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MSRA Content > Gastrointestinal - Level 1 > Flashcards

Gastrointestinal - Level 1 Flashcards

1
Q

Epidemiology of upper GI bleed?

A
  • Mortality 5-12%

- Upper GI 4x more common than lower GI bleed

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2
Q

Aetiology of upper GI bleed?

A 
o	Peptic Ulcers
o	NSAIDs
o	Alcohol
o	Oesophageal varices
o	Gastritis
o	Mallory Weiss Syndrome
o	Reflux oesophagitis
o	Malignancy
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3
Q

Risk factors of upper GI bleed?

A

o Peptic ulcer disease – alcohol, NSAIDs, corticosteroids, CKD, Age

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4
Q

Symptoms of upper GI bleed?

A

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

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5
Q

Signs of upper GI bleed?

A 
o	Pallor
o	Low BP
o	Tachycardia
o	Low JVP
o	Reduced urine output
o	Cool and clammy
o	Stigmata of liver/tumour disease
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6
Q

Management of upper GI bleed - if haemodynamically unstable?

A 
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
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7
Q

Management of upper GI bleed - if shocked?

A

 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

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8
Q

Management of upper GI bleed - risk assessments?

A

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

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9
Q

Management of upper GI bleed - endoscopy?

A

o Urgent if haemodynamically unstable with severe bleed (<4 hours)
o Offer within 24 hours if stable

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10
Q

Management of upper GI bleed - specific managements - variceal bleeding?

A

 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)

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11
Q

Management of upper GI bleed - specific managements - oesophageal varices?

A

• Band ligation

o Transjugular intrahepatic portosystemic shunt if failed injection

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12
Q

Management of upper GI bleed - specific managements - gastric varices?

A

• Injection of N-butyl-2 cyanoacrylate

o Transjugular intrahepatic portosystemic shunt if failed injection

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13
Q

Management of upper GI bleed - specific managements - non-variceal bleeding?

A

 Endoscopic adrenaline injection with 1 of: clipping, thermal coagulation or fibrin
 PPIs
 If re-bleed then repeat endoscopy or interventional radiology

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14
Q

Management of upper GI bleed - prevention?

A

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

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15
Q

Complications of upper GI bleed?

A

Rebleed
o Signs – tachycardia, falling JVP, decreasing hourly urine, haematemesis, fall in BP
o Must call senior urgently and repeat endoscopy with surgical intervention

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16
Q

Definition of constipation?

A
  • 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
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17
Q

Rome criteria for constipation?

A
  • Rome IV Criteria - <3 times a week
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18
Q

Definition of chronic constipation?

A
  • Chronic constipation = >12 weeks
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19
Q

Definition of faecal impaction?

A

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

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20
Q

Definition of functional (primary) constipation?

A
  • 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
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21
Q

Epidemiology of constipation?

A
  • Increases with age
  • 2-3x higher in women
  • Common in pregnancy
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22
Q

Risk factors of constipation?

A 
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
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23
Q

Secondary causes of constipation - drugs?

A

 Aluminium containing antacids, iron or calcium supplements
 Opioids, NSAIDs
 Antimuscarinics – procyclidine, oxybutynin
 TCAs, APs
 Antiepileptic drugs – carbamazepine, gabapentin, pregabalin, phenytoin
 Antispasmodics – hyoscine
 Diuretics – furosemide

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24
Q

Secondary causes of constipation - organic?

A

 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

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25
Q

Symptoms of constipation?

A

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

26
Q

Symptoms of faecal impaction?

A

 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

27
Q

Assessment of constipation?

A
  • 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
28
Q

Management of constipation - initial self management?

A

o Eat healthy balanced diet (whole grains, fruits, vegetables)
o Increase fibre intake gradually
o Ensure fluid intake adequate
o Increase exercise/activity

29
Q

Management of constipation - short duration - lifestyle advice?

A

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
30
Q

Management of constipation - short duration - drug treatment?

A

 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

31
Q

Management of constipation - chronic constipation - lifestyle advice?

