GI Treatment Pathways

Question 1

What is the maintenance therapy for Crohn’s disease?

Answer 1

Azathioprine or methotrexate (immunosuppression).

Question 2

What is used to treat an exacerbation of Crohn’s disease?

Answer 2

Steriods (high dose then taper off). If severe IV and if mild-moderate oral.

Question 3

When would you give anti-TNF (infliximab, adalimumab) in Crohn’s disease?

Answer 3

To induce remission and as maintenance in refractory disease.

Question 4

What is the maintenance treatment for UC?

Answer 4

5ASA e.g. mesasalazine (topical).

Question 5

What are the side effects of 5ASAs?

Answer 5

Diarrhoea, idiosyncratic nephritis.

Question 6

What is used to treat an exacerbation of UC?

Answer 6

Steroids (high dose then taper off).

Question 7

What is the purpose of azathioprine or methotrexate in UC?

Answer 7

Steroid sparing.

Question 8

When would you use anti-TNF in UC?

Answer 8

If intolerant of immunomodulation or developing symptoms despite immunomodulation.

Question 9

When is surgery indicated in UC?

Answer 9

If medically unresponsive, intolerable, dysplasia/malignancy, growth retardation in children, attempted resolution of extra-intestinal disease.

Question 10

What is the emergency surgery for UC?

Answer 10

Sub-total colectomy.

Question 11

What are the 2 elective surgeries for UC?

Answer 11

Proctocolectomy with end ileostomy.

Proctocolectomy with ileorectal anastomosis.

Question 12

When is surgery indicated in Crohn’s disease?

Answer 12

If stenosis causing obstruction, enterocutaneous fistula, intra-abdominal fistulas, abscesses, bleeding, free perforation.

Question 13

How would you manage constipation in IBS?

Answer 13

Increase fibre intake but only soluble fibre, simple laxatives (not lactulose).

Question 14

What tests should you carry out if IBS is expected?

Answer 14

FBC, ESR, CRP and coeliac serology.

Question 15

How would you manage diarrhoea in IBS?

Answer 15

Avoid sorbitol, alcohol and caffeine. Reduce fibre intake. Loperamide.

Question 16

How would you manage colic/bloating in IBS?

Answer 16

Antispasmodics e.g. mebeverine or hyoscine.

Question 17

How would you manage psychological symptoms/visceral hypersensitivity in IBS?

Answer 17

Consider CBT and tricyclics e.g. amitryptiline.

Question 18

What are the parts of the Glasgow criteria for assessing severity of acute pancreatitis?

Answer 18

PaO2 low, Age>55, Neutrophilia (WBC>15), calcium low, renal function (urea high), enzymes (LDH and AST high), albumin low, sugar high.

Question 19

What are the 6 steps in the management of acute pancreatitis?

Answer 19

1. Fluid resuscitation.
2. Correct electrolytes.
3. Careful fluid balance.
4. Oxygen.
5. Analgesia.
6. Treat underlying cause e.g. gallstones.

Question 20

What are the 2 surgeries used for chronic pancreatitis?

Answer 20

Pustow procedure - cut open pancreas and stick jejunum in. .

Frey procedure.

Question 21

What are the 5 steps in liver failure management?

Answer 21

1. Rest up to 3 months.
2. Fluids, no alcohol.
3. High protein diet with lots of calories.
4. Sodium bicarbonate bath, colestyramine or ursodeoxycholic acid for itch.
5. Observe for fulminant hepatic failure.

Question 22

How would you treat the complications of liver failure?

Answer 22

Ascites - restrict fluid, low salt diet, weight daily, diuretics (spironolactone first).
Bleeding - IV vit K and platelets, FFP and blood as needed.
Infection - ceftriaxone.
Hypoglycaemia - IV glucose.
Encephalopathy - lactulose, maybe rifamixin (antibiotic).

Question 23

How would you diagnose spontaneous bacterial peritonitis?

Answer 23

Do an ascitic tap in all ascites. Neutrophil count >250cells/mm3.

Question 24

What is the treatment for spontaneous bacterial peritonitis?

Answer 24

Piperacillin and tazobactam, alba (albumin), terlipressin if vascular instability.

Question 25

What would you do to manage variceal bleeding?

Answer 25

1. Terlipressin IV.
2. Broad spectrum antibiotics (piperacillin/tazobactam).
3. Banding.
4. If banding fails, insert Sengstaken-Blakemore tube.

Question 26

When would you refer someone with dyspepsia for an upper GI endoscopy?

Answer 26

If dysphagia or over 55 with persistent symptoms or alarm signs.

Question 27

What would you do with someone who has dyspepsia first?

Answer 27

Stop exacerbating factors and review in 4 weeks.

Question 28

If no improvement after changing lifestyle, what would you do next in dyspepsia?

Answer 28

Test for H.pylori (urease breath test or faecal antigen test).

Question 29

What would you do if the test for H.pylori was negative?

Answer 29

Prescribe a PPI or ranitidine and see them in 4 weeks.

Question 30

What would you do if the test for H.pylori was positive?

Answer 30

Give PPI, amoxicillin (metronidazole if penicillin allergic) and clarithromycin for 1 week.

Question 31

What would you do after H.pylori eradication therapy?

Answer 31

Wait 4 weeks, retest and if +ve try again.

Question 32

What would you do if H.pylori test was positive after 2 lots of eradication therapy?

Answer 32

Refer to a specialist.

Question 33

What is the initial GORD management?

Answer 33

1. Lifestyle advice.
2. Antacids to relieve symptoms.
3. PPI.

Question 34

What would you do if GORD was still symptomatic after initial treatment?

Answer 34

Add ranitidine.

Question 35

What is SEPSIS 6?

Answer 35

B - blood cultures, septic screen, U&Es.
U - urine output - monitor hourly. 
F - fluid resuscitation. 
A - antibiotics IV.
L - lactate measurement. 
O - Oxygen to correct hypoxia.