Gastroenterology Flashcards
Criteria for urgent (2ww) referral for direct access OGD to investigate for oesophageal or gastric Ca?
- dysphagia
- aged 55 or over with weight loss and either upper abdo pain or reflux or dyspepsia.
When should a patient with dyspepsia be referred for a direct access non-urgent OGD to investigate for possible oesophageal/gastric Ca?
if aged 55 and over with any 1 of:
- treatment resistant dyspepsia
- raised PLT count
- N+V
2ww referral criteria for suspected pancreatic cancer?
aged 40 and over with jaundice
Who should get an urgent (2ww) direct access CT scan to investigate for possible pancreatic cancer?
if aged 60 and over with weight loss ad any of: abdo pain back pain new onset diabetes nausea vomiting diarrhoea constipation
(or urgent ultrasound if CT not available)
Most appropriate analgesics for pain associated with alcoholic peripheral neuropathy in a patient with severe liver disease?
duloxetine, gabapentin or pregabalin
NOT TCAs e.g. amitriptyline due to risk of increased sedative effects when severe liver disease
Why should opioids be avoided or used with caution in patients with hepatic impairment?
can precipitate hepatic encephalopathy and coma
Proportion of bowel cancers diagnosed following screening each year?
up to 25%
Criteria for 2ww referral for suspected colorectal cancer?
- FIT test reveals occult blood in faeces
- Aged 40 or over with unexplained weight loss and abdo pain
- Aged 50 and over with unexplained rectal bleeding
- Aged 60 and over with iron deficiency anaemia or change in bowel habit.
-Consider 2ww referral if abdo or rectal mass.
-Consider 2ww referral in those <50yrs with rectal bleeding and any of the following unexplained sign/symptoms:
abdo pain
weight loss
change in bowel habit
Fe deficiency anaemia
When should FIT tests be offered to patients?
To adults WITHOUT rectal bleeding who:
are aged 50 and over with unexplained change in bowel habit or Fe deficiency anaemia OR
are aged 60 and over with anaemia without Fe deficiency
Clinical criteria for a diagnosis of IBS?
Abdo pain/discomfort which is either relieved by defecation or associated with altered bowel frequency/stool form, and accompanied by 2 of:
altered stool passage (straining, urgency, incomplete evacuation)
made worse by eating
passage of mucus
abdo bloating/distension/tension/hardness
When should you consider referral for non urgent direct access OGD for pt with haeamatemsis?
always consider referral in this case to assess for oesophageal Ca!
When should pt with upper abdominal pain be considered for non-urgent upper GI endoscopy to assess for oesophageal cancer?
if age 55 and over with upper abdo pain + low Hb OR
age 55 and over with upper abdo pain + raised PLT OR
age 55 and over with upper abdo pain + N+V
Investigation that should be considered if pt has an upper abdo mass consistent with an enlarged gallbladder?
Consider urgent direct access US scan to assess for gallbladder cancer
1st line management of IBS?
Diet and lifestyle:
- adequate fluid intake-8 cups per day
- reduce caffeine and alcohol
- fibre-avoid insoluble, but can increase oats, nuts and seeds
- sweetners-avoid sorbitol if diarrhoea
- probiotics for 4/52 in those that want to do a trial-can help if diarrhoea/bloating predominant sx
- low FODMAP diet (NOT 1st line)-general dietary advice 1st line, can consider r/f to dietician re low FODMAP diet if persistent or refractory sx
- avoid life stressors
1st line pharmacological tx of IBS?
laxative (NOT lactulose) OR anti-motility/anti-spasmodic OR anti-diarrhoeal based on predomoinant sx
2nd line pharmacological tx of IBS?
TCAs (off label)-for refractory abdo pain
r/v after 4 weeks
3rd line pharmacological tx of IBS?
SSRIs (citalopram or fluoxetine)-for refractory abdo pain
Indication for linaclotide use in IBS?
licensed for moderate-severe IBS with constipation, used if max tolerated dose of standard laxatives not helped after 1 year, and should be reviewed after 3 months
Medication advised by NICE for patients with Lynch syndrome (HNPCC) to prevent colorectal cancer?
Daily aspirin 150 or 300mg OD to be taken for more than 2 years
F/u recommended for people who have had potentially curative surgical treatment for non-metastatic colorectal cancer?
Should be followed up for 3 years for detection of local recurrence and distant metastases-serum CEA and CT CAP.
