GI Flashcards
What is a hernia
Protrusion of a viscus through a defect in the wall through its containing cavity
Main complications of hernias
irreducible
obstruction (bowel contents cant pass through)
incarcerated
strangulated
Rfs for inguinal hernia
Obesity, constipation, chronic cough, heavy lifting, male
Which inguinal hernia most likely to strangulate? where does this hernia go through? what about the other?
indirect (through deep inguinal ring) - these ones are more likely to strangulate!!!
Direct - though posterior wall of inguinal canal
What Ix can be done if unsure about a hernia
USS
Usual presentation of hernia
lump ± pain (?incarceration)
Non surgical mx of small hernia?
watch and wait
stop smoking, weight loss, diet
2 complications of mesh surgery for hernias
Recurrence within 5 years = 1%
Wound infection
Intestinal injury
presentation of femoral hernia
Lump in groin inferior and lateral to pubic tubercle
*superior and lateral = inguinal
Most common DDx of femoral hernia? how to differentiate OE?
Hydrocele - possible to get above on examination
Issue with femoral hernias ?
High strangulation rate (20% @ 3 months)
presentation of strangulated hernia?
Red, tender, tense, irreducible ± colicky abdo pain + vomit + distension (obstruction - a surgical emergency)
Red flags of dyspepsia? name 3
Wt loss, recurrent vomiting, dysphagia, chronic bleeding
ALARMS
Anaemia, Loss of wt, Anorexia, Recent onset (if >55), Melaena, Swallowing difficulty
most common causes of dyspepsia
Functional - without ulcers (70%)
Peptic ulcers
oesophagitis
Diagnosis of funcitional dyspepsia?
ROME criteria
6M Post-prandial fullness, early satiety, epigastric pain/burning + no struc
Name 2 drugs that cause dyspepsia
Nitrates Bisphosphonates Corticosteroids NSAIDs - Decrease mucus and bicarbonate secretion
How to PPIs work for dyspepsia?
decreases expression of H+/K+ antiporter on luminal membrane of parietal cells
Ix in dyspepsia?
FBC for alarm e.g. IDA
Test for h.pylori
Endoscopy (upper GI) if ALARMS or >55 (2 week wait)
Barium swallow may be useful
Lifestyle advice for dyspepsia
stop offending drugs, decrease tobacco, avoid aggravating foods, lose weight+ over the counter antacids
eg of a H2 receptor antagonist?
PPI?
ranitidine
Omeprazole
Stomach cells - what do they do? Chief cells - G-cells Parietal cells D-cells - Goblet cells -
Chief cells - pepsinogen (to pepsin by HCl)
G-cells - gastrin (antrum)
Parietal cells - intrinsic factor and HCl (fundus + body)
D-cells - somatostatin (antrum)
Goblet cells - mucus + bicarbonate
What stops acid production?
somatostatin
describe h pylori
G - curved bacillus
Sx of PUD
Fullness, bloating, early satiety, epigastric pain/burning
Cause of PUD?
H.pylori through mucus layer
Ix for H pylori
C13 urea breath test - may be done in primary care
Stool antigen test + CLO test (pink with h.pylori)
Type of anaemia in PUD
iron deficiency (bleeding + h pylori uses iron for own growth)
Mx of h pylori
PAC - 2 WEEKS
PPI + amoxicillin + clarithromycin, or
PPI + metronidazole + clarithromycin
What things help protect against ulcers
Mucus, bicarbonate, prostaglandins
What arteries may be affected by PUD in duodenum ? stomach ?
duodenal cap, may erode gastroduodenal artery
Common at lesser curve of stomach , may erode L gastric artery
Differentiate pain caused by DU and GU
DU - post prandially (1-3 hours), which is relieved by eating
GU - on eating
If pain radiates to back with ulcers where might it be?
posterior duodenal ulcer as related pancreas
What may be cause of PUD if h pylori negative and recurrent ulcers?
Zollinger-Ellison syndrome
(gastrin-secreting tumour or hyperplasia of the islet cells in the pancreas causes overproduction of gastric acid, resulting in recurrent peptic ulcers)
PUD ix? when for endoscopy? biopsy?
