Gastroenterology Flashcards

Question

What Hb gives what score in blatchford scoring?

Answer 1

Men 12 - 13 = 1 10 - 12 = 3 < 10 = 6 Women 10 - 12 = 1 < 10 = 6

Answer 2

100 - 109 = 1 90 - 99 = 2 < 90 = 3

Answer 3

Pulse >=100/min = 1 Presentation with melaena = 1 Presentation with syncope = 2 Hepatic disease = 2 Cardiac failure = 2

Answer 4

Resuscitation ABC, wide-bore intravenous access * 2 platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre fresh frozen plasma to patients who have either a fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal prothrombin complex concentrate to patients who are taking warfarin and actively bleeding

Answer 5

Endoscopy should be offered immediately after resuscitation in patients with a severe bleed all patients should have endoscopy within 24 hours

Answer 6

Management of non-variceal bleeding NICE do not recommend the use of proton pump inhibitors (PPIs) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding although PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy if further bleeding then options include repeat endoscopy, interventional radiology and surgery

Answer 7

Management of variceal bleeding terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy) band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures

Answer 8

whilst it may cause inflammation anywhere in the gastrointestinal tract, the disease burden is not evenly distributed: 80% of patients have small bowel involvement, usually in the ileum, with around 30% of patients having ileitis exclusively 50% of patients have ileocolitis 20% of patients have colitis exclusively 30% of patients have perianal disease

Answer 9

Crohn's disease typically presents in late adolescence or early adulthood. Features include: -presentation may be non-specific symptoms such as weight loss and lethargy -diarrhoea the most prominent symptom in adults Crohn's colitis may cause bloody diarrhoea -abdominal pain: the most prominent symptom in children -perianal disease: e.g. Skin tags or ulcers extra-intestinal features are more common in patients with colitis or perianal disease

Answer 10

Investigations raised inflammatory markers increased faecal calprotectin anaemia low vitamin B12 and vitamin D

Answer 11

Arthritis: pauciarticular, asymmetric Erythema nodosum Episcleritis Osteoporosis Arthritis is the most common extra-intestinal feature in both CD and UC Episcleritis is more common in CD

Answer 12

Arthritis: polyarticular, symmetric Uveitis Pyoderma gangrenosum Clubbing Primary sclerosing cholangitis Primary sclerosing cholangitis is much more common in UC Uveitis is more common in UC

Answer 13

General points patients should be strongly advised to stop smoking some studies suggest an increased risk of relapse secondary to NSAIDs and the combined oral contraceptive pill but the evidence is patchy

Answer 14

Inducing remission -glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients -enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children) -5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective -azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. -Methotrexate is an alternative to azathioprine -infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on azathioprine or methotrexate -metronidazole is often used for isolated peri-anal disease

Answer 15

Maintaining remission as above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis) azathioprine or mercaptopurine is used first-line to maintain remission

Answer 16

+TPMT activity should be assessed before starting methotrexate is used second-line

Answer 17

perianal fistulae -an inflammatory tract or connection between the anal canal and the perianal skin -MRI is the investigation of choice for suspected perianal fistulae - can be used to determine if there (is an abscess and if the fistula is simple (low fistula) or complex (high fistula that passes through or above muscle layers) -patients with symptomatic perianal fistulae are usually given oral metronidazole anti-TNF agents such as infliximab may also be effective in closing and maintaining closure of perianal fistulas -a draining seton is used for complex fistulae a seton is a piece of surgical thread that's left in the fistula for several weeks to keep it open. This is useful because persisting fistula tracks after premature skin closure predispose to abscess formation

Answer 18

perianal abscess requires incision and drainage combined with antibiotic therapy a draining seton may also be placed if a tract is identified

Answer 19

patients are also at risk of: small bowel cancer (standard incidence ratio = 40) colorectal cancer (standard incidence ratio = 2, i.e. less than the risk associated with ulcerative colitis) osteoporosis

Answer 20

Ulcerative colitis (UC) is a form of inflammatory bowel disease. Inflammation always starts at rectum (hence it is the most common site for UC), never spreads beyond ileocaecal valve and is continuous. The peak incidence of ulcerative colitis is in people aged 15-25 years and in those aged 55-65 years.

Answer 21

The initial presentation is usually following insidious and intermittent symptoms. Features include: -bloody diarrhoea -urgency -tenesmus -abdominal pain, particularly in the left lower quadrant -extra-intestinal features

Answer 22

Endoscopy barium enema

Answer 23

colonoscopy + biopsy is generally done for diagnosis however in patients with severe colitis colonoscopy should be avoided due to the risk of perforation - a flexible sigmoidoscopy is preferred

Answer 24

typical findings: -red, raw mucosa, bleeds easily -no inflammation beyond submucosa (unless fulminant disease) -widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps ('pseudopolyps') -inflammatory cell infiltrate in lamina propria -neutrophils migrate through the walls of glands to form crypt abscesses -depletion of goblet cells and mucin from gland epithelium -granulomas are infrequent

Answer 25

Barium enema loss of haustrations superficial ulceration, 'pseudopolyps' long standing disease: colon is narrow and short -'drainpipe colon'

Answer 26

Most ulcerative colitis flares occur without an identifiable trigger. However, a number of factors are often linked: stress medications NSAIDs antibiotics cessation of smoking

Answer 27

Mild / Mod / Severe

Answer 28

Fewer than four stools daily, with or without blood No systemic disturbance Normal erythrocyte sedimentation rate and C-reactive protein values

Answer 29

Four to six stools a day, with minimal systemic disturbance

Answer 30

More than six stools a day, containing blood Evidence of systemic disturbance, e.g. fever tachycardia abdominal tenderness, distension or reduced bowel sounds anaemia hypoalbuminaemia

Answer 31

proctitis topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates if remission is not achieved within 4 weeks, add an oral aminosalicylate if remission still not achieved add topical or oral corticosteroid

Answer 32

proctosigmoiditis and left-sided ulcerative colitis topical (rectal) aminosalicylate if remission is not achieved within 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid

Answer 33

extensive disease topical (rectal) aminosalicylate and a high-dose oral aminosalicylate: if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid

Answer 34

Severe colitis should be treated in hospital intravenous steroids are usually given first-line intravenous ciclosporin may be used if steroid are contraindicated if after 72 hours there has been no improvement, consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery

Answer 35

proctitis and proctosigmoiditis -topical (rectal) aminosalicylate alone (daily or intermittent) or -an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or -an oral aminosalicylate by itself: this may not be effective as the other two options left-sided and extensive ulcerative colitis -low maintenance dose of an oral aminosalicylate

Answer 36

Following a severe relapse or >=2 exacerbations in the past year oral azathioprine or oral mercaptopurine

Answer 37

5-aminosalicyclic acid (5-ASA) is released in the colon and is not absorbed. It acts locally as an anti-inflammatory. The mechanism of action is not fully understood but 5-ASA may inhibit prostaglandin synthesis

Answer 38

Sulphasalazine a combination of sulphapyridine (a sulphonamide) and 5-ASA many side-effects are due to the sulphapyridine moiety: rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, lung fibrosis other side-effects are common to 5-ASA drugs (see mesalazine)

Answer 39

Mesalazine a delayed release form of 5-ASA sulphapyridine side-effects seen in patients taking sulphasalazine are avoided mesalazine is still however associated with side-effects such as GI upset, headache, agranulocytosis, pancreatitis*, interstitial nephritis

Answer 40

Aminosalicylates are associated with a variety of haematological adverse effects, including agranulocytosis - FBC is a key investigation in an unwell patient taking them.

Answer 41

The diagnosis of IBS should be considered if the patient has had the following for at least 6 months: Abdominal pain, and/or Bloating, and/or Change in bowel habit

Answer 42

positive diagnosis of IBS should be made if the patient has abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms: altered stool passage (straining, urgency, incomplete evacuation) abdominal bloating (more common in women than men), distension, tension or hardness symptoms made worse by eating passage of mucus Features such as lethargy, nausea, backache and bladder symptoms may also support the diagnosis

Answer 43

Red flag features should be enquired about: rectal bleeding unexplained/unintentional weight loss family history of bowel or ovarian cancer onset after 60 years of age

Answer 44

Red flag features should be enquired about: rectal bleeding unexplained/unintentional weight loss family history of bowel or ovarian cancer onset after 60 years of age

Answer 45

The management of irritable bowel syndrome (IBS) is often difficult and varies considerably between patients. NICE updated it's guidelines in 2015. First-line pharmacological treatment - according to predominant symptom pain: antispasmodic agents constipation: laxatives but avoid lactulose diarrhoea: loperamide is first-line

Answer 46

For patients with constipation who are not responding to conventional laxatives linaclotide may be considered, if: optimal or maximum tolerated doses of previous laxatives from different classes have not helped and they have had constipation for at least 12 months

Answer 47

Second-line pharmacological treatment low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors Other management options psychological interventions - if symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS), consider referring for cognitive behavioural therapy, hypnotherapy or psychological therapy complementary and alternative medicines: 'do not encourage use of acupuncture or reflexology for the treatment of IBS'

Answer 48

General dietary advice have regular meals and take time to eat avoid missing meals or leaving long gaps between eating drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas restrict tea and coffee to 3 cups per day reduce intake of alcohol and fizzy drinks consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice) reduce intake of 'resistant starch' often found in processed foods limit fresh fruit to 3 portions per day for diarrhoea, avoid sorbitol for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).

Answer 49

Angiodysplasia is a vascular deformity of the gastrointestinal tract which predisposes to bleeding and iron deficiency anaemia. There is thought to be an association with aortic stenosis, although this is debated. Angiodysplasia is generally seen in elderly patients

Answer 50

Features anaemia gastrointestinal (GI) bleeding if upper GI then may be melena if lower GI then may present as brisk, fresh red PR bleeding

Answer 51

Diagnosis colonoscopy mesenteric angiography if acutely bleeding Management endoscopic cautery or argon plasma coagulation antifibrinolytics e.g. Tranexamic acid oestrogens may also be used

Answer 52

Bile-acid malabsorption is a cause of chronic diarrhoea. This may be primary, due to excessive production of bile acid, or secondary to an underlying gastrointestinal disorder causing reduced bile acid absorption. It can lead to steatorrhoea and vitamin A, D, E, K malabsorption. Secondary causes are often seen in patients with ileal disease, such as with Crohn's. Other secondary causes include: cholecystectomy coeliac disease small intestinal bacterial overgrowth

Answer 53

Investigation the test of choice is SeHCAT nuclear medicine test using a gamma-emitting selenium molecule in selenium homocholic acid taurine or tauroselcholic acid (SeHCAT) scans are done 7 days apart to assess the retention/loss of radiolabelled 75SeHCAT Management bile acid sequestrants e.g. cholestyramine

Answer 54

Cholestyramine is a bile acid sequestrant used in the management of hyperlipidaemia. It decreases bile acid reabsorption in the small intestine, therefore upregulating the amount of cholesterol that is converted to bile acid. The main effect it has on the lipid profile is to reduce LDL cholesterol. It is also occasionally used in Crohn's disease for treatment diarrhoea following bowel resection. Adverse effects abdominal cramps and constipation decreases absorption of fat-soluble vitamins cholesterol gallstones may raise level of triglyceride

Answer 55

Diverticulosis is an extremely common disorder characterised by multiple outpouchings of the bowel wall, most commonly in the sigmoid colon. Strictly speaking the term diverticular disease is reserved for patients who are symptomatic - diverticulosis is the more accurate term for diverticula being present. Risk factors increasing age low-fibre diet Diverticulosis can present in a number of ways: painful diverticular disease: altered bowel habit, colicky left sided abdominal pain. A high fibre diet is usually recommended to minimise symptoms diverticulitis

Answer 56

One of the diverticular become infected. The classical presentation is: left iliac fossa pain and tenderness anorexia, nausea and vomiting diarrhoea features of infection (pyrexia, raised WBC and CRP)

Answer 57

Management: mild attacks can be treated with oral antibiotics more significant episodes are managed in hospital. Patients are made nil by mouth, intravenous fluids and intravenous antibiotics (typical a cephalosporin + metronidazole) are given

Answer 58

Complications of diverticulitis include: abscess formation peritonitis obstruction perforation

Answer 59

Ischaemia to the lower gastrointestinal tract can result in a variety of clinical conditions. Whilst there is no standard classification it can be useful to separate cases into 3 main conditions acute mesenteric ischaemia chronic mesenteric ischaemia ischaemic colitis

Answer 60

Common predisposing factors increasing age atrial fibrillation - particularly for mesenteric ischaemia other causes of emboli: endocarditis, malignancy cardiovascular disease risk factors: smoking, hypertension, diabetes cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use

Answer 61

Common features abdominal pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings rectal bleeding diarrhoea fever bloods typically show an elevated white blood cell count associated with a lactic acidosis

Answer 62

Diagnosis CT is the investigation of choice

Answer 63

Acute mesenteric ischaemia is typically caused by an embolism resulting in occlusion of an artery which supplies the small bowel, for example the superior mesenteric artery. Classically patients have a history of atrial fibrillation.

