Gastroenterology Flashcards
1
Q
Metaplasia vs dysplasia
A
Metaplasia = abnormal change of one cell type to another
Dysplasia = the presence of abnormal cells
2
Q
What would warrant an urgent 2-week referral in patient with suspected oesophageal cancer?
A
Dysphagia at any age, OR
Aged > 55 with weight loss AND any of the following:
- upper abdominal pain
- reflux
- dyspepsia
3
Q
What is a hiatus hernia?
A
= where the stomach herniates up through the diaphragm
4
Q
What is a type 1 hiatus hernia?
A
Type 1: sliding – stomach slides up through diaphragm, gastro-oesophageal junction passing up into thorax
5
Q
What is a type 2 hiatus hernia?
A
Type 2: rolling – separate portion of stomach (i.e., fundus) folds around + enters diaphragm opening alongside oesophagus
6
Q
What is a type 3 hiatus hernia?
A
Type 3: combination of sliding + rolling
7
Q
What is a type 4 hiatus hernia?
A
Type 4: large opening with additional abdominal organs entering the thorax
8
Q
Management for GORD
A
- full-dose PPI for 4 to 8 weeks
- Offe
9
Q
Main pharmacological treatment for GORD
A
= proton-pump inhibitors, PPIs (e.g., Omeprazole + Lansoprazole)
10
Q
GORD: What can be given if patient is having an inadequate response to PPIs?
A
= Histamine H2-receptor antagonists (e.g., Famotidine)
11
Q
How long should patient be on full-dose PPIs in initial treatment stage of GORD?
A
= 4 to 8 weeks
12
Q
What is laparoscopic fundoplication, and what is it used for?
A
= procedure which involves tying the fundus of stomach around the lower oesophagus to narrow the lower oesophageal sphincter
Used to help treat chronic GORD
13
Q
What is Barrett’s Oesophagus?
A
= (pre-malignant) condition in which lower oesophageal epithelium changes squamous > columnar epithelium due to chronic acid reflux
14
Q
What is Zollinger-Ellison syndrome?
A
= rare condition, in which duodenal or pancreatic tumours secrete excess gastrin (= a hormone that stimulates acid secretion in stomach)
Can result in severe dyspepsia, diarrhoea + peptic ulcers
Typically non-cancerous tumours
15
Q
Is Helicobacter pylori gram-positive or gram-negative?
A
= gram-negative
16
Q
What does H. pylori produce to help neutralise acid around itself?
A
= ammonium hydroxide
17
Q
How long does a patient need to be off PPIs for an accurate H. pylori test?
A
= need to be 2 weeks without using a PPI
18
Q
Which 2 methods are for initial detection of H. pylori?
A
- carbon 13 urea breath test
- stool antigen test
19
Q
How is H. pylori eradicated?
A
Triple therapy:
- PPI (e.g., Omeprazole), AND
- 2 antibiotics (e.g., Amoxicillin + Clarithromycin)
20
Q
How long is a patient required to be on a triple therapy regime for eradication of H. pylori?
A
= 7 days
21
Q
What is achalasia?
A
= motility disorder of the oesophagus, in which lower oesophageal sphincter fails to relax
22
Q
What is pseudoachalasia?
A
= an achalasia-pattern dilatation of the oesophagus from causes other than primary denervation
23
Q
Typically in motility disorders, such as achalasia, do patients experience dysphagia with solids, liquids or both?
A
= solids + liquids
24
Q
If there is a physical obstruction, are patients more likely to experience dysphagia with solids, liquids or both?
A
= solids (which can then progress to liquids as the narrowing becomes tighter)
25
Gold-standard method of diagnosing achalasia
= high-resolution manometry
26
A 'bird-beak' appearance on barium swallow is suggestive of...
= achalasia
27
Achalasia Treatment: What is pneumatic dilation?
= involves insertion of balloon down an endoscope, which is then blow up within the lower oesophageal sphincter. Leads to tearing of the muscle fibres
28
Achalasia Treatment: What is peroral endoscopic myotome (POEM)?
= endoscope inserted through mouth to cut muscles in the oesophagus. Cutting the muscles loosens them + prevents them from tightening and interfering with swallowing
29
Achalasia Treatment: What is surgical myotomy?
= surgically cutting muscle fibres of the lower oesophageal sphincter
30
Common complications of achalasia? (2)
- aspiration pneumonia
- risk of squamous cell carcinoma
31
What is the process by which squamous epithelium in oesophagus is turned into > columnar epithelium?
