GIT Flashcards
appendicitis
RF younger
Sx anorexia, fever, rif pain
OE rosvig pos, psoas and obturator, mcburny point tenderness.
Ix: USS,
Dx: clinica/imaging
Rx: OT.
ascending cholangitis - biliary tree bact infection secondary to statis of some form.
RF: >50, stones, primary/secondary cclorosing cholangitis, stricture of biliary tree. injury to bile duct (OT)
** Sx/OE: fever, ruq pain, jaundice.
Ix inflam markers, elevated bili/GGT/ALP; uSS/CT to identify cause of obstruction
Dx Sx and evidenc einflam (imaging/bloods)
Rx urgent OT, ERCP. amp/gent/met
cholecystitis
RF aging, FHx same, obesity, sudden weight changes, DM , pregnancy, ocp.
Sx severe RUQ pain, radiatse to back/shoudler, n/v/fever. often w colic sx
** OE (differentiates from colic), local peritonism. murphy pos. fever
Ix: USS, CBD > 6mm wall.. ECG/amylase.CXR for ddx, LFT but non specific.
Dx uss
Rx admit, lap chole, abx.
diveritculitis
RF age, smoking, obesity, low fibre diet
Sx LLQ pain, change in bowel habit, previous hx of same, n/v/fever/pr bleeding
OE usually LLQ tender, clinical sx cosntipation
Ix CT A/P w contrast
Dx CT/hx.
Rx :
- mild: tol PO intake and no comrobidity: bowel rest, simple anagliesa, low fibre diet 2-3 days.
- > 48 hours ongoing/worsenning/red sided Sx or immunosup: Aug DF BD 5 days, if severe then hospital iv gent/met/amp.
food intol: non immune mediated. ?sensitised nerve fibres.
RF: BS, hedaches…
Sx: any age, hours - days. variable reaction.
- bowel irritation, headaches, fatigue, mouth ulcers, sinus cnogestion, hives/swelling, sometimes eczema/rash
- often dose dependent…
- commonly: MSG, food additives, cereals, dairy.
Ix: elimination diet. no specific testing required.
Dx: clinical
Rx: dietary modification.
DDx oral allergy syndrome (raw fruit/veg w perioral sx/rhinitis), coeliac, tick bite (mammalian meat allergy), exercise induced food dept. allergy.
food alergy : igE mediated
RF IBS
Sx: childhood onset. allergenic reaction immediately (mins - hours), reproducible.
- rash aroudn mouth, urticaria, angioedema, vomitting, sob, anaphlyxais (varies on scale)
- commonly eggs milk peanut tree nut sesame crustaceans, wheat. soy.
Ix: skin prict tests, IgE specific allergenic test (RAST)
Dx: hx/ix.
Rx
- complete avoidance.
- non treanut/seafood allery improve w age.
- anaphylaxis managment plan.
- loratiadine vs. nocte doxylamine.
- consider referral for desensitisation.
DDx coleaic, tick bite (mammalian meat allergy), exercise induced food dept. allergy.
food allergy: non Ige mediated/mixed food allergy
coeliac
eosinophillic oesophagitis
FPIES. (food protein induced enterocollitis syndrome)
- cows milk, fish, chikcen, rice) - recurrent vomitting 1-4 hours after eating.
intersusseption
- invagination of bowel onto itself
- sequalae BO, congestion of mesenteric vessels, ischaemia of bowel wall.
RF: 2 months - 2 yeras. recent intussusception, meckels diveritumul, HSP, lymphoma, recent rotavirus vaccine, recent bowel surgeyr,.
Sx: intermittent abdo pain/distress (increases 12-24 hours), well between episodes. palpable abdo mass. red current jelly stools.
OE: sausage shaped mass in R abdomen. shock, peritonitis if per, distended if obstructed.
Ix: USS, can do AXR is BO/perf. but not diagnostic.
Dx: USS/clasically sx/age
Rx: analgesia, fluid bolus, NGT if BO, IV amox/gent/met, Surg review w NBM (can self reduce)
DDx
ischaemic colitis
- chronic ischaemic ischaemia = low flow to artery in mesentry, mild to gangrenous colitis/acute.