Answer 64

Chronic mesenteric ischaemia is a relatively rare clinical diagnosis due to it's non-specific features and may be thought of as 'intestinal angina'. Colickly, intermittent abdominal pain occurs.

Answer 65

ischaemic colitis describes an acute but transient compromise in the blood flow to the large bowel. This may lead to inflammation, ulceration and haemorrhage. It is more likely to occur in 'watershed' areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.

Answer 66

nvestigations 'thumbprinting' may be seen on abdominal x-ray due to mucosal oedema/haemorrhage Management - usually supportive - surgery may be required in a minority of cases if conservative measures fail. Indications would include generalised peritonitis, perforation or ongoing haemorrhage

Answer 67

Clostridioides difficile is a Gram positive rod often encountered in hospital practice. It produces an exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous colitis. C. difficile develops when the normal gut flora are suppressed by broad-spectrum antibiotics. Clindamycin is historically associated with causing C. difficile but the aetiology has evolved significantly over the past 10 years. Second and third-generation cephalosporins are now the leading cause of C. difficile. Other than antibiotics, risk factors include: proton pump inhibitors

Answer 68

Pathophysiology anaerobic gram-positive, spore-forming, toxin-producing bacillus transmission: via the faecal-oral route by ingestion of spores releases two exotoxins (toxin A and toxin B) that act on intestinal epithelial cells and inflammatory cells resulting in colitis

Answer 69

Features diarrhoea abdominal pain a raised white blood cell count (WCC) is characteristic if severe toxic megacolon may develop

Answer 70

Normal WCC

Answer 71

↑ WCC ( < 15 x 109/L) Typically 3-5 loose stools per day

Answer 72

↑ WCC ( > 15 x 109/L) or an acutely ↑ creatinine (> 50% above baseline) or a temperature > 38.5°C or evidence of severe colitis(abdominal or radiological signs)

Answer 73

Hypotension Partial or complete ileus Toxic megacolon, or CT evidence of severe disease

Answer 74

Diagnosis is made by detecting C. difficile toxin (CDT) in the stool C. difficile antigen positivity only shows exposure to the bacteria, rather than current infection

Answer 75

First episode of C. difficile infection first-line therapy is oral vancomycin for 10 days second-line therapy: oral fidaxomicin third-line therapy: oral vancomycin +/- IV metronidazole

Answer 76

Recurrent episode recurrent infection occurs in around 20% of patients, increasing to 50% after their second episode within 12 weeks of symptom resolution: oral fidaxomicin after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin Life-threatening C. difficile infection oral vancomycin AND IV metronidazole specialist advice - surgery may be considered Other therapies bezlotoxumab is a monoclonal antibody which targets C. difficile toxin B NICE do not currently support its use to prevent recurrences as it is not cost-effective faecal microbiota transplant may be considered for patients who've had 2 or more previous episodes

Answer 77

Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles. Although the polyps themselves don't have malignant potential, around 50% of patients will have died from another gastrointestinal tract cancer by the age of 60 years. Genetics autosomal dominant responsible gene encodes serine threonine kinase LKB1 or STK11

Answer 78

Features hamartomatous polyps in the gastronintestinal tract (mainly small bowel) small bowel obstruction is a common presenting complaint, often due to intussusception gastrointestinal bleeding pigmented lesions on lips, oral mucosa, face, palms and soles Management conservative unless complications develop

Answer 79

Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women.

Answer 80

Clinical features dysphagia of BOTH liquids and solids typically variation in severity of symptoms heartburn regurgitation of food may lead to cough, aspiration pneumonia etc malignant change in small number of patients

Answer 81

Investigations oesophageal manometry excessive LOS tone which doesn't relax on swallowing considered the most important diagnostic test barium swallow shows grossly expanded oesophagus, fluid level 'bird's beak' appearance chest x-ray wide mediastinum fluid level

Answer 82

Treatment pneumatic (balloon) dilation is increasingly the preferred first-line option less invasive and quicker recovery time than surgery patients should be a low surgical risk as surgery may be required if complications occur surgical intervention with a Heller cardiomyotomy should be considered if recurrent or persistent symptoms intra-sphincteric injection of botulinum toxin is sometimes used in patients who are a high surgical risk drug therapy (e.g. nitrates, calcium channel blockers) has a role but is limited by side-effects

Answer 83

Barrett's refers to the metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium. There is an increased risk of oesophageal adenocarcinoma, estimated at 50-100 fold. There are no screening programs for Barrett's - it's typically identified when patients have an endoscopy for evaluation of upper gastrointestinal symptoms such as dyspepsia. Barrett's can be subdivided into short (<3cm) and long (>3cm). The length of the affected segment correlates strongly with the chances of identifying metaplasia. The overall prevalence of Barrett's oesophagus is difficult to determine but may be in the region of 1 in 20 and is identified in up to 12% of those undergoing endoscopy for reflux.

