gastro

Question 1

oesophageal varices prophylaxis for bleeding

Answer 1

propranolol (non cardioselective beta blocker)

Question 2

Child pugh liver cirrosis

Answer 2

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

Question 3

hep B mother about to give birth

Answer 3

give child hep B vaccine and hep B immunglobulin after birth

Question 4

ischaemic colitis most common in

Answer 4

splenic flexure

Question 5

roux en Y bypass supplementation needed

Answer 5

iron

- mostly absorbed in duodenum

Question 6

hepatic encephalopathy features

Answer 6

Features
confusion, altered GCS (see below)
asterix: ‘liver flap’, arrhythmic negative myoclonus with a frequency of 3-5 Hz
constructional apraxia: inability to draw a 5-pointed star
triphasic slow waves on EEG
raised ammonia level (not commonly measured anymore)

Question 7

hepatic encephalopathy treatment

Answer 7

lactulose

2nd line rifaxminin (a`bx that changes gut flora)

Question 8

abdominal pain: sudden onset, severe
ascites
tender hepatomegaly

Answer 8

Budd Chiari - hepatic vein thrombosis

Ix - US with doppler flow studies

Causes
polycythaemia rubra vera
thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies
pregnancy
oral contraceptive pill

Question 9

Ix to detect cirrhosis

Answer 9

Transient elastography

Question 10

Sulphasalazine

Answer 10

a combination of sulphapyridine (a sulphonamide) and 5-ASA
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)

Question 11

Pyogenic liver abscess Rx

Answer 11

Most likely staph or e coli

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

Question 12

5 ASA MOA

Answer 12

not absorbed and released in colon - local antiinflammaotry

Question 13

Most common ERCP Side effect -

Answer 13

pancreatitis

Question 14

which diabetic med causes cholestasis

Answer 14

gliclazide (sulfonylureas)

Question 15

H pylori

Answer 15

urea breath test (CLO)

Question 16

Melanosis coli

Answer 16

pigment laden macrophages

- laxative abuse

Question 17

refeeding syndrome

Answer 17

hypophosphataemia
hypokalaemia
hypomagnesaemia: may predispose to torsades de pointes
abnormal fluid balance

Question 18

Primary biliary cholangitis Diagnosis and Mx

Answer 18

Diagnosis
anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific
smooth muscle antibodies in 30% of patients
raised serum IgM

Management
pruritus: cholestyramine
fat-soluble vitamin supplementation
ursodeoxycholic acid
liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) - recurrence in graft can occur but is not usually a problem

Question 19

Primary biliary cholangitis complications and associations

Answer 19

Complications
cirrhosis
osteomalacia and osteoporosis
significantly increased risk of hepatocellular carcinoma

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

Question 20

autoimmune hepatitis types

Answer 20

Type I
Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)

Affects both adults and children

Type II
Anti-liver/kidney microsomal type 1 antibodies (LKM1)

Affects children only

Type III
Soluble liver-kidney antigen

Affects adults in middle-age

Question 21

autoimmune hepatitis Features and Mx

Answer 21

Features
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

Management
steroids, other immunosuppressants e.g. azathioprine
liver transplantation

Question 22

carcinoid syndrome cardiac abnormalities

Answer 22

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

Question 23

Wilson’s features

Answer 23

Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea:

liver: hepatitis, cirrhosis
neurological: basal ganglia degeneration, speech, behavioural and psychiatric problems are often the first manifestations. Also: asterixis, chorea, dementia, parkinsonism
Kayser-Fleischer rings
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails

Question 24

Wilson’s Diagnosis and Mx

Answer 24

Diagnosis
reduced serum caeruloplasmin
reduced serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
increased 24hr urinary copper excretion

Management
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

Question 25

Features multiple gastroduodenal ulcers diarrhoea malabsorption

Answer 25

Zollinger-Ellison syndrome Zollinger-Ellison syndrome is condition characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas. Around 30% occur as part of MEN type I syndrome Features multiple gastroduodenal ulcers diarrhoea malabsorption Diagnosis fasting gastrin levels: the single best screen test secretin stimulation test

Question 26

Ulcerative colitis pathology and barium enema findings

Answer 26

Pathology red, raw mucosa, bleeds easily no inflammation beyond submucosa (unless fulminant disease) widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps ('pseudopolyps') inflammatory cell infiltrate in lamina propria neutrophils migrate through the walls of glands to form crypt abscesses depletion of goblet cells and mucin from gland epithelium granulomas are infrequent Barium enema loss of haustrations superficial ulceration, 'pseudopolyps' long standing disease: colon is narrow and short -'drainpipe colon'

Question 27

Peutz Jehger's Syndrome

Answer 27

Features hamartomatous polyps in GI tract (mainly small bowel) pigmented lesions on lips, oral mucosa, face, palms and soles intestinal obstruction e.g. intussusception gastrointestinal bleeding Management conservative unless complications develop

Question 28

C diff MX

Answer 28

Management first-line therapy is oral metronidazole for 10-14 days if severe or not responding to metronidazole then oral vancomycin may be used fidaxomicin may also be used for patients who are not responding , particularly those with multiple co-morbidities for life-threatening infections a combination of oral vancomycin and intravenous metronidazole should be used

