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Phase 3 > Gastro > Flashcards

Gastro Flashcards

1
Q

A 62 year old man with hx of chronic alcohol abuse presents with 2 day hx of deteriorating confusion.
On examination he is drowsy, has a temp of 39, pulse of 110, and small amount of ascites. Examination of cns reveals left sided hemiparesis with up going left plantar response. What is likely diagnosis?

A

Cerebral abscess

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2
Q

What is the most common cause of severe viral gastroenteritis worldwide?

A

Rotavirus

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3
Q

How does rotavirus infection spread?

A

Faeco oral route

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4
Q

In which patients is rotavirus most common?

A

Children 6m to 6y

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5
Q

How does rotavirus lead to diarrhoea and vomiting?

A

RNA virus replicates in intestinal mucosal cells

Damages transport mechanisms leading to salt and water depletion

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6
Q

How is a diagnosis of rotavirus made?

A

Clinical features
Stool culture - virus
PCR

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7
Q

What is treatment for rotavirus?

A

Rehydration

Correction of electrolyte imbalances

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8
Q

What is jaundice? When is it clinically detectable?

A

Yellow discolouration of sclera, skin and mucous membranes as a result of accumulation of bile pigments (bilirubin)
Clinically detectable at >50micromol/L

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9
Q

What HPC questions are important in a patient with jaundice? And what differentials do these questions highlight?

A

Abdo pain: gallstones, cholangitis, pancreatic Ca
Colour of urine/stool – conjugated bilirubin
Pruritis – cholestasis
Fever, rigors – cholangitis
Alcohol intake - cirrhosis
Blood transfusions - haemolytic transfusion reaction
Recent travel - hepatitis
Drug history including IVDU - hepatitis

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10
Q

What is courvoisiers law?

A

In presence of jaundice, enlarged gallbladder is unlikely to be due to gallstones/chronic cholecystitis

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11
Q

What is Murphys sign?

A

Tenderness elicited on palpation at the midpoint of the right subcostal margin on inspiration

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12
Q

What signs might you look for in a patient with jaundice on examination?

A

General inspection – ascites, widespread jaundice
Hands – palmar erythema, Duputryen’s, clubbing, asterixis, leukonychia
Sclera - icterus
Mouth - fetor hepaticus
LN in neck
Upper chest – spider naevi, gynaecomastia, ecchymosis
Abdomen – hepatosplenomegaly, ascites, caput medusae

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13
Q

Why do you get palmar erythema in cirrhosis?

A

Impaired breakdown of sex hormones

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14
Q

What is Charcots triad?

A

RUQ pain
Jaundice
Fever
Ascending cholangitis

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15
Q

How is jaundice classified? Give examples of each

A

Pre-hepatic: haemolysis
Intra-hepatic: Viral hepatitis, Cirrhosis, Alcoholic hepatitis, Drugs
Post-hepatic: Obstruction, Cholangitis

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16
Q

What are differences between unconjugated and conjugated bilirubin?

A

Conjugated: Converted to urobilinogen and excreted giving stool its dark colour, Hyperbilirubinaemia
Unconjugated: Not water soluble, Does not pass into urine as bound to albumin, Mild jaundice as liver usually handles increased bilirubin

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17
Q

Which enzyme conjugates bilirubin in the liver? What is it conjugated with?

A

Glucuronyltransferase

Conjugates with glucuronic acid

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18
Q

How does haem get metabolised to bilirubin?

A

Haem oxygenase converts haem to biliverdin

Biliverdin reductase converts to bilirubin

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19
Q

What are the main bilirubin products found in the urine and faeces?

A

Breakdown products of urobilinogen
Urine: urobilin
Faeces: stercobilin

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20
Q

What differences in LFTs would you see in intra or extra hepatic jaundice?

A

Intrahepatic: Transaminases very high : Alk Phos high
Extrahepatic: Transaminases high : Alk Phos very high

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21
Q

What investigations would you do for a patient who is jaundice?

A

Bedside: Urine
Bloods: FBC, LFTs, U+Es, Clotting (PT/INR)
Imaging: USS abdomen – identify obstruction
Special tests: Serum autoimmune antibody tests (ANA, ASMA, anti-smooth muscle, liver/kidney microsomal antibodies), Serum viral markers (hep A, B, C)

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22
Q

What is the management for alcoholic hepatitis?

A

Supportive: Adequate nutritional intake – may require NG
Corticosteroids: Evidence to suggest reduces inflammatory process

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23
Q

What are some causes of hepatitis?

A 
Toxic damage
Drugs 
Poisons/chemical 
Alcohol 
Infections
Viral 
Bacterial
Fungal 
Protozoa 
Immunological damage 
Autoimmune
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24
Q

What are differences between acute and chronic viral hepatitis?

A

Acute (<6months): Fever / nausea / malaise / myalgia, Hepatomegaly, Pain, Jaundice
Chronic (>6 months): May be asymptomatic, Symptoms associated with cirrhosis

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25
Q

What is Gardners syndrome?

A 
Hereditary dominant condition 
Multiple osteomas - skull bones
Cutaneous soft tissue tumours
Polyposis coli 
Thyroid tumours
Hypertrophy of pigment layer of retina
Liver tumours
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26
Q

What is the management of acute pancreatitis?

A 
IV fluids
Sliding scale insulin 
Nasogastric suction
Antibiotics 
Analgesia
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27
Q

What is the typical endoscopic appearance of a GIST?

A

Discrete
Well defined single lesion
Normal mucosa covering surface

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28
Q

What is the Glasgow score for pancreatitis? PANCREAS

A

P Arterial O2: <8 scores 1
A ge: > 55 scores 1
N eutrophils/ White cell count: >15 scores 1
C Serum calcium: <2 scores 1
R renal function, Serum urea: >16 scores 1
E nzymes: LDH > 600 or AST/ALT >200 scores 1
A Serum albumin: <32 scores 1
S ugar, Blood glucose: >10 scores 1

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29
Q

What is abetalipoproteinanemia?

A

Bassen kornzweig syndrome
Problems with normal absorption of fat and fat soluble vitamins
Mutation in microsomal triglyceride transfer protein resulting in deficiency of apo B48 and B100
Failure to thrive, diarrhoea, acanthocytosis, steatorrhoea

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30
Q

What is blind loop syndrome?

A

Small intestinal bacterial overgrowth syndrome
Derangement to normal physiological processes of digestion and absorption - impaired micelle formation
Vit B12 deficiency/ADEK, fat malabsorption, steatorrhoea, intestinal wall injury

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31
Q

What type of virus is rotavirus?

A

Double stranded RNA

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32
Q

Which is the most common virus responsible for causing diarrhoea worldwide?

A

Rotavirus

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33
Q

Which virus can follow ingestion of dust containing faecal material?

A

Hepatitis A

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34
Q

A 19 year old man is being investigated for suspected ileal crohns. What imaging should be done?

A

MR enterography

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35
Q

A 64 year old woman with painless jaundice is being investigated for suspected carcinoma of the head of the pancreas. What imaging should be performed?

A

CT scan with contrast - determine if resectable or if any mets

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36
Q

What is the most common gastrointestinal symptom of systemic sclerosis?

A

Progressive dysphagia

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37
Q

Why do patients with systemic sclerosis get progressive dysphagia?

A

Initially decrease in incidence and amplitude of contractions of lower oesophagus and incomplete relaxation of lower oesophageal sphincter
Resting tone of sphincter is reduced allowing reflux -> oesophagitis, shortening of oesophagus, stricture formation

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38
Q

A 54 year old woman was referred for abnormal LFTs. She had symptoms of fatigue and itching for 3 months. She drank 5 units of alcohol a week and did not use recreational drugs. She had no significant medical history. Her BMI is 24. She had hepatomegaly but was not jaundiced. USS liver was normal. Investigations show: albumin 38, ALT 40, ALP 286, bilirubin 27. What would be the most likely diagnosis?

A

Primary biliary cirrhosis

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39
Q

What is the pathology underlying primary biliary cirrhosis?

A

Autoimmune condition
T cell mediated destruction of intrahepatic bile ducts due to breakdown of immune tolerance to mitochondrial antigens accompanied by ductopenia
Antimitochondrial antibodies in 95%

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40
Q

Why does a normal USS liver make primary sclerosing cholangitis less likely than primary biliary cirrhosis?

A

PSC usually evidence of strictures or dilatation on abdo USS

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41
Q

What is transaminitis and when is it common?

A

Raised ALT and AST

Autoimmune hepatitis/other causes of hepatitis

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42
Q

If there is a markedly raised ALP but only a small raise in ALT, what does this suggest?

A

Cholestatic picture

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43
Q

What is the classic triad of mesenteric ischaemia?

A

Gastrointestinal emptying
Abdominal pain
Underlying cardiac disease

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44
Q

What symptoms of mesenteric ischaemia represent advanced ischaemia?

A 
Nausea
Vomiting
Abdominal distension
Ileus
Frank peritonitis
Gross or occult blood per rectum
Shock
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45
Q

What are risk factors for mesenteric ischaemia?

A 
Congestive heart failure
Cardiac arrhythmias particularly AF
Recent MI
Atherosclerosis
Underlying hypercoagulable state
Hypovolaemia
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46
Q

A 65 year old male presents with abdominal pain. He gives a past history of stroke and MI. On examination there is distension of the abdomen and the stools were maroon coloured. Lactate is 5mmol/L. What is the likely diagnosis ?

A

Acute mesenteric ischaemia

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47
Q

What is the most common cause of unconjugated hyperbilirubinaemia?

A

Gilbert’s syndrome

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48
Q

What might precipitate Gilbert syndrome?

A

Dehydration
Fasting
Menstrual periods
Stress - illness or exercise

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49
Q

What are characteristics of chronic pancreatitis?

A 
Chronic epigastric pain
Bloating
Steatorrhoea
Loss of weight
Diabetes
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50
Q

What are causes of chronic pancreatitis?

A

Alcohol
Duct obstruction - gallstones
Pancreatic cancer

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51
Q

Which GI cancer does coeliac disease increase the risk of?

A

Intestinal lymphoma

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52
Q

How does chlorpromazine cause acute cholestasis?

