Gastroendocrinology

Question 1

How do you assess someone with upper GI bleeding?

Answer 1

The Blatchford score at first assessment, and

the full Rockall score after endoscopy.

Consider early discharge for patients with a pre-endoscopy Blatchford score of 0

Question 2

Management for upper GI bleeding?

Answer 2

transfer patients with massive bleeding with blood, platelets and clotting factors.

Platelets who are actively bleeding and have platelet count less than 50x109
FFP:
- actively bleeding and have PT or activated PTT greater than 1.5 than normal
- if fibrinogen level remains less than 1.5 despite FPP, offer cryoprecipitate as well.

Question 2

when to do endoscopy for upper gi bleeding?

Answer 2

unstable pts:
- immediately after resuscitation

Other patients:
- within 24 hours of admission

Question 3

what is the management of non-variceal bleed?

Answer 3

Endoscopic treatment:
- do not give adrenaline
- use mechanical method e.g. clips/ thermal coagulation with adrenaline/ fibrin or thrombin with adrenaline

PPI:
- only offer to pts with non-variceal bleed at endoscopy

Tx after first or failed endoscopy:
- consider a repeat endoscopy, with tx

Question 3

Management for variceal bleed?

Answer 3

offer terlipressin at presentation. stop tx after definitive heamosuasis is achieved, or after 5 days .

offer prophylactic abx at presentation to pts with suspected or confirmed variceal bleeding.

oesophageal varices:
- use band ligation in pts with upper GI bleed –> consider TIPS

Gastric varices:
Offer endoscopic injection of N-butyl-2-cyanoacrylate –> TIPS

Question 4

How do you manage a volvulus

Answer 4

sigmoid volvulus:

1. treat conservatively with decompression by sigmoidoscope and insertion of a flatus tube. (pt sat in the left lateral position). The tube is left in situ for a period of 24 hours to allow for continued passage of contents and aid recovery
2. most patients will need flexible sigmoidoscopy

Question 5

In what scenario would emergency surgical management of volvulus be required?

Answer 5

• evidence of bowel ischaemia
• perforation

will undergo sigmoid colectomy - usually Hartmann as most pts are frail and morbid, because primary anastomosis is not advised

Question 6

management of ceacal volvulus?

Answer 6

bowel resection, right hemicolectomy.

1. NG tube
2. fluids
3. analgesia
4. correct electrolyte imbalance

Question 7

what is the investigation choice for volvulus and what do you see on x-ray?

Answer 7

CT abdomen-pelvis with IV contrast.

Sigmoid : coffee bean sign on x-ray.

Question 8

which patients do you see caecal volvulus?

Answer 8

there is a bimodal distribution.
In patients who are young ( intestinal malformation) whilst in older pts ( same as sigmoid)