PassMedicine Flashcards
What is the test used to diagnose liver cirrhosis
Transient elastography
Who should be offered a screening for liver cirrhosis
- People with hepatitis C
- Men who drink >50 units of alcohol per week
- Women who drink >35 units of alcohol per week
- People diagnosed with alcohol-related liver disease
How are patients with liver cirrhosis followed up
- Upper endoscopy to check for varies after initial diagnosis
- Liver ultrasound every 6 months (+/- alfa fetoprotein) for hepatocellular carcinoma
What are the common presenting symptoms of coeliac disease
Bloating
Flatulence
Abdominal pain
Fatigue
Weight loss
Dermatitis herpetiformis
Anaemic
Low Ferritin
Low folate
What is the gold standard test for diagnosing coeliac disease
Endoscopic intestinal biopsy
- villous atrophy
- crypt hyperplasma
- increased intraepithelial lymphocytes
- lamina propria infiltration with lymphocytes
What is barrels oesophagus
Were squamous epithelium is replaced with columnar epithelium
What is the management of Barretts oesophagus
Metaplasia - endoscopic surveillance every 3-5 years
Dysplasia - Endoscopic intervention - Radiofrequency ablation is 1st line, endoscopic mucosal resection can also be done
What are the main signs of acute mesenteric ischaemia
Sudden onset, severe abdominal pain
Vomiting and a rapid episode of bloody diarrhoea
Pain out of proportion with the clinical findings
TriadL Cardiovascular disease (usually AF), raised lactate and soft but tender abdomen.
What VBG findings will there be in acute mesenteric ischaemia
Metabolic acidosis
Elevated lactate
What imaging is used to diagnose ischaemic bowel
CT angiography abdomen and pelvis with contrast
What type of inheritance is haemochromatosis
Autosomal recessive
Who requires an urgent referral for upper GI
- All patients with dysphagia
- All patients with an upper abdominal mass
Patients >55 with weight loss AND:
- Upper abdominal pain
- Reflux
- Dyspepsia
Who requires a non-urgent GI referral
- Patients with haematemesis
-Patients > 55 with:
- Treatment resistant dyspepsia
- Upper abdo pain with low haemoglobin levels
- Raised platelet count and symptoms
- Nausea or vomiting with weight loss, reflux, dyspepsia and upper ando pain
What are the signs of acute cholecystitis
- Pain in RUQ - more severe and persistent than biliary colic
- Pain may radiate to back or right shoulder
- Pyrexia
- Murphys sign positive - arrest of inspiration on palpation of RUQ
- NOT jaundiced
What are the signs of ascending cholangitis
Triad of: Charcots triad
- Fever
- RUQ pain
- Jaundice
If very severe - Reynolds pentad:
- Fever
- RUQ pain
- Jaundice
- Shock (low bp, tachycardia)
- Altered mental status
What are the causes of vitamin B12 deficiency
- Pernicious anaemia (most common)
- Atrophic gastritis (secondary to H pylori)
- Gastrectomy
- Malnutrition (alcoholism)
What is the pathophysiology of pernicious anaemia
Antibodies are created against intrinsic factor (+/- gastric parietal cells)
- Intrinsic factor antibodies bind to intrinsic factor - this blocks vitamin B12 binding sight
- Gastric parietal cell antibodies - caused reduced acid production and atrophic gastritis. This causes reduced intrinsic factor which again causes reduced vitamin B12 absorption.
What is the role of vitamin B12
- Production of blood cells
- Myelination of nerves
A deficiency causes megaloblastic anaemia and neuropathy
What are the features of vitamin B12 deficiency?
Anaemia:
- Lethargy, pallor, dyspnoea
Neurological:
- Peripheral neuropathy (pins and needle), numbness (symmetrical) and affects the legs more than the arms.
- Subacute combined degeneration of the spinal cord (progressive weakness, ataxia, parasthesias, spasticity, paraplegia).
