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MRCP part 2 > Gastro > Flashcards

Gastro Flashcards

1
Q

HCC surveillance

A

For high risk patients:

  • cirrhosis secondary to HBV, HCV, haemochromatosis, male alcoholics (who would comply), males w/ PBC
  • some non-cirrhotics with HBV/HCV

6 monthly USS abdo and AFP -> CT triple phase thereafter

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2
Q

Colonoscopic surveillance for colorectal cancer

A

Low risk: 1-2 polyps, both <1cm
-> 5 year surveillance initially

Intermediate risk: 3-4 small polyps OR 1 polyp >1cm
-> 3 year surveillance initially

High risk: >4 small polyps OR >2 polyps >1cm
-> 1 year surveillance initially

IBD - start after 10 years with disease

Lower risk: 5 year follow up colonoscopy

  • Extensive colitis with no active inflammation
  • OR left sided colitis
  • OR Crohn’s colitis of <50% colon

Intermediate risk: 3 year colonoscopy

  • Extensive colitis with mild active inflammation
  • OR post-inflammatory polyps
  • OR family history of colorectal cancer in a first degree relative aged 50 or over

Higher risk: 1 year follow up colonoscopy

  • Extensive colitis with moderate/severe active inflammation
  • OR stricture in past 5 years
  • OR dysplasia in past 5 years declining surgery
  • OR primary sclerosing cholangitis / transplant for primary sclerosing cholangitis
  • OR family history of colorectal cancer in first degree relatives aged <50 years

Acromegaly
- colonoscopy at age 40
+/- follow up depending on findings
- if elevated IGF1 - every 3 years

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3
Q

Barrett’s surveillance

A

Metaplasia, no dysplasia:

1) <3cm & gastric metaplasia -> repeat OGD and if still same, consider discharge
2) <3cm & intestinal metaplasia - repeat OGD every 3-5 years
3) >3cm - repeat OGD every 2-3 years

Dysplasia:

1) Unsure if dysplasia - repeat OGD with high dose PPI
2) Low grade dysplasia - repeat OGD every 6 months until 2x non-dysplastic OGD
3) High grade dysplasia - mdt and therapeutic intervention - radiofrequency ablation (if flat) OR endoscopic resection (if macroscopically visible)

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4
Q

H Pylori

A

When to test:

  • uncomplicated dyspepsia after 1 month PPI
  • OR phx gastro-duodenal ulcers

Tests:

  • urea breath test: most accurate
  • stool helicobacter antigen: next best
  • serology: low cost, low accuracy but good negative predictive

Treat if positive:

1) 7 days: PPI + amox + metro OR clari
2) PPI + amox + clari/metro alternative
3) PPI + amox + tetracycline OR levofloxacin

Re-test for H Pylori if:

  • associated peptic ulcer / MALT lymphoma
  • severe symptoms / recurrent
  • NB: if acid suppression required, use H2 antagonist
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5
Q

Hereditary colorectal cancer causes

A

1) HNPCC (hereditary non polyposis colorectal cancer)
- AD DNA mismatch repair genes
- most common inherited cause
- upper / lower GI ca, ovarian, endometrial
- amsterdam II criteria: 3-2-1
- 3 family members with relevant cancers
- 2 generations affected
- 1 or more ca before age 50
- colonoscopic surveillance by age 20-25 or 5 yrs before youngest age of familial ca -> 2 yearly screening

2) familial adenomatous polyposis
- AD APC tumour suppressor gene
- carpet of polyps
- start screening around aged 10 yearly
- by aged 30 typically have subtotal colectomy & IPAA
- subtype: Gardner’s syndrome

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6
Q

Whipple’s disease aetiology and ix

A
  • tropheryma whippelii
  • hla b27 linkage
  • more common middle aged men
  • multisystem disorder
  • OGD: jejunal biopsy - macrophages in lamina propria with periodic acid schiff granules
  • exclude DDx
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7
Q

Whipple’s disease sx

A
  • MSK: arthralgia (migratory large joint usually), arthritis
  • GI: vague abdo pain, malabsorption
  • neuro: myoclonus, dementia, ataxia, opthalmoplegia, seizures
  • lymphadenopathy
  • cardio: endocarditis, pericarditis
  • pulmonary: pleural effusion, chronic cough, ILD-like pulmonary HTN
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8
Q

