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MRCP Part 1 > General Medicine: Gastroenterology > Flashcards

General Medicine: Gastroenterology Flashcards

1
Q

Who gets an urgent endoscopy?

A

All with dysphagia or upper abdo mass
>-55 yrs with weight loss + reflux symptoms

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2
Q

How do you test for H. pylori? How do PPIs play a role

A

Urea breath test or stool antigen test
Must be 2 weeks off PPI for test

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3
Q

What do you do if there is Peptic ulcer disease with
+ve H. Pylori
-ve H. Pylori

A

+ve: PPI + Amoxicillin + metronidazole/ clarithromycin for 7 days
-ve: PPIs/H2RA for 1 month

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4
Q

How do you treat a patient with GORD that does not respond to initial PPI treatment

A

If endoscopy +ve: 2x dose 1 month
If endoscopy -ve: H2RA/ prokinetic

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5
Q

How do you treat barrett’s oesophagus?

A

High dose PPI
Endoscopic surveillance every 3-5 years
Resect/ablate if dysplasia identified

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6
Q

How can pain help differentiate peptic ulcers?

A

Worse when hungry, relieved on eating: Duodenal
Pain worse on eating: Gastric

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7
Q

Patient with duodenal ulcer has a 30 minute history of vomiting, low BP and high HR, what has likely happened and how is it treated?

A

Duodenal artery bleed
IV PPIs
Endoscopic treatment

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8
Q

What would indicate ulcer perforation
Clinically
On imaging

A

Acute abdomen/peritonism
CXR/CT showing free air

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9
Q

How does coeliac differ clinically from IBS or IBD

A

No PR bleeding like IBD
Pain following gluten consumption, not on eating and relieved on defecation like IBS

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10
Q

How do you investigate for coeliac

A

IgA (Anti-Ttg/EMA) AFTER 6 weeks gluten
Jejunum biopsy if confirmation needed

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11
Q

How do you manage coeliac disease?

A

Gluten free diet

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12
Q

When would you clinically suspect IBS?

A

6 months abdo pain, altered stool form and 2 of:

  • Altered stool passage
  • Bloating
  • Worse on eating
  • Mucus
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13
Q

What tests confirm IBS

A

-ve inflammatory, coeliac and faecal calprotectin

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14
Q

How do you treat IBS

A
  1. Loperamide if diarrhoea, non-lactulose laxative for constipation
  2. Tricyclics
  3. SSRIs
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15
Q

How can Crohn’s and UC be distinguished clinically

A

Crohn’s: Skin tags and mouth ulcers
Ulcerative Colitis: Bloody diarrhoea + mucus

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16
Q

Which IBD is associated with
Gallstones
PSC
Renal stones

A

Crohn’s: Stones
UC: PSC

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17
Q

Goes beyond mucosal
Goblet cells
Granulomas
Which IBD involves the above 3 features

A

Crohn’s

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18
Q

Crypt abcesses and pseudopolyps are features of which IBD?

A

UC

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19
Q

Which IBD has cobblestoning?

A

Crohn’s

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20
Q

What is the gold standard investigation for IBD? What is the exception to this?

A

Endoscopy + biopsy
Don’t perform if severe colitis, use flexible sigmoidoscopy

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21
Q

For Crohn’s remission, how do you
Induce
Maintain

A

Induce
1. Glucocorticoids
2. Mesalazine
3. Azathioprine/mercaptopurine
Maintain
- Stop smoking
1. Azathioprine/mercaptopurine
2. Methotrexate if TPMT activity has been checked

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22
Q

For UC remission, how do you
Induce
Maintain

A

Induce
Mild moderate:
1. Topical AS
Proct: oral AS/steroid
Severe: IV steroids + ciclosporin if no improvement

Maintain
Mild-moderate:
Top/oral/both AS
Severe or >=2 relapses per year: oral immunosuppressants

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23
Q

How do you manage a perianal abscess in Crohn’s?

A

Incision and drainage
Draining seton if tract identified

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24
Q

How do you manage perianal fistulae in Crohn’s?

A

MRI to visualise extent
Oral metronidazole +/- anti-TNF agents if symptomatic

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25
Q

Compare the complications of Crohn’s and UC

A

Crohn’s: Bowel cancer (small>large), osteoporosis
UC: Colorectal cancer

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26
Q

43 year old woman presents with a 3 month Hx fatigue, joint pain and now a 1 month history of hair loss and bronzed skin, what is the likely diagnosis?

A

Haemochromatosis (CH6-HFE mutation)
More likely in >40s and post-menopausal women (period removes iron)

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27
Q

Why is transferrin saturation better than serum ferritin?

