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Medicine and Surgery Mushkies > Passmed Gastro Mushkies > Flashcards

Passmed Gastro Mushkies Flashcards

1
Q

4 things that contain gluten?

A

Wheat
Barley
Rye
Oats

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2
Q

3 notable gluten free foods?

A

Rice
Potatoes
Corn (Maize)

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3
Q

Why are patients with coeliac disease offered the pneumococcal vaccine?

A

They have a degree of functional hyposplenism

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4
Q

What is GORD?

A

Symptoms of oesophagitis secondary to refluxed gastric contents

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5
Q

Complications of GORD?

A 
BABUO
Barrett's oesophagus
Anaemia 
Benign Strictures
Ulcers
Oesophagitis
Oesophageal carcinoma
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6
Q

Tx of GORD?

A
  1. Endoscopically proven = PPi 1-2m, if responsive then low dose tx, if no response then double dose PPI for 1 month
  2. Endoscopically negative = PPi 1m, if response then offer low dose tx, if no response then H2RA or prokinetic for 1m
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7
Q

5 features suggestive of hypernatraemic dehydration?

A
  1. Jittery movements
  2. Increased muscle tone
  3. Hyperreflexia
  4. Convulsions
  5. Drowsiness or coma
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8
Q

Most common cause of gastroenteritis in children?

A

Rotavirus

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9
Q

3 drugs that cause liver cirrhosis?

A

MMA

  1. Methotrexate
  2. Methyldopa
  3. Amiodarone
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10
Q

What should not be prescribed in the acute management of upper GI bleeding and why?

A

PPI should not be prescribed until post-endoscopy as it may mask the site of bleeding

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11
Q

Scoring to assess an acute upper GI bleed?

A

Blatchford score

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12
Q

What score can be used to assess an acute upper GI bleed after endoscopy?

A

Rockall score

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13
Q

What are the components of the Blatchford score?

A
  1. Urea
  2. Haemoglobin
  3. Systolic BP
  4. Other = Pulse, melaena, syncope, hepatic disease, cardiac failure
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14
Q

What is the management of an acute upper Gi bleed?

A
  1. Resuscitation = ABC, IV wide bore access, plt transfusion if <50 x10*9, FFP if fibrinogen <1g/L or APTT >1.5x normal
  2. Endoscopy
  3. Variceal vs. non-variceal?
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15
Q

What is the additional management for a non-variceal bleed?

A
  1. Dont use PPI until after endoscopy

2. If further bleeding –> repeat endoscopy, interventional radiology, surgery

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16
Q

What is the additional management for a variceal bleed?

A
  1. Terlipressin and prophylactic Abx
  2. Oesophageal = band ligation, Gastric varices = N-butyl-2-cyanoacrylate
  3. TIPS last line
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17
Q

Which IBD is associated with gallstones?

A

Crohn’s (Terminal ileus is where bile salts are reabsorbed, if this area is inflamed then bile salts are not absorbed and people are prone to developing gallstones)

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18
Q

What may you see on endoscopy with UC?

A

Pseudopolyps

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19
Q

What kind of ulcers may you see on radiology with Crohns?

A

Rose thorn ulcers

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20
Q

What is the best first line management for NAFLD?

A

Weight loss

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21
Q

What is the most common cause of liver disease in the developed world?

A

NAFLD

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22
Q

What blood test can be used to identify NAFLD?

A

Enhanced liver fibrosis (ELF) blood test

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23
Q

What are the components of the ELF test?

A
  1. Hyaluronic acid
  2. Procollagen III
  3. Tissue inhibitor of metalloproteinase 3
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24
Q

How does a fibroscan work?

A

Liver stiffness measurement assessed with transient elastography

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25
Q

What are 3 early signs of haemochromatosis?

A

Fatigue, erectile dysfunction and arthralgia

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26
Q

What is haemochromatosis?

A

An autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation

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27
Q

What causes haemochromatosis?

A

Mutations of the HFE gene on Chromosome 6

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28
Q

What is the prevalence of haemochromatosis?

A

Prevalence in people of European descent = 1/200

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29
Q

What are the complications of haemochromatosis?

A
  1. Reversible = cardiomyopathy, skin pigmentation

2. Irreversible = liver cirrhosis, DM, arthropathy, hypogonadotrophic hypogonadism

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30
Q

What are the presenting features of haemochromatosis? x6

A
  1. Early sx = fatigue, ED, arthralgia (and thus arthritis)
  2. Bronze skin pigmentation
  3. DM
  4. Liver = CLD
  5. Heart = CCF secondary to DCM
  6. Hypogonadotrophic hypogonadism
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31
Q

Pain when hungry and relieved by eating?

A

Duodenal ulcer

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32
Q

What are risk factors for peptic ulcer disease?

A
  1. Alcohol
  2. NSAIDs
  3. SSRIs
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33
Q

What kind of peptic ulcer is more common?

A

Duodenal ulcers

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34
Q

What is the first line management of hepatic encephalopathy and why?

A

Lactulose, because it inhibits production of ammonia in the intestine and thus reduced hyperammonaemia

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35
Q

How can you grade hepatic encephalopathy?

A

Grade I = irritability
Grade II = confusion/inappropriate behaviour
Grade III = incoherent
grade IV = coma

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36
Q

What antibiotic can be used to treat hepatic encephalopathy and why?

A

Rifaximin, as it modulates gut flora thus resulting in decreased ammonia production

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37
Q

How can you classify the severity of UC?

A
  1. Mild = <4 stools/day, small amount of blood
  2. Moderate = 4-6 stools/day, varying amounts of blood, no systemic upset
  3. Severe = >6 stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised ESR)
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38
Q

What is the management of mild/moderate UC?

