Gastro Flashcards
Ix of Crohns
Bloods: FBC, U+E, LFT, CRP, ferritin, B12, folate, vitamin D
Stool: MC +S, c diff
Faecal calprotectin
Endoscopy - Colonoscopy and histology
Imaging -Small bowel enema, MRI, capsule
Pelvic MRI - perianal disease
CTAP - abscesses, fistulae,obstruction, AXR - dilation, obstruction
Mx crohns - inducing remission
- IV hydrocortisone 100mg oral,topical/iv
- 5 ASA
- Azathioprine, Mercaptopurine, (check TPMT) methotrexate
- Infliximab, adalimumab, ustekinumab, vedolizumab.
- Surgery
Maintaining remission in crohns
- Stop smoking
- Azathioprine/mercaptopurine/
- methotrexate,
- 5 ASA (ifhadsurgery)
- Surgery - treat disease or complications
- Ileocaecal resection
- strictures -balloon dilatation
- fistulae, perforation.
IX UC
Bloods: FBC, CRP, LFT, ferritin, vit D, folate, b12.
Stool: MC+S, c diff, faecal calprotectin
Endoscopy: colonoscopy (flexi sigmoidoscopy + biopsy if acute) and histology
Imaging - CT/MRI/AXR USS
MX UC inducing remission.
based on Severity (Mayo score) /extent.(endoscopy)
Mild/moderate: 1. Topical 5ASA 4weeks not worked 2. Add oral 5ASA 3. switch/add topical steroid
Severe disease (but systemically well)
- Oral steroids 2 weeks
- Infliximab.
Surgery - incomplete response to medical treatment.
Dysplasia on surveillance colonoscopy.
Subtotal colectomy with end ileostomy.(preserve rectum)
->then ileoanal anastamosis/proctectomy + permanent ileostomy.
Assessing severity of UC
Mayo score
Mild: 1/2 more stools than normal, streaks of bood, erythema/mild friability.
Moderate: 3-4 more than normal, obvious blood most of the time, marked erythema, loss of vascular pattern, erosions.
Severe: 5/day more than normal, blood without stool, spontaneous bleeding/ulceration.
Maintenance therapy UC
Proctosigmoiditis: Topical ASA +/- oral ASA
Left sided UC - Oral ASA
consider Azathioprine/mercaptopurine if > 2 flares/year.
Assessing an acute flare of IBD
Truelove and Witt criteria
Mild: small amounts of blood in stool, bowel movements <4,
Moderate: , obvious blood in stool most of time, 4-6 stools per day,
Severe: Hb <105, Blood without stool, HR>90, BO >6x aday, CRP>30, Fever >37.8
Acute flare of IBD
Initial ix
FBC, CRP, U+E, LFTs,
Hep B/C, HIV, VZV, TB screen.
Stool MC+S, Cdiff,
Imaging - AXR, CT
Mx acute flare of IBD
A-E
1. NBM, iV fluids
Iv Hydrocortisone 100mg
LMWH
no improvement in 72h
2.IV infliximab (crohns)
Iv ciclosporin - not if HTN, Renal impairment (uc)
- Surgery. (colectomy)
- failure of medical tx.
- toxic dilation
- haemorrhage
- imminent perforation
Coeliac symptoms
Weight loss
variable bowel habit
oligomenorrhea
ddx: hyperthyroid, crohns.
Coeliac ix
Bloods:
low Hb,low iron, folate deficiency, b12
IgA tTG >7 iU/ml.
Referral for gastroscopy and duodenal biopsy. (before change diet)
Referral to dieticians for gluten free advice.
Referral for a bone density scan. (osteopenia)
First degree relative screening as 10% relatives will have/develop.
Coeiliac not improving on gluten free diet?
Repeat IgA tTG
Re refer to dieticians for dietary advice.
if still neg, fecal calprotectin - IBD screen, fecal elastase for pancreatic exocrine insufficiency.
Iron deficiency anaemia ix
Colonoscopy
gastroscopy
Coeliac serology
Duodenal ulcer mx
a proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole)
Gastric ulcer mx
Ix: biopsy + CLO test.
Urea breath test
HP stool antigen
PPI, amoxicillin, clari/metronidazole
Blatchford score
Urea, Hb Systolic BP sex HR melaena recent syncope hepatic disease cardiac failure.
initial Mx Upper GI bleed (unstable)
ABCDE
2222/major haemorrhage if drowsy, airway/blood loss +++.
