Gastroenterology and hepatology handbook Flashcards

Ascites, UGIB, Peptic ulcer, IBD, GERD, Acute pancreatitis, Acute liver failure

1
Q

What are the investigations for ascites?

A
  • Perform diagnostic paracentesis. Initial laboratory investigation of ascitic fluid should include an ascitic fluid cell count and differential, ascitic fluid total protein, SAAG and cytology
  • USG abdomen
  • Alpha-fetoprotein
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2
Q

What is the conservative treatment for ascites?

A
  1. Low salt diet (≤2 g Na/day)
  2. Fluid restriction (1–1.5 L/day) if dilutional hyponatraemia Na <120–125 mmol/L
  3. Monitor input/output, body weight, urine sodium
  4. Spironolactone starting at 50 mg daily (single morning dose) alone or with
    Frusemide 20 mg daily as combination therapy.
  5. Increase the dose stepwise (maintaining the 100mg:40mg ratio) every 5– 7 days to the maximum dose of spironolactone 400 mg/day and Frusemide 160 mg/day if sub-optimal response (if weight loss and natriuresis are inadequate)
  6. Amiloride (10–40 mg/day) can be substituted for spironolactone in patients with tender gynaecomastia
  7. Once ascites has largely resolved, dose of diuretics should be reduced and discontinued later whenever possible.
  8. All diuretics should be discontinued if there is severe hyponatraemia <120 mmol/L, progressive renal failure, worsening hepatic encephalopathy, or incapacitating muscle cramps
    - Frusemide should be stopped if there is severe hypokalaemia (<3 mmol/L)
    - Spironolactone should be stopped if there is severe hyperkalaemia (>6 mmol/L)
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3
Q

What is the management of refractory ascites?

A

C. Therapeutic paracentesis can be used in refractory ascites
- Exclude spontaneous bacterial peritonitis before paracentesis
- Caution in patients with hypotension and raised serum creatinine, monitor vital signs during paracentesis
- If >5L fluid removed, give IV albumin 6–8g per litre tapped
D. Consider TIPS in refractory ascites
E. Referral to liver transplant centre for potential candidate

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4
Q

What is the initial management of variceal hemorrhage

A

 Maintain systolic BP at 90–100 mmHg but avoid excessive
volume restitution (increase portal pressureearly rebleeding
and higher mortality)
 Restrictive blood transfusion, aim at Hb 7–9 g/dL
 Correction of significant coagulopathy and thrombocytopenia
may be considered

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5
Q

What is the management after stabilization of patient with variceal bleeding?

A

Vasoactive agents prior to endoscopy to patient with suspected variceal bleeding and maintained for 2-5 days after endoscopic treatment
Terlipressin 2mg IV bolus Q4H
Octreotide 50mg IV bolus, then 50mg/hr IV infusion
Somatostatin 250mg IV bolus, then 250mg/hour iV infusion

IV thiamine for alcoholics
Prevention of sepsis
Endoscopic treatment: when haemodynamic condition is stabilized (SBP >70mmHg)
Esophageal variceal ligation (EVL) for esophageal varices; tissue glue like N-butyl-cyanoacrylate injection for gastric endoscopy

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6
Q

What is management of uncontrolled/recurrent variceal bleeding?

A

G. Uncontrolled/recurrent variceal bleeding
 Recurrent bleeding should be managed by repeated endoscopy
 Refer to emergency surgery (port-systemic shunting, devascularisation) or TIPS as salvage therapies for uncontrolled bleeding
 Balloon tamponade should only be used as temporary measure
(up to 24 hr) until definitive therapy is planned. If haemostasis is not achieved, other therapeutic options should be considered
H. Prevention of rebleeding
 EVL combined with a non-selective beta-blocker* (NSBB: propranolol, nadolol) is recommended as secondary prevention

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7
Q

What are peptic ulcer healing drugs?

A

H2 antagonist for 8 weeks: famotidine 20mg bd
PPI for 4-6 weeks (PPI should be taken 30-60 min before meals)
Pantprazole 40mg om
Rabeprazole 20mg om

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8
Q

What is 1st line anti H.pylori therapy?

A

Standard triple therapy
PPI (BD) + clarithromycin (500 mg BD) + amoxicillin (1g BD) for 7–14 days (substitute amoxicillin with metronidazole 400 mg BD in case of penicillin allergy)

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9
Q

What is salvage therapy for anti H.pylori therapy?

A

Levofloxacin-based triple therapy
PPI (BD) + levofloxacin (500 mg daily) + amoxicillin (1g BD) for 10–14 days
Bismuth quadruple therapy
PPI (BD) + bismuth subsalicylate (524 mg four times a day) + tetracycline (500 mg four times a day) + metronidazole (400 mg four times a day) for 10–14 days
Non-Bismuth quadruple therapy
PPI (BD) + clarithromycin (500 mg BD) + amoxicillin (1g BD) + metronidazole (400 mg BD) for 14 days

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10
Q

What is the history taking for IBD?

