SIM - Peptic Ulcers Flashcards
What are the key parts of a history that should be taken in an AtoE exam?
SAMPLE
Signs and symptoms - SOCRATES and red flags
Allergies
Medications - including recent changes
pMH
Last oral consumption
Events/environment - severity, progression
What is the SIRS criteria for sepsis?
Temperature <36 or >38
Respiratory rate >22/min
HR >90bpm
WCC less than 4000 or greater than 12,000
What is the qSOFA criteria for sepsis?
SBP <100mmHg
RR >20/min
GCS <= 14
Define peptic ulcer
Erosion of the gastric mucosa, commonly duodenal or gastric – measuring more than 5mm in diameter
What type of peptic ulcer is more common?
Duodenal
What are the risk factors for peptic ulcers?
Dietary – caffeine, spicy foods, alcohol + trigger foods
Smoking
NSAIDs – regular use, risk highest with first regular prescription
SSRIS, corticosteroids, bisphosphonates
H.Pylori infection
Zollinger-Ellison syndrome – excessive gastrin (stimulates stomach acid production)
What is the basic pathophysiology of a peptic ulcer?
Erosion of gastric mucosa down to submucosal layer– reduction in protective mucin layer over epithelial cells and blood flow, damaged by stomach acid, bacterial toxins or indirectly from inflammation
Chronic inflammation at the base
May continue erosion into blood vessels located in submucosa or perforate through serosa.
What is the treatment for an uncomplicated peptic ulcer (H.pylori negative)?
Lifestyle and dietary changes - smaller meals more often, sitting up after meal etc
PPIs
May also consider antacids or histamine 2 receptor antagonists.
What are the common signs and symptoms of an uncomplicated peptic ulcer?
epigastric pain – gastric within 30 minutes of eating, duodenal relieved initially worse 2-3 hours after eating – may be worse with associated trigger foods.
Weight loss from food avoidance
Nausea
Epigastric tenderness on examination
What are the signs and symptoms of a complicated peptic ulcer?
Bleed – Malena, haematemesis, haemodynamic instability,
Perforation – peritonitic (pain, rigidity, tenderness and distention), haemodynamically unstable – erect CXR first imaging tool
What investigations should be done for a peptic ulcer?
Bedside – obs
Bloods – FBC, LFTs, U&Es, CRP,
Imaging – endoscopy
Other: H,pylori antigen testing in stool, C-13 Urea breath test (first line), rapid urease test
What is the treatment for a H.pylori related peptic ulcer?
H.pylori eradication: Triple therapy: PPI, amoxicillin, metronidazole or clarithromycin for seven days.
Quadruple therapy: bismuth, PPI, metronidazole, tetracyclin.
What are the complications of a peptic ulcer and their treatment?
Perforation – IV fluids fo resus, NG tube to reduce gastric content, IV proton pump, antibiotics, operative is continues to deteriorate.
Haemorrhage – IV proton pump, first line endoscopic intervention, if failed urgent interventional angiography with transarterial embolization or surgery.
What cancer does H.pylori increase the risk of?
MALT Lymphoma.
What is the anatomical differentiation between an upper and lower GIT bleed?
Upper is proximal to the ligament of Treitz that marks the duodenojejunal junction
What are some differentials for an Upper GIT bleed?
peptic ulcer, oesophageal varices, mallory weiss tear, gastritis, oesopaghitis, swallowed blood, malignancies.
What are some differentials for a lower GIT bleed?
chrons, UC, diverticulitis, malignancy, haemorrhoids.
What forms the initial part of resus for a GI bleed patient?
AtoE assessment – typically requires 500ml 0.9% NaCl (or other IV crystalloid solution) over 15 mins
Blood transfusion – if significant haemorrhage or Hb<70g/L, and alongside local protocol
Platelet transfusion -> if actively bleeding with platelet count less than 50x10^9/litre
What additional treatment may be needed for a GI bleed patient on warfarin?
