GI SAQ Flashcards

1
Q

35/M
2years intermittent back pain
9months chronic diarrhea, gradually becomes bloody.
12 bloody bowel movements today
Today present with fever, acute bloody diarrhea
AXR mildly dilated transverse colon (5cm)
1. Further Hx
2. Ix
3. Most likely cause
4. Long term sequelae

A
  1. OPQRST, tenesmus, bowel changes, TOCC
  2. CBC for anemia, ferritin (IDA), ESR, CRP, fecal calprotectin, pANCA (UC), pASCA (CD), HLAB27, stool for ova/cyst and culture, colonoscopy and biopsy. X ray spine and hip for SPAR features. IGRA for TB.
  3. IBD
  4. CRC
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2
Q

25/F travel to Philippines, present with cough, headache, fever
Bloods: leucocytosis, LFT derangement, jaundice?, AKI
1. Name 2 important travel history
2. What are 3 ddx
3. She went kayaking and capsized what is your diagnosis now and what is the PHYLUM?
4. Confirmatory test
5. What tx, one oral one IV

A
  1. OTCC, dates of travel, activities, inset bite, needle/blood exposure, sex hx, soil/water contact, chemoprophylaxis
  2. Malaria, dengue fever, typhoid fever, rickettsioses, leptospirosis, meliodosis
  3. Spirochaete (leptospira spp)
  4. Weil Felix test
  5. Oral doxycycline, IV penicillin/ceftriaxone
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3
Q

A 52-year-old woman presents with abdominal pain, fever, loose stool and blood mixed with stool for 3 days.
1. List 4 differentials
2. Augmentin 2 weeks ago for new CAP. What is most likely dx now?
3. Name 1 Ix to confirm dx
4. 1 complication if untreated
5. Name 2 medical treatment for condition
6. If failed aforementioned treatment, what treatment can be offerred?

A
  1. Pseudomembranous colitis, bacterial dysentery/inflammatory gastroenteritis, ulcerative colitis, diverticular bleeding, CRC
  2. Pseudomembranous colitis
  3. Stool for clostridium difficile toxin
  4. Toxic megacolon, sepsis, colonic peforation
  5. Oral metronidazole (mild-moderate symptoms), oral vancomycin (if severe) –> not given IV as not as effective
  6. Surgery
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4
Q

Middle-aged man presented with melena. He drinks half bottle of whisky per day. PE no stigmata of chronic liver disease.
Blood with Hb 9.x, MCV 102,
LFT has normal albumin, bilirubin, raised GGT, raised AST and ALT, AST higher than ALT.
1. 2 ddx for macrocytic anemia
2. Name 2 ddx for melena considering the whole clinical picture
3. 1 contraindication for upper endoscopy, which is found on X ray or bloods

A
  1. Non megaloblastic (large normal nucleus, matuer RBCs): liver disease, alcohol use, hypothyroidism, hereditary spherocytosis
    Megaloblastic (structurally abnormal nucleus resulting in large, immature RBCs): B12 deficiency, folate deficiency, fanconi anemia
    Reticulocytosis: haemolysis (zieve syndrome: secondary to aclohol induced liver injury)
  2. Peptic ulcer, esophageal varices, mallory weiss tear
  3. Pneumoperitoneum: gree gas under diaphragm found on erect CXR
    Absolute contraindications: perforated bowel, peritonitis, toxic megacolon in unstable patient
    Relative contraindications: severe neutropenia, coagulopathy, severe thrombocytopenia or impaired platelet function (seen in bloods)
  4. Perforation/bleed/infection, sedation related
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5
Q
A
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6
Q

M/52, 4/7 Hb 12.6 MCV 97 Albumin 44 Bilirubin 9 ALT 31 AST 23 Transient elastography stiffness 14.45 (cirrhosis), contrast 335dB (steatosis) HbsAg pos, HbeAg neg
1. Question to ask in history taking
2. Would you start hep b treatment? why?
3. What Ix would you perform with reasons
4. 3 years after treatment, HBsAg -ve. Is this patient cured>
5. What does the HBsAg-ve result indicate for his Mx (implication of HBsAg -ve to patient)

