Gastro and HPB

Question 1

Crohn’s Disease

Transmural inflammation; skip lesions; end to end.
Goblet cell hyperplasia and granulomas

Peak incidence

Answer 1

Diarrhoea tends to be non bloody.
Weight loss more prominent than UC.
Mouth ulcers, perianal disease

Abdo mass in RIF

Impaired bile acid absorption causes oxalate gallstones

Question 2

Ulcerative Colitis

Continuous disease proximal from the anus; confined to the submucosa.
Neutrophils cause crypt abscesses

Answer 2

Diarrhoea tends to be bloody and mucoid
Uveitis
High risk of colon cancer and primary sclerosing cholangitis

Abdo pain in LIF + tenesmus

Question 3

Common features of IBD

Answer 3

Diarrhoea
Arthritis
Pyoderma gangrenosum
Erythema nodosum

Question 4

The severity of UC

Mild: 6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

Answer 4

Management of UC

Inducing Remission:
Rectal ASA e.g. mesalazine/steroids for distal colitis
Oral ASA, then oral prednisolone if unresponsive.
Severe UC needs admission for IV steroids

Maintenance:
Oral ASA
Azathioprine or mercaptopurine

NOT METHOTREXATE

Question 5

Viral Hepatitis

?foreign travel
?IVDU
?tattoos

Answer 5

SX:
N+V, anorexia
myalgia and lethargy
RUQ pain

Question 6

Intermittent RUQ pain, usually after meals

Abrupt onset and gradual decline

Answer 6

Biliary Colic

5 Fs.

Question 7

Bile duct infection secondary to gallstones

RUQ pain, jaundice and fever/rigors

Answer 7

Ascending Cholangitis

Question 8

Severe and persistent biliary colic
May radiate to back/shoulder tip

Murphy’s sign: arrest of inspiration with hand in RUQ

Answer 8

Acute Cholecystitis

Question 9

Abdo pain, distension and vomiting with history of gallstones

Answer 9

Gallstone ileus

Question 10

Persistent biliary colic with N+V, anorexia and weight loss

Courvoisier sign: painless, palpable gallbladder with jaundice.
Sister Mary Joseph Nodule - periumbilical lymph node.
BAD BAD BAD

Answer 10

Cholangiocarcinoma

Question 11

Acute pancreatitis

Answer 11

GETSMASHED.

Severe epigastric pain with vomiting

Question 12

Wilson’s Disease
AR copper storage disease
Onset usually 10-25 years.

Dx: decreased serum caeruloplasmin; increased 24hr urinary Cu excretion

Mx; penicillamine (Cu chelator)

Answer 12

Excessive copper deposition in tissues

Liver: hepatitis, cirrhosis
Neurological: basal ganglia degeneration, speech and behaviour
Also: asterixis, chorea, dementia
Eyes: Kayser-Fleischer rings
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails

Question 13

Dyspepsia and 2WW

Answer 13

Refer if:
dysphagia
upper abdo mass consistent with stomach cancer
>55 and weight loss

Question 14

AR inheritence
HFE gene mutations on chromosome 6
Iron accumulation leads to DM, cirrhosis, hypogonadotrophic hypogonadism and skin pigmentation

Answer 14

Haemochromatosis:

1/200 in Europe
Early Sx include fatigue, erectile dysfunction and arthralgia

Question 15

H.pylori infection
Gram negative bacilli

Mx:
PPI + amoxicillin/metronidazole + clarithromycin

Answer 15

Associations
Peptic ulcer disease (95% of duodenal ulcers, 75% of gastric ulcers)
Gastric cancer
B cell lymphoma of MALT 
Atrophic gastritis

Question 16

UGI Bleed

Blatchford Score

Answer 16

Urea (raised)
Hb (lowered)
SBP (lowered)
Others: pulse >100, melaena, syncope, heart.liver disease.

Question 17

Hepatitis B Serology

HBsAg is used in vaccines, but normally implies acute disease if found on blood results.

Answer 17

Anti-HBs (>100) implies immunity (exposure or immunisation)

Anti-HBc implies previous (or current) infection.
IgM anti-HBc appears during acute or recent hepatitis B
IgG anti-HBc persists
HbeAg is a marker of infectivity

Question 18

C.difficile - gram positive
Dx: CD toxin in stool
Causes pseudomembranous colitis

Answer 18

Diarrhoea, abdo pain, raised WCC
May develop toxic megacolon.

Clindamycin and cephalosporins are the culprits.

10-14 days of Metronidazole