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Medical School Finals > Core: Gastrointestinal > Flashcards

Core: Gastrointestinal Flashcards

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USMLE® Step 1 flashcards
1
Q

Patient - High BMI, middle aged, heartburn worse on lying flat or after eating a large meal. Dry and irritating cough.

A

GORD

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2
Q

GORD Aetiology

A
  • Hiatus hernia
  • Loss of LOS tone
  • Gastric acid hypersecretion
  • Smoking
  • Alcohol
  • Pregnancy
  • H.pylori infection.
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3
Q

GORD Pathology

A
  • Between swallowing to oesophageal muscles are relaxed except for the sphincters which stop stomach contents moving into a lower pressure space.
  • LOS relaxes only on swallowing.
  • Transient LOS relaxation occurs in those w/ GORD allowing for reflux.
  • Diaphragm + bunching of gastric mucosa act as anti-reflux mechanisms. These are disrupted in hiatus hernia.
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4
Q

GORD Presentation

A
  • Heartburn
  • Regurgitation when lying flat
  • Waterbrash
  • Dry irritated cough
  • Responds to PPI.
  • If severe haematemesis.
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5
Q

GORD Complications

A
  • Barrets Oesophagus - metaplasia from squamous to columnar epithelium. Pre-malignant.
  • Oeosphageal carcinoma
  • Gastric ulcer disease
  • Peptic stricture.
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6
Q

GORD Ix

A

1) Often clinical - Red flags = weight loss and dysphagia
2) Endoscopy for hernia or oesophagitis and BO
3) pH and manometry
4) Best = Trial of PPI.

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7
Q

GORD Rx

A

1) Lifestyle - lose weight, stop smoking, less alcohol, not lying too flat.
2) OTC antacids - Gaviscon (creates a raft)
3) PPI - omeprazole etc. Prevents acid secretion
4) H2 antagonists - ranitidine
5) Prokinetic agents to speed up gastric emptying - Metoclopramide and domperidone.
6) Hernial repair.

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8
Q

Patient - Recurrent burning epigastric pain, worse when hungry and relieved by eating.

A

Duodenal ulcer

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9
Q

Patient - recurrent burning epigastric pain which is related to meals and worsened by food.

A

Gastric Ulcer

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10
Q

Peptic ulcer Aetiology

A
  • H.pylori
  • NSAID’s
  • Smoking/alcohol
  • GORD
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11
Q

Peptic ulcer pathology

A
  • Ulcer is a break in the epithelium.
  • Lesion penetrates to the muscularis propria.
  • Lots of inflammation
  • DU seen at the duodenal cap.
  • GU seen on the lesser curve near incisura.
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12
Q

Peptic Ulcer Presentation

A
  • Recurrent burning epigastric pain
  • Pain often indicated w/ one finger.
  • DU occurs at night and when hungry, relieved by food.
  • GU pain occurs in relation to food.
  • Nausea however vomiting is infrequent.
  • Haematemesis.
  • IDA
  • Erosion and perforation.
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13
Q

Peptic Ulcer Ix

A

1) H.pylori - serological testing IgG antibodies. or C-urea breath test.
2) Endoscopy for Dx
3) Red flags = Anaemia, Loss of weight, Anorexia, Recent onset, Melaena, Swallowing issues.

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14
Q

Peptic Ulcer Rx

A

1) Remove offending agent; NSAID, smoking, alcohol.
2) H.pylori eradication = Oemprazole 20mg + Clarithromycin 500mg + amoxicillin BD for 7/14 days.
3) Long term PPI or H2 antagonist

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15
Q

Patient - Young woman, Hx of gynae problems and depression present w/ intermittent abdominal pain w/ diarrhoea and constipation.

A
  • IBS
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16
Q

IBS Aetiology/pathology

A
  • UK
  • Biopsychosocial
  • Triggers = Affective disorder, stress trauma, infection, ABx, abuse etc.
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17
Q

IBS Presentation

A

Rome criteria.

