Liver & GI Flashcards
1
Q
Without a liver, what would you die from?
A
Hypoglycaemia
2
Q
Describe the pathogenesis of ascites
A
Systemic vasodilation leads to:
a. → RAAS
b. NAd
c. Vasopressin
& ∴ → Fluid retention
3
Q
Reversible causes of renal failure in liver disease
A
- Drugs
- Infection
- GI bleeding
- Myoglobulinuria
- Renal tract obstruction
4
Q
Name 4 drugs which can cause renal failure in liver disease.
A
- Diuretics
- NSAIDS
- ACEI
- Aminoglycosides
5
Q
5 bedside tests for encephalopathy
A
- Serial 7s
- WORLD backwards
- Animal counting in 1 minute
- Draw 5 point star
- No. connection test
6
Q
What is enterotoxin?
A
A toxin produced in or affecting the intestines, such as those causing food poisoning or cholera
7
Q
5 causes of gastritis
A
- Mucosal ischaemia
- Increased acid
- Bile reflux
- Alcohol
- Helicobacter infection
8
Q
How does mucosal ischaemia cause gastritis
A
Less blood in capillaries to cells lining the stomach
Less mucin produced
Acid can get in & kill cells
Ulcer forms
9
Q
How does helicobacter infection cause gastritis?
A
Lives in the mucin layer
Produces chemical mediators
- Increase acid secretion
- → inflammation → intestinal metaplasia
10
Q
3 main presentations of malabsorption
A
- Severe weight loss
- Change in stools → steatorrhoea
- Iron deficiency anaemia
11
Q
Tests for gallstones
A
Bloods
- ALT
- Bilirubin
- Amylase
Ultrasound
MRCP
CT abdo & pelvis
12
Q
Treatment options for gallstones
A
- Conservative management
- Radiological drain
- ERCP
- Cholecystectomy
13
Q
Define functional gut disorders
A
Chronic GI symptoms in the absence of organic disease to explain the symptoms
14
Q
Define dyspepsia
A
A symptom or combination of symptoms that alerts a clinician to the presence of an upper GI problem
Symptoms include: epigastric pain or burning, early satiety and post-prandial fullness, belching, bloating, nausea, discomfort in upper abdomen
15
Q
1st line investigations to investigate dyspepsia
A
FBC, CRP, LFT, coelical serology
Stool helicobacter pylori
16
Q
Define Crohn’s disease
A
Crohn’s disease (CD) is a disorder of unknown aetiology characterised by transmural inflammation of the gastrointestinal (GI) tract.
17
Q
Key diagnostic features of Crohn’s
A
Presence of risk factors
Abdo pain
Prolonged diarrhoea
Perianal lesions
18
Q
Risk factors for Crohn’s disease
A
White ancestry
Age 15-40 or 50-60 yrs
Family history
Cigarette smoking
19
Q
1st line investigations for Crohn’s
A
FBC
Iron studies
Serum vit B12
Serum folate
Stool testing
CRP & ESR
Abdo x-ray
MRI abdo/pelvis
20
Q
Give one differential to Crohn’s & why they are not the diagnosis
A
Ulcerative colitis
- Colonoscopy will differentiate UC from Crohn’s
- No small bowel involvement or oral or perianal disease
21
Q
Define ulcerative colitis
A
A type of IBD that characteristically involves the rectum & extends proximally to affect a variable length of the colon
22
Q
Key diagnostic factors for UC
A
Presence of risk factors
Rectal bleeding
Diarrhoea
Blood in stool
23
Q
RF for UC
A
Family history of IBD
HLA-B27
Infection
NSAIDs
24
Q
1st line investigations for UC
A
Stool studies for infective pathogens
Faecal calprotectin
FBC
Comprehensive metabolic panel (including LFTs)
ESR
CRP
Abdo radiograph
25
Key diagnostic factors for IBS
Presence of risk factors
Abdo discomfort
Alteration of bowel habits associated with pain
Abdo bloating or distension
26
Risk factors for IBS
Physical & sexual abuse
PTSD
Age \<50
Female
27
1st line investigation for IBS
FBC
28
Key diagnostic factors for GORD
Presence of risk factors
Heartburn
Acid regurgitation
29
Risk factors for GORD
Family history
Older age
Hiatus hernia
Obesity
30
1st line investigation for GORD
PPI trial
31
2 differential diagnoses for GORD
