Gastrointestinal - Level 1 Flashcards
Epidemiology of upper GI bleed?
- Mortality 5-12%
- Upper GI 4x more common than lower GI bleed
Aetiology of upper GI bleed?
o Peptic Ulcers o NSAIDs o Alcohol o Oesophageal varices o Gastritis o Mallory Weiss Syndrome o Reflux oesophagitis o Malignancy
Risk factors of upper GI bleed?
o Peptic ulcer disease – alcohol, NSAIDs, corticosteroids, CKD, Age
Symptoms of upper GI bleed?
Haematemesis
Bright-red implies active haemorrhage
Coffee-ground vomit assumed to be blood and implies bleeding ceased
Malaena (black stools)
Proximal to ascending colon, smells of altered blood
Dizziness
Fainting
Abdominal pain
Signs of upper GI bleed?
o Pallor o Low BP o Tachycardia o Low JVP o Reduced urine output o Cool and clammy o Stigmata of liver/tumour disease
Management of upper GI bleed - if haemodynamically unstable?
o Monitor vital signs o 2 WBC o Bloods – FBC, U&E, LFT, glucose, clotting o IV 0.9% saline 500ml stat o Urine output measured
Management of upper GI bleed - if shocked?
A – protect airway, NBM
B – O2 if needed
C - IV access (2 14-16G WBC)
• FBC, LFT, U&E, glucose, clotting, cross-match 6 units
• Fluid resuscitation (0.9% saline)
• Blood Products:
o Transfuse with massive bleeding according to local protocols, Platelets if <50x109/litre, FFP if PT/APTT>1.5x, If patient’s fibrinogen <1.5g/l despite FFP, use cryoprecipitate
• Monitor vital signs every 15 mins
• Treat patients on warfarin according to protocols
E – notify surgeons of all severe bleeds
Management of upper GI bleed - risk assessments?
o Blatchford Score at first assessment
If 0 then consider early discharge
>0 suggests high risk – likely to require medical intervention
o Rockall Score after endoscopy
<3 low risk, >8 high risk of death
Management of upper GI bleed - endoscopy?
o Urgent if haemodynamically unstable with severe bleed (<4 hours)
o Offer within 24 hours if stable
Management of upper GI bleed - specific managements - variceal bleeding?
Terlipressin at presentation (2 mg every 4 hours until bleeding controlled, reduced if not tolerated to 1 mg every 4 hours - stop when haemostasis or after 5 days)
Prophylactic Antibiotics (Tazocin IV)
Management of upper GI bleed - specific managements - oesophageal varices?
• Band ligation
o Transjugular intrahepatic portosystemic shunt if failed injection
Management of upper GI bleed - specific managements - gastric varices?
• Injection of N-butyl-2 cyanoacrylate
o Transjugular intrahepatic portosystemic shunt if failed injection
Management of upper GI bleed - specific managements - non-variceal bleeding?
Endoscopic adrenaline injection with 1 of: clipping, thermal coagulation or fibrin
PPIs
If re-bleed then repeat endoscopy or interventional radiology
Management of upper GI bleed - prevention?
Drugs
Stop NSAIDs during acute phase
Continue low-dose aspirin for 2o prevention of CVD if haemostasis achieved
Discuss with cardiologist concerning clopidogrel
Test for H.pylori and eradication if positive
Complications of upper GI bleed?
Rebleed
o Signs – tachycardia, falling JVP, decreasing hourly urine, haematemesis, fall in BP
o Must call senior urgently and repeat endoscopy with surgical intervention
Definition of constipation?
- Infrequent, difficult-passing stools or sensation of incomplete emptying
- Rome IV Criteria - <3 times a week
- In reality - stools less frequently than patient’s normal pattern
Rome criteria for constipation?
- Rome IV Criteria - <3 times a week
Definition of chronic constipation?
- Chronic constipation = >12 weeks
Definition of faecal impaction?
Faecal Impaction = retention of faeces to extent that spontaneous evacuation unlikely
o Overflow incontinence is leakage of liquid stool from proximal colon round impacted faeces without sensation
Definition of functional (primary) constipation?
- Functional (primary) constipation = chronic constipation without a cause
o Normal transit – constipation with no time delay in passage of stool
o Slow transit – prolonged delay in passage of stool
o Outlet delay – pelvic floor dyssynergia
Epidemiology of constipation?
- Increases with age
- 2-3x higher in women
- Common in pregnancy
Risk factors of constipation?
o Diet – low fibre or low calorie o Lack of exercise/mobility o Older age o Dehydration o Anxiety/Depression o Hx of sexual abuse o Eating disorders
Secondary causes of constipation - drugs?
