Gastroenterology Flashcards
Indications for an NG tube
To empty stomach
Pre-op
Intestinal obstruction
Gastric outlet obstruction
Intraoperatively
Inflate/deflate stomach
Irreversible dysphagia
Feed ill patients
complications with total parenteral nutrition
General
Thrombosis
Infection
Pneumothorax
Metabolic
Electrolyte distrubance
Refeeding syndrome if there has been prolonged starvation
Deficiency syndromes
Hypercapnea due to excessive CO2 production
Management of obesity
Lifestyle changes
Exercise
Diet change
Supervised low calorie diet
600kcal deficit
Drugs
Orlistat – pancreatic lipase inhibitor
Surgery
BMI >40 or >35 with obesity related complications
Different types of procedures
Restrictive – gastric banding
Malabsorptive – biliopancreatic diversion
Can be both – Roux-en-y bypass
How do you manage obesity based on MUST scores
Score of 1 = medium risk and observation is necessary, 2 is high risk and the patient should be treated by dieticians according to local guidance
How do you manage ?GORD
PPI for all suspected cases
ALARMS-55 criteria = 2 week wait referral
Barium swallow If hiatus hernia suspected
24 hour luminal pH monitoring and mamometry
To confirm a GORD diagnosis if endoscopy is clear
how do you treat confirmed GORD
Lifestyle modification
Lose weight
Drink less alcohol
Avoid caffeinated drinks
Eat small regular meals and avoid large meals before bed (<3 hours)
Raise the head of the bed at night
Avoid irritating drugs to the mucosa (NSAIDS, potassium salts)
medical therapy
alginate +/- antacids
PPIs
If PPIs work but patient doesn’t want long term meds - surgery (nissen fundoplication or en-roux bypass if obese)
If PPI doesn't work increase dose, consider H2 antagonist + do further investigations to exclude: zollinger ellinson syndrome functional GORD/hypersensitivity CYP450 related hypermetabolism of PPI non adherence
metclopramide/domperidone may be added to increase gastric emptying
why is surgery not indicated for GORD if the patient isn’t PPI responsive
indicates poor surgical outcomes
what are the surgical indications for GORD
Hiatus hernia with severe symptoms - Hiatus hernias on their own should not be treated without accompanying symptoms
Refractory disease with maximum medical treatment WITH pH evidence of disease
long term complications of GORD
Oesophageal strictures
Oesophageal ulcers/oesophagitis
Barretts oesophagus
what is the management of a barretts oesophagus
yearly endoscopies
whats the treatment of plummer-vinsen syndrome
iron and web dilation via OGD
Tx of oesophageal malignancy
Staging/grading
OGD including trans-oesophageal USS and biopsy
CT thorax/abdomen
PET to assess for metastatic disease
Laproscopy to exclude peritoneal mets prior to resection
If local disease (confined to T1/T2 levels) – radical resection of oesophagus
Pre-op chemotherapy improves survivability but causes morbidity
Chemoradiotherapy complications can be considered if surgery is not indicated
Palliation can include oesophageal stenting to restore swallowing
management of achlasia
Conservative/lifestyle measures
Chew food well
Always eat upright
Drink lots with meals
Botox injection
Provides temporary relief if unsuitable for invasive procedures
Endoscopic balloon dilation
Complications – oesophageal rupture
Hellers cardiamyotomy - definitive
Muscles of cardia (lower oesophagus) are divided
management of peptic ulcer disease
Lifestyle measures
Avoid food that worsens symptoms
Stop smoking
Test for H-pylori
if H-pylori -ve:
Medications PPIs/H2As, Stop NSAIDS if possible
H-pylori +ve triple therapy (PPI + clarithromycin + amoxicillin, metronidazole if pen allergic) if resistant to triple therapy - bismuth chelate followed by 2 antibiotics for 14 days followed by prolonged PPI therapy
surgical - last resort Highly selective vagotomy Vagotomy and pyloroplasty Gastrectomy May be required in zollinger-ellison syndrome
management of upper GI haemorrhage
keep Hb above 8, consider transfusion if <7g/dl
Give Terlipressin
assess using Glasgow-Blatchford score - >6 = 50% mortality, any score above 0 = high risk for GI bleed (alternative = Rockall score)
Tx = endoscopy + endothermy/adrenaline
IV omeprazole - 80mg stat + 8mg/hr for 72 hours
monitor for rebleed
Definitive surgery (laporotomy or angiographic emoblisation)
