MED: Gastroenterology Flashcards

Question

What malignancies are associated with coeliac disease?

Answer 1

**Enteropathy-associated T-cell lymphoma (EATL):** - A rare and aggressive type of non-Hodgkin lymphoma arising from intraepithelial lymphocytes in the small intestine - EATL has a poor prognosis and is often associated with refractory coeliac disease type II. **Small bowel adenocarcinoma:** - The risk of small bowel adenocarcinoma is also increased in coeliac disease, although the overall incidence remains low.

Answer 2

- Peripheral arthritis - large joints e.g. knees, ankles, and wrists, non-destructive, non-deforming - Axial arthritis - ankylosing spondylitis and sacroiliitis, can cause low back pain and morning stiffness. - Erythema nodosum - painful, raised, erythematous nodules on the lower extremities. - Pyoderma gangrenosum - rapidly progressing, painful ulcers with undermined, violaceous borders, often involving the lower extremities or peristomal skin. - Uveitis - eye pain, photophobia, and blurred vision. - Episcleritis - eye redness and mild pain - Scleritis - more painful and can lead to vision loss if untreated. - Primary sclerosing cholangitis - Cholelithiasis and fatty liver disease - Anaemia, vitamin B12 and folate malabsorption. - Increased risk for venous and arterial thromboembolic events, including DVT, PE, and stroke

Answer 3

**Blood tests:** - FBC, CRP, ESR, LFTs, serum albumin, and iron studies, vitamin B12 and folate levels - Info about inflammation, anaemia, and nutritional status **Stool tests:** - Stool cultures, ova and parasite examination, and faecal calprotectin - Can help differentiate between IBD and infectious or non-inflammatory causes of diarrhoea. **Colonoscopy and biopsy:** - Findings include aphthous ulcers, cobblestoning, non-caseating epithelioid cell granulomata, discontinuous/patchy inflammation with skip lesions **Capsule endoscopy:** - In cases where traditional endoscopy is inconclusive, video capsule endoscopy can be utilized to visualize the small bowel and detect areas of inflammation not reachable by colonoscopy or upper endoscopy. **CT/MRI:** - MRI preferred in CD due to its lack of ionizing radiation and superior soft tissue contrast. **Ultrasound:** - May be used as a non-invasive imaging modality, particularly for assessing disease activity, complications, or response to therapy. **Histology:** - Non-caseating granulomas, transmural inflammation, lymphoid aggregates, crypt architectural abnormalities, and cryptitis or crypt abscesses

Answer 4

**Conservative:** - Education on features and flare ups - Support - www.crohnsandcolitis.org.uk - Stop smoking - Careful with NSAIDs and COCP (increased risk of relapse) **Inducing remission:** - First line = glucocorticoids e.g. pred (PO, topical or IV) - Enteral feeding with an elemental diet may be used in addition / instead of other measures, particularly if concern regarding steroid SEs (e.g. young children) - Second line = 5-ASA drugs (e.g. mesalazine) - Azathioprine or mercaptopurine may be used as an add-on medication but not as monotherapy - Methotrexate is an alternative to azathioprine - Infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on azathioprine or methotrexate - Metronidazole often used for isolated peri-anal disease **Maintaining remission:** - First line = azathioprine or mercaptopurine *(cannot be given with TPMT mutation, cannot have live vaccines, must have pneumococcal and influenza vaccines)* - Second line = methotrexate **Surgery:** - For complications (obstruction, fistula, abscess, severe localised disease unresponsive to treatment)

Answer 5

- Strictures - managed with endoscopic balloon dilation, stricturoplasty, or bowel resection - Fistulas - can cause abscess formation, recurrent infections, and malabsorption. Management includes medical therapy, endoscopic or surgical interventions - Abscesses - managed with antibiotics and percutaneous or surgical drainage. - Perianal disease - fissures, abscesses, and fistulas. Treatment may involve medical therapy, surgical intervention - Malabsorption and nutritional deficiencies - iron, vitamin B12, and fat-soluble vitamins, resulting in anemia, osteoporosis, and other nutritional deficiencies. - Colorectal cancer - regular surveillance colonoscopy with biopsies is recommended for early detection and management.