ACS
* Must be ruled out before considering GORD in people with chest pain
* ECG may show ST changes or Q waves in ACS
* Troponin may be elevated
Stable angina
* ECG may show ST changes or Q waves
32
Define Barrett's oesophagus
A change in the normal squamous epithelium of the oesophagus to specialised internal metaplasia
33
Key diagnostic factors for Barrett's oesphagus
Presence of risk factors
Heart burn
Regurgitation
Dysphagia
34
Risk factors for Barrett's oesphagus
Acid/bile reflux or GORD
Increased age
White ethnicity
Male sex
35
1st line investigations to order for Barrett's oesphagus
Upper GI endoscopy with biopsy
Barium oesophagogram
36
Aetiology of Barrett's oesophagus
Gasto-oesophageal reflux
37
Differentials for Barrett's oesphagus
Oesophagitis
* Upper GI endoscopy will show no Barrett's on biopsy
GORD
* Upper GI endoscopy will show no Barrett's on biopsy
Oesophageal carcinoma
* Biopsy will reveal adenocarcinoma
38
Key diagnostic factors for oesophageal cancer
Presence of risk factors
Dysphagia - difficulty swallowing
Odynophagia - painful swallowing
Weight loss
39
Risk factors for oesophageal cancer
Male sex
Tobacco use
Alcohol use
GORD & Barrett's oesophagus
40
A 55-year-old man presents with severe dysphagia to solids and worsening dysphagia to liquids. His social history is significant for 40 pack-year cigarette smoking and a 6-pack of beer per day. He has lost over 10% of his body weight and currently is nourished only by milkshake supplements. He complains of some mild odynophagia and is constantly coughing up mucus secretions.
What is the 1st investigation you would do?
What condition do you suspect?
Oesophageal cancer
Oesophagogastroduodenoscopy (OGD) with biopsy
Comprehensive metabolic profile
41
Key diagnostic factors of gastric cancer
Presence of risk factors
Abdo pain
Weight loss
Lymphadenopathy
42
Risk factors for gastric cancer
Pernicious anaemia
Helicobacter pylori
N-nitroso compounds
Diet low in fruit & veg
43
1st line investigation if you suspect gastric cancer
Upper GI endoscopy with biopsy
44
Key diagnostic factors for colorectal cancer
Presence of risk factors
Increasing age
Rectal bleeding
Change in bowel habit
Rectal mass
+ve family history
Abdo mass
45
Risk factors for colorectal cancer
Increasing age
Family history
Adenomatous polyposis coli mutation
46
1st investigations to consider if you suspect colorectal cancer
FBC
Liver biochemistry
Renal function tests
Colonoscopy
47
3 differential diagnoses to colorectal cancer
IBS
UC
Crohn's
48
Define a peptic ulcer
A break in the mucosal lining of the stomach or duodenum more than 5mm in diameter (small than this = erosion)
49
Risk factors for peptic ulcers
Helicobacter pylori infection
NSAID use
Smoking
Increased age
50
Key diagnostic factors for a peptic ulcer
Abdo pain
Presence of risk factors
51
Differential for peptic ulcer disease
Oesophageal cancer
* Endoscopy will show mass
* Presence of alarm features (eg weight loss, bleeding, anaemia, vomiting etc)
Stomach cancer
* Alarm features
* Endoscopy shows mass
GORD
* History of heartburn or pain rising from the lower chest → throat
* Endoscopy shows absence of ulcers
52
Risk factors for appendicitis
Low dietary fibre
Improved personal hygeine
Smoking
53
Location of the appendix
McBurney's point
1/3 of the way from the R ASIS to the Umbilicus
54
A 22-year-old male presents to the emergency department with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrant of the abdomen. The pain was steady in nature and aggravated by coughing. Physical examination reveals a low-grade fever (38°C [100.5°F]), tenderness on palpation at right lower quadrant (McBurney's sign),
What 1st line investigations will you order?
