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MRCP2 > Gastro > Flashcards

Gastro Flashcards

1
Q

Management of alcoholic hepatitis?

A

Prednisolone

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2
Q

What is the management of Clostridium difficile?

A

Gram positive rod
1. Oral metronidazole
2. Oral vancomycin
3. Fidaxomicin if not responding (useful for recurrence)
Life threatening: Oral vancomycinc and IV metronidazole

‘For severe infection in patients with multiple co-morbidities who are receiving treatment with other antibacterials, or for second or subsequent episode of infection, fidaxomicin can replace vancomycin’

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3
Q

What can cause a raised faecal calprotectin?

A 
IBD
Bowel malignancy
Coeliac disease
Infectious colitis
NSAIDs
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4
Q

Systemic sclerosis

What is the LES pressure?

A

As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased.

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5
Q

Pathophysiology of Achalasia?

A

Failure of oesophageal peristalsis and of failure to relax lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus

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6
Q

What is paracentesis induced circulatory dysfunction?

A

Occurs in large volume paracentesis (>5 L)

Associated high rate of ascites recurrence, hepatorenal syndrome, dilutional hyponatraemia, mortality

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7
Q

How is colorectal cancer screened in UK?

A

Faecal Immunochemical Test (FIT)
Every 2 years age 60-74
Age 74+ can request
If abnormal result, offered colonoscopy

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8
Q

Complications and prognosis of eosinophilic oesophagitis?

A

Complications:
Strictures, impaction, mallory-weiss tears

Prognosis:
Chronic condition

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9
Q

How is paracentesis induced circulatory dysfunction diagnosed in lab tests?

A

PICD is definitively diagnosed through laboratory results, with increases of more than 50% of baseline plasma rennin activity to > 4 ng/mL/h on the days 5-6 following paracentesis

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10
Q

What should you do for decompensated liver disease?

A

Investigate and exclude causes of decompensation

Enhance nitrate clearance with phosphate enemas aiming for minimum three loose stools per day and lactulose to enhance binding of nitrate in the intestine.

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11
Q

What are the three pictures of drug induced liver disease and can you name some causes?

A

hepatocellular, cholestatic or mixed

The following drugs tend to cause a hepatocellular picture:
paracetamol
sodium valproate, phenytoin
MAOIs
halothane
anti-tuberculosis: isoniazid, rifampicin, pyrazinamide
statins
alcohol
amiodarone
methyldopa
nitrofurantoin

The following drugs tend to cause cholestasis (+/- hepatitis):
combined oral contraceptive pill
antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
anabolic steroids, testosterones
phenothiazines: chlorpromazine, prochlorperazine
sulphonylureas
fibrates
rare reported causes: nifedipine

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12
Q

Diagnosis of Colorectal cancer?

A
  1. Colonoscopy
    2 Double contrast barium enema
  2. CT colongraphy

Staging:
CTTAP
Pelvic - MRI scan

CEA used for follow up (correlate roughly with disease burden)

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13
Q

Complications of coeliac disease?

A

anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
hyposplenism
osteoporosis, osteomalacia
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility, unfavourable pregnancy outcomes
rare: oesophageal cancer, other malignancies

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14
Q

Management of diffuse oesophageal spasm?

A

calcium channel blockers are optimal for those presenting primarily with chest pain

dysphagia resistant to pharmacological therapies require more invasive or surgical treatments

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15
Q

Test for malabsorption?

A

D-xylose test.

Xylose is a sugar that does not require enzymes to be digested. Patient’s drink a set volume of D-xylose, and then levels of D-xylose are measured in the blood and urine. If no D-xylose is present that the small bowel is not absorbing properly, and it is not a problem of enzymatic function.

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16
Q

Investigation for small bowel bacterial overgrowth?

A
  1. Hydrogen breath test
  2. Small bowel aspiration and culture (gold standard)
    - -> more than 100,000 bacteria per ml
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17
Q

Management of alcoholic hepatitis?

A

Prednisolone

AST: ALT >2:1

MDS >32 associated with 50% mortality

Pentoxifylline reduce mortality in hepatorenal syndrome

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18
Q

How do you investigate eosinophilic oesophagitis?

A

Endoscopy and biopsy

PPI Trial - persistence of oesinophilia and no improvement of symptoms

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19
Q

Investigation of Achalasia?

A
  1. Manometry: excessive LOS tone which doesn’t relax
  2. Barium Swallow - birds beak and fluid level, expanded oesophagus
  3. CXR - wide mediastinum
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20
Q

How should you investigate dysphagia?

A
  1. UGI endoscopy
  2. Fluoroscopy (if motility)
  3. FBC
  4. Ambulatory oesophageal pH and manometry if achalasia/GORD awaiting surgery
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21
Q

Colorectal Cancer Screening with IBD.

Low Risk:

A

 Extensive colitis with no inflammation
 OR left sided colitis
 OR Crohn’s colitis <50% colon

Screen every 5 years

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22
Q

How is ascites grouped into categories?

