1
Q
What test is used to monitor treatment in haemochromatosis?
A
Transferrin saturation and ferritin
2
Q
What is achalasia?
A
Failure of oesophageal peristalsis and relaxation of the LOS due to degenerative loss of ganglia from Auerbach’s plexus.
3
Q
What are the clinical features of achalasia?
A
- Dysphagia to solids and liquids.
- Heartburn
- Regurgitation of food
- Variation in severity of sx
- Malignant change in small number of patients.
4
Q
What can often be seen on CXR when someone has achalasia?
A
Retrocardic air-fluid level.
5
Q
How would you investigate achalasia?
A
- Oesophageal manometry (diagnostic).
- Barium Swallow (bird beak appearance)
- CXR (retrocardic air-fluid level)
6
Q
What is the first line treatment for Achalasia?
A
Pneumatic dilation (balloon).
7
Q
What are second line options for the treatment Achalasia?
A
- Surgical intervention (Heller cardiomyotomy)
- Botulinum toxin injection into sphincter
- Drug therapy with CCBs and nitrates.
8
Q
Which marker is used to monitor the recurrence of colorectal cancer?
A
CEA (carcinoembryonic antigen).
9
Q
What are some causes of liver decompensation?
A
- Constipation
- Infection
- Electrolyte imbalances
- Alcohol intake
- Dehydration
- UGIB
10
Q
What are the causes of liver cirrhosis?
A
- Alcohol
- Hepatitis B and C
- NALFD
11
Q
What is transient elastography?
A
-Known as Fibroscan
- 50 Mhz wave passed into liver from end of US probe
- Measures stiffness of liver
12
Q
What are risk factors for gastric cancer?
A
- Smoking
- Nitrates in diet
- Pernicious anaemia
- H.pylori infection
- Blood group A
- Atrophic gastritis
13
Q
What are typical features of gastric cancer?
A
- Abdominal pain (typically vague epigastric)
- Weight loss
- Nausea and vomiting
- Dysphagia
- UGIB
- Lymphadenopathy (Virchow’s and Sister Mary Joseph’s node)
14
Q
How is gastric cancer diagnosed?
A
Oesopho-gastro-duodenoscopy with biopsy (signet ring cells, more cells = worse prognosis).
15
Q
Where is secretin secreted from?
A
S cells within the upper small intestine.
16
Q
What is the action of secretin?
A
- Increases secretion of bicarbonate rich fluid from pancreas and hepatic duct cells.
- Decreases gastric acid secretion
- Trophic affect on pancreatic acinar cells
17
Q
Where is Gastrin secreted from?
A
- G cells in antrum of stomach.
18
Q
What is the action of Gastrin?
A
- Increases acid secretion by gastric parietal cells
- Pepsinogen and If secretion
- Increases gastric motility
- Stimulates parietal cell maturation
19
Q
Where is CCK secreted?
A
I cells in upper small intestine
20
Q
What is the action of CCK?
A
- Increases secretion of enzyme rich fluid in pancreas,
- Increases contraction of gallbladder and relaxation of sphincter of Oddi.
- Decreases gastric emptying
- Trophic affect on pancreatic acinar cells
- Induces satiety
21
Q
Where is Vasoactive Intestinal peptide (VIP) secreted from?
A
Small intestine and Pancreas
22
Q
What is the action of Vasoactive Intestinal Peptide (VIP)?
A
- Stimulates secretion from small intestine and pancreas
- Inhibits gastric acid secretion.
23
Q
Where is somatostatin secreted from?
A
D cells in the pancreas and stomach
24
Q
What is the action of somatostatin?
A
- Decreases acid and pepsin secretion
- Decreases Gastrin secretion
- Decreases pancreatic enzyme secretion
- Decreases insulin and glucagon secretion
- Inhibits trophic effects of gastrin
- Stimulates gastric mucous production
25
What is the investigation of choice in Primary sclerosing cholangitis?
MRCP/ERCP
26
What is primary sclerosing cholangitis?
Inflammation and fibrosis of intra and extra hepatic bile ducts.
27
What conditions is PSC associated wtih?
- Ulcerative colitis
- HIV
- Crohn's (much less common than UC)
28
What are the features of PSC?
- Jaundice
- Pruritus
- Raised bilirubin + ALP
- RUQ pain
- Fatigue
29
What are the complications of PSC?
- Cholangiocarcinoma in 10% of patients
- Increased risk of colorectal cancer
30
What is the mode of inheritance of Peutz-Jeghers syndrome?
Autosomal dominant
31
What is Peutz-Jeghers syndrome?
Autosomal dominant condition characterised by numerous hamartomatous polyps forming in GI tract. Pigmented freckles on face, lips, palms and soles.
