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Exam > MEDICINE - GASTROENTEROLOGY > Flashcards

MEDICINE - GASTROENTEROLOGY Flashcards

1
Q

Liver cirrhosis

A

chronic inflammation and damage to liver cells (fibrosis and nodule formation)

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2
Q

4 main causes of liver cirrhosis

A

Alcohol-related liver disease
Non-alcoholic fatty liver disease (NAFLD)
Hepatitis B
Hepatitis C

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3
Q

signs of liver cirrhosis

A

Cachexia (wasting of the body and muscles)
Jaundice
Hepatomegaly
Small nodular liver
Splenomegaly
Spider naevi (telangiectasia with a central arteriole and small vessels radiating away)
Palmar erythema caused by elevated oestrogen levels
Gynaecomastia and testicular atrophy in males due to endocrine dysfunction
Bruising due to abnormal clotting
Excoriations (scratches on the skin due to itching)
Ascites (fluid in the peritoneal cavity)
Caput medusae (distended paraumbilical veins due to portal hypertension)
Leukonychia (white fingernails) associated with hypoalbuminaemia
Asterixis (“flapping tremor”) in decompensated liver disease

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4
Q

non invasive liver screen

A

-US liver (used to diagnose fatty liver)
-Hepatitis B and C serology
-Autoantibodies (autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis)
-Immunoglobulins (autoimmune hepatitis and primary biliary cirrhosis)
-Caeruloplasmin (Wilsons disease)
-Alpha-1 antitrypsin levels (alpha-1 antitrypsin deficiency)
-Ferritin and transferrin saturation (hereditary haemochromatosis)

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5
Q

autoantibodies in liver disease

A

Antinuclear antibodies (ANA)
Smooth muscle antibodies (SMA)
Antimitochondrial antibodies (AMA)
Antibodies to liver kidney microsome type-1 (LKM-1)

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6
Q

decompensated liver cirrhosis LFT

A

All raised:
-Bilirubin
-Alanine transaminase (ALT)
-Aspartate transferase (AST)
-Alkaline phosphatase (ALP)

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7
Q

how to assess fibrosis in Non alcoholic fatty liver disease?

A

enhanced liver fibrosis blood test
- three markers (HA, PIIINP and TIMP-1) and score calculation

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8
Q

enhanced liver fibrosis 10.51 or above

A

advanced fibrosis

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9
Q

US in non alcoholic fatty liver disease

A

fatty changes, increased echogenicity

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10
Q

liver cirrhosis ultrasound signs

A

-Nodularity of the surface of the liver
-A “corkscrew” appearance to the hepatic arteries with increased flow as they compensate for reduced portal flow
-Enlarged portal vein with reduced flow
-Ascites
-Splenomegaly

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11
Q

screening for hepatocellular carcinoma

A

alfa-fetoprotein and US

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12
Q

transient elastography (fibro scan)

A

assesses stiffness of liver and degree of fibrosis

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13
Q

which pts are at risk of cirrhosis?

A

-Alcohol-related liver disease
-Heavy alcohol drinkers (men drinking more than 50 units or women drinking more than 35 units per week)
-Non-alcoholic fatty liver disease and advanced liver fibrosis (score 10.51 or more on the ELF blood test)
-Hepatitis C
-Chronic hepatitis B

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14
Q

what to assess when someone has portal hypertension?

A

oesophageal varices (via endoscopy)

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15
Q

MELD score

A

% risk of 3 month mortality in pts with compensated cirrhosis

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16
Q

Child Pugh Score

A

5 factors of severity of cirrhosis (min 5, max 15)
A – Albumin
B – Bilirubin
C – Clotting (INR)
D – Dilation (ascites)
E – Encephalopathy

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17
Q

Monitoring complications of liver cirrhosis

A
  • MELD score every 6 months
  • Ultrasound and alpha-fetoprotein every 6 months for hepatocellular carcinoma
  • Endoscopy every 3 years for oesophageal varices
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18
Q

decompensated liver cirrhosis features

A

A – Ascites
H – Hepatic encephalopathy
O – Oesophageal varices bleeding
Y – Yellow (jaundice)

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19
Q

5 year survival in liver cirrhosis

A

50%

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20
Q

complications of liver cirrhosis?

