Gastro Flashcards
1
Q
Barretts oesophagus leads to..?
A
oesophageal adenocarcinoma (~50-100x)
2
Q
Risk factors of Barrett’s oesophagus?
A
GORD - strongest RF
Male (7:1)
Smoking
Central obesity
3
Q
Management of Barrett’s oesophagus?
A
- endoscopic surveillance with biopsies: recommended every 3-5 y if metaplasia present
- high-dose PPI
4
Q
management of Barrett’s oesophagus if dysplasia identified on biopsy?
A
endoscopic intervention
- endoscopic mucosal resection
- radio frequency ablation
5
Q
Hep B in pregnancy: most appropriate strategy for reducing the vertical transmission rate?
A
if mother HBeAg +ve: give newborn vaccine + Immunoglobulin
- if not very infective, only vaccine needed
6
Q
what is the only test recommended for H. pylori post-eradication therapy
A
Urea breath test
7
Q
What medications should not be taken before urea breath test for H pylori?
A
- within 4 wks of antibiotics
- within 2 wks of antisecretory drug e.g. PPI
8
Q
pregnancy:
pruritus, often in the palms and soles +
no rash (although skin changes may be seen due to scratching) +
raised bilirubin
A
Intrahepatic cholestasis of pregnancy
9
Q
Management of Intrahepatic cholestasis of pregnancy
A
- ursodeoxycholic acid for symptomatic relief
- weekly liver function tests
- women are typically induced at 37 weeks
10
Q
Features of HELLP?
A
Haemolysis, Elevated Liver enzymes, Low Platelets
11
Q
Features of Acute fatty liver of pregnancy?
A
- abdominal pain, nausea & vomiting, jaundice
- headache
- hypoglycaemia
- severe disease may result in pre-eclampsia
12
Q
Ix of Acute fatty liver of pregnancy?
A
ALT high - typically >500
13
Q
Mx of Acute fatty liver of pregnancy?
A
supportive care, delivery is definitive management
14
Q
main risk factor for cholangiocarcinoma?
A
Primary sclerosing cholangitis
15
Q
Features of cholangiocarcinoma?
A
- persistent biliary colic symptoms
- anorexia, jaundice and weight loss
- palpable mass in RUQ (Courvoisier sign)
- periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen
16
Q
most common type of inherited colorectal cancer
A
hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
17
Q
most common genes involved with HNPCC?
A
MSH2 (60% of cases)
MLH1 (30%)
18
Q
Genetics of FAP?
A
- auto dominant
- APC gene (tumour suppressor) mutation on chromosome 5
19
Q
Conditions associated with Coeliac disease?
A
- Autoimmune thyroid disease/ Autoimmune hepatitis
- Dermatitis herpetiformis
- Irritable bowel syndrome
- Type 1 diabetes
- First-degree relatives (parents, siblings or children) with coeliac disease
20
Q
HLA assoc with coeliac disease?
A
HLA-DQ2 (95% of patients) and HLA-DQ8 (80%).
21
Q
IX to diagnose chronic pancreatitis?
A
CT abdo: pancreatic calcification (Sensitivity is 80%, specificity is 85%)
- If imaging inconclusive, faecal elastase to assess exocrine function
22
Q
Management of chronic pancreatitis?
A
pancreatic enzyme supplements
analgesia
antioxidants: limited evidence base
23
Q
Diagnosis of Spontaneous bacterial peritonitis
A
paracentesis: neutrophil count > 250 cells/ul
24
Q
most common organism found on ascitic fluid culture in Spontaneous bacterial peritonitis
A
E coli
25
Mx of Spontaneous bacterial peritonitis
IV cefotaxime
26
Antibiotic prophylaxis is given to patients w ascites if?
- 1 episode of SBP
| - patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
27
What antibiotic prophylaxis is given to patients with ascites to prevent SBP?
oral ciprofloxacin or norfloxacin
28
Primary sclerosing cholangitis - assoc w which type of IBD?
Ulcerative colitis
29
genetics of Haemochromatosis
auto recessive
| - mutations in HFE gene on chromosome 6
30
Reversible complications of Haemochromatosis
Cardiomyopathy (Dilated),
Skin pigmentation
Fatigue
Transaminase elevation
31
Irreversible complications of Haemochromatosis
- Liver cirrhosis**
- Arthropathy
Might have some improvement in some:
- Diabetes mellitus
- Hypogonadotrophic hypogonadism
- arthralgia
32
Mx of Gastric MALT lymphoma?