A
  1. Proctitis = rectal aminosalicylate –> 4wks –> aminosalicylate –> topical/oral corticosteroids
  2. Proctosigmoiditis and L-sided = rectal aminosalicylate–> oral aminosalicylate –> oral corticosteroid (and stop topical)
  3. Extensive disease = topical and oral aminosalicylate –> 4wks –> oral aminosalicylate + oral corticosteroid (and stop topical)
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39
Q

What is the management of severe UC?

A
  1. IV steroids (IV ciclosporine if steroid c/i)

2. If after 72hrs there has been no improvement, add IV ciclosporine or consider surgery

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40
Q

How do you maintain remission in mild/moderate UC?

A
  1. Proctitis and proctosigmoiditis –> topical aminosalicylate +/- oral aminosalicylate
  2. L sided and extensive = oral aminosalicylate
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41
Q

How do you maintain remission after a severe UC relapse or after >1 exacerbations in the past year:

A

Oral azothioprine/oral mercaptopurine

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42
Q

What may be a cause of an acute flare of up Hep B?

A

Hepatitis D superinfection

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43
Q

What kind of virus is Hep D?

A

ssRNA

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44
Q

What is the scoring system for a flare up of UC?

A

Truelove and Witts

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45
Q

What are the Truelove and Witts criteria for severe UC?

A

> 6 stools per day + 1 of:

  1. Temp > 37.8C
  2. HR > 90
  3. Anaemia <105
  4. ESR > 30mm/hr
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46
Q

What do you see on investigation of Crohns?

A
  1. Blood = CRP correlates with disease activity
  2. Endoscopy = deep ulcers and skip lesions on colonoscopy
  3. Histology = inflammation from mucosa to serosa, goblet cells, granulomas
  4. Small bowel enema = Strictures (Kantor’s string sign), proximal bowel dilation, rose thorn ulcers, fistulae
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47
Q

What are the liver findings of RHF?

A

A smooth, tender and pulsatile liver edge

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48
Q

What kind of cancer is associated with Barrett’s?

A

Oesophageal adenocarcinoma

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49
Q

What are 4 RFs for oesophageal carcinoma?

A 
Alcohol 
Smoking
GORD
Barrett's oesophagus
Achalasia 
Plummer-Vinson syndrome
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50
Q

What kind of tube can be used to manage a variceal haemorrhage?

A

Sengstaken-Blakemore tube

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51
Q

What can be used for prophylaxis of variceal haemorrhage?

A
  1. Propranolol

2. Endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy

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52
Q

What regular prescription is a risk factor for C diff infection?

A

PPIs

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53
Q

What does C diff release that causes pseudomembranous colitis?

A

Exotoxin

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54
Q

How does one diagnose C diff colitis?

A
  1. C diff toxin (CDT) in stool

2. C diff antigen positivity only shows exposure to the bacteria rather than current infection

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55
Q

What is the first line tx of C diff colitis?

A

Oral metronidazole 10-14 days

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56
Q

What is the most common cause of HCC worldwide?

A

Hep B

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57
Q

What is the most common cause of HCC in Europe?

A

Hep C

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58
Q

What are 2 scoring systems for liver cirrhosis?

A
  1. Child-Pugh

2. Model for End Stage Liver Disease (MELD)

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59
Q

What are the components of Child-Pugh classification?

A

BAPEA (each one out of 3, total /15)

  1. Bilirubin
  2. Albumin
  3. PT
  4. Encephalopathy
  5. Ascites
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60
Q

What is the score for Child-Pugh Score A?

A

<7

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61
Q

What is the score for Child-Pugh Score B?

A

7-9

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62
Q

What is the score for Child-Pugh Score C?

A

> 9

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63
Q

What are the components of the MELD score?

A 
A combination of patient's
1. Bilirubin
2. Creatinine
3. INT 
to predict survival, a formula is used to calculate the score
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64
Q

What are serum caeruloplasmin, serum copper, and urinary copper levels in Wilsons?

A
  1. Serum caeruloplasmin reduced
  2. Serum copper reduced
  3. Increased 24hr urinary copper excretion
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65
Q

What causes wilsons disease?

A

Mutation in ATP7B gene on chromosome 13, leading to increased copper absorption from the small intestine and decreased hepatic copper excretion

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66
Q

What are the features of Wilsons disease?

A
  1. Liver = hepatitis, cirrhosis
  2. Neurological = basal ganglia degeneration, speech, behavioural and psychiatric problems
  3. Kayser Fleischer Rings
  4. Renal tubular acidosis
  5. Blue nails
  6. Haemolysis
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67
Q

What is the first line treatment for wilsons?

A

Penicillamine (copper chelator)

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68
Q

What must be given prior to an appendicectomy?

A

Prophylactic Abx

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69
Q

What are anti-smooth muscle antibodies a marker of?

A

Autoimmune hepatitis

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70
Q

What HLA is autoimmune hepatitis associated with?

A

HLA DR3

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71
Q

How many types of autoimmune hepatitis are there?

A

3

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72
Q

What is the epidemiology and antibody of Type I autoimmune hepatitis?

A
  1. Adults and children

2. Anti-smooth muscle antibodies

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73
Q

What is the epidemiology and antibody of Type II autoimmune hepatitis?

A
  1. Children

2. Anti-liver/kidney microsomal type 1 antibodies (LKM1)

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74
Q

What is the epidemiology and antibody of Type III autoimmune hepatitis?

A
  1. Adults

2. Soluble liver-kidney antigen

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75
Q

How can you manage autoimmune hepatitis?

A
  1. Steroids
  2. Immunosuppresants e.g. azathioprine
  3. Liver transplantation
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76
Q

What is the first line treatment for IBS with regards to:

  1. Pain
  2. Constipation
  3. Diarrhoea
A
  1. Antispasmodic agents
  2. Laxatives but avoid lactulose
  3. Loperamide
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77
Q

What is the MOA of loperamide?

