Gastro

Question 1

Which of the following regarding Autoimmune Hepatitis is most correct?
Answers:
1. There is an expected response to immunosuppressants/immunomodulators
2. It is rare to get other autoimmune diseases with this
3. Associated with a shorter life span
4. Occurs most commonly in young males
5. Rare post liver transplant something

Answer 1

1. There is an expected response to immunosuppressants/immunomodulators

Question 2

Hepatitis involves the replication of which mini chromosomes?
1. RNA in the nucleus
2. DNA in the nucleus
3. RNA in the cytoplasm
4. DNA in the cytoplasm

Answer 2

2. DNA in the nucleus

Question 3

What is correct about the MELD score?
1. It takes bleeding time and bilirubin into account.
2. It is used to assess survival in pre-liver transplantation patients

Question 4

What is included in the assessment of the MELD score?

Question 5

What is the contraindication to surgery for gastric ulcer?
Answers:
c) Failure of PPI therapy
d) Non-compliance to treatment
e) 24h oesophageal pH positive on standard dose PPI twice daily
f) Extensive barretts oesophagus
g) Reflux related asthma??

Answer 5

d) Non-compliance to treatment????

Question 6

Man with gastric ulcer - clot over it and slow oozing blood on endoscopy. What is management?
Answers:
8. h) PPI + eradication
9. i) surgery
10. j) Endoscopy - injection +/- thermoablation
11. k) Tranexamic acid
12. l) H. pylori empiric treatment

Answer 6

Endoscopy - injection +/- thermoablation

Question 7

A 13 year old girl from India several episodes over last few years, moves to NZ 6 months ago with increasing amount, and gets occasional epigastric discomfort. Both parents are healthy and her stool culture is negative. What is the best option to manage her?
Answers:
a) PPI therapy (eg omeprazole)
b) Upper endoscopy
c) Empiric H pylori antibiotic treatment
d) Urease breath test/ Fecal H pylori test?
e) Change lifestyle

Answer 7

a ?but she is from india idk

Question 8

A 19 year old female with a 3 month history of weight loss, fatigue, loose bowel motions 3-4 times daily with some fresh blood, loss of appetite, and post-prandial abdominal discomfort. No known allergies, no infection. Abdomen is tender painful on examination with no masses. PR shows blood and tenderness. Rigid sig shows inflammation, biopsy is done but the result has not come back yet. What is the next treatment?
1. a) Mesalazine+Aothiaprine
2. b) High dose prednisolone + Mesalazine scaling up
3. c) IV fluid, hydrocortisone, parenteral nutrition
4. d) Barium swallow and enema
5. e) Prednisone enemas with methotrexate and ciprofloxacin

Question 9

83 year old man with multiple cardiac problems (eg cardiomegaly) presents with an episode of bloody diarrhoea. Endoscopy reveals inflammation and ulceration at splenic flexure. FBC shows slightly raised WBC (i think) but is otherwise normal.
What does he most likely have?
a) UC b) CD c) IC d) IBS

Answer 9

IC

Question 10

Which is true about antigens and antibodies in Hepatitis B
- IgM antibodies to the HBV core protein (IgM anti-HBc) suggests recent exposure of reactivation
- antibodies to HBcAg (core antigen) persist for longer than those to HBsAg (surface antigen)
- the amount of HBV DNA in the circulation indicated the viral load: increased risk of cirrhosis and HCC (this fluctuates – so must measure more than once)
- HBeAg + HBV DNA indicates active replication
- antibodies to HBsAg (surface antigen) without HBV DNA indicate immunity due to vaccination or previous infection

Answer 10

• antibodies to HBcAg (core antigen) persist for longer than those to HBsAg (surface antigen)

Question 11

Hepatitis B has 8 genotypes (A-H)
- genotype C causes advanced liver disease more frequently than B or D
- HBeAg seroconversion is lower in genotype C

Question 12

Which is true about Genotype 1 of Hepatitis C

Answer 12

• 50% cure rate in NZ (on combination therapy)

Question 13

Which of the following is NOT included in alcoholic hepatitis
- leucocytosis
- macrocytosis (due to folate deficiency)
- jaundice
- pain
- fever
- ALT > AST

Answer 13

(AST should be more elevated than ALT as is a hepatocellular issue rather than a biliary tree issue and deficiency of B12 causes low ALT)

Question 14

Signs and symptoms of alcoholic hepatitis

Answer 14

• fatigue, fever, jaundice, tender hepatomegaly

Question 15

What cannot reduce bleeding in those with varices?

