Gastroenterology Flashcards

1
Q

What epithelium lines the oesophagus ?

A
  • Non keratanised stratified squamous epithelium
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2
Q

what plexus controlks the instrinsic peristaltic movement of the oesophagus ?

A

Enteric plexus : consists of an outer myenteric plexus and inner submucosal plexus

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3
Q

Explain the pathophysiology behind achalasia

A
  • Loss of inhibitory ganglion cells of the myenteric plexus in the distal oesophagus and LOS.
  • Leads to a failure of peristalsis and relaxation of the LOS
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4
Q

How does Achalasia present ?

A
  • Dysphagia of BOTH liquids and solids
  • Heartburn, unresponsive to Tx
  • Regurgitation of undigested food
  • Weight loss
  • Chest pain
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5
Q

What is the initial Ix for achalasia ?

A
  • Barium swallow -> will show dilated oesophagus with narrowing at LOS (birds beak)
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6
Q

What is the diagnostic investigation for achalasia ?

A
  • Oesophageal manometry
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7
Q

What is pseuodachalasia ?

A
  • Obstruction of the distal oesophagus by something other than destruction of myenteric plexus
  • Caused by : malignancy, scleroderma, strictures.
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8
Q

What are the endoscopic treatment options for achalasia ?

A
  • Pneumatic (balloon) dilation
  • Intra-sphincteric injection of botulinum toxin (inhibits Ach release, preventing contraction).
  • Perioral endoscopic myotomy
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9
Q

What is the surgical treatment options for achalasia ?

A

Heller cardiomyotomy

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10
Q

What are the medical treament options for achalasia ?

A
  • CCB (nifedipine)
  • Long acting nitrates
  • They act to reduce lower oesophageal pressure
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11
Q

What kind of malignancy are patients with achalasia for >10yrs at an increased risk of ?

A
  • Squamous cell carcinoma
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12
Q

What factors can exacerbate / worsen Sx of GORD

A
  • Greasy and spicy foods
  • Coffee and tea
  • Alcohol
  • NSAIDs
  • Stress
  • Smoking
  • Obesity
  • Hiatus hernia
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13
Q

What are the symptoms of GORD

A
  • > Dyspepsia
    • Heartburn
    • Acid regurg
    • Retorsternal / epigastric pain
    • Bloating
    • Nocturnal cough
    • Hoarse voice
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14
Q

Red flags for 2 wk wait OGD

A
  • Dysphagia (difficulty swallowing) at any age gets an immediate two week wait referral
  • Aged over 55 (this is generally the cut-off for urgent versus routine referrals)
  • Weight loss
  • Upper abdominal pain
  • Reflux
  • Treatment-resistant dyspepsia
  • Nausea and vomiting
  • Upper abdominal mass on palpation
  • Low haemoglobin (anaemia)
  • Raised platelet count
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15
Q

Stepwise management of GORD

A
  1. Lifestyle changes
  2. Reviewing medications (e.g., stop NSAIDs)
  3. Antacids (e.g., Gaviscon, Pepto-Bismol and Rennie) – short term only
  4. Proton pump inhibitors (e.g., omeprazole and lansoprazole)
  5. Histamine H2-receptor antagonists (e.g., famotidine)
  6. Surgery
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16
Q

Lifestyle changes for GORD

A

Reduce tea, coffee and alcohol
Weight loss
Avoid smoking
Smaller, lighter meals
Avoid heavy meals before bedtime
Stay upright after meals rather than lying flat

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17
Q

what should be ruled out when treating GORD

A
  • H. pylori -> gram neg aerobic bacteria
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18
Q

H.pylori eradication

A
  • Triple therapy
  • PPI (e.g., omeprazole)
    Two antibiotics (e.g., amoxicillin and clarithromycin) for 7 days
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19
Q

Complication of GORD

A
  • Barrett’s oesophagus
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20
Q

Epithelial changes in Barrett’s

A

squamous to columnar epithelium = metaplasia

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21
Q

Management of Barrett’s

A
  • Endoscopic monitoring for progression to adenocarcinoma
  • PPI
  • Endoscopic ablation (e.g., radiofrequency ablation)
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22
Q

Rare condition causing severe dyspepsia, diarrhoea and peptic ulcers

A
  • Zollinger-Ellison Syndrome
  • Duodenal or pancreatic tumour secretes excessive gastrin
  • Gastrin = stimulates acid secretion in the stomach
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23
Q

RF for peptic ulcers

A

-> Disrupting mucus barrier = H.pylori, NSAIDs
-> Increasing stomach acid = stress, alcohol, caffeine, smoking, spicy foods

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24
Q

How do peptic ulcers present ?

