Gastro Flashcards

Question

What is the mechanism of increased resistance in portal HTN?

Answer 1

increased fibrosis decreased NO

Answer 2

HLA DR3 and DR4/8 very steroid sensitive associated with hypergammaglubulinemia (2x IgG level) AST >10x or AST >5x Type 1: ANA, Anti smooth muscle, Anti actin b (adults/children), 99% specific, sens 43% Type 2: Anti LKM 1 (children only), 99% specific Type 3: Soluble liver-kidney antigen - middle age adults Raised IgG level **liver biopsy:** inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis Tx: 1. steroids if symptomatics 2. +/- Azathiopurines Normalisation of lab takes >12months

Answer 3

bili >50 with impaired renal function Low protein <10g/L in ascites

Answer 4

15-18 months after ## Footnote - Hepatitis C antibody testing should not be done immediately after birth due to maternal transmission of antibodies - Whilst hepatitis C RNA is transmitted via breast milk this does not cause an increased risk of transmission. - Hepatitis b and HIV have much higher rates of vertical transmission compared to hepatitis C. - the risk of hepatitis C transmission is higher in patients who have HIV co-infection.

Answer 5

age >40 malnutrition CYP2c1 inducers (carbamazepine, phenytoin) Hypophosphataemia is protective

Answer 6

Terlipressin

Answer 7

portal vein thrombosis, hepatic encephalopathy, advanced HCC, pulm HTN

Answer 8

B: slow, low activity of disease C: associated with higher rates of HCC and cirrhosis F: associated with fulminant liver disease

Answer 9

This is a rare neuroendocrine tumor typically of the pancreas and with high malignant potential. The clinical syndrome of watery diarrhea, hypokalemia, acidosis, hypochlorhydria, and hypercalcemia.

Answer 10

* Childs Pugh C * Alcohol use * Red wale sign present endoscopically * high portal pressures >12mmHg * Hx of prev variceal bleed

Answer 11

alcoholic disease and NAFLD

Answer 12

1. High HBV DNA, HBeAg +ve, normal LFTs 2. High HBV DNA, HBeAg +ve, Abnormal LFTs 3. Low HBV DNA, HBeAg -ve, normal LFTs 4. High HBV DNA, HBeAg -ve, Abnormal LFTS

Answer 13

Immune clearance and Immune escape

Answer 14

associated with reduced survival and increased rate of hepatorenal syndrome

Answer 15

For patients who opt for a PPI, the clinical response should be evaluated after an eight-week course of treatment with repeat endoscopy. PPIs and corticosteroid therapy are effective therapy with similar efficacy. six-food elimination diet can improve symptoms and esophageal eosinophilia and help identify causative foods. As a result, a six-food elimination diet is a reasonable primary option for adults

Answer 16

Being male, elderly, caucasian and obese

Answer 17

endocrine (gastrin) paracrine (locally delivered histamine and somatostatin) neural (acetylcholine) autocrine (transforming growth factor-alpha) factors

Answer 18

Albumin28-35 Bilirubin 20-30 PT/INR Ascites Encephalopathy 1 year survival: A: 100% B: 80% c: 45%

Answer 19

Associated in IBF (crohn's) - early surgery due to stricturing disease

Answer 20

- increased CS free survival - Better mucosal healing - Improvement in mayo score - Reduction in faecal calprotectin REDUCED serious infection cf. aza alone

Answer 21

Anti IF 100% specific, low sensitivity Anti parietal: high sensitivity, less specific

Answer 22

MMA is elevated in B12 def, not folate HomoC is elevated in both

Answer 23

Cholestatic

Answer 24

- steroids at diagnosis - perianal dx - <40 - Smoking - high ASCA titre - NOD2 - UGI involvement - strictures - deep ulcers

Answer 25

<40 extensive disease PSC high pANCA titre deep ulcers

Answer 26

microscopic colitis - chornic diarrhoea - tx: budesonide, may need MTx for maintenance)

Answer 27

Azathiopurine - usually around 3 weeks from starting tx Other aza related: Serum like sickness **Myelosupression - dependent on 6TG level** **Hepatitis (related to 6MMP, dose dependent)** Non-melanoma skin cancer Lymphoma: >65, young male w EBV neg