(as seen in Barrett's Oesophagus)
= metaplasia
32
How is Barrett's oesophagus diagnosed?
= histological testing of biopsy
33
Major danger in Barrett's oesophagus?
= progression to adenocarcinoma
34
Frequency of endoscopic surveillance in Barrett's oesophagus depends on what?
= degree of dysplasia
35
Barrett's Oesophagus: In those with no dysplasia, how often do they require an endoscopy for surveillance?
= every 2 to 5 years
36
Barrett's Oesophagus: In those with low-grade dysplasia, how often do they require an endoscopy for surveillance?
= every 6 months
37
Barrett's Oesophagus: In those with high-grade dysplasia, how often do they require an endoscopy for surveillance?
= every 3 months
38
Pharmacological management for Barrett's oesophagus?
= proton pump inhibitor (PPI)
39
Drugs: -prazole
= proton pump inhibitor
40
Drugs: -tidine
= H2-receptor Antagonists
41
What do H2-receptor Antagonists do?
= block the action of histamine in the stomach, decreasing the production of stomach acid
42
What is Boerhaave Syndrome?
= involves tearing of the oesophagus (full thickness/ transmural), usually consequence of vigorous vomiting (high intraoesophageal pressure)
43
Boerhaave syndrome vs Mallory-Weiss tear
Boerhaave syndrome involves rupture of the full thickness of the oesophagus wall (transmural)
Whereas, Mallory-Weiss tear causes you to vomit blood however, doesn't tear all the way through the oesophagus
44
Mackler's triad: chest pain, vomiting, subcutaneous emphysema, is a sign of?
= Boerhaave syndrome (transmural oesophageal rupture)
45
What is fluoroscopy?
= type of medical imaging that shows a continuous x-ray image on a monitor, like an x-ray movie
46
Why is endoscopy avoiding in patients with suspected boerhaave syndrome?
= may extend tear, or introduce air into the mediastinum
47
Pharmacological management of Boerhaave Syndrome (2)
- IV PPI (to reduce acidity + irritation)
- prophylactic antibiotic therapy
48
Barium swallow x-ray: corkscrew appearance is suggestive of what condition?
= diffuse oesophageal spasm (DES)
49
What is Mallory-Weiss Syndrome?
= tear of the tissue in lower oesophagus, often caused by violent coughing or vomiting
50
How is Mallory-Weiss Syndrome diagnosed?
= endoscopy (tears appear as red longitudinal breaks in mucosa)
51
Pharmacological supportive treatment for Mallory-Weiss tear (2)
- IV PPIs (acid suppression)
- antiemetics (if nauseous + vomiting)
52
What is Plummer-Vinson Syndrome?
= premalignant disorder characterised by triad of iron deficiency anaemia, dysphagia and cervical oesophageal webs
53
Key imaging technique in diagnosis of Zenker's Diverticulum (pharyngeal pouch)?
= barium swallow
54
What is Zenker's Diverticulum?
AKA as pharyngeal pouch
= herniation of the posterior pharyngeal wall though it's muscular wall
55
Is a small or large bowel perforation more common?
= small bowel obstruction
56
What is 'third-spacing'?
= in a bowel obstruction, fluid cannot reach the colon, and cannot be reabsorbed. As a result, there is fluid loss from intravascular space into GI tract, this leads to hypovolaemia + shock. This abnormal loss of fluid is referred to as 'third-spacing'
57
3 main causes of a bowel obstruction
(account for 90% of cases)
- adhesions (small bowel)
- hernias (small bowel)
- malignancy (large bowel)
58
Coffee bean sign seen on x-ray is indicative of?
= sigmoid volvulus
59
What is a closed-loop obstruction?
= this is when there are 2 points of obstruction along the bowel; meaning that there is a middle section sandwiched between 2 points of obstruction
60
'Tinkling' bowel sounds are suggestive of?
= bowel obstruction
61
What is volvulus of bowel?
= occurs when a loop of intestine twists around itself and the mesentery that supports it, causing bowel obstruction
62
On x-ray, what are distended loops of bowel suggestive of?
= bowel obstruction
63
Gold-standard imaging for bowel obstruction
= CT scan
64
Technique used for initial treatment of bowel obstruction?
= drip + suck
65
What might you see on an erect x-ray if there is an intra-abdominal perforation?
= air under the diaphragm
66
Which type of IBD is more likely to present with bleeding + mucous in stool?
= UC
67
In which type of IBD is the entire GI tract affected?
= Crohn's
68
Which type of IBD is associated with 'skip lesions' on endoscopy?
