Countdown to finals: Hepatology and Gastroenterology. Jamie Davis Doug Sharpe

Transcription

1 Countdown to finals: Hepatology and Gastroenterology Jamie Davis Doug Sharpe

2 Clinical Case 1 72 year old male presents to A&E generally unwell, sweaty, clammy, pale. Hx given by ambulance crew of dark vomit. RR sats 94% RA HR 91 BP 105/64 AVPU

3 Key points ABC approach High flow 02 Access & Bloods Fluid resuscitate RR sats 97% RA HR 85 BP 123/85 AVPU

4 Presenting Complaint 3 hour history of 4-5 dark vomits Felt dizzy and collapsed at home NEAS called. PMH: HTN, IHD (NSTEMI), Gout, T2DM

5 Drug History Atorvastatin 80mg ON Bisoprolol 2.5mg OD Clopidogrel 75mg OD Codeine 30mg QDS Gliclazide 80mg BD Metformin 1g OD Indomethacin 50mg QDS Ramipril 2.5mg OD Tamsulosin 400mcg OD

6 Abdo Exam- Signs

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8 Management ABC approach Extent of blood loss Examination- PR IV access Bloods: FBC, clotting, U & E, Glu, Group & Save, PT, LFT CXR Cross-match 4 units if acute bleeding or haemodynamic compromise Correct hypovolaemia

9 Monitoring BP and HR hourly Aim urine output >30 mls per hour Observed area

10 Risk Stratification

11 Indications for Urgent Endoscopy Elderly patients (>70years) with co-morbidity and active bleeding Any haemodynamically unstable patients (after resuscitation) Known or suspected varices Re-bleeding If an endoscopy would alter your immediate management and is safe i.e the patient has been given volume resuscitation

12 Ongoing Care NBM High dose PPI for 72 hours Patients with known or suspected portal hypertension should receive: Terlipressin 2mg iv qds Cefuroxime 750mg iv tds Vitamin K 10mg iv for 3 days

13 Causes of Upper GI bleeds Peptic ulcer Varices Mallory weiss tear GI malignancy Boerhaaves syndrome

14 DU/GU Duodenal ulcers most common Risk factors: h.pylori Drugs Epigastric pain before meals, relieved by eating Gastric ulcers Elderly, lesser curve of stomach Endoscopy to exclude malignancy Treatment Avoid foods, stop smoking, PPI/H2RA, h.pylori eradication

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16 Varices Portal hypertension causes dilated collateral veins, lower oesophagus. Suspect cirrhosis if signs of liver disease High mortality

17 Clinical Case 2 23 year old female student presents to GP with 2/3 months abdominal pain and loose stool

18 History Key Points Duration/onset symptoms Type of stool Associated symptoms: rash, ulcers, fatigue Weight loss Previous bowel habit PMH: inflammatory conditions SH: smoking, problems at home

19 Rash Further investigations?

20 Bloods Hb 85 MCV 76 Folate deficiency Vit B12 deficiency Thromboycytopenia Neutropenia Howell-Jolly bodies.

21 Coeliac Disease Inability to absorb gliadin, alcohol soluble fraction of gluten. Wide variation in symptoms and signs Gluten: rye, wheat and barley. 1/100 people in UK All ages, all ethnic groups Familial tendancy

22 Extra-Intestinal Manifestations Anaemia Dermatitis Herpetiformis Neurological symptoms Osteopenia and osteoporosis from calcium and vitamin D malabsorption Hyposplenism associated with a number of autoimmune disorders including DM type 1, hypothyroidism and primary biliary cirrhosis.

23 Coeliac Investigations Antiendomysial antibodies of immunoglobulin IgA Upper endoscopy with biopsy of the duodenum Management Gluten free diet

24 Crohns Chronic inflammatory bowel disease of unknown aetiology that can affect any part of the GI tract from the mouth to the anus The clinical course is characterised by exacerbations and remissions. There are two age peaks: and years.

25 UC Idiopathic chronic inflammatory disease of the colon that follows a course of relapse and remission. Ulcerative Colitis is the most common type of IBD Autoimmune condition triggered by colonic bacteria causing inflammation in the gastrointestinal tract Peak ages & Equal in men/women

26 Risk Factors-IBD Genetics In Crohn s 15-20% will have a family member affected with IBD - In UC a family history is present in around 25-40% Smoking increases the risk 3-4 fold and smokers tend to have more aggressive disease in Crohn s - decreases the risk in UC Others: - diet - drugs (NSAIDs use) - intercurrent infections (Upper respiratory tract infections)

