Gastro Flashcards
Inguinal hernia
Risk factors
Types
Presentation
Obesity, constipation, chronic cough, heavy lifting, male
Direct (20%) - directly through weakness in posterior wall of inguinal canal medially to inferior epigastric vessels - easily reduced
Indirect (80%) - through deep inguinal ring ± superficial associated with patent inguinal canal - more likely to strangulate
A lump ± pain
Indirect may cause pain in scrotum + dragging
Cough impulse - finger through top of scrotum into external ring and palpate for lump when coughing
Dyspepsia
What
Red Flags
Early post prandial vs late
Pain or discomfort in upper epigastric region may be heartburn or acid reflux
ALARMSAnaemia, Loss of wt, Anorexia, Recent onset (if >55), Melaena, Swallowing difficulty
Early post prandial: gastritis, GORD, gastric Ca
Late post prandial: duodenal ulcer
ROME criteria
For functional dyspepsia: 6M Post-prandial fullness, early satiety, epigastric pain/burning + no struc
Drugs causing dyspepsia (4)
Nitrates
Bisphosphonates
Corticosteroids
NSAIDs - Decrease mucus and bicarbonate secretion
N.b. PPI decreases expression of H+/K+ antiporter on luminal membrane of parietal cells
Dyspepsia Mx
> 55 or alarms (Y) Endoscopy 2-week (N) Lifestlye
Lifestlye - stop offending drugs, decrease tobacco, avoid aggravating foods, lose weight+ over the counter antacids
Test for h.pylori (Y) triple therapy 1 week (N) GORD - PPI 4/52 - if no response H2 receptor antagonist (ranitidine) or long term
Areas of the stomach (5)
Cells in the stomach (5)
Acid stimulating hormones
Acid suppressing hormone
Cardia, fundus, body, antrum, pylorus
Chief cells - pepsinogen (to pepsin by HCl)
G-cells - gastrin (antrum)
Parietal cells - intrinsic factor and HCl (fundus + body)
D-cells - somatostatin (antrum)
Goblet cells - mucus + bicarbonate
Gastrin (CCK-2), histamine (H2), ACh (M3)
Somatostatin
H.pylori infection Appearance Mechanism Ix Mx
G- curved bacillus
H.pylori through mucus layer
Urease secretor - urea + water -> ammonia + CO2 -> neutralise acid (for survival) + mucosal cell death, chronic inflammation -> ulceration
C13 urea breath test - may be done in primary care
Stool antigen test + CLO test (pink with h.pylori)
N.b. must stop PPI for 2 weeks before or ABX 4 weeks
TRIPLE THERAPY - PAM/PAC
PPI + amoxicillin + clarithromycin/metronidazole (1 week)
H.pylori anaemia mechanisms
H.pylori uses iron for own growth
Decreases vitamin C
Micro-erosions and chronic bleeding
Peptic ulcer disease
Types
Causes
Presentation
80% duodenal ulcer - Common at duodenal cap, may erode gastroduodenal artery
20% gastric ulcer - Common at lesser curve, may erode L gastric artery
H.pylori (95% DU, 80% GU), NSAIDs, smoking, alcohol, stress, bile acids, pepsin, Zollinger-Ellison syndrome
Epigastric pain point to pain with one finger
-DU - post prandially (1-3 hours), which is relieved by eating
-GU - on eating
Pain radiation to back if posterior duodenal ulcer as related pancreas
Nausea, oral flatulence, bloating, distension
GORD Presentation (5)
Heartburn: burning feeling rising stomach to neck relieved by antacid. Related to meals, posture (lying down), straining
Water brash: excessive salivation
Acid brash: retrosternal discomfort - regurgitation of acid or bile
Odynophagia - painful swallowing related oesophagitis or stricture
Belching
Causes for GORD
Increased intra-abdominal pressure - Obesity, pregnancy
Increased gastric pressure - Large meals, hiatus hernia
Lifestyle factors: smoking, alcohol, fat (*delays gastric emptying), coffee
Decreased oesophageal peristalsis
Systemic sclerosis
Smoking,
Drugs
-Affecting oesophageal motility (nitrates, anticholinergics, TCA)
Damage mucosa (NSAID, bisphosphonates)
GORD Mx
Lifestyle: reduce weight, stop smoking, reduce alcohol, raise bed at night, regular small meals, avoid drugs
OTC: aluminium or magnesium salts (antacids), alginates (protective layer - gaviscon)
Initial nice first line: PPI for one month or H2 antagonist
Step down PPI for long-term suppression
If oesophagitis on endoscopy - PPI 2 months
Hiatus hernia What Causes Types Mx
Herniation of part of abdominal viscera through oesophageal aperture of diaphragm. Mainly gastric cardia
