Gastro

Question 1

Councilman bodies on liver post mortem

Answer 1

Yellow fever

Question 2

The three classical causes of ALT in the 1000s

Answer 2

Acute hepatitis
Ischaemia
Drug tox ( paracetamol, anaesthetic agents, alcohol, labetalol)

Question 3

right upper quadrant pain, evidence of upper GI bleeding and jaundice after liver biopsy

Answer 3

Haemobilia
- bleeding into the biliary tree following connection between splanchnic circulation and either the intrahepatic or extrahepatic biliary system

Endoscopy only diagnostic in 12%
MRI with cholangiopancreatographic may help
Angiography is diagnostic and then embolisation of the lesion

Question 4

Patient presents with drop in Hb. Colonoscopy and OGD normal two years ago. What investigation is more likely to contribute to diagnosis

Answer 4

Capsule endoscopy
?angiodysplasia - second leading cause of lower GI bleeding in >60yr

Treated with sclerotherapy,angioembolisatiob or selective resection

Capsule endoscopy used to identify the source of occult GIB when an OGD/colonoscopy N

Question 5

How many bloody stools in a day is severe in UC

Answer 5

More than 6

<4 and 4-6 are mild and moderate

Question 6

Patient with Crohn’s or coeliac disease, started on sertraline…what may develop?

Answer 6

Lymphocytic colitis

Lymphocytic infiltrates on biopsy

Question 7

Patient presents with two years of Abdo pain and loose stool.

They then develop cognitive decline , and eye exam reveals upgaze palsy, and pendular oscillations of both eyes. With each eye movement there is concurrent movement of the jaw

Diagnosis

Answer 7

Whipple’s
Eye involvement is only in 20% but pathognomonic

Diagnose with jejunal biopsy

Question 8

Eye features of Whipple’s disease occur in 20% but are thought to be pathognomonic. What are they?

Answer 8

upgaze palsy, and pendular oscillations of both eyes. With each eye movement there is concurrent movement of the jaw

Diagnose with jejunal biopsy

Question 9

Patient with diabetes presents with chronic diarrhoea

Found to have low vitamin B 12 and high folate levels

Answer 9

Small bowel bacterial overgrowth syndrome

Question 10

Investigation for suspected Bile acid malabsorption

Answer 10

SeHCAT test - a form of nuclear imaging test

Mx: bile acid sequestrants e.g. cholestyramine

Question 11

Combined oral contraceptive pill use + acute abdominal pain/distension
ascites and deranged liver function tests
Diagnosis

Answer 11

?Budd-Chiari syndrome
Aka hepatic being thrombosis

Triad of sudden onset abdominal pain, ascites, and tender hepatomegaly

Question 12

What is budd chiari

Answer 12

Hepatic vein thrombosis

…sudden onset abdominal pain, ascites, and tender hepatomegaly

Question 13

Spontaneous bacterial peritonitis is diagnosed with….

Answer 13

neutrophil count > 250 cells / mm^3

Question 14

Variceal uncontrolled haemorrhage, not resolved by banding in endoscopy

Answer 14

Sengstaken-Blakemore tube

If that fails then TIPSS (connects hepatic vein to portal vein, can exacerbate hep enceph)

Question 15

UC flare marker of need for surgery

Answer 15

At day three CRP >45 mg/l or a stool freq of >8/day predicts the need for surgery in 85% of cases.

Question 16

Jejunal biopsy shows deposition of macrophages containing PAS-positive granules

Answer 16

Whipple’s

Question 17

Patient with Barrett’s management

Answer 17

Endoscopic surveillance w biopsy and high dose PPI

If metaplasia then Endoscopy 3-5y
If dysplasia then Endoscopic mucosal resection , radiofreq ablation

Question 18

Risk of cancer for Crohn’s

Answer 18

Small bowel standard incidence ratio 40

Colorectal standard incidence ratio 2 (less than in UC)

Question 19

Pt has varices so has TIPS. 2 months later develops breathless and reduced ET. No other symptoms.

Answer 19

Pulmonary hypertension is known complication

Causes an increased cardiac preload by diverting blood past cirrhotic liver, increasing peripheral resistance

Question 20

Colonic Adenoma surveillance

Answer 20

Low risk:
1or 2 adenomas, less than 10mm….. 5y colonoscopy

Intermediate
3 or 4 small, or 1-2 w one >10mn……3y colonoscopy

High
5 or more smaller, or 3 / more but larger…….1y colo

Question 21

What topical disease has mega-oesophagus? -dilated on barium

Answer 21

Chronic phase of Chagas disease
Trypanosoma cruzi

Can also have mega colon,CHF and Arrhythmia

Question 22

Management of primary biliary cirrhosis

Answer 22

Ursodeoxycholine acid

AMA antibodies

Question 23

Management for achalasia

Answer 23

pneumatic (balloon) dilation first line

Nifedipine , lowers oesoph pressure

Question 24

Absolute contraindications for transjugular intrahepatic portosystemic shunt TIPPS

Answer 24

Severe and progressive liver failure (Child-Pugh score >12)
Uncontrolled hepatic enceph (commonly makes it worse)
R HF
Uncontrolled sepsis
Unrelieved biliary obstruction

Question 25

What is TIPPS procedure

Answer 25

transjugular intrahepatic portosystemic shunt percutaneous creation of a tract between the intrahepatic portal vein and the hepatic vein. So blood can bypass the liver and lowers portal pressure

Question 26

Barrett's w low grade dysplasia. Management

Answer 26

PPI, repeat colonoscopy in 6m If there is still dysplasia, then enoscopic ablation

Question 27

Progression rate of low grade dysplasia in barrett's oesoph

Answer 27

9%/yr to high grade or oesoph Ca

Question 28

Cancer surveillance for Crohn's

Answer 28

1y scope in moderate/severe or PSC/fam hx in under 50/dysplasia/structure 3yr if mild, or fam hx over 50/postinflam polyps

Question 29

colorectal carcinoma w liver mets management

Answer 29

staged surgical resection of carcinoma and liver lesions - 5-year survival rate of up to 30% biopsy is not an option as would seed the tumour

Question 30

when do you get acalculous cholecystitis ?

