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Phase 2a > Liver & GI > Flashcards

Liver & GI Flashcards

1
Q

Without a liver, what would you die from?

A

Hypoglycaemia

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2
Q

Describe the pathogenesis of ascites

A

Systemic vasodilation leads to:

a. → RAAS
b. NAd
c. Vasopressin

& ∴ → Fluid retention

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3
Q

Reversible causes of renal failure in liver disease

A
  • Drugs
  • Infection
  • GI bleeding
  • Myoglobulinuria
  • Renal tract obstruction
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4
Q

Name 4 drugs which can cause renal failure in liver disease.

A
  • Diuretics
  • NSAIDS
  • ACEI
  • Aminoglycosides
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5
Q

5 bedside tests for encephalopathy

A
  • Serial 7s
  • WORLD backwards
  • Animal counting in 1 minute
  • Draw 5 point star
  • No. connection test
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6
Q

What is enterotoxin?

A

A toxin produced in or affecting the intestines, such as those causing food poisoning or cholera

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7
Q

5 causes of gastritis

A
  • Mucosal ischaemia
  • Increased acid
  • Bile reflux
  • Alcohol
  • Helicobacter infection
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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

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9
Q

How does helicobacter infection cause gastritis?

A

Lives in the mucin layer

Produces chemical mediators

  • Increase acid secretion
  • → inflammation → intestinal metaplasia
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10
Q

3 main presentations of malabsorption

A
  • Severe weight loss
  • Change in stools → steatorrhoea
  • Iron deficiency anaemia
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11
Q

Tests for gallstones

A

Bloods

  • ALT
  • Bilirubin
  • Amylase

Ultrasound

MRCP

CT abdo & pelvis

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12
Q

Treatment options for gallstones

A
  • Conservative management
  • Radiological drain
  • ERCP
  • Cholecystectomy
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13
Q

Define functional gut disorders

A

Chronic GI symptoms in the absence of organic disease to explain the symptoms

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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

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15
Q

1st line investigations to investigate dyspepsia

A

FBC, CRP, LFT, coelical serology

Stool helicobacter pylori

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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.

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17
Q

Key diagnostic features of Crohn’s

A

Presence of risk factors

Abdo pain

Prolonged diarrhoea

Perianal lesions

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18
Q

Risk factors for Crohn’s disease

A

White ancestry

Age 15-40 or 50-60 yrs

Family history

Cigarette smoking

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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

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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
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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

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22
Q

Key diagnostic factors for UC

A

Presence of risk factors

Rectal bleeding

Diarrhoea

Blood in stool

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23
Q

RF for UC

A

Family history of IBD

HLA-B27

Infection

NSAIDs

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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

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25
Q

Key diagnostic factors for IBS

A

Presence of risk factors

Abdo discomfort

Alteration of bowel habits associated with pain

Abdo bloating or distension

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26
Q

Risk factors for IBS

A

Physical & sexual abuse

PTSD

Age <50

Female

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27
Q

1st line investigation for IBS

A

FBC

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28
Q

Key diagnostic factors for GORD

A

Presence of risk factors

Heartburn

Acid regurgitation

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29
Q

Risk factors for GORD

A

Family history

Older age

Hiatus hernia

Obesity

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30
Q

1st line investigation for GORD

A

PPI trial

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31
Q

2 differential diagnoses for GORD

A

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
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32
Q

Define Barrett’s oesophagus

A

A change in the normal squamous epithelium of the oesophagus to specialised internal metaplasia

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33
Q

Key diagnostic factors for Barrett’s oesphagus

A

Presence of risk factors

Heart burn

Regurgitation

Dysphagia

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34
Q

Risk factors for Barrett’s oesphagus

A

Acid/bile reflux or GORD

Increased age

White ethnicity

Male sex

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35
Q

1st line investigations to order for Barrett’s oesphagus

A

Upper GI endoscopy with biopsy

Barium oesophagogram

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36
Q

Aetiology of Barrett’s oesophagus

A

Gasto-oesophageal reflux

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37
Q

Differentials for Barrett’s oesphagus

A

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
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38
Q

Key diagnostic factors for oesophageal cancer

A

Presence of risk factors

Dysphagia - difficulty swallowing

Odynophagia - painful swallowing

Weight loss

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39
Q

Risk factors for oesophageal cancer

A

Male sex

Tobacco use

Alcohol use

GORD & Barrett’s oesophagus

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40
Q

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?

