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Final Year - ICSM > Gastroenterology_Medicine > Flashcards

Gastroenterology_Medicine Flashcards

1
Q

What are the markets of liver synthetic dysfunction?

A

Bilirubin

Albumin - slow to change so gives good idea of chronic disease

Coagulation screen (APTT, PT, INR)

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2
Q

Causes of hepatic decompensation in CLD? Key features of decompensation?

Dx & Mx of decompensated chronic liver disease?

A

Cause of hepatic decompensation in CLD:

  • Hypokalaemia
  • Constipation (given lactulose in hospital)
  • Alcohol
  • GI bleed (lots of protein (Hb) enters the bowel –>liver can’t cope)
  • HCC

Decompensated CLD –> Ascites, jaundice & encephalopathy

  • Severely scarred liver (cirrhosis) in CLD –> back pressure on portal vein –> PORTAL HTN = splenomegaly, ascites, varices - caput medusae, oesophageal & rectal

Ix:

  • Serum Ascites Albumin Gradient (SAAG) - serum albumin conc vs ascites conc - 11.1g/L
    • <11.1g/L = exudative cause - peritonitis (infection), peritoneal malignancy OR n_ephrotic syndrome_ (pee out albumin so low serum albumin)
    • Otherwise = transudative cause - cirrhosis, renal failure, HF
  • >250 neutrophils = spontaneous bacterial peritonitis (SBP) –> Tazocin/3rd gen cephalosporin
    • If protein conc <15g/L give prophylactic oral ciprofloxacin

Mx:

  • Paracentesis (ascitic drain) –> post-paracentesis circulatory dysfunction (drops BP) SO if >5L drained give human albumin solution (HAS) 8g/L drained
  • Spironolactone (2nd line - Furosemide) - to prevent fluid accumulation
  • (Salt restrict)
  • Hepatic encephalopathy (liver not dealing with toxins) - give Lactulose + Rifaximin to prevent
  • Coagulopathy - OGD (check for varices) + vit K (needed for clotting)
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3
Q

Gallstone disease - spectrum? RFs? Types of gallstone?

A

Spectrum:

  • Biliary colic - obstruction of gallbladder/bile duct (usually by stones)
    • Sx: RUQ pain (after fatty meal) ± scapular pain
  • Cholecystitis - inflammation of gallbladder
    • Sx: RUQ pain + FEVER
  • Ascending cholangitis - infection ascending biliary tract + entering systemic circulation
    • Sx: Charcot’s triad = RUQ pain, fever + JAUNDICE
    • Severe Sx: Reynold’s pentad = above + CONFUSION + SEPSIS

RFs (5Fs): Fat, Female, Fertile, Forty, Fair

Types of gallstone: mixed (80%), cholesterol (10%, bigger & smaller in #), pigment (10%, smaller & more numerous)

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4
Q

Interpreting LFTs + causes

A

Liver - raised AST + ALT

  • Causes: viral/alcoholic hepatitis, hepatotoxic drugs
  • Most causes increase in ALT > increase in AST EXCEPT Alcoholic hepatitis - AST 2x > ALT
  • AST also rises in muscle damage e.g. MI (normal ALT)

Biliary - raised GGT + ALP

  • Causes: gallstones, cholecystitis, cholangitis, PSC/PBC
  • NOTE: acute alcohol intake increases GGT
  • NOTE: ALP can come from BONE (& placenta) - only biliary if GGT also raised
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5
Q

Chronic liver disease

  • Functions of liver? Outcome of failure?
  • Causes? Ix?
  • Important complication?
  • Scoring?
A

Functions of the liver –> failure:

  • Albumin (plasma oncotic pressure) –> oedema
  • Bilirubin metabolism –> jaundice
  • Clotting factors –> coagulopathy
  • Detoxification –> encephalopathy

Causes:

  • Common - alcoholic liver disease, viral hepatitis, NASH (non-alcoholic steatohepatitis)
  • Less common - AI hepatitis, PSC/PBC, HF, alpha1-antitrypsin def, haemochromatosis, Wilson’s disease

Ix:

  • Alcohol history
  • Hep B/C serology
  • Ferritin, transferrin, A1AT, ceruloplasmin (Wilson’s)
  • Ig, auto-abs (ANA in AI hep, AMA in PBC)

Important complication = VARICES

  • Normal venous return: GI tract –hepatic portal vein –> liver –> hepatic vein –> systemic circulation
  • Physiological hepatosystemic anastomoses (connection of portal vein to systemic circulation) sites - oesophagus, spleen, umbilicus, rectum
    • MEMORY AID: BUTT, GUT, CAPUT
  • Pathological process:
    • In the case of cirrhosis - nodules impede flow of blood through the liver to the hepatic vein –> reducing blood flow to the systemic circulation
    • Backflow of blood to the hepatic portal vein = increased –> backflow to hepatosystemic anastomoses:
      • Oesophagus –> Oesophageal varices
      • Spleen –> Splenomegaly
      • Umbilicus –> Caput Medusae
        • ​Only from portal HTN if running from below umbilicus up
      • Rectum –> Rectal varices

