Gastroenterology

Question 1

How many units of alcohol is the recommendation?

Answer 1

Men and women should drink no more than 14 units of alcohol per week!

If you do drink as much as 14 units per week, it is best to spread this evenly over 3 days or more

If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum.

Question 2

What is the commonest cause of hepatocellular carcinoma?

Answer 2

Chronic hepatitis B is the most common cause of HCC worldwide with chronic hepatitis C being the most common cause in Europe.

The main risk factor for developing HCC is liver cirrhosis, for example secondary to hepatitis B & C, Alcohol, Haemochromatosis and Primary Biliary Cirrhosis. Other risk factors include:

• 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

Question 3

Signs and symptoms of HCC?

Answer 3

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
- Tends to present late

Question 4

What is the acute treatment for variceal haemorrhage?

Answer 4

Acute treatment of variceal haemorrhage:

1. ABC: patients should ideally be resuscitated prior to endoscopy
2. Correct clotting: FFP, vitamin K
3. Vasoactive agents:
   - Terlipressin is currently the only licensed vasoactive agent. Benefit in initial haemostasis and preventing rebleeding.
   - Octreotide may also be used although there is some evidence that Terlipressin has a greater effect on reducing mortality.
4. Prophylactic antibiotics. Quinolones are typically used. Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper GI bleeding.
5. Endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation
6. Sengstaken-Blakemore tube if uncontrolled haemorrhage
7. Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
   - connects the hepatic vein to the portal vein
   - exacerbation of hepatic encephalopathy is a common complication

Question 5

What drug is given for prophylaxis of variceal haemorrhage?

Answer 5

Propranolol: reduced rebleeding and mortality compared to placebo

Question 6

What is Wilson disease? Mode of inheritance?

Answer 6

Wilson’s disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion.

The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease

Question 7

Signs and symptoms of wilson disease?

Answer 7

Features result from excessive copper deposition in the tissues, especially the BRAIN, LIVER and CORNEA:

• Liver: hepatitis, cirrhosis
• Neurological:
• basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia
• Speech, behavioural and psychiatric problems are often the first manifestations
• also: asterixis, chorea, dementia, parkinsonism
• Kayser-Fleischer rings
  green-brown rings in the periphery of the iris
  due to copper accumulation in Descemet membrane
• renal tubular acidosis (esp. Fanconi syndrome)
• haemolysis
• blue nails

Question 8

How is Wilsons disease investigated?

Answer 8

• Slit lamp examination for Kayser-Fleischer rings
• Reduced serum caeruloplasmin
• Reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin). Free (non-ceruloplasmin-bound) serum copper is increased
• Increased 24hr urinary copper excretion

Question 9

Which drug is given in management of Wilsons disease?

Answer 9

Penicillamine (chelates copper) has been the traditional first-line treatment.

Trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future

Question 10

What are the associated factors for NAFLD?

Answer 10

Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of liver disease in the developed world. It is largely caused by obesity and describes a spectrum of disease ranging from:
- steatosis - fat in the liver
- steatohepatitis - fat with inflammation, non-alcoholic steatohepatitis (NASH)
- progressive disease may cause fibrosis and liver cirrhosis

Associated factors:
- obesity
- type 2 diabetes mellitus
- hyperlipidaemia
- jejunoileal bypass
- sudden weight loss/starvation

Question 11

Investigations for NAFLD?

Answer 11

(Incidental finding of NAFLD - typically asymptomatic fatty changes on liver ultrasound)
in these patients, NICE recommends the use of the Enhanced Liver Fibrosis (ELF) blood test to check for advanced fibrosis.

if the ELF blood test was not available:
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 12

Management for NAFLD?

Answer 12

Management:

The mainstay of treatment is lifestyle changes (particularly weight loss) and monitoring.

there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g. metformin, pioglitazone)

Question 13

Anti-smooth muscle antibodies (SMA) is associated with which condition?

Answer 13

Autoimmune hepatitis

Question 14

What is the main stay of coeliac disease management?

Answer 14

The management of coeliac disease involves a GLUTEN-FREE DIET. Gluten-containing cereals include:
- wheat: bread, pasta, pastry
- barley: beer
- rye
- oats

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

Question 15

What antibody is checked to check for compliance to a gluten-free diet?

