Gastro Flashcards

Question

What is the management of C. difficile infection?

Answer 1

First episode of C. difficile infection first-line therapy is oral vancomycin for 10 days second-line therapy: oral fidaxomicin third-line therapy: oral vancomycin +/- IV metronidazole Recurrent episode recurrent infection occurs in around 20% of patients, increasing to 50% after their second episode within 12 weeks of symptom resolution: oral fidaxomicin after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin Life-threatening C. difficile infection oral vancomycin AND IV metronidazole specialist advice - surgery may be considered

Answer 2

Terminal illeum

Answer 3

Crohn's disease Crohn's disease can affect any part of the gastrointestinal tract from mouth to anus, but it most commonly affects the terminal ileum. This can lead to inflammation and thickening of the bowel wall, leading to the formation of an abdominal mass that can often be palpated in the right iliac fossa. Furthermore, Crohn's disease is characterised by transmural inflammation which may result in complications such as strictures, abscesses or fistulas, which could also contribute to a palpable mass.

Answer 4

Functional hyposplenism. Patients with coeliac disease require regular immunisations due to functional hyposplenism. The spleen plays a crucial role in the immune system, particularly in filtering bacteria and producing antibodies. In patients with coeliac disease, there can be a decrease in splenic function, which increases their susceptibility to certain infections, especially those caused by encapsulated bacteria such as Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis. Therefore, it is essential for these patients to receive regular immunisations against these organisms.

Answer 5

no antibiotics in past 4 weeks, no antisecretory drugs (e.g. PPI) in past 2 weeks Ranitidine is an H2-receptor antagonist that reduces gastric acid secretion but does not directly affect H. pylori. However, it may cause false-negative results if used within two weeks before testing as it can reduce bacterial load by decreasing acidity levels in the stomach. PPIs may cause false-negative results if used within two weeks before testing as they can reduce bacterial load by decreasing acidity levels in the stomach, similar to H2-receptor antagonists. However, since lansoprazole was stopped six weeks ago, this should not be a concern.

Answer 6

Ferritin and transferrin saturation are the most useful investigations for monitoring the adequacy of venesection. Transferrin saturation should be kept below 50% and the serum ferritin concentration below 50 ug/L. Please note that these figures are different from the haemochromatosis diagnostic values (transferrin saturation >55% in men and >50% in women, ferritin >500 ug/L). Ferritin is the primary intracellular iron-storage protein that directly correlates with the degree of iron overload in the blood. Transferrin saturation determines the proportion of transferrin (the primary iron transporter in the blood) that is occupied by iron. It therefore also correlates with the degree of iron overload and hence the effectiveness of venesection.

Answer 7

Both Dubin-Johnson syndrome (DJS) and Rotor syndrome are rare genetic disorders that affect bilirubin metabolism, resulting in mild jaundice. Dubin-Johnson syndrome is a benign disorder characterized by conjugated (direct) hyperbilirubinemia (elevated levels of direct bilirubin in the blood), leading to mild jaundice. It is genetically inherited in an autosomal recessive manner.

Answer 8

portal hypertension and liver cirrohosis Spontaneous bacterial peritonitis (SBP) is an ascitic fluid infection without an evident treatable intra-abdominal source. SBP occurs almost always in patients with known cirrhosis and ascites, commonly as a result of alcoholic liver disease, hepatitis B, hepatitis C, and non-alcoholic fatty liver disease. SBP should be suspected in a patient with known liver disease who present with fever, abdominal tenderness, abdominal distention, vomiting and altered mental state.

Answer 9

the most common organism found on ascitic fluid culture is E. coli

Answer 10

intravenous cefotaxime is usually given

Answer 11

paracentesis: neutrophil count > 250 cells/ul the most common organism found on ascitic fluid culture is E. coli

Answer 12

patients who have had an episode of SBP patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome NICE recommend: 'Offer 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' Alcoholic liver disease is a marker of poor prognosis in SBP.

Answer 13

The Child-Pugh score is a clinical scoring system used to assess the severity of chronic liver disease, particularly cirrhosis, and to predict prognosis and treatment decisions.

Answer 14

exacerbation of hepatic encephalopathy is a common complication

Answer 15

insert a Sengstaken-Blakemore tube Contraindications for the placement of this tube encompass cessation or deceleration of the bleed, recent surgical procedures involving the gastro-oesophageal junction, and established oesophageal strictures. Given that the patient has not responded to initial treatment and lacks a history of recent surgery affecting the gastro-oesophageal junction, inserting a Sengstaken-Blakemore tube would be most appropriate to manage the bleeding. Before considering a Transjugular Intrahepatic Portosystemic Shunt (TIPS), it is advisable to insert a Sengstaken-Blakemore tube due to TIPS being associated with an elevated risk of precipitating hepatic encephalopathy

Answer 16

scurvy, which is caused by a deficiency in vitamin C. Vitamin C is essential for collagen synthesis, and its deficiency can lead to impaired wound healing, gum disease, and other connective tissue abnormalities.

Answer 17

paracetamol sodium valproate, phenytoin MAOIs halothane anti-tuberculosis: isoniazid, rifampicin, pyrazinamide statins alcohol amiodarone methyldopa nitrofurantoin

Answer 18

combined oral contraceptive pill antibiotics: flucloxacillin, co-amoxiclav, erythromycin* anabolic steroids, testosterones phenothiazines: chlorpromazine, prochlorperazine sulphonylureas fibrates rare reported causes: nifedipine

Answer 19

methotrexate methyldopa amiodarone

Answer 20

Fatigue, erectile dysfunction and arthralgia

Answer 21

Budd-Chiari syndrome, or hepatic vein thrombosis, is usually seen in the context of underlying haematological disease or another procoagulant condition. Budd-Chiari syndrome is a rare condition caused by obstruction of hepatic venous outflow, leading to liver congestion, hepatomegaly, and portal hypertension. The blockage occurs due to thrombosis or stenosis of the hepatic veins or inferior vena cava.

