Gastroenterology

Question 1

What is the best initial test for coeliac disease and why?

Answer 1

Tissue transglutaminase IgA antibodies
Total IgA antibodies

IgA deficiency is seen in about 2-3% of coeliac patients (hence need to rule out otherwise low tTG might be false negative)

tTG is the enzyme that deaminates gliadin. Antibodies get produced against both these components of the reaction.

If tTG negative can test anti deaminated gliadin peptide

Gene testing for HLA-DQ2/HLA-DQ8 is a good negative predictive test or negative, non specific if positive.

Question 2

What is the malignancy risk associated with coeliac disease?

Answer 2

Risk of transformation of intraepithelial lymphocytes (IELs) to a monoclonal IEL population (enteropathy associated T cell lymphoma). Bad 5 year survival of <44%

Question 3

Treatment of coeliac disease?

Answer 3

1. Gluten free diet with dietician input
2. If refractory - make sure actually gluten free and diagnosis is correct (test antibodies)
3. Trial immunosuppression with biologics

Question 4

What are four risk factors for colectomy at UC diagnosis?

Answer 4

Extensive colitis (proximal to splenic flexure)
Age <40
Systemic corticosteroids
Elevated inflammatory markers

Question 5

How would you treat local HCC without portal hypertension?

Answer 5

Resection

Question 6

How would you treat local HCC with portal hypertension?

Answer 6

Transplant if candidate
TACE if not

Question 7

How would you treat advanced or metastatic HCC, Childs Pugh A?

Answer 7

Atezolizumab (PDL1)
Bevaziumab (VEGF)

Question 8

How would you treat advanced or metastatic HCC, Childs Pugh B or C?

Answer 8

Palliate

Question 9

Describe the symptoms associated with hepatopulmonry syndrome

Answer 9

Platypnoea - breathless when sitting up
Orthodeoxia - hypoxia when sitting up

Due to preferential blood supply to lung bases - where there is dilation of pulmonary capillaries and AV malformations/shunts in hepatopulmonary syndrome