MRCP Gastro Flashcards
1
Q
What is pernicious anaemia
A
anti parietal and anti IF antibodies
B12 deficiency (absorbed in terminal ileum)
2
Q
Autoimmune hepatitis 2 types and autoantibodies
A
type 1: anti smooth muscle
type 2: anti-LKM
IgG
3
Q
Treatment for CLD encephalopathy
A
Encephalopathy:
lactulose,
rifaximin (modify gut microbiome)
4
Q
Treatment for CLD ascites
A
Ascites: drain, diuretics- spiro first line to prevent reaccumulation (second line furosemide), albumin (HAS), TIPS (in refractory ascites)
5
Q
What is whipple’s disease?
A
Tropheryma whippelii infection
Present:
abdo pain,
arthritis,
steathorrhoea
Mx: co trimox
jejunal biopsy: deposition of macrophages containing Periodic acid-Schi
6
Q
Cirrhosis surveillance for varices and HCC
A
3 monthly OGD
6 monthly USS (+AFP if hepB)
7
Q
What is Haemochromatosis?
AKA bronze diabetes
A
IRON deposit in pancreas
tanned, diabetes, cirrhosis
loss of hair, hypogonadism
8
Q
Investigation for hepatic encephalopathy
A
Serum Ammonia Level
9
Q
What tests suggest haemochromatosis?
A
Transferrin saturation >60%
Ferritin >500
TIBC <20
Iron >30
HFE gene mutation (C282Y mutation)
decreased plasma hepcidin
10
Q
What is hepcidin
A
regulatory of iron in body
- inhibitrs intestinal absorption and drives into cells
11
Q
What is a common bowel symptoms following Giardia infection?
A
Lactose intolerance for few week
12
Q
What is giardiasis?
A
Traveller’s diarrhoea
Protozoon Giardia lamblia
Faeco-oral
Mx: single dose tinidazole OR one week metronidazole
13
Q
Differentiate between acute and chronic bowel ischaemia
A
Acute- acute abdominal pain, guarding
Chronic- pain only after meals, may not have acute abdomen due to adequate collateral circulations
14
Q
What other conditions are associated with rise in amylase (apart from pancreatitis)
A
acute mesenteric ischaemia
15
Q
Differentiate between right sided and left sided colorectal cancer
A
Right- NO altered bowel habit/rectal bleed
- less likely to present with bowel obstruction as food is still liquid chyme
Left- altered bowel habit/rectal bleed
- solid faeces
16
Q
What is the investigation of choice for iron deficiency microcytic anaemia?
A
Colonoscopy +/- OGD
17
Q
What is the abx choice for SBP?
A
IV ceftriaxone
18
Q
What is SBP and related pathogen?
A
Infected ascites
E.coli/Enterococcus/Streptococcus
19
Q
What is glascow score for pancreatitis?
A
pO2 <8 (hypoxic)
Age >55
Neutrophil >15
Calcium <2
Renal urea >16
Enzyme ALT >200, LDH >600
Albumin <32
Sugar >10 (hypergly)
Significant hypocalcaemia=severe
20
Q
What type of bilirubin confirms Gilbert’s?
A
Unconjugated bilirubin (high)
21
Q
What is Gilbert’s syndrome?
A
Reduced UDP-glucoronyltransferase activity
- enzyme that conjugates in liver
22
Q
Outline the most sensitive investigation test and confirming eradication for H.pyelori?
A
13C urea breath test is most sensitive
should have 2 week wash out of PPI before test
drink 13C urea->h.pyelori urease will convert 13c urea to ammonia and 13c- CO2
23
Q
What is the treatment for h.pyelori
A
2 abx for 2 weeks
+ PPI for 1 week
24
Q
When should you consider OGD 2WW?
A
> 50 years
anaemia/weight loss/anorexia
melaena/haematemesis/dysphagia
ALARM sx
25
Why does cirrhosis cause gynacomastia?
XS oestrogen
26
What is pseudomembranous colitis?
C.diff colitis
27
What is first line treatment for C.diff colitis?
Vancomycin
28
How does pharyngeal pouch present?
Intermittent swallowing difficulty
Regurgitation
Halitosis
29
What causes gastrin secretion and what inhibits?
amino acid secretes
pH <3 inhibits
30
What extraintestinal features are seen in UC?
Episcleritis (Red painful eye)
Pyoderma gangrenosum
Erythema nodosum
31
What is UC and where does it affect?
Starts from rectum -> ileocaecal valve
(terminal ileitis)
Continuous
Crypt abscess on biopsy
pseudocyst
32
What is the treatment of choise in UC that is not controlled with sulfasalazine (mesalazine) or steroids?
Thiopurine: azathioprine or 6mercaptopurine
33
What is characteristic symptom of IBS?
Abdominal discomfort eased by bowel opening
| Mx: soluble fibre
34
What is first line endoscopic thearpy for oesphageal varice?
Band ligation
35
Which chemotherapy is orally administered for advanced colorectal cancer?
Capecitabine
36
Which chemotherapy is intravenously (central line) administered for advanced colorectal cancer?
