GIT/Hepatology Flashcards
What HLA is associated with coeliac disease?
HLA DQ2 HLA DQ8
What are two rashes associated with IBD?
Pyoderma gangrenosum (painful ulceration) Erythema nodosum (painful lumps)
What single symptom with ongoing diarrhoea is a key indicator of inflammatory bowel disease?
Waking to pass stools overnight
Which form of IBD is smoking protective against?
Smoking is protective against ulcerative colitis Smoking is a risk factor for Crohn’s and associated with more severe disease
Faecal calprotectin
- highly accurate at distinguishing between inflammatory bowel disease and irritable bowel syndrome - not medicare rebatable - FOBT is not useful in diagnosis of IBD - infectious diarrhoea can give a false positive calprotectin
What sinister diagnosis must be considered in patients with vomiting with bg of cancer?
Cerebral metastasis!
Which bowel disease is discolouration of teeth associated with?
Coeliac disease can cause loss of tooth enamel
Which bloods would you order in suspected Coeliac disease?
- transglutaminase-IgA (tTg-IgA) - deamidated gliadin peptide-IgG (DPG-IgG)
Management of 1 out 3 positive FOBT?
Refer for colonoscopy
What is the most common adverse effect of azathioprine?
Leucopenia, anaemia and thrombocytopenia - hepatitis occurs infrequently
How common in non-specific abdominal pain in children?
5-10% of primary school aged children - present with severe episodes of abdominal pain, child is well between episodes, usually no impact on oral intake or bowel habit
Clinical manifestation of coeliac
- malabsorption - abdominal symptoms - extra-intestinal symptoms: fatigue, rashes
What are some atypical presentations of coeliac disease?
- iron deficiency - infertility - osteoporosis - headaches - lethargy - transaminase elevation - dermatitis herpetiformis - other autoimmune conditions
What are the eligibility for weight loss surgery?
BMI >40 or >35 with obesity related co-morbidity
Management for patients at “moderate risk of bowel cancer”
- first degree relative diagnosed <55 or two first degree relatives - Q5yearly colonoscopy from 50-74 - Q2yearly FOBT from 40-49 - consider low dose aspirin 100-300mg daily for at least 2.5 years
How long should aspirin at minimum should aspirin be used to be prophylactic against bowel cancer?
For at least 2.5 years between 50-70
- can consider even in patients without a family history of colorectal cancer
- also may need to consider limiting processes meat consumption and limiting lean red meat to 455g per week
- FOBT every 2 years ffrom 50-74
Clinical presentation of acute mesenteric ischemia?
- acute onset abdominal pain
- nausea and vomiting
- associated with minimal abdominal signs
What vaccination is contraindicated in children with history of intussusception?
Rotavirus vaccination
What is the triad of ascending cholangitis?
Fever
RUQ tenderness
Jaundice
Spot diagnosis: painless jaundice + palpable gallbladder?
Malignant obstruction of common bile duct
“Courvoisier’s law”
50-70% of patients with periampullary cancer of the head of pancreas will have these findings
Causes of trismus?
- acute and chronic TMJ disorders
- oral infections
- surgery
- haematoma following dental injection
- tetanus
- acute dystonic reastion
- oral firbosis
- head and neck radiotherapy
Drugs use for inflammatory bowel disease
- steroids
- thiopurines (azathioprine, mercaptopurine)
- methotrexate
- ciclosporin
- TNF inhibitors (adalimumab, infliximab)
- anti-integrin antibodies (vedolizumab)
What pre screening must be done prior to starting immunomodulatory therapy for IBD?
- screening for TB and hep B as these are the most common reactivations seen from immunomodulation
- vaccination history + serology (live vaccines MMR, varicella, yellow fever, JE, BCH, rotavirus, typhoid, poilo) cannot be given to immunocompromised patients
- need to ensure influenza and pneumoboccal vaccinations are UTD
TNF inhibitors
- adalimumab, infliximab
- need to be reviewed clinically every 3-6 months to check efficacy and adverse effects (especially infection)
Azathioprine and mercaptopurine
- need baseline FBC, LFTs prior to starting
- check FBC every week for first 4 weeks and then every 2 weeks and again at 12 weeks and every 3 months while on therapy
- macrocytosis and lymphoenia are common side effects
- assess LFTS every 3 months
- need annual skin check
Methotrexate
- commonly causes abnormal LFTs, especially if diabetic, obese, CKD, viral hepatitis or ETOH
- hepatotoxicity correlates with total cumulative dose and manifests as fibrosis leading to cirrhosis
- FBC, UEC, LFT monthly for 6 months and then every 1-2 months
Ciclosporin initiation and monitoring
- FBC, EC, LFT, electrolytes, fasting lipis and BP at baseline
- monitor as per specialist
- annual skin check to detec early skin cancer is recommended
- routine blood concentration monitoring is not generally required
Ulcerative colitis
- chronic inflammatory condition confined to the mucosal layer of the colon
- inflammatory changes are continuous and extend from rectus toward to the caecum
- diagnosis is made by endoscopy and histology and in absence of infection
Initial therapy for active proctitis or distal colitis in UC?
