Gastroenterology

Question 1

IBS

Answer 1

Altered gut reactivity in response to various stimuli ( environmental or luminal ), etc.

Question 2

Dukes A colonic carcinoma

Answer 2

> COLONOSCOPY
Annually for 2 years then 3 yearly
FOB
6 monthly for 4 years then once yearly
CEA
to monitor for recurrence

Question 3

Causes of Colorectal Carcinoma

Answer 3

-Sporadic 75%
-Family history 15-20%
-HNPCC 5%
-FAP 1%
-IBD 1%

Question 4

Achalasia

Answer 4

• Progressive dysphagia to both solids and liquids.
  -Esophageal manometry is the most sensitive test.

Question 5

King’s College Criteria for Liver Transplantation

Answer 5

pH <7.30 or

INR >6.5 (PT >100 seconds) and serum creatinine >300 µmol/L (>3.4 mg/dL) in patients with grade 3 or 4 hepatic encephalopathy.

Question 6

-Infective Endocarditis

Answer 6

Up to half of patients presenting with Streptococcus bovis endocarditis have colorectal tumours.

Question 7

Prostaglandins

Answer 7

Prostaglandins inhibit gastric acid secretion.

Question 8

NASH

Answer 8

NASH is associated with increased prevalence of insulin resistance/type 2 diabetes.

Approximately 20% develop cirrhosis.

It is more common in men due to the protective effects of oestrogen. The treatment is complex and multi-modal but should focus on weight reduction.

Data from small clinical trials using pioglitazone have shown modest improvement in liver biopsy appearance over one year.

Question 9

Spontaneous bacterial peritonitis

Answer 9

Spontaneous bacterial peritonitis is diagnosed by ascitic fluid examination which reveals a neutrophil count of >250/ml, and is typically caused by aerobic gram negative bacteria.
- E.coli, Klebsiella.
- Antibiotics such as co-amoxiclav, tazosin, or ciprofloxacin are typically used as first line treatment.

Question 11

Refractory Ascites

Answer 11

TIPS( Transjugular intrahepatic portosystemic shunt) is an appropriate intervention for patients with refractory ascites who do not respond to maximum medical therapy.

Question 12

Giardiasis

Answer 12

The history of abdominal bloating with intermittent diarrhoea and strong smelling bowel gas is typical of giardiasis. As long as a fresh stool sample is examined, trophozoites are found in 60%+ of samples.

A single dose of tinidazole or a course of metronidazole is the treatment of choice.

Question 13

Refeeding syndrome

Answer 13

Hypophosphatemia

Question 14

Alcoholic hepatitis

Answer 14

• Tender hepatosplenomegaly, Fever, Cirrhosis
• AST: ALT 2:1 rarely over 300
• Cardiomyopathy of Alcoholism is dilated or congested form.

Question 15

Gastric Tumour

Answer 15

Endoscopic Ultrasound is superior to conventional CT scan for conventional tumour staging

Question 16

Gastric Cancer Classification

Answer 16

STAGES
1A- Confined to mucosa with no LN involvement.
1B- Tumour that either invades the submucosa (T1) with limited lymph node involvement (N1) or invades the muscularis propria (T2) with no nodal involvement (N0).
2B- tumour that has invaded the muscularis propria (T2) with some lymph node involvement (N1) or a tumour that has invaded the subserosa (T3) without nodal involvement (N0).
3A- tumours that extend into the serosa (T4a) without nodal involvement (N0) .
3C- tumour that invades the serosa (T4a) with significant nodal involvement (N3), or a tumour that invades adjacent structures (T4b

Question 17

Gatro- oesophageal Reflux disease

Answer 17

NICE guidance states the following: “Oesophageal manometry and ambulatory 24-hour oesophageal pH monitoring (to quantify reflux and assess the relationship between reflux episodes and the person’s symptoms).
Laparoscopic fundoplication is the treatment of choice for patients with GORD refractory to or intolerant of proton pump inhibitor therapy.

