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MRCP Part 1 > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

Common causes of steatorhoea

A
  • Chronic pancreatitis
  • Crohn’s disease
  • Obstructed biliary flow
  • Coeliac disease
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2
Q

Acute mesenteric Ischaemia VS

Chronic mesenteric ischaemia VS

Acute on chronic mesenteric ischaemia VS

Acute pancreatitis VS

Chronic pancreatitis

A
  • Acute mesenteric ischaemia: predisposing factors of ischaemia >> High amylase, abdominal pain, vomiting
  • Chronic mesenteric ischaemia: predisposing factors of ischaemia >> normal amylase, abdominal pain after meal for a long time
  • Acute on chronic mesenteric ischaemia: predisposing factors >> high amylase, acute abdominal pain, vomiting, abdominal pain after meal for a long time
  • Acute pancreatitis: Factors of GET SMASHED > Acute severe abdominal pain, raised amylase [-ve/absent factors for ischaemia]
  • Chronic pancreatitis: Mainly alcohol, other risk factors > steatorrhoea, weight loss, chronic pain, recent onset DM
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3
Q

Mixed cryoglobinaemia (type 2 cryoglobinaemia) a/w HCV >>> C/F & Findings

A
  • C/F:
    • Meltzer’s triad:
      • Pulpable purpura (non-blancing rash)
      • Arthralgia (swelling, stiffness)
      • Myalgia
    • Livedo reticularis
    • Glomerulonephritis (MCGN/MPGN)
  • Dx: Histology
    • Low C4
    • RF +ve
    • Criculating cryoglobulin
  • IOC: HCV serology
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4
Q

Hepatocellular carcinoma VS differentials

A
  • Raised AFP >>>>> rules out other hepatic cause
  • Absence of acute s/s >>> HCC;
    • Presence of acute S/S, jaundice, abdominal pain> may indicate acute HBV infection, alcoholism etc.
  • Weight loss >>> HCC
    • NO weight loss in chronic active hepatitis, Acute HBV, Alcoholism, and SBP
  • Worsening ascites >>> HCC
    • Tender ascites + acute abdominal pain >>> SBP
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5
Q

Weight loss in colon cancer > cause

A

Anorexia

  • In absence of anorexia > consider the following factors
    • Dysguesia (Loss of taste) > seen in cancer patients > very few weight loss
    • TNF (role in weight loss still unclear)
    • IL-6 (role in weight loss still unclear)
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6
Q

Cause of Dysguesia (taste changes) in cancer patients

A
  • Opioid analgesics
  • Cancer chemotherapy
  • Antibiotics
  • Radiation therapy to head, neck
  • Dry mouth
  • Dental problems
  • Mouth infection
  • Nausea, Vomiting
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7
Q

Patient is on parenterial nutrition for UC >>> develops symptoms of deficiency >>>

Most common feature of the following deficiencies:

  1. Chromium deficiency
  2. Copper deficiency
  3. Magnesium deficiency
  4. Selenium deficiency
  5. Zinc deficiency
A
  1. Chromium deficiency (RARE) >> glucose intolerence
  2. Copper deficiency (RARE) >> cardiac dysrrythmias, altered lipoprotein metabolism
  3. Magnesium deficiency >> hypocalcaemia, neuromuscular excitability
  4. Selenium deficiency (seen as “Keshan disease” in areas where soil has low selenium content) >> cardiomyopathy
  5. Zinc deficiency (IBD patients loose more amount of zinc from gut) >> dermatitis, alopecia

*** Parenteral nutrition has risk of low Mg

*** IBD has risk of low Zn

*** If IBD + Parenteral nutrition >>> decide by looking at ‘presentations’

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8
Q

Colonoscopy finds polyps in the gut:

Predict ‘risks of malignant change’ from ‘features of polyp’

A
  • Low risk for malignant change:
    • Pedunculated (Stalked) polyp
    • Tubular architecture
    • Size <1.5cm
  • High risk for malignant change:
    • Sessile (flat) polyps
    • Villous architecture
    • Severe dysplasia
    • Squamous cell carcinoma
    • Size >1.5cm