  • In the preceding 3 months there should be atleast 3days/month of recurrent abdominal pain + 2 of the following.
    1) Improvement of pain w/ shitting
    2) Onset associated w/ change in frequency
    3) Onset associated w/ change in stool form.
  • Increased gas
  • N&V
  • Gynae problems
  • Fibromyalgia
  • Fatigue
  • Poor sleep
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18
Q

IBS Ix

A

1) Clinical
2) Further Ix if associated w. bleeding, nocturnal pain, weight loss, or in patients that would be typical for IBD or malignancy.
3) Bloods; FBC, U&E, Coeliac.

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19
Q

IBS Rx

A

1) Lifestyle changes and trigger avoidance
2) Constipation = laxatives such as biscodyl or sodium picosulphate which don’t ferment.
2) Diarrhoea - loperamide following each loose stool.
3) Bloating and abdo pain - mebeverine
4) Psych referral if required.

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20
Q

Patient - Recurrent flares of abdominal pain associated w/ steatorrhea, apthous ulcers around the mouth and perianal skin tags.

A

Crohn’s disease

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21
Q

CD Aetiology

A
  • UK
  • Genetics; NOD2
  • Bacterial infection, diet, bowel vascular supply.
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22
Q

CD Pathology

A
  • From mouth to anus.
  • Like terminal ileum and ascending colon.
  • Non-caseating granuloma.
  • Full thickness of the bowel wall (transmural)
  • Chronic inflammation (T cell mediated)
  • Whole bowel is thickened w/ inflammation and oedema. Lumen is narrowed.
  • Deep ulcers and fissures result in cobblestone appearance.
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23
Q

CD Presentation

A
  • Diarrhoea (often w/ blood)
  • Colicky abdominal pain
  • Weight loss
  • Fever, malaise, lethargy, anorexia.
  • Steatorrhoea if small bowel disease.
  • Perianal disease; skin tags and fissures.
  • Systemic issues; malabsorption, erythema nodosum, uveitis, arthropathy, Clubbing, Gallstones.
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24
Q

CD Ix

A

1) Diagnostic = Colonoscopy + endoscopy + biopsy.
2) Bloods; FBC (microcytic anaemia, IDA), Raised CRP/ESR.
3) Faecal calprotectin and lactoferrin are both raised.

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25
Q

CD Rx

A

Induce then maintain remission

1) Steroids induce remission - Pred 30-60mg/day
2) Abx cover for complications such as abscesses and perianal disease (cipro and metronidazole)
3) Maintain remission w/ AZA 2.5mg/kg/day or mercaptopurine 1.5mg/kg/day or MTX 25mg OW then
4) Anti-TNF - infliximab, adalimumab.
5) Surgical resection in those who fail to respond.

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26
Q

Patient - Bloody diarrhoea w/ mucus. Recurrent bouts of increased frequency, abdominal pain and urgency.

A
  • Ulcerative colitis
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27
Q

UC Aetiology

A
  • UK
  • Genetics; FHx
  • Immune system - ANCA positive
  • Bacterial overgrowth
  • NSAID usage
  • Smoking is protective.
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28
Q

UC Pathology

A
  • Solely affect the large bowel.
  • Can affect the rectum alone (proctitis.
  • Can extend proximally to involve the descending colon or the whole colon.
  • Mucosa is red and friable
  • Continuous chronic inflammation and infiltrate into the lamina propria.
  • CRYPT ABSCESSES AND GOBLET CELLS.
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29
Q

UC Presentation

A
  • Bloody diarrhoea w/ mucus
  • Lower abdo pain
  • B features
  • Relapse and remitting
  • Urgency
  • tenesmus
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30
Q

UC acute attack

A
  • > 6 stools daily w/ blood +++
  • > 37.5
  • > 90bpm
  • <100g/L Hb
  • <30g/L albumin

Rx =

  • Admit + fluid resus
  • Prophylactic ABx and anticoagulation
  • Monitor stool and bloods.
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31
Q

UC Ix

A

1) Bloods; FBC (IDA), Raised ESR and CRP, ANCA positive.
2) Gold standard = colonoscopy + biopsy.
3) AXR to rule out toxic megacolon.