Score for prognosis & need for liver transplant = Child-pugh score (A = 5-6; B = 7-9; C = 10-15 –> C is most severe)

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6
Q

Jaundice breakdown & causes by type & Ix to differentiate

A

Pre-hepatic - unconjugated bilirubin comes from breakdown of RBCs

  • Haemolysis related-causes (excess prod) - AIHA, SCD, G6PD def, malaria
  • Ix:
    • Bloods: excess unconjugated bilirubin (exceeds capacity of liver to conjugate it)
    • Urine: normal (unconjugated bilirubin is insoluble)
    • Stool: normal as liver functioning normally

Hepatic - bilirubin absorbed into liver –> conjugated –> excreted via biliary tract into duodenum

  • Liver disease related-causes - cirrhosis, hepatitis, Gilbert’s syndrome, drugs
  • Ix:
    • Bloods: high unconjugated (liver less able to conjugate quickly) & conjugated bilirubin (leakage of conjugated bilirubin into circulation)
    • Urine: dark (leaked conjugated bilirubin is soluble)
    • Stool: slightly pale (reduced conjugated bilirubin to GI tract)

Post-hepatic - conjugated bilirubin –> soluble urobilingogen (yellow): 1) Absorbed into circulation –> excreted via kidneys 2) Remaining –oxidised–> stercobilin (brown)

  • Biliary disease related-causes (prevent bile outflow) - gallstones, head of pancreas tumour, cholangiocarcinoma, PSC/PBC
  • Ix:
    • Bloods: high conjugated bilirubin (backlog as obstruction at biliary tree so can’t reach duodenum and instead leaks into blood)
    • Urine: dark (leaked conjugated bilirubin is soluble)
    • Stool: very pale (no conjugated bilirubin reaches GI tract –> no stercobilin generated)
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7
Q

Chronic diarrhoea - ddx? Sx? Distribution? Histology? Ix? Mx?

A

IBD

  • Truelove & Witts’ severity index = severity criteria for IBD
  • Crohn’s disease
    • Sx: RIF pain (terminal ileum), failure to thrive (incl. between attacks)
    • Distribution: mouth to anus (esp. terminal ileum), skip lesions
    • Histology: transmural, non-caseating granuloma (also in sarcoidosis)
    • Ix:
      • OGD/colonoscopy/capsule endoscopy
      • Gastografin follow-through
    • Mx:
      • Induction:
        • Steroids (induce remission)
        • 5-ASA (mesalazine)
      • Maintenance:
        • Steroid-sparing agents (methotrexate, azathioprine, mercaptopurine)
        • Biologics e.g. Anti-TNF (infliximab)
  • Ulcerative colitis
    • Sx: gen. abdo pain, PR blood & mucus
    • Distribution: ONLY rectum & colon, continuous
    • Histology: mucosa & submucosa, mucosal ulcers, crypt abscesses
    • Ix:
      • Flexible sigmoidoscopy/colonoscopy
    • Mx:
      • Induction:
        • 5-ASA
        • Steroids
      • Maintenance:
        • 5-ASA (mesalazine)
        • Steroid-sparing agents (azathioprine)
        • Biologics (infliximab)
      • Surgery (proctocolectomy, IJ pouch)

Coeliac disease

  • Def: inflammatory response to gluten (immune reaction to gliadin)
    • DQ2/8 (on HLA typing)
  • Sx: abdo Sx (steatorrhoea, diarrhoea, bloating), failure to thrive
    • Exam: blistering rash on both knees. aphthous mouth ulcers
    • Assoc: T1DM
  • Distribution: duodenum
  • Histology: subtotal villous atrophy with crypt hyperplasia
  • Ix: (maintain normal diet - eat gluten for 6wks before testing)
    • Haematinics - macrocytic anaemia, low Fe, B12/folate
    • Serological testing:
      • Screening: Anti-TTG & total IgA (check for selective IgA def in case this caused false ‘-ve’ anti-tTg abs)
      • If weakly +ve –> anti-endomysial abs (more sensitive & specific)
    • OGD & duodenal biopsy
      • Histology: sub-total villous atrophy with crypt hyperplasia
  • Mx: gluten avoidance

Irritable bowel syndrome - Dx of exclusion

  • Sx: bloating, related to stress, diarrhoea/constipation, relieved by defecation
    • “Pellet-like stools”
  • Ix: faecal calprotectin (an inflammatory marker of GI tract = less likely to be IBS, more likely IBD)
  • Mx: dietary changes, stress Mx, anti-spasmodics, probiotics, laxatives/loperamide, anti-depressants
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8
Q

Mesenteric ischemia:

  • What is the blood supply to the GI tract?
  • What area of GI tract is vulnerable to ischaemia?
  • Breakdown of mesenteric ischemia? Sx? Ix? Mx?

