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3rd year medicine > gastro > Flashcards

gastro Flashcards

1
Q

70y M

surgical outpatient clinic

change in bowel habit 3months - increased freq of loose stools and occasional constipation

systemically unwell - malaise, lethargy, reduced appetite, nausea but no vomiting, night sweats, difficulty sleeping

lost 3kg weight past month

no blood in stool

civil engineer - work in developing countries

apyrexial

abdo - fullness in right iliac fossa - tender

no lymphadenopathy

Hb 99 (135-180 g/L)

WCC 8 (4-11 x109/L)

MCV 85 (76-100 fL)

Na+ 141 (136-145 mM)

K+ 4.2 (3.5-5.1 mM)

Ur 7.3 (1.7-8.3 mM)

Cr 80 (62-106 µM)

Alb 30 (35-52 g/L)

CRP 43 (0-5 mg/L)

ESR 56 (0-15 mm/h)

which two investigations will be most helpful

how urgently should these investigations be requested

A

CT abdo pelvis

colonoscopy - allows for histological diagnosis

done within 2 weeks - high suspicion of malignancy

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2
Q

what are associated with right iliac fossa mass

A

caecal carcinoma

appendix abscess

chrons disease

hepatomegaly - can extend into RIF and so can the normal variant, Riedel’s lobe

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3
Q

CT scan - inflammatory stricturing of the caecum and terminal ileum.

colonoscopy - significant inflammatory change in the caecum and terminal ileum.

Biopsies were taken from this area.

The colonoscopic and radiographic appearances suggest Crohn’s disease or infection.

What two infectious organisms could be responsible?

A

Tuberculosis

Yersinia

patient has ileal-caecal TB

tuberculosis and yersinia can both mimic ileo-caecal chrons disease

CXR should be performed to demonstrate previous/active pulmonary TB (half of patients dont present with hx of pulmonary TB)

rare causes in UK - look for travel in hx

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4
Q

colonoscopic and radiographic appearances suggest Chron’s disease or infection

Histology confirmed diffuse infiltration of the caecum and terminal ileum, with the presence of non-caseating granulomas as well as mixed acute and chronic inflammatory changes.

no evidence of carcinoma or lymphoma

productive cough for few weeks - one episode of haemoptysis

CXR - what are the findings?

most likely underlying diagnosis given the chest radiograph?

would you be confident to diagnose chrons and start on steroids?

A

bilateral ill defined upper lobe infiltrates/consolidation

tuberculosis

no - TB more likely with CXR findings - treat TB after obtaining sputum sample

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5
Q

management for TB

A

RIPE

Rifampicin - 6 months

Isoniazide - 6 months

Pyrazinamide - 2 months

Ethambutol - 2 months

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6
Q

24yr W

presents to GP with husband

eyes looked yellow for past 3 days

2 wk hx lethargy, anorexia, non-specific upper abdo pain

no alcohol excess

no travel abroad recently

4months ago - borderline hypothyroidism - no treatment

jaundiced but euthyroid (normal thyroid function)

multiple spider naevi on anterior chest wall

liver palpable 3cm below costal margin

spleen palpable 2cm below costal margin

Hb 119 120-155 g/L

WCC 4.5 4-11 x109/L

Plt 156 150-450 x109/L

Ferritin 670 13-150 µg/L high

Bili 56 2-17 µM high

ALP 230 35-104 iu/L high

ALT1230 <31 IU/L high

INR 1.0 0.9-1.2

what are the three main differential diagnoses at this stage

A

autoimmune hepatitis (particularly in young women) - can develop spider naevi and enlarged spleen even without cirrhosis

viral hepatitis

  • hepatits likely diagnosis as spider naevi and splenomegaly suggest cirrhosis/ portal HTN (doesnt fit thyroid disease)

non-alcoholic fatty liver disease (but doesnt usually present acutely with jaundice)

hypo and hyperthyroidism –> abnormal LFTs and jaundice (in severe disease and with coexisting heart failure)

high ferritin reflects acute phase response - hemochromatosis (excess iron –> liver damage) presents after 5th decade <– normal transaminases in haemochromatosis

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7
Q

24yr W

presents to GP with husband

eyes looked yellow for past 3 days

2 wk hx lethargy, anorexia, non-specific upper abdo pain

no alcohol excess

no travel abroad recently

4months ago - borderline hypothyroidism - no treatment

jaundiced but euthyroid (normal thyroid function)

multiple spider naevi on anterior chest wall

liver palpable 3cm below costal margin

spleen palpable 2cm below costal margin

ALT significantly raised

ALP and bilirubin raised

ferritin significantly raised

viral serology -ve

total protein and serum globulins raised

ANA +ve

smooth muscle antibody (SMA) +ve

liver ultrasound normal

most appropriate next step in management

A

liver biopsy

  • high clinical suspicion of AIH (type 1) - cant be diagnosed without liver histology

after diagnosis:

high dose steroids then addition of azathioprine

test TMPT levels (chemical in bone) before starting azathiaprine - can cause myelosuppression

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8
Q

24yr W

presents to GP with husband

eyes looked yellow for past 3 days

2 wk hx lethargy, anorexia, non-specific upper abdo pain

no alcohol excess

no travel abroad recently

4months ago - borderline hypothyroidism - no treatment

jaundiced but euthyroid (normal thyroid function)

multiple spider naevi on anterior chest wall

liver palpable 3cm below costal margin

spleen palpable 2cm below costal margin

ALT significantly raised

ALP and bilirubin raised

ferritin significantly raised

viral serology -ve

total protein and serum globulins raised

ANA +ve

smooth muscle antibody (SMA) +ve

liver ultrasound normal

percutaneous liver biopsy (shown in pic)

what is the most likely diagnosis

A

autoimmune hepatitis

florid interface hepatitis (ie inflammation spilling over the portal tract limiting membrane on to the hepatocytes)

inflammatory exudate is rich in plasma cells

AIH most likely - female, elevated globulins, -ve viral serologies, no drug hx

bile ducts normal therefore primary biliary cholangitis unlikely

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9
Q
A
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10
Q

24yr W

presents to GP with husband

eyes looked yellow for past 3 days

2 wk hx lethargy, anorexia, non-specific upper abdo pain

no alcohol excess

no travel abroad recently

4months ago - borderline hypothyroidism - no treatment

jaundiced but euthyroid (normal thyroid function)

multiple spider naevi on anterior chest wall

liver palpable 3cm below costal margin

spleen palpable 2cm below costal margin

ALT significantly raised

ALP and bilirubin raised

ferritin significantly raised

viral serology -ve

total protein and serum globulins raised

ANA +ve

smooth muscle antibody (SMA) +ve

liver ultrasound normal

percutaneous liver biopsy (shown in pic)

started on Prednisolone 30mg - rapid clinical and biochem remission

azathiprine added and steroids tapered

after 3months LFT normal, asymptomatic

daily meds: pred 5mg, azathioprine 50mg

she requests if she can discontinue her drugs - what should you advise?

A

AIH therapy at least two yrs after blood tests have normalised before discontinuing therapy

liver biopsy before stopping therapy

if stopped before two yrs most patients relapse

life long therapy: patients with cirrhosis, severe initial presentation, prior relapse

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11
Q

patient is on azathioprine for autoimmune hepatitis. patient informs you that they are 12 weeks pregnant. she has read up about the side effects of azathioprine and is concerned. what should be your advice

A

continue current medication

safe to be on azathioprine whilst pregnant

risk of stopping is greater than risk of teratogenic effects

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12
Q

what are the signs and symptoms of autoimmune hepatitis

A

female

jaundice

hepatosplenomegaly

raised LFTS

-ve viral serology

+ve ANA and SMA

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13
Q

79yr M

acute stroke

unsafe swallow

NG tube inserted but hard to aspirate any gastric contents

most appropriate next management step

A

CXR

must be confirmed in right position before being flushed or used

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14
Q

CXR shown below

what position is the NG tube

A

down the right main bronchus

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15
Q

what should the pH level be between for an NG tube aspirate to check if its in the right position

what if the pH is not within range

A

pH btwn 1-5.5

if not within range or aspirate cant be obtained - CXR

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16
Q

58yr M

gastro outpatients

4month hx gradually progressive dysphagia

initially discomfort with solids now cant tolerate solids and only small quantities of fluid

hx of probable GORD with heartburn and belching over yrs

weight loss 6mnths

10-15 cigarettes per day

drinks 2-3 pints per day

meds: antacid liquid med

no lymphadenopathy

no abdo masses

two most likely diagnoses

most appropriate next investigation

A

oesophageal stricture:

peptic stricture (hx of GORD more likely to mean peptic in origin)

oesophageal carcinoma

oesophagogastroduodenoscopy (OGD) - 2ww pathway

  • would diagnose peptic stricture and oesophageal carcinoma
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17
Q
A
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18
Q

OGD shows stricture in lower third of oesophagus

biopsies show inflammation only

which two initial treatments should this patient be offered

A

proton pump inhibitor

balloon dilatation, following benign biopsy - treatment for symptomatic benign peptic strictures

endoscopy and biopsy confirmation of benign disease needed

treatment of GORD - PPI

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19
Q

patient underwent balloon dilation of peptic stricture

immediately post-procedure he experienced chest pain and SOB

which diagnosis would you consider

which further investigations would you arrange urgently

A

oesophageal perforation

  • most common complication of balloon dilatation - may cause mediastinitis. surgical emphysema may be palpable in neck

do CT scan with oral contrast - for perforation post-oesophageal dilatation suspected

