MRCP Part 2 (Gastroenterology)

Gold standard investigation for SBBOS?

Small bowel aspiration and culture

Management of IBS; Antispasmodigs TCAs SSRIs then...?

Linaclotide (guanylate cyclase-C agonist)

Diagnosis? Post appendectomy presents with generalised abdominal pain and pyrexia?

Liver abscess (post appendectomy points toward intra abdominal cause and Vit B12 stored by liver and can be released in infection)

Best prognostic test in Hep C?

Liver biopsy

Management of carcinoid tumours?

Somatostatin analogues= octreotide Cyproheptadine for diarrhoea

Is achalasia associated with Squamous cell or adenocarcinoma?

Squamous

Severe vomiting and diarrhoea 6 hours ?

Staph aureus Bacillus cereus

First and second line therapy to induce remission in Crohn's? If refractory? If perianal?

Steroids 2nd line: mesalazine If refractory or fistulating: Infliximab If perianal: Metronidazole Maintenance: azathioprine or mercaptopurine

Which doesn't skew 5-HIAA tests? Banana Strawberry Avocado Aubergine Pineapple Apple Plums Walnuts Tomatoes

Strawberry and apple are ok to eat :)

Other than extensive colitis, what 4 other things put you in high risk, 1 year follow up category?

Stricture past 5 years Dysplasia in past 5 years declining surgery Primary SC/transplant for PSC FH colorectal cancer aged <50

Treatment of NAFLD?

Lifestyle

Most likely to improve survival of alcoholic hepatitis?

Prednisolone

Hep C treatment ribavarin C/I?

Pregnancy, alcoholic, decompensated liver disease

Is HCC associated with Primary biliary cirrhosis or primary sclerosing cholangitis?

Primary biliary cirrhosis

Is IgM, AMA and high Alk phosphate associated with Primary biliary cirrhosis or primary sclerosing cholangitis?

Primary biliary cirrhosis

Is UC associated with Primary biliary cirrhosis or primary sclerosing cholangitis?

Primary sclerosing cholangitis

Is cholangiocarcinoma associated with Primary biliary cirrhosis or primary sclerosing cholangitis?

Primary sclerosing cholangitis

Flu prodrome then bloody diarrhoea after 2-3 days. Most common in UK. Treatment?

Campylobacter Only if immunocompromised- clarithromycin

Management of C.diff

1st line- PO metronidazole 10-14 days 2nd line - PO vabc Life threatening - PO vanc and IV met. If severe with multiple co-morbidities/2nd infection - Oral fidaxomicin

At what gestation does fatty liver affect?

28-42 weeks

What improves prognosis in... 1. UGI bleed 2. Alcoholic hepatitis 3. Rehydration in hepatorenal syndrome 4. Hepatic encephalopathy

1. Antibiotics 2. Prednisolone 3. HAS 4. Rifaximin

Following eradication of high-grade dysplasia or intra-mucosal carcinoma how often should surveillance OGD be done?

3 months for 1st year, 6 months second year then annually

According to the Truelove and Witt criteria how many bowel movements and amount of blood in stool constitutes a moderate UC flare?

4-6 stools Mild-severe bloody stool

For what Hb level do you aim in a stable patient with UGI bleed?

70-80

According to the Truelove and Witt criteria how many bowel movements and amount of blood in stool constitutes a mild UC flare?

<4 small amounts of blood

What would warrant an OGD in a patient with dyspepsia?

>55years or any of: Chronic GI bleed progressive unintentional weight loss Progressive difficulty swallowing Persistent vomiting Iron deficiency anaemia Epigastric mass Suspicious barium meal

Guess the Dukes stage and 5-year survival? Confined to mucosa and submucosa

A 95% men and 100% women

What is the Lille score in alcoholic hepatitis?

If score >0.45 this signifies pred should not be continued in a patient with severe alcoholic hepatitis (recommended at 40mg for 28 days to increase survival but should be evaluated at 7 days with Lille score)

Autoimmune hepatitis associated immunoglobulins and HLA?

IgG HLA B8, DR3

AST and ALT profile in alcoholic hepatitis?

