combined gastro

NAFLD is comprised of

NAFL

NASH

risk factors NAFLD

obesity, hypertension, type 2 dia betes and hyperlipidaemia

lab results in NAFLD

mild increases aminotransferases ± y-GT (ALT>AST), but AST>ALT as fibrosis develops

US results NAFLD

steatosis

management NAFLD

• lifestyle (exercise, calorie restriction)

• orlistat

• pioglitazone/vit E in biopsy proven NASH

• bariatric surgery in Child-Pugh A

evolution NAFLD

cirrhosis

HCC

NAFLD definition

most common chronic liver disease

accumulation fat in hepatocytes

NASH vs NAFLD

NASH - hep steatosis, liver injury, fibrosis

NAFLD - insulin-resistance (obesity, DM, etc)

clinical NAFLD

asympto

mild RUQ discomfort from hepatomegaly, fatigue, acanthosis nigricans in kids

metabolic sd criteria

3+ of:

• abd obesity (waist men >102cm, women >88cm)

• triglycerides >150mg/dL

• low HDL <40 men, <50 women

• HTN (>130/85)

• fasting glucose >100mg/dL

advanced NAFLD lab results

hyper Bi, low albumin/abnormal INR

ferrint and transferrin increased

ANA, anti-smooth m Ab

dg NASH can only be made w/

liver biopsy

etiology Celiac

multifactorial - genetic, immuno, enviro

at risk groups CD

type 1 dm, down’s, autoimmune thyroid

symptoms celiac disease

abd discomfort, weight loss, diarrhea

non-classic = chronic constipation, nausea, flatulence, vomit

non-GI symptoms CD

failure thrive/weight loss, anemia, osteoporosis, dental enamel defects, fatigue, neuropathy, arthritis, increased liver enzymes

dermatitis herpetiformis in CD

erythematous macule > urticarial papule > tense vesicles

severe pruritis, symmetrical

physical exam CD

tachycardia, bloat, rashes, easy bruising, neuropathy

investigational plan CD

CBC

vitamin and mineral levels (iron, b12, folic acid, vit D)

immuno

upper GI endo + duodenal biopsy (1 from bulb, 4 distal of papilla Vater)

when should biopsies be taken if suspicion celiac disease

if high clinical suspicion or + sero testing

before a GF diet

features of Celiac on endo

mucosal fissuring + nodular, bulb atrophy w/ visible submucosal vessels, reduction Kerckring folds

what grade Marsh we need for biopsy to dg celiac

>2

complications if untreated CD

vitamin deficiency, anemia, osteoporosis, ulcerative jejunitis, enteropathy associated T cell lymphoma, NH lymphoma, small bowel adenocarcinoma

ttt celiac disease

GF diet (no wheat, barley, rye)

evolution CD after following GF diet

6 months resolution in most patients

Ab levels fall

ttt follow up celiac disease

• measure TTG 6m after GF diet

ttt refractory CD

steroids ± immunomodulators

acute diarrhea definition

<14d

causes acute diarrhea

viral (noro/rotavirus)

e coli food poisoning

c difficile

traveler’s diarrhea (giardia, entameoba histolytica)

key investigationS for acute diarrhea

stool micro culture sensitivities (MCS) for all patients

C difficile in at risk (old, recent abts)

stool for ova/cysts/parasites in 14-30d diarrhea, MSM, ID, travelers

indication atb for acute diarrhea

severe/prolonged (>5d)

complications

systemic signs infection

extremes age, ID

blood or mucoid stool

chronic diarrhea definition

>1m

investigations for chronic diarrhea

• cbc, creat, electrolytes, thyroid fxn

• celiac screen (TTG, EMA Ab)

• fecal calprotectin

• stool MCS, C difficile toxin

If nothing → flexible sigmoidoscopy

when should patient w/ chronic diarrhea do full colonoscopy instead of flexible sigmoidoscopy