Question 18

Risk factors for oesophageal cancer:

Answer 18

ADENOCARCINOMA
- Barret Esophagus

SQUAMOUS CELL CARCINOMA
-Plummer Vinson
-Aclasia

> > BA PAS
- Smoking, Alcohol common in both

Question 20

Hepatopulmonary syndrome

Answer 20

• Oxygenation defect induced by pulmonary vascular dilatation in patients with liver cirrhosis or pulmonary HTN.
• Contrast enhanced Transthoracic Echo is used to demonstrate intrapulmonary vascular dilatation. Immediate visualization in the left ventricle ( within 3 cardiac cycle) indicates intracardiac shunting. Delayed visualization in the left ventricle ( 3-6 cardiac cycle) is diagnostic of intrapulmonary shunting.

Question 21

Wilson’s disease

Answer 21

• Autosomal Recessive
• Wilson’s disease is caused by a defect in the ATP7B gene located on chromosome 13.

Question 22

Microscopic Colitis

Answer 22

PPIs are a cause of microscopic colitis, which can present with chronic diarrhoea, colonoscopy and biopsy should be considered when patients present in this way and are taking a PPI.

Question 23

Esophageal Varices

Answer 23

A non-cardioselective B-blocker (NSBB) Propranolol is used for the prophylaxis of oesophageal bleeding.

• reduced rebleeding and mortality compared to placebo
  endoscopic variceal band ligation (EVL)
  superior to endoscopic sclerotherapy.
• Transjugular Intrahepatic Portosystemic Shunt (TIPSS)

Question 24

Eosinophilic Oesophagitis

Answer 24

• Eosinophilic oesophagitis is characterised by an allergic inflammation of the oesophagus. An oesophageal biopsy will show dense infiltrate of eosinophils in the epithelium.
• Epidemiology:
  3:1 male:female ratio
  Average age at diagnosis is 30-50 years old

Risk factors for developing eosinophilic oesophagitis:
Allergies/ asthma: suffering from food/ environmental allergies or atopic dermatitis and asthma increases the risk of diagnosis
Male sex
Family history of eosinophilic oesophagitis or allergies
Caucasian race
Age between 30-50
Coexisting autoimmune disease e.g. coeliac disease

Investigations:
Endoscopy: diagnosis can only be made on the histological analysis of an oesophageal biopsy. There must be more than 15 eosinophils per high power microscopy field to diagnose the condition. Other findings on endoscopy include reduced vasculature, thick mucosa, mucosal furrows, strictures and laryngeal oedema. Histologically, the diagnosis is made more likely in the presence of epithelial desquamation, eosinophilic microabscesses, and abnormally long papillae
PPI trial: persistence of eosinophilia and no improvement of symptoms after trialling a proton pump inhibitor. This can help the clinician differentiate between eosinophilic oesophagitis and GORD, which can be a tricky task.

Management:
- Dietary modification: This is both effective in adults and children. There are three methods available to begin excluding food from the diet. The elemental diet (involves taking an amino acid mixture for six weeks), exclusion of six food groups (involves avoiding foods commonly associated with allergy e.g. nuts, soy, egg, seafood), and the targeted elimination diet (involves excluding foods that have been identified as allergy-triggering during allergy testing). It is important to involve a dietitian when attempting to modify diet.
Topical steroids e.g. fluticasone and budesonide are options when dietary modification fails. This requires the patient to swallow solutions of the steroid to line the oesophagus. This should be done for eight weeks before being reassessed
Oesophageal dilatation: 56% of patients require this at some point in their treatment to reduce the symptoms associated with oesophageal strictures

Complications:
Strictures of the oesophagus (56%)
Impaction: 55% of patients experience this, and 38% of these require endoscopic removal of the impaction
Mallory-Weiss tears

Question 25

Gastrin

Answer 25

- Secretes from G cells in antrum of stomach Increases acid secretion by gastric parietal cells, pepsinogen and IF secretion, increases gastric motility, stimulates parietal cell maturation

Question 26

CCK

Answer 26

- I cells in upper small intestine - Increases secretion of enzyme-rich fluid from pancreas, contraction of gallbladder and relaxation of sphincter of Oddi, decreases gastric emptying, trophic effect on pancreatic acinar cells, induces satiety

