GI + Liver

Question 1

common causes of raised Alkaline phosphate

Answer 1

ALKPHOS -

• Any fracture
• Liver damage (post-hepatic jaundice)
• Kancer (cancer)
• Paget’s disease of the bone; Pregnancy
• Hyperparathyroidism
• Surgery

Question 2

Give 4 causes of hepatitis/cirrhosis

Answer 2

1. Alcohol
2. viruses (Hepatitis A-E, EBV, CMV)
3. drugs (paracetamol overdose, rifampicin, statins)
4. Autoimmune (Autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis)

Question 3

Which drugs can cause cholestasis?

Answer 3

flucloxacillin, co-amoxiclav, nitrofurantoin, sulphonylureas and steroids

Question 4

what is hereditary haemochromatosis?

Answer 4

autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation.

Question 5

diagnostic test for hereditary haemochromatosis

Answer 5

molecular genetic testing for the C282Y and H63D mutations

liver biopsy: Perl’s stain

Question 6

Typical iron study profile in patient with haemochromatosis

what can joint x-rays show?

Answer 6

transferrin saturation > 55% in men or > 50% in women
raised ferritin (e.g. > 500 ug/l) and iron
low TIBC

**Joint x-rays characteristically show chondrocalcinosis

Question 7

management of hereditary haemochromatosis

Answer 7

Venesection is the first-line treatment
monitoring adequacy of venesection: transferrin saturation should be kept below 50% and the serum ferritin concentration below 50 ug/l
desferrioxamine may be used second-line

Question 8

symptoms to ask for in HPC for GI conditions -

Answer 8

Abdominal pain
Difficulty swallowing
Reflux
Nausea/Vomiting
Bowel Habit alteration
Blood loss
unintentional Weight loss
Fevers
Nocturnal symptoms

….then expand appropriately

Question 9

additional quesns to ask if someone has difficulty swallowing?

Answer 9

is it solids only or fluids or both that are difficult to swallow?
when did it start?
has it progressed?

Question 10

additional quesns to ask if someone has nausea/vom?

Answer 10

how often?

contents - blood, bile, food, etc.

Question 11

additional quesns to ask if someone has altered bowel habits?

Answer 11

what is normal for them - frequency and consistency and how is it now?
any blood? - if yes then is it fresh or mixed into the poo

Question 12

what do nocturnal symptoms signify?

Answer 12

if someone is waking up in the night to open their bowels or with pain, then this worrying and points more towards an organic bowel condition like IBD or cancer

Question 13

if you suspect or pt has liver disease, what questions are important to ask in PMH and social hx?

Answer 13

previous blood transfusions, tattoos, foriegn travel

Question 14

what test is important to do in someone with chronic lower GI symptoms?

Answer 14

stool faecal calprotectin

Question 15

what stool test is important to do in someone with upper GI dyspeptic symptoms?

Answer 15

stool H.pylori antigen test

Question 16

how many stool cultures do u need to do?

Answer 16

3

Question 17

how to interpret faecal calprotectin results?

Answer 17

<50 - normal. high NPV so unlikely IBD
>150 - refer to gastro
intermediate - repeat in 1 month and refer if it remains elevated

Question 18

what are some alarm features with regards to GI disease that will require further investigations for organic diseases

Answer 18

hx -dysphagia, blood loss, weight loss, nocturnal symptoms, age>45, family history of IBD, GI cancer, acutely unwell, recent onset of symptoms

exam -
Jaundice
Abnormal mass
Lymphadenopathy

tests -
Deranged bloods e.g. Anemia, LFTs, CRP
Positive coeliac serology
Raised faecal calprotectin

Question 19

ddx for dysphagia?

Answer 19

structural - oesophageal cancer, benign stricture, reflux oesophagitis

motility - achalasia, aperistalsis, oesophageal spasm

Question 19

ddx for dysphagia?

Answer 19

structural - oesophageal cancer, benign stricture, reflux oesophagitis

motility - achalasia, aperistalsis, oesophageal spasm

Question 20

what are peptic ulcers?

Answer 20

Peptic ulcers involve ulceration of the mucosa of the stomach (gastric ulcer) or the duodenum (duodenal ulcer). Duodenal ulcers are more common.

Question 21

what is the protective layer in the stomach comprised of and what can it be broken down by?

Answer 21

There is a protective layer in the stomach comprised of mucus and bicarbonate secreted by the stomach mucosa. This protective layer can be broken down by:

Medications (e.g. steroids or NSAIDs)
Helicobacter pylori

Question 22

increased acid in the stomach or consequently the duodenum can result from?

Answer 22

Stress
    Alcohol
    Caffeine
    Smoking
    Spicy foods

Question 23

presentation of peptic ulcer disease

Answer 23

Epigastric discomfort or pain
Nausea and vomiting
Dyspepsia
Bleeding causing haematemesis, “coffee ground” vomiting and melaena
Iron deficiency anaemia (due to constant bleeding)

Question 24

how to differentiate gastric ulcer from duodenal?

