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Gastroenterology ISCE Crash Course Presented by: Mahum Faisal 2021 ● History taking on common presenting complaints ● How to formulate a differential diagnosis Outline ● Important investigations to request in gastroenterology ● ISCE stations Part I + II ● Reflection and general advice on how to approach the examAbdominal Pain Wash hands; PPE; Introduce yourself and gain consent Start with 1-2 open questions Site Onset Character Radiation Associated GI symptoms Timing Exacerbating and alleviating factors Severity Previous episodes + hospital admissionsAnatomical regions Jaundice Reflux Trauma Fever Haematemesis Rigors Nausea, vomiting Travel Fever, rigors, nausea and Bowel habit Fever, rigors, nausea and vomiting, LUTS Radiation vomiting, LUTS Bowel habit LUTS Fever, diarrhoea, nausea and Nausea and vomiting Fever vomiting LMP, vaginal discharge, dysmenorrhea, dyspareunia Sore throat, runny nose, coughSurgical Sieve Vascular Inflammatory - Mesenteric ischaemia, Ischaemic colitis - IBS, Crohn’s, Ulcerative colitis, Infection Neoplastic - Gastroenteritis, , hepatitis, diverticulitis, UTI - Colorectal cancer, Ovarian cancer Trauma Congenital - Splenic injury - Wilm’s tumour, coeliacs, Hirshsprung’s disease Autoimmune - Coeliac disease Drugs/ degenerative Metabolic Endocrine -hypo/ hyperthyroidism, hypercalcaemia, paracetamol poisoning, hepatic encephalopathy - DKAPMH Systems review - Atrial fibrillation, Diabetes ICE Surgical history - Cholecystectomy, Appendectomy Social History - Smoker Medications Alcohol! - Type, strength, quantity, CAGE screening Allergies Employment Quality of life Family history Thanks patient and ends consultation - IBD, Coeliac’s disease, Bowel cancerChange in bowel habit Wash hands; PPE; Introduce yourself ; Consent Open questions Nature of stools - type, colour, smell, blood, mucus, steatorrhea Frequency Duration Associated GI symptoms Red flags ICEDDX Differential diagnosis Questions Ischaemic colitis, mesenteric ischaemia Gastroenteritis Anyone else at home unwell? Relation to food? Greasy stools, bloating? Timing Diverticulitis Fever, Lower left abdominal pain Coeliac disease Bloating, constipation, skin changes, FH Hypo/ hyperthyroidism Hypo → constipation, weight gain , lethargy Hyper → diarrhoea, sweating, palpitations, amenorrhea IBD Mucus, blood, tenesmus, weight loss, fatigue, FH IBS Stress, pain in relation to defecation Colorectal cancer Weight loss, anorexia, malaise, rectal bleeding, massesCystic fibrosis, hirschprungs disease, simple constipation, intussception, meckel’s diverticulum Drug induced Pancreatic insufficiency FH PMH - IBD, Coeliac disease, bowel cancer, ovarian cancer - IBD, Diverticulitis, atrial fibrillation, CVD, other autoimmune conditions, pancreatitis Social PSH - Occupation - Smoking - Alcohol Medications - Travel - New antibiotics, opioids, iron - Quality of life supplementation, laxatives System review Allergies Hypo/ Hyper thyroidism Thank patient and end consultation appropriatelyHaematemesis Wash hands, PPE, Introduce yourself, consent Open questions Timing Frequency Onset Precipitating factors Progression Colour Amount Associated gi symptoms Red flag Symptoms severityDDx Questions to ask Varices Alcohol, known varices, liver disease Oesophagitis Odynophagia, dysphagia,reflux, nausea, cough, sore throat, chest pain, feeling of something being stuck in their throat Malignancy Anorexia, malaise, weight loss, dysphagia Mallory weiss tear History of retching, weakness, lightheadedness, shortness of breath, syncope Boerhaave syndrome Chest pain, heavy alcohol intake, severe or repeated vomiting Aortoenteric fistula Gastritis Epigastric pain, nausea, reflux Peptic ulcer disease Gastric ulcer - pain gets