Mesalazine rectal preparation
PLUS
5-aminosalicylate oral preparation
Note patients with isolated proctitis can be treated with suppositories alone if inflammation is limited to 20cm from anal verge
IF inaffective
- add rectal steroids: budesonide/hydrocort/prednisolone
Name four 5-aminosalicylate preperations used in UC
- sulfasalazine
- mesalazine
- balsalazide
- olsalazine
2 different doses, first for induction and second for maintenance
Management for unresponsive active proctitis or distal colitis with UC?
Prednisolone 40-50mg (children 1-2mg/kg) daily until clinical response and then taper over 6-8 weeks
First line management for mild to moderate extensive ulcerative colitis
Oral 5-aminosalicylate +/- prednisolone if no response
(sulfasalazine: 2-4g daily initiation and 1-2g maintenance)
(mesalazine: 2-4.8g daily initiation and 1-3g maintenance)
Treatment of moderate to severe chronically active or frequently relapsing
Thioprine (azathioprine, mercaptopurine)
OR
TNF inhibitor (infliximab, vedolizumab)
What is the definition of acute ulcerative colitis?
- in the presence of 6 or more blood stools/day plus at least one of the following
- Temp > 37.8
- HR >90
- HB <105
- ESR >30
** always need to exclude GIT infection i.e. Cdiff or CMV)
Rescue therapy in severe crohn’s flare
Hydrocortisone 100mg IV Q6H
Crohn’s disease
- can effect any part of the GI tract
- inflammation is often focal and trasmural
- smoking is a risk factor and marker for severity
What is the first line induction treatment for mild to moderate Crohn disease?
40-50mg of prednisolone daily until clinical response and taper over 6-8 weeks
Note - induction therapy for severe crohn’s is IV hydrocortisone 100mg Q6H
If this isn’t working need to escalate to thiopurines or methotrexate and then consider TNF inhibitor (mab)
What are the first line agents for Crohn’s maintenance/
- azathioprine
- mercaptopurine
Crohn’s considerations
- smoking: should cease smoking
- malabsorption: blie salt malabsorption, may require long term B12 supplementation
- dietary measures: malnutrition is common in Crohn’s, low fibre diet with flares may be useful, lactose intolerance can occur in patients with diffuse small intestine disease
- micronutrients at risk” zinc, iron, B12, calcium, magnesium, folic acid and vitamin D
Fertility, pregnancy and IBD
- recommended patients delay pregnancy until remission
- active disease at time of conception increases risk of persistent disease during pregnancy
- no evidence that drugs used in management if IBD affect fertility
- potential harm of steroid use in pregnancy is much less that that of untreated IBD
- 5-aminosalicylates are consider safe in pregnancy
- silfasalaze can cause oligospermia and reduce sperm motility
- methotrexate is contraindicated in pregnancy, need to wait 3 months before conception
- thiopurines are cat D however not associated with risk of congenital abnormality
- if immunomodulators are used shoudl not give the bub a live vaccine for the first 12 months of life
Does IBD predispose to oestopenia or osteoporisis?
YES!
Need to be screened and monitored for same
- aim for 1000-1300mg calcium daily
- advise general preventative measures: regular weight baring exercise, calcium, cease smoking and reduce excessive ETOH
- if starting systemic steroids measure BMD and given vitamin D + calcium supplements
What is the most common systemic complication of IBD?
Iron deficiency anaemia
- parenteral iron is preferred
Indications for gastroscopy in suspected GORD
Red flags:
- anaemia, dysphagia, odynophagia, haematemesis, melaena, vomiting, weight loss
- new symptoms in older person
- changing symptoms
- severe/frequent symptoms
- indaquate response to treatment
- diagnostic clarification
Non-pharmacological management of mild GORD
- weight loss
- eating smaller meals
- drink fluids mostly between meals rather than with meals
- avoid lying down after eating
- avoid eating dinner for 2-3 hours before bed or exercise
- elevate the head of the bed at night
- stop smoking!
First line medical management of mild GORD
- Antacid
- H2 receptor OR PPI
Standar PPI doses
- esomeprazole 20mg daily
- omeprazole 20mg daily
- pantoprazole 40mg dialy
- rabeprazole 20mg daily
What is defined as “frequent” GORD symptoms?