*** If multiple polyps are found > do frequent colonoscopy

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9
Q

Drug-induced chronic hepatitis & other causes of chronic hepatits (figure)

A
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10
Q

Drug induced hepatitis VS Differentials

A
  • Drug induced hepatitis (DIH) vs Autoimmune hepatitis
    • Both: More in Female, Anti-LKM Ab +ve, deranged LFTs, Jaundice, hepatomegaly
    • DIH has short history; Autoimmune hepatitis has long history
    • DIH has causative drug; Autoimmune doesn’t have
  • DIH vs PBC
    • DIH has very high ALT, AST ::::: PBC has very high ALP + relatively normal ALT, AST
    • DIH has anti-LKM Ab +ve ::::: PBC has AMA Ab +ve
  • DIH vs PSC
    • DIH has very high ALT, AST ::::: PSC has very high ALP + relatively normal ALT, AST
    • DIH has anti-LKM Ab +ve ::::: PSC has ANCA +ve
  • DIH vs Gallstones
    • DIH has very high ALT, AST ::::: Gallstones has very high ALP + relatively normal ALT, AST
    • DIH has anti-LKM Ab +ve ::::: Gallstone has no such Ab
  • Drug-induced hepatitis, hepatitis B, C vs Drug-induced cholestasis +/- hepatitis
    • Hepatittis has normal ALP ::::: Cholestasis has very high ALP
    • Then, look into drugs of each category of hepatitis, cholestasis and cirrhosis
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11
Q

NAFLD vs Differentials

A

*** If obesity, DM, GDM + high ALT >>> consider NAFLD (since it has very high prevalence ~25% in general population

*** ALT >> AST is a criteria for NALFD, however, if only ALT is given >>> consider very high ALT

  • NAFLD vs Autoimmune hepatitis
    • NAFLD has no positive auto-ab; Autoimmune hepatitis has positive auto-antibody
  • NAFLD vs PBC
    • NAFLD is asymptomatic; PBC has pruritus, lethargy
    • NAFLD has no auto-Ab; PBC has AMA positive
  • NAFLD vs Gallstone
    • NAFLD is asymptomatic; Gallstone has abdominal pain
  • NAFLD vs Cirrhosis
    • NAFLD has normal bilirubin, PT, Platelet count; Cirrhosis has high bilirubin, high PT, and low Platelet count
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12
Q

Crohn’s disease:

Epidemiology

A
  • 6-10% of individuals with IBD have one or more affected relatives
  • High co-efficient of heritability for Crohn’s disease.
    • high heritability co-efficient suggests how phenotype in an individuals is due to genetic defects among the individuals of a community
    • High heritability suggests > variation is due to genetics
    • Low heritabiltiy suggests > variation is due to environmental factors
  • CD is more in female slightly (M:F = 1:1.2)
  • CD occurs at more early median age in females than males
  • CD is more in Jews >>> than non-jews; and Ashkenazi jews >>> Sephradic jews
  • NO proven link between CD and TB
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13
Q

Chronic diarrhoea + scleroderma/systemic /CREST syndrome > Dx > Tx

(= Intermittent bloating, diarrhoea + above)

A

Small Bowel Bacterial Overgrowth (SBBOS)

TOC: Metronidazole

If not available, Rifaximine

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14
Q

Chronic diarrhoea + Diverticulosis > Dx > Tx

A

Small Bowel Bacterial Overgrowth (SBBOS)

TOC: Metronidazole

If not available, Rifaximine

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15
Q

Chronic diarrhoea + Neonates with congenital GI abnormalities > Dx > Tx

A

Small Bowel Bacterial Overgrowth (SBBOS)

TOC: Metronidazole

If not available, Rifaximine

(SBBOS can later cause bile acid diarrhoea type -3)

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16
Q

Chronic diarrhoea + IBD (UC or CD) + steatorrhoea, flatulence, Low vitamin B12 (+/- its features) > Dx > Tx

A

Small Bowel Bacterial Overgrowth (SBBOS)

TOC: Metronidazole

If not available, Rifaximine

SBBOS can later cause bile acid darrhoea

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17
Q

Chronic diarrhoea + any of:

(Metformin intake/

DM patients taking multiple meds/

Ileal resection/

Cholecystectomy/)

or SeHCAT test +ve

> Dx > Ix > Tx

A

Dx: Bila acid diarrhoea

Ix: SeHCAT test

Tx: Cholestyramine

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18
Q

Chronic diarrhoea + crohn’s disease > D/D > Tx

A
  • If steatorrhoea, flatulence, low vitamin B12 > Dx: SBBOS > TOC: Rifaximin, Metronidazole (SBBOS can cause type-3 bile acid diarrhoea)
  • If absence of such > Dx: Type-1 bile acid diarrhoea (bile acid malabsorption) > TOC: Cholestyramine
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19
Q

Barrett’s oesophagus VS differentials

A
  • Pathognomic signs:
    • Gastric looking mucosa spreading to lower oesophageal sphicter
    • Columnar metaplasia
    • New velvet-like mucosa of lower oesophagus
  • Barrett’s VS Achalasia
    • Barrett’s have above findings ::::: Achalasia: Absence of above findings + hiypertensive (high tone) of LES
    • Achalasia is a oesophageal motility disorder
  • Barrett’s VS Erosive oesophagitis
    • Both may have heart burn, dyspepsia, regurgitation, mucosal change
    • In the lower oesophagus, Barett’s > gastric mucosa, velvety-like mucosa ::::: Erosive oesophagitis > erosion of oesophageal own mucosa itself
    • In the lower oesophagus, Barett’s > Columnar epithelium ::::: Erosive oesophagitis > Squamous epithelium
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20
Q

Chronic pancreatitis VS differentials

A
  • Key features:
    • Alcohol is the most common cause in adults
    • Weight loss is important for diagnosis
    • Serum amylase can be normal
    • Other imporant features: Pain worse fater a meal, chronic diarrhoea
  • C.P vs Acute pancreatitis:
    • Both > Alcohol, epigastric pain
    • C.P > Chronic pain ::::: A.P > Acute severe pain
    • C.P > Chronic diarrhoea ::: A.P > Acute/absent diarrhoea
    • C.P > weight loss ::::: A.P > absent weight loss
    • C.P > pain worse after a meal ::::: A.P > rare
    • C.P. > often normal amylase ::::: A.P > always raised amylase
  • C.P vs PUD
    • Both > Chronic abdominal pain, weight loss
    • C.P. > Diarrhoea ::::: PUD > Absent
  • C.P vs Coeliac disease
    • Both > Diarrhoea, weight loss
    • C.P > Abdominal pain ::::: Coeliac disease > NO abdominal pain
  • C.P vs Cirrhosis of liver
    • Both > Alcohol history
    • C.P > Diarrhoea, epigastric pain, weight loss ::::: Cirrhosis > Absent those + Ascites
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21
Q

Lactose intolerence VS differentials

A
  1. A change of diet (from Easi-Asian or African diet to European diet/Western diet) or
  2. Taking more European/Western diet (which is dairy-rich)
  3. Intake of dairy-rich diet
  4. Any ‘change of diet’ due to recent travel to ‘anywhere’
  5. Recent Giardia infection (/given its Tx Tinidazole)
  • After any of above 6 > if intermittent diarrhoea, bloating >>> Dx: Lactose intolerence
  • Lactose intolerance VS IBS
    • Both > Intermittent diarrhoea, bloating +/- abd. pain
    • L.I. > Above history/recent GI infection :::: IBS: Absent of above such history
  • Lactose intolerence VS Coeliac disease
    • Both > possible diarrhoea, cramping, pain, bloating distension etc,
    • L.I. > Above history/recent GI infection ::::: Coeliac disease > Absent of such history
    • L.I. > more in people of Africa or East-Asia origin ::::: Coeliac > more in western, europe, ireland origin people
  • Lactose intolerance VS Chronic pancreatitis
    • L.I. > Intermittent diarrhoea, bloating ::::: C.P. > Chronic diarrhoea
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22
Q

Cause of gynaecomastia in cirrhosis

A
  • 1st cause: Altered oestrogen metabolism >>> high level of oestrogen
  • 2nd cause: If we started on ‘spironolactone (aldosterone antagonist’ >>> Side-effect
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23
Q

