Gastrointestinal Protocols Training (Day 1)
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The document outlines protocols for the diagnosis and management of gastrointestinal disorders such as gastroesophageal reflux disease (GERD), dysphagia, peptic ulcer disease (PUD), and Helicobacter pylori (H. pylori) infections, emphasizing current guidelines and treatment options. Key recommendations include the use of proton pump inhibitors (PPIs) for GERD and PUD, diagnostic testing for dysphagia, and eradication therapy for H. pylori in specific patient populations. It also addresses management strategies for complications and considerations for special patient groups.
Gastrointestinal Protocols Training (Day 1)
- 1. GI Protocols Training (Day 1) PROF. DR. MOHAMED-NAGUIB WIFI P R O F E S S O R O F M E D I C I N E A N D H E P A T O G A S T R O E N T E R O L O G Y , C A I R O U N I V E R S I T Y H E A D O F G I T D E P A R T M E N T , S H A R M I N T E R N A T I O N A L H O S P I T A L
- 2. GERD
- 3. Introduction •Gastroesophageal Reflux Disease (GERD) is a condition where gastric contents reflux into the esophagus, causing symptoms such as heartburn and regurgitation. •The protocol aims to provide guidance on diagnosis, management, and treatment options based on the 2024 ACG guidelines.
- 4. Diagnosis Symptoms Diagnostic Approach Classic Symptoms Empiric PPI trial (8-week course), especially in the absence of alarm symptoms. Persistent Symptoms Diagnostic endoscopy if GERD symptoms persist despite PPI therapy, or if alarm symptoms (e.g., dysphagia, bleeding) are present. Atypical Symptoms Perform pH or impedance-pH testing if extraesophageal symptoms (e.g., chronic cough) are present and GERD is suspected.
- 6. TTT recommendations Treatment Dosing Recommendation Proton Pump Inhibitors (PPI) or Vonoprazan Once daily before meals Strong recommendation for initial therapy, especially for patients with typical symptoms of GERD. PPI or Vonoprazan for Erosive Esophagitis Twice daily before meals Strong recommendation for healing erosive esophagitis and preventing recurrence. Weight Loss in Obese Patients Lifestyle modification Strong recommendation, particularly in patients with BMI >25 or recent weight gain. Avoid Meals Before Bedtime Avoid eating 2-3 hours before sleep Conditional recommendation to improve nocturnal symptoms. Elevate Head of Bed Elevate 6-8 inches Conditional recommendation for patients with nocturnal GERD. Step-down Therapy Intermittent PPI or on-demand therapy Conditional recommendation in patients with non-erosive GERD who respond to PPI therapy.
- 7. GERD Medications Summary Medication Class Main Use in GERD Proton Pump Inhibitors (PPIs) First-line therapy for moderate to severe GERD and erosive esophagitis. Vonoprazan (PCAB) Alternative to PPIs with faster acid suppression, used for refractory GERD and H. pylori treatment. H2-Receptor Antagonists (H2RAs) Mild to moderate GERD, especially useful for nocturnal symptoms and in combination with PPIs. Antacids Short-term relief of mild GERD symptoms; not for long-term management. Prokinetics Adjunctive therapy for GERD, especially in patients with motility disorders or delayed gastric emptying.
- 8. Special Situations Patient Population Special Considerations Pregnant Patients Use antacids or sucralfate as first-line therapy. Consider H2RAs or PPIs if lifestyle measures are insufficient. Patients with Barrett's Esophagus Long-term PPI therapy is recommended to reduce the risk of esophageal adenocarcinoma. Patients with NSAID Use Strongly consider PPI therapy to prevent erosive esophagitis, especially if long-term NSAID therapy is necessary.
- 9. Refractory GERD Condition Next Steps Persistent Symptoms on PPI Optimize PPI therapy (ensure proper dosing before meals). Consider twice-daily PPI or referral for diagnostic testing such as pH monitoring. Regurgitation Despite PPI Consider anti-reflux surgery or endoscopic treatments such as transoral incisionless fundoplication (TIF).