Whipple’s disease mx

A

IV penicillin / ceftriaxone
AND
12 months PO co-trimoxazole

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9
Q

Primary sclerosing cholangitis liver biopsy histology

A

Onion skin

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10
Q

Primary biliary cirrhosis/cholangitis liver biopsy histology

A
  • Dense lymphocytic infiltrate of portal tracts

- Focal / variable granulomatous destruction of medium-sized interlobular bile ducts

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11
Q

Bacillus cereus gastroenteritis features

A
  • enterotoxin mediated
  • 1-4 hour onset
  • reheated rice
  • profuse vomiting +/- diarrhoea (watery)
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12
Q

S Aureus gastroenteritis

A
  • enterotoxin mediated
  • few hours onset
  • usually related to dairy consumption
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13
Q

Campylobacter jejuni gastroenteritis

A
  • 48 hour onset
  • contaminated food e.g. chicken
  • fever, abdo pain
  • vomiting
  • diarrhoea (may be bloody)
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14
Q

Carcinoid syndrome

A
  • symptoms resulting from well differentiated NETs of GI tract and lungs - symptoms related often to serotonin production +/- other hormones.
  • Symptoms usually arise when tumours metastasize to liver and release this into systemic circulation
  • diarrhoea
  • flushing
  • restrictive pericarditis -> right heart valvular disease
  • wheeze
  • telangiectasia
  • other hormones produced inc: GnRH (acromegaly), ACTH (cushing’s)
  • Ix: urinary 5-HIAA, serum chromogranin A, CT CAP +/- MRI
  • Mx: octreotide (symptoms), surgical resection
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15
Q

Familial Mediterranean fever

A
  • AR X-some 16
  • Ashkenazi Jews and Turkish / Armenian / Arabic
  • recurrent fever and peritonitis
  • Mx: colchicine
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16
Q

King’s college criteria for liver transplant in paracetamol overdose

A

ph < 7.3

OR

in 24 hr period, all of

  • INR > 6 (PT >100s)
  • creatinine > 300
  • grade III or IV encephalopathy
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17
Q

Treatment of HCC in chronic hep C

A
  • evidence of cirrhosis? -> liver transplantation if single mass <5cm or up to 3 lesions <3cm
  • no evidence of cirrhosis? -> consider resection
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18
Q

PBC bloods

A

Anti mitochondrial antibodies (M2 subtype is most specific)
Elevated IgM
Elevated HDL

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19
Q

Antibodies in autoimmune hepatitis

A

Raised IgG

  • type 1: ANA / anti-SMA - all ages
  • type 2: anti liver/kidney microsomal type 1 (LKM1) - children only
  • type 3: soluble liver-kidney antigen - middle age
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20
Q

Liver biopsy autoimmune hepatitis

A

Piecemeal necrosis / bridging necrosis - used for confirmation of diagnosis

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21
Q

Chromogranin A

A

Raised in the majority of NETs except insulinomas

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22
Q

Washout period for H Pylori breath testing

A
  • 6 weeks abx

- 2 weeks PPI

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23
Q

Treating Hep B

A

1) peg Interferon alpha-2a
2) entecavir & tenofovir

IF

  • > 30yrs AND >2000 copies AND raised ALT on 2 tests >3 months apart
  • < 30 yrs AND > 2000 copies AND raised ALT (2 tests) AND fibrosis/inflammation on scan
  • any patient >20000 copies AND raised ALT (2 tests)
  • any patient with transient elastostography > 11kpa
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24
Q

Bacterial overgrowth features and aetiology

A
  • malabsorptive symptoms
  • can occur with diverticular disease or radiation enteritis
  • b12 malabsorption
  • BUT bacteria produce folate - can be elevated
  • can lead to SCDC
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25
Q

GVHD post liver transplant

A
  • approx 15 days post transplant
  • jaundice and deranged LFTs
  • maculopapular rash
  • colitis
  • pancytopenia
  • ix: liver USS / doppler -> biopsy (skin / GI / bone marrow), exclude infectious causes e.g. cmv
    Mx:
  • adjust immunosuppressant medication dose
  • skin: topical steroids / topical tacrolimus
  • liver: systemic steroid
  • GI: systemic + non-abosorbable steroid; octreotide for diarrhoea
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26
Q