What is the difference between Mesenteric ischemia & ischemic colitis? Sx? Ix?

A

Blood supply

  • Coeliac axis - oesophagus, stomach, start of small intestine
  • Superior mesenteric artery (SMA) - most of the small intestines up to 2/3 transverse colon
  • Inferior mesenteric artery (IMA) - from 2/3 along transverse colon down to rectym
  • NOTE: area 2/3 along transverse colon @splenic flexure = WATERSHED ZONE (limited supply from superior & inferior mesenteric arteries) –> vulnerable to ischaemia!!

_​_Mesenteric ischemia

  • Acute - occlusion of SMA by thrombus/embolus
    • Sx: severe abdo pain, normal abdo exam, shock
    • Ix:
      • AXR (gasless abdo)
      • VBG (lactic acidosis)
      • CT abdo with contrast (if suspect mesenteric ischaemia)/CT angiogram (if LA)
        • If not primary surgery –> followed by mesenteric angiography (Dx non-occlusive mesenteric ischaemia)
    • Mx: resus + CCOT + NBM
      • Empirical abx
      • Bypass ± bowel resection
      • Heparin post-op
  • Chronic - narrowing of SMA by atherosclerosis (stable angina of bowel)
    • Sx: colicky post-prandial abdo pain (more work for bowel to do –> pain, just like in stable angina & exercise)
    • Ix: as above
    • Mx: medical optimisation + bypass (angioplasty + stent if not suitable for surgery)

Ischemic colitis

  • Occlusion of inferior mesenteric artery (IMA) by thrombus/embolus
  • Sx: abdo pain, PR bleeding
  • Ix: sigmoidoscopy/colonoscopy
  • Mx: seek GI & surgical input (can develop chr ulcerating IC)
    • Mild - conservative (IV abx, fluids, bowel rest, DM control)
      • Prophylactic LMWH
    • Segmental resection + stoma
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9
Q

Most common reason to do AXR? Most common causes of this reason by type?

AXR interpretation?

Key volvulus signs on AXR?

A

Reason to do AXR: worried about bowel obstruction (small/large bowel)

Small bowel obstruction on AXR:

  • valvulae conniventes (from one wall to other)
  • Central to image
  • >3cm distension
  • Causes: adhesions (surgery, sepsis), hernia, neoplasm, volvulus, IBD

Large bowel obstruction on AXR:

  • Haustra (Not full width of bowel)
  • Outsides of image
  • >6cm distension
  • Causes: neoplasm, diverticular disease, volvulus, faecal impaction

NOTE: 3/6/9 rule = upper limits of normal for bowel (small = 3cm, large = 6cm, caecum = 9cm)

Volvulus signs (twisting of loop of bowel on mesentery –> balloon animal):

  • Coffee bean sign - sigmoid volvulus (large bowel just before rectum)
  • Embryo sign - caecal volvulus (large bowel just after small bowel)
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10
Q

Acute abdo DDx lower quadrants

A

RLQ:

  • Appendicitis
  • Salpingitis (can be bilateral) - ascending inf from vagina into fallopian tubes

LLQ:

  • Sigmoid volvulus
  • Sigmoid diverticulitis - outpouching of mucosal tissue in sigmoid colon

Diffuse/either:

  • Ectopic pregnancy
  • Ovarian torsion
  • Renal calculi
  • Pyelonephritis (ascending lower UTI)
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11
Q

Acute abdo DDx upper quadrants

A

RUQ:

  • Biliary cholic, cholecystitis, ascending cholangitis
  • Perforated duodenal ulcer
  • Acute hepatitis (e.g. viral)

LUQ:

  • Splenic rupture
  • IBS (complication - splenic flexure syndrome)
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12
Q

Acute abdo DDx epigastric & diffuse

A

Epigastric:

  • Peptic ulcer disease (PUD) - worse after eating (increased HCL), nocturnal (RFs: NSAIDs, H. pylori inf)
  • Pancreatitis - radiates (to back), N&V ± Cullen’s/Turner’s
  • Aortic dissection - tearing, radiates (to back)
  • MI - crushing, radiates (carotids & arms)

Diffuse:

  • Peritonitis - distension & guarding, caused by haemorrhage/perforation
  • Bowel obstruction, bowel strangulation
  • Acute hepatitis
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13
Q

Why do patients with chronic liver disease get oedematous?

