General Gastro Flashcards
UGIB differential
Descending order of frequency:
Gastric and duodenal ulcers
-upper abdo pain
-worse with eating with gastric ulcer
-improves with eating with duodenal ulcer
-H pylori, CMV, HSV infection
-NSAIDs
-Stress ulcer
Erosive gastritis and duodenitis
-early satiety, post prandial fullness, epigastric pain or burning
-H pylori
-NSAIDs
-alcohol
-radiation
Erosive esophagitis
-dysphagia/odynophagia
-retrosternal pain
-food impaction
-GORD
-medications
-HSV, CMV, candida, HIV infections
Varices
-stigmata chronic liver disease
-portal hypertension (ascites, splenomegaly, thrombocytopenia)
Portal hypertensive gastropathy
-stigmata chronic liver disease
-portal hypertension (ascites, splenomegaly, thrombocytopenia)
Angiodysplasia
-ESRF
-AS
Mallory Weiss
-epigastric or back pain
-vomiting, straining at stool, lifting, coughing, blunt abdo trauma, hiatus hernia
Mass lesion
-weight loss
-anorexia
-nausea
-early satiety
UGIB evaluation and management
History
-haematemeis, coffee ground, melena, haematochezia
-alcohol abuse, previous GI bleed, liver disease, heart disease, coagulopathy
-use of: NSAIDs, aspirin, anti platelet, anticoagulant
Exam
-tachycardia or orthostatic hypotension: moderate to severe bleed
-supine hypotension: life threatening bleed
-DRE
-peritonitism: possible perforation
Bloods
-Hb may be normal (losing whole blood)
-MCV should be normal in acute
-raised urea:creatinine
Emergency management
-ensure airway safe and keep nil by mouth
-monitor oxygenation
-bolus crystalloid while awaiting blood
-MTP for life threatening bleed
-PRBC for haemodynamic instability
-aim Hb >70 in all except CAD (>80) and acute MI (>100)
-platelets if <50 and life threatening bleed
-withhold antithrombotics and consider reversal if life threatening bleed
-pantoprazole IV
-if cirrhotic, given ceftriaxone and terlipressin or octreotide
-gastro consult and endoscopy within 24 hrs
Glasgow blatchford for discharge threshold
LGIB causes
Diverticular
Cancer
Colitis (infective, ischaemic, inflammatory)
Ulcers (stercoral, NSAID, rectal)
Haemorrhoids
Radiation
Angioectasia
LGIB evaluation and management
Oakland risk stratify for discharge
History:
Haematochezia, melena, haematemesis
Abdominal pain
Previous GI bleed, liver disease, heart disease, coagulopathy
Last colonoscopy and results
NSAIDs and antithrombotics
Exam
Tachycardia, orthostatic or supine hypotension
DRE
Abdominal tenderness, peritonism
Bloods
Hb may be normal (losing whole blood)
MCV should be normal in acute
Normal urea:creatinine
Initial management
Fluid bolus for life threatening
Aim Hb >70 in most. Aim >80 in heart disease and 100 in MI
Platelets <30 and severe bleed
Withhold anti coagulation. Consider reversal in life threatening
Continue aspirin secondary prevention
No TXA
CTA
If significant bleeding despite resus
Positive CTA
Urgent transcatheter angio +- embolisation or non urgent colonoscopy
Elective colonoscopy
May not require colonoscopy if diverticular bleed found within 12 months
Consider upper endoscopy if severe haematochezia
For diverticular bleeding:
Discontinue NSAIDs and aspirin primary prevention
Continue aspirin secondary prevention and anti coagulation
Discuss discontinuing P2Y12
H pylori eradication
PPI, clarithromycin and amoxicillin or metronidazole for 14 days
PPI, bismuth, tetracycline and metronidazole for 10-14 days
PPI, levofloxacin and amoxicillin for 10-14 days
Prove eradication 4 weeks post completion of treatment. Use urea breath test, faecal antigen or biopsy based test. Withhold PPI for 2 weeks prior to
Alcoholic hepatitis evaluation and management
Heavy alcohol use (>5 STD per day) for 6 months
Jaundice < 3 months
SIRS may be present
May have decompensated cirrhosis
AST 50-400
AST:ALT >2
Bili >30
Exclude other causes
-DILI: medication history
-Obstruction: abdo US + liver inaging (HCC and biliary obstruction)
-Viral screen (IgM HAV, IgM HEV, HBsAg, HBcAb, HCV antibodies)
-Autoimmune (ANA, ASM, AMA, IgG
-Ischaemic (shock, cocaine use)
Nutritional support
Thiamine and multivitamin
MELD < 20
Outpatient management
MELD >20
-Consider NAC
-Steroids (not in MELD >50)
-Consider transplant
Crohns evaluation
History and exam
-Diarrhoea, abdominal pain and fatigue
-Can have fever, weight loss, growth failure
-Previous treatment, hospitalisation, surgery, complications (fistula, stricture, abscess)
Bloods
-FBC (anaemia), CRP (raised), EUC (dehydration)
Stool
-C diff
-Multiplex + MCS
-Calprotecin, lactoferrin
Imaging
-CT enterography
-MR enterography in young
-MRI for perianal fistula or abscess
Colonoscopy
-Biopsy
-Disease distribution
-Cancer surveillance
Severity
-Mild: ambulatory, eating and drinking, no fevers, abdominal pain/tenderness or complications
-Moderate: fail to respond to mild treatment, fever, weight loss, abdominal pain/tenderness, nausea/vomiting, significant anaemia