Psychiatric:
- memory loss, poor concentration, confusion, depression, irritability
Other:
- Mild jaundice, glossitis, angular cheilitis
** Increased risk of gastric cancer - vitamin B therapy resolves the anaemia but the atrophic gastritis remains **
what are the signs and symptoms of vitamin C deficiency (scurvy) Vitamin C = Ascorbic acid
- ecchymosis (easy bruising)
- Poor wound healing
- Follicular hyperkeratosis and perifollicular hyperkeratosis (cork screw hairs)
- Gingivitis + bleeding and receding gums
- Sjogren’s syndrome
- Arthralgia
- Oedema
- Weakness, malaise, anorexia, depression
What are the classic features of pancreatic cancer
- Painless jaundice
- Pale stools, dark urine, pruritus
- Abdominal masses (hepatomegaly, gallbladder, epigastric mass)
- Cholestatic liver function tests
- Anorexia, weight loss, epigastric pain
What is Boerhaave syndrome
Rupture of the oesophagus
Causes crepitus on examination
What is the pattern of inheritance of Gilberts syndrome
Autosomal Recessive
Isolated increase of UNCONJUGATED bilirubin
What is the treatment for alcoholic hepatitis
Glucocorticoids (for example, prednisolone)
What histology is seen in Crohns
Inflammation in all layers from mucosa to serosa
Increased goblet cells
Granulomas
What histology is seen in Ulcerative Colitis
No inflammation beyond the submucosa
Crypt abscesses
Depletion of goblet cells and mucin
Granulomas are infrequent
How is primary biliary cholangitis diagnosed
The M rule:
Anti-mitochondrial antibodies
Raised IgM
Middle aged females
Abnormal liver function tests (raised ALP and yGT)1
What is the difference between primary biliary cholangitis and primary sclerosis cholangitis
Both are cholestatic liver diseases that can cause liver cirrhosis and liver failure.
Both cause poor flow of bile through the liver and bile ducts.
Primary sclerosis cholangitis:
- A chronic, progressive condition characterised by inflammation, scarring and structuring of the intrahepatic and extra hepatic bile ducts’.
- Some segments are unaffected so it gives a bead appearance.
- 2x as common in males, a strong link with ulcerative colitis
- Survival is 15 years
- Cholangiocarcinoma
Primary Biliary Cholangitis:
- A chronic, progressive, autoimmune condition leading to destruction of the small intrahepatic bile ducts
- More common than PSC
- more common in females, middle aged
- Associated with other autoimmune diseases
What is the treatment for primary biliary cholangitis
First line:
Ursodeoxycholic acid
Itch - cholecystramine
What is non-alcoholic fatty liver disease
Excessive fat in the liver cells, specifically triglycerides. The fat deposits interfere with functioning of the liver cells.
It can progress to cause hepatitis or lover cirrhosis.
What are the risk factors for non-alcoholic fatty liver disease
Same risk factors as CVD and diabetes
25% of the population is thought to have NAFLD
- Middle aged
- Obesity
- Type 2 diabetes
- High cholesterol
- Hypertension
- Smoking
What are the investigations for non-alcoholic fatty liver disease
- Raised ALT (often 1st indication of NAFLD)
- Liver ultrasound (for hepatic steatosis - fatty liver)
- Enhanced liver fibrosis blood test (for fibrosis)
- Transient elastography (used for fibrosis)
- Liver biopsy is gold standard
Transient elastography is most commonly done
Which blood test is characteristic of alcoholic hepatitis
The AST/ALT ratio being >2:1
What is the management for C difficile infection
stop all opioids - Reduce gut motility and clearance of C. difficult which increases risk of toxic megacolon.