Widening of diaphragmatic hiatus, pulling up of stomach due to oesophageal shortening (e.g. chronic GORD), pushing up of stomach by intra-abdo pressure - Obesity, pregnancy, ascites, advanced age
Sliding (90%) - gastro-oesophago junction slides into thoracic cavity
Rolling (10%) - gastro-oesophago junction remains in place but stomach herniates next to oesophagus
Lifestlye as GORD + PPI longterm + surgery e.g. gastropexy if refractory
Blood supply/muscle/epithelium of the oesophagus
Upper third
Middle third
Lower third
Inferior thyroid/Striated/Stratified squamous
Aortic & Oesophageal/Mixed/Stratified squamous
Left gastric/Smooth/Columnar
Barretts oesophagus What Causes Most common patient Complications Treatment
Any portion of normal distal squamous epithelium is replaced by metaplastic columnar epithelium
Chronic GORD (comp at 5%) ± HH
50M
H.pylori and NSAIDs
5% progress to adenocarcinoma of the oesophagus in 10-20 years
Low grade: Lifestyle as for GORD + long term PPI ± ablation
High grade: oesophagectomy
Oesophagus Ca
Types
Risk factors
Red flags (5)
80% SCC (upper ⅔) or adenocarcinoma (lower ⅓) - both are common and aggressive
Both - smoking (x10 for SCC, x2 for AC), alcohol
AC- Barrett’s, obesity and other GORD things
SCC - chronic inflammation and stasis e.g. achalasia
RED FLAG PRESENTATION:
Dysphagia (solids>liquids)
Vomiting
Anorexia and weight loss
Symptoms of GI related blood loss e.g. melaema
Symptoms of infiltration - intractable hiccups and persistent retrosternal pain
Upper ⅓ specific - hoarseness and cough - less common
Lymphadenopathy
Dysphagia causes
Oesophageal: GORD, oesophagitis, oesophageal cancer (food sticking), pharyngeal cancer
Neurological: CVA, achalasia, diffuse oesophageal spasm, MS, MND
Others: pharyngeal pouch, external compression (mediastinal tumour), CREST or scleroderma
Achalasia What Mechanism Presentation Ix Management
Disorder of motility of lower oesophageal sphincter
Smooth muscle layer has impaired peristalsis and sphincter fails to relax
Often an acquired aganglionic segment
Possible effect of interstitial cells of Cajal (pacemaker cells)
Dysphagia (solids>liquids) DDx: GORD/ stricture
Regurgitation (90%)
Chest pain in 50% - retrosternal and after eating
?Inhalation pneumonias
CXR - vastly dilated oesophagus behind heart
Barium swallow - characteristic bird’s beak dilated oesophagus with distal narrowing
Manometry - gold standard high resting pressure and incomplete relaxation on swallowing
CCB/nitrates - reduce pressure in LOS may lead to GORD
Surgery - endoscopic dilatation may lead to perforation
Upper GI bleed
Causes
Presentation
Peptic ulcer (most common), oesophagitis, gastritis, varices, Mallory-Weiss tear, malignancy, drugs
Haematemesis
-Bright red - fresh - above stomach, active haemorrhage
-Altered - coffee ground - stomach or below
Melaena - black tarry stools usually due to UGIB but occasionally from small bowel
Haematochezia - fresh blood usually due to colonic bleeding
Abdominal pain - ?location
Features of underlying cause - dyspepsia, weight loss, jaundice
High urea levels can indicate an upper GI bleed versus lower GI bleed
Upper GI bleed
Management
Score
If shock = fluid resuscitation + high flow O2
2 wide bore cannula and send bloods (FBC/UE/LFT/crossmatch/coag)
Fluid bolus 500ml over 15 mins (up to 2L) while waiting for bloods
Transfuse with blood, platelets (<50), FFP (INR or APTT >1.5x normal), prothrombin complex (if warfarin) according to major haemorrhage protocol
CXR, ECG, ABG, catheter, regular monitoring
Endoscopy (<24 hours)
Rockall risk score
- Pre endoscopy for mortality
- Post endoscopy for re bleed
Ileus vs paralytic ileus vs pseudoobstruction
- Non-mechanical obstruction
- Absence of normal peristalsis
- Like mechanical but no cause found
Causes of intestinal obstruction
Small
Large
Adhesions (75% - from prior operations), strangulated hernia, malignancy (caecum as small bowel malignancy rare) or volvulus
Colorectal malignancy - patients > 70, increased risk further down bowel as faeces more solid, diverticulum, sigmoid volvulus
Toxic megacolon
What
Features
Causes
Acute form of colonic distension.