2 or more episodes a week
How long should initial treatment course of PPI go for?
4-8 weeks and if symptom control is adequate can step down to maintenance therapy
What is GORD maintenance therapy?
- aims to control symptoms and reduce complications from condition and treatment!
- down titrate to PPI to lowest dose and frequency at which symptoms are controlled
- stopping PPI can results in prolonged remission of symptoms in 30% of patients, however can possible cause rebound hypersecretion of acid
-
Potential risks of long and short term PPI use
- interstitial nephritis (short term use)
- hypomagnesaemia
- increased risk of pneumonia
- C diff and other GIT infections
- impaired nutrient absorption
- risk of fracture
Which anti-reflex rx is safe in pregnancy?
H2-receptor antagonists
GORD In children
- may present with vomiting and regurg
- common in infants and usually improves by 12 months
- signs: FTT, oesophatitis, stricture, refusing to feed, recurrent pneumonia, anaemia, dental erosinons, apnoea, apparent life threatening events
- GORD can be a symptom of allergy to cow milk protein, often irritable child with diarrhoea and can be difficult to feed
- change of formula to non-dairy may help
Suggested formula for ? GORD In infants
Changing the type of formula (eg dairy to soy, or soy to protein hydrolysate) may be helpful if allergy is suspected. A 2- to 4-week trial of an extensively hydrolysed formula (eg Alfaré, Pepti-Junior Gold) or elemental formula (eg Neocate, EleCare) may be appropriate; these are only available on prescription
Barrett’s oesophagus
- premalignant condition
- metaplastic epitherlium replaced the stratified squamous epitherlium that normally lines the oesophagus
- can be associated with strictures or oesophagitis
- significantly increased risk of adenocarcinoma (75%)
- should be under endoscopic surveillance
- PPI therapy is effective for sx of oesophagitis
- aspirin may be protective, studies are underway
Achalasia
- degeneration of ganglia of nerves innervating the oesophagus
- unclear cause
- cardinal features: lack of relaxation of the LOS, aperistalsis of oesophageal body
- causes dysphagia, regurgitation, chest discomfort/pain
- management: laparoscopic myotomy, balloon dilation, botox injection
- could trial nitrates and CCB in mild disease
Distal oesophageal spasm
- can cause dysphagia and regurgitation
- can also cause non cardiac chest pain
- always exclude cardiac cause
- may ebe precipitated or exacerbated by GORD
- ingestion of warm water at onset of attack may help
- rx: GTN may shorten attack
- if frequent and disabling can consider nifedipine or diltiazem
Oesophageal food bolus
- underlying causes: GORD, stricture, schatzki ring, esophagitis, spasm, cancer
- 25-50ml carbonated drink
- otherwise try a smooth muscle relaxant: GTN and or glucagon 1mg s/c or IV
- if these measure fail patient may require endoscopic retrieval of bolus
Management of oesophageal candidiasis
Nystatin 100 000 units/ml
1ml Q6H for 10-14 days
In which group of patients is viral oesophagitis seen?1
Generally severely immunocompromised patients
- present with dysphagia and odynophagia
- causes: HSV and CMV
What percentage of aussies have H pylori?
30%
Migraines, low SES, institutionalised and elderly patients have a higher prevalence
H pylori risks
- PUD 15-20%
- gastric cancer up to 2%
- associated risk with gastric MALT lymphoma (though uncommon)
H pylori and peptic ulcer disease
- most duodenal ulcers are due to HP
- 2/3 of gastric ulcers can be attributed to HP also
- NSAIDs are the most common cause of other ulcers
- rare causes = Zollinger-Ellison syndrome, Crohn disease and viruses
What is the most common presentation of PUD?
- epigastric pain or discomfort
- may be accompanied by associated nausea, vomiting and heart burn
- ulcer is more likely if there is a remitting and relapsing course with noctural waking with epigastric pain
Management of PUD
- If uncomplicated can be treated by HP eradiction alone
- if complicated or NSAID related will need to have ongoing PPI therapy for 8 weeks
Why should H pylori be excluded prior to empircal PPI?
Gastritis/PUD/GORD have a lot of overlap, difficult to tell based on clinical picture without endoscopy.
If not ruling out HP unable to eliminate the ongoing risks of PUD and gastric cancer
Also long term use of PPI in patients with HP accelerates the progression of adverse gastric mucosal changes.
Hence should always test and treat H pylori before starting long term PPI!
What is the “test and treat” strategy for dyspepsia?
- non invasive HP testing and eradication
What is the test of choice for H pylori diagnosis?
