Gastro Flashcards
Basic advice for a healthy diet
BMI - 18.5-25
Base meals on starch - slower release carbohydrates
5 fruit and veg a day
Eat food high in fat, salt or sugar infrequently
Eat some meat, fish, eggs and beans - 2 portions of fish a week and reduce intake of red or processed meat
Eat some milk and dairy products
Moderate alcohol - less than 14 units over 3 or more days
Advice for taking supplements
Scant evidence for those able to follow a balanced diet
Women attempting to conceive - 400mcg/day folic acid from pre-conception to 12wks
Vitamin D (10mcg/day) for breast-feeding, over 65yrs old, dark skinand those not exposed to sun
Risks of too much sugar
Caries Diabetes Obesity - osteoarthritis - cancer - hypertension - increased oxidative stress
Best approach for weight loss
Motivational therapy
- referral to dietitian
- exercise and diet strategies
- targeted weight loss - psychotherapy
Treatment for obestiy
Primary prevention
Orlistat - lowers fat absorption
Surgery - potential for significant weight loss but also significant mortality
Define leucoplakia
Oral mucosal white patch that will not rub off and not attributable to other known disease
Premalignant lesion
Cause of oral hairy leucoplakia
Caused by EBV - seen in HIV
Define apthous ulcers
Shallow, painful ulcers on tongue or oral mucosa that heal without scarring
Causes of severe ulcers
Crohn's disease Coeliac disease Behcet's Trauma Erythema multiforme Lichen planus Pemphigus Pemphigoid Infections - herpes simplex, syphilis
Treatment of minor ulcers
Avoid oral trauma - hard toothbrush and foods
Avoid acidic foods and drinks
Tetracycline or antimicrobial mouthwashes (chlorhexidine)
Topical steroids - triamcinolone gel
Topical analgesia
Treatment of severe ulcers
Systemic corticosteriods - oral prednisolone 30-60mg/d PO for a week
Thalidomide - contraindicated in pregnancy
Biopsy if not healing after 3wks to exclude malignancy
Features of oral candidiasis
White patches or erythema of the buccal mucosa
Patches hard to remove and may bleed if scraped
Risk factors for oral candidiasis
Extremes of age
DM
Antibiotics
Immunosuppression - long-term corticosteriods (inhalers), cytotoxics, malignancy, HIV
Treatment for oral candidiasis
Nystatin suspension 400 000u (4ml swill and swallow/6hr)
Fluconazole - for oropharyngeal thrush
Define cheilitis
Angular stomatitis
Fissuring of the mouth’s corners
Causes of cheilitis
Denture problems
Candidiasis
Deficiency or iron or riboflavin (vitamin D)
Define gingivitis
Gum inflammation +- hypertrophy
Causes of gingivitis
Poor oral hygiene Drugs - pheytoin, ciclosporin, nifedipine Pregnancy Vitamin C deficiency Acute myeloid leukaemia Vincent's angina
Define microstomia
Mouth is too small
Causes of microstomia
Thickening and tightening of perioral skin after burns
Epidermolysis bullosa - destructive skin and mucous membrane blisters +- ankyloglossia
Systemic sclerosis
Causes of oral pigmentation
Peutz-Jehers’ - perioral brown spots
Addisons’ disease - pigmentation anywhere in mouth
Malignant melanoma
Telangiectasia - systemic sclerosis
Fordyce glands - creamy yellow spots at the border of the oral mucosa and lip vermilion
Sebaceous cysts
Aspergillus niger - black tongue
Sign of lead poisoning
Blue line at gum-tooth margin
Causes of yellow-brown discolouration of teeth
Prenatal or childhood tetracycline exposure
Causes of furred or dry tongue
Dehydration
Drug therapy
After radiotherapy
Crohn’s disease
Define glossitis
Smooth, red, sore tongue
Causes of glossitis
Iron, folate or B12 deficiency
Define macroglossia
Tongue is too big
Causes or macroglossia
Myxoedema
Acromegaly
Amyloid
Features of tongue cancer
Raised ulcer with firm edges
Risk factors of tongue cancer
Smoking
Alcohol
Pathway of spread of tongue cancer
Anterior 1/3 drains to submental node
Middle 1/3 to submandibular nodes
Posterior 1/3 to deep cervical nodes
Treatment for tongue cancer
