Gastroenterology

Question 1

best test for h.pylori

Answer 1

13c urea breath test

• can’t do within 4 weeks of antibacterial or 2 weeks of PPI
• can use for h.p eradication too

Question 2

c.diff mx

Answer 2

1st episode: oral vanc for 10ds, 2nd line: oral fidaxomicin, 3rd: oral vanc +/- IV metro

recurrent episode

• within 12wks of syms resolving: PO fidaxomicin
• after 12wk: PO fid or vanc

life-threatening c.diff: oral vanc and IV metro
- hypotension, partial/complete ileus, toxic megacolon, CT evidence of severe disease

severe: use oral vanc
- high WCC, high Cr, temp, evidence of severe colitis on abdo/radiological

Question 3

SBP

• tx
• most common organism?
• classic paracentesis result
• which prophylacitc abx?

Answer 3

Most common organism on ascitic fluid culture: e.coli
Tx: IV cefotaxime
Paracentesis: neutrophils >250

Prophylactic abx: cipro or norfloxacin

Prophylactic abx if:
	- Had an episode of SBP
	- Fluid protein <15 and 
		○ child-pugh score of 9 or more 
		○ or hepatorenal syndrome 
	- Give until ascites has resolved 

Alcoholic liver disease: poor prognosis

Question 4

variceal haem: acute mx and prophylaxis

Answer 4

Acute treatment

1. ABC: resus ideally before endoscopy
2. Correct clotting w FFP + vit K
3. Terlipressin (constricts splanchnic vessels)
4. Prophylactic IV abx (reduce mortality if cirrhosis) - quinolones
5. THEN: endoscopy – variceal band ligation
6. If uncontrolled haem: sengstaken-blakemore tube
7. If above fail: TIPSS (connects hepatic vein to portal vein. common comp: exacerbation of hepatic encephalopathy)

Prophylaxis:
• Propranolol
Endoscopic variceal band ligation at 2wkly intervals until all varices eradicated – PPI cover for this time to prevent ulceration

Question 5

zollinger ellison

• features
• cause
• dx

Answer 5

• High gastrin levels (from tumour of duod or pancreas)
  
  • Multiple GI ulcers, diarrhoea, malabsorption
  • Dx: fasting gastrin levels
    30% part of MEN 1

Question 6

zollinger ellison

• features
• cause
• dx

Answer 6

• High gastrin levels (from tumour of duod or pancreas)
  
  • Multiple GI ulcers, diarrhoea, malabsorption
  • Dx: fasting gastrin levels
    30% part of MEN 1

Question 7

HCC
- most common cause worldwide? in europe?
- mx?
(- RF)

Answer 7

• Most common cause of HCC in world: chronic hep B
  
  • Most common cause in europe: chronic hep C

Options
- Child-pugh A cirrhosis, no portal HTN, 1 lesion <2cm: surgical resection
- Child-pugh A-B cirrhosis & 2-3 tumours 3cm or less or one 5cm or less & no spread to vasculature or outside liver: liver transplant (bridge to transplant: TACE or RFA)
- Child-pugh A-B cirrhosis, good performance status with evidence of vascular/lymphatic or extrahepatic spread: sorafenib (prolongs survival)
Child-pugh C cirrhosis: supportive tx

Main RF: liver cirrhosis
- Due to hepatitis B & C, alcohol, haemochromatosis and primary biliary cirrhosis.

Other risk factors include:
	· A1ATD
	· hereditary tyrosinosis
	· glycogen storage disease
	· aflatoxin
	· drugs: oral contraceptive pill, anabolic steroids
	· porphyria cutanea tarda
	· male sex
diabetes mellitus, metabolic syndrome

Question 8

most common comp of ercp

Answer 8

pancreatitis

Question 8

most common comp of ercp

Answer 8

pancreatitis

Question 9

h.pylori eradication

Answer 9

PPI + clarithromycin and
- amoxicillin
or metronidazoe

Question 10

associations w h.pylori

Answer 10

• Peptic ulcer disease (95% of duod, 75% of gastric)
  
  • Gastric cancer
  • B cell lymphoma of MALT tissue (if get rid of HP > regression in 80%)
• Atrophic gastritis

Question 11

mallory weiss v boerhaave’s

Answer 11

Mallory-weiss syndrome
Severe vomiting > painful mucodal lacerations at GOJ > haematemesis
- Common in alcoholics

Boerhaave syndrome
Severe vomiting > oeos rupture

Question 12

causes of acute pancreatitis

Answer 12

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

Question 13

carcinoid syndrome

• from what 2 cancers
• 1st feature
• other fts
• Ix (2)
• Mx

Answer 13

Carcinoid syndrome: liver mets (or lung carcinoid)

Features
• flushing (often earliest symptom)
• diarrhoea
• bronchospasm
• hypotension
• right heart valvular stenosis (left heart can be affected in bronchial carcinoid)
• other molecules such as ACTH and GHRH may also be secreted > EG cushings
• pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour

Investigation
• urinary 5-HIAA
• plasma chromogranin A y

Management
• somatostatin analogues e.g. octreotide
• diarrhoea: cyproheptadine may help

DETAILS
Carcinoid syndrome
• usually occurs when mets are in liver + release serotonin into systemic circulation
may also occur with lung carcinoid as mediators are not ‘cleared’ by the liver

Question 14

angiodysplasia is ass w what heart/valve condition

Answer 14

AS