Gastroenterology Flashcards
(33 cards)
Dyspepsia: Defn
= pain/reflux/vomiting/indigestion/heartburn for 4 weeks
Dyspepsia: causes
7
- Uninvestigated (not had an OGD)
- Functional dyspepsia (= symptoms following a normal OGD; may need long-term acid suppression treatment)
- GORD (= ‘endoscopically-determined reflux disease’ eg leading to oesophagitis)
- Peptic ulcer disease
- Barrett’s (= metaplastic change of squamous mucosa, increased risk of adenocarcinoma)
- Upper GI cancer
- Medications - NSAIDs, steroids, bisphosphonates, calcium blockers, alpha blockers
Dyspepsia:
‘Uninvestigated’ Mx
(2)
Choose one of two strategies:
- Full-dose PPI for 1 month
OR
- Test for H Pylori (urea breath test/stool antigen) +/- eradication therapy
(If symptoms persist after choosing one, then try the other strategy)
Gastro referral/OGD if recurrent or refractory symptoms despite primary care treatment
Dyspepsia:
H Pylori eradication
7 day triple therapy
PPI (eg lansoprazole 30mg)
+ Amoxicillin 1g BD
+ Clarithromycin 500mg BD / Metronidazole 400mg BD
(Second line: various options including levofloxacin, tetracycline, tripotassium)
Suspected oral cavity cancer
—> urgent dentist/oral surgeon review in 2 weeks, if…
Lump on lip or in oral cavity
Red patches +/- white patches in oral cavity (erythroplakia/erythroleukoplakia)
Peptic ulcers (gastric v duodenal)
Gastric:
- Repeat OGD to confirm healing (+ H.pylori test repeat if appropriate) 6 - 8 weeks after treatment
- May need long term acid suppression treatment
Duodenal:
- Repeat H.pylori test if appropriate 6-8 weeks after treatment
- May need long term acid suppression treatment
I.e. difference is gastric needs repeat OGD, (duodenal doesn’t)
PPI
CI; Cautions, SE
CI:
- 2 weeks before endoscopy (may mask symptoms of upper GI cancer)
Cautions, if risk of:
- Osteoporosis
- Hypomagnesaemia
SE include:
- Headache, dizziness
- GI (diarrhoea, N&V, abdo pain)
- Dry mouth
- Peripheral oedema
- Fatigue, sleep disturbance
- Myalgia, pruritis
Barrett’s oesophagus
=, cause, Sx, Dx, risk, Mx 3 & 3
= metaplastic changes of squamous mucosa - dysplasia can be low/high grade
Main cause: GORD
Sx: Barrett’s itself has no symptoms, but often people have Sx of GORD
Dx: At endoscopy
Increased risk of adenocarcinoma - needs monitoring, e.g. regular endoscopies, biopsies
Mx:
1 Lifestyle changes
2. Test and treat H Pylori
3. May need long-term acid suppression Rx
Dysplasia Mx options:
- mucosal resection
- radiofrequency ablation
- Oesophagectomy
Jaundice - Pre-hepatic
4
= too much unconjugated hyperbilirubinaemia
- Physiological, e.g. neonatal
- Gilbert’s (inherited metabolic disorder - defect in conjugation of BR —> raised unconjugated levels —> Jaundice): no Rx. Think about in questions which mention jaundice + stress/fever/exercise/pregnancy
- Thalassaemia
- Haemolytic anaemias
Jaundice - hepatic
5
Hepatitis (infectious, alcohol, AI, drugs) Cirrhosis Liver mets Drugs (e.g. Abx, antiepileptics) Haemochromatosis
Jaundice - post-hepatic
3
Gallstones
Common bile duct stricture
Ca of head of pancreas
Jaundice - admission
6
- Red flag Sx
- BR >100
- Abnormal clotting profile/showing signs of coagulopathy
- Abnormal renal function
- Suspected paracetamol OD
- Frail or significant comorbidities
NAFLD
- Aim for recommended target of 10% weight loss over 6 months
Hepatology referral:
- High risk of advanced liver fibrosis
- Signs of advanced liver disease on examination
- Uncertainty in diagnosis
Ix - may include liver fibroscan and biopsy
2º care may use pioglitazone or vitamin E drug treatment (off-label) in addition to lifestyle changes.
Ultimately there may be a role for liver transplantation.
Liver cirrhosis
=; Types 2; Ix; Mx
End stage of many liver conditions that cause parenchyma damage —> eventually leads to fibrosis and portal hypertension
Types:
- Compensated (liver still functioning, no obvious signs)
- Decompensated (liver damaged to point where clinical signs develop, e.g. ascites, jaundice)
Ix:
If suspected, can arrange transient elastography testing, but most refer to gastro/hepatology.
Mx: aim to slow progress (e.g. stop alcohol) and reduce complications (e.g. varies, ascites, encephalopathy)
Irreversible —> may need transplantation
Hepatitis A
= inflammation of liver due to hepatitis A virus
Faeco-oral transmission
Usually self limiting. Usually lasts under 2 months
Dx: through Hepatitis A IgM or IgG / Hep A RNA detection
May have raised ALT, ALP, BR, PT
4 phases:
- Incubation
- Prodromal (flu-like and GI symptoms) - up to 2 weeks
- Icteric (pruritis, hepatomegaly, fatigue) - up to 3 months
- Convalescent (malaise, hepatic tenderness) - up to 6 months
No long-term sequelae - supportive treatment.
Local health unit notification - a notifiable disease.
Vaccination for those at risk of acquiring (eg. Travel to high prevalence areas or IV drug user)
Monitor LFTs/PT depending on levels
Hepatitis B
= inflammation of liver due to hepatitis B virus
Transmission: perinatally, sexual contact, IVDU, transfusion, tattoo, needle-stick, surgery abroad, etc.
