Gastroenterology

Question 1

AXR: 4wk corrected pre-term infant, febrile and vomiting - Diagnosis + management

Answer 1

Pneumatosis intestinalis (gas in bowel wall) - pathognomonic for nectrotising enterocolitis (NEC)

1. IVC + NGT
2. IVF bolus + full maintenance (NaCl 0.9% + 5% dextrose)
3. NBM + bowel rest
4. NGT on free drainage
5. IVABx - Amox 50mg/kg + gent 7mg/kg + metro 12.5mg/kg
6. Emergent surgical review

Question 2

Target haematological parameters in variceal bleeding

Answer 2

Hb >70
INR <1.6
Plt >50
Fibrinogen >1.0
Ionised Ca normal range
Normal ROTEM parameters

Question 3

Emergent management of variceal bleeding

Answer 3

Urgent endoscopy for variceal banding
Blood over IV fluids
Seek and correct coagulopathy
IV octreotide 50mcg bolus, 50mcg/hr
IV antibiotics for gram neg cover – eg ceftriaxone 1g
Also accept prevention of alcohol withdrawal with diazepam

Question 4

Components of Child-Pugh score

Answer 4

Bilirubin
Albumin
INR
Ascites
Encephalopathy

Score 1-3 for all components
Full score below

Question 5

NG vs IV rehydration in paediatrics - Indation, fluid choice and rate

Answer 5

Question 6

Signs of severe dehydration in paediatric patient

Answer 6

• Altered conscious state
• Poor skin turgor – greater than 2 second skin fold visible
• Sunken eyes
• Reduced CRT and other signs of shock
• Deep acidotic breathing
• Reduced urine output

Question 7

Causes of non-obstructive hepatitis

Answer 7

Acute viral hepatitis
Toxins (esp Paracetamol, Mushrooms)
Idiosyncratic drug reaction
Chronic liver failure secondary to alcohol abuse
Autoimmune liver disease
Ischaemic liver injury
Malignancy
Budd Chairi Syndrome (Hepatic vein thrombosis)
Wilson’s disease
Idiopathic

Question 8

Risk of untreated triple AAA rupture by size

Answer 8

40% if >6cm - average survival 17mo
20% if <6cm - average survival 34mo
Increased risk if >4cm
Risk of rupture outweighs elective surgical risk when >5cm

Question 9

Types of AAA repair endoleak

Answer 9

Question 10

H Pylori eradication therapy regime

Answer 10

Esomeprazole 20mg BD
+
Amoxicillin 1g BD
+
Clarithromycin 500mg BD
For 7-14 days

If penicillin hypersensitivity:
Replace amoxicillin w/ metronidazole 400mg BD

Question 11

Eponymous clinical signs of pancreatitis

Answer 11

*​ Grey Turner’s sign
-​ bluish discolouration of left flank
-​ indicates retroperitoneal haemorrhage
-​ non specific as present in other causes of retroperitoneal haemorrhage

*​ Cullen’s sign
-​ yellow blue discolouration around the umbilicus
- rare
-​ caused by pancreatic enzymes that have tracked along the falciform ligament and digested subcutaneous tissues around the umbilicus

Question 12

Ranson’s Criteria for pancreatitis

Answer 12

Not particularly useful in ED (common exam question, however) More accurate predictor for alcoholic pancreatitis than for other causes

On presentation:
-​ Age > 55 years
-​ WCC > 16,000/µL
-​ Glucose > 10 mmol/L
-​ LDH > 350 IU/L
-​ AST > 250 IU/L

Within 48 hours
-​ base deficit > 4 meq/L
-​ Haematocrit drop > 10%
-​ Urea rise > 5 mg/dL
-​ Arterial pO2 < 60 mmHg
-​ Ca2+ < 2 mmol/L
-​ Estimated fluid sequestration > 6 L

Limitations:
-​ Does not alter therapy
-​ Only 50% predictive of complications
-​ Not relevant for 80% of patients who have a benign course
-​ Clinical / non invasive markers of severity may be as effective in prognosis prediction