A

serum-ascites albumin gradient (SAAG) <11 g/L or a gradient >11g/L

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23
Q

What is paracentesis induced circulatory dysfunction?

A

Occurs in large volume paracentesis (>5 L)
Associated high rate of ascites recurrence, hepatorenal syndrome, dilutional hyponatraemia, mortality

increases of more than 50% of baseline plasma rennin activity to > 4 ng/mL/h on the days 5-6 following paracentesis

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24
Q

SAAG <11g/L

A 
Peritoneal carcinomatosis
Tuberculous peritonitis
Pancreatic ascites
Bowel obstruction
Biliary ascites
Postoperative lymphatic leak
Serositis in connective tissue diseases
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25
Q

Acute Pancreatitis causes?

A

Popular mnemonic is GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

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26
Q

Treatment of Achalasia?

A
  1. Nifedipine or nitrates
  2. Intra-sphincteric injection of botulinum toxin
  3. Heller cardiomyotomy
  4. Pneumoatic balloon dilation
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27
Q

What is the presentaiton of eosinophilic oesophagitis?

A

Dysphagia, strictures, fibrosis, food impaction, regurgitation, anorexia, weight loss

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28
Q

Management for small bowel bacterial overgrowth?

A
  1. Rifaximin

Also effective results with co-amoxiclav or metronidazole

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29
Q

What is dumping syndrome?

Early and Late

A

early: food of high osmotic potential moves into small intestine causing fluid shift

late (rebound hypoglycaemia): surge of insulin following food of high glucose value in small intestine - 2-3 hours later the insulin ‘overshoots’ causing hypoglycaemia

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30
Q

Symptoms of Carcinoid Tumours?

A 
Flushing
Diarrhoea
Bronchospasm
Hypotension
Right Heart Valvular stenosis
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31
Q

Is Azathioprine safe in Pregnancy if on it for Crohn’s Disease?

A

Yes, better than relapse of Crohn’s disease

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32
Q

Management of Acute UGI bleed?

A

Resuscitation:

  1. RBC if < 70
  2. Platelets if <50
  3. FFP if Fibrinogen < 1 or PT/APPT > 1.5x normal
  4. Prothrombin complex if warfarin and active bleeding

Endoscopy:

  1. Immediately if severe bleed
  2. Within 24 hours otherwise

Non-Variceal Bleeds:

  • No PPI before endoscopy
  • Further bleed after endoscopy - repeat endoscopy/IR/surgery

Variceal Bleeds:

  1. Terlipressin and prophlactic antibiotics before
  2. Band ligation > sclerotherapy
  3. Transjugular intrahepatic portosystemic shunts (TIPS) if not controlled
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33
Q

What is management for maintaining remission in Crohn’s Disease?

A
  1. Stop smoking
  2. Azathioprine/Mercaptopurine
    If macroscopic resection, 3/12 azathioprine and metronidazole
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34
Q

SAAG > 11g/L

A

Indicates portal hypertension

Cirrhosis
Alcoholic hepatitis
Cardiac ascites
Mixed ascites
Massive liver metastases
Fulminant hepatic failure
Budd-Chiari syndrome
Portal vein thrombosis
Veno-occlusive disease
Myxoedema
Fatty liver of pregnancy
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35
Q

Symptoms of Carcinoid Tumours?

A 
Flushing
Diarrhoea
Bronchospasm
Hypotension
Right Heart Valvular stenosis (or triscupid regurg) - endocardial plaques of fibrous tissue
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36
Q

Complications of gastrectomy?

A 
Dumping syndrome (early and late)
Weight loss, early satiety

Iron-deficiency anaemia

Osteoporosis/osteomalacia

Vitamin B12 deficiency

Other complications
increased risk of gallstones
increased risk of gastric cancer

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37
Q

What is the test for Bile Acid Malabsorption?

A

SeHCAT
Scan at 7 days apart

SeHCAT is bile acid analogue which can be detected by a nuclear medicine scan. The SeHCAT test involves a baseline scan, and then a 7 day scan. A 7-day SeHCAT retention value of less than 15% is generally considered indicative of bile salt malabsorption

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38
Q

Complications of coeliac disease?

A

anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
hyposplenism
osteoporosis, osteomalacia
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility, unfavourable pregnancy outcomes
rare: oesophageal cancer, other malignancies

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39
Q

What is alkaptonuria?

A

rare autosomal recessive disorder of phenylalanine and tyrosine metabolism caused by a lack of the enzyme homogentisic dioxygenase (HGD) which results in a build-up of toxic homogentisic acid. The kidneys filter the homogentisic acid (hence black urine) but eventually it accumulates in cartilage and other tissues.

Alkaptonuria is generally a benign and often asymptomatic condition. Possible features include:
pigmented sclera
urine turns black if left exposed to the air
intervertebral disc calcification may result in back pain
renal stones

Treatment
high-dose vitamin C
dietary restriction of phenylalanine and tyrosine

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40
Q

Autoimmune Hepatitis Markers

Type 2

A

LKM1 (anti-liver/kidney microsomal type 1 antibodies)

Affects children only

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41
Q

What is eosinophilic oesophagitis?