Reversal of anti-coagulation - discuss with senior consider prothrombin complex
What treatment is given for a oesophageal variceal bleed?
Trelipressin – vasoconstriction of splenic artery – useful if suspect esophageal varices/liver cirrhosis – should continue aspirin due to risk of IHD
Give prophylactic antibiotics if risk of peritonitis
When is endoscopy involved in an upper GI bleed patient?
Endoscopy patient – may be immediately after resus if unstable up to 24hrs if admitted or outpatient if low risk.
Calculate risk using Glasgow-Blatchford
What is the purpose of the Glasgow-Blatchford score?
Calculated before endoscopt - identify low risk GI bleed patients who do not require intervention score of 0 discharge and outpatient endoscopy.
Higher than 0 require intervention.
What treatment is used during an endoscopy for a oesopagheal varices GI bleed patient?
band ligation for oesophageal, Operation for: transjugular intrahepatic portosystemic shunts.
What endoscopy treatment can be given for non-variceal upper GI bleed patients?
mechanical (clips), thermal coagulation + adrenaline, fibrin/thrombin with adrenaline, offer PPI after endoscopy.
Adrenaline should not be given on its own.
What is the Full Rockall score?
risk stratification of adverse outcomes following a GI bleeds, taken after endoscopy, Less than 3 is a low risk, 3-4 is moderate risk, above 4 is a high risk.
What are the common signs and symptoms of a GI bleed?
Haematemesis
Melaena
Abdominal pain
Nausea and vomiting
Syncope/dizziness
Bright red stool (haemotochezia)
Hypotension and tachycardia.
What is important to ask in a GI bleed history?
History of liver disease
Profuse recent vomiting
Peptic ulcer/gastritis
H.pylori infection
Alcohol use
NSAIDs/anti-coagulants
What investigations are important to do in a GI bleed?
FBC - assess Hb and platelets
U+Es - urea raised after significant bleed
LFTs - liver disease
CRP - infection and inflammation
Coagulation screen - deranged clotting
Group &save /cross match - possible blood tranfusion
12-lead ECG
CXR
What non-medical intervention may be done if endoscopy is not available for an upper GI bleed?
Balloon tamponade - insert over area applies pressure to bleeding blood vessels to reduce blood loss.
What are the different ranges of hyperkalemia?
Mild 5.5 to 5.9
Moderate 6.0 to 6.4
Severe 6.5+
How might hyperkalemia present?
Acute - typically asymptomatic - malaise, muscle weakness and palpitations, reduced muscle power and reflexes, resp failure, flacid paralysis
Chronic - fatigue, weakness (starts in lower extremities), irregular heartbeat,
What are some common causes of hyperkalemia?
Drugs: K+ sparing diuretics, ACEis/ARBS, Beta blockers, LMWH, trimethoprim
Renal - AKI, rhabdomyolysis, type 4 renal tubular acidosis
Endocrine - hyperglycemia, adrenal insufficiency
Other - burns
Artefact - haemolysed blood sample or severe thrombocytosis
What ECG changes are seen in hyperkalemia?
Tented T waves
Prolongation of PR interval
Prolongation of QRS complex
Flattening/absence of P-waves
Bradyarryhtmias
Sine wave QRST and asystole
What are the signs of hypokalemia on an ECG?
T wave inversion
ST depression
Prominent U wave
(T wave pushed down)
What is the first line treatment of hyperkalemia?
Cardiac protection 10ml of 10% calcium chloride IV
What are the steps of treatment hyperkalemia?
- cardiac protection - 10ml 10% CaCl2
- Shift into cells - IV insulin-glucose, neb salbutamol, sodium zirconium
- Remove from body - dialysis, IV furosemide, potassium-exchange polymers
- Monitoring - continuous ECG, K+ at 2,4/6,24 intervals, glucose monitoring
- Prevent reoccurrence
