Gastroenterology Flashcards
1
Q
Which blood test is the best to screen for hepatitis B infection?
A
HBsAg - surface antigen - implies active infection or chronic disease. In acute - present for 1-6 months. If present >6months - chronic
2
Q
What is the first marker to appear in acute hepatitis B infection?
A
HBsAg
3
Q
Will there be anti-HBs in chronic Hepatitis B?
A
No - negative in chronic disease
4
Q
What does anti-HBs imply?
A
Immunity - either previous exposure or immunisation
5
Q
What does the presence of anti-HBc signify?
A
Either acute or previous infection - IgM anti-HBc in acute or recent infection, present for 6 months. IgG persists long term
6
Q
What does HBeAg indicate?
A
Breakdown of core antigen from liver cells - marker of infectivity and viral replication
7
Q
What will hep B blood tests show in someone who is immunised?
A
Anti-HBs positive, all else negative
8
Q
What will blood tests show in someone with previous hepatitis B infection who is not a carrier?
A
Anti-HBc positive, anti-HBs negative
9
Q
What is a recognised complication of TIPSS procedure?
A
exacerbation of hepatic encephalopathy
10
Q
What are 3 forms of prophylaxis for oesophageal varices?
A
- propranolol
- endoscopy variceal band ligation- should be done 2 weeks apart until all varices banded
- TIPSS if above unsuccessful
11
Q
What should be done along side prophylactic EVL for varices?
A
PPI cover to prevent EVL-related ulceration
12
Q
What is melanosis coli?
A
caused by laxative abuse - anthraquinone compounds e.g. senna, cascara result in pigment-laden macrophages in the bowel
13
Q
When is the carbon isotope 13 (13C) urea breath test not recommended to diagnosis H pylori?
A
- within 4 weeks of treatment with antibiotics
- within 2 weeks of antisecretory drug e.g. PPI
14
Q
How is the urea breath test performed?
A
- patients consume drink containing carbon isotope 13 (13C) enriched urea
- broken down by H pylori urease
- after 30 min patient exhales into glass tube - mass spectrometry analysis calculates amount of 13C CO2
15
Q
What is the CLO test?
A
rapid urease test for H pylori; bippsy sample mixed with urea and pH indicator, colour change if H pylori urease activity
16
Q
What is a drawback of using serum antibody to diagnose H pylori?
A
remains positive after eradication
17
Q
What is the difference between culture of gastric biopsy and gastric biopsy for diagnosing H pylori?
A
culture will provide info on abx sensitivity; gatsric biopsy provides histological evaluation alone, no culture
18
Q
What are 3 risk factors for giardiasis?
A
- foreign travel
- swimming / drinking water from a river or lake
- male-male sexual contact
19
Q
What are 3 investigations for giardiasis?
A
- stool microscopy for trophozoite and cysts - sensitivity 65%
- stool antigen detection assay - greater sensivitiy and quicker
- PCR assays being developed
20
Q
How serioues is hepatitis A?
A
typically a benign, self-limiting disease - serious outcome very rare
21
Q
What is the incubation period for hepatitis A?
A
2-4 weeks
22
Q
What are 5 factors associated with NAFLD?
A
- obesity
- T2DM
- hyperlipidaemia
- jejunoileal bypass
- sudden weight loss/ starvation
23
Q
What type of virus causes hepatitis A?
A
RNA picornavirus
24
Q
How is hepatitis A spread?
A
faeco-oral route, often in institutions
25
What are the clinical features of hepatitis A?
* flu-like prodrome
* RUQ pain
* tender hepatomegaly
* jaundice
* deranged LFTs
26
What vaccination is available for hepatitis A?
effective vaccine available, booster dose should be given 6-12 months after the initial dose
27
What are 6 groups of people who should be vaccinated for hepatitis A?
1. people travelling to / going to reside in areas of intermediate - high prevalence if aged >1 year
2. chronic liver disease
3. haemophilia
4. MSM
5. IVDU
6. occupational risk: lab worker, staff of large residential institutions, sewage, primates
28
What is thought to be the main mechanism by whcih obesity leads to NAFLD?
insulin resistance
29
What LFT findings are present in NAFLD?
ALT typically greater than AST
30
What test is used to test for advanced fibrosis in incidentally identified NAFLD (asymptomatic fatty changes on liver US)?
