Risk factors for a GORD
Hiatus hernia Smoking EtoH Obesity Pregnancy Drugs
List the criteria for performing an OGD
>55yrs Symptoms >4weeks Dysphagia Persistently symptomatic despite treatment Wt loss
List the grading criteria of GORD
Los angeles classification
Management of GORD
Conservative
- Loss weight
- Small regular meals
- Stop smoking and drink
- Stop drugs ( NSAIDs, Steroids, CCBs)
Medical - OTC antacids - Full dose PPI for 1-2 months Lansoprazole 30mg Od - Double dose PPI - Add in H2RA Ranitidine 300mg nocte - Nissen Fundoplication
Classify the different types of hiatus hernia
- Sliding
- Rolling
- Mixed
Note rolling hernias should be repaired as it may strangulate
Name the scoring system to predict re bleeds and mortality in upper GI haemorrhage
Rockall score
Classify peptic ulcers
Acute: drugs or stress
Chronic: Drugs, H.Pylori, Increase Ca, Zollinger Ellions
List the complications of peptic ulcer disease
- Haemorrhage
- perforation
- Gastric outflow obstruction
- Malignancy
List the investigations you would carry out in patients with suspected peptic ulcer disease
Bloods ( FBC< urea increase in haemorrhage C13 breath test OCD - stop PPIs 2 weeks before - CLO/ urease test - Take biopsies of all ulcers Gastrin levels in Zollinger Ellison
Outline the surgical options for patients with PUD
Vagotomy
Antrectomy with vagotomy
Subtotal gastrectomy
Complication of surgery for PUD
Physical
- Stump leakage
- Abdominal fullness
- Reflux or billions vomiting
- Stricture
Metabolic
- Dumping syndrome (Early = osmotic hypovolaemia, late= reactive hypovolaemia)
- Blind loop syndrome
- malabsorption
- Anaemia
- Osteoporosis
- Wt loss
Outline the pathophysiology of achalasia
Dengeneration of myenteric plexus (Auerbach’s)
Decreased peristalsis
LOS fails to relax
List the causes of achalasia
Idiopathic
Oesophageal Ca
Chagas disease (T.cruzii)
Investigations for achalasia
Barium swallow(Birds beak)
Manometry: failure of relaxation and decreased peristalsis
CXR: widened mediastinum
OGD: exclude malignancy
Treatment of achalasia
- Medical
- CCB
- Nitrates - Interventional
- Endoscopic ballon dilatation - Surgical
- Heller’s cardiomyotomy
Genetic links associated with coeliac disease
HLA-DQ2
HLADQ8
CD8+ mediated response to the gladden in gluten
Presentation of coeliac disease
GLIAD
- GI Malabsorption
- fatigue
- weakness
- Carb (abdo distension)
- Steatorrhoea
- Hyperoxaluria
- Protein losing enteropathy
- anaemia
- Bone pain, osteoporosis ( Vit D and Ca)
- Increased INR (Vit K)
- Angular stomatitis (b2)
- Polyneuropathy (B1 and B6) - Lymphoma and carcinoma
- Enteropathy associated T cell lymphoma
- Adenocarcinoma - Immune associations
- T1DM
- PBC - Anaemia
- Increase or decrease MCV
- Hyposplenism - Dermatology
- Dermatitis herpetiformis
(symmetrical vesicles on extensor services_, granular deposits of IgA)
Name the antibodies you would look for in suspected coeliac disease
Antiendomyosial IgA
Anti TTG IgA
Anti gliadin IgG
Outline the appearance of the duodenum as seen on endoscopy in patients with coeliac
1/3 of the duodenum
Subtotal villous atrophy
Crypt hyperplasia
Intra epithelial lymphocytes
Triad of symptoms seen in malabsorption
Diarrhoea
Weight loss
Lethargy
List potential causes of malabsorption
Coeliac Crohn's Decrease in bile ( PBC, ileal resection) Pancreatic insufficiency Small bowel resection Tropical sprue Bacterial overgrowth Infection Hurry, post gastrectomy dumping
Pathology of tropical sprue
Vilious atrophy and malabsoprtion
Occurring the Far and Middle east
Cause is unknown
Treatment of tropical sprue
Tetracycline 250mg/6hr PO
Folic acid 15mg/d PO
Optimum nutrition
Signs of UC on barium swallow
- Lead piping, no hausfrau
- Thumbprinting (mucosal thickening)
- Pseudopolyps
Name the criteria used to grade the severity UC
Truelove and Witts criteria
Maintenance therapy for patients with UC
1) 5 ASA (sulfasalazine)
2) Asathioprine
3) Infliximab
