GI - Upper GI Bleed, Small Bowel Obstruction, Large Bowel Obstruction, Pseudo-obstruction, Diverticular Disease and Diverticulitis, Gastritis Flashcards by Alex Hanson

Upper GI bleed - where is the bleed from?

Oesophagus

Stomach

Duodenum

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Upper GI bleed - what defines an upper GI bleed from a lower GI bleed?

Defined as an UGIB if bleeding is from a source proximal to the LIGAMENT of TREITZ

Ligament of Treitz is a suspensory ligament of the duodenum, and marks the boundary between the upper and lower GI tract

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Upper GI bleed - what are some causes?

Oesophageal varices
Mallory-Weiss tear - tear of oesophageal mucous membrane
Ulcers or stomach or duodenum
Cancers of stomach or duodenum

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Upper GI bleed - what is the common presentation?

Haematemesis - ‘COFFEE GROUND’ vomit, caused by digested blood
Melaena - tar like, black, greasy, digested blood
Haemodynamic instability due to blood loss so:
hypotensive
tachycardic
other shock signs

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Upper GI bleed - what is the scoring system used on initial presentation, and what is taken into account?

Glasgow-Blatchford Score

Establishes risk of having upper GI bleed

Score>0 high risk of UGIB

Features taken into account:
Decreased Hb
INCREASED UREA
BP
HR
Melaena
Syncope

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Upper GI bleed - why does urea increase?

Blood in GI tract broken down by acid and digestive enzymes, and one of the breakdown products is urea, which is then absorbed in the intestines

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Upper GI bleed - what is the rockall scoring?

Comprised of both a pre and post endoscopy score - added together for overall value

Pre-endoscopy score:
Age 0-2
Shock 0-2
Co-morbidity 0-3

Comprised of two sections:

Post endoscopy score:
Section1,
Diagnosis 0-2
Bleeding 0-2

Section 2,
A - Age
B - BP
C - Comorbidity
D - Diagnosis
E - Endoscopic Findings

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Upper GI bleed - what is the main diagnostic and therapeutic investigation?

Upper GI endoscopy

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Upper GI bleed - what are the other bedside, bloods, and imaging you can do?

Bedside:
Obs
ECG
Monitor urine output

Bloods:
FBC
U&E
LFTs
VBG/ABG
Group and save with cross match

Imaging:
Chest X-ray - look for oesophageal perforation, aspiration, free air under diaphragm

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Upper GI bleed - what do ‘group and save’ and ‘crossmatch’ mean?

Group and save - lab checks patient blood group, keeps sample in case need to match blood to it

Crossmatch - lab finds blood, tests it is compatible, kept in fridge to be used if necessary

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Upper GI bleed - what is the management?

ABATED

A - ABCDE resuscitation

B - Bloods (FBC for Hb, U&E for urea)

A - Access, cannulas

T - Transfuse

E - Endoscopy

D - Drugs (stop anticoagulants and NSAIDs)

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Small Bowel Obstruction - what is it?

The passage of food, fluids and gas through small intestines becomes blocked

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Small Bowel Obstruction - what are the causes?

Adhesions - following surgery (most common cause)

Hernias

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Small Bowel Obstruction -what are the clinical features?

Diffuse, central abdo pain, can be colicky

N+V - typically bilious vomiting

Constipation

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Small Bowel Obstruction - what are the findings on examination?

‘Tinkling’ bowel sounds

Abdo distension

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Small Bowel Obstruction - what are the investigations to do?

Abdo XRAY - generally 1st line

CT - definitive investigation, more sensitive

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Small Bowel Obstruction - what do you see on abdo XRAY?

Distended small bowel loops with fluid levels

Dilated if small bowel > 3cm in diameter

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Small Bowel Obstruction - what is the management?

Initially:

NBM
IV fluids
NG tube with free drainage

Some patients settle with conservative management, but otherwise will require surgery

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Large Bowel Obstruction - what is it?

The passage of food, fluids and gas, through large intestines become blocked

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Large Bowel Obstruction - what are the causes?

Tumour - colon carcinoma

Volvulus

Diverticular disease

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Large Bowel Obstruction - what are the clinical features?

Abdo pain, colicky

Absence of flatus or stools

N+V

Large Bowel Obstruction - what are the investigations?

Abdo XRAY - usually 1st line

CT - high sensitivity and specificity

Large Bowel Obstruction - what do you see on an abdo XRAY, and what are the diagnostic diameter parameters?

Dilatation:
- Caecum 10-12cm
- Ascending colon 8cm
- Recto-sigmoid 6.5cm

Diameters greater than these is diagnostic for obstruction

Presence of free intra-peritoneal gas indicates colonic perforation

Large Bowel Obstruction - what is the initial management and perforation management?

