Gastroenterology Flashcards
1
Q
Fibrosis in the liver is caused by which inflammatory cell?
A
Stellate cell
2
Q
3 ways of diagnosing liver cirrhosis
A
Liver biopsy
Fibroscan
MRI-E
3
Q
5 parameters in the Child Pugh score
A
- Bilirubin
- Albumin
- Ascites
- Encephalopathy
- INR
4
Q
Mortality risk score in cirrhosis
A
MELD score - Uses creatinine, Bilirubin and INR.
5
Q
What is the SAAG score and its cut off
A
Serum albumin: Ascites albumin.
>11 = portal hypertension (transudative)
6
Q
Medical management of ascites
A
- Spironolactone
- Frusemide
- Low salt diet
- Albumin
7
Q
Role of Rifaximin
A
Reduced encephalopathy
8
Q
Management of variceal bleeding
A
- Antibiotics - Ceftriaxone or Norfloxacin
- Octerotide or Teripressin (to vasocontrict Splanchnic circulation)
- Variceal banding/ Glue injection/ Balloon Tamponade
- TIPS
9
Q
Blood pressure aim in variceal bleeding
A
SBP 90
10
Q
Hb Aim in variceal bleeding
A
Hb 70
11
Q
MOA of Octreotide
A
Somatostatin analogue
- decreases glucagon to decrease splanchnic vasodilation
- decreases gastric acid production
12
Q
MOA of Terlipressin in UGI bleeds
A
Vasoconstricts splanchnic circulation
13
Q
Management of stage 2 and 3 HCC
A
TACE + Sorafenib/Levatinib (multi-kinase inhibitors)
14
Q
What percentage of adults exposed to Hep B develop chronic infection?
A
5%
15
Q
Hep B e Antigen positive indicates:
A
Active viral replication
16
Q
Fibroscan is only diagnostic for what stages?
A
Stage 1 - cirrhosis ruled out
Stage 4 - cirrhosis ruled in
17
Q
When is Hep B treated?
A
During Clearance and Escape phase.
Rising ALT = development of fibrosis
18
Q
Hep B treatment
A
Entecavir
Tenofovir
19
Q
Hep B treatment in pregnancy + birth
A
Use tenofovir for treatment of mum
Immunoglobulin and Vaccination to baby
20
Q
Endoscopic management of peptic ulcer disease
A
INJECT adrenaline + CLIP or CAUTERIZE
21
Q
Ulcerative Colitis histological features:
A
Lymphocytes+ Goblet cell depletion + crypt distortion/ abscesses.
22
Q
Crohn’s histological features
A
Granulomas
Transmural
23
Q
IBD high risk genes
A
NOD2/CARD 15
24
Q
Marker used for monitoring IBD disease activity
A
Faecal calprotectin
25
Initial therapy Crohn's Disease
Corticosteroids + AZA/6MP/MTX
26
Initial therapy UC
Corticosteroids + AZA/6MP/MTX/5ASA
27
Management of refractory disease in IBD
1. Infliximab/Adalimumab
2. Vedolizumab/Ustekinumab
Rescue therapy in UC only - Cyclosporine
28
Drug which reduces risk of colorectal cancer in UC
Sulfasalazine/Mesalazine (5ASAs)
29
MOA of Thiopurines
Inhibit purine synthesis
Inhibit Tcell and Bcell proliferation
Induce T cell apoptosis
30
Why do we measure TMPT levels
High TPMT means increased shunting to inactive 6MMP metabolite.
Low TPMT means increased 6-TGN active metabolite which increases the risk of myelotoxicity.
31
Interaction of Thiopurines and Allopurinol
Allopurinol blocks Xanthine Oxidase pathway --> Increased shunting to active 6-TNG metabolite.
32
MOA of Cyclosporine
Calcineurin Inhibitor. Blocks synthesis of IL-2 in T-cells.
33
Steroid of choice in UC
Budesonide
34
Vedolizumab MOA
a4b7 integrin inhibitor. Gut specific.
Blocks T lymphocytes interacting with intestinal endothelium MAdCAM–1 cells.
Note: Works on T lymphocytes, not on intestinal cells.
35
MOA Ustekinumab
IL-12 and IL-23 inhibitor
36
Crohn's 1 year risk of recurrence post bowel resection
80%
37
Drug which improves the histological features of NASH
Pioglitazone
38
Inheritance of Hereditary Hemochromatosis
Autosomal recessive
39
Complications of Hereditary Hemochromatosis
- cirrhosis
- HCC
- Diabetes
- Cardiomyopathy
40
Management of Hereditary Hemochromatosis
1. Phlebotomy ONLY if ferritin >400 or iron deposition tissue injury. (Iron chelation NOT used)
41
Changes in starvation
1. Ketosis
2. Proteolysis
3. Pancytopenia
4. Electrolyte loss
5. Reduced hypothalamic hormones
6. Cardiac dysfunction/arrythmias
42
Mechanism of re-feeding.
