Gastroenterology Flashcards
When there is bloating, what do you have to consider?
Women
where
when
central/lower/upper abdomen
What is the pathway you should be thinking when a patient presents with upper abdominal bloating?
THAT VARIES
HP- h polyri
you may also look at faecal antigen test
serology test for antibody of hp
Breath test if they havent experiences before
SIBO- small intestinal bacterial overgrowth- only consider this if IBS is ruled out too
How does SIBO occur?
it occurs when there is fermentation of food within the small bowel because there is abnormal amount of bacteria.
Could occur due to small bowel anomaly, diverticulosis, after surgery, in response to radiotherapy
Tx: Abx
What is the pathway you should be thinking when a patient presents with upper abdominal bloating?
THAT DOES NOT VARY
Vomitting and weightloss are red flags. These could indicate obstruction, malignancy, scarring to peptic ulceration
If endoscopy is negative then this could indicate gastric residue, gastroparesis,
Examination- looking for masses/ascities
What is the pathway you should be thinking when a patient presents with central/lower abdominal bloating?
THAT VARIES
Neg ttg test (coeliac
What is the pathway you should be thinking when a patient presents with central/lower abdominal bloating?
THATS PERSISTENT
Ultrasound
CT
Colonscopy
What does thyroid do?
The thyroid gland regulates tissue metabolism and development
It is controlled by thyroid stimulating hormones (TSH) from the pituitary gland and it produces triiodothyronine T3 and thyroxine T4 hormones
What is hypothyroidism
Causes?
A condition in which the thyroid gland produces insufficient thyroid hormone for the bodys requirements.
Causes include auimmune thyroid disease (hashimoto’s), radioactive iodine or surgery and drugs such as lithium carbonate and sulfonamides
Signs and symptoms of hypothyroidism?
What is hyperthyroidism?
Causes
This is a condition where the body produces too much T3 and T4 hormones.
Causes include autimmune and thyroid disease (graves disease) thyroiditis and thyroid nodules
Signs and symptoms of hyperthyroidism
Tx Hypothyroidism vs Hyperthyroidism
Epidemiology of Coeliac Disease?
Who are the high risk population?
What is gluten?
A composite of storage proteins termed prolamiens and glutelins.
What is an extra intestinal manifestation of Coeliac Disease?
Dermatitis Herpetiformis- itchy skin rash. These are most commonly located on the elbows, knees, buttocks, lower back and scalp.
Tiredness
Neuropathy
Osteoporosis
Ix for Coeliac?
After taking a biopsy for coeliac Ix, what are histoligists looking out for?
What is the classification called?
Some people might refuse to do a gastroscopy when investigating for coeliac. What would you do then?
Check for HLA genes
Also check for bloods- calcium, vit D, TSH, HbA1c, FBC, LFT
Dexa- look at NICE guidance (i.e we do not need to test everyone we see)
Tx for coeliac disease?
Also think about relatives
What is the classification for hyponatraemia?
Units?
Causes of Hyponatraemia?
Medication-
Reduced blood volume
EABV states (liver/heart/renal failure)
SIADH
Renal salt wasting
Primary polydipsia
Pseudohyponatraemia
Symtoms of hyponatraemia?
Nausea
Vomiting
Confusion
Reduced GCS
Headache
Seizures
Case 1
68 yo lady
HTN, CKD3b, DM2 (diet controlled)
Meds: amloipine, BFZ, atorvastatin, omeprazole
Admitted with pneumonia (CAP CURB 2 nedding O2)
Treated with abx as per hospital formulary
Day 2 developls hyponatraemia
Na 131 (135-145) k 4,5 Bic 21 Ur 8.9 Cr 189
Inflammatory markers and clinical status improving
What is important to look for on a clinical examination?
Look for severe symptoms like reduced GCS etc
Fluid status - oedema, fluid overload, ascities
Signs of hypoaldosteronsim
Signs of thyroid dysfunction
Urine Output
Case 1
68 yo lady
HTN, CKD3b, DM2 (diet controlled)
Meds: amloipine, BFZ, atorvastatin, omeprazole
Admitted with pneumonia (CAP CURB 2 nedding O2)
Treated with abx as per hospital formulary
Day 2 developls hyponatraemia
Na 131 (135-145) k 4,5 Bic 21 Ur 8.9 Cr 189
Inflammatory markers and clinical status improving
What Ix would you want to order to help with diagnosis?
