12 - Gastroenterology Flashcards
1
Q
What are some causes of diarrhoea?
A
2
Q
How do most patients with IBD present initially, and how do you take a history of this presenting system?
A
Change in bowel habit
- How often and is this different from usual?
- Has the form changed?
- Any blood?
- Tenesmus?
- Faecal urgency or incontinence?
- Do they easily flush?
- Waking in night to defecate?
3
Q
What are the differences between Crohn’s and UC?
A
- Crohn’s has perianal disease but UC does not
- Crohn’s often non-bloody but UC is bloody
- Crohn’s has skip lesions but UC constant
- Crohn’s is transmural but UC superficial
- Crohn’s has granulmoas but UC has crypt abscesses
- Crohn’s worsened by smoking but UC smoking is protective
4
Q
If a patient presents with change in bowel habit, what are some investigations you should do and what might they show?
A
- Blood Tests (FBC, ESR, CRP)
- Stool Tests (to exclude infective causes)
- Faecal Calprotectin
- AXR
- Endoscopy
- CT/MRI
5
Q
If a patient presents with an IBD flare, you do an AXR and flexi sig, what do they show?
A
AXR: proximal constipation and assess for toxic megacolon
Flexi Sig: inflammation, safer than colonoscopy
6
Q
What are some of the symptoms and signs of UC?
A
Symptoms:
- Episodic or chronic diarrhoea
- Mucus or bloody stools
- Crampy abdominal pain
- Tenesmus due to proctitis
Signs: fever and tender distended abdomen if acute, clubbing, oral ulcers, erythema nodosum
7
Q
How do you assess the severity of UC?
A
Truelove and Witt’s Criteria
8
Q
What are some of the complications with UC?
A
Acute:
- Toxic megacolon with risk of perforation
- VTE
- Low K+
Chronic:
- Colon cancer (surveillance colonoscopy with multiple random biopsies)
9
Q
How is chronic UC managed?
A
Goals are to induce then maintain remission
GIVE BONE PROTECTION AS IBD AND STEROIDS RISK FOR OSTEOPOROSIS
1st Line: Mesalazine (5-ASA) for induction/remission
2nd Line: Azathioprine and Biologics
10
Q
How is acute UC managed?
(use image)
A
- Prophylactic heparin as high VTE risk
- Steroids (usually IV hydrocortisone but can have oral/rectal) to induce
- Rescue therapy if not responding in 3-5 days is ciclosporin, biologics or surgery (colectomy)
11
Q
What monitoring is needed for acute UC treatments as immunosuppressants are used in the treatment?
A
- FBC
- U+Es
- LFTs
12
Q
What surgery is done for UC patients?
A
Subtotal colectomy and terminal ileostomy if failure of medical therapy or toxic megacolon
13
Q
What are some of the signs and symptoms of Crohn’s?
A
Symptoms:
- Diarrhoea
- Abdominal pain
- Weight loss
- Fatigue, fever, malaise
Signs: bowel ulceration on colonoscopy, perianal abscess, skin tags, fistulas, skin and eye problems
14
Q
What can exacerbate Crohn’s?
A
- Smoking
- NSAIDs
15
Q
What are some complications with Crohn’s?
A
- SBO
- Toxic megacolon
- Abscess fromation
- Fistulae e.g entero-enteric, colovesical
- Colon cancer
- Malnutrition
- Perianal disease
16
Q
What investigations should you do if you suspect Crohn’s?
A
- Bloods: FBC, U+Es, ESR, CRP, B12, Folate, Ferritin
- Stool culture: exclude E.Coli, Shigella, Campylobacter
- Colonoscopy and biopsy
- Capsule endoscopy
- MRI
17
Q
How is chronic Crohn’s managed?
A
- Quit smoking and optimise nutrition
- 1st Line: Oral steroids (prednisolone) to induce
- 2nd Line: Azathioprine if relapsing on steroid taper or Biologics like Anti-TNFa
- 3rd Line: Surgery to either resect affected areas, or control perianal disease
18
Q
How is acute Crohn’s managed?
