Gastroenterology Flashcards
Dyspepsia: Defn
= pain/reflux/vomiting/indigestion/heartburn for 4 weeks
Dyspepsia: causes
7
- Uninvestigated (not had an OGD)
- Functional dyspepsia (= symptoms following a normal OGD; may need long-term acid suppression treatment)
- GORD (= ‘endoscopically-determined reflux disease’ eg leading to oesophagitis)
- Peptic ulcer disease
- Barrett’s (= metaplastic change of squamous mucosa, increased risk of adenocarcinoma)
- Upper GI cancer
- Medications - NSAIDs, steroids, bisphosphonates, calcium blockers, alpha blockers
Dyspepsia:
‘Uninvestigated’ Mx
(2)
Choose one of two strategies:
- Full-dose PPI for 1 month
OR
- Test for H Pylori (urea breath test/stool antigen) +/- eradication therapy
(If symptoms persist after choosing one, then try the other strategy)
Gastro referral/OGD if recurrent or refractory symptoms despite primary care treatment
Dyspepsia:
H Pylori eradication
7 day triple therapy
PPI (eg lansoprazole 30mg)
+ Amoxicillin 1g BD
+ Clarithromycin 500mg BD / Metronidazole 400mg BD
(Second line: various options including levofloxacin, tetracycline, tripotassium)
Suspected oral cavity cancer
—> urgent dentist/oral surgeon review in 2 weeks, if…
Lump on lip or in oral cavity
Red patches +/- white patches in oral cavity (erythroplakia/erythroleukoplakia)
Peptic ulcers (gastric v duodenal)
Gastric:
- Repeat OGD to confirm healing (+ H.pylori test repeat if appropriate) 6 - 8 weeks after treatment
- May need long term acid suppression treatment
Duodenal:
- Repeat H.pylori test if appropriate 6-8 weeks after treatment
- May need long term acid suppression treatment
I.e. difference is gastric needs repeat OGD, (duodenal doesn’t)
PPI
CI; Cautions, SE
CI:
- 2 weeks before endoscopy (may mask symptoms of upper GI cancer)
Cautions, if risk of:
- Osteoporosis
- Hypomagnesaemia
SE include:
- Headache, dizziness
- GI (diarrhoea, N&V, abdo pain)
- Dry mouth
- Peripheral oedema
- Fatigue, sleep disturbance
- Myalgia, pruritis
Barrett’s oesophagus
=, cause, Sx, Dx, risk, Mx 3 & 3
= metaplastic changes of squamous mucosa - dysplasia can be low/high grade
Main cause: GORD
Sx: Barrett’s itself has no symptoms, but often people have Sx of GORD
Dx: At endoscopy
Increased risk of adenocarcinoma - needs monitoring, e.g. regular endoscopies, biopsies
Mx:
1 Lifestyle changes
2. Test and treat H Pylori
3. May need long-term acid suppression Rx
Dysplasia Mx options:
- mucosal resection
- radiofrequency ablation
- Oesophagectomy
Jaundice - Pre-hepatic
4
= too much unconjugated hyperbilirubinaemia
- Physiological, e.g. neonatal
- Gilbert’s (inherited metabolic disorder - defect in conjugation of BR —> raised unconjugated levels —> Jaundice): no Rx. Think about in questions which mention jaundice + stress/fever/exercise/pregnancy
- Thalassaemia
- Haemolytic anaemias
Jaundice - hepatic
5
Hepatitis (infectious, alcohol, AI, drugs) Cirrhosis Liver mets Drugs (e.g. Abx, antiepileptics) Haemochromatosis
Jaundice - post-hepatic
3
Gallstones
Common bile duct stricture
Ca of head of pancreas
Jaundice - admission
6
- Red flag Sx
- BR >100
- Abnormal clotting profile/showing signs of coagulopathy
- Abnormal renal function
- Suspected paracetamol OD
- Frail or significant comorbidities
NAFLD
- Aim for recommended target of 10% weight loss over 6 months
Hepatology referral:
- High risk of advanced liver fibrosis
- Signs of advanced liver disease on examination
- Uncertainty in diagnosis
Ix - may include liver fibroscan and biopsy
2º care may use pioglitazone or vitamin E drug treatment (off-label) in addition to lifestyle changes.