IV access, urinary catheter
Fluids STAT
Cross match 6 units, transfuse 2 units o neg.
optimise clotting ?plts, vit k, FFP.
Monitor vital signs every 15 mins, put on cardiac monitor.
Monitor fluid balance.
Blatchford score
NBM
Call surgeons/gastro requires urgent endoscopy once stable.
Then IV omeprazole 80mg STAT
If variceal - endoscopy in 4h -banding/sclerotherapy.
Terlipressin 2mg IV QDS
Tazocin IV
Sengstaken-Blakemore tube if life threatening.
Post OGD tx (heater probe and clip applied) mx
IV PPI 72h, 8mg/h Rpt Hb and clotting can eat next day eradicate H.pylori if CLO+ve or not done. Home after 72h if well
6weeks PPI, then stop
lifestyle advice
avoid NSAIDs.
Variceal management
ABC
Fluids
cross match 4 units transfuse 2 immediately
optimise clotting, vit K 10mg Iv, FFP, asperwt PT
Terlipressin 2mg
OGd within 4h if active bleeding.
Not stopped -> sengstaken blakemore tube. , further OGD, TIPPS/ surgery.
Then terlipressin for 48-72h
Rpt hb and clotting and correct
IV abx (augmenting, ciprofloxacin)
consider lactulose if encephalopathic
Non cardioselective beta blockers are 1st line for prevention of variceal bleeding.
if not poss, regular endoscopy and variceal band ligation.
Blood volume loss Classes
Class1: 0-750ml
0-15%, HR<100, normal Bp/CRt/Urine output >30
RR normal. Restless.
Class 2: 750-1500ml 15-30% lost. increased DBP. CRT >2s. 20-30ml/h UO. increased RR pale extremities. anxious/aggressive.
Class 3: 1500 -2000ml 30-40% HR>120 reduced BP CRT>2 UO 5-15 ml/h RR>20 pale, confused, agresive
Class 4: >2000 >40% lost. Very low BP undetectable CRT anuric RR>20 pale, clammy, cold. confused, lethargic, unconscious.
melaena ix:
ABCDE IV fluids Further hx. DRE FBC, U+E, clotting. erect CXR
hb<70
cross matched if stable.
tranfuse 2 units immediately
OGD.
if not show bleeding site + blood in stomach site -> mesenteric angiography.
Melaena but not blood on ogd -> Colonoscopy.
Ix haematemesis
FBC, U+E, LFTs clotting, cross match, blood glucose (marker of liver synthetic function)
Autoimmune hepatitis ix
Sx: Jaundice, hepatomegaly,
fever, amenorrheoa
FBC, LFTs viral serology total protein, serum globulins ANA anti SMA ANti LKMA liver biopsy - inflam plasma cells, spilling over portal tract -> hepatocytes. submassive piecemeal necrosis
Mx AI hepatitis
High dose prednisolone 30mg
then taper.
then add azathioprine
(check TPMT before) - can continue in pregnancy.
treat for 2 years after blood tests normalised.
Biopsy before stopping therapy.
Liver transplant
Increased risk of HCC. regular screening.
Drug for food poisoning
Ciprofloxacin - good against salmonellae/c.jej.
Quinolon cautions
Pts >60yo -> tendon damge. Aortic aneurysm Epilepsy - lower seizure threshold. Children - skeletal deformities. Pregnancy.
C.Diff mx
Admit to hosp
Request 3x stool culture for CDT
Start oral metronidazole.
Contraindications for loperamide
Bloody diarrhoea IBD Bacterial enterocolitis (e.coli) avoid for C.diff. High temperature.
Metronidazole cautions
Alcohol - Disulfiram like effect
flushing, abdo pain, hypotension. up to 3 days after tx.
Toxic megacolon
dilation of colon >10cm
Ix Progressive dysphagia
OGD + biopsy
Mx benign peptic stricture
Balloon dilatation - complication - perforation (chest pain, SOB, mediastinitis, palpable surgical emphysema )
Tx of underlying GORD with PPIs.
Refractory - Oesophageal stent
post balloon dilatation perforation ix
CT scan oral contrast.
Extra gi manifestations UC related to activity
Erythema nodosum apthous ulcers episcleritis anterior uveitis acute arthropathy
Not related to activity
- sacroileitis,ank spond -> HLA b27, Lower back and SI XRays.