if low grade then 80% respond to H. pylori eradication
33
Factors in Ulcerative colitis increasing risk of colorectal cancer
- disease duration > 10 years
- pancolitis
- onset < 15 years old
- unremitting disease
- poor compliance to treatment
34
Indications for 1 year follow up colonoscopy in UC (due to high risk of developing colorectal ca)
- Extensive colitis with moderate/severe active endoscopic/histological inflammation
- OR stricture in past 5 years
- OR dysplasia in past 5 years declining surgery
- OR primary sclerosing cholangitis / transplant for primary sclerosing cholangitis
- OR family history of colorectal cancer in first degree relatives aged <50 years
35
Indications for 3 year follow up colonoscopy in UC (due to intermediate risk of developing colorectal ca)
- Extensive colitis with mild active endoscopy/histological inflammation
OR post-inflammatory polyps
OR FHx of colorectal cancer in a first degree relative >/= 50
36
Indications for 5 year follow up colonoscopy in UC (due to low risk of developing colorectal ca)
- Extensive colitis with no active endoscopic/histological inflammation
- OR left sided colitis
- OR Crohn's colitis of <50% colon
37
H pylori causes...
- peptic ulcer disease (95% of duodenal ulcers, 75% of gastric ulcers)
- gastric adenoCa
- B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of patients)
- atrophic gastritis
38
findings supportive of coeliac disease on endoscopic intestinal biopsy:
- villous atrophy
- crypt hyperplasia
- increase in intraepithelial lymphocytes
- lamina propria infiltration with lymphocytes
39
Ix of achalasia: what would you see on oesophageal manometry?
- excessive LOS tone which doesn't relax on swallowing
| - considered the most important diagnostic test
40
Ix of achalasia: what would you see on barium swallow?
shows grossly expanded oesophagus, fluid level
| 'bird's beak' appearance
41
Ix of achalasia: what would you see on CXR?
wide mediastinum, retrocardiac air-fluid level
42
Management of achalasia?
1st line: pneumatic (balloon) dilatation
If recurrent/ persistent symptoms: Heller cardiomyotomy surgery.
- if high surgical risk: intra-sphincteric injection of botulinum toxin
- medications e.g. nitrates, CCBs
43
most common cause of HCC in UK/europe?
Hep C
44
most common cause of HCC worldwide?
Hep B
45
Classifying severity of ulcerative colitis?
- mild: < 4 stools/day, only a small amount of blood
- moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
- severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
46
Mx of mild-moderate ulcerative colitis?
extensive disease: Rectal + Oral Aminosalicylate
Proctosigmoiditis + left sided UC: rectal only
proctitis: rectal only
47
Mx of mild-moderate ulcerative colitis if remission not achieved within 4 wks with just rectal aminosalicylate
add oral aminosalicylate.
| if still not achieved: add topical/ oral steroid
48
Mx of mild-moderate ulcerative colitis if remission not achieved within 4 wks with just rectal + oral aminosalicylate for extensive disease?
stop topical treatments, offer high dose oral aminosalicylate + oral steroid
49
Mx of severe colitis?
IV steroids
- if steroids CI, IV ciclosporin
50
Maintaining remission in a flare of mild- mod UC with proctitis/ proctosigmoiditis?
Rectal aminosalicylate alone
| OR oral + rectal OR oral only
51
Maintaining remission in a flare of mild- mod UC with left sided and extensive UC?
low maintenance dose of an oral aminosalicylate
52
Maintaining remission in a flare of severe UC or >=2 exacerbations in the past year?
oral azathioprine or oral mercaptopurine
53
what artery may be affected in a posteriorly sited duodenal ulcer?
gastroduodenal artery
- may require laparotomy, duodenotomy and under running of the ulcer
54
UGIB scoring system to determine need for admission/ timing of endoscopic intervention?
Blatchford score
- 0 is low risk
- all others are considered high risk and require admission and endoscopy
55
Screening for cirrhosis: who should be offered transient elastography (Fibroscan)
- people with hepatitis C virus infection
- men who drink >50u of ETOH/wk + women who drink >35 units of ETOH/wk
- those diagnosed with alcohol-related liver disease
56
Ix for those with confirmed liver cirrhosis?
- upper endoscopy to look for varices
| - Liver US every 6 mo +/- AFP to screen for HCC
57
Heyde syndrome?
triad of aortic stenosis, an acquired coagulopathy and anaemia due to bleeding from intestinal angiodysplasia
58
Diagnosis of angiodysplasia if acutely bleeding?
mesenteric angiography
59
Diagnosis of angiodysplasia?
colonoscopy
60
Mx of angiodysplasia?
endoscopic cautery or argon plasma coagulation,
| antifibrinolytics e.g. TXA, oestrogens
61
SEs of PPIs?
hypoNa, HypoMg
osteoporosis
microscopic colitis
C diff colitis
62
main foods that contain gluten?
- wheat: bread, pasta, pastry
- barley: beer
- rye
- oats
63
notable foods which are gluten-free?
rice, potatoes, corn (Maize)
64
mx of NAFLD?
mainstay of tx is lifestyle changes (particularly weight loss) and monitoring
65
Risk factors for developing eosinophilic oesophagitis?