A

-Malnutrition and muscle wasting
-Portal hypertension, oesophageal varices and bleeding varices
-Ascites and spontaneous bacterial peritonitis
-Hepatorenal syndrome
-Hepatic encephalopathy
-Hepatocellular carcinoma

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21
Q

portal vein anatomy

A

comes from superior mesenteric and splenic veins

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22
Q

portal hypertension

A

increased back pressure on the portal system due to resistance to blood flow in the liver
results in splenomegaly

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23
Q

collaterals between portal and systemic venous systems

A

Distal oesophagus (oesophageal varices)
Anterior abdominal wall (caput medusae)

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24
Q

prophylaxis of bleeding in stable oesophageal varices

A

Non-selective beta blockers (e.g., propranolol) first-line
Variceal band ligation (if beta blockers are contraindicated)

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25
Q

Mx of bleeding esophageal varices

A
  • fresh frozen plasma
  • blood tranfusion
  • vasopressin analogues (terlipressin and somatostatin)
  • broad spectrum Abx
  • variceal band ligation under endoscopy
  • Sengstaken-Blakemore tube
  • TIPS
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26
Q

what is TIPS

A

Transjugular intrahepatic portosystemic shunt - so blood flows directly from portal vein to hepatic vein

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27
Q

what is the protein content of cirrhosis ascites?

A

low - transudative

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28
Q

mx of ascites

A

-paracentesis
- tips
- aldosterone antagonists
- prophylactic abx (ciprofloxacin or norfloaxacin) when <15g/L protein in ascitic fluid

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29
Q

most common organisms in spontaneous bacterial peritonitis

A

-Escherichia coli
-Klebsiella pneumoniae

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30
Q

hepatorenal syndrome

A

impaired kidney funciton caused by changed in blood flow to the kidneys due to liver cirrhosis and portal hypertension. liver transplant is treatment

31
Q

Hepatic encephalopathy

A

(portosystemic encephalopathy)
due to build up of ammonia (as liver metabolism of ammonia is impaired and ammonia bypasses the liver due to collateral vessels)

32
Q

acute presentation of hepatic encepatholpathy

A

reduced consciousness and confusion +- changed to personality, memory, mood

33
Q

Factors that trigger hepatic encepatholpathy

A

dehydration
constipation
infection
GI bleed
electrolyte disturbance

34
Q

Mx of hepatic encephalopathy

A
  • lactuose
  • Abx (rifaximin or alternatively metronidazole or neomycin)
35
Q

Alcohol-related liver disease steps

A
  1. Alcoholic fatty liver (hepatic steatosis)
  2. Alcoholic hepatitis
  3. Cirrhosis
36
Q

Excessive alcohol consumption

A
  • slurred speech
  • bloodshot eyes
  • telangiectasia
  • tremor
37
Q

Blood test results in alcohol-related liver disease

A
  • raised MCV
  • raised ALT and AST
  • AST:ALT ratio >1.5
  • raised gamma GT
  • raised ALP and bilirubin
  • Low albumin
38
Q

early alcoholic liver disease US

A

fatty changes and increased echogenicity

39
Q

Liver biopsy

A

to confirm alcohol related hepatitis or cirrhosis

40
Q

Mx of alcohol-related liver disease

A
  • corticosteroids
  • liver transplant
  • vitamin B
  • psychological interventions
41
Q

CAGE questions

A

C – CUT DOWN? Do you ever think you should cut down?
A – ANNOYED? Do you get annoyed at others commenting on your drinking?
G – GUILTY? Do you ever feel guilty about drinking?
E – EYE OPENER? Do you ever drink in the morning to help your hangover or nerves?

42
Q

AUDIT questionnaire

A

alcohol use disorders identification test (8or more is harmful)

43
Q

alcohol withdrawal steps

A

6-12 hours: tremor, sweating, headache, craving and anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: delirium tremens

44
Q

delirium tremens

A

alcohol stimulates GABA receptors (relaxing) and inhibits glutamate (NMDA) receptors (excitatory) - when alcohol is removed there is down regulation of gaba and up regulation of NMDA.

