MET3 Revision - Gastroenterology II

Question 1

State the causes of upper GI bleeds [5]

Answer 1

Peptic Ulcer Disease – 44%
Oesophagitis - 28%
Gastritis/Erosions – 26%
Erosive Duodenitis – 15%
Varices – 13%
Portal Hypertensive gastropathy – 7&
Malignancy - 5%
Mallory Weiss Tear – 5%
Vascular Malformation – 3%

Question 2

State the causes of lower GI bleeds [5]

Answer 2

Diverticular disease (30%)
* Haemorrhoids (14%)
* Mesenteric Ischaemia (12%)
* Colitis (9%)
* Cancer (6%)
* Rectal ulcers (6%)
* Angiodysplasia (3%)
* Radiation (3%)
* Drugs
* Other

Question 3

What is this cause of upper GI bleeding? [1]

Answer 3

Gastritis

Question 4

What is the most common cause of portal HTN worldwide? [1]

Answer 4

Schistomiasis

Question 5

Describe pathophysiology is diverticular disease causing lower GI bleeding? [1]

How does diverticular disease lead to lower GI bleeding? [1]

Answer 5

Diverticular disease:
- a condition where small pouches (called diverticula) form in the lining of your bowel and push out through your bowel wall due to high intra-luminal pressure
-

Diverticulae lie adjacent to mesenteric blood flow and because they cause decreased thickness of colonic thickness; increases chance of bleeding

Question 6

What are causes of diverticular disease? [6]

Answer 6

• Constipation
• Genetics
• Obesity
• NSAIDs
• Low fibre diet
• Muscle spasm

Question 7

State 5 causes of haemorrhoids [5]

Answer 7

• Straining (in bowel movement)
• Sitting for long periods
• Chronic diarrhoea or constipation
• Overweight / obese
• Pregnancy

Question 8

Describe how colonic cancer develops [3]

Answer 8

1. polyps;
2. larger polyp (severe dysplasia)
3. adenocarcinoma

Question 9

State 4 reasons that cause colitis which in turn causes lower GI bleeding [4]

Answer 9

Ishcaemic colitis: in distal transverse colon / descending colons - position as watershed area between SMA & IMA can lead to bleeding

IBD

Infection

NSAIDs

Question 10

What are the different classes of blood loss? (% and volume lost?) [4]

Answer 10

Class 1:
- 10-15%
- 750mls

Class 2:
- 15-30%
- 1.5L

Class 3:
- 30-40%
- 2L

Class 4:
- >40%
- 3L

Question 11

Describe the symptoms that classify each class of shock with regards to blood loss? [4]

Answer 11

Class 1:
- no clinical signs

Class 2:
- postural hypotension
- generalised vasoconstriction

Class 3:
- Hypotension
- Tachycardia over 120
- Tachyopnea

Class 4:
- Marked hypotension
- Marked tachycardia
- marked tachyopnea
- Comatose

Question 12

Which cannulae are wide bore? [4]

Answer 12

• 14G (300ml/min)
• 16G (150 ml/min)
• 17G
• 18G (75ml/min)

Question 13

What are possible complications of massive blood transfusion [5]

Answer 13

- Fluid overload

• Electrolyte / Acid-Base disturbance
• Transfusing products devoid of clotting factors (consider giving additional platelets)
• Hypothermia (blood transfused is cold)

Repeated transfusions:
- Iron overload

Question 14

Which blood tests would you suggest for investigating upper GI bleed? [7]

Answer 14

• Blood gas: contains Hb and lactate levels
• FBC: Hb and clotting levels
• U&E: kidney function
• LFTs
• Coagulation screen
• Cross match (to find a compatible samples for transfusion)
  OR
• Group and save (instruct transfusion lab to find blood group of patient and save serum of sample sent for later cross match

Question 15

How do you optimise clotting:

• What levels should: platelets [1] and INR [1] be above/below? [2]
• Drug management? [2]

Answer 15

Platelets: > 50
INR: < 1.5

Do not give any anti-coagulants the Ptx may be on (warfarin, clopidogrel, aspirin, DOAC)
Reverse warfarin with vitamin K

Question 16

What drugs might be prescribed if have an upper GI bleed? [2]

Answer 16

PPI:
- Decrease lesions identified at endoscopy level; but no difference in transfusion, surgery or mortality
- NICE does not rec. PPI before endoscopy

Tranexamic acid?
- improves clotting in area of GI bleeding, but may improve clotting with poor vascular blood flow & cause CAD.

