Non-Alcoholic fatty liver disease (NAFLD)

• What is Non-Alcoholic fatty liver disease?

• It is a clinical histopathological entity with evidence of hepatic steatosis, either by imaging or by histology and, by definition, occurs in patient with little or no history of alcohol consumption. The disease ranges from fat accumulation in liver cells to a necro-inflammatory component, known as non-alcoholic steatoheaptitis (NASH).

• Why do we worry about NAFLD?
• It can become Non alcoholic steatohepatitis (NASH)
• NASH is histologically indistinguishable from alcoholic steatoheaptitis, and may progress to cirrhosis in up to 20 % of patients
• NAFLD does not increase short morbidity or mortality but if it progresses to NASH, it increases chance of cirrhosis and may require liver transplant

• Who gets NAFLD?
• Anyone can get it but criteria require the person to be diagnosed to have no history of ETOH abuse 
• Other risk factors 
• central obesity 
• type 2 diabetes mellitus 
• dyslipidaemia 
• metabolic syndrome 

• What causes it?
• Unknown 

• How do you diagnose it?
• Demonstration of hepatic steatosis by imaging or biopsy 
• Exclusion of significant alcohol consumption 
• Exclusion of other causes of hepatic steatosis 
• No coexisting causes for chronic liver disease
• Other investigations to exclude other causes
• anti hepatitis C virus antibody 
• hepatitis A IgG
• Hepatitis B surface antigen 
• Plasma iron, ferritin, and total iron binding capacity 
• Serum gamma-globulin level, antinuclear antibody, anti-smooth muscle antibody, and anti-liver/kidney microsomal antibody - 1

• What is the treatment?
• Weight lose 
• lifestyle changes

Gastroenterology index page

• Giardiasis
• Gastroenterology examination video 
• Non alcohol fatty liver disease (NAFLD)
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Giardiasis

• What is giardia? 
• Giardia duodenalis is a parasite
• It is the most common gastrointestinal protozoan that causes chronic diarrhoea 

• How dose it spread?
• It is transmitted by the ingestion of food or water contaminated by faeces, by exposure to faecally contaminated surfaces and through person-to-person contact. 

• What are the signs and symptoms?
• stomach cramps
• excessive gas or bloating 
• diarrhoea, which may be water, usually last 1 to several weeks
• frequent loose or pale, greasy faeces which may float in the toilet bowl 
• fatigue
• weight loss
• lactose intolerance may occur in 20 to 40% cases and last several weeks
• fever and bloody diarrhoea are uncommon 
• symptoms usually appear 1-2 weeks following infection and resolver within 2-4 weeks

** many infected have no symptoms**

• How do you diagnose it ?
• Diagnosis is made by stool MCS or multiplex

• How do you treat it ?
• Tinidazole 2 g orally 
• metronidazole 2g orally daily for 3 days or 400 mg orally 8 hourly for 5-7 days 

Reference

• http://www.sahealth.sa.gov.au/wps/wcm/connect/Public+Content/SA+Health+Internet/Health+topics/Health+conditions+prevention+and+treatment/Infectious+diseases/Giardia+infection/

Iron deficiency

What is iron deficiency?

• Royal College of pathologists of Australasia definition of iron deficiency is serum ferritin level of < 30 for an adult 

Who gets iron deficiency?

• Basically everyone 
• Pre-menopausal and pregnant women are at higher risk
• Vegetarian with a balanced diet should not have iron deficiency

What causes iron deficiency?

• 2 major categories
• Not taking in enough iron such as coeliac disease, poor diet etc
• Loosing iron such as blood loss

What are the clinical features of iron deficiency?

• No clinical features in many cases and found out from routine blood test
• Clinical features include: fatigue

How is it diagnosed?

• It is diagnosed via iron studies, not as straight forward as it sounds 
• Ferritin is the most reliable indicator of iron level but it elevates with acute inflammation so a CRP is recommended to order with ferritin together 
• Transferrin saturation levels reflecting transport iron, if it is less than 20% indicate an iron supply that is insufficient to support normal erythropoiesis
• Total iron binding capacity increases in iron deficiency in an attempt to increase iron uptake 

What is the treatment for iron deficency?

• Dietary modification is inadequate to treat iron deficiency, only enough to prevent 
• treatment is around 100 - 200 mg elemental iron daily in divided doses 
• Over the counter product only contains very small amount of iron content
• If iron replenish is required urgently (prior to operation or pre-obstetric delivery), IV iron can be used. (Usually ferronjet 1000 mg can be given over 15 minutes)
• There are quite many iron oral formulas available: Here

What is the outcome?

• Variable depends on the cause
• takes 3 to 4 weeks to have a clinical significant impact
• Hb level should increase by approximately 20 g/L every 3 weeks

References:

• RACGP check program 2016 Blood disorder 
• South Australia health. Blood safe iron deficiency anaemia resources

Respiratory history

System review questions:

• chest pain
• shortness of breath
• wheeze
• cough
• sputum
• haemoptysis 
• exercise tolerance
• smoking history