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GI/LiverA 73-year-oldman presents with difficulty swallowing. He struggles with solids. Swallowing is not painful. His wife has noticedthat he has very badbreath, even worse than usual. Sometimes, he regurgitates undigestedfood. In clinic today he has a sipofwater andyou note gurgling noises upon swallowing. Which ofthe following investigations wouldbe most useful?A barium swallow is performedon this another patient that has had problems swallowing. Given the most likely diagnosis what is an appropriate next stepin management ?A 56-year-old man was admitted to the hospital presenting difficulty in swallowing. He had type 2 diabetes and hypertension. He suddenly felt unwell and subsequently noticed he could swallow solids, but not liquids, so he came to the hospital for evaluation within the first 24 h hours after the onsetof symptoms. On examination, he was alert andoriented, but he lookedanxious andwas very concernedabout his pharyngeal discomfort. The patient hadno dysarthria. Sensory anddeeptendon reflex examination was normal. No dysphonia, ptosis or facial muscle weakness normal, pharyngeal reflex was not examined.on was performed and was What is the next most important investigation for this patient?Dysphagia • Solids then liquids à think stricture • Benign: Oesophageal ring, pharyngeal pouch (Zenker’s diverticulum) etc • Malignant: Oesophageal cancer, lung cancer, lymphoma etc • Solids and liquids à think motility problem • Achalasia, bulbar palsy, systemic sclerosis etc Tends to be felt as Occurs soon after eating something stuck in chest associated with coughing behind the sternumOesophageal spasm • Tends to be very painful and symptomatic • Manage with oral calcium channel blocker initially +- PPI if there are GORD symptomsA 65-year-oldman present with difficulty swallowing solids, odynophagia andretrosternal chest pain. He has lost 5kg ofweight in the last 6months andhis BMI is now 30. Past medical history includes hypertension, hypercholesterolaemia, T2DM, asthma, GORD, Barrett's oesophagus andan appendicectomy. He drinks around20 units ofalcohol per week anddoes not smoke. An endoscopy is performedandbiopsies sent tothe lab. A barium swallow is performedandshows a loweroesophagel stricture with an 'apple core' effect. What is the most likely diagnosis?A 56year oldman comes tothe GP he has a long term history ofheart burn this was treatedby a GP with a PPI for 8weeks but this remains andhas noimprovement. He is a smoker andhas a BMI of35andhis weight is stable. On bloods his Haemoglobin is 150Men: 135-180g/l Mean cell volume: 9082-100fl Platelets 400150-400109/l Whitebloodcells104.0-11.0109/l Neutrophils 62.0-7.0109/l Lymphocytes1.51.0-3.0109/l What is the appropriate next stepinmanagemnet. Oesophageal Cancer Adenocarcinoma Squamous cell carcinoma Lower 1/3rd oesophagus Upper oesophagus Site Common Risk GORD Smoking Factors Obesity Alcohol Metabolic syndrome Diet: nitrosamines, red meat etc More common (45%) Less common (40%) Epidemiology Stage dependent Treatment • Surgery first line if possible: Endoscopic resection + ablation or oesophagectomy. • Chemo +/- radiotherapy if not surgical candidate • Stage IV: surgery not indicated à CT +/- RT, palliationA 54-year-oldwoman goes tothe GP with heartburn andepigastric pain. The pain is worse just after meals. She is able toswallow solids andliquids normally anddoes not have any other symptoms. Sheis otherwise well with nopast medical history ofnote anddoes not use any regular medication. The GP advises OTC antacids, but she returns 4weeks later with no improvement ofher symptoms. What is the next best stepfor this patient?A H. pylori test comes back positive. Which ofthe following is the most appropriate treatment?Which ofthe following features wouldbe an indication for urgent upper GI endoscopy?A 45year oldpatient presents with recurrent epigastric pain this is typically worse when they are hungry . They say that they have taken tosnacking more as this helps with the pain andthis