Answer 28

Infliximab

Answer 29

dysplasia fluminant colitis/toxic megacolon failure of medical therapy

Answer 30

Pouchitis - 1/3 will develop it - 2/3 of above will develop recurrent pouchitis - of that, 1/4 will develop chronic pouchitis Criteria: Diarrhoea >6/da, endoscopic: oedema, granularity, friability, loss of vascular pattern, mucosal haem, or ulceration (4) Polymorphonuclear leucocyte infiltrate and percetnage of ulceration Female infertility Incontinence Pouch failure

Answer 31

Precursor to oesophageal adenocarcinoma - metaplasia of squamous to columnar - RF: chronic GORD, Age>50, overweight, high SES, alcohol, smoking 1. after initial dx --> repeat scope in 1 year to check for dysplasia 2. if no dysplasia on 2 scope biopsies: 3 year FU -> if no dysplasia --> long term PPI If low grade dysplasia: repeat scope in 1 year if high grade dysplasia --> surgical resection if not medically fit: 3 monthyl scope or endoscopic ablative therapy

Answer 32

Rapid onset of benefit Lower rate of complications reduced mortality and rebleeding

Answer 33

IGV 1 (Fundus) >GOV1 or GOV2 or IGV2

Answer 34

1. cardiopulm disease that cannot be corrected 2. Malignancy outside of the liver <5yrs - not including superficial skin cancers 3. Active alcohol or drug use (must be abstinent for 6 months) 4. raised ICP in acute liver failure AIDS/Age/Obesity are relative CI

Answer 35

Chronic pancreatitis

Answer 36

Mucinous cystic neoplasm IPMN NET ## Footnote pseudocyst serous cystoadenoma are both benign

Answer 37

Smoking Chronic pancreatitis CF BRCA2 >BRCA1 LYNCH sx Peitz-Jeghers syndrome Hereditary pancreatitis FAMMM FDR - MORE = HIGHER RISK ## Footnote 9% SURVIVE 5 YEARS

Answer 38

gram negative curved rod with flagella - duondenal ulcers - worse gastritis - CagA= more virulent, produces VacA cytotoxin *antiCagA ab can cross react with platelet antigen --> ITP) - reduced oesophageal cancer - Eradication ==> long term remission of PUD - Resistance: - Clarithromycin 94%, Metronidazole 68% - Tx: Amoxil, tetracycline, bismuth +/- levofloxacin | only give triple therapy if clarithro resistance is <15% and known ## Footnote in the absence of knowledge about resistance, USE QUADRUPLE THERAPY for 14 days

Answer 39

no change in death, transfusion, intervention, but increased risk of venous events

Answer 40

NO A + clopi is safer than clopi alone weird right!

Answer 41

Spurler > NBVV> clot > dot > clean base

Answer 42

- control active bleeding (90%) - Reduce rebleeding - improve morbidity - reduce mortality ## Footnote Adrenaline + Endoscopic secondary haemostatic modality (any) --> improves all outcomes

Answer 43

High dose PPI infusion for 72hr: improves rebleeding in 3 days, 30 days, morbidity, surgery, mortality at 30d LOS transfusion need

Answer 44

similar rebleeding rate and transfusion requirements, and mortality

Answer 45

start aspirin within a week There is a increase risk of bleed at 4 weeks, but higher death if you don't

Answer 46

atleast 4 weeks after tx WH abx and bismuth >28 days WH PPI >14 days Tests: urea breath test, faecal antigen test *serology takes 2 years to clear*

Answer 47

- restart APA on day 3 - if onDAPT: - continue aspirin - if low risk stigmata (Forrest 2c/3) continue DAPT

Answer 48

Dabi and Riva (not Apixaban) has higher bleeding cf warfarin INR <2.5 can scope with warfarin ## Footnote Best cumulative survival data would recommend restarting 1-2 weeks

Answer 49

Histology: villous atrophy intraepithelial lymphocytosis Cryot hyperplasia Anti TTG is test of choice (but check IgA level) Anti-endomysial IgA (is also specific) IgG test: Anti-DGP, Antiendomysial IgG, Anti TTG IgG Associated with T1DM and other autoimmune **HLA DQ2/DQ8** Down's syndrome, Turner's, William's Pancreatitis There is an increases risk of SB adenocarcinoma

Answer 50

Avoid wheat, rye, barley *Oat crossreactivity is rare*

Answer 51

Fe deficiency Fat soluble vitamin DEKA B12 Folate Copper def Vitamin def --> bone dx in 25%