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20
Q

presentation of peptic ulcer disease

A

epigastric pain

dyspepsia (indigestion)

heartburn

duodenal - pain may be relived by eating

gastric - pain with meals

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21
Q

causes of peptic ulcer

A

h.pylori

NSAIDs

also consider steroids, alcohol, SSRIs

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22
Q

complications of peptic ulcers

A

haematemesis (erosion usually into gastroduodenal artery)

perforation (peritonitic)

can also see malaena, anaemia, weight loss

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23
Q

investigations for peptic ulcer disease

A

first Ix: H.pylori breath test

ALARM syptoms: endoscopy

  • Anorexia
  • Loss of weight
  • Anaemia due to iron deficiency
  • Recent onset of persistent symptoms: vomiting
  • Malaena, haematemesis

>55 + weight loss + upper abdo pain/reflux/ dyspepsia –> endoscopy

new onset dysphagia –> endoscopy

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24
Q

management for peptic ulcer disease

A

if h.pylori +ve –> triple therapy:

  • one week triple therapy: PPI + clarithromycin + amoxicillin/metronidazole

review after 4 weeks with urea breath test - if not eradicated repeat Rx

if h.pylori -ve: PPI or H2 antagonist (ranitidine) for 4weeks

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25
Q

what is Zollinger ellison syndrome

A

gastrin secreting tumour - cause of dyspepsia

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26
Q

symptoms of iron deficiency anaemia

A

SOB, fatigue, palpitations

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27
Q

causes of iron deficiency anaemia

A

blood loss - menorrhagia, GI bleed

malabsorption - coeliac disease, gastrectomy

diet - seen in pregnancy

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28
Q

investigations for iron deficiency anaemia

A

FBC:

  • microcytic anaemia: decreased MCV, decreased ferritin
  • isolated inreased urea + normal creatinine –> large protein meal
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29
Q

management of iron deficiency anaemia

A

if Hx of menorrhagia –> oral iron

otherwise scope for GI bleed

UGI endoscopy and colonoscopy

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30
Q

what is the difference between diverticulosis and diverticulitis

A

diverticulosis = the disease process

diverticulitis: acutely inflamed

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31
Q

symptoms and signs of diverticulitis

A

LIF pain

fever

constipation (or diarrhoea)

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32
Q

investigations and management of diverticulitis

A

investigations:

CT abdo

increased WCC, increased CRP

do not do colonoscopy acutely due to perforation risk

management:

NBM

IV fluids

abx

analgesia

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33
Q

diverticular complications

A

perforation –> peritonitis, shock, free gas on CXR

Rx: consider Hartmann’s procedure

Haemorrhage –> rectal bleeding

abscess –> swinging fever (subdiaphragmatic)

stricture

fistula - bladder, uterus, vagina, skin

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34
Q

what is familial adenomatous polyposis (FAP)

A

auto dominant

many polyps by 20’s

APC gene mutation

100% chance of cancer if not removed

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35
Q

what is Peutz-Jeghers syndrome

A

auto dominant

pigmentation around lips

increased cancer risk in other organs

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36
Q

juvenile hamartomatous polyps

A

may see bleeding, intussusception

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37
Q

what are pseudopolyps

A

scar tissue surrounding areas of intact mucosa (looks like polyps)

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38
Q

what is lynch syndrome

A

HNPCC (hereditory non polyposis colorectal cancer)

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39
Q

investigations and management for colorectal cancer

A

Ix:

colonoscopy + biopsy

CT colonography

Mx:

surgery, chemo

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40
Q

TNM staging of cancer

A

stage I: in mucosa and muscular layer

stage IIa: grown through the wall of organ but not spread

IIb: growth through visceral peritoneum

IIc: grown into nearby structures

Stage III: metastasis to lymph nodes

stage IVa: mets to one other distant organ

IVb: many other distant organs

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41
Q

what surgical approach would you use for a low rectal tumour

A

abdominoperineal (AP) resection

excision of distal colon, rectum and anal sphincters - colostomy

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42
Q

what surgical approach would you use for a high rectal tumour

A

anterior resection

>5cm from anus

rectal sphincter remains intact and functioning if anastamosis performed

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43
Q

what surgical approach would you use for a sigmoid colon tumour

A

sigmoidcolectomy

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44
Q

what surgical approach would you use for a descending colon tumour

A

left hemicolectomy

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45
Q

what surgical approach would you use for a caecal/ ascending colon tumour

A

right hemicolectomy and extended right hemicolectomy

extended for any transverse colon cancers

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46
Q

risk factors for gallstones

A

fair, fat, fertile, female, forty

white

increased BMI

middle aged woman

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47
Q

what is biliary colic and what symptoms do you get

A

stone stuck/ compressed into GB neck/ cystic duct

continuous RUQ pain , nausea, vomiting

attacks usually <6hr, often after fatty food

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48
Q

investigations and management for biliary colic

A

Ix:

normal inflammatory markers

LFTs - raised ALP

USS abdo

Mx:

analgesia

elective cholecystectomy - 4-6 weeks

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49
Q

RUQ pain

fever

local peritonism

pain lasts >12hrs

murphys sign positive

diagnosis?

A

cholecystitis

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50
Q

investigations and management for acute cholecystitis

A

LFTs - ALP raised

WCC & CRP raised

USS

Mx: urgent cholecystectomy if peritonitis or worsening signs

IV fluids, abx

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51
Q

RUQ pain

fever

jaundice

A

ascending cholangitis

= inflammation + infection of biliary tract

stone moved to CBD

classic triad of symptoms

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52
Q

investigations and management for ascending cholangitis

A

ERCP: to confirm and remove CBD stones

IV fluids

abx

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53
Q

what is a gallstone ileus + management?

A

small bowel obstruction

AXR: bowel obstruction, air in biliary tree

stone usually stuck in terminal ileum

remove with enterotomy

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54
Q

what is Mirrizzi’s syndrome

A

extrinsic compression of hepatic duct from a compacted stone in the cystic duct

symptoms: RUQ pain, fever, jaundice

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55
Q

what is a gall bladder mucocele

A

distended gall bladder filled with clear fluid

usually from an outflow obstruction - stone in cystic duct

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56
Q

what is a gallbladder empyema

A

complication of cholecystitis

pus in gallbladder

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57
Q

what is a hernia (inguinal + femoral)

A

passage of tissue from a site where it is normally found to a site where it is not normally found

cough impulse

cannot get above

reducible

can become:

irreducible/incarcerated - cant push back to correct location

strangulated - constriction leads to ischaemia, pain - can perforate

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58
Q

risk factors for hernias (inguinal + femoral)

A

things that increase abdo pressure

  • obesity

increased age

surgery

cough

constipation

pregnancy

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59
Q

what is a femoral hernia and what are the symptoms of strangulation

A

rarer than inguinal hernias

more common in women

often irreducible

often strangulate –> repair urgently

strangulation:

  • colicky abdo pain

signs of bowel obstruction

lump below inguinal ligament

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60
Q

what are indirect inguinal hernias

A

most common

all ages

through inguinal canal via deep inguinal ring

can strangulate so repair

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61
Q

what are direct inguinal hernias

A

through weakness in posterior wall of inguinal canal

reduce easily and rarely strangulate

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62
Q

causes of upper GI bleed

A

mallory weiss tear

varices

ulcers

gastritis

malignancy

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63
Q

presentation of upper GI bleed

A

haematemesis or malaena

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64
Q

management of upper GI bleed

A

ABCDE

fluid resus

bloods inc crossmatch

urgent endoscopy

if cant control bleed then surgery

terlipressin if varices suspected

Blatchford score (need for intervention) first, Rockall score (adverse outcome) after endoscopy

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65
Q

what is the blatchford score

A

to determine risk (and therefore need for intervention) of upper GI bleed

50% chance of need for intervention if 6 or more points

blood urea

Hb <100 = 6

systolic BP

pulse > 100 = 1

presentation with malaena = 1

presentation with syncope = 2

hepatic disease = 2

cardiac failure = 2

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66
Q

what is the Rockall score

A

adverse outcome of upper GI bleed

age

60-79 = 1

80> = 2

shock

tachycardia >100bpm = 1

hypotension SBP <100 = 2

comorbidities

Cardiac failure, IHD or any major co-morbidity = 2 points

renal failure, liver failure, or metastatic disease = 3 points

7/7 is 50% chance mortality

after diagnosis: out of 11

Mallory-Weiss tear, no lesion seen nor SRH (stigmata of recent haemorrhage) = 0 points

All other diagnoses apart from GI malignancy = 1 point

GI malignancy = 2 points

major stigmata of recent haemorrhage:

None or dark spot only = 0 points

Blood, adherent clot, spurting vessel = 2 point

score over 8 = high risk of mortality

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67
Q

what is the main risk factor for upper GI ulcers

A

NSAID use

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68
Q

usually healthy

been out binge drinking

repeated vomiting

and then blood in vomit

diagnosis?

A

mallory weiss tear

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69
Q

chronic alcohol excess

malnourished

massive haematemesis

diagnosis?