Aluminium containing antacids, iron or calcium supplements
Opioids, NSAIDs
Antimuscarinics – procyclidine, oxybutynin
TCAs, APs
Antiepileptic drugs – carbamazepine, gabapentin, pregabalin, phenytoin
Antispasmodics – hyoscine
Diuretics – furosemide
Secondary causes of constipation - organic?
Endocrine
• DM, hypercalcaemia, hypermagnesaemia, hypokalaemia, hypothyroidism, uraemia
Myopathies
• Amyloidosis, myotonic dystrophy
Neurological
• Autonomic neuropathy, CVA, Hirschsprung’s, MS, Parkinsons, SCI
Structural
• Anal fissures, colonic strictures, IBD, masses, rectal prolapse
Other
• IBS
Symptoms of constipation?
o Defaecation
Infrequent, difficulty passing or sensation of incomplete emptying
Typically, <3 times per week
o Lower abdominal pain
o Distention
o Bloating
o Non-specific symptoms in elderly – confusion, nausea, loss of appetite, overflow diarrhoea, retention
Symptoms of faecal impaction?
Hard, lumpy stools which may be large and infrequent or small and frequent
Manual methods of extraction (finger in vagina=rectocele, finger in anus=rectal ulcer)
Faecal incontinence
Assessment of constipation?
- Examination
o Abdominal exam – pain, distention, masses, palpable colon - DRE
o In all adults
o In children – do not routinely perform DRE
Refer for DRE urgently if <1 years old with idiopathic constipation that does not respond to 4 weeks optimum treatment
Management of constipation - initial self management?
o Eat healthy balanced diet (whole grains, fruits, vegetables)
o Increase fibre intake gradually
o Ensure fluid intake adequate
o Increase exercise/activity
Management of constipation - short duration - lifestyle advice?
o Stop drug if think that’s the cause
If opioids: offer osmotic and stimulant laxative
Lifestyle advice o Eat healthy balanced diet (whole grains, fruits, vegetables) o Increase fibre intake gradually o Ensure fluid intake adequate o Increase exercise/activity
Management of constipation - short duration - drug treatment?
Bulk-forming laxative (ispaghula)
Add/switch to osmotic laxative (macrogol)
Add stimulant laxative (senna)
Gradually reduce laxative once passing comfortable stools over 3 times a week
If opioid induced – offer osmotic and stimulant laxative, if inadequate – give naloxegol
Management of constipation - chronic constipation - lifestyle advice?
o Stop drug if think that’s the cause
If opioids: offer osmotic and stimulant laxative + naloxegol if inadequate
o Lifestyle advice
Management of constipation - chronic constipation - drug treatment?
Bulk-forming laxative (ispaghula)
If ineffective:
• Hard stools - Add/switch to osmotic laxative (macrogol)
• Soft stools - Add stimulant laxative (senna)
Management of constipation - chronic constipation - if at least 2 laxatives from different classes for 6 months failed?
Prucalopride or lubiprostone
• 4 weeks and 2 weeks respectively
Management of faecal impaction?
o If hard stools – high dose oral macrogol
o If soft stools or ongoing hard stools after macrogol – start or add stimulant laxative
o If inadequate or too slow to work:
Hard stools –bisacodyl + glycerol suppository
Soft stool – bisacodyl or glycerol suppository
o If still inadequate:
Sodium phosphate enema
Management of constipation during pregnancy?
o Lifestyle measures
o If ineffective:
Bulk-forming laxative – ispaghula
Osmotic laxative – Lactulose
Consider senna if needed
Management of constipation in children - disimpaction?
Movicol Paediatric using escalated dose regimen
Add stimulant laxative if not resolved in 2 weeks
Review in 1 week
Management of constipation in children - maintenance therapy?
Movicol Paediatric
Add stimulant laxative if needed
Continue for several weeks after regular bowel motions and reduce gradually
Refer if no response in 3 months
Follow up of constipation in primary care?
o Oral laxative – reduced after 2-4 weeks of regular soft bowel movements - if relapse then increase dose
o If refractory to laxative – consider FBC, TFT, HbA1c, U&E, Ca for secondary causes
Referral for constipation, when?
o Any secondary causes which cannot be managed in primary care
Specialist investigations for constipation?
- Flexible sigmoidoscopy/Colonoscopy
- CT
- Anorectal manometry, defaecation proctogram
- Colon transit time
Specialist management of constipation?
- Biofeedback training by physio
* Surgery – subtotal colectomy
Complications of constipation?
o Haemorrhoids or anal fissure
o Progressive retention, loss of sensory and motor function
o Faecal loading and impaction
Incontinence
Bowel obstruction/perforation/ulceration
Recurrent UTIs
Rectal bleeding/prolapse
Definition of diarrhoea?
