GASTROENTEROLOGY Flashcards
Coeliac DIsease
Give a description of how a person may present with Coeliac Disease?
Can present with Steatorrhoea (foul and pale smelling stools), abdo discomfort, diarrhoea, N+V, fatigue, weakness and weight loss
Autoimmune disease> blood film suggests macrocytic anaemia (B12 deficiency is seen in coeliac disease), MCV high and ferritin low
Coeliac Disease
Define Coeliac Disease and the aetiology?
T-Cell mediated autoimmune disorder affecting small intestin: arises due to sensitivity to gluten (prolamin) which results in inflammation and villous atrophy of small bowel=malabsorption
Coeliac Disease
Describe the signs and symptoms of Coeliac Disease and what you may find on phsycial examination?
Gastrointestinal symptoms include:
- Abdominal pain
- Distension
- Nausea and vomiting
- Diarrhoea
-
Steatorrhoea (indication of severe disease)
Systemic symptoms encompass: - Fatigue
Weight loss or failure to thrive in children (indication of severe disease)
DANDS WiFe
Physical Examination:
Pallor (secondary to anaemia)
Short stature and wasted buttocks (secondary to malnutrition)
Signs of vitamin deficiency due to malabsorption (e.g., bruising secondary to vitamin K deficiency)
Dermatological manifestations: dermatitis herpetiformis (pruritic papulovesicular lesions over the buttocks and extensor surfaces of the arms, legs, and trunk).
Abdominal distension
Coeliac Disease
Give 4 differentials for Coeliac Disease?
I**rritable bowel syndrome (IBS): Characterised by chronic abdominal pain, bloating, and altered bowel habits without any organic cause.
Inflammatory bowel disease (IBD): Crohn’s disease and ulcerative colitis are forms of IBD and may present with abdominal pain, diarrhoea, weight loss, and systemic signs of inflammation.
Food intolerance/allergy: Abdominal discomfort, bloating, and diarrhoea are common.
Gastroenteritis: Acute diarrhoea and vomiting, often with fever.
FIIG
Coeliac Disease
Describe the gold standard investigation for Coeliac Disease Diagnosis and give other investigations such as Histological appearence (VCL)?
Gold Standard:Oesophago-gastroduodenoscopy (OGD) and duodenal/jejunal biopsy, considered the gold standard for diagnosis.
* Stool culture to exclude infectious causes.
* Histology typically reveals sub-total villous atrophy, crypt hyperplasia, and intra-epithelial lymphocytes (Villous Atrophy, Crypt Hyperplasia and Lymphocyte Inflitration)
* Blood tests include FBC, U&E, bone profile, LFT, Iron, B12, and Folate levels
* Serological tests such as anti-TTG IgA antibody, IgA level, anti-TTG IgG, anti-endomyseal antibody, although anti-gliadin is not recommended by NICE.
Coeliac Disease
Describe the managment of Coeliac Disease and 4 complications- A HOE?
Primary managment of coeliac disease- gluten free diet and patient education about gluten containing foods with regular monitoring to ensure adherence and potential complications
Complications: Anaemia
** Hyposplenism-increasing susceptibilty to encapsulated organs
Osteoporosis: DEXA
** Enteropathy-associated T Cell Lymphoma (EATL)- rare type of non-hodgkins
Ulcerative Colitis
Define Ulcerative Colitis and aetiology?
Chronic relapsing-remitting inflammatory bowel disease- primarily affecting the large bowel
Cause: combo of genetic predisposition, enviromental factors and dyregulation of immune system
Higher incidence among non and ex-smokrts
Ulcerative Colitis
Describe Sign, Symptoms, Extra-Intestinal Manifestations and Physical Examination findings of UC?
Gastrointestinal symptoms include:
Diarrhea often containing blood and/or mucus
Tenesmus or urgency
Pain in the left iliac fossa
Systemic symptoms include:
**Weight loss
Fever
Physical Examination: Pallor due to Anaemia and Clubbing, Abdo Exam: Distention and Tenderness and PR exam: tenderness and blood/mucus
Extra-Intestinal:
Derm- Erythema Nodosum, Pyoderma Gangrenosum
Ocular: Anterior Uveitis, Episcleritis, Conjuctivitis
MSK: Clubbing, non-deforming asymmetrical arthritis, sacroilitis
Hepatobilliary: PSC
AA Amyloidosis
Ulcerative Colitis
Describe the critierias for Severity in UC and give 3 differential diagnoses?
- Truelove
- Witts
Acute Exacerbation of UC
Mild: Bowel movement (<4)
Blood in stools: small amounts of blood
Pyrexia: No
Pulse>90: No
Anaemia: No
ESR: 30 or below
Moderate:
Bowel Movement (4-6)
Blood: between mild and severe
Pyrexia: No
PUlse>90: No
Anaemia (No)
ESR: 30 or below
Severe:
Bowel Movements: 6 or more plus atleast one systemic upset
Blood: visible blood
Pyrexia: Yes
Pulse: Yes
Anaemia: Yes
ESR: above 30
Differentials: IICk
I- Infectious Colitis: acute onset diarrhoea, fever, abdo pain and may be assoc with recent antibiotics use, travel or contaminated food/water
Ischaemic Colitis: Sudden onset abdo pain, blood in stools, history or risk factors for vascular disease
Chrons: Abdo pain, weight loss, diarrhoea, oral ulcers, anal fissures, perianal fistulas
Ulcerative Colitis
Describe the 5 types of investigations for UC and explain what they are looking for?
