Gastroenterology Flashcards
Is IBD associated with any autoimmune disease, if so which ones
Yes
SLE
AS
Hashimotos thyroiditis
How would IBD typically present
Intermittent bloody diarrhoea with mucous
weight loss
abdo pain
perianal pain & abscess
What are the extra-intestinal manifestations of IBD?
Skin
Erythema nodosum
Pyoderma gangrenosum
Joint arthropathy
Peripheral large joint arthritis
Ankylosis spondylitis
Sacroilitis
Mouth
Aphthous ulcers
Eye
Iritis
Uveitis
Episcleritis
Chronic liver disease
Cirrhosis
Chronic active hepatitis
Fatty liver PSC
Cholangiocarcinoma
Metastatic CRC
Amyloid CLD
What investigations would u order if a patient comes in with bloody diarrhoea + what results might u see
Bloods
FBC
Low hb — sec to iron deficiency anaemia
Low platelets — bleeding diasthesis sec to CLD
Elevated haematocrit — sec to dehydration
U&E
Elevated urea»_space; Cr = dehydration
Electrolyte abnormalities sec to diarrhoea — hypoK + metabolic acidosis
LFTs
Low albumin — sec to protein losing enteropathy
Deranged LFTs due to CLD or PSC
PT/APTT
ESR/CRP
Blood cultures
Stool studies
Gram stain
C&s
Microscopy — check for ova, cysts, leukocytes
C.difficile toxin
Imaging
Plain film abdo — if UC = toxic megacolon, mucosal orders (ie thumb printing), perforation
Colonoscopy & biopsy
If UC
Confluent lesions — most severe in rectum & distal colon
No strictures
If CD
Strictures — string sign
Skip lesions
Cobble stoning of mucous
Deep fissured ulcerations
Fistula
Loss of haustra
what are some red flags for diarrhoea?
weight loss
intractable vomiting
severe dehydration
bloody stool
temp >38.1
incontinence
urgency
nocturnal symptoms
PUD is most common in which part of the GIT
duodenal is most common
gastric is 2nd most common
what causes PUD
helicobacter pylori infection
how does PUD present
epigastric pain — dull
worsened by food = gastric ulcer
worsened when hungry + relieved by meals = duodenal ulcer
heartburn
risk factors for PUD
chronic NSAID use
polypharmacy in elderly —- esp SSRIs, steroids, aspirin, anticoagulants, alendronate
prev PUD
h.pylori infection
age >60 y/o
chronic kiney or liver disease
smoking
alcohol
stress (cushing’s ulcers)
burns (curling’s ulcers)
what Ix would u order for suspected PUD
bloods
FBC — ?microcytic anaemia
OGD — visualise ulcer
to test for h.pylori
CLO Campylobacter-like test — requires OGD to be done + biopsy
UBT urea breath test
if possible compications
erect CXR — ?pneumoperitoneum
how would u Tx PUD
acute phase
if active bleeding = blablabla
if symptomatic but not bleeding
PPI
+/- H2 antagonists —- if persistent symptoms or C/I to PPI
antacids
if H.pylori +ve triple therapy — 2 Abx + PPI BD for 14/7
eg. esomeprazole + amoxicillin +clarithromycin
if penicillin allergic = metronidazole
long term
conservative Tx
dont smoke
avoid alcohol
weight loss
stop NSAIDs + medication rationalisation
medical Tx = as with acute phase
monitoring: repeat OGD after PPI — ensure gastric ulcer healing
DDx for epigastric pain
PUD
malignant ulcer — sec to gastric ca
oesophagitis
GERD
pancreatits
ACS —- inferior MI
AAA
acute cholecystitis
biliary colic
what is coeliac disease?
small bowel autoimmune disorder — characterised by mucosal inflammation + villous atrophy + crypt hyperplasia upon exposure to dietary gluten — improves upon withdrawal of gluten from diet
risk factors for coeliac disease
1st degree relative — 15%risk
HLA-DQ2 & HLA-DQ8
IgA deficiency
dermatitis herpetiformis
other autoimmune conditions
IBD
T1DM
how would coeliac disease present
symptoms (Hx)
diarrhoea — steatorrhoea sec to fat malabsorption
abdo bloating + excessive flatus
weight loss
fatigue
+/- vesicular rash (dermatitis herpetiformis)
faltering growth
Ix for suspected coeliac disease
bloods
FBC —— microcytic/macrocytic anaemia sec to iron & B12 deficiency
iron studies
folate & B12 levels
CRP/ESR
anti-tTG IgA & IgA levels
anti-EMA Ab (endomysial)
OGD & D2 biopsy
findings
macroscopic villous atroophy
scalloping
loss of mucosal folds
r/o other causes
stool
c&s, microscopy (ova & parasites)
faecal calprotectin
faecal elastase —- ?pancreatic insufficiency
chloride sweat test —- ?CF
how do u classify coeliac disease
classic
refractory —– persistent symptoms & villous atrophy despite strict adherence to gluten free diet for 6 months
asymptomatic
histology & endoscopy findings of CD Crohn’s disease vs UC ulcerative colitis
histology:
CD:
transmural inflammation
presence of granulomas
UC:
mucosal & submucosal inflammation
polymorphonuclear cells aggregate
endoscopy
CD:
skip lesions
cobble stoning of mucous
deep fissured ulcerations
fistulas
loss of haustra
strictures – string sign
UC:
continuous lesions
presence of crypts
formation of residual mucosal tissue
Tx of IBD inflammatory bowel disease
severe acute phase
according to UC: true love and witts criteria or CD: CD activity index
admit to hospital
NPO + maintenance fluids
IV hydrocortisone + rectal steroids
monitor
vitals
physical exam — distension, bowel sounds, tenderness
Ix daily: FBC, ESR, CRP, U&E +/- PFA
if by day 3 CRP >45 or >5 stools/day = action required
colectomy OR
rescue therapy: cyclosporin/infliximab
Tx CD:
inducing remission = steroids +/- purines
steroids
if left-sided colon disease = prednisolone
if right-sided colon = budesonide (ileal release)
add ons (to step up)
azothioprine/mercaptopurine
methotrexate
infliximab/adalimumab
maintaining remission = purines
1st line = azothioprine, mercaptopurine
2nd line = methotrexate
surgical Tx = colectomy
doesnt cure – aim: remove worst affected areas + rest distal bowel
Tx UC:
mild UC:
5-ASA (sulphasalazine, mesalazine)
prednisolone 20mg OD
+/- steroid foams (colifoam) BD
moderate UC
5-ASA
prednisolone 40mg/wk –> 30mg/wk –> 20mg/wk 4 wks
steroid enema BD