• iron deficiency anemia

• abnormal calprotectin + suspicion IBD

• older patients to screen CRC, polyps

causes chronic diarrhea

IBS

micro colitis

IBD

colonic cancer

meds, diet

constipation criterai (Rome IV)

2+ in at least 3m of:

• < 3 stools/w

• straining >25% of time

• hard stools >25% time

• incomplete evacuation, anorectal blockage >25%

• manual manoeuvres >25%

causes constipation

• low fibre

• metabolic/endocrine (DM, hypothyroidism)

• IBS

• opiates, antidepressants, antimuscarinics

• spinal cord lesions, Parkinson’s

• depression, anorexia

• GIT obstruction, CRC, Hirschprung

• rectal prolapse

indications laxatives in constipation

symptoms impact patients QoL (osmotics preferred)

which patients with constipation should be referred to specialist center for surgery

defecatory disorders (rectal prolapse, rectocele, pelvic floor dyssynergia)

scheme diagnostic investigations for patient w/ raised liver transferases

1. HCV, HBV test, autoAb, ferritin (hemochromatosis), a1anti trypsin, cerulopasm in young patients

2. US

3. transient elastography (cirrhosis), liver MRI or MRCP, echo, CT abd

4. liver biopsy, ERCP

blood tests for liver can be divided into

• liver fxn - albumin, Bi, PT time

• biochem - AST, ALT → hepatocell damage, ALP, g-GT → cholestasis; total protein

• viral markers

• hema, immno, markers fibrosis and genetics

anti-mitochondrial Ab and IgM test is for which disease

primary biliary cholangitis

anti- nuclear, smooth muscle (actin), liver/kidney microsomal antibody, IgG is for whcih disease

autoimmune hep

raised IgG4 is for which diseases

autoimmune hep, cholangiopathy, pancreatitis

a1 antitrypsin deficiency leads to

cirrhosis ± emphysema

ANCA is for which disease

primary sclerosing cholangitis

markers of liver fibrosis are for which diseases

non alcoholic fatty liver disease

HCV

when to do differentiation bw conjugated and un Bi

congenital disorders of bilirubin metabolism or to exclude haemolysis

vit k role in doing PT time in patient

give vit K IV first

vit k defieincy in biliary obstruction

ALT:AST ratio in viral hep, alcoholic liver disease + steotohep, liver disease w/o cirrhosis

viral hep ALT:AST <1, >1 if cirrhosis

alcoholic liver disease AST>ALT

liver disease w/o cirrhosis (alcohol, obesity), steatohep ALT:AST <1

raised ALP means

cholestatic jaundice

metastases liver

cirrhosis

g-GT elevation means

alcohol

fatty liver disease

cholestasis (rises w/ ALP)

thrombocytopenia is a common finding in

cirrhosis, alcohol

macrocytic RBCs are in

alcohol

markers of liver fibrosis

APRI

fibrotest

enhanced liver fibrosis test

scintiscan indications

acute cholecystitis

jaundice from biliary atresia or hep in neonate

hepatic venous cannulation allows what dg

budd-chiari

indications liver biopsy

• mutliple parenchymal liver diseases

• abnormal liver tests, hepatomegaly, fever of unknown etiology

• anormalities on imaging

• drug related liver disease

• post liver transplant

• prognosis - staging liver disease, hemochromatosis, alchol induced liver disease

COs to liver biopsy

• >1.5 INR

• platelets <60 ×10^9/L

• ascites

• extrahep cholestasis

patho cirrhosis

activation hepatic stelate cells, stimualted by activated kupffer cells

defenestration and capillarization of liver sinusoidal endothelial cells

morpho categorization cirrhosis

• micronodular - noduels <3mm

• macronodular - >3mm

• mixed

in patient w/ ascites, ldh and glucose should be tested if

secondary peritonitis suspected

complications spironolactone vs furosemide

spirono - hyperka+

furosemide - renal fxn lowers, weight loss, orthostatis symptoms

currhosis defined by

fibrosis

conversion normal architecture to abnormal nodules

etiologies cirrhosis based on morpho classification

• micro - alcohol, hemochromatosis, biliary obstruction

• macro - hcv, hbv, a1 antitrypsin

clasification cirrhosis based on clinical stage

• compensated - perform vital fxns, no clinical

  • decomp - sufficient organ damage, liver can’t perform fxns, fxnal decline rapid

