Gastroenterology

Question 1

Describe Hepatitis A

Answer 1

RNA virus
spread via faecal-oral or shellfish
endemic in Africa and south america

Presentation: Fever, malaise, anorexia, nausea, arthralgia, jaundice, hepatosplenomegaly, adenopathy

Rx: supportive, avoid alcohol. Rarely IFNa for life

Question 2

Describe Hepatitis B, tests, and management, and complications.

Answer 2

DNA virus
spread: blood products, Sexual,
endemic in far east, africa and Mediterranean.

Presentation: Resemble Hep A, arthralgia and urticaria

Tests: PCR Viral Load, LFTs, HIV + Hep D (increased risk of HCC progression), Antibody screen

Management:

• Avoid alcohol. Immunise sexual contacts
• Chronic liver inflammation - PEG IFNa-2a, lamivudine, entecavir, adefovir (aim to clear HBsAG and prevent cirrhosis and HCC)

Complications: cirrhosis in 20%, HCC in 5-10%, fulminant hepatic failure, cholangiocarcinoma, cyroglobulinaemia.

Question 3

Describe Hepatitis C, its management, and complications.

Answer 3

RNA favivirus,
spread: blood products, IVDU, Sexual, acupuncture

Presentation
Early - mild/asymptomatic
85% silent chronic infection
25% cirrhosis in 20 yrs
<4% HCC

Ix: LFT (AST:ALT <1:1), anti-HCV antibodies (exposure), HCV-PCR (ongoing infection/chronicity), liver biopsy

Management:

• quit alcohol
• Direct acting agents with specific regimes influences by the genotype (1, 2+3, 4+5+6)
• Protease inhibitors (doceprevir and telaprevir); PEG IFNa, Ribavarin, sofosbuvir

Complications: Cirrhosis, HCC, glomerulonephritis, cyroglobulinaemia, thyroiditis, autoimmune hepatitis, polyarteritis nodosa, polymyositis, porphyria cutanea tarda, non-Hodgkin’s lymphoma.

Question 4

Describe Hepatitis D

Answer 4

incomplete RNA virus that needs HBV for assembly.
may cause acute liver failure/cirrhosis
Rx - liver transplant

Question 5

Describe Hepatitis E

Answer 5

RNA virus similar to HAV common in indochina

Associated with pigs

Question 6

Causes of hepatitis

Answer 6

Infection: Viral, CMV/EBV, Leptospirosis, malaria, Q fever, syphillis, yellow fever
Alcohol + drugs/toxins
Autoimmune hepatitis
Wilson’s.

Question 7

Describe Mesenteric Ischaemia, its symptoms, and risk factors

Answer 7

Primarily caused by arterial embolism

Symptoms: presents with abdominal pain, diarrohoea, fever, rectal bleeding, metabolic acidosis, increased WBC

Risk factors: Atrial fibrillation, Increasing age, endocarditis, DVT, Cardiovascular disease, smoking, hypertension, diabetes

Question 8

What are the inherited causes of unconjugated hyperbilirubinaemia?

Answer 8

Gilbert’s syndrome and Crigler-Najjar syndrome

Question 9

What are the inherited causes of conjugated hyperbilirubinaemia?

Answer 9

Rotor’s syndrome and Dubin-Johnson syndrome

Question 10

Describe Hepatocellular carcinoma and causes; Sx. Ix, Rx

Answer 10

Accounts for ~90% of primary liver tumours though 90% of all liver tumours are metastatic. It is common in China and Africa (40% of cancers) and 3 times more common in men

HBV is leading cause, HCV, autoimmune hepatitis, cirrhosis (alcohol, haemochromatosis, PBC), NAFLD, alfatoxin, anabolic steroids

Sx: fatigue, decreased appetite, weight loss, RUQ pain, jaundice, ascites

Ix:CT, MRI and biopsy, AFP,

Rx: Resecting solitary tumours (<3cm)
Liver transplant (milan criteria for transplant is 1 nodule less than 5cm or 2-3 less than 3cm)
tumour embolisation
chemotherapy
Percutaneous ablation

Question 11

Describe Non-alcoholic fatty liver disease (NAFLD) and risk factors

Answer 11

Fatty liver entails steatosis +/- inflammation (steatohepatitis).
Consider if a patient presents with deranged LFT (typically raised ALT) or a fatty liver on ultrasound and drink less than 18u/wk.
It may progress to hepatic fibrosis +/- HCC.
Typically occurs in middle-aged obese females.

