Gastroenterology

Question 1

What is the difference between Dysphagia and Odynophagia?

Answer 1

Dysphagia = Difficulty in swallowing

Odynophagia = Pain on swallowing

Question 2

What are the key questions in Dysphagia?

Answer 2

Difficulty in starting swallowing?

Associated symptoms? (regurgitation, change in voice pitch, weight loss)

Solids, liquids, or both?

Intermittent or progressive?

History of heartburn?

Change in eating habits/diet?

Question 3

What is Barrett’s Oesophagus?

Answer 3

Barrett’s oesophagus is a condition characterised by partial replacement of the normal squamous epithelium of the lower oesophagus by a metaplastic columnar epithelium containing goblet cells (intestinal metaplasia).

Barrett’s oesophagus is important clinically because those afflicted are predisposed to oesophageal adenocarcinoma.

Question 4

How is Barrett’s Oesophagus managed?

Answer 4

Acid suppressive therapy with high-dose PPI indefinitely (or surgical fundoplication)

Surveillance gastroscopy every 3 years if no dysplasia

Question 5

Most likely source of source of a significant gastrointestinal bleed occuring as a complication of peptic ulcer disease?

Answer 5

Gastroduodenal Artery

Question 6

Epigastric pain that is relieved by eating.

Answer 6

Duodenal Ulcer - Peptic Ulcer Disease (PUD)

Question 7

Epigastric pain that is worsened by eating.

Answer 7

Gastric Ulcers

Question 8

Name 3 features of Crohn’s disease over UC (CD)?

Answer 8

Upper gastrointestinal symptoms, mouth ulcers, perianal disease

Skip lesions may be present. ‘Cobble stone appearance’

Inflammation in all layers from mucosa to serosa - increased goblet cells, granulomas

Non-bloody diarrhoea

Obstructions and fistulae may occur

Question 9

Name 5 features of UC over Crohns?

Answer 9

Bloody diarrhoea more common
Abdominal pain in the left lower quadrant

Tenesmus - feeling you need to go

Risk of colorectal cancer high in UC than CD

Inflammation always starts at rectum and never spreads beyond ileocaecal valve

Continuous

No inflammation beyond submucosa (Crypt abcesses and pseudopolyps form)

Question 10

How is synthetic capacity of liver tested? (Liver function)

Answer 10

ABC

Albumen

Bilirubin

Coagulation (Prothrombin Time)

Question 11

What is the problem if ALT, AST > 5x upper limit; and ALP, GGT <5x upper limit?

Answer 11

Most likely Hepatocellular damage

Question 12

What is the problem if ALP, GGT > 5x upper limit; and ALT, AST <5x upper limit?

Answer 12

Most likely Obstructive

Question 13

What are the risk factors for PUD? (4)

Answer 13

NSAID use

H Pylori infection

Smoking

Hx, Fam Hx.

Question 14

What are 90% of duodenal ulcers also positive for?

Answer 14

H. pylori

Question 15

How is PUD investigated?

Answer 15

Endoscopy -> gold standard. Must biopsy due to malignancy risk.

FBC, EUC -> ~anaemia, malabsorption

H. Pylori Investigation

Question 16

How is H. Pylori investigated? (3+3)

Answer 16

Non-invasive:

Urea breath test -> highly specific + sensitive. Expensive.

Serology -> rapid, but lacks specificity + no Ddx b/w past and current infection.

Faecal antigen testing -> cheap, specific (>95%)

Invasive (w/ antral biopsy):

Histology -> specific. False -ve’s, time.

Rapid urease tests -> cheap, quick, specific. Poor sensitivity.

Culture -> gold standard. Slow, laborious, insensitive.

Histology -> specific.

Question 17

What are the ddxs of PUD?

Answer 17

Coeliac disease

Gastric cancer

Chronic pancreatitis

Biliary disease

Question 18

How is PUD treated?

Answer 18

Heal ulcer -> H. Pylori eradication. PPI 8-12wks.

Maintenance therapy (reduce risk) -> stop NSAIDs, smoking. PPI/H2RA in some.

Treat complications -> surg.

Question 19

How is H. Pylori treated?

Answer 19

Eradication of H. Pylori - Triple therapy:

2x Abx, 1x PPI

Amoxycillin + clarithromycin + esomeprazole. ~1wk.

Confirm eradication w/ breath test

Question 20

What are the signs of impaired liver function?

Answer 20

Jaundice -> poor bilirubin clearance

Encephalopathy -> failure to clear by-products of metabolism

Bleeding -> impaired clotting factors

Hypoglycaemia

Question 21

What are the signs of Chronic liver injury?

Answer 21

Catabolic status (+/- poor nutrition)

• Skin thinning*
• Loss of muscle bulk*
• Leukonychia*

Impaired albumin synthesis -> reduced oncotic pressure

Reduced aldosterone clearance -> Na+ retention

Reduced oestrogen clearance -> mild feminisation

Question 22

What are ascites?

Answer 22

Accumulation of free fluid in peritoneal cavity. -> distension, shifting dullness. ~hernia, abdominal vein distension.

Question 23

What are the causes of ascites?

