Learning Objectives GI Flashcards
Learning objectives AH1 Rotation outline:
What are the causes of acute upper GI bleed? List 6 (3 marks)
What are the clinical features of UGIB? (2 marks)
What needs to be covered on history: Think: Symptoms/ALARMS symptoms, Pmhx, medications:
Exam: DRSABCDE, Goals of assessment, VS, peripheral stigmata of disease, abdo, DRE, underlying comorbidites
Investigations: Labs, Imaging (4 marks) important!
What are common causes of upper GI bleeds (2.5 marks)
What is the risk assessment tool associated with UGIB bleeds called? What is the rockall score and its use?
Risk assessment score
- Glasglow Blatchford Score (GBS)
- Use - calculated in ED for risk stratification for further investigation
- Interpretation: 1+ = high risk bleed requires intervention
Rockall score
- Use calculate risk of recurrent risk after endoscopy
Outline management of acute UGIB:
Resus (ABCDE), Medical (different if varices), Upper endoscopy, preventing reoccurence.
Differential diagnosis for Melaena: Upper GI vs Lower GI.
Outline brief assessment for Melaena:
Investigations for patient with melaena?
Lower GI bleed:
Eitology: List 4- (2 marks)
Clinical features:
Management: (emergency, definitive management: Unstable vs stable) Give examples.
Upper GI Bleed: Toronto notes:
Definition:
Eitology: Above GE, Stomach, duodenum
Clinical features:
Treatment:
Prognosis:
What is an esophageal varice?
Eitology:
Clinical features:
Investigations:
Management. Acute, long term.
What is a Mallory-weiss tear?
Definition?
Eitology:
Clinical features:
Management:
What is the function of the pancreas?
Where is it located?
What is the main fuct of the pancreas? What are the two major cell types of the pancreas?
What is the function of the exocrine component of the pancreas? What are the 3 major pancreatic enzymes? Functions?
What are the three endocrine hormones of the pancreas?
What are important pancreatic markers? (lipase and amylase explain)
What are the three diagnostic criteria for acute pancreatitis?
What are the causes of acute pancreatitis? (IGETSMASHED)
What are the most common causes?
Pathophysiology: read !
What can acute pancreatitis lead to?
What are the gross and microscopic features of pancreatitis?
Clinical features: List 4 (symptoms), Signs (list 4)
What is your differential diagnosis for patient with severe epigastric pain radiating to back? (4 marks) GI/CV?Obsgyn/uro
What are complications of pancreatitis? Think: local and systemic: (2 marks for each)
Local
- Pseudocyst (delayed) - encapsulated fluid collection; mass effect can cause biliary or gastric outlet obstruction; prone to infection, rupture & haemorrhage; treat by aspiration
- Pancreatic fat necrosis
- Infection & pancreatic sepsis
- Haemorrhage - retroperitoneal haemorrhage, portal vein thrombosis (portal vein sits just posterior to pancreas)
Systemic
- Hypovolemic shock & multi-organ failure : 3rd space loss (capillary leak) + SIRS (systemic cytokine release) + GI loss (vomiting, ↓intake) + retroperitoneal haematoma
- AKI - hypovolemia; ↑intra-abdominal pressure –> abdominal compartment syndrome with occlusion of renal veins
- Metabolic derangement - HAGMA, ↓Ca2+
- Respiratory failure - (systemic cytokine release), pleural effusion, APO (cytokines + IVFs)
- Diabetes mellitus
- DIC
Investigations:
Bedside?
Labs? Bloods and findings? (2 marks) What is diagnostic?
Imaging and findings?
Investigation:
Bedside
- VBG - HAGMA, hypocalcaemia
- ↑BSL - necrosis of endocrine part of pancreas
- ECG
- BHCG
Labs Bloods
- FBC (neutrophils↑)
- Lipase (3x upper limit) - NOW THE DIAGNOSTIC TEST OF CHOICE
- UECs, LFTs, CRP
- G&H and cross-match
- Coagulation
LFTs
- ↑AST & ALT - very high suggests gallstone pancreatitis due to CBD obstruction (but also may be mildly elevated from surrounding inflammation)
- ↑bilirubin/GGT - very high suggests gallstones as cause
- ↓albumin (<32 used for severity)
UECs
- Hypocalcaemia - enzyme release –> mesenteric fat necrosis –> free fatty acid release –> Ca2+ binds to fatty acids causing soap precipitation in abdomen
- ↑urea & creatinine (AKI)
- CRP >200 suggests necrotizing pancreatitis (used in severity)
Imaging
- Erect CXR - perforation, complications (ARDS, APO, effusion)
- USS abdomen (1st line imaging) - gallstones, biliary obstruction
- CT abdomen with IV contrast - complications (haemorrhage, pseudocyst, necrosis), necrotic tissue has no enhancement
- ERCP - identify and remove stones; if gallstone cause or diagnosis is uncertain
Imaging of pancreatitis?