Question 27

Secretin

Answer 27

- S cells in upper small intestine -Increases secretion of bicarbonate-rich fluid from pancreas and hepatic duct cells, decreases gastric acid secretion, trophic effect on pancreatic acinar cells

Question 28

VIP

Answer 28

- Stimulates secretion by pancreas and intestines, inhibits acid secretion

Question 29

Somatostatin

Answer 29

- D cells in the pancreas and stomach - 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

Question 30

Acute mesenteric ischemia

Answer 30

Acute mesenteric ischaemia is typically caused by an embolism resulting in occlusion of an artery which supplies the small bowel, for example the superior mesenteric artery. Classically patients have a history of atrial fibrillation. Management Urgent surgery is usually required poor prognosis, especially if surgery is delayed.

Question 32

Ischemic colitis

Answer 32

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. Management - usually supportive - surgery may be required in a minority of cases if conservative measures fail. Indications would include generalised peritonitis, perforation or ongoing haemorrhage

Question 33

Cholera

Answer 33

Cholera Overview caused by Vibrio cholerae - Gram-negative bacteria Features - profuse 'rice water' diarrhoea - dehydration - hypoglycaemia Management - Oral rehydration therapy - Antibiotics: doxycycline, ciprofloxacin

Question 34

Spontaneous bacterial peritonitis

Answer 34

Spontaneous bacterial peritonitis (SBP) is a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis. Features - ascites - abdominal pain - fever 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' - Alcoholic liver disease is a marker of poor prognosis in SBP.

Question 35

Budd-Chiari Syndrome

Answer 35

Budd-Chiari syndrome, or hepatic vein thrombosis, is usually seen in the context of underlying haematological disease or another procoagulant condition. Causes - 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 The features are classically a triad of: abdominal pain: sudden onset, severe ascites → abdominal distension tender hepatomegaly Investigations - Ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation

Question 36

Hepatitis C

Answer 36

- Hepatitis C - 55-85% become chronically infected. - daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with or without ribavirin are used

Question 37

Small bowel overgrowth syndrome

Answer 37

Diagnosis - Hydrogen breath test Rx. 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 38

Autoimmune Hepatitis

Answer 38

Type 1 Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA) Type 2 Anti LKM1 antibodies Type 3 Soluble liver kidney antigen

Question 39

SAAG > 11g/L (indicates portal hypertension)

Answer 39

- Liver disorders are the most common cause cirrhosis/alcoholic liver disease acute liver failure liver metastases - MCardiac right heart failure constrictive pericarditis - Other causes Budd-Chiari syndrome portal vein thrombosis veno-occlusive disease myxoedema

Question 40

SAAG <11g/L

Answer 40

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

Question 41

Oesophageal/Gastric Cancer

Answer 41

Oesophageal/Gastric Cancer - Endoscopic ultrasound (EUS) is better than CT or MRI in assessing mural invasion.

Question 42

Angiodysplasia

Answer 42

Management - for active bleeding lesions: Endoscopic therapy is first-line: argon plasma coagulation (APC) or bipolar cautery can be used to coagulate visible vessels. Adrenaline injection may provide temporary haemostasis in unstable patients or where endoscopy fails, mesenteric angiography with embolisation can be considered surgery (e.g. segmental bowel resection) is a last resort for refractory or massive bleeding - For recurrent or less severe bleeding: Antifibrinolytics (e.g. tranexamic acid) may reduce bleeding episodes Hormonal therapy with oestrogens and progesterone may be trialled in refractory cases (evidence is limited) - supportive care: iron supplementation for anaemia blood transfusion as required

Question 43

Heyde's syndrome

Answer 43

Angiodysplasia is associated with aortic stenosis and can cause gastrointestinal bleeding. The combination of these two conditions is known as Heyde's syndrome.

