Gastroenterology

Question 1

Ongoing management of CLD/Liver Cirrhosis?

Answer 1

Goals:

• Slow disease progression
• Prevent decompensation
• Consider for Transplantation

CAS

C: Review her current LFT trends, synthetic function, liver biopsy (if had any) to identify previous aetiologies.

A: liver screen and treat 2ndary contributary factors. Cease alcohol/toxins. Loose weight.

S: I’d follow-up 3-6 monthly and perform a regular exam to identify jaundice, ascites and HE. If Cirrhosis - needs q6m USS, AFP and q2y variceal surveillance

NP: low salt (<2g/d), link up with dietician (HEHP diet, nutritional supplementation), FR (if ascites), Vaccinations.

P: directed at complications

• Ascites: spiro/lasix (50:20), monitor EUCs, paracentesis, consider TIPPS if refractory. I’d check patient’s cardiac status and encephalopathy first.
• Encephalopathy: stop driving, lactulose, rifaximine
• Varices: BB as primary prophylaxis, variceal banding - 6-8 weekly until erradication
• HCC: Milan criteria - 3 x <3cm or 1 x <5cm –> consider transplant. If not candidate, RFA, alcohol, resection, chemotherapy.
• SBP: Norflox.
• Transplant: MELD >10

Question 2

Investigation & Management of Dysphagia - Oropharyngeal

Answer 2

Oropharyngeal dysphagia

• Difficulty initiating swallow
• Nasopharyngeal regurgitation (through nose)
• Aspiration / chocking / dysphonia
• sensation of residual food remaining in pharynx
• Contrast to esophageal dysphagia - impaction symptoms several seconds after initiating swallow

DDx - choose most likely 3 for each patient.

• Structural (oropharyngeal Ca, Zenker’s, cervical webs)
• Myogenic (myositis, dystrophy, NMJ)
• Neurogenic (stroke, MS, SOL, GBS, MND, PD)
• Infectious (mucositis - herpes, candida, CMV…etc)
• Metabolic (amyloid, Cushing’s thyrotoxicosis)

Investigations

• Examine for mass, LN, CN
• Bloods guided by symptoms: TFT, cortisol, myositis panel, anti-Ach-R…etc
• Brain imaging
• Modified Barium Swallow: degree of oropharyngeal dysfunction, the severity of aspiration
• Nasoendoscopy: structural lesion
• Manometry: assess UES relaxation/pressure ?myotomy

Management

• Treat the cause
• Speech therapist involvement for swallow rehabilitation
• Consider enteral nutrition (if aspiration risk high)
• Dietary modification: cut up foods, thickened liquids
• Endoscopic balloon dilatation
• Cricopharyngeal myotomy /cPOEM: for tight UES

Question 3

Investigation & Management of Dysphagia - oesophageal

Answer 3

DDx

• Solids dysphagia
  
  • Progressive: stricture (gradual), malignancy (more rapid)
    
    • Strictures: peptic, RTx, EoE
    • Compression (e.g. heart, vessels, LN)
  • Intermittent
    
    • EoE
    • Oesophageal web or ring
• Liquid +/- solid dysphagia
  
  • Achalasia (failure of LOS relaxation) - regurgitation of bland/undigested food
  • Distal oesophageal spasm (DES) & other motility disorders
  • Scleroderma - usually both solids + liquids (90% of SS patients have oesophageal involvement)
• Odynophagia
  
  • Infection: e.g. candida, HSV
  • Medication-induced
• Functional dyspepsia

Investigations

• Gastroscopy
• Barium swallow (controversial)
• If both unrevealing Manometry

Management (Achalasia)

• Pneumatic dilatation
• POEM / surgical myotomy
• Botox
• Nitrates

Question 4

Ongoing Mx of IBD

Answer 4

Goals

• Minimize symptoms/flare-up
• Prevent disease-related complications
• Prevent treatment-related complications

CA

• Review endoscopy + biopsy + surgical specimen to confirm Dx
• Assess current state with bloods (CRP, ESR), faecal calprotectin, Hb

Monitoring of the disease & complications

• Clinical assessment: UCDAI or CDAI (or Truelove-Witts), including assessment for perianum
• Biochemical assessment: CRP, ESR, faecal calprotectin
• Endoscopic/Radiology: regular colonoscopy if disease activity suspected, CRC surveillance, MRE for SB Crohn’s disease
• Nutritional assessment: macro, micro deficiencies (angular stomatitis, chelitis), fat pads, muscle bulk
• Treatment
  
  • Education of disease, dietician involvement, review adherence, psychology involvement
  • Acute flare: rule out infection, systemic steroids, topical 5-ASA/steroids, consider IFX rescue
  • Discuss escalation of treatment: anti-TNFs, Vedolizumab, Ustekinumab - infection screening

Monitoring of medication-related complications

• Malignancy screening (especially skin cancer + Lymphoma), Osteoporosis
• Steroids complications: HBA1C, Lipids, DEXA, Vitamin D, CMP…etc, talk about OP
  
  • Vaccinations
• AZA/6-MP: 3 monthly LFTs and FBC, monitor signs of pancreatitis, lymphoma symptoms
• IFX: monitor FBC, Lymphoma (Hepato-Splenic T-cell lymphoma), demyelinaiton, HF