Countdown to finals: Hepatology and Gastroenterology

Jamie Davis

Doug Sharpe

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 28

• 02 sats 94% RA

• HR 91

• BP 105/64

• AVPU

Key points

• ABC approach

• High flow 02

• Access & Bloods

• Fluid resuscitate

• RR 19

• 02 sats 97% RA

• HR 85

• BP 123/85

• AVPU

Presenting Complaint

• 3 hour history of 4-5 dark vomits

• Felt dizzy and collapsed at home

• NEAS called.

• PMH: HTN, IHD (NSTEMI), Gout, T2DM

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

Abdo Exam- Signs

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

Monitoring

• BP and HR hourly

• Aim urine output >30 mls per hour

• Observed area

Risk Stratification

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

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

Causes of Upper GI bleeds

• Peptic ulcer

• Varices

• Mallory weiss tear

• GI malignancy

• Boerhaaves syndrome

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

Varices

• Portal hypertension causes dilated collateral veins, lower oesophagus.

• Suspect cirrhosis if signs of liver disease

• High mortality

Clinical Case 2

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

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

Rash

Further investigations?

Bloods

• Hb 85 MCV 76

• Folate deficiency

• Vit B12 deficiency

• Thromboycytopenia

• Neutropenia

• Howell-Jolly bodies.

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

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.

Coeliac

• Investigations

– Antiendomysial antibodies of immunoglobulin IgA

– Upper endoscopy with biopsy of the duodenum

• Management

– Gluten free diet

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: 15-30 and 60-80 years.

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 15-25 & 55-65 • Equal in men/women

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)

IBD: Crohns vs UC

Abdominal pain

Diarrhoea

Blood/ mucus in stool

Increased urgency

Fatigue

Weight loss

Anorexia

Perirectal pain

Arthritis

Growth Failure

Crohns

Colicky Abdominal Pain

Diarrhoea

Blood/ mucus in stool

Increased Urgency

Tenesmus

Malaise

Fever

Weight loss

Severe dehydration

UC

IBD: Crohns vs UC

Complications of Crohns

Abscesses

Fistulae

Sinus tracts

Strictures

Adhesions

Colon cancer

IBD: CD vs UC

Extra intestinal manifestations: IBD

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.

Management

Stomas

Case 3

• 65 year old man referred to MAU with a short history of becoming “off colour” – GP is ?jaundiced

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

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.

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

Types of Jaundice

Pre-hepatic Jaundice: Overproduction of bilirubin - haemolysis

Decreased uptake – (Rifamipcin, Gilberts Syndrome)

Impaired conjugation AST, ALP, AST - Normal

Types of Jaundice

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

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)

Imaging

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

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

Decompensated Cirrhosis

• Medical emergency – roughly 10% mortality

• Needs prompt management as at risk of: • Infections

• AKI

• Alcohol withdrawal

• GI bleeding

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

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

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)

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