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Gastroenterology Tutorial
By Lucy Havard & Suroosh
Madanipour
Session plan
 3 key topics (45 mins)
 IBD (UC & Crohn’s) + IBS;
 Dyspepsia & peptic ulcer disease;
 Liver disease;
 OSCE practice (15 mins)
 SBAs (20 mins)
 Suggested further revision topics
IBD
 Ulcerative colitis vs Crohn’s disease
 Features?
 Extra-intestinal?
 Complications?
 Pathology?
 Histology?
 Endoscopy?
 Radiology?
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
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’.
IBS
 Clinical features?
 Red flags?
 Ix?
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).
Coeliac disease
 Pathology?
 Assoc. conditions?
 Ix?
 Findings on Bx?
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.
Dyspepsia
 Red flags?
 Urgent referral criteria?
 ‘Undiagnosed dyspepsia’ Mx?
Dyspepsia
NICE guidelines 2004
 Red flags = chronic GI bleeding; progressive unintentional weight
loss; progressive difficulty swallowing; persistent vomiting; IDA;
epigastric mass, suspicious barium meal.
 Urgent referral for endoscopy = red flag Sx; pts >55yrs w/: recent
(rather than recurrent) & unexplained OR persistent (4-6wks).
 Undiagnosed dyspepsia Mx:
 Review medications for possible causes
 Lifestyle advice
 Trial of full-dose PPI for 4wks
 ‘Test & treat’ using carbon-13 urea breath test.
Helicobacter pylori
 What is it?
 Associations?
 Mx?
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.
Liver Disease
Objectives
Know what you need to know about:
Jaundice
Differentials for Cirrhosis
Liver Function Tests
The alcoholic patient
Liver Failure
Jaundice
 Definition?
-Yellow skin, sclerae, mucosa due to
increased bilirubin
 Visible?
>35micromol/L
Jaundice
 Pre hepatic
 Hepatic
 Post hepatic
Fava Beans
 G6PD Deficiency
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
Pre-Hepatic
 Lab tests
- Urine: No bilirubin (conjugation makes
bilirubin water soluble)
- Serum: Increased unconjugated bilirubin
Hepatic
 Hepatocyte failure:
-Hepatitis
-Cirrhosis
-Cancer
 Failure of excretion:
-PBC, PSC
-Obstruction: Gall stones, pancreatic cancer, atresia
-Drug induced cholestatis: Flucloxacillin, Fusidic
Acid, Steroids
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?
Post Hepatic
 Largely Obstructive
-Gallstones
-Pancreatic Cancer at the head
-Cholangiocarcinoma
 Courvoisier’s Law
-Painless jaundice suggests a cause other
than gallstones
Cirrhosis
 What is it?
-Consequence of chronic liver disease
-Characterised by fibrosis, regenerative
nodules and decline in liver function
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
Kayser-Fleischer Ring – Wilson’s
Disease
LFTs
AST/ALT/ALP/Gamma GT/Bil/Alb/INR?
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)
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
De Ritis Ratio
 Ratio of AST/ALT
 Greater than 2 – more likely Alcoholic
hepatitis
 Less than 1 – more likely Viral hepatitis
Causes of ALT over 1000
 Viral hepatitis
 Drugs
 Ischaemia
 Alcohol may give raised ALT but lower
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
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
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
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”
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)
The Alcoholic Patient
Complications
 Withdrawal
 Nutritional Deficiency
 Clotting Function
 Portal Hypertension
 Hepatorenal Syndrome
 Encephalopathy
Gastroenterology Tutorial
Withdrawal
 Alcohol depresses neurotransmitters
 Removal of depressant leads to
hyperexcitable state – potential for
neurotoxicity and seizures
 Chlordiazepoxide – start with 20mg
Nutrition
 Calorie Rich
 Low Fat
 1.5kg/day of protein
 Vitamin supplementation
 Carnitine to reverse fatty liver
 Vitamin C, glutamine/acamprosate – reduce
cravings
 Vitamin K - clotting
 Thiamine – vitamin B1 – Wernicke - Korsakoff
Wernicke’s Encephalopathy
 Ataxia
 Ophthalmoplegia
 Nystagmus
 Confusion
 Korsakoff’s if untreated
 Be wary of “sub-dural” history in SBAs
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
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.
