General gastro Flashcards
What is acute upper gastrointestinal bleeding most commonly due to
Peptic ulcer disease
Oeseophageal varices
Risk assessment in upper gastrointestinal bleeding
Use the blatchford score at first assessment(admission risk marker - patients with 0 may be considered for early discharge)
Full rockall score after endoscopy
Immediate management of acute GI bleed
A-E resus
Platelet transfusion if actively bleeding
FFP if low fibrinogen or APTT elevated
Immediate endoscopy after resuscitation within 24 hrs
Why should PPIs not be prescribed in an acute GI bleed
Should not be prescribed until post-endoscopy as they may mask the site of bleeding
Management of variceal bleeding
terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices
transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures
Symptoms and signs of giardiasis
Asymptomatic Watery malodorous diarrhoea Abdominal cramps and distension Nausea Epigastric discomfort
What is giardiasis often accompanied by
Acquired lactose-intolerance
Transmission of giardiasis
Some trophozoites transform into environmentally resistant cysts that are spread by focal-oral route
Waterborne transmission is the major source of infection but transmission can occur from ingestion of contaminated food or direct person-to-person contact
Diagnosis of giardiasis
Enzyme immunoassay for antigen or molecular test for parasite DNA in stool
Microscopic examination of stool(characteristic trophozoites or cysts in stool are diagnostic)
Treatment for giardiasis
Metronidazole(warn to not drink alcohol to avoid disulfiram-like reaction)
What is Barrett’s oesophagus
Metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium
What type of cancer does Barrett’s oesophagus predispose to
Oesophageal adenocarcinoma
Risk factors for Barrett’s oesophagus
GORD is the single strongest risk factor
male gender (7:1 ratio)
smoking
central obesity
Mx of Barrett’s oesophagus
endoscopic surveillance with biopsies(recommended for patients with metaplasia every 3-5 yrs)
high-dose proton pump inhibitor
Options if dysplasia of any grade is identified in the oesophagus
Endoscopic mucosal resection
Radiofrequency ablation
Most common site for UC
Rectum(inflammation always starts there)
Never spreads beyond ileocaecal valve
Initial presentation of UC
bloody diarrhoea urgency tenesmus abdominal pain, particularly in the left lower quadrant extra-intestinal features
Extra-intestinal features of UC
Pauciarticular arthritis Asymmetric erythema nodosum Episcleritis Osteoporosis PSC Uveitis
Pathology features of UC
red, raw mucosa, bleeds easily
no inflammation beyond submucosa (unless fulminant disease)
widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps
inflammatory cell infiltrate in lamina propria
neutrophils migrate through the walls of glands to form crypt abscesses
depletion of goblet cells and mucin from gland epithelium
granulomas are infrequent
What might a barium enema show in UC
loss of haustrations
superficial ulceration, ‘pseudopolyps’
long standing disease: colon is narrow and short -‘drainpipe colon’
Classification of UC
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
What is proctitis
Inflammation of the rectum
Inducing remission in proctitis
topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior
if remission is not achieved within 4 weeks, add an oral aminosalicylate
if remission still not achieved add topical or oral corticosteroid
Inducing remission in proctosigmoiditis and left-sided ulcerative colitis
Topical aminosalicylate
If remission is not achieved within 4 weeks, an oral corticosteroid for 4 to 8 weeks in addition to the high-dose aminosalicylate should be offered.
Management of mild-to-moderate ulcerative colitis that is extensive
A topical aminosalicylate and a high-dose oral aminosalicylate
If remission is not achieved within 4 weeks, stop topical aminosalicylate treatment and offer a high-dose oral aminosalicylate and 4 to 8 weeks of an oral corticosteroid.
Treatment of acute severe ulcerative colitis
IV corticosteroids(hydrocortisone or methylpred)
Assess need for surgery
IV cyclosporin if corticosteroids are contra-indicated
Maintaining remission in mild, moderate or severe ulcerative colitis
maintenance therapy with an aminosalicylate is recommended in most patients. Corticosteroids are not suitable for maintenance treatment because of their side-effects.
