Week 13 - GI & Liver

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mewinstanley@googlemail.com
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131680
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Week 13 - GI & Liver
Updated:
2012-01-31 07:35:37
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GI Liver
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GI & lver pathology, LFTs IBD etc
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  1. Give 3 bacterial causes of infectious diarrhoea?
    • Campylobacter Jejuni
    • Giardia Lambla
    • Shigella
    • C Diff
    • etc
  2. What causes Giardiasis?
    What are the CF?
    How is it Tx?
    Protozoan infection → Giardia Lambla

    CF → Diarrhoea, malabsorption, weightloss, asymptomatic [Immunodeficiency]

    Tx → Metronidazole
  3. What is Whipples Disease?
    What are the CF?
    What are the histopathological findings?
    T Whipplei infection

    CF → middle aged men, weight loss, arthralgia, diarrhoea, abdo pain [?CNS]

    H/P → small bowel biopsy → PAS +ve macrophages, foamy histocytes
  4. What is Coeliac Disease?
    What are the CF?
    How is it Tx?
    Gluten Sensitive villous Atrophy

    CF → Steatorrhoea, bloating, abdo pain, fatigue, weakness, IDA

    Tx → Gluten free diet [exclude wheat, rye & barley]
  5. What is the underlying pathophysiology behind Coeliac Disease?
    T cell mediated hypersensitivity [^^intraepithelial lymphocytes] HLA DQ2

    Villous atrophy → decreased enterocyte lifespan

    Crypt hyperplasia → ^^num of cells

    Risk of developing T cell lymphoma of small bowel
  6. What is tropical sprue?
    *dear god I hope this doesnt come up*

    • Infectious coeliac disease, ridiculously uncommon
    • Pc → malabsorption
  7. Ouline the CF of ulcerative colitis [UC]?
    Gradual onset chronic bloody diarrhoea [>4daily]

    • 1/1000 pop
    • Peak 15-25yo
  8. Outline the pathology of UC?
    • Pathology
    • Chronic inflammation of large intestine [Rectum always involved]
    • Confined to mucosa & submucosa [no granulomas]
    • Branching of crypts [^^mucosal division]
    • Crypt abscesses [^^neutrophils]
  9. Outline the CF of Crohns Disease?
    Can occur anywhere from mouth to anus

    • 3/1000 pop
    • peak 15-35yo

    • CF
    • cramping abdo pain
    • mouth ulcers
    • fever
    • weight loss
    • fatigue
    • diarrhoea
    • rectal bleeding
  10. Outline the pathological features of Crohns?
    Assoc w defective innate immune resp [abn resp to commensals]

    • Any part of gut from mouth to anus
    • Transmural inflammation → fissures [can form fistulas]
    • Granulomas [Diagnostic] no caseous necrosis

    Stenosis, inflammation & fistula formation
  11. What features of a Hx indicate inflammatory bowel disease? [IBD]
    • Stool → frequency, consistency, urgency, blood?
    • Abdo pain, malaise
    • Fever
    • Extraintestinal symptoms [joints, eyes, skin]
    • Travel
    • FH
    • Smoking
  12. What investigations would you do for suspected IBD?
    • Bloods → FBC [anaemia & ^^PLTs], ^^ESR & CRP
    • U+Es, LFTs [sclerosing cholangitis → Crohns complication]
    • Stool culture & C diff toxin
    • Faecal Calprotectin → WBC marker → active disease
    • AXR → Dilation = bad
    • Colonoscopy → not in active → ^^perfs
  13. What are the Tx options for IBD?

    Acute exacerbations?
    Aminosalicylates [Sulphosalazine] → maintain remission in UC, no use in Crohns

    Thiopurines [Azathioprine] → induce remission & maintenance in UC & Crohns [purine antimetabolite, t cell apoptosis]

    Methotrexate → folate scavenger, anti-metabolite, good in crohns, poor in UC

    Biologics [Infliximab] → Anti-TNF monoclonal Ab

    Steroids → in acute exacerbations
  14. What is diverticular disease?
    What are the common CF?
    • Diverticula = mucosal outpouchings thru musclaris externa
    • Usually sigmoid colon [Low roughage diet]

    • CF
    • LIF pain
    • ?perforation → abscess/faecal peritonitis
    • Fistulate → bladder/bowel
    • Bleeding
    • Bowel obstruction
  15. Describe the Pc of Ischaemia affecting the gut?
    Acute → sudden onset abdo pain, blood PR, Shock

