Which ABx do you give for acute diverticulitis?
7-10 days of: (Augmentin DF or metronidazole), plus: (ciprofloxacin or bactrim). If no good after 2-4 days, CT abdo performed for extent of disease. (NOT endoscopy or barium enema - risk of perf in acute phase). If abscess >4cm present, treat with percut catheter drainage. Surgery if catheter drainage not possible.
What's the best investigation choice for acute diverticulitis not improving on several days of ABx?
CT abdo. You don't want endoscopy or barium enema --> risk of perf in the acute phase
Serum amylase > 3x ULN is almost diagnostic of?
The most common cause of acute pancreatitis is? Second most common cause? and most common cause of chronic pancreatitis?
Acute 1st - Gallstones, 2nd - ETOH
Barium swallow which shows 'cork-screw' appearance of oesophagus, due to uncoordinated contractions = what Dx?
Diffuse oesophageal spasms
What's the Mx of diffuse oesophageal spasms?
What intervention may reduce the incidence of future complications of diverticulosis?
High fibre diet & fibre supplements
What are the most common causes of obscure GI bleed in those 40 yrs old? (name 2 for each)
What's the best investigation to evaluate small bowel pathology?
Capsule endoscopy. This is superior to small bowel follow through, fluoroscopy, gastroscopy or CT gastroscopy.
T/F? Capsule endoscopy is superior to gastroscopy (endoscopy) for evaluation of small bowel pathology
For which hepatitis (A - E) would you treat with antivirals in the acute phase? Which antivirals would you use, and for how long?
Hep C - treat with pegIFN for 6-24 weeks - decreases risk of chronic viral hepatitis. If this doesn't clear HCV RNA in 3/12, add in ribavirin.
T/F? Antiviral therapy is indicated in acute HBV
False; you let the body clear the infection itself (>90%).
Which drug has been found in RCTs to be effective in reversing opioid induced adynamic ileus? (without significant systemic effects)
Alvimopan (may not be on PBS)
T/F? With regards to treatment of chronic HBV, a combination of peg-IFN plus nucleos(t)ide analogue (ie tenofovir or entecavir) is more successful than either alone in disease remission & eradication
False, equivalent if you give single or combined therapy, so okay to give single, eg entecavir.
T/F? Statins are C/I in those with cirrhosis
False, not C/I in cirrhosis. They do cause transaminitis, but rarely cause true hepatitis.
What's the most important prognostic factor (ie predicts worst outcome) in someone with alcoholic hepatitis?
What intervention has been shown to reduce short-term mortality in people with alcoholic hepatitis & encephalopathy?
Methylpred for 1/12 (32mg/daily)
T/F? With regards to acute alcoholic hepatitis & encephalopathy, pentoxifylline, a TNF-inhibitor, has been shown to reduce short term mortality by reducing risk of?
What's the best imaging choice for appendicitis?
CT abdo (as per UTD) - more sens & spec than other imaging modalities
What's first-line medication for SBP? How about secondary prevention after SBP episode?
Cefotaxime IV (also can use ceftriaxome or augmentin DF), followed by norfloxacin oral to prevent recurrence
What's the intervention of choice to prevent encephalopathy for someone with cirrhosis who has an acute GI bleed?
Name the 3 absolute indications for surgery in UC
1) Severe haemorrhage
What's the next step once you have clinically diagnosed GORD?
Start empiric PPI - if pt conditions improves (usually within a week), confirms diagnosis.
What other features on history would prompt you to do endoscopy on someone with GORD?
- Presence of dysphagia
GORD symptoms refractory to PPIs should be investigated by what test? (hint: NOT endoscopy)
Dyspnoea, platypnoea, and orthodeoxia in a pt with cirrhosis suggests what condition?
Platypnoea - increased dyspnoea in the erect posture
This is the classic triad for what condition? 1) CLD, and 2) increased alveolar-arterial gradient on room air, and 3) intrapulm R to L shunt due to vascular dilatation
How is hepatopulmonary syndrome diagnosed?
Contrast-enhanced echo showing shunt (sensitive test)
What's the treatment for hepatopulmonary syndrome?
