Gastroenterology Flashcards
1
Q
What are some key causes for Upper GI bleeding?
A
Peptic ulcer disease (50%)
Oesophageal Varices
Mallory Weiss Tear
Cancers of stomach/duodenum
2
Q
What is Peptic ulcer disease?
A
Break in the mucosal lining of the stomach, duodenum or lower Oesophagus more than 5mm diameter.
3
Q
What is the most common area for a peptic ulcer?
A
Duodenal ulcers
4
Q
What can cause a peptic ulcer?
A
Imbalance between factors promoting mucosal damage and those promoting duodenal defence
5
Q
Who is typically affected by peptic ulcers?
A
More common in men than women
Prevalence 11-20% for men
6
Q
What are the risk factors for Peptic Ulcers?
A
Increasing age
H.Pylori infection
NSAIDS
Drugs - SSRIs, Corticosteroids
Smoking
Alcohol
7
Q
What are the clinical signs of of peptic ulcer disease?
A
Evidence of bleeding
Hypotension
Tachycardia
Melaena
Epigastric Tenderness
Pallor - due to anaemia
8
Q
What are some signs of Upper GI bleeding via peptic ulcers?
A
Burning Epigastric pain
Nausea & Vomiting
Haematemesis
Melaena
Reduced appetite
Weight loss
Fatigue - Anaemia
9
Q
What is the pain like in an Upper GI bleed from a peptic ulcer?
How can this be used to distinguish the site of the ulcer?
A
Burning pain
Gastric ulcer - pain worsened by eating
Duodenal Ulcer - Pain relieved by eating and worse when hungry
10
Q
What are the investigations that you would do in a suspected peptic ulcer that is currently bleeding?
A
Upper GI endoscopy:
Diagnostic and therapeutic
FBC
H.Pylori Tests
U&E:
urea is raised
LFTs - Assess severity of Liver disease
Venous Blood Gas - raised lactate
Erect CXR - concerned about perforation
11
Q
What is the Glasgow Blatchford Score (GBS)
A
Scoring system used in a suspected upper GI bleed. Those with a score of >0 require admission.
Drop in Haemoglobin
Rise in Urea
Systolic BP
HR
Melaena
Hx of Syncope
Hepatic disease Hx
HF
12
Q
What is the first line treatment for a peptic ulcer that is not bleeding?
A
Conservative Lifestyle Tx - treat RFs
H.pylori Neg:
PPI - omeprazole
H.pylori Pos:
Tripple Therapy - Omeprazole, Clarithromycin, Amoxicillin
13
Q
What is the first line treatment for a peptic ulcer that is bleeding?
A
First Line:
ABCDE
Blood transfusion - if blood loss
Upper GI endoscopy - within 24 hrs
High dose IV PPI - after Endoscopy
14
Q
What is the Second line treatment for a Peptic ulcer which is bleeding?
A
Surgery or embolisation
15
Q
What are some complications of peptic ulcer disease?
A
Perforation
Gastric outlet obstruction
peritonitis - caused by an ulcer/haemorrhage of an ulcer passing straight through into the stomach
Pancreatitis - can also occur as a result of peritonitis
16
Q
What are Oesophageal Varices?
A
Dilated submucosal veins within the lower 1/3rd of the oesophagus that develop as a consequence of portal hypertension
17
Q
What is the cause of oesophageal varices?
A
Portal Hypertension
18
Q
What are the risk factors for oesophageal varices?
A
Liver Cirrhosis (50% of Px have varices)
Portal HTN
Decompensated liver Cirrhosis
19
Q
What are the clinical signs of oesophageal varices?
A
Hypotension
Tachycardia
Pallor
Signs of chronic liver damage – jaundice, easy bruising (liver not produced coagulation factors) and ascites
Splenomegaly
Ascites
20
Q
What are the symptoms of oesophageal varices?
A
Haematemesis
Melaena
Sx of blood loss:
Dizziness
dyspnoea
Chest pain
Syncope
21
Q
What are the primary Investigations for oesophageal varices?
A
Upper GI endoscopy:
Diagnostic
FBC - Anaemia
LFTs - assess liver disease severity
U&Es - Urea is raised in upper GI bleed
22
Q
What is the management for bleeding oesophageal varices?
A
Resus:
ABCDE
IV Fluids - if in shock
Blood transfusion
Terlipressin
Prophylactic Abx
Balloon Tamponade in emergency
23
Q
What is Terlipressin and what does it do?
A
ADH analogue that can cause splanchnic vasoconstriction to reduce blood flow in the portal vein and reduce portal pressure
24
Q
What Abx are given in oesophageal varices as prophylaxis?
A
Quinolones:
eg. ciprofloxacin
25
What is the definitive management of oesophageal varices?
1st line:
Variceal Band ligation
Sclerotherapy and transjugular intrahepatic portosystemic shunt (TIPS) are also able to be used
26
What prophylactic Tx should be given to prevent formation or rupture of oesophageal varices?
Beta blocker - propranolol to reduce portal pressure
Variceal band ligation
27
What are some complications of Oesophageal varices?
Rupture and GI bleeding
Rebleeding once fixed
Encephalopathy
Infection
28
What is the pathogenesis of oesophageal varices?
Portal HTN due to decompensated liver cirrhosis leads to increased back pressure into the left gastric vein.
This causes the veins draining the oesophagus to become engorged and dilate
They are then at increased risk of rupture causing an Upper GI bleed
29
What are some factors that cause mucosal damage and therefore increase risk of peptic ulcers?
Gastric acid - high volumes
H.Pylori
NSAIDs
30
What are some protective factors of the upper GI tract that are reduced that can lead to peptic ulcers?
Reduced Prostaglandins (NSAIDs) leading to poor muscosal production
Mucus damage (via H.pylori)
Bicarbonate loss leading to no neutralisation of stomach acid
31
Define a small bowel obstruction (SBO)?
Inability of the gut to absorb the necessary nutrients sufficient to sustain life due to a mechanical blockage of the small intestine
32
What is the most common indication for emergency laparoscopy?
Small bowel obstructions
33
What is the average age of a Px who has a small bowel obstruction?
70s
34
What are the symptoms of a small bowel obstruction?
Colicky pain - typically in umbilical region
Nausea and Vomiting - Early sign in SBO
Bloating/distension
Absolute constipation - Late sign in SBO
35
What are the clinical signs of a Large and small bowel obstruction?
Abdominal tenderness and distension
Tinkling bowel sounds
Rectal exam - empty or blood suggesting strangulation
Tachycardia
Hypotension
36
Which tests are ordered in the diagnosis of Large/small bowel obstruction?
CT Scan - diagnostic for an obstruction
FBC - anaemia/infection
U&Es - Likely have renal dysfunction secondary to hypovolaemia
Venous blood gas/Lactate - may be increased
CRP/ESR - inflammatory
Potentially Gastrograffin contrast scan
37
What is the gold standard diagnostic test for a Large/small bowel obstruction?
CT Scan:
Diagnostic
Location and cause may also be indicated
38
What is the treatment for all patients with a Large/small bowel obstruction?
Manage pain - analgesia and anti emetics
Assess fluid balance - NG tube/ Urinary catheter
IV Fluids
Nutrition if > 5 days without intake.
39
What is the treatment for patients with a small bowel obstruction due to adhesions?
Signs of Ischaemia or Shock:
Resus and Operate
No-ischaemia:
Gastrografin challenge and determine whether there is a need to operate
40
What is the treatment for all patients with a small bowel obstruction due to a hernia?
Inguinal/Femoral/Umbilical - operate and repair
Incisional Hernia - Treat as adhesive SBO
41
What are the complications of a Small Bowel Obstruction?
Intestinal necrosis
Sepsis
Multi-organ failure particularly renal
Intestinal perforation
42
What are the 2 types of oesophageal cancer?
Adenocarcinoma
Squamous cell carcinoma
43
What most commonly predisposes Oesophageal adenocarcinoma?
Barret's metaplasia where glandular columnar epithelium replaces the squamous epithelium in the lower oesophagus
44
What is the location of an adenocarcinoma of the Oesophagus?
Lower third of the oesophagus near gastro-oesophageal junction
45
What is the location of a Squamous cell carcinoma of the oesophagus?
Usually upper or middle third of the oesophagus
46
What are the risk factors for adenocarcinoma of the Oesophagus?
Barrett's Oesophagus
GORD
Obesity
Smoking
Coeliac Disease
Scleroderma
47
What are the risk factors for SSC of the oesophagus?
Smoking
Alcohol
Achalasia
Plummer Vinson syndrome
Hot beverages
Nitrosamines
48
Who is more commonly affected by oesophageal cancer?
Males
80 years old
Western world
SSC is more common in Japan
49
What are the clinical signs of oesophageal cancer?
Lymphadenopathy
Vocal Cord Paralysis
Pallor - anaemia
Melaena - due to oesophageal bleeding
50
What are the symptoms of oesophageal cancer?
