Gastroenterology 2 🚽 Flashcards
Oesophageal varices investigation
Gastroscopy
Medication for prophylaxis for oesophageal varices
Beta blocker (propanolol)
Medications when oesophageal varices ruptured
Ocreotide first, Terlipressin second. Abx
Endoscopic management for esophageal varices. Consider portal HTN too
Band ligation. Balloon Tamponade if bleeding. TIPS to decrease portal hypertension
Mallory-Weiss management
Treat like every upper GI bleed. Can-do epinephrine, thermal therapy, sclerosant therapy in endoscopy. Gastric artery ligation 2nd. Antibiotics. If bleeding stops can just give PPI.
Boerhaave Invx
If suspect, do contrast oesophagram with gastrographin
Treatment for boerhave
Broad-spectrum antibiotics, repair the tear, mediastinal wash, fluids, NPO
Some main investigations for lower GI bleed
Colonoscopy/push enteroscopy/Cam. Vascular studies is a second line. Open laparoscopy last line
Diverticulosis management
High fibre meals high water intake
Diverticulitis management
Antibiotics and if perforation do surgery and peritoneal lavage
Investigations for diverticulitis/diverticulosis
Colonoscopy (not for itis) or CT. Chest x-ray if perforation
Stages 1–4 for haemorrhoids
One – not visible, two – returns itself, three – returns with finger, four – doesn’t return
First line management ideas for haemorrhoids
High fibre, exercise, stool softener, topical steroids
Aside from Conservative management, haemorrhoids grade one – two can both be managed with which intervention
Sclerotherapy
Aside from Conservative management, haemorrhoids grade 2 and 3 can both be managed with which intervention
Rubber band ligation or haemorrhoidopexy
Grade 4 haemorrhoids usually need what Treatment
Haemorrhoidectomy
General GI bleed management
ABC, two bore needles, crossmatch, take bloods, IV saline, catheter and urine output, ECG, chest x-ray, terlipressin if suspect varices, antibiotics. If upper bleed do endoscopy within 24 hours
GERD investigations in a patient less than 40
PPI trial for one month
GERD investigations for a patient more than 40 years old or has dysphasia or has a ALARMS symptoms
Endoscopy and 24 hour pH monitoring
First line therapy for GERD
Lifestyle modifications, antacids if mild, PPI if more severe
Indications for Nissen fundoplication
GERD refractory to medical therapy or has complications
Los Angeles classification grade A
GERD. One or more mucosal erosions confined to mucosal folds. Do not exceed 5 mm
Los Angeles classification grade B
Mucosal breaks confined to mucosal folds. Do exceed 5 mm
Los Angeles classification grade C
Mucosal breaks beyond mucosal folds
Los Angeles classification D
75% or more of the circumference of the oesophagus is eroded
Two potential investigations for hiatal hernia
Endoscopy (to rule out other pathology). CT plus IV contrast diagnose is it
Treatment for most cases of hiatal hernia
Conservative. Decrease weight. PPI
Indications for surgery in hiatal hernia
Medications did not work, or complicated case
Barretts oesophagus endoscopic surveillance, if no dysplasia
Every 3 to 5 years
Barretts oesophagus surveillance, if dysplasia present
Endoscopy every 6 to 12 months
How to manage Barretts in young patients or patients with high-grade dysplasia
Perform in oesophagectomy
Eosinophilic oesophagitis management
Corticosteroids and avoid trigger in diet
Investigation of choice for oesophageal cancer
Endoscopy. Then for metastasis do CT, Laparoscopy to check for partner your maths, and consider endoscopic ultrasound
Treatment for oesophageal cancer in the initial stages (mucosa in submucosal invasion)
Ablation, endoscopic resection, or oesophagectomy
Advanced oesophageal cancer treatment
Iver Lewis and chemotherapy
For late stages of oesophageal cancer patients may get dysphasia, how can we manage this
Stent placement
Investigations for acute/general gastritis
H. pylori test (either urea breath or stool antigen), B12, endoscopy and biopsy
General treatment for acute gastritis/ulcers
PPIs and treat cause
Treatment for H. pylori
Triple therapy (PPI, clarithromycin, amoxicillin or metronidazole) can also add bismuth
Bleeding peptic ulcer management
PPI, tranexamic acid, somatostatin analog, do endoscopy if active bleeding
Investigations for peptic ulcer disease
Endoscopy is the gold standard, and should biopsy to rule out malignancy. Chest x-ray if suspect perforation. Order urea breath test, full blood count, Gastro
Management of gastric cancer (local versus extensive)
If local can do endoscopic resection. If extensive should do gastrectomy and lymph node ectomy
Peritonitis investigations
Supine and upright abdomen x-ray (in case of perforation), CT, paracentesis undo SAAG
Treatment for peritonitis
Third generation cephalosporin, consider albumin infusion if suspected liver cause, laparoscopic surgery if perforation case
Infectious diarrhoea treatment Generally