Answer 6

Whilst isolated symptoms do not require investigation, patients fitting any of the following criteria should be referred for oesophago-gastroduodenoscopy (OGD): - Age >55 years - Symptoms >4 weeks - Dysphagia - Persistent symptoms despite treatment - Relapsing symptoms - Weight loss - Excessive vomiting - GI bleeding *Other tests include:* - A barium swallow test should be performed to rule out hiatus hernia. - A 24 hour oesophageal PH monitoring may be needed to distinguish GORD from other causes. - Patients showing systemic symptoms, or who have lesions shown on OGD, should have a FBC to rule out anaemia.

Answer 7

**Lifestyle changes:** - Reduce weight - Stop smoking - Decrease alcohol intake - Raise head at night (sleep propped up) - Avoid hot drinks, alcohol and eating within 3hrs of going to sleep - Avoid nitrates, anticholinergics, tricyclic antidepressants, NSAIDs, K+ salts, alendronate **Drugs:** - Patient without any red flag symptoms should be given a 4 week full-does PPI therapy course. - If symptoms return, the dosage of PPI should be stepped down to the lowest level that still relieves symptoms. - Offer H2RA therapy if there is inadequate response to a PPI **Consider referring anyone to a specialist who:** - Has unexplained GORD symptoms not responding to treatment. - Is considering surgery. **Surgery:** - Laparoscopic fundoplication, also known as a Nissen fundoplication, is the surgical procedure of choice. - It is indicated for patients who have a confirmed GORD diagnosis via endoscopy, respond to PPI therapy, but do not wish to continue it long term / cannot tolerate acid suppression therapy.

Answer 8

- Oesophagitis - Strictures - Barrett's oesophagus - Oesophageal adenocarcinoma - Respiratory complications - chronic cough, asthma exacerbations, laryngitis, and recurrent pneumonia.

Answer 9

An iron storage disorder in which iron depositions in multiple organs (such as the liver, skin, pituitary, heart and pancreas) leading to oxidative damage

Answer 10

**Primary (hereditary):** - Autosomal recessive mutations to the haemochromatosis (HFE) gene on chromosome 6. **Secondary (acquired):** - Frequent blood transfusions - each new transfusion introduces new iron which is recycled and stored - Iron supplementation - over-supplementing, particularly with concurrent vitamin C. - Diseases of erythropoiesis - ineffective erythropoiesis leads to iron accumulation

Answer 11

- Asymptomatic - Non-specific signs of iron overload (fatigue, arthralgias, impotence) - Signs of organ damage, such as diabetes - Joint symptoms are usually a non-inflammatory osteoarthritis presentation in the metacarpophalangeal and proximal interphalangeal joints, but may be present in larger joints such as the hip and shoulder. - 'classic triad' of cirrhosis, diabetes mellitus and bronze pigmentation is rarely the initial presentation. - Pigmentation will initially present as skin bronzing but if it has progressed then may be grey or brown. - Pigmentation most commonly occurs on the face and neck, extensor surfaces of the forearms, dorsum of the hands, lower legs, genitals, and in old scars.

Answer 12

**Bloods:** - Serum ferritin - raised - Transferrin saturation - raised - LFTs - AST and ALT raised - FBC - normal **Molecular Testing:** - HFE gene mutation **Liver biopsy:** - If clinical evidence of liver involvement and/or serum ferritin >2247pmol/L - To estimate hepatocyte iron content and assess extent of fibrosis or cirrhosis.

