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Gastro > Liver Tumours + Benign + Genetic Disease + Acute GI bleed > Flashcards

Liver Tumours + Benign + Genetic Disease + Acute GI bleed Flashcards

1
Q

What is most common tumour in liver

A

Metastases from lung breast/ GI
Primary = cholangiocarcinoma / HCC
Hepatoblastoma / sarcoma = very rare

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2
Q

What are symptoms of liver mets

A 
Fever 
Weight loss
RUQ pain due to stretch 
Jaundice late except cholangiocarcinoma
Hepatomegaly 
CLD signs 
Decompensated if CKD
Intraperitoneal haemorrhage if rupture
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3
Q

How do you investigate mets

A 
FBC, LFT, hepatitis serology, AFP
USS or CT
MRI to distinguish benign / malignanct
ERCP for cholangiocarcinoma 
Liver biopsy 
Find primary
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4
Q

How do you treat mets

A

Chemo
Resection
Radiofrequency ablation
Prognosis <6 months

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5
Q

What is carcinoid syndrome

A

Release of serotonin due to lung or liver mets (from GI)

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6
Q

What are symptoms of carcinoid syndrome

A 
Abdo pain 
FLushing
Palpitations
DIarrhoea - proceeds Dx by 2 years
Bronchospasm / wheeze
Hypotension 
R valve stenosis and triscupid insufficiency 
ACTH / GnRH = CUshing's
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7
Q

What is the Ddx for carcinoid

A

Phaeochromocytoma

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8
Q

How do you Dx and treat carcinoid

A 
Urinary 5-HIAA 
Somatostatin analogue (octeoride)
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9
Q

What causes HCC

A 
Cirrhosis - secondary to any cause
HBV= most common
HVC 
Autoimmune
NAFLD
AIH
Steroid / drugs
Alpha 1 anti-trypsin deficiency
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10
Q

What are the symptoms of HCC

A 
Cirrhosis + mass on screening 
Fatigue
Anorexia
Weight loss
RUQ pain 
Jaundice
Ascites
HSM
Pruritus
Haemorrhage 
Decompensated CKD
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11
Q

How do you Dx HCC

A

AFP + USS for surveillance if cirrhotic
CT / MRI
AVOID biopsy as risk of seeding
Examine testis as AFP raised in testicular tumour

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12
Q

How do you treat HCC

A

early disease: surgical resection
liver transplantation
radiofrequency ablation
transarterial chemoembolisation
sorafenib: a multikinase inhibitor

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13
Q

What is Wilson’s disease

A

Excess deposition of copper in the liver
Autosomal recessive
Onset usually between 10-25

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14
Q

What are symotoms in children

A

LIver hepatitis / cirrhosis / failure

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15
Q

How do adults with Wilsons present

A 
CNS Signs
Basal ganglia degeneration 
Tremor, dysarthria, dysphagia, dementia, Parkinsonism, ataxia
Speech and behaviour 
Chorea - jerky 
Other 
Dark ring round eyes due to copper 
Blue nails 
Astrexis - liver flap
Altered mood - depresion / libido / mania / psychosis 
Fatigue 
Renal tubular acidosis
Haemolysis 
Memory
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16
Q

How do you Dx Wilson

A 
Urine copper excretion increased
Serum copper decreased
Cereoplasmin decreased 
LFT
Genetic test to confirm
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17
Q

How do you treat Wilson’s

A

DIet
Penicillamine - chelator= 1st line
Liver transplant

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18
Q

What is most common liver disease in children

A

Anti-trypsin deficiency

More likely to cause emphysema in adult

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19
Q

What are signs of A1 anti-trypsin deficiency

A

SOB
CIrrhosis
Cholestatic jaudnice

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20
Q

How do you Dx A1

A

A1AT level
Obstructive lung disease on spirometry
Liver biopsy
Dx pre-natal

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21
Q

How do you treat A1AT deficienct

A

Smoking cessation
Liver transplant if decompensate
Lung transplat

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22
Q

What is haemochromotosis

A

AR

Increased iron absorption whcih deposited in joints / liver / heart / pancreas / pituitary / adrenal and skin

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23
Q

What are symtpoms

A 
Fatigue
Arthralgia
Decreased libido and erectile dysfunction 
Bronzed skin 
DM
Hypogonadism 
CLD / hepatomegaly / cirrhosis
Dilated cardiomyopathy
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24
Q

What are the reversible symptoms

A

Cardiomyopathy

Skin - pigmentation

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25
Q

What are irreversible

A

Cirrhosis
DM
Hypogonadism
Arthropathy

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26
Q

How do you Dx

A 
Increased LFT, transferrin sat and ferritin - do these if any abnormal 
Transferrin = most accurate >50%
Low total iron binding capacity 
HFE genotype
MRI / liver biopsy to make Dx
Joint X-Ray for arthralgia
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27
Q

