GI Medicine Flashcards
1
Q
Staph. aureus: enterotoxin from food Vomiting shortly after consumption Bacillus cereus: reheated rice Vomiting later, 1-2h hx
A
Gastroenteritis
2
Q
Salmonella, Shigella, Campylobacter Lower abdo pain + diarrhoea
A
Dysentry
3
Q
Baby, 3-6 weeks old, projectile vomiting Palpable mass in epigastrium, succession splash
A
Pyloric Stenosis
4
Q
Burns, haematemesis
A
Curling’s Ulcer
5
Q
Sepsis, IC lesion, organ failure, haematemesis
A
Cushing’s Ulcer
6
Q
Gastrin-secreting tumour
Recurrent ulceration, high serum gastrin
A
Zollinger Ellison
7
Q
Massive haematemesis, macrocytic anaemia, Hx of alcoholism
A
Oesophageal Varices
8
Q
Short hx of change in bowel habit Tenesmus and mucus
A
Rectal Carcinoma
9
Q
Reduced food intake, low fibre diet, lack of exercise/mobility, elderly
A
Simple Constipation
10
Q
Constipation due to pain
A
Anal Fissure
11
Q
Young, constipated, distended abdomen
A
Agangliosis
12
Q
Hx of broad-spec abx, green diarrhoea
A
C Diff
13
Q
Visit to Eastern Europe/Russia
Pale stool, foul flatus, watery diarrhoea
A
Giardia
14
Q
Prev hx. of chronic constipation
A
Overflow
15
Q
Diarrhoea, recently started OCP, diet controlled
A
Lactose Intolerance
16
Q
Bloody diarrhoea + intense abdo pain
A
Ischaemic Colitis
17
Q
Loose stool, weight loss, hypopigmentation, onycholysis
A
Thyrotoxicosis
18
Q
Worse epigastric pain on meals/EtOH
A
Chronic Pancreatitis
19
Q
Rapidly progressive dysphagia, weight loss, hypoproteinaemia
Apple core lesion on barium swallow
A
Oesophageal Carcinoma
20
Q
Progressive difficulty with speech/ swallowing
Weak facial muscles, absent jaw jerk
A
Bulbar Palsy
21
Q
Weight loss + anorexia + iron deficiency Signet-ring cells, leather bottle stomach
A
Adenocarcinoma
22
Q
Immunosuppression
Generalised ulceration of oesophagus
A
Oesophageal Candidiasis
23
Q
Infiltration of atypical lymphocytes Thickened folds
A
MALT lymphoma
24
Q
Slit-like vascular spaces Proliferating spindle cells Purple, plaque-like lesions
A
Kaposi’s Sarcoma
25
Cholestatic jaundice, ↑ALP Beading of intrahepatic ducts Associated with UC
Sclerosing Cholangitis
26
Ulcer on L shin IBD/Vasculitis/haem malignancy
Pyoderma Gangrenosum
27
Acute illness + raised bilirubin
Gilbert's Syndrome
28
RNA
| Jaundice, Diarrhoea + Fever
Hepatitis A
29
Thrombus in hepatic portal vein Secondary to thrombogenic disorders
Budd Chiari
30
Chronic liver disease + jaundice Antimitochondrial antibodies
Primary Biliary Cirrhosis
31
dsDNA
| Mild fibrosis
Chronic Hep B
32
Haemosiderin within hepatocytes Darken skins
| Raised transaminase
Genetic Haemochromatosis
33
Copper accumulation
| Neuro (adults), liver (children)
Wilson's disease
34
In acute oesophageal variceal bleeding, what is the management?
Variceal band ligation is the NICE recommended method of stopping oesophageal variceal bleeding. Sengstaken-Blakemore tube and TIPSS is recommended if this fails. Propranolol is used as bleeding prophylaxis.
35
Rules with PPI in regards to endoscopy?
Stop taking 2 weeks before as it can mask underlying pathology.
36
Inheritance pattern in hereditary haemochromatosis?
Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6
37
Epidemiology of haemochromatosis?
1 in 10 people of European descent carry a mutation in the genes affecting iron metabolism, mainly HFE
38
Early symptoms of haemachromatosis?
early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands)
Bronze diabetes
39
What are the reversible complications of haemochromatosis? 2
Cardiomyopathy
| Skin Pigmentation
40
What are the irreversible complications of haemochromatosis? 4
Diabetes Mellitus
Hypogonadotrophic hypogonadism
Arthropathy
Liver Cirrhosis
41
Classic presentation of enterotoxigenic E.coli?
Watery travellers diarrhoea with stomach cramps and nausea, think Enterotoxigenic E. coli.
42
How to rule out the causative organism in diarrhoea questions?
Divide into Bloody vs non bloody
43
Diarrhoea in Camplyobacter Jejuni?
Bloody diarrhoea
44
Most common cause of pyogenic liver abscess?
S. aureus in kids
| E. coli in adults
45
Investigation + Management plan of a pyogenic liver abscess?
CT scan
Drainage (typically percutaneous) and antibiotics
amoxicillin + ciprofloxacin + metronidazole
if penicillin allergic: ciprofloxacin + clindamycin
Surgical resection typically used when this fails
46
Features of a carcinoid syndrome?