Answer 30

Typically occurs in the very ill patient on the intensive care unit, or after extensive burns

Question 31

what is a succussion splash?

Answer 31

AKA gastric splash sloshing sound heard through a stethoscope during sudden movement of the pt on abdo auscultation - gas and fluid in an obstructed organ, as in gastric outlet obstruction or gastroparesis

Question 32

Pt w ulcerative proctitis on oral mesalazine 2g BD presents w flare: inflamed distal 7 cm of rectum, with normal mucosa above.... Management

Answer 32

Topical treatment with mesalazine suppositories is the most appropriate first-line measure for a proctitis flare. already on a high dose of oral 5-aminosalicylic acid

Question 33

regurge of undigested food and halotosis

Answer 33

zenker's diverticulum | diagnosed w barium swallow

Question 34

pt presents with change in bowel habit, PR bleeding, and history of Osteomas of the skull and mandible diagnosis

Answer 34

Gardner's syndrome variant of FAP w osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin

Question 35

features of Gardner's syndrome

Answer 35

variant of FAP w colorectal Ca, osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin

Question 36

mx of hepatic encephalopathy

Answer 36

treat any underlying cause | Lactulose and Rifaximin

Question 37

MOA of Rifaximin and lactulose in hep encephalopathy

Answer 37

rifaxmin decreases ammonia production | Lactulose promotes excretion of ammonia and increasing the metabolism of ammonia by gut bacteria

Question 38

diagnosis of autoimmune pancreatitis

Answer 38

imaging and raised serum IgG4

Question 39

Classic presentation of graft Vs host disease post liver transplant

Answer 39

15 days post, abnormal LFTs jaundice hepatomegaly Macpap rash on palms and soles Diarrhoea Urgent USS and Doppler

Question 40

Pt w UC | anorexia, jaundice, RUQ pain and weight loss over 6m

Answer 40

cholangiocarcinoma (in 10% of Primary sclerosing cholangitis)

Question 41

east africa, eosinophiilia, liver failure, varices

Answer 41

Schistosoma mansoni and Schistosoma japonicum

Question 42

most common autoimmune hepatitis

Answer 42

type 1 Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (ASMA)

Question 43

scoring system for autoimmune hepatitis

Answer 43

revised original AIH score

Question 44

tx of autoimmune hep

Answer 44

induce remission w pred, then taper and add azathioprine if IgG, ALT normalise then can stop treatment completely (40% req lifelong)

Question 45

Chronic Hepatitis C complication

Answer 45

Membranoproliferative glomerulonephritis Hepatocellular Cancer Cryoglobulinaemia: typically type II (mixed monoclonal and polyclonal) sjogrens

Question 46

immunocompromised pt develops watery diarrhoea Management

Answer 46

Cryptosporidium Largely supportive Nitazoxanide is licensed in the US for immunocompetent patients

Question 47

confused after transjugular intrahepatic portosystemic shunt TIPPS

Answer 47

Hepatic encephalopathy TIPPS precipitates it in 25% increased portosystemic passage of nitrogen from the gut

Question 48

in well-man check, patient has Ferritin 15, MCV 76, Hb 132

Answer 48

iron deficiency (without anaemia) Endoscopy if postmenopausal women and men >50yr,

Question 49

which immunoglobulin is classically raised in autoimmune hepatitis?

Answer 49

IgG

Question 50

Single most important factor to indicate the need for a liver transplant post paracetamol overdose

Answer 50

pH < 7.3 , 24hr after ingestion Or all of: PT>100 Cr >300 Grade 3 or 4 enceph (King's College Hospital criteria for liver transplantation)

Question 51

Which autoimmune hepatitis has highest rate of cirrhosis?

Answer 51

``` Type 2 (82%) --Soluble liver-kidney antigen ``` T3 (75%) T1 (45%)

Question 52

Which autoimmune hepatitis has best response to steroids

Answer 52

3

Question 53

indication of alcoholic liver disease rather than non-alcoholic fatty liver

Answer 53

AST : ALT ratio > 2 Normal GGT can exclude alcohol only

Question 54

Newly diagnoses coeliac disease , responded to gluten exclusion. Now asymptomatic. Abnormal transaminases, why?

Answer 54

Hepatic steatosis is common finding at diagnosis or within a yr of treatment Usually returns to normal Auto immune hep tends to be middle aged women, chronic fatigue & pruritis

Question 55

sudden onset bilat red eyes in history of IBD. Mx?

Answer 55

Episcleritis (more common in Crohn's) | Topical corticosteroids

Question 56

what do you measure to determine cause of ascites?

Answer 56

serum-ascites albumin gradient (SAAG) Serum albumin / ascitic albumin >11g/L indicates portal hypertension