Ultimately there may be a role for liver transplantation.
Liver cirrhosis
=; Types 2; Ix; Mx
End stage of many liver conditions that cause parenchyma damage —> eventually leads to fibrosis and portal hypertension
Types:
- Compensated (liver still functioning, no obvious signs)
- Decompensated (liver damaged to point where clinical signs develop, e.g. ascites, jaundice)
Ix:
If suspected, can arrange transient elastography testing, but most refer to gastro/hepatology.
Mx: aim to slow progress (e.g. stop alcohol) and reduce complications (e.g. varies, ascites, encephalopathy)
Irreversible —> may need transplantation
Hepatitis A
= inflammation of liver due to hepatitis A virus
Faeco-oral transmission
Usually self limiting. Usually lasts under 2 months
Dx: through Hepatitis A IgM or IgG / Hep A RNA detection
May have raised ALT, ALP, BR, PT
4 phases:
- Incubation
- Prodromal (flu-like and GI symptoms) - up to 2 weeks
- Icteric (pruritis, hepatomegaly, fatigue) - up to 3 months
- Convalescent (malaise, hepatic tenderness) - up to 6 months
No long-term sequelae - supportive treatment.
Local health unit notification - a notifiable disease.
Vaccination for those at risk of acquiring (eg. Travel to high prevalence areas or IV drug user)
Monitor LFTs/PT depending on levels
Hepatitis B
= inflammation of liver due to hepatitis B virus
Transmission: perinatally, sexual contact, IVDU, transfusion, tattoo, needle-stick, surgery abroad, etc.
Initially acute infection - fever, malaise, nausea, RUQ pain, jaundice
Chronic infection - usually asymptomatic, may have signs of chronic liver disease
Serology:
- HBsAG (surface antigen) - 1st marker to rise in acute infection
- IgM anti-HBc - 1st antibody to rise
- IgG anti-HBc - usually persists for life (therefore indicates past infection)
- Immunisation indicated by Anti-HBs without Anti-HBc
Chronic hep B - 8-20% get cirrhosis (2-5% get HCC)
Symptomatic care (no cure) & refer to hepatology/gastro/ID
Local health protection unit notification (notifiable disease!)
Offer contacts vaccination (e.g. household contacts, IVDU):
- Usually 3 doses at 0, 1, 6 months (can be more rapid programme at 0, 1, 2 months)
Hepatitis C
= slow, progressive liver disease
Transmission routes similar to Hep B
Test for antibodies and Hep C RNA:
+ve… repeat again
-ve… repeat in 3-6 months if at risk
Complications…cirrhosis (10-30%), HCC (1-3%)
Local health protection unit notification (notifiable disease!)
Refer to hepatology/gastro/ID:
- will get antiviral meds (e.g. Sofosbuvir, Ledipasvir) which are replacing interferon use
- Liver transplant
Charcot’s triad
For cholangitis (infection of common bile duct) - ADMIT!
- Fever
- Jaundice
- RUQ pain
Acute pancreatitis
Causes 11; Sx 4; Key Ix; Mx 5
Causes - I GET SMASHED (first 4 are most common)
Idiopathic , Gallstones , Ethanol (alcohol) , Trauma
Steroids, Mumps (or other infections), Autoimmune, Scorpion bite, Hyperlipidaemia/hypercalcaemia/hyperparathyroidism, ERCP, Drugs (e.g. valproate, azathioprine)
Sx:
- Epigastric pain (may ease with sitting forward)…
- … radiates to back
- Vomiting
- Grey discolouration (paraumbilical = Cullen’s sign; flanks = Grey-Turner’s)
Key Ix is raised Amylase
Modified Glasgow Score used for predicting severity
Mx:
- Admit!