RF: DM, dyslipidaemia, parenteral feeding, jejuno-ileal bypass, wilson’s disease, drugs (amiodarone, methotrexate, tetracycline).

Question 12

Describe Autoimmune Hepatitis; Sx, Ix and Mx

Answer 12

An inflammatory liver disease characterised by suppressor T-cell defects with autoantibodies against hepatocyte surface antigens. AIH predominantly affects young or middle-aged women.

Sx: acute hepatitis (fever, jaundice, RUQ pain) and signs of autoimmune disease e.g. fever, malaise, urticarial rash, polyarthritis, pleurisy, pulmonary infiltration or glomerulonephritis, amenorrhoea,

Ix: serum bilirubin, AST, ALT and ALP are usually raised, hypergammaglobulinaemia, +ve autoantibodies (e.g. Antismooth muscle antibodies, ANA).

Mx: Prednisolone or azathioprine (steroid sparing)

Question 13

What are some causes of Constipation?

Answer 13

• General e.g. Poor diet, lack of exercise, poor fluid intake, IBS, old age, hospital environment
• Anorectal disease (especially if painful) e.g. Anal or colorectal cancer, fissures, strictures, rectal prolapse, proctaglia fugax, mucosal ulceration, pelvic muscle dysfunction
• Intestinal obstruction e.g. Colorectal carcinoma, strictures (crohn’s), pelvic mass, diverticulosis, pseudo-obstruction.
• Metabolic/endocrine e.g. Hypercalcaemia, Hypokalaemia, porphyria, lead poisoning.
• Drugs e.g. Opiates, anticholinergics, iron, diuretics, calcium channel blockers.
• Neuromuscular e.g. Spinal or pelvic nerve injury, aganglionosis, diabetic neuropathy
• Other e.g. Psychological, anorexia nervosa, depression, child abuse.

Question 14

Describe Crohn’s Disease; presentation, Ix, Mx

Answer 14

A chronic inflammatory GI disease characterised by transmural granulomatous inflammation affecting any part of the gut from mouth to anus (especially terminal ileum). Skip lesions present.
Usually presents between 20-40yrs. Smoking increased risk and NSAIDs may exacerbate disease.

Presentation: Diarrhoea/urgency, abdominal pain, weight loss, fever, malaise, anorexia. Other signs include aphthous ulcerations, abdominal tenderness, perianal abscess/fistulae/skin tags. Clubbing, joint and eye problems also occur.

Ix

• Bloods FBC, ESR, CRP, LFT, INR, Ferritin, B12.
• Colonoscsopy + rectal biopsy.

Mx:

• Prednisolone for mild attacks/remission
• azothioprine as steroid sparing agent.
• sever attacks require IV hydrocortisone, and metronidazole.
• perianal disease: PO antibiotics, immunosuppresant therapy +/- infliximab and local surgery

Additional therapy
Conservative: elemental diets
Medical: Azathioprine, sulfasalazine, methotrexate, TNFa inhibitors (infliximab, adalimumab)
Biological: Vedolizumab (a4b7 integrin inhibitor), ustekinumab(IL23 inhibitor)
Surgical - if failure to respond to drugs, intestinal obstruction, perforation, fistulae, abscess
- small bowel: stricturoplasty/resection
- large bowel: panproctocolectomy + ileostomy/ subtotal colectomy + ileorectal anastomosis

Question 15

Describe Ascending Cholangitis; symptoms and management

Answer 15

A bacterial infection of the biliary tree. Most common predisposing factor is gallstones.

Symptoms: Charcot triad of RUQ pain, fever and jaundice occurs in about 20-50% of patients. Fever is most common followed by RUQ and then jaundice. May also be hypotensive and/or confused.

Mx: -IV antibiotics e.g. Cefuroxime and Metronidazole
-ERCP after 24-48hrs to relieve any obstruction

Question 16

Describe Hereditary Haemorrhagic Telangiectasia and its symptoms.

Answer 16

Also known as Osler-Weber-Rendu disease, it’s a rare autosomal dominant disorder that affects blood vessels and results in a tendency for bleeding.

Symptoms: Telangiectasia, Epistaxis, visceral lesions, strong family history. GI bleeds, Arteriovenous malformations.