- Decreased stool consistency from water, fat or inflammatory discharge
- Acute <2 weeks
- Persistent >2 weeks
Definition of dysentery?
o Loose stools with blood and mucus
o Organisms that cause bloody diarrhoea include campylobacter, entamoeba histolytica, E.coli, salmonella serotypes and Shigella
Definition of Traveller’s diarrhoea?
o Diarrhoea starting during or shortly after foreign travel
o Organism most commonly E.coli, Salmonella, Viruses, Cryptosporidium, Giardia
Causes of diarrhoea?
o Gastroenteritis o Parasites/protozoa o IBS o Colorectal cancer o IBD
- Drugs
o Antibiotics, PPI, NSAIDs, laxative, alcohol, cytotoxics - Rarer Causes
o Chronic pancreatitis, laxative abuse, lactose intolerance, overflow diarrhoea, ileal resection, thyrotoxicosis, Ischaemic colitis
Types of diarrhoea?
Bloody Diarrhoea
Campylobacter, Shigella/Salmonella, E.coli, amoebiasis
IBD, colorectal cancer, colonic polyps, colitis
Mucous
IBS, colorectal cancer, polyps
Frank Pus
IBD, diverticulitis, abscess or fistula
Explosive
Cholera, giardia, rotavirus
Other symptoms associated with disease in diarrhoea?
fever, pain, weight loss, clubbing, anaemia, oral ulcers, masses
Assessment of dehydration in diarrhoea?
o Mild – thirst, oliguria, dry mouth
o Moderate – sunken fontanelle, sunken eyes, tachypnoea, tachycardia
o Severe – Decreased skin turgor, drowsiness
Examination in diarrhoea?
- Abdominal Examination
- DRE
Investigations in diarrhoea?
- Bloods (if chronic cause)
o FBC, LFTs, ESR/CRP, U&E, TFTs, Ca, Vitamin B12, folate, iron, coeliac serology - Stool microscopy & culture
o Only used if patient has been abroad, severely ill, prolonged symptoms or works as food-handler, immunocompromised, received antibiotics/PPI/hospital admission recently
If chronic diarrhoea - what other tests can be done?
o HIV serology is suspected
o Stool sample
o C.diff testing
o Faecal calprotectin test if distinguishing between IBS/IBD <40
Management of diarrhoea - prevention?
o Hygiene (hand, water sources, no ice cubes, salads)
o Eat only freshly prepared hot food
o Food handlers – no work until stool samples negative
Management of diarrhoea - symptomatic relief?
Usually self-limiting
Maintain oral intake
ORT (Dioralyte) – contains glucose, Na, K, Cl
Loperamide used in mild-to-moderate Traveller’s diarrhoea but avoid in dysentery or infection
Management of diarrhoea -when to admit?
Admission if seriously ill, dehydrated >5%, high fever, infants
Management of diarrhoea - fluid therapy
• If severe – IV saline bolus 500ml
o 20mg/kg if child
• ORT in children – 50mls/kg over 4 hours, continue breastfeeding
• IV fluids 0.9% saline + 20mmol/L K/L IVI
When to refer chronic diarrhoea to gastroenterologist?
Coeliac disease, Crohn’s, UC, bile acid diarrhoea, microscopic colitis, malabsorption
Antibiotic therapy used in gastroenteritis - Entamoeba histiolytica?
Mild to moderate - Metronidazole 400mg TDS for 5-10 days, followed by diloxanide 500mg TDS for 10 days
Amoebic dysentery - Metronidazole 800mg TDS for 5 days, followed by diloxanide 500mg TDS for 10 days
Alternative to Metronidazole is Tinidazole
Antibiotic therapy used in gastroenteritis - Campylobacter?
Consider is severe, immunocompromised, symptoms worsening or >1 week
Erythromycin 250mg-500mg QDS for 5-7 days
Ciprofloxacin 500mg BD for 5-7 days - if macrolides cannot be taken
Antibiotic therapy used in gastroenteritis - Cryptosporidium?
No antibiotics
Antibiotic therapy used in gastroenteritis - Giardia Intestinalis?
Metronidazole 400mg TDS for 5 days
Tinidazole is alternative
Antibiotic therapy used in gastroenteritis - Salmonella & Shigella?
Consider if severe, elderly, immunocompromised, valve problems
Ciprofloxacin 500mg BD for 1 day (5 days if Shigella Dysenteriae)
Alternatives - azithromycin 500mg OD for 3 days
