Common GI Presentations Flashcards
What are the causes of normal vomit?
- Caused by gastroenteritis or being generally unwell.
- Also caused by upper GI obstruction:
- Pyloric stenosis
- Peptic ulcer disease
- Intussusception
What are the causes of coffee-ground vomit?
- Non-specific gastritis most commonly the cause.
- Very infrequently a sign of a significant bleed.
What are the common causes of haematemesis?
- Oesophageal or gastric varices.
- Duodenal ulcer or gastric ulcer.
- Significant Mallory Weiss tear.
- The patients are significantly unwell and they often have molena as well.
What is the cause of bilious vomiting?
Post-pyloric obstruction
What questions would you ask someone in the hx if they present with vomiting?
- Recent holidays?
- Strange foods?
- Dodgy takeaway
- Anyone else unwell?
- Change in medications?
- Worth checking the BNF to make sure they have not been started on anything that is making them vomit.
- What are their regular medications?
- Symptoms to suggest infection?
- PMHx?
Describe how you would assess a patient who is vomiting.
- Full ABCDE assessment
- Are they actively vomiting?
- Are they haemodynamically stable?
- Examination
- Look at dentition
- Look at hands
- Abdominal examination
- Any abdo pai?
- Bowel sounds present?
- NEVER forget to PR.
- Bloods
- U&E, CRP, Mg, Bone, Glucose
- FBC, clotting, XM
- Venous gas
- Pregnancy test!
- Urinalysis
- CXR/AXR
- CT Abdo
Describe the management of a patient who is vomiting.
- Treatment of underlying cause
- MOST IMPORTANT
- Ensure well-hydrated and electrolytes are corrected.
- If UGIB
- Fluid resuscitation
- Blood products
- Discussion with GI / surgeons
- Antiemetics
What are the anti-emetics which can be used in a patient who is vomiting?
How do they work?
What are their side-effects?
- Prochlorperazine
- Can be sedating
- Metoclopromide
- Aids gastric motility
- Extra-pyramidal side-effects
- Oculogyric crisis in young women
- Ondansetron
- Acts centrally
- Delays gastric emptying
- Good in chemotherapy
- Cyclizine
- Can give a ‘high’
What is dyspepsia?
- A collection of symptoms:
- Retrosternal discomfort
- Bloating / borborygmi (highly active bowel sounds)
- Heaviness
What are the types of dyspepsia?
-
Organic dyspepsia
- Duodenal ulcer / gastric ulcer
- Oesophagitis / duodenitis
- Gastric cancer
- H. pylori
-
Functional dyspepsia
- Ulcer type e.g. Epigastric pain
- Dysmotility type e.g. Early satiety, distension, nausea
- Reflux type e.g. Retrosternal discomfort
What are the red flag symptoms associated with dyspepsia?
- Weight loss
- Dysphagia
- Iron deficiency anaemia
- Recurrent vomiting
- Worrying medications
- Steroids
- NSAIDs
Describe the treatment of dyspepsia.
- Organic dyspepsia
- Treatment of underlying cause
- High dose PPI
- Functional dyspepsia
- Lifestyle modification (symptoms can disappear after weight loss)
- Weight
- Alcohol
- Smoking
- Consider acid suppression
- Lifestyle modification (symptoms can disappear after weight loss)
What are the symptoms of GORD?
- Heartburn
- Retrosternal pain related to eating, lying down.
- Regurgitation of acid / bile
- Waterbrash
- Excess salivation, often acidic
- Nocturnal cough / wheeze
Describe the treatment of GORD.
- Trial of acid suppression
- Endoscopy
- Assess for oesopagitis / hiatus hernia.
- Assess for Barretts (causes patient to have a higher risk of developing oesophageal cancer).
- Consider oesophageal manometry and pH impedance
- May prompt anti-reflux surgery.
- Important points:
- GORD may mimic an MI and vice-versa.
- Oesophageal spasm is a very rare condition
- Consider an alternatie diagnosis.
What are the 4 key questions to ask a patient who presents with dysphagia?
-
Interval
- Difficulty in initiating swallowing
- Repeated attempt to ‘get food over’
- Dysphagia immediately after swallowing
-
Type of food
- Liquids - suggests possible pharyngeal cause.
- Solids - mechanical obstruction.
- Both - likely oesophageal dysmotility.
-
Pattern
-
Intermittent
- Oesophageal dysmotility
- Atypical causes
- Progressive
- E.g. solids → liquids
- Organic oesophageal cause
-
Intermittent
-
Associated features
- Weight loss
- Heartburn
- Cough
- Odynophagia
- ?Systemic disease
- Asthma
- Scleroderma
Which diseases are likely to represent oropharyngeal dysphagia?
- Previous stroke
- MND
- Pharyngeal pouch
- Parkinson’s disease
Describe the assessment of a patient who presents with dysphagia.
