Gastro Flashcards
A 35 year old woman complains of a cough for many months and is found to have TB. She is HIV positive and complains of painful swallowing. What is the likely cause? And why?
Oesophageal candidiasis
Immunocompromised patient
Causes odynophagia, dysphagia and substernal chest pain
What is a mallory Weiss tear? How do diagnose it?
Occur at gastro-oesophageal junction
Can be caused by repeated vomiting following alcohol consumption
Bleeding usually stops spontaneously within 2 days
Endoscopy needed for diagnosis
How does acute pancreatitis present?
Severe upper abdominal pain, can transmit to back and left shoulder blade
Eating or drinking might make it worse, particularly fatty foods
Nausea and vomiting
Diarrhoea
Fever
What is angiodysplasia?
Vascular lesion of GI tract, swollen fragile blood vessels which can result in blood loss from GI tract
What is an acute abdomen?
Condition of severe abdominal pain, usually requiring hospitalisation +/- emergency surgery
Caused by acute disease of or injury to the abdominal organs
History usually
What different pathological processes could be underlying an acute abdomen?
Inflammation Infection Distension Perforation Ischaemia Neoplasm
What would be on your differential list for a patient with acute abdominal pain in the right hypochondrium?
Gall bladder: gallstones
Stomach: peptic ulcer, gastritis
Hepatic flexure colon: cancer
Lung: pneumonia
What would be on your differential list for a patient presenting with acute abdominal pain in their epigastric region?
Gall bladder: gallstones Stomach: peptic ulcer, gastritis Transverse colon: cancer Pancreas: pancreatitis Heart: MI
What would be on your differential list for a patient with acute abdominal pain in the left hypochondrium?
Spleen: rupture Pancreas: pancreatitis Stomach: peptic ulcer Splenic flexure colon: cancer Lung: pneumonia
What would be on your differential list for a patient with acute abdominal pain in the right lumbar region?
Ascending colon: cancer
Kidney: stone, hydronephrosis, UTI
What would be on your differential list for a patient with acute abdominal pain in the left lumbar region?
Descending colon: cancer
Kidney: stone, hydronephrosis, UTI
What would be on your differential list for a patient with acute abdominal pain in the umbilical region?
Small bowel: obstruction/ischaemia
Aorta: leaking AAA
What would be on your differential list for a patient with acute abdominal pain in the right iliac fossa?
Appendix: Appendicitis
Caecum: tumour, volvulus, closed loop obstruction
Terminal ileum: crohns, mekels
Ovaries/fallopian tube:ectopic, cyst, PID
Ureter: renal colic
What would be on your differential list for a patient with acute abdominal pain in the hypogastric region?
Uterus: fibroid, cancer
Bladder: UTI, stone
Sigmoid colon: diverticulitis
What would be on your differential list for a patient with acute abdominal pain in the left iliac fossa?
Sigmoid colon: diverticulitis, colitis, cancer
Ovaries/fallopian tube: ectopic, cyst, PID
Ureter: renal colic
What intestinal problems could cause an acute abdomen?
Acute appendicitis, mesenteric adenitis, Mekel’s diverticulitis, perforated peptic ulcer, gastroenteritis, diverticulitis, intestinal obstruction, strangulated hernia
What is mesenteric adenitis?
Abdominal lymphadenopathy which causes abdominal pain
Usually in children
What are potential hepatobiliary causes of an acute abdomen?
Biliary colic, cholecystitis, cholangitis, pancreatitis
What is cholecystitis?
Inflammation of gall bladder commonly due to blockage of the cystic duct with gallstones (Cholelithiasis) which causes a build up of bile and therefore increased pressure in the gallbladder
What is cholangitis?
Infection of the common bile duct commonly caused by infection secondary to a gallstone or tumour
What can be vascular causes for an acute abdomen?
Ruptured AAA, mesenteric ischaemia, ischaemic colitis
What are potential urological causes for an acute abdomen?
Renal colic, UTI, testicular torsion, urinary retention
What are potential gynaecological causes for an acute abdomen?
Ectopic pregnancy, ovarian cyst (rupture/haemorrhage/torsion), salpingitis, Mittelschmerz (ovulation pain)
What might be some medical causes for an acute abdomen?
Pneumonia, MI, DKA
What can cause right iliac fossa pain?
APPENDICITIS acronym Appendix/ abscess Pelvic inflammation Period pain Ectopic/ endometriosis Neoplasm Diverticulitis Intussusseption (inversion of one portion of intestine within another) Chrohn’s/ Cyst IBD Torsion IBS Stones
What can cause left iliac fossa pain?
SUPERCLOTS acronym Sigmoid diverticular disease Ureteric colic Pelvic inflammation/ period pain Ectopic/ endometriosis Rectal abscess/haematoma Colon cancer Left lower pneumonia Ovarian cyst Torsion Stones
What are important questions in a history for an acute abdomen?
Site and duration Onset – sudden vs gradual Character – colicky, sharp, dull, burning Radiation – e.g. Into back or shoulder Associated symptoms Timing – constant, coming and going Exacerbating and relieveing factors Severity Have you had a similar pain previously? What do you think could be causing the pain?
What associated symptoms would you want to ask about in an acute abdomen history?
GI: bowels last opened, bowel habit (diarrhoea/constipation), PR bleeding/melaena, dyspeptic symptoms, vomiting
Urine: dysuria, heamaturia, urgency/frequency
Gynae: normal cycle, LMP, dysmenorrhoea/menorrhagia, discharge
Others: fever, appetite, weight loss, distention
What is Rovsing’s sign?
