Gastro Flashcards
What’s the rule for PBC?
The M rule:
IgM
anti-Mitochondrial ab M2
Middle aged females
Early signs - asymptomatic eg raised ALP on routine LFTs, fatigue pruritis
Suggestive of?
PBC
What other conditions is PBC associated with?
Sjogren’s syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease
When for liver transplant in PBC?
Bilirubin >100
Histology showing:
inflammation in all layers from mucosa to serosa
goblet cells
granulomas
Suggestive of?
Crohns
Diarrhoea, weight loss, arthralgia, lymphadenopathy, ophthalmoplegia - what condition? cause? more common in who?
Whipples disease - Infection by tropheryma whipplei
More common in HLA B27 +ve and middle aged MEN
jejunal biopsy shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules - which disease?
Whipples disease
Severity of UC flare ups?
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)
Mx of severe UC colitis?
Admission + IV steroids
(IV ciclosporin if CI)
If no improvement in 72h consider adding IV ciclosporin / surgery
Flushing, diarrhoea, bronchospasm, tricuspid stenosis, pellagra
Diagnosis? ix? mx?
Carcinoid syndrome
Ix - Urinary 5-HIAA + plasma chromogranin A y
Mx - Somatostatin analogue (octretride)
- Cyproheptadine may help with diarrhoea
biospy shows pigment laden macrophages in someone having diarrhoea is suggestive of? Colonscopy findings?
Laxative abuse (esp Senna)
Colonoscopy - dark-brown discolouration in the proximal colon (Melanosis coli)
What needs to be offered to everyone with Coeliac, how often and why?
Pneumococcal vaccination 5 yearly due to functional hyposplenism
Grading of hepatic encephalpathy?
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
Prophylaxis of hepatic encephalopathy?
Lactulose (increased excretion and metabolism of ammonia)
Can also add Rifaximin (Modulates gut flora -> decreased ammonia production)
Suspected pathophysiology of hepatorenal syndrome?
Sphlanchnic vasodilation -> underfilling of kidneys
Noticed by juxtaglomerular apparatus -> RAAS activation -> Renal vasoconstriction (doesn’t counterbalance enough)
Difference between Type 1 and 2 Hepatorenal syndrome?
Type 1 - rapidly progressive - v. poor prognosis
Type 2 - slowly progressive - poor prognosis but better than type 1
Electrolyte abnormalities in refeeding syndrome?
Hypophosphataemia (HALLMARK)
-> muscle weakness inc cardiac (-> cardiac failure) and diaphragm (-> resp failure)
Hypokalaemia
Hypomagnesaemia (can lead to trosades de pointes)
Abnormal fluid balance
Mode of transmission - C Diff
Faecoral via ingestion of spores
Markers of pancreatitis severity?
age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST
mx of eosinophilic oesophagitis?
Dietary modification + topical steroids
Oesophageal dilatation - reduces sx associated with strictures
Signs of life threatening C Diff? Mx?
Hypotension
Partial or complete ileus
Toxic megacolon, or CT evidence of severe disease
Mx: Oral Vanc + IV Metro
What bloods in Coeliac?
TTG ab
IgA - if IgA deficiency gives false +ve
(Can also look at anti-fliadin and anti-casein ab)
Histology:
villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes
Coeliac
Drug causes of cirrhosis?
Methotrexate
Methyldopa
Amiodarone
Drug causes of cholestasis +- hepatitis?
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin* (reduced w erythromycin stearate)
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine
Iron studies:
transferrin saturation > 55% in men or > 50% in women
raised ferritin (e.g. > 500 ug/l) and iron
low TIBC
Suggestive of? Which marker is most sensitive and specific for the condition?
Haemochromatosis
Transferrin sat > ferritin
- in early disease ferritin is usually normal
Liver and neurological disease -> diagnosis?
Wilsons
Tx for Wilsons?
Currently - Pencillamine (chelates copper)
Future - Trientine HCl (also chelating agent)
Tetrathomolybdate also under ix for possible use
What is angiodysplasia thought to be debatably associated with?
