Gastro Ix Mx Flashcards
(60 cards)
Spontaneous bacterial peritonitis (sbp)
Ascites due to cirrhosis + these sx;
Fever, abdominal pain or tenderness, and confusion
Ix = paracentesis
paracentesis: neutrophil count > 250 cells/ul
the most common organism found on ascitic fluid culture is E. coli
Mx = IV cefotaxime (+diuretics?)
Achalasia
Ix: 1st = Oesophageal manometry - excessive LOS tone which doesn’t relax on swallowing
Barium swallow (w X-Ray) - ‘bird’s beak’ + fluid level
Chest x-ray = wide mediastinum + fluid level
Mx: 1st = pneumatic (balloon) dilation
Persistent sx = Surgery + Heller cardiomyotomy
High surgical risk = intra-sphincteric injection of botulinum toxin
Pts for PBD should be a low surgical risk as surgery may be required if complications occur
Surgical intervention with a Heller cardiomyotomy should be considered if recurrent or persistent symptoms
Acute (ascending) cholangitis
(gallstones -> E.coli infection of the biliary tree)
Ix: 1st = USS (bile duct dilation/stones)
Mx = IV antibiotics + ERCP
(ERCP) after 24-48 hours to relieve any obstruction
Charcot’s triad = RUQ pain + fever + jaundice*
fever is the most common feature, seen in 90% of patients
RUQ pain 70%
jaundice 60%
Hypotension and confusion are also common (the additional 2 factors in addition to the 3 above make Reynolds’ pentad)
*Jaundice is only visible when bilirubin is >35
Alcoholic hepatitis
Ix = GGT, AST:ALT>2 (3=alcoholic hepatitis!)
Mx = Pred
Maddrey’s discriminant function (DF) is often used during acute episodes to determine who would benefit from glucocorticoid therapy
It is calculated by a formula using prothrombin time and bilirubin concentration
Anal fissure
Acute <6 weeks<chronic
Risk factors
constipation
inflammatory bowel disease
sexually transmitted infections e.g. HIV, syphilis, herpes
Features
painful, bright red, rectal bleeding
around 90% of anal fissures occur on the posterior midline.
if the fissures are found in alternative locations then other underlying causes should be considered e.g. Crohn’s disease!
Acute (<1week) Mx:
1st = Bulk forming laxative (2nd = lactulose)
Mx of a chronic anal fissure:
1st = Topical GTN
2nd = surgery/botulinum toxin
- Dietary advice: high-fibre diet with high fluid intake
- Lubricants such as petroleum jelly may be tried before defecation
- Topical anaesthetics
- Analgesia
The above techniques should be continued
If topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
Appendicitis
Examination
Generalised peritonitis if perforation has occurred or localised peritonism
Rebound and percussion tenderness, guarding and rigidity
Digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even right-sided tenderness with a pelvic appendix
Psoas sign = pain on extending hip if retrocaecal appendix. Retrocaecal appendicitis may have relatively few signs
Ix = Raised inflammatory markers + history + Urinalysis
Urinalysis (B-hcg, UTI, renal colic)
a neutrophil-predominant leucocytosis is seen in 80-90%!
In patients with appendicitis, urinalysis may show mild leucocytosis but no nitrites
thin, male patients with a high likelihood of appendicitis may be diagnosed clinically
USS is useful in females where pelvic organ pathology is suspected. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion
Mx = Laproscopic Appendicectomy + prophylactic antibiotics
Perforated appendicitis (15-20% of pt’s) = Copious abdominal lavage
Appendix mass but no peritonitis = Broad-spectrum antibiotics and consideration given to performing an internal appendicectomy
Be wary in the older patients who may have either an underlying caecal malignancy or perforated sigmoid diverticular disease
Autoimmune hepatitis
Ix = ANA/SMA/LKM1/SLA ab’s, raised IgG levels, biopsy
Liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
Acute hepatitis = Fever, jaundice etc (only 25% present in this way)
Amenorrhoea is v common!
Mx = Steroids,
also other immunosuppressants e.g. azathioprine
liver transplantation
Barrett’s oesophagus
Dyspepsia/dysphagia ix flow chart??