A

Allergic inflammation of the oesophagus. Likely an allergic reaction to ingested food

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42
Q

Autoimmune Hepatitis features and risk factors:

A
  • chronic liver disease
  • acute hepatitis: fever, jaundice etc (only 25% present in this way)
  • amenorrhoea (common)
  • ANA/SMA/LKM1 antibodies, raised IgG levels
  • liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis

Risk Factors:
- autoimmune history
Hypergammaglobulinaemia
- HLA B8, DR3

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43
Q

Management of eosinophilic oesophagitis?

A

Dietary modification

  1. Elemental diet
  2. Exclusion of six food groups
  3. Targeted elimination

Combine with topical steroids (fluticasone/budesonide) if dietary modification fails

Oesophageal dilation

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44
Q

Colorectal Cancer Screening with IBD.

Moderate Risk:

A

 Extensive colitis with inflammation (mild)
 OR post-inflammatory polyps
 OR family history of colorectal cancer first degree >50 years

Screen every 3 years

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45
Q

Dubin-Johnson syndrome - tell me about it

A

Benign
Autosomal recessive
Hyperbilirubinaemia (conjugated, present in urine)

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46
Q

What is management for inducing remission in Ulcerative Colitis?

A
  1. Topical (rectal) aminosalicylate
  2. Add oral aminosalicylate if >4 weeks and no effect
  3. If no remission, add oral steroid

N.B. there is some variation between proctitis, proctosigmoiditis and extensive disease

Severe
IV steroids or IV ciclosporin if contraindicated
If no improvement in 72 hours, add IV ciclosporin or surgery

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47
Q

Tell me about HNPCC

A

Autosomal dominant
Proximal colon or endometrial cancer
Amsterdam criteria help in diagnosis

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48
Q

What is management for inducing remission in Crohn’s Disease?

A
  1. Steroids (budesonide if need low S/E profile)
  2. 5-ASA (unless severe)
  3. Azathioprine/Mercaptopurine (if 2+ exacerbation in 12 months)
  4. Infliximab or Adalimumab (refractory or fistulating disease)
    N.B. Metronidazole for isolated peri-anal disease
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49
Q

Autoimmune Hepatitis Markers

Type 1

A

ANA
SMA (anti-smooth)

Affects adults and children

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50
Q

Management of Ascites?

A
  1. Reduce dietary sodium
  2. If Na <125, fluid restrict
  3. Spironolactone +/- Loop diuretic
  4. Drainage if tense. If large volume, give albumin cover
  5. Prophylactic antibiotics (Ciprofloxacin or norfloxacin if protein <15g and cirrhosis)
  6. Consider TIPS
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51
Q

Colorectal Cancer Screening with IBD.

High Risk:

A

 Extensive colitis with inflammation (severe)
 OR stricture in past 5 years
 OR dysplasia in past 5 years declining surgery
 OR PSC/transplant for this
 OR family history cancer in first degree relative <50 years

Screen every 1 year

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52
Q

Acute Upper GI Bleed. Which scoring system and for when?

A

Blatchford - first assessment

Rockall score - after endoscopy

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53
Q

What is management for maintaining remission in Ulcerative Colitis?

A
  1. Topical aminosalicylate
  2. Oral and topical aminosalicylate
  3. Oral aminosalicylate

(Any one of the above)

If severe exacerbation or 2+ in one year:
1. Azathioprine or Mercaptopurine

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54
Q

When is capsule endoscopy used?

A

The SIGN guidelines for occult bleeding recommend OGD and colonoscopy. If they are both normal they recommend either repeat OGD or capsule endoscopy. If the capsule is negative then either a second capsule or enteroscopy is indicated.

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55
Q

What is the triad in Budd-Chiari Syndrome?

A

Abdominal pain (sudden onset, severe)
Ascites
Tender hepatomegaly

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56
Q

Management of eosinophilic oesophagitis?

A

Dietary modification

  1. Elemental diet
  2. Exclusion of six food groups
  3. Targeted elimination

Combine with topical steroids (fluticasone/budesonide) if dietary modification fails

Oesophageal dilation

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57
Q

Radiological evidence of diffuse oesophageal spasm?

A

barium swallow demonstrates a ‘corkscrew appearance’

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58
Q

Tell me about FAP

A 
Autosomal dominant
APC defect (tumour suppressor)
TOtal colectomy with ileo-anal pouch formation age 20
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59
Q

What is dumping syndrome?

Early and Late

A

early: food of high osmotic potential moves into small intestine causing fluid shift (colicky abdominal pain, diarrhoea and nausea)

late (rebound hypoglycaemia/postprandial hyperinsulinemic hypoglycaemia): surge of insulin following food of high glucose value in small intestine - 2-3 hours later the insulin ‘overshoots’ causing hypoglycaemia

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60
Q

Complications of gastrectomy?