- Allergies/ asthma: food/ environmental allergies or atopic dermatitis
- Male sex
- Family history of eosinophilic oesophagitis or allergies
- Caucasian race
- Age between 30-50
- Coexisting autoimmune disease e.g. coeliac disease
66
Management of eosinophilic oesophagitis?
- elemental diet/ targeted elimination diet
- topical steroids (fluticasone/ budesonide) for 8/52 before reassessment
- oesophageal dilation: 56% will require this at some point due to strictures
67
Complications assoc with eosinophilic oesophagitis?
strictures, impaction, mallory-weirs tears
68
Lactase breaks down what into what?
cleaves disaccharide lactose -> glucose + galactose
69
Sucrase breaks down what into what?
cleaves sucrose into fructose + glucose
70
Maltase: breaks down what into what?
cleaves maltose -> glucose + glucose
71
what should be assessed before starting azathioprine/ mercaptopurine?
TPMT (Thiopurine methyltransferase) activity.
| - some have a deficiency -> greater risk of severe side effects
72
inducing remission in Crohn's disease?
- steroids 1st line
- enteral feeding w elemental diet
- 2nd line: 5-ASA (e.g. mesalazine), azathioprine/ mercaptopurine
- infliximab (in refractory disease and fistulating Crohn's)
73
Inducing remission in Isolated peri-anal crowns disease?
metronidazole useful
74
Maintaining remission in Crohns disease?
- stop smoking
- 1st line: azathioprine/ mercaptopurine (TPMT activity assessed before starting)
- 2nd line: methotrexate
75
Complications of Crohn's disease?
- strictures/ fistulae
- small bowel cancer (standard incidence ratio = 40)
- colorectal cancer (standard incidence ratio = 2, i.e. less than the risk associated with ulcerative colitis)
- osteoporosis
76
Genetics of Wilson's disease?
auto recessive, defect in ATP7B gene on chromosome 13
77
Neurological features of Wilsons disease?
basal ganglia degeneration: most copper is deposited in the putamen and globes pallidus
- psych, asterixis, chorea, dementia, Parkinsonism
78
Diagnosis of Wilson's disease?
reduced serum caeruloplasmin, total serum copper,
| Increased 24h urinary copper excretion
79
Mx of Wilsons disease?
penicillamine
| Trientine hydrochloride
80
Genetics of Peutz Jeghers?
autosomal dominant
| -responsible gene encodes serine threonine kinase LKB1 or STK11
81
Features of Peutz Jeghers?
- hamartomatous polyps in GI tract (mainly small bowel)
- pigmented lesions on lips, oral mucosa, face, palms and soles
- intestinal obstruction e.g. intussusception
- GI bleeding
- ~50% will have died from another GI cancer by age 60
82
what gene mutations increase risk of pancreatic cancer?
BRCA2 gene, KRAS gene mutation
83
Ix of choice of pancreatic cancer?
high resolution CT abdomen
| - might show "double duct" sign - presence of simultaneous dilatation of the common bile and pancreatic ducts
84
Mx of pancreatic cancer - palliation?
ERCP with stenting
85
Mx of pancreatic cancer if suitable for surgery?
Whipples resection (pancreaticoduodenectomy) +/- adjuvant chemotherapy following surgery.
86
Liver failure: which clotting factor is paradoxically increased?
fVIII
- bc VIII is synthesised in endothelial cells throughout the body, unlike other clotting factors which are synthesised purely in hepatic endothelial cells
87
Mx of pyloric stenosis
Ramstedt pyloromyotomy
88
1st line management of acute anal fissure?
bulk-forming laxatives
89
1st line mx of chronic anal fissure?
Topical GTN
90
what electrolyte imbalances may cause acute pancreatitis?
hypertriglyceridaemia, hyperchylomicronaemia, hyperCa, Hypothermia
91
what drugs may cause acute pancreatitis?
azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate
92
Histological findings in gastric adenocarcinoma?
signet ring cells
- higher numbers assoc w worse prognosis
93
Gastric cancer associations?
- H. pylori infection
- blood group A: gAstric cAncer
- gastric adenomatous polyps
- pernicious anaemia
- smoking
- diet: salty, spicy, nitrates
- may be negatively associated with duodenal ulcer
94
Ix of gastric cancer?
- diagnosis: endoscopy with biopsy
| - staging: CT or endoscopic ultrasound - endoscopic ultrasound has recently been shown to be superior to CT
95
First line for staging of gastric cancer?
CT scanning of the chest abdomen and pelvis
- consider: Laparoscopy to identify occult peritoneal disease, PET CT (particularly for junctional tumours)
96
Mx of gastric cancers?
