Gastro conditions Flashcards
When is it appropriate to refer someone for an upper GI endoscopy in relation to suspicions of gastric/oesophageal cancer?
When someone has dysphagia
When someone is over 55 and has new onset dysphagia with weight loss and abdo pain/ reflux/ dyspepsia
What is cholecystitis?
Inflammation of the gallbladder
What is the most common case of cholecytsitis?
Gallstones
What symptoms will someone with gallstones classically present with?
Pain in the RUQ
Palpable mass in RUQ
Positive Murphy’s sign
Signs of inflammation
How do you test for Murphy’s sign, when would you do it and when is it positive?
Palpate under the 9th costal cartilage when you suspect gallbladder pathology
On inspiration, the gallbladder will move down and hit your hand causing the pain to be in pain
Who is most likely to get cholecystitis?
Those in the western world
What is the first line investigation for cholecystitis?
If asymptomatic no investigations are needed
If symptomatic do LFTs and an ultrasound of the biliary tree
If nothing is found on ultrasound and you still suspect gallstones due to a widened biliary tree or deranged LFTs do an MRCP
If MRCP is not conclusive you can do and EUS
How is cholecystitis managed?
If the patient is waiting for treatment tell them to avoid foods that trigger their symptoms
Do a laparoscopic cholecystectomy and then a clearance of the bile duct
What are some risks for acute cholecystitis?
Having existing gallstones
Having previous episodes of RUQ pain
When someone has gallstones when will their pain characteristically come on?
After fatty meals
What is cholangitis?
Inflammation of the biliary tree
What is the difference between cholecystitis and cholangitis?
Cholecystitis= inflammation of the gallbladder Cholangitis= inflammation of the biliary tree
What is pancreatitis?
Inflammation of the pancreas
What symptoms will someone with acute pancreatitis present with?
Deep boring pain in the epigastric pain that localises to the LUQ, radiates to the back, is persistent, alleviated by sitting forward or lying on their side, takes 10-20 mins to reach maximal intensity Vomiting Jaundice Grey Cullens or Turner's sign Fever Tachycardia
What is Grey Cullens and Turner’s sign? When would you see it?
Bruising around the flank and umbilicus
Seen in pancreatitis
What is pain in acute pancreatitis characteristically like?
Starts in epigastric region
Localises to LUQ
Takes 10-20 mins to reach maximal intensity
Deep and boring
Radiates to back
Alleviated by sitting forwards or lying on the side
Constant
How will a patient with acute pancreatitis lie?
Sometimes very still and on their side
What are the first line investigations for acute pancreatitis?
LFTs, bloods, serum amylase and lipase
Ultrasound pancreas if you suspect gallstones
MRI if there is persistent organ failure
What are risk factors for pancreatitis?
Alcohol use
How is pancreatitis managed?
ABC first
Fluid resus
Supportive treatments like oxygen, analgesia, enteral feeding if they are unable to eat
Treat the causes eg remove gallstones surgically if thats the cause
What are complications of acute pancreatitis?
ARDs
Systemic complications eg sepsis, shock, renal failure
Necrosis of the pancreas, formation of a pseudocyst or abcess etc
What is it important to note if the suspected cause of pancreatitis is gallstones?
They may not be visible on ultrasound if there is inflammation so you may have to wait for a few days
What is an anal fissure?
A split in the skin in the distal anal canal
What symptoms will someone with anal fissures classically present with?
A tearing pain in the anus on defecation
Burning sensation that lasts 1-2 hours after defecation
Anal spasm
Blood in the stool or when wiping
Who is most likely to get anal fissures?
Young adults
Pregnant women
What are some causes of anal fissures?
Cancer STI Pregnancy IBD Poor toileting Opiate analgesia use
What is the first line investigation for anal fissure?
None- diagnosis can be clinical and after examination (get them to lie on their side and spread their buttocks but note you may not be able to see it if its superficial or if there is anal spasm)
How are anal fissures managed?
If they are constipated treat the constipation
If stool is normal advise a high fibre diet and lots of fluid intake
If not healed in a week offer rectal GTN ointment
If pain is severe offer analgesia or anaesthetics
If you suspect cancer or if its atypical looking, refer to the relevant specialist
What are complications of anal fissures?
Chronic fissure
Recurrence
Incontinence after surgery
What is coeliac disease?
An autoimmune disorder wherein there is a reaction to dietary gluten peptides that results in villous atrophy and increased lymphocytes etc
What symptoms would someone with coeliac disease classically present with?
Abdominal pain/discomfort/distention Bloating Unexplained weight loss Unexplained anaemia, B12/folate deficiency Faltering growth Mouth ulcers
What are risk factors for coeliac disease?
Genetic/having a first degree relative with it
Having an autoimmune thyroid disorder
Having type 1 diabetes
Who is more likely to get coeliac disease?
Women
Those with a first degree relative
People in Europe/US
What is the first line investigation for coeliac disease?