USS findings? What to rule out as cause?
CT with contrast findings? List 4 features:
What is the Glasgow criteria for acute pancreatitis severity?
Whats it uses?
What is the Ranson criteria? Whats its use? Criteria? Interpretation?
Grading severity Glasgow criteria
- Use - assess severity <48 hours of admission
Criteria = PANCREAS
- Pa02 <60mmHg
- Age >55y
- Neutrophils - WCC >15
- Ca2+ <2mmol/L
- Renal function - urea >16 (or >1.8)
- Enzymes - LDH >600,
- Albumin < 32
- Sugar - BSL >10
Interpretation
- ≥3 in <48hrs = severe pancreatitis –> needs transfer to ICU
Ranson criteria
- Use - estimate mortality after >48 hours of investigation
- Criteria - similar criteria to Glasgow but uses both initial values & values after 48 hours of admission
Interpretation
- 0-2: 2% mortality
- 3-4: 15% mortality
- 5-6: 40% mortality
- 7-8: 100% mortality
Outline management for acute pancreatitis:
Think, Resus, supportive (mainstay), Specific (underlying causes, medical, surgical) Monitoring, communication, referral, monitor and follow up.
What is ERCP? What are complications of it?
ManagementResus
- DRS
- A - intubate if ↓LOC or ARDS
- B - protective ventilation, high flow O2 15L non-rebreather
- C - 2x IV access, aggressive IVFs (pancreatitis are IV depleted but fluid overloaded due to 3rd spacing & SIRS response), replace electrolytes
Supportive care (mainstay of pancreatitis)
- U/O & IDC - monitor fluid balance with fluid chart
Nutrition
- NBM initially then enteral feeding via nasojejunal tube (bypass pancreas to ↓stimulation)
- IVFs & correct electrolytes
- Analgesia - opioids
- VTE - TED stockings, assess risk but enoxaparin often not used immediately as may require surgery
Specific management
- Treat underlying causes: Biliary obstruction - treat gallstones (cholecystectomy etc.)
- Cease alcohol
Medical
- Alcoholic pancreatitis - put on AWS + thiamine + diazepam
- Abx - ONLY for confirmed necrotising pancreatitis or evidence of infection only (done by aspirating necrotic area); use meropenem
Surgical
- Gallstone pancreatitis (as for choledocholithiasis)
- ERCP - remove CBD stone
- Laparoscopic cholecystectomy - done on same admission due to high recurrence rate
Other surgical procedures (rare)
- Debridement of infected necrotising pancreatitis - only other surgical indication
- Drainage of pancreatic cyst
Monitoring
- Vitals - hourly
- Communication, referral, monitor and follow up
Referral - general surgeon review, ATODs etc.
- Follow-up CT for complications
ERCP complications (must rule out if present)
- Bleeding
- Cholangitis (introduce organisms into tract)
- Pancreatitis
- Perforation
- Strictures
What is chronic pancreatitis? What is it characterized by?
What are the causes (eitology)? Common? Others?
Pathophysiology? Read: What does it result it?
Clinical features (2.5 marks) (signs)
Differentials for malabsorption syndromes? (most common causes- 5 cs) 2.5 marks!
Definition: Irreversible pancreatic damage characterised by
- Fibrosis
- Necrosis
- Inflammation
Etiology
Common
- Chronic alcoholic (>90%)
- Cystic fibrosis (2nd most common cause)
Others
- Pancreatic duct obstruction - chronic gallstones, other CBD obstruction (malignancy, divisum)
- Autoimmune pancreatitis
- Tropical pancreatitis
- Idiopathic
Pathophysiology
- Alcohol - see mechanisms above
- Recurrent acute pancreatitis results in: (similar to liver cirrhosis)
- Fibrosis
- Exocrine atrophy (destruction of exocrine pancreas)Cystic dilated ducts
- Results in loss of pancreatic function causing clinical features
- Steatorrhea - fatty, pale stools
- Malabsorption –> weight loss, decreased albumin
- Fat intolerance
Late stage endocrine pancreas also lost
- Hyperglycaemia
Clinical features
- Recurrent attacks of severe epigastric pain radiating to back
- May be poorly localised upper abdominal and back pain
Pancreatic insufficiency
- Malabsorption syndrome - steatorrhea, bloating/indigestion, weight loss, nutritional deficiencies (B12, folate etc.), anemia
- DM
- Repeated episodes of jaundice
- If gallstone induced biliary obstruction (gallstone causing the pancreatitis)
DDx malabsorption
Most common causes (5Cs)
- Chronic pancreatitis
- Celiac disease
- Crohn disease
- CF
- Chronic infection - giardiasis, tropical sprue, Whipple’s
Investigations in chronic pancreatitis? (think:malabsorption steatorrhoea, DM)
Blood? Stool? Imaging?