A

Dumping syndrome (early and late)
Weight loss
early satiety

Iron-deficiency anaemia
Osteoporosis/osteomalacia
Vitamin B12 deficiency

risk of gallstones
risk of gastric cancer

Bile gastritis
Afferent loop syndrome
Efferent loop syndrome

61
Q

What is characteristically seen on histology of gastric cancer?

A

Signet cells.

Large vacuole of ucin which displaces nucleus to one side

62
Q

WHat associations are there with gastric cancer?

A 
H. Pylori
Group A Blood
Gastric adenomatous polyps
Pernicious anaemia
Smoking
Salty, spicy, nitrates in diet
63
Q

How do you investigate and stage gastric cancer?

A

Diagnosis with endoscopy and biopsy

Stage with endoscopic ultrasound

May also stage with CTTAP and laparoscopy to identify occult peritoneal disease

PET CT (for junctional tumours)

64
Q

How do you classify gastric cancer?

A

Type 1 - true oesophageal cancer (may be associated with barraetts)

Type 2 - carcinoma of cardia. Arise from cardiac type epithelium or short segments with intestinal metaplasia at the oesophagogastric junction

Type 3 - sub cardial cancers that spread across the junction. Involve similar nodal stations to gastric cancer

65
Q

How do you treat gastric cancer?

A

Proximal disease 5-10cm from OG junction- subtotal gastrectomy

<5cm from OG junction - total gastrectomy

Type 2 tumours (extending into oesophagus) - oesophageogastrectomy

Early disease confined to mucosa (<2cm, no ulceration, no lymphovascular involvement) - endoscopic sub mucosal resection

66
Q

GI parasitic infections:
Signs and symptoms and treatment

Enterobiasis (threadworm)

A

Enterobius vermicularis

pruritus ani (esp. at night)

placing scotch tape at the anus, this will trap eggs that can then be viewed microscopically

mebendazole

67
Q

GI parasitic infections:
Signs and symptoms and treatment

Ancylostoma duodenale

A

Hookworms that anchor in proximal small bowel

Most asymptomatic
iron deficiency anaemia

Larvae may be found in stools left at ambient temperature, otherwise infection is difficult to diagnose

infects by cutaneous penetration, migrates to lungs, coughed up and then swallowed

mebendazole

68
Q

GI parasitic infections:
Signs and symptoms and treatment

Ascariasis

A

roundworm Ascaris lumbricoides

Infections begin in gut following ingestion, then penetrate duodenal wall to migrate to lungs, coughed up and swallowed

Diagnosis is made by identification of worm or eggs within faeces

mebendazole

69
Q

GI parasitic infections:
Signs and symptoms and treatment

Strongyloidiasis

A

Strongyloides stercoralis

Rare in west

nematode living in duodenum of host

skin penetration. They then migrate to lungs and are coughed up and swallowed. Then mature in small bowel are excreted

An auto infective cycle where larvae will penetrate colonic wall

asymptomatic,
respiratory disease
skin lesions

Diagnosis is usually made by stool microscopy

mebendazole

70
Q

GI parasitic infections:
Signs and symptoms and treatment

Cryptosporidium

A

Protozoal infection

cysts which are excreted

diarrhoea and cramping abdominal pains. worse if immunosuppressed

Cysts may be identified in stools

metronidazole

71
Q

GI parasitic infections:
Signs and symptoms and treatment

Giardiasis

A

Diarrhoeal infection

Giardia lamblia (protozoan)

Ingestion of cysts

abdominal pain, bloating and passage of soft or loose stools

Diagnosis is by serology or stool microscopy

metronidazole

72
Q

Gilbert’s Syndrome

A

Autosomal recessive

Defective bilirubin conjugation

Deficiency in UDP glucuronosyltransferase

Ix: Rise in bilirubin following prolonged fast or IV nicotinic acid

73
Q

Which features of haemochromatosis are reversible (4), some improvement (3) and which are irreversible (2)?

A

Reverisble: Cardiomyopathy, skin pigmentation (also transaminitis and fatigue)

Some improvement:
diabetes mellitus, hypogonadotrophic hypogonadism, arthralgia

Irreversible:
Liver cirrhosis, arthropathy

74
Q

Who do you genetic test for hereditary haemochromatosis?

A

Elevated serum ferritin (> 300 microgram / L in males; > 200 microgram / L in females)

Elevated transferrin saturation (> 45 %)

First degree relative with haemochromatosis

75
Q

Management of H. Pylori?

A

Management - eradication may be achieved with a 7 day course of

a proton pump inhibitor + amoxicillin + clarithromycin,

or
a proton pump inhibitor + metronidazole + clarithromycin

76
Q

Management of hepatic encephalopathy ?

A
  1. Lactulose

2. Rifaximin (secondary prevention)

77
Q

Grading of hepatic encephalopathy?