    Chronic → abdominal angina [pain on eating] weight loss
  16. Give 3 causes of Ischaemic gut?
    • Mesenteric A/V thrombosis
    • Mesenteric artery embolus
    • Hypotension [Watershed infarction i.e. area between 2 large arteries] → not enough blood to perf
    • Strangulated Hernia
    • Volvulus
  17. Outline the anatomy and histology of the Oesophagus?
    • non keratinising stratified squamous epitherlium
    • Upper 1/3 = skeletal muscle
    • Lower 1/3 = Smooth muscle

    • 4 Layers
    • Mucosa → strat squam epithel
    • Submucosa
    • Muscularis propria
    • Serosa
  18. What is Barretts oesophagus?
    What are the RF?
    What are the CF?
    • Glandular metaplasia as a response to mucosal injury
    • 3 histological types → like cardia of stomach, like body of stomach, intestinal w goblet cells
    • LGD =Low grade dysplasia

    • CF
    • Assoc w adenocarcinoma
    • Ulceration
    • Benign strictures
    • LGD → cells polarised, nuclei stratified
    • HGD → lost polarity, abn mitoses, necrosis, prominent nucleoli
  19. What are the causes of acute gastritis?
    • Alcohol
    • NSAIDs
    • Trauma
  20. What are the causes of chronic Gastritis?
    [ABC]
    Autoimmune → Atrophic, A-Ab against parietal cells & extrinsic factor

    Bacterial → H. Pylori

    Chemical → iron tablets alcohol
  21. Outline the pathological features of H. Pylori infection?
    Colonisation of gastrric mucosa → chronic active inflammation

    Antral predominant → hypergastrinaemia & duodenal ulceration

    Pangastritis → hypochlorhydia, multifocal atrophic gastritis

    • Duodenal ulceration → 1st part of duodenum,
    • posterior → erode into gastroduodenal art [bleeding]
    • Anterior → peritoneum [peritonitis]
  22. Outline the anatomy & histology of the small intestine
    • Small calibre, 1.5m length
    • Duodenum = retroperitoneal
    • Jejunum & Ileum = Peritoneal

    • 5 Layers
    • Mucosa → villi & crypts
    • Muscularis mucosae
    • Sub-mucosa
    • Muscularis propria
    • Subserosal fat/ Adventitia
  23. Outline the anatomy & histology of the Large intestine?
    Caecum → ascending colon → hepatic flexure → transverse colon → splenic flexure → descending colon → sigmoid colon
  24. DDx for colon Ca?
    Majority → adenocarcinoma of glandular epithelium

    Rarer → Small cell Ca, SCC, Mets, adenosquamous Ca
  25. Outline the pathogenesis of colon Adenocarcinoma?
    • Adenoma-Carcinoma sequence
    • Dysplastic lesion [adenoma]
    • progress to carcinoma

    • Adenoma = tunular or villous
    • invasion thru stalk
  26. What features of an adenoma indicate malignant potential?
    • Size >10mm
    • Number >5
    • Villous Morphology
    • High grade dysplasia
  27. What are the RF for colon ca?
    • Adenomas [large/ numerous]
    • IBD [esp UC]
    • FH → FAP/ HNPCC
    • Other Ca
    • >50yo

    • FAP → >30 adenomas, polyps/flat, AD inherit
    • HNPCC → hereditary non-polyposis colon Ca → adenoma-carcinoma faster
  28. What is Dukes staging?
    Give the 5year survival associated w each stage & any caveats.
    • A → direct invasion, not past MP → 93%
    • B → Direct, beyond MP → 77%
    • C → Lymph invasion, no mets → 47%
    • C1 = clear apical node
    • C2 = apical node fucked
    • D → Distal mets → 6%

    • Caveats
    • Vascular invasion in B = poor prognosis
    • ^ local recurrance? → perineural invasion/ unclear surgical margin
  29. What is hepatitis A?
    How is it transmitted?
    • Hep A
    • ssRNA, unenveloped hepatovirus
    • causes acute hepatitis [never chronic]

    • TMx
    • Faecal-oral spread
  30. What is Hep B?
    How does it cause hepatitis?
    How is it spread?
    • Hep B
    • dsDNA hepadnavirus
    • causes acute and chronic hepatitis
    • Chronic if asymptomatic infection [young]