AST:ALT ratio >2:1

Post full thickness burn, RUQ pain, high WCC, high amylase. USS- thickened gallbladder, pericholecystic fluid, no stones seen.

Acalculous cholecystitis (often occurs in ITU/post burns)

Barium swallow 'bird beak' appearance is characteristic of?

Achalasia

Is Barrett's associated with Squamous cell or adenocarcinoma?

Adenocarcinoma

Slow onset bloody diarrhoea after travelling? >7 days Treatment?

Amoebiasis Metronidazole

1st and 2nd line management in diffuse oesophageal spasm DES

Long acting nitrate Ca channel blockers Widespread pneumatic dilation or endoscopic botox (dilation if severe as botox would require multi level injections)

What treatment can be given in UGI bleed which decreases mortality in patients with cirrhotic livers?

Antibiotics

What factors are included in the Child-Pugh score?

Ascites Albumin Bilirubin Clotting Encephalopathy

What are the Amsterdam criteria for HNPCC?

At least 3 family members affected Spanning at least 2 generations At least one diagnosed <50 years

Guess the Dukes stage and 5-year survival? Extends through muscularis propria

B >80%men and 90% women

Guess the Dukes stage and 5-year survival? Regional lymph nodes involvement

C 65% men and 65% women

Do TPMT levels before starting?

Mercaptopurine or Azathioprine

What do inclusion bodies in colonic mucosa demonstrate?

CMV

What else can be added in UC flare if no improvement with steroids after 72 hours?

Ciclosporin (if C/I e.g in CKD- can apply for infliximab)

Causes of ascites with SAAG >11g/L

Cirrhosis Alcoholic hepatitis Cardiac ascites Mixed ascites Massive liver metastases Fulminant hepatic failure Budd-Chiari syndrome Portal vein thrombosis Veno-occlusive disease Myxoedema Fatty liver of pregnancy

Typical presentation of alcoholic hepatitis?

Clinical jaundice Hepatic bruit

Most common malignancy in HNPCC

Colon Endometrial

Inherited conjugated hyperbilirubinemia?

Crigler najjar (kernicterus, AD) Dubin-johnson (black liver) Rotors (mainly conjugated)

Goblet cells and granulomas are pathognomonic of what disease?

Crohn's

Anti-Saccharomyces cerevisiae antibodies are more likely to be positive in what disease?

Crohn's disease

Guess the Dukes stage and 5-year survival? Distant spread

D >5% men and 10% women

Where is somatostatin secreted from?

D cells

If strong family history of colorectal ca, what should you test for?

DNA mismatch repair genetic mutation

In UC there is an increased likelihood of needing surgery if...? (2)

Day 3- CRP >45 mg/l or a stool frequency of >8/day predicts the need for surgery in 85% of cases.

Hep B treatment IF alpha C/I?

Depression

Treatment for haemachromatosis?

Phlebotomy once Ferritin >1000 500mls every 1-2 weeks (Once ferritin level falls to the range 50-100 microgram / L, phlebotomy regime can transition to a maintenance schedule every 2-4 months)

Following successful eradication of low-grade dysplasia, how often should surveillance OGD be done?

Every 6 months for 1st year then annually

Traveller's diarrhoea within 12-48hrs Treatment

E.Coli Doxycycline

What malignancy does Coeliac disease increase your risk of?

EATL (Enteropathy associated T cell lymphoma)

Secondary management of ascending cholangitis after antibiotics and fluid resus

ERCP to urgently decompress the biliary system

How should patients with NAFLD be followed up for risk of serious liver disease?

Enhanced liver fibrosis blood test If positive=(>10.51) specialist monitoring and intervention If negative= repeat 3 yearly

Investigation for risk of serious liver disease in patient with NAFLD?

Enhanced liver fibrosis blood test (If high, for specialist monitoring and intervention. If the ELF result is negative (< 10.51) then the individual is likely to have a benign prognosis from their NAFLD and can be monitored in primary care. For these individuals, a repeat ELF blood test is recommended every 3 years.)

40 year old man had a two year history of intermittent dysphagia, with bolus obstruction and choking, particularly after eating bread or steak.

