Gastroenterology Flashcards
Dysphagia | History Taking
- Difficulty swallowing solids and liquids from the start?
Yes; motility disorder, achalasia
No; stricture, benign/malignant - Difficult to initiate swallowing movement?
Yes; bulbar palsy - Painful swallowing?
Yes; viral infection, ulceration, oesophagitis, oesophageal spasm - Dysphagia intermittent or constant and getting worse?
Oesophageal spasm, malignancy - Neck bulge or gurgle on drinking?
Yes; pharyngeal pouch
Nausea & Vomiting | Types, Investigations & Management
Coffee-ground; upper GI bleed
Recognisable food; gastric stasis
Faeculent; small bowel obstruction
Morning; pregnancy, raised ICP
1hr post-food; gastric stasis, gastroparesis
Vomiting that relieves pain; peptic ulcer
Preceded by loud gurgling; GI obstruction
Non-bilious; pre-duodenal, gastric contents empty
ABG; metabolic hypochloraemic alkalosis (HCl)
Plain AXR; bowel obstruction
OGD; GI bleed, persistent vomiting
CT head; raised ICP
[Management]
PO/IV antiemetic; cyclizine, ondansetron
IV fluids + K replacement
U&Es
Dyspepsia | Aetiology
Medical
Pharmacological
Lifestyle
‘Alarm s’ymptoms
GORD Peptic ulcer disease Functional dyspepsia (without ulceration); stress, anxiety, depression Barrett's oesophagus Upper GI malignancy
Drug-induced; aspirin, NSAIDs, bisphosphonates, corticosteroids, CCB, alpha/beta blockers, anticholinergics, SSRIs
Obesity
Trigger foods; coffee, chocolate, tomatoes, fatty/spicy foods
Smoking
Alcohol
Frequency, duration, pattern of symptoms
Impact on QoL
Age >55yrs Dysphagia Weight loss Iron deficiency anaemia Treatment resistance/persistent sx Haematemesis/malaena
Dyspepsia | Investigations & Management
Lifestyle
Pharmacological
H. pylori
Carbon-13 urea breath test/stool antigen test for H. pylori (results affected by abx in past 4/52/PPI in past 2/52)
[Management] Lose weight if high BMI Avoid trigger foods Eating smaller meals Eat evening meal 3-4hrs before going bed Raise bed head Stop smoking Reduce alcohol consumption to recommended limits Relaxation strategies/psychological therapy for mental health issues
OTC antacids (Rennie/Zantac)/alginates (Gaviscon) for 1/12
Consider reducing/stopping drugs that exacerbate sx
Stop NSAIDs, use alternative
If no improvement, then test for H. pylori
[H. pylori -ve]
Trial of PPI for 1/12; omeprazole 20-40mg, lansoprazole 30mg
[H. pylori +ve] Triple therapy of PPI + abx + abx for 7/7 Amoxicillin 1g BD Clarithromycin 500mg BD Metronidazole 400mg BD
Prophylactic PPI
Peptic ulcer disease | Aetiology, Investigation & Management
4x DU > GU
Differentials
Complications
Management
Follow up
GU; H. pylori, NSAIDs, steroids, SSRIs
DU; elderly, H. pylori, NSAIDs
Zollinger-Ellison syndrome; hypersecretory state, multiple PUs, diarrhoea, weight loss, hypercalcaemia
DDx; oesophagitis/GORD, non-ulcer dyspepsia, gastritis, pancreatitis, gastroenteritis, coeliac disease, Crohn’s disease, gastric malignancy, IBS
Inv; OGD endoscopy
[Complications]
Haemorrhage, perforation
Gastric outlet obstruction; strictures/stenosis due to chronic inflammation and scarring
Gastric malignancy; H. pylori +ve
[Management] Lifestyle as above Review mdx H. pylori +ve; triple therapy H. pylori -ve; PPI for 4-8/52
Proven GU; repeat endoscopy, repeat C-urea breath test, 6-8/52 later to confirm healing and eradication
Prophylactic low-dose PPI
If refractory/recurrent sx despite optimal Tx, refer to gastroenterologist
GORD | Aetiology, Clinical features & Management