AS
Adverse effects of PPIs?
hyponatraemia, hypomagnasaemia
osteoporosis → increased risk of fractures
microscopic colitis
increased risk of C. difficile infections
Ix of small bowel bacterial overgrowth syndrome? similar to which other condition in presentation?
H breath test
Similar to IBS in presentation
Dysphagia, aspiration pneumonia, halitosis
Suggestive of which disease?
Pharyngeal pouch
How is SBP diagnosed?
Paracentesis with neutrophils >250 cells/ul
raised ALP/GGT and associated hyperbilirubinemia suggests?
Cholestatic picture
Which investigation is best for local staging of oesophageal / gastric ca?
Endoscopic USS
What drug can be useful if someone has had multiple episodes of C. Diff in the past?
Bezlotoxumab - Mab targeting C Diff toxin
H. pylori post-eradication therapy test?
Urea breath test
Where is Gastrin secreted from?
What does it do?
G cells in antrum of the stomach
Increases acid secretion by gastric parietal cells, pepsinogen and IF secretion, increases gastric motility, stimulates parietal cell maturation
Where is CCK released from?
What does it do?
I cells in upper small intestine
Increases secretion of enzyme-rich fluid from pancreas, contraction of gallbladder and relaxation of sphincter of Oddi, decreases gastric emptying, trophic effect on pancreatic acinar cells, induces satiety
Where is Secretin released from?
What does it do?
S cells in upper small intestine
Increases secretion of bicarbonate-rich fluid from pancreas and hepatic duct cells, decreases gastric acid secretion, trophic effect on pancreatic acinar cells
Where is VIP released from?
What does it do?
Small intestine, pancreas
Stimulates secretion by pancreas and intestines, inhibits acid secretion
Where is somatostatin released from?
What does it do?
D cells in the pancreas & stomach
Decreases acid and pepsin secretion, decreases gastrin secretion, decreases pancreatic enzyme secretion, decreases insulin and glucagon secretion
inhibits trophic effects of gastrin, stimulates gastric mucous production
What does a high SAAG tell us?
Indicates portal HTN
Scoring system for likelihood of appendicitis?
Alvarado score
What is the scoring system for prognosis in liver cirrhosis?
Child-Pugh
What is the scoring system used in end-stage liver disease?
MELD score - Model for End-Stage Liver Disease
Uses a combination of a patient’s bilirubin, creatinine, and the international normalized ratio (INR) to predict survival.
Which Mab can be used for C Diff? When to consider FMT?
Bezlotoxumab
FMT can be used if pts have had 2+ episodes
Best bloods to monitor tx in haemochromatosis?
Transferrin saturation and ferritin
What is angiodysplasia?
What is it associated with?
Vascular deformity of GI tract -> bleeding and IDA
Associated with AS and generally older patients
Which drugs cause cholestasis?
Cholestasis Always Stops The Paediatrician From Saving the NHS
COCP
Antibiotics (fluclox, co-amox, erythromycin)
Steroids (anabolic)
Testosterone
Phenothiazines (chlorpromazine, prochlorperazine)
Fibrates
Sulfonylureas
Nifedipine
What are some common triggers for liver decompensation in cirrhotic patients?
Constipation / Diarrhoea
Infection
Electrolyte imbalances
Dehydration
UGIB
Increased alcohol intake
Medical prophylaxis against oesophageal variceal bleeding?
NSBB - Propanolol
Mx of ascites?
Aldosterone antagonists eg Spironolactone
1st line test for small bowel overgrowth syndrome? mx?
H breath testing
mx: Rifaximin
Mx of FAP?
Total proctocolectomy w/ ileal pouch anastomosis due to extremely high risk of Colorectal Ca
Prophylaxis of variceal haemorrhage?
Propanolol (Non-cardioselective B blocker)
What is the screening test for Haemochromatosis?
general population: transferrin saturation > ferritin
family members: HFE genetic testing
Charcots triad + pentad for ascending cholangitis?
Triad - Fever, RUQ pain, jaundice
Pentad = + hypotension + confusion
What are the options for H Pylori eradication therapy?
PPI + amoxicillin + clarithromycin, or
PPI + metronidazole + clarithromycin (pen allergic)
What causes biliary colic pain and what cells are involved?
