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1

What is the primary factor leading to accumulation of ascities in patients with cirrhosis?

Splanchnic dilatation

2

What is the pathophysiology of ascites in cirrhosis?

Cirrhosis -> portal hypertension (sinusoidal pressure > 12 mmHg)-> splanchnic dilatation-> increase splanchnic pressure -> formation of ascities
Splanchnic dilatation also results in arterial underfilling -> activation of vasoconstriction and antinatriuretic factors -> sodium retention -> plasma volume expansion -> ascites

3

what is the serum to ascites albumin gradient (SAAG)? What is it used to identify?

SAAG = serum albumin - ascites albumin
Used to identify the presence of portal hypertension
> 11 = portal HT (cirrhosis, HF, bud chiari, alcholic hepatitis)

4

what does the appearance of the following ascitic fluid suggest:
clear yellow
brown
turbid
milky
pink or bloody

Clear yellow = normal bili and protein
brown = high bili
turbid = infection
milky = elevated triglyceride concentration usually secondary to lymphoma
Pink or bloody = traumatic tap, malignancy, cirrhosis, punctured vessel

5

What Ix do you order for an ascitic fluid?

MCS
Protein; if >=2.5 or 3 gldL then exudate, if 1.0 = malignancy
Amylase, lipase- elevated if due to pancreatitis or gut perforation
Tb- Tb PCR
Cytology - malignant cells

6

what is the treatment for ascites due to cirrhosis?

1. Spironolactone50-100 mg PO OD, increase by 100 mg q 4 days up to 400 mg OD.
2, Can add Frusemide40 mg PO. Increase by 40 mg q 4 days up to 160 mg OD
3. Amiloride 10-20 mg OD if pt cannot tolerate spironolactone

7

what is the Tx fro severe and refractory ascites sue to liver cirrhosis?

1. Transplant only definitive therapeutic option
2. TIPS to shunt between hepatic and portal veins

8

what does B12 deficiency lead to?

Pernicious anaemia identified by macrocytosis, intramedullary haemolysis and peripheral neuropathy

9

Where is our source of Vit B12?
Where is Vitamin B12 stored?
How is Vitamin B12 absorbed?

Meat and dairy is the only source of Vit B12
Total body stores are 2-5 mg with half of stores in the liver
Cobalamin is liberated from food by acid and pepsin. Binds to R-factors in the saliva and gastric juice.
In the duodenum, cobalmin freed from R-proteins due to actions of PANCREATIC proteases. Then binds to intrinsic factor.
The IF-Cbl complex binds to ileal receptors in the terminal ileum.

10

MOA Azathioprine?

Immunosuppressive drug.
A purine anti-metabolite.
Metabolised via mercaptopurine to thioguinine metabolites which interfere with purine synthesis imparing with lymphocyte proliferation, celluluar immunity and anti-body responses.

11

Indications for Azathioprine

Prevention of post transplant rejection
immune and inflammatory diseases

12

What is the significance of TMPT testing when starting azathioprine?

1 in 300 ppl have low or no TPMT activity and are at severe risk of myelosuppresion. Avoid use or reduce dose to 1/10.

13

What is the interaction of azathioprine and allopurinol?

Allopurinol reduces azathioprine metabolism increasing the risk of severe bone marrow toxicity

14

What results would you expect in a pt with azathioprine resistance?

high 6MMP, low 6-TGN

15

Describe the pathway of azathioprine metabolism

AZA -> 6-MP -> 6 - MMP via TPMT
AZA -> 6-MP -> 6-TIMP -> 6-TXMP -> 6- TGN

16

What is the recommended treatment for Hepatitis C Genotype 1?

Sofosbuvir (Nucleotide polymerase inhibitor) + ribavirin + PEG for 12 weeks or
Olysio for 12 weeks + ribavirin + PEG for 24 weeks

If not elgible to receive interferon:
Solvadi + Olysio +/- ribavirin for 12 weeks or
Solvadi + ribavirin for 24 weeks

17

How many Hep C genotypes are there?

6

18

What is the treatment for Hep C Genotype 2?

Solvadi + ribavirin for 12 weeks

19

What is the treatment for Hep C Genotype 3?

Solvadi + ribavirin for 24 weeks

20

What is the treatment for Hep C Genetoype 4?

Solvadi + ribavirin + PEG for 12 weeks or
Olysio fro 12 weeks + ribavirin + PEG for 24-28 weeks

If not eligible for interferon:
Solvadi + ribavirin for 24 weeks

21

what is the treatment for Hep C genotype 5 or 6?

Solvadi + ribavirin + PEG for 12 weeks or
Ribavirin + PEG for 48 weeks

If not eligible to receive Interferon there are no recommended treatment options

22

What are the American Gastro Association guidelines for a pt with Barrett's oesophagus:
without dysplasia
low grade dysplasia
High-grade dysplasia in the absence of eradication therapy

No dysplasia : 3-5 years
Low grade: 6-12 months
High grade dysplasia in the absence of eradication therapy: 3 months

23

What is the treatment for recurrent C. diff infection?