FBC - ID anaemia
H.pylori testing
Endoscopy ONLY IF first presentation >55 or ALARMS
Biopsy if NSAID and H.Pylori -ve as ?Zollinger-Ellison
mx of ulcer that is h pylori -ve NSAID induced
PPI or H2RA for 8 weeks
Comps of PUD
Haematemesis, melaena if erosion of large blood vessel
Acute abdomen and peritonism with perforation
What is GORD
Reflux of acid contents (bile - particularly caustic/acid) into oesophagus
What does GORD cause?
oesophagitis, ulceration, stricture formation or Barrett’s Oesophagus
Epithelial change in barretts?
metaplasia or squamous epithelium to glandular
Some Rfs for GORD
pregnancy
obesity
smoking, alcohol, coffee
3 things someone with GORD might present with?
Heartburn: burning feeling rising stomach to neck relieved by antacid. Related to meals, posture (lying down), straining
Water brash: excessive salivation
Acid brash: retrosternal discomfort - regurgitation of acid or bile
Odynophagia - painful swallowing related oesophagitis or stricture
Belching
Hoarseness
Cough - particularly at night
Gold standard Ix in GORD? other?
Gold standard is endoscopy
FBC to exclude anaemia
Barium swallow for hiatus hernia
Oeseophageal pH monitoring
±CXR
What would make you urgent refer for Ca with GORD?
ALARMSAnaemia, Loss of wt, Anorexia, Recent onset (if >55), Melaena (GI bleed), Swallowing difficulty
+ vomiting, Barrett’s oesophagitis, lump
Lifestyle Mx of GORD
reduce weight, stop smoking, reduce alcohol, raise bed at night, regular small meals,
Avoid causative drugs
Drugs that affect oesophageal motility?
nitrates, anticholinergics, TCA
Drugs that damage mucosa
NSAID
bisphosphonates
If you see oesophagitis on endoscopy what drug mx?
PPI 2/12
Surgical mx of GORD?
Laparoscopic fundoplication
Pres of a hiatus hernia? why?
GORD - oesophageal sphincter becomes less competent
Ix for hiatus hernia?
CXR
Barium study
Endoscopy
Mx of hiatus hernia
Lifestlye as GORD + PPI longterm + surgery e.g. gastropexy if refractory
Mx of oesophagitis
2/12 PPI
Name 2 PPIs
lansoprazole, omeprazole
2 key Ix for barretts?
Endoscope - proximal displacement
Biopsy - histological confirmation of columnarisation
Mx of low vs high grade barretts?
Low grade: Lifestyle as for GORD + long term PPI ± ablation
High grade: oesophagectomy
Cell type for Ca of oesophagus?
80% SCC (upper ⅔)
or adenocarcinoma (lower ⅓)
Red flags for presentation of oesophageal Ca?
Dysphagia (solids>liquids)
Vomiting
Anorexia and weight loss
Symptoms of GI related blood loss e.g. melaema
Symptoms of infiltration - intractable hiccups and persistent retrosternal pain
Upper ⅓ specific - hoarseness and cough - less common
Lymphadenopathy
name 3 Ix for oesophageal Ca
FBC, UE, LFT, glucose, CRP
*Endoscopy with brushing and biopsy of lesion
CXR for metastases
CT/MRI of chest and upper abdomen for staging
Double contrast barium swallow - for dysphagia
Bronchoscopy if hoarseness
DDx for dysphagia . name 3
Oesophageal: GORD, oesophagitis, oesophageal cancer (food sticking), pharyngeal cancer
Neurological: CVA, achalasia, diffuse oesophageal spasm, MS, MND
Others: pharyngeal pouch, external compression (mediastinal tumour), CREST or scleroderma
what is achalasia
Disorder of motility of lower oesophageal sphincter
- Smooth muscle layer has impaired peristalsis and sphincter fails to relax
3 Ix for achalasia? which is gold standard?
CXR
Barium swallow
Manometry - gold
[Tube passed into the oesophagus - measures pressure at rest / swallowing]
Seen on CXR of achalasia?
