q

how is H.plori tested for?

A

breath test
stool antigen test
blood test

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67
Q

what are the tests for peptic ulcers?

A

test for H.pylori
endoscopy with biopsy
barium contrast x ray - highlights ulcers
ct scan or mri in complications

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68
Q

what is the treatment for peptic ulcers?

A

CAP - Clarithromycin, Amoxicillin (antibiotics), PPI eg omeprazole (reduce stomach acid)
- H2 blockers - reduce stomach acid to lesser extent
-antacids
- cytoprotective agents for lining of stomach

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69
Q

how is acute cholecystitis diagnosed and treated?

A
  • examination (murpheys sign), bloods/ultrasound to confirm- urgent diagnosis needed
  • iv fluids, analgesia, antibiotics, surgery
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70
Q

what are the main symptoms of acute cholecystitis?

A
  • RUQ or epigastric pain
  • fever
  • leucocytosis
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71
Q

what is charcots triad?

A

3 symptoms indicating bile ducts problems
- fever
- jaundice
- RUQ pain

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72
Q

what is the treatment of Ascending cholangitis?

A
  • antibiotics
  • ERCP
  • gallstone removal
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73
Q

what causes enteric fever (typhoid fever)?

A

salmonella typhi

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74
Q

what are symptoms of enteric fever?

A
  • prolonged fever
  • abdo pain, green diarrhoea, maybe constipation
  • headache, malaise
  • rose spot rash on trunk
  • relative bradycardia
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75
Q

how is enteric fever diagnosed?

A
  • blood cultures
  • bone marrow culture, if blood -ve, more sensitive
  • stool culture - shows extend of shedding
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76
Q

what is the treatment for enteric fever?

A

antibiotics - azithromycin, ciprofloxacin, cephalosporins
- need early diagnosis and antibiotics ASAP

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77
Q

what are complications of enteric fever?

A

GI bleed
Perforation / peritonitis
Myocarditis
Abscesses

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78
Q

what is the stool/urine colour in jaundice?

A

pre-hepatic - stool normal, urine slightly dark/normal
hepatic - stool normal/pale, urine dark
post-hepatic - stool pale, urine dark

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79
Q

what jaundice causes itching?

A

post-hepatic
sometimes hepatic

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80
Q

what jaundice has both conjucated and unconjucated bilirubin elevated?

A

hepatic

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81
Q

what are the liver enzymes tests for pre hepatic jaundice?

A

normal

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82
Q

generally, when are alkaline phosphate ALP levels elevated?

A
  • liver disease - eg hepatitis
  • impairment of bile flow eg. bile duct obstruction, primary biliary cirrhosis, and cholangitis.
  • bone disease eg pagets
  • GI eg celiac
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83
Q

when is Gamma-Glutamyl Transferase (GGT) elevated?

A
  • biliary outflow obstruction
  • Primary Biliary Cholangitis
  • liver disease
  • HF, pancreatitis etc
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84
Q

what does elevated Aspartate Aminotransferase (AST) liver enzyme show?

A

indicates hepatocellular damage
- but not specific to liver - can be elevated with muscle damage

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85
Q

what do elevated levels of Alanine Aminotransferase (ALT) show?

A
  • hepatocellular damage - (more specific then AST)
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86
Q

how much is one unit of alcohol?

A

8 grams or 10ml of pure alcohol

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87
Q

how do work out number of units in an alcoholic drink?

A

Strength of the drink (% ABV)
x
Amount of liquid (Litres)

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88
Q

what is the guideline for drinking per week?

A

no more than 14 units

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89
Q

what are some alcohol withrawal syndromes?

A

Tremulousness
Activation syndrome - characterized by tremulousness, agitation, rapid heartbeat and high blood pressure
Seizures
Hallucinations
Delirium tremens - can be severe/fatal

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90
Q

what syndrome is caused by pre-natal exposure of alcohol?

A

Foetal Alcohol Spectrum Disorder (FASD)

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91
Q

what is the alcohol harm paradox?

A

the observation that people of low socioeconomic status (SES) tend to experience greater alcohol-related harm than those of high SES, even when the amount of alcohol consumption is the same or less than for individuals of high SES

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92
Q

what do the NICE Guidance 24 : Alcohol-use disorders: preventing alcohol use disorders target?