A

varices

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70
Q

heartburn

epigastric pain

dysphagia

dignosis

A

oesophagitis

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71
Q

severe epigastric pain

radiate to back

nausea + vomiting

diagnosis?

A

acute pancreatitis

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72
Q

causes of pancreatitis

A

I GET SMASHED

idiopathic

gall stones

ethanol

trauma

steroids

mumps

autoimmune

scorpion bite

hypercalcaemia, hypertriglyceridaemia

ERCP

drugs

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73
Q

investigations and management of acute pancreatitis

A

raised amylase (or lipase) - 3 times upper limit of normal

glasgow score: PANCREAS

Mx:

supportive - IV fluids, analgesia

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74
Q

what is the glasgow score

A

for pancreatitis - gallstone and alcohol induced

score of 3 or more indicates severe pancreatitis –> ITU

PANCREAS

P - PaO2 <8kPa

A - Age >55-years-old.

N - Neutrophilia: WCC >15x10(9)/L.

C - Calcium <2 mmol/L

R - Renal function: Urea >16 mmol/L

E - Enzymes: LDH >600iu/L; AST >200iu/L

A - Albumin <32g/L (serum)

S - Sugar: blood glucose >10 mmol/L

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75
Q
A
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76
Q

causes of RUQ pain

A

cholecystitis

pyelonephritis

hepatitis

pneumonia

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77
Q

causes of LUQ pain

A

gastric ulcer

ureteric colic

pyelonephritis

pneumonia

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78
Q

causes of RLQ pain

A

appendicitis

ureteric colic

inguinal hernia

chrons

UTI

gynae

testicular torsion

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79
Q

causes of LLQ pain

A

UC

diverticulitis

UTI

ureteric colic

gynae

testicular torsion

inguinal hernia

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80
Q

epigastric pain

A

gastric ulcer

pancreatitis

cholecystitis

MI

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81
Q

periumbilical pain

A

AAA

appendicits

small bowel obstruction

large bowel obstruction

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82
Q

what test should you do in a woman with abdo pain

A

urine pregnancy test (HCG) - to rule out ectopic

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83
Q

most common cause of bowel obstruction

A

adhesions

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84
Q

pain

distension

vomiting

absolute constipation

chrons patient recently underwent surgery

most likely diagnosis

A

adhesions

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85
Q

coffee bean AXR

most likely diagnosis

A

volvulus

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86
Q

investigations and management for obstruction

A

AXR

need NG tube and Iv fluids “drip and suck”

surgery if does not settle or worsening signs

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87
Q

what does this sign show

A

apple core sign

sign of colorectal cancer

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88
Q

what does this xray show

A

small bowel obstruction

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89
Q

what does the AXR show

A

coffee bean sign

sigmoid volvulus

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90
Q

what does this AXR show

A

large bowel obstruction

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91
Q

what does this AXR show

with air under diaphragm

A

riglers sign -both sides of wall of intestine can be seen

pneumoperitoneum - free air in abdo

causes of pneumoperitoneum:

  • perforated abdominal viscus (e.g. perforated bowel, perforated duodenal ulcer)
  • recent abdominal surgery
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92
Q

what does this AXR show

A

IBD

Thumbprinting: mucosal thickening of the haustra due to inflammation and oedema causing them to appear like thumbprints projecting into the lumen.

Lead-pipe (featureless) colon: loss of normal haustral markings secondary to chronic colitis.

Toxic megacolon: colonic dilatation without obstruction associated with colitis.

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93
Q

abdo pain, rigidity, guarding

may also have N+V, fever, signs of sepsis

what does this x ray show

A

free gas under diaphragm on erect CXR –> perforation

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94
Q

what are the main causes of perforation

A

2ndry to OBSTRUCTION

perforated ulcer

malignancy

diverticulitis

appendicitis

IBD

infection e.g c.difficile

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95
Q

colicky umbilical pain that moves to constant RIF pain - may be guarding, rebound tenderness

fever + systemic signs - increased HR

anorexia

vomiting

diarrhoea

constipation

rovsings sign +ve

diagnosis?

A

appendicitis

rovsings sign +ve: palpating LLQ illicits pain in RLQ

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96
Q

investigations and management for appendicitis

A

clinical dx

but can do USS or CT

difinitive treatment: laparoscopic appendicectomy

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97
Q

pale stool

A

post hepatic obstruction - biliary or pancreatic duct obstruction

e.g. pancreatic cancer, stones

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98
Q

steatorrhoea cause

A

pale, foul smelling, floats

coeliac

pancreas pathology

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99
Q

blood mixed into faeces

causes

A

infections

UC

colon cancer

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100
Q

blood when wiping

causes

A

haemorrhoids

anal fissure

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101
Q

causes of diarrhoea in young people

A

infection

IBD

IBS

coeliac

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102
Q

causes of diarrhorea in old people

A

cancer

IBS

diverticular disease

bacterial overgrowth -e.g. in diabetes

chrons (2nd age peak)

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103
Q

progressive dysphagia (problems with food then drink)

weight loss

fatigue

A

oesophageal cancer

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104
Q

what does the image show

A

bird beak appearance on barium swallow

–> achalasia

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105
Q

causes of an oesophageal stricture

A

chronic GORD

hiatus hernia

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106
Q

investigations for dysphagia

A

endoscopy +/- barium swallow (more Ix for achalasia)

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107
Q

how does UC and chrons present

A

UC: LLQ pain, bloody diarrhoea

Chrons: RLQ pain, bloody diarrhoea, can have ulcers in mouth

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108
Q

what is angiodysplasia and what is Ix and Mx

A

angiodysplasia

  • vascular malformation - often lesions in caecum or ascending colon

fresh PR blood. may also see malaena

Ix: colonoscopy - visualise lesion

Mx: conservative, or cauterisation if does not cease

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109
Q

pale stools

dark urine

jaundic

increased ALP

conjugated hyperbilirubinaemia

diagnosis?

A

post hepatic jaundice

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110
Q

causes of post hepatic jaundice

A

gall stones

cancer of head of pancreas

cholangiocarcinoma - bile duct cancer

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111
Q

short episodes of jaundice

in young adult

otherwise well

brought on by stress, illness, fasting

diagnosis?

management?

A

Gilberts syndrome

short episodes of jaundice

inherited condition

cant process bilirubin properly

often presents in young adults

otherwise well

no treatment needed

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112
Q

what does increased conjugated bilirubin mean

A

post hepatic jaundice

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113
Q

what does increased unconjugated bilirubin show

A

pre or intra hepatic jaundice

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114
Q

what does increased ALT/AST mean

A

problem in the liver

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115
Q

what does increased ALP/gamma GT mean

A

problem in biliary system or lower

ALP can be raised in pregnancy and in bone disorders too

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116
Q

what does increased amylase/lipase mean

A

pancreatitis if >3x upper limit of normal

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117
Q

heartburn

acid regurgitation

retrosternal or epigastric pain

bloating

nocturnal cough

hoarse voice

diagnosis?

A

GORD

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118
Q

red flag signs for endoscopy referral

A

dysphagia

age >55

weight loss

upper abdo pain/reflux

treatment resistant dyspepsia (indigestion)

nausea & vomiting

low haemoglobin

raised platelet count

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119
Q

when would you get an urgent referral for endoscopy

A

upper GI bleed - fresh blood, coffee ground vomit, malaena

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120
Q

lifestyle management of GORD

A

reduce tea, coffee, alcohol

weight loss

avoid smoking

smaller, lighter meals

avoid heavy meals before bed

stay upright after meals

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121
Q

management for GORD

A

acid neutralising PRN:

  • gaviscon
  • rennie

PPI: (reduce acid secretion)

Omeprazole

lansoprazole

ranitidine - H2 receptor antagonist (reduce stomach acid)

alternative to PPIs

surgery for reflux - laparoscopic fundoplication

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122
Q

dyspepsia (indigestion) investigations

A

h.pylori urea breath test

has to be taken before starting PPI or not taken a PPI in two weeks

endoscopy if red flag symptoms

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123
Q

management of H.pylori

A

thriple therapy

PPI

2 x Abx - amoxicillin + clarithromycin for 7 days

use urea breath test to check for eradication after treatment

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124
Q

what is the change of cells in Barretts oesophagus

A

metaplasia from squamous to columnar epithelium

leads to improvement in reflux symptoms

premalignant - risk of adenocarcinoma

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125
Q

management for Barretts oesophagus

A

monitored for adenocarcinoma - regular endoscopy

PPI

ablation treatment during endoscopy - photodynamic therapy, laser therapy, cryotherapy - for patients with dysplasia

aspirin can reduce rate of adenocarcinoma

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126
Q

chrons pathophysiology

A

crows NESTS

N - No blood or mucous (less common)

E- Entire GI tract

S- Skip lesions on endoscopy

T- Terminal ileum most affected & Transmural (full thickness inflammation

S-Smoking - risk factor (dont set nest on fire)

chron’s also associated with weight loss, strictures and fistulas

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127
Q

ulcerative colitis pathophysiology

A

(U - C -> CLOSE UP)