A
- IV hydration/eclectrolytes
- IV hydrocortisone
- VTE prophylaxis
- Consider nutritional support
19
Q
What is the mainstay of treatment for acute IBD?
A
- Prophylactic IV heparin
- Steroids
20
Q
What is the first choice medication for perianal disease or fistulating disease in Crohn’s?
A
Biologics like anti-TNFa then surgery
21
Q
What are some side effects of Azathioprine and Infliximab used in Crohn’s treatment?
A
Azathioprine (monitor FBC, U+Es, LFTs): abdominal pain, hepatitis, pancreatitis, leucopenia
Infliximab (check CXR and IGRA for TB): lymphoma risk, reactivate TB,
22
Q
What are some of the side effects of Mesalazine (5ASA)?
A
Decreases risk of colorectal cancer but:
- diarrhoea
- headache
- nausea & rash
- interstitial nephritis
23
Q
What is the pathophysiology of coeliac disease?
A
Autoimmune condition where T cells react to the gliadin fraction of gluten and cause villous atrophy in the small bowel and malabsorption
24
Q
When should you suspect coeliac disease?
A
- Diarrhoea with weight loss and iron deficiency/B12 anaemia
- FHx in first degree relative
25
What are some symptoms of coeliac's disease?
- Loose stools
- Stinking stools/Steatorrhea
- Bloating
- Wind
- Weight loss
- Dermatitis herpetiformis
- Mouth ulcers
26
What are some of the complications of Coeliac's disease if left untreated?
- Small bowel lymphoma
- GI cancer
- Osteoporosis
- Gluten ataxia
27
How is coeliac disease diagnosed?
**_Diagnostic test:_**
***OGD and duodenal biopsies*** whilst on gluten-containing diet. Will show villous atropy, intraepithelial lymphocyte infiltration and crypt hyperplasia
**_Supporting tests:_**
***- IgA Tissue Transglutaminase*** ***and Total IgA*** in case of deficiency (do biopsy if positive serology)
- Anaemia
- Low ferritin and B121
MUST CONTINUE EATING NORMAL GLUTEN DIET UNTIL DIAGNOSIS!!!!
28
How is coeliac's disease treated?
Refer to dietician for lifelong gluten-free diet. Remove:
- Barley
- Rye
- Oats (might be ok)
- Wheat
**Can still eat:** potatoes, maize, soya, sugar, rice
29
What are some important questions to ask in a history if a patient presents with diarrhoea?
- Acute or chronic?
- Travel?
- Diet change?
- Contact with D+V?
- Bloody? (Campylobacter, Shigella, E Coli, UC, cancer)
- Mucus? (Polyps, IBS, cancer)
- Frank pus?
- Explosive?
- Steatorrhea?
30
What are some causes of explosive diarrhoea?
- Rotavirus
- Giardia
- Cholera
31
What are some investigations you should do for diarrhoea?
- **Examination:** assess for dehydration, PR for impacted faeces
**- Bloods**: FBC, ESR, CRP, coeliac serology, U+Es, TSH
**- Stool:** culture and faecal elastase
**- Lower GI endoscopy:** colitis and cancer
32
How should you manage diarrhoea?
- Treat cause
- Hydration (preferably oral) and Electrolyte replacement
- Codeine Phosphate or Loperamide (not in colitis as risk of toxic megacolon)
- Avoid antibiotics unless systemic upset
- Consider closing ward or informing PHE.
33
How does C.Diff colitis present and why is it dangerous?
- Diarrhoea with systemic upset (raised WCC, CRP)
- Colitis (yellow plaques)
Can progress to toxic megacolon and then multiorgan failure!!!
34
How is C.Diff diagnosed?
- Stool test (PCR and ELISA)
- AXR
35
How should we treat C.Diff?
**- Stop causative antibiotic**
**- Start vancomycine PO for 10 days**
- Prevent spread by isolation, **handwashing (not gelling),** gloves, cleaning
- Urgent colectomy if toxic megacolon
36
What are some red flag symptoms for dyspepsia and reflux? (epigastric pain)
**_ALARMS_**
- Anaemia
- Loss of weight
- Anorexia
- Recent onset
- Melena/Haematemesis
- Swallowing difficulty
37
When should you urgently refer to endoscocopy with dysphagia/dyspepsia?
