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Gastroenterology Flashcards

1
Q

How does gastroenteritis present and what can it be caused by?

A

D&V - caused by ingesting bacteria, viruses or toxins
No blood or mucus in the stool
Signs of dehydration - dry mucous membranes, reduced skin turgor

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2
Q

Which bacteria most commonly cause gastroenteritis?

A

1) Staph aureus - usually found in cooked meats and cream products
2) Bacillus cereus - mainly found in reheated rice
3) Clostridium perfringens - usually found in reheated meat dishes or cooked meats
4) Campylobacter
5) E coli incl. E coli O157 which can cause HUS
6) Salmonella
7) Shigella

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3
Q

What is the most common cause of infantile gastroenteritis?

A

Rotavirus

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4
Q

What is the most common cause of viral infectious gastroenteritis in all ages in England and Wales?

A

Norovirus

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5
Q

What is a common cause of respiratory infections that can also cause gastroenteritis esp. in children?

A

Adenoviruses

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6
Q

What are parasitic causes of gastroenteritis?

A

1) Cryptosporidium
2) Entamoeba histolytica
3) Giardia intestinalis
4) Schistosoma

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7
Q

How is gastroenteritis managed?

A

1) Conservatively with NG/IV fluid replacement or oral rehydration sachets
2) If severe, abx can be used

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8
Q

What are indications of antibiotics in gastroenteritis?

A

1) Systemically unwell
2) Immunosuppressed
3) Elderly

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9
Q

Which antibiotic can be used to treat salmonella and shigella?

A

Ciprofloxacin

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10
Q

What antibiotic can be used to treat campylobacter?

A

Macrolide e.g. erythromycin

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11
Q

What antibiotic can be used to treat cholera?

A

Tetracycline, to reduce transmission

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12
Q

Is food poisoning a notifiable disease in the UK?

A

Yes

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13
Q

How does norovirus present?

A

1) Abrupt onset, usually short lived GI upset 24-48h after inoculation
2) Typically self-limiting in healthy people but can cause pre-renal AKI in the frail

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14
Q

How do you prevent norovirus?

A

Strict handwashing with soap and warm water e.g. in hospitals, nursing homes and cruise ships

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15
Q

How does a peptic gastric ulcer present?

A

1) Iron deficiency anaemia - due to persistent blood loss
2) Abdominal pain made worse by eating

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16
Q

How does a peptic duodenal ulcer present?

A

1) Iron deficiency anaemia - due to persistent blood loss
2) Abdominal pain improved by eating

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17
Q

What are viral causes of gastroenteritis?

A

1) Rotavirus
2) Norovirus
3) Adenovirus

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18
Q

How does infective gastroenteritis present?

A

1) Sudden onset diarrhoea
2) Blood/mucus in stool
3) Faecal urgency
4) Nausea/sudden onset vomiting
5) Fever
6) General malaise
7) Abdominal pain/cramps
8) Associated headache
9) Myalgia
10) Bloating and flatulence
11) Weight loss
12) Malabsorption

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19
Q

How do you diagnose gastroenteritis?

A

1) Clinical - history + examination
2) Stool culture/sensitivity - not routinely needed for children/adults presenting with acute diarrhoea
3) Assess hydration status

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20
Q

What type of bacteria is clostridium difficile?

A

Gram positive

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21
Q

What are risk factors for developing clostridium difficile infection?

A

1) Use of broad-spectrum abx - clindamycin, ciprofloxacin, cephalosporins, penicillins
2) Healthcare setting
3) Age > 65
4) Co-morbidities - IBD, cancer, CKD
5) Immunosuppression - diabetes, HIV
6) PPI

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22
Q

How does C difficile present?

A

Asymptomatic OR
1) Watery/bloody diarrhoea
2) Painful abdo cramps
3) Nausea
4) Dehydration - dry mucous membranes, tachycardia, oliguria
5) Fever
6) Anorexia
7) Weight loss
8) Confusion

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23
Q

What are potential complications of C difficile?

A

1) Pseudomembranous colitis
2) Toxic megacolon
3) Sepsis

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24
Q

What is the definitive/gold standard diagnosis of C difficile?