A
  1. HPI (sx of liver disease: jaundice, tea colored urine, pruritis, bleeding tendency), constitional sx
    drug Hx: steroids, TCM, hepatotoxic drug
    social Hx: alcohol, IVDU with needle sharing, unsafe sex
    family Hx: hx of HCC, HBV status of partner/children, HBV vaccination status of partner/children
  2. Yes, cirrhosis
    All patients HBeAg+ve or -ve with ALT >ALN and DNA>2000iu/ml with moderate necroinflammation/fibrosis
    Patients with cirrhosis with anydetectable HBV DNA irrespective of ALT levels
    HBeAg+ve patients with high HBV DNA but persistently normal ALT
  3. AFP for HCC screening, PIVKA (tumor marker) available in HA now, liver USG for HCC screening. Upper endoscopy for esophageal varices screening. HBV DNA for pretreatment baseline
  4. No
  5. Resolved infection, occult hep B
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7
Q

Oesophageal varices M/60, chronic Hep B with no regular follow-up. Chronic alcohol drinker(non + 1 I recall NO alcohol history?). Positive shift dullness. Non-drinker. BP 85/50, HR 110 Blood test results: Hb 8.0 MCV 102 PLT 45 Urea 16
1. Reason for high MCV
2. Why thrombocytopenia?
Endoscopy confirmed eso varices, red wale sign but no active bleeding. No gastric ulcer.
3. Explain the reason for oesophageal varices
4. Other than esophageal varices, what other possible features specific to cirrhosis would you expect to find on upper endoscopy?
5. one 1st line intervention during endoscopy

A
  1. Reticulocytosis due to bone marrow compensation for acute blood loss. Liver cirrhosis.
  2. Hypersplenism (portal hypertension causing congestion), decreased thrombopoietin production in liver (decreased megakaryopoiesis) –> reduced platelet production –> thrombocytopenia
  3. Collateral portosystemic venous shunting due to portal hypertension, dilatation of submucosal veins
  4. Gastric varices, portal hypertensive gastropathy
  5. Endoscopic band ligation. (IV terlipressin, PPI, prophylactic antibiotics. B blocker for secondary prevention: carvedilol)
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8
Q
A

a) Types of accomodation, activities, inset bite, needle/blood exposure, sex history, soil/water contact, chemoprophylaxis
b) Malaria, dengue, typhoid, rickettsiosis, leptospirosis, melioidosis
c) Malaria caused by anopheles mosquito
d) Thin blood smear (after POCT)
e) P. falciparum treatment: Artemisinin combination therapies (ACTs): artesunate + doxycycline, artesunate + mefloquine. There is quinine resistant P. falciparum so not as effective.
PV, PM and PO (majority): cloroquine 600mg base, mefloquine for chloroquine resistant PV
f) haemolysis, jaundice, thrombocytopenia, pancytopenia, SIRS, acute respiratory distress, acute renal failure

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9
Q
A

a) non alcoholic fatty liver disease
b) obesity, T2DM, hypertriglyceridemia, metabolic syndrome
c) Abdominal ultrasound, fibroscan (elastography)
d) HCC, PCOS, hypertension, early atheroclerosis, nephropathy, OSA

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10
Q
A

a) TB lung
b) Lateral flow urine lipoarabinomannan (LF-LAM) assay, sputum culture (ziehl neelson stain) or sputum smear microscopy
c)
2 tests for latent TB:
IGRA (inferon gamma release assay): WBC infected with M. tuberculosis with release IFNgamma when mixed with antigens derived from M.tuberculosis
Tuberculin skin test: (>5mm if HIV positive/high risk, >15mm if no known risk factors for TB)
d) Immunodulators + biologics for fistulizing CD
Immunomodulators: thiopurines (azathioprine), methotrexate

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11
Q
A

a)Accomodation, insect bite, needle exposure, sex history, TOCC
b) Dengue, typhoid, rickettsiosis, leptospirosis
c) Thin blood smear
d) artesunate + doxycycline, mefloquine

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12
Q
A

a) myelosuppresion (pancytopenia)
b) levofloxacin, tazocin (piperacillin +tazobactam) + oral fluconazole
c) TPMT and NUDT15 in HK locality
d) Other immunomodulator: methotrexate
Biologics: anti TNFa (infliximab, etanercept), natalizumab, vedolizumab (mAb vs integrin alpha 4 beta 7 peyers patch adhesion molecule)