- PSC
Child Pugh score cirrhosis mortality
Bilirubin +1 <34.2umol/L, +2 34.2-51.3, +3 >51.3
Albumin +1 >35g/L, +2 28-35, +3 <28
INR +1 <1.7, 1.7-2.2 +2, >2.2 +3
ascites absent, slight, moderate +3
encephalopathy. none, grade 1/2, grade 3/4
> 8 = high risk of variceal bleed.
RFs variceal bleed
High portal pressures (>12mmhg)
Large varices
abnormal variceal wall at endoscopy (e.g. haemocystic spots)
High child pugh score
Cirrhosis signs
Clubbing Parotid enlargement Dupuytrens contracture gynaecomastia testicular atrophy HCC - USS, CT, afp
Liver biopsy complications
Abdo pain/shoulder tip pain
Bleeding. (risk if severe cirrhosis, clotting disorder, extensive ascities, uncooperative)
Bowel perf, biliary peritonitis, renal laceration.
Pneumothorax.
Tx Alcohol withdrawal
- IV pabrinex slow. >10mins for 5 days.
- 4 hourly observations
- Glasgow modified alcohol withdrawal score/CIWA-Ar score.
- Oral benzodiazepine based on score.
- Arrange Gastro review.
serum ascites albumin gradiet
> 1.1g/dL = portal hypertension. could be cirrhosis, alcoholic hepatitis, portal venous thrombosis, HF, massive hepatic mets.
low SAAG <1.1g/dL
=peritoneal cause.
malignancy, infections (TB), pancreatitis, nephrotic syndrome, serositis including lymphoma.
what should you send ascitic tap off for?
Culture and sensitivity LDH Cytology total Protein albumin conc Cell count and differential GLucose
Ix pancreatic cancer
CT CAP
Mx pancreatic cancer
> 3cm , liver mets.
Percutaneous, endoscopic biliary stent insertion, brush cytology.
Risk factors for pancreatic cancer
Smoking alcohol diabetes 60% in head, 15% tail, 25% body. median survival <6months. Can present with acute pancreatitis Ca19-9 is non specific.
PBC presentation
Lethargy Pruritus AST ALP GGT middle aged woman Jaundice (late) xanthelasma Spider naevi Splenomegaly
progressive inflammation and destruction of interlobular bile ducts, fibrosis, cholestasis -> cirrhosis.
PBC ix
USS upper abdomen - exlude biliary dilatation, assess liver parenchyma, +/- biopsy.
viral hep serology
ANA, Anti mitonchondial Ab
serum lipids
Blood clotting profile
Contraindication for liver biopsy
Platelets <100 INR >1.3 hb <100 Acute confused. Extensive ascites - drain them first.
complications of PBC
Malabsorption Osteoporosis HCC Liver failure Haematemesis Hypothyroidism
Mx PBC
Ursodeoxycholic acid - prevents progression.
Cholestyramine - alleviates pruritus. (give 2h apart from UDCA)
Fat soluble vitamin prophylaxis.
Liver transplant.
Alcoholic hepatitis ix
GGT elevated
AST:ALT >2
Mx alcoholic hepatitis
Prednisolone.
(using maddreys discriminant function)
Pentoxyphylline
Ascites mx
Reduce sodium intake Fluid restrict if na <125 spironolactone drainage - if tense Ciprofloxacin if protein <15 TIPS
Mx hepatic encephalopathy
Tx cause (infection, gi vleed, Post TIPS) constipation, drugs, hypokalaemia, renal failure, protein.
Lactulose - excrete ammonia.
rifaximin
embolise shunts
liver transplant
64M Intermittent epigastric pain - boring to back. diarrhoea (steatorrhoea) recent diabetes wt loss prev Etoh/smoking hx.
Chronic pancreatitis
Ix Chronic pancreatitis
Amylase LFTs Serum albumin/corrected ca FBC AXR - calcification in pancreatic area. CT - calcification, atrophy, duct dilatation. pancreatic pseudocysts. MRCP
Complications of chronic pancreatitis
Carcinoma 2-3% Intractable pain - opiate addiction Pseudocyst Malabsorption Diabetes
pt comes in after outbreak of food poisoning in hotel - what actions?