Answer 15

Tissue transglutaminase antibodies

Question 16

Diarrhea, the stool floats in the toilet water, but there is no blood. What is the most likely causative organism?

Answer 16

Giardia lamblia causes fat malabsorption, therefore greasy stool can occur

Question 17

What is the first line pharmacological treatment for IBS?

Answer 17

First-line pharmacological treatment - according to predominant symptom:

Pain: antispasmodic agents
Constipation: laxatives but avoid lactulose
Diarrhoea: Loperamide is first-line

General dietary advice:
- 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).

Question 18

What are the features of hepatic encephalopathy?

Answer 18

Hepatic encephalopathy is largely believed to occur from accumulation of ammonia in the blood stream due to the livers decreased ability to detoxify ammonia that is produced and transported from the gastrointestinal tract.

Features:
- Confusion, altered GCS
- Asterix: ‘liver flap’, arrhythmic negative myoclonus with a frequency of 3-5 Hz
- Constructional apraxia: inability to draw a 5-pointed star
- Triphasic slow waves on EEG
- Raised ammonia level (not commonly measured anymore)

Question 19

What is the first line treatment for hepatic encephalopathy?

Answer 19

Management:

1. Treat any underlying precipitating cause
2. NICE recommend LACTULOSE first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy
   - lactulose is thought to work by promoting the excretion of ammonia and increasing the metabolism of ammonia by gut bacteria
3. Antibiotics such as rifaximin are thought to modulate the gut flora resulting in decreased ammonia production

• other options include embolisation of portosystemic shunts and liver transplantation in selected patients

Question 20

What is the investigation of choice for crohn’s disease? What is usually seen?

Answer 20

Crohn’s disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus.

Bloods:
C-reactive protein correlates well with disease activity

Colonoscopy is the investigation of choice!
- features suggestive of Crohn’s include deep ulcers, skip lesions

Histology
- inflammation in all layers from mucosa to serosa
- goblet cells, granulomas

Small bowel enema
- high sensitivity and specificity for examination of the terminal ileum
- strictures: ‘Kantor’s string sign’
- proximal bowel dilation
- ‘rose thorn’ ulcers
- fistulae

Question 21

Commonest organism found in ascitic culture of spontaneous bacterial peritonitis?

Answer 21

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

Question 22

What is the antibiotic given for SBP? What is the prophylaxis?

Answer 22

Management of SBP:
Intravenous Cefotaxime

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
• 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’

Question 23

What is Courvoisir’s law?

Answer 23

Courvoisier’s law states that in the presence of a palpably enlarged gallbladder and accompanied with mild jaundice, the cause is unlikely to be gallstones.

Question 24

Signs and symptoms of pancreatic cancer?

Answer 24

• Classically painless jaundice
• Pale stools, dark urine, and pruritus
• Cholestatic liver function tests
• Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
• However, patients typically 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) is more common than with other cancers

Question 25

Investigation of choice for suspecte pancreatic cancer?

Answer 25

- 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

Question 26

What procedure is done for pancreatic ca?

Answer 26

- less than 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

Question 27

What is the management for haemochromatosis?

Answer 27

- Venesection is the first-line treatment monitoring adequacy of venesection: transferrin saturation should be kept below 50% and the serum ferritin concentration below 50 ug/l - Desferrioxamine may be used second-line

Question 28

Which drugs are given in Crohn's to induce and maintain remission?

Answer 28

Patients should be strongly advised to stop smoking! Inducing remission: - Glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients. - 5-ASA drugs (e.g. Mesalazine) are used second-line to glucocorticoids but are not as effective - Azathioprine or mercaptopurine may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine - Infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on azathioprine or methotrexate - metronidazole is often used for isolated peri-anal disease Maintaining remission: - As above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis) - Azathioprine or mercaptopurine is used first-line to maintain remission - Methotrexate is used second-line - 5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery Surgery: - around 80% of patients with Crohn's disease will eventually have surgery Crohn's disease is notorious for the developmental of intestinal fistulae; these may form between the rectum and skin (perianal) or the small bowel and skin. Fistulation between loops of bowel may also occur and result in bacterial overgrowth and malabsorption. Management of enterocutaneous fistulae involves controlling sepsis, optimising nutrition, imaging the disease and planning definitive surgical management.

Question 29

What are the symptoms and signs of haemochromatosis?

