Gastro Flashcards
acute upper gastrointestinal bleeding scoring systems?
the Glasgow-Blatchford score at first assessment
helps clinicians decide whether patient patients can be managed as outpatients or not
the Rockall score is used after endoscopy
provides a percentage risk of rebleeding and mortality
includes age, features of shock, co-morbidities, aetiology of bleeding and endoscopic stigmata of recent haemorrhage
Acute upperr GI bleed mx
Resus
- A to E
- platelet transfusion- actively bleeding platelet count of less than 50 x 10*9/litre
- fresh frozen plasma to patients fibrinogen level < 1 g/litre, or a PT (INR) or aPTT greater than 1.5x normal
- prothrombin complex concentrate to patients who are taking warfarin and actively bleeding
endoscopy within 24 hours
non-variceal bleeding
- NO PPI before endoscopy (give after)
Variceal
- terlipressin and prophylactic antibiotics before endoscopy
- band ligation - oesophageal varices
- injections of N-butyl-2-cyanoacrylate - gastric varices
- transjugular intrahepatic portosystemic shunts (TIPS) if not controlled with above
Alcoholic ketoacidosis
tx
infusion of saline & thiamine
Alcoholic liver disease ix & mx
ix
- gamma-GT elevated
- AST:ALT is normally > 2, a ratio of > 3 is suggestive of acute alcoholic hepatitis
Mx
- glucocorticoids (e.g. prednisolone) -> acute episodes of alcoholic hepatitis (Maddrey’s discriminant function (DF) used )
(pentoxyphylline sometimes)
Ascities mx
reducing dietary sodium
(fluid restriction only if sodium is < 125 mmol/L)
aldosterone antagonists: e.g. spironolactone
drainage if tense ascites (therapeutic abdominal paracentesis)
- large-volume paracentesis for the treatment of ascites requires albumin ‘cover’. Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality
reduce the risk of spontaneous bacterial peritonitis -> prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less, until the ascites has resolved
transjugular intrahepatic portosystemic shunt (TIPS) in some
. Three types of autoimmune hepatitis
1
- Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)
- adults & children
2
- Anti-liver/kidney microsomal type 1 antibodies (LKM1)
- children
3
- Soluble liver-kidney antigen
- adults
raised IgG levels in all
Carcinoid ix & mx
metastases are present in the liver and release serotonin into the systemic circulation
Ix
- urinary 5-HIAA
- plasma chromogranin A y
Mx
- somatostatin analogues e.g. octreotide
- diarrhoea: cyproheptadine may help
C. difficile infection ix & mx
C. difficile toxin (CDT) in the stool ( NOT antigen positivity )
Mx
First episode of C. difficile infection
1.oral vancomycin for 10 days
2. therapy: oral fidaxomicin
3: oral vancomycin +/- IV metronidazole1.
Recurrent
- within 12 weeks of symptom resolution: oral fidaxomicin
- after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin
Life-threatening C. difficile infection (Hypotension
Partial or complete ileus
Toxic megacolon, or CT evidence of severe disease)
- oral vancomycin AND IV metronidazole
- Surgery
isolation in side room: the patient should remain isolated until there has been no diarrhoea (types 5-7
on the Bristol Stool Chart) for at least 48 hours
——–
Other therapies
- bezlotoxumab
- faecal microbiota transplant
Coeliac disease ix and mx
reintroduce gluten for at least 6 weeks prior to testing.
serology
tissue transglutaminase (TTG) antibodies (IgA) are first-choice
& endomyseal antibody (IgA)
Endoscopic intestinal biopsy - gold standard
findings supportive of coeliac disease:
-villous atrophy
- crypt hyperplasia
- increase in intraepithelial lymphocytes
- lamina propria infiltration with lymphocytes
Mx
- gluten-free diet (TTG used for checking compliance)
- functional hyposplenism: pneumococcal infection every 5 years
Types of inherited colon cancer
HNPCC (Lynch syndrome)
- most common form of inherited colon cancer
- other ca- endometrial cancer
- AD inheritance
FAP
- autosomal dominant
- formation of hundreds of polyps by the age of 30-40 years.
- mutation in a tumour suppressor gene called adenomatous polyposis coli (APC) gene
- total proctocolectomy with ileal pouch anal anastomosis
- variant: Gardner’s syndrome- osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin
Peutz-Jeghers syndrome
- autosomal dominant
- numerous hamartomatous polyps in the gastrointestinal tract -> small bowel obstruction & bleeding
- pigmented freckles on the lips, face, palms and soles
Constipation mx
first-line laxative: bulk-forming laxative first-line, such as ispaghula
second-line: osmotic laxative, such as a macrogol
croons disease mx:
induce remission.