32
What is Whipple's disease?
Rare, multi-system disorder caused by Tropheryma whippelii infection. More common in Men and HLA B27 positive individuals.
33
What are the features of Whipple's disease?
- Malabsorption: diarrhoea, weight loss.
- Large joint arthralgia
- Skin hyperpigmentation and photosensitivity.
- Pleurisy
- Pericarditis
- Neurological (rare): dementia, myoclonus, ataxia, seizures, ophthalmoplegia.
34
How would Whipple's disease be identified on jejunal biopsy?
Deposition of macrophages containing Periodic acid-Schiff (PAS) granules.
35
What is the management of Whipple's disease?
Oral co-trimoxazole for 1 year.
Occasionally preceded by course of IV penicillin.
36
Which mode of investigation is best suited for staging oesophageal/gastric cancer?
Endoscopic ultrasound
37
What are the main risk factors to developing hepatocellular carcinoma?
- Chronic hepatitis B or C
- Alcohol
- Haemochromatosis
- alpha-1-antitrypsin deficiency
- hereditary tyrosinosis
- glycogen storage disease
- aflatoxin
- drugs: oral contraceptive pill, anabolic steroids
- porphyria cutanea tarda
- male sex
- diabetes mellitus, metabolic syndrome
38
What are the features of hepatocellular carcinoma?
- Tends to present late
- Liver cirrhosis or failure (pruritus, jaundice, ascites, RUQ, hepatosplenomegaly)
- raised AFP
39
Who are at high risk of developing hepatocellular carcinoma and should be considered for screening?
- patients liver cirrhosis secondary to hepatitis B & C or haemochromatosis
- men with cirrhosis secondary to alcohol
40
What are the management options for hepatocellular carcinoma?
- Surgical resection in early disease
- Liver transplant
- Radiofrequency ablation
- Transarterial chemoablation
- sorafenib: a multikinase inhibitor
41
Which condition affecting the liver does is the exception that does not cause hepatocellular carcinoma?
Wilson's Disease
42
What is Primary biliary cholangitis?
Chronic liver disorder typically seen in middle aged females.
- Autoimmune condition
- Interlobular bile ducts are damaged by inflammation causing chronic cholestasis (slow bile) and leads to cirrhosis.
43
What conditions are associated with Primary biliary cholangitis?
- Sjogren's syndrome (80% patients)
- Rheumatiod arthritis
- Thyroid disease
- Systemic sclerosis
44
What are the clinical features of Primary Biliary Cholangitis?
- fatigue
- pruritus
- cholestatic jaundice
- raised ALP
- RUQ pain
- hyperpigmentation (pressure points)
- xanthelasmas, xanthomata
- clubbing
- hepatosplenomegaly
45
How is primary biliary cholangitis diagnosed?
- anti-mitochondrial antibodies M2 subtype (present in 98%)
- smooth muscle antibodies
- raised serum IgM
- RUQ US or MRCP to rule out obstruction
46
What is the management of Primary biliary cholangitis?
- first-line: ursodeoxycholic acid (slows progression)
- pruritus: cholestyramine
- fat-soluble vitamin supplementation
- liver transplantation
47
What is Coeliac disease?
Autoimmune disease caused by a sensitivity to gluten. Leads to villous atrophy causing malabsorption.
48
What conditions are associated with coeliac disease?
- Autoimmune thyroid disease
- Dermatitis herpetiformis
- Irritable bowel syndrome
- Type 1 diabetes
- First-degree relatives (parents, siblings or children) with coeliac disease
49
What are the signs and symptoms of coeliac disease?
- Chronic or intermittent diarrhoea
- Failure to thrive or faltering growth
- Persistent or unexplained GI symptoms including N&V.
- Prolonged fatigue
- Recurrent abdominal pain, cramping or distension
- Sudden or unexpected weight loss
- Unexplained iron-deficiency anaemia, or other unspecified anaemia
50
What complications are associated with coeliac disease?
- 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
- rare: oesophageal cancer, other malignancies
51
What are the features of Crohn's disease?
- Diarrhoea (usually non bloody)
- Weight loss
- Prominent upper GI sx
- Mouth ulcers
- Perianal disease
- Palpable mass in R iliac fossa.
52
What are the extra intestinal features of Crohn's?
Gallstones (due to reduced bile absorption)
Oxalate renal stones
53
What are the complications of Crohn's?
-Intestinal obstruction
- Fistula
- Colorectal cancer
54
What are the pathological findings of Crohn's?
Mouth to anus
Skip lesions
55
What are the histological findings of Crohn's?
