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Year 3 OSCE > Case 15- Gut Disorders > Flashcards

Case 15- Gut Disorders Flashcards

1
Q

Symptoms suggesting IBS

A

Abdominal pain/ discomfort
Pain relieved on opening bowels
Associated with a changed in bowel habit
Abnormal stool passage
Bloating
PR mucus
Pain worse after eating

NB- may also have nausea, lethargy, backache, bladder symptoms

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2
Q

Investigations for IBD

A

Stool sample- faecal calprotectin, OCP, microscopy culture and sensitivity
FBC, CRP, TFT, LFT, Fe studies, serum vitamin B12, folate
Endoscopy (OGD/ colonoscopy) with biopsy- diagnostic (swallow capsule is alternative)
Imaging- look for complications (CT/ MRI)

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3
Q

Investigations for coeliac

A

FBC UE calcium magnesium haemantics etc.
IgA levels
Raised IgA antibodies- anti TTG, anti endomyseal antibodies
Endoscopy with small intestine biopsy- gold standard

NB- if patient on gluten free diet, must reintroduce gluten 6 weeks before testing

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4
Q

Differentials for IBS

A

Chrons, UC, coeliac, colon cancer, lactose intolerance, ovarian cancer

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5
Q

General appearance in certain gut disorders

A

IBS- healthy, no weight loss

Chrons- weight loss, malnourishment

UC- weight loss in severe cases

CRC- weight loss

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6
Q

Pain in certain gut disorders

A

IBS- alleviated by defecation, diffuse, no nighttime pain

Chrons- constant, right lower abdomen, may occur at night

UC- left lower abdomen, may occur at night

CRC- often no pain

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7
Q

Stool habits in certain conditions

A

IBS- diarrhoea, constipation, no blood, no nighttime diarrhoea

Chrons- non bloody, watery diarrhoea, increased frequency, can occur at night

UC- bloody diarrhoea with mucus

CRC- right sided: melaena, diarrhoea, left sided: constipation

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8
Q

Extraintestinal findings UC

A

Arthritis
Spondylitis
Erythema nodosum
Finger clubbing
Iritis

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9
Q

Extraintestinal features of Chrons

A

Perianal lesions
Erythema nodosum
Arthropathy
Pyoderma gangrenosum
Aphthous ulcers
Clubbing
Iritis
Gall stones

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10
Q

Gastroenteritis

A

Abdominal pain, fever, n and v, lethargy, either watery diarrhoea or bloody diarrhoea, volume depletion

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11
Q

Management of suspected gastroenteritis

A

Isolate patient and PPE
FBC UE
Stool sample for microscopy, culture and sensitivities and OCP
Fluids and loperamide/ metoclopramide if needed
Antibiotics if causative agent found and patient at high risk

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12
Q

Coeliac symptoms

A

Diarrhoea, bloating, abdominal discomfort, abdominal distension, anaemia (iron folate or B 12), fatigue, weight loss, failure to thrive, dermatitis herpetiformis (can b across abdomen),mouth ulcers, steatorrhea, angular stomatitis

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13
Q

C diff infection investigations

A

Stool test for c diff toxin (antigen only shows exposure to bacteria, not current infection)
FBC UE- raised WCC, electrolyte disturbance (diarrhoea)

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14
Q

Investigations for IBS

A

Bloods- FBC, ESR, CRP
Faecal calprotectin- exclude IBD (perhaps diarrhoea predominant)
Anti TTG antibodies- exclude coeliac (anti endomyseal also)

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15
Q

Over 60 and mild symptoms

A

Think cancer

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16
Q

Management of Crohn’s disease

A

Lifestyle- diet, exercise, smoking and alcohol

Crohns- IV steroids (induce remission) azathioprine and merctopurine (maintain remission)- assess TMPT activity first

Surgical resection (typically ileoceacal resection, or stricture/adhesiolysis/fistula correction)

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17
Q

IBD Common Extra Intestinal Sx

A

Clubbing
Iritis
Arthropathy (joint pain)
Erythema nodosum

NB- dermatitis herpetiformis is coeliac

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18
Q

IBS Management

A

Lifestyle advice- fluids, regular small meals, reduce processed foods, smoking & alcohol etc., reduce fizzy drinks

Medical- Loperamide for diarrhoea, laxatives for constipation (not lactulose), buscopan for cramps

Safety net- red flags/things get worse

NB- if symptoms aren’t managed with the above, TCA (amitriptyline), SSRI, and CBT can be trialled