Answer 13

**Patient advice:** - Avoid iron and iron-containing supplements - Avoid vitamin C supplements (increases the bioavailability of iron for enteric absorption) - Limit or avoid alcohol - Consider hepatitis A and B vaccinations if no previous encounter. **Stage 0: Normal transferrin saturation and ferritin with no clinical symptoms:** - Monitoring iron labs and symptoms every 3 years **Stage 1: Transferrin saturation > 45%, normal ferritin, no clinical symptoms:** - Monitoring iron labs and symptoms every 1 year **Stage 2, 3, 4: Transferrin saturation > 45%, raised ferritin and/or clinical symptoms:** - Phlebotomy // venesection - blood removed to stimulate haematopoiesis, thereby utilising some of the excess iron for haem synthesis - Iron chelation therapy - if phlebotomy contraindicated (e.g. anaemia, cardiac disease or venous access issues). Both oral agents (Deferasirox) and parenteral agents (Desferrioxamine) are available **Liver transplant:** - Patients with end-stage cirrhotic liver disease

Answer 14

- Liver fibrosis / cirrhosis - Hepatocellular carcinoma - Diabetes - Arrhythmia due to iron deposition in conduction pathway - Cardiomyopathy: either dilated or dilated-restrictive - Chronic congestive heart failure - Hypogonadism

Answer 15

- IBS with predominant constipation (IBS-C) - IBS with predominant diarrhoea (IBS-D) - IBS with mixed bowel habits (IBS-M) - IBS unclassified (IBS-U)

Answer 16

Suggested primary care investigations are: - full blood count - ESR/CRP - coeliac disease screen (tissue transglutaminase antibodies)

Answer 17

**Rome IV criteria:** *A patient must have recurrent abdominal pain for at least 1 day per week during the previous 3 months, and this pain should be associated with at least 2 of 3 three criteria:* - Pain related to defecation: The pain is either relieved or worsened by bowel movements. - Change in frequency of stool: The patient experiences an increase or decrease in the number of bowel movements per day. - Change in form (appearance) of stool: The stool becomes harder or softer, or there is a change in its consistency. **These symptoms must be present for the last 3 months, with symptom onset at least 6 months before diagnosis.**

Answer 18

**First-line pharmacological treatment:** - pain: antispasmodic agents - constipation: laxatives but avoid lactulose - diarrhoea: loperamide **Second-line pharmacological treatment:** - low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) **Psychological interventions:** - If symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS), consider referring for CBT, hypnotherapy or psychological therapy **General dietary advice:** - have regular meals and take time to eat - avoid missing meals or leaving long gaps between eating - drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas - restrict tea and coffee to 3 cups per day - reduce intake of alcohol and fizzy drinks - consider limiting intake of high-fibre food - reduce intake of 'resistant starch' often found in processed foods - limit fresh fruit to 3 portions per day - for diarrhoea, avoid sorbitol - for wind and bloating consider increasing intake of oats and linseeds

Answer 19

An important cause of acute liver failure and occurs as a result of impaired blood flow to the hepatic parenchyma

Answer 20

**Mostly no cause identified** *Any condition resulting in a shock state may precipitate ischaemic hepatitis:* - Heart failure - Septic shock - Hypovolemic shock - Respiratory failure *Other causes include:* - Portal vein thrombosis - Budd-Chiari syndrome - Sickle cell crisis - Hepatic artery thrombosis

Answer 21

- Patients are generally older and often suffer from chronic cardiac, vascular, pulmonary, or hepatic comorbidities, which may be complicated by shock. - The patient will present acutely unwell - Symptoms are generally non specific and include abdominal pain, nausea, and vomiting. - The clinical picture may be complicated by signs and symptoms of shock

Answer 22

**Liver enzymes:** - Transaminases in the thousands, rising to these levels within 24 hours, falling to half within 72 hours, and normalising within 2 weeks - ALP will not typically show such a great increase, but may go up to twice the upper limit of normal - LDH levels will also rise dramatically, often the ALT/LDH ratio will be less than 1 - Bilirubin levels start to rise as aminotransferase levels decline, and may go up to 4 times normal **Viral serology:** - To rule out acute viral hepatitis, typically hepatitis A, B or E **Toxicology:** - Toxin mediated hepatic damage is another cause of transaminases in the thousands, especially paracetamol overdose **Serum creatinine:** - Levels may be elevated as a result of hypotensive injury to the kidneys and may support a diagnosis of ischaemic hepatitis. **Other tests:** - Anti-smooth muscle antibody for autoimmune hepatitis - Right upper quadrant USS with doppler to assess for portal vein thrombosis, Budd-Chiari syndrome, or congestive hepatomegaly - If the diagnosis remains unclear, a liver biopsy may be performed

Answer 23

The mainstay of management is resolution of the precipitant of the hepatic ischaemia. Prompt resolution of any haemodynamic instability by providing fluid resuscitation, restoring cardiac output, and treating sepsis where appropriate is essential as delays in management are lethal. Admission into an intensive treatment unit with close ongoing monitoring is often necessary.

