GI Flashcards
1
Q
Constipation evaluation and management
A
Hx
- PC
- > onset/duration/frequency
- > bristol stool chart
- > blood in stool/on paper
- > mucus in stool
- > precipitating event/with-holding behaviour
- > soiling/urinary incontinence
- Red flags
- > ribbon like stools = ano-rectal malformation
- > under 6 months
- > not passing meconium
- > persistent vomiting
- Past hx
- > feeding hx (excessive cow milk/low fibre/picky eating)
- > ASD/ADHD
- Family hx
- > coeliac
- > hypothyroid
- > diabetes
- Medications
- > opioids
- Development
- > any issues
- > poor growth is red flag
- Social
- > relation to school/toilet training
- > barriers to toileting
Exam
- Plot growth
- Neuro
- > gait
- Abdo
- > faecal mass (usually LIF)
- Spine
- > occult dysraphism
- Anal area
- > fissures
- > abnormalities
- No need for internal exam
Management
- Overal
- > may take weeks to months (dilated bowel)
- > advise parents prolonged medications safe (compliance)
- > goal is 1 soft/easy to pass stool per day
- Behavioural modification
- > foot stool/elbows forward/toilet seat
- > 5 min toilet sits TDS post meal
- > stool chart with reinforcements
- > ensure toileting is positive experience
- Dietary modification
- > avoid excessive cows milk
- > increase fibre
- Pharm
- > ensure adequate hydration
- > infant <1 mnth = coloxyl drops
- > infant 1-12 mnths = movicol (iso-osmotic lax) or lactulose
- > children >12mnths = movicol + paraffin oil
- Disimpaction for severe
- > outpatient = adult movicol sachets for 1 wk (RCH table)
- > inpatient = 1-3L glycoprep daily via NG for 1 wk
2
Q
Gastroenteritis evaluation and management
A
Hx
- PC
- > onset/duration/quantity of vomiting/diarrhoea
- > bilious vomiting
- > blood/mucus in stools
- > fever/cramps/abdo pain/tenesmus
- > treatment so far/hypotonic and hypertonic fluids
- Exposure
- > food and water
- > travel
- > medications
- > sick contacts (family/school/daycare)
- Consider alternative diagnosis
- > vomiting without diarrhoea
- > bilious vomiting
- > persistent diarrhoea 1 week
- > blood in stool
- > severe abdo pain/signs or very unwell
- Risk factors for severe
- > short gut syndrome
- > ileostomy
- > lung/heart disease
- > immunosuppressed
- > under 6 months old
- > repeat presentations
Exam
- Vitals
- > haemodynamicaly stable
- > febrile?
- Viral
- > abode soft/non tender
- > active bowel sounds
- Mild dehydration (3%)
- > thirst
- Moderate dehydration (5%)
- > lethargy
- > delayed cap refill
- > tachycardia/tachypnoea
- > sunken eyes
- > poor skin turgor/dry mucus membranes
- Severe dehydration (10%)
- > very delayed cap refill/mottled skin
- > signs of shock
- > kussmauls breathing
Investigations
- Stool MCS
- > diarrhoea not improving by 1 week
- > appear septic
- > recent travel
- > blood in stool
- > immunocompromised
- Electrolytes + glucose
- > severe dehydration/doughy skin (hypernatraemia)
- > home therapy with hyper/hypotonic fluids
- > risk factors for severe disease
Management
- Ondansetron
- > not recommended <6 months old
- Not dehydrated
- > discharge home with information + safety net
- > small frequent fluids
- > continue breastfeeding
- > hydralyte capsule/icepole
- > avoid hypertonic (lemonade) or hypotonic (plain water)
- Mild/moderate
- > trial of oral fluids = 10-20mL/kg of hydralyte via syringe over 1hr
- > ongoing vomiting/diarrhoea = rapid NGT hydralyte
- > continuing vomiting = slow NGT + ondansetron
- IV rehydration
- > severe dehydration/failed slow NGT/risk for severe
- > shocked = 10-20mL/kg boluses 0.9% saline
- > 10mL/kg/hr 0.9% saline + 5% glucose +- K for 4 hrs
- Monitor
- > VBG (electrolytes + acid/base)
- > bare weight/clinical status
3
Q
Intussusception evaluation and management
A
Hx
- PC
- > intermittent pain/distress worsening over 12-24hrs
- > may appear very well between episodes
- > recurrent jelly stools = bowel ischaemia/necrosis
- > vomiting (bilious = obstruction)
- > diarrhoea
- > pallor (particularly during episodes)
- > lethargy
- Risk factors
- > meckles
- > HSP
- > Peutz jegher syndrome
- > recent bowel surgery/rotavirus vaccination
Exam
- Vitals
- > hypovolaemic shock
- Abdo
- > assess for peritonism
- > sausage shaped mass from right abdo crossing midline
- > distension
- > inspect for anal source of bleed
Initial investigations
- Glucose
- VBG
- FBC
- Urea/creatinine
- Group and hold
Management
- Call for help
- Keep NBM
- IV access
- > analgesia
- > fluid boluses if shocked
- Suspected obstruction/peritonism
- > abdo xray
- > gastric decompression with NG
- > urgent surgery
- > IV amoxicillin + gentamicin + metronidazole
- No signs of obstruction/peritonism
- > ultrasound