Sign of appendicitis: palpation of left lower quadrant of persons abdomen increases pain felt in the right lower quadrant
A 55 year old male undergoes an endoscopy after being referred by his GP with recurrent indigestion. Endoscopy reveals a small duodenal ulcer and H. pylori is demonstrated to be present. How would you treat this patient?
Omeprazole, metronidazole and clarithromycin: triple therapy for a week. Continue PPI after this
What is Cullen’s sign?
Superficial oedema and bruising in subcutaneous fat around umbilicus
Takes 24-48 hours to appear and can predict acute pancreatitis
What is grey turners sign?
Bruising of the flanks - sign of retroperitoneal haemorrhage
What resuscitation management might be required for an acute abdomen?
Secure airway Oxygen Fluid Balance: IVF, catheter, bloods, Xmatch Analgesia IV Antibiotics Thromboprophylaxis
Describe the pathophysiology of Crohn’s disease
Has skip lesions between patches of inflammation
Can affect anywhere between mouth and anus
Has a particular predominance for terminal ilium
Intramural inflammation with lymphocyte infiltration
Inflammation spreads through layers of bowel including up to the serosa
May be granulomas present
What is bacterial overgrowth syndrome?
Occurs in patients who have had reconstructive bowel surgery, particularly on ileo caecal valve
Involves a change in the small bowel intestinal flora to more colonic, with increased numbers of organisms
Symptoms: diarrhoea, flatulence, abdominal distension and pain
What is cryptosporidiosis?
Protozoan infection pathogenic in immunocompromised disease
Can causes severe colitis in patients with AIDS
What is whipples disease?
Rare infection caused by tropheryma whipplei, bacteria which predominantly colonises the duodenum but can cause systemic upset
Main symptom: malabsorption
What is the duke classification for colorectal carcinoma?
Duel stage A: confined to mucosa Stage B1: involves muscularis propria Stage B2: invades beyond muscularis propria, but doesn't invade local or regional lymph nodes Stage C1: regional lymph nodes Stage C2: apical lymph node Stage D: distant metastases
A 72 year old man presents with acute severe abdominal pain. He has a history of ischaemic heart disease for which he takes nitrates, atenolol and amlodipine
On examination his pulse is 115 and irregularly irregular, a blood pressure of 104/72 and a temperature of 37.4. Examination of the abdomen reveals diffusely tender abdomen with absent bowel sounds. What is the likely diagnosis?
Mesenteric ischaemia - absent bowel sounds, AF and presence of vascular disease
Name 3 genetic causes for liver cirrhosis
Alpha 1 anti trypsin deficiency
Wilson’s disease
Haemochromatosis
What is the frames brief advice tool?
Feedback: on patient’s risk for alcohol problems
Responsibility: highlight that individual is responsible for change
Advice: advise reduction or give explicit direction to change
Menu: provide a variety of options for change
Empathy: emphasise a warm, reflective and understanding approach
Self-efficacy: encourage optimism about changing behaviour
What is toxic mega colon?
Rare but important complication in UC
Hallmarks are systemically compromised patient, abdominal radiograph showing colon dilation over 6cm
What are management options for toxic mega colon?
Conservative: fluid resuscitation, IV antibiotics, hydrocortisone, cyclosporine
Surgical: colectomy required if evidence of perforation, increased toxicity or persistent dilation
A 56 year old man is brought into a&e by the police. He was arrested for being drunk and disorderly. He complained of feeling unwell and vomited on route to the hospital. He is a known alcoholic with liver disease. What is the most appropriate immediate management?
Thiamine and vitamin B to prevent alcohol induced brain damage - wernickes Korsakoff’s syndrome
What is bupropion?
Atypical antidepressant used as a smoking cessation drug to reduce cravings but can also be used to reduce withdrawal symptoms in alcoholism
What are some surgical causes of abdominal pain?
Obstruction Perforation Peptic ulcer disease Malignancy Biliary colic Cholecystitis Pancreatitis Ruptured AAA Renal colic Diverticulitis
What are some medical causes of abdominal pain?
Diabetic ketoacidosis
GORD
Hepatitis
Colitis
What is courvoisiers law?
Palpable gallbladder in the presence of jaundice is unlikely to be due to gallstones
What are ALARM symptoms for oesophageal cancer?
Persistent dyspepsia in those over 55 Unintentional weight loss Unexplained iron deficiency anaemia GI bleeding Odynophagia Dysphagia Persistent vomiting Epigastric mass
What are the components of the Glasgow prognostic score for acute pancreatitis?
PANCREAS PaO2 55 Neutrophils, WCC >15 Calcium 16 Enzymes, LDH >600, AST >200 Albumin 10
A 55 year old alcoholic presents with haematemesis. His pulse is 120, bp 108/70. He has numerous spider naevi over his chest. His abdomen is distended with ascites. What would you request next for this patient?
Urgent Endoscopy
Bleeding oesophageal varices top of differential list
What is charcots triad for ascending cholangitis?
Colicky right upper quadrant pain
Jaundice
Swinging fevers
A 44 year old female presents with 3 month history of fatigue, and malaise. IgG is raised. LFTs show: raised AST, ALT, ALP and gamma GT. What is the likely diagnosis?
Autoimmune hepatitis
72 year old male discharged from hospital after suffering an MI. After discharge he presents with muscle aches and pains. His LFTs show: raised AST, ALT, ALP and gamma GT. What is the likely diagnosis?
Drug induced hepatitis - statins
An 18 year old female presents with a sore throat. LFTs show isolated raised bilirubin. What is the likely diagnosis?
Gilbert’s syndrome
A man has eaten some undercooked meat at a bbq and you suspect he has gastroenteritis caused by E. coli or v cholerae. What is the pathological mechanism causing diarrhoea in this man?