ALARMS:
Anaemia
Loss of Weight
Anorexia
Recent sudden Sx worsen
Melaena/Haematemesis
Swallowing - Progressive Dysphagia
Hoarse Voice - due to pressure on recurrent laryngeal nerve
51
What is the primary investigation for oesophageal cancer?
Upper GI Endoscopy (OGD) and Biopsy
Staging Ix:
CT Chest abdo pelvis (CAP)
Endoscopic ultrasound (EUS)
HER2 Testing
52
What is the first line staging investigation for oesophageal cancer?
CT chest, abdomen and pelvis (CAP)
53
What is the management of Oesophageal cancer for both Adenocarcinoma and SCC?
If operable:
Adenocarcinoma - Oesophagectomy
SCC - Radical chemoradiotherapy
Advanced/Metastatic:
Chemotherapy
Palliation - Stenting for Dysphagia
Trastuzumab for HER2 Positive
54
When does Oesophageal cancer tend to present and what is the prognosis?
Tends to present late
Has a prognosis of 15% 5yr survival
55
What are the main types of cancer is a gastric cancer?
Adenocarcinoma (90-95%)
SCC (5%)
56
What are the main types of Adenocarcinoma Gastric cancer?
Type 1 (Intestinal) - Usually exophytic or ulcerating
Type 2 (Diffuse) - Flat, causing linitus plastica
57
What are the modifiable risk factors for Gastric cancer?
H.pylori infection (significant)
smoking
alcohol
diet
Obesity
58
Where is gastric cancer most common?
Japan
59
What are the non-modifiable risk factors for gastric cancer?
Genetics - CDH-1 gene (mutated Cadherin)
Male
Increased age
Pernicious anaemia
Blood type A
Gastric Adenomatous polyps
60
What are the clinical signs of gastric cancer?
Fe Deficiency anaemia - Koilonychia
Palpable mass
Melaena
Leser-Trelat sign - sudden onset keratosis
61
What are the symptoms of gastric cancer?
Severe epigastric Abdominal pain
Dyspepsia
Anorexia and weight loss
Dysphagia
Nausea and vomiting
Signs of Metastasis - Liver dysfunction etc
62
What is the primary investigation of gastric cancer?
Upper GI Endoscopy and Biopsy
1st line staging - CT-CAP
63
What is the management of Gastric cancer?
Surgery only indicated if no evidence of metastatic disease
Surgery - remove tumour/stomach
Advanced disease:
Chemotherapy - 5-Fluorouracil/Cisplatin
Palliative gastrectomy
64
What are some complications of Gastric cancer?
Bleeding
Gastric outlet obstruction
Perforation
Metastasis
65
What are the features of Intestinal Gastric cancer?
Better Prognosis
Exophytic
Ulcerating lesions
Well formed and differentiated glandular structures
66
What are the features of Diffuse gastric cancer?
Has a much worse prognosis
Poorly cohesive
Infiltrates the gastric wall
Can affect any part of the stomach
67
What are the main areas where a Peptic Ulcer develops?
Gastric ulcer - stomach
Duodenal Ulcer
68
What investigations would be done if the patient had no red flags/was not bleeding with a suspected peptic ulcer?
Urea breath test
Stool antigen test
Looking for H.pylori infection as a possible cause
69
If testing for H.pylori infection what must be done?
The patient must be off PPI for 2+ weeks to prevent false negative results
70
What is the pathophysiology of a SBO (same for a LBO)?
Mechanical or functional obstruction of the small intestine preventing the normal passage of abdominal contents.
This leads to dilation of the proximal bowel and compression of mesenteric vessels.
Causes transudation of large volumes of electrolyte rich fluid into the bowel (third spacing).
Arterial supply is compressed and you get ischaemia
71
What are the main causes of a SBO?
Bowel adhesions (50%) - due to previous abdominal surgery
Incarcerated hernias (15%)
Crohn's Disease
Volvulus - rarely SBO but commonly LBO
Paralytic ileus
Malignancy
72
How do surgeries lead to bowel adhesions?
Formation of fibrous scar tissue between organs and tissue can constrict and adhere to the bowel preventing expansion
73
What is a Paralytic Ileus?
Functional Obstruction due to failure of peristalsis:
Often caused post abdominal surgery
May also be due to electrolyte imbalances (hypokalaemia)
74
What is the cause of the pain felt in SBO?
When there is a mechanical obstruction to the SBO and peristalsis occurs this can lead to pain.
75
What are the main causes of a large bowel obstruction?
Malignancies - colorectal cancer (90% of all causes)
Stricture - complication of diverticulitis and IBD
Volvulus - Sigmoid / Caecal
Hirschsprung's Disease
76
What is a Volvulus and what are the 2 main types?
occurs when a loop of intestine twists around itself and the mesentery that supplies it, causing a bowel obstruction.
Sigmoid is most common (80%) - associated with elderly Px
Caecal is less common associated with Pregnancy and can occur at any age.
77
What are the Symptoms of a Large bowel obstruction?
Colicky generalised abdominal pain
Bloating
Absolute constipation - Early sign in LBO
Nausea and Vomiting - Late sign in LBO
78
What is a good way to distinguish whether a Px has a small or large bowel obstruction based off their Symptoms?
SBOs present with nausea and vomiting first before constipation
LBOs present with constipation first before nausea and vomiting
79
What may be a differential diagnosis when a Px presents with symptoms of dysphagia?
Achalasia
This however is non progressive and so Px dont say at first it was difficult to swallow then fluids then food etc.
80
What are the main lymph nodes that Gastric cancer may spread to?
Virchow's Node - Supraclavicular
Sister Mary Joseph Node - Umbilical
81
What is the prevalence of bowel (colorectal) cancer?
4th most prevalent cancer in the UK.
Behind breast, prostate and lung
3rd most Prevalent world wide
82
How do bowel cancers arise?
sporadic cancers arising from:
Adenomatous Polyp to progress to adenocarcinoma
Defects in DNA repair genes
83
What are the risk factors for Bowel cancer?
50+
Increasing age
Smoking
Obesity
IBD
FHx - FAP, HNPCC
84
What is Bowel Cancer?
Usually an adenomatous cancer that typically affects the colon (colorectal) more than it affects the small bowel
85
What is Familial adenomatous Polyposis (FAP)?
Autosomal dominant
Malfunctioning tumour suppressor genes of APC (adenomatous polyposis coli)
Leads to many Polyps developing which can progress to cancer
86
What is Hereditary Nonpolyposis Colorectal Cancer (HNPCC)?
Lynch syndrome
Autosomal dominant
Mutations in DNA mismatch repair genes (MMR)
Increases the risk of multiple cancers particularly colorectal
87
What are the symptoms of Left sided bowel cancer?
General Cancer Sx
Change in bowel habit with blood and mucus in stools
Diarrhoea
Alternation constipation and diarrhoea
Thin/altered stool
88
What are the clinical signs of Bowel cancer?
LS CC - rectal mass, PR bleeding
RS CC - Iron Deficiency anaemia
89
What are the 2 broad areas of colorectal cancers?
Left sided (LS) Colorectal cancer
Right Sided (RS) colorectal cancer.
These may have different signs and Sx
90
What is the Diagnostic investigation used for Bowel cancer diagnosis?
FIT Test - screening test for micro blood particles in faeces
Gold standard - Colonoscopy and Biopsy
Digital Rectal exam
38% of colorectal cancers can be detected by DRE
1st Line staging - CT-CAP
91
What is the staging classification for bowel cancer?
TNM Dukes staging:
Tumour: TX - T4
Nodes: NX-N2
Metastasis: M0-M1
92
What is the FIT test?
Faecal immunochemical Test for bowel cancer screening:
Looks for Hb in stool.
Performed in anyone over 50 with unexplained Weight loss and no other symptoms.
Performed in over 60s with a change in bowel habit
93
What is the Treatment for Bowel cancer?
Surgical resection - curative if no mets
+ chemotherapy
94
What is a Pseudo-Obstruction of the bowel?
Where there is no blockage to the bowel however the intestine is unable to contract and push food, stool and air through the digestive tract
(Failure of Peristalsis)
95
What is Hirschsprung's Disease?
Congenital disorder where there is defective relaxation and peristalsis of the distal colon causing a bowel obstruction.
Neonates born with incomplete Innervation of the colon to rectum.
A ganglionic segments of the bowel cannot contract (peristalsis) leading to obstruction
96
What is Dyspepsia?
Functional Dyspepsia is a form of a Functional Gut disorder like IBS where there are Sx of Indigestion without any other clear cause.
Dyspepsia can also be a symptom of certain conditions such as PUD
97
What are the Sx of Dyspepsia?
Early satiation
Epigastric pain and Reflux (like GORD)
Heartburn
Bloating
Hoarse Cough
Extreme Fullness.
98
What is the cause of Dyspepsia?
Functional Dyspepsia - Unknown Cause.