Answer 24

- Alcoholism - Hiatal hernia - Bulimia nervosa - Hyperemesis gravidarum - GORD

Answer 25

- Severe vomiting - Coughing - Blunt abdominal trauma - Strained defecation - Oesophageal instrumentation

Answer 26

**Initial laboratory investigation:** - FBC, including haematocrit to assess severity of initial bleeding episode - Coagulation studies and platelet counts to detect coagulopathies and thrombocytopenias (routine platelet count, PT, and APTT) - typically normal - LFTs to rule out liver disease - Renal function, urea, creatinine, and electrolyte levels (to guide intravenous fluid therapy) - urea may be high in a patient with ongoing bleeding - Cross-matching/ blood grouping and antibody screen (potential blood transfusion) **Other tests to consider:** - ECG, troponin, creatinine kinase (should be considered in patients with a history of CAD, symptoms of cardiac ischaemia, massive bleeding, or multiple comorbidities) **Diagnosis of aetiology:** - Upper endoscopy: It should be performed in all patients after stabilisation. It is the test of choice for diagnosis and treatment and should be done within 24 hours. - Findings include single and longitudinal tear that typically appears as a red longitudinal break in the mucosa.

Answer 27

- Establishment of a good central or peripheral IV access (usually 2 lines) along with fluid replacement. - Packed RBCs infusion indicated if the Hb <8 gm/dl or if patient presents with signs of shock or severe bleeding. - Nasogastric decompression using NG tube could be performed, especially in patients with ongoing bleeding or those suspected of having concomitant upper GI bleeding sources. - Electrolyte imbalance correction - Coagulation factors need to be optimised before proceeding with endoscopy.

Answer 28

**Pharmacological treatment:** - PPIs or H2 antagonists = first-line, given to all waiting for endoscopy / have clinically significant upper GI bleeding - Anti-emetics: considered if N/V, which may be a cause / aggravating factor - Somatostatin and its long-acting synthetic analogue octreotide: not routinely recommended for patients with non-variceal upper GI bleeding; however, they may be considered as an adjunct treatment to PPIs and endoscopy until more definitive diagnostic tests and therapeutic procedures are implemented **Endoscopic treatment:** - Oesophagogastroscopy is investigation of choice in all cases of upper GI bleeding. It is indicated after medical treatment is given in case of actively bleeding (spurting or oozing haemorrhage) MWT. - Endoscopic band ligation (with or without epinephrine injection) - Haemoclip placement is an effective method to control actively bleeding lesions. - Thermocoagulation therapy **Surgery:** - Surgery usually reserved for situations where endoscopic haemostasis of bleeding has failed or transmural oesophageal perforation has occurred

Answer 29

Glasgow-Blatchford bleeding score Clinical Rockall score >> Used to stratify patients as low or high risk. Patients are classified according to who should have an endoscopic evaluation, who may be discharged with minimal risk of complications, and who should be admitted to hospital for further observation.

Answer 30

a chronic inflammatory condition of the gut

Answer 31

smoking drugs: NSAIDs, PPIs and SSRIs

Answer 32

- Diarrhoea - chronic, watery, non-bloody diarrhoea that can persist for weeks to months or even years if left untreated - Abdominal pain - intermittent abdominal pain or cramping that can be mild to moderate in intensity. - Faecal urgency and incontinence - Bloating and flatulence - Weight loss - consequence of malabsorption or decreased oral intake due to fear of exacerbating diarrhoea. - Nocturnal diarrhoea *Extraintestinal manifestations:* - Joint pain - Erythema nodosum, pyoderma gangrenosum - Increased prevalence of concomitant autoimmune disorders including celiac disease, thyroid dysfunction, rheumatoid arthritis, and type 1 diabetes mellitus