Endotoxins stimulating secretion of electrolytes into the intestinal lumen by activating and increasing cAMP. This increases the amounts of Na, K and bicarbonate in the apical side of the lumen which then draws water across
Why do patients with pancreatic insufficiency get diarrhoea?
Nutrients not broken down properly so biologically active in lumen exerting osmotic effects and increasing water content in large bowel
What is diarrhoea?
200ml of water per daily excrement
How is hepatitis b most frequently acquired worldwide?
Vertical transmission in the perinatal period
Describe the different types of hepatitis infections
A and E: always acute
B: chronic if in neonate, acute in adult
C: chronic only
D: only ever present if b is present
Which part of the intestine will contain a meckels diverticulum?
Ileum, two feet from ileocolic junction
What is a gallstone ileus?
Small bowel obstruction
Stones enter GI system via cholecystoduodenal fistula and migrate distally until they exit rectum or become lodged in the narrowest part of intestine - terminal ileum
What is a pilonidal sinus? How do you treat them?
Caused by ingrowing hairs
Painful redness and swelling at base of coccyx
People who are prone to them can be successfully treated by waxing the affected area. They often present as abscesses due to infection
A 35 year old man complains of sharp pains in anal region during defecation. There are small patches of blood on the tissue. What is the likely diagnosis?
Anal fissure
A 52 year old man presents with 3 month history of increasing discomfort in perineal region. He complains of throbbing and swelling and is struggling to sit down. What is the likely diagnosis?
Perianal abscess
How would a perianal haematoma present?
Tenderness in perianal region Lump Pea sized Bluish in colour Painful No history of weight loss or other red flag symptoms
What are classic symptoms of rectal cancer?
Fresh blood
Mucus
Tenesmus
Diarrhoea
What is biliary colic?
RUQ pain in absence of raised white cell count, normal LFTs and fever
What is the embryological origin of the digestive tract?
Endoderm
A patient has presented with signs and symptoms of hepatitis A. What red flag signs will you look out for that will make you consider emergency admission to hospital?
Severe illness: collapse, severe pain
Vomiting
Dehydrated
Signs of hepatic decompensation: consciousness level, bleeding tendency
What is the commonest reason for hospital admission in hepatitis A?
Supportive therapy: IV fluids
Is statutory notification of hepatitis A diagnosis required?
Yes, notifiable disease. Communicate to Local protection unit (public health department)
What advice should you give to a patient on preventing hepatitis A transmission?
Emphasis on hygiene measures, frequent and thorough hand washing
What is the typical duration of illness with hepatitis A?
2-10 weeks
What dietary advice should be given to a patient with hepatitis A?
High carb, low fat and protein
Avoid alcohol
Avoid medications metabolised in the liver
What is the transmission route of hepatitis A?
Faecal-oral route
Consuming contaminated food and water or coming into contact with food through compromised personal hygiene and poor sanitation associated with developing countries
Give some complications of a cholecystectomy
Biliary leak from cystic duct or gall bladder bed
Injury to bile duct leading to stricture and secondary biliary liver injury
List some complications of gallstones
Acute cholecystitis Acute cholangitis Gallstone related pancreatitis Biliary enteric fistula Gallstone ileus Bowel obstruction
What LFT abnormality would you expect to see in a patient with a fatty liver?
Twofold elevation of AST and ALT
Mild elevation of ALP and gGT
What is the rule of 2s for a meckels diverticulum?
2% population
2 feet from ileocolic junction
2 inches long
What is a major side effect of clindamycin?
C diff - pseudomembranous colitis
What is the blood supply to the liver?
Dual circulation
Portal: blood from intestines via superior and inferior mesenteric and splenic veins
Systemic: hepatic vein and artery
What are the functions of the liver?
Metabolism Bile production Detoxification Excretion - bilirubin, drugs Plasma protein synthesis - albumin, clotting factors Storage - glycogen, vitamins, minerals
What carbohydrate metabolism occurs in the liver?
Glucose enters hepatocyte (insulin dependent) and is converted to glycogen
Gluconeogenesis occurs to produce glucose
What lipid metabolism occurs in the liver?
Triglyceride oxidation
Converts excess carbohydrate and protein into fatty acids and triglycerides which are exported and stored in adipose tissue
Synthesis of cholesterol, HDL and apolipoproteins
What protein metabolism occurs in the liver?
Catabolism - amino acid breakdown by transamination and deamination. ALT/AST
NH3 converted to urea
What protein metabolism abnormalities would exist in liver disease?
Blood urea nitrogen low due to decrease amino acid breakdown
Hyperammonemia - potentially fatal
What plasma proteins are made by the liver?
Albumin
Globulins
Fibrinogen and clotting factors
How is bilirubin modified and excreted?
Bilirubin formed from breakdown of haem
Bilirubin and albumin transported to liver
Conjugated to bilirubin glucuronide in the liver
Secreted in bile
Converted to urobilinogen by gut bacteria
80% excreted (converted to stercobilin)
20% reabsorbed and excreted in urine
What drug metabolism occurs in the liver?
First pass metabolism
Phase 1: oxidation, reduction, hydrolysis by cytochrome p450
Phase 2: glucuronidation, sulfation, acetylation
Enzymes like gamma GT
What components of the immune system are synthesised by the liver?
Acute phase proteins - CRP
Complement components
What do decreased albumin levels indicate?
Poor liver function: decreased production
Poor kidney function: increased loss
What bleeding/clotting tests are measures of liver function?
Prothrombin time and INR
Partial thromboplastin time
Individual factor deficiencies
Why do alkaline phosphatase levels rise in liver damage? What else could cause a rise?