Flushing (often earliest symptom)
Diarrhoea
bronchospasm
hypotension
right heart valvular stenosis (left heart can be affected in bronchial carcinoid)
other molecules such as ACTH and GHRH may also be secreted resulting in, for example, Cushing's syndrome
pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour
47
What is pellagra?
Pellagra is a disease caused by low levels of niacin, also known as vitamin B-3. It's marked by dementia, diarrhea, and dermatitis, also known as “the three Ds”. If left untreated, pellagra can be fatal.
48
Investigations and management for carcinoid tumours?
Investigation
urinary 5-HIAA
plasma chromogranin A
Management
somatostatin analogues e.g. octreotide
diarrhoea: cyproheptadine may help
49
Best tests to assess synthetic function of the liver?
Remember that 'liver function tests' do not always accurately reflect the synthetic function of the liver. This is best assessed by looking at the prothrombin time and albumin level.
50
What is H. pylori primarily associated with?
Main : Peptic ulcer disease (95% of duodenal ulcers, 75% of gastric ulcers)
Gastric cancer
B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of patients)
atrophic gastritis
51
Biggest modifiable risk factor for reducing episodes in Crohns?
Stop smoking
52
How to induce remission in Crohn's Disease?
Glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective
azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy.
infliximab is useful in refractory disease and fistulating Crohn's.
Patients typically continue on azathioprine or methotrexate.
metronidazole is often used for isolated peri-anal disease.
53
How do you maintain remission in Crohn's?
Azathioprine or mercaptopurine is used first-line to maintain remission
Methotrexate is used second-line
5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery
54
Complications of Crohn's Disease?
small bowel cancer
colorectal cancer
Osteoporosis
55
What do you need to do before giving Azathioprine or Mercaptopurine for Crohn's ?
Assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine
56
What is the single laboratory finding that should prompt an immediate consideration of liver cirrhosis and urgent review by hepatology?
Thrombocytopenia (platelet count <150,000 mm^3) is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease
57
How do you diagnose liver cirrhosis?
Other techniques such as transient elastography (Fibroscan) and acoustic Radiation force impulse imaging are increasingly used and were recommended by NICE in their 2016 guidelines
For patients with NAFLD, NICE recommend using the enhanced liver fibrosis score to screen for patients who need further testing
Liver biopsy used to be used however this has a bleeding risk
58
What is transient elastography (Fibroscan)?
Uses a 50-MHz wave is passed into the liver from a small
transducer on the end of an ultrasound probe
Measures the 'stiffness' of the liver which is a proxy for fibrosis
59
Epidemiology and aetiology of cyclical vomiting syndrome?
Epidemiology
Rare
More common in children than adults
Females are slightly more affected than males
Aetiology
Unknown
80% of children and 25% of adults who develop CVS also have migraines
Presentation
Severe nausea and sudden vomiting lasting hours to days
Prodromal intense sweating and nausea
Well in between episodes
60
Investigations and management for cyclical vomiting syndrome?
Investigations
Clinical Diagnosis
A pregnancy test may be considered in women
Routine blood tests to exclude any underlying conditions
Management
Avoidance of triggers
Prophylactic treatments include amitriptyline, propranolol and topiramate.
Ondansetron, prochlorperazine and triptans in acute episodes.
61
What can cause Budd-Chiari Syndrome?
Polycythaemia rubra vera
Thrombophilia: activated protein C resistance, antithrombin III deficiency, protein C & S deficiencies
Pregnancy
Oral contraceptive pill
62
How can you investigate Budd-Chiari syndrome?
Ultrasound with Doppler flow studies is very sensitive and should be the initial radiological investigation
63
A transjugular intrahepatic portosystemic shunt procedure connects which two vessels?
Hepatic Vein and Portal vein
However it can connect the hepatic vein to IVC
Ultimately bypassing the liver.
64
Investigations and Management for C. difficile?
Diagnosis
is made by detecting Clostridium difficile toxin (CDT) in the stool
Clostridium difficile antigen positivity only shows exposure to the bacteria, rather than current infection
Management
first-line therapy is oral metronidazole for 10-14 days
if severe or not responding to metronidazole then oral vancomycin may be used
fidaxomicin may also be used for patients who are not responding , particularly those with multiple co-morbidities.
For life-threatening infections a combination of oral vancomycin and intravenous metronidazole should be used
Typically isolate for 48 hrs
65
Management for pharyngeal pouch
Surgery
66
Management for autoimmune hepatitis?
Steroids, immunosuppressants like azathioprine can also be used.
Liver transplantation
67
Amenorrhoea
ANA/smooth muscle antibodies/LKM1 antibodies, raised IgG levels
liver biopsy: inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis
Autoimmune hepatitis
68
How many types of autoimmune hepatitis are there and describe them?
3
Type 1: Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA). Affects both adults and children
Type 2: Anti-liver/kidney microsomal type 1 antibodies (LKM1)
Affects children only
Type 3: Soluble liver-kidney antigen
Affects adults in middle-age
69
How is Hepatitis A transmitted?
Shellfish, in particular, are common sources of hepatitis A infections, as the virus is transmitted via the faecal-oral route. It is usually self-limiting and is not associated with chronicity. Importantly, Hepatitis A can be prevented through vaccinations.