It is characterized by a very dilated colon (megacolon), accompanied by abdominal distension (bloating), and sometimes fever, abdominal pain, or shock.
IBD, C.diff, hursprungs,
Bowel obstruction
Presentation (5)
SBO vs LBO (3)
Vomiting (early in SBO, faeculent in low level), Abdominal pain (diffuse, central, abdominal, colicky=SBO, constant=LBO), Constipation (early in low level, late in high-level) Abdominal distension (SBO
Bowel obstruction
Ix
Xray findings & SBO vs LBO
Fluid charts to monitor intake and output
Plain AXR - supine and erect
Bloods: FBC, UE, Amylase, group and crossmatch
Distended loops of bowel proximal to obstruction
Fluid levels and distended small bowel throughout = paralytic ileus
Gas under diaphragm = perforation
Valvular laddering small bowel in SBO
Hausta in LBO
Central vs Peripheral (SBO vs LBO)
Bowel obstuction management
If uncomplicated: fluid resus + correct electrolytes, intestinal decompression e.g. endoscopy, NG Tube (Sip & Suck)
If no clear diagnosis = laparotomy + consent for stoma
Early surgery if peritonitis or evidence of perforation
Sigmoid voluvlus What Complications Risk factors Presentation Xray sign Management
Chronic constipation - large elongated atonic bowel
Faeces and gas filled sigmoid loop twists on mesentery to create closed-loop obstruction
Venous infarction leading to perforation and faecal peritonitis - *shock and temp
Elderly, constipation, megacolon, previous sigmoid volvulus
Onset, colicky lower abdo pain, gross abdominal distension, failure to pass flatus or stool
Tympanic distended abdomen with palpable mass
*Empty rectum
AXR - *coffee bean sign - grossly dilated sigmoid loop
CT scan to assess bowel wall ischaemia
Urgent admission and decompression - pass sigmoidoscope+ flatus tube alongside (in place for 24 hours)
Elective surgery for recurrence - resection of sigmoid colon
Ogilvie’s What Causes Presentation X-ray Management
Acute colonic pseudo-obstruction associated with massive dilatation in absence of mechanical obstruction
Recent pelvic surgery or cardiac event
Medications - opioids and antidepressants
Recent trauma or bed rest
Conditions affecting nerves or muscles (Parkinson’s or muscular dystrophy)
Abdo pain, bloating, N+V, intermittent constipation, no faeces or flatus
Massive distension, normal bowel sounds, minimal tenderness, empty air filled rectum on DRE
AXR - massive dilatation of colon (megacolon)
Treat cause
NG tube to decompress stomach
Antiemetic prokinetic e.g. metoclopramide
IV neostigmine (AChE inhibitor) + IV fluids + ABX ± decompression with flexible scope
Presentation
Abdominal abscess
Peritonitis
Abscess: fever + pain (psoas = flank to groin)
Signs: swinging pyrexia + palpable mass
Peritonitis: pain + anorexia + nausea + vomiting
Signs: high fever, tachycardia, tenderness on palpation, guarding, rebound tenderness
Ix and Management
Abdominal abscess
Peritonitis
FBC: leukocytosis, UE: dehydration, LFT, amylase, lipase: panc, blood culture, peritoneal fluid (culture and amylase level), imaging: AXR, CXR (air under diaphragm)
Abscess: broad spec ABX: metronidazole + 3rd gen ceph + surgical drainage
Peritonitis: support with IV fluid, IV ABX met + cefotaxime then open or laparoscopic surgery
Anal fissure What Presentation Cause Management
Tear in mucosa of anal canal
Pain on defecation (shards of glass), bright red blood on stool or paper
Constipation, IBD
Dietary fibre, adequate fluids, warm baths, topical ointment, laxatives (Adult = bulk forming ispaghula husk, child = osmotic e.g. lactulose)
Pain relief: simple analgesia, warm baths, GTN ointment (relaxes smooth muscle reducing anal tone) 2x daily for 8 weeks
Surgery
Anal fistula What Causes Ix Management
Track communicates between skin and anorectal canal due to discharging abscess from blockage of intramuscular glands