- Proximally sited disease greater > 5-10cm from the OG junction = sub total gastrectomy
- Total gastrectomy if tumour is <5cm from OG junction
- For type 2 junctional tumours (extending into oesophagus) oesophagogastrectomy is usual
+/- Lymphadenectomy +/- pre/post op chemo
97
Features of Carcinoid syndrome?
flushing (often earliest symptom), diarrhoea, bronchospasm, hypotension
- right heart valvular stenosis
- ACTH and GHRH may also be secreted--> Cushing's syndrome
- pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour
98
What is carcinoid syndrome?
- usually occurs when mets are present in the liver and release serotonin into the systemic circulation
- may also occur with lung carcinoid as mediators are not 'cleared' by the liver
99
Ix of carcinoid syndrome?
raised urinary 5-HIAA, plasma chromogranin A y
100
Mx of carcinoid syndrome?
- somatostatin analogues e.g. octreotide
| - diarrhoea: cyproheptadine may help
101
monoclonal antibody which targets Clostridium difficile toxin B- might be used to prevent further recurrence
bezlotoxumab
102
Mx of c diff Infection if not responding to normal management? (2nd line)
oral fidaxomicin
103
1st line mx of C diff?
oral vancomycin for 10 days
104
NICE bariatric referral BMI cut-offs
with risk factors (T2DM, HTN etc): > 35 kg/m^2
| no risk factors: > 40 kg/m^2
105
first-line bariatric intervention in patients with a BMI of 30-39kg/m^2
primarily restrictive: laparoscopic-adjustable gastric banding (LAGB)
- fewer SEs
106
bariatric intervention in patients with a BMI of >40?
consider gastric bypass/ sleeve gastrectomy
107
bariatric intervention in patients with a BMI of >60?
primarily malabsorptive: biliopancreatic diversion with duodenal switch
108
features of autoimmune hepatitis?
- may present with signs of chronic liver disease
- acute hepatitis: fever, jaundice etc (only 25% present in this way)
- amenorrhoea (common)
- ANA/SMA/LKM1 antibodies, raised IgG levels
109
liver biopsy of autoimmune hepatitis?
inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis
110
mx of autoimmune hepatitis?
steroids, other immunosuppressants e.g. azathioprine
| - liver transplant
111
most common organism found in pyogenic liver abscesses in children?
Staph aureus
112
most common organism found in pyogenic liver abscesses in adults?
E coli
113
Management of pyogenic liver abscess?
drainage (typically percutaneous) and antibiotics
- amoxicillin + ciprofloxacin + metronidazole
if penicillin allergic: ciprofloxacin + clindamycin
114
first line test for diagnosis of small bowel overgrowth syndrome
hydrogen breath test
115
Risk factors for Small bowel bacterial overgrowth syndrome?
- neonates with congenital gastrointestinal abnormalities
- scleroderma
- diabetes mellitus
116
management of Small bowel bacterial overgrowth syndrome?
- correct underlying disorder
- 1st line: Rifaximin
(2nd line: co-amox/ metronidazole)
117
Oesophageal/Gastric Cancer - What is the best investigation to assess for mural invasion?
Endoscopic ultrasound
- can display all the layers of the wall of the oesophagus and should routinely be performed with CT or MRI scans.
118
most common type of oesophageal ca?
adenoca now
119
risk factors of gastro/oesophageal adenocarcinoma?
```
GORD
Barrett's oesophagus
smoking
achalasia
obesity
```
120
risk factors of gastro/oesophageal squamous cell carcinoma?
```
smoking
alcohol
achalasia
Plummer-Vinson syndrome
diets rich in nitrosamines
```
121
Management of oesophageal cancer?
surgical resection - e.g Ivor-Lewis type oesophagectomy.
| +/- adjuvant chemo
122
pathophysiology of hepatorenal syndrome?
vasoactive mediators cause splanchnic vasodilation -> reduces systemic vascular resistance > less blood going to kidneys
123
Management of hepatorenal syndrome?
- terlipressin - causing vasoconstriction of the splanchnic circulation.
- volume expansion w 20% albumin
- Transjugular intrahepatic portosystemic shunt
- ideal treatment = liver transplant
124
most common site affected in UC
rectum
125
Pathophysiology of Zollinger-Ellison syndrome?
excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas.
~ 30% occur as part of MEN type I syndrome
126
Diagnosis of Zollinger-Ellison syndrome?
fasting gastrin levels: the single best screen test
| secretin stimulation test
127
features of villous adenomas?
characteristically secrete large amts of mucous
- secretory diarrhoea
- microcytic anaemia
- hypokalaemia
128
features of Dubin-Johnson syndrome?
- benign auto recessive
- hyperbilirubinaemia (conjugated)
- defective hepatic bilirubin excretion
- defect in the cannicular multi specific organic anion transporter (cMOAT) protein
129
Associations of primary biliary cirrhosis?