Duodenal infusion of faeces.
Sig more effective than the use of vancomycin

24

What is the recommended guidelines for colorectal ca screening for average or slightly increased risk (Asymptomatic or one first or second degree relative with CRC diagnosed at 55 years or older)

FOBT every 2 years from age 50 years

25

What is the recommended guidelines for colorectal ca screening for moderately increased risk (1-2% of population) (asymptomatic with 1 first degree relative with CRC diagnosed before 55 years or 2 first degree or 1 first degree and one second degree on the same side of the family with CRC diagnosed at any age without high risk features)?

Colonoscopy
Sigmoidoscopy plus double contrast barium enema or CT colonography if colonoscopy CI.
Every 5 years from age 50 years or at an age 10 years younger than the age of 1st diagnosis of CRC in the family. Whichever comes first.
Consider offerring FOBT in intervening years.

26

What is the recommended guidelines for colorectal ca screening for high risk (=3 1st degree or second degree relatives on the same side of the family diagnosed with CRC (suspected Lynch syndrome, also known as HNPCC) or other Lynch syndrome related cancers or
- >=2 first or second degree relatives on the same side of the family Dx with CRC, including any of the following high risk features: multiple CRC in one person, CRC before 50 y, family member who has or had Lynch syndrome related cancer or
- 1 fist degree or second degree relative with CRC, with suspected FAP or
- somebody in the family whom the presence of a high risk mutation in the adenomatous polyposis coli (APC) or one of the mismatch repair genes has been identified

- refer to genrtic screening of affected relatives.
- FAP: flexible sigmoidoscopy or
- Colonoscopy in attentuated FAP
Those at risk for FAP

27

what do the following mean?
Autocrine
Endocrine
Neurocrine
Paracrine

Autocrine - self communicating e.g. NO, IGF
Endocrine - hormones
Neurocrine - Vagus nerve e.g. Ach, VIP
Paracrine - parallel, talking next door e.g. somatostatin

28

Where are the following peptide hormones produced? Function?
Gastrin
CCK
Secretin
Glucagon
Gastric inhibitory peptide
VIP
Serotonin
Substance P

Gastrin - Antral G cells. Regulates gastric H+.
CCK - Intestinal I cells. Regulates pancreatic enzyme regulation.
Secretin - Intestinal S cells. Regulation of HCO3.
Glucagon - Intestinal L cells. Regulation of Insulin.
Gastric inhibitory peptide - Intestinal K cells. Reg of insulin release. Inhibitor of H+.
VIP - Myenteric inhibitory motorneurons/submucosal neurons. Neural inhibitor of of motility/stimulant of fluid secretion.
Serotonin - EC cell of digestive tract. Stimulus of peristalsis.
Substance P - Neurotransmitter.

29

what is the rate limiting step in acid production?

H/K/ATPase pump

30

What are some of the AE of PPIs in studies?

Increased risk of Pneumonia, Gastroenteritris e.g. Campylobacter, Salmonella, OP.
Significant risk of C. diff in meta analysis.

31

What are the causes of Hypergastrinaemia?

Atrophic gastritis - pericious anaemia, H. pylori
Renal failure
Hypercalcaemia
Hyperlipidaemia
Vagotomy/SB resection
Gastrin secreting tumour
Prolonged acid inhibition e.g. PPI, H2RAs

32

What is Zollinger-Ellison Syndrome?

Gastrin secreting tumour -> ulcer disease.
1/3 of pts have MEN1

33

How do you Dx ZES?

Gastrinoma triangle - bound by junction of cystic and CBD, junction of 2nd-3rd parts of duodenum and junction of neck and body of pancreas.
Step 1 - Fasting gastrin > 1000 pg/mL in absence of PPI.
If eelvated gastrin, confirm with basal acid output test.
Step 2 - BAO = acid output > 10 mEq/ hr.
Secretin provocation
Step 3 - secretin provocation test to confirm Dx.
Should expect increase of gastrin>200pg/ml above baseline within 15 minutes of infusion.

34

Which cells control persitalsis?

Interstitial cells of Cajal in myenteric plexus. Serves as pacemaker cells leading to slow waves potential -> contraction of smooth muscle

35

Which motility disorders are associated with loss of interstitial cells of Cajal?

Slow transit constipatiomn/chronic idiopathic constipation
Internal anal sphincter achalasia
Gastroparesis (idiopathic and diabetic)
Afferent loop syndrome
Megacolon and megaduodenum
Paraneoplastic dysmotlity
Crohn's disease
Achalasia of LES

36

What are the acute causes of pancreatitis?

Alcohol
Gallstones
Drugs
Infection
metabolic
ERCP, post
Ischaemia - rare, after prolonged Sx in prone position

37

Causes of chronic pancreatitis?