Histological features
the columnar epithelium may resemble that of either the cardiac region of the stomach or that of the small intestine (e.g. with goblet cells, brush border)
Risk factors
gastro-oesophageal reflux disease (GORD) is the single strongest risk factor
male gender (7:1 ratio)
smoking
central obesity
Interestingly alcohol does not seem to be an independent risk factor for Barrett’s although it is associated with both GORD and oesophageal cancer.
Whilst Barrett’s oesophagus itself is asymptomatic clearly patients will often have coexistent GORD symptoms.
Management
high-dose proton pump inhibitor
whilst this is commonly used in patients with Barrett’s the evidence base that this reduces the change of progression to dysplasia or induces regression of the lesion is limited
endoscopic surveillance with biopsies
for patients with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years
if dysplasia of any grade is identified endoscopic intervention is offered. Options include:
1st = radiofrequency ablation: particularly for low-grade dysplasia
2nd = endoscopic mucosal resection
Cholecystitis (gallbladder inflammation)
RUQ pain
May radiate to the right shoulder
Fever and signs of systemic upset
Murphy’s sign - inspiratory arrest upon palpation of the right upper quadrant
LFTs are normal
Ix: 1st = USS
2nd = Cholescintigraphy (HIDA scan)
Mx = IV ab’s + cholecystectomy
Deranged LFTs may indicate Mirizzi syndrome - a gallstone impacted in the distal cystic duct causing extrinsic compression of the common bile duct
HIDA scan = Technetium-labelled HIDA (hepatobiliary iminodiacetic acid) is injected IV and taken up selectively by hepatocytes and excreted into bile
In acute cholecystitis there is cystic duct obstruction (secondary to odema associated with inflammation or an obstructing stone) and hence the gallbladder will not be visualised
NICE now recommend early laparoscopic cholecystectomy, within 1 week of diagnosis!
Cirrhosis
Ix: 1st = Transient elastography 2nd = Acoustic radiation force impulse imaging
Then enhanced liver fibrosis score
Mx = ?
Coeliac disease
Caused by sensitivity to the protein gluten. Repeated exposure leads to villous atrophy which in turn causes malabsorption
Which conditions are associated with coeliac disease?
Ix:
If patients are already taking a gluten-free diet they should be asked, if possible, to reintroduce gluten for at least 6 weeks prior to testing!
Ix: GS = Endoscopic duodenal biopsy 2nd = anti-TTG 3rd = endomyseal, gliadin
findings supportive of coeliac disease:
villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes
Mx = gluten-free diet + pneumococcal vaccine (every 5yrs) + influenza vaccine
Some notable foods which are gluten-free include:
rice
potatoes
corn (maize)
TTG-abs may be checked to check compliance with a gluten-free diet.
Immunisation = Patients with coeliac disease often have a degree of functional hyposplenism so should therefore be immunised
Conditions associated with coeliac disease :
Dermatitis herpetiformis (a vesicular, pruritic skin eruption)
+ AI disorders (type 1 diabetes mellitus and autoimmune hepatitis).
Crohn’s disease
Ix = Colonoscopy
Mx:
Maintaining remission: S-A-S 1st = stop smoking 2nd = purine synth antagonist (aza/mercaptopurine) 3rd = surgery, what type?
Acute: mind the GAP! (Crohns - skip lesions)
1st = Glucocorticoids (hydro/pred/dex)
2nd = Aminosalicyclates (mesalazine)
3rd = Purine synth anatagonists (aza/mercaptopurine) + Infliximab
Perianal = metronidazole
CRP correlates well with disease activity
Histology
inflammation in all layers from mucosa to serosa
goblet cells
granulomas
Small bowel barium enema
high sensitivity and specificity for examination of the terminal ileum;
strictures: ‘Kantor’s string sign’
proximal bowel dilation
‘rose thorn’ ulcers + cobblestoning
fistulae
Diverticular disease
Ix:
X-Ray = identifies perforation
CT = identifies acute inflammation + abcess formation
Confirmatory Ix = colonoscopy, CT cologram or barium enema
Mx = Increase dietary fibre intake
- Mild = conservatively with antibiotics
- Peri colonic abscesses = drain (surgically or radiologically)
- Recurrent episodes requiring hospitalisation = segmental resection
- Hinchey IV perforations (generalised faecal peritonitis) = resection + stoma + HDU admission
- Less severe perforations = Laparoscopic washout and drain insertion.