RF: vasc RF. AF. age.
Sx: severe abdo pain, bloody diarrhoea, unwell. shock. RLQ usually.
OE: degree of illness out of proprtion to clinical signs.
Ix CT, colonoscopy /biopsy gold standard.
Dx colonoscopy urgent.
IBD extraarticualr
Ank Spond
uveitis
pyoderma gangrenosum
erythema nodosum
apthous ulcers
primary sclerosis cholangitis
vte
coelaic
Ix
- TTG, IgA level . +/- EMA
anti gliadin antibody is less specific.
Mx:
- scope to confirm + repeat at 12 months post diagnosis
- bloods repeat at 6-12 months post GF diet to see if resolved.
- monitor b12/folate/TSH/vit D + BMD consideration.
- screen family members
- consider PTH/zinc.
- DT
watch for lymphoma. adenocarcinoma. IBD, primary billiary cirrhosis, dermatitis herpetiformus.
join coeliac society.
IBS Dx/OE
cause not clear - visceral hypersensitivity/diet/gut micro/stress.
Ddx: functional; bact.overgrowth (if bloating/flat main issue)
Dx: abdo pain/discomfort > 3 / month, for 3 months, w > 2:
1) improvement w defecation
2) onset of Sx associated w change in bowel frequency
3) onset of Sx associated w change in stool appearance.
OE: not much to find - rule out ddx: coeliac (EMA/antiTTG)/ibd (calprotectin)/pancreatic insuf (fecal elastase)
- often associated: migraines, dysmenorrhoea, FM, anxiety/dept/reflux/urinary frequ
no specific Ix for Dx.
IBS Mx
Mx:
- non pharma:
- reassure no long term sequalae, explain aeitology
- often food intolerance related: exclusion diet, gradual reintroduce once found trigger. (DT)
- stop smoking
- weight reduction
- optimise diet
- reduce gums/fizzy drinks
- reduce etOH
- regular meals/sleephygiene
if diarrhoea PRN loperamide
if constipatino gentle fibre - metamucila good option, avoid bran.
if abdo pain; buscopan.
+/- SSRI.
Crohns (IBD)
PC: 20s usually.
mouth to anus, skip lesions. get fistulas/perianal disease.
Sx: abdo pain, diarrhoea, weight loss, mailaise, anorexia, obstructive/fistla/blood diarrhoea. nutritional def.
NOCTURNAL BO = IBD.
clue for Dx: pos faecal calprotectin. (elevated CRP, low labumin, iron def anaemia)
Dx : scopes
IBD Mx
RF for poor outcome:
- > 5kg weight loss, unable to manage ADLs, steroids at first presentation, not eating, longterm reliance on opioids for pain.
Mx:
- no cure, goal to treat active disease/improve wellbeing/maintain steroid free remission/prevent complications.
1) sulfasalazine, c/sterods for flare; with GE
metro for fistula flares.
2) regular review for sx severity/condition review
3) annual colonoscopic surveillance if high risk; otherwise 3-5 yearly.
4) DEXA
5) monitor bloods
6) PCV, HPV/HBV. avoid live if immunosuppressed.
7) 1-3 yearly CST if on immunomodulators.
8) quit smoking
9)psychological impact.
UC
PC: large intestine/retrograde from rectum. continuous.
commonly bloody diarrhoea.
- watch for toxic megacolon complication
Mx: as above, also consider surgical removal of large intestine if severe/refractory.
localised enemas w mesalazine/PR steroid etc. THEn PO
IBD e/articular Sx
- large joint arthorpathy
- ank spond
uveitis
iritis
episcelritis
conjunctivitis
pyoderma gangrenosum (ulcer)
erthema nodosum (painful)
apthous ulcers
primary sclerosing cholangitis
VTE
gallstones
lactase def
frothy, watery, explosive diarrhoea - soon after ingestion of lactose.
most commonly associated w acute GI post infection / loss of enzyme, can go on for 1-2 weeks.