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13
Q
A

a) needle exposure, sex history
b)
c) fibroscan, AFP
d) non alcoholic steatohepatitis

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14
Q

A 60+/M presents to you for regular checkup. He has a history of diabetes and hypertension on metformin and losartan. On this checkup, his blood pressure is 150/90mmHg and his BMI is 35 kg/m2. His blood tests are as follows (elevated HbA1c, elevated creatinine, elevated AST/ALT
a. Other than the deranged LFT, what are the clinical problems that this patient has? Give 4.
b. What is the likely cause of his liver condition?
c. What non-invasive investigation can you perform to confirm your diagnosis?
d. What other diabetes drug can you give to improve his liver condition? (2) What is the mechanism?

A

a. hypertension, obese, DM, renal impairment
b. NASH
c. Transient elastograph with CAP (controlled attenuation parameter), USG liver
d. TZD (pioglitazone) been shown to reverse severe liver cirrhosis, GLP1 agonist (liraglutide)

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15
Q

A 50+/M is a chronic drinker who drinks whiskey and beer on a daily basis. He presents to you with epigastric discomfort. His laboratory results are as follows (normal CBC, elevated AST>ALT ~200-300/ALP, markedly elevated GGT, serum glucose normal). Temperature: 37.5 degree. He regularly drinks but admits that he hasn’t been drinking as much these past few days as he has run out of cash (I’m not sure if this is from medicine or psychiatry).
a. Give 3 differential diagnoses for his liver biochemistry (3)
b. List 3 immediate examinations (3)
He has been agitated since admission. RG 5.3.
He suddenly collapses and develops a GTCS.
c. What is the condition he is suffering from? (1)
d. What should have been given to prevent this condition from developing? (1)
e. What is the general management of his condition? (2)

A

a. Alcoholic hepatitis, NASH, acute hepatitis (Hep A,E, acute on chronic HBV), drugs
b. Neurological examination: cerebellar signs
c. Wernickes encephalopathy ?? (delirium tremens)
d. High dose IV thiamine
e. Monitor BP and temperature (hypo/hyperthermia, hypotension and tachycardia can occur). Monitor neurological signs (opthalmoplegia can be resolved within hours) Treat any concurrent illnesses (e.g. delirium tremens, hepatic encephalopathy, sepsis)

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16
Q

A 50+/M has severe knee pain. He has been prescribed naproxen by his GP. The knee pain has worsened and he has increased his intake of naproxen. Now he presents to you with epigastric pain. An OGD is performed, biopsy is taken and H. pylori is identified. He is also given triple therapy. After 8 weeks, the H pylori has been confirmed to be eradicated.
a. Name 2 methods to diagnose H pylori on OGD biopsy
b. List 2 other gastroduodenal diseases caused by H pylori apart from gastric ulcer
c. What is included in the triple therapy he has been given?
d. List 2 complications of gastric ulcer
e. List 2 methods to reduce PUD in the future if he needs to continue taking anti-inflammatory medication

A

a. rapid urease test, culture, microscopy
b. gastric cancer, hyperplastic polyp, gastric MALT lymphoma
c. Amoxicillin, clarithromycin, omeprazole
d. Gastric cancer, perforation, hemorrhage
e. Give PPI with NSAID, use COX2 selective NSAIDS (celecoxib –> has better pharmaco profile), stop NSAID

17
Q
A

Globulin and bilirubin elevated. ALP and GGT elevated (ductal enzymes)

  1. USG of the liver
  2. No biliary obstruction: AMA (antimitochondrial antibody), immunoglobulin pattern. Think PBC. (PSC not as common: no blood tests available. Not autoimmune hepatitis as middle aged woman and ductal enzyme elevation (affects younger women)
  3. Primary biliary cholangitis
  4. UDCA (ursodeoxycholic acid)
  5. Cholestyramine
  6. Liver cirrhosis and liver cancer
  7. Liver transplantation
18
Q
A
  1. Non alcoholic fatty liver disease (NAFLD) or fatty liver
  2. Obesity, diabetes, hypercholesterolemia, drugs e.g. amiodarone
  3. Liver biopsy and controlled attenuation parameter (transient elastography)
  4. Liver cirrhosis and liver cancer
19
Q