Hep C in pregnancy advice

A
  • vertical transmission 1.5-5%
  • mode of delivery does not affect
  • no evidence not to breastfeed
  • testing baby: RNA 2-6 months, serology at 14 months
  • ribavirin is teratogenic - should not be used in pregnancy -> aim to eradicate virus before trying for a family
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27
Q

Side effects of ileal resection

A
  • reduced bile salt reabsorption -> increased chance of stone formation & diarrhoea (give cholestyramine)
  • decreased vitamin b12 absorption
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28
Q

Hepatitis E

A

Similar to hepatitis A - symptoms, faeco-oral transmission and epidemiology
Increased chance of fulminant hepatitis during pregnancy

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29
Q

Sphincter of Oddi dysfunction

A

Recurrent biliary abdo pain +/- elevated cholestatic LFTs +/- radiological evidence of impaired biliary drainage
May cause recurrent pancreatitis
Mx:
- nifedipine (?similar to placebo)
- sphincterotomy
- botox injection (esp if pain but no elevated LFTs / radiological evidence)

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30
Q

Treatment of hepatitis B

A

Indications:

  • without cirrhosis
  • > generally observe if HBeAg + but treat if decompensate / flare
  • > > 2000 copies, ALT >2x upper limit or 1-2x + liver biopsy mod-sev inflammation
  • with cirrhosis
  • > if detectable HBV DNA and decompensated
  • > if HBV DNA >2000 and compensated
  • > if HBV DNA <2000 but detectable, compensated liver disease but ALT rise

1) pegylated interferon 2 alpha
- NB: contraindicated in decompensated liver disease
2) tenofovir / entecavir

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31
Q

Zollinger-Ellison syndrome

A

= Gastrinoma
Increased acid -> peptic ulceration, deconjugation of bile salts -> fat malabsorption (+/- b12 deficiency)
1) OGD + h pylori testing (exclude other causes)
2) 3x fasting serum gastrin
3) secretin stimulation test (-> raised gastrin if +ve) in borderline cases
4) CT CAP / MRI imaging +/- EUS

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32
Q

Diagnostic tests for abdominal TB

A
  • bloods: TB quantiferon, TB culture
  • ascitic fluid: TB culture (<10%), TB PCR (better)
  • laparoscopy & peritoneal biopsy (95%)
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33
Q

Treatment of radiation proctitis

A
  • rectal sucralfate
  • rectal steroids
  • metronidazole
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34
Q

Pellagra

A 
nicotinic acid (vitamin b3) deficiency
OR B6 deficiency (precursor needed for nicotinamide)
- dementia
- dermatitis
- diarrhoea
- tremor / ataxia 
- insomnia
- seizures
- peripheral neuropathy
- can be a side effect of carcinoid syndrome OR TB treatment (more commonly B6 -> give pyridoxine)
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35
Q

Thumbprinting sign

A

Non-specific sign of bowel mucosal oedema e.g. UC OR ischaemic colitis

36
Q

Azathioprine & crohn’s in pregnancy

A
  • folic acid supplementation

- continue same dose of azathioprine

37
Q

Constipation predominant IBS

A

Soluble fibre supplementation e.g. ispahula husk or psyllium

38
Q

RF small bowel lymphoma

A

coeliac disease (both B and T cell lymphomas) - poor adherence to gluten-free diet especially

39
Q

Drug causes of pancreatitis

A
  • steroids
  • 6-MP/azathioprine, 5-ASA
  • furosemide
  • isoniazid, metronidazole
  • statins
  • amiodarone
  • ACEi/ARBs
  • valproate
40
Q

Acute fatty liver of pregnancy vs intrahepatic cholestatis

A

Fatty liver: pain, jaundice, acute liver failure
Cholestasis: predominantly itching, jaundice, elevated liver enzymes +/- deranged INR
- Acute fatty liver mx: delivery
- Intrahepatic cholestasis mx: 1) USDA 2) cholestyramine (can give vit k deficiency)

41
Q

Criggler-Najjar

A
  • unconjugated hyperbilirubinaemia
  • can be triggered by infection
  • type 1 disease presents severely in the neonate -> kernicterus
  • type 2 is less severe
  • Mx: phototherapy, plasma exchange, phenobarbital
42
Q

Dubin-Johnson syndrome

A
  • AR conjugated hyperbilirubinaemia
  • dark (melanin) granules on liver biopsy
  • benign -> no treatment required
  • normal urinary coproporphyrin excretion, with 80% being coproporphyrin I
43
Q

