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MRCP - Passmed > Gastro > Flashcards

Gastro Flashcards

1
Q

What’s the rule for PBC?

A

The M rule:

IgM
anti-Mitochondrial ab M2
Middle aged females

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2
Q

Early signs - asymptomatic eg raised ALP on routine LFTs, fatigue pruritis

Suggestive of?

A

PBC

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3
Q

What other conditions is PBC associated with?

A

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

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4
Q

When for liver transplant in PBC?

A

Bilirubin >100

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5
Q

Histology showing:
inflammation in all layers from mucosa to serosa
goblet cells
granulomas

Suggestive of?

A

Crohns

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6
Q

Diarrhoea, weight loss, arthralgia, lymphadenopathy, ophthalmoplegia - what condition? cause? more common in who?

A

Whipples disease - Infection by tropheryma whipplei

More common in HLA B27 +ve and middle aged MEN

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7
Q

jejunal biopsy shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules - which disease?

A

Whipples disease

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8
Q

Severity of UC flare ups?

A

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)

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9
Q

Mx of severe UC colitis?

A

Admission + IV steroids
(IV ciclosporin if CI)

If no improvement in 72h consider adding IV ciclosporin / surgery

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10
Q

Flushing, diarrhoea, bronchospasm, tricuspid stenosis, pellagra

Diagnosis? ix? mx?

A

Carcinoid syndrome

Ix - Urinary 5-HIAA + plasma chromogranin A y

Mx - Somatostatin analogue (octretride)
- Cyproheptadine may help with diarrhoea

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11
Q

biospy shows pigment laden macrophages in someone having diarrhoea is suggestive of? Colonscopy findings?

A

Laxative abuse (esp Senna)

Colonoscopy - dark-brown discolouration in the proximal colon (Melanosis coli)

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12
Q

What needs to be offered to everyone with Coeliac, how often and why?

A

Pneumococcal vaccination 5 yearly due to functional hyposplenism

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13
Q

Grading of hepatic encephalpathy?

A

Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma

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14
Q

Prophylaxis of hepatic encephalopathy?

A

Lactulose (increased excretion and metabolism of ammonia)

Can also add Rifaximin (Modulates gut flora -> decreased ammonia production)

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15
Q

Suspected pathophysiology of hepatorenal syndrome?

A

Sphlanchnic vasodilation -> underfilling of kidneys

Noticed by juxtaglomerular apparatus -> RAAS activation -> Renal vasoconstriction (doesn’t counterbalance enough)

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16
Q

Difference between Type 1 and 2 Hepatorenal syndrome?

A

Type 1 - rapidly progressive - v. poor prognosis

Type 2 - slowly progressive - poor prognosis but better than type 1

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17
Q

Electrolyte abnormalities in refeeding syndrome?

A

Hypophosphataemia (HALLMARK)
-> muscle weakness inc cardiac (-> cardiac failure) and diaphragm (-> resp failure)

Hypokalaemia

Hypomagnesaemia (can lead to trosades de pointes)

Abnormal fluid balance

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18
Q

Mode of transmission - C Diff

A

Faecoral via ingestion of spores

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19
Q

Markers of pancreatitis severity?

A

age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST

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20
Q

mx of eosinophilic oesophagitis?

A

Dietary modification + topical steroids

Oesophageal dilatation - reduces sx associated with strictures

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21
Q

Signs of life threatening C Diff? Mx?

A

Hypotension
Partial or complete ileus
Toxic megacolon, or CT evidence of severe disease

Mx: Oral Vanc + IV Metro

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22
Q

What bloods in Coeliac?

A

TTG ab

IgA - if IgA deficiency gives false +ve

(Can also look at anti-fliadin and anti-casein ab)

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23
Q

Histology:
villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes

A

Coeliac

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24
Q

Drug causes of cirrhosis?

A

Methotrexate
Methyldopa
Amiodarone

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25
Q

Drug causes of cholestasis +- hepatitis?

A

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

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26
Q

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?

A

Haemochromatosis

Transferrin sat > ferritin
- in early disease ferritin is usually normal

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27
Q

Liver and neurological disease -> diagnosis?

A

Wilsons

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28
Q

Tx for Wilsons?

