GI Treatment Pathways Flashcards
What is the maintenance therapy for Crohn’s disease?
Azathioprine or methotrexate (immunosuppression).
What is used to treat an exacerbation of Crohn’s disease?
Steriods (high dose then taper off). If severe IV and if mild-moderate oral.
When would you give anti-TNF (infliximab, adalimumab) in Crohn’s disease?
To induce remission and as maintenance in refractory disease.
What is the maintenance treatment for UC?
5ASA e.g. mesasalazine (topical).
What are the side effects of 5ASAs?
Diarrhoea, idiosyncratic nephritis.
What is used to treat an exacerbation of UC?
Steroids (high dose then taper off).
What is the purpose of azathioprine or methotrexate in UC?
Steroid sparing.
When would you use anti-TNF in UC?
If intolerant of immunomodulation or developing symptoms despite immunomodulation.
When is surgery indicated in UC?
If medically unresponsive, intolerable, dysplasia/malignancy, growth retardation in children, attempted resolution of extra-intestinal disease.
What is the emergency surgery for UC?
Sub-total colectomy.
What are the 2 elective surgeries for UC?
Proctocolectomy with end ileostomy.
Proctocolectomy with ileorectal anastomosis.
When is surgery indicated in Crohn’s disease?
If stenosis causing obstruction, enterocutaneous fistula, intra-abdominal fistulas, abscesses, bleeding, free perforation.
How would you manage constipation in IBS?
Increase fibre intake but only soluble fibre, simple laxatives (not lactulose).
What tests should you carry out if IBS is expected?
FBC, ESR, CRP and coeliac serology.
How would you manage diarrhoea in IBS?
Avoid sorbitol, alcohol and caffeine. Reduce fibre intake. Loperamide.
How would you manage colic/bloating in IBS?
Antispasmodics e.g. mebeverine or hyoscine.
How would you manage psychological symptoms/visceral hypersensitivity in IBS?
Consider CBT and tricyclics e.g. amitryptiline.
What are the parts of the Glasgow criteria for assessing severity of acute pancreatitis?
PaO2 low, Age>55, Neutrophilia (WBC>15), calcium low, renal function (urea high), enzymes (LDH and AST high), albumin low, sugar high.
What are the 6 steps in the management of acute pancreatitis?
- Fluid resuscitation.
- Correct electrolytes.
- Careful fluid balance.
- Oxygen.
- Analgesia.
- Treat underlying cause e.g. gallstones.
What are the 2 surgeries used for chronic pancreatitis?
Pustow procedure - cut open pancreas and stick jejunum in. .
Frey procedure.
What are the 5 steps in liver failure management?
- Rest up to 3 months.
- Fluids, no alcohol.
- High protein diet with lots of calories.
- Sodium bicarbonate bath, colestyramine or ursodeoxycholic acid for itch.
- Observe for fulminant hepatic failure.
How would you treat the complications of liver failure?
Ascites - restrict fluid, low salt diet, weight daily, diuretics (spironolactone first).
Bleeding - IV vit K and platelets, FFP and blood as needed.
Infection - ceftriaxone.
Hypoglycaemia - IV glucose.
Encephalopathy - lactulose, maybe rifamixin (antibiotic).
How would you diagnose spontaneous bacterial peritonitis?
Do an ascitic tap in all ascites. Neutrophil count >250cells/mm3.
What is the treatment for spontaneous bacterial peritonitis?
Piperacillin and tazobactam, alba (albumin), terlipressin if vascular instability.
What would you do to manage variceal bleeding?
- Terlipressin IV.
- Broad spectrum antibiotics (piperacillin/tazobactam).
- Banding.
- If banding fails, insert Sengstaken-Blakemore tube.
When would you refer someone with dyspepsia for an upper GI endoscopy?
If dysphagia or over 55 with persistent symptoms or alarm signs.
What would you do with someone who has dyspepsia first?
Stop exacerbating factors and review in 4 weeks.
If no improvement after changing lifestyle, what would you do next in dyspepsia?
Test for H.pylori (urease breath test or faecal antigen test).
What would you do if the test for H.pylori was negative?
Prescribe a PPI or ranitidine and see them in 4 weeks.
What would you do if the test for H.pylori was positive?
Give PPI, amoxicillin (metronidazole if penicillin allergic) and clarithromycin for 1 week.
What would you do after H.pylori eradication therapy?
Wait 4 weeks, retest and if +ve try again.
What would you do if H.pylori test was positive after 2 lots of eradication therapy?
Refer to a specialist.
What is the initial GORD management?
- Lifestyle advice.
- Antacids to relieve symptoms.
- PPI.
What would you do if GORD was still symptomatic after initial treatment?
Add ranitidine.
What is SEPSIS 6?
B - blood cultures, septic screen, U&Es. U - urine output - monitor hourly. F - fluid resuscitation. A - antibiotics IV. L - lactate measurement. O - Oxygen to correct hypoxia.
