1
Q
Describe appendicitis
A
- Appendix is a small, thin tube of bowel sprouting from the caecum
- appendicitis is inflammation of the appendix
- results from obstruction of the appendix and subsequent infection and inflammation of the appendix
- peak incidence in ages 10-20
2
Q
What are the symptoms of appendicitis?
A
- abdominal pain, typically central then settling in the right iliac fossa
- loss of appetite, N+V
3
Q
What are the signs of appendicitis?
A
- tender to McBurney’s point
- guarding to RIF
- rebound tenderness and percussion tenderness indicate peritonitis
- rovsing’s sign positive
4
Q
Describe the diagnosis of appendicitis
A
- mostly clinical based on signs and raised inflammatory markers
- CT can be useful in confirming diagnosis
- USS can be useful to exclude ovarian and gynae pathology
- if clinically appendicitis but tests negative, proceed to diagnostic laparoscopy
5
Q
What are the common differential diagnoses for appedicitis?
A
- ectopic pregnancy
- ovarian cysts
- meckel’s diverticulitis
- mesenteric adenitis
6
Q
What are the possible complications fo an appendicectomy?
A
- bleeding/ infection/ pain/ scars
- damage to bowel, bladder or other organs
- removal of normal appendix
- anaesthetic risk
- DVT/PE
Laparoscopic is associated with fewer risks and faster recovery
7
Q
Describe the management of appendicitis
A
Appendicectomy is the definitive management for acute appendicitis.
Laparoscopic surgery is associated with fewer risks and faster recovery compared to laparotomy.
8
Q
Define haemochromatosis
A
Haemochromatosis is an iron storage disorder that results in excessive total body iron and deposition of iron in tissues.
The human haemochromatosis protein (HFE) gene is located on chromosome 6.
Majority of cases are due to mutation in the HFE gene. Mutation is autosomal recessive.
9
Q
What are the symptoms of haemochromatosis?
A
Usually presents after the age of 40 when the iron overload becomes symptomatic.
Chronic tiredness Joint pain Pigmentation Hair loss Erectile dysfunction Amenorrhoea Cognitive symptoms
10
Q
What is the diagnosis of haemochromatosis?
A
Serum ferritin.
Ferritin is an acute phase reactant meaning that it goes up with inflammatory conditions such as infection.
Transferrin saturation is helpful in distinguishing between iron overload and other causes of high ferritin.
If both are high, do genetic testing to confirm.
11
Q
What are the complications of haemochromatosis?
A
Type 1 DM
Liver cirrhosis
Iron deposits in the pituitary and gonads lead to endocrine and sexual problems
Cardiomyopathy
Hepatocellular carcinoma
Hypothyroidism
Chrondocalcinosis
12
Q
What is the management of haemochromatosis?
A
Venesection Monitoring serum ferritin Avoid alcohol Genetic counselling Monitoring and treatment of complications
13
Q
Define acute cholangitis
A
Acute cholangitis is infection and inflammation in the bile ducts.
14
Q
What are the causes of acute cholangitis?
A
- Obstruction int he bile ducts stopping bile flow (i.e. gallstones in the common bile duct)
- Infection introduced during an ERCP procedure
15
Q
What are the most common organisms that cause acute cholangitis?
A
- E. coli
- Klebsiella species
- Enterococcus species
16
Q
Describe the presentation of acute cholangitis
A
charcot’s triad:
- RUQ pain
- Jaundice
- Fever
17
Q
What is the management of patients with acute cholangitis?
A
Acute management of sepsis ad acute abdo:
- Nil by mouth
- IV fluids
- Blood culture
- IV antibiotics
Imaging to diagnose CBD stones and cholanditis:
- Abdo US
- CT
- MRCP
ERCP
18
Q
Define acute pancreatitis
A
Pancreatitis refers to inflammation of the pancreas. Presents with rapid onset of symptoms
19
Q
What are the key causes of pancreatitis?
A
- Gallstones
- Alcohol
- Post ERCP
20
Q
What are the full list of causes of pancreatitis?
A
I GET SMASHED
Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting Hyperlipidaemia ERCP Drugs
21
Q
Describe the presentation of acute pancreatitis
A
- Severe epigastric pain
- Radiating through to the back
- Associated vomiting
- Abdominal tenderness
- Systemically unwell
22
Q
What are the investigations of acute pancreatitis?
