Gastroenterology Flashcards
Antibiotics used for prophylaxis in variceal UGIB
Broad spectrum, to cover SBP, ofer quinolones in people with cirrhosis
Management of variceal upper GI bleed
1) A-E and escalation status!
A, B
C: Examination, IV access X 2, bloods (G&S, coag, VBG, FBC, U&E, LFT)
Fluids / blood transfusion if needed
patient needs to be stable before endoscopy
2) Review medications
Stop NSAIDs, anticoagulant, antiplatelets, antihypertensives, clopidogrel, reverse if can
3) Correct coagulopathy - ?FFP, vit K, platelets
4) Antibiotics - prophylaxis in cirrhosis against SBP (b4 endoscopy)
5) Terlipressin - splanchnic vasoconstriction, reduce portal pressures, reduce bleeding (b4 endoscopy)
6) Endoscopy - are they fit? can they lie for 15 mins? Glasgow blatchford score.
- Band, glue
7) NBM, fluid balance, stool chart
not work
Sengstaken blakemore tube
Interventional radiology - CT + embolisation
Surgery
TIPS (transjugular intrahepatic porto-systemic shunt) connects hepatic vein to portal vein
Prophylaxis of UGIB in varices
1) Propranolol
2) Endoscopic variceal ligation
For medium- large varices,
every 2 weeks until eradicated, give prophylactic PPI as well to endoscopic variceal ligation induced ulcers
3) Tranjugular intrahepatic portosystemic shunt (TIPS)
Assessment of severity of UGIB
1) Pre-endoscopy = Glasgow blatchford = need for endoscopy
2) Post-endoscopy = rockall = mortality post endoscopy
Antibiotic prophylaxis in variceal upper GI bleeds
broad spectrum antibiotics, often quinolone
give for 5-7 days
Terlipressin in variceal upper GI bleeds
1) Give 2mg QDS for 3-5 days or until definitive endoscopic haemostasis achieved
reduces portal pressure and helps control haemorrhage
75mg aspirin in UGIB - what to do
can continue!
Heparin reversal in UGIB
dose timing
Give protamine
8 hrs before = half the dose
Warfarin reversal in UGIB
Give PCC and IV vitamin K if actively bleeding
If stable, give vitamin K IV
endoscopy - what’s done in variceal management
- band ligation
- gastric = intravariceal injection of N-butyl-2-cyanoacrylate glue.
non variceal endoscopy management
- Clips + adrenaline
- Thermal coagulation + adrenaline
-fibrin/ thrombin injection + adrenaline
Alternative to UGIB if endoscopy doesn’t work
1) Sengstaken blakemore tube
2) Interventional radiology - CT + embolisation
3) Surgery - tie off artery
Who needs re-scoping after UGIB?
Bleeding due to
1) Varices
2) PUD - in 6-8 weeks, to ensure resolution and no underlying carcinoma
How long NBM for post endoscopy?
over night - may need further endoscopy, especially if concern about haemostasis
When to offer platelet transfusion in upper GI bleed patients?
Actively bleeding AND platelets < 50 x 10^9
if not actively bleeding AND stable - don’t offer
Who give fresh frozen plasma to?
Actively bleeding and INR / activated partial thromboplastin > 1.5 times normal
If fibrinogen level remains less than 1.5 g/litre despite fresh frozen plasma use, offer cryoprecipitate as well
Coagulopathy correction in UGIB
1) Platelets if platelet < 50 AND actively bleeding
2) INR > 1.5 or activated partial thrombplastin time ratio > 1.5 = give fresh frozen plasma
If INR > 1.5 and on warfarin, give PCC and vit K!
3) Fibrinogen < 1.5 = fresh frozen plasma -> if still low despite FFP, give cryoprecipitate
Refeeding syndrome - electrolyte disturbances
phosphate
potassium
magnesium
thiamine
calcium
sodium
Symptoms of re-feeding syndrome
1) No ATP = muscle cannot contract = myocardium cannot (heart failure) diaphragm cannot (respiratory failure)
2) Low calcium and K+: Cardiac: Arrhythmia
3) Neurological: Weakness, paresthesia, tetany, seizure
4) low thiamine: Wernicke encephalopathy
5) Peripheral oedema
5) Low phosphate - low ATP in muscles = can cause rhabdomyolysis
High risk patient for re-feeding, going to re-feed, what want to do?
1) Check baseline electrolytes (phosphate, K+, Mg2+, calcium, sodium, thiamine)
2) Give thiamine first 200mg
3) feed < 50% normal intake 10kcal/kg/day, slowly increase
4) monitor bloods & electrolytes, replace as appropriate, balance fluids
Ascitic fluid - what is sent off in an ascitic TAP?
1) Cytology
2) MC&S
3) Gram stain
4) Protein, albumin, glucose, LDH, amylase, WCC
Management of ascites
1) Low sodium diet
2) Aldosterone antagonist (increase sodium excretion) +/- loop diuretics
3) Review meds - stop NSAIDs, ACEI, not give aminoglycosides, alpha blockers
4) Can fluid restrict
aim to reduce sodium and water if sodium < 125
exudate: underlying cause manage if possible
tense ascites: therapeutic paracentesis
TIPS - refractory ascites in cirrhosis
ascites + cirrhosis + ascitic protein < 15 g/L give prophylactic abx, ciprofloxacin, until resolution of ascites, reduce risk of SBP
- ascites + cirrhosis -> consider transplant
What is ascites?