Increased release from damaged hepatocytes
High levels with blocked ducts
Bone disease
What causes a rise in gamma GT?
If rise alongside ALP - liver disease/ bile duct obstruction
Persistently increased in chronic alcoholics
What causes ALT and AST to rise?
Acute liver injury
ALT usually increased more than AST except in alcoholic hepatitis where AST > ALT
What different measures of bilirubin are there? And what do these show?
Total: conjugated plus unconjugated
Unconjugated > conjugated: haemolysis, cirrhosis, Gilbert’s
Conjugated > unconjugated: decreased elimination - viral hepatitis, drugs, alcoholic liver disease, blockage of bile ducts
What type of bilirubin abnormalities might newborns have?
Unconjugated bilirubinaemia - increased haemolysis
Conjugated bilirubinaemia - biliary atresia, neonatal hepatitis
What is kernicterus?
Bilirubin encephalopathy
Blood brain barrier not developed in newborns
What are different patterns of liver injury?
Hepatocyte degeneration: Hepatocyte ballooning, Feathery degeneration, Steatosis - macro/micro vesicular, Accumulation of iron or copper
Necrosis: centrolobular, mid zonal, periportal
Inflammation: portal, lobular, interface
Fibrosis: portal fibrous expansion, bridging fibrosis, nodule formation
What can cause hepatic failure?
Hepatocyte necrosis: drugs, HAV, HBV
Progression of chronic liver disease - cirrhosis
Encephalopathy - raised blood ammonia levels
Describe the changes that occur in cirrhosis
Entire liver architecture disrupted
Portal/portal and portal/central bridging fibrosis
Nodules of proliferating hepatocytes surrounded by fibrosis
Vascular relationships lost - abnormal communication resulting in portal and arterial blood bypassing hepatocytes
What can lead to portal hypertension?
Cirrhosis: increased resistance to portal blood flow
Pre hepatic: portal vein thrombosis
Post hepatic: constrictive pericarditis, budd-Chiari
What types of neoplasia can occur in the liver?
Benign adenoma
Hepatocellular carcinoma
Cholangiocarcinoma
Mets
What GI presentations can cause vomiting?
Gastroenteritis Appendicitis Pyloric stenosis Stenosing gastric cancer Intestinal obstruction
What GI presentations can cause dysphagia?
Gastro-oesophageal Reflux Disease Benign oesophageal stricture Oesophageal cancer Pharyngeal pouch Pharyngeal cancer
What GI causes can lead to acute abdominal pain?
Perforated Peptic Ulcer Appendicitis Gastroenteritis Obstruction Diverticular disease IBD Ischaemia Pancreaticobiliary
What GI causes can lead to chronic abdominal pain?
Irritable Bowel Syndrome Chronic peptic ulcer GORD Gastritis Gastric Cancer IBD
What GI presentations can cause haematemesis?
Peptic Ulcer Acute Gastritis Mallory-Weiss Tear Oesophageal cancer Gastric Cancer Oesophageal varices GORD
What are Peyers patches in the small intestine?
Organised lymphoid nodules mainly in ileum
Preventing growth of pathogenic bacteria in intestines
Describe the morphology of oral ulcers
Surface Slough
Granulation Tissue
Fibrosis
List some causes of oral ulceration
Simple Apthous Trauma (physical, heat, chemical, radiation) Infections (viral, bacterial) Drugs (cytotoxics, NSAIDS, bisphosphonates) Bullous Disease Allergic Crohn’s Disease Malignancy
What are risk factors for oral cancer?
Smoking/smokeless tobacco Spirits Older Male co-morbidities
What factors might be present in a younger patient with oral cancer?
HPV related (especially HPV16) Over-express p16, inactivate p53 and Rb
What can h pylori cause as a carcinogen?
Chronic Gastritis
Increases risk of Adenocarcinoma and Gastric MALT Lymphoma
What problems will be present in a patient with autoimmune chronic gastritis?
Antibodies to parietal cells, intrinsic factor Reduced pepsinogen 1 secretion Endocrine cell hyperplasia B12 deficiency Defective acid secretion
What are some causes of chronic gastritis?
Autoimmune
Chemical: drugs (NSAIDs), alcohol
H pylori
What virulence factors do h pylori possess?
Flagella (motile in mucus)
Urease (urea to ammonia, lower pH)
Adhesins
Cytotoxin associated gene A
How does h pylori lead to gastric lymphoma?
H. pylori induces polyclonal B cell proliferation
Name some causes of constipation
Low-fibre diets IBS Hirschsprungs Autonomic neuropathy Parkinsons colon tumours
Name some causes of chronic diarrhoea
IBD IBS coeliac pancreatic insufficiency colon tumours carcinoid syndrome
Name some causes of nausea and vomiting
Bowel obstruction Gastroenteritis Head injury Raised ICP Migraine
What are some causes of localised abdominal distension?
Organomegaly Bladder obstruction Hernia Inflammatory mass Tumours
Give some differentials for rectal bleeding
Blood mixed with stool – colon carcinoma
Blood streaks on stool – rectal carcinoma
Blood after defecation – haemorrhoids
Blood mixed with mucus – colitis
Bleeding – diverticular disease
Bleeding and pain – anal fissure/carcinoma
Melena – upper GI bleed
Describe the appearance of the bowel in crohns
Transmural inflammation: serosal fat wrapping, granulomas and lymphoid aggregates
Deep, fissuring ulcers
Stenosis and fistula formation
Describe the inflammation present in IBD
Increased inflammatory cells in lamina propria
Gland architectural distortion
Metaplasia – paneth cell/ pyloric
Cryptitis and crypt abscesses
Goblet cell depletion
Deep fissuring ulcers in CD / Superficial ulcers in UC
Transmural inflammation with lymphoid aggregates in CD
Granulomas in CD
Normal areas in between inflamed areas in CD
What different types of polyps can be present in the bowel?