A

90% of raised serum ferritin due to other causes (CKD, ALD, cancer) not iron overload

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28
Q

How do you calculate transferrin saturation? How does this explain a raised result in haemochromatosis?

A 
Serum iron / TIBC 
Iron overload (high iron) / reduced binding (due to genetic defect)
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29
Q

How do you manage haemochromatosis? What is the metrics for success?

A

1st line:Venesection
2nd: Desferrioxamine
<50% transferrin / <50ug/l ferritin

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30
Q

What is the venesection regime for haemochromatosis?

A

Initial: 500ml every 1-4 weeks
Maintenance: 3-4 year

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31
Q

How should the following be screened for haemochromatosis?
General population
Family members

A

General: Transferrin
Family: HFE mutation

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32
Q

What pattern of inheritance is haemochromatosis?

A

Autosomal recessive

33
Q

23 year old patient presents with tremor, poor memory and a history of deteriorating mental health. They also have blue nails and appear slightly yellow. What is the suspected diagnosis?

A

Wilson’s disease
Presents in 10-25yrs olde, younger show liver signs first, older show neurological signs
Neuropsychiatric changes with jaundice/blue nails + Kayser-Fleischer rings

34
Q

What is the underlying pathology of Wilson’s disease

A

AR inheritance of ATP7B gene
Reduced hepatic excretion and increased intestinal absorption of copper

35
Q

What are the 1st line and GS tests for Wilson’s disease?

A

1st line
Reduced serum caeruloplasmin (.’. total serum as 95% of this is in caeruloplasmin)
Raised 24hr copper excretion
GS: Genetics for ATP7B gene

36
Q

What is the management of Wilson’s disease?

A

Penicillamine

37
Q

Which hepatitis are spread via
Faeco-oral
Bodily

A

fAEco-oral
Rest are bodily fluids

38
Q

Which hepatitis have vaccines?

A

A+B

39
Q

Which hepatitis are RNA-based?

A

A, C, E

40
Q

Which hepatitis are only acute in nature?

A

A+E (get it, cos its acute?)
A: 2-4 week incubation
E: 3-8 weeks

41
Q

Since hep A+E are both acute and faeco-oral, how can you tell them apart?

A

A: younger (inc children), Hx recent foreign travel
E: Older men, between tropic of cancer and equator (Latin, top half of Africa, SE asia), Hep B infection
Ultimately serology tells them apart

42
Q

How can you clinically distinguish Hep A+ B

A

Itch and joint pain more common in B
B spread through bodily fluids

43
Q

Which hepatitis is most associated with transient jaundice, fatigue, joint pain but typically asymptomatic

A

Hep C

44
Q

How do you screen and diagnose Hep C

A

Screen with Antibodies
Confirm with PCR

45
Q

How do you treat for Hepatitis A-E

A

A: Supportive, avoid alcohol, 2 immunisations
B: 1. peg-IF 2. Antivirals; immunise sex partners
C: Combo of protease inhibitors +/- ribavirin
D: Interferon, may need transplant
E: Supportive

46
Q

Amenorrhea + jaundice +/- fever in a young female is most likely what condition?

A

Autoimmune hepatitis
Amenorrhea most common feature, acute fever and jaundice only in 25% patients

47
Q

In suspected AIH, what do the following liver screen results mean
Raised IgG
ANA
SMA
LKM1
Soluble liver/kidney antigen

A

IgG: Common to all forms
ANA + SMA: Type 1 (adults + children)
LKM1: Children only
Soluble: Type 3, middle aged adults

48
Q

Following serology for AIH, what would help confirm diagnosis

A

‘Piecemeal’ necrosis on liver biopsy

49
Q

How do you manage AIH

A

Steroids/Immunosuppressants
Liver transplant if this fails

50
Q

Differentiate NAFLD And ALD in terms of
Clinical features
Bloods
Imaging
Treatment

A

NAFLD // ALD
Asymptomatic // liver disease picture
ALT > AST // AST > ALT, raised gGT
USS echogenicity, Fibrosis on ELF // none specific
Weight loss, monitoring // Prednisilone

51
Q

What are the causes of acute liver failure

A

Paracetamol overdose
Alcohol
Hep A+B
Acute fatty liver of pregnancy

52
Q

Acute history of jaundice + confusion + flapping tremor indicates what

A

Acute liver failure

53
Q

What is the best lab test to determine acute liver failure

A

Check PT and albumin for synthetic function
LFTs still useful

54
Q

What imaging can help identify cirrhosis

A

1st: USS
Fibroscan or ELF better but not widely used

55
Q

What is the treatment for acute liver failure?