Answer 15

• vitamin K (as liver is not functioning thus unable to make cofactors)

Question 16

Young man with new epigastric pain. No other symptoms. How would you manage him

Answer 16

Omeprazol

Question 17

Woman has been on H2-Receptor antagonists over the counter for post-prandial dyspepsia. They ran out 6m ago, now getting symptoms. What should you do:
- endoscopy
- PPI
- H2-R antagonists
- lifestyle

Answer 17

• PPI

Question 18

Which is NOT important in initial management of upper GI bleed
- history of similar bleed
- previous meal content
- brachial pulse volume
- NSAID use

Answer 18

previous meal content

Question 19

Gold standard test for coeliac disease ?

Answer 19

duodenal biopsy

Question 20

Does GORD include nasal polyps?

Answer 20

NO!!!!!!!!!!!

Question 21

Complications of Ulcerative Colitis do not include:

Answer 21

• dermatitis hepatiform (this is more common in coeliac disease)

Question 22

Is genotype 4 the most common type of herpatitis in NZ?

Answer 22

No 1-3 are more common

Question 23

Next step in managing 2/3 faecal occult blood
- rigid sigmoidoscopy
- flexi-sigmoidoscopy
- colonoscopy
- wait 6 months

Answer 23

• colonoscopy

Question 24

What is the gold-standard test for progressive dysphagia to solids
- endoscopy
- barium swallow
- chest x ray
- video fluoroscopy
- systemic sclerosis antibodies

Answer 24

endoscopy  allows for biopsy and/or dilation of strictures (+/- barium swallow to exclude pharyngeal pouch which could otherwise be perforated by endoscopy)

Question 25

Decompensation of liver disease
- all of the above:
o leukonychia: synthetic function
o multiple bruises: synthetic function
o asterixis: hepatic encephalopathy
o drowsiness: hepatic encephalopathy
o jaundice: excretory function
o hyperventilation: hepatic encephalopathy and acidosis
o ascites: portal hypertension and synthetic function
o pedal/sacral oedema: synthetic function and R sided HF

Question 26

How to confirm diagnosis of cholecystitis

Answer 26

• USS and positive murphy’s sign
  o ask patient to breath out, plaxing hand below right costal margin then ask to breath in

Question 27

A 30 year old man presents with 3 weeks of bloody diarrhoea. Colonoscopy shows pancolitis but no involvement of the terminal ileum. Biopsies from the colon show a mixed inflammatory infiltrate with crypt distortion and crypt abscesses but no granuloma formation. Regarding this patient’s illness which of the following statements is most correct? (UC)
A. Testing for the CARD15/NOD2 gene mutation is likely to be positive in this patient.
B. Confluent inflammation of the whole colon with no ileal involvement, no full thickness lesions or skip lesions suggests this is ulcerative colitis.
C. Corticosteroid therapy can be considered first line therapy for induction and maintenance of remission in this situation.
D. Rectally administered 5-aminosalicylic acid is the treatment of choice for this patient.

Answer 27

B. Confluent inflammation of the whole colon with no ileal involvement, no full thickness lesions or skip lesions suggests this is ulcerative colitis.

Question 28

Q2. With regard to the distribution and complications of IBD which statement is most accurate?
A. The vast majority of UC patients have disease that involves the whole colon
B. UC patients are more likely to have surgery for their IBD
C. Ileocaecal Crohn’s is more common that small bowel involvement alone
D. UC causes marked thickening and scarring of the colon

Answer 28

C. Ileocaecal Crohn’s is more common that small bowel involvement alone

Question 29

Q3. Regarding the epidemiology of IBD which statement is most accurate?
A. New Zealand is an island off the northern tip of Australia.
B. New Zealand’s incidence of UC is significantly higher than its CD incidence.
C. Most IBD patients in NZ are of Māori or Pasifika ethnicity
D. NZ has one of the highest rates of CD recorded

Answer 29

D. NZ has one of the highest rates of CD recorded

Question 30

Q4. Regarding the treatment of IBD which statement is most true?
A. It is more common for CD patients to fail treatment and require surgery than UC.
B. The management of IBD is purely pharmacological and with effective therapeutic choices the remission rate is 100%.
C. 5ASA for UC is superior given orally than rectally and the combination of oral and rectal therapy is contraindicated.
D. Prednisone is an effective treatment for the remission and maintenance of CD but not UC.