- 1st: glucocorticoids-
- 2nd line: 5-ASA drugs (e.g. mesalazine)
- azathioprine/ mercaptopurine/ infliximab/ metronidazole
Maintaining remission
- stopping smoking
- 1st line: azathioprine or mercaptopurine (assess TPMT before giving either)
surgery
diverticular disease & diverticulitis tx
diverticular disease - high fibre diet
Diverticulitis
- mild - oral antibiotics
- more significant episodes - intravenous fluids and intravenous antibiotics (typical a cephalosporin + metronidazole)
referral criteria for endoscopy
Urgent (2ww)
- all patients w dysphagia
- all pts w upper abdo mass consistent w stomach ca
- Pts >= 55 years w weight loss AND: upper abdo pain/ reflux/ dysphagia
Non-urgent
- Pts w haematemesis
- Pts >= 55 yrs: treatment-resistant dyspepsia/ upper abdominal pain & anaemia/ raised platelet count w N&V, weight loss, reflux, dyspepsia, upper abdo pain
achalasia tx & ix
ix
- oesophageal manometry
mx
1- pneumatic (balloon) dilation if low surgical risk (intra-sphincteric injection / botulinum toxin if high)
2 - Heller cardiomyotomy if recurrent or persistent
gastric ca dx
diagnosis: oesophago-gastro-duodenoscopy with biopsy
signet ring cells
(if lymphatic spread:
left supraclavicular lymph node (Virchow’s node)
periumbilical nodule (Sister Mary Joseph’s node))
GORD tx
Dyspepsia not ix w endoscopy
- review meds & lifestyle advice
- Trial of full-dose proton pump inhibitor for one month OR a ‘test and treat’ approach for H. pylori (carbon-13 urea breath test)
Endoscopically proven oesophagitis
full dose proton pump inhibitor (PPI) for 1-2 months
if response then low dose treatment as required
if no response then double-dose PPI for 1 month
Endoscopically negative reflux disease
full dose PPI for 1 month
if response then offer low dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions
if no response then H2RA or prokinetic for one month
Haemochromatosis ix & mx
(remember autosomal recessive)
general population - transferrin saturation
Testing family w fhx - genetic testing for HFE mutation
Mx
1- venesection - transferrin saturation target < 50% & ferritin concentration < 50 ug/l
2- desferrioxamine
H pylori ix & mx
ix - urea breath test carbon 13 -should not be performed within 4 weeks of antibiotic or within 2 weeks of a proton pump inhibitor)
eradication may be achieved with a 7-day course of
a proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole)
if penicillin-allergic: a proton pump inhibitor + metronidazole + clarithromycin
hepatic encephalopathy mx
actulose first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy
treat any underlying precipitating cause
most common cause of Hepatocellular carcinoma?
Chronic hepatitis B is the most common cause of HCC worldwide with chronic hepatitis C being the most common cause in Europe.
IBS mx
First-line pharmacological treatment - according to predominant symptom
- pain: antispasmodic agents
- constipation: laxatives but avoid lactulose
- diarrhoea: loperamide is first-line
Second-line
- low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors
Liver cirrhosis ix
transient elastography (fibroscan) and acoustic radiation force impulse imaging
for patients with NAFLD -> enhanced liver fibrosis (ELF) scan
Also FIB4 score & NALFD fibrosis score
& fibroscan
Further investigations
NICE recommend doing an upper endoscopy to check for varices in patient’s with a new diagnosis of cirrhosis
liver ultrasound every 6 months (+/- alpha-feto protein) to check for hepatocellular cancer
Oesophageal ca ix & mx
Upper GI endoscopy - dx
Endoscopic ultrasound - locoregional staging (mural invasion)
CT chest, abdomen and pelvis - initial staging
mx
- Operable disease (T1N0M0) - surgical resection - Ivor-Lewis type oesophagectomy
Pernicious anaemia ix & tx
anti intrinsic factor antibodies: sensivity is only 50% but highly specific for pernicious anaemia (95-100%)
FBC, vB12 & folate levels
Mx
IM vB12 - 3 injections per week for 2 weeks followed by 3 monthly treatment of vitamin B12 injections. More frequent if neurological fx
Refeeding syndrome metabolic consequences
hypophosphataemia
hypokalaemia
hypomagnesaemia:
abnormal fluid balance
NICE recommend that if a patient hasn’t eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days.
Spontaneous bacterial peritonitis (SBP) mx
intravenous cefotaxime
Antibiotic prophylaxis w ascites: oral ciprofloxacin or norfloxacin
- patients who have had an episode of SBP
- fluid protein <15 g/l
UC mx
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
Inducing remission!!
Mild to moderate
- Proctitis, proctosigmoiditis and left-sided ulcerative colitis: topical (rectal) aminosalicylate -> oral aminosalicylate -> oral corticosteroid
- extensive disease: topical and a high-dose oral aminosalicylate -> oral corticosteroid
Severe
intravenous steroids (/cicosporin) in hospital
Maintaining remission!!
After mild-to-moderate ulcerative colitis flare
- proctitis and proctosigmoiditis: topical and/or oral aminosalicylate
- left-sided and extensive ulcerative colitis: oral aminosalicylate
Following a severe relapse or >=2 exacerbations in the past year
- oral azathioprine or oral mercaptopurine
Conditions associated with thiamine deficiency:
vB1
Wernicke’s encephalopathy: nystagmus, ophthalmoplegia and ataxia
Korsakoff’s syndrome: amnesia, confabulation
dry beriberi: peripheral neuropathy
wet beriberi: dilated cardiomyopathy
Consequences of niacin deficiency:
vB3
pellagra: dermatitis, diarrhoea, dementia
Vitamin C deficiency
(scurvy) leads to defective synthesis of collagen resulting in capillary fragility (bleeding tendency) and poor wound healing
Features vitamin C deficiency
gingivitis, loose teeth
poor wound healing
bleeding from gums, haematuria, epistaxis
general malaise
Bile-acid malabsorption ix & tx
SeHCAT
bile acid sequestrants e.g. cholestyramine
Small bowel bacterial overgrowth syndrome (SBBOS) ix & mx
(associated w scleroderma & DM)
Dx- hydrogen breath test
Management- rifaximin