, vastly dilated oesophagus behind heart
Seen on barium swallow achalasia?
characteristic bird’s beak dilated oesophagus with distal narrowing
Drug mx of achalasia?
CCB/nitrates - botox injection
reduce pressure in lower oesophageal sphincter
Surgery for achalasia is normally endoscopic dilation - main comp?
perforation
Gi features of scleroderma?
Reflux oesophagitis, delayed gastric emptying, Watermelon stomach (- may cause GI bleeding / anaemia)
3 autoantibodies in scleroderma
Anti-topoisomerase 1
Anti-centromere antibody (ACA)
Anti-RNA polymerase III
Gi mx of scleroderma
lifestyle - like GORD
PPI
Pro-motility agents - metoclopramide or domperidone
Dilatation of oesophaeal strictures
3 DDx of upper GI bleed?
PUD, mallory weiss, malignancy, varicies
What to think if Haematemesis is bright red? coffee?
Bright red - fresh - above stomach, active haemorrhage
Altered - coffee ground - stomach or below
cause of mallory weiss?
Persistent vomiting/wretching
Ix of mallory weiss
Endoscopy, FBC including HCT to assess severirt
Renal function/urea for fluid replacement
Cross-match and blood group
2 comps of mallory weiss
aspiration pneumonia
Mediastinitis is perforation
Hypovolaemic shock / death
What are oesophageal varicies?
Dilated veins at junction between portal and systemic venous circulation account for 10% of UGI bleeds
What usually is the cause of oesophageal varicies?
chronic liver disease -> portal hypertension
Ix in varicies?
Endoscopy, FBC (Hb and HCT), clotting, renal function, LFT
OE upper GI bleed?
Assess blood loss + look for signs of shock Pallor and anaemia Pulse + BP Cool extremities, chest pain, confusion Dehydration Stigmata of liver disease
3 Ix in upper GI bleed
*Endoscopy post resuscitation or within 24 hours
FBC: measure haemoglobin 4 hourly, platelets >50 requires platelet transfusion and FFP for coagulation factors
Crossmatch blood 2-6 units
Coagulation profile: PTT and aPTT - coagulopathy may occur with UGIB
LFT for liver disease
UE + Ur + Cr - serum urea nitrogen:criteria > 30 -> UGIB
CXR (perf oesoph), erect and supine AXR
Initial Mx of upper GI bleed if shocked?
fluid resuscitation + high flow O2
2 wide bore cannula and send bloods (FBC/UE/LFT/crossmatch/coag)
Fluid bolus 500ml over 15 mins (up to 2L) while waiting for bloods
Transfuse with blood, platelets (<50), FFP (INR or APTT >1.5x normal), prothrombin complex (if warfarin) according to major haemorrhage protocol
CXR, ECG, ABG, catheter, regular monitoring
What score system for mortality in upper GI bleed?
Rockall
(Age: 60-80 = 1, 80+ = 2
Shock: tachycardia PR > 100 = 1, hypotension = 2
Co-morbidity: heart (IHD, HF) = 2, renal/liver/malignancy = 3)
What has to be done post upper GI bleed and when?
endoscopy <24 hours
name 2 mx options of acute non variceal bleed? eg PUD
Mechanical clips
Thermal coagulation with adrenaline
Fibrin or thrombin with adrenaline
mx of oestophageal variceal bleed?
gastric?
band ligation
Endoscopic injection of N-butyl-2-cyanoacrylate
Bowel obstruction presentation
nausea / vomiting
pain
failure to pass bowel movements
distension
bowel sounds in obstruction?
high pitched
What does a silent bowel indicate?
ileus
ix in obstruction / ileus?
Bloods: FBC, UE, Cr, group and crossmatch
Fluid charts to monitor intake and output
Plain AXR - supine and erect
Seen on AXR in obstruction?
paralytic ileus?
perforation?
Distended loops of bowel proximal to obstruction
Fluid levels and distended small bowel throughout = paralytic ileus
Gas under diaphragm = perforation
Mx of uncomplicated obstruction?
fluid resus + correct electrolytes, intestinal decompression e.g. endoscopy, NG Tube (Sip & Suck)
No diagnosis in obstruction mx?