- All patients with dysphagia
- Patients \>55 with ALARM features and dyspepsia
- Treatment refractory dyspepsia
38
What are some causes of dyspepsia?
- Duodenal ulcer
- Gastric ulcer (H.Pylori)
- Gastritis
- GORD
- Malignancy
39
How is dyspepsia treated (in the absence of red flags)?
- Decrease alcohol and tobacco
**- PPI or H2 blockers**
**- H.Pylori test** and eradication therapy if positive
- Stop any drugs that will precipitate e.g NSAIDs
40
How is functional dyspepsia treated?
NO OBVIOUS CAUSE:
- PPIs
- Psychotherapy
- Amitriptylline
41
What are some causes of dysphagia?
42
What are some key questions to ask if a patient is presenting with dysphagia?
Need to work out if oesophageal or oro-pharyngeal dysphagia
43
How do you distinguish between oesophageal and oro-pharyngeal dysphagia with your investigations?
**_Oesophageal:_** Either obstruction or neuromuscular issue. Need *OGD* first to exclude obstructive cause, then *barium swallow or manomoetry* to look for neuromuscular issue
**_Oropharyngeal:_** Usualy neurological disease like stroke as cannot move bolus to back of mouth. Examine cranial nerves, get speech therapy assessent and *videofluroscopy*
44
What are some causes of upper GI bleeds?
- Peptic ulcers
- Varices
- Mallory Weiss Tear
- Malignancy
45
What are the different presentations of upper GI bleeds?
- Haematemesis
- Coffee ground vomiting
- Melaena
- Fresh PR bleeding
46
When a patient has an upper GI bleed you must assess a few things after taking a history when first seeing them. What are these?
**Need to work out if variceal bleed as this is emergency!!!!!!**
**- Risk factors for bleeding:** any known varices, stigmata of chronic liver disease, NSAIDs, anticoagulants, antiplatelets, past GI bleeds
**- Is the patient shocked?:** clammy, increased cap refill, tachycardic, hypotension
**- Rockall Score**
47
What are the two assessment scores for GI bleeding and what do they determine?
**- ROCKALL:** Predicts risk of death and rebleeding with upper GI bleed. Pre and post enscopy scores.
**- Glasgow Blatchford:** Predicts need for intervention with GI bleed with blood transfusion or therapeutic endoscopy. Helps decide whether to admit the patient
48
How do you calculate the Rockall score for upper GI bleeds?
Bedside parameters and endoscopy results to predict risk of dying and rebleeding:
- Age
- Comorbidity
- Shock
- Source of bleeding
- Stigmata of recent bleeding
49
How do you calculate the Glasgow-Blatchford score for upper GI bleeding?
Uses results of basic blood tests before endoscopy to calculate need for admission/intervention:
- Blood urea
- Hb
- Systolic BP
- Other markers
Score over 6 is 50% chance for needing intervention
50
What initial investigations should you order for a patient with a suspected upper GI bleed?
**- FBC:** check for anaemia and low platelets due to liver disease
**- U+Es**: will show raised urea
**- Clotting**: see if any corrections needed
**- Group and Save**
**- Crossmatch:** if haemodynamically unstable for blood transfusion
**- LFTs**
**- VBG**
51
What is the management for an upper GI bleed due to varices?
MEDICAL EMERGENCY
- Gain **IV access** with 2 large bore cannulas for bloods and fluids
**- Catheterise** and fluid balance
**- NBM**
**- Fluid resus** if haemodynamically unstable whilst waiting crossmatch
**- Blood transfusion**
**- PPI**
**- Correct any coagulation** issues
**_- IV terlipressin_** to reduce splanchnic blood flow and **I_V broadspectrum abx_**
**- Urgent endoscopy** for *banding, Linton tube or TIPSS*
52
When should you not give IV terlipressin for variceal bleeding?
- Ischaemic heart disease
- Peripheral vascular disease
53
What is the management for an upper GI bleed that is not due to varices?