**ELF blood test** (enhanced liver fibrosis) - hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1
31
What is the mainstay of treatment for NAFLD?
lifestyle changes (weight loss) + monitoring (research into role of gastric-banding and insulin-sensitising drugs e.g. metformin, pioglitazone)
32
What is the management of advanced fibrosis in patients with NAFLD?
referred to liver specialist - likely to have liver biopsy to stage more accurately
33
What do blood tests typically show in alcoholic liver disease?
AST/ALT ratio >2:1, GGT > 2x normal
34
What distinguishes chronic hep B from acute hep B in blood tests?
anti-HBc antibody positive in chronic (not acute)
35
What is the leading cause of chronic viral infection of the liver in the West?
hepatitis C
36
Which gender is classically affected by AIH?
female
37
What are 4 characteristic blood tests in AIH?
1. high gamma globulins, esp IgG
2. High transaminases >2000
3. ANA
4. SMA
38
What are 9 features of haemochromatosis?
1. cutaneous hyperpigmentation - bronze
2. diabetes mellitus
3. chronic liver disease
4. dilated cardiomyopathy
5. cardiac conduction disorders
6. hypothyroidism
7. hypogonadism - impotence, loss of libido
9. arthropathy
39
What are 4 examples of causes of secondary NAFLD?
1. amiodarone
2. tamoxigen
3. hep C
4. PCOS
40
What is found on blood tests in NAFLD?
ALT raised up to 3x ULN, ALT:AST >1. persistent elevation LFTs for >3 months
41
What is the inheritance pattern of hereditary haemochromatosis?
autosomal recessive
42
Which race is typically affected by haemochromatosis?
caucasian
43
What type of arthralgias are common in haemochromatosis?
pseudogout and chronic arthropathy; small joints of hands commonly affected
44
What blood tests are key in diagnosing haemochromatosis?
transferrin saturation (30% is normal) rises >45% (+ ferritin elevated)
45
What is the inheritance pattern of Wilson's disease?
autosomal recessive
46
What is the characteristic blood test finding in Wilson's disease?
reduced serum caeruloplasmin
47
What type of hyperbilirubinaemia is seen in Gilbert's syndrome?
unconjugated (no bilirubinuria)
48
What 2 things increase the unconjugated plasma bilirubin in Gilbert's syndrome?
1. low energy diet
2. IV injection of nicotinic acid
49
What are 6 conditions that predispose to Budd-Chiari syndrome?
1. myeloproliferative disorders e.g. PCV, paroxysmal nocturnal haemoglobinuria
2. pregnancy
3. tumours
4. chronic inflammatory diseases
5. clotting disorders
6. infections
50
What are 5 key features of the presentation of Budd Chiari syndrome?
1. hepatomegaly
2. ascites
3. abdominal pain
4. LFTs may be mildly elevated
5. ascitic fluid has high protein content
51
What may be present on imaging in Budd-Chiari syndrome?
* CT or MTI may show prominent caudate lobe
* doppler US may help exclude hepatic venous or inferior vena cava thrombosis
52
What will liver biopsy show in Budd-Chiari syndrome?
centrilobular congestion
53
What are 3 possible aspects of the treatment of Budd-Chiari syndrome?
1. treat underlying haematological condition
2. surgical decompression of liver e.g. TIPS, balloon angioplasty/stent for inferior vena caval web
3. liver transplant
54
In which part of the pancreas do most pancreatic carcinoma cases occur?
head of pancreas (70%)
55
what is Courvoisier's law?
in the presence of a palpable gallbladder, painless jaundice is unlikely ot be caused by gallstones (gallstones cause shrunken, fibrotic gallbladder)
56
What is the management of pancreatic carcinoma?
surgery (radical pancreaticoduodenectomy aka Whipple's) - suitable in <10% who present
57
What is the first line management for mild to moderate C difficile infection?
oral vancomycin 10 days
58
What are 5 complications of Clostridium difficile infection?
1. Pseudomembranous colitis
2. Toxic megacolon
3. Perforation of the colon
4. Sepsis
5. Death
59
What is the second line management for mild to moderate C difficile infection?
oral fidaxomicin, 10 days
60
What are the causes of portal hypertension and how can they be divided?