Achieving remission often requires a short course of prednisolone
Outline the management of acute severe UC
- Resus
- Hydrocortisone
- Thromboprophylaxis
- Monitoring
Signs of Crohns as seen on colonoscopy
- Skip lesions
- Rose thorn ulcers
- Cobblestone mucosa
- String sign of kantour
List some of the complications of Crohn’s
- Fistuale
- Strictures
- Abscess
- Malabsorption
- Toxic megacolon
Outline the criteria used to diagnosis IBS
ROME Criteria - Abdo discomfort for >12 weeks with 2 of relieved by poking change in stool frequency change in stool form
and two of
- Urgency
- Incomplete emptying
- Bloating
- Mucous PR
- Worsening symptoms after food
Exclusion criteria
- > 40yrs
- Bloody stools
- Anorexia
- Wt loss
- Diarrhoea
List the causes of chronic pancreatitis
AGITS Alcohol Genetic - CF - HH Immune - Lymphoplasmacytic sclerosing pancreatitis ( increase in IgG4) Triglycerides increase Structural - Obstructed by a tumour
Clinical features of chronic pancreatitis
Epigastric pain - relived by sitting back or with hot water bottle Steatorrhoea Wt loss DM
List the investigations you would do to confirm pancreatitis and what would they show
Increase glucose Decrease faecal elastase Us of the pancreas AXR speckled pancreatic calcifiction Ct pancreatic calcification
Treatment of chronic pancreatitis
DRUGS
- Analgesia ( may need coeliac plexus block
- Creon
- ADEK vitamins
- DM Rx
DIET
- No EtOH
- Decrease in fat
- Decrease in carbs
Surgery
- Pancreatectomy
List the causes of acute pancreatitis
GET SMASHED Gallstones EtOH Trauma Steriods Mumps Autoimmune Scorpion venom Hyperlipidaemia ERCP Drugs
Clinical features seen in patients with acute pancreatitis
Jaundice
Rigid abdomen
Cullen’s sign: periumbilical bruising
Turner’s sign: Bruising of the flanks
Outline the investigations and management plan you would initated in a patient presenting to A&E with acute pancreatitis
IX
- Amylase >1000mL, levels will rise after the first 24-48 hours
- Bloods
- ABG, monitor acid base balance
- AXR, no psoas shadow ( increase in retroperitoneal fluid)
Sentinel loop (air filled dilatation)
Treatment
- NBM
- IV fluid, catheter
- Plan nutrition, no oral feeding for a week
- Analgesic, morphine
- Abx
- Refer to ITU if detonation
What are the Glasgow Criteria and what is it used for?
Glasgow criteria used to determine the severity of the patients pancreatitis Consists of the following - PaO2 - Age -Neutrophilia - Calcium - Renal function - Enzymes - Albumin -Sugar
Discuss the pathology associated with diverticulitis
Stool or undigested food becomes trapped int he diverticulum
Bacteria multiple
Inflammatory response
List the potential complications of diverticulitis
Perforation
Haemorrhage
Fistula
Abscess
Treatment of diverticulitis
Admit if unstable Give broad spec abs ( co-amoxiclav) Clear fluids only Surgery if - Faecal peritonitis - uncontrolled sepsis - fistula obstruction
Causes of ischaemic colitis
Occlusion of the branches of the superior mesenteric artery or the inferior mesenteric artery
New onset abdominal pain
Bright red blood will be visible and the patient is likely to be in metabolic acidosis
Risk is the translocation of intestinal bacteria across the lumen
Systemic inflammatory response
List the potential complication of diverticulitis and the subsequent management
- Septic peritonitis
- Progression of systemic inflammatory response
- Multi organ dysfunction syndrome
- Resuscitation with fluids
- Give abs
- Give heparin
- Post angiography give thrombolytics if needed
List the types of haemorrhoids
- Internal haemorrhoids
2. External haemorrhoids
Causes of haemorrhoids
Constapation Congestion Pregnancy CCF Portal hypertension
Treatment for haemarroids
- Increase fluid and fibre
Topical analgesics
Stool softener - Non operative
Rubber band ligation
Infra red coagulation
Cryotherapy
Describe a fistulae in ano
A track communicating between skin and anus
Caused by Abscess, perianal sepsis, Crohns disease, Diverticulitis, TB.