Serology- first screen for IgA ttg (they must be eating a diet with gluten in it for 6 weeks leading up to it)
If positive refer to specialist for endoscopy so that it can be confirmed and ruled out
What must be done in prep for serology for coeliac disease?
The patient must eat gluten at least in one meal for 6 weeks leading up to the test
How is coeliac disease managed?
Refer to a dietician who will teach them about what contains gluten and what doesn’t, how to avoid contamination, food labelling etc
Also offer annual review to check height/weight, review symptoms, check adherence to diet etc
What are haemorrhoids?
Naturally occuring vascular tissue in the distal anal canal that becomes pathological
What are the 2 types of haemorrhoids and how do they differ?
Internal= lie proximal to the dentate line in the anal canal External= lie distal to the dentate line in the anal canal
What symptoms will someone with haemorrhoids classically present with?
Perianal pain or discomfort
Bleeding from the anus- in the stool or on wiping
What are some risk factors for developing haemorrhoids?
Constipation
Pregnancy
Age 45-65
Presence of a space occupying lesion
How are haemorrhoids managed?
They may naturally heal, in the meantime ensure the patient is not constipated, give analgesia and local haemorrhoid ointment
If severe, admit
Surgically remove by doing a haemorrhoidectomy, band ligation etc
What is the first line investigation for haemorrhoids?
Anal exam
Consider colonoscopy if you suspect other things are wrong
FBC if there has been prolonged bleeding and you suspect anaemia
What is diverticular disease?
Presence of diverticula with mild abdominal pain or tenderness but no systemic symptoms
What symptoms will a someone with diverticular disease present with classically?
Intermittent abdominal pain in the left lower quadrant
Pain worse after eating
Pain relieved by passing faeces or flatus
Constipation or diarrhoea
Intermittent rectal bleeding
Who is more likely to get diverticular disease?
Older people (over 50)
People who aren’t vegetarian
People on a low fibre diet
What is the first line investigation for diverticular disease?
Bloods: FBC to check anaemia, CRP to check inflammation
Endoscopy or radiography
How is diverticular disease managed?
Primarily lifestyle advice like high fibre diet (need to do for weeks to see effects), exercise, high fluid intake, avoid NSAIDs and opioid analgesia
Advise paracetamol if they really need pain relief
Antispasmodics if they have stomach cramps
How may diverticular disease present differently in asian people? How does this differ to normal presentation
It may be right sided instead of left sided
What is GORD?
Symptoms or complications that arise from the reflux of acid contents from the stomach into the oesophagus or above
What symptoms will someone with GORD present with classically?
Heartburn
Epigastric pain
Acid regurgitation
They may also have: Bitter taste in mouth Asthma Cough Laryngitis
What are some risk factors for developing GORD?
Higher BMI/obesity
Family history of acid reflux or heartburn
Drugs that reduce the pressure of the lower oesophageal sphincter
Previous oesophagitis
Hiatus hernia
What is the first line investigation for GORD?
None- usually diagnosis is clinical and further investigation eg OGD/endoscopy is only needed if treatment doesn’t work or complications eg Barrett’s oesophagus are expected
How is GORD managed?
4-8 week full dose PPIs
What medications have the ending ‘zole’?
PPIs
What might increase someones risk of Barrett’s oesophagus?
Having long term GORD
Having a hiatus hernia
Having previous oesophagitis
Being male
What are some complications of GORD?
Barrett’s oesophagus
Oesophageal cancer
Stricture
What is a hiatus hernia?
A protrusion of abdominal contents through a widened hiatus of the diaphragm
What symptoms will someone with a hiatus hernia classically present with?
Many are asymptomatic Symptoms of GORD= acid regurgitation and heartburn Dysphagia Odynophagia Anaemia Cough
Who is more are risk of developing a hiatus hernia?
Pregnant women
Those of older age (above 50)
Obese/overweight people
What is the first line investigation for hiatus hernia?
None- diagnosis can be clinical and further investigations are only needed if there are complications/symptoms are persistent after treatment
Chest x ray
OGD
Bloods- check for anaemia, inflammation
How are hiatus hernias managed?
If symptoms aren’t bad treatment isn’t needed
PPIs for reflux symptoms
Lifestyle advice like eat smaller meals more frequently, avoid foods that trigger reflux, stop smoking
Surgical repair can be done if symptoms are bad via Nissen fundoplication
What surgical procedure is used to repair hiatus hernias?
Nissen fundoplication
What is a type I hiatus hernia?
Sliding- wherein the OGD is above the hiatus of the diaphragm and a portion of the stomach had slid up
What is a type II hiatus hernia?
Rolling- wherein the OGD is at the normal level but a pouch of the stomach has protruded above the hiatus of the diaphragm
What is a type III hiatus hernia?
Mixed- wherein the ODG is above the normal levels and a pouch of the stomach has protruded above the hiatus too
What is a type IV hiatus hernia?
When other organs apart from the stomach protrude above the hiatus of the diaphragm
What type of hiatus hernia is most common?
