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
2
Q
what is the differene in cells in acute vs chronic liver injury?
A
acute - cell damage/loss
chronic - fibrosis
3
Q
what can cause acute liver injury?
A
viral (A,B, EBV)
drug
alcohol
Vascular
Obstruction
Congestion
4
Q
what can cause chronic liver injury?
A
alcohol
viral (B,C)
autoimmune
metabolic (iron, copper)
5
Q
what are the presentations of acute liver failure?
A
malaise - feeling ill/unwell
nausea
anorexia
jaundice
6
Q
what are the presentations of chronic liver injury?
A
ascites
oedema
haematemesis (varices)
malaise
anorexia
wasting
easy bruising
itching
hepatomegaly
abnormal LFTs
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
8
Q
what does elevated unconjucated billirubin show?
A
pre-hepatic
9
Q
what does elevated conjucated bilirubin show?
A
post hepatic - bile duct obstruction
10
Q
what can cause pre hepatic jaundice?
A
Haemolysis, Gilberts
11
Q
what can cause hepatic jaundice?
A
Hepatitis: viral, drugs immune, alcohol
Ischaemia
Neoplasm
Congestion (CCF)
12
Q
what can cause post hepatic jaundice?
A
Gallstones.
Surgical strictures.
Extra-hepatic malignancy - pancreatic
Pancreatitis.
Parasitic infection - inflammation
13
Q
what does very high AST/ALT normally show?
A
liver damage- liver disease/hepatitis/injury
14
Q
how is biliary obstruction shown on imaging?
A
dilated intrahepatic bile ducts on ultrasound
15
Q
what are risk factors for gallstones?
A
female, fat, fertile
ileal disease
TPN- Total parenteral nutrition
clofibrate - drug lowers cholesterol
16
Q
where do most gallstones form?
A
gallbladder
17
Q
how do you distinguish gallstones in gallbladder vs bile duct?
A
gallbladder - cholecystitis
bile duct - cholangitis and/or pancreatitis, obstructive jaundice
18
Q
how are gallbladder stones managed?
A
- Laparoscopic cholecystectomy
- Bile acid dissolution therapy (<1/3 success
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)
20
Q
what are the most common reason for drug induced acute liver failure?
A
- paracetamol
- idiosynchratic drug reaction - unpredicatable, uncommon reaction
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
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
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
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
25
what are Paracetamol-induced liver failure severity indicators ?
- Late presentation - (NAC less effective >24 hr)
- **Acidosis** (pH <7.3)
- **Prothrommbin time > 70 sec**
- **Serum creatinine** ≥ 300 µmol/l
26
what causes ascites?
- Chronic liver disease - cirrhosis (most)
+/- Portal vein thrombosis
- Neoplasia (ovary, uterus, pancreas...)
- Pancreatitis
- heart failure
- kidney disease
- TB
27
what is the pathogenesis of ascites?
- increased intrahepatic resistance + systemic vasodilation
- causes portal hypertension and secretion of RAAS, noradrenaline, vasopressin
- causes fluid retention and ascites
28
what is the management of ascites?
- fluid and salt restriction diet
- diuretics - spironolactone +/- ferosemide
- large-vol paracentesis (fluid drainage)
- trans-jugular intrahepatic portosystemic shunt (TIPS)
29
what can mallorys hyalin with neurophils and fat suggest on a stain?
injured liver cells - fatty liver due to alcohol
30
what does fatty liver lead to?
alcoholic hepatitis/ cirrhosis
then acute decompensation
31
what causes portal hypertension?
- cirrhosis
- fibrosis
- portal vein thrombosis
32
what is a complication of ascities (bacterial)?
Spontaneous bacterial peritonitis
33
how is Spontaneous bacterial peritonitis managed?
- antibiotic prophylaxis
- consider liver transplant
34
how is Spontaneous bacterial peritonitis
distinguished?
- neutophils in ascitic fluid
- often gram -ve stain - use blood culture bottles for this
35
what are some tests for encephalopathy?
Serial 7’s
WORLD backwards
Animal counting in 1 minute
Draw 5 point star
Number connection test
36
what are the causes of chronic liver disease?