Over-shoot of insulin to carbohydrate load.
Leads to K, Mg, PO4 moving intracellularly.
Increased salt retention = oedema
43
Increased risk of which type of gall stone in bowel resection
oxalate stone.
44
Management of short gut
1. Electrolyte supplementation
2. Vit B, C supplementation
3. PPI/ octreotide to reduce GI secretions
4. Imodium/Codeine to slow transit.
5. Pancreatic enzymes
6. Dry meals
7. Teduglutide
45
MOA of Teduglutide
a GLP-2 analogue. Promotes mucosal growth
46
Antibodies for Coeliac disease - and which are most specific.
1. Tissue transglutaminase (TTG) antibody
2. IgA endomysial antibodies
3. Deaminated gliadin peptide (DGP) antibody
EMA and TTG most specific
47
Histological findings in coeliac disease
Villous atrophy
Crypt hyperplasia
Increased lymphocytes
48
Rule out genetic tests for Coeliac disease
HLADQ2
| HLADQ8
49
MOst common Hep C genotype in Australia
Type 3
50
Other Hepatitis C manifestations
Cryoglobulinemia
Membranoproliferative GN
Porphyria cutanea Tarda
51
Hepatitis cancer screening schedule
6 monthly liver US and AFP
52
Variceal bleed prophylaxis
Beta-blockers - propanolol/ carvidelol
OR
Banding
53
Pathophysiology of Hepatorenal syndrome.
Arterial vasodilatation in the splanchnic circulation, which is triggered by portal hypertension, causes progressive rise in cardiac output and fall in systemic vascular resistance. This leads to renal hypoperfusion and AKI. Bacterial translocation may play a role.
54
Hepatorenal Syndrome types
HRS-AKI Type 1 - Atleast 2x increase in serum creatinine in 2 weeks.
HRS-AKI Type 2 - Less than 2x increase in serum creatinine. < 90days.
HRS-CKD - eGFR <60 for >3 months with no other cause.
55
HCC transplant criteria - nodule size and number
<3 nodules <4.5cm (or 6.5 if only 1)
56
Assessment of oesophageal motility/ dysphagia
Manometry
| Gastroscope
57
Management of oesophageal spasm
soft food, PPI, GTN, Ca Channel blockers, botox, dilatation
58
Endoscopic findings in eosinophilic oesophagitis
exudate rings
| furrows
59
Management of eosinophilic oesophagitis
```
PPI
fluticasone puffer
budesonide slurry
dilatation if stricturing
Food elimination diet
```
60
Pathophys of Achalasia
Lower oesophageal sphincter unable to relax
61
Manometry and Barium swallow findings in achalasia
Pressure wave contractions
Aperistalsis
Steeple/birds beak appearance
62
Management of Achalasia
```
Botox
Balloon dilatation
Ca channel blockers, GTN
POEMS procedure
surgical myotomy
```
63
Drugs causing transaminitis
Drugs causing mixed picture
Drugs causing cholestatic picture
Drugs causing transaminitis
- Paracetamol, statins, Isoniazid.
Drugs causing mixed picture
- Anti-epileptics - Carbamazepine, Phenytoin, Lamotrigine.
Drugs causing cholestatic picture
- Abx - flucloxacillin, Amoxycillin, Cephalosporins.
64
Causes of severe transaminitis
Ischaemic hepatitis, Viral hepatitis, Paracetamol, Thrombosis.
65
Pathophys of EtOH withdrawal.
EtOH is a CNS depressant. Therefore there is compensatory upregulation of GABA, glutamate and NMDA receptors with time. Cessation of EtOH unmasks CNS upregulation.
66
AST:ALT >2 = ?
Alcoholic hepatitis
| Note: mortality benefit with prednisolone.
67
AST:ALT <2 = ?
NASH
68
Drug which reduces EtOH cravings
Naltrexone
69
Symptoms of a Carcinoid tumor
- Secretory diarrhoea
- Flushing
- Telangiectasia
- Valvular heart lesions
- Asthma/ bronchocontriction
70
Management of C.difficle
1. Oral Vancomycin/Metronidazole
2. Bezlotoxumab --> MAB for toxin B
3. Faecal transplant
71
Pathologic feature of alcoholic hepatitis
Neutrophil influx
72
Precipitants of hepatic encephalopathy
```
Drugs
Dehydration
Ammonia (GI bleed, constipation, protein)
Thrombus
HCC
Portosystemic shunts
```
73
Which part of the bowel are bile acids re-absorbed
Terminal Ileum
74
Drug of choice in managing agitation in hepatic encephalopathy
Haloperidol.
| Avoid Benzo's due to up-titration of Benzo receptors in encephalopathy.
