GASTRO

Question 1

When do you urgently refer patients with dyspepsia?

Answer 1

All patients who’ve gotdysphagia

All patients who’ve got anupper abdominal massconsistent with stomach cancer

Patients aged >= 55 years who’ve gotweight loss, AND any of the following:

upper abdominal pain

reflux

dyspepsia

Question 2

How to test for H Pylori?

Answer 2

carbon-13 urea breath test or a stool antigen test, or laboratory-based serology
there is no need to check for H. pylori eradication if symptoms have resolved following test and treat
however, if repeat testing is required then a carbon-13 urea breath test should be used

Question 3

When do you non urgently refer for dyspepsia

Answer 3

Patients with haematemesis

Patients aged >= 55 years who’ve got:
treatment-resistant dyspepsia or
upper abdominal pain with low haemoglobin levels or
raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain

Question 4

Management of dyspepsia in GP

Answer 4

1. Review medications
2. Lifestyle advice
3. Trial PPI month OR a ‘test and treat’ approach for H. pylori
   if symptoms persist after either of the above approaches then the alternative approach should be tried

Question 5

upper gastrointestinal bleeding which is most commonly due to

Answer 5

peptic ulcer disease or oesophageal varices

Question 6

Which blood products are used in acute upper GI bleed

Answer 6

platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre
fresh frozen plasma to patients who have either a fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal
prothrombin complex concentrate to patients who are taking warfarin and actively bleeding

Question 7

Mx variceal bleed

Answer 7

terlipressin and prophylactic antibiotics
band ligation should be used for oesophageal varices
injections of N-butyl-2-cyanoacrylate for patients with gastric varices
transjugular intrahepatic portosystemic shunts (TIPS) last line

Question 8

How and who is screened for hepatocellular carcinoma?

Answer 8

ultrasound (+/- alpha-fetoprotein)

liver cirrhosis secondary to
hepatitis B & C
haemochromatosis
men with liver cirrhosis secondary to alcohol

Question 9

Immunology of primary biliary cholangitis

Answer 9

anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific

Question 10

Associating of primary biliary cholangitis

Answer 10

Sjogren’s syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease

Question 11

Management of primary biliary cholangitis

Answer 11

first-line: ursodeoxycholic acid

pruritus: cholestyramine

fat-soluble vitamin supplementation

liver transplantation e.g. if bilirubin > 100 (PBC is a major indication)

Question 12

Hepatitis B serology

Answer 12

surface antigen (HBsAg) is the first marker to appear and causes the production of anti-HBs
HBsAg normally implies acute disease (present for 1-6 months)
if HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective)
Anti-HBs implies immunity (either exposure or immunisation). It is negative in chronic disease
Anti-HBc implies previous (or current) infection. IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months. IgG anti-HBc persists
HbeAg results from breakdown of core antigen from infected liver cells as is, therefore, a marker of infectivity. Marker of HBV replication and infectivity

Question 13

Mx c difficile

Answer 13

first-line therapy is oral vancomycin for 10 days
second-line therapy: oral fidaxomicin
third-line therapy: oral vancomycin +/- IV metronidazole

Recurrent episode
recurrent infection occurs in around 20% of patients, increasing to 50% after their second episode
within 12 weeks of symptom resolution: oral fidaxomicin
after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin

Life-threatening C. difficile infection
oral vancomycin AND IV metronidazole

Question 14

What is used to monitor treatment in haemochromatosis

Answer 14

Ferritin and transferrin saturation

Question 15

Prophylaxis of variceal haemorrhage

Answer 15

Propranolol
Endoscopic varicealband ligation
TIPPS if above unsuccessful