Contra-indications of mesalazine
Blood clotting abnormalities
Side effects of aminosalicylates
Arthralgia
GI discomfort
Leucopenia
Nausea
Which parameters should be monitored before starting an oral aminosalicylate
Renal function
Trigger factors for UC
Stress
Medications(NSAIDs, antibiotics)
Cessation of smoking
Area commonly affected by crohn’s disease
Terminal ileum and colon
Complications of crohn’s disease
Intestinal strictures Abscesses in the wall of intestine Fistulae Anaemia Malnutrition Colorectal and small bowel cancers
Extra-intestinal features of crohn’s
Arthritis(pauciarticular) Asymmetric erythema nodosum Episcleritis(more common CD) Osteoporosis Mouth ulcers Perianal disease
Ix for Crohn’s disease
raised inflammatory markers
increased faecal calprotectin
anaemia
low vitamin B12 and vitamin D
Inducing remission in Crohn’s disease
glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients
Enteral feeding with an elemental diet
Second-line remission intervention in CD
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective
azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine
Useful addition in refractory and fistulating CD
infliximab is useful in refractory disease and fistulating Crohn’s. Patients typically continue on azathioprine or methotrexate
What can be used for isolated peri-anal disease in CD
Metronidazole
Maintaining remission in CD
Stopping smoking is a priority
azathioprine or mercaptopurine is used first-line to maintain remission
+TPMT activity should be assessed before starting
methotrexate is used second-line
What type of bacterium is C.diff
Gram positive rod
What does C.diff cause
It produces an exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous colitis.
Risk factors for C.diff infection
Clindamycin
Second and third gen cephalosporins
PPIs
Features of pseudomembranous colitis
diarrhoea
abdominal pain
a raised white blood cell count (WCC) is characteristic
if severe toxic megacolon may develop
Diagnosis of pseudomembranous colitis
Is made by detecting Clostridium difficile toxin (CDT) in the stool
Clostridium difficile antigen positivity only shows exposure to the bacteria, rather than current infection
1st line antibiotic for c diff infection
Oral vancomycin
What is toxic megacolon
Nonobstructive dilation of the colon usually associated with systemic toxicity
Common causes of toxic megacolon
IBDs
Infections(C diff, salmonella, CMV)
Factors which precipitate toxic megacolon
Hypokalaemia
Medications(anticholinergics, opioids, antidepressants)
Barium enema
Colonscopy and bowel preparations
Diagnosis of toxic megacolon
Radiographic evidence of the dilation of the colon greater than 6 cm
Fever Tachycardia Neutrophilic leukocytosis Anaemia Hypotension
Management of toxic megacolon
Supportive
Abx(vancomycin and metronidazole)
Treat underlying cause
Surgical review
Surgical management of toxic megacolon
current surgical treatment of choice in acute toxic megacolon is subtotal colectomy with ileostomy and either a Hartmann pouch, sigmoidostomy, or rectostomy
What are pseudo polyps
Widespread ulceration in UC with preservation of adjacent mucosa which has the appearance of polyps
What is GORD
acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus
Oesophagus has a squamous epithelial lining making it more sensitive to the effects of stomach acid. The stomach has a columnar epithelial lining that is more protected against stomach acid
GORD presentation
Heartburn Acid regurgitation Retrosternal or epigastric pain Bloating Nocturnal cough Hoarse voice
When should referral for endoscopy be made for GORD
Dysphagia (difficulty swallowing) at any age gets a two week wait referral Aged over 55 (this is generally the cut off for urgent versus routine referrals) Weight loss Upper abdominal pain / reflux Treatment resistant dyspepsia Nausea and vomiting Low haemoglobin Raised platelet count
Lifestyle advice for GORD
Reduce tea, coffee and alcohol Weight loss Avoid smoking Smaller, lighter meals Avoid heavy meals before bed time Stay upright after meals rather than lying flat
Mx of GORD
Gaviscon/Rennie
Omeprazole
Ranitidine as alternative to PPI
Surgical mx of GORD
Surgery for reflux is called laparoscopic fundoplication. This involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.