- Inflammation in all layers (mucosa to serosa)
- Increased goblet cells
- Granulomas
56
What are the endoscopic findings of Crohn's?
Skip lesions - Cobblestone appearance
Deep ulcers
57
What are the radiological findings of Crohn's?
Kantor's string sign - strictures
Proximal bowel dilation
Rose thorn ulcers
Fistulae
58
What are the features of UC?
Bloody diarrhoea
LLQ abdominal pain
Tenesmus (inclination to evacuate bowels)
59
What are the extra intestinal features of UC?
Primary sclerosing cholangitis
60
What complications are associated with UC?
Colorectal cancer (higher risk than Crohn's)
61
What are the pathological findings of UC?
Inflammation begins in rectum and never goes beyond ileocaecal valve.
Continuous disease
62
What are the histological findings of UC?
No inflammation beyond submucosa
Inflammatory cell infiltrate in lamina propria:
- crypt abscesses
- depleted goblet cells
- depleted mucin
63
What are the endoscopic findings in UC?
Widespread ulceration (pseudopolyps)
64
What are the radiological findings of UC?
Loss of haustrations
Superficial ulceration (pseudopolyps)
Drainpipe colon in longstanding disease
65
What are some secondary causes of bile-acid malabsorption?
Crohn's
Cholecystectomy
Coeliac disease
Small intestinal bacterial overgrowth
66
What is the investigation of choice for bile-acid malabsorption?
SeHCAT
Scans are done 7 days apart to assess retnetion/loss of radiolabelled SeHCAT
67
How is bile-acid malabsorption managed/
Bile acid sequestrants e.g. Cholestyramine
68
What are the main side effects of sulfasalazine?
Rashes
Oligospermia
Headache
Heinz body anaemia
Megaloblastic anaemia
Lung fibrosis
GI upset
Agranulocytosis
69
What are the common side effects of mesalazine?
GI upset
Headache
Agranulocytosis
Pancreatitis
Interstitial nephritis
70
What are some recognised associations with Autoimmune hepatitis?
-Other autoimmune disorders e.g. coeliac, T1DM, pernicious anaemia
- Hypergammaglobulinaemia
- HLA B8 and DR3 antibodies.
71
What are the features of autoimmune hepatitis?
- Signs of chronic liver disease
- Acute hepatitis : fever, jaundice etc.
- Amenorrhoea
- ANA/SMA/LKM1 antibodies
- Raised IgG levels
- 'Piecemeal necrosis' on liver biopsy (inflammation extending beyond limiting plate)
72
What antibodies are involved in Type 1 autoimmune hepatitis
Anti-nuclear antibodies (ANA) +/- anti-smooth muscle antibodies (SMA)
Affects both children and adults
73
What antibodies are involved in type 2 autoimmune hepatitis?
Anti-liver/kidney microsomal type 1 antibodies (LKM1)
Affects children only.
74
What antibodies are involved in type 3 autoimmune hepatitis?
Soluble liver/kidney antigen
Affects middle aged adults.
75
What is the management of autoimmune hepatitis?
-Steroids
- Immunosuppressants e.g. azathioprine
- Liver transplant
76
Where are the majority of gastrinomas located?
First part of the duodenum
77
What is Zollinger-Ellison syndrome?
Condition characterised by excessive levels of gastrin secondary to a gastrin secreting tumour.
Commonly found in first part of duodenum or pancreas.
30% occur as part of MEN type 1 syndrome.
78
What are the features of Zollinger-Ellison syndrome?
- Multiple gastroduodenal ulcers
- Diarrhoea
- Malabsorption
79
How is Zollinger-Ellison syndrome diagnosed?
- Fasting gastrin levels
- Secretin stimulation test
80
What is eosinophilic oesophagitis?
Allergic inflammation of the oesophagus. Dense infiltrate of eosinophils within epithelium.
3:1 male to female ratio.
30-50yrs
81
What are risk factors for developing eosinophilic oesophagitis?
- Allergies/asthma
- Male sex
- Family history
- Caucasian
- Aged 30-50years
- Coexisting autoimmune disease
82
What are the typical features of eosinophilic oesophagitis?
- Dysphagia
- Strictures/fibrosis
- Food impaction
- Regurgitation
- Vomiting
- Anorexia
- Weight loss
83
What investigations should be performed for eosinophilic oesophagitis?
-Endoscopy : diagnosis requires histological analysis, >15 eosinophils per microscopy field.
- Trial of PPI: no improvement in sx.
84
What is the management of eosinophilic oesphagitis?
- Dietary modification: targeted elimination diet, elemental diet or exclusion of 6 food groups.
