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RACP Written Exam 2021 > Gastroenterology > Flashcards

Gastroenterology Flashcards

(63 cards)

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1
Q

Indications for treatment in Haemachromatosis either with;

  • Phlebotomy
  • Chelation (if unable to undergo phlebotomy)
A

Ferritin persistently > 500 (Absolute if >1000)
End Organ involvement
- Liver: LFT derangement, biopsy or MRI
- Cardiac: MRI

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2
Q

Indications for Liver Biopsy in Haemachromatosis

A

Abnormal LFTs
Ferritin >1000
Hepatomegaly or other signs of CLD

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3
Q

Indications for chelation

A

Phelbotomy contraindicated

  • Severe Anaemia
  • Haemodynamic Compriomise
  • Limited life expectancy
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4
Q

Findings of NASH on liver biopsy

A

Hepatic Steatosis
Hepatic Ballooning
Hepatic lobular degeneration

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5
Q

Findings of NAFL on liver biopsy

A

Steatosis with hepatocyte balling or portal inflammation (but not both)

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6
Q

Findings of Cirrhosis on liver biopsy

A

Bridging fibrosis

Stellate cell activation

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7
Q

Findings of PBC on liver biopsy

A

Peri-portal inflammation

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8
Q

Findings of ASH on liver biopsy

A

Steatosis

Mallory Hyaline bodies

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9
Q

Findings of AIH on liver biopsy

A

Interface hepatitis

Portal tract inflammation (lymphocytic, plasma cells and multinucleate giant cells)

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10
Q

HCC screening surveillance benefit

A 
Hepatitis B carriers
 - Asian males >40 
 - Asian females > 50 
 - Family hx of HCC 
 - With cirrhosis 
African/North American blacks with Hep B 
Cirrhosis 
 - Hepatitis C cirrhosis 
 - Genetic Haemachromatosis
- Alpha 1 antitrypsion 
Stage 4 PBC
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11
Q

HCC screening algorithm

A

6 monthly ultrasound +/- AFP
Lesion found of US
<1cm: Repeat U/S in 3 months
>1cm: CT or MRI

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12
Q

Primary Billiary Cirrhosis diagnostic criteria

A

2/3

  • ALP elevated
  • AMA elevated
  • Histology of biopsy (Peri-portal inflammation)
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13
Q

Treatment for PBC

A

Urosodeoxycholic Acid

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14
Q

Main side effects of PPI’s (eight)

A

1) Pneumonia
2) Gastroenteritis
3) Osteoperosis
4) Hypomagnasaemia
5) Interstitial nephritis
6) Microscopic colitis
7) C Diff Colitis (more likely to get recurrent C Diff colitis if on PPI)
8) Hypergastrinaemia - unknown clinical effect

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15
Q

Diagnosis of Zollinger Ellison Syndrome

A

1) Fasting Gastrin >10000
2) Gallium 68 Dotate CT-PET

Note: 1/3 patients with ZE have MEN 1

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16
Q

Diagnostic test for chronic pancreatitis

A

Faecal elastase

Note Faecal elastase is not disrupted by creon.

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17
Q

Hereditary pancreatitis

A

Autosomal dominant
Recurrent mild attacks of pancreatitis age > 5
Chromosone 7q35

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18
Q

Pre-malignant pancreatic cysts

A

1) IPMN: Location - head of pancreas
2) MCN: Tail of pancreas.

Both Mucin producing and pre-malignant

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19
Q

Risk factors for pancreatic cancer

A 
1) Modifiable 
> Smoking 
2) Non-modifiable 
> Cystic Fibrosis 
> BRCA1/2
> Lynch Syndrome 
> FAMMM
> Hereditary pancreatitis
> Peutz-Jeghers syndrome 
> Familial history of pancreatic cancer
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20
Q

Findings of Esophageal Eosinophilia on histology

A

> or equal to 15 intraepithelial eosinophils per high powered field

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21
Q

Finding on biopsy of IBD

A

Architectural change

Lymphoplasmacit infiltrate

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22
Q

Which gene is associated with chrons disease

A

NOD2

They have more fibrostenotic complications of the bowel

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23
Q

Smoking effect on CD vs UC

A

CD:

  • Refractory
  • Fistulising disease
  • Surgical recurrence

–> smoking cessation is a therapy for CD

UC
- protective

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24
Q

Which subset of IBD has the worst risk of cancer?