EtOH
Genetic
Duct obstruction
Tropical
Systemic disease
AI
Idiopathic

38

Have studies shown statins reduce risk of pancreatitis?

Yes.
Fibrates no.

39

How do you treat post ERCP pancreatitis?

NSAIDs

40

Acute Mesenteric ischaemia. Cause, Presentation, Ix, Tx?

Causes:
occlusive (85-95%) or non occlusive (20-30%) obstruction of arterial or venous flow.
SMA embolism in 50%
SMA thrombosis 15-25%
Non occlusive - usually due to splanchnic vasoconstriction
Mesenteric venous occlusion 5%
Focal segmental inschaemia
SMA embolism from LA or ventricular mural thrombus is the most common cause

Presentation:
>50 y
Underlying cardiac disease
Acute onset of severe ado pain
AS, tender, pain out of proportion to examination

Ix:
Gold standard is mesenteric angiography

Tx:
Papaverine- phosphodiesterase inhibitor can be used at the time of angiography to relieve mesenteric vasoconstriction in pts with embolic and non embolic arterial occlusion as well as nonexclusive ischaemia.
Laparotomy and embolectomy
Mesenteric artery thrombus - Surgical revascularisation
Mesenteric venous thrombus - anitcoag and resection of infarcted bowel
Non- occlusive - Tx cause, resection is ischaemia present

41

Chronic Mesenteric Ischaemia. Cause, Presentation, Ix, Tx?

Intestinal angina.
Manifestation of mesenteric arthersclerosis.

Presentation:
Abdo pain 30 minutes after eating - due to diversion of small bowel blood flow to gut after eating.
Leads to sitophobia - fear of eating

Ix:
Splanchnic angiography - occlusion of at least 2 of the major splanchnic arteries
Doppler US a screening test but cannot confirm Dx
MR and CT angiography useful but abnormal study still warrants a splanchnic angiography.

Tx:
Surgical revascularisation is the definitive Tx
Percutaneous angioplasty with or without stunting can be attempted in pts who are poor surgical candidates for bypass Sx.

42

Primary Biliary Cirrhosis: What, Presentation, Ix, Tx?

Chronic cholestatic liver disease of unknown cause. Ongoing immunologic attack on interlobular bile ducts eventually lead to cirrhosis and liver failure.
Affects middle aged F, median onset 50y.

Presentation:
Fatigue
Dry eyes
Dry mouth
Pruritis
Jaundice and cutaneous hyperpigmentation rarely observed.


Ix:
High Bili
ALP 1.5 x ULN
AST and ALT 5xULN
Mitochondrial antibody present in 90-95% at titres > 1:40
Liver bx if ab -ve
Histo - focal duct obliteration with granuloma formation known as florid duct lesion is pathognomonic.

Tx:
Ursodeoxycholic acid , offers survival benefit
Symptomatic Tx of dry eyes, dry mouth and pruritis
Liver transplant highly effective for end stage PBC

43

What test has the most NPV in coeliac disease?

HLA DQ2/8 negative

Very unlikely to have disease

Consider testing in non dx histo or negative serology

44

PUD: most common cause? Common site? Dx?

H. pylori and NSAIDs cause > 90%

Duodenum most common, 95% in bulb or pyloric channel.

In the stomach most are in the antrum.

Duodenal ulcers have increased acid secretion compared with gastric.

Dx confimed by upper endoscopy with rapid urease test and histo.

If Bx not taken, then urea breath test or faecal antigen test

PPIs can casue false negatives and should be stopped 7-14 days prior

45

Where are the following absorbed in the GIT? Iron, folate, B12/bile salts

iron - duodenum

folate - jejunum
absorption > in proximal then distal jejunum

B12/bile salts - ileum

46

Tx of alcoholic hepatitis?

Based on Maddrey discriminant function score (MDF)

MDF ≥32 = severe alcoholic hepatitis. Tx with prednisone or pentoxifylline.
Pentoxyfylline used when pt has fever (SBP), bleeding, RF as prednisone CI.

Cease EtOH
Supportive care

47

How do you calculate the Maddrey discriminant function score (MDF)?

4.6 [PT (s) - control PT (s)] + total bilirubin.
>= 32 suggest severe alcoholic hepatitis with short term mortality risk of 50%

48

What is the MELD score? How do you calculate it?

Prognostic Index to assess mortality in pts with ALD

MELD score:
Total Bilirubin
Serum albumin
INR
Ascites
Hepatic encephalopathy

MELD 5-6 = 100% 1 y survival
MELD 7-9 = 81% 1 y survival
MELD 10-15 = 45% 1 yr survival

49

Biggest predictor of varices?

Portal pressure (hepatic venous portal pressure)
> 10 suggest high risk of bleeding
HVPG is the only measurable factor

Child Pugh score C = 70% risk of bleed

50

NAFLD. What, Dx, Tx?

