Gastroenterology Flashcards
Which of the following is first line treatment for Hepatitis C in Australia?
A. Sofosbuvir + velpatasvir + voxilaprevir
B. Grazoprevir + elbasvir
C. Glecapravir + pibrentasvir
D. Ledipasvir + sofsbuvir
C. Glecapravir + pibrentasvir for 8-12 weeks (Maviret)
Which class of HCV drug is glecaprevir?
NS3/4A protease inhibitor
What class of drug is sofosbuvir?
Nucleoside (NS5B) polymerase inhibitor (in Epclusa - better in Adv Liver Disease - rather then Maviret)
What class of drug is voxilaprevir? When is it indicated?
NS3/4A protease inhibitor
Add to velpatasvir (NS5a inhbitor) + sofosbuvir (Nucleoside NS5B polymerase inhbitor) Epclusa* for refractory HCV - VOSEVR
What class of drug is Velpatasvir?
NS5a inhibitor
What class of drug is dasabuvir?
Non-nucleoside NS5B polymerase inhibitor
Lanafibranor may be useful in which condition?
peroxisome proliferator–activated receptor agonist that reduces ballooning and lobular inflammation in NASH
Which of the following biologics is not helpful in UC?
A. Vedolizumab
B. Tofacitnib
C. Secukinumab
D. Ozanimod
C. Secukinumab - anti IL-17a, used in ank spond and psoriatic arthritis
Vedolizumab = anti-integrin a4B7, Tofacitnib =JAK inhibitor, Ozanimod = S1P receptor modulator
Where is iron absorbed?
Duodenum
Where is calcium absorbed?
Duodenum
Where is B12 absorbed?
Terminal ileum
Where are bile salts absorbed?
Terminal ileum
Where is folate absorbed?
Duodenum
Which class of HCV drugs should not be used in decompensated liver disease?
NS3/4a protease inhibitors, due to raised drug levels in setting of hepatic failure
Drug classes ending with -evir (i.e. glecaprevir, voxilaprevir, grasoprevir)
Which coagulation factors are not made in the liver?
FVIII (endothelial cell production), FXIIIa (megakaryocytes)
Biopsy findings of primary sclerosing cholangitis
Associated lab and disorder?
Degeneration of small bile ducts with periductal Sclerosis/fibrosis
Onion skin pattern
p-ANCA, IBD (UC++)
Biopsy findings of primary biliary cholangitis (same as primary biliary cirrhosis)
Antibody?
Bile duct degeneration with periductular GRANULOMATOUS inflammation
“Florid” bile duct lesions
Anti-Mitochondrial antibody (sMall bile ducts)
Inhibitors of gastrin release
• Gastric pH <2
• Somatostatin
• Calcitonin
• Gastric inhibitory polypeptide (GIP)
• Glucagon
• Vasoactive inhibitory peptide (VIP).
Stimulators of gastrin release
L-Amino acids (i.e. phenylalanine, tryptophan, cysteine, tyrosine)
• Vagal stimulation
• Gastric distension
• Epinephrine (adrenaline)
• Calcium
• Acetylcholine
Biopsy findings of autoimmune hepatitis and assoicated antibodies?
lymphocytic piecemeal necrosis
ANA - antinuclear antibody
SMA - anti-smooth muscle
Anti- LKM
AMA - anti-mitochrondrial Ab
Anti-integrins with a role in IBD
Vedolizumab (a4B7)
Abrilumab (a4B7)
Etrolizumab (anti-B7)
Ontamalimab (MADCAM)
Jak inhibitors with a role in IBD
Filgotinib (JAK1)
Tofacitinib (in UC)
Upadacitnib
Treatment of primary biliary cholangitis
Ursodeoxycholic acid).
What is Gilbert Syndrome
Treatment?
Autosomal recessive disorder of unconjugated hyperbilirubinemia due to mutation in UGT1A1
Causes episodes of jaundice
Generally no treatment needed - avoid irinotecan
Disorders associated with PBC
Sjogrens (most common)
Autoimmune thyroiditis
CREST
RA
Treatment of eosinophilic colitis
Dietary modification (elimination)
Steroids
Main antibodies associated with T2 AIH
Anti-liver/kidney microsomal-1 (anti-LKM-1) antibodies
Anti-liver cytosol-1 (anti-LC1) antibodies
Main antibodies associated with T1 AIH
Anti-smooth muscle antibody (ASMA)
ANA
Micronutrient deficiency causing high output cardiac failure
B1 - “wet beri beri”
Dry beri beri = neurologic complications (i.e. convulsions, weakness, numbness, hyperreflexia)
PAS-positive macrophages on small bowel biopsy is representative of what?
