Passmed Gastro Mushkies Flashcards
1
Q
4 things that contain gluten?
A
Wheat
Barley
Rye
Oats
2
Q
3 notable gluten free foods?
A
Rice
Potatoes
Corn (Maize)
3
Q
Why are patients with coeliac disease offered the pneumococcal vaccine?
A
They have a degree of functional hyposplenism
4
Q
What is GORD?
A
Symptoms of oesophagitis secondary to refluxed gastric contents
5
Q
Complications of GORD?
A
BABUO Barrett's oesophagus Anaemia Benign Strictures Ulcers Oesophagitis Oesophageal carcinoma
6
Q
Tx of GORD?
A
- Endoscopically proven = PPi 1-2m, if responsive then low dose tx, if no response then double dose PPI for 1 month
- Endoscopically negative = PPi 1m, if response then offer low dose tx, if no response then H2RA or prokinetic for 1m
7
Q
5 features suggestive of hypernatraemic dehydration?
A
- Jittery movements
- Increased muscle tone
- Hyperreflexia
- Convulsions
- Drowsiness or coma
8
Q
Most common cause of gastroenteritis in children?
A
Rotavirus
9
Q
3 drugs that cause liver cirrhosis?
A
MMA
- Methotrexate
- Methyldopa
- Amiodarone
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
11
Q
Scoring to assess an acute upper GI bleed?
A
Blatchford score
12
Q
What score can be used to assess an acute upper GI bleed after endoscopy?
A
Rockall score
13
Q
What are the components of the Blatchford score?
A
- Urea
- Haemoglobin
- Systolic BP
- Other = Pulse, melaena, syncope, hepatic disease, cardiac failure
14
Q
What is the management of an acute upper Gi bleed?
A
- Resuscitation = ABC, IV wide bore access, plt transfusion if <50 x10*9, FFP if fibrinogen <1g/L or APTT >1.5x normal
- Endoscopy
- Variceal vs. non-variceal?
15
Q
What is the additional management for a non-variceal bleed?
A
- Dont use PPI until after endoscopy
2. If further bleeding –> repeat endoscopy, interventional radiology, surgery
16
Q
What is the additional management for a variceal bleed?
A
- Terlipressin and prophylactic Abx
- Oesophageal = band ligation, Gastric varices = N-butyl-2-cyanoacrylate
- TIPS last line
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)
18
Q
What may you see on endoscopy with UC?
A
Pseudopolyps
19
Q
What kind of ulcers may you see on radiology with Crohns?
A
Rose thorn ulcers
20
Q
What is the best first line management for NAFLD?
A
Weight loss
21
Q
What is the most common cause of liver disease in the developed world?
A
NAFLD
22
Q
What blood test can be used to identify NAFLD?
A
Enhanced liver fibrosis (ELF) blood test
23
Q
What are the components of the ELF test?
A
- Hyaluronic acid
- Procollagen III
- Tissue inhibitor of metalloproteinase 3
24
Q
How does a fibroscan work?
A
Liver stiffness measurement assessed with transient elastography
25
What are 3 early signs of haemochromatosis?
Fatigue, erectile dysfunction and arthralgia
26
What is haemochromatosis?
An autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation
27
What causes haemochromatosis?
Mutations of the HFE gene on Chromosome 6
28
What is the prevalence of haemochromatosis?
Prevalence in people of European descent = 1/200
29
What are the complications of haemochromatosis?
1. Reversible = cardiomyopathy, skin pigmentation
| 2. Irreversible = liver cirrhosis, DM, arthropathy, hypogonadotrophic hypogonadism
30
What are the presenting features of haemochromatosis? x6
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
31
Pain when hungry and relieved by eating?
Duodenal ulcer
32
What are risk factors for peptic ulcer disease?
1. Alcohol
2. NSAIDs
3. SSRIs
33
What kind of peptic ulcer is more common?
Duodenal ulcers
34
What is the first line management of hepatic encephalopathy and why?
Lactulose, because it inhibits production of ammonia in the intestine and thus reduced hyperammonaemia
35
How can you grade hepatic encephalopathy?
Grade I = irritability
Grade II = confusion/inappropriate behaviour
Grade III = incoherent
grade IV = coma
36
What antibiotic can be used to treat hepatic encephalopathy and why?
Rifaximin, as it modulates gut flora thus resulting in decreased ammonia production
37
How can you classify the severity of UC?