A

Interferes with hepatocyte secretion of bile

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53
Q

How do aflatoxins and mycotoxins lead to hepatocellular carcinoma?

A

Toxins induce a specific mutation in the tumour suppressor gene p53 leading to tumourigenesis

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54
Q

What is the Rockall scoring system used for?

A

Identify patients at risk of adverse outcome following acute upper gastrointestinal bleeding

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55
Q

What are the clinical features used to calculate a Rockall score?

A

Age: 60-79 score 1, 80 an above score 2
Shock: pulse over 100/systolic over 100 score 1, systolic less than 100 score 2
Co-morbidities: CHF, IHD score 2, Renal failure, liver failure, metastatic cancer score 3
Diagnosis: Mallory Weiss score 0, all other score 1, GI malignancy score 2
Evidence of bleeding: score 2
Score less than 3 carries good prognosis
Total score more than 8 carries high risk of mortality

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56
Q

What is a Glasgow-Blatchford bleeding score used for?

A

Stratifies upper GI bleeding patients who are “low-risk” and candidates for outpatient management

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57
Q

What are the clinical features used to calculate a Blatchford bleeding score?

A 
Blood urea raised: up to 6 points
Haemoglobin low: up to 6 points
Systolic blood pressure: up to 3 points
Pulse >100 = 1 point
Presentation with melaena = 1 point
presentation with syncope = 2 point
Hepatic disease = 2 point
Cardiac failure =2 point
Total score 6 or more: over 50% chance of needing an intervention
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58
Q

What is the best single screening test for Zollinger-Ellison syndrome?

A

Fasting serum gastrin

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59
Q

What gastric pH is highly suggestive of Zollinger-Ellison syndrome?

A

Less than 2.0

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60
Q

What is a secretin stimulation test and how is used to diagnose Zollinger-Ellison syndrome?

A

2-U/kg bolus of secretin is administered intravenously after an overnight fast, and serum levels of gastrin are determined at 0, 2, 5, 10, and 15 minutes. An increase in serum gastrin of greater than 200 pg/mL is diagnostic

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61
Q

What are the antibiotics of choice to treat antibiotic associated colitis?

A

Oral vancomycin or metronidazole

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62
Q

What are the normal and deficient genes in alpha 1 antitrypsin deficiency? Which are the least and most severe genotypes?

A 
M is normal gene
S: associated with 60% production
Z: 15% production
PiMM: 100% (normal)
PiMS: 80% of normal serum level of A1AT
PiSS: 60% of normal serum level of A1AT
PiMZ: 60% of normal serum level of A1AT
PiSZ: 40% of normal serum level of A1AT
PiZZ: 10-15% (severe alpha 1-antitrypsin deficiency)
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63
Q

What are the intestinal features of Crohn’s disease?

A

Bowel frequency
Diarrhoea
Apthous ulcers
Perianal fistulae

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64
Q

What are the extra intestinal features of Crohn’s disease?

A

Spondyloarthropathy
Uveitis
Episcleritis

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65
Q

How is a diagnosis of acute hepatitis B made?

A

Presence of:
Hepatitis B surface antigen- HBsAg
IgM antibodies to hepatitis B core antigen- IgM anti-HBc

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66
Q

How is a diagnosis of acute hepatitis A made?

A

Positive IgM antibodies to hep A virus- IgM anti-HAV

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67
Q

What does the presence of IgG anti-HAV antibody in a patient with acute hepatitis suggest?

A

Illness is not caused by hep A

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68
Q

How is a diagnosis of acute hep C made?

A

Anti-HCV antibody

HCV RNA

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69
Q

How is a diagnosis of acute hep E made?

A

Pronounced elevation of Alk phos

Presence of serum IgM anti-HEV

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70
Q

What is Weil’s disease?

A

Severe form of Leptospirosis

Headaches, muscle pains, fevers, bleeding from lungs, meningitis, jaundice, kidney failure, bleeding

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71
Q

How is leptospirosis infection spread?

Who is particularly at risk?

A

Direct contact with infected soil, water or urine
Organism enters through skin abrasions/cuts
Sewage workers

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72
Q

In what proportion of patients admitted with cirrhotic ascites does spontaenous bacterial peritonitis occur?

A

15%

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73
Q

With regard to differentiation of transudate from exudate, what is the preferred means for characterizing ascites?

A

Serum-ascitic albumin gradient (SAAG)

Transudative ascites occurs when a patient’s SAAG level is greater than or equal to 1.1 g/dL

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74
Q

What are causes of transudative ascites?

A 
Hepatic cirrhosis
Alcoholic hepatitis
Heart failure
Fulminant hepatic failure
Portal vein thrombosis
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75
Q

What are causes of exudative ascites?

A 
Peritoneal carcinomatosis
Inflammation of the pancreas or biliary system
Nephrotic syndrome
Peritonitis
Ischemic or obstructed bowel
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76
Q

What organisms commonly cause spontaneous bacterial peritonitis?

A

Escherichia coli
Klebsiella pneumoniae
Enterococcal species
Streptococcus pneumoniae

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77
Q

What are indications for a diagnostic paracentesis?

A

New-onset ascites: Fluid evaluation helps to determine etiology, differentiate transudate versus exudate, detect presence of cancerous cells
Suspected spontaneous or secondary bacterial peritonitis

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78
Q

What are indications for a therapeutic paracentesis?

A

Respiratory compromise secondary to ascites

Abdominal pain or pressure secondary to ascites (including abdominal compartment syndrome)

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79
Q

What are contraindications for paracentesis?

A

An acute abdomen that requires surgery is an absolute contraindication
Severe thrombocytopenia (platelet count <20) and coagulopathy (INR >2.0) are relative contraindications Patients with an INR greater than 2.0 should receive fresh frozen plasma (FFP) prior to procedure
Patients with a platelet count lower than 20 should receive an infusion of platelets before the procedure
Pregnancy
Distended urinary bladder
Abdominal wall cellulitis
Distended bowel
Intra-abdominal adhesions

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80
Q

What should fluid from a diagnostic paracentesis be tested for?

A 
Cell count
Culture
Protein
Glucose
LDH
CEA
Alk phos
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81
Q

What is CEA?

A

Carcinoembryonic antigen

Glycoprotein shed from the surface of malignant cells

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82
Q

What are the grades of hepatic encephalopathy?

A

Grade 1: drowsy but coherent, mood change
Grade 2: drowsy, confused at times, inappropriate behaviour
Grade 3: very drowsy and stuporous but rousable
Grade 4: comatose, barely rousable

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83
Q

What treatment should be given for suspected spontaneous bacterial peritonitis?

A

Broad spec Abx for enteric organisms and gram positive cocci e.g. Cefotaxime

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84
Q

How does Terlipressin control variceal bleeding?

A

Causes splanchnic vasoconstriction

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85
Q

Why is a low protein diet recommended for patients with chronic liver disease?

A

Protein breakdown in the bowel results in ammonia production which is implicated in precipitation of hepatic encephalopathy

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86
Q

A 50 year old lady is referred for a barium swallow after a 6 month Hx chest pain associated with dysphagia. The scan shows a corkscrew pattern, what is the likely diagnosis?

A

Diffuse oesophageal spasm

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87
Q

What is the treatment for diffuse oesophageal spasm?

A

Calcium channel blockers

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88
Q

A 50 year old alcoholic man with a 2 year history of dyspepsia is found by his GP to be anaemic. An endoscopy shows part of the stomach through the hiatus alongside the oesophagus with the sphincter below the diaphragm. What is the likely diagnosis?

A

Para oesophageal hiatus hernia

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89
Q

A 70 year old Iranian man presents with progressive dysphagia and weight loss. An endoscopy reveals a 40% circumferential tumour in the proximal third of the oesophagus. What is the likely diagnosis?

A

Squamous cell carcinoma

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90
Q

A 30 year old man presents to ED after collapsing. He initially complained of severe chest pain following 2 episodes of forceful vomiting. A chest X-ray shows air in the mediastinum and neck and a pleural effusion. What is the likely diagnosis?

A

Oesophageal perforation - Boerhaaves syndrome

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91
Q

What can be used to confirm the diagnosis of oesophageal perforation?

A

Gastrograffin swallow

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92
Q

A 28 year old lady is referred for a barium swallow after a long Hx of dysphagia for both solids and liquids associated with regurgitation. The scan shows tapering of the lower end of the oesophagus. What is the likely diagnosis?

A

Achalasia

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93
Q

What is the treatment for achalasia?

A

Endoscopic pneumatic dilatation of the oesophagus
Endoscopic injection of Botox
Surgical division of the sphincter

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94
Q

What are the manning criteria for diagnosis of IBS?

A 
Abdominal distension
Pain relief with bowel action
More frequent stools with onset of pain
Looser stools with onset of pain
Passage of mucus
Sensation of incomplete evacuation
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95
Q

Which drugs can cause acute pancreatitis?

A 
Steroids
Oestrogens
Thiazides
Valproate
Azathioprine 
Cisplatin
Vinca alkaloids
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96
Q

What are the 2 most common causes of acute pancreatitis?

A

Gallstones and alcohol

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97
Q

What is the initial management for a patient with acute pancreatitis?

A 
Analgesia
NBM
IVI
NG tube
Urinary catheter
Score for severity using Glasgow score 
If severe: HDU and pancreatic specialist
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98
Q

What is the safest management for patients with acute mesenteric ischaemia?

A

Laparotomy
Excision of non viable bowel
Defunction, to return another day

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99
Q

What is the management for anal fissure?

A

Topical GTN

Sphincterectomy

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100
Q

What acute medical events may precipitate colonic pseudo-obstruction?

A

Pneumonia
Myocardial infarction
Hypoxia

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101
Q

How can you exclude mechanical large bowel obstruction?

A

Rectal examination
Rigid sigmoidoscopy
Plain X-ray
CT scan

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102
Q

How do you manage colonic pseudo obstruction?

A 
IVI
Correct electrolyte abnormalities
Avoid opioid analgesia
Nasogastric aspiration 
Rectal tube
Enema
Ocreotide infusion 
IV neostigmine 
Colonoscopic decompression
Surgery
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103
Q

How might you drain a pelvic abscess?

A

Spontaneous
Surgically per rectum
Radiologically guided

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104
Q

In what time frame should a post operative ileus resolve?