- alcohol
- NASH
- viral hepatitis - B, C
- immune - autoimmune hepatitis, primary biliary cirrhosis, sclerosing cholangitis
- metabolic - wilsons, haemochromatosis
- vascular - Budd-Chiari
37
what do laborartory tests show when testing for autoimmune hepatitis?
- Elevated liver enzymes (ALT, AST).
- High serum globulin or gamma-globulin levels.
- Presence of autoantibodies - eg ANA, ASMA, ALKM-1, SLA/LP
38
what is essential to diagnose autoimmune hepatitis?
liver biopsy
- Shows interface hepatitis, lymphoplasmacytic infiltration, rosette formation of hepatocytes, and, in chronic cases, fibrosis or cirrhosis
39
what are differential diagnosis of autoimmune hepatitis?
- viral hepatitis
- alcoholic liver disease
- non-alcoholic fatty liver disease
- drug-induced liver injury
40
how is autoimmune hepatitis treated?
- corticosteroids - Prednisone or prednisolone
- azathioprine in comination with above
- immunosuppressants
- liver transplant in liver failure
41
what are the clinical presentations/ laboratory tests for primary biliary cholangitis?
- 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
42
what are the treatment options for Primary Biliary Cholangitis?
- Ursodeoxycholic Acid (UDCA) - improves survival
- Obeticholic Acid (OCA) - if above is not tolerated
- Cholestyramine for pruritus
- liver transplant
43
what are the treatment options for Primary sclerosing Cholangitis?
- Ursodeoxycholic Acid (UDCA) - improves LFTs, not survival
- Cholestyramine for pruritus
- liver transplant
44
what condition is Primary Sclerosing Cholangitis linked to?
IBD usually ulcerative colitis
45
what condition is Primary biliary Cholangitis linked to?
sjogren syndrome
rheumatoid artharitis
systemic sclerosis
46
what is inflammed in Primary Biliary Cholangitis (PBC) vs Primary Sclerosing Cholangitis (PSC)?
PBC - intrahepatic bile duct
PSC - intra and extrahepatic bile duct
47
what does Primary Sclerosing Cholangitis present with?
- itching
- pain +/- rigors
- cholangitis
- raised ALP and GGT
- more common in males than females
48
how is Primary Sclerosing Cholangitis diagnosed?
blood tests - raised ALP, AST/ALT
antibodies - anti-smooth muscle, anti-nulcear, PANCA
MRCP - gold standard - "beads on a string"
49
what is Haemochromatosis?
genetic disorder characterized by excessive absorption and accumulation of iron in the body
50
what is the most common gene mutation in Haemochromatosis?
C282Y
H63D
- autosomal recessive
51
how is a diagnosis made for Haemochromatosis?
- suggested by raised ferritin and transferrin levels
- confirmed by genotyping and liver biopsy
52
what can alpha1-antitrypsin deficiency lead to?
liver disease
emphysema - protein deficiency in blood
53
what do 50% of cases with hepatcellular carcinoma produce?
alpha fetoprotein
54
what are risk factor for non-alcoholic fatty liver?
- obesity
- diabetes
- hyperlipidaemia
55
what are the LFTs in non-alcoholic fatty liver?
mildly elevated
56
what is NASH?
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
57
what may hepatic vein occlusion be caused by and be treated with?
caused by thrombosis, membrane obstruction, veno-occlusive disease
treated by: anticoagulants, TIPS - shunt
58
what are the main causes of diarrhoea?
infections - bacteria/viruses
inflammation - chrons
loss of absorptive area - coeliac
Pancreatic disease
Drugs - antibiotics
colon cancer
IBS
59
what is the main difference in causes of acute/chronic diarrhoea?
acute - viral/bacteria
chronic - parasites or non infectious
60
what pathogens cause watery diarrhoea?
cholera
staph aureus
rotavirus
norovirus
giardia
(non-inflammatory)
61
what pathogens cause bloody, mucoid diarrhea?
shingella
e.coli
salmonella
c.diff
campylobacter jejuni
(inflammatory)
62
whats the most common cause for travellers diarrhoea?
Enterotoxigenic e.coli
63
what does ETEC, EHEC, EIEC cause?