Other causes may be PUD.
99
What is a Mallory-Weiss Tear (MWT)?
Longitudinal lacerations limited to the mucosa and submucosa
Found at the border of the gastro-oesophageal junction (GOJ)
100
What is the pathophysiology of a MWT?
Dilations and tears caused by a sudden rise in intra abdominal and transmural pressure across the GOJ secondary to vomiting and retching in the presence of pre existing gastric mucosal damage.
101
What are the risk factors for MWT?
Any condition that predisposes retching/vomiting:
Gastroenteritis, Bulimia etc.
Alcoholism
Chronic cough
Hiatus hernia
GORD
102
Who is typically affected by a MWT?
Male with acute Hx of retching after a night out.
40-60yrs
103
What are the symptoms of a MWT?
Preceding retching and vomiting
Haematemesis
Melaena - rare
Epigastric pain
104
What are the primary investigations for a MWT?
Upper GI endoscopy
FBC - anaemia
U&Es - raised urea
105
What is the management of a MWT?
Usually self limiting - manage contributing factors
If persistent bleeding:
Upper GI endoscopy - clipping/thermal coagulation
High dose IV PPI (pantoprazole) - give after endoscopy
106
What is the difference between a MWT and an oesophageal varices?
A MWT is caused by increased intraabdominal/transmural pressures that cause tears in preexisting mucosal damage.
An oesophageal varices is a consequence of portal HTN due to decompensated liver failure which causes dilation of the oesophageal blood vessels that then become prone to rupture.
Both can cause an upper GI bleed
107
If you have a patient with acute haematemesis what should you consider?
Hx of Liver disease + portal HTN = Oesophageal Varices
No Hx of liver disease but acute Hx of Retching = MWT
108
Describe h.pylori.
A gram negative bacilli with a flagellum that is present in 50% of the populations gastric mucosa
109
How does helicobacter pylori infection cause gastric damage?
Lives in gastric mucus
Secretes urease which splits urea in stomach into CO2 + ammonia
Ammonia + H+ 🡪 ammonium
Ammonium, proteases, phospholipases and vacuolating cytotoxin A damages gastric epithelium
Causes inflammatory response reducing mucosal defense 🡪 mucosal damage
Also causes increased acid secretion
Gastrin release (from G cells) 🡪 more acid secretion
Triggers release of histamine 🡪 more acid secretion
Increases parietal cells mass 🡪 more acid secretion
Decreases somatostatin (released from D cells) 🡪 more acid secretion
110
What conditions can arise as a result of H.pylori infection?
Peptic Ulcer Disease (PUD)
Gastritis
Gastric carcinomas
111
What is the diagnostic test to investigate H.pylori infection?
1st line: Urea breath test
Stool antigen test
112
What is the treatment of H.pylori infection?
Triple-therapy: For 7 days
Proton Pump Inhibitor - Omeprazole
Clarithromycin
Amoxicillin
113
What is Inflammatory bowel disease?
Umbrella term for 2 main diseases causing inflammation of the GIT Tract.
Ulcerative Colitis and Crohn's Disease.
114
What is Crohn's Disease?
Form of IBD
Granulomatous inflammation of any part of the gut
Characterised by Skip lesions arising anywhere between the mouth and anus.
Transmural inflammation with granuloma formation
115
What are the features of Crohn's Disease?
Crohn's (Crows NESTS):
N - No Blood or mucus in stool
E - Entire GI Tract - from mouth to anus can be affected
S - Skip Lesions on Endoscopy
T - Terminal Ileum is most affected and Transmural inflammation
S - Smoking is a risk factor - dont set the nest on fire
CHRISTMAS:
C - Cobblestones
H - High temperature
R - Reduced lumen
I - Intestinal fistulae
S - Skip lesions
T - Transmural
M - Malabsorption
A - Abdominal pain
S - Submucosal fibrosis
116
Where is the most commonly affected region of the GI tract in Crohn's Disease?
The Terminal ileum and colon.
117
What is the inflammation like in Crohn's Disease?
Transmural - full thickness
Occurs in skip lesions (points of inflammation and no inflammation) across GIT
Can lead to fistulas, Strictures and adhesions
118
Who is typically affected by Crohn's Disease?
Highest incidence and prevalence in Northern Europe, UK and North America
F>M
Presents mostly at 20-40
119
What are the risk factors for Crohn's Disease?
FHx - NOD2 mutation
Caucasian
Female
HLA-B27
Smoking
Chronic Stress
120
What are the signs of Crohn's Disease?
Abdominal tenderness
Fever
Malabsorption
Blood, fistulas, fissures on PR exam
Aphthous - mouth ulcers
Extra-intestinal Manifestations: (less common in Crohns')
Erythema nodosum
Anal fissures
Episcleritis
121
What are the symptoms of Crohn's Disease?
Diarrhoea
RLQ abdominal pain (ileum)
Fatigue, fever, Nausea, vomiting
Tenderness
122
What is Ulcerative Colitis?
Form of IBD
Inflammation of the rectum which extends proximally but never beyond the ileocecal valve.
Mucosal and Submucosal inflammation with crypt abscesses and neutrophil infiltration.
123
Where is the most commonly affected region in Ulcerative colitis?
Only affects the rectum (proctitis) and continuous colon.
Never past the ileocecal valve to the small bowel
124
What is the inflammation like in Ulcerative Colitis?
continuous inflammation of the Large bowel.
Mucosal and Submucosal layers are affected (not transmural)
Can lead to crypt abscesses and neutrophil infiltration.
125
What are the features of Ulcerative Colitis?
U-C = CLOSEUP:
Continuous inflammation From distal (rectum) to proximal (ileocaecal valve (never past it))
Limited to colon and rectum
Only superficial mucosa affected
Smoking is protective
Excrete blood and mucus
Use aminosalicylates
Primary Sclerosing Cholangitis
ULCERATIONS:
Ulcers
Large intestine
Carcinoma – risk of
Extra-intestinal manifestations – uveitis, erythema nodosum, sclerosing cholangitis
Remnants of older ulcers - pseudo polyps
Abscesses in crypts
Toxic megacolon – risk of
Inflamed, red, granular mucosa
Originates at rectum
Neutrophil invasion
Stool is bloody and has mucous
126
Who is typically affected by ulcerative Colitis?
Highest incidence in Northern Europe, UK and North America
Affects males and females equally
Presents mostly at 15-30
Non-Smokers
Bimodal age distribution from 15-25yrs to 55-75yrs
127
What are the risk factors for Ulcerative Colitis?
FHx
HLA-B27
Caucasian
Non-smoker - Smoking relieves UC
NSAIDs – associated with onset of IBD and flares of disease
Chronic stress and depression triggers flares
128
What are the clinical signs of Ulcerative Colitis?
Abdominal Tenderness
Fever
Fresh Blood on rectal exam
Extra-intestinal manifestations (more common in UC)
129
What are the symptoms of Ulcerative Colitis?
Diarrhoea
Blood and Mucus in stool
Urgency and Tenesmus (rectal defaecation pain)
Abdominal pain - particularly in the LLQ
Weight loss and malnutrition - more common in Crohn's
130
What are the Extra-intestinal manifestations of IBD?
Skin Rashes - Erythema nodosum, Pyoderma Gangrenosum
Arthritis and osteoporosis
Episcleritis (Crohn's > UC)
Uveitis (UC > Crohn's)
PSC and AIH - UC
131
What is the most common extra intestinal manifestation in IBD?
Arthritis
132
What are the diagnostic investigations for IBD?
Routine Bloods - anaemia, infection, LFTs, TFTs, Kidney function
CRP - inflammation and active diseaes
Faecal Calprotectin - 90% sensitive and specific to IBD
Endoscopy (OGD and colonoscopy) + biopsy is diagnostic
Imaging - CT/Abdo USS for complications - fistulas, fissures, strictures
133
What is the main raised inflammatory marker in IBD?
Faecal Calprotectin levels:
released by the intestines when inflamed can help distinguish between IBD and IBS.
134
What is the gold standard diagnostic test for IBD?
Endoscopy/Colonoscopy + biopsy
135
What is the First line treatment in inducing remission in Crohn's Disease?
Steroids - oral prednisolone or IV Hydrocortisone
If ineffective alone then add immunosuppressant:
Azathioprine
Mercaptopurine
Methotrexate
Infliximab
Adalimumab
136
What is the first line treatment for maintaining remission of Crohn's disease?
First line:
Azathioprine/Mercaptopurine
137
When is it possible to use surgery to treat Crohn's Disease?
When the disease only affects the distal ileum
Can also be used to treat strictures and fistulas secondary to Crohn's
Usually a Right Hemi-colectomy
138
What is the First line treatment in inducing remission in Ulcerative Colitis?
Mild to moderate disease:
First line - Aminosalicylate (Mesalazine)
Second line - Corticosteroids (prednisolone)
Severe Disease:
First line - IV Corticosteroids (hydrocortisone)
Second Line - IV Ciclosporin
139
What is the first line treatment for maintaining remission of Ulcerative Colitis?