C- Continuous inflammation

L- Limited to colon and rectum

O- Only superficial mucosa affected

S- Smoking is protective

E- Excrete blood and mucus

U- Use aminosalicylates

P-Primary Sclerosing Cholangitis

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128
Q

testing for IBD

A

routine bloods for anaemia, infection, TFTs, LFTs, CRP (for active disease)

faecal calprotectin (released by intestine when inflamed) - screening test

endoscopy (OGD and colonoscopy) with biopsy - diagnostic

USS, CT, MRI - to look for complications - fistulas, abscesses, strictures

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129
Q

management of chrons

A

inducing remission:

  • first line: steroids - oral pred or IV hydrocortisone

add immunosuppressants (biologics) if steroids arent working e.g. azathioprine, methotrexate, infliximab

maintaining remission:

first line: azathioprine, mercaptopurine

alternatives: methotrexate, infliximab, adalimumab

surgery:

when disease only affects distal ileum - surgical resection

surgery to treat strictures and fistulas

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130
Q

management of UC

A

inducing remission:

mild to moderate:

first line: aminosalicylate (e.g. mesalazine oral or rectal)

second line: corticosteroids- pred

severe disease:

first line: IV corticosteroids (hydrocortisone)

second line: IV ciclosporin

maintaing remission:

aminosalicylate (mesalazine)

azathioprine

mercaptopurine

surgery:

UC affects colon and rectum - panproctocolectomy

left with ileostomy or ileo-anal anastomosis (J-pouch)

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131
Q

which type of IBD has no inflammation beyond submucosa

A

UC

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132
Q

which type of IBD has loss of haustrations on barium enema

A

UC - with toxic megacolon

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133
Q

which type of IBD has mouth ulcers

A

chrons

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134
Q

which type of IBD is most likely to have a fistula

A

chrons

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135
Q
A
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136
Q

which IBD is more likely to have gallstones 2ndry

A

chrons

common 2ndry to reduced bile acid reabsorption

as well as oxalate renal stones

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137
Q

which IBD is more likely to have primary sclerosing cholangitis

A

UC

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138
Q

which IBD has a greater risk of colorectal cancer

A

UC

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139
Q

which IBD has a greater risk of fistula

A

chrons

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140
Q

which IBD has skip lesions

A

chrons

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141
Q

what is the diagnosis

A

cobblestone appearance

–> Chrons

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142
Q

diagnosis?

A

UC

lead pipe appearance on AXR

  • loss of haustrations
  • toxic megacolon

ulcers seen on colonoscopy

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143
Q

diagnosis?

A

chrons

  • rose thorn appearance
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144
Q

diagnosis

A

Chrons

  • Kantor’s string sign
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145
Q

which IBD has crypt absesses and depletion of globlet cells

A

UC

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146
Q

which IBD has bloody diarrhoea

A

UC

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147
Q

which IBD has perianal disease

A

chrons

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148
Q

which IBD has increased goblet cells

A

chrons

149
Q

which IBD has tenesmus as a presenting feature

A

UC

150
Q

which IBD has pseudopolyps seen on endoscopy

A

UC

151
Q

which IBD has weight loss

A

chrons

152
Q
A
153
Q

which cancers is a patient at increased risk of following radiotherapy for prostate cancer

A

increased risk of bladder, colon, rectal cancer

154
Q

management for prostate cancer

A

localised prostate cancer (T1/T2):

conservative: active monitoring + watch and wait

radical prostatectomy

radiotherapy: external beam + brachytherapy

localised advanced prostate cancer (T3/T4):

  • hormonal therapy
  • radical prostatectomy: erectile dysfunction common complication
    radiotherapy: increased risk of bladder, colon and rectal cancer

metastatic prostate cancer disease - hormonal therapy :

  • synthetic GnRH agonist e.g. goserelin
  • anti-androgen
  • orchidectomy
155
Q

4yr old boy

discharged from hospital 6 wks ago - viral gastroenteritis

now has 4-5 loose stools a day - for last 4 wks

most likely diagnosis

A

lactose intolerance

transient lactose intolerance common complication of viral gastroenteritis

Mx: removal of lactose from diet for a few months then reintroduction

156
Q

most common cause of gastroenteritis in children

treatment

A

rotavirus - diarrhoea (+ fever + vomiting for first 2 days)

diarrhoea can last up to a week

treatment = rehydration

157
Q

most common cause of chronic diarrhoea in infants

A

cow’s milk intolerance

other causes:

  • toddlers diarrhoea
  • coeliac disease
  • post-gastroenteritis lactose intolerance
158
Q

alcoholic liver disease progression

A
  1. alcohol related fatty liver
    - build up of fat in liver

reversible in around 2 weeks if stop drinking

  1. alcoholic hepatitis
    - chronic drinking -> inflammation in liver
    - reversible with permanent abstinence
  2. cirrhosis
    - scar tissue - irreversible
159
Q

what is the recommended alcohol consumption

A

no more than 14 units per week - spread evenly over 3 or more days

no more than 5 units in a day

160
Q

complications of alcohol

A

alcoholic liver disease

cirrhosis and complications e.g. hepatocellular carcinoma

alcohol dependence and withdrawal

Wernicke- Korsakoff Syndrome

pancreatitis

alcoholic cardiomyopathy

161
Q

signs of liver disease

A

jaundice

hepatomegaly

spider naevi

palmar erythema

gynaecomastia

brusing - due to abnormal clotting

ascites

caput medusae - engorged superficial epigastric veins

asterixis - flapping tremor

162
Q
A
163
Q

investigations for alcoholic liver disease

A

bloods:

  • FBC - raised MCV

LFTs - raied ALT & AST, particularly raised gamma GT

ALP raised later in disease

low albumin

raised bilirubin in cirrhosis

clotting - raised prothrombin time due to reduced synthetic function of liver

U+Es deranged in hepatorenal syndrome

USS:

increased echogenicity - fatty changes early on

cirrhosis - fibroscan

endoscopy - oesophageal varices - portal HTN

CT & MRI

  • fatty infiltration

hepatocellular carcinoma

hepatosplenomegaly

abnormal blood vessel changes

ascites

liver biopsy

  • to confirm diagnosis of alcohol related hepatitis or cirrhosis
164
Q

mangement for alcoholic liver disease

A

stop drinking permanently

detox regime

nutritional support with vitamins (thiamine)

steroids - improve short term outcomes

treat complications (portal HTN, varices, ascites, hepatic encephalopathy)

referral for liver transplant in severe disease - must abstain from alcohol for 3 months prior to referral

165
Q

how many hrs after alcohol ceasation does delerium tremens present

A

24-72hrs

166
Q

patient chronic alcoholic

caesed drinking 48hrs ago

presenting with acute confusion

severe agitation

delusions and hallucinations

tremor

tachycardia

HTN

hyperthermia

ataxia (difficulty coordinating movements)

arrhythmias

diagnosis and management

A

delerium tremens

management: benzodiazepine - chlordiazepoxide PO 5-7 days

IV high dose vitamin B (pabrinex) - followed by lower dose oral thiamine

167
Q

what comes first Wernicke’s encephalopathy or Korsakoffs syndrome

A

Wernicke’s encephalopathy

168
Q

chronic alcoholic recent caesation

confusion

oculomotor disturbances

ataxia

diagnosis

A

Wernicke’s encephalopathy

given thiamine to prevent Korsakoffs syndrome

169
Q

recent chronic alcohol caesation

memory impairment (retrograde and anterograde)

behavioural changes

diagnosis?

A

Korsakoffs syndrome - irreversible

full time institutional care

170
Q

35y M

RUQ pain - past 24hrs

pruritis + fever

no weight loss

ongoing treatment of Hep B

compliant with meds

no alcohol

uses recreational drugs

jaundiced

needle track marks on arm

most likely diagnosis:

peptic ulcer

gallstones

hepatocellular carcinoma

hepatitis D superinfection

alcoholic liver disease

A

hepatitis D superinfection

differential for chronic hep B patients with acute flare up

risk factors IVDU

171
Q

what other Hep virus does hepatitis D need to replicate

A

hep D needs hep B to replicate

172
Q

how is hep B transmitted

A

exchange of bodily fluids

173
Q

how is hep D transmitted

A

exchange of body fluids

174
Q
A
175
Q

how to diagnose hepatitis D

management

A

reverse polymerase chain reaction of hep D RNA

management: interferon

176
Q

differentials for raised ALP + raised calcium

A

bone metastases

hyperparathyroidism

177
Q

differentials for raised ALP + low calcium

A

osteomalacia

renal failure

178
Q

17yr F

six wk hx nausea + abdo discomfort

Hb low

ALP raised

most likely diagnosis

A

pregnancy

ALP significantly raised in pregnancy

179
Q

causes of dupuytren’s contracture

A

thickening of palmar fascia in hand - most commonly to little and ring fingers

causes:

manual labour

phenytoin treatment

alcoholic liver disease

diabetes

trauma to hand

180
Q

management for dupuytrens contracture

A

surgical treatment when metacarpophalangeal joints cannot be straightened and therefore hand cant be placed flat on table

181
Q

43yr M

homeless

fever

yellow skin

for 1 wk

muscle and joint pains

mild abdo discomfort

IVDU - 2 yrs

drinks 15 units alcohol per week

visible needle track marks both arms

temp 38.2

mild hepatomegaly

LFTs raised (ALT)

hep B test:

HBsAg: +ve

anti -HBs: -ve

IgM anti-HBc: +ve

most likely diagnosis?

