Gastro Intestinal Tract rapid revision.pptx

Git

1. GIT RAPID REVISION

2. A 73-year-old man with a history of alcoholism and hepatitis C presents with lethargy and hypersomnia . He has been sleeping all day, and not taking any of his medications. On examination, the patient has ascites , palmar erythema , edema, and spider telangiectasias . He also has a flapping motions of his hands when dorsifiexed . Laboratory test results reveal a normal ammonia level. What is the most likely diagnosis? What is the best initial therapy? What is the best therapy to reduce recurrences or improve quality of life?

3. Toxic substances E arliest clinical manifestation E arliest examination finding M ost relevant investigation B est initial therapy Best therapy

4. Toxic Substances

5. Most likely diagnosis: Hepatic encephalopathy (HE).

6. Earliest clinical manifestation Earliest examination finding

7. Best initial therapy:

8. Best therapy:

9. 9

10. Which of the following is not a precipitating factor for hepatic encephalopathy in patients with chronic liver disease - a) Hypokalemia b) Hyponatremia c) Hypoxia d) Metabolic acidosis 10

11. Precipita ting factors

12. 12

13. 13

14. 14

15. 15

16. 16

17. 17

18. Triphasic waveforms in hepatic encephalopathy occurs in stage of - a) Coma stage-IV b) Confusion stage-I c) Deep coma stage-V d) Drowsiness stage-II 18

19. A symmetric high-voltage, triphasic slow wave pattern is seen on EEG in the following a) Hepatic encephalopathy b) Uremic encephalopathy c) Hypoxic encephalopathy d) Hypercarbic encephalopathy 19

20. While the typical triphasic waves are common in hepatic encephalopathy . Atypical triphasic waves occur in other metabolic encephalopathies such as – • Uremia • Hypothyroidism • Hypercalcemia • Hyponatremia • Hypoglycemia • Lithium intoxication 20

21. 21

22. A 47-year-old man with chronic alcoholism presents with abdominal pain and fever. He has had multiple admissions for variceal bleeds and ascites requiring large volume paracentesis . The pain is diffuse and has been getting worse since yesterday. He also has fever, chills, and rigors. On examination, he has diffuse tenderness over the abdomen with shifting dullness and a fluid wave. What is the most common organisms? E.Coli Staphylococcus S.typhi Legionella

23. A 47-year-old man with chronic alcoholism presents with abdominal pain and fever. He has had multiple admissions for variceal bleeds and ascites requiring large volume paracentesis . The pain is diffuse and has been getting worse since yesterday. He also has fever, chills, and rigors. On examination, he has diffuse tenderness over the abdomen with shifting dullness and a fluid wave. • What is the most accurate diagnostic test? • What is the best therapy? • What are the most common organisms?

24. Spontaneous bacterial peritonitis (SBP):- Most common Organism C linical features A ccurate diagnostic test Antibiotic & P rophy lactic antibiotic A ntibiotic in liver failure

25. Assessment of liver severity MELD score Discriminant function score Child pugh scoring 25

26. The Model for End-stage Liver Disese (MELD) is a prospectively developed and validated chronic liver disease severity scoring system that uses a patient’s laboratory values for – Serum bilirubin Serum creatinine The international normalized ratio (INR) for prothrombin time to predict three month survival. 26

27. MELD = 3.78×ln[serum bilirubin (mg/ dL )] + 11.2×ln[INR] + 9.57×ln[serum creatinine (mg/ dL )] + 6.43 40 or more — 71.3% mortality 30–39 — 52.6% mortality <9 — 1.9% mortality 27

28. 28

29. 29

30. 30

31. A 49-year-old alcoholic man presents with hematemesis that began 2 hours ago. He was intubated for airway protection. His past medical history is significant for Hepatitis C that has not been treated. He consumes 1 bottle of whiskey a day. He is tachycardic to 140, with a blood pressure of 99/ 68 mm Hg. Dried blood is seen in the oral cavity and palmar erythema is present. Telangiectasias are visible on the thorax. AST:ALT is 100:56, prothrombin time is 24 seconds, and hemoglobin is 6.0 g/ dL . What is the next best step in management? I VF & blood products Octreotide Endo scopic band ligation TIPS

