Gastroenterology Flashcards

1
Q

Coeliac disease

A

Complex immune-mediated disorder triggered by gluten ingestion in genetically predisposed individuals (carrying HLA-DQ2 or HLA-DQ8)

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2
Q

Coeliac disease aetiology

A

Genetic predisposition – HLA-DQ2 & HLA-DQ8
Gluten exposure – gliadin is particularly implicated
Environmental factors – early-life gluten exposure, infections, changes in gut microbiota & other lifestyle factors

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3
Q

Coeliac disease gastrointestinal symptoms

A

Diarrhoea – loose, watery or bulky stools
Abdominal pain and bloating
Steatorrhoea – fatty, foul-smelling stools can occur due to impaired fat absorption
N&V – particularly in severe disease

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4
Q

Coeliac disease extraintestinal manifestations

A

Dermatitis herpetiformis – intensely pruritic, vesicular rash, typically affecting the elbows, knees and buttocks
Fatigue – malabsorption of essential nutrients or anaemia
Iron deficiency anaemia
Weight loss – may occur as a result of malabsorption
Bone pain and fractures – malabsorption of calcium and vitamin D
Peripheral neuropathy – numbing, tingling or burning sensations in the extremities

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5
Q

Coeliac disease investigations

A

Anti-tTG – most widely used initial screening test for coeliac disease (false negative may occur in patients with selective IgA deficiency)
Anti-endomysial antibodies – may be used when confirmation of the diagnosis is needed
Total serum IgA levels – important to exclude selective IgA deficiency
Duodenal biopsy (gold standard) – villous atrophy, crypt hyperplasia, increased intraepithelial lymphocytes

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6
Q

Coeliac disease management

A

Gluten free diet
Tissue transglutaminase antibodies may be checked to check compliance with a GF diet
Vitamin supplements
May often have a degree of functional hyposplenism – offered the pneumococcal vaccine

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7
Q

Coeliac disease GI complications

A

Malabsorption – iron deficiency anaemia, folic acid deficiency, vitamin B12 deficiency, fat-soluble vitamin deficiencies (ADEK) & weight loss
Lactose intolerance – loss of lactase-producing enterocytes
Refractory coeliac disease – persistent symptoms despite strict GF diet

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8
Q

Coeliac disease other complications

A

Malignancies – enteropathy-associated T-cell lymphomas, small bowel adenocarcinoma
Bone – osteoporosis, osteopenia
Dermatological – dermatitis herpetiformis
Neurological – peripheral neuropathy, gluten ataxia
Reproductive – infertility & adverse pregnancy outcomes (recurrent miscarriages, low birth weight)
Autoimmune conditions – T1DM, autoimmune thyroiditis, Sjogren’s syndrome, autoimmune liver diseases

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9
Q

Crohn’s disease

A

Chronic inflammatory bowel disease characterised by transmural inflammation that can affect any part of the GI tract from mouth to anus

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10
Q

Crohn’s disease GI clinical features

A

Abdominal pain – may be localised or diffuse, inflammation involving terminal ileum can cause RIF pain
Diarrhoea – non-bloody diarrhoea, often with increased frequency and urgency (bloody = more severe inflammation or the presence of ulcerations)
Weight loss – nutritional deficiencies, malabsorption, anorexia
Perianal disease – anal fissures, perianal abscesses & fistulas
Oral manifestations – aphthous ulcers can occur on the buccal mucosa, tongue or lips
Obstructive symptoms – strictures, adhesions & bowel obstruction may present as N&V, abdominal distension and constipation

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11
Q

Crohn’s disease extraintestinal manifestations

A

Arthritis – typically affects large joints (knees, ankles and wrists), axial arthritis
Skin – erythema nodosum presents as painful, raised erythematous nodules on the lower extremities, pyoderma gangrenosum is characterised by rapidly progressing, painful ulcers
Ocular – uveitis, episcleritis
Hepatobiliary – PSC is characterised by inflammation and fibrosis of the bile ducts, cholelithiasis and fatty liver disease
Haematological – anaemia, increased risk of VTE

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12
Q

Crohn’s disease investigations

A

Blood tests – FBC, CRP, ESR, LFTs, serum albumin, iron studies, vitamin B12 and folate levels, serological markers (ASCA and pANCA) may aid in differentiating CD from UC
Stool tests – cultures, ova and parasite examination & faecal calprotectin (marker of intestinal inflammation) can help differentiate between IBD and other causes
Colonoscopy
CT & MRI