Answer 22

polycythaemia rubra vera thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies pregnancy combined oral contraceptive pill: accounts for around 20% of cases

Answer 23

abdominal pain: sudden onset, severe ascites → abdominal distension tender hepatomegaly

Answer 24

ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation

Answer 25

first-line: ursodeoxycholic acid slows disease progression and improves symptoms pruritus: cholestyramine fat-soluble vitamin supplementation liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) recurrence in graft can occur but is not usually a problem

Answer 26

Venous blood gas is the most useful of the listed investigations. Approximately 90% of patients with ischaemic bowel will have elevated lactate and associated metabolic acidosis. This will confirm suspicion for the diagnosis and also give information about the severity. However, lactate is not specific. A CT angiography abdomen and pelvis with contrast is needed urgently to assess for ischaemic bowel. Acute mesenteric ischaemia causes a raised lactate and is the first-line investigation

Answer 27

🩸 Definition: A transient, self-limiting ischemia of the colon due to low blood flow, often from hypoperfusion rather than complete blockage. 📍 Location: Colon (especially watershed areas like splenic flexure & rectosigmoid junction) 🩸 Definition: A life-threatening condition caused by severe reduction or blockage of blood flow to the small intestine. 📍 Location: Small intestine (Jejunum & Ileum)

Answer 28

Steatorrhoea is caused by fat malabsorption and can occur if a tumour blocks the pancreatic duct meaning insufficient pancreatic juices are secreted hence, there is a reduction in lipase and bile salts. This, coupled with the history of smoking/alcohol intake and history of type 2 diabetes mellitus increases the likelihood of underlying presentation of pancreatic cancer. While pancreatic cancer classically presents as 'painless jaundice', often presentations are less clear cut. NICE guidelines advise referring a patient for a high-resolution CT scan of the pancreas if aged 60 or over with weight loss and any one of diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation or new-onset diabetes. This patient is aged 64 and has presented with evidence of weight loss and upper abdominal pain radiating to the back. Therefore, a high-resolution CT scan of the pancreas is indicated as this can provide detailed imaging of the pancreas and surrounding structures, helping to identify any abnormalities and explore the possible differential diagnosis of a pancreatic picture such as pancreatic cancer

Answer 29

Raised AFP Alpha-fetoprotein

Answer 30

high sensitivity and specificity for examination of the terminal ileum strictures: 'Kantor's string sign' proximal bowel dilation 'rose thorn' ulcers fistulae

Answer 31

Right heart failure is actually one of the most common causes of hepatomegaly. It is characterised by a firm, smooth and tender to touch liver edge. The real clue in this question is that it is also pulsatile, which is due to the back-up of blood due to the failure of the right side of the heart to work effectively. The fact that it is pulsatile, distinguishes it from the other possible answers. COPD is a common cause of right-sided heart failure. This is often referred to as cor pulmonale. Some other features of right-sided heart failure include; a raised JVP, ascites, and peripheral oedema.

Answer 32

The correct answer is transferrin saturation. The diagnosis here is haemochromatosis, given the presentation and investigations - the bronze tint to the skin, chondrocalcinosis of the finger joints, raised glucose suggesting iron deposition in the pancreas, and liver disease suggesting iron deposition in the liver too. In the general population, transferrin saturation is considered the most useful marker initially. Ferritin is often also measured but is not as sensitive. If the transferrin saturation indicates a diagnosis of haemochromatosis, genetic testing may then be undertaken.

Answer 33

white cell count

Answer 34

appendicitis and testicular problems (infection and torsion). Therefore it is imperative to examine the testes to ensure you do not miss a source of referred pain. A digital rectal examination is also important to perform but for someone with abdominal pain and no pelvic pain it would be less important than a scrotal examination. The key thing you would be looking for is a perianal abscess which would always present with pain around the anus and in the pelvis as well as a fever which is why this is a less correct answer, remember the question is seeking the single best answer and so although many of the answers may be plausible it is the best one that is correct.

Answer 35

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

Answer 36

All patients who've got dysphagia All patients who've got an upper abdominal mass consistent with stomach cancer Patients aged >= 55 years who've got weight loss, AND any of the following: upper abdominal pain reflux dyspepsia

Answer 37

Patients with haematemesis Patients aged >= 55 years who've got: treatment-resistant dyspepsia or upper abdominal pain with low haemoglobin levels or raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain

Answer 38

This can be summarised at a step-wise approach 1. Review medications for possible causes of dyspepsia 2. Lifestyle advice 3. Trial of full-dose proton pump inhibitor 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

Answer 39

Intestinal angina

Answer 40

classically characterised by a triad of severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit - by far the most common cause is atherosclerotic disease in arteries supplying the GI tract

Answer 41

drainage (typically percutaneous) and antibiotics amoxicillin + ciprofloxacin + metronidazole if penicillin allergic: ciprofloxacin + clindamycin

Answer 42

the second most common malignancy following colorectal cancer is endometrial cancer.

Answer 43

IgM anti-Mitochondrial antibodies, M2 subtype Middle aged females

Answer 44

early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus cholestatic jaundice hyperpigmentation, especially over pressure points around 10% of patients have right upper quadrant pain xanthelasmas, xanthomata also: clubbing, hepatosplenomegaly late: may progress to liver failure

Answer 45

first-line: ursodeoxycholic acid slows disease progression and improves symptoms pruritus: cholestyramine fat-soluble vitamin supplementation liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) recurrence in graft can occur but is not usually a problem

Answer 46

Sjogren's syndrome (seen in up to 80% of patients) rheumatoid arthritis systemic sclerosis thyroid disease

Answer 47

The most accepted theory regarding the pathophysiology of HRS is that vasoactive mediators cause splanchnic vasodilation which in turn reduces the systemic vascular resistance. This results in 'underfilling' of the kidneys. This is sensed by the juxtaglomerular apparatus which then activates the renin-angiotensin-aldosterone system, causing renal vasoconstriction which is not enough to counterbalance the effects of the splanchnic vasodilation.

