Gastro Flashcards

1
Q

What are the defence mechanisms of the GI microbiome?

A

Intestinal microflora:
- prevent infection by interfering and competing with pathogens
- produce its own antibacterial substances
Gastric acid kills most organisms that are swallowed
Bile has antibacterial properties

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2
Q

What is diarrhoea?

A

The passage of loose or watery stools, typically at least three times in 24hrs.

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3
Q

What are the types of diarrhoea?

A

Acute - 14 days or fewer in duration
Persistant diarrhoea - 14-30 days duration
Chronic diarrhoea - >30 days duration

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4
Q

What are the causes of diarrhoea?

A

Infective: intraluminal infection, systemic infections (sepsis, TSS, tropical infections, COVID)

Non-infective: cancer, chemical (poisoning, sweeteners, medications), IBD, IBS/malabsorption, endocrine (thyrotoxicosis), radiation

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5
Q

What are the characteristics and causes of watery diarrhoea?

A

Non-inflammatory
Infection in proximal small bowel
Bacteria implicated: vibrio cholerae, E. coli, Clostridium perfringens, Bacillus cereus (reheated rice), S. aureus, C. difficile
Viral causes: Rotavirus, norovirus
Parasitic: Giardia, Cryptosporidium

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6
Q

What condition is associated with rice water diarrhoea?

A

V. cholerae infection

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7
Q

What is dysentery?

A

bloody diarrhoea

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8
Q

What is H. pylori?

A

Gram -ve rod, commensal bacteria, usually asymptomatic acquisition

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9
Q

What conditions are caused by H. pylori?

A

Peptic ulcer disease (PUD), chronic gastritis, gastric adenocarcinoma, gastric mucosal lymphoma

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10
Q

What is the pathophysiology of H. pylori infection?

A
  • H. pylori synthesises urease, an enzyme which produces ammonia
  • Ammonia damages the gastric mucosa as well as neutralising the protective stomach acid which allows the organs, to survive in the stomach
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11
Q

What are the diagnostic tests for H. pylori infection?

A

Biopsy
Stool antigen
C-urea breath test

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12
Q

What is the treatment for H. pylori infection?

A

Triple therapy: clarithromycin, amoxicillin, PPI (lansoprazole, omeprazole)

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13
Q

What is E. coli?

A

Gram -ve rod, often commensal bacteria
Most strains are harmless but some serotypes are pathogenic:
- ETEC (EnteroToxigenic), EAEC (EnteroHaemorrhagic), EPEC (EnteroPathogenic) → watery diarrhoea
EHEC (EnteroHaemorrhagic) → bloody diarrhoea
Serotype 0157:H7 → Haemolytic Uremic Syndrome
( → haemorrhagic diarrhoea + nephritic syndrome)

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14
Q

What is the treatment for E. coli?

A

Amoxicillin, trimethoprim, nitrofurantoin

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15
Q

What is C. difficile?

A

Gram +ve spore-forming, toxin-producing bacteria
Mainly induced w/ antibiotics (ciprofloxacin, co-amoxiclav, cephalosporins, clindamycin)

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16
Q

What is the pathophysiology of C. difficile infection?

A

Causes pseudomembranous colitis
- Normal GIT flora killed by antibiotics and C. difficile replaces them
- Results in dangerous severe diarrhoea (very watery; ↑↑dehydration)
Highly infectious

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17
Q

What is the treatment for C. difficile?

A

Stop using C-antibiotics (ciprofloxacin, co-amoxiclav, cephalosporins, clindamycin)
Give vancomycin

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18
Q

Which bacteria cause dysentry?

A

C - Campylobacter
E - E. coli
S - Shigella
S - Salmonella

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19
Q

What factors are essential to refer to in the history for GI infections?

A

Onset/duration
Characteristics of stool
Food/drink
Travel
Immune status
Unwell contacts
Hobbies + fresh water
Animal contact
Medications

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20
Q

What are the indications for testing in GI infections

A

Severe illness: signs of hypovolemia, severe abdo pain, hospitalization
Bloody diarrhoea+ mucus
High-risk host: Age ≥70 years, immunocompromising condition , IBD , pregnancy
Symptoms persisting for more than one week
Public health concerns (eg, diarrhoeal illness in food handlers, HCW, individuals in day care centers)

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21
Q

What can be tested in a stool sample?