Answer 52

Anti-TTG 3-6 monthly, then annually *histological can take years* Non-responsive: - persistent sx, lab despite 6-12 gluten avoidance - causes: >inadvertent gluten ingestion >other food >SIBO >Microscopic colitis >IBS >refractory CD

Answer 53

sx: dysphagia and food impaction, CP, heartburm, abdominal pain, refractory GERD Solid>fluid Common in young men Assoc: with CBZ hypersensitivity syndrome **Histology:** >15 intraepithelial eos/HPF >Basal zone hyperplasia >dilated intercellular spaces **Endoscopic:** Longitudinal furrows Oedema reduce vasculature excudate concentric rings strictures Tx: > 6 food elimination diet: **Milk, wheat,** eggs, soy, nuts, fish/shellfish > then reintroduce one at a time >Elemental diet: 93% response >most respond to PPI (?NERD vs antiinfl effect of PPI) >Topical steroids: fluticasone, **budesonide,** ciclesonide >Dilation: 7% risk of perf, 75% risk of CP, bleed

Answer 54

Male, caucasian, age, overweight, chronic heartburn *GORD sx for 1 week, increases risk of adeno by 7x*, **smoking, FHx**

Answer 55

**PPI: **reduces progression to HDG or OAC. by 71% High dose PPI +**aspirin** reduces progression **Surgical therapy is no more beneficial than high dose PPI**

Answer 56

rare multi-system disorder caused by **Tropheryma whippelii infection** HLA-B27 +ve and middle aged men **Features** malabsorption: diarrhoea, weight loss large-joint arthralgia lymphadenopathy skin: hyperpigmentation and photosensitivity pleurisy, pericarditis neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus Investigation jejunal biopsy shows deposition of **macrophages **containing **Periodic acid-Schiff (PAS) granules** Management guidelines vary: **oral co-trimoxazole **for a year is thought to have the lowest relapse rate, sometimes preceded by a course of IV penicillin

Answer 57

Ammonia is produced by enterocyte from glutamine. Healthy liver clears the ammonia by **converting it to glutamine** *muscle can also remove ammonia peripherally* **hypokalaemia increases renal ammonia production**

Answer 58

Lactulose Rifaximin Protein restriction is not recommended - can substitute to vegetable protein

Answer 59

>11 g/L or 1.1 = portal HTN, alcoholic hepatitis, HF etc <11 or 1.1 - malignancy - TB - serositis - nephrotic sx - pancreatitis

Answer 60

WCC >500 = abnormal Nt >250/mm3 = peritonitis *if bloody, subtract 1 nt for 250 RBC* TP <10g/L = high risk for SBP Low glucose: bacteria, WCC, malignant cell consumption Perforation: if 2/3 TP >10 Gluc <2.8 LDH >ULN for serum Cytology: 100% positive in peritoneal carcinomatosis

Answer 61

>250 PMN/mm3 Bacteria: E.coli and Klebsiella are the most common Tx: Cefotaxime 2gram Q8H for 5/7, fluoroquinolones - Early abx saves lives Hold NSBB in frail, hypotensive pts **prophylaxis:** - Hx of SBP: Cotrim or fluroquinolone - IP with ascites with TP <10-15: only during hospitalisation - Cirrhosis with GI bleed: Ceftriaxone 1g, then Cotrim or cipro for 7 days ## Footnote Use of PPI in pts with liver disease - increases risk of SBP slightly

Answer 62

>250 PMN/mm3 Bacteria: E.coli and Klebsiella are the most common Tx: Cefotaxime 2gram Q8H for 5/7, fluoroquinolones - Early abx saves lives Hold NSBB in frail, hypotensive pts **prophylaxis:** - Hx of SBP: Cotrim or fluroquinolone - IP with ascites with TP <10-15: only during hospitalisation - Cirrhosis with GI bleed: Ceftriaxone 1g, then Cotrim or cipro for 7 days ## Footnote Use of PPI in pts with liver disease - increases risk of SBP slightly

Answer 63

10: GO varices 12: Variceal bleed 16: decomp-> mortality 20: faillure to control bleed -> low 1 year survival 22: marked increase in mortality

Answer 64

30% mortality with each bleed, 70% will rebleed in 1 year 40% of pts with cirrhosis will have varices Porto-hepatic pressure grad >12mmHg Tx: 1. Primary prevention: Screen yearly >NSBB or endoscopic variceal ligation 2. Secondary prevention: Endoscopic ligation + NSBB > STOP BB in pt with SBP <90, AKI or **hyponatraemia <130** Risk of variceal bleed: 5-15%/year - related to** variceal size ** - risk amplified in progression of Child-pugh score and red wale marks, red sign - alcohol abuse -** HVPG >12mmHg** previous bleed 60-70%