75
Management of hepatic encephalopathy
1. Treat cause + correct hypokalemia
2. Lactulose
3. Rifaximin
4. Neomycin
5. L-ornithine-L-aspartate (LOLA
76
Effect of hypokalemia in hepatic encephalopthy
Increases renal ammonia production
77
IBS trigger foods
Foods that may trigger symptoms include high fiber foods, lactose, high-fat foods, gluten, partially absorbed sugar alcohols like sorbitol and mannitol, and FODMAP (Fermentable Oligo-Di-Monosaccharides and Polyols)
78
Familial screening for colorectal cancer in first degree relatives.
5 yearly colonoscopies starting age 40 or at 10years younger than affected family members diagnosis, whichever is earliest.
79
MOA of Lactulose in Hepatic encephalopathy
1. Decreased intestinal pH - leads to increased uptake of ammonia by bacteria to produce non-toxic ammonium.
2. Reduces Urease producing bacteria
3. Reduces glutamate absorption.
80
Initial nutrition for ICU patients with pancreatitis
Nasojejunal feeding
81
Primary Biliary Cirrhosis pathology and histology
Pathology - ALP raised, AMA 1:40 or higher. Other PBC specific antibodies are sp200 and gp210.
Can have positive ANA.
Histology - liver histology in PBC is featured by chronic inflammation in the portal tracts
and the formation of noncaseating granulomas.
82
Auto-immune Hepatitis pathology
AIH is associated with positive
- anti-smooth muscle (65%)
- anti-dsDNA
- anti-ssDNA
- ALKM-1
- ALC-1 (anti liver cytosol)
- p-ANCA
- AMA
- ANA
83
In what trimester does Acute Fatty liver of pregnancy occur
3rd trimester. Week 30-38
If maternal-fetal fatty acid metabolism is defective, products of metabolism can accumulate in maternal blood and hepatocytes, medical emergency.
84
Mechanism of A1AT disease in liver and lung
A1AT is a protease inhibitor.
Liver - non-functioning mutant A1AT proteins accumulate
Lung - AAT usually breaks down elastase. Loss of A1AT causes excess elastase therefore elastin deficiency.
85
Pathophys of Gilbert's disease
defect in bilirubin glucuronidation
86
Side effect of high 6MMP levels
hepatotoxicity
87
High risk features requiring yearly colonoscopies
- Primary sclerosing cholangitis
- active IBD
- Colorectal dysplasia
- Colonic strictures
- Pseudo polyps
- FHx of colorectal ca <50yrs age
88
Antibody marker for Primary biliary cirrhosis
AMA
89
Skin symptom asscoaited with coeliac disease
Dermatitis Herpetiformis
90
Faecal transplantation has the most evidence in which disease ?
Pseudomembranous colitis
91
Absolute contraindications to TNF inhibitors
Heart failure
Demyelinating disease
Solid organ tumors
92
Histological findings in NASH
Hepatocyte ballooning
93
What proportion of the livers blood supply comes from the portal vein
75% (most of the rest is from hepatic artery)
94
Drug of choice for alcohol withdrawal in patients with liver disease
Oxazepam/ Lorazepam
95
Two cell types involved in iron absorption
Duodenal enterocytes - Fe3+ is converted to Fe2+ via VitC reductase then brought into the enterocyte by the DMT transporter.
It is transported out of the enterocyte by ferroportin.
Reticuloendothelial macrophages - found in spleen. Eats old RBCs and releases iron back into circulation - inhibited by hepcidin.
96
Which cell secretes Gastrin. What are its triggers and inhibitors.
Secreted by G-cells in the gastric antrum. Works on parietal cells to increase HCL release.
Stimulated by: Vague nerve, aromatic amino acids, Stomach distention, hypercalcaemia.
Inhibited by: Low pH, Somatostatin, glucagon.
97
Why is the Faecal immunochemical test better than FOBT?
More sensitive and specific.
| No dietary changes/restrictions required.
98
Symptoms of Thiamine deficiency
Dry Beriberi - motor and sensory symmetrical peripheral neuropathy
Wet Beriberi- Heart failure, tachycardia, cardiomyopathy.
Wernike encephalopathy - nystagmus, ophthalmoplegia, ataxia, and confusion.