- Topical steroid e.g. fluticasone, budesonide 8/52 course
- Oesophageal dilatation
85
What complications are associated with eosinophilic oesophagitis?
- Strictures
- Impaction
- Mallory-Weiss tears
86
What are common adverse effects of PPis?
- Hyponatraemia
- Hypomagnasaemia
- Osteoporosis
- Microscopic colitis
- Increased risk of C.difficile
87
What is helicobacter pylori?
Gram negative bacteria associated with variety of GI problems, principally peptic ulcer disease?
88
What is the pathophysiology of H.pylori?
- Chemotaxis away from low pH areas, using flagella to burrow into mucous lining to reach epithelial cells
- Secretes urease resulting in alkalinisation of acid environment
- Releases bacterial cytotoxins that disrupt gastric mucosa.
89
What conditions are associated with H.pylori infection?
- Peptic ulcer disease
- Gastric cancer
- B cell lymphoma of MALT tissue
- Atrophic gastritis
90
What is the management of H.pylori infection?
7 day course of PPI + Amoxicillin + (clarithromycin or metronidazole)
If pen allergic PPI + Metronidazole + Clarithromycin
91
What are the features of carcinoid tumours?
- Flushing
- Diarrhoea
- Bronchospasm
- Hypotension
- R heart valvular stenosis
- Increased serotonin secreted by mets.
- Pellagra
92
What investigations diagnose Carcinoid tumours?
Urinary 5-HIAA
Plasma chromogranin A y
93
What is the management of carcinoid tumours?
Somatostatin analogues e.g. octreotide
Cyproheptadine may help diarrhoea.
94
What are the NICE guidelines for referral for bariatric surgery?
Early referral for very obese patients (BMI >40kg/m2)especially with conditions associated with obesity e.g. T2DM, hypertension.
95
What are the different types of bariatric surgery?
- Primary restrictive operations: Laparoscopic-adjustable gastric banding (LAGB), Sleeve gastrectomy, Intragastric balloon.
- Primarily malabsorptive operations: Biliopancreatic diversion with duodenal switch (BMI >60).
- Mixed operations: Roux-en-Y gastric bypass.
96
What is ischaemic colitis?
Acute but transient compromise to blood flow to large bowel. May lead to inflammation, ulceration and haemorrhage.
97
Where is ischaemic colitis most likely to occur?
Splenic flexure
98
What condition does thumbprinting on AXR suggest?
Ischaemic colitis
99
What is the mainstay treatment for hydatid cysts?
Surgery
100
What are the clinical features of hydatid cyst infection?
- Cysts usually occur in liver and lungs
- Usually asymptomatic until cysts >5cm in diameter.
- Biliary colic, jaundice and urticaria in biliary rupture
- Infection
- Organ dysfunction
101
What investigations should be performed in hydatid cysts?
AUSS 1st line
CT to differentiate hydatid cysts from other types.
Serology
Antibody/antigen testing
102
What findings within LFTs suggest ALD?
Gamma-GT elevated
AST:ALT >2.
AST:ALT >3 strongly suggests acute alcoholic hepatitis
103
What medication is used to treat alcoholic hepatitis?
Glucocorticoids e.g. prednisolone
Pentoxyphylline occasionally used
104
What are causes of ascites that have a serum ascites albumin gradient >11?
- Liver disorders (most common)
-Cardiac: R heart failure, constrictive pericarditis
- Budd-Chiari syndrome
- Portal vein thrombosis
- Veno-occlusive disease
- Myxoedema
105
What are causes of ascites that have a serum ascites albumin gradient <11
-Hypoalbuminaemia: nephrotic syndrome, severe malnutrition
- Malignancy: peritoneal carcinomatosis
- Infection: tuberculosis, peritonitis
- Pancreatitis
- Bowel obstruction
- Biliary ascites
- Post-op lymphatic leak
- Serositis in CTD
106
What are the management options for ascites?
- Reduce dietary sodium
- Fluid restriction if Na <125mmol
- Aldosterone antagonists e.g. spironolactone
- Drainage if tense (large vol requires albumin cover)
- Prophylactic antibiotics to reduce risk of SBP, ciprofloxacin or norfloxacin
- TIPS in some patients
107
What is angiodysplasia?
Vascular deformity of GI tract which predisposes individuals to bleeding and iron deficiency anaemia.
108
What condition is associated with angiodysplasia?
Aortic stenosis
109
What is the management of angiodysplasia?
Endoscopic cauterisation or argon plasma coagulation.
Antifibrinolytics e.g. tranexamic acid
Oestrogens may also be used
110
What is the first line treatment for a mild-moderate flare of UC?
Topical aminosalicylates
111
How is UC classified?