Prolonged reflex can cause oesophagitis, benign oesophageal stricture, or Barrett’s oesophagus (premalignant)
[Aetiology]
LOS relaxation/dilatation, hiatus hernia, dysmotility, obesity, gastric acid hyper secretion, delayed gastric emptying
Smoking, alcohol, pregnancy
Symptoms; retrosternal discomfort/burning after meals, lying, stooping, or straining, relieved by antacids, regurgitation, odynophagia (oesophagitis/ulceration)
Nocturnal asthma, chronic cough, laryngitis (hoarseness, throat clearing)
[Management]
Lifestyle as above
Raise bed head with wood/bricks by 10-20cm if practical
Do not use additional pillows, as increases IAP worsening sx
OTC antacids (Rennie/Zantac)/alginates (Gaviscon)
Add H2-blocker/PPI for 8/52
Avoid drugs affecting oesophageal motility (nitrates, anticholinergics, CCB)
Laparoscopic LOS banding
Upper GI bleed | Differentials, Investigations & Management
Scoring systems
Peptic ulcers
Mallory-Weiss tear; forceful retching, alcohol, bulimia
Oesophageal varices; vasopressin analogue (octreotide)
Oesophagitis
Gastritis
Drugs
Malignancy
Glasgow Blatchford score; pre-endoscopy to identify low risk patients who can be managed as OP or those in need of intervention
Rockall score; post-endoscopy
[Investigations]
FBC (Hb, Hct), G&S, clotting screen, crossmatch
High urea; from ingested blood
Hb <70g/L; transfuse red cells
Correct clotting abnormalities; Vit K, FFP, plts
OGD endoscopy assess and Tx, cautery
Oesophageal banding
Diarrhoea | Aetiology
Acute; pathogens, drugs
Chronic
Red flags
IBS; diarrhoea alternating with constipation
[Acute] <14/7
Viral; norovirus
Bacterial; salmonella, campylobacter, E. coli, shigella
Parasitic; giardia, cryptosporidium, entamoeba
Drugs; abx, cytotoxic drugs (chemo, MTX), metformin, laxatives, SSRIs
Lactose intolerance; worsened by dairy products
[Chronic] >14/7 Parasitic infection IBD, IBS Coeliac disease Colorectal cancer Diverticulitis Ischaemic colitis Hyperthyroidism, DM Overflow from faecal impaction
[Red flags] PR bleeding Recent abx/hospital admission (C. diff) Weight loss Painless, watery, high-volume diarrhoea (dehydration risk) Palpable mass Anaemia
Crohn’s disease | Epidemiology, Investigations & Management
Extra-intestinal features
Complications
Contraception counselling, malabsorption
UKMEC 1-2 for all
CHC, POP, depot, implant, Cu-IUD, LNG-IUS, barrier
Relapsing-remitting Mouth to anus Transmural (full thickness) intestinal wall inflammation Terminal ileum, 70% Skip lesions RFs; smoking, 20-40yrs
Erythema nodosum, apthous ulcers, osteoporosis
Faecal calprotectin Ferritin/B12/folate/Vit D; malabsorption CRP, ESR Small bowel imaging; pill camera Colonoscopy + biopsy MRI/CT; abscesses, fistula AXR; toxic megacolon Bone profile
[Management] Assess impact on QoL (Avoid NSAIDs for pain) Oral prednisolone 40mg IV fluids + electrolyte replacement IV corticosteroids; hyd/methylpred Azathioprine Biologics antiTNFa; infliximab Surgical 50-80%; resection, ileostomy
[Complications] Perianal disease, abscesses Fistulas, stricture Small bowel obstruction Malnutrition Abdominal sepsis Small bowel/colorectal cancer Toxic dilatation
Ulcerative colitis | Epidemiology, Diagnosis & Management
Scoring system
Complications
Relapsing-remitting Proctitis, 30%; affecting rectum only L-sided colitis, 40%; Pancolitis, 30%; entire colon stops at ileocaecal valve Continuous inflammation RFs; non-smokers, 20-40yrs Smoking is protective
Erythema nodosum, aphthous ulcers, episcleritis, arthritis, osteoporosis