A

Backflow of blood into the hepatic portal vein –> increased hydrostatic pressure –> more fluid leaking out into interstitium

Less albumin produced by liver –> less oncotic pressure

Overall net fluid movement into interstitium

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14
Q

Decompensated chronic liver disease - what is it? what is the physical presentation?

A

CLD can be stable but insults such as alcohol/infection –> decompensation (liver failing to carry out normal function)

Presentation: ASCITES (+ worsening jaundice/coagulopathy/asterixis/hypoglycaemia)

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15
Q

At the end of abdo exam what do you offer to do?

A

GOR(D)

  • external Genitalia
  • hernial Orificies
  • digital Rectal
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16
Q

Structures in each region of abdomen?

A
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17
Q

Exposure in abdo exam?

A

Ideally nipples to knees but in this case, I will do nipples to the groin due to possible patient discomfort

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18
Q

diarrhoea with profound hyperkalaemia + persists with fasting

what is the diagnosis?

A

VIPoma - neuroendocrine tumour (starts in pancreas)

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19
Q

IBS presentation

A
  • Chr abdo pain + bloating + altered bowel habit but improves with defecation
  • Dx of exclusion
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20
Q

WHat is inclusion bodies (owl eyes) associated with?

A

CMV colitis

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21
Q

IBD - UC Vs Crohn’s (epidemiology, pattern, histology)

A

Smoking: protects UC, worsens Crohn’s

Site: rectum (colon) in UC, terminal ileum (entire GI tract) in Crohn’s

Pattern: continuous (worse distally) in UC, skip lesions (patchy) in Crohn’s

Histology: mucosa - crypt abscesses in UC, trans-mural - non-cas granuloma in Crohn’s

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22
Q

Erythema nodosum is associated with which conditions?

A

IBD (also pyoderma gangrenosum),

Sarcoidosis

TB

Meds (OCP, sulphonamides, aspirin/NSAIDs)

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23
Q

What is the severity index score for acute colitis (e.g. IBD)?

A

Truelove & Witts’ severity index

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24
Q

Extra-intestinal signs of IBD

A

A PIE SAC

  • APHTHOUS - MOUTH ULCERS (CROHNS)
  • PYODERMA GANGRENOSUM
  • I (EYE)- IRITIS, UVEITIS, EPISCLERITIS (CROHNS)
  • ERYTHEMA NODOSUM
  • SCLEROSING CHOLANGITIS (PRIAMRY- UC)
  • ARTHRITIS
  • CLUBBING FINGERS (CD> UC)
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25
Q

Peptic/duodenal ulcer - Ix? Mx? Key DDx?

A

Duodenal > gastric ulcers

Key Investigation:

  • Stool antigen test (urea breath test not done due to COVID) to test for H. pylori

Triple therapy- 1 week

  • PPI
  • Clarithromycin
  • Amoxicillin OR Metronidazole

DDx: Zollinger-Ellison syndrome (very rare cause): Gastrin secreting neuroendocrine tumour in pancreas - gastrinoma

  • Would have FHx: MEN + multiple ulcers post-treatment
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26
Q

Sign most commonly suggestive of bowel obstruction

A

Tinkling bowel sounds

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27
Q

Primary Sclerosis Cholangitis (PSC) vs Primary Biliary Cholangitis (PBC)

  • Associations? Ix? Tx?
A
  • PSC - intrahepatic & extrahepatic (horrible & progressive disease, obstructive jaundice)
    • Associations: UC (10% but 80% PSC have UC), Cholangiocarcinoma
    • Ix: MRCP, pANCA
      • ‘Beads on string’ on ERCP
    • Tx: supportive, liver transplant
  • PBC - intrahepatic only (benign condition - middle-aged female, intractable itching)
    • Associations: AI diseases (RA, Sjogren’s, hypothyroidism)
      • Sicca syndrome (70%) - dry eyes & mouth (like Sjogren’s syndrome)
      • Fat malabsorption w/ steatorrhoea (incl vitamins ADEK):
        • Low vit D can cause osteomalacia & proximal myopathy e.g. difficulty climbing stairs & pain in lower back
        • Low vit K can cause coagulopathy
    • Ix: ​anti-mitochondrial Ab (AMA), high cholesterol
    • Tx: ursodeoxycholic acid (prognostic benefit)
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28
Q

AI hepatitis - RFs? Ix? Mx? Complications?

A

RFs:

  • Immune dysregulation (thyroiditis, T1DM, UC, Coeliac, RA)
  • Genetic predisposition:
    • For T1 AIH - HLA-DR3/4
    • For T2 AIH - HLA-DQB1/DRB1

Ix:

  • Anti-smooth muscle Ab (SMA), ANA
    • T1: Anti-soluble liver antigen or liver/pancreas (SLA/LP), pANCA
    • T2: anti-LKM1

Mx: high-dose prednisolone + long-term azathioprine

Complications:

  • Cirrhosis in 40%, relapse high if stop IS
29
Q

How do you tell between spleen & kidney on examination?

