Gastroenterology Flashcards
Discuss the definition and differential for an Upper GI Bleed
- bleed anywhere from mouth to ligament of Treitz Differential - Peptic ulcer - Esophageal varices - Mallory Weiss tear - arterial venous malformation - tumour
Discuss the presentation and investigation for an Upper GI Bleed
Presentation - hematemesis (bright red or coffee ground emesis) - melena - increased bowel movements - hematochezia - anemia (dyspnea, pre-syncope, orthostatic dizziness, CP) - abdominal pain - DRE Investigation - Blood type and crossmatch - CBC, electrolytes, BUN, creatinine, AST, ALT, GGT, ALP, albumin, bilirubin, INR - BUNx10:Creatinine ratio >1.5
Discuss an approach to Upper GI Bleed
ABC
- two large bore IV
- foley catheter
- NG tube
Transfusion
- indication for pRBC
- hemastatic instability despite fluid rescusitation
- moderate anemia in high risk patients (elderly, CAD), <90
- severe anemia (<70)
- platelets or FFP if indicated
Empiric Treatment
- IV PPI to stabilize ulcer and promote clotting
- Esomeprazole 50mg IV or Panteprazole 40mg IV
- IV Somatostatin (Octreotide) for variceal as it constricts splanchic arteries decreasing portal hypertension
- Octreotide 50mcg bolus or 50mch/hr infusion
- Prophylactic antibiotic for cirrhosis
- Ciprofloxacin 400-1000mg IV for 7 days
- Ceftriaxone 1g IV daily for 7 days
- Prokinetic (metoclopramide) for EGD
Discuss the indications for EGD with Upper GI bleed
Urgent EGD if any of the following - Hemodynamically unstable - Hematochezia - Suspected varices - serious comorbidity Lower GI Bleed - wait for bleeding to stop and then do colonoscopy
Discuss therapy of EGD with upper GI bleed
Injection - injection of vasoconstrictor (epinephrine, saline, scleorsants) Thermal Therapy - electrocoagulation - laser photocoagulation Mechanical Therapy - hemoclips, rubber bands - closure of vessel
Discuss preventative treatments for peptic ulcer disease
H-Pylori Therapy - Clarithromycin 500mg PO BID for 10-14d - Amoxicillin 1g PO BID (or flagyl if allergy) - PPI Proton Pump Therapy - Lansoprazole 30mg PO BID - Pantoprazole 40mg PO BID
Discuss preventative treatments for varices
Treat Varices
- Esophageal varices: injection with sclerosants
- Gastric varices: injfection with glue (cyanoacrylate)
- successful then beta blocker to decrease risk of re-bleed
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
- for recurrent variceal bleed
- catheter is introduced through jugular vein into hepatic vein where a permanent stent is placed connecting main branch of portal vein to hepatic vein
- can worsen hepatic encephalopathy
Treat Underlying Cause
- liver transplant
List the stigmata of chronic liver disease
- Jaundice, scleral icterus
- Temporal muscle wasting
- parotid gland enlargement
- spider nevi
- caput medusa
- ascites
- gynecomastic
- testicular atrophy
- asterixis
- clupping
- Dupuytren’s contrature
- palmar erythema
- thenar and hypothenar wasting
Discuss the differential for jaundice
Primarily Conjugated/Direct Bilirubin
- Hepatic Cellular/High AST/ALT
- alcoholic hepatitis
- non-alcoholic hepatitis
- Hepatitis A,B,C,D,E
- Tylenol
- Hemachromatosis
- Wilson's disease
- Alpha-1 anti-trypsin
- Autoimmune chronic active hepatitis
- portal vein thrombosis, budd-chiari syndrome
- Cholestasis/High ALP/GGT
- extra-hepatic
- gallstone disease
- malignancy (pancreatic, cholangiocarcinoma)
- stricture (primary sclerosing, cholangitis)
- intra-hepatic
- medication (amox-clav)
- sepsis
- TPN
- pregnancy
- primary biliary cirrhosis
- primary sclerosing cholangitis
Primary Unconjugated/Indirect Bilirubin
- hemolysis
- Gilbert's syndromeDiscuss further investigation for unconjugated hyperbilirubinemia
Hemolysis - CBC - reticulocyte count - Blood film - LDH - haptoglobin - bilirubin Gilbert's Syndrome - increased bilirubin after fasting - UGT1A1 - DNA mutation
Discuss further investigation for hepatic cellular causes
Alcohol Hepatitis - chronic alcohol abuse - AST:ALT >2 NASH - metabolic syndrome Hepatitis A - positive anti-hepatitis A virus IgM antibodies Hepatitis B - HBsAg for screening of active or cleared infection - HBV DNA PCR for active infection - Anti-HBs Ab for clearance or immunity - Anti-HBc Ab for past infection Hepatitis C - positive HCV RNA Hemachromatosis - high ferritin >1000 - high transferrin - high % iron saturation (>50%) - genetic testing Wilson's Disease - low ceruloplasmin - high 24hr urinary copper Autoimmune Chronic Active Hepatitis - positive ANA - positive anti-smooth muscle antibody
