Gastro extra

Question 1

What is the strict definition of acute liver failure and what are the top causes?

Answer 1

Liver failure <8 weeks in those with no previous liver disease.
otherwise it is Decompensated liver failure.

Causes:

• paracetamol overdose
• Viral hepatitis
• Idiosyncratic drug reaction
• Budd Chairi
• Autoimmune
• Ischemia

Question 2

What are the clinical findings and you’re major investigations in a patient with acute liver failure (someone with no known liver disease)?

Answer 2

Encephalopathy 
Jaundice 
Hepatic Foetor 
Metabolic acidosis 
Coagulopathy 
Circulatory collapse 

Bloods:

• FBC
• Coagulation
• Glucose
• U&Es
• LFTs
• viral serology
• paracetamol levels
• autoimmune markers

Orifices:
- urine cultures

X-rays:

• US of liver
• Doppler for Budd Chiari

Special tests:

• ascitic tap
• EEG if in doubt about encephalopathy

Question 3

General management of Acute liver failure?

Answer 3

ITU support:

General:

• Monitor fluid output
• Monitor Glucose

Encephalopathy:

• Nurse 30 degree angle
• Manitol

Hypoglycaemia
- Dextrose with Saline between

Coagulopathy
- Vitamin K

Renal failure:
- Dialysis

**liver transplant?

Question 4

When draining Ascites when should albumin be given?

Answer 4

Every 2.5L drained

other management prior to paracentesis is:

• fluid/ salt restriction
• spirolactone
• albumin

Question 5

Which drug should be avoided in decompensated liver disease?

Answer 5

Gentamicin

Question 6

In someone with decompensated liver disease with encephalopathy - what things do you want to screen for?

Answer 6

Sepsis

• systemic
• SBP

Bleeding

Renal failure

Constipation

Medication/ drugs
- anything causing sedation

Question 7

What can be used to assess a patient in A&E for their alcohol consumption?

Answer 7

FAST screening tool

Fast Alcohol Screening Tool *

Question 8

What is the general management for patients with drawing of alcohol?

Answer 8

Screen them using FAST screen
- if low risk they can be discharged with follow up to addiction services

High risk: (previous seizure, high scoring FAST):

Unexceptional group:
(no liver disease, jaundice, COPD, >70, pregnant, head injury)
- fixed dose diazepam for 48 hours

Exceptional group:
(live disease, jaundice, COPD, >70 pregnant, head injury)
- symptom triggered lorazepam

Question 9

What are the endoscopic findings of coeliac and what is the management

Answer 9

Endoscopically:

• Absence of mucosal folds
• Scalloping of mucosa

Management:

• Gluten free diet (wheat, Barley, rae)
• Ca2+, Vit D and Iron
• Pneumococcal vaccine

Follow up 12 months

Question 10

What are the main causes of gastritis?

Answer 10

H. Pylori 
NSAIDs 
Alcohol
Pernicious anaemia
Critically ill - reduces gastrointestinal flow

Question 11

What are the major types of gastritis?

Answer 11

H.Pylori
- urease - creates Co2 and ammonia which induces more gastrin.

Erosive:

• NSAIDs
• Alcohol

Autoimmune:

• anti - parietal cell antibodies
• Anti- intrinsic factor
• atrophic type

Stress/ Ischemic

• prolonged critical illness
• Raise ICP

Question 12

What are the key symptoms of PBC, what investigations are done and what is the treatment?

Answer 12

Female typically:

Fatigue 
Hepatosplenomegaly 
Jaundice 
pigmented xanthelesma 
Athropathy 

Investigations:

• LFTs (obstructive)
• IgM Anti - mitochondrial antibodies

Management:

• cholestyramine
• Ursodeoxycholic acid
• liver transplant

Question 13

What are the key symptoms of PSC, what investigations are done and what is the treatment?

Answer 13

Male
Jaundice
RUQ pain
Heptosplenomeglay

Investigations:
- MCRP

Management:

• liver transplant
• Ursodeoxycholic acid

Question 14

What investigations should be done into constipation?

Answer 14

Bloods:

• FBC (malignancy)
• ESR
• U&Es - dehydration? Obstruction to kidneys?
• Ca2+
• TFTS

Orifices:
- Colonoscopy if suspicion of malignancy

X-ray
- abdominal x-ray for any obstruction

Question 15

List some causes of constipation:

Answer 15

General:

• Poor diet and excersies
• Dehydration
• pain

Colorectal disease:

• colorectal cancer
• Anal fissure

Metabolic:

• Hypercalcemia
• hypothyroidism

Drugs:

• opioids
• Tricyclics (anti-cholinergic)

Question 16

What are some laxatives which can be used?

Answer 16

Bulking agents:

• Ispaghula husk
• contraindicated in intestinal obstruction

Stimulator laxatives:

• Senna
• Bisacodyl
• avoided in intestinal obstruction

Osmotic:

• lactulose
• avoided in intestinal obstruction
• electrolyte imbalances

Question 17

What are two methods used to investigate the staging of gastric cancer, and what are the complications of a gastrectomy?

Answer 17

CT scan. C/A/P

If negative an oesophageal US can be done to stage locally.

Complications:

• B12 deficiency
• CA2+ deficiency
• Dumping syndrome

Question 18

In an elderly person with achalasia - what can be a cause?

Answer 18

Reduced vagal stimulation

Question 19

What investigations can be done to diagnose a hiatus hernia?

Answer 19

Endoscopy
- Z line will be seen

CXR
- Bubble sign

Barium swallow

Treatments:

• lifestyle
• PPIs

Surgery:

• Cruroplasty
• Nissan’s fundoplication

Question 20

List two causes of bowel obstruction seen in HIV and infection which affect G.I system:

Answer 20

Enteropathy lymphoma - Burkits
Kaposi’s sarcoma
*typically lead to an intussusception like pathology

CMV
Cryptosporidium Parvum
Mycobacterium avium (TB)

Question 21

What are the causes of chronic pancreatitis and how is it investigated?

Answer 21

Alcohol abuse 
CF 
Autoimmune (requires steroids) 
Metabolic - hyperlipidaemia, hypercalcemia 
Strictures 

Investigations:

• Serum lipases
• faecal elastase
• serum amylase (might be moderately raised)
• HbA1c
• CT abdomen - calcification
• note that often neuropathic analgesia is used as treatment

Question 22

What are the stages of liver disease in alcohol? Histologically what is seen in alcohol hepatitis?

Answer 22

Steatosis
Hepatitis - painful and enlarged
Cirrhosis (nodular, fibrotic and diffuse)
Hepatocellular carcinoma

Mallory Bodies
Neutrophil infiltration