5 FU
| fluorouracil
37
What is Gardner syndrome?
AD-
APC gene
Chromosome 5q21
multiple polyps (adenoma)
soft tissue tumours (lipoma)
| Mx: total colectomy
38
What is peutz-jeghers syndrome?
Autosomal dominant
mutation in STK11 gene
Chr 19
polyposis
peri-oral pigment
39
Why is lactulose given in decompesanted liver disease and hepatic encephalopathy?
reduces systemic absorption of ammonia
40
Symptoms of carcinoid syndrome?
diarrhoea
flushing
wheeze
41
Mangement of Whipple's
2 weeks ceftriaxone/penicillin
then 1 year of co-trimoxazole
42
Which cancer is chronic hep B associated with?
HCC
43
What is UC associated with?
PSC
inflammation and fibrosis of bile duce
44
Which auto-antibody is PBC associated with?
anti-mitochondrial antibody
Note:
IgM
Middle aged men
AMA
| middle aged women, associated with autoimmune disease
45
Which condition presents with auto-immune features, macrocytic anaemia?
Pernicious anaemia
46
SAAG equation
SAAG = Serum Albumin Concentration - Ascites Albumin Concentration
47
Transudative ascites
11 g/L or More
Generally transudative causes
Cirrhosis
Heart Failure
Renal Failure
48
Exudative ascites
11 g/L or more (extra)
Generally exudative causes (because inflammation leads to an increase in vascular permeability which, in turn, causes more protein leakage into the ascitic fluid)
Peritonitis
Malignancy
Tuberculosis
Nephrotic Syndrome
- This is an anomaly as it is NOT exudative.
- It causes a low SAAG because the patients lose albumin through their urine resulting in a low serum albumin concentration.
49
Outline severity of UC
Mild <4
Moderate 4-6
Severe >6 + sepsis
50
Hepatitis management A-E
Management
Cholestyramine for pruritus
Avoid alcohol
Hepatitis A and E
Self-limiting
Resolves with supportive care
Hepatitis B
Antiviral Therapy (e.g. tenofovir, peginterferon alfa)
Hepatitis C
Antiviral Therapy (e.g. sofosbuvir/velpatasvir)
51
Outline management for UC to induce remission
Proctitis
- rectal mesalazine +/- oral mesalazine +/- oral prednisolone
Proctosigmoiditis
- rectal mesalazine + oral mesalazine
- rectal steroid + oral mesalazine
Extensive
- rectal mesalazine + oral mesalazine
Severe
- IV hydrocortisone +/- IV ciclosporin/surgery
52
Which type of oesophageal cancer are Barrett's at risk of?
Adenocarcinoma of oesophagus
53
Ouline Barretts's frequencey of OGD and management
No dysplasia
- every 2-5 years
Low grade
- every 6 months
- repeat OGD with biosy
High grade
- every 3 months
- endoscopy ablation with resection/radiofrequency ablation
High dose ppi
54
Which gastric cancer is associated with peptic ulcer history and pancreatic mass?
Gastrinoma
- 60% malignant
- 40% MEN1
55
What is zollinger ellison syndrome and associated with?
Gastrin producing tumours
Severe peptic ulcer disease
| check serum gastrin
56
Drugs that cause cholestatic liver injury
(raised GGT, ALP, BR)
penicillin
erythromycin
COCP
57
Drugs that cause hepatic liver injury
(Transaminitis (AST/ALT)
Paracetamol
pheytoin
alcohol
TB drugs
Allopurinol
58
Drugs that cause mixed cholestatic/hepatic liver injury
Co-amox
Carbamazepine
Sulfasalazine
Sulphonamide
59
What is the management for haemochromatosis?
phlebectomy to reduce haematocrit to <40%
60
What is wilson's disease?
CLD and early onset dementia from copper deposits
61
What is abetalipoproteinaemia?
failure to make chylomicrons in villi
DAKE malabsorption
| D- ricket
K- prolonged INR/PT
62
What genetic mutations is seen in coeliac disease?
HLA DQ2 or HLADQ8
63
What should be checked in coeliac?
Screening:
- IgG- TTG
- IgA immunoglobulin
- Anti-Endomysial
Gold standard:
- OGD + duodenal biopsy
64
What do you see in coeliac but not in pernicious anaemia?
Iron deficiency anaemia
65
What is seen in OGD biopsy for coeliac?
villous atrophy of small bowel
lymphocytic duodenosis
Crypt hyperplasia
Increased intraepithelial lymphocytes
66
What deficiency causes angioedema without urticaria?
What is it associated with?
C1 esterase inhibitor deficiency
Lymphoproliferative disease
67
Differentiating factor between Dubin Johnson syndrome and Rotor syndrome?
Dubin=liver biopsy dark pigmented
Rotor= normal biopsy
| both isolated conjugated hyperbilirubinaemia (indirect BR)
## Footnote
Dubin Dark
68
What skin manifestation do you see in coeliac?
Dermatitis herpetiformis
| itchy bullous rash
69
What is HUS (haemolytic uraemic syndrome) caused by?