- ddx: zollinger eliison syndrome/sensory loss w Dm arthroapthy, progressive diasabiltiy w CF, whipples, tropical sprue, HIV enetropathy, coealiac spru.
barrets
relative risk increased for adenocarinoma oesphagus
absolute risk < 2% life time risk.
RF: central obesity, smoking, fhx cancer, sex,a ge, hx GORD.
Dx: endsocopy - metaplasia from squamous to columnar
Mx:
endoscopy screening program. modify RF w lifestyle changes.
consider PPI - wont regress but helps symptomatically.
PPI SFX
long term:
micronutrient def - b12/folate
OP
infections such as GE
hypomagnesemia
alopecia
photosesitivity
impaired LFTs
EoE
same as GORD; but intermittent bolus obstructions.
specific food trigger often.
RF male > female, atopic hx
Dx: endoscopic appearans/histo findings. peristent gastric eosinophillia after PPI trial (GORD will improve)
if severe: risk boerhaave syndrome.
Mx:
NON PHARMA
-dietary exclusion - consider allergy patch testing
-6 food elimination: milkd, wheat, egg, soy, nuts then reintroduce.
PHARMA
-topical fluticasone (swallow MDI rather than inhale, 2 puffs BD)
-SFX: candidiasis.
final: dilatataion
GORD red flags
red flags
- dyaphagia, odonyphagia
- haematemeis
- weight loss
- > 55
- iron def +/- anaemia
- nocturnal abdo pain
- persistent
- FHx?Phx barrets/GI maliganncy
- new or changing Sx, particularly in older person
- inadequate reponse to PPI.
GORD Ix + HPylori
only Ix if red flags/Sx refractory to Rx/diagnosis unclear.
1) endoscopy, 2/4 patients will have negative endoscopye.
2) consider HPylori - post Rx confirm if negative at 6 weeks.
- do for all < 55 yo. or if any RF: (lower SES, migrant/refugee, fhx PUD/gastric cancer)
Dx otherwise based on therapeutic trial of PPI 2weeks.
- if no red flags, and improved w PPI, then reduce to prn
GORD Mx
Non pharma
- raise bed head, weight loss, smoking cessation, small/regular meals,. avoid acidic foods/hot drinks, avoid lying down after eating, fluid in between meals not prior, eat > 3 hours until bed.
Pharma
- cease nsaids/bisphosphonates, avoid drugs relaxing LOS: ccb/nitrates/cholinergics
- Rx Hpylori (calrithro/amoxyl/ppi), if pos (2 weeks better)
- PRN gastrogel 10-20mL/ H2 receptor antag ranitidine 150mg,
+ PPI 20 –> if insuff 20 BD –> 40 BD if ongoing but refer at this point.
- trial PPI for 4-8 weeks; then down titrate slowly then PRN only.
alcoholic liver disease
stages:
1) alcoholic fatty liver- worry when AST/ALT > 1.5
2) alcoholic hepatitis - AST usually 3 x the ALT. /rapidly progressive sx inc. RUQ pain/jaundice/fever/neutrophillia
3) alcoholic liver cirrhosis.
OE:
plethroic face
thickenend greasy skin
macroglosia
telangiectasia
suffused conjunctivae
rosacea
parotid swelling
chleitis
Ix: bloods inc. caeroplasmins/viral heaptitis, cmv for alt cause.
USS +/- fibroscan
Mx:
stop etOH, prevent progression.
MDT: DT, GE, psychiatrists/psychologist
manage withdrawl: thiamine repacement/bzd.
stop smoking/manage obesity which is often associated
vaccinate Hep B + A, and PCV/influenza.
CLD causes
etOH
fatty liver
autoimmune
chronic viral
primary biliary cirrhosis
haemachromatosis
drugs
cryptogenic (no cause)
OE:
alcoholic faceies
spider naevia, caput medusae
gynaecomastia
splenomegaly (portal HTN)
ascites
hepatomegaly (vs. small and nodular)
bruising, peripheral oedema/neuorpathy
atrophied testes/spare pubic hair.
