Case rounds: Gastrointestinal & hepatology

Question 1

complications of primary haemachromatosis

Answer 1

skin pigmentation
diabetes (pancreatic deposition)
cardiomyopathy
hepatic cirrhosis
chondrocalcinosis and arthropathy
hypogonadism and pituitary dysfunction

Question 2

pattern of inheritance primary haemachromatosis

Answer 2

autosomal recessive and is associated with a gene mutation in the HFE gene – genetic testing will confirm the diagnosis

Question 3

What investigations would you do for haemachromatosis?

Answer 3

DIAGNOSIS
iron studies (show high iron/ferritin + low TIBC)

COMPLICATIONS
ECG, echo 
liver biopsy
radigraph joints with pain
genotyping

Question 4

What is the management of haemachromatosis?

Answer 4

Venesection -reduce serum iron/ferritin, haematocrit and transferrin saturation.
Manage diabetes

Question 5

What is the first line treatment for oesophageal varices?

Answer 5

Non-cardioselective beta-blokers = first line treatment of prevention of variceal bleeding.
Regular endoscopy with variceal band ligation is the second-line managment

Question 6

Why do long term alcohol abusers get splenomegaly?

Answer 6

Portal hypertension causes congestion in splenic vein- cirrhosis causes back-log of blood in spleen

Question 7

3 key signs of portal hypertension

Answer 7

splenomegaly
visible abdominal veins
ascites

Question 8

Blood tests for bleeding varices

Answer 8

• coagulation studies
• FBC, U+Es
• cross match 6 units
• blood glucose

Question 9

acute management of bleeding varices

Answer 9

• blood transfusion
• refer to on call endoscopy
• IV vasopressin analogue
• IV antibiotics

Question 10

best management for bleeding varices?

Answer 10

band ligation/sclerotherapy

Question 11

Rifaximin- when is it used?

Answer 11

End stage liver disease

Broad spectrum non-absorbed Abx so bacteria in gut don’t survive, minimising work on liver

Question 12

normal range HB

Answer 12

120-155

Question 13

normal range WCC

Answer 13

4-11 x109

Question 14

normal range PLT

Answer 14

150-450

Question 15

Key word in AWS?

Answer 15

marked tremor, sweaty

Question 16

Causes of macrocytosis

Answer 16

• alcohol abuse
• folate
• B12
• pregnancy

Question 17

AWS common presentations

Answer 17

• seizures
• tachycardia, sweating, tremor
• -

Question 18

Autoimmune hepatitis is positive for what antibody?

Answer 18

ANA

Serum immunoglobulins are also commonly raised

Question 19

Management of autoimmune hepatitis

Answer 19

• Prednisolone 30mg initially

- Then taper steroids and continue azathioprine for 2-3 years minimum

Question 20

AIH patients are at increased risk of what?

Answer 20

HCC

Question 21

commonest site of pancreatic cancer

Answer 21

60% in head

Question 22

prognosis pancreatic cancer

Answer 22

<2%

Question 23

Typical presentation of PBC?

Answer 23

lethargy and pruritus
minor increase in AST/gamma-GT
increase of ALP

Question 24

What may be markedly high in PBC?

Answer 24

serum lipids- often have hypercholesteraemia

Question 25

contraindications for biopsy

Answer 25

Platelets <100 x10⁹/L
INR >1.3
Hb <100 g/L 
ACS- cannot consent, increased complications
Ascites- RF for bleeding

Question 26

PBC patients are at risk of developing which conditions?

Answer 26

Malabsorption (fat soluble vits)
Osteoporosis
Hepatocellular carcinoma (cirrhosis)
Liver failure
Haematemesis (varices)
Hypothyroidism

Question 27

Which medications are used initially to treat PBC?

Answer 27

Cholestyramine (alleviate pruritus)
Ursodeoxycholic acid (lower lipids, statins affect liver function so not given)
Fat-soluble vitamin prophylaxis
Liver transplantation- last resort