4. IBD
Crohn’s disease Ulcerative colitis
(overall higher incidence)
Features Weight loss more prominent
Upper gastrointestinal
symptoms, mouth ulcers,
perianal disease e.g. fistulas,
fissures etc.
Abdominal mass palpable in
the right iliac fossa
Bloody diarrhoea more
common
Abdominal pain in the left
lower quadrant
Tenesmus
Extra-intestinal Primary sclerosing cholangitis
(PSC) more common
Complications Obstruction, fistula, colorectal
cancer
Risk of colorectal cancer
higher in UC than CD
Pathology Lesions may be seen
anywhere from the mouth to
anus
Skip lesions may be present
Inflammation always starts at
rectum and never spreads
beyond ileocaecal valve
Continuous disease
5. CD UC
Histology Inflammation in all layers
from mucosa to serosa
Increased goblet cells
Granulomas
No inflammation beyond
submucosa (unless
fulminant disease) -
inflammatory cell
infiltrate in lamina propria
Granulomas are
infrequent
Endoscopy Deep ulcers, skip lesions
- 'cobble-stone'
appearance
Widespread ulceration
with preservation of
adjacent mucosa which
has the appearance of
polyps ('pseudopolyps')
Radiology Small bowel enema -
high sensitivity &
specificity for
examination of the
terminal ileum; strictures
- ‘Kantor’s string sign’;
proximal bowel dilation;
‘rose thorn’ ulcers.
Barium enema - loss of
haustrations; superficial
ulceration
‘pseudopolyps’; in long-
standing disease, colon
is narrow & short -
‘drainpipe colon’.
7. IBS
NICE guidelines 2008
A Dx of IBS should be considered if the pt has had
the following for >6m: abdo pain &/or bloating
&/or change in bowel habit.
Red flag features = rectal bleeding;
unexplained/unintentional weight loss; FHx
bowel/ovarian Ca; o/set >60yrs.
Suggested Ix = FBC, ESR/CRP, coeliac disease
screen (TTG abs).
9. Coeliac disease
NICE guidelines 2009
Caused by sensitivity to gluten. Repeated exposure leads to villous
atrophy which in turn causes malabsorption.
Assoc. conditions = dermatitis herpetiformis (a vascular, pruritic skin
eruption); autoimmune disorders (DMT1, autoimmune hepatitis).
Ix = tissue transglutaminase (TTG) antibodies (IgA) are first-choice
according to NICE; endomyseal ab (IgA); antigliadin ab (IgA or IgG)
tests not recommended by NICE; anti-casein abs are also found in
some pts.
Jejunal Bx = villous atrophy, crypt hyperplasia, inc. in intraepithelial
lymphocytes, lamina propria infiltration w/ lymphocytes.
13. Helicobacter pylori
A gram -ve bacteria assoc. w/ a variety of GI
problems, principally peptic ulcer disease.
Associations = peptic ulcer disease (95% of
duodenal ulcers, 75% gastric ulcers); B cell
lymphoma of MALT tissue; atrophic gastritis.
Mx = eradication may be achieved w/ a 7 day
course of PPI + amoxicillin + clarithromycin OR
PPI + metronidazole + clarithromycin.
19. Pre Hepatic
ANYTHING that causes haemolysis
-Breaks down RBCs and release
UNconjugated bilirubin into the
bloodstream.
Bilirubin metabolism
-Gilbert’s – glucoronyltransferase deficiency
-5% of population – doesn’t make you ill -
SBA
20. Pre-Hepatic
Lab tests
- Urine: No bilirubin (conjugation makes
bilirubin water soluble)
- Serum: Increased unconjugated bilirubin
22. Hepatic
Lab Tests
- Urine: Bilirubin (conjugated bilirubin is
water soluble), making the urine DARK
COLOURED
- Stool: Pale – less bilirubin entering the gut
Think BILE OBSTRUCTION – conjugated
bilirubin usually excreted into gut via bile.
Urobilinogen absent in urine too. Why?
23. Post Hepatic
Largely Obstructive
-Gallstones
-Pancreatic Cancer at the head
-Cholangiocarcinoma
Courvoisier’s Law
-Painless jaundice suggests a cause other
than gallstones
24. Cirrhosis
What is it?