A

Oesophageal cancer

Oesophagogastroduodenoscopy (OGD) with biopsy

Comprehensive metabolic profile

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41
Q

Key diagnostic factors of gastric cancer

A

Presence of risk factors

Abdo pain

Weight loss

Lymphadenopathy

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42
Q

Risk factors for gastric cancer

A

Pernicious anaemia

Helicobacter pylori

N-nitroso compounds

Diet low in fruit & veg

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43
Q

1st line investigation if you suspect gastric cancer

A

Upper GI endoscopy with biopsy

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44
Q

Key diagnostic factors for colorectal cancer

A

Presence of risk factors

Increasing age

Rectal bleeding

Change in bowel habit

Rectal mass

+ve family history

Abdo mass

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45
Q

Risk factors for colorectal cancer

A

Increasing age

Family history

Adenomatous polyposis coli mutation

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46
Q

1st investigations to consider if you suspect colorectal cancer

A

FBC

Liver biochemistry

Renal function tests

Colonoscopy

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47
Q

3 differential diagnoses to colorectal cancer

A

IBS

UC

Crohn’s

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48
Q

Define a peptic ulcer

A

A break in the mucosal lining of the stomach or duodenum more than 5mm in diameter (small than this = erosion)

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49
Q

Risk factors for peptic ulcers

A

Helicobacter pylori infection

NSAID use

Smoking

Increased age

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50
Q

Key diagnostic factors for a peptic ulcer

A

Abdo pain

Presence of risk factors

51
Q

Differential for peptic ulcer disease

A

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
Q

Risk factors for appendicitis

A

Low dietary fibre

Improved personal hygeine

Smoking

53
Q

Location of the appendix

A

McBurney’s point

1/3 of the way from the R ASIS to the Umbilicus

54
Q

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?

A

FBC, CRP & imaging (seek advice from radiologist)

Appendicitis

55
Q

Define cirrhosis

A

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
Q

Risk factors for cirrhosis

A

Alcohol misuse

IVDU

Unprotected intercourse

Obesity

57
Q

Key diagnostic factors for cirrhosis

A

Pressence of risk factors

Abdo distension

Jaundice & pruritis

Blood in vomit (haematemesis) & black stool (melaena)

Palmar erythema

Spider naevi

58
Q

1st line investigations to order if you suspect cirrhosis

A

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
Q

Differentials to cirrhosis & how to distinguish between them

A

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
Q

What is the proper name for gallstones disease

A

Cholelithiasis

61
Q

Define cholelithiasis

A

Presence of solid concretions in the gallbladder

62
Q

Risk factors for cholelithiasis

A

Increasing age

Female sex

Obesity, diabetes, and metabolic syndrome

Family history of gallstones

63
Q

Key diagnostic factors for cholelithiasis

A

RUQ or epigastric pain (typically lasting >30 mins)

Presence of risk factors

64
Q

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?

A

Abdo ultrasound

Serum LFTs

FBC

Serum lipase or amylase

(suspect gallstones)

65
Q

3 differentials to cholelithiasis (gallstones) & how to differentiate between them.

A

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
Q

How to treat biliary colic?

A

With an NSAID eg diclofenac

67
Q

How can cholelithiasis be treated?

A

Treat biliary colic with NSAIDs

Symptomatic gallstones:

  • Laparoscopic cholecystectomy
  • Bile duct clearance
68
Q

Define acute cholecystitis

A

Acute gallbladder inflammation

One of the major complications of gallstones

69
Q

Key diagnostic factors for cholecystitis

A

Pain in RUQ

Tenderness in RUQ

Signs & symptoms of inflammation

Palpable mass

70
Q

Risk factors for cholecystitis

A

Gallstones

Physical inactivity

Low fibre intake

Severe illness

71
Q

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?

A

Acute cholecystitis

CT or MRI of abdomen

Ultrasound of abdomen

FBC

CRP

Bilirubin

LFTs

Serum lipase or amylase

72
Q

3 differentials to acute cholecystitis & how to distinguish between them

A

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
Q

Treatment of acute cholecystitis

A

URGENT

  • Manage sepsis & organ failure if present
  • Fluid resuscitation
  • Analgesia
  • Antibiotics (if infection suspected)
  • Laparoscopic cholecystectomy
74
Q

What is the difference between ascending and acute cholangitis?

A

They are the same thing - an infection of the biliary tree

A patient with acute cholecystitis would not have signs of jaundice

75
Q

Risk factors for ascending cholangitis

A

Age >50

Cholelithiasis

Benign stricture

Malignant stricture

76
Q

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?

A

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
Q

Treatment of acute cholangitis

A

If you suspect sepsis, begin treatment for this immediately.

Stabilise pt - broad-spectrum antibiotics & iv hydration

Biliary decompression - surgical or non-surgical

78
Q

Fill in the table with information on biliary cholic, cholangitis and cholecystitis

A
79
Q

Define primary biliary cholangitis

A

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
Q

Risk factors for ascending biliary cholangitis

A

Female sex

Age 45-60

Family history of PBC/autoimmune disease

Smoking

81
Q

Aetiology of primary biliary cholangitis

A

Conventionally thought to be an autoimmune disease.

