gastro random use

Question 1

Which ABx do you give for acute diverticulitis?

Answer 1

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.

Question 2

What’s the best investigation choice for acute diverticulitis not improving on several days of ABx?

Answer 2

CT abdo. You don’t want endoscopy or barium enema –> risk of perf in the acute phase

Question 3

Serum amylase > 3x ULN is almost diagnostic of?

Answer 3

Acute pancreatitis

Question 4

The most common cause of acute pancreatitis is? Second most common cause? and most common cause of chronic pancreatitis?

Answer 4

Acute 1st - Gallstones, 2nd - ETOH

Question 5

Barium swallow which shows ‘cork-screw’ appearance of oesophagus, due to uncoordinated contractions = what Dx?

Answer 5

Diffuse oesophageal spasms

Question 6

What’s the Mx of diffuse oesophageal spasms?

Answer 6

Sublingual nitroglycerin

Question 7

What intervention may reduce the incidence of future complications of diverticulosis?

Answer 7

High fibre diet & fibre supplements

Question 8

What are the most common causes of obscure GI bleed in those 40 yrs old? (name 2 for each)

Question 9

What’s the best investigation to evaluate small bowel pathology?

Answer 9

Capsule endoscopy. This is superior to small bowel follow through, fluoroscopy, gastroscopy or CT gastroscopy.

Question 10

T/F? Capsule endoscopy is superior to gastroscopy (endoscopy) for evaluation of small bowel pathology

Answer 10

True

Question 11

For which hepatitis (A - E) would you treat with antivirals in the acute phase? Which antivirals would you use, and for how long?

Answer 11

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.

Question 12

T/F? Antiviral therapy is indicated in acute HBV

Answer 12

False; you let the body clear the infection itself (>90%).

Question 13

Which drug has been found in RCTs to be effective in reversing opioid induced adynamic ileus? (without significant systemic effects)

Answer 13

Alvimopan (may not be on PBS)

Question 14

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

Answer 14

False, equivalent if you give single or combined therapy, so okay to give single, eg entecavir.

Question 15

T/F? Statins are C/I in those with cirrhosis

Answer 15

False, not C/I in cirrhosis. They do cause transaminitis, but rarely cause true hepatitis.

Question 16

What’s the most important prognostic factor (ie predicts worst outcome) in someone with alcoholic hepatitis?

Answer 16

Ongoing alchohol

Question 17

What intervention has been shown to reduce short-term mortality in people with alcoholic hepatitis & encephalopathy?

Answer 17

Methylpred for 1/12 (32mg/daily)

Question 18

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?

Answer 18

Hepatorenal syndrome

Question 19

What’s the best imaging choice for appendicitis?

Answer 19

CT abdo (as per UTD) - more sens & spec than other imaging modalities

Question 20

What’s first-line medication for SBP? How about secondary prevention after SBP episode?

Answer 20

Cefotaxime IV (also can use ceftriaxome or augmentin DF), followed by norfloxacin oral to prevent recurrence

Question 21

What’s the intervention of choice to prevent encephalopathy for someone with cirrhosis who has an acute GI bleed?

Answer 21

Rifaximin

Question 22

Name the 3 absolute indications for surgery in UC

Answer 22

1) Severe haemorrhage

Question 23

What’s the next step once you have clinically diagnosed GORD?

Answer 23

Start empiric PPI - if pt conditions improves (usually within a week), confirms diagnosis.

Question 24

What other features on history would prompt you to do endoscopy on someone with GORD?

Answer 24

• Presence of dysphagia

Question 25

GORD symptoms refractory to PPIs should be investigated by what test? (hint: NOT endoscopy)

Answer 25

Oesophageal manometry

Question 26

Dyspnoea, platypnoea, and orthodeoxia in a pt with cirrhosis suggests what condition?

Answer 26

Platypnoea - increased dyspnoea in the erect posture

Question 27

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

Answer 27

Hepatopulmonary syndrome

Question 28

How is hepatopulmonary syndrome diagnosed?

