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Give an outline of the causes of N+V?
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What are the red flags for Nausea + Vomiting?
- Weight loss
- anaemia
- Blood [haematemesis/Malaena]
- Dysphagia
- Palpable abdo mass
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How is N+V Investigated?
- <55yo = H.Pylori serology/Stool antigen
- >55yo = Endoscopy
- Red flags = endoscopy
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Define diarrhoea? And give 3 types:
Diarrhoea = >200g stool daily [by volume] stool takes shape of container, assoc w urgency + incontinence
Osmotic [stops when fasted, too much water drawn into bowel] -> drugs [lactulose, Mg salts] sweeteners
Secretory [high volume, increase in secretion of anions -> movement of water] -> toxins [cholera, C diff, E.coli], tumours, drugs [erythromycin]
Motility -> IBS, stimulating laxatives [senna]
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Give 3 causes of Travellers diarrhoea?
- Campylobacter Jejuni
- E coli
- Giardia
- Cryptosporidium
- Bloody? -> dysentery
- Salmonella typhi
- Shigella
- Campylobacter
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Give 4 CF of GORD
- heart burn
- regurgitation
- brackish taste at back of mouth
- chronic cough
- sore throat
- horaseness
- dental erosions
- chest pain
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Give 3 Mx for GORD
- PPI -> omeprazole
- PRN Antacid
- Lifestyle modification -> weight loss, elevate head in bed
- Surgical -> Nissen fundoplication
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What is the main complication of GORD? Give 2 others
- Oesophageal strcture
- bleeding
- ulcer
Barretts Oesophagus -> gastric epithelial metaplasia with risk of trasnformation to carcinoma -> surveillence
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Give 3 causes for peptic ulcer disease?
H. Pylori infection -> serology/stool antigens -> triple therapy [PPI, amoxil, clarith/metronidazole]
Drugs -> NSAIDs -> Disrupt mucosal permeability, ^^susceptible to damage
Lifestyle -> smoking, alcohol, caffeine
Physiological stress -> burns patients, CNS, Trauma [ICU patients]
Hyper secretory state [rare] Zolinger Ellison Gatrinoma
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Give 3 CF suggestive of Peptic Ulcer
- Episodic epigastric pain
- Before food, relieved by eating
- vomiting
- anaemia
- Haematemesis/Perforation
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Give 3 causes of upper GI bleeding?
Common;
- Ulcers [H.Pylori, NSAID]
- Oesephageal varices
- Mallory-Weiss tear
- Erosive Oesophagitis
- Erosive Gastritis
Uncommon;
- Tumours
- AV Malformation
- Portal Hypertensive Gastopahty
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What is the acute Mx of Upper GI Bleeding?
- Major Haemorrhage Protocol
- ABC
- Fluid resuscitation
- Urgent Endoscopy
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Outline the acute Mx of Oesopheageal varices?
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Mx of varices? Acute + chronic
Acute
- Terlipressin IV -> vasopressin analogue, achieve haemostasis
- TIPSS -> Transjugular Intrahepatic Porto-Systemic Shunt -> relieve portal hypertension
Chronic
- Prophylaxis -> Prpanolol/Carvedolol
- TIPSS
- Banding
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Look at this pretty picture
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Give 3 causes of Jaundice?
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What is Gilberts Syndrome?
- Congenital Hyperbilirubinaemia
- jaundiced during times of stress [isolated rise in bilirubin]
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What is Portal vein thrombosis?
Thrombosis of hepatic portal vein [cirrhosis, pancretitis, post-splenectomy]
CF -> sudden onset RUQ pain, signs of Portal HTN [Ascites, caput medusae]
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What is PSC? [Primary Sclerosing Cholangitis]
- Inflammation + obstruction of bile ducts [intra+extrahepatic]
- Autoimmune, Linked to UC, M>F 2:1
CF -> Chronic fatigue, malabsorption, cirrhosis, Cholangiocarcinoma
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Give 3 causes of acute liver failure?
Uncommon but serious problem
- Drugs -> Paracetamol, halothane, Anti-TB
- Cryptogenic -> unknown
- Viral infection -> Hep, A, B, E
- Poisons -> Magic Mushrooms
- Misc -> Budd-chiari, wilsons, liver mets, lymphoma
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Outline the 4 stages of hepatic encephalopathy?
1 - slurred speech, poor concentration, retardation
2 - drowsy, occaisionally aggressive, lethargic
3 - Confusion, dec GCS, Gross disorientation
4 - Unconscious
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Give 4 CF of Acute liver failure
- Heptatic encephalopathy
- Derebral oedema
- Jaundice
- Fetor Hepaticus [smelly breath]
- Ascites + oedema -> late
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Ix of acute liver failure?
- Prothrombin [PT] time -> prognostic indicator
- Bilirubin
- Transaminases
- HBsAg
- Serology -> HEV, HCV, CMV, HSV, EBV
- USS liver + doppler hepatic veins
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Mx of acute liver failure?