No specific treatment. Liver transplant can help
What's the investigation of choice for chronic pancreatitis?
MRCP - shows dilated ducts with calculi or strictures or pseudocysts. Not as sensitive as ERCP, but not as invasive. You'd pull out ERCP if there's no calcification on plain XR and no steatorrhoea.
What's the best test for diagnosing Wilson's disease?
Elevated copper excretion in urine
T/F? Genetic studies is a practical way of diagnosing Wilson's
False, >300 mutations can cause Wilson's, not a practical solution. Diagnose rather on elevated urine copper excretion & reduced serum ceruloplasmin.
In Wilson's disease, would you except (low/normal/high) serum ceruloplasmin and urine copper excretion?
Serum ceruloplasmin - LOW
Name the 2 commonest bugs that cause SBP
How is SBP diagnosed?
Abdominal paracentesis - total WCC >500, or if PMN >250.
What's the best way to catch the bug responsible for causing SBP? And what do these bugs tend to be (name 2)?
Blood cultures. E Coli, Pneumococci
What are the causes of Vitamin B12 deficiency, apart from dietary and pernicious anaemia? Name 2.
Deficiency of B12 from malabsorption.
How do you differentiate between these different causes of B12 deficiency? Pernicious anaemia, pancreatic enzyme deficiency, small bowel bacterial overgrowth
Pernicious anaemia - give intrinsic factor
What are the distinguishing features on liver biopsy for alcoholic and non-alcoholic liver disease?
None - they look the same: have macrovesicular steatosis, focal infiltration with neutrophils, and Mallory hyalin. Dx based on history (metabolic syndrome vs ++ ETOH) and AST : ALT ratios
Liver biopsy shows 'Mallory bodies'. Diagnosis?
Non-specific; can be seen in both non- & alcoholic liver disease
What % of ppl with acute HCV go on to have chronic HCV?
How is chronic HCV diagnosed?
Liver biopsy, or elevated aminotransferase levels persisting 6/12 (can be normal in 40%), and confirm diagnosis with anti-HCV
What's the indication for chronic HCV treatment?
Compare HBV therapy (IFN & nucleo(s)tide analogues) with HCV therapy (IFN & ribavirin). What's the key difference?
You don't treat acute HBV (body clears it >90%). You treat chronic with either IFN or nucelos(t)ide analogues - they are as effective as monotherapy as combined. IFN is definitive course, nucleoside analogues are indefinite.
What investigation is key to diagnosing acute colitis of UC?
Sigmoidoscopy. Don't need colonoscopy as usually involvement is distal colon / anorectal region, with variable proixmal extent.
What proportion of UC cases are confined to rectosigmoid; extend to proximal splenic flexure; extend beyond splenic flexure?
1/3, 1/3, /13
PC: LLQ pain + tenesmus, relieved with bloody diarrhoea
Intestinal biopsy revealing PAS positive macrophages with intracellular or extracellular bacilli is diagnostic of?
Whipple's disease, a multi-system disease caused by tropheryma whipplei, an actinobacillus affecting GI tract (diarrhoea, steatorrhoea, weight loss), joints (large-joint migratory arthritis with fever)
What's the treatment for Whipple's disease?
What's first-line Mx for acute flare of colitis? Second-line? Third-line?
Middle-aged lady, pruritis, cholestasis, elevated ALP, Dx =?
What's the best single test for diagnosis of PBC?
Anti-mitochondrial antibody (present in 95%)
A middle aged lady comes in, is well, and has an isolated raised ALP on routine bloods. What are you worried about?
Early PBC. Later on ppl get fatigue, pruriti.
T/F? Liver biopsy is essential for definitive diagnosis of PBC.
False; diagnosis on Hx (middle aged lady, fatigue, pruritis), elevated ALP, positive AMA.
Name 2 extraintestinal manifestations of Crohn's disease?
What is the indications for NAC?
ALI secondary to paracetamol OD
T/F? In pts with paracetamol OD getting NAC, a further increase in their prothrombin time indicates treatment failure
False - NAC can actually further prolong PT, does NOT mean liver failure is worsening.