Mild = <4 stools/day, minimal blood
Moderate= 4-6 stools/day, varying amounts of blood, no systemic upset.
Severe = >6 bloody stools/day + systemic upset
112
What is the treatment for severe UC?
- IV steroids (ciclosporin if steroid contraindicated)
- Add ciclosporin to Iv steroids if no improvement after 72hrs.
- Surgery
113
What is the first line diagnostic test for small bowel overgrowth syndrome?
Hydrogen breath test (significant rise suggest disease).
114
What vasoactive agents are used in the acute management of oesophageal varices?
Terlipressin (1st line and only licensed)
Octreotide may also be used.
115
What is the treatment for C.difficile infection?
1st line - oral vancomycin
2nd line - oral oral fidaxomicin
3rd line oral vancomycin + IV metronidazole
116
What is the pathophysiology of c.diff?
- anaerobic gram-positive, spore-forming, toxin-producing bacillus
- transmission: via the faecal-oral route by ingestion of spores
- releases two exotoxins (toxin A and toxin B) that act on intestinal epithelial cells and inflammatory cells resulting in colitis
117
What are some common causative agents for c.diff?
Cephalosporins
Clindamycin
PPIs
118
What imaging is used to help stage oesophageal cancer?
- Endoscopic ultrasound is the preferred method for locoregional staging
- CT scanning of the chest, abdomen and pelvis is used for initial staging
FDG-PET CT may be used for detecting occult metastases if metastases are not seen on the initial staging CT scans.
Laparoscopy is sometimes performed to detect occult peritoneal disease
119
What is familial adenomatous polyposis (FAP)?
- Rare autosomal dominant condition which leads to the formation of hundreds of polyps by the age of 30-40 years. Patients inevitably develop carcinoma.
- mutation in a tumour suppressor gene called adenomatous polyposis coli gene (APC), located on chromosome 5.
120
What is coeliac disease?
sensitivity to the protein gluten. Repeated exposure leads to villous atrophy which in turn causes malabsorption.
121
Which conditions are associated with coeliac disease?
- dermatitis herpetiformis
- autoimmune: type 1 diabetes mellitus, autoimmune hepatitis
122
What investigations are used to diagnose coeliac disease?
- tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE
- endomyseal antibody (IgA)
needed to look for selective IgA deficiency, which would give a false negative coeliac result
- endoscopic intestinal biopsy.
123
What findings on endoscopic intestinal biopsy favour a diagnosis of coeliac?
- villous atrophy
- crypt hyperplasia
- increase in intraepithelial lymphocytes
- lamina propria infiltration with lymphocytes
124
What is the management for liver abscesses?
- drainage (typically percutaneous) and antibiotics
- amoxicillin + ciprofloxacin + metronidazole
- if penicillin allergic: ciprofloxacin + clindamycin
125
Which organism commonly cause liver abscesses?
Staph aureus in children
E.coli in adults
126
What are the features of angiodysplasia?
- vascular deformity of the GI tract which predisposes to bleeding and iron deficiency anaemia.
127
What is Courvoisier's sign and what does it indicate?
a palpable gallbladder in the presence of painless jaundice is unlikely to be gallstones.
128
What are some complications of coeliac disease?
- 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
- rare: oesophageal cancer, other malignancies
129
What medication is used as prophylaxis of oesophageal bleeding?
A non-cardioselective B-blocker (NSBB) e.g. Propranolol
130
Which drugs cause hepatic liver disease?
paracetamol
sodium valproate, phenytoin
MAOIs
halothane
anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
statins
alcohol
amiodarone
methyldopa
nitrofurantoin
131
Which drugs cause a cholestasis picture of liver disease?
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine
132
What conditions other than coeliac disease cause villous atrophy?
tropical sprue
hypogammaglobulinaemia
gastrointestinal lymphoma
Whipple's disease
cow's milk intolerance
133
What is the treatment for chronic anal fissure?
Topical GTN
134
Which clotting factor is characteristically raised in liver disease?
Factor VIII
135
What are some risk factors associated with pancreatic cancer?
increasing age
smoking
diabetes
chronic pancreatitis (alcohol does not appear an independent risk factor though)
hereditary non-polyposis colorectal carcinoma
multiple endocrine neoplasia
BRCA2 gene
KRAS gene mutation
136
What are the features of pancreatic cancer?
- painless jaundice
- pale stools, dark urine, and pruritus
- cholestatic liver function tests
- abdominal masses may be found (in decreasing order of frequency)
hepatomegaly: due to metastases
gallbladder: Courvoisier's law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
epigastric mass: from the primary tumour
- many patients present in a non-specific way with anorexia, weight loss, epigastric pain
- loss of exocrine function (e.g. steatorrhoea)
- loss of endocrine function (e.g. diabetes mellitus)
- atypical back pain is often seen
- migratory thrombophlebitis (Trousseau sign)
137
What investigations are utilised in diagnosing pancreatic cancer?