A
  • price, availability, marketing of alcohol
  • licensing
  • screening and brief interventions
  • supporting children and young people
  • referral
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93
Q

what alcohol harm preventions are there in the UK?

A
  • Minimum Unit Pricing
  • Restriction on alcohol advertising
  • dry january - enables choice
  • Alcohol labelling (industry self-regulation), Drinking guidelines
  • Media campaigns
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94
Q

what is at risk drinking?

A

A pattern of drinking which brings about the risk of physical or psychological harm – Screening tools

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95
Q

what is harmful drinking?

A

Harmful drinking a pattern of drinking which is likely to cause physical or psychological harm

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96
Q

what is Alcohol use disorder or Alcohol dependence?

A

diagnoses based on DSM-V criteria for AUD or ICD criteria for dependence.
Not solely defined by consumption levels, but also by behavioural, cognitive and physiological responses or problems related to alcohol use.

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97
Q

what are some alcohol screening questions and tools?

A
  • A Clinical Interview – a single question about heavy drinking days
  • FAST - Fast Alcohol Screening Test
  • AUDIT - Alcohol Use Disorders Identification Test
  • CAGE Questions
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98
Q

what are some medications for alcohol dependence?

A
  • Acamprosate Calcium (Campral)
  • Disulfiram (Antabuse).
  • Nalmefene (Selincro).
  • Naltrexone also in drug dependence
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99
Q

what is a positive score in the FAST screening tool?

A

3 or more

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100
Q

what do the scores in an AUDIT screening indicate?

A

up to 7 - low risk - no intervention
8-15, 16-19 - increasing/high risk - brief advice
over 20 - possible dependance - referral

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101
Q

what are the CAGE questions for drinking alcohol?

A

C - cutting down?
A - Annoyed you by people saying to cut down?
G - Guilty feeling about dreeking
E - Eye-opener - taking a drink in the morning?
- 2 or more +ve responses indicate a likely problem

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102
Q

what is the FRAMES interventions for at-risk dinking?

A

Feedback about the risk of personal harm or impairment
Stress personal Responsibility for making change
Advice to cut down or, if necessary, stop drinking
Provide a Menu of alternative strategies for changing drinking patterns
Empathetic interviewing style
Self efficacy: intuitive style which leaves patient enhanced in feeling able to cope with goals they have agreed

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103
Q

what is substance misuse?

A

Relates to the harmful use of any substance for non-medical purposes or effect

104
Q

what is addiction?

A
  • Involves compulsive use of a substance despite harmful consequences
  • Often involves structural and biochemical changes to parts of the the brain linked to reward, self-control and stress
105
Q

what is psychological dependance?

A

Feeling that life is impossible without the drug. Emotional effect: feelings of fear, pain, shame, guilt, loneliness if not on drug

106
Q

what is physical dependance?

A

Body needs more and more of a drug for same effect (tolerance) Depending on substance: withdrawal symptoms, eg runny nose, stomach cramps, muscle aches

107
Q

what are the ICD-10: F10-F19 diagnostic codes?

A

classify mental and behavioral disorders due to psychoactive substance use

108
Q

what is the most common cause for an upper GI bleed?

A

peptic ulcer

109
Q

what is the glasgow-blathford score?

A

score to asses likelyhood of an upper GI bleed, consisting of:
low systolic BP
high blood urea
low haemoglobin
(pulse over 100, malaena, syncope, hepatic disease, cardiac disease)

110
Q

what is the management of an upper Gi bleed?

A

endoscopy - keep NBM
gastric band/clips

111
Q

what patient history makes variceal bleed vs non-variceal upper GI bleed more likely?

A

variceal
- history of liver diease & alcohol excess

non-variceal
- history of peptic ulcers, NSAIDS use or anticoagulation or antiplatelets

112
Q

what medications is given to variceal vs non-variceal bleeds?

A

variceal - Antibiotics and Terlipressin
non-variceal - PPI

113
Q

what are the possible causes of an upper GI bleed?

A
  • peptic ulcer - gastric/duodenal
  • oesophageal varices
  • mallory-weiss syndrome
  • haemorrhagic gastropathy and erosion
  • Gastroesophageal Reflux Disease
114
Q

what are symptoms/signs of upper GI bleed?