1st line laxatives for IBS?
bulk forming e.g. isphagula/fybogel
lactulose NOT recommended
H pylori eradication tx?
1 week of PPI BD plus amoxicillin 1g BD plus either clarithromycin 500mg BD or metronidazole 400mg BD. Twice daily tx course.
if allergic to penicillin then clarithromycin (250mg BD) + metronidazole
Vaccination recommendations for patients with coeliac disease?
due to risk of functional hyposplenism should receive pneumococcal vaccination and have booster every 5 years
influenza vaccine should be given on an individual basis
What ferritin level confirms iron deficiency?
less than 15
When is ferritin a reliable indicator of iron deficiency in pregnancy?
only in the 1st trimester if no other inflammation or infection present
*ferritin falls in the 2nd trimester then increases slowly back up in 3rd trimester
What investigation is required for all people with confirmed iron deficinecy anaemia?
coeliac screen
1st line iron tablets advised for tx of iron deficiency anaemia?
ferrous sulphate 200mg 2 or 3 times a day, to continue for 3 months after correction of anaemia
FBC should be rechecked 2-4 weeks after starting tx-if pt not responding should refer, Hb should rise by about 2g/100ml over 3-4 weeks, then check again at 2-4 months
Bloods monitoring after person with iron deficiency anaemia has stopped taking iron tablets?
FBC monitoring every 3 months for 1 year, then recheck after a further year and again if sx of anaemia develop subsequently
When should an urgent referral be considered for patients under the age of 50 with iron deficiency anemia?
if present with rectal bleeding
Who requires referral to gastro for iron deficiency anaemia?
- all men and postmenopausal women unless they have overt non GI bleeding
- all people aged 50 and over with marked anaemia, or a significant FH of colorectal Ca, even if coeliac disease is found
- pre menopausal women if aged under 50 and have colonic symptoms, strong FH of GI cancer (2 affected 1st degree relatives or 1 first degree affected under age of 50) or persistent iron deficiency anaemia despite treatment.
If a patient has one first degree relative with colorectal cancer or a first degree relative affected with colorectal cancer before age of 50 (patients’ lifetime risk 1/12), what surveillance should be offered?
colonoscopy at age 55
What pharmacological management should be given initially in addition to lifestyle advice for uninvestigated dyspepsia?
Give full dose PPI for 1 month OR check for H pylori-if +ve then 1st line eradication therapy
if sx persist or recur following initial management then switch to the alternative strategy
if investigated-OGD, and severe oesophagitis is found, should have 8 week trial of full dose PPI, and offer LT as maintenance tx
if GORD found then 4 week trial of full dose PPI
H pylori eradication tx if patient is allergic to penicillin and has previously had tx with clarithromycin?
metronidazole 400mg BD and levofloxacin 250mg BD plus PPI BD for 7-10 days
How is H pylori retesting arranged?
should be 4 weeks (ideally 8 weeks) after initial eradication therapy
urea breath test is 1st line
if +ve prescribe 2nd line eradication therapy-if unsuccessful r/f for endoscopy-PPI must be stopped at least 2 weeks prior to endoscopy
Annual blood monitoring in primary care for patients with coeliac disease?
FBC LFTs TFTs ferritin, Vit B12, folate, calcium, Vit D coeliac serology
On the diagnosis of which medical conditions should testing for coeliac disease be performed?
T1DM
AI thyroid disease
When is referral for psychological interventions appropriate for patients with IBS?
if patients do not respond to drug treatments after 1 year and have a continuing sx profile
options=CBT, hypnotherapy and/or psychological therapy
Dose of gluten that patient must be eating prior to blood tests to investigate for coeliac disease?
10g of gluten per day for 6 weeks
When are immunosuppressive drugs started for Crohns disease?
if 2 or more exacerbations in a 12 month period, then azathioprine, mercaptopurine (both 1st line, note increased risk of non melanoma skin cancer) or MTX can be added, may also be started if unable to taper PO steroids
aminosalicylates may be considered for a 1st presentation or single inflammatory exacerbation in 12 month period if steroids CI or not tolerated
NICE recommended investigations if suspect IBS?
consider: FBC CRP and ESR coeliac serology to exclude an alternative diagnosis
How long should live vaccines be postponed for after stopping immunosuppressant treatment?
6 months
Management of suspected renal colic in patient who does not require immediate hospital admission?
- arrange urgent (within 24hr) imaging-non contrast CT, US if woman is pregnant or in children
- analgesia-NSAID by any route