Usually results fro insulin resistance and metabolic syndrome.
Inflammation and fibrosis associated with NAFLD is referred to as NASH.
10% progress to cirrhosis.

Dx: US, VT, MRI can confirm heaptic steatosis but cannot indetify inflammtion and fibrosis. Liver Bx confirms NASH

Tx:
Weight loss and managment of co-morbidities

51

What is the criteria for liver transplantation in fulminant hepatic failure?

PT > 100 sec irrespective of grade of encephalotpathy OR
any 3 of the following
- Age 40 y
- non A-B hepatitis, halaothane of drug reaction
- Jaundice to encephalopathy > 7 d
- PT > 50 s
- serum bilirubin > 300

52

What is the criteria for liver transplantation in fulminant hepatic failure in paracetamol overdose?

pH 100 and
serum Cr > 300
in pts with grade III or IV encephalopathy

53

CI to liver transplant?

Ongoing smoking and EtOH

54

Indications for liver transplant?

MELD score> 15 in adult
Small HCC
Liver disease that would result in a 2 year mortality rate of >50% without liver tranplantation
Diuretic resistnat ascites
recurrent HE
recurrent SBP
recurrent or persistent GI haem
Intractable cholangitis
HPS
Portopulmonary HT
Metabolic syndromes curable with lvier tranplant e.g. falilial amyloidosis, urea cycle disorders, oxalosis

55

Most common indication for liver transplant?

Hepatoma

56

Why do you perform weekly CMV levels post transplant for 7 months?

High risk of CMV infection.
High titres indicate high dose immunosuppression.
Decrease immunosuppressive doses and start valganciclovir

57

How common is liver rejection post transplant?
Signs of liver rejection.
Tx?

30-40%. Can occur at 1 week.

Elevated liver enzymes.
Biliary stricture or rejection. Perform MRCP and if negative then liver biopsy.

Responsive to steroids.

58

What is the most common cause of deranged LFTs?

NAFLD

59

How do you distinguish between achalasia and peptic stricture?

In achalasia - acute onset, days to both solids and liquids

In Oesophageal peptic stricture - chronic, progressive to solids and then liquids

60

What is Plummer Vinson syndrome?

Dysphagia with Fe def anaemia associated with oseophageal web (thin membranes located in the middle or upper oesophagus)

61

A biopsy is always indicated in the Dx of HCC. T/F

False.
In the setting of CLD and elevated AFP the characteristic findings of HCC is sufficient.

Dedicated 4 phase mulit-detector CT or dynamic contrast MRI is sufficient with late arterial phase imaging is recommended.

Manifest as enhancing mass with hyper-vascularity during the arterial phase and washout dueing the venous phase.

62

When is a percutaneous image-guided biopsy indicated?

Liver met > 1 cm when imaging findings not characteristic of HCC or hemangioma

63

What is the Tx for HCC?

Liver resection
However many patients are ineligible due to extent of tumour nor liver dysfuntion.

Non surgical candidates:
Local tumour ablation
TACE
RTx
Systemic Tx


64

What are the indications for an ERCP?

Stone in CBD
Co-exiting cholangitis (fever, jaundice, septic shock)
Persistent biliary obstruction (conjugated bili > 5 mg per deciliter)
Clinical deterioration and increasing LFTs

In the absence of cholangitis and biliary obstruction, ERCP within 24-72h does not lead to reduction in mortality

65

ERCP is indicated in biliary/gallstone pancreatitis. T/F

False.
Do not benefit from ERCP with or without sphincterotomy.

66

What are the causes of pseudo-obstruction?

Hypothyroidism (bradycardia, hypothermia)
Hypokalaemis
Diabtes
Uraemia
Hypocalcaemia and hyperparathyroidism

67

Fistulae occur in 20-25% of Crohn's pts. T/F

True

68

Metronidazoel and cipro are effectivein fistulising Crohn's. T/F

True however long term therapy have adverse effects.
Cipro is used although no more effective.

69

How many pts remain fistula free after Infliximab at 1 year?

35%
Heals > 50% of fistulae

70

Tacrlimus is more effective than other therapies at healing fistulas in crohn's disease?

True. Becoming second line therapy after TNF (infliximab)

71

What is the main circulating form of Vit D?

If you suspect renal impairment in Vit D def, which form of Vit D do you measure?

Main is 25(OH) Vitamin D

Renal impairment
1,25 (OH) Vitmain D - the bioactive form

72

C. difficile Tx?

Orla metronidazole
Oral Metro x 2
Oral vanc (can include IV metronidazole with vanc)
Faecal transplant, may need more than one infusion

Exclusions for faecal tranplant:
ICU
Immunocompromised

73

Mx of bloating in IBS?

Trial low FODMAPs diet:
Fermentable
Oligosachharides - frutans, galacto-oligosaccharides
Disacchardies e.g. lactose
Monosaccharides - fructose in excess of glucose
Polyols - sorbitol, mannitol, maltitol, xylitol and isomalt

peppermint oil
- antispasmotic and anti-flatulent effects

Iberogast (STW5)
- herbal agent containing extracts if the plant Iberis amara that increases motility.