A

3-4 days
Small bowel mobility usually in 24
Gastric motility in 3-4 days

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105
Q

What is required if a post operative ileus has not resolved after 4 days?

A

Nasogastric aspiration - prevent gastric dilatation and risk of aspiration pneumonitis
IVI
Correct electrolytes
Minimal oral fluids

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106
Q

An 82 year old man with a long Hx of dementia and advanced oesophageal carcinoma is admitted from a nursing home as an emergency with sudden onset total dysphagia. He is unable to tolerate solids or liquids which he immediately regurgitates. He had been stented 2 weeks previously and had initially had excellent symptomatic relief. Examination is unremarkable. What is the likely diagnosis?

A

Bolus obstruction due to inadvertent ingestion of a large piece of food
Stent displacement other option but tends to occur early with metal stents before they are fully deployed

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107
Q

A 19 year old student experiences worsening dysphagia for 3 months. She has lost a stone in weight and has had 2 courses of antibiotics for persistent chest infection. What is the likely diagnosis?

A

Achalasia with aspiration pneumonias

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108
Q

A 55 year old vagrant man has a long history of recurrent epigastric pain. He presents with weight loss and severe vomiting. On admission he is noted to be dehydrated and abdominal examination demonstrates succussion splash. What is the likely diagnosis?

A

Pyloric stenosis secondary to long history of peptic ulceration which has been left untreated, healing with scarring

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109
Q

What is gallstone ileus?

A

Inflamed gallbladder adheres to small bowel and with time the gallstone erodes through and migrates distally, usually occluding the distal ileum

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110
Q

How do you manage gallstone ileus?

A

Laparotomy

Stone extraction through proximal enterotomy

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111
Q

Why do patients with pancreatitis sit forward?

A

Allows stomach and small bowel to fall away from the pancreas into the retroperitoneum

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112
Q

An 85 year old lady who previously declined a cholecystectomy is admitted as an emergency with diffuse abdominal pain and vomiting. She has a tachycardia and is hypotensive 80/50. On examination her abdomen is rigid. What is the likely diagnosis? What needs to be done?

A

Biliary peritonitis

Laparotomy with extensive washout of the peritoneal cavity

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113
Q

What is the dukes grading system for colonic carcinoma?

A 
A: confined to bowel wall
B: reaches serosa
C1: local nodes involved
C2: apical nodes involved
D: distant metastasis
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114
Q

What is the treatment for anal fissure?

A

GTN cream

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115
Q

What is the treatment for sigmoid volvulus?

A

Urgent endoscopic decompression
Sigmoid colectomy
Percutaneous endoscopic colostomy

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116
Q

What imaging/special test should be done when achalasia is suspected?

A

Oesophageal manometry

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117
Q

What does oesophageal manometry show in achalasia?

A

Absence of peristaltic waves
High resting intra oesophageal pressure
Impaired relaxation of lower oesophageal sphincter
High resting lower oesophageal sphincter pressure

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118
Q

A 62 year old woman undergoes OGD for dysphagia and is seen to have a suspicious looking lesion in the distal oesophagus. A biopsy is taken which confirms adenocarcinoma. What is the next step?

A

CT scan to look for distant mets

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119
Q

A 44 year old woman has been taking high dose proton pump inhibitor for 2 years for reflux oesophagitis but barely has control of her symptoms. An OGD has confirmed the presence of reflux oesophagitis. She is keen on anti reflux surgery. What should be done next?

A

24 hour pH studies provide a modified DeMeester score and manometry to exclude motility disorder

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120
Q

What is a DeMeester score?

A 
Measure of acidity and a surrogate of severity of GORD
Supine reflux
Upright reflux
Total reflux
Number of episodes
Number of episodes longer than 5 mins
Longest episode
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121
Q

A 55 year old smoker has been diagnosed with oesophageal carcinoma. He is otherwise fit and well. A CT scan of the chest and abdomen is reported as normal. What is the next step?

A

Endoluminal ultrasound for further staging to look for signs of irreducibility such as invasion into the pericardium or pleura

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122
Q

Why does bleeding happen in diverticular disease?

A

Perforating vessels are eroded

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123
Q

What is an indication for colectomy in diverticular disease?

A

Large volume bleed or recurrent bleeds

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124
Q

In a case of angiodysplasia with ongoing bleeding and visualisation on imaging is poor, what other method can be used to image?

A

Red cell scan or angiography

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125
Q

A 37 year old farmer presents with a gradual onset of malaise, headaches, myalgia and night sweats. He has lymphadenopathy and hepatomegaly. His chest xray is normal. His 2-mercaptoethanol test is positive. What does he have?

A

Brucellosis

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126
Q

What causes Brucellosis?

A

Ingestion of unpasteurized milk or undercooked meat from infected animals, or close contact with their secretions

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127
Q

What is the best test for Brucellosis?

A

2-mercaptoethanol test
Tube agglutination which tests for anti-O-polysaccharide antibody
Titre of 1:160 is diagnostic

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128
Q

What type of bug is Brucella?

A

Gram negative coccobacillus

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129
Q

What are the symptoms/features of Brucellosis?

A 
Malaise
Headache
Night sweats
Lymphadenopathy
Hepatosplenomegaly
Orchitits
Osteomyelitis
Meningoencephalitis
Endocarditis
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130
Q

What is the treatment for Brucellosis?

A

6 weeks of combined doxycycline and rifampicin

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131
Q

When is the optimal time to assess paracetamol level after an overdose with respect to determining need for n-acetylcysteine?

A

4 hours after
If a very significant overdose is suspected or the patient presents more than 4 hours after, treatment should be started expectantly

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132
Q

How is n-acetylcysteine treatment administered?

A

Loading dose over 1 hour

Infusions at 4 hours and 16 hours

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133
Q

What should be done for a patient with an allergic reaction to n-acetylcysteine who has taken a paracetamol overdose?

A

Slow the infusion rate
Give IV corticosteroids and/or antihistamines
If still not tolerating - oral methionine

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134
Q

What is pseudoxanthoma elasticum? How does it present?

A

Abnormalities in collagen and elastic tissue affecting skin, eye and blood vessels
GI bleeding
Premature atherosclerosis -CAD
Intermitttent claudication
Yellow papular skin lesions, lax skin
Peau d’orange retina, angioid streaks radiate from optic nerve

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135
Q

An 11 year old boy presents to ED with massive haematemesis. He is found to be very tall and thin and has loose lax and wrinkled skin. What is the diagnosis?

A

Pseudoxanthoma elasticum

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136
Q

What are complications of a duodenal ulcer if left untreated?

A

Perforation
Gastric outlet obstruction
Haemorrhage

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137
Q

What are clinical signs of gastric carcinoma?

A

Epigastric mass
Jaundice
Ascites
Enlarged supraclavicular (virchows) node, Troisiers sign

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138
Q

A 30 year old man is being investigated after being admitted for haematemesis. An OGD reveals multiple large deep peptic ulcers, he has a ten month history of chronic diarrhoea and is found to have a high serum gastrin level. What is the diagnosis?

A

Zollinger Ellison syndrome

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139
Q

What are risk factors for oesophageal cancer?

A 
Smoking
Alcohol
GORD
Barrett's oesophagus
Achalasia
Plummer-Vinson syndrome
Diets rich in nitrosamines
Coeliac disease
Scleroderma
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140
Q

How is diagnosis of oesophageal cancer made?

A

Upper GI endoscopy first line
Staging initially CT chest, abdomen and pelvis
If overt metastatic disease, further complex imaging unnecessary
If CT does not show metastatic disease, then local stage assessed by endoscopic ultrasound
Staging laparoscopy is performed to detect occult peritoneal disease PET CT is performed in those with negative laparoscopy

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141
Q

How is oesophageal cancer managed?

A

Operable disease - surgical resection, Ivor- Lewis oesophagectomy or transhiatal resection (for distal lesions), a left thoraco-abdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis
In addition to surgical resection many patients will be treated with adjuvant chemotherapy

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142
Q

What is an Ivor Lewis oesophagectomy?

A

Mobilisation of the stomach and division of the oesophageal hiatus
Abdomen is closed and a right sided thoracotomy performed
Stomach is brought into the chest and the oesophagus mobilised further
An intrathoracic oesophagogastric anastomosis is constructed

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143
Q

A 65-year-old male undergoes a Hartmann’s procedure for a sigmoid cancer. On day 2 post-op, nurses are concerned as his colostomy has not passed any wind or stool yet and he is complaining of increasing bloatedness. You review the patient and witness him vomit profusely. How would you manage this?

A

Conservative with nasogastric tube insertion for stomach decompression for symptom control and placing the patient nil by mouth to allow bowel rest

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144
Q

What is the management of mesenteric ischaemia?

A

Initial management includes analgesia, fluids and keeping the patient nil by mouth
Definitive treatment includes thrombolytic therapy, angioplasty or surgery

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145
Q

What are predisposing factors for mesenteric ischaemia?

A

Increasing age
Atrial fibrillation
Other causes of emboli: endocarditis
Cardiovascular disease risk factors: smoking, hypertension, diabetes
Cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use

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146
Q

What are features of small and large bowel which can help you detect small and large bowel obstruction on X-ray?

A

Small bowel: Maximum normal diameter = 35 mm, Valvulae conniventes extend all the way across
Large bowel: Maximum normal diameter = 55 mm, Haustra extend about a third of the way across

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147
Q

What is the management of ascending cholangitis?

A

Intravenous antibiotics

Endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction

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148
Q

In colorectal cancer patients who’s tumours lie below the peritoneal reflection, what type of imaging should be done to evaluate staging?

A

MRI

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149
Q

What are some factors which will affect the healing of a colorectal anastamosis?

A

Adequate blood supply
Mucosal apposition
No tissue tension

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150
Q

Which chemotherapy agents are used as adjuncts in colorectal cancer?

A

5FU

Oxaliplatin

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151
Q

What are surgical options for rectal cancer?

A

Anterior resection and total mesorectal excision

Abdomino perineal excision of rectum (APER) - if sphincter involved or very low tumour

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152
Q

Why is neoadjuvant radiotherapy an option for rectal cancer when it isn’t for colorectal?