Question 17

Specific treatment for variceal bleeding? [2]

Answer 17

Terlipressin:
- causes mesenteric and splachnic vasoconstriction
- contraindicated in IHD

Antibiotics:
- cephalosporin; quinolone; augmentin
- reduces liklihood of sepsis, which decreases portal pressure
- treat chest infection if aspiratio has occurred.

NOTE: Propanolol is prophylaxis

Question 18

Name the scoring system used to determine if risk of re-bleeding [1]
Which scores result in outpatient endoscopy [1]

Answer 18

Blatchford score
< 2: low risk - outpatient endoscopy
> 6: endoscopic Rx

Question 19

Name another score (other than Blatchford score) for upper GI blleds [1]
What is important to note about this score [1]

Answer 19

Rockall score: needs endoscopic diagnosis to calculate full score

Question 20

Describe management of high risk, actively bleeding ulcer [4]

Answer 20

Adrenaline:
- vasoconstriction
- causes local tamponade of blood vessels

Clip: closes bleeding

Diathermy: (therapeutic treatment that uses electric currents (radio and sound waves) to generate heat in layers of your skin below the surface)

Haemospray: powder in endoscope; promotes clotting}}

Question 21

Describe the endoscopic management of varices [3]

Answer 21

Band ligation

Injection sclerotherapy (glue)

Sengestaken blakemore tube: compresses varices

Question 22

Explain post-endoscopical / medical therapy for ulcers: [3]

Answer 22

PPIs:
- allow ulcers to heal
- increase gastric pH; improves clotting ability (low pH activates pepsin which inactivates platelets)
- some patients will need continous infusion for 72hrs

H. pylori eradication (triple therapy: 1xPPI; 2xantibiotics)

Reassess of OGD

Question 23

Describe post-endoscopic treatment of varices [4]

Answer 23

• Beta blockers (reduce portal pressure: carvedilol; propanolol)
• Sequential banding procedures (close future varices)
• TIPPS: blood from portal vein goes straight from liver into systemic system (reduces pressure)
• Liver transplant

Question 24

When would you use interventional radiology or red cell scanning with GI bleeds? [2]

Describe the procedures [2]

Answer 24

If endoscopy fails / too unwell to have endoscopy

Interventional radiology:
- CT angiogram: IDs bleeding vessel
- Angiography: embolise the vessel

Surgery:
- If have uncontrolled bleeding
- Failed 2x endoscopic treatment

Question 25

What is the most common cause of small bowel bleeding? [1]

Answer 25

Angiodysplasia: abnormal, tortuous, dilated small blood vessel in the mucosal and submucosal layers of the GI tract.

Question 26

The NICE clinical knowledge summaries (updated January 2021) suggest management of uncomplicated diverticulitis in primary care with.. [4]

Answer 26

The NICE clinical knowledge summaries (updated January 2021) suggest management of uncomplicated diverticulitis in primary care with:

• Oral co-amoxiclav (at least 5 days)
• Analgesia (avoiding NSAIDs and opiates, if possible)
• Only taking clear liquids (avoiding solid food) until symptoms improve (usually 2-3 days)
• Follow-up within 2 days to review symptoms

Question 27

Describe the presentation of diverticulosis [3]

Answer 27

Diverticulosis may cause lower left abdominal pain that relieved by defecation, constipation or rectal bleeding

Question 28

How do you manage diverticulosis?
- Which laxatives are advised / not advised? [2]

Answer 28

Management is with increased fibre in the diet and bulk-forming laxatives (e.g., ispaghula husk). Stimulant laxatives (e.g., Senna) should be avoided

Question 29

Describe management plan for upper bleeds [6]

Answer 29

The initial management can be remembered with the ABATED mnemonic:

A – ABCDE approach to immediate resuscitation
B – Bloods
A – Access (ideally 2 x large bore cannula)
T – Transfusions are required
E – Endoscopy (within 24 hours)
D – Drugs (stop anticoagulants and NSAIDs)

Question 30

A patient has suspected bleeding varices. What two drugs should you prescribe? [2]
Is this before or after endoscopy? [1]

Answer 30

Terlipressin & Antibiotics (Ceftriaxone)
BEFORE endoscopy

Question 31

Which drug classes are a risk factor for upper GI bleeds? [5]

Answer 31

NSAIDs
Aspirin
Steroids
Thrombolytics
Anticoagulants

Question 32

Describe pathophysiology of PUD [2]

Answer 32

The mucosa lining inner lining of the stomach and duodenum secretes bicarbonate into this mucus coating to neutralise stomach acid & digestive enzymes

Disruption of the mucus barrier or increase stomach acid increase the risk of mucosal ulceration.

