Gastroenterology

Question 1

Early dumping syndrome

Answer 1

• Rapid onset - 15 minutes
• Colicky abdominal pain, diarrhoea, nausea, tachycardia
• Sympathetic nervous response - due to rapid emptying of food into bowel causing fluid shifts

Question 2

Late dumping syndrome

Answer 2

• Onset 2-3 hours post meal
• Dizziness, fatigue, diaphoresis, weakness
• Postprandial (reactive) hypoglycaemia - following insulin peak

Question 3

Hepatitis B serology - Previous infection

Answer 3

HBsAg-
HBsAb+
HBcAb+
HBeAg-

Question 4

Hepatitis B serology - Previous vaccination

Answer 4

HBsAg-
HBsAb+
HBcAb-
HBeAg-

Question 5

Hepatitis B serology - Chronic infection

Answer 5

HBsAg+
HBsAb-
HBcAb+
HBeAg+

Question 6

Hepatitis B serology - Acute infection

Answer 6

HBsAg+
HBsAb-
HBcAb+
HBeAg+

Question 7

Hepatitis B serology - Precore mutant infection

Answer 7

HBsAg+
HBsAb-
HBcAb+
HBeAg-

Question 8

Indications for infliximab and adalimumab in Crohn’s disease

Answer 8

• Refractory to steroids and AZA/MP/MTX

- Refractory fistulising Crohn’s disease

Question 9

Indications for H. pylori eradication

Answer 9

MALT lymphoma
Active peptic ulcer disease
PHx of documented peptic ulcer

Question 10

Common cause of portal hypertension

Answer 10

Cirrhosis - 90%
Portal vein thrombosis
Hepatic schistosomiasis

Question 11

Portal hypertension - diagnosis

Answer 11

Hepatic venous pressure gradient (HVPG) = wedged hepatic venous pressure (WHVP) - free hepatic venous pressure (FHVP)

PHT = HVPG greater than 5
Clinically significant PHT = HVPH greater than 10

Question 12

Cirrhosis - predictors of 3 month mortality

Answer 12

MELD score

• INR
• Creatinine
• Bilirubin
• Haemodialysis

Question 13

Cirrhosis - predictors of 1-2 year mortality

Answer 13

Child-Pugh score

• Encephalopathy
• Ascites
• Bilirubin
• Albumin
• Prothrombin time / INR

Question 14

Site of folic acid absorption

Answer 14

Proximal jejunum

Question 15

Site of fat absorption

Answer 15

Duodenum

Question 16

Site of bile salt absorption

Answer 16

Terminal ileum

Question 17

Site of vitamin B12 (cobalamin) absorption

Answer 17

Terminal ileum

Question 18

Alpha-1 antitrypsin deficiency (AAT) - liver pathophysiology

Answer 18

Toxic gain of function - accumulation in hepatocyte of unsecreted variant AAT protein

Question 19

Site of vitamin C absorption

Answer 19

Proximal jejunum

Question 20

Site of iron absorption

Answer 20

Duodenum

Question 21

Site of calcium absorption

Answer 21

Proximal jejunum

Question 22

Serology - primary biliary cirrhosis (PBC)

Answer 22

AMA +ve
ANA +ve
ALP elevated
Lipids elevated

Question 23

Serology - primary sclerosing cholangitis

Answer 23

P-ANCA +ve
Serum IgM elevated
Hypergammaglobulinaemia
ALP elevated

Question 24

Serology - autoimmune hepatitis type-1 (AIH-1)

Answer 24

Anti-SMA +ve
ANA +ve
P-ANCA +ve

Question 25

Serology - autoimmune hepatitis type-2 (AIH-2)

Answer 25

Anti-LKM +ve | ANA +ve

Question 26

Paracetamol poisoning - indications for N-acetyl cysteine (NAC)

Answer 26

- Concentration above treatment line in normogram at ≥4 hours - Single ingestion more than 150mg/kg (or 7.5g total), if concentration unavailable - Unknown time of ingestion and concetration more than 10mg/L - Evidence of liver injury and past history of paracetamol ingestion

Question 27

Eosinophilic oesophagitis - presentation

Answer 27

``` Oesophageal dysfunction / dysphagia Food bolus obstruction Corrugated iron rings, longitudinal furrows Young males History of atopy ```

Question 28

Eosinophilic oesophagitis - treatment

Answer 28

PPI - sufficient up to 80% Topical corticosteroid (eg. fluticasone) Oesophageal dilatation

Question 29

Barrett's oesophagus - treatment

Answer 29

- Surveillance - until high grade dysplasia - PPI - reduces progression - Oesophagectomy - young patients - Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) - preferred treatment

Question 30

Achalasia - treatment

Answer 30

- Dilatation - treatment of choice, younger patients - Botox - 70% success, elderly patients - Myotomy - surgical division of LOS - GTN / CCB - less effective

Question 31

Most common pharmacological cause of gastric ulceration

Answer 31

``` Aspirin - 45% Ibuprofen - 25% Indomethacin - 25% Diclofenac - 15% Meloxicam - less ulcers, but not completely benign ```

Question 32

H.pylori associated ulcers - treatment

Answer 32

Triple therapy - Amoxycillin - Clarithromycin - PPI

Question 33

Most likely Hepatitis C genotype to progress to cirrhosis / HCC

Answer 33

Genotype 3 - Associated with steatosis - Increased progression to cirrhosis / HCC - Lower response rates to treatment

Question 34

Hepatitis C - treatment

Answer 34

``` Genotype: 1 – sofosbuvir, ledipasvir 2 – sofosbuvir, ribavirin 3 – sofosbuvir, daclatasvir 4, 5, 6 – sofosbuvir, peg-interferon, ribavirin (usually 12 weeks duration) ```

Question 35

Hepatitis C direct acting antivirals (DAA) - mechanism of action

Answer 35

Sofosbuvir - nucleoside NS5B polymerase inhibitor Ledipasvir - NS5a inhibitor Daclatasvir - NS5a inhibitor

Question 36

Chronic hepatitis B - treatment

Answer 36

Entecavir OR Tenofovir OR Pegylated interferon (until 6 months after HBeAg seroconversion and undetectable HBV DNA; if HBeAg -ve chronic hepatitis, treat until HBsAg clearance)

Question 37

Hepatocellular carcinoma (HCC) - treatment

Answer 37

Resection - very early stage, less than 2 cm Transplantation - early stage, 3 nodules ≤3cm Chemoembolisation (TACE) - larger tumours Sorafenib - advanced stage, slows progression

Question 38

Hepatocellular carcinoma (HCC) - surveillance

Answer 38

6-monthly liver US and AFP

Question 39

Spontaneous bacterial peritonitis - treatment

Answer 39

IV Ceftriaxone | Prophylaxis - norfloxacin, Bactrim DS

Question 40

Ulcerative colitis - treatment (induction)

Answer 40

Sulfasalazine or 5-aminosalicylate - in mild to moderate | Corticosteroids - in severe

Question 41

Ulcerative colitis - treatment (maintenance)

Answer 41

Sulfasalazine | 5-aminosalicylate

Question 42

Crohn's disease - treatment (induction)

Answer 42

Corticosteroids - eg. budesonide

Question 43

Crohn's disease - treatment (maintenance)

Answer 43

Thiopurine - eg. azathioprine | Infliximab - in refractory or fistulising disease