74

Symptoms of IBS?

Abdo pain
Bloating
Abnormal bowel habits e.g. intermittent diarrhoea and constipation

75

What is the pathophysiology of hepatopulmonary renal syndrome?

A vascular disorder of the lung which occurs in the setting of chronic liver disease.
- dilatation of pulmonary capillaries
- Pleural and pulmonary AV malformations/shunts
- arterial hypoxaemia and orthodeoxia (reduction in arterial oxygen tension from supine to upright position). Due to a preferential perfusion of lung bases in an upright position where the vascular abnormalities are typically found. This is called PLATYPNOEA.

76

How do you Dx and Mx Heptopulmonary syndrome?

Dx:
bubble study. TTE with microbuble contrast. Left heart will usually not have microbubbles unless there us a intracardiac or intrapulmonary shunt.

Tx:
Liver tranplant
No medical therapy

77

Tx of NAFLD?

1st line - weight loss

Vitamin E may help, doses > 400IU associated with increased mortality
Pioglitazone can improve histology however AE are weight gain, oedema and HF.

78

What is a common presentation of Eosinophilic oesophagitis? Dx, Tx

Food bolus obstruction is common.
Young male with Hx of atopy.

Dx:
Endoscopy and biopsies demonstrating > 15/hpf

Tx:
Trial pts on PPI first to see if response
1st line
- diet therapy and avoidance of allergens
- SFED for 8 weeks then reintroduce 1 at a time (no milk, wheat, soy, seafood, eggs)

Topical inhaled corticosteroid or systemic corticosteroids provide short term relief.
PPI - 30% will respond
Elimination diets
Endoscopic dilatation

79

How are bile salts synthesised?

In liver from cholesterol and conjugated.
Transported into bile ducts ad stored in gallbladder.
Released into doudenum post prandially.
Reabsorbed in the terminal ileum.

80

What is bile salt diarrhoea? Tx

If biles salts are not reabsorbed in the terminal ileum, they enter the colon ancause diarrhoea by:
- inducing secretion of Na and H2O
- increasing colonic motility and stimulating defacation
- Increasing mucous secretion
- muscosal damage

Tx
Cholestyramine - oral bile acid sequestion

81

What is the criteria for Dx of AIH? Tx?

ANA or SMA >=1:40 or >=1:80 = 1 point OR
LKM = 2 points OR
SLA +ve = 2 points
IgG > upper limit normal 1 point
IgG > 1.10 x ULN = 2points
Liver histology compatible with AIH = 1 point
Liver histo typical AIH = 2 points
Absence of viral hepatitis = 2 points

Points >=6 probable AIH
Points >= 7 definite AIH

Tx:
Prednisone
+/- Azathioprine

82

Hepatocellular derangement for the following:
EtOH hepatitis
Viral
Drugs
Iscahemic Hepatitis

EtOH
- AST> ALT (S for schooner)

Viral
-ALT > AST

Drugs
- temporal relationship is key
- Drugs can cause any pattern
- common are abx, NSAIDs, MTX, AZA, paracetamol

Ischaemic hepatitis
- AST, ALT in 1000s
- AST settles quicker than ALT which drops slowly
- can get subsequent rise in Bilirubin

83

UC: What are the markers of severity? Tx?

No of bloody stools > 6/d + 1 or more of the following:
Febrile > 37.8
HR>90
Hb 30
CRP > 45
Severe inflammation on colonoscopy

Tx:
Colorectal surgical consult D3 onwards if no improvement with steroids
rescues drugs
- cyclosporin or
- infliximab
D5-6, no clinical response than colectomy in rescue failure

84

What is IgG4 related disease? What organs are affected?
Tx

Fibroinflammatory disease characterised by:
- Tumefactive lesions
- dense lymphoplasmacytic infiltrate on Bx
- storiform fibrosis
- similar histopathological features in all tissues

Often but not always an elevated IgG4

Can affect all organs
- pancreas and biliary tree
- salivary glands, lymph nodes
- retroperitoneal fibrosis also common

Tx:
Steroids

85

What are the RF for Hep B reactvation with immunosuppression?

Previous or active disease are at risk of reactivation

sAg +ve > sAg -ve, cAB -ve

Rituximab and anthracyclines

86

Who should receive Hep B prophylaxis Tx during immunosuppression?

All pts sAg +ve
All pts sAg-ve and HbcAb +ve and receive rituximab

Prophylaxis should continue for 6-12 months post CTx
12 months post Rituximab

87

HbcAb +ve and HbsAg -ve. Should they receive Hep B prophylaxis prior to CTx?

Controversial and guideline varies.
Definitely in pts receiving Rituximab

88

Rifaximin.
MOA
Indication
AE

minimally absorbed oral antibiotic -> alteration of bacterial flora.

