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GI conditions MLA revision Eilidh Simpson Final year ScotGEM studentIBS vs IBD • IBS: Intestinal discomfort; Bowel habit abnormalities; Stool abnormalities + at least 6 months of associated abdominal pain or discomfort • Exclude other causes first • Lifestyle advice; treat symptoms (loperamide; laxatives) • IBD: • Crohn’s: NESTS No blood or mucus; Entire tract affected; Skip lesions; Terminal ileum most affected; Transmural; Smoking is a risk factor; also strictures and fissures • Steroids to induce remission • Maintain remission with azathioprine and mercaptopurine; alternative is methotrexate • Colitis: CLOSEUP Continuous inflammation; Limited to colon and rectum; Only superficial mucosa; Smoking protective; Excrete blood and mucus; Use aminosalicylates; PSC • Mild-moderate acute: aminosalicylate (mesalazine); steroids (oral or rectal) • Severe acute: IV steroids • Mild-mod remission: topical/oral aminosalicylate • Severe remission: oral azathioprine or oral mercaptopurineA 25-year-old woman presents has a 7-month history of crampy abdominal pain with diarrhoea. She has been passing watery stools with some mucus and her symptoms improve with opening her bowels or passing flatus. There is no rectal bleeding or black tarry stools. An abdominal examination is unremarkable and she has no significant family history. When asked, she mentions that diarrhoea is the most bothersome symptom and would like some help. Investigations are performed: Hb 117 g/L (115 - 160) Platelets 200 * 10 /L (150 - 400) WBC 5.3 * 10 /L (4.0 - 11.0) ESR 15 mm/hr (<17) CRP 8 mg/L (<10) What is the next best step in her management? A: Offer bulk forming laxatives B: Offer hyoscine butylbromide C: offer loperamide D: refer to gastro for endoscopy E: test for anti TTGA 25-year-old woman presents has a 7-month history of crampy abdominal pain with diarrhoea. She has been passing watery stools with some mucus and her symptoms improve with opening her bowels or passing flatus. There is no rectal bleeding or black tarry stools. An abdominal examination is unremarkable and she has no significant family history. When asked, she mentions that diarrhoea is the most bothersome symptom and would like some help. Investigations are performed: Hb 117 g/L (115 - 160) Platelets 200 * 10 /L (150 - 400) WBC 5.3 * 10 /L (4.0 - 11.0) ESR 15 mm/hr (<17) CRP 8 mg/L (<10) What is the next best step in her management? A: Offer bulk forming laxatives B: Offer hyoscine butylbromide C: offer loperamide D: refer to gastro for endoscopy E: test for anti TTGA 32-year-old presents with an exacerbation of their ulcerative colitis reporting 6-8 bloody stools per day for 3 days. On exam, they had a mild fever at 38 C and mild tachycardia with a heart rate of 105bpm. All other observations were within normal range and blood results found increased raised inflammatory markers only. The patient was admitted, and remission of the flair achieved with steroid therapy. This is her second admission, with the last being 6 months ago when she presented with similar symptoms and examination/investigation findings. On discharge what medication, if any, should be trialled? : A: No regular treatment B: Oral aminosalicylate C: Oral azathioprine D: Oral methotrexate E: Topical aminosalicylateA 32-year-old presents with an exacerbation of their ulcerative colitis reporting 6-8 bloody stools per day for 3 days. On exam, they had a mild fever at 38 C and mild tachycardia with a heart rate of 105bpm. All other observations were within normal range and blood results found increased raised inflammatory markers only. The patient was admitted, and remission of the flair achieved with steroid therapy. This is her second admission, with the last being 6 months ago when she presented with similar symptoms and examination/investigation findings. On discharge what medication, if any, should be trialled? : A: No regular treatment B: Oral aminosalicylate C: Oral azathioprine D: Oral methotrexate E: Topical aminosalicylateRemember for MLA • Know how to differentiate between Crohn’s and colitis • Remember 2 line treatments • Remember to exclude other causes before IBS • >=2 exacerbations of IBD is severe so this will need more treatment to prevent relapse • Watch out for teratogenic drugs like methotrexate • Don’t forget about coeliac disease: anti-TTG, anti-EMA, dermatitis herpetiformis, anaemia, villous atrophy and crypt hyperplasia • Common causes: peptic ulcers; Mallory-Weiss tear; varices; cancers • Scores: • Glasgow-Blatchford at INITIAL presentation: risk of having UGIB: Includes high urea • Rockall score: AFTER endoscopy: risk of rebleed and mortality Upper GI • Manage: ABCDE; endoscopy within 24 hours; • Terlipressin and abx for variceal bleed before endospcy bleed • Beta blocker for variceal bleed after endoscopy • PPI after band ligation for variceal bleed • PPI only AFTER endoscopy in NON-variceal bleedA 63-year-old man with a longstanding history of alcoholism is currently recovering post-procedure in the gastroenterology ward. He was admitted to the Emergency Department