32. A 49-year-old alcoholic man presents with hematemesis that began 2 hours ago. He was intubated for airway protection. His past medical history is significant for Hepatitis C that has not been treated. He consumes 1 bottle of whiskey a day. He is tachycardic to 140, with a blood pressure of 99/ 68 mm Hg. Dried blood is seen in the oral cavity and palmar erythema is present. Telangiectasias are visible on the thorax. AST:ALT is 100:56, prothrombin time is 24 seconds, and hemoglobin is 6.0 g/ dL . • What is the most likely diagnosis? • What is the next best step in management? • What is the best initial therapy? • What is the most appropriate and paramount therapy? • What if bleeding cannot be controlled? • What must the patient be discharged on if they survive?

33. Most likely diagnosis: Acute upper GI bleed likely secondary to variceal bleeding. Varices are dilated submucosal veins in the lower third of the esophagus that have become engorged due to portal hypertension most commonly from cirrhosis.

34. Diagnosis N ext best step B est initial therapy Most appropriate therapy H ow to control bleeding D ischarge advice

35. 35

36. 36

37. Next best step in management:

38. Best initial therapy:

39. Upper G astrointestinal bleed Peptic ulcer disease Gastrointestinal erosion Esophagitis E sophageal v arices Mallory We iss tear Vascular malformations Acute pharmacological therapy IV OCTREOTIDE TERLIPRESSIN Continuous intravenous infusion of octreotide (100 mcg bolus, followed by 50–100 mcg/h) reduces splanchnic blood flow and portal blood pressures and is effective in the initial control of bleeding related to portal hypertension. It is administered promptly to all patients with active upper gastrointestinal bleeding and evidence of liver disease or portal hypertension until the source of bleeding can be determined by endoscopy. In countries where it is available, terlipressin may be preferred to octreotide for the treatment of bleeding related to portal hypertension because of its sustained reduction of portal and variceal pressures and its proven reduction in mortality.

40. Most appropriate and paramount therapy:

41. If bleeding cannot be controlled:

42. After discharge treatment:

43. TIPS

44. What should be the abdominal pressure in abdominal compartment syndrome ? 10mmHG 15mmHG 20mmHG 25mmHG

45. Ascitis USG abdomen Puddle sign Shifting dullness Fluid thrill Intraabdominal HTN Compartment syndrome Tense Ascitis

46. 50 100 500 Massive Ascitis

47. Hepatorenal syndrome

48. Which of the following drugs should be avoided in hepatorenal syndrome ? Octreotide Terlipressin Diuretics N orepinephrine

49. Hepatorenal syndrome occurs in up to 10% of patients with advanced cirrhosis and ascites. Definition Criteria PPT Factors Pathogenesis HRS 1 HRS 2 Rx Ultimate Rx

50. Hepatorenal syndrome is renal failure with normal tubular function in a patient with chronic liver disease in the absence of an identifiable cause of renal failure. Kidneys are histologically normal and the renal failure is functional. Such kidneys have been successfully transplanted and function well.

51. Hepatopulmonary Syndrome

52. Wh y there is pla typnea in hepato pulmonary syndrome ? Due to vascular d ilatations at the base of the lung Due to vascular d ilatations at the apex of the lung Due to pulmonary restriction caused by massive ascites Due to decreased venous return

53. Autoimmune Hepatitis

54. 59

55. 60 ANA (Antinuclear Antibodies); anti- ASGPR (antibody to asialoglycoprotein receptor); anti LC1 (antibody to Liver cytosol type 1); anti- LKM1 (antibody to soluble liver kidney microsome Type 1); anti, SLA (antibody to soluble liver antigen

56. Laboratory Findings Serum aminotransferase levels may be greater than 1000 units/L , and the T otal bilirubin is usually increased.

