Gastroenterology Crash Course

Question 1

Bilirubin high

What investigation should be next?

Answer 1

Unconjugated bilirubin

Gilberts syndrome - benign inherited disorder of bilirubin processing in the liver

Question 2

Gilbert’s syndrome

Answer 2

Benign inherited disorder of bilirubin processing in the liver
Causes recurrent episodes of unconjugated hyperbilirubinaemia
Reduced conjugation of bilirubin - variant in the promotor region of the gene for the enzyme UGT
Episodes precipitated by stressful events - no specific treatment

Question 3

Bilirubin metabolism

Answer 3

Question 4

Crigler-najjar syndrome

Answer 4

Autosomal recessive
Younger age
Unconjugated bilirubin

Question 5

Dubin-Johnson syndrome

Answer 5

Conjugated bilirubin (high)

Question 6

IgM raised
Antinuclear and anti-mitochondrial +
CMB IgG +
Liver enlarged but no biliary dilatation, no gallstones and no focal lesions
What is the most appropriate treatment?

Answer 6

Ursodeoxycholic acid (UDCA)
Primary biliary cholangitis - autoimmune cholestatic liver disease that can lead to cirrhosis
Always be suspected in unexplained raised alp
Anti-mitochondrial - 95% have this
First line is UDCA - bile acid with multiple effects

Question 7

3 key autoimmune liver disease
Autoimmune hepatitis
PBC
PSC

Answer 7

Question 8

PSC is more common in…

Answer 8

Males

Question 9

PBC and autoimmune hepatitis are more common in…

Answer 9

Females

Question 10

Treatment for autoimmune hepatitis?

Answer 10

Pred + azathioprine

Question 11

UDCA treats

Answer 11

PBC

Question 12

LFTs in autoimmune hepatitis

Answer 12

High ALT/AST

Question 13

PBC LFTs

Answer 13

High ALP/GGT

Question 14

PSC LFTS

Answer 14

High ALP/GGT

Question 15

NSAIDs are a common cause of upper GI bleeding that may be exacerbated by …

Answer 15

SSRIs - may increase bleeding risk!
NSAIDS inhibit synthesis of prostaglandins - can lead to gastric/duodenal ulcer
Look at the urea:creatinine ratio in suspected upper GI bleed
Recurrent vomiting followed by haematemesis is classic of MW tear

Question 16

Scoring system for Upper GI bleed (further management)

Answer 16

Blatchford score

Question 17

PERC score?

Answer 17

D-dimer PE

Question 18

PESI score?

Answer 18

PESI score - mortality with PE

Question 19

Oakland score?

Answer 19

Lower GI bleed

Question 20

Child-Pugh score?

Answer 20

Cirrhosis

Question 21

Blatchford and rockall - what is the difference?

Answer 21

Question 22

Barium swallow

Answer 22

Achalasia

Birds beak

Question 23

Achalasia

Answer 23

Rare motility disorder affecting the oesophagus that typically presents with dysphasia
Due to enervation of neutrons within the myenteric plexus
Results in failed relaxation of the lower oesophageal sphincter
Diagnosed on manometers and treated by disrupting the muscle fibres by surgery or endoscopy

Question 24

Unexplained rectal bleeding?

Answer 24

Urgent referral to gastroenterology
Older - malignancy concern
Younger with bloody diarrhoea and no infection - IBD concern

Question 25

UC vs Crohn’s

Answer 25

Question 26

Histology in UC

Answer 26

Mucosal inflammation Continuous Diffuse crypt changes

Question 27

Histology in Crohn’s

Answer 27

Transmural inflammation Skip lesions Granulomas

Question 28

Complications of UC

Answer 28

Toxic mega-colon Perforation Bleeding Malignancy

Question 29

Complications of Crohn’s

Answer 29

Abscess Perforation Fistula Obstruction

Question 30

Blood diarrhoea, tenesmus and urgency, abdo pain | UC or Crohn’s?

Answer 30

Likely UC

Question 31

Granuloma | UC or Crohn’s?

Answer 31

Crohns

Question 32

Mild-to-moderate UC treatment?

Answer 32

Treat with oral mesalazine

Question 33

Mesalazine for…

Answer 33

Mild to mod UC

Question 34

Acute flare of UC can be graded according to what criteria?

Answer 34

``` True love and Witt criteria Acute Severe UC is a medical emergency and requires high dose IV steroids Mild to mod = optimisation of mesalazine Related to aspirin Reduces inflammatory mediators ```

Question 35

Mild Moderate Severe UC

Answer 35

Question 36

Oral budesonide for…

Answer 36

Crohns

Question 37

Crohns

Answer 37

Imaging and endoscopy Major differential for terminal ileitis Mild to moderate - budesonide first line

Question 38

Crohns management

Answer 38

Induce remission Maintenance Surgery

Question 39

IBS

Answer 39

``` Chronic GI disorder characterised by chronic abdominal pain and altered bowel habits Very common (5-20%) of population Disorder of the gut-brain interaction Exclude red flags ```

Question 40

Faecal calprotectin is useful at differentiating

Answer 40

Ibs and ibd

Question 41

IBS treatment

Answer 41

Patient centred discussion FODMAP diet Pain, constipation, diarrhoea - solve with antispasmodic, loperamide, laxatives

Question 42

Duodenal biopsy - subtotal villous atrophy with crypt hyperplasia and increased intraepithelial lymphocytosis = …

Answer 42

Coeliac disease

Question 43

Coeliac disease

Answer 43

Immune mediated enteropathies triggered by dietary gluten peptides Gluten refers to the proteins found within wheat and other cereal grains Diarrhoea, weight loss and bloating High prevalence of IgA deficiency - but check for anti TTG antibodies