Gastro Long Flashcards
IBS Hx
- Sx that led to diagnosis
- Abdo pain + diarrhea/constipation/mixed
- No alarm features: Bleeding, anaemia, weight loss, vomiting, dysphagia, onset >age 50, nocturnal Sx
- No organic cause - Risk factors
- Hx of Gastroenteritis
- FHx
- Food intolerances
- Hx of physical/sexual abuse
- Previous somatisation disorder
- Anxiety/depression
- Low birth weight
ROME 4 criteria
For IBS
- Abdo pain associated with change in bowel habits
- Two of the following
- pain relieved or aggravated by defecation
- Pain associated with more frequent or less frequent stools
- Pain associated with looser or harder stools - Occurs over a period of at least 3 months and began >6 months ago
Ix for IBS
Coeliac testing to rule it out
FBE to assess for anaemia
CRP for IBD
Food diary for food intolerance
Mx IBS
- Diet High in insoluable fibre
- Low FODMAP diet
- Osmotic laxatives for constipation, not discomfort
- Loperamide for diarrhea
- Mebeverine or peppermint oil for pain
- Low dose TCA for pain and diarrhea
- SSRI Moderately effective - Avoid narcotics
Associated complications with previous peptic ulcer surgery
- Pain/bloating due to bile reflux gastritis
- Recurrent ulceration
- Early or late dumping
- Post vagotomy diarrhea
- Anaemia due to iron/B12/Folate deficiency
- Osteomalacia/Osteoporosis
Causes of lack of response to a Gluten free diet in Coeliac disease
- Incorrect diagnosis
- Patient not adhering to the diet
- Collagenous sprue
- Intestinal lymphoma
- Diffuse ulceration
- Other intercurrent disease
Complications of Coeliac
T cell lymphoma
Ulceration of small bowel
Incidence of carcinoma of the GI tract is slightly higher
Malabsorption/chronic Diarrhea Sx Hx
- Steatorrhea
- Weight loss
- Weakness (from K+ deficiency)
- Anaemia
- Bone pain (osteomalacia)
- Glossitis and angular stomatitis (Vitamin B group deficiency)
- Bruising (Vit K Deficiency)
- Oedema (Protein deficiency)
- Peripheral neuropathy
- Skin rash (eczema, dermatitis herpetiformis)
- Amenorrhea (protein depletion)
Malabsorption/chronic Diarrhea etiology questions
- Gastrectomy/bowel surgery
- Hx of liver or pancreatc disease
- Drugs (e.g. ETOH, neomycin, choletyramine)
- Hx off crohns
- Previous RTx
- Gluten free diet treatment at any stage
- Hx of DM
- Risk factors for HIV infection
- Ix for malabsorption
Big 6 screening tests
- Low serum iron
- Prolonged PT
- Low Calcium
- Low cholesterol
- Low carotene
- Positive Sudan stain of the stool for fat
Fecal fat estimation over 3 days
-Abnormal if >7 grams
Glucose or lactulose breath hydrogen test for SIBO
- Evaluate the consequences of malabsorption
FBE and focus on red cell indices Iron studies Folate B12 Albumin Vid D, CMP, ALP Clotting profile Cholesterol and carotene
- Find the cause of Malabsorption
- XR: blind loops, diverticula etc
- Gscope and small bowel Bx
- Anti endomysial (Tissue transglutaminase) best screening for Coeliac, if negative check IgA for deficiency
- Faecal fat levels - if greatly elevated than likely pancreatic disease
Causes of abnormal B12 absoprtion
Ileal disease
SIBO
PErnicious anaemia
Pancreatic disease
Cause and Tx of malabsorption:
Lipolytic phase defects
Chronic pancreatitis
CF
Mx
REverse causes
Pancreatic enzymes
Medium chain triglycerides
Cause and Tx of malabsorption:
Miceller Phase defect
Extrahepatic biliary obstruction
CLD
SIBO
Terminal ileal disease -Crohns, resection
Mx
REverse causes
Cholestyramine if bile acid cathartic effect is important
Medium chain triglycerides for steatorrhea
Fat soluable vitamine supps
Cause and Tx of malabsorption:
Mucosal and deliver phase defects
Coeliac disease Tropical sprue Lymphoma Whipple's Disease Small bowel ischemia Amyloidosis Hypogammaglobinemia HIV
Mx
Reverse causes
Fat soluable vitamin supps
Coeliac MX
- Gluten free diet: Exclude wheat, rye and barley
- -Sx improve in weeks and histo in months
- Reasonable to re-biopsy in 3 months to confirm histo healing