Answer 65

1. Resuscitation **>Hb 70-80** 2. Antibiotic prophylaxsis - reduces mortality 3. Lower the portal pressure >Terlipression (only one to improve mortality) cf. octreotide, sandostatin >TIPSS >Surgical shunt 4. Occlude the varix - **Glue **is superior to banding (only if experienced) < pitfall: too quick or too much --> embolisation, too slow = needle in varix - Ligation is superior to sclerotherapy - Other: balloon tamponade (Sengstaken Blakemore tube), esophageal 5. PPI post banding (reduce post banding ulcers) **aim endoscopy withnin 12hr**

Answer 66

IV vit K Treat infection Optimise renal function Consider DIC (dem. FVIII) Cryoprecipitate (fibrinogen, VIII, XIII, vWF) *PCC and rcom activated FVII has not proven to improve outcomes* Plt >50,000 Hyperfibrynolysis: TXA and epsilon aminocaproic acid

Answer 67

- most common is Non-variceal bleed and most is PUD - Aim Hb 70-90 *(improves survival, reduce further bleed, and AE)*, unless high risk (IHD) aim >90 Endoscopy: <24hr --> reduce LOS, and transfusion requirement

Answer 68

Urea, Hb, SBP, other (syncope, heaptic disease, HF, melena, HR >100) <1: can be OP

Answer 69

1a: active arterial bleeding 2a: NB visible vessel 2b: adherent clot 1b: oozing without visible vessel ***(risk of rebleeding on medical management is lower (10-20), better than 2a, 2b)*** 2c: flat spot 3. clean ulcer base

Answer 70

Predict rebleeding and mortality Age, haemodynamics, comorbidities, dx, Recent haemorrhage

Answer 71

Albumin <30 INR >1.5 Altered mental state SBP Age >65

Answer 72

PUD: - dual therapy *(Inject adrenaline + clip or cauterise)*: reduction in rebleed, surgery, and mortality Glue/powder: allow platelet adherence -> only used as salvage therapy as high risk of rebleeding Salvage therapy: failed haemostatis on 2nd attempt: - hemostatic spray/OTSC - TAE or surgery

Answer 73

Progressive rise in creatinine >150mg/L Normal urine sediment, no proteinuria Absence of shock Urine Na <10-20 Cirrhosis with ascites No response to fluid or no nephrotoxins Reduced cardiac reservce increases the risk of developing HRS Prevention: 1. Precent SBP **2. IV albumin for pt with SBP at diagnosis and on day 3**

Answer 74

HRS with AKI BAD - double creat to >226umol/L or 50% reduction in 24h CrCl to <20ml/min) **in < 2 weeks** - requiring RRT increases mortality significantly Reversal of HRS prior to OLTx affects survival post tx Tx: 1. Volume expansion: Albumin or blood > 1g/kg/d up 100g/d 2. WH NSBB 3. Terlipression *(V1 receptor agonist - vasoconstrict* 1-2mg IV q4-6h with albumin higher reversal of HRS > improved survival in responders > reduced Na retention 4: Hb >80 ## Footnote - median survival 1 month

Answer 75

T-lymphocytic autoimmune dx of small intralobular bile duct - non-obstructive cholestatic disease - Femal 30-60 - 100x increase in FDR - Fatigue and pruritis (worse at night) are the most common sx - elevated **ALP** - Elevated **GGT, 5'nucleotidase ** - eosinophilia (early) - AMA (95% pf pt with PBC and 98% specific) May have: elevated ANA, lipids Other AI: - sjogrens, RA, thyroid dx - metabolic bone dx Tx: Ursodeoxycholic acd - improves liver test - improves disease progression - improves tx free survival - **no effect on pruritis or fatigue**

Answer 76

Paracetamol induced liver failure: - Arterial pH<7.30 **or** Grade 3 or 4 encephalopathy with PT >100sec/INR>6.5 and Cr >340mg/L Non-paracetamol: PT>100sec or any three: - age <10 or >40 - Non A and non-B viral hepatitis, idiosyncratic drug reaction, Wilson - Jaundice >7days prior to encephalopathy - PT>50sec or INR >3.5 - Bili >180mg/L

