Gastroenrology Flashcards by ian rowley

Non GI symptoms of IBS

Dysmenorrhoea
Dysparaunia
Increased urinary frequency and urge
Back pains
Headaches
Poor sleeping 
Fatigue

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Triggers for ibs

Anxiety 
Depression
Stress
GI infection
Antibiotics
Abuse 
Eating disorders

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Associated disorders with ibs

TMJ dysfunction
ME
Fibromyalgia

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Treatments of IBS constipation

Ispaghula husk

High fibre diet

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Treatment of IBS diarrheoa

Loperamide

Codein

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Treatment of IBS cramps

Mebevarine

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Treatment of IBS mental state

Antidepressants

Psychiatrist

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General treatment of IBS. What does it do?

Linaclotide - increases motility aiding consitpation and decreases bowel sensation

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Diagnostic criteria for ibs

In last 3 months
At least 3 days a month of abdo pain/discomfort
With at least 2 of improves with deification, associated with change in stool frequency, associated with change in stool form
And no organic cause suspected

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Extra gastroentestinal symptoms with inflammatory bowel disease

Arthritis or arthralgia 
Ankalosing spodylitis
Clubbing
Uveitis
Erythema nodosum
Pyoderma gangrenosum 
Sclerosing cholangitis  
Liver problems fatty to cirrhosis

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Complications of inflammatory bowel disease

Anaemia
Bowel cancer
Decreased fertility and miscarriage
Toxic megacolon

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General symptoms of inflammatory bowel disease (both types)

Diarrhoea day and night
Abdominal pains
Weight loss
Anorexia
Lethargy 
Nausea and vomiting

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In which ibd is smoking protective?

Ulcerative colitis

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Risk factors for ibd

Family history 
Jewish ethnicity 
Caucasian 
Upbringing - hygiene hypothesis 
Lack of breast feeding

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What is a big risk factor in ibd for bowel cancer? What screening should be done?

Primary sclerosing cholangitis
Normal - colonoscopy every 2 yrs after 10 then yearly after 20
With AC - yearly colonoscopy

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What immunological tests can be used in ibd?

What do they mean?

Faecal calprotectin - component of neutrophils thus if raised in faeces inflammation of bowel wall.
ANCA - antibodies against neutrophil proteins

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Which ibd is more common in females?

Crohns

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Which ibd is most common?

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What are the clinical features that suggest crohns disease over uc?

Smelly faeces
Perianal disease
Internal fistulas with faceces appearing where it shouldn’t
Colicky pain

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What condition may an acute presentation of crohns disease mimic

Appendicitis

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What colonoscopic features would suggest crohns over uc?

Cobblestoning
Fistulas and abscesses
Aphthoid ulceration

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What histological changes suggest crohns over uc?

Transmurial inflammation

Granulomas

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What radiological features suggest crohns over uc?

Asymmetrical pattern
Stricturing
Skip lesions
String sign of cantor

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What test would be needed to elicit string sign of cantor?

Barium swallow

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What are treatment options for crohns disease exacerbations?

Mild attack - prendisolone | Severe attack - hydrocortisone, metronidazole, infliximab

Long term treatment options for crohns disease?

``` Azothioprine Sulfasalazine Infliximab Methotrexate Surgery ```

How can severity of uc be graded? | What else suggest severity?

severe - >6 per day with blood +++ | Fever, tachycardia, anaemia, hypoalbuminia, high esr

In what gender is uc more common?

Males

What specific symptoms may uc patients complain of?

Blood and mucus in diarrhoea | Urgency or tenesmus

Which is more painful, crohns or uc?

Crohns

What would be seen on colonoscopy that would be suspicious of uc?

General inflammation and ulceration | Mucosal islands

What biopsy changes would suggest uc over crohns?

Superficial inflammation Crypt abscesses Inflammatory cells Lack of goblet cells

Specific radiological signs of uc over crohns?

Thumb printing - thickening of mucosa on haustra Loss of haustra - lead pipe sign Collar button ulcers

Treatment to induce remission in uc?

Prednisolone | Ciclosporin

Drugs to maintain remission in uc?

Mesalazine | Azothioprine

How would mesalazine be give in UC ?

Suppository or modified release

What drugs would be considered in UC not directly related to immune modulation?

``` Heparin as high clotting risk! Bisphosphonate if on steroids Antibiotic cover if on immunosuppressants Laxitives if constipated Probiotics if pouchitis ```

What surgical options exist for ulcerative colitis?

Proctocolectomy with terminal ileostomy | Colectomy with ileo-anal pouch

When do most cases of crohns develop?