1. **Pre-hepatic** - portal vein thrombosis, abdo trauma
2. **Intrahepatic - presinusoidal**: schistosomiasis, drugs, sarcoid
3. **Intrahepatic - sinusoidal**: cirrhosis, polycystic liver, metastatic malignant disease
4. **Intrahepatic - postsinusoidal**: veno-occlusive disease
5. **Post-hepatic** - Budd-Chiari syndrome
61
What is the commonest cause of portal hypertension in the Western world?
liver cirrhosis
62
What is the commonest cause of portal hypertension in Africa?
schistosomiasis
63
What evidence may be seen on blood tests of splenomegaly in portal hypertension and why?
pancytopenia - reticuloendothelial hyperplasia (not reversible)
64
What are 4 key investigations in portal hypertension?
1. bloods
2. portal doppler US - portal vein patency
3. MRI or CT aniography - portal and hepatic veins
4. Abdo US (cirrhosis, ascites, splenomegaly)
65
Is measurement of portal pressure required to diagnose portal hypertension?
no - invasive, expensive + complication - can be clinical
66
What are the direct and indirect methods for portal pressure measurement?
* **direct**: cannulation of hepatic vein + measuring free hepatic vein pressure
* **indirect**: balloon occlusion of hepatic vein + measurement of wedged hepatic vein pressure; calculte hepatic venous pressure gradient from this
67
What are the key features of PBC (primary biliary cholangitis)?
Presents in middle aged females with lethargy, pruritus
- IgM
- Anti-mitochondrial antibodies (M2 subtype)
- obstructive LFTs (raised ALP and GGT)
68
What vitamin is thiamine also known as?
B1
69
What is the classic triad of Wernicke's encephalopathy?
1. encephalopathy
2. ataxia
3. ophthalmoplegia/nystagmus
(+ peripheral sensory neuropathy)
70
What are 2 investigations in Wernicke's encephalopathy?
1. decreased red cell transketolase
2. MRI
71
How does Korsakoff's differ from Wernicke's encephalopathy?
same symptoms, plus anterograde + retrograde amnesia, + confabulations
72
What process is happening in primary biliary cholangitis (/cirrhosis)?
autoimmune disease of the liver with destruction of the bile canaliculi within the liver
73
What is the treatment of life-threatening C difficile infection?
oral vancomycin and IV metronidazole; specialist advice (surgery may be considered)
74
What are 3 criteria for life-threatening C difficile infection?
1. Hypotension
2. Partial or complete ileus
3. Toxic megacolon, or CT evidence of severe disease
75
What is the management of recurrent C diff?
* if recurs within 12 weeks of symptoms resolution: oral fidaxomicin
* after 12 weeks: oral vancomycin OR fidaxomicin
76
Why is spironolactone the diuretic of choice for ascites?
patients with cirrhosis develop a secondary hyperaldosteronism
77
What are 2 adverse effects of spironolactone?
1. hyperkalaemia
2. gynaecomastia (less common with eplerenone)
78
What is Curling's ulcer?
acute peptic stress ulcer, complication of severe burns - necrosis of gastric mucosa secondary to hypovolaemia
79
Of UC and Crohn's, which one is exacerbated by smoking and which is improved?
* Crohn's - smoking makes it worse
* UC - smoking makes it better
80
What management is used first line to induce remission in Crohn's disease in adults?
glucocorticoids - oral, topical or IV
81
What alternative to glucocorticoid therapy may be used to induce remission in Crohn's in some situations?
enteral feeding with elemental diet - in addition or instead of other measures, particularly if concern re side effects of steroids (e.g. young children)
82
What treatment is second-line to glucocorticoids for inducing remission in Crohn's disease?
5-ASA drugs e.g. mesalazine
83
What drugs may be used as add-on therapy to induce remission in Crohn's disease?
azathioprine or mercaptopurine (methotrexate is alternative to azathioprine) - NOT used as monotherapy
| glucocorticoids first line, 2nd line 5-ASAs
84
What drug may be used for isolated perianal disease in Crohn's?
metronidazole
85
What is used first line to maintain remission in Crohn's?
azathioprine or mercaptopurine
| methotrexate second line
86
What is the investigation of choice for suspected perianal fistulae?
MRI
| looks for abscess and whether simple (low) or complex (high fistula)
87
What is the difference between a simple and complex perianal fistula?
simple is a low fistula, complex is a high fistula that passes through or above muscle layers
88
What are the management options for perianal fistulae in CD?
* oral metronidazole
* anti-TNF e.g. infliximab - good for closing
* draining seton - for complex fistulae
89
When is platelet transfusion indicated in UGIB?
active bleeding + platlet count <50
90
What is an aorto-enteric fistula?
in previous abdominal aortic aneurysm surgery, aorto-enteric fistulation is rare but important cause of major haemorrhage
91
What should be given in UGIB for patient on warfarin?