Inflammatory polyps
Hyperplastic polyps (no neoplastic potential)
Hamartomatous polyps – Juvenile, Peutz-Jeghers
Sesile Serrated polyps
Adenomas – tubular, tubulo-villous, villous, Dysplasia - low vs high grade
What is peutz jeghers syndrome?
Autosomal dominant disorder characterised by development of hamartomatous polyps in GI tract and hyperpigmented macules on lips and oral mucosa
What cells do GIST tumours arise from?
Interstitial cells of Cajal – Gut pacemaker
What tumours of the appendix can occur?
Mucocele
Low- grade Appendiceal Mucinous Neoplasm (LAMN)
Goblet cell carcinoid
Adenocarcinoma
Which histocompatibility complex is associated with coeliac disease?
HLA B8
What food types contain gluten which triggers coeliac?
Wheat
Rye
Barley
What pathological changes are present in coeliac disease?
Subtotal or total villous atrophy
Crypt hyperplasia
What may cause splenomegaly?
Blood oncological conditions: leukaemia, lymphoma
Cirrhosis: portal hypertension
Infections: malaria, glandular fever
Haemolytic anaemia
What does whipples disease present with?
Diarrhoea Abdominal pain Lymphadenopathy Fever Weight loss Arthritis
What are some causes of hepatomegaly?
Congestive cardiac failure Alcoholic liver disease Chronic bronchitis Diabetes Mellitus Liver mets Leukaemia Hepatitis Haemochromatosis
What are some causes of intestinal pseudo obstruction?
Hypothyroidism Hypokalaemia Diabetes Uraemia Hypocalcaemia
Give some GI causes of vomiting
Gastroenteritis Appendicitis Pyloric stenosis Stenosing gastric cancer Intestinal obstruction
Name some GI causes of dysphagia
GORD Benign oesophageal stricture Oesophageal cancer Pharyngeal pouch Pharyngeal cancer
Name some GI causes of acute abdominal pain
Perforated peptic ulcer Appendicitis Gastroenteritis Obstruction Diverticular disease IBD Ischaemia Pancreaticobiliary
Name some GI causes of chronic abdominal pain
IBS Chronic peptic ulcer GORD Gastritis Gastric cancer IBD
Name some GI causes of haematemesis
Peptic ulcer Acute gastritis Mallory Weiss tear Oesophageal cancer Gastric cancer Oesophageal varices GORD
What is an ulcer?
Local defect in the surface of an organ produced by the shedding of inflamed necrotic tissue
What is the morphology of an ulcer?
Surface Slough
Granulation tissue
Fibrosis
Define lower GI bleed
Bleeding distal to ligament of treitz
What commonly causes lower GI bleeds in children and adolescents?
Meckels diverticulum
Polyps
IBD
Intussusception
What commonly causes lower GI bleeds in adults?
Diverticular disease
Angiodysplasia
Neoplasm
Ischaemic colitis
What causes bleeding in diverticular disease?
Rupture of vasa recta
What are the most common regions for angiodysplasia?
Caecum and ascending colon
How can angiodysplasia be identified on colonoscopy?
Distinct red mucosal patches consisting of capillaries
How does a lower GI bleed due to IBD tend to present?
Bloody diarrhoea
What typically causes ischaemic colitis?
Hypoperfusion
Vasospasm
Occlusion
How does a patient with ischaemic colitis typically present?
Abdominal pain accompanied with bloody diarrhoea
What is the average age at which a patient with FAP will develop colon cancer?
39 years
What resuscitation steps might you take for a patient with a severe lower GI bleed?
Large bore IVs Aggressive volume replacement Cross match and transfuse as needed Coagulation studies Admission to a close monitoring unit
What investigations can you do to localise the source of a lower GI bleed?
Proctoscopy: anal outlet bleeding, proctitis, cancer Flexible sigmoidoscopy: anus and rectum Colonoscopy Radio nucleotide imaging Angiography NGT lavage - rule out upper GI bleed
What are advantages and disadvantages of a colonoscopy?
High diagnostic yield 85% lesions identified Assess colon and ileum Low complication rate Therapeutic Diminished visualisation with profuse bleeding Requires bowel prep
What are advantages and disadvantages of radionucleotide imaging for GI bleeds?
Sensitivity Can be repeated in 24 hours Low complication rate Not a good localising study Precursor to angiogram
What are advantages and disadvantages of mesenteric angiography?
Sensitivity
Diagnostic and therapeutic
Selective embolisation
Invasive study
What are potential complications of mesenteric angiography?
Pseudoaneurysm
Bowel infarction
MI due to vasopressin
What are advantages and disadvantages of CT angiography for GI bleeds?
Accessible Quick Sensitive Anatomic detail No bowel prep needed Not therapeutic
What surgery is performed if the site of a GI bleed is identified vs if it isn’t identified?
Identified: segmental resection with anastamosis
Not identified: total colectomy and end ileostomy
What proportion of polypectomys will result in post procedure bleeding?
6%
How do you treat post polypectomy bleeding?
Endoscopic injection therapy
Electro coagulation
Endoscopic clipping
What are most common causes of small intestine bleeding?
Angiodysplasia Small bowel diverticula Meckels diverticulum Neoplasia Crohn's disease Aorto enteric fistula
What are common organisms which can cause infective colitis?