A

μ-opioid receptor agonist in the myenteric plexus of the large intestine. It works like morphine, decreasing the activity of the myenteric plexus, which decreases the tone of the longitudinal and circular smooth muscles of the intestinal wall

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78
Q

What can be considered for pts with IBS with constipation who have not responded to conventional laxatives?

A

Linaclotide

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79
Q

What is the 2nd line treatment for IBS?

A

Low dose TCA e.g. amitryptiline

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80
Q

What psychological intervention can be given for IBS?

A

CBT

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81
Q

What is a s/e of metoclopramide?

A

EPSEs e.g. acute dystonia

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82
Q

What is the MOA of metoclopramide?

A

D2 receptor antagonist

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83
Q

What are 4 uses of metoclopramide?

A
  1. Nausea
  2. GORD
  3. Prokinetic for gastroparesis secondary to diabetic neuropathy
  4. Combined with analgesics for migraine
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84
Q

How does metoclopramide exert its anti-emetic action?

A

D2 receptors in the CTZ

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85
Q

What causes itchiness in CKD?

A

Uraemic pruritis

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86
Q

When does jaundice start to appear?

A

When bilirubin reaches an excess of 35umol/l

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87
Q

What blood marker may rise due to an upper GI bleed and why?

A

Urea, as an upper GI bleed can act as a ‘protein meal’ and cause a temporary, disproportionate rise in the urea

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88
Q

What is the marker for HCC?

A

AFP

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89
Q

What is the management for a liver abscess?

A

IV Abx + image guided percutaneous drainage

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90
Q

What is the first line management for a hydatid cyst?

A

Surgical resection

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91
Q

What are the most common organisms found in pyogenic liver abscesses?

A

S. aureus and E. coli

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92
Q

What is haemochromatosis?

A

An autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6

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93
Q

What are the haematinics for a pt with haemochromatosis?

A
  1. Raised ferritin
  2. Raised transferrin
  3. Low TIBC
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94
Q

What can you see on X-ray of joints in pts with haemochromatosis?

A

Chondrocalcinosis

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95
Q

What is the mainstay of treatment in haemochromatosis?

A

Regular venesection

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96
Q

What kind of cancer is achalasia is risk factor for?

A

Squamous cell carcinoma of the oesophagus

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97
Q

What is the NICE definition of malnutrition?

A
  1. BMI <18 or
  2. Unintentional weight loss >10% in last 3-6m or
  3. BMI < 20 and unintentional weight loss greater than 5% within the last 3-6 months
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98
Q

What is the gram stain and shape of C.dif?

A

Gram positive rod

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99
Q

When should metoclopramide be avoided?

A

In bowel obstruction, as it is a pro-kinetic and could thus cause a perforation

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100
Q

Does diarrhoea or constipation act as a trigger for liver decompensation in cirrhotic pts?

A

Constipation

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101
Q

What is a fibroscan?

A

Transient elastography, measures ‘stiffness’ of the liver which is a proxy for fibrosis

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102
Q

How long do pts with C diff need isolation for?

A

At least 48hrs

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103
Q

What is the triad of presentation of chronic mesenteric ischaemia?

A
  1. Severe colicky post prandial abdo pain
  2. Weight loss
  3. Upper abdominal bruit
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104
Q

How can you classify ischaemia to the lower GI tract?

A
  1. acute mesenteric ischaemia
  2. chronic mesenteric ischaemia
  3. ischaemic colitis
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105
Q

What is the management of acute mesenteric ischaemia?

A

Urgent surgery

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106
Q

What may be seen on abdo x-ray in ischaemic colitis?

A

Thumbprinting, due to mucosal oedema/haemorrhage

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107
Q

What is the investigation of choice for acute mesenteric ischaemia?

A

CT

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108
Q

Where is ischaemic colitis most likely to occur?

A

Watershed areas like the splenic flexure

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109
Q

What are the causes of acute pancreatitis?

A

Gallestones
Ethanol
Trauma
Steroids
Mumps (and Coxsackie B)
Autoimmune (e.g. PAN) and Ascaris infection
Scorpion venom
Hypertriglycerideaemia, hypercalcaemia, hypothermia
ERCP
Drugs e.g. azathioprine, steroids, furosemide, sodium valproate, mesalazine

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110
Q

What is the management of Barrett’s oesophagus?

A

High dose PPI and endoscopic surveillance every 3-5 years

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111
Q

What is the increased risk of oesophageal carcinoma with Barrett’s?

A

50-100 fold

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112
Q

What is not an independent risk factor for Barrett’s although it is associated with both GORD and oesophageal cancer?

A

Alcohol

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113
Q

What can be done if dysplasia is seen upon screening for Barrett’s?

A

Endoscopic mucosal resection or RFA

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114
Q

What does transferrin do and how does it behave in states of iron deficiency?

A

Transferrin is the body’s carrier of iron around the blood. In states of iron deficiency, transferrin increases as the body tries to “make the most” of what iron it has left, meaning that transferrin levels go up

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115
Q

What is the transferrin level in ACD and why?

A

Anaemia of chronic disease is the body’s physiological response to a danger, such as a potentially harmful pathogen. Like humans, pathogens require iron for metabolism and survival. Therefore, in ACD, the body reduces iron available for pathogens by circulating less around the blood. This means that transferrin decreases.

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116
Q

How does TIBC differ between IDA and ACD and why?

A

TIBC measures the number of binding sites on transferrin available for iron. It therefore also increases in ID and decreases in ACD

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117
Q

What is the triad of presentation of liver failure?