Irritable bowel syndrome (IBS)
what are the red flag sx?
Ix = FBC + ESR/CRP + anti-TTG (to exclude coeliacs)
Red flag features should be enquired about:
rectal bleeding
unexplained/unintentional weight loss
family history of bowel or ovarian cancer
onset after 60 years of age
Mx:
First-line pharmacological treatment - according to predominant symptom;
pain: antispasmodic agents
constipation: laxatives but avoid lactulose. 1st = Laxatives 2nd = ->12 months-> Linaclotide
3rd = amitriptyline ->12 months->4th = psych (CBT etc)
diarrhoea: loperamide is first-line
constipation:
General dietary advice
have regular meals and take time to eat
avoid missing meals or leaving long gaps between eating
drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas
restrict tea and coffee to 3 cups per day
reduce intake of alcohol and fizzy drinks
consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)
reduce intake of ‘resistant starch’ often found in processed foods
limit fresh fruit to 3 portions per day
for diarrhoea, avoid sorbitol
for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).
Gallstones (cholelithiasis) & biliary colic
RF’s - Fat, Female, Fertile(pregnant), Forty
Oestrogen increases activity of HMG-CoA reductase
other notable risk factors include:
diabetes mellitus
Crohn’s disease
rapid weight loss e.g. weight reduction surgery
drugs: fibrates, combined oral contraceptive pill
Ix = USS
Mx = Elective laparoscopic cholecystectomy
Reassure people with asymptomatic gallbladder stones (found incidentally)
↑ cholesterol -> ↓ bile salts and biliary stasis
The pain occurs due to the gallbladder contracting against a stone lodged in the cystic duct
Features
colicky right upper quadrant abdominal pain
worse postprandially, worse after fatty foods
the pain may radiate to the right shoulder/interscapular region
nausea and vomiting are common
In contrast to other gallstone-related conditions, in biliary colic there is NO FEVER and LFTs + inflamm markers are normal
Around 15% of patients are found to have gallstones in the common bile duct (choledocholithiasis) at the time of cholecystectomy, This can result in obstructive jaundice in some patients
Gastro-oesophageal reflux disease (GORD)
Ix: GI endoscopy -> oesophageal pH monitoring(GS!)
Indications for upper GI endoscopy*. Must have all of the following;
>55yo
sx > 4 weeks or persistent symptoms despite treatment
dysphagia
relapsing symptoms
weight loss
Mx = PPI
Endoscopically proven oesophagitis
full dose proton pump inhibitor (PPI) for 1-2 months
if response then low dose treatment as required
if no response then double-dose PPI for 1 month
Endoscopically negative reflux disease
full dose PPI for 1 month
if response then offer low dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions
if no response then H2RA or prokinetic for one month
*High urea levels can indicate an upper GI bleed due to the ‘protein meal of the blood’. This dos not occur in a lower GI bleed
Gastroenteritis & infectious colitis (c.diff)
Ix = stool sample
Mx = stop any current antibiotics
1st episode:
1st = oral vanc 2nd = oral fidax 3rd = oral vanc/Iv metro
Recurrent episode:
Within 12 weeks of sx resolution = oral fidax
after 12 weeks = oral vanc OR fidax
Life-threatening:
oral vanc + IV metro
specialist advice - surgery may be considered
Other therapies = Faecal microbiota transplant
may be considered for patients who’ve had 2+ recurrent episodes
Gastrointestinal perforation
Haemochromatosis
Increased chance of developing which cancer?