IV prothrombin complex concentrate
92
How is induction of remission done in UC in general?
Mild-moderate:
- If distal disease - rectal 5ASA
- If disease more extensive topical + oral 5ASA
( -> oral 5ASA -> steroid)
Severe:
- IV steroid (ciclosporin if CI)
93
How is remission maintained in UC?
Oral 5ASA or oral +-topical (sometimes topical alone)
94
What is the drug used to maintain remission in UC if there has been a severe relapse or 2 or more in the last year?
Azathioprine or mercaptopurine (NOT methotrexate)
95
How is the severity of a UC flare graded?
Truelove and Witts
- mild - <4 stools per day, only small amount of blood
- moderate - 4-6 stools/day, varying blood, no systemic upset
- severe - >6 stools/day, systemic upset
96
What type of virus is hepatitis C?
RNA Flavivirus
97
Is breastfeeding contraindicated in mothers with hepatitis C?
No
98
What proportion of patients develop symptoms after exposure to hepatitis C virus?
30%
99
What are the symptoms of hepatitis C virus?
Transient rise in serum aminotransferases, jaundice, fatigue, arthralgia
100
What is the investigation for hepatitis C?
serum HCV RNA
101
What does the presence of HCV antibodies indicate?
Current or previous HCV infection
102
What is the definition of chronic hepatitis C infection?
Persistence of HCV RNA for >6 months
103
What are 7 complications of chronic HCV?
1. Rheum: arthralgias, arthritis
2. Sjögren’s syndrome
3. Cirrhosis
4. HCC
5. Cryoglobulinaemia
6. Porphyria cutanea tarda
7. Membranoproliferative glomerulonephritis
104
What is the treatment of chronic HCV?
Depends on viral genotype - treated with combination of protease inhibitors (daclatasvir + sofosbuvir or sofosbuvir + simeprevir) +- ribavirin
105
What is the goal of treatment of HCV?
Sustained virological response (SVR) - undetectable serum HCV RNA 6 months after end of treatment
106
What are 3 side effects of ribavirin (used to treat HCV)?
1. Cough
2. Haemolytic anaemia
3. Teratogenic - shouldn’t conceive within 6 months of stopping treatment
107
What are 5 side effects of interferon alpha (used to treat HCV in the past)?
1. Flu like symptoms
2. Depression
3. Fatigue
4. Leukopenia
5. Thrombocytopenia
108
What are 5 side effects of interferon alpha (used to treat HCV in the past)?
1. Flu like symptoms
2. Depression
3. Fatigue
4. Leukopenia
5. Thrombocytopenia
109
What is the presentation of bile-acid malabsorption?
chronic diarrhoea - steatorrhoea, and vitamin ADEK malabsorption
110
What are 6 causes of bile-acid malabsorption?
1. Primary: excessive production of bile acid
2. ileal disease e.g. Crohn's
3. cholecystectomy - disturbs cycle of bile release + reabsorption - too much bile progresses to large intestine
4. coeliac disease
5. small intestinal bacterial overgorwith
111
What is the test of choice to diagnose bile-acid malabsorption?
* **SeHCAT** - nuclear medicine test (gamma-emitting selenium molecule in **selenium homocholic acid taurine** or taroselcholic acid)
* scans done **7 days apart** to assess retention/loss of radiolabelled SeHCAT
112
What is the management of bile-acid malabsorption?
bile acid sequestrants e.g. cholestyramine
113
How does cholestyramine work to treat bile-acid malabsorption?
binds to bile acids in the small intestine and promotes reabsorption into cycle of bile acid production
114
What are 3 criteria for referral for urgent endoscopy for oesophageal / gastric cancer?
1. dysphagia
2. upper abdominal mass
3. age >55y with weight loss AND: upper abdo pain/ reflux / dyspepsia
115
What are 2 criteria for endoscopy for gastric/oesophageal cancer?
1. **haematemesis**
2. aged **>55y** AND: treatment-resistant **dyspepsia** OR upper abdo **pain** and low **Hb** OR raised **platelets** OR **nausea or vomiting** + weight loss / reflux / dyspepsia / upper abdo pain
116
What are 3 steps for the management of patients who have undiagnosed dyspepsia but don't meet the referral criteria for OGD?
1. review medications for cause
2. lifestyle advice
3. full dose PPI for 4 weeks OR test and treat for H pylori
117
What is the test for H pylori eradication, if performed?
carbon-13 urea breath test
118
What are 4 situations H. pylori re-testing after treatment can be considered?