A

Microscopy
Culture
Multi-pathogen molecular panels (GE PCR panel)
Ova, cysts and parasites x3
Toxin detection (C difficile)

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22
Q

What is Acute Cholecystitis?

A

Gallbladder inflammation caused by cystic duct obstruction by gall stones

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23
Q

What are the symptoms of acute cholecystitis?

A

Right upper quadrant or epigastric pain, fever and leukocytosis

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24
Q

What is the diagnostic test for acute cholecystitis?

A

USS

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25
What is the treatment for acute cholecystitis?
IV fluids, analgesia and antibiotics Surgery: cholecystectomy
26
What is ascending cholangitis?
Obstruction of the common bile duct resulting in inflammation
27
What are the symptoms of ascending cholangitis?
Charcot's triad: Fever, abdominal pain and jaundice
28
What is the management of ascending cholangitis?
Prompt admission + IV antibiotics ERCP (Endoscopic retrograde cholangiopancreatography) - also used for diagnosis Cholecystectomy
29
What is the most common cause of upper GI bleeding?
Peptic ulcer (50%)
30
what is the Glasgow-Blatchford score?
A scoring method to decide whether a patient presenting with upper GI bleeding should be admitted or sent home.
31
What factors are considered in the Glasgow-blatchford score?
- Systolic blood pressure - Blood urea - Haemoglobin - Pulse ≥ 100 - Melaena (black, tarry stools due to blood) - Syncope - Hepatic disease - Cardaic failure
32
What are the two types of upper GI bleeding?
Variceal and Non-variceal bleeding
33
When is variceal bleeding suspected?
In patients with a history of liver disease or alcohol excess
34
What is the first line treatment for variceal bleeding?
Antibiotics and terlipressin (inhibits portal circulation) reduce mortality
35
What is the endoscopic treatment for variceal bleeding?
Band ligation (within 12 hours)
36
When is non-variceal bleeding suspected?
In patient with a history of peptic ulcers, using certain medications; NSAIDs, anticoagulation or antiplatelets
37
What is the first line treatment for non-variceal bleeding?
Consider proton pump inhibitors
38
What are the causes of intraluminal obstruction of the GI tract?
tumour - carcinoma, lymphoma block lumen diaphragm disease - diaphragm-like membranes of mucosa and submucosa form in bowel lumen creating pinhole lumen and subsequent obstruction meconium ileus - meconium = first stool produced by neonate, in meconium ileus it gets stuck and blocks the ileum gallstone ileus - impacted gallstone blocks lumen of small instestine
39
What are the causes of intramural GI obstruction?
inflammatory - Crohn's, diverticulitis tumours neural - Hirschsprung's disease - occurs in babies when the nerve cells do not migrate all the way down to the distal colon/rectum --> immobile distal colon/rectum so can't pass stool
40
What are the causes of extramural bowel obstruction?
adhesions volvulus tumour (peritoneal deposits)
41
Where does volvulus occur most often?
Sigmoid colon
42
What are the 2 types of oesophageal cancer?
- adenocarcinoma - lower 1/3 oesophagus, associated with Barrett's oesophagus - squamous cell carcinoma - upper 2/3 oesophagus, smoking + alcohol
43
What are the risk factors for oesophageal cancer?
male older age smoking alcohol use (SCC) Barrett's oesophagus (AC) GORD (AC) hiatus hernia (AC) FHx
44
where are the typical sites of oesophageal cancer metastasis?
perioesophageal lymph nodes, liver, lungs
45
What are the key presentations of oesophageal cancer?
usually presents at advanced stage anaemia weight loss anorexia melaena haematemesis odynophagia (progressive difficulty swallowing)
46
What are the risk factors/causes of gastric carcinoma?
H. pylori infection smkoing CDH-1 mutation --> 80% risk FHx pernicious anaemia (autoimmune chronic gastritis)
47
What are the key presentations of gastric carcinomas?
severe epigastric pain anaemia weight loss fatigue progressive dysphagia
48
what are the signs of gastric carcinoma metastases?
jaundice (liver mets), Krukenberg tumour (ovarian mets)
49
what are the investigations for gastric carcinoma?
gastroscopy + biopsy CT/MRI for staging, PET to ID mets
50
What is the chemotherapy for gastric carcinoma?
ECF - epirubicin, cisplatin, fluorouracil
51
Which 2 inherited conditions massively increase the risk of colorectal polyps?
Familial adenomatous polyposis (FAP) - autosomal dominant APC gene (tumour suppressor) mutation - 95% risk of corectal polyps by 50 Hereditary non-polyposis colon cancer/Lynch syndrome - autosomal dominant MSH-1 mutation = DNA mismatch for repair gene - rapidly increases progression, adenoma --> adenocarcinoma