Answer 48

Type 1 HRS Rapidly progressive Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks Very poor prognosis Type 2 HRS Slowly progressive Prognosis poor, but patients may live for longer

Answer 49

vasopressin analogues, for example terlipressin, have a growing evidence base supporting their use. They work by causing vasoconstriction of the splanchnic circulation volume expansion with 20% albumin transjugular intrahepatic portosystemic shunt

Answer 50

µ-opioid receptor agonist which does not have systemic effects as it is not absorbed through the gut The mechanism by which loperamide works is through stimulation of µ-opioid receptors in the submucosal neural plexus of the intestinal wall. This, in turn, reduces peristalsis of the intestines decreasing gastric motility.

Answer 51

diagnosis of bile acid malabsorption as a complication of the ileocecal resection

Answer 52

cholestyramine Cholestyramine is a bile acid sequestrant used in the management of hyperlipidaemia. It decreases bile acid reabsorption in the small intestine, therefore upregulating the amount of cholesterol that is converted to bile acid. The main effect it has on the lipid profile is to reduce LDL cholesterol. It is also occasionally used in Crohn's disease for treatment diarrhoea following bowel resection

Answer 53

abdominal cramps and constipation decreases absorption of fat-soluble vitamins cholesterol gallstones may raise level of triglycerides

Answer 54

An erect chest x-ray

Answer 55

whilst metoclopramide is primarily a D2 receptor antagonist, the mechanism of action is quite complicated: it is also a mixed 5-HT3 receptor antagonist/5-HT4 receptor agonist the antiemetic action is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone. At higher doses the 5-HT3 receptor antagonist also has an effect the gastroprokinetic activity is mediated by D2 receptor antagonist activity and 5-HT4 receptor agonist activity

Answer 56

Acute urinary retention

Answer 57

A palpable, non tender, enlarged gallbladder accompanied with painless jaundice is unlikely to be due to gallstones. Instead consider malignancy 1️⃣ Pancreatic Head Cancer (Most Common) Compresses the common bile duct, leading to obstruction Causes progressive, painless jaundice and weight loss 2️⃣ Cholangiocarcinoma (Bile Duct Cancer) Tumor in the bile duct causing obstruction 3️⃣ Periampullary Tumors Tumors near the ampulla of Vater 4️⃣ Benign Causes (Rare) Strictures (e.g., post-surgical, autoimmune)

Answer 58

Cephalosporins such as ceftriaxone, not just clindamycin, are strongly linked to C.difficile

Answer 59

vomiting, thoracic pain, subcutaneous emphysema

Answer 60

Boerhaave syndrome is a spontaneous esophageal rupture due to forceful vomiting or retching, leading to full-thickness (transmural) perforation of the esophagus. It is a life-threatening surgical emergency.

Answer 61

cholangiocarcinoma (in 10%) increased risk of colorectal cancer

Answer 62

tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE endomyseal antibody (IgA) needed to look for selective IgA deficiency, which would give a false negative coeliac result Requires IgA sufficiency (check total IgA levels first)

Answer 63

sporadic (95%) hereditary non-polyposis colorectal carcinoma (HNPCC, 5%) familial adenomatous polyposis (FAP, <1%)

Answer 64

more than half of colon cancers show allelic loss of the APC gene. It is believed a further series of gene abnormalities e.g. activation of the K-ras oncogene, deletion of p53 and DCC tumour suppressor genes lead to invasive carcinoma.

Answer 65

Currently seven mutations have been identified, which affect genes involved in DNA mismatch repair leading to microsatellite instability. The most common genes involved are: MSH2 (60% of cases) MLH1 (30%)

Answer 66

It is due to a mutation in a tumour suppressor gene called adenomatous polyposis coli gene (APC), located on chromosome 5.

Answer 67

positive anti-neutrophil cytoplasmic antibody (ANCA) pANCA and anti-smooth muscle cell antibodies.

Answer 68

Hypophosphataemia, hypokalaemia and hypomagnesaemia hypophosphataemia this is the hallmark symptom of refeeding syndrome may result in significant muscle weakness, including myocardial muscle (→ cardiac failure) and the diaphragm (→ respiratory failure) hypokalaemia hypomagnesaemia: may predispose to torsades de pointes abnormal fluid balance

Answer 69

Refeeding syndrome describes the metabolic abnormalities which occur on feeding a person following a period of starvation. It occurs when an extended period of catabolism ends abruptly with switching to carbohydrate metabolism.

Answer 70

Shift from Fat to Carbohydrate Metabolism: In refeeding syndrome, the reintroduction of carbohydrates leads to a shift from fat to carbohydrate metabolism. This switch activates insulin secretion, which in turn increases cellular uptake of glucose. Intracellular Movement of Phosphate: Insulin and increased glucose uptake stimulate the intracellular movement of phosphate, which is used in the synthesis of ATP and 2,3-diphosphoglycerate in erythrocytes. This intracellular shift reduces serum phosphate levels. Decreased Phosphate Stores: Patients with chronic malnutrition often have depleted phosphate stores, although their serum phosphate levels may initially be normal. When refeeding starts, the sudden demand for phosphate in anabolic processes exceeds the supply, leading to hypophosphatemia.

Answer 71

Cardiac Dysfunction: Hypophosphatemia can impair myocardial contractility, leading to heart failure. It may also cause arrhythmias due to its role in maintaining normal cellular electrophysiology. Respiratory Failure: Phosphate is essential for ATP production, necessary for respiratory muscle function. Severe hypophosphatemia can lead to muscle weakness, including the diaphragm and intercostal muscles, potentially resulting in acute respiratory failure. Neurological Complications: These can range from confusion and seizures to coma, attributable to disturbed ATP metabolism in the central nervous system. Haematological Effects: Reduced 2,3-diphosphoglycerate levels in erythrocytes affect oxygen release from haemoglobin, leading to tissue hypoxia. Hypophosphatemia can also result in hemolysis. Rhabdomyolysis: Phosphate depletion impairs ATP production in muscles, which can lead to muscle breakdown and rhabdomyolysis.