A
  • Pre-syncope/syncope
  • Haematemesis - coffee ground vomit
  • abdo pain
  • Malaena - black tarry stools
  • high HR, low BP
115
Q

what can cause intestinal intraluminal obstruction?

A
  • tumours - carcinoma/lymphoma
  • diaphragm disease - fibrous - by NSAIDs
  • meconium ileus (newborn stool blockage)
  • gallstone ileus (large gallstone breaking into bowel)
116
Q

what can cause intestinal intramural obstruction?

A
  • inflammatory - crohn’s disease (strictures-narrowing) & diverticulitis- in sigmoid colon
  • tumours
  • neural - Hirschsprung’s disease - in babies no ganglia cells to contract bowels
117
Q

what can cause intestinal extraluminal obstruction?

A
  • adhesions - from previous surgery
  • volvulus - sigmoid twisting
  • tumour - peritoneal deposits
118
Q

what is a GI obstruction?

A

anything that prevents the passage of it’s contents

119
Q

what are the symptoms of a GI obstruction?

A

abdo pain - colic pain
vomiting
distension
constipation

120
Q

what are the most common reasons for small bowel obstructions?

A
  • adhesions - scar tissue
  • hernias
  • tumours
  • Intussusception - invagination of intestine
  • volvulus - twisting of intestine
121
Q

what is a gallstone ileus?

A

form of small bowel obstruction caused by a gallstone
- normally enters intestine by a fistula which is a abnormal connection thats formed

122
Q

what do you look for when examining someones abdomen for bowel obstruction?

A

distended
tympanic - drum like sound - shifting
tender
hernia
bowel sounds - high pitched/tinkling
scars

123
Q

what are the investigations for bowel obstruction?

A

X-ray
CT scan
ultrasound
blood tets - CBC - infection/anemia, LFT & KFT, lactic acid levels - bowel ischemia

124
Q

what are the treatments for bowel obstruction?

A
  • NG tube - decompression
  • fluids, electrolytes
  • surgery - on scar tissue/adhesions
  • stents
  • pain relief
125
Q

what are common reasons for large bowel obstruction?

A
  • colorectal cancer
  • diverticulitis
  • volvulus
  • strictures
  • Colonic Pseudo-Obstruction (Ogilvie Syndrome)
126
Q

what is a precurser of oesophageal adenocarcina?

A

barrets oesophagus - obesity is a risk factor

127
Q

what are oesophageal cancer symptoms?

A

non-specific
- reflux and difficulty swallowing

128
Q

what are risk factors of gastric cancer?

A
  • helicobacter pylori infections
  • age, male
  • diet - smoked food and high salt
  • tobacco and alcohol
  • family history
129
Q

what is a precurser for colorectal cancer?

130
Q

what gene mutation has been found to cause colorectal cancer?

A

APC gene - breaks down beta catenin

131
Q

why are hereditary nonpolyposis
colorectal cancers important to spot?

A

(lynch syndrome)
- autosomal dominant inheritance
- risk of further cancers and colorectal cancer
- have fewer polyps but higher risk of devloping colorectal cancer

132
Q

what can cause diarrhoea?

A

non-infective causes:
neoplasm
inflammation - crohns/ulcerative colitis
IBS
anatomical - short gut
hormones - hyperthyroidism
radiation
chemical - drugs

infective causes
bacteria/viruses/parasites

133
Q

what are some common pathogens that cause bloody diarrhoea?

A

shingella
e.coli
campylobacter
salmonella
c.diff

134
Q

what common pathogens cause non-bloody diarrhoea?

A

e.coli
cholera
c.diff
noravirus
rotavirus
giardia

135
Q

what most likely causes diarrhoea at different onset stages?

A

within 6 hours - toxin mediated
within 24h - viruses
a couple days - bacteria

136
Q

what medication is used to treat c.diff?

A

metronidazole or vancomycin

137
Q

what is the timelength of acute vs chronic hepatitis?

A

acute 0-6 months
chronic - over 6 months

138
Q

what are the signs/symptoms of acute hepatitis?

A
  • None or non-specific, e.g. malaise, lethargy, myalgia
  • abdo pain
  • jaundice - pale tools/dark urine
  • tender hepatomegaly
  • signs of fulminant hepatitis - bleeding etc.
  • Raised transaminases (ALT/AST > GGT/ALP)
  • raised bilirubin
139
Q

what are some causes of acute hepatitis?