First line: Oral vancomycin for 10 days
Second line: Oral fidaxomicin
Third line-: Oral vancomycin +/- IV metronidazole
How is Ulcerative colitis classified
Mild:
<4 stools/day, only a small amount of blood
Moderate:
4-6 stools/day, varying amount of blood, no systemic upset
Severe:
>6 bloody stools/day, features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
How is mild - moderate ulcerative colitis managed to induce remission
Proctitis:
- Topical (rectal) aminosalicylate (mesalazine)
- If remission isn’t achieved within 4 weeks - add oral aminosalicylate
- If remission isn’t achieved - add topical or oral corticosteroid (prednisolone)
Proctosigmoiditis + left-sided UC:
- Topical (rectal) aminosaclytate
- If remission isn’t achieved within 4 weeks - add a high dose oral aminosalicylate OR high dose oral aminosalycilate and topical corticosteroid
- If remission still isn’t achieved - stop topical treatment and offer oral aminosalycilate and oral corticosteroid
Extensive disease:
- Topical (rectal) aminosalicylate and a high dose oral aminosalycilate
- If remission isn’t achieved within 4 weeks - stop topical treatment and add a high dose oral aminosalicylate and an oral corticosteroid
How is severe ulcerative colitis managed to induce remission
Should be treated in hospital
First line:
- IV steroids
Other:
- IV cyclosporin if steroids contraindicated
If no improvement after 72 hours:
- add IV cyclosporin to the IV steroids OR consider surgery
How is remission maintained in ulcerative colitis after a mild-moderate flare
Proctitis and proctosigmviditis:
- Topical aminosalycylate alone
OR
- An oral aminosalicylate + topical aminosalicylate
Left-sided and extensive ulcerative colitis:
- Low maintenance dose of an oral aminosalicylate
How is remission of a severe episode of ulcerative colitis maintained
Severe relapse or >2 exacerbations in the past year:
- Oral azathioprine or oral mercaptopurine
Which scoring systems are used to classify the severity of liver cirrhosis
Child-Pugh OR Model for End stage liver disease (MELD)
What are the associations of H. Pylori Infection
Peptic ulcer disease - 95% duodenal, 75% gastric (most common)
gastric Cancer
B cell lymphoma
Atrophic gastritis
How is H. Pylori infection treated
A 7 day course of:
- PPI + Amoxicillin + (clarithromycin OR metronidazole)
- If penicillin allergy - PPI + metronidazole + clarithromycin
What is achalasia
Failure of oesophageal peristalsis and relaxation of the lower oesophageal sphincter due to the degenerative loss of ganglia from Auerbachs plexus
What is the treatment for achalasia
First-line:
- Pneumatic balloon dilatation
If recurrent or persistent symptoms:
- Heller cardopmyotomy
Other:
- Intra-sphincter injection of botulinum toxin
- Drug therapy (nitrates, calcium channel blockers)
What is Wilson’s disease
An autosomal recessive condition characterised by the toxic accumulation of copper in the liver and brain.
Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion.
What are the features of Wilsons disease
What are the features of Wilsons disease
Symptom onset is usually between 10-25 years.
Children - present with liver disease
Young adults - Present with neurological disease
What are the signs of Wilsons disease
Liver - hepatitis, cirrhosis
Neurological - speech, behaviour and psychiatric problems, asterisks, chorea, dementia, Parkinsonism
Kayser-Fleischer rings
Blue nails
Haemolysis
Renal tubular acidosis
Where is most copper deposited in Wilsons disease
In the brain most coper is deposited in the basal ganglia, particularly in the putamen and globes pallid us
What are the investigations for wilsons disease
Liver biopsy - definitive diagnosis
24 hour copper urine assay
Slit lamp examination for Kayser-Fleischer rings
reduced serum caeruloplasmin
Reduced total serum copper
Diagnosis confirmed by genetic analysis of ATP7B gene
What is the treatment for Wilsons disease
First line - Penicillamine
Alternative - Tridentine hydrochloride
What type of bacteria is clostridioides difficile
A gram positive rod
Which antibiotic is most likely to cause C difficile infection
Clindamycin
Cephalosporins - Ceftriazone, ceftazidime
What is the management of a first episode of C difficile infection
First-line - oral vancomycin for 10 days
Second-line - Oral fidaxomicin
Third line - Oral vancomycin +/- IV metronidazole
What is the management of a recurrent episode of C difficile
Within 12 weeks of symptoms resolution - Oral fidaxomicin
After 12 weeks of symptom resolution - Oral vancomycin OR fidaxomicin
What s the treatment for life threatening C difficile infection
Oral vancomycin AND IV metronidazole
What acid base disturbance is seen with prolonged vomiting
Metabolic alkalosis + Hypokalaemia
What is the treatment for IBS
Pain - Antispasmodic agents
Constipation - Laxiatives (ispaghulta husk). AVOID lactulose.
Diarrhoea - Loperamide is first line
Which antibiotic is most likely to cause spontaneous bacterial peritonitis
E. coli
What is the treatment for spontaneous bacterial peritonitis
IV cefotaxime
If patients have ascites - can give antibiotic proplhyaxis (ciprofloxacin or norfloxacin
What are the anatomical borders of ulcerative colitis
Inflammation starts at the rectum and does not spread beyond the ileocaecal valve
What investigation is done to diagnose a Mallory-Weiss syndrome
Endoscopy - Treated with ablation
What is small bowel bacterial overgrowth syndrome
A disorder caused by an excessive amount of bacteria in the small bowel resulting in gastrointestinal symptoms.