A

Rectum is an extraperitoneal structure

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153
Q

What is a Hartmans procedure?

A

Resection of sigmoid colon

End colostomy

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154
Q

What are risk factors for anal fissures?

A

Constipation
Inflammatory bowel disease
Sexually transmitted infections - HIV, syphilis, herpes

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155
Q

What are management steps for acute and chronic anal fissures?

A

Dietary advice: high fibre diet, high fluid intake
Bulk forming laxatives
Lubricants such as petroleum jelly before defecation
Topical anaesthetics
If chronic (over 6 weeks)
Topical GTN
If after 8 weeks not effective, refer for surgery or Botox

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156
Q

What is the NHS colorectal cancer screening program?

A

Screening every 2 years to people aged 60-74 years in England
Patients over 74 may request screening
Eligible patients are sent faecal occult blood tests through the post
Patients with abnormal results are offered colonoscopy

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157
Q

As part of the colorectal cancer screening service, what proportion of patients who had positive faecal occult blood tests and therefore were offered colonoscopy will actually turn out to have cancer?

A

4/10 will have polyps which may be removed due to premalignant potential
1/10 will be found to have cancer

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158
Q

What is courvoisiers law?

A

In the presence of a palpably enlarged gallbladder which is nontender and accompanied by painless jaundice, the cause is unlikely to be gallstones

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159
Q

What is the minimum number of biopsies that should be obtained on OGD when oesophageal cancer is suspected?

A

8

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160
Q

In the presence of cirrhosis, what size of liver lesion is highly suggestive of malignancy? What test can be done to back this up?

A

Over 2cm

Alpha foetoprotein - level over 400

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161
Q

What organism causes amoebic liver abscess?

A

Entamoeba histolytica

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162
Q

How do you treat an amoebic liver abscess?

A

Metronidazole

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163
Q

A 42 year old lady presents with right upper quadrant pain and a sensation of abdominal fullness. An ultrasound scan demonstrates a 6.5cm hyperechoic lesion in the right lobe of the liver. Serum AFP is normal. What is it?

A

Haemangioma

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164
Q

In which patients are you most likely to see a liver cell adenoma?

A

Women in their 3rd to 5th decade

On oral contraceptives

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165
Q

What is a major predisposing factor for liver abscess?

A

Biliary sepsis

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166
Q

What are common symptoms of liver abscess?

A

Fever
Right upper quadrant pain
Jaundice

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167
Q

What causes hyatid liver cysts?

A

Echinococcus infection

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168
Q

What are some causes of small bowel obstruction?

A

Incarcerated hernia
Crohn’s disease
Internal malignancy
Adhesions

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169
Q

What are complications of small bowel obstruction?

A

Intestinal necrosis
Sepsis
Multi organ failure

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170
Q

How are flares of UC classified?

A

Mild: fewer than 4 stools/day with/without blood, no systemic disturbance, normal ESR and CRP
Moderate: 4-6 stools/day, minimal systemic disturbance
Severe: more than 6/day with blood, systemic disturbance - fever, tachy, abdo tenderness, distension, reduced bowel sounds, anaemia, Hypoalbuminaemia

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171
Q

A 15 year old boy is admitted with colicky abdo pain for 6 hrs. On examination he has a soft abdomen. He has brown spots around his mouth feet and hands. His mother underwent surgery for intussusception aged 12 and has similar skin lesions, what is the most likely underlying diagnosis?

A

Peutz jeghers syndrome

Pigmented skin lesions, hamartomatous polyps resulting in intussusception and an autosomal inheritance pattern

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172
Q

Which patients are identified as being malnourished?

A

BMI less than 18.5
Unintentional weight loss of over 10% in 3-6 months
BMI less than 20 and unintentional weight loss over 5% over 3-6 months

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173
Q

Which patients are identified as at risk of malnutrition?

A

Eaten little or nothing over 5 days, who are likely to eat little for a further 5 days
Poor absorptive capacity
High nutrient losses
High metabolism

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174
Q

What are the guidelines on identifying a patient suitable for parenteral nutrition?

A

Identity as malnourished or at risk

Identify unsafe/inadequate oral intake or non functional GI tract/perforation/inaccessible

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175
Q

A 65 year old man with a history of dyspepsia is found to have a gastric MALT lymphoma on biopsy. What treatment should be offered?

A

H pylori eradication

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176
Q

What blood test results would you expect in mesenteric ischaemia?

A

Elevated WBC associated with acidosis and raised lactate

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177
Q

What are the guidelines for 2 week wait referral for colorectal services?

A

Patients >= 40 years with unexplained weight loss and abdominal pain
Patients >= 50 years with unexplained rectal bleeding
Patients >= 60 years with iron deficiency anaemia or change in bowel habit
Tests show occult blood in their faeces
Consider if: rectal or abdominal mass, unexplained anal mass or anal ulceration, patients < 50 years with rectal bleeding and unexplained symptoms/findings: abdominal pain, change in bowel habit, weight loss, iron deficiency anaemia

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178
Q

Who gets faecal occult blood test screening?

A

Every 2 years to all men and women aged 60 to 74 years Patients aged over 74 years may request screening
In addition FOBT should be offered to:
Patients >= 50 years with unexplained abdominal pain or weight loss
Patients < 60 years with changes in their bowel habit or iron deficiency anaemia
patients >= 60 years who have anaemia even in the absence of iron deficiency

179
Q

What are causes of mesenteric adenitis?

A

Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp

180
Q

What is triple therapy for eradication of h pylori?

A

Proton pump inhibitor
Amoxicillin
Metronidazole or clarithromycin
For one week with PPI continuing after

181
Q

A 60 year old man underwent a whipples procedure one week ago. He is recovering well then suddenly drops his BP and has a Hb of 65 down from 106 the previous day. What investigation should be carried out?

A

Coeliac angiography - imaging plus embolisation if a bleeding point is identified

182
Q

What are some risk factors for colonic carcinoma?

A 
High fat, low fibre diet
Age over 50
Personal Hx colorectal adenoma or carcinoma 
1st degree relative with colorectal cancer
Familial polyposis coli
Gardner syndrome
Turcot syndrome
Juvenile polyposis syndrome
Peutz Jeghers syndrome
HNPCC
UC and Crohns
183
Q

What is Gardner syndrome?

A

Autosomal dominant form of polyposis characterised by presence of multiple polyps in colon together with tumors outside the colon including osteomas of the skull, thyroid cancer, epidermoid cysts, fibromas

184
Q

What is Turcot syndrome?

A

Mismatch repair cancer syndrome -biallelic DNA mismatch repair mutations
Neoplasia typically occurs in both gut and the central nervous syste. In the large intestine, familial adenomatous polyposis occurs; in the CNS, brain tumors

185
Q

What are risk factors for Crohn’s disease?

A 
Smoking
Family history
COCP
Diet
Ethnicity
186
Q

Which HLA is associated with Crohn’s disease?

A

HLA DR1

187
Q

An 82 year old presents with constipation, colicky abdominal pain and abdominal distension. He complains of passing motions covered in blood and slime for 2 months. What is the likely diagnosis?

A

Carcinoma of the recto sigmoid junction

188
Q

What are risk factors for colonic carcinoma?

A

Increasing age
High fat diet
Inflammatory bowel disease
Family history - bowel cancer, hereditary polyposis

189
Q

What is left sided colon cancer more likely to present with?

A 
Obstructive symptoms: tenderness, distension
Cachexia
Hepatomegaly
Ascites
Rectal mass
Blood and slime
190
Q

What is the most common cause of morbidity with gastroenteritis?

A

Dehydration

191
Q

Over what time frame should viral gastroenteritis resolve?

A

3 - 8 days

192
Q

When is coeliac disease most commonly diagnosed?

A

8-12 months

30-50 years

193
Q

Where do peptic ulcers most commonly occur?

A

Duodenum (80%)

Stomach (20%)

194
Q

What is the most common cause of upper GI haemorrhage?

A

Gastritis

195
Q

How does peptic ulceration present?

A

Electively: nausea, intermittent epigastric pain
Emergency: acute upper GI bleed, perforation

196
Q

What percent of gastric ulcers are malignant?

A

10%

197
Q

How many biopsies should be taken from the edge of gastric ulcers seen at OGD?

A

Minimum of 6

198
Q

What are some causes/associations of dupuytrens contracture?

A 
Epilepsy/anti convulsant drugs
Peyronies disease 
Alcoholic liver disease 
Diabetes 
Smoking
Trauma
Heavy manual labour 
AIDS
199
Q

How is hep A transmitted?

A

Faecal oral route

200
Q

What is the incubation period of hep A?

A

2-6 weeks

201
Q

What type of virus is hep A?

A

Unenveloped RNA virus

202
Q

What serology is present with hep A?

A

HAV IgM antibody - acute active infection

HAV IgG antibody - previous infection or vaccination

203
Q

How is Hep E transmitted?

A

Faecal oral route

204
Q

Who is particularly vulnerable to hep E virus severity?

A

Pregnant women

205
Q

What type of virus is hep E?

A

Single stranded non enveloped RNA virus

206
Q

How is hep C transmitted?

A

Blood borne transmission

207
Q

What type of virus is hep C?

A

Enveloped RNA virus

208
Q

What is the incubation period of hep C?

A

6-9 weeks

209
Q

What proportion of hep C acute infections will progress to chronic?

A

75%

210
Q

What will hep C serology show?

A

HCV IgG antibody - infection at some point

HCV RNA PCR - can detect virus early, decreasing PCR suggests resolution

211
Q

What is the aim of hep C management?

A

Prevent cirrhosis, liver failure or development of hepatocellular carcinoma

212
Q

What early treatment can be given to reduce risk of developing chronic infection in hep C?

A

Interferon alpha

Ribavirin

213
Q

How is hep B transmitted?

A

Blood borne transmission

214
Q

What type of virus is hep B?

A

Double stranded DNA

215
Q

What proportion of acute hep B infections progress to chronic?

A

20%

216
Q

What complication is hep B linked with?

A

Hepatocellular carcinoma

217
Q

What is the incubation period for hep B?

A

40-160 days

218
Q

What will hep B serology show in acute infection?