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)
38
What is the management of mild/moderate UC?
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)
39
What is the management of severe UC?
1. IV steroids (IV ciclosporine if steroid c/i)
| 2. If after 72hrs there has been no improvement, add IV ciclosporine or consider surgery
40
How do you maintain remission in mild/moderate UC?
1. Proctitis and proctosigmoiditis --> topical aminosalicylate +/- oral aminosalicylate
2. L sided and extensive = oral aminosalicylate
41
How do you maintain remission after a severe UC relapse or after >1 exacerbations in the past year:
Oral azothioprine/oral mercaptopurine
42
What may be a cause of an acute flare of up Hep B?
Hepatitis D superinfection
43
What kind of virus is Hep D?
ssRNA
44
What is the scoring system for a flare up of UC?
Truelove and Witts
45
What are the Truelove and Witts criteria for severe UC?
>6 stools per day + 1 of:
1. Temp > 37.8C
2. HR > 90
3. Anaemia <105
4. ESR > 30mm/hr
46
What do you see on investigation of Crohns?
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
47
What are the liver findings of RHF?
A smooth, tender and pulsatile liver edge
48
What kind of cancer is associated with Barrett's?
Oesophageal adenocarcinoma
49
What are 4 RFs for oesophageal carcinoma?
```
Alcohol
Smoking
GORD
Barrett's oesophagus
Achalasia
Plummer-Vinson syndrome
```
50
What kind of tube can be used to manage a variceal haemorrhage?
Sengstaken-Blakemore tube
51
What can be used for prophylaxis of variceal haemorrhage?
1. Propranolol
| 2. Endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy
52
What regular prescription is a risk factor for C diff infection?
PPIs
53
What does C diff release that causes pseudomembranous colitis?
Exotoxin
54
How does one diagnose C diff colitis?
1. C diff toxin (CDT) in stool
| 2. C diff antigen positivity only shows exposure to the bacteria rather than current infection
55
What is the first line tx of C diff colitis?
Oral metronidazole 10-14 days
56
What is the most common cause of HCC worldwide?
Hep B
57
What is the most common cause of HCC in Europe?
Hep C
58
What are 2 scoring systems for liver cirrhosis?
1. Child-Pugh
| 2. Model for End Stage Liver Disease (MELD)
59
What are the components of Child-Pugh classification?
BAPEA (each one out of 3, total /15)
1. Bilirubin
2. Albumin
3. PT
4. Encephalopathy
5. Ascites
60
What is the score for Child-Pugh Score A?
<7
61
What is the score for Child-Pugh Score B?
7-9
62
What is the score for Child-Pugh Score C?
>9
63
What are the components of the MELD score?
```
A combination of patient's
1. Bilirubin
2. Creatinine
3. INT
to predict survival, a formula is used to calculate the score
```
64
What are serum caeruloplasmin, serum copper, and urinary copper levels in Wilsons?
1. Serum caeruloplasmin reduced
2. Serum copper reduced
3. Increased 24hr urinary copper excretion
65
What causes wilsons disease?
Mutation in ATP7B gene on chromosome 13, leading to increased copper absorption from the small intestine and decreased hepatic copper excretion
66
What are the features of Wilsons disease?
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
67
What is the first line treatment for wilsons?
Penicillamine (copper chelator)
68
What must be given prior to an appendicectomy?
Prophylactic Abx
69
What are anti-smooth muscle antibodies a marker of?
Autoimmune hepatitis
70
What HLA is autoimmune hepatitis associated with?
HLA DR3
71
How many types of autoimmune hepatitis are there?
3
72
What is the epidemiology and antibody of Type I autoimmune hepatitis?
1. Adults and children
| 2. Anti-smooth muscle antibodies
73
What is the epidemiology and antibody of Type II autoimmune hepatitis?
1. Children
| 2. Anti-liver/kidney microsomal type 1 antibodies (LKM1)
74
What is the epidemiology and antibody of Type III autoimmune hepatitis?
1. Adults
| 2. Soluble liver-kidney antigen
75
How can you manage autoimmune hepatitis?
1. Steroids
2. Immunosuppresants e.g. azathioprine
3. Liver transplantation
76
What is the first line treatment for IBS with regards to:
1. Pain
2. Constipation
3. Diarrhoea
1. Antispasmodic agents
2. Laxatives but avoid lactulose
3. Loperamide
77
What is the MOA of loperamide?