Radiotherapy
Surgery
Causes of white intra-oral lesions
Idiopathic keratosis Leucoplakia Lichen planus Poor dental hygiene Candidiasis Squamous papilloma Carcinoma Hariy oral leucoplakia Lupus erythematosus Smoking Ahthous stomatitis Secondary syphilis
Indications for upper GI endoscopy
Diagnostic - haematemesis/malaena - dysphagia - dyspepsia - duodenal biopsy - persistent vomiting - iron deficiency Therapeutic - treatment of bleeding lesions - variceal banding and sclerotherapy - argon plasma coagulation for suspected vascular abnormality - stent insertion, laser therapy - stricture dilation, polyp resection
Pre-procedure for upper GI endoscopy
Stop PPIs 2wks prior
Nil by mouth 6 hrs before
Don’t drive for 24hrs if sedation used
Upper GI endoscopy procedure
Sedation optional - midazolam 1-5mg slowly IV
Nasal prong O2 - 2L/min + monitor sats
Spray pharynx with local anaesthetic
Continuous suction - prevent aspiration
Complications of upper GI endoscopy
Sore throat
Amnesia - sedation
Perforation
Bleeding - aspirin, clopidogrel, warfarin or DOACs stopped if therapeutic
Uses of duodenal biopsy
Gold standard for coeliac disease
Whipple’s disease
Giardiasis
Lymphoma
Uses of sigmoidoscopy
Views rectum + distal colon - to splenic flexure
Flexible has replaced rigid - 25% cancers still out of reach
Therapeutic - decompression of sigmoid volvulus
Sigmoidoscopy procedure
Do PR exam first
Biopsies
Indications of colonscopy
Diagnostic - rectal bleeding - iron-deficiency anaemia - persistent diarrhoea - positive faecal occult blood test - assessment or suspicion of IBD - colon cancer surveillance Therapeutic - haemostasis - clipping vessels - bleeding angiodysplasia lesion - colonic stent deployment - volvulus decompression - pseudo-obstruction - polypectomy
Colonoscopy preparation
Stop iron 1wk prior
Discuss bowl preparation and diet required
Colonoscopy procedure
Do PR first
Sedation and analgesia
Complications of colonoscopy
Abdominal discomfort
Incomplete examination
Haemorrhage after biopsy or polypecotmy
Perforation
Post-procedure of colonoscopy
No alcohol
No operating machinery for 24 hrs
Indications of video capsule endoscopy (VSE)
Evaluate obscure GI bleeding
Detect small bowel pathology
Pre-procedure for VSE
Small bowel imaging (contrast) or patency capsule test - if pt has abdo pain or symptoms suggesting obstruction
Clear fluids only evening before
Nill by mouth from morning till 4hr after capsule swallowed
VSE procedure
Capsule swallowed
Transmits wirelessly to capture devise worn by pt
Normal activities take place during day
Complications of VSE
Capsule retention - endoscopic or surgical removal
Obstruction
Incomplete exam - slow transit, achalasia
Problems with VSE
No therapeutic options
Poor localisation of lesions
May miss more subtle lesions
Routes for liver biopsy
Percutaneous - if INR in range
Transjugular - with FFP
Indications for liver biopsy
Increased LFTs of unknown origin
Assessment of fibrosis in chronic liver disease
Suspected cirrhosis
Suspected hepatic lesions/cancer
Pre-op for liver biopsy
Nil by mouth for 8 hr
INR < 1.5
Platelets > 50x10^9/L
Liver biopsy procedure
Sedation and analgesia may be given
Do under US/CT guidance
Liver borders percussed
Lidocaine 2% infiltrated down to the liver capsule
Breathing rehearsed and needle biopsy taken with breath held in expiration
Lie on right hand side for 2hr
Stay in bed for 4 hr
Check BP and pulse every 15 mins for 1 hr then 30 mins for 2 hrs then hourly
Discharge 4 hr post op
Complications of liver biopsy
Local pain
Pneumothorax
Bleeding
Death
Define dysphagia
Difficulty swallowing
Key questions to ask with dysphagia
Difficulty swallowing solids and liquids from the start - y - motility disorder - n - stricture - benign or malignant Difficult to initiate swallowing - y - bulbar palsy Swallowing painful - y - ulceration - malignancy, oesophagitis, viral infection, Candida Dysphagia intermittent - intermittent - oesophageal spasm - constant and worsening - malignant stricutre Neck buldge or gurgle - y - pharyngeal pouch