Campylobacter jejuni E. coli Shigella C diff Amoebiasis Cryptosporidium Giardia
What is acute phase treatment for UC?
Enemas in distal disease
Steroids +/- Azathioprine in disease extending proximally
What is the management for toxic megacolon?
Initially: IV steroids +/- cyclosporine with careful monitoring of clinical indices, FBC and CRP
If things deteriorate or fail to improve within 48 hours then surgical intervention
When is caecal volvulus more common?
Pregnancy
Distal colonic obstruction
How do you manage a caecal volvulus?
Laparotomy if fit, derotation, fixation/resection
If bowel looks non viable then hemicolectomy
A 51 year old man is referred to open access endoscopy unit with Hx of new onset dyspepsia and iron deficiency anaemia. He undergoes endoscopy at which there is diffuse thickening of the gastric mucosa with occasional superficial erosions. What is the likely pathology?
Gastric lymphoma
T cell Hodgkin’s lymphoma related to h pylori infection
Symptoms mimic gastritis/peptic ulceration
What are risk factors for developing a gastric ulcer?
H pylori Smoking Chronic liver disease Chronic renal failure Hyperparathyroidism Drugs: aspirin, steroids, NSAIDs)
What are risk factors for gastric carcinoma?
Diet: high salt, high starch, pickled and smoked food)
Cigarette smoking
Blood group A
Alcohol
Premalignant conditions: pernicious anaemia, menetriers disease, adenomatous polyposis, juvenile polyps, previous gastric resection)
What is the treatment for gastric carcinoma?
D2 gastrectomy with pre op chemo: epirubicin, cisplatin and 5-fluorouracil
A 34 year old man is admitted with suspected perforated acute appendicitis and undergoes an emergency laparotomy. On the ward 2 hours after, he is noted to have irregular tachycardia of 120bpm. His BP is 120/70 and he is pyrexial at 38.5. What is the likely problem?
Atrial fibrillation related to infection
When is anastomotic leak a particular problem in colorectal surgery?
Low anterior resection
What are signs and symptoms of thiamine deficiency?
Muscle tenderness, weakness, reduced reflexes Confusion, memory impairment Impaired wound healing Poor balance, falls Constipation Reduced appetite Fatigue
List some possible causes for a dupuytrens contracture
Epilepsy Diabetes Mellitus Alcoholic liver disease Smoking Trauma Heavy manual labour
What is the mutated gene defect in hereditary non polyposis colonic carcinoma?
Mismatch repair genes important for DNA surveillance
What is the typical presentation for a patient with HNPCC?
Colon cancer at age 40
Females with endometrial and ovarian carcinoma
What is von Hippel Lindau disease?
Autosomal dominant condition associated with presence of phaeochromocytomas, CNS haemangiomas and hypernephromas
Due to absence of tumour suppressor gene vHL
What is peutz jeghers syndrome?
Autosomal dominant condition associated with mucocutaneous pigmentation and multiple GI hamartomas
Name some drugs which associated with acute pancreatitis
Steroids Oestrogens Thiazides Valproate Azathioprine Alcohol Chemo: cisplatin/vinca alkaloids
A 68 year old female with difficulty swallowing. She has not lost any weight, she has a history of rheumatic fever as a child and on examination she is in atrial fibrillation. What is the likely cause of her dysphagia?
Left atrial dilatation
A 60 year old has longstanding history of GORD. He complains of difficulty in swallowing but has not lost any weight. What is the likely cause of his dysphagia?
Benign stricture of the oesophagus
A 67 year old male with a history of ischaemic heart disease and stroke presents with a few months progressive difficulty swallowing and weight loss of one stone. To begin with it affected solids more than liquids but he is now having difficulty with liquids as well. What is the likely cause of his dysphagia?
Carcinoma of the oesophagus
A 35 year old male has longstanding difficulty swallowing. He has difficulty with both liquids and solids. He has not lost any weight. An endoscopy shows a dilated oesophagus with food debris in it. What is the likely cause of his dysphagia?
Achalasia of the cardia
What are risk factors for dupuytrens contracture?
Male sex Age over 40 Family history Diabetes mellitus High alcohol intake Smoking Trauma Anticonvulsant medication
Give some causes for portal hypertension
Pre hepatic: portal vein thrombosis, splenic vein thrombosis, tumoral compression
Hepatic: cirrhosis, hepatitis, alcoholic hepatitis, primary biliary cirrhosis, Wilson’s disease, haemochromatosis
Post Hepatic: thrombosis of IVC, right HF, constrictive pericarditis, severe tricuspid regurgitation, budd chiari syndrome, arterial portal venous fistula
What can be some causes of poor nutrition?
Poverty Isolation – eating alone Sarcopenia Physical ill health Mental ill health Dementia
What is malnutrition?
State of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome
What are some potential consequences of malnutrition in secondary care?
Increased Complications
Increased Sepsis
Increased length of stay
Increased Readmission Rate
What are potential consequences of malnutrition in primary care?
Increased Hosp Admissions
Increased Dependency
Increased GP visits
Increased Treatment Costs
Which types of patients are at risk of malnutrition?
Elderly (especially if institutionalised)
Chronic ill-health e.g. diabetes, renal, COPD, neuro
Cancer
Deprivation / poverty
GI disorders / post GI surgery
Alcoholics
Drug Dependency
Poor Dentition/oral care
Dysphagia
Patients with Altered Nutritional Requirements: Critical care, Sepsis, Cancer, Trauma, Surgery, Renal Failure, Liver Disease, GI and pancreatic disorders, COPD, Pregnancy
What screening tool is used to identify patients at risk of malnutrition?
MUST: malnutrition universal screening tool
What are the components of the MUST screening tool?