Answer 72

BMI < 16 kg/m2 unintentional weight loss >15% over 3-6 months little nutritional intake > 10 days hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high) If two or more of the following: BMI < 18.5 kg/m2 unintentional weight loss > 10% over 3-6 months little nutritional intake > 5 days history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids

Answer 73

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.

Answer 74

hyperkalaemia, hyperphosphataemia, and hypocalcemia.

Answer 75

penicillamine (chelates copper) has been the traditional first-line treatment trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future tetrathiomolybdate is a newer agent that is currently under investigation

Answer 76

slit lamp examination for Kayser-Fleischer rings reduced serum caeruloplasmin reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) free (non-ceruloplasmin-bound) serum copper is increased increased 24hr urinary copper excretion the diagnosis is confirmed by genetic analysis of the ATP7B gene slit lamp examination for Kayser-Fleischer rings reduced serum caeruloplasmin reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) free (non-ceruloplasmin-bound) serum copper is increased increased 24hr urinary copper excretion the diagnosis is confirmed by genetic analysis of the ATP7B gene

Answer 77

Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea: liver: hepatitis, cirrhosis neurological: basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus speech, behavioural and psychiatric problems are often the first manifestations also: asterixis, chorea, dementia, parkinsonism Kayser-Fleischer rings green-brown rings in the periphery of the iris due to copper accumulation in Descemet membrane present in around 50% of patients with isolated hepatic Wilson's disease and 90% who have neurological involvement renal tubular acidosis (esp. Fanconi syndrome) haemolysis blue nails

Answer 78

Alcohol excess

Answer 79

hepatomegaly (metastases) gallbladder (Courvoisier's law) epigastric mass (primary)

Answer 80

1️⃣ Resuscitation: IV fluids, but avoid excessive resuscitation (risk of worsening portal hypertension). Blood transfusion: Aim for Hb 7-8 g/dL (restrictive strategy). Correct coagulopathy (vitamin K, FFP, platelets if needed). 2️⃣ Terlipressin/Octreotide: Start immediately before endoscopy. 3️⃣ Prophylactic Antibiotics: IV Ceftriaxone (or oral Norfloxacin if mild). 4️⃣ Urgent Endoscopy (within 12 hours): Endoscopic variceal band ligation (EVL) = first-line treatment. Sclerotherapy if EVL is not possible. 5️⃣ Consider Balloon Tamponade (Sengstaken-Blakemore tube): If bleeding is massive & uncontrolled before definitive therapy. 6️⃣ Transjugular Intrahepatic Portosystemic Shunt (TIPS): Considered if bleeding persists despite endoscopic therapy & medical management. 7️⃣ Long-term Prevention (Secondary Prophylaxis): Non-selective beta-blockers (e.g., Propranolol, Carvedilol) to reduce portal pressure. Repeat band ligation until varices obliterated.

Answer 81

1️⃣ Resuscitation (If Hemodynamically Unstable) IV Access: Two large-bore (⩾18G) cannulas Fluid Resuscitation: Crystalloids (if hypotensive) Blood Transfusion: Hb target: 7–8 g/dL (restrictive strategy, unless cardiac history) Correct Coagulopathy: FFP if INR >1.5 (or PCC for warfarin) Platelets if <50 × 10⁹/L Oxygen and Monitor Vitals 2️⃣ Risk Stratification (Predicts Mortality & Need for Endoscopy) Glasgow-Blatchford Score (GBS) → Determines need for hospital admission Rockall Score → Predicts mortality risk 3️⃣ Medications Before Endoscopy IV Proton Pump Inhibitor (PPI) – Omeprazole 80 mg IV bolus → 8 mg/hr infusion Helps stabilize clot formation but does not prevent rebleeding. Stop NSAIDs, anticoagulants if possible (restart if essential). 4️⃣ Endoscopy (Within 24 Hours, or Urgent if Unstable) Peptic Ulcer Bleeding → Treat as per Forrest Classification High-risk ulcers (active bleeding, visible vessel, clot) → Endoscopic therapy Options: Injection of adrenaline, thermal coagulation, or hemoclips Mallory-Weiss Tear → Usually self-limiting, but may need adrenaline injection. Dieulafoy’s Lesion (arterial malformation) → Requires endoscopic coagulation or clipping. 🔄 Post-Endoscopic Management & Prevention 1️⃣ High-Dose IV PPI for 72 Hours Omeprazole IV infusion (reduces rebleeding in peptic ulcers). 2️⃣ Eradicate H. pylori (If Peptic Ulcer Disease) Triple therapy: PPI + Clarithromycin + Amoxicillin (or Metronidazole if allergic). 3️⃣ Restart Anticoagulation (If Indicated) Wait ~48-72 hours after hemostasis if needed (balance rebleeding vs. thrombotic risk). 4️⃣ Secondary Prevention Stop NSAIDs if possible or use PPI protection if essential. For high-risk patients: Consider long-term PPI therapy. Management of non-variceal bleeding NICE do not recommend the use of proton pump inhibitors (PPIs) before endoscopy to patients with suspected variceal upper gastrointestinal bleeding although PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy if further bleeding then options include repeat endoscopy, interventional radiology and surgery

Answer 82

patients who have had an episode of SBP patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome NICE recommend: 'Offer 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'

Answer 83

Paracetamol

Answer 84

pernicious anaemia. The light yellow tinge is caused by the combination of pallor (due to the anaemia) and mild jaundice (caused by the haemolysis).

Answer 85

first-line: ursodeoxycholic acid slows disease progression and improves symptoms pruritus: cholestyramine fat-soluble vitamin supplementation liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) recurrence in graft can occur but is not usually a problem

Answer 86

cirrhosis → portal hypertension → ascites, variceal haemorrhage osteomalacia and osteoporosis significantly increased risk of hepatocellular carcinoma (20-fold increased risk)

Answer 87

A non-cardioselective B-blocker (NSBB) propanol Portal hypertension secondary to liver cirrhosis is common due to the scarred liver causing increased pressure in the portal venous system. In order to accommodate the pressure, the oesophageal, gastric and rectal veins enlarge and form thin-walled varices. Beta-blockers that are non-cardioselective (i.e. they act on beta-2 adrenoreceptors on vascular smooth muscle as well as cardiac beta-1 adrenoreceptors) will cause vasodilation in these engorged vessels and reduced heart rate which lowers the blood pressure in the variceal veins and reduces the risk of rupture.

