Gastroenterology Flashcards
1
Q
Substances involved in relaxation of Lower oesophageal sphincter
A
NO (nitrous oxide) & VIP (vasoactive intestinal peptide)
2
Q
Diagnosis of eosinophilic oesophagitis
A
Biopsy >15 Eos/hpf at mid & prox oesophagus
3
Q
Mechanism of action of PPI in eosinophilic oesophagitis
A
reduces chemotaxis of eosinophils
4
Q
Manometry findings in achalasia
A
Incomplete LOS relaxation & aperistalsis
5
Q
The types of achalasia based on manometry findings
A
Type I: no discernible P increase
Type II: panoesophageal pressurisation –> good prognosis (mostly p/w chest pain)
Type III: early, synchronous contractions (‘spasm’)
6
Q
Manometry findings in distal oesophageal spasm
A
synchronous, uncoordinated contraction of smooth muscle of oesophageal body
7
Q
Endoscopic stigmata of peptic ulcer with high risk of rebleeding on medical management
A
Active arterial bleeding (Forrest Ia) - 90%
Non-bleeding visible vessel (Forrest IIa) - 50%
Adherent clot (Forrest IIb) - 25-30%
Oozing without visible vessel (Forrest Ib) - 10-20%
8
Q
Benefit of high dose PPI infusion for 72hrs for high risk ulcers post-endoscopy
A
Reduction in
- Re-bleeding
- Blood transfusion requirements
- Hospital LOS & mortality
9
Q
Risk factors of variceal bleeding
A
varix size, presence of red wale mark on varix, CP score, continuous EtOH abuse, HVPG>12mmHg, prev bleed
10
Q
Benefit of octreotide in variceal bleeding
A
avoid early re-bleeding
11
Q
Antibiotic choice & benefit of Abx in variceal bleeding
A
Ceftriaxone –> Norflox (total 7/7) - reduces re-bleeding, infection, death
12
Q
Causes for isolated anti-HBc +ve (-ve HBsAg & anti-HBs)
A
- Distant quiescent HBV infection (most common, born in HBV endemic areas)
- False +ve
- Resolving acute HBV infection
- Occult HBV infection
13
Q
When to treat HBV infection?
A
- When HBeAg +ve & HBV DNA>20k + raised ALT
- When HBeAg -ve & HBV DNA>2k + raised ALT
- If fibrosis/cirrhosis
14
Q
Adverse effect of entecavir in tx of HBV
A
lactic acidosis
15
Q
Advantages of Tenofovir alafenamide over Tenofovir disoproxil
A
less risk of nephrotoxic & reduced BMD
16
Q
Drug of choice for tx of HBV during pregnancy
A
Tenofovir disoproxil. not entecavir or pegylated interferon
17
Q
Adverse effects & contraindication of pegylated interferon
A
- Rare neuropsychiatric SE, trigger autoimmune dx
- Contraindications: decompensated liver dx, significant comorbidities or pregnancy
18
Q
Groups with high risk of HCC with HBV infection
A
- Cirrhosis
- 1st deg relative
- Asian men >40 years
- Asian women >50 years
- ATSI>50 years
- African men & women >20 years
19
Q
Regime for prevention of HBV transmission in pregnancy
A
Tenofovir 3rd trimester (for VL >10^6: start wk 30 to 4-12 wks post-delivery) + vaccination & HBIg for child (reduces risk fr 95% to 10%, tenofovir further reduced it)
- Not indication for C-section
- Breastfeeding is not contraindicated
- Test HBsAg & anti-HBs at 9 months of age
20
Q
Treatment of Hep D virus infection
A
peg interferon alfa for >48 wks
21
Q
Hep C genotype most difficult to treat with direct acting antivirals
A
Genotype 3 (most common in Aus)
22
Q
Extra-hepatic manifestations of HCV infection:-
A
- MPGN (immune complex),
- porphyria cutanea tarda