Discuss further investigation for cholestasis jaundice
- differentiate intra and extra hepatic through ultrasound and dilation of bile duct
Extra-Hepatic - gallstone
- mass
- Primary Sclerosing Cholangitis: positive ANA, positive smooth muscle antibody, positive peri-nuclear anti-neutrophil cystoplasmic antibody
Intra-Hepatic - Primary biliary cirrhosis: positive anti-mitochondrial antibody, positive ANA
Discuss the complications of liver cirrhosis
Decreased Liver Function - increased INR and coagulopathy - decreased albumin leading to ascites, spontaneous bacterial peritonitis and hepatic renal syndrome - hyperbilirubinemia - increased ammonia leading to hepatic encephalopathy Portal Hypertension - varices - portal hypertensive gastropathy - gastric antral vascular ectasia Hepato-Cellular Carcinoma
Discuss diagnotics paracentesis and interpretation
Paracentesis
- cell count and differential
- biochemistry including albumin, bilirubin, protein, amylase, lipase T protein, triglyceride
- gram stain, culture
- cytology
Serum Ascites Albumin Gradient (SAAG)
- albumin concentration in serum - albumin concentration in ascites fluid
- SAAG >11 with low protein (<2.5) then portal hypertension due to cirrhosis
- SAAG >11 with high protein (>2.5) then portal hypertnesion due to heart failure
- SAAG <11 then ascites not due to portal hypertension (TB, pancreatitis, renal failure)
Discuss the pathophysiology, presentation, investigations, diagnosis and management for ascites
Pathophysiology - cirrhosis have decreased albumin leading to decreased oncotic pressure resulting in extravasation of fluid into peritoneum Presentation - distended abdomen - ankle swelling - bulging flanks - positive shifting dullness - positive fluid wave test Investigation - paracentesis - abdominal ultrasound or CT Management - discontinue NSAID, ACEi, ARB, BB - salt restriction <2g/day - Diuretics spironolactone 100mg PO daily + Furosemide 40mg PO OD - therapeutic paracentesis
Discuss the pathophysiology, presentation, investigations, diagnosis and management for spontaneous bacterial peritonitis
Pathophysiology
- bacterial infection of peritoneum
- e coli, streptococcus, kliebsella
Presentation
- abdominal pain
- confusion
- fever, hypotension
- jaundice
Diagnosis
- paracentesis with neutrophil >250
Treatment
- fluid resuscitation with albumin
- antibiotics for 5 days
- Cefotaxime 2g IV Q8H or Ceftriaxone 2g IV Q8H
- Ciprofloxacin 200mg Q12HDiscuss the pathophysiology, presentation, investigations, diagnosis and management for hepatorenal syndrome
Pathophysiology - low albumin lead to extravasation of fluid, decreased effective circulating volume -> increase RAS and sympathetic activity -> renal vasoconstriction and failure Types - 1: rapidly progressive renal failure over 2 weeks (doubling creatinine >250 in 2 weeks or halfing creatinine clearance <20mL/min) - 2: slowly progressive renal failure Management - reverse precipitant - octreotide 100-200mcg SC TID - Midodrine 7.5-12.5mg PO OD
Discuss the pathophysiology, presentation, investigations, diagnosis and management for hepatic encephalopathy
Pathophysiology - inability to detoxify ammonia into urea with poor liver function and encephalopathy Presentation - day night reversal, confusion - lethargy, personality change - worsened confusion - coma - asterixis - fail to connect number test or clock drawing Management - discontinue sedatives and diuretics - Lactulose 30-45mL BID - Rifaximin 550mg PO BID to change gut flora and remove ammonia
Discuss liver transplan criteria
Model of End-Stage Liver Disease
- accounts for serum bilirubin, serum creatinine and INR
- 7 normal
- > 15 require liver transplant
- > 25 require full liver transplant
List the differential for acute pancreatitis
I GET SMASHED
- Idiopathic
- Gallstone
- Ethanol
- Trauma
- Steroids, surgery, sphincter of Oddi dysfunction
- Mumps
- Autoimmune
- Scorpian Bite
- High calcium, triglycerides, hypotherma
- ERCP
- Drugs (NSAID, diuretic, immunosuppression)
Discuss the Ranson Criteria for acute pancreatitis