E.coli0157
haemolytic anaemia
AKI
thrombocytopenia
| SCHISTOCYTES on blood film due to shearing of RBC- > microthrombi
70
What are the causes of bloody diarrhoea?
CHESS
campylobacter = uncooked/unpasteurise
Haemorrhagic E.coli0157 = = meat
E.hitolytica
Salmonella = egg/pork/poultry
Shigella
71
What is the mortality rate from variceal haemorrhage?
30%
72
What is the most sensitive test for detecting hep c infection?
HCV RNA (from 1-2 wks)
| Anti-HCV only from 6 weeks
73
Down's syndrome patient presenting with symptoms of bowel obstruction
Meckel's diverticulum
74
What do you see in ultrasound of PSC?
intra and extra hepatic duct dilatation
75
What causes encephalopathy?
Ammonia
Uraemia
76
What is crigler najjar syndrome?
another form of glucuronosyltransferase deficiency
Type 1: AR = early death in childhood
Type 2: AD/AR = milder illness (unconjugated hyperbili)
77
What non gynae cause of CA125 rise?
Cirrhosis
Ascites
Breast cancer
| Note: ovarian cancer
78
How can a mass cause AKI?
compression of ureters
79
What causes c.diff, investigation and management?
Recent abx (disrupt gut flora)
- clindamycin
- cefalexine
Toxin (infx) and antigen (exposure)
Mx:
First ep:
1) Vanc
2) fidoxamicin
3) van +/- metro IV
Recurrent:
1) fidoxamicin
2) faecal transplant
80
What imaging should you do with biliary obstruction secondary to pancreatic cancer?
CTAP
81
What are the risk factors for gallstone?
Fat
Female
Fertile
Forty
Fair
Crohn
Colestyramine
Cirrhosis
Clofibrate
Cholesterol
COCP
Ileal resection
82
Which endocarditis is associated with colorectal cancer?
Step bovis
83
What is small intenstianal bacterial over growth?
Scleroderma => Chronic stricture/dilatation/diverticulum in small bowel => dysmotility => intestinal overgrowth (E.coli) => chronic diarrhoea
84
What extrahepatic manifestations is HCV associated with?
mixed cryoglobinemia
= immune complex deposition causing vascular inflammation
| transient rash and arthritis
85
Hepatitis transmission route?
A
B
C
D
E
A+E = eat ass (faecal oral)
B= bodily fluid, blood, birth
(ds DNA as second letter, everything else is RNA)
C= Chronic, IV (c)
D= best buds (need B for infection)
Vaccine exist for A+B (Anti-Body)
B+C => cirrhosis and HCC
A+E = acute
E= pregnancy
86
Causes of pyogenic liver abscess
S.aureus
E.coli
| amoebic abscess present later i.e entamoeba histolytica
## Footnote
Hyatid liver abscess SHOULD NOT BE ASPIRATED (risk of seeding)
87
How does crohn's manifest?
mouth to anus with skip lesions
Mouth ulcers
whole thickness in all layers
88
Causes of pancreatitis?
GET SMASHED
Gallstone
Ethanol
Trauma
Steroid
Mumps
Autoimmune
Scorpion bite
Hypothermia/hypercalcaemia/hyperlipidaemia
ERCP
Drugs
89
Which UC medication is associated with pancreatitis?
Azathioprine
90
Which cancer is UC associated with?
Cholangiocarcinoma
91
What is pyoderma gangrenosum?
purple coloured ulcerated lesion on skin
92
What prophylactic medication should be given for oesophageal varice?
Beta blocker
| reduce portal pressure
## Footnote
carvedilol
93
How does intrahepatic cholestasis of pregnancy present and when?
Pruritis
2nd or 3rd trimester
94
How does hyperemesis cause deranged LFT?
ALT and bili mildly raised
95
What condition must be ruled out in IBS?
Coeliac
96
Mangement of acute UC?
AXR
- toxic megacolon
- bowel wall >6cm, loss of haustra, thumb print (oed)
Stool MCS (infx)
IV hydrocortisone
Flexifig
VTE
97
What is anti-LKM associated with?
Autoimmune hepatitis
Drug induced hepatitis
98
Which autoantibody is PSC associated with?
pANCA
99
Which drugs can cause DILI?
MINK
Methydopa
Isoniazid
Nitrofurantoin
Ketoconazole
100
Outline management for maintaining remission for UC
Proctitis and proctosigmoiditis:
- rectal mesalazine (daily/intermittent)
- oral mesalazine + rectal mesalazine (daily/intermittent)
- oral mesalazine
Extensive/left sided UC:
- low maintenance oral mesalazine
Severe relapse OR >=2 exacerbations/year
- oral azathioprine
- mercaptopurine
101
Outline management for inducing remission in Crohns
1. steroid OR budesonide OR mesalazine
2. ADD ON azathioprine/mercaptopurine/methotrexate
- 2 or more exacerbations in 12 months
- Glucocorticoid dose cannot be tapered
- WARNING: assess thiopurine methyltransferase (TPMT) levels before starting azathioprine or mercaptopurine
3. infliximab + metho/azathio (refractory/fistulating/severe)
102
Outline management fo maintaining remission for Crohns
STOP SMOKING
First: Azathioprine/mercaptopurine as monotherapy
Second: methotrexate if above not tolerated.