Biliary colic - contraction of gall bladder against obstruction particularly after fatty foods
This is stimulated by CCK (Cholecystokinin) from I cells in duodenum
How does hepatorenal syndrome present? How can it be managed?
ascites, low urine output, and a significant increase in serum creatinine
Mx - Terlipressin (vasopressin analogue) - leads to splanchnic vasoconstriction -> reduced portal pressure improving renal blood flow
Diarrhoea, weight, arthralgia, lymphadenopathy, ophthalmoplegia
Suggestive of which disease?
Whipples disease
What is Zollinger-Ellison syndrome? example of how it can be caused and hormone involved?
This is when tumours in GI system / pancreas lead to increased acidity of the stomach
Eg Gastrinoma - too much gastrin -> increased H secretion by gastric parietal cells
What is the role of secretin?
Secretin increases secretion of bicarbonate-rich fluid from pancreas and hepatic duct cells
Also decreases stomach acid secretion
What should be done in patients where NAFLD is found?
Refer for ELF (enhanced liver fibrosis) test
Diagnostic test for PSC? What does it show
endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) are the standard diagnostic investigations, showing multiple biliary strictures giving a ‘beaded’ appearance
Diagnostic ix of choice in pancreatic ca?
High res CT
Which type of oesophageal ca is associated with GORD / Barretts?
Oesophageal adenocarcinoma
Inheritance pattern of Wilsons diease?
Wilsons is autosomally recessive
Gold standard ix in GORD?
24hr oesophageal pH monitoring - consider when endoscopy is -ve
What is courvoisiers sign?
Palpable gallbladder in presence of painless jaundice unlikely to be gallstones
can be seen in eg cholangiocarcinoma, pancreatic ca, choledocholithiasis, PSC, biliary stricture
What is HNPCC also known as? Which ca does it increase risk of? gene?
HNPCC is also known as lynch syndrome - autosomally dominant
Increases risk of colorectal ca (also endometrial)
MSH2 in 60% and MLH1 in 30%
What is a possible complication of TPN and the liver?
Can lead to TPN associated liver disease / LFT derangement (much milder increase than other forms of liver disease)
What are the features of Peutz Jeghers syndrome?
Autsomally dominant condition -> Multiple hamartomatous polyps in GI tract
Pigmented leisons on palm, lips, face and soles
Can cause complications eg intestinal obstruction (often due to intussusception), GI bleeding (+IDA)
What are some complications assoicated with Coeliac?
Anaemia - IDA, B12 and folate (F>B12)
Hyposplenism
Osteoporosis + malacia
Lactose intolerance
Enteropathy associated T cell lymphoma of SI
Subfertility
Rarely - oesophageal ca + other malignancies
IDA + AS is suggestive of which condition and how can it be diagnosed?
Angiodysplasia
Dx:
Colonoscopy or mesenteric angiography (if acutely bleeding)
Where is most of the copper deposited in Wilsons in the brain?
Basal ganglia -> parkinsonian symptoms
Symptoms of diabetes mellitus, a tan, and erectile dysfunction. This including signs of heart failure and liver disease on examination should trigger the potential diagnosis of what condition?
Gene involved?
Haemochromatosis - associated with HFE gene and is autosomally recessive
Why is ALT not very useful in assessing severity of liver cirrhosis?
Elevated in conditions with hepatocellular damage but isn’t correlated with severity of cirrhosis
Additionally, in late cirrhosis - ALT can be low / normal due to reduced hepatic mass
When should a +ve diagnosis of IBD be made?
A positive diagnosis of IBS should be made if the patient has abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms:
> altered stool passage (straining, urgency, incomplete evacuation)
> abdominal bloating (more common in women than men), distension, tension or hardness
> symptoms made worse by eating
> passage of mucus
Can mothers with hep B breastfeed their babies?
Yes they can as HBV isnt transmitted via breast milk
What is the most important intervention to reduce risk of further episodes of Crohns?
Stop smoking
Why can duodenal ulcers cause bleed?
They’re usually posteriorly sited and can erode gastroduodenal artery
Why can you get diarrhoea after Ileal resection?
How can this be treated?
