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1
Q

What is autoimmune hepatitis?

A

A chronic liver disease with autoantibodies and raised IgG

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2
Q

Who is mostly affected by autoimmune hepatitis

A

Young women

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3
Q

Features of autoimmune hepatitis

A 
Signs of chronic liver disease
Acute hepatitis
Jaundice
Hepatomegaly
Amenorrhoea
Nausea
Fatigue, pruritis
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4
Q

Which immunoglobulin is involved in autoimmune hepatitis?

A

IgG

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5
Q

Management of autoimmune hepatitis

A

Steroids
Immunosuppression with azathioprine
Liver transplant

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6
Q

How to calculate number of units of alcohol

A

number of ml x ABV and divide by 1000

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7
Q

Recommended number of alcoholic units per week

A

14

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8
Q

How many units in 25ml of pure spirit?

A

1

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9
Q

How many units in a pint of beer?

A

3

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10
Q

How many units in half a 175ml standard glass of wine?

A

1

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11
Q

What type of drug is sulphasalazine?

A

5-aminosalicyclic acid

Combined with a sulphonamide called sulphapyridine

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12
Q

Side effects of sulphasalazine

A 
Rashes
Oligospermia
Headache
Heinz body anaemia
Megaloblastic anaemia
Lung fibrosis
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13
Q

What type of drug is mesalazine?

A

delayed release 5-aminosalicyclic acid

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14
Q

Side effects of 5-aminosalicyclic acid medications

A 
GI upset
Headache
Agranulocytosis
Pancreatitis
Interstitial nephritis
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15
Q

Which 5-aminosalicyclic acid is typically associated with pancreatitis?

A

Mesalazine

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16
Q

Examples of 5-aminosalicyclic acid drugs

A

Sulphasalazine
Mesalazine
Olsalazine

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17
Q

Which medical condition is associated with cyclical vomiting syndrome?

A

Migraine

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18
Q

Cyclical vomiting syndrome - acute management

A

Ondansetron
Prochlorperazine
Triptans

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19
Q

Cyclical vomiting syndrome - prophylaxis

A

Amitryptilline
Propranolol
Topiramate

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20
Q

Inheritance of Gilbert’s syndrome

A

Autosomal recessive

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21
Q

What is Gilbert’s syndrome?

