Gastro Flashcards
GORD
Lifestyle
- Encourage weight loss, reduce/quit smoking and alcohol. - Eat small meals regularly, more than 3 hours before bed. - Raise the head of the bed at night
- Avoid hot drinks and alcohol
- Avoid drugs that exacerbate and drugs such as NSAIDs
and aspirin.
Medical
- Antacids, e.g. magnesium or aluminium hydroxide +/- alginates for e.g. gaviscon
- H2RAs and then PPIs are used in a stepwise approach
- If Sx return after the initial course of PPIs then ‘test and treat’ for H.Pylori. Must stop taking PPIs two week before test.
- Prokinetic drugs such as metoclopramide/domperidone may also be added to increase gastric emptying - can cause EPSE in parkinson’s patients.
Barrett’s Oesophagus
Metaplasia of stratified squamous epithelium to glandular columnar epithelium due to long-standing reflux.
Found on endoscopy when investigating GORD Sx or likewise. Once identified, regular endoscopic surveillance with biopsies, looking for dysplasia/carcinoma in-situ, which can be treated with endoscopic resection.
Risk of malignant change is 0.5% per patient per year.
Staging and Grading of an oesophageal cancer
OGD including trans-oesophageal USS and biopsy.
CT of thorax/abdomen
PET to assess for metastatic disease
Laparoscopy to exclude peritoneal metastases prior to resection.
Management of oesophageal cancer
Radical oesophagectomy for T1/2 tumours
Chemotherapy pre-surgery improves survival but increases morbidity
Chemoradiotherapy for inoperable tumours and palliative stenting can be performed if palliative is option taken.
Achalasia
Lifestyle measures - chew food well, sit upright and drink lots of water with meals
Botulinum injection can provide temporary relief
Endoscopic balloon dilation (risk of oesophageal rupture)
Heller’s cardiomyotomy
H.Pylori Rx
PPI + 2 antibiotics (omeprazole, clarithromycin and amoxicillin)
Metronidazole can be used in penicillin allergic patients
Management of a GI haemorrhage
Transfuse to keep Hb > 8. call 2222 for major haemorrhage protocol.
Assess using Glasgow-Blatchford score, if above 6 then this indicates a mortality of over 50% and urgent intervention is needed
IV omeprazole 80mg stat and then 8mg/h for 72 hours.
Endoscopy within 4 hours or when stabilised - here can administer treatment (adrenaline injection, diathermy of ulcer, banding of varices).
High level monitoring is needed to assess the need for re-bleed.
Definitive management is with laparotomy (angiographic embolisation if not fit for surgery).
Rockall score is used post-endoscopy
Crohns - Flare and Maintenance
Mild Flare (symptomatic but systemically well) - oral pred, tapered down in clinic
Severe attack (symptoms plus systemic upset) -
admit to hospital and make NBM
A-E resuscitation,
start on IV steroids (hydrocortisone 100mg/6h),
high level monitoring is required
Thiopurines - azathioprine + mercaptopurine second line.
Biologic agents used in refractory disease not responding to medical treatment. Once improving then transfer to oral pred, if no improvement then surgical advice should be sought.
Maintenance
First line: azathioprine or 6-mercaptopurine
Second line: Methotrexate - if thiopurines contraindicated or unsuccessful or methotrexate was used to induce remission.
Oral metronidazole can be used in anal disease
Ulcerative Colitis - Flare and Maintenance
Acute flare - Mild
Proctits/Proctosigmoiditis: topical aminosalicylates (e.g. mesalazine suppository/enema) +/- oral mesalazine.
More extensive disease
First line: loading dose oral mesalazine, +/- oral beclometasone and topical mesalazine
Second line: after 4 weeks - oral pred
Third line: tacrolimus after a further 2-4 weeks
Fourth line: biological agents, considered by specialist
Fulminating/Severe UC
MDT management
First line: IV corticosteroids, assess the patient with regard to surgical intervention
SC heparin
Avoid anti-motility durgs e.g. opiods
Second line: IV ciclosporin if Sx worsen or no improvement after 72 hours of IV steroids.
Third line: biological agents
Likelihood for surgery is suggested by over 8 motions a day, pyrexia, tachycardia, colonic dilatation, low albumin, low Hb or CRP > 45.
Maintenance:
First line: Topical for proctosigmoiditis, oral if left sided. Sulfasalazine, mesalazine
Second line: Oral thiopurines - azathioprine, mercaptopurine
Coeliac Disease
lifelong gluten free diet
verify that gluten-free diet is working with endomysial antibody tests
Chronic Pancreatitis
Analgesia for pain management Creon and Multivite Monitoring of blood sugars Treatment of alcohol abuse Low fat diet Partial pancreatectomy/pancreaticojejunostomy if there is unremitting pain, narcotic abuse or weight loss.
Diverticulitis
Mild - stay at home, rest bowel with fluids only, at least 3L of water minimum, oral co-amoxiclav +/- metronidazole.
Severe - admit if pain intolerable, keep NBM, give analgesia, IV fluids, IV cef and met. Order CXR, AXR and contrast CT. do not scope in acute attack.
Haemorrhoids
Conservative - consume plenty of fluids and don’t strain. Topical analgesia and a bulk forming laxative
Sclerotherapy for 1st and 2nd degree piles
Banding for 1st - 3rd degree piles
Surgery - reserved for 3rd and 4th degree piles
