12 - Gastroenterology Flashcards
What are some causes of diarrhoea?
How do most patients with IBD present initially, and how do you take a history of this presenting system?
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?
What are the differences between Crohn’s and UC?
- 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
If a patient presents with change in bowel habit, what are some investigations you should do and what might they show?
- Blood Tests (FBC, ESR, CRP)
- Stool Tests (to exclude infective causes)
- Faecal Calprotectin
- AXR
- Endoscopy
- CT/MRI
If a patient presents with an IBD flare, you do an AXR and flexi sig, what do they show?
AXR: proximal constipation and assess for toxic megacolon
Flexi Sig: inflammation, safer than colonoscopy
What are some of the symptoms and signs of UC?
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
How do you assess the severity of UC?
Truelove and Witt’s Criteria
What are some of the complications with UC?
Acute:
- Toxic megacolon with risk of perforation
- VTE
- Low K+
Chronic:
- Colon cancer (surveillance colonoscopy with multiple random biopsies)
How is chronic UC managed?
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
How is acute UC managed?
(use image)
- 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)
What monitoring is needed for acute UC treatments as immunosuppressants are used in the treatment?
- FBC
- U+Es
- LFTs
What surgery is done for UC patients?
Subtotal colectomy and terminal ileostomy if failure of medical therapy or toxic megacolon
What are some of the signs and symptoms of Crohn’s?
Symptoms:
- Diarrhoea
- Abdominal pain
- Weight loss
- Fatigue, fever, malaise
Signs: bowel ulceration on colonoscopy, perianal abscess, skin tags, fistulas, skin and eye problems
What can exacerbate Crohn’s?
- Smoking
- NSAIDs
What are some complications with Crohn’s?
- SBO
- Toxic megacolon
- Abscess fromation
- Fistulae e.g entero-enteric, colovesical
- Colon cancer
- Malnutrition
- Perianal disease
What investigations should you do if you suspect Crohn’s?
- Bloods: FBC, U+Es, ESR, CRP, B12, Folate, Ferritin
- Stool culture: exclude E.Coli, Shigella, Campylobacter
- Colonoscopy and biopsy
- Capsule endoscopy
- MRI
How is chronic Crohn’s managed?
- 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
How is acute Crohn’s managed?
- IV hydration/eclectrolytes
- IV hydrocortisone
- VTE prophylaxis
- Consider nutritional support
What is the mainstay of treatment for acute IBD?
- Prophylactic IV heparin
- Steroids
What is the first choice medication for perianal disease or fistulating disease in Crohn’s?
Biologics like anti-TNFa then surgery
What are some side effects of Azathioprine and Infliximab used in Crohn’s treatment?
Azathioprine (monitor FBC, U+Es, LFTs): abdominal pain, hepatitis, pancreatitis, leucopenia
Infliximab (check CXR and IGRA for TB): lymphoma risk, reactivate TB,
What are some of the side effects of Mesalazine (5ASA)?
Decreases risk of colorectal cancer but:
- diarrhoea
- headache
- nausea & rash
- interstitial nephritis
What is the pathophysiology of coeliac disease?
Autoimmune condition where T cells react to the gliadin fraction of gluten and cause villous atrophy in the small bowel and malabsorption
When should you suspect coeliac disease?
- Diarrhoea with weight loss and iron deficiency/B12 anaemia
- FHx in first degree relative
What are some symptoms of coeliac’s disease?
- Loose stools
- Stinking stools/Steatorrhea
- Bloating
- Wind
- Weight loss
- Dermatitis herpetiformis
- Mouth ulcers
What are some of the complications of Coeliac’s disease if left untreated?
- Small bowel lymphoma
- GI cancer
- Osteoporosis
- Gluten ataxia
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!!!!
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
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?
What are some causes of explosive diarrhoea?
- Rotavirus
- Giardia
- Cholera
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
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.
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!!!
How is C.Diff diagnosed?
- Stool test (PCR and ELISA)
- AXR
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
What are some red flag symptoms for dyspepsia and reflux? (epigastric pain)
ALARMS
- Anaemia
- Loss of weight
- Anorexia
- Recent onset
- Melena/Haematemesis
- Swallowing difficulty
When should you urgently refer to endoscocopy with dysphagia/dyspepsia?
- All patients with dysphagia
- Patients >55 with ALARM features and dyspepsia
- Treatment refractory dyspepsia
What are some causes of dyspepsia?
- Duodenal ulcer
- Gastric ulcer (H.Pylori)
- Gastritis
- GORD
- Malignancy
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
What are some causes of dysphagia?
What are some key questions to ask if a patient is presenting with dysphagia?
Need to work out if oesophageal or oro-pharyngeal dysphagia
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
What are some causes of upper GI bleeds?
- Peptic ulcers
- Varices
- Mallory Weiss Tear
- Malignancy
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
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
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
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
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)
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
What are the different classifications of haemorraghic shock?
IMPORTANT
How do you follow up a patient following a variceal bleed or following haematemesis due to an ulcer?
When is a patient is sick they experience weight loss due to?
Loss of muscle (not fat)
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
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
What deficiency syndrome occurs with the following vitamin deficiencies:
- A
- B1
- B2
- B6
- B12
- C
- D
- E
- K
- Phosphate
What is the feeding hierarchy?
Should always encoruage oral feeding!
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)
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
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
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
What patients are at high risk of developing refeeding syndrome?
- Prolonged starvation
- Severely malnourished
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
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
What are some of the complications of parenteral nutrition?
What are some clinical signs of anorexia nervosa?
- Lanugo
- Low BMI
- Calluses on knuckles
- Eroding teeth
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
What are some risk factors for an upper GI bleed?
- Age
- NSAIDs and anticoagulants
- Coagulation disorders
- Liver disease
How do you do a nutritional assessment in patients with IBD?
- Dietary intake history
- BMI
- Body composition
- MUST
What are some differentials for bloody diarrhoea?
- IBD
- Infective: shigella, e.coli, giardia
- Malignancy
- Diverticulitis
