Gastro Flashcards
Management for asymptomatic cholelithiasis?
Observe
Management for symptomatic cholelithiasis?
Analgesia - paracetamol/diclofenac
Elective laparoscopic cholecystectomy
Consider anti-spasmodic e.g. hyoscine
Management for choledocholithiasis regardless of symptoms?
ERCP + biliary sphincterotomy + stone extraction
Laparoscopic cholecystectomy
Analgesia - paracetamol/diclofenac
Investigations (imaging) for acute cholecystitis?
Abdominal US (no sepsis)
Contrast-enhanced CT/MRI (sepsis)
Consider MRCP if no stones seen on US but bile duct is dilated/abnormal LFTs
Management of cholecystitis?
Analgesia - paracetamol/NSAID/opioid
Laparoscopic cholecystectomy within a week of diagnosis
Consider:
Antibiotics - local protocol
Fluid resus
Investigations for cholangitis
Abdominal US
Contrast abdo CT: If US -ve but still high suspicion
Management for ascending cholangitis?
Initial stabilisation:
- piperacillin + tazobactam
- IV fluids
- strong opioid + paracetamol
ERCP
Investigations for acute pancreatitis?
Serum lipase/amylase elevated
Imaging not needed for diagnosis but can be done to find possible causes/exclude diff diagnoses
- CXR/abdominal US
Management for acute pancreatitis?
Fluid resus
Analgesia e.g. NSAID, opioid
IV ABs only if infection strongly suspected
Nutritional support
Additional definitive management depending on scenario
What is the definitive management for gallstone pancreatitis + cholangitis?
Emergency ERCP within 24 hours
Definitive management for gallstone pancreatitis + no cholangitis
Cholecystectomy within 2 weeks
Definitive management for pancreatitis + bile duct obstruction
EUS to identify bile duct stones. If present wait 48 hrs for spontaneous improvement
ERCP + sphincterotomy
Alcoholic pancreatitis management
B1 (thiamine)
B9 (folic acid)
B12 (cyanocoblamin)
Alcohol abstinence and benzos for withdrawal
How is a clinical diagnosis of acute pancreatitis made?
3x normal amylase
Characteristic pain (epigastric radiating to back)
What are the investigations/management for appendicitis
If classical signs with thin, male patients —> laparoscopic appendicetomy
If female/unsure —> ultrasound
Investigation for primary sclerosis cholangitis?
MRCP - diagnostic (strictures, dilations inside/outside liver with hallmark beaded appearance
HBsAg
Positive 4 weeks after virus exposure
Persistence implies chronic infection
Anti-HBs
Provides lifelong immunity
Suggests resolved infection
Anti-HBc
Order IgM and IgG tests
If both +ve then acute infection
If only IgG +ve then chronic infection
HbeAg
Usually disappears after peak in ALT. If present after 3 months suggest chronic infection
Anti-Hbe
Positive if virus has been cleared
Sometimes +ve if patient is asymptomatic carrier
Management for HAV?
Supportive care, no antiviral therapy
If worsening jaundice and encephalopathy —> liver transplant
Management for HBV
Acute:
Supportive care.
If severe/acute liver failure give antiviral therapy and assess for transplant
Chronic:
Antiviral therapy
Transplant for decompensated cirrhosis
Investigations for HCV?
HCV antibody immunoassay (EIA)
- indicates current/past infection
If +ve do HCV RNA PCR:
- indicates current infection
Management for HCV?
Antiviral therapy
Management of ascites
Spironolactone
If refractory:
Large volume paracentesis and albumin replacement/TIPSS
Consider liver transplant
Who gets urgent 2WW referral colonoscopy for colorectal cancer?
> 40: unexplained weight loss AND abdominal pain
> 50: unexplained rectal bleeding
> 60: iron deficiency anaemia OR changed in bowel habit
Any age male and female with <110 and <100 Hb respectively
Imaging for pancreatic cancer?
CT for all patients with suspected disease in 2 weeks
USS if urgent CT not possible
Most common type of colorectal cancer?
Adenocarcinoma (>90%)
Investigations for oesophageal cancer
OGD with biopsy (first line)
CT/MRI thorax + abdomen for visceral mets
PET if mets/nodal spread
EUS for local lymph node staging
Management for alcoholic liver disease
Alcohol abstinence with withdrawal management
Nutrition supplementation
Influenza + pneumococcal vaccine
Prednisolone if severe:
Maddrey’s factor > 32 or hepatic encephalopathy
Liver transplant for end-stage ALD
What is Maddreys discriminant function calculated with
PT and serum bilirubin
Investigation for intusseption
Ultrasound for target like mass
Crohn’s disease management
Induce remission: steroids, + immunosuppressants (azathioprine, mercaptopurine, methotrexate). Biologics (severe)/5ASAs (1st presentation) for steroids not tolerated
Maintain remission: immunosuppressants
Surgery e.g. small bowel resections
Ulcerative colitis management
Acute hospitalisation: IV steroids + biologics if >3 days no change
Induce remission:
Mild - 5ASAs, steroids (2nd), biologics (3rd)
Moderate/severe - steroids + biologics
Maintain remission:
Mild/mod - topical (proctitis)/oral 5ASAs
Severe/2 or more exacerbations in past 12 months that needed steroids - azathioprine/mercaptopurine
Classification of IBD flares
Mild: < 4 stools a day, no systemic
Moderate: 4-6 stools a day, minimal systemic
Severe: > 6 stools a day, systemic
Systemic includes: tachycardia, fever, abdo distension/tenderness, anaemia, reduced bowel sounds, hypoalbuminaemia, cachexia < 18.5/sudden weight loss
Haemorrhoid grading
- No prolapse
- Prolapse on straining, return on relaxing
- Prolapsed but can be manually reduced
- Cannot be reduced
Oesophageal cancer management
0-IA: endoscopic resection +/- ablation
IB-III: oesophagectomy (IIB-III): pre-op chemo +/- post-op chemo
IV: chemotherapy
Which people are referred for an OGD via 2WW pathway for oesophageal/gastric cancer?
Any age dysphagia
> 55 years old:
- weight loss and:
— abdominal pain, reflux or dyspepsia
Cirrhosis investigation
Transient elastography (fibroscan)
Acoustic radiation force impulse imaging