Sjogrens (seen in up to 80%),
Rheumatoid arthritis,
systemic sclerosis,
thyroid disease
130
Clinical features of primary biliary cirrhosis?
```
early: pruritus, fatigue, abnormal LFTs (e.g. raised LFTs)
cholestatic jaundice
hyperpigmentation
RUQ pain in 10%
xanthelasmas, xanthomata
clubbing, hepatosplenomegaly
may progress to liver failure
```
131
diagnosis of primary biliary cirrhosis?
anti-mitochondrial antibodies M2 subtype,
smooth muscle antibodies (in 30%),
raised serum IgM
132
1st line mx of primary biliary cirrhosis?
Ursodeoxycholic acid
| - slows disease progression and improves symptoms
133
Mx of primary biliary cirrhosis?
1st line: ursodeoxycholic acid
pruritus: cholestyramine
fat soluble vitamin supplementation
liver transplant - PBC is a major indication
134
Complications of primary biliary cirrhosis?
- cirrhosis -> portal hypertension -> ascites, variceal haemorrhage
- osteomalacia, osteoporosis
- 20 fold increased risk of HCC
135
features of acute liver failure?
- jaundice
- coagulopathy: raised prothrombin time
- hypoalbuminaemia
- hepatic encephalopathy
- renal failure is common ('hepatorenal syndrome')
136
Management of ascites?
- reduce dietary sodium
- fluid restriction may be recommended (if Na<125)
- spironolactone +/- furosemide
- therapeutic abdominal paracentesis
- prophylactic antibiotics: ciproflox/ norfloxacin (if ascitic protein=15)
- Transjugular intrahepatic portosystemic shunt may be considered
137
Primary sclerosing cholangitis: associations?
- UC (80% of pts w PSC have UC)
- Crohn's
- HIV
138
Features of primary sclerosing cholangitis?
- cholestasis: jaundice, pruritus, raised bilirubin + ALP
- RUQ pain
- fatigue
139
Ix of primary sclerosing cholangitis?
- ERCP/ MRCP: showing multiple biliary strictures giving a 'beaded' appearance
- p-ANCA +ve
140
Complications of primary sclerosing cholangitis?
- cholangiocarcinoma
| - increased risk of colorectal ca
141
First-line pharmacological treatment of irritable bowel syndrome?
pain: antispasmodic agents
constipation: laxatives but avoid lactulose
diarrhoea: loperamide is first-line
142
Management of patients with constipation in irritable bowel syndrome who are not responding to conventional laxatives?
linaclotide
143
Second-line pharmacological treatment of irritable bowel syndrome?
low-dose TCAs (e.g. amitriptyline 5-10 mg)
144
Causes of Budd-Chiari syndrome (ie. hepatic vein thrombosis)?
- polycythaemia rubra vera
- thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies
pregnancy
- combined oral contraceptive pill: accounts for around 20% of cases
145
Features of Budd-Chiari syndrome?
abdominal pain: sudden onset, severe
ascites → abdominal distension
tender hepatomegaly
146
First line ix of Budd-Chiari?
US with doppler flow studies
147
Ix for Haemochroamtosis in general population?
transferrin saturation + ferritin
148
Ix for Haemochroamtosis in family members?
genetic testing for HFE mutation
149
Diagnostic tests of Haemochromatosis?
- molecular genetic testing for the C282Y and H63D mutations
| - liver biopsy: Perl's stain
150
Mx of haemochromatosis?
1st line: venesection
| 2nd line: desferrioxamine
151
Mx of ascending cholangitis?
IV abs
| + ERCP after 24-48h to relieve any obstruction
152
where is gastrin produced?
G cells in antrum of the stomach
153
what does gastrin do?
- increases acid secretion by gastric parietal cells
| - increases gastric motility, parietal cell maturation, pepsinogen and IF secretion
154
what stimulates gastrin to be released?
distension of stomach, vagus nerve, luminal peptides/ amino acids
inhibited by: low pH, somatostatin
155
What does CCK do?
- increases secretion of enzyme-rich fluid from pancreas, contraction of gallbladder and relaxation of sphincter of Oddi
- decreases gastric emptying
- induces satiety
156
what produces Cholecystokinin (CCK)?
I cells in the upper small intestine
157
what produces secretin?
S cells in upper small intestine
158
What does secretin do?
- increases secretion of bicarbonate-rich fluid from pancreas and hepatic duct cells
- decreases gastric acid secretion
159
What does VIP do?
Stimulates secretion by pancreas and intestines
| - inhibits acid secretion
160
where is VIP produced?
small intestine, pancreas
161
What does somatostatin do?
- decreases acid and pepsin secretion
- decreases gastrin + pancreatic enzyme + insulin/ glucagon secretion
- stimulates gastric mucous production
162
Where is somatostatin produced?