16-30 | And 60-80

What age does UC most commonly develop?

15-25

What signs would present in a crohns disease patient with fistulas?

Pneumatouria | Faecouria

How does pyoderma gangrinosum present?

Rapid onset rapidly enlarging ulcer often with a purple edge

How should pyoderma gangrinosum be treated?

Remove necrotic tissue but NO wide excision Swab and abx if +ve Steroids If severe immunosuppression

What are the stages of proximal progression of uc?

``` Proctitis Proctosigmoiditis Left sided Extensive Pancolitis Backwash ilitis ```

Other forms of ibd than uc and cd

Microscopic ulcerative colitis Microscopic lymphocytic colitis Microscopic collagenous colitis

What environmental factors may play a role in ibd?

Hygiene hypothesis Breast feeding Nutrition Smoking (CD - exacerbates, UC protective) Appendectomy (UC - protective, CD - exacerbates) Intestinal microflora - immune response against?

Where is particularly influenced by crohns?

Terminal ilium | Ascending colon

Which of uc or cd increases gallstone risk?

Differentials of IBD?

Lymphoma Infection Carcinoma

What sorts of anaemia appear in IBD?

Microcytic iron deficiency Normocytic of chronic disease Megaloblastic due to terminal ilial disease

Tests to run on a ?IBD patient?

Bloods - FBC (anaemia, infection), CRP (inflammation), liver biochemistry (liver involvement), ANCA Stool cultures Abdo xray Barium follow through or oral contrast CT Colonoscopy

When should colonoscopy be performed in suspected UC?

After acute episode due to risk of perforation during

What are disease activity markers in CD?

Hb Albumin Inflammatory markers

Normal sizes for small, large and cecum on AXR?

3,6 and 9 cm

Signs of toxic megacolon on axr

Colon >6cm Thin walled Gas filled Mucosal islands

How could lone proctitis be treated in UC?

Rectal steroids

What would trigger surgery in a chronic presentation of UC?

Incomplete response to meds Excessive steroid use None compliance Cancer risk

Acute indications for surgery in UC?

Toxic megacolon Failure of treatment Haemorrhage Perforation

What are the presentations of the microscopic colitis's?

Watery diarrhoea | Macroscopically normal

Prevalence of diverticular disease?

>50% of over 50s with 95% being asymptomatic

Presentation of chronic diverticular disease?

Left iliac fossa pain, erratic bowel habits, constipation

Diagnosis of chronic diverticular disease?

Colonoscopy

Treatment of chronic diverticular disease

High fibre diet | Smooth muscle relaxants

Symptoms of acute diverticulits

Severe left iliac fossa pain Bowel disturbance Fever

Signs of acute diverticulitis

Tenderness guarding and rigidity | Sometimes palpable mass

Diagnosis of acute diverticulitis?

Ct showing colonic wall thickening, diverticula and abscesses Do not do colonoscopy!

Bloods in acute diverticulitis?

Raised esr and crp | Leucocytosis

Treatment of acute diverticulitis

Cephalosporin and metronidazole | Iv fluids

Complications of acute diverticulitis

Perforation - peritonitis, fistula Obstruction Bleeding

Causes of upper gi bleeding

``` Peptic ulcer Mallory weiss tear Oesophageal varices Nsaids/steroids/anticoagulants/thrombolytics Oesophagitis Gastric erosions Malignancy ```

What can cause gastritis?

Alcohol, nsaids, hpylori, atrophic gastritis, granulomas (chrones, sarcoidosis), reflux

Presentation of gastritis?

Epigastric pain, vomiting, haematemesis

Diagnosis of gastritis?

Endoscopy and biopsy

Treatment of gastritis

Ppi or ranitidine, | Hpylori eradication

What score can be used to predict mortality in upper gi bleeding? Components?

Rockall score Age SBP and pulse Comorbidites

Acute management of a upper gi bleed?

``` Airway High flow O2 Cannulate with resuscitation fluids Bloods - fbc, u+e, lft, clotting, crossmatch Catheter and monitor Cxr, abg, ecg Omeprazole bolus and ivi Urgent endoscopy Inform surgeons Keep nil by mouth ```

What may show on U+Es in a GI bleed?

Increased urea from digested blood

What does an itch tell you about jaundice?

That it is a conjugated hyperbilirubinaemia not unconjugated. Unconjugated does not itch.

``` What would be found in the urine in: Conjugated Unconjugated Bilirubinaemia And heamolytic anaemia ```

Conjugated - bilirubin Unconjugated - urobiliogen Hamolytic - haemoglobin