What do you suspect?
FBC, CRP & imaging (seek advice from radiologist)
Appendicitis
55
Define cirrhosis
Cirrhosis is the pathological end-stage of any chronic liver disease
Cirrhosis is a diffuse pathological process, characterised by fibrosis and conversion of normal liver architecture to structurally abnormal nodules known as regenerative nodules
56
Risk factors for cirrhosis
Alcohol misuse
IVDU
Unprotected intercourse
Obesity
57
Key diagnostic factors for cirrhosis
Pressence of risk factors
Abdo distension
Jaundice & pruritis
Blood in vomit (haematemesis) & black stool (melaena)
Palmar erythema
Spider naevi
58
1st line investigations to order if you suspect cirrhosis
LFTs
Gamma-glutamyl transferase (GGT)
Serum albumin
Serum sodium - Hyponatraemia is a common finding in cirrhotic patients with associated ascites, and worsens as the liver disease progresses.
Prothrombin time
Platelet count
59
Differentials to cirrhosis & how to distinguish between them
Budd-Chiari syndrome
* Doppler ultrasound and abdominal CT: absence of hepatic vein filling.
Portal vein thrombosis
* Signs and symptoms of the underlying cause such as acute pancreatitis
* Doppler ultrasound and abdominal CT: portal vein filling defect, absence of flow in the portal vein.
Splenic vein thrombosis
* Signs and symptoms of pancreatitis
* Abdo ultrasound & CT evidence of splenic vein thrombosis
60
What is the proper name for gallstones disease
Cholelithiasis
61
Define cholelithiasis
Presence of solid concretions in the gallbladder
62
Risk factors for cholelithiasis
Increasing age
Female sex
Obesity, diabetes, and metabolic syndrome
Family history of gallstones
63
Key diagnostic factors for cholelithiasis
RUQ or epigastric pain (typically lasting \>30 mins)
Presence of risk factors
64
A 46-year-old obese woman presents with a 6-hour history of moderate steady pain in the right upper quadrant (RUQ) that radiates through to her back. This pain began after eating dinner, gradually increased, and has remained constant over the last few hours. She has experienced previous episodes of similar pain for which she did not seek medical advice. Her vital signs are normal. The pertinent findings on physical examination are tenderness to palpation in the RUQ without guarding or rebound
What are the first investigations you would do?
What do you suspect?
Abdo ultrasound
Serum LFTs
FBC
Serum lipase or amylase
(suspect gallstones)
65
3 differentials to cholelithiasis (gallstones) & how to differentiate between them.
Peptic ulcer disease (PUD)
* May have ulcer risk factors: infection, NSAID use, smoking etc
* Do an upper GI endoscopy → peptic ulcer
Gallbladder cancer
* Ultrasound
Gallbladder polyps
* Abdo ultrasound - polypoidal lesion
66
How to treat biliary colic?
With an NSAID eg diclofenac
67
How can cholelithiasis be treated?
Treat biliary colic with NSAIDs
Symptomatic gallstones:
- Laparoscopic cholecystectomy
- Bile duct clearance
68
Define acute cholecystitis
Acute gallbladder inflammation
One of the major complications of gallstones
69
Key diagnostic factors for cholecystitis
Pain in RUQ
Tenderness in RUQ
Signs & symptoms of inflammation
Palpable mass
70
Risk factors for cholecystitis
Gallstones
Physical inactivity
Low fibre intake
Severe illness
71
A 20-year-old obese woman with a 2-year history of gallstones presents to the emergency department with severe, constant right upper quadrant (RUQ) pain, nausea, and vomiting after eating fried chicken for dinner. She denies any chest pain or diarrhoea. Three months ago she developed intermittent, sharp RUQ pains. On physical examination she has a temperature of 38°C (100.4°F), moderate RUQ tenderness on palpation, but no evidence of jaundice.