Answer 29

Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. Presenting features: 1. Early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands) 2. 'bronze' skin pigmentation 3. diabetes mellitus 4. liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition) 5. Cardiac failure (2nd to dilated cardiomyopathy) 6. Hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism) 7. Arthritis (especially of the hands)

Question 30

Signs and symptoms of acute appendicitis?

Answer 30

Abdominal pain is seen in the vast majority of patients: - Peri-umbilical abdominal pain (visceral stretching of appendix lumen and appendix is midgut structure) radiating to the right iliac fossa (RIF) due to localised parietal peritoneal inflammation. - The migration of the pain from the centre to the RIF has been shown to be one of the strongest indicators of appendicitis. patients often report the pain being worse on coughing or going over speed bumps. Children typically can't hop on the right leg due to the pain. Other features: - Vomit once or twice but marked and persistent vomiting is unusual - Diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation of some loose stools. A pelvic abscess may also cause diarrhoea - Mild pyrexia is common - temperature is usually 37.5-38oC. Higher temperatures are more typical of conditions like mesenteric adenitis - Anorexia is very common. It is very unusual for patients with appendicitis to be hungry - Around 50% of patients have the typical symptoms of anorexia, peri-umbilical pain and nausea followed by more localised right lower quadrant pain

Question 31

What are the examinations performed in suspected appendicits?

Answer 31

Examination: - Generalised peritonitis if perforation has occurred or localised peritonism - Retrocaecal appendicitis may have relatively few signs - Digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even right-sided tenderness with a pelvic appendix - Rovsing's sign (palpation in the LIF causes pain in the RIF) is now thought to be of limited value

Question 32

What is the management of appendicitis?

Answer 32

1. Appendicectomy which can be performed via either an open or laparoscopic approach. Laparoscopic appendicectomy is now the treatment of choice! 2. Administration of prophylactic intravenous antibiotics reduces wound infection rates. 3. Patients with perforated appendicitis (typical around 15-20%) require copious abdominal lavage. 4. Patients without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy. 5. be wary in the older patients who may have either an underlying caecal malignancy or perforated sigmoid diverticular disease. trials have looked at the use of intravenous antibiotics alone in the treatment of appendicitis. The evidence currently suggests that whilst this is successful in the majority of patients, it is associated with a longer hospital stay and up to 20% of patients go on to have an appendicectomy within 12 months.

Question 33

Colicky abdominal pain RUQ, worse postprandially, worse after fatty foods

Answer 33

Biliary colic

Question 34

Triad of symptoms seen in Budd-Chiari syndrome?

Answer 34

Budd-Chiari syndrome presents with the triad of sudden onset abdominal pain, ascites, and tender hepatomegaly. Budd-Chiari syndrome is a condition characterized by obstruction to hepatic venous outflow. It usually occurs in a patient with a hypercoagulative state (e.g. antiphospholipid syndrome) but can also occur as a result of physical obstruction (e.g. tumour). The venous congestion can cause hepatomegaly and portal hypertension which can can also result in splenomegaly and ascites.

Question 35

What is the test to detect for H.pylori?

Answer 35

Testing for H. pylori infection: Initial diagnosis: NICE recommend using a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology 'where its performance has been locally validated' Test of cure: - there is no need to check for H. pylori eradication if symptoms have resolved following test and treat - however, if repeat testing is required then a carbon-13 urea breath test should be used

Question 36

How long must symptoms be present for to diagnose IBS?

Answer 36

The diagnosis of IBS should be considered if the patient has had the following for AT LEAST 6 MONTHS: 1. abdominal pain, and/or 2. bloating, and/or 3. change in bowel habit A positive diagnosis of IBS should be made if the patient has abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to 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 Features such as lethargy, nausea, backache and bladder symptoms may also support the diagnosis

Question 37

Investigations for IBS in primary care setting?

Answer 37

Suggested primary care investigations are: - Full blood count - ESR/CRP - Coeliac disease screen (tissue transglutaminase antibodies)

Question 38

Risk factors for diverticulosis?

Answer 38

Diverticulosis is an extremely common disorder characterised by multiple outpouchings of the bowel wall, most commonly in the sigmoid colon. Risk factors: - Increasing age - Low-fibre diet Diverticulosis can present in a number of ways: - Painful diverticular disease: altered bowel habit, colicky left sided abdominal pain. A high fibre diet is usually recommended to minimise symptoms

Question 39

What is the presentation for dicerticulitis?

