Gasteroenterology Flashcards
Give two signs Coeliac disease is often associated with.
Iron deficiency anaemia
Non specific diarrhoea
How do we test for Coeliac disease?
Using tTG IgA antibodies
tTG = Tissue transglutaminase antibody
; Coeliac disease is autoimmune
What is the Gold standard for diagnosing Coeliac disease?
Give two features you may see.
Duodenal biopsy.
Villus atrophy (smaller villi).
Crypt hyperplasia
What is IBD?
Inflammatory bowel disease.
Umbrella term for Crohn’s disease and Ulcerative Colitis.
Inflammation of the GI Tract.
What are Crohn’s and Ulcerative Colitis NOT?
IBS
Give two differences between Ulcerative Colitis and Crohn’s disease?
Crohn’s disease = affects the entire GI tract and is transmural inflammation.
Ulcerative Colitis = only affects the large colon and there is no inflammation beyond the submucosa. Starts working from the rectum upwards.
How does smoking affect Crohn’s disease and Ulcerative Colitis risk?
Smoking increases the risk of Crohn’s disease.
Smoking decreases the risk of Ulcerative Colitis.
Which medication increases the risk of Crohn’s disease/Ulcerative Colitis?
NSAIDs
Give one key sign of IBD.
Erythema nodosum
What is the Gold standard in diagnosing Crohn’s disease?
Colonoscopy (cobblestone appearance)
What is the Gold standard in diagnosing Ulcerative Colitis?
Colonoscopy and biopsy. (need biopsy in UC!)
How do we treat Crohn’s disease?
Stop smoking
Corticosteroids to reduce inflammation: Prednisolone/ Budenoside
Aminosalicylate, azathioprine
For maintenance: Azathioprine.
How do we treat Ulcerative Colitis?
5- ASAs. Topical then oral.
In acute admission of UC, treat as an emergency with:
IV Corticosteroids/Ciclosporin/infliximab
What is the Gold standard in diagnosing Colorectal Carcinoma?
Colonoscopy and biopsy.
What is the acronym in identifying Red flag symptoms?
Fatigue Lethargy Appetite loss Weight loss Sweats (night)
What is one clear way to differentiate between gastric and duodenal ulcers?
Gastric = worse after eating Duodenal = relieved by eating
What are patients with Ulcerative Colitis at risk of even once treated?
Adenocarcinoma so give regular colonoscopies after 10 years.
osce question. How do we investigate for a suspected peptic ulcer?
Full Blood count
U&Es for dehydration/ bleed
Upper GI endoscopy
Biopsy
What is the main treatment for peptic ulcers
PPIs.
What is a key feature in a history which may indicate pancreatitis?
Heavy drinking
Epigastric pain radiating to the back - what are 2 key differentials?
AAA - Abdominal aortic aneurysm
Pancreatitis.
What are the investigations to look at in acute pancreatitis?
Amylase
Lipase
Ultrasound for ?gallstone
What are the two most common causes of acute pancreatitis?
Heavy drinking
Gallstones
What are the key markers in acute pancreatitis Vs. chronic pancreatitis?
Acute = high amylase Chronic = reduced elastase
With pancreatitis, what are some key features we will see in the presentation?
Epigastric pain
Steatorrhoea
Diabetes; pancreas makes insulin!
Which is the one DNA Hepatitis type?
Hepatitis B
What is the Gold standard in diagnosing Cirrhosis?
Biopsy
When will you see Hepatitis D?
Only if patient already has hepatitis B!
When may someone have negative IgG but still have antibodies?
Vaccination
What is Cirrhosis?
Chronic liver disease where we see diffuse fibrosis.
With weight loss in a gastroenterology history, which differential diagnoses should you think of?
Coeliac disease/ Crohn’s disease.
What do Crohn’s and Coeliac most commonly present with?
Iron deficiency anaemia.
Which is the gold standard first test for coeliac disease?
Small bowel biopsy. IgA tTG (tissue transglutaminase) also used in Coeliac disease.
Which medications are used primarily in GORD?
Proton pump inhibitors
High iron, high ferritin and low TIBC indicates what diagnosis?
Primary haemochromatosis.
Give some features of primary haemochromatosis.
Hepatomegaly, arthralgia, tiredness.
Autosomal recessive
Treat with venesection to reduce iron/ ferritin.