ETEC - non invasive watery diarrhoea - LT and ST entertoxins
EHEC - Shiga-like toxin. Can cause Haemolytic Uraemic Syndrome (HUS)
EIEC - similar to shingella
64
what are symptoms of cholera infection and how is it treated?
- "rice water" diarrhoea, vomiting, dehydration
- doxycyline and fluids
65
what bacteria causes peptic ulcers?
helicobacter pylori
66
how is H.plori tested for?
breath test
stool antigen test
blood test
67
what are the tests for peptic ulcers?
test for H.pylori
endoscopy with biopsy
barium contrast x ray - highlights ulcers
ct scan or mri in complications
68
what is the treatment for peptic ulcers?
**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
69
how is acute cholecystitis diagnosed and treated?
- examination (murpheys sign), bloods/ultrasound to confirm- urgent diagnosis needed
- iv fluids, analgesia, antibiotics, surgery
70
what are the main symptoms of acute cholecystitis?
- RUQ or epigastric pain
- fever
- leucocytosis
71
what is charcots triad?
3 symptoms indicating bile ducts problems
- fever
- jaundice
- RUQ pain
72
what is the treatment of Ascending cholangitis?
- antibiotics
- ERCP
- gallstone removal
73
what causes enteric fever (typhoid fever)?
salmonella typhi
74
what are symptoms of enteric fever?
- prolonged fever
- abdo pain, green diarrhoea, maybe constipation
- headache, malaise
- rose spot rash on trunk
- relative bradycardia
75
how is enteric fever diagnosed?
- blood cultures
- bone marrow culture, if blood -ve, more sensitive
- stool culture - shows extend of shedding
76
what is the treatment for enteric fever?
antibiotics - azithromycin, ciprofloxacin, cephalosporins
- need early diagnosis and antibiotics ASAP
77
what are complications of enteric fever?
GI bleed
Perforation / peritonitis
Myocarditis
Abscesses
78
what is the stool/urine colour in jaundice?
pre-hepatic - stool normal, urine slightly dark/normal
hepatic - stool normal/pale, urine dark
post-hepatic - stool pale, urine dark
79
what jaundice causes itching?
post-hepatic
sometimes hepatic
80
what jaundice has both conjucated and unconjucated bilirubin elevated?
hepatic
81
what are the liver enzymes tests for pre hepatic jaundice?
normal
82
generally, when are alkaline phosphate ALP levels elevated?
- **liver disease** - eg hepatitis
- **impairment of bile flow** eg. bile duct obstruction, primary biliary cirrhosis, and cholangitis.
- bone disease eg pagets
- GI eg celiac
83
when is Gamma-Glutamyl Transferase (GGT) elevated?
- biliary outflow obstruction
- Primary Biliary Cholangitis
- liver disease
- HF, pancreatitis etc
84
what does elevated Aspartate Aminotransferase (AST) liver enzyme show?
indicates hepatocellular damage
- but not specific to liver - can be elevated with muscle damage
85
what do elevated levels of Alanine Aminotransferase (ALT) show?
- hepatocellular damage - (more specific then AST)
86
how much is one unit of alcohol?
8 grams or 10ml of pure alcohol
87
how do work out number of units in an alcoholic drink?
Strength of the drink (% ABV)
x
Amount of liquid (Litres)
88
what is the guideline for drinking per week?
no more than 14 units
89
what are some alcohol withrawal syndromes?
Tremulousness
**Activation syndrome** - characterized by tremulousness, agitation, rapid heartbeat and high blood pressure
Seizures
Hallucinations
Delirium tremens - can be severe/fatal
90
what syndrome is caused by pre-natal exposure of alcohol?
Foetal Alcohol Spectrum Disorder (FASD)
91
what is the alcohol harm paradox?
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
92
what do the NICE Guidance 24 : Alcohol-use disorders: preventing alcohol use disorders target?
- price, availability, marketing of alcohol
- licensing
- screening and brief interventions
- supporting children and young people
- referral
93
what alcohol harm preventions are there in the UK?
