M Ow Flashcards
What are the two types of liver impairment indicated by a blood test?
Cholestatic (obstruction to billary drainage - GGT and ALP elevation
Hepatocellular - think of hepatitis - AST and ALP
Can be mixed.
Albumin is low - this indicates that their is impairment in liver function
What does GGT elevated alone indicate?
Steatosis - fat deposited into liver cells
Caused by alcohol or non-alcoholic fatty liver disease.
Non-alcohoic fatty liver disease is a metabolic syndrome i.e diabetes, dyslipidaemia, hypertension, increased BMI
What are some causes of hepatitis?
Viral hepatitis Alcoholic hepatitis Non-alcoholic hepatitis Autoimmune hepatitis Ischaemic hepatitis Haemochromatosis Drug induced
What type of liver damage do drugs cause?
Cholestasis
Hepatitis
Mixed
What type of liver damage do tumours cause?
Cholestatic or mixed
Primary cancer is hepatocellular carcinoma
Secondary is metastatic
What is the pathway of non-alcoholic fatty liver disease?
Normal liver can become fatty for many reasons. This can develop into streatosis.
This can occasional cause inflammation that develops into hepatic disease, which can progress to cirrhosis.
Caused be excess fat deposition.
What the the features of hepatitis E?
Similar to hepatitis A.
What viruses can cause hepatitis?
EBV, CMV, Hepatitis A, B, C, D and E
What are the symptoms of EBV and CMV infection?
Usually asymptomatic.
EBV causes infection mononucleosis and CMV causes mononucleosis-like syndrome
Systemic symptoms
Presence of atypical lymphocytes
What are the features of autoimmune hepatitis?
Episodic disease - repeated abnormal tests that go up and down
Do an autoimmune screen for certain Abs
Liver biopsy
What are the features of ischaemic hepatitis?
Acute catostrophic.
Not common
Severe shock, from sepsis or bleeding or blood clot to the hepatic artery.
Causes a sudden loss of blood flow to the liver -> high transaminases (AST and (ALT)
What are the features of haemochromatosis?
Hereditary - autosomal recessive
Mutation of the HFE gene (C282Y)
Europeans at high risk
Low hepcidin levels -> increased iron absorption in the GI tract.
Secondary - iron overload or repeated blood transfusions.
Look at the ferritin and iron saturation (high saturation)
What are the features of drug induced liver damage?
What drugs, what supplements, how much, how often for how long.
Paracetamol overdose - antidote is N-acetlycysteine. Narrow window to give antidote.
Are they at risk of self harm?
Many drugs can affect
and present as cholestasis, mixed or predominately hepatitis
What are the features of drug induced liver tumours?
Only happen in patients with underlying cirrhosis or chronic hep B infection
Or metastasis
If AST and ALT are in the thousands what are the possible causes?
- viral
- ischaemia
- paracetamol
What does a AST > 2x ALT suggest?
Alcoholic hepatitis (AST/ALT ratio)
What does a low platelet count in the context of liver disease indicate?
Portal hypertension -> spelnomegaly
Portal hypertension only happens with cirrhosis
What are the investigations to determine the cause of liver damage?
Ultrasound - gallstoners, gallbladder
- Bile ducts not obstructed
- liver look
Hepatitis serology
- HAV IgM
- HAV IgG
HBsAg
HBsAB
HB core antigen
Anti-HCV AB - if positive then do PCR
Iron studies
Liver autoantibodies
How do you treat portal hypertension with ascities?
Give diuretic. Give high protein diet to return albumin levels to normal and cause an increase in osomotic pressure in the blood. Low salt diet. Stop alcohol.
What is a sign of encaphalopathy?
Hepatic flap and not responding
What can initiate a cause of ascities and encapolopathy in someone with cirrhosis?
Any big event, such as pneumonia can cause progression of disease (decompensation)
What is a risk in portal hypertension?
Bleeding from variceal bleed.
What complication can occur in patients with cirrhosis and ascities?
Spontaneous bacterial peritonitis
The bacteria can migrate through an impaired gut barrier and impaired immune system. The bacteria grows in ascities. Must have ascities to develop.
Do an ascitic tap - should be lots of neutrophils
If the transaminisase in the liver test are in the thousands, what can you rule out as a cause?
Alcohol and non-alcoholic fatty liver disease.
Most likely not autoimmune
What are the causes of acute and chronic Hep B?
Acute happens in adults (IV drugs and sex) and chronic happens from birth (child to child and vertical)
Mode of transmission determines.
What are the four important blood tests in hepatitis B?
HBsAg (acute and chronic)
Anti-HBs (Cleared and vaccinated)
HBcAb IgM (recent infection, not long term infection)
HBcAB IgG (acute and chronic and cleared)
There can be times when people are infected with Hep B but are surface antigen negative but core antigen IgM positive.
In a chronic infection, they will be HBcAb IgM negative and HBcAb IgG positive
What are the 4 phases of chronic hepatitis?