Varices
 Bleeding episodes – 30-50% mortality rate
 B-blocker propanolol maintenance and
banding ligation
 Emergency – Terlipressin, Sengstaken-
Blakemore balloon tamponade, antibiotics –
quinolone
 Ultimatley transjugular intrahepatic
portosystemic shunt may relieve pressure
Hepatorenal Syndrome
 40% of cirrhotics within 5 years of
diagnosis
 Follows portal hypertension
 Splanchnic vasodilation – reduced renal
bloodflow
 Indicated by worsening creatinine clearance
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
Orthotopic Liver
Transplant
• Gum Hypertrophy – Ciclosporin use
• Incisional Hernias
1 year after admission for alcoholic hepatitis
40% of people are dead
A sobering thought
OSCE scenario
 Mrs Jones has come into hospital to have an
operation to repair a hernia. Please consent
her for this operation.
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”
 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”
 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
SBAs
 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
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?
A) Cytomegalovirus
B) Epstein-Barr Virus
C) Kawasaki disease
D) Toxoplasmosis
E) Hepatitis A Infection
 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.
 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
A) OGD (oesophago-gastro-duodenoscopy)
B) Ciprofloxacin
C) Terlipressin
D) Oral Beta Blockers
E) Lactulose
 Answer = C – Terlipressin
 Explanation - Terlipressin causes
splanchnic vasoconstriction thereby
restricting bleeding from varices, which is
the likely cause of bleeding in this patient
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)
What is the most likely cause of this
derangement?
A) DM
B) Hyperparathyroid
C) Drug Induced
D) Hyperthyroid
E) Hypertension
 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.
 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
Gastroenterology Tutorial
What is the diagnosis?
A) Crohn’s Colits
B) Ectopic Pregnancy
C) Ischaemic Colitis
D) Small Bowel Obstruction
E) Large Bowel Obstruction
 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.
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?
A) Analysis for clostridium toxin
B) Blood Culture
C) Colonoscopy
D) Duodenal Biopsy
E) Stool Microscopy and Culture
 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.
 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
A) Abdominal Ultrasound
B) Gastrogaffin Enema
C) Endoscopy
D) Laparotomy
E) Serum AFP
 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.
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?
A) Tenesmus
B) Weight loss
C) Lethargy
D) Back Pain
E) Nausea
 Answer = B – weight loss
 Explanation – weight loss is not a feature of
IBS & underlying malignancy or IBD needs
to be excluded.
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?
A) Diverticulitis
B) Crohn’s Disease
C) Ulcerative Colitis
D) Colorectal Cancer
E) Infective Diarrhoea
Answer = C – Ulcerative colitis
Explanation – Sx are typical of UC: left lower
quadrant pain, blood in stool, feeling of
incomplete evacuation etc.
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?
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
 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.
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
 Answer = A – abdominal mass palpable in
the RIF
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
 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.
Suggested further revision topics
 Clostridium difficile
 GORD
 Oncology - stomach, colon, liver
 Dysphagia
 PBC
 PSC
 Wilson’s
 Pancreatitis
The End!!

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Gastroenterology Tutorial

  • 1. Gastroenterology Tutorial By Lucy Havard & Suroosh Madanipour
  • 2. Session plan  3 key topics (45 mins)  IBD (UC & Crohn’s) + IBS;  Dyspepsia & peptic ulcer disease;  Liver disease;  OSCE practice (15 mins)  SBAs (20 mins)  Suggested further revision topics
  • 3. IBD  Ulcerative colitis vs Crohn’s disease  Features?  Extra-intestinal?  Complications?  Pathology?  Histology?  Endoscopy?  Radiology?
  • 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’.
  • 6. IBS  Clinical features?  Red flags?  Ix?
  • 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).
  • 8. Coeliac disease  Pathology?  Assoc. conditions?  Ix?  Findings on Bx?