A
- FBC
- U+E
- LFT
- Calcium
- ABG
- Amylase if raised more than 3 times upper limit, it is acute pancreatitis
- CRP
- USS
- CT abdo
23
Q
What is the glasgow score in terms of pancreatitis?
A
Used to determine severity of pancreatitis:
0-1 mild
2 moderate
3 or more severe
PANCREAS PaO2 <60 Age >55 Neutrophils >15 Calcium <2 uRea >16 Enzymes (LDH>600 or AST/ALT>200) Albumin <32 Sugar (glucose>10)
24
Q
What is the management of acute pancreatitis?
A
ABCDE IV fluids Nil by mouth Analgesia Monitor
Tx of gallstones: ERCP/cholecystectomy
Abs for infection
Tx of complications
25
What are the complications of acute pancreatitis?
```
Necrosis of the pancreas
Infection in a necrotic area
Abscess formation
Acute peripancreatic fluid collection
Pseudocysts
Chronic pancreatitis
```
26
What is the stepwise progression of alcoholic liver diease?
1. Alcohol related fatty liver
drinking leads to build up of fat in the liver. Can be reversed in 2 weeks with abstinence.
2. Alcoholic hepatitis
Drinking over a long period causes inflammation in the liver sites. Mild hepatitis can be reversed,
3. Cirrhosis
Liver is made up of scar tissue rather than healthy tissue. Irreversible.
27
What are the signs of liver disease?
```
Jaundice
Hepatosplenomegaly
Spider Naevi
Palmer erythema
Gynaecomastia
Bruising
Ascites
Caput Medusae
Asterixis
```
28
What are the investigations and findings in alcoholic liver disease?
Bloods:
- FBC: raised MCV
- LFTs: High ALT+AST+GGT. ALP will be raised later. Low albumin and high bilirubin
- Clotting: elevated PT
- U+Es: deranged
USS: show early changes and fibroscan to check elasticity of liver to assess degree of cirrhosis.
Endoscopy:
assess for and treat oesophageal varices when portal hypertension is suspected
CT and MRI can look for fatty infiltration of the liver
Liver Biopsy to confirm diagnosis of alcohol related hepatitis or cirrhosis.
29
What is the general management of alcoholic liver disease?
Stop drinking
Consider detoxification
Nutritional support
Steroids improve short term outcomes
30
What is portal hypertension?
Result of resistance in the vessels in the liver due to fibrosis affecting the structure and blood flow
31
What are the most common causes of liver cirrhosis?
Alcoholic liver disease
Non-alcoholic fatty liver disease
Hep B
Hep C
32
What are the investigations and findings in liver cirrhosis?
Liver biochemistry often normal but in decompensated cirrhosis, all markers deranged
Albumin drops and prothrombin time increases
Hyponatramia
Urea and creatinine deranged
USS: nodullarity, corkscrew appearance, enlarged portal vein
33
What are the markers for synthetic function of the liver?
Albumin and prothrombin time
34
What is the first line investigation for assessing fibrosis in non-alcoholic fatty liver disease?
Enhanced liver fibrosis blood test.
Measures HA, PIIINP and TIMP-1
35
What is a fibroscan?
Can be used to check the elasticity of the liver. Retest every 2 years in patients at risk of cirrhosis:
- Hep C
- heavy alcoholics
- diagnosed alcoholic liver disease
- non-alcoholic liver disease
- chronic hep B
36
What is the diagnostic test for liver cirrhosis?
Liver biopsy
37
What score is used to measure severity and prognosis of cirrhosis?
Child-pugh score
38
Which score is used to give estimated 3 month mortality and help guide referral for liver transplant?
MELD score
39
What is the general management of cirrhosis?
US and alpha fetoprotein every 6 months for hepatocellular carcinoma
Endoscopy every 3 years in patients with varices
High protein, low sodium diet
MELD score every 6 months
Consideration of a liver transplant
40
What is the treatment of stable varices?
1. propanolol reduces portal hypertension
2. elastic band ligation of varices
3. injection of scllerosant
4. TIPS
41
What are the non-invasive liver screens and what do they look for?