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32
Q

UC Rx

A

1) 5ASA bound to sulfasalazine, ASA is cleaved in the gut and works topically there.
2) Proctitis = Enema or suppository of 5ASA.
3) Severe disease = steroids oral pred or IV hydrocortisone.
4) Salvage = Ciclosoprin
5) Surgery

33
Q

Coeliac Aetiology

A
  • Immunology - gliadin from gluten binds to antigen presenting cells leading to inflammatory response.
  • Genetics; FHx, HLA-DQ2 associations.
  • Inflammation of the mucosa of the upper small bowel.
  • Resolves when gluten in removed.
  • Atrophy or villi and crypt hyperplasia.
34
Q

Coeliac Presentation

A
  • Any age
  • Often in childhood or 5th decade of life.

Kids =

  • Failure to thrive post weaning
  • Abdominal distention
  • Abnormal stools
  • Buttock wasting
  • IDA
  • Non-specific bowel issues.
  • Screened for in all those w/ T1DM, downs and thyroid disease.

Adults =

  • Diarrhoea
  • steatorrhea
  • Abdo pain
  • Weight loss
35
Q

Coeliac Ix

A

1) Bloods; Anti-ttg and anti-endomysial antibodies
- IgA and IgA TTG
2) FBC, LFT etc.
3) Gold standard = Small bowel biopsy and histology showing villous atrophy and crypt hyperplasia.

36
Q

Coeliac Rx

A

1) Avoid all gluten forever. Mic drop.

37
Q

Achalasia (motility disorder) Aetiology

A
  • UK
  • Autoimmune
  • Neurological
  • Infective (similar picture to Chaga’s disease which affects the neural plexus of the gut)
  • Inflammation of the myenteric plexus of the oesophagus w/ a reduction in ganglion cell numbers.
  • Loss of NO neurones; inhibitory neurones.
38
Q

Achalasia Presentation

A
  • Dysphagia or SOLIDS AND LIQUIDS from onset
  • Regurgitation of food.
  • Chest pain (oesophageal spasm)
  • Oesophageal distention
  • Aspiration of food.
39
Q

Achalasia Ix

A

1) CXR dilated oesophagus
2) Barium swallow - lack of peristalsis and bird beak due to fail in LOS relax.
3) Oesophagoscopy - exclude carcinoma. In true achalasia, the endoscope will pass easily.

40
Q

Achalasia Rx

A

1) None
2) Nifedipine and sildenafil ?
3) Endoscopic dilatation of LOS but often needs repeating as wears off
4) BOTOX

41
Q

Diverticular disease Aetiology

A

Diverticulosis - presence of diverticula
Diverticulitis - Inflammation

  • Congenital - contains all three layers of bowel wall (Meckel’s diverticulum)
  • Acquired as pulsion from increased luminal pressure (straining) pushes bowel wall through weak points in the wall, where blood vessels penetrate.
  • Related to low dietary fibre
42
Q

Diverticulitis aetiology

A
  • Diverticular disease
  • Poop obstructs the neck of the pouch
  • Bacterial growth
  • Gas and inflammation
  • May cause perforation.
43
Q

Diverticular disease presentation

A
  • Often asymptomatic
  • Found incidentally on colonoscopy or barium enema.
  • Acute diverticulitis = Severe L iliac fossa pain (sigmoid colon)
  • Fever
  • Constipation
  • Tenderness and guarding in area.
  • Profuse PR bleed
  • Can perforate or form fistula w/ bladder or vagina.
44
Q

Diverticular disease Ix

A

1) Barium enema + Flexi sigmoidoscopy

Acute diverticulitis;

1) FBC (infection)
2) Raised ESR/CRP
3) CT colongraphy; wall thickening, diverticular

45
Q

Diverticular disease Rx

A

1) Increase dietary fibre
2) Smooth muscle relaxants if required.

Acute =
1) Mild - oral cipro + metro
Severe - admit, IV fluids and IV ABX

46
Q

Bowel Ca Aetiology

A
  • Risks = age, sat fats and red meats, sugar, polyps, FHx of Ca or polyps, IBD, smoking.
  • Genetics - genetic hit hypothesis –> Normal mucosa –> polyp –> adenocarcinoma.
  • Familial adenomatous polyposis (<1%)
  • Hereditary non-polyposis colon cancer (2-3%)
47
Q

Bowel Ca Presentation

A
  • Change in bowel habit - looser and more frequent motions
  • PR bleed
  • Tenesmus
  • IDA
  • Abdo pain
  • Abdo mass
  • All patients >40yo w/ altered bowel habit … consider
  • RED FLAGS
48
Q

Bowel Ca Ix

A

1) Colonoscopy + biopsy is gold standard.
2) CT colon
3) Endoanal USS and pelvic MRI for perianal disease.
4) Chest/abdo CT/PET for staging

49
Q

Bowel cancer screening

A
  • Faecal occult blood

- Carcinoembryonic antigen

50
Q

Bowel Ca Rx

A

1) Resect if possible (+/- adjuvant/neo-adjuvant chemo/radio)
2) Chemo in those w/ stage 3 Ca.