= laparotomy + consent for stoma
When does sigmoid volvulus occur?
in chronic constipation
Main complication of signoid volvulus
Venous infarction leading to perforation and faecal peritonitis - *shock and temp
Seen on AXR of sigmoid volvulus? other Ix for what?
*coffee bean sign - grossly dilated sigmoid loop
CT scan to assess bowel wall ischaemia
Mx of signoid volvulus? if recurrent?
Urgent admission and decompression - pass sigmoidoscope+ flatus tube alongside (in place for 24 hours)
Elective surgery for recurrence - resection of sigmoid colon
what happens in paralytic ileus? who is it in normally?
no peristalis - bowel just basically packing in
- occurs in elderly with co morbidities
how to avoid vomiting in mx of paralytic ileus?
resus through NG tube
What is ogilivie’s abdomen?
Acute colonic pseudo-obstruction associated with massive dilatation in absence of mechanical obstruction
Sx / signs of ogilivie’s
Abdo pain, bloating, N+V, intermittent constipation, no faeces or flatus
massive distension
Seen on AXR of ogilives
MEGACOLON
massive distension
mx of ogilives?
Treat cause
IV fluids - NBM
Endoscopic decompression
NG tube for decompression if vomiting
[Antiemetic prokinetic e.g. metoclopramide IV neostigmine (AChE inhibitor) + IV fluids + ABX ± decompression with flexible scope]
Mx of electrolyte imbalance
Surgery if required
What is hirschprugs
Absence of parasympathetic ganglion cells in myenteric and submucosal plexus of rectum
Usual Dx of hirschrungs is when?
abdominal distension and failure to pass meconium within 48 hrs
Ix in hirschsprung’s ? In older children?
AXR - dilated lower bowel
Rectal biopsy - absence of ganglionic cells
older children- anal manometry
triad of gastro osophageal obstruction
Wretching (no vomiting)
Pain
Failed attempt to pass NG tube
Pres / signs of intra abdo abscess?
peritonitis?
Abscess: fever + pain (psoas = flank to groin)
Signs: swinging pyrexia + palpable mass
Peritonitis: pain + anorexia + nausea + vomiting
Signs: high fever, tachycardia, tenderness on palpation, guarding, rebound tenderness
Ix in Peritonitis/intra-abdominal sepsis
FBC: leukocytosis, UE: dehydration, LFT, amylase, lipase: panc,
blood culture,
peritoneal fluid (culture and amylase level),
imaging: AXR, CXR (air under diaphragm)
Mx of abdo abscess
broad spec ABX: metronidazole + 3rd gen ceph + surgical drainage
Mx of peritonitis
IV fluid, IV ABX metronidazole + cefotaxime then open or laparoscopic surgery
what is an anal fissure? how does it present?
Tear in mucosa of anal canal
Pain on defecation (shards of glass), bright red blood on stool or paper
mx of anal fissure
Adult = bulk forming ispaghula husk, child = osmotic e.g. lactulose)
dietry fibre, adequate fluid
GTN ointment
ix / mx of anal fistula
MRI
Fistulotomy and excision
Ix in anorectal abscess ? MX?
Digital rectal exam
MRI - for fistula
Prompt drainage, medication for pain, ABX
What is a pilonidal sinus? mx?
Top of bum crack
[Small hole or tunnel at skin caused by obstruction of hair follicles at natal cleft which may lead to abscess formation and sinus]
Excision of sinus tract and primary closure
Advise: hygiene and hair removal
What does a perianal haematoma look like? bleed / pain?