Do NOT offer glucocorticoids to maintain remission
| low TPMT activity are at increased risk of myelosuppression and toxicity
103
How do you treat intestinal pseudo-obstruction in advanced PD?
Domperidone
| Note: metoclopramide worsen movement disorder
104
What is Budd Chiari syndrome
Occlusion of hepatic vein
| ascites and splenomegaly and hepatomegaly
## Footnote
associated with COCP/Polycythaemia
105
What does elevated SAAG in ascitic tap indicate?
PORTAL HYPERTENSION
106
What are ALARM symptoms for OGD referral ?
| >55 plus ALARM symptoms
Anaemia
Loss of weight
Anorexia
Recent onset of pregressive sx
Melaena/haematemesis/dysphagia
107
What is the treatment for bile acid diarrhoea post cholecystectomy?
First line: Cholestyramine
Second line: codeine
108
When is variceal banding used?
Grade 2 or 3 varice
Bleeding varice
109
What tumour marker strongly indicates metastatic colorectal cancer/recurrence?
CEA
110
How do you diagnose small intestinal bacterial overgrowth?
small bowel aspirate and cultures
111
What is HELLP syndrome?
Haemolysis elevated liver enzyme low platelet
risk of eclampsia- need Magsulf
Mx: deliver of baby
112
Risk of ischaemic colitis
AF
vascular disease
thrombophilia
COCP
113
What is watershed areas?
regions in the colon between 2 major arteries that supplying colon.
Splenic flexure is the area between SMA and IMA
rectosigmoid junction is the region between the IMA and the superior rectal artery
| prone to ischaemia due to fewer collateral
114
What blood tests are abnormal in haemolytic anaemia?
unconjugated BR
abnormal haptoglobulin
115
How do you diagnose and manage PBC?
anti-AMA (usually no need for biopsy)
Mx: ursodeoxycholic acid and cholestyramine
116
Which organs make direct contact with left kidney retroperitoneally?
pancreas and adrenal gland
117
What should you check in chronic pancreatitis and how do you supplement that?
Faecal elastase (insufficiency)
Pancreatic enzyme (malabsorption)
| Note: amylase may be normal
118
What do you see on ultrasound of PBC?
intrahepatic duct destruction
119
Charcot triad of ascending cholangitis?
Jaundice
RUQ pain
Fever
120
Common causes of ascending cholangitis?
Gallstone
ERCP
121
What investigations should be done for young person with recurrent peptic ulcer?
Screen for gastrinoma
octreotide scan- for neuroendocrine
122
4 causes of chronic hepatitis
Hep B
Hep C
autoimmune
drugs (MINK)
123
Which antibody is autoimmune hepatitis associated with?
anti-smooth muscle
124
What is the incubation period of Hep A?
2-4 weeks
125
What artery supplied distal 1/3 transverse colon, splenic flexture, descening colon, sigmoid colon, rectum?
Inferior mesentaric artery
126
Wilson disease chromosome
13
127
Which vitamin is deficient in zollinger ellison syndrome?
B12
| gastric acid inhibits formiation of vit 12
128
What feature indicates UC flare needs surgery (colectomy)
> 8 bowel motions per day
Pyrexia
Tachycardia
Abdominal X-ray showing colonic dilatation (toxic megacolon)
Low albumin, low haemoglobin, high platelet count, CRP above 45 mg/L
129
What is the kings criteria for liver transplant?
pH <7.3 or INR >6.5
and Creatinine >300
and Grade 3 hepatic encephalopathy
## Footnote
Symptoms
Grade 1: altered mood/behaviour, minimal change GCS
Grade 2: asterixis, drowsy
Grade 3: confused, incoherent
Grade 4: comatose, unresponsive to pain GCS 3
130
What dose AST:ALT >2 suggest?
alcoholic hepatitis
| Make ASS of themself
131
Tumour markers:
HCC: AFP
Pancreatic: CA199
Trophoblastic: beta HCG
Ovarian: CA125
Colorectal: CEA
132
Management of wilson's
Medical
Penicillamine (copper chelator)
Zinc Therapy (blocks copper absorption in the intestines)
Trientine
Surgical
Liver Transplantation
133
Which hepatitis is associated with shellfish?
Hep A
134
Outline UGIB managment
Fluid resus
OGD in 24 hrs
- direct adrenaline/clips
- variceal banding for varice
- embolisation IR
IV PPI if non variceal bleed pre OGD
Terlipressin and abx pre OGD (better than octreotide)
- this must be given before OGD!!!!
135
Difference between NASH and NAFLD
NASH is severe form of NAFLD with fatty liver, and liver fibrosis
| AST:ALT <1 is NAFLD
136
What gastric proton pump does omeprazole irreversibly bind to?