- Minimum Unit Pricing
- Restriction on alcohol advertising
- dry january - enables choice
- Alcohol labelling (industry self-regulation), Drinking guidelines
- Media campaigns
94
what is at risk drinking?
A pattern of drinking which brings about the risk of physical or psychological harm – Screening tools
95
what is harmful drinking?
Harmful drinking a pattern of drinking which is likely to cause physical or psychological harm
96
what is Alcohol use disorder or Alcohol dependence?
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.
97
what are some alcohol screening questions and tools?
- A Clinical Interview – a single question about heavy drinking days
- FAST - Fast Alcohol Screening Test
- AUDIT - Alcohol Use Disorders Identification Test
- CAGE Questions
98
what are some medications for alcohol dependence?
- Acamprosate Calcium (Campral)
- Disulfiram (Antabuse).
- Nalmefene (Selincro).
- Naltrexone also in drug dependence
99
what is a positive score in the FAST screening tool?
3 or more
100
what do the scores in an AUDIT screening indicate?
up to 7 - low risk - no intervention
8-15, 16-19 - increasing/high risk - brief advice
over 20 - possible dependance - referral
101
what are the CAGE questions for drinking alcohol?
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
102
what is the FRAMES interventions for at-risk dinking?
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
103
what is substance misuse?
Relates to the harmful use of any substance for non-medical purposes or effect
104
what is addiction?
- 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
what is psychological dependance?
Feeling that life is impossible without the drug. Emotional effect: feelings of fear, pain, shame, guilt, loneliness if not on drug
106
what is physical dependance?
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
what are the ICD-10: F10-F19 diagnostic codes?
classify mental and behavioral disorders due to psychoactive substance use
108
what is the most common cause for an upper GI bleed?
peptic ulcer
109
what is the glasgow-blathford score?
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
what is the management of an upper Gi bleed?
endoscopy - keep NBM
gastric band/clips
111
what patient history makes variceal bleed vs non-variceal upper GI bleed more likely?
variceal
- history of liver diease & alcohol excess
non-variceal
- history of peptic ulcers, NSAIDS use or anticoagulation or antiplatelets
112
what medications is given to variceal vs non-variceal bleeds?
variceal - Antibiotics and Terlipressin
non-variceal - PPI
113
what are the possible causes of an upper GI bleed?
- peptic ulcer - gastric/duodenal
- oesophageal varices
- mallory-weiss syndrome
- haemorrhagic gastropathy and erosion
- Gastroesophageal Reflux Disease
114
what are symptoms/signs of upper GI bleed?
- Pre-syncope/syncope
- Haematemesis - coffee ground vomit
- abdo pain
- Malaena - black tarry stools
- high HR, low BP
115
what can cause intestinal intraluminal obstruction?
- tumours - carcinoma/lymphoma
- **diaphragm disease** - fibrous - by NSAIDs
- meconium ileus (newborn stool blockage)
- **gallstone ileus** (large gallstone breaking into bowel)
116
what can cause intestinal intramural obstruction?
- inflammatory - crohn's disease (strictures-narrowing) & diverticulitis- in sigmoid colon
- tumours
- neural - Hirschsprung’s disease - in babies no ganglia cells to contract bowels
117
what can cause intestinal extraluminal obstruction?
- adhesions - from previous surgery
- volvulus - sigmoid twisting
- tumour - peritoneal deposits
118
what is a GI obstruction?
anything that prevents the passage of it's contents
119
what are the symptoms of a GI obstruction?
abdo pain - colic pain
vomiting
distension
constipation
120
what are the most common reasons for small bowel obstructions?
- adhesions - scar tissue
- hernias
- tumours
- Intussusception - invagination of intestine
- volvulus - twisting of intestine
121
what is a gallstone ileus?
form of small bowel obstruction caused by a gallstone
- normally enters intestine by a fistula which is a abnormal connection thats formed
122
what do you look for when examining someones abdomen for bowel obstruction?
distended
tympanic - drum like sound - shifting
tender
hernia
bowel sounds - high pitched/tinkling
scars
123
what are the investigations for bowel obstruction?
X-ray
CT scan
ultrasound
blood tets - CBC - infection/anemia, LFT & KFT, lactic acid levels - bowel ischemia
124
what are the treatments for bowel obstruction?