Question 33

Risk factors for PUD? [6]

Answer 33

Helicobacter pylori is associated with the majority of peptic ulcers:
- 95% of duodenal ulcers
- 75% of gastric ulcers

Drugs:
- NSAIDs
- SSRIs
- corticosteroids
- bisphosphonates

Zollinger-Ellison syndrome (duodenal or pancreatic tumour secretes excessive quantities of gastrin - stimulates acid secretion in the stomach)

Question 34

State for duodenal or gastric ulcers the following:

• % related to H.pylori
• Weight loss is more likely
• If malignant

Answer 34

Duodenal:
- 95/99% related to H.pylori
- Not malignant (most cases)
- Weight loss less likely

Gastric:
- Weight loss likely (pain on eating)
- 60/70% related to H.pylori
- NSAIDs significant cuase
- 5-10% malignant

Question 35

Describe management of PUD [4]

Answer 35

PPI:
- lansoprazole
- omeprazole

Treat H.pylori using triple therapy (x2 antibiotics; x1 PPI)

Stop NSAIDs

Confirm eradicaiton using endoscopy and / or faecal antigen or urea breath test

Question 36

Why do NSAIDs increase chance of gastric related ulcers? [1]

Answer 36

Inhibition of COX-1 in the gastrointestinal tract leads to a reduction of prostaglandin secretion and its cytoprotective effects in gastric mucosa

Question 37

Describe the different pathways for duodenal and gastric ulcer pathways

Answer 37

Duodenal ulcer pathway;
antral gastritis, increased acid secretion which causes gastric metaplasia in the duodenal and leads to a duodenal ulcer

Gastric ulcer pathway:
corpus gastritis – inflammation in the body of the stomach, decreased acid secretion which causes gastric atrophy and predisposes you to dysplasia/neoplasia.

Question 38

Describe the managment for patients who have recurrent peptic ulcers [3]

Answer 38

Reducing the NSAID dose & substituting the NSAID with paracetamol

If symptoms recur after initial treatment: offer a PPI at the lowest dose possible to control symptoms:
* esomeprazole
* lansoprazole
* omeprazole

Offer H2 antagonist therapy if there is an inadequate response to a PPI:
- famotidine
- nizatidine

BMJ Best Practise

Question 39

When should barium radiography be used for investigating POD? [1]

Answer 39

Barium radiography should be reserved for patients who are unable or unwilling to undergo endoscopy, and it is not routinely recommended.

Question 40

Describe the presentation of the complications of significant peptic ulcerations [4]

Answer 40

Haematemesis (vomiting blood)
Coffee ground vomiting
Melaena (black, tarry stools)
Fall in haemoglobin on a full blood count

Question 41

Where is the most common place for duodenal ulceration?

Answer 41

Duodenal ulcers occur most frequently in the first portion of the duodenum (over 95%), with approximately 90% located within 3 cm of the pylorus and are usually less than or equal to 1 cm in diameter

Question 42

Investigations for perforated peptic ulcer? [5]

Answer 42

Bloods:
- Leukocytes present
- Anaemia

U & E:
- Significant bleeding may alter electrolytes
- Urea may be raised: digested blood is protein source

Liver function: useful to rule out biliary pathology

XR:
- upright XR if acute upper abdominal pain
- See free air presence

CT scan: if not seen on XR, but clinical presentation suggests

Question 43

Describe the treatment pathway for the initial resuscitation of perforated peptic ulcer disease [4]

Answer 43

IV fluids

Nasogastric tube insertion:
- reduces amount of gastric fluids in GIT AND allows nill by mouth

IV PPI
- loading and maintence doses
- enhance sealing of perforation

Antibiotics:
- stop sepsis due to leaking of fluids into peritoneum

Use one of the following methods to achieve haemostatic control of an actively bleeding ulcer via endoscopy:

A mechanical method (e.g., clips) with adrenaline (epinephrine)

Thermal coagulation with adrenaline

Fibrin or thrombin with adrenaline.