52
What are the risk factors for colorectal polyps/cancer?
familial inherited genetic disposition adenomas/polyps alcohol smoking ulcerative colitis
53
what are the key presentations of colorectal polyps/cancer?
mostly in distal colon --> LLq pain, bloody mucousy stools, tenesmus
54
What are the investigations for colorectal polyps/cancer?
FIT test Colonoscopy + biopsy
55
What is dyspepsia?
indigestion --> early satiation, epigastric pain + reflux, extreme fullness
56
What is achalasia?
oesophageal dysmotility (impaired peristalsis), LOS fails to relax
57
what are the key presentations of achalasia?
non-progressive dysphagia (difficulty swallowing anything) substernal pain food regurgitation aspiration pneumonia (food or liquid breathed into the airways)
58
What are the investigations for achalasia?
1st line = upper GI endoscopy GS = oesophageal manometry other = barium swallow (bird's beak sign)
59
What is the treatment for achalasia?
only curative option = surgery (balloon stenting) nitrates + nifedipine can help pre-surgery to relax the LOS
60
What does achalasia increase the risk of?
oesophageal squamous cell lung cancer
61
What is ischaemic colitis?
ischaemia of colonic arterial supply (inferior mesenteric artery); colon inflamed due to hypoperfusion
62
What are the risk factors for ischaemic colitis?
>60 yrs old female clotting problems high cholesterol heart failure previous abdominal surgery
63
what are the most common sites affected by ischaemic colitis?
splenic flexure, sigmoid colon + cecum (watershed areas between the two major arteries supplying the colon - SMA/IMA)
64
what are the key presentations of ischaemic colitis?
LLQ pain + bright red bloody stool signs of hypovolemic shock (pallor, agitation, confusion)
65
What is the gold standard test for ischaemic colitis?
colonoscopy + biopsy
66
What are the treatments for ischaemic colitis?
IV fluid + antibiotics (prophylactic) Surgery only treatment if becomes gangrenous
67
What is pseudomembranous colitis?
infection of the colon caused by clostridium difficile
68
what are the risk factors for pseudomembranous colitis?
antibiotic exposure advanced age hospitalisation or residence in a nursing home exposure to infected family member IBD CKD HIV
69
What is the pathophysiology of pseudomembranous colitis?
C. difficile bacteria produce toxins which cause an inflammatory response in the large intestine, leading to increased vascular permeability and pseudomembrane (raised yellow and white plaques on inflamed mucosa made up of neutrophil, fibrin, mucin and cellular debris) formation.
70
What are the key presentations of pseudomembranous colitis?
diarrhoea abdominal pain fever abdominal tenderness nausea + vomiting abdominal distension shock symptoms
71
What are the investigations for pseudomembranous colitis?
FBC, stool sample (FIT, PCR, immunoassay) Abdo XR Sigmoidoscopy/colonoscopy
72
What is the management for pseudomembranous colitis?
antibiotics (fidaxomicin, vancomycin, metronidazole) supportive care
73
what is mesenteric ischaemia?
ischaemia of the small intestine AMI = acute attack CMI = longer lasting (month +)
74
What are the risk factors for mesenteric ischaemia?
Older age low/high bp Heart disease High cholesterol Smoking Clotting problem Inflammatory problems e.g. pancreatitis, diverticulitis
75
What are the key presentations for mesenteric ischaemia?
triad: 1. acute severe pain in the central/right iliac fossa 2. No abdo signs on exam 3. rapid hypovolemic shock
76
What are the investigations for mesenteric ischaemia?
FBC + ABG = persistent metabolic acidosis CT angiogram
77
What is the treatment for mesenteric ischaemia?
Fluid resuscitation, antibiotics, IV heparin infarcted bowel --> surgery
78
What are haemorrhoids?
Swollen veins around anus disrupt anal cushions causing prolapse of parts of the anal cushions through the anal passage
79
what is the classification of haemorrhoids?
1st degree: no prolapse 2nd: prolapse when straining and return on relaxing 3rd: prolapse when straining, do not return on relaxing, but can be pushed back 4th: prolapsed permanently
80
What are the risk factors for haemorrhoids?
constipation anal sex age 45-65 pregnancy pathological pelvic lesions
81
What are the 2 types of haemorrhoid presentation?
Internal - originate above internal rectal plexus (dentate line), less painful as has decreased sensory supply external - originate below dentate line, so painful patient can't sit down
82
What are the key presentations of haemorrhoids?