K+/H+ ATPase in parietal cells
137
What drug can cause transient ischaemic colitis in watershed areas?
cocaine (just like coronary spasm)
138
What does anti HBsurfarce antibody imply?
| Anti-sick antibody
Immune (prev vaccine)
Natural infection
| vaccine has surface antigen
139
HbSAg indicates
SICK
incubation
acute illness
140
HbeAg indicates
EASILY spread (infective)
| only Escapes in acute infection
141
HbCAg indicates?
C through the window period
142
Anti-HbC antibody
Came across Hep B
(NOT VACCINATED)
previous infection/ongoing
IgM= acute
IgG= chronic
143
Anti-Hbe antibody
Anti-easily spread
low transmissbility
144
How does pancreatic cancer present?
abdo pain radiating to back
painless jaundice
145
Where is the gallstone likely to have blocked to cause pancreatitis?
Ampulla of vater
146
How does acute pancreatitis cause ARDS?
protein risk oedema fluid due to alveolar permeability
147
What is typhoid fever?
salmonella typhi
diarrhoea/constipation settles
later fever, headache, cough, rose spots blanching
transaminitis and neutropenia
cef/cipro
148
What is the most sensitive index of viral replication for Hep B?
Hep B virus DNA
149
What is the hallmark of hep E virus infection?
marked cholestasis
150
What barium swallow findings suggest Achalasia?
Bird beak
| oesophgeal motility disorder
## Footnote
dysphagia to both liquid and solid
151
What is the abx of choice for cholera?
PO doxycycline single dose
| OR PO Cipro
152
which bacterial food poisoning present with vomiting 2-4hrs post ingestion?
s.aureus
| enterotoxin contaminant
## Footnote
diarrhoea watery and profuse after vomiting
153
How does Yersinia present?
uncooked meat
1 day after ingestion
154
What is Mirizzi syndrome?
Gallstone in cystic duct
155
How does Hep A present?
Flu like illness
then jaundice
156
What is the management for pyogenic liver abscess?
amoxicillin + ciprofloxacin + metronidazole
157
What cancer is barrett's oesophagus associated with?
Oesophageal adenocarcinoma
158
Outline different types of hepatitis and steatosis
Alcoholic hepatitis (cholestatic)
Alcoholic hepatic steatosis (transaminitis)
Autoimmune hepatitis (ASM, cholestatic)
Non alcoholic hepatic steatosis (fatty liver no ETOH)
Non alcoholic steatohepatitis (transaminitis, no ETOH)
159
What laboratory findings do you see in Wilson's?
Low caeruloplasmin
Low serum copper (bound to above)
High urinary copper
Low serum uric acid (urinary excretion)
High AST
160
What imaging should be ordered for bowel obstruction (tinkling bowel sound)
AXR
161
What does HBV DNA viral load tell you?
Risk of progression of Hep B to cirrhosis
162
What is the triad of Wernicke's encephalopathy?
Opthalmoplegia
Ataxia
Confusion
163
What is deficient in wernicke?
vitamin B (thiamine)
164
What is korsakoff syndrome?
Chronic wernicke with memory loss
165
How do you differentiate between IBS and alternative diagnosis?
Pain not relieved by defecation
166
What is systemic mastocytosis?
XS mast cell producing blood disorder
increased histamine production thus increased gastric acid
hypened allergic reaction
167
What is transudate ascitic fluid and causes
protein <30 (assuming normal alb)
cirrhosis
HF
Nephritis
Nephrotic (low alb)
Budd Chiari
168
What is exudate ascitic fluid and causes
protein >30
infection (SBP/TB)
inflamm (pancreatitis)
malignancy
169
What does deficiency in vitamin C cause?
scurvy
| vit c hydroxylate procollagen proline and lysine
170
What is lynch syndrome and management?
hereditary non polyposis colon cancer syndrome
ASPIRIN may reduce risk of cancer
171
If liver enzymes and amylase are elevated where is the obstruction ?
after pancreatic duct joins the common bild duct therefore DISTAL CBD
172
What is the biochemical hallmark of refeeding syndrome?
HYPOPHOSPHATAEMIA
| Insulin released from carb intake drives phos into cells
173
Which gastric cancer is h.pyelori associated with?
gastric MALT lymphoma
174
Which endocrine abnormality is zollinger ellison associated with?
Hyperparathyroidism
175
What can affect 5HIAA levels
dietary (vegetarians)
remove dietary factors and retest
176
Which traveller diarrhoea cause skin rash?
Yersinia
Mx: cipro
| uncooked meat
177
What is the side effect of metformin?
Bile acid malabsorption
diarrhoea
178
What is the triad of symptomatic pancreatic pseudocyst?
epigastric pain
fever
mass in epigastrium
179
What is menetiers disease?
Rare giant gastric folds
180
What diseases cause HCC?
Chronic Alcoholism
Chronic viral hepatitis
Haemochromatosis
alpha 1 antitrypsin
181
What is a common side effect of bisphosphonate?
Oesophagitis
(reflux without red flags)
182
Melanosis coli
brown pigmentation in chronic laxative use (senna)
183
What severity liver disease do you see clotting abnormality?
