Upper GI and hepatobiliary

Question 1

what are the risk factors for biliary colic?

Answer 1

obesity
female
pregnancy
middle age
diabetes mellitus
Crohn’s disease
rapid weight loss, e.g. weight reduction surgery
drugs: fibrates, combined oral contraceptive pill

Question 2

what are the features of biliary colic?

Answer 2

colicky RUQ pain - worse after eating fatty foods
pain may radiate to right shoulder
nausea and vomiting
no fever, normal CRP and LFTs

Question 3

how is biliary colic investigated?

Answer 3

ultrasound

Question 4

how is biliary colic treated?

Answer 4

elective laparoscopic cholecystecomy

Question 5

what are the causes of chronic pancreatitis?

Answer 5

alcohol
cystic fibrosis
haemochromatosis
ductal obstruction: tumours, stones

Question 6

what are the features of chronic pancreatitis?

Answer 6

pain typically worse 15 to 30 minutes after meal
steatorrhoea
diabetes mellitus - more than 20 years after symptoms begin

Question 7

how is chronic pancreatitis investigated?

Answer 7

abdominal X-ray - shows calcification
CT scan (more sensitive, preferred diagnostic test)
faecal elastase - shows exocrine insufficiency

Question 8

how is chronic pancreatitis treated?

Answer 8

pancreatic enzyme supplements
analgesia

Question 9

what is ascending cholangitis?

Answer 9

bacterial infection (typically E. coli) of the biliary tree

Question 10

what are the features of ascending cholangitis?

Answer 10

fever
jaundice
RUQ pain
hypotension, confusion
raised CRP

Question 11

how is ascending cholangitis investigated?

Answer 11

ultrasound

Question 12

how is ascending cholangitis treated?

Answer 12

IV antibiotics
ERCP after 24-48 hours to relieve obstruction

Question 13

what are the causes of acute pancreatitis?

Answer 13

gallstones
ethanol
trauma
steroids
mumps
autoimmune
snake/scorpion bite
hypercalcaemia, hypothermia, hypertriglyceridaemia
ERCP
drugs

Question 14

what drugs can cause acute pancreatitis?

Answer 14

azathioprine
mesalazine
bendroflumethiazide
furosemide
sodium valproate
steroids

Question 15

what are the features of acute pancreatitis?

Answer 15

severe epigastric pain that radiates to the back
nausea, vomiting
fever
Cullen’s sign and Grey-Turner’s sign (rare)

Question 16

how is acute pancreatitis investigated?

Answer 16

serum amylase and lipase (lipase more sensitive and specific)
ultrasound to determine aetiology
contrast-enhanced CT

Question 17

what factors indicate severe pancreatitis?

Answer 17

age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST

Question 18

what are the complications of acute pancreatitis?

Answer 18

peripancreatic fluid collections (most resolve, may develop into pseudocysts or abscesses)
pseudocyst (conservative management)
pancreatic necrosis
pancreatic abscess (infected pseudocyst)
haemorrhage

Question 19

what is Boerhaave’s syndrome?

Answer 19

spontaneous rupture of the oesophagus as a result of repeated episodes of vomiting

Question 20

what are the features of Boerhaave’s syndrome?

Answer 20

sudden onset severe chest pain that may complicate severe vomiting
subcutaneous emphysema on chest wall

Question 21

how is Boerhaave’s syndrome diagnosed?

Answer 21

CT contrast swallow

Question 22

how is Boerhaave’s syndrome managed?

Answer 22

thoracotomy and lavage

Question 23

what are the features of acute cholecystitis?

Answer 23

RUQ pain that may radiate to right shoulder
fever
Murphy’s sign: pain on palpation of RUQ during inspiration
normal LFTs - deranged LFTs suggest Mirizzi syndrome

Question 24

how is acute cholecystitis investigated?

Answer 24

ultrasound

Question 25

how is acute cholecystitis treated?

Answer 25

IV antibiotics early laparoscopic cholecystectomy, within 1 week of diagnosis

Question 26

what is Mirizzi syndrome?

Answer 26

gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct

Question 27

how can the cause of ascites be determined?

Answer 27

calculate SAAG if SAAG >11g/L, portal hypertension (transudate, low protein content) if SAAG <11g/L, exudate

Question 28

what are the causes of a high SAAG?

Answer 28

cirrhosis/alcoholic liver disease acute liver failure liver metastases right heart failure constrictive pericarditis Budd Chiari syndrome

Question 29

what are the causes of a low SAAG?

Answer 29

malignancy infection pancreatitis nephrotic syndrome

Question 30

what are the features of PSC?

Answer 30

cholestasis: jaundice, pruritus raised bilirubin and ALP RUQ pain fatigue increased risk of cholangiocarcinoma and colorectal cancer

Question 31

how is PSC investigated?

Answer 31

ERCP or MRCP showing ‘beaded’ appearance p-ANCA may be positive

Question 32

what are the investigation findings of alcoholic liver disease?

Answer 32

raised gamma-GT ratio of AST: ALT is normally > 2

Question 33

how is alcoholic liver disease treated?

Answer 33

prednisolone - Maddrey’s discriminant function used to determine who would benefit (uses PT and bilirubin concentration) sometimes pentoxyphylline

Question 34

what is the inheritance pattern of haemochromatosis?

Answer 34

autosomal recessive - HFE gene

Question 35

what are the features of haemochromatosis?

Answer 35

fatigue, erectile dysfunction, arthralgia bronze skin pigmentation diabetes mellitus hepatomegaly, cirrhosis cardiac failure (dilated cardiomyopathy) hypogonadism

Question 36

what are the investigation findings of haemochromatosis?

Answer 36

raised iron, ferritin and transferrin saturation (ts considered most useful) low transferrin low TIBC genetic testing for HFE gene

Question 37

how is haemochromatosis managed?

Answer 37

venesection desferrioxamine second-line

Question 38

what are the medical associations with primary biliary cholangitis?

Answer 38

Sjogren's syndrome (seen in up to 80% of patients) rheumatoid arthritis systemic sclerosis thyroid disease

Question 39

what are the features of primary biliary cholangitis?

Answer 39

early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus cholestatic jaundice hyperpigmentation, especially over pressure points around 10% of patients have right upper quadrant pain xanthelasmas, xanthomata also: clubbing, hepatosplenomegaly late: may progress to liver failure

Question 40

how is primary biliary cholangitis investigated?

Answer 40

raised IgM and anti-mitochondrial antibodies RUQ ultrasound or MRCP to exclude extrahepatic biliary obstruction

Question 41

how is primary bilary cholangitis managed?

Answer 41

ursodeoxycholic acid cholestyramine for pruritus

Question 42

what is Budd-Chiari syndrome?

Answer 42

hepatic vein thrombosis can be caused by polycythaemia rubra vera, thrombophilia, pregnancy

Question 43

what are the features of Budd-Chiari syndrome?

Answer 43

acute hepatitis sudden onset, severe abdominal pain ascites tender hepatomegaly

Question 44

how is Budd-Chiari syndrome investigated?

Answer 44

ultrasound with Doppler flow studies

Question 45

what are the features of autoimmune hepatitis?

Answer 45

acute hepatitis: fever, jaundice signs of chronic liver disease amenorrhoea raised IgG ALKM1/ANAs/ASMAs