Rotor syndrome

A
  • benign mixed conjugated and unconjugated hyperbilirubinaemia
  • no identified genetic basis to date
  • normal liver histology
  • increased 2x urinary coproporphyrin excretion, 65% being coproporphyrin I
44
Q

Definitive differentiation between IDA and anaemia of chronic disease

A 
Bone marrow biopsy: iron content 
EPO levels (although NB: CKD unreliable where both may co-exist)
45
Q

Antibodies to help distinguish UC vs crohn’s

A

pANCA
- 60-70% UC vs 10-15% crohn’s

anti saccharomyces cerevisiae antibodies (ASCA) IgG
- 60-70% crohn’s vs 10-15% UC

46
Q

Post transfusion purpura

A

human platelet antigen 1a mediated thrombocytopenia with purpura
occurs approx 1 wee
Mx IVIG, PLEX, high dose corticosteroids

47
Q

Hydatid liver disease

A
  • cause: tapeworm echinococcus granulosis
  • faeco-oral transmission
  • Ix: CT/USS - 40% cysts calcify
  • Mx: aspiration (PAIR procedure) OR surgery (if complicated by daughter cysts) & adjunctive albendazole (monotherapy if very small cysts)
48
Q

Pernicious anaemia ix

A

abs against intrinsic factor -> b12 malabsorption
Ix:
- elevated serum gastrin
- anti-IF / anti gastric parietal cell antibodies

49
Q

Causes of false positive CA-125

A
  • cirrhosis with ascites
  • intra-abdominal cancers
  • pancreatitis
  • heart failure
  • PID, endometriosis, fibroids
50
Q

HIV cholangiopathy

A
  • HIV-associated infections causing biliary stricturing
  • e.g. cryptosporidium, CMV, giardia, mycobacterium
  • Ix: HIV, serology, MRCP -> ERCP + brushings / biopsy
  • Mx: treat cause, ursodeoxycholic acid, ERCP + sphincterotomy / stent depending on biliary tree findings
51
Q

Pyoderma gangrenosum mx

A

PO steroids
Anti-TNF e.g. infliximab
Topical / PO calcineurin inhibitors e.g. tacrolimus

52
Q

Melanosis coli

A
  • brown pigmentation in colon

- causes: senna abuse

53
Q

Tropical sprue

A
  • Possible post gastroenteritis malabsorption syndrome (?bacterial overgrowth)
  • Villous atrophy on OGD and b12/folate/iron deficiency
  • Mx: vitamin supplementation and doxycycline
54
Q

Nutcracker oesophagus

A

Cause of intermittent dysphagia

Oesophageal manometry >180 mmHg

55
Q

Treatment of hepatitis C

A

Indications

  • failure to reduce viral load by 2 log10 at week 4
  • all patients with detectable RNA over 6 months
  • genotyping

1) protease inhibitor combinations e.g. sofosbuvir
2) +/- peg interferon +/- ribavirin

56
Q

Haemochromatosis diagnosis

A

Transferrin saturation >55% (50% in women)
Raised ferritin / iron
Low TIBC
HFE gene analysis

57
Q

Crohn’s flare mx in pregnancy

A

Steroids - low foetal concentrations

58
Q

Primary sclerosing cholangitis symptoms

A 
Intermittent jaundice
Pruritis
Weight loss
Fevers/night sweats 
Assoc diarrhoea (UC)
59
Q

PSC mx

A
  • Cholestyramine for pruritis
  • No clear role for USDA - improves things biochemically but no effect on mortality / time to liver transplantation
  • Ultimately liver transplant
60
Q

Zieve syndrom

A

Triad

  • haemolytic anaemia
  • conjugated hyperbilirubinaemia
  • hyperlipidaemia

Transient condition associated with alcohol abuse -> resolves with cessation

61
Q

Traveller’s diarrhoea

A

Common pathogens: campylobacter, E Coli, salmonella, shigella, cholera

Mx

  • ciprofloxacin + loperamide at onset can reduce durating by 2-3 days (other abx inc azithromycin)
  • metronidazole if amoebic cause considered
62
Q

UC flare mx in pregnancy

A
  • prednisolone
  • 5-ASA can be restarted as maintenance
  • azathioprine also safe
63
Q

