GI: Presentations Flashcards
What is the differential diagnosis for acute epigastric pain?
- acute pancreatitis
- gastritis/duodenitis
- peptic ulcer disease
- perforated peptic ulcer
- oesophagitis (GORD)
- ruptured AAA
- MI
- mesenteric ischaemia
- biliary disease
In a Pt with acute epigastric pain, which drugs should you particularly ask about?
Drugs that can induce peptic ulcer disease:
- NSAIDs
- steroids
- bisphosphonates
- salicylates
Drugs that can induce acute pancreatitis:
- sodium valproate
- steroids
- thiazides
- azathioprine
A Pt presents with haematemesis. What are the 4 most common causes? Suggest some rarer causes.
Most common:
- Oesophagitis/gastritis/duodenitis
- Bleeding peptic ulcer
- Oesophageal varices
- Mallory-Weiss tear
Rarer causes:
- Oesophageal cancer
- Gastric cancer
- Boerhaave’s syndrome
- Bleeding diathesis
- Trauma to oesophagus/stomach
- Vascular angiodysplasia in oesophagus/stomach
- Arterio-venous malformation
- Aorto-enteric fistula
What scoring system is used to determine severity of haematemesis?
ROCKALL SCORE: used to predict risk of rebleeding and mortality in Pts with upper GI haemorrhage, and as an indicator of severity to guide urgency of endoscopy.
Initial score (pre-endoscopy):
- age: 60-79yrs (1 point); >80 yrs (2 points)
- shock: HR >100bpm (1 point); systolic BP <100mmHg (2 points)
- comorbidities: heart failure, ischaemic disease, any major comorbidities (2 points); renal or liver failure, disseminated malignancy (3 points)
Final score (post-endoscopy):
- stigmata of recent haemorrhage: blood in upper GI tract, adherent clot, visible or spurting BV (2 points)
- diagnosis: mallory-weiss tear or no lesions identified (0 points); all other diagnoses (1 point); malignancy of upper GI tract (2 points)
In which 4 cases should a Pt presenting with haematemesis have an emergency OGD?
- suspicion of continuing upper GI bleeding
- suspicion of oesophageal varices as cause of bleeding
- initial Rockall score 3+
- Pt has aortic graft - suspect aorto-enteric fistula until proven otherwise
What investigation should be performed in a Pt presenting with haematemesis if OGD has failed to reveal source of bleeding?
angiography
How would you manage a Pt presenting ith ongoing haematemesis?
A-E assessment
- place 2 wide-bore cannulae and send bloods at same time
- fluid resuscitation, up to 2L normal saline
- activate major haemorrhage protocol:
- give O- RBCs and FFP in at least 2:1 ratio (via blood warmer)
- tranexamic acid (e.g. 1g bolus in non-traumatic bleeding)
- platelet concentrates to maintain levels >100 x 10^9
- repeat coagulation screens after every 4 units to determine need for other blood products, e.g. cryoprecipitate
A Pt presents with acute RUQ pain. What is the diffferential diagnosis?
Hepatobiliary system:
- BILIARY COLIC
- CHOLECYSTITIS
- ASCENDING CHOLANGITIS
- hepatitis
- cholangiocarcinoma
Other GI conditions:
- DUODENAL ULCER
- PANCREATITIS
- Small bowel obstruction
Non-GI conditions:
- Basal pneumonia
- pyelonephritis
- aortic dissection
- ruptured AAA