C13/14 urea breath test
- C13 is not radioactive and preferred for women of childbearing age
Serology has lots of false positive and false negatives
Need to ensure that antiboitics therapy should not be taken for at least 4 weeks and PPI should be withheld for 1 week (preferrably 2 weeks) prior to breath test
How is H pylori eradication confirmed?
Repeat U13/14 urea breath test at least 4 weeks AFTER therapy (again need to w/h PPI for at least 1 week)
What are the indications for H pylori eradication?
- PUD past or present
- dyspepsia
- selected NSAID users
- atrophic gasrtitis
- patients requiring long term PPI
- high risk of gastric cancer
- low grade gastric MALT lymphoma
What are the benefits of H pylori eradication?
- heals ulcer and reduces relapses
- may reduce symptoms and long term risk of PUD and cancer
- reducses risk of PUD and gastric bleeding
- reduces long term risk of gastric cancer
- reduces progression of intestinal metaplasia
What is first line management for H pylori eradication
- esomeprazole 20mg BD for 7 days
- amoxicillin 1g BD for 7 days
- clarithromycin 500mg BD for 7 days
Success rate of above is 85-90%
Most common cause for failure is HP resistance to clarithromycin
Adverse effects: taste disturbance, nausea and loose stools
What is the recommended H pylori eradication regimen for patients with allergy to penicilin?
- esomeprazole 20mg BD for 7 days
- metronidazole 400mg BD for 7 days
- clarithromycin 500mg BD for 7 days
Risk factors ofr NSAID GIT bleed or perforation
- older age
- history of upper GIT bleed
- history of PUD
- H pylori infection
- concomitant drugs (anticoagulants, antiplatatlelts, SSRIs, SNRIs and corticosteroids)
- significant comorbidity
- smoking
How many patients on NSAIDs have ulcers on endoscopy?
15-30%
Which NSAIDs carry the highest ulcer risk?
- NSAIDs with long hald lices r.e. piroxicam
Which NSAIDs are safest from an ulcer point of view?
- COX2 selective NSAID (celecoxib) reduce thr risk of ulcer disease
- however concomitant aspirin negates this effect!
-
Factors influencing management choices to minimise CVD and GIT risks of NSAID use
4 groups
- Low GIT risk, low CVD risk (non selective NSAID)
- high GIT risk, low CVD risk (COX2 or non selective + PPI)
TEST AND TREAT H PYLORI
- low GIT risk, high CVD risk on aspirin (non selective NSAID)
- high GIT risk, high CVD risk on aspirin (avoid OR non selective NSAID + PPI)
Management of bleeding peptic ulcer
- prompt endoscopy
- PPI infusion: pantoprazole 80mg IV over 15-30min, then 8mg/hour for up to 3 days (or 40mg pantop Q12H)
Which patients need prophylactic PPI to prevent stress ulcers?
- patients with > 30% TBSA burns
- severely ill patients with coagulopathy
- mechanical ventilation > 48 hrs
Autoimmune gastritis
- associated with autoantibodies to parietal cells and intrinsic factor
- causes glandular mucosal atrophy reducing secretion of acid and intrinsic factor
- reduction of acid leads to impaired iron absorption
- reduction of intrinsic factor reduces B12 absorption
- often asymptomatic, may develop pernicious anaemia as a result
Common anti-emetics and their actions/dosing
Multiple neural pathways targetted: dopaminergic, serotonergic, histaminergic, cholinergic, neurokinin and cannabinoid
First line management of hyperemesis gravidarim
- usually begins around week 6 and resolves around 14 weeks
- non pharm: small frequent meals, high carb, low fat, change to multivitamin without iron, hydration, high protein snacks, plain biscuits/crackers mane, avoid spicy and strong odours
- pyidoxine 12.5mg mane, midday and 25mg nocte PLUS
- doxylamine 2mg nocte, increase as tolerated to 12.5mg mane, midday and 25mg nocte
Second line management of hyperemesis in pregnancy
- metoclopramide (cat A)
- ondasetron (cat B)
- prochlorperazine (cat C)
- promethazine (cat C)
Management of chronic idiopathic nausea and vomiting
- reflux is underdiagnosed cause of nausea
- consider trialing acid suppression
- may consider low dose TCA or anxiolytic drugs and CBT in refractory cases
- alternatively consider mitrazapine for patients with poor appetite and weight loss
Functional dyspepsia
- epigastric pain/burning, early satiety and or discomfort after meals
- symptoms present for > 6 months
- with appropriate investigation to rule out structural and metabolic causes
- epigastric burning = PPI
- bloating/discomfort = domperidone 10mg TDS before meals