- Co-ordinate w ICU/HDU
- NANC in paracetamol
- Cerbral oedema/Encephalopthy -> Reduce ammonia burden -> Lactulose, 30degree head tilt
- Coagulopathy -> FFP
- NBM -> IV glucose to avoid hypo, NGT, TPN
- Transplantation
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Define Cirrhosis?
- Diffuse hepatic fibrosis + nodule formation leading to a loss of the normal liver architecture
- Stage 1 -> compensated & asymptomatic -> 10-20yrs
- Stage 2 -> decompensated -> lver failure, varices, ascites
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Give 4 causes for liver cirrhosis?
- Alcohol
- Chronic viral hepatitis [B+C]
- Non-alcoholic fatty liver
- Immune -> PSC/Autoimmune liver disease
- Biliary -> PBC, CF
- Genetic -> haemochromatosis, Wilsons
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Give 6 CF of Cirrhosis?
- Hepatomegaly [or small + hard]
- Ascites
- Circulatory changes -> spider naevi, palmar erythema, cyanosis
- Portal Hypertension -> Spleenomegaly, caput, variceal bleeds
- Gynaecomastia
- haemorrhagic tendency -> Bruises, purpura, epistaxis
- Hepatic encephalopathy
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Draw the mechanism of ascites?
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Give 3 investigations for cirrhosis?
- Liver biopsy = gold standard
- Bloods -> PLTS, ^INR, ^[bilirubin], hypoalbuminaemia
- USS -> advanced disease
- CT-abdo
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Mx
- Treat cause
- treat complications
- adequate nutrition
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Give 2 complications of liver cirrhosis?
- Ascites -> fluid in peritoneal cavity -> Spontaeneous bacterial peritonitis
- Hepato-renal syndrome -> renal vascoconstriction + underfilling
- Varices -> oesophageal
- Hepatocellular carcinoma -> resect + transplant or percutaneous ethanol ablation
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How do you Mx Ascites?
- Only symptomatic relief
- Fluid restriction
- Diuretics -> Spironalactone/Epleranone + Furosemide
- Paracentesis [for refractory]
- Peritoneo-venous shunt
- Transjugular Intrahepatic porto-systemic shunt
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What is Primary Biliary Cirrhosis [PBC]?
- Progressive cholestatic liver diseas of unknown aetiology [assoc with anti-mitochondrial antibody]
- middle aged women with xanthelasma
LFT -> cholestatic picture
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Outline the CF, genetics Ix + Mx of Haemachromatosi?
- Hereditary condition -> Fe deposition in liver, pancrease and endocrine glands
- Genetics -> C282Y + H63D
CF -> M>F, >40yo, fatigue, arthropathy, bronze diabetes, cardiac failure
Ix -> ^^serum ferritin, ^Plasma[Fe], Transferrin saturation >45%
Mx -> weekly venesection, treat cirrhosis + DM, Ix FH
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Alcoholic liver disease
>28units/week, 21 in fems
continuous >>binge
^^oxidative stress of ETOH metabolism
Ix -> ^^GGT + Macrocytosis
Mx -> stop drinking, treat addiction, Thiamine
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Hep A?
- ssRNA unenveloped hepatovirus
- causes acute hepatitis
- Faecal-oral spread
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Hep B?
- dsDNA hepatovirus
- acute + chronic infection
chronic = infected whilst young
Patho -> CD8+ T cell mediated hepatocyte necrosis
Serology -> eAg = ^^infective, sAg = chronic carrier
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Hep C?
- ssRNA enveloped Flavivirus
- 6 major genotypes
Chronic infection since immune response is not pretective [sero = RNA positive -> PCR]
TMx -> IVDU, Blood + products
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Define UC + give its pathological features?
- Gradual onset bloody diarrhoea [>4/day]
- 15-25yo
- begins @ ano-rectal margin w proximal extension
- confined to mucosa + submucosa [no granulomas]
- crypt distortion + crypt abscess
- loss of goblet cells
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How is UC Mx? Give 2 drugs + their MoA
5-ASA -> Mesalazine -> bowel specific aminosalycate -> decreases Pg + Leukotrienes
Corticosteroids -> Systemic anti-inflammatory
Azathioprine -> Purine anti-metabolite, inhibit mitosis -> decrease inflammatory cells
Colectomy = curative
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Define Crohns and give 4 CF?
Inflammatory disease of alimetary canal, can occur anywhere from mouth to anus.
CF
- Cramping abdo pain
- mouth ulcers
- fever
- weight loss
- fatigue
- diarrhoea
- rectal bleeding
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Outline the pathology of Crohns?
- Mouth to anus
- Patchy disease [skip lesions]
- Transmural inflammation -> fissures + fistulae
- Granulomas
- non-caseous necrosis
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Give 3 drugs for Crohns + their MoA?
Azathioprine -> Purine antimetabolite
Corticosteroids -> systemic antiinflammatory
MTX -> folic acid antagonist -> 1/week
Infliximab -> Anti-TNF
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What is IBS + how is it managed?
recurrent cramping abdo pain with psuchological interactions
- Diarrhoeal symptoms -> loperamide
- Constipation -> Lactulose
- Pain + bloating -> Mebeverine/Peppermint oil
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