A
  • viral - hep A/B/C/D/E, HSV
  • non-viral - bacteria, leptospirosis, syphilis, TB
  • drugs
  • alcohol
  • non-alcoholic fatty liver disease
  • pregnancy
  • autoimmune hepatitis
140
Q

what are signs/symptoms of chronic hepatitis?

A
  • can be asymptomatic
  • clubbing, palmar erythema, Dupuytren’s contracture, spider naevi
  • transamines ALT/ST may be normal
  • low albumin
141
Q

what may cause chronic hepatitis?

A
  • hep B/C most commonly
  • drugs, alcohol
  • non-alcoholic liver disease
  • autoimmune hepatitis
142
Q

how is hep A transmitted?

A

Faeco-oral transmission
- Contaminated food & water

143
Q

is hep A symptomatic or asymptomatic?

A

usually symptomatic - abdo pain
immune after infection

144
Q

how is a Hep A infection managed?

A

supportive - eg manage liver failure, painkillers etc.
- primary prevention like vaccines for travellers etc.
- self-limiting - no chronic disease, clears 3-6 months

145
Q

what are the 4 genotypes of hep E and how are they transmitted?

A

G1 & G2 - Faeco-oral transmission - contamined food/water
G3 & G4 - zoonotic - undercooked meat

146
Q

who is at risk of chronic hepatitis from hep E?

A

immunosuppressed - from G3/4 only

147
Q

is hep E symptomatic or asymptomatic?

A

> 95% cases asymptomatic
- can have extra-hepatic manifestations eg neurological

148
Q

how is chronic hepatitis from hep E managed?

A
  • Reverse immunosuppression (if possible)
  • If HEV RNA persists, ribavirin ≥ 3 mths
149
Q

what is the transmission of hep B?

A

Transmission via blood and body fluids
- mother to child, sexual contact, blood products

150
Q

is hep b symptomatic or asymptomatic?

A

usually symptomatic in adults
usually asymptomatic in infants

151
Q

how is hep b treated?

A
  • oral nucleos(t)ide analogues - TDF/TAF - inhibit viral replication
  • pegylated interferon-α 2a - stimulates immune response - many side effects
152
Q

how is hep B prevented in mother to baby?

A
  • vaccinations given at birth and later
  • HBIG given at birth if mothers e-antigen +ve or high HBV or low birth weight
  • tenofovir given to mother in pregnacy if high HBV
153
Q

how is hep D transmitted?

A

Blood-borne virus - Transmission via blood and body fluids
- transmitted with hep B

154
Q

how is hep D treated?

A
  • pegylated inteferon-α 48 weeks
  • Myrcludex B
155
Q

how is hep C transmitted?

A
  • via blood and body fluids
  • drug users mainly
156
Q

what are the outcomes of hep B?

A

usually Spontaneous resolution

157
Q

what are the the outcomes of hep C infection?

A

30% Spontaneous resolution
70% Chronic HCV infection - possible cirrhosis and carcinoma

158
Q

how is hep C treated?

A

Directly-acting antiviral (DAA) therapy
- need to know genotype

159
Q

what are the infective features of hep C?

A
  • infection does not cause immunity
  • can be re-infected
  • no vaccine
160
Q

how is hep c detected/tested for?

A

HCV Antibody Test
HCV RNA Test
Genotype Test

161
Q

what hepatitis have vaccines?

162
Q

what criteria is used to asses celiac disease?

A

modified marsh criteria - type 0 to 4
- asses villi atrophy and hypoplasia of small bowel

163
Q

what is the management of celiac disease?

A
  • gluten free diet
  • vaccinations
  • nutritional supplements
164
Q

what is the risk of not going gluten free in celiac disease?

A
  • Gastrointestinal Complications - diarrhea, constipation, malabsorption, lactose intolerance
  • fertility issues
  • Dermatitis Herpetiformis - skin rash
  • Peripheral Neuropathy
  • antaxia - problems with balance
  • increased risk of cancer
  • osteoporosis
  • increased risk of developing other autoimmune disorders
165
Q

what do blood tests detect when testing for celiac disease?

A
  • anti-tissue transglutaminase (tTG) antibodies
  • anti-endomysial antibodies (EMA).
166
Q

what are the tests/investigations for coeliac disease?