- IF lack of response to gluten free diet: inadvertant gluten exposure, or another problem (lactose intolerance, pancreatic insufficiency, SIBO), refractory sprue (may respond to steroids), or lymphoma (T cell enteropathy - unresponsive to steroids)
- Pneumococcal vaccine - due to hyposplenism of coeliac disease
- OP Ix and management
Causes of Colitis
- IBD
- Infections, including C. Diff
- Radiation
- Ischemic Colitis
- Diversion colitis
- Toxic exposures
- Microscopic or collagenous colitis
- Lymphocytic colitis
MAnifestations of Crohns
• Local Disease
○ Anorectal disease (fissures, fistula, pararectal abscess, rectovaginal fistula)
○ Obstruction (usually terminal ileum); stricturing; SBO
○ Fistula
○ Toxic megacolon and perforation
○ Carcinoma of small and large bowel
• Extracolonic Manifestations
○ PSC
○ Gallstones
○ Urate and calcium oxalate stones, pyelonephritis, hydronephrosis
○ Malabsorption due to small bowel involvement
○ Osteomalacia
○ Poor wound healing
○ Plus the ones below for UC
MAnifestations of UC
• Local Disease
○ Toxic megacolon
○ Perforation
○ Massive Hemorrhage
○ Strictures
○ Carcinoma of colon
• Extracolonic Manifestations
○ Liver disease: Fatty liver, PSC, Cirrhosis, Carcinoma of bile duct, Amyloidosis
○ Blood disorders: Anaemia, Thromboembolism
• Arthropathy: Peripheral; Ank Spond
• Skin and Mucus membranes: Ulcers, Pyoderma Gangrenosum, Erythema nodosum (coincides with active disease)
• Ocular: Uveitis, conjunctivitis, episcleritis
Ix for IBD
- Exclude infections
- CASES
- Gonorrhea and syphillus in MSM
- Immunosuppressed: HSV, CMV, Cryptosporidium, TB - AXR
- Bowel wall thickening (oedema), gaseous distension, toxic megacolon, SBO - Blood count
- Anaemia, WCC, ESR, CRP - LFTs, UECs
- Liver disease, renal stones, amyloidosis - Cscope
- Antibody testing
- p ANCA negative, and ASCA psotive (anti saccharomyces cerevisiae antibodies) - specific for crohns over UC
Severity of UC
Mild: <4 bowel motions/day, minimal bleeding, normal temp and pulse
Acute severe: >6 motions/day, profuse bleeding, Temp >37.5, pulse >90, abdo tenderness
Fulminant: >10 motions/day, continuous bleeding, fever and tachycardia, abdo tenderness and distension
Mx of UC
Acute attack
- Correct hypokalemia
- Avoid barium enema, opiates and anticholinergics to prevent toxic megacolon or perforation
- If severe, IV ABx
- IV Steroids
- -IF unresponsive to steroids, IV cyclosporin/infliximab rescue as alternative to colectomy
- Surgical review and stoma therapist contact early
Chronic management
- SSZ or Mesalazine
- Chronic steroid use des not reduce relapse rate
- Correct IRon and folate deficiency
- AZA and 6-mercaptopurine for repeated episodes of UC
- Proctitis: Topical steroids or mesalazine enema BD + PO immunosuppressant
- Cancer screening
Indications for Surgery in UC
Chronic ill health
SEvere disease
Complications: PErforation, massive bleeding
Severe disease not responding to optimal medical treatment in 7-10 days
All manifestations are cured by colectomy except:
-Ank Spond, liver disease, and occasional PG
Mx of Crohns
- SSX and Mesalazine more effective in colonic disease
- Steroids more effective in small bowel disease
- Budesonide useful in ileocolonic disease
- AZA and 6 mercaptopurine useful for those who cannot cease steroids and to reduce relapse (including post resection surgery); MTX is alternative if AZA fails
- Diarrhea in ileal disease: bile salt sequestering (Cholestyramine, colestipol)
- Severe perianal disease: MEtronidazole or Cipro; AZA
- TNF Alpha inhibitors for refractory fistulas
- Surgery: resections for fistulas, stricturplasty if obstruction
Testing prior to starting AZA or 6MP and monitoring
Prior:
-TPMT
Monitoring:
- FBE weekly in 1st month, then 2nd weekly in 2nd month, then monthly
- LFTs monthly
SE of AZA or 6MP
Leukopenia Pancreatitis Allergy (Fever, rash, arthritis) Lymphoma Can be continued in pregnancy if cannot use other therapy