Answer 84

Histological features the columnar epithelium may resemble that of either the cardiac region of the stomach or that of the small intestine (e.g. with goblet cells, brush border) Risk factors gastro-oesophageal reflux disease (GORD) is the single strongest risk factor male gender (7:1 ratio) smoking central obesity

Answer 85

Whilst Barrett's oesophagus itself is asymptomatic clearly patients will often have coexistent GORD symptoms. Management high-dose proton pump inhibitor whilst this is commonly used in patients with Barrett's the evidence base that this reduces the change of progression to dysplasia or induces regression of the lesion is limited endoscopic surveillance with biopsies for patients with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years if dysplasia of any grade is identified endoscopic intervention is offered. Options include: radiofrequency ablation: preferred first-line treatment, particularly for low-grade dysplasia endoscopic mucosal resection

Answer 86

All patients who've got dysphagia All patients who've got an upper abdominal mass consistent with stomach cancer Patients aged >= 55 years who've got weight loss, AND any of the following: upper abdominal pain reflux dyspepsia

Answer 87

Patients with haematemesis Patients aged >= 55 years who've got: treatment-resistant dyspepsia or upper abdominal pain with low haemoglobin levels or raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain

Answer 88

This can be summarised at a step-wise approach 1. Review medications for possible causes of dyspepsia 2. Lifestyle advice 3. Trial of full-dose proton pump inhibitor for one month OR a 'test and treat' approach for H. pylori if symptoms persist after either of the above approaches then the alternative approach should be tried

Answer 89

Testing for H. pylori infection initial diagnosis: NICE recommend using a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology 'where its performance has been locally validated' test of cure: there is no need to check for H. pylori eradication if symptoms have resolved following test and treat however, if repeat testing is required then a carbon-13 urea breath test should be used

Answer 90

Helicobacter pylori is a Gram-negative bacteria associated with a variety of gastrointestinal problems, principally peptic ulcer disease. Pathophysiology Helicobacter pylori has 2 main mechanisms to survice in the acidic gastric environment: chemotaxis away from low pH areas, using its flagella to burrow into the mucous lining to reach the epithelial cells underneath secretes urease → urea converted to NH3 → alkalinization of acidic environment → increased bacterial survival pathogenesis mechanism: Helicobacter pylori releases bacterial cytotoxins (e.g. CagA toxin) → disruption of gastric mucosa

Answer 91

Associations peptic ulcer disease 95% of duodenal ulcers 75% of gastric ulcers gastric cancer B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of patients) atrophic gastritis The role of H pylori in Gastro-oesophageal reflux disease (GORD) is unclear - there is currently no role in GORD for the eradication of H pylori

Answer 92

Management eradication may be achieved with a 7-day course of a proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole) if penicillin-allergic: a proton pump inhibitor + metronidazole + clarithromycin

Answer 93

Urea breath test patients consume a drink containing carbon isotope 13 (13C) enriched urea urea is broken down by H. pylori urease after 30 mins patient exhale into a glass tube mass spectrometry analysis calculates the amount of 13C CO2 should not be performed within 4 weeks of treatment with an antibacterial or within 2 weeks of an antisecretory drug (e.g. a proton pump inhibitor) sensitivity 95-98%, specificity 97-98% may be used to check for H. pylori eradication

Answer 94

Rapid urease test (e.g. CLO test) biopsy sample is mixed with urea and pH indicator colour change if H pylori urease activity sensitivity 90-95%, specificity 95-98%

Answer 95

Serum antibody remains positive after eradication sensitivity 85%, specificity 80%

Answer 96

Culture of gastric biopsy provide information on antibiotic sensitivity sensitivity 70%, specificity 100%

Answer 97

Gastric biopsy histological evaluation alone, no culture sensitivity 95-99%, specificity 95-99%

Answer 98

Stool antigen test sensitivity 90%, specificity 95%

Answer 99

Gastro-oesophageal reflux disease (GORD) may be defined as symptoms of oesophagitis secondary to refluxed gastric contents NICE recommend that GORD which has not been investigated with endoscopy should be treated as per the dyspepsia guidelines

Answer 100

Endoscopically proven oesophagitis full dose proton pump inhibitor (PPI) for 1-2 months if response then low dose treatment as required if no response then double-dose PPI for 1 month Endoscopically negative reflux disease full dose PPI for 1 month if response then offer low dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions if no response then H2RA or prokinetic for one month

Answer 101

Complications oesophagitis ulcers anaemia benign strictures Barrett's oesophagus oesophageal carcinoma

Answer 102

More common in older men Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles Usually not seen but if large then a midline lump in the neck that gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen

Answer 103

Other features of CREST syndrome may be present, namely Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased. This contrasts to achalasia where the LES pressure is increased

Answer 104

All patients require an upper GI endoscopy unless there are compelling reasons for this not to be performed. Motility disorders may be best appreciated by undertaking fluoroscopic swallowing studies. A full blood count should be performed. Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery.

Answer 105

Triad of: dysphagia (secondary to oesophageal webs) glossitis iron-deficiency anaemia Treatment includes iron supplementation and dilation of the webs

Answer 106

Until recent times oesophageal cancer was most commonly due to a squamous cell carcinoma but the incidence of adenocarcinoma is rising rapidly. Adenocarcinoma is now the most common type of oesophageal cancer and is more likely to develop in patients with a history of gastro-oesophageal reflux disease (GORD) or Barrett's. The majority of adenocarcinomas are located near the gastroesophageal junction whereas squamous cell tumours are most commonly found in the upper two-thirds of the oesophagus.

Answer 107

GORD Barrett's oesophagus smoking obesity

Answer 108

Features dysphagia: the most common presenting symptom anorexia and weight loss vomiting other possible features include: odynophagia, hoarseness, melaena, cough

Answer 109

Diagnosis Upper GI endoscopy with biopsy is used for diagnosis Endoscopic ultrasound is the preferred method for locoregional staging CT scanning of the chest, abdomen and pelvis is used for initial staging FDG-PET CT may be used for detecting occult metastases if metastases are not seen on the initial staging CT scans. Laparoscopy is sometimes performed to detect occult peritoneal disease

Answer 110

Treatment Operable disease (T1N0M0) is best managed by surgical resection - the most common procedure is an Ivor-Lewis type oesophagectomy The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis resulting in mediastinitis In addition to surgical resection many patients will be treated with adjuvant chemotherapy

Answer 111

smoking alcohol achalasia Plummer-Vinson syndrome diets rich in nitrosamines

Answer 112

Malabsorption is characterised by diarrhoea, steatorrhoea and weight loss. Causes may be broadly divided into intestinal (e.g. villous atrophy), pancreatic (deficiency of pancreatic enzyme production or secretion) and biliary (deficiency of bile-salts needed for emulsification of fats)

Answer 113

Intestinal causes of malabsorption coeliac disease Crohn's disease tropical sprue Whipple's disease Giardiasis brush border enzyme deficiencies (e.g. lactase insufficiency)

Answer 114

Pancreatic causes of malabsorption chronic pancreatitis cystic fibrosis pancreatic cancer

Answer 115

Biliary causes of malabsorption biliary obstruction primary biliary cirrhosis

Answer 116

Other causes bacterial overgrowth (e.g. systemic sclerosis, diverticulae, blind loop) short bowel syndrome lymphoma