FBC, ferritin/B12/folate LFTs/albumin CRP, ESR Faecal calprotectin Flexible sigmoidoscopy Colonoscopy + biopsy
Truelove & Witts criteria; assesses severity
[Complications] Toxic megacolon Perforation, VTE Colorectal cancer Osteoporosis
[Management]
Aims to induce, then maintain remission
Induce; PO prednisolone 40mg, IV hyd/methylpred
Maintain; mesalazine
IV fluids + electrolyte replacement
Biologics; infliximab
Surgical, 20%; subtotal colectomy + terminal ileostomy, proctectomy + ileoanal pouch
Coeliac disease | Clinical features, Investigations & Management
Extra-intestial features
Associated conditions
Complications
Gluten hypersensitivity
Triad; diarrhoea, weight loss, anaemia
Malabsorption
Aphthous ulcers, dermatitis herpetiformis
Metabolic bone disease, autoimmune thyroid disease, T1DM, IBS
Must not remove gluten from diet until bloods tests and biopsy are taken (inaccurate results otherwise)
FBC; anaemia, iron/B12/folate def
Ferritin/B12/folate/Vit D; malabsorption
tTG antibody/IgA
Duodenal biopsy; subtotal villous atrophy, crypt hyperplasia
[Management]
Lifelong gluten-free diet
Dietician input/advice
Gluten-free food on prescription
[Complications]
Osteoporosis
Small bowel cancer
Acute pancreatitis | Aetiology, RFs & Clinical features
Symptoms
Signs
Most commonly caused by gallstones (pancreatic duct obstruction) or alcohol misuse
RFs; ERCP, blunt abdominal trauma, local surgery, autoimmune (SLE), tumours
(Drugs; thiazide diuretics, AZA, oestrogens, gliptins)
Continuous epigastric pain radiating to back
Worse on movement
Alleviated in foetal position/knees bent
2° to gallstones; sudden knife-like, after large meal
2° to alcohol; less abrupt onset, poorly localised, dull
Signs; epigastric tenderness, generalised peritonitis (rebound/guarding), distension
Cullen’s (umbilicus)/Grey-Turner’s sign (flank); haemorrhagic pancreatitis, serious, late complication
Acute pancreatitis | Investigations, Management & Complications
Aetiology; I GET SMASHED
Idiopathic, gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion sting, hyperTG/hyperCa, ERCP, drugs
[Glasgow Criteria]
Oxygen, age, WBC, ⬇︎Ca, U, LDH, ⬇︎albumin, glucose
Lipase > amylase
Hypocalcaemia; Ca used up in fat necrosis, sign of severity
USS abdo; to look for gallstones
Erect CXR; to r/o perforation
CT abdo; *GS to assess extent of pancreatic necrosis
[Management] Gallstones; therapeutic ERCP, cholecystectomy IV fluids Analgesia; tramadol NG feeding Prophylactic abx
[Complications] Resulting from pseudocyst Chronic pancreatitis Pancreatic necrosis Abscess Fistulae SIRS/Sepsis Multiple organ failure DIC ARDS; leaky vessels, mass inflammation, SOB
Chronic pancreatitis | Clinical features, Investigations & Management
RFs
Screening
Alcohol excess
RFs; smoking, autoimmune disease, obstruction, drugs
Epigastric pain relieved on sitting upright/forwards
Precipitated by eating, N&V
Steatorrhoea, malnutrition, DM/impaired glucose tolerance
Jaundice, chronic liver disease
USS abdo/CT
LFTs (amylase not useful in chronic pancreatitis)
Screening for DM (HbA1c), osteoporosis (DEXA scan)
[Management]
Smoking/alcohol cessation
High-calorie diet intake
Corticosteroids
Pancreatic enzyme supplementation ‘Creon’
Tx hypercalcaemia/TG
ERCP + stenting
Pancreatic carcinoma | Epidemiology, Investigations & Management
RFs
RFs; smoking, alcohol, DM, chronic pancreatitis, obesity
Ductal adenocarcinoma
HoP, 60%
Metastasize early, presents late
Painless obstructive jaundice