How do you treat

A

Venesection for life
Monitor LFT and glucose
HCC if cirrhotic
Iron chelation if can’t do venesection (desoferoxiamine)

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28
Q

What is the chance of inheriting haemochromatosis if one parent affects

A

0% as AR

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29
Q

What are common causes of liver access

A

S.Aureus in children

E.coli in adults

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30
Q

What are the symptoms of absces

A 
RUQ pain
Fever
N+V
Rigors
Reduced E+D
Jaundice 
Sepsis
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31
Q

What puts you at high risk of abscess

A

Biliary sepsis

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32
Q

How do you Dx abscess

A

USS

CT

33
Q

How do you treat

A

IV Ax
Amox + cipro + met
Percutaneous needle drainage - don’t delay
Surgery if fails to resolve

34
Q

What are benign liver tumour

A

Liver haemangioma - hyperchoiec USS

Liver cell adenoma - linked to OCP

35
Q

What is hydatid liver cyst

A

Caused by tapeworm
Common in the liver and lung
Type 1 hypersensiitivy

36
Q

What are the symptoms of hydatid

A 
RUQ pain
Unwell
Jaundice
Colic
Urticarial lesion
37
Q

How do you Dx

A

CT

Differentiate from amoebiasis

38
Q

How do you treat

A

Surgery

39
Q

What causes amoebiasis

A

Entamoeba Histolytica

40
Q

What are the symptoms of amoebiasis

A 
Mild diarrhoea - severe
Liver and colonic abscess
Bloody diarrhoea
Single mass filled with anchovy puss
Fever
Jaundice 
RUQ pain
41
Q

How do you Dx

A

Serology +Ve

42
Q

How do you Rx

A

Metronidazole

Amoebicide for cyst carriage

43
Q

What are the symptoms of upper GI bleed [5]

Sign of upper GI bleed [1]

A

Collapse, shock
Haematemesis - bright red or coffee
Malena
Epigastric discomfort, dyspepsia, reflux
NSAID use

Signs: increased urea but normal renal function

44
Q

What causes upper GI
Esophageal [4]
Gastric [4]
Duodenum [3]

A

Esophageal:
- Esophagitis, cancer, Mallory Weiss Tear, varices
Gastric:
- Cancer, Dieulafoy lesion, Diffuse erosive gastritis, gastric ulcer
Duodenum:
- Duodenal ulcer
- Periampullary tumor
- Aortoenteric fistula

45
Q

What puts you at increase risk of bleed [6]

A 
Age
Co-morbid
Inpatient
NSAID
Aspirin
Liver disease
46
Q

What imaging and tests in acute setting [3]

A

CXR / AXR
ECG
ABG

47
Q

What anaemia is suggestive of bleed [2]

A

Iron deficiency

DO ENDOSCOPY

48
Q

What other imaging [4]

A

Balloon / MR enteroscopy - small bowel
CT angiogram
Meckelscan
CT CAP

49
Q

What scoring systems are used in risk assessment for upper GI bleeding? [2]

A

Blatchford score at first assessment

Full Rockall score done after endoscopy

50
Q

What score suggest admission / endoscopy

A

> 6

Consider early discharge if 0

51
Q

What does blatchford score take into account [8]

A

Sex
Urea
Hb
SBP
Hepatic / cardiac failure
Tachycardia
Malaena
Syncope

52
Q

What does Rockall look at [7]
How is this score interpreted?

A

Pre-endoscopy scoring:
Age
Shock, tachy+1, hypotension +2
Comorbidity

Complete Rockall score - estimates mortality in patients with active upper GI bleed who have had endoscopy:
- Age, shock, comorbidity
- Diagnosis: Mallory Weiss tear, no lesion identified, upper GI malignancy
- Major stigmata of recent haemorrhage e.g., blood, adherent clot, visible spurting vessel

Final Rockall score (Maximum score: 11): <3 good prognosis; >8 poor.

53
Q

How do you manage all upper GI bleed [6]

A

Keep head down
A - protect airway
B - high flow O2
C - 2 large bore cannula, IV fluids, blood, FBC, U+E, LFT, cross-match 6U, coag, transfusion
D - catheter / fluid restrict
E - NBM, glucose, urea levels

54
Q

When do you transfuse [4]

A

o Red cells: Hb<10
o Platelets: actively bleeding and platelets 50x109/L
o FFP: actively bleeding, INR or APTT x1.5 ULN; if fibrinogen level remains <1.5g/L despite this, use cryoprecipitate as well
o Prothrombin complex concentrate: on warfarin and actively bleeding

55
Q

Maintenance after resuscitation for Upper GI bleed [5]

A
  • maintenance fluids
  • catheter
  • consider CV line
  • correct any coagulopathy
  • PABRINEX if alcoholic
56
Q

Subsequent mx when stable?
Varices medical management [2]
Erosive esophagitis [4]