A carcinoma of a gastrological cause should only be considered given which sign?
Weight loss.
Which additional test should we definitely request to assess liver function?
Blood glucose.
How do we treat oesophageal varices?
Band Ligation.
Beta blockers
High GGT (gamma GT) and High MCV are indicative of what?
Alcohol misuse.
Wernicke’s encephalopathy may be due to what?
Vitamin B12 Deficiency
What is Wernicke’s encephalopathy?
Ataxia
Confusion
Nystagmus
Which are the most important tests to request in liver failure?
ANA (antinuclear antibodies) and SMA (smooth muscle antibodies). = excludes autoimmune hepatitis.
Is the prognosis for pancreatic cancer good or bad?
Bad; less than 2% for 5-year survival.
What is PBC?
Which markers will be increased?
Primary biliary cholangitis = cirrhosis of the liver.
High AST, ALT, gamma-GT (GGT).
What is a contraindication to performing a biopsy?
Low platelets, high INR; puts them in danger from bleeding excessively.
Name three signs associated with PBC (primary biliary cirrhosis).
Jaundice
Spider naevi
Splenomegaly
Jaundice
Name two signs associated with chronic pancreatis. (Where would the pain be felt)?
Epigastric pain
Weight loss.
What colour is stool in steatorrhoea?
Pale stool.
Fat malabsorption.
Which is the most common cause of chronic pancreatisi?
Alcohol.
Which marker is mainly elevated in hepatocellular carcinoma?
serum Alpha-feroprotein. This is a tumour marker.
Name the three main signs of a malignant liver.
Weight loss
Jaundice
Hepatomegaly
Which hepatitis forms predispose an individual to hepatocellular carcinoma?
B/C.
Hepatitis D is found in co-infection with which other hepatitis form?
Hepatitis B.
Which forms of hepatitis are spread vertically?
Hepatitis B/C; blood borne and spread from mother to foetus.
Which hepatitis forms are spread via the faecal-oral route?
Hepatitis A and E; contaminated water.
Do vaccinations currently exist for Hepatitis C?
No. Currently only for hepatitis A and E.
On biopsy what do multiple nodules indicate?
Cirrhosis.
What is the most likely cause of haematemesis?
Oesophageal varices.
What does high anti-SMA indicate?
Autoimmune hepatitis.
What do high anti-mitochondrial antibodies indicate?
Biliary cirrhosis.
What do high transferrin levels indicate?
Haemochromatosis.
Which condition can often be mistake for a GI infection and causes thickening of the ileum/caecum?
Crohn’s disease.
Smoking aggravates Ulcerative Colitis. True or false?
False. Smoking aggravates Crohn’s disease.
How do we treat Ulcerative Colitis?
Corticosteroids.
What is the main cause of duodenal ulcers?
H.Pylori infections.
What is a measure for hepatocellular carcinoma?
Alpha fetoprotein.
When can we see Hepatitis D?
Hepatitis D can only be seen with hepatitis B.
Antimitochondrial antibodies are indicative of what?
Primary biliary cirrhosis
Hepatitis B is what kind of virus?
DNA virus
Which medication do we use to treat Gout?
Allopurinol
What is an alternative to allopurinol intreating Gout patients if they have duodenal ulcers?
Colchicine.
What causes most duodenal ulcers?
H. Pylori infection
What is a test for H.Pylori?
Urea breath test
Stool test
CLO (campylobacter like organism)
Culture
Right upper quadrant pain can present as which differentials?
Cholangitis Pancreatitis GORD Ulcers Cholecystitis.
What is acute cholangitis?
Acute inflammation of the entire biliary tree. Typically presents with Charcot’s triad.
What is Charcot’s triad?
Fever, jaundice, RUQ pain.
What is Cholangiocarcinoma?
Cancer of the bile duct trees.
What is Murphy’s sign?
RUQ tenderness on inspiration
What is Cholecystitis?
Inflammation of the gallbladder
How does acute cholecystitis present?
RUQ pain, Murphy’s sign, fever
5Fs
What is the most common cause of small bowel obstructions?
Adhesions. Surgery causes adhesions. If someone has had surgery, think of this as the cause.
What should you think of regarding surgery and the small bowel?
Adhesions.
Which is the most common cause of large bowel obstruction?
Colon cancer
Is the presentation of small bowel obstruction acute or chronic?
Acute
What is McBurney’s sign?
