GI - Upper GI Bleed, Small Bowel Obstruction, Large Bowel Obstruction, Pseudo-obstruction, Diverticular Disease and Diverticulitis, Gastritis Flashcards
Upper GI bleed - where is the bleed from?
Oesophagus
Stomach
Duodenum
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
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
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
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
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
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
Upper GI bleed - what is the main diagnostic and therapeutic investigation?
Upper GI endoscopy
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
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
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)
Small Bowel Obstruction - what is it?
The passage of food, fluids and gas through small intestines becomes blocked
Small Bowel Obstruction - what are the causes?
Adhesions - following surgery (most common cause)
Hernias
Small Bowel Obstruction -what are the clinical features?
Diffuse, central abdo pain, can be colicky
N+V - typically bilious vomiting
Constipation
Small Bowel Obstruction - what are the findings on examination?
‘Tinkling’ bowel sounds
Abdo distension
Small Bowel Obstruction - what are the investigations to do?
Abdo XRAY - generally 1st line
CT - definitive investigation, more sensitive
Small Bowel Obstruction - what do you see on abdo XRAY?
Distended small bowel loops with fluid levels
Dilated if small bowel > 3cm in diameter
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
Large Bowel Obstruction - what is it?
The passage of food, fluids and gas, through large intestines become blocked
Large Bowel Obstruction - what are the causes?
Tumour - colon carcinoma
Volvulus
Diverticular disease
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:
- Antacids
- H2 blocker, Ranitidine
- PPI
- Bismuth subcitrate - use it in combintion with antibiotics + PPI for H. Pylori infections
