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Gastroenterology Flashcards

1
Q

Serum to Ascites albumin gradient

  • causes of high gradient
  • causes of low gradient (5)
A
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2
Q

Use of Beta blocker in Primary Prophylaxis of Variceal Bleeding

A

Beta blockers

  • reduced bleeding rates vs placebo
  • reduce risk of first variceal bleed by 50%
  • medium to large sized varices benefit more
  • No clear mortality benefit
  • poorly tolerated at required dose (given low baseline BP in cirrhotic patients already)
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3
Q

What’s a biliopancreatic diversion with duodenal switch look like?

A

The Biliopancreatic Diversion with Duodenal Switch – abbreviated as BPD/DS – is a procedure with two components.

  1. A smaller, tubular stomach pouch is created by removing a portion of the stomach, very similar to the sleeve gastrectomy. A segment of the distal (last portion) small intestine is then brought up and connected to the outlet of the newly created stomach,
  2. Next, a large portion of the small intestine is bypassed - bypassed small intestine, which carries the bile and pancreatic enzymes that are necessary for the breakdown and absorption of protein and fat, is reconnected to the last portion of the small intestine so that they can eventually mix with the food stream.
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4
Q

Significance of H. pylori infection

A
  1. Gastric Cancer - up to 2% lifetime risk
  2. MALT lymphoma
  3. PUD
  • nearly all duodenal ulcers
  • 2/3 of gastric ulcers
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5
Q

Hep C - on treatment and post treatment monitoring

A
  • Examples of antiviral combinations: Sofosbuvir/Ledipasvir, Sofosbuvir/daclasstavir, paritaprevir/ritonavir
  • Give for 12w if no cirrhosis, for 12-24w with cirrhosis
  • Monitor LFTs at week 0, 4 and 12
  • Decompensated cirrhosis – need to be referred to gastroenterologist. Avoid protease inhibitors – can precipitate liver failure. Have to consider transplant
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6
Q

Monitoring post SVR (Sustained Virologic Response) in Hep C

A
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7
Q

Contraindications to Liver transplantion in hep C

A

Think of difficult CASES

  • Coronary/cerebrovascular disease - significant
  • Advanced HCC
  • Substance misuse including alcohol use
  • Extra-hepatic infection
  • Inadequate Social support
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8
Q

Indications for assessment by liver transplant centre in Hep C (8)
-mnemonic MESHSCAM

A
  • MELD score >13
  • Encephalopathy - Recurrent or chronic hepatitic encephalopathy
  • SBP
  • Hepatorenal syndrome
  • Small HCC
  • Child Pugh >B7
  • Ascites, refractory
  • Malnutrition, severe
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9
Q

Genetic HLA type(s) associated with coeliac disease

A

HLA DQ2
HLA DQ8

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10
Q

What is the single preferred test for diagnosis of coeliac disease

A

IgA anti-tissue transglutaminase (anti-tTG) for individuals >2 years old
If an IgA deficiency is suspected either
-measure IgA levels and or test IgG deamidated gliadin peptides

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11
Q

Genetics of Hereditary Haemochromatosis

A

Autosomal recessive disorder of HFE (Hereditary Fe) gene with 2 missense mutations on chromosome 6

Only C282Y homozygotes and occasional C282Y/H63D compound heterozygotes develop clinically significant iron overload

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12
Q

Effect of pre PPI prior to endoscopy for UGIB

A

Cochrane Review 2010
- No significant difference in mortality, rebleeding rates or requirements for surgery between PPI and controls
BUT
-there was significant reduction in endoscopic stigmata of haemorrhage and need for endoscopic intervention in patients treated with PPI
?start the healing process prior to endoscopy

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13
Q

Effect of Post endoscopy PPI in H+M

A

Rate of rebleeding, blood transfusion requirement, and duration of hospital stay are lower
Mortality was less but not statistically significant
These were all high risk ulcers

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14
Q

Features of GI ulcers and likelihood of bleeding without therapy

A

Therefore, top 4 = intervene
Flat spots, clean-based ulcers = no intervention

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15
Q

Endoscopic Treatment of Oesophageal varices

A

Endoscopic rubber band ligation preferred

  • significant reduction in bleeding at 1 year and 2 year
  • significant mortality benefit at 2 years
  • can get post band bleeding from ulceration 5 - 7 days post
  • Preferred over injection sclerotherapy - due to reduced mortality and rebleeding.
  • Sclerotherapy rarely performed now.
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16
Q

Management of gastric varices

A

Suggestion that glue based injection was superior to band ligation or sclerotherapy in:

  • Initial haemostasis
  • Recurrent bleeding risk

Guidelines for bleeding gastric varices:

  • Endoscopy performed at centers with experience in their management.
    • If no experience in glue injection, consider banding.
  • Interventional radiology support:
    • transjugular intrahepatic portosystemic shunting (TIPS)
    • balloon-occluded retrograde transvenous obliteration (BRTO)

Pitfalls of glue injection:

  • Too quick -> embolization – splenic/pulmonary infarcts a 1-4% risk
  • Too much -> embolization) – max 3-4ml depending on size of varix
  • Too slow –> glue needle in varix
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17
Q

Complications of TIPS procedure

A

Shunts blood from portal to hepatic circulation (bypasses liver)
Worsens/increases hepatic encephalopathy
Acute and long term stenosis
Risk of worsening liver disease in Child Pugh C patients

Beware in right heart failure (TTE preferable prior)

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18
Q

Evidence based therapies for NAFLD

A
  • Loss of weight is the best therapy for NAFLD
    • -7 to 10% = improves liver histology
    • -10% = can resolve NAFLD
  • Metformin
    • -improved liver function (LFTs), improves steatosis and time to development of diabetes
  • Statins are safe in fatty liver (unless large, isolated GGT rise)
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19
Q

Investigations in Haemochromatosis
-What is the most sensitive initial screening tool

A
  • Fasting morning transferrin saturation
    • -most sensitive initial screening tool
    • -if >45% will detect almost all C282Y homozygotes = do HFE genotypes
  • Serum Ferritin - less useful in Dx
    • -Rises later in Fe overload
    • -Acute phase reactant, can be elevated by alcohol, steatosis or inflammatory states
    • -if >1000 (and no confounders), liver biopsy is indicated
  • If both transferrin saturation and serum ferritin are normal
    • -NPV 97% so no further testing is indicated
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20
Q

Surveillance of Liver Nodule

A
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21
Q

Indications for liver transplantation in acute liver failure

A
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22
Q

AST:ALT Ratio

A
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23
Q

Diagnostic Algorithm of HCC

A

Characteristic finding: Arterial enhancement and portal vein washout

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24
Q

Management and Prognosis of HCC

A

Cannot use TACE (chemo-embolisation) in decompensated disease due to these patients requiring arterial supply for O2 to liver