A

HBsAg present - ongoing infection
HBeAg present - acute viral replication
Anti HBc IgM
HBV DNA by PCR present

219
Q

What will serology show in chronic hep B infection?

A

HBsAg present
IgM core antibodies promoted to IgG - Anti HBcIgG
Variable HBeAg and HBV DNA - if present, risk of post necrotic cirrhosis and hepatocellular carcinoma

220
Q

What will serology show if there is a resolved hep B infection?

A

HBsAg not present
IgG surface antibody present - anti HBs IgG
Anti HBc IgG likely present
No HBV DNA

221
Q

What will serology show if a person is vaccinated against hep B?

A

Anti HBs IgG only

222
Q

What is the management for hep B?

A

Admission if acutely unwell
Supportive management of symptoms - itching, nausea
Treatment of chronic compensated liver disease related to hep B - interferon alpha, anti retro viral
Monitor ALT, HBeAg, HBV DNA
Surveillance for development of cirrhosis/HCC

223
Q

What type of virus is hep D?

A

Defective single stranded RNA virus

224
Q

Which virus does hep D require the presence of in order to replicate?

A

Hep B

225
Q

How can be hep D be acquired?

A

At the same time as HBV - co infection
Sometime after HBV - superinfection
Blood borne transmission

226
Q

Which immunisation protects against hep D infection?

A

Hep B immunisation

227
Q

What is the management for hep D?

A

Interferon

Liver transplant

228
Q

Which HLA subtypes are associated with autoimmune hepatitis?

A

DR3 and DR4

229
Q

What are the 2 types of autoimmune hepatitis?

A

Type 1: presence of ANA and ASMA

Type 2: presence of anti LKM1, anti LC1

230
Q

How is autoimmune hepatitis diagnosed?

A

Raised circulating autoantibodies
Elevation of transaminases: ALT more than AST
Low albumin
Increased PT

231
Q

How is autoimmune hepatitis managed?

A

Treatment indicated when transaminases 1.5x upper limit normal
Corticosteroids
Azathioprine - measure TPMT first

232
Q

What risk stratification tools do you use for someone presenting with upper GI bleeding?

A

Blatchford score at first assessment

Rockall score pre/post endoscopy

233
Q

What is the management for an acute upper GI bleed?

A 
Resuscitation
Terlipressin if suspect variceal bleed
Antibiotic prophylaxis 
Endoscopy with band ligation 
Consider TIPS if not controlled
234
Q

What are signs of decompensated liver disease?

A

Haematemesis/variceal bleed
Ascites
Hepatic encephalopathy

235
Q

What proportion of blood flow to the liver is portal?

A

75%

236
Q

What is fulminant hepatic failure?

A

When failure takes place within 8 weeks of the onset of the underlying illness

237
Q

What is chronic decompensated hepatic failure?

A

Latent period >6 months

238
Q

What are the causes of a distended abdomen?

A 
Fat
Fluid
Faeces
Flatus 
Foetus
239
Q

What is the most common cause of ascites?

A

Cirrhosis

240
Q

Why does ascites occur?

A

Increased hydrostatic pressure in hepatic sinusoids
Peripheral arterial vasodilation
Activation of RAAS
Renal salt and water retention

241
Q

What is a complication of ascites?

A

Spontaneous bacterial peritonitis

Hyponatraemia

242
Q

How can you determine whether ascites is transudate or exudate?

A

Serum ascites albumin gradient

243
Q

How do you manage ascites?

A

Diuretics: dietary sodium restriction, spironolactone
Paracentesis: if resistance to medical treatment, albumin infusion
TIPS

244
Q

What is the mechanism that leads to encephalopathy in cirrhosis?

A

Toxins bypassing liver

Ammonia produced in GI tract by bacteria degrading protein

245
Q

What are features of encephalopathy?

A 
Changes in behaviour, memory, concentration 
Insomnia
Depression, euphoria, irritability 
Somnolence 
Disorientation
Increased tone and hyperreflexia 
Coma
246
Q

How is encephalopathy managed?

A

Minimise absorption of nitrogenous material: laxatives - lactulose TDS, reduces colonic pH and limits ammonia absorption
Antibiotics: rifaximin - reduce bowel organisms - reduced ammonia production
Maintain nutrition: protein initially restricted

247
Q

What is a child Pugh score used to calculate?

A

Life expectancy in patients with cirrhosis

248
Q

What is hepatorenal syndrome?

A 
Peripheral vasodilation in advanced liver disease
Fall in systemic vascular resistance 
Hypovolaemia 
Vasoconstriction of renal circulation 
Reduced renal perfusion - AKI 
Poor prognosis
249
Q

What is abdominal migraine?

A

Cyclical vomiting syndrome

Attacks of vomiting precipitated by stress, infections, menses

250
Q

What are poor prognostic features for a patient presenting with acute haematemesis?

A

Age above 70
Signs of shock (tachy, SBP less than 100)
Adherent clot
Visible vessel on endoscopic examination
Concomitant illness - cirrhosis, diabetes

251
Q

Which antibiotic is used for travellers diarrhoea and non invasive diarrhoeal illness when treatment is necessary?

A

Clarithromycin

252
Q

What is travellers diarrhoea?

A

At least 3 loose to watery stools in 24h with or without abdo cramps, fever, nausea, vomiting or blood in the stool

253
Q

What does vitamin A deficiency cause?

A

Night blindness (nyctalopia)

254
Q

What does vitamin B1 deficiency cause? (Thiamine)

A

Beri Beri: Polyneuropathy, Wernicke Korsakoff syndrome, Heart failure

255
Q

What does vitamin B3 deficiency cause? (Niacin)

A

Pellagra: Dermatitis, Diarrhoea, Dementia

256
Q

What does vitamin B6 deficiency cause? (Pyridoxine)

A

Anaemia
Irritability
Seizures

257
Q

What does vitamin B7 deficiency cause? (Biotin)

A

Dermatitis

Seborrhoea

258
Q

What does vitamin B9 deficiency cause? (Folic acid)

A

Megaloblastic anaemia

Deficiency during pregnancy: neural tube defects

259
Q

What does vitamin B12 deficiency cause? (Cyanocobalamin)

A

Megaloblastic anaemia

Peripheral neuropathy

260
Q

What does vitamin C deficiency cause?

A

Scurvy: gingivitis, bleeding

261
Q

What does vitamin D deficiency cause?

A

Rickets

Osteomalacia

262
Q

What does vitamin E deficiency cause?

A

Mild haemolytic anaemia in newborn infants
Ataxia
Peripheral neuropathy

263
Q

What does vitamin K deficiency cause?

A

Haemorrhagic disease of the newborn

Bleeding diathesis

264
Q

What are features of zollinger ellison syndrome?

A

Multiple gastroduodenal ulcers
Diarrhoea
Malabsorption

265
Q

How is a diagnosis of zollinger Ellison syndrome made?

A

Fasting gastrin level

Secretin stimulation test

266
Q

Which auto antibodies are associated with autoimmune hepatitis?

A

ANA
Anti smooth muscle
Anti liver kidney microsomal type 1

267
Q

What are features of autoimmune hepatitis?

A 
Signs of chronic liver disease
Acute hepatitis: fever, jaundice 
Amenorrhoea
ANA
Anti smooth muscle antibody
Raised IgG
Liver biopsy: inflammation beyond limiting plate
268
Q

What is management of autoimmune hepatitis?

A

Steroids
Immunosuppressant - azathioprine
Liver transplant

269
Q

What is primary sclerosing cholangitis associated with?

A

UC
Crohns
HIV

270
Q

What are features of primary sclerosing cholangitis?

A

Cholestasis: jaundice and pruritus
Right upper quadrant pain
Fatigue

271
Q

How is primary sclerosing cholangitis investigated?

A

ERCP: shows multiple biliary strictures - beaded appearance
ANCA
Liver biopsy: fibrous obliterative cholangitis - onion skin

272
Q

What are complications of primary sclerosing cholangitis?

A

Cholangiocarcinoma

Increased risk of colorectal carcinoma

273
Q

What are presenting features of haemochromatosis?

A 
Fatigue
Erectile dysfunction 
Arthralgia
Bronze skin pigmentation
Diabetes mellitus 
Chronic liver disease
Hepatomegaly
Cirrhosis 
Cardiac failure (dilated cardiomyopathy)
Hypogonadism (cirrhosis and pituitary dysfunction)
Arthritis
274
Q

What is mutated in haemochromatosis?

A

HFE gene on chromosome 6

275
Q

What are features of c diff infection?

A

Diarrhoea
Abdominal pain
Raised WCC
Toxic megacolon if severe

276
Q

What is the management for c diff infection?

A

Oral metronidazole for 10-14 days
If severe or not responding, oral vancomycin
If life threatening, oral vancomycin and IV metronidazole

277
Q

What are complications of diverticular disease?

A 
Diverticulitis
Haemorrhage
Abscess formation
Post infective strictures
Fistulae
278
Q

A patient is found to be HBsAg and IgM Anti HBc positive. What is the appropriate management?

A

Bed rest - acute hepatitis B

279
Q

A 50 year old man with chronic hep B has been on treatment for 7 months. He has developed tingling in his hands and is finding it increasingly difficult to climb stairs. Which medication is likely to be causing his symptoms?

A

Telbivudine - myopathy and peripheral neuropathy

280
Q

A 34 year old HIV positive woman has been diagnosed with chronic hep B. She has recently missed a period and is concerned she might be pregnant. What is the optimum treatment for her?

A

Truvada - treatment of choice for chronic hep B if also HIV positive, safe in pregnancy

281
Q

A 25 year old woman with confirmed chronic hep B is planning to become pregnant. What is the best treatment option?

A

Interferon

282
Q

A 56 year old man receiving chemo for diffuse large B cell lymphoma has intra nuclear owls eyes inclusion bodies on histology. What treatment should be offered?

A

Ganciclovir - CMV

283
Q

A 32 year old woman is admitted with acute renal failure. She is HBV positive and recently started a new treatment as her virus was lamivudine resistant. What has likely caused the renal failure?

A

Adefovir

284
Q

A 55 year old man who has sex with men presents with general malaise, right upper quadrant pain and yellowing of the eyes. He has multiple casual sexual partners in the preceding months and admits to not always using a condom. On examination he is jaundiced, tender in RUQ and you can feel a liver edge. What is the most likely infection?