Signs associated with dysphagia
Cachectic Anaemic Examine mouth Feel for supra-clavicular nodes Systemic disease - sclerosis, CNS
Investigations for dysphagia
FBC - anaemia U&Es - dehydration Upper GI endoscopy +- biopsy Contrast swallow - pharyngeal pouch Video fluroscopy - neurogenic causes Oesophageal manometry - dysmotility
Findings in vomit
Coffee grounds - upper GI bleed
Recognisable food - gastric stasis
Feculent - small bowel obstruction
Timing of vomit
Morning - pregnancy or raised ICP
1hr post food - gastric stasis/gastroparesis
Relieves pain - peptic ulcer
Preceded by loud gurgling - GI obstruction
Investigations for vomiting
Bloods - FBC, U&Es, LFTs, Ca2+, glucose, amylase
ABG - metabolic alkalosis from loss of gastric contents indicates severe vomiting - pH > 7.45, increased HCO3-
Plain AXR - if suspected bowel obstruction
Upper GI endoscopy - bleed or persistent vomitting¬
Treatment for N+V
Identify and treat underlying causes
Symptomatic relief - oral route first anti-emetic, IV fluids with K+ replacement
Monitor fluid and electrolyte balance
H1 receptor antagonists antiemetics
Cyclizine - 50mg/8h PO/IV/IM - GI causes
Cinnarizine - 30mg/8hr PO - vestibular disorders
D2 receptor antagonists antiemetics
Metoclopramide - 10mg/8h PO/IV/IM - GI causes + prokinetic
Domperidone - 60mg/12h PR, 20mg/6hr PO - prokinetic
Prochlorperazine - 12.5 mg IM, 5mg/8h PO - vestibular + GI causes
Haloperidol - 1.5mg/12h PO - chemical causes (opioids)
5HT3 receptor antagonist antiemetics
Ondansetron - 4-8mg/8hr IV slowly - doses can be higher for chemo
Other antiemetics
Hyoscine hydrobromide - 200-600mcg SC/IM - antimuscarinic, antispasmodic and antisecretory - don’t prescribe with prokinetic
Dexamethasone - 6-10mg/d PO/SC - unknown MOA, adjuvant
Midazolam - 2-4mg/d SC (syringe driver) - unknown MOA, anti-emetic effect outlasts sedative effect
Mechanical causes of dysphagia
Malignant stricture - pharyngeal cancer - oesophageal cancer - gastric cancer Benign strictures - oesophageal web or ring - peptic stricture Extrinsic pressure - lung cancer - mediastinal lymph nodes - retrosternal goitre - AAA - left atrial enlargement Pharyngeal pouch
Motility disorders causing dysphagia
Achalasia Diffue oesophageal spasm Systemic sclerosis Neurological bulbar palsy - pseudobulbar palsy - Wilson's or Parkinson's disease - syringobulbia - bulbar poliomyelitis - Chagas's disease - Myasthenia gravis
Other causes of dysphagia
Oesophagitis
Globus
Symptoms of dyspepsia
Epigastric pain often related to hunger, specific foods or time of day
Fullness after meals
Heartburn (retrosternal pain)
Tender epigastrium
Red flags of dyspepsia
Anaemia - iron deficiency Loss of weight Anorexia Recent onset/progressive Melaena/haematemsis Swallowing difficulty
Treatment for H.pylori
PPI + 2 antibiotics for 1 week
- Lansoprazole 30mg/12hr PO
- Clarithromycin 250mg/12hr PO
- Amoxicillin 1g/12hr PO
Risk factors for a peptic ulcer
H.pylori Drugs - NSAIDs, steriods, SSRI Increased gastric acid secretion Increased gastric emptying - lowers duodenal pH Blood group O Smoking Stress
Symptoms and signs of a peptic ulcer
Asymptomatic or epigastric pain
+- weight loss
Epigastric tenderness
Risk factors for gastritis
Alcohol NSAIDs H.pylori Reflux/hiatus hernia Atrophic gastritis Granulomas - Crohn's, sarcoidosis CMV Zollinger-Ellison syndrome
Symptoms of gastritis
Epigastric pain
Vomiting
Complications of peptic ulcer disease
Bleeding
Perforation
Malignancy
Reduced gastric outflow
Treatment of functional dyspepsia
H.pylori eradication
PPIs and psychotherapy
Low-dose amitriptyline - 10-20mg each night PO
H.pylori tests
CLO test Histology Culture 13C breath test - most accurate non-invasive Stool antigen Serology
Differential diagnosis of dyspepsia
