Gastroenterology III

Question 1

You find gallstones in the gall bladder incidentally when investigating the liver.

How do you manage them? [1]

Answer 1

Stones that are found incidentally, as a result of imaging investigations unrelated to gallstone disease in people who have been completely symptom-free for at least 12 months before diagnosis do not require intervention.

Question 2

How do you treat Hep A? [1]

Answer 2

This is managed conservatively with supportive care and tends to be self-resolving.

Question 3

How do you investigation for ? Boerhaaves [1]

Answer 3

CT contrast swallow

Question 4

Bariatric surgery is immediately offered if BMI is whaT? [1]

Answer 4

> 50 = first line treatment

Question 5

Describe the three types of bariatric surgery? [3]

Answer 5

laparoscopic-adjustable gastric banding (LAGB)
* it is normally the first-line intervention in patients with a BMI of 30-39kg/m^2
produces less weight loss than malabsorptive or mixed procedures but as it has fewer complications

sleeve gastrectomy
* stomach is reduced to about 15% of its original size

intragastric balloon
* the balloon can be left in the stomach for a maximum of 6 months

Question 6

How might total parenteral nutrition present on FBC? [1]

Answer 6

Deranged LFTs

Question 7

The King’s College Hospital Criteria for Liver Transplant in non-paracetamol related liver failure can be used to answer this question. They state that the criteria for liver transplant are

[1] OR

Any three of: [3]

Answer 7

The King’s College Hospital Criteria for Liver Transplant in non-paracetamol related liver failure can be used to answer this question. They state that the criteria for liver transplant are

Prothrombin time >100 seconds OR

Any three of:

Drug-induced liver failure
Age < 10 or > 40
1 week from 1st presentation of jaundice to encephalopathy
Prothrombin time >50s
Bilirubin ≥300µmol/L.

Question 8

Pain when swallowing +/- history of heartburn

XS alcohol or smoking

No weight loss, systematically well

Answer 8

Oesophagitis

Question 9

Dysphagia +
there may be a history of HIV or other risk factors such as steroid inhaler use

Answer 9

Oesophageal candidiasis

Question 10

Dysphagia of both liquids AND solids from the start

Heartburn

Regurgitation of food - may lead to cough, aspiration pneumonia etc

Answer 10

Achalasia

Question 11

Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough. Halitosis may occasionally be seen

Answer 11

Pharyngeal pouch

Question 12

Dysphagia with liquids as well as solids

May present with extraocular muscle weakness or ptosis

Answer 12

Myasthenia gravis

Question 13

There may be a history of anxiety
Symptoms are often intermittent and relieved by swallowing
Usually painless - the presence of pain should warrant further investigation for organic causes

Answer 13

Globus hystericus

Question 14

Answer 14

Oesphagitis

Question 15

Answer 15

Haemophilus influenzae

Question 16

Answer 16

myasthenia gravis

Question 17

Answer 17

Acanthosis nigricans

Question 18

Answer 18

Achalasia

Question 19

Answer 19

Plummer-Vinson syndrome

Question 20

Answer 20

Plummer-Vinson

Question 21

What is Reynold’s pentad? [1]

What does it indicate? [1]

Answer 21

Charcots triad + hypotension and confusion

Ascending cholangitis

Question 22

If normal triple therapy does not work for PPI - how can you alter treatment? [1]

Answer 22

If triple therapy fails to eradiate H. Pylori the first time, the treatment can be repeated with metronidazole replacing clarithromycin, whichever was not used in the initial course

Question 23

Which biological therapy can be used to treat GIST? [1]

Answer 23

Imatinib

Question 24

Biological agents:

Which of the following is used when treating renal transplants?

Basiliximab
Etanercept
Bevacizumab
Adalimumab
Cetuximab

Answer 24

Biological agents:

Which of the following is used when treating renal transplants?

Basiliximab
Etanercept
Bevacizumab
Adalimumab
Cetuximab

Question 25

Biological agents:

Which of the following is used when treating EGF positive colorectal cancers?