Answer 39

One of the diverticular become infected. The classical presentation is: 1. Left iliac fossa pain and tenderness 2. anorexia, nausea and vomiting 3. diarrhoea 4. features of infection (pyrexia, raised WBC and CRP) Management: - mild attacks can be treated with oral antibiotics - more significant episodes are managed in hospital. Patients are made nil by mouth, intravenous fluids and intravenous antibiotics (typical a cephalosporin + metronidazole) are given Complications of diverticulitis include: - abscess formation - peritonitis - obstruction - perforation

Question 40

Causes of liver cirrhosis?

Answer 40

- Alcohol - Non-alcoholic fatty liver disease (NAFLD) - Viral hepatitis (B and C)

Question 41

Investigation to detect liver cirrhosis?

Answer 41

Transient elastography is now the investigation of choice to detect liver cirrhosis Brand name 'Fibroscan' uses a 50-MHz wave is passed into the liver from a small transducer on the end of an ultrasound probe measures the 'stiffness' of the liver which is a proxy for fibrosis

Question 42

What causes c.diff infection?

Answer 42

Clostridium difficile is a Gram positive rod often encountered in hospital practice. It produces an exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous colitis. Clostridium difficile develops when the normal gut flora are suppressed by broad-spectrum antibiotics. Clindamycin is historically associated with causing Clostridium difficile but the aetiology has evolved significantly over the past 10 years. Second and third generation cephalosporins are now the leading cause of Clostridium difficile. Other than antibiotics, risk factors include: - proton pump inhibitors Features: - diarrhoea - abdominal pain - a raised WBC count is characteristic - if severe toxic megacolon may develop Diagnosis: - is made by detecting Clostridium difficile toxin (CDT) in the stool - Clostridium difficile antigen positivity only shows exposure to the bacteria, rather than current infection

Question 43

What is the first line drug for c.diff infection?

Answer 43

First episode of C. difficile infection: 1. First-line therapy is oral Vancomycin for 10 days 2. second-line therapy: oral Fidaxomicin 3. Third-line therapy: oral vancomycin +/- IV metronidazole

Question 44

Toxic megacolon is associated more commonly in which conditions?

Answer 44

Toxic megacolon is an acute form of colonic distension. It is characterized by a very dilated colon (megacolon), accompanied by abdominal distension (bloating), and sometimes fever, abdominal pain, or shock. Toxic megacolon is usually a complication of inflammatory bowel disease, such as ulcerative colitis and, more rarely, Crohn's disease, and of some infections of the colon, including Clostridium difficile infections, which have led to pseudomembranous colitis.

Question 45

What are the risk factors for Barrett's esophagus?

Answer 45

- Gastro-oesophageal reflux disease (GORD) is the single strongest risk factor - male gender (7:1 ratio) - smoking - central obesity

Question 46

What is the investigation performed for suspected coeliac disease?

Answer 46

Coeliac disease is caused by sensitivity to the protein gluten. Repeated exposure leads to villous atrophy which in turn causes malabsorption. Conditions associated with coeliac disease include dermatitis herpetiformis (a vesicular, pruritic skin eruption) and autoimmune disorders (type 1 diabetes mellitus and autoimmune hepatitis). If patients are already taking a gluten-free diet they should be asked, if possible, to reintroduce gluten for at least 6 weeks prior to testing. Immunology: - Tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE - Endomyseal antibody (IgA) Duodenal biopsy: - villous atrophy - crypt hyperplasia - increase in intraepithelial lymphocytes - lamina propria infiltration with lymphocytes

Question 47

What are the causes of Ascites with a serum-ascites albumin gradient (SAAG) <11 g/L?

Answer 47

A low SAAG (<11g/L) suggests the ascitic fluid is an EXUDATE. - Malignancy - Infection - Pancreatitis - Nephrotic syndrome

Question 48

What are the causes of Ascites with a serum-ascites albumin gradient (SAAG) >11 g/L?

Answer 48

A high SAAG (>11g/L) indicates PORTAL HYPERTENSION. The ascitic fluid is a TRANSUDATE. - Liver cirrhosis - Hepatic failure - Cardiac ascites - Venous occlusion (e.g. Budd Chiari syndrome) - Alcoholic hepatitis - kwashiorkor malnutrition.