Answer 33

**Initial investigations for chronic diarrhoea:** - Blood tests: FBC, CRP, TFTs and coeliac serology - Stool samples: to exclude infective causes and for faecal calprotectin levels - If malignancy is suspected then a 2-week wait referral should be considered **Colonoscopy and biopsy:** *Only diagnosed by histology examination* - Lymphocytic colitis: increased number of intraepithelial and lamina propria lymphocytes (>20 per 100 cells) - Collagenous colitis: as above, along with a thickened collagenous band in the subepithelial layer (>10μm)

Answer 34

**Lifestyle factors:** - Stopping smoking - Stopping medications such as NSAIDs, PPIs and SSRIs where possible - Decreasing caffeine intake - Decreasing dairy intake (in patients with lactose intolerance) - Decreasing alcohol consumption **Pharmacological interventions:** *Considered if lifestyle factors are unsuccessful in managing symptoms* - Mild cases = anti-diarrhoeal drugs such as loperamide may be effective in achieving symptomatic relief - Budesonide = effective in the induction and maintenance of remission. A typical dosage is 9mg daily for 8 weeks and the medication then stopped to assess response. If symptoms recur, then re-initiation of budesonide may be necessary. - No response to budesonide = immunomodulators (e.g. azathioprine) and biologics (e.g. anti-TNF-alpha drugs).

Answer 35

- H pylori is associated with the majority of peptic ulcers - Drugs - NSAIDs, SSRIs, corticosteroids, bisphosphonates - Zollinger-Ellison syndrome - rare cause characterised by excessive levels of gastrin, usually from a gastrin secreting tumour

Answer 36

- epigastric pain - nausea - duodenal ulcers - epigastric pain when hungry, relieved by eating - gastric ulcers - epigastric pain worsened by eating

Answer 37

Helicobacter pylori should be tested for either a Urea breath test or stool antigen test should be used first-line

Answer 38

**H pylori negative:** - PPIs until the ulcer is healed **H pylori positive:** - Eradication therapy

Answer 39

Sjogren's syndrome (seen in up to 80% of patients) Rheumatoid arthritis Systemic sclerosis Thyroid disease

Answer 40

- Early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus - Cholestatic jaundice - Hyperpigmentation, especially over pressure points - Right upper quadrant pain - Xanthelasmas, xanthomata - Also: clubbing, hepatosplenomegaly - Late: may progress to liver failure

Answer 41

- Anti-mitochondrial antibodies (AMA) M2 subtype - Smooth muscle antibodies in 30% of patients - Raised serum IgM

Answer 42

First line = Ursodeoxycholic acid - Pruritus - cholestyramine - Fat-soluble vitamin supplementation - Liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) - recurrence in graft can occur but is not usually a problem

Answer 43

- Cirrhosis - Osteomalacia and osteoporosis - Significantly increased risk of hepatocellular carcinoma

Answer 44

- ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC - Crohn's (much less common association than UC) - HIV

Answer 45

- Often asymptomatic in its early stages - fatigue - pruritus - right upper quadrant pain - jaundice - As the disease progresses, patients may develop complications related to cirrhosis, portal hypertension, and cholangiocarcinoma.

Answer 46

The development of cholangiocarcinoma is a significant concern in PSC, with a lifetime risk of 5-15% +increased risk of colorectal cancer

Answer 47

**Bloods:** - elevated ALP and GGT - p-ANCA may be positive **ERCP or MRCP:** - standard diagnostic investigations - showing multiple biliary strictures giving a 'beaded' appearance There is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often described as 'onion skin'

Answer 48

There is no curative treatment for PSC, and management focuses on symptom relief, prevention, and management of complications. - Ursodeoxycholic acid (UDCA) - Endoscopic interventions, such as balloon dilatation and stenting, can be employed to manage dominant strictures. - Liver transplantation is the only definitive treatment for end-stage liver disease due to PSC.

Answer 49

a disorder characterised by excessive amounts of bacteria in the small bowel resulting in gastrointestinal symptoms.

