Corrections 3 Flashcards
(133 cards)
1
Q
What type of virus is CMV?
A
One of the herpes viruses
2
Q
Who does CMV typically only cause disease in?
A
HIV or those immunosuppressed following organ transplantation
3
Q
Mx of CMV infection?
A
IV ganciclovir
4
Q
Features of congenital CMV?
A
- growth retardation
- pinpoint petechial ‘blueberry muffin’ skin lesions
- microcephaly
- sensorineural deafness
- encephalitiis (seizures)
- hepatosplenomegaly
5
Q
What levels should be checked 4 months following immunisation against hep B to ensure an adequate response to immunisation?
A
Anti-HBs
6
Q
Transmission of hep A, B, C, D & E?
A
Hep A: faeco-oral
Hep B: blood-borne
Hep C: blood-borne
Hep D: blood-borne
Hep E: faeco-oral
7
Q
Hepatitis D only occurs in people who are also infected with what?
A
Hep B
8
Q
Hep D co-infection vs superinfection?
A
Co-infection: Hepatitis B and Hepatitis D infection at the same time.
Superinfection: A hepatitis B surface antigen positive patient subsequently develops a hepatitis D infection.
9
Q
Purpose of giving irradiated blood?
A
Reduces risk of graft versus host disease by destroying T cells
10
Q
What class of abx is typically used in the mx of a variceal haemorrhage?
A
Quinolones e.g. ciprofloxacin
11
Q
Give 3 indicators of a ‘life-threatening’ C. diff infection (requiring IV metronidazole + oral vancomycin)
A
1) hypotension
2) partial or complete ileus
3) toxic megacolon or CT evidence of severe disease
12
Q
Purpose of prescribing albumin when treating large volume ascites with paracentesis?
A
Reduce post-paracentesis circulatory dysfunction
13
Q
Formula for units in alcohol?
A
Units = ml x % / 1000
14
Q
What antibody may be positive in PSC?
A
p-ANCA
15
Q
What is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease?
A
Thrombocytopenia
16
Q
For patients with NAFLD, what investigation is recommended to screen for patients who need further testing?
A
enhanced liver fibrosis score
17
Q
A lemon tinge to the skin is associated with what condition?
A
Pernicious anaemia (due to mild jaundice combined with pallor)
18
Q
Pathophysiology behind pernicious anaemia?
A
1) antibodies to intrinsic factor +/- gastric parietal cells
2) intrinsic factor antibodies → bind to intrinsic factor blocking the vitamin B12 binding site
3) gastric parietal cell antibodies → reduced intrinsic factor production → reduced vitamin B12 absorption
4) vitamin B12 is important in both the production of blood cells and the myelination of nerves → megaloblastic anaemia and neuropathy
19
Q
What is the most common cause of B12 deficiency?
A
Pernicious anaemia
20
Q
What conditions is pernicious anaemia associated with?
A
Other autoimmune disorders e.g. thyroid disease, T1DM, Addison’s, vitiligo, RA
21
Q
Features of pernicious anaemia?
A
1) anaemia features
2) neuro:
- peripheral neuropathy (‘pins and needles’)
- subacute combined degeneration of the spinal cord
- neuropsychiatric features
3) mild jaundice: combined with pallor results in a ‘lemon tinge’
4) atrophic glossitis → sore tongue
22
Q
Symptoms of subacute combined degeneration of the cord?
A
- progressive weakness
- ataxia
- paresthesias
- may progress to spasticity and paraplegia
23
Q
What is there an increased risk of in pernicious anaemia?
A
Gastric cancer
24
Q
What cancer can PSC predispose to?
A
Cholangiocarcinoma
25
Screening for haemochromatosis in:
a) general population
b) family members
a) transferrin saturation (& ferritin)
2) HFE testing
26
Features of carcinoid tumours?
- flushing
- diarrhoea
- bronchospasm
-hypotension
- right heart valvular stenosis
- ACTH and GHRH may also be secreted (e.g. resulting in Cushing's)
- pellagra
27
How can pellagra sometimes rarely develop in carcinoid tumours?
As dietary tryptophan is diverted to serotonin by the tumour
28
How can Cushing's develop as a result of a carcinoid tumour?