A

Defective conjugation of bilirubin

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22
Q

Features of Gilbert’s syndrome

A

Unconjugated hyperbilirubinaemia

Jaundice during illness, fasting, exercise

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23
Q

Investigations for Gilbert’s syndrome

A

Rise in bilirubin after fasting or IV nicotinic acid

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24
Q

Mechanism of action of metoclopramide

A

D2 receptor antagonist

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25
Side effects of metoclopramide
Extrapyramidal effects - oculogyric crisis Hyperprolactinaemia Tardive dyskinesia Parkinsonism
26
Referral method for a patient with dysphagia
Urgent
27
Referral method for a patient with upper abdominal mass consistent with gastric cancer
Urgent
28
Referral method for patients 55 years+ who have weight loss AND upper abdo pain
Urgent
29
Referral method for patient over 55 with treatment resistant dyspepsia
Routine
30
Referral method for patient with haematemesis
Routine
31
Referral method for patient over 55 with weight loss and reflux
Urgent
32
Referral method for patient over 55 with weight loss and dyspepsia
Urgent
33
Referral for patients over 55 with upper abdo pain and low haemoglobin
Routine
34
Referral for patients over 55 with raised PLT count plus: nausea, vomiting, reflux, dyspepsia, upper abdo pain
Routine
35
Testing for H pylori
Carbon-13 urea breath test Stool antigen test "Test and treat"
36
Inherited causes of unconjugated hyperbilirubinaemia
Gilbert's syndrome | Crigler-Najjar syndrome
37
Crigler-Najjar syndrome basic facts
Autosomal recessive Type 1 will not survive to adulthood Type 2 may improve with phenobarbital
38
Inherited causes of conjugated hyperbilirubinaemia
Dubin-Johnson syndrome | Rotor syndrome
39
Dubin-Johnson syndrome
``` Autosomal recessive Common in Iranian Jews Defective hepatic excretion of bilirubin Grossly black liver Benign ```
40
Rotor syndrome
Autosomal recessive Defect in the hepatic uptake and storage of bilirubin Benign
41
Drug causes of liver cirrhosis
Methotrexate Methyldopa Amiodarone
42
Drug causes of cholestasis
Combined oral contraception Flucloxacillin, co-amoxiclav, erythromycin Anabolic steroids
43
What is the MELD scoring system for?
Liver cirrhosis
44
PPI mechanism of action
Irreversible blockade of H+/K+ ATPase of gastric parietal cell
45
Side effects of PPIs
``` Hyponatraemia Hypomagnesaemia Osteoporosis Microscopic colitis Increased risk of c. diff ```
46
Plummer-Vision syndrome
Dysphagia Glossitis Iron deficiency anaemia
47
Treatment of Plummer-Vision syndrome
Dilation of webs | Iron supplements
48
Booerhaave syndrome
Oesophageal rupture due to severe vomiting
49
Melanosis coli
Pigmentation of the bowel wall | Pigment laded macrophages
50
Cause of melanosis coli
Laxative abuse | particularly senna
51
What is ferritin?
Intracellular protein that binds to iron and stores it to be released in a controlled fashion at sites where iron is required
52
Causes of raised ferritin without iron overload
``` Inflammation Alcohol excess Liver disease CKD Malignancy ```
53
Causes of raised ferritin with iron overload
Hereditary haemochromatosis Following repeated transfusions
54
How do you assess whether there is iron overload?
Transferrin saturation
55
What is a normal transferrin saturation?
<45% in women <50% in men
56
Causes of reduced ferritin
Iron deficiency anaemia
57
What is cholestyramine?
Bile acid sequestrant
58
How does cholestyramine work?
Reduces bile acid reabsorption in the small intestine
59
Who is cholestyramine used for?
Hyperlipidaemia Increases amount of cholesterol coverted to bile acids Reduces LDL
60
Side effects of cholestyramine
``` Abdominal pain Constipation Cholesterol gallstones May raise Triglyceride levels Decreased absorption of fat soluble vitamins ```
61
What is pellegra?
Disease due to lack of vitamin B3, niacin
62
What is niacin
Vitamin B3
63
Features of pellegra
``` Inflamed skin Diarrhoea Dementia Sores in the mouth Skin becomes darker ```
64
Management of alcoholic hepatitis
Prednisolone | Pentoxyphylline
65
Crohn's disease - pathology
