Upper GI conditions Flashcards
How do you treat a variceal bleed?
- Resuscitation - maintain pulse, blood pressure, antibiotics
- Terlipressin - vasoconstrictor, predominantly splanchnic
- Endoscopic variceal ligation (EVL)
- sengtaken-blakemore tube- to delay until EVL, or delay until TIPS if EVL fails
- TIPS
Secondary prophylaxis
- EVL
- BB (Propanolol)
What is haemolytic uremic syndrome?
Condition where the small blood vessels in your kidneys become damaged and inflamed- this causes clots to form. The clots clog the filtering system in the kidneys and lead to kidney failure.
What causes haemolytic uremic syndrome?
E Cloli, specifically EHEC
What does haemolytic uremic syndrome present as?
Abdominal pain Fever pallor petechiae - tiny spots of bleeding under the skin or in the mucous membranes (mouth or eyelids) Oliguria - pee less than usual Bloody diarrhoea
What is seen in the blood count of a patient with haemolytic uremic syndrome?
High WBC Low platelets Low Hb RBC fragments LDH greater than 1.5x normal
What is haemangioma
A benign liver lesion - single hypervascularised tumour
No treatment
What is a focal nodular hyperplasia lesion?
A begnin nodule formation of normal liver tissue. There is a central scar containing a large artery and branches. There is a hyperplastic response to abnormal arterial flow. The cells in this lesion can be sinudoidal, kupffer, hepatocytes etc
Do focal nodular hyperplasia cause pain?
Can cause pain but most are asymptomatic.
More common in young and middle aged women
What is a hepatic adenoma lesion?
A benign neoplasm composed of normal hepatocytes (no portal tract, central veins or bile ducts). Associated with contraceptive pill
Far more common in women but men have a greater risk of malignancy
Hoe does hepatic adenoma lesion present?
Asymptomatic
RUQ pain
rupture, haemorrhage
malignant transformation (rare)
What is the treatment for hepatic adenoma lesion?
Women:
Stop contraceptive, weight loss
imaging after 6 months (<5cm = annual MRI, >5cm surgery)
Males:
Surgery irrespective of size
What is a simple liver cyst? And what treatment is given
Liquid collection lined by an epithelium
None
imaging 3-6 months
can do surgical intervention
What are some symptoms of a simple liver cyst?
asymptomatic (mostly) intracystic haemorrhage infection rupture - rare compression
What is a hydatid cyst?
develop these cysts when ingest the eggs of the tapeworm Enchinococcus granulosus.
Presents as disseminated disease (throughout body) or erosion of cysts into adjacent structures
How ids a hydatid cyst treated?
Albendazole (stops worms from absorbing sugar) percutaneous drainage Surgery: -opening and letting it drain -removing cyst/liver lobe
What are some symptoms of polycystic liver disease?
Abdominal pain
Abdominal distension
Aytpical symptoms due to voluminous cysts resulting in compression of adjacent tissue or failure of the affected organ
What are symptoms of a liver abcess (cyst filled with pus)
High fever leukocytosis abdominal pain complex liver lesion on imaging Hx of abdominal or biliary infection/dental procedure
What is the management of liver abscess?
Amoxicillin, gentamycin, metronidazole
aspiration/ drainage
surgery if no improvement
What is cholelithiasis?
Gallstones
What are the different kind of gallstones?
Cholesterol gall stones
Pigment gallstones- excess of bilirubin
mixture gallstones
What are some complications of gallstones?
Acute cholecystitis Chronic cholecystitis Mucocoele (build up of mucous as blocked) Empyema - mucous sac infected Carcinoma Asecinding cholangitis Obstructive jaundice Gallstone ileus Acute pancreatitis Chronic pancreatitis
What is the treatment of gallstones?
Cholecystectomy
Ursodexycholic acid (dissolves stones but should only be used in patients with small stones and unimpaired gallbladder)
Buprenorphine/pethidine (analgesia for biliary colic)
Atropine/GTN for biliary spasm
What is biliary colic?
Waxing/waining postprandial epigastric/RUQ pain due to transient cystic duct obstruction by gallstones
What are some symptoms of biliary colic?
RUQ pain that radiates to the back
4-6/8hrs pain duration, settles on its own
No fever, no leukocytosis, raised ALP
What ttreatment is given in biliary colic?
Analgesics - not morphine
low fat diet
consider cholecystectomy if recurrent
What is cholecystitis?
Inflammation of the gallbladder
What pathogenesis occurs in acute cholecystitis?
GB wall distension, inflammation and oedema due to the obstruction - initialy sterile then will become infected due to bacteria. Can cause adhesions, empyema, rupture, peritonitis
What signs are expected in acute cholecystitis?
RUQ pain >24hrs +/- fever
tender in RUQ
Murphy’s sign - if you press below R costal margin, the patient won’t be able to breath in
elevated WBC expected but not reliable
What is the Tokyo guidelines?
Grading for acute cholecystitis
Grade 1 - mild inflammation
Grade 2- inflammation
Grade 3 - organ dysfunction
What investigations are carried out in acute cholecystitis?
US (1st line)
Nuclear HIDA scan - dye in biliary system and no filling of GB
MRCP
What will be seen on an ultrasound in acute cholecystitis?
Distended gallbladder
increased wall thickness
peri-cholecystic fluid - fluid around GB
Positive sonographic Murphy’s sign
What treatment is given in acute cholecystitis?
- Early cholecystectomy for acute 48-72hrs
- elective cholecystectomy for acute >72hrs and chronic
- if patient too sick then cholecystostomy (drain GB)
What is Choledocholithiasis?
Presence of gallstones in the CBD
What is the treatment for choledocholithiasis?
ERCP - for stone extraction
Eary/interval cholecystectomy is considered after recovery from ERCP
What is Cholangitis?
Inflammation of the bile duct due to obstruction in the CBD. Can be due to stones or strictures.
Can lead to sepsis and septic shock
What are symptoms/signs of cholangitis
Charcot’s triad: persistant RUQ pain, fever, jaundice
Raised WBC
Obstructive LFTS (high bilirubin and ALP)
For suppurative - hepatic encephalopathy and hypotension
What is the treatment for cholangitis?
IV fluids IV antibiotics If emergency decompression is required: -ERCP -Percutaneous transhepatic drainage
What is gallstone pancreatitis?
Acute inflammation of the pancreas due to gallstones- reflux of bile into pancreatic duct or obstruction of ampulla of Vater by stone
What LFT is commonly high in gallstone pancreatiits?
ALT >150 (3x normal value)
What is the treatment for gallstone pancreatitis?
IV fluids, light diet, analgesia
Once resolving ERCP and stone extraction
Mild cases - cholecystectomy on adomission
Severe - cholecystectomy within 4 weeks
What are some DDs of RUQ pain?
Biliary disease -Acute/chronic cholecytits -CBD stone -Cholangitis Inflammed/perforated peptic ulcer Pancreatitis Hepatitis Rule out: -appendicitis -renal colic -pneumonia -pleurisy -AAA
