Miscellaneous

Question 1

H.Pylori Eradication Therapy

Answer 1

Triple Therapy
- Esomeprazole 20mg PO BD x 7-14days
- Amoxicillin 1g PO BD x 7-14 days
- Clarithromycin 500mg PO BD x 7-14 days

Test of cure with Urea breath test 4-6 weeks after completion of therapy. Nil PO Abx for 4 weeks and nil PPI for 1 week before testing. H2-Receptor antagonists have no effect on test and can continue to be used.
Can use antacids until day of test

Penicillin allergy? Replace amoxicllin with metronidazole 400mg PO BD

Failure of therapy? Likely due to resistance of clarithromycin. Refer to gastro

Question 2

Upper GI Bleeding Differential

Answer 2

Differential
- Bleeding gastric or duodenal ulcer
- Erosive gastritis or duodenitis
- Bleeding oesophageal varice
- Portal hypertensive gastropathy
- Angiodysplasia
- Mallory-Weiss tear
- Gastric Cancer

Question 3

Irritable Bowel Syndrome

Answer 3

Management
- Fibre - 25g for females and 30g for males per day.
- Low FODMAP diet
- Referral to Psychologist for CBT - Especially when predictable scenarios of worsening symptoms (Exams, public speaking, travelling on public transport)
- Keep food diary to identify food triggers
- Regular meal times and portion control

Question 4

Indications for antibiotics in Diverticulitis

Answer 4

1- Immune Compromise
2 - Right-sided diverticulitis
3 - Failure to improve after 72 hours of conservative treatment

Abx choice
- Augmentin Duo Forte i PO BD x 5 days
- Penicillin?
- Bactrim 160/800mg PO BD x 5 days + Metronidazole 400mg PO BD x 5 days.

Question 5

Recognition and treatment for complicated diverticulitis

Answer 5

Clinical findings
- +’ve blood culture, perforation, peritonitis, sepsis, abscess > 5cm

Management
- Inpatient
- IV antibiotics
- IV fluids
- Consider surgery if peritonitis with perforation, abscess not amenable to percutaneous drainage or bowel obstruction

• Colonoscopy 6 weeks after CT-diagnosed complicated diverticulitis to review for possibility of perforated colon cancer (and not diverticulitis) as initial cause of symptoms.

Question 6

Management of uncomplicated diverticulitis

Answer 6

• Clear liquid diet 2-3 days
• Low fibre diet until pain improves
• Acetaminophen + Antispasmodics for pain

Question 7

Anal Fissure

Answer 7

Tear in lining of anal canal distal to dentate line.
- Located posterior midline of the anal canal in 90% of cases. Anterior midline in 25% of females.
- Kissing fissures (anterior and posterior) in 3% of cases

Pathophysiology circle
- Acute anal fissure -> Pain -> Internal and sphincter spasm -> High resting anal pressure -< Redcued anodermal perfusion -> Local ischaemia -> Poor healing -> Acute anal fissure

Acute < 8 weeks
Chronic >= 8 weeks. Can appear with surrounding mucosal hypertrophy and skin tags.

Causes
- Local Trauma (Constipation, diearrhoea, penetrative intercourse), Crohns disease, malignancy, infection

Non-pharmacological treatment
- High fiber diet to achieve soft bowel motions
- 5 serves of vegetables and 2 serves of fruit per day to achieve soft bowel motions
- Sitz baths TDS

Pharmacological Management
- Movicol / Coloxyl and Senna / Lactulose Aperients
- Glyceryl Trinitrate -.2% ointment topically QID
- Proctosedyl ointment topically.

Chronic fissure refractive to above? Consider referral to colorectal surgeon for lateral sphincterotomy or local botox.

Question 8

Coeliac Disease Testing

Answer 8

Coeliac Serology (IgA anti-tissue transglutaminase, anti-deamidated gliadin antibodies. Total IgA
- Can be performed if patient is consuming 8-10g of gluten per day (4 slices of wheat-based bread)

HLADQ2/DQ8 testing not appropriate screening test. 50% +’ve in Australian population.

Positive coeliac serology should lead to endoscopy to review for intra-epithelial lymphocytosis with blunting in the duodenal villi.

Question 9

Functional Abdominal Pain disorders in Children and Adolescents

Answer 9

Functional Dyspepsia
- Sensation of fullness after eating, feeling full after eating small amounts of food, epigastric burning pain unrelated to bowel movement.
- Present for >= 4 days per month.

IBS
- Pain during defaecation, altered stool appearance, altered stool frequency >= 4 days per month.

Abdominal Migraine
- Abdomina pain associated with migraine lasting >= 1 hour on >= 2 occasions in 6 months.