What are the conditions that give an increased risk of small bowel bacterial overgrowth syndrome
Scleroderma
Diabetes mellitus
Neonates with GI abnormalities
How is small bowel bacterial overgrowth syndrome diagnosed
Hydrogen breath test
Often gets better after a trial of antibiotics
What is the treatment of small bowel bacterial overgrowth syndrome
Rifampicin
OR
Co-amoxiclav or metronidazole
Malnutrition Diagnosis
- BMI <18.5
- BMI <20 and unintentional weight loss >5% within the last 3-6 months
- Unintentional weight loss >10% within the last 3-6 months
What is the triad used to diagnose Plummer-Vinson syndrome
- Dysphagia (secondary to oesophageal webs)
- Glossitis
- Iron-deficiency anaemia
Which levels are used to monitor haemochromatosis
Ferritin
Transferrin saturation
What is the screening for haemochromatosis
General population - Transferrin saturation > ferritin
Family members - HFE genetic testing
What is the screening for Wilsons disease
Caeruloplasmin
What are some of the common side effects of proton pump inhibitors
Hyponatraemia
Hypomagnasaemia (muscle weakness)
Osteoporosis
Microscopic colitis
Increased risk of C difficile infection
What is transferrin
The bodys carrier of iron around the blood
ID - In states of iron deficiency, transferrin increases to try and make the most of what iron it has left
ACD - Decreases
What is total iron binding capacity
Measures the number of binding sites on transferrin available for iron.
ID - increases
ACD - decreases
What are the signs of spontaneous bacterial peritonitis
Ascites
Abdominal pain
Fever
How is spontaneous bacterial peritonitis diagnosed
Paracentesis - neutrophil count >250 cells
What are the signs of ischaemic colitis
- most common in the splenic flexure area
- thumb printing seen on abdominal x-ray
- bloody diarrhoea
- conservative management
- large bowel
- transient, less severe symptoms
What is Budd-Chiari syndrome
AKA hepatic vein thrombosis.
Usually seen in the context of other haematological disease or another procoagulant condition.
What are the causes of Budd-Chiari syndrome
Polycythaemia rubra vera
thrombophilia
pregnancy
What are the signs of Budd-Chiari syndrome
Abdominal pain - sudden onset, severe pain
Ascites
Tender hepatomegaly
Investigated using ultrasound with doppler flow studies
What is the m most common cause of inherited colon cancer
HNPCC (Lynch syndrome)
What is Lynch syndrome
An autosomal dominant condition.
90% of patients with the condition develop cancer:
- Often in the proximal colon
- Endometrial cancer is the second most common
What is Familial adenomatous polyposis
An autosomal dominant condition which leads to the formation of hundreds of polyps by the age of 30-40.
What is Familial adenomatous polyposis
An autosomal dominant condition which leads to the formation of hundreds of polyps by the age of 30-40.
It causes a mutation in a tumour suppressor gene.
How is vitamin B12 replaced
Intramuscularly
No neurological features:
- 3 injections per week for 2 weeks (1mg)
- followed by 3 monthly treatment injections (1mg)
What is primary sclerosis cholangitis
A chronic condition of unknown cause affecting the gallbladder and liver.
Inflammation and scarring of the bile duct occur and result in obstruction of the duct system and eventually cirrhosis and failure.
what is done to diagnose primary sclerosis cholangitis
Either MRCP OR ERCP can be used first line.
Will show alternating biliary strictures and dilatation inside and/or outside the liver - hallmark beaded appearance.
p-ANCA might be positive.
What is primary sclerosis cholangitis associated with
Ulcerative colitis
4% of patients with UC have PSC
80% of patients with PSC have UC
Can cause cholangiocarcinoma or colorectal cancer
what are the features of primary sclerosis cholangitis
Cholestasis:
- pruritus
- jaundice
- raised bilirubin + ALP
- RUQ pain
- Fatigue
What is the mechanism of action for loperamide
Reduces gastric motility through stimulation of opioid receptors
What is metaplasia
The replacement of one mature cell type with another mature cell type - as an adaptive response
What is dysplasia
Replacement of one mature cell type with a less mature cell type
the development of abnormal types of cells within a tissue
can be pre cancerous
what is neoplasia
The uncontrolled, abnormal growth of cells or tissues in the body. Causing a tumour = neoplasm.