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
78
What can be considered for pts with IBS with constipation who have not responded to conventional laxatives?
Linaclotide
79
What is the 2nd line treatment for IBS?
Low dose TCA e.g. amitryptiline
80
What psychological intervention can be given for IBS?
CBT
81
What is a s/e of metoclopramide?
EPSEs e.g. acute dystonia
82
What is the MOA of metoclopramide?
D2 receptor antagonist
83
What are 4 uses of metoclopramide?
1. Nausea
2. GORD
3. Prokinetic for gastroparesis secondary to diabetic neuropathy
4. Combined with analgesics for migraine
84
How does metoclopramide exert its anti-emetic action?
D2 receptors in the CTZ
85
What causes itchiness in CKD?
Uraemic pruritis
86
When does jaundice start to appear?
When bilirubin reaches an excess of 35umol/l
87
What blood marker may rise due to an upper GI bleed and why?
Urea, as an upper GI bleed can act as a 'protein meal' and cause a temporary, disproportionate rise in the urea
88
What is the marker for HCC?
AFP
89
What is the management for a liver abscess?
IV Abx + image guided percutaneous drainage
90
What is the first line management for a hydatid cyst?
Surgical resection
91
What are the most common organisms found in pyogenic liver abscesses?
S. aureus and E. coli
92
What is haemochromatosis?
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
93
What are the haematinics for a pt with haemochromatosis?
1. Raised ferritin
2. Raised transferrin
3. Low TIBC
94
What can you see on X-ray of joints in pts with haemochromatosis?
Chondrocalcinosis
95
What is the mainstay of treatment in haemochromatosis?
Regular venesection
96
What kind of cancer is achalasia is risk factor for?
Squamous cell carcinoma of the oesophagus
97
What is the NICE definition of malnutrition?
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
98
What is the gram stain and shape of C.dif?
Gram positive rod
99
When should metoclopramide be avoided?
In bowel obstruction, as it is a pro-kinetic and could thus cause a perforation
100
Does diarrhoea or constipation act as a trigger for liver decompensation in cirrhotic pts?
Constipation
101
What is a fibroscan?
Transient elastography, measures 'stiffness' of the liver which is a proxy for fibrosis
102
How long do pts with C diff need isolation for?
At least 48hrs
103
What is the triad of presentation of chronic mesenteric ischaemia?
1. Severe colicky post prandial abdo pain
2. Weight loss
3. Upper abdominal bruit
104
How can you classify ischaemia to the lower GI tract?
1. acute mesenteric ischaemia
2. chronic mesenteric ischaemia
3. ischaemic colitis
105
What is the management of acute mesenteric ischaemia?
Urgent surgery
106
What may be seen on abdo x-ray in ischaemic colitis?
Thumbprinting, due to mucosal oedema/haemorrhage
107
What is the investigation of choice for acute mesenteric ischaemia?
CT
108
Where is ischaemic colitis most likely to occur?
Watershed areas like the splenic flexure
109
What are the causes of acute pancreatitis?
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
110
What is the management of Barrett's oesophagus?
High dose PPI and endoscopic surveillance every 3-5 years
111
What is the increased risk of oesophageal carcinoma with Barrett's?
50-100 fold
112
What is not an independent risk factor for Barrett's although it is associated with both GORD and oesophageal cancer?
Alcohol
113
What can be done if dysplasia is seen upon screening for Barrett's?
Endoscopic mucosal resection or RFA
114
What does transferrin do and how does it behave in states of iron deficiency?
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
115
What is the transferrin level in ACD and why?
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.
116
How does TIBC differ between IDA and ACD and why?
TIBC measures the number of binding sites on transferrin available for iron. It therefore also increases in ID and decreases in ACD
117
What is the triad of presentation of liver failure?
Encephalopathy, jaundice and coagulopathy
118
What do you call renal failure alongside acute liver failure?
Hepatorenal syndrome
119
What are 2 prerequisites needed before performing a urea breath test?
1. No Abx in past 4 weeks
| 2. No PPIs/antisecretory drugs in the past 2 weeks
120
What are 3 classical features of carcinoid syndrome?
Abdo pain, diarrhoea and flushing
121
What is the investigation of choice for carcinoid tumours?
Urinary 5-HIAA
122
How can you manage carcinoid tumours?