**- Gain IV access** for bloods and fluid resus if haemodynamically unstable. ***Transfuse*** if Hb\<70 and correct any clotting abnormalities. ***Give platelets if actively bleeding***
**- Catheterise** and fluid balance
**- Endoscopy with adrenaline injections** (may need ***PPI*** and ***H.Pylori*** eradiaction ***after*** based on findings/biopsy)
54
What is some prophylaxis for variceal bleeds if a patient is known to have varices?
Varices are due to portal hypertension from cirrhosis so lower this pressure:
- Propanolol (B-blocker)
- Endoscopic banding
55
What are the different classifications of haemorraghic shock?
IMPORTANT
56
After haemostasis has been achieved with an upper GI bleed, what primary prophylaxis should you give to patients to prevent rebleeding?
- PPI
- Stop NSAIDs
- Low dose aspirin for secondary prevention of vascular events
- Discuss whether to continue clopidogrel
57
How do you follow up a patient following a variceal bleed or following haematemesis due to an ulcer?
58
When is a patient is sick they experience weight loss due to?
Loss of muscle (not fat)
59
What tool is used to assess if a patient is malnourished?
**MUST**
- Acutely ill and no nutritional intake for \>5 days
- Unplanned weight loss in last 3-6 months
- BMI
60
How should you manage someone with medium (1) or high (2 or more) risk of malnutrition?
**Medium:** record dietary intake for 3 days
**High**: refer to dietician
61
What deficiency syndrome occurs with the following vitamin deficiencies:
- A
- B1
- B2
- B6
- B12
- C
- D
- E
- K
- Phosphate
62
What is the feeding hierarchy?
Should always encoruage oral feeding!
63
What are some ways to support normal oral feeding?
- Stop mealtime interruptions
- High calorie options encouraged or food fortification
- Ensure dentures are in
- Ensure correct cutlery
- Give assistance with eating
- Nutritional supplements as suggested by dietician
64
If a patient cannot feed orally despite maximally supporting them or they are not meeting their nutritional requirements with oral feeding, what can be offered to provide nutrition?
**NG Tube:** short term feeding that can give all fluids and food or used for supplementary feeding to patient's usual intake
**PEG/RIG/PEGJ/RIGJ:** medium to long term feeding placed into stomach or jejunum by endoscopy or radiologically
**TPN:** nutrition and fluid into central line when GI tract obstructed or not working (diseased or short gut)
65
What are the disadvantages of each of the following feeding methods:
- NG Tube
- PEG
- RIG
- TPN
**NG Tube:** risk of aspiration from food removed but can still aspirate on saliva, need to check pH or CXR everytime before feeding to check in stomach, patient has to mobilise with drip
**- PEG:** risk of aspiration from saliva, have to pierce stomach so risks, cannot be done endoscopically if poor anatomy
**- RIG:** have to be changed regularly due to balloon, easily dislodged
**- TPN:** line sepsis, liver dysfunction
66
What is the BMR of a standard man and woman?
Amount of energy expended at rest. It provides enough energy for the functioning of the vital organs only
67
What is refeeding syndrome?
Presents as acute congestive HF due to fluid shifts associated with reintroduction of carbohydrate after prolonged starvation. Also respiratory and neurological dysfunction
- Hypophosphataemia
- Hypokalaemia
- Hypomagnesaemia
68
What patients are at high risk of developing refeeding syndrome?
- Prolonged starvation
- Severely malnourished
69
What is the pathophysiology of refeeding syndrome?
When in starvation insulin levels drop and phosphate levels drop
When carbohydrate is reintroduced **insulin rapidly rises to produce glycogen** and this **requires phosphate**. **Phosphate, Mg, K are forced into cells and Na out causing fluid shifts**
Hypophosphataemia reduces ATP production so impaired function of cardiac muscle. Also 2,3-DGP is reduced in red cells so cannot deliver oxygen to tissues as well
70
How can we prevent refeeding syndrome?
**- Reintroduction of food slowly** e.g 5-10kcal/kg/day and check Mg, PO4 and K+ until full feeding
- Before feeding replenish phosphate levels with **IV phosphate infusion**
**- Multivitamins**
71
What is contained in the solution for parenteral nutrition?