bright red fresh PR bleeding + mucousy bloody stool bulging pain pruritis ani
83
What are the investigations for haemorrhoids?
PR exam for external protoscopy for internal
84
What is the management for haemorrhoids?
topical treatments for symptomatic relief scleropathy (injection of phenol oil) rubber band ligation
85
What is a perianal abscess?
Walled off collection of pus resulting from infection of the soft tissues around the anus
86
What are the risk factors for perianal abscesses?
Anal sex Crohn's disease male hard stool 21-40 yrs old
87
What are the key presentations of perianal abscesses?
Pus in stool Constant pain and tenderness Perianal swelling Low-grade fever Tachycardia
88
What is the management for perianal abscesses?
surgical removal + drainage
89
What is an anal fistula?
Abnormal connection under the skin between the anal canal to the skin of the buttocks.
90
What is the aetiology of anal fistulae?
Most often form in a reaction to an anal gland that has developed a pus-filled infection (abscess). The abscess discharges (toxic substances) which aid fistula formation as abscess grows.
91
What are the risk factors for anal fistulae?
Anal abscess → 50% chance of developing fistula Crohn’s disease Chronic diarrhoea Radiation treatment for rectal cancer
92
What are the key presentations of anal fistulae?
Pain + swelling Fever Malaise Fatigue Perianal redness, soreness, puruitis Pus drainage Bloody/mucousy discharge
93
What are the investigations for anal fistulae?
Fistula probe (dye used to identify internal opening) Anoscope Imaging e.g. USS, MRI
94
What is the management for anal fistulae?
Surgical removal + drainage - Fistulotomy - Fill the internal opening with special glue or plug - Reconstructive surgery - Seton placement (rubber band progressively tightened in fistula) antibiotics if infected
95
What is an anal fissure?
tear in anal skin lining below dentate line
96
how common are anal fissures?
occur in 1 in 350 people
97
what are the risk factors for anal fissures?
Hard stool/constipation Pregnancy Opiate analgesia (associated with constipation) Crohn’s Trauma such as childbirth
98
What are the key presentations for anal fissures?
Very severe pain on defecation Tearing sensation on passing stool Fresh blood in stool Anal spasm Puruitis ani
99
What are the treatment options for anal fissures?
Stool softening; increase fibre + fluid intake Topical creams e.g. lidocaine ointment Surgery
100
What are pilonidal sinuses/abscesses?
Hair follicles get stuck in natal cleft (bum crack) which can form small tracts (sinuses) or get infected (abscesses)
101
What are the risk factors for pilonidal sinuses/abscesses?
16-40 yrs old Male FHx Stiff hair + hirsutism
102
What is the pathophysiology of pilonidal sinuses/abscesses?
Broken hair is driven into the skin of the natal cleft by the rolling action of the buttocks. This provokes a foreign body-type reaction and chronic inflammation results in a sinus..
103
What is the presentation of a pilonidal sinus/abscess?
swollen, pus filled, odorous abscess on natal cleft
104
What is the treatment for pilonidal sinuses/abscesses?
hair removal + local hygiene Antibiotic therapy with infected abscess
105
What are the symptoms of coeliac disease?
often asymptomatic failure to thrive in young children Diarrhoea Steattorhoea Fatigue Weight loss Mouth ulcers Anaemia secondary to iron B12 or folate deficiency Dermatitis herpetiformis (itchy, blistering abdominal rash)
106
What is the gluten challenge?
6 week gluten containing diet 1g/day - 4 slices bread/day for diagnosis of coeliac
107
What are the investigations for coeliac disease?
serology: anti-ttG, ↑total IgA duodenal biopsy; crypt hyperplasia + villous atrophy + epithelial lymphocyte infiltration
108
What are the risk factors for coeliac disease?
Hashimoto's thyroiditis T1DM Thyroid disease PBC PBS Autoimmune hepatitis Genetic
109
What is the management for coeliac disease?
lifelong gluten-free diet = essentially curative + replace vitamins/mineral deficiency
110
What are the complications of coeliac disease if left untreated?
vitamin deficiency, anaemia, osteoprosis, ulcerative jejunitis, enteropathy-associated T-cell lymphoma of the intestine, Non-Hodgkin Lymphoma, small bowel adenocarcinoma
111
What are the Trueglove and Witts criteria?
>6 bloody stools/day tachycardia >90bpm pyrexia >38oC Hb >10.5 g/dL ESR >30mm/h
112
What is Crohn's disease?
Transmural autoimmune inflammation affecting the whole GI tract, especially terminal ileum + proximal colon (usually rectum spared) associated with skip lesions on endoscopy
113
What is the aetiology of Crohn's disease?