2-4mm dark blueberry under skin
pain common
bleeding uncommon
mx of perianal haematoma
excise under LA or leave for 5 days
Why do haemorrhoids not hurt but perianal haematoma does?
haemorrhoids Painless as above dentate line therefore visceral innervation
below dentate line - inferior rectal nerve
pres of haemorrhoids
Bright red painless rectal bleeding on defecation
Ix of haemorrhoids
digital rectal exam
proctoscopy
Mx haemorrhoids
prevent constipation
rubber band ligation
haemorrhoidectomy
what is a positive rovsings sign
palpation of LLQ increases pain in RLQ (stretches peritoneal lining
DDx appendicitis. Name 3
GI obstruction, constipation, perforated ulcer, Meckel’s, diverticulitis, Crohn’s
Urological: torsion, calculi, UTI
Gynae: ectopic, ovarian cyst, PID
DKA
Ix in appendicitis
Urinalysis (UTI), pregnancy test, FBC (raised WCC), CRP, USS
Mx appendicitis
Laparoscopic or open appendicectomy
IV fluids + opiate analgesia
IV metronidazole and third gen cephalosporin
What is diverticular disease? where common?
A herniation of mucosa through thickened colonic muscle, common at sigmoid and descending colon
Complications of diverticular disease
Perforation, obstruction, fistula, abscess, stricture
haemorrhage
Ix in diverticular disease - Name 3
*Colonoscopy to rule out CoCa
Flexisig @ bleed
FBC - normal at uncomp, raised WCC at diverticulitis, bleeding - raised Pt and anaemia
Uncomplicated - BaEnema
CXR (upright) for pneumoperitoneum
AXR large/small bowel dilatation, ileus, obstruction etc.
Mx of aSx diverticular
high fibre
avoid NSAIDS/ opiates
Mx of diverticular disease
paracetamol for pain
bulk forming laxatives
fluids + fibre
Mx of diverticulitis
Broad-spec ABX (co-amoxiclav) for 7d, paracetamol, clear liquids 2-3 days
30% require surgery: sepsis, fistula, obstruction, perforation resection + colostomy
what is merkels diverticulum
remnant of vitellointestinal duct @ distal ileum
When could merkels be a DDx
Always consider in DDx of rectal bleed or intestinal obstruction
Mx ischaemic bowel?
Resus O2, IV fluid
Papaverine relieve spasm, heparin for Mestenteric venous thrombosis
Surgical angioplasty to SMA
What is chronic mesenteric ischemia often called? presentation?
Intestinal angina
Wt loss, postprandial pain, fear of eating
Rfs for chorinic mesenteric ischemia
smoking, HTN, DM, hyperlipidaemia
CMI ix
angiography is gold standard
FBC, LFT, UE for malnutrition and dehy
mx od CMI
Nitrate therapy, anticoagulation
operate - bypass surgery
3 causes of malabsorption
coeliac
chrons
cystic fibrosis
Ix of malabsorption. Name 3
FBC, LFT, ESR, CRP
Iron studies (ferritin), folate, B12
Albumin and corrected calcium
Clotting screen + INR (vitamin K)
Anti-endomysial, anti-reticulin, alpha-gliadin Faecal elastase (A1AT), microscopy and culture
AUSS gallbladder, liver, pancreas
Barium studies - structural
Ileocolonoscopy + biopsy
Basic features of malabsoption of
Iron/fol/B12
Vit A
Vit D/Ca
Vit K
Pallor/glossitis
Hyperkeratosis/scaliness / night blondness
Osteomalacia / penia
Bleeding
gene in coeliac
HLA-DQ2 (and DQ8)
Histology coeliac
villous atrophy and crypt hyperplasia, increased intraepithelial lymphocytes, lymphocyte infiltration of LP
Pres of coeliac
IBS, chronic fatigue
diarrhoea, wt loss, anaemia …… loads
Skin features of coeliac
dermatitis herpetiformis: blistering at arms, legs, buttocks
antibodies in coeliac
Tissue transglutaminase tTG IgA
Endomysial antibody EMA IgA
3 parts of mx coeliac
1 Ix consider for comp
Lifelong strict gluten-free diet
prescription entitlement,
calcium/vitamin D supplements
Offer annual review: height and weight, symptoms
*Consider DEXA for osteoporosis (75% have low BMD due to affecting total bone mass reached as teen)
What disease is similar to coeliac and can be differentiated by jejunal biopsy?