Answer 88

Hypophosphatemia is recognised by a serum phosphate level <0.80 mmol/L. It is further classified as mild (ˆ¼0.64-0.80 mmol/L), moderate (ˆ¼0.32-0.64 mmol/L) and severe (<0.32 mmol/L). In mild to moderate hypophosphataemia where patients are asymptomatic, enteral replacement is required using Phosphate Sandozµ effervescent tablets. Each tablet contains 16.1mmol of phosphate, 20.4mmol of sodium and 3.1mmol of potassium. An adult dose is usually up to 6 tablets daily in divided doses, which is dissolved in water to produce a solution that can safely be administered via feeding tubes. Dose adjustments to be made according to response. Intravenous phosphate replacement is required for patients with severe hypophosphataemia or when symptomatic. Phosphate Polyfusorµ is a commonly used 500ml solution which contains 50mmol of phosphate, 81mmol of sodium and 9.5mmol of potassium. The maximum dose is 500ml Polyfusorµ per infusion and maximum infusion rate is 150ml Polyfusorµ per hour.

Answer 89

commonly presents with abdominal pain in children. The pain is typically crampy and often located in the right lower quadrant, reflecting ileal involvement. This symptom is due to transmural inflammation caused by the disease.

Answer 90

the mainstay of treatment is lifestyle changes (particularly weight loss) and monitoring there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g. metformin, pioglitazone)

Answer 91

Endoscopic intestinal biopsy, however, is the gold standard for the diagnosis of coeliac disease and should be offered to all adult patients if the diagnosis is suspected following serology. Jejunal biopsy is correct, as the duodenum and jejunum are the most affected portions of bowel in coeliac disease, while the ileum is not as affected (unlike in Crohn's disease), and would not be an appropriate place for a biopsy sample from a professional.

Answer 92

if dysplasia of any grade is identified endoscopic intervention is offered. Options include: radiofrequency ablation: preferred first-line treatment, particularly for low-grade dysplasia Endoscopic mucosal resection (EMR) This has a high risk of progression to adenocarcinoma of the oesophagus. An alternative is oesophagectomy. NICE recommend considering endoscopic therapy as an alternative to oesophagectomy in people with high-grade dysplasia and intramucosal cancer, especially in patients who are considered unsuitable for surgery.

Answer 93

high-dose proton pump inhibitor whilst this is commonly used in patients with Barrett's the evidence base that this reduces the change of progression to dysplasia or induces regression of the lesion is limited endoscopic surveillance with biopsies for patients with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years if dysplasia of any grade is identified endoscopic intervention is offered. Options include: radiofrequency ablation: preferred first-line treatment, particularly for low-grade dysplasia endoscopic mucosal resection

Answer 94

Barrett's refers to the metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium. There is an increased risk of oesophageal adenocarcinoma, estimated at 50-100 fold. There are no screening programs for Barrett's - it's typically identified when patients have an endoscopy for evaluation of upper gastrointestinal symptoms such as dyspepsia.

Answer 95

gastro-oesophageal reflux disease (GORD) is the single strongest risk factor male gender (7:1 ratio) smoking central obesity

Answer 96

Barrett's can be subdivided into short (<3cm) and long (>3cm). The length of the affected segment correlates strongly with the chances of identifying metaplasia. The overall prevalence of Barrett's oesophagus is difficult to determine but may be in the region of 1 in 20 and is identified in up to 12% of those undergoing endoscopy for reflux.

Answer 97

aldosterone antagonist spironolactone

Answer 98

Osteomalacia is a condition characterised by the softening of bones due to inadequate mineralisation, primarily caused by vitamin D deficiency Pathophysiology: In coeliac disease, the ingestion of gluten leads to an autoimmune response that damages the intestinal mucosa, impairing nutrient absorption. This malabsorption can result in low serum levels of vitamin D and calcium, crucial for bone health. Clinical Features: Patients may present with bone pain, muscle weakness, and increased susceptibility to fractures. Symptoms can be subtle and may include fatigue and difficulty walking. Diagnosis: Diagnosis involves serum biochemistry showing low calcium and phosphate levels, elevated alkaline phosphatase, and low 25-hydroxyvitamin D levels. A bone biopsy may show unmineralised osteoid. Treatment: Management includes a strict gluten-free diet to promote intestinal healing and supplementation with vitamin D and calcium. Regular monitoring of bone density is recommended.

Answer 99

Raised transferrin saturation and ferritin, with low TIBC is the characteristic iron study profile in haemochromatosis

Answer 100

abdominal x ray, This patient may have developed a toxic megacolon, which is classically demonstrated by the transverse colon being > 6 cm in diameter in combination with signs of systemic upset. Patients identified as having a toxic megacolon are usually treated aggressively with medical therapy for 24-72 hours. If there is no sign of improvement during this time a colectomy is performed.

Answer 101

Plummer-Vinson syndrome, also known as Paterson-Brown-Kelly syndrome, is a rare condition characterized by the triad of iron deficiency anaemia, dysphagia due to esophageal webs, and atrophic glossitis. The patient's symptoms of pain in her tongue and pain on swallowing, along with angular stomatitis and a red smooth tongue, are consistent with this disorder. Additionally, her blood tests reveal microcytic anaemia (low Hb and low MCV), which is suggestive of iron deficiency. Treatment includes iron supplementation and dilation of the webs

Answer 102

Thiopurine methyltransferase (TPMT) activity is an enzyme involved in the metabolism of azathioprine and mercaptopurine. Some people have a deficiency of TPMT due to genetic mutations, and these people are at a greater risk of experiencing severe side effects from conventional doses of azathioprine or mercaptopurine.

Answer 103

Metoclopramide should be avoided as it is a pro-kinetic anti-emetic so could cause a perforation in bowel obstruction.

