Gastro Flashcards
What are the differences between Crohn’s and UC?
In Crohn’s:
Less common to have blood or mucus in stool
Entire GI tract is affected unlike UC where it is colon and rectum
Skip lesions on endoscopy unlike UC where there is continuous inflammation
Terminal ileum most affected
Transmural inflammation unlike UC where inflammation only in superficial mucosa
Smoking is risk factor where it is protective in UC
Strictures and fistulas are present
What are the presenting features of IBD?
Diarrhoea, abdominal pain, rectal bleeding, fatigue, weight loss, faecal urgency, nocturnal defecation, tenesmus, clubbing, mouth ulcers
What diseases are associated with IBD?
Erythema nodosum, pyoderma gangrenosum, eneteropathic arthritis, primary sclerosing cholangitis, red eye condiitons e.g. episcelritis, scleritis, anterior uveitis
What investigations should initially be performed in patient presenting with IBD symptoms?
FBC, inflammatory markers, haematinics, U+E, LFTs, TFTs, anti-TTG (rule out coeliac), stool microscopy (rule out infection), faecal calprotectin (1st line)
What is the gold standard investigation for diagnosing IBD?
Colonoscopy with multiple intestinal biopsies
What is the management for acute mild UC?
1st line = Aminosalicylates - topical then oral (unless extensive disease when oral first)
2nd line = oral prednisolone
What is the management for acute severe UC?
1st line = IV hydrocortisone
2nd line = IV ciclosporin
3rd line = infliximab or surgery
How is remission maintained in UC?
1st line = aminosalicylates
2nd line = azathioprine or mercaptopurine
3rd line = methotrexate
How is remission induced in Crohn’s?
1st line = steroids PO/IV depending on severity
Enteral nutrition
2nd line = steroids + another immunosuppressant medication
What is used to maintain remission in Crohn’s?
1st line = azathioprine, mercaptopurine
2nd line = methotrexate
What are people with IBD at risk of developing?
Bowel cancer
Osteoporosis
What are the symptoms of IBS?
Abdominal pain, diarrhoea, constiption, fluctuating bowel habit, bloating, worse after eating, improved by opening bowels, straining - symptoms often triggered by something
What investigations need to be done to diagnose IBS?
All results will be normal in IBS
FBC, inflammatory markers, coeliac serology, faecal calprotectin, CA125
What criteria is used to help diagnose IBS?
Rome IV criteria
What lifestyle advise can be given to patients with IBS?
Regular small meals, adjust fibre intake, limit caffeine/alcohol/fatty foods, low FODMAP, regular exercise, reduce stress
What is 1st line antidiarrhoeal and laxative in IBS?
Loperamide for diarrhoea
Ispaghula husk and other bulk forming laxatives
What autoantibodies are associated with coeliac disease?
Anti-TTG, anti-EMA, anti-DGP
Which part of the bowel is most affected in coeliac disease?
Jejunum in small intestine
What is the presentation of someone with coeliac disease
Failure to thrive, diarrhoea, bloating, steatorrhoea, weight loss, mouth ulcers, dermatitis herptiformis, anaemia
How long do patients need to be eating gluten for before testing for coeliac serology?
6 weeks
What is the 1st line investigation for coeliac disease?
Total IgA and anti-TTG
What is the gold standard investigation for coeliac disease and what is seen?
Endoscopy and jejunal biopsy - crypt hyperplasia and villous atrophy
What are the complications of coeliac disease?
Nutritional deficiencies, anaemia, osteoporosis, hyposplenism, ulcerative jejunitis, non-hodgkin lymphoma
What are the symptoms of GORD?
Heartburn, acid reflux, retrosternal or epigastric pain, bloating, nocturnal cough, hoarse voice
What are the 2ww referral criteria for urgent endoscopy?
Difficulty swallowing
> 55 AND weight loss, upper abdo pain, reflux, treatment resistant symptoms, N+V, upper abdo mass, anaemia, rasied platelet count
What is a hiatus hernia?
Herniation of the stomach up through the diaphragm, allows contents of stomach to reflux into oesophagus very easily
What are the best investigations to diagnose hiatus hernia?
CXR, CT scan, endoscopy, barium swallow test
What lifestyle advice can be given to someone with GORD?
Reduce tea/coffee/alcohol, weight loss, avoid smoking, smaller meals, avoid heavy meals before bedtime, stay upright after meals
What medications can be used to treat GORD?
Antacids (e.g. Gaviscon), PPI (e.g. omeprazole), H2 receptor antagonists (e.g. famotidine)
When should a H.pylori test be offered to someone?