A 30-year-old Chinese lady presented with difficulty in swallowing for 6 months. She felt something sticking behind the chest and the swallowing difficulty was found with both solid and fluid. There was occasional regurgitation of food after meal. She has lost more than 5 kg of her weight. Her past health was unremarkable. A recent upper endoscopy and biopsy was told to be normal. Barium swallow showed dilated oesophagus with narrowing of the gastro-oesophageal junction.
(a) What is the most likely diagnosis?
(b) What other investigation would you consider to confirm your diagnosis?
(c) What are the medical treatments for this condition?
(d) What are the endoscopic procedures used to treat this condition?


A

a) achalasia
b) esophageal manometry
c) nitrate (nitroglycerin), CCB (nifedipine)
d) endoscopic pneumatic dilation, peroral endoscopic myotomy, endoscopic botoxc injection (high failure rate: only reserved for elderly)

20
Q

A 63-year-old man with known alcohol-related liver disease and cirrhosis presents with a 5-day history of confusion and abdominal swelling.
(a) Give three possible pathogenic mechanisms.
(b) Name four categories of predisposing causes of hepatic encephalopathy, with two examples in
each category

A

a) HE from decompensate cirrhosis, intoxication/withdrawal, SBP with sepsis
b) nitrogen compound related: high protein diet, GIB. Decreased blood supply to liver: overdiuresis, excessive paracentesis.
Metabolic: hypoK, acid base imbalance, sedative use.
Increased shunting: portosystemic shunt, surgical shunting.

21
Q

A 55-year-old female presented with malaise and generalized pruritus for 6 months. Physical examina- tion revealed mild jaundice and bilateral ankle oedema. Abdominal examination showed mildly en- larged liver and prominent spleen. The followings were the results of the liver function test: albumin
32 g/L, bilirubin 80 umol/L, ALT 26 U/L, AST 50 U/L, ALP 300 U/L, GGT 450 U/L.
(a) What essential information needs to be obtained in her medical history?
(b) What is the simplest investigation to rule out obstructive biliary problem?
(c) What is the likely diagnosis if both (a) and (b) are unremarkable?
(d) What are other confirmative tests to diagnose (c)?
(e) What is the treatment of choice for this disease?
(f) What is the final treatment if the condition continues to deteriorate?

A

a) other sx of cholestasis e.g. dark urine, any other features of cirrhosis, any past history of AI disease
b) USG HBS
c) PBC
d) serum Ig pattern, lipid profile, AMA M2, liver biopsy (non suppurative destruction)
e) UDCA + symptomatic treatment (cholestyramine, vit ADEK, Ca, MCT fat restriction, bisphosphonate)
f) LT

22
Q

Miss Lee, a 32-year-old woman presented with abdominal pain, loose stool mixed with blood for 3 months.
(a) Give four differential diagnoses.
(b) Name two endoscopic features of ulcerative colitis.
(c) Name one histological feature of ulcerative colitis.
(d) Name one medical treatment for ulcerative colitis.
(e) Name one biliary extraintestinal feature of ulcerative colitis.

A

a) IBD, chronic infection (e.g. TB), CA colon, chronic ischemic colitis
b) diffuse shallow ulceration, pseudopolyp, diffuse granular appearance, continuous involvement from anorectal margin
c) mucosal limited inflammation, cryptitis with goblet cell depletion
d) 5-ASA (oral or enema)
e) PSC

23
Q

A 30-year-old man presented with abdominal pain, fever and rectal bleeding for 1 week. He was diag- nosed to have ulcerative colitis for 5 years and was taking oral mesalazine prior to this presentation. His last flare up of disease was about 1 year ago, which required the use of systemic steroid. There was no recent travel history. Examination showed fever, tachycardia and mild diffuse tenderness of the ab- domen. Erect CXR did not show any free gas under diaphragm.
(a) What would be the initial simple investigations that you would order?
(b) What would be the initial treatment for him?
(c) If he did not respond to your medical treatment after 5 days and abdominal X-ray showed pro- gressive dilatation of the colon, what would be the other treatment options?