Indication:
Hepatic encephalopathy
- maintains remission from encephalopathy
- reduces the risk of hospitalisation with encephalopathy

89

What is the acute Mx of hepatic encephalopathy?

Treat underlying precipitant
Lactulose titrated to 3-4 bowel motions/d
Empirical Antibiotics
WH diuretics as dehydrated

90

What is the used in the prevention and Tx of encephalopathy?

Nutrition
- high energy, high protein
Branch amino acids
- hepatamine (restricted to tranplant centres)
- lactulose(non-absorbable oral disaccharides)
- Rifaximin (on PBS if pt is on lactulose)

91

How can you distinguish between NASH and alcoholic hepatitis on histo?

Neutrophils present in alcoholic hepatitis.
Neutrophilic infiltration is most specific for EtOH hepatitis.

Not present in NASH.

92

Which medication is most associated with oesophageal ulceration (pill induced oesophagitis)?

Antibiotics, 60%
Doxy and tetracyclines in particular

Bisphosphonates - oral alendronate
NSAIDs

93

Which protease inhibitors are indicated in HCV Tx?
AE

Telepravir
- anaemia, rash, pruritis
Bocepravir
- anaemia, rash, dysgeusia
Improved SVR from 40-70%
Genotype 1 only

94

What is the best imaging for choledocholithiasis?
If stone undetected, next best imaging?

ERCP GOLD standard - high specificity and sensitivity.
If ERCP -ve then:

Endoscopic US
- minimally invasive
Can be performed prior to ERCP, done in same procedure. Reduce risk of invasive Mx.
- good views of CBB and has an advantage over cross sectional imaging for small stones.

95

Indications for Endoscopic US?

Diagnostic:
Choledocholithiasis
pancreatic head assessment
pancreatic cysts
Oesophageal tumour staging
Mediastinal masses

Therapeutic:
draining of pancreatic pseudocysts
drainage of biliary obstruction

96

Child Pugh Score classification of liver cirrhosis.
Components to score - Pour another beer at eleven
Classes

Prothrombin time
Ascites
Bilirubin mg/dL
Albumin
Encephalopathy

Class A 5-6 points:
Severenliver disease

Class B 7-9:
Moderateraly severe liver disease

CLass C 10-15 points:
Most severe liver disease

97

Pts with cirrhosis.
What is the screening recommendation for:
Small varices
No varices

Small varices
- yearly

No varices
- 2nd yearly

98

Recommended primary prophylaxis against variceal bleed.
Medication vs. Surgical

Medications: does not improve mortality but reduces bleeding rates compared to placebo
Propanolol or nadolol
- aim HR 55bpm

Endoscopic ligation - reduces mortality
Every 2-4 weeks until varices obliterated
FU endcoscopy 1-3 months after obliteration then every 6-12 months indefinitely

BB can be ceased when varices erradicated

99

Mx of acute variceal bleed?

Non aggressive resus
Octreotide and terlipressin (glypressin) to control bleeding in 80% of cases
Endoscopy with banding
Ceftriaxone followed by norfloxacin

100

TIPS has been shown to increase survival in patients with cirrhosis and variceal bleeding. T/F

True
Early use of TIPS associated with sig reduction in Tx failure and mortality in pts with cirrhosis who were hospitalised for acute variceal bleed and at high risk of Tx failure

101

When should a Dx of Hepatorenal syndrome 1 be considered?

When there is an increase in SCr of 150% or more from baseline.

HRS1 is acute
HRS2 is chronic, over months

102

Terlipresin. MOA

Long acting vasopressin analog.
Mediates vassoconstriction by activation of vasopressin receptor on vascular smooth muscle cells within the splanchnic bed.
Reverse splanchnic vasodilation.

Optimal duration of therapy is >3 days.

103

SBP. What prophylaxis is recommended after the 1st episode?

Norfloxacin 400 mg OR bactrim DS equally effective.

SBP spontaneously recurs in 70%.
First episode is often a trigger for OLTx referral

104

How may PMN is Dx of SBP?

> 250 PMN/ml

105

Which immunosuppressive therapy is used post liver transplant?
AE?

Cyclasporine/Tacrolimus
- HTN, nephrotoxic, DM, lipids, tremor, Hirsutism, neurological

MMF:
diarrhoea
nausea
GI intolerance

Azathioprine:
Hepatitis
Pneumonitis/pancreatitis
GI disturbance
leukopenia

106

Post liver tranplant:
Early complications post transplant,

Graft failure, rare
Infection - bacterial, CMV, fungal
- PJP proph with bactrim 1/2 DS tablet OD for 6/12
- CMV proph with valganciclovir for 3/12
- if requires CMV Tx, use Ganciclovir IV for 10-14/7
Biliary stricture
Renal/DM/Cosmetic

107

Post liver tranplant:
Late complications post transplant, > 3 months

Cancer:
PTLD - post tranplant lymphoproliferative disorder
Skin

Vascular- AMI

Renal (15% Cr >0.15, 5% Cr>0.25)