Incubation period of 2-4 weeks.
70
What are the drugs that can cause pancreatitis?
```
Azathioprine
mesalazine
didanosine
bendroflumethiazide
furosemide
pentamidine
steroids
sodium valproate
```
My Drug bendroflumethiazide finds APVs
71
First line investigations in Coeliac?
Tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE
Endomyseal antibody (IgA)
anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE
anti-casein antibodies are also found in some patients
Make sure the patient has gluten in their diet ( you might need to ask them to reintroduce it to their diet)
72
What is intussuception?
Intussusception is a condition in which one segment of intestine "telescopes" inside of another, causing an intestinal obstruction (blockage).
73
Inheritance pattern of Peutz- Jeghers syndrome and patterns?
Autosomal dominant - responsible gene encodes serine threonine kinase LKB1 or STK11.
Features
hamartomatous polyps in GI tract (mainly small bowel)
pigmented lesions on lips, oral mucosa, face, palms and soles
intestinal obstruction e.g. intussusception
gastrointestinal bleeding
74
What is the main benefit of prescribing albumin when treating large volume ascites'?
An albumin infusion is used when draining large volumes of fluid via paracentesis as it has benefit in reducing paracentesis-induced circulatory dysfunction and mortality when compared to alternative treatments.
75
What is used to group the causes of ascites?
Serum albumin ascites gradient (SAAG):
<11 g/L or a gradient >11g/L
SAAG > 11g/L indicates portal hypertension but also can point to cirrhosis, Budd- Chiari, Alcoholic hepatitis...
76
What is the management of ascites?
Management
Reducing dietary sodium
Fluid restriction is sometimes recommended if the sodium is < 125 mmol/L
Aldosterone antagonists: e.g. spironolactone
Drainage if tense ascites (therapeutic abdominal paracentesis): large-volume paracentesis for the treatment of ascites requires albumin 'cover'.
Prophylactic antibiotics to reduce the risk of SBP.
NICE recommend: 'Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less, until the ascites has resolved'
a transjugular intrahepatic portosystemic shunt (TIPS) may be considered in some patients
77
Dysphagia that affects both solids and liquids from the start
Achalasia
78
Signs and symptoms of scurvy?
Vitamin C deficiency
```
Ecchymosis, easy bruising
Poor wound healing
Gingivitis with bleeding and receding gums
Sjogren's syndrome
Arthralgia
Oedema
```
79
Abdominal pain, rectal bleeding and diarrhoea
Pain worse after eating a larger meal
History of HTN/IHD
Ischemic colitis
Particularly at the splenic flexure (watershed area)
near where the SMA blood supply changes to the IMA. Add to this the pain gets worse after eating, when the bowel requires more blood flow for its increased energy demands for digestion and ischaemic colitis would be the diagnosis to investigate first.
80
Investigation of choice for ischaemic colitis?
CT (gold standard)
'thumbprinting' may be seen on abdominal x-ray due to mucosal oedema/haemorrhage
81
Chronic liver failure who then progresses to develop renal failure.
Hepatorenal syndrome
Hepatorenal syndrome is split into type 1 and 2. Type 1 is a rapid onset hepatorenal syndrome (less than two weeks). This typically occurs following an acute event such as an upper GI bleed. Type 2 is a more gradual decline in renal function and is generally associated with refractory ascites.
82
Pathophysiology of Hepatorenal syndrome?
Vasoactive mediators cause splanchnic vasodilation which in turn reduces the systemic vascular resistance. This results in 'underfilling' of the kidneys. This is sensed by the juxtaglomerular apparatus which then activates the renin-angiotensin-aldosterone system, causing renal vasoconstriction which is not enough to counterbalance the effects of the splanchnic vasodilation.
83
Management of hepatorenal syndrome?
Management options
Vasopressin analogues, for example terlipressin, have a growing evidence base supporting their use. They work by causing vasoconstriction of the splanchnic circulation
volume expansion with 20% albumin
transjugular intrahepatic portosystemic shunt
84
Investigations + Management of primary biliary cirrhosis?
Diagnosis
anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific
smooth muscle antibodies in 30% of patients
raised serum IgM
```
Management
pruritus: cholestyramine
fat-soluble vitamin supplementation
ursodeoxycholic acid
liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) - recurrence in graft can occur but is not usually a problem
```
85
Why do coeliacs people have to keep very upto date with their vaccinations?
Functional hyposplenism
86
Triad of acute liver failure?
Triad of encephalopathy, jaundice and coagulopathy
87
Liver failure vs chronic liver cirrhosis?
The key differentiating features between a chronic liver disease and acute failure is the raised prothrombin time, the very high bilirubin and the presence of encephalopathy, all of which you would not expect to see in a stable chronic liver disease picture.
88
How do you grade hepatic encephalopathy?
```
Grading of hepatic encephalopathy
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
```
89
Management of hepatic encephalopathy?
Management
Treat any underlying precipitating cause
NICE recommend lactulose first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy
Lactulose is thought to work by promoting the excretion of ammonia and increasing the metabolism of ammonia by gut bacteria
Antibiotics such as rifaximin are thought to modulate the gut flora resulting in decreased ammonia production
other options include embolisation of portosystemic shunts and liver transplantation in selected patients
90
Pain relief on eating?
ddx: Duodenal ulcer?