A

Toxigenic C difficile in stool + colonic histopathology showing pseudomembranes

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25
What two key investigations are done to diagnose C difficile?
Stool culture + colonic biopsy
26
What would you see on colonic biopsy in C difficile?
Pseudomembranes
27
How do you treat C difficile?
1) PO vancomycin ± IV metronidazole if severe 2) Second line = fidaxomicin
28
What is the key antibiotic used to treat C difficile?
Vancomycin
29
How do you treat recurrent C difficile infection?
Faecal transplant
30
How is C difficile managed?
1) PO vancomycin ± IV metronidazole 2) Avoid anti-diarrhoeal agents 3) Fluid replacement and supportive treatment
31
What does MALT stand for in MALT lymphoma?
Mucosa-associated lymphoid tissue
32
What is a MALT lymphoma?
Rare, low-grade non-Hodgkin's lymphoma that usually presents in the stomach but can present elsewhere
33
What type of lymphoma is MALT lymphoma?
Non-Hodgkin's (low-grade)
34
Where does MALT lymphoma typically present?
Stomach
35
What does MALT lymphoma develop from?
B lymphocytes in the marginal zone
36
What is MALT lymphoma strongly associated with?
H. pylori infection
37
What are risk factors for MALT lympoma?
1) H. pylori infection 2) Chronic inflammation 3) Autoimmune conditions
38
How does MALT lymphoma present?
1) Abdominal pain 2) Nausea and vomiting 3) Weight loss 4) Symptoms of anaemia 5) ± B symptoms - night sweats, fever, weight loss
39
What is the initial treatment for local and disseminated MALT lymphoma?
H. Pylori eradication therapy - this can treat the lymphoma in many cases
40
What are other treatment options for MALT lymphoma if H. Pylori eradication therapy fails?
1) Chemotherapy and radiotherapy - if disease is progressive or the patient has high risk features e.g. being H. pylori negative at presentation 2) Disseminated disease - chemotherapy + rituximab if there is threat to vital organ function otherwise watch + wait approach
41
What is the most common cause of duodenal ulcers?
H. pylori (90%)
42
What % of duodenal ulcers are caused by H. pylori?
90%
43
What type of pathogen is H. pylori?
Gram negative bacteria
44
What does H. pylori do?
Buries itself into the gastric epithelium and releases urease that neutralises pH of the stomach and damages the epithelium
45
What does H. pylori release?
Urease
46
How does urease cause damage?
Neutralises pH of the stomach and damages the epithelium
47
How do you diagnose for H. pylori?
Rapid urease test (quick and reliable) - endoscopy + biopsy
48
How do you do a rapid urease test?
On gastric biopsy at upper GI endoscopy
49
What do you do if rapid urease test is positive?
Start H. pylori treatment
50
What advice do you give to patients pre-endoscopy for H. pylori testing to avoid false negatives?
Patient should not take antibiotics or bismuth products for 4 weeks and no PPI for 2 weeks
51
What medication should patients not take pre-endoscopy for H. pylori testing to avoid false negatives?
1) Antibiotics or bismuth products for 4 weeks 2) PPI for 2 weeks
52
What is the first line treatment for H. pylori?
Triple therapy - amoxicillin + clarithromycin + PPI (BD for 7 days)
53
When should you initiate triple therapy for H. pylori?
Only in cases of documented H. pylori infection
54
How does triple therapy work?
Abx target H. pylori bacterium + PPI aids epithelial healing
55
How do you treat H. pylori in penicillin allergy?
Metronidazole + clarithromycin + PPI (BD for 7 days)
56
How is H. pylori infection managed?
1) Triple eradication therapy 2) After 4-8 weeks patients can be re-tested for H. pylori to check it has been eradicated - if not can re-treat (metronidazole instead of clarithromycin in non-penicillin allergy OR tetracycline/quinolone if both metronidazole and clarithromycin have been tried) 3) If the patient has had two courses of eradication therapy and still tests positive, refer to gastro for endoscopy
57
When should patients be re-tested for H. pylori to check it has been eradicated (endoscopy + biopsy + rapid urease test)?
4-8 weeks after initiating triple therapy
58
When should patients be referred to gastro endoscopy for H. pylori infection?
After two courses of eradication triple therapy
59
What are the two types of peptic ulcer disease?
1) Gastric ulcer 2) Duodenal ulcer
60
Which type of peptic ulcer is more common?
Duodenal (four times more common)
61
What causes peptic ulcers?
1) The stomach lining protects itself with mucin and bicarbonate secretion and mucosal blood flow 2) However, damage can occur if these barriers are not sufficient, or if external factors e.g.H. Pylori are present
62
What are other risk factors for duodenal ulcers (as well as H pylori)?