A

Encephalopathy, jaundice and coagulopathy

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118
Q

What do you call renal failure alongside acute liver failure?

A

Hepatorenal syndrome

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119
Q

What are 2 prerequisites needed before performing a urea breath test?

A
  1. No Abx in past 4 weeks

2. No PPIs/antisecretory drugs in the past 2 weeks

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120
Q

What are 3 classical features of carcinoid syndrome?

A

Abdo pain, diarrhoea and flushing

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121
Q

What is the investigation of choice for carcinoid tumours?

A

Urinary 5-HIAA

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122
Q

How can you manage carcinoid tumours?

A
  1. Somatostatin analogues e.g. octreotide

2. Cyproheptadine for diarrhoea

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123
Q

What substances are released by carcinoid tumours?

A

vasoactive amines (such as 5-HT, noradrenaline and dopamine), peptides (such as bradykinin) and prostaglandins which account for the symptoms

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124
Q

Why does GI carcinoid syndrome only occur when hepatic metastases arise?

A

Vasoactive products are inactivated by the liver

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125
Q

Name two conditions associated with coeliac disease?

A

T1DM and Autoimmune thyroid disease

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126
Q

What HLAs are coeliac disease associated with?

A

HLA-DQ2 and HLA-DQ8

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127
Q

What skin condition is associated with Coeliac disease?

A

Dermatitis herpetiformis

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128
Q

What are some complications of coeliac disease?

A
  1. Anaemia (iron, folate > B12 deficiency)
  2. Hyposplenism
  3. Osteoporosis, osteomalacia
  4. Lactose intolerance
  5. EATL
  6. Subfertility
  7. Rare = oesophageal cancer, other malignancies
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129
Q

What drug, other than antibiotics, is a risk factor for c diff colitis?

A

PPIs

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130
Q

What is acalculous cholecystitis?

A

Gallbladder inflammation in the absence of stons due to intercurrent illness e.g. diabetes, organ failure

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131
Q

What are 4 complications of ERCP?

A

Bleeding
Duodenal perforation
Cholangitis
Pancreatitis

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132
Q

What is used for the prophylaxis of oesophageal bleeding from varices?

A
  1. Propranolol

2. Endoscopic variceal band ligation > Endoscopic sclerotherapy

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133
Q

What is the most common cause of painless massive GI bleeding in an infant?

A

Meckel’s diverticulum

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134
Q

What is a cause of bubbly urine?

A

Enterovesical fistula

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135
Q

What is the most likely cause of an enterovesical fistula?

A

Colorectal malignancy

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136
Q

What is Goodsall’s rule for perianal fistulae?

A

It states that if the perianal skin opening is posterior to the transverse anal line, the fistulous tract will open into the anal canal in the midline posteriorly, sometimes taking a curvilinear course. A perianal skin opening anterior to the transverse anal line is usually associated with a radial fistulous tract

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137
Q

What drug can be used to help a high output fistula and why?

A

Octreotide, as it will tend to reduce the volume of pancreatic secretions

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138
Q

Which is more common, HNPCC or FAP?

A

HNPCC

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139
Q

What is the best way to screen for haemochromatosis in the general population?

A

Transferrin saturation

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140
Q

What is the M rule for PBC?

A
  1. IgM
  2. Anti-Mitochondrial Abs, M2 subtypes
  3. Middle aged females
141
Q

What is the classic presentation of PBC?

A

Itching in a middle aged woman

142
Q

What other disease do 70-80% people with PBC have (association)?

A

Sjogrens

143
Q

What skin change can you get with PBC?

A

Hyperpigmentation, especially over pressure points

144
Q

What anti-emetic is c/i in Parkinsons and why?

A

Metoclopramide as it is a dopamine antagonist so it may worsen symptoms

145
Q

What causes hepatic encephalopathy?

A

Accumulation of ammonia in the blood stream due to the livers decreased ability to detoxify ammonia that is produced and transported from the gastrointestinal tract

146
Q

How does lactulose help with hepatic encephalopathy?

A

Reduction of intestinal ammonia load through its action as a cathartic and its ability to inhibit ammoniagenic coliform bacteria by acidifying the colonic lumen

147
Q

What is second line prophylaxis for hepatic encephalopathy after lactulose?

A

Rifamixin (modulates gut flora resulting in reduced ammonia production)

148
Q

How does NICE define malnutrition?

A
  1. Body Mass Index (BMI) of less than 18.5
  2. Unintentional weight loss greater than 10% within the last 3-6 months
  3. BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months
149
Q

What percentage of the UK population are coeliacs?

A

1%

150
Q

What are the levels of anti-HBs levels we are aiming for after vaccination?

A

> 100mIU/ml, although >10 mIU/ml or more are accepted as enough to protect against infection

151
Q

What is the 1st line test for Coeliac disease?

A

Anti-TTG Abs

152
Q

What is SBBOS?

A

Small bowel bacterial overgrowth syndrome, characterised by excessive amounts of bacteria in the small bowel resulting in GI symptoms

153
Q

What are 3 RFs for SBBOS?

A
  1. Neonates with congenital GI abnormalities
  2. Scleroderma
  3. DM
154
Q

What is a differential for SBBOS?

A

IBS

155
Q

How does one diagnose SBBOS?

A
  1. Hydrogen breath test
  2. Small bowel aspiration and culture
  3. Course of Abx as diagnostic trial
156
Q

What is the management of SBBOS?

A
  1. Correction of underlying disorder

2. Abx therapy: Rifamixin (although co-amox and metronidazole are also effective in the majority of pts)

157
Q

What is the first line investigation for acute mesenteric ischaemia?

A

Serum lactate

158
Q

What is the WHO definition for diarrhoea?