Diagnosis of haemorrhoids
Bright red, painless rectal bleeding(on toilet paper/in toilet bowel)
Anal itching/irritation
Feeling of rectal fullness or incomplete evacuation on bowel movements
Soiling
Pain(not in internal)
When should patients with haemorrhoids be admitted
Extreme pain
Internal haemorrhoids which have prolapsed
Lifestyle advice to aid healing of the haemorrhoid
Advise on the importance of correct anal hygiene. The anal region should be kept clean and dry to aid healing and reduce irritation and itching. Recommend careful perianal cleansing and to pat (rather than rub) the area dry.
Avoid still withholding
Mx of haemorrhoids
Simple analgesia
Topical haemorrhoids preparation(corticosteroids)
Secondary care medical treatments for haemorrhoids
Rubber band ligation
Injection sclerotherapy
Infrared coagulation/photocoagulation
Indications for liver transplant
acute liver failure or chronic liver failure. hepatocellular carcinoma.
Factors suggesting unsuitability for liver transplant
Significant co-morbidities (e.g., severe kidney, lung or heart disease)
Current illicit drug use
Continuing alcohol misuse (generally 6 months of abstinence is required)
Untreated HIV
Current or previous cancer (except certain liver cancers)
Scar associated with liver transplant
“rooftop” or “Mercedes Benz” incision along the lower costal margin for open surgery
Post-transplant care
Lifelong immunosuppression Avoid alcohol and smoking Treating opportunistic infections Monitoring for disease recurrence (i.e. of hepatitis or primary biliary cirrhosis) Monitoring for cancer
Stages of non-alcoholic fatty liver disease
Non-alcoholic Fatty Liver Disease
Non-Alcoholic Steatohepatitis (NASH)
Fibrosis
Cirrhosis
Risk factors for NAFLD
Obesity Poor diet and low activity levels Type 2 diabetes High cholesterol Middle age onwards Smoking High blood pressure
Diagnosis of NAFLD
Liver ultrasound
1st line recommended ix for assessing fibrosis in NAFLD
Enhanced liver fibrosis blood test (ELF)
Otherwise NAFLD fibrosis score
Then fibroscan
Mx of NAFLD
Weight loss Exercise Stop smoking Control of diabetes, blood pressure and cholesterol Avoid alcohol
Stages of alcoholic liver disease
Alcohol related fatty liver - build up of fat from drinking
Alcoholic hepatitis - usually reversible with permanent abstinence
Cirrhosis
Complications of alcohol
Alcoholic Liver Disease Cirrhosis and HCC Alcohol Dependence and Withdrawal Wernicke-Korsakoff Syndrome (WKS) Pancreatitis Alcoholic Cardiomyopathy
IX in alcoholic liver disease
FBC - raised MCV
LFTs - elevated ALT and AST, low albumin
Clotting - elevated prothrombin time
U&Es - deranged in hepatorenal syndrome
Imaging ix in alcoholic liver disease
Fibroscan - assess degree of cirrhosis
Endoscopy
CT/MRI
Liver biopsy
General mx of alcoholic liver disease
Alcohol cessation Detox regime Thiamine and high protein diet Steroids Liver transplant
Alcohol withdrawal symptoms 6-12 hrs
tremor, sweating, headache, craving and anxiety
Alcohol withdrawal symptoms 12-24 hrs
Hallucinations
Alcohol withdrawal symptoms 24-48 hrs
Seizures
Alcohol withdrawal symptoms 24-72 hrs
Delirium tremens
Delirium tremens presentation
Acute confusion Hypertension Hyperthermia Tachycardia Delusions and hallucinations Tremor
Which tool can be used to guide treatment in alcohol withdrawal
CIWA-Ar (Clinical Institute Withdrawal Assessment – Alcohol revised) tool
Mx of effects of alcohol withdrawal
Chlordiazepoxide
IX high-dose B vitamins(pabrinex) followed by regular lower dose oral thiamine
Features of wercicke’s encephalopathy
Confusion
Oculomotor disturbances (disturbances of eye movements)
Ataxia (difficulties with coordinated movements)
Features of korsakoffs syndrome
Memory impairment (retrograde and anterograde) Behavioural changes