``` Mouth to anus Inflammation of all layers down to serosa Skip lesions Goblet cells, granulomas Strictures, fissures, adhesions ```
66
Crohn's disease - features
``` Weight loss, lethargy Diarrhoea which may be bloody Abdominal pain Anal skin tags Anal ulcers ```
67
Crohn's disease and UC - extra intestinal disease which is related to disease activity
Arthritis (asymmetrical) Erythema nodosum Episcleritis Osteoporosis
68
Crohn's disease and UC - extra intestinal disease which is not related to disease activity
Arthritis (symmetrical) Uveitis Pyoderma gangrenosum Clubbing
69
Crohn's disease - investigations
Raised ESR and CRP Raised faecal calprotectin Low B12, low Vit D Anaemia
70
Crohn's disease - inducing remission
``` Steroids 5-aminosalicylate drugs Elemental diet Azathioprine or mecaptopurine Methotrexate Infliximab in refractory cases ```
71
Crohn's disease - maintaining remission
Azathioprine or mercaptopurine
72
Bile acid malabsorption - primary causes
Excessive production of bile acid
73
Bile acid malabsorption - secondary causes
GI disorder preventing bile acid absorption, e.g. Crohn's Cholecystectomy Coeliac disease Small intestinal bacteria overgrowth
74
Bile acid malabsorption - investigations
Nuclear medicine SeHCAT
75
Bile acid malabsorption - management
Bile acid sequestrants - cholestyramine
76
Bile acid malabsorption - features
Chronic diarrhoea Steatorrhoea Vitamin A, D, E, K malabsorption
77
What is angiodysplasia?
Vascular deformity in the GI tract which predisposes to bleeding and IDA
78
Who is affected by angiodysplasia?
Elderly | Possible link to aortic stenosis
79
Angiodysplasia - diagnosis
Colonoscopy | Mesenteric angiography if acutely bleeding
80
Angiodysplasia - management
Endoscopic cautery or coagulation Antifibrinolytics - tranexamic acid Oestrogens
81
What is achalasia?
Failure of oesphageal peristalsis | Failure of relaxation of LOS
82
Achalasia - who is affected?
Middle age | Men and women
83
Achalasia - presentation
Dysphagia to liquids AND solids Variation in symptom severity Heartburn Regurgitation of food (may cause cough, pneumonia) Malignant change in small number of patients
84
Achalasia - investigations
Oesophageal manometry Barium swallow CXR
85
Achalasia - what does oesophageal manometry show?
Excessive LOS which doesn't relax on swallowing
86
Achalasia - what does barium swallow show?
Grossly expanded oesophagus with fluid level | 'birds beak' appearance
87
Achalasia - what does chest xray show?
Wide mediastinum | Fluid level
88
Achalasia - management
Pneumatic balloon dilation Surgery if persistent symptoms Botox if unfit for surgery
89
What is Budd chiari syndrome?
Hepatic vein thrombosis
90
Budd chiari syndrome - features
Sudden severe abdominal pain Ascites causing abdominal distension tender hepatomegaly
91
Budd chiari syndrome - investigations
Doppler ultrasound
92
Budd chiari syndrome - causes
Polycythaemia vera Thrombophilia Pregnancy Combined oral contraceptive pill
93
What is carcinoid syndrome?
When carcinoid tumours release serotonin into systemic circulation
94
Where are the tumours that normally cause carcinoid syndrome?
Liver metastasis Sometimes lung carcinoid
95
Carcinoid tumours - features
``` Flushing Diarrhoea Bronchospasm Hypotension Pellegra ```
96
Carcinoid tumours - investigations
Urinary 5-HIAA | Plasma chromoranin A y
97
Carcinoid tumours - management
Somatostatin analogues - octreotide | Cyproheptadine for diarrhoea
98
What percentage of colorectal cancers are caused by HNPCC?
5%
99
Inheritance of HNPCC
Autosomal dominant
100
What cancers are HNPCC at risk of?
Colorectal in 90% patients | Endometrial
101
What percentage of colorectal cancers are caused by FAP?
<1%
102
Inheritance of FAP
Autosomal dominant
103
Management of FAP
Total colectomy by mid 20's
104
Gardner's syndrome
``` Variation of FAP Osteomas of skull and mandible Retinal pigmentation Thyroid ca Epidermoid cysts on the skin ```
105
What is haemochromatosis?
Disorder of iron absorption and metabolism resulting in iron accumulation
106
Haemochromatosis - genetics
Majority due to HFE gene on chromosome 6 Autosomal recessive 1 in 10 carry gene, 1 in 200 have disease