  • 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.
  • 10. Dyspepsia  Red flags?  Urgent referral criteria?  ‘Undiagnosed dyspepsia’ Mx?
  • 11. Dyspepsia NICE guidelines 2004  Red flags = chronic GI bleeding; progressive unintentional weight loss; progressive difficulty swallowing; persistent vomiting; IDA; epigastric mass, suspicious barium meal.  Urgent referral for endoscopy = red flag Sx; pts >55yrs w/: recent (rather than recurrent) & unexplained OR persistent (4-6wks).  Undiagnosed dyspepsia Mx:  Review medications for possible causes  Lifestyle advice  Trial of full-dose PPI for 4wks  ‘Test & treat’ using carbon-13 urea breath test.
  • 12. Helicobacter pylori  What is it?  Associations?  Mx?
  • 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.
  • 15. Objectives Know what you need to know about: Jaundice Differentials for Cirrhosis Liver Function Tests The alcoholic patient Liver Failure
  • 16. Jaundice  Definition? -Yellow skin, sclerae, mucosa due to increased bilirubin  Visible? >35micromol/L
  • 17. Jaundice  Pre hepatic  Hepatic  Post hepatic
  • 18. Fava Beans  G6PD Deficiency
  • 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
  • 21. Hepatic  Hepatocyte failure: -Hepatitis -Cirrhosis -Cancer  Failure of excretion: -PBC, PSC -Obstruction: Gall stones, pancreatic cancer, atresia -Drug induced cholestatis: Flucloxacillin, Fusidic Acid, Steroids
  • 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
  • 26. Kayser-Fleischer Ring – Wilson’s Disease
  • 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)
  • 38. Complications  Withdrawal  Nutritional Deficiency  Clotting Function  Portal Hypertension  Hepatorenal Syndrome  Encephalopathy
  • 40. Withdrawal  Alcohol depresses neurotransmitters  Removal of depressant leads to hyperexcitable state – potential for neurotoxicity and seizures  Chlordiazepoxide – start with 20mg
  • 41. Nutrition  Calorie Rich  Low Fat  1.5kg/day of protein  Vitamin supplementation  Carnitine to reverse fatty liver  Vitamin C, glutamine/acamprosate – reduce cravings  Vitamin K - clotting  Thiamine – vitamin B1 – Wernicke - Korsakoff
  • 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.
  • 45. Varices  Bleeding episodes – 30-50% mortality rate  B-blocker propanolol maintenance and banding ligation  Emergency – Terlipressin, Sengstaken- Blakemore balloon tamponade, antibiotics – quinolone  Ultimatley transjugular intrahepatic portosystemic shunt may relieve pressure
  • 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
  • 48. Orthotopic Liver Transplant • Gum Hypertrophy – Ciclosporin use • Incisional Hernias
  • 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
  • 54. SBAs
  • 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?
  • 57. A) Cytomegalovirus B) Epstein-Barr Virus C) Kawasaki disease D) Toxoplasmosis E) Hepatitis A Infection
  • 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
  • 60. A) OGD (oesophago-gastro-duodenoscopy) B) Ciprofloxacin C) Terlipressin D) Oral Beta Blockers E) Lactulose
  • 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
  • 73. A) Abdominal Ultrasound B) Gastrogaffin Enema C) Endoscopy D) Laparotomy E) Serum AFP
  • 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?
  • 76. A) Tenesmus B) Weight loss C) Lethargy D) Back Pain E) Nausea
  • 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?
  • 79. A) Diverticulitis B) Crohn’s Disease C) Ulcerative Colitis D) Colorectal Cancer E) Infective Diarrhoea
  • 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.
  • 88. Suggested further revision topics  Clostridium difficile  GORD  Oncology - stomach, colon, liver  Dysphagia  PBC  PSC  Wilson’s  Pancreatitis

Editor's Notes

  1. Cholest on blood cells and folate def – macrolytic borderline an Low platelets – portal hypertension/alcohol toxic
  2. Cholest on blood cells and folate def – macrolytic borderline an Low platelets – portal hypertension/alcohol toxic