Tropical sprue - Jejunal biopsy - incomplete villous atrophy (Coeliac = total villous atrophy)
mx of tropical sprue
Fluid replacement
Antibiotics - tetracycline 6-12 months
Nutritional support - folate, B12, iron (not with tetracyline - chelation)
Initial sx / Red flags for gastric Ca
Vauge sx - dyspepsia, wt loss, dysphagia
ALARMS: anaemia, loss of wt, anorexia, recent onset, swallowing difficulty
Which node indicates gastric ca
Virchow’s node (Troisier’s sign )
Couple key Ix in gastric Ca
FBC (anaemia), LFT (to liver)
Flexible endoscopy/gastroscopy + biopsy
Sprial CT Abdo and thorax for mets
mx of gastro Ca
Nutritional support/deficiency screen + symptom control (pain,nausea,const,dep)
SURGERY
Distal tumour - subtotal gastrectomy
Proximal - total gastrectomy
Perioperative chemo
What is common mutation in Gastrointestinal stromal tumors
Mx?
80% have KIT receptor tyrosine kinase mutation
Complete surgical resection
Imatinib (tyrosine kinase inhibitor) - adjuvant
What is a MALT lymphoma
mucosa-associated lymphoid tissue
Subtype of non-Hodgkin’s lymphoma
usual association with malt tumours
H.pylori @ 90% gastric MALT
C.jejuni @ small bowel MALT
Mx of early stage MALT
eradication of H.pylori - may cause complete remission in 70%
+ Endoscopic follow up
Mx of advanced MALT
Eradication of h pylori
+ Rituxumab, + chemo + radi
surgery
where are carcinoid tumours usually
70% of all are in the major bronchi (R side)
What do carcinoid tumours secrete?
Vasoactive serotonin + bradykinin
What effect does Vasoactive serotonin + bradykinin secretion have with carcinoid tumours
Bronchospasm, diarrhoea, skin flushing, R sided valvular lesions
Ix in carcinoid tumour
Plasma chromogranin A (sensitive but not specific)
24 hr urinary 5-HIAA (>25mg = strong evidence)
Endoscopy or endoscopic ultrasound
CT/MRI
FBC, renal, UE, LFT, TFT, PTH, calcium, calcitonin, prolactin, aFP, CEA, b-HC
What mx if surgical resection not possible in carcinoid tumour
somatostatin analogue e.g. *ocreotide which blocks 5-HT release,
radiotherapy and chemotherapy
2 genetic causes of colorectal Ca
FAP - familial adenomatous polyposis - AD - mutation at APC gene 100% penetrance
HNPCC - hereditary non-polyposis colorectal cancer/ Lynch syndome, AD, 80% lifetime risk, defective DNA mismatch repair: colon, endometrial, ovary, stomach
Ix in colorectal ca
*PR exam + Colonoscopy + biopsy of lesion
FBC and LFT (anaemia and liver mets) Flexible sigmoidoscopy (detects 60%) CEA: carcinoembryonic antigen FOB - faecal occult blood Barium enema if colonoscopy fails
CT for mets (A/T/P) + liver USS
Screening for colorectal
60 - 75, 2 yearly with FIT (faecal immunochemical test) then +ve for colonoscopy
Why is IBS important
Significant negative impact on QoL and social functioning
For exams anyway
Dx of IBS
6 month history of ABC (abdominal pain, bloating, change of bowel habit) +
Relieved by defecation or altered bowel frequency + 2 or more of
Mucus, worse on eating, abdominal bloating, altered passage (Straining, urgency)
IBS Ix [think of DDx]
FBC, ESR, CRP Coeliac screen (EMA/TTG) Ca-125 (ovarian cancer) Faecal calprotectin (IBD) ± TFT, faecal occult blood, colonoscopy
IBS Mx ?
diarrhoea?
constipation?
bloating?
abdo pain?
Lifestyle, dietary and physical activity
Decrease stress, relaxation, active physical activity, less caffeine, regular meals, fluids, decrease alcohol, high-fibre foods
Medications - placebo effect Diarrhoea - loperamide Bloating - peppermint oil Constipation - laxatives e.g. ispaghula Abdo pain - antispasmodics - buscopan (hyoscine butylbromide) Psychological therapy
UC vs Crohns
Rectal?
skip lesions? thickness?