A

Spleen (vs kidney):

  • Moves down with inspiration
  • You can’t get above it
  • Has a notch
  • Dull to percussion & not ballotable
30
Q

Causes of hepatomegaly, splenomegaly & enlarged kidney(s)?

A

Hepatomegaly causes:

  • Hepatitis (infective and non-infective)
  • Hepatocellular carcinoma/hepatic mets
  • Wilson’s disease, Haemochromatosis
  • Primary biliary cirrhosis
  • Leukaemia, Myeloma, haemolytic anaemia
  • Glandular fever
  • Tricuspid regurgitation

Splenomegaly causes:

  • Portal HTN secondary to liver cirrhosis
  • Splenic mets
  • Haemolytic anaemia, Congestive HF, Glandular fever

Large kidney causes:

  • Bilaterally enlarged: polycystic kidney disease, amyloidosis
  • Unilaterally enlarged: renal tumour
31
Q

What are signs of chronic stable liver disease? Some specific signs for the cause of the CLD?

A

Spider naevi (≥5), palmar erythema, gynecomastia, Dupuytren’s contracture (alcoholic liver disease), clubbing

NOTE - Spider naevi:

  • SVC distribution (above nipples)
  • Press on them and flush from inside out

Specific signs:

  • Needle marks/tattoos - hep C
  • Parotid swelling - alcohol-related liver disease
  • Bronzed complexion/insulin injection signs - haemochromatosis
  • Obesity/DM - non-alcoholic fatty liver disease
  • Xanthelasma - cholestatic disorder
32
Q

Different kinds of erythema?

A

Nodosum - pain over shins

Multiforme - target lesions (life-threatening = Steven’s Johnson Syndrome)

Ab igne - hot water bottle (chr heat exposure)

Marginatum - acute rheumatic fever

Chronicum migrans - lyme disease

33
Q

Findings on abdo exam general inspection?

34
Q

IBD complications?

A

Crohn’s: strictures, obstruction, fistulae

UC: toxic megacolon, colonic carcinoma, PSC

35
Q

Abdo examination differentiating observations from inspection

A
  • Distended abdo - CLD, hepato-splenomegaly, PCKD
  • AV-fistula - renal failure on dialysis, renal transplant
  • Stoma - IBD, surgical
36
Q

Chr diarrhoea, bloating, PMH scleroderma - Dx?

A

Small bowel bacterial overgrowth

37
Q

Suspected bile acid malabsorption - test?

A

SeHCAT test

38
Q

Barley, wheat & rye - should be avoided when?

A

coeliac disease (rice, maize, soya ok)

39
Q

Middle-aged women with non-specific bloating - Dx? Mx?

A

Possible ovarian cancer –> 2WW + CA125

40
Q

When to admit UC case? Mx?

A

Severe UC (if does not meet –> managed in outpatients):

  • 6+ bowel move/day
  • Frank blood
  • Temp ≥37.8, HR ≥90, anaemia, ESR ≥30
41
Q

IBD Hx, asymmetrical joint swelling, HLA-B27 - Dx?

A

Enteropathic arthritis

42
Q

Alcoholic liver disease - presentation? Bloods? Decompensated Mx?

A

Presentation: peripheral neuropathy, cerebellar, Wernicke’s, gout, parotitis, Dupuytren’s contracture

Bloods: AST > ALT (2:1)

Decompensated Mx:

  • Discrimination function calculated (PT/INR + bilirubin):
    • <32/Inf/upper GI bleed –> no steroids
    • Otherwise –> steroids
43
Q

Pan-acinar emphysema, young-onset liver disease, PiZZ phenotype - Dx?

A

Alpha-1-antitrypsin def

44
Q

Raised transferrin saturation, tanned, DM - Dx?

A

Hereditary haemochromatosis

45
Q

Hep B Serology reading?

A
  • Active hepatitis requires HbsAg
  • Anti-HBs – vaccinated or previous infection
  • Anti-HBc – must have cleared infection/had in past
  • Acute inf Anti-HBc IgM
  • Chronic inf Anti-HBc IgG
  • HBeAg +ve = high infectivity
46
Q

Hep C Serology reading?

A
  • HCV-RNA = acute
  • Anti-HCV = previous infection
  • Both = chronic infection
47
Q

Hep B + HIV co-inf Tx?

48
Q

Needle-stick injury from hep B patient + no prev vaccine - Tx?

A

Accelerated hep B vaccination

49
Q

Raised BMI, raised ALT/AST - Dx?

A

Non-alcoholic fatty liver disease

50
Q

Abdo exam - don’t forget what?