Korsakoff encephalopathy - selective anterograde and retrograde amnesia.
99
Clinical signs of Budd-Chiari
```
Ascites
Hepatomegaly
Loss of hepatojugular reflex
Peripheral oedema
Distension of abdominal veins
```
100
H.pylori treatment
Esomeprazole + Clarithromycin + Amoxycillin (metronidazole if penicillin allergy) for 7 days.
Then cease. No requirement for ongoing PPI.
101
In which disease is periodic acid Shiff positive macrophages seen?
Tropheryma Whipplei infection
102
Most sensitive test for spontaneous bacterial peritonitis
High ascitic fluid neutrophil count
103
Malnutrition deficiencies in bacterial overgrowth
Calcium
Vik K
Vit A
B12 (but high folate)
104
Two Hep C treatment regimes
1. Sofosbuvir (NS5B) + Velpatasvir (NS5A)
| 2. Glecaprevir (NS3/4A) + Pibrentasvir (NS5A)
105
What is NOD 2 associated with?
ilieal Crohns disease
106
B12 absorption
1. Binds to transcobalamin 1
2. Cleaved from transcobalamin in duodenum by Trypsin
3. Binds to intrinsic factor
4. Absorbed in ileum
5. Binds to transcobalamin 2 for transport to organs
107
What molecule does NOD2/CARD15 act on?
muramyl dipeptide
108
Extra-intestinal manifestation in IBD which mirrors intestinal disease activity
large joint arthritis
109
Benefit of pre-endoscopic PPI
reduced endoscopic intervention
110
Criteria for liver transplant in paracetamol overdose
- pH <7.3
OR
- Cr>300 + PT>100secs/ INR >6.5 + encephalopathy
111
Criteria for liver transplant in non-paracetamol cause
```
PT > 100secs / INR >6.5
OR
3 other minor criteria (Kings college criteria)
- age <11 or >40
- bili >300
- coma in >7 days (not acute)
- INR >3.5
- drug toxicity/ acute hepatitis
```
112
Where is folate absorbed
proximal jejunum
113
Pernicious anaemia best test
gastroscopy and biopsy
114
Pernicious anaemia can be triggered by
H.pylori
| Thyroid disorders
115
What is destroyed when iron is high
ferroportin by Hepcidin
116
Haemachromatosis complication unlikely to resolve after treatment
Diabetes
117
Sulfasalazine effect on extra-intestinal arthritis in IBD
No effect on sacro-iliac disease
Has effect on peripheral joints
118
Active disease for IBD peripheral signs
Erythema nodosum
Episcleritis
Arthritis
119
Infliximab in pregnancy
Can use. Stop in 3rd trimester
120
Post op Mx for Crohns
- Metronidazole for 3 months
- Smoking cessation
- Azathioprine or infliximab
121
T cell involved in Hep B
CD8
122
T cell involved in Hep C
CD4
123
Medications which induce CYP281 - causing worse liver failure
Phenytoin
Carbamazepine
TB drugs
Note higher risk in chronic alcoholism but not in acute ingestion
124
A1AT genetics
PiMM - normal
PiZZ - liver disease
Nul - respiratory disease only
125
NAFLD gene for progressive disease
PNPLA3
126
Most important management for alcoholic hepatitis
Nutrition
127
When to give steroids in Alcoholic hepatitis
MELD or MADDREY score > 21
128
MOA of terlipression
Splanchnic vasoconstriction
129
1st line for eosinophillic oesophagitis
PPI
130
components of the MELD score
INR, bilirubin, creatinine
131
HNPCC features
R sided
age <50
MSI high
132
Drug most likely to achieve clinical remission in 1 year in ulcerative colitis
Vedolizumab
133
Calcifications and recurrent pancreatitis
Hereditary Pancreatitis
134
Variceal haemorrhage risk is best assessed by:
Variceal size
135
Management of perianal Crohns
TNFa - Infliximab, Adalimumab
136
Should steroids in acute severe UC be delayed until infective colitis is ruled out.
NO. Give steroids immediately
137
Management of CMV colitis in IBD
Treatment of CMV colitis is intravenous ganciclovir 5mg/kg twice daily
for 3-5 days followed by oral valganciclovir 900mg PO twice daily for 2-3
weeks.
138
Autoimmune hepatitis antibody screen
antinuclear antibodies (ANA)
anti-smooth muscle antibodies (ASMA)
anti-mitochondrial antibodies (AMA)
anti-liver/kidney microsomal-1 antibodies (anti-LKM-1)
immunoglobulin G (IgG) or gamma globulin level.
139
Management of auto-immune hepatitis
Prednisolone monotherapy +/- Azathioprine if moderate-severe disease.