Answer 50

- neonates with congenital gastrointestinal abnormalities - scleroderma - diabetes mellitus

Answer 51

- chronic diarrhoea - bloating, flatulence - abdominal pain

Answer 52

- Hydrogen breath test - Small bowel aspiration and culture - used less often as invasive and results are often difficult to reproduce *Clinicians may sometimes give a course of antibiotics as a diagnostic trial*

Answer 53

- 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.

Answer 54

*Based on the extent and severity of colonic involvement:* - Ulcerative proctitis: Inflammation is limited to the rectum. - Proctosigmoiditis: Involves the rectum and sigmoid colon. - Left-sided colitis: Extends from the rectum to the splenic flexure. - Pancolitis: Affects the entire colon.

Answer 55

- Toxic megacolon - acute and severe colonic dilation, associated with systemic toxicity and increased risk of perforation. - Perforation - full-thickness colonic injury, leading to peritonitis and sepsis. - Haemorrhage - severe blood loss, requiring transfusion or surgical intervention. - Strictures - chronic inflammation and fibrosis may lead to bowel obstruction. - Colorectal cancer - long-standing UC increases the risk of colorectal cancer, necessitating regular surveillance colonoscopy.

Answer 56

- Arthritis (peripheral or axial) - Ankylosing spondylitis - Osteoporosis. - Erythema nodosum, pyoderma gangrenosum, and aphthous stomatitis. - Uveitis, episcleritis, and scleritis. - PSC, autoimmune hepatitis, and cholelithiasis. - Anaemia, thrombocytosis, and increased risk of VTE

Answer 57

**Bloods:** - FBC *(anaemia, leukocytosis)* - CRP/ESR - CMP (including LFTs) **Stool sample:** - Test for c. Dif / other infective pathogens - Faecal calprotectin *(raised)* **Abdominal X-Ray:** - Dilated loops with air-fluid level secondary to ileus - Free air = perforation - Toxic megacolon = transverse colon dilated to ≥6cm in diameter **Flexible sigmoidoscopy / Colonoscopy & Biopsy:** GOLD STANDARD FOR DX - Continuous colitis extending from rectum proximally - Superficial inflammation (not beyond submucosa) - Loss of vascular marking - Diffuse erythema - Ulceration and psuedopolyps - Crypt abscesses - Depletion of goblet cells and mucin **Barium enema:** - Loss of haustrations - Superficial ulceration, 'pseudopolyps' - Long standing disease = colon is narrow and short (drainpipe colon)

Answer 58

**Inducing remission:** *(Topical > oral if no improvement after 4w)* - 1st line: Topical/Oral aminosalicylates e.g. mesalazine - 2nd line: Topical/Oral CS e.g. pred, beclomethasone - 3rd line (steroid resistant): Oral tacrolimus - 4th line: Biological agents e.g. infliximab - 5th line (resistant disease): Surgery (colectomy with ileostomy or ileojejunal pouch) **Maintaining remission:** - ASA (topical, topical + oral, oral) **Surgical:** - Surgery may be indicated for patients with UC who have complications, such as toxic megacolon, perforation, or severe bleeding, or who fail to respond to medical therapy.

Answer 59

- mild: < 4 stools/day, only a small amount of blood - moderate: 4-6 stools/day, varying amounts of blood, no systemic upset - severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

Answer 60

**EMERGENCY** > Treated in hospital with MDT approach - 1st line = IV corticosteroids - 2nd line = IV ciclosporin (CS contraindicated or ineffective) - 3rd line = Surgery

Answer 61

Clindamycin

Answer 62

- diarrhoea - abdominal pain - a raised WCC is characteristic - if severe toxic megacolon may develop

Answer 63

- Detecting C. difficile toxin (CDT) in the stool - C. difficile antigen positivity only shows exposure to the bacteria, rather than current infection

Answer 64

**First episode:** - First-line = oral vancomycin for 10 days - Second-line = oral fidaxomicin - Third-line = oral vancomycin +/- IV metronidazole **Recurrent episode:** - Within 12 weeks of symptom resolution = oral fidaxomicin - After 12 weeks of symptom resolution = oral vancomycin OR fidaxomicin **Life-threatening:** - Oral vancomycin AND IV metronidazole - Specialist advice - surgery may be considered