Abscess, Crohns, rectal carcinoma
MRI
Surgery
Anorectal abcess What Causes Risk factors Presentation Management Common causative organism
Collection of pus in anal or rectal region (usually perianal abscess (60%))
Infection of fissure, STI, blocked anal gland
Diabetes, immunocompromised, IBD, anal sex
Discharging rectum, fever, perianal pain - throbbing, *worse on sitting - may be confirmed on DRE
Perianal abscess- tender, inflamed, localised swellings
Prompt drainage
Gut organisms i.e. E.coli
Pilonodal sinus
What
Complications
Management
Small hole or tunnel at skin caused by obstruction of hair follicles at natal cleft
May lead to abscess formation and sinus
Excision of sinus tract and primary closure
Advise: hygiene and hair removal
Perianal haematoma What Presentation Innervation Management
Dilated vascular plexuses, below the dentate line. - External haemorrhoids
2-4mm dark blueberry under skin
Bleeding uncommon, pain common
Below dentate line is somatic nerve - very sensitive to pain - inferior rectal nerve
May excise under LA or leave for 5 days or so
Haemorrhoids What Grading (1-4 Presentation Mangement
Abnormally enlarged vascular mucosal cushions in anal canal - internal haemorrhoids
Grade 1: no prolapse
Grade 2: prolapse on strain, reduce spontaneously
Grade 3: prolapse on strain, reduce manually
Grade 4: permanent prolapse
Painless as above dentate line therefore visceral innervation
Constipation, prolonged straining, increased abdo P (ascites, pregnancy, chronic cough)
Bright red painless rectal bleeding on defecation (on paper or dripping, not mixed in stool)
Anal itch from chronic mucus discharge
Refer on 2 week wait if suspect anal cancer
Prevent constipation: fibre, fluid, bulk forming laxative + topical anaesthetic
Rubber band ligation (grade 2), haemorrhoidectomy if large, refractory, v.painful
Appendicitis
What
Presentation
Rovsing’s sign
Sudden obstruction to the lumen usually by obstruction of the lumen resulting in invasion of appendix by gut flora
Early periumbilical pain (T10) moves to RIF as peritoneum involved (*McBurneys point ⅓ distance from anterior superior iliac spine to umbilicus) Pain aggravated by movement therefore shallow breathing + no coughing
Nausea, vomiting, anorexia
Low grade pyrexia
Rovsing’s sign +ve - palpation of LLQ increases pain in RLQ (stretches peritoneal lining)
Appendicitis DDx
GI obstruction, constipation, perforated ulcer, Meckel’s, diverticulitis, Crohn’s
Urological: torsion, calculi, UTI
Gynae: ectopic, ovarian cyst, PID
DKA
Appendicitis management
Admit all cases
Laparoscopic or open appendicectomy
IV fluids + opiate analgesia
IV metronidazole and third gen cephalosporin
Diverticular disease
What
Common site
Risk factors
A herniation of mucosa through thickened colonic muscle
Common at sigmoid and descending colon
Age (>50 (50% @50 have diverticular)), obesity, low dietary fibre *increases luminal pressure (at complicated - smoking, NSAIDs)
Diverticulitits
Presentation
Uncomplicated: incidental on colon screen, lower left sided abdo pain worse on eating, better on flatus/defecation ± bloating, bleeding, constipation
Diverticulitis: LLQ pain (Asian’s RLQ) + *bleeding
Intermittent pain with change in bowel habits
Fever and tachycardia
Anorexia, nausea, vomiting
Localised tenderness and abdominal mass, reduced bowel sounds unless obstruction
Complications of diverticulitits (5)
POFAS
Perforation, obstruction, fistula, abscess, stricture
Diverticulitits
Ix
*Colonoscopy to rule out CoCa
Flexi sig @ bleed
FBC - normal at uncomp, raised WCC at diverticulitis, bleeding - raised Pt and anaemia
Uncomplicated - BaEnema
CXR (upright) for pneumoperitoneum
AXR large/small bowel dilatation, ileus, obstruction etc.
