Core: Gastrointestinal Flashcards
Patient - High BMI, middle aged, heartburn worse on lying flat or after eating a large meal. Dry and irritating cough.
GORD
GORD Aetiology
- Hiatus hernia
- Loss of LOS tone
- Gastric acid hypersecretion
- Smoking
- Alcohol
- Pregnancy
- H.pylori infection.
GORD Pathology
- 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.
GORD Presentation
- Heartburn
- Regurgitation when lying flat
- Waterbrash
- Dry irritated cough
- Responds to PPI.
- If severe haematemesis.
GORD Complications
- Barrets Oesophagus - metaplasia from squamous to columnar epithelium. Pre-malignant.
- Oeosphageal carcinoma
- Gastric ulcer disease
- Peptic stricture.
GORD Ix
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.
GORD Rx
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.
Patient - Recurrent burning epigastric pain, worse when hungry and relieved by eating.
Duodenal ulcer
Patient - recurrent burning epigastric pain which is related to meals and worsened by food.
Gastric Ulcer
Peptic ulcer Aetiology
- H.pylori
- NSAID’s
- Smoking/alcohol
- GORD
Peptic ulcer pathology
- 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.
Peptic Ulcer Presentation
- 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.
Peptic Ulcer Ix
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.
Peptic Ulcer Rx
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
Patient - Young woman, Hx of gynae problems and depression present w/ intermittent abdominal pain w/ diarrhoea and constipation.
- IBS
IBS Aetiology/pathology
- UK
- Biopsychosocial
- Triggers = Affective disorder, stress trauma, infection, ABx, abuse etc.
IBS Presentation
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
IBS Ix
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.
IBS Rx
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.
Patient - Recurrent flares of abdominal pain associated w/ steatorrhea, apthous ulcers around the mouth and perianal skin tags.
Crohn’s disease
CD Aetiology
- UK
- Genetics; NOD2
- Bacterial infection, diet, bowel vascular supply.
CD Pathology
- 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.
CD Presentation
- 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.
CD Ix
1) Diagnostic = Colonoscopy + endoscopy + biopsy.
2) Bloods; FBC (microcytic anaemia, IDA), Raised CRP/ESR.
3) Faecal calprotectin and lactoferrin are both raised.
CD Rx
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.
Patient - Bloody diarrhoea w/ mucus. Recurrent bouts of increased frequency, abdominal pain and urgency.
- Ulcerative colitis
UC Aetiology
- UK
- Genetics; FHx
- Immune system - ANCA positive
- Bacterial overgrowth
- NSAID usage
- Smoking is protective.
UC Pathology
- 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.
UC Presentation
- Bloody diarrhoea w/ mucus
- Lower abdo pain
- B features
- Relapse and remitting
- Urgency
- tenesmus
UC acute attack
- > 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.
UC Ix
1) Bloods; FBC (IDA), Raised ESR and CRP, ANCA positive.
2) Gold standard = colonoscopy + biopsy.
3) AXR to rule out toxic megacolon.
UC Rx
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
Coeliac Aetiology
- 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.
Coeliac Presentation
- 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
Coeliac Ix
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.
Coeliac Rx
1) Avoid all gluten forever. Mic drop.
Achalasia (motility disorder) Aetiology
- 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.
Achalasia Presentation
- Dysphagia or SOLIDS AND LIQUIDS from onset
- Regurgitation of food.
- Chest pain (oesophageal spasm)
- Oesophageal distention
- Aspiration of food.
Achalasia Ix
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.
Achalasia Rx
1) None
2) Nifedipine and sildenafil ?
3) Endoscopic dilatation of LOS but often needs repeating as wears off
4) BOTOX
Diverticular disease Aetiology
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
Diverticulitis aetiology
- Diverticular disease
- Poop obstructs the neck of the pouch
- Bacterial growth
- Gas and inflammation
- May cause perforation.
Diverticular disease presentation
- 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.
Diverticular disease Ix
1) Barium enema + Flexi sigmoidoscopy
Acute diverticulitis;
1) FBC (infection)
2) Raised ESR/CRP
3) CT colongraphy; wall thickening, diverticular
Diverticular disease Rx
1) Increase dietary fibre
2) Smooth muscle relaxants if required.