BMI: very underweight less than 18.5, underweight 18.5 - 19.9
Weight loss score: >10%, 5-10%
Acute disease effect score
What tests can be done to look for h pylori? What special instructions should be given before?
Urea breath test: 2 weeks before, stop taking abx, bismuth and PPI
Blood test: antibodies to h pylori, can remain positive for years
Stool test: diagnose infection and confirm cure after treatment
Biopsy: usually done opportunistically during endoscopy
What are aspects of a nutritional assessment?
Weight Height BMI Percentage weight loss Anthropometrics (MUAC, TSF, Grip Strength, MAMC) Biochemistry Assessment of current intake Subjective global assessment Hydration ?Bowels and nausea ?Swallowing difficulties/oral health Re-feeding syndrome
What are some risk factors for hiatus hernia?
Obesity
Increased intra abdominal pressure
Previous hiatal operation
What is the appropriate management for a patient who scores 0 on their must assessment?
Repeat screening weekly
If patient obese, consider outpatient referral to dietician
What is the appropriate management for a patient who scores 1 on their must assessment?
Observe and record food and drink intake Highlight risk at nursing handover and medical rounds Offer milky drinks and snacks Encourage high calorie meal choices Repeat screening weekly
What would be classed as clinically significant weight loss?
Unintentional weight loss greater than 10% in past 3-6 months
What is the appropriate management for a patient who scores 2+ on their must assessment?
Inform medical team Refer to dietician Observe and record food and drink intake Highlight risk at nursing handover and medical rounds Offer milky drinks and snacks Encourage high calorie meal choices Repeat screening weekly
What measurements can be taken to assess someone’s nutritional status?
% weight loss
MUAC: mid upper arm circumference
Hand grip strength
TSF: triceps skin fold
What are some causes of low albumin?
Sepsis Acute/chronic inflammatory conditions Cirrhosis Nephrotic syndrome Malabsorption Malnutrition
What are some benefits of adequate nutrition support?
Increased immune function Enhanced wound healing Improved ventilation and respiratory reserve Mobility Better psychological status Decreased length of stay Decreased infectious complications Decreased morbidity and mortality
What is a potential complication of chronic liver disease for which you may need to do an ascitic tap?
Spontaneous bacterial peritonitis
What type of diet should be advised in advanced chronic liver disease and why?
Low protein
Protein breakdown in bowel results in ammonia production which is implicated in precipitation of hepatic encephalopathy
What are different types of nutritional support?
Whole food by mouth Nasogastric tube Nasoduodenal tube Nasojejunal tube Gastrostomy tube Jejunostomy tube Total parenteral nutrition Peripheral parenteral nutrition
What oral nutritional support can be provided?
High energy/protein diet
Little and often
Food fortification
Build up soups/shakes
What are indications for enteral nutrition?
Nil by mouth - dysphagia Sedated - low GCS Unable to meet nutritional requirements orally - poor appetite, drowsy, high requirements due to disease Strictures Pre op nutrition support Oncology
What are problems with enteral nutrition?
Tube removal
Loose stools
Vomiting and nausea
Aspiration
What does nice guidance say about enteral feeding and dementia?
Artificial feeding should not be used in people with severe dementia for whom dysphagia or disinclination to eat is a manifestation of disease severity
Why is parenteral nutrition used?
Intestinal failure - post op ileus, bowel obstruction, short bowel syndrome, fistulas
What is refeeding syndrome?
Potentially life threatening complication in severely malnourished patients
Fluid and electrolyte shifts, metabolic complications
Who is particularly at risk of refeeding syndrome?
Chronic alcoholics Chronic malnutrition Anorexia nervosa Prolonged fasting Patients unfed for >5 days with evidence of stress and depletion Chronic antacid users Chronic diuretic users Oncology patients on chemotherapy Malabsorption
What factors are levels of risk of refeeding syndrome based on?
BMI
Unintentional weight loss
Length of time with little/no nutrition
Electrolyte levels prior to initiation of feeding
What electrolyte disturbances occur in refeeding syndrome?
Hypokalaemia Hypomagnesaemia Hypophosphataemia Thiamine deficiency Salt and water retention
What are potential complications of refeeding syndrome?
Cardiac failure Cardiac arrest Pulmonary oedema Arrhythmias Respiratory depression Liver dysfunction Polyuria Bowel disturbance Weakness Confusion Lethargy Seizures Tremors Death
When refeeding a patient, what precautions should be taken to avoid refeeding syndrome?
Introduce feed slowly
Vitamins prescribed to support metabolism: forceval, ketovite tablets, pabrinex, vit B co strong
Daily monitoring and replacement of electrolytes
What conditions can lead to malabsorption?
Coeliac disease Pancreatitis Surgical resection of ileum Crohn's Lactase deficiency
What are symptoms of malabsorption?
Weight loss Abdominal distension Diarrhoea Steatorrhoea Pernicious anaemia Hypochromic anaemia
What tests can be done for coeliac disease?
Endomysial antibody
IgG antigliadin antibody
Jejunal biopsy
Anti TTG (tissue transglutaminase)
What tests can be done for chronic pancreatitis?
Function: faecal elastase
Form: cross-sectional imaging (CT)
What are the Rome III criteria for diagnosing irritable bowel syndrome?
Recurrent abdominal pain or discomfort at least 3 days a month in past 3 months
Associated with two or more of following: improvement with defecation, onset associated with a change in frequency of
stool, onset associated with a change in appearance of stool
What investigations can be done for irritable bowel syndrome?
Bloods: B12, folate, iron, tTG, thyroid function
Stool: Faecal calprotectin
Colonsocopy
What stool volumes mean diarrhoea?