= Crohn's
69
In which type of IBD is only the superficial mucosa affected?
= UC
70
In which type of IBD is smoking a protective factor?
= UC
71
What region does Crohn's disease typically affect most?
= terminal ileum
72
In which type of IBD do you typically use amino salicylates (e.g., Mesalazine)?
= UC
73
Which type of IBD is associated with primary sclerosis cholangitis?
= UC
74
Anti-tissue transglutaminase antibody (anti-TTG) is positive in which condition?
= coeliac disease
75
What stool sample test is useful in diagnosis of IBD?
= Faecal calprotectin
76
Investigation of choice for establishing IBD diagnosis
= colonoscopy (with multiple intestinal biopsies)
77
First and second-line treatment for mild to moderate ulcerative colitis
First-line: aminosalicylate (e.g., oral or rectal Mesalazine)
Second-line: corticosteroids (e.g., oral or rectal Prednisolone)
78
Treatment for severe acute UC flare-up
= IV steroids (e.g., IV hydrocortisone)
79
What is used first-line to maintain remission in UC?
= Aminosalicylate (e.g., oral or rectal Mesalazine)
80
What is used to induce remission in Crohn's disease? (pharmacological)
= steroids (e.g., oral Prednisolone or IV hydrocortisone)
81
What is used to maintain remission in Crohn's disease?
= either Azathioprine or Mercaptopurine
82
Most common causes of acute pancreatitis in UK?
= gallstones + alcohol
83
Causes of acute pancreatitis?
GET SMASHED
G – gallstones
E – ethanol (alcohol)
T – trauma
S – steroids
M – mumps (other viruses, Coxsackie B)
A - autoimmune disease (SLE) or Sjogren’s syndrome
S - scorpion venom (rare)
H – hypertriglyceridemia, hyperchylomicronaemia, hypercalcaemia, hypothermia
E – endoscopic retrograde cholangiopancreatography (ERCP)
D – drugs (e.g., Azathioprine, Mesalazine, Didanosine, Bendroflumethiazide, Furosemide, Pentamidine, Steroids, Sodium Valproate)
84
What electrolyte imbalance can be seen in patients with acute pancreatitis?
= hypocalcaemia
85
Cullen's + Grey Turner's sign are suggestive of...
= haemorrhagic pancreatitis
(retroperitoneal haemorrhage)
86
What is Cullen's sign?
= bruising around umbilicus
87
What is Grey Turner's sign?
= bruising on flanks
88
Diagnostic test for acute pancreatitis?
= serum amylase or lipase
89
Is serum amylase or serum lipase more specific for diagnosing acute pancreatitis?
= serum lipase
90
If serum or lipase levels are inconclusive + there is a high suspicion of acute pancreatitis, what is the best imaging option?
= CT of abdomen with contrast
91
What is the Modified Glasgow Criteria used for?
= assess severity of acute pancreatitis within the first 48-hours of admission
92
Management for acute pancreatitis
= supportive
IV fluids for resuscitation, + oxygen therapy as required
Nasogastric tube – if patient vomiting profusely
If patient able to eat, encourage if tolerated
Catheterisation – monitor urine output, start fluid balance chart
Aim for urine output at least > 0.5ml/kg/hr
Opioid analgesia (e.g., Morphine)
93
In which cases may a broad-spectrum antibiotic be considered in the treatment of acute pancreatitis?
= in cases of confirmed pancreatic necrosis
94
How is pancreatic necrosis confirmed?
= fine needle aspiration of the necrosis
95
If there is suspicion of pancreatic head malignancy, what procedure may be done?
= Whipple's procedure
96
What is a Whipple's procedure?
= operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct
(= pancreaticoduodenectomy)
97
Is chronic pancreatitis more common in males of females?
= males (4:1)
98
Main causes of chronic pancreatitis? (2)
- chronic alcohol use
- idiopathic (unknown)
99
Patient presents with long-term back pain, tenderness in epigastrium, DM and signs of malabsorption. What would you be suspicious of?
= chronic pancreatitis
100
Most appropriate initial test to investigate for chronic pancreatitis?
= faecal elastase level
(low in chronic pancreatitis)
101
When might you think to use steroids in managing chronic pancreatitis?
= only if autoimmune aetiology
102
3 key complications in relation to hernias
- Incarceration
- Obstruction
- Strangulation
103
Hernias: What is incarceration?
= when hernia can not be reduced back (irreducible)
104
What is a Richter's Hernia?