What does NAC do in paracetamol OD?
Paracetamol breaks down into toxic metabolites, NAPQI. NAC binds to NAPQI to prevent hepatic toxicity.
What's the principal iron regulatory hormone in the body?
Which part of the GI tract is involved in excesive iron reabsorption in HH?
Duodenal crypt cells
What exactly goes on with HH?
HH AR condition, due to mutations in HFE gene in chromosome 6. Causes increased iron absorption through duodenal crypt cells, thought to be due to decreased synthesis of hepcidin, leading to iron overload.
What % of pts with clinical HH get HCC?
Name 2 'siderophilic' (iron loving) microbes that are more likely to cause infections in HH pts?
T/F? A transferrin saturation
False! >50% is seen in HH
What subtype of HCV is most likely to go on to cause chronic hepatitis, cirrhosis and HCC?
HCV genotype 1b
What's the antidote to mushroom poisoning (with fulminant hepatic failure)?
Silymarin (silibinin or milk thistle)
The Forrest classification of endoscopic appearance of GI bleeds is Ia, Ib, IIa, IIb, IIc, and III. Which stage is a/w highest chacne of rebleeding?
Stages Ia & Ib (active bleeding, a - spurting, b - oozing), both a/w 55% chance of rebleed)
Describe the three stages (I, II, III) of the Forrest classification for endosopic appearance of GI bleed
I - active bleeding
What's the most important imaging modality for the diagnosis of acute pancreatitis?
CT abdo; needed to 1) exclude other serious intra-abdo conditions, eg mesenteric infarct or perforated ulcer; 2) stage severity of acute pancreatitis, 3) determine if complications are present, such as involvement of other bits of the abdo
Cowdry bodies are seen under light microscopy of swabs taken from oesophageal ulcers in an HIV person with CD4
Cowdry bodies are composed of nucleic acid & protein, and are seen in cells infected with Herpes simplex virus, VZV, CMV. Treatment is acyclovir.
T1DM a/w abdo pain, bloaitng sensation, diarrhoea & steatorrhoea. Papulovesicular rash on extensor aspect elbows. What's the Dx? What singel tiest should be used to diagnose this?
What's the management of thrombosed external haemorrhoid?
What's the treatment of hihg-grade dysplasia in Barrett's?
What's the treatment of autoimmune hepatitis?
What's the treatment of acute flare of UC?
1st line (mild-mod) Topical mesalamine for 4-8wks, if no good add in topical corticosteroids for 2wks, if still no good methylpred or PNL.
What's the treatment of acute colonic pseudo-obstruction?
When cecal diameter >9cm. Drip & suck (NG & rectal tubes). Cease opioids, anticholinergics, CCB (worsen constipation). If no improvement after 1-2 days, use neostigmine injection. If this fails, colonoscopic decompression (risk of perf).
What's the drug oc choice for treating Wilson's?
What's the different management strategies for iscshemic colitis affecting inferior mesentery vs. affecting superior mesentery?
Inferior mesentery artery ischemia - get pt HDS and maintain perfusion while waiting for collateral vasculature to develop
What's the treatment of choice for PBC? Does it improve survival?
Ursodeoxycholic acid - yes, improves long term survival.
In acute pancreatitis, which of the following blood results will be LOW? WCC count, amylase, glucose, calcium, bilirubin
Calcium - 'saponification' of intestinal fatty acids with calcium at the necrotic site
What's the next step in management of chronic mesenteric ischemia, once atherosclerotic risk factors have been as well-controlled as possible?
Angioplasty with stenting
What's the treatment of acute anal fissure? How about chronic / recurrent fissures?
Acute - High fibre diet, sitz bath, analgesics
What's the screening recommendation for IBD re: CRC?
Colonoscopy every 2 yrs, starting 8-10 yrs from disease onset. Pt for colectomy if there's carcinoma or dysplasia in flat lesions or mass lesions
T/F? PPI can reduce intestinal iron absorption
What's the difference between deferoxamine and deferasirox?
Both used as iron chelating agents in HH; deferoxamine is subcut or IV; deferasirox is oral.