Due to malabsorption of bile salts
This can be treated with oral cholestyramine
What some causes of raised ferritin without iron overload?
Inflammation (due to ferritin being an acute phase reactant)
Alcohol excess
Liver disease
Chronic kidney disease
Malignancy
What are some causes of raised ferritin with iron overload (raised transferrin sat)?
Primary iron overload (hereditary haemochromatosis)
Secondary iron overload (e.g. following repeated transfusions)
Where does inflammation in ulcerative colitis not spread past?
The ileocaecal valve
What are the histological features of Crohns?
Inflammation in all layers from mucosa to serosa
> increased goblet cells
> granulomas
What are the histological features of UC?
No inflammation beyond submucosa (unless fulminant disease) - inflammatory cell infiltrate in lamina propria
> neutrophils migrate through the walls of glands to form crypt abscesses
> depletion of goblet cells and mucin from gland epithelium
> granulomas are infrequent
Endoscopic features of Crohns?
Deep ulcers, skip lesions - ‘cobble-stone’ appearance
Endoscopy reveals: “Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)”
In which condition?
UC
RFs for gastric ca?
H pylori
Pernicious anaemia
Diet - salt + salt preserved foods, nitrates
Ethnic - japan / china
Smoking
Blood group A
Most common type of inherited colorectal Ca?
Hereditary non-polyposis colorectal carcinoma (HNPCC) aka Lynch syndrome
What is the triad of Plummer-Vinson syndrome?
How is treated?
dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia
Treatment includes iron supplementation and dilation of the webs
Which area of bowel is most likely to be affected by ischaemic colitis?
Splenic flexure (aka left colic flexure)
How can you assess mural invasion in oesophageal / gastric ca?
Endoscopic ultrasound - helps with loco-regional staging
Which laxative should be avoided in IBS?
Lactulose
What is seen in jejunal biopsy of those with Whipples disease?
jejunal biopsy shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules
Which syndrome typically presents with multiple gastroduodenal ulcers causing abdominal pain and diarrhoea?
What is this often associated with?
Zollinger-Ellison - gastrin secreting tumour
30% is associated with MEN 1
Diarrhoea + Hypokalaemia is suggestive of which condition?
Villous adenoma - colonic polyps with potential for malignant transformation
May often secrete large amounts of mucous potentially leading to electrolyte disturbance
Which patients should be offered abx prophylaxis against SBP?
Those with ascites if:
- previous episode of SBP
- Fluid protein <15g/l and either ChildPugh score of 9 or more / Hepatorenal syndrome
Abx = oral cipro / norfloxacin
What is Budd-Chiari syndrome and what is the triad?
Budd-Chiari syndrome, or hepatic vein thrombosis, is usually seen in the context of underlying haematological disease or another procoagulant condition
Triad:
> abdominal pain: sudden onset, severe
> ascites → abdominal distension
> tender hepatomegaly
What is the most common complication of ERCP?
Pancreatitis
When should oral aminosalicyates be added to rectal in mx of mild-moderate flares of UC?
Flare extending past the left-sided colon
Where are gastrinomas typically found
1st part of duodenum
Mx of SBP?
IV Cefotaxime
Metabolic ketoacidosis with normal/ low glucose is suggestive of?
Alcoholic ketoacidosis
Causes of raised anion gap metabolic acidosis?
Methanol
Uraemia (renal failure)
Diabetic ketoacidosis
Paracetamol use (chronic)
Iron, isoniazid
Lactic acidosis
Ethylene glycol
Salicylate overdose
What is a high SAAG suggestive of?
Portal HTN (>11g/L)
Which cells release somatostatin in the GI system?
D cells in pancreas and stomach
What is microscopic colitis and how does this present? ix? cause?
Present with chronic diarrhoea, colonoscopy and biopsy should be considered when patients present in this way
can be caused by PPI use
What does gastrin do?
Increases acid secretion by gastric parietal cells
Increases pepsinogen secretion
IF secretion
Increases gastric motility
Stimulates parietal cell maturation
What are the RFs for squamous cell carcinoma v adenocarcinoma in oesophageal ca?