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19
Q

UC Sx

A

Abdominal pain (LLQ), tenderness, diarrhoea, blood in stool, faecal urgency, tenesmus

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20
Q

IBD differentials

A

Crohns, diverticulitis, IBS, mesenteric ischaemia, infective colitis, ectopic pregnancy, endometriosis, appendicitis

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21
Q

Chrons vs UC

A

Skip lesions, transmural inflammation, affects everywhere from mouth to anus (spares rectum), pANCA positive in UC but likely negative in Crohns

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22
Q

Crohn’s Sx

A

Abdominal pain (RLQ), diarrhoea, perianal lesions, blood in stool (LESS THAN UC), malnutrition, weight loss, anaemia, abdominal mass, mouth ulcers

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23
Q

Complications of Crohns

A

More prone to strictures fistulas and adhesions (transmural)

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24
Q

Where does UC Affect

A

Colon and rectum (always starts at rectum, and never spreads beyond the ileocecal valve)

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25
Where does Crohns typically affect
Terminal ileum
26
Crohns on imaging
Kantor string sign Proximal bowel dilation Rose thorn ulcers Fistulae Comb sign Carnetts sign
27
E. coli
Common amongst travellers Watery stools Abdominal cramps and nausea
28
Giardiasis
Prolonged non bloody diarrhoea Giardia causes fat malabsorption, therefore greasy stool can occur. It is resistant to chlorination, hence risk of transfer in swimming pools.
29
Shigella
Bloody diarrhoea Vomiting and abdominal pain
30
Staph aureus
Severe vomiting Short incubation period
31
Campylobacter
Flu like prodrome with crampy abdominal pain, fever, and diarrhoea (can be bloody) Mimic appendicitis Complication- GBS NB- Campylobacter infection is often self-limiting but if severe then treatment with clarithromycin (c for c) may be indicated
32
Bacillus cereus
Either vomiting within 6 hours (rice) Diarrhoea after 6 hours
33
Amoebiasis
Gradual onset bloody diarrhoea, abdominal pain, tenderness which may last several weeks
34
Something to ask a patient with diarrhoea or cough
Any recent travel
35
Coeliac management
Gluten free diet life long Iron, vitamin, calcium, and vitamin D supplementation (osteoporosis and anaemia are complications)
36
Management of c diff
First episode- Vancomycin 10 days (oral- get into colon) or oral fidaxomicin 2nd line (3rd line, oral vancomycin, IV metronidazole) Recurrent episode- within 12 weeks, oral findaxomicin, after 12 weeks, oral vancomycin or oral findaxomicin Life threatening- oral vancomycin and IV metronidazole NB- fidaxomicin if recurrent episodes NB- Bezlotoxumab may be used in conjunction with antibiotics to reduce the risk of recurrence in such patients. However, it is not currently recommended for the prevention of C.difficile infection by NICE due to it not being cost-effective.
37
Aminosalicylates (eg. Mesalazine and sulphalazine)
Colonic anti inflammatories SE- headache, lung fibrosis, pancreatitis, agranulocytosis (always check FBC when someone taking them is unwell)
38
Causes of c diff
PPI’s Cephalosporin eg, cefotaxime, cefuroxime Then clindamycin
39
Features of c diff infection
Diarrhoea Abdominal pain Lymphocytosis Severe- toxic megacolon
40
White cell count and C diff severity
Mild- normal WCC Moderate- WCC below 15, loose stools Severe- WCC above 15, creatinine 59% above baseline, raised temp, evidence of severe colitis Life threatening- hypotension, partial or complete ileus, toxic megacolon, CT evidence of severe disease
41
Conditions associated with coeliac disease
Autoimmune thyroid disease Dermatitis herpetiformis IBS T1DM
42
Histology of coeliac disease
Villus atrophy with crypt hyperplasia
43
Complications of coeliac disease
Anaemia- iron, folate, and vitamin B12 Hyposplenism Osteoporosis and osteomalacia Lactose intolerance T cell lymphoma of the small intestine Subfertility
44
Endoscopic findings supportive of coeliac disease
Villus atrophy Crypt hyperplasia Increased epithelial lymphocytes Laminate propria infiltration with lymphocytes
45
Management of coeliac disease
Gluten free diet (bread, pasta, pastries, beer, oats) Immunisations- yearly flu vaccine, pneumococcal vaccine very 5 years
46
Histology of Crohn’s disease