Should be offered to anyone with dyspepsia - need 2 weeks without using PPI before testing
Always consider testing in treatment resistant symptoms
What is the treatment for H.pylori infection?
PPI + two antibiotics
e.g. amoxicillin + clarithromycin
What change occurs in the epithelium in Barrett’s oesophagus?
Metaplasia from squamous (oesophagus) to columnar epithelium (stomach epithelium)
What treatment can be done in Barrett’s oesophagus to prevent development into adenocarcinoma?
Endoscopic ablation
What is Zollinger-Ellison syndrome ?
Rare condition in which duodenal and pancreatic tumours secrete excessive gastrin –> GORD
Associated with multiple endocrine neoplasia type 1
What is the most common type of oesophageal cancer in UK?
Adenocarcinoma in lower 1/3 of oesophagus
What is the treatment for oesophageal and stomach cancer?
Surgical resection and adjuvant chemotherapy
What is the investigation of choice for diagnosing stomach cancer and what is seen?
Endoscopy and biopsy
Signet ring cells may be seen
What are the two genetic conditions associated with increased risk of bowel cancer?
Famiilial adenomatous polyposis
Hereditary nonpolyposis colorectal cancer (Lynch syndrome) = most common and also associated with endometrial cancer
What are the 2ww criteria for suspected bowel cancer?
Over 40 with abdo pain and weight loss
Over 50 with unexplained rectal bleeding
Over 60 with change in bowel habit or iron deficiency anaemia
Positive FIT test
What test is used in bowel cancer screening and when is bowel cancer screening used?
FIT test
Done in those aged 60-74 every 2 years
If positive send for colonoscopy
What is the tumour marker associated with bowel cancer?
CEA (not useful in diagnosis but used in follow up after cancer diagnosis)
What are the risk factors for peptic ulcers?
H.pylori, NSAIDs, alcohol, caffeine, smoking, spicy foods, SSRIs, steroids
What pain is associated with gastric and duodenal ulcers ?
Epigastric pain
Gastric - worse when eating
Duodenal - 2-3 hours after eating that it presents
What is the management for peptic ulcers?
Stop any offending medication
Treat H.pylori infection if present
PPI
Repeat endoscopy to ensure they heal
What complications can occur due to peptic ulcers?
Bleeding, perforation, gastric outlet obstruction
What are the presenting features of appendicitis?
Abdominal pain - starts central and moves down to McBurney’s point
Anorexia, N+V, low grade fever, constipation, abdominal distention, guarding, rebound tenderness, percussion tenderness
What is Rosving’s sign?
Palpation of the LIF causes pain in the RIF
What is psoas sign?
Passive extension of the right thigh with the person in left lateral position elicits pain in right lower quadrant
What is obturator sign?
Passive internal rotation of the flexed right thigh elicits pain in the right lower quadrant
What are the differential diagnoses for appendicitis?
Ectopic pregnancy, ovarian cysts, Meckel’s diverticulum, mesenteric adenitis, testicular torsion, incarcerated hernia (groin should always be examined)
What are the risk factors for developing diverticular disease?
Low fibre diet, obesity, use of NSAIDs
What laxative should be used in diverticular disease?
Bull-forming laxatives e.g. ispaghula husk
AVOID stimulant laxatives
What are the key presenting features of diverticulitis?
Pain in left iliac fossa, fever, diarrhoea, N+V, rectal bleeding, palpable abdominal mass, raised inflammatory markers
What is the management of uncomplicated diverticulitis? (in GP)
Oral co-amoxiclav, analgesia, only take clear liquids, follow up to review
What is the management of severe diverticulitis? (in secondary care)
Nil by mouth, IV antibiotics, IV fluids, analgesia, urgent investigations
Which is more common small bowel obstruction or large?
SBO
What are the causes of small bowel obstruction?
Adhesions, hernias, strictures, intussception
What are the causes of large bowel obstruction?
Malignancy, volvulus, diverticular disease
What is the presentation of bowel obstruction?
Vomiting (billous vomiting), abdominal distention, diffuse abdominal pain, absolute constipation, lack of flatulence
What is the management for bowel obstruction?
Nil by mouth, IV fluids to hydrate, NG tube with free drainage to allow stomach contents to freely drain
Surgery to correct underlying cause
What is ileus?
Normal peristalsis that pushes the contents along the length of the intestines temporarily stops due to bowel surgery/injury
What are the symptoms of ileus?
Bilious vomiting, abdominal distention, diffuse abdominal pain, absolute constipation and lack of flatulence, absent bowel sounds
What is the management of ileus?