NASH
cause: insulin resistance, etOH, obesity.
+/- AN, rapid weight loss, lipodystrophy, drugs inc. oestrogens. c/steroid/mtx.
increases risk DM/metabolic syndrome/cvasc disease + some cancers, can cause cirrhosis –> HCC.
spectrum
1) simple steatosis.
2) steatohepatitis (NASH)
3) cirrhosis
more likely to have cirrhosis if:
AST/ALT > 1, ALT raised, old, serum albumin + platelets low, obesity, hyperglycaemia, DM, metabolic syndrome.
uss
consider fibroscan.
and use NAFL fibrosis score.
Mx: if LFTs OK and no evidence cirrhosis/portal HTN on uss –> 6 month aggresively lifestyl changes and if LFTs still off –> GE.
metabolic syndrome
fasting TIG > 1.7 or on statin
fasting HDL <1
BP > 130/85 or on Rx
FBG: > 5.6mmol/L + T2DM
aim remember: male wcc < 94, female < 80.
haematchromatosis
HFE gene testing.
- only C282Y homozygotes + sometimes heterozygotes, get clinically significantly overloaded
worry re: fibrosis, cirrhosis, hcc, cardiac arrithmia, cardiomyopathy, DM , arthropathy, skin hyperpigmentation w overload.
if venesection dependent: 500mL 1-2 weekly, red cross lifeblood = free.
aim for ferritin 50-100.
screen family if homozycgote C282Y.
Hep B
- HBsAg pos = acute + anti HBc IgM
- HBsAg pos = chronic + anti HBc IgG
- HbSAg neg, antiHBc IgG pos + anti HBs pos = resolved infection
- only anti HBs pos = vaccinated
Rx
- most people clear + becomes HBsAg negative within 6 months - if still positive then chronic hep B (95% of people)
- if fulminant hepatitis/liver failure + ongoing at 6 months = Rx.
- Rx w specialist/prescriber for entecavir. : check HbV DNA 4-6 monthly, then 6 monthly.
if not being treated but chronic hep B: LFT 6 monthly + HBV DNA annually
Hep C
RF: prison, IVDU, sexual partner w HCV, HIV, MSM, child w mum w HCV, liver disease, birth in high prevalent area. blood transusion prior 1990. tatoo/piercings
HCV antibody positive; then go and do PCR , dont need genotype now (as non pbs criteria) but if treatment resitent then do it.
Rx
- need to be a registered prescriber.
- exclude cirrhosis with biopsy/fibroscan + AST/platelet ratio.
- consider coinfection w HIV/HBV
- review meds for interactions (LFT related)
- exclude pregnancy
–> first line: direct acting antiviral drugs. 8-12 weeks.
failure : treatment non adherence, reinfection, virological failure (rare) –> specialist.
hepatitis Rx - GP role
GP role if not prescriber
- monitoring adherence
- social support
- drug SFx monitoring
- level of RNA monitoring
hep c sequalae/long term monitoring
sequalae: 2-5% annual risk of HCC.
- if cirrhosis: need 6 monthly uss + AFP
- if abnormal LFT: exclude alt causes / specialist re-refer.
- if no CLD, no cirrhosis: no long term f/u required.
- if RF for reinfection: repeat HCV RNA yearly after new exposures.
abstain from etOH if possible
- 4 s.d/day = increased risk of rapidly progressive liver diasese.
- ensure vaccines for HBV + HAV + PCV up to date
HCV transmission info
- blood/blood contact.
- not to donate blood
- not to share toothpaste/razor
- mother to baby transmission is low - but possible.
- avoid BF with cracked/bleeding nipples.
- sexual transmission is low amongst monogamous heterosexual partners (0.5%/year) = but possible
- needle exchange program
autoimmune hepatitis
10-40 yo female
fatigue/anorexia/jaundice.
ddx alcoholic hepatitis, viral heptatitis. NAFLD
pos ANA
sm Abdy
antiLKM1
igG high
Dx: biopsy
Rx: pred, azathioprine.