A

Hepatitis B

285
Q

When should a diagnosis of IBS be considered?

A

Abdominal pain
Bloating
Change in bowel habit
Present for at least 6 months

286
Q

When can a positive diagnosis of IBS be made?

A 
Abdominal pain relieved by defecation or associated with altered bowel frequency stool form and 2 of the following:
Altered stool passage 
Abdominal bloating
Symptoms made worse by eating
Passage of mucus
287
Q

What are important red flags to ask about when considering IBS as a diagnosis?

A

Rectal bleeding
Unintentional weight loss
Family history of bowel or ovarian cancer
Onset after 60 years of age

288
Q

What does streptococcus bovis increase the risk of? How should it be investigated?

A

Colorectal cancer

Colonoscopy +/- CT abdo pelvis

289
Q

Which patients need urgent referral for upper GI endoscopy on 2 week wait?

A

Patients who have dysphagia
Upper abdominal mass
Aged 55 and over who have weight loss and pain, reflux or dyspepsia

290
Q

Which patients need non urgent referral for upper GI endoscopy?

A

Haematemesis
Patients 55 and over who have treatment resistant dyspepsia, upper abdo pain with low Hb, raised platelet count with nausea, weight los, reflux, dyspepsia, pain,

291
Q

How are patients managed who do not meet the criteria for upper GI endoscopy but have undiagnosed dyspepsia?

A

Review medications for possible causes
Lifestyle advice
Trial of full dose PPI for 1 month or test and treat for h pylori

292
Q

What test is recommended for h pylori?

A

Carbon 13 urea breath test, stool antigen test or lab based serology
Test of cure is carbon 13 urea breath test

293
Q

How is remission induced in UC?

A

Distal colitis: rectal mesalazine
Oral aminosalicylates
Oral prednisolone second line if fail to respond (wait 4 weeks)
Severe colitis needs admission and IV steroids

294
Q

How is the severity of UC decided?

A

Mild: <4 stools a day, small amount of blood
Moderate: 4-6 stools/day, varying blood, no systemic upset
Severe: >6 bloody stools/day and systemic upset

295
Q

How is remission maintained in UC?

A

Oral aminosalicylates: mesalazine

Azathioprine and mercaptopurine

296
Q

How should remission be induced in crohns?

A 
Glucocorticoids 
Enteral feeding with elemental diet 
5-ASA eg mesalazine second line 
Azathioprine or mercaptopurine as add on
Infliximab in refractory disease and fistulating crohns
297
Q

How is remission maintained in crohns?

A

Stop smoking
Azathioprine or mercaptopurine
Methotrexate second line
5-ASA - mesalazine if had previous surgery

298
Q

A 46 year old man is being investigated for indigestion. Jejunal biopsy shows deposition of macrophages containing PAS positive granules. What is the most likely diagnosis?

A

Whipples disease

299
Q

What is whipples disease?

A

Tropheryma whippelii infection

Common in those who are HLA B27 positive and middle aged men

300
Q

What is Budd Chiari syndrome?

A

Obstruction to hepatic venous outflow usually due to a hypercoagulable state but can also be due to tumour
Venous congestion causes hepatomegaly and portal hypertension which can result in splenomegaly and ascites

301
Q

What are some causes of budd chiari?

A

Polycythemia rubra Vera
Thrombophilia: activated protein c resistance, antithrombin III deficiency, protein c and s deficiency
Pregnancy
Oral contraceptive pill

302
Q

What are features of budd chiari?

A

Abdominal pain, sudden onset, severe
Ascites
Tender hepatomegaly

303
Q

What are features of whipples disease?

A

Malabsorption: diarrhoea, weight loss
Large joint arthralgia
Lymphadenopathy
Skin: hyperpigmentation and photosensitivity
Pleurisy
Pericarditis
Neurological symptoms: opthalmoplegia, dementia, seizures, ataxia, myoclonus

304
Q

What is the management of whipples disease?

A

Oral co-trimoxazole for a year

Sometimes preceded by a course of IV penicillin

305
Q

What is the prophylaxis for variceal haemorrhage?

A

Propranolol
Endoscopic variceal band ligation at 2 week intervals
PPI cover to prevent ulceration

306
Q

Why might a patient with UC have ascites and peripheral oedema?

A

Protein losing enteropathy

307
Q

A 58 year old gentleman, presenting to GP with epigastric pain
which occurs at varying times throughout day and night. Feels bloated at times with episodes of bletching. Feels nauseated. No regular prescribed medications. Has started new manual job so has been taking Ibuprofen regularly to relieve muscular aches and pains. Current smoker. Epigastric tenderness on examination. What are some differential diagnoses?

A 
Gallstones – including cholecystitis, pancreatitis
Gastric oesophageal reflux disease
Peptic ulcer disease 
IBD
Malignancy
308
Q

What is dyspepsia?

A 
Abdominal discomfort
Bloating 
Satiety 
Nausea 
Loss of appetite
Regurgitation
309
Q

What are indications (red flags) for OGD?

A 
Dysphagia 
Unexplained upper abdo pain with weight loss 
Upper abdo mass +/- dyspepsia 
Persistent vomiting and weight loss
Unexplained weight loss 
Iron deficiency anaemia
Unexplained worsening of dyspepsia 
Patients aged >55 years with unexplained and persistent recent onset dyspepsia
310
Q

What investigations should be done for someone presenting with dyspepsia?

A

Bloods: FBC plus haematinics – iron deficiency anaemia
Imaging: Erect CXR, USS if suspect gallstones
Special tests: Endoscopy, H.pylori investigation

311
Q

What is H pylori?

A

Gram negative urease-producing spiral shaped bacteria

312
Q

Which conditions are associated with h pylori?

A

Chronic gastritis
Peptic ulcer disease
Gastric cancer
Gastric B cell lymphoma

313
Q

How is h pylori diagnosed?

A

Non-invasive: C-urea breath test – ingest 13C-urea, broken down by H.pylori to produce 13C in expired breath. Stool antigen. Serum
Invasive: CLO test – pH dependent colour change due to presence of ammonia, Histology

314
Q

What is the management for a duodenal ulcer?

A

Conservative: Smoking cessation advice, Stop NSAIDs – discuss harm after medical treatment
Medical: H. pylori eradication – 1st line PPI + amoxicillin + clarithromycin or metronidazole – for 7 days. Recurrence of symptoms – long term lowest dose PPI. Repeat endoscopy 6-8 weeks after treatment to assess
Surgical: Reserved for complications – haematemesis, perforation (duodenal > gastric)

315
Q

What are some causes of haematemesis?

A 
Oesophagitis 
Peptic ulcer
Vascular malformations
Varices
Mallory Weiss tear
Cancer
Gastric erosion
316
Q

24 year old, visits her GP with ongoing symptoms of tiredness / lethargy. Experiencing abdominal discomfort. Reduced appetite and weight loss. Daily episodes of diarrhoea. What are some differential diagnoses?

A

IBS
IBD
Coeliac disease
GI infection

317
Q

In a young patient presenting with symptoms of IBS/coeliac. What investigations need to be done?

A

Bedside: Stool sample – culture
Bloods: FBC – anaemia, Haematinics, LFTs
Imaging: Plain AXR – if suspecting colitis
Special tests: Serum antibodies – total IgA and IgA tissue transglutaminase antibodies (tTG). Only accurate if remaining on gluten diet

318
Q

What is coeliac disease?

A

Immune-mediated, inflammatory systemic disorder provoked by gluten and related prolamines, leading to malabsorption of nutrients
Multi-genetic disorder associated with HLA types
Familial tendency
Gliadin = toxic portion of gluten, Initiate inflammatory cascade

319
Q

In which patients is serology for coeliac disease indicated?

A 
Symptomatic patients
Autoimmune disease (T1DM, Thyroid disease, Addison’s)
IBS
Unexplained osteoporosis 
1st degree relative with coeliac (10-fold increase)
Down’s syndrome (20-fold increase) 
Turner’s syndrome 
Infertility and recurrent miscarriage
320
Q

What is the management for coeliac disease?

A

Long term gluten-free diet following confirmation of diagnosis
Annual review: Weight/height, Symptom control, Adherence to gluten-free diet, Consider specialist dietetic/ nutritional advice

321
Q

Which patients should be screened for malnutrition?

A 
All hospital admissions
All 1st outpatient appt
Care homes
Registration at GP 
On clinical concern
322
Q

Which patients may need nutritional support?

A

Malnourished patients
BMI < 18.5 kg/m2
>10% unintentional weight loss over 3-6 months
BMI <20 kg/m2 + 5% unintentional weight loss over 3-6 months

323
Q

Which patients are at risk of malnutrition?

A

Eaten little or nothing for more than 5 days +/- likely to continue to eat little for the next 5 days
Poor absorptive capacity

324
Q

What are the main electrolyte disorders in refeeding syndrome?

A

Hypophosphataemia
Hypokalaemia
Hypomagnesaemia

325
Q

Describe the pathology of refeeding syndrome

A

Starvation: protein catabolism, adjustment to new metabolic state
Refeeding: conversion to glucose metabolism, insulin release, intracellular shifts of phosphate, magnesium and potassium

326
Q

What are 2 key investigations in chronic pancreatitis?

A

Faecal elastase

CT abdomen

327
Q

Which condition is typified by a corkscrew oesophagus?

A

Oesophageal spasm

328
Q

What can be trialled to treat oesophageal spasm?

A

Nitrates

Calcium channel antagonist

329
Q

In which circumstances should you start acetylcysteine without knowing the plasma levels of paracetamol?

A

Uncertainty about time of overdose, but potentially toxic
Overdose staggered over longer than an hour
Overdose taken 8-36 hours before presenting

330
Q

What is the treatment of choice for giardiasis?

A

Metronidazole

331
Q

How is giardiasis transmitted?

A

Contamination of food or water with protozoan Giardia lamblia

332
Q

What are the colorectal cancer referral guidelines? Who needs urgent referral?

A

Patients over 40 with weight loss and pain
Patients over 50 with unexplained rectal bleeding
Patients over 60 with iron deficiency anaemia or change in bowel habit
Tests show occult blood in faeces

333
Q

Who should be offered faecal occult blood testing?