Non-ulcer dyspepsia Duodenal/gastric ulcer Duodenitis Oesophagitis/GORD Gastric malignancy Gastritis
Causes of GORD
Lower oesophageal spinchter hypotension Hiatus hernia Oesophageal dysmotility Obesity Gastric acid hypersecretion Delayed gastric emptying Smoking Alcohol Pregnancy Drugs - tricyclics, anticholinergics, nitrates
Symptoms of GORD
Oesophageal - heartburn - belching - acid brash - waterbrash - odynophagia Extra-oesophageal - nocturnal asthma - chronic cough - laryngitis - sinusitis
Complications of GORD
Oesophagitis Ulcers Benign strictures Iron-deficiency Barrett's oesphagus
Treatment of GORD
Lifestyle - weight loss - smoking cessation - small regular meals - reduce hot drinks, alcohol, citrus fruits, onions, fizzy drinks, spicy foods, caffeine, chocolate - avoid eating 3 hrs before bed Drugs - antacids relieve symptoms - PPI Surgery
Describe a sliding hiatus hernia
Gastro-oesophageal junction slides up into the chest
Acid reflux occurs as LOS becomes less competent
Describe a paraoesophageal hernia
Gastro-oesophageal junction remains in abdomne but buldge of stomach herniates up into chest alongside oesophagus
Clinical features of hiatus hernia
Common - 30% > 50yrs, esp obese women
Large hernias -> GORD
Imaging of hiatus hernia
Upper GI endoscopy visualises mucosa but cannot exclude hitatus hernia
Treatment of hiatus hernia
Weight loss
Treat GORD
Surgery
Surgical indications for hiatus hernia
Intractable symptoms despite aggressive medical therapy
Complications
Define haematemesis
Vomiting of blood
- may be bright red or like coffee grounds
- indicates upper GI bleed
Define malaena
Black stools due to altered blood
- indicates upper GI bleed
Stages of a GI bleed history
Past GI bleeds Dyspepsia/known ulcers Known liver or oesophageal varices Dysphagia Vomiting Weight loss Drugs - antiplatelets, anticoagulants, NSAIDs Alcohol use Co-morbidities - liver disease
Signs of a GI bleed
Peripherally cool/clammy Capillary refil >2s Urine output <0.5mL/kg/h Reduced GCS Tachycardic - pulse > 100bpm Systolic BP <100mmHg
Investigations for upper GI bleed
FBC - anaemia and platelet count
- thrombocytopenia suggestive of chronic liver disease
U&Es - raised urea
Clotting
Group and save - may need blood transfusion
LFTs
Venous blood gas - quick haemoglobin result
Acute management of upper GI bleeed
2 large-bore (14-16g) IV cannulae
- give IV fluids if haemodynamically compromised
- give O Rh- blood
Correct clotting - FFP, vitamin K, platelets
If suspicion of varices - IV Terlipressin and IV antibiotics
Arrange urgent upper GI endoscopy
Monitor hourly
Rockall risk-scoring for upper GI bleeds
Age - <60, 60-79, >80
Cormorbidity - No, Heart failure or IHD, Renal or liver failure, Metastases
Shock - No shock, Tachycardia, Hypotension
Source of bleeding - M-W tear, all other diagnosis, malignancy
Stigmata of recent bleeding - None, blood in upper GI tract visible of spurting vessel
Blatchford score
Admission risk markers
- blood urea
- haemoglobin
- systolic BP
- others
Features of Crohn’s disease
Mouth to anus Skip lesions Transmural inflammation Fissuring ulcers Lymphoid and neutrophil aggregates Non-caseating granulomas Increased incidence in smokers
Features of UC
Rectum then proximally Continuous Mucosal and submucosa inflammation Crypt abscesses Decreased incidence in smokers
IBD investigations
Blood tests - FBC - anaemia or raised platelets - U&Es - deranged electrolytes of AKI - CRP - inflammatory marker Stool tests - cultures - exclude infection colitis - Faecal calprotectin - raised in active disease Imaging - AXR - proximal constipation - CT - acute complications - MRI enterography - small bowel Crohn's - MRI rectum - perianal Crohn's Endoscopy - flexible sigmoidoscopy - safest in bloody diarrhoea - colonoscopy - proximal disease - capsule endoscopy - small bowel mucosa
What are patients admitted to hospital with acute IBD at high risk of?
