Gastric hormones

Question 1

Things that increase gastrin secretion

Answer 1

Antrum distension
presence of peptides
hypercalcaemia
vagal stimulation

Question 2

Things that inhibit gastrin secretion

Answer 2

acid in stomach
VIP
somatostatin
GIP
glucagon
calcitonin

Question 3

CCK role is what?

Answer 3

regulation of pancreatic enzyme secretion

Question 4

Gastrin produced where?

Answer 4

G cells in stomach ANTRUM

Question 5

Side effects of PPIs?

Answer 5

CAP increased risk RR 1.89 /aspiration strep pneumo
Gastro rates from campylobacter and salmonella, C diff RR2.9
Osteoporosis - but conflicting evidence

Unclear if interacts with clopidogrel, probably ok
post HOC analyses no impact on CV events

Question 6

What causes hypergastrinaemia? (clinical states)

Answer 6

Prolonged acid inhibition
Zollinger ellison
Vagotomy or small bowel resection
Atrophic gastritis (pernicious anaemia or H pylori)
Renal failure
Hypercalcaemia
Hyperlipidaemia (but artifactual)

Question 7

Zollinger ellison associated with what endocrine syndrome?

Answer 7

MEN1 in 1/3 cases (parathyroid hyperplasia, pituitary and pancreatic tumours)
Chromosome 11q13

Question 8

How do you diagnose Zollinger Ellison?

Answer 8

Fasting gastrin over 1000
Gatate PET-CT the new TEST OF CHOICE
Can also do secretin provocation looking for rise over 200

Question 9

Statin and fibrate effect on risk of pancreatitis?

Answer 9

statin reduce risk in hypercholesterolaemia

fibrate INCREASE risk in hypertriglyceridaemia

Question 10

Do cessation of smoking and alcohol reduce the long term risk of chronic pancreatitis after first episode?

Answer 10

smoking yes

drinking no

Question 11

New evidence that ERCP pancreatitis can be effectively prevented with what?

Answer 11

NSAID suppository

Question 12

What is the gene and defective gene product in hereditary pancreatitis?

Answer 12

autosomal dominant
Trypsinogen gene PRSS1
Recurrent mild attacks from age 5

SPINK1 mutation, CFTR mutation other causes, chymotrypsin C

Question 13

What is the pathology behind autoimmune pancreatitis?

Answer 13

IgG4 disease
Recurrent mild attacks, can also present with a mass and look like cancer- sausage shaped panc mass
Associated with RA, sjogren's PBC
RAISED SERUM IgG4
Responds to steroids! Sometimes need AZA

Question 14

How do you show successful eradication of H pylori?

Answer 14

6 weeks post end regimen breath test. PPI off one week

If fails, clarithromycin resistance, or metro resisitance
Can try amox, moxiflox, omep

Question 15

Symptoms of eosinophilic oesophagitis:

Answer 15

dysphagia
food impaction
chest/abdo pain
refractory GORD

histo: oesophageal eosinophilia- don’t have ANY normally!!
also basal zone hyperplasia

Question 16

Eosinophilic hypersensitivity is associated with what drug side effect in asians?

Answer 16

Carbamazepine hypersensitivity syndrome!!!

Question 17

New treatment for eosinophilic oesophagitis

Answer 17

six food elimination diet! –>81% histo remission
most common trigger is milk and wheat
Take away all 6 for 8 weeks then reintroduce slowly
don’t do skin prick testing- useless
Nuts wheat soy eggs seafood milk

there is also a subtype that get better on PPIs ?anti-inflammatory effects-usually do this first now

can also swallow budesonide - gross

Question 18

What is achalasia?

Answer 18

failure of relaxation of lower oesophageal sphincter

• in type 1 there is no relaxation of LES
• in type 2 there is no relaxation or peristalsis, the whole thing just pushes in; less response to surgery

Question 19

If you see a barium swallow with small bowel with crazy looking valvulae conniventes- think what?

Answer 19

Small bowel diverticulae strongly associated with bacterial overgrowth.
Can see wt loss, B12 def, folate def, positive hydrogen breath test.
Scleroderma can do a similar thing,.

Question 20

What does HLA DQ2 DQ8 do in coeliac?

Answer 20

Useful to rule OUT

Question 21

diagnose coeliac…need 5 of 6 of…

Answer 21

typical symptoms of celiac disease; positivity of serum celiac disease immunoglobulin, A class autoantibodies at high titer; human leukocyte antigen (HLA)-DQ2 or DQ8 genotypes; celiac enteropathy at the small bowel biopsy; and response to the gluten-free diet

Really need to see improvement of the nonspecific histo findings on re-endoscopy after changing diet

Question 22

Coeliac associations

Answer 22

Dermatitis herpeteformis- arms and trunk respond to gluten free diet
Autoimmune conditions (IgA def, DM, thyroidhypo)
Down and Turner sydnrome
Liver disease

Question 23

Coeliac serology- pros and cons?

Answer 23

Anti tissue transglutaminase- sensitive (95) an IgA so not seen in def
Deamidated anti Gliadin- IgG useful in IgA def but less sensitive (90%)
Both 100% specific

Anti endomysial is IgA- 95,100 sens spec

Question 24

What are some strategies to approach indeterminate cases of coeliac?

Answer 24

Do HLA typing
Exclude other causes of atrophy- drugs like NSAIDs, MMF, olmesartan, giardia, lymphoma, overgrowth, CVID
Re-check after gluten challenge

Question 25

What gives you low resting LES tone?

Answer 25

``` Gastric distension Alcohol Fat Smoking CCK Caffeine ``` All the good stuff plus CCK

Question 26

Severity of reflux oesophagitis at endoscopy dependent or independent of degree symptoms?

Answer 26

Independent - so reason for doing the scope is to check for complications like Barrets and red flags BUT Barretts DOES correlate with duration of symptoms

Question 27

Does H pylori cause GERD?

Answer 27

No

Question 28

What do you have to make sure before considering for nissen fundoplication?

Answer 28

Prove that there is reflux with pH monitoring | Prove that there is no achalasia- resting LES under 10 mmHg

Question 29

What is the epithelial change in barrett's esophagus?

Answer 29

squamous to columnar epithelium

Question 30

What are the recommendations for Barrett's surveillance?

Answer 30

Barrett's itself doesnt matter, just worried if get dysplasia No dysplasia: surveillance endoscopy every 3-5 years Low grade dysplasia: 6 monthly biopsies High grade dysplasia: this is basically cancer. Surveillance and biopsy every three months; or resection or ablation to be considered if young.

Question 31

Get into head- different risk factors for different types of oesophageal cancer:

Answer 31

Adeno- Barrett's | Squamous- smoking (and alcohol)

Question 32

Coeliac complications

Answer 32

Anaemia: iron, B12, folate (folate more common than B12) Hyposplenism Osteoporosis, osteomalacia Lactose intolerance Enteropathy associated T cell lymphoma of the small intestine Subfertility Oesophageal cancer (rare)