Investigations for UC include:
Blood tests: FBC may show anaemia and a raised white cell count, ESR/CRP is typically raised, LFTs may show a low albumin.
Microbiological investigations: Stool microscopy culture and sensitivity, and stool C. difficile toxin to exclude infective colitis.
**Faecal calprotectin: **Distinguishes between inflammatory bowel syndrome and inflammatory bowel disease. Raised in inflammatory Bowel Disease
**Radiological investigations: **Abdominal X-ray and erect chest x-ray in acute settings to exclude toxic megacolon and perforation.
**Endoscopic investigations: **Colonoscopy, barium enema, and biopsy are used to confirm the diagnosis.
Colonoscopy will reveal **continuous inflammation with an erythematous mucosa, loss of haustral markings, and pseudopolyps.
Biopsy will reveal loss of goblet cells, crypt abscess, and inflammatory cells** (predominantly lymphocytes)
Barium enema will reveal **lead-piping inflammation **(secondary to loss of haustral markings), **thumb-printing **(a marker of bowel wall inflammation), and pseudopolyps (due to areas of ulcerating mucosa adjacent to areas of regenerating mucosa).
*
Ulcerative Colitis
Describe the Management of UC: Mild-Moderate Disease and Acute Severe Disease and Surgical Options?
The aim of step 1 treatment is to induce remission. If this does not work after 4 weeks, or symptoms worsen, move to step 2.
The first step in management for a moderate first presentation is to offer a** topical aminosalicylate as first-line treatment. If remission is not achieved within 4 weeks, consider adding an oral aminosalicylate.
**
Proctitis and proctosigmoiditis:
Step 1: Topical ASA or oral ASA.
Step 2: Consider adding oral prednisolone. If this does not help after 2-4 weeks or symptoms worsen, consider adding oral tacrolimus.
Left sided or extensive disease
Step 1: High dose oral ASA.
Step 2: Consider adding oral prednisolone. If this does not help after 2-4 weeks or symptoms worsen, consider adding oral tacrolimus.
Acute severe disease
Step 1: IV corticosteroids (if contraindicated or not tolerated, use IV ciclosporin).
Step 2: If no improvement in 72 hours or worsening symptoms, add IV ciclosporin or consider surgery (if IV ciclosporin contraindicated or not tolerated, consider infliximab).
Indications for emergency surgery:
Surgery should be considered in patients with:
Acute fulminant ulcerative colitis
Toxic megacolon who have little improvement after 48-72 hours of intravenous steroids
Symptoms worsening despite intravenous steroids
Surgical Options: Pranproct**ocolectomy with permanent end ileostomy
Colectomy: with temp end illeostomy/ileorectal anastomosis or Illeal pouch anal anastomosis (IPAA)
Ulcerative Colitiis
Describe Short Term/Acute Complications, Long Term and Variable Term Complications?
Short Term/Acute:
Toxic Megacolon (severe for or colitis)
Massvie Lower GI haemorrhage
Long Term:
Colorectal Cancer (concomitant PSC)
Cholangiocarcinoma
Colonic Strictures: Large Bowel Obstruct
Variable:
PSC- inflammation and fibrosis of extra-intra-hepatic biliary tree
Inflammatory Pseudopolyps
Liver Failure
Describe hyper-acute liver failure finding in patient with overdose of paracetamol?
Asterixis: Hepatic flap> grade 2 or 3 hepatic encephalopathy sign>cardinal feature of liver failure» incoherence and restlessness are features of Grade 3 hepatic encephalopathy
Liver Failure
Describe Liver Failure (acute, subacute, hyperacute, and give causes of Liver Failure?
Liver failure can occur acutely (if onset of symptoms is in <26 weeks in a patient with a previously healthy liver) in which case it is known as acute liver failure. This can be further divided into hyperacute (7 days or less), acute (8-21 days) and subacute (4-26 weeks).
Chronic liver failure is the onset of liver failure on a background of cirrhosis.
The causes of liver failure are as follows:
Infection (Hepatitis A, B and E, CMV, yellow fever, leptospirosis)
Drugs (Paracetamol overdose, halothane,isoniazid, MDMA, alcohol)
Toxins (Amanita phalloides mushroom, carbon tetrachloride)
Vascular (Budd-Chiari syndrome)
Primary biliary cirrhosis
Haemochromatosis
Wilson’s disease
Autoimmune hepatitis
Alpha-1 antitrypsin deficiency
Non-alcoholic fatty liver disease
Fatty liver of pregnancy
Malignancy
HELLP syndrome
Liver Failure
Describe 4 clinical features of liver failure and how to differentiate between liver failure and chronic liver disease?
Hepatic encephalopathy- in liver failure (nitrogenous waste-ammonia)- accumulates in circulation-this is able to cross the BBB- once in cerebral circulation-detoxified by astrocytes>form glutamine> excess of glutamine disrupts osmotic balance>astrocytes begin to swell>rise to cerebral oedema
Abnormal bleeding
Ascites
Jaundice
cerebral oedema is severe, raised intracranial pressure may develop. This is more common in fulminant hepatic failure
separate the signs of liver failure from the signs of chronic liver disease. The presence of both indicates a de-compensation of chronic liver disease.
