Gastroenterology

Question 1

Inducing remission in UC

Answer 1

1)Proctitis
- topical (rectal) aminosalicylate
- after 4 weeks, add an oral aminosalicylate
- add topical or oral corticosteroid
2) proctosigmoiditis and left-sided ulcerative colitis
- topical (rectal) aminosalicylate
- after 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
- stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
3) extensive disease
- topical (rectal) aminosalicylate and a high-dose oral aminosalicylate
- after 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid

4)SEVERE colitis
-admit
- IV steroids are usually given first-line
(IV ciclosporin may be used if steroids are contraindicated)
- after 72 hours add IV ciclosporin to IV corticosteroids or consider surgery

Question 2

Maintenance of remission in UC

Answer 2

Following a mild-to-moderate ulcerative colitis flare:
1) 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
2)left-sided and extensive ulcerative colitis
- low maintenance dose of an oral aminosalicylate

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

Question 3

Inducing remission in Crohn’s disease

Answer 3

1st line- glucocorticoids (PO, topical or IV)
2nd line- 5-ASA drugs e.g. mesalazine
3rd line- can add on azathioprine or mercaptopurine

NOTE: metro used for isolated peri-anal disease

Question 4

Maintaining remission in Crohn’s disease

Answer 4

1st line- azathioprine or mercaptopurine (NOTE: TPMT activity should be assessed before starting)
2nd line- methotrexate is used second-line

Question 5

What is the most useful investigations to monitor response to haemochromatosis management?

Answer 5

Ferritin and transferrin saturation

Question 6

What are the possible adverse effects of metoclopramide?

Answer 6

1) extrapyramidal effects
-acute dystonia e.g. oculogyric crisis
2) diarrhoea
3) hyperprolactinaemia
4) tardive dyskinesia
5) parkinsonism

Question 7

What are ALT, ALP and ALT/ALP ratio in hepatocellular disease (paracetamol OD)?

Answer 7

Raised (at least 2 fold) ALT, ALP normal, ALT/ALP high (5+)

Question 8

What are ALT, ALP and ALT/ALP ratio in Cholestatic disease?

Answer 8

Normal ALT. Raised ALP (at least 2 fold), ALT/ALP <2

Question 9

How do you treat bile acid malabsorption?

Answer 9

Cholestyramine

Question 10

What are risk factors for small bowel bacterial overgrowth syndrome?

Answer 10

neonates
scleroderma
diabetes mellitus

Question 10

What are both types of oesophageal cacner associated with?

Answer 10

Adenocarcinoma- Barrett’s oesophagus (US/UK)- lower third
Squamous cell carcinoma- Achalasia (third world)- upper two thirds

Question 11

What is TIBC in IDA vs in Anaemia of Chronic disease?

Answer 11

IDA- high TIBC
Anaemia of Chronic Disease- low/normal

Question 12

What is Peutz-Jeghers syndrome?

Answer 12

• Autosomal dominant
  -Hamartomatous polpypis in GI tract (mainly small bowel)
  -Can present as small bowel obstruction or GI bleeding
  -Pigmented lesions on lips, oral mucosa, face, palms and soles

Question 13

How do you treat a complex perianal abscess?

Answer 13

Seton placement

Question 14

How do you treat someone with both vitamin B12 and folic acid deficiencies?

Answer 14

treat the B12 deficiency first to avoid precipitating subacute combined degeneration of the cord

Administer intramuscular vitamin B12 followed by oral folic acid

Question 15

How does achalasia present?

Answer 15

dysphagia of BOTH liquids and solids

Question 16

What are the investigations for achalasia?

Answer 16

1) oesophageal manometry
- considered the most important diagnostic test

2) barium swallow
- ‘bird’s beak’ appearance

3) chest x-ray
- wide mediastinum
- fluid level

Question 17

What is the Glasgow-Blatchford score?

Answer 17

helps clinicians decide whether patients can be managed as outpatients or not in the context of GI bleeds

Question 18

What is the Rockall score?

Answer 18

used after endoscopy
provides a percentage risk of rebleeding and mortality

Question 19

Management of non-variceal bleeds?

Answer 19

PPIs then endoscopy

Question 20

Management of variceal bleeds?

Answer 20

1st: terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)

2nd: band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices

3rd: transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures

Question 21

What is the management of alcoholic hepatitis?

Answer 21

1) glucocorticoids (e.g. prednisolone) during acute episodes

2) pentoxyphylline is also sometimes used

Question 22

What is angiodysplasia?

Answer 22

Angiodysplasia is a vascular deformity of the gastrointestinal tract which predisposes to bleeding and iron deficiency anaemia.

Question 23

How is angiodysplasia diagnosed?

Answer 23

• colonoscopy
• mesenteric angiography if acutely bleeding

Question 24

What is the management of angiodysplasia?

Answer 24

• endoscopic cautery or argon plasma coagulation
• antifibrinolytics e.g. Tranexamic acid
• oestrogens may also be used

Question 25

What are the clinical features of Budd-Chiari syndrome?

Answer 25

TRIAD
1) abdominal pain: sudden onset, severe
2) ascites → abdominal distension
3) tender hepatomegaly

Question 26

What is the investigation for Budd-Chiari?

Answer 26

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

Question 27

What are the investigations for carcinoid tumours?

Answer 27

1) urinary 5-HIAA
2) plasma chromogranin A y

Question 28

What is the management of carcinoid tumours?

Answer 28

1) somatostatin analogues e.g. octreotide
2) diarrhoea: cyproheptadine may help

Question 29

What is management of cyclical vomiting?

Answer 29

1) Avoidance of triggers
2) Prophylactic treatments e.g. amitriptyline, propranolol and topiramate.
3) Acute episodes: Ondansetron, prochlorperazine and triptans

Question 30

What is the mode of inheritance of haemochromatosis?

Answer 30

Autosomal recessive

Question 31

What are the complications of haemachromatosis?

Answer 31

Reversible:

Cardiomyopathy
Skin pigmentation

Irreversible:

Liver cirrhosis**
Diabetes mellitus
Hypogonadotrophic hypogonadism
Arthropathy

Question 32

What is the mode of inheritance in Gilbert’s syndrome?

Answer 32

Autosomal recessive

Question 33

What is the most common cause of hepatocellular carcinoma worldwide and in Europe?

Answer 33

Worldwide: Hep B
Europe: Hep C

Question 34

What is Whipple’s disease?

Answer 34

• rare multi-system disorder caused by Tropheryma whippelii infection. - - - more common in those who are HLA-B27 positive and in middle-aged men.

Question 35

What is the investigation for Whipple’s disease and what do you expect to see?

Answer 35

jejunal biopsy: shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules

Question 36

What is the management of Whipple’s disease?

Answer 36

oral co-trimoxazole for a year (lowest risk of relapse)

Sometimes preceded by course of IV penicillin

Question 37

What is the mode of inheritance of Wilson’s disease?

Answer 37

Autosomal recessive

Question 38

What is the management of Wilson’s disease?

Answer 38

penicillamine (chelates copper)