1 - Immune tolerant -carriers but not causing damage
2 Immune clearance - the body tries to clear the virus causing inflammation (20-30 years old)
- immune control - the body controls the virus - no damage to the liver
4 immune escape - inflammation comes back causing damage
Patients can go between phases without knowing and they may need treatment so constant monitoring
What causes encephalopathy in liver disease?
The liver is not able to remove toxins from the blood so they accumulate
Ammonia from diet.
Treat with lactulose.
What are the issues with portal hypertension?
Esophageal varicies Caput medusae Haermorrhoids Ascities Hypersplenism - anaemia, neutropeni, thrombocytopenia
How do ascities develop?
Portal hypertension caused splanchnic vasodilation (bowel, spleen and kidneys) - this decreases the blood flow to the kidneys and activates the RAAS system. This causes the retention of fluid. This increase the hydrostatic pressure but there is a decreased protein level in the blood.
This causes renal vasoconstriction. This causes renal impairment -> hepatorenal syndrome
What is alpha fetoprotein?
Liver cancer marker.
Where does maroon colored blood in the poo come from?
Proximal colon or SI
What rules out celiac disease?
Bleeding in the poop
What rules out IBS?
No bleeding with IBS.
Having a normal bowel habit prior to illness is unusual.
Abrupt onset is unusual for IBS
Usually don’t get nocturnal symptoms
What is IBS and IBD?
Irritable bowel syndrome and inflammatory bowel disease
What are symptoms of inflammatory bowel disease?
Can have bleeding in diarrhea
What are the two types of IBD?
Chron’s disease
- affects any part of the GI tract
- discontinuous lesions (skip lesions), only get diarrhoea if it affects the colon
- can cause deep ulcers and strictures and fistulas
- coblestone appearance
- transmural inflammation
- Granulomas may be present
- Made worse by smoking
Usually occurs in the iliocolonic junction
Ulcerative colitis
- colon only
- continous inflammation, starting at the rectum
- shallow ulcers
- mucosal inflammation, diffuse and granular. Doesn’t effect the granular layer and so does not cause stricturing or fistulas
- smoking is protective
- inflammatory
Begins in the rectum and spreads proximal.
Treat by removing the colon.
What are the four presentations with Chron’s?
1) Inflammatory -
1a) Colitis (diahorrea, bleeding),
1b) Ileitis (abdominal pain, an hour after food),
1c) gastritis/duodeniis (dyspepsia)
2) Stricturing - abdominal pain and distension, vomiting, bowels not opening.
3) Fistulising - connections formed (bowel to kidney, SI to skin, rectum to vagina)
4) Perianal - abscess, anal fissure, perianal fistual
What are the symptoms of ulcerative colitis?
Always inflammatory because it does not impact beyond the mucosa.
Diarrhoea, bleeding, Frequent bowel motions and urgency Abdominal discomfort Fever, malase, weight loss Blood tests - raised ESR and CRP and platelets
At risk of toxic megacolon - inflammation drives arrest of the movement of the colon and progressively dilates - increases the risk of perforation.
Because it only affects the mucosa, you don;t get fistulas or fissures
What are the extra-intestinal manifestations of IBD?
Joint pain or arthrytis
Eye - uveitis or episcleritis
Mouth ulcers
Skin - erythema nodosum - painful, tender nodular rash on lower limps
Pyoderma causes a necrotic lesion on the skin.
These may present before the main chron’s symptoms
What does the terminal ilium do?
Bile reabsorption (fat malabsorption) and B12 absorption
Removal will cause B12 malabsorption and bile salt malabsorption -> fat malabsorption -> causes fatty diahorrea (steatorrhoea)
More bile salt excreted and it is an irritant in the colon, stimulates water and electrolyte secretion - secretory diarrhoea
What are the treatments for IBD?
Steroids
Immunosuppression - azathioprine
Anti-inflammatory
Biologics (anti-TNF)
Surgery - when medical treatments fail. It is curative in UC but not in Chron’s. In Chron’s it can be used to remove bowel obstructions, perforations, fistulas and abscesses
What is the most common reason for iron malabsorption, inadequate dietary intake and abnormal loss?
Celiac disease.
Vegetarian
Overt and occult bleeding
How do you determine who to investigate further in iron deficiency anaemia?
Young woman without GI symptoms - likely menstrual loss
Young women with GI symptoms - often needs investigating
Older women (post menopausal) and men - always investigate
What are the most likely causes of iron deficient anaemia?
Inadequate dietary intake,
Malabsorption
Abnormal loss - bleeding
What does the colour of the blood indicate?
Black - upper GI/upper SI
Bright red - outlet bleeding
Bright red mixed with stools - left colon
Dark red - proximal colon i.e. caecum to transverse colon
What are the causes of stomach blood loss?
Peptic ulcer - NSAIDs and H. pylori
Oesophagitis - usually caused by reflex (usually haematemasis not melaina).
Varascies - heavy and forceful with bleeding (haemataemasis and melina)
mallory-Weiss tear (caused by retching)
Cancer in the stomach - usually mild bleeding
Vascular malformations - malformations in the capillaries.
What can cause colon bleeding?