NOD-2 mutations + environmental; bacteria cause immune mediated response (T cells) → TNFa, IL-1, IL-6
114
What are the risk factors for CD?
Smoking Jewish FHx
115
What is the pathophysiology of Crohn's?
Initial lesion starts as an inflammatory infiltrate around intestinal crypts that subsequently develops into ulceration of the superficial mucosa. This progresses to involve all layers of the intestinal wall and the mesentery and regional lymph nodes.
116
What are the presentations of CD?
Pain in Right lower quadrant Malabsorption (as SI affected, colon = only H2O absorbed) + B12/folate/iron deficiencies Gallstones + kidney stones Watery diarrhoea Failure to thrive Weight loss Primary sclerosing cholangitis seen in 75% of CD patients Extra GI: aphthous mouth ulcers, uveitis/episcleritis, erythema nodosum/pyoderma gangrenosum, spondyloarthritis (spine ache)
117
What are the investigations for CD?
pANCA -ve (may be ASCA +ve) Faecal calprotectin ↑ Biopsy = transmural inflammation with non-caseating granulomas Endoscopy - skip lesions, cobblestoned appearance of GI tract, string sign (narrowing of GI tract)
118
What are the characteristic features of Crohn's seen on endoscopy?
skip lesions cobblestone appearance string sign (narrowed GI tract)
119
What is the management for CD?
For flares: sulfasalazine + prednisolone For remission: azathioprine + methotrexate biologics : anti-TNFa: Infliximab, IL 12 + 23 inhibitor: Ustekenumab * Surgery is not curative as entire bowel can be affected
120
What are the complications of CD?
fistula, strictures, abscesses, small bowel obstruction
121
What is Ulcerative Colitis?
Autoimmune colitis that presents with continuous inflammation only affecting the superficial mucosa and limited to the colon and rectum.
122
What is the aetiology of Ulcerative Colitis?
Associated with HLAB27 gene + pANCA
123
What are the risk factors of UC?
FHx Jewish Smoking = protective (reduces inflammation)
124
What are the presentations of UC?
Pain in LLQ + tenesmus (rectal defecation pain) Bloody mucosal watery diarrhoea Extraintestinal signs: uveitis/episcleritis, pyoderma gangrenosum,/erythema nodosum, spondyloarthropathy, primary sclerosing cholangitis (90% UC pts have PSC)
125
What are the investigations for UC?
pANCA +ve Faecal calprotectin ↑ (non-specific) Biopsy = mucosal inflammation with crypt hyperplasia Colonoscopy = continuous, “lead pipe” sign (loss of haustrations) Severity of flares are assessed by Trueglove + Witts scoring (mild/moderate/severe)
126
What are the characteristic signs of UC seen on colonoscopy?
continuous lesions pseudo-polyps crypt abcesses lead pipe sign (loss of haustrations)
127
What is the management for UC?
Flares = sulfasalazine + prednisolone For remission = azathioprine, methotrexate, cyclosporin (calcineurin inhibitor) biologics : anti TNFa - Infliximab Surgery (total/partial colectomy) → curative
128
What is coeliac disease?
Autoimmune T4 hypersensitivity to gluten which causes inflammation in the small bowel
129
What is the aetiology of coeliac disease?
HLADQ2 (90%) + HLA-DQ8
130
What is the pathophysiology of coeliac disease?
Auto-antibodies are created in response to gluten exposure that target the epithelial cells of the intestine and lead to inflammation. Anti-tissue transglutaminase (anti-TTG) and anti-endomysial (anti-EMA) are IgA antibodies related to disease activity and rise with more active disease. Inflammation affects the small bowel, particularly the jejunum and causes atrophy of the intestinal villi which usually absorb nutrients from food passing through the SI. The inflammation causes malabsorption of nutrients and the symptoms of the disease.
131
What is a functional gut disorder?
Chronic GI symptoms in the absence of organic disease to explain the symptoms also termed "disorders of gut-brain interaction"
132
What are the 2 most commonly recognised functional gut disorders?
IBS (bowel) Functional dyspepsia (stomach)
133
What are the indications of functional gut disorders?
visceral hypersensitivity motility disturbances altered mucosal and immune function altered CNS processing altered gut microbiota
134
What is dyspepsia?
a symptoms or combination of symptoms which indicate an upper GI problem, Typical symptoms: epigastric pain, early satiety, post-prandial fullness, bloating, nausea, burping, discomfort in upper abdomen
135
What are the alarm features with functional gut disorders?
age >45 yrs short hx of symptoms documented unintentional weight loss nocturnal symptoms family history of GI cancer/IBD GI bleeding palpable abdominal mass or lymphadenopathy evidence of iron deficiency anaemia on blood testing evidence of inflammation on blood/stool testing