- NG tube - decompression
- fluids, electrolytes
- surgery - on scar tissue/adhesions
- stents
- pain relief
125
what are common reasons for large bowel obstruction?
- colorectal cancer
- diverticulitis
- volvulus
- strictures
- Colonic Pseudo-Obstruction (Ogilvie Syndrome)
126
what is a precurser of oesophageal adenocarcina?
barrets oesophagus - obesity is a risk factor
127
what are oesophageal cancer symptoms?
non-specific
- reflux and difficulty swallowing
128
what are risk factors of gastric cancer?
- helicobacter pylori infections
- age, male
- diet - smoked food and high salt
- tobacco and alcohol
- family history
129
what is a precurser for colorectal cancer?
adenomas
130
what gene mutation has been found to cause colorectal cancer?
APC gene - breaks down beta catenin
131
why are hereditary nonpolyposis
colorectal cancers important to spot?
(lynch syndrome)
- autosomal dominant inheritance
- risk of further cancers and colorectal cancer
- have fewer polyps but higher risk of devloping colorectal cancer
132
what can cause diarrhoea?
non-infective causes:
neoplasm
inflammation - crohns/ulcerative colitis
IBS
anatomical - short gut
hormones - hyperthyroidism
radiation
chemical - drugs
infective causes
bacteria/viruses/parasites
133
what are some common pathogens that cause bloody diarrhoea?
shingella
e.coli
campylobacter
salmonella
c.diff
134
what common pathogens cause non-bloody diarrhoea?
e.coli
cholera
c.diff
noravirus
rotavirus
giardia
135
what most likely causes diarrhoea at different onset stages?
within 6 hours - toxin mediated
within 24h - viruses
a couple days - bacteria
136
what medication is used to treat c.diff?
metronidazole or vancomycin
137
what is the timelength of acute vs chronic hepatitis?
acute 0-6 months
chronic - over 6 months
138
what are the signs/symptoms of acute hepatitis?
- 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
what are some causes of acute hepatitis?
- 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
what are signs/symptoms of chronic hepatitis?
- can be asymptomatic
- clubbing, palmar erythema, Dupuytren’s contracture, spider naevi
- transamines ALT/ST may be normal
- low albumin
141
what may cause chronic hepatitis?
- hep B/C most commonly
- drugs, alcohol
- non-alcoholic liver disease
- autoimmune hepatitis
142
how is hep A transmitted?
Faeco-oral transmission
- Contaminated food & water
143
is hep A symptomatic or asymptomatic?
usually symptomatic - abdo pain
immune after infection
144
how is a Hep A infection managed?
supportive - eg manage liver failure, painkillers etc.
- primary prevention like vaccines for travellers etc.
- self-limiting - no chronic disease, clears 3-6 months
145
what are the 4 genotypes of hep E and how are they transmitted?
G1 & G2 - Faeco-oral transmission - contamined food/water
G3 & G4 - zoonotic - undercooked meat
146
who is at risk of chronic hepatitis from hep E?
immunosuppressed - from G3/4 only
147
is hep E symptomatic or asymptomatic?
>95% cases asymptomatic
- can have extra-hepatic manifestations eg neurological
148
how is chronic hepatitis from hep E managed?
- Reverse immunosuppression (if possible)
- If HEV RNA persists, ribavirin ≥ 3 mths
149
what is the transmission of hep B?
Transmission via blood and body fluids
- mother to child, sexual contact, blood products
150
is hep b symptomatic or asymptomatic?
usually symptomatic in adults
usually asymptomatic in infants
151
how is hep b treated?
- oral nucleos(t)ide analogues - TDF/TAF - inhibit viral replication
- pegylated interferon-α 2a - stimulates immune response - many side effects
152
how is hep B prevented in mother to baby?
- 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
how is hep D transmitted?
Blood-borne virus - Transmission via blood and body fluids
- transmitted with hep B
154
how is hep D treated?
- pegylated inteferon-α 48 weeks
- Myrcludex B
155
how is hep C transmitted?
- via blood and body fluids
- drug users mainly
156
what are the outcomes of hep B?
usually Spontaneous resolution
157
what are the the outcomes of hep C infection?