means they have gaineda bit ofweight. What is the most likely diagnosis?When is Screening for bowel cancer offeredin Scotland?Dyspepsia Management • If symptoms resolve à no further action is required • Lifestyle changes • Weight loss • Smoking cessation • Small, regular meals etc • Avoid • Alcohol • Coffee • Chocolate • NSAIDs • Calcium channel blockers Dyspepsia – ALARM Symptoms A naemia (Fe deficiency) L oss of weight A norexia R ecent onset/progressive M elaena/haematemesis S wallowing difficultyTimelines for OGD Referral • Non-urgent (6 weeks) if ≥55 y/o with: • Treatment resistant dyspepsia or • Upper abdo pain with low Hb • ↑ platelets with any of: N&V, weight loss, reflux, dyspepsia, upper abdo pain • N&V with any of the following: weight loss, reflux, dyspepsia, upper abdo pain • 2 weeks • Dysphagia OR • ≥55 y/o with weight loss and one of: upper abdo pain, reflux, dyspepsiaOther cancer red flags • Over 40 painless progressive jaundice> carcinoma head of pancreas till proven otherwise 2 week referral CT pancreas • Palpable liver mass unexplained US in 2 weeks • Refer adults using a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer if: • they are aged 40 and over with unexplained weight loss and abdominal pain or • they are aged 50 and over with unexplained rectal bleeding or • they are aged 60 and over with: • iron-deficiency anaemia or • changes in their bowel habit, or • tests show occult blood in their faeces.Which ofthe following is the most common cause ofascites?In the treatment ofascites which is the 1st linetreatment?AscitesAscites management 1. A-E have low threshold for IV antibiotics (cefotaxime) if spontaneous bacterial peritonitis suspected 2. Ascitic tap and sample fluid 1. Most common organism = E. coli 3. Na restriction needs to be strict (generally not enough on its own) 4. Diuretics 1. Spironolactone 1st line 2. Furosemide if more serious, commonly used in combinationA 34-year-oldman comes tothe A&E complaining ofpale stools and dark urine for 3weeks. He has a long Hx ofalcohol excess. O/E there is ankleandabdominalswelling. HR93, BP 90/60. Ifan abdominal ultrasound, what is most likely toobserved?A 34-year-oldman comes tothe A&E complaining ofpale stools and dark urine for 3weeks. He has a Hx ofalcohol excess. O/E there is ankleandabdominalswelling. HR93, BP 90/60. He has been diagnosedwith cirrhosis. Which ofthe following treatments is most important?A 35 year old women presents to her GP after turning yellow. Her medical history involves severe raynauds disease , she states that she is also very joints.ve to the sun and that she has problems with intermittently swollen LFTS which show an isolatedelevatedbilirubin. Which test wouldalso beeyond done initially to helpinvestigate this ladys jaundice?Conjugated bilirubin is water soluble and therefore causes dark urine. Obstruction means Bilirubin does not pass from bile to GI tract. Causing pale stoolsCopyrights apply Primary Biliary Cholangitis • Features • Assc. Sjogren’s, RA, systemic sclerosis, thyroid • Female, fatigue, itchy • O/E: xanthelasmas, clubbing, hepatosplenomegaly • Investigations • AMA (+ve in 98%), • Smooth muscle Ab (30%), serum IgM • MRCP – exclude extrahepatic biliary obstruction • Management • 1 line: Ursodeoxycholic acid • Itch: Cholestyramine • N.B. At 20x risk of hepatocellular carcinomaPrimary Sclerosing Cholangitis • Biliary disease of unknown aetiology • Risk factors: UC, Crohn’s, HIV • Fe• Cholestasis – jaundice, itch • RUQ pain • Fatigue • Investigations • Raised bilirubin & ALP • MRCP – beaded biliary tree • p-ANCA +ve • Complications • Cholangiocarcinoma (10%) • Colorectal cancer• haematemesis.Sheistransfered toresus.Her BPis112/80hisheartrateis 110bpmRR16,CRP<2s.Shedeniesabomdinalpainormaleana.Shehasno PMHofnote.Sheisgiven2largeboreIVcannulasand plasmalyteasinitail resusfluid.Sheremainsstableinitailwithpulsedroppingto100. • Herbloodscomebackas • Investigations Haemoglobin135g/L(115-165) MCV85fL(80-96) Whitecellcount9x109/L(4.0-11.0) Platelet380x109/L(150-400) • Urea6.0mmol/L(3.0-7.0) Creatinine80umol/L(60-110) • Whatisthemostappropriatenextstep