Aminosalicylate - Mesalazine
Azathioprine
Mercaptopurine
140
What aminosalicylate is used to treat Ulcerative Colitis?
Mesalazine - oral or rectal
141
When is Surgery used in Ulcerative Colitis?
Typically UC only affects the colon and rectum
Surgery to remove these can remove the disease leaving the patient with a ileostomy (stoma)
142
What are some complications of Crohn's Disease?
Peri-anal Abscess
Anal Fissure
Anal Fistula
Strictures and obstruction
Perforation and Sepsis
Anaemia and Malabsorption
Osteoporosis
143
What are some complications of Ulcerative Colitis?
Toxic Megacolon
Perforation
Colonic Adenocarcinoma
Strictures and Obstruction
Extra-intestinal Manifestations
144
How is Toxic Megacolon identified?
AXR or CT
145
What can cause Crohn's Disease?
NOD-2 mutation
Bacterial immune mediated response - TNFalpha, IL-1, IL-6
146
What can Cause Ulcerative Colitis?
Unknown aetiology
NSAIDs - associated with IBD onset and flares
Potentially autoimmune as it is associated with HLA-B27 gene and pANCA
147
What is Irritable Bowel Syndrome?
Irritable bowel syndrome is a chronic, functional bowel disorder characterised by abdominal pain and altered bowel habits with no underlying pathology.
148
What part of the GI Tract is often affected in irritable bowel Syndrome?
The lower GI Tract.
149
What is the Prevalence of IBS and who does it typically affect?
Prevalence - Up to 20% of the population.
Affects more women than men
Common in younger adults.
150
What are some possible risk factors for IBS?
Female sex
FHx
GI infection/inflammation
Dietary factors
Psychosocial Factors - stress/anxiety/depression
Drugs
151
When should you consider a diagnosis of IBS?
In a Px who has had any of these symptoms for at least 3+ months:
Abdominal Pain
Bloating
Changing in bowel habits
With NO UNDERLYING CAUSE
152
What are the symptoms of IBS?
Abdominal Pain
Bloating
Change in bowel habit
Constipation
Diarrhoea
IMPROVED AFTER OPENING BOWELS
worse after eating.
153
What Investigations should be done to rule out other causes of Sx in IBS?
Diagnosis of exclusion:
Blood Tests - FBC, CRP, ESR all normal
Faecal Calprotectin - negative (excludes IBD)
Anti -TTG Abs - Excludes Coeliacs
Cancer is excluded
154
What is required for the Diagnosis of IBS?
Sx suggesting IBS:
Abdominal pain and/or discomfort
Relieved on opening bowels or
Associated with a change in bowel habit
AND 2 OF:
Abnormal stool passage
bloating
worse Sx after eating
Mucus with stools
155
What is the Initial Conservative management of IBS?
Positive Diagnosis - Tell them that although they have no pathology present they do have IBS (a condition)
Advice and reassurance - no serious underlying pathology present.
Adequate fluid intake and Regular physical activity.
General healthy diet advice - eg. more fibre if IBS-C
Probiotic supplements - 4 weeks
Second Line = Medications
156
What are the first and second line medications used in IBS? (second line management)
Sx Management:
First Line:
Loperamide - if diarrhoea is key symptom
Linaclotide - if constipation is key symptom
Second Line:
Tricyclic antidepressants - amitriptyline (5-10mg)
Third Line:
SSRI - Citalopram
CBT - help Px psychologically manage the condition.
157
What are some complications of IBS?
Mood disorders - increased risk of depression and anxiety
Poor Quality of Life
158
What are the different types of IBS?
IBS-C = mostly constipation
IBS-D = mostly diarrhoea
IBS-M = mostly mixed (mix of C/D)
159
What is Coeliacs Disease?
An autoimmune conditions where exposure to gluten peptides causes an autoimmune reaction that causes inflammation in the small intestine.
This results in malabsorption
160
What are the Genes and the auto antibodies associated with coeliacs disease?
HLA DQ2, HLA DQ8
Anti-tissue transglutaminase (anti-TTG)
Anti-endomysial (Anti-EMA)
161
What is the pathophysiology of Coeliacs Disease?
Gluten Peptides (Gliadin) binds to secretory IgA in mucosal membrane
Gliadin-IgA is transcytosed to the lamina propria where the enzyme Tissue Transglutaminase (TTG) deaminates Gliadin which increases its Immunogenicity.
Deaminated gliadin is taken up by macrophages and expressed on MHC II complex via HLA DQ2 and DQ8
APCs present Gliadin antigen to T helper cells so they release inflammatory cytokines and stimulate B cells
This causes villous atrophy, crypt hyperplasia and intraepithelial lymphocyte infiltration
🡪 reduced SA to absorb nutrients 🡪 B12, folate and iron cannot be absorbed 🡪 anaemia
162
What is the prevalence of Coeliacs disease in the UK?
1%
163
What are the risk factors for Coeliacs disease?
FHx
HLA DQ2/HLA DQ8
PHx of autoimmune disease
IgA deficiency
Downs
Turners
164
How does Coeliacs disease often present?
Often ASx
Can present with:
Diarrhoea
Steatorrhea – fatty stools due to reduced fat absorption in intestines
Abdominal pain
Abdominal distension
Weight loss
Failure to thrive
Nutritional deficiency
Anaemia - secondary to Fe, Vit B12 or folate def.
165
What skin condition is associated with coeliacs disease?
Dermatitis Herpetiformis
An itchy vesicular skin eruption caused by deposition of IgA
Treated with Dapsone
166
What should patients with suspected coeliacs disease do prior to investigation?
Gluten challenge:
Should be ON a gluten containing diet for 6 weeks prior to investigations
167
What diagnostic investigations are carried out for coeliacs disease?
Carried out Post gluten challenge:
Serology:
Total IgA - exclude IgA deficiency
Raised anti-TTG Abs
Raised anti-EMA Abs
Anti-Gliadin
Endoscopy and intestinal biopsy:
Crypt hypertrophy
Villous Atrophy
Increased intraepithelial lymphocytes
FBC:
Low Hb
Low B12
Low Folate
Low Ferritin
168
What is the gold standard diagnostic test for Coeliacs disease?
Small bowel biopsy and Histology
169
What other investigations may you consider for coeliacs disease?
FBC
Nutritional Status
HLA Testing
170
What autoimmune conditions is Coeliacs disease associated with?
T1DM
Thyroid disease
Autoimmune Hepatitis
PBC
PSC
171
What are some complications of untreated coeliacs disease?
Vitamin Deficiency
Malabsorption
Anaemia
Osteoporosis
Ulcerative jejunitis
Non-hodgkin lymphoma
Enteropathy associated T cell lymphoma of the intestine
172
What is the management of coeliacs disease?
A lifelong gluten free diet - can be curative but will relapse upon consuming gluten
Dietary supplements - Ca Vit D, Fe if the Px diet is insufficient
Dexa-scan for osteoporotic risk.
173
What factors can increase acid production?
Stress
Alcohol
Caffeine
Smoking
Spicy Foods
174
What is the Rockall Score?
Used for Px who have had an endoscopy. it is a % risk for rebleeding. considers:
Age
Features of Shock - Tachycardia/Hypotension
Co-morbidities
Causes of bleeding
Endoscopic Stigmata
175
What is the general management for an upper GI bleed?
ABATED:
ABCDE
Bloods
Access - 2 bore cannula
Transfuse
Endoscopy - urgent within 24 hrs
Drugs - Stop anticoagulants and NSAIDs
176
What is acute gastritis?
Inflammation of the stomach that tends to present with nausea and vomiting
177
What is Enteritis?
Inflammation of the intestines that tends to present with diarrhoea
178
What is Gastroenteritis?
Inflammation of the GI Tract from the stomach all the way through the intestines.
This tends to present with nausea, vomiting and diarrhoea
179
What is the most common cause of gastroenteritis?
Viral infection
180
What are the common viral causes of gastroenteritis?
Rotavirus
Norovirus
Adenovirus
181
Who is typically affected by gastroenteritis?
It can affect anyone and people generally recover well.
It can be serious in Px who are immunocompromised, very young or very old.
182
What must be done if a patient has gastroenteritis in a healthcare environment?
Isolate the patient to prevent spread to other patients
183
What are the clinical features of viral gastroenteritis?
Diarrhoea
Nausea
Vomiting
184
How long until symptoms are resolved for the main viral causes of gastroenteritis?
Rotavirus - 3-8 days
Norovirus - 1-3 days
Adenovirus - 1-2 weeks
185
What are the risk factors for gastroenteritis?
Ingestion of undercooked food
Reheating meals
poor sanitary conditions
Travelling to endemic areas - SE Asia, Sub Saharan Africa
Immunosuppression
186
What are the general symptoms of gastroenteritis?