On Admission - Age >55 - WBC >16 - Glucose >200 - LDH >350 - AST >250 First 2 Days of Admission - HCT fall by 10% - Ca <8 - PO2 <60 - Base deficit (24-HCO3) >4 - Fluid Sequestration >6L Severity - Mild <=3 - Severe >=4
Discuss the presentation and management of chronic pancreatitis
Presentation - epigastric pain radiating to back - steatorrhea - diabetes - weight loss - vitamin deficiency - pancreatic cancer Management - stop alcohol, smoking - small, frequent low fat meals - analgesic - suppression of pancreatic enzymes
Differentiate Chrons and Ulcerative Colitis
Location - any part of GI tract with Chron's - Rectum and progress proximally with Ulcerative Rectal bleeding - common in ulcerative Diarrhea - frequent in ulcerative Abdominal Pain - post-prandial in Chron's - pre-defecatory urgency in Ulcerative Fever - common in Chron's Palpable Mass - common in Chron's Endoscopic - Apthous ulcers, patchy lesions and pseudopolyps in Chron's - continuous diffuse inflammation, friability, loss of normal vascular patter in ulcerative Histologic - transmural with skip lesions, noncaseating granuloma, deep fissuring and strictures in Chron;s - mucosal distribution with continuous disease, crypt abscess in Ulcerative Radiological - Cobblestone mucosa with frequent strictures or fistula in Chron's - Lack of haustra in Ulcerative Colon Cancer Risk - Chron's increased - Ulcerative only for proctitis
Discuss common extra-intestinal manifestations of IBD
Dermatologic - Erythema nodosum - Pyoderma Gangrenosum - Perianal skin tags - Oral mucosa lesions Rheumatologic - Peripheral arthritis - AK - Sacroilitis Ocular - Uveitis - Episcleritis Hepatobiliary - Cholelithiasis - Primary sclerosing cholangitis Urologic - Calculi - uteric obstruction Other - thromboembolism - osteoporosis
Discuss the management for Chron’s disease
Mild
- antibiotics (Flagyl or Cipro) and 5-Asa
Moderate
- Steroid and immune modulator azathioprine, methotrexate
Severe
- surgery for stricture, obstruction, fistula, performation, bleeding
- biologics infliximab or Adalimumab
Discuss the classification and management for ulcerative colitis
Classification
-Mild <4 stools/day
-Moderate >4 stools/day with minimal signs of toxicity (fever, tachy, high ESR)
- Severe >6 stools/day and signs of systemic toxicity
- Fulminant: >10 stools/day with continuous bleeding, systemic toxicity, abdominal tenderness and colonic dilatation
Management
- mild 5-ASA
- moderate 5-ASA and prednisone
- severe surgery and cyclosporine
- immunomodulator or biologic
Define diarrhea and chronic diarrhea
- loss of >500mL per day of fluid and solutes from GI tract or >200g of stool daily
- chronic if >14d
Discuss findings for stool analysis
Stool Osmotic Gap - 290-2*(Stool Na+K) where normal <50 - osmotic diarrhea >125 Inflammatory Bowel Disease - High fecal leukocyte - Calprotectin Carbohydrate Malabsorption - low stool pH Stool C&S - for bacteria and fungi Stool O&P - for parasite
Discuss the differential for chronic diarrhea
Inflammatory (blood or pus with fever, leukocytosis)
- inflammatory bowel disease
- infection: C diff, ysernia, campylobacter
- ischemic bowel
- radiation colitis
- neoplastic
Steatorrhea
- infection: giardia
- inflammatory: pancreatitis
- celiac
Watery Diarrhea
- functional
- secretory (osmotic gap <50, diarrhea despite fasting)
- cholera
- laxatinve, post-ileal resection, cholecystectomy
- hyperthyroidism
- CRC
- osmotic
- celiac
- carbohydrate malabsorptionDiscuss the presentation, investigation and management of malabsorption
Presentation
- fatigue, weakness, weight loss
- steatorrhea, diarrhea
- deficiencies (carb, protein, fat, iron, calcium, vitamin)
Investigations
- 72hrs stool collection for weight, fat content and pH
- pH <5.5 then carbohydrate malabsorption
- >6g of fat over 24hr then fat malabsorption
- low urine D-xylose following ingestion then carbohydrate malabsorption
Management
- underlying cuase
- correct deficiency
Discuss the presentation, investigation and management for Celiac
- associated with DLA-DQ2, HLA-DQ8
- associated with other autoimmune disease
Presentation - mouth ulcer, abdominal pain, steatorrhea
- isolated iron deficiency
- early osteoporosis
Diagnosis - tTG IgA >20 and EMA IgA on small bowel biopsy
Management - gluten free diet
- supplementation