Answer 77

Vax high risk groups Post exp prophylaxis: - 1 dose of vax within 2 weeks if <40 - if >40, <1, frail or immunocompromised or liver dx: Vax and Ig

Answer 78

Single lesion <5cm or 3 separate lesion<3cm no evidence of vascular invasion no evidence of regional nodal or met sx UCSF: <6.5cm cumulative tumour size < 8cm *sum of tumour size and the number of nodules and Log10 AFP are significant;y associated with HCC specific death *

Answer 79

AST/ALT >2 Mod leucocytotis eleavated AST, ALT <300 Steroids and diet are the only tx that improves mortality **Maddret discrominant score** - >32: give steroids - uses PT and bilirubin MELD >11, high mortality **pentoxifyline: inhibitor of TNF as an alterantive to steroids**

Answer 80

ATP7B mutation AR low ceruloplasmin Liver: steotosis, fulminant hepatic failure, Coombs neg HA, cirrhosis (not HCC) ALP usually normal Neuro: - behaviour - tremor - speech - PD sx - Ataxia - drooling - dystonia - 98% will have KF rings **- MRI: basal ganglia** hyperintensity on T2 elevated copper in CSF Psych: - psychosis, depression anxiety Age of dx: 5-35 Tx: 1. D-penicillamine: > not good for neuro sx (may worsen) 2. Trientine 3. Tetrathiomolybate Diet: AVOID: - liver, kidney, shellfish, nut, fruits, beans, peas, unprocess wheat, chocolate, cocoa, mushroom - Oral zinc --> interferes with Cu absorption

Answer 81

* Obesity (80%) * type 2 diabetes mellitus (60%) ○ T2DM is associated with 2 fold increase in Advance liver fibrosis, HCC, liver mortality * Hyperlipidaemia * Metabolic syndrome * PCOS * jejunoileal bypass *** sudden weight loss/starvation** Other conditions that are associated: Hypothyroidism, OSA, hypopituitarism, Hypogonadism, Pancreatoduodenal resection, Psoriasis

Answer 82

hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1

Answer 83

§ Steotosis (0-3) § Lobular inflammation (0-3) ** § Hepatocellular ballooning (0-2)** >=5 = NASH (fibrosis may or may not be seen ## Footnote FIBROSIS IS THE MAJOR DETERMINANT OF ADVERSE OUTCOMES

Answer 84

FIB 4 Score: Age, AST, ALT, Plt

Answer 85

○ <6 kPa = low liver stiffness, clinically significant fibrosis is very low (NPV 90%) ○** >12.5 kPa** = High working dx of advanced fibrosis or cirrhosis (PPV 80%) ○ To note: fibroscan cannot differentiate between fibrosis and inflammation

Answer 86

- CVD is the most common cause of death in NAFLD pts NAFLD is an independent RF for CVD

Answer 87

- **Histological resolution of NASH** (90% of pts) can occur with10% weight loss - **10% weight loss c**an result in **fibrosis regression** (45% of pts) ○ Exercise independent of weight loss may reduce hepatic disease (reduce HS and improve insulin sensitivity) ○ Mediterranean diet (**high monounsaturated fatty acids)** § Reduce liver fat, improve insulin resistance § Reduce risk of developing metabolic syndrome § Reduce death from CVD in NAFLD pts Coffee reduced progression of fibrosis in patients with NAFLD

Answer 88

- STATINS: ○ Reduce fibrosis and incidence of cirrhosis decompensation and HCC ○ Statin may be used to reduce LDL cholesterol and reduce risk of CVD **○ No proven benefit or harm to liver disease **

Answer 89

- Metformin improved LFTs and insulin sentivity but NOT HISTOLOGY - Pioglitazone: IMPROVES histology including fibrosis VitE: NASH resolution in non-diabetic pt - ADR: **haemorrhagic stroke, prostate cancer**

Answer 90

- Metformin improved LFTs and insulin sentivity but NOT HISTOLOGY - Pioglitazone: IMPROVES histology including fibrosis VitE: NASH resolution in non-diabetic pt - ADR: **haemorrhagic stroke, prostate cancer**

Answer 91

- smoking - high BMI, low physical activity - Non-hereditary chronic pancreatitis - FAmilial cause - BRCA 2, BRCA 1, PALP2 - pancreatic cysts CA19-9 is senstitive/specific 70-90%; needs lewis blood group antigen *(absent in 10%)* **Usually ductal adenoca**