Pneumoperitoneum causes (5)
Perforated duodenal ulcer – The most common cause of rupture in the abdomen.
Perforated peptic ulcer
Bowel obstruction
Ruptured diverticulum
Penetrating trauma
Ruptured inflammatory bowel disease (e.g., megacolon)
Necrotising enterocolitis/pneumatosis coli[1]
Bowel cancer
Ischemic bowel
Diverticular disease Mx
Diverticulitis Mx
Lifestyle advice - High fibre
Admit if significant blood loss (?transfusion)
Fluids + fibre
Bulk forming laxative (ispaghula)
Paracetamol for pain
Admit if pain uncontrollable, hydration not maintained, significant bleeding, perforation
Broad-spec ABX (co-amoxiclav) for 7d, paracetamol, clear liquids 2-3 days
30% require surgery: sepsis, fistula, obstruction, perforation resection + colostomy
Meckels diverticulum
Vestigial remnant of vitellointestinal duct @ distal ileum (within 100cm of ileocaecal valve)
Asymptomatic or haemorrhage (50% of complications) more common at children <2 or intestinal obstruction
*Always consider in DDx of rectal bleed or intestinal obstruction
Acute mesenteric ischaemia
Pathophysiology
Causes
Presentation triad
Impaired blood to intestine, bacterial translocation (passage int bact to sterile tissue) and systemic inflammatory response
Arterial emboli (mural thrombus post MI, AF, endocarditis) Art thrombosis (atherosclerosis, AAA) Non Occlusive Mesenteric Ischemia (hypotension, vasopressors)
Severe abdo pain (usually RIF), no abdominal signs, rapid hypovolemia
Acute mesenteric ischaemia
Ix
Complications (2)
Management
AXR for obstruction, ileus, thickened bowel, thumbprinting (oedema and inflammation)
*Gold standaard: angiography
Septic peritonitis, SIRS-Sepsis
Resus O2, IV fluid Heparin for MVT Gentamycin and Metroidazole Surgical angioplasty to SMA Mortality 90%
Chronic mesenteric ischemia What RF Presentation Ix Management
Intestinal angina - chronic atherosclerotic disease
Smoking, HTN, DM, hyperlipidaemia
Wt loss, postprandial pain, fear of eating, upper abdominal bruit
FBC, LFT, UE for malnutrition and dehydration, arteriography is gold standard
Nitrate therapy, anticoagulation, operate - bypass surgery
3 Types of bowl ischaemia
- Acute mesenteric ischemia
- Chronic mesenteric ischemia
- Chronic colonic ischaemia
Ischaemic colitits Pathology Presentation Ix Management
Low flow in inferior mesenteric artery
Acute pain LIF & bloody diarrhoea
Metabolic acidosis
Colonoscopy: blue swollen mucosa
Barium enema: thumb printing in early phase - oedema
Relieve hypoperfusion: bowel rest and supportive care
Malabsorption presentation (5)
Change in weight and growth
GI symptoms: chronic diarrhoea (3 or more for 4W), steatorrhoea
Family history Coeliac, Crohn’s, CF
Signs of deficiency: iron, folate, B12, bleeding (vit K), oedema (protein/calorie)
Malabsoption causes Mucosal, Intraluminal Structural Extra GI
Coeliac, lactose intol, cow’s milk protein allergy, infection (giardiasis, whipple’s, tropical sprue, travellers), HIV enteropathy, lymphatic obstruction (lymphoma, TB, cardiac disease)
Enzymes etc: *pancreatic insufficiency: CF, chronic panc, Ca panc, Zollinger-Ellison, *bile acid malabsorption: cholestatic jaundice or terminal ileum disease
Intestinal hurry: post-gastrectomy, vagotomy, Crohn’s (fistulae etc), amyloidosis, short bowel syndrome
Hyper/hypo thyroid/parathyroid, DM, carcinoid, eating disorder
Malabsoption Ix