= where part of bowel wall and lumen herniate through a defect, with the other side of that section of bowel remaining within peritoneal cavity
105
What is a Maydl’s Hernia?
= where 2 different loops are contained in within the hernia
106
What is a tension-free hernia repair?
= involves placing a mesh over defect in abdominal wall to stop hernia reoccurring
107
What is a tension hernia repair?
= surgical operation to suture muscles + tissue on either side of defect back together again
108
Which of the following is known as an 'indirect' hernia?
- where the bowel herniates through the inguinal canal
- where the bowel herniates through a weakness in the Hesselbach's triangle
- where the bowel herniates through the inguinal canal
109
Which of the following is known as an 'direct' hernia?
- where the bowel herniates through the inguinal canal
- where the bowel herniates through a weakness in the Hesselbach's triangle
- where the bowel herniates through a weakness in the Hesselbach's triangle
110
Gold-standard diagnosis for colorectal cancer?
= colonoscopy with biopsy
111
3 types of colon cancer?
- sporadic (95%)
- hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
- familial adenomatous polyposis (FAP, <1%)
112
APC gene mutation is associated with which type of colon cancer?
= familial adenomatous polyposis (FAP)
113
Which of the following is most likely to present with abdominal pain, iron-deficiency anaemia, (and often presents late)
- right-sided colon cancer
- left-sided colon cancer
- right-sided colon cancer
114
Which of the following is most likely to present with rectal bleeding, change in bowel habit, tenesmus
- right-sided colon cancer
- left-sided colon cancer
- left-sided colon cancer
115
What colorectal cancer screening is there in UK? (2)
FIT test - for those 60-74, offered every 2 years
Flexible sigmoidoscopy - for those aged 55
116
Curative treatment option for colorectal cancer
= resectional surgery
117
Which of the following types of resectional surgery, is most appropriate for cancer located in caecum, ascending or proximal transverse colon?
- right hemicolectomy
- left hemicolectomy
- high anterior resection
- anterior resection
- abdomino-perineal excision of rectum
- right hemicolectomy
118
Which of the following types of resectional surgery, is most appropriate for cancer located in the distal transverse or descending colon?
- right hemicolectomy
- left hemicolectomy
- high anterior resection
- anterior resection
- abdomino-perineal excision of rectum
- left hemicolectomy
119
Which of the following types of resectional surgery, is most appropriate for cancer located in the sigmoid colon?
- right hemicolectomy
- left hemicolectomy
- high anterior resection
- anterior resection
- abdomino-perineal excision of rectum
- high anterior resection
120
Which of the following types of resectional surgery, is most appropriate for cancer located in the rectum?
- right hemicolectomy
- left hemicolectomy
- high anterior resection
- anterior resection
- abdomino-perineal excision of rectum
- anterior resection
121
Which of the following types of resectional surgery, is most appropriate for cancer located in the anal verge?
- right hemicolectomy
- left hemicolectomy
- high anterior resection
- anterior resection
- abdomino-perineal excision of rectum
- abdomino-perineal excision of rectum
122
What is an anterior resection?
= surgical procedure to remove the diseased portion of your bowel and rectum
123
How is spontaneous bacterial peritonitis diagnosed?
= paracentesis (removal of fluid from abdomen through a slender needle)
124
Management of spontaneous bacterial peritonitis
= IV Cefotaxime
125
What is irritable bowel syndrome (IBS)?
= common functional GI disorder characterised by recurrent abdominal pain, and alterations in bowel habits, with no identifiable organic cause
126
Is IBS more common in males or females?
= females
127
What is required for a diagnosis of IBS?
= all differentials need to be excluded,
128
In addition to more criteria, for a diagnosis of IBS, how long must a patient have abdominal pain or discomfort?
(alongside other things)
= 6 months
129
First-line pharmacological treatment for diarrhoea in IBS?
= Loperamide
130
First-line pharmacological treatment for constipation in IBS?
= Bulk-forming laxatives (e.g., Ispaghula husk)
(avoid lactulose, as can cause bloating)
131
First-line pharmacological treatment for pain/ cramps in IBS?
= antispasmodics
(little evidence for their benefit)
132
Which antidepressant is second-line pharmacological treatment in IBS?
= tricyclic antidepressant (e.g., Amitriptyline 5-10mg)
133
What is Linaclotide (in IBS)?
= specialist secretory drug for constipation in IBS, used when first-line laxatives are inadequate
134
What is the Glasgow-Blatchford Bleeding Score?