Answer 30

A. It is more common for CD patients to fail treatment and require surgery than UC.

Question 31

Q5. Regarding the use of biologics in IBD in NZ which statement is most true?
A. Both Adalimumab and Infliximab are indicated and funded for UC and CD in NZ.
B. Special authority applications for Adalimumab usually require the recent completion of a Crohn’s disease activity index or fistula assessment score for initiation and continuation.
C. While infliximab is effective for fistulizing CD, Adalimumab is not used for this indication in NZ.
D. In patients with severe and disabling Crohn’s disease Adalimumab is funded for use prior to initiation of Azathioprine.

Answer 31

B. Special authority applications for Adalimumab usually require the recent completion of a Crohn’s disease activity index or fistula assessment score for initiation and continuation.

Question 32

Q6. Regarding the efficacy of current available treatments in IBD which statement is most true?
A. Registration studies of Infliximab and Adalimumab demonstrated significantly improved response and remission rates for CD when compared to previous studies of Azathioprine and Methotrexate.
B. Registration studies of Infliximab and Adalimumab demonstrated significantly improved response and remission rates for UC when compared to previous studies of 5ASA.
C. Initial studies of Infliximab demonstrating fistula closure rates of 60% were an immense improvement on previously available treatments.
D. Infliximab has been shown to be superior to Adalimumab for the treatment of UC.

Answer 32

C. Initial studies of Infliximab demonstrating fistula closure rates of 60% were an immense improvement on previously available treatments.

Question 33

Q7. Regarding the long-term risks of using biologics in IBD which statement is most correct?
A. Biologics are associated with increased rates of opportunistic infection when compared to prednisone and other immunosuppressants.
B. Biologics significantly increase the risk of Hodgkin’s lymphoma.
C. Biologics are unsafe in pregnancy and should be stopped as soon as possible.
D. While biologics are useful for the treatment of skin conditions like psoriasis; they can paradoxically cause such conditions when used to treat other conditions.

Answer 33

D. While biologics are useful for the treatment of skin conditions like psoriasis; they can paradoxically cause such conditions when used to treat other conditions.

Question 34

Q8. Regarding the long-term efficacy of using biologics in IBD which statement is most correct?
A. Biologics in real-life practice are just as efficacious as they were in the registration studies and that efficacy continues over long periods of time.
B. Secondary loss of response to biologic is a problem in both CD and UC.
C. Azathioprine and Infliximab have similar molecular weights but Infliximab is more immunogenic because of its high antigenicity.
D. Secondary loss of response is a problem with Infliximab, a chimeric antibody, but not with Adalimumab, a fully humanized antibody.

Answer 34

B. Secondary loss of response to biologic is a problem in both CD and UC.

Question 35

Q9. Regarding the prevention of secondary loss of response to biologic due to anti-drug antibodies which statement is most correct?
A. The absence of anti-drug antibodies on ELISA testing always indicates that any secondary loss of response is due to other mechanisms.
B. Methotrexate, but not Azathioprine, is effective for preventing anti-drug antibody formation and secondary loss of response.
C. Episodic, rather than continuous, use of Infliximab is associated with increased rates of anti-drug antibody formation.
D. In NZ we have excellent access to novel therapies for the treatment of patients who have lost response due to anti-drug antibodies.

Answer 35

C. Episodic, rather than continuous, use of Infliximab is associated with increased rates of anti-drug antibody formation.

Question 36

Q10. Regarding the management of secondary loss of response to biologic which statement is most correct?
A. In a patient who has had secondary loss of response and anti-drug antibodies to Infliximab and Adalimumab, use of novel therapies such as anti-IL12/23 or anti-adhesion molecules would be the best current medical alternative if they were available in NZ.
B. If a patient with CD on Adalimumab has very low drug levels and anti-drug antibodies present, the only available treatment option is to increase the dose of Adalimumab.
C. When a patient on Adalimumab has low levels of drug but no antibodies present it can be assumed they are non-adherent to the medication regimen.
D. In NZ there is no way to gain access to intensified (double dosed) Adalimumab or Infliximab, even for a short time.

Answer 36

A. In a patient who has had secondary loss of response and anti-drug antibodies to Infliximab and Adalimumab, use of novel therapies such as anti-IL12/23 or anti-adhesion molecules would be the best current medical alternative if they were available in NZ.

Question 37

16. Pancreatic Cancer
    Investigations:
    ● ALP and bilirubin raised if obstruction is present
    ● CT or MRCP are the preferred tests
    ● In the case of obstructive jaundice, can use ERCP as the initial investigation
    ● Fine needle aspiration is usually needed for confirmation of the diagnosis

Answer 37

● CT or MRCP are the preferred tests