A

a) CBC, LRFT, ESR/CRP glucose HBsAg, T/S
AXR for any significant IO
Stool culture microscopy, ova/cyst +/-CD toxin PCR
b) Induction steroid + mesalazine +/-thiopurine, IV 2GC + metronidazole
c) NPO total bowel rest + NGT suction, broad spectrum IV Abx, consult surger x emergency colectomy

24
Q
A

a) liver abscess
b) SOL with double target sign, central hypodensity with hyperdensity and surrounding edema
c) percutaneous drainage, IV antibiotics (3GC + metronidazole)
d) surgical drainage
e) biliary sepsis (ascending infection), intestinal sepsis (portal empyema), DM, alcoholism
f) e.coli, klebsiella

25
Q

A 57-year-old man presented with abdominal pain and fever. He had been suffering from hepatitis B virus related cirrhosis. Physical examination revealed generalized abdominal tenderness with positive shifting dullness.
(a) What is the likely active problem?
(b) What is the essential invasive procedure to make the diagnosis?
(c) What are the two essential investigations for the specimen obtained in the procedure?
(d) What is the most common organism identified in this condition?
(e) What is the renal complication developed from this condition?
(f) What is the treatment for this condition?
(g) How to reduce the chance of recurrence of this condition? 


A

a) spontaneous bacterial peritonitis
b) diagnostic paracentesis
c) WBC with D/C, C/ST
d) E.coli
e) hepatorenal syndrome
f) systemic 3rd gen cephalosporin
g) long term selective intestinal decontamination with norfloxacin

26
Q

A 75-year-old man presented with repeated vomiting for 3 days. There was quite severe epigastric dis- comfort every time after meal for a while and he had lost about 20 pounds recently. Physical examina- tion showed he was dehydrated with marked epigastric distension and the presence of succession splash.
(a) What simple radiological investigation can be performed to confirm your clinical suspicion?
(b) What is the clinical diagnosis? And the possible underlying causes?
(c) List the initial management of this patient.
(d) List some possible electrolyte disturbances of this patient

A

a) AXR for enlarged gastric bubble with paucity of distal gas
b) GOO: benign (ulcer, benign stricture), malignancy (pancreas, stomach, duodenum, CA ampulla of Vater)
c) ABC, fluid resuscitation, NPO NGT on suction, maintenance fluids, monitor vitals, CBC, LRFT, clotting T/S, correct electrolytes/ acid base
d) hypoNa, hypoK, hypoCl metabolic acidosis

27
Q

A 50-year-old man presented with fresh haematemesis. He used to drink 12 bottles of beer per day but there was otherwise no significant past medical illness. His blood pressure was 90/40 mmHg and his pulse rate was 120 per minute. Examination showed multiple spider naevi in his chest, palmar erythema and ascites. Urgent endoscopy was arranged.
(a) Before you sent him to endoscopy, what kind of intravenous replacement fluid you should give him? Please specify the name of the fluid and the rate of replacement.
(b) Name three most likely causes of his gastrointestinal bleeding.
(c) Name two drugs that can possibly control the gastrointestinal bleeding and their underlying mechanisms.

A

a) 1L NS + 40mmol KCl over 4h, aim SBP 90-100 before endoscopy
b) peptic ulcer disease, variceal bleeding, mallory weiss tear
c) terlipressin: reduce SMA and splenic blood flow –> reduce portal BP – >reduce GI BP –> decreases portal venous inflow thereby reducing portal pressure

Octreotide: somatostatin inhibits the release of vasodilator hormones such as glucagon, indirectly causing splanchnic vasoconstriction and decreased portal venous inflow

28
Q

A 55-year-old woman presented with malaise and pruritus for 6 months. She did not take any long- term Western and traditional Chinese medications. Physical examination showed mild jaundice and generalized scratched marks over the body and limbs. The results of the liver function test were as fol- lows: albumin 35 g/L, bilirubin 84 μmol/L, ALT 34 U/L, AST 45 U/L, ALP 300 U/L, GGT 350 U/L. Ultrasound of the liver and biliary system was normal.
(a) What is the likely diagnosis?
(b) Name 3 essential investigations to confirm the diagnosis.
(c) What are the two essential treatments for this patient at this stage?
(d) Name three investigations to monitor the disease progression regularly.
(e) What is the ultimate treatment if this condition is not under control by medical therapy?