ENDOCOPY + BIOPSY + BARIUM ENEMA
UC
goblet cell depletion, crypt abscesses, non-rectal sparing, continuous disease, ulcers, pseudopolyps
confined to mucosa and submucosa
C
granulomatous lesions, goblet cells, rectal sparing, skip lesions, mucus cobblestoning, transmural inflammation
Non GI manifestations of crohns? name 3
Erythema nodosum, pyoderma gangrenosum, arthritis, iritis, conjunctivitis
Key Pres of crohns
Diarrhoea (chronic >6W) ± blood
Abdominal pain
Weight loss
*periods of acute exacerbation
Name 4 Ix in crohns
[Which for active disease monitoring?
Differentiate from IBS?]
FBC (all decreased), UE (renal disease as right ureter may be obstructed in ileocaecal disease), LFT (fatty liver)
ESR/CRP - high CRP -> active disease
Faecal calprotectin (IBS vs IBD)
Stool culture and microscopy
*Ileocolonoscopy + biopsy (UGI symptoms may require gastroduodenoscopy)
AXR (obstruction)
Malabsorption (iron, B12, folate, albumi
ASCA
Crohns mx to induce remission? what if 2 or more exacerbations in 12 months ?
oral pred
add azathioprine or mercaptopurine (or methotrexate + folic acid)
mx to maintain remission crohns
Monotherapy with azathioprine, mercaptopurine or methotrexate
Smoking cessation
What do you always monitor in crohns
osteoperosis
Ix UC. NAME 3
FBC (all decreased), UE, LFT (PSC)
ESR/CRP - high CRP -> active disease, ESR > 30
Faecal calprotectin (IBS vs IBD)
Stool culture and microscopy inc CMV and c.diff
Sigmoidoscopy + rectal biopsy (may be safer in severe disease to avoid perforation)
*First line: colonoscopy with multiple biopsies (x2 from 5 sites including distal ileum and rectum)
AXR (toxic megacolon)
Malabsorption (iron, B12, folate, albumin)
p-ANCA
Induce remission
mild UC?
Acute/severe?
oral mesalazine
if no improvement in 4 weeks + oral prednisolone
Admit + IV hydrocortisone + IV fluids
Add IV ciclosporin if no response in 72 hours
Maintain remission UC
oral mesalazine
types of laxative and Eg
Bulk forming - increase faecal mass, stimulating peristalsis ispaghula husk
Stool softener - for impacted faeces: arachis oil enema
Stimulant - increase motility e.g. senna, docusate
Osmotic - retain fluid in bowel - e.g. lactulose
Which toxin can -> HUS
Shiga toxin
Induce remission
mild UC?
Acute/severe?
oral mesalazine
if no improvement in 4 weeks + oral prednisolone
Admit + IV hydrocortisone + IV fluids
Add IV ciclosporin if no response in 72 hours
Maintain remission UC
oral mesalazine
types of laxative and Eg
Bulk forming - increase faecal mass, stimulating peristalsis ispaghula husk / Fybogel
Stool softener - for impacted faeces: arachis oil enema
Stimulant - increase motility e.g. senna, docusate
Osmotic - retain fluid in bowel - e.g. lactulose / movicol
Which toxin can -> HUS
Shiga toxin
[HUS is normally caused post E.Coli 157]
Name 3 Xray signs of small bowel obstruction
Central multiple bowel loops no gas in the large bowel Presence of ladders [lines across bowel loops] Large bowel spared
3 Xray signs of large bowel obstruction
1 big loop
peripherally
presence of haustrations
small bowel spared
What is drip and suck?
NG tube to stop vomiting [suck]
NBM
IV fluids [drip]
[this is conservative Mx for small bowel obstruction]
Blood pressure post AAA rupture aim
> 70 but not much more
What is boars sign?
pain under right scapular in cholecystitis
What do you have to check before using immunologic therapy for IBD
Tb as can cause latent -> active
[after immune supression ]
