Gastroenterology Flashcards
Management needlestick
High risk if significant exposure to blood or body fluids from source known to be HIV, HCV or HBV infected
Bloods baseline HIV / Hep B / Hep C serology
→ If starting HIV PEP also take FBC,U&E and LFTs
HIV PEP if high risk 1-72 hrs after exposure
Hep B vaccine if mod or high risk+ >1 year since last immunisation or whole course if never immunised if 0-7 days after exposure
Rpt bloods in 3 months
Risk of seroconversion from known positive needlestick injury
-HIV 0.3%
* HBV 30%
* HCV 1.8%
Admission criteria for abnormal LFTs
Admit if acutely unwell with:
-clinical evidence of liver disease.
-ALT higher than 250, ALP higher than 300, or bilirubin higher than 100.
Urgent hepatology if:
INR> 1.5
PT>18
plts< 100.
albumin< 35 + other abnormal LFTs.
Or well with:
clinical evidence of liver disease.
ALT> 250, ALP> 300, or bilirubin> 100.
8 causes RUQ pain
Biliary colic
Cholecystitis
Hepatitis/abscess
Congestive hepatomegaly
Pneumonia
PE
Renal colic
Pyelonephritis
4 causes epigastric pain
Pancreatitis
Gastritis/peptic ulcer
MI
Pericarditis
11 causes of RLQ pain
Appendicitis
Hernia
IBD
Ruptured AAA
Psoas abscess
testicular/ovarian torsion
Ectopic pregnancy
Endometriosis
PID/epididymitis
UTI
Renal colic
6 causes B12 deficiency
pernicious anaemia (75% of cases).
interference of B12 absorption from gastric or ileal disease:
Crohn’s disease.
gastrectomy.
ileal resection.
coeliac disease.
prolonged use of PPIs, metformin, COCP, colestyramine, methotrexate
When should you test for B12 deficiency?
Macrocytosis, pancytopaenia
Peripheral neuropathy, myelopathy, optic neuritis, cognitive change, dementia
If malabsorption suspected in Crohn’s, coeliac, pancreatic deficiency
What to do if B12 levels low
> 180 normal
130-180 low normal- advise OTC supplements
<130 with neuro symptoms/macrocytosis/anaemia then assess for pernicious anaemia (anti-gastric parietal cell Ab, anti-intrinsic antibodies) and malabsorption (anti-TTG IgA, faecal elastase)
If pernicious anaemia or macrocytosis or neuro deficit: IM for life (unless FBC not normalised in 8 weeks, then unlikely B12 deficiency)
If no to above, PO OTC 100mcg daily, recheck in 2 months
If suspected malabsorption- routine gastro ref
Red flags for bloating
Persistent and progressive distension- ascites, ovarian cancer
Rectal bleeding
Weight loss- ovarian, renal, colorectal ca
Onset age>50
Iron deficiency anaemia
IBS Ix
FBC, ferritin, B12, folate
TTG IgA (if +ve urgent gastro)
TFT, U+E, LFT, bone
CA-125 (if bloating)
Urinalysis/pregnancy test
Faecal calprotectin if chronic diarrhoea age<50 (If>150 urgent gastro ref)
C diff/molecular enterics (if diarrhoea)
USS (USC if raised CA-125)
CTAP if suspected ascites/older adults
HIV test if chronic diarrhoea
IBS management
Exclude bile salt malabsorption (eg post cholecystectomy), coeliac, IBD, cancer, lactose intolerance, wheat intolerance, infection, endometriosis, diverticulitis
Treat constipation
Treat diarrhoea
Avoid fizzy drinks, chewing gum, diet advice
Peppermint oil (OTC), mebeverine
Hyoscine butylbromide, amitriptyline 10mg ON or citalopram
Dietician? FODMAP
?probiotics
PMHSS/stress management
Definition of IBS
Recurrent abdominal pain or discomfort at least 1 day per month in the last 3 months, plus at least 2 of the following:
Relationship to defecation
Associated with change in frequency of stool
Associated with change in form (appearance) of stool
Symptom duration at least 6 months
Diet advice IBS
Regular meals, eat slowly
Food diary
Consider lactose or wheat intolerance
Reduce fatty food, spicy food, caffeine, fizzy drinks, fruit juice, sorbitol and alcohol.
increase or decrease fibre depending on current bowel habit.
limit fresh fruit to 3 portions per day.
consider eating more oats (e.g. porridge) to help with wind and bloating.
have adequate fluid – 2L water
Treatment of IBS diarrhoea
Loperamide if no infection/IBD
Fybogel 1 sachet BD
If cholecystectomy, trial 4g colestyramine OD-BD for 2 weeks
Trial ondansetron 4-8mg BD-TDS 2 weeks
What are the high risk symptoms for bowel cancer?