yesterday due to repeated episodes of vomiting, during which he vomited approximately one cup of blood and experienced severe epigastric pain. He had already undergone endoscopic variceal band ligation with appropriate pre-procedure prophylaxis yesterday. The patient has no known past medical history or allergies. What medication should be prescribed for this patient? A: IV terlipressin B: IV terlipressin; omeprazole; prophylactic antibiotics C: oral bisoprolol D: oral prophylactic antibiotics E: oral propanololA 63-year-old man with a longstanding history of alcoholism is currently recovering post-procedure in the gastroenterology ward. He was admitted to the Emergency Department yesterday due to repeated episodes of vomiting, during which he vomited approximately one cup of blood and experienced severe epigastric pain. He had already undergone endoscopic variceal band ligation with appropriate pre-procedure prophylaxis yesterday. The patient has no known past medical history or allergies. What medication should be prescribed for this patient? A: IV terlipressin B: IV terlipressin; omeprazole; prophylactic antibiotics C: oral bisoprolol D: oral prophylactic antibiotics E: oral propanololRemember for MLA • Remember risk factors for ulcers: NSAIDs, H pylori • Remember that anticoag can increase risk of bleed from ulcers • Watch out for haemodynamically unstable patients in questions: low BP, tachycardia, signs of shock • Remember when to use scores, rather than specific details from scores • Acute Cholecystitis: • Inflammation IN gallbladder, caused by blocked duct • Murphy’s sign • Aaround GBirst: thickened GB wall, stones/sludge; fluid • MRCP if can’t see on USS • Manage: remove within 72h of symptoms, or leave 6-8weeks then remove; ERCP to remove stones Cholecystitis vs • Acute Cholangitis: • Bile duct inflammation Cholangitis • Causes: obstruction; infection from ERCP (e coli, klebsiella, enterococcus) • CHARCOT’s triad: RUQ pain; fever; jaundice • Manage: NBM; IV fluids; blood cultures; IV abx • ERCP to remove stones • PTC (percutaneous transhepatic cholangiogram): drain through liver to bile ducts if ERCP failedA 52 year old man presents to the emergency department with acute abdominal pain and feeling unwell. He is normally fit and well and enjoys long distance running. His past medical history includes a broken finger from an old cricket injury and gallstones that he has never been troubled by. On examination he is noted to have icteric sclera. His heart rate is 106 bpm with a blood pressure of 125/85mmHg. His temperature is 38.1ºC. There is marked rebound tenderness and guarding in the right upper quadrant. Bowel sounds are quiet. What is the most likely diagnosis? A: Pancreatic malignancy B: Gallbladder malignancy C: Acute cholecytitis D: Ascending cholangitis E: Gallstone ileusA 52 year old man presents to the emergency department with acute abdominal pain and feeling unwell. He is normally fit and well and enjoys long distance running. His past medical history includes a broken finger from an old cricket injury and gallstones that he has never been troubled by. On examination he is noted to have icteric sclera. His heart rate is 106 bpm with a blood pressure of 125/85mmHg. His temperature is 38.1ºC. There is marked rebound tenderness and guarding in the right upper quadrant. Bowel sounds are quiet. What is the most likely diagnosis? A: Pancreatic malignancy B: Gallbladder malignancy C: Acute cholecytitis D: Ascending cholangitis E: Gallstone ileusA 45-year-old woman presents to the emergency department. She is in intense pain in the right upper quadrant of her abdomen, is pyrexic, and is both tachycardic and tachypnoeic. Which of the following is this woman most likely suffering from? A: acute cholangitis B: Acute cholecystitis C: Acute pancreatitis D: Biliary colic E: Gallstone ileusA 45-year-old woman presents to the emergency department. She is in intense pain in the right upper quadrant of her abdomen, is pyrexic, and is both tachycardic and tachypnoeic. Which of the following is this woman most likely suffering from? A: acute cholangitis B: Acute cholecystitis C: Acute pancreatitis D: Biliary colic E: Gallstone ileus • Primary biliary cholangitis: • Autoimmune: attacks small bile ducts in liver; causes obstructive jaundice, liver disease • Typical: white woman, 40-60y, abnormal LFTs (raised AlkPhos) • Autoantibodies: AMA (diagnostic); ANA ; also, raised IgM • Treat: ursodeoxycholic acid • M rule: IgM; aMa; Middle aged females • Primary sclerosing cholangitis: • Condition in intrahepatic and extrahepatic bile ducts: inflamed, form strictures PBC vs PSC • Typical: male, aged 30-40, UC, FHx • LFTs: raised AlkPhos • Autoantibodies: NOT helpful for diagnosis but can have: p-ANCA; ANA, anti-SMA • MRCP is diagnostic; should also do colonoscopy for ?UC • Treat: no specific treatments; ERCP for strictures; cholestyramine for pruritus; replace fat soluble vitamins • Monitor for cholangiocarcinoma A 45-year-old woman has 8 months of fatigue and pruritus. Despite scratching, she experiences no relief and there is no associated