= used at initial presentation in suspected upper GI bleed. Estimates the risk of patient having an upper GI bleed
135
What score on the Glasgow-Blatchford Bleeding Score indicates a high risk of an upper GI bleed?
= > 0
136
What is the Rockall Score?
= used after endoscopy to estimate the risk of re-bleeding + mortality
(in relation to upper GI bleeds)
137
How is an upper GI bleed diagnosed?
= OGD endoscopy
138
What is 'group + save'?
= lab checks patient’s blood group + saves a sample to match blood if needed
139
What is 'crossmatch'?
= lab allocates units of blood, tests if its compatible, and keeps it ready in the fridge
140
Prothrombin complex concentrate can be given to patients who are actively bleeding and..?
= are taking Warfarin
141
What pharmacological management is used in pat?
= Terlipressin
142
What is Terlipressin + when is it used?
= acts as a vasopressin analogue that works by reducing portal venous pressure in the liver
Used in patients with suspected oesophageal varies
143
What are given to patients with suspected oesophageal varies (2)
- Terlipressin
- broad-spectrum antibiotics
144
Endoscopic treatment for oesophageal variceal bleed?
= variceal band ligation
145
True or False: It is recommended to use a PPI before endoscopy in patients with non-variceal upper GI bleeding?
= False
NICE recommend AGAINST using a PPI until after endoscopy in patients with non-variceal upper GI bleeding
146
4 most common causes of liver cirrhosis?
- alcohol-related liver disease
- non-alcoholic fatty liver disease (NAFLD)
- hepatitis B
- hepatitis C
147
What would you expect albumin, prothrombin time, sodium levels and platelet levels to be in a patient with liver cirrhosis?
Albumin - low
Prothrombin time - high
Sodium levels - low (fluid retention)
Thrombocytopenia
148
What is alpha-fetoprotein a marker for?
= hepatocellular cancer
149
Patients with which type of liver disease can make use out of enhanced liver fibrosis (ELF) blood test to assess liver fibrosis?
= non-alcoholic fatty liver disease
150
Imaging technique used to diagnose non-alcoholic fatty liver disease (once other causes are excluded)?
= USS
151
What is transient elastography?
AKA 'FibroScan' - helps to determine the degree of fibrosis, it is used to assess stiffness of the liver using high-frequency sounds waves
152
What test is used to confirm diagnosis of liver cirrhosis?
= biopsy
153
What is MELD score?
= recommended to calculate every 6 months in patients with compensated cirrhosis. It gives an estimated 3-monthly mortality as %
154
What is the Child-Pugh score?
= uses 5 factors to assess the severity of cirrhosis + prognosis
155
How is Child-Pugh score calculated?
5 factors. Each factor is scored 1, 2 or, 3. Minimum score overall: 5 (scoring 1 for each factor), and maximum is 15 (scoring 3 in each factor)
156
4 features of decompensated liver disease?
'AHOY'
A - ascites
H - hepatic encephalopathy
O - oesophageal varices bleeding
Y - yellow (jaundice)
157
How do patients with liver cirrhosis present with cachexia (excessive muscle wasting)?
Patients often have a loss of appetite resulting in reduced intake. Cirrhosis affects protein metabolism in the liver + reduces the amount of protein the liver produces.
It also disrupts the ability of the liver to store glucose as glycogen + release it when requires.
Less protein available for maintaining muscle tissue, its broken down and used for fuel
158
What is variceal ligation?
= involves a rubber band wrapped around the base of the varices, cutting off the blood flow through the vessels
159
What is a transjugular intrahepatic portosystemic shunt (TIPs) - used in reducing portal hypertension
= procedure that involves inserting a stent (tube) to connect the portal veins to adjacent blood vessels that have lower pressure. This relieves the pressure of blood flowing through the diseased liver and can help stop bleeding and fluid back up.
160
Cirrhosis causes
- exudative ascites
- transudative ascites
- transudative ascites (low protein content)
161
Stepwise progression of alcohol-related liver disease (3 steps)
1. alcoholic fatty liver
2. alcoholic hepatitis
3. cirrhosis
162
UK: Recommendation for alcohol consumption
= 14 units per week, spread over 3 or more days. (Not more than 5 units in a single day)
163
Vitamin B1 is also known as?
= thiamine
164
What is the CAGE Questionnaire used for?
= quickly screen for harmful alcohol use
165
What are the CAGE questions?
C – Cut down? Do you think you should cut down?
A – annoyed? Do you get annoyed at others commenting?
G – guilty? Do you ever feel guilty about drinking?
E – eye opener? Do you every drink in the morning to help with your hangover or nerves?