Answer 117

Melanosis coli is a disorder of pigmentation of the bowel wall. Histology demonstrates pigment-laden macrophages. It is associated with laxative abuse, especially anthraquinone compounds such as senna

Answer 118

Epidemiology Rare More common in children than adults Females are slightly more affected than males

Answer 119

Aetiology Unknown 80% of children and 25% of adults who develop CVS also have migraines Presentation Severe nausea and sudden vomiting lasting hours to days Prodromal intense sweating and nausea Well in between episodes

Answer 120

Aetiology Unknown 80% of children and 25% of adults who develop CVS also have migraines Presentation Severe nausea and sudden vomiting lasting hours to days Prodromal intense sweating and nausea Well in between episodes The following may be present: Weight loss Reduced appetite Abdominal pain Diarrhoea Dizziness Photophobia Headache

Answer 121

Investigations Clinical Diagnosis A pregnancy test may be considered in women Routine blood tests to exclude any underlying conditions Management Avoidance of triggers Prophylactic treatments include amitriptyline, propranolol and topiramate. Ondansetron, prochlorperazine and triptans in acute episodes.

Answer 122

Whipple's disease is a rare multi-system disorder caused by Tropheryma whippelii infection. It is more common in those who are HLA-B27 positive and in middle-aged men. Features malabsorption: diarrhoea, weight loss large-joint arthralgia lymphadenopathy skin: hyperpigmentation and photosensitivity pleurisy, pericarditis neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus

Answer 123

nvestigation jejunal biopsy shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules Management guidelines vary: oral co-trimoxazole for a year is thought to have the lowest relapse rate, sometimes preceded by a course of IV penicillin

Answer 124

utoimmune hepatitis is condition of unknown aetiology which is most commonly seen in young females. Recognised associations include other autoimmune disorders, hypergammaglobulinaemia and HLA B8, DR3. Three types of autoimmune hepatitis have been characterised according to the types of circulating antibodies present

Answer 125

Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA) Affects both adults and children

Answer 126

Anti-liver/kidney microsomal type 1 antibodies (LKM1) Affects children only

Answer 127

Soluble liver-kidney antigen Affects adults in middle-age

Answer 128

Features may present with signs of chronic liver disease acute hepatitis: fever, jaundice etc (only 25% present in this way) amenorrhoea (common) ANA/SMA/LKM1 antibodies, raised IgG levels liver biopsy: inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis

Answer 129

Management steroids, other immunosuppressants e.g. azathioprine liver transplantation

Answer 130

The following drugs tend to cause a hepatocellular picture: paracetamol sodium valproate, phenytoin MAOIs halothane anti-tuberculosis: isoniazid, rifampicin, pyrazinamide statins alcohol amiodarone methyldopa nitrofurantoin

Answer 131

The following drugs tend to cause cholestasis (+/- hepatitis): combined oral contraceptive pill antibiotics: flucloxacillin, co-amoxiclav, erythromycin* anabolic steroids, testosterones phenothiazines: chlorpromazine, prochlorperazine sulphonylureas fibrates rare reported causes: nifedipine

Answer 132

iver cirrhosis methotrexate methyldopa amiodarone

Answer 133

Gilbert's syndrome is an autosomal recessive* condition of defective bilirubin conjugation due to a deficiency of UDP glucuronosyltransferase. The prevalence is approximately 1-2% in the general population. Features unconjugated hyperbilirubinaemia (i.e. not in urine) jaundice may only be seen during an intercurrent illness, exercise or fasting

Answer 134

Investigation and management investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid no treatment required

Answer 135

Common symptoms include: nausea and vomiting, anorexia myalgia lethargy right upper quadrant (RUQ) pain Questions may point to risk factors such as foreign travel or intravenous drug use.

Answer 136

The liver only usually causes pain if stretched. One common way this can occur is as a consequence of congestive heart failure. In severe cases cirrhosis may occur.

Answer 137

Pain similar to biliary colic but more severe and persistent. The pain may radiate to the back or right shoulder. The patient may be pyrexial and Murphy's sign positive (arrest of inspiration on palpation of the RUQ)

Answer 138

n infection of the bile ducts commonly secondary to gallstones. Classically presents with a triad of: fever (rigors are common) RUQ pain jaundice

Answer 139

Persistent biliary colic symptoms, associated with anorexia, jaundice and weight loss. A palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen

Answer 140

Usually due to alcohol or gallstones Severe epigastric pain Vomiting is common Examination may reveal tenderness, ileus and low-grade fever Periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign) is described but rare

Answer 141

Typical symptoms are malaise, anorexia and weight loss. The associated RUQ pain tends to be mild and jaundice is uncommon.

Answer 142

Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of liver disease in the developed world. It is largely caused by obesity and describes a spectrum of disease ranging from: steatosis - fat in the liver steatohepatitis - fat with inflammation, non-alcoholic steatohepatitis (NASH), see below progressive disease may cause fibrosis and liver cirrhosis

Answer 143

NAFLD is thought to represent the hepatic manifestation of the metabolic syndrome and hence insulin resistance is thought to be the key mechanism leading to steatosis. Non-alcoholic steatohepatitis (NASH) is a term used to describe liver changes similar to those seen in alcoholic hepatitis in the absence of a history of alcohol abuse. It is relatively common and thought to affect around 3-4% of the general population. The progression of disease in patients with NASH may be responsible for a proportion of patients previously labelled as cryptogenic cirrhosis.