Severe
184
What oesophageal abnormality is seen in systemic sclerosis (CREST)
oesophageal stricture
185
What is truelove and witts criteria for acute severe colitis?
fever>37.8
BO >6 times with blood
ESR >30
HR >90
Anaemia
186
What are the causes of toxic megacolon?
IBD
C.diff
Dysentry (CHESS)
187
Why should you not perform flexi sig in severe colitis?
risk of perforation
188
What is mallory weiss tear caused by?
alcohol binge
recurrent vomiting
189
What immune complication do you see in Whipples?
immune reconstitution inflammatory syndrome
| return of diarrhoea, arthalgia, fever
## Footnote
need steroids
190
What are the features of drug induced lupus?
pleuritis
pericarditis
arthritis
photosensitive rash (SLE)
191
What is the managmenet for diverticulosis and diverticulitis?
Diverticulosis: increase fibre
Acute diverticulitis: IV abx
Perforation: surgery
192
What bed side investigation should be done in low GCS patient initially?
CBG
193
How is smoking associated with Crohns and UC?
Crohns: risk
UC: reduced risk
194
What is tropical Spru
Vietnam
Months of diarrhoea and malabsorption of vitamins
infection
| Mx: 4-6 wk of ampicillin/tetracyclin
195
What medication induces remission rapidly in UC?
infliximab/ciclosporin
| hence saved for severe UC
196
What is the diagnosis of seronegative arthritis, diarrhoea and malabsorption?
Whipple's
197
What are e antigen positive people at risk of?
Higher risk of HCC than those negative
198
How does chronic pancreatitis present?
chronic epigastric pain
steatorrhoea
weight loss
pancreatic calcification
pseudocyst
199
What is NAC?
N-acetylcysteine for pcm overdose
200
Which ulcer is h.pyelori most associated with
duodenal ulcer (90%)
| peptic-80%
201
How often should patients with Duke's A tumour monitored?
yearly
202
Which part of bowel does the reabsorption of bile acid?
terminal ileum
therefore bile reach colon
increasing gastric transit time
deconjugated by gut microbiome
stimulating water and electrolye secretion
thus bile acid diarrhoea
| Mx: cholestyramine
203
What is the treatment for diabetic gastroparesis (autoimmune neuropathy)
domperidone
204
What is painless jaundice, weight loss, no abdo pain
pancreatic adenocarcinoma
205
How would you manage patients who have persistent reflux despite maximal PPI, ongoing respiratory symptoms and young
fundoplication
206
What is the investigation for whipple's
small bowel barium follow through and biopsy of small intestine- PAS macrophage
207
Which food has highest folic acid?
Liver
208
How does achalasia present?
sudden onset dysphagia TO BOTH solid and liquid
no weight loss
regurgitation
| failure to relax lower spincter
209
What is the diagnostic investigation of choice for achalasia?
Ix: oesophageal manomatry
210
Differentiate between pyogenic and amoebic liver abscess
pyogenic- following recent biliary/GI infection
Pyogenic- multiple abscess
Amoebic- single mass
211
What is entamoeba histolytica?
Amoebiasis is caused by Entamoeba histolytica (an amoeboid protozoan) and spread by the faecal-oral route
mild diarrhoea or severe amoebic dysentery.
high leukocyte in stool- inflamm
Mx: Metronidazole
212
Outline pregnancy associated liver disease:
Intrahepatic cholestasis of pregnancy:
- pruritus
- raised bilirubin
Acute fatty liver of pregnancy:
- liver failure
- transaminitis and higher BR
HELLP
- hemolysis, Elevated Liver enzymes, and a Low Platelet
- RUQ pain
- nausea & vomiting
213
What is the most common cause of UGIB?
Chronic peptic ulcer
214
Outline the timescale for symptoms with food poisoning by different organisms post ingestion
s.aureus - 2-4 hrs, vomit,
yersinia- bloody diarrhoea, 4-10 days
salmonella- diarrhoea, 8-48hrs
campylobacter- incubation 3-7 days (flulike, diarrhoea, abdo pain)
bacillus cereus - reheated rice (5-18hrs D+V)
215
What additional medication should be taken with pancreatic supplements to increase efficacy of latter ?
PPI (reduced acid breakdown)
216
What is eruptive xanthomas and what is it associated with?
Yellow papules in extensors
Lipoprotein lipase deficiency
- chylomicron acquire apoC2 which activate lipoprotein lipase on vascular endothelium
- this releases TG->fatty acid from chylo into tissues
- chylo become smaller and become cholesterol rich
- remnant taken up by liver and metabolised
217
What deficiency is seen in familial hypercholesterolaemia
LDL receptor
Apolipoprotein B (part of LDL for receptor binding)
218
What can cause false negative amylase in acute pancreatitis?
hypertriglyceridaemia - chylomicron specifically
| most common lipidaemia a/w pancreatitis
219
What condition is splenic atrophy associated with?
coeliac disease
| Howell jolly bodies in blood film for hyposplenism
220
Mechanism of lansoprazole
H/K ATP pump inhibitor
221
Mechanism of ranitidine
H2 receptor inhibitor
222
Outline the site of absorption of essential nutrients in GI tract
Duodenum- release protease
Jejunum - absorb amino acid
Caecum - water absorption
223
Which cell produces gastrin and where?