Blood testing: FBC, LFT, ESR, CRP Iron studies (ferritin), folate, B12 Albumin and corrected calcium Clotting screen + INR (vitamin K) Anti-endomysial, anti-reticulin, alpha-gliadin
Stool testing: Faecal elastase (A1AT), microscopy and culture AUSS gallbladder, liver, pancreas Barium studies - structural Ileocolonoscopy + biopsy
Coeliac disease
What
Pathology
Histology changes (3)
An immune mediated gluten sensitive enteropathy leading to malabsorption
Heightened immune response to gluten (gliadin protein produces immune reaction at HLA-DQ8 producing toxic T-cells) in genetically predisposed individuals
Intraepithelial lymphcytes, villous atrophy & crypt hyperplasia
Coeliac disease presentation
Classical
Non classical
Other manifestations (3)
Classical: (20%)
Diarrhoea, wt loss, steatorrhoea, failure to thrive, fatigue, abdo pain, anaemia 80% (mouth ulcer, angular stomatitis, iron/B12/folate)
Non-classical: (80%)
IBS bloating, fullness, chronic fatigue
Skin: dermatitis herpetiformis: blistering at arms, legs, buttocks
Neurological: Cerebellar ataxia, peripheral neuropathy, dementia, depression
Other: amenorrhoea and subfertility
Coeliac Ix (5)
Tissue transglutaminase tTG IgA
Endomysial antibody EMA IgA
FBC anaemia in 50%: iron/folate (DIJFIB)
B12, ferritin, folate, calcium, albumin
LFT - should be normal on GFD if not consider AI disease: PBC, PSC, AI hep
Biopsy x4 from D2 or onwards showing subtotal villous atrophy and crypt hyperplasia
Tropical sprue
What
Presentation
Managment
Malabsorptive disease of small bowel characterised by inflammation and villous flattening found in topical areas: SE asia, caribbean
Very similar presentation to coeliac disease: begins with acute diarrhoea, fever and malaise -> chronic steatorrhoea, malabsorption, malaise, weight loss, vitamin deficiencies (iron, folate, B12, A, D, K), ankle oedema (albumin)
Fluid replacement
Antibiotics - tetracycline 6-12 months
Gastric cancer Where Presentation Ix Spread
50% pylorus, 25% lesser curve, 10% cardia, 5% lymphoma
Vague: dyspepsia, wt loss, vomiting, dysphagia, anaemia RED FLAGS for dyspepsia:
ALARMS: anaemia, loss of wt, anorexia, recent onset, swallowing difficulty
With early cancer only have uncomplicated dyspepsia but MOST PRESENT LATE
FBC (anaemia), LFT (to liver)
Flexible endoscopy/gastroscopy + biopsy *should biopsy all ulcers (multiple ulcer edge biopsy) as all may heal on Rx Signet ring cells
Local, lymphatic, blood-borne, transcoelomic *to ovary = Krukenberg’s tumour
To lung and liver
Gastric Ca referal Referral (immed) 2 week (any age) 2 week (>55) 2 week (cond)
Sig acute GI bleed
Dyspepsia + dysphagia/wt loss/vomiting/IDA/mass
Recent onset dyspepsia
Worsening dyspepsia + Barrett’s/atrophic gastritis (pernicious anaemia)
Gastrointestinal stromal tumour
The most common mesenchymal neoplasms of the gastrointestinal tract. GISTs arise pacemaker interstitial cell of Cajal,
They are defined as tumors whose behavior is driven by mutations in the KIT receptor tyrosine kinase mutation gene (85%)
MALT lymphoma What Why different to lymphoma Presentation Organisms
Subtype of non-Hodgkin’s lymphoma - extranodal marginal site lymphoma
Lymphoid proliferation is in mucosa-associated lymphoid tissue not LNs, follow a different course to nodal B-cell lymphomas
Gastric (⅓): most common, assoc H.pylori
Present with dyspepsia ± fever, nausea, const, wt loss, pain + ulcer
Or - Non gastric: head, neck, lung, eye
H.pylori @ 90% gastric MALT
C.jejuni @ small bowel MALT