A

> 3 loose or watery stools per day

159
Q

What is the WHO definition for acute diarrhoea?

A

<14 days

160
Q

What is the WHO definition for chronic diarrhoea?

A

> 14 days

161
Q

What is the sex ratio of PBC?

A

9F:1M

162
Q

What 4 conditions is PBC associated with?

A

Sjogrens
RA
Systemic sclerosis
Thyroid disease

163
Q

What is the management of PBC?

A
  1. Pruritis = cholestyramine
  2. Fat-soluble vitamin supplementation
  3. UDCA
  4. Liver transplantation if bilirubin >100
164
Q

What are 3 complications of PBC?

A
  1. Cirrhosis
  2. Osteomalacia and osteoporosis
  3. HCC
165
Q

Which IBD are perianal skin tags associated with?

A

Crohns Disease

166
Q

What is the first and second line treatments for inducing remission of Crohns?

A
  1. Steroids
  2. Mesalazine
  3. Azathioprine/mercaptopurine as add-on therapy
167
Q

What conservative measure must be taken in pts with Crohns?

A

Stop smoking

168
Q

What are the first and second line treatments for maintaining remission of Crohns?

A
  1. Azathioprine/mercaptopurine
  2. Methotrexate
  3. Mesalazine
169
Q

What percentage of Crohns patients will eventually have surgery?

A

80%

170
Q

What must be assessed before offering azathioprine or mercaptopurine?

A

TPMT activity (thiopurine methyltransferase)

171
Q

What electrolyte abnormality can PPIs cause?

A

Hyponatraemia (thought to cause SIADH)

172
Q

What are 4 complications of PPIs?

A
  1. Hyponatraemia, hypomagnaesaemia
  2. Osteoporosis
  3. Microscopic colitis
  4. C.diff
173
Q

What is it called when you have the sensation of having a ‘lump in the throat’ when there is one?

A

Globus hystericus (a.k.a. globus hystericus)

174
Q

What is the part of the colon most likely to be affected by ischaemic colitis?

A

The splenic flexure

175
Q

What is the single strongest RF for Barrett’s?

A

GORD

176
Q

How do you calculate units of alcohol?

A

(ml x ABV)/1000

177
Q

What are the most common organisms found on ascitic fluid culture with SBP?

A
  1. E. coli

2. Klebsiella

178
Q

What are the most common gram-positive organisms causing SBP?

A
  1. S. pneumoniae
  2. S. viridans
  3. S. aureus
179
Q

When should you give antibiotic prophylaxis for ascites?

A
  1. Pts who have had an episode of SBP

2. Fluid protein <15g/L/Child-Pugh >9/hepatorenal syndrome

180
Q

How can you differentiate between an upper GI and lower GI bleed?

A

Measure urea levels

181
Q

What is zollinger-ellison syndrome?

A

Condition characterised by excessive levels of gastrin, usually from a gastrin-secreting tumour of the duodenum or pancreas

182
Q

What syndrome is Zollinger Ellison syndrome associated with?

A

MEN 1

183
Q

How long before upper GI endoscopy should PPIs be prescribed?

A

2 weeks

184
Q

What is melanosis coli?

A

Abnormal pigmentation of the large bowel due to the presence of pigment-laden macrophages, most commonly due to laxative abuse

185
Q

Within what time frame should all pts with a suspected upper GI bleed have an endoscopy?

A

Within 24 hours

186
Q

What is the most likely cause of liver failure after a cardiac arrest?

A

Ischaemic hepatitis

187
Q

What are the types of hepatorenal syndrome?

A
  1. Rapid onset, usually following an acute event e.g. upper GI bleed
  2. Gradual decline, usually due to refractory ascites
188
Q

How can you manage hepatorenal syndrome?

A
  1. Terlipressin
  2. Volume expansion with 20% albumin
  3. TIPS
189
Q

What is the most accepted theory regarding the pathophysiology of HRS?

A

Splanchnic vasodilation

190
Q

What is the triad of Plummer-Vinson Syndrome?

A
  1. Dysphagia
  2. Glossitis
  3. IDA
191
Q

Which vessels does a TIPS join together?

A

The hepatic vein and portal vein

192
Q

What is the main benefit of prescribing albumin when treating large volume ascites?

A

It reduces postparacentesis circulatory dysfunction

193
Q

What is SAAG

A

Serum-ascites albumin gradient

194
Q

What ‘cover’ needs to be given when performing therapeutic abdominal paracentesis?

A

Albumin

195
Q

What should be given to pts with ascites (with protein <15g/L) for prophylaxis against SBP?

A

Ciprofloxacin

196
Q

Peutz-Jeghers inheritance?

A

AD

197
Q

Peutz-Jeghers features?

A
  1. Hamartomatous polyps in GI tract
  2. Hyperpigmentation on lips, oral mucosa, face, palms and soles
  3. Intestinal obstruction e.g. intussusception
  4. GI bleeding
198
Q

Peutz-Jeghers tx?

A

Conservative unless complications develop

199
Q

Truelove and Witts criteria for UC?

A
  1. Mild = <4 stools/day, only a small amount of blood
  2. Moderate = 4-6 stools/day, varying amounts of blood, no systemic upset
  3. Severe = >6 bloody stools per day + features of systemic upset
200
Q

Vit C aka?

A

Ascorbic acid

201
Q

Scurvy pathophysiology?

A

Vit C is a cofactor for enzymes used in the production of proline and lysine, required for collagen synthesis

202
Q

Perifollicular haemorrhage?

A

Vitamin C deficiency

203
Q

Follicular hyperkeratosis?

A

Vitamin C deficiency

204
Q

Grading of hepatic encephalopathy?

A
  1. Irritability
  2. Confusion, inappropriate behaviour
  3. Incoherent, restless
  4. Coma
205
Q

Mx of hepatic encephalopathy?

