GI Flashcards
(104 cards)
What is mesenteric ishceamia?
mesenteric ishceamia
- reduction in gut perfusion (small bowel)
- can be acute or chronic (chronic is grumbling pain, like angina in ACS but after food instead of exercise, they loose weight and have food fear)
What are symptoms of mesenteric ishceamia?
mesenteric ishceamia
- central non specific abdo pain
- vomiting
- diahroea
- can lead to peritonitis and systemic sepsis
What investigations would you do for mesenteric ishceamia?
mesenteric ishceamia
- FBC > rasied WCC/CPR
- blood gas> lactate/acid
- ECG> look for AF (clot)
- CT angio to see vessels
What is the treatment for mesenteric ishceamia?
mesenteric ishceamia is an EMERGENCY
- fluid Ressus
- antibiotics (broad spectrum)
- laporectomy (WITHIN 60 MINS)
- send to ITU
- palliate?
Most common causes to consider for upper GI bleed?
What are important things from history that would make you think of these differentials?
Upper GI bleed
- most common cause is peptic ulcer disease (duodenal) NSAIDS (chronic inflammatory conditions) Hpylori
- mallory-weiss tear (wretching/vomitting)-small amounts of blood
- variceal tear (alcoholic, malignancy)-large amounts of blood)
- osphagitis/gastritis (small amounts) (epigastric pain, NSAIDS)
How might someone with an upper GI bleed present?
Upper GI bleed
- Haematemesis – bright red or coffee ground (brown)
- Melaena – tar black stools, iron smell (if horrific amount in pt. w/ arterial stent, consider chance of arterio-enteric fistula!!)
- Gastritis – epigastric pain, vomiting
- Peripherally shut down – Cold, ↓CRT, ↓UO (<0.5ml/kg/hr)
- Dyspnoea (due to anaemia) – indicates large bleed
- Hypotensive <90/60 → dizzy and syncope
- Tachycardic > 100bpm (compensate for ↓BP)
- ↓GCS
- Abdo bruising
*Haematochezia – fresh blood or maroon indicates lower GI bleed
How would you manage an upper GI bleed?
(what things in your AtoE?
what imaging?
what scores should you calculate and whats ultimate treatment?
AtoE assessment
- A
- Breathing -give oxygen, ABG and erect chest Xray
- Circulation
-x2 wide bore cannulas
Bloods
-Hb (may be normal as takes 30mins to fall)
-Urea ((prognostic Glasgow Blatchford score and AKI)
-LFT and coagulation (synthetic function and surgery)
-Clotting (↓Vit K)
-ABG
-Cross-match 4-6 units if Hb < 70 (1 unit for each 10g/L that Hb is less than 140g/L)
-Monitor urine output with catheter (hourly monitoring)
-ECG
- give IV 0.9% Saline or Hartmann’s (whilst waiting for blood)
- if patient deteriorating despite fluids give O Rh- blood
Disability
Environment-rectal exam -check melaena
Imaging
- erect chest X ray (pneumoperitonium)
- CT abdo and pelvis (diagnostic)
Referrals/after care
- NBM – 24h
- MUST CALCULATE ROCKALL + BLATCHFORD SCORES!!!
- REFER for urgent endoscopy (with 24 hrs admission or 2hrs after stabilisation). Not in perforation
What is the treatment for variceal bleeds?
Variceal bleeds
- Prophylactic Abx
- IV Terlipressin 2mg/6hr QDS 5 d (↓mortality by 34% by ↓portal pressure; CI: IHD) CONSULTANT LED
-Active bleed –URGENT endoscopic band ligation (osophageal) or sclerotherapy (gastric) (both 1st line)
What is the prophylactic treatment of variceal bleeds?
What is the secondary prevention for variceal bleeds (once they’ve bled once)
Variceal bleeds (60% will rebleed in 1st year)
- Primary prevention – Propanolol or repeat endoscopic banding ligation
- Secondary prevention i.e. after bleed – TIPS or endoscopic banding
Complications of variceal bleeds?
Variceal bleed complications
- Variceal bleeds have ↑Risk of SBP (spontaneous bacterial peritonitis)- give prophylactic IV AB
- Aspiration pneumonia
What is the definitive treatment for active GI bleed (non variceal) ?
Depends on endoscopy findings
- if high risk: achieve endoscopic heamostasis (2 or clips, cautery, adrenaline) start PPI
- if low risk: no endoscopic heamostasis required. Start PPI
SURGERY – if severe or uncontrollable bleed
What scores are important in upper GI bleeds?
