Other GI conditions

Question 1

Dyspepsia - syx, ix, mx

Answer 1

syx

• Epigastric discomfort
• Fullness or bloating
• Excessive flatus
• Nausea
• Fatty food intolerance
• Red flag syx: Wt loss, recurrent vomiting, dysphagia, GI bleeding

Ix
(1.) bloods: FBC, U+E, LFT, clotting 
(2.) imaging: endoscopy should be considered >55y in:
• Syx persist despite Rx.
• Raised plt or N+V.
• Prev dx of Barrett's oesophagus 
(3.) Other tests: H. pylori screening

mx
(1.) general lifestyle measures: wt loss, avoid trigger foods, eat smaller meals, avoid eating right before going to bed, smoking cessation, reduce alcohol intake

(2.) Rx the cause e.g. GORD, PUD, H. pylori

Question 2

PCM overdose: syx + mx + ix

Answer 2

Clinical features

• Asyx
• RUQ pain
• N+V
• Jaundice + encephalopathy from liver damage

Mx
Refer to TOXBASE
(1.) Activated charcoal - if presented <1hr
(2.) If ingestion <4hrs, wait until 4hr to take level and rx with NAC based on level (i.e. if above rx level, rx with NAC)
(3.) NAC/N-Acetylcysteine – if staggered or >15hrs ingestion
(4.) Liver transplant if
- arterial pH <7.3, 24hrs after ingestion OR
- all of the following: PTT >100s, crt >300, encephalopathy

Ix
- Glucose, U+E, LFT, INR, ABG, FBC, blood paracetamol level

Question 3

antidotes for salicylate, opiates, benzo, tricylic antidepressants, lithium, CO

Answer 3

• Salicylate: haemodialysis
• Opiates: naloxone
• Benzo: flumazenil
• Tricyclic anti-depressants: IV bicarbonate
• Lithium: volume resus with normal saline, if severe – haemodialysis
• Carbon monoxide: 100% hi flow oxygen with NRM

Question 4

Peritonitis - what is it, causes, syx + signs, mx, ix

Answer 4

Infection of the peritoneum, this can be generalised or localised.

• Localised = inflammation in limited area such as adjacent to inflamed appendix or cholecystitis
• Generalised = widespread inflammation e.g. after rupture

Causes

• Perforated organ e.g. appendix, peptic ulcer perforation, ectopic pregnancy rupture
• Iatrogenic (surgery, endoscopy, dialysis)
• Trauma
• Spontaneous bacterial peritonitis
• etc

Clinical features

• Sudden onset acute abdo pain: worse on touch + movement e.g. coughing. Pt may lie still
• High grade fever
• N+V
• Anorexia
• O/e: guarding, rigidity, rebound tenderness, percussion tenderness, distended abdo,

Mx
ABCDE + alert seniors
- SBP: board spectrum abx (cefalosporin)
- Surgery: localised percutaenous drainage or laparotomy washout

Ix

• Urinalysis
• bHCG
• FBC, CRP, UE, LFT, amylase, clotting, G&S
• blood culture
• ABG - lactate indicate ischaema
• Erect CXR - air under diaphragm = rigler’s sign

Question 5

Perforation: causes, Syx, Ix, Mx

Answer 5

Causes

• PUD and sigmoid diverticulum.
• iatrogenic e.g. endoscopy
• trauma
• mesenteric ischaemia
• boerhaave syndrome (excessive vomit leading to esophageal perforation)
• toxic megacolon

Syx

• Rapid onset abdo pain
• Systemically unwell
• Malaise
• Vomiting
• Lethargy
• May be septic
• Peritonism features: guarding, rigid

Ix

• obs, abdo ex
• FBC, CRP, UE, LFT, G&S
• Imaging: erect CXR, AXR, CT (GOLD)

Mx
ABCDE + Sepsis 6
- Broad spectrum abx
- IV fluids
- NBM
- Analgesia
- Surgery: identify cause + washout + mx of perforation: Repair with omental patch in PUD or Resect perforated diverticula (Hartmann’s procedure)

Question 6

GI haemorrhage

Answer 6

Causes:

• PUD (Hpylori, NSAID, smoking)
• Mallory-weiss tear
• Oesophageal/gastric varices
• Gastritis. Oesophagitis etc
• Malignancy
• Drugs: NSAIDs, aspirin, steroids, thrombolytics, anticoagulants

Syx
Depending on underlying pathology 
- Haematemesis (blood or coffee-ground)
- Melena (black tarry stools) 
- Epigastric pain in PUD
- Signs of hypovolemic shock = tachy, hypotension 

Mx
Acute mx: ABCDE
- Bloods: FBC, UE, LFT, clotting, G&S
- Blood transfusion if Hb<70g/l
- Urgent endoscopy within 24 hours 
- Stop anticoagulants and NSAIDs
- Terlipressin 
- Prophylactic broad spectrum Abx if varices suspected 
- Risk assess with Glasgow-blatchford score / rockall score

Question 7

What are the two risk assessment tools to assess Upper GI bleed, what does each one consider

Answer 7

GBS

• Scoring system in suspected upper GI bleed on initial presentation.
• Establishes risk of having an upper GI bleed to help decide to discharge or not
• It is used prior to endoscopy and to categorise pts in hi risk groups.
• Looks at urea, hb, systolic BP, HR, melaena, syncope, liver disease, heart failure.

> 0 = hi risk GI bleed + likely to require medical intervention (i.e. transfusion, endoscopy or surgery)

<0 = outpatient OGD

Rockall score
- Used for pts that have had an endoscopy to calculate their risk of rebleeding and overall mortality
- Take in to account RF from presentation and endoscopy findings such as:
o Age
o Signs of shock (e.g. tachycardia or hypotension)
o Co-morbidities
o Cause of bleeding (e.g. Mallory-Weiss tear or malignancy)
o Endoscopic stigmata of recent haemorrhage such as clots or visible bleeding vessels