Question 44

After initial resuscitation, describe the operative management for PPUs [3]

Answer 44

Operative:
- Closure of perforation < 2 cm ulcer
- Resection of lesion > 2cm ulcer
- Use piece of omentum to cover}

Question 45

Describe the post-op management of PPUs [2]

Answer 45

Upper endoscopy:
- ID cause of perforation & healing of ulcer
- Biopsy for H. pylori

H.pylori eradication:
- triiple therapy for 10-14 days

Question 46

Describe what is meant by Zollinger-Ellison syndrome [1]

It is made from a triad of which three causes? [3]

Answer 46

Zollinger-Ellison syndrome (ZES) is a condition caused by a gastrin-secreting tumour that causes hypersecretion of gastric acid leading to ulcer disease.

Triad:
1) gastric acid hypersecretion, sustained by:
2) fasting serum hypergastrinemia causing:
3) peptic ulcer disease and diarrhea

Question 47

How do you calculate fluid maintenance in children? [1]

Answer 47

100ml/kg for the first 10kg, 50ml/kg for the next 10kg and 20ml/kg for every subsequent kg.

Question 48

Which antibodies are raised in type 1 autoimmine hepatitis? [2]
Which Ig? [1]

Answer 48

ANA/SMA/LKM1 antibodies, raised IgG levels

Question 49

liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis

This would suggest which pathology? [1]

Answer 49

Autoimmune hepatitis

Question 50

Describe how a liver biopsy might show autoimmune hepatitis [2]

Answer 50

liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis

Question 51

Which enzyme converts haemoglobin to biliverdin?

Biliverdin reductase
Haem oxygenase
Glucuronyl transferase
HMG-CoA
Dihydro-folate reductase

Answer 51

Which enzyme converts haemoglobin to biliverdin?

Biliverdin reductase
Haem oxygenase
Glucuronyl transferase
HMG-CoA
Dihydro-folate reductase

Question 52

Which classification system is used to grade lower GI bleeds?

Oakland score
Los Angeles classification
Forrest classification
Glasgow-Imrie score
Glasgow-Blatchford score

Answer 52

Which classification system is used to grade lower GI bleeds?

Oakland score
Los Angeles classification
Forrest classification
Glasgow-Imrie score
Glasgow-Blatchford score

Question 53

Primary biliary cirrhosis is associated with which immunoglobulin? [1]

Answer 53

IgM

Question 54

A 25 year old male with a history of coeliac disease presents with a bilateral, intensely itchy rash on his elbows. On examination there are numerous papulovesicular lesions with surrounding erythema and excoriation marks.

What is the most appropriate treatment option in this case?

A NSAIDs
B Oral corticosteroids
C Corticosteroid cream
D Moisturisers
E Dapsone

Answer 54

A 25 year old male with a history of coeliac disease presents with a bilateral, intensely itchy rash on his elbows. On examination there are numerous papulovesicular lesions with surrounding erythema and excoriation marks.

What is the most appropriate treatment option in this case?

A NSAIDs
B Oral corticosteroids
C Corticosteroid cream
D Moisturisers
E Dapsone

Question 55

What is Heyde’s syndrome? [1]

Answer 55

Heyde syndrome is a multisystem disorder characterized by the triad of aortic stenosis (AS), gastrointestinal bleeding, and acquired von Willebrand syndrome.

Question 56

Which of the following is not a pathological feature of ulcerative colitis?

A Friable mucosa
B Erosions
C Cobblestoning
D Crypt hyperplasia
E Inflammatory infiltrate

Answer 56

Which of the following is not a pathological feature of ulcerative colitis?

A Friable mucosa
B Erosions
C Cobblestoning
D Crypt hyperplasia
E Inflammatory infiltrate

Question 57

Question 52.
What is the most common type of gastric cancer?

A Lymphoma
B Leiomyosarcoma
C Neuroendocrine tumour
D Adenocarcinoma
E Gastrointestinal stromal tumour (GIST)

Answer 57

Over 90% of gastric cancers are adenocarcinoma, which is historically divided into two histological subtypes known as intestinal and diffuse.

