GASTROENTEROLOGY Flashcards
A patient attends your clinic with suspected IBD. Their presenting complaint is having a change in bowel habit. What might you ask in your history to assess this change in bowel habit?
How often are they going to the toilet?
Has this changed from their usual?
Has the form of the stool changed?
Are they waking overnight to open their bowels?
Is there any blood in the motion?
Do they have tenesmus?
Do they have fecal urgency or incontinence?
Do the motions flush away easily?
What are the two conditions involved in IBD?
Chron’s disease and UC
What features distinguish Chron’s from UC?
Format for below: Chron’s vs UC
Affects anywhere from mouth to anus vs always affects rectum and extends proximally.
Skip lesions vs continuous
Transmural inflammation vs mucosa and submucosal inflammation only
Fissuring ulcers vs crypt absecesses
Increased incidence in smokers vs decreased incidence in smokers
Name two features specific to the microscopic appearance of Chron’s
Lymphoid and neutrophil aggregates
Non caseating granulomas
Name 3 investigations would you do for a patient who presents with a change in bowel habits
Blood tests - FBC, U&Es, CRP
Stool tests - stool cultures, faecal calprotectin
Simple imaging - AXR
Endoscopy - flexible sigmoidoscopy, colonoscopy, capsule endoscopy
Cross sectional imaging - CT abdomen, MRI enterography, MRI recutum.
What are the causes of an upper GI bleed?
Oesophageal varices
Mallory-Weiss tear
Peptic ulcers
Cancers of stomach or duodenum
A patient presents with a GI bleed, what do you need to ascertain from their PMH?
Hx of varices or chronic liver disease
Any stigmata of (chronic) liver disease
use of :NSAIDs,Anti-platelets,Anti-coagulants
What are the 2 scoring systems used in GI bleeding and what do they score?
Rockall- for patients that have or are going to have endoscopy, their risk of dying
Blatchford- establishes the risk of patient who you ?GI bleed is a GI bleed, used to determine whether should intervene
What parameters does the Blatchford score take into account?
Drop in Hb
Rise in Urea
Blood pressure
Heart rate
Malaena
Syncope
What do you need to establish if a patient has a GI bleed?
Is it variceal?
What is the initial management for patients with GI bleeding
Used mneumonic ABATED
A- A-E assessment
B- Bloods
A-Access- IV access - if pt haemodynamically compromised, resus fluids and then transfuse
T- Transfuse
E- Endoscopy
D- Drugs, stop any NSAIDs or Anticoagulants
What bloods do you need to do for a patient with GI bleeding and WHY?
FBC and Platelets- Check if Hb is dropping and thrombocytopenia can indicate chronic liver disease. Platelets need to be replaced if lost
U&Es- rising urea supports diagnosis of GI bleed
LFTs- check liver function, may show impaired function/liver disease
VBG- quick Hb reading
Coag screening - are they bleeding due to a clotting disorder?
Crossmatch/group and save- crossmatch if patient is haemodynamically unstable
You have started initial management for a patient with GI bleeding, the cause of this is suspected ruptured varices, what additional steps would you add in your management?
IV terlipressin
IV broad spec antibiotics
Endoscopic banding to stop the bleeding
If this fails- Linton tube or TIPSS (trans jugular intrahepatic porto systemic shunt)
What is the most common cause of non-variceal GI bleeding?
Peptic ulcer disease
What is dieulafoys?
An abnormally large artery in the lining of GI tract, most commonly the stomach
What are the risk factors for peptic ulcer disease?
Long term Steroid use
Long term NSAID use
H.pylori
Alcohol
Stress
Spicy food
Caffeine
Smoking
How would a patient present with peptic ulcer disease?
Epigastric pain
Dyspepsia
Nausea and vomitting
Bleeding- malaena, coffee ground vomit or haematemesis
Iron deficiency anaemia
If duodenal ulcer (more common) = have epigastric pain when hungry, relieved by eating.
If gastric ulcer = epigastric pain worsened by eating
How would you treat a patient that presents with peptic ulcer disease?
If actively bleeding see ABATED mnemonic in Z2F
Rapid urease test to check for H.pylori- treat with amoxicillin and clarithromycin for 7 days +PPI
PPIs is the mainstay of treatment
What the complications of peptic ulcer disease?
Bleeding
Perforation leading to acute abdomen and/or peritonitis
Scarring/ strictures leading to pyloric stenosis
Alcoholic liver disease has 3 stages of liver damage. What are they?
- Fatty liver (steatosis)
- Alcoholic hepatitis (inflammation and necrosis)
- Alcoholic liver cirrhosis
What risk factors may be present in a patient attending your clinic with alcoholic liver disease?
Prolonged heavy alcohol consumption
Hep C
Female
How may a patient with alcoholic liver disease present? (as if you were taking a Hx)
(Question made after talking to Reg in ward round about common presentations)
PC: Right upper quadrant abdominal pain. Sudden onset (as asymptomatic to start) Nauseous. Loss of appetite. Jaundice in eyes and skin. Haematemesis, jaundice.
PMH: previous admissions with alcohol related problem. Hepatitis C.
DH: previous use of diazepam, lorazepam, disulfiram, use of thiamine.
FH: alcohol misuse in family is a potential RF. Hepatitis in family.
SH: alcohol binging, live alone, smoker (occasionally).
What may you find on examination of a patient with alcoholic liver disease?
Hepatomegaly.
Obvious distension to abdomen - ascites.
Discomfort in RUQ.
Engorged para-umbilical veins
Splenomegaly
Jaundice of sclera and skin
Palmar erythema
Spider naevi i.e Cutaneous telangiectasia (trunk, face, UL)
Asterixis - i.e. liver flap
Caput medusae
Signs of malnutrition - wasting and anorexia
Confusion
What are functions of the liver?
Stores glycogen, releases glucose, absorbs fats, fat soluble vitamins and iron, makes cholesterol.
Bile salts dissolve dietary fats
Haemaglobin breakdown into bilirubin.
Produces most clotting factors
Has Kupfer cells to engulff antigens
Excretes drugs and breaks down alcohol
Produces important proteins - albumin and binding proteins