VTE - need prophylactic heparin
IBD steriod treatment
Acute flare ups
- topically - suppositories, enemas
- orally - prednisolone or budesonide in small bowel disease
- IV - hydrocortisone (100mg qds for 3-5 days)
UC treatment
Maintain remision - Mesalazine Rescue therapy - ciclosporin - biologics - surgery
Crohn’s treatment
Maintain remission - azathioprine - biologics - perianal or fistulating Rescue therapy - biologics - surgery
Presentation of coeliac disease
Loose stools Bloating Wind Abdo cramps Weight loss Dermatitis herpetiformis
Complications of untreated coeliac disease
Small bowel lymphoma
Small bowel cancer
Osteoporosis
Gluten ataxia and neuropathy
How to diagnose coeliac disease
Continue normal diet
Tissue transglutaminae - raised
OGD and duodenal biopsies - villous atrophy and intra-epithelial lymphocytosis
Treatment of coeliac disease
Gluten free diet
- barley
- wheat
- oats
- rye
Functions of the liver
Nutrition - stores glycogen - releases glucose - absorbs fats, fat soluble vitamins and iron - manufactures cholesterol Bile salts dissolve dietary fats Breakdown of haemoglobin to haemoglobin Manufactures clotting factors Detoxification - drug excretion - alcohol breakdown Kupfer cells engulf antigens Manufactures proteins - albumin - binding proteins
Risk factors of liver disease
Blood transfusion prior to 1999 in UK IVDU Operations/vaccinations with dubious sterile procedures Sexual exposure Medications FH of liver disease, diabetes, IBD Obesity Alcohol Foreign travel
Features of acute liver disease
No pre-existing liver disease Resolves in 6 months Causes - viral - Hep A, Hep E, CMV, EBV - drug-induced liver injury (DILI)
Features of chronic liver disease
Starts with acute liver disease On-going effects beyond 6 months May lead to cirrhosis and its complications Causes - alcohol - Hep C - Non-alcoholic steatohepatitis - autoimmune (PBC, PSC, AIH)
Grading of hepatic encephalopathy
Grade 1 - psychomotor slowing - constructional apraxia - poor memory - reversed sleep pattern Grade 2 - lethargy - disorientation - agitation/irritability - asterixis Grade 3 - drowsy Grade 4 - coma
Investigations for liver disease
Thrombocytopenia - liver fibrosis LFTs - ALT - hepatocytes - ALP - ducts Bilirubin, Albumin and Prothrombin time - synthetic function USS - cirrhosis
Hepatic causes of deranged LFTs
ALT > 500 - viral - ischaemia - toxic - paracetamol - autoimmune ALT 100-200 - non-alcoholic steatohepatitis - autoimmune hepatitis - chronic viral hepatitis - drug induced liver injury
Cholestatic causes of deranged LFTs
Dilated ducts - gallstones - malignancy Non-dilated ducts - alcoholic hepatitis - cirrhosis - PBC, PSC, alcohol - drug-induced liver injury - antibiotics
Components of the liver screen
Hepatitis B&C serology Iron studies - ferritin and atransferrin saturation Autoantibodies and immunoglobulins Caeuruloplasmin - under 30 yrs Alpha-a-antitrypsin Coeliac serolgy TFTs, lipids and glucose
Commonest causes of chronic liver disease
Alcoholic liver disease
Non-alcoholic steatohepatitis
Viral hepatitis - B+C
Less common causes of chronic liver disease
Women - autoimmune hepatitis - PBC Men - PSC - associated with IBD - haemachromatosis Adolescents - Wilsons disease - anti LKM autoimmune hepatitis
Treatment of chronic liver disease
Removing underlying aetiology to prevent further damage and progression to cirrhosis
- stop drinking
- weight loss
- antivirals
- venesection
Diagnosis of cirrhosis
Chronic liver disease pts with thrombocytopenia or clinical stigmata of chronic liver diease
Imaging - splenomegaly, coarse texture and nodularity
Fibroscan - quicker
Management of cirrhosis
Screen for varices
Spironolactone - ascites
DEXA scan for osteoporosis
Alpha-fetoprotein and USS every 6 months - hepatocellular carcinoma
What should be performed on all patients admitted with ascites?
Diagnositc ascitic tap - cell count and MC&S
- look for spontaneous bacterial peritonitis
Components of nutritional assessment
Appetite Diet history Changes in oral intake Changes in weight Malnutrition Universal Screening Tool (MUST)
Steps of nutritional support
Food and encouragement - protected mealtimes - high calorie options encouraged - food fortification Nutritional supplements - large calories but small volumes NG tube PEG Parenteral
NG tube
Short term
Supplementary feeding or solo
Get in way and attached to drip
Do on eliminated aspiration - pts aspirate on saliva
PEG
Longer term access to - Stomach - PEG - Small bowel - PEG-J Placed endoscopically (PEG) or Radiologically - (RIG) Indicated - feeding difficulty - need to provide supplementary feeding Do on eliminated aspiration - pts aspirate on saliva
Parenteral nutrition
Nutrition and fluid directly into patients veins
Indicated when
- GI tract not accessible - blocked
- GI tract not working - short, leaking, diseased
Mix of fluid, marco and micronutrients
Given via dedicated central line
Risks of line sepsis and liver dysfunction