A 
Grading of hepatic encephalopathy
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
78
Q

What are the risks of hepatitis D superinfection?

A

fulminant hepatitis, chronic hepatitis status and cirrhosis.

79
Q

Symptoms and signs of cholangiocarcinoma

A

Persistent biliary colic symptoms, associated with anorexia, jaundice and weight loss. A palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen

80
Q

Symptoms and signs of amoebic liver abscess?

A

Typical symptoms are malaise, anorexia and weight loss. The associated RUQ pain tends to be mild and jaundice is uncommon.

81
Q

Investigation and treatment of hepatocellular carcinoma?

A

Ix:
Screen with USS and alpha-fetoprotein if high risk

Management:
Surgical resection (early disease)
Liver transplant
Radiofrequency ablation
Transarterial chemoembolisation
Sorafenib (multikinase inhibitor)
82
Q

Types of hepatorenal syndrome and pathophysiology?

A

Thought to be caused by splanchnic vasodilation causing underfilling kidneys with RAAS activation, but this isn’t enough to counter balance.

Type 1
Rapidly progressive
Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks
Very poor prognosis

Type 2
Slowly progressive
Prognosis poor, but patients may live for longer

83
Q

Management of hepatorenal syndrome?

A

Terlipressin
20% albumin
Transjugular intrahepatic portosystemic shunt

84
Q

Symptoms, management and complications of hydatid cysts?

A

Caused by Echinococcus granulosus.

Form a fibrous outer capsule

Cysts are allergens and cause Type 1 hypersensitivity reaction

Symptoms:
90% in liver and lung
Asympomatic or symptoms if >5cm
Morbidity if cyst bursts, infection or organ dysfunction

Treatment:
Surgery (do not rupture walls of cyst!)

85
Q

Symptoms and management of hyperemesis Gravidarum

A

Symptoms:
5% pre-pregnancy weight loss
Dehydration
Electrolye imbalance

Management:
Cyclizine
Ondansetron/metoclopramide 2nd line
IV hydration
Thiamine if severe
86
Q

Complications of hyperemesis gravidarum?

A 
Wernicke's encephalopathy
Mallory-Weiss tear
central pontine myelinolysis
acute tubular necrosis
fetal: small for gestational age, pre-term birth
87
Q

What are the four types of inherited jaundice? Separate by conjugation or not.

A

Unconjugated:
Gilbert’s
Crigler-Najjar

Conjugated
Dubin-Johnson (black liver)
Rotor (benign)

88
Q

List inherited glycogen storage disease (four)

A

Von Gierke’s disease (type I)
Glucose-6-phosphatase Hepatic glycogen accumulation. Key features include hypoglycaemia, lactic acidosis, hepatomegaly

Pompe’s disease (type II)
Lysosomal alpha-1,4-glucosidase
Cardiac, hepatic and muscle glycogen accumulation. Key features include cardiomegaly

Cori disease (type III)
Alpha-1,6-glucosidase (debranching enzyme)
Hepatic, cardiac glycogen accumulation. Key features include muscle hypotonia

McArdle's disease (type V)	
Glycogen phosphorylase (myophosphorylase)	
Skeletal muscle glycogen accumulation. Key features include myalgia, myoglobinuria with exercise
89
Q

List inherited lysosomal storage dsisease (six)

A

Gaucher’s disease
Beta-glucocerebrosidase
Most common lipid storage disorder resulting in accumulation of glucocerebrosidase in the brain, liver and spleen. Key features include hepatosplenomegaly, aseptic necrosis of the femur

Tay-Sachs disease
Hexosaminidase A
Accumulation of GM2 ganglioside within lysosomes. Key features include developmental delay, cherry red spot on the macula, liver and spleen normal size (cf. Niemann-Pick)

Niemann-Pick disease
Sphingomyelinase
Key features include hepatosplenomegaly, cherry red spot on the macula

Fabry disease
Alpha-galactosidase-A
Accumulation of ceramide trihexoside. Key features include angiokeratomas, peripheral neuropathy of extemeties, renal failure

Krabbe’s disease
Galactocerebrosidase
Key features include peripheral neuropathy, optic atrophy, globoid cells

Metachromatic
leukodystrophy Arylsulfatase A
Demyelination of the central and peripheral nervous system

90
Q

List inherited mucopolysaccharidoses diseases (two)

A

Hurler syndrome (type I)
Alpha-1-iduronidase
Accumulation of glycosaminoglycans (heparan and dermatan sulfate). Key features include gargoylism, hepatosplenomegaly, corneal clouding

Hunter syndrome (type II)	
Iduronate sulfatase	
Accumulation of glycosaminoglycans (heparan and dermatan sulfate). Key features include coarse facial features, behavioural problems/learning difficulties short stature, no corneal clouding
91
Q

What increases and what reduces iron absorption?