A
  • recent travel, medication (antibiotics, NSAID), sexual and vaccination smoking, prior appendicectomy, family history, recent episodes of infectious GE
  • bowel habit: stool frequency and consistency (nocturnal, usually >6 weeks duration), urgency, tenesmus, per rectal passage of blood and mucus abdominal pain, malaise, fever, weight loss
  • perianal abscess / fistulae: current or in the past
  • extra- intestinal manifestations: joint, eye, skin, oral ulcer
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11
Q

What is the PE for IBD?

A

G/C, hydration, Temp, weight, BMI, nutritional assessment, BP/P, pallor, oral ulcer
abdominal distension or tenderness, palpable masses, perianal inspection and PR

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12
Q

What is the radiological investigation for IBD?

A
  1. AXR: small bowel or colonic dilatation (toxic megacolon: transverse colon diameter >5.5 cm associated with systemic toxicity), assess disease extent (inflamed colon contains no solid faeces), mass in right iliac fossa, calcified calculi, sacroiliitis
  2. CT/MR enterography/abdomen/pelvis: disease extent and activity, inflammatory vs fibrotic stricture, extraluminal complication, fistula, perianal disease
  3. Barium fluoroscopy: superior sensitivity for subtle early mucosal disease but is largely replaced by CTE/MRE
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13
Q

What are the lab investigations for IBD?

A
  1. Blood test
    - CBP and ESR: look for anaemia and thrombocytosis
    - LFT, electrolytes, RFT, Mg
    - CRP: correlates with disease activity, response to treatment and risk of relapse
    - Iron studies, vitamin B12 and folate level
    - Antibodies: Anti-Saccharomyces cerevisiae antibody (ASCA) and Anti- neutrophil cytoplasmic antibody (ANCA) have limited role in diagnosing
    CD (ASCA+ve/ANCA-ve) and UC (ANCA+ve/ASCA-ve)
    - G6PD status: caution when using sulphasalazine
  2. Stool
    - Microscopy and culture to rule out infective causes e.g. Campylobacter
    spp., E.coli O157:H7, amoebae and other parasites
    - PCR testing for Clostridium difficile toxin
  3. Microbiologic study of tissue biopsy
    - to exclude Mycobacterium tuberculosis infection
    - to exclude cytomegalovirus colitis in severe or refractory colitis
  4. Faecal calprotectin
    - marker of colonic inflammation
    - useful to differentiate IBD from functional diarrhoea, monitor disease
    activity and predict clinical relapse
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14
Q

What is the test for GERD?

A

Empirical PPI trial (BD dose PPI for 4 weeks)
For patients with typical GERD symptoms (heartburn and regurgitation) and without alarming symptoms an initial trial of empirical PPI is appropriate
Patients with chest pain suspected due to GERD should have IHD excluded before empirical PPI trial

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15
Q

What are the indications for endoscopy in GERD?

A

 NotfordiagnosisofGERDwithtypicalsymptom.
 Presence of alarm features (dysphagia, odynophagia, unintentional
weight loss, anaemia, haematemesis and/or melaena, recurrent vomiting, family history of gastric and/or esophageal cancer, chronic non-steroidal anti-inflammatory drug use, age >40 years in areas of a high prevalence of gastric cancer).
 Persistent symptom after empirical PPI trial (need to stop PPI for at least 1 week prior to endoscopy).
 Diagnosis of complications of GERD including oesophagitis, Barrett’s oesophagus.
 Severe oesophagitis(LA Grade C-D)after8-week PPI treatment to assess healing and exclude Barrett’s oesophagus.
 History of oesophageal stricture in patients who have recurrent dysphagia.
 Evaluation before anti-reflux surgery.

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16
Q

What are the indications of esophageal pH monitoring in GERD?

A

 When diagnosis of GERD is in doubt (off PPI for 1 week before test).
 Whentreatmentisineffective(keepPPIbeforetest)to define those with or without continued abnormal acid exposure times.
 Evaluation before endoscopic or surgical therapy (off PPI for 1 week before test).
 Persistent/recurrent symptoms after reflux surgery.

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17
Q

What are the indications for esophageal manometry in GERD?

A

 NotindicatedforuncomplicatedGERD.
 Pre-operative assessment to exclude severe oesophageal motility
disorders before anti-reflux surgery

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18
Q

What is the indications for esophageal impedence testing in GERD?