Carcinoid What Secrete Presentation Carcinoid syndrome Management
Rare, slow-growing neuroendocrine tumours occuring in tissue derived from embryonic gut often asymptomatic
Vasoactive serotonin + bradykinin
Pain, wt loss, palpable mass
Vague R sided abdominal discomfort
R sided mass, hepatomegaly, telangiectasia, tricuspid regurg, pellagra (niacin deficiency - dermatitis and diarrhoea)
Flushing (post coffee, alcohol, food), diarrhoea, abdo pain, palpitations, hypotension, wheezing, abdo pain, wt loss, right sided palpable abdo mass
If possible surgical resection
If non-resectable somatostatin analogue e.g. *ocreotide which blocks 5-HT release, radiotherapy and chemotherapy
Colo rectal Ca
Where
Types
Presentation
⅔ in colon, ⅓ in rectum, 40% in rectum and sigmoid
Mainly adenocarcinoma, also GIST, carcinoid
Mainly local, mets to LIVER
Age, Fam Hx, IBD, Obesity, smoking, high alcohol, sedentary, DM
FAP - familial adenomatous polyposis - AD - mutation at APC gene 100% penetrance
HNPCC - hereditary non-polyposis colorectal cancer, AD, 80% lifetime risk,
Change in bowel habit, rectal bleeding + anaemia
Right side: weight loss, anaemia, occult bleed, mass in RIF
Left side: colicky pain, rectal bleed, obstruction, tenesmus, less advanced at pres
Jaundice, hepatomegaly
Colorectal Ca urgent referal (3)
Screening
> 40 with rectal bleed and change of bowel habit for >6W
60 with rectal bleed alone
Unexplained IDA
60 - 75, 2 yearly with FOB then +ve for colonoscopy
Staging for Colorectal Ca
Duke’s + 5 year survival A - mucosa 90 B - into muscularis propria through serosa 70 C - regional LN 30 D - distant mets/liver 5
IBS
Criteria
Extra bowel symptoms
DDx
6 month history of ABC (abdominal pain, bloating, change of bowel habit) +
Relieved by defecation or altered bowel frequency + 2 or more of
Mucus, worse on eating, abdominal bloating, altered passage (Straining, urgency)
Migraine, backache, lethargy, urinary frequency/urgency, dyspareunia, depression
Coeliac, IBD, gynaecological (ovarian cancer, endometriosis, PID)
IBS
Ix (5)
Management
FBC, ESR, CRP Coeliac screen (EMA/TTG) Ca-125 (ovarian cancer) Faecal calprotectin (IBD) ± TFT, faecal occult blood, colonoscopy
Lifestyle, dietary and physical activity
Decrease stress, relaxation, active physical activity, less caffeine, regular meals, fluids, decrease alcohol, high-fibre foods
Medications - placebo effect
-Diarrhoea - loperamide
-Constipation - laxatives e.g. fibrogel
-Abdo pain - antispasmodics - buscopan (hyoscine butylbromide)
Psychological therapy
Crohns vs UC
Macro
Micro
On barium
Macrocytically
CD - rectal sparing, skip lesions, mucus cobblestoning
UC - non-rectal sparing, continuous disease, ulcers, polyps
Microcytically
CD - transmural inflammatory cell infiltrate, granuloma, focal crypt abscess, increased goblet cells
UC - inflammatory cell infiltrate confined to mucosa and submucosa, focal crypt abscess, goblet cell depletion
On barium
CD - rose thorn ulcers, kantors string sign
UC - loss of haustrations, narrow short colon (lead pipe)
Extra bowel manifistations of IBD
JELCS - joints (large jt, anky spon, sacroilitis), eyes (conjunc, iritis, episcleritis), liver (fatty), colon (POMFAN), skin (Erythema nodosum, pyoderma gangrenosum, clubbing) + granulomata
Crohns
Presentation
Complications
Diarrhoea (chronic >6W) ± blood Abdominal pain Weight loss *periods of acute exacerbation Systemic symptoms - malaise, anorexia, fever JELCS
