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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
Q

Where does Crohns typically affect

A

Terminal ileum

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26
Q

Crohns on imaging

A

Kantor string sign
Proximal bowel dilation
Rose thorn ulcers
Fistulae
Comb sign
Carnetts sign

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27
Q

E. coli

A

Common amongst travellers
Watery stools
Abdominal cramps and nausea

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28
Q

Giardiasis

A

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.

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29
Q

Shigella

A

Bloody diarrhoea
Vomiting and abdominal pain

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30
Q

Staph aureus

A

Severe vomiting
Short incubation period

31
Q

Campylobacter

A

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
Q

Bacillus cereus

A

Either vomiting within 6 hours (rice)
Diarrhoea after 6 hours

33
Q

Amoebiasis

A

Gradual onset bloody diarrhoea, abdominal pain, tenderness which may last several weeks

34
Q

Something to ask a patient with diarrhoea or cough

A

Any recent travel

35
Q

Coeliac management

A

Gluten free diet life long
Iron, vitamin, calcium, and vitamin D supplementation (osteoporosis and anaemia are complications)

36
Q

Management of c diff

A

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
Q

Aminosalicylates (eg. Mesalazine and sulphalazine)

A

Colonic anti inflammatories
SE- headache, lung fibrosis, pancreatitis, agranulocytosis (always check FBC when someone taking them is unwell)

38
Q

Causes of c diff

A

PPI’s
Cephalosporin eg, cefotaxime, cefuroxime
Then clindamycin

39
Q

Features of c diff infection

A

Diarrhoea
Abdominal pain
Lymphocytosis
Severe- toxic megacolon

40
Q

White cell count and C diff severity

A

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
Q

Conditions associated with coeliac disease

A

Autoimmune thyroid disease
Dermatitis herpetiformis
IBS
T1DM

42
Q

Histology of coeliac disease

A

Villus atrophy with crypt hyperplasia

43
Q

Complications of coeliac disease

A

Anaemia- iron, folate, and vitamin B12
Hyposplenism
Osteoporosis and osteomalacia
Lactose intolerance
T cell lymphoma of the small intestine
Subfertility

44
Q

Endoscopic findings supportive of coeliac disease

A

Villus atrophy
Crypt hyperplasia
Increased epithelial lymphocytes
Laminate propria infiltration with lymphocytes

45
Q

Management of coeliac disease

A

Gluten free diet (bread, pasta, pastries, beer, oats)
Immunisations- yearly flu vaccine, pneumococcal vaccine very 5 years

46
Q

Histology of Crohn’s disease

A

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
Q

Small bowel enema signs of Crohns

A

Kantors string sign (strictures)
Proximal bowel dilation
Rose thorn ulcers
Fistulae

48
Q

Complications of Crohn’s disease

A

Small bowel and CR cancer
Osteoporosis

49
Q

Diverticulosis

A

Outpouchings in bowel wall, commonly the sigmoid colon- reserved for asymptotic patients
Risks- increasing aged low fibre diet

50
Q

Diverticula disease

A

Altered bowel habit, colicky left sided abdominal pain
High fibre diet can minimise symptoms

51
Q

Diverticulitis

A

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
Q

Management of diverticulitis

A

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
Q

Red flag symptoms in a suspected IBS case

A

Rectal bleeding
Unexplained or unintentional weight loss
Family history of bowel or ovarian cancer
Onset of age after 60 years

54
Q

Features of UC

A

Bloody diarrhoea
Urgency
Tenesmus
Abdominal pain (LLQ)
Extra intestinal features

55
Q

Histology of UC

A

No inflammation beyond submucosa
Pseudopolyps
Crypt abscesses
Depletion if goblet cells

56
Q

Barium enema UC findings

A

Loss of haustrations
Superficial ulceration aka pseudo polyps
Drainpipe colon (long standing disease)

57
Q

Causes of UC flares

A

Stress
Medications eg, NSAIDs, ABX, cessation of smoking

58
Q

Classification of UC flare severity

A

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
Q

Management of mild to moderate UC

A

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
Q

Management of severe UC (colitis)

A

Admit to hospital
IV steroids
Ciclosporin if steroids can’t be used

61
Q

Maintaining remission in UC

A

Mild/moderate- aminosalicyate

Severe/2 exacerbations in a year-/oral azathioprine or mercaptopurine

62
Q

Classification of diverticulitis

A

Hinchey system

1- para colonic abscess
2- pelvic abscess
3- purulent peritonitis
4- faecal peritonitis

63
Q

Investigations for diverticulitis

A

Colonoscopy avoided whilst symptomatic to avoid risk of perforation

Other tests like erect CXR (air), FBC (WCC), CRP, AXR, CT

64
Q

Investigations s for gastroenteritis

A

Bedside- abdominal examination, observations
Bloods- FBC UE LFT CRP
Specialist- stool sample fir microscopy culture and sensitive, and OCP

65
Q

Enterohaemorrhagic E. coli

A

Avoid antibiotics- increase chance of HUS
also avoid antidiarrhoeals (also in shigella)

66
Q

Management of coeliac disease

A

Life long gluten free diet
May require vitamin substitution eg. Iron, calcium, vitamin D

67
Q

Antibodies and coeliac disease

A

Levels of IgA and tTG will drop 3-12 months after introduction of a gluten free diet

68
Q

Odansetron

A

5HT3 antagonist, good for chemo/radio therapy induced nausea

69
Q

Constipation in IBS

A

Bulk forming laxative- iphagea husk

70
Q

Surgical management of UC

A

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
Q

Imaging choice for Crohn’s patients with perianal fistulae

A

MRI

72
Q

Perianal fistulae

A

MRI investigation of choice
patients with symptomatic perianal fistulae are usually given oral metronidazole
a draining seton is used for complex fistulae

73
Q

Perianal abscess

A

requires incision and drainage combined with antibiotic therapy

Year 3 OSCE (61 decks)

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