Gastro

Question 1

acute upper gastrointestinal bleeding scoring systems?

Answer 1

the Glasgow-Blatchford score at first assessment
helps clinicians decide whether patient patients can be managed as outpatients or not

the Rockall score is used after endoscopy
provides a percentage risk of rebleeding and mortality
includes age, features of shock, co-morbidities, aetiology of bleeding and endoscopic stigmata of recent haemorrhage

Question 2

Acute upperr GI bleed mx

Answer 2

Resus
- A to E
- platelet transfusion- actively bleeding platelet count of less than 50 x 10*9/litre
- fresh frozen plasma to patients fibrinogen level < 1 g/litre, or a PT (INR) or aPTT greater than 1.5x normal
- prothrombin complex concentrate to patients who are taking warfarin and actively bleeding

endoscopy within 24 hours

non-variceal bleeding
- NO PPI before endoscopy (give after)

Variceal
- terlipressin and prophylactic antibiotics before endoscopy
- band ligation - oesophageal varices
- injections of N-butyl-2-cyanoacrylate - gastric varices
- transjugular intrahepatic portosystemic shunts (TIPS) if not controlled with above

Question 3

Alcoholic ketoacidosis
tx

Answer 3

infusion of saline & thiamine

Question 4

Alcoholic liver disease ix & mx

Answer 4

ix
- gamma-GT elevated
- AST:ALT is normally > 2, a ratio of > 3 is suggestive of acute alcoholic hepatitis

Mx
- glucocorticoids (e.g. prednisolone) -> acute episodes of alcoholic hepatitis (Maddrey’s discriminant function (DF) used )

(pentoxyphylline sometimes)

Question 5

Ascities mx

Answer 5

reducing dietary sodium
(fluid restriction only if sodium is < 125 mmol/L)

aldosterone antagonists: e.g. spironolactone

drainage if tense ascites (therapeutic abdominal paracentesis)
- large-volume paracentesis for the treatment of ascites requires albumin ‘cover’. Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality

reduce the risk of spontaneous bacterial peritonitis -> prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less, until the ascites has resolved

transjugular intrahepatic portosystemic shunt (TIPS) in some

Question 6

. Three types of autoimmune hepatitis

Answer 6

1
- Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)
- adults & children

2
- Anti-liver/kidney microsomal type 1 antibodies (LKM1)
- children

3
- Soluble liver-kidney antigen
- adults

raised IgG levels in all

Question 7

Carcinoid ix & mx

Answer 7

metastases are present in the liver and release serotonin into the systemic circulation

Ix
- urinary 5-HIAA
- plasma chromogranin A y

Mx
- somatostatin analogues e.g. octreotide
- diarrhoea: cyproheptadine may help

Question 8

C. difficile infection ix & mx

Answer 8

C. difficile toxin (CDT) in the stool ( NOT antigen positivity )

Mx

First episode of C. difficile infection
1.oral vancomycin for 10 days
2. therapy: oral fidaxomicin
3: oral vancomycin +/- IV metronidazole1.

Recurrent
- within 12 weeks of symptom resolution: oral fidaxomicin
- after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin

Life-threatening C. difficile infection (Hypotension
Partial or complete ileus
Toxic megacolon, or CT evidence of severe disease)
- oral vancomycin AND IV metronidazole
- Surgery

isolation in side room: the patient should remain isolated until there has been no diarrhoea (types 5-7
on the Bristol Stool Chart) for at least 48 hours
——–
Other therapies
- bezlotoxumab
- faecal microbiota transplant

Question 9

Coeliac disease ix and mx

Answer 9

reintroduce gluten for at least 6 weeks prior to testing.

serology
tissue transglutaminase (TTG) antibodies (IgA) are first-choice
& endomyseal antibody (IgA)

Endoscopic intestinal biopsy - gold standard

findings supportive of coeliac disease:
-villous atrophy
- crypt hyperplasia
- increase in intraepithelial lymphocytes
- lamina propria infiltration with lymphocytes