A

Currently - Pencillamine (chelates copper)

Future - Trientine HCl (also chelating agent)
Tetrathomolybdate also under ix for possible use

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29
Q

What is angiodysplasia thought to be debatably associated with?

A

AS

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30
Q

Adverse effects of PPIs?

A

hyponatraemia, hypomagnasaemia
osteoporosis → increased risk of fractures
microscopic colitis
increased risk of C. difficile infections

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31
Q

Ix of small bowel bacterial overgrowth syndrome? similar to which other condition in presentation?

A

H breath test

Similar to IBS in presentation

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32
Q

Dysphagia, aspiration pneumonia, halitosis

Suggestive of which disease?

A

Pharyngeal pouch

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33
Q

How is SBP diagnosed?

A

Paracentesis with neutrophils >250 cells/ul

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34
Q

raised ALP/GGT and associated hyperbilirubinemia suggests?

A

Cholestatic picture

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35
Q

Which investigation is best for local staging of oesophageal / gastric ca?

A

Endoscopic USS

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36
Q

What drug can be useful if someone has had multiple episodes of C. Diff in the past?

A

Bezlotoxumab - Mab targeting C Diff toxin

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37
Q

H. pylori post-eradication therapy test?

A

Urea breath test

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38
Q

Where is Gastrin secreted from?

What does it do?

A

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

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39
Q

Where is CCK released from?

What does it do?

A

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

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40
Q

Where is Secretin released from?

What does it do?

A

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

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41
Q

Where is VIP released from?

What does it do?

A

Small intestine, pancreas

Stimulates secretion by pancreas and intestines, inhibits acid secretion

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42
Q

Where is somatostatin released from?

What does it do?

A

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

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43
Q

What does a high SAAG tell us?

A

Indicates portal HTN

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44
Q

Scoring system for likelihood of appendicitis?

A

Alvarado score

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45
Q

What is the scoring system for prognosis in liver cirrhosis?

A

Child-Pugh

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46
Q

What is the scoring system used in end-stage liver disease?

A

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.

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47
Q

Which Mab can be used for C Diff? When to consider FMT?

A

Bezlotoxumab

FMT can be used if pts have had 2+ episodes

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48
Q

Best bloods to monitor tx in haemochromatosis?

A

Transferrin saturation and ferritin

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49
Q

What is angiodysplasia?

What is it associated with?

A

Vascular deformity of GI tract -> bleeding and IDA

Associated with AS and generally older patients

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50
Q

Which drugs cause cholestasis?

A

Cholestasis Always Stops The Paediatrician From Saving the NHS

COCP
Antibiotics (fluclox, co-amox, erythromycin)
Steroids (anabolic)
Testosterone
Phenothiazines (chlorpromazine, prochlorperazine)
Fibrates
Sulfonylureas
Nifedipine

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51
Q

What are some common triggers for liver decompensation in cirrhotic patients?

A

Constipation / Diarrhoea
Infection
Electrolyte imbalances
Dehydration
UGIB
Increased alcohol intake

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52
Q

Medical prophylaxis against oesophageal variceal bleeding?

A

NSBB - Propanolol

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53
Q

Mx of ascites?

A

Aldosterone antagonists eg Spironolactone

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54
Q

1st line test for small bowel overgrowth syndrome? mx?

A

H breath testing

mx: Rifaximin

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55
Q

Mx of FAP?

A

Total proctocolectomy w/ ileal pouch anastomosis due to extremely high risk of Colorectal Ca

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56
Q

Prophylaxis of variceal haemorrhage?

A

Propanolol (Non-cardioselective B blocker)

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57
Q

What is the screening test for Haemochromatosis?

A

general population: transferrin saturation > ferritin

family members: HFE genetic testing

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58
Q

Charcots triad + pentad for ascending cholangitis?

A

Triad - Fever, RUQ pain, jaundice

Pentad = + hypotension + confusion

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59
Q

What are the options for H Pylori eradication therapy?

A

PPI + amoxicillin + clarithromycin, or
PPI + metronidazole + clarithromycin (pen allergic)

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60
Q

What causes biliary colic pain and what cells are involved?

A

Biliary colic - contraction of gall bladder against obstruction particularly after fatty foods

This is stimulated by CCK (Cholecystokinin) from I cells in duodenum

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61
Q

How does hepatorenal syndrome present? How can it be managed?