Ensure side room gloves aprons
inform local health protection consultant even if out of hours.
drug induced liver damage ix
differential WCC - e.g. eosinophils = allergic response to drug
USS - exclude Causes of intra/extrahepatic obstruction
Serology for hepatitis
Hepatotoxic drugs
statins macrolides paracetamol roziglitazone flucloxacillin
Haemochromatosis features
Hfe gene on chr 6 increased fe absorption MEALS Myocardial - dilated cardiomyopathy arrythmias
Endocrine - DM, pituitary hypogonadism, amenorrheoa, infertility
Parathyroid- hypocalcemia, osteoporosis
Arthritis-2nd and 3rd MCPs, joints, knees, shoulders
Liver - CLD, cirrhosis, HCC
hepatomegaly
Skin - slate grey
Ix Haemochromatosis
LFTs Ferritin increased FE increased TIBC decreased glucose blood genotype XR - chondrocalcinosis ECG, Echom Liver biopsy - pearls stain MRI - loading
Mx Haemochromatosis
Regular venesection
Analgeisa
Refer diabetologist
screen 1st relatives.
Hepatorenal syndrome tx
IV albumin
Terlipressin
haemodialysis
liver transplant
Mx Liver cirrhosis
Nutrition etoh abstinence Cholestyramine - pruritus Screening 6m for HCC AFP/USS endoscopy
Treat cause - HCV - interferon a, PBC UDCA, wilsons - penicillamine
tx decompensation
Tx decompensated liver cirrhosis
Ascites - fluid and salt restrict, spironolactone, frusemide, tap, daily wts, tipps HAS.
coagulopathy - vit K, FFP, plts, blood
Encephalopathy - avoid sedatives, lactulose + enemas
rifaximin
sepsis SBP - tazocin
Hepatorenal syndrome - iV albumin, terlipressin
Wilsons features
cu transport ATPase mutation = hepatocyte cant put cu into cerulopasmin
cu sequestered into tissues
CLANKAH
Cornea - kayser fleischer rings
Liver disease- acute hep - cirrhosis
Arthritis
Neuro - parkinsonism, psychosis, ataxia
kidney - Fanconis syndrome - osteomalacia
abortions
Haemolytic anaemia
Ix wilsons
24h urinary cu
caerulopasmin reduced, copper reducedd
Mx wilsons
diet- avoid chocolate, liver, nuts
Penicillamine - lifelong. SE: nausea, rash, leukopenia, anaemia, plats,
Monitor FBC, cu extretion
Liver
PBC
F>M 50s intrahepatic bile duct destruction, granulomas ALP raised Pruritus, fatigue Pigmentation of face osteoporosis, osteomalacia (vit Ddef) Cirrhosis, coagulopathy Cholesterol, xanthelasma Steatorrhoea
Ix: LFTs, ALP, GGT, late BR, PT, albumin abs - AMA IgM cholesterol TSH US Liver biopsy
tx: cholestyrmaine diarrhoea - codeine bisphosphonates ADEK vits UDCA - Liver transplant
jaundice -> survival <2y
PSC
intra and extrahepatic duct fibrosis, strictures, M>F
jaundice, pruritus fatigeu complications: cholangiocarcinoma, CRC, bacterial cholangitis ASw UC ALP -> BR pANCA ANA, SMA MRCP - beaded ducts biopsy
mx - cholestyramine, codeine, ADEK vits, UCDA, abx, endoscopic stenting,
Transplant
Carcinoid tumours
neuroendocrine -> 5HT, etc.
Sites: appendix, ileium, colorectum, stomach,
-appendicitis, intussusseption, abdo pain.
FIVE HT Flushing diarrhoea valve fibrosis wheeze hepatic pellagra
Ix: Increased urine 5 hdroxyindoleacetic acid, increased plasma chromogranin A
CT
tx: octreotide, loperamide
resectjkn
HCC features
Tender hepatomegaly Jaundice weight loss ascites cachexia
HCC ix
AFP glucose clotting Calcium/albumin CXR USS Hepatitis serology CT
HCC rfs
Male
Alcoho
HBV/HCV
Haemochromatosis
Mode of transmission of hepatitis
Hep A feaco oral Hep B Blood borne, vertical, std Hep C blood borne, vertical, std Hep D co infection w hep b hep E faeco oral
Rate of transmission of hep / hiv from needlesticks
hep B 1in3
hep c 1in 30
hiv 1 in 300
complications of hepc
Cirrhosis
HCC
mesangiocapillary glomerulonephritis - nephritic syndrome
Hep C mx
Genotype and viral load pre tx
viral RNA level monitor response to tx
DAA regimen
Glasgow criteria for severity of pancreatitis
WCC >15 Glucose >10 LDH >600 AST >200 urea >15 Ca <2 Albumin <32 pO2 <8