G cell in antrum and duodenum
gastrin stimulate parietal cell to secrete gastric acid
224
What is the investigation for chronic enteric fever carrier (salmonella typhi)
culture of intestinal secreation/faeces/urine
225
Differentiate between haemochromatosis and wilsons presentation
Haemo: joint pain, loss of libido, low testosterone
Wilson: liver, basal ganglia, eyes
226
What vitamin B is thiamine
B1
227
What neurological symptoms can B12 deficiency cause?
peripheral neuropathy
subacute cord degeneration
228
What is the role of HDL ?
transport cholesterol from foam cell to liver -> bile excretion
anti-inflammatory
HDL cholesterol go to organs for steroid synthesis
229
Outline metabolism of VLDL to LDL and IDL
Liver makes VLDL transporting endogenous cholesterol and TG to peripheral tissue -> further hydrolysed in blood -> form IDL and LDL
LDL cleared by liver by LDL receptors and macrophage
XS LDL not taken up -> udergo oxidation and form foam cell -> atherosclerotic plaque
230
How do you investigate diabetes induced gastroparesis?
gamma scintigraphy, gastric emptying study
231
How do you investigate for small bowel bacterial overgrowth?
lactose hydrogen breath test
232
Which medication is useful in controlling diarrhoea associated with carcinoid syndrome
octreotide
233
What is the most sensitive imaging for PSC intra and extra hepatic duct stricture/dilatation?
MRCP
234
What is the mode of action of laxatives with examples
Osmotic: lactulose
Sofener: docusate
Motility: Senna
Bulk forming: movicol
235
Top 3 drugs for hepatic encephalopathy
lactulose
enemas
rifaximin
236
How does terlipressin work?
reduce splanchnic circulation hence reduce portal HTN
237
What are polyposis syndromes?
Familial adenomatous polyposis
- APC gene
- a/w medulloblastoma
Peutz -Jeghers syndrome
- STK11 (LKB1) on Ch 19
- harmatomas
HNPCC (Lynch syndrome)
- DNA mismatch repair gene mutation
- CEO (colorectalm, endometrial, ovarian)
- a/w glioblastoma
238
Why does haemochromatosis present with hypogonadism?
iron deposit in pituitary
239
What is imatinib and which 2 conditions is it used in?
CML
GI stromal tumour
| Tyrosine kinase inhibitor
240
What is SeHCAT test for?
bile acid malabsorption
note: metformin can increase bile acid excretion causing diarrhoea thus switch to IR.
241
What cancer is coeliac associated with?
Intestinal lymphoma (T-cell)
242
What is barrett's
columnar metaplasia
| need surveillance as meta->dysplasia->adenocarcinoma
243
Why do you check TPMT deficiency prior to azathioprine
risk of myelosuppression
244
Which artery is the posterior duodenum supplied by?
posterior superior pancreaticoduodenal artery
245
What is an important complication of sulfasalazine therapy?
pancytopenia
246
What is GAVE
| gastric antral vascular ectasia
watermelon stomach
247
Which age group does PSC affect?
men <50 years
248
Which bug causes diarrhoea in HIV patients with low CD4 <100
Crytosporidium
249
What is the recommended daily K replacement ?
1mmol /kg/day
| note with GI loss- 90-120 per day is recommended
250
What is child pugh grade for?
cirrhosis mortality
251
What markers are used to grade in child pugh?
encephalophathy
bilirubin
ascites
albumin
INR and PT
252
What GI side effect is mycophenolate mofetil MMF used in renal transplant associted with?
crohns like enterocolitis
- skip lesions
253
What does ALT:AST >2 suggest?
NAFLD
254
How does malnutrition cuase steatohepatitis and hypercholesterolaemia?
anabolic process in liver to maintain albumin levels
255
Which bacteria is most likely cause of SBP?
E.COLI
256
What is hepatorenal syndrome and what clinical sign do you see in all patient?
vasoactive mediators cause splanchnic vasodilation
which reduces the systemic vascular resistance.
Causing hypoperfusion of kidney
RAAS activation cause renal vasoconstriction which is not enough to counterbalance the effects of the splanchnic vasodilation.
| JAUNDICE AND ASCITES
257
What infections is an absolute contraindication to liver transplant?
HIV with AIDS
258
Which gene is Wilson's associated with?
ATP7B gene
259
What is the function of gastrin released from antral G cells?
stimulates parietal cells to secrete H+
increases gastric motor activity
260
What is the function of secretin?
stimulates pancreatic secretion in response to duodenal acid
261
What is the role of somatostatin in gastro?
decreases gastrin secretion
262
What is short bowel syndrome and who are at risk?
previous GI surgery
causing fast transit hence malabsorption and diarrhoea
263
What is protein losing enteropathy?
leaking protein in gut
264
Which blood test would be useful in protein losing enteropathy?
alpha 1 antitrypsin
| not degraded by protease
265
What is the treatment for bacterial overgrowth syndrome?
rotating antibiotic therapy (metronidazole and cipro)
266
What is the investigation of choice for bacterial overgrowth syndrome?