Initial steps:

NBM
IV fluids
NG tube with free drainage
if cause does not require surgery, trial conservative Rx for 72 hours, if no resolution, further management required

If perforation suspected:
Emergency surgery
IV antibiotics

SBO and LBO - which occurs first in which obstruction: Vomiting? Constipation

Vomiting - occurs earlier in small bowel obstruction Constipation - occurs earlier in large bowel obstruction

Pseudo-obstruction - what is it?

Condition where intestinal dilatation and symptoms resemble an obstruction, but on examination there is no obstruction

Pseudo-obstruction - what is the pathophysiology behind it?

Mechanism unknown, but thought to be due to an interruption of the autonomic nerve supply to the colon, resulting in absence of smooth muscle action in bowel wall

Pseudo-obstruction - what are some causes?

Electrolyte imbalance - hypercalcaemia Meds - opioids, CCBs, anti-depressants Recent surgery Neurological disease - Hirschsprung's disease, Parkinson's, MS

Pseudo-obstruction - what are the clinical features?

Most patient's present with the clinical features of SBO and LBO: Abdo pain Abdo distension Constipation N+V - later feature

Pseudo-obstruction - what are the investigations?

Bloods: U&Es - check for electrolyte disturbances Abdo XRAY Abdo CT with contrast

Pseudo-obstruction - what is the management?

- NBM - IV fluids - NG tube inserted to aid decompression - If not resolved in 24-48h, then endoscopic decompression Surgery

Diverticular Disease - what is a diverticulum?

Outpouching of gut wall

Diverticular Disease - where is the usual site of diverticula?

Usual site is between the taenia coli, where vessels pierce the muscle to supply the mucosa

Diverticular Disease - what is diverticulosis?

Diverticulosis is just the presence of diverticula

Diverticular Disease - when would you use 'Diverticular Disease', instead of diverticulosis?

Diverticular disease is reserved for when patients with diverticula become symptomatic

Diverticular Disease - what is Diverticulitis?

Is when one or a few of the diverticula become infected and inflamed

Diverticular Disease - what part of the large intestine are diverticula most common?

Sigmoid colon

Diverticular Disease - what are symptoms for diverticular disease?

Abdo pain Altered bowel habit Bleeding

Diverticular Disease - how is it diagnosed?

Commonly diagnosed as an incidental finding Barium enema

Diverticular Disease - what is the main cause?

Low-fibre western diet, which leads to high intraluminal pressure that forces mucosa to herniate through muscle layers of the gut

Diverticular Disease - what is the treatment?

Increase dietary fibre intake Antispasmodics - Mebeverine

Diverticulitis - what are the risk factors?

Age Lack of dietary fibre Obesity Smoking NSAID use

Diverticulitis - what are the symptoms?

Acute diverticulitis typically presents: - LIF severe pain - N+V - change in bowel habit, constipation (50%), diarrhoea (25%) - Urinary frequency, urgency, dysuria, due to irritation of the bladder by the inflamed bowel

Diverticulitis - what are the signs?

Tender LIF Pyrexia Tachycardia

Diverticulitis - what investigations can you do?

FBC - raised WCC CRP - raised Chest XRAY - may show pneumoperitoneum in cases of perforation Abdo XRAY CT

Diverticulitis - what is the management?

Mild cases: - Oral antibiotics - Liquid diet - Analgesia If symptoms don't settle within 72 hours, admit for IV antibiotics

Diverticulitis - what are the complications?

Perforation and development of abscess Perforation and development of faecal peritonitis Development of fistula

Gastritis - what is it?

It is inflammation of the gastric mucosa (lining of the stomach)

Gastritis - what are the causes?

MOST COMMON - H. Pylori NSAIDs Alcohol Autoimmune gastritis

Gastritis - what are the symptoms?

Most people with gastritis are asymptomatic If symptoms are present: - Indigestion - Epigastric pain - N+V - Bloating - LoA

Gastritis - what are the investigations?

Usually incidental finding at endoscopy (where a biopsy is taken) Breath test for H.Pylori Barium swallow

Gastritis - what is the management?

Lifestyle: - Smaller meals - Avoid irritant foods - Avoid alcohol - Smoking cessation Meds: 1. Antacids 2. H2 blocker, Ranitidine 3. PPI 4. Bismuth subcitrate - use it in combintion with antibiotics + PPI for H. Pylori infections

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GI - Upper GI Bleed, Small Bowel Obstruction, Large Bowel Obstruction, Pseudo-obstruction, Diverticular Disease and Diverticulitis, Gastritis Flashcards

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