Basiliximab
Etanercept
Bevacizumab
Adalimumab
Cetuximab

Answer 25

Biological agents:

Which of the following is used when treating EGF positive colorectal cancers?

Basiliximab
Etanercept
Bevacizumab
Adalimumab
Cetuximab

C for Colorectal

Question 26

Biological agents:

Which of the following is used intreating Crohns? [2]

Basiliximab
Etanercept
Bevacizumab
Adalimumab
Cetuximab

Answer 26

Biological agents:

Which of the following is used intreating Crohns?

Basiliximab
Etanercept
Bevacizumab
Adalimumab
Cetuximab

Question 27

Basiliximab is used to treat renal transplants

What is it’s MoA?

Tyrosine kinase inhibitor
TNF alpha inhibitor
Anti VEGF
Epidermal growth factor inhibitor
IL2 binding site

Answer 27

Basiliximab is used to treat renal transplants

What is it’s MoA?

Tyrosine kinase inhibitor
TNF alpha inhibitor
Anti VEGF
Epidermal growth factor inhibitor
IL2 binding site

Question 28

Cetuximab is used to treat EGF +ve colorectal cancers.

What is it’s MoA?

Tyrosine kinase inhibitor
TNF alpha inhibitor
Anti VEGF
Epidermal growth factor inhibitor
IL2 binding site

Answer 28

Cetuximab is used to treat EGF +ve colorectal cancers.

What is it’s MoA?

Tyrosine kinase inhibitor
TNF alpha inhibitor
Anti VEGF
Epidermal growth factor inhibitor
IL2 binding site

Question 29

Bevacizumab is used to treat colorectal cancer and renal and glioblastomas.

What is it’s MoA?

Tyrosine kinase inhibitor
TNF alpha inhibitor
Anti VEGF
Epidermal growth factor inhibitor
IL2 binding site

Answer 29

Bevacizumab is used to treat colorectal cancer and renal and glioblastomas.

What is it’s MoA?

Tyrosine kinase inhibitor
TNF alpha inhibitor
Anti VEGF
Epidermal growth factor inhibitor
IL2 binding site

Question 30

How do you treat acute pancreatitis? [5]

Answer 30

fluid resuscitation
* aggressive early hydration with crystalloids. In severe cases 3-6 litres of third space fluid loss may occur
aim for a urine output of > 0.5mls/kg/hr

intravenous opioids are normally required to adequately control the pain

patients should not routinely be made ‘nil-by-mouth’ unless there is a clear reason e.g. the patient is vomiting
- enteral nutrition should be offered to anyone with moderately severe or severe acute pancreatitis within 72 hours of presentation

NICE state the following: ‘Do not offer prophylactic antimicrobials to people with acute pancreatitis’:
- Even though they present with raised WCC

Surgery if indicated

Question 31

A patient has suspected acute pancreatitis.

Imaging reveals they have gallstones.
What surgery is indicated

ERCP
Early cholecystectomy
Radiological drainage or surgical necrosectomy
Debridement

Answer 31

A patient has suspected acute pancreatitis.

Imaging reveals they have gallstones.
What surgery is indicated

ERCP
Early cholecystectomy
Radiological drainage or surgical necrosectomy
Debridement

Question 32

A patient has suspected acute pancreatitis.

Imaging reveals they an obstructed biliary tree.
What surgery is indicated?

ERCP
Early cholecystectomy
Radiological drainage or surgical necrosectomy
Debridement

Answer 32

A patient has suspected acute pancreatitis.

Imaging reveals they an obstructed biliary tree.
What surgery is indicated?

ERCP
Early cholecystectomy
Radiological drainage or surgical necrosectomy
Debridement

Question 33

A patient has overdosed on paracetamol.

How do you decide their management depending on the length of time they overdosed? [2]

Answer 33

Patients with an overdose of < 150mg/kg that has been ingested within a 1 hour period - not staggered:
- Take blood paracetamol level and wait for result before initiating treatment

Staggered overdose:
- first line treatment is with N-acetylcysteine regardless of the time from ingestion