1. Somatostatin analogues e.g. octreotide
| 2. Cyproheptadine for diarrhoea
123
What substances are released by carcinoid tumours?
vasoactive amines (such as 5-HT, noradrenaline and dopamine), peptides (such as bradykinin) and prostaglandins which account for the symptoms
124
Why does GI carcinoid syndrome only occur when hepatic metastases arise?
Vasoactive products are inactivated by the liver
125
Name two conditions associated with coeliac disease?
T1DM and Autoimmune thyroid disease
126
What HLAs are coeliac disease associated with?
HLA-DQ2 and HLA-DQ8
127
What skin condition is associated with Coeliac disease?
Dermatitis herpetiformis
128
What are some complications of coeliac disease?
1. Anaemia (iron, folate > B12 deficiency)
2. Hyposplenism
3. Osteoporosis, osteomalacia
4. Lactose intolerance
5. EATL
6. Subfertility
7. Rare = oesophageal cancer, other malignancies
129
What drug, other than antibiotics, is a risk factor for c diff colitis?
PPIs
130
What is acalculous cholecystitis?
Gallbladder inflammation in the absence of stons due to intercurrent illness e.g. diabetes, organ failure
131
What are 4 complications of ERCP?
Bleeding
Duodenal perforation
Cholangitis
Pancreatitis
132
What is used for the prophylaxis of oesophageal bleeding from varices?
1. Propranolol
| 2. Endoscopic variceal band ligation > Endoscopic sclerotherapy
133
What is the most common cause of painless massive GI bleeding in an infant?
Meckel's diverticulum
134
What is a cause of bubbly urine?
Enterovesical fistula
135
What is the most likely cause of an enterovesical fistula?
Colorectal malignancy
136
What is Goodsall's rule for perianal fistulae?
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
137
What drug can be used to help a high output fistula and why?
Octreotide, as it will tend to reduce the volume of pancreatic secretions
138
Which is more common, HNPCC or FAP?
HNPCC
139
What is the best way to screen for haemochromatosis in the general population?
Transferrin saturation
140
What is the M rule for PBC?
1. IgM
2. Anti-Mitochondrial Abs, M2 subtypes
3. Middle aged females
141
What is the classic presentation of PBC?
Itching in a middle aged woman
142
What other disease do 70-80% people with PBC have (association)?
Sjogrens
143
What skin change can you get with PBC?
Hyperpigmentation, especially over pressure points
144
What anti-emetic is c/i in Parkinsons and why?
Metoclopramide as it is a dopamine antagonist so it may worsen symptoms
145
What causes hepatic encephalopathy?
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
How does lactulose help with hepatic encephalopathy?
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
What is second line prophylaxis for hepatic encephalopathy after lactulose?
Rifamixin (modulates gut flora resulting in reduced ammonia production)
148
How does NICE define malnutrition?
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
What percentage of the UK population are coeliacs?
1%
150
What are the levels of anti-HBs levels we are aiming for after vaccination?
>100mIU/ml, although >10 mIU/ml or more are accepted as enough to protect against infection
151
What is the 1st line test for Coeliac disease?
Anti-TTG Abs
152
What is SBBOS?
Small bowel bacterial overgrowth syndrome, characterised by excessive amounts of bacteria in the small bowel resulting in GI symptoms
153
What are 3 RFs for SBBOS?
1. Neonates with congenital GI abnormalities
2. Scleroderma
3. DM
154
What is a differential for SBBOS?
IBS
155
How does one diagnose SBBOS?
1. Hydrogen breath test
2. Small bowel aspiration and culture
3. Course of Abx as diagnostic trial
156
What is the management of SBBOS?
1. Correction of underlying disorder
| 2. Abx therapy: Rifamixin (although co-amox and metronidazole are also effective in the majority of pts)
157
What is the first line investigation for acute mesenteric ischaemia?
Serum lactate
158
What is the WHO definition for diarrhoea?
>3 loose or watery stools per day
159
What is the WHO definition for acute diarrhoea?
<14 days
160
What is the WHO definition for chronic diarrhoea?
>14 days
161
What is the sex ratio of PBC?
9F:1M
162
What 4 conditions is PBC associated with?
Sjogrens
RA
Systemic sclerosis
Thyroid disease
163
What is the management of PBC?
1. Pruritis = cholestyramine
2. Fat-soluble vitamin supplementation
3. UDCA
4. Liver transplantation if bilirubin >100
164
What are 3 complications of PBC?
1. Cirrhosis
2. Osteomalacia and osteoporosis
3. HCC
165
Which IBD are perianal skin tags associated with?