Question 44

FAP

Answer 44

Familial adenomatous polyposis - once diagnosed patients typically have a total proctocolectomy with ileal pouch anal anastomosis due to the extremely high risk of developing colorectal cancer

Question 45

Colon Cancer

Answer 45

three types of colon cancer: sporadic (95%) hereditary non-polyposis colorectal carcinoma (HNPCC, 5%) familial adenomatous polyposis (FAP, <1%)

Question 46

Gardner’s syndrome

Answer 46

A variant of FAP called Gardner's syndrome can also feature osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin

Question 47

Crohn’s Disease

Answer 47

Ongoing diarrhoea in Crohn's patient post-resection with normal CRP → cholestyramine

Question 48

Urea Breath Test

Answer 48

Urea breath test - no antibiotics in past 4 weeks, no antisecretory drugs (e.g. PPI) in past 2 weeks

Question 49

Dermatitis herpetiformis

Answer 49

Dermatitis herpetiformis is an autoimmune blistering skin disorder associated with coeliac disease. It is caused by the deposition of IgA in the dermis. More than 90% of patients exhibit small bowel biopsy findings consistent with some degree of gluten-sensitive enteropathy. Features itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees, buttocks) Diagnosis skin biopsy: direct immunofluorescence shows deposition of IgA in a granular pattern in the upper dermis Management gluten-free diet dapsone

Question 50

Coagulopathy of Liver disease

Answer 50

In liver failure all clotting factors are low, except for factor VIII which is paradoxically supra-normal.

Question 51

Hepatitis B Serology

Answer 51

previous immunisation: anti-HBs positive, all others negative previous hepatitis B (> 6 months ago), not a carrier: anti-HBc positive, HBsAg negative previous hepatitis B, now a carrier: anti-HBc positive, HBsAg positive

Question 52

Pyoderma Gangrenosum

Answer 52

oral steroids as first-line treatment. other immunosuppressive therapy, for example, ciclosporin and infliximab, have a role in difficult cases.

Question 53

Esophageal Varices

Answer 53

Terlipressin is a synthetic analogue of vasopressin and acts as a vasoconstrictor. It reduces portal venous pressure by causing splanchnic vasoconstriction, which can help control variceal bleeding. According to the British Society of Gastroenterology guidelines, terlipressin should be administered as soon as variceal bleeding is suspected and continued until an endoscopy can be performed.

Question 54

Primary billiary Cirrhosis

Answer 54

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

Question 55

Primary Billiary Cirrhosis

Answer 55

Clinical features early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus cholestatic jaundice hyperpigmentation, especially over pressure points around 10% of patients have right upper quadrant pain xanthelasmas, xanthomata also: clubbing, hepatosplenomegaly late: may progress to liver failure Diagnosis immunology 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

Question 56

Primary Biliary Cholangitis

Answer 56

Primary biliary cholangitis (previously referred to as primary biliary cirrhosis) is a chronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1

Question 57

Primary Biliary Cholangitis

Answer 57

Increased risk of hepatocellular carcinoma (20-fold increased risk)

Question 58

Gluten free Foods

Answer 58

Some notable foods which are gluten-free include: - rice - potatoes - corn (maize)

Question 59

Chronic Pancreatitis

Answer 59

CT pancreas is the preferred diagnostic test for chronic pancreatitis - looking for pancreatic calcification

Question 61

Pyogenic Liver Abscess

Answer 61

The most common organisms found in pyogenic liver abscesses are Staphylococcus aureus in children and Escherichia coli in adults. Management >>drainage (typically percutaneous) and antibiotics >>amoxicillin + ciprofloxacin + metronidazole >>if penicillin allergic: ciprofloxacin + clindamycin

Question 62

Zollinger Ellison Syndrome

Answer 62

The majority of gastrinomas are found in the first part of the duodenum.

Question 63

Non-alcoholic fatty liver disease

Answer 63

Associated factors 1-obesity 2- Type 2 diabetes mellitus 3- hyperlipidaemia 4- jejunoileal bypass 5- sudden weight loss/starvation

Question 64

Non-alcoholic fatty liver disease

Answer 64

NICE recommends the use of the enhanced liver fibrosis (ELF) blood test to check for advanced fibrosis the ELF blood test is a combination of hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1. -non-invasive tests may be used to assess the severity of fibrosis these include the FIB4 score or NALFD fibrosis score these scores may be used in combination with a FibroScan (liver stiffness measurement assessed with transient elastography) this combination has been shown to have excellent accuracy in predicting fibrosis

Question 65

Budd-Chiari syndrome

Answer 65

Budd-Chiari syndrome - ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation.