A

Increased with:
Vitamin C
Gastric Acid

Reduced with:
PPI
Tetracycline
Gastric achlorhydria
Tannin (tea)
92
Q

Management of IBS
Pain
Constipation
Diarrhoea

A

Pain - anti-spasmodic

Constipation - laxative (avoid lactulose). If not improvement after 12 months, linaclotide

Diarrhoea - loperamide

Second Line:
Low dose TCA
CBT

Third Line:
SSRI

93
Q

IBS dietary advice

A 
Regular meals
Avoid missing meals
Plenty of fluid
Restrict coffee, alcohol and fizzy drinks
Limit high fibre food
Limit fresh fruit 3 potion
94
Q

What features of ischaemic hepatitis?

A

Due to acute hypoperfusion
Inciting event
Increase in aminotransferase levels >1000 or 50x normal

95
Q

Contraindications to percutaneous liver biopsy?

A 
deranged clotting (e.g. INR > 1.4)
low platelets (e.g. < 60 * 109/l)
anaemia
extrahepatic biliary obstruction
hydatid cyst
haemoangioma
uncooperative patient
ascites
96
Q

Who should be screened for liver cirrhosis? How?

If cirrhosis, what then?

A

People with hepatitis C
Men with 50+ units alcohol
Women 35+ units alcohol
Alcohol-related liver disease

Screen with transient elastography

Upper endoscopy for varicies
Liver USS every 6 months (+/- alpha-feto protein)

97
Q

Causes of malabsorption (separate into three types)

A 
Intestinal causes of malabsorption
coeliac disease
Crohn's disease
tropical sprue
Whipple's disease
Giardiasis
brush border enzyme deficiencies (e.g. lactase insufficiency)

Pancreatic causes of malabsorption
chronic pancreatitis
cystic fibrosis
pancreatic cancer

Biliary causes of malabsorption
biliary obstruction
primary biliary cirrhosis

Other causes
bacterial overgrowth (e.g. systemic sclerosis, diverticulae, blind loop)
short bowel syndrome
lymphoma

98
Q

When should metoclopramide be avoided and when may it be helpful?

A

Metoclopramide should be avoided in bowel obstruction, but may be helpful in paralytic ileus.

Adverse effects
extrapyramidal effects: oculogyric crisis. This is particularly a problem in children and young adults
hyperprolactinaemia
tardive dyskinesia
parkinsonism
99
Q

What is microscopic colitis?

Name some risk factors:

A

chronic inflammatory condition of the gut.

Risk factors
smoking
drugs: NSAIDs, PPIs and SSRIs

100
Q

Features of microscopic colitis?

A 
Watery diarrhoea
Faecal urgency and incontinence
Abdominal pain
Constitutional symptoms
Mild anaemia
RF or ANA positive occasionally
Raised inflammatory markers
101
Q

Features and associated factors for non-alcoholic fatty liver disease

A 
Associated factors
obesity
type 2 diabetes mellitus
hyperlipidaemia
jejunoileal bypass
sudden weight loss/starvation
Features
usually asymptomatic
hepatomegaly
ALT is typically greater than AST
increased echogenicity on ultrasound
102
Q

Management of NAFLD

ALT >AST

A

No evidence to screen. Only manage incidental findings

  1. Enhanced liver fibrosis scan and blood tests
  2. Lifestyle changes (lose weight, normal alcohol)
  3. pioglitazone or vitamin E can be used

A score of > 10.51 suggests severe fibrosis.

Repeat ELF blood test every 3 years if <10.51

103
Q

Investigation and management of oesophageal cancer

A
  1. UGI endoscopy
  2. Contrast swallow if motility disorder, but not for tumours
  3. Staging with CT TAP
  4. If no metastasis, local endoscopic USS

Management
Ivor-Lewis Oesophagectomy

104
Q

Triad in Plummer Vinson syndrome?

A

Dysphagia - oesophageal webs
Glossitis
Iron deficiency anaemia

Oesophageal webs are premalignant for SCC
Freuquently webs improve with iron replacement
Dilation may be required
Add in PPI for reflux

105
Q

Investigation of pancreatic cancer

A
  1. USS (60-90% sensitivity)

2. High resolution CT if diagnosis suspected

106
Q

What is peutz-jeghers syndrome?

A

Autosomal dominant
Numerous hamartomatous polyps in GI tract
Associated pigmented freckles on lips, face, palms and soles

107
Q

Causes of jaundice in pregnancy?

A

Intrahepatic cholestasis of pregnancy
- rx ursodeoxycholic acid with weekly liver function tests. Induce at 37 weeks

Acute fatty liver of pregnancy

  • sx abdo pain, N&V, headache, jaundice, hypoglycaemia, ALT 500+
  • rx supportive

HELLP

108
Q

Primary Biliary Cirrhosis (cholangitis) features?