hep C infection

alcoholic liver disease

chronic hep B infection

previous hep B vaccination

acute hep B infection

A

acute hep B infection

HBsAg: surface antigen

= ongoing infection, acute infection (present 1-6months) or chronic if >6months

causes production of anti-HBs: immunity (either exposure or immunisation)

-ve in chronic disease

anti-HBc: previous (or current) infection

anti-HBc = caught ie negative if immunized

IgM anti-HBc: acute or recent hep B infection (present ~6mnths)

IgG anti-HBc persists

hbeAg: shows breakdown of core antigen from infected liver cells: marker of infectivity

HBsAg +ve

anti-HBs -ve

IgM anti-HBc +ve

= acute infection

IgM = acute infection

chronic infection = IgG anti-HBc +ve

anti-HBc +ve, HBsAg +ve: previous hep B, now a carrier

anti-HBs +ve, HBsAg -ve, anti-HBc -ve = previous vaccine

182
Q

the 4 degrees of haemorrhoids

A

venous ‘vascular cushions’ enlarged due to increased pressure (eg. 2ndry to straining in constipation)

1st degree: no prolapse

2nd degree: prolapse when straining and return on relaxing

3rd degree: prolapse when straining, do not return on relaxing but can be pushed back

4th degree: prolapsed permanently

183
Q

differentials for right red blood on toilet paper

A

haemorrhoids

anal fissure (tear or open sore (ulcer))

184
Q

constipation

painless bright red bleeding on toilet paper

sore anus

feeling a lump around or in anus

diagnosis?

A

haemorrhoids

185
Q

investigations and management for haemorrhoids

A

external haemorrhoids visible on inspection

internal haemorrhoids - proctoscopy

management:

  • consider differentials (fissure, cancer, IBD)
  • symptomatic: anusol cream, local anaesthetic (instillagel), topical steroids
  • laxatives to treat constipation
  • band ligation
  • surgical haemorrhoidectomy
186
Q

4 main causes of liver cirrhosis

A

alcoholic liver disease

non-alcoholic fatty liver disease

hepatitis B

hepatitis C

187
Q

jundice

hepatosplenomegaly

palmar erythema

spider naevi

gynaecomastia

ascites

caput medusa

flapping tremor

diagnosis

A

liver cirrhosis

188
Q
A
189
Q

what screening test for hepatocellular carcinoma do you do for someone with liver cirrhosis

A

USS + alpha fetoprotein (tumor marker)

every 6 months

190
Q

dignostic test for non-alcoholic fatty liver disease

A

enhanced liver fibrosis (ELF) blood test

<7.7 = none to mild fibrosis

>7.7 to 9.8 = moderate fibrosis

>9.8 = severe fibrosis

191
Q

USS:

nodularity of surface of liver

corkscrew appearance to arteries with increased flow

enlarged portal vein with reduced flow

ascites

splenomegaly

diagnosis

A

liver cirrhosis

192
Q

when should a fibroscan be carried out of the liver

A

tests elasticity of liver - assesses degree of cirrhosis

restest every 2 yrs in patients at risk of cirrhosis:

  • hep C
  • heavy alcohol drinkers (men>50 units or women>35 units per week)
  • diagnosed alcoholic liver disease
  • non alcoholic fatty liver disease + evidence of fibrosis on ELF blood test
  • chronic hep B (yrly)
193
Q

what is the investigation for oesophageal varices

A

endoscopy when portal HTN is suspected

194
Q

what is used to confirm the diagnosis of liver cirrhosis

what is the scoring system for cirrhosis

A

liver biopsy

child-pugh score for cirrhosis

bilirubin

albumin

INR

ascites

encephalopathy

scores from 5-15

MELD score - every 6 months in patients with compensated cirrhosis

percentage estimated 3 month mortality - guides referral for liver transplant

195
Q

management for cirrhosis

A

USS + alpha fetoprotein - every 6 months for HCC

endoscopy every 3 yrs in patients without known varices

high protein, low sodium diet

MELD score - every 6 months

consideration of liver transplant

managing complications

196
Q

how do varices form

A

liver cirrhosis causing increased resistance of blood flow in liver

–> increased back pressure in portal system (portal HTN)

back pressure causes swollen veins (varices)

197
Q

treatment of stable varices

A

propanolol - decreases portal HTN - beta blocker

elastic band ligation of varices

injection of sclerosant

transjugular intra-hepatic portosystemic shunt (sent from portal vein into hepatic vein without having to travel through liver)

198
Q

management for bleeding varices

A

resus:

  • vasopressin analogues (terlipressin) - vasoconstriction
  • correct coagulopathy with vit K and fresh frozen plasma
  • prophylactic broad spec abx

consider intubation and intesive care

urgent endoscopy

  • injection of sclerosant into varices - inflammatory obliteration
  • elastic band ligation

sengstaken-blakemore tube - inflatable tube inserted into oesophagus to tamponade the bleeding varices - used when endoscopy fails

AT PEST

- ABCDE - vit K + fresh frozen plasma

- terlopressin

- prophylactic abx

- endoscopy

- sengastaken-blakemore tube

- Transjugular intrahepatic portosystemic shunt

199
Q

what is ascites

management for ascites caused by cirrhosis of the liver

A

ascites: fluid in peritoneal cavity

portal HTN causes leaking from capillaries in liver and bowel into peritoneal cavity

management:

  • low sodium diet
  • anti-aldosterone diuretics (spironolactone)
  • paracentesis (ascitic tap/ drain)
  • prophylactic abx (ciprofloxacin)
  • consider TIPS
  • consider liver transplantation
200
Q

criteria for diagnosis of IBS

A

diagnosis of exclusion:

  • normal FBC, ESR, CRP
  • faecal calprotectin -ve to exclude IBD
  • -ve coeliac disease serology (anti-TTG antibodies)
  • cancer not suspected or excluded
201
Q

symptoms of IBS

A

symptoms for >6months

abdo pain/ discomfort:

  • relieved on opening bowels or
  • associated with change in bowel habit

AND 2 of:

  • abnormal stool passage (urgency, straining, incomplete evacuation)
  • bloating
  • worse symptoms after eating
  • PR mucus

can also have nausea, lethargy, backache, urinary symptoms

202
Q

management of IBS

A

healthy diet and exercise

  • low FODMAP

trial of probiotic supplements - 4 weeks

first line management:

  • loperamide - for diarrhoea
  • laxatives for constipation (avoid lactulose)

(linaclotide after 12months if other laxatives failed)

  • hyoscine butylbromide (Buscopan) - antispasmodic for cramps

second line:

  • amitriptyline (tricyclic antidepressant)

third line: SSRIs antidepressants

CBT

203
Q

30yr F

abdo pain associated with alternating diarrhoea + constipation

which is least consistent with a diagnosis of irritable bowel

  • feeling of incomplete stool evac
  • waking at night due to pain
  • abdo bloating

faecal urgency

passage of mucous with stool

A

waking at night due to pain

204
Q

24 F

few wks hx diarrhoea, passing mucus, lethargy, abdo discomfort relieved by defaecation

blood tests: Na+: 138 (N)

K+ 4.0 (N)

urea: 4.5 (N)
cr: 80 (N)

Hb: 11 -low (115-160)

platelets: 320 (N)

WBC: 4.0 (N)

CRP: 1.0 (N)

TTG antibody: -ve

which one of the following would be most suitable for her:

  • linaclotide
  • codeine
  • sertraline
  • loperamide
  • amitripyline
A

IBS

  • relief on defaecation + normal bloods

loperamide for diarrhoea

205
Q

24y M

9 month hx diarrhoea

investigations all normal

IBS

most appropriate management

A

loperamide

first line treatment of diarrhoea in IBS

206
Q

35Y F

abdo pain associated with bloating for 6 months

which of the following symptoms is least associated with a diagnosis of IBS

  • feeling of incomplete stool evacuation

weight loss

back pain

lethargy

nausea

A
207
Q

48y M

known liver cirrhosis

A&E: malaise + abdo tenderness

jaundice

tender hepatomegaly

drinks heavily - ~ 35 units per week

Hb 135 (135-180)

platelets 140 (150-400)

neutrophils 23 (2-7)

bilirubin 46 (3-17)

ALP 120 (30-100)

ALT 342 (3-40)

albumin 34 (34-54)

suspect alcoholic hepatitis

most appropriate treatment for acute severe alcoholic hepatitis as determined by the Maddrey discriminant function

IV abx

liver transplant

prednisolone

chlordiazepoxide

A

prednisolone 40mg/day for 28 days

  • corticosteroids used to manage severe alcoholic hepatitis
208
Q

30yr unkempt F

no fixed abode

severe right upper quadrant pain

decreased consciousness levels

vomiting

confused and combative

thin

jaundiced

large bruises on arms and legs

needle track marks noted on anterior cubital fossa

abdo exam - tenderness in RUQ

RR: 22

O2 sats: 98% on air

HR: 112

BP: 103/98

temp: 37.8

GCS: 12

Hb: 102 (115-160)

MCV: 101 (82-100)

WBC: 12 (4-11)

INR:2.5 (<1.1)

bilirubin: 89 (high)

ALT: 375 (high)

AST: 790 (extra high)

ALP: 170 (slightly high)

GGT 425 (high)

amylase 350 (slightly high)

diagnosis

A

alcoholic hepatitis

AST/ALT ration of 2:1 = alcoholic hepatitis

AST raised over ALT suggests cirrhosis

209
Q

which one of the following is least useful in assessing severity of liver cirrhosis

