Gastroenterology

Gastroenterology

1. GORD or Dyspepsia

   • Urgent OGD if >55 and new onset or ALARM symptoms
     • ALARM: Anaemia, Loss of weight, Anorexia, Recent onset/progressive symptoms, Melaena/haematemesis, Swallowing difficulty
   • Age <55 and no ALARM then H.pylori stool antigen test as must not have PPI for 2 weeks for accurate test
   • Mx: H.pylori negative then give lifestyle advice and start on PPI and review in 4 weeks
     • Lifestyle advice includes: weight loss, diet, smoking, eating late
     • H.pylori positive then begin triple therapy for 7 days

2. Inflammatory bowel disease

   • Crohns vs colitis: crohns more painful - abscess, strictures, fistula etc
   • Bloods, stool culture, scope and biopsy
   • Fluids, mesalazine etc, if needed (severe) steroids
   • Witts criteria for severity
   • Crohns MRI small bowel
   • Mx UC: 5ASA topical.oral; steroids for flare; azathioprine
   • Mx Crohns: 5ASA and steroids are less effective; steroids for flare; azathioprine; biologicals:IFX
   • >2 steroid course/year then azathioprine
   • Crohns
     • Transmural, skip lesions, cobblestones, rose thorn ulcers, granulomas (non-caseating), goblet cells preserved
     • Associated with PBC, increased oxalate renal stones, fistulae, cholangiocarcinoma, SBO
     • Commonly distal ileum and right colon
     • Mx with Metronidazole can cause peripheral neuropathy
   • Ulcerative colitis
     • Superficial (mucosal), pseudopolyps, goblet cells lost, no granulomas, crypt abscesses

3. Toxic megacolon

   • Cultures, including tropical PCR
   • Resus and correct K+/Mg++
   • Drip+suck
   • Abx if infective
   • If IBD IV hydrocortisone
   • review drugs

4. Mucinous cyst neoplasm

   • EUS & cyst evaluation

5. Primary biliary cirrhosis

   • Auto-antibodies against mitochondrial components
   • Obstructive image, pruritis
   • raised ALP
   • Mx: Ursodeoxycholic acid supplement (bile salt)
   • Mx2: Cholestyramine, bile salts sequestrance to reduce itching

6. Cirrhosis

   • Complications
     • Portal HT: platelets?; variceal bleeding; ascites
     • HCC: screen with USS and AFP
     • Hepato renal syndrome
     • Encephalopathy
   • Decompensated presentation
     • worsening jaundice; encephalopathy; ascites; renal failure
     • Caused by: GI bleeding; dehydration; electrolyte abnormality; sepsis; PB thrombosis; drugs; new insult; hepatoma; constipation
   • SBP (Spontaneous Bacterial Pertitonitis)
     • ascites and sudden deterioration
     • Mx: Cefotaxime and Tazocin or if recent draining of ascites then Metronidazole
     • Common causes E.coli, Klebsiella, and strep

7. Hepatits

   • Alcohol - best to stop
   • USS for HCC every 6 months
   • Low salt diet and spironolactone for ascites
   • Hep B
     • Hep B acute to Hbs Ag
       • HBe Ag + then give antivirals
     • 1-6 months incubation
     • Associated: arthritis, arthralgia, urticaria
     • Chance of chronic infection- 5%
     • Hbs Ag present >6 months = chronic infection
     • Complications: HCC, cirrhosis, membranous glomerulonephritis, polyarteritis nodosa,
     • Exposure: if immunised give booster; if no immunisation IVIg + accelerated vaccine course. Risk of transmission 30 %.
     • Hep D only bad if superinfection on ALREADY hep B infection
   • Hep A
     • incubation 2-4 weeks
   • Hep C
     • Hep C is chronic presents with cirrhosis
       • incubation 2-3 months
     • Complications: HCC, autoimmune hepatitis, porphyria cutanea tarda, mixed essential cryoglobulinaemia
   • Hep E only severe in pregnancy, 20% mortality rate

8. Acute liver failure

   • Tranplant criteria
     • Paracetamol induced ALF
       • Arterial pH<7.3 (following fluid resus); OR PT>100 seconds and serum creatinine>300 in patients and grade III/IV coma
     • Non-paracetamol induced ALF
       • PT>100 seconds; OR any 3 of the following: drug toxicity (indeterminate cause of ALF), age<10 years, age>40 years, jaundice to coma interval>7days, PT>50 seconds (INR>3.5), serum bilirubin>300
   • Development of encephalopathy and coagulopathy within 12 weeks of the onset of jaundice in absence of pre-existing liver disease
   • Hyper 7 days, acute 1-4 weeks and subacute 5-12 weeks
   • Common causes: paracetamol 40%, acute viral hepatitis 13%, idiosyncratic drug reactions 12%
   • Rare: autoimmune hepatitis, herbal supplements, mushroom poisoning, Budd-Chiari syndrome, pregnancy, heat stroke, rhabdomyolysis, herpes hepatitis, ischaemic hepatitis, malignant infiltration, fulminant Wilson's disease
   • Hepatic encephalopathy: build up of ammonia goes to brain causing cerebral oedema and hepatic encephalopathy. Lactulose and enema reduce nitrogen forming bacteria.
     • Present with altered mood, reversed sleep pattern, asterixis, dyspraxia, confusions, slurred speech and coma
       • Coma stages I-IV getting gradually worse IV is coma. Stage III and IV poor prognosis