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.
Liver Failure
Describe the investigations for Liver Failure (such as blood tests)?
Clinical Examination: encephalopathy and chronic liver disease
Blood tests: clotting, albumin, FBC, CRP/UE/LFT
Ascites: Peritoneal Tap (look for SBP)
Abdo USS
Doppler US for Budd-Chiari Syndrome
Blood Tests:
INR to look for coagulopathy and diagnose liver failure
LFT and albumin: check liver enzymes, bilirubin, assess synthetic function
FBC: Lueocytosis (infection), thrombocytopenia (in chronic liver disease), anaemia (normocytic could indidcate haemolytics anaemia, Wilsons, GI bleed from Oseophogeal Varices, Macrocytic- indicate B12 and Folate decrease in alcohol excess)
UE: establish baseline renal dunction/electrolyte abnormalities (hypokalaemia can worsen encephalopathy)
Tests to determine cause: Paracetamol level (paracetamol overdose)
Hepatitis
Epstein-Barr virus
Cytomegalovirus serology (viral infection)
Iron studies (haemochromatosis)
α-1 anti-trypsin (α-1 antitrypsin deficiency)
Caeruloplasmin level (Wilson’s disease)
Iron studies (hereditary haemochromatosis)
Auto-antibodies (autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis)
LIver Failure
Describe complications of liver failure- what is the most common?
The most common complication of acute liver failure is infection (Bacterial)» thought due to decreased phagocyte action, reduced complement levels and invasive medical interventions> present atypically with no fever or raised WCC
Other complications:
Cerebral Oedema with or without raised ICP
Bleeding
Hypoglycaemia
Mutli-organ failure
Liver Failure
Describe the management of liver failure?
Treat the underlying cause if possible
Monitor observations closely including blood glucose
For encephalopathy:
Lactulose is given to help nitrogenous waste loss through the bowels (reducing encephalopathy)
**IV mannitol **can be given to reduce cerebral oedema in encephalopathy
For coagulopathy
**Vitamin K **- helps production of coagulation factors
**Fresh frozen plasma **can be given if patient is bleeding
Spontaneous bacterial peritonitis
Broad spectrum antibiotics
Renal dysfunction
May require haemofiltration
If patient required fluid resuscitation, human albumin solution rather than crystalloid fluid.
Liver transplantation may be necessary
Acute Pancreatitis
Describe 2 causes of acute pancreatitis and the pathophysiology?
- Alcohol
- Gallstones
Patho: autodigestion of pancreatic tissue by pancreatic enzymes: leading to necrosis
Acute Pancreatitis
Describe the clinical features seen in acute pancreatitis?
- Severe epigastric pain: that may radiate through to the back
- vomiting is common
- examination: epigastric tenderness, ileus and low grade fever
- periumbilical disColouration: Cullens sign and Flank (2 flanks) discoluration: Grey Turners sign
- Rare: ischaemic (purtscher) retinopathy- temp or permanent blindness
Acute Pancreatitis
Describe the 3 types of investigations for acute pancreatitis?
- **Serum amylase: **raised in 75% of pts> typically 3x ULN» levels dont correlate with severity»specifity is 90%
-
Serum Lipase: more sensitive and specific than amylase»longer half life
3.** Imaging:** diagnosis can be made without imaging if characterisitc pain +amylase/lipase is 3x ULN» early US is important to assess aetiology (gallstones/biliary obstruction)»contrast-enhanced CT
Ulcerative Colitis
Describe the liver condtion associated with Ulcerative Colitis?
PRIMARY SCLEROSING CHOLANGITIS: jaundice, raised alp, Gamma GT and pruritis
Primary Sclerosing Cholangitis
Describe PSC and associated conditions?
Biliary diease: inflammation and fibrosis of Intra and Extra-hepatic bile ducts
Ulcerative Colitis
Chrons (less common)
HIV
Primary Sclerosing Cholangitis
Describe the clinical features of PSC and the investigation findings?
Features:
* cholestasis
jaundice, pruritus
raised bilirubin + ALP
* right upper quadrant pain
* fatigue
*Investigation:
endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography **(MRCP) **are the standard diagnostic investigations, showing multiple **biliary strictures giving a ‘beaded’ appearance
p-ANCA may be positive
there is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often described as ‘onion skin’**
Primary Sclerosing Cholangitis
Describe the complications that may arise with PSC?
Complications:
cholangiocarcinoma (in 10%)
increased** risk of colorectal cancer**
Ulcerative Colitis
What is the first-line treatment for mild-moderate flare of distal ulcerative colitis?
Topical (rectal) aminosalicylates- Mesalazine
Ulcerative Colitis
Name the two medications used for a severe relapse or >2 exacerbations in the past year in UC?