Facts on Gamma-glutamyl tranferase (GGT)

A
  • GGT in raised in fatty liver disease
  • In hepatic metastasis >>> high GGT + high ALP (not alone GGT)
  • A rise does NOT always indicate liver pathology; Phenytoin and alcohol mildly increase GGT
  • It can be high in pancreatic carcinoma suggesting liver pathology (consider if pain radiates to back, high viscosity etc. pacreatic features)
  • Raised transaminases (ALT, AST) indicate infectious liver disease; Raised GGT indicates cholestasis
  • GGT is present in many tissues, including liver
  • In pregnancy > GGT is normal; ALP is elevated (due to placental source)
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24
Q

Venesection is a useful treatment for - ?

A

Cardiomyopathy (/cardiac failure) a/w Haemochromatosis

  • upto 2 times per week >>> improve symptoms and reduce the need of diuretic therapy
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25
Q

TOC for Gastric MALT (Mucosa associated Lymphoid Tissue)

A
  • H. pylori eradication therapy
    • As 95% cases of MALT lymphoma are A/W H. pylori
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26
Q

Vitamin C is essential for which process of collagen synthesis ?

A

Hydroxylation of procollagen priline and lysine

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27
Q

Organ that comes in direct contact with lef kidney (not seperated by visceral peritoneum) >> so, has more risk in nepherectomy

A
  • Pancreas
  • Left supra-renal gland
  • Colon

*** Add left-colonic flexure in the section of left kidney (with peritoneum in between)

*** Distal part of small intestine includes jejunum

*** Kidneys are retroperitoneal organ between T12 to L3 vertebrae

*** Right is placed superiorly than left kidney

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28
Q

Limited haematemesis + stable patient + O/E: normal + Hb normal + H/OO aspirin intake > Dx

A

Gastric erosion

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29
Q

Mechanism of action of lactulose

A
30
Q

Altered bowel habit + blood in the stool + polyp in the descending colon at Duke A stage >>> further approach/ time interval of colonoscopy

A
31
Q

Site of ‘amino acid’ absorption

A

Jejunum

32
Q

BSG guidlines on ‘follow-up’ period for ‘adenomatous polyp or dysplastic polyp’ in the colon

A
33
Q

Patient has history of cystic fibrosis (/pancreatic insufficiency) + steatorrohea + on pancreatic supplements >>> goes on a trip to India >>> worsening of stetorrhoea + Low BMI >>> 1st line IOC

A

72-hour faecal fat analysis

*** Then, we can do small bowel imaging, biopsy, endoscopy

*** Faecal elastase is NOT helpful (a test for chronic pancreatitis), as patient is already previously diagnosed with pancreatic insufficiency

34
Q

TOC to achieve sustained remission in UC or CD

A

Azathioprine

Alternative: Mercaptopurine

35
Q

Long history of indigestion + dysphagia to both solid and liquid + episodes of regusgitation that helps to releive feelings of fullness and retrosternal pain >>> Dx

(NO weight loss, O/E normal)

A

Achalasia cardia

36
Q

UC on treatment (maximal mesalazine, steroid enema, prednisolone) > acute attack >

Criteria for progression to colectomy

A
  • Stool frequency >8/day
  • If stool is 3-8/day >>> CRP >45 is a/w progression to colectomy

*** not associated Hb, WBC count

*** Colonic diameter >5.5cm > urgent surgical referral (not associated with oucomes on day 3 particularly)

37
Q

The most common site of ischaemic colitis

A

Splenic flexure

2nd common: Descending colon/sigmoid colon

38
Q

Hepatitis C + transient raised rash on legs + some mild joint pain - >>> The condition most commonly a/w HCV

A

Mixed cryoglobulinaemia

39
Q

Contraindications of percutaneous liver biopsy

A
  1. Deranged clotting; INR > 1.5
  2. Low platelets <50 x109/L
  3. Anaemia (not included in pastest)
  4. Haemagioma suspected
  5. Hydarid cyst OR suspected echinococcus infection
  6. Bile duct obstruction/dilatation
  7. Uncocoperative patient
  8. Severe/Tense ascites (not the mild ascites)
  9. Difficulty body habitus
40
Q

Patient with aspirin/clopidogrel history due to cardiac disease >>> collapse >>> findings that is most specific for upper GI bleeding

A

High urea >6.5

N: 2.5 to 6.5 mmol/L

*** Why: As bleeding in upper GIT > blood goes into digestion > as it is a source of protein > produces ‘urea’ as by-product

*** NO other signs: low Hb, epigastric tenderness are as specific as it for upper GI bleeding

41
Q

Investigation for ‘flare of acute severe ulcerative colitis’ ?