- 10. Dysphagia
- 11. Introduction •Dysphagia is the difficulty in swallowing that can occur due to various causes, including neurological disorders, structural abnormalities, or systemic diseases. •The following protocol outlines a step-by-step approach for the diagnosis and management of dysphagia, focusing on clinical assessment, diagnostic testing, and therapeutic interventions.
- 12. Initial Assessment Assessment Component Key Points Details History Identify onset, duration, and progression of symptoms, including solids or liquids causing difficulty. Ask about recent weight loss, cough during eating, regurgitation, heartburn, or aspiration. Risk Factors Review for history of GERD, stroke, neurological diseases, head and neck cancer, or previous surgeries. Consider smoking, alcohol use, and long-term medication use (e.g., NSAIDs, PPIs). Alarm Symptoms Screen for weight loss, progressive symptoms, pain with swallowing (odynophagia), and frequent choking. Alarm symptoms may indicate malignancy or severe esophageal disorders, requiring urgent intervention.
- 13. Alarm Symptoms
- 14. Diagnosis Test/Procedure Indications Details Barium Swallow Initial imaging test to visualize esophageal motility and identify structural abnormalities. Detects narrowing (strictures), achalasia, and motility disorders. Upper Endoscopy (EGD) Indicated for alarm symptoms, suspected esophageal cancer, or persistent/refractory dysphagia. Provides direct visualization of the esophagus, allows for biopsies, and can treat strictures. Esophageal Manometry Used when a motility disorder like achalasia or diffuse esophageal spasm is suspected. Measures the pressure and coordination of esophageal contractions and the function of the lower esophageal sphincter (LES). 24-Hour pH Monitoring Indicated in patients with GERD-related dysphagia, especially with normal endoscopy results. Assesses acid exposure in the esophagus and correlates it with dysphagia symptoms. Videofluoroscopic Swallowing Study (VFSS) Recommended in patients with oropharyngeal dysphagia to evaluate the coordination of swallowing muscles. Identifies aspiration risk and helps guide therapeutic interventions such as speech therapy.
- 15. Diagnosis Parrot peak HRM: absent esophageal peristalsis pathognomonic for achalasia
- 16. Type Key Causes Examples Oropharyngeal Dysphagia Neurological or muscular disorders affecting the initiation of swallowing. Stroke, Parkinson's disease, multiple sclerosis, myasthenia gravis. Esophageal Dysphagia Structural or motility disorders of the esophagus that cause difficulty with passage of food. GERD, esophageal cancer, strictures, achalasia, esophagitis, or peptic ulcer disease. Functional Dysphagia Dysphagia without any structural or motility abnormalities, often associated with functional disorders. Globus sensation, functional esophageal disorders, anxiety-related swallowing issues. Classification of Dysphagia
- 17. TTT Condition Treatment Options Details GERD-Related Dysphagia Proton Pump Inhibitors (PPIs), H2-receptor antagonists, lifestyle modifications (e.g., weight loss, diet). PPIs are the first-line treatment to reduce acid exposure and inflammation. Achalasia Per-oral Endoscopic Myotomy (POEM), pneumatic dilation, or Heller myotomy surgery. POEM, pneumatic dilation or surgery offers more permanent relief. Oropharyngeal Dysphagia Speech and swallowing therapy, dietary modifications, enteral feeding if needed. Therapy focuses on improving swallowing mechanics and preventing aspiration.
- 19. Peptic Ulcer
- 20. Introduction •Peptic ulcer disease (PUD) includes ulcers located in the stomach (gastric ulcers) or duodenum (duodenal ulcers). •These ulcers develop due to the imbalance between mucosal protective factors and aggressive factors such as gastric acid, pepsin, or Helicobacter pylori infection.
- 21. Risk Factors Risk Factor Details Helicobacter pylori (H. pylori) A common cause of PUD, especially in duodenal ulcers. Infection requires eradication therapy. NSAID Use Nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk of gastric and duodenal ulcers. Aspirin and Anticoagulants Long-term use of low-dose aspirin or anticoagulants raises the risk of ulcer formation and bleeding. Smoking Smoking impairs mucosal defenses and delays ulcer healing. Excessive Alcohol Use Alcohol irritates the gastric lining and can contribute to ulcer development. Chronic Conditions Conditions like liver cirrhosis, renal failure, or chronic obstructive pulmonary disease (COPD) increase the risk of ulcers.