Initially acute infection - fever, malaise, nausea, RUQ pain, jaundice
Chronic infection - usually asymptomatic, may have signs of chronic liver disease
Serology:
- HBsAG (surface antigen) - 1st marker to rise in acute infection
- IgM anti-HBc - 1st antibody to rise
- IgG anti-HBc - usually persists for life (therefore indicates past infection)
- Immunisation indicated by Anti-HBs without Anti-HBc
Chronic hep B - 8-20% get cirrhosis (2-5% get HCC)
Symptomatic care (no cure) & refer to hepatology/gastro/ID
Local health protection unit notification (notifiable disease!)
Offer contacts vaccination (e.g. household contacts, IVDU):
- Usually 3 doses at 0, 1, 6 months (can be more rapid programme at 0, 1, 2 months)
Hepatitis C
= slow, progressive liver disease
Transmission routes similar to Hep B
Test for antibodies and Hep C RNA:
+ve… repeat again
-ve… repeat in 3-6 months if at risk
Complications…cirrhosis (10-30%), HCC (1-3%)
Local health protection unit notification (notifiable disease!)
Refer to hepatology/gastro/ID:
- will get antiviral meds (e.g. Sofosbuvir, Ledipasvir) which are replacing interferon use
- Liver transplant
Charcot’s triad
For cholangitis (infection of common bile duct) - ADMIT!
- Fever
- Jaundice
- RUQ pain
Acute pancreatitis
Causes 11; Sx 4; Key Ix; Mx 5
Causes - I GET SMASHED (first 4 are most common)
Idiopathic , Gallstones , Ethanol (alcohol) , Trauma
Steroids, Mumps (or other infections), Autoimmune, Scorpion bite, Hyperlipidaemia/hypercalcaemia/hyperparathyroidism, ERCP, Drugs (e.g. valproate, azathioprine)
Sx:
- Epigastric pain (may ease with sitting forward)…
- … radiates to back
- Vomiting
- Grey discolouration (paraumbilical = Cullen’s sign; flanks = Grey-Turner’s)
Key Ix is raised Amylase
Modified Glasgow Score used for predicting severity
Mx:
- Admit!
- IV fluids
- Analgesia
- Close monitoring
- May need ITU
Chronic pancreatitis
Irreversible, fibrosis
Sx: epigastric pain, radiates to back, bloating, steatorrhea
Dysfunction…
Endocrine: less insulin —> diabetes
Exocrine: less digestive enzymes —> malabsorption
Mx:
Supportive, pain relief, dietician, etc.
Pancreatic cancer
Sx:
Painless jaundice, Weight loss, Ascites
Surgical or palliative treatment
(Picked up quite late, and therefore also…)
…Poor prognosis: <5% 5-year survival
Irritable Bowel Syndrome
=; RF 5; Sx 3; Dx 3; Ix 4 key +2; Diet 3; Rx 4; Refer
= functional bowel disorder, no clear cause, variety of symptoms, no Dx test, can have significant impact on QoL
- can be constipation or diarrhoea predominant
Possible risk factors:
- Diet (alcohol, spicy food, caffeine)
- genetics
- GI infection
- Antibiotics
- Psychosocial factors
Consider if any ABC symptoms:
Abdominal pain , Bloating , Change in bowel habit —> PRESENT FOR 6 MONTHS
Dx:
Abdo pain present EITHER relieved by defecation OR assoc w altered bowel frequency/form
AND at least 2 of… Altered stool passage Abdo bloating/distension/tension/hardness Sx worse with eating Mucus PR
AND….
Differential ruled out
Ix:
FBC, ESR, CRP, coeliac antibody testing
+ Ca125 if considering ovarian cancer, fecal calprotectin if considering IBD
Diet advice:
- Adjust fibre levels, caffeine low, carbonated drinks low, adequate fluids levels, max 3 portions fresh fruit per day, regular meals, etc
- If probiotics - take for at least 4 weeks
- May need dietician referral, e.g. for trial of low FODMAP diet
Rx:
Abdo pain/spasms —> Mebeverine, Peppermint oil, Alverine
Constipation —> bulk laxatives (e.g. ishagula) …NB Lactulose not recommended
Loose stool —> anti-motility drug - loperamide recommended
Second line if abdo pain persists: can consider low dose TCA (off label)
Refer to gastro…
Ongoing Sx which persist despite initial management or diagnostic uncertainty
Coeliac Disease
= chronic, AI disorder against gluten —> damages lining of small intestine —> malabsorption and weight loss
Gluten found in wheat, barley, rye
Sx include:
Abdo pain
Loose stool
Fatigue
Ix:
1st line: IgA tTGA (tissue transglutaminase antibody) …….. if unavailable then IgA EMA (endomysial antibody)
NB stay on gluten whilst bloods!
If +ve —> refer for biopsy of small intestine (again stay on gluten!) - look for subtotal villus atrophy
Classic rash with coeliac disease: Dermatitis herpetiformis
Complications:
- Anaemia (Fe, B12, folate)
- Nutritoonal deficiency
- Osteoporosis
- Lymphoma
Treatment: gluten-free diet
Monitoring:
Usually annual bloods…coeliac serology, FBC, haematinics, LFTs, bone bloods
Crohn’s disease: Mx
Admit if flare-up…
- Severe diarrhea (6-8 times per day)
- Fever, unwell, dehydrated, suspected obstruction, etc
Acute Mx: corticosteroids
Maintenance Mx:
- Aminosalicylates (e.g. mesalazine)
- Immunosuppressants (e.g. methotrexate, azathioprine)
- Biologic therapy (e.g. infliximab)
Surgery may ultimately be needed