Complications of Chronic pancreatitis? (list 4) 2 marks
Bloods
- HbA1c
- FBC - anemia
- Lipase (usually normal)
- UEC CMP - deficiencies
- LFTs - ↑ALP/GGT if obstruction, hypoalbuminemia
- Nutrients - iron, B12, folate, vitamin A D E K
- Coagulation - vit K
- Coeliac serology
Stool
- OCP & MCS
- Faecal elastase
- 72h faecal fat test (measures exocrine function)
Imaging
- AXR - pancreatic calcifications
- Abdominal CT or USS - calcifications, dilated ducts, pseudocyst
- Endoscopic USS (EUS)* (most sensitive) - dilated ducts, abnormal parenchyma
- ERCP - abnormalities of ducts
Pathology of Chronic fibrosing pancreatitis: (x ray, ct macro, micro findings)
Management: Resus, active, supportive?
What is “pancreatic divisum”? What is the cause of it? how does it present?
Autoimmune pancreatitis? Clinical features? Ix? Rx?
Pancreatic neoplasm: Most common type? Clinical features (list 4) 2 marks?
- Complications of :
- Acute pancreatitis?
- Chronic pancreatitis?
What is your differential for pancreatic cyst? (2 marks)
What are the types of pancreatic neoplasms?
What are the risk factors for pancreatic ductal adenocarcinoma? Mutations associated with it?
Patho: Gross:
Pancreatic masses
Pancreatic cyst differential
- Simple pancreatic cysts
- Pseudocyst
- Cystadenoma
- Syndromes - ADPKD, VHL disorder
- Ductal adenocarcinoma with cystic degeneration
What are clinical feature of Head of pancreas tumour (70%)? Tail of pancreas?
What is your Differential diagnosis for Painless jaundice? (obstructive, hepatic, pre-hepatic)
What investigations are needed for head of pancreas tumour?
Why is the K10 screening tool for depression important in pancreatic cancer?
Head of pancreas tumour (70%)
- Present earlier due to obstruction of CBD
- Non-specific - weight loss, fatigue, nausea
Specific
- Painless obstructive jaundice with pruritus (characteristic)
- Courvoisier’s sign = palpable gall bladder (due to obstruction) + obstructive jaundice
- Malabsorption syndrome- steatorrhea due to obstruction of pancreatic ductMay have vague constant epigastric pain
Body or tail of pancreas (30%)
- Vague epigastric pain radiating to the back
- Non-specific - weight loss, fatigue
Others
- Depression
- Significantly higher incidence in PaCa patients
- Depression and anxiety may even precede symptoms or knowledge of the diagnosis
- Migratory thrombophlebitis (Trousseau’s sign) - inflammation of veins in the lower leg
- Type 1 DM - B-cell destruction
- Hepatomegaly - biliary obstruction
DDx painless jaundice
Obstructive
- Head of pancreas tumour - until proven otherwise
- Cholangiocarcinoma
Hepatic
- Chronic viral hepatitis, ALD, NAFLD, drugs, liver Ca, PBC, autoimmune, PBC, PSC
Pre-hepatic
- Haemolytic anemia, gilbert’s syndrome
Management principles of pancreatic cancer?
What are the different types of endocrine tumors of the pancreas?
What are important tests for liver function? list
What does PT/INR test determine? whats its clinical use?
What role does serum albumin have?
Serum direct Bilirubin?
What are the diagnositic blood tests for:
Autoimmune hepatitis?
Hepatitis A, B, C?
Haemochromatosis?
Wilsons disease?
NASH?
Drug induced liver injury?
DDx for hepatomegaly?
Tests for liver injury:
Hepatocellular injury?
Cholestatic injury?
What is the liver picture in hepatitis? Alcoholic liver disease?