Answer 65

Hypophosphataemia, hypokalaemia and hypomagnesaemia

Answer 66

Pneumococcal

Answer 67

The Malnutrition Universal Screening Tool (MUST)

Answer 68

Triad of: - dysphagia (secondary to oesophageal webs) - glossitis - iron-deficiency anaemia Treatment includes iron supplementation and dilation of the webs

Answer 69

Giardia lamblia Giardia causes fat malabsorption, therefore greasy stool can occur. It is resistant to chlorination, hence risk of transfer in swimming pools.

Answer 70

Right heart failure

Answer 71

Can cause hypogonadotrophic hypogonadism Low FSH, LH, oestrogen, testosterone, progesterone

Answer 72

autosomal recessive disorder characterised by excessive copper deposition in the tissues

Answer 73

Wilson's disease

Answer 74

**Liver:** - Hepatitis, cirrhosis **Neurological:** - Basal ganglia degeneration - Speech, behavioural and psychiatric problems are often the first manifestations - Also: asterixis, chorea, dementia, parkinsonism **Also:** - Kayser-Fleischer rings - green-brown rings in the periphery of the iris - Renal tubular acidosis (esp. Fanconi syndrome) - Haemolysis - Blue nails

Answer 75

- Slit lamp examination for Kayser-Fleischer rings - Reduced serum caeruloplasmin - Reduced total serum copper - Increased free (non-ceruloplasmin-bound) serum copper - Increased 24hr urinary copper excretion >>Diagnosis is confirmed by genetic analysis of the ATP7B gene

Answer 76

- Penicillamine (chelates copper) = traditional first-line treatment - Trientine hydrochloride = alternative chelating agent which may become first-line in the future

Answer 77

non-cardioselective B-blocker (NSBB) e.g. propranolol

Answer 78

**ABC:** - Patients should be resuscitated prior to endoscopy - Blood transfusion may be needed **Correct clotting:** - FFP, vitamin K, platelet transfusions may be required **Vasoactive agents:** - Terlipressin to stop active bleeding - Octreotide may also be used **Prophylactic IV antibiotics:** - Have been shown to reduce mortality in patients with liver cirrhosis - Quinolones are typically used *Both terlipressin and antibiotics should be given before endoscopy in patients with suspected variceal haemorrhage* **Endoscopy:** - Endoscopic variceal band ligation - Once bleeding controlled **If uncontrolled haemorrhage:** - Sengstaken-Blakemore tube **Transjugular Intrahepatic Portosystemic Shunt (TIPSS):** - If above measures fail - Connects the hepatic vein to the portal vein - Exacerbation of hepatic encephalopathy is a common complication

Answer 79

first-line laxative = bulk-forming laxative such as ispaghula Second-line = osmotic laxative, such as a macrogol

Answer 80

**1. High-dose PPI** **2. Endoscopic surveillance with biopsies** - Metaplasia (but not dysplasia) = every 3-5 years - Dysplasia of any grade = endoscopic intervention is offered **3. Endoscopic intervention** - Radiofrequency ablation: preferred first-line treatment, particularly for low-grade dysplasia - Endoscopic mucosal resection

Answer 81

squamous cell carcinoma of the oesophagus

Answer 82

topical (rectal) aminosalicylates e.g. mesalazine suppositories if remission is not achieved within 4 weeks, add an oral aminosalicylate if remission still not achieved add topical or oral corticosteroid

Answer 83

lactulose as it can increase gas production, thereby making symptoms worse in some patients.

Answer 84

clopidogrel

Answer 85

metoclopramide

Answer 86

↑ Transferrin saturation ↑ serum ferritin ↓ total iron binding capacity

Answer 87

Gilbert's syndrome

Answer 88

COCP antibiotics such as co-amoxiclav, phenothiazines, sulphonylureas, fibrates and anabolic steroids

Answer 89

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

Answer 90

COLON Also endometrial

Answer 91

- Sporadic (95%) - Hereditary non-polyposis colorectal carcinoma (HNPCC, 5%) - Familial adenomatous polyposis (FAP, <1%)

Answer 92

duodenal tumours

Answer 93

A variant of FAP Also features osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin

Answer 94

An autoimmune disorder affecting the gastric mucosa that results in vitamin B12 deficiency.