A
  • blood test - detect antibodies
  • endoscopy biopsy - asses damage to intestine
  • genetic testing - associated genetic markers
167
Q

what are some signs/symptoms of celiac disease?

A
  • chronic diarrhea/constipation
  • abdo pain/cramping
  • weight loss/malnutrition
  • Dermatitis Herpetiformis
  • anemia, iron b12 deficiencies
  • fatigue/weakness
  • joint/muscle pain
  • reproductive issues
  • numbness/tingling
  • tooth enamel defects
168
Q

what are the signs/symptoms of cholera infection?

A
  • profuse, watery diarrhea
  • vomiting
  • rapid dehydration
  • hypovolemic shock - suken eyes, wrinkled skin, decreased skin tugor
169
Q

what are the signs/symptoms of shigella infection?

A
  • Bloody diarrhea
  • abdominal pain
  • fever
  • tenesmus (feeling of incomplete evacuation)
170
Q

what are the signs/symptoms of a c.diff infection?

A

Watery diarrhea
abdominal pain
fever
loss of appetite
nausea
colitis

171
Q

what are the signs/symptoms of norovirus?

A
  • sudden onset of vomiting & diarrhea
  • abdo cramps
  • nausea
  • sometimes fever
172
Q

how is hep B detected/tested for?

A

HBsAg Test
Anti-HBc Test
HBV DNA Test

173
Q

how is hep A detected/tested for?

A

hep A antibody test

174
Q

what hepatitis can become chronic?

A

hep B
hep C

175
Q

how is hep E detected/tested for?

A

Anti-HEV IgM Test

176
Q

what common Ig are tested for in hepatitis?

A

IgM - associated with acute hepatitis
IgG - associated with chronic hepatitis

177
Q

what can cause erosin of the mucosal lining in the stomach?

A

stress
drugs
alcohol
helicobacter
autoimmune condition

178
Q

what is gastritis?

A

inflammation of the gastric mucosa, the inner lining of the stomach
can be chronic or acute

179
Q

what is the management for gastritis and gastric ulcers?

A
  • PPIs - omeprazole
  • H2 receptor antagonists
  • Protect the Stomach Lining - sucralfate, Misoprostol
  • avoid NSAIDs
180
Q

what can cause malabsorption?

A
  • coeliac disease - gluten damages villi
  • crohns disease - inflammation
  • Chronic Pancreatitis - less pancreatic enzymes
  • liver disease - less bile produced
  • bacteria overgrowth - competition for nutriets
  • gardia - damage to mucosal lining
  • lactose intolerance
  • Glucose-Galactose Malabsorption
  • short bowel syndrome - due to surgery
181
Q

what are gallstones made of?

A
  • cholesterol gallstones - mainly cholesterol, and calcium and bilirubin
  • Pigment Gallstones - bilirubin - darker - less common
182
Q

how does CCK effect bile/gallbladder?

A
  • Stimulation of Gallbladder Contraction
  • Relaxation of the Sphincter of Oddi
  • Increased Bile Production
183
Q

what does the billiary system drain into?

A

ampulla of vater

184
Q

what are the symptoms of gallstones?

A
  • pain - sharp, upper right abdomen
  • fever
  • jaundice
  • Nausea and Vomiting
185
Q

what are the investigation for gallstones?

A
  • blood test - Alanine Transaminase, bilirubin, amylase
  • ultrasound
  • MRCP - MRI scan of bile system
  • CT abdomen and pelvis
186
Q

what does high bilirubin show when investigation gallstones?

A

blockage of biliary tree

187
Q

what does Alanine Transaminase show when investigating gallstones?

A

high = inflammation/infection
/ obstruction

188
Q

what does amylase show when investigating gallstones?

A

high = pancreatitis/ pancreatic damage

189
Q

what are the treatment options for gallstones?

A
  • concervative management - Analgesia/antibiotics
  • radiological drain - Tube through skin into gallbladder
  • ERCP - endoscopy through stomach to biliary tree
  • cholecystectomy - keyhole operation
    to remove gallbladder and
    stones
190
Q

what is Empyema vs
Mucocoele in the gallbladder?