Vomiting
Diarrhoea
Abdominal cramps
Fever
Lethargy
187
What are the general clinical signs of a Px with gastroenteritis?
Dehydration
Electrolyte imbalance
Hypotension
Tachycardia
Reduced Urine Output
188
What are the potential causes of gastritis?
Autoimmune
Increased acid - overcome mucosal buffer
H. pylori - stimulates more acid production
NSAIDs - inhibit COX and prostaglandin synthesis
Mucosal ischaemia - loss of barrier function
Campylobacter infection
Viral infection
189
What is the gold standard diagnostic test for gastritis?
Endoscopy + biopsy
190
What are the key bacterial causes of Gastroenteritis?
E.coli - particularly E.coli 0157 (HTEC/STEC)
Campylobacter
Shigella
Salmonella
Bacillus Cereus
Yersinia
191
What investigations should be done for a patient with gastroenteritis?
If mild/moderate - no Ix required and Px are discouraged from attending hospital to prevent spread
Ix to consider:
FBC
U&E
Stool culture - for bacteria
Stool Microscopy
192
What is the management for gastroenteritis?
Viral - usually self limiting - 7 days
Mild-moderate:
Bland diet, oral rehydration
Severe:
IV fluids
193
What should be avoided in gastroenteritis caused by E.coli 0157?
Antibiotics as these can lead to HUS.
194
What are some complications of gastroenteritis?
Dehydration
Malnutrition
Post infectious IBS
195
What is GORD?
Gastro-oesophageal Reflux Disease
Where acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus.
196
What is the lining of the lower oesophagus and the lining of the stomach?
Oesophagus - Squamous epithelial lining
Stomach - Columnar Epithelial Lining
197
What can GORD be caused by?
Increased sphincter relaxation
Raised Intragastric pressure - Pregnancy/Obesity
Reduced Sphincter tone
Hiatus Hernia
Anatomical abnormalities of the GOJ
Oesophageal Dysmotility
198
What are the risk factors of GORD?
Increasing Age
FHx
Obesity - raised Intragastric Pressure
Pregnancy - raised intragastric pressure
Hiatus Hernia - disrupts GOJ
Smoking and alcohol
Drugs - nitrates, caffeine, CCBs
Fatty foods
199
What are the Symptoms of GORD?
Heartburn
Acidic taste at back of mouth
Dysphagia
nausea
Hoarseness and chronic cough
Dyspepsia
200
What are the diagnostic investigations for GORD?
H.pylori test - stool antigen/Urea breath test
Endoscopy - often normal
24 hr pH study
Oesophageal manometry - functionality test of LOS
201
What is the conservative management of GORD?
Lifestyle advice:
weight loss
avoidance of triggering foods
smaller lighter meals
stop smoking
avoid heavy meals before bed
Sleep with head tilted upwards
202
What medical management could be used for GORD?
Acid neutralising medication - Gaviscon, Rennie
PPI - omeprazole, Lansoprazole
H2 receptor antagonist - ranitidine, cimetidine
Surgery - Laparoscopic fundoplication
203
What are some complications of GORD?
Barrett's Oesophagus
Oesophageal ulceration/stricture.
204
What bacteria leads to an increased risk of GORD/ barrett's Oesophagus?
Helicobacter Pylori:
Gram negative aerobic bacteria
205
What is Barrett's Oesophagus?
The constant reflux of acid into the lower oesophagus causes a change in the epithelium called metaplasia.
This is a change from the stratified squamous epithelium to the columnar epithelium for the stomach.
Barrett's Oesophagus is considered premalignant.
206
What does barrett's Oesophagus predispose a patient to?
Considered premalignant.
Predisposes the Px to adenocarcinoma.
207
What is the treatment of Barrett's Oesophagus?
Using Proton Pump Inhibitors
Omeprazole
Ablation therapy in Px with Dysplasia may be used to destroy the epithelium for it to be replaced with normal tissue.
208
What is Achalasia?
An oesophageal motility disorder characterised by an inability for the LOS (lower oesophageal sphincter) to relax in response to swallowing.
209
What is the pathophysiology of Achalasia?
Unknown but thought to be due to a loss of inhibitory neurones secreting VIP and NO within the Auerbach plexus.
This leads to the constant contraction of the LOS and dilation of the oesophagus above the LOS.
210
What are the risk factors for achalasia?
Genetics
Infection - Chagas disease (Trypanosoma Cruzi)
Autoimmune disease
211
What are the symptoms of Achalasia?
NON PROGRESSIVE DYSPHAGIA -
BOTH solids and liquids (dysphagia)
Regurgitation
Heartburn
Coughing when lying down
Weight loss - due to reduced oral intake.
212
What are the primary investigations of Achalasia?
Upper GI Endoscopy (OGD) - low sensitivity for achalasia but excludes malignancy.
Oesophageal Manometry - GS for establishing the diagnosis
Barium Swallow - Bird beak - diagnostic except in early disease.
213
\What is the gold standard investigation for establishing a diagnosis of achalasia?
Oesophageal manometry:
Incomplete relaxation of the LOS +
Oesophageal aperistalsis
214
What is the management of Achalasia?
Medical:
CCBs (nifedipine) + nitrates to reduce the pressure and relax LOS.
(often ineffective)
Surgical - Heller's Cardiomyotomy is first line for those fit for surgery.
Balloon Stent
215
What are some complications of Achalasia?
GORD - as a complication of cardiomyotomy.
Malignancy
Aspiration pneumonia due to regurgitation
perforation.
216
What are the risk factors for barrett's Oesophagus?
GORD
Middle age
male - 7x more likely
Caucasian
smoking
obesity
217
What are the Ix for Barrett's Oesophagus?
upper GI Endoscopy and Biopsy
Reveals metaplasia
218
What are the 2 types of bowel Ischaemia?
Mesenteric Ischaemia - Small bowel
Ischaemic Colitis - Large bowel
219
What is Bowel Ischaemia?
Diminished blood flow to the bowel where there is not enough oxygen or nutrients supplied to the bowel that leads to inflammation
220
What causes Ischaemic colitis?
Atherosclerosis
Thrombosis
Emboli
Affecting the IMA (sometimes SMA)
Decreased CO and arrhythmias
Vasculitis
221
What are the most common sites affected in ischaemic colitis?
Watershed areas:
Splenic Flexure (most common)
Sigmoid Colon + Cecum
222
What are the causes of Mesenteric Ischaemia?
Superior mesenteric artery thrombosis – most common
Superior mesenteric artery embolism (e.g. due to AF)
Mesenteric vein thrombosis – common in younger patients with
hypercoagulable states
Non-occlusive diseases
223
What are the two types of Mesenteric Ischaemia?
Acute mesenteric Ischaemia (AMI) - acute attack, abdominal MI
Chronic Mesenteric Ischaemia (CMI) - long lasting over months, Abdominal Angina
224
What are the risk factors for bowel ischaemia?
Increasing age
Atrial Fibrillation
CVD RFs
Endocarditis
Malignancy
Cocaine use
Vasculitis
225
What are the symptoms of Ischaemic colitis?
LLQ pain
Bright bloody stool
+/- signs of hypovolaemic shock
226
What are the symptoms of mesenteric Ischaemia?
Triad of:
Central/RIF acute severe abdominal pain (disproportionate pain to clinical findings)
No abdominal signs on exam
(guarding/rebound tenderness)
Rapid Hypovolaemic Shock – pale skin, weak rapid pulse, reduce urine output, confusion
227
What is the diagnostic investigation of Ischaemic Colitis?
Colonoscopy + biopsy is GS
Only after Px is fully recovered.
CT/MRI Angiography
Rule out other causes (h.pylori)
228
What is the diagnostic investigation of mesenteric Ischaemia?
CT angiogram
+ FBC, ABG to look for persistent metabolic acidosis
229
What is the management of Ischaemic Colitis?
Conservative:
Symptomatic Tx
IV fluids,
Prophylactic Abx
Surgery if infected colon - bleeding, peritonitis etc.
230
What is the management of Mesenteric Ischaemia?
Emergency:
Fluid Resus
Abx
IV Heparin - lower thrombo-emboli and reduce clotting
Surgery - remove infarcted bowel
231
What is appendicitis?
Acute inflammation and bacterial infection of the appendix.
232
What is the pathogenesis of appendicitis?
Luminal obstruction of the appendix leads to the trapping of pathogens and bacteria within the appendix causing infection and inflammation.
The inflammation may proceeds to gangrene and rupture via perforation.
This will release faecal contents and infective material into the peritoneum causing peritonitis
233
What are complications of a ruptured appendix?
Peritonitis
Sepsis
Death
234
What is the appendix and where is it located?
a small thin tube arising from the caecum .
Located in the Right Ileac Fossa (RIF) at the point where the 3 teniae coli meet.
235
What are the risk factors for appendicitis?
