GIT

Question 1

What causes anal fissures? What is the non-pharm management?

Answer 1

Usually constipation/diarrhoea. Posterior midline 90%. If lateral may be Crohn’s, cancer, infection. Mx: high fibre diet, sitz baths TDS after bowel motions to relax sphincter and improve blood flow, stool softeners.

Question 2

What topical agents are used to manage anal fissures?

Answer 2

Rectinol (zinc + anaesthetic), soovit (anaesthetic + steroid). To reduce sphincter spasm + improve blood flow: topical GTN rectogesic (use lying down), diltiazem or nifedipine.

Question 3

How are haemorrhoids managed?

Answer 3

Fibre/fluid, avoid straining. Surgery if not responding or older. Thrombosed - can excise if < 72hr, otherwise cool compress, donut pillow, sitz baths.

Question 4

What is a pilonidal sinus/cyst vs a perianal abscess? Management.

Answer 4

Pilonidal - in midline, sinus if no collection/infection. Treatment is eradication of tract and heal from bottom up, need packing if open. Abscess not in midline, surgery to treat abx as adjunct.

Question 5

How do you manage pruritis ani?

Answer 5

Consider dermatoses. Soap substitute, greasy emollient barrier, psyllium if stool loose, loose cotton underwear. Can use advantan and diprosone if required.

Question 6

What are the risk factors/indicators for hepatitis C?

Answer 6

Deranged LFTs/jaundice, MSM, IVDU, prison, transfusion before 1990, needlestick injury, unsterile tattoo/piercing, active HIV or Hep B, birth in parts of Asia/Africa.

Question 7

What tests are indicated before treating hepatitis C?

Answer 7

RNA for active Hep C, FBE, UEC, LFT, INR, HIV, Hep A ,Hep B. Cirrhosis: APRI score < 1 unlikely, can U/S but fibroscan better.

Question 8

How is Hep C treated? What are the contraindications and followup?

Answer 8

8-12weeks of maviret or epclusa, test of cure 3mo later. C/I: ESKD, liver Ca, HIV, decompensated cirrhosis. Pregnancy unclear. Avoid PPI, statins, antieplipetics. Specialist if cirrhosis, GFR < 50 coinfection or complex drug use.

Question 9

When are scopes indicated in GORD? How is GORD treated pharmacologically?

Answer 9

Diagnosis unclear, anaemia or dysphagia, severe or changing symptoms. Initial PPI 4-8 weeks then aim to reduce gradually (1/2 dose or alt daily, then PRN).

Question 10

What are the non-pharm aspects of GORD management?

Answer 10

Identify triggers and avoid (fat, alcohol, coffee, chocolate, citrus, spice), eat small meals, eat slowly, avoid before bed 2-3hr, avoid lying down post meals, use wedge pillow, reduce smoking, weight loss.

Question 11

How is GORD managed in pregnancy?

Answer 11

Antacids first line. Ranitidine safe. PPIs are B3, trial PRN only if required - omeprazole has most experience.

Question 12

How do you reduce colorectal cancer risk?

Answer 12

Avoid smoking, limit alcohol < 2 std, high fibre diet 90g wholegrains, moderate red meat 3 portions per week and avoid charred/processed, exercise, BMI < 25. Low dose aspirin for 2.5 years.

Question 13

What are the differentials for dyspepsia (epigastric burning after eating)?

Answer 13

GORD, PUD, biliary colic, gastritis (H. pylori, NSAID, alcohol), pancreatitis, crohn’s, coeliac, oesophagitis; gastric/oesophageal/pancreatic cancer; cardiac ischaemia.

Question 14

How do you manage peptic ulcers? What if pt is on aspirin?

Answer 14

Test for h.pylori. Usually 4-8 weeks PPI. If no cause, may need lifelong PPI. If develop whilst on aspirin or long term NSAID, continue PPI.

Question 15

What is the workup for deranged LFTs with hepatocellular pattern?

Answer 15

If mild, check again 6mo. Initial: screen alcohol, drugs (panadol), Hep B, Hep C, ferritin, U/S for NASH. 2nd line: autoimmune (SPEP, ANA), thyroid, coeliac. 3rd: wilsons, alpha 1, muscle disorders.

Question 16

What are the causes of a raised ALP?

Answer 16

Diabetes, pregnancy 3rd trimester, drugs (erythromycin, fluclox, oestrogen), cancer (liver, GB, pancreas), biliary colic, PSC, PBC.

Question 17

What can cause c.diff? How is it treated?

Answer 17

Abx even after months. PPIs also implicated. Treat if symptomatic: metonidazole 10d or vanc.

Question 18

How is uncomplicated diverticulitis managed?3 indications for abx and which abx?

Answer 18

Clear liquid diet 2-3d, low fibre diet until pain improves, panadol and antispasmodics. Abx if R sided, immunocompromised or not improving in 3 days: AugBD 5 days or bactrim + metro 5 days

Question 19

What is complicated diverticulitis? Management and followup

Answer 19

Bacteraemia, sepsis, abscess >5cm, perforation, peritonitis. IV abx/fluid + gut rest. Need scope 6-8 weeks and aim for soft stools.

Scopes also if atypical symptoms or imaging. No evidence for seeds/fibre.

Question 20

Pancreatitis - common causes, investigations, management.

Answer 20

Triglycerides, calcium, alcohol, gallstone, ERCP. FBE, UEC, LFT, BSL, CXR, Lipase, ECG. Analgesia, antiemetic, fluid.