Mx
- gluten-free diet (TTG used for checking compliance)
- functional hyposplenism: pneumococcal infection every 5 years

Question 10

Types of inherited colon cancer

Answer 10

HNPCC (Lynch syndrome)
- most common form of inherited colon cancer
- other ca- endometrial cancer
- AD inheritance

FAP
- autosomal dominant
- formation of hundreds of polyps by the age of 30-40 years.
- mutation in a tumour suppressor gene called adenomatous polyposis coli (APC) gene
- total proctocolectomy with ileal pouch anal anastomosis
- variant: Gardner’s syndrome- osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin

Peutz-Jeghers syndrome
- autosomal dominant
- numerous hamartomatous polyps in the gastrointestinal tract -> small bowel obstruction & bleeding
- pigmented freckles on the lips, face, palms and soles

Question 11

Constipation mx

Answer 11

first-line laxative: bulk-forming laxative first-line, such as ispaghula

second-line: osmotic laxative, such as a macrogol

Question 12

croons disease mx:

Answer 12

induce remission.
- 1st: glucocorticoids-
- 2nd line: 5-ASA drugs (e.g. mesalazine)
- azathioprine/ mercaptopurine/ infliximab/ metronidazole

Maintaining remission
- stopping smoking
- 1st line: azathioprine or mercaptopurine (assess TPMT before giving either)

surgery

Question 14

diverticular disease & diverticulitis tx

Answer 14

diverticular disease - high fibre diet

Diverticulitis
- mild - oral antibiotics
- more significant episodes - intravenous fluids and intravenous antibiotics (typical a cephalosporin + metronidazole)

Question 15

referral criteria for endoscopy

Answer 15

Urgent (2ww)
- all patients w dysphagia
- all pts w upper abdo mass consistent w stomach ca
- Pts >= 55 years w weight loss AND: upper abdo pain/ reflux/ dysphagia

Non-urgent
- Pts w haematemesis
- Pts >= 55 yrs: treatment-resistant dyspepsia/ upper abdominal pain & anaemia/ raised platelet count w N&V, weight loss, reflux, dyspepsia, upper abdo pain

Question 16

achalasia tx & ix

Answer 16

ix
- oesophageal manometry

mx
1- pneumatic (balloon) dilation if low surgical risk (intra-sphincteric injection / botulinum toxin if high)
2 - Heller cardiomyotomy if recurrent or persistent

Question 17

gastric ca dx

Answer 17

diagnosis: oesophago-gastro-duodenoscopy with biopsy
signet ring cells

(if lymphatic spread:
left supraclavicular lymph node (Virchow’s node)
periumbilical nodule (Sister Mary Joseph’s node))

Question 18

GORD tx

Answer 18

Dyspepsia not ix w endoscopy
- review meds & lifestyle advice
- Trial of full-dose proton pump inhibitor for one month OR a ‘test and treat’ approach for H. pylori (carbon-13 urea breath test)

Endoscopically proven oesophagitis
full dose proton pump inhibitor (PPI) for 1-2 months
if response then low dose treatment as required
if no response then double-dose PPI for 1 month

Endoscopically negative reflux disease
full dose PPI for 1 month
if response then offer low dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions
if no response then H2RA or prokinetic for one month

Question 19

Haemochromatosis ix & mx

Answer 19

(remember autosomal recessive)

general population - transferrin saturation

Testing family w fhx - genetic testing for HFE mutation

Mx
1- venesection - transferrin saturation target < 50% & ferritin concentration < 50 ug/l
2- desferrioxamine

Question 20

H pylori ix & mx

Answer 20

ix - urea breath test carbon 13 -should not be performed within 4 weeks of antibiotic or within 2 weeks of a proton pump inhibitor)

eradication may be achieved with a 7-day course of
a proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole)

if penicillin-allergic: a proton pump inhibitor + metronidazole + clarithromycin

Question 21

hepatic encephalopathy mx

Answer 21

actulose first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy

treat any underlying precipitating cause

Question 22

most common cause of Hepatocellular carcinoma?