1. poor compliance to eradication therapy
2. aspirin or NSAID indicated
3. family history of gastric malignancy
4. person requests re-testing
119
If re-testing after H pylori eradication is performed, when should it be done?
8 weeks after initial eradication therapy
120
What is the genetic abnormality that causes Wilson's disease?
defect in ATP7B gene on chromosome 13
121
What is usual onset of symptoms of Wilson's disease?
10-25 years
| children present with liver disease, young adults - neurological
122
123
What are 7 features of Wilson's disease?
1. hepatitis, cirrhosis
2. basal ganglia degeneration
3. speech, behavioural and psychiatric problems
4. asterixis, chorea, dementia, parkinsonism
5. Kayser-Fleischer rings
6. renal tubular acidosis (esp. Fanconi syndrome)
7. haemolysis
8. blue nails
124
Where in the brain is most copper deposited in Wilson syndrome?
basal ganglia - particularly putamen and globus pallidus
125
What is the cause of Kayser-Fleischer rings?
green-brown rings in the periphery of the iris due to copper accumulation in Descemet membrane
126
What will serum caeruloplasmin and total serum copper show in Wilson's disease?
* caeruloplasmin: **reduced**
* copper: **reduced** (95% of plasma copper carried by caeruloplasmin; free copper increased_
127
What will 24h urinary copper excretion show in Wilson's?
increased copper excretion
128
How is a diagnosis of Wilson's disease confirmed?
genetic analysis of ATP7B gene
129
What are 3 options for the treatment of Wilson's disease?
1. **penicillamine** (copper chelator)
2. **trientine hydrochloride** - alternative
3. **tetrahiomolybdate** - newer, under ix
130
What is the AST:ALT ratio in alcoholic hepatitis?
AST:ALT is 2:1
| alcoholics sip tequila
131
What are 2 possible aspects of the management of alcoholic hepatitis?
1. steroids
2. pentoxyphylline
132
How is a decision to use steroids in alcoholic hepatitis made?
based on Maddrey's Discriminant Function (MDF) (based on prothrombin time, bilirubin)
133
Which gene is responsible for hereditary haemochromatosis?
HFE gene on both copies of chromosome 6
134
What are the early symptoms of hereditary haemochromatosis?
fatigue, erectile dysfunction, arthralgia (often hands)
135
What are 2 complications of hereditary haemochromatsis which are reversible with treatment?
1. cardiomyopathy
2. skin pigmentation
136
What are 4 features of hereditary haemochromatosis which are not reversible with treatment?
1. liver cirrhosis
2. diabetes mellitus
3. hypogonadotrophic hypogonadism
4. arthropathy
137
What is the inheritance pattern of Peutz-Jeghers syndrome?
autosomal dominant
| responsible gene encodes serine threonine kinase LKB1 or STK11
138
What are the key features of Peutz-Jeghers syndrome?
* hamartomatous polyps in GI tract (mainly small bowel)
* pigmented lesions on lips, oral mucosa, face, palms, soles
139
What complications may patients with Peutz-Jeghers syndrome develop?
* GI bleeding
* small bowel obstruction - commonest presenting complaint (often due to insussusception)
* malignancy - not from polyps but other forms of GI cancer
140
What is the management of Peutz-Jeghers syndrome?
conservative unless complications develop
141
What is the first line abx to treat campylobacter enteritis?
clarithromycin
142
What is the first line abx to treat non-typhoid salmonella?
ciprofloxacin
143
What is the first line abx to treat shigellosis?
ciprofloxacin
144
What imaging may be performed in suspected PBC?
RUQ US or MRCP to exclude extrahepatic biliary obstruction
145
What is the commonset cause of travellers' diarrhoea?
E coli
146
What are 4 aspects of the management of PBC?
1. ursodeoxycholic acid - first line
2. cholestyramine for purutius
3. fat soluble vitamin supplementation
4. liver transplant if bili >100
147
What are the features of E coli diarrhoea?
watery stools, abdominal cramps and nausea
148
What is the presentation of giardiasis?
prolonged, non-bloody diarrhoea
149
What is the presentation of cholera?
profuse, watery diarrhoea; severe dehydration resulting in weight loss; (not common amongst travellers)
150
Which 2 bacterial causes of diarrhoea have a short incubation period (1-6h)?