- IV fluids
- Analgesia
- Close monitoring
- May need ITU
Chronic pancreatitis
Irreversible, fibrosis
Sx: epigastric pain, radiates to back, bloating, steatorrhea
Dysfunction…
Endocrine: less insulin —> diabetes
Exocrine: less digestive enzymes —> malabsorption
Mx:
Supportive, pain relief, dietician, etc.
Pancreatic cancer
Sx:
Painless jaundice, Weight loss, Ascites
Surgical or palliative treatment
(Picked up quite late, and therefore also…)
…Poor prognosis: <5% 5-year survival
Irritable Bowel Syndrome
=; RF 5; Sx 3; Dx 3; Ix 4 key +2; Diet 3; Rx 4; Refer
= functional bowel disorder, no clear cause, variety of symptoms, no Dx test, can have significant impact on QoL
- can be constipation or diarrhoea predominant
Possible risk factors:
- Diet (alcohol, spicy food, caffeine)
- genetics
- GI infection
- Antibiotics
- Psychosocial factors
Consider if any ABC symptoms:
Abdominal pain , Bloating , Change in bowel habit —> PRESENT FOR 6 MONTHS
Dx:
Abdo pain present EITHER relieved by defecation OR assoc w altered bowel frequency/form
AND at least 2 of… Altered stool passage Abdo bloating/distension/tension/hardness Sx worse with eating Mucus PR
AND….
Differential ruled out
Ix:
FBC, ESR, CRP, coeliac antibody testing
+ Ca125 if considering ovarian cancer, fecal calprotectin if considering IBD
Diet advice:
- Adjust fibre levels, caffeine low, carbonated drinks low, adequate fluids levels, max 3 portions fresh fruit per day, regular meals, etc
- If probiotics - take for at least 4 weeks
- May need dietician referral, e.g. for trial of low FODMAP diet
Rx:
Abdo pain/spasms —> Mebeverine, Peppermint oil, Alverine
Constipation —> bulk laxatives (e.g. ishagula) …NB Lactulose not recommended
Loose stool —> anti-motility drug - loperamide recommended
Second line if abdo pain persists: can consider low dose TCA (off label)
Refer to gastro…
Ongoing Sx which persist despite initial management or diagnostic uncertainty
Coeliac Disease
= chronic, AI disorder against gluten —> damages lining of small intestine —> malabsorption and weight loss
Gluten found in wheat, barley, rye
Sx include:
Abdo pain
Loose stool
Fatigue
Ix:
1st line: IgA tTGA (tissue transglutaminase antibody) …….. if unavailable then IgA EMA (endomysial antibody)
NB stay on gluten whilst bloods!