• Intestinal-type: most common, gland-forming. Further divided into papillary, tubular or mucinous adenocarcinomas.
• Diffuse-type: less common, composed of discohesive cells. Classically signet cells see on histology. Can lead to extensive infiltration of the stomach and more likely to have a familial element.

Question 58

A 24 year old female with a known history of Crohn’s disease presents with a painful, bilateral rash on her shins. There are numerous red-purple nodules approximately 2-6 cm in size scattered on both shins that are painful to touch.

What is the most appropriate treatment? [1]

Answer 58

Erythema nodosum is a self-limiting disease that can be treated with NSAIDs (e.g. naproxen). Steroids may be prescribed in some setting (e.g. sarcoidosis).

Question 59

Which criteria is used to define Lynch syndrome based on family history?

A Duke criteria
B Amsel criteria
C Amsterdam criteria
D GOLD criteria
E West Haven criteria

Answer 59

Which criteria is used to define Lynch syndrome based on family history?

C Amsterdam criteria

AC can be remembered using the 3-2-1 rule:
- ≥3 family members affected (colorectal cancer or endometrial cancer)
- ≥2 two generations (e.g. parents and grandparents or parents and children)
- ≥1 family member diagnosed at young age (before 50 years old)

Question 60

A 42 year old female with Crohn’s disease presents to ED with acute RUQ pain. The pain started last night, has been getting worse and is now associated with nausea and fever. Her only medication is azathioprine. The attending doctor thinks this could be an episode of acute cholecystitis secondary to gallstones.

What is the most likely mechanism for the development of gallstones in her case?

A Hyperlipidaemia secondary to azathioprine
B Haemolytic anaemia secondary to Crohn’s
C Increased absorption of bilirubin from the small bowel
D Reduced absorption of bile salts from the terminal ileum
E Reduced production of bile salts from the liver

Answer 60

A 42 year old female with Crohn’s disease presents to ED with acute RUQ pain. The pain started last night, has been getting worse and is now associated with nausea and fever. Her only medication is azathioprine. The attending doctor thinks this could be an episode of acute cholecystitis secondary to gallstones.

What is the most likely mechanism for the development of gallstones in her case?

A Hyperlipidaemia secondary to azathioprine
B Haemolytic anaemia secondary to Crohn’s
C Increased absorption of bilirubin from the small bowel
D Reduced absorption of bile salts from the terminal ileum
E Reduced production of bile salts from the liver

Question 61

What are the NICE 2 week cancer pathway criteria for ? pancreatic cancer? [2]

Answer 61

Suspected pancreatitis cancer:
- Aged 40 and over with jaundice
- Aged 60 and over with weight loss and any of diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation or new-onset diabetes.

Question 62

A 32-year-old woman presents to the GP with difficulty swallowing. This has been worsening over many years and can happen with both liquids and solids. She has modified her eating habits to smaller portions and softer food. She often regurgitates food many hours after eating. She undergoes a gastroscopy that is reported as normal. She is referred to the gastroenterology team for further investigation.

What would be the gold-standard investigation to make the diagnosis?

Gastroscopy under general anaesthetic
Barium swallow
High-resolution manometry
CT chest and abdomen
Gastric emptying studies

Answer 62

A 32-year-old woman presents to the GP with difficulty swallowing. This has been worsening over many years and can happen with both liquids and solids. She has modified her eating habits to smaller portions and softer food. She often regurgitates food many hours after eating. She undergoes a gastroscopy that is reported as normal. She is referred to the gastroenterology team for further investigation.

What would be the gold-standard investigation to make the diagnosis?

High-resolution manometry
- This patient likely has underlying achalasia of which high-resolution manometry is the gold-standard investigation.
- involves insertion of a catheter through the nose to sit within the oesophagus. This catheter contains multiple sensors that are able to determine the pressure at different points within the oesophagus.

NB: B: Barium swallow is an excellent test for achalasia that may show typical features but is not the gold-standard

Question 63

Which criteria is used to describe Barrett’s endoscopically?

A Sidney
B Seattle
C Rome
D Prague
E Glasgow-Blatchford

Answer 63

Which criteria is used to describe Barrett’s endoscopically?

A Sidney
B Seattle
C Rome
D Prague
E Glasgow-Blatchford