Will require a surgical repair.
Clinical features of bowel obstruction
Vomiting ( can be faecal) Colic pain Distension Constipation Tinkling/absent bowel sounds Rigid abdomen Sm
Types of bowel obstruction
Adhesive obstruction
Hernia obstruction
Volvulus
Intessupation
Management of bowel obstruction
ABCDE patient
Surgical management to relieve the obstruction
NBM
Discuss the pattern of abdominal pain in acute appendicitis
Early inflammation
- appendiceal irritation
- not well localised
- Pain referred to the dermatome corresponding to spinal cord entry level.
Late inflammation
- parietal peritoneum irritation
- pain localised to the PIF
List the key signs seen with appendicitis
Guarding and tenderness @ McBurneys pt
Rosing’s sign: pressure in the LIF increase pain in the RIF
Posts sign: pain on extending the hip
Cope sign: Flexion and external rotation of the hip = pain
Classify the types of jaundice and give causes for each class
- PRE HEPATIC
Excess BR production
Ineffective erythropoesis e.g. thallasaemia - HEPATIC
* Unconjugated
Decrease BR uptake (drugs)
Decrease BR conjugation
- Hypothyroidism
- Gilberts
- Criglers Najjar
*Conjugated Hepatocellular dysfunction - Congen: HH, Wilsons, - Infection: Hep a/b/c CMV, EBV - Toxins: EtOH - AI - Vascular: Budd Chiaria
Decrease Hepatic BR Excretion
- Dublin-Johnson
- Rotors
3. POST HEPATIC Obstruction - Stones - Ca Pancreas - PSC - PBC - Drugs
List the causes of liver failure
Cirrhosis Acute - Infection - Toxins - Vascular (Budd Chiari) - Others (Wilsons, AIH)
Management of patients with liver failure
- Manage in ITU
- Rx underlying cause
- Good nutrition via a NGT
- Thaimine supplements
- Prophylactic PPI
MONITORING
Fluids
Bloods
Glucose
List the complications of acute liver failure
Bleeding - Vit K, platelets, FFP Sepsis - Tazocin Ascites - Fluid restritction, spiro, fruse Hypoglycaemia - regular BM Encephalopathy - lactulose and enaemas Seizures - lorazepam Cerebral oedema - mannitol
Name the criteria used in acute liver failure for liver tx
Kings College Hospital Criteria *PARACETAMOL induced - pH <7.3 - All of PT>100s Cr >300uM Grade 3/4 encephalopathy
*NON PARACETAMOL induced PT>100s 3/5 of drug induced Age <5 or >40 >1wk of jaundice Pt>50 BR> 300uM
Causes of cirrhosis
Chronic EtOH Chronic HCV NAFLD Genetic Autoimmune hepatitis Drugs Neoplasm Vascular; Budd Chiari, RHF, Constrictive pericarditis
Clinical features seen on examination of a patient with cirrohosis
Hands
- Clubbing (+/- periostitis)
- Leuconychai (decrease in albumin)
- Terry’s nails ( white proximally, red distally)
- palmer erythema
- Dupuytron’s contractures
Face
- Pallor
- Xanthelasma
- Parotid enlargement
Trunk
- Spider naevi
- Gynaecomastia
- Loss of 2 sexual hair
Abdo
- Striae
- Splenomegaly
- Dilated superficial veins
- Testicular atrophy
List the complications of cirrohosis
- Decompensation resulting in hepatic failure
- Jaundice
- Encephalopathy
- Hypoalbuminaemia, oedema, ascites
- Coagulopathy
- Hypoglycaemia - Spontaneous Bacterial Peritonitis
3. Portal HTN (SAVE) Splenomegaly Ascites Varies - Oesophageal varices - Caput medusa - Worsening existing piles Encephalopathy
- Increase risk of HCC
The following conditions are associated with the presence of certain abs. Please list the abs associated with each condition
- AIH
- PBC
- PSC
- Ca
AIH
- SMA
- SLA
- LKM
- ANA
- High IgG
PBC
- AMA
- High IgM
PSC
- ANCA
- ANA
CA
- Alpha-fetoprotein
Causes of portal HTN
PRE HEPATIC
- Portal vein thrombosis
HEPATIC
- Cirrohosis
- Schisto
- Sarcoidosis
POST HEPATIC
- Budd chiari
- RHF
- Constrictive pericarditis
Describe the pathophysiology of encephalopathy
- Decreased hepatic metabolic function
- Diversion of the toxins from the liver directly into systemic system
- Ammonia accumulates and pass to brain where astrocytes clear it causing conversion of glutamate to glutamine
- Increase in glutamine
- Osmotic imbalance