A

All men and women aged 60 to 74 every 2 years
Patients over 50 with unexplained abdo pain or weight loss
Patients less than 60 with changes in bowel habit or iron deficiency anaemia
Patients over 60 who have anaemia even in absence of iron deficiency

334
Q

What are risk factors for oesophageal candidiasis?

A

HIV/immunosuppression

Steroid inhaler use

335
Q

What is a dieulafoys lesion?

A

Large tortuous arteriolar commonly in the stomach wall submucosally that erodes and bleeds

336
Q

What are clinical features of iron deficiency anaemia on examination/history?

A 
Glossitis
Angular stomatitis
Koilonychia
Pica 
Conjunctival pallor
337
Q

Why do alcoholics become thiamine deficient?

A

Alcohol interferes with active gastrointestinal transport of thiamine
If chronic liver disease: activation of thiamine pyrophosphate from thiamine is decreased and capacity of liver to store thiamine is diminished
Malnourishment

338
Q

What can cause a thiamine deficiency?

A

Alcoholism
Vomiting during pregnancy
Dietary insuffiency
Gastric carcinoma

339
Q

What is the definition of chronic hepatitis c?

A

Persistence of HCV RNA in blood for 6 months

340
Q

What are potential complications of chronic hepatitis c?

A 
Rheumatological: arthralgia, arthritis 
Eye: Sjögren's syndrome
Cirrhosis 
Hepatocellular carcinoma
Cryoglobulinaemia 
Porphyria cutanea tarda 
Membranoproliferative glomerulonephritis
341
Q

What are complications of primary biliary cirrhosis?

A 
Malabsorption 
Osteomalacia
Coagulopathy
Sicca syndrome
Portal HTN 
Hepatocellular cancer
342
Q

If a total paracentesis is used to treat tense ascites, what else should be done alongside?

A

6-8g albumin or colloid equivalent should be infused for every litre of ascitic fluid removed

343
Q

Which investigation is most appropriate to check that a rectal anastamosis is sound prior to performing an ileostomy reversal?

A

Gastrografin enema

344
Q

What are causes of raised ferritin without iron overload?

A 
Inflammation 
Alcohol excess
Liver disease
CKD
Malignancy
345
Q

What is the Amsterdam criteria for diagnosis of HNPCC?

A

3 or more relatives with colorectal cancer, endometrial carcinoma, small bowel adenocarcinoma, ureter or renal pelvis cancer
2 or more successive generations affected
1 or more tumour before age 50
FAP excluded
Confirmed with histology

346
Q

How does Chagas’ disease present?

A

Megaoesophagus or megacolon

347
Q

Which patients most commonly get Chagas’ disease?

A

South American men between 20-40 years

348
Q

What is the problem in Chagas’ disease?

A

American trypanosomiasis infection with Trypanosoma Cruzi

Causes denervation of myenteric Auerbachs plexus in bowel wall

349
Q

What is gardners syndrome?

A

AD Familial colorectal polyposis
Skull osteoma, thyroid cancer and epidermoid cysts
Mutation to APC gene on chromosome 5
Most require colectomy to reduce risk of colorectal cancer

350
Q

What is the recommendation for screening in patients with 2 first degree relatives with colon cancer?

A

Colonoscopy beginning at 35 or 5 years younger than earliest case in family
Every 5 years after that
Yearly FOBT

351
Q

How should more serious liver disease be assessed for in a patient with NAFLD?

A

Enhanced liver fibrosis blood test: hyaluronic acid, procollagen III and TIMP1

352
Q

What is the most common cause of liver disease in the developed world?

A

NAFLD

353
Q

What is the key mechanism leading to steatosis in NAFLD?

A

Hepatic manifestation of metabolic syndrome

Insulin resistance leads to steatosis

354
Q

What factors are associated with NAFLD?

A 
Obesity
Hyperlipidaemia
T2DM
Jejunoileal bypass
Sudden weight loss/starvation
355
Q

What are features of NAFLD?

A

Asymptomatic
Hepatomegaly
ALT>AST
Increased echogenicity on USS

356
Q

What are colorectal 2ww referral criteria?

A

Patients 40 or more with unexplained weight loss and abdominal pain
Patients 50 or more with unexplained rectal bleeding
Patients 60 or more with iron deficiency or change in bowel habit
Tests show occult blood in faeces

357
Q

Who is offered FOBT screening?

A

Every 2 years all men and women aged 60 to 74
Patients 50 or more with unexplained abdo pain or weight loss
Patients less than 60 with change in bowel habit or iron deficiency anaemia
Patients 60 or more with anaemia

358
Q

What are risk factors for the development of c diff infection?

A 
Increasing age
Antibiotic use (particularly broad spec)
IBD 
PPI use
Long hospital stays
Immunosuppression
Surgery to GI tract
359
Q

What type of bug is c diff? How does it cause pseudomembranous colitis?

A

Gram positive rod

Produces exotoxin which causes intestinal damage

360
Q

What are features of c diff infection?

A

Diarrhoea
Abdominal pain
Raised white cell count
If severe - toxic megacolon

361
Q

What is the management of c diff?

A

Oral metronidazole for 10-14 days
If severe or not responding - oral vancomycin
If life threatening - oral vancomycin and IV metronidazole

362
Q

What is the pathophysiology of hepatorenal syndrome?

A

Vasoactive mediators cause splanchnic vasodilation which in turn reduces SVR
This in turn results in under filling of the kidneys
This is sensed by juxtaglomerular apparatus which activates RAAS causing renal vasoconstriction which is not enough to counterbalance

363
Q

What is the pathophysiology of haemochromatosis?

A

Autosomal recessive disorder
Accumulation of iron in parenchymal organs
Gene mutations in HFE gene on chromosome 6 lead to reduced hepcidin production which in turn leads to increased ferroportin mediated iron efflux from storage and increased gut absorption
Excess iron produces free radicals which can lead to DNA damage, impaired protein synthesis, impaired cell integrity, cell injury and fibrosis

364
Q

What are the types of hepatorenal syndrome?

A

Type 1: Rapidly progressive, doubling of serum creatinine to >221 in less than 2 weeks. Very poor prognosis
Type 2: slowly progressive. Poor prognosis but may live for longer

365
Q

What are management options for hepatorenal syndrome?

A

Vasopressin analogues: terlipressin causes vasoconstriction of splanchnic circulation
Volume expansion with 20% albumin
Transjugular intrahepatic portosystemic shunt
Transplant

366
Q

What are potential complications of an upper GI endoscopy?

A 
Perforation
Bleeding
Reaction to sedation/anaesthetic
Infection
Aspiration pneumonia
367
Q

What is a lundh test?

A

Direct test of pancreatic function in which duodenal contents collected for 2 hours following meal containing carbs, protein and fat
Low enzymatic activity - amylase, trypsin of lipase indicates pancreatic insufficiency

368
Q

How is a diagnosis of Wilson’s disease made?

A

Reduced serum caeruloplasmin
Reduced serum copper
Increased 24h urinary copper excretion

369
Q

Which conditions are associated with dupuytrens contracture?

A 
Alcohol excess
Liver cirrhosis
AIDS 
Diabetes mellitus
Phenytoin use
Peyronie’s disease
370
Q

If a patient has no response to hep B vaccine (anti HBs <10) what else needs to be done?

A

Test for current or past infection
Give further vaccine course (3 doses)
Test again
If still failed to respond then HBIG would be required for protection if exposed

371
Q

What is gynaecomastia?

A

Presence of over 2cm palpable firm subareolar gland and ductal breast tissue

372
Q

What are causes of gynaecomastia?

A

Lack of testosterone: congenital absence of testes, androgen resistance, klinefelters, orchitis, renal disease
Increased oestrogen: testicular tumours, cancer secreting hCG, adrenal tumour, congenital adrenal hyperplasia, liver disease, hyperthyroidism, obesity
Drugs: digoxin, metronidazole, ketoconazole, spironolactone, GnRH agonists, finasteride, anabolic steroids, antipsychotics

373
Q

What investigations should be done for gynaecomastia?

A 
Renal function
LFTs
TFTs
Hormones: oesradiol, testosterone, prolactin, beta hCG, AFP, LH 
Karyotyping 
USS/mammogram
USS testes 
CXR
374
Q

How long before an endoscopy should omeprazole be stopped?

A

At least 2 weeks prior

375
Q

What is SAAG?

A

Serum ascites albumin gradient
Value below 11 - not portal HTN
Value above 11- portal HTN

376
Q

What are some causes of budd-chiari?

A

Polycythemia rubra Vera
Thrombophilia: activated protein c resistance, antithrombin III deficiency, protein c and s deficiencies
Pregnancy
Oral contraceptive pill

377
Q

What is pseudomyxoma peritonei?

A

Rare mucinous tumour most commonly from appendix

Accumulation of large amounts of gelatinous material in abdomen

378
Q

What is a urea breath test?

A

Patients consume drink containing carbon isotope 13 enriched urea
Urea broken down by h pylori urease
After 30 mins patient exhales into glass tube
Mass spec calculates amount of 13C CO2

379
Q

Which drugs may interfere with the results of a urea breath test?

A

Antibiotics within 4 weeks

PPI within 2 weeks

380
Q

What is a CLO test?

A

Rapid urease test
Biopsy sample mixed with urea and pH indicator
Colour change if h pylori urease activity

381
Q

What is the first line management for hepatic encephalopathy? How does it work?

A

Lactulose orally or per rectum
Reduction of intestinal ammonia load through purgative action and inhibiting anmoniagenic coliform bacteria by acidifying colonic lumen

382
Q

What is transient elastography?

A

Fibroscan
Uses 50mhz wave passed into liver from transducer on USS probe
Measures stiffness of liver which is a proxy for fibrosis

383
Q

Who should be offered transient elastography?

A

People with hep C
Men who drink over 50 units/week and women who drink over 35 and have done so for several months
People diagnosed with alcohol related liver disease

384
Q

What surveillance should patients with cirrhosis have?

A

OGD to check for varices in newly diagnosed

Liver USS every 6 months +/- alpha fetoprotein to check for hepatocellular cancer

385
Q

Which bugs can cause gastroenteritis?

