Gastro

Question 1

The ‘double duct’ sign may be seen in –

Answer 1

The ‘double duct’ sign may be seen in pancreatic cancer

Question 2

Avoid – in bowel obstruction

Answer 2

Avoid metoclopramide in bowel obstruction

Question 3

A combination of liver and neurological disease points towards –

Answer 3

A combination of liver and neurological disease points towards Wilson’s disease

Question 4

Proton pump inhibitors should be stopped – before an upper GI endoscopy

Answer 4

Proton pump inhibitors should be stopped 2 weeks before an upper GI endoscopy

Question 5

In an acute upper GI bleed, the — score can identify low risk patients who may be discharged

Answer 5

In an acute upper GI bleed, the Blatchford score can identify low risk patients who may be discharged

Question 6

Management of non-variceal bleeding

NICE do not recommend the use of — before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding although – should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy
if further bleeding then options include repeat endoscopy, interventional radiology and surgery

Management of variceal bleeding

• – and prophylactic — should be given to patients at presentation (i.e. before endoscopy)
• – should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices
• – shunts should be offered if bleeding from varices is not controlled with the above measures

Answer 6

Management of non-variceal bleeding
NICE do not recommend the use of proton pump inhibitors (PPIs) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding although PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy
if further bleeding then options include repeat endoscopy, interventional radiology and surgery

Management of variceal bleeding
terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices
transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures

Question 7

A transjugular intrahepatic portosystemic shunt (TIPS) procedure connects the – vein to the – vein

Answer 7

A transjugular intrahepatic portosystemic shunt (TIPS) procedure connects the hepatic vein to the portal vein

Question 8

Intestinal angina (or chronic mesenteric ischaemia) is classically characterised by a triad of –+–+– abdominal pain, —, and an – bruit - by far the most common cause is atherosclerotic disease in arteries supplying the GI tract

Answer 8

Intestinal angina (or chronic mesenteric ischaemia) is classically characterised by a triad of severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit - by far the most common cause is atherosclerotic disease in arteries supplying the GI tract

Question 9

Common features in bowel ischaemia

Common predisposing factors
increasing –
— particularly for mesenteric ischaemia
other causes of emboli: endocarditis, malignancy
cardiovascular disease risk factors: smoking, hypertension, diabetes
–: ischaemic colitis is sometimes seen in young patients following — use

Common features
abdominal pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings
rectal bleeding
diarrhoea
fever
bloods typically show an elevated white blood cell count associated with a lactic acidosis

Diagnosis
—is the investigation of choice

Answer 9

Common features in bowel ischaemia

Common predisposing factors
increasing age
atrial fibrillation - particularly for mesenteric ischaemia
other causes of emboli: endocarditis, malignancy
cardiovascular disease risk factors: smoking, hypertension, diabetes
cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use

Common features
abdominal pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings
rectal bleeding
diarrhoea
fever
bloods typically show an elevated white blood cell count associated with a lactic acidosis

Diagnosis
CT is the investigation of choice

Question 10

Large-volume paracentesis for the treatment of ascites requires — ‘cover’. Evidence suggests this reduces paracentesis-induced — and mortality

Answer 10

Large-volume paracentesis for the treatment of ascites requires albumin ‘cover’. Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality

Question 11

– is a key step in the initial management of dyspepsia

Medications that can cause dyspepsia include x3

Answer 11

Reviewing medications is a key step in the initial management of dyspepsia

Medications that can cause dyspepsia include beta-blockers, calcium channel blockers and NSAIDs, for example.

Question 12

Dyspepsia

The 2015 NICE guidelines ‘Suspected cancer: recognition and referral’ further updated the advice on who needs urgent referral for an endoscopy (i.e. within 2 weeks).

Urgent

All patients who’ve got —

All patients who’ve got an —consistent with stomach cancer

Patients aged >= – years who’ve got weight loss, AND any of the following:
upper abdominal –
–
—

Non-urgent

Patients with –

Patients aged >= – years who’ve got:
treatment-resistant – or
upper abdominal pain with low — levels or
raised – count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain

Answer 12

Dyspepsia

The 2015 NICE guidelines ‘Suspected cancer: recognition and referral’ further updated the advice on who needs urgent referral for an endoscopy (i.e. within 2 weeks). The list below combines the advice for oesophageal and stomach cancer, with the bold added by the author, not NICE.

