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. Gall stones

   • Gall bladder not palpable because they become thick walled and contracted
   • raised ALP and GGT
   • Biliary colic: colicy pain that subsides, often after eating fatty meals
   • Acute cholestasis, similar yo biliary colic but does not subside, Murphy's sign and pyrexia might be present
   • Ascending cholangitis: Charcot's triad - RUQ pain, fever, jaundice. Treat with Ciprofloxacin and Metronidazole
   • Gall stone ileus: SBO due to gall stone, can develop if fistula between gangrenous gall bladder and ileum. Pain, distension and vomiting

3. 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

4. Toxic megacolon

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

5. Coeliac

   • T cell mediated AID with gluten
   • Causes villous atrophy and malabsorption
   • Associated with AID, Irish and dermatitis herpetiformis, and MALT lymphoma
   • Dermatitis herpetiformis is IgA deposition present in the dermis, associated with gluten-sensitive arthropathy. Intensely itchy, vesicular and papular. Treat with dapsone and gluten free diet.
   • Ix: TTG test but this may come back negative is patient has selective IgA deficiency - present in 1/50 patients with coeliac.
     • Other false negative causes: patient stopped eating gluten or longstanding disease where decreased protein levels mean IgA no longer produced
   • Ix: duodenal biopsy from 4 sites looking for- villous atrophy, crypt hyperplasia, increased WBC
   • COELIAC ONLY DRINK CIDER (alcohol)

6. Acute pancreatitis

   • Almost always ethanol or gall stones = 90%
   • Hartmanns around 4L first 24 hours for best prognosis to avoid microvascular collapse (if haematocrit climbs)
   • If septic emergency ERCP & stone removal
   • abdo pain and amylase/lipase x2
   • sequelae = pseudocyst
   • Bruising around umbilicus/flank
   • Measure severity: PaO2<8kPa, age>55 years, Neutrophilia WBC>15x10^9, Calcium<2mmol/L, renal fx urea>16mmol/L, enzymes LDH>600iu/L or AST>200iu/L, Albumin<32g/L, Glucose>10mmol/L
     • >3 call ITU

7. Mucinous cyst neoplasm

   • EUS & cyst evaluation

8. 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

9. Pancreatic carcinoma

   • Courvoisier's sign: jaundice with palpable non-tender gall bladder suggests malignant blockage within biliary tree causing obstructive picture, typically cancer of head of pancreas
   • 5 year survival 0.4% ver low usually diagnosed too late
   • Extremely painful

10. 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

11. 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

12. Non-variceal upper GI bleed

    • Blatchford score
    • Stop offending drugs (NSAIDS often)
    • Mx: Gastroscopy with adrenaline, clips of hear
      • Admit for observations
      • Radiology would rescue the situation
    • IV Pantoprazole used for upper GI bleeds caused by ulcer

13. Variceal bleeding

    • Check INR and platelets
    • Pre-OGD give terlipressin and Abx
    • Mx: banding, rescue with sengstaken and TIPSS
    • Preventative if grade 1 review in 1 year, grade 1 with red flags or grade 2/3 then non selective beta blocker or band ligations and repeat OGD in 1 year. none seen then repeat OGD 2-3 years
    • Platelets given if <50, 1 bag increase by 10

14. Chronic pancreatitis

    • Suspect in past history of heavy alcohol intake, smoking, hereditary in young people, trauma.pseudocyst/stones/tumours
    • CT results: dilated pancreatic duct, pancreatic atrophy, pancreatic exocrine failure and complications seen is pseudocyst
    • Ix: bloods, amylase, Foecal elastase!, CT, tropical PCR
    • Presentation: incidental, central abdominal post-prandial pain, weight loss, steatorrhoea, Vit A/E/D/K/B12 deficiency, diabetes is late presentation with hypos more common when pancreas lack alpha cells that produce glucagon

15. 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