91
How does significant bleeding occur in PUD?
Bleeding in peptic ulcer disease (PUD) occurs when the base of the ulcer erodes into a vessel supplying the muscles of the stomach or duodenal wall. This man has a duodenal ulcer, as his pain is relieved by eating. Classically, posterior duodenal ulcers erode the gastroduodenal artery, which can cause significant bleeding.
92
Management of acute bleeding in PUD?
Management
ABC approach as with any upper gastrointestinal haemorrhage
IV proton pump inhibitor
The first-line treatment is endoscopic intervention
if this fails (approximately 10% of patients) then either:
urgent interventional angiography with transarterial embolization or
surgery
93
How can you differentiate between primary Sjogrens and Primary biliary cholangitis?
Primary Bilary Cholangitis can cause sicca syndrome in 70% of cases so if the ALP is raised, the dry mouth is more likely to be due to PBC than to a primary Sjogren
94
What are adverse risks associated with PPIs?
HYPONATREMIA and hypomagnesemia
Increased risk of fractures
Increased risk of C. Difficile
95
How to maintain remission in ulcerative colitis?
Maintaining remission
Following a mild-to-moderate ulcerative colitis flare
Proctitis and proctosigmoiditis:
topical (rectal) aminosalicylate alone (daily or intermittent) or
an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent)
or
an oral aminosalicylate by itself: this may not be effective as the other two options
Left-sided and extensive ulcerative colitis
low maintenance dose of an oral aminosalicylate
Following a severe relapse or >=2 exacerbations in the past year
oral azathioprine or oral mercaptopurine
96
How do you manage severe colitis?
Severe colitis
Should be treated in hospital
IV steroids are usually given first-line
intravenous ciclosporin may be used if steroid are contraindicated
if after 72 hours there has been no improvement, consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery
97
How do you induce remission in mild-moderate colitis?
Proctitis
1. Topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates
If remission is not achieved within 4 weeks, add an oral aminosalicylate
If remission still not achieved add topical or oral corticosteroid
proctosigmoiditis and left-sided ulcerative colitis
1. Topical (rectal) aminosalicylate
2. If remission is not achieved within 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
3. If remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
extensive disease
topical (rectal) aminosalicylate and a high-dose oral aminosalicylate:
if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
98
RUQ pain, itching.
| Sweet smelling breath
Acute liver failure
Breath is a sign called Fetor hepaticus which is a late sign in hepatic encephalopathy
99
Patient has a worsening severe flare up of ulcerative colitis. Bloods show systemic disturbance. What investigation would you like to do ?
Abdominal X ray
This patient may go on to develop toxic megacolon
100
Features of NASH and first line management?
```
Features
usually asymptomatic
hepatomegaly
ALT is typically greater than AST
increased echogenicity on ultrasound
```
Management: Lifestyle changes (particularly weight loss)
101
Negative AMA
ERCP shows strictures having a beaded appearance
Postive pANCA
Primary Sclerosing cholangitis
Although not all patients with primary sclerosing cholangitis (PSC) with have positive pANCA, if you see it in a question with negative antimitochondrial antibodies (which would suggest primary biliary cirrhosis if positive) think PSC. This is backed up by the classic 'beaded' strictures on ERCP
UC Beads
102
First line investigations for primary sclerosing cholangitis?
Investigation
Endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) are the standard diagnostic investigations, showing multiple biliary strictures giving a 'beaded' appearance
ANCA may be positive
There is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often described as 'onion skin'
103
First line investigation for oesophageal carcinoma?
Upper GI endoscopy
CT can help stage after the diagnosis is made
104
A 4-year-old presents with sudden onset of dysphagia. He undergoes an upper GI endoscopy and a large bolus of food is identified in the mid oesophagus. He has no significant history, other than a tracheo-oesophageal fistula repair soon after birth.
Benign oesophageal stricture
105
What is courvoisier's law?
Courvoisier's sign states that in a patient with a painless, enlarged gallbladder and mild jaundice the cause is unlikely to be gallstones. Furthermore, it is more likely to be a malignancy of the pancreas or biliary tree.
106
Investigations + Management of Wilson's disease?
Diagnosis
reduced serum caeruloplasmin
reduced serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
increased 24hr urinary copper excretion
Management
penicillamine (chelates copper) has been the traditional first-line treatment
107
What is one of the most useful tests to differentiate IBS and IBD?
Faecal Calprotectin
108
Droopy eyelid, difficulty swallowing and facial weakness. Double vision
Myasthenia gravis
109
What are the symptoms of hypomagnesemia ?
```
Features may be similar to hypocalcaemia:
paraesthesia
tetany
seizures
arrhythmias
decreased PTH secretion → hypocalcaemia
```
110
What is Rovsing's Sign?
If palpation of the left lower quadrant of a person's abdomen increases the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing's sign and may have appendicitis.
111
Name 3 drugs that can cause drug induced cirrhosis?
Liver cirrhosis
methotrexate
methyldopa
amiodarone
112
Name 6 types of drugs that can cause drug induced cholestasis/ hepatitis?