57. Characteristic Autoantibodies for Autoimmune Hepatitis Antinuclear Antibodies (ANA) Anti LKM Antibodies (Anti- Liver-kidney microscomal antibodies) Anti- SLA (Antibodies against Soluble Liver Antigens) Anti- SMA (Antibodies against smooth muscle Antigens 62

58. Rx 63

59. VIRAL HEPATITIS

60. All these human hepatitis viruses are RNA viruses, except hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV),

61. Almost all cases of acute viral hepatitis are caused by one of five viral agents: hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), HBV-associated delta agent or hepatitis D virus (HDV), and hepatitis E virus (HEV). 66

62. All these human hepatitis viruses causes hepatitis except? hepatitis G virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV),

63. Other transfusion-transmitted agents (e.g., " hepatitis G" virus and "TT" virus , have been identified but do not cause hepatitis ). All these human hepatitis viruses are RNA viruses , except for hepatitis B, which is a DNA virus

64. The liver biopsy in acute hepatitis due to hepatitis B virus is likely to show all of the following, except- a) Ballooning change of hepatocytes b) Ground glass hepatocytes c) Necrosis of hepatocytes d) Acidophil bodies 69

65. Most common Virus associated with transfusion-associated hepatitis? Vaccine / prophylaxis is nor available for? Malignant potential is present with ? Progression to chronicity is seen with ? Perinatal transmission is most significant with ? Hepatitis spread by parenteral routes? Non-parenteral hepatitis? 70

66. Hepatitis B is not transmitted through ? Most common hepatitis to progress to chronicity is ? Most common cause of fulminant Hepatitis in pregnant women ? Most common cause of epidemic hepatitis is ? Most common cause of sporadic? Most common cause of sporadic Hepatitis in children is ? 71

67. Which of the following hepatitis viruses has significant perinatal transmission - a) Hepatitis E virus b) Hepatitis C virus c) Hepatitis B virus d) Hepatitis A virus 72

68. 74

69. 75

70. 76

71. Role of serological markers in Hepatitis B 77

72. Early diagnosis of acute hepatitis-B infection is made by- a) Presence of Hbe Ag in serum b) Presence of IgM anti- HBc in serum c) Presence of Hbs Ag in serum d) Presence of IgG anti- HBc in serum 78

73. 79

74. 80

75. Hepatitis B infectivity is indicated by - a) Anti- HBsAg b) HBsAg + HBeAg c) Anti- HBsAg + Anti- HBc d) Anti- HBeAg + Anti- HBsAg 81

76. A thirty-year man presented with nausea, fever and jaundice of 5 days duration. The biochemical tests revealed a bilirubin of 6.7 mg/dl (conjugated 5.0 mg/ dl) with SGOT/SGPT(AST/ALT) of 1230/900IU/ ml. The serological tests showed presence of HBs Ag., IgM anti- HBc and HbeAg . The most likely diagnosis is – a) Chronic hepatits B infection with high infectivity b) Acute hepatitis B infection with high infectivity c) Chronic hepatitis B infection with low infectivity d) Acute hepatitis B infection with low infectivity 82

77. 83

78. Reverse transcriptase of hepatitis B virus is coded on the following gene - a) C gene b) S gene c) P gene d) X gene 84

79. Which one of the pair is not correct regarding hepatitis B management a) Supportive care - acute viral hepatitis B b) Antiviral drugs - chronic viral hepatitis B c) Supportive care - chronic viral hepatitis B d) Antiviral drugs - acute viral hepatitis B 85

80. Rx of chronic HBV infection - a) Interferon b) Adefovir dipivoxil c) Lamivudine d) Famcyclovir e) Ganciclovir 86

81. A young man presents with HBsAg positive anti HBcIgG positive, HBeAg negative and normal levels of AST and ALT. He is asymptomatic. What is the next line of management. a) Wait and Watch b) Lamivudin c) Immunoglobulin d) Liver Transplant 87

82. Hepatitis C

83. HCV is the most common Virus associated with ? The most common/prominent mode of transmission is through ? Hepatitis C does not spread through ? No vaccine / prophylaxis is available for HCV 89

84. Antibodies of Hepatitis C :- 90

85. 91

86. Diagnosis & Treatment