Tumour marker, Ca 19-9, helps assess prognosis
Inv; USS abdo, CT abdo, biopsy Pancreatic mass Dilated biliary tree Hepatic metastases ERCP/MRCP visualises biliary tree anatomy/obstruction
[Management]
Surgical resection; Whipple’s procedure, if no mets + post-op chemo
ERCP + biliary stenting to relieve jaundice/anorexia
Jaundice | Types
Prehepatic
Intrahepatic
Obstructive/cholestatic
RFs
[Pre-hepatic] unconjugated, water-insoluble Haemolytic anaemias Malaria Drugs; paracetamol, rifampicin Gilbert's syndrome; idiopathic, benign
[Intrahepatic] Viral hepatitis EBV, HIV Alcohol NAFLD Autoimmune hepatitis; PBS, PSC, AIH Metabolic; haemochromatosis, Wilson's disease
Malignancy of the biliary system; HCC, cholangiocarcinoma, gallbladder Ca
[Post-hepatic] Gallstones Strictures Pancreatic Ca Pancreatitis Parasitic infection
RFs; alcohol, IVDU, foreign travel, blood transfusions, occupational exposure (healthcare/sex workers), obesity, pregnancy, inherited blood/liver disorders
Hepatitis gives you obstructive jaundice picture, dark urine pale stools
Jaundice | Investigations
LFT analysis
FBC; haemolysis, infection U&Es LFTs Clotting screen Amylase Viral hepatitis screen (ABC) (Ca 19-9)
[If LFTs non-obstructive] Viral hepatitis screen Immunoglobulins Autoantibodies Ferritin; haemochromatosis Alpha-1-antitrypsin AFP; HCC Caeruloplasmin; Wilson's disease (low) copper TFTs
USS abdo; gallbladder stones, dilated bile ducts, liver/pancreas masses, cysts
CT abdo; liver, pancreas
[LFT analysis]
Isolated raised bilirubin; Gilbert’s syndrome, repeat LFTs + FBC to r/o anaemia/haemolysis
Cholestatic ALP > ALT; intrahepatic cholestasis, cholangitis, extra-hepatic obstruction, Paget’s disease (bone), repeat LFTs + GGT to confirm liver cause
Hepatitic raised ALT > ALP; hepatitis infection (ALT > AST), paracetamol-induced liver injury, alcoholic hepatitis (AST > ALT)
AST + ALT only raised in obstructive picture if complicated by cholangitis
Mixed; cholestasis + hepatocyte damage, due to CBD stones causing ascending cholangitis
Low albumin; chronic liver disease
Jaundice | Management
Red flags
Primary care
[Red flags] Age >40yrs + obstructive jaundice Encephalopathy; altered GCS, ataxia, asterisks Cholangitis; fever, RUQ pain, jaundice Abnormal clotting/coagulopathy Paracetamol OD Bilirubin >100 micromol/L
[Primary care]
Gilbert’s syndrome
Hepatitis A
Hepatitis A | Aetiology, Clinical features & Management
Symptoms
Signs
A; faeco-oral, shellfish B; BBV, arthralgia, urticaria C; similar to B D; must co-exist with HBV E; similar to A, undercooked pork
Preventative measures
General advice
Pharmacological
Follow up
Viral/infectious; EBV, CMV, HIV, malaria
Autoimmune; PBC, PSC, haemochromatosis, Wilson’s disease
Drug-induced/alcohol
[Symptoms]
Flu-like sx; fatigue, malaise, joint/muscle pain, fever
GI; anorexia, N/V, RUQ pain, constipation/diarrhoea, itch/urticaria
Headache, cough, sore throat
Signs; jaundice, pale stools, dark urine, pruritus, hepatomegaly, splenomegaly, lymphadenopathy, RUQ tenderness
[Preventative measures] Ensure good personal hygiene Wash hands after toilet/before food prep Practice safe sex Vaccination against HBV Avoid food/water with high risk of contamination by faeces; fruit/veg grown close to the ground/soil, raw seafood (bottom feeders) that filter sewage-polluted waters PPE for occupational exposure