The following drugs tend to cause cholestasis (+/- hepatitis): CAFASP
Combined oral contraceptive pill
Antibiotics: flucloxacillin, co-amoxiclav, erythromycin*
Anabolic steroids, testosterones
Phenothiazines: chlorpromazine, prochlorperazine
Sulphonylureas
Fibrates
113
What is the scoring system used to first assess an Upper GI bleed?
Blatchford Score
| Rockall Score - after endoscopy
114
What are the components and uses of the Blatchford score?
```
8 Different Factors:
Urea (mmol/l):
6·5 - 8 = 2
8 - 10 = 3
10 - 25 = 4
> 25 = 6
```
```
Haemoglobin (g/l):
Men
12 - 13 = 1
10 - 12 = 3
< 10 = 6
```
Women
10 - 12 = 1
< 10 = 6
Systolic Blood Pressure (mmHg)
100 - 109 = 1
90 - 99 = 2
< 90 = 3
```
Pulse >=100/min = 1
Presentation with melaena = 1
Presentation with syncope = 2
Hepatic disease = 2
Cardiac failure = 2
```
115
What are the treatments for IBS?
First-line pharmacological treatment - according to predominant symptom
pain: antispasmodic agents
constipation: laxatives but avoid lactulose
diarrhoea: loperamide is first-line
For patients with constipation who are not responding to conventional laxatives linaclotide may be considered, if:
optimal or maximum tolerated doses of previous laxatives from different classes have not helped and
they have had constipation for at least 12 months
Second-line pharmacological treatment
low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors
116
What are the complications of coeliac disease?
Complications (6)
Anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
Hyposplenism
Osteoporosis, osteomalacia
Lactose intolerance
Enteropathy-associated T-cell lymphoma of small intestine
Subfertility, unfavourable pregnancy outcomes
rare: oesophageal cancer, other malignancies
117
How much weight loss is malnutrition?
Unintentional weight loss greater than 10% within the last 3-6 months is diagnostic of malnutrition
118
What is the main risk factor for hepatocellular carcinoma?
Chronic hepatitis B is the most common cause of HCC worldwide with chronic hepatitis C being the most common cause in Europe.
The main risk factor for developing HCC is liver cirrhosis, for example secondary* to hepatitis B & C, alcohol, haemochromatosis and primary biliary cirrhosis.
119
What are the management plans for hepatocellular carcinoma?
```
Management options
early disease: surgical resection
liver transplantation
radiofrequency ablation
transarterial chemoembolisation
sorafenib: a multikinase inhibitor
```
120
Hepatocellular carcinoma screening?
Screening with ultrasound (+/- alpha-fetoprotein) should be considered for high risk groups such as:
patients liver cirrhosis secondary to hepatitis B & C or haemochromatosis
men with liver cirrhosis secondary to alcohol
121
What are the investigations and management for haemochromatosis?
Diagnostic tests
Molecular genetic testing for the C282Y and H63D mutations
liver biopsy: Perl's stain
Typical iron study profile in patient with haemochromatosis
transferrin saturation > 55% in men or > 50% in women
raised ferritin (e.g. > 500 ug/l) and iron
low TIBC
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
122
Describe the pathophysiology of Gilbert's and the features?
Gilbert's syndrome is an autosomal recessive* condition of defective bilirubin conjugation due to a deficiency of UDP glucuronosyltransferase. The prevalence is approximately 1-2% in the general population.
```
Features
unconjugated hyperbilirubinaemia (i.e. not in urine)
jaundice may only be seen during an intercurrent illness, exercise or fasting
```
123
What is the investigations and management for Gilbert's Syndrome?
Investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid
Management: no treatment required
124
Why does Crohn's disease lead to gallstones?
Crohn's disease can result in terminal ileitis, this is the section of the bowel where bile salts are reabsorbed. When this area is inflamed and the bile salts are not absorbed and people are prone to development of gallstones.
125
What are the risk factors for the development of gallstones?
6
Other risk factors for the development of gallstones include
Increasing age
Family history.
Sudden weight loss - eg, after obesity surgery.
Loss of bile salts - eg, ileal resection, terminal ileitis. (Crohn's disease)
Diabetes - as part of the metabolic syndrome.
Oral contraception - particularly in young women
126
What is the use of chlordiazepoxide?
Alcoholic withdrawal
127
What is the management of acute severe alcoholic hepatitis?
Oral prednisone
128
What is Spontaneous bacterial peritonitis and what are the features?
Spontaneous bacterial peritonitis (SBP) is a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.
Features
Ascites
abdominal pain
fever
129
Investigations and Management of SBP?
Diagnosis
Paracentesis: neutrophil count > 250 cells/ul
the most common organism found on ascitic fluid culture is E. coli
Management
intravenous cefotaxime is usually given
130
Why is ferritin not used to assess if a patient is anaemic in infection?
During infection, ferritin is an unreliable indicator of iron stored in the body as it is an acute phase protein. Transferrin saturation should be used instead
131
In what diseases is metaclopramide contraindicated in?
Parkinson's
| Bowel Obstruction
132
What is refeeding syndrome?
Refeeding syndrome describes the metabolic abnormalities which occur on feeding a person following a period of starvation. It occurs when an extended period of catabolism ends abruptly with switching to carbohydrate metabolism. The metabolic consequences include:
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia: may predispose to torsades de pointes
Abnormal fluid balance
These abnormalities can lead to organ failure.