Staphylococcus aureus, Bacillus cereus
151
What is the presentation of Staphylococcus aureus GI infection?
severe vomiting with short incubation period
152
What are the clinical features of GI campylobacter infection?
* flu-like prodrome (**headache, malaise**) followed by crampy abdo pains, fever, diarrhoea - may be **bloody**
* abdo pain - may mimic appendicitis
153
What are the 2 types of illness seen with GI Bacillus cereus?
1. vomiting within 6 hours, stereotypically due to rice
2. diarrhoeal illness occurring after 6h
154
# ```
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What is the typical presentation of amoebiasis?
gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks
155
What are 2 types of diarrhoeal illness with an incubation period >7days?
* giardiasis (non bloody)
* amoebiasis (bloody)
156
What molecular genetic testing may be performed for haemochromatosis?
C282Y and H63D
157
What are 4 further tests in addition to transferrin saturation and ferritin that may be used to investigate hereditary haemochromatosis?
1. liver function tests
2. molecular genetic testing
3. MRI - to quantif liver and/or cardiac iron
4. liver biopsy - only if suspected cirrhosis
158
Which 2 blood tests are most important in monitoring hereditary haemochromatosis?
1. transferrin saturation - aiming for <50%
2. ferritin - aiming <50 ug/L
159
What is the first and second-line treatment of hereditary haemochromatosis?
1. first line: venesection
2. 2nd: desferrioxamine
160
What is Barrett's oesophagus?
metaplasia of lower oesophageal mucosa, usual **squamous** epithelium is replaced by **columnar** epithelium
| Simple to Cancer
161
What is the risk associated with Barrett's oesophagus?
risk of oesphageal adenocarcinoma 50-100x
162
How is Barrett's oesophagus subdivided and WHY?
short (<3cm) and long (>3cm) - correlates with chances of identifying metaplasia
163
What are 4 risk factors for Barrett's oesophagus?
1. GORD
2. male gender
3. smoking
4. central obesity
164
What are 3 aspects of the management of Barrett's oesopahgus?
1. High-dose PPI
2. Endoscopic surveillance with biopsies
3. If dysplasia identifies: radiofrequency ablation / endoscopic mucosal resection
165
How often is endoscopic surveillance of Barrett's oesophagus recommended in patients with metaplasia (but no dysplasia)?
every 3-5 years
166
What is the chemical name for vitamin A and what are the symptoms of a deficiency state?
* retinoids
* night-blindness (nyctalopia)
167
What is the chemical name for vitamin B1 and what are the symptoms of a deficiency state?
* thiamine
* beriberi: polyneuropathy, Wernicke-Korsakoff's syndrome, heart failure
168
What is the chemical name for vitamin B3 and what are the symptoms of a deficiency state?
* niacin
* pellagra - dermatitis, diarrhoea, dementia
169
What is the chemical name for vitamin B6 and what are the symptoms of a deficiency state?
* pyridoxine
* deficiency state: anaemia, irritability, seizures
170
What is the chemical name for vitamin B7 and what are the symptoms of a deficiency state?
* biotin
* dermatitis, seborrhoea
171
What is the chemical name for vitamin B9 and what are the symptoms of a deficiency state?
* folic acid
* megaloblastic anaemia, neural tube defects (pregnancy)
172
What is the chemical name for vitamin B12 and what are the symptoms of a deficiency state?
* cyanocobalamin
* megaloblastic anaemia, peripheral neuropathy
173
What is the chemical name for vitamin C and what are the symptoms of a deficiency state?
* ascorbic acid
* scurvy: gingivitis, bleeding e.g. gums
174
What is the chemical name for vitamin D and what are the symptoms of a deficiency state?
* ergocalciferol, cholecalciferol
* rickets, osteomalacia
175
What is the chemical name for vitamin E and what are the symptoms of a deficiency state?
* tocopherol, tocotrienol
* mild haemolytic anaemia in newborns, ataxia, peripheral neuropathy
176
What is the chemical name for vitamin K and what are the symptoms of a deficiency state?
* naphthoquinone
* haemorrhagic disease of newborn, bleeding diathesis
177
When is drug treatment indicated in campylobacter infection?
* severe symptoms - high fever, bloody diarrhoea, >8 stools / day
* symptoms > 1 week
* immunocompromised patient
178
What are the BMI categories?
* Underweight < 18.5
* Normal 18.5 - 25
* Overweight: 25-30
* Obese I: 30-35
* Clinically obese (II): 35-40
* Morbidly obese (III): >40
179
What is the most common organism found on ascitic fluid culture in SBP?