Question 66

Budd-Chiari syndrome

Answer 66

Budd-Chiari syndrome Budd-Chiari syndrome, or hepatic vein thrombosis, is usually seen in the context of underlying haematological disease or another procoagulant condition. Causes 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 The features are classically a triad of: abdominal pain: sudden onset, severe ascites → abdominal distension tender hepatomegaly Investigations ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation

Question 69

TIPSS

Answer 69

Transjugular Intrahepatic Portosystemic Shunt commonly causes an exacerbation of hepatic encephalopathy Important for meLess important Transjugular Intrahepatic Portosystemic Shunt is the correct answer. This procedure is the recommended treatment for a variceal haemorrhage uncontrolled with endoscopy. The hepatic vein is cannulated percutaneously via the internal jugular vein, using a needle under radiological guidance. A connection is created and a stent is inserted through the liver from the hepatic to the portal vein, thereby reducing portal pressure and reducing the risk of a bleed. Encephalopathy is found in up to 25% of cases as blood normally detoxified in the liver, now bypasses this stage and toxins are delivered in greater quantity to the cerebral circulation

Question 70

High Risk of refeeding syndrome

Answer 70

Patients are considered high-risk if one or more of the following: 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)

Question 71

How to prevent refeeding syndrome

Answer 71

NICE recommend that if a patient hasn't eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days.

Question 72

Refeeding Syndrome

Answer 72

Refeeding syndrome is a recognised complication of TPN - the hallmark feature is hypophosphataemia

Question 73

Total Parental Nutrition

Answer 73

Basics Commonly used in nutritionally compromised surgical patients Bags contain combinations of glucose, lipids and essential electrolytes, the exact composition is determined by the patients nutritional requirements. Although it may be infused peripherally, this may result in thrombophlebitis. Longer term infusions should be administered into a central vein (preferably via a PICC line). Complications - Infectious - Catheter-related bloodstream infections (CRBSIs) - Sepsis from central line contamination - Metabolic - Hyperglycaemia or hypoglycaemia - Electrolyte disturbances - Refeeding syndrome: Sudden intracellular shift of electrolytes when feeding is restarted in malnourished patients - the hallmark feature is hypophosphataemia. Hypokalaemia and hypomagnesaemia may also occur - Hepatobiliary - Fatty liver (hepatic steatosis) - Cholestasis - Gallstones - Long-term liver fibrosis - Mechanical / Vascular - Pneumothorax, catheter malposition - Venous thrombosis - Thrombophlebitis (especially with peripheral TPN) - Nutritional / Bone - Vitamin and trace element imbalances - Metabolic bone disease (osteopenia/osteoporosis)

Question 74

Cholangiocarcinoma

Answer 74

Courvoisier's sign - a palpable gallbladder in the presence of painless jaundice is unlikely to be gallstones

Question 75

Cholangiocarcinoma

Answer 75

Cholangiocarcinoma is the medical term for bile duct cancer. Primary sclerosing cholangitis is the main risk factor for cholangiocarcinoma Features persistent biliary colic symptoms associated with anorexia, jaundice and weight loss a palpable mass in the right upper quadrant (Courvoisier sign) periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen raised CA 19-9 levels often used for detecting cholangiocarcinoma in patients with primary sclerosing cholangitis

Question 76

Complications of Coeliac Disease

Answer 76

Complications 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

Question 77

Ulcerative colitis Exacerbation

Answer 77

Abdominal pain, diarrhoea, and rectal bleeding in a patient with ulcerative colitis who recently stopped smoking suggest an exacerbation of ulcerative colitis.

Question 78

Primary sclerosing cholangitis

Answer 78

Primary sclerosing cholangitis is a biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts. Associations ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC Crohn's (much less common association than UC) HIV Features cholestasis jaundice, pruritus raised bilirubin + ALP right upper quadrant pain fatigue Investigation endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) are the standard diagnostic investigations, showing multiple biliary strictures giving a 'beaded' appearance p-ANCA may be positive there is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often described as 'onion skin' Complications cholangiocarcinoma (in 10%) increased risk of colorectal cancer