Question 49

Triad of Plummer-Vinson syndrome?

Answer 49

Triad of: - Dysphagia (secondary to oesophageal webs) - Glossitis - Iron-deficiency anaemia

Question 50

Treatment with which drug is associated with a high risk of Clostridium difficile?

Answer 50

Clindamycin

Question 51

What is the management to eradicate H.pylori?

Answer 51

Eradication may be achieved with a 7 day course of: a proton pump inhibitor + amoxicillin + clarithromycin OR a proton pump inhibitor + metronidazole + clarithromycin

Question 52

Rovsing's sign

Answer 52

positive if palpation of the left lower quadrant of the abdomen increases the pain felt in the right lower quadrant. This may be an indicator of appendicitis, although it is not positive in all cases.

Question 53

Psoas sign/ Cope's test

Answer 53

Patient lies on their left side and the clinician extends the right hip with the knee fully extended. Abdominal pain on this movement indicates irritation of iliopsoas and possible appendicitis. This test usually indicates an appendix that lies in the retrocaecal position.

Question 54

McBurney's point location?

Answer 54

The site where the pain from appendicitis is usually most severe on palpation. The point is on the right side of the abdomen, approximately one-third of the distance from the anterior superior iliac spine to the umbilicus

Question 55

Which antibody is characteristically associated with primary biliary cholangitis?

Answer 55

Anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific for primary biliary cholangitis.

Question 56

What is achalasia?

Answer 56

Esophageal achalasia is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter (LES). It is characterized by incomplete LES relaxation, increased LES tone, and lack of peristalsis of the esophagus (inability of smooth muscle to move food down the esophagus) in the absence of other explanations like cancer or fibrosis. Achalasia is characterized by difficulty in swallowing, regurgitation, and sometimes chest pain. Unknown underlying cause.

Question 57

What is achalasia?

Answer 57

Esophageal achalasia is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter (LES). It is characterized by incomplete LES relaxation, increased LES tone, and lack of peristalsis of the esophagus (inability of smooth muscle to move food down the esophagus) in the absence of other explanations like cancer or fibrosis. Achalasia is characterized by difficulty in swallowing, regurgitation, and sometimes chest pain. Unknown underlying cause. Dysphagia equally to BOTH SOLIDS AND LIQUIDS from the outset is suggestive of achalasia. A barium swallow which shows a grossly expanded oesophagus that tapers at the lower oesophageal sphincter ('bird's beak' appearance) confirms the diagnosis.

Question 58

What is seen in barium enema in Ulcerative colitis?

Answer 58

- Loss of haustrations - superficial ulceration, 'pseudopolyps' - Long standing disease: colon is narrow and short -'Lead pipe colon'

Question 59

What is the most common extra-intestinal feature in both crohn's and UC?

Answer 59

Arthritis is the most common extra-intestinal feature in both CD and UC.

Question 60

Which features are common to both CD and UC? which features are found more in one than the other?

Answer 60

Common: - Diarrhea - erythema Nodosum - Arthritis - Pyoderma gangrenosum UC (more common features): - Ileocaecal valve to rectum. CONTINUOUS disease - No inflammation beyond SUBMUCOSA, crypt abscess - Bloody diarrhea - Primary sclerosing cholangitis - Uveitis - Colorectal Cancer CD (more common features): - Non bloody diarrhea - Weight loss - Abdominal pain - Mouth to anus, SKIP LESIONS - Inflammation all layers. Goblet cells, granulomas - Bowel obstruction, FISTULA

Question 61

Examples of proton pump inhibitors?

Answer 61

Proton pump inhibitors (PPI) cause irreversible blockade of H+/K+ ATPase of the gastric parietal cell. Examples include Omeprazole and Lansoprazole.