107
Haemochromatosis - screening
General population: transferrin saturation, ferritin Family members: HFE mutation
108
Haemochromatosis - features
``` Fatigue Erectile dysfunction Arthralgia Bronze skin pigmentation Diabetes Chronic liver disease Cardiac failure secondary to dilated cardiomyopathy ```
109
Haemochromatosis - reversible features
Cardiomyopathy | Skin pigmentation
110
Haemochromatosis - irreversible features
Liver cirrhosis Diabetes Hypogonadotrophic hypogonadism Arthropathy
111
Haemochromatosis - investigations
``` Raised transferrin, ferritin and iron Low TIBC Gene mutation - HFE Liver biopsy shows Perl's stain Joint xrays - chondrocalcinosis ```
112
Haemochromatosis - management
Venesection | Desferrioxamine
113
NAFLD - features
Usually asymptomatic Hepatomegaly ALT > AST Increased echogenecity on ultrasound
114
NAFLD - how to assess for fibrosis
ELF - enhanced liver fibrosis blood test NAFLD fibrosis score Fibroscan
115
NAFLD - spectrum of disease
1) Steatosis 2) Steatohepatitis - fat with inflammation (NASH) 3) progressive disease leading to fibrosis and liver cirrhosis
116
NAFLD - management
Weight loss Monitoring Possible future management with insulin sensitising drugs e.g. metformin
117
Pancreatic cancer - pathology
80% adenocarcinomas found at pancreatic head
118
Pancreatic cancer - features
Painless jaundice Epigastric pain Weight loss Loss of exocrine function causes steatorrhoea Loss of endocrine function causes diabetes Atypical back pain Migratory thrombophlebitis
119
Pancreatic cancer - investigations
Ultrasound | High resolution CT
120
Pancreatic cancer - associations
``` Age Smoking Diabetes Chronic pancreatitis HNPCC BRCA2 MEN ```
121
Pancreatic cancer - management
Majority not suitable for surgery by time of presentation - Whipple's resection Stenting for palliation
122
Ulcerative colitis - disease location
Rectum Never spreads beyond ileocaecal valve Continuous disease
123
Ulcerative colitis - pathology
No inflammation beyond submucosa Widespread ulceration leads to "pseudopolyps" Crypt abscesses Inflammatory cell infiltrate in lamina propria
124
Ulcerative colitis - features
Bloody diarrhoea Urgency Tenesmus Abdo pain
125
Ulcerative colitis - findings on barium enema
Loss of haustrations Superficial ulcerations "pseudopolyps" Long standing disease causes short and narrow colon called drainpipe colon
126
Ulcerative colitis - symptoms of mild flare
less than 4 per day With or without blood Normal ESR/CRP
127
Ulcerative colitis - moderate flare
4-6 per day | Minimal systemic disturbance
128
Ulcerative colitis - severe flare
>6 per day With blood Systemic disturbance
129
Ulcerative colitis - triggers for flares
Stress NSAIDS Antibiotics Smoking cessation
130
Ulcerative colitis - inducing remission
Topical or oral mesalazine Topical or oral steroids IV steroids IV ciclosporin
131
Ulcerative colitis - maintaining remission
Topical or oral mesalazine Oral azathioprine if multiple relapses Probiotics can help prevent relapse
132
What is Peutz-Jegher's syndrome?
Numerous hamartomatous polyps in the GI tract
133
Peutz-Jegher's syndrome - inheritance
Autosomal dominant
134
Peutz-Jegher's syndrome - features
Hamartomatous polyps in GI tract Pigmented lesions on lips, oral mucosa, face, palms, soles Intestinal obstruction GI bleeding
135
Peutz-Jegher's syndrome - malignancy risk
Polyps don't have malignant potential but 50% die by age 60 of cancer
136
Peutz-Jegher's syndrome - management
Screen family members | Colorectal surveillance every 2 years from age 25
137
Functions of vitamin A
Converted to retinal Important for epithelial cell differentiation Antioxidant
138
Consequences of vitamin A deficiency
Night blindness
139
What causes Whipple's disease?
Tropheryma whippelii
140
Whipple's disease - features
Malabsorption causing weight loss and diarrhoea Large joint athralgia Lymphadenopathy Hyperpigmentation, photosensitivity Pleurisy, pericarditis Neuro symptoms = dementia, seizures, ataxia
141
Whipple's disease - investigations
Jejunal biopsy - macrophages contain periodic acid-shiff (PAS) granules
142
Whipple's disease - management