A
  • Confirmatory test: Flexible sigmoidoscopy
    • Biopsy will be available within 72hours (ideally within 24hours)
    • Do histopatholgical diagnosis within 5days > to confirm the Dx and to exclude CMV
      • If CMV +ve >>> means poor treatment response and high relapse rate

***Colonscopy and barium enema is contraindicated in this case due to risk of perforation

42
Q

Tiredness, lethargy + previously diagnosed with IBS (without proper inv.) + mouth ulcers + IDA (= Low Hb, Low Ferritin) + Low Vitamin B12 >>> Dx >>> IOC

A

Dx: Coeliac disease

IOC: Anti-TTG IgA antibodies

*** Combined IDA + Low Vitamin B12 > Dx: Coeliac;
Rules out pernicious anaemia (only low B12), and GI bleeding (only IDA)

*** Even if only IDA, BUT previously (mis)diagnosed with IBS by GP indicates coeliac disease

43
Q

Indications of small bowel follow through

A
  • Dysphagia
  • Pharyngeal pouch
  • Pyloric stenosis
  • Bowel obstruction
  • Volvulus
  • Diverticula

*** Here, it may be needed, NOT usually needed

44
Q

Increasing fatigue + previously Dx as IBS by GP + Low Hb + Low Ferritin (IDA) + normal B12, Folate >>> Dx >>> IOC

A

Dx: Coeliac disease

IOC: Anti-TTG IgA antibodies

*** Combined IDA + Low Vitamin B12 > Dx: Coeliac;
Rules out pernicious anaemia (only low B12), and GI bleeding (only IDA)

*** Even if only IDA, BUT previously (mis)diagnosed with IBS by GP indicates coeliac disease

45
Q

The component of lipid profile that is responsible for ‘lipaemic sample’

A

Chylomicrons

*** Due to chylomicrons > lipid profiles can be uniterpretable

46
Q

Lipid profile: HDL and IDL

A
47
Q

Lipid profile: LDL and VLDL

A
48
Q

Down syndrome + constipation + vomiting

O/E: Signs of bowel obstruction +/- X-ray of small bowel obstruction >>>>> D/D >>>>> Dx

A
  • If children >>>>> Dx: Intessusception
  • If age is around or above 18 >>>>> Dx: Meckel’s diverticulum
49
Q

Large variceal haemorrhage >>>

Long term prophylaxis against further bleeding

A

Propranolol

*** Non-selective beta blockers >>> reduce portal blood pressure >>> prevent re-bleeding

50
Q

Abdominal pain + diarrhoea 6-8 times + blood, mucous + palpation: tender abdomen, particularly on left side +

Rectal biopsy: intense infiltration of mucosa and submucosa with neutrophils, crypt abscess, lamina propria with lymphoid aggregates, plasma cells, mast cells, eosinophils >>> Dx

A

Ulcerative colitis

51
Q

Bowel opens 6times/day + bloody diarrhoea + High CRP + high ESR +

Colonoscopy: only proctitis

Biopsy: Ulcerative colitis >>> TOC

A

Rectal mesalazine

(as it is Distal UC)

*** In case of proximal UC >>> 1st line: Oral mesalazine (aminoglycosides); 2nd line (less favoured than mesalazine): Oral steroid (short course of tappering dose)

52
Q

Abdominal pain, vomiting, fever +

tender epigastrium and RUQ +

high ALT, high bilirubin +

very high ALP + high amylase — >>> Dx

A

Obstruction at the distal common bile duct

(After pancreatic duct meets common bile duct)

53
Q

Patient with Lynch syndrome (= HNPCC) + family history: father died of colon cancer:

Medication that will reduce the risk of progression to colon cancer ?