Crohns Disease
166
What is the first and second line treatments for inducing remission of Crohns?
1. Steroids
2. Mesalazine
3. Azathioprine/mercaptopurine as add-on therapy
167
What conservative measure must be taken in pts with Crohns?
Stop smoking
168
What are the first and second line treatments for maintaining remission of Crohns?
1. Azathioprine/mercaptopurine
2. Methotrexate
3. Mesalazine
169
What percentage of Crohns patients will eventually have surgery?
80%
170
What must be assessed before offering azathioprine or mercaptopurine?
TPMT activity (thiopurine methyltransferase)
171
What electrolyte abnormality can PPIs cause?
Hyponatraemia (thought to cause SIADH)
172
What are 4 complications of PPIs?
1. Hyponatraemia, hypomagnaesaemia
2. Osteoporosis
3. Microscopic colitis
4. C.diff
173
What is it called when you have the sensation of having a 'lump in the throat' when there is one?
Globus hystericus (a.k.a. globus hystericus)
174
What is the part of the colon most likely to be affected by ischaemic colitis?
The splenic flexure
175
What is the single strongest RF for Barrett's?
GORD
176
How do you calculate units of alcohol?
(ml x ABV)/1000
177
What are the most common organisms found on ascitic fluid culture with SBP?
1. E. coli
| 2. Klebsiella
178
What are the most common gram-positive organisms causing SBP?
1. S. pneumoniae
2. S. viridans
3. S. aureus
179
When should you give antibiotic prophylaxis for ascites?
1. Pts who have had an episode of SBP
| 2. Fluid protein <15g/L/Child-Pugh >9/hepatorenal syndrome
180
How can you differentiate between an upper GI and lower GI bleed?
Measure urea levels
181
What is zollinger-ellison syndrome?
Condition characterised by excessive levels of gastrin, usually from a gastrin-secreting tumour of the duodenum or pancreas
182
What syndrome is Zollinger Ellison syndrome associated with?
MEN 1
183
How long before upper GI endoscopy should PPIs be prescribed?
2 weeks
184
What is melanosis coli?
Abnormal pigmentation of the large bowel due to the presence of pigment-laden macrophages, most commonly due to laxative abuse
185
Within what time frame should all pts with a suspected upper GI bleed have an endoscopy?
Within 24 hours
186
What is the most likely cause of liver failure after a cardiac arrest?
Ischaemic hepatitis
187
What are the types of hepatorenal syndrome?
1. Rapid onset, usually following an acute event e.g. upper GI bleed
2. Gradual decline, usually due to refractory ascites
188
How can you manage hepatorenal syndrome?
1. Terlipressin
2. Volume expansion with 20% albumin
3. TIPS
189
What is the most accepted theory regarding the pathophysiology of HRS?
Splanchnic vasodilation
190
What is the triad of Plummer-Vinson Syndrome?
1. Dysphagia
2. Glossitis
3. IDA
191
Which vessels does a TIPS join together?
The hepatic vein and portal vein
192
What is the main benefit of prescribing albumin when treating large volume ascites?
It reduces postparacentesis circulatory dysfunction
193
What is SAAG
Serum-ascites albumin gradient
194
What 'cover' needs to be given when performing therapeutic abdominal paracentesis?
Albumin
195
What should be given to pts with ascites (with protein <15g/L) for prophylaxis against SBP?
Ciprofloxacin
196
Peutz-Jeghers inheritance?
AD
197
Peutz-Jeghers features?
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
Peutz-Jeghers tx?
Conservative unless complications develop
199
Truelove and Witts criteria for UC?
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
Vit C aka?
Ascorbic acid
201
Scurvy pathophysiology?
Vit C is a cofactor for enzymes used in the production of proline and lysine, required for collagen synthesis
202
Perifollicular haemorrhage?
Vitamin C deficiency
203
Follicular hyperkeratosis?
Vitamin C deficiency
204
Grading of hepatic encephalopathy?
1. Irritability
2. Confusion, inappropriate behaviour
3. Incoherent, restless
4. Coma
205
Mx of hepatic encephalopathy?
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
2 medications that cause hyponatraemia?
1. PPIs
| 2. SSRIs
207
PPI MOA?
Irreversible blockade of the H+/K+ ATPase of the gastric parietal cell
208
S/e of PPIs?