Pain is felt 1/3 distance between the ASIS and umbilicus.
What is a key differential of right iliac fossa pain?
Appendicitis. Often starts in the umbilicus and then moves to the RIF. Good to ask patient if they first feel pain in the umbilicus.
What is a key differential of left iliac fossa pain?
Diverticulitis
Where are diverticulae most commonly found?
In the sigmoid colon
What is the marker for colorectal cancer?
CEA - carcinoembryonic antigen.
What is the difference between the indirect and direct hernia?
Indirect = Goes through the deep ring, lateral to the epigastric vessels. Direct = Goes through the superficial ring, medial to the epigastric vessels.
To check for hernias, what do we ask the patient to do?
Cough in the abdomen.
Where is Diverticular pain felt?
Left lower abdomen.
How do we test for H.Pylori?
CLO, urea breath test.
What is a common complication of using NSAIDs?
Ulcers
What is dysentery?
Diarrhoea associated with passage of blood
What is steatorrhoea and what will the stool look like?
Fatty stool. Stool will be pale.
What is the Gold standard in diagnosing Coeliac disease?
tTG - tissue transglutaminase.
THEN biopsies.
What is Coeliac disease?
Enteropathy triggered by Gliadin in gluten.
What is a difference between UC and Crohn’s?
Crohn’s - mouth to anus.
UC - colon.
Are patchy skip lesions found in Crohn’s or UC?
Crohn’s. UC is continuous (non-stop) inflammation.
What is dysphagia?
Difficulty swallowing
Give x3 causes of dysphagia.
Oesophagitis
Peptic ulcers
Oesophageal cancer
Give 2 features of peptic ulcer disease
Worse after eating, radiates to the back.
How can we relieve symptoms from peptic ulcer disease.
Antacids
How may erythromycin concentration affect warfarin concentration?
Erythromycin is a cytochrome enzyme inhibitor = inhibits the metabolism of warfarin = INCREASES WARFARIN THERAPEUTIC EFFECT.
Which different markers do we look at for acute Vs. chronic pancreatitis?
Acute pancreatitis = check amylase
Chronic pancreatitis = check elastase
Where is pain in Crohn’s disease most commonly seen?
The right iliac fossa.
What is Murphy’s sign an indication of?
Cholecystitis
High evels of unconjugated bilirubin Vs. conjugated bilirubin could be indicative of what?
High Unconjugated bilirubin: Liver cannot conjugate fast enough = too much breakdown of Hb into bilirubin. e.g. Haemolytic anaemia. Deficiency of conjugating enzyme e.g. Gilburt’s syndrome.
High Conjugated bilirubin: liver is working (conjugating) but there is obstruction in the bile flow. e.e PBC, Gallstones
Which molecule does bilirubin derive from?
Haemoglobin.
High conjugated bilirubin can be caused by what?
Obstruction - Gallstones, primary biliary cirrhosis.
Which is more associated with ulcers - Crohn’s or UC?
Crohn’s
Which is more associated with bloody diarrhoea - Crohn’s or UC?
UC
Which is more associated with watery diarrhoea - Crohn’s or UC?
Crohn’s disease
What are the 3 signs of acute pancreatitis
Cullen’s
Grey Turner’s
Fox’s sign
Which microorganism do we associate as the cause of food poisoning?
Campylobacter Jejuni
What is cholangitis?
Inflammation of the bile duct system.
Which vertebral level is the transpyloric plane?
L1
What is the most common cause of SBO?
Adhesions (from previous surgery) and hernia
What is the most common cause of LBO?
Malignancy
What is MRCP and when is it best indicated?
Magnetic resonance cholangiopancreatography. Best at evaluating the biliary tree.
Describe where the pain of appendicitis is best felt.
Firstly central pain then spreads to the right iliac fossa.
How do we treat acute pancreatitis?
Oral feeding
IV fluids
IV analgesia
Blood gas analysis
How do we treat acute cholecystitis?
IV fluids and analgesia
90% of gallstones are asymptomatic. True or false?
True.
What is a common recurrence weeks following acute pancreatitis?
Pancreatic pseudocyst
What is Courvoisier’s Law?
Implies a diagnosis in the gallbladder other than gallstones. No pain, palpable gallbladder with jaundice.
Commonly seen in pancreatic carcinoma.
Constipation is associated with gallstones. True or false?