- 22. Diagnosis Test/Procedure Purpose Upper Endoscopy (EGD) Gold standard for visualizing ulcers and obtaining biopsies. Recommended for patients with alarm symptoms (e.g., bleeding, weight loss). H. pylori Testing Use urea breath test, stool antigen test, or biopsy for H. pylori detection in symptomatic patients or those with a history of ulcers. Laboratory Tests Complete blood count (CBC) to assess anemia, serum electrolytes, and liver function tests in patients with complications. Fecal Occult Blood Test Detects hidden gastrointestinal bleeding.
- 25. Indications for Ward Admission Criteria Details Uncomplicated Peptic Ulcer Patients with non-severe, uncomplicated ulcers that require observation, IV PPI therapy, and monitoring. Mild to Moderate GI Bleeding Patients with evidence of upper GI bleeding (melena, hematemesis) but hemodynamically stable. H. pylori Treatment Patients requiring inpatient care for IV antibiotic treatment of H. pylori when outpatient care is not feasible. Failure of Outpatient Management Patients with ulcers not responding to outpatient PPI or eradication therapy. Comorbidities Patients with ulcers and stable comorbid conditions (e.g., cardiovascular disease, diabetes) that require monitoring.
- 26. Indications for ICU Admission Criteria Details Hemodynamically Unstable Bleeding Patients with active upper GI bleeding and hemodynamic instability (hypotension, tachycardia) despite resuscitation efforts. Perforated Peptic Ulcer Patients with a perforated ulcer presenting with peritonitis, requiring emergency surgery or intensive monitoring. Severe GI Bleeding Patients with significant GI bleeding requiring multiple blood transfusions or ongoing active bleeding despite endoscopic intervention. Refractory or Massive Bleeding Patients who require repeated endoscopic therapy or interventional radiology for ongoing or recurrent bleeding. Septic Shock Due to Perforation Patients with sepsis due to perforated ulcers or other complications, requiring vasopressors and ICU-level support. Acute Respiratory Distress Syndrome (ARDS) Patients with peptic ulcer perforation leading to sepsis and multi-organ failure, requiring mechanical ventilation.
- 27. Initial Management Treatment Indication Dosage Proton Pump Inhibitors (PPIs) First-line therapy for PUD to reduce gastric acid secretion and promote healing. Esomeprazole, Omeprazole 20-40 mg once daily for 4-8 weeks. H2-Receptor Antagonists Alternative in cases where PPIs are contraindicated or not tolerated. Ranitidine 150 mg twice daily or 300 mg at bedtime for 4-8 weeks. H. pylori Eradication For H. pylori-positive patients, using triple therapy (PPI + antibiotics). PPI + Amoxicillin 1 g + Clarithromycin 500 mg twice daily for 10-14 days. NSAID Discontinuation Stop NSAIDs in patients with NSAID-induced ulcers. If discontinuation is not possible, continue PPIs. Maintain PPI therapy while NSAIDs are used.
- 28. Management of complications Complication Management Bleeding Ulcer Endoscopic hemostasis is performed in actively bleeding ulcers, followed by high-dose PPI therapy. Perforated Ulcer Surgical intervention is indicated in cases of perforation. Obstruction Balloon dilation or surgery is considered for gastric outlet obstruction caused by chronic ulcers.
- 29. Bleeding
- 30. H. Pylori
- 31. Introduction •Helicobacter pylori (H. pylori) is a Gram- negative bacterium commonly associated with gastritis, peptic ulcer disease, and gastric cancer. •This protocol outlines the recommended approach for diagnosing and managing H. pylori infection based on the latest guidelines.