Whipple’s disease (Tropheryma whipplei)
Main deficiencies in SIBO
A, B12 (cobalamin consumption), K
Folate is elevated due to increased bacterial production
What does a raised HPVG represent?
Raised HVPG (>5mmhg) = hepatic cause of portal HTN
>10 = varices, >12 = variceal bleeding
Which hepatitis c genotype is elbasvir plus grazoprevir recommended for?
G1 and 4
Which hepatitis c genotype is sofusbavir plus ledapasvir recommended fro?
G1
Most specific antibody for AIH
Anti-SLA/LP
First line therapy for unresectable stage C HCC
Atezolizumab (anti-PL1) + bevacizumab
Transplant criteria in HCC
2-3 nodules all <3cm OR single lesion <5cm
ECOG 0
No macrovascular invasion, regional nodal spread or distal mets
S/E of JAK inhibitors
VTE and herpes zoster - increased compareed with other biologics
Best described for tofacitinib
Bareets esophagus - Intestinal metaplasia distal oesphage when to scope?
No dysplasia:” 3-5 years
Low grade dysplasia 6-12 months
High-grade dysplasia in the absence eradication therapy 3 months
Most Common long term complication liver transplantation?
Metabolic syndrome, 50% will develop.
Components of Child-Pugh
A albumin
B bilirubin
C coag
D drain the asciites
E encephalopathy
IBD extra intestinal dependant on disease?
oral ulcer
erythema nodosum
large join arthritis
episcleritis
IBS extra intestinal independaent of GI disease
Primary sclerosing cholangitis
Ank Spon
Uveitis
PYoderma gangrenosum
Kidney stones
gall stones
Ustekinumab target and disease?
IL-12 and IL-23 p40 subunit - Crohn’s disease
Hormones that stimulate appetite
Ghrelin, AgRP, NPY
Most nutrients take place in jejunum where are these exceptions instead absorbed?
Iron
VIt B12 and bile salts
Water/lipids
Na
Ca
Frucotse
Iron - Duodenum
Vit B12/Bile sats = terminal ileum
Water/lipids passive diffusion all SI
Na - active transport
Ca - duodenum and upper small intestine.
Frutose - faciliated diffusion
Common cause responsible to GERD?
Transient relaxations fo lower oesphageal sphincter
GERD: p.w heartburn, endoscopy, Ambulatory pH monitoring. 4-8 weeks PPI at start.
Drugs cuasing hepatocellular picture:
paracetamol, ioniaside, valproate, phenytoin, statins, ETOH, amiodarone, methyldopa
Drugs causing cholestatic picture
Abx: Aug DF, erythromycin, flucloxacillin, methotrexate, amiodarone, sulphonyllureas, fibrates, chlorpromazine
What is SA-AG cut off and what are common causes < then vs > then?
> 11 - cirrhosis cardiac failure, nephrotic syndrome
<11 malignancy pancreatitis and tuberculosis
Causes of hypergastrinameia?
Gastrin, released from G cells in Antrum
1. prolonged PPI (most common)
2. Atrophic gastritis - pernicious anemia, H pylori
3. Vagotomy or small bowel resection
4. Gastrin secreting tumor (ZES) - Gastrinoma >1000
5. Renal Failure
6. HyperCa
7. Hyperlipidemia
HLA assoicated with Coeliac Disease
DQ2 and DQ8, strong negative predictive value. Useful to rule out
Which Liver Disease HCC Rare?
AIH (autoimmune hepatitis) primary billary cirrhosis (PBC) and Wilsons Disease
Wilsons Disease
inheritance?
enzyme defect?
classic presentation?
serum copper and ceruloplasmin?
Treatment:
AUtosomal recessive disase
enxyme ATP7B
hepaitis, cirrhosisi and pyshciatric disorders
high 24hr urine copper excretion
low serum copper and low ceruloplasmin
Tx: liver trientine and zine, just neuro zinc.
Enzyme target for AIH type II and antibody that predicts worse outcome?
Cyp450 2D6, Anti - LMK enzyme.