- Cerebral oedema
Classification of encephalopathy
- Confusion: irritable, mild confusion, sleep inversion
- Drowsy: Increased disorientation, slurred speech, asterixis
- Stupor: rousable, incoherence
- Coma: Unrousable +/- extensor plantars
Presentation of encephalopathy
Asterixis Confusion Dysarthria Constructional apraxia Seizures
List the possible precipitants of encephalopathy
HEPATICS Haemorrhages Electrolytes Posions Alcohol Tumour (HCC) Infection Constipation Sugar
What liver enzymes will be raised in alcoholics
- AST
- ALT
- GGT
What is the triad of Wernicke’s encephalopathy
Confusion
Opthalmoplegia
Ataxia
Korsakoff’s: amnesia to confabulation
A patient presents with anorexia, D/V, and a jaundiced look about them
On examination you note ascites, tender hepatomegaly.
On questioning the patient reveals to you the have been drinking 100 units a week of vodka for the past five years
1. List your working diagnosis
2. What investigations will you do and what do you expect them to show
3. Outline the management plan for this patient
- Alcoholic hepatitis
- Bloods
- Increase MCV
- GGT, AST,ALT
- Ratio of AST:ALT will be > 2 - Plan
- Stop EtOH
- Withdrawal treatment
Tapering regimen of chlordiazepoxide PO/ Lorazepam IM
- Give parbinex
- Optimise nutrition
- Daily weights and bloods
- Alcohol cessation support
List the different types of hepatitis and the mode of transmission associated with each one
A: Orally spread, seafood B: IV, blood, body fluids, vertically babies C: IV, Blood D: IV, Prior infection with HBV E: PO, Developing world
Hepatitis generally develops over three phases. List the phases and the symptoms associated with each one
PRODROMAL PHASE
HAV,HVB
Flu like, arthralgia
ICTERIC PHASE Acute jaundice Hepatitis - abdo pain - hepatomegaly - cholestasis Extra hepatic features (due to immune complexes) - Cryoglobulinaemia - PAN -GN - Arthritis
CHRONIC PHASE
- HCV
- Cirrhosis
Mainly supportive care
Anti-virals in chronic disease
Outline the pathology ad risk factors associated with NAFLD
Cause of hepatitis and cirrhosis associated with insulin resistance and metabolic syndrome
Non alcoholic steatohepatitis is most extreme
RF Obesity HTN T2DM Hyperlipidaemia
What are the components of metabolic syndrome
Central obesity \+2 of - Increased triglycerides - Decreased HDL - HTN - Hyperglycaemia (DM,IGT,IFG)
Note: patients will generally have increased transaminases
AST:ALT <1
Causes of Budd-Chiari syndrome
- Hypercoagulable state
- Myeloproliferative disorders
- PNH
- anti-phospholipid
- OCP - Local tumour
- HCC - Congenital
- Membraneous obstruction of IVC
What is the triad associated with Budd Chiari syndrome
- RUQ pain
- Hepatomegaly
- Ascites SAAg >1.1g/dL
Jaundice may be present
Do the JAK2 mutation analysis
CD55
CD59
Management of a patient with newly diagnosed Budd Chiari syndrome
Anticoagulate unless +ve varices Ascites: fluid and salt restirctionm spiro, fruse Thrombolysis Angioplasty TIPSS
Describe the pathophysiology of alpha-1 antitrypsin deficiency
Sorption involved in the control of the inflammatory cascade by inhibiting neutrophil disease
Synthesised in the liver
List the investigations you would request if you suspect a patient had alpha-1 antitrypsin deficiency and what they would show
Bloods: decrease in serum a1AT
Liver biopsy: PAS +ve, diastase-resistant globules
CXR: Emphysematous change
Spirometry: Obstructive defect
Describe the pathophysiology of hereditry haemochromatosis
Autosommal recessive genetic disorder
Abnormal iron metabolism
Increase FE absorption
Increase deposition in multiple organs
Clinical features associated with HH
(iron) MEALS
Myocardial: dilated cardiomyopathy
arrhythmias
Endocrine: DM, hypogondaism, hypocalcaemia
Arthritis
Liver: HCC, cirrohosis
Skin: slate grey discolouration
A patient presents and tells you his mother had HH. He asks about the inheritance pattern.