Question 29

Ix of oesophageal/gastric carcinoma mural invasion

Answer 29

endoscopic ultrasound

Question 30

Gastric cancer | assw what skin disorder

Answer 30

acanthosis nigricans

Question 31

severe alcoholic hepatitis Rx

Answer 31

prednisolone

Question 32

coeliac's disease ab

Answer 32

IgA tissue transglutaminase (TTG) antibodies | will be negative in IgA deficiency

Question 33

IBS Rx

Answer 33

First-line pharmacological treatment - according to predominant symptom pain: antispasmodic agents constipation: laxatives but avoid lactulose diarrhoea: loperamide is first-line Second-line pharmacological treatment low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors

Question 34

Budd chiari - hepatic vein thrombosis

Answer 34

The features are classically a triad of: abdominal pain: sudden onset, severe ascites tender hepatomegaly ``` Causes polycythaemia rubra vera thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies pregnancy oral contraceptive pill ``` Investigations ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation

Question 35

severe UC flare Rx

Answer 35

IV hydrocortisone passing >6 bloody stools/day, has a low-grade pyrexia and displays features of systemic upset and therefore is classed as severe UC

Question 36

ascites - protein <15 ?prophylaxis for SBP

Answer 36

Patients with ascites (and protein concentration <= 15 g/L) should be given oral ciprofloxacin or norfloxacin as prophylaxis against spontaneous bacterial peritonitis

Question 37

Antibiotic prophylaxis should be given to patients with ascites if:

Answer 37

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'

Question 38

most common ischaemic colitis site

Answer 38

splenic flexure

Question 39

ischaemic colitis

Answer 39

Ischaemic colitis describes an acute but transient compromise in the blood flow to the large bowel. This may lead to inflammation, ulceration and haemorrhage. It is more likely to occur in 'watershed' areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries. Investigations 'thumbprinting' may be seen on abdominal x-ray due to mucosal oedema/haemorrhage

Question 40

NAFLD ASx found, how often to monitor for liver fibrosis

Answer 40

enhanced liver fibrosis (ELF) testing is recommended to aid diagnosis of liver fibrosis

Question 41

C diff - pseudomembranous colitis common causes

Answer 41

clindamycin: RR = 31.8 cephalosporins: RR = 14.9 ciprofloxacin: RR = 5.0

Question 42

VIPoma (vasoactive intestinal peptide)

Answer 42

VIP (vasoactive intestinal peptide) source: small intestine, pancreas stimulation: neural actions: stimulates secretion by pancreas and intestines, inhibits acid and pepsinogen secretion ``` VIPoma 90% arise from pancreas large volume diarrhoea weight loss dehydration hypokalaemia, hypochlorhydia ```

Question 43

Pancreatitis causes

Answer 43

Gallstones Ethanol Trauma Steroids Mumps (other viruses include Coxsackie B) Autoimmune (e.g. polyarteritis nodosa), Ascaris infection Scorpion venom Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia ERCP Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

Question 44

autoimmune hepatitis ``

Answer 44

Features 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 Management steroids, other immunosuppressants e.g. azathioprine liver transplantation

Question 45

signet ring cells

Answer 45

Gastric adenocarcinoma

Question 46

Jejunal villous atrophy | causes

Answer 46

``` coeliac disease tropical sprue hypogammaglobulinaemia gastrointestinal lymphoma Whipple's disease cow's milk intolerance ```

Question 47

Hepatosplenomegaly causes

Answer 47

chronic liver disease* with portal hypertension infections: glandular fever, malaria, hepatitis lymphoproliferative disorders myeloproliferative disorders e.g. CML amyloidosis

Question 48

Crohn's disease small bowel enema signs

Answer 48

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

Question 49

Crohn's Disease Ix

Answer 49

Bloods C-reactive protein correlates well with disease activity Endoscopy colonoscopy is the investigation of choice features suggest of Crohn's include deep ulcers, skip lesions Histology inflammation in all layers from mucosa to serosa goblet cells granulomas

Question 50

Angiodysplasia

Answer 50

vascular deformity in GI tract bleeding and Fe Def Anaemia assw Aortic stenosis Diagnosis colonoscopy mesenteric angiography if acutely bleeding Management endoscopic cautery or argon plasma coagulation antifibrinolytics e.g. Tranexamic acid oestrogens may also be used

Question 51

Crohn's disease (general and inducing remission)

Answer 51

General points patients should be strongly advised to stop smoking some studies suggest an increased risk of relapse secondary to NSAIDs and the combined oral contraceptive pill but the evidence is patchy Inducing remission glucocorticoids (oral, topical or intravenous) first. Budesonide is an alternative in a subgroup of patients enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children) 5-ASA drugs (e.g. mesalazine) 2nd line azathioprine or mercaptopurine* can be add on but not monotherapy Methotrexate is an alternative to azathioprine infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on azathioprine or methotrexate metronidazole is often used for isolated peri-anal disease

Question 52

Crohn's Disease

Answer 52

Maintaining remission as above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis) azathioprine or mercaptopurine is used first-line to maintain remission methotrexate is used second-line 5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery Surgery around 80% of patients with Crohn's disease will eventually have surgery

Question 53

before azathioprine must assess

Answer 53

TMPT thiopurine methyltransferase

Question 54

Complications of Crohn's disease

Answer 54

