Week 7: Gastroenterology (1) (GI bleeding and disorders) Flashcards

Question

pathophysiology of coeliac

Answer 1

The primary mechanism involved in celiac disease is related to an inappropriate adaptive immune response to gluten-derived peptides. It has been ascertained that prolamines contain critical epitopes presented by either HLA-DQ2 or HLA-DQ8 induce a CD4⁺ T-lymphocytes response. -→ gliadin

Answer 2

* Loose stools * Bloating * Wind * Abdominal cramps * Weight loss * Dermatitis herpetiformis * No symptoms (incidental when investigating iron def anaemia or due to family history of coeliac disease)

Answer 3

* Untreated coeliac- increased risk fo small bowel lymphoma, small bowel cancer, osteoporosis and neurological complications such as gluten ataxia and neuropathy

Answer 4

**Diagnosis** * If you suspect coeliac disease it is important that the patient continues eating a normal diet until the diagnosis is made. * tTG (tissue transglutaminase) is raised in most cases of coeliac disease, but is not a diagnostic test in adult patients * OGD and duodenal biopsies is the diagnostic test, and histologically you will see villous atrophy and intra-epithelial lymphocytosis

Answer 5

Dietitians are key as treatment is a lifelong gluten free diet. Gluten is found in Barley, Rye, Oats and Wheat although some patients are able to reintroduce oats into their diet.

Answer 6

* Heartburn, reflux and indigestion are very common symptoms and often used interchangeably. * It is important that you clarify in your history exactly what the patient’s symptoms are when they use these terms, eg is it abdominal pain, retrosternal burning, waterbrash, vomiting or upper GI wind. * In the absence of any red-flag symptoms it is reasonable to **empirically try a PPI +/- test for H Pylori.** * If there are any red flag symptoms, atypical symptoms, associated dysphagia or weight loss or new onset at an older age investigations are indicated and an OGD (oesophago-gastro-duodenoscopy) should be considered. can treat with antacids and PPIs e.g. omeprazole

Answer 7

Dysphagia can be caused by pathology in a number of different sites. * A good clinical history is key as this can guide if the dysphagia is due to a problem with the **oro-pharyngeal phase of swallowing** (patient struggles to get the food to leave the mouth) or the **oesophageal phase** (things usually leave the mouth ok and then get stuck). * Patients may also describe difficulty swallowing when in fact they mean that swallowing is painful (odynophagia).

Answer 8

* Either a physical obstruction or neuromuscular problem is present. * **Obstruction** may be a tumour, a benign (peptic) stricture or inflammation from oesophagitis. * **Neuromuscular** problems include achalasia, dysmotility and presbyoesophagus. * OGD is usually needed to exclude an obstructive cause first and barium swallow or oesophageal manometry will look for neuromuscular problems. * Treatment depends on the cause; dilatation for benign strictures and surgery or stenting for cancers.

Answer 9

* Difficulty getting the food to leave the mouth is usually due to problems coordinating the muscles that move the food bolus to the back of the mouth, as a result of neurological disease such as stroke. * It is important to examine the patient’s cranial nerves and obtain a speech therapy assessment of the safety of their swallow. * A video-fluoroscopy may be helpful, if their swallow remains unsafe with altered consistencies of food and fluid an enteral feeding tube may be necessary.

Answer 10

* Find out what the patient means by passing blood. * Is this haematemesis (fresh blood vomited), * Coffee ground vomit (supposed to indicate altered blood but may in fact be anything that has been in the stomach) * Melaena (black, tarry sticky stool) * Fresh PR bleeding (usually indicates a lower GI bleed, but may, in a haemodynamically unstable patient suggest a brisk upper GI bleed). * The next step is thinking about risk factors for bleeding. * Is the patient known to have varices or chronic liver disease * Do they have stigmata of chronic liver disease * Have they been on NSAIDs, antiplatelets or anticoagulants?

Answer 11

* FBC – to check the level of Haemoglobin and platelet count (thrombocytopenia may be suggestive of chronic liver disease and platelets will need replacing if low and bleeding) * U&E – a raised urea supports your diagnosis of upper GI bleeding * Clotting – abnormal clotting should be corrected in order to help control the bleeding * Group and Save (Cross Match if haemodynamically unstable) – you may need to give a blood transfusion * LFTs – remember however that normal liver function tests do not exclude chronic liver disease * Venous Blood gas – this is a quick way to get a haemoglobin result

Answer 12

**1) ROCKALL score** **2) Blatchford score**

Answer 13

* Predicts risk of death and rebleeding from an upper GI bleed * Split in * Pre-endoscopy score * Post-endoscopy score that can only be completed with endoscopy findings * Higher the score the more chance of dying

Answer 14

* Predicts need for intervention (blood transfusion or therapeutic endoscopy) * Requires blood tests * Most useful in deciding if a patient needs admitting or not

Answer 15

Variceal bleeding is a medical emergency and most often presents with fresh haematemesis +/- melaena. * Initial action: Fluid resuscitation if haemodynamically compromised (followed by blood) * IV Terlipressin AND IV antibiotics * Definitive treatment: endoscopic banding

Answer 16

* endoscopic banding, * but if this does not control the bleeding a Li**nton or Sengstaken tube may be required as a temporary measure**, or a TIPSS (trans-jugular intrahepatic porto-systemic shunt) procedure.

Answer 17

Non-variceal bleeding covers a whole range of conditions, most **commonly ulcer disease** but also various vascular malformations such as angiodysplasia and dieulofoys. These conditions are more likely to stop bleeding on their own than variceal bleeds, and it is important to ensure that the patient is as haemodynamically stable as possible before their endoscopy in order to decrease the risks of this procedure and to increase the likelihood of definitive intervention being possible. * Initial action: gain IV access. Fluid resuscitation if haemodynamically compromised (followed by blood) * Prescription: there is no evidence for giving PPI before the endoscopy, but this may be indicated post-endoscopy * Definitive treatment: Discuss with the gastroenterology team. Dependent on the pathology found there are various different endoscopic treatments possible. If the bleeding cannot be stopped by endoscopy, radiological embolization or surgery may be possible. The Endoscopist will advise on the need for any medications (such as PPI to treat ulcers) after the endoscopy.

Week 7: Gastroenterology (1) (GI bleeding and disorders) Flashcards

(42 cards)