Question 62

Comparison of CD and UC:

Answer 62

CD: - Diarrhoea usually non-bloody - Weight loss more prominent - Upper gastrointestinal symptoms, mouth ulcers, perianal disease - Abdominal mass palpable in the right iliac fossa - Obstruction, fistula - Lesions may be seen anywhere from the mouth to anus. Skip lesions may be present - Inflammation in all layers from mucosa to serosa - Deep ulcers, skip lesions - 'COBBLE-STONE' appearance Small bowel enema: - strictures: 'Kantor's string sign' - 'rose thorn' ulcers - fistulae UC: - Bloody diarrhoea more common - Abdominal pain in the left lower quadrant - Tenesmus - PSC more common - Risk of colorectal cancer high in UC than CD - Inflammation always starts at rectum and never spreads beyond ileocaecal valve. Continuous disease - No inflammation beyond submucosa (unless fulminant disease) - Barium enema: - loss of haustrations - superficial ulceration, 'pseudopolyps' - long standing disease: colon is narrow and short -'Lead Pipe colon'

Question 63

Wernicke's encephalopathy is due to a deficiency of?

Answer 63

Wernicke's encephalopathy is a neuropsychiatric disorder caused by thiamine (vitamin B1) deficiency which is most commonly seen in alcoholics.

Question 64

What is the classical triad of wernicke's encephalopathy?

Answer 64

Classically, Wernicke encephalopathy is characterised by the triad 1. Ophthalmoplegia/nystagmus 2. Ataxia 3. Confusion.

Question 65

Which drug is contraindicated in parkinsonism for GORD?

Answer 65

Metoclopramide. As metoclopramide is a dopamine antagonist it may worsen symptoms in patients with Parkinson's disease. Metoclopramide is a D2 receptor antagonist* mainly used in the management of nausea. Other uses include: gastro-oesophageal reflux disease prokinetic action is useful in gastroparesis secondary to diabetic neuropathy Adverse effects: 1. extrapyramidal effects: oculogyric crisis. This is particularly a problem in children and young adults 2. hyperprolactinaemia 3. tardive dyskinesia 4. parkinsonism

Question 66

Which other cancer is commonly associated with HNPCC besides colorectal ca?

Answer 66

Endometrial cancer. HNPCC, an autosomal dominant condition, is the most common form of inherited colon cancer. Patients with HNPCC are also at a higher risk of other cancers, with endometrial cancer being the next most common association, after colon cancer.

Question 67

H.Pylori is mostly strongly associated with which condition?

Answer 67

Associations: 1. Peptic ulcer disease (95% of duodenal ulcers, 75% of gastric ulcers) - gastric cancer - B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of patients) - atrophic gastritis

Question 68

Example of Aminosalicylate drug? (used for IBD)

Answer 68

Mesalazine - mesalazine is still however associated with side-effects such as GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis Sulphasalazine - a combination of sulphapyridine (a sulphonamide) and 5-ASA

Question 69

Antibody found in PBC?

Answer 69

Anti-mitochondrial antibodies

Question 70

What is triple therapy for H.Pylori eradication? 'Test and treat'

Answer 70

Triple therapy after positive H.pylori test: PPI and 2 antibiotic combination for 1 week. - Lansoprazole - Amoxicillin - Clarithromycin If H.Pylori test negative then give acid suppression alone (omeprazole or ranitidine).

Question 71

First line treatment for primary biliary cholangitis?

Answer 71

Ursodeoxycholic acid. Pruritus: cholestyramine

Question 72

Investigation for carcinoid syndrome?

Answer 72

Carcinoid syndrome: usually occurs when metastases are present in the liver and release serotonin into the systemic circulation. Flushing (often the earliest symptom) Diarrhoea Bronchospasm Hypotension Ix: Urinary 5-HIAA Mx: Somatostatin analogues e.g. Octreotide

Question 73

Clotting factor results seen in liver failure?

Answer 73

Liver failure: all clotting factors are low except for factor VIII which is high. This is because factor VIII is synthesised in endothelial cells throughout the body, unlike the other clotting factors which are synthesised purely in hepatic endothelial cells.

Question 74

Which TB medication causes peripheral neuropathy?

Answer 74

Isoniazid. Usually, prophylactic pyridoxine is prescribed at the same time as Isoniazid to prevent the peripheral neuropathy.

Question 75

Transformation in Barrett's oesophagus?

Answer 75

Barrett's oesophagus is a condition in which the normal squamous epithelium of the oesophagus is replaced by columnar epithelium. typically as a result of chronic gastro-oesophageal reflux disease (GORD).

Question 76

Antibody tested for pernicious anaemia?

Answer 76

Anti intrinsic factor antibodies: sensivity is only 50% but highly specific for pernicious anaemia (95-100%)