US liver
Hep B and C serology
Autoantibodies (autoimmune hep, primary biliary cirrhosis and primary sclerosing cholangitis)
Immunoglobulins (autoimmune hep and primary biliary cirrhosis)
Caerulopllasmin (wilsons disease)
Alpha 1 anti-trypsin levels (alpha 1 anti-trypsin deficiency)
Ferritin and transferrin saturation (hereditary haemochromatosis)
42
What are the investigations in non-alcoholic fatty liver disease?
Liver US
Enhanced liver firbosis blood test (first line)
NAFLD fibrosis score (2nd line)
Fibroscan (3rd line)
43
What is the management of non-alcoholic fatty liver disease?
```
Weight loss
Exercise
Stop smoking
Control of diabetes, BP and cholesterol
Avoid alcohol
```
44
What are the causes of hepatitis?
```
Alcoholic hep
Non-alcoholic fatty liver disease
Viral hep
Autoimmune hep
Drug induced hep
```
45
What is the presentation of hepatitis?
```
Abdo pain
Fatigue
Puritis
Muscle and joint aches
Nausea and vomiting
Jaundice
Fever (viral hep)
```
46
What is hep A and how is it transmitted?
It is an RNA virus. Transmitted via faecal-oral route
47
How does hep A present?
```
Nausea
Vomiting
Anorexia
Jaundice
Cholestasis - dark urine and pale stools
Hepatomegaly
```
48
What is the management for hep A?
Resolves without treatment in 1-3 months
49
What is hep B and how is it transmitted?
DNA virus. Transmitted by direct contact with blood or bodily fluids
50
What percentage of people go onto get chronic hep B?
Most people recover within 2 months but 10% go onto become chronic hep B carriers
51
What are the viral markers and their meaning for hep B?
Surface antigen (HBsAg) - active infection
E antigen (HBeAg) - high infectivitiy
Core antibodies (HBcAb) - past or current infection
Surface antibody (HBsAb) - vaccination or past or current infection
Hep B virus DNA (HBV DNA) - direct count of viral load
52
What is hep c and give the transmission?
RNA virus
| Spread by blood and bodily fluids
53
What is the disease course of hep c?
25% full recovery
| 75% becomes chronic
54
What are the complications of hep c?
Liver cirrhosis and hepatocellular carcinoma
55
What is the test for hep c?
Hep C antibody is the screening test
Hep C RNA testing is used to confirm diagnosis of hep C
56
What is the management of hep c?
direct acting antivirals are tailored and successfully cure the infection in over 90% of patients
57
What is hep D and E?
can only get hep d if you have hep b as well
Hep e is faecal oral route and v rare in the UK
58
Who does type 1 autoimmune hepatitis affect and what are the associated anitbodies?
Occurs in adults
Women
Around or after menopause
Less acute than type 2
Anti-nuclear antibodies
Anti-smooth muscle antibodies
Anti-soluble liver antigen
59
Who does type 2 autoimmune hepatitis affect and what are the associated anitbodies?
Teenagers or early twenties with acute hep with high transaminases and jaundice
Anti-liver kidney microsome-1 (anti-LKM1)
Anti-livre cytosol antigen type 1 (anti-LC1)
60
What are the treatments for autoimmune hepatitis?
High dose steroids (prednisolone) tapered over with other immunosuppressants
61
What is wilson's disease?
Excessive accumulation of copper in the body caused by a mutation in the wilsons disease protein on chromosome 13
62
Describe the presentation of Wilson's disease?
```
Hepatic problems (cirrhosis)
Neurological problems
Psychiatric problems
Kayser-Fleischer rings
Haemolytic anaemia
Renal tubular acidosis
Osteopenia
```
63
What is the diagnosis of Wilson's disease?
Initial investigation: Serum caeruloplasmin low = Wilson's
Diagnostic investigation: liver biopsy
Other:
24hr urine copper
Low serum copper
Kayser-Fleischer rings
64
What is the management of Wilson's disease?
Copper chelation with:
Penicillamine
Trientene
65
What is primary biliary cirrhosis?
Where the immune system attacks the small bile ducts. This causes obstruction of the outflow of bile (cholestasis) leading to bile acids, billilrubin and cholesterol building up in the body
66
Describe the presentation of primary biliary cirrhosis
```
Fatigue
Pruritus
GI disturbance and abdo pain
Jaundice
Pale stools
Xanthoma and xanthelasma
Signs of cirrhosis and failure
```
67
What is primary biliary cirrhosis associated with?