- Mixed cryoglobulinaemia,
- lichen planus,
- arthritis, rash,
- Neuropathy
- Lymphoproliferative disorders (NHL, MALT)
23
Q
Antiviral for Hep C which can’t be used for decompensated cirrhosis
A
NS3/4a protease inhibitors e.g. Glecaprevir
24
Q
Antiviral classes for:-
- Sofusbuvir
- Velpatasvir, Ledipasvir
- Glecaprevir, Voxilaprevir
A
Sofusbuvir - NS5b RNA polymerase inhibitors
Velpatasvir/Ledipasvir - NS5a inhibitors
Glecaprevir/Voxilaprevir - NS3/4a protease inhibitors
25
Medications contraindicated when taking Velatasvir/Sofusbavir (Epclusa)
Carbamazepine, Amiodarone
26
Medications contraindicated when taking Glecaprevir/pibrentasvir (Mavyret)
Atorvastatin, simvastatin, carbamazepine
27
HCV variant most significant for resistance to direct acting antivirals
Y93H mutation
28
Formula for hepatic vein pressure gradient and upper limit pressure causing clinical sequelae
HVPG=WHVP-FHVP
| >10mmHg likely clinical sequelae (3-5mmHg normal)
29
Primary mechanism of ascites
- Primarily due to portal HTN (not hypoalbuminaemia)
30
Criteria to diagnose spontaneous bacterial peritonitis from ascitic fluid
leucocytes >500, PMN >250cells/microL
31
Most common organism in SBP
Enterobacteriaceae (E coli & Klebsiella)
32
Antibiotic for
| Spontaneous bacterial peritonitis
Ceftriaxone; If on norflox/bactrim -> Tazocin because more likely nosocomial & involves Ceft-res GN
33
Precipitants of Hepatic Encephalopathy
- Infection
- Bleeding
- Constipation/diarrhoea
- Metabolic/electrolyte derangeement
- Drugs - opioid
34
Tx for Hepatorenal syndrome AKI
Albumin (1g/kg for D1-2 then 20-40g/day subsequent days + terlipressin
35
Radiological diagnosis of Hepatocellular Carcinoma
arterial enhancement AND portal venous or delayed washout
36
Why is TACE contraindicated in portal hypertension?
TACE blocks hepatic artery, required portal vein to supply liver
37
Milan Criteria for liver transplant
- Single tumour <5cm OR 3 tumours <3cm each
- No extrahepatic involvement
- No major vessel involvement
38
Patient group to receive Sorafenib in advanced stage HCC
CP A cirrhosis, ECOG 0-1
39
Mechanism of action of Sorafenib
Anti VEGF, anti-angiogenesis
40
Adverse effects of Sorafenib
fevers, diarrhoea, bleeding risk (need gscope & banding prior), palmar-plantar eryhtrodysesthesia
(Lenvatinib less risk to this)
41
Immunotherapy used in unresectable HCC
Atezolizumab (anti-PDL1) & Bevacizumab (anti-VGEF)
42
Genetic variant with high risk of non-alcohol fatty liver disease
PNPLA3 genetic risk variants (in Hispanics)
43
Histological findings of NASH
>5% hepatosteatosis wt inflammation & ballooning of hepatocytes with or without fibrosis
44
Gene mutations associated with Hereditary Haemochromatosis
C282Y (85%) & H63D (minority of cases & lower likelihood of iron overload)
*only homozygous significant. similar risk to gen ppln if heterozygous
45
indication for therapeutic phlebotomy in Hereditary Haemochromatosis
Ferritin>1k OR liver dysfunction (elevated ALT/AST, hepatomegaly) OR cardiac dysfunction (HF, arrhythmia)
46
Components in MEDL score
Cr, Bili, INR, Na, HDx
47
Inclusion criteria for liver transplant
Chronic liver dx with life-threatening cx
- MELD >15 (Cr, Bili, INR, Na, HDx)