- ultrasound has a sensitivity of around 60-90%
- high-resolution CT scanning is the investigation of choice if the diagnosis is suspected
- imaging may demonstrate the 'double duct' sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts
138
What s the management of pancreatic cancer?
- < 20% are suitable for surgery at diagnosis
- a Whipple's resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple's include dumping syndrome and peptic ulcer disease
- adjuvant chemotherapy is usually given following surgery
- ERCP with stenting is often used for palliation
139
What is Gilbert's syndrome?
Autosomal recessive condition of defective bilirubin conjugation due to a deficiency of UDP glucuronosyltransferase.
140
What are the features of Gilbert's?
- unconjugated hyperbilirubinaemia (i.e. not in urine)
- jaundice may only be seen during an intercurrent illness, exercise or fasting
141
What are some risk factors of developing bowel ischaemia?
- increasing age
- atrial fibrillation - particularly for mesenteric ischaemia
- other causes of emboli: endocarditis, malignancy
- cardiovascular disease risk factors: smoking, hypertension, diabetes
- cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use
142
How is irritable bowel syndrome diagnosed?
Must have 6month hx of abdominal pain relieved by defecation or associated with altered bowel frequency stool form... AND 2 of the following 4 symptoms:
- altered stool passage (straining, urgency, incomplete evacuation)
- abdominal bloating (more common in women than men), distension, tension or hardness
- symptoms made worse by eating
- passage of mucus
143
What is the management for IBS?
1st line: pain: antispasmodic agents
constipation: laxatives but avoid lactulose
diarrhoea: loperamide is first-line
2nd line: low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg)
3rd line: cognitive behavioural therapy, hypnotherapy or psychological therapy if sx persist >12months despite pharmacological rx.
144
What dietary advice should be offered to those with IBS?
- have regular meals and take time to eat
- avoid missing meals or leaving long gaps between eating
- drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas
- restrict tea and coffee to 3 cups per day
- reduce intake of alcohol and fizzy drinks
- consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)
- reduce intake of 'resistant starch' often found in processed foods
- limit fresh fruit to 3 portions per day
- for diarrhoea, avoid sorbitol
- for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).
145
What is VIP?
Vasoactive intestinal peptide
- source: small intestine, pancreas
- stimulation: neural
- actions: stimulates secretion by pancreas and intestines, inhibits acid and pepsinogen secretion
146
What are the features of VIPomas?
90% arise from pancreas
large volume diarrhoea
weight loss
dehydration
hypokalaemia, hypochlorhydia
147
What is refeeding syndrome?
Metabolic abnormalities which occur on feeding after a period of starvation.
Catabolism ends abruptly and switches to carbohydrate metabolism.
148
What metabolic abnormalities occur in refeeding syndrome?
- Hypophosphataemia (may result in significant muscle weakness including cardiac and diaphragm leading to cardiac/resp failure).
- hypokalaemia
- hypomagnesaemia: may predispose to torsades de pointes
- abnormal fluid balance
149
What features suggest you are at high risk of refeeding syndrome?
- BMI < 16 kg/m2
- unintentional weight loss >15% over 3-6 months
- little nutritional intake > 10 days
- hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)
150
What factors are used in the Child-Pugh scoring system for severity of liver cirrhosis?
- Bilirubin
- Albumin
- Prothrombin time
- Encephalopathy
- Ascites
151
What factors are used in the MELD scoring system for severity of liver cirrhosis?
- Bilirubin
- INR
- creatinine
152
What risk factors are associated with NAFLD?
- obesity
- type 2 diabetes mellitus
- hyperlipidaemia
- jejunoileal bypass
- sudden weight loss/starvation
153
What are the features of NAFLD?
- usually asymptomatic
- hepatomegaly
- ALT is typically greater than AST
- increased echogenicity on ultrasound
154
What are the most prevalent type of gastric cancers?
Gastric adenocarcinoma (arises from the glandular epithelium of the stomach lining)
155
What are the risk factors associated with developing gastric adenocarcinoma?
- Helicobacer pylori
triggers inflammation of the mucosa → atrophy and intestinal metaplasia → dysplasia
- pernicious anaemia, atrophic gastritis
- diet (salt and salt-preserved foods, nitrates)
- ethnicity: Japan, China
- smoking
- blood group A
156
What findings on gastric biopsy indicate gastric adenocarcinoma?