A

o Stop drug if think that’s the cause
 If opioids: offer osmotic and stimulant laxative + naloxegol if inadequate

o Lifestyle advice

32
Q

Management of constipation - chronic constipation - drug treatment?

A

 Bulk-forming laxative (ispaghula)
 If ineffective:
• Hard stools - Add/switch to osmotic laxative (macrogol)
• Soft stools - Add stimulant laxative (senna)

33
Q

Management of constipation - chronic constipation - if at least 2 laxatives from different classes for 6 months failed?

A

 Prucalopride or lubiprostone

• 4 weeks and 2 weeks respectively

34
Q

Management of faecal impaction?

A

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

35
Q

Management of constipation during pregnancy?

A

o Lifestyle measures

o If ineffective:
 Bulk-forming laxative – ispaghula
 Osmotic laxative – Lactulose
 Consider senna if needed

36
Q

Management of constipation in children - disimpaction?

A

 Movicol Paediatric using escalated dose regimen
 Add stimulant laxative if not resolved in 2 weeks
 Review in 1 week

37
Q

Management of constipation in children - maintenance therapy?

A

 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

38
Q

Follow up of constipation in primary care?

A

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

39
Q

Referral for constipation, when?

A

o Any secondary causes which cannot be managed in primary care

40
Q

Specialist investigations for constipation?

A
  • Flexible sigmoidoscopy/Colonoscopy
  • CT
  • Anorectal manometry, defaecation proctogram
  • Colon transit time
41
Q

Specialist management of constipation?

A
  • Biofeedback training by physio

* Surgery – subtotal colectomy

42
Q

Complications of constipation?

A

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

43
Q

Definition of diarrhoea?

A
  • Decreased stool consistency from water, fat or inflammatory discharge
  • Acute <2 weeks
  • Persistent >2 weeks
44
Q

Definition of dysentery?

A

o Loose stools with blood and mucus
o Organisms that cause bloody diarrhoea include campylobacter, entamoeba histolytica, E.coli, salmonella serotypes and Shigella

45
Q

Definition of Traveller’s diarrhoea?

A

o Diarrhoea starting during or shortly after foreign travel

o Organism most commonly E.coli, Salmonella, Viruses, Cryptosporidium, Giardia

46
Q

Causes of diarrhoea?

A 
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
47
Q

Types of diarrhoea?

A

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

48
Q

Other symptoms associated with disease in diarrhoea?

A

fever, pain, weight loss, clubbing, anaemia, oral ulcers, masses

49
Q

Assessment of dehydration in diarrhoea?

A

o Mild – thirst, oliguria, dry mouth
o Moderate – sunken fontanelle, sunken eyes, tachypnoea, tachycardia
o Severe – Decreased skin turgor, drowsiness

50
Q

Examination in diarrhoea?

A
  • Abdominal Examination

- DRE

51
Q

Investigations in diarrhoea?

A
  • 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
52
Q

If chronic diarrhoea - what other tests can be done?

A

o HIV serology is suspected
o Stool sample
o C.diff testing
o Faecal calprotectin test if distinguishing between IBS/IBD <40

53
Q

Management of diarrhoea - prevention?

A

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

54
Q

Management of diarrhoea - symptomatic relief?

A

 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

55
Q

Management of diarrhoea -when to admit?

A

 Admission if seriously ill, dehydrated >5%, high fever, infants

56
Q

Management of diarrhoea - fluid therapy

A

• 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

57
Q

When to refer chronic diarrhoea to gastroenterologist?

A

 Coeliac disease, Crohn’s, UC, bile acid diarrhoea, microscopic colitis, malabsorption

58
Q

Antibiotic therapy used in gastroenteritis - Entamoeba histiolytica?

A

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

59
Q

Antibiotic therapy used in gastroenteritis - Campylobacter?

A

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

60
Q

Antibiotic therapy used in gastroenteritis - Cryptosporidium?

A

No antibiotics

61
Q

Antibiotic therapy used in gastroenteritis - Giardia Intestinalis?

A

Metronidazole 400mg TDS for 5 days

Tinidazole is alternative

62
Q

Antibiotic therapy used in gastroenteritis - Salmonella & Shigella?

A

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

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