Carcinoid tumours can secrete pituitary hormones, such as ACTH
29
1st line investigation in a carcinoid tumour?
Urinary 5-HIAA
30
Mx of a carcinoid tumour?
somatostatin analogues e.g. octreotide
diarrhoea: cyproheptadine may help
31
What is the first marker to appear in Hep B infection?
HBsAg (surface antigen)
32
What is HBsAg positive in?
Acute & chronic infection
(if positive >6 months then this implies chronic disease i.e. infective)
33
What does positive anti-HBsAg indicate?
Immunity due to vaccination
34
What does positive Anti-HBcAg IgM indicate?
Acute infection
35
What does positive Anti-HBcAg IgG?
Either:
a) acute infection (*IgG levels will not rise until 1/2 months into an infection)
b) chronic infection
3) immunity due to previous infection
36
Hep B serology results in previous immunisation?
Positive anti-HBsAg
All others negative
37
Hep B serology results in previous hep B (>6 months ago), not a carrier?
anti-HBc positive
HBsAg negative
38
Hep B serology results in previous hep B, now a carrier?
anti-HBc positive
HBsAg positive
39
Does UC flare up to the splenic flexure count as a distal flare?
Yes - 1st line is rectal aminosalicylates
40
What is the investigation of choice for diagnosis of small bowel overgrowth syndrome?
Hydrogen breath testing
41
Mx of Barrett's oesophagus?
1) high dose PPI
2) endoscopic surveillance with biopsies (every 3-5 years)
3) if dysplasia of any grade is identified endoscopic intervention is offered.
42
1st line intervation in Barrett's with dysplasia?
1st line --> radiofrequency ablation
2nd line --> endoscopic mucosal resection
43
What does C. difficile antigen positivity only show?
Exposure to the bacteria, rather than current infection (i.e. C. diff colonisation)
44
What should be avoided prior to a urea breath test for H/ pylori?
Antibiotics --> stop 4 weeks before
Antisecretory drugs (e.g. PPIs, H2 receptor antagonists) --> stop 2 weeks before
45
Histology of coeliac disease?
- villous atrophy
- raised intra-epithelial lymphocytes
- crypt hyperplasia
46
What are the 4 grades of hepatic encephalopathy?
Grade I: irritability
Grade II: confusion, inappropriate behaviour
Grade III: incoherent, restless
Grade IV: coma
47
Mx of patients who do not meet referral criteria ('undiagnosed dyspepsia')?
1) Review medications for possible causes of dyspepsia
2) Lifestyle advice
3) Trial of full-dose PPI for one month OR a 'test and treat' approach for H. pylori
(if symptoms persist after either of the above approaches then the alternative approach should be tried)
48
What 2 investigations are recommended for the initial diagnosis of H. pylori?
1) carbon-13 urea breath test
or
2) stool antigen
49
Are granulomas seen in UC or Crohn's?
Crohn's
50
Are pseudopolyps seen in UC or Crohn's?
UC
51
What is key in determining the severity of C. difficile infection?
WCC
52
What investigations are required in patients with GORD being considered for fundoplication surgery?
1) Endoscopy
2) Barium swallow
3) Oesophageal pH
4) Manometry studies
53
What mx can be done in treatment resistant GORD?
Nissen fundoplication
54
Role of oesophageal manometry?
This measures the pressures within the lower oesophageal sphincter and helps to confirm the diagnosis of GORD.
55
What weight loss is diagnostic of malnutrition?
Unintentional weight loss greater than 10% within the last 3-6 months
56
What are the 3 possible criteria for a diagnosis of malnutrition?
1) BMI <18.5
2) BMI <20 and unintentional weight loss greater than 5% within the last 3-6 months
3) Unintentional weight loss greater than 10% within the last 3-6 months
57
What does a TIPS connect?
The hepatic vein to the portal vein
58
Is transferrin saturation or ferritin better for haemochromatosis screening?
Transferrin saturation
59
What drugs can cause acute pancreatitis?
- mesalazine
- steroids
- sodium valproate
- furosemide
- bendroflumethiazide
- azathioprine
60
What 2 respiratory conditions may acute pancreatitis cause?
1) ARDS
2) Pleural effusion (exudative)
61
How can LFTs determine the cause of acute pancreatitis?