Signet ring cells
157
What are contraindications to liver biopsy?
- deranged clotting (e.g. INR > 1.4)
- low platelets (e.g. < 60 * 109/l)
- anaemia
- extrahepatic biliary obstruction
- hydatid cyst
- haemoangioma
- uncooperative patient
- ascites
158
What is gastric MALT lymphoma and what condition is it strongly associated with?
type of non-Hodgkin lymphoma that arises from the mucosal lymphoid tissue of the stomach. It has been found to be strongly associated with chronic H. pylori infection
159
What medications must be stopped and for how long prior to a urea breath test?
No antibacterial for past 4 weeks and no PPI for past 2 weeks
160
What should be assessed before starting azathioprine or mercaptopurine therapy in Crohn's disease?
Thiopurine methyltransferase (TPMT) is an enzyme involved in the metabolism of azathioprine and mercaptopurine. Some people have a deficiency of TPMT due to genetic mutations, and these people are at a greater risk of experiencing severe side effects from conventional doses of azathioprine or mercaptopurine.
161
What are the typical investigation findings in alcoholic ketoacidosis?
Metabolic acidosis
Elevated anion gap
Elevated serum ketone levels
Normal or low glucose concentration
162
What are some causes of chronic pancreatitis?
- Alcohol
- genetic: cystic fibrosis, haemochromatosis
- ductal obstruction: tumours, stones, structural abnormalities including pancreas divisum and annular pancreas
163
What are the features of chronic pancreatitis?
- pain is typically worse 15 to 30 minutes following a meal
- steatorrhoea: symptoms of pancreatic insufficiency usually develop between 5 and 25 years after the onset of pain
- diabetes mellitus develops in the majority of patients. It typically occurs more than 20 years after symptom begin
164
What investigations are used to diagnose chronic pancreatitis?
- abdominal x-ray shows pancreatic calcification in 30% of cases
- CT is more sensitive at detecting pancreatic calcification. Sensitivity is 80%, specificity is 85%
- functional tests: faecal elastase may be used to assess exocrine function if imaging inconclusive
165
What is the management for chronic pancreatitis?
- pancreatic enzyme supplements
- analgesia
- antioxidants: limited evidence base - one study suggests benefit in early disease
166
What are the causes of acute liver failure?
- Paracetamol overdose
- alcohol
- viral hepatitis (usually A or B)
- acute fatty liver of pregnancy
167
What are the features of acute liver failure?
- jaundice
- coagulopathy: raised prothrombin time
- hypoalbuminaemia
- hepatic encephalopathy
- renal failure is common ('hepatorenal syndrome')
168
What treatment should be given to babies born to mothers with chronic hep B or acute hep B infection?
vaccination + hepatitis B immunoglobulin given to newborn
169
What is Budd-Chiari syndrome?
hepatic vein thrombosis, is usually seen in the context of underlying haematological disease or another procoagulant condition.
170
What are the features of Budd Chiari syndrome?
- abdominal pain: sudden onset, severe
- ascites → abdominal distension
- tender hepatomegaly
171
What are some causes of Budd-Chiari syndrome?
- polycythaemia rubra vera
- thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies
- pregnancy
- combined oral contraceptive pill: accounts for around 20% of cases
172
What investigation is used to identify Budd-Chiari syndrome?
ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation
173
What are the SAAG >11 causes of ascites?
Liver disorders are the most common cause
- cirrhosis/alcoholic liver disease
- acute liver failure
- liver metastases
Cardiac
- right heart failure
- constrictive pericarditis
Other causes
- Budd-Chiari syndrome
- portal vein thrombosis
- veno-occlusive disease
- myxoedema
174
What are the SAAG <11 causes of ascites?
Hypoalbuminaemia
- nephrotic syndrome
- severe malnutrition (e.g. Kwashiorkor)
Malignancy
- peritoneal carcinomatosis
Infections
- tuberculous peritonitis
Other causes
- pancreatitis
- bowel obstruction
- biliary ascites
- postoperative lymphatic leak
- serositis in connective tissue diseases
175
What is used to treat ongoing diarrhoea in a crohns patient post resection?
Cholestyramine
176
What are some adverse effects of cholestyramine?
abdominal cramps and constipation
decreases absorption of fat-soluble vitamins
cholesterol gallstones
may raise level of triglycerides
177
What is the gold standard investigation for GORD?
24hr oesophageal pH monitoring
178
What are some causes of increased ferritin without iron overload?
Inflammation (due to ferritin being an acute phase reactant)
Alcohol excess
Liver disease
Chronic kidney disease
Malignancy
179
What is the strongest risk factor for anal cancer?
HPV infection
180
What is the treatment for Wilson's disease?