30% Spontaneous resolution
70% Chronic HCV infection - possible cirrhosis and carcinoma
158
how is hep C treated?
Directly-acting antiviral (DAA) therapy
- need to know genotype
159
what are the infective features of hep C?
- infection does not cause immunity
- can be re-infected
- no vaccine
160
how is hep c detected/tested for?
HCV Antibody Test
HCV RNA Test
Genotype Test
161
what hepatitis have vaccines?
A & B
162
what criteria is used to asses celiac disease?
modified marsh criteria - type 0 to 4
- asses villi atrophy and hypoplasia of small bowel
163
what is the management of celiac disease?
- gluten free diet
- vaccinations
- nutritional supplements
164
what is the risk of not going gluten free in celiac disease?
- 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
what do blood tests detect when testing for celiac disease?
- anti-tissue transglutaminase (tTG) antibodies
- anti-endomysial antibodies (EMA).
166
what are the tests/investigations for coeliac disease?
- blood test - detect antibodies
- endoscopy biopsy - asses damage to intestine
- genetic testing - associated genetic markers
167
what are some signs/symptoms of celiac disease?
- 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
what are the signs/symptoms of cholera infection?
- profuse, watery diarrhea
- vomiting
- rapid dehydration
- hypovolemic shock - suken eyes, wrinkled skin, decreased skin tugor
169
what are the signs/symptoms of shigella infection?
- Bloody diarrhea
- abdominal pain
- fever
- tenesmus (feeling of incomplete evacuation)
170
what are the signs/symptoms of a c.diff infection?
Watery diarrhea
abdominal pain
fever
loss of appetite
nausea
colitis
171
what are the signs/symptoms of norovirus?
- sudden onset of vomiting & diarrhea
- abdo cramps
- nausea
- sometimes fever
172
how is hep B detected/tested for?
HBsAg Test
Anti-HBc Test
HBV DNA Test
173
how is hep A detected/tested for?
hep A antibody test
174
what hepatitis can become chronic?
hep B
hep C
175
how is hep E detected/tested for?
Anti-HEV IgM Test
176
what common Ig are tested for in hepatitis?
IgM - associated with acute hepatitis
IgG - associated with chronic hepatitis
177
what can cause erosin of the mucosal lining in the stomach?
stress
drugs
alcohol
helicobacter
autoimmune condition
178
what is gastritis?
inflammation of the gastric mucosa, the inner lining of the stomach
can be chronic or acute
179
what is the management for gastritis and gastric ulcers?
- PPIs - omeprazole
- H2 receptor antagonists
- Protect the Stomach Lining - sucralfate, Misoprostol
- avoid NSAIDs
180
what can cause malabsorption?
- 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
what are gallstones made of?
- cholesterol gallstones - mainly cholesterol, and calcium and bilirubin
- Pigment Gallstones - bilirubin - darker - less common
182
how does CCK effect bile/gallbladder?
- Stimulation of Gallbladder Contraction
- Relaxation of the Sphincter of Oddi
- Increased Bile Production
183
what does the billiary system drain into?
ampulla of vater
184
what are the symptoms of gallstones?
- pain - sharp, upper right abdomen
- fever
- jaundice
- Nausea and Vomiting
185
what are the investigation for gallstones?
- blood test - Alanine Transaminase, bilirubin, amylase
- ultrasound
- MRCP - MRI scan of bile system
- CT abdomen and pelvis
186
what does high bilirubin show when investigation gallstones?
blockage of biliary tree
187
what does Alanine Transaminase show when investigating gallstones?
high = inflammation/infection
/ obstruction
188
what does amylase show when investigating gallstones?
high = pancreatitis/ pancreatic damage
189
what are the treatment options for gallstones?
- 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
what is Empyema vs
Mucocoele in the gallbladder?
- 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
what conditions have gallstones in the common bile duct?
- Choledocholithiasis
- Cholangitis
- Pancreatitis
192
where are the gallstones in gallstone ileus?
ileocaecal valve
193
what is the pathological features of crohns disease?