Answer 144

Associated factors obesity type 2 diabetes mellitus hyperlipidaemia jejunoileal bypass sudden weight loss/starvation

Answer 145

Features usually asymptomatic hepatomegaly ALT is typically greater than AST increased echogenicity on ultrasound

Answer 146

NICE produced guidelines on the investigation and management of NAFLD in 2016. Key points: there is no evidence to support screening for NAFLD in adults, even in at risk groups (e.g. type 2 diabetes) the guidelines are therefore based on the management of the incidental finding of NAFLD - typically asymptomatic fatty changes on liver ultrasound in these patients, NICE recommends the use of the enhanced liver fibrosis (ELF) blood test to check for advanced fibrosis the ELF blood test is a combination of hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1. An algorithm based on these values results in an ELF blood test score, similar to triple testing for Down's syndrome

Answer 147

Patients who are likely to have advanced fibrosis should be referred to a liver specialist. They will then likely have a liver biopsy to stage the disease more accurately. Management the mainstay of treatment is lifestyle changes (particularly weight loss) and monitoring there is ongoing research into the role of gastric banding and insulin-sensitising drugs (e.g. metformin, pioglitazone)

Answer 148

Primary biliary cholangitis (previously referred to as primary biliary cirrhosis) is a chronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1). The aetiology is not fully understood although it is thought to be an autoimmune condition. Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis which may eventually progress to cirrhosis. The classic presentation is itching in a middle-aged woman

Answer 149

Associations Sjogren's syndrome (seen in up to 80% of patients) rheumatoid arthritis systemic sclerosis thyroid disease

Answer 150

Clinical features early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus cholestatic jaundice hyperpigmentation, especially over pressure points around 10% of patients have right upper quadrant pain xanthelasmas, xanthomata also: clubbing, hepatosplenomegaly late: may progress to liver failure

Answer 151

Diagnosis immunology anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific smooth muscle antibodies in 30% of patients raised serum IgM imaging required before diagnosis to exclude an extrahepatic biliary obstruction (typically a right upper quadrant ultrasound or magnetic resonance cholangiopancreatography (MRCP)

Answer 152

Management first-line: ursodeoxycholic acid slows disease progression and improves symptoms pruritus: cholestyramine fat-soluble vitamin supplementation liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) recurrence in graft can occur but is not usually a problem

Answer 153

Complications cirrhosis → portal hypertension → ascites, variceal haemorrhage osteomalacia and osteoporosis significantly increased risk of hepatocellular carcinoma (20-fold increased risk)

Answer 154

Primary sclerosing cholangitis is a biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts. Associations ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC Crohn's (much less common association than UC) HIV

Answer 155

Features cholestasis jaundice, pruritus raised bilirubin + ALP right upper quadrant pain fatigue

Answer 156

nvestigation endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) are the standard diagnostic investigations, showing multiple biliary strictures giving a 'beaded' appearance p-ANCA may be positive there is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often described as 'onion skin'

Answer 157

Complications cholangiocarcinoma (in 10%) increased risk of colorectal cancer

Answer 158

Hepatocellular carcinoma (HCC) is the third most common cause of cancer worldwide. Chronic hepatitis B is the most common cause of HCC worldwide with chronic hepatitis C being the most common cause in Europe.

Answer 159

The main risk factor for developing HCC is liver cirrhosis, for example secondary* to hepatitis B & C, alcohol, haemochromatosis and primary biliary cirrhosis. Other risk factors include: alpha-1 antitrypsin deficiency hereditary tyrosinosis glycogen storage disease aflatoxin drugs: oral contraceptive pill, anabolic steroids porphyria cutanea tarda male sex diabetes mellitus, metabolic syndrome

Answer 160

Features tends to present late features of liver cirrhosis or failure may be seen: jaundice, ascites, RUQ pain, hepatomegaly, pruritus, splenomegaly possible presentation is decompensation in a patient with chronic liver disease raised AFP

Answer 161

Screening with ultrasound (+/- alpha-fetoprotein) should be considered for high risk groups such as: patients liver cirrhosis secondary to hepatitis B & C or haemochromatosis men with liver cirrhosis secondary to alcohol

Answer 162

Management options early disease: surgical resection liver transplantation radiofrequency ablation transarterial chemoembolisation sorafenib: a multikinase inhibitor

Answer 163

Pancreatic cancer is often diagnosed late as it tends to present in a non-specific way. Over 80% of pancreatic tumours are adenocarcinomas which typically occur at the head of the pancreas.

Answer 164

Associations increasing age smoking diabetes chronic pancreatitis (alcohol does not appear an independent risk factor though) hereditary non-polyposis colorectal carcinoma multiple endocrine neoplasia BRCA2 gene KRAS gene mutation

Answer 165

Features classically painless jaundice pale stools, dark urine, and pruritus cholestatic liver function tests the following abdominal masses may be found (in decreasing order of frequency) hepatomegaly: due to metastases gallbladder: Courvoisier's law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones epigastric mass: from the primary tumour many patients present in a non-specific way with anorexia, weight loss, epigastric pain loss of exocrine function (e.g. steatorrhoea) loss of endocrine function (e.g. diabetes mellitus) atypical back pain is often seen migratory thrombophlebitis (Trousseau sign) is more common than with other cancers

Answer 166

Investigation ultrasound has a sensitivity of around 60-90% high-resolution CT scanning is the investigation of choice if the diagnosis is suspected imaging may demonstrate the 'double duct' sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts

Answer 167

Management less than 20% are suitable for surgery at diagnosis a Whipple's resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple's include dumping syndrome and peptic ulcer disease adjuvant chemotherapy is usually given following surgery ERCP with stenting is often used for palliation

Answer 168

Wilson's disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson's disease is caused by a defect in the ATP7B gene located on chromosome 13. The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease

Answer 169

Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea: liver: hepatitis, cirrhosis neurological: basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus speech, behavioural and psychiatric problems are often the first manifestations also: asterixis, chorea, dementia, parkinsonism Kayser-Fleischer rings green-brown rings in the periphery of the iris due to copper accumulation in Descemet membrane present in around 50% of patients with isolated hepatic Wilson's disease and 90% who have neurological involvement renal tubular acidosis (esp. Fanconi syndrome) haemolysis blue nails

Answer 170

nvestigations slit lamp examination for Kayser-Fleischer rings reduced serum caeruloplasmin reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) free (non-ceruloplasmin-bound) serum copper is increased increased 24hr urinary copper excretion the diagnosis is confirmed by genetic analysis of the ATP7B gene

Answer 171

Management penicillamine (chelates copper) has been the traditional first-line treatment trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future tetrathiomolybdate is a newer agent that is currently under investigation

Answer 172

udd-Chiari syndrome, or hepatic vein thrombosis, is usually seen in the context of underlying haematological disease or another procoagulant condition. Causes polycythaemia rubra vera thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies pregnancy combined oral contraceptive pill: accounts for around 20% of cases

Answer 173

The features are classically a triad of: abdominal pain: sudden onset, severe ascites → abdominal distension tender hepatomegaly