3-5 yearly mortality if not Rx
cirrhosis clinical signs/monitring
Sx: anorexia, nausea, vomitting, peripheral oedema, bloating/distension, bleeding tendency, drowsiness, ecephalopathy
OE:
look for alcoholic facies
spider naevi
palmar erythema
peripheral oedema/ascietes
jaundice
hepatosplenomegaly. if not small/fibrotic liver
ascites
gynaecomastia
monitorign: 6/12 uss + AFP/LFTs + regular scopes for varices assessment.
hcc risk 2-5%/year.
complications cirrhosis
sbp
encephalopathy
heptaorenal syndrome
hypernatremia
portal HTN w varices
portal vein thrombosis
renal failure
often associated w OP, vit D def, malnutrition.
primary billiary cirrhosis
uncommon cause of CLD
women, 30-60.
Dx: obstructive pattern of liver biochem AMA pos (antimit abdy).
Rx: specialist
complications: fat solubile vit def, hypercholesterolaemia, BMD.
wilsons disease
genetic
copper excess
5-35yo usually
–> cirrhosis w copper accumulation
+ presents w kayser fleischer rings.
Dx: usually via corneal findings
+ caeruplasmin low.
+ high 24 hour urinary copper excretion
Rx: specialist.
haemorrhoids
mx:
- adequate fibre intake
- hydration
- avoid straining
- respond to urge to defect + try not to initiatie defecation without urge
- sitz baths for comfort
- procetosedyl: hydrocort/ciclocaine for short term use - SFX; candidaisis, localsied SFX w dermatitis.
if bleeding: surg. / unable to reduce,
or if large thrombosed external: no Rx required - should spontneously rupture + pain settled at 102 weeks. if severe –> surg.
proctalgia fugax
short attacks of sharp stabbling pain near anal area. wakes pt from sleep. painless when not having episode
no clear cause
Rx: reassurance, explanation - ?muscular spasm: local warmth, ingestion of food, firm pressure to perineum. if severe: specialist - anecdotal evidence salb/gtn/ccb
bowel cancer prevention
- identify risk per Red book/cancer network guidliens - # 1’ and 2’ realtives
- prevention
- adopt healthy lifestyle
- regular exercise
- diet low in fat, high in veggies
- high in fibre
- avoid smoking
- avoid excessive alcohol
- individual specific CRC screening
- consider low dose aspirin if high risk bewteen 50-50 for 2.5 years.
- early recognition of sx
Iron def sx
- reduced aeorbic work performance
- dev delay
- adverse pregnancy outcome
- ipaired immune function
- glossitis
- pica
- angular chelitis
b12 def
Sx
- peripheral neuropathy
- spinal cord dmage
- otic atrophy
- dementia
- angular chelitis
- glossitis
- Rx: IMI alternative days for 2 weeks; then 3 monthly (or if less severe just 3 monthly) , usually life long requierd
- ensure IF negative (pernicious anaemia). /cause identified.
pyloric stenosis (child)
2-6 week chronological age.
progressive non billious vomitting. often projectiled + soon after feeds. can also be blood stained
see visible gastric peristalsis + pyloric mass in RUQ (olive)
Rx: ED. concern re hypocholareamic hypokalaemic me alkalosis. Surg review
carcinoid syndrome
wheezing, flushing, diarrhoea.
cause mostly liver mets from pancreatic/gut tumours
excessiev serotonin/histmine
Mx: oncology/pal acre
hirschprungs
first yaer of life
vomitting, abdo distension, enterocolitis.
RF: trismy 21.
= colonic functional obstruction w assocated absence of ganglion cells.
Sx: vomitting, explosive passage of liquid/foul stools + abdo distension
usually clue: delaeyd mec.
Dx: AXR. –> ED.
albendazole
- use for tapeworm (dog/fox)
+ heliminth infection/strongyloides. (instead of ivermectin).
+ cutaneous larva migrans.