Aged 40 years or older and with unexplained weight loss and abdominal pain
Aged 50 years or older with unexplained rectal bleeding
Aged 60 years or older with IDA or CIBH
Any adult with a rectal mass or abdominal mass
Younger than 50 years with rectal bleeding and abdominal pain, CIBH, weight loss, or IDA
Non infective causes of diarrhoea
IBS
Bile salt diarrhoea (post cholecystectomy)
Diet
Diverticulitis
Large or small bowel cancer
IBD
Coeliac disease
HIV, enteric sexually transmitted infections
Ischaemic colitis
Microscopic and collagenous colitis
Small bowel bacterial overgrowth
Lactose intolerance
Liver or pancreatic disease- Exocrine pancreatic insufficiency
Malabsorption syndromes
Post‑abdominal surgery
Gastrointestinal neuroendocrine tumours
C difficile treatment
Vancomycin 125mg QDS PO
2nd line fidaxomycin
Dermatitis herpetiformis
Inflammatory immunobullous disease of the skin and a cutaneous manifestation of coeliac disease
Symmetrical blisters to appear in clusters, resembling herpes simplex.
Describe colorectal polyp surveillance
low risk management for 1 to 2 small adenomas less than 1 cm:
<55 years or FHx of colorectal cancer, offer colonoscopy at five years.
>55 years + good bowel preparation, advise bowel screening programme.
intermediate risk management – for 3 to 4 small adenomas or at least one ≥ 1 cm offer colonoscopy at three years.
high risk management – for 5 or more small adenomas or ≥ 3 if at least one ≥ 1 cm offer colonoscopy at one year.
If hyperplastic polyps < 1cm in the rectum or sigmoid colon, no malignant potential, no surveillance
Which medications worsen constipation? (10)
Antacids
Antimuscarinics (hyoscine, oxybutynin)
Clozapine
Mebeverine
TCAs
Gabapentin
CCBs
Diuretics
Ondansetron
Iron + calcium
Opioids
When to refer USC colorectal without FIT test
Abdo or rectal mass
Anal mass or ulceration
Abdo pain with obstructive symptoms
IDA in men/post menopausal women
If vulnerable group (homeless, language barrier, elderly)
What medication should you avoid in anal fissures?
Nicorandil
Most common location anal fissure
Posterior midline of anus (6 oclock)
Sometimes after childbirth anterior midline
If elsewhere consider Crohn’s
Treatment of anal fissure
Xyloproct ointment before bowel movement
If no improvement after 1 week: GTN ointment 0.4% BD 6 weeks (SE headaches, use alongside docusate)
Review in 6 weeks, can rpt GTN if helped but not fully healed
If not healing ?cancer
Risk factors and management of anorectal abscess
Risk factors: smoking, diabetes/immunosuppression, IBD
Admit for drainage
Treatment acute diverticulitis
If clinically unwell- admit
Co-amoxiclav 625mg TDS PO 5 days
Or cipro + metro Or cotrimox + metro
Clear fluids, paracetamol
Treatment haemorrhoids
Adequate fluid + fibre, toileting position, avoid straining
Fybogel 1st line, laxido/lactulose 2nd line, senna 3rd line
Anusol 1st line, Anusol plus HC/germaloid 2nd line
Risk factors for gallstones
Older age, female, FHx, obesity, rapid weight loss, ileal resection, T2DM, pregnancy, COCP, crohn’s, haemolysis
Management gallstones
Admit if obstructive jaundice or suspected pancreatitis/cholangitis
Routine ref cholecystectomy if symptommatic, stones in CBD or calcified porcelain gallbladder or prev jaundice/pancreatitis
Low fat diet, weight reduction, smoking cessation, reduce alcohol
Referral criteria hernias
Admit:
severe abdominal pain or vomiting with an irreducible hernia.
suspected strangulation, incarceration, or obstruction of any hernia.