A

 To detect non-acid reflux when oral PPI therapy is ineffective

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19
Q

What is the management of GERD>

A

 Life style modification: body position, food, weight reduction, behaviour.
 Severe oesophagitis (LA Grade C-D): standard PPI dose# for 8 weeks. Doubling the dose to twice daily may be necessary in some patients when symptoms or oesophagitis are not well controlled. Maintenance therapy is required in severe oesophagitis/Barrett’s esophagus and lowest PPI dose should be used to minimize long term adverse effects.
 Non-erosive GERD (NERD)/ mild oesophagitis (LA Grade A-B): standard dose H2 antagonists (H2RA) or PPI# for 8 weeks. On- demand/intermittent H2RA can be used as maintenance treatment.

Standard dose acid suppressant for GERD
pantoprazole 40 mg daily, rabeprazole 20 mg daily, lansoprazole 30 mg daily, dexlansoprazole 30 mg daily, esomeprazole 40 mg daily, famotidine 20 mg bd.

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20
Q

What is the indications for anti reflux surgery in GERD?

A

 Unresponsiveorintoleranttomedicaltreatment
 ComplicationsofGERDunresponsivetomedicaltherapy

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21
Q

What is the diagnostic critiria for acute pancreatitis?

A

Presence of at least 2 of the following criteria
1. Abd pain consistent with acute pancreatitis
2. Serum amylase or lipase >3 x ULN
3. Imaging (CT, MRI, USG) criteria

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22
Q

How do you asess the severity and prognosis of acute pancreatitis?

A

Risk factors of severity at admission including age >55, obesity (BMI >30), altered mental state and comorbidities
Clinical parameters

CRP: 150mg/L at 48 hours predicts a severe attack
Contrast enhanced XT pancreas to diagnose severity of acute pancreatiits and to identify complications especially pancreatic necrosis, full extent of which cannot be appreciated until at least 3 days days after symptom onset.

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23
Q

What investigations to be done in suspicion of biliary pancreatitis?

A

ALT > 3 ULN in a non alcohol patient would be highly suggestive of gallstone etiology
USG hepatobiliary system for detection of galstone and dilated bile ducts
Consider MRCP to rule out biliary pathology, being noninvasive compared with EUS
Arrange early ERCP and sphincterotomy within 24-72 hours after admission, fi there is acute cholangitis or evidence of persistent CBD stones

24
Q

What is the management of severe acute pancreatitis in ICU?

A
25
Q

What are the precipitating factors of hepatorenal syndrome (HRS)?

A

Sepsis (spontaneous bacterial peritonitis)
Severe alcoholic hepatitis
Upper GI bleeding

26
Q

Define acute liver failure?
What is the classification?

A
27
Q

What history taking and Ix done to find etiology and assess severity of acute livet failure?

A
28
Q

How to manage acute liver failure?

A
29
Q

How to manage hepatic encephalopathy depending on grade of severity?

A
30
Q

How to manage intracranial hypertension in acute liver failure?

A
31
Q

How to manage coagulopathy and bleeding in acute liver failure?

A
32
Q

How to manage haemodynamic/renal failure in acute liver failure?

A
33
Q

What criteria for considering liver transplantation in acute live failure?

A
34
Q

What are the contraindications for liver transplantation?

A

 HIV infection
 Active alcohol or substance abuse (relative contraindications)
 Systemic infections
 Life-limiting co-existing medical conditions: advanced heart, lung or neurologic conditions.
 Uncontrolled psychiatric disorder
 Inability to comply with pre- and post-transplant regimens

35
Q

What is the child pugh grading of severity of chronic liver disease?

A
36
Q

What is the management of hepatic encephalopathy in cirrhotic patients?

A
37
Q

What are the indications for referral for consideration of liver transplantation in chronic liver disease and HCC?

A
38
Q

What are the indications for referral for consideration of liver transplantation in acute liver failure/acute on chronic liver failure?

A

These patients should be referred early to avoid delay in work-up for potential liver transplantation if they have any of the following criteria
 Those with rising INR(>2.0)
 Evidence of early hepatic encephalopathy

39
Q

What is initial management of UGIB?
What are the indications for emergency endoscopy?

A
40
Q

In UGIB what are contraindication for endoscopy
Post endoscopy management
Recurrent bleeding management

A
41
Q

What scorings systems are used for prognosis in UGIB?

A
42
Q

What are indications for follow up endoscopy in peptic ulcer disease?

A

 Uncomplicated DU => Unnecessary if asymptomatic
 GU or complicated (bleeding/ obstruction) or giant DU (>2cm)
=> Necessary till complete healing confirmed

43
Q

What is LA classification of reflux esophagitis

A

A mucosal break(s) <5mm, no extension between tops of mucosal folds
B mucosal break >5mm, no extension between tops of mucosal folds
C mucosal breaks continuous between tops of mucosal folds, but not circumferential
D mucosal break(s) involving >75% of circumference

44
Q

What extent of endoscopy and biopsy for histological evaluation in IBD?
What are features indicative of crohns vs ulcerative colitis?