-Consequence of chronic liver disease
-Characterised by fibrosis, regenerative
nodules and decline in liver function
25. Cirrhosis - Differential
Chronic Hep B
Chronic Hep C
Haemochromatosis – Celtics/Nordics – Bronze Diabetes – High ferritin + iron,
low TIBC – reverse of Iron Definciency anaemia
NAFLD – Insulin Resistance, Amiodarone, Methotrexate
Primary bilary cirrhosis – Raised IgM – Antimitochondrial antibodies. Lots of
autoimmune associations. Deadly
Sclerosing cholangitis – Ulcerative colitis - cholangiocarcinoma
Autoimmune hep – Learn your HLAs, ANA positive
Cystic fibrosis
Budd-Chiari syndrome – thrombosis/tumour at portal vein – fulminant liver
failure or insidious cirrhosis
Wilsons disease – Psych symptoms, Kayser-Fleischer Rings, treat
w/Penicillamine. Tests – low Cu, low caeruloplasmin – because Cu is being
sequestered elsewhere
Alpha1 antitrypsin deficiency – low serum levels – young patient with
emphysema. “Serpinopathy” – serine protease inhibitor deficiency
Drugs – eg methotrexate
28. A set of results – What do you
think?
ALT 32 (10-35)
ALP 268 (35-104)
Bilirubin 205 (0-20)
Albumin 26 (34-50)
INR 1.53
Platelets 129 (150-400)
HB 11 .9 (11.5-15.5)
MCV 102 (80-99)
29. AST/ALT
Asparate/alanine transaminase
Released from “bursting” liver cells
If this has already happened then may be normal
The person without a liver won’t have elevated
ALT/AST
AST not specific to liver – also cardiac/skeletal
muscle
30. De Ritis Ratio
Ratio of AST/ALT
Greater than 2 – more likely Alcoholic
hepatitis
Less than 1 – more likely Viral hepatitis
31. Causes of ALT over 1000
Viral hepatitis
Drugs
Ischaemia
Alcohol may give raised ALT but lower
32. ALP/Gamma GT/5’NTD
Enzymes of bile canaliculi
Raised levels could mean obstruction of bile
duct or intrahepatic cholestasis
ALP not specific to liver – can suggest bone
disease eg. mets/osteomalacia
Use Gamma GT/5’NTD to see if raised
ALP is biliary or not
33. INR
Measure of Prothrombin Time and thus
Extrinsic Pathway
Demonstrates liver’s ability to synthesise
Vitamin K dependent clotting factors
II,VII,IX,X
Activated partial thromboplastin time
(ApTT) measure of Intrinsic Pathway
In liver failure PT will be prolonged first
34. Hypoalbuminaemia
Chronic malnutrition – no protein input
Liver disease – dysfuctional synthesis
Nephrotic syndrome - lost in urine
Consequence – loss of oncotic pressure >generalised
oedema
Note – ascites NOT due to loss of oncotic pressure, it is
due to aberrant activation of the RAA system and
therefore nephrogenic Na retention. And/or vasodilation
of splanchnic circulation. Mechanisms are still unclear
Hypoalbuminaemia often telling sign of impending
death on COOP wards
35. Take home message for LFTs
How well is this person’s liver?
Assess the SYNTHETIC FUNCTION
which comprises:
INR
Bilirubin
Albumin
When these are compromised, the liver can said
to be “decompensating”
36. A set of results – What do you
think?
ALT 32 (10-35)
ALP 268 (35-104)
Bilirubin 205 (0-20)
Albumin 26 (34-50)
INR 1.53
Platelets 129 (150-400)
HB 11 .9 (11.5-15.5)
MCV 102 (80-99)
40. Withdrawal
Alcohol depresses neurotransmitters
Removal of depressant leads to
hyperexcitable state – potential for
neurotoxicity and seizures
Chlordiazepoxide – start with 20mg
42. Wernicke’s Encephalopathy
Ataxia
Ophthalmoplegia
Nystagmus
Confusion
Korsakoff’s if untreated
Be wary of “sub-dural” history in SBAs
43. Bleeding Disorder
Liver synthetic function compromised
Give Vitamin K regardless - 10mg/day IV
for 3 days
Give platelets/FFP as needed esp. in portal
hypertention – splenic pooling
44. Portal Hypertension
Portal pressure gradient (difference
between portal vein and hepatic vein) of
greater than 10mmHg
Varices – backpressure leads to
overdilatation of veins at anastomotic
sites.
46. Hepatorenal Syndrome
40% of cirrhotics within 5 years of
diagnosis
Follows portal hypertension
Splanchnic vasodilation – reduced renal
bloodflow
Indicated by worsening creatinine clearance
47. Hepatic Encephalopathy
Liver responsible for metabolism of toxins.
Ammonia particularly important
Lactulose - clear gut flora and bind NH3
Rifaxamin – non-absorbable antibiotic to
clear gut flora
49. 1 year after admission for alcoholic hepatitis
40% of people are dead
A sobering thought
50. OSCE scenario
Mrs Jones has come into hospital to have an
operation to repair a hernia. Please consent
her for this operation.