Raised bilirubin --> gallstones
Isolated raised gamma-GT --> alcohol
62
Role of testing faecal elastase in chronic pancreatitis?
Can be used to assess exocrine function: reduced levels are indicative of exocrine pancreatic insufficiency
63
How can chronic pancreatitis increase risk of osteoporosis?
Malabsorption of vit D & calcium as well as chronic inflammation.
64
What are the 2 most common cause of ascending cholangitis?
1) gallstones
2) post-ERCP
65
What does ERCP involve?
The passage of an endoscope into the 2nd part of the duodenum and cannulation of the ampulla.
66
Role of ERCP in ascending cholangitis?
Can determine the underlying cause of cholangitis and can also be therapeutic, by way of stone extraction and/or stent placement.
67
What is the gold standard investigation and intervention for acute cholangitis?
ERCP
68
Why is ERCP not always used in cholangitis?
Is invasive and therefore carries much more risk than other imaging modalities.
As a result, it is frequently preceded by MRCP where available.
69
What imaging is typically used if US is negative in ascending cholangitis?
Contrast enhanced CT-abdomen
70
What is a sphincterotomy?
Incising the sphincter of Oddi, where the biliary system joins the duodenum.
This aids drainage and passage of any CBD stones.
71
How can temp affect acute pancreatitis?
Hypothermia can cause acute pancreatitis
72
What drugs are a risk factor for peptic ulcer disease?
(4)
1) NSAIDs
2) Steroids
3) Bisphosphonates
4) SSRIs
73
What type of bacteria is H. pylori?
Gram -ve aerobic
74
LFTs in acute cholecystitis?
Typically normal
75
Where can biliary colic pain radiate to?
Interscapular region
76
Is mesalazine or sulfasalazine a bigger risk factor for pancreatitis?
Mesalazine
77
Describe pain in acute diverticulitis
Colicky abdo pain in LIF
78
What Glasgow-Blatchford score indicates a high risk for an upper GI bleed?
Above 0
Consider early discharge in patients with a score of 0
79
What are 2 main complications of an acute haemolytic transfusion reaction?
1) DIC
2) Renal failure
80
How is a diagnosis of chronic mesenteric ischaemia made?
CT angiography
81
Best way to manage variceal haemorrhage whilst waiting for endoscopy?
Insert a Sengstaken-Blakemore tube
82
What is the area most likely to be affected by ischaemic colitis?
Splenic flexure
83
What are 2 common bacterial contaminants of platelet transfusions?
1) Staph. epidermis
2) Bacillus cereus
84
1st line investigation in acute mesenteric ischaemia?
Lactate (VBG)
85
ACute vs chronic mesenteric ischaemia
Both affecting small bowel
Acute --> typically caused by AF
Chronic --> 'intestinal angina', typically preceded by eating
86
If endoscopy is negative, what is next step in GORD?
24hr oesophegeal pH monitoring
87
Gold standard test for diagnosis of GORD?
24hr oesophageal monitoring
88
Mechanism of PPIs?
Irreversibly block the H+/K+ ATPase of the gastric parietal cell --> reduce gastric acid secretion
89
What is involved in fundoplication?
Tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.
90
What is the most commonly affected section of bowel in diverticulosis?
Sigmoid colon
91
What type of laxatives can be offered in diverticulosis if patients have constipation?
Bulk-forming e.g. ispaghula husk
92
What type of laxatives should be AVOIDED in diverticulosis?
Stimulants
93
Is a colonoscopy indicated in diverticulitis?
No - should be avoided initially due to the increased risk of perforation in diverticulitis
94
What investigation is recommended for assessing liver fibrosis in chronic hepatitis C?
Transient elastography
95
What is the investigation of choice for Meckel’s diverticulum in stable children?
Technetium scan
96
What is the most common cause of pseudomembranous colitis?
C. diff infection (typically following abx)
97
Patients with diverticulitis flares can be managed with oral antibiotics at home. If they do not improve within 72 hours, what is next step?
Admit for IV ceftriaxone + metronidazole
98
Give 3 drugs that can cause cirrhosis
1) methotrexate
2) amiodarone
3) sodium valproate
99
Caeruloplasmin levels in liver disease?
Low
100
Caeruloplasmin levels in Wilson’s?
