BMJ Qs 1

Question 1

Hydatid disease

Answer 1

Tapeworm Echinococcus granulous
Welsh farmer
On ERCP we can see cystic compression of the biliary tree
Benzimidazole

Question 2

Hepatic abscess

Answer 2

Streptococcus milleri
Ameba
Clue ^Temp ^WBC

Question 3

Alcoholic hepatitis

Answer 3

Tender hepatosplenomegaly and fever are consistent with a diagnosis of alcoholic hepatitis, which frequently occurs on a background of cirrhosis.
Lab: leucocytosis, low platelets, ^ MCV

Liver function tests typically show an AST elevated greater than the ALT with at least a 2:1 ratio, transaminases are typically only slightly elevated; rarely over 300 and virtually never over 500. The alkaline phosphatase may well be significantly elevated giving the liver profile an ‘obstructive’

Question 4

Liver mass on CT

Answer 4

Cholangiocarcinoma

Question 5

Liver cysts

Answer 5

Poly cystic liver disease
Hydatidic disease

Question 6

SBP

Answer 6

Bacteria

Question 7

Medications that causes cholestasis

Answer 7

Co-amoxiclav

Question 8

Response t IF in Hep. c

Answer 8

Favorable : Genotypes 2-3
Female
Young
Non -Black age
4 Repetic iro
No cirrhosis

Question 9

Haemochromatosis

Answer 9

aim
lower end of normal range
1 Ferritin < 50 ug | L

Question 10

PBC

Answer 10

primary biliary cirrhosis presents with tiredness and itching, in association with clinical (splenomegaly) and biochemical pancytopenia) evidence of portal hypertension

Question 11

Campylobacter infection and others

Answer 11

pain in their right iliac fossa is a prominent feature
Reactive arthritis can develop following infection with a number of enteric pathogens including Shigella, Salmonella, Campylobacter and Yersinia

Question 12

Gastric adenomas

Answer 12

Neoplastic progression is greater with polyps larger than 2 cm in diameter
occurs in
28.5-40% of villous adenomas
5% of tubular adenomas

Current BSG guidance

Question 13

Wernicke’s encephalopathy

Answer 13

confusion, oculomotor signs, and ataxia affecting gait and stance

Wernicke’s encephalopathy is a medical emergency, requiring urgent intravenous thiamine, Vitamin B1.
The episode has been precipitated by intravenous dextrose administration which has exhausted his vitamin B reserves, hence B vitamins must be administered to all alcoholic patients requiring dextrose

Question 14

Multiple endocrine neoplasia

Answer 14

Hypergastrinaemia may be the cause of the diarrhoea.
There is also hypercalcaemia as a result of the parathyroid hyperplasia indicative of this condition. There may not necessarily be a family history, sporadic cases make up 10% of new cases.
The infertility would fit with a prolactinoma

Question 15

Pancreatitis acute

Answer 15

A poor prognostic indicator in the first 48 hours of acute pancreatitis include calcium <2 mmol/L

Poor prognostic indicators in the first 48 hours of acute pancreatitis include:
Age >55 years
WCC >15 ×109/L
Glucose >10 mmol/L
Urea >16 mmol/L
Albumin <30 g/L
AST >200 U/L
Calcium <2 mmol/L
LDH >600 U/L
PaO2 <8 kPa

Question 16

Barrett’s oesophagus surveillance

Answer 16

low-grade dysplasia
repeat endoscopy in 6 months

Question 17

Secretin CCK Gastrin VIP

Answer 17

Secretin is secreted from the small intestine when there is acid in the small intestine. It inhibits gastric motility and acid production and stimulates bicarbonate secretion from the pancreas and liver.
CCK stimulates gallbladder emptying and pancreatic enzyme release.
Gastrin stimulates gastric acid secretion and gastric motility.
Motilin stimulates intestinal peristalsis.
VIP induces smooth muscle relaxation, stimulates secretion of water into pancreatic juice and bile, and causes inhibition of gastric acid secretion; whilst in the intestine it greatly stimulates secretion of water and electrolytes

Question 18

Aorto-enteric fistula

Answer 18

The strongly positive faecal occult blood (FOB) suggests significant GI haemorrhage.
Aorto-enteric fistulae (AEF) are now known to occur following endovascular repair of abdominal aortic aneurysms (AAA) and secondary to aortic grafting of any kind, presumably because of mechanical forces of dislodged or migrating devices.
This patient may well have had an aorto-bifemoral graft as treatment for peripheral vascular disease

Question 19

Perforation

Answer 19

In this case, the clinical presentation may represent a perforation or ‘post-polypectomy syndrome.’ CT scan of the abdomen and pelvis can differentiate the two diagnoses via the absence or presence of free air

f the diagnosis is post-polypectomy syndrome (pain and inflammatory reaction to transmural diathermy injury) then this can be managed by admission and antibiotics/intravenous fluids. If perforation is detected, surgery may be required but often conservative management will be successful

Question 20

Drug reaction to nevirapine

Answer 20

Rashes are common on starting treatment with nevirapine, occurring in ~15% of patients. Acute hepatitis is also common and fatal reactions

Question 21

Paracetamol overdose

Answer 21

INR > 2.0 en las primeras 48 hours

INR >3.5 en las primeras 72 horas
Refer to specialist unit

Other factors which drive referral to a specialist unit include:
Encephalopathy or raised intracranial pressure (ICP) - signs of CNS oedema include BP >160/90 mmHg (sustained) or brief rises (systolic >200 mmHg), bradycardia, decerebrate posture, extensor spasms, and poor pupil responses
Renal impairment (creatinine >200 μmol/L) - monitor urine flow and daily U&E and serum creatinine (use haemodialysis if >400 μmol/L)
Systolic BP <80 mm Hg despite adequate fluid resuscitation
Hypoglycaemia
Metabolic acidosis (pH <7.3 or bicarbonate <18 mmol/L)

Question 22

Sigmoid volvulus

Answer 22

A sigmoid volvulus would cause large bowel obstruction

Differential diagnosis
Toxic Meg’s a colon
Intestinal pseudo-obstruction

Question 23

prescription and administration of oral bowel-cleansing agents

Answer 23

ake OCP pill as usual but take extra precautions against pregnancy for 1 week

Question 24

Ascitis of Budd-Chiari Sd

Answer 24

presentation may be less acute, sudden onset of ascites, right upper quadrant pain and nausea is characteristic The ascites is associated with portal hypertension as indicated by a serum-ascites albumin gradient (SAAG) >11 g/L. Hepatomegaly is present due to venous congestion of the liver and the transaminases are usually only mildly deranged.

Question 25

Cerebral abscess

Answer 25

The combination of fever and focal neurological signs makes a cerebral abscess the most likely diagnosis here.The history of alcohol abuse is a risk factor

Question 26

Mixed essential cryoglobulinaemia in Hep C

Answer 26

This gentleman has renal failure with evidence of a primary renal pathology: significant proteinuria, relative hypertension

condition is associated with renal impairment, systemic vasculitic manifestations (including neuropathy, skin manifestations), and arterial thrombosis

Urine dipstick
+++Proteinuria indicates primary renal pathology