Answer 104

Urinary 5-HIAA plasma chromogranin A y

Answer 105

Transient elastography, also known as Fibroscan Diagnosis traditionally a liver biopsy was used. This procedure is however associated with adverse effects such as bleeding and pain other techniques such as transient elastography and acoustic radiation force impulse imaging are increasingly used and were recommended by NICE in their 2016 guidelines for patients with NAFLD, NICE recommend using the enhanced liver fibrosis score to screen for patients who need further testing What is transient elastography? brand name 'Fibroscan' uses a 50-MHz wave is passed into the liver from a small transducer on the end of an ultrasound probe measures the 'stiffness' of the liver which is a proxy for fibrosis

Answer 106

people with hepatitis C virus infection men who drink over 50 units of alcohol per week and women who drink over 35 units of alcohol per week and have done so for several months people diagnosed with alcohol-related liver disease

Answer 107

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

Answer 108

cholangiocarcinoma (in 10%) increased risk of colorectal cancer

Answer 109

Riboflavin It is caused by a variety of reasons, including infection, mechanical factors, drug-related side effects and nutritional deficiencies. In the case of the latter, deficiencies of iron, zinc and vitamins from the B group are the most common causes. Of those in the vitamin B group, deficiencies of riboflavin (B2), niacin (B3), pyridoxine (B6), folate (B9) and cyanocobalamin (B12) are typically linked to the condition. Riboflavin is a cofactor of flavin adenine dinucleotide (FAD) and flavin mononucleotide (FMN) and is important in energy metabolism.

Answer 110

vitamin D3

Answer 111

vitamin B5

Answer 112

vitamin B1

Answer 113

GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis *pancreatitis is 7 times more common in patients taking mesalazine than sulfasalazine

Answer 114

Aminosalicylates are associated with a variety of haematological adverse effects, including agranulocytosis - FBC is a key investigation in an unwell patient taking them.

Answer 115

many side-effects are due to the sulphapyridine moiety: rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis other side-effects are common to 5-ASA drugs (see mesalazine) mesalazine: GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis *pancreatitis is 7 times more common in patients taking mesalazine than sulfasalazine

Answer 116

Zollinger-Ellison Syndrome characteristically presents with multiple peptic ulcers as well as diarrhoea, along with a family history of multiple endocrine neoplasia. The patient has no family history or mention of diarrhoea.

Answer 117

Corticosteroids Selected management notes for alcoholic hepatitis: glucocorticoids (e.g. prednisolone) are often used during acute episodes of alcoholic hepatitis Maddrey's discriminant function (DF) is often used during acute episodes to determine who would benefit from glucocorticoid therapy it is calculated by a formula using prothrombin time and bilirubin concentration pentoxyphylline is also sometimes used the STOPAH study (see reference) compared the two common treatments for alcoholic hepatitis, pentoxyphylline and prednisolone. It showed that prednisolone improved survival at 28 days and that pentoxyphylline did not improve outcomes

Answer 118

abdominal pain typically vague, epigastric pain may present as dyspepsia weight loss and anorexia nausea and vomiting dysphagia: particularly if the cancer arises in the proximal stomach overt upper gastrointestinal bleeding is seen only in a minority of patients if lymphatic spread: left supraclavicular lymph node (Virchow's node) periumbilical nodule (Sister Mary Joseph's node)

Answer 119

diagnosis: oesophago-gastro-duodenoscopy with biopsy signet ring cells may be seen in gastric cancer. They contain a large vacuole of mucin which displaces the nucleus to one side. Higher numbers of signet ring cells are associated with a worse prognosis staging: CT scan of the chest, abdomen, and pelvis is indicated in all patients to look for metastatic disease other modalities they may be used for staging include endoscopic ultrasound, (FDG)-PET scanning and pre-operative staging laparoscopy

Answer 120

For many years the Child-Pugh classification was used to classify the severity of liver cirrhosis. However, in recent years the Model for End-Stage Liver Disease (MELD) has been increasingly used, particularly patient's who are on a liver transplant waiting list Child-Pugh classification Score 1 2 3 Bilirubin (µmol/l) <34 34-50 >50 Albumin (g/l) >35 28-35 <28 Prothrombin time, prolonged by (s) <4 4-6 >6 Encephalopathy none mild marked Ascites none mild marked Summation of the scores allows the severity to be graded either A, B or C: < 7 = A 7-9 = B > 9 = C MELD Uses a combination of a patient's bilirubin, creatinine, and the international normalized ratio (INR) to predict survival. A formula is used to calculate the score: MELD = 3.78Ã—ln[serum bilirubin (mg/dL)] + 11.2Ã—ln[INR] + 9.57Ã—ln[serum creatinine (mg/dL)] + 6.43 The 3-month mortality based on MELD scores: 40 or more: 71.3% mortality 30 - 39: 52.6% mortality 20 - 29: 19.6% mortality 10 - 19: 6.0% mortality < 9: 1.9% mortality

Answer 121

steroids, other immunosuppressants e.g. azathioprine liver transplantation

Answer 122

may present with signs of chronic liver disease acute hepatitis: fever, jaundice etc (only 25% present in this way) amenorrhoea (common) ANA/SMA/LKM1 antibodies, raised IgG levels liver biopsy: inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis

Answer 123

Recognised associations include other autoimmune disorders, hypergammaglobulinaemia and HLA B8, DR3.

Answer 124

Full blood count, ESR, CRP, antibody testing for coeliac disease - endomysial antibodies or tissue transglutaminase

Answer 125

During infection, ferritin is an unreliable indicator of iron stored in the body as it is an acute phase protein. Transferrin saturation should be used instead

Answer 126

The best test to see whether iron overload is present is transferrin saturation. Typically, normal values of < 45% in females and < 50% in males exclude iron overload.