45
Q

delirium tremens presentation

A

Acute confusion
Severe agitation
Delusions and hallucinations
Tremor
Tachycardia
Hypertension
Hyperthermia
Ataxia (difficulties with coordinated movements)
Arrhythmias

46
Q

Chlordiazepoxide (librium)

A

benzodiazepine to combat effects of alcohol withdrawal

47
Q

diazepam

A

used to reduce effect of alcohol withdrawal - orally, 10-40mg every 1-4h and reduced over 5-7days

48
Q

what vitamin is given in delirium tremens?

A

IM high dose vit B (PABRINEX) and long term oral thiamine - to prevent Wernicke-Korsakoff syndrome

49
Q

what does thiamine deficiency lead to?

A

Wernicke’s encephalopathy and Korsakoff syndrome.

50
Q

features of Wernicke’s encephalopathy

A

Confusion
Oculomotor disturbances (disturbances of eye movements)
Ataxia (difficulties with coordinated movements)

51
Q

features of Korsakoff syndrome

A

Memory impairment (retrograde and anterograde)
Behavioural changes

52
Q

which one is irreversible? wernickes vs korsakoff

A

korsakoff syndrome

53
Q

how many adults have non alcoholic fatty liver disease?

A

25%

54
Q

stages of non alcoholic fatty liver disease?

A

Non-alcoholic fatty liver disease
Non-alcoholic steatohepatitis (NASH)
Fibrosis
Cirrhosis

55
Q

risk factors for non alcoholic fatty liver disease?

A

Middle age onwards
Obesity
Poor diet and low activity levels
Type 2 diabetes
High cholesterol
High blood pressure
Smoking

56
Q

what is non alcoholic fatty liver disease associated with?

A

metabolic syndrome

57
Q

what is a metabolic syndrome?

A

HTN, obesity, and diabetes

58
Q

non alcoholic fatty liver disease blood tests/ diagnosis

A
  • raised ALT
  • enhanced liver fibrosis >10.51
  • hepatic steatosis and increased echogenicity on US liver
    -Fibroscan
  • Liver biopsy
  • NAFLD fibrosis score
  • Fibrosis 4 (FIB4)
59
Q

AST ALT ratio <1

A

normal

60
Q

AST ALT ratio >0.8 in NAFLD

A

advanced fibrosis

61
Q

AST ALT ratio >1.5

A

alcohol related liver disease

62
Q

Gold standard test to diagnose NAFLD

A

Liver biopsy

63
Q

Mx of NAFLD

A

exercise, stop smoking, reduce BP and cholesterol, limit alcohol, weight loss;
+ vit E, pioglitazone, bariatric surgery, liver transplant

64
Q

Hep A details

A

RNA, faecal-oral transmission, vaccine, treatment supportive

65
Q

Hep B details

A

DNA, blood/bodily fluids transmission, vaccine, supportive+antiviral treatment

66
Q

Hep C

A

RNA, blood transmission, no vaccine, direct acting antivirals treatment

67
Q

Hep D

A

RNA, transmision is with Hep B, no vaccine, pegylated interfereon alpha treatment

68
Q

Hep E

A

RNA, faecal-oral transmission, no vaccine, supportive treatment

69
Q

is vital hepatitis a notifiable disease?

A

yes - UK Health security agency

70
Q

Other (non viral) causes of hepatitis

A

Alcoholic hepatitis
Non-alcoholic steatohepatitis (NASH)
Autoimmune hepatitis
Drug induced hepatitis (e.g. paracetamol overdose)

71
Q

presentation of viral hepatitis

A

Abdominal pain
Fatigue
Flu-like illness
Pruritus (itching)
Muscle and joint aches
Nausea and vomiting
Jaundice

72
Q

hepatitic picture on LFTs

A

high AST and ALT
proportionally less rise in ALP

73
Q
A

Exam (17 decks)

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