Recurrent disease

OP

108

Post liver tranplant:
When does acute rejection occur?
% of rejections
Tx

7-10 days
- cholestatic LFTs due to portal based inflammation

30%

Bolus steroids

109

Post liver tranplant:
When does chronic rejection occur?
% of rejections
Tx

Months to years post tx
- cholestatic LFTs due to vanishing bile duct syndrome

3%

Tx: increase immunosuppression, tacrolimus
may not be treatable

110

Recurrent disease post liver transplant. Recurrence rates for following:
HCV
HBV
PSC
PBC

HCV:
Universal recurrence
Mean time to recurrent cirrhosis is 7 years

HBV:
Without prophylaxis recurrence is very common
Long life antivirals with Entecavir

PSC:
30% develop recurrence
Morbidity common
Mortality rare

PBC:
Mortality rare

111

University of California, San Francisco criteria for liver transplant in HCC.

Single nodule

112

Best serological marker for acute infection?

Hep B core IgM

113

In pts untreated post transfusion Hep C, what is the lifetime risk of progression to cirrhosis?

20%

114

Which colonic poly has the highest potential for malignant transformation?

Villous

115

What is the most common mechanism for malignant ascites?

Obstruction of abdo lymphatics

116

The risk factor with the greatest impact on the development of oesophageal cancer is?

Barrett's oseophagus

117

What are the 4 types of Inherited pancreatits?

Hereditary:
AD
80% penetrance
recurrent mild attacks from > 5 yo
Chromosoem 7q35
Trypsinogen gene PRSS1
Increased risk of cancer

SPINK1 mutation:
adolescents with pancreatitis and normal tripsinogen activity
1/4 pts have no FHX

CFTR gene mutation:
idiopathic chronic pancreatitis
male infertility

AI pancreatitis:
IgG4 disease, mild currents attacks, presents with mass

118

achalasia:
Manometry finding
Tx

Failure of LES relaxation with swallowing

Tx
Botulinum toxin
-similiar efficacy to dilatation and safer
-median effect for 12 months

119

In the liver which are is most prone to ischaemia?

Zone 3 (around central vein)

Zone 1 - affected PBC

120

Diffuse oesophageal spasm:
Manometric finding
Barium swallow
Tx

Dysphagia to solid and liquids, chest pain

Mannometry:
intermittent, 20% or more simultaneous contractions with high amplitude > 30 mmHg.
Non peristaltic contracions in response to swallowing.

Barium swallow:
Cork screw oesophagus

Tx:
CCB

121

Nut cracker oesophagus aka hypertensive peristalsis:
Presenation
Manometric finding
Tx

Asymptomatic

Manometric finding of average distal pressures > 220 mmHg during 10 x 5 ml liquid swallows.

Tx:
CCB

122

What is dumping syndrome?
Early vs. late
Tx

Caused by destruction or bypass of the pyloric sphincter
Occurs 20% of pts post pyloroplasty or distal gastrectomy.

Eraly:
Occurs 15-30 minutes after meal
N/V/D, cramps, vomiting
Diaphoresis, palpitations and flushing
Due to rapid emptying of hyperosmolar chyme (particularly carbs) into the small bowel leading to fluid retention due to osmotic gradient and release of serotonin and VIP.

Late dumping:
Same symptoms as above a couple of hours after eating.
Due to hyoglycaemic following postprandial insulin peak.

Tx:
Dietary changes
Avoid carbs

123

When to suspect factitious diarrhoea?
Presentation
Electrolyte abnormality
Appearance of colon
Ix to confirm

Long standing blaoting and watery diarrhoea
Postural drop

serum K low
Urine Na low = 2
Urinary potassium higher 50

Melanosis coli is the appearance of colon

Confirm with stool and urine testing for laxatives using thin later chromatography (bisacodyl or senna)

124

What is a small bowel series aka small bowel enema, enteroclysis?

contrast travelling through the small bowel to Ix obstruction, stricture.

125

What is a pooled red blood cell scan?

Ix whether liver mass on CT/US is benign or malignant, and to exclude haemangioma in case a liver biopsy is required because the haemangioma will actively bleed if it undergoes biopsy.

Haemangioma of the liver will accumulate the radioactive tracer to a greater degree than the surrounding liver tissue.

126

Which Ix provides the most information for staging in Oesophageal cancer?

EUS

127

Which gastro procedures require antibiotic prophylaxis?

Percutaneous gastrostomy or jejunostomy tube insertion wither endoscopic or radiologically
- Cephazolin reduces risk of peristomal infective complications
- add Vanc is MRSA

EUS or EUS with FNA if:
adjacent to GIT and may be considered for solid lesions adjacent to the lower GIT. Not recommended if lesion is adjacent to the upper GIT.