A

a) primary biliary cholangitis
b) Ig pattern, lipid profile, AMA M2, +/- liver biopsy
c) symptomatic: cholestyramine/ rifampin if refractory to UDCA, vit ADK replacement, fat restriction/MCFA for steatorrhea
d) serum IgM, ALP/ bilirubin, histology
e) liver transplantation

29
Q

A 25-year-old woman had incidental finding of abnormal liver biochemistry listed as follows: albumin 44 g/L, bilirubin 15 μmol/L, ALT 300 U/L, AST 245 U/L, ALP 120 U/L, GGT 33 U/L. She had a
past history of thyroid disease. Tests for chronic hepatitis B and C were both negative. There was no recent or long-term history of taking medications.
(a) What is the likely diagnosis?
(b) What are the essential tests to confirm the diagnosis?
(c) What are the drugs to treat and control this condition?
(d) What is the final treatment of choice if liver decompensation develops in the future?

A

a) autoimmune hepatitis
b) Ig pattern, ANA, ASMA, anti LKM1, antiSLA +/-biopsy (interface hepatitis)
c) prednisolone + azathioprine combination. If ALT >10xULN or ALT >5xULN + gammaglobulin >2x ULN or histology shows bridging necrosis/multiacainar necrosis
d) liver transplant

30
Q

A 42-year-old man is admitted with a 48-hour history of nausea and increasing vomiting. He is known to have had a colon carcinoma resected 18 months prior to admission. His wife passes comment that he has been increasing constipated and when he vomits in the Accident & Emergency Department you suspect this could be faeculent fluid. Your initial impression of intestinal obstruction is supported by the presence of a distended abdomen with tinkling bowel sounds. Rectal examination demonstrates no fae- cal material.
(a) What would be your first line investigation to confirm the diagnosis of intestinal obstruction and what would you be looking for in this instance?
He continues to vomit. Renal function tests demonstrate a serum creatinine of 130 μmol/L (normal range 70–120 μmol/L) and a serum urea of 15.3 mmol/L (normal range 4.5–7.5 mmol/L). Sodium is
132 mmol/L, potassium 3.2 mmol/L, chloride 95 mmol/L, bicarbonate 32 mmol/L.
(b) List two further options to help improve his symptoms of vomiting.
(c) His blood pressure is 110/60 and the nurses mention to you that he has not passed urine since he has been admitted to hospital. The nurses ask you to write up some intravenous fluids.
(i) Exactly what would you write on the kardex for fluid replacement?
(ii) What would you ask the nurses to do as part of the fluid balance regimen?
(d) The acute condition stabilises but the cause remains uncertain. Please list two investigations of intestinal obstruction that you would wish to undertake in this patient and explain in < 20 words what you would be looking for as a result of each investigation.

A

a) AXR erect and supine: dilated bowel and air fluid levels
b) NG tube decompression, antiemetic therapy
c) 1L NS +40mmol KCl to run over 4 hours, monitor urine output regularly
d) colonoscopy to look for recurrence of primary, abd CT to look for lymphadenopathy or liver mets, contrast enema to look for stricture

31
Q

A 60-year-old woman presented with central abdominal pain and fever. Physical examination revealed tenderness in epigastric region. Bowel sound was sluggish. Erect chest x-ray showed no free gas under diaphragm. Blood investigations showed high white cell count of 18 × 109/L and increased ALP, GGT and bilirubin levels of 455 U/L, 400 U/L and 70 umol/L respectively.
(a) What are the two common possible diagnoses?
(b) What are the further investigations required to find out the exact cause?
(c) What are the immediate managements while waiting for the results from the further investiga- tions?
(d) Name the endoscopic procedure and its therapeutic interventions that may be required in a semi-urgent manner