Answer 23

Common

Cardiac failure, hepatic cirrhosis (2nd to splanchnic v. dilation), malignant hepatic/peritoneal disease.

Others:

Pancreatitis, lymph obstruction, hepatic vein obstruction (Budd-Chiari, veno-occlusive disease), infection.

Hypoproteinaemia -> nephrotic syndrome, malnutrition, protein losing enteropathy.

Question 24

What are the current alcohol guidelines?

Answer 24

No more than 2 a day and no more than 4 on a single occasion.

Question 25

What is NAFLD made up of?

Answer 25

Simple steatosis (Fatty Liver) and non-alcoholic steato-hepatitis (NASH)

Question 26

How is fatty infiltration of the liver confirmed?

Answer 26

Ultrasound, MRI or Liver Biopsy

Question 27

What co-morbidity most commobly exists with NAFLD?

Answer 27

Metabolic Syndrome

Question 28

What is the management of NAFLD?

Answer 28

Weight control Reduction in cardiovascular risk factors such as smoking, diabetes, hypertension and dyslipidaemia. Referral to Cardiologist, Dietician, Endocrinologist Statins

Question 29

Which is more common in Australia - IBS or IBD?

Answer 29

IBS (approx. 50 times more)

Question 30

What suggests IBD over IBS? (5)

Answer 30

Weight loss Elevated C-reactive protein (CRP) Nocturnal diarrhoea (especially if wakes patient from sleep) Blood in stools Fever Obstructive symptoms Anaemia Iron deficiency Low albumin.

Question 31

Which are more likely to have fistulas - Crohns or UC?

Answer 31

Crohns

Question 32

What is smoking a risk factor for - Crohns or UC?

Answer 32

Crohns Protective in UC

Question 33

Which is more likely to have bloody + mucus diarrhoea - Crohns or UC?

Answer 33

UC

Question 34

What are 5 possible signs of Crohns on physical?

Answer 34

* *Iron deficiency anaemia -\>** Koilonychia, pallor, angular stomatitis, glossitis * *Abdo -\>** tenderness + masses (inflammation) * *Perianal -\>** skintags, fissures, fistulas **MSK -\>** arthritis, osteoporosis. Crohn’s w/ HLA-B27 -\> sacroilitis + ank spond **Eye -\>** conjunctivitis, iritis, uveitis Erythema nodosum - red lumps on shins **Hepatobiliary:** Primary sclerosing cholangitis Fatty liver Autoimmune hepatitis **Haem:** VTE + ATE Autoimmune haemolytic anaemia

Question 35

What is first line therapy for IBD?

Answer 35

Mesalazine - 5-aminosalicyclic acid (5-ASA)

Question 36

What is Adalimumab and when is it used?

Answer 36

TNF inhibitor Used in IBD, RA, other HLAB27s

Question 37

Name 4 different drug types used for IBD flaires?

Answer 37

Aminosalicylates (5-ASA) Corticosteroids Immunomodulators (azathioprine, 6-mercaptopurine and methotrexate) Biologic agents (infliximab, adalimumab, vedolizumab and ustekinumab) Antibiotics (metronidazole, ciprofloxacin and others).

Question 38

What 3 complications of IBD should be monitored?

Answer 38

Osteoporosis Iron deficiency anaemia Colon cancer

Question 39

What is the most common cause of acute nausea/vomiting?

Answer 39

Viral gastroenteritis or bacterial food poisoning.

Question 40

What are serious causes of nausea and vomiting not to be missed? (5\_

Answer 40

Surgical causes • Pancreatitis – cholecystitis – appendicitis – small bowel obstruction • Diabetic ketoacidosis • Addisonian crisis • Raised intracranial pressure (usually with other neurological features) • Hepatitis • Ingestion of irritants/allergens

Question 41

How should acute nausea and vomiting be investigated?

Answer 41

Electrolytes and renal function Full blood count Pancreatic and liver enzymes Glucose.

Question 42

What investigations could be considered in chronic nausea and vomiting?

Answer 42

Question 43

The two most common causes of acute pancreatitis are:

Answer 43

Gallstones and Alcohol

Question 44

How is acute pancreatitis diagnosed?

Answer 44

Diagnosis is established by the presence of two of the three criteria: * acute upper abdominal pain; * serum amylase and/or lipase levels greater than three times the upper limit of normal; and/or * findings on CT, MRI, or ultrasound

Question 45

What is more specific in Acute pancreatitis?

Answer 45

Lipase - if 3x upper limit suggestive

Question 46

Why is serum calcium important in Acute Pancreatitis?

Answer 46

Hypercalcemia may cause pancreatitis, which may then, in turn, cause hypocalcemia!

Question 47

What is the management of Acute Pancreatis?

Answer 47

"PANCREAS" Perfusion (fluid replacement), Analgesia, Nutrition, Clinical (observation), Radiology (imaging), ERC (endoscopic stone extraction), Antibiotics, Surgery (surgical intervention, if necessary).

Question 48

How is Liver Cirrhosis Assessed?

Answer 48

A - Albumin B - Bilirubin C - Coagulations (PT) Ascites and Encephalopathy