- HCC that fulfill the UCSF criteria
Additional indications:-
▫ 2-yr mortality rate >50% w/out transplant
▫ Diuretic-resistant ascites, recurrent HE, recurrent SBP, recurrent GI haemorrhage
▫ Intractable cholangitis
▫ Hepatopulmo syndrome; portopulmo HTN
▫ Metabolic syndromes (e.g. familial amyloidosis, urea cycle disorders, oxalosis)
▫ Polycycstic liver dx
48
King's College Hospital Criteria for acute liver failure (paracetamol-induced)
```
- pH of ABG <7.3 OR
All 3 of the following:-
- INR>6.5
- Cr>300
- Grade III/IV encephalopathy
```
49
King's College Hospital Criteria for acute liver failure (not paracetamol-induced)
```
- INR >6.5 OR
3 out of 5:-
- Age <10 or >40
- Bili >300
- Jaundice-to-Coma time of >7/7
- Drug toxicity
- INR>3.5
```
50
UCSF Criteria for liver transplant in HCC
- Single nodule <6.5cm or
| - Up to 3 nodules, largest <4.5cm or Cumulative tumour size<8cm
51
Immune cells involved in coeliac disease
CD4 T cells
52
Coeliac ab serology testing
Either request tTG-IgA + Total IgA level (2-3% coeliac Ig A def) OR tTG-IgA + DGP-IgG (de-amidated gliadin)
53
Findings from small bowel biopsy in coeliac
intraepithelial lymphocytes, crypt hyperplasia & villous atrophy
54
HLA a/w coeliac disease which can be used to exclude diagnosis
HLA-DQ2, HLA-DQ8
55
susceptibility genes ininflammatory bowel disease
NOD2/CARD15
56
Histological findings in :-
| UC vs Crohn's
UC: Confined to mucosa & submucosa, Lymphocytic infiltrate & goblet cell depletion, Crypt distortion, cryptitis & crypt abscesses
Crohn's: Transmural inflamm with lymphocytic infiltrate & macrophages. Granulomas can be present
57
Antibodies a/w UC vs Crohn's
UC - ANCA
| Crohn's - ASCA (anti-saccharomyces cerevisiae ab)
58
Extra-intestinal Manifestations
| of UC a/w active disease
Oral ulcers
Erythema nodosum
Large joint arthritis
Episcleritis
59
Extra-intestinal Manifestations
| of UC independent of disease
```
Primary sclerosing cholangitis
Ankylosing spondylitis
Uveitis
Pyoderma gangrenosum
Kidney stones, gallstones
```
60
thiopurine + anti-TNF in young males is a/w which malignancy?
hepatosplenic T-cell lymphoma
61
Indications for Anti-TNF alpha antibodies in IBD
i. Inflammatory CD refractory to steroid & AZA/MP/MTX
ii. Refractory fistulizing CD
iii. Acute severe UC failing IV steroid
iv. Mod-severe chronic UC failing 5-ASA/thiopurine
62
What to do if loss of response to TNF blocker?
check trough drug level & anti-drug ab (ADA)
- if therapeutic drug level -> switch out of class
- if subtherapeutic & ADA +ve, switch to another TNF blocker
63
Mechanism of action of Vedolizumab
Inhibitor of α4β7 integrin on T lymp surface --> blocks MAdCAM-1 on intestinal endothelium --> inhibits trafficking of leukocytes to sites of inflamm
64
Mechanism of action of Ustekinumab
mAb to p40 subunit of IL12/IL23
65
Definition of acute severe colitis for UC
bloody stool freq >6/day + one of these (HR>90, temp>37.8C, Hb<105, ESR>30)
66
Surgical indication for UC
- Fulminant dx
- Failed medical tx
- Dysplasia/cancer
67
Surgical indication for Crohn's
Failed medical tx (ineffective, poorly tolerated) with complications - stricture, fistula, abscess, perforation
68
When to perform annual surveillance colonoscopy in IBD?