Question 17

Describe Peutz-Jeghers syndrome

Answer 17

Autosomal Dominant disorder
Geraldine mutations of tumour suppressor gene STK11
cause mucocutaneous dark freckles on lips, oral mucosa, palms and soles, + multiple GI polyps (hamartomas), causing obstruction, intussception, or bleeds.
15-fold increase risk of developing GI cancer
Perform colonoscopy (from age 18) and OGD (from age 25) every 3yrs

Question 18

Describe Bowel Obstructions; Symptoms and management

Answer 18

Types:

• Small Bowel Obstruction: Vomiting present earlier, distension is less, and pain is higher in the abdomen. AXR shows central gas shadows with valvulae conniventes that completely cross the lumen and no gas in the large bowel.
• Large Bowel Obstruction: Pain is more constant, more distension. AXR shows dilated large bowel with Haustra peripherally arranged.

Symptoms: Vomiting, Colicky pain, constipation, distension,

Mx: -Drip and Suck, NGT and IV fluids

• Consider CT to look for cause of obstruction
• if strangulated emergency surgery is needed.

Question 19

Describe Diverticular Disease; symptoms. complications, management

Answer 19

Outpouching of gut wall, which may become inflamed. They can be congenital or more commonly acquired through age

Symptoms: There may be later altered bowel habit plus left-sided colic relieved by defecation. Nausea and flatulence. Diarrhoea may occur if inflamed.

Complications

• perforation
• haemorrhage usual cause of big rectal bleeds
• fistulae
• abscess

Mx
referral for colonoscopy to exclude bowel cancer
-high fibre diet
-mebeverine (anti-spasmodic)
-Abx if fever and diarrhoea

Question 20

chronic pancreatitis -causes, symptoms, investigations, management, complications

Answer 20

Causes:Alcohol mostly
Gallstones
Rarely: 
- familial - CF, haemochromatosis, 
- Pancreatic duct obstruction
- Hyperparathyroidism
- Congenital.

Epigastric pain ‘bores’ through to back, relieved by sitting forward or hot water bottles on epigastrium, also bloating, steatorrhoea, weight loss, brittle diabetes.
Erythema ab igne

Ix: US +/- CT looking for pancreatic calcification. 
MRCP + ERCP
AXR
Signs of pancreatic insuff: 
- Increase glucose (brittle diabete)
- Low faecal elastase
- do breath tests

Mx:Conservative: diet - no alcohol,low fat, medium chain triglycerides
Medical: Analgesia, lipase (e.g. creon), fat soluble vitamins, insulin
Surgery: - for unremitting pain, narcotic abuse, weight loss Pancreatectomy or pancreaticojejunostomy

Complications
Pseudocysts, diabetes, biliary obstruction, local arterial aneurysms, splenic vein thrombosis, gastric varices, pancreatic carcinoma

Question 21

Describe Zollinger-Ellison Syndrome; symptoms, Ix, Mx

Answer 21

Gastrin-secreting tumour, which cause multiple refractory and recurrent peptic ulcers. Can present as MEN1 Autosomal dominant disorder

Symptoms: Epigastric pain, diarrhoea, weight loss, GI bleeding. Treatment resistant dyspepsia.

Ix
-FBC: IDA, 
Ferritin may be low
Parathyroid hyperplasia is a common feature of MEN1,
Calcium may be elevated. 
H.Pylori testing,
endoscopy if severe or red-flags
fasting Gastrin levels
prolactin levels
CT for staging

Mx: -ABCDE approach if GI bleeding.

• Oral PPIs
• Surgical resection of primary tumour.

Question 22

Describe Irritable Bowel Syndrome; Sx, red flags, Mx

Answer 22

A group of abdominal symptoms for which no organic cause can be found. Most are likely due to disorders of interstitial motility or enhanced visceral perception. Faecal calprotectin can exclude IBD.

Sx: Abdominal pain relieved by defecation or associated with altered stool form and at least 2 of urgency, incomplete evacuation, abdominal bloating, worsening symptoms after food. Symptoms are chronic and exacerbated by stress, menstruation.

Red Flags: age over 40yrs, history less than 6 months, anorexia, weight loss, waking at night with pain/diarrhoea, mouth ulcers, abnormal CRP, ESR, Hb, coeliac serology. Investigate PR bleeding urgently.

Mx: -Ensure healthy diet

• Fibre, lactose, fructose, wheat, starch, caffeine, sorbitol, alcohol, fizzy drinks can worsen symptoms try modifying diet to balance symptoms.
• anti-spasmodic S e.g. Mebeverine may help
• Psychological wellbeing +/- CBT amitryptilline can help.

Question 23

What is acute cholecystitis; symptoms, Mx

Answer 23

Follows stone or sludge impaction in the neck of the gallbladder.