A

Aspirin

54
Q

Diarrhoea + gradual weight loss + abnormal blood film: Howel-Jolly bodies + conjunctival pallor + mild ankle oedema + Low Hb, Low MCV + mild high creatinine, ALT. mild low albumin >>>

Dx

A

Coeliac disease

55
Q

Patient with C/F of chronic pancreatitis > Inv to assess pancreatic insufficiency

A

Feacal elastase

*** Pancreatic elastase is excreted in the feaces unchanged > useful tool to represent pancreatic exocrine function

*** > 200 mcg elastase/ gm of stool is normal; less than that means insufficiency

56
Q

Use of faecal calprotectin &

Serum amylase

A
  • Faecal calprotectin > to differentiate IBD and IBS (if any doubt in history/features)
  • Serum amylase is elevated in -
    • Acute pancreatitis
    • Acute mesenteric ischaemia
57
Q

COPD + end-stage pancreatic cancer + severe SOB + taking MR morphine sulphate, naproxen, paracetamol, regular high-dose seretide + gross tense ascites + raised ALT, ALP, bilirubin + all other normal >>>

Mx to give symptomatic relief

A

Ascitic drain

if still no releif >>> oral diazepam

58
Q

CLD + h/o several hematemesis + poor compliance with propranolol + high urea >>>

TOC

A

IV Terlipressin

*** High urea is specific for current active variceal bleeding > so initial Tx is Terlipressin

59
Q

Patient was on Tx in hospital for post-operative case, pneumonia, wound infection etc. >>> develops worsening diarrhoea + brown water flecked with blood + high WBC, high creatinine >>> IOC

A

CDT (clostridium difficile toxin)

60
Q

Tiredness/lethargy + intermittent diarrhoea, bloating + stool is difficult to flush away + (low Hb + low MCV) + Low Ca >>> Dx >>> IOC

A

Dx: Coeliac disease

IOC: Anti-TTG antibodies

61
Q

Dieulafoy’s lesion

A
62
Q

Hematemesis + uncontrollable retching > then blood and vomit + normal Hb >>> Dx

A

Mallory Weiss Tear

63
Q

Non-bloody diarrhoea for months + weight loss + SOB + wheeze + facial flushing + CT shows small tumour with liver mets >>> Dx >>> Tx before surgery

A
  • Carcinoid syndrome
  • Tx before surgery: Octreotide
64
Q

Modified Glasgow crietria for prdicting severity/prognosis of acute pancreatitis

A
  • pO2 <8kPa
  • Age >55years
  • WBC >15x109/L
  • Corrected calcium <2mmol/L
  • ALT >100 IU
  • LDH >600 IU
  • Glucose >10mmol/L
  • Urea <16 mmol/L
  • Albumin >32 g/L

To remember: pAW CAL GUA

65
Q

Coeliac disease + bleeding abnormality (/increased susceptibility to bleeding) > Cause

A

Vitamin K deficiency

66
Q

Arthralgia + erectile dysfunction + deep tan + CLD + high levels of serum iron, ferritin, TIBC, glucose >>> Dx

A

Haemochromatosis

67
Q

Tiredness + abdominal pain + intermittent diarrhoea + weight loss + itchy vesicular rash on elbows, knees + microcytic hypochromic anaemia + low ferritin, folate, albumin >>> Dx >>> Inv

A

Dx: Coeliac disease

Inv: Duodenal biopsy (Only select when TTG-IgA is not in the option, or already done)

68
Q

Recurrent bluish red rash on neck + facial telangiectasia + watery diarrhoea + wheeze + mild pedal oedema + high JVP + pansystolic murmur +

A
69
Q

Polycythyemia rubra vera + acute > abdominal pain, vomiting, nausea, abdominal distension, tender hepatomegaly + ascites > high protein content >>>>> DX

A

Budd-Chiari syndrome

70
Q

Ulcerative colitis +

jaundice, pruritus, intermittent abdominal pain +

hepatosplenomegaly, mild ascites +

obstructive jaundice + AMA negative

>>>>> DX

A

PSC (primary sclerosing cholangitis)

71
Q
A

MRCP Part 1 (3 decks)

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