ALT

prothrombin time

bilirubin

presence of ascites

presence of encephalopathy

A

ALT

bilirubin, albumin, PTT, encephalopathy, ascites: child-pugh classification

bilirubin, creat, INR: MELD score

210
Q

65y M

liver cirrhosis of unknown cause

which one is the most likelt to indicate poor prognosis

ALT >200

caput medusae

ascites

gynaecomastia

splenomegaly

A

ascites

in child-pugh classification

211
Q

35yr

IVDU

diagnosed with Hep C after abnormal LFTs

assessed for liver cirrhosis

most appropriate test to perform

A

transient elastography - fibroscan

now investigation of choice to detect liver cirrhosis

all hep C patients assessed for liver cirrhosis

also endoscopy - to check for varices in new diagnosis of cirrhosis

USS + alpha fetoprotein - check for HCC

212
Q

55y M

worsening tiredness

bruising

chronic liver disease 2ndry to chronic hep C

suspects cirrhosis

single lab finding that should prompt immediate consideration of liver cirrhosis and urgent review by hepatology :

  • platelet count = 90 (150-400)

ASR= 80 ALT= 85

ALP=155

urea=11 (2-7)

Hb=85 (135-180)

A

thrombocytopenia (platelet count <150)

most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease

AST/ALT raised >2.5

urea: decrease expected

anaemia

213
Q

67 M

chronic hep B

stable for past 10yrs

yelloowing of skin

confusion

which of the foloowing may cause this mans liver decompensation

  • high carbohydrate diet
  • low protein diet
  • diarrhoea
  • constipation
  • high fibre diet
A

constipation

  • trigger for liver decompensation in cirrhotic patients

due to accumulation of toxic products in body

other causes of liver decompensation:

  • infection
  • electrolyte imbalances
  • dehydration
  • upper GI bleeds
  • increased alcohol intake
214
Q

causes of hepatitis

A

alcohol hepatitis

non-alcoholic fatty liver disease

viral hepatitis

drug induced hepatitis

215
Q

presentation of hepatitis

A

abdo pain

fatigue

pruritis (itching)

muscle and joint aches

nausea + vomiting

jaundice

fever (viral hepatitis)

high AST & ALT

less raised ALP

high bilirubin

216
Q

which viral hepatitis are transmitted via faecal oral route

acute or chronic

treatment?

vaccine?

A

A&E

acute

hep A can cause cholestasis - dark urine, pale stools, hepatomegaly

no treatment needed

vaccine available for hep A not hep E

217
Q

which viral hepatitis is a DNA virus

A

hep B

218
Q

which hepatitis are spread by blood and bodily fluids and are therefore increase risk for IVDU

A

hep B, C, D

219
Q

which other hepatitis does hep D need to survive

treatment?

A

hep B infection

attaches to HBsAg antigen

increases the complications and disease severity of hep B

no treatment

220
Q

what are risk factors for hep B

A

sharing needles (IVDU or tattoos)

sexual intercourse

can be passed by vertical transmission from mother to child during pregnancy

221
Q
A
222
Q

what are the viral markers for hep B

A

HBsAg: surface antigen - active infection

HBeAg: E antigen - marker of viral replication - high infectivity

HBcAb: core antibodies - past or current infection

HBsAb: surface antibodies - vaccine, past or current infection

HBV DNA: hep B virus DNA - direct count of viral load

HBsAg +ve, everything else -ve: vaccination

HBsAg +ve, HBsAb +ve, IgM HBcAb +ve, HBeAg +ve (acute infection)

IgG HBcAb +ve: chronic

HBsAb +ve, HBcAb +ve, HBsAg -ve : past infection

223
Q

management of hep B

A

routine vaccination

screen people at risk

screen for other blood born viruses (Hep C, HIV) + STDs

refer to gastro, hepatology, infectious diseases for specialist

notify public health

stop smoking and alcohol

education about reducing spread

testing for complications:

  • fibroscan for cirrhosis
  • USS for HCC
  • antivirals - slow progression - pegylated interferon
  • liver transplant for end stage liver disease
224
Q

testing for hep C

A

hep C antibody - screening test

hep C RNA testing - diagnostic

225
Q

management for hep C

A

screening at risk patients

screen for other blood born conditions

notify public health

stop smoking and alcohol

refer for specialist

education on reducing spread

fibroscan - cirrhosis

USS - HCC

direct acting antivirals 8-12 wks - ribavirin

liver transplant for end-stage liver disease

226
Q

what are the two types of autoimmune hepatitis

A

type 1: in adults

type 2: in children

type 1:

usually women

late 40/50s

around or after menopause

can affect children aswell

both types can cause amenorrhoea

fatigue

features of liver disease on examination

autoantibodies (ANA, anti-actin (antismooth muscle antibody (SMA), anti-SLA/LP)

type 2:

teenage or early 20s

acute hepatitis with high AST, ALT + jaundice

IgG levels raised

autoantibodies (anti LKM1 and anti-LC1)

227
Q

diagnosis and management of autoimmune hepatitis

A

diagnosis: liver biopsy - ‘piecemeal necrosis’

treatment:

  • high dose steroids (prednisolone)

+ azathioprine introduced later as pred weened off

228
Q

25yr F

periods have stopped

copper coil

several -ve home pregnancy tests

RUQ pain + reduced appetite

hepatomegaly

yellow sclera

bilirubin: 25

ALP: 200

ALT:420

GGT:72

albumin:28

ANCA -ve

Antimitochondrial antibdosy -ve

ANA raised

anti-tripsin antibody raised

first line treatment

A

severe autoimmune hepatitis

type 1

first line: steroids

autoimmune hepatitis can often cause ammenorrhoea

229
Q

26Y F

RUQ pain

yellow sclera

hepatomegaly

which of the following set of bloods would most support a diagnosis of autoimmune hepatitis?

ALT = 3 - 40 iu/l
AST = 3 - 30 iu/l
ALP = 30 - 100 iu/l

a) ALT & AST 250, ALP 120, antimitochrondial ab -ve
b) ALT & AST 250, ALP 600, antimitochrondial ab -ve
c) ALT & AST 55, ALP 600, antimitochrondial ab -ve
d) ALT & AST 55, ALP 600, antimitochrondial ab +ve
e) ALT & AST 250, ALP 600, antimitochrondial ab +ve

A

ALT & AST 250, ALP 120, antimitochrondial ab -ve

autoimmune hep more likely to show predominantly raised ALT/AST than ALP

antimitochrondial ab -ve in autoimmune hep

antimitochrondial ab +ve in primary biliary cirrhosis

230
Q

22 M

abdo pain - 1day hx getting worse RUQ

fever + malaise over last wk

10 units a week

non smoker

no drugs

recently returned from travelling south east asia - hostels, eating street food

no vaccines - malaria prophylaxis

sexually active - long term female partner

jaundice

hepatomegaly

no splenomegalu or lymphadeonpathy

bloods, USS - no abnormalities

what is the treatment and prognosis

A

consuming undercooked meat/ unclean water in developing countries –> risk factor for hepatitis A

hep E is usually pig meat related

symptoms for hep A 2-4 weeks after transmission

supportive treatment

no risk of hepatocellular carcinoma

231
Q

who should be vaccinated for hep A

A

travellers - in high or intermediate prevalence aged>1

chronic liver disease

haemophilia

men who have sex with men

IVDU

occupational risk: lab workers, large residential institutions, sewage workers, workers with primates

232
Q

23yr F

10-week booking scan

well, at 9+4 weeks gestation

routine bloods including hep B virus serology

HBsAg +ve

Anti-HBsAg IgG -ve

Anti-HBsAg IgM -ve

anti-HBcAg IgG +ve

how would you describe her HBV status

A

current chronic HBV infection

HBsAg +ve : current infection

anti-HBcAg IgG +ve : caught the infection, IgG: chronic

233
Q

weight loss

abdo pain

anorexia

nausea + vomiting

jaundice

pruritis

diagnosis

A

hepatocellular carcinoma

234
Q

painless jaundice

weight loss

A

cholangiocardinoma

presents with painless jaundice (similar to pancreatic cancer)

235
Q

what is a risk factor disease for cholangiocarcinoma

A

primary sclerosing cholangitis

236
Q

investigations for liver cancer

A

alpha-fetoprotein: hepatocellular carcinoma

CA19-9: cholangiocarcinoma

USS to identify tumours

CT/MRI diagnosis and staging

ERCP for biopsies to diagnose cholangiocarcinoma

237
Q

treatment for hepatocellular carcinoma

A

HCC very poor prognosis

resection in early disease

liver transplant when HCC is isolated

kinase inhibitors - inhibit proliferation of cancer cells: sorafenib, regorafenib, lenvatinib - extend life by months

HCC resistant to chem and radiotherapy

238
Q

treatment of cholangiocarcinoma

A

poor prognosis

srugical resection early on

ERCP - stent to improve symptoms - draining bile

resistant to chemo and radiotherapy

239
Q

what is a haemangioma

A

common benign tumour of liver

no symptoms

no potential for cancer

no treatment or monitoring needed

240
Q

what is focal nodular hyperplasia

A

benign liver tumour of fibrotic tissue

asymptomatic

no malignant potential

related to oestrogen - more common in women and on oral contraceptive pill

no treatment or monitoring needed

241
Q

upper abdo/back pain

painless obstructive jaundice

unintentional weight loss

pale stools

steatorrhoea (fatty stools)

dark urine

palpable mass in epigastric region

diagnosis?