A

Hands/arms:

  • Leukonychia (hypoalbuminaemia in liver cirrhosis), Koilonychia (IDA), clubbing (IBD, cirrhosis, coeliac), palmar erythema (liver disease/pregnant)
  • Liver flap
  • Feel for HR/RR

Neck/chest: lymphadenopathy (incl Virchow’s node), inspect back/chest for spider naevi (>5 sign), gynecomastia, loss of axillary hair etc.

Abdo: distension (fluid, fat, foetus, flatus, faeces)

  • Hepatomegaly - mets/HCC, cirrhosis, hepatitis, RVF, haem (leukaemia/lymphoma)
  • Splenomegaly - portal HTN, haem (lymphoma/leukaemia/myelofibrosis), malaria
  • Check for Murphy’s/Rovsing’s if relevant
  • Spleen vs kidney - can’t get above spleen, spleen notched, spleen not ballotable, spleen moves down on inspiration
  • AAA palpation (expansile = AAA)
  • Bowel sounds (tinkling = obstruction, absent = paralytic ileus/peritonitis)

Other: ankle oedema = hypoalbuminaemia (liver disease)

51
Q

Upper GI bleed - scoring for need for intervention? Mx?

A

Blatchford score

Variceal bleed

  • Massive haemorrhage –> balloon tamponade
  • A-E assessment –> IV fluids, blood transfusion
    • F1 Essentials:
      • 2x large bore cannula
      • VBG
      • G&S/X-match
      • Bleep the bleed reg
  • Drugs with prognostic benefit:
    • IV Terlipressin (ADH analogue –> vasoconstriction)/Somatostatin (used for same reason)
    • Prophylactic abx - Ceftriaxone/Norfloxacin (abx)
  • Intervention (discuss with on-call bleed registrar) –> endoscopic band ligation
52
Q

Viral hepatitis

A

Hep A: faecal-oral –> acute

Hep B: blood-borne –> acute/chronic –> serology

  • Contains: Core Ag (cAg), E Ag (eAg), DS-DNA, surface antigens (sAg)
    • eAg present if active & infective
    • Infection response –> generate sAb (surface) + cAb (core)
    • Vaccination gives sAg (no reproductive capacity) –> develop sAb (but not cAb)
  • Serology:
    • HBsAg/HBeAg - actively infecte
      • IgM = acute; IgG = chronic
      • eAg = highly infective
    • HBsAb - protective (cleared/vaccinated)
    • HBcAb - only if previously cleared
  • Can be assoc with Polyarteritis Nodosa (vasculitic rash) & mononeuritis multiplex
  • Tx: IFN-alpha & lamivudine

Hep C: blood-borne –> chronic –> HCV RNA

  • More likely to become chronic than Hep B
  • Assoc w/ mixed cryoglobulinaemia (purpuric skin lesions, Raynaud’s phenomenon)
    • RF +ve, low C4, normal C3
    • Can have +ve anti-LKM1 ab (also in AI hep)
  • Tx: PEG-IFN alpha & ribavirin

Hep D: blood-borne –> co/superinfection w/ Hep B virus

Hep E: faecal-oral –> acute, pregnancy

53
Q

Very high BMI (± T2DM) + high ALT - Dx?

A

Non-alcoholic fatty liver disease

54
Q

Persistent dysphagia that comes and goes for fluid/food - Dx?

55
Q

Peptic ulcer disease - RFs? Types? What artery is most likely to bleed in duodenal ulcer?

Presentation? Ix? Mx? Scoring to evaluate risk of re-bleed/death?

A

RFs:

  • H. pylori exposure
  • Aspirin/NSAID use

Types:

  • Gastric - pain worsened by meal (pain 30m-1hr after meal), loose weight, vomiting, assoc w/ NSAIDs
  • Duodenal - MORE COMMON, pain relieved by meal (pain 2-3hrs after meal), assoc w/ H. pylori, worse by stress/at night –> radiates to back, put weight on, malaena
    • Gastroduodenal artery - runs posterior to 1st/2nd parts of duodenum –> likely cause of bleeding in PUD

Presentation:

  • Chr/recurrent upper abdo pain - related to eating & nocturnal
    • Can be severe/radiate to back in Duodenal ulcers if ulcers penetrates pancreas
  • Pointing sign on exam - show where pain is with 1-finger
  • NOTE: ‘Coffee grounds’ vomiting = upper GI bleed (mostly due to PUD > gastric erosions)

Ix:

  • OGD endoscopy = gold-standard
    • Immediately if dyspepsia + upper GI bleed
    • Within 2wks if ≥55yrs + weight loss + dyspepsia/reflux/upper abdo pain –> exclude malignancy
    • Repeat within 6-8wks to ensure ulcer healing/rule out malignancy
  • H. pylori stool antigen/breath test (2wk wash out period after PPI or 4wks after abx, retest 6-8wks after starting Tx)
  • Bloods - FBC