What investigations would you do if you suspect he had HH and what would they show
Inheritance pattern: Autosommal recessive
Bloods
- abnormal LFTs
- Increase ferritin
- Increase Fe
- Decrease TIBC
Genotype
Liver biopsy: pearls stain to quantify the FE and severity
Describe the pathophysiology of Wilson’s disease
Mutation of Cu transporting ATPase
Imparied hepatocyte incorporation of Cu into caeruloplasmin and exertion into bile
Cu accummulation in liver and other organs
List the clinical features of Wilson’s disease
Cornea: Kayser Fleischer rings Cirrhosis Chondrocalcinosis Parkinsonism Fanconii's syn (T2 RTA) Haemolytic anaemia, coomb's negative
Treatment of Wilson’s disease
Avoid high Cu foods Penicillamine lifelong (Cu chelator)
Clinical features associated with PBC
Pruritus Pigmentation of the face Bones, osteoporosis, osteomalacia Big organs, HSM Cirrhosis and coagulopathy Cholesterol Steatohorrea
What will be seen on liver biopsy in patients with PBC
Non caesating granulomatous inflammation
Management of PBC
- General
- Pruritis (colestyamine)
- Diarrhoea (Codeine phosphate)
- Osteoporosis (Bisphosphanates) - Specific
- ADEK vitamins
- Urodeoxcholic acid - Liver transplant
A patient is refer from his GP with symptoms of pruritus, on going abdo pain and episodes of pale stools and dark urine
His most recent LFT’s are included in the referral and show a raised ALP and BR as well as positive ANA and pANCA antibodies.
What is your working diagnosis?
What other investigation would you order and what would it show?
How would you treat the pruritus?
- Primary sclerosing cholangitis
- Endoscopic retrograde cholangiopancreatography, beaded appearance of the ducts
- Colestryamine
List the five symptoms seen in Reynolds pentad present in cholangitis
Mental confusion Shock Fever Jaundice Abdo pain
What makes up chariot’s triad
Right upper quadrant pain
Intermittent fever
Jaundice
Common causing organism seen in cholangitis
Klebsiella
E.coli
Enterobacter
List the investigations you would order in a case of suspected cholangitis
LFT FBC WCC Inflammatory markers U&Es Blood cultures
Imaging
- Abdo xr ( includes KUB)
- Contrast enhanced CT
- MR cholangiopanreatography
List the different types of stones seen in biliary colic
Cholesterol stones: large, solitary and radiolucent
Black pigment stones: small, friable. irregular and radiolucent
Mixed stones: calcium salts and cholesterol
Brown stones: stasis and infection
List the imaging done to dx cholecyctisis
Ultrasound
ERCP
Outline the differences between cholecystitis and binary colic
RUQ pain Vomiting Fever Local peritonism GB mass
Difference: Inflammatory component ( fever, raised white cell count)
Note Murphy’s sign
Two fingers over the RUQ and ask the patient to inhale , inspiration causes pain
List the management of binary colic/cholecystitis
- Analgesic such as opioids
- Abx ( must be IV in hospital)
- Surgical
- Early cholecystectomy
- Laparoscopic cholecystectomy
Treatment of H.pylori
7/7 Rx
Lansoprazole 30mg BD
Amoxicillin 1g BD
Clarithromycin 500mg BD
Name the immunosupressants used in liver transplant patients
Ciclosporin or Tacrolimus \+ Azathioprine or Mycophenolate \+ Prednisolone