- Transmural Inflammation - full thickness of intestine
- fistulas - abnormal connections between intestine
- strictures - narrowing of intestine
- Skip Lesions
- granulomas
194
what are pathalogical features of ulcerative colitis?
- Continuous Mucosal Inflammation of colon and rectum
- Crypt Abscesses - inflammatory cells
- Pseudopolyps - areas of regeneration
195
what are symptoms of crohns and ulcerative colitis?
- fatigue
- weight loss - more in crohns
- pain in abdomen
- diarrhoea (bloody & pus in ulcerative colitis)
- rectal bleeding mainly in ulcerative colitis
196
what are the complications of ulcerative colitis?
- megacolon - severe - colon dilates and ruptures
- severe bleeding due to ulceration
- colon cancer high risk
- anemia
- osteoporosis
197
what are the complications of crohns?
- Perianal disease - fissures and skin tags
- Strictures - narrowing of intestine - bowel obstruction
- osteoporosis
- anemia
- colon cancer risk
198
what are the investigations for crohns/ulcerative colitis?
- 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
what are the treatment/management options for crohns/ulcerative colitis?
- medications: Aminosalicylates, corticosteroids, JAK inhibitors, immunomodulators
- anti-diarrhoea drugs (Loperamide) & analgesia
- diet changes & nutritional supplements - eg low residue
- surgery - colectomy
200
are Extraintestinal Manifestations more common in crohns or ulcerative colitis?
crohns
- such as eyes, skin and joints
201
what is Functional Dyspepsia?
- persistent or recurrent pain or discomfort centered in the upper abdomen
- often associated with early satiety, bloating, or nausea
202
what are coeliac serology tests?
antibody tests
- IgA Anti-tissue Transglutaminase (tTG)
- IgA Endomysial Antibodies (EMA)
- IgA Anti-deamidated Gliadin Peptide (DGP)
203
how is IBS diagnosed using rome criteria?
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
how else is IBS diagnosed other than rome criteria?
- 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
what is the treatment of IBS?
- 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
what are ibs symptoms?
- 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
what are the subtypes of IBS?
IBS-D
IBS-C
IBS-M
IBS-U
208
what is the definition of functional GI disorders?
Chronic GI symptoms in the absence of organic disease to explain the symptoms.
"disorders of gut-brain interaction"
209
what investigations are required for functional dyspepsia?
- history
- examinations
- FBC, CR, LFT, coeliac serology
- stool - helicobacter.p
- if alarm features - endoscospy/ct scan
210
what does faecal calprotectin show?
gi inflammation
211
what are the investigations required for ibs?
- 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
what does CRP show in a blood test
C-reactive protein made by liver
- high = inflammation/infection
213
what is peritonitis?
inflammation of the peritoneum - visceral and parietal
214
how is peritonitis classified?
- acute/chronic
- primary (no apparent source) or secondary (contamination by bacteria/fungi by rupture/perforation - appendicitis)
- localised or generalised (often chronic/serious)
215
what are the causes of peritonitis?
- 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
what microorganisms most commonly cause peritonitis?
- Escherichia coli - cirrhosis
- klebsiella, e.coli, clostridium spp, steptococci - secondary
- TB - spread by blood
217
what are symptoms of localised peritonitis?
Pain
Nausea and vomiting
Fever
Tachycardia
Localised guarding
Rebound tenderness
Shoulder tip pain ( subphrenic)
Tender rectal and / or vaginal examination (pelvic peritonitis).
218
what are symptoms of generalised peritonitis in early stages?
- Abdominal pain ( worse by moving or breathing)
Tenderness
Generalised guarding
Infrequent bowel sounds àcease ( paralytic ileus)
Fever
Tachycardia
219
what are generalised peritnitis symptoms in the late stages?
- Generalised rigidity
Distension
Absent bowel sounds
Circulatory failure
Thready irregular pulse
(Hippocratic face)
Loss of consciousness
220
what investigations are required for pericarditis?
- urine dipstix - UTI
- ECG - if cardiac history
- Bloods, U&E, FBC - inflammation markers/kidney function
- Serum amylase - pancrease involvement
- xray, ultrasound, ct scan
221
what is the management of peritonitis?