Typically affects young age - 10-20yrs
Male
Frequent Abx use
Smoking
236
What is the key clinical sign of appendicitis?
periumbilical pain which migrates to the RIF over the first 24hrs where it becomes localised.
Often tenderness at Mcburney's Point on palpation.
237
What is McBurney's Point?
2/3 distance from umbilicus to the ASIS
238
What are some other symptoms of appendicitis?
classical abdominal pain.
Low grade fever
Reduced appetite and anorexia
Nausea and Vomiting
Diarrhoea - rare
239
What are the clinical signs associated with appendicitis?
RIF tenderness - rebound or percussion tenderness.
Rovsing's Sign - pain in RIF when pressing on the LIF
Guarding on abdominal palpation.
Obturator and Psoas signs
240
What are the signs of appendix rupture?
Tachycardia, hypotension and generalised peritonism
Rebound tenderness on RIF
Percussion tenderness
241
What is Rebound Tenderness?
increased pain when suddenly releasing deep palpations
242
What can cause appendicitis?
Fae Colith - hard solidified faeces causing a obstruction to appendix
Lymphoid Hyperplasia - in peyer's Patches
other blockages
243
What are the primary investigations for appendicitis?
Mostly a clinical diagnosis
CT abdo + pelvis = GS for diagnosis
Raised inflammatory markers on FBC (Increase WCC), CRP/ESR
Exclude ectopic pregnancy by serum hCG
244
What are the key differential diagnoses of appendicitis?
Ectopic pregnancy
Ovarian Cysts
Merkel's Diverticulum
Diverticulitis
Mesenteric Adenitis
245
What is the management of appendicitis?
Abx and then Appendectomy (laparoscopic)
Must drain abscesses - these are resistant to Abx
246
What must be ruled out in an appendicitis diagnosis? How is this done?
Ectopic pregnancy in females of child bearing age.
Perform pregnancy test
Bloods have Serum hCG test.
247
What is Diverticular Disease?
A Symptomatic outpouching of the intestinal Mucosa (diverticula) most commonly affecting the sigmoid colon in the absence of inflammation/infection
This is without inflammation and infection
248
What are some different definitions within diverticular disease?
Diverticulum
Diverticulosis
Diverticular disease
Diverticulitis
249
What is the Diverticulum?
An outpouching/pocket in the intestinal wall often located at perforating artery sites.
250
What is Diverticulosis?
The presence of an outpouching in an Asymptomatic patient.
(95% of diverticula are ASx)
When this is Symptomatic this is diverticular disease
251
What is Diverticulitis?
Inflammation of an outpouching due to infection typically causing lower abdominal pain.
252
What is the pathophysiology of diverticular disease?
Wall of large intestine has a layer of circular muscle.
The points where arteries enter are areas of weakness.
Increased pressure over time can cause the mucosa to herniate through the muscle layer and pouch causing a diverticulum.
253
Where do you not get diverticula forming?
The rectum as it is surrounded by an outer layer of longitudinal muscle preventing the herniation of the bowel mucosa
254
What are some risk factors for diverticular disease?
Increasing age (>50yrs)
Low Dietary fibre
Obesity
Sedentary lifestyle
Smoking
NSAIDs
Connective Tissue disorders - M, ED.
255
What are the symptoms of diverticular disease?
LLQ pain
Fresh Rectal bleeding
Constipation (change in bowel Habit)
nausea and vomiting.
+ urinary symptoms,
256
What are some additional signs/symptoms of acute diverticulitis?
Pyrexia
Raised inflammatory markers - CRP, ESR WCC
May have diarrhoea
257
What are the primary investigations for diverticular disease?
CT Abdo + pelvis with contrast - GS
FBC - Inc WCC
U&Es
CRP/ESR - Elevated
Venous blood gas
Blood cultures
258
What is the gold standard Ix for diverticular disease?
CT Abdo and Pelvis with contrast
259
What is the management of Diverticulosis?
Conservative
Watch and Wait
260
What is the management of Diverticular disease?
Bulk forming laxatives (ispaghula Husk)
Surgery is possible
261
What is the management of Diverticulitis?
Abx - Co-Amoxiclav
Paracetamol (analgesia)
IV Fluid
Liquid Food
Surgery if bleeding is not controlled
262
What are some possible complications of Diverticulitis?
Perforation
Peritonitis
Peridiverticular abscess
Large haemorrhage requiring blood transfusions
Fistula (e.g., between the colon and the bladder or vagina)
Ileus / obstruction
263
What is Meckel's Diverticulum?
Paediatric disorder
Failure of obliteration of vitelline duct
Rule of 2s:
2 yrs old
2 inches long
2 ft from ileocaecal valve
Dx is Technitium Scan
264
What is Diarrhoea?
A presenting Sx with many DDx
Often 3+ watery stools daily
but could be a increase in the normal bowel passage for an individual Px
265
What level of the Bristol Stool chart symbolises Diarrhoea?
5-7
266
What are the Different types of Diarrhoea?
Watery
Secretory
Osmotic
Functional
Steatorrhea
Inflammatory
Dysentery
267
What is Dysentery?
Severe bloody diarrhoea
268
What are the different time frames for diarrhoea?
Acute - <14 days
Subacute - 14-28 days
Chronic >28 days
269
What are the 2 overarching causes of diarrhoea?
Infective causes
Non-infective causes
270
What are some non-infective causes of diarrhoea?
Neoplasms - colorectal cancer
Inflammatory - IBD
Irritable bowel - IBS
Coeliacs
Hormonal - Hyperthyroidism
Radiation
Chemical
271
What kind of diarrhoea can infective causes cause?
Non-bloody
Bloody (dysentery)
272
What is the chain of infection?
Agent
Mode of transmission
Portal of entry
Host
Person to person spread
Reservoir
Portal of exit
273
What are some diarrhoeal diseases?
Dysentery
Typhoid
Hepatitis
Cholera
274
What are the different groups of infective causes of diarrhoea?
Viral - most common
Bacterial
Worms
Abx - leading to C.diff
Parasites
275
What are the main viral causes of diarrhoea?
Rotavirus - kids
Norovirus - adults
276
What are the main bacterial causes of Diarrhoea?
Campylobacter - most common
E.coli
Salmonella
Shigella
Cholera
Clostridium Difficile
277
What are some parasitic causes of Diarrhoea?
Giardiasis
Entamoeba Histolytica
278
What kind of diarrhoea is caused by E.coli (ETEC) What is the incubation period?
0-3 days
Watery stools
Abdominal cramps
This is often travellers Diarrhoea
279
What type of diarrhoea is caused by Bacillus Cereus and what is the incubation period?
Abrupt onset vomiting and diarrhoea often after reheating/undercooked rice.
<6hrs
280
What type of diarrhoea is caused by S.aureus? What is the incubation period?
Severe vomiting and diarrhoea.
2-4 hrs
281
What type of diarrhoea is caused by Shigella? How is it acquired and what is the incubation period?
Bloody diarrhoea
abdominal pain and vomiting
From contaminated food/water
0-3 days incubation
282
What type of diarrhoea is caused by Campylobacter? how is it acquired and what is the incubation period?
Flu like prodrome
Bloody diarrhoea
Abdominal pain and fever
Typically from undercooked poultry
2-4 days
283
What type of diarrhoea is caused by Cholera, How is it acquired and what is the incubation period?
Profuse "Rice water stool" watery diarrhoea
Severe dehydration due to 20+L lost
0-5 days
284
What type of diarrhoea is caused by Salmonella, how is it acquired and what is the incubation period?
Bloody diarrhoea
Vomiting, abdominal cramps and fever
Typically from undercooked meats, raw eggs.
0-3 days.
285
What bacterial infections will lead to low volume bloody diarrhoea?
Shigella / E.coli 0157 (EHEC)
Salmonella
Campylobacter
286
What is the incubation period of norovirus?
12-48 hrs
Symptoms resolve in 1-3 days
287
What is the incubation period of Rotavirus?
2-3 days
Symptoms resolve in 3-8 days
288
What are the treatments for diarrhoea?
Viral - often self limiting
Bacterial - depends on the type of infection
Non-infective - Tx underlying cause
289
What is the most serious complication of diarrhoea, how is it counteracted?
Dehydration and electrolyte loss
Give fluids + diuralite
290
What cause of diarrhoea should you think of if the Px presents with diarrhoeal symptoms if they are under the age of 3?
Rotavirus
291
What cause of diarrhoea should you think of if the Px presents with A Hx of broad spectrum Abx?
Clostridium Difficile
292
What cause of diarrhoea should you think of if the Px presents with Ricewater stools?
Cholera
293
What cause of diarrhoea should you think of if the Px presents with Guillain Barre?
Campylobacter
294
What is the general management for diarrhoea?
Often self limiting.
Abx may cause HUS in Shigella/E.coli 0157 cause.
295
What Abx may predispose a patient to C.diff infection?
4 Cs:
Clindamycin,
Co-amoxiclav
Cephalosporins
Ciprofloxacin
296
When may you use Abx in shigella infection? what would you prescribe?