A

a) acute cholangitis, gallstone pancreatitis
b) CBC, LRFT blood culture, amylase, USG HBS, ERCP diagnostic and therapeutic
c) IV fluids, IV antibitotics, NPO, NG tube for decompression. Monitor the vitals, abd signs.
d) ERCP with sphincterotomy/papillotomy (using papillotome) and stone extraction, +/- stent insertion

32
Q

A 33-year-old man presented with tea-coloured urine for 1 week. He also complained of loss of ap- petite and malaise. Physical examination showed jaundice without other stigmata of chronic liver dis- ease. The results of the liver function test were as follows: albumin 42 g/L, bilirubin 150 umol/L, ALT 1500 U/L, ALP 120 U/L, GGT 60 U/L.
(a) Name five common differential diagnoses.
(b) Name five investigations to delineate the exact cause.

A

a)
Viral hepatitis: HAV, HEV. HBV related: acute HBV, acute exacerbation of chronic HBV infection (IgM anti HAV)
Wilsons disease
Drugs induced (paracetamol, TCM)
Autoimmune hepatitis

b)
Serology for HAV, HBV, HEV
IgM anti HAV (acute on chronic), anti HEV IgM
HepB status
HBsAg, IgM anti HBc
Ig pattern
ANA and autoimmune marker (anti smooth muscle AB), anti LKN1 Ab)
Serum ceruloplasmin and Cu level

33
Q

A 50-year-old gentleman was admitted to the medical ward with four-day history of fresh per rectal bleeding. Name three common causes and discuss the investigations to arrive at a diagnosis.

A

causes of fresh PR bleed
Anorectal diseases: hemorrhoid, fissure, rectal varices
LGIB: CR disease (diverticulitis/angiodysplasia/CRC)
UGIB: ulcer disase

Ix
Initial assessment: secure ABC if necessary
Haemodynamic state: BP/P, RR, sO2, hydration satus
Blood tests: CBC (Hb and MCV, plt), RFT, high urea disproportional to Cr: more proximal GI bleed
OGD
Colonoscopy: diagnose LGIB

34
Q

A 65-year-old hepatitis B-related cirrhosis patient is admitted with reaccumulation of ascites. The as- cites has been previously controlled by diuretics. Discuss the possible causes for the reaccumulation of the ascites, and the investigations you would perform to arrive at a diagnosis.

A

Cause of reaccumulation of ascites
Disease factors
* Worsening of cirrhosis
* New complications of chronic hepatitis/cirrhosis (malignant ascites due to HCC with portal vein obstruciton, peritoneal metastases or tumor rupture), SBP0
Patient factors: non compliance to mx e.g. diuretics, salt and fluid restriction

Ix: diagnostic paracetensis
* Appearance: straw/blood stained/chylour
* WCC
* Culture: usu gram-ve (e.coli, klebsiella) or streptococci (pneumococcus)
* Cytology
* Protein (not very useful)
bloods: CBC, clotting profile, LFT (synthetic liver function by albumin, PT)
* USG abdomen
* AFP
* Triphasic CT scan if suggestive of HCC

35
Q

A 40-year-old chronic hepatitis B patient who has been taking lamivudine for 2 years complains of malaise and right upper quadrant abdominal discomfort. The alanine aminotransferase level is 1233 U/ L (normal 53 U/L).
(a) Name three possible causes for the elevation of alanine aminotransferase level.
(b) How would you investigate?
(c) How would you treat the patient with respect to the three possible causes?

A

a) reactivation of the HBV: emergenc of resistant variants, clearance of HBeAg, corticosteroid withdrawal/ initiation of rituximab
Concomitant viral hep A or E infection (HAV has only 1 serotype, only 1 attack), HEV can have multiple attacks
Superimposed infectiono f HDV (rare)
Drug induced hepatic injury e.g. TCM, herbs, alcohol
Ischemic liver injury
Autoimmune hepatitis (seldom acute)

b)
Bloods: CBC, LRFT, clotting profile
Serology: IgM anti HAV, anti HDV, anti HEV
HBV: IgM anti HBc, HBsAg, HBeAg, anti HBe, HBV DNA +/- HBV PCR for YMDD Mutation

Resistant strain: change to TDF
Concomitant viral hepatitis: supportive, avoid alcohol
Drug induced hepatic injury: identify and withhold drug/alcohol