A

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

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62
Q

Diarrhoea, weight, arthralgia, lymphadenopathy, ophthalmoplegia

Suggestive of which disease?

A

Whipples disease

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63
Q

What is Zollinger-Ellison syndrome? example of how it can be caused and hormone involved?

A

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

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64
Q

What is the role of secretin?

A

Secretin increases secretion of bicarbonate-rich fluid from pancreas and hepatic duct cells

Also decreases stomach acid secretion

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65
Q

What should be done in patients where NAFLD is found?

A

Refer for ELF (enhanced liver fibrosis) test

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66
Q

Diagnostic test for PSC? What does it show

A

endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) are the standard diagnostic investigations, showing multiple biliary strictures giving a ‘beaded’ appearance

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67
Q

Diagnostic ix of choice in pancreatic ca?

A

High res CT

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68
Q

Which type of oesophageal ca is associated with GORD / Barretts?

A

Oesophageal adenocarcinoma

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69
Q

Inheritance pattern of Wilsons diease?

A

Wilsons is autosomally recessive

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70
Q

Gold standard ix in GORD?

A

24hr oesophageal pH monitoring - consider when endoscopy is -ve

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71
Q

What is courvoisiers sign?

A

Palpable gallbladder in presence of painless jaundice unlikely to be gallstones

can be seen in eg cholangiocarcinoma, pancreatic ca, choledocholithiasis, PSC, biliary stricture

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72
Q

What is HNPCC also known as? Which ca does it increase risk of? gene?

A

HNPCC is also known as lynch syndrome - autosomally dominant

Increases risk of colorectal ca (also endometrial)

MSH2 in 60% and MLH1 in 30%

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73
Q

What is a possible complication of TPN and the liver?

A

Can lead to TPN associated liver disease / LFT derangement (much milder increase than other forms of liver disease)

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74
Q

What are the features of Peutz Jeghers syndrome?

A

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)

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75
Q

What are some complications assoicated with Coeliac?

A

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

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76
Q

IDA + AS is suggestive of which condition and how can it be diagnosed?

A

Angiodysplasia

Dx:
Colonoscopy or mesenteric angiography (if acutely bleeding)

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77
Q

Where is most of the copper deposited in Wilsons in the brain?

A

Basal ganglia -> parkinsonian symptoms

78
Q

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?

A

Haemochromatosis - associated with HFE gene and is autosomally recessive

79
Q

Why is ALT not very useful in assessing severity of liver cirrhosis?

A

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

80
Q

When should a +ve diagnosis of IBD be made?

A

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

81
Q

Can mothers with hep B breastfeed their babies?

A

Yes they can as HBV isnt transmitted via breast milk

82
Q

What is the most important intervention to reduce risk of further episodes of Crohns?

A

Stop smoking

83
Q

Why can duodenal ulcers cause bleed?

A

They’re usually posteriorly sited and can erode gastroduodenal artery

84
Q

Why can you get diarrhoea after Ileal resection?

How can this be treated?

A

Due to malabsorption of bile salts

This can be treated with oral cholestyramine

85
Q

What some causes of raised ferritin without iron overload?

A

Inflammation (due to ferritin being an acute phase reactant)
Alcohol excess
Liver disease
Chronic kidney disease
Malignancy

86
Q

What are some causes of raised ferritin with iron overload (raised transferrin sat)?

A

Primary iron overload (hereditary haemochromatosis)

Secondary iron overload (e.g. following repeated transfusions)

87
Q

Where does inflammation in ulcerative colitis not spread past?

A

The ileocaecal valve

88
Q

What are the histological features of Crohns?

A

Inflammation in all layers from mucosa to serosa
> increased goblet cells
> granulomas

89
Q

What are the histological features of UC?

A

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

90
Q

Endoscopic features of Crohns?

A

Deep ulcers, skip lesions - ‘cobble-stone’ appearance

91
Q

Endoscopy reveals: “Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)”

In which condition?

A

UC

92
Q

RFs for gastric ca?

A

H pylori
Pernicious anaemia
Diet - salt + salt preserved foods, nitrates
Ethnic - japan / china
Smoking
Blood group A

93
Q

Most common type of inherited colorectal Ca?

A

Hereditary non-polyposis colorectal carcinoma (HNPCC) aka Lynch syndrome

94
Q

What is the triad of Plummer-Vinson syndrome?