Supportive care - nil by mouth, NG tube, IV fluids, mobilisation, TPN
Where is the most common location for volvulus?
Sigmoid colon
What are the risk factors for volvulus?
Chronic constipation, nursing home residents, high fibre diet, pregnancy, adhesions
What is seen on an abdominal XR of someone with sigmoid volvulus?
Coffee bean sign
What investigation is required to diagnose volvulus?
Contrast CT abdomen/pelvis
What is the management of volvulus?
Supportive care
Endoscopic decompression can be attempted - flexible sigmoidoscope inserted
Surgery - Hartmann’s procedure (sigmoid), ileocaecal resection (caecal)
What are the causes of upper GI bleed?
Peptic ulcers (most common), mallory-weiss tear, oesophageal varices, stomach cancers
What is the presentation of upper GI bleed?
Haematesmesis, coffee ground vomit, melaena
What scoring system is used in those with suspected upper GI bleed?
Glasgow-Blatchford bleeding score - a score above 0 = high risk of bleeding
What scoring system is used post endosocpy to estimate risk of rebleeding and mortality in upper GI bleed?
Rockall score
What is the management of upper GI bleed?
ABCDE
Bloods - high urea in upper GI bleeds, crossmatch
Transfusions - blood, platelets and clotting factors
If due to oesophageal varices - terlipressin and broad spectrum antibiotics
OGD within 24 hours - diagnose and treat the source of bleeding
What medication can be used as prophlyaxis of oesophageal bleeding in those with GI bleed?
Non-cardioselective beta blockers e.g. propranolol
What causes chronic mesenteric ischaemia?
Narrowing of the mesenteric blood vessels by atherosclerosis (intestinal angina)
What are the classic triad of signs/symptoms associated with chronic mesenteric ischaemia?
Central colicky abdominal pain after eating
Weight loss
Abdominal bruit
What is the management of chronic mesenteric ischaemia?
CT angiography to diagnose
Secondary prevention and reduction in risk factors
Revascularisation to improve blood flow to intestines
What is acute mesenteric ischaemia?
Caused by rapid blockage in blood flow through the mesenteric artery - usually a thrombus
What is a key risk factor for acute mesenteric ischaemia?
AF
What are the presenting features of acute mesenteric ischaemia?
Acute, non-specific abdominal pain (pain disproportionate to examination findings), shock, peritonitis and sepsis
What is the investigation of choice in acute mesenteric ischaemia?
Contrast CT
What is the management of acute mesenteric ischaemia?
Surgery to remove necrotic bowel and remove thrombus in the blood vessel
What are the risk factors for developing haemorrhoids?
Constipation, straining, pregnancy, obesity, increased age
What are the symptoms associated with haemorrhoids?
Painless bright red bleeding typically on tissue, sore/itchy anus, feeling lump around anus
What is the stepwise management for haemorrhoids?
Lifestyle advice
1. Topical treatments - anusol
2. Rubber band ligation
3. Surgery e.g. hamorrhoid artery ligation or removal
What is the presentation of anal fissure?
Painful bright red rectal bleeding
What is the management of anal fissure?
High fibre diet and bulk forming laxatives
If chronic topical GTN followed by surgery
What are the symptoms of pilonidal sinus abscess?
Pain, discharge, swelling at site
Cycles of being asymptomatic and periods of pain and discharge
What is the management of pilonidal sinus abscesses?
If asymptomatic - no management required
If acute - incision and drainage
If chronic - excision of pits and obliteration of underlying cavity
What are the complications associated with hernias and what do they mean?
Incarceration - where the hernia cannot be reduced back into the proper position
Obstruction - when hernia causes of blockage in passage of faeces
Strangulation - hernia is non-reducible and base of hernia is tight and blood supply is cut off (painful)
When is conservative management appropriate with hernias?
When the hernia has a wide neck (less complications) and patient has significant morbidities
How is a hernia repaired surgically?
Tension-free repair - mesh over the defect in the abdominal wall
What is an indirect inguinal hernia?
Bowel herniates through inguinal canal/tract, consequence of deep inguinal ring not shutting after the testes have descended through it during foetal development
What is a direct inguinal hernia?
Occurs due to weakness in abdominal wall, hernia protrudes directly through abdominal wall and not along tract
What is a femoral hernia?
Herniation of abdominal contents through femoral canal
Have narrow opening making femoral hernias high risk for complications
What is seen on histology in Crohn’s disease?
Granulomas and increased goblet cells
What is seen on histology in UC?
Crypt abscesses, depletion of goblet cells
How does oesophageal rupture present?
Emphysema in neck, vomiting and chest pain after eating