Polyps Carcinoma of the colon Inflammatory bowel disease Diverticula Anal fissure haemorrhoids
What can cause SI bleeding?
Least common.
Angiodysplasia
polyps
Does IBS lead to any nutritional deficiencies?
No. Celiacs does.
Causes eratic bowel habit, abdominal dyscomfort.
What are the symptoms of celiacs disease?
How do you test for celiacs disease?
Erratic bowel habit, abdominal discomfort, malabsorption
Do celiac serology - tissue transglutaminase IgA Ab which is in response to gluten and DGP IgG - make sure gluten hasn’t been removed from the diet.
Then send for a gastroscopy if positive. Then do duodenal biopsies - MARCH criteria - flattening of the villi, increased intrapepithelial lymphocytes.
Some people think that there is a gene test. If it is positive is not useful, can rule out if negative.
What are three associations with coeliac disease?
Dermatitis herpertiformis - skin rash caused by gluten exposure
First degree relative with coeliac disease
Type I diabetes
What is the treatment of coeliac disease?
Gluten free diet
- wheat, barley, rye, oats
What is the hormone that stimulates release of the bile from the gall bladder?
Cholecystokinin
What is the defination of biliary colic, cholelithiasis, cholecystitis, choledocolithiasis and cholangitis?
1) biliary colic is a symptom - pain in right upper quadrant
2) gall stones in the gall bladder
3) inflammation of the gall bladder
4) gall stone causing obstruction in the duct
5) obstruction in the duct and an associated infection
What are the common causes of cholestasis?
- stones, biliary disease (primary biliary cirrhosis, primary sclerosing cholangitis)
- drugs
- tumours
What are the symptoms of cholangitis?
Fever
Jaundice
Right uper quadrant pain
What is an MRCP?
An MRI of the pancreatic and biliary system.
What do you do to treat stones in the bile duct?
Endoscopic, retrograde cholangiopancreatography
Done with X-ray guidance into the stomach-> duodenum
Can clear the stones with this procedure. A tube is inserted into the sphincter of odi, a blood is inflated and is pulled back out bringing the stones with it.
Patients still need a cholecystectomy.
What is primary biliary cirrhosis?
Inflammation and destruction of the very small intrahepatic ducts. Need to do a biopsy to see. can’t see with a scan. Causes cholestatic disase.
Can be diagnosed with an anti-mitochondrial antibody (AMA) antibody screen
Diagnosis requires
- high ALP
- positive AMA
- liver biopsy
Most are asymptomatic
- may have fatigue, itch or steatorrhoea (because of poor bile salt secretion) or deficiency of fat soluble vitamins
- no jaundice but increase in bile salts in the circulation
Can cause fibrosis and cirrhosis of the liver by bile being diverted to the liver cells causing inflammation.
Progressive disease
- jaundice
- liver cirrhosis
What is Primary sclerosing cholangitis?
Medium to large bile ducts in the liver (medium sized intrahepatic ducts) and extra hepatic bile ducts.
immune mediated - no antibody diagnostic
See multiple strictures in the bile duct.
Is often associated with IBD
What is the treatment for cholestasis?
Ursodeoxycholic acid (UDCA)
What are the features of primary sclerosing cholangitis?
Affects extra and intrahepatic bile ducts - causes distinctive stricturing that can be seen on MRCP
Affects the medium size bile ducts in the liver and the extra hepatic ducts.
Immune mediated by antigen unknown.
Radiological diagnosis - occasional requires biopsy
Often associated with ulcerative colitis
Asymptomatic in 50%
build up of bile in the circulation.
Symptomatic - itch, pruritus, fatigue, may have steatorrhoea
More rapidly progressing than primary billary cirrhosis
Progressive disease - jaundce, cholangitis, cirrhosis
Treatment - no medications, treat symptoms and any structural abnormalities such as strictures (balloon inflation). Liver transplant
What other than stones can obstruct the bile duct?
Pancreatic cancer (head of the pancreas)
Cholangiocarcinoma (cancer of bile duct) - can occur anywhere in the bile duct
Cause obstructive jaundice -
painless jaundice, palpable epigastric mass, palpable gallbladder
What are the consequences of portal hypertension?
Esophageal varicies
Caput medusae
Haemorrhoids
Ascites - spontaneous bacterial perotonitis
Hypersplenism - anaemia, neutropenia, thrombocytopenia (first thing to fall)
What causes the ascities in portal hypertension?
Cirrhosis -> increased resistance to flow -> portal hypertension -> increased hydrostatic pressure + decreased albumin (decreased osmotic pressure)
Portal hypertension also causes splanchnic vasodilation -> systemic arterial under filling -> ADH and renin production -> H20 retention.
What is the most common cause of iron malabsorption?
Celiac disease
What should you see in IBD?
Markers of inflammation
What will you get with bleeding from the stomach?
Melina and/or haematemesis
Where does billary colic pain radiate to?
The back, sometimes the tip of the shoulder.
Usually comes on after food.
What can normocytic anaemia be caused by?
Chronic infection resulting in reduced BM function.
May also be caused by bleeding.