How is treated?

A

dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia

Treatment includes iron supplementation and dilation of the webs

95
Q

Which area of bowel is most likely to be affected by ischaemic colitis?

A

Splenic flexure (aka left colic flexure)

96
Q

How can you assess mural invasion in oesophageal / gastric ca?

A

Endoscopic ultrasound - helps with loco-regional staging

97
Q

Which laxative should be avoided in IBS?

A

Lactulose

98
Q

What is seen in jejunal biopsy of those with Whipples disease?

A

jejunal biopsy shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules

99
Q

Which syndrome typically presents with multiple gastroduodenal ulcers causing abdominal pain and diarrhoea?
What is this often associated with?

A

Zollinger-Ellison - gastrin secreting tumour

30% is associated with MEN 1

100
Q

Diarrhoea + Hypokalaemia is suggestive of which condition?

A

Villous adenoma - colonic polyps with potential for malignant transformation

May often secrete large amounts of mucous potentially leading to electrolyte disturbance

101
Q

Which patients should be offered abx prophylaxis against SBP?

A

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

102
Q

What is Budd-Chiari syndrome and what is the triad?

A

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

103
Q

What is the most common complication of ERCP?

A

Pancreatitis

104
Q

When should oral aminosalicyates be added to rectal in mx of mild-moderate flares of UC?

A

Flare extending past the left-sided colon

105
Q

Where are gastrinomas typically found

A

1st part of duodenum

106
Q

Mx of SBP?

A

IV Cefotaxime

107
Q

Metabolic ketoacidosis with normal/ low glucose is suggestive of?

A

Alcoholic ketoacidosis

108
Q

Causes of raised anion gap metabolic acidosis?

A

Methanol
Uraemia (renal failure)
Diabetic ketoacidosis

Paracetamol use (chronic)
Iron, isoniazid
Lactic acidosis
Ethylene glycol
Salicylate overdose

109
Q

What is a high SAAG suggestive of?

A

Portal HTN (>11g/L)

110
Q

Which cells release somatostatin in the GI system?

A

D cells in pancreas and stomach

111
Q

What is microscopic colitis and how does this present? ix? cause?

A

Present with chronic diarrhoea, colonoscopy and biopsy should be considered when patients present in this way

can be caused by PPI use

112
Q

What does gastrin do?

A

Increases acid secretion by gastric parietal cells

Increases pepsinogen secretion

IF secretion

Increases gastric motility

Stimulates parietal cell maturation

113
Q

What are the RFs for squamous cell carcinoma v adenocarcinoma in oesophageal ca?

A

SCC:
- Alcohol
- Smoking
- Plummer Vinson
- Achalasia

Adenocarcinoma
- Alcohol
- Smoking
- Barretts oesophagus

114
Q

What are the majority of pancreatitis in pregnancy secondary to?

A

Secondary to gallstones

115
Q

Factors that affect severity of pancreatitis?

A

age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST

116
Q

Alcoholic hepatitis bloods + mx?

A

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

117
Q

What imaging is required in PBC?

A

required before diagnosis to exclude an extrahepatic biliary obstruction

typically a RUQ USS or MRCP

118
Q

Which one of the following features is not seen in carcinoid syndrome?

A

HTN

119
Q

Most common cause of HCC?

A

hepatitis B most common cause worldwide
hepatitis C most common cause in Europe

120
Q

Obesity with abnormal LFTs – dx?

A

NAFLD

121
Q

When is surgery indicated in UGIB?

A

Surgery is indicated in patients with ongoing acute bleeding despite repeated endoscopic therapy

122
Q

Does Wilsons increase risk of HCC?

A

No

123
Q

Conditions of urea breath test?

A

no antibiotics in past 4 weeks,

no antisecretory drugs (e.g. PPI) in past 2 weeks

124
Q

Advanced dementia not eating well - can you use PEG?

A

PEG insertion is not normally recommended in advanced dementia patients

125
Q

What percentage of patients with Peutz-Jeghers syndrome will have died from a related cancer by the age of 60 years?

A

50%

126
Q

What are the features of the child pugh scoring and offer poor prognosis for Liver cirrhosis?

A

Bilirubin levels
Albumin levels
PT time
Encephalopathy
Ascites

127
Q

Mx of HCC?