Answer 174

Investigations ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation

Answer 175

Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6*. It is often asymptomatic in early disease and initial symptoms often non-specific e.g. lethargy and arthralgia Epidemiology 1 in 10 people of European descent carry a mutation in the genes affecting iron metabolism, mainly HFE prevalence in people of European descent = 1 in 200, making it more common than cystic fibrosis

Answer 176

resenting features early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands) 'bronze' skin pigmentation diabetes mellitus liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition) cardiac failure (2nd to dilated cardiomyopathy) hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism) arthritis (especially of the hands)

Answer 177

Cardiomyopathy Skin pigmentation

Answer 178

Liver cirrhosis** Diabetes mellitus Hypogonadotrophic hypogonadism Arthropathy

Answer 179

There is continued debate about the best investigation to screen for haemochromatosis. general population transferrin saturation is considered the most useful marker ferritin should also be measured but is not usually abnormal in the early stages of iron accumulation testing family members genetic testing for HFE mutation These guidelines may change as HFE gene analysis become less expensive Typical iron study profile in patient with haemochromatosis transferrin saturation > 55% in men or > 50% in women raised ferritin (e.g. > 500 ug/l) and iron low TIBC

Answer 180

Further tests liver function tests molecular genetic testing for the C282Y and H63D mutations MRI is generally used to quantify liver and/or cardiac iron liver biopsy is now generally only used if suspected hepatic cirrhosis

Answer 181

Outline venesection is the first-line treatment monitoring adequacy of venesection: transferrin saturation should be kept below 50% and the serum ferritin concentration below 50 ug/l desferrioxamine may be used second-line

Answer 182

Ferritin is an intracellular protein that binds iron and stores it to be released in a controlled fashion at sites where iron is required.

Answer 183

This is typically defined as > 300 µg/L in men/postmenopausal women and > 200 µµg/L in premenopausal women. Ferritin is an acute phase protein and may be synthesised in increased quantities in situations where inflammatory activity is ongoing. Falsely elevated results may therefore be encountered clinically and need to be taken in the context of the clinical picture and blood results. We can split the causes of increased ferritin levels into 2 distinct categories; without iron overload and with iron overload The best test to see whether iron overload is present is transferrin saturation. Typically, normal values of < 45% in females and < 50% in males exclude iron overload.

Answer 184

Inflammation (due to ferritin being an acute phase reactant) Alcohol excess Liver disease Chronic kidney disease Malignancy

Answer 185

Primary iron overload (hereditary haemochromatosis) Secondary iron overload (e.g. following repeated transfusions)

Answer 186

Carcinoid syndrome usually occurs when metastases are present in the liver and release serotonin into the systemic circulation may also occur with lung carcinoid as mediators are not 'cleared' by the liver

Answer 187

Features flushing (often the 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 resulting in, for example, Cushing's syndrome pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour

Answer 188

nvestigation urinary 5-HIAA plasma chromogranin A y Management somatostatin analogues e.g. octreotide diarrhoea: cyproheptadine may help

Answer 189

unconjugated

Answer 190

conjugated

Answer 191

Crigler-Najjar syndrome, type 1 autosomal recessive absolute deficiency of UDP-glucuronosyl transferase do not survive to adulthood Crigler-Najjar syndrome, type 2 slightly more common than type 1 and less severe may improve with phenobarbital

Answer 192

Dubin-Johnson syndrome autosomal recessive. Relatively common in Iranian Jews mutation in the canalicular multidrug resistance protein 2 (MRP2) results in defective hepatic excretion of bilirubin results in a grossly black liver benign

Answer 193

Rotor syndrome autosomal recessive defect in the hepatic uptake and storage of bilirubin benign

Answer 194

Interpreting hepatitis B serology is a dying art form which still occurs at regular intervals in medical exams. It is important to remember a few key facts: surface antigen (HBsAg) is the first marker to appear and causes the production of anti-HBs HBsAg normally implies acute disease (present for 1-6 months) if HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective) Anti-HBs implies immunity (either exposure or immunisation). It is negative in chronic disease Anti-HBc implies previous (or current) infection. IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months. IgG anti-HBc persists HbeAg results from breakdown of core antigen from infected liver cells as is, therefore, a marker of infectivity. Marker of HBV replication and infectivity HBsAg = ongoing infection, either acute or chronic if present > 6 months anti-HBc = caught, i.e. negative if immunized

Answer 195

Example results previous immunisation: anti-HBs positive, all others negative previous hepatitis B (> 6 months ago), not a carrier: anti-HBc positive, HBsAg negative previous hepatitis B, now a carrier: anti-HBc positive, HBsAg positive

Answer 196

NICE defines malnutrition as the following: a Body Mass Index (BMI) of less than 18.5; or unintentional weight loss greater than 10% within the last 3-6 months; or a BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months

Answer 197

Screening for malnutrition is mostly done using MUST (Malnutrition Universal Screen Tool). A link is provided to a copy of the MUST score algorithm. it should be done on admission to care/nursing homes and hospital, or if there is a concern. For example an elderly, thin patient with pressure sores it takes into account BMI, recent weight change and the presence of acute disease categorises patients into low, medium and high risk

Answer 198

Management of malnutrition is difficult. NICE recommend the following points: dietician support if the patient is at high-risk a 'food-first' approach with clear instructions (e.g. 'add full-fat cream to mashed potato'), rather than just prescribing oral nutritional supplements (ONS) such as Ensure if ONS are used they should be taken between meals, rather than instead of meals

Answer 199

Metoclopramide is a D2 receptor antagonist* mainly used in the management of nausea. Other uses include: gastro-oesophageal reflux disease prokinetic action is useful in gastroparesis secondary to diabetic neuropathy often combined with analgesics for the treatment of migraine (migraine attacks result in gastroparesis, slowing the absorption of analgesics)

Answer 200

Adverse effects extrapyramidal effects acute dystonia e.g. oculogyric crisis this is particularly a problem in children and young adults diarrhoea hyperprolactinaemia tardive dyskinesia parkinsonism

Answer 201

Common causes of hepatomegaly Cirrhosis: if early disease, later liver decreases in size. Associated with a non-tender, firm liver Malignancy: metastatic spread or primary hepatoma. Associated with a hard, irregular. liver edge Right heart failure: firm, smooth, tender liver edge. May be pulsatile

Answer 202

Proton pump inhibitors (PPI) cause irreversible blockade of H+/K+ ATPase of the gastric parietal cell. Examples include omeprazole and lansoprazole.