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25
SBP Treatment and prevention
* **_Recurrence rate at one year 70% -reduced to 20% with long-term norfloxacin secondary prophylaxis_** * **_EVERY PATIENT THAT HAS EPISODE OF SBP GOES ONTO 2ndry PROPHYLAXIS_** * **_No difference between bactrim and norfloxacin (Austin study)._** * ​Primary prophylaxis in **those with low protein (\<10g/L) ascites** or **bilirubin \>50** with impaired renal function
26
SBP fluid Dx and organisms
27
Criteria for liver transplantation in HCC
28
Distinguishing features of Crohn's Disease -name at least 7
29
Extraintestinal manifestations of inflammatory bowel disease - Which 4 are associted with active GI disease - Which 5 are found independent of GI activity
30
Role of Thiopurines in IBD
31
Side effects of Thiopurines
32
Side effects of TNFa inhibitors
Infusion/injection site reactions - most common
33
Vedolizumab - drug target - mechanism
* **Inhibits trafficking of leukocytes** to sites of inflammation * Approved for treatment UC and Crohn’s * Excellent safety profile – due to specificity for the gut
34
Ustekinumab - drug target - use in IBD
35
Basic approach to the treatment for UC
36
Octreotide drug profile
37
Terlipressin drug profile
38
Predictive Factors in Achalasia
39
Gilbert Syndrome - Genetic Defect - Underlying mechanism of disease - presentation and triggers - treatment and progosis
40
Autoantibodies of autoimmune hepatitis
41
Treatment of Autoimmune Hepatitis
Pred and AZA!
42
Treatment of coeliac disease
**Avoidance of gluten -** found in wheat, barley and rye
43
Secondary Complications of Coeliac Disease
So many! But some important ones: Fe deficiency Impaired splenic function Neurologic disorders Infertility or recurrent abortion Ulcerative jejunoileitis dermatitis herpetiformis! Autoimmune Malignnacy - **T cell lymphoma**, adenocarcinoma of the jejunum
44
Feature on biopsy found in **alcoholic hepatitis** and **_NOT_** in **chronic viral hepatitis:**
Neutrophil infiltrate
45
Primary Billiary Cholangitis - Mechanism of disease - Epidemiology - Presentation - Serologic hallmark - Disease modifying Rx
46
Indications for NAC -Name 4 situations where you would automatically start NAC
47
Paracetamol Toxicity - Definition of an acute toxic dose - Management - When to refer to liver unit (5)
48
Paracetamol metabolism (draw) - normal - what happens with toxic dose
49
Where are bile acids reabsorbed
Ileum
50
Wilson's Disease treatment
Wilson’s disease is treated with penicillamine, which acts as a copper chelator.
51
Treatment of HCC
52
Child-Pugh Classificaiton of Cirrhosis Severity
53
Secondary Prophylaxis post op in oesophageal varices
* **1 Non-selective B blocker** - propanolol once stable (day 3 to 5) * reduces rebleeding and mortality * poorly tolerated * **2 Subsequent endoscopic banding session**s every 2-4 weeks until eradication of varices - median number 3 to 4 banding sessions * reduces rebleeding and mortality * followed by 6 - 12 monthly surveillance
54
**Sulfasalazine** - drug profile
55
Crohn's Disease vs Ulcerative Colitis
Also: 1. **Granulomas** present in CD but not UC 2. **Smoking is protective in UC** and harmful in CD 3. Disease course is **relapsing-remitting in UC** and **progressive in CD** 4. **Treatment:** early combined therapy preferred in **CD**, **step up** therapy preferred in **UC**
56
4 Absolute indications for immunosuppressive therapy in autoimmune hepatitis
57
Where is folate mostly absorbed in the GIT
Jejunum and Duodenum
58
First line therapy in **Hep C** with **decompensated Liver Disease**
* *Sofosbuvir + Velpatasvir + Ribavirin for 12 weeks** - this is a pan-genotypic regimen, therefore use regardles of type (different dosing so still need to know type)
59
Precipitants of Hepatic Encephalopathy in Patients with Cirrhosis
60
Octreotide vs Terlipressin in bleeding oesophageal varices
**Octreotide (somatostatin analogue)** * -Cochrane Review 2007 = **no reduction in mortality** but may **_reduce rebleeding and number of patients failing initial haemostasis._** Non significant reduction in blood transfused in high quality trials **Terlipressin (synthetic vasopressin analogue)** * -Cochrane Review 2009 = **significant _reduction in mortality_ compared to placebo.** No difference compared to endoscopic Rx, octreotide, somatostatin * **ADR:** peripheral vasoconstriction - avoid in PAD, elderly * **Terlipressin may be superior to octreotide**
61
Rifaximin use in Management of Hepatic Encephalopathy
**Reduces hospitalisations** with **HE.** * Doesn’t reduce mortality but does reduce ongoing episodes of encephalopathy and hospital admission
62
Epidemiology of IBD
63
Which Benzodiazepines should be used in **Alcohol Withdrawal** in patients with advanced **cirrhosis** or **acute alcoholic hepatitis**?
Lorazepam Oxazepam
64
Extrahepatic manifestations of Hep C
PCT - Porphyria Cutanea Tarda
65
Basic approach to the treatment of Crohn's disease
66
NAFLD, NAFL, NASH and Cryptogenic cirrhosis - definitions
67
Sorafenib Drug Info
68
Complications of hepatic cirrhosis
69
Types of Direct Acting Antivirals in Hep C
70
FibroScan/Transient Elastography
71
Antibodies associated with Type 1 and Type 2 autoimmune hepatitis
72
4 Risk Factors for Malignancy in Autoimmune Hepatitis
73
(6) Causes of **ALT \> 1000**
* drugs * acute viral hepatitis - HAV, HBV, HDV, CMV, EBV * Ischaemia/trauma * Autoimmune hepatitis * Outflow obstruction (budd chiari) * Wilsons disease \*\*note NOT etoh!
74
Subtypes of microscopic colitis
* *Lymphocytic colitis:** intraepithelial lymphocytic infiltrate (\>20 per high powered field) * *Collagenous colitis:** colonic subepithelial collagen band (\>10micrometres thick)
75
Type 1 vs Type 2 Hepatorenal Syndrome
Type 1 * acute deterioration * precipitating factor * sepsis/beeding * acute on chronic liver failure * if untreated, outcome very poor (50% transplant-free survival at 11 days) * Potentially reversible * albumin + terlipresin - mean survival 45 days * complicates ~ 1/4 of SBP **Type 2** * slow progresion/indolent * annual incidence of 8% in patients with cirrhosis and ascites * often a/w refractory ascites * May have periods of Type 1 HRS * Poor outcome without transplant * 6 month transplant-free survival 6/12 = 40-50%
76
Genotypes of Hepatitis C and implications for treatment
**_Genotypes - most important factor for treatment selection_** **Response to treatment 1\>2\>3** **Genotype 1 -** most prevalent worldwide, many effective directly acting antivirals (DAA) = **best responding** * Subtype 1a - most common in the US, more difficult to treat * Subtype 1b * *Genotype 2 -** respond to same therapies as genotype 3 but with better SVR rates * *Genotype 3 -** most significant predictor o**f poor treatment response,** esp if patient has cirrhosis * *Genotypes 4/5/6 - l**imited data for each, lower response to DAA compared with genotype 1
77
Role of Antibiotics in Bleeding Oesophageal Varices
Cochrane Review 2010 **- Reduces all cause + infection mortality** compared to placebo/no Rx - **Reduced bacterial infections** (SBP, pneumonia, UTI, bacteraemia) **- Reduced rebleeding rates**?may reduce portal pressure ABx used - **IV (Ceftriaxone)** 3rd gen cephalosporins for 3 days or PO/IV Quinolones
78
Management Recommendations in NAFLD
Metformin IS beneficial in NAFLD, also low carb, Mediterranean diet
79
Risk factors for fibrosis in Chronic Hep C
80
What foods to avoid in coeliac disease
Those containing the protein gluten: Wheat Barley Rye

Gastroenterology (3 decks)

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