51
Q

Bowel obstruction Aetiology

A
  • Small intestine - adhesions (post-surgical), Hernia, Crohn’s disease, intussusception, extrinsic mass.
  • Colon - Ca, sigmoid volvulus, diverticular disease.
  • Foreign body, faecaloma, imperforate anus.
  • Most often due to mechanical blockage, however can be caused by paralytic ileus (after invasive abdo sugery)
52
Q

Bowel obstruction pathology

A
  • Block leads to proximal bowel distention.
  • Increased fluid secretion into proximal dilated segments (fluid level)
  • If strangulated; ischaemia occurs and perforation can occur.
  • Distally; failure to pass stool or wind.
53
Q

Bowel obstruction Presentation

A

Often acute

  • Abdominal colic
  • Faecal vomiting
  • Constipation and failure to pass wind.
  • o/e
  • Distended abdomen w/ increased bowel sounds
  • Tenderness
  • Examine hernial orifices.
54
Q

Bowel obstruction Ix

A

1) AXR - dilated loops of bowel proximal to obstruction and fluid levels on erect films.

55
Q

Bowel obstruction Rx

A

1) ABCDE + fluid resus (saline +potassium)

2) Emergency laparotomy.

56
Q

Ischaemic bowel Aetiology

A
  • Consider as part of the PVD spectrum.
  • Vascular emboli - superior mesenteric artery (or inferior)
  • Vascular stenosis
  • Vasculitis (HSP, SLE)
  • RF’s include those for IHD.
  • Incarcerated hernia.
  • Intussusception
  • Volvulus (twisting of the GI tract.) often sigmoid.
  • SPLENIC FLEXURE is most common site as its a watershed area between blood supplies.
57
Q

Ischaemic bowel presentation

A
  • Often occurs in the elderly.
  • However consider in anyone with a Hx suggestive of and RF’s.
  • Intussusception occur in younger kids.
  • Presents w/ bright red PR bleed.
  • Sudden onset abdo pain
  • Developing shock.

Mucosal infarct - transient and reversible.
Mural - mucosa and submucosa; heals w/ fibrosis and strictures.
Transmural - necrosis extends through and needs resecting.

58
Q

Ischaemic Bowel Ix

A

1) AXR - thumb printing
2) FBC/ABG - lactic acidosis and shock
3) Urgent CT to exclude perforation
4) Flexi sigmoid + biopsy
5) Coloscopy once treated looking for strictures and fibrosis.

59
Q

Ischaemic Bowel Rx

A

1) Conservative management
2) Urgent laparotomy if at risk of perforation.
3) Intussusception - air sufflation
4) Untwist a volvulus.

60
Q

Constipation Aetiology

A
  • Pregnancy
  • Low fibre
  • Immobility
  • DM
  • Hypercalcaemia
  • Hypothyroid
  • IBS
  • Opiates, CCB, antidepressants, iron
  • Spinal cord lesions
  • PD
  • GI obstruction
61
Q

Rome criteria for constipation

A

2 or more of the following for atleast 12 weeks.

a) Infrequent passage of stool <3/week
b) straining >25% of the time
c) Passage of hard stool
d) Incomplete evac
e) Sensation of anorectal block

62
Q

Constipation Presentation

A
  • Constipation
  • Abdo bloating
  • Painful pooping
  • Overflow diarrhoea
  • Rectal bleeding
  • Signs of rectal pathology; fissure etc.
63
Q

Constipation Ix

A

1) Baseline bloods; anaemia, WCC, TFT
2) AXR - faecal loading
3) Colonoscopy
4) Colonic transit study
5) Anorectal manometry

64
Q

Constipation Rx

A

1) Rx underlying cause
2) In slow transit - increase fibre and fluids
3) Bulking agents = fibre, fybogel
4) Laxatives

65
Q

Laxative types

A

Osmotic - increasing colonic flow of water. Soften stool and ease movement.
eg - magnesium sulphate, lactulose and macrogol

Stimulatory - activate colonic contraction and cause intestinal secretion
eg - docusate, Bisacodyl and sodium picosulphate.

