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Clin Phys > 4. Peptic Ulceration, Neuroendocrine Tumours and Crohns Disease > Flashcards

4. Peptic Ulceration, Neuroendocrine Tumours and Crohns Disease Flashcards

1
Q

diarrhoea

A

passage of 3 or more bowel motions
increased fluidity of stool
water insoluble faecal solids to hold water

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2
Q

gut fluid load

A

upper tract: 10L

small intestine: 6L to jejunum
2.5L to ileum

1.5L to colon
1.4L absorbed
0.1L out

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3
Q

small intestines function
and parts

A

absorption of nutrients
duodenum most proximal portion
jejunum middle portion
ileum most distal portion

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4
Q

mechanisms of diarrhoea (types)

A

secretory diarrhoea - over secretion of water and electrolytes
caused by bacterial toxins
no healthy cells to absorb nutrients so there is a leakage of fluid

inflammatory diarrhoea - cellular damage of mucosa causes hypersecretion

osmotic diarrhoea - osmotically active solutes
lactose intolerance
lactulose intake

motility - increased motility eg IBS

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5
Q

secretory diarrhoea

A

many infections
cholera toxin increases levels of cyclic AMP
cyclic AMP increases chloride secretion
and increases water secretion
so leads to dehydration

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6
Q

inflammatory diarrhoea

A

cellular damage of intestinal mucosa
decreased water and Na absorption
blood and mucus

ulcerative colitis - affects colon only
Crohn’s disease - small intestine, colon, perineum and occasionally stomach

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7
Q

acute/chronic

A

acute 2 weeks history
chronic 4 or more weeks of diarrhoea

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8
Q

Bristol stool chart

A

type 1-7
hard- watery

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9
Q

colicky pain

A

colicky pain is usually a sharp, localized gastrointestinal or urinary pain that can arise abruptly, and tends to come and go in spasmlike waves

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10
Q

risk factors for diarrhoea

A

Viruses. …
Bacteria and parasites. …
Medications and antibiotics
Lactose intolerance. …
Fructose. …
Artificial sweeteners. …
Surgery. …
Other digestive disorders.

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11
Q

investigations for diarrhoea

A

faecal calprotectin
normal <50ug/mg
marker for inflammatory bowel disease

C-reactive protein
normal 5mg/L
inflammatory marker in blood
marker for autoimmune diseases

Hb (haemoglobin)
anaemia symptom for IBD

full blood count

iron, vitamin B12, folic acid

screening for certain viral infections

colonoscopy/gastroscopy/capsule endoscopy

CT/MRI small bowel imaging

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12
Q

examination for diarrhoea

A

pallor
skin lesions
abdomen soft/tender

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13
Q

changes to mucosa

A

mucosa of terminal ileum
ulcerations -> leaking contents -> diarrhoea

inflamed caecal mucosa - mucosa eroded and patchy

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14
Q

management of diarrhoea

A

induction of remission
reduce inflammation
oral rehydration solution (glucose&sodium&water)

maintenance of remission
long term

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15
Q

Crohn’s disease

A

chronic inflammatory condition affecting any part of the gut

age 15-40 y/o
15% have relatives with crohn’s or ulcerative colitis
more common in smokers

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16
Q

clinical features of Crohn’s disease

A

diarrhoea, abdominal pain, weight loss

malaise lethargy, anaemia

mouth aphthous ulcers (more frequent and persistent)

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17
Q

types of Crohn’s disease

A

small bowel crohn’s disease 50%
colonic crohns disease 20%
perianal crohns disease 30%

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18
Q

perianal fistula
(crohns)

A

An anal fistula is a small tunnel that develops between the end of the bowel and the skin near the opening of the bottom (anus). It’s usually caused by an infection near the anus, which results in a collection of pus (abscess) in the nearby tissue. When the pus drains away, it can leave a small channel behind.
Fistulas can cause a lot of discomfort, and if left untreated, may cause serious complications. Some fistulas can cause a bacteria infection, which may result in sepsis, a dangerous condition that can lead to low blood pressure, organ damage or even death.

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19
Q

SKIN: erythema nodosum
(crohns)

A

Erythema nodosum is swollen fat under the skin causing bumps and patches that look red or darker than surrounding skin. It usually goes away by itself, but it can be a sign of something serious

an inflammatory disorder affecting subcutaneous fat. It presents as tender red nodules on the anterior shins.