A

Viruses : Rotavirus, Adenovirus, astrovirus

Bacterial : Salmonella, Campylobacter, E coli 0157, Shigella

386
Q

When should stool microbiology be performed in a person with gastroenteritis?

A 
Travel abroad
More than 7 days
Blood in stool
Immunocompromised
Sepsis
387
Q

What is the Mackler triad for boerhaave syndrome?

A

Vomiting
Thoracic pain
Subcutaneous emphysema

388
Q

Which patients with ascites require antibiotic prophylaxis for SBP?

A

If they have had a previous episode of SBP
Fluid protein 15g/L or less and child Pugh score of at least 9 or hepatorenal syndrome
Prophylactic ciprofloxacin or norfloxacin

389
Q

How is a diagnosis of SBP made?

A

Paracentesis: neutrophil count >250 cells/microL

390
Q

What is the management of SBP?

A

IV cefotaxime

391
Q

What is the Hinchey classification?

A

Classifies diverticular perforation
Stage 1: diverticulitis with pericolic abscess
Stage 2: diverticulitis with distant abscess (retroperitoneal or pelvic)
Stage 3: purulent peritonitis
Stage 4: faecal peritonitis

392
Q

When do different features of alcohol withdrawal occur?

A

Symptoms: 6-12 hours
Seizures: 36 hours
Delirium tremens: 72 hours

393
Q

Why does chronic alcohol consumption lead to withdrawal symptoms if stopped abruptly?

A

Chronic alcohol consumption enhances GABA mediated inhibition in CNS and inhibits NMDA glutamate receptors
Withdrawal causes the opposite so leading to overactivity and therefore seizures and delirium

394
Q

What are the components of the child Pugh score?

A 
All Alcoholics Bring Empty Prosecco
Albumin
Ascites
Bilirubin
Encephalopathy
Prothrombin time
395
Q

What criteria is used to assess severity of UC in adults? What classes as severe?

A

Truelove and Witts
Severe if: blood in stool or more than 6/day plus at least 1 of - temp over 37.8, heart rate over 90, Hb less than 105, ESR over 30

396
Q

Which drugs contribute to causing c diff?

A 
Clindamycin
Cephalosporins 
Penicillins
Fluoroquinolones 
PPIs
397
Q

Which blood test is most suggestive of Wilson’s disease? Which other tests are useful in diagnosis?

A

Reduced serum caeruloplasmin
Reduced serum copper
Increased 24hr urinary copper excretion

398
Q

What defines upper vs lower GI bleed?

A

Distal or proximal to the ligament of Trietz

399
Q

What makes meckels diverticulum susceptible to bleeds?

A

Ectopic gastric/pancreatic mucosal tissue

400
Q

What features are required for a diagnosis of IBS to be considered?

A

Abdo pain
Bloating
Change in bowel habit
For at least 6 months

401
Q

What is the Rome 3 criteria for diagnosis of IBS?

A

Recurrent abdo pain 3 or more days per month in last 3 months associated with at least 2 of:
Pain/discomfort improved after defecation
Onset associated with change in frequency of stool
Onset associated with change in form of stool, alternating between diarrhoea and constipation
No evidence of inflam, anatomical, metabolic or neoplasticism process that could be causing symptoms

402
Q

What are red flag symptoms which should be enquired about when suspecting IBS?

A

Rectal bleeding
Unintentional weight loss
FH bowel or ovarian cancer
Onset after age 60

403
Q

What are suggested primary care investigations for IBS?

A

FBC
ESR/CRP
Coeliac screen (anti TTG)

404
Q

What are features of primary biliary cirrhosis?

A 
Granulomatous destruction of bile ducts
Insidious pruritis then jaundice 
Sicca syndrome
Finger clubbing
Xanthomata and hyperlipidaemia
Neuropathy
Arthritis
405
Q

What are risk factors for gallstones?

A 
Fair
Fat
Forty 
Fertile 
Female
406
Q

What is Dubin Johnson syndrome?

A

Autosomal recessive disorder causes isolated increase of conjugated bilirubin
Causes black liver
Due to mutation in multiple drug resistance protein 2

407
Q

What is rotor syndrome?

A

Autosomal recessive disorder with isolated conjugated bilirubinaemia due to inability to excrete it

408
Q

Why do diverticuli occur most frequently in sigmoid colon?

A

Faeces more solid here

Lumen smaller and less able to stretch

409
Q

Where does angiodysplasia occur most commonly?

A

Caecum and ascending colon

410
Q

What are problems with an end to end anastomosis?

A

Stricture
Leakage
Dehiscence

411
Q

What are different types of bowel anastamosis?

A

End to end
Side to end
Side to side

412
Q

What is suggested by AST>ALT with overall rise less than 5 times?

A

Alcohol related

Cirrhosis

413
Q

At what level of bilirubin is jaundice clinically detectable?

A

Levels over 40

414
Q

Why is there a coagulopathy in liver disease?

A

Failure of activation of vitamin k and therefore lack of Vit k dependent clotting factors

415
Q

What are the 4 stages of liver disease?

A

Liver cell necrosis
Inflammatory infiltrate
Fibrosis by fibroblasts
Nodular regeneration which can be micro (viral) or macronodular (alcohol)

416
Q

What is management of ascites?

A

Salt/fluid restrict
Diuretics particularly spironolactone
Paracentesis
Provide 20% albumin solution to prevent reaccumulation

417
Q

What should be used to treat hepatic encephalopathy?

A

Lactulose - osmotic laxative - inhibiting bacterial growth which produce ammonia

418
Q

What is the initial management of unruptured sigmoid volvulus?

A

Flatus tube insertion

Second line: insertion of percutaneous colostomy tube

419
Q

What is the histology of coeliac disease?

A

Villous atrophy
Raised intra epithelial lymphocytes
Crypt hyperplasia

420
Q

What is the acute treatment of variceal haemorrhage?

A

A to E
Correct clotting: FFP, vitamin K
Vasoactive agents: terlipressin
Prophylactic antibiotics if liver cirrhosis
Endocscopic variceal band ligation
Sengstaken blakemore tube if uncontrolled
Transjugular intrahepatic portosystemic shunt

421
Q

What can be used for prophylaxis of variceal bleeding?

A

Propranolol
Endoscopic variceal band ligation at 2 weekly intervals until all varices eradicated
PPI cover to prevent EVL induced ulceration

422
Q

What are causes of chronic liver disease?

A

Infective: hep B, hep C
Toxic: alcohol
Metabolic: NAFLD, haemochromatosis, alpha 1 antitrypsin, Wilson’s
Autoimmune: autoimmune hepatitis, PSC, PBC

423
Q

How would you investigate the cause of chronic liver disease?

A 
HBV and HCV serology
Hx of alcohol excess
Ferritin, transferrin
Alpha 1 antitrypsin
Caeruloplasmin
Immunoglobulins
Autoantibodies
424
Q

What are features of decompensated liver disease?

A 
Coagulopathy 
Asterixis
Ascites
Worsening jaundice
Hypoglycaemia
425
Q

What are complications of cirrhosis?

A

Portal HTN: variceal haemorrhage, SBP, thrombocytopenia

Hepatocellular failure: encephalopathy, Hepatocellular Ca, hypoalbuminaemia, coagulopathy

426
Q

What are causes of splenomegaly?

A

Haem: CML, myelofibrosis, spherocytosis (may have had splenectomy in childhood)
Infective: malaria, EBV
Other: portal HTN, amyloidosis, sarcoidosis

427
Q

What defines massive splenomegaly?

A

Extends beyond midline

428
Q

What are indications for stoma in IBD?

A

Crohns: failure of medical management, obstruction, fistulae
UC: failure of medical management, toxic megacolon, malignancy

429
Q

What types of stomas are done for IBD?

A

Crohns: de functioning loop ileostomy
UC: end ileostomy (pan proctocolectomy), diversion ileostomy with ileal rectal pouch formation

430
Q

What are histological features of Crohns?

A

Presence of granuloma formation
Transmural inflammation
Lymphocytic infiltration

431
Q

What are endoscopic differences between crohns and UC?

A

Crohns: inflammation is not continuous with presence of skin lesions, cobblestone appearance, mouth to anus, terminal ileum affected
UC: uniform inflammation, thin walls, loss of vascular pattern, rectum always affected, large bowel only

432
Q

What are extra articular features of Crohns?

A 
Erythema nodosum
Pyoderma gangrenosum 
Iritis 
Conjunctivitis 
Episcleritis 
Large joint arthritis 
Ankylosing spondylitis 
Aphthous ulceration
433
Q

What are complications of Crohns?

A 
Perianal abscess and fistulae
Enteric fistulae
Perforated bowel 
Small bowel obstruction
Colonic carcinoma
Malnutrition
434
Q

What drugs can contribute to an upper GI bleed?

A 
NSAIDs 
Aspirin 
Corticosteroids 
Anticoagulants
Thrombolytics
435
Q

Explain how the urea breath test for h pylori works

A

H pylori produce urease to break down urea into ammonia and CO2
Radio isotope of carbon 13/14 in form of urea is ingested and radio isotope CO2 can be measured

436
Q

What is gold standard test for GORD?

A

Oesophageal pH manometry

437
Q

What is dumping syndrome?

A

Rapid gastric emptying due to food entering small bowel too quickly
After gastric surgery

438
Q

Why might an anti endomysial antibodies be negative in a patient with severe coeliac disease?

A

Severe malabsorption can lead to IgA deficiency

439
Q

What are histological features of coeliac disease?

A

Subtotal villous atrophy
Increased intraepithelial lymphocytes
Hypoplasia of small bowel architecture
Proliferation of crypts of Lieberkuhn

440
Q

What cancers are associated with coeliac disease?

A

GI T cell lymphoma
Gastric
Oesophageal

441
Q

Which antibodies can be tested for in coeliac disease?

A

Anti tissue transglutaminase
Alpha gliadin
Anti endomysial

442
Q

What is post obstructive diuresis?

A

Urine output exceeding >200ml/hr after cleaning an obstruction

443
Q

What drugs are required to be stopped before a urea breath test?

A

No abx for 4 weeks

No PPI for 2 weeks

Phase 3 (23 decks)

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