Symptoms: Colicky pain but more severe and persistent, it may radiate to the back or right shoulder. Patient may be pyrexial and Murphy’s sign positive I.e. Arrest of inspiration on palpation of RUQ.

Mx: -NBM, pain relief, Cefuroxime.
-laparoscopic cholecystectomy is treatment of choice for all patients fit for GA.

Question 24

Causes of acute pancreatitis; symptoms, management

Answer 24

Cause: GET SMASHED, Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion venom, Hypertriglyceridaemia + Hypercalcemia + Hypothermia, ERCP, Drugs e.g. Azothioprine, mesalazine, Bendroflumethiazide, steroids, sodium valproate.

Sx: Severe epigastric pain or central abdominal radiating to back, sitting forward may relieve, vomiting, low-grade fever, abdominal tenderness, ileus, peri umbilical discolouration (Cullen’s sign) and flank discolouration (grey-turners signs).

Mx: -serum amylase/lipase, CRP

• assess using Glasgow, Ranson scoring systems.
• NBM, plenty of saline.
• hourly pulse, BP, UO, daily FBC U+E Ca glucose, amylase, ABG.

Question 25

Describe appendicitis; Sx, Ix, Complications, Mx

Answer 25

Most common surgical emergency. Can occur at any age but highest incidence is in 10-20yrs. It is rare before the age of 2.

Sx: Classically peri umbilical pain that moves the right iliac fossa.
Anorexia is an important feature
Constipation is usual though diarrohoea may occur. Guarding, rebound + percussion tenderness.

Tachycardia, Fever (37.5-38.5), furred younger, lying still, coughing hurts, shallow breaths.

Rovsing's sign (pain worse in RIF when LIF pressed)
Psoas sign (pain on extending hip if retrocaecal appendix)
Cope sign (pain on flexion and internal rotation of right hip if appendix in close relation to obturator internus)

Ix-Bloods may show neutrophil leucocytosis, elevated CRP. USS may help, CT has high diagnostic activity if diagnosis unclear-

Complications

• perforation, commoner in children as diagnosis is often delayed.
• Appendix mass, appendix abscess.

Mx

• inform on-call GI surgeon, admit
• Prompt appendicectomy
• Abx metronidazole 500mg/8h + Cefuroxime 1.5g/8h

Question 26

What is Coeliac disease; presentation, Ix, Mx

Answer 26

T-cell mediated autoimmune disease of the small bowel in which prolamin (gluten) intolerance cause villous atrophy and malabsoprtion. It is associated with HLA DQ2 in 95% and DQ8 in the rest. Also associated with other autoimmune disease and dermatitis herpetiformis.

Presentation: stinking stools/ steattorrhoea, diarrohoea, abdominal pain, bloating, aphthous ulcers, angular stomatitis, weight loss, lethargy, failure to thrive.

Ix:

• Bloods FBC (anaemia), increased RCDW (mixed megaloblastic and microcytic picture) low Ferritin (iron-deficiency), Low B12. Antibodies e.g. Alpha-gliadin, transglutaminase and anti-endomysial antibodies. They are IgA so check IgA levels in case of deficiency.
• Endoscopy, jejuno or duodenal biopsy shows subtotal villous atrophy, intra-epithelial WBCs, crypt hyperplasia. Beware negatives results if already on gluten-free diet.

Mx

• life-long gluten free diet.
• advice on coeliac UK charity
• increase risk of GI T-cell lymphoma if poorly controlled monitor by testing antibodies.

Question 27

What is dyspepsia and peptic ulcer disease; Sx, red flags, Mx

Answer 27

Dyspepsia (indigestion), may be functional (non-ulcer) or be associated with ulcers either duodenal or gastric. Duodenal ulcers are x4 more common than gastric, gastric mainly occur in the elderly.

Symptoms: Epigastric pain often related to hunger
(pain before meals relieved by eating = duodenal, pain after food relieved by antacids = gastric) +/- bloating, fullness after meals, heartburn (retrosternal burning pain caused by reflux), tender epigastrium.

Red Flags:
ALARMS
Anaemia
Loss of weight
Anorexia
Recent onset/progressive symptoms
Melena/haematemesis
Swallowing difficulty.

Mx:
-if over 55yrs and ALARMS - refer for upper GI endoscopy under 2WW
-If not,
Conservative: stop drugs causing dyspepsia (e.g NSAID), lifestyle changes (weight loss, smoking cessation, avoiding acidic foods)
Medical: trial over-counter antacids (e.g. magnesium trisilicate), review in 4wks.
-No improvement
test for H.pylori
–> if -ve: PPI or H2 blockers for 4 weeks
–> if +ve triple eradication therapy, (Omeprazole, clarithromycin, amoxicillin ) must be PPI free for 2 weeks
-If still no improvement consider upper GI endoscopy.