Urine and serum osmolality
Urine U + E - sodium
Cortisol
TFTs - hyperthyroidism
Blood glucose
Case 1
68 yo lady
HTN, CKD3b, DM2 (diet controlled)
Meds: amloipine, BFZ, atorvastatin, omeprazole
Admitted with pneumonia (CAP CURB 2 nedding O2)
Treated with abx as per hospital formulary
Day 2 developls hyponatraemia
Na 131 (135-145) k 4,5 Bic 21 Ur 8.9 Cr 189
Inflammatory markers and clinical status improving
What could the possible causes be?
SIADH
Medication
Hypovolaemia
Failure (heart/ renal/liver)
Addison’s
Severe hypothyroidism
Renal salt wasting
Pseudohyponatraemia
What medications would you stop with a patient with hyponatraemia?
Case 1
68 yo lady
HTN, CKD3b, DM2 (diet controlled)
Meds: amloipine, BFZ, atorvastatin, omeprazole
Admitted with pneumonia (CAP CURB 2 nedding O2)
Treated with abx as per hospital formulary
Day 2 developls hyponatraemia
Na 131 (135-145) k 4,5 Bic 21 Ur 8.9 Cr 189
Inflammatory markers and clinical status improving
What may confound your Ix/ results?
Diuretics
Hyperglycaemia
Raised Lipids
Case 2
81 yo man
Admitted due to hypoxia
CXR shows alveolar oedema, Kerly B lines, Pleural effusions
Anasarca (global body oedema)
On high doses of furosemide in the community but not effective
Places on high dose of IV furosemide regime nasal oxygen
Fluid and salt resticted
Na 133 mmol/L on admission and falling on day 2 and 3
Good urine output
Weight static- you want to see weightloss as it signifys fluid loss
What is important to look for on clinical examination?
Need to check if they fluid overload in extracellular compartment
look at sacrum, jvp, heart sounds, capillary refill time
CHeck urine output.
Case 2
81 yo man
Admitted due to hypoxia
CXR shows alveolar oedema, Kerly B lines, Pleural effusions
Anasarca (global body oedema)
On high doses of furosemide in the community but not effective
Places on high dose of IV furosemide regime nasal oxygen
Fluid and salt resticted
Na 133 mmol/L on admission and falling on day 2 and 3
Good urine output
Weight static- you want to see weightloss as it signifys fluid loss
Ix?
BNP- suggestive of heart failure
Case 2
81 yo man
Admitted due to hypoxia
CXR shows alveolar oedema, Kerly B lines, Pleural effusions
Anasarca (global body oedema)
On high doses of furosemide in the community but not effective
Places on high dose of IV furosemide regime nasal oxygen
Fluid and salt resticted
Na 133 mmol/L on admission and falling on day 2 and 3
Good urine output
Weight static- you want to see weightloss as it signifys fluid loss
What would you do with the diuretic dose in this gentleman and what may help you decide?
Very difficult but needs careful review of volume status, if felt to be EABV may need redcution of diuretics. however if felt to be truly overloaded, may benefit from ongoing cautious diuresis.
Needs senior doctor management
Case 3
24 yo male
Normally fit and well
D+V for several days
Likely food poisoning
Not improving at home so admitted for IV fluids and antiemetics
Clinical Examination?
Most likely will be lethargic
Cappilary refill time
Raised JVP
Thirsty
Skin turgor is not a marker of dehydration
U+ E Ix
Case 3
24 yo male
Normally fit and well
D+V for several days
Likely food poisoning
Not improving at home so admitted for IV fluids and antiemetics
Possible causes?
hypovolemia
Pathway for hyponatraemia?
If the patient is hypovolaemic and hyponatraemic how do you calculate the amount of sodium replacement?
Infusion rate:
0.6 x weight (kg) x 0.5
Infusion rate: amount of sodium replacement X (1000/154)
Management for mild/moderate cases of hypervolaemic hyponatraemia?
FLuid and salt restriction, consider diuretics. Treat underlying cause
Management for mild/moderate cases of euvolaemic hyponatraemia?
Treat the cause (eg chest infection, malignancy or hormal insufficency)
If treatinf SIADH- Commence fluid retriction (500-750ml/day) with close follow up