1. Hyponatraemia, hypomagnasaemia
2. Osteoporosis
3. Microscopic colitis
4. C.diff colitis risk
209
Abdo pain and fever in pts with cirrhosis and portal HTN?
Spontaneous Bacterial Peritonitis
210
Spontaneous Bacterial Peritonitis definition?
An ascitic fluid infection without an evident treatable intra-abdominal source
211
SBP diagnosis?
Neutrophil count >250 cells/ul on paracentesis
212
Most common organism found on ascitic fluid culture of SBP?
E. coli
213
Abx for SBP?
IV Cefotaxime
214
When is Abx prophylaxis given for SBP?
1. Pts who have had an episode of SBP
| 2. Fluid protein <15 g/l and hepatorenal syndrome/high Child-Pugh score
215
Abx prophylaxis for SBP?
Oral ciprofloxacin
216
Achalasia Hx?
1. Dysphagia of both liquids and solids from the start
2. Heartburn
3. Regurgitation of food
217
Classification of dysphagia?
1. Extramural
2. Mural
3. Intramural
4. Neurological
218
Extramural causes of dysphagia?
1. Mediastinal masses
| 2. Cervical spondylosis
219
Mural causes of dysphagia?
1. Achalasia
2. Oesophageal spasm
3. Hypertensive LOS
220
Intramural causes of dysphagia?
1. Tumours
2. Strictures
3. Oesophageal web
4. Schatzki rings
221
Neuro causes of dysphagia?
1. CVA
2. Parkinsons
3. MS
4. Brainstem pathology
5. Myasthenia Gravis
222
Initial management of severe alcoholic hepatitis?
Prednisolone 40mg/day for 28 days
223
Bleeding gums?
Scurvy
224
Swam in pool on holiday, now has diarrhoea that floats, what infection?
Giardia lamblia - causes fat malabsorption and is resistant to chlorination in swimming pools
225
When is biologic therapy considered for acute tx of Crohns?
When symptoms don't improve after 5 days of IV hydrocortisone
226
Commonest disease pattern in Crohns?
Stricturing terminal ileal disease
227
4 risks of ERCP?
1. Bleeding
2. Duodenal perforation
3. Cholangitis
4. Pacnreatitis
228
Mallory Weiss syndrome pathophysiology?
Severe vomiting --> painful mucosal lacerations at the GOJ resulting in haematemesis
229
What is Wilsons disease?
An autosomal recessive disorder characterised by excess copper deposition in tissues
230
Blue nails?
Wilsons disease
231
How to differentiate between IBS and IBD in primary care?
Faecal calprotectin
232
Hx of CVD, high lactate, and soft but tender abdomen?
Mesenteric ischaemia
233
Mx of acute mesenteric ischaemia?
Urgent surgery
234
Ix for Dx of PSC?
MRCP as it is sensitive and non-invasive
235
When may ERCP be used instead of MRCP?
1. Therapeutic procedure can also be done
| 2. If cant tolerate MRCP due to metal implants
236
What is PSC?
Biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts
237
What percentage of UC pts have PSC?
4%
238
What percentage of PSC pts have UC?
80%
239
3 associations of PSC?
1. UC
2, Crohns
3. HIV
240
Features of PSC?
1. Cholestasis: jaundice and pruritis
2. RUQ pain
3. Fatigue
241
Ix for PSC?
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
Complications of PSC?
1. Cholangiocarcinoma (in 10%)
| 2. Inreased risk of colorectal carcinoma
243
Peutz Jeghers mutations?
LKB1 or STK11
244
What Ix do pts with GORD being considered for fundoplication surgery require?
Oesopheageal pH and manometry studies
245
What is ferritin?
An intracellular protein that binds iron and stores it to be released in a controlled fashion at sites where iron is required
246
Increased ferritin levels?
1. >300 ug/L in men/postmenopausal women
| 2. >200 ug/L in premenopausal women
247
Liver biopsy of autoimmune hepatitis?
Piecemeal necrosis
248
Management of liver abscess?
Abx and drainage
249
What abx are given for a pyogenic liver abscess?
Amoxicillin + ciprofloxacin + metronidazole
250
Most common organisms found in pyogenic liver abscesses?
1. S. aureus in children
| 2. E. coli in adults
251
Diagnostic marker for carcinoid syndrome?
24hr urinary 5-HIAA (hydroxyindoleacetic acid)
252
C.diff antigen positive, c.diff toxin negative management?