SCC:
- Alcohol
- Smoking
- Plummer Vinson
- Achalasia
Adenocarcinoma
- Alcohol
- Smoking
- Barretts oesophagus
What are the majority of pancreatitis in pregnancy secondary to?
Secondary to gallstones
Factors that affect severity of pancreatitis?
age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST
Alcoholic hepatitis bloods + mx?
Bloods:
- gamma-GT is characteristically elevated
- the ratio of AST:ALT is normally > 2, a ratio of > 3 is strongly suggestive of acute alcoholic hepatitis
Mx:
- glucocorticoids (e.g. prednisolone) are often used during acute episodes of alcoholic hepatitis
- Use Maddrey’s discriminant function (DF) is often used during acute episodes to determine who would benefit from glucocorticoid therapy
What imaging is required in PBC?
required before diagnosis to exclude an extrahepatic biliary obstruction
typically a RUQ USS or MRCP
Which one of the following features is not seen in carcinoid syndrome?
HTN
Most common cause of HCC?
hepatitis B most common cause worldwide
hepatitis C most common cause in Europe
Obesity with abnormal LFTs – dx?
NAFLD
When is surgery indicated in UGIB?
Surgery is indicated in patients with ongoing acute bleeding despite repeated endoscopic therapy
Does Wilsons increase risk of HCC?
No
Conditions of urea breath test?
no antibiotics in past 4 weeks,
no antisecretory drugs (e.g. PPI) in past 2 weeks
Advanced dementia not eating well - can you use PEG?
PEG insertion is not normally recommended in advanced dementia patients
What percentage of patients with Peutz-Jeghers syndrome will have died from a related cancer by the age of 60 years?
50%
What are the features of the child pugh scoring and offer poor prognosis for Liver cirrhosis?
Bilirubin levels
Albumin levels
PT time
Encephalopathy
Ascites
Mx of HCC?
Based on Barcelona Classification for Liver Cancer Treatment System
Child-Pugh A cirrhosis w/out portal HTN + single leison <2cm = surgical resection
Child-Pugh A and B cirrhosis and 2-3 tumours <= 3 cm or 1 tumour <=5 cm without vascular invasion or extrahepatic spread = should be considered for liver transplantation.
-> As a bridge to liver transplantation these patients can be treated with TACE or RFA
For those patients who have Child-Pugh A or B cirrhosis , good performance status, and evidence of vascular, lymphatic or extrahepatic spread the multiple tyrosine kinase inhibitor, Sorafenib, has been shown to prolong survival
Child-Pugh C = Best supportive care
Budd-Chiari syndrome ix of choice?
USS with Doppler flow studies is very sensitive and should be the initial radiological investigation
How to distinguish between acute and chronic hep b infection?
AntiHBc ->if IgM +ve = acute infection
if IgG +ve -> chronic infection
In window period everything is negative but AntiHBc (IgM) -> +ve
What do you need to do before mx of PBC?
Imaging is required before making a diagnosis of PBC to exclude extrahepatic biliary obstruction
Risk of HCC with PBC
20x risk
Upon liver biopsy, which of the following pathological features is likely to be observed in liver cirrhosis?
Excess collagen and extracellular matrix deposition in periportal and pericentral zones leading to the formation of regenerative nodules
Histology in alcoholic steatohepatitis?
Macrovesicular fatty change with giant mitochondria, spotty necrosis and fibrosis
Histology in NAFLD?
Triglyceride accumulation with the proliferation of myofibroblasts
Reversal agent of dabigatran?
Idarucizumab - praxbind
Diagnositic test of gilberts?
unconjugated hyperbilirubinaemia (i.e. not in urine)
investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid
Mx of UC flare?
Start w topical aminosalicylate (unless extensive diseaes then start with topical and oral)
No remission in 4w -> oral aminosalicylate (unless extensive disease stop topical and add oral steroid)
For proctitis -> add topical / oral corticosteroid
For proctosigmoiditis -> stop topical and oral aminosalicylate + corticosteroid
Maintaining UC remission Following a severe relapse or >=2 exacerbations in the past year?