A

Varices: TERLIPRESSIN and prophylactic CIPROFLOXACIN before endoscopy
Erosive esophagitis or gastritis: PPI
- ADRENALINE injection + thermal coagulation/fibrin glue/ endoclips

57
Q

Definitive treatment of varices [3]

A
  • Endoscopic mx: banding for esophageal, sclerotherapy for gastric
    Endoscopy if Blatchford >6
    Immediate if severe
    Or within 24 hours of admission
  • Active bleeding: Sengaksten-Blakemore tube (gastric balloon inflated first then oesophageal balloon second and balloon deflated within next 12h to prevent necrosis
  • TIPSS if can’t be stopped endoscopically
58
Q

What do you give after endoscopy as prophylaxis [2]

A

BB

Band ligation and PPI continuous infusion until eradicated

59
Q

Angiodysplasia
Ep
Ax
Sx
Ix [4]
Mx [2]

A

Ep: elderly
Ax: submucosal AV malformations
Sy/Si: fresh PR bleeding
Ix:
- FBC
- colonoscopy (excl. other causes)
- Tc radionuclide labelled red cell imaging during active bleeding to identify lesions (if >1mL/min)
- CT or mesenteric angiography
Mx:
- mesenteric angiography with therapeutic embolization during bleeding
- endoscopic laser argon photocoagulation or resection

60
Q

What does terlipressin do [2]

A

Vasoconstriction of splanchnic blood supply

Reduce portal tension

61
Q

What investigations in rectal bleed [6]

A

QFIT
FBC, U+E, LFT, ferritin
Coeliac
CRP
Calprotectin
DRE

62
Q

What are more common causes of rectal bleed [6]

A

Diverticulitis: large vol, dark blood
Malignancy
Haemorrhoids: fresh blood
IBD
Angiodysplasia: R colon
Gastroenteritis

63
Q

What are rare causes [6]

A

Trauma
Ischameic colitis
Radiation proctitis
Aorta enteric fistula following AAA repair
Meckels

64
Q

What are symptoms of lower GI bleed [3]

A

Magenta stool, brighter if L colon
Normal urea
Collapse

65
Q

How do you investigate lower GI bleed [4]

A

DRE
Colonoscopy
Bloods
Angiogram if patient unstable to identify bleeding

66
Q

What bloods for lower GI bleed?

A

FBC, U+E, LFT, Ca, TFT
Clotting
Amylase
CRP
Group and save
Stool MC+S
Coeliac
Calprotectin
QFIT

67
Q

What imaging

A

AXR if sign of sepsis / peritonitis

68
Q

Immediate mx lower GI bleed [7]

A 
ABCDE
Proctoscopy
Insert 2 cannula
Catheter 
Crystalloid resus
Blood transfusion
Ax if sepsis / perforation
69
Q

Can you put bleeding down to haemorrhoids

A

Not without internal inspection as can be impalpable

70
Q

What artery affected in lower GI bleeds?

A

Gastroduodenal

71
Q

When should you consider admission [4]

A

> 60
Co-morbid
Haemodynamically unstable
Aspirin / NSAID use

72
Q

What does tips do

A

connect hepatic and portal vein

reduce portal hypertension

73
Q

Why do you do U+E

A

Colonoscopy require lots of laxatives before

74
Q

Why is ferritin useful

A

Drops before Hb

75
Q

For upper GI bleeding, when is surgery indicated? [4]

A
  • > 60y/o
  • continued bleeding despite endoscopic intervention
  • recurrent bleeding
  • known CV disease with poor response to hypotension
76
Q

Surgical mx for duodenal ulcer

A

laparotomy, duodenotomy (longitudinal (NOT transverse) to avoid stenosis) and under running of ulcer where large bites using 0 Vicryl taken above and below ulcer base to occlude vessel

77
Q

Surgical mx for gastric ulcer [2]
Antral ulcer
Lesser curve ulcer involving left gastric artery
Bleeding persists

A

laparotomy, gastrostomy and underrunning of bleeding site
 Antral ulcer: partial gastrectomy
 Lesser curve ulcer (involving left gastric artery): partial gastrectomy or under running of ulcer
 Bleeding persists: total gastrectomy

78
Q

Subsequent mx of lower GI bleed
Hemorrhoidal bleeding
Haemodynamically stable/unstable

A

o Haemorrhoidal bleeding: proctosigmoidoscopy
o Haemodynamically stable: elective colonoscopy
o Haemodynamic instability:
- CT or percutaneous angiography to identify patch of angiodysplasia
+/- coiling (or surgery if unavailable)

79
Q

Mx of lower GI bleed if vessel is identified

What to do if there is an unidentified source of bleeding? [3]

A

o Selective mesenteric embolization: if identified vessel

o Unidentified colonic source of bleeding: laparotomy, on table colonic lavage and attempt resection

Gastro (17 decks)

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