Learn - Gastro

Question 1

H. pylori - RF / Protection

Answer 1

RF:
- PUD (duodenal > gastric)
- Gastric adenoCa & MALT lymphoma
(Rx H pylori in early MALT cures it)

Protective (but should still Rx):

• Oesophageal Cancer, Barretts
• GORD

Question 2

How do medications (& which) aggravate reflux sx

Answer 2

1) impair LES fxn
- Beta-agonists, anticholinergics, TCA, progesterone, CCB

2) damage oesophageal mucosa
- aspirin/NSAIDs, doxy, quinidine, bisphosphonates

Question 3

PPI v H2 antagonists for healing reflux/acid suppression

Answer 3

PPI: start high & step down after dx confirmation
- 50% healed by 2wks, peak 90% by 12wk

H2 antagonists: 60% healed by 12wks

Question 4

H pylori test - what affects it

Answer 4

ABx <4wks
PPI <2wks

Everyone after Rx should wait >4wks (>2wks after PPI stopped) & proof of cure
If ulcer - need repeat endoscopy to Ax healing

Question 5

H pylori - who needs Rx?

Answer 5

Everyone should have eradication Rx

Gastric ulcers, complicated ulcers (or NSAID related) - 8wks PPI also
Duodenal ulcers - uncomplicated: just eradication Rx

Question 6

H pylori eradication Rx

Answer 6

Triple Rx - 1 week at least - ideally 10-14d
1. Amoxicillin 1g BD
2. Clarithromycin 500mg BD
3. Esomeprazole 20mg BD
(consider quadruple by adding Metronidazole, esp if penicillin sensitive)

2nd line salvage: Quadruple 10-14 days w/ PPI, Tetracycline, Metro, colloidal bismuth

Question 7

SAAG - what is it and what conditions

Answer 7

Serum albumin - Ascitic albumin (cutoff 11)

High gradient SAAG >11 - indicates ascites due to portal HTN

• cirrhosis
• CHF / constrictive pericarditis
• Veno-occlusive dis (PVT, budd chiari)
• Portal fibrosis/massive hepatic mets

Low gradient SAAG <11

+ low total protein: nephrotic syndrome, Tb peritonitis

+ high total protein: Pancreatitis, Cancer (peritoneal), Tb, Chylous ascites, serositis

Question 8

Kings criteria - liver transplant
PARACETAMOL INDUCED

Answer 8

pH (arterial) < 7.3
regardless of encephalopathy

or

all 3:

1. INR > 6.5 (PT >100s)
2. Cr >300umol
3. Grade III/IV encephalopathy

Question 9

King’s criteria - liver transplant

NON PARACETAMOL INDUCED

Answer 9

INR > 6.3
regardless of encephalopathy

or

3 of 5:

1. INR > 3.5 (PT >50s)
2. BR >300umol
3. >7 days jaundice to encephalopathy
4. Age <10 or >40
5. Aetiology - drug induced rxn OR non A/B Hepatitis

Question 10

CRC screening - gen popn
- high risk (definition)

Answer 10

FOBT Q2y 50-74y (colonoscopy if +ve)

High risk:

3x FDR (or can include SDR theres a <55y, & either side of family)

>35yo: FOBT
>45yo: Colonoscopy 5yr until 74 (or CT-colonography)

(add 5yrs on for intermediate risk: FDR<55 or 2x FDR (or 3 FDR/SDR)

+ Aspirin >100mg from 45y unless C/I

Question 11

Barretts Rx

Answer 11

No dysplasia - ongoing surveillance, longer length = more freq

Low grade dysplasia: if confirmed x2 6m apart: RFA decreases progression

High grade dysplasia: remove (endoscopic resection, oesophagectomy)
Then Rx rest of Barrets (RFA)

+ High PPI (es 40mg BD) + aspirin

Annual gastroscopy for >5yrs

Question 12

Endoscopy of ulcer - mgmt options

Answer 12

Combo Rx: adrenaline injection (1:100,000) +

• endoscopic clip (OR)
• Cauterize

Salvage Rx - Disruptive technology

• OTSC (100% haemostasis)
• spray (alongside clip)

Last resort:

• TAE (transcath embolization)
• Surgery

Question 13

Biologic that worsens IBD

Answer 13

IL -17

• Secukinumab
• Ixekinumab

Question 14

IBD Biologic good in joints

Answer 14

Anti TNF

• I-CAGE
• Infliximab
• Certolizumab
• Adalimumab
• Golimumab
• Etanercept