A
  • Sigmoidoscopy is sufficient in acute severe colitis, take a minimum of 2 biopsies at rectum and sigmoid colon

Ileocolonoscopy
Features suggestive of crohns disease
- patchy distribution of inflammation with skip lesions, rectal sparing, stricture, fistula, perianal disease
- deep ulcers, linear ulcers, multiple aphthous ulcers, cobblestoning mucosa
- a minimum of 2 biopsies from each of the 6 segments (terminal ileum, ascending, transverse, descending, sigmoid and rectum) including macroscopically normal segments

Features suggestive of ulcerative colitis
- rectal involvement, extend proximally in a continuous, confluent and concentric fashion; clear and abrupt demarcation between inflamed and normal mucosa;
- caecal patch: patchy inflammation in caecum, observed in left-sided colitis
- backwash ileitis: continuous extension of macroscopic or microscopic inflammation from caecum to distal ileum, observed in up to 20% of patients with pancolitis; associated with a more refractory course
- severity:
o mild: mucosal erythema, decreased vascular pattern, mild friability
o moderate: marked erythema, absent vascular pattern, friability,
erosions
o severe: spontaneous bleeding, ulceration

Anorectal ultrasound: assessment of fistulizing perianal CD
Small bowel capsule endoscopy: high clinical suspicion of CD but -ve endoscopic/radiologic findings (CT/MR enterography is required to exclude small bowel strictures before capsule endoscopy in a patient with Crohns disease, because of the risk of capsule retention)

45
Q

What is general management for IBD?

A
46
Q

What is the 5-ASA and steroid formulation for IBD?

A
47
Q

What is the Montreal phenotypic classification for crohns disease?

A
48
Q

How to assess severity of crohns disease?

A
49
Q

What are the drugs used to cause remission in crohns disease?

A

Aminosalicylates: sulphasalazine: 3-6g/day is modestly effective in colonic disease. Mesalazine: limited efficacy in ileal/colonic disease (but less AE)
Antibiotics for concomitant infection
Corticosteroid: Ca and vit D supplements +/-osteoprotective therapy if given >12 weeks
Prednisone
Budesonide CIR
**
Immunomodulator**
Thiopurines: check TPMT and NUDT15 activity if available. Azathioprine 1.5-2.5mg/kg/day
Methotrexate. Induction: 25mg once per week for 16 weeks, maintenance: 15mg once per week, IM or SC. Folic aci 5mg weekly, given oral 3 days after methotrexate

Biologics
Anti TNF: infliximab (chimeric anti TNF antibody): loading with 5m/kg at 0, 2 and 6 weeks then at 8 weekly intervals IV infusion, adalimumab (humanized anti TNF): loading with 80mg/40mg or 160mg.80mg at 0 and 2 wk, than 40mg every other week
Anti-alpha4beta7: vedolizumab
Anti IL12/23 p40: ustekinumab: human monoclonal antibody

50
Q

What is surgical management in crohns disease?

A

Aim at bowel conservation
- an option in localized disease, septic complication, non-inflammatory obstructive symptom (stricturoplasty for small bowel, endoscopic dilatation for large bowel)
- perianal disease: examination under anaesthesia (EUA) to assess extent of disease, drain collections, seton drainage, advancement flaps, fistula plugs

51
Q

What is the montreal phenotypic classification of ulcerative colitis?

A
52
Q

What criteria to assess activity of ulcerative colitis?
What are prognostic indicators?

A
53
Q

What is the drug management of ulcerative colitis depending on degree of severity?

A
54
Q

How to diagnose hepatorenal syndrome?

A

A diagnosis of exclusion: exclusion of other potential causes of acute or subacute kidney injury
 Volume depletion: improvement of serum Cr after 2 days of diuretic withdrawal and volume expansion with albumin (1 g/kg)
 Haemodynamic shock
 Nephrotoxic drugs (NSAID, aminoglycosides, iodinated contrast)
 Structural kidney diseases: proteinuria (>500 mg/day),
microscopic hematuria (>50 RBCs/hpf), abnormal renal
ultrasonography

55
Q

What is the management of hepatorenal syndrome?

A
56
Q

When is prophylactic use of nucleoside analogues used in hep B infection recieving immunosuppressant therapy?

A

HBsAg (active infection), anti HBc (occult hep B)

57
Q

Algorithm of high-risk / moderate-risk groups of patients planned for corticosteroids, immunosuppressive or immunomodulator therapy

A