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13
Q

Crohn’s disease histopathological examination

A

Non-caseating granulomas
Transmural inflammation
Lymphoid aggregates
Crypt architectural abnormalities
Cryptitis/crypt abscesses

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14
Q

Crohn’s disease management

A

Smoking cessation
Inducing remission – glucocorticoids (oral, topical or IV) generally used, mesalazine is used as second-line; azathioprine may be used as add-on to induce remission, metronidazole for isolated peri-anal disease
Maintaining remission – stop smoking, azathioprine is used first-line, methotrexate is second-line
Surgery for complications

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15
Q

Crohn’s disease GI complications

A

Strictures – chronic inflammation and fibrosis may lead to narrowing of bowel lumen
Fistulas – abnormal connections between different bowel segments/bowel and other organs
Abscesses
Perianal disease
Malabsorption & nutritional deficiencies
Colorectal cancer – regular surveillance colonoscopy with biopsies is recommended

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16
Q

Crohn’s disease extraintestinal complications

A

Arthritis
Uveitis, episcleritis, scleritis
Erythema nodosum and pyoderma gangrenosum
PSC, cholelithiasis and fatty liver disease
Thromboembolic events

17
Q

IBS

A

Common functional gastrointestinal disorder characterised by recurrent abdominal pain and alterations in bowel habits, with no identifiable cause

18
Q

IBS clinical features

A

Diagnosis should be considered if patient has had the following for at least 6 months:
- Abdominal pain and/or
- Bloating and/or
- Change in bowel habit
Positive diagnosis should be made if the patient has abdominal pain relieved by defecation/associated with altered bowel frequency stool form, in addition to 2 of the following symptoms:
- Altered stool passage (straining, urgency, incomplete)
- Abdominal bloating, distension, tension or hardness
- Symptoms made worse by eating
- Passage of mucus

19
Q

IBS investigations

A

FBC
ESR/CRP
Coeliac disease screen

20
Q

IBS management

A

First-line pharmacological treatment
- Pain: antispasmodic agents
- Constipation: laxatives but avoid lactulose (linaclotide may be considered if not responding to conventional laxatives)
- Diarrhoea: loperamide is first-line
Second-line pharmacological treatment: low-dose tricyclic antidepressants (eg. amitriptyline)
Psychological interventions, general dietary advice

21
Q

Ulcerative colitis

A

Chronic inflammatory bowel disease causing continuous colonic mucosa inflammation and ulceration

22
Q

UC clinical features

A

Diarrhoea – often with blood, mucus or pus & typically worsens during a flare-up
Abdominal pain – crampy and localised to the left lower quadrant, usually relieved after defecation
Rectal bleeding – may lead to anaemia
Urgency and tenesmus
Weight loss
Fatigue

23
Q

UC complications

A

Toxic megacolon – acute and severe colonic dilation, associated with systemic toxicity and increased risk of perforation
Perforation – full-thickness colonic injury
Haemorrhage – severe blood loss
Strictures – chronic inflammation and fibrosis may lead to bowel obstruction
Colorectal cancer

24
Q

UC extra-intestinal manifestations

A

MSK – arthritis, anky spondy, osteoporosis
Dermatological – erythema nodosum, pyoderma gangrenosum and aphthous stomatitis
Ocular – uveitis, episcleritis and scleritis
HPB – PSC, autoimmune hepatitis, cholelithiasis
Haematology – anaemia, thrombocytosis and increased risk of VTE

25
Q

Ulcerative colitis investigations

A

FBC, CRP, ESR
Faecal calprotectin
Gold standard – colonoscopy
CT scan/MRI

26
Q

UC severity

A

Mild: < 4 stools/day, only a small amount of blood
Moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
Severe: >6 bloody stools per day & features of systemic upset

27
Q

UC medical management

A

1st line – aminosalicylates (sulfasalazine)
Corticosteroids – used to management moderate-to-severe US or acute flares, should be tapered and discontinued once remission is achieved
Immunomodulators – azathioprine, for patients who fail to respond or are intolerant to 5-ASAs and corticosteroids
Biological therapies – infliximab, used for patients with moderate-to-severe UC who are refractory to conventional treatments

28
Q

UC surgical management

A

For patients who have complications (toxic megacolon, perforation or severe bleeding) or who fail to respond to medical therapy
Standard procedure – proctocolectomy with ileal pouch-anal anastomosis
- Removes the entire colon and rectum, with the creation of a pouch from the small intestine to restore bowel continuity