A
  • Empyema - infection due to pus filling gallbladder - can cause spetic shock
  • Mucocoele - mucus forming causing distension
  • both likely due to blockage of cystic duct
191
Q

what conditions have gallstones in the common bile duct?

A
  • Choledocholithiasis
  • Cholangitis
  • Pancreatitis
192
Q

where are the gallstones in gallstone ileus?

A

ileocaecal valve

193
Q

what is the pathological features of crohns disease?

A
  • Transmural Inflammation - full thickness of intestine
  • fistulas - abnormal connections between intestine
  • strictures - narrowing of intestine
  • Skip Lesions
  • granulomas
194
Q

what are pathalogical features of ulcerative colitis?

A
  • Continuous Mucosal Inflammation of colon and rectum
  • Crypt Abscesses - inflammatory cells
  • Pseudopolyps - areas of regeneration
195
Q

what are symptoms of crohns and ulcerative colitis?

A
  • fatigue
  • weight loss - more in crohns
  • pain in abdomen
  • diarrhoea (bloody & pus in ulcerative colitis)
  • rectal bleeding mainly in ulcerative colitis
196
Q

what are the complications of ulcerative colitis?

A
  • megacolon - severe - colon dilates and ruptures
  • severe bleeding due to ulceration
  • colon cancer high risk
  • anemia
  • osteoporosis
197
Q

what are the complications of crohns?

A
  • Perianal disease - fissures and skin tags
  • Strictures - narrowing of intestine - bowel obstruction
  • osteoporosis
  • anemia
  • colon cancer risk
198
Q

what are the investigations for crohns/ulcerative colitis?

A
  • bloods - CRP & ESR - inflammation markers, FBC (anemia?)
  • stool tests - calprotectin - inflammation markers, presence of blood and bacteria (differential diagnosis)
  • colonoscopy and endoscopy
  • biopsy
  • genetic testing - NOD2 = crohns
199
Q

what are the treatment/management options for crohns/ulcerative colitis?

A
  • medications: Aminosalicylates, corticosteroids, JAK inhibitors, immunomodulators
  • anti-diarrhoea drugs (Loperamide) & analgesia
  • diet changes & nutritional supplements - eg low residue
  • surgery - colectomy
200
Q

are Extraintestinal Manifestations more common in crohns or ulcerative colitis?

A

crohns
- such as eyes, skin and joints

201
Q

what is Functional Dyspepsia?

A
  • persistent or recurrent pain or discomfort centered in the upper abdomen
  • often associated with early satiety, bloating, or nausea
202
Q

what are coeliac serology tests?

A

antibody tests
- IgA Anti-tissue Transglutaminase (tTG)
- IgA Endomysial Antibodies (EMA)
- IgA Anti-deamidated Gliadin Peptide (DGP)

203
Q

how is IBS diagnosed using rome criteria?

A

Rome IV criteria:
- abdominal pain/discomfort at least once a week for the past three months
- associated with two or more of the following criteria:
- Improvement with defecation
- Change in Frequency of Stool
- Change in Form (Appearance) of Stool

204
Q

how else is IBS diagnosed other than rome criteria?

A
  • symptoms of abdo pain over 6 months and:
  • relieved by defecation
  • Altered stool passage - straining, urgancy, imcomplete
  • bloating
  • worse after eating
  • mucus in stools
  • exluclusion of other causes eg IBD
205
Q

what is the treatment of IBS?

A
  • diet changes - Low-FODMAP Diet, Soluble fiber supplements
  • probiotics
  • medications: Antispasmodic (cramping), Laxatives or Anti-diarrheal, Serotonin Modulators
  • CBT if associated with stress/anxiety
  • regular exercise
206
Q

what are ibs symptoms?

A
  • Abdominal Pain or Discomfort: Often relieved by a bowel movement.
  • Altered Bowel Habits: Constipation, diarrhea, or a mix of both (alternating).
  • Bloating and Gas
  • Mucus in Stool
207
Q

what are the subtypes of IBS?

A

IBS-D
IBS-C
IBS-M
IBS-U

208
Q

what is the definition of functional GI disorders?

A

Chronic GI symptoms in the absence of organic disease to explain the symptoms.
“disorders of gut-brain interaction”

209
Q

what investigations are required for functional dyspepsia?