False.
Which test is used primarily to assess stones?
ERCP - endoscopic retrograde cholangiopancreatography.
What is MRCP commonly used for?
To assess the biliary tree.
What is one of the first diagnostic tests used to assess GI symptoms
OGD - oesophagogastroduodenoscopy
What is the standard treatment for a gastric carcinoma?
Chemotherapy. Palliative radiotherapy IF there is GI bleeding.
Constipation is associated with gallstones. True or false.
False.
Which symptoms are associated with Achalasia?
Dysphagia, cramping, weight loss.
What is important apart from weight loss to determine malignancy?
Time frame; a time frame of 6 months for example is not suggestive of malignancy.
When is barium swallow necessary?
Motility disorders e.g GORD.
Which test confirms achalasia?
Oesophageal manometry
Give 3 contraindications to a liver biopsy.
INR >1.3
Platelets <100x10^9
Extensive ascites.
Acute confusional state.
When is hepatocellular carcinoma likely as a diagnosis?
When there is already a background of chronic liver disease
What causes asterixis?
Encephalopathy due to liver failure.
When may you see angular stomatitis?
Vitamin B12 deficiency, iron deficiency anaemia.
What is Cullen’s sign?
Haemorrhagic patch around the umbilicus.
What is Grey Turner’s sign?
Bilateral flank bruising.
What is achalasia?
Disorder of the oesophagus = lower oesophageal sphincter (LOS) fails to relax.
Name two risk factors of achalasia.
Viral infections, autoimmune responses.
What are the presenting symptoms of achalasia.
Inability to swallow (dysphagia) Heartburn Coughing Chest pain Regurgitating food
What are the signs of achalasia on physical examination?
Weight loss
No specific findings otherwise
What is the incidence of achalasia?
1/100 000 incidence per year.
How do we investigate achalasia?
Gold standard = eosophageal manometry. This will show impaired relaxation of the LOS.
EGD - eosophageal gastroduodenoscopy. Dilated oesophagus indicates achalasia.
Define acute cholangitis
Inflammation of the bile duct
Give 2 risk factors of acute cholangitis.
Age >50 years
Cholelithiasis
Benign/ malignant stricture
What is Charcot’s triad?
Fever
Jaundice
RUQ pain
Where is Charcot’s triad seen?
Acute Cholangitis
What are the signs of Acute Cholangitis?
Jaundice
RUQ pain, tenderness
Pruritus
What is pruritus?
Itching of the skin
Give x3 first line investigations to consider in acute cholangitis.
FBC
Creatinine
Urea
ABG analysis
Give x3 further investigations to consider in acute cholangitis.
Abdominal CT
MRCP - magnetic resonance cholangiopancreatography
EUS - endoscopic ultrasonography
Which is the best liver marker of liver function?
INR - international normalised ratio.
Which is the best liver marker to assess liver inflammation?
AST, ALT.
How do we confirm a diagnosis of Primary biliary cirrhosis (PBC)?
Anti-mitochondrial antibodies (AMA)
Associated with other autoimmune disorders e.g. RA.
How do we confirm a diagnosis of Primary sclerosing cholangitis (PSC)?
ERCP/MRCP. Beaded bile duct appearance.
Abdominal distension and shifting dullness is suggestive of what?
Ascites.
Which is the primary test we want to use to assess ascites?
Paracentesis.
When will we see unconjugated bilirubin Vs conjugated bilirubin?
Unconjugated = Pre-hepatic, hepatocellular Conjugated = hepatocellular, intrahepatic, extrahepatic obstruction.
Give x2 causes of high unconjugated bilirubin
Haemolytic anaemia, Gilbert’s syndrome
Give x2 causes of high conjugated bilirubin
Think hepatocellular cases e.g. hepatitis, PBC (cirrhosis),
What are the different causes of epididymitis?
Epididymitis younger than 35 yrs: STI e.g. Chlamydia, Neisseria
Epididymitis older than 35 yrs: enteric bacteria e.g. E Coli.
Give x6 criteria diagnostic of ulcerative colitis.
Fever Frequency of stool >6 Bloody stool Tachycardia Raised ESR Anaemia
Are fistulae associated with Crohn’s or UC?
Crohn’s
What is an important difference to highlight with blood and stools in an abdominal history?
Is the blood on the stools or mixed in with the stools?