166
How long after alcohol consumption creases can tremors, sweating, headaches, craving + anxiety start?
- 6-12 hours
- 12-24 hours
- 24-48 hours
- 24-72 hours
- 6-12 hours
167
How long after alcohol consumption creases can hallucinations start?
- 6-12 hours
- 12-24 hours
- 24-48 hours
- 24-72 hours
- 12-24 hours
168
How long after alcohol consumption creases can seizures start?
- 6-12 hours
- 12-24 hours
- 24-48 hours
- 24-72 hours
- 24-48 hours
169
How long after alcohol consumption creases can delirium tremens start?
- 6-12 hours
- 12-24 hours
- 24-48 hours
- 24-72 hours
- 24-72 hours
170
What is delirium tremens? and why does it happen?
= medical emergency associated with alcohol withdrawal
Alcohol stimulates GABA receptors (inhibitory), and inhibit glutamate receptors (excitatory receptors), causing a relaxing effect on electrical activity of the brain. When alcohol is removed, GABA under-functions, and glutamate over-functions, causing extreme excitability of brain + excessive adrenergic activity
171
What is Chlordiazepoxide + what is it used for?
= Benzodiazepine, used to combat effects of alcohol withdrawal
172
Managing alcohol withdrawal?
Chlordiazepoxide
High-dose B vitamins IM or IV, followed by long-term oral thiamine
173
Confusion, oculomotor disturbances (eye movements) + ataxia are signs of which of the following:
- Wernicke's encephalopathy
- Korsakoff syndrome
- Wernicke's encephalopathy
174
Memory impairment (retrograde + anterograde) + behavioural changes are signs of which of the following:
- Wernicke's encephalopathy
- Korsakoff syndrome
- Korsakoff syndrome
175
Which of the following are the liver enzymes:
- ALT + AST
- ALP + GGT
- Amylase
- Lipase
- ALT + AST
176
Which of the following as associated with the biliary system?
- ALT + AST
- ALP + GGT
- Amylase
- Lipase
- ALP + GGT
177
Is ALT or AST predominately produced by the liver?
= ALT
178
Is ALP or GGT predominately produced in hepatobiliary system?
= GGT
179
What might a normal GGT, but high ALP suggest?
= bone problem
(high osteoclastic activity)
180
What might a sudden increase in ALP + GGT indicate?
= hepatocellular carcinoma
181
What might a high GGT indicate?
= heavy alcohol use
182
Gold standard for diagnosing non-alcoholic fatty liver disease (NAFLD)?
= liver biopsy
183
First-line test for assessing fibrosis in non-alcoholic fatty liver disease?
= enhanced liver fibrosis (ELF) blood test
184
What is haemochromatosis?
= genetic condition resulting in iron overload. There is excessive total body iron + deposition of iron in tissues. This is an iron storage disorder
(autosomal recessive)
185
Which of the following is associated with skin pigmentation (bronze)?
- Haemochromatosis
- Wilsons disease
- Haemochromatosis
186
Haemochromatosis: What serum ferritin + transferrin saturation levels would you expect?
Serum ferritin - high
Transferrin saturation - high
187
What is Perl's stain used for alongside liver biopsy?
= used to establish iron concentration in the liver
(can be used in haemochromatosis investigations)
188
What kind of imaging can be used to quantify the iron concentration in the liver?
= MRI scan
189
Management of haemochromatosis?
= venesection
Important to monitor serum ferritin + treat complications
190
What is venesection?
= regularly removing blood to remove excess iron. Used in treating haemochromatosis
191
What is Wilson's disease?
= autosomal recessive genetic condition resulting in excessive accumulation of copper in body tissues, particularly in the liver
192
Which of the following typically presents in teenagers or young adults?
- Haemochromatosis
- Wilson's disease
- Wilson's disease
193
Kayser-Fleischer rings on examination suggest patient has..?
= Wilson's disease
194
What is caeruloplamin?
= protein that carries copper in the blood
195
In Wilson's disease, is serum caeruloplasmin high or low?
= low
196
What is the 'double panda sign' on MRI brain suggestive of?
= Wilson's disease
197
First-line treatment for Wilson's disease
= copper chelation, using Penicillamine
198
Zinc salts effect on copper absorption in the GI tract?
= inhibits copper absorption in the GI tract
199
Middle-aged women presenting with itching, a positive anti-AMA and a raised alkaline phosphatase.
What is the diagnosis?
= Primary Biliary Cholangitis
200
What is Primary Biliary Cholangitis (PBC)?