What is your first line of investigation?
What do you suspect?
Acute cholecystitis
CT or MRI of abdomen
Ultrasound of abdomen
FBC
CRP
Bilirubin
LFTs
Serum lipase or amylase
72
3 differentials to acute cholecystitis & how to distinguish between them
Acute cholangitis
* Charcot's traid - fever, jaundice, abdo pain
* MRI
Chronic cholecystitis
* Repeated bouts of mild attacks or chronic irritation by large gallstones
Peptic ulcer disease
* Burning epigastric pain that occurs hours after meals or with hunger
* Endoscopy may reveal a peptic ulcer
73
Treatment of acute cholecystitis
URGENT
- Manage sepsis & organ failure if present
- Fluid resuscitation
- Analgesia
- Antibiotics (if infection suspected)
- Laparoscopic cholecystectomy
74
What is the difference between ascending and acute cholangitis?
They are the same thing - an infection of the biliary tree
A patient with **acute** cholecystitis would not have signs of jaundice
75
Risk factors for ascending cholangitis
Age \>50
Cholelithiasis
Benign stricture
Malignant stricture
76
A 65-year-old woman presents to the emergency department with a 2-day history of progressive right upper quadrant (RUQ) pain that she rates as 9/10. She reports experiencing fever, and being unable to eat or drink due to nausea and abdominal pain at baseline, exacerbated by food ingestion. Her bowel movements are less frequent and have become loose. Her pain is not relieved by bowel movement and is not related to food. She has not recently taken antibiotics, nor does she use non-steroidal anti-inflammatory drugs or drink alcohol. On examination, she is febrile at 39.4°C (102.9°F); supine BP is 97/58 mmHg; standing BP is 76/41 mmHg; HR is 127 bpm; and respiratory rate is 24 breaths per minute with normal oxygen saturation. Her examination is remarkable for scleral and sublingual icterus, tachycardia, RUQ pain with no rebound, and involuntary guarding on the right side. Faecal occult blood test is negative. Laboratory results show a WBC of 18.0 × 10⁹/L (18,000/microlitre) (reference range 4.8-10.8 × 10⁹/L or 4800-10,800/microlitre) with 17% (reference range 0% to 4%) bands and PMNs of 82% (reference range 35% to 70%). AST is 207 units/L (reference range 8-34 units/L), ALT is 196 units/L (reference range 7-35 units/L), alkaline phosphatase is 478 units/L (reference range 25-100 units/L), total bilirubin is 107.7 micromol/L (6.3 mg/dL) (reference range 3.4 to 22.2 micromol/L or 0.2 to 1.3 mg/dL), and amylase is 82 units/L (53-123 units/L).
What diagnosis do you suspect?
How can you rule out differentials?
Acute cholangitis = diagnosis
Differentials:
Cholecystitis - jaundice is present so not this
Peptic ulcer disease - symptoms do not improve with food, no RFs for PUD (eg NSAIDs, alcohol, infection)
Acute pancreatitis - no history of alcohol consumption or medication
77
Treatment of acute cholangitis
If you suspect sepsis, begin treatment for this immediately.
Stabilise pt - broad-spectrum antibiotics & iv hydration
Biliary decompression - surgical or non-surgical
78
Fill in the table with information on biliary cholic, cholangitis and cholecystitis
79
Define primary biliary cholangitis
A chronic disease of the small intrahepatic bile ducts - characteristic by progressive bile duct damage (and eventual loss) occuring in the context of chronic portal tract inflammation
80
Risk factors for ascending biliary cholangitis
Female sex
Age 45-60
Family history of PBC/autoimmune disease
Smoking
81
Aetiology of primary biliary cholangitis
Conventionally thought to be an autoimmune disease.
