Gastroenterology

Question 1

Why do patients admitted with acute IBD need heparin?

Answer 1

Need prophylactic heparin as they are at high risk of VTE

Question 2

What is main maintenance treatment in UC?

Answer 2

Mesalazine

Question 3

What is maintenance treatment in Crohn’s?

Answer 3

Azathioprine and biologics

Question 4

What are the first choice medications in perianal or fistulating Crohn’s?

Answer 4

Biologics

Question 5

Which medications are generally used in acute IBD?

Answer 5

Steroids: topically, orally or IV

Question 6

What different symptoms may a patient with coeliac disease present with?

Answer 6

None, loose stools, bloating, wind, abdominal cramps, weight loss, dermatitis herpetiformis

Question 7

What are complications associated with coeliac disease?

Answer 7

Increased risk of: small bowel lymphoma, osteoporosis, gluten ataxia and neuropathy

Question 8

What investigations should be done for coeliac disease?

Answer 8

Tissue transglutaminase (tTG) and OGD with duodenal biopsies

Question 9

What can be see on histology with coeliac disease?

Answer 9

Villous atrophy and intra-epithelial lymphocytosis

Question 10

If a young patient has liver disease with a low caeruloplasmin, what is the most likely pathology?

Answer 10

Wilson’s disease- abnormal copper storage

Question 11

What screening do patient’s with cirrhosis have for hepatocellular carcinomas?

Answer 11

Alpha-fetoprotein and USS every 6 months

Question 12

What imaging is best to diagnose cirrhosis?

Answer 12

Fibroscan

Question 13

Through which lines can parenteral nutrition be given?

Answer 13

A dedicated central line

Question 14

Do NG tubes or PEGs eliminate aspiration risk?

Answer 14

No as patients can still aspirate on saliva

Question 15

Which two assessment scores are used for GI bleeding?

Answer 15

ROCKALL score: predicts risk of death and re bleeding of upper GI- done after endoscopy
Glasgow-Blatchford score: predicts need for intervention (inpatient Vs outpatient)

Question 16

How do you initially manage variceal bleeding?

Answer 16

1. Gain IV access, fluid resuscitation is haemodynamically unstable
2. IV Terlipressin
3. Refer to GI team

Question 17

What are the definitive treatment options for variceal bleeding?

Answer 17

Oesophageal banding, Linton/Senstaken tube, TIPSS procedure

Question 18

What is the management of non-variceal upper GI bleeding?

Answer 18

Fluid resus if haemodynamically unstable
Discuss with gastroenterology team
Investigate with endoscopy

Question 19

What nutritional assessment tool can be used to help identify malnutrition of a patient?

Answer 19

MUST

Malnutrition universal screening tool

Question 20

What form of management is indicated for a patient with ongoing acute GI bleeding despite repeated endoscopic therapy?

Answer 20

Emergency surgery or interventional radiology

Question 21

What are some oesophageal causes of haematemesis?

Answer 21

Oesophageal varices, oesophagitis, cancer, Mallory Weiss tear

Question 22

Is sudden weight loss associated with acute exacerbations of NAFLD?

Answer 22

Yes

It triggers importation of toxic lipids to the liver which trigger steatosis, inflammation and hepatocyte cell death

Question 23

What is budd-chiara syndrome?

Answer 23

Hepatic vein thrombosis

Question 24

What classic triad is associated with Budd-Chiara syndrome?

Answer 24

Abdo pain: sudden onset, severe
Ascites
Tender hepatomegaly

Question 25

What is the most sensitive and specific lab finding for diagnosing cirrhosis?

Answer 25

Thrombocytopenia (low platelets)

Question 26

what are some common causes of mouth ulceration?

Answer 26

recurrent apthous ulcers, trauma, nutritional deficiencies (iron, B12, folate), viral/fungal infections, leukoplakia, crohn's

Question 27

what are some early signs of HIV which can be seen in the mouth?

Answer 27

kaposi sarcoma (reddish-blue oral macule) oral hairy leukoplakia (white patches on lateral borders of tongue) secondary to EBV infection

Question 28

intermittent dysphagia of both liquids and solids is likely due to what pathology?

Answer 28

oesophageal spasm

Question 29

progressive dysphagia of liquids to solids is likely due to what pathology?

Answer 29

neurological disorder

Question 30

progressive dysphagia affecting both solids and liquids with regurgitation that often relieves symptoms is likely due to what pathology?

Answer 30

achalasia

Question 31

what is achalasia?

Answer 31

dysmotility where there is inadequate relaxation of the lower oesophageal sphincter and aperistalsis of the oesophagus

Question 32

what is the first line imaging study done for patients with difficulty swallowing both liquids and solids indicating dysmotility?

Answer 32

barium swallow

Question 33

what is seen on barium swallow with achalasia?

Answer 33

bird beak

Question 34

what might be seen on an Xray with achalasia?

Answer 34

widened mediastinum from the dilated oesophagus

Question 35

what is the gold standard investigation for achalasia? what is the diagnostic finding?

Answer 35

manometry high resting pressure of lower oesophageal sphincter is diagnostic

Question 36

how might oesophageal spasm typically present?

Answer 36

transient retrosternal chest pain and intermittent dysphagia (can mimic angina)

Question 37

what is seen on barium swallow with oesophageal spasm?

Answer 37

corkscrew oesophagus

Question 38

why is barium swallow preferred in the investigation of suspected pharyngeal pouch compared to endoscopy?

Answer 38

risk of perforation with endoscopy

Question 39

what is the M rule associated with primary biliary cholangitis?

Answer 39

IgM raised anti-Mitochondrial antibodies Middle aged female

Question 40

What is the typical presentation of GORD?