Answer 22

Chronic hepatitis B is the most common cause of HCC worldwide with chronic hepatitis C being the most common cause in Europe.

Question 23

IBS mx

Answer 23

First-line pharmacological treatment - according to predominant symptom
- pain: antispasmodic agents
- constipation: laxatives but avoid lactulose
- diarrhoea: loperamide is first-line

Second-line
- low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors

Question 24

Liver cirrhosis ix

Answer 24

transient elastography (fibroscan) and acoustic radiation force impulse imaging

for patients with NAFLD -> enhanced liver fibrosis (ELF) scan
Also FIB4 score & NALFD fibrosis score
& fibroscan

Further investigations
NICE recommend doing an upper endoscopy to check for varices in patient’s with a new diagnosis of cirrhosis
liver ultrasound every 6 months (+/- alpha-feto protein) to check for hepatocellular cancer

Question 25

Oesophageal ca ix & mx

Answer 25

Upper GI endoscopy - dx Endoscopic ultrasound - locoregional staging (mural invasion) CT chest, abdomen and pelvis - initial staging mx - Operable disease (T1N0M0) - surgical resection - Ivor-Lewis type oesophagectomy

Question 26

Pernicious anaemia ix & tx

Answer 26

anti intrinsic factor antibodies: sensivity is only 50% but highly specific for pernicious anaemia (95-100%) FBC, vB12 & folate levels Mx IM vB12 - 3 injections per week for 2 weeks followed by 3 monthly treatment of vitamin B12 injections. More frequent if neurological fx

Question 27

Refeeding syndrome metabolic consequences

Answer 27

hypophosphataemia hypokalaemia hypomagnesaemia: abnormal fluid balance NICE recommend that if a patient hasn't eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days.

Question 28

Spontaneous bacterial peritonitis (SBP) mx

Answer 28

intravenous cefotaxime Antibiotic prophylaxis w ascites: oral ciprofloxacin or norfloxacin - patients who have had an episode of SBP - fluid protein <15 g/l

Question 29

UC mx

Answer 29

mild: < 4 stools/day, only a small amount of blood moderate: 4-6 stools/day, varying amounts of blood, no systemic upset severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers) Inducing remission!! Mild to moderate - Proctitis, proctosigmoiditis and left-sided ulcerative colitis: topical (rectal) aminosalicylate -> oral aminosalicylate -> oral corticosteroid - extensive disease: topical and a high-dose oral aminosalicylate -> oral corticosteroid Severe intravenous steroids (/cicosporin) in hospital Maintaining remission!! After mild-to-moderate ulcerative colitis flare - proctitis and proctosigmoiditis: topical and/or oral aminosalicylate - left-sided and extensive ulcerative colitis: oral aminosalicylate Following a severe relapse or >=2 exacerbations in the past year - oral azathioprine or oral mercaptopurine

Question 30

Conditions associated with thiamine deficiency:

Answer 30

vB1 Wernicke's encephalopathy: nystagmus, ophthalmoplegia and ataxia Korsakoff's syndrome: amnesia, confabulation dry beriberi: peripheral neuropathy wet beriberi: dilated cardiomyopathy

Question 31

Consequences of niacin deficiency:

Answer 31

vB3 pellagra: dermatitis, diarrhoea, dementia

Question 32

Vitamin C deficiency

Answer 32

(scurvy) leads to defective synthesis of collagen resulting in capillary fragility (bleeding tendency) and poor wound healing Features vitamin C deficiency gingivitis, loose teeth poor wound healing bleeding from gums, haematuria, epistaxis general malaise

Question 33

Bile-acid malabsorption ix & tx

Answer 33

SeHCAT bile acid sequestrants e.g. cholestyramine

Question 34

Small bowel bacterial overgrowth syndrome (SBBOS) ix & mx

Answer 34

(associated w scleroderma & DM) Dx- hydrogen breath test Management- rifaximin