worse with food Duodenal ulcer - pain is relieved with foodPMH FH - Liver disease, peptic ulcer disease,GORD, - Bleeding disorders bleeding disorders , known varices PSH Social - Smoking - Alcohol - Occupation Medications - NSAIDS, Aspirin, Corticosteroids, Quality of life Antidepressants, Warfarin ICE Allergies Systems review Thanks patient and closes consultationJaundice Wash hands, PPE, introduce yourself, consent Open questions Site Onset Duration Urine Stools Associated symptoms Previous episodes Red flagsPre hepatic Hepatic Post hepatic Increased hemolysis: Alcoholic liver disease Ascending cholangitis Gilbert’s disease Non alcoholic liver disease Gallstones G6PD deficiency Autoimmune hepatitis Primary sclerosing cholangitis Sickle cell anaemia Viral Hepatitis Primary biliary cirrhosis Pancreatic cancerOTHER: Infectious disease → Yellow fever Trauma → Common bile duct injury → recent surgery? Congenital → Biliary atresia, ABO hemolytic disease, Rhesus disease, Hereditary spherocytosis, G-6-PD Pregnancy → Obstetric cholestasis of pregnancy, Acute fatty liver diseasePMH FH - Blood disorders - Gallstones, bleeding disorders PSH Social - Smoking - Recent surgeries - Occupation - Employment Medications - Travel - Co amoxiclav, isoniazid, rifampicin - QOL Allergies ICE Systems reviewInvestigations Bedside Special tests Observations Faecal calprotectin Imaging Bloods - FBC, U+E, LFT, CRP, Coag, amylase, Anti TTG, Folic acid, b12, CXR Barium swallow Serum BHc Endoscopy Acute bloods Abdominal Xray - ABG, cultures, VBG Fast Scan Colonoscopy Bloods for theatre - Group and save, cross match Ultrasound scan Urine dipstick CT MSU + Culture MRI Pregnancy test Stool test Abdominal pain Haematemesis Change in bowel habit ISCE Stations Jaundice Part II Abdominal distentionStation 1Student briefing You are a 5 year medical studenton placement in the emergency department Setting Emergency department Patient details Sarah Jane (32 years) Task This patient has presentedwith abdominal pain The examiner will stop you at 7 minutes and ask you some questions regardingthe clinical investigationsand management of this patient.Case Summary PC - Abdominal pain HPC - Today, Sudden onset of severe epigastric pain radiating into the back. This has been going on for the past 1 hr. Nothing makes its better, 9/10 pain, not improved with simple analgesia. Nausea and vomiting. Never had any episodes like this before. Medications - N/A No allergies FH- N/A Social - Smoker, Alcohol (20 units of alcohol). Used to work in retail but has recently became unemployed. She has also broken up with her partner and is feeling rather down. This has led her to drink more. Lives alone at home. On examination: HR - 114 BP - 80/90 RR- 18 02- 96% OA Tender on palpation of the epigastrium. Guarding noted.Hbc - 130 (115- 160) Wcc - 15* 10^9/ L (4-11) Platelets- 275 * 10^9 (150-400) Sodium - 140 (135-145) Potassium - 3.9 (3.5-5.0) Urea - 5.0 (2.0-7) Creatinine- 110 (55-120) Bilirubin - 56 (3-17) ALT - 23 (3-40) AST- 20 (3-30) ALP - 145 - (30- 100) CRP - 254 (<10) Serum amylase - 1560 (70-300)Management plan Acute Chronic/ Holistic Medical A-E assessment assessment Monitor and treat complications NBM - Necrosis Pain relief Patient education - Infection Anti emetics MDT - Dietary support - Abscess Fluids Psychosocial support/ - Chronic pancreatitis Escalate and investigate assessment - Sepsis AAA support - ARDS Investigations Glasgow prognostic score Pancreatic Bloods supplementation Surgical Ultrasound Laparoscopic cholecystectomy MRCP Diabetes management ERCP Debridement or fine needle CT aspirationStation 2Student briefing You are a 5 year medical studenton placement in the emergency department Setting Emergency department Patient details John Wicks (34) Task