E. coli
180
What is diagnostic of SBP?
ascitic paracentesis neutrophils >250
181
What is the management of SBP?
IV cefotaxime
182
What is given as prophylaxis for SBP?
ciprofloxacin or norfloxacin
183
What are the indications for SBP prophylaxis?
1. previous episode SBP
2. fluid protein < 15 g/L and Child Pugh at least 9 or HRS
184
# hat are the
What is achalasia?
failure of oesophageal peristalsis and relaxation of LOS due to degenerative loss of ganglia from Auerbach's plexus - LOS contracted and oesophagus above dilated
185
What will barium swallow show in achalasia?
grossly expanded oesophagus, fluid level, 'bird's beak' appearance
186
What is the most important diagnostic test for achalasia?
oesophageal manometry - excessive LOS tone which doesn't relax on swallowing
187
What is the first-line treatment for achalasia?
pneumatic (balloon) dilation
188
What treatments are available for achalasia if a) they have recurrent or persistent symptoms despite pneumatic dilation b) they are high surgical risk?
* a) Heller cardiomyotomy
* b) intra-sphincteric injection of botulinum toxin
189
What is acrodermatitis enteropathica?
recessively inherited partial defect in intestinal zinc absorption.
190
Which patients may develop zinc deficiency?
patients with anorexia nervosa
191
What is likely to cause a bloody infectious diarrhoea after a barbecue?
Campylobacter
192
What are the blood test features of alcohol ketoacidosis?
* metabolic acidosis
* raised anion gap
* ketonaemia
* normal capillary blood glucose
193
What is the management of alcoholic ketoacidosis?
IVF and thiamine infusion
194
What are 4 extraintestinal IBD features that are related to disease activity?
1. Arthritis: pauciarticular, asymmetric
2. Episcleritis
3. Erythema nodosum
4. Osteoporosis
195
What are 5 extraintestinal features of IBD that are unrelated to disease activity?
1. Arthritis: polyarticular, symmetrical
2. Uveitis
3. Pyoderma gangrenosum
4. Clubbing
5. Primary sclerosing cholangitis
196
Of episcleritis / uveitis which is more common in CD / UC?
* Episcleritis - more common in CD
* Uveitis - more common in UC
197
What is the most common extraintestinal feature in IBD?
arthritis
198
Is PSC more common in CD or UC?
UC
199
What are the 3 types of autoimmune hepatitis (antibodies + age)?
* **Type I**: ANA and/or SMA, affects both **adults and children**
* **Type II**: anti-liver/kidney microsomal type 1 antibodies (LKM1) , affects **children**
* **Type III**: soluble liver-kidney antigen, affects adults in **middle age**
200
What are 4 features common in autoimmune hepatitis?
1. signs of CLD
2. acute hepatitis: fever, jaundice (25%)
3. amenorrhoea - common
4. ANA / SMA / LKM1 antibodies, raised IgG
201
What will be seen on biopsy in autoimmune hepatitis?
inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis
202
What are the management options for autoimmune hepatitis?
* steroids
* other immunsuppressants e.g. azathioprine
* liver transplant
203
Which neurotransmitters are involved in the alcohol withdrawal response?
decreased inhibitory GABA and increased NMDA glutamate transmission (normally chronic alcohol consumption enhances GABA mediated inhibition in CNS and inhibits glutamate receptors)
204
What is the peak incidence of seizures during alcohol withdrawal?
36 hours
205
What is the peak incidence of delirium tremens after alcohol withdrawal?
48-72h
206
Which patients withdrawing from alcohol should be admitted to hospital?
complex withdrawals e.g. delirium tremens, seizures, blackouts
207
Which benzodiazepine for alcohol withdrawal may be needed in liver failure?
lorazepam
208
What are 5 causes of raised ferritin without iron overload?
1. inflammation
2. alcohol excess
3. liver disease
4. chronic kidney disease
5. malignancy
209
What is the best way to assess whether iron overload is present with increased ferritin?
transferrin saturation
210
What are 2 standard diagnostic investigations for PSC and what will they show?
* ERCP or MRCP
* multiple biliary strictures - beaded appearance
211
Which blood test may be positive in PSC?
p-ANCA
212
Waht may be seen on liver biopsy in PSC?
fibrous, obliterative cholangitis - onion skin
213
What are 2 complications of PSC?