Routine ref groin hernia if:
history of incarceration, difficulty in reducing hernia
increased risk of strangulation (femoral hernias)
inguino-scrotal hernia
progressive increase in size (month to month)
significant pain causing functional impairment
symptomatic hernia of any kind with significant impact on activities of daily living.
recurrence of hernia or post‑operative painless swelling which lasts 3 months or more
Red flags sarcoma
Soft tissue lump:
>5cm in diameter.
Deep to fascia (fixed) and any size.
Growing (especially observed rapid growth).
Painful.
Recurring after a previous sarcoma excision.
Then USC USS
GORD red flags
Dysphagia
Weight loss age>55
Patient aged 55 years or older with:
treatment-resistant dyspepsia.
upper abdominal pain with low haemoglobin levels
raised platelet count with any nausea, vomiting, weight loss, reflux, dyspepsia, or upper abdominal pain.
nausea or vomiting with reflux, dyspepsia, or upper abdominal pain.
Which medications can exacerbate dyspepsia? (10)
Beta-blockers
Aspirin
Bisphosphonates
CCBs
Steroids
Nitrates
NSAIDs
SSRIs, TCAs
Theophylline
Ix for dyspepsia
Bloods if age>55
H pylori (in dyspepsia, not in GORD) - no PPI for 2 weeks
Initial management GORD
Smaller meals and not eating for at least 3 to 4 hours before bed
Sleeping with the head of the bed raised
Weight reduction
Smoking cessation
Limiting alcohol
Avoiding triggers – can include spicy, acidic or fatty foods, peppermint, fizzy drinks, coffee, chocolate
Stop NSAIDs/bisphosphonates
Omeprazole 20mg OD 4 weeks (30 mins before breakfast)
If inadequate response famotidine 20mg BD
Define treatment resistant dyspepsia
Upper abdominal pain or discomfort, heartburn, acid reflux, nausea and/or vomiting with no response to omeprazole 20mg OD for 4 weeks or famotidine/ranitidine or lifestyle advice
If age>55 yrs arrange direct access OGD, if<55 routine gastro referral
Note: treatment resistant heartburn/GORD is different, can try 6 months double dose PPI or full dose + famotidine/ranitidine before routine upper GI surg referral for ?fundoplication
What is odynophagia? Main causes
Pain on swallowing, usually caused by irritation of the oesophageal mucosa. Causes include:
Infections -candida, HSV, CMV.
Chemical- drug induced, radiation,
Crohn’s disease, dermatological causes, severe reflux.
Xerostomia (dry mouth) – check medication causes (e.g., antidepressants, antihypertensives, antipsychotics, diuretics), Sjogren’s syndrome.
Oesophageal malignancy.
What is globus?
Non painful lump or fullness in the throat with unimpaired food bolus transport.
Alleviated by eating and/or drinking fluid.
Most noticeable with swallowing saliva.
Causes of oropharyngeal dysphagia
often neuro- Parkinson disease, MS, Stroke, motor neurone disease
may be caused by a local tumour in the pharynx.
Relevant hx for faecal incontinence
Obstetric hx (episiotomy, shoulder dystocia, perineal tears)
Prev surgery
Chronic constipation and straining
Chronic diarrhoea
IBD, IBS
MS, spinal injury, cauda equina, stroke, dementia
Rectocele/cystocele/pelvic floor laxity
Referral criteria for faecal incontinence
suspected cauda equina- admit ED
Persistent symptoms- refer Pelvic Health Hub.
Routine colorectal surgery referral if:
external rectal prolapse.
rectovaginal fistula.
previous sphincter repair or sacral nerve stimulator and ongoing issues.
If the patient has a suspected neurological cause, or symptoms are exacerbated by an existing neurological condition, request routine
Name 7 extraintestinal manifestations of IBD
Skin, e.g. erythema nodosum, pyoderma gangrenosum
Arthropathy
Eye, e.g. episcleritis, iritis
Mouth ulcers
Night sweats
Primary sclerosing cholangitis (PSC)
Relationship between smoking and IBD
Smoking increases the risk of developing Crohn’s disease.
Smoking reduces the risk of ulcerative colitis. Smoking cessation can precipitate ulcerative colitis
What Ix results suggest IBD?
Anaemia, leucocytosis, thrombocytosis, raised CRP/ESR, or
faecal calprotectin greater than 150 microgram/g.