Mx: consider STOPPING NSAIDs

  • Active bleed:
    • Urgent evaluation (A-E + Blatchford score) + blood transfusion
    • OGD endoscopy (Dx & Tx) –> high-dose IV PPI afterwards (continue oral PPI for 6wks)
    • Rockall score (for risk of rebleed/death) –> if re-bleed –> repeat endoscopy & Tx endoscopically/emergency surgery
  • If H. pylori +ve:
    • H. pylori eradication - triple therapy for 7 days (PPI + 2 abx = Amox + clari/metro) –> retest 6-8wks after starting Tx (leave washout 2wks after PPI, 4wks after abx)
      • If pen allergic –> PPI + Clari + Metro
    • If long-term NSAID/aspirin use:
      • Consider stopping NSAIDs/aspirin
      • Ulcer healing Tx - full-dose PPI/H2 antagonist for 8wks –> H. pylori eradication afterwards
  • If H. pylori -ve: treat underlying cause + PPI (4-8wks, 2nd line = H2 antagonist)
  • If recurrent/refractory ulcers –> long-term PPI/H2 antagonist
56
Q
  • Joint pain in both knees, XR shows chondrocalcinosis
  • Wakes at night frequently to urinate, PMHx T2DM, low albumen on blood

Dx? Classification? Presentation? Ix? Mx?

A

Dx: haemochromatosis

  • Risk of HCC (hepatocellular carcinoma)

Classification:

  • Hereditary - AR, gene on chr6 (carried by 1:10 Europeans)
  • Secondary e.g. from frequent blood transfusions (SCD)

Presentation - from Fe-deposition in various tissues:

  • Arthritis (esp hands), bronze DM (tan), cirrhosis
    • Hypogonadism (accumulates in testis)
    • Dilated cardiomyopathy (accumulates in heart)
  • XR - chondrocalcinosis is assoc w/ pseudogout & haemochromatosis

Ix:

  • Blood iron profile:
    • TF saturation high (>55% men, >50% women)
    • Ferritin normal/slightly high (>500)
    • Low TIBC (as all transferrin saturated)

Mx:

  • Venesection (until transferrin saturation normal)
  • Desferrioxamine (iron chelator to prevent recurring)
  • Monitoring ; TF saturation <50% & serum ferritin <50ug/l
57
Q

abdominal discomfort and bloating, worse after eating foods containing milk

stools have a foul smell and tend to float

recently returned from a backpacking trip in Thailand

Dx? Ix?

A

Giardiasis

Ix: stool microscopy for OCP (trophozoite, cysts) - 65% sensitive

  • Stool antigen detection assay has greater sensitivity and faster turn-around time
58
Q

What 2 things can make ALT go >1000? What are some more weird causes of slightly high ALT?

A

Ischaemic liver

Massive paracetamol overdose

Very rarely: fulminant hepatitis (B/C)

Weird causes of slightly raised ALT: Addison’s coeliac, anorexia

59
Q

Young female with unilateral leg tremor

  • Psychiatric issues
  • Exam: tremor, bradykinesia, dark circles round iris

Dx? Ix? Mx?

A

Dx: Wilson’s disease (AR)

  • Neuropsych issues + liver involvement (no increased risk of HCC unlike haemochromatosis)
  • Basal ganglia degeneration - movement disorders, dysarthria

Ix:

  • Conservative:
    • Urinalysis - elevated urinary copper
    • Kayser-Fleischer rings on slit-lamp exam
  • Bloods: hepatic bloods, reduced serum ceruloplasmin
  • Genetic testing (trinucleotide repeat) - condition appears earlier & earlier each generation

Mx: chelation w/ penicillamine

60
Q

Sewage worker, RUQ pain, fever

  • Bloods –> renal failure + hepatitis

Dx?

A

Weil’s disease aka Leptospirosis

  • Rodent vectors (sewage worker)
  • Causes renal & liver failure
61
Q

Mouth ulcer causes?

A

Aphthous ulcers: stress, Behcet’s disease (vasculitis), Crohn’s, Fe/B12/folate def

Oral leukoplakia = white coating/lacing

  • Hairy leukoplakia in EBV (lateral tongue)
62
Q

Case:

  • 57yrs, burning pain after eating & lying flat, improved with cold drinks, high BMI, smokes, drinks alcohol, occasional bitter taste in back of the mouth
  • Difficulty swallowing in recent months

Dx? Presentation? Ix? Mx? Complication?