Question 21

What are 4 risk factors for pancreatic cancer?

Answer 21

2 first degree relatives, BRCA2 gene carrier, chronic pancreatitis, cystic fibrosis.

Question 22

How is coeliac disease diagnosed?

Answer 22

Anti-tissue transglutaminase and anti deamidated gliadin abs if having gluten for 4-6 weeks; HLA DQ2/DQ8 can exclude if negative. Scope w biopsy for intraepithelial lymphocytosis w blunting of duodenal villi is gold standard.

Question 23

What are the risks/associations of coeliac disease?

Answer 23

Untreated - lymphoma. Screen for TSH, iron, B12, Vit D, DEXA scan. Dermatitis herpetiformis - itchy symmetrical blistering rash, may start as vesicles. Biopsy to confirm. FDR should be screened.

Question 24

What are the Rome IV criteria for IBS diagnosis? What are some differentials?

Answer 24

6mo of abdo pain at least 1d/week for 3mo and 2 of: pain w defaecation, pain assoc w change in stool freq or stool form. DDx: coeliac, IBD, food intolerance, giardia, H.pylori, SIBO, gastroparesis, obstruction.

Question 25

What tests are indicated for IBS? And for food intolerances?

Answer 25

FBE, CRP, coeliac ab, calprotectin. Trial of exclusion diet better as breath tests only look for malabsorption. 125mL low fat milk for lactose challenge.

Question 26

How is IBS managed?

Answer 26

Food diary to identify triggers, soluble fibre if constipated (psyllium), regular meal times, low FODMAP trial, CBT. PRN loperamide, buscopan, iberogast (bloating). Amitriptyline 2nd line.

Question 27

What are the different causes of haematemesis?

Answer 27

PUD (gastric, oesophageal, duodenal), severe gastritis/oesophagitis, varisces, mallory-weiss tear, cancer, vascular ectasia or AV malformation.

Question 28

How does oesophageal spasm present? Management.

Answer 28

Deep constricting retrosternal pain, worse w hot or cold drinks. Exclude cardiac then treat empirically: sip warm water when painful. GTN 400microg spray or 600microg tab PRN. Diltiazem, imdur if severe/recurrent

Question 29

What are the features of ulcerative colitis and crohn’s disease?

Answer 29

UC: recurrent loose stools w blood/mucus, only affects large bowel, less pain/fever. Ca risk after 7 year. CD: recurrent diarrhoea, blood/mucus, pain, perianal disease, mouth ulcers. 50% ileocolic.

Question 30

Hep B serology - what results in acute, chronic, resolved and vaccinated Hep B infection?

Answer 30

A: HBsAg +, Anti-HBc +, Anti-HBc IgM +, Anti-HBs -ve. C: HBsAg +, Anti-HBc +, Anti-HBc IgM -ve, Anti-HBs -ve. R: HBsAg -ve, Anti-HBc +, Anti-HBs +. V: HBsAg -ve, Anti-HBc -ve, Anti-HBs +.

Question 31

What tests are indicated if Hep B infection is diagnosed?

Answer 31

HBV DNA, HBe antigen, FBE, LFT, INR, Hep A, C, D and HIV. Consider APRI or fibroscan. Consider Ca screen (cirrhosis, asian >40, ATSI >50) - alpha fetoprotein + U/S.

Question 32

How is Hep B managed (5 features)?

Answer 32

Refer for treatment depending on activity. Avoid smoking and alcohol. Vaccinate for Hep A. Contact tracing for 6mo, use condoms. Screen and vaccinate household contacts.

Question 33

How is acute infectious diarrhoea treated? What are 3 concerning causes?

Answer 33

Redhydration only. If severe, cipro 500BD 3 days. Giardia (foul smelling, greasy chronic) = metro. Amoebiasis - blood + liver abscess. Shigellosis - blood for 1 week.

Question 34

How are gallbladder polyps managed?

Answer 34

Monitor if < 10mm, no IBD or PSC, age < 60 and not indian. Monitor 6mo to 1 year (< 5mm)

Question 35

How is functional and opioid induced constipation managed?

Answer 35

F: footstool, fibre, fluid, exercise. Bulk laxative then osmotic movicol/lactulose then stimulant senna. O: avoid lactulose and bulk forming, due to bloat/gas. Can use prucalopride 1-2mg.

Question 36

When is H.pylori testing indicated? How is it treated?

Answer 36

Dyspepsia, PUD, FDR w gastric ca. Consider if long term PPI use. Tx: esomeprazole 20mg BD, amoxicillin 1g BD, clarithromycin 500mg BD for 7-14 days.

Question 37

What is the followup for treated H. pylori?

Answer 37

Re-test if complicated PUD, stopping PPI. Breath test 4-6 weeks. Stool test can also check for eradication. Serology not helpful. Don’t treat twice, refer.

Question 38

What are 4 pathologies caused by gallstones?

Answer 38

Biliary colic - cholelithiasis. Acute GB inflammation - pain + fever, cholecystitis. If shock + confusion + jaundice suggests cholangitis. If lower, can cause pancreatitis.

Question 39

What are the features of Hep A infection? What are some differentials?

Answer 39

Incubation 2-5 weeks. N/V, headache, epigastric pain, diarrhoea. Later get jaundice and LFT derangement. Resolve in 3-6 weeks. DDx: hepatitis, CMV, EBV, yellow fever, syphilis, autoimmune hepatitis,.