Penicillamine
181
What is Dupin-Johnson syndrome?
- benign autosomal recessive disorder resulting in hyperbilirubinaemia (conjugated, therefore present in urine).
- defect in the canillicular multispecific organic anion transporter (cMOAT) protein. This causes defective hepatic bilirubin excretion
182
What is Heyde's syndrome?
aortic stenosis and angiodysplasia resulting in chronic gastrointestinal blood loss.
183
What medication should be avoided in IBS/
Lactulose - may exacerbate sx e.g. bloating flatulence and abdo discomfort
184
Which medications can cause dyspepsia?
NSAIDs
bisphosphonates
steroids
May cause reflux due to relaxation of LOS:
calcium channel blockers
nitrates
theophyllines
185
What factors may indicate severe pancreatitis?
- age > 55 years
- hypocalcaemia
- hyperglycaemia
- hypoxia
- neutrophilia
- elevated LDH and AST
186
What does pigment laden macrophages in lamina propria on colonic biopsy indicate?
Laxative abuse
187
What are some causes of hepatosplenomegaly?
- chronic liver disease with portal hypertension
- infections: glandular fever, malaria, hepatitis
- lymphoproliferative disorders
- myeloproliferative disorders e.g. CML
- amyloidosis
188
What is the management for alcoholic hepatitis?
- glucocorticoids (e.g. prednisolone) are often used during acute episodes of alcoholic hepatitis
Maddrey's discriminant function (DF) is often used during acute episodes to determine who would benefit from glucocorticoid therapy
- pentoxyphylline is also sometimes used
189
What are the features of type 1 hepatorenal syndrome?
- Rapidly progressive
- Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks
- Very poor prognosis
190
What are the features of type 2 hepatorenal syndrome?
- Slowly progressive
- Prognosis poor, but patients may live for longer
191
What are the management options for hepatorenal syndrome?
- 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
192
What is the first line treatment for small bowel bacterial overgrowth syndrome?
Rifaximin
193
Which factor of UC patients makes them more susceptible to colorectal cancer?
Chronic inflammation
194
What is the increased risk of someone with primary biliary cirrhosis developing hepatocellular carcinoma compared to normal population?
20 fold increased risk
195
What are the features of acute fatty liver of pregnancy?
- abdominal pain
- nausea & vomiting
- headache
- jaundice
- hypoglycaemia
- severe disease may result in pre- eclampsia
196
What is the management of acute fatty liver in pregnancy?
Supportive management
Definitive is delivery of baby
197
What are the most common causes of HCC?
Worldwide: Chronic hepatitis B
Europe: Chronic hepatitis C
198
What are risk factors for developing HCC?
- Cirrhosis
- alpha-1 antitrypsin deficiency
- hereditary tyrosinosis
- glycogen storage disease
- aflatoxin
- drugs: oral contraceptive pill, anabolic steroids
- porphyria cutanea tarda
- male sex
- diabetes mellitus, metabolic syndrome
199
What are the features of HCC?
- Tends to present late
- Features of liver cirrhosis or failure may be seen: jaundice, ascites, RUQ pain, hepatomegaly, pruritus, splenomegaly
- Possible presentation is decompensation in a patient with chronic liver disease
- Raised AFP
200
What are the management options for HCC?
- early disease: surgical resection
- liver transplantation
- radiofrequency ablation
- transarterial chemoembolisation
- sorafenib: a multikinase inhibitor
Based on Barcelona classification system.
201
What are the risk factors for developing an anal fissure?
- constipation
- inflammatory bowel disease
- sexually transmitted infections e.g. HIV, syphilis, herpes
202
What are the features of anal fissures?
- painful, bright red, rectal bleeding
- around 90% of anal fissures occur on the posterior midline.
- if the fissures are found in alternative locations then other underlying causes should be considered e.g. Crohn's disease
203
What is the management for acute anal fissures?
- soften stool
- dietary advice: high-fibre diet with high fluid intake
- bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
- lubricants such as petroleum jelly may be tried before defecation
- topical anaesthetics
- analgesia
204
What is the management of chronic anal fissures?
- topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
- if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
205
Which genetic factors are strongly associated with coeliac disease?
HLA-DQ2 ( founding 95% of coeliacs) and HLA-DQ8
206
What is the most consistent laboratory finding in Wilson's disease?
reduced serum caeruloplasmin
207
What is Plummer-vinson syndrome?
Triad of:
dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia
208
What percentage of people with a positive qFIT will have colorectal cancer?
5-15%
209
What is the investigation of choice for mild acid malabsorption?
SeHCAT (Selenium-75-labelled homocholic acid taurine) test
210