51. OSCE mark scheme – consenting a
patient for an operation
Introduction
Introduce with name and grade
Discuss aim of Consultation “I’ve come to discuss the options
we have ahead in your case”
Check Understanding “Tell me about what you
understand what’s happened so far”
Elicit patient’s concerns “what are you particularly worried
about”
Explain indication of Proc’/Op’ “You’ve got …. Which
means….”
“We’ve discussed your case So we need to do…to
investigate/treat/etc”
Explain preparation required before “the procedure involves”
52. Explain the implications of not doing “If you don’t
have… then….”
Talk through procedure
Before “First we…”
During “then during…” [Describe Procedure/Op]
After “After you will… until results/stable/free to
go/etc”
Discuss Risks and benefits “there are some
common Risks which you should be aware of”
Discuss Alternatives “Just so that
you’re sure we should discuss other options
Describe out come likelihood of success
“In the majority of cases….”
Discharge date “Hospital for ..days/free
to go”
Follow up “come and see us in…”
Restrictions on lifestyle after “rest/do not eat/stay on the ward”
53. Asks for questions - “Do you have any questions?”
Explore concerns - “Is there anything else you’re worried
about”
Future management plan - “right now we need to
do.../we’re waiting for…/wait till op’”
Offer leaflets - “if you’d like some more information…
leaflet’s available”
Summarise key points - “Quickly recap what we’ve talked
about”
Formalise consent - “Well if that’s ok then please sign the
consent form
to show that you understand what’s about to take place”
Mention free withdrawal - “this is not a contract you are
free to withdraw at any stage”
Thank patient
55. A 5-year-old boy presents with fever, rash and
hepatomegaly.
He was well until seven days before when he
developed malaise, headache and fever.
Subsequently a maculopapular rash had
appeared over the trunk. An enlarged liver was
noted by the family doctor.
He had a full term normal delivery with no
neonatal problems. His immunisations are up
to date. There is no family or social history of
note.
Question 1
56. On examination
Temperature 38.2
RR 20
Pulse 100
He has marked cervical lymphadenopathy, a 2
cm tender hepatomegaly and 3 cm spleen. Full
blood count shows occasional atypical
lymphocytes, and his AST is slightly elevated.
What is the most likely diagnosis?
58. Answer = B – Epstein Barr virus
Explanation: Hx of fever, rash
lymphadenopathy and hepatosplenomegaly
is in keeping with a mononucleosis-like
illness. This suspicion is supported by the
atypical lymphocytes and elevated liver
enzymes, which suggest a mild hepatitis is
present. EBV, CMV & toxoplasmosis can
cause this picture; EBV is the most common
of these & therefore the most likely.
59. A 70-year-old male presents with
haematemesis and melaena.
His presenting blood pressure is 80/46 mmHg,
with a heart rate of 114 bpm. He is known to
have idiopathic cirrhosis, and there is mild
encephalopathy.
You start to resuscitate him with colloid,
blood, FFP and dextrose.
Which of the following is the most appropriate
next step at this moment?
Question 2
61. Answer = C – Terlipressin
Explanation - Terlipressin causes
splanchnic vasoconstriction thereby
restricting bleeding from varices, which is
the likely cause of bleeding in this patient
62. Question 3
A 50-year-old woman is seen in the clinic
because of deranged liver function tests
(LFTs).
She drinks 4 units of alcohol weekly.
On examination she is obese with a BMI of
45kg/m2 and her LFTs show:
ALT 140 (5-40)
AST 150 (10-40)
ALP 250 (45-105)
63. What is the most likely cause of this
derangement?
A) DM
B) Hyperparathyroid
C) Drug Induced
D) Hyperthyroid
E) Hypertension
64. Answer = A – Diabetes Mellitus
Explanation – DM associated with obesity
is the most likely cause of non-alcoholic
fatty liver disease (NAFLD) in this patient.
It is caused by fatty accumulation in the
liver leading to inflammation.
65. A 24-year-old woman is admitted with
vomiting and generalised abdominal pain, six
weeks after having undergone emergency
abdominal surgery for an acute perforated
appendicitis.
Her erect abdominal x ray is shown on the
next slide:
Question 4
67. What is the diagnosis?
A) Crohn’s Colits
B) Ectopic Pregnancy
C) Ischaemic Colitis
D) Small Bowel Obstruction
E) Large Bowel Obstruction
68. Answer = D – small bowel obstruction
Explanation - a perforated appendix implies
that peritonitis occurred which increases the
risk of future adhesions leading to bowel
obstruction. This erect AXR shows the air
fluid levels in the small bowel and small
bowel diameter exceeding 2.5 cm. Although
an ectopic pregnancy should always be a
consideration in a woman of child-bearing
age, the presentation and x ray features are
diagnostic.