POMFAN - perforation, oral ulcer/obstruction, malabsorption, fissure/fistula, anal skin tags/abscess), neoplasia
Ix for IBD
FBC (all decreased), UE (renal disease as right ureter may be obstructed in ileocaecal disease), LFT (fatty liver)
ESR/CRP - high CRP (>30) active disease
Faecal calprotectin (IBS vs IBD)
Stool culture and microscopy
Ileocolonoscopy - CD/colonoscopy + biopsies
AXR (obstruction)
Malabsorption (iron, B12, folate, albumin)
ASCA - CD/p-ANCA-UC
CD Management
To induce remission
Maintaining remission
To induce remission
If first presentation or single exacerbation in 12M
Glucocorticoid monotherapy (oral pred/IV hydro)
If 2 or more exacerbations in 12M
Add azathioprine or mercaptopurine (or methotrexate + folic acid)
Or surgery (if limited to distal ileum)
Maintaining remission
Monotherapy with azathioprine, mercaptopurine or methotrexate
Smoking cessation
Monitor for osteopenia/osteoporosis
Presentation of UC
Bloody diarrhoea
TOBUM, tenesmus (feel incomplete), oooo (colicky) pain, bloody diarrhoea, urgency, mucus
Systemic: fever, malaise, wt loss, anorexia
JELCS
*If abdo tenderness associated with abdo distension -> ? toxic megacolon and arrange acute admission
Management of UC To induce remission - Moderate - Severe Maintain remission
Mild/moderate
Procto/sigmoiditis: topical mesalazine (suppository/enema) ± oral mesalazine
Step 2 (both): if no improvement in 4 weeks + oral prednisolone
Step 3 (both): if no improvement in 4 weeks + oral tacrolimus
To induce remission: Acute/severe
Admit + IV hydrocortisone + IV fluids
Add IV ciclosporin if no response in 72 hours
Consider surgery if toxic megacolon/>8 stools n.b. *surgery colectomy is curative
Maintain remission
Procto/sigmoiditis: topical or oral + topical mesalazine
Infliximab
Constipation management
Bulk forming - increase faecal mass, stimulating peristalsis - Fibrogel
Stool softener - for impacted faeces: arachis oil enema
Stimulant - increase motility e.g. senna, docusate
Osmotic - retain fluid in bowel - e.g. lactulose
Enema - good for rapid evacuation e.g. phosphate enema
Red flags of diarrhoea
Other things to consider
Blood (CMV, shigella, salmonella, c.jej, e.histolytica), recent ABX (c.diff), vomiting, wt loss, watery + high volume (dehydration)
Foreign travel, fever, food poisoning, stress
Causes of diarrhoea
Infection esp viral gastroenteritis
Drugs - ABX, cytotoxic, PPI, NSAID, metformin, thyroxine, SSRI, statin
Constipation with overflow
Food allergy + anxiety
Chronic disease e.g. IBD *can’t confirm without stool culture
Ix for chronic diarrhoea
Assess for red flags
FBC - anaemia, or raised platelet (inflammation)
LFT + albumin
Malabsorption: B12, red cell folate, iron studies, calcium
TFT
Coeliac Ab
Stool for culture and sensitivity
Features vitamin C deficiency
gingivitis, loose teeth
poor wound healing
bleeding from gums, haematuria, epistaxis
general malaise
Plummer-Vinson syndrome
dysphagia, glossitis and iron-deficiency anaemia +/- chelitits
Oesphageal varicies prophylaxis
B Blockers/Band ligation
Melanosis coli
abnormal pigmentation of the large bowel due to the presence of pigment-laden macrophages. It is most commonly due to laxative abuse
Interprete Abdo X-ray
Big cuddly spanish giants
Bones, Calcium, Soft tissue, Gas
Starting biologics caution
TB reactivation - Do chest X-ray
Coeliac increases risk of what cancer
Non hodgkins lymphoma
