Gastro diseases Flashcards
GORD
may be due to hiatus hernia, gastroparesis, raised abdo pressure, and unhealthy diet; using NSAIDs regularly, and binge drinking
heartburn, esp on bending; fluid/food regurgitation on squeezing, waterbrash, nocturnal cough (gastric fluid reflux to larynx when flat), chest pain (from oesophageal spasm), dysphagia or odynophagia (though rare unless complicated)
if middle aged or older with alarming symptoms, or young and v alarming, then endoscopy to exclude other conditions; 24hr-pH measurement if considering surgery
endoscopy may show oesophagitis (erythema, even ulcers and strictures - these cause dysphagia and need endoscopic dilatation)
barret’s oesophagus: metaplasia of distal oesphageal epithelium from squamous to columnar, usually no symptoms but 10% lifetime risk of getting adenocarcinoma from it
conservative (lifestyle, weightloss, antacids), medical (PPI or H2ra), endoscopic and surgical if eg large hiatus hernia
achalasia
degen of ganglia in distal oesopgaus/LOS causes peristalsis and sphincter relaxation to fail, and the oesophagus to gradually dilate; more common in middle aged people
similar condition when myenteric plexus destroyed in Chagas disease or oesophageal cancers
presents: insidious, intermittent dysphagia, worse if swallowing when slouched, better for liquids than solids; heartburn and chest pain may occur, and in late stages regurg and aspiration; SCC is rare complication
upper GI endsocopy to exclude malignancy, barium swallow will show narrowing v distal with proximal dilatation and reduced peristalsis; oesophageal manometry is diagnostic, shows the absent peristalsis and raised LOS pressure
medical options not usually helpful
endoscopic dilation or botulinum injection help but inc risk of GORD and have small risk of perforation
oesophageal carcinoma
ACC in lower third, SCC anywhere, more common in middle and far east; smoking, alcohol, betel nut, tobacco chewing, achalasia are risk factors
presentation: painless, rapidly progressing dysphagia, weight loss; late focal invasion will give chest pain or hoarse voice, spread to cervical lymph nodes; may form fistula from oesophagus to bronchus giving coughing after eating, pneumonia or pleural effusion
upper GI endoscopy to find and biopsy, barium swallow will show length of tumour if endoscope couldnt pass by it; abdo, thorax CT for staging or endoscopic US
if operable, oesophagectomy; if not then stent it to relieve dysphagia, radiotherapy and analgesics
minor oesophageal conditions
pharyngeal pouch: dysphagia, night time cough, halitosis, lump in throat; diagnose with barium swallow
eosinophillic oesophagitis: vomiting in kids or dysphagia in adults
oesophageal rings/webs: intermittent dysphagia to solids over years, rings distal and webs proximal; usually spotted by radiology
mallory-weiss tear: mucoasal tear leading to haematemsis; typical history will say initial vomitus does not contain blood; will usually settle spontaneously, acid suppression or endoscopic therapy needed in rare cases
peptic ulcers
penetrate the mucosa, may be from distal oesophagus through to duodenum
gastric more common in elderly and duodenal more in <40yos
present with: epigastric pain (g - after eating and relieved by antacids, d - nocturnal and relieved by food), vomiting (rare for duodenal, common for gastric), gastric common to lose appetite/weight but duodenal may even gain weight; endoscopy to diagnose, can biopsy for H pylori or in gastric case to check for malignancy at edge of ulcer, should do second endoscopic scan to check healing of gastric ulcers due to risk of malignancy; duodenal wont go malignant but have higher risk of perforation
besides H pylori, risk inc’d by smoking, NSAIDs, stress (esp due to chronic disease eg cirrhosis etc)
perforation: severe upper abdo pain rapidly generalising, air under diaphragm, rigid and silent abdo
gastric outlet obstruction if near pylorus: distension, vomit old food, dehydration, hypokalaemic alkalosis, NG aspiration of stomach contents then endoscope to investigate; drip n suck (iv nutrition, NG aspiration); treat with balloon dilation
gastric carcinoma
v common cancer death worldwide, esp china and japan; incidence falling in Uk
often from chronic ulcers, diets with lots of pickled or smoked foods; smoking and alcohol
epigastric pain unrelated to meals, relieved by acid suppressants; weight/appetite loss; haematemesis rare except in late disease; supraclavicular lymph node and migratory thrombophlebitis are rare but classic signs
endoscopy will show irregular ulcer looking thing, biopsy the edges; FBCs and LFTs, CXR, abdo CT can help with staging
malabsorption
malaise, anorexia, bloating, diarrhoea (esp stool bulk change rather than freq so much), weight loss
specifics: steatorrhoea (fat malabsorption), oedema and ascites (protein), paraesthesia or tetany (mg/ca), skin rash (zn, vit B), cheilitis/glossitis (vit B), neuropathy and psych changes (B12), night blindness (vit A), bruising (vit K or vit C), bone pain or osteoporosis (vit D)
investigations to find cause: serology (FBC, Fe, B12, folate, albumin, U&Es, coeliac antibodies), barium follow through, capsule endoscopy, lactose and glucose breath tests, other specific tests if cause suspected
coeliac disease
T cell inflam of small bowel against a-gliadin
infants: diarrhoea, malabsorption, failure to thrive upon weaning
children: abdo pain, anaemia, short stature, delayed puberty