Oral azathioprine / oral mercaptopurine
Methotrexate UC v Crohns?
methotrexate is not recommended for the management of UC (in contrast to Crohn’s disease)
What is H Pylori associated w?
peptic ulcer disease
- 95% of duodenal ulcers
- 75% of gastric ulcers
gastric cancer
B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of patients)
atrophic gastritis
What is PSC associated with?
ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC
Crohn’s (much less common association than UC)
HIV
Diabetes and NAFLD link?
Associated with T2DM not T1DM
Which bypass is associated with NAFLD? what else?
jejunoileal bypass
obesity
type 2 diabetes mellitus
hyperlipidaemia
sudden weight loss/starvation
CI for liver biopsy?
deranged clotting (e.g. INR > 1.4)
low platelets (e.g. < 60 * 109/l)
anaemia
extrahepatic biliary obstruction
hydatid cyst
haemoangioma
uncooperative patient
ascites
Where do the majority of VIPomas arise from? presentation?
Pancreas
WDHA syndrome
WD-watery diarrhea
H- hypokalemia
A- achlorhydria
signet ring cells found in which GI ca?
Gastric adenocarcinoma
Malignant colorectal ca mx?
Colorectal carcinoma is one of the only oncological diseases where the presence of a metastatic deposit can be treated with curative intent
Factors that lead to gastrin secretion?
C - Calcium
A - Amino Acid, Acetylcholine
P - Peptide (luminal)
E - Epinephrine
Features and non-typical of achalasia?
Whilst dysphagia of solids and liquids is a classic history for achalasia, certain features such as significant weight loss are not consistent and suggest cancer - ‘pseudoachalasia’
Globus hystericus features?
There may be a history of anxiety
Symptoms are often intermittent and relieved by swallowing
Usually painless - the presence of pain should warrant further investigation for organic causes
Kantor’s string sign on CT is seen in?
Crohns
Oesophageal ca barium swallow?
Oesophageal stricture with apple core effect
Dilated tapering oesophagus is the finding on barium swallow suggests what?
Achalasia
can also see Hypertensive lower oesophageal sphincter
Corkscrew oesophagus is a finding on barium swallow for what dx?
Oesophagitis
Is there a Hep C vaccine?
NOOOOOO
A CT abdomen is arranged, which demonstrates simultaneous dilatation of the common bile duct and pancreatic ducts.
This suggests what dx and what is the sign?
The ‘double duct’ sign may be seen in pancreatic cancer
NB can also be seen w cholangiocarcinoma however pancreatic ca is more common
How can smoking trigger UC flare?
If you stop smoking!!!
In haemochromatosis what features are reversible with treatment?
Cardiomyopathy and skin pigmentation
Gastric enzymes and their products?
Amylase - in saliva + pancreatic secretions = starch -> sugar
Brush border enzymes:
- Maltase - disaccharide maltose -> glucose + glucose
- Sucrase - sucrose -> fructose + glucose
- Lactase - disaccharide lactose -> glucose + galactose
HLA associations of coeliac?
HLA-DQ2 (95% of patients) and HLA-DQ8 (80%).
Which laxative can be carcinogenic?
Co-danthramer is genotoxic and should only be prescribed to palliative patients due to its carcinogenic potential
Roux-en-Y gastric bypass. Of which vitamin/mineral is she most likely to require supplementation?
Iron +- Ca - duodenum is primary site of absorption for calcium and iron and gastric bypass operations bypass the duodenum
Acute fatty liver of pregnancy?
Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery.
Abdo pain, N+V, jaundice, hypoglycaemia, severe disease can -> pre-eclampsia
ix ALT raised
mx supportive + when stable delivery = definitive
Causes of jejunal villous atrophy?
coeliac disease
tropical sprue
hypogammaglobulinaemia
gastrointestinal lymphoma
Whipple’s disease
cow’s milk intolerance
Which adverse effect of aminosalicylates is reduced with mesalazine?
sulphapyridine side-effects = rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis
Obesity - NICE bariatric referral cut-offs
with risk factors (T2DM, BP or other condition related to raised BMI): > 35 kg/m^2
no risk factors: > 40 kg/m^2
Which Ig is raised with differnt GI disorder?