- 32. Groups indicated to T&T for H. pylori Indication Details Peptic Ulcer Disease (PUD) Test and treat all patients with a current or prior history of peptic ulcer disease. Marginal Zone B-cell Lymphoma (MALT Type) H. pylori eradication is indicated in patients with marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT). Uninvestigated Dyspepsia (Age <60) Test and treat patients under 60 years with dyspeptic symptoms without alarm features. Uninvestigated Dyspepsia (High-risk for Gastric Cancer) In populations at high risk for gastric cancer, test and treat patients starting at 45-50 years of age. Functional Dyspepsia Eradication therapy is recommended for patients with functional dyspepsia, even in the absence of ulcers. Household Members of H. pylori Positive Patients Test and treat adult household members of individuals with confirmed H. pylori infection (non-serological tests). Patients on Long-term NSAIDs or Aspirin Test and treat patients who are currently taking or planning to start long-term NSAIDs or low-dose aspirin to prevent ulcers. Unexplained Iron Deficiency Anemia Test and treat for H. pylori in patients with unexplained iron deficiency anemia. Idiopathic Thrombocytopenic Purpura (ITP) H. pylori eradication is indicated in patients with idiopathic (autoimmune) thrombocytopenic purpura.
- 33. Diagnostic tests Test/Procedure Purpose Urea Breath Test (UBT) Gold standard for non-invasive diagnosis. Confirms active infection. Stool Antigen Test Non-invasive test to detect H. pylori antigens in stool. Endoscopy with Biopsy Recommended for patients with alarm features or treatment failure. Biopsy can detect H. pylori and allow for histological assessment.
- 34. TTT of treatment-Naive patients Regimen Drugs (Doses) Dosing Frequency FDA Approval Recommendation Optimized Bismuth Quadruple PPI (standard dose), Bismuth subcitrate (120–300 mg) or subsalicylate (300 mg), Tetracycline (500 mg), Metronidazole (500 mg) PPI: b.i.d. Bismuth: q.i.d. Tetracycline: q.i.d. Metronidazole: t.i.d. or q.i.d. No Strong (Moderate quality of evidence) Rifabutin Triple Omeprazole (10 mg), Amoxicillin (250 mg), Rifabutin (12.5 mg) 4 capsules t.i.d. Yes Conditional (Low quality of evidence) PCAB Dual Vonoprazan (20 mg), Amoxicillin (1,000 mg) Vonoprazan: b.i.d. Amoxicillin: t.i.d. Yes Conditional (Moderate quality of evidence) PCAB Triple Vonoprazan (20 mg), Clarithromycin (500 mg), Amoxicillin (1,000 mg) Vonoprazan: b.i.d. Clarithromycin: b.i.d. Amoxicillin: b.i.d. Yes Conditional (Moderate quality of evidence)
- 35. Summary of recommendations Recommendation Strength of Evidence Use Bismuth Quadruple Therapy (BQT) as first-line treatment in treatment-naive patients. Strong Recommendation based on moderate quality of evidence. Perform test-of-cure with a non-invasive test (UBT or stool antigen) 4 weeks after completing therapy. Strong Recommendation for confirming eradication.
- 36. Upper GI Bleeding (Hematemesis + Melena)
- 37. Assessment A. Examination: 1- Vital Signs: Blood pressure, Pulse, Saturation 2- Conscious level: GCS 3- General exam: Stigmata of CLD; jaundice, palmar erythema, clubbing, petechiea, flapping tremors 4- Abdominal exam: Abdomen lax or tenderness, rigidity, splenomegaly, Ascitis B. Investigations: 1- CBC, PT, INR, PTT, creat, Na, K, ABG 2- Blood sample for cross-matching and blood preservation 3- Erect Abdomen Xray 4- ECG 5- Diagnostic Tapping if ascites present (as Spontaneous bacterial peritonitis can be a precipitating factor for bleeding).
- 39. General Measures 1. Stabilization: O Airway Management: Ensure patency, consider intubation if severe bleeding or altered mental status. O Hemodynamic Stabilization: Establish two large-bore IV lines (16 gauge or larger). Administer isotonic crystalloid solution (e.g., normal saline or lactated Ringer's). Transfuse packed red blood cells (PRBCs) if hemoglobin <7 g/dL or ongoing significant bleeding.