27 IBD: Crohns vs UC Crohns Abdominal pain Diarrhoea Blood/ mucus in stool Increased urgency Fatigue Weight loss Anorexia Perirectal pain Arthritis Growth Failure UC Colicky Abdominal Pain Diarrhoea Blood/ mucus in stool Increased Urgency Tenesmus Malaise Fever Weight loss Severe dehydration

28 IBD: Crohns vs UC

29 Complications of Crohns Abscesses Fistulae Sinus tracts Strictures Adhesions Colon cancer

30 IBD: CD vs UC

31 Extra intestinal manifestations: IBD

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34 Investigations Bloods Stool samples Tests for Antibodies to the yeast Saccharomyces cerevisiae (ie anti- S. cerevisiae antibodies (ASCA) or Perinuclear antineutrophil cytoplasmic antibody (p-anca) to differentiate between the two Ileocolonoscopy (and biopsies) defines the presence and severity of morphological recurrence and predicts the clinical course (CD) Flexible sigmoidoscopy confirm UC Upper GI endoscopy differentiate between Crohns and peptic ulcer disease AXR useful if you suspect obstruction or perforation If there is evidence of disease further investigations e.g. Barium Contrast Studies, CT, MRI and abdominal US can be done.

35 Management

36 Stomas

37 Case 3 65 year old man referred to MAU with a short history of becoming off colour GP is?jaundiced

38 Key points in Hx Duration/progression Pain or associated Sx?Pyrexial Pale Stools/Dark urine Social alcohol intake, foreign travel, drug abuse Drug Hx recreational + prescribed Hx of weight loss

39 Background: 3 day Hx of worsening discolouration No Hx of any pain, fever or recent altered meds Moderate alcohol intake (12 units per week) C/O weight loss, pale stools for 3/7 PMH HTN, Diabetes Examination: Patient well, no signs of stigmata of CLD, NEWS 0.

40 Investigations FBC - Hb: 142 WCC: 8 MCV: 98 U&E - Na+ : 138 K+ : 4.5 Urea: 3.2 Creat: 51 LFT s - Bilirubin: 32 AST: 87 ALT: 92 ALP:350 Other tests to consider: Coag, Hepatitis screen, ferritin, paracetamol assay

41 Types of Jaundice Pre-hepatic Jaundice: Overproduction of bilirubin - haemolysis Decreased uptake (Rifamipcin, Gilberts Syndrome) Impaired conjugation AST, ALP, AST - Normal

42 Types of Jaundice Intra-hepatic Jaundice: Impaired uptake, conjugation or excretion of bilirubin Reflects hepatocellular damage AST:ALT raised

43 Types of Jaundice Post-hepatic Jaundice: Often called obstructive Blockage in biliary tree causing reduced drainage. ALP increased (greater increase in ALP than AST/ALT)

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45 Imaging

46 Case 2 65 year old man referred to MAU with a short history of becoming off colour GP is?jaundiced Background: HTN, Diabetes US report from 2012 shows marked liver cirrhosis Patient known history of alcohol XS Examination: Visible jaundice, gross ascites with fluid thrill/shifting dullness

47 Definitions Decompensation of cirrhosis Underlying cirrhosis (usually with portal hypertension) Deterioration in function usually due to a precipitant Acute alcoholic hepatitis Steatohepatitis (fat + hepatocellular injury + inflammation +/ fibrosis) Presents with Jaundice (can get ascites portal hypertension etc), Reversible if patients are non cirrhotic Maddreys Discriminant

48 Decompensated Cirrhosis Medical emergency roughly 10% mortality Needs prompt management as at risk of: Infections AKI Alcohol withdrawal GI bleeding

49 Decompensated Cirrhosis Medical emergency roughly 10% mortality Needs prompt management as at risk of: Infections Cultures blood and urine If septic treat suspected source as trust policy All patients need an ascitic tap» If neutrophils > 0.25 consider SBP» Will need IV co-amox

50 Decompensated Cirrhosis Medical emergency roughly 10% mortality Needs prompt management as at risk of: AKI At risk of AKI and hyponatraemia Fluid resuscitate to ensure U.O >0.5ml/kg/hr Stop diuretics + nephrotoxics

51 Decompensated Cirrhosis Medical emergency roughly 10% mortality Needs prompt management as at risk of: Alcohol withdrawal Sx;anxiety, tremors, confusion, seizures Management: Commence CIWA Chlordiazepoxide 50mg hourly PRN IV Pabrinex (2pairs TDS)

52 Decompensated Cirrhosis Medical emergency roughly 10% mortality Needs prompt management as at risk of: GI bleeding Risk of variceal bleeding Important to check coag and PT : if prolonged will need 10mg IV vit K (if over 20s 2 units FFP) Transfuse Hb <70g/L platelets <50