Gastro

Question 1

Management for asymptomatic cholelithiasis?

Answer 1

Observe

Question 2

Management for symptomatic cholelithiasis?

Answer 2

Analgesia - paracetamol/diclofenac
Elective laparoscopic cholecystectomy

Consider anti-spasmodic e.g. hyoscine

Question 3

Management for choledocholithiasis regardless of symptoms?

Answer 3

ERCP + biliary sphincterotomy + stone extraction
Laparoscopic cholecystectomy
Analgesia - paracetamol/diclofenac

Question 4

Investigations (imaging) for acute cholecystitis?

Answer 4

Abdominal US (no sepsis)
Contrast-enhanced CT/MRI (sepsis)

Consider MRCP if no stones seen on US but bile duct is dilated/abnormal LFTs

Question 5

Management of cholecystitis?

Answer 5

Analgesia - paracetamol/NSAID/opioid
Laparoscopic cholecystectomy within a week of diagnosis

Consider:
Antibiotics - local protocol
Fluid resus

Question 6

Investigations for cholangitis

Answer 6

Abdominal US

Contrast abdo CT: If US -ve but still high suspicion

Question 7

Management for ascending cholangitis?

Answer 7

Initial stabilisation:
- piperacillin + tazobactam
- IV fluids
- strong opioid + paracetamol

ERCP

Question 8

Investigations for acute pancreatitis?

Answer 8

Serum lipase/amylase elevated

Imaging not needed for diagnosis but can be done to find possible causes/exclude diff diagnoses
- CXR/abdominal US

Question 9

Management for acute pancreatitis?

Answer 9

Fluid resus
Analgesia e.g. NSAID, opioid
IV ABs only if infection strongly suspected
Nutritional support

Additional definitive management depending on scenario

Question 10

What is the definitive management for gallstone pancreatitis + cholangitis?

Answer 10

Emergency ERCP within 24 hours

Question 11

Definitive management for gallstone pancreatitis + no cholangitis

Answer 11

Cholecystectomy within 2 weeks

Question 12

Definitive management for pancreatitis + bile duct obstruction

Answer 12

EUS to identify bile duct stones. If present wait 48 hrs for spontaneous improvement

ERCP + sphincterotomy

Question 13

Alcoholic pancreatitis management

Answer 13

B1 (thiamine)
B9 (folic acid)
B12 (cyanocoblamin)

Alcohol abstinence and benzos for withdrawal

Question 14

How is a clinical diagnosis of acute pancreatitis made?

Answer 14

3x normal amylase
Characteristic pain (epigastric radiating to back)

Question 15

What are the investigations/management for appendicitis

Answer 15

If classical signs with thin, male patients —> laparoscopic appendicetomy

If female/unsure —> ultrasound

Question 16

Investigation for primary sclerosis cholangitis?

Answer 16

MRCP - diagnostic (strictures, dilations inside/outside liver with hallmark beaded appearance

Question 17

HBsAg

Answer 17

Positive 4 weeks after virus exposure
Persistence implies chronic infection

Question 18

Anti-HBs

Answer 18

Provides lifelong immunity
Suggests resolved infection

Question 19

Anti-HBc

Answer 19

Order IgM and IgG tests

If both +ve then acute infection
If only IgG +ve then chronic infection

Question 20

HbeAg

Answer 20

Usually disappears after peak in ALT. If present after 3 months suggest chronic infection

Question 21

Anti-Hbe

Answer 21

Positive if virus has been cleared
Sometimes +ve if patient is asymptomatic carrier

Question 22

Management for HAV?

Answer 22

Supportive care, no antiviral therapy

If worsening jaundice and encephalopathy —> liver transplant

Question 23

Management for HBV

Answer 23

Acute:
Supportive care.
If severe/acute liver failure give antiviral therapy and assess for transplant

Chronic:
Antiviral therapy
Transplant for decompensated cirrhosis

Question 24

Investigations for HCV?

Answer 24

HCV antibody immunoassay (EIA)
- indicates current/past infection

If +ve do HCV RNA PCR:
- indicates current infection

Question 25

Management for HCV?

Answer 25

Antiviral therapy

Question 26

Management of ascites

Answer 26

Spironolactone If refractory: Large volume paracentesis and albumin replacement/TIPSS Consider liver transplant

Question 27

Who gets urgent 2WW referral colonoscopy for colorectal cancer?

Answer 27

> 40: unexplained weight loss AND abdominal pain > 50: unexplained rectal bleeding > 60: iron deficiency anaemia OR changed in bowel habit Any age male and female with <110 and <100 Hb respectively

Question 28

Imaging for pancreatic cancer?

Answer 28

CT for all patients with suspected disease in 2 weeks USS if urgent CT not possible

Question 29

Most common type of colorectal cancer?

Answer 29

Adenocarcinoma (>90%)

Question 30

Investigations for oesophageal cancer

Answer 30

OGD with biopsy (first line) CT/MRI thorax + abdomen for visceral mets PET if mets/nodal spread EUS for local lymph node staging

Question 31

Management for alcoholic liver disease

Answer 31

Alcohol abstinence with withdrawal management Nutrition supplementation Influenza + pneumococcal vaccine Prednisolone if severe: Maddrey’s factor > 32 or hepatic encephalopathy Liver transplant for end-stage ALD

Question 32

What is Maddreys discriminant function calculated with

Answer 32

PT and serum bilirubin

Question 33

Investigation for intusseption

Answer 33

Ultrasound for target like mass

Question 34

Crohn’s disease management

Answer 34

Induce remission: steroids, + immunosuppressants (azathioprine, mercaptopurine, methotrexate). Biologics (severe)/5ASAs (1st presentation) for steroids not tolerated Maintain remission: immunosuppressants Surgery e.g. small bowel resections

Question 35

Ulcerative colitis management

Answer 35

Acute hospitalisation: IV steroids + biologics if >3 days no change Induce remission: Mild - 5ASAs, steroids (2nd), biologics (3rd) Moderate/severe - steroids + biologics Maintain remission: Mild/mod - topical (proctitis)/oral 5ASAs Severe/2 or more exacerbations in past 12 months that needed steroids - azathioprine/mercaptopurine

Question 36

Classification of IBD flares

Answer 36

Mild: < 4 stools a day, no systemic Moderate: 4-6 stools a day, minimal systemic Severe: > 6 stools a day, systemic Systemic includes: tachycardia, fever, abdo distension/tenderness, anaemia, reduced bowel sounds, hypoalbuminaemia, cachexia < 18.5/sudden weight loss

Question 37

Haemorrhoid grading

Answer 37

1. No prolapse 2. Prolapse on straining, return on relaxing 3. Prolapsed but can be manually reduced 4. Cannot be reduced

Question 38

Oesophageal cancer management

Answer 38

0-IA: endoscopic resection +/- ablation IB-III: oesophagectomy (IIB-III): pre-op chemo +/- post-op chemo IV: chemotherapy

Question 39

Which people are referred for an OGD via 2WW pathway for oesophageal/gastric cancer?

Answer 39

Any age dysphagia >55 years old: - weight loss and: — abdominal pain, reflux or dyspepsia

Question 40

Cirrhosis investigation

Answer 40

Transient elastography (fibroscan) Acoustic radiation force impulse imaging