Drug causes of bile salt malabsorption

A

Metformin

64
Q

Gastro causes of iron deficiency anaemia

A

Bleeding from UGI/LGI cancers
Malabsorptive syndromes inc coeliac, tropical sprue, bacterial overgrowth
Gastrectomy -> reduced acidification of ferric (3+) -> ferrous (2+) iron -> less absorbed in the duodenum

65
Q

Site of folate absorption

A

Jejunum

66
Q

Site of b12 absorption

A

Terminal ileum

67
Q

Site of b3 (nicotinic acid) absorption

A

Duodenum

68
Q

Bile salt malabsorption

A
  • cause of chronic diarrhoea
  • causes: terminal ileal resection, metformin, coeliac, small bowel bacterial overgrowth, cholecystectomy, chronic pancreatitis
  • Ix: SeHCat scan OR 14C glycolate test
  • Mx: cholestyramine
69
Q

Risk factors for gastric cancer

A
  • smoking and etoh
  • nitrosamines (food additives)
  • smoked foods
  • chronic H Pylori
  • gastritis with intestinal metaplasia
  • hypertrophic gastritis
  • pernicious anaemia
  • occupational exposure: heavy metals, rubber, asbestos
70
Q

Drug Mx of GIST

A

Imatinib

71
Q

Etoh hepatitis immunoglobulins

A

Markedly raised IgA

Slightly raised IgM/IgG

72
Q

Immunoglobulins in liver disease

A

EtoH hepatitis - IgA
Autoimmune hepatitis - IgG
Primary biliary sclerosis - IgM

73
Q

Hepatic adenoma

A
  • benign
  • hypoechoic liver lesion on USS
  • low AFP
  • assoc w/ OCP/oestrogen -> cessation usually -> regression
  • otherwise elective surgical resection if symptomatic
74
Q

Familial adenomatous polyposis

A
  • AD APC mutation (xsome 5)
  • carpet of adenomas -> from age 10 start colonoscopic surveillance -> panproctocolectomy + IPAA
  • assoc duodenal tumours
  • Gardner’s syndrome: mandibular / skull osteomas, retinal pigmentation, thyroid carcinoma, epidermoid cyst
75
Q

Maintenance therapy crohn’s

A

1) azathioprine if >2 flares in 1 year
2) methotrexate
3) ?5-ASA if previous surgery
4) infliximab - use if perianal disease / fistulating disease

76
Q

Entamoeba histolytica liver abscess management

A

1) metronidazole
2) percutaneous drainage
3) surgical drainage

77
Q

Mx achalasia

A

1) myotomy e.g. heller’s laparoscopic myotomy - if of good functional status OR POEM
2) pneumatic dilatation - if worse functional status
3) intrasphinteric botox
4) CCBs e.g. nifedipine, ISMN

78
Q

Laxative abuse bloods

A
  • hypokalaemia

- metabolic alkalosis

79
Q

VIPoma

A
  • profuse watery diarrhoea
  • hypokalaemia
  • hypochloraemic metabolic acidosis
80
Q

Oral and oesophageal candidiasis

A

PO fluconazole > nystatin (even with AARTs)

81
Q

Ulcerative colitis mx: mild-mod proctitis

A

1) Rectal 5-ASA (>rectal steroid)
2) + PO 5-ASA
3) + topical / PO steroid

82
Q

Ulcerative colitis mx: mild-mod proctosigmoiditis

A

1) topical 5-ASA (enema > suppository)
2) + PO 5-ASA
OR switch to 5-ASA + steroid enema
3) stop all topicals -> PO 5-ASA + PO steroid

83
Q

Ulcerative colitis mx: mild-mod extensive disease

A

1) topical + PO 5-ASA

2) stop topical -> PO 5-ASA + PO pred

84
Q

Type of renal stones in patients with small bowel resections

A

Calcium oxalate stones… fat malabsorption -> reduced ability of calcium to bind dietary oxalate in the gut -> increased oxalate uptake

85
Q

Reversible complications in haemochromatosis

A
  • cardiomyopathy (DCM)

- skin pigmentation

86
Q

Irreversible complications in haemochromatosis

A
  • liver cirrhosis (although liver damage pre-cirrhosis is reversible)
  • diabetes
  • arthropathy
    (- hypogonadotrophic hypogonadism)

MRCP part 2 (11 decks)

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