adults: bloating, lethargy, diarrhoea or constipation, Fe deficiency anaemia, malabsorption, sometimes oral ulcers and psych disturbance
often linked to other autoimmune diseases esp sjogrens syndrome, prim bil cirr, thyroid disease, ins dep diabetes, dermatitis herpetiformis
duodenal biopsy gold standard (villous atrophy and crypt hyperplasia and intraepithelial lymphocytosis)
look for IgA to TTG but false neg if patient has IgA deficiency, can screen for it and monitor response to treatment
FBC (anemia), U&A (ca, vit B12 and K, vit D, albumin)
dietician to support lifelong gluten free diet, correct deficiencies
IBDs
relapsing/remitting
crohns: non-continuous skip lesions: mostly in ilel-colonic region (40% of cases), SI (30%), purely colonic (20%), purely perianal (10%); inflam involves full thickness of the wall with deep ulcers giving cobblestone appearance, somtimes fistulae and abscesses through to bladder, vagina, other parts of gut; get giant cell granuloma on histology
UC: always rectum and can extend in continuous fashion to sigmoid (40%) or whole colon (20%); other 40% have extensive colitis past sigmoid but not a full pancolitis; inflam confined to mucosa with crypt abscesses; chronic inflam incs dysplasia which incs carcinoma risk
35% of people get extra-intestinal manifestations of these diseases
IBDs clinical features
generally abdo pain and diarrhoea
ileal crohns: inflam abscess causing (post prandial) pain giving anorexia, weight loss and non-bloody diarrhoea; can get malabsorption and SBO
prox crohns: more likely to get vomiting
crohns colitis: bloody diarrhoea, malaise, fever but sigmoidoscopy often shows rectal sparing
perianal crohns: skin tags, anal fissures or fistulas
UC: bloody diarrhoea; proctitis and proctosigmoiditis give fresh rectal bleeding, tenesmus, only get constitutional symptoms if severe; extensive or pancolitis give more abdo pain and constitutional symptoms, severe may have raised pulse and temp plus >6poos daily
toxic megacolon: severe colitis giving abdo distension and strong constitutional symptoms with high risk of perforation; can occur in crohns colitis but usually is UC
extraintestinal manifestations of IBD
uveitis, scleritis, angular stomatitis and mouth ulcers (crohns), erythema nodosum/multiforme, pyoderma gangrenosum, ankylosing spondylitis, arthropathy, osteoporosis, oxalate kidney stones, amyloidosis, glomerulonephritis, gallstones, autoimmune hepatitis, primary sclerosing cholangitis, fatty liver, pleuropericarditis, fibrosing alveolitis, pulmonary vasculitis, neuropathy, myopathy
IBD investigation and management
FBC, U&E, CRP, ESR (CRP more acute inflam marker, ESR good as more chronic marker of inflam)
endoscopy/sigmoidoscopy; full colonoscopy to assess extent of disease
abdo x-ray if suspect toxic megacolon or crohns SBO
barium follow through for crohns disease, if this and CT fail to spot then capsule endoscopy; if patients too unwell for these procedures can do radiolabelled white cell scan (for areas of inflam, less accurate though)
oral steroids in crohns help induce remission; oral 5-ASA may help maintain remission if freq relapses; surgical resection of affected area
suppository steroids to induce remission in UC, enemas if severe and oral if still not responding; start with oral if extensive; oral 5-ASA to maintain remission if freq relapses
note 90% UC is relapsing remitting but other 10% have chronic active disease and these are esp likely to have surgery
IBS
may be constipation predominant, diarrhoea predominant, or mixed-stool pattern (40:20:40%)
cramping abdo pain and symptoms dont occur at night, incomplete evacuation can occur
TCAs, CBT may help; antispasmodics in some cases if postprandial cramp usually, diet changes often dont help much
classical presentation: pain relieved by diarrhoea with alternating diarrhoea and constipation; usually disease of under 40s so beware diagnosing in older people as may be a malignancy
colonic adenocarcinoma
2nd most common cancer in UK, 30,000 cases a year
risk factors: genetic, red meat, sat animal fats, chronic inflam, smoking
65% rectosigmoid, 10% LC or TC, 25% RC
rectal bleeding, altered bowel habit; anorexia, weight loss, abdo mass, anaemia; tenesmus if in rectum; non-specific abdo pain
flexible sigmoidoscopy (any patient with fresh rectal bleeding); colonoscopy if bowel habit altered, sigmoidoscopy shows polyps, family history
barium enema less sensitive but may show strictures
serum CEA can be supportive (but false positives and negatives); FBC and iron studies can support diagnosis
for staging: CT of abdo, LFTs, pelvic MRI
management through MDT with surgery, chemo for palliation or adjuvant to the surgery
faecal occult blood test every 1-2yrs after age 60; flexible sigmoidoscopy can be done as screening
diverticular disease
50% of over 50s have some diverticula
diverticulosis: colicky left iliac fossa pain relieved by defaecation; pellet stools; bloating; must exclude colorectal cancer if these present; colonoscopy though has risk of perforation, rigid sigmoidoscopy an alternative; inc fluid and fibre intake
diverticular bleeding: can occur, and may ultimately lead to anaemia and altered bowel habit but rule out IBD and bowel cancer first
diverticulitis: fever, raised white count and inflam markers, pain; no colonoscopy, do CT to look for an abscess; antibiotics and analgesia if mild; stricture, perforation, fistula, abscess may need surgery