Answer 95

antibodies to intrinsic factor +/- gastric parietal cells

Answer 96

- Anaemia features - Peripheral neuropathy - 'pins and needles', numbness - Subacute combined degeneration of the spinal cord - progressive weakness, ataxia and paresthesias that may progress to spasticity and paraplegia - Neuropsychiatric features - memory loss, poor concentration, confusion, depression, irritabiltiy other features - Mild jaundice - combined with pallor results in a 'lemon tinge' - Glossitis → sore tongue

Answer 97

- Macrocytic anaemia - Hypersegmented polymorphs on blood film - Low WCC and platelets may also be seen - Vitamin B12 level of >= 200 nh/L is generally considered to be normal - Anti intrinsic factor antibodies - Anti gastric parietal cell antibodies - Schilling test is no longer routinely done (radiolabelled B12 given on two occasions, firstly on its own, secondly with oral IF. Urine B12 levels are then measured)

Answer 98

- Vitamin B12 replacement - usually given IM - Folic acid supplementation may also be required

Answer 99

increased risk of gastric cancer

Answer 100

**Mild:** - Normal WCC **Moderate:** - ↑ WCC (<15) - Typically 3-5 loose stools /d **Severe:** - ↑ WCC (>15) - or an acutely ↑ creatinine (>50% above baseline) - or a temperature > 38.5°C - or evidence of severe colitis (abdominal or radiological signs) **Life-threatening:** - Hypotension - Partial or complete ileus - Toxic megacolon, or CT evidence of severe disease

Answer 101

oral azathioprine or oral mercaptopurine

Answer 102

The Mackler triad for Boerhaave syndrome

Answer 103

Spontaneous perforation of the esophagus that results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure (eg, severe straining or vomiting)

Answer 104

bile acid sequestrants e.g. cholestyramine

Answer 105

What can be a trigger for liver decompensation in cirrhotic patients?

Answer 106

A type of functional kidney impairment that occurs in patients with advanced liver disease. The key features include ascites, low urine output, and a significant increase in serum creatinine

Answer 107

- Vasopressin analogues, for example terlipressin, - Volume expansion with 20% albumin - Transjugular intrahepatic portosystemic shunt

Answer 108

bile duct dilatation

Answer 109

urea breath test

Answer 110

- combined oral contraceptive pill - antibiotics: flucloxacillin, co-amoxiclav, erythromycin* - anabolic steroids, testosterones - phenothiazines: chlorpromazine, prochlorperazine - sulphonylureas - fibrates - rare reported causes: nifedipine

Answer 111

Unintentional weight loss greater than 10% within the last 3-6 months

Answer 112

PPI + clarithromycin + amoxicillin, or PPI + clarithromycin + metronidazole

Answer 113

A draining seton

Answer 114

- dysphagia of BOTH liquids and solids - typically variation in severity of symptoms - heartburn - regurgitation of food - may lead to cough, aspiration pneumonia etc - malignant change in small number of patients

Answer 115

**oesophageal manometry:** - excessive LOS tone which doesn't relax on swallowing - considered the most important diagnostic test **barium swallow:** - shows grossly expanded oesophagus, fluid level - 'bird's beak' appearance **chest x-ray:** - wide mediastinum - fluid level

Answer 116

**First line = pneumatic (balloon) dilation** - less invasive and quicker recovery time than surgery - patients should be a low surgical risk as surgery may be required if complications occur **Second line = surgical intervention with a Heller cardiomyotomy** - if recurrent or persistent symptoms **Alternatives:** - intra-sphincteric injection of botulinum toxin is sometimes used in patients who are a high surgical risk - drug therapy (e.g. nitrates, CCB) has a role but is limited by side-effects

Answer 117

Idarucizumab