136
What does a raised faecal calprotectin indicate?
Increased numbers of white blood cells in bloodstream which cross into gut lumen and release calprotectin --> sign of inflammation
137
What is IBS?
Irritable Bowel Syndrome = functional chronic bowel disorder which can be characterised by constipation, diarrhoea or mixed symptoms
138
What is the epidemiology of IBS?
affects around 17 % of adults in the UK higher prevalence in women
139
what is the aetiology of IBS?
thought to be multifactorial with a variety of possible causes which include: - food poisoning/gastroenteritis triggers - stress - irregular eating or abnormal diet - certain medications - interaction between the brain and gut
140
What are the risk factors for IBS?
Physical + sexual abuse PTSD Age <50 yrs Female Previous enteric infection FHx family/job stress
141
What are the ABC symptoms which indicate IBS consideration in diagnosis?
Abdominal pain/discomfort Bloating Change in bowel habit
142
What are the key presentations of IBS?
Abdo pain + bloating (relieved by defecation) Altered stool form + frequency
143
What are the investigations for IBS?
Diagnosis is by ruling out other conditions e.g. coeliac which is done through serology, faecal calprotectin, ESR/CRP/blood cultures
144
What are the differentials for IBS?
coeliac, IBD, colorectal cancer, ovarian cancer
145
What is the management for IBS?
Conservative = patient education (diet changes) + reassurance Moderate = IBS-C → laxatives (e.g. senna), IBS-D → antimotility drug (loperamide) Severe = TCA (tricyclic antidepressants e.g. amitriptyline) + consider CBT/GI referral
146
What is appendicitis?
Inflammation of the appendix, usually due to lumen obstruction. Surgical emergency
147
What is the peak age for appendicitis?
10-20 years
148
What are the causes of appendicitis?
Faecolith (hard solidified faeces) Lymphoid hyperplasia (seen in teens, peyer’s patches), filarial worms
149
What are the risk factors for appendicitis?
Low dietary fibre Good personal hygiene (due to reduced exposure/imbalance of GI microbial flora which can lead to a modified response to viral infection and trigger appendicitis Smoking
150
What is the pathology of appendicitis?
Blockage is typically infected with E.coli and as pressure inside the appendix increases, risk of rupture is increased (SBP)
151
What are the key presentations of appendicitis?
Umbilical pain which localises to McBurney’s point + rebound tenderness of abdominal guarding Pyrexia
152
What are the clinical signs of appendicitis?
Rovsing’s sign (pressure on RLQ causes pain in LLQ) Obturator sign (discomfort felt on slow internal movement of hip joint while right knee is flexed) PSOAS sign (pain when lying on left side, extending right leg)
153
What are the investigations for appendicitis?
FBC, CRP CT abdomen + pelvis Pregnancy test to rule out ectopic pregnancy, urinalysis
154
What is the management for appendicitis?
Antibiotics then appendectomy (laparoscopic) Drainage of abscesses as systemic antibiotics will be ineffective, follow with intra-abscess antibiotics
155
What is gastritis?
Inflammation of the gastric mucosa
156
What is the aetiology of gastritis?
Most commonly due to H. pylori infection Can also be caused by NSAIDs, alcohol misuse, autoimmune (related to pernicious anaemia + anti-IF antibiotics), mucoid ischaemia, reflux of bile salts into stomach, campylobacter (Guillain Barre)
157
What are the risk factors for gastritis?
NSAID use Alcohol use/abuse Previous gastric surgery Autoimmune disease
158
What is the pathophysiology of gastritis?
Severe inflammatory response to infection → gastric mucosa degradation, increased mucosal permeability and gastric epithelial cytotoxicity
159
What are the key presentations of gastritis?
Epigastric pain with diarrhoea N+V Indigestion
160
What are the investigations for gastritis?
If H. pylori suspected → stool antigen test/urea breath test Endoscopy + biopsy
161
What is the management for gastritis?
H. pylori = triple therapy (CAP - clarithromycin, amoxicillin, PPI)
162
What is the major complication of H. pylori gastritis?
Peptic ulcer disease
163
What is small bowel obstruction?
A form of intestinal failure where the gut is unable to absorb the necessary water, macronutrients (carbohydrates, proteins, fats), micronutrients, and electrolytes sufficient to sustain life.
164
What is the aetiology of small bowel obstruction?
Adhesions (50%) Hernia (15%) - groin (inguinal/femoral) Cancer (10%)
165
What are the key presentations of SBO?
Colic (sharp cramping pain) Bilious vomiting (green vomit) Hernia orifices bloating/distension Abdominal tenderness/peritonism