A

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

128
Q

Budd-Chiari syndrome ix of choice?

A

USS with Doppler flow studies is very sensitive and should be the initial radiological investigation

129
Q

How to distinguish between acute and chronic hep b infection?

A

AntiHBc ->if IgM +ve = acute infection

if IgG +ve -> chronic infection

In window period everything is negative but AntiHBc (IgM) -> +ve

130
Q

What do you need to do before mx of PBC?

A

Imaging is required before making a diagnosis of PBC to exclude extrahepatic biliary obstruction

131
Q

Risk of HCC with PBC

A

20x risk

132
Q

Upon liver biopsy, which of the following pathological features is likely to be observed in liver cirrhosis?

A

Excess collagen and extracellular matrix deposition in periportal and pericentral zones leading to the formation of regenerative nodules

133
Q

Histology in alcoholic steatohepatitis?

A

Macrovesicular fatty change with giant mitochondria, spotty necrosis and fibrosis

134
Q

Histology in NAFLD?

A

Triglyceride accumulation with the proliferation of myofibroblasts

135
Q

Reversal agent of dabigatran?

A

Idarucizumab - praxbind

136
Q

Diagnositic test of gilberts?

A

unconjugated hyperbilirubinaemia (i.e. not in urine)

investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid

137
Q

Mx of UC flare?

A

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

138
Q

Maintaining UC remission Following a severe relapse or >=2 exacerbations in the past year?

A

Oral azathioprine / oral mercaptopurine

139
Q

Methotrexate UC v Crohns?

A

methotrexate is not recommended for the management of UC (in contrast to Crohn’s disease)

140
Q

What is H Pylori associated w?

A

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

141
Q

What is PSC associated with?

A

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

142
Q

Diabetes and NAFLD link?

A

Associated with T2DM not T1DM

143
Q

Which bypass is associated with NAFLD? what else?

A

jejunoileal bypass

obesity
type 2 diabetes mellitus
hyperlipidaemia
sudden weight loss/starvation

144
Q

CI for liver biopsy?

A

deranged clotting (e.g. INR > 1.4)
low platelets (e.g. < 60 * 109/l)
anaemia
extrahepatic biliary obstruction
hydatid cyst
haemoangioma
uncooperative patient
ascites

145
Q

Where do the majority of VIPomas arise from? presentation?

A

Pancreas

WDHA syndrome
WD-watery diarrhea
H- hypokalemia
A- achlorhydria

146
Q

signet ring cells found in which GI ca?

A

Gastric adenocarcinoma

147
Q

Malignant colorectal ca mx?

A

Colorectal carcinoma is one of the only oncological diseases where the presence of a metastatic deposit can be treated with curative intent

148
Q

Factors that lead to gastrin secretion?

A

C - Calcium
A - Amino Acid, Acetylcholine
P - Peptide (luminal)
E - Epinephrine

149
Q

Features and non-typical of achalasia?

A

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’

150
Q

Globus hystericus features?

A

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

151
Q

Kantor’s string sign on CT is seen in?

A

Crohns

152
Q

Oesophageal ca barium swallow?

A

Oesophageal stricture with apple core effect

153
Q

Dilated tapering oesophagus is the finding on barium swallow suggests what?

A

Achalasia

can also see Hypertensive lower oesophageal sphincter

154
Q

Corkscrew oesophagus is a finding on barium swallow for what dx?

A

Oesophagitis

155
Q

Is there a Hep C vaccine?

A

NOOOOOO

156
Q

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?

A

The ‘double duct’ sign may be seen in pancreatic cancer

NB can also be seen w cholangiocarcinoma however pancreatic ca is more common

157
Q

How can smoking trigger UC flare?

A

If you stop smoking!!!

158
Q

In haemochromatosis what features are reversible with treatment?

A

Cardiomyopathy and skin pigmentation

159
Q

Gastric enzymes and their products?

A

Amylase - in saliva + pancreatic secretions = starch -> sugar

Brush border enzymes:
- Maltase - disaccharide maltose -> glucose + glucose
- Sucrase - sucrose -> fructose + glucose
- Lactase - disaccharide lactose -> glucose + galactose

160
Q

HLA associations of coeliac?

A

HLA-DQ2 (95% of patients) and HLA-DQ8 (80%).