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20
Q

Pyoderma gangrenosum
(crohns)

A

Pyoderma gangrenosum is a rare skin condition that causes painful ulcers

daily doses of corticosteroids. These drugs may be applied to the skin, injected into the wound or taken by mouth (prednisone)

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21
Q

iritis
conjunctivitis
(crohns)

A

Iritis is swelling and irritation (inflammation) in the colored ring around your eye’s pupil (iris).

Conjunctivitis is a condition that occurs when the conjunctiva (a thin layer of cells covering the front of your eyes) becomes inflamed.

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22
Q

joint complications (crohns)

A

arthralgia - describes joint stiffness

sacroiliitis - painful condition that affects one or both sacroiliac joints. These joints sit where the lower spine and pelvis meet. Sacroiliitis can cause pain and stiffness in the buttocks or lower back, and the pain might go down one or both legs.

arthritis - common condition that causes pain and inflammation in a joint.

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23
Q

management of crohn’s disease

A

assessment of severity/extent
steroids
nutrition/exclusive enteral feeding (you receive all of your calories through formula and you do not eat regular food. liquid diet)
drugs (infliximab)
surgery (resection)

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24
Q

drugs for crohns disease

A

targets a single pro-inflammatory cytokine TNF

produced by macrophages and intiates a cascade of inflammation

infliximab was the first drug used in inflammatory bowel disease

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25
Q

epigastric pain

A

pain or discomfort right below your ribs in the area of your upper abdomen. It can have many causes, including acid reflux, gallstones, or indigestion.

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26
Q

anadin

A

painkiller

taking it for too long can cause peptic ulcers

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27
Q

rectal examination

A

doctor uses finger to check for problems in rectum

checks for melaena
digested blood in stool due to gastrointestinal bleeding

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28
Q

management for peptic ulcers

A

fluid resuscitation

stop non steroidal medications eg. anadin

proton pump inhibitors (omeprazole)

upper GI endoscopy (from mouth)

29
Q

peptic ulcers

A

sore on the lining of your stomach, small intestine or esophagus

result of inflammation

can cause indigestion, abdominal pain, vomiting…

30
Q

non steroidal medications

A

systemic and local effects

reduced mucosal prostaglandins

affect mucosal blood flow

reduced mucosal integrity

31
Q

stomach epithelium

A

epithelium has 2 gland types

oxyntic gland = parietal cells
body and fundus (80% of stomach)

pyloric gland = G cell
antrum (20% of stomach)

32
Q

the stomach secretes…

A

acid
water
electrolytes
glycoproteins
mucin
intrinsic factor
enzymes

33
Q

gastric acid

A

necessary for
protein digestion
absorption of Ca+, iron, vitamin B12, thyroxin
prevention of bacterial overgrowth and enteric infections
reduction or elimination of food allergenicity

gastric acid in excess results in ulceration

34
Q

control of acid secretion

A

balance of neural, hormonal and paracrine pathways

activated directly by stimuli from brain

reflex activation by stimuli in stomach and intestines (distension, protein/lipid/acid)

35
Q

hormone and paracrine mechanism of acid secretion control

A

hormone released into blood
reaches targets via bloodstream
ie. gastrin

paracrine released into tissue
reaches targets by diffusion
ie. histamine and somatostatin

36
Q

stimulation of acid secretion cephalic phase

A

smelling or thinking about food
as stimuli
Gastric juice is secreted

37
Q

stimulation of acid secretion gastric phase

A

food has just arrived
beginning of gastric phase
stomach stretched
Acid continues to be secreted in response to distension
pH is lowered
gastrin release

38
Q

stimulation of acid secretion gastric phase

A

food has just arrived
mediated by vagus nerve
stomach stretched
Acid continues to be secreted in response to distension
pH is lowered
gastrin releases

39
Q

stimulation of acid secretion intestinal phase

A

somatostatin inhibition (gastrin and histamine)

decreases vagus stimulation

inhibits gastrin release

40
Q

gastric lipase

A

initiates digestion of fats
hydrolyses 20% of tyiglycerides
resistant to acid
secreted by fundic chief cells
detectable by 10 weeks of gestation

41
Q

pepsinogen

A

secreted by gastric chief cells
proenzyme converted to pepsin by gastric acid
necessary for protein digestion
stimulated by cephalic vagal input

42
Q

pepsin

A

digestive enzyme
mucolytic
ulcerogenic
inactive at ph>4

43
Q

intrinsic factor

A

secreted by parietal cells
binds to vitamin B12

intrinsic factor-vitamin B12 complex:
binds to cubilin repector in ileal mucosa
absorbed by endocytosis