Inflammatory bowel disease- typically affects terminal ileum and colon but can be seen anywhere from mouth to anus in skip lesions (patchy, non continuous inflammation) Transmural inflammation (from mucosa to serosa), goblet cells, granulomas More likely to get deep ulcers, fistulae, strictures
47
Small bowel enema signs of Crohns
Kantors string sign (strictures) Proximal bowel dilation Rose thorn ulcers Fistulae
48
Complications of Crohn’s disease
Small bowel and CR cancer Osteoporosis
49
Diverticulosis
Outpouchings in bowel wall, commonly the sigmoid colon- reserved for asymptotic patients Risks- increasing aged low fibre diet
50
Diverticula disease
Altered bowel habit, colicky left sided abdominal pain High fibre diet can minimise symptoms
51
Diverticulitis
When a diverticula becomes infected Left iliac fossa pain and tenderness Anorexia, nausea, and vomiting Diarrhoea (bloody) Features of infection (pyrexia, raised WBC, CRP)
52
Management of diverticulitis
Mild- oral antibiotics at home Severe (and if symptoms don’t settle over 72 hours)- IV antibiotics in hospital (cephalosporin with metronidazole), NBM, IV fluids NB- low fibre diet recommended during diverticulitis recovery
53
Red flag symptoms in a suspected IBS case
Rectal bleeding Unexplained or unintentional weight loss Family history of bowel or ovarian cancer Onset of age after 60 years
54
Features of UC
Bloody diarrhoea Urgency Tenesmus Abdominal pain (LLQ) Extra intestinal features
55
Histology of UC
No inflammation beyond submucosa Pseudopolyps Crypt abscesses Depletion if goblet cells
56
Barium enema UC findings
Loss of haustrations Superficial ulceration aka pseudo polyps Drainpipe colon (long standing disease)
57
Causes of UC flares
Stress Medications eg, NSAIDs, ABX, cessation of smoking
58
Classification of UC flare severity
Mild- fewer than 4 stools per day Moderate- 4-6 with minimal systemic disturbance Severe- more than 6, with blood, systemic disturbance eg. Fever, tachycardia, abdominal tenderness or distension, reduced bowel sounds, anaemia, hypoalbuminaemia NB- severe disease- admit to hospital
59
Management of mild to moderate UC
Inducing remission Proctitis/ sigmoiditis- topical (rectal) aminosalicylate (mesalazine), add oral corticosteroid if emission not achieved (oral mesalazine for sigmoiditis) Extensive disease- topical (rectal) and oral aminosalicylate (mesalazine), add oral glucocorticoid and aminosalicylate (mesalazine) if emission not achieved
60
Management of severe UC (colitis)
Admit to hospital IV steroids Ciclosporin if steroids can’t be used
61
Maintaining remission in UC
Mild/moderate- aminosalicyate Severe/2 exacerbations in a year-/oral azathioprine or mercaptopurine
62
Classification of diverticulitis
Hinchey system 1- para colonic abscess 2- pelvic abscess 3- purulent peritonitis 4- faecal peritonitis
63
Investigations for diverticulitis
Colonoscopy avoided whilst symptomatic to avoid risk of perforation Other tests like erect CXR (air), FBC (WCC), CRP, AXR, CT
64
Investigations s for gastroenteritis
Bedside- abdominal examination, observations Bloods- FBC UE LFT CRP Specialist- stool sample fir microscopy culture and sensitive, and OCP
65
Enterohaemorrhagic E. coli
Avoid antibiotics- increase chance of HUS also avoid antidiarrhoeals (also in shigella)
66
Management of coeliac disease
Life long gluten free diet May require vitamin substitution eg. Iron, calcium, vitamin D
67
Antibodies and coeliac disease
Levels of IgA and tTG will drop 3-12 months after introduction of a gluten free diet
68
Odansetron
5HT3 antagonist, good for chemo/radio therapy induced nausea
69
Constipation in IBS
Bulk forming laxative- iphagea husk
70
Surgical management of UC
Removing the colon and rectum (panproctocolectomy) will remove the disease. The patient is then left with either a permanent ileostomy or something called an ileo-anal anastomosis (J-pouch). This is where the ileum is folded back in itself and fashioned into a larger pouch that functions a bit like a rectum. This “J-pouch” which is then attached to the anus and collects stools prior to the person passing the motion.
71
Imaging choice for Crohn's patients with perianal fistulae
MRI
72
Perianal fistulae
MRI investigation of choice patients with symptomatic perianal fistulae are usually given oral metronidazole a draining seton is used for complex fistulae
73
Perianal abscess
requires incision and drainage combined with antibiotic therapy

Year 3 OSCE (61 decks)

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