inmanagement?Oesophageal Varices • Develop in most patients with cirrhosis – complication of portal hypertension – only 1/3 will bleed from them. • ABCDE – platelets, fresh frozen plasma, prothrombin complex concentrate Treatment • Propranolol or carvedilol (prophylactically) • Endoscopic variceal ligation (moderate/large varices without bleeding) • Terlipressin infusion – vasoactive drug (acute resuscitation) • Sengstaken-Blakemore tube • TIPSS – transjugular intrahepatic portosystemic shunt (when pharmacological/endoscopic treatment fails)A 42-year-old obese woman complains of episodes of moderate intermittent RUQ pain lasting 30 minutes which radiates to her shoulder after two young children while her partner works abroad. She is otherwiseking well and abdominal examination was unremarkable. Bloods were normal andyou discuss further investigations with your senior. What is the most likely diagnosis?An ultrasoundscan confirms the presence ofgallstones in the gallbladder. There are none in the common bileduct. What is the most appropriate immediate management?A53-year old femalecarehomeassistantcomplainsof increasing debilitating fatiguefor 6 months. Shebelievesitmay beher Hashimoto'sso wantsto discussaltering her doseof levothyroxine. On further questioning sherevealsshehasalso been experiencing an occasional symptomsof note. Her pastmedical history includesHashimoto'sdisease, mild asthma, carpal tunnel syndromeand a subtotal hysterectomy. Her medicationsincludelevothyroxine100mcg od and a salbutamol inhaler prn. ShehasNKDA, isa non-smoker and drinksonly occasionally at events. T4: 120 (70-140mmol/l); TSH: 3.0 (0.5-5.7mI/L)reshown below: AST/ALT: 42 (5-35), AlkPhos: 240 (30-150), bilirubin: 10 (3-17), GGT: 115 (, albumin (35-50) Given thediagnosis, whichof thefollowing ismostlikely to confirm themostlikely diagnosis?Risk Factors and Complications of Gallstones •Female •Fat •Forty + •Fertile •Fair •Cholelithiasis = stones in gallbladder •Choledocholithiasis= stones in bile duct Biliary colic Acute cholecystitis AcuteCholangitis • Intermittent • Epigastric/RUQ pain • Charcot’s triad epigastric / RUQ pain +/- biliary colic • RUQ pain • Nausea • N&V, fever, anorexia • Fever +/- rigors • Jaundice • Triggered by fatty • Tachycardia, food peritonism, +ve • No systemic Murphy’s sign symptoms • Neutrophilia, US à thick gallbladder • Blood results normalA patient with a history ofgallstones presents with acute upper epigastric pain, radiating tothe back alongsidenausea andvomiting. Given the most likely diagnosis what is the most important next step in management?Which ofthe following tests is most useful in the assessment of pancreatic exocrine function? Acute Pancreatitis Severity Prediction – Modified Glasgow Criteria • P aO2 <8kPa • A ge >55 years • N eutrophilia WBC >15x10^9/L • C alcium • R enal function Urea >16mmol/L • E nzymes AST>200iu/L; LDH >600iu/L • A lbumin >32g/L • S ugar blood glucose >10mmol/L Acute Pancreatitis - Causes • Gallstones • Steroids • Ethanol • Mumps • Trauma • Autoimmune • Scorpion venom • Hyperlipidaemia, hypothermia, • Important ones! hypercalcaemia • ERCP • Drugs Acute Pancreatitis Cullen’s Sign Grey-Turner SignManagement of acute pancreatitis 1. A-E and access need for critical care can be very sick 2. Nil by mouth and IV fluids large volumes 3. Analgesia and antiemetics 4. Antibiotics not generally required only if high fever and sigs suggestive of localised infection 5. Start oral diet as soon as tolerable 6. If related to gallstones then cholecystectomy done during same admissionA 20-year-oldwoman visits her GP. For the last month, she has been suffering from abdominal pain which is worst in the right iliac fossa. She has alsohaddiarrhoea for the past month andhas hadtorun for the toilet a few times but has never been incontinent. Her girlfriend thinks she has lost weight toobut she doesn't regularly weigh herself socan't be sure. She denies nausea, vomiting, dyspepsia, abdominal