D cells in the pancreas & stomach
163
What hormone is useful to test for in chronic pancreatits/ pancreatic insufficiency?
secretin
164
gold standard test for diagnosis of GORD?
24h oesophageal pH monitoring
165
GORD: indications for upper GI endoscopy?
- age > 55 years
- symptoms > 4 weeks or persistent symptoms despite treatment
- dysphagia
- relapsing symptoms
- weight loss
166
what laxative to avoid in management of irritable bowel syndrome?
lactulose
167
most common complication of ERCP?
acute pancreatitis
168
common complication of TIPSS procedure?
exacerbation of hepatic encephalopathy
169
Red flag features that suggest smth apart from IBS?
- rectal bleeding
- unexplained/unintentional weight loss
- family history of bowel or ovarian cancer
- onset after 60 years of age
170
Which laxative is shown to have carcinogenic potential?
co-danthramer
- should only be prescribed to palliative patients due to its carcinogenic potential.
171
score for likelihood of acute appendicitis?
Alvarado score
172
features of Plummer-Vinson syndrome?
triad of
- dysphagia (secondary to oesophageal webs)
- glossitis
- iron deficiency anaemia
tx includes iron supplementation and dilation of the webs
173
Drugs associated with cholestasis?
- COCP
- abx: flucloxacillin, co-amoxiclav, erythromycin
- anabolic steroids, testosterones
- chlorpromazine, prochlorperazine
- sulphonylureas e.g. gliclazide
- fibrates
- rare: nifedipine
174
what is monitored in haemochromatosis to assess for adequacy of treatment?
transferrin saturation should be <50%
| serum ferritin <50 ug/l
175
features of post-cholecystectomy syndrome?
dyspepsia, vomiting, pain, flatulence, diarrhoea
| - in up to 40% post surgery
176
Management of post-cholecystectomy syndrome?
low fat diet,
bile acid sequestrants e.g. Cholestyramine
dyspepsia - PPIs
177
Management of hepatic encephalopathy?
tx underlying cause
- Lactulose 1st line: increases excretion of ammonia
- +/- Rifaximin: modulate gut flora to decrease ammonia production
178
cotton wool spots on fundoscopy post head trauma and in conditions such as acute pancreatitis, fat embolisation, amniotic fluid embolisation and vasculitic diseases?
Purtscher retinopathy
179
multikinase inhibitor used in management of HCC?
sorafenib
180
drugs that may lead to liver cirrhosis
methotrexate
methyldopa
amiodarone
181
malabsorption of ____ is a common cause of diarrhoea following ileal resection?
bile salts
182
management of malabsorption of bile salts post ileal resection?
cholestyramine
183
Pathophysiology of Whipple's disease?
rare multi-system disorder caused by Tropheryma whippelii infection.
- most often affects joints/ digestive system
- chronic, curable, systemic bacterial infection
184
features of Whipple's disease?
malabsorption: diarrhoea, weight loss,
- large joints arthralgia
- lymphadenopathy
- skin: hyperpigmentation and photosensitivity
- pleurisy, pericarditis
- ophthalmoplegia, dementai, seizures, ataxia, myoclonus
185
Ix of Whipple's disease?
jejunal biopsy: deposition of macrophages containing Periodic acid-Schiff (PAS) granules
186
Mx of Whipple's disease?
oral co-trimoxazole for a year, sometimes preceded by course of IV penicillin
187
histological features of Crohn's disease?
- inflammation of all layers from mucosa to serosa
- increased goblet cells
- granulomas
188
histological features of Ulcerative colitis?
- no inflammation beyond submucosa- inflammatory cell infiltrate in lamina propria
- crypt abscesses
- depletion of goblet cells and mucin
- granulomas are infrequent
189
Intestinal causes of malabsorption
| - e.g. villous atrophy
- coeliac disease
- Crohn's disease
- tropical sprue
- Whipple's disease
- Giardiasis
- brush border enzyme deficiencies (e.g. lactase insufficiency)
190
pancreatic causes of malabsorption?
| - due to deficiency of pancreatic enzyme production/ secretion
chronic pancreatitis, pancreatic ca, cystic fibrosis
191
Biliary causes of malabsorption?
| - deficiency of bile salts needed for emulsification of fats
biliary obstruction, primary biliary cirrhosis
192
Other causes of malabsorption?
bacterial overgrowth e.g. systemic sclerosis, diverticula, blind loop
- short bowel syndrome
- lymphoma
193
autoimmune hepatitis is assoc with raised Ig of which subtype?
IgG
194
Primary biliary cirrhosis is assoc with raised Ig of which subtype?
IgM
195
Alcoholic liver disease is assoc with raised Ig of which subtype?
IgA
196
Features of VIPoma?
- 90% arise from pancreas
- large volume diarrhoea, dehydration
- weight loss
- hypoK, low levels of HCl stomach acid
197
antibiotics associated w c diff?