140
Drug which is added to Hep C treatment (Sofosbuvir + Velpatasvir) in decompensated liver disease patients
Ribavirin - It is a guanosine (ribonucleic) analog used to stop viral RNA synthesis and viral mRNA capping, thus, it is a nucleoside inhibitor.
141
Use of glecaprevir plus pibrentasvir is contraindicated with the use of which other drug
Oestradiol
142
Use of sofosbuvir with a second DAA for the treatment of HCV is contraindicated with concomitant use of which other drug.
Amiodarone - high risk of bradycardia.
143
APRI score
100xAST ratio / Plt count - estimates fibrosis of the liver for those with hepatitis C
144
Highest risk immunosuppression for Hepatitis reactivation
1. CD20 and Haematopoietic SCT
| 2. Prednisolone and Alemtuzumab
145
Evaluation of ascites
1. SAAG >11 (note this is a GRADIENT not a RATIO)
2. Protein count >25 = infection/ malignancy/ cardiogenic
3. WCC (neuts, PMN) >250 = treat for SBP.
146
Ammonia metabolism in liver
converted to glutamine
147
Holotranscobalamin (holoTC) transports vitamin B-12 into the cells by binding to which receptor
CD320
148
Most common extra-intestinal manifestation in IBD
Joint - IBD is a.w. a non-destructive peripheral arthritis, primarily affecting the large joints and ankylosing spondylitis.
149
surveillance intervals for polyps on colonoscopy
```
No polyps - FOBT
Low risk (<1cm, <2 polyps)- 5 years
High risk (>1cm, <4 polyps) - 3 years
Multiple (>4) - 1 year
Incomplete colonoscopy/resection <6 months.
```
150
What is absorbed at each part of the GIT
Stomach - water, alcohol, iodide, fluoride
Duodenum/proximal jejunum - iron, vitamins, minerals, folate
Ileum - B12, lipids, monosaccharides, amino acids
Large bowel - Vit K, water, short chain fatty acids
151
Highest risk feature and lowest risk feature for varices from the following:
- high number of variceal columns
- large size
- red wale markings
- Child Pugh C
- High portal vein pressure
Highest risk - variceal size
| Lowest risk - number of variceal columns
152
What type of mutation causes the C282Y mutation in hereditary hemochromatosis
cysteine to tyrosine substitution
153
Complications of Hemochromatosis
• Liver disease with fibrosis or cirrhosis, with hepatocellular
carcinoma occurring in up to a third of cirrhotic patients
• Arthritis
• Gonadal failure
• Diabetes mellitus
• Cardiac failure and arrhythmias.
154
Symptoms of hemochromatosis that do not improve post treatment (regular venesection)
- arthropathy
| - insulin dependant diabetes may partially improve
155
HCC surveillance method and timing
6 monthly liver US and AFP
156
Causes of high ferritin (5)
- liver disease
- HLH
- chronic inflammation
- HIV
- malignancy
157
Markers for macrocytic anaemia that differentiates if it is due to B12 or folate deficiency + interpretation.
B12 deficiency - homocystine high/ MMA high
Folate deficiency - homocystine high/ MMA normal.
MMA = methylmalonic acid
158
Management for fistulising Crohns disease
TNF agents - work really well for fistulizing disease
159
When should the follow up C-scope be after bowel resection for Crohns?
6 months - early scopes due to high risk of recurrence
should also give metronidazole to everyone post op
160
Least effective TNFa agent for Ulcerative colitis
Adalimumab - more evidence in Crohns
161
IBS diagnostic criteria (Rome IV criteria)
1. Symptoms >3month and >once a week
2. Pain on defecation
3. Associated with change in frequency and form of stool
162
Can Hep C patients be used as organ donors?
Yes - treatment with 4 weeks of antivirals prevents recipient infection,
163
Which TNF agent has poor efficacy in IBD
Etanercept - as it only works on soluble TNF
164
Why is Certolizumab preferred in pregnancy
It is PEGylated therefore dont cross the placenta
165
Which gene controls hepcidin expression
HFE
166
Liver zones and causes of injury
Zone I: The periportal zone
Is best oxygenated and, therefore, is most resistant to ischemia. Affected first in viral hepatitis and toxic substance ingestion, e.g., cocaine.
Zone II: intermediate zone (affected in yellow fever)
Zone III: pericentral vein/centrilobular zone
The least oxygenated zone, and thus most susceptible to ischemia. Most sensitive to metabolic toxins (e.g., ethanol, CCl4, halothane, rifampin, acetaminophen)
Has the highest amount of cytochrome P-450