distension anddoes not recall seeing any bloodin her stool. On examination, you note an ulcer in her mouth, a tender abdomen andswollen tender lumps on her shins. Which ofthe following investigations woulddefinitively confirm the diagnosis?This patient is referredto a gastroenterologist anda diagnosis of Crohn’s disease is made. Which of the following is usedto induce remission of mild Crohn’s disease?Which of the following is NOTa feature associatedwith Crohn's disease?A 25-year-oldman with a backgroundofGilbert's syndrome, ankylosing spondylitis, anddepression is referredtothe gastroenterology department with a 2-month history ofdiarrhoea ~5 times a day, urgency, frequency andrectal bleeding. He is a marine biologist, non-smoker, drinks 14units per week andhas 2pet cats. Abdominal examination was normal. Bloodresults show mild anaemia anda raisedESR. Stoolcultures werenegative. A colonoscopy is arranged. What is the most likely diagnosis?Which ofthe following is not a component ofthe Truelove andWitts criteria for assessing the severity ofulcerative colitis?The 25-year-oldmarine biologist is prescribeda course oforal prednisolone, sulfasalazine andsteroidenemas toinduce remission ofhis ulcerative colitis. This has failedandhe has know developed abdominal swelling andpneumoperitoneum is seen on erect CXR. Which ofthe following is likely tobe requiredin the management of this patient's condition?What is the maintenance therapy that is usedfor 1rst line left sided UC?Truelove and Witts Criteria – Ulcerative Colitis Mild UC Moderate UC Severe UC Bowel movements per <4 4-6 >6 day Rectal bleeding Small amount Moderate amount Large amount Temperature (Celsius) – Apyrexial 37.1-37.8 >37.8 measured at 6am Resting heart rate <70 bpm 70-90 bpm >90 bpm Haemoglobin >110g/L 105-110g/L <105g/L ESR <30 >30Management of Severe UC • IV fluids and electrolytes as required • Methylprednisolone 60mg IV • If no improvement after 2 hours or worsening despite Tx – ciclosporin • Bloods + stools samples • Heparin thromboprophylaxis • Surgery if : • Severe attacks that do not respond to medical treatment • Complications of a severe attack • Megacolon • perforation • Malignancy or dysplasiaMaintenance Therapy for UC • Mild to moderate treat with topical mesalazine for proctitis • Oral mesalazine if more widespread • Maintenance: PR or PO azathioprine • If >2 relapses in past year – PO azathioprine or mercaptopurine • N.B. requires TPMT testing prior to initiating treatmentManagement of Crohn's Induction 1. Induction= Corticosteroid 1. Prednisolone 1st line budesonide less effective but less side effects (offered those that don’t tolerate pred well) 2. Maintaining remission = Azathioprine or mercaptopurine 3. Methotrexate (N.B. know side effects) 4. Infliximab 5. Surgery required in 80%Methotrexate side effects • Mucositis • Myelosuppression • Pneumonitis • Pulmonary fibrosis • Liver fibrosisCrohn's Maintenance 1. STOP SMOKING 2. Azathioprine 1. Good treatment but linked to serious rare bone marrow suppression and pancreatitis and very rarely drug induced hepatitis 3. Methotrexate 1. Should only be used if required for remission or azathioprine ineffective 4. Anti-TNFA 30-year-oldwoman presents with chronic diarrhoea. She reported that her stools float andare difficult toflush away, although there is nochange in the colour ofher urine. She does not smoke nor drink. The table shows her bloodresults. Which ofthe following is the most likely diagnosis?Coeliac disease • 1st line investigation: IGA TTG • If IGA defiency then IgG DGP • Tx : gluten-free dietA 48yo homeless man has developed difficulty breathing and has palpitations. He is recovering in hospital following an alcoholic binge of over 100 units several days ago and has been encouraged to eat and drink normally prior to discharge. He is very unkempt. His BMI is 19. T36.7 ° C, HR 95bpm, BP 115/80mmHg, SaO 2 98% on 4L oxygen. Which single pair of tests is the most appropriate next step?Heart failure , diaphragmatic The Refeeding Syndrome paralysis SeizuresGood Luck!