- active disease
- PSC
- Family hx of 1st deg relatives
69
Risk of absent ileocecal valve
small intestinal bacterial overgrowth
70
Signs of zinc deficience
oligospermia, hair loss, growth retardation, hypogonadism in males, delayed wound healing, bullour-pustular dermatitis, alopecia
71
Stool tests for:-
- inflammation
- protein-losing enteropathy
- lack pancreatic enzymes
- inflammation -> calprotectin
- protein-losing enteropathy -> A1AT
- lack pancreatic enzymes - elastase
72
Medications causing cholestatic picture in DILI
Augmentin, cephalosporin, fluclox, OCP
73
Medications causing hepatocellular picture in DILI
paracetamol, statins, isoniazid
74
Causes of markedly elevated ALT & AST (>25 ULN)
- Ischaemic hepatitis (hypotension, renal failure, elevated LDH)
- Viral hepatitis
- Drug induced (paracetamol)
- Hepatic vein thrombosis
75
Causes with AST:ALT >2
EtOH/NAFLD, Hep C cirrhosis or Wilson's(if in acute liver failure)
76
Histology findings in Alcohol-related liver damage
globular red hyaline material within hepatocytes
77
Histology findings in Alcoholic hepatitis
neutrophil infiltrate
78
Mechanism of action of acamprosate vs naltrexone
acamprosate - reduces neuronal hyperexcitability of withdrawal
naltrexone - blocks effects of endogenous opioids to reduce cravings
79
Histological findings in primary sclerosing cholangitis
degeneration of small bile ducts with periductal sclerosis/fibrosis - onion skin pattern
80
Histological findings in primary biliary cholangitis
bile duct degeneration with periductal granulomatous inflammation - florid bile duct lesion
81
difference between osmotic vs secretory diarrhoea
secretory - large volume watery stool despite fasting (consider carcinoid syndrome)
82
tests for carcinoid syndrome
urinary 24-hr 5-HIAA (metabolite of serotonin), chromogranin A
83
diagnosis of irritable bowel syndrome
recurrent abdo pain, at least one day per week in last 3/12 + at least 2:-
1. relieved with defecation, 2. assoc wt change in freq & 3. changeform/appearance of stool
84
Mechanism of action of PPI
Selectively inhibit H-K ATPase in gastric parietal cells --> suppress gastric acid secretion
85
Types of adenoma with the highest oncogenic potential
Tubular adenoma, tubulovillous adenoma
| > sessile > hyperplastic
86
Amsterdam Criteria --> refer for genetic counselling/testing for risk of CRC/Lynch
- 3 relatives w CRC, 1 of whom is 1st deg relative of the other 2
- At least 2 successive generations involved
- At least 1 of the ca dx
87
Malignancy related to familial adenomatous polyposis
- colorectal ca
- ampullary/duodenal ca - 5 yearly duodenoscopy
- desmoid tumours
88
When to perform prophylactic colectomy in classical FAP?
age 15-25 once adenomas observed
89
Screening colonoscopy for
| Peutz-jeghers syndrome
Screening colonoscopy at 8 y/o then every 3 yrs fr 18 +/- capsule endoscopy/MR enterography
90
Effects of Cholecystokinin production (produced from D cell)
- slow down gastric emptying
- Pancreatic enzyme release
- Smooth muscle contraction
91
what happens with
| loss of interstitial cells of Cajal
motility disorder of the GI
92
Histology of autoimmune hepatitis
lymphoplasmocytic infiltrate in portal tract that extends into the lobule causing hepatic necrosis with rosetting of liver cells
93
Drugs precipitating Autoimmune hepatitis
Minocycline, nitrofurantoin, INH, PTU, Methyldopa
94
antibodies a/w autoimmune hepatitis type 1
anti-SMA, ANA
95
antibodies a/w autoimmune hepatitis type 2
anti-LKM1, anti-LKM3
96
Initial tx for autoimmune hepatitis
prednisolone & azathioprine
97
Blood test findings in primary biliary cholangitis
Elevated IgM, high lipids, AMA (95%), ANA (30%)