Middle aged women
Other autoimmune diseases
Rheumatoid conditions
68
What is the diagnosis of primary biliary cirrhosis/
ALP raised first
Bilirubin and others raised later
Diagnostic: Anti-mitochondrial antibodies
Anti-nuclear antibodies
ESR raised
IgM raised
Livery biopsy
69
What is the treatment for primary biliary cirrhosis?
Ursodeoxycholic acid
Colestyramine
Liver transplant
immunosuppression
70
What is primary sclerosing cholangitis?
Where the intrahepatic and extrahepatic ducts become strictured and fibrotic. Causes an obstruction to the flow of bile out of the liver
71
What are the risk factors for primary sclerosing cholangitis
Male
Aged 30-40
UC
Family history
72
What is the presentation of primary sclerosing cholangitis?
```
Jaundice
Chronic RUQ pain
Pruritus
Fatigue
Hepatomegaly
```
73
What is the diagnosis of primary sclerosing cholangitis?
Gold standard: MRCP
High ALP
p-ANCA
ANA
aCL
74
What is the management of primary sclerosing cholangitis?
Liver transplant can be curative
ERCP
Ursodeoxycholic acid
Colestyramine
75
What is the test for H. pylori
Need to not use PPI for 2 weeks before
Urea breath test
Stool antigen test
Rapid urease test
76
What is the eradication regime for H. pylori?
Triple therapy with PPI + 2 antibiotics for 7 days
77
What is the presentation of peptic ulcers?
```
Epigastric discomfort or pain
N+V
Dyspepsia
Bleeding "coffee ground" vomit and melaena
Iron deficiency anaemia
```
Eating worsens pain = gastric ulcers
Eating improves pain = duodenal ulcers
78
What are the features of crohns?
Crows NESTS
```
No blood or mucus
Entire GI tract
Skip lesions on endoscopy
Terminal ileum most affected
Transmural inflammation
Smoking is a risk factor
```
79
What are the features of ulcerative colitis?
U-C- CLOSEUP
```
Continuous inflammation
Limited to colon and rectum
Only superficial mucosa affected
Smoking is protective
Excrete blood and mucus
Use aminosalicylates
Primary sclerosing cholangitis
```
80
What is the test for inflammatory bowel disease?
1st line: Stool microscopy
Faecal calprotectin is a useful screening test
Endoscopy with biopsy is diagnostic
81
What is the management of crohns?
First line: steroids
± immunosuppressant
Maintaining:
First line: Azathiprine or mercaptopurine
Surgery if it only affects the distal ileum
82
What is the management of UC?
Inducing remission mild to moderate:
First line: aminosalicylate e.g. mesalazine
Second line: corticosteroids
Inducing remission severe:
First line: IV corticosteroids
Second line: IV ciclosporin
Maintaining remission:
aminosalicylate, azathioprine or mercaptopurine
Surgery
83
What is the diagnosis of coeliac disease?
Must be carried out when they are still on gluten diet.
Raised anti-TTG
Raised EMAs
Endoscopy and intestinal biopsy shows:
crypt hypertrophy
villous atrophy
84
What is necrotising enterocolitis?
Disorder affecting premature neonates where part of the bowel becomes necrotic.
85
What is the presentation of necrotising enterocolitis?
```
Intolerance to feeds
Vomiting with green bile
Generally unwell
Distended, tender abdomen
Absent bowel sounds
Blood in stools
```
86
What is the diagnosis of necrotising enterocolitis?
Abdominal xray: diagnostic
- dilated loops of bowel
- bowel wall oedema
- pneumatosis intestinalis
- Pneumoperitoneum
- gas in portal veins
87
What is Budd-Chiari syndrome?
Obstruction of the hepatic venous outflow
88
What is the presentation of Budd-Chiari syndrome?
Sudden onset abdominal pain
Ascites
Tender hepatomegaly
89
What condition increases plasma urea levels?
Gastric ulcer
90
Relapsing coeliac disease that initially settled with gluten free diet could mean which condition?
T-cell lymphoma
91
ABG of obstructive sleep apnoea
Compensated respiratory acidosis
92
Which is the most sensitive blood test for acute pancreatitis?
Lipase
93
What is the triad for acute liver failure presentation?
Encephalitis
Coagulopathy
Jaundice
94
History of PSC and painless jaundice = which cancer?
Cholangiocarcinoma
95
Which dermatological condition is linked with IBD?
Erythema nodosum