- clindamycin: RR = 31.8
- cephalosporins: RR = 14.9
- ciprofloxacin: RR = 5.0
198
Management of HCC with Child-Pugh A cirrhosis without signs of portal hypertension, who have single lesion <2cm in size?
surgical resection
199
Management of HCC with Child Pugh A and B cirrhosis, and 2-3 tumours <=3cm or 1 tumour <=5cm WITHOUT vascular invasion or extra hepatic spread?
Liver transplantation
| - as a bridge to liver transplantation: Transarterial chemoembolization (TACE) or Radio Frequency ablation (RFA)
200
Management of HCC with Child Pugh A or B cirrhosis, good performance status and evidence of vascular, lymphatic or extra hepatic spread?
Sorafenib (multiple tyrosine kinase inhibitor) has been shown to prolong survival
201
Management of Child-Pugh C cirrhosis with end stage liver disease?
supportive/ palliative care
202
Mx of alcoholic ketoacidosis?
IV saline + thiamine
203
causes of jejunal villous atrophy? (apart from coeliac disease)
- coeliac disease
- tropical sprue
- hypogammaglobulinaemia
- GI lymphoma
- Whipple's disease
- cows milk intolerance
204
what vitamin supplementations are required in gastric bypass operations?
- all bypass the duodenum
| - need iron supplementation
205
Ix that can confirm diagnosis of Gilbert's syndrome?
rise in bilirubin following prolonged fasting or IV nictotinic acid (nicotinic acid test)
206
what elements make up the Child-Pugh score
Bilirubin, Albumin, INR, Ascites, encephalopathy
207
Ix of choice for bile acid malabsorption?
SeHCAT
| - scan to assess retention/ loss of radiolabelled SeHCAT
208
Mx of bile acid malabsorption?
Bile acid sequestrants e.g. cholestyramine
209
Ix of suspected severe acute flare of Ulcerative colitis?
flexi sig
| - for biopsies to confirm diagnosis and exclude CMV
210
what Ix is recommended if metastases are not seen on initial staging CT scans? (for oesophageal cancer)
FDG-PET CT scans
| - to detect occult metastases
211
US scan showing 'sand sign' (debris within hepatic cyst moving freely) and neighbouring sister cysts?
characteristic of hydatid disease
| - echinococcus granulosus
212
3rd line management of c diff infection (1st episode)?
| ie. after oral vancomycin course, oral fidaxomicin
oral vancomycin +/- IV metronidazole
213
management of life threatening c Diff infection
| ie. hypotension, partial/ complete ileus, toxic megacolon or CT evidence of severe disease
oral vancomycin AND IV metrondiazole
| - may need to consider surgery
214
management of recurrent episode of c diff infection?
within 12 wks of symptom resolution: oral fidaxomicin
| after 12 wks: oral vancomycin OR fidaxomicin
215
what type of autoimmune hepatitis ONLY affects children?
type 2
| - Anti-liver/kidney microsomal type 1 antibodies (LKM1)
216
management of pruritus in primary biliary cirrhosis?
cholestyramine
217
primary biliary cirrhosis: what management slows disease progression and improves symptoms?
ursodeoxycholic acid
218
investigation of occult GI bleeding if scopes normal?
repeat OGD or capsule endoscopy
> If capsule is negative then either a second capsule or enteroscopy is indicated.
219
what management is useful in inducing remission in patients who have refractory (and fistulating) Crohn's disease?
infliximab
220
NICE recommended screening tool for inflammatory bowel disease?
faecal calprotectin
- can also be used to monitor the response to treatment
- In adults, sensitivity of 93% and specificity of 96% for IBD. In children, the specificity falls to around 75%.
221
other causes of raised faecal cal protection apart from IBD?
- bowel malignancy
- coeliac disease
- infectious colitis
- use of NSAIDs
222
what additional risk comes with dual immunomodulator and biological therapy e.g. azathioprine + infliximab compared to biological therapy (e.g. azathioprine) alone?
increased risk of non-melanoma skin cancer (standardised incidence ratio 3.46) and other cancers (standardised incidence ratio 2.82)
223
Ulcerative colitis acute flare: management if no improvement seen after 72 hours of IV steroids or pt deteriorates despite steroids?
Urgent surgical review
| + IV ciclosporin (2mg/kg/day)
224
features of alkaptonuria?
| - build up of toxic homogentisic acid
- homogentisic acid accumulates in cartilage and other tissues
> pigmented sclera
> urine turns black if exposed to air
> intervertebral disc calcification --> back pain
> renal stones
225
alkaptonuria: management?
- high dose vitamin C
| - dietary restriction of phenylalanine and tyrosine
226
Why are there valve abnormalities in carcinoid syndrome?