44
Q

causes of peptic ulcers

A

H.pylori infection
use of NSAIDS non-steroidal-anti-inflammatory-drugs
Crohns disease

45
Q

H. pylori

A

colonises gastric epithelium of 50% of worlds population

causes gastritis, peptic ulcers, mucosa-associated-lymphoid tissue lymphoma MALT, gastric cancer

46
Q

H. pylori acute and chronic infection

A

acute:
causes hypochlorhydria

chronic:
hypochlorhydria or hyperchlorhydria

(stomach acid)

47
Q

how H. pylori produces mucosal damage

A

organisms synthesise urease, which produces ammonia, that damages the gastric mucosa

colonises epithelial cells and decreases the production of mucus

so stomach mucosa is exposed to its own secretions

gastric acids causes the formation of ulcers

48
Q

how NSAIDs cause peptic ulcers

A

Inhibition of COX-1 in the gastrointestinal tract leads to a reduction of prostaglandin secretion and its cytoprotective effects in gastric mucosa. This therefore increases the susceptibility to mucosal injury.

49
Q

Gastrinomas and Zollinger-Ellison syndrome

A

gastrinomas are rare tumours
autonomous production of gastrin, leads to overproduction of gastric acid

Zollinger-Ellison syndrome is a rare condition in which one or more gastrinomas grow in the pancreas or in the upper part of the small intestine.

50
Q

neuroendocrine cells

A

peptide hormone-producing cells that share a neural-endocrine phenotype

51
Q

neuroendocrine neoplasms/tumours

A

rare tumours that develop in neuroendocrine system/ in neuroendocrine cells

52
Q

D cells (location and products)

A

GI tract
Somatostatin

53
Q

Enterochromaffin (location and products)

A

GI tract
Serotonin, substance P

54
Q

Enterochromaffin-like (location and products)

A

GI tract
Histamine

55
Q

G cells (location and products)

A

Stomach& duodenum
Gastrin

56
Q

VIP cells (location and products)

A

GI tract
VIP

57
Q

A cells (location and products)

A

Pancreas
Glucagon

58
Q

B cells (location and products)

A

Pancreas
Insulin

59
Q

Chromaffin (location and products)

A

Adrenals
Catecholamines

60
Q

C cells (location and products)

A

Thyroid
Calcitonin

61
Q

Histopathological assessment of NEN

A

cell morphology

immunohistochemistry

Ki67

62
Q

Immunohistochemistry of NEN

A

general markers (chromogranin, synaptophysin, cytokeratin)

peptide hormones (serotonin)

receptors

63
Q

Ki67

A

assesses tumour grading

marker of proliferation and shows how many cells are in cycle

if Ki67 > 20% : neuroendocrine carcinoma (poorly differentiated)

Ki67 > 20% : neuroendocrine tumours of G3 grade (well diff)

Ki67 3-20% : neuroendocrine tumours of G2 grade (well diff)

Ki67 < 2% : neuroendocrine tumours of G grade (well diff)

64
Q

Carcinoid syndrome

A

Carcinoid syndrome is the collection of symptoms some people with a neuroendocrine tumour may have.

It is more common when the tumour has spread to the liver and releases hormones such as serotonin into the bloodstream.

65
Q

Carcinoid syndrome symptoms

A

flushing
diarrhoea
abdominal pain
carcinoid heart disease
telangiectasias
bronchospasm
pellagra

66
Q

Carcinoid crisis & symptoms

A

a rare but serious condition called a carcinoid crisis, which involves severe flushing, breathlessness and a changes in your blood pressure.

severe symptoms of carcinoid syndrome (bronchospasm and flushing) and hypotension

67
Q

flushing due to carcinoid syndrome

A

dry and intermittent
provoked by alcohol, exercise, food containing tyramines (blue cheese and choc)
involves face and upper trunk (above nipple)

68
Q

diagnosing flushing due to other causes (not carcinoid syndrome)

A

+diarrhoea - medullary thyroid carcinoma, pancreatic VIPoma

wet flushing - menopause

constant - alcoholism, polycythemia, mitral valve disease

+headaches - phaeocromocytoma or mastocytosis

+rash features - rosacea, mastocytosis

69
Q

initial diagnostic approach

A

biopsy of lesions (compatibility w neuroendocrine neoplasm)

history and clinical examination

biochemical tests “biomarkers”

imaging studies to localise primary and metastatic lesions

histology - gold standard

Clin Phys (14 decks)

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