A

Associated with sjogrens syndome, RA, systeic sclerosis, thyroid diseae

AMA (98%)
Anti-smooth (30%)
raised serum IgM

Fatigue, pruritus, cholestatic jaundice, hyperpigmentation, RUQ pain, xanthelasmas

109
Q

Management and complications of primary biliary cholangitis (cirrhosis)

A 
Management:
Cholestyramine
Fat soluble vitamin supplementation
Ursodeoxychoic acid
Liver transplant
Complications
Cirrhosis
Osteomalacia
Osteoprosis
Malabsorption
Portal HTN
Hepatocellular cancer
110
Q

Adverse effects of PPIs

A 
Hyponatraemia
Hypomagnasaemia
Osteoprosis
Microscopic colitis
C. Difficile
111
Q

What is pseudomyxoma Peritonei

A

Rare mucinous tumour most commonly arising from appendix

Treat with cytoreductive surgery and peritonectomy

112
Q

Management of pyogenic liver abscess?

A

drainage (typically percutaneous) and antibiotics

amoxicillin + ciprofloxacin + metronidazole

if penicillin allergic: ciprofloxacin + clindamycin

113
Q

Pyogenic liver abscess organisms?

A

Staphylococcus aureus in children

Escherichia coli in adults.

114
Q

Refeeding Syndrome - metabolic consequences?

A

hypophosphataemia
hypokalaemia
hypomagnesaemia: may predispose to torsades de pointes
abnormal fluid balance

115
Q

Patients at high risk of refeeding syndrome are:

A

BMI < 16 kg/m2
unintentional weight loss >15% over 3-6 months
little nutritional intake > 10 days
hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)

NICE recommend that if a patient hasn’t eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days.

116
Q

How is H. Pylori tested?

A

CLO (Campylobacter-Like Organism) at OGD

Uses a reagent on biopsy sample

117
Q

What is small bowel bacterial overgrowth syndrome? Name some risk factors

A

Excessive amounts of bacteria in small bowel leading to GI symptoms.

Risk factors:
Neonates with congenital GI abnormalities
Scleroderma
Diabetes

118
Q

Features of small bowel bacterial overgrowth syndrome?

A

Chronic diarrhoea
Bloating
Flatulence
Abdominal Pain

Low B12, normal folate (usually)

119
Q

Diagnosis of small bowel bacterial overgrowth syndrome?

A

Hydrogen breath test

Small bowel aspiration and culture (gold standard)

120
Q

Treatment of small bowel bacterial overgrowth syndrome?

A

Rifaximin

121
Q

Which people with ascites should be given prophylacctic antibiotics?

A

Episode of SBP
FLuid protein <15g/L and child pugh score 9+ or hepatorenal syndrome

Oral ciprofloxacin or norfloxacin

122
Q

Diagnosis and management of SBP?

A

Diagnosis
paracentesis: neutrophil count > 250 cells/ul
the most common organism found on ascitic fluid culture is E. coli

Management
intravenous cefotaxime is usually given

123
Q

Management of acute variceal haemorrhage?

A
  1. Terlipressin
  2. Prophylactic antibiotics (quinolones)
  3. Endoscopy (band ligation > sclerotherapy)

Do not give PPI

Sengstaken-Blakemore tube if uncontrolled haemorrhage

Transjugular intrahepatic portosystemic shunt (TIPSS)

124
Q

Prophlaxis of variceal haemorrhage?

A

Propranolol
isosorbide mononitrate if beta-blocker contra-indicated

Endoscopic variceal band ligation at 2 weekly intervals

‘Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices.’

125
Q

How to manage blood products in variceal haemorrhage?

A

Platelets if <50
Hb if <70
Vit K and FFP if >1.5x INR/APTT/PT
Fibrinogen if < 1g

126
Q

Management of varicies in cirrhosis?

A

No varices - Rescope 2-3 years

Grade 1 varices -Rescope 1 year

Grade 2 or 3 varices or signs of bleeding - Non-cardio selective beta blocker

127
Q

Contraindications for TIPSS?

A

Absolute contraindications:

Severe and progressive liver failure (Child-Pugh score >12 is associated with a high risk of early death)
Uncontrolled hepatic encephalopathy
Right-sided heart failure
Uncontrolled sepsis
Unrelieved biliary obstruction

Relative contraindications:

Severe uncorrectable coagulopathy (INR >5)
Thrombocytopenia <20 * 109/l
Portal and hepatic vein thrombosis
Pulmonary hypertension
Central hepatoma
128
Q

What are villous adenomas?

A

Colonic polyps with potential for malignant transformation.

Secrete large amounts of mucous. May have electrolyte disturbances

non-specific lower gastrointestinal symptoms
secretory diarrhoea may occur
microcytic anaemia
hypokalaemia

129
Q

Conditions of thiamine deficiency (b1)?

A

Wernicke’s encephalopathy: nystagmus, ophthalmoplegia and ataxia
Korsakoff’s syndrome: amnesia, confabulation
dry beriberi: peripheral neuropathy
wet beriberi: dilated cardiomyopathy

130
Q

Causes and consequences of B6 deficiency?