general clinical cirrosis

• fatigue, anorexia, malaise, weight loss, m wasting, fever

gi clinical cirrhosis

• eso/gastro/duod/rectal/stomal varices

• portal hypertensive gastropathy/colopathy

• gi bleed

• parotid enlarged

• diarrhea

  • cholelithiasis

hema clinical cirrhosis

anemia, hemolytic

folate deficienc

splenomegaly → pancytopenia

thrombocytopenia

leukopenia

impaired caog, DIC

hemosiderosis

pul clinical cirrhosis

hepatix hydrothorax r side

hepatopul sd

cardiac clinical cirrhosis

hyperdynamic circ

renal clinical cirrhosis

secondary hyperald, renal tubular acidosis, hepatorenal sd

endocrin clincial cirrhosis

hypogonadism, feminization, dm

neuro clinical cirrhosis

hepatic encephalopathy

per neuropathy

musculoskeletal clinical cirrhosis

reduct lean m mass, hypertrophic osteoarthropathy, synovitis, clubbing

derma clinical cirrhosis

spider telangiectases, palmar erythema, dupuytrens contractures, jaundice

gold standard dg cirrhosis

liver biopsy

physical exam cirrhosis

• spider telangiectases, palmar erythema, dupuytrens contracture, gynecomastia

• portal htn - ascites, splenomegaly, caput medusa

• hepatic encephalopathy - confusion, asterixis, fetor hepaticus

• jaundice, bilat parotid enlarged, scanty chest and axillary hair

lab tests of hepatocell necrosis in cirrhosis results

AST:ALT <1 if non-alcoholic cause chronic hep

reverse in cirrhosis

lab tests cholestasis in cirrhosis

AKP, Bi, GGTP, 5’ nucleotidasw

tests of synthetic fxn in cirrhosis

albumin, prothrombin time

what to test for hemochromatosis cause cirrhosis

HFE mutation

test for Wilson’s cause of cirrhosis

ceruloplasmin

serum + urinary copper

autoAb in cirrhosis

ANA, AMA, LKM

SMA (autoimmune hep, primary biliary cirrhosis)

abd US in cirrhosis can detect

ascites, biliary dilatation, screening HCC

nodularity, irregularity, increased echo, atrophy

indications CT cirrhosis

dg hemochromatosis

EGD indications cirrhosis

screen portal hypertensive gastropathy, GI varices

ttt hemochromatosis

phlebotomy

venesection

ttt wilson

d-penicillamine

ttt hbv causing cirrhosis

lamivudine, adefovir dipivoxil (IF avoided)

ttt autoimmune hep

steroids

ttt primary biliary cirrhosis

urseodeoxycholic acid

steroids

fat soluble vitamins (a,d,k)

biphosphonates for osteoporosis

screening HCC in cirrhotic patient

US and serum AFP every 6m

vax against hep a and b

severity cirrhosis classified w/

child-pugh score - Bi, albumin, INR, ascites, encepalopathy

child pugh score results

A - compensated, favourable prognosis

C - high risk death

score used in allocation liver transplants, predicting mortality within 3m of surgery in patients who had TIPS procedure

MELD

portal htn definition

>12mmHG portal v p

causes portal htn

prehepatic PHT - portal/splenic v thrombosis

hepatic - schistosomiasis, cirrhosis, alcoholic hep, budd-chiari

posthep - IVC webs, thrombosis, cardiac, pul htn

clinical consequences portal htn

• varices (gastroesoph, anorectal, retroperitoneal, stomal)

• portal hypertensive gastropathy and colopathy

• caput medusae

• ascites, hepatic hydrothorax

• congestive splenomegaly

  • hepatic encephalopathy