Oral co-trimoxazole for 1 year | Sometimes IV penicillin prior to orals
143
Wilson's disease - inheritance
Autosomal recessive
144
Wilson's disease - pathology
Excessive copper deposition in tissues
145
Wilson's disease - when does it present?
Age 10-25 liver symptoms in children neuro symptoms in adults
146
Wilson's disease - features
``` Hepatitis, cirrhosis Speech and psychiatric problems Chorea, Parkinsonism, dementia Kayser-Fleischer rings Renal tubular acidosis Haemolysis Blue nails ```
147
Wilson's disease - investigations
Raised free serum copper Raised 24 hour urinary copper excretion Low serum caeruloplasmin Low total serum copper
148
Wilson's disease - management
Penicillamine
149
What is primary sclerosing cholangitis?
inflammation and fibrosis of the intra and extra hepatic bile ducts
150
Primary sclerosing cholangitis - associations
Ulcerative colitis Crohn's HIV
151
Primary sclerosing cholangitis - features
Cholestasis causing jaundice, pruritis, increased bilirubin, increased ALP RUQ pain Fatigue
152
Primary sclerosing cholangitis - Investigations
MRCP - biliary strictures giving beaded appearance pANCA liver biopsy - fibrous obliterative colangitis 'onion skin' Raised bilirubin, raised ALP
153
Primary sclerosing cholangitis - complications
Cholangiocarcinoma in 10%
154
Primary sclerosing cholangitis - management
Symptomatic | liver transplant
155
Management of pruritis from liver disease
Colestyramine
156
What is clostridium difficile?
gram negative rod produces exotoxin that causes pseudomembranous colitis
157
C diff - risk factors
PPIs Clindamycin Cephalosporins - ceftriaxone, cefotaxime
158
C diff - features
Diarrhoa Abdo pain Raised WCC Toxic megacolon
159
C diff - diagnosis
C diff toxin in the stool
160
C diff - management
1) Oral metronidazole 2) Oral vancomycin 3) Oral vancomcyin + IV metronidazole
161
Coeliac disease - associations
``` Autoimmune thyroid disease Dermatitis herpetiformis IBS T1DM 1st degree relative ```
162
Coeliac disease - features
``` Diarrhoea FTT Persistent GI symptoms - nausea, vomiting, abdo pain Prolonged fatigue Weight loss ```
163
Coeliac disease - investigations
anaemia tissue transglutaminase antibody endomyseal antibody biopsy
164
Coeliac disease - why do you need to test for endomyseal antibody?
To check for selective IgA deficiency which would give a false negative
165
Coeliac disease - biopsy findings
Villous atrophy Crypt hyperplasia Increased intraepithelial lymphocytes Lamina propria infiltration with lymphocytes
166
Coeliac disease - management
Gluten free diet | Pneumoccal vaccine
167
Coeliac disease - complications
``` Anaemia, low B12, low folate Hyposplenism Lactose intolerance Enteropathy associated T cell lymphoma of small intestines Subfertility ```
168
IBS - management
1st line: Symptomatic | 2nd line: linaclotide in constipation type, low dose tricyclic antidepressant (amitryptilline)
169
IBS - dietary advice
``` regular meals, 8 cups of fluid per day Limit high fibre food Oats and linseeds for bloating Limit fruit to 3 portions Limit tea/coffee to 3 ```
170
What is H pylori?
Gram negative bacteria associated with GI disease
171
H pylori - associations
Peptic ulcers Gastric cancer B cell lymphoma of MALT tissue Atrophic gastritis
172
H pylori - management
7 days of PPI + amoxicillin + clari OR met If pen allergic: PPI + clari + met
173
What is vitamin C needed for?
Collagen synthesis Facilitates iron absorption Cofactor for norepinephrine synthesis
174
What does vitamin C deficiency cause?
Scurvy Impaired collagen synthesis causes capillary fragility and poor wound healing
175
Features of scurvy
Gingivitis, loose teeth Poor wound healing Bleeding from gums, haematuria, epistaxis Malaise
176
Risk factors for scurvey
Severe malnutrition Drug abuse, alcohol abuse Poverty
177
What is vitamin C found in?
``` Citrus fruits Potatoes, tomatoes Sprouts Cauliflower, broccoli Cabbage Spinach ```
178
Hepatocellular carcinoma - most common cause in Europe
Chronic hep C
179
Hepatocellular carcinoma - most common cause worldwide
Chronic hep B
180
Hepatocellular carcinoma - presentation