Serotonin induced fibrosis of the valvular endocardium, usually tricuspid and pulmonary
- usually results in right heart failure
227
Management of acute alcoholic hepatitis?
Prednisolone (improves survival at 28 days)
| - can sometimes use pentoxyphylline but this does not improve survival
228
in severe alcoholic hepatitis, how long to continue prednisolone for?
7 days then reassess
229
Maddrey Discriminant Score
- used in Alcoholic hepatitis
> Prednisolone has been shown in meta-analyses to confer a significant reduction in 28-day mortality in patients with an MDS >32 or hepatic encephalopathy, however, there was no demonstrable benefit at 90 days or at one year.
230
primary indications for TIPSS (transjugular intrahepatic portosystemic shunt)?
uncontrolled variceal haemorrhage
refractory ascites
hepatic pleural effusion
231
Absolute contraindications for TIPSS?
- Severe and progressive liver failure (Child-Pugh score >12 is associated with a high risk of early death)
- Uncontrolled hepatic encephalopathy
- Right-sided heart failure
- Uncontrolled sepsis
- Unrelieved biliary obstruction
232
endoscopic management of oesophageal varices?
band ligation
233
endoscopic management of gastric varices?
injections of N-butyl-2-cyanoacrylate
234
what is the best marker to determining the risk of developing liver cirrhosis in patients with Hepatitis B?
Hepatitis B DNA levels
| ie. viral load
235
Venesection regime for haemochromatosis?
initially 500ml every 1-2 weeks
then once ferritin levels ~50-100, transition to maintenance of once every 2-4 months.
aim ferritin <50
236
Following successful treatment of Barretts oesophagus with low grade dysplasia, how often should endoscopic surveillance be offered?
every 6 months for the first year and then annually thereafter
237
Following successful treatment of Barretts oesophagus with high-grade dysplasia or intra-mucosal carcinoma, how often should endoscopic surveillance be offered?
every 3 months for the first year, every 6 months for the second year and then annually thereafter.
238
Fabry disease
X-linked recessive lipid storage disorder > deficiency in the fat enzyme alpha-galactosidase
accumulation of alpha-galactosyl-lactosyl-ceramide in various tissues, including kidney, liver, blood vessels and nerve ganglion cells
239
Clinical features of Fabry disease
- acroparaesthesia: tingling, burning pain in the hands and feet triggered by stress such as emotion, extreme temperatures, or exercise
- Angiokeratoma corporis diffusum: lightly verrucous, deep-red to blue-black papules on the trunk (in the bathing trunk distribution)
- Cardiac: mitral valve prolapse or regurgitation usually, but any valvular heart defect can occur
- Strokes: including young strokes/TIAs
- Chronic Kidney Disease: proteinuria usually, can present late in fulminant renal failure needing dialysis
240
Haemobilia?
bleeding into the biliary tree following connection between splanchnic circulation and either the intrahepatic or extrahepatic biliary system. E.g. post biopsy
Characterized by RUQ pain, upper GI bleeding and jaundice.
241
Should you continue azathioprine in pregnancy?
Yes
242
Investigation of choice for suspected perianal fistulae?
MRI
- can be used to determine if there (is an abscess and if the fistula is simple (low fistula) or complex (high fistula that passes through or above muscle layers)
243
radiological appearance of autoimmune pancreatitis?
diffuse enlargement, giving the appearance of a 'sausage-shaped' pancreas
244
Causes of high SAAG ascites > 11g/L?
High SAAG: (indicates portal hypertension)
Liver disorders: cirrhosis, acute liver failure, liver mets
Cardiac:
right heart failure
constrictive pericarditis
```
Other causes:
Budd-Chiari syndrome
portal vein thrombosis
veno-occlusive disease
myxoedema
```
245
Causes of low SAAG ascites (<11)?
Low albumin:
Hypoalbuminaemia
nephrotic syndrome
severe malnutrition (e.g. Kwashiorkor)
Malignancy: peritoneal carcinomatosis
Infections: tuberculous peritonitis
```
Other: pancreatitis
bowel obstruction
biliary ascites
postoperative lymphatic leak
serositis in connective tissue diseases
```
246
what is Zieve's syndrome?
haemolytic anaemia, cholestatic jaundice, and hyperlipidaemia.
247
2nd line tx of pyoderma gangrenosum if not responding to oral steroids?
- antiTNF e.g. infliximab, adalimumab
| - topical or oral tacrolimus
248
best management for patient with recurrent hepatic hydrothorax not responsive to medical mx?
liver transplant
249
Anti-Saccharomyces cerevisiae antibodies
| - Assoc with which IBD?
Crohns Disease
250
Treatment of H Pylori in Penicillin allergic patients or as a second line after triple therapy?
Quadruple therapy:
bismuth subsalicylate, tetracycline, metronidazole, and a proton pump inhibitor for 14 days