A
  1. Treat underlying cause
  2. Lactulose (promotes excretion of ammonia and increases metabolism of ammonia by gut bacteria)
  3. Rifamixin (modulates gut flora resulting in decreased ammonia production)
206
Q

2 medications that cause hyponatraemia?

A
  1. PPIs

2. SSRIs

207
Q

PPI MOA?

A

Irreversible blockade of the H+/K+ ATPase of the gastric parietal cell

208
Q

S/e of PPIs?

A
  1. Hyponatraemia, hypomagnasaemia
  2. Osteoporosis
  3. Microscopic colitis
  4. C.diff colitis risk
209
Q

Abdo pain and fever in pts with cirrhosis and portal HTN?

A

Spontaneous Bacterial Peritonitis

210
Q

Spontaneous Bacterial Peritonitis definition?

A

An ascitic fluid infection without an evident treatable intra-abdominal source

211
Q

SBP diagnosis?

A

Neutrophil count >250 cells/ul on paracentesis

212
Q

Most common organism found on ascitic fluid culture of SBP?

A

E. coli

213
Q

Abx for SBP?

A

IV Cefotaxime

214
Q

When is Abx prophylaxis given for SBP?

A
  1. Pts who have had an episode of SBP

2. Fluid protein <15 g/l and hepatorenal syndrome/high Child-Pugh score

215
Q

Abx prophylaxis for SBP?

A

Oral ciprofloxacin

216
Q

Achalasia Hx?

A
  1. Dysphagia of both liquids and solids from the start
  2. Heartburn
  3. Regurgitation of food
217
Q

Classification of dysphagia?

A
  1. Extramural
  2. Mural
  3. Intramural
  4. Neurological
218
Q

Extramural causes of dysphagia?

A
  1. Mediastinal masses

2. Cervical spondylosis

219
Q

Mural causes of dysphagia?

A
  1. Achalasia
  2. Oesophageal spasm
  3. Hypertensive LOS
220
Q

Intramural causes of dysphagia?

A
  1. Tumours
  2. Strictures
  3. Oesophageal web
  4. Schatzki rings
221
Q

Neuro causes of dysphagia?

A
  1. CVA
  2. Parkinsons
  3. MS
  4. Brainstem pathology
  5. Myasthenia Gravis
222
Q

Initial management of severe alcoholic hepatitis?

A

Prednisolone 40mg/day for 28 days

223
Q

Bleeding gums?

A

Scurvy

224
Q

Swam in pool on holiday, now has diarrhoea that floats, what infection?

A

Giardia lamblia - causes fat malabsorption and is resistant to chlorination in swimming pools

225
Q

When is biologic therapy considered for acute tx of Crohns?

A

When symptoms don’t improve after 5 days of IV hydrocortisone

226
Q

Commonest disease pattern in Crohns?

A

Stricturing terminal ileal disease

227
Q

4 risks of ERCP?

A
  1. Bleeding
  2. Duodenal perforation
  3. Cholangitis
  4. Pacnreatitis
228
Q

Mallory Weiss syndrome pathophysiology?

A

Severe vomiting –> painful mucosal lacerations at the GOJ resulting in haematemesis

229
Q

What is Wilsons disease?

A

An autosomal recessive disorder characterised by excess copper deposition in tissues

230
Q

Blue nails?

A

Wilsons disease

231
Q

How to differentiate between IBS and IBD in primary care?

A

Faecal calprotectin

232
Q

Hx of CVD, high lactate, and soft but tender abdomen?

A

Mesenteric ischaemia

233
Q

Mx of acute mesenteric ischaemia?

A

Urgent surgery

234
Q

Ix for Dx of PSC?

A

MRCP as it is sensitive and non-invasive

235
Q

When may ERCP be used instead of MRCP?

A
  1. Therapeutic procedure can also be done

2. If cant tolerate MRCP due to metal implants

236
Q

What is PSC?

A

Biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts

237
Q

What percentage of UC pts have PSC?

A

4%

238
Q

What percentage of PSC pts have UC?

A

80%

239
Q

3 associations of PSC?

A
  1. UC
    2, Crohns
  2. HIV
240
Q

Features of PSC?

A
  1. Cholestasis: jaundice and pruritis
  2. RUQ pain
  3. Fatigue
241
Q

Ix for PSC?

A
  1. MRCP (or ERCP) with multiple biliary strictures giving a ‘beaded’ apperance
  2. ANCA may be positive
  3. Biopsy –> ‘onion skin’ fibrous, obliterative cholangitis
242
Q

Complications of PSC?

A
  1. Cholangiocarcinoma (in 10%)

2. Inreased risk of colorectal carcinoma

243
Q

Peutz Jeghers mutations?

A

LKB1 or STK11

244
Q

What Ix do pts with GORD being considered for fundoplication surgery require?

A

Oesopheageal pH and manometry studies

245
Q

What is ferritin?

A

An intracellular protein that binds iron and stores it to be released in a controlled fashion at sites where iron is required

246
Q

Increased ferritin levels?

A
  1. > 300 ug/L in men/postmenopausal women

2. >200 ug/L in premenopausal women

247
Q

Liver biopsy of autoimmune hepatitis?

A

Piecemeal necrosis

248
Q

Management of liver abscess?

A

Abx and drainage

249
Q

What abx are given for a pyogenic liver abscess?

A

Amoxicillin + ciprofloxacin + metronidazole

250
Q

Most common organisms found in pyogenic liver abscesses?

A
  1. S. aureus in children

2. E. coli in adults

251
Q

Diagnostic marker for carcinoid syndrome?

A

24hr urinary 5-HIAA (hydroxyindoleacetic acid)

252
Q

C.diff antigen positive, c.diff toxin negative management?