Answer 28

Contrast-enhanced echo showing shunt (sensitive test)

Question 29

What's the treatment for hepatopulmonary syndrome?

Answer 29

No specific treatment. Liver transplant can help

Question 30

What's the investigation of choice for chronic pancreatitis?

Answer 30

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.

Question 31

What's the best test for diagnosing Wilson's disease?

Answer 31

Elevated copper excretion in urine

Question 32

T/F? Genetic studies is a practical way of diagnosing Wilson's

Answer 32

False, \>300 mutations can cause Wilson's, not a practical solution. Diagnose rather on elevated urine copper excretion & reduced serum ceruloplasmin.

Question 33

In Wilson's disease, would you except (low/normal/high) serum ceruloplasmin and urine copper excretion?

Answer 33

Serum ceruloplasmin - LOW

Question 34

Name the 2 commonest bugs that cause SBP

Answer 34

E coli

Question 35

How is SBP diagnosed?

Answer 35

Abdominal paracentesis - total WCC \>500, or if PMN \>250.

Question 36

What's the best way to catch the bug responsible for causing SBP? And what do these bugs tend to be (name 2)?

Answer 36

Blood cultures. E Coli, Pneumococci

Question 37

What are the causes of Vitamin B12 deficiency, apart from dietary and pernicious anaemia? Name 2.

Answer 37

Deficiency of B12 from malabsorption.

Question 38

How do you differentiate between these different causes of B12 deficiency? Pernicious anaemia, pancreatic enzyme deficiency, small bowel bacterial overgrowth

Answer 38

Pernicious anaemia - give intrinsic factor

Question 39

What are the distinguishing features on liver biopsy for alcoholic and non-alcoholic liver disease?

Answer 39

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

Question 40

Liver biopsy shows 'Mallory bodies'. Diagnosis?

Answer 40

Non-specific; can be seen in both non- & alcoholic liver disease

Question 41

What % of ppl with acute HCV go on to have chronic HCV?

Answer 41

85%

Question 42

How is chronic HCV diagnosed?

Answer 42

Liver biopsy, or elevated aminotransferase levels persisting 6/12 (can be normal in 40%), and confirm diagnosis with anti-HCV

Question 43

What's the indication for chronic HCV treatment?

Answer 43

Age

Question 44

Compare HBV therapy (IFN & nucleo(s)tide analogues) with HCV therapy (IFN & ribavirin). What's the key difference?

Answer 44

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.

Question 45

What investigation is key to diagnosing acute colitis of UC?

Answer 45

Sigmoidoscopy. Don't need colonoscopy as usually involvement is distal colon / anorectal region, with variable proixmal extent.

Question 46

What proportion of UC cases are confined to rectosigmoid; extend to proximal splenic flexure; extend beyond splenic flexure?

Answer 46

1/3, 1/3, /13

Question 47

PC: LLQ pain + tenesmus, relieved with bloody diarrhoea

Answer 47

UC

Question 48

Intestinal biopsy revealing PAS positive macrophages with intracellular or extracellular bacilli is diagnostic of?

Answer 48

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)

Question 49

What's the treatment for Whipple's disease?

Answer 49

Bactrim

Question 50

What's first-line Mx for acute flare of colitis? Second-line? Third-line?

Answer 50

First-line: steroids

Question 51

Middle-aged lady, pruritis, cholestasis, elevated ALP, Dx =?

Answer 51

PBC

Question 52

What's the best single test for diagnosis of PBC?

Answer 52

Anti-mitochondrial antibody (present in 95%)

Question 53

A middle aged lady comes in, is well, and has an isolated raised ALP on routine bloods. What are you worried about?

Answer 53

Early PBC. Later on ppl get fatigue, pruriti.

Question 54

T/F? Liver biopsy is essential for definitive diagnosis of PBC.

Answer 54

False; diagnosis on Hx (middle aged lady, fatigue, pruritis), elevated ALP, positive AMA.

Question 55

Name 2 extraintestinal manifestations of Crohn's disease?