Which test definitively confirms colorectal carcinoma?
Colonoscopy/ sigmoidoscopy + biopsy.
CT Chest, abdomen pelvis will help stage the cancer, not confirm.
What is a good acronym for safety netting on the wards?
BODEX. Bloods Observation Drug chart ECG X-ray
What is the difference between a loop and end ileostomy?
Loop ileostomy = 2 orifices.
End ileostomy = 1 orifice.
What is an end ileostomy?
Everything distal to the ileum is removed. i.e. colectomy.
When may you need to perform an end ileostomy?
Ulcerative Colitis.
Large bowel dilatation with air in the rectum is indicative of what?
Mechanical/ Pseudo obstruction unless presenting with ischaemia/sepsis = toxic megacolon.
How can we differentiate between the small and large bowel on abdo x ray?
small - valvulae conniventes (go all the way round bowel).
large - haustra
What is the difference between direct and indirect hernias?
Direct = exit the abdomen via the superficial ring only. Indirect = exit the abdomen via the superficial and deep ring.
Which are more common - inguinal or femoral hernias?
Inguinal hernias.
How do we initially treat small bowel obstruction?
Analgesia
IV fluids; big issue in SBO is severe dehydration.
NG tube (decompresses the stomach).
Nil by mouth
What is the main issue with SBO initially?
Patient will be severely dehydrated.
On the abdominal x ray, which sign will show dilatation of the small bowel?
Valvulae conniventes - lines that extend across the whole way. Haustra do not.
What is sigmoid volvulus?
Obstruction within the sigmoid colon.
Which initial test is necessary in bowel obstruction?
As well as an xray, a DRE!
DRE is needed to exclude a rectal lesion.
Toxic megacolon usually involves which part of the colon?
The transverse colon.
The coffee bean sign on an abdominal radiograph is usually seen in which pathology?
Sigmoid volvulus.
Google coffee bean sign if unsure!
Which is the most commonly injured solid organ in the abdomen?
Spleen.
Sigmoid colonic resection can be used for which procedure? Think location.
Left lower flank = diverticular disease.
How would we differentiate between small bowel obstruction and small bowel ileus clinically?
Small bowel obstruction would present with bowel sounds.
What does Pabrinex involve? When would we give pabrinex?
Vitamin B and C.
After a patient is starving/dehydrated. To prevent Wernicke’s encephalopathy.
What is the triad for Wernicke’s encephalopathy?
Ataxis
Confusion
Nystagmus (opthalmoplegia).
Which bacterial microorganisms can mimic Crohn’s disease?
Tuberculosis
Yersinia
Which are the two most common causes of large bowel obstruction?
Colonic carcinoma
Sigmoid volvulus
Where would abdominal symptoms of diverticular disease be felt?
Lower left abdomen.
Left iliac fossa.
How is diverticular disease treated?
Firstly conservatively: nil by mouth and IV antibiotics.
Then CT, colonoscopy.
Where do most diverticular disease complications occur?
Sigmoid region.
Toxic megacolon is associated with which three conditions?
Ulcerative Colitis
Salmonella
Crohn’s disease
Which test is usually requested with an abdominal x ray?
Chest x ray.
What is a key differential of abdominal pain with quiet bowel sounds and rigidity?
Peritonitis.
;rigidity and absent bowel sounds.
Define micturition.
Passing urine.
Define micturition.
Passing of urine.
Pain and profuse diarrhoea after antibiotic treatment. What is your top differential diagnosis?
Pseudomembranous Colitis.
Which is the most common causative microorganism of Pseudomembranous Colitis?
Clostridium Difficile.
What should be avoided in pseudomembranous colitis?
Anti-diarrhoeal agents.
When will free air beneath the diaphragm be a normal finding?
Following surgery.
What is the first most appropriate treatment for appendicitis?
Nil by mouth and urgent laparotomy and appendicectomy.
At which level does the aorta bifurcate?
Umbilicus = L4.
What must you remember about sigmoid volvulus?
Bowel sounds will be increased.
Define volvulus
Twisted bowel
What is the difference between an ileus and a large/ small bowel obstruction?
Ileus is not a mechanical obstruction
LBO/SBO is mechanical
Name two of the most common causes of SBO.
Name two of the most common causes of LBO.
SBO = adhesions and hernias LBO = cancer and volvulus.
Where can a lead pipe sign be seen from an abdominal x ray?