A

Causes of vitamin B6 deficiency
isoniazid therapy

Consequences of vitamin B6 deficiency
peripheral neuropathy
sideroblastic anemia

131
Q

Signs and symptoms of scurvy?

A

Follicular hyperkeratosis and perifollicular haemorrhage
Ecchymosis, easy bruising
Poor wound healing
Gingivitis with bleeding and receding gums
Sjogren’s syndrome
Arthralgia
Oedema
Impaired wound healing
Generalised symptoms such as weakness, malaise, anorexia and depression

132
Q

What is Whipple’s disease? What are the signs?

A

Tropheryma whippelii infection

HLA-B27 positive and in middle-aged men.

malabsorption: diarrhoea, weight loss
large-joint arthralgia
lymphadenopathy
skin: hyperpigmentation and photosensitivity
pleurisy, pericarditis
neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus

133
Q

Investigation and management of Whipple’s disease?

A

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

Management
guidelines vary: oral co-trimoxazole for a year is thought to have the lowest relapse rate, sometimes preceded by a course of IV penicillin

134
Q

Features of Wilson’s disease?

A

Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea:
liver: hepatitis, cirrhosis
neurological: basal ganglia degeneration, speech, behavioural and psychiatric problems are often the first manifestations. Also: asterixis, chorea, dementia, parkinsonism
Kayser-Fleischer rings
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails

135
Q

Diagnosis of Wilson’s disease?

A

Diagnosis
reduced serum caeruloplasmin
reduced serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
increased 24hr urinary copper excretion

136
Q

Management of Wilson’s disease?

A

Management
penicillamine (chelates copper)

trientine hydrochloride is an alternative chelating

137
Q

What is Zollinger-Ellison Syndrome?

A

gastrin secreting tumour usually of the duodenum or pancreas

30% are MEN Type 1

Features
multiple gastroduodenal ulcers
diarrhoea
malabsorption

Diagnosis
fasting gastrin levels: the single best screen test
secretin stimulation test

138
Q

Management of pouchitis in UC reconstruction?

Presentation?

A

his presents with increased stool frequency, urgency, incontinence and nocturnal seepage.

Management
metronidazole or ciprofloxacin.

In 5 % of cases, pouchitis can become chronic, ultimately leading to pouch failure and requiring pouch excision.

139
Q

What are elastase levels?

A

Normal > 200
100-200 - mild
<100 insufficiency

140
Q

Vitamin D/Ca/Po Results and their diseases

A

Paget’s disease Ca - N, Po - N, ALP - H
Primary Osteoporosis Ca - N, Po - N, ALP - N
Primary hyperparathyroidism Ca - H, Po - L, ALP - H
Secondary hyperparathyroidism Ca - L, PO - H, ALP - H
Vitamin D deficiency Ca - L, PO - L, ALP - H

141
Q

What can you give to someone with small bowel obstruction due to cancer?

A

Steroids and bowel rest

142
Q

Following UGI bleed, what should you do with the anti-platelets??

A

If UGI controlled and no bleed:

Aspirin can continue if for secondary prevention

143
Q

How to differentiate secretary diarrhoea

A

Very large daily stool weight indicates organic pathology

Maintenance of large stool weight on fasting suggests secretory diarrhoea
Osmotic diarrhoea diarrhoea is reduced with fasting

144
Q

How does VIP cause diarrhoea?

A

VIP is a hormone that stimulates the secretion and inhibits the absorption of sodium, chloride, potassium and water within the small intestine and increases bowel motility. These actions lead to a secretory diarrhoea, hypokalaemia, and dehydration.

145
Q

Pellegra is see in which syndrome?

A

Carcinoid syndrome

146
Q

Histology of autoimmune hepatitis?

A

interface hepatitis (inflammation with lymphocytic infiltrate at the junction between hepatocytes and portal tracts).

147
Q

What are the Dukes scales?

A

A - confined to mucosa and submucosa
B - extends through muscularis propria
C - regional lymph node involvement
D - distal spread

148
Q

Management of hyponatraemia in liver cirrhosis?

A

Sodium 126-135 mmol/L with normal creatinine - Continue normal diuretic regimen and observe, do not fluid restrict the patient.

Sodium 121-125 mmol/L with normal creatinine - International opinion is to continue diuretics, however, the British Society of Gastroenterology recommend a more cautious approach, and suggest either stopping diuretics or reducing the dose.

Sodium 121-125 mmol/L with raised creatinine (>150 mmol/L or >120 mmol/L and rising) - Stop diuretics and volume expand with human albumin solution 4.5%, gelofusine, or haemaccel

Sodium <121 mmol/L - Incredibly controversial, but the British society of gastroenterology suggest stopping diuretics and volume expanding with human albumin solution 4.5%, gelofusine, or haemaccel (which all contain sodium concentrations similar to that of normal saline).

149
Q

Colonoscopic surveillance of adenomas?

A

Low Risk - every 5 years (adenoma < 10mm in size)
Intermediate - every 3 years
High risk - every year

MRCP2 (6 decks)

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