Answer 55

Arthralgia

Question 56

What is the indications for NAC?

Answer 56

ALI secondary to paracetamol OD

Question 57

T/F? In pts with paracetamol OD getting NAC, a further increase in their prothrombin time indicates treatment failure

Answer 57

False - NAC can actually further prolong PT, does NOT mean liver failure is worsening.

Question 58

What does NAC do in paracetamol OD?

Answer 58

Paracetamol breaks down into toxic metabolites, NAPQI. NAC binds to NAPQI to prevent hepatic toxicity.

Question 59

What's the principal iron regulatory hormone in the body?

Answer 59

Hepcidin

Question 60

Which part of the GI tract is involved in excesive iron reabsorption in HH?

Answer 60

Duodenal crypt cells

Question 61

What exactly goes on with HH?

Answer 61

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.

Question 62

What % of pts with clinical HH get HCC?

Answer 62

15-20%

Question 63

Name 2 'siderophilic' (iron loving) microbes that are more likely to cause infections in HH pts?

Answer 63

Yersinia

Question 64

T/F? A transferrin saturation

Answer 64

False! \>50% is seen in HH

Question 65

What subtype of HCV is most likely to go on to cause chronic hepatitis, cirrhosis and HCC?

Answer 65

HCV genotype 1b

Question 66

What's the antidote to mushroom poisoning (with fulminant hepatic failure)?

Answer 66

Silymarin (silibinin or milk thistle)

Question 67

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?

Answer 67

Stages Ia & Ib (active bleeding, a - spurting, b - oozing), both a/w 55% chance of rebleed)

Question 68

Describe the three stages (I, II, III) of the Forrest classification for endosopic appearance of GI bleed

Answer 68

I - active bleeding

Question 69

What's the most important imaging modality for the diagnosis of acute pancreatitis?

Answer 69

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

Question 70

Cowdry bodies are seen under light microscopy of swabs taken from oesophageal ulcers in an HIV person with CD4

Answer 70

Cowdry bodies are composed of nucleic acid & protein, and are seen in cells infected with Herpes simplex virus, VZV, CMV. Treatment is acyclovir.

Question 71

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?

Answer 71

Coeliac disease.

Question 72

What's the management of thrombosed external haemorrhoid?

Answer 72

Pain relief

Question 73

What's the treatment of hihg-grade dysplasia in Barrett's?

Answer 73

Esophagectomy

Question 74

What's the treatment of autoimmune hepatitis?

Answer 74

Glucocorticoids

Question 75

What's the treatment of acute flare of UC?

Answer 75

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.

Question 76

What's the treatment of acute colonic pseudo-obstruction?

Answer 76

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).

Question 77

What's the drug oc choice for treating Wilson's?

Answer 77

Oral penicillamine

Question 78

What's the different management strategies for iscshemic colitis affecting inferior mesentery vs. affecting superior mesentery?

Answer 78

Inferior mesentery artery ischemia - get pt HDS and maintain perfusion while waiting for collateral vasculature to develop

Question 79

What's the treatment of choice for PBC? Does it improve survival?

Answer 79

Ursodeoxycholic acid - yes, improves long term survival.

Question 80

In acute pancreatitis, which of the following blood results will be LOW? WCC count, amylase, glucose, calcium, bilirubin

Answer 80

Calcium - 'saponification' of intestinal fatty acids with calcium at the necrotic site

Question 81

What's the next step in management of chronic mesenteric ischemia, once atherosclerotic risk factors have been as well-controlled as possible?

Answer 81

Angioplasty with stenting

Question 82

What's the treatment of acute anal fissure? How about chronic / recurrent fissures?

Answer 82

Acute - High fibre diet, sitz bath, analgesics

Question 83

What's the screening recommendation for IBD re: CRC?

Answer 83

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

Question 84

T/F? PPI can reduce intestinal iron absorption

Answer 84

True

Question 85

What's the difference between deferoxamine and deferasirox?

Answer 85

Both used as iron chelating agents in HH; deferoxamine is subcut or IV; deferasirox is oral.