Gastroenterology and hepatology handbook Flashcards
Ascites, UGIB, Peptic ulcer, IBD, GERD, Acute pancreatitis, Acute liver failure
What are the investigations for ascites?
- 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
What is the conservative treatment for ascites?
- Low salt diet (≤2 g Na/day)
- Fluid restriction (1–1.5 L/day) if dilutional hyponatraemia Na <120–125 mmol/L
- Monitor input/output, body weight, urine sodium
- Spironolactone starting at 50 mg daily (single morning dose) alone or with
Frusemide 20 mg daily as combination therapy. - 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)
- Amiloride (10–40 mg/day) can be substituted for spironolactone in patients with tender gynaecomastia
- Once ascites has largely resolved, dose of diuretics should be reduced and discontinued later whenever possible.
- 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)
What is the management of refractory ascites?
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
What is the initial management of variceal hemorrhage
Maintain systolic BP at 90–100 mmHg but avoid excessive
volume restitution (increase portal pressureearly rebleeding
and higher mortality)
Restrictive blood transfusion, aim at Hb 7–9 g/dL
Correction of significant coagulopathy and thrombocytopenia
may be considered
What is the management after stabilization of patient with variceal bleeding?
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
What is management of uncontrolled/recurrent variceal bleeding?
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
What are peptic ulcer healing drugs?
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
What is 1st line anti H.pylori therapy?
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)
What is salvage therapy for anti H.pylori therapy?
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
What is the history taking for IBD?
- 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
What is the PE for IBD?
G/C, hydration, Temp, weight, BMI, nutritional assessment, BP/P, pallor, oral ulcer
abdominal distension or tenderness, palpable masses, perianal inspection and PR
What is the radiological investigation for IBD?
- 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
- CT/MR enterography/abdomen/pelvis: disease extent and activity, inflammatory vs fibrotic stricture, extraluminal complication, fistula, perianal disease
- Barium fluoroscopy: superior sensitivity for subtle early mucosal disease but is largely replaced by CTE/MRE
What are the lab investigations for IBD?
- 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 - 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 - Microbiologic study of tissue biopsy
- to exclude Mycobacterium tuberculosis infection
- to exclude cytomegalovirus colitis in severe or refractory colitis - Faecal calprotectin
- marker of colonic inflammation
- useful to differentiate IBD from functional diarrhoea, monitor disease
activity and predict clinical relapse
What is the test for GERD?
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
What are the indications for endoscopy in GERD?
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.
What are the indications of esophageal pH monitoring in GERD?
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.
What are the indications for esophageal manometry in GERD?
NotindicatedforuncomplicatedGERD.
Pre-operative assessment to exclude severe oesophageal motility
disorders before anti-reflux surgery
What is the indications for esophageal impedence testing in GERD?
To detect non-acid reflux when oral PPI therapy is ineffective
What is the management of GERD>
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.
What is the indications for anti reflux surgery in GERD?
Unresponsiveorintoleranttomedicaltreatment
ComplicationsofGERDunresponsivetomedicaltherapy
What is the diagnostic critiria for acute pancreatitis?
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
How do you asess the severity and prognosis of acute pancreatitis?
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.
What is the management of severe acute pancreatitis in ICU?
Define acute liver failure?
What is the classification?
What history taking and Ix done to find etiology and assess severity of acute livet failure?
How to manage acute liver failure?
How to manage hepatic encephalopathy depending on grade of severity?
How to manage intracranial hypertension in acute liver failure?
How to manage coagulopathy and bleeding in acute liver failure?
How to manage haemodynamic/renal failure in acute liver failure?
What criteria for considering liver transplantation in acute live failure?
What is the child pugh grading of severity of chronic liver disease?
What is the management of hepatic encephalopathy in cirrhotic patients?
What are the indications for referral for consideration of liver transplantation in chronic liver disease and HCC?
What is initial management of UGIB?
What are the indications for emergency endoscopy?
In UGIB what are contraindication for endoscopy
Post endoscopy management
Recurrent bleeding management
What scorings systems are used for prognosis in UGIB?
What is general management for IBD?
What is the 5-ASA and steroid formulation for IBD?
What is the Montreal phenotypic classification for crohns disease?
How to assess severity of crohns disease?
What is the montreal phenotypic classification of ulcerative colitis?
What criteria to assess activity of ulcerative colitis?
What are prognostic indicators?
What is the drug management of ulcerative colitis depending on degree of severity?
What is the management of hepatorenal syndrome?
When is prophylactic use of nucleoside analogues used in hep B infection recieving immunosuppressant therapy?
HBsAg (active infection), anti HBc (occult hep B)
Algorithm of high-risk / moderate-risk groups of patients planned for corticosteroids, immunosuppressive or immunomodulator therapy