Alcoholic liver disease - IgA
AI hepatitis - IgG
PBC - IgM
After AGM you drink lots of alcohol, then ge AI hepatitis which leads to cirrhossi
drug causes of dyspepsia?
Causes
NSAIDs
bisphosphonates
steroids
The following drugs may cause reflux by reducing lower oesophageal sphincter (LOS) pressure
calcium channel blockers*
nitrates*
theophyllines
Mx of pyogenic liver abscess and the organisms?
drainage (typically percutaneous) and antibiotics
amoxicillin + ciprofloxacin + metronidazole
if penicillin allergic: ciprofloxacin + clindamycin
most common organisms found in pyogenic liver abscesses are Staphylococcus aureus in children and Escherichia coli in adults.
Mx of IBS?
First-line pharmacological treatment - according to predominant symptom
>pain: antispasmodic agents
>constipation: laxatives but avoid lactulose
>diarrhoea: loperamide is first-line
2nd line:
low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors
Psychological interventions but acupuncture / reflexology not recommeneded
A retrocardiac air-fluid level can be seen in CXR of which patients?
Achalsia
Severe abdo pain + fundoscopy reveals shows multiple micro infarcts (cotton wool spots)
dx?
Pancreatitis
Which one of the following types of bariatric surgery is most likely to cause significant malabsorption?
Biliopancreatic diversion with duodenal switch
Which drugs can cause hepatocellular picture in LFTs - largely raised ALT also AST
paracetamol
sodium valproate, phenytoin
MAOIs
halothane
anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
statins
alcohol
amiodarone
methyldopa
nitrofurantoin
Colorectal cancer screening - PPV of FOB ?
5 - 15%
Investigation of choice for bile acid malabsorption?
SeHCAT
Cholestatic LFTs in HIV cause?
Sclerosing cholangitis due to infections such as CMV, Cryptosporidium and Microsporidia
Pancreatitis in HIV?
Pancreatitis in the context of HIV infection may be secondary to anti-retroviral treatment (especially didanosine) or by opportunistic infections e.g. CMV
Dubin-Johnson syndrome outcome?
autosomal recessive disorder resulting in hyperbilirubinaemia (conjugated, therefore present in urine)
Defect in canillicular multispecific organic anion transporter (cMOAT) protein. This causes defective hepatic bilirubin excretion
An OGD 3 weeks ago showed gastric erosions and ulcers
Dx? and ix?
Zollinger Ellison syndrome
ix = Fasting gastrin - best, secretin stimulation test
surgical options of bariatric surgery?
laparoscopic-adjustable gastric banding (LAGB)
it is normally the first-line intervention in patients with a BMI of 30-39kg/m^
sleeve gastrectomy - typically BMI >40
biliopancreatic diversion with duodenal switch - usually reserved for very obese patients (e.g. BMI > 60 kg/m^2)
Which of the following anti-retroviral drugs is most characteristically associated with pancreatitis?
Didanosine
MSH2 gene. What is the function of this gene?
HNPCC DNA mismatch repair
adverse effects is least associated with sulfasalazine?
Visual disturbance
In liver disease, particularly in the context of severe acute alcoholic hepatitis as presented in this case, there is often a coagulopathy due to impaired synthesis of clotting factors by the damaged liver
Which clotting factor is increased however?
Factor 8 (VIII) - ?decreased clearance by dysfunctional liver
Causes of hepatosplenomegaly
chronic liver disease* with portal hypertension
infections: glandular fever, malaria, hepatitis
lymphoproliferative disorders
myeloproliferative disorders e.g. CML
amyloidosis
chronic diarrhoea in PPI use is suggestive of what? ix?
Microscopic colitis
Colonoscopy + biopsy showing presence of increased numbers of intra epithelial lymphocytes (≥20 lymphocytes per 100 epithelial cells), with little or no disruption of the mucosal architecture
Ongoing diarrhoea in Crohn’s patient post-resection with normal CRP → mx?
Cholestyramine
The majority of gastrinomas are found where?
1st part of duodenum
The endoscopic appearance of the small bowel is unremarkable. Biopsy samples show non-specific eosinophilia.
Suggests what dx?
small bowel overgrowth syndrome