Excess ascitic fluid in the peritoneal cavity
Causes of ascites
Transudate, SAAG > 11g/L
Liver: Cirrhosis (portal hypertension), liver failure (low albumin), mets
Heart: Right sided heart failure, constrictive pericarditis
Other: Budd chiari syndrome (hepatic vein thrombus), portal vein thrombus, veno-occlusive disease
SAAG < 11g/L
Transudate: Low albumin
Exudate
Infection - TB, SBP
Inflammation - serositis in connective tissue disorders, pancreatitis
Cancer - peritoneal mets - GI, ovarian
Presentation of ascites
Need 500ml of fluid for symptoms
- Abdominal distension, discomfort
- Loss of appetite, nausea, vomiting
- Weight gain (gain fluid)
- ## SOB (diaphragmatic splinting)
Ascitic fluid analysis
MC&S, cytology, gram stain,
albumin, protein, glucose, amylase, LDH, WCC
Ascitic fluid analysis - protein
0.3-4g d/L is normal
> 4 = SBP
Ascitic fluid analysis - WCC
WCC > 250u/L = abnormal
Mostly neuts - SBP
Mostly lymphocytes = TB
Ascitic fluid - glucose
Similar to serum = normal
Less = infection, ca (used up!)
Ascitic fluid - amylase
Same as serum = normal
More = pancreatitis
Red cell count in ascitic fluid
0 = normal
> 100 = cancer, TB
> 1000 haemorrhage, haemorrhagic pancreatitis, trauma
SAAG
More albumin in serum than in ascitic fluid!
Serum albumin - ascitic fluid albumin
> 11g/L = cirrhosis/ liver failure, heart, thrombus (BCS, portal vein)
< 11g/L = cancer, infection (SBP, TB), inflammation (pancreatitis, serositis), low albumin
Cirrhosis -how cause ascites
1) portal hypertension
Increase capillary hydrostatic pressure
NO released, splanchni vasodilation, reduce renal perfusion, RASS activated, retain more sodium and water - worsen ascites
2) Failure of hepatic function
Low albumin = reduce oncotic pressure
Transudate, but SAAG can be < 11g/L or > 11g/L
Medications to avoid in ascites secondary to cirrhosis
NSAIDs
ACEI - renal hypoperfusion, activate RAAS more, more sodium and water retention
Alpha blockers - as above
Nephrotoxic medications - aminoglycosides!
When give prophylaxis in ascites patients? what give?
1) Had 1 episode SBP
2) Ascites + cirrhosis + protein < 15 -> give until ascites resolved
ciprofloxacin
What is SBP?
Why happens?
Infection of ascitic fluid, no other source identified that cannot be treated surgically
Overgrowth bacteria in gut -> enter portal vein -> portal hypertension force out into ascitic fluid
Patient likely compromised immune system (liver is toast and cannot make normal immune system proteins)
Normally 50% due to E.Coli
Presentation of SBP
1) Diffuse abdominal pain
2) Fever - normally due to a dampened immune system and slightly lower temperature, so take temp spike seriously!
3) Worsening ascites / symptoms of cirrhosis/ liver failure (encephalopathy, jaundice)
may have had diarrhoea before - bacterial overgrowth sign!
Why give pabrinex IV not oral?
Alcohol inhibits absorption of vitamin B1 up to 50%
What is wernicke’s encephalopathy?
Acute reversible encephalopathy secondary to low thiamine (B1)
Causes of wernicke’s encephlopathy?
Reduced intake, reduced absorption, increased losses
- Eating disorders
- Chronic alcoholics
- Hyperemesis of pregnancy
- IBD/ bariatric/ upper GI surgery
Symptoms of wernicke’s encephlopathy
Triad, don’t often have all 3
- Ataxia: Broad-based gate
- Altered mental status: confusion, disorientation, inattention
- Ophthalmoplegia: VI palsy, conjugate gaze palsy III/IV/VI, sluggish pupils, anisocoria (unequal pupil sizes)
Management of ? wernickes
Give pabrinex IV thiamine 500mg TDS for 3-5 days
If improve = wernickes -= give 250mg OD for another 3-5 days or until improved fully
No improve after 500mg IV TDS - then high dose oral thiamine 100mg
Can give IM, but need good muscle mass to absorb, alcoholics less likely to have this!
What can wernicke’s cause?
Korsakoffs
Korsakoffs – what is it?
Irreversible encephalopathy secondary to prolonged thiamine deficiency
Korsakoff’s symptoms
- retrograde and antegrade amnesia
- confabulation
- apathy
- no insight
Medication review in ascites
ACEI, ARB, NSAIDs, alpha blockers, nephrotoxic drugs
Ascites in cirrhosis refractory to management options
TIPS!
FFP VS PCC