Question 28

Describe Ulcerative colitis; sx, Ix, Rx

Answer 28

Inflammatory disorder of colonic mucosa

• rectum (50% proctitis)
• colon (30% left sided colitis)
• entire colon (20% pancolitis)

3x more common in non-smoker

Hyperaemic/haemorrhagic granular colonic mucosa +/- pseudopolyps

Sx:Episodic or chronic diarrhoea +/- blood and mucus, crampy abdominal discomfort, bowel frequency related to severity. Proctitis - urgency/tenesmus.
Systemic symptoms during attacks - fever, malaise, weight loss, n+v, distension.
Extra-intestinal: clubbing, aphthous oral ulcers, erythema nodosum, pyoderma gangrenosum, large joint arthritis, conjunctivitis, Ankylosing spondylitis, PSC, amyloidosis

Ix:FBC (may show anaemia), ESR (greater than 30mm/hr in severe UC), CRP (raised inflammatory marker), LFT (evidence of extra-intestinal involvement),
Stool MC+S to exclude infectious cause.
AXR (mucosal thickening, colonic dilatation, CXR (exclude perforation).
Colonoscopy shows disease extend and allows biopsy (shows inflammatory infiltrate, depleted goblet cells, glandular distortion, mucosal ulcers, crypt abscesses)

Rx
Inducing remission: Steroids and 5-ASA(sulfasalazine or mesalazine)
- depending on severity PO or IV
- rescue therapy: ciclosporin and antibiotics
Maintaining remission: 5-ASA
Surgery: proctocolectomy + terminal ileostomy (Indications are perforation, massive haemorrhage, toxic dilatation, failed medical therapy.)

Question 29

What is Cirrhosis, causes, complications, ix, Rx

Answer 29

Cirrhosis implies irreversible liver damage characterised histologically by loss of normal hepatic architecture with bridging fibrosis and nodular regeneration.

Causes: chronic alcohol abuse, HBV, HCV infection. Others include haemochromatosis, a1AT deficiency, wilson’s disease, NAFLD, PBC, PSC, AIH, drugs (amiodarone, methyldopa, methotrexate)

Complications

• hepatic failure = coagulopathy, encephalopathy, hypoalbuminaemia, sepsis, SBP, hypoglycaemia
• Portal hypertension = ascites, splenomegaly, oesophageal varices

Ix: Raised bilirubin, AST, ALT, ALP, yGT. decreased Albumin. Decreased platelets and WCC indicate hypersplenism.
liver biopsy confirms diagnosis.
ascitic tap

Rx: General: good nutrition, alcohol abstinence (baclofen 10mg/8hr PO - helps craving), Aboid NSAIDs, sedatives, opioids. Colestyramine (4g/12h PO) - for pruritis

Specific:
IFN a(+/- ribavarin) - Hep C V
High dose ursodeoxycholic acid - PBC
Penicillamine - Wilson’s disease

Question 30

Signs of chronic liver disease

Answer 30

leuconychia, clubbling, palmar erythema, hyperdynamic circulation, Dupuytren’s contracturem spider naevi, xanthelasma, gynaecomastia, atrophic testes, loss of body hair, partoid enlargement, hepatomegaly.

Question 31

Signs of decompensated liver disease

Answer 31

ascites, jaundice, encephalopathy.

Question 32

Describe Alcoholic liver disease; Sx, Ix, Mx

Answer 32

Primary cause of liver disease, progresses to cirrhosis in 80%. Also risks of variceal bleeding and HCC.

Sx: Malaise, tachycardia, anorexia, D+V, tender hepatomegaly +/- jaundice. Upper GI bleeds, ascites.

Ix:
FBC: raised WCC, low platelets, Increased MCV
increased INR, AST:ALT ratio is typically >2
Increased urea

Mx:
-Prednisolone 40mg PO OD 4wks after an infection screen.

Question 33

Describe PSC: Sx, Ix, Rx, Complications

Answer 33

non-malignant non-bacterial inflamation, fibrosis and strictures of the intra- and extrahepatic bile ducts
Associated with HLA-A1,B8,DR3 Males, AIH and IBD especially UC.