66
Q

Appendicitis Aetiology

A
  • Common emergency
  • DDX in acute abdomen
  • Occurs when appendix lumen is obstructed by a shit ball.
  • Necrosis occurs and can cause perforation or peritonitis.
67
Q

Appendicitis presentation

A
  • w/ abdominal pain
  • Umbilicus localising to McBurney’s point.
  • Guarding
  • N&V
  • Constipation and diarrhoea.
  • Back pain if retrocaecal.
  • o/e =
  • tender mass RIF
  • Rovsig sign = RIF pain when LIF pressed.
68
Q

Appendicitis Ix

A

1) Bloods; raised WCC, ESR and CRP
2) USS inflamed appendix
3) CT abdo is sensitive and specific.

69
Q

Appendicitis Rx

A

1) Appendix is removed via laparotomy.

2) ABx - metronidazole (500mg/8h) + cefuroxime (1.5g/8h)

70
Q

Dysphagia causes

A

1) Oesophageal CA
- Dysphagia + red flags.
- PMH of smoking and alcohol etc.

2) Oesophagitis
- Heartburn

3) Oesophageal candidiasis
- HIV
- Steroid inhalers

4) Achalasia
- Dysphagia w/ solids and liquids from onset.
- Aspiration

5) Pharyngeal pouch
- Cough
- Regurgitation
- Bad breath
- Older men

6) Systemic sclerosis
- CREST Sx

7) Myasthenia gravis
- Fatigable
- Liquids and solids
- Ocular muscle weakness etc.

8) Globus hystericus
- Anxiety
- Intermittent
- Painless

71
Q

Toxic megacolon Ix in UC flare

A
  • Plain AXR

- Transverse colon diamerer >6cm

72
Q

Spontaneous bacterial peritonitis

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Secondary infection for those w/ ascites secondary to liver cirrhosis
    - Often E.coli
  2. Ascites
    - Fever
    - Abdominal pain
  3. Paracentesis of ascetic fluid >250 neutrophils
  4. IV cefotaxime.
    - Prophylaxis when protein <15g/L or hepatorenal syndrome w/ oral fluoroquinolone.
73
Q

Ascites - Types.

A

Albumin >11g/L

  • Cirrhosis
  • Alcoholic hepatitis
  • Cardiac
  • Massive liver mets
  • Liver failure
  • Portal vein thrombosis.
74
Q

Side effects of long term PPI

A
  • Muscle aches and hypomagnesaemia
  • Osteoporosis
  • Microscopic colitis
  • Increased risk of C.diff
75
Q

Carcinoid syndrome

A
  • Wheeze, flushing and diarrhoea.
  • Increased serotonin
  • Rx w/ ocreotide.
76
Q

Malnutrition

A
  • Loss of 10% of body weight within the last 3-6 months.
77
Q

Small intestine bacterial overgrowth

A
  • Excess growth of bacteria in Small bowel
  • RF = DM, scleroderma, neonates w/ congenital GI issues.
  • Diarrhoea, bloating, farts, abdo pain
  • Dx w/ hydrogen breath test, small bowel aspiration and culture.
  • Rx underlying disorder
  • Rifaximin.
  • Or augmentin or metro
78
Q

Refeeding syndrome

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Refeeding after times of starvation; eating disorders etc.
    - Extended period of catabolism ends in lots of carbs.
  2. Hypophosphataemia
    - Hypokalaemia
    - Hypomagnesaemia
    - Abnormal fluid balance.
  3. Bloods and electrolytes
  4. Prevention;
    - High risk = low BMI, low nutritional intake >10 days, hypokalaemia, hypophosphataemia or hypomagnesaemia.
  • Aim to refeed at no more than 50% of requirement for the first 2 days.

Medical School Finals (24 decks)

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