Features of liver cirrhosis or failure Raised AFP Acute decompensation in a patient with chronic liver disease
181
Causes of cirrhosis
``` Chronic hep B Chronic hep C Alcohol Haemochromatosis Primary biliary cholangitis ```
182
Features of liver cirrhosis
``` Jaundice Ascites RUQ pain Hepatomegaly Splenomegaly Pruritis ```
183
How do you screen for HCC?
Ultrasound +/- AFP
184
Who gets screened for HCC?
Cirrhosis secondary to hep B, hep C or haemachromatosis Men with cirrhosis secondary to alcohol
185
Hepatocellular carcinoma - management
Surgical resection liver transplant Radiofrequency ablation Transarterial chemoembolisation
186
Primary biliary cholangitis - pathology
Intralobular bile ducts damaged by chronic inflammation Causes progressive cholestasis May progress to cirrhosis
187
Primary biliary cholangitis - cause
Autoimmune
188
Primary biliary cholangitis - who is affected?
Middle aged women
189
Primary biliary cholangitis - features
``` Asymptomatic Pruritis Cholestatic jaundice Hyperpigmentation over pressure points RUQ pain Xanthelasma Clubbing Hepatosplenomegaly ```
190
Primary biliary cholangitis - investigations
Antimitochondrial antibodies Smooth muscle antibodies Raised IgM Ultrasound/MRCP to exclude extrahepatic biliary obstruction
191
Primary biliary cholangitis - complications
Cirrhosis HCC Osteomalacia, osteoprosis
192
Primary biliary cholangitis - management
Ursodeoxycholic acid Cholestyramine for pruritis Liver transplant
193
Features of globus hystericus
Anxiety history Painless Intermittent symptoms relieved by swallowing
194
Oesophageal cancer - features
Dysphagia Weight loss Vomiting
195
Oesophageal cancer - investigations
Upper GI endoscopy Staging CT Staging ultrasound Staging laparoscopy
196
Oesophageal cancer - management
Surgical resection + chemo
197
Oesophageal cancer - two types
Adenocarcinoma and squamous cell carcinoma
198
Oesophageal cancer - adenocarcinoma location
lower 3rd
199
Oesophageal cancer - adenocarcinoma risk factors
``` GORD Barrett's Smoking Achalasia Obesity ```
200
Oesophageal cancer - squamous cell location
Upper 2/3rds
201
Oesophageal cancer - squamous cell risk factors
Smoking Alcohol Achalasia Plummer-Vison syndrome
202
Oesophageal cancer - which type is most common in the UK?
Adenocarcinoma
203
What is Barrett's oesophagus?
Metaplasia of the lower oesophageal mucosa from squamous epithelium to columnar
204
Barrett's oesophagus - risk factors
GORD male smoking central obesity
205
Barrett's oesophagus - management
Endoscopic surveillance every 2-5 years | High dose PPI
206
Barrett's oesophagus - risk
50-100 fold increased risk of carcinoma
207
Features of ascending cholangitis
Fever RUQ pain Jaundice
208
What is ascending cholangitis?
infection of bile ducts
209
Features of acute cholecystitis
Severe persistent RUQ pain Radiates to back/shoulders Pyrexia Murphy's sign positive
210
Features of cholangiocarcinoma
``` Persistent biliary colic Jaundice, weight loss Palpable mass RUQ Left supraclavicular LN Periumbilical LN ```
211
Features of amoebic liver abscess
Malaise, anorexia, weight loss | Mild RUQ
212
Features of gallstone ileus
Abdo pain and distension | Vomiting
213
What is gallstone ileus?
Small bowel obstruction secondary to impacted gallstone
214
What causes gallstone ileus?
May develop if fistula forms between gangrenous gallbladder and duodenum
215
What is congestive hepatomegaly?
Liver pain due to capsular stretch | Normally due to congestive heart failure
216
Features of viral hepatitis
Nausea, vomiting, mylagia Lethargy RUQ pain
217
Risk factors for viral hepatitis
IVDU | Foreign travel
218
What is the best way to screen for cirrhosis?
Fibroscan
219
What amount of alcohol would make you refer for fibroscan?
Men >50 units | Women >25 units
220
Best questionnaire to assess for alcohol misuse?
AUDIT
221
What is the most common extra-intestinal feature in both Crohn's and UC?
Arthritis
222
How many ml in one pint?
568
223
Testing for H. pylori post-eradication therapy
Urea breath test
224
What is the main mode of action of linaclotide?
Increases the amount of fluid in the intestinal lumen

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