Oral Azathioprine or Oral Mercaptopurine
Upper GI Bleed
Describe what Upper GI bleeds are most commonly caused by and what are the clinical features?
Commonly: Oesophageal Varices/Peptic Ulcer Disease
Clinical features:
1.haematemesis
the most common presenting feature
often bright red but may sometimes be described as ‘coffee gound’
2. melena
the passage of altered blood per rectum
typically black and ‘tarry’
3. a raised urea may be seen due to the ‘protein meal’ of the blood
4. features associated with a particular diagnosis e,g,
oesophageal varices: stigmata of chronic liver disease
**peptic ulcer disease: abdominal pain
**
Upper GI Bleed
Describe oesophogeal causes of upper GI bleed?
- Osophageal Varices-large volume of fresh blood/swallowed blood may case melena
- Oesophagitis-small vol of fresh blood/history of GORD
- Cancer- Small volume of blood-except as preterminal event with erosion of major vessels/assoc symptoms of dysphagia and weight loss
- Mallory Weiss Tear- brisk small to mod vol of bright red blood- bout of repeated vomiting
Upper GI bleed
Describe Gastric causes of upper GI bleed?
- Gastric Ulcer- small low vol of bleeds common- tend to present as IDA»can have erosion into sig vessel
- Gastric Cancer- frank haematemesis or altered blood mixed with vomit» prodromal features of dyspepsia»amount of blood is variable but erosion of major vessel» considerable haemorrhage
- Dieulafoy lesion- no prodromal features prior to haematemesis and melena»AV malformation may cause considerable haemorrhage
- Diffuse erosive gastritis- usually haematemesis and epigastric discomfort» underlying cause like recent NSAID usage» large vol haemorrhage may occur with considerable haemodynamic compromise
Upper GI bleed
Describe duodenal causes of upper GI bleed?
- Duodenal ulcer- posteriorly sited and may erode gastroduodenal artery» haematemesis, melena and epigatric discomfort» pain of duodenal ulcer diff of gastric ulcer» occurs several hours after eating
- Aorto-enteric fistula- previous AAA surgery-this remains rare but importatn cause of major haemorrhage
Upper GI Bleed
Describe the risk assessment and the parameters of the different scores used for upper GI bleeds?
Risk assessment:
the Glasgow-Blatchford score at first assessment
-helps clinicians decide whether patient patients can be managed as outpatients or not
the Rockall score is used after endoscopy
-provides a percentage risk of rebleeding and mortality
includes age, features of shock, co-morbidities, aetiology of bleeding and endoscopic stigmata of recent haemorrhage
Upper GI bleed?
Describe the Blatchford score used for Upper GI bleed?
Admission risk marker Score
**Urea **(mmol/L)- (High urea levels in upper GI bleeds are due to the ‘protein meal’ of blood)
6·5 - 8 = 2
8 - 10 = 3
10 - 25 = 4
> 25 = 6
Haemoglobin (g/L)
Men
12 - 13 = 1
10 - 12 = 3
< 10 = 6
Women
10 - 12 = 1
< 10 = 6
**Systolic blood pressure **(mmHg) 100 - 109 = 1
90 - 99 = 2
< 90 = 3
**Other markers: **
Pulse >=100/min = 1
Presentation with melaena = 1
Presentation with syncope = 2
Hepatic disease = 2
Cardiac failure = 2
Patients with a Blatchford score of 0 may be considered for early discharge.
Primary Biliary Cholangitis (PBC)
Describe what is PBC and the associations?
CHRONIC LIVER DISORDER-Autoimmune condition- interlobular bile ducts- damaged by chronic inflammatory process» progressive cholestasis» cirrhosis
Associations:
Sjogrens Syndrome
RA
Systemic Sclerosis
Thryroid problems
Primary Biliary Cholangitis (PBC)
Describe the clinical features associated with PBC?
Early: asymptomatic: raised ALP on routine LFTs/fatigue/pruritis
* Cholestatic jaundice
* Hyperpigmentation
* RUQ pain
* Xanthelasmas/Xanthomata
* Clubbing/hepatosplenomegaly
* Late: progress to liver failure
Primary Biliary Cholangitis (PBC)
Describe how you would diagnose PBC?
- AMA- M2 subtype
- Smooth muscle antibodies
- raised serum IgM
- Imaging: required before diagnosis: exlcude extra heaptic biliary obstruction (RUQ-US or MRCP)
Primary Biliary Cholangitis (PBC)
Describe the managment and complications of PBC?
Management:
1st line: URSODEOXYCHOLIC ACID (slow disease progression and improve symptoms)
Pruritis: CHOLESTYRAMINE
Fat-soluble vitamin supplementation
liver transplant: if bilirubin >100
Complications:
Cirrhosis»Portal HTN»Ascites and variceal haemorhage
Osteomalacia and Osteoporosis
Sig increased risk of HCC