Testing prior to starting MTX and monitoring
Prior
- Start folic acid
- Baseline LFTs
- Counsel to avoid ETOH
- Rule out Hep B and C
Monitoring
- LFTs monthly for 3 months, then 3 monthly
- Consider Liver Bx if >50% of LFTs abnormal in one year
SE of MTX
Hepatotoxic
Bone marrow depression
Interstitial pneumonitis
Contraindicated in pregnancy/conception (men and women)
Testing prior to starting anti TNF and monitoring
Prior:
- Update immunisations
- Pap smear
- Rule out Hep B and C
- Quantiferon
- CXR for TB
- Consider: HIV, VZV antibody, ANA, anti dsDNA testing
Monitoring:
-6 monthly review
SE of Anti TNF
Infusion reaction Neutropenia Infections Hepatosplenic T cell lymphoma Demyelinating disease Heart failure Skin rashes (psoriasis like) Probably safe in pregnancy
Cscope timing recommendations based on previous polyps
No polyps or small: 10 years
1-2 small tubular adenomas: 5-10 years
3-10 tubular adenomas or one or more tubular adenoma > 10 mm: 3 years
>10 adenomas: <3 years
One or more villous adenomas or sessile serrated polyps >10 mm: 3 years
Hx in CLD patient
- PHx of hepatitis or jaundice and contacts
- ETOH intake
- IVDU, sharing needles, sexual orientation, transfusions, tattoos
- Diabetes, CCF, arthropathy (haemachromatosis)
- Overseas travel (acute hepatitis)
CAuses of cirrhosis
- ETOH
- Post viral (Hep B and C)
- NASH
- Drugs
- Autoimmune chronic hepatitis
- HAemachromatosis
- Wilson’s Disease
- PSC
- PBC
- Secondary biliary cirrhosis
- Alpha 1 antitrypsin
- CF
- Budd-Chiari Syndrome
- Cardiac failure, chronic constrictive pericarditis
- Cryptogenic
Complications of Cirrhosis
- Portal HTN and ascites
- Portal vein thrombosis
- SBP
- Hepatic encephalopathy
- Hepatorenal Syndrome
- HCC
- OP or osteomalacia
Child Pugh score
Albumin Bilirubin Ascites Encephalopathy INR
A - alb >35, Bili <35, no ascites or encephalopathy, INR <1.7
B- Alb 30-35, Bili 35-50, managable ascites, minimal encephalopathy, INR 1.7-2.3
C - Alb <30, Bili >50, bad ascites, advanced encephalopathy, INR >2.3
Causes of SAAG >11
Cirrhosis
Alcoholic hepatitis
RHF, Constrictive pericarditis
Budd-chiari, inferior vena cava obstruction
Crohns complications
• Local Disease
○ Anorectal disease (fissures, fistula, pararectal abscess, rectovaginal fistula)
○ Obstruction (usually terminal ileum); stricturing; SBO
○ Fistula
○ Toxic megacolon and perforation
○ Carcinoma of small and large bowel
• Extracolonic Manifestations
○ PSC
○ Gallstones
○ Urate and calcium oxalate stones, pyelonephritis, hydronephrosis
○ Malabsorption due to small bowel involvement
○ Osteomalacia
Poor wound healing
UC complications
• Local Disease
○ Toxic megacolon
○ Perforation
○ Massive Hemorrhage
○ Strictures
○ Carcinoma of colon
• Extracolonic Manifestations
○ Liver disease: Fatty liver, PSC, Cirrhosis, Carcinoma of bile duct, Amyloidosis
○ Blood disorders: Anaemia, Thromboembolism
• Arthropathy: Peripheral; Ank Spond
• Skin and Mucus membranes: Ulcers, Pyoderma Gangrenosum, Erythema nodosum (coincides with active disease)
Ocular: Uveitis, conjunctivitis, episcleritis
Indications for liver transplant
End stage (irreversible) liver failure
Life expectancy <12/12
Child-Pugh B/C
MELD >14
Hepatocellular carcinoma (UCSF)
One HCC <6.5cm
≤3 HCC, ≤4.5 cm diameter
Irreversible complications of liver disease
Hepatopulmonary syndrome
Massive polycystic liver disease
Acute (Fulminant) Liver failureLiver Screen
Alcohol, HBV, HCV
Genetic: Wilson’s disease, Haemochromatosis, A1AT
defic
Auto-immune: Primary biliary cirrhosis, primary
sclerosing cholangitis, Autoimmune hepatitis
Other: NASH, drugs, budd chiari syndrome
Liver Tx Chronic Cx
Chronic rejection (Progressive cholestasis) -Dx: liver biopsy Infections SEs of immunosuppression Malignancy Portal vein thrombosis Biliary strictures/leak CVS risk Bone health Fatigue Sexual dysfunction
Median survival 20 yaers