Crohn’s/ UC.
Give x3 causes of splenomegaly.
Malaria
Inflammatory disease e.g. rheumatoid arthritis
Infection e.g. infective mononucleosis.
What does high ALT indicate?
Alanine transferase = indicator of injury
Remember high ALT in isolation can be a marker of bone injury, Vitamin D deficiency, bony metastases
What does high ALP indicate?
Alkaline phosphatase = indicator of obstruction
What is Gilbert’s syndrome?
Impaired conjugation of bilirubin (so a pre-hepatic issue).
Which markers will be high in Gilbert’s syndrome?
Bilirubin (Gilbert’s is an issue of conjugating bilirubin). ALT and ALP are normal.
Name three functions of the liver.
Conjugates and eliminates bilirubin
Makes albumin
Makes clotting factors
How is bilirubin produced?
Bilirubin is a product of haemoglobin breakdown.
When will ALT>AST compared with AST>ALT?
ALT>AST = chronic liver disease (injury) AST>ALT = Cirrhosis, hepatitis (obstruction)
Why will urine be darker in hepatic/post hepatic causes?
Conjugated Bilirubin makes the urine darker. Bilirubin is conjugated in the liver so by this point conjugation has happened.
When will stool be pale?
When there is fat in the stool. i.e. there has been poor fat absorption.
Would we typically request an erect or supine X-ray?
Supine x-ray.
Which test would we request to assess an anastomosis and any evidence of leakage?
WATER SOLUBLE enema not barium enema. Barium enema is contraindicated in suspected bowel perforation.
What is rapid sequence induction?
A technique to rapidly secure the airways with an endotracheal tube.
What is a key investigation to request when querying Crohn’s disease or UC?
STOOL SAMPLE!
Calprotectin.
Which of the causes of right iliac fossa pain is more likely in older patients?
Meckel’s diverticulitis
first carcinoma
What is Rovsing’s sign?
Pain upon palpation in left iliac fossa produces pain in the right iliac fossa.
What is Obturator’s sign?
Pain when passively internally rotating the hip
Which scoring system is used in appendicitis?
Alvarado.
Which presentation would not be indicated for emergency surgery?
An abscess
Which is the antibiotic we use to treat Clostridium difficile?
Vancomycin
Which test should not be performed in acute diverticulitis?
Colonoscopy
When would we not choose DC cardioversion for a patient with AF who is haemodynamically compromised?
If the patient is vomiting. Otherwise WOULD DC cardiovert if patient is unstable but with vomiting firstline = IV fluids.
Which is the first line management in patients who are vomiting?
IV fluids.
What is loin to groin pain indicative of what?
Renal colic.
What is the first line therapy for renal colic (stones)?
Diclofenac = analgesic.
What is the first line investigation for gastric cancer?
OGD + biopsy.
Which is the most appropriate investigation for Colorectal cancer?
Colonoscopy + biopsy.
Which is a unconventional cause of abdominal pain?
Diabetic Ketoacidosis.
How do we treat Diabetic Ketoacidosis?
IV fluids, K+ replacement,
How do we treat hyperkalaemia?
Insulin, calcium gluconate, glucose.
What affect does insulin have on potassium levels?
Insulin lowers blood potassium levels.
What is the characteristic cell of Chronic lymphoblastic leukaemia?
Smudge cells - remnants of cells.
Which two conditions present similarly but are more distinguishable by onset?
Abdominal aortic aneurysm (more acute onset)
Pancreatitis (slower onset)
What is the difference between cholangitis and cholecystitis?
Cholangitis = affects whole of the biliary tree whereas cholecystitis is inflammation of the gallbladder solely.
Will we see jaundice in cholangitis or cholecystitis?
More in cholangitis.
Which conditions are associated with B12 deficiency?
Macroglossitis/ stomatitis?
Which cell marker is associated with B12 deficiency?
Anti-parietal cell
Which cell marker is associated with Coeliac disease?
tTG - tissue transglutaminase.
When would we request a urea breath test?
If we were unsure about a H.Pylori confirmation. If stem says H. Pylori, this means we do not need the urea breath test.
When may a question point toward a Zollinger-Ellison syndrome diagnosis?
High calcium, high gastrin = can cause ulcers; gastric acid.
How do we treat Ulcerative Colitis?
Azathioprine and Infliximab.