Oral fluids is best, but IV fluids if vomiting or situation severe. Empiric antibiotics only if suspect infectious bacterial diarrhoea
C diff antibiotics
Fidoximicin or oral vancomycin for mild
Fidoximicin or oral vancomycin for more severe
Fulminant cases, oral vancomycin and IV metronidazole are best
Pneumoperitoneum investigation and management
Chest x-ray, supine abdominal x-ray, CT. And laparoscopy to fix
Investigation for C. difficile
Toxin A and B to check in stool, PCR is also okay.: colonoscopy can be done
Investigations/diagnosis of Crohn’s
Endoscopy and biopsy. Blood tests are important to
Treatment overview for Crohn’s
Steroids for flares. Mesalazine is the best initial maintenance therapy, reserved for mild diseases. Azathioprine and MTX reserved for moderate disease. TNF alphas for late
Colon cancer surveillance for Crohn’s patients
Start eight years after diagnosis. Do every 1 to 3 years
Investigations for ulcerative colitis
Stool culture to rule out infection. Bloods are important. Radiograph to rule out megacolon, colonoscopy and biopsy is diagnostic
Management overview for ulcerative Colitis
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Acute: mesalamine for mild, CSs for moderate, IV steroids for severe
Maintenance: mesalamine for mild, other biologicals for step up
Last line colectomy
Diagnosis/investigations for appendicitis
Dx by Clinical diagnosis and imaging. Ultrasound can be done first and is the main stay in kids and pregnancy. CT with contrast is the best however. MRI for preg and children is an alternative.
Management for appendicitis. Consider non-ruptured, ruptured, ruptured but stable
Antibiotics and appendectomy. Appendectomy should be done within 12 hours of diagnosis. If that is perforation appendectomy should be done immediately. If perforated but patient is still stable can do IV antibiotics, drainage of any abscess, and a rescue appendectomy
Diagnosis and investigations for small bowel obstruction
Best initial test is abdominal x-ray. CT is best to find the cause (diagnostic). Do ABG, full blood count, lactate et cetera also
What investigation can be done for patients who do not respond to Conservative treatment for SBO, and can potentially rule out the need for surgery
Small bowel follow through with Gastrografin
Nonsurgical/Conservative treatment for SBO
Fluids, NPO, NG decompression, attempt to treat underlying cause
Indications for surgery for SBO
Peritonitis, acidosis, continuous pain, systemic symptoms, or need to lyse adhesions. Or Conservative therapy does not work for 24 hours
Patient has fever and paralytic ileus 5–7 days after bowel surgery. What is happening
Anastomotic leak
Patient has closed loop large bowel obstruction. How to manage according to GI surgeon guy
Do Hartmanns procedure and anastomosis later
Management of large bowel obstruction (general)
Hospitalised, Xray and CT, Gastrografin enema, Colonoscopy. Surgery usually required
When do you not do surgery in SBO
If abdomen soft non-tender. Or if partial SBO
Stage 1234 colorectal cancer
Stage one is mucosal. Stage two is muscularis. Stage three is lymph nodes. Stage four is distant metastasis.
How to manage a stage one colo rectal cancer
Resect locally
How to manage a stage 2 colorectal cancer
Partial colectomy and lymph node ectomy
How to manage a stage three colorectal cancer
Partial colectomy and lymph node ectomy And chemotherapy
How to manage a stage 4 colorectal cancer
Partial colectomy and lymph node ectomy And chemotherapy. Consider full colectomy
Patient with lynch syndrome. Went to screen for colorectal cancer
Start a 20 and do every one year
When to start screening for colorectal cancer in FAP
Start at 10 years old
Management of toxic megacolon
Broad-spectrum antibiotics and corticosteroids. NG decompression, fluids. It doesn’t improve after 48 hours colectomy
Ischaemic colitis best initial test. And then best test overall
CTA without contrast, endoscopy and biopsy respectively (needed for Dx)
Management of mild colonic ischaemia
Bed rest and observe. NGT if Ileus
Management of moderate colonic ischaemia
Antibiotics
Management of severe colonic ischaemia
Exploratory laparotomy. May need to resect the necrotic bowel. Indicated if you see peritonitis, gangrene , pneumatosis
Best initial investigation and best overall investigation for acute mesenteric ischaemia
CTA (non invasive), mesenteric angiography (invasive) respectively. Angio needed to confirm Dx
When to invx penetrative retroperitoneal trauma? and blunt trauma?
Always invx penetrative. blunt only if zone 1
Treatment of gallstone ileus
Laparotomy to extract stone, close to fistula, cholecystectomy
Diagnosis of gallstone ileus
X-ray of the abdomen first, to see small bowel obstruction and pneumobilia. This usually confirms the diagnosis. Can do upper GI barium contrast
Suspect cholelithiasis , How to investigate
Ultrasound, and MRCP/ERCP if US equivocal
Management of incidental asymptomatic gallstones in GB
No treatment needed.