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What are the investigations for SBO?
FBC, U+Es, Lactate, C-reactive protein CT scan
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What is the management for SBO?
Analgesia IV fluids (for resuscitation) Nasogastric tube, antiemetics (alleviate nausea) Nasogastric tube, urinary catheter (assess fluid balance) Operation (key hole or open)
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What is GORD?
Gastroesophageal reflux disease = reflux of gastric contents into the oesophagus resulting in symptoms and/or complications
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What percentage of people living in developed countries are affected by GORD?
10-20%
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What is the pathophysiology of GORD?
Abnormally frequent occurrences of transient lower oesophageal sphincter relaxation causing reflux of gastric contents into the oesophagus. This causes damage to the oesophageal mucosa of varying severity depending on the duration of contact.
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What are the risk factors for GORD?
FHx Older age Hiatus hernia obesity Pregnancy Drugs e.g. antimuscarinics Scleroderma (scarring of lower oesophageal sphincter)
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What are the key presentations for GORD?
Heartburn Regurgitation *symptoms worse lying down as acid can reflux more easily Dysphagia Chronic cough + nocturnal asthma bloating /early satiety
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What are the investigations for GORD?
Clinical diagnosis if no red flags Red flags = dysphagia, haematemesis, weight loss → endoscopy (oesophagitis or Barrett's oesophagus), oesophageal manometry (measures LOS pressure + gastric acid pH)
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What is the management for GORD?
Conservative = lifestyle changes (smaller meals, 3+ hrs before bed) PPI, antacids, alginates (gaviscon) Last resort = surgical tightening of LOS (Nissen fundoplication = wrapping of fundus around LOS externally to increase pressure)
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What are the potential complications of GORD?
Oesophageal sphincters: usually 60+ patients, progressively worsening dysphagia, Tx: oesophageal dilation + PPI Barrett’s Oesophagus: 10% GORD patients develop, always involves hiatal hernia, metaplasia of oesophageal lining (SSNKE → simple columnar), ↑risk of adenocarcinoma
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What is a Mallory Weiss Tear?
Linear lower oesophageal mucosal tear due to sudden increase in intra-abdominal pressure
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What are the risk factors for Mallory Weiss tears?
Alcohol Chronic cough Bulimia Hyperemesis gravidarum (pregnancy complication of severe N+V, weight loss, dehydration No hx of liver disease or pulmonary hypertension (more likely to be oesophageal varices rupture)
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What are the key presentations for Mallory Weiss tears?
Haematemesis (after retching/vomiting Hx) + hypotensive if severe - often mild therefore this is unlikely
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What is the gold standard investigation for a Mallory Weiss tear?
oesophagogastroduodenoscopy
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What is the management for a Mallory Weiss tear?
Most spontaneously heal within 24hrs (80-90%) Supportive treatment
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What is the management for a Mallory Weiss tear?
Most spontaneously heal within 24hrs (80-90%) Supportive treatment
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What is PUD?
Peptic ulcer disease = break in the mucosal lining of the stomach or duodenum more than 5mm in diameter with depth to the submucosa more commonly duodenal than gastric
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What are the risk factors for PUD?
Chronic use of NSAIDs H. pylori infection Smoking Old age FHx Zollinger-ellison syndrome
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What is Zollinger Ellison Syndrome?
A digestive disorder where gastrin-secreting tumours cause this triad of symptoms: pancreatic tumours, gastric acid hypersecretion, widespread peptic ulcers
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What is the pathophysiology of PUD?
The ulcers result from an imbalance between factors promoting mucosal damage and those mechanisms promoting gastroduodenal defence (prostaglandins, mucus, bicarbonate, mucosal blood flow).