An acute infection, e.g. campylobacter can cause elevated calprotectin. Confirm faecal infective screen is negative before refer urgent gastro for colonoscopy
Main treatments of IBD
Mesalazine- risk blood dyscrasia, stop and check FBC if sore throat/bleeding/bruising/purpura. Monitor u+e before starting, 3m then yearly
Pred, budesonide (+ adcal d3 BD)
Azathioprine+ 6mercaptopurine. Myelo and immune suppression. Avoid allopurinol.
Methotrexate- stop if sore throat/bleeding/bruising/SOB, once weekly dose, contraception during + 6m after
Main causes of iron deficiency anaemia
Excessive blood loss:
GI blood loss-NSAIDs, cancer, ulcer
Menstrual blood loss (menorrhagia)
Recurrent epistaxis
Renal tract malignancy
Regular blood donation
After major surgery with inadequate replacement
Dietary inadequacy especially in elderly and vegetarians
Malabsorption (coeliac disease), after gastric surgery, medications (PPI, antacids, calcium)
Excessive requirements, e.g. pregnancy
Patterns to notice in abnormal LFTs
Relatively greater increase in ALT and AST compared to ALP and GGT – problem with hepatocytes.
Relatively greater increase in ALP and GGT compared to ALT and AST (cholestatic pattern) – suggests biliary obstruction.
Abnormal synthetic function- raised bilirubin, elevated INR and PT, and low albumin.
Portal hypertension- low plts-> pancytopenia if advanced.
Name 9 commonly prescribed drugs that can cause abnormal LFTs
Statins, methotrexate, azathioprine, 6MP, anticonvulsants, flucloxacillin, erythromycin, co-amox, nitrofurantoin.
Clinical features of acute hepatitis
Fever
GI – abdo pain, anorexia, nausea, vomiting
Icteric features- jaundice, dark urine, pale faeces
Enlarged tender liver or spleen
Urticaria, and joint pains (particularly in hepatitis A and B)
Signs of cirrhosis
Jaundice
Leuconychia
Spider naevi
Palmar erythema
Gynaecomastia
Muscle wasting
Liver enlargement
Shrunken liver
Hardened liver edge
Ascites
Splenomegaly
Causes isolated raised ALP
Growth in childhood and adolescence
Third trimester and postpartum
Transient hyperphosphataemia
Right‑sided heart failure
Paget’s disease
Bone malignancy- osteosarcoma, multiple myeloma, mets
Hyperparathyroidism
Osteomalacia
What to do with isolated rise in bilirubin
Conjugated:unconjugated bilirubin
FBC, Blood film
Reticulocyte count
Haptoglobins, LDH
Haemolysis if:
predominant unconjugated bilirubin.
anaemia with reticulocytosis.
reduced haptoglobins.
If predominant unconjugated, other tests normal and bili<85 then Gilbert’s
Raised ALP predominant causes
Cholestatic:
Abscess, cancer
Stones in CBD
post‑operative stricture
Inflammatory strictures from chronic pancreatitis
Amyloidosis, sarcoidosis
Drugs:
Flucloxacillin and co-amox, COCP
Pregnancy
Primary sclerosing cholangitis
Primary biliary cirrhosis
Causes of ALT predominant abnormal LFTs
NAFLD
Alcohol liver disease
Coeliac disease
Hepatitis A, B, C, CMV, EBV
Medications
Haemochromatosis
Wilson’s disease
Alpha-1 antitrypsin deficiency
If abnormal LFTs thought to be NAFLD and low fib-4 score, what would your management be?
Alcohol cessation
Weight loss
CV + diabetes risk reduction
Reassess in 4 years
Management if ALT predominant abnormal LFTs
Rpt ALT in 3m if<100, 1m if 100-300, immediately if 300+
If still abnormal, Fib-4 + liver aetiology screen
Management if ALP predominant abnormal LFTs
Imaging + liver aetiology screen
NAFLD assessment
LFT (AST and ALT), FBC, prothrombin time (PT), albumin, HbA1c, and lipids.
FIB-4 socre >1.3 refer routine hepatology
Symptoms and signs of pancreatic cancer
Pain epigastric-> back
New unexpected onset diabetes
New alcohol intolerance
Painless jaundice
Dark ‘tea’ urine
Weight loss
Nausea/vomiting
Anorexia
Pale buoyant stool
Ascending cholangitis