133
What are the recommendations in refeeding syndrome?
NICE recommend that if a patient hasn't eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days.
134
What is small bowel bacterial overgrowth syndrome and what are the risk factors and features?
Small bowel bacterial overgrowth syndrome (SBBOS) is a disorder characterised by excessive amounts of bacteria in the small bowel resulting in gastrointestinal symptoms.
Risk factors for SBBOS
neonates with congenital gastrointestinal abnormalities
scleroderma
diabetes mellitus
It should be noted that many of the features overlap with irritable bowel syndrome:
chronic diarrhoea
bloating, flatulence
abdominal pain
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Investigations and Management in SBBOS?
Diagnosis
Hydrogen breath test
small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce
clinicians may sometimes give a course of antibiotics as a diagnostic trial
Management
Correction of underlying disorder
Antibiotic therapy: rifaximin is now the treatment of choice due to relatively low resistance. Co-amoxiclav or metronidazole are also effective in the majority of patients.
136
Treatment with Isoniazid leads to what vitamin deficiency? What are the complications of this deficiency?
Vitamin B6 (pyridoxine)
Vitamin B6 is a water soluble vitamin of the B complex group. It is converted to pyridoxal phosphate (PLP) which is a cofactor for many reactions including transamination, deamination and decarboxylation.
Causes of vitamin B6 deficiency
isoniazid therapy
Consequences of vitamin B6 deficiency
peripheral neuropathy
sideroblastic anemia
137
A 62-year-old presents with upper abdominal pain. She has recently been discharged from hospital where she underwent an ERCP to investigate cholestatic liver function tests. The pain is severe. On examination she is apyrexial and has a pulse of 96 / min.
Acute pancreatitis
138
What is the most common organism in ascending cholangitis?
E. coli
139
What is ascending cholangitis?
Ascending cholangitis is a bacterial infection (typically E. coli) of the biliary tree. The most common predisposing factor is gallstones.
140
Features of ascending cholangitis?
Charcot's triad of right upper quadrant (RUQ) pain, fever and jaundice occurs in about 20-50% of patients
fever is the most common feature, seen in 90% of patients
RUQ pain 70%
jaundice 60%
hypotension and confusion are also common (the additional 2 factors in addition to the 3 above make Reynolds' pentad)
Other features
Raised inflammatory markers
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What are the features of Reynold's Pentad?
```
RUQ pain
Fever
Jaundice
Hypotension
Confusion
```
142
What is the management for ascending cholangitis?
Management
Intravenous antibiotics
Endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
143
What is gallstone ileus?
This describes small bowel obstruction secondary to an impacted gallstone. It may develop if a fistula forms between a gangrenous gallbladder and the duodenum.
Abdominal pain, distension and vomiting are seen.
144
What is the management of gallstone ileus?
Laparotomy and removal of the gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with.
145
What is the mechanism of action of loperamide?
Opioids agonist
Diphenoxylate is another example
146
What antibiotics can lead to C. difficile?
Clindamycin is historically associated with causing Clostridium difficile but the aetiology has evolved significantly over the past 10 years. Second and third generation cephalosporins are now the leading cause of Clostridium difficile.
147
What drugs can affect the accuracy of a urea breath test?
Urea breath test - no antibiotics in past 4 weeks, no antisecretory drugs (e.g. PPI) in past 2 weeks
148
Liver failure that follows a cardiac arrest?
Ischaemic hepatitis
Very high aminotransferase levels (over 1000)
149
What is alcoholic ketoacidosis and how does it occur?
Alcoholic ketoacidosis is a non-diabetic euglycaemic form of ketoacidosis. It occurs in people who regularly drink large amounts of alcohol. Often alcoholics will not eat regularly and may vomit food that they do eat, leading to episodes of starvation. Once the person becomes malnourished, after an alcohol binge the body can start to break down body fat, producing ketones. Hence the patient develops a ketoacidosis.
150
How does alcoholic ketoacidosis present?
```
It typically presents with a pattern of:
Metabolic acidosis
Elevated anion gap
Elevated serum ketone levels
Normal or low glucose concentration
```
151
Management of alcoholic ketoacidosis?
The most appropriate treatment is an infusion of saline & thiamine. Thiamine is required to avoid Wernicke encephalopathy or Korsakoff psychosis.
152
What does a barium swallow show in oesophageal cancer?
The film shows narrowing and irregularity with hold-up of contrast noted in the mid thoracic oesophagus consistent with oesophageal cancer.
153
What is kantor's string sign?
There is a long segment of narrowed terminal ileum in a 'string like' configuration in keeping with a long stricture segment.
Crohn's Disease
154
Investigations in Crohn's disease?
Bloods
C-reactive protein correlates well with disease activity
Endoscopy
colonoscopy is the investigation of choice
features suggest of Crohn's include deep ulcers, skip lesions
Small bowel enema
Kantor string sign
155
What is HNPCC?
HNPCC, an autosomal dominant condition, is the most common form of inherited colon cancer. Around 90% of patients develop cancers, often of the proximal colon, which are usually poorly differentiated and highly aggressive
156
What is the most common association with HNPCC?
