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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
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
26
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
27
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
28
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
29
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 ```
30
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
31
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
32
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)
33
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
34
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
35
Management of constipation during pregnancy?
o Lifestyle measures o If ineffective:  Bulk-forming laxative – ispaghula  Osmotic laxative – Lactulose  Consider senna if needed
36
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
37
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
38
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
39
Referral for constipation, when?
o Any secondary causes which cannot be managed in primary care
40
Specialist investigations for constipation?
* Flexible sigmoidoscopy/Colonoscopy * CT * Anorectal manometry, defaecation proctogram * Colon transit time
41
Specialist management of constipation?
* Biofeedback training by physio | * Surgery – subtotal colectomy
42
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
43
Definition of diarrhoea?
- Decreased stool consistency from water, fat or inflammatory discharge - Acute <2 weeks - Persistent >2 weeks
44
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
45
Definition of Traveller's diarrhoea?
o Diarrhoea starting during or shortly after foreign travel | o Organism most commonly E.coli, Salmonella, Viruses, Cryptosporidium, Giardia
46
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
47
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
48
Other symptoms associated with disease in diarrhoea?
fever, pain, weight loss, clubbing, anaemia, oral ulcers, masses
49
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
50
Examination in diarrhoea?
- Abdominal Examination | - DRE
51
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
52
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
53
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
54
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
55
Management of diarrhoea -when to admit?
 Admission if seriously ill, dehydrated >5%, high fever, infants
56
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
57
When to refer chronic diarrhoea to gastroenterologist?
 Coeliac disease, Crohn’s, UC, bile acid diarrhoea, microscopic colitis, malabsorption
58
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
59
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
60
Antibiotic therapy used in gastroenteritis - Cryptosporidium?
No antibiotics
61
Antibiotic therapy used in gastroenteritis - Giardia Intestinalis?
Metronidazole 400mg TDS for 5 days Tinidazole is alternative
62
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

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