[Management] Avoid alcohol Avoid contact, work/school for 1/52 Ensure good personal hygiene Wash hands after toilet/before food prep Practice safe sex Avoid sharing needles A; symptomatic control, analgesia, antiemetic, antihistamine
[Follow up]
Monitor LFTs + PT
Safety net for signs of hepatic decompensation
Hepatitis B | RFs & Transmission
RFs; IVDU, needlestick, mother-baby vertical transmission, sexual contact, foreign travel, blood transfusions, organ/blood donoring
BBV, bodily fluids Sharing needles/needlestick injuries Mucous membranes Blood transfusions Tattoos, piercings, acupuncture Sharing toiletry items; toothbrushes, razors Sexual contact Mother-to-baby perinatally, not via breastfeeding
Hepatitis B | Serology
HBsurfaceAg; CURRENT infection
IgM anti-HBcore; recent infection within last 6/12
IgG anti-HBcore; past infection persists for life
Anti-HBsurface; recovery from infection, persists for life
HBsAg/HBeAg = acute
Anti-HBc + anti-HBs = immunity following past infection
Anti-HBs = vaccine immunity
NO IgM = chronic
Interpret with LFTs to determine whether recovered immunity, acute/chronic infection
Hepatitis B/C | Investigations, Complications & Management
Follow up
[Investigations] Serology/immunoglobulins Clotting studies; significant liver damage Autoantibodies Liver USS Liver biopsy
[Complications] Fulminant hepatic failure Cirrhosis HCC Decompensated liver disease; oesophageal varies, ascites, coagulopathy, encephalopathy
[Management]
Avoid sharing personal items, contaminated with blood/bodily fluids
Avoid unprotected sex
Avoid sharing needles/drug equipmenet
Do not donate blood/organs
Avoid alcohol, further liver damage/HCC
Pregnancy; specialist care, neonate immunisation
Referral to specialist; gastroenterology, hepatology
[Pharmacological Tx]
To prevent progression to cirrhosis
Antivirals
Liver transplantation
[Follow up]
Liver USS
Monitor serology
AFP; HCC screen
Liver failure | Diagnosis, Types & Management
Complications Tx
Coagulopathy Encephalopathy Hypoalbuminaemia Hypoglycaemia Sepsis, SBP
Signs; jaundice, hepatic encephalopathy, asterixis, apraxia, fetor hepaticus (pear drops)
Acute LF
Chronic LF; on a background of cirrhosis
Fulminant LF; sudden/severe, massive necrosis
[Management] Tx complications
Cerebral oedema; mannitol
Ascites; fluid restrict, low-salt diet, daily weights, diuretics
Bleeding; Vit K, plts, FFP, plts, blood, OGD
Hypoglycaemia; glucose 50mL of 50%
Encephalopathy;
Hepatorenal syndrome (HRS); cirrhosis, ascites, renal failure
Liver transplantation
Cirrhosis | Clinical features, Investigations & Management
RFs
Complications
Fibrosis, irreversible damage
Usually from long-term continuous damage
RFs; alcohol, HBV/HCV, obesity, autoimmune/genetic LD,
Symptoms; tiredness, loss of appetite, N&V, weight loss, muscle wasting
Signs; leuconychia, telangiectasia, clubbing, palmar erythema, Dupuytren’s contracture, spider naevi, xanthelasma, gynaecomastia, hepatosplenomegaly, ascites, loss of body hair, atrophic testes
Blood; liver screen for ?cause Liver USS; HCC MR liver Ascitic tap + fluid analysis USS fibroscan Liver biopsy (Thrombocytopenia diagnostic in chronic liver disease pts)
[Management] Tx complications Alcohol abstinence Avoid NSAIDs, sedatives, opiates Ascites; fluid restrict, low-salt diet, etc SBP; piperacillin + tazobactam 'Tazocin' Encephalopathy; prophylactic lactulose + rifaximin Renal failure; Liver transplantation
[Complications] Portal HTN Oesophageal varices Infection; SBP Ascites Hepatic encephalopathy HRS/AKI; oliguria, high Cr, low Na HCC Osteoporosis