Reassure and monitor, as antigen positivity only shows exposure to bacteria rather than current infection
253
Why is a sushi chef predisposed to oesophageal carcinoma?
Fish is high in nitrosamines, a known carcinogen
254
Pharyngeal pouch epidemiology?
More common in older pts, 5x more common in men
255
Mx of pharyngeal pouch?
Surgery
256
What vitamin is teratogenic in high doses?
Vitamin A
257
Vitamin A aka?
Retinol
258
Vitamin A deficiency presentation?
Night blindness
259
Simple way to describe NAFLD?
A hepatic manifestation of metabolic syndrome, and hence insulin resistance is thought to be the key mechanism leading to steatosis
260
Mx of NAFLD?
1. Lifestyle changes
| 2. Gastric banding and metformin, pioglitazone (insulin sensitising drugs) in the future
261
Classification of raised ferritin?
1. W/ iron overload (10%)
| 2. W/o iron overload (90%)
262
Causes of raised ferritin w/o iron overload?
1. Inflammation
2. Alcohol
3. Liver disease
4. CKD
5. Malignancy
263
Causes of raised ferritin w/ iron overload?
1. Primary iron overload = Hereditary haemochromatosis
| 2. Secondary iron overload = e.g. following repeated transfusions
264
Test to see if iron overload is presnet?
Transferrin saturation
265
3 types of colon cancer?
1. Sporadic (95%)
2. HNPCC (5%)
3. FAP (<1%)
266
HNPCC inheritance?
AD
267
How many mutations identified for HNPCC?
7
268
Name of criteria for HNPCC Dx?
Amsterdam (3-2-1 rule)
269
2 most common cancers associated with HNPCC?
1. Colorectal
| 2, Endometrial
270
Gold standard ix for osesophageal cancer?
Endoscopy
271
Jaundice, abdo pain and pruritis in pregnancy?
Acute fatty liver of pregnancy
272
What is the classification system for severity of Liver cirrhosis?
Child-Pugh
273
5 criteria in Child Pugh scoring system for liver cirrhosis?
1. Bilirubin
2. Albumin
3. PT
4. Encephalopathy
5. Ascites
274
Child-Pugh grades?
1. A = <7
2. B = 7-9
3/ C = >9
275
MELD?
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
What is Murphy's sign?
Arrest of inspiration on palpation of the RUQ, a sign of acute cholecystitis
277
What is the pathophysiology of hepatorenal syndrome?
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
Types of hepatorenal syndrome?
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
Mx of hepatorenal syndrome?
1. Volume expansion with 20% albumin
2. VP analogues e.g. Terlipressin (cause splanchnic vasoconstriction)
3. TIPSS
280
Vitamin B3 aka?
Niacin
281
Role of niacin (vit B3)?
Precursor to NAD+ and NADP+ and hence plays an essential metabolic role in cells
282
Consequence of niacin deficiency?
Pellagra (diarrhoea, dementia, dermatitis)
283
Vitamin B1 deficiency?
Beriberi
284
Types of beriberi?
1. Wet = tachypnoea, dyspnoea, pedal oedema
| 2. Dry = pain, paraesthesia, confusion
285
What is Wernicke-Korsakoff syndrome a type of?
A type of dry beri beri
286
Raised ferritin, raised transferrin saturation, low TIBC?
Hereditary haemochromatosis
287
What is the function of transferrin?
Main protein that transports iron in the blood
288
First line tx for HH?
Venesection
289
Joint XR in HH?
Chondrocalcinosis
290
Most common site affected in UC?
Rectum
291
Peak incidence of UC?
1. 15-25 y/o
| 2. 55-65 y/o
292
Test for H.pylori post-eradication therapy?
Urea breath test
293
Features of pancreatic cancer?
1. Painless jaundice
2. Loss of exocrine function = steatorrhoea
3. Loss of endocrine function = DM
4. Atypical back pain
5. Trousseau's sign
294
Ix for pancreatic cancer
1. US
| 2. High resolution CT
295
Mx of pancreatic cancer?
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
S/e of whipple's procedure?
1. Dumping syndrome
| 2. Peptic ulcer disease
297
What is dumping syndrome?
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
Liver and neuro disease?
Wilson's disease
299
Acute upper GI bleed scores at first assessment and after endoscopy?
1. Blatchford score
| 2. Rockall score
300
Vitamin B6 aka?
Pyridoxine
301
2 consequences of Vit B6 deficiency?