This patient has presentedwith vomiting The examiner will stop you at 4 minutes.PC - Vomiting HPC - For the past week patient has been experiencing severe heartburn, epigastric pain and nausea. Today, vomited ¼ cup full of bright red blood. Feels quite lightheaded and dizzy but did not lose consciousness. No previous episodes. PMH significant for GORD, Osteoarthritis, Atrial fibrillation. DH- Gaviscon, NSAID, Warfarin. Allergic to penicillin. No significant family history. Social smoker, rarely drinks alcohol. Works as a teacher in a primary school and lives alone. On examination HR 88 BP 80/90 RR- 13 Temp 37.1 02 - 98% OA Abdomen is tender in the epigastric region Normal bowel soundsHBc - 88 g/L (135- 180) MCV- 70 (82-100) WCC - 5.0 *10^9 (4-11) Platelets 550*10^9 (150-400) Sodium - 136 (135- 145) Potassium - 4.9 (3.5 - 5.0) Urea - 12 (2.0 - 7 mmol/l) Creatinine - 66 (55-120) PT - 22 (10-14) APTT - 40 (25-35) INR - 3.7 (2.0 and 3.0) Bilirubin - 10 (3-17) ALT - 23 (3-40) AST - 26 (3-30) ALP- 66 - (30-100) Gamma GT - 44 - (8-60) CRP - 15 (<10)Acute Major haemorrhage protocol Medical A- E assessment Senior help Suction the blood (if uncnscious) Conservative/ holistic PPI - Omeprazole Give blood and blood products assessment Consider repeat Pain relief endoscopy in patients at Antiemetics Patient education high risk of bleeding again Lifestyle modification Blatchford and Rockall score Stop the NSAID → Topical ibuprofen gel Investigate for H pylori Take bloods Warfarin monitoring - Urea breath test Treatment - PPI + Urgent escalation to theatre metronidazole + clarithromycin Endoscopy to stabilise the patient Variceal Bleeding A- E assessment Resuscitation Scoring system Endoscopy Offer Terlipressin to patients at presentation Offer prophylactic antibiotic Oesophageal bleeding → 1st line = Banf ligation → TIPS Gastric bleeding → 1st line = Endoscopic injection of N-butyl-2-cyanoacrylate → TIPS Tube Signs of liver disease and treat accordinglyStation 3Student briefing You are a 5 year medical studenton placement in general medicine Setting Medical assessment unit Patient details John Roberts (72) Task This patient has presentedwith abdominal pain The examiner will stop you at 7 minutes and ask you some questions regardingthe clinical investigationsand management of this patient.PC - Abdominal pain HPC - Today, 10 am experienced some crampy intermitted abdominal pain. Feels very nauseous and has also been vomited twice. Has not been able to open his bowels for the past 3 days and has not passed wind. PMH Diabetes, inguinal hernia, dementia PSH n/a Medication Metformin No allergies FH - N/A Social - Retired, lives at home alone. Son occasionally visits father at home but is struggling to care for him. On examination HR - 76, BP 90/80 RR- 12 temp 37.8 Inguinal hernia Abdomen is tender, distended, high pitched tinkling bowel soundsAcute: A-E assessments NBM Pain relief Antiemetic Antibiotics Conservative/ Holistic Social care package Medical Drip and suck Insert urinary catheter Surgical Laparotomy Palliative careStation 4Student briefing You are a 5 year medical studenton placement in general medicine Setting GP Patient details Tyler jones (22) Task This patient has presentedwith a change in bowel habit The examiner will stop you at 7 minutes and ask you some questions regardingthe clinical investigationsand management of this patient.PC - Change in bowel habit HPC - Started 4 days ago, having frequent episodes (5-6x a day) of diarrhoea. Associated with mucus but no blood. Central crampy abdominal pain. No previous episodes. Been feeling quite unwell in himself, feels quite tired and has noticed he has also lost some weight. PMH - N/A Medications - N/A Allergies - allergy to penicillin - comes out in a rash FH - father