    • Pathology
    • CD8+ T cell mediated hepatocyte necrosis

    • TMx
    • Contaminated blood/blood products
    • eAg → ^^infective
    • sAg → chronic carrier
  31. What is hepatitis C?
    How is it transmitted?
    • Hep C
    • ssRNA enveloped Flavivirus
    • 6major genotypes
    • Chronic infection → immune resp is not protective [RNA+ve Pts]

    • TMx
    • IVDU, Blood & blood products
  32. What are the pathological features of alcoholic Liver disease?
    • Liver cell necrosis [Fatty ghosts]
    • Mallory bodies → aggregations of intermediate filament
    • Neutrophils
    • Fibrosis
  33. Define Cirrhosis?
    • Irreversible destruction of liver architecture
    • Assoc w fibrosis & nodule formation [following hepatocyte necrosis]
    • Functionally less efficient than normal liver
  34. Give 3 intrahepatic causes of obstructive biliary disease?
    • Viral hepatitis
    • Alcohol
    • Cirrhosis
    • Primary biliary cirrhosis [PBC]
    • Primary Sclerosing Cholangitis [PSC]
  35. Outline the CF & pathology of Primary Biliary Cirrhosis?
    • CF
    • Cholestatic Pc [icterus, itch, greasy noxious stools]
    • Middle aged women, anti-mitochondrial Ab +ve

    • Patho
    • Chronic granulomatous prtal inflammation & scarring
    • Destrction of intrahepatic bile ducts
  36. Outline the CF & Pathology of Primary sclerosing cholangitis?
    • PSC
    • CF
    • middle aged men, anti-mitochondrial -ve
    • itching, icterus & cholestasis

    • Patho
    • Inflammation, obliterative fibrosis
    • segmental dilation of intra & extrahepatic ducts
    • onion ring fibrosis
  37. Give 3 extrahepatic causes of obstructive biliary disease?
    • Gallstones
    • tumour of pancreatic head
    • external compression of common bile duct [inflamm/ malignancy]
  38. What LFT results would you expect in the Pt w hepatocellular disease? [acute hepatitis]
    • ^Bilirubin
    • ^AST
    • +/= Alk Phos
    • Low Albumin
  39. What would the LFTs be in Cholestasis?
    • ^Bilirubin
    • ^^GGT
    • ^^Alk Phos
    • ^AST
  40. You susupec your Pt is drinking to much alchol, what would you test? What would the results be?
    • ^MCV
    • ^GGT
    • Signs of hepatocellular damage [^Bilirubin, ^AST]
  41. A mad alky Pt visits your practice, you suspect Alcoholic Liver disease. What would the LFTs be?
    • ^^AST
    • ^ALT
    • AST:ALT >2
    • ^^MCV
  42. You suspect Hep C, what would the LFTs be?
    • +/= AST
    • ^^ALT
    • AST:ALT <1 [may reverse if cirrhosis]
    • ~MCV
  43. Draw the biliary system?
  44. What are gallstones made of?
    What factors create lithogenic bile?
    Gallstones → cholesterol/ bilirubin

    • Lithogenic bile
    • ^^cholesterol secretion
    • Decreased bile salt formation
    • Excessive bilirubin [haemolytic anaemia] → precipitate
  45. What are the RF for gallstones?
    • Fair
    • Fat
    • Forty
    • Female
    • Fertile
  46. Pt presents w acute cholecystitis
    -O/E?
    -Blood results?
    -Patho?
    -Outcome?
    O/E → severe RUQ pain, tenderness & fever

    Bloods → ^WCC, normal serum amylase

    Patho → stone obstructing cystic duct, supersaturation of bile & chmical irritation

    Outcome → spontaneuous resolution, empyema, gangrene, rupture
  47. Pt Presents with painless icterus, whats they got?
    Most likely Ca of pancreatic head

    • Ductal adenocarcinoma
    • perineural invasion → virtually incurable
    • Tx w whipples resection
    • remove duodenum, distal stomach & head of pancreas at the level of the sup mesenteric vesses
  48. For acute pancreatitis
    -RF
    -Pc
    -Pathology
    -Conseuquences
    • RF
    • Gallstones, ^^alcohol, Post-ERCP, hypercalcaemia

    Pc → severe upper abdo pain, fever ^^WCC, ^^Serum amylase

    Pathology → gallstone in ampulla of vater causes bile reflux down pancreatic duct → chemical irritation

    Consequences → Pseudocyst, abscess formation
  49. What sorta tumour did steve jobs have?
    • Pancreatic endocrine tumour
    • [Not as bad as ductal adenocaricnoma but still pretty shit]

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