A

Vit K to improve PT
Lactulose 10-20ml/8 hrs
Cefotaxmine
Stop drugs, monitor CVD and renal function

56
Q

What electrolyte needs to be avoided if an acute liver failure patient has CLD/ascites

A

Na+
Would increase fluid retention

57
Q

6 month history of fatigue + weight loss. Also have red hands, distended abdo veins and splenomegaly. Suggests what?

A

Chronic liver failure

58
Q

What indicates decompensation of liver failure

A

Jaundice + ascites + confusion
Variceal bleeds and easy brusing

59
Q

How can you grade hepatic encephalopathy

A

I: Change in mood, cant draw star
II: Confused
III: InCoherent
IV: Coma

60
Q

What features would prompt thoughts of hepatorenal syndrome in a cirrhosis patient? How can you treat it?

A 
Cirrhosis + Ascites + Renal failure 
Type 1 (2 weeks): terlipressin + dialysis 
Type 2 (6 months): Hepatic portal stenting
61
Q

Patient with fever, abdo pain and metabolic acidosis has you worried about what. How do you treat

A

Spontaneous bacterial peritonitis
Ascitic culture then immediate cephalosporin therapy

62
Q

What are the 3 most common organisms involved with SBP?

A

E.Coli
K. Pneumoniae
G+ve coccus (staph, entero)

63
Q

How do you treat the following complications of liver failure?
Malnutrition
Encephalopathy
Ascites
SBP
Varices

A

High calorie + protein, low salt meals every 2-3 hours
Lactulose
Spironolactone + restrict sodium
Ascitic culture + cephalosporin
Propanolol + band ligate/sclerose/TIPs if stable
Terlipressin, IV abx, Vit-k + fresh frozen plasma, band ligate

64
Q

How can you identify if liver failure is due to paracetamol overdose?

A

Arterial pH <7.3 after 24hrs OR all 3 of

  • PT >100s
  • Creatinine >300umol/L
  • Grade III/IV encephalopathy
65
Q

What measure can help determine if ascites is liver related or not?

A

Serum Albumin Ascites Gradient
>11g indicates likely liver failure

66
Q

How can hepatocellular and cholangiocarcinoma be differentiated
Clinically
Disease markers
Treatment

A

Hepatic // cholangio
Late liver symptoms, painful // painless RUQ mass, obstructive jaundice
AFP // CA 19-9
Resect if early, ablate + chemo + sorafenib if late // Surgery or palliative stening and chemo

67
Q

What causative pathology is more associated with
Hepatocellular carcinoma
Cholangiocarcinoma

A

Cholangio: PSC
HCC: Hep B (world), Hep C (Europe), PBC, HC, Alcohol

68
Q

How can you distinguish between coeliac and bacterial overgrowth syndrome based on lab findings?

A

Folate low in coeliac, high in overgrowth syndrome

69
Q

How do PPIs and lithium affect sodium levels?

A

PPIs cause hypo

Lithium causes hyper

70
Q

What does right sided tenderness on PR indicate

A

Acute appendicitis

71
Q

Why do coeliacs require regular immunisations?

A

Functional hyposplenism

72
Q

What LFT findings are seen in autoimmune hepatitis?

A

ALT/AST (intrahepatic) raised more than ALP (bile duct)

73
Q

What causes pigment laden macrophages in intenstinal mucosa?

A

Laxative abuse

74
Q

How do you manage a C.diff infection where

1st time

Recurrent

A

1st time

Oral vancomycin 10 days

Oral fidaxomicin

Oral vanc +/- IV metronidazole

Recurrent

<=12 weeks: oral fidaxomicin

>12 weeks: Oral vancomycin OR fidaxomicin

Life threatening

Oral vancomycin + IV metronidazole

75
Q

What is the diagnosis and treatment for the following symptoms

Confusion, Hx alcohol abuse and malabsorption

Diarrhoea, Dermatitis, Dementia, beefy red tongue

Night blindness and dry eyes

Spontaneous bleeding and gingival swelling

A

Deficiencies in

B1 (thiamine)

B3 (nicotinamide)

A

76
Q

Lethargy and fatigue with a macrocytic anaemia and megaloblasts means what

Diagnosis?

Treatment?

A

Anti-IF and parietal cell biospy

Lifelong cobalamin

77
Q

INR vs albumin for acute liver failure detection?

A

INR

Albumin takes longer to drop so is seen in chronic liver failure

78
Q

When is TIPSS considered for use?

A

Portal hypertension in Budd-Chiari

Refractory ascites

Secondary prophylaxis of variceal bleeding

79
Q

Why does Crohn’s and terminal ileal disease cause gallstones?

A

Causes loss of bile salts

MRCP Part 1 (32 decks)

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