1. Peripheral neuropathy
| 2. Sideroblastic anaemia
302
Ix of achalasia?
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
Mx of achalasia?
1. Intra-sphincteric injection of botulinum toxin
2. Heller's cardiomyotomy
3. Pneumatic (balloon) dilatation
304
MOA of metoclopramide?
D2 receptor antagonist
305
Uses of metoclopramide?
1. GORD
2. Prokinetic action useful in DN gastroparesis
3. Combined with analgesics for tx of migraine
306
S/e of metoclopramide?
1. EPSE e.g. oculogyric crisis
2. Hyperprolactinaemia
3. Tardive dyskinesia
4. Parkinsonism
307
Should metoclopramide be avoided in bowel obstruction?
Yes
308
Best measures of synthetic function of the liver?
PT and albumin levels
309
Severe nausea and sudden vomiting, prodromal intense sweating and nausea?
Cyclical vomiting syndrome
310
Dx of cyclical vomiting syndrome?
Clinical
311
IBD with crypt abscesses?
UC
312
IBD with increased goblet cells and granulomas?
Crohns
313
Kantor's string sign?
Crohns
314
Rose thorn ulcers?
Crohns
315
Loss of haustrations on barium enema?
UC
316
Pseudopolyps?
UC
317
Long term PPIs can mask the signs of what cancer?
Gastric
318
How can PPIs increase chance of fractures?
Due to malabsorption of calcium and magnesium
319
Signet ring cells?
Gastric adenocarcinoma
320
Dx of gastric cancer?
Endoscopy with biopsy
321
Assessing mural invasion in oesophageal/gastric cancer?
Endoscopic US
322
Ab for PSC?
pANCA
323
How to stop oesophageal variceal bleeding?
1. Variceal band ligation
| 2. Sengstaken tube and TIPSS if this fails
324
Prophylaxis of variceal bleeding?
1. Propranolol
| 2. Endoscopic variceal band ligation
325
Methotrexate for UC?
ABSOLUTELY NOT
326
4 RFs for Barrett's oesophagus?
1. GORD
2. Male gender (7:1)
3. Smoking
4. Central obesity
327
Mx of Barrett's?
1. Endoscopic surveillance with biopsies
| 2. High dose PPI therapy
328
Endoscopic surveillance for Barrett's frequency?
Every 3-5 years
329
Mx of dysplasia found on Barrett's surveillance?
1. Endoscopic mucosal resection
| 2. RFA
330
3 complications of Crohns?
1. Small bowel cancer
2. Colorectal cancer
3. Osteoporosis
331
Alcohol units/wk?
Max 14/wk for men and women
332
How to calculate units of alcohol?
Multiply number of ml by ABV and divide by 1000
333
SAAG > 11g/L indicates what?
Portal HTN
334
Mx of ascites?
1. Reduce dietary sodium
2. Fluid restriction
3. Spironolactone
4. Therapeutic abdominal paracentesis
5. Prophylactic Abx
6. TIPSS
335
Ix of choice to detect liver cirrhosis?
Transient elastography (Fibroscan)
336
Watery travellers diarrhoea with stomach cramps and nausea?
Enterotoxigenic E coli
337
Boerhaave's perforation triad?
The Mackler Triad:
1. Vomiting
2. Thoracic pain
3. Subcutaneous emphysema
338
Plummer Vinson syndrome triad?
1. Dysphagia (secondary to oesophageal webs)
2. Glossitis
3. IDA
339
Mx of Plummer Vinson syndrome?
Iron supplementation and dilatation of the webs
340
Coffee bean sign?
Sigmoid volvulus
341
Carcinoid syndrome heart effect?
TIPS
| Tricuspid insufficiency and pulmonary stenosis
342
H. pylori eradication?
1. PPI + amoxicillin + clarithromycin
| 2. PPI + metronidazole + clarithromycin
343
H. pylori associations?
1. Peptic ulcer disease
2. Gastric caner
3. Gastric MALToma
4. Atrophic gastritis
344
Best 1st line management for NAFLD?
Weight loss
345
Coeliac disease deficiencies?
1. Iron
2. Folate
3. Vitamin B12
346
How long pts must eat gluten before being tested for Coeliacs?
6 weeks
347
Melanosis coli?
Disorder of pigmenation of the bowel, associated with laxative abuse
348
Pigment-laden macrophages?
Melanosis coli
