Gastrointestinal Flashcards
What is the management pathway for irritable bowel syndrome?
- Address diet
- Look for dietary triggers
- Keep food diary
- Avoid foods that commonly worsen symptoms
- Decrease beans/pulses = bloating
- Increase oats = constipation
- Increase fluid intake, reduce caffeine = diarrhoea
(see NICE guidelines, e.g. reduce alcohol/fizzy drinks/caffeine) - Exercise
- Pharmacological: Dependent on symptoms
- Laxatives for constipation
- Loperamide for diarrhoea - Probiotic trial for four weeks
- Referral for CBT, psychological therapy or hypnotherapy
- If symptoms do not respond after 12 months of pharmacological treatment
(Hypnotherapy = patient sits with eyes closed and the clinician talks to them)
What is the first line treatment for H.Pylori infection in a person who has NKDA, and hasn’t been treated for any infections before?
7 day, twice daily course of triple therapy:
PPI
Amoxicillin
Clarithromycin/Metronidazole
Note: this only treats the infection,further treatment is needed for any ulcers
(PPI can be omeprazole 20-40mg)
What is the first line treatment for H.Pylori infection in a person who has a penicillin allergy, and hasn’t been treated for recent infections?
7 day, twice daily course of triple therapy:
PPI
Clarithromycin
Metronidazole
Note: this only treats the infection,further treatment is needed for any ulcers
(PPI can be omeprazole 20-40mg)
What is the first line treatment for H.Pylori infection in a person who has NKDA, and has been treated recently with clarithromycin?
7 day, twice daily course of triple therapy: PPI Bismuth Metronidazole Tetracycline
Note: this only treats the infection,further treatment is needed for any ulcers
(PPI can be omeprazole 20-40mg)
How does second line treatment change from first line treatment of H.Pylori?
Same 7 day, twice daily course but:
For NKDA without Previous treatment for infection;
- change clarithromycin to metronidazole or vice versa
For penicillin allergic individuals;
- swap clarithromycin for levofloxacin
For NKDA with previous exposure to metronidazoleor clarithromycin (C/M);
- change C/M for quinolone or tetracycline
Note: this only treats the infection,further treatment is needed for any ulcers
What is the acute treatment pathway for peptic ulcer disease in adults?
Eradicate H. Pylori infection - 1 week course (see other slides)
Stop NSAIDs (if possible)
Full dose PPI or H2 Receptor antagonist for 8 weeks
If previously positive for H. Pylori:
Peptic ulcer - C13 breath text after 6-8 weeks
Gastric ulcer - endoscopy after 6-8 weeks
If symptoms recur: PPI at lowest dose necessary
What is the long term treatment pathway for peptic ulcer?
PPI at lowest dose necessary to control symptoms
Use H2 receptor antagonist If PPI doesn’t improve things
Annual review
What is the management pathway for an acute upper GI bleed?
- Resuscitation and transfusion if necessary
- Risk assessment - Glasgow-Blatchford bleeding score
- Endoscopy within 24 hours of admission
- Risk assessment - Rockall bleeding score
- If variceal bleeding present (oesophageal/gastric): Terlipressin and antibiotic prophylaxis
- If non-variceal (ulcers), one of the following:
A)Haemoclips +/- adrenaline
B)Thermal coagulation (cautery) + adrenaline
C)Fibrin/thrombin + adrenaline - If gastric varices (dilated submucosal veins):
A)N-butyl-2-cyanoacrylate endoscopic injection
B)If still not controlled - transjugular intrahepatic portosystemic shunts (TIPS) - If oesophageal varices:
A)Band ligation
B)If still not controlled - transjugular intrahepatic portosystemic shunts (TIPS)
What is the Glasgow-blatchford score?
A risk assessment tool to stratify upper GI bleed risk in adults when deciding if hospital admission and intervention is required.
Depends on: Hb, BP, HR, serum urea, serum nitrogen, melaena, syncope, heart failure and liver failure
What is the Rockall score?
A risk assessment for acute upper GI bleeding similar to the blatchford score but it incorporates endoscopic findings, therefore carried out after endoscopy, to predict mortality.
Rockall score of 0-2 can be considered for early discharge = good prognosis
Score 3+ = poor prognosis, start high dose IV PPI and observe for 2-3 days
ABCDE:
Age
- 60-79 = 1
- > 80 = 2
Blood pressure
- > 100 and tachycardia = 1
- <100 = 2
Co-morbidity
- HF/IHD = 2
- Renal/liver failure = 3
Diagnosis
- All (except Mallory Weiss tear) = 1
- Malignancy of UGI = 2
Evidence of bleeding (on endoscopy) - stigmata of recent haemorrhage (SRH)
Anything other than a dark spot = 3
What colour of cannula is wide bore for massive haemorrhage fluid resuscitation?
White and grey
Smallest are yellow and blue
What is the treatment for chron’s disease?
Depends on severity of symptoms
Mild/moderate (symptomatic but systemically well):
- Acute = Prednisalone 40mg for one week, then reduce every week by 5mg
- Dietary change
- Maintenance = Azothioprine or anti-TNFalpha, and possible nutrition supplements (enteral)
- If drugs fail, then surgery, most often multiple operations
Severe (emergency; nutrition and hydration issues):
- IV hydration and electrolytes
- IV hydrocortisone or methylprednisalone
- VTE prophylaxis with LMWH (preferred!)
- Possible blood transfusion
- No improvement - switch steroids to biological (immunoglobulins for TNFalpha or integrin etc)
What is the treatment for ulcerative colitis?
Depends on severity
Mild: PR Mesalazine (topical anti inflammatory)
Moderate: (4-6 motions per day) oral prednisalone 40mg for one week then taper down by 5mg per week
Severe: (>6 motions) IV hydration, electrolyte replacement, IV hydrocortisone, and enoxaparin
If it all fails - surgery
What is the treatment for IBS?
Depends on symptoms: FIRST LINE;
Spasms (abdo pain) - anticholinergic (dicycloverine) or smooth muscle relaxant (mebeverine)
Diarrhoea - loperamide
Constipation - osmotic agent (macrogol), stimulant (senna) or softener (docusate)
Diet:
Decrease caffeine
Limit high fibre foods and fruit
Fluids increase
Psychological intervention:
Only if there is no response after 12 months treatment (CBT, hypnotherapy, psych therapy)
Which antibiotics are used for a c.diff infection?
Metronidazole or vancomycin
Which antibiotic is often used for simple travellers diarrhoea? (I.e. no blood in stools, no fever or increased WCC in stools)
Rifaximin - treats ETEC; enterotoxigenic escherichia coli
Which antibiotics are used for severe campylobacter gastroenteritis?
The macrolides - clarithromycin or azithromycin
How can we distinguish between ulcerative colitis and chron’s disease by symptoms?
UC will have bloody diarrhoea and extra-gastrointestinal manifestations of oral ulcers, erythema nodosum, pyoderma gangrenosum….
Chron’s will have non bloody diarrhoea, eye problems, fistulae, skin tags, abdominal masses/tenderness, and weight loss!
Why do we not treat e.coli H7O157 with antibiotics?
Treatment with antibiotics makes e.coli H7O157 worse, can cause TTP or HUS! (Autoimmune or other other thrombotic microangiopathy respectively)
Why do we not use loperamide or codeine in the case of a suspected invasive infection?
It slows motility and reduces the rate at which bacteria naturally leave the body, it can worsen the infection