82
Q

Pathophysiology of primary biliary cholangitis

A

Damage to and progressive destruction of the biliary epithelial cells lining the small intrahepatic bile ducts

83
Q

Investigation of primary biliary cholangitis

A

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
Q

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?

A

Primary biliary cholangitis

  • shown in abnormal liver biochem
  • itch & fatigue
85
Q

Goals of treatment of primary biliary cholangitis

A

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
Q

1st line treatment for primary biliary cholangitis

A

Ursodeoxycholic acid

87
Q

Define acute pancreatitis

A

A disorder of the exocrine pancreas

It is associated with acinar cell injury with local and systemic inflammatory responses

88
Q

Risk factors for acute pancreatitis

A

Middle-aged women

Young to middle-aged men

Gallstones

Alcohol

89
Q

Key diagnostic factors for acute pancreatitis

A

Upper abdo pain

Nausea & vomiting

Signs of hypovolaemia

Signs of pleural effusion

90
Q

1st diagnostic investigations to order if you suspect acute pancreatitis & what they will show?

A

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
Q

Aetiology of acute pancreatitis

A

Alcohol consumption

Gallstones

Idiopathic

92
Q

3 Differentials to acute pancreatitis & how to differentiate between them

A

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
Q

Define chronic pancreatitis

A

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
Q

Key diagnostic factors for chronic pancreatitis

A

Presence of risk factors

Abdo pain

Steatorrhoea

Jaundice

95
Q

Risk factors for chronic pancreatitis

A

Alcohol

Smoking

Family history

Coeliac

96
Q

Aetiology of chronic pancreatitis

A

Alcohol

Idiopathic

97
Q

First line imaging test to diagnose chronic pancreatitis

A

CT or MRI of the abdomen

98
Q

3 differentials to chronic pancreatitis & how to rule them out

A

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
Q

Management of chronic pancreatitis

A

Alcohol & smoking cessation

Dietary advice & supplementation in case of malabsorption of fat, protein & fat-soluble vitamins

100
Q

Aetiology of alcoholic liver disease

A

Chronic, heavy alcohol ingestion

101
Q

Key diagnostic factors for alcoholic liver disease

A

Presence of risk factors

Abdo pain

Hepatomegaly

Haematemesis & melaena

102
Q

1st diagnostic investigations to order to investigate alcoholic liver disease

A

AST & ALT

Serum AST/ALT ratio

Serum alkaline phosphatase

Serum bilirubin

103
Q

Treatment of alcoholic liver disease

A

Alcohol abstinence/withdrawal

Weight reduction + smoking cessation

Supplements

Corticosteroids for some pts

104
Q

Differential for alcoholic liver disease & how to distinguish between them

A

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
Q

Risk factors for NAFLD

A

Obesity

Insulin resistance or diabetes

Dyslipidaemia

Hypertension

106
Q

Key diagnostic factors for NAFLD

A

Presence of risk factors

Absence of significant alcohol use

Fatigue & malaise

Hepatosplenomegaly

107
Q

1st investigations to order if you suspect NAFLD

A

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
Q

Pathophysiology of NAFLD

A

Not fully understood

Insulin resistance → excessive triglycerides in liver → hepatic steatosis

109
Q

Differential to NAFLD

A

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
Q

Management of NAFLD

A

Focusses on reducing risk factors - weight loss, diabetes treatment, antihyperlipidaemics

111
Q

Define cirrhosis

A

The pathological end-stage of any chronic liver disease

112
Q

Risk factors for liver cirrhosis

A

Alcohol misuse

IVDU

Unprotected sex

Obesity

113
Q

1st investigations to order when investigating liver cirrhosis

A

LFTs

GGT

Serum albumin

Serum sodium

114
Q

2 differentials to liver cirrhosis

A

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
Q

What directly causes oesophageal varices?

A

Portal hypertension

116
Q

Define oesophageal varices

A

Dilated collateral blood vessels that develop as a complication of portal hypertension

117
Q

Key diagnostic factors of oesophageal varices

A

Presence of risk factors for variceal bleeding

Haematemesis

Melaena

Haematochezia

118
Q

Risk factors for oesophageal varices

A

Portal hypertension

Large varices

Red wale marks

Decompensated cirrhosis

119
Q

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?

A

NAFLD

120
Q

1st investigations for oesophageal varices

A

Gastroscopy

FBC

Electrolytes

Serum LFTs

121
Q

When should you suspect oesophageal variceal bleeding?

A

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
Q

Define haematemesis

A

Vomiting blood

123
Q

Common causes of haematemesis

A
  • Oesophageal varices
  • Severe GORD
  • Tear in the oesophagus
  • Swallowed blood
124
Q
A

Phase 2a (12 decks)

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