Gastroenterology Long Case

Question 1

IBS

Answer 1

1. Risk factors (FHx, food intolerance, depression, somatisation)
2. Symptoms (abdominal pain, stool, >3months, rule out alarm symptoms)
3. Investigations (FBE, CRP, celiac serology, TSH, ESR, stool OCP, food diary, colonoscopy)
4. Management (low FODMAP diet, increase fibre, laxatives, loperamide, TCA, SSRI)

Question 2

Peptic ulcer

Answer 2

1. Risk factors (H. pylori, NSAIDs, family Hx, ETOH)
2. Symptoms (dyspepsia, alarm symptoms)
3. Investigations (gastroscopy + biopsy, H. pylori (biopsy/stool/urea breath test/serology)
4. Management (PPI, eradication therapy, surgical)
5. Complications (bleeding, malignancy)

Question 3

Malabsorption

Answer 3

1. Risk factors
   - bowel surgery
   - liver dx
   - pancreatic exocrine def
   - Crohn’s/IBD
   - coeliac disease
   - previous radiotherapy
   - alcohol, cholestyramine
2. Presentation
   - steatorrhea
   - anaemia
   - bone pain
   - weakness
   - bruising
   - peripheral neuropathy
   - rash
   - oedema
3. Investigations
   - FBE
   - iron studies, B12, folate
   - INR
   - albumin
   - Vit D, Ca, Phos, ALP
   - zinc, selenium, vit C
   - cholesterol
   - liver US
   - DEXA
   - find cause - AXR, faecal calprotectin, gastroscopy + biopsy, coeliac serology (tissue transglutaminase)
4. Management
   - reverse causes
   - diet
   - HEHP oral supplementation
   - pancreatic supplementation
   - vitamin supplementation
   - cholestyramine
   - antibiotics
   - TPN
5. Complications
   - micronutrient def
   - infertility
   - hepatic steatosis
   - osteoporosis
   - psychosocial
   - infections (vaccinate)
6. Outlook
   - impact

Question 4

IBD

Answer 4

1. Diagnosis
2. Risk factors
   - smoking, family history
   - NOD2/CARD15
3. Presentation
   - colitis
   - systemic symptoms
   - extra-intestinal manifestations (eyes, arthritis, skin, liver - PSC, nutritional)
4. Investigations
   - FBE
   - ESR, CRP
   - albumin
   - ASCA, pANCA
   - LFT
   - faecal calprotectin
   - endoscopy + biopsy
   - nutritional ax
5. Management
   - smoking cessation
   - induce remission
   - mesalazine (topical/oral)
   - steroids (topical/oral)
   - azathioprine/6MP
   - MTX
   - TNF - infliximab/adalimumab
   - vedolizumab
   - surgical
6. Complications
   - fistulizing dx (metro/cipro/EUA/seton)
   - abscesses
   - malabsorption
   - fulminant colitis (exclude CMV)
   - colon cancer
   - complications of medication
7. Outlook
   - pregnancy
8. General wellbeing
   - remission
   - vaccinations
   - cancer screening - colonoscopy/sun avoidance/skin checks
   - bone health
   - mental health
   - nutritional assessment

Question 5

Chronic liver disease

Answer 5

1. Diagnosis
2. Risk factors
   - viral hepatitis
   - alcoholic liver disease
   - NAFLD
   - drugs (MTX, amiodarone, isoniazid, antibiotics, PTU)
   - autoimmune
   - PSC
   - PBC
   - alpha-1-antitrypsin
   - haemachromatosis
   - CF
3. Presentation
   - Child Pugh score
   - compensated/decompensated
   - ascites
   - bilirubin/jaundice
   - coagulopathy/bleeding
   - low albumin/oedema
   - encephalopathy
   - HRS
4. Investigations
   - FBE, UEC, LFT, INR
   - liver cirrhosis screen - hepatitis serology, autoimmune profile, coeliac serology, alpha-1-AT, iron studies, caeruloplasmin, AFP
   - liver US doppler
   - paracentesis
   - fibroscan
   - liver biopsy
5. Management
   - manage underlying condition
   - non pharmacological - high protein, low salt diet, alcohol cessation
   - salt restrict, spironolactone/frusemide, therapeutic taps, TIPS, norfloxacin prophylaxis
   - variceal surveillance/propranolol
   - lactulose and rifaximin
   - transplantation
   - HCC surveillance - 6 monthly US and AFP
6. Complications
   - bone health
   - malnutrition
7. Outlook
   - impact
   - transplant candidate

Question 6

Hepatitis B and C

Answer 6

1. Risk factors
   - IVDU, sexual history, tattoos, vertical transmissions, blood transfusions
2. Presentation
   - incidental vs symptomatic hepatitis/cirrhosis
3. Investigations
   - LFT
   - viral load/serology
   - fibroscan
   - HCC screen (hep B > risk)
4. Management
   - education - avoid retransmission
   - alcohol cessation/weight reduction
   - combination anti-viral therapy
   - monitor for SVR
5. Complications
   - cirrhosis
   - HCC
   - extra-hepatic manifestation of hep C - haemoatological/autoimmune/dermatological/renal
6. Impact/outlook

Question 7

Liver Transplantation

Answer 7

1. Diagnosis (underlying dx)
   - indication
   - decompensation
2. Transplantation
   - perioperative period - surgical
   - matching/CMV
3. Investigations/Monitoring
   - LFT
   - liver biopsy
4. Complications of transplant
   - anastomotic stricture
   - infection
   - rejection
   - metabolic
   - graft failure
   - renal failure
   - recurrence of native disease
5. Management
   - follow-up
   - prednisolone
   - MMF
   - tacrolimus
6. Complications of immunosuppression
7. General health
   - cardiovascular risk
   - vaccinations
   - PJP prophylaxis
   - diabetes
   - hypertension
   - bone health
   - malignancy screen
8. Impact/outlook
   - QOL
   - ADLs
   - support
   - further transplant?

Question 8

Liver transplant (exam)

Answer 8

1. Signs of CLD
2. Jaundice
3. Liver tenderness - acute rejection
4. Complications of immunosuppression - candidiasis, Cushing’s
5. BP
6. Neuro exam

Question 9

Colon cancer

Answer 9

1. Diagnosis
2. Risk factors
   - smoking, age, male
   - family history
   - obesity, diabetes
   - IBD
   - transplant
3. Presentation
   - altered bowel habits
   - PR bleeding/anaemia
   - ECOG
4. Investigations
   - biopsy
   - staging
5. Management
   - surgical ?stoma education
   - radiotherapy ?proctitis/cystitis
   - chemotherapy
6. Complications
7. Outlook
   - prognosis
   - social supports