Answer 40

Intermittent heartburn which gets worse after meals and on lying down, acid brash (metallic taste from acid regurgitation), dysphagia and atypical chest pain

Question 41

How is GORD diagnosed?

Answer 41

Clinically, although if there are ALARM symptoms Ix can be done to rule out serious pathology

Question 42

What are ALARM symptoms associated with dyspepsia that would warrant upper GI endoscopy?

Answer 42

A- anaemia L- loss of weight A- anorexia R- recent onset of progressive symptoms M- malaena/haematemesis S- swelling difficulty

Question 43

What lifestyle advice can be given for GORD?

Answer 43

Smoking cessation, weight loss, less fatty/spicy/acidic foods, raise the head of the bed

Question 44

How do we treat GORD pharmacologically?

Answer 44

PPI therapy for 4-8 weeks, over the counter antacids/alginates (not continuously but for symptomatic relief) If symptoms persist low dose PPI treatment or H2 antagonist can be trialled

Question 45

What is fundoplication?

Answer 45

A surgery considered for GORD involving wrapping the gastric fundus around the oesophagus

Question 46

What are some complications of GORD?

Answer 46

Barretts oesophagus, oesophagitis, oesophageal strictures, oesophageal carcinoma

Question 47

What is a differential for GORD which may be considered in patients with atopic history presenting with dysphagia and vomiting?

Answer 47

Eosinophillic oesphagitis: diagnosed on biopsy and treated with aerosolised glucocorticoids

Question 48

What investigations are done for suspected oesophageal cancer?

Answer 48

Bloods: FBC (GI blood loss), LFTs (liver mets?), U+Es (suitable for contrast CT?) OGD (oesophagogastroduodenoscopy) with biopsy Staging CT

Question 49

What are immediate things to do when a patient has an upper GI bleed from varices?

Answer 49

A-E: oxygen, IV access, Bloods, fluid resuscitation. Assess for signs of shock Blatchford score Terlipressin and prophylactic antibiotics Transfusion of blood products as required

Question 50

How is alcoholic ketoacidosis managed?

Answer 50

Infusion of saline and thiamine

Question 51

How long must a patient be consuming gluten before serology tests are done for coeliac disease?

Answer 51

They must eat gluten for at least 6 weeks before they are tested

Question 52

What dietary change is recommend to patients with ascites?

Answer 52

Low sodium diet

Question 53

Why do patients with coeliac disease get offered the pneumococcal vaccine?

Answer 53

Hyposplenism (splenic reticuloendothelial atrophy)

Question 54

What are common presenting symptoms of alcoholic hepatitis?

Answer 54

RUQ pain, anorexia, weight loss, jaundice, muscle wasting and fever

Question 55

What LFT change is typical of alcoholic hepatitis?

Answer 55

AST/ALT>2 is characteristic of alcoholic hepatitis

Question 56

if a patient tests positive for C diff antigen but not for c diff toxin A/B, are they likely to have an active c diff infection?

Answer 56

no these results suggest colonisation but no active infection

Question 57

in which of the IBDs are pseudopolyps seen on colonoscopy?

Answer 57

ulcerative colitis

Question 58

what are some side effects of mesalazine?

Answer 58

GI upset, agranulocytosis, interstitial nephritis, pancreatitis

Question 59

what are first line investigations for a patient with suspected IBS which are expected to be normal?

Answer 59

FBC, ESR, CRP, coeliac screen

Question 60

what are classic electrolyte disturbances seen with refeeding syndrome?

Answer 60

hypo: -kalaemia -magnesaemia -phophataemia

Question 61

what is the management of baretts oesophagus?

Answer 61

lifestyle advice, high dose PPI therapy and endoscopic surveillance

Question 62

how does pancreatic cancer typically present?

Answer 62

painless jaundice, pale stools, dark urine, cholestatic liver function tests

Question 63

what effect can PPIs have on electrolytes?

Answer 63

hyponatraemia hypomagnesaemia

Question 64

what is budd chiari syndrome?

Answer 64

hepatic vein thrombosis usually on background of hypercoaguable disease/state

Question 65

what is the triad associated with budd chiari syndrome?

Answer 65

sudden onset severe abdo pain ascites tender hepatomegaly

Question 66

what is initial Ix for suspected budd chiari syndrome?

Answer 66

USS abdo with doppler

Question 67

what causes whipples disease?

Answer 67

tropheryma whippelii infection

Question 68

what are common features of whipples disease?

Answer 68

diarrhoea, weight loss, fever, large joint arthralgia, lymphadenopathy

Question 69

what will be seen on jejunal biopsy in whipples disease?

Answer 69

macrophages containing periodic acid schiff (PAS)

Question 70

what gene mutations are associated with HNPCC?

Answer 70

MSH2/MLH1

Question 71

what gene mutations are associated with FAP?

Answer 71

APC gene mutations

Question 72

what is investigation of choice when investigating primary sclerosing cholangitis?

Answer 72

ERCP or MRCP

Question 73

what is surgical management of achalasia?

Answer 73

pneumatic dilatation or heller cardiomyotomy

Question 74

how is c.dif diagnosed?

Answer 74

stool culture looking at c dif toxin

Question 75

what does c.diff antigen positivity show us?

Answer 75

shows exposure to the bacteria rather than current infection

Question 76

what antibiotics are most associated with c.dif?

Answer 76

clindamycin and cephalosporins (start with cef)

Question 77

should PPIs be given before endoscopy in suspected upper GI bleed?

Answer 77

no evidence this improves clinical outcomes and may obscure endoscopic findings

Question 78

what is first line management of primary biliary cholangitis?

Answer 78

ursodeoxycholic acid