82
Pathophysiology of primary biliary cholangitis
Damage to and progressive destruction of the biliary epithelial cells lining the small intrahepatic bile ducts
83
Investigation of primary biliary cholangitis
3 factors:
Presence of cholestatic liver biochemistry - prominent elevation of alkaline phosphatase and or gamma-GT
Autoantibody profile compatible with PBC
Compatibile or diagnostic liver histology on liver biopsy
84
A 50-year-old woman undergoing health screening is found to have a cholestatic pattern on her liver function test results. Her alkaline phosphatase and gamma-GT concentrations are elevated, although transaminases, bilirubin, and albumin concentrations are normal. On questioning she mentions that she had been getting increasingly tired over the past few years but felt that this was simply a result of her age and work pattern. She also describes occasional itch that feels as if it is deep underneath the skin and that is not associated with a rash. She had no other past medical history but had a family member who had autoimmune thyroid disease. Clinical examination reveals no abnormal findings other than excoriations related to itch and xanthelasmata around the eyes.
What is her diagnosis?
Primary biliary cholangitis
- shown in abnormal liver biochem
- itch & fatigue
85
Goals of treatment of primary biliary cholangitis
To slow or stop progression of the disease to prevent the development of cirrhosis
To manage the symptoms of the disease to improve pt QOL
86
1st line treatment for primary biliary cholangitis
Ursodeoxycholic acid
87
Define acute pancreatitis
A disorder of the exocrine pancreas
It is associated with acinar cell injury with local and systemic inflammatory responses
88
Risk factors for acute pancreatitis
Middle-aged women
Young to middle-aged men
Gallstones
Alcohol
89
Key diagnostic factors for acute pancreatitis
Upper abdo pain
Nausea & vomiting
Signs of hypovolaemia
Signs of pleural effusion
90
1st diagnostic investigations to order if you suspect acute pancreatitis & what they will show?
Serum lipase or amylase \>3 times the upper limit of the normal range
FBC - leukocytosis & haematocrit \>44%
CRP - may be raised
Urea/creatinine - if elevated suggest dehydration/hypovolaemia (severe case)
91
Aetiology of acute pancreatitis
Alcohol consumption
Gallstones
Idiopathic
92
3 Differentials to acute pancreatitis & how to differentiate between them
Peptic ulcer disease
* Longstanding epigastric pain, doesn't radiate to the back
* Identifiable cause, eg helicobacter pylori, NSAIDs, etc
Perforated viscus
* Will present with acute abdo peritoneal signs, tachycardia and sepsis
* Abdo is rigid & tender in all 4 quadrants
Oesophageal spasm
* Dysphagia, odynophagis, weight loss
93
Define chronic pancreatitis
Characterised by pancreatic inflammation
**Chronic** pancreatitis is characterised by recurrent or persistent abdominal pain and progressive injury to the pancreas and surrounding structures, resulting in scarring and loss of function.
94
Key diagnostic factors for chronic pancreatitis
Presence of risk factors
Abdo pain
Steatorrhoea
Jaundice
95
Risk factors for chronic pancreatitis
Alcohol
Smoking
Family history
Coeliac
96
Aetiology of chronic pancreatitis
Alcohol
Idiopathic
97
First line imaging test to diagnose chronic pancreatitis
CT or MRI of the abdomen
98
3 differentials to chronic pancreatitis & how to rule them out
Pancreatic cancer
* CT, MRI, or EUS may detect a pancreatic mass or duct stricture.
Acute pancreatitis
* Distinguishing features of severe acute pancreatitis include evidence of persistent organ failure
Biliary colic
* The duration of pain is shorter (1 to 2 hours) than in chronic pancreatitis.