Answer 127

The NICE guidelines for anaemia-iron deficiency (2013), state the following investigations: 1) Check full blood count: This has already been done as this patient has been identified as having anaemia so is a distractor answer. 2) If results show a low Hb and low MCV in a non-pregnant person check the ferritin level Serum ferritin levels correlate with the total amount of iron stored in the body, with low levels indicating low iron stores and therefore iron deficiency anaemia. Iron deficiency anaemia can be caused by gastrointestinal causes such as blood loss from GI tract, peptic ulcers, gastric carcinoma or angiodysplasia. Gynaecological causes include menstruation and pregnancy. Malabsorption from Coeliac disease, gastrectomy or H.Pylori infection can also cause iron deficiency. As there are many causes, some more sinister than others, it is always good to investigate the causes of an anaemia. It is important to note that ferritin levels can be elevated when inflammation or co-existing conditions such as liver disease, malignancy or hyperthyroidism are present thus giving spurious readings. In this case, as stated by NICE guidelines, a different measure of iron status should be considered such as iron, total iron binding capacity or transferrin saturation.

Answer 128

Because iron and ferritin are bound the total body ferritin levels may be decreased in cases of iron deficiency anaemia. Measurement of serum ferritin levels can be useful in determining whether an apparently low haemoglobin and microcytosis is truly caused by an iron deficiency state.

Answer 129

Pellagra is a disease caused by a severe deficiency of niacin (vitamin B3) and/or tryptophan (an amino acid that can be converted into niacin). It's characterized by the "four Ds": dermatitis, diarrhea, dementia, and death (if untreated).

Answer 130

It's characterized by the "four Ds": dermatitis, diarrhea, dementia, and death (if untreated).

Answer 131

Beriberi is a deficiency disease resulting from a lack of thiamine, also known as vitamin B1. Thiamine is essential for energy metabolism, nerve function, and heart health. Beriberi is due to a thiamine (vitamin B1) deficiency and can be further categorized into wet beriberi (presenting with tachypnoea, dyspnoea and pedal oedema) and dry beriberi (presenting with pain, paresthesia and confusion). Wernicke-Korsakoff syndrome is a subtype of dry beriberi.

Answer 132

Niacin is a water soluble vitamin of the B complex group. It is a precursor to NAD+ and NADP+ and hence plays an essential metabolic role in cells. Biosynthesis Hartnup's disease: hereditary disorder which reduces absorption of tryptophan carcinoid syndrome: increased tryptophan metabolism to serotonin

Answer 133

flushing (often the earliest symptom) diarrhoea bronchospasm hypotension right heart valvular stenosis (left heart can be affected in bronchial carcinoid) other molecules such as ACTH and GHRH may also be secreted resulting in, for example, Cushing's syndrome pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour

Answer 134

Carcinoid syndrome can affect the right side of the heart. The valvular effects are tricuspid insufficiency and pulmonary stenosis

Answer 135

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

Answer 136

urinary 5-HIAA plasma chromogranin A y

Answer 137

A carcinoid is a slow-growing type of neuroendocrine tumor originating in the cells of the neuroendocrine system. In some cases, metastasis may occur. Carcinoid tumors of the midgut are associated with carcinoid syndrome.

Answer 138

refers to arthritis affecting fewer than five joints. It can occur in both ulcerative colitis and Crohn's disease as an extra-intestinal manifestation, without a significant difference in prevalence between the two conditions.

Answer 139

Pauciarticular arthritis refers to arthritis affecting fewer than five joints. It can occur in both ulcerative colitis and Crohn's disease as an extra-intestinal manifestation, without a significant difference in prevalence between the two conditions. Osteoporosis, defined as a reduction in bone mineral density leading to an increased risk of fracture, can also occur as a complication of both UC and Crohn's disease due to factors such as chronic inflammation, steroid use and malnutrition. However, there isn't a clear distinction between these two diseases regarding their association with osteoporosis. Episcleritis, which involves inflammation of the episclera (a thin layer on top of the white part of the eye), is another extra-intestinal manifestation that can be seen in both UC and Crohn's disease. Again, there isn't a significant difference in its occurrence between these two conditions. Lastly, Erythema nodosum, a skin condition that results in red tender lumps usually on the shins, can occur as an extra-intestinal manifestation of inflammatory bowel diseases (IBD). It is more commonly associated with Crohn's disease rather than ulcerative colitis. Therefore, out of these options presented, primary sclerosing cholangitis stands out as being much more common in ulcerative colitis compared to Crohn's disease.

Answer 140

peptic ulcer disease 95% of duodenal ulcers 75% of gastric ulcers gastric cancer B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of patients) atrophic gastritis

Answer 141

Helicobacter pylori is a Gram-negative bacteria associated with a variety of gastrointestinal problems, principally peptic ulcer disease. Pathophysiology Helicobacter pylori has 2 main mechanisms to survice in the acidic gastric environment: chemotaxis away from low pH areas, using its flagella to burrow into the mucous lining to reach the epithelial cells underneath secretes urease → urea converted to NH3 → alkalinization of acidic environment → increased bacterial survival pathogenesis mechanism: Helicobacter pylori releases bacterial cytotoxins (e.g. CagA toxin) → disruption of gastric mucosa

Answer 142

After confirming elevated urinary 5-HIAA levels, further investigations such as colonoscopy and CT abdomen should be considered for localisation of the primary carcinoid tumour and staging of disease. They would not be diagnostic of a carcinoid in the absence of a positive urinary 5-HIAA. Further investigations should be tailored to the patient's clinical presentation as carcinoid tumours can arise from a variety of sources relating to the embryonic development of the gut. Foregut tumours (lung, thymus, stomach, or proximal duodenum) account for up to 25% of cases. Midgut tumours (small intestine, appendix or proximal colon) account for up to 50% and hindgut tumours (distal colon or rectum) account for approximately 15%.

Answer 143

Coeliac disease commonly presents with anaemia, but it is often a mixed picture. It causes a deficiency in iron, folate and vitamin B12 (although folate deficiency is more common than vitamin B12 deficiency). B12 is absorbed in the terminal ileum. It requires the presence of intrinsic factor to be absorbed (absent in pernicious anaemia). Folate is absorbed in the duodenum and jejunum. Iron is mainly absorbed in the duodenum.