Acute =
1) Mild - oral cipro + metro
Severe - admit, IV fluids and IV ABX
Bowel Ca Aetiology
- 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%)
Bowel Ca Presentation
- 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
Bowel Ca Ix
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
Bowel cancer screening
- Faecal occult blood
- Carcinoembryonic antigen
Bowel Ca Rx
1) Resect if possible (+/- adjuvant/neo-adjuvant chemo/radio)
2) Chemo in those w/ stage 3 Ca.
Bowel obstruction Aetiology
- 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)
Bowel obstruction pathology
- 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.
Bowel obstruction Presentation
Often acute
- Abdominal colic
- Faecal vomiting
- Constipation and failure to pass wind.
- o/e
- Distended abdomen w/ increased bowel sounds
- Tenderness
- Examine hernial orifices.
Bowel obstruction Ix
1) AXR - dilated loops of bowel proximal to obstruction and fluid levels on erect films.
Bowel obstruction Rx
1) ABCDE + fluid resus (saline +potassium)
2) Emergency laparotomy.
Ischaemic bowel Aetiology
- 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.
Ischaemic bowel presentation
- 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.
Ischaemic Bowel Ix
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.
Ischaemic Bowel Rx
1) Conservative management
2) Urgent laparotomy if at risk of perforation.
3) Intussusception - air sufflation
4) Untwist a volvulus.
Constipation Aetiology
- Pregnancy
- Low fibre
- Immobility
- DM
- Hypercalcaemia
- Hypothyroid
- IBS
- Opiates, CCB, antidepressants, iron
- Spinal cord lesions
- PD
- GI obstruction
Rome criteria for constipation
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
Constipation Presentation
- Constipation
- Abdo bloating
- Painful pooping
- Overflow diarrhoea
- Rectal bleeding
- Signs of rectal pathology; fissure etc.
Constipation Ix
1) Baseline bloods; anaemia, WCC, TFT
2) AXR - faecal loading
3) Colonoscopy
4) Colonic transit study
5) Anorectal manometry
Constipation Rx
1) Rx underlying cause
2) In slow transit - increase fibre and fluids
3) Bulking agents = fibre, fybogel
4) Laxatives
Laxative types
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.
Appendicitis Aetiology
- Common emergency
- DDX in acute abdomen
- Occurs when appendix lumen is obstructed by a shit ball.
- Necrosis occurs and can cause perforation or peritonitis.
Appendicitis presentation
- 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.
Appendicitis Ix
1) Bloods; raised WCC, ESR and CRP
2) USS inflamed appendix
3) CT abdo is sensitive and specific.
Appendicitis Rx
1) Appendix is removed via laparotomy.
2) ABx - metronidazole (500mg/8h) + cefuroxime (1.5g/8h)
Dysphagia causes
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
Toxic megacolon Ix in UC flare
- Plain AXR
- Transverse colon diamerer >6cm
Spontaneous bacterial peritonitis
- Causes
- Presentation
- Ix
- Rx
- Secondary infection for those w/ ascites secondary to liver cirrhosis
- Often E.coli - Ascites
- Fever
- Abdominal pain - Paracentesis of ascetic fluid >250 neutrophils
- IV cefotaxime.
- Prophylaxis when protein <15g/L or hepatorenal syndrome w/ oral fluoroquinolone.
Ascites - Types.
Albumin >11g/L
- Cirrhosis
- Alcoholic hepatitis
- Cardiac
- Massive liver mets
- Liver failure
- Portal vein thrombosis.
Side effects of long term PPI
- Muscle aches and hypomagnesaemia
- Osteoporosis
- Microscopic colitis
- Increased risk of C.diff
Carcinoid syndrome
- Wheeze, flushing and diarrhoea.
- Increased serotonin
- Rx w/ ocreotide.
Malnutrition
- Loss of 10% of body weight within the last 3-6 months.
Small intestine bacterial overgrowth
- 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
Refeeding syndrome
- Causes
- Presentation
- Ix
- Rx
- Refeeding after times of starvation; eating disorders etc.
- Extended period of catabolism ends in lots of carbs. - Hypophosphataemia
- Hypokalaemia
- Hypomagnesaemia
- Abnormal fluid balance. - Bloods and electrolytes
- 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.