Answer 24

In your MCQ exams, eating typically worsens the pain of gastric ulcers and improves the pain of duodenal ulcers.

Question 25

what type of epithelial lining does the oesophagus have and what type of lining does the stomach have?

Answer 25

The oesophagus has a squamous epithelial lining . The stomach has a columnar epithelial lining

Question 26

presentation of GORD

Answer 26

Dyspepsia is a non-specific term used to describe indigestion. It covers the symptoms of GORD: ``` Heartburn Acid regurgitation Retrosternal or epigastric pain Bloating Nocturnal cough Hoarse voice ```

Question 27

management of GORD

Answer 27

``` lifestyle advice - Reduce tea, coffee and alcohol Weight loss Avoid smoking Smaller, lighter meals Avoid heavy meals before bed time Stay upright after meals rather than lying flat ``` antacids when required PPIs H2RAs surgery - laparoscopic fundoplication

Question 28

what is barretts oesophagus

Answer 28

metaplasia of lower oesophageal epithelium from squamous to columnar epithelium as a result of constant reflux of acid. Barretts oesophagus is considered a “premalignant” condition and is a risk factor for the development of adenocarcinoma of the oesophagus. **when this happens, patients typically get an improvement in reflux symptoms

Question 29

how are ppl with barretts oesophagus monitored?

Answer 29

regular endoscopy to monitor for adenocarcinoma. In some patients there is a progression from Barretts oesophagus (columnar epithelium) with no dysplasia to low grade dysplasia to high grade dysplasia and then to adenocarcinoma.

Question 30

tx of barretts oesophagus

Answer 30

PPIs Ablation treatment during endoscopy using photodynamic therapy, laser therapy or cryotherapy is used to destroy the epithelium so that it is replaced with normal cells. This is not recommended in patients with no dysplasia but has a role in low and high grade dysplasia in preventing progression to cancer.

Question 31

h pylori

Answer 31

gram -ve bacteria. damages gastric mucosa causing gastritis and increases risk of ulcers and stomach cancer. it also produces ammonia to neutralise the stomach acid which also damages the epithelial cells. Anyone with dyspepsia is offered a H.pylori test and this needs 2 weeks without using PPI before testing for h.pylori

Question 32

what test is used to diagnose h.pylori

Answer 32

H.pylori stool antigen test urea breath test can also be used rapid urease test can be performed during endoscopy.

Question 33

how is h.pylori treated?

Answer 33

triple-therapy regimen that comprises a proton pump inhibitor and 2 antibacterials. in general - 1. pts with no penicillin allergy - A proton pump inhibitor, plus amoxicillin, and either clarithromycin or metronidazole (treatment choice should take into account previous treatment with clarithromycin or metronidazole) for 7 days 2. penicillin allergy - A proton pump inhibitor, plus clarithromycin, and metronidazole fir 7 days

Question 34

management of peptic ulcers

Answer 34

diagnosed using upper GI endoscopy. During endoscopy a rapid urease test (CLO test) can be performed to check for H. pylori. Biopsy should be considered during endoscopy to exclude malignancy as cancers can look similar to ulcers during the procedure. Medical treatment is the same as with GORD, usually with high dose proton pump inhibitors. Endoscopy can be used to monitoring the ulcer to ensure it heals and to assess for further ulcers.

Question 35

complications of PUD

Answer 35

Bleeding from the ulcer is a common and potentially life threatening complication. Perforation resulting in an “acute abdomen” and peritonitis. This requires urgent surgical repair (usually laparoscopic). Scarring and strictures of the muscle and mucosa. This can lead to a narrowing of the pylorus (the exit of the stomach) causing difficulty in emptying the stomach contents. This is known as pyloric stenosis. This presents with upper abdominal pain, distention, nausea and vomiting, particularly after eating.

Question 36

what medications put u at risk of duodenal ulcers?

Answer 36

nsaids steroids SSRIs

Question 37

in ppl presenting with dyspepsia, who require urgent endoscopy?

Answer 37

everyone with dysphagia those >/=55 with ALARM Symptoms or persistent/refractory symptoms ``` ALARM Symptoms - Anaemia Loss of weight Anorexia Recent onset/progressive symptoms Melaena/haematemesis Swallowing difficulties ```

Question 38

functional dyspepsia management (INCOMPLEYTE)

Answer 38

it is common eradicate H.pylori if present PPIs, psychotherapy and low dose amitryptyline may help

Question 39

complications of GORD

Answer 39

``` oesophagitis benign strictures ulcers iron deficiency barretts oesophagus ```

Question 40

causes of GORD

Answer 40

``` lower oesophageal sphincter hypotension hiatus hernia (common in pts >50 esp obese pts) obesity oesophageal dysmotility gastric acid hypersecretion smoking alcohol pregnancy ```