Answer 144

thyrotoxicosis laxative abuse appendicitis radiation enteritis

Answer 145

Giardia lamblia causes fat malabsorption, therefore greasy stool can occur. It is resistant to chlorination, hence risk of transfer in swimming pools.

Answer 146

Thrombocytopenia (platelet count <150,000 mm^3) 'Multiple factors, including splenic sequestration, reduced activity of the hematopoietic growth factor thrombopoietin, bone marrow suppression by chronic hepatitis C virus infection and anti-cancer agents, and antiviral treatment with interferon-based therapy, can contribute to the development of thrombocytopenia in cirrhotic patients'.

Answer 147

alcohol non-alcoholic fatty liver disease (NAFLD) viral hepatitis (B and C)

Answer 148

Gastric carcinoma is the correct answer. The fatigue and weight loss, alongside the anaemia and elevated urea levels, make this the most likely answer. Gastric cancer can present with an upper gastrointestinal (GI) bleed which would result in raised urea due to digestion of blood. The patient's dark, foul-smelling stools are indicative of digested blood being passed in the stool.

Answer 149

Small bowel biopsy is the correct answer. This patient is presenting with features of coeliac disease. Coeliac disease is an autoimmune condition that affects the small bowel causing villous cell atrophy. Whilst carrying out the IgA-tTG test is considered the first-line investigation, endoscopy and biopsy are the gold standard investigation for confirmation as histological examination can reveal the presence of typical changes associated with coeliac such as villous atrophy. This patient has signs of coeliac disease such as bloating, diarrhoea, and fatigue. The fatigue and pallor (as seen in this patient) often stem from the fact iron deficiency is common in patients with coeliac disease. Type 1 diabetes and coeliac disease are both autoimmune conditions and there is a well-established association between the two due to the shared genetic and autoimmune nature.

Answer 150

While haemochromatosis can certainly manifest in abnormal liver function tests with a raised ferritin, the transferrin saturation - calculated as (iron / TIBC) x 100 - is well below the 40% threshold for females (based on British Society of Haematology guidelines) which would prompt consideration of iron overload. Furthermore we would normally expect ferritin to be even higher (>1000 ug/L) in haemochromatosis. Note that milder elevations of serum ferritin is commonly seen in NAFLD, as seen here.

Answer 151

Alcoholic hepatitis is unlikely given her level of alcohol intake. NICE guidelines state that consumption of less than 20g (2.5 units) per day in women, and less than 30g (3.75 units) per day in men, is used as the cut-off to diagnose NAFLD

Answer 152

obesity type 2 diabetes mellitus hyperlipidaemia jejunoileal bypass sudden weight loss/starvation

Answer 153

NICE produced guidelines on the investigation and management of NAFLD in 2016. Key points: there is no evidence to support screening for NAFLD in adults, even in at risk groups (e.g. type 2 diabetes) the guidelines are therefore based on the management of the incidental finding of NAFLD - typically asymptomatic fatty changes on liver ultrasound in these patients, NICE recommends the use of the enhanced liver fibrosis (ELF) blood test to check for advanced fibrosis the ELF blood test is a combination of hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1. An algorithm based on these values results in an ELF blood test score, similar to triple testing for Down's syndrome An excellent review by Byrne et Al1 in 2018 reviewed the diagnosis and monitoring of NAFLD. It made the following suggestions if the ELF blood test was not available: non-invasive tests may be used to assess the severity of fibrosis these include the FIB4 score or NALFD fibrosis score these scores may be used in combination with a FibroScan (liver stiffness measurement assessed with transient elastography) this combination has been shown to have excellent accuracy in predicting fibrosis Patients who are likely to have advanced fibrosis should be referred to a liver specialist. They will then likely have a liver biopsy to stage the disease more accurately.

Answer 154

the mainstay of treatment is lifestyle changes (particularly weight loss) and monitoring there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g. metformin, pioglitazone)

Answer 155

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

Answer 156

serum sodium < 125mmol/L, but would not be appropriate as a stand-alone intervention for this patient.

Answer 157

oesophagitis ulcers anaemia benign strictures Barrett's oesophagus oesophageal carcinoma The correct answer is Achalasia. Achalasia is a primary oesophageal motility disorder characterised by the failure of relaxation of the lower oesophageal sphincter and absence of normal peristalsis in the body of the oesophagus. It is not a complication of gastro-oesophageal reflux disease (GORD). Now let's discuss each incorrect answer: Oesophageal carcinoma can indeed be a complication of GORD. Chronic exposure to gastric acid can lead to metaplastic changes in the oesophageal epithelium, known as Barrett's oesophagus, which increases the risk for development of oesophageal adenocarcinoma. Barrett's oesophagus is a well-recognised complication of chronic GORD. It occurs due to repeated injury to the squamous epithelium lining the lower oesophagus from refluxed gastric acid, leading to replacement with columnar epithelium that predisposes to malignancy. Anaemia could also be a complication of GORD, although it is less common than others. This could happen due to chronic blood loss from erosive esophagitis or from iron deficiency secondary to poor absorption caused by proton pump inhibitor therapy often used in treating GORD. Lastly, benign strictures, also known as peptic strictures, are another recognised complication of GORD. They occur due to fibrotic healing following repeated episodes of inflammation caused by acid reflux, leading to narrowing and potential obstruction in the lower part of the oesophagus.

Answer 158

Gastro-oesophageal reflux disease (GORD) may be defined as symptoms of oesophagitis secondary to refluxed gastric contents NICE recommend that GORD which has not been investigated with endoscopy should be treated as per the dyspepsia guidelines. 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

Answer 159

is an X-linked recessive disorder that primarily affects males. It presents in infancy or early childhood with eczema, recurrent infections (due to immunodeficiency), and thrombocytopenia with small platelets leading to bleeding problems.

Answer 160

is a neurodegenerative disorder that typically presents before adolescence with progressive gait instability (ataxia), dysarthria, loss of deep tendon reflexes and hypertrophic cardiomyopathy.

Answer 161

Sulphasalazine. This drug, used in the treatment of ulcerative colitis and rheumatoid arthritis, can cause haemolytic anaemia with Heinz bodies.