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What are the key presentations of PUD?
Epigastric pain (gastric PUD - worse on eating and better between meals, duodenal PUD - worse between meals and better with food) Gastric PUD - typically weight loss, Duodenal PUD - typically weight gain ‘Pointing sign’ (patients can show the site of pain with one finger)
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What are the investigations for PUD?
Non invasive tests if no red flags (55+, haematemesis/melaena, anaemia, dysphagia): C-urea breath test, stool antigen test If red flags - urgent endoscopy + biopsy
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What is the treatment for PUD?
Stop NSAIDs, if H. pylori +ve —> triple therapy (CAP - clarithromycin, amoxicillin, PPi)
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What are the potential complications of PUD?
Complications: bleeding, ruptured left gastric artery or gastroduodenal artery (more common)
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What is diverticular disease?
Outpouching of colonic mucosa Diverticulum = outpouching at perforating artery sites Diverticulosis = asymptomatic outpouching Diverticular disease = symptomatic outpouch Diverticulitis = inflammation of outpouch (infection)
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What are the risk factors of diverticular disease?
>50 yrs Low dietary fibre Diet high in salt, meat, sugar Obesity (BMI>30) NSAID and opioid use smoking
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What is the pathophysiology of diverticular disease?
A low fibre diet increases intestinal transit time and decreases stool volume resulting in increased intraluminal pressure and colonic segmentation, which predispose to diverticular formation. Precise mechanism is not fully understood.
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What are the key presentations of diverticular disease?
LLQ pain, guarding, tenderness Constipation Fresh rectal bleeding Leukocytosis Fever bloating
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What is the gold standard investigation for diverticular disease?
CT abdo pelvis
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What is the management for diverticular disease?
Diverticulosis = nothing, watch and wait Diverticular disease = bulk forming laxatives, surgery (gold standard) Diverticulitis = antibiotics (co-amoxiclav) and paracetamol. IV fluid + liquid food, rarely surgery
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What is intestinal obstruction?
Mechanical bowel obstruction Can be partial (allows passage of flatus and occasionally stool - not a surgical emergency and may resolve itself) or complete (emergency situation in which the lumen of the intestine is completely blocked resulting in failure to pass flatus and stool - generally associated with peritonitis - will not respond to non-operative treatment in most cases)
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What is the aetiology of partial intestinal obstruction?
Adhesions Crohn’s Strangulating hernias Malignancy
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What is the aetiology of complete bowel obstruction?
Malignancy Volvulus Intussusception (bowel telescopes in on itself)
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What are the key presentations of partial intestinal obstruction?
First vomiting, then constipation Mild abdominal distension + pain Tinkling bowel sounds (hypersonant bowels on percussion in both SBO/LBO
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What are the key presentations of complete intestinal obstruction?
First constipation, then vomiting Gross distension + pain hyperactive, then normal, then absent bowel sounds
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What are the investigations for intestinal obstruction?
XR (dilated bowel loops + transluminal fluid-gas shadows *LBO → coffee bean sign (if sigmoid volvulus) CT abdomen = GS
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What is the management for intestinal obstruction?
Fluid resuscitation Nasogastric tube Antiemetics + analgesia Antibiotics Surgery last resort
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What is Hirschsprung disease?
congenital malformation where the child is bron without a colonic nerve supply --> inability to pass stool often resulting in lower bowel obstuction
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What is pseudoobstruction of the bowel?
no mechanical obstruction, often a result of post-operative state (e.g. opiate induced paralytic ileus)