Gastro

Question 1

What is the most likely culture growing in an alcohol patient with ascitic fluid?

Answer 1

E. Coli

Question 2

Why are all patients with Coeliac offered the pneumococcal vaccine?

Answer 2

They often have a degree of hyposplenism

Question 3

Management of hepatic encephalopathy

Answer 3

1. Treat underlying precipitants (e.g. infection, GI bleed, constipation, drugs (sedatives, diureticvs, hypokalaemia)
2. Lactulose - thought to increase excretion of ammonia (± rifaxamin for secondary prophylaxis)
3. Consider embolisation of portosystemic shunts and liver transplant in some patients.

Question 4

Tumour marker for hepatocellular carcinoma?

Answer 4

AFP

Question 5

Gilbert’s syndrome - management

Answer 5

Conservative - no treatment required (bilirubin tends to be transient rise due to deficiency in glucoronyl transferase)

Question 6

Screening tool used for malnutrition

Answer 6

MUST score (malnutrition universal screen tool) - determines low, medium and high risk patients

Question 7

What is the recommended drug for prophylaxis of variceal bleeding?

Answer 7

Non-cardiac selective beta blocker, e.g. propranolol

Question 8

Vitamin deficiency caused by Crohn’s and why?

Answer 8

B12 as it affects terminal ileum

Question 9

Management of hepatorenal syndrome

Answer 9

1. Vasopressin analogues, for example terlipressin, have a growing evidence base supporting their use. They work by causing vasoconstriction of the splanchnic circulation
   volume expansion with 20% albumin
   transjugular intrahepatic portosystemic shunt
2. Volume expansion with 20% albumin
3. Transjugular intrahepatic portosystemic shunt

Question 10

Classificiation of inflammatory bowel disease (mild, moderate and severe)

Answer 10

1. Mild - systemically well, <4 stools per day
2. Moderate - systemically well, >4 stools per day
3. Severe - systemically UNWELL, >6 stools per day

Question 11

What advice should be given to patients undergoing OGD regarding their PPI or H2 receptor antagonist?

Answer 11

Stop at least 2 weeks prior to endoscopy as it can mask serious underlying pathology, e.g. gastric cancer

Question 12

Hiatus hernia classification (x2)

Answer 12

1. Sliding (80%) - LOS slides through the oesophageal hiatus; acid reflux common
2. Rolling (20%) - LOS remains in the abdomen but the fundus herniates through the diaphragm; GORD is less common as LOS is intact

Question 13

2 ways gastric cancer may be staged - which one has been shown to be more superior?

Answer 13

CT or endoscopic USS can be done; USS shown to be more superior

CT CAP needs to be doneas first line + laparoscopy to identify occult peritoneal disease ± PET CT (particularly for junctional tumours

Question 14

Management of gastric carcinoma

Answer 14

1. Disease >5-10cm from OG junction - Mx with subtotal gastrectomy - inferior stomach joined with jejunum
2. Total gastrectomy - tumour <5cm from OG junction (proximal disease)
3. Oesophagogastrectomy if extends to oesophagus
4. If confined to mucosa - endoscopic submucosal resection
5. Other interventions:
   - Lymphadenectomy
   - Chemotherapy pre- or post-operatively

Question 15

Diagnosis for Zollinger-Ellison syndrome

Answer 15

Fastin gastrin levels - single best screen test

Secretin stimulation test may also be done

Question 16

Primary biliary cirrhosis - antibody

Answer 16

Anti-mitochondrial antibody

Question 17

Management of acute cholecystitis

Answer 17

1. NMB, carefully monitor
2. Medical - analgesia, IV fluids, antibiotics
3. Surgical - cholecystectomy ideally within 48h of presentation

Question 18

Ascending cholangitis - clinical features

Answer 18

1. Charcot’s triad (20-50%) - RUQ pain, fever, jaundice

2. Hypotension and confusion

Question 19

Management of ascending cholangitis

Answer 19

1. IV antibiotics

2. ERCP after 24-48h to relieve any obstruction

Question 20

Primary sclerosing cholangitis is associated with what inflammatory bowel disease?

What malignancy does it carry an increased risk of?

Answer 20

Ulcerative colitis

Cholangiocarcinoma (and colorectal cancer)

Question 21

Prognosis of liver cirrhosis can be quantified with what scoring system

Answer 21

Child-Pugh classification

Question 22

Acute management of variceal haemorrhage

Answer 22

1. ABCDE - resuscitate first before endoscopy
2. Endoscopic variceal band ligation (1st choice); or endoscopic sclerotherapy
3. Terlipressin
4. Sengstaken-Blakemore tube
5. Transjugular intrahepatic portosystemic shunt (TIPS)
6. IV antibiotics - quinolones
7. Correct clotting - FFP, vitamin K

Question 23

Prophylaxis of variceal bleed

Answer 23

1. Propanolol - helps decrease re-bleeding and mortality (may be given to pts w/ varices who have never had an acute bleed)
2. Endoscopic variceal band ligation + PPI - do every 2 weeks until all varices eradicated

Question 24

Management of ascites caused by portal HTN

Answer 24

1. Dietary sodium restriction
2. Oral spironolactone (large dose)
3. Furosemide - aim to lose 0.5kg/day; do not do diuresis too fast - inc. encephalopathy risk
4. Paracentesis - for medication resistant; Rx with IV albumin infusion to inc. circulating volume
5. TIPS if above fails

Question 25

Management of hepatitis B infection

Answer 25

pegylated interferon-alpha - reduces viral replication by 30%

Question 26

Hepatitis B in pregnancy

Answer 26

All women are offered vaccination in pregnancy

If baby born with mum acquired HBV in pregnancy/chronically infected = complete vaccination course + Hep B immunoglobulin

Question 27

Hep B markers present in:

1. Previous immunisation
2. Previous HBV (>6m), now NOT carrier
3. Previous HBV, now is a carrier

Answer 27

1. anti-HBs
2. anti-HBc (IgG), anti-HBs
3. anti-HBc, HBsAg

Question 28

Metabolic consequences of re-feeding syndrome

Answer 28

hypophosphataemia
hypokalaemia
hypomagnesaemia
abnormal fluid balance