- 40. General Measures 2. Monitoring: O Continuous monitoring of vital signs. O Monitor urine output. 3. Medical Management: O Nil Per Os (NPO): Nothing by mouth to prepare for potential endoscopy. O Proton Pump Inhibitors (PPIs): Administer IV bolus of 80 mg followed by continuous infusion of 8 mg/h for 72 hours. O Vasoactive Medications: Octreotide: IV bolus of 50 mcg, followed by continuous infusion of 50 mcg/h. O Antibiotics: For cirrhotic patients, administer ceftriaxone 1 g IV daily.
- 44. Ia IIa Ib IIb IIc III Forrest classification of ulcer bleeding: (a) Ia – spurting, (b) Ib – oozing, (c) IIa – Visible vessel, (d) IIb – Adherent clot, (e) IIc – Flat spot, (f) III – clean ulcer base.
- 47. FB Ingestion
- 48. Introduction •Foreign body ingestion is a common clinical scenario that can lead to significant morbidity and requires prompt evaluation and management. •Most ingested foreign bodies pass spontaneously, but some require endoscopic intervention to avoid complications such as perforation, obstruction, or infection. •This protocol outlines the steps for the endoscopic management of foreign body swallowing in adult patients.
- 49. Initial assessment Assessment Details History Determine the time of ingestion, type of object, symptoms (pain, dysphagia, vomiting, choking) Nature of the Foreign Body Identify whether the object is sharp, long (>6 cm), corrosive (batteries, chemicals), or food-related Symptoms Assess for pain, difficulty swallowing, respiratory distress, drooling, chest pain, or gastrointestinal bleeding Comorbid Conditions Check for conditions such as esophageal stricture, prior esophageal surgery, or psychiatric disorders (history of intentional ingestion) Physical Examination Check for signs of obstruction (e.g., drooling, inability to swallow), perforation (e.g., subcutaneous emphysema), or respiratory distress
- 50. Red Flags Requiring Immediate Action: • Signs of esophageal perforation (severe chest pain, subcutaneous emphysema, crepitus). • Difficulty breathing or respiratory distress due to airway compression. • Sharp objects, button batteries, or magnets that may cause tissue injury. • Foreign bodies longer than 6 cm, which are less likely to pass the duodenum. • Food impactions that do not resolve with glucagon or other conservative measures.
- 51. Diagnosis Investigation Indications X-ray (Neck, Chest, Abdomen) Initial test for radiopaque objects, assessment of foreign body location, and detection of complications (perforation, pneumoperitoneum) CT Scan (without contrast) Non-radiopaque objects or suspected perforation, and to determine exact location and surrounding structures Endoscopy (Diagnostic/Intervention) Direct visualization and removal; indicated for both diagnosis and treatment, especially for sharp objects or food impactions Barium Swallow or Upper GI Series Avoid unless there is strong suspicion of an esophageal stricture, as it may interfere with endoscopy
- 52. Timing of Endoscopy Type of Foreign Body Timing of Endoscopic Removal Sharp objects (e.g., pins, bones, glass) Urgent (within 2-6 hours) to prevent perforation. Button batteries (esophagus) Emergent (within 2 hours) to prevent corrosive injury or perforation. Magnets Emergent (within 2 hours) if multiple magnets are swallowed due to the risk of intestinal perforation. Food impaction Urgent (within 24 hours) if there is complete obstruction. Blunt objects (e.g., coins, marbles) Elective (within 24 hours) unless symptomatic or larger than 2.5 cm in diameter. Long objects (>6 cm) Urgent (within 24 hours) due to risk of duodenal obstruction.
- 53. Endoscopic Techniques for FB Removal: Endoscopic Tool Indications Retrieval Net For blunt objects, such as coins, marbles, and food boluses. Rat-Tooth or Alligator Forceps For irregular or sharp objects like bones, pins, or dental objects. Polypectomy Snare For large blunt objects and food boluses. Overtubes To protect the airway and esophagus during the retrieval of sharp objects or larger foreign bodies. Endoscopic Basket For small, round objects or food boluses that require precision grasping. Dormia Basket For foreign bodies in the stomach or lower esophagus, especially food boluses. Magnet Attachment For removal of magnetic objects in the gastrointestinal tract.