Hydrogen breath test
267
How does bacterial overgrowth present?
bloating
diarrhoea
constipation
268
What does IgM anti-HBc indicate?
ACUTE HEP B infection (mother)
269
When is HBV DNA useful?
Chronic hep B
270
Which PPI is known to interact with clopidogrel (DAPT)
Omeprazole
271
When is prothrombin complex used?
warfarin reversal
272
When should terlipressin be given?
suspected variceal bleed at presentation
273
What platelet level is a contraindication for liver biopsy?
Platelet <50
INR >1.5
274
What is cryoglobinaemia?
Immunoglobulins undergo reversible precipitation at 4 deg
dissolve when 37 deg
275
What are the 3 types of cryoglobinaemia?
1: monoclonal (25%)
2: mixed mono and polyclonal (25%)
3: polyclonal (50%)
276
Which cryoglobinaemia is associated with severe pulmonary fibrosis?
Mixed (type 2)
277
Which cryoglobinaemia do you see raynaud's?
Type 1 (monoclonal - IgM or IgG)
278
What histological findings do you see in Crohn's biopsy?
Transmural
Skip lesion
Non caseating granuloma
Goblet cells
Cobblestone
Rosethorn
279
What histological findings do you see in UC biopsy?
mucosal and submucosal
continuous
crypt abscess
280
What is IgG4 related disease associated with?
chronic pancreatitis
| multi organ immune mediated condition
281
Management of haemochromatosis
Management
Regular (venesection)
Iron-chelating medications eg. desferrioxamine
282
Which blood test suggest UGIB
raised urea disproportionate to creatinine
| blood digested into urea as it is protein
283
What 2 conditions should be considered in isolated hyperbilirubinaemia?
Gilbert's and Haemolytic anaemia
284
What test should be done to rule out haemolytic anaemia
Coomb's
285
What mineral deficiency do you see dermatitis and alopecia?
Zinc deficiency
286
What triggers Gilberts?
Mild jaundice from stress/infection/fasting
287
What does normal LFT apart from raised bilirubin suggesT?
Gilbert's
288
Apart from rectal bleed, weight loss and CIBH, what other symptom should prompt you for structural cuase of bowel disease?
Nocturnal diarrhoea
289
Where is wedged hepatic venous pressure recorded for portal hypertension?
hepatic sinusoids in hepatic veins
290
What does isolated ALT rise suggest?
NAFLD
291
In severe colitis with generalised abdominal tenderness, what should be ruled out?
Toxic megacolon
292
Which hepatitis is most common cause of acute liver failure?
Hep A and E
293
What is the investigation of choice for perianal abscess in Crohn's?
MRI pelvis
294
When is azathioprine used in Crohn's?
1. 2 or more exacerbations within 12 months requiring steroids
295
What are the 4 pregnancy related liver disorders?
1. cholestatic
2. Acute fatty liver
3. Hyperemesis
4. HELLP
296
Why are 2 colonscopies recommended to diagnose angiodysplasia assicated with aortic stenosis?
May not pick up angiodysplasia
| capsule endoscopy is next step after x2 colonoscopy
297
How does VIPoma cuase diarrhoea?
gut hormone secreting tumour in pancreas or small bowel causing watery diarrhoea and electrolyte deficienties (K+)
298
How is cholera contracted?
Shellfish with perfuse watery diarrhoea
299
Which blood test should be checked prior to starting thiopurines?
TPMT
300
What are the 3 complications of thiopurines
1. myelosuppresion
2. deranged LFT
3. PANCREATITIS
301
What is an example of protein losing enteropathy?
sarcoidosis
302
Which electrolyte abnormality is seen in alcohlism and malnutrition?
Hypomagnesaemia
303
How does hypomagnesaemia cause hypocalcaemia?
Mg needed for PTH release => low PTH means low Ca
304
What is the management for Achalasia?
Dilation with balloon
305
What is the analgesia of choice for chronic abdominal pain from chronic pancreatitis?
opiates
306
Which GI cancer is paraprotein release seen?
MALT lymphoma
307
What is the link between aspirin and GI cancer?
reduced risk
308
What is the link between vitamin C and GI cancer?
low vitamin C increases risk of cancer
309
When is erythema marginatum seen?
Rheumatic fever
| pink red rash with pale centre
310
When is the onset of Wilson's?
10-25 years
311
What is Hyatid disease and what is the vector?
cyst forming by echinococcus granulosis
farm animals (sheep)
312
What is Pellagra?
DDD
Diarrhoea
dermatitis
dementia
| nicotinic acid deficiency as carcinoid tumour uses
313
What type of cell is MALT lymphoma?
B cell
314
What is TIPSS and when is it used?
forming low resistace channel between hepatic vein and portal vein
only indicated in refractory ascites