Urgent

All patients who’ve got dysphagia

All patients who’ve got an upper abdominal mass consistent with stomach cancer

Patients aged >= 55 years who’ve got weight loss, AND any of the following:
upper abdominal pain
reflux
dyspepsia

Non-urgent

Patients with haematemesis

Patients aged >= 55 years who’ve got:
treatment-resistant dyspepsia or
upper abdominal pain with low haemoglobin levels or
raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain

Question 13

— should be stopped in Clostridium difficile infections

Answer 13

Opioids should be stopped in Clostridium difficile infections

Question 14

Ulcerative colitis: flares

MILD:
Fewer than — stools daily, with or without blood
No systemic disturbance
Normal— and – values

MODERATE
–stools a day, with minimal systemic disturbance

The Truelove and Witts’ severity index is recommended by NICE when assessing the severity of ulcerative colitis in adults.
Ulcerative colitis is classified as ‘severe’ when the patient has blood in their stool, or is passing more than – stools per day plus at least one of the following features:
THEA
Temperature greater than –°C
Heart rate greater than – beats per minute
Anaemia (Hb less than –g/ L)
Erythrocyte sedimentation rate greater than – mm/hour

Any patient with features of severe ulcerative colitis should be admitted to hospital as an emergency.
They should be treated with intravenous —to induce remission.

Answer 14

Mild:
Fewer than four stools daily, with or without blood
No systemic disturbance
Normal erythrocyte sedimentation rate and C-reactive protein values

MODERATE
Four to six stools a day, with minimal systemic disturbance

The Truelove and Witts’ severity index is recommended by NICE when assessing the severity of ulcerative colitis in adults. Ulcerative colitis is classified as ‘severe’ when the patient has blood in their stool, or is passing more than 6 stools per day plus at least one of the following features:
Temperature greater than 37.8°C
Heart rate greater than 90 beats per minute
Anaemia (Hb less than 105g/ L)
Erythrocyte sedimentation rate greater than 30 mm/hour

Any patient with features of severe ulcerative colitis should be admitted to hospital as an emergency. They should be treated with intravenous corticosteroids to induce remission.

Question 15

The A–/A– ratio in alcoholic hepatitis is 2:1

Answer 15

The AST/ALT ratio in alcoholic hepatitis is 2:1

Question 16

Spontaneous bacterial peritonitis: most common organism found on ascitic fluid culture is –

Answer 16

Spontaneous bacterial peritonitis: most common organism found on ascitic fluid culture is E. coli

Question 17

– are the investigations of choice in primary sclerosing cholangitis

Answer 17

ERCP/MRCP are the investigations of choice in primary sclerosing cholangitis

Question 18

– is a benign condition causing a mild rise in bilirubin - no treatment needed

Answer 18

Gilbert’s syndrome is a benign condition causing a mild rise in bilirubin - no treatment needed

Question 19

– (e.g. low BP secondary to blood loss) may result in ischaemic hepatitis

Answer 19

Acute hypoperfusion (e.g. low BP secondary to blood loss) may result in ischaemic hepatitis

Question 20

In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is –

Severe colitis
should be treated in hospital
intravenous – are usually given first-line
intravenous — may be used if— are contraindicated
if after 72 hours there has been no improvement, consider adding intravenous – to intravenous —or consider surgery

– is not recommended for the management of UC (in contrast to Crohn’s disease)

Answer 20

In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is topical (rectal) aminosalicylates

Severe colitis
should be treated in hospital
intravenous steroids are usually given first-line
intravenous ciclosporin may be used if steroid are contraindicated
if after 72 hours there has been no improvement, consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery

Question 21

– can be used to monitor hepatocellular carcinoma recurrence

Answer 21

AFP can be used to monitor hepatocellular carcinoma recurrence

Question 22

Budd-Chiari syndrome presents with the triad of sudden onset –+, +–

Answer 22

Budd-Chiari syndrome presents with the triad of sudden onset abdominal pain, ascites, and tender hepatomegaly

Question 23

Metronidazole is the first line antibiotic for use in patients with – infection

Answer 23

Clostridium difficile

Question 24

Carcinoid tumours can also secrete pituitary hormones, such as –

Answer 24

Carcinoid tumours can also secrete pituitary hormones, such as ACTH

Question 25

During –, ferritin is an unreliable indicator of iron stored in the body as it is an acute phase protein.
– saturation should be used instead

Answer 25

During infection, ferritin is an unreliable indicator of iron stored in the body as it is an acute phase protein. Transferrin saturation should be used instead