Answer 92

AD Tumour suppressor gene, APC 100-1000 colonic adenomas **100% penetrance** adenoma at 16, carcinoma at 39 Duodenal malignancy 12% Clinical syndrome: **Gardner's:** osteomas, odontomas, epidermoid cyst, desmoid tumour **Turcot's**: CNS malignancies **Attenuated FAP**: less polyps, present later in life, 100% penetrance

Answer 93

AR MutY - codes MYH, OGG1, MTH1 80% penetrance Clinical: multiple adenoma (>15) Age <50 Accounts for 40% of attenuated FAP without APC mutation

Answer 94

- AD - numerous hamartomatous polyp in the GI tract - these polyps don't have malignant potential - pigmented freckles on the lips, face, palms, soles - - around 50% of patients will have died from another gastrointestinal tract cancer by the age of 60 years. - gene encodes serine threonine kinase **LKB1 or STK11** Can cause SBO or GI bleed Associated with: - pancreatic ca - CRC - sex-cord tumours

Answer 95

Familial juvenile polyposis Cowden's disease Bannayan-Ruvalcaba-Riley

Answer 96

Mostly sporadic - MLH1 MSH 2 (60% of Lynch, MLH1 30% of Lynch) MSI - 100% of HNPCC <15% of sporiadic CRC 80% penetrance **RIGHT SIDED** Generally <10 adenoma OTher than GI: - endometrial 40-60% - - ovarian 10-12% - Gastric 10-20%

Answer 97

- mucinous - poor differentiation - R) sided - Lymphocytic infiltrate - Expanding growth pattern IHC: MLH1/PSM2 MSH2/MSH6 Methylation: somatic variant Germ line is only 3%

Answer 98

FAP: - sigmoidoscopy annually from **12 until 35**, then 3 yearly - Gastroscopy: 1-3 yearly, starting **30-35** - Colonoscopy if polyp found HNPCC: - colonoscopy biennually from **25 or 5 years earlier than the youngest cancer in family** - Annually in mutation carrier - Pelvic exam/TVUSS yearly from **25** - Gastroscopy every 2 years, in mutation carriers

Answer 99

FDR x 1 >55: not recommended **1 FDR <55 or 2 FDR any age: **5 yearly from 50 or 10 years earlier than the youngest person with can - FHx of FAP/HNPCC or other - 1 FDR + >2 FDR/SDR on same side of family -

Answer 100

chronic paracetamol overdose in an alcohol user is characterised by markedly elevated aminotransferase (>3000 IU/l), combined with hypovolemia, jaundice, coagulopathy, hypoglycaemia, acute renal failure in over 50%

Answer 101

+ve: Duodenal -ve: Gastric

Answer 102

1a - Spurter 2a - NBVV 2b - clot 2c - dot 3: clean base

Answer 103

combination reduces rebleeding and need for surgery obsviously mre ADR: - perforation - gastric wall necrosis

Answer 104

SS in reduction in rebleeding in 3 days and in 30days no SS in need for surgery or 30 day mortality

Answer 105

Mortality risk increases >7days off aspirin

Answer 106

- clarithromycin +/- metronidazole resistance - clarithromycin resistance rate is increasing - ONLY for triple therapy if clarithromycin resistances **known** AND is < **15%** Otherwise use: quadruple tx for 14 days 1. Clarithro + metronidazole + amoxicillin + PPI 2. Bismuth + metronidazole + tetracycline + PPI or sequential therapy

Answer 107

- EVERYONE - no sooner than 4 weeks from treatment completion - breath test: > abx/bismuth needs to be WH for 28 days > WH PPI for 7-14 days - Pre-faecal antigen test: > JUST PPI WH for 14 days

Answer 108

Scope when INR <2.5

Answer 109

Whipple's disease Whipple's disease is a rare multi-system disorder caused by Tropheryma whippelii infection. It is more common in those who are HLA-B27 positive and in middle-aged men. Features malabsorption: diarrhoea, weight loss large-joint arthralgia lymphadenopathy skin: hyperpigmentation and photosensitivity pleurisy, pericarditis neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus Investigation jejunal biopsy shows deposition of macrophages containing **Periodic acid-Schiff (PAS) granules ** Management guidelines vary: oral **co-trimoxazole** for a year is thought to have the lowest relapse rate, sometimes preceded by a course of IV penicillin