161
Q

Which laxative can be carcinogenic?

A

Co-danthramer is genotoxic and should only be prescribed to palliative patients due to its carcinogenic potential

162
Q

Roux-en-Y gastric bypass. Of which vitamin/mineral is she most likely to require supplementation?

A

Iron +- Ca - duodenum is primary site of absorption for calcium and iron and gastric bypass operations bypass the duodenum

163
Q

Acute fatty liver of pregnancy?

A

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

164
Q

Causes of jejunal villous atrophy?

A

coeliac disease

tropical sprue

hypogammaglobulinaemia

gastrointestinal lymphoma

Whipple’s disease

cow’s milk intolerance

165
Q

Which adverse effect of aminosalicylates is reduced with mesalazine?

A

sulphapyridine side-effects = rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis

166
Q

Obesity - NICE bariatric referral cut-offs

A

with risk factors (T2DM, BP or other condition related to raised BMI): > 35 kg/m^2

no risk factors: > 40 kg/m^2

167
Q

Which Ig is raised with differnt GI disorder?

A

Alcoholic liver disease - IgA
AI hepatitis - IgG
PBC - IgM

After AGM you drink lots of alcohol, then ge AI hepatitis which leads to cirrhossi

168
Q

drug causes of dyspepsia?

A

Causes
NSAIDs
bisphosphonates
steroids

The following drugs may cause reflux by reducing lower oesophageal sphincter (LOS) pressure
calcium channel blockers*
nitrates*
theophyllines

169
Q

Mx of pyogenic liver abscess and the organisms?

A

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.

170
Q

Mx of IBS?

A

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

171
Q

A retrocardiac air-fluid level can be seen in CXR of which patients?

A

Achalsia

172
Q

Severe abdo pain + fundoscopy reveals shows multiple micro infarcts (cotton wool spots)

dx?

A

Pancreatitis

173
Q

Which one of the following types of bariatric surgery is most likely to cause significant malabsorption?

A

Biliopancreatic diversion with duodenal switch

174
Q

Which drugs can cause hepatocellular picture in LFTs - largely raised ALT also AST

A

paracetamol
sodium valproate, phenytoin
MAOIs
halothane
anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
statins
alcohol
amiodarone
methyldopa
nitrofurantoin

175
Q

Colorectal cancer screening - PPV of FOB ?

A

5 - 15%

176
Q

Investigation of choice for bile acid malabsorption?

A

SeHCAT

177
Q

Cholestatic LFTs in HIV cause?

A

Sclerosing cholangitis due to infections such as CMV, Cryptosporidium and Microsporidia

178
Q

Pancreatitis in HIV?

A

Pancreatitis in the context of HIV infection may be secondary to anti-retroviral treatment (especially didanosine) or by opportunistic infections e.g. CMV

179
Q

Dubin-Johnson syndrome outcome?

A

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

180
Q

An OGD 3 weeks ago showed gastric erosions and ulcers

Dx? and ix?

A

Zollinger Ellison syndrome

ix = Fasting gastrin - best, secretin stimulation test

181
Q

surgical options of bariatric surgery?

A

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)

182
Q

Which of the following anti-retroviral drugs is most characteristically associated with pancreatitis?

A

Didanosine

183
Q

MSH2 gene. What is the function of this gene?

A

HNPCC DNA mismatch repair

184
Q

adverse effects is least associated with sulfasalazine?

A

Visual disturbance

185
Q

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?

A

Factor 8 (VIII) - ?decreased clearance by dysfunctional liver

186
Q

Causes of hepatosplenomegaly

A

chronic liver disease* with portal hypertension
infections: glandular fever, malaria, hepatitis
lymphoproliferative disorders
myeloproliferative disorders e.g. CML
amyloidosis

187
Q

chronic diarrhoea in PPI use is suggestive of what? ix?

A

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

188
Q

Ongoing diarrhoea in Crohn’s patient post-resection with normal CRP → mx?

A

Cholestyramine

189
Q

The majority of gastrinomas are found where?

A

1st part of duodenum

190
Q

The endoscopic appearance of the small bowel is unremarkable. Biopsy samples show non-specific eosinophilia.

Suggests what dx?

A

small bowel overgrowth syndrome

MRCP - Passmed (17 decks)

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