A
  • history
  • examinations
  • FBC, CR, LFT, coeliac serology
  • stool - helicobacter.p
  • if alarm features - endoscospy/ct scan
210
Q

what does faecal calprotectin show?

A

gi inflammation

211
Q

what are the investigations required for ibs?

A
  • history & examination
  • FBC, CRP, coeliac serology
  • Stool calprotectin
  • Stool culture for parasites/bacteria
  • ca-125 in women - overian cancer marker
  • endoscopy/ct scan if suspected cancer
212
Q

what does CRP show in a blood test

A

C-reactive protein made by liver
- high = inflammation/infection

213
Q

what is peritonitis?

A

inflammation of the peritoneum - visceral and parietal

214
Q

how is peritonitis classified?

A
  • acute/chronic
  • primary (no apparent source) or secondary (contamination by bacteria/fungi by rupture/perforation - appendicitis)
  • localised or generalised (often chronic/serious)
215
Q

what are the causes of peritonitis?

A
  • perforation - appendix, ulcer, diverticulum
  • postoperative complications
  • transmural translocation - pancreatitis, ischaemic bowel, primary bacterial peritonitis
  • female genital tract infection
  • haematogenous spread (rare) - sepsis
  • liver cirrhosis
216
Q

what microorganisms most commonly cause peritonitis?

A
  • Escherichia coli - cirrhosis
  • klebsiella, e.coli, clostridium spp, steptococci - secondary
  • TB - spread by blood
217
Q

what are symptoms of localised peritonitis?

A

—Pain
—Nausea and vomiting
—Fever
—Tachycardia
—Localised guarding
—Rebound tenderness
—Shoulder tip pain ( subphrenic)
—Tender rectal and / or vaginal examination (pelvic peritonitis).

218
Q

what are symptoms of generalised peritonitis in early stages?

A
  • Abdominal pain ( worse by moving or breathing)
    —Tenderness
    —Generalised guarding
    —Infrequent bowel sounds àcease ( paralytic ileus)
    —Fever
    —Tachycardia
219
Q

what are generalised peritnitis symptoms in the late stages?

A
  • Generalised rigidity
    —Distension
    —Absent bowel sounds
    —Circulatory failure
    —Thready irregular pulse
    —(Hippocratic face)
    —Loss of consciousness
220
Q

what investigations are required for pericarditis?

A
  • urine dipstix - UTI
  • ECG - if cardiac history
  • Bloods, U&E, FBC - inflammation markers/kidney function
  • Serum amylase - pancrease involvement
  • xray, ultrasound, ct scan
221
Q

what is the management of peritonitis?

A
  • fluids - dehydration
  • antibiotics
  • analgesics
  • surgery - repair viscus and drain
222
Q

what is Spontaneous bacterial peritonitis?

A
  • bacterial infection of ascitic fluid, secondary peritonitis associated with liver
  • rapid progression
  • risk of septic shock & orga failure
223
Q

what is ascites?

A

Effusion and accumulation of serous fluid in the abdominal cavity

224
Q

what are the stages of ascites?

A
  • Stage 1 detectable only after careful examination / Ultrasound scan (Mild)
  • Stage 2 easily detectable but of relatively small volume.
  • Stage 3 obvious, not tense ascites. (moderate)
  • Stage 4 tense ascites. (Large)
225
Q

what is the difference between Diuretic resistant ascites and Diuretic intractable ascites?

A

resistant - doesn’t respond to high dose diuretic or sodium restriction

intractable - more severe - complications from diuretic therapy - need draining not diuretics

226
Q

what is diagnostic criteria for refractory ascites?

A
  • Lack of response to maximal doses of diuretic for at least 1 week.
  • Diuretic-induced complications
  • Early recurrence of ascites within 4 weeks of fluid mobilization.
  • Persistent ascites despite sodium restriction.
  • Mean weight loss <0.8 kg over 4 days.
  • Urinary sodium excretion is less than sodium intake.
227
Q

what are the causes of ascities?

A
  • cirrhosis
  • malignancy - gynelogical 50%
  • heart failure
  • Tb
  • pancreatitis
228
Q

what are the theories that explain ascites pathophysiology?

A
  • under-filling - portal hypertension
  • over-filing - inappropriate na & o2 retention
  • peripheral arterial vasodilation
229
Q

what causes chylous ascites?