``` small bowel cancer (standard incidence ratio = 40) colorectal cancer (standard incidence ration = 2, i.e. less than the risk associated with ulcerative colitis) osteoporosis ```

Question 55

liver damage (hepatocellular picture)

Answer 55

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

Question 56

NAFLD

Answer 56

``` Associated factors obesity type 2 diabetes mellitus hyperlipidaemia jejunoileal bypass sudden weight loss/starvation ``` ``` Features usually asymptomatic hepatomegaly ALT is typically greater than AST increased echogenicity on ultrasound ```

Question 57

coeliac complications

Answer 57

anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease) hyposplenism osteoporosis, osteomalacia lactose intolerance enteropathy-associated T-cell lymphoma of small intestine subfertility, unfavourable pregnancy outcomes

Question 58

cholestasis RUQ pain Fatigue

Answer 58

Primary sclerosing cholangitis strong association with UC Complications cholangiocarcinoma (in 10%) increased risk of colorectal cancer

Question 59

primary sclerosing cholangitis Ix

Answer 59

endoscopic retrograde cholangiopancreatography (ERCP) magnetic resonance cholangiopancreatography (MRCP) showing multiple biliary strictures giving a 'beaded' appearance ANCA may be positive there is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often described as 'onion skin'

Question 60

haemochromatosis screening

Answer 60

general public - ferritin family hx - HFE genotyping Typical iron study profile in patient with haemochromatosis transferrin saturation > 55% in men or > 50% in women raised ferritin (e.g. > 500 ug/l) and iron low TIBC

Question 61

SBP

Answer 61

Diagnosis paracentesis: neutrophil count > 250 cells/ul the most common organism found on ascitic fluid culture is E. coli Management intravenous cefotaxime is usually given Antibiotic prophylaxis should be given to patients with ascites if: 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'

Question 62

inflamation where for crohn's

Answer 62

all layers mucosa and submucosa for UC

Question 63

Gilbert's Ix

Answer 63

Investigation and management investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid no treatment required

Question 64

Small bowel bacterial overgrowth It should be noted that many of the features overlap with irritable bowel syndrome: chronic diarrhoea bloating, flatulence abdominal pain

Answer 64

Diagnosis hydrogen breath test small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce clinicians may sometimes give a course of antibiotics as a diagnostic trial Management correction of underlying disorder antibiotic therapy: rifaximin is now the treatment of choice due to relatively low resistance. Co-amoxiclav or metronidazole are also effective in the majority of patients.

Question 65

dabigatran reversal

Answer 65

Idarucizumab (Praxbind)

Question 66

liver disease causes splanchnic vasodilation and underfilling of the kidneys (hepatorenal syndrome)

Answer 66

type 1 (rapid) 2 (slower) Management options 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

Question 67

UGI bleed | indications for surgery

Answer 67

Patients > 60 years Continued bleeding despite endoscopic intervention Recurrent bleeding Known cardiovascular disease with poor response to hypotension

Question 68

dysphagia (secondary to oesophageal webs) glossitis iron-deficiency anaemia

Answer 68

plummer vinson syndrome replace iron and dilatation of webs

Question 69

Features multiple gastroduodenal ulcers diarrhoea malabsorption

Answer 69

?zollinger ellison Diagnosis fasting gastrin levels: the single best screen test secretin stimulation test MEN 1 3Ps hyperparathyroipd, pancreas, pituitary (also adrenal and thyroid)

Question 70

Flushing, diarrhoea, bronchospasm, tricuspid stenosis, pellagra

Answer 70

carcinoid with liver mets - diagnosis: urinary 5-HIAA

Question 71

Some common factors indicating severe pancreatitis include:

Answer 71

``` age > 55 years hypocalcaemia hyperglycaemia hypoxia neutrophilia elevated LDH and AST ```

Question 72

why do coeliac patients need vaccines

Answer 72

functional hyposplenism

Question 73

HIV: biliary and pancreatic disease

Answer 73

biliary disease with HIV is sclerosing cholangitis due to infections such as CMV, Cryptosporidium and Microsporidia Pancreatitis in the context of HIV infection may be secondary to anti-retroviral treatment (especially didanosine) or by opportunistic infections e.g. CMV

Question 74

Villous adenoma | colonic polyps secreting mucous

Answer 74

The vast majority are asymptomatic. Possible features: non-specific lower gastrointestinal symptoms secretory diarrhoea may occur microcytic anaemia hypokalaemia

Question 75

what types of fat cause pancreatitis

Answer 75

chylomycrons and triglycerides

Question 76

prevent crohn's relapse most effective

Answer 76

stop smoking

Question 77

urea breath test useful for

Answer 77

check H pylori POST eradication

Question 78

Obesity - NICE bariatric surgery referral cut-offs

Answer 78

with risk factors (T2DM, BP etc): > 35 kg/m^2 | no risk factors: > 40 kg/m^2