GI: Presentations

Question 1

What is the differential diagnosis for acute epigastric pain?

Answer 1

• acute pancreatitis
• gastritis/duodenitis
• peptic ulcer disease
• perforated peptic ulcer
• oesophagitis (GORD)
• ruptured AAA
• MI
• mesenteric ischaemia
• biliary disease

Question 2

In a Pt with acute epigastric pain, which drugs should you particularly ask about?

Answer 2

Drugs that can induce peptic ulcer disease:

• NSAIDs
• steroids
• bisphosphonates
• salicylates

Drugs that can induce acute pancreatitis:

• sodium valproate
• steroids
• thiazides
• azathioprine

Question 3

A Pt presents with haematemesis. What are the 4 most common causes? Suggest some rarer causes.

Answer 3

Most common:

1. Oesophagitis/gastritis/duodenitis
2. Bleeding peptic ulcer
3. Oesophageal varices
4. Mallory-Weiss tear

Rarer causes:

1. Oesophageal cancer
2. Gastric cancer
3. Boerhaave’s syndrome
4. Bleeding diathesis
5. Trauma to oesophagus/stomach
6. Vascular angiodysplasia in oesophagus/stomach
7. Arterio-venous malformation
8. Aorto-enteric fistula

Question 4

What scoring system is used to determine severity of haematemesis?

Answer 4

ROCKALL SCORE: used to predict risk of rebleeding and mortality in Pts with upper GI haemorrhage, and as an indicator of severity to guide urgency of endoscopy.

Initial score (pre-endoscopy):

• age: 60-79yrs (1 point); >80 yrs (2 points)
• shock: HR >100bpm (1 point); systolic BP <100mmHg (2 points)
• comorbidities: heart failure, ischaemic disease, any major comorbidities (2 points); renal or liver failure, disseminated malignancy (3 points)

Final score (post-endoscopy):

• stigmata of recent haemorrhage: blood in upper GI tract, adherent clot, visible or spurting BV (2 points)
• diagnosis: mallory-weiss tear or no lesions identified (0 points); all other diagnoses (1 point); malignancy of upper GI tract (2 points)

Question 5

In which 4 cases should a Pt presenting with haematemesis have an emergency OGD?

Answer 5

1. suspicion of continuing upper GI bleeding
2. suspicion of oesophageal varices as cause of bleeding
3. initial Rockall score 3+
4. Pt has aortic graft - suspect aorto-enteric fistula until proven otherwise

Question 6

What investigation should be performed in a Pt presenting with haematemesis if OGD has failed to reveal source of bleeding?

Answer 6

angiography

Question 7

How would you manage a Pt presenting ith ongoing haematemesis?

Answer 7

A-E assessment

1. place 2 wide-bore cannulae and send bloods at same time
2. fluid resuscitation, up to 2L normal saline
3. activate major haemorrhage protocol:
   - give O- RBCs and FFP in at least 2:1 ratio (via blood warmer)
   - tranexamic acid (e.g. 1g bolus in non-traumatic bleeding)
   - platelet concentrates to maintain levels >100 x 10^9
   - repeat coagulation screens after every 4 units to determine need for other blood products, e.g. cryoprecipitate

Question 8

A Pt presents with acute RUQ pain. What is the diffferential diagnosis?

Answer 8

Hepatobiliary system:

1. BILIARY COLIC
2. CHOLECYSTITIS
3. ASCENDING CHOLANGITIS
4. hepatitis
5. cholangiocarcinoma

Other GI conditions:

1. DUODENAL ULCER
2. PANCREATITIS
3. Small bowel obstruction

Non-GI conditions:

1. Basal pneumonia
2. pyelonephritis
3. aortic dissection
4. ruptured AAA