A

abdominal surgery
trauma,
malignancy,
radiation,
congenital

230
Q

what is the pathophysiology of liver ascites?

A
  • portal hypertension
  • NO vasodilators release
  • systemic BP falls - due to vasodilation
  • RAAS activated
  • increased Na and water retention by kidneys
  • increased plasma hydrostatic pressure
  • increased fluid in peritoneal cavity
231
Q

what is the protein concentration for exudate vs transudate ascites?

A

exudate - above 2.5g/dL
transudate - below 2.5g/dL

232
Q

what causes transudate ascites (high SAAG)?

A
  • Cirrhosis
  • Hepatic failure
  • Venous occlusion (e.g. Budd Chiari syndrome)
  • Fulminant hepatic failure
  • Alcoholic hepatitis
  • Kwashiorkor malnutrition
  • congeestive HF
233
Q

what type of ascites is chylous ascites?

A

exudate
- milk appearance
- from thoracic or intestinal lymph

234
Q

what are symptoms of ascites?

A
  • abdo distension
  • nausea, loss of appetite
  • constipation
  • cachexia, weight loss
  • pain/discomfort (signifies (non)malignant
  • shortness of breath
235
Q

what tests are needed to diagnose ascites?

A

inspection of fluid - transparent/yellow, Cloudy purulent fluid = infection, blood = trauma/cancer
- proteins/amylase
- PMN - neutrophil count
- cytology - cancer
- gram stain - bacteria
- ultrasound, CT, xray - raised diaphram and fluid

236
Q

what is the SAAG test for ascites?

A
  • portal hypertensive (SAAG >1.1 g/dL) - transudatee
  • non–portal hypertensive (SAAG < 1.1 g/dL) - exudate
  • correlates with portal pressure
237
Q

where are morison pouch ascites?

A

posterior subhepatic space

238
Q

what indicates malignant ascites?

A
  • low SAAG + high protein level
  • cytology test for cancer cells
239
Q

how much fluid is usually required to diagnose ascites?

240
Q

what is hellmer sign?

A

displacement of the lateral edge of the liver toward the midline
- due to ascites

241
Q

what can cause chylous/milky ascites fluid?

A
  • lymphoma
  • malignancy
  • TB
242
Q

what does clear/straw ascites fluid most commonly show?

243
Q

what does cloudy ascites fluid show?

A
  • bacterial peritonitis
  • perforated bowel
  • pancreatitis
244
Q

what can lower glucose in ascites than in serum signify?

A

TB
malignancy

245
Q

what causes exudate ascites (low SAAG)

A

Malignancy
Infection
Pancreatitis
Nephrotic syndrome

246
Q

what causes dieased peritoneum?

A
  • infections
  • malignancy
  • Familial Mediterranean fever
  • Vasculitis
  • Granulomatous peritonitis
247
Q

how is SAAG calculated?

A

SAAG = (serum albumin) – (ascitic fluid albumin)

248
Q

how is ascites treated/managed?

A
  • treat underlying cuase
  • salt and fluid restriction
  • diuretics
  • albumin supplements
  • paracentesis - needle fluid removal
  • TIPS - shunt (for diuretic-refractory)
  • peritoneovenous shunt
249
Q

what is the most sensitive/easiest
way to detect ascitic fluid?

A

ultrasonography

250
Q

what is dukes staging system?

A

for bowel cancer
A - cancer is in the inner lining of the bowel
B - cancer has grown through the muscle layer of the bowel
C - cancer has spread to at least 1 lymph node close to the bowel
D - cancer has spread to another part of the body, such as the liver, lungs or bones.

251
Q

what is tested for when dyspepsia is suspected?

252
Q

what drugs are given to reduce mortality in GI bleeds?

A

antibiotics
Terlipressin - reduces bleeds

253
Q

where does microscopic colitis happen?

254
Q

what is the difference between cholangitis and cholecystitis?

A

cholangitis - bile ducts, jaundice
cholecystitis - gallbladder, pain/fatty stools

255
Q

what suggests a Uncomplicated gallstone?

A

RUQ pain/bloating with no Fever or jaundice etc

256
Q

what does raised alp with ggt show?

A

Cholestasis
- gallstones, pancreatic malignancy

257
Q

what does an isolated raised GGT show?

A

alcohol excess

2A (9 decks)

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