Stool volume >200mls/day
Stool weight >200g/day
What is the treatment for pseudomembranous colitis?
Metronidazole
Describe the colonic inflammation in ulcerative colitis
Superficial
Continuous
Always present in the rectum
Limited to the colon
What features would make you suspect an acute severe colitis?
Stools >6/day Temp >37.8 Pulse >90 Hb 30mm/hr Truelove-Witts criteria
What investigations would you do for acute severe colitis?
Bloods Stool culture, blood culture Stool for c.difficile toxin Abdominal x-ray Sigmoidoscopy and biopsy
What would you do to manage acute severe colitis?
Admission Fluid resuscitation Steroids: IV 5 days Antibiotics If not getting better: Ciclosporin, Inflixamab, Colofixamab, Surgery
What is the most common cause of upper GI haemorrhage?
Peptic ulcer disease
List two risk factors for peptic ulcer formation
H. pylori
Drugs
Smoking
What are the symptoms of dyspepsia?
Epigastric pain
Heartburn
Reflux
How do you manage dyspepsia?
Alarm signs or >55yrs: Upper GI endoscopy Lifestyle Antacids PPI If no improvement: H. pylori test
How do we test for H. Pylori?
Carbon-13 urea breath test or a stool antigen test
What treatment regimen is used to eradicate H pylori?
PPI, amoxicillin and either clarithromycin or metronidazole
What are the alarms symptoms for dyspepsia?
Anaemia Loss of weight Anorexia Recent onset of progressive symptoms Melaena / haematemesis Swallowing difficulty
What is the management for a mallory Weiss tear?
Most bleeds are minor and discharge is usual within 24 hours
OGD if necessary: Clip, Adrenaline
A 27 year old presents with a 3 day Hx Melaena and has vomited a cup full of blood this morning. On examination pulse 105, BP 104/68, T 37.0, RR 14, Sats 98%, Pale conjunctive, Chest clear. HS normal. Abdomen soft. Mild epigastric tenderness. PR – black tarry stools. No fresh blood. What is the immediate management?
ABCDE approach
Consider need for 02
Large bore cannulas to each ACF
Blood for FBC, Xmatch, U+E, clotting, LFT
Start iv fluid replacement: Crystalloids, Blood, Consider clotting products
Calculate Blatchford score
Further management dependent upon likely cause/severity of bleeding
A 42 year old unemployed man presents with a one hour history of vomiting fresh blood. He has a background history of excess alcohol usage. What is the likely diagnosis?
Ruptured oesophageal varices
How do you manage ruptured oesophageal varices?
Initially manage as per all GI haemorrhage
Terlipressin
Prophylactic antibiotics
If endoscopy fails SB (Sengstaken–Blakemore) tube temporary salvage
Consider TIPSS (Transjugular intrahepatic portosystemic shunt)
What is the appropriate follow up after a ruptured oesophageal varices event?
Repeat endoscopy initially after 3 months, then after 6 more months then yearly
Management of liver disease
Consider beta-blockade (prophylaxis)
What bowel signs and symptoms require urgent referral for suspected bowel cancer?
Bleeding and: Abdominal pain Change in bowel habit Weight loss Iron-deficiency anaemia Rectal / abdominal mass Faecal occult blood
What is the management for diverticulitis?
Mild attacks managed at home with oral fluids and antibiotics
If more severe: NBM, IV fluid, Antibiotics, USS/CT to detect abscesses, CT-guided drainage of abscesses
How does haemorrhoidal disease typically present?
Painless rectal bleeding or sudden onset of perianal pain with a tender palpable perianal mass
What is the difference between internal and external haemorrhoids?
Internal haemorrhoids proximal to dentate line in anal canal
Eternal haemorrhoids distal to dentate
What are treatment options for haemorrhoids?
Increase dietary fibre, rubber band ligation, infrared photocoagulation, sclerotherapy, surgical haemorrhoidectomy
What are potential complications of haemorrhoids?
Recurrence or worsening of symptoms, excessive bleeding and non-reducible prolapse
What are some causes of colitis?
Infective inc. psueomembranous IBD Ischaemic Radiation Necrotizing enterocolitis in newborns
List some associated symptoms of IBD
Eyes: episcleritis, uveitis
Kidneys: stones, hydronephrosis, fistulae, UTI
Skin: erythema nodosum, pyoderma gangrenosum
Mouth: stomatitis, apthous ulcers
Liver: steatosis
Biliary tract: gallstones, sclerosis cholangitis
Joints: spondylitis, Sacroiliitis, peripheral arthritis
Circulation: phlebitis
How does angiodysplasia present?
Chronic, painless intermittent rectal bleeding
May be long periods of time between bleeds
What can be seen on colonoscopy in a patient with angiodysplasia?
Abnormal epithelium
Small lesions with irregular edges and a draining vein
What is the management for angiodysplasia?
Supportive care
Angiography with embolisation
Colonoscopy with: Cautery, Clips, Adrenaline, R colon is thin walled so risk of perforation
Why does Crohn’s increase risk of gallstones?
Decreased bile salt content due to terminal ileum resection/disease involvement so higher concentration of cholesterol in bile
Why can cholangitis lead to a prolonged prothrombin time?
Gallstone obstructs pancreas
This leads to reduced fat soluble vitamin uptake so reduced vit K and therefore increased PT
Why do you not give morphine to a patient with acute pancreatitis?
Causes sphincter of oddi to contract so may make it worse
What investigations would you do for suspected diverticulitis?
FBC ESR CRP CT colon Don't do colonoscopy during acute attack due to risk of perforation
