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