Ix = Transferrin saturation, TIBC, ferritin
Transferrin saturation > 55% in men or > 50% in women
Raised ferritin (e.g. > 500 ug/l) and iron
low TIBC
Further tests and diagnosis
Genetics = C282Y and H63D mutations
MRI is generally used to quantify liver and/or cardiac iron
LFT’s
liver biopsy is now generally only used if suspected hepatic cirrhosis
Mx: 1st = venesection (monitored w transferrin saturation)
2nd = desferrioxamine
Transferrin saturation should be kept <50%
and
Serum ferritin concentration <50 ug/l
Ca = Hepatocellular carcinoma
Haemorrhoids
Mx = soften stools + local anaesthetics + rubber-band ligation
Newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy
Surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments
Acutely thrombosed external haemorrhoids
Typically present with significant pain and a purplish, oedematous, tender subcutaneous perianal mass
Pt presents <72 hours = refer for excision
Otherwise mx = stool softeners, ice packs and analgesia
Symptoms usually settle within 10 days
Femoral Hernia
Only 5% of abdominal hernias are femoral
More common in women (M:F 1:3)
More common in multiparous women due to increased abdominal pressure
Ix = Clinical exam 2nd = USS
Mx = Surgical repair (given the risk of strangulation)
Features:
Non-reducible, although can be reducible in a minority of cases
Given the small size of the femoral ring, a cough impulse is often absent
Complications;
Incarceration = where the herniated tissue cannot be reduced
Incarceration -> Strangulation
These hernias will be tender and likely non-reducible, and may also present with a systemically unwell patient
The risk of strangulation is much higher with femoral hernias (the strangling female!) than inguinal hernias and increases as the time from diagnosis rises;
Bowel obstruction, again a surgical emergency
Bowel ischaemia and resection due to the above, which may lead to significant morbidity and mortality for the patient.
Hernia support belts/trusses should NOT be used for femoral hernias due to the risk of strangulation;
In an emergency situation, a laparotomy may be the only option
Hiatus hernias
Protrusion of the stomach through the LOS
Sx = heartburn, dysphagia, regurgitation, chest pain
Ix: 1st = Endoscopy
Barium swallow = most sensitive test!
Mx = weight loss + PPI
Symptomatic paraesophageal hernias = surgery
There are two types:
Sliding (95%) = The gastroesophageal junction slides above the diaphragm
Rolling (paraoesophageal) = The gastroesophageal junctions remains below the diaphragm but a separate part of the stomach herniates through the oesophageal hiatus
RFs = Obesity + increased intraabdominal pressure (e.g. ascites, multiparity)
Mesenteric ischaemia
Acute mesenteric ischaemia = embolism of an artery which supplies the small bowel (e.g. superior mesenteric artery)
Classically patients have a history of AF
Chronic mesenteric ischaemia is a relatively rare clinical diagnosis due to it’s non-specific features and may be thought of as ‘intestinal angina’. Colickly, intermittent abdominal pain occurs.
Acute:
The abdominal pain is typically severe, of sudden onset and out-of-keeping with physical exam findings.
Mx = urgent surgery is usually required
poor prognosis, especially if surgery delayed
Chronic:
The abdominal pain is typically severe, of sudden onset and out-of-keeping with physical exam findings
Mx = Immediate laparotomy is usually required, particularly if signs of advanced ischemia e.g. peritonitis or sepsis
Poor prognosis, especially if surgery delayed
Large bowel obstruction
Tumour = 60%
More distal colonic/rectal tumours present with obstruction, as these tend to obstruct earlier due to the smaller lumen diameter
Ix: 1st = X-ray 2nd = CT scan
Mx = NBM + IV fluids + NG tube
Peritonitis/Perforation = IV antibiotics for surgery
If the cause of obstruction itself does not require surgery, conservative management for up to 72 hours can be trialled, after which further management may be required if there is no resolution
Nausea and vomiting are late symptoms that may suggest a more proximal lesion
Perforation presents with peritonism (free intra-peritoneal gas)
Normal diameter limits;
Caecum = 10-12 cm
Ascending colon = 8 cm
Recto-sigmoid = 6.5 cm
Anything bigger is diagnostic of obstruction
Around 75% of LBO’s will eventually require surgery