1. cholangiocarcinoma
2. colorectal cancer
214
What are 2 types of hiatus hernia?
1. sliding (95%) - GOJ moves above diaphragm
2. rolling (paroesophageal): GOJ remains below diaphragm but separate part of stomach herniates through
215
What are 2 risk factors for hiatus hernia?
* obesity
* increased intraadominal pressure - ascites, multiparity
216
What is the most sensitive test for hiatus hernia? What is often done first line?
barium swallow - many patients have endoscopy on 2ww first due to symptoms
217
What is the approach to management of hiatus hernias?
* conservative management - weight loss
* medical: PPI
* surgical: fundoplication only has role in symptomatic paraoesophageal (rolling) hernias
218
What is the period from infection to developing symptoms of norovirus?
15 - 50 hours
219
Is norovirus a notifiable disease in the UK?
no
220
How is a diagnosis of norovirus made?
clinical history and stool culture viral PCR
221
What are 3 differences between E coli and norovirus gastroenteritis?
* E coli has longer incubation period (3-4 days, up to 10 days)
* E coli commonly causes severe abdo cramping
* E coli frequently causes bloody diarrhoea, noro does not
222
How long do norovirus symptoms typically resolve after?
72h
223
What is an association with cyclical vomiting syndrome?
* migraines - also present in 80% of children and 25% adults
224
What is the typical history in cyclical vomiting syndrome?
* severe nausea and sudden vomiting lasting hours to days
* prodromal intense sweating and nausea
* well in between episodes
225
How is a diagnosis of cyclical vomiting syndrome made?
* clinical diagnosis
* pregnancy test in women
* routine blood tests to exclude other aetiologies
226
What are 3 drugs which can be given as prophylaxis in cyclical vomiting syndrome?
1. amitriptyline
2. propranolol
3. topiramate
227
What are 3 drugs which can be used in cyclical vomiting syndrome?
1. ondansetron
2. prochlorperazine
3. triptans
228
What are 6 complications of hepatitis B infection?
1. chronic hepatitis
2. fulminant liver failure
3. hepatocellular carcinoma
4. glomerulonephritis
5. polyarteritis nodosa
6. cryoglobulinaemia
229
What are 5 risk factors for responding poorly to 3 doses of the hepatitis B vaccine?
1. age > 40 years
2. obesity
3. smoking alcohol excess
4. immunosuppression
230
What should be done in someone who has had a course of 3 doses of hepatitis B vaccine and anti-HBs level is 10-100?
one additional vaccine dose should be given
231
What should be done in someone who has had a course of 3 doses of hepatitis B vaccine and anti-HBs level is < 10?
* non-responder - test for current or past infection
* give further course (i.e. further 3 doses) with testing following
* if fails to resopnd, HBIG would be required for protection if exposed to the virus
232
What are 4 types of drugs which can be used first-line to treat hepatitis B?
1. pegylated interferon-alpha
2. tenofovir
3. entecavir
4. telbivudine
233
What are 6 infectious causes of bloody diarrhoea?
1. salmonella
2. shigella
3. campylobacter jejuni
4. Yersinia enterocolitica
5. E. coli
6. Entamoeba histolytica
234
What is the guidance regarding antibiotics in acute pancreatitis?
Should NOT give prophylactic antibiotics - could cause infected pancreatic necrosis
235
What products should be avoided by patients with coeliac disease?
* wheat
* barley
* rye
* spelt
* kamut
* triticale
| maize is OK
236
What is the first line antibiotic management of acute uncomplicated diverticulitis?
co-amoxiclav
237
What are 2 drug options for achalasia and what limits their use?
* nitrates, CCBs
* side-effects
238
What are 7 features of zinc deficiency?
1. acrodermatitis - red, crusted lesions periorally and perianally
2. alopecia
3. short stature
4. hypogonadism
5. hepatosplenomegaly
6. geophagia (ingesting clay/soil)
7. cognitive impairment
239
What will CXR show in achalasia?
wide mediastinum, fluid level
240
What is the classical presentation of achalasia?
dysphagia of BOTH liquids and solids at same time; heartburn, regurgtation
241
What are 5 risk factors for squamous cell oesophageal cancer?
1. smoking
2. alcohol
3. achalasia
4. Plummer-Vinson syndrome
5. diets rich in nitrosamines
242
What options are available if ELF testing is not available to investigate NAFLD (diagnosis + monitoring)?
FIB4 score or NAFLD fibrosis scan +- FibroScan