Type I
What are some complications of hiatus hernia?
Strangulation
Obstruction
If a hiatus hernia is asymptomatic what should you warn the patient of for when they should go to a&e about it?
If it becomes red, hot, swollen or painful ie signs of infection and strangulation
What is constipation?
Difficulty passing stool
What symptoms will someone with constipation present with classically?
Difficulty passing stool- trying to defecate for long, having to strain hard
Infrequent passing of stool
Feeling excavation is incomplete
Who is more at risk of constipation
Older people (over 65) Pregnant women Those with a low fibre diet Those with a sedentary lifestyle Those with low fluid intake
What is the first line investigation for constipation?
None, most of it is clinical
How is constipation managed?
Lifestyle advice: high fibre diet, high fluid intake, exercise
Normal constipation: first line bulk forming laxative, second line osmotic laxative, if neither work and constipation is chronic consider prucalopride
Opioid induced constipation: do not give bulk forming laxative, first line osmotic
How does treatment for opioid induced constipation differ from treatment for normal constipation?
They are not given bulk forming laxatives
What are some complications of constipation?
Anal fissure
Haemorrhoids
Faecal impaction
What is an example of a bulk forming laxative?
Isphagula
What is an example of an osmotic laxative?
Lactulose
Macrogol
What is ascending cholangitis?
Inflammation/infection and blockage of the CBD that can spread systemically
What symptoms will someone with ascending cholangitis classically present with? Explain why each arises
Charcot’s triad:
Fever (with rigors)= due to infection
Jaundice= due to blocked flow of bile in CBD
RUQ pain= due to location of gallbladder/CBD
What triad of symptoms is associated with ascending cholangitis?
Charcot’s= fever, jaundice, RUQ pain
What is Charcot’s triad and what is it associated with?
It is a triad of symptoms that is typical of someone with ascending cholangitis and includes fever (with rigors), jaundice and RUQ pain
What is cholelithiasis?
Formation of gallstones
What classic symptom will someone with gallstones describe?
A sharp, stabbing pain in their RUQ a few hours following fatty meals
What is peptic ulcer disease?
A break in the mucosal lining of the stomach or duodenum bigger than 5mm and down to te submucosa
What are the 2 locations of common ulcers
Duodenum Stomach (gastric)
What symptoms will someone with peptic ulcer classically present with?
Burning pain in epigastric region (after meals)
Melaena
High BP
What are the risk factors for developing peptic ulcer disease?
Being on NSAIDs
Family history
H pylori infection
What is the first line investigation for peptic ulcer disease?
Upper GI endoscopy
What investigations are done for peptic ulcer disease? Explain why?
Upper GI endoscopy- to identify the source of bleeding
FBC- to check for anaemia
H pylori breath test- to check if infection by h pylori is the cause of peptic ulcer
How is peptic ulcer disease managed?
If h pylori positive then h pylori eradication therapy
If h pylori negative then treat the cause (ulcer healing therapy if NSAID induced, if bleeding give them transfusions)- give PPI and 2 antibiotics
What is ulcerative colitis?
A type inflammatory bowel disease wherein there is disruption to the bowels starting from the rectum and extending proximally upwards to a point in the large colon
What symptoms will someone with ulcerative colitis classically present with?
Blood in stool
Diarrhoea >6 weeks
Tenesmus- a painful urge to defecate even when you don’t need to
Pain before defecation that is relieved after defecation
Weight loss
Abdominal pain- especially in the left lower quadrant
Uveitis and episcleritis
Erythema nodosum or pyoderma gangrenosum
Apthous mouth ulcers
Pallor
Clubbing
What are some extra GI manifestations of UC?
Eyes- uveitis and episcleritis Mouth- apthous ulcers Pallor- due to anaemia Nails- clubbing Skin- erythema nodosum or pyoderma gangrenosum rash
Who is more likely to get UC?
Those with family history
Those who are HLA B-27 positive
What investigations would you do for someone with UC and why?
Colonoscopy- to image the colon and see the pattern of bowel disruption
FBC- check for anaemia
U+Es, vitamins etc- check to see if they are malnourished in any way
Faecal calprotectin- WCC in faeces may be raised, it will not be in IBS
Stool culture and microscopy- to rule out c diff infection
Thyroid function tests- to rule out hypothyroidism
Inflammatory markers- ESR and CRP may be raised
How is UC managed?
First line aminosalicyclates- these are given topically or enema first then orally if needed
If that doesnt work consider immunosupressive drugs or biologics (if multiple episodes of corticosteroids are needed to induce remission in a year)
In an acute flare up give IV corticosteroids
Colectomy may be needed if the disease progresses
What are some complications of UC?
Haemorrhage
Toxic megacolon
Colonic adenocarcinoma- screen them more regularly
Benign stricture
What layer is invasion limited to in UC?
Mucosa or submucosa
What cell is UC associated with?
Th17
What part of the colon is affected in UC?
The rectum is always affected
Then the large bowel extending proximally in