A

Dx: GORD

  • Decreased lower oesophageal sphincter (LOS) pressure:
    • Drugs - nitrates, CCBs (smooth muscle relaxation)
    • Alcohol, smoking
    • Hiatus hernia

Presentation: RFs (above), heartburn (worse lying down/at night), reflux incl bitter taste in mouth (after meals)

Ix:

  • 8wk PPI trial
  • If dyspepsia consider OGD for: anaemia, weight loss, dysphagia, >55yrs
  • Oesophageal pH study (<4 for >4% of time = GORD)

Mx:

  • Conservative: weight loss, smoking cessation, head of bed elevation/avoid eating late at night, reduce alcohol
  • Medical:
    • Standard-dose PPI (20mg omeprazole) - continued long-term (if Sx continue after stopping/erosive oesophagitis/Barrett’s oesophagus)
    • H2 antagonist (e.g. cimetidine)
  • Surgery (only if PPIs work but don’t want long-term medical Tx) e.g. laparoscopic fundoplication

Complication: Barrett’s oesophagus –> oesophageal adenocarcinoma

63
Q

Zollinger-Ellison syndrome - def? presentation?

Other causes of poorly healing peptic ulcers?

A

Gastrinoma (pancreatic islet-cell tumour)

  • Multiple peptic ulcers & relapses
  • Diarrhoea
  • NOTE: can be good for OSCE - PUD presentation + diarrhoea

ZE syndrome - is one cause of poorly healing gastric ulcers, others:

  • Crohn’s, gastric Ca
  • Bisphosphonates
  • TB, CMV
64
Q

Causes of peptic ulcers?

A

Stress ulcers:

  • Cushing’s ulcers - severe head trauma, stress, raised ICP
    • Increased vagal tone –> increased acid prod
  • Curling’s ulcers - severe burns

Drugs: CSs, NSAIDs, bisphosphonates, SSRIs

  • Bisphosphonates (30mins before food & stand for 30mins after taking)
65
Q

Anal fissure - def? RFs? Presentation? Ix? Mx?

A

Def: tears of the squamous lining of the distal anal canal

  • <6 weeks = acute, ≥6wks = chronic
  • 90% @posterior midline

RFs: constipation, IBD, STIs (HIV, syphilis, herpes)

Presentation: painful, bright red, rectal bleeding

Ix: PR exam

Mx:

  • Acute <1wk:
    • Soften stool - high-fibre diet + high fluid intake, fybogel (2nd - lactulose)
    • Lubricants (for passing stool), topical anaesthetic, analgesia
  • Chronic: maintain above + topical GTN
    • After 8wks (if above not effective) –> GI referral for sphincterotomy (or botulinum toxin)
66
Q

Portal HTN - Def? Causes?

A

Portal hypertension - increase in the pressure within portal vein, which carries blood from the digestive organs to the liver

  • Hepatic venous pressure gradient (HPVG) = gold standard for assessing severity and a pressure >= 5mmg

Causes:

  • Pre-hepatic – Portal/splenic vein thrombosis, congenital atresia of portal vein
  • Hepatic – Cirrhosis, Schistosomiasis, hepatic mets
  • Post-hepatic – Budd-Chiari Syndrome, Veno-occlusive disease, constrictive pericarditis
67
Q

Dysphagia DDx? Ix?

A

Dysphagia - difficulty swallowing

  • vs Odynophagia - painful swallowing
  • vs Globus sensation - lump in throat, no pain

Oropharyngeal - difficulty initiating swallowing (± cough, choking, aspirating, regurgitation) - pressure in throat

  • Oral:
    • mastication (CN 5,7,11) e.g. CVA
    • Low saliva e.g. Sjogren’s syndrome
  • Pharyngeal:
    • Neuromuscular - CVA, Myasthenia Gravis, Parkinson’s
    • Upper oesophageal sphincter - decreased relaxation

Oesophageal - difficulty after swallowing - pressure in chest

  • Solids & liquids - motor
    • Intermittent: oesophageal dysmotility
    • Progressive (solids –> both): achalasia, systemic sclerosis
  • Solids only - obstructive
    • Non-progressive: lower oesophageal rings/webs, oesophagitis
    • Progressive: stricture, cancer

Ix:

  • Barium swallow if possible proximal oesophageal lesion
  • Upper endoscopy ± biopsy
  • If affects solids & liquids –> manometry
68
Q

Haemorrhoids - presentation, grading, Ix, Mx?

A

Presentation: rectal bleeding & perianal pain

Grading:

  • 1 - prominent BVs (no prolapse)
  • 2 - prolapse on bearing down + spontaneous reduction
  • 3 - manual reduction
  • 4 - can’t be manually reduced

Ix:

  • Bedside: Anoscopic exam, stool (occult haem)
  • Bloods: FBC
  • Imaging: Colonoscopy/flex sigmoidoscopy

Mx:

  • Conservative - fibre, fluids
  • Medical = G1 - topical CS
  • Surgical:
    • G2/3: band ligation
    • G4: surgical haemorrhoidectomy

Final Year - ICSM (20 decks)

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