GI

Question 1

PBC features, criteria

Answer 1

Middle aged female
AI, destruction of intrahepatic bile ducts
Chronic progressive cholestatic disease of liver

Criteria (2 out of 3 is probable)

1. AMA (M2 AMA)
2. Increase ALP, GGT for >6m
3. Histological features consistent with Dx

Question 2

Tx of PBC

Answer 2

Specific therapy
- Ursodeoxycholic acid (UDCA)

Mx of Pruritus

• Cholestyramine
• Rifampicin
• Opioid antagonist (uncommonly used)
• Liver transplant

Mx of cholestasis Cx

• Vit D, Ca, Bisphosphonate for metabolic bone disease
• Statin for HL
• Medium chain triglycerides for lipid malabsorption
• Vit deficiency (Vit D; Vit K if increase PT)

Question 3

Anti-smooth muscle Abs

Answer 3

For AI hepatitis

Question 4

Alcoholic liver disease Dx

Answer 4

Hx of alcohol use (M:30 g/day; F:20 g/day)
PE for signs of CLD
Staging of severity with liver chemistry, CBC, PT

Question 5

AutoAbs for AIH

Answer 5

Type 1:
Anti-smooth muscle Ab
ANA (Anti nuclear Ab)
Elevated IgG

Type 2: Anti-liver-kidney microsomal Ab (Anti-LKM Ab)

Type 3: Ab to soluble liver Ag (Anti-SLA)

Question 6

MELD score
(Model for end stage liver disease)

Answer 6

BICE

Bilirubin
INR
Creatinine
Etiology

Question 7

Child-Pugh score

Answer 7

ABCDE

Albumin
Bilirubin
PT
Ascites (distension)
Encephalopathy

A - 5-6 (compensated, normal liver function)
B - 7-9 –> can go for transplant
C - 10-15

*5-15 score

Question 8

Acute liver failure

What score for liver transplant?

Answer 8

King’s college criteria

- Panadol induced or not

Question 9

Causes of Chronic diarrhea

Answer 9

1. Osmotic (Lactase deficiency)
2. Malabsorption
3. Secretory (Endocrine tumors, BS malabsorption)
4. Inflammatory (IBD)
5. Motility (IBS)
6. Chronic infection (uncommon in HK)

Question 10

HP - Urea breath test, stool Ag ELISA affected by

RB

Answer 10

PPI
ABX
Bismuth

But not affected by H2 blocker / antacids
Post-tx do test 4 wk later
Ab test not used after tx as it will be positive for 6-12m

Question 11

ELISA

Answer 11

Enzyme-linked immunosorbent assay

Question 12

3 categories of GERD

RB

Answer 12

1. Non-erosive reflux disease (Sx but OGD normal)
2. Erosive esophagitis (OGD abnormal)
3. Extra-esophageal disease

Question 13

RF for GERD

RB

Answer 13

1. Obesity (high BMI)
2. Smoking
3. Alcohol
4. FH

Question 14

Dx of GERD

RB

Answer 14

1. Symptom questionnaires
2. OGD
3. Ambulatory 24h esophageal pH monitoring
4. PPI testing

Question 15

Tx of GERD

RB

Answer 15

1. Dietary and lifestyle modification
2. Medical: Antacids, H2 blocker, PPI
3. Endoscopic: Fundal plication

Question 16

Ix for HBV cirrhosis patient with ascites

RB

Answer 16

1. CBC - degree of hypersplenism; anemia
2. LFT
   - Albumin: chronic liver disease
   - Globulin: increased in cirrhosis
   - Bilirubin: only high when late stage of cirrhosis
   - AST/ALT does not reflect degree of cirrhosis
   - ALP/GGT also should be normal unless SOL
3. Clotting: Prolong PT = liver dysfunction
4. AFP
5. HB serology
   - HBsAg tested annually,
6. 1-1% annual rate of seroconversion
   - HBeAg / anti-HBe
   - HBV DNA
7. Diagnostic paracentesis for ascites
   - WCC w/ D to r/o SBP
   - Protein level - tend to be low in cirrhosis
   - Malignant cytology
8. RFT: as baseline before starting diuretics
9. USG liver every 6m to detect HCC

Question 17

When to start antiviral for HBV

RB

Answer 17

HBV DNA viral load is high

ALT 1.5-2x ULN

Question 18

HBV vs HCV in causing HCC

Answer 18

HBV is directly oncogenic
20% HCC from HBV does not have cirrhosis (80% has)
but 100% of HCC from HCV has cirrhosis

Question 19

TACE

Answer 19

Transcatheter arterial chemoembolization

Question 20

Mx of HE

RB

Answer 20

1. Identify and treat precipitating factor
2. Normal protein diet
3. IV 10% dextrose to provide adequate calorie intake (to prevent protein breakdown)
4. Lactulose as enema and orally (to induce bowel movements 2-4 times/day)
   ?Rifaximin as abx

Question 21

S/S of Crohn’s disease

Answer 21

Inflammation (abd pain, diarrhea, LOW)
Obstruction (cramp, V, distension)
Fistulization

Question 22

S/S of UC

Answer 22

Bloody diarrhea
Abd pain
Tenesmus, urge
Fever, LOW

Question 23

Anti-Saccharomyces cerevisiae Abs (ASCA)

Anti-neutrophil cytoplasmic Abs (ANCA)

Answer 23

ASCA more for Crohn’s

ANCA more for UC

Question 24

Cx of UC

Answer 24

1. Toxic megacolon
2. Perforation
3. Cancer

Question 25

Extraintestinal manifestations of IBD

Answer 25

1. Arthritis: Large joints, AS, sacroilitis 2. Uveitis, iritis, episcleritis 3. Erythema nodosum, pyoderma gangrenosum 4. Primary sclerosing cholangitis (PSC) 5. Bone loss, osteoporosis 6. Vit B12 deficiency

Question 26

Tx of IBD

Answer 26

Mild: - 5-ASA (aka Mesalazine) - ABX for acute Moderate to severe - Steroid for acute flares - Immunosuppressants - Azathioprine, 6MP (Purine analog to inhibit T cell fx) - Infliximab (TNF-inhibitor)

Question 27

Precipitating factors for HE | RB

Answer 27

1. Increased protein intake Decreased blood supply 2. GIB (high protein content in blood in the gut + decreased blood to already cirrhotic liver) 3. Over-diuresis (with dehydration, electrolytes disturbances) CNS disturbance (GABA) 4. Constipation (bacteria produce bacteria?) 5. Infection, esp SBP, HBV, HCV 6. Hynoptics 7. Alcohol 8. Shunting procedures, e.g. TIPS 9. Inappropriate paracentesis (w/o adequate albumin infusion)

Question 28

SBP usu which organism

Answer 28

``` Gram neg E coli, Klebsiella (or Streptococci from skin) Tx = 3rd gen cephalosporin Long term: Norfloxacin (FQ) ```

Question 29

Complications of Cirrhosis

Answer 29

1. Ascites 2. SBP (Spontaneous bacterial peritonitis) 3. Hepatorenal syndrome 4. Variceal bleeding 5. Hepatic encephalopathy 6. HCC

Question 30

TIPS

Answer 30

Transjugular intrahepatic portosystemic shunt | For recurrent variceal bleeding

Question 31

Quadruple therapy for HP

Answer 31

``` PPI Bismuth Metronidazole Tetracycline for 7 days ```

Question 32

Budd-Chiari syndrome

Answer 32

Abd pain Ascites Hepatomegaly Caused by occlusion of hepatic vein (mainly thrombosis, can also be compression by tumor)