In a ERCP if:
- complete biliary drainage may not be achieved or
- communicating pancreatic cysts or pseudocysts
- before tranpapillary or transmural drainage of pseudocyst

128

Cardiac procedures requiring antibiotic prophylaxis?

Valve replacement
CABS
Cardiac transplantation
Transcatheter aortic valve implantation (TAVI)
Insertion of ventricular assist devices
- cephazolin
Add vanc if MRSA

129

Barrett's oesophagus:
Changes on endoscopy
Tx

metaplasia of the squamous epithelium of the lower oesophagus to a columnar epithelium of intestinal type
Premalignant condition associated with 40-125 fold increase in the incidence of adenocarcinoma of the oseophagus.

Tx:
High grade dysplasia
- endoscopic mucosal resection for Dx and staging AND/OR ablation followed by high dose acid suppression
- Further Mx: Oesophagectomy, endoscopic ablation (photodynamic or radiofrequency)

Surveillance every 3 months

130

Barrett's oesophagus.
Pt has erosive oesophagitis above squamocolumnar junction and is not on a PPI and endoscopy reveals dysplastic epithelium with features of active inflammation. Next step?

Repeat biopsies after 2 months of Tx with PPI

131

Presbyoesophagus:
What?
Age group
Presenatation
Manometry

Manifestations of degenerating motor function in the aging oesophagus.

Pts > 80 yo

Asymptomatic but may complain of chest pain or dysphagia.

Mannometry:
tertiary contractions (ranging from minor to severe)
Decreased amplitude

132

Oesophageal ca:
Types

Types:
Adenocarcinoma - more common in western world, affects distal
Squamous cell - 90% overall, more common in developing world, affects proximal oesophagous.

M>F

RF:
SCC- alcohol, tobacco, corsive injury to oesophagus, HPV not proven, precursor is squmouse dysplasia, no proven role fo

Adeno - Smoking, OBESITY, H. pylori, GORD and BE

Presentation:
Progressive solid food dysphagia most common and reduced oral intake.
Anaemia from GI bleeding.

Staging:
Endoscopy diagnostic
Endoscopic US- used for staging and accurate for establishing tumour stage
CT for distant mets
PET- changes staging in 20%

Staging:
O = tumour in mucosa
1 = tumour in submucosa
2a = into muscle
2b = into lymph nodes
3 = beyond muscle
4 = mets

Tx:
Stage 0
-endoscopic mucosal ressection

Stage I
- oesophagectomy + lymph node clearance

Stage II and III
- oesophagectomy alone, 5-34% 5 year survival

Neoadjuvant = pre-op CTx and RTx improves survival compared to Sx alone for both cancers
Role of adjuvant CT and RT unclear

Stage IV:
Symptom control
- stent or RTx
CTx controversial, not sown to be superior to supportive care
- 2 drugs (5-FU and cisplatin) is SD
- 3 drugs (epi, cis + 5FU) is alternative with increased toxicity.
No survival benefit.

133

Stages of Hep B infection and Tx options:
I-IV

Tx phase II and IV, when ALT is persis or intermittently elevated

Phase 1: immune tolerance
HBsAg > 6 months
HBeAg +ve
Anti-HBe ab +ve
ALT normal
HBV DNA >= 20 000
Liver histo normal
Mx: Montior q 3-6 months

Phase 2: Immune clearance
HBsAg > 6 months
HBeAg +ve
Spontaneous conversion to anti-HBe may occur
ALT persistently or intermittently elevated
HBV DNA >= 20 000
Liver histo moderate to severe heaptitis
Mx:
Tx

Phase 3: Immune control
HbsAg > 6 months
HbeAg -ve
Anti-Hbe ab +ve
ALT normal
DNA 6 months
HbeAg -ve
Anti-Hbe ab +ve
ALT elevated inter or persist
DNA >2000
Liver histo mod to severe hep
Mx: Tx

134

Tx for decompensated cirrhosis (HbeAg +ve or -ve) secondary to Hep B?

Screen for AFP and US for HCC q 6-12 months
Treat early
Combination with Tenofavir and Entacavir
PegInterferon is CONTRAINDICATED
Life long Tx required
Refer for OLT

135

Tx of compensated (HbeAg +ve or -ve) liver cirrhosis in Hep B?

Screen for HCC with US and AFP every 6-12 months.
HBV DNA 2000 IU/ml
- Treat
- Tenof or Entec
- to avoid flares, PEGInterferon should be used in early well copensated liver failure

136

Mx of infants of mothers with HBSAg +ve?

All infants should recieve vaccine and HBIG

137

PEG interferon can be given in pregnancy? T/F

False. CI.

138

Monitoring of Hep B?

Confirm Antiviral response to Tx at 12 weeks
Monitor at 24,36 and 48 weeks
Complete response, 2000 IU/ml
- Consider add on therapy and monitor q 3 months

139

Hbe Ag +ve mother. Risk of chronic HCC to child?

90%
HbeAg -ve mother =