In severe infection/diarrhoea
Prescribe Azithromycin or Ciprofloxacin
297
What is Clostridium Difficile?
Gram +tve spore forming bacteria
298
What causes C.diff?
Induced by Abx (Ciprofloxacin, Co-amoxiclav, Cephalosporin, Clindamycin) which kill normal gut flora and allow C.diff to colonise.
299
What is the Treatment for C.diff infection?
Stop C's Abx
Vancomycin is now first line against C.diff
300
What strains of E.coli cause Watery diarrhoea?
ETEC (Travellers)
EPEC
EAEC
301
What Strain of E.coli Causes bloody diarrhoea?
EHEC (Enterohaemorrhagic E.Coli)
Also known as E.coli 0157
302
What can happen if you treat EHEC with Abx?
Cause Haemoloytic Uremic Syndrome (HUS)
However can be treated with Amoxicillin or Trimethoprim/Nitrofurantoin.
303
What condition does C.difficile Cause?
Pseudomembranous Colitis
304
What is Pseudomembranous Colitis?
Inflammation of the colon caused by C.diff infection leading to watery diarrhoea, nausea fever
305
What is Meckel's Diverticulum?
Most common congenital abnormality of the GI Tract when there is incomplete obliteration of the vitelline duct.
Affects 2-3% of the population
Usually a diverticulum in the ILEUM
306
What are the Symptoms of Meckel's Diverticulum?
Often ASx
In 50% of cases the distal ileum contains gastric mucosa that secretes HCL which can lead to peptic ulcers causing bleeding and GI pain.
307
What is the treatment of Meckel's Diverticulum?
Surgical Removal of the Diverticula
(often laparoscopically)
308
What are the different Perianal disorders?
Haemorrhoids
Fistulae
Fissures
Perianal Abscesses
Pilonidal Sinus/Abscess
309
What are Haemorrhoids?
Swollen veins surrounding the anus disrupting the connective tissue cushions.
310
How do Haemorrhoids develop?
Multifactorial:
Conditions that raise intraabdominal pressure (eg. constipation, COPD,)
+
Straining leads to swelling of the haemorrhoid tissue causing a swell/bleed.
311
What is the most common cause of Haemorrhoids?
Constipation with increased straining.
Anal Sex
312
What are the risk factors for Haemorrohoids?
Constipation +/- straining
Heave lifting
Increasing age
Anal Sex
Raised Intra-abdominal pressure
313
What are the types of haemorrhoids?
Internal
External
314
What are internal Haemorrhoids?
Originate ABOVE the dentate line.
Less painful due to a reduced sensory supply.
May feel like incomplete emptying
315
What are External Haemorrhoids?
Originate BELOW the Dentate Line
Very painful - Px may not be able to sit down.
316
What is the Dentate line?
Divides the anal canal into an upper 2/3rds supplied by the inferior mesenteric plexus
Lower 1/3rd supplied by the pudendal nerve
317
What are the symptoms of Haemorrhoids?
Bright red rectal bleeding
May have mucusy /bloody stool
Pruritis ani (itchy bum)
Bulging pain
318
What are the diagnostic investigations for Haemorrhoids?
PR exam - external piles are palpable (may be visible)
Proctoscopy - for internal Haemorrhoids
319
What is the first line treatment for haemorrhoids?
Conservative management:
Increased dietary fibre and fluid intake
Analgesia - paracetamol
Topical Tx - anusol
320
What are the second line treatments for Haemorrhoids?
Rubber band Ligation
321
What is a Perianal Abscess?
Walled off collection of stool + bacteria around the anus.
322
What is the most common cause of a perianal abscess?
Anal sex causing anal gland infection
323
What are the symptoms of a perianal abscess?
Puss in stool
Constant pain and tenderness around anus
324
What is the treatment of a perianal abscess?
Surgical drainage and removal
Abx resistant due to the walling off.
325
What is an anal fistula?
Abnormal connection "Tracks" between the epithelialized surface of the anal canal and the skin.
326
What are the causes of an anal fistula?
often progress from perianal abscesses
abscess discharges (toxic substances) which aids the production of a fistula as the abscess grows.
327
What are the symptoms of a anal fistula?
Bloody mucusy discharge
often visible and very painful
Pruritus ani
328
What is the treatment for an anal fistula?
Surgical - Fistulotomy
Drain Abscess + Abx.
329
What is an Anal Fissure?
Tear in the anal skin lining below the dentate line
These are very painful due to the strong sensory supply.
330
What is the most common cause of anal fissures?
Hard faeces
331
What is the symptoms of an anal fissure?
Extreme defaecation pain
Pruritus ani
Anal bleeding
332
What are the treatments for anal fissures?
Increased dietary fibre and fluids - soften stool
Topical creams - lidocaine ointment, GTN ointment,
Surgery if medication fails
333
What are Pilonidal Sinuses?
Hair follicles that get stuck in the natal cleft (bum crack) resulting in inflammation, irritation and can become infected
334
Who is more commonly affected by Pilonidal Sinus?
Males + hairy people
20-30yrs
335
What are the symptoms of Pilonidal Sinus?
Swollen pus filled smelly abscess on bum crack
Visible on exam
Painful swelling over days
336
What is the treatment of Pilonidal Abscesses?
Surgical removal of the sinus tract
Hygiene Advice
337
What viral infection can cause colitis?
CMV colitis
Characterised by Owl Eye Inclusion bodies
338
What is CMV infection a sign of?
Immunosuppressed Px
An AIDS defining illness
339
What is Zenker's DIverticulum?
"Pharyngeal Pouch)
When the cricopharyngeal muscle overtightens causing the throat above it to outpouch.
Food can enter this pouch and accumulates leading to smelly breath and regurgitations
340
How do NSAIDs lead to gastritis?
NSAIDs inhibit COX which prevents prostaglandin synthesis.
This means that prostaglandins cannot stimulate mucin production and therefore there is reduced mucosal defence.
This allows the stomach acid to then attack the gastric wall leading to ulcer formation and gastritis
341
How does Lactose intolerance lead to gas.
cant break down lactose.
Once in the colon, the bacteria can ferment the unbroken down lactose leading to gas production.
342
How is the biopsy assessed for Coeliacs?
Marsh Classification:
0 normal
1 raised intra epithelial lymphocytes (IEL)
2 raised ILE + crypt hyperplasia
3a partial villous atrophy (PVA)
3b subtotal villous atrophy (SVA)
3c total villous atrophy (TVA)
343
What foods can contain gluten peptides?
Wheat
Barley
Rye
344
Define Malabsorption?
The failures to fully absorb nutrients in the small intestine either because of the destruction to the epithelium or due to a problem in the lumen meaning food cannot be digested
345
What disorders of the intestine can lead to malabsorption?
Coeliac disease
Tropical Sprue
Crohn’s
Parasitic infection
346
What are the symptoms of malabsorption?
Weight loss
Steatorrhea
Diarrhoea
347
What are the signs of malabsorption?
Anaemia – decreased iron, B12, folate
Bleeding disorders – decreased Vitamin K
Oedema – decreased protein
Metabolic bone disease – decreased vitamin D
Neurological features
348
What are the investigations for malabsorption?
FBC
Increased/decreased MCV
Decreased calcium/iron/B12 and folate
Increased INR
Stool sample microscopy
Coeliac tests
349
What are some pathological reasons for malabsorption?
lack of enzymes - pancreatic insufficiency/blockage. bile acid obstruction.
defective epithelial transport
insufficient absorptive area - gluten sensitive enteropathy (coeliacs)/ Inflammation (Crohn's)
Defective intraluminal digestion - lack of digestive enzymes (pancreatic, CF, bile secretion)
bowel resection or bypass.
Lymphatic obstruction
350
What are the Micro and Macro features of Crohn's Disease?
Macroscopically
Skip lesions
Cobblestone appearance due to ulcers and fissures in mucosa
Thickened and narrow
Microscopically
Transmural – affects all layers of bowels
Non-caseating granulomas (aggregations of epithelioid histiocytes)
Goblet cells
351
What are the Macro and Micro features of Ulcerative Colitis?
Macroscopically
Continuous inflammation (no skip lesions)
Ulcers
Pseudo-polyps
Microscopically
Mucosal inflammation
No granulomata
Depleted goblet cells
Increased crypt abscesses
Paneth cells are involved in innate immunity and suggest an inflammatory condition when found in the descending colon
352
What are the differential diagnoses to exclude for IBD?
Alternative causes of diarrhoea should be excluded
Salmonella spp.
Giardia intestinalis
Rotavirus
353
Give examples of functional gut disorders?
IBS (bowel)
Functional Dyspepsia (stomach)
354
hat are functional gut disorders?
Chronic GI symptoms in the absence of organic disease to explain the symptoms.
355
What is the prevalence of Functional Gut disorders?