99
Management of chronic pancreatitis
Alcohol & smoking cessation
Dietary advice & supplementation in case of malabsorption of fat, protein & fat-soluble vitamins
100
Aetiology of alcoholic liver disease
Chronic, heavy alcohol ingestion
101
Key diagnostic factors for alcoholic liver disease
Presence of risk factors
Abdo pain
Hepatomegaly
Haematemesis & melaena
102
1st diagnostic investigations to order to investigate alcoholic liver disease
AST & ALT
Serum AST/ALT ratio
Serum alkaline phosphatase
Serum bilirubin
103
Treatment of alcoholic liver disease
Alcohol abstinence/withdrawal
Weight reduction + smoking cessation
Supplements
Corticosteroids for some pts
104
Differential for alcoholic liver disease & how to distinguish between them
Hep B infection
- History may reveal high risk behaviour, eg IVDU, multiple sexual partners
- History may have an absence of chronic heavy alcohol abuse
- Serum test positive for Hep B surface antigens or IgM antibody
105
Risk factors for NAFLD
Obesity
Insulin resistance or diabetes
Dyslipidaemia
Hypertension
106
Key diagnostic factors for NAFLD
Presence of risk factors
Absence of significant alcohol use
Fatigue & malaise
Hepatosplenomegaly
107
1st investigations to order if you suspect NAFLD
AST & ALT - ratio will be \<1. Unlike in alcoholic liver disease where it is \>2
Total bilirubin - elevated in decompensated disease
Alkaline phosphatase - elevated
108
Pathophysiology of NAFLD
Not fully understood
Insulin resistance → excessive triglycerides in liver → hepatic steatosis
109
Differential to NAFLD
Alcoholic liver disease
No specific differentiating signs or symptoms
- History will show excessive alcohol intake
- AST:ALT ratio typically \>2 in alcoholic liver disease
110
Management of NAFLD
Focusses on reducing risk factors - weight loss, diabetes treatment, antihyperlipidaemics
111
Define cirrhosis
The pathological end-stage of any chronic liver disease
112
Risk factors for liver cirrhosis
Alcohol misuse
IVDU
Unprotected sex
Obesity
113
1st investigations to order when investigating liver cirrhosis
LFTs
GGT
Serum albumin
Serum sodium
114
2 differentials to liver cirrhosis
Budd-Chiari - Doppler US & abdo CT show absence of hepatic vein filling
Portal vein thrombosis - Doppler US & abdo CT: portal vein filling defect, absence of flow in the portal vein.
115
What directly causes oesophageal varices?
Portal hypertension
116
Define oesophageal varices
Dilated collateral blood vessels that develop as a complication of portal hypertension
117
Key diagnostic factors of oesophageal varices
Presence of risk factors for variceal bleeding
Haematemesis
Melaena
Haematochezia
118
Risk factors for oesophageal varices
Portal hypertension
Large varices
Red wale marks
Decompensated cirrhosis
119
A 42-year-old man is referred to the liver clinic with mild elevation in aminotransferases for several years. He has a medical history significant for obesity, hypertension, and hypercholesterolaemia. He does not smoke or drink alcohol and there is no high-risk behaviour. He has a family history of premature cardiac disease. He is taking a diuretic and, because of his elevated liver tests, was recommended to discontinue his statin medication several months ago. Other than complaints of mild fatigue, the patient feels well. Examination is notable for a BMI of 37 kg/m², truncal obesity, and mild hepatomegaly.
What condition do you suspect?
NAFLD
120
1st investigations for oesophageal varices
Gastroscopy
FBC
Electrolytes
Serum LFTs
121
When should you suspect oesophageal variceal bleeding?
In patients who present with
Signs or symptoms of liver failure or decompensated cirrhosis including
* Jaundice
* Ascites
* Hepatic encephalopathy
* Physical signs of chronic liver disease
* Deranged LFTs
122
Define haematemesis
Vomiting blood
123
Common causes of haematemesis
* Oesophageal varices
* Severe GORD
* Tear in the oesophagus
* Swallowed blood
124