- fluids - dehydration
- antibiotics
- analgesics
- surgery - repair viscus and drain
222
what is Spontaneous bacterial peritonitis?
- bacterial infection of ascitic fluid, secondary peritonitis associated with liver
- rapid progression
- risk of septic shock & orga failure
223
what is ascites?
Effusion and accumulation of serous fluid in the abdominal cavity
224
what are the stages of ascites?
- 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
what is the difference between Diuretic resistant ascites and Diuretic intractable ascites?
resistant - doesn't respond to high dose diuretic or sodium restriction
intractable - more severe - complications from diuretic therapy - need draining not diuretics
226
what is diagnostic criteria for refractory ascites?
- 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
what are the causes of ascities?
- cirrhosis
- malignancy - gynelogical 50%
- heart failure
- Tb
- pancreatitis
228
what are the theories that explain ascites pathophysiology?
- under-filling - portal hypertension
- over-filing - inappropriate na & o2 retention
- peripheral arterial vasodilation
229
what causes chylous ascites?
abdominal surgery
trauma,
malignancy,
radiation,
congenital
230
what is the pathophysiology of liver ascites?
- 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
what is the protein concentration for exudate vs transudate ascites?
exudate - above 2.5g/dL
transudate - below 2.5g/dL
232
what causes transudate ascites (high SAAG)?
- Cirrhosis
- Hepatic failure
- Venous occlusion (e.g. Budd Chiari syndrome)
- Fulminant hepatic failure
- Alcoholic hepatitis
- Kwashiorkor malnutrition
- congeestive HF
233
what type of ascites is chylous ascites?
exudate
- milk appearance
- from thoracic or intestinal lymph
234
what are symptoms of ascites?
- abdo distension
- nausea, loss of appetite
- constipation
- cachexia, weight loss
- pain/discomfort (signifies (non)malignant
- shortness of breath
235
what tests are needed to diagnose ascites?
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
what is the SAAG test for ascites?
- portal hypertensive (SAAG >1.1 g/dL) - transudatee
- non–portal hypertensive (SAAG < 1.1 g/dL) - exudate
- correlates with portal pressure
237
where are morison pouch ascites?
posterior subhepatic space
238
what indicates malignant ascites?
- low SAAG + high protein level
- cytology test for cancer cells
239
how much fluid is usually required to diagnose ascites?
500ml
240
what is hellmer sign?
displacement of the lateral edge of the liver toward the midline
- due to ascites
241
what can cause chylous/milky ascites fluid?
- lymphoma
- malignancy
- TB
242
what does clear/straw ascites fluid most commonly show?
cirrhosis
243
what does cloudy ascites fluid show?
- bacterial peritonitis
- perforated bowel
- pancreatitis
244
what can lower glucose in ascites than in serum signify?
TB
malignancy
245
what causes exudate ascites (low SAAG)
Malignancy
Infection
Pancreatitis
Nephrotic syndrome
246
what causes dieased peritoneum?
- infections
- malignancy
- Familial Mediterranean fever
- Vasculitis
- Granulomatous peritonitis
247
how is SAAG calculated?
SAAG = (serum albumin) – (ascitic fluid albumin)
248
how is ascites treated/managed?
- treat underlying cuase
- salt and fluid restriction
- diuretics
- albumin supplements
- paracentesis - needle fluid removal
- TIPS - shunt (for diuretic-refractory)
- peritoneovenous shunt
249
what is the most sensitive/easiest
way to detect ascitic fluid?
ultrasonography
250
what is dukes staging system?
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
what is tested for when dyspepsia is suspected?
h.pylori
252
what drugs are given to reduce mortality in GI bleeds?
antibiotics
Terlipressin - reduces bleeds
253
where does microscopic colitis happen?
colon
254
what is the difference between cholangitis and cholecystitis?
cholangitis - bile ducts, jaundice
cholecystitis - gallbladder, pain/fatty stools
255
what suggests a Uncomplicated gallstone?
RUQ pain/bloating with no Fever or jaundice etc
256
what does raised alp with ggt show?
Cholestasis
- gallstones, pancreatic malignancy
257
what does an isolated raised GGT show?
alcohol excess