Low (due to liver disease)
Urinary copper will be high
101
What is a tumour marker for HCC?
AFP
102
1st line investigation for assessing fibrosis in NAFLD?
Enhanced liver fibrosis (ELF) test
103
What investigation can help determine liver fibrosis?
Transient elastography (fibroscan)
104
Who is a transient elastography used in?
Patients AT RISK of cirrhosis:
1) Alcohol-related liver disease
2) Heavy alcohol drinkers
3) NAFLD & advanced liver fibrosis (indicated by ELF test)
4) Hep C
5) Chronic hep B
105
What score gives an estimated 3-month mortality as a percentage for patients with compensated cirrhosis?
MELD (Model for End-Stage Liver Disease) score
106
How often should MELD score be used?
Every 6 months in patients with compensated cirrhosis.
107
What score measures the severity of cirrhosis & prognosis?
Child-Pugh score
108
How are complications monitored for in cirrhosis?
1) MELD score every 6m
2) US & AFP every 6m
3) Endoscopy every 3 years for oesophageal varices
109
What are the 4 key features of decompensated liver failure?
AHOY
A: Ascites
H: Hepatic encephalopathy
O: Oesophageal varices
Y: Yellow (jaundice)
110
How does cirrhosis lead to splenomegaly?
Portal HTN
111
If beta blockers are contraindicated, what is the next option for prophylaxis of bleeding in stable oesophageal varices?
Variceal band ligation
112
What are the 2 main indications for TIPS?
1) refractory ascites
2) bleeding oesophageal varices
113
How does cirrhosis lead to fluid and sodium retention?
1) Loss of fluid to peritoneal cavity (ascites)
2) The drop in circulating volume caused by fluid loss into the peritoneal cavity causes reduced blood pressure in the kidneys.
3) Kidneys release renin in response
4) This causes increased aldosterone secretion via the renin-angiotensin-aldosterone system.
5) Increased aldosterone causes the reabsorption of fluid and sodium in the kidneys
114
When are prophylactic abx indicated in ascites?
<15 g/L protein in ascitic fluid
115
What are the 2 most common organisms causing SBP?
1) E. coli
2) Klebsiella
116
Mx of SBP?
1) Taking a sample of ascitic fluid for culture before giving antibiotics
2) IV broad-spectrum antibiotics according to local policies (e.g., piperacillin with tazobactam)
117
What is most important toxin that can build up in cirrhosis?
Ammonia
118
What is Abx of choice in hepatic encephalopathy?
Rifaximin
119
Define binge drinking
6 or more units for women or 8 or more units for men in 1 sitting
120
What AUDIT score indicates harmful drinking?
≥8
121
What is metabolic syndrome?
Obesity + diabetes + HTN
122
What is often first indication in LFTs that a patient has NAFLD?
Raised ALT
123
What is the normal AST:ALT ratio?
<1
124
ALT vs AST in NAFLD?
ALT is typically greater than AST
(compared to alcohol fatty liver)
125
What gene mutation is involved in haemochromatosis?
C282Y mutation in human haemochromatosis protein (HFE) gene on chromosome 6
126
What can be used to establish the iron concentration in the liver?
Liver biopsy with Pearl's stain, or MRI
127
Complications of haemochromatosis?
) 2ary diabetes (iron affects the functioning of the pancreas)
2) Liver cirrhosis
3) Endocrine and sexual problems (hypogonadism, erectile dysfunction, amenorrhea and reduced fertility)
4) Cardiomyopathy (iron deposits in the heart)
5) HCC
6) Hypothyroidism (iron deposits in the thyroid)
7) Chondrocalcinosis (calcium pyrophosphate deposits in joints) causes arthritis (pseudogout)
128
How is copper excreted?
In the bile
129
What is A1AT?
Protease inhibitor
130
What is a critical protease enzyme that is inhibited by alpha-1 antitrypsin?
Neutrophil elastase.
131
What can a liver biopsy show in alpha-1 antitrypsin deficiency?
Liver biopsy shows periodic acid-Schiff positive staining globules in hepatocytes, resistant to diastase treatment.
These represent a buildup of the mutant proteins.
132
What is the 1st line treatment for patients with advanced (including metastatic) HCC?
Sorafenib
133