A

pancreatic cancer

  • most commonly adenocarcinoma of head of pancreas –> obstruction of bile duct –> obstructive jaundice picture

Courvoisier’s law: painless jaundice + non-tender palpable gallbladder = pancreatic cancer until proven otherwise

242
Q

diagnosis of pancreatic cancer

A

CA19-9 tumour marker (blood test)

CT can for staging

endoscopic USS with biopsy

243
Q

management of pancreatic cancer

A

whipple’s procedure:

  • for tumour head of pancreas with no spread
  • removes head of pancreas, gallbladder, duodenum, pylorus
  • modified whipples: leaving pylorus - same success rates

distal pancreatectomy for tumour of body/ tail of pancreas

adjuvant chemo

late disease management

  • palliative chemo to extend life
  • bile duct stent
244
Q

what is a hiatus hernia

symptoms

treatment

A

herniation of stomach through diaphragm

normally diaphragm helps maintain narrow sphincter- stops acid refluxing

when this is widened due to heniation-> symptoms: reflux

treatment: reflux meds

or surgical repain if high risk of complication or severe symptoms

245
Q

types of hiatus hernia

A

type 1: sliding

  • stomach slides up through diaphragm

type 2: rolling

  • separate portion of stomach (e.g. fundus) enters through diaphragm

type 3: mixed

  • bit of both happens

type 4:

large hernia allows other intraabdominal organs to pass through

246
Q

diagnosis with hep markers

A

active acute infection

low infectivity - e antigen -ve + low titre of HBV DNA

247
Q
A
248
Q

diagnosis?

A

chronic infection

IgG present

high infectivit: HBeAg +ve

249
Q

diagnosis?

A

previous hep B infection which has now cleared

has IgG anti-HBc +ve

anti-HBs +ve

250
Q

has booster Hep B vaccination a few wks ago after needle stick injury

diagnosis

A

anti-HBs +ve

antigens remove after a few weeks

251
Q

risk factors for Hep B

A

MSM

IVDU

haemodyalysis patients

blood transfusion recipients

sub saharan africa, asia, pacific islands

252
Q

incubation period for hep B to show symptoms

A

2-3 months

can be up to 6 months

253
Q

complications of hep B

A

carrier/ chronic state

cirrhosis

hepatocellular carcinoma

254
Q

management of hep B

A

acute phase: supportive

notify HPA - manage contacts

chronic:

  • treat infection: antivirals + interferons
  • no alcohol
  • lose weight
  • regular LFTs

6 monthly USS liver + AFP testing

fibroscan

pregnancy: vaccination, HBIG

255
Q
A
256
Q

55yr M

acute confusion

jaundice

ascites

lifelong abstinance from alcohol

anti HCV +ve

everything else -ve

A

hepatitis C

257
Q

hep C serology testing

A
258
Q

management for hep C

A

vaccinate for hep A and B

notify HPA

referral

contacts

smoking and alcohol cessation

acute:

  • regular monitoring for clearance
  • interferon

chronic:

  • regular blood testing: viral load, clotting studies

liver USS
fibroscan

antivirals + interferon

259
Q

30yr F

anti- vax person

reduced appetite

nausea

jaundiced

dark urine

just came back from nepal - drinking from wells

no IVDU, no sexual activity

diagnosis

A

hep A

  • most common form of acute viral hepatitis
260
Q

testing for hep A

A

IgM anti-HAV

261
Q

management for hep A

A

supportive

avoid alcohol

pregnancy: risk of miscarriage

262
Q

which hepatitis has ~75% conversion rate to chronic hep

A

hep C

263
Q

what other viruses can cause hepatitis except A-E

A

CMV

EBV

adenovirus

HSV

264
Q

which animal carries hep E

A

pigs

faeco-oral route

265
Q

Q fever is a parasitic infection that can cause hepatitis

which microoganism is responsible

A

coxiella burnetii

Q fever: fever symptoms - look for coxiella burnetii when they cant find another cause

266
Q

19yr F

sore throat

swollen glands on neck - tender

jaundice

diagnosis

Ix

A

EBV

  • causing glandular fever/also called infectious mononucleosis

Ix: monospot test

267
Q

gastric carcinoma which bacteria

A

heicobacter pylori

268
Q

female, middle aged

episodic RUQ pain

diagnosis?

A

biliary colic

fat fair female fertile

269
Q

65yr F

jaundice

weight loss

passing clay coloured stools

recurrent bouts of colicky RUQ pain

mass palpable in RUQ

diagnosis?

A

cholangiocarcinoma

pale stools + jaundice points to post hepatic

weight loss suggests cancer

biliary colic symptoms associated with anorexia, jaundice, weight loss

palpable mass: Couvoisier sign

periumbilical lymphadenopathy

270
Q

fever

RUQ pain

jaundice

diagnosis

A

ascending cholangitis

triad of:

jaundice

RUQ pain

fever

271
Q

murphys sign +ve

fever

RUQ pain

diagnosis

A

cholecystitis

dont have the triad

272
Q

hx gallstones

abdo pain

distension

vomiting

A

gallstone ileus

small bowel obstruction 2ndry to impacted gallstone

273
Q

painless jaundice

diagnosis

A

pancreatic cancer until proven otherwise

274
Q

65y M

hx chronic hep B infection

symptoms of liver cirrhosis

alpha-fetoprotein elevated

diagnosis?

A

hepatocellular carcinoma

275
Q

which IBD is gallstones linked with

A

chrons disease

276
Q

which IBD has loss of goblet cells

A

ulcerative colitis

277
Q

primary sclerosing cholangitis is associated with which IBD

A

Ulcerative colitis

4% of patients with UC have PSC

80% of patients with PSC have UC

278
Q
A
279
Q

ix for primary sclerosing cholangitis

A

ERCP or MRCP

beaded appearance

pANCA may be positive

280
Q

complication of primary sclerosing cholangitis

A

cholangiocarcinoma (10%)

increased risk of colorectal cancer

281
Q

duodenal vs gastric ulcer presentation

A

duodenal ulcer:

  • epigastric pain relivied by eating

gastric ulcer:

  • epigastric pain made worse by eating

both:

  • hx of NSAID use and alcohol
  • features of upper gastrointestinal haemorrhage (haematemesis, malaena)
282
Q

30yr

foul smelling oily diarrhoea

abdo bloating

fatigue

weight loss

papulovesicular lesions on extensor aspects of arms

diagnosis?

A

coeliac disease

283
Q

20yrs

bloody diarrhoea

urgency

tenesmus

abdo pain (left lower quadrant)

diagnosis

A

Ulcerative colitis

284
Q

IBS features

A

IBS considered with features for at least 6 months:

  • abdo pain
  • bloating
  • change in bowel habit

positive diagnosis IBS:

  • abdo pain relieved by defecation
  • associated with altered bowel frequency or form

+ any two of:

  • altered stool passage (straining, urgency, incomplete evacuation)
  • abdo bloating
  • symptoms made worse by eating
  • passage of mucus
285
Q

which liver disease is diabetes associated with

A

non-alcoholic fatty liver disease

286
Q

Ix and Mx for non-alcoholic fatty liver disease

A

Ix:

ELF (enhanced liver fibrosis) blood test to check for advanced fibrosis

Mx:

lifestyle changes - weight loss

287
Q

type 2 diabetes

mild hepatomegaly

drinks one glass of wine per week

slightly raised ALT

liver USS: echogenicity

diagnosis

A

alcoholic fatty liver disease

288
Q

kayser fleischer rings

renal tubular acidosis

liver disease

diagnosis

A

Wilsons disease

copper deopsition

mutation in chromosome 13

kayser fleischer rings

renal tubular acidosis

289
Q

most likely consequence of vitamin B1 deficiency

A

peripheral neuropathy

B1 : thiamine

can be caused by alcohol withdrawal

290
Q

what type of ABG do you get from vomiting

A

metabolic alkalosis

291
Q

patients with which conditions should be screened for coeliac disease

A

autoimmune thyroid disease

type 1 diabetes

screen for coeliac disease

292
Q

complications of coeliac disease

A

small bowel T cell lymphoma

anaemia: iron, folate, vit B12 deficiency

lactose intolerance

293
Q

HBsAg negative, anti-HBs positive, IgG anti-HBc negative

A

previous immunisation

294
Q

watery diarrhoea after pneumonia

new marked neutrophilia

which bacteria

A

clostridium difficile

Features:

diarrhoea

abdominal pain

a raised white blood cell count (WCC) is characteristic

295
Q

mx of Clostridium difficile

A

first line: oral metronidazole 10-14days

if severe or not responding: oral vancomycin

296
Q

risk factor drugs for Clostridium difficile infection

A

clindamycin

PPI

297
Q
A
298
Q

metabolic ketoacidosis with normal or low glucose

A

alcohol

299
Q

ascites: high SAAG gradient (>11)