Answer 203

Adverse effects hyponatraemia, hypomagnasaemia osteoporosis → increased risk of fractures microscopic colitis increased risk of C. difficile infections

Answer 204

For many years the Child-Pugh classification was used to classify the severity of liver cirrhosis. However, in recent years the Model for End-Stage Liver Disease (MELD) has been increasingly used, particularly patient's who are on a liver transplant waiting list

Answer 205

Score 1 2 3 Bilirubin (µmol/l) <34 34-50 >50 Albumin (g/l) >35 28-35 <28 Prothrombin time, prolonged by (s) <4 4-6 >6 Encephalopathy none mild marked Ascites none mild marked

Answer 206

Summation of the scores allows the severity to be graded either A, B or C: < 7 = A 7-9 = B > 9 = C

Answer 207

MELD Uses a combination of a patient's bilirubin, creatinine, and the international normalized ratio (INR) to predict survival. A formula is used to calculate the score: MELD = 3.78×ln[serum bilirubin (mg/dL)] + 11.2×ln[INR] + 9.57×ln[serum creatinine (mg/dL)] + 6.43 The 3-month mortality based on MELD scores: 40 or more: 71.3% mortality 30 - 39: 52.6% mortality 20 - 29: 19.6% mortality 10 - 19: 6.0% mortality < 9: 1.9% mortality

Answer 208

Pernicious anaemia is an autoimmune disorder affecting the gastric mucosa that results in vitamin B12 deficiency. It is helpful to remember that pernicious means 'causing harm, especially in a gradual or subtle way' - the symptoms of signs are often subtle and diagnose is often delayed. Whilst pernicious anaemia is the most common cause of vitamin B12 deficiency, it's not the only cause. Other causes include atrophic gastritis (e.g. secondary to H. pylori infection), gastrectomy, malnutrition (e.g. alcoholism).

Answer 209

Pathophysiology antibodies to intrinsic factor +/- gastric parietal cells intrinsic factor antibodies → bind to intrinsic factor blocking the vitamin B12 binding site gastric parietal cell antibodies → reduced acid production and atrophic gastritis. Reduced intrinsic factor production → reduced vitamin B12 absorption vitamin B12 is important in both the production of blood cells and the myelination of nerves → megaloblastic anaemia and neuropathy

Answer 210

Risk factors more common in females (F:M = 1.6:1) and typically develops in middle to old age associated with other autoimmune disorders: thyroid disease, type 1 diabetes mellitus, Addison's, rheumatoid and vitiligo more common if blood group A

Answer 211

Features anaemia features lethargy pallor dyspnoea neurological features peripheral neuropathy: 'pins and needles', numbness. Typically symmetrical and affects the legs more than the arms subacute combined degeneration of the spinal cord: progressive weakness, ataxia and paresthesias that may progress to spasticity and paraplegia neuropsychiatric features: memory loss, poor concentration, confusion, depression, irritabiltiy other features mild jaundice: combined with pallor results in a 'lemon tinge' glossitis → sore tongue

Answer 212

nvestigation full blood count macrocytic anaemia: macrocytosis may be absent in around of 30% of patients hypersegmented polymorphs on blood film low WCC and platelets may also be seen vitamin B12 and folate levels a vitamin B12 level of >= 200 nh/L is generally considered to be normal antibodies anti intrinsic factor antibodies: sensivity is only 50% but highly specific for pernicious anaemia (95-100%) anti gastric parietal cell antibodies in 90% but low specificity so often not useful clinically Schilling test is no longer routinely done radiolabelled B12 given on two occasions, firstly on its own, secondly with oral IF. Urine B12 levels are then measured

Answer 213

Management vitamin B12 replacement usually given intramuscularly no neurological features: 3 injections per week for 2 weeks followed by 3 monthly treatment of vitamin B12 injections more frequent doses are given for patients with neurological features there is some evidence that oral vitamin B12 may be effective for providing maintenance levels of vitamin B12 but it is not yet common practice folic acid supplementation may also be required Complications other than the haematological and neurological features detailed above increased risk of gastric cancer

Answer 214

Functions cofactor for the conversion of homocysteine into methionine via the enzyme homocysteine methyltransferase cofactor for the isomerization of methylmalonyl CoA to Succinyl Co A via the enzyme methylmalonyl mutase used to regenerate folic acid in the body

Answer 215

Causes of vitamin B12 deficiency: pernicious anaemia Diphyllobothrium latum infection Crohn's disease

Answer 216

Vitamin A is a fat soluble vitamin. Functions converted into retinal, an important visual pigment important in epithelial cell differentiation antioxidant Consequences of vitamin A deficiency night blindness

Answer 217

Thiamine is a water soluble vitamin of the B complex group. One of it's phosphate derivates, thiamine pyrophosphate (TPP), is a coenzyme in the following enzymatic reactions: pyruvate dehydrogenase complex pyruvate decarboxylase in ethanol fermentation alpha-ketoglutarate dehydrogenase complex branched-chain amino acid dehydrogenase complex 2-hydroxyphytanoyl-CoA lyase transketolase Thiamine is therefore important in the catabolism of sugars and aminoacids. The clinical consequences of thiamine deficiency are therefore seen first in highly aerobic tissues such as the brain (Wenicke-Korsakoff syndrome) and the heart (wet beriberi).

Answer 218

Causes of thiamine deficiency: alcohol excess. Thiamine supplements are the only routinely recommend supplement in patients with alcoholism malnutrition

Answer 219

Conditions associated with thiamine deficiency: Wernicke's encephalopathy: nystagmus, ophthalmoplegia and ataxia Korsakoff's syndrome: amnesia, confabulation dry beriberi: peripheral neuropathy wet beriberi: dilated cardiomyopathy

Answer 220

Vitamin C is a water soluble vitamin. Functions -antioxidant -collagen synthesis: acts as a cofactor for enzymes that are required for the -hydroxylation proline and lysine in the synthesis of collagen -facilitates iron absorption -cofactor for norepinephrine synthesis

Answer 221

Vitamin C deficiency (scurvy) leads to defective synthesis of collagen resulting in capillary fragility (bleeding tendency) and poor wound healing Features vitamin C deficiency gingivitis, loose teeth poor wound healing bleeding from gums, haematuria, epistaxis general malaise Ecchymosis, easy bruising