- Water
- Glucose
- Nitrogen
- Lipid
- Electrolytes
- Vitamins and trace elements
Given over 12-24h by central venous catheter
72
What are some of the complications of parenteral nutrition?
73
How do you calculate the calories in a PN bag?
(Nitrogen x 25) + Lipids + Glucose
74
What are some clinical signs of anorexia nervosa?
- Lanugo
- Low BMI
- Calluses on knuckles
- Eroding teeth
75
What are some complications with anorexia nervosa?
- Osteoporosis
- Fractures
- Hypoglycaemia
- Hypothermia
- Liver failure
- Infection
76
If a patient with anorexia nervosa attends hospital they are usually very unwell, how should you start feeding these patients?
Keep low threshold for abx therapy
- Get dietician review ASAP
- IV phosphate replacement and Vit B complex
- Slow NG tube feeding under MHA
77
This patient has UC, what does the x-ray show?
**- Toxic megacolon**
**- Mucosal oedema** due to visible bowel wall
- Not visible on this x-ray but always look for **proximal constipation**
78
What antibiotic prophylaxis should you give to patients with ascites following SBP?
Ciprofloxacin
79
What are some risk factors for an upper GI bleed?
- Age
- NSAIDs and anticoagulants
- Coagulation disorders
- Liver disease
80
How do you do a nutritional assessment in patients with IBD?
- Dietary intake history
- BMI
- Body composition
- MUST
81
What are some differentials for bloody diarrhoea?
- IBD
- Infective: shigella, e.coli, giardia
- Malignancy
- Diverticulitis
82
What are some important questions to ask about nausea and vomiting to determine the underlying cause?
- What is in the vomit? e.g coffee grounds, feculent
- Timing? e.g morning could be pregnancy, post food ulcer
83
What investigations should you do for acute nausea and vomiting?
**- Bloods:** FBC, U+Es, LFTs, Ca, Glucose, Amylase
**- ABG**: check for alkalosis as loss of acid from stomach
**-CT Abdo with contrast:** if suspect bowel obstruction
**- Endoscopy:** if suspect upper GI bleed
84
What is the treatment for acute nausea and vomiting?
- Try oral antiemetics but if cannot keep down give IV
- Check if dehydrated and give IV fluid replacement with K+
85
What are some causes of a high MCV?
- Alcohol
- Low B12 and folate
- Hypothyroidism
- Myelodysplasia
- Reticulocytosis (e.g from bleed)
- Azathioprine
- Pregnancy
86
What are some differentials for diarrhoea (not including infective differentials)?
- IBD
- IBS
- Coeliacs
87
Which parasite causes steatorrhoea?
Giardia - treat with metronidazole
88
Why does C.Diff have a high recurrence rate?
- Spore formation
- If recurrence give Fidoxamicin
89
What are some symptoms of carcinoid syndrome?
- Wheezy breathlessness
- Watery diarrhoea
- Flushing
Give octreotide
90
What are some causes of low sodium?
- SIADH
- Thiazides
- Addison's
- Dehydration with water replacement
- Cirrhosis
- Heart failure
91
What is the albumin gradient?
Serum Albumin - Ascitic Albumin
If \<11 this is normal, cannot have cirrhosis!!!!!
\>11 means portal HTN and cirrhosis
92
What antibiotic can cause drug induced cholestasis?
Co-amoxiclav and Flucloxacillin
93
What is transferrin saturation like in Hereditary Haemochromatosis?
All transferrin saturated, if less than 50% saturation cannot be HH
94
What is the significance of a raised transferrin?
It is an acute phase protein so can be raised for lots of reasons
95
What are some causes of clubbing?
- Cirrhosis
- Lung cancer
- ILD
- Bronchiectasis
- Coealiacs
- IE
- Idiopathic
NOT COPD!! misdiagnosis or lung cancer if in COPD
96
How can you distinguish between severe constipation and LBO?
Will have no flatulence in LBO
97
What is the difference in the pain in pancreatitis and SBO?
- Pancreatitis pain constant
- SBO colickly
98
What does bowel urgency indicate?
RECTAL DISEASE
