Gastro

Question 1

Management of UC

Answer 1

Acute:
- correct electrolytes
- avoid anti-cholinergics and opioids
- broad spec abx eg metronidazole
- IV steroids
- cylclosporin if non-steroid responsive
- infliximab
- surgery
Mild-moderate:
- sulphasalazine/mesalazine
- azathioprine/mercaptopurine
- cyclo/infliximab
- colectomy (if severe disease, chronic ill health, 7-10days non responsive to medical tx)
Cancer surveillance

Question 2

Liver transplant

Answer 2

Exercise
Avoid alcohol and hepatotoxins
Cardiovascular risk assessment 
Cancer screening (skin and other)
Vaccinations
Immunosuppression
- drug levels/renal function
- compliance
- complications (diabetes, hypertension, osteoporosis, infections, malignancy, nephrotoxicity)
- drug interactions 
Monitoring LFTs
- rejection
- recurrence of disease
Management of underlying disease e.g hepatitis b/c
Pregnancy counselling 
Psychiatric

H

Question 3

Management of flare of UC

Answer 3

Grading severity:
- fulminant greater then 10 BM, tachycardia, fever, abdo pain, bleeding
- severe greater then 6
- moderate greater than 4
- mild fewer then 4
Induce remission:
ASA
- mainstay of treatment in mild to moderate disease, topical and oral
Steroids 
- IV if severe/fulminant
- consider orals in moderate non responding to 5-ASA 
Antibiotics
- IV if severe
UC - cyclosporine or infliximab if failed steroids at day 3
Vitamin D
VTE prophylaxis
Nutrition
Pain management
Avoid NSAIDs 
Monitor for complications - toxic megacolon, haemorrhage, abscess, obstruction, dehydration
Involve surgeons early

Question 4

Complications of coeliac disease

Answer 4

Malabsorption, weight loss
Nutritional deficiencies
- Iron
- B12
- D,E,K,A
Hyposplenism - Vaccinate
Dermatitis herpetiformis
T-cell lymphoma
Refractory sprue
Increased small bowel ulceration
"Gluten ataxia"
Arthritis 

Associated disease to consider

• IgA deficiency - blood transfusion reactions
• type 1 diabetes
• deranged LFTs
• thyroid disease

Question 5

Management of complications of cirrhosis

Answer 5

Treat underlying cause
Abstinence
Avoid potentialy hepatotoxic drugs and dose accodringly
Asess for liver transplant

Ascites
- spironolactone
- therapeutic drainage
- salt restriction/fluid restriction
- TIPS
- early treatment of SBP
Varices
- primary: non selective B-blocker or serial endoscopic banding if high risk
- secondary: both of the above
- refractory: TIPS
Encephalopathy
- grading
- lactulose
- rifaxamin
- treat precipitant e.g. UGI bleed, constipation, SBP
HCC
- surviellence 6 monthly with USS, role of AFP
Hepato-renal syndrome
- trial of terlipressin and albumin
- dialysis if bridge to transplant an option

Question 6

Complications of IBD

Answer 6

INTESTINAL
increased risk of infection with C. diff
increased malignancy risk - surveillance after 8 years
toxic megacolon
GI bleeding or perforation
fistulas  and abscess formation
strictures and bowel obstruction

EXTRAINTESTINAL
Arthritis
- axial - ankylosis spondylitis, assoc with HLAB27
- peripheral

Ophthalmic: Scleritis and iritis

Dermatological: erythema nodosum and pyoderma gangrenous

vitamin deficiencies:
- B vits, fat soluble vits, essential fatty acids, magnesium, zinc, selenium

Anaemia
iron deficiency secondary to blood loss
anaemia of chronic disease

Osteoporosis:
secondary to steroid use
secondary to Ca malabsorption

Hyper coagulable state

liver disease
- PSC and UC

increased incidence of gallstone and renal stone disease

Question 7

Management of coeliac disease

Answer 7

diagnosis is initially by serology
- IgA EMA, IgA TTG (IgG DGP if IgA deficient)
confirmed by duodenal biopsy whilst on a gluten containing diet
- intraepithelial lymphocytosis, crypt hyperplasia and villous atrophy

HLA DQ2 and DQ8 - high NPV

Management

• Gluten free diet - wheat, rye and barley (oats can be OK)
• dietician

Monitoring for complications

Small intestinal absorption

• FBC, ferritin, B12 and folate
• Calcium, ALP

Osteoporosis

• usually managed with adherence to GFD
• consider vit D
• maintain dietary Ca intake > 1000mg/day
• measure bone density 1 year after GFD if >55 or other RFs

Anaemia
- monitor annual FBC and haematinics

Associated autoimmune conditions
- check TFTs and serum glucose

Risk of lymphoma

• reduced when adherence to GFD
• no hard and fast rules about colonoscopy F/U - usually done 2-5 years after diagnosis

Functional hyposplenism
“your spleen disappears” - P Roberts
- vaccinate against pneumococcus +/- Haemophilus and meningococcus