-Severe: fail to respond to steroids or biologics, cachetic, complications, hospitalisation, persistent vomiting, peritonism, high fevers
Monitoring:
-Faecal lactoferrin and calprotectin
-CRP
-MRE/CTE
-Colonoscopy
-
IBD extraintestinal manifestations
Eye (uveitis, scleritis, episcleritis)
Skin (erythema nodosum, pyoderma gangrenosum)
Bone (arthropathy, osteoporosis, osteonecrosis)
Liver (primary sclerosing cholangitis, cholelithiasis)
Thomboembolic disease (venous and arterial)
Nephrolithiasis
Autoimmune diseases
Crohns management
Avoid NSAIDs
Cease smoking
Treat stress, depression and anxiety
Mild disease
-Sulfasalazine for colonic or ileocolonic. Does not achieve remission
-Ileal release budesonide for remission induction in ileal and right colon disease
-Oral prednisone for remission induction
-No evidence for mesalamine
Severe
-Combination anti TNF (infliximab, adalimumab) and immunomodulator (azathioprine, 6 mercaptopurine, methotrexate)
-Anti interleukin antibody therapy
-Anti integrin antibody therapy
-JAK inhibitor therapy
-Short term steroids
Flare
-Treat dehydration
-Consider perforation, abscess and partial bowel obstruction
-Rule out GI infection
-Consider IV steroids
Ulcerative colitis evaluation
History and exam
-Haematochezia, diarrhoea, mucous, urgency, tenesmus, abdo pain
-Past treatment, hospitalisation, surgery, complications
-Screen for fulminant colitis, toxic megacolon, perforation
Blood
-FBC (anaemia), EUC (dehydration), CRP
Stool
-C diff
-Multiplex + MCS
-Calprotectin
Colonoscopy
-Distribution
-Biopsy
Montreal classification
-proctitis, left sided, extensive colitis
Severity
-ACG activity index score
Monitoring
-Faecal calprotectin or colonoscopy
-Goal is mucosal healing
Ulcerative colitis long term management
Mild induction
-Rectal 5-ASA in proctitis
-Oral + rectal 5-ASA in left sided
-Oral 5-ASA for extensive
-Oral budesonide for any type if failed induction. Oral steroids is an alternative
Mild maintenance
-Rectal 5-ASA for proctitis
-Oral 5-ASA for left sided and extensive
Moderate induction
-Oral budesonide
Moderate-severe induction
-Oral systemic steroids
-Anti TNF (infliximab, adalimumab) + azathioprine
-Anti integrin or JAK inhibitor if failed anti TNF)
Moderate severe maintenance
-Continue anti TNF, anti integrin or JAK inhibitor if used for induction
-Switch from steroids to azathioprine
Toxic megacolon
Complication and CD and UC
History
-Diarrhoea
-Continuous haematochezia
-Abdominal pain and distension
Exam
-Haemodynamic instability
-Fever
-Altered level of consciousness
-Distended and tender abdominal +- peritonism
Bloods
-Hypokalaemia and metabolic alkalosis (diarrhoea)
-Metabolic acidosis (Ischaemic colitis)
-Neutrophilia
-Anaemia
-Hypoalbuminaemia
-Raised CRP
Stool
-C diff
-Multiplex + MCS
Imaging
-CTE: Colonic dilation >6cm
Management
-Cease NSAIDs, opioids, anticholinergics
-Bowel rest +- NG tube
-Rehydration
-Electrolyte replacement
-IV steroids
-IV antibiotics
-Infliximab or cyclosporine
-Serial abdo xrays
-Surgery
Ulcerative colitis acute management
VTE prophylaxis
Cease opioids, anticholinergics and NSAIDs
C diff testing
-treat with vancomycin if positive
Flexisig within 72hrs
IV steroids
Infliximab or cyclosporine if not responding to steroids
May require surgery
Consider toxic megacolon
Gastroenteritis evaluation and management
History
-Acute diarrhoea
-Nausea, vomiting, abdominal pain, tenesmus, urgency, flatulence
Watery diarrhoea
-Mild (normal activities): Hydration +- loperamide
-Travel associated moderate severe: Hydration + azithromycin
-Non travel moderate severe with no, low or fever <72hrz: Hydration + loperamide
-Non travel moderate severe with fever >72hrs: Hydrstion, stool studies and azithromycin
Bloody diarrhoea
-No or low grade fever: Hydrstion, stool studies then directed antibiotic therapy (concern for shiga toxin E. coli and HUS)
-Severe illness with fever: Hydration, stool studies and azithromycin
Stool studies if
-Bloody diarrhoea
-Severe illness
-Hospitalised
-High risk host
-Symptoms lasting over 1-2 weeks
Azithromycin dosing
1mg once or 500mg daily for 3 days
C diff evaluation and management
Who to test
-Over 3 loose stools per 24 hrs
-Recent hospitalisation or antibiotic use
-At risk of severe disease
Test
-NAAT
-If positive NAAT, then toxin EIA
-If both positive, likely CDI
-If NAAT positive and toxin EIA negative, infection still possible
Severity:
-Mild: diarrhoea, fever, abdominal pain, nausea
-Severe: hypovolaemia, lactic acidosis, hypoalbuminaemia, WCC > 15, AKI
-Fulminant: hypotension, shock, lieus, megacolon
Mild CDI management
-Oral vancomycin, fidaxomicin or metronidazole
Severe CDI management
-Oral vancomycin or fidaxomicin
-Consider need for surgery and faecal microbiota transplant
Fulminant CDI
-Oral vancomycin + IV metronidazole
-Can use vancomycin enema if ileus
-Consider need for surgery and faecal microbiota transplant