Eosinophillic oesophagitis (Mx avoid certain food, chew more, or swallowed steroid inhaler)

Which aminosalicylate can cause pancreatitis?

Mesalazine

What cancer is the skin disease associated with? Pyoderma gangrenosum

Name the skin disease Myeloproliferative

What does a 'cherry red spot on OGD' indicate in a UGI bleed?

High-risk for rebleed. The first step in management is therefore variceal band ligation. ( terlipressin and antibiotics-quinolones or cephalosporins to reduce the risk of sepsis and rebleed when back on ward). Also high risk of re bleed if visible vessel

Crypt abscesses are pathognomonic of what disease?

Histological features of: UC

Diagnosis? Abnormal LFTs, RUQ pain, intermittent urticarial episodes?

Hydatid cyst which leaks causing anaphylactic reactions

What investigations must be ordered and what is the monitoring for Mesalazine

FBC and Renal function should be monitored before starting an oral aminosalicylate, at 3 months and then annually thereafter

Screening investigation for IBD?

Faecal calprotectin

Diagnosis? Man from Cyprus with abdominal pain and fever. Previous admissions with same presentation and no cause found. Treatment?

Familial Mediterranean Fever Tx- Colchicine

How do you screen the general population vs family members for haemochromatosis?

Gen population - transferring saturation Family members- HFE deficiency

Traveller's diarrhoea, weeks later, bloating Treatment

Giardia Metronidazole

Inherited unconjugated hyperbilirubinemia?

Gilbert's

Test of cure in H.pylori and gastric ulcer seen on OGD?

H.pylori- breath test 2 weeks post PPI Gastric ulcer- repeat OGD 6-8 weeks

Managing hyponatremia in liver cirrhosis? If 126-135 If 121-125 If 121-125 and raised creatinine If <121

If 126-135- monitor If 121-125- Stop/reduce diuretic dose If 121-125 +/-raised creatinine- Stop diuretics and volume expand with HAS

Diagnosis? right upper quadrant pain and melaena following liver biopsy.

Haemobilia (biopsy needle has hit the splanchnic vein and this has resulted in bleeding into the biliary tree)

Diagnosis? Fe deficiency anaemia ?cause and aortic stenosis

Heyde's syndrome (aortic stenosis and small bowel angiodysplasia)

When is platelets and FFP indicated in an UGI bleed?

If platelets <50 and when INR/APTT >1.5x normal

What cancer is the skin disease associated with? migratory thrombophlebitis

Name the skin disease Pancreatic cancer

Which of these are irreversible, can improve or reversible with venesection in haemochromatosis? DM Arthralgia Fatigue Arthritis Transaminitis Hypogonadism Cirrhosis

Irreversible- arthritis, cirrhosis Improvement possible- DM, Hypogonadism, arthralgia Reversible- Fatigue, transaminitis, cardiomyopathy, skin pigmentation

What does haemorrhagic nodules on endoscopy indicate?

Ischaemic colitis

What would cause an AST/ALT >1000 ?

Ischaemic hepatitis and paracetamol OD

Next line investigation if strong suspicion of Coeliac but negative anti-endomysial antibody

Jejunal biopsy (endomyseal antibody is a type of IgA which is low in coeliacs)

Severity score of UC ?mild ?mod ?severe

Mild <4 stools/day, small amount of blood Moderate 3-6 stools/day, varying blood Severe >6 bloods stools/day +features of systemic upset

What cancer is the skin disease associated with? Necrolytic migratory erythema

Name the skin disease Glucagonoma

What cancer is the skin disease associated with? Sweet's syndrome

Name the skin disease Haematological malignancy

What cancer is the skin disease associated with? Erythema gyratum repens

Name the skin disease Lung cancer

What cancer is the skin disease associated with? Acquired Ichthyosis

Name the skin disease Lymphoma

Anti-tumour necrosis factor agents used in combination with immunomodulating agents in Crohn's have a higher risk of...?

Non melanoma skin cancer

Drug induced hepatic cholestasis

OCP Flucloxacillin Chlorpromazine Erythromycin Anabolic steroids

What picture of LFTs does PBC and PSC give?