1) NSAIDs 2) Chronic steroid use 3) SSRIs 4) Increase in gastric acid secretion 5) Smoking 6) Blood group O 7) Increased gastric emptying
63
Why does increased gastric emptying cause duodenal ulcers?
More acid in the duodenum
64
What are risk factors for gastric ulcers?
1) NSAIDs 2) H. Pylori 3) Smoking 4) Delayed gastric emptying 5) Severe stress
65
How do you manage H. pylori positive peptic ulcer disease?
Triple eradication therapy - amoxicillin + clarithromycin + PPI
66
How do you manage H. Pylori-negative peptic ulcer disease?
4-8 weeks of full dose PPI treatment e.g. omeprazole 20mg, lansoprazole 30mg + lifestyle advice
67
What lifestyle advise is given to manage H. Pylori negative peptic ulcer disease?
1) Stop smoking 2) Cut down on alcohol 3) Have more regular, smaller meals and eat 4 hours before bed 4) Avoid acidic, fatty or spicy foods and coffee 5) Encourage weight loss if obese 6) Try to avoid stress 7) Avoid NSAIDs, steroids, bisphosphonates, potassium supplements, SSRIs and crack cocaine 8) Try over the counter antacids
68
Which drugs should you avoid in peptic ulcer disease?
1) NSAIDs 2) Steroids 3) Bisphosphonates 4) Potassium supplemnets 5) SSRIs 6) Crack cocaine
69
How should patients with a gastric ulcer be followed up?
Repeat endoscopy 6-8 weeks after the start of PPI treatment to ensure ulcer healing and rule out malignancy
70
What is the reason for repeat endoscopy 6-8 weeks after PPI treatment of a gastric ulcer?
1) To ensure ulcer healing 2) To rule out malignancy
71
How should H. Pylori negative duodenal ulcers be followed up?
1) Ask about adherence and lifestyle factors should be enforced 2) If symptoms continue, other rarer causes of duodenal ulcers should be considered e.g. malignancy, use of ulcer-promoting drugs, missed H. pylori infection, Zollinger-Ellison syndrome, Crohn's disease 3) If these are ruled out - low dose PPI
72
What are rarer causes of duodenal ulcers?
1) Malignancy 2) Use of ulcer-promoting drugs 3) Zollinger-Ellison syndrome 4) Crohn's disease
73
How does peptic ulcer disease (dyspepsia) present?
1) Epigastric pain 2) Fullness 3) Bloating 4) Nausea 5) Intolerance of fatty foods
74
What is the key symptom in duodenal ulcers?
Relieved by food or drinking milk
75
Which ulcer has a higher risk of being or becoming malignant?
Gastric ulcers
76
What is the key symptom in gastric ulcers?
Made worse by eating
77
When should patients > 55 years with dyspepsia be referred for 2ww urgent endoscopy to investigate for cancer?
If they have ALARMS signs 1) Anaemia 2) Loss of weight 3) Anorexia 4) Recent onset of symptoms 5) Malaena/haematemesis 6) Dysphagia OR 7) Epigastric mass 8) Persistent vomiting
78
How can you test for H. pylori without endoscopy?
Urease breath test or stool antigen test
79
What is follow up in duodenal ulcers?
Repeat test for H.pylori
80
What is GORD?
Clinical diagnosis based on the presence of typical symptoms (dyspepsia, heartburn, or acid reflux) resulting from the reflux of gastric contents into the oesophagus caused by a defective lower oesophageal sphincter
81
How is GORD diagnosed?
1) Clinical - based on typical symptoms 2) ± therapeutic trial of PPI may aid in diagnosis
82
What are the typical symptoms of GORD?
1) Dyspepsia (heartburn) 2) Sensation of acid regurgitation
83
What are atypical symptoms of GORD?
1) Epigastric/chest pain 2) Nausea 3) Bloating 4) Belching 5) Globus 6) Laryngitis 7) Tooth erosion
84
What are alarm symptoms in GORD?
1) Weight loss 2) Anaemia 3) Dysphagia 4) Haematemesis 5) Malaena 6) Persistent vomiting
85
What are risk factors for GORD?
1) Obesity 2) Alcohol use 3) Smoking 4) Intake of specific foods e.g. coffee, citrus foods, spicy foods, fat
86
What investigations can you do in GORD?
1) Trial of standard PPI therapy 2) OGD - if alarm features or atypical, persistent or relapsing symptoms 3) Oesophageal manometry
87
What are indications for an OGD in GORD?
1) Alarm features 2) Persistent or relapsing atypical symptoms
88
How do you manage GORD?
1) Lifestyle interventions 2) PPI therapy 3) Antacids for symptomatic relief 4) Anti-reflux surgery - for refractory cases
89
What lifestyle interventions can help with GORD?
1) Weight loss 2) Dietary changes 3) Elevation of the head of the bed at night 4) Avoidance of late night eating
90
How do you manage patients < 40 years who present with typical symptoms of GORD and no red flags?
Commence treatment with standard dose PPI for 8 weeks + lifestyle changes
91
How do you treat refractory cases of GORD?
Anti-reflux surgery
92
What are complications of GORD?
1) Oesophageal ulcer 2) Barrett's oesophagus 3) Oesophageal stricture 4) Adenocarcinoma of the oesophagus

Stage 3 (61 decks)

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