GI

Question 1

Indications for Colectomy in UC

Answer 1

• Toxic megacolon
• Colonic perf
• Hemorrhage
• No improvement after 3-5 days

Question 2

Toxic Megacolon Definition

Answer 2

> 6cm colon radiographically plus at least 3:

1. Fever >38
2. HR >120
3. Neutrophils >10.5
4. Anemia

Plus one of:

1. Dehydration
2. Confusion
3. Electrolyte disturbance
4. Hypotension

Question 3

UGIB + cirrhosis. If ABx indicated? If so, what and how long?

Answer 3

CTX 1g/24hrs x 7days, can stop when active bleeding or octreotide stopped

Question 4

Which ulcers are high risk and require IV PPI 72hrs post EGD?

Answer 4

1. Bleeding ulcers
2. Not-bleeding ulcers but visible vessel
3. Adherent, non-removal clot

Question 5

Who to screen for Hpylori?

Answer 5

PUD
MALT lymphoma- Tx of H.pylori will cure! 
Gastric cancer
Long-term NSAIDs/ASA
Unexplained iron deficiency
 ITP

Question 6

Who to treat for H.pylori if tests positive?

Answer 6

Everyone for fear of increased cancer risk

Question 7

US (not AFP) is needed q6mos for HCC screening in HBV + patients with these characteristics…

Answer 7

– Asian M >40, Asian F >50
– African >20
– All cirrhotics
– Fam Hx HCC starting age 40
– All HIV co-infected starting age 40

Question 8

Chronic HBV, who to treat?

Answer 8

– Cirrhosis
– Extra hepatic manifestations
– HBeAg-pos with elevated ALT and HBVDNA>20,000IU/ml
– HBeAg-neg with elevated ALT and HBV DNA>2,000IU/ml
– 3rd trimester with high DNA levels (HBV DNA >200,000 IU/ml) to prevent fetal transmission
• Baby should also get HBIG (in addition to HBV vaccines) after birth

Question 9

Extrahepatic manifestations of HBV?

Answer 9

1. Heme–>aplastic anemia
2. Vasculitis–> PAN
3. Renal–> Membranous Nephropathy>MPGN

Question 10

Extrahepatic manifestations of HCV?

Answer 10

• Autoimmune
– thyroid disease, myasthenia, sjogren’s
• Renal
– MPGN>MN
• Derm
– PCT, lichen planus, leukocytoclasticvasculitis
• Heme
– cryoglobulinemia, lymphoma, AIHA,ITP
• Other – DM

Question 11

Most common cause of death in NAFLD?

Answer 11

CV in origin!

Question 12

Which patients need SBP proph?

Answer 12

1) Previously had SBP
2) Cirrhosis who present with GI bleeding (don’t need to have ascites)
3) Cirrhotic with ascitic fluid protein is <15 g/L and at least one of:
- impaired renal function (Cr ≥ 106, BUN ≥ 8.9, Na ≤ 130)
- impaired liver function (Child-Pugh ≥ 9 and Bili ≥ 51 umol/L)

Question 13

Stool Osmotic Gap calculation. What does a low and high gap mean clinically?

Answer 13

Stool Osmotic Gap= 290 (expected stool osmolality) – 2(stool Na + stool K)
– Normal gap = 50 – 100
– Low gap = suggests secretory diarrhea
• Toxins (cholera, ETEC, VIP, Gastrinoma, non-osmotic laxative abuse

– High gap = suggestive of osmotic diarrhea
• Celiac, chronic pancreatitis, lactase deficiency, lactulose, osmotic laxative abuse, Whipple’s

Question 14

When to screen for HH?

Answer 14

Suspect if:

1. Tsat >45%
2. Ferritin >200 in men
3. Ferritin >150 in women

Question 15

Ferritin targets for phlebotomy and chelation in HH?

Answer 15

Women ferritin >50

Men ferritin >100

Question 16

Which family members should be screened if confirmed case of HH?

Answer 16

All 1st degree relatives >18

Screen with iron studies AND genetic testing

Question 17

Treatment for microscopic colitis?

Answer 17

– Imodium, stop NSAIDs and offending meds

– Budesonide PO

Question 18

Diagnostic criteria for PBC?

Answer 18

Diagnosis requires 2 of 3:
– Persistent elevation in ALP >6 months
– AMA antibody titre >1:40 (95% sensitive, 98% specific)
– Liver biopsy (only needed when diagnosis unclear)

Question 19

Who to vaccinate against HAV?

Answer 19

travellers, chronic liver disease, MSM, IVDU, recurrent plasma derived clotting factors, zoo-keepers or vets handling with non-human primates

Question 20

Patient with acute hepatitis B, treatment is supportive but what must you tell household contacts?

Answer 20

Ensure household and sexual contacts are immune and provide hepatitis B immune globulin and hepatitis B vaccine if they are not immune

Question 21

Treatment of HBV. Compare and contrast Peg-interferon vs. Nucleotide Analogues

Answer 21

Peg-Interferon
•Pros
– Finite therapy (typically48w)
– Generally more durable response
• Cons
– Side effects(lots)
– Only specific patients benefit
• Low DNA, high ALT
– Unable to use in decompensated cirrhotics!

Nucleotide Analogues (tenofovir, entecavir, lamivudine)
•Pros
– Potent viral suppression
– Well tolerated
– Tenofovir/Entecavir very high barrier to resistance, considered 1st line
• Cons
– Generally many years of therapy, and can be life long (especially in eAg negative disease)
– Expensive
– Unlikely to convert to seroconverts Ag