A

Reassure and monitor, as antigen positivity only shows exposure to bacteria rather than current infection

253
Q

Why is a sushi chef predisposed to oesophageal carcinoma?

A

Fish is high in nitrosamines, a known carcinogen

254
Q

Pharyngeal pouch epidemiology?

A

More common in older pts, 5x more common in men

255
Q

Mx of pharyngeal pouch?

A

Surgery

256
Q

What vitamin is teratogenic in high doses?

A

Vitamin A

257
Q

Vitamin A aka?

A

Retinol

258
Q

Vitamin A deficiency presentation?

A

Night blindness

259
Q

Simple way to describe NAFLD?

A

A hepatic manifestation of metabolic syndrome, and hence insulin resistance is thought to be the key mechanism leading to steatosis

260
Q

Mx of NAFLD?

A
  1. Lifestyle changes

2. Gastric banding and metformin, pioglitazone (insulin sensitising drugs) in the future

261
Q

Classification of raised ferritin?

A
  1. W/ iron overload (10%)

2. W/o iron overload (90%)

262
Q

Causes of raised ferritin w/o iron overload?

A
  1. Inflammation
  2. Alcohol
  3. Liver disease
  4. CKD
  5. Malignancy
263
Q

Causes of raised ferritin w/ iron overload?

A
  1. Primary iron overload = Hereditary haemochromatosis

2. Secondary iron overload = e.g. following repeated transfusions

264
Q

Test to see if iron overload is presnet?

A

Transferrin saturation

265
Q

3 types of colon cancer?

A
  1. Sporadic (95%)
  2. HNPCC (5%)
  3. FAP (<1%)
266
Q

HNPCC inheritance?

A

AD

267
Q

How many mutations identified for HNPCC?

A

7

268
Q

Name of criteria for HNPCC Dx?

A

Amsterdam (3-2-1 rule)

269
Q

2 most common cancers associated with HNPCC?

A
  1. Colorectal

2, Endometrial

270
Q

Gold standard ix for osesophageal cancer?

A

Endoscopy

271
Q

Jaundice, abdo pain and pruritis in pregnancy?

A

Acute fatty liver of pregnancy

272
Q

What is the classification system for severity of Liver cirrhosis?

A

Child-Pugh

273
Q

5 criteria in Child Pugh scoring system for liver cirrhosis?

A
  1. Bilirubin
  2. Albumin
  3. PT
  4. Encephalopathy
  5. Ascites
274
Q

Child-Pugh grades?

A
  1. A = <7
  2. B = 7-9
    3/ C = >9
275
Q

MELD?

A

Model for End Stage Liver disease, uses a combination of 3 factors to predict mortality of liver cirrhosis

  1. Bilirubin
  2. Creatinine
  3. INR
276
Q

What is Murphy’s sign?

A

Arrest of inspiration on palpation of the RUQ, a sign of acute cholecystitis

277
Q

What is the pathophysiology of hepatorenal syndrome?

A
  1. Vasoactive mediators cause splanchnic vasodilation which in turn reduces systemic vascular resistance, resulting in ‘underfilling’ of he kidneys
  2. Sensed by the JGA which then activates RAAS, causing renal vasoconstriction not enough to counterbalance the effects of splanchnic vasodilation
278
Q

Types of hepatorenal syndrome?

A
  1. Type I = rapidly progressive, poor prognosis, doubling of creatinine in less than 2 weeks
  2. Type II = slowly progressive, prognosis still poor but may live for longer
279
Q

Mx of hepatorenal syndrome?

A
  1. Volume expansion with 20% albumin
  2. VP analogues e.g. Terlipressin (cause splanchnic vasoconstriction)
  3. TIPSS
280
Q

Vitamin B3 aka?

A

Niacin

281
Q

Role of niacin (vit B3)?

A

Precursor to NAD+ and NADP+ and hence plays an essential metabolic role in cells

282
Q

Consequence of niacin deficiency?

A

Pellagra (diarrhoea, dementia, dermatitis)

283
Q

Vitamin B1 deficiency?

A

Beriberi

284
Q

Types of beriberi?

A
  1. Wet = tachypnoea, dyspnoea, pedal oedema

2. Dry = pain, paraesthesia, confusion

285
Q

What is Wernicke-Korsakoff syndrome a type of?

A

A type of dry beri beri

286
Q

Raised ferritin, raised transferrin saturation, low TIBC?

A

Hereditary haemochromatosis

287
Q

What is the function of transferrin?

A

Main protein that transports iron in the blood

288
Q

First line tx for HH?

A

Venesection

289
Q

Joint XR in HH?

A

Chondrocalcinosis

290
Q

Most common site affected in UC?

A

Rectum

291
Q

Peak incidence of UC?

A
  1. 15-25 y/o

2. 55-65 y/o

292
Q

Test for H.pylori post-eradication therapy?

A

Urea breath test

293
Q

Features of pancreatic cancer?

A
  1. Painless jaundice
  2. Loss of exocrine function = steatorrhoea
  3. Loss of endocrine function = DM
  4. Atypical back pain
  5. Trousseau’s sign
294
Q

Ix for pancreatic cancer

A
  1. US

2. High resolution CT

295
Q

Mx of pancreatic cancer?

A
  1. Less than 20% suitable for surgery at diagnosis
  2. Whipple’s resection for resectable lesions at the head of the pancreas
  3. Adjuvant chemo following surgery
  4. ERCP with stenting for palliation
296
Q

S/e of whipple’s procedure?

A
  1. Dumping syndrome

2. Peptic ulcer disease

297
Q

What is dumping syndrome?