rash. She has Hashimoto's thyroiditis treated with levothyroxine and her grandmother had ulcerative colitis. She has never drank alcohol. An examination reveals xanthelasma around the eyes. Blood tests show: Hb 120 g/L 160) - Platelets 3149* (150 - 10 /L 400) WBC 8.5 * (4.0 - 10 /L 11.0) Bilirubin 28 µmol/L (3 - 17) ALP 291 u/L (30 - 100) ALT 84 u/L (3 - 40) γGT 135 u/L (8 - 60) Albumin 37 g/L (35 -50) What test is most specific for the likely diagnosis? A: Anti-liver/kidney microsomal type 1 antibodies B: Anti-mitochondrial antibodies C: Anti-nuclear antibodies D: Anti smooth muscle antibodies E: Perinuclear anti-neutrophil cytoplasmic antibodies A 45-year-old woman has 8 months of fatigue and pruritus. Despite scratching, she experiences no relief and there is no associated rash. She has Hashimoto's thyroiditis treated with levothyroxine and her grandmother had ulcerative colitis. She has never drank alcohol. An examination reveals xanthelasma around the eyes. Blood tests show: Hb 120 g/L 160) - Platelets 3149* (150 - 10 /L 400) WBC 8.5 * (4.0 - 10 /L 11.0) Bilirubin 28 µmol/L (3 - 17) ALP 291 u/L (30 - 100) ALT 84 u/L (3 - 40) γGT 135 u/L (8 - 60) Albumin 37 g/L (35 -50) What test is most specific for the likely diagnosis? A: Anti-liver/kidney microsomal type 1 antibodies B: Anti-mitochondrial antibodies C: Anti-nuclear antibodies D: Anti smooth muscle antibodies E: Perinuclear anti-neutrophil cytoplasmic antibodies • Acute: • Rapid onset, normal function returns after • vomitingic pain radiating to back; systemically unwell; associated • Bloods: amylase is >3x upper limit in acute pancreatitis; lipase, more sensitive and specific Acute Vs • Score: Glasgow score: severity of pancreatitis: 0-3 • Manage: supportive: usually improve within 3-7 days Chronic Pancreatitis • Chronic: • 3 key causes: gallstones; alcohol; post-ERCP • Chronic epigastric pain; loss of exocrine and endocrine function (faecal elastase); damage and strictures • Manage: abstain from alcohol and smoking; analgesia, replace enzymes; ?insulin if DM; surgery?; ERCP with stentsA 61-year-old man is admitted to the hospital with severe abdominal pain that is typically worst shortly after eating a meal. He admits to regularly drinking at least 25 units of alcohol per week for the last 30 years and has recently been diagnosed with type 2 diabetes mellitus by his GP. An abdominal CT scan shows calcification of his pancreas. Given the likely diagnosis, which of the following tests can be used to assess this organ's exocrine function? A: Faecal calprotectin B: Faecal elastase C: Serum amylase D: Serum calcium E: Serum lipaseA 61-year-old man is admitted to the hospital with severe abdominal pain that is typically worst shortly after eating a meal. He admits to regularly drinking at least 25 units of alcohol per week for the last 30 years and has recently been diagnosed with type 2 diabetes mellitus by his GP. An abdominal CT scan shows calcification of his pancreas. Given the likely diagnosis, which of the following tests can be used to assess this organ's exocrine function? A: Faecal calprotectin B: Faecal elastase C: Serum amylase D: Serum calcium E: Serum lipaseA 67-year-old man presents to the GP with a history of pale and oily stools over the past 2 weeks. There is no pain during or after defecation, and the patient feels well at rest. He has previously been diagnosed with chronic pancreatitis after being referred to an endocrinologist for chronic postprandial pain, which he still suffers from. He has drank 20 units of alcohol a day for the past 40 years and continues to do so. Alongside the chronic pancreatitis, he has been diagnosed with type 2 diabetes and hypertension, for which he takes daily amlodipine and metformin. What is the most appropriate management? A: Cholestyramine B: ERCP C: Loperamide D: Pancreatic enzyme supplement E: PancreaticoduodenectomyA 67-year-old man presents to the GP with a history of pale and oily stools over the past 2 weeks. There is no pain during or after defecation, and the patient feels well at rest. He has previously been diagnosed with chronic pancreatitis after being referred to an endocrinologist for chronic postprandial pain, which he still suffers from. He has drank 20 units of alcohol a day for the past 40 years and continues to do so. Alongside the chronic pancreatitis, he has been diagnosed with type 2 diabetes and hypertension, for which he takes daily amlodipine and metformin. What is the most appropriate management? A: Cholestyramine B: ERCP C: Loperamide D: Pancreatic enzyme supplement E: PancreaticoduodenectomyRemember for MLA • Any ?surgical patient: nil by mouth, NG tube, IV fluids • Remember to look for Charcot’s triad in the question • Watch for sepsis: 1 line sepsis six before surgery • Revise the different antibodies and what they’re associated with • Work out how much amylase has risen by if given bloods • Remember amylase can also rise in small bowel obstructionReferences: https://www.passmedicine.com/menu.php https://www.nice.org.uk/about/what-we-do/our- programmes/nice-guidance/nice-guidelines https://zerotofinals.com/