If +ve —> refer for biopsy of small intestine (again stay on gluten!) - look for subtotal villus atrophy
Classic rash with coeliac disease: Dermatitis herpetiformis
Complications:
- Anaemia (Fe, B12, folate)
- Nutritoonal deficiency
- Osteoporosis
- Lymphoma
Treatment: gluten-free diet
Monitoring:
Usually annual bloods…coeliac serology, FBC, haematinics, LFTs, bone bloods
Crohn’s disease: Mx
Admit if flare-up…
- Severe diarrhea (6-8 times per day)
- Fever, unwell, dehydrated, suspected obstruction, etc
Acute Mx: corticosteroids
Maintenance Mx:
- Aminosalicylates (e.g. mesalazine)
- Immunosuppressants (e.g. methotrexate, azathioprine)
- Biologic therapy (e.g. infliximab)
Surgery may ultimately be needed
Ulcerative colitis: Mx
Admit if severe UC:
- 6-8 eps of loose stool per day
- Blood in stool
- Fever, dehydration, tachycardia, hypotension, raised inflammatory markers
Maintenance options:
- Aminosalicylates (e.g. mesalazine)
- Thiopurines (e.g. azathioprine, mercaptopurine)
- Calcineurin inhibitors (e.g. ciclosporin)
- Biologic therapy (e.g. infliximab)
Familial Polyposis
Autosomal dominant (abnormality on APC gene) —> hundreds of polyps in the bowel
Sx: blood PR, loose stool - many present with colon cancer
Ix:
- CEA (carcinoembryonic antigen)
- Colonoscopy
- Genetic testing
Treatment usually surgery due to cancer risk
Colorectal cancer
2/3 in colon, 1/3 in rectum
Most are adenocarcinomas, develop from polyps
RFs include FHx, IBD, high meat low fibre diet, familial polyp condition
Varied presentation:
- Left sided: bleeding, pain, obstruction, tenesmus
- Right sided: anaemia, weight loss, mass
Ix: colonoscopy, sigmoidoscopy, barium enema, CT colonography, biopsy
Staging: Dukes A —> B (B = mets!)
Surgery:
E.g. right or left hemicolectomy, sigmoid colectomy, AP or anterior resection, chemo, RT
BMI
18.5 - 24.99 Healthy weight 25 - 29.99 Overweight 30 - 34.99 Obesity 1 35 - 39.99 Obesity 2 >40 Obesity 3
Complications:
CVD risk, DM, depression, cancer, fertility, MSK
Weight gain: Mx
Orlistat (pancreatic lipase inhibitor):
BMI >30
Or
BMI >28 with risk factor (e.g. DM, HTN)
Liraglutide is an option but needs secondary care advice
Weight loss surgery…
1st line if BMI >50
Option if BMI >40 or BMI>35 with health problem that could benefit from weight loss
Orlistat
=; dose; target; CI 2; cautions 2; SE 2
= lipase inhibitor. Works by reducing the absorption of dietary fat.
Recommended dose 120mg up to TDS:
- taken with water
- immediately before, during or up to one hour after each meal
Target - 5% weight loss in 12 weeks (discontinue if target not met)
Contraindications:
- Chronic malabsorption syndrome
- Chronic cholestasis
Cautions:
- CKD and/or volume depletion
SE:
- GI: abdo pain, oily spotting, flatulence, fecal urgency, fecal incontinence, fatty stools
- Headaches, resp infections, UTI, hypoglycaemia, fatigue, anxiety, gingival and tooth disorders, menstrual disturbances
Leukaemia
=; types
= malignant cells take over bone marrow and may spill into general circulation
Acute - RAPID proliferation of cells
- ALL (lymphoblastic): more common in children, acute illness, tiredness, non-specific joint aches —> initial Mx steroid, e.g. dex, vincristine
- AML (myeloid): more common in older adults, pancytopenia, fever, infections —> Attempt to induce remission using cytotoxic agents, e.g. daunorubicin
Chronic - prolonged hx, rare in children
- CLL: most >60yo, non-specific Sx, LNs, sometimes found through asymptomatic lymphocytosis —> monoclonal Abs, e.g. rituximab, purine analogues, steroids, RT, etc
- CML: middle age/elderly, non-specific features, bleeding —> meds e.g. imatinib, stem cell transplantation
Suspected adult leukaemia
Consider 48 hour FBC if any of…
Pallor Fatigue Unexplained fever Recurrent infection Unexplained bruising Generalised LN Unexplained bleeding Unexplained petechiae Hepatosplenomegaly
Lymphoma
=; Types 2
= neoplastic disorder of lymphoid tissue
Hodgkin’s - may be younger
- Presence of Reed-Sternberg cells
- LNs, weight loss, night sweats, fever
—> meds: e.g. bleomycin, vinblastine
Non-Hodgkin’s - usually older
- Painless generalised lymphadenopathy
—> RT, meds eg. Rituximab