has some form of IBD Social - non smoker, drinks occasional alcohol, studies at university. Largely affecting his studies. On examination HR- 76, BP- 120/85 , RR - 12 , Temp 37.5 Abdomen is soft, non tender Normal bowel soundsHBC - 110 (135-180) MCV - 65 (82-100) Wcc - 6.0 * 10 ^9 (4-11) Platelets - 330 *10^9 (150-400) Sodium - 138 (135-145) Potassium - 3.6 (3.5-5.0) Urea - 6 (2-7) Creatinine - 110 - (55-120) CRP- 45 (<10) ESR- 20 (< age/2) B12 - 68 (200-900) Folic acid - 2.0 - (3.0) Faecal calprotectin - >200 ug/g (<150)Acute Medical A- E assessment Induction Pain relief 1st line = Corticosteroids Antiemetics 2nd line = >2 exacerbations → IV fluids Holistic corticosteroids + azathioprine/ Patient education IV Hydrocortisone mercaptopurine Diet and lifestyle 3rd line TNF a inhibitors Escalate and investigate MDT Maintenance Psychosocial support Immunosuppressive therapy Bloods Peer support - FBC, U+E, LFT, CRP, Stoma care Biologics ESR,Bone profile Serum B12 and folate Colonoscopy Surgical Biopsy Surgical resection and CT stoma Barium enema Management A-E assessment Ulcerative colitis Pain relief, Antiemetic Oxygen IV fluids Investigations IV hydrcortisone Referral to gastroenterology Bloods Conservative Patient education ● FBC Psychosocial support - signpost ● LFT ● U+E Lifestyle changes Smoking cessation ● Bone profile Colonoscopic surveillance ● CRP ● ESR Medical ● VBG Mild to moderate disease (proctitis, proctosigmo) ● Blood cultures 1st line = PR aminosalicyclates Stool sample 2nd line = topical and oral aminosalicyclate 3rd line = topical + oral aminosalicyclate + steroid Faecal calprotectin Left sided/ extensive ulcerative colitis 1st line = High dose oral aminosalicyclate and topical Abdominal X Ray 2nd line = High dose oral aminsalicyclate + steroid Colonoscopy Maintaining remission Azathioprine, mercaptopurine, biologics Biopsy MR of small bowel Surgery Bowel resection - Stoma formation CT abdomen Holistic/ social Psychological support - assess for depression Truelove witts index Bone health and risk of osteoporosisStation 5Student briefing You are a 5 year medical studenton placement in emergency department Setting ED Patient details Colin Edwards (42) Task This patient has presentedwith abdominal pain Please handover the patient to general surgery.PC - Abdominal Pain HPC: A 45 year old male presents with acute RUQ pain, which started 3 hours ago. The pain is described as sharp and is intermittent. But it has gotten worse through the day and not responding to simple analgesia. Associated symptoms include fever and nausea and vomiting. PMH includes previous myocardial infarction (2015) DH - bisoprolol, ramipril, atorvastatin, No allergies. FH- N/A . Non smoker, drinks occasional alcohol and works as a banker. Lives at home with his partner and 2 children. On examination HR 87 BP 100/85 RR - 15 Temp - 38.2 O2 - 92% OA Confused and drowsy Tender to palpate in RUQ Murphy’s sign + Bowel sounds present Bloods - Elevated WCC, deranged LFTS Ultrasound scan - shows gallbladder thickening (>3 mm) and cholelithiasisHello, my name is…. I am the… I’m calling about a patient on X ward… their hospital number is ….. Situation This patient has presented with abdominal pain Background Case summary Assessment Observations A- E assessment including examination findings Bloods Details of imaging Recommendation What you have done Need for a review Confirm the management plan - anything else you need to do SEPSIS A- E assessment Sepsis management 3 IN: Further management: IV fluids IV antibiotics IV oxygen Prep for theatre Bloods 3 OUT: Group and save cross match Anticoagulate them Cultures Urinary catheter Refer to the surgeons Lactate Emergency Laparoscopic cholecystectomyBiliary colic Acute cholecystitis Ascending