One of the most common GI conditions that doctors encounter (1 in 3)
More common in women - due to hormones
More common in young people
356
What are some differential diagnoses for IBS?
IBD
Colorectal cancer
Ovarian cancer
357
What are the alarm features of GI conditions?
Age >45
Hx of Symptoms
Unintentional Weightloss
Nocturnal Sx
FHx of GI cancer or IBD
GI bleeding
Palpable mass or lymphadenopathy
Evidence of Fe anaemia
Evidence of Inflammation on blood/stool sample.
358
What is the Dukes staging of Bowel Cancer?
Duke stage:
A – 95% 5 year survival, limited to muscularis mucosae (mucosa)
B - 75% 5 year survival, traverses bowel lining and into submucosa (not lymph)
C - 35% 5 year survival, involvement of regional lymph nodes
D - 10% 5 year survival - mets
359
How can The causes of Upper GI bleeds be broken classified?
Oesophagus
Stomach
Duodenum
360
What are the Oesophageal causes of Upper GI Bleeds?
Oesophagitis
Varices
Malignancy
Gastro-oesophageal reflux disease (GORD)
Mallory-Weiss tear
361
What are the stomach causes of Upper GI Bleeds?
Peptic ulcer disease
Mallory-Weiss tear
Gastric varices
Gastritis
Malignancy
362
What are the duodenal causes of Upper GI Bleeds?
Peptic ulcer disease
Diverticulum
Aortoduodenal fistula
Duodenitis
363
Why are Oesophageal Varices prone to rupture?
As these vessels are thin and not meant to transport higher pressure blood, they can rupture
Rupture 🡪 haematemesis
Rupture 🡪 blood digested 🡪 melaena
364
What is the Classical Peptic Ulcer disease presentation?
The classical description of bleeding in PUD is of a posterior duodenal ulcer eroding through into the gastroduodenal artery.
365
Explain how H. pylori can lead to PUD?
Lives in gastric mucus
Secretes urease which splits urea in stomach into CO2 + ammonia
Ammonia + H+ 🡪 ammonium
Ammonium, proteases, phospholipases and vacuolating cytotoxin A damages gastric epithelium
Causes inflammatory response reducing mucosal defense 🡪 mucosal damage
Also causes increased acid secretion
Gastrin release (from G cells) 🡪 more acid secretion
Triggers release of histamine 🡪 more acid secretion
Increases parietal cells mass 🡪 more acid secretion
Decreases somatostatin (released from D cells) 🡪 more acid secretion
366
Explain how NSAIDs lead to PUD?
Mucus secretion stimulated by prostaglandins
COX-1 needed for prostaglandin synthesis
NSAIDs inhibit COX-1
No COX-1 = mucous isn’t secreted
Reduced mucosal defense 🡪 mucosal damage
367
Explain how NSAIDs lead to PUD?
Mucus secretion stimulated by prostaglandins
COX-1 needed for prostaglandin synthesis
NSAIDs inhibit COX-1
No COX-1 = mucous isn’t secreted
Reduced mucosal defense 🡪 mucosal damage
368
Explain how Mucosal Ischaemia can lead to PUD?
Stomach cells not supplied with sufficient blood
Cells die off and don’t produce mucin
Gastric acid attacks those cells
Cells die 🡪 formation of ulcer
Treatment - H2 blocker
369
Explain how an increase in stomach acid can lead to PUD?
Overwhelms mucosal defence
Acid attacks mucosal cells
Cells die 🡪 formation of ulcer
Stress can increase acid production
Treatment – PPI and H2 blocker
370
Explain how Bile Reflux leads to PUD?
Duodeno-gastric reflux
Regurgitated bile strips away mucus layer
Reduced mucosal defense
371
What are the red flags for Cancer causing an Upper GI Bleed?
Unexplained weight loss
Anaemia
Evidence of GI bleeding e.g. melaena or haematemesis
Dysphagia
Upper abdominal mass
Persistent vomiting
372
What are the different classifications of bowel obstruction?
Site of blockage:
Simple
Intra luminal
In the wall
Outside the bowel
373
What are some causes of bowel obstruction?
Crohn’s
Adhesions
Malignancy
Diverticulitis
Volvulus
Hernias
Hirschsprung’s disease
374
What are some intraluminal causes of bowel obstruction?
Tumours:
- Carcinoma
- Lymphoma
Diaphragm disease - NSAIDs cause repeated ulceration then fibrosis
Gallstone ileus – rare form of small bowel obstruction caused by an impaction of a gallstone within the lumen
Meconium ileus – in neonates, content of bowel is sticky 🡪 blockage
375
What are some within the wall causes of Bowel obstruction?
Tumours
Crohn’s – inflammation, fibrosis and contraction
Diverticulitis – outpouchings in the sigmoid
376
What are some Outside the Bowel causes of Bowel obstruction?
Tumours – disseminated malignancy of peritoneum
Ovarian cancer can spread into peritoneum
Adhesions – fibrosis after surgery
Post-surgery
Fibrous connections between loops of small bowel 🡪 bowel becomes kinked
Corrected surgically
Volvulus – sigmoid colon has a “floppy” mesentery
Sigmoid colon can twist
Causes obstruction of the sigmoid
If there is ischaemia and infarction, sigmoid colon is resected
377
What type of oesophageal cancer is most common?
Squamous cell carcinoma (90%) in upper 2 thirds
378
What is the pathogenesis of FAP?
Apc bound to GSK
Beta catenin binds apc complex in high levels of apc
In mutations, apc protein misfolded so can’t bind to beta catenin
Beta catenin able to move into nucleus 🡪 endothelial proliferation 🡪 adenoma
379
What are the Symptoms of Right sided colorectal cancer?
Usually asymptomatic until they present with iron deficiency anaemia due to bleeding
May present with a mass
Weight loss
Abdominal pain
380
What are some differential Diagnoses of Colorectal Cancer?
Anorectal pathology
Haemorrhoids
Anal fissue
Anal prolapse
Colonic pathology
Diverticular disease
IBD
Ischaemic colitis
Small intestine and stomach pathology
Massive upper GI bleed – haematochezia
Meckel’s diverticulum
381
What is the Epidemiology of Dyspepsia?
Common – affecting up to 25% of population a year
382
What are the diagnostic investigations for Dyspepsia?
Endoscopy is used to find an underlying cause.
If there is no obvious cause then it may be functional dyspepsia
383
What is the Treatment for Dyspepsia?
If underlying cause then Tx.
If functional - Give reassurance and dietary review.
384
What are some differential Diagnoses for a Mallory Weiss Tear?
Gastroenteritis
Peptic ulcer
Cancer
Oesophageal varices
385
What are the investigations for Crohn's Disease?
Colonoscopy – diagnostic
Biopsy
Barium enema
Stool sample – rules out infectious diseases
FBC
Raised ESR/CRP
Often low Hb due to anaemia
Faecal calprotectin – indicates IBD but not specific
386
What are the investigations for Ulcerative Colitis?
Colonoscopy - diagnostic
Biopsy – crypt abscesses
Barium enema
Bloods:
FBC – raised ESR and CRP, low Hb
Test for pANCA – negative in Crohn’s
Iron deficiency anaemia
Faecal calprotectin - Indicates IBD
Stool sample – rule out infectious causes
CT/MRI
Abdominal X-ray - Toxic Megacolon
387
What are functional Gut disorders?
These are disorders of the gut-brain interaction that do not have a detectable structural or biochemical abnormality.
They are abnormal symptoms within a normal gut.
388
How is IBS Diagnosed?
Rome IV Criteria:
IBS is defined as recurrent abdominal pain that has occurred, on average, at least:
one day per week
over the last three months
and symptoms begin at least six months ago.
In addition, pain is associated with ≥2 of the following criteria:
Related to defecation
Associated with change in stool frequency
Associated with change in stool form (appearance)
All with normal results on Ix
389
What is Tropical Sprue?
Severe malabsorption (of 2 or more substances) accompanied with diarrhoea and malnutrition.
390
Where does Tropical Sprue occur?
To visitors or residents of tropical areas such as Asia, Caribbean Islands, and South America
391
What can cause appendicitis?
Obstruction:
Faecolith – stones made of faeces
Filarial worms
Undigested seeds
Lymphoid hyperplasia – can obstruct tube and lymphoid follicles can grow during viral infection
Bacteria – Campylobacter jejuni, Yersinia, salmonella, bacillus cereus
392
Why is a raised urea suggestive of an Upper GI bleed?
Raised urea is more suggestive of an upper GI bleed; It occurs due to proteins in the blood being digested by enzymes in the upper GI tract, causing an increase in nitrogenous waste.
This is especially true if the creatinine is within normal limits, which confirms the urea rise is not due to impaired renal function.
393
What are the GI Red Flag Signs?
ALARMS:
Anaemia
Loss of weight
Anorexia
Recent onset of progressive symptoms
Massess/Melena - or bleeding from any part of GIT
Swallowing Difficulties
+55yrs