A

portal HTN

300
Q

haemochromatosis

A

fatigue, erectile dysfunction, arthralgia

bronze skin pigmentation

cardiomyopathy

liver cirrhosis

diabetes mellitus

301
Q

primary biliary cholangitis which antibodies

A

anti-mitochondrial antibodies (AMA) in 98%

302
Q

coeliac disease antibody

A

TTG antibodies (IgA) first choice (anti-tissue transglutaminase antibody)

303
Q

mesenteric ischaemia features

A

central abdo pain

AF other cardiovascular disease

diarrhoea, rectal bleeding

metabolic acidosis (due to dying tissue causing increase in lactic acid)

304
Q

odynophagia + HIV

A

oesophageal candidiasis

305
Q

complications of coeliac disease

A

anaemia: iron, folate, vit B12 deficiency

hyosplenism

osteoporosis, osteomalacia

lactose intolerance

enteropathy-associated T-cell lymphoma of small intestine

subfertility

oesophageal cancer

306
Q

strong FHx of colorectal and endometrial cancer

A

HNPCC (hereditary non-polyposis colorectal carcinoma)

307
Q

symptoms of B1 (thiamine) deficiency

A

Wernicke’s encephalopathy: nystagmus, ophthalmoplegia, ataxia

Korsakoff’s syndrome: amnesia, confabulation

dry beriberi: peripheral neuropathy

wet beriberi: dilated cardiomyopathy

308
Q

middle aged female

fatigue

pruritis

raised IgM

A

primary biliary cirrhosis

309
Q

causes of metabolic alkalosis

A

vomiting/ aspiration

diuretics

hypokalaemia

cushings syndrome

primary hyperaldosteronism

Bartter’s syndrome

310
Q

causes of normal anion gap metabolic acidosis

A

diarrhoea

addisons disease

renal tubular acidosis

311
Q

variceal haemorrhage Mx

A

ABC: resus prior to endoscopy

correct clotting: FFP, vit K

vasoactive agents: terlipressin

prophylactic IV abx in patients with liver cirrhosis

endoscopy - band ligation

Sengstaken-Blakemore tube if uncontrolled haemorrhage

transjugular intrahepatic portosystemic shunt (TIPSS) if above fail

312
Q

prophylaxis of variceal haemorrhage

A

propanolol

variceal band ligation - performed at two-weekly intervals until all varices have gone

PPI prevent ulceration

313
Q
A
314
Q
A
315
Q
A
316
Q
A
317
Q

best investigation to characterise course of anal fistula

A

pelvic MRI

318
Q

gastric tubes aspirate under what pH are safe to use

A

aspirate pH <5.5 = safe to use

over 5.5 = CXR

319
Q

what surgical incision for open cholecystectomy

A

Kocher’s

incision under right subcostal margin

320
Q

surgical incision for appendectomy

A

Lanz

321
Q

surgical incision for c-section

A

pfannenstiel’s

322
Q

surgical abdominal incisions

A
323
Q

what do patients with GORD being considered for fundoplication surgery require

A

oesophageal PH

manometry studies (measures pressure within lower oesophageal sphincter and helps confirm diagnosis of GORD)

324
Q

small bowel bacterial overgrowth syndrome mx

A

rifaximin

325
Q

ix for small bowel bacterial overgrowth syndrome

A

hydrogen breath test

326
Q

risk factors and features of small bowel bacterial overgrowth syndrome

A

risk factors:

  • neonates with congenital gastro abnormalities
  • scleroderma
  • diabetes mellitus

features:

  • chronic diarrhoea
  • bloating, flatulence
  • abdo pain
327
Q

what do you need to monitor in patients with ileostomy

A

monitor fluid balance and stoma output - at risk of volume depletion, electrolyte and metabolic acidosis if the ieostomy ouptut increase of dietary intake is disrupted

328
Q

most common causative agent for ascending cholangitis

A

E.coli

followed by Klebsiella

329
Q

alcoholic ketoacidosis mx

A

IV saline 0.9% + thiamine (B1)

330
Q

raised anion gap metabolic acidosis

raised serum ketones

normal/ low blood glucose

A

alcoholic ketoacidosis

occurs in chronic alcoholics following an episode of reduced intake of food

331
Q

mx for severe flare of UC

A

treated in hopsital with IV corticosteroids

332
Q

mx of anal fissure <6 wks

A

anal fissure = tear

first line: bulk forming laxatives

high-fibre diet

lubricants

topical aneasthetics

analgesia

333
Q

mx of chronic anal fissure (>6 wks)

A

first line = GTN

if not effective after 8 wks then sphincterotomy (surgery) or botulinum toxin

334
Q

surgical mx for achalasia

A

heller cardiomyotomy

other treatments:

  • intra sphincteric injection of botulinum toxin

pneumatic (balloon) dilation

335
Q

test to ensure there are no leaks in colorectal anastomosis

A

gastrografin enema

336
Q

mild to moderate flare of UC extending past the left-sided colon mx

A

rectal + oral mesalazine

337
Q

mx for acute episodes or alcoholic hepatitis

A

glucocorticoids (e.g. prednisolone)

Maddrey’s discriminant function - to determine who benefits from glucocorticoids

calculated using prothrombin time (PT) and bilirubin

338
Q

mx to maintain remission for severe relapse or >=2 exacerbations in past year

A

oral azathioprine or oral mercaptopurine

339
Q

epigastric pain + diarrhoea + gastroduodenal ulcers

A

Zollinger-Ellison syndrome

associated with multiple endocrine neoplasia type 1 (mainly associated with hyperparathyroidism)

340
Q

flushing

diarrhoea

bronchospasm

hypotension

weight loss

A

carcinoid syndrome - mets in liver and release serotonin

341
Q

ix for carcinoid tumours

A

urinary 5-HIAA

342
Q

dysplasia on biopsy in Barrett’s oesophagus

further treatment?

A

requires endoscopic intervention

  • endoscopic mucosal resection
  • radiofrequency ablation
343
Q

mx for Barrets oesophagus

A

high dose proton pump inhibitor

endoscopic surveillance with biopsies:

  • for patients with metaplasia (but not dysplasia) - endoscopy recommended every 3-5 yrs

endoscopic intervention for dysplasia

344
Q

diagnosis?

A

barrets oesophagus

345
Q

which conditions on diagnosis should be screened for coeliac disease

A

type 1 diabetes

autoimmune thyroid disease

346
Q

pancreatic pseudocyst

A

peripancreatic fluid collection

typically occurs >4wks after acute pancreatitis

mildly raised amylase

manage conservatively initially

347
Q

why is epidural analgesia better after abdo surgery

A

faster return of normal bowel function after abdo surgery

348
Q

histology:

villous atrophy, raised intra-epithelial lymphocytes and crypt hyperplasia

A
349
Q

charcot’s triad + hypotension + confusion

A

Reynold’s pentad

350
Q

AST:ALT ratio in alcoholic hepatitis

A

2:1

351
Q

mild - moderate flare of distal UC first line mx

A

topical (rectal) amiosalicylates (mesalazine)

352
Q

primary biliary cholangitis - the M rule

A

the M rule:

  • IgM

anti-Mitochondrial antibodies (AMA), M2 subtype - found in 98%

Middle aged females

features:

  • hx lethargy + pruritis

LFTS: ALP and GGT raised

353
Q

itching in middle aged females

A

primary biliary cholangitis

354
Q

most common extra-colonic malignancy of HNPCC

A

endometrial cancer

355
Q

what other tumour is FAP at risk of

A

duodenal tumour

also Gardner’s syndrome - osteomas of skull, mandible, rentinal pigmentation, thyroid carcinoma, epidermoid cysts

356
Q

triad of:

encephalopathy

jaundice

coagulopathy

A

acute liver failure

jaundice

coagulopathy: raised prothrombin time

encephalopathy

renal failure is commone (hepatorenal syndrome)

357
Q

what type of cancer do you get with Barrets oesophagus

A

adenocarcinoma of the oesophagus

358
Q

mx of hepatorenal syndrome

A

vasopressin (terlipressin)

359
Q

severity index for UC

A

Truelove witts severity index

360
Q

atraumatic bilateral flank bruising

A

grey turners sign

acute pancreatitis

361
Q

mx for primary biliary cholangitis

A

first line: Ursodeoxycholic acid

362
Q

ix for primary sclerosing cholangitis

A

MRCP/ERCP

363
Q

types of oesophageal cancer

A

adenocarcinoma:

  • most common type in US/UK
  • associated with GORD, barrett’s oesophagus
  • smoking, achalasia, obesity
  • lower third of oesophagus near junction

squamous cell cancer

  • more common in developing world
  • upper two-thirds of oesophagus
  • smoking, alcohol, plummer-vinson, achalasia, diets rich in nitrosamines
364
Q

ix and mx of oesophageal cancer

A

ix: upper GI endoscopy
mx: resectable: surgerical resection - Ivor-Lewis oesophagectomy

365
Q

most important viral infection in solif organ transplant recipients

A

cytomegalovirus

mx: ganciclovir

366
Q

scoring system to measure severity of an upper GI bleed

A

Blatchford score

367
Q

ix and mx for wilsons disease

A

ix: serum caeruloplasmin
mx: penicillamine

368
Q

recently treated for pyelonephritis

now loose stools

diagnosis

mx

A

pseudomembranous colitis

from C.diff infection

usually occurs after being treated with abx

mx: oral metronidazole

3rd year medicine (31 decks)

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