cholangitis Features Features: Features RUQ radiating between RUQ Charcots triad: shoulderblades Fever RUQ Nausea and vomiting Elevated Wcc Fever Restless Abnormal LFT Jaundice Bloods are normal! Murphy’s sign + Bloods show elevated wcc and abnormal LFT Manage with pain relief and Investigate with investigate for gallstones ultrasound Management IV antibiotics and ERCP Manage with IV antibiotics and early laproscopic cholecystectomyStation 4Student briefing You are a 5 year medical studenton placement in general medicine Setting GP Patient details Jess Richards (28) Task This patient has presentedwith a jaundice The examiner will stop you at 7 minutes and ask you some questions regardingthe clinical investigationsand management of this patient.PC - Jaundice HPC - Noticed her skin starting to yellow 2-3 days ago, initially thought she had a tan however, doesnt seem to fade. Feeling unwell in herself with general aches and pain, fever, loss of appetite, nausea and vomiting and RUQ. Systems review dark urine and joint pains. Usually uses protection however, on one occasion she had unprotected sexual intercourse with a male 3 months ago. PMH n/a Medications On examination COCP HR - 76, BP - 120/86 RR- 14, Temp - 37.8 No allergies Visible jaundice FH- na hepatomegaly Abdomen is soft non tender Social Bowel sounds present Smoker Drinks 16 units of alcohol a week Works as a sex worker HBs Ag = + Anti HBc = + IgM anti-HBc = + IgG anti- HBc = - Anti-HBs = -Hepatitis A Class - RNA picornavirus Transmission - Faecal- oral spread Incubation - 2-6 weeks Endemic in Africa and South American Features Flu like symptoms RUQ Jaundice Hepatosplenomegaly Bloods → abnormal LFT Management Conservative → notify public health Supportive treatment Usually self limitingHepatitis B Class : DNA hepadnavirus Mode of transmission: infected blood, bodily fluids, pregnancy Incubation period is 6- 20 weeks Risk groups - IV drug users, Sexual partners, health workers Endemic - Far east, Africa, Mediterranean You can’t get hepatitis D without B! Complications Chronic hepatitis Liver failure Hepatocellular carcinoma Management Notify public health Antiviral therapy - Chronic liver inflammation, ALT >30 , Cirrhosis, HBV DNA- >2000 IU/ml Monitor and treat complications Vaccination Hepatitis C Class - RNA flavivirus Method of transmission - IV drug users, Complications Chronic Hepatitis C Management Ribavirin Interferon alphaHepatitis E Class - RNA Mode of transmission - Spread by faecal- oral route Incubation period - 3-8 weeks Common in central and south east asia, north and west africa, mexicoStation 5Student briefing You are a 5 year medical studenton placement in general medicine Setting Gastroenterologyward Patient details Lucy smith (38) Task This patient has presentedwith abdominal distention.Please examine the patients gastroenterologysystem.Flapping Tremor Hepatomegaly Shifting dullness Management Conservative Investigations Patient education Bloods Diet and exercise FBC, LFT, Urea, creatinine, Coagulation Alcohol abstinence panel, albumin Medical: Treatment of underlying cause - i.e Imaging: alcoholic hepatitis - Prednisolone PO Liver ultrasound MRI Liver biopsy Monitor and prevent complications - SBP, Ascites, upper GI bleed, Contrast CT encephalopathy, hepatorenal syndrome Ascitic tap ELF Surgical TransplantationGeneral advicePREP You won’t be able to cover everything! - IT’S OKAY Make a checklist of key common presenting complaints Random history/ exam generator Practice answering vivas in the mirror! Practice Practice Practice NIGHT BEFORE Take it easy! EXAM DAY Healthy breakfast Music, meditate 2 minute brief - Calm yourself, think of ddx Remember to pause and think before giving your answer Enjoy yourself! CONFIDENCE !!!Questions?