- CXR
- ?Hilar / bronchial mass
- ?Right-sided consolidation
- Suggests aspiration
- Oesophageal fluid level
- Endoscopy
- Dysphagia to solids!
- Weight loss
- Progressive symptoms
- Barium swallow
- Unable to navigate with edoscopy
- Normal endoscopy
What are the differentials for dysphagia?
- Oesophageal stricture
- Peptic - longstanding reflux oesophagitis
- Anastomotic
- Radiotherapy - particularly breast / lung
- Corrosives - bleach
- Oesophageal carcinoma
- Progressive
- Weight loss
- Achalasia
- Absent peristalsis
- Increased LOS pressure
- Regurgitation of solid foodstuffs
- Eosinophilic oesophagitis
- Intermittent food bolus obstruction
- Hx of asthma / eczema / atopy
- Candidiasis
- Steroid use
- Immunosuppressed
- Odynophagia
A patient presents systemically unwell, complaining of weight loss and they have iron deficiency anaemia.
This is their endoscopy.
What is the diagnosis?
Oesophageal carcinoma
What does this CXR show?
- Classical achalasia.
- Tightening of the LOS towards the end not allowing any food through. Food builds up and eventually stimulates the gag reflex and they vomit it back up.
What disease classically gives this appearance on endoscopy?
- Eosinophilic oesophagitis.
- Concentric rings are classical of this.
What are the 6 Fs of abdominal distension?
- Foetus
- Flatus
- Faeces
- Fluid
- Fat
- Fatal tumour
Describe the assessment of abdominal distension.
- Concise hx
- Thorough clinical examination
- Shifting dullness
- Organomegaly
- PR
- Bowel sounds
What is the definition of chronic diarrhoea?
- 3 or more loose / liquid stools per day for >4 weeks
- Stool volume >200mL/day
What is osmotic diarrhoea?
- Malabsorbed osmotically active substances e.g. carbohydrates / peptides.
- Typically resolves with fasting.
- Often related to laxative abuse.
What causes secretory diarrhoea?
- Often stimulated by a toxin e.g. bacteria, or a peptide e.g. VIPoma (vasointestinal peptide).
What questions would you ask in the hx of a patient presenting with diarrhoea?
- Duration
- >4/52 requires further investigation
- Family Hx
- GI cancer
- IBD
- Coeliac
- Previous surgery / pancreatic disease
- Do they have diarrhoea because they have no large intestine or a short bowel?
- Drugs
- ABx / PPI / NSAIDs / Alcohol
- Travel
- Systemic disease
- Thyroid / diabetes / connecive tissue disorders
What are the features of diarrhoea which point to a specific cause?
- Blood in the stools
- Often signifies a colonic cause
- Steattorhoea
- Failing to flush
- Pale
- Fat globules
- Organic pathology
- <3 months and continuous
- Weight loss
- Nocturnal
How would you investigate a patient presenting with bowel symptoms?
- STOOL
- Culture
- Faecal elastase
- Faecal calprotectin (with caution)
- NEVER FORGET PR
- Constipated
- Rectal mass
- Bloods
- FBC
- U&E, CRP
- TFTs
- Anti-tTG and immunoglobulins
- 7-alpha-cholestanone (patients often get diarrhoea after cholecystectomy because cannot absorb bile acid so they need to be given bile acid.)
When is a colonoscopy indicated?
- All change in bowel habut > 50
- Rectal bleeding
- Weight loss
- Strong FHx
- Picture - malignant polyp in the sigmoid colon (can cause diarrhoea with a little PR bleeding).
What are the key features of IBD?
- Weight loss
- Iron deficiency anaemia with thrombocythaemia
- Slowly progressive
- Nocturnal symptoms (IBS will NOT have nocturnal diarrhoea; IBD may well have)
- Extra-intestinal manifestations (shown in the picture)
What are the key features of IBS?
- Abdominal pain
- No bleeding
- Investigations normal
- Dietary
- Gluten hypersensitivity
- Lactose intolerance
What are the components of constipation?
- Passage of hard, infrequent stools <3 / week
- Straining
- Incomplete evacuation
What is the commonest cause of constipation?
And the other common causes?
-
DRUGS
- Opiates
- Anticholinergics
- Iron
- Diet
- Poor fibre intake
- IBS
- Anorectal disease
- Strictures
- Fissures
Describe the management of constipation.
-
Correct the correctable
- Change analgesia
- Rehydrate
- Treat their infection
- Manage their diet better
-
Laxatives
-
Osmotic laxatives
- Lactulose / laxido
- Don’t lose lon term effect
- Stimulant laxatives
- Senna / Bisacodyl
- Lose long term effect - ‘cathartic colon’
- Faecal softeners
- Glycerin suppositories
- Docusate sodium
- Phosphate enema
-
Osmotic laxatives