Sx: Chronic biliary obstruction and biliary cirrhosis –> liver failure and death
Jaundie, pruritis, RUQ abdo pain, fatigue, hepatomegaly, portal hypertension

Ix: Bloods: Raised ALP + bilirubin, hypergammaglobulinaemia, AMA-ve but ANA, SMA and ANCA may be +ve.
ERCP (multiple strictures of biliary tree with a characteristic ‘beaded’ appearance)
MRCP
Liver biopsy shows a fibrous, obliterative cholangitis (onion skin).

Rx
Medical: cholestyramine 4-8g/24hr PO, UDCA, abx for bacterial cholangitis
Surgical: endocscopic stenting
liver transplant for end-stage disease, recurrence occurs in up to 30%.

Yearly US and colonoscopy for bile duct, gallbladder, liver and colon cancer

Complications: bacterial cholangitis
Cholangiocarcinoma
colorectal cancer

Question 34

Describe PBC - Sx, Ix, Rx, complications

Answer 34

Interlobular bile ducts are damaged by chronic autoimmune granulomatous inflammation causing cholestasis which may lead to fibrosis, cirrhosis and portal hypertension.
The M rule, Middle aged females, anti-Mitochondrial antibodies, IgM.

Sx: typically middle-aged 50yrs, females, often asymptomatic and diagnosed after finding increased ALP on routine LFT. Lethargy, sleepiness, and pruritus may precede jaundice by years. Clubbing. Sjogren’s

Ix: Increased ALP, y-GT, mildly raised AST,ALT. Late disease shows hyperbilirubinaemia, hypoalbuminaemia, AMA+ve. US to exclude post-hepatic cholestasis.

Rx:
Symptomatic
-Colestyramine for pruritus
-codeine phosphate for diarrhoea
-osteoporosis treatment
Specific
-Vitamin ADEK
-Ursodeoxycholic acid
-When jaundice develops transplantation is usually required.

Complications: Osteoporosis/ osteomalacia
malabsorption of fat soluble vitamins
coagulopathy
Portal hypertension, ascites, variceal haemorrhage, hepatic encephalopathy, HCC

Question 35

Describe hereditary haemochromotosis

Answer 35

An inherited disorder of increases intestinal iron absorption leading to deposition of excess iron in joints, liver, heart, pancreas, pituitary, adrenals and skin. Disease appears earlier and more severely in men menstrual blood loss is protective

Sx:
early- asymptomatic or, lethargy, arthralgia (2nd+3rd MCP joints + knee psuedogout), decreased erections. Later- slate-grey skin pigmentation, chronic liver disease signs, cirrhosis, dilated cardiomyopathy, bronze diabetes, hypogonadism

Ix: Bloods show increased LFTs and serum ferritin plus elevated glucose. Echo and liver biopsy.

Mx: venesection, monitor LFT and DM may progress to cirrhosis and then HCC

Question 36

Describe pancreatic cancer; RF, Sx, Ix, Rx

Answer 36

Typically presents in males >60yrs old.
Mostly ducal adenocarcinoma which metastasise early and present late.
KRAS2 mutation
60%- head of the pancreas, 25% - body and 15%- tail. Others in the ampulla of vater or pancreatic islet cells both of which have better prognosis.

RF: Smoking, alcohol, DM, chronic pancreatitis, increased waist circumference and high fat/red meat diet

Sx: Head- painless obstructive jaundice
Body/Tail - epigastric pain that radiates to the back
Weight loss, diabetes, acute pancreatitis

Ix
Blood-FBC, U+E,LFT, amylase, CA 19-9
Imaging- ultrasound or CT
EUS - FNA biopsy
MRCP - exclude stones

Rx: Surgery: pancreatodeuodenectomy (Whipple’s) - if fit and tumour <3cm with no mets
Post op chemo
Palliation - endoscopic or percutaneous stent insertion (ERCP); palliative bypass surgery
Pain relief

Question 37

King’s College Hospital criteria for liver transplantation (paracetamol liver failure)

Answer 37

Arterial pH < 7.3, 24 hours after ingestion

or all of the following:
prothrombin time > 100 seconds
creatinine > 300 µmol/l
grade III or IV encephalopathy

Question 38

Calculate alcohol units

Answer 38

volume (ml) * ABV / 1,000

Question 39

Low ferritin causes

Answer 39

Iron deficiency causes:

• Bleeding (GI, menorrhagia, haematuria)
• mal-absorption - Coeliac
• Deficient diet
• Pregnancy

Question 40

Raised ferritin

Answer 40

Inflammatory marker 
Iatrogenic 
Haemachromatosis 
lymphoma 
CLL