69. Question 5
A 26-year-old female returns from a back packing holiday in
Eastern Europe with diarrhoea.
One week ago she developed profuse watery diarrhoea together
with colicky abdominal pain. She goes to the toilet
approximately 10 times daily. She occasionally feels nauseous
but has had no vomiting. She has lost approximately 5 kg in
weight with this illness.
On examination she has a temperature of 37.7C and appears
slightly dehydrated. There is some slight tenderness on
abdominal examination but no specific abnormalities are
detected. PR examination reveals watery, brown faeces.
Which investigation would be most appropriate for this patient?
70. A) Analysis for clostridium toxin
B) Blood Culture
C) Colonoscopy
D) Duodenal Biopsy
E) Stool Microscopy and Culture
71. Answer = E – stool microscopy & culture
Explanation – this pt has traveller’s
diarrhoea. In view of the Sx & the location
of her holiday, giardiasis seems the likely
diagnosis. This is best diagnosed through
microscopic examination of the faeces
where cysts may be seen. Rx =
Metronidazole.
72. A 55-year-old publican presents with a
haematemesis.
His wife provides a history that he has consumed
approximately four cans of lager per day together
with liberal quantities of spirits for many years. He
has tried to stop drinking in the past but failed.
Examination reveals that he is oriented but
distressed, a pulse of 120 beats per minute, a blood
pressure of 108/70 mmHg, he has numerous spider
naevi over his chest. Abdominal examination
reveals a distended abdomen with ascites.
What would you request next for this patient?
Question 6
74. Answer = B – endoscopy
This patient with alcohol abuse presents
with features of chronic liver disease and is
now shocked due to haematemesis.
Bleeding oesophageal varices should be top
of the differential list and other diagnoses to
consider would include peptic ulceration or
haemorrhagic gastritis. An urgent
endoscopy should be requested.
75. Question 7
A 35-year-old female presents with
abdominal pain associated with bloating for
the past 6 months, Which one of the
following symptoms is least associated with
a diagnosis of irritable bowel syndrome?
77. Answer = B – weight loss
Explanation – weight loss is not a feature of
IBS & underlying malignancy or IBD needs
to be excluded.
78. Question 8
A 22-year-old man presents with a three week
history of diarrhoea. He says his bowels have
not been right for the past few months and he
frequently has to run to the toilet. These
symptoms had seemed to be improving up
until three weeks ago. For the past week he has
also been passing some blood in the stool and
reports the feeling of incomplete evacuation
after going. He has lost no weight and has a
good appetite. Examination of his abdomen
demonstrates mild tenderness in the left lower
quadrant but no guarding. What is the most
likely diagnosis?
80. Answer = C – Ulcerative colitis
Explanation – Sx are typical of UC: left lower
quadrant pain, blood in stool, feeling of
incomplete evacuation etc.
81. Question 9
A 26-year-old woman who is known to
have type 1 diabetes mellitus presents with
a three-month history of diarrhoea, fatigue
and weight loss. She has tried excluding
gluten from her diet for the past 4 weeks
and feels much better. She requests to be
tested so that a diagnosis of coeliac disease
is confirmed. What is the most appropriate
next step?
82. A) Check her HbA1c
B) No need for further investigation as the
clinical response is diagnostic
C) Check anti-endomysial antibodies
D) Arrange jejunal biopsy
E) Ask her to reintroduce gluten for the next 6
weeks before reassessing
83. Answer = E – ask her to reintroduce gluten
for the next 6wks before further testing
Explanation – serological tests and jejunal
biopsy may be negative if the patient is
following a gluten-free diet. The patient
should eat some gluten in more than one
meal every day for at least 6 weeks before
further testing.
84. Question 10
Which one of the following features is more common in
Crohn's disease than ulcerative colitis?
A) Abdominal mass palpable in RIF
B) Tenesmus
C) Bloody Diarrhoea
D) Faecal Incontinence
E) Abdominal pain in left lower quadrant
85. Answer = A – abdominal mass palpable in
the RIF
86. Question 11
Of the following, which one is the most useful
prognostic marker in paracetamol overdose?
A) ALT
B) Prothrombin Time
C) Paracetomol levels at presentation
D) Paracetomol levels at 12h
E) Parecetomol levels at 24h
87. Answer = B – prothrombin time
Explanation - an elevated prothrombin time
signifies liver failure in paracetamol
overdose and is a marker of poor prognosis.
However, arterial pH, creatinine and
encephalopathy are also markers of a need
for liver transplantation.