A
  1. When food, especially sugar, moves too quickly from the stomach to the duodenum (rapid gastric emptying).
  2. Mostly associated with conditions following gastric or esophageal surgery,
298
Q

Liver and neuro disease?

A

Wilson’s disease

299
Q

Acute upper GI bleed scores at first assessment and after endoscopy?

A
  1. Blatchford score

2. Rockall score

300
Q

Vitamin B6 aka?

A

Pyridoxine

301
Q

2 consequences of Vit B6 deficiency?

A
  1. Peripheral neuropathy

2. Sideroblastic anaemia

302
Q

Ix of achalasia?

A
  1. Manometry = excessive LOS tone which doesnt relax on swallowing
  2. Barium swallow = ‘bird’s beak’ appearance, grossly expanded oesophagus, fluid level
  3. CXR = wide mediastinum, fluid level
303
Q

Mx of achalasia?

A
  1. Intra-sphincteric injection of botulinum toxin
  2. Heller’s cardiomyotomy
  3. Pneumatic (balloon) dilatation
304
Q

MOA of metoclopramide?

A

D2 receptor antagonist

305
Q

Uses of metoclopramide?

A
  1. GORD
  2. Prokinetic action useful in DN gastroparesis
  3. Combined with analgesics for tx of migraine
306
Q

S/e of metoclopramide?

A
  1. EPSE e.g. oculogyric crisis
  2. Hyperprolactinaemia
  3. Tardive dyskinesia
  4. Parkinsonism
307
Q

Should metoclopramide be avoided in bowel obstruction?

A

Yes

308
Q

Best measures of synthetic function of the liver?

A

PT and albumin levels

309
Q

Severe nausea and sudden vomiting, prodromal intense sweating and nausea?

A

Cyclical vomiting syndrome

310
Q

Dx of cyclical vomiting syndrome?

A

Clinical

311
Q

IBD with crypt abscesses?

A

UC

312
Q

IBD with increased goblet cells and granulomas?

A

Crohns

313
Q

Kantor’s string sign?

A

Crohns

314
Q

Rose thorn ulcers?

A

Crohns

315
Q

Loss of haustrations on barium enema?

A

UC

316
Q

Pseudopolyps?

A

UC

317
Q

Long term PPIs can mask the signs of what cancer?

A

Gastric

318
Q

How can PPIs increase chance of fractures?

A

Due to malabsorption of calcium and magnesium

319
Q

Signet ring cells?

A

Gastric adenocarcinoma

320
Q

Dx of gastric cancer?

A

Endoscopy with biopsy

321
Q

Assessing mural invasion in oesophageal/gastric cancer?

A

Endoscopic US

322
Q

Ab for PSC?

A

pANCA

323
Q

How to stop oesophageal variceal bleeding?

A
  1. Variceal band ligation

2. Sengstaken tube and TIPSS if this fails

324
Q

Prophylaxis of variceal bleeding?

A
  1. Propranolol

2. Endoscopic variceal band ligation

325
Q

Methotrexate for UC?

A

ABSOLUTELY NOT

326
Q

4 RFs for Barrett’s oesophagus?

A
  1. GORD
  2. Male gender (7:1)
  3. Smoking
  4. Central obesity
327
Q

Mx of Barrett’s?

A
  1. Endoscopic surveillance with biopsies

2. High dose PPI therapy

328
Q

Endoscopic surveillance for Barrett’s frequency?

A

Every 3-5 years

329
Q

Mx of dysplasia found on Barrett’s surveillance?

A
  1. Endoscopic mucosal resection

2. RFA

330
Q

3 complications of Crohns?

A
  1. Small bowel cancer
  2. Colorectal cancer
  3. Osteoporosis
331
Q

Alcohol units/wk?

A

Max 14/wk for men and women

332
Q

How to calculate units of alcohol?

A

Multiply number of ml by ABV and divide by 1000

333
Q

SAAG > 11g/L indicates what?

A

Portal HTN

334
Q

Mx of ascites?

A
  1. Reduce dietary sodium
  2. Fluid restriction
  3. Spironolactone
  4. Therapeutic abdominal paracentesis
  5. Prophylactic Abx
  6. TIPSS
335
Q

Ix of choice to detect liver cirrhosis?

A

Transient elastography (Fibroscan)

336
Q

Watery travellers diarrhoea with stomach cramps and nausea?

A

Enterotoxigenic E coli

337
Q

Boerhaave’s perforation triad?

A

The Mackler Triad:

  1. Vomiting
  2. Thoracic pain
  3. Subcutaneous emphysema
338
Q

Plummer Vinson syndrome triad?

A
  1. Dysphagia (secondary to oesophageal webs)
  2. Glossitis
  3. IDA
339
Q

Mx of Plummer Vinson syndrome?

A

Iron supplementation and dilatation of the webs

340
Q

Coffee bean sign?

A

Sigmoid volvulus

341
Q

Carcinoid syndrome heart effect?

A

TIPS

Tricuspid insufficiency and pulmonary stenosis

342
Q

H. pylori eradication?

A
  1. PPI + amoxicillin + clarithromycin

2. PPI + metronidazole + clarithromycin

343
Q

H. pylori associations?

A
  1. Peptic ulcer disease
  2. Gastric caner
  3. Gastric MALToma
  4. Atrophic gastritis
344
Q

Best 1st line management for NAFLD?

A

Weight loss

345
Q

Coeliac disease deficiencies?

A
  1. Iron
  2. Folate
  3. Vitamin B12
346
Q

How long pts must eat gluten before being tested for Coeliacs?

A

6 weeks

347
Q

Melanosis coli?

A

Disorder of pigmenation of the bowel, associated with laxative abuse

348
Q

Pigment-laden macrophages?

A

Melanosis coli

Medicine and Surgery Mushkies (52 decks)

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