The neoplasm can be benign or malignant.
what is the treatment for Barretts oesophagus
High dose PPI
Metaplasia (but no dysplasia):
- Endoscopic surveillance every 3-5 years
dysplasia:
- endoscopic mucosal resection and removal of cancerous cells
- radiofrequency ablation
What is usually deficient in coeliac disease
Mixed picture anaemia
Iron
Folate
B12
What is the treatment for gallstones
Asymptomatic gallstones located in the gallbladder are common and do not require treatment.
If stones are present in the common bile duct - theres an increased risk of cholangitis or pancreatitis and surgical management should be considered.
Symptomatic gallstones = laparoscopic cholecystectomy
What is the treatment for hepatic encephalopathy
First line - Lactulose
Secondary prophylaxis - rifaximin
What are the signs of acute liver failure
jaundice
raised prothrombin time
hypoalbuminaemia
hepatic encephalopathy
renal failure
fetor hepaticus (hepatic encephalopathy)
Check coagulation and albumin - liver enzymes usually remain normal for a long time
What is the treatment used to induce remission in crohns
First line: Glucocorticoids
Second line: Mesalazine
Add on: Aathioprine or mercaptopurine (or methotrexate)
Refractory disease: Infliximab
Isolated peri-anal disease: Metronidazole
What is the treatment used to maintain remission in crohns disease
Azathioprine or mercaptopurine
Stopping smoking
Second line: Methotrexate
which gene mutations are associated with HNPCC
MSH2/MLH1
Which test is most specific at diagnosing an acute liver failure
A raised prothrombin time
How long before an upper GI endoscopy should PPI be stopped
2 weeks before
When should someone with G ORD be investigated with an upper GI endoscopy
- Age >55
- symptoms > 4 weeks or persistent despite treatment
- Dysphagia
- Relapsing symptoms
- Weight loss
If endoscopy is negative - use 24hr oesophageal pH monitoring (gold standard test for diagnosis)
What must patients have before being considered for fundoplication surgery
Oesophageal pH
Manometry studies
Which metabolic disturbances can occur due to refeeding symdrome
- Hypophosphataemia
- Hypokalaemia
- Hypomagnesaemia (torsades des pointes)
- Abnormal fluid balance
Who is at risk of refeeding syndrome
One of the following:
- BMI <16
- Unintentional weight loss >15% over 3-6 months
- Little nutritional intake >10 days
- Hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding
Two or more of the following:
- BMI <18.5
- Unintentional weight loss >10% over 3-6 months
- Little nutritional intake >5 days
- History of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics, antacids
What is the recommendation for re-feeding
If a patient hasn’t eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days
What are the causes of raised bilirubin
Unconjugated bilirubin - Prehepatic or hepatic jaundice.
Conjugated bilirubin - Hepatocellular injury or cholestasis
Which site is most affected by crohns disease
The ileum (causes weight loss because theres malabsorption)
What are the risk factors for developing gallstones
Increasing age
family history
sudden weight loss
loss of bile salts (crohns)
diabetes
oral contraception
What are the features of appendicitis
- Right sided tenderness on PR exam
- Peri-umbilical abdominal pain radiating to the right iliac fossa
- mild pyrexia
- anorexia
- pain worse going over speed bumps or coughing
- children can’t hop of the right leg due to pain
what test is gold standard for the diagnosis of coeliac disease
Jejunal biopsy
what is used to treat symptoms of carcinoid syndrome
Octreotide
which part of the bowel is most affected in ulcerative colitis
Rectum
what are the most common signs of ulcerative colitis
Bloody diarrhoea
urgency
tenesmus
abdominal pain - particularly left lower quadrant
Extra clinic features:
primary sclerosing cholangitis
uveitis
colorectal cancer
which drugs cause a hepatocellular picture of liver disease
paracetamol
sodium valproate
phenytoin
MAOI
anti-tuberculosis
statins
alcohol
amiodarone
methyldopa
nitrofurantoin
Which drugs can cholestasis
COCP
antibiotics - flucloxacillin, co-amoxiclav, erythromycin