A

Patients with PSC

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25
Colonoscopy's in patient sixth IBD
3 yearly baseline (Commence 8 years after diagnosis) Annually - PSC - Fhx CRC in first degree relative <50 yo - Colonic stricture or multiple pseudopolyps - Active Disease - Prvious dysplasia
26
ASCA vs ANCA for differentiating UC from CD
``` pANCA+/ASCA- = Ulcerative Colitis ASCA+/pANCA- = Chrons Disease ```
27
Therapy for UC
First line: 5ASA (oral + rectal) Second line: Thiopurines (if patients need more than 1 Course of steroids in a year) Third line: Infliximab/Vedolizumab Can use corticosteroids
28
Chron's Disease therapy
Individualised approach Treat to target approach Steroids: Induction Steroid sparing agents: Thiopurines, methotrexate ASA not effective
29
Adverse effects of ASA
Intersitial nephritis (annual UEC) Diarrhoea Azospermia (reversible)
30
Steroids in IBD
Only for induction, not for maintenance Prednisolone 40mg/day with slow taper Nb Budesonide good in mild ileocolonic CD or UC - releases at the ileum with high first pass metabolism (not on the PBS)
31
Risk of elevated 6MMPR metabolite
Hepatoxicity (measure metabolites) Measure TPMT prior to commencement, rationale being that if there are low TPMT they are at risk of rapid leukopenia. Heterozygotes - half the dose
32
Which metabolites of Azathioprine has a therapeutic effect in IBD
TGN
33
Adverse effects of thiopurines
1) Myelo suppression 2) Hepatitis 3) Pancreatitis 4) Nausea/Vomiting 5) Lymphoma - hepatosplenic t-cell lymphoma 6) Non-melanoma skin cancers
34
Thiopurine metabolite testing
High MMP, Low TGN = shunter | Given allopurinol
35
Which drugs are responsible for hepatosplenic t-cell lymphoma in young males with IBD?
Thipurine + Anti-TNF
36
What does adalimumab target
TNF (anti-tif drug)
37
Vedolixumab better in CD or UC?
UC
38
Ustekinimab use in Australia
CD
39
Anti-TNF drugs for fistulizing CD
1) Infliximab or adalimumab
40
Adverse effects of Anti-TNF
1) Reactivate TB (need screening prior) 2) Lymphoma 3) Melanoma (!!!) 4) Demyelinating disorders 5) Lupus like syndrome 6) Heart failure in pre-existing NYHA 3-4
41
Vedolizumab mechanism of action
Blocks alpa4beta7-MADCAM which stops diapesis of the T cells into the gut tissue Gut specific = no systemic immunosuppression UC or CD
42
Ustekinumab mechanism of action
Blocks IL12/23 via p40 subunit
43
Biologics in IBD
TNF blockers Vedolizumab Ustekinumab
44
Only indication for Fecal transplant (FMT)
Refractory C.Diff
45
Which treatments for IBD increase risk of skin cancer?
1) TNF: Melanoma | 2) Thiopurines: Non-melanomatous skin cancer
46
Acute severe ulcerative colitis
Initially 1) QID hydrocortisone 2) Clexane 3) IV Fluids 4) Aim HB>100 Flexible sigmoidoscopy for CMV No response at 3-5 days 1) Surgery Nb: Mortality = 1%
47
Which treatment do you start in peri-anal disease with CD
Anti-TNF (Infliximab)
48
Indication for C-section in patients with CD
Active perianal disease
49
Safest biologic during pregnancy
Anti-TNF
50
Vaccinations at diagnosis for patients with IBD
"the big five" 1) Hep B 2) HPV 3) VZV - note live and therefore not able to be given on immunomodulator 4) Pneumococus 5) Infuenza
51
Indications for 6 monthly ultrasound screening in Hep B
1) Cirrhosis 2) Asian male >40 3) Asian female >50 4) African descent 5) HBD + 6) First degree family member with HCC
52
Treatment indications for Chronic Hep B
1) HBE Ag+ - HBV >20,000 DNA - ALT > 2 times ULN 2) HBE Ag- - HBV >2,000 - ALT >2 times ULN
53
Which is the most suggestive of chron's disease over ulcerative colitis?
Perianal fistula
54
Best first test in patient with chronic diarrhoea?
Fecal calprotectin (released by neutrophils migrating into the lumen) Early predictor of flares
55
Which extraintestinal manifestation is most highly associated with disease activity in CD
large joint arthritis (knees, hands and wrists)
56
Treatment for Pyoderma Gangrenosum
Topical steroids | Topical Tacrolimus
57
Treatment for PSC
Liver Transplant
58
HLH On azathioprine (thiopurines)
Commonly triggered by EBV infection
59
Oxford criteria for failure of treatment for acute sever UC
- >8 stools per day - Ongoing blood in stool - CRP > 44
60
How does Vedolizumab act?
Binds to and inhibits alpha 4 beta 7 trafficking into the gut
61
Follow up colonoscopy for > 1-2 adenomas <10mm with no villous/high grade dysplasia > 3-4 or any with villous, high grade dysplasia or >10mm > 5-9 > 10+
``` As per the Cancer Council Guidelines > 1-2: 5 years > 3-4 or concerning features: 3 years > 5-9: 1 year > 10+: <1 year ```
62
Grades of immunotherapy induced colitis (number of stools greater than normal)
``` > Grade 1: < 4 movements/day > Grade 2: 4-6 bowel movements/day > Grade 3: 7 bowel movements/day > Grade 4: Life threatening hypovolaemia or electrolyte disturbance > Grade 5: Death ```
63
Treatment for checkpoint induced colitis
Always exclude infectious cause of diarrhoea Grade 1: Symptomatic management (loperamide), continue ICI Grade 2: Observation, withhold ICI Grade 3: Oral prednisone 1mg/kg, withhold ICI (asses response at D5) Grade 4: IV methylprednisone 1mg/kg, withhold ICI (assess response at D3) If failure to improve at the discussed reassessment period (usually 72 hours) then consider starting steroid sparing agent, i.e Infliximab at 5mg/kg. There can be two doses of Infliximab given. For grades 3-4 checkpoint inhibitors should be permanently discontinued.

RACP Written Exam 2021 (18 decks)

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