Endometrial cancer
Pancreatic cancer in males
157
What is diverticulosis?
Diverticulosis is an extremely common disorder characterised by multiple outpouchings of the bowel wall, most commonly in the sigmoid colon. Strictly speaking the term diverticular disease is reserved for patients who are symptomatic - diverticulosis is the more accurate term for diverticula being present
158
How does diverticulosis present?
Diverticulosis can present in a number of ways:
painful diverticular disease: altered bowel habit, colicky left sided abdominal pain. A high fibre diet is usually recommended to minimise symptoms
159
How does diverticulitis present?
One of the diverticular become infected. The classical presentation is:
Left iliac fossa pain and tenderness
anorexia, nausea and vomiting
diarrhoea
features of infection (pyrexia, raised WBC and CRP)
160
How do you manage Diverticulitis?
Management:
mild attacks can be treated with oral antibiotics
more significant episodes are managed in hospital. Patients are made nil by mouth, intravenous fluids and intravenous antibiotics (typical a cephalosporin + metronidazole) are given
161
What are some complications of diverticulitis?
```
Complications of diverticulitis include:
abscess formation
peritonitis
obstruction
perforation
```
162
What is the most common cause of inherited colorectal cancer?
HNPCC
(FAP is 2nd most common)
Gardner's Syndrome is a variant of FAP
163
RUQ pain, fatigue and dizziness.
| Tender hepatomegaly. Pulsatility.
Right heart failure
The real clue in this question is that it is also pulsatile, which is due to the back-up of blood due to the failure of the right side of the heart to work effectively. The fact that it is pulsatile, distinguishes it from the other possible answers.
164
What are the classical symptoms of gallstones?
The classical symptoms are of colicky right upper quadrant pain that occurs postprandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal.
165
What is a good investigation when you suspect gall stones?
Abdominal Ultrasound
166
What is the biggest cancer risk from primary sclerosing cholangitis?
Cholangiocarcinoma (around 10%)
167
Whats the scoring system that can be used to assess severity of pancreatitis?
Modified Glasgow Score: PANCREAS
```
Pa02 <8kPa
Age >55 years
Neutrophilia WBC >15x10^9
Calcium <2mmol/L
Renal function Urea >16mmol/L
Enzymes LDH >600 ; AST >200
Albumin <32g/L
Sugar Blood glucose >10mmol/L
```
168
A woman who is know to have gallstones presents with pain in her right upper quadrant. On examination she is not jaundiced and has a temperature of 37.8C. Palpating under the right costal margin causes her to catch her breath.
Acute Cholecystitis
Pain similar to biliary colic but more severe and persistent. The pain may radiate to the back or right shoulder.
The patient may be pyrexial and Murphy's sign positive (arrest of inspiration on palpation of the RUQ)
169
A 72-year-old man who is known to have heart failure and type 2 diabetes mellitus presents with a persistent dull ache in his right upper quadrant. Blood tests show a mild elevation of the alanine aminotransferase level.
Congestive hepatomegaly
The liver only usually causes pain if stretched. One common way this can occur is as a consequence of congestive heart failure. In severe cases cirrhosis may occur.
170
What is melanosis coli?
Melanosis coli is a disorder of pigmentation of the bowel wall. Histology demonstrates pigment-laden macrophages
It is associated with laxative abuse, especially anthraquinone compounds such as senna
171
Increased Goblet cells.
| UC/Crohn's
Crohn's
172
What is acute cholecystitis and describe the pathophysiology??
Inflammation of the gallbladder.
Pathophysiology
- Develops secondary to gallstones in 90% of patients (acute calculous cholecystitis)
- the remaining 10% of cases are referred to as acalculous cholecystitis
173
Where is acalculous cholecystitis seen?
Typically seen in hospitalised and severely ill patients
Multifactorial pathophysiology: gallbladder stasis, hypoperfusion, infection
In immunosuppressed patients it may develop secondary to Cryptosporidium or cytomegalovirus
associated with high morbidity and mortality rates
174
Features of cholecystitis?
Features
Right upper quadrant pain
May radiate to the right shoulder
Fever and signs of systemic upset
Murphy's sign on examination: inspiratory arrest upon palpation of the right upper quadrant
Occasionally mildly deranged LFT's (especially if Mirizzi syndrome)
175
Investigations of choice in acute cholecystitis?
Investigation
Ultrasound is the first-line investigation of choice
If the diagnosis remains unclear then cholescintigraphy (HIDA scan) may be used
technetium-labeled HIDA (hepatobiliary iminodiacetic acid) is injected IV and taken up selectively by hepatocytes and excreted into bile.
In acute cholecystitis there is cystic duct obstruction (secondary to odema associated with inflammation or an obstructing stone) and hence the gallbladder will not be visualised
176
What is the management of acute cholecystitis?
Treatment
Intravenous antibiotics
NICE now recommend early laparoscopic cholecystectomy, within 1 week of diagnosis. Previously, surgery was delayed for several weeks until the inflammation has subsided
177
Endoscopy in upper GI bleed timing?
All patients should have endoscopy within 24 hours
178
What medications should you consider stopping in C. difficile and why?