= autoimmune condition where the immune system attacks the small bile ducts in the liver, resulting in obstructive jaundice + liver disease
201
What causes pruritus in PBC?
- raised bilirubin
- raised cholesterol
- raised bile-acids
- raised bile-acids
202
Raised ALP + presence of anti-mitochondrial antibodies (AMA) indicates a diagnosis of
- Primary Biliary Cholangitis
- Primary Sclerosing Cholangitis
- Primary Biliary Cholangitis
203
What is Ursodeoxycholic acid used to treat?
= primary biliary cholangitis
204
What is primary sclerosis cholangitis?
= a condition where the intrahepatic + extrahepatic bile ducts become inflamed + damaged, developing strictures, that obstruct the flow of bile out the liver and into the intestines
205
Difference between primary biliary cholangitis + primary sclerosis cholangitis?
PSC is characterised by damage of medium to large extra-hepatic and intra-hepatic bile ducts
Whereas PBC chiefly targets small intrahepatic bile ducts
206
Primary sclerosing cholangitis (PSC) is strongly associated with which other condition?
= ulcerative colitis
207
Autoantibodies are HELPFUL in diagnosis of which of the following:
- PBC
- PSC
(not the other)
- PBC
208
Diagnostic imaging investigation in primary sclerosing cholangitis?
= MRCP
209
Definitive treatment of primary sclerosing cholangitis?
= no treatments proven to be effective
210
What is Colestyramine? and what is it used to relieve?
= bile acid sequestrate, used for symptoms of pruritus
211
Which of the following responds well to treatment with steroids?
- primary sclerosing cholangitis
- IgG4-related sclerosing cholangitis
- IgG4-related sclerosing cholangitis
212
What is acute cholecystitis?
= refers to inflammation of the gallbladder, which is caused by a blockage of the cystic duct, preventing gallbladder from draining (usually caused by gallstones)
213
What is Murphy's Sign? and what is it suggestive of?
Murphy's sign = elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right upper quadrant. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive
Suggestive of cholecystitis
214
First-line investigation in acute cholecystitis?
= abdominal USS
215
Treatment for acute cholecystitis
- IV antibodies
- Cholecystectomy, recommended within 1 week of diagnosis
216
What 2 ducts join to form the ampulla of Vater?
Common bile duct + Pancreatic duct
217
Risk factors for gallstones (4)
'4 F's'
Fat
Fair
Female
Forty
218
Severe colicky epigastric or RUQ pain, often triggered by fatty meals is associated with what diagnosis?
= gallstones
219
First-line investigation in gallstones?
= abdominal USS
220
Management for gallstones
ERCP - used to remove gallstones
If symptomatic or complications - cholecystectomy (removal of gallbladder)
221
What is alpha-1 antitrypsin deficiency?
= genetic condition caused by low levels of alpha-1 antitrypsin
222
What is alpha-1 antitrypsin?
= protease inhibitor
(offers protection)
223
What organs does alpha-1 antitrypsin deficiency affect? (2)
- lungs (COPD + bronchiectasis)
- liver (fibrosis + cirrhosis)
224
Diagnosis of alpha-1 antitrypsin deficiency is based upon what 2 investigations?
Low serum alpha-1 antitrypsin + genetic testing
225
Is giving an infusion of alpha-1 antitrypsin to boost levels in deficiency recommended?
= no, there is doubt about the clinical benefit + cost effectiveness
226
What should painless jaundice make you think of? (2)
- cancer of the head of the pancreas
- cholangiocarcinoma
(pancreatic cancer more common)
227
Main risk factor for hepatocellular carcinoma?
= cirrhosis
228
Patients with liver cirrhosis are offered screening for hepatocellular carcinoma.
What is part of the screening programme, and how often?
= every 6 months with and ultrasound and checking alpha-fetoprotein (tumour marker)
229
First-line imaging investigation for hepatocellular carcinoma?
= liver USS
230
What is transarterial chemoembolization (TACE)?
= interventional radiology procedure.
Chemotherapy drug is injected into the hepatic artery feeding the tumour, delivering the dose directly to the tumour. This is followed by embolization of the vessel, to block the tumour’s blood supply
231
What is a cholangiocarcinoma?
= type of cancer that originates in the bile ducts, may affect intra- or extra-hepatic ducts
232
Cholangiocarcinoma is associated with which condition?
= primary sclerosing cholangitis (PSC)
233
CA19-9, is a tumour marker for which type of cancer?
= cholangiocarcinoma
234
Which type of peptic ulcer is most common?