Glasgow Blatchford score
-need for admission and endoscopic intervention (0-1 = discharge w/ OP OGD)
Rockall score
-predicts risk of Re-bleeding and mortality post-endoscopy (higher the score, worse the mortality)
When someone is bleeding, when do you transfuse?
when do you give FFP and when do you give platelets?
Transfuse
-Cross-match 4-6 units if Hb < 70 (1 unit for each 10g/L that Hb is less than 140g/L)
Giving platelets
-Give platelets if platelet count <50 x109/L.
Giving FFP
- Give FFP if active bleed and PTT or APT > 1.5x times normal
- If a patient’s fibrinogen level remains less than 1.5 g/litre despite fresh frozen plasma use, offer cryoprecipitate as well
What do you do if someone is on warfarin with an MAJOR BLEED?
Warfarin and ACTIVE MAJOR BLEEDS
- STOP warfarin
- IV Vitamin K 5mg
- Prothrombin complex e.g. Beriplex, Octiplex
- Re-check INR 24hrs
What do you do about warfarin if MINOR bleed? (INR 5-8 vs INR >8)
Warfarin in minor bleeds
- stop warfarin
- IV vitamine K 1-3mg (if IRN>8 you can give another dose in 24 hours if not helped)
- Continue when INR <5
What do you do about raised INR for someone who is NOT bleeding? (INR 5-8 vs INR >8)
Warfarin for non bleeds
INR 5-8
-hold warfarin 2 days
-reduce next maintenance dose
INR >8
-stop warfarin
PO vitamin K 1-5mg
Restart when INR < 5.0
What is GORD? What are the causes?
What are the complications of long term GORD?
GORD
- reflux of stomach acid + bile into oesophagus
- long term GORD can lead to osohagitis/ulcers/strictures and Barrett’s osophagus (squamous to columnar)
Causes of GORD?
RF for GORD?
Cause is often physiological:
- Lower oesophageal sphincter defect hypotension
- Hiatus hernia
- Loss of oesophageal peristaltic function or slow Gastric emptying
- RF: abdominal obesity, over-eating, smoking, alcohol, pregnancy, drugs (TCA, anti-chol, nitrates)
Symptoms of GORD? (oesophageal and extra osophageal)
GORD symptoms
-Heart burn (reflux)
>Worse post-meal, lying down
>Relieved by anti-acids (PPI or H2 antag)
-Belching
-Waterbrash – acid causes ↑↑salivation
-Odynophagia – painful swallowing may indicate oesophagitis or ulcers
Extra-osophageal
- Nocturnal asthma or chronic cough (very common)
- Laryngitis - hoarseness, throat clearing
- Sinusitis (acid can get in sinuses>inflammation)
Name some RED FLAGS for people with swallowing/heart burn problems?
ALARMS
- Aneamia
- Loss of weight
- Anorexia
- Recent onset of progressive symptoms (4 weeks)
- Massess/melena/heamatemasis
- Swallowing issues (pain or inability)
ANYONE of ANY AGE> 2 week upper GI endoscopy referral
if >55years only need dysphagia
investigations for GORD?
- Endoscopy (stop PPI 2 weeks before scope)
- ANYONE of ANY AGE with DYSPHAGIA
- >55 years with ALARMS
- or if treatment refractive
If endoscopy is normal:
-24hr pH study ± Manometery – if endoscopy normal
Managment for GORD? (conservative)
CONSERVATIVE managment for GORD
- raise bed head when sleeping
- weight loss ↓abdo obesity → ↓pressure on stomach
- stop smoking
- diet habits (small and regular, avoid hot drinks, alcohol, coffee, eat 3 hours before bed)
- avoid drugs affecting gastric mobility (nitrates, anticholinergics, CCB-affect sphincter)
- avoid drugs that damage mucosa – NSAIDs, K+ salts, Bisphosphonates, steroids
Managment for GORD? (medical)
MEDICAL managment for GORD
Antacids – Magnesum trisilicate mixture (continuous use not recommended)
Alginates – Gaviscon (continuous use not recommended)
Endoscopy –ve, but symptoms:
1st line: review drugs and lifestyle advice
2nd line: PPI – full dose 1 month and H pylori testing
-If response → low dose PPI PRN
-If no response → H2 antagonist (ranitidine) or pro-kinetic PRN
Endoscopic proven +ve oesophagitis:
1st line: straight to PPI – full dose 1-2 months
If +ve response → carry on with low dose PPI PRN
If no response → H2 antagonist (ranitidine)
Managment for GORD? (surgical)
When would this be appropriate?
Managment for GORD (surgical)
- Nissen Fundoplication or magnetic beadband or radio frequency induced hypertrophy
- Aims to ↑resting LGOS
- consider in severe GORD (as confirmed by pH manometry BEFOREHAND) or if refractory to drugs