- > contrast enema reduction
- Surgical reduction
- > suspected perforation or failed enema reduction
Imaging
- Abdo xray
- > 50% sensitive
- > empty distal bowel + obstruction
- > soft tissue mass in upper abdomen
- > crescent sign = mass surrounded by lucent bowel gas
- > pneumoperitoneum = perforation
- Ultrasound
- > high sensitivity/specificity
- > target sign
- Contrast enema
- > contraindicated when perforation suspected
- > gold standard for diagnosis (coiled spring appearance)
- > used for surgical planning/therapeutic effect
4
Q
Crohns evaluation and management
A
Hx
- PC
- > fatigue
- > weight loss
- > diarrhoea
- > abdo pain
- > GI bleeding
- Past hx
- > obstruction
- > gall stones
- > kidney stones
- Family
- > IBD
- > Ashkenazi jew
- Medications
- > recent antibiotic use
- Social
- > travel
- > sick contacts
Exam
- Vitals
- > may be febrile
- BMI
- > baseline
- Skin
- > erythema nodosum
- > pyoderma gangrenosum
- Eyes
- > episcleritis
- > uveitis
- Mouth
- > ulcers
- Abdo
- > RIF mass + tenderness
- Anal
- > skin tags
- > fistulae
- > abscesses
- DRE
- > occult blood
- > mass
Investigations
- FBC
- CMP
- ESR/CRP
- Iron
- Folate
- Stool MCS
- > ova
- > cysts
- > parasites
- > c diff toxin
- > culture
- Abdo xray
- > bowel distension
- Small bowel radiograph + oral contrast
- > string sing
- CT/MRI/ultrasound/PET
- > if radiograph equivocal
- Colonoscopy + upper endoscopy
- > cobblestoning
- > skip lesions
- > terminal ileum only/not rectum (suggestive)
- Biopsy
- > caseating granuloma
- CD vs UC
- > negative pANCA
- > positive sacchoromyces
- IBD vs IBS
- > faecal lactoferrin + calprotectin
Management
- Limited small bowel disease
- > prednisone oral for 2 months + taper
- > consider adding methotrexate + folate
- > inflixamab if severe or resistant
- Extensive small bowel disease
- > prednisone + methotrexate +- infliximab until remission
- > trial enteral feeding
- > consider strictureplasty +- resection
- Upper GI
- > worse prognosis
- > esomeprazole + prednisone + methotrexate + infliximab
- Fistula
- > fistulotomy or seton
- > metronidazole + ciprofloxacin oral
- Maintenance
- > taper and cease steroid
- > IM methotrexate weekly +- infliximab
- > cease smoking
- > loperamide (diarrhoea) + dicycloverine (spasm) PRN
5
Q
Ulcerative colitis evaluation and management
A
Hx
- PC
- > blood diarrhoea (determine number)
- > lower abdo pain
- > faecal urgency/incontinence
- > tenesmus
- > fever/fatigue/weight loss
- Family hx
- > IBD
- Social
- > travel
- > recent antibiotics
- > sick contacts
Exam
- Vital
- > fever
- > tachycardia
- Eyes
- > scleritis
- > uveitis
- Skin
- > pyoderma gangrenosum
- > erythema nodosum
- Abdo
- > tenderness
- DRE
- > bloody
Investigations
- FBC
- > anaemia
- LFTs
- > primary sclerosing cholangitis
- EUCs
- Albumin
- ESR/CRP
- Stools MCS
- > parasites
- > ova
- > cysts
- > c diff toxin
- UC vs CD
- > pANCA positive
- > saccharomyes negative
- Abdo xray
- > extent of disease
- Flexible sigmoidoscopy +- colonoscopy
- > mucosal granularity (wet sand paper)
- > polyps/pseudopolyps
- > normal ileum/backwash ileitis
- Biopsies
- > absence of caseating granulomas
Management
- Mild/moderate
- > mesalazine rectal/oral (distal/extensive) for 3-6 weeks
- > consider hydrocortisone rectal foam/oral prednisone
- > consider tacrolimus oral
- Severe
- > admit for inpatient care
- > maximise therapy
- > consider IV steroids +- infliximab
- > may require surgical resection + ileostomy
- Remission
- > taper steroids
- > may require ongoing daily rectal/oral mesalazine
6
Q
Coeliac evaluation and management
A
Hx
- PC
- > chronic diarrhoea
- Past
- > thyroid
- > diabetes
- Development
- > FTT
- > short stature
Exam
- Stomatitis
- Dermatitis herpetiformis
- > intensely itching
- > symmetrical distribution
- > vesicles may cluster
- > on normal or red skin
- > scalp/shoulders/buttocks/knees/elbows
Investigations
- FBC
- > microcytic anaemia
- Iron
- B12
- Folate
- Serology (ensure on gluten diet)
- > IgA-tissue transglutaminase
- > endomysial antibody
- Duodenal biopsy (if serology +ive)
- > Marsh classification
- > intraepithelial lymphocytes
- > villi:crypt decreased
- Endoscopy
- > scalloping of mucosal folds
- HLA testing
- > if not on gluten diet
- Not on gluten diet
- > challenge with 10g gluten per day
- > retest in 2 weeks to 2 months
Management
- Education
- Dietician
- > gluten free diet
- > risk of obesity (simple carbohydrates/trans fats)
- Vitamin supplementation
- > ergocalciferol (D2) 1000-2000units oral daily
- > calcium carbonate 1000-1500mg oral daily
- > ferrous sulfate 300 TDS oral if iron deficient
- Bone density
- > monitor yearly