= duodenal ulcer
235
Factors which disrupt the mucus barrier in the stomach, which increases risk of peptic ulcer formation? (2)
- H.pylori
- NSAID use
236
Which type of peptic ulcer presents with pain straight after eating?
= gastric ulcer
237
Which type of peptic ulcer presents with pain 2-3 hours after eating?
= duodenal ulcer
238
How is a peptic ulcer diagnosed?
= endoscopy
239
Management of peptic ulcer
If H. pylori present: start eradication therapy
If no H. pylori: PPI until ulcer has healed
240
What is coeliac disease?
= an autoimmune condition triggered by eating gluten
241
Which part of the small bowel is most commonly affected in those with coeliac disease?
= jejunum
242
Dermatitis herpetiformis is associated with which condition?
= coeliac disease
243
First-line blood tests for coeliac disease (2)
- total IgA levels (to exclude IgA deficiency, as it can cause a false-negative)
- anti-tissue transglutaminase antibodies (anti-TTG)
(important patient is still eating gluten)
244
What confirms diagnosis of coeliac disease after positive antibody test?
= endoscopy + jejunal biopsy
245
What are the following findings on a jejunal biopsy indicative of?
- crypt hyperplasia
- villous atrophy
= coeliac disease
246
Management of coeliac disease?
= lifelong gluten-free diet
247
What is McBurney's point? and tenderness over this point indicates what?
McBurney's point: 1/3 of the way from anterior superior iliac spine to the umbilicus
Tenderness over this point is suggestive of appendicitis
248
What is Rovsing's sign?
= palpation of left iliac fossa causes pain in the RIF
Suggestive of appendicitis
249
Definitive treatment of appendicitis
= removal of inflamed appendix (appendicectomy)
250
Diverticulosis vs diverticulitis
Diverticulosis = refers to presence of diverticula, without inflammation or infection
Diverticulitis = refers to inflammation + infection of diverticula
251
Which part of the large colon is most likely to be affected by diverticula formation?
= sigmoid colon
252
Management of diverticulosis
- increased fibre in diet
- bulk-forming laxatives
253
Management of uncomplicated acute diverticulitis?
- oral co-amoxiclav
- analgesia (avoid NSAIDs + opiates)
- only take fluid liquids
254
What are the 3 main branches of the abdominal aorta that supply the abdominal organs?
- coeliac artery
- superior mesenteric artery
- inferior mesenteric artery
255
How is chronic mesenteric ischaemia diagnosed?
= CT angiography
256
First-line management of chronic mesenteric ischaemia?
Revascularisation to improve blood flow to intestines - via endovascular procedure - percutaneous mesenteric artery stenting
257
How is acute mesenteric ischaemia diagnosed?
= contrast CT
258
Which of the following would you expect to see in a patient with mesenteric ischaemia?
- metabolic acidosis normal lactate
- metabolic alkalosis with normal lactate
- metabolic acidosis with raised lactate
- metabolic alkalosis with raised lactate
- metabolic acidosis with raised lactate
259
Mortality associated with acute mesenteric ischaemia?
>50% (very high)
260
How is pulmonary embolism diagnosed? (steps)
CXR first - rule-out other pathology
Well's score:
- if PE likely: perform CTPA, or alternative imaging
- unlikely: perform d-dimer, if +ve, perform CTPA
261
First-line imaging option in diagnosing a PE?
= CT pulmonary angiogram
262
Which of the following would be expect a patient with a PE to present with?
- respiratory acidosis, low pO2
- respiratory alkalosis, low pO2
- respiratory acidosis, high pO2
- respiratory alkalosis, high pO2
- respiratory alkalosis, low pO2
263
Mainstay of treatment in PE?
= anticoagulation with DOAC, Apixaban or Rivaroxaban
264
If DOAC cannot be used in treating a pulmonary embolism, what is next option?
= LMWH
265
If patient presents with a massive PE and haemodynamic compromise, how is this treated?
= continuous infusion of unfractionated heparin and consider thrombolysis
266
For long-term anticoagulation following a PE, which of the following is first-line?
- DOAC
- Warfarin
- LMWH
- DOAC
267
For long-term anticoagulation following a PE, which of the following is first-line in those with anti-phospholipid syndrome?
- DOAC
- Warfarin
- LMWH
- Warfarin
268
For long-term anticoagulation following a PE, which of the following is first-line in pregnancy?
- DOAC
- Warfarin
- LMWH
- LMWH
269
What is the 'double duct sign' on CT?
= pancreatic cancer