Obstructive

Barium swallow showing narrowing and irregularity

Oesophageal cancer

Medication to maintain remission in UC?

Oral aminoglycosides (mesalazine)

Treatment of alcoholic hepatitis?

Pabrinex Nutritional support Prednisolone

Diagnosis? Glossitis, kolionychia and dysphagia

Plummer-Vinson syndrome

First and second line in C.diff?

PO metronidazole 10-14 days If severe or not responding- PO vanc Life threatening- IV metronidazole

First line treatment of MALT lymphoma

PPI

Glasgow severity score for pancreatitis

PaO2 <8 Age >55 Neutrophilia WCC >15 Calcium <2 Renal function, Urea>16 Enzymes, AST>200 LDH>600 Albumin <32 Sugar, BM>10

Treatment of Hep B

Pegylated interferon-alpha Others- tenofovir and entecavir If decompensated end stage liver cirrhosis, use Lamivudine (interferon can cause transient rise in ALT can cause liver failure in these patients)

Treatment of Hepatitis C

Pegylated interferon-alpha + ribavirin + a protease inhibitor (e.g. boceprevir, simeprevir and telaprevir)

Causes of ascites with SAAG <11g/L

Peritoneal carcinomatosis Tuberculous peritonitis Pancreatic ascites Bowel obstruction Biliary ascites Post operative lymphatic leak Serositis in connective tissue diseases

What is the disorder? Freckles on lips, GI bleed, polyps GI tract?

Peutz Jeghers Syndrome

First and second line therapy to induce remission in UC?

Rectal mesalazine Rectal steroids Oral aminoglycosides 2nd line: PO prednisolone Metronidazole for pouchitis (often pouchitis following ileal pouch-anal anastomosis)

Next line management in hepatic encephalopathy refractory to lactulose?

Rifaximin (antibiotic)

D&V within 12 hours, can be bloody Treatment?

Salmonella Conservative, if severe Ciprofloxacin

What medication is associated with lymphocytic microscopic colitis?

Sertraline

Bloody diarrhoea and vomiting after 2-3 days Treatment?

Shigella Ciprofloxacin

Which is more specific for diagnosis Crohns? TTG or anti-endomysial antibodies

TTG (Although anti EMA if positive is highly specific, because coeliac disease results in an IgA deficiency, which anti-endomysial antibodies (EMA) are, it is not as sensitive)

First line antibodies to test for in Coeliacs?

TTG, IgA

Treatment of hepatorenal syndrome

Terlipressin and HAS (Type 1 rapidly progressive, type 2 slower but still poor prognosis)

Management of variceal bleeding whilst waiting endoscopy?

Terlipressin, prophylactic antibiotics

Diagnosis? 24 year old, epigastric pain, alanine transaminase 8,400 IU/L (normal range <45), Bilirubin 24 micromol/L (normal <15) and INR 2.8

The marked elevation of the INR in the context of the raised ALT and relatively normal bilirubin indicates that this patient is likely to be developing fulminant hepatic failure. (Idiosyncratic drug reactions (including recreational drugs such as 'ecstasy') and paracetamol overdose are the commonest cause for this presentation.)

Which IBD is pro-thrombotic during flare's and needs LMWH as an inpatient?

UC

Urgent or non urgent referral if... Dysphagia, upper abdo mass and >55 with weight loss AND upper abdo pain, reflux or dyspepsia?

URGENT

What should patients diagnosed with PBC be treated with?

Ursodeoxycholic acid

What is the disorder? Passing large amounts PR mucous, diarrhoea and hypokalemic

Villous adenoma

Drugs which cause dyspepsia (6)

What do all these drugs cause? NSAIDs Bisphosphonates Calcium channel blockers Nitrates Theophylline Steroids

Name the components of the Rockall score

What score is this? Age Systolic BP and pulse Comorbidity- IHD, cardiac, renal and liver failure.

What does the Deposition of macrophages containing PAS-positive granules within villi demonstrate?

Whipple's disease

King's college criteria for liver transplantation in paracetamol OD

pH <7.3 or all three of - grade 3 encephalopathy, PT>100/INR >6.5, Creatinine >300

What is SAAG?

serum albumin - ascites albumin