Anti-peristaltic and anti- motility medications
e.g Opioids
It will reduce the clearance of C. difficile and increase the chance of toxic megacolon occurring
179
What Hep B serology results would show acute infection?
HBsAg positive, anti-HBs negative, IgM anti-HBc positive
180
What Hep B serology results would show previous vaccination?
HBsAg negative, anti-HBs positive and anti-HBc negative
181
What Hep B serology results would show chronic infection?
Chronic infection would result in IgG anti-HBc positive status.
If the patient has positive IgM, indicating an acute infection, rather than chronic.
182
What is Zollinger - Ellison syndrome, what are the features and how do you diagnose it?
Zollinger-Ellison syndrome is condition characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas. Around 30% occur as part of MEN type I syndrome
Features
multiple gastroduodenal ulcers
diarrhoea
malabsorption
Diagnosis
fasting gastrin levels: the single best screen test
secretin stimulation test
183
Hepatitis D?
Hepatitis D superinfection is an differential for chronic hepatitis B patients with acute flare up
184
Obese T2DM with abnormal LFTs
non-alcoholic fatty liver disease
185
Which vitamin, if taken in high doses, can be teratogenic?
Vitamin A is teratogenic in high doses, and pregnant women should not exceed a daily intake of >10,000IU. Women are therefore advised to avoid any supplements containing vitamin A, such as normal multivitamin tablets, in pregnancy (NHS Choices)
186
What is used as prophylaxis for variceal bleeding?
propranolol: reduced rebleeding and mortality compared to placebo
187
Patients with Barrett's metaplasia are at higher risk of?
Adenocarcinoma of the oesophagus
Adenocarcinoma is also related to GORD
188
According to the Truelove and Witts' severity index, which of the following is most likely to indicate severe colitis??
The Truelove and Witts' severity index is recommended by NICE when assessing the severity of ulcerative colitis in adults. Ulcerative colitis is classified as 'severe' when the patient has blood in their stool, or is passing more than 6 stools per day plus at least one of the following features:
Temperature greater than 37.8°C
Heart rate greater than 90 beats per minute
Anaemia (Hb less than 105g/ L)
Erythrocyte sedimentation rate greater than 30 mm/hour
189
How would the LFTs change in autoimmune hepatitis?
Autoimmune hepatitis is more likely to show predominantly raised ALT / AST on LFTs than ALP
Autoimmune hepatitis predominantly involves inflammation in the liver and thus ALT / AST are likely to be raised
190
What is the management of appendicitis?
Laparoscopic appendicectomy is now the treatment of choice
Administration of prophylactic intravenous antibiotics reduces wound infection rates
patients with perforated appendicitis (typical around 15-20%) require copious abdominal lavage.
Patients without peritonitis who have an appendix mass should receive broad-spectrum antibiotics and consideration given to performing an interval appendicectomy.
191
What is Sister Mary Joseph's node?
Sister Mary Joseph node is a palpable nodule in the umbilicus due to metastasis of malignant cancer within the pelvis or abdomen
192
Uses of the midline incision?
Commonest approach to the abdomen
Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum (avoid falciform ligament above the umbilicus)
Bladder can be accessed via an extraperitoneal approach through the space of Retzius
193
Uses of Kocher incision?
Incision under right subcostal margin e.g. Cholecystectomy (open)
194
Use of the lanz incision?
Appendicectomy
195
Use of Gridiron incision?
Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically acceptable than Lanz)
196
Use of Pfannenstiel incision?
Transverse supra pubic, primarily used to access pelvic organs
197
Use of Mcevedy incision?
Groin incision e.g. Emergency repair strangulated femoral hernia
198
Use of Rutherford Morrison incision?
Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation.
199
What is the most appropriate tool to screen for malnutrition?
MUST
200
What is antiphospholipid syndrome?
Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder or secondary to other conditions, most commonly systemic lupus erythematosus (SLE)
A key point for the exam is to appreciate that antiphospholipid syndrome causes a paradoxical rise in the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade
201
What are gluten containing cereals?
```
The management of coeliac disease involves a gluten-free diet. Gluten containing cereals include:
wheat: bread, pasta, pastry
barley*: beer
rye
oats**
```
202
What are gluten free?
Some notable foods which are gluten-free include:
rice
potatoes
corn (maize)
203
CDT negative
CD antigen positive
What do you do?
Reassure and continue monitoring.
| Clostridium difficile antigen positivity only shows exposure to the bacteria, rather than current infection
204
What increases the risk of squamous cell carcinoma of the oesophagus?
Achalasia
205
A 41-year-old man with cerebral palsy is admitted with abdominal pain and diarrhoea. His carers report him passing 5-6 watery stools per day for the past four days. On examination he has a mass in the left side of the abdomen.
Constipation causing overflow
206
Which drugs paint a hepatocellular picture?
SPAM MAVAH
Paracetamol
Sodium valproate, phenytoin
MAOIs
Halothane
Anti-tuberculosis: isoniazid, rifampicin, Pyrazinamide
Statins
Alcohol
Amiodarone
methyldopa
207
What is the triad for Boerhaave's Perforation?
The Mackler triad for Boerhaave syndrome:
Vomiting, thoracic pain, subcutaneous emphysema. It typically presents in middle aged men with a background of alcohol abuse.