A
  1. Epigastric pain -> worse on eating with gastric, better after eating with duodenal
  2. N&V
  3. Dyspepsia
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25
Q

Signs of UGIB from a peptic ulcer (4)

A
  1. Haematemesis
  2. Melaena
  3. Hypotension
  4. tachycardia
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26
Q

Diagnosis of a peptic ulcer

A
  • Endoscopy with a rapid urease test to check for H.pylori
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27
Q

Treatment of peptic ulcer

A
  1. Stopping NSAIDs
  2. Treating H. pylori infections
  3. Proton pump inhibitors (e.g., lansoprazole or omeprazole)

Repeat endoscopy 4-8 wks later to ensure healing of ulcer

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28
Q

Complications of a peptic ulcer

A

-> Bleeding
-> Perforation = acute abdominal pain and peritonitis
-> Scaring and strictures = can lead to gastric outlet obstruction = presents with early fullness / upper abdo discomfort / abdo distention and vomiting, particularly after eating

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29
Q

4 causes of an UGIB

A
  1. Peptic ulcers (most common)
  2. Mallory-Weiss tear
  3. Oesophageal varices
  4. Stomach cancers
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30
Q

3 presenting features of an UGIB

A
  1. Haematemesis
  2. Coffee ground vomit
  3. Meleana
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31
Q

What score is used to assess the risk of a pt having an UGIB based on inital presentation ?

A

Glasgow-Blatchford Bleeding Score

  • Haemoglobin (falls in upper GI bleeding)
  • Urea (rises in upper GI bleeding)
  • Systolic blood pressure
  • Heart rate
  • Presence of melaena (black, tarry stools)
  • Syncope (loss of consciousness)
  • Liver disease
  • Heart failure
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32
Q

An isolated rise in what suggest an UGIB

A

UREA

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33
Q

what score is used after endoscopy to estimate the risk of rebledding and mortality in an UGIB

A

-> Rockall score

  • Age
  • Features of shock (e.g., tachycardia or hypotension)
  • Co-morbidities
  • Cause of bleeding (e.g., Mallory-Weiss tear or malignancy)
  • Endoscopic findings of recent bleeding (e.g., clots and visible bleeding vessels)
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34
Q

Initial management of UGIB

A

-> A – ABCDE approach to immediate resuscitation
-> B – Bloods
-> A – Access (ideally 2 x large bore cannula)
-> T – Transfusions are required
-> E – Endoscopy (within 24 hours)
-> D – Drugs (stop anticoagulants and NSAIDs)

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35
Q

what bloods are sent in an UGIB

A
  • Haemoglobin (FBC)
  • Urea (U&Es)
  • Coagulation (INR and FBC for platelets)
  • Liver disease (LFTs)
  • Crossmatch 2 units of blood
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36
Q

what additional medications are given if an UGIB is due to suspected oesophageal varcies ?

A

Terlipressin
Blood spectrum Abx

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37
Q

Features of crohn’s disease

A

NESTS

-> N – No blood or mucus (PR bleeding is less common).
-> E – Entire gastrointestinal tract affected (from mouth to anus).
-> S – “Skip lesions” on endoscopy.
-> T – Terminal ileum most affected and Transmural (full thickness) inflammation.
-> S – Smoking is a risk factor (don’t set the nest on fire).

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38
Q

Features of ulcerative colitis

A

CLOSE UP

-> C – Continuous inflammation
-> L – Limited to the colon and rectum
-> O – Only superficial mucosa affected
-> S – Smoking may be protective (ulcerative colitis is less common in smokers)
-> E – Excrete blood and mucus

-> U – Use aminosalicylates
-> P – Primary sclerosing cholangitis

39
Q

Bloods done in IBD

A
  • Faecal calprotectin
40
Q

Inducing remission in UC

A
  • MILD TO MODERATE : Aminosalicylate (e.g., oral or rectal mesalazine) first-line, Corticosteroids (e.g., oral or rectal prednisolone) second-line
  • SEVERE : IV hydrocortisone
41
Q

Maintaining remission in UC following a mild to moderate flare

A
  • Low maintenance dose of oral aminosalicylate
42
Q

Inducing remission in crohn’s

A

Oral pred or IV hydrocortisone first line

43
Q

Maintaining remission in crohn’s

A
  • First line : azathioprine or mercaptopurine
44
Q

3 key features of IBS

A

-> I – Intestinal discomfort (abdominal pain relating to the bowels)
-> B – Bowel habit abnormalities
-> S – Stool abnormalities (watery, loose, hard or associated with mucus)

45
Q

Autoantibodies involved in coeliac disease

A

-> Anti-tissue transglutaminase antibodies (anti-TTG)
-> Anti-endomysial antibodies (anti-EMA)
-> Anti-deamidated gliadin peptide antibodies (anti-DGP)

46
Q

Seen on endoscopy in coeliac disease

A
  • Villous atrophy
  • Crypt hyperplasia
  • Jejunum most affected
47
Q

Genotypes associated with coeliac disease

A

HLA-DQ2
HLA-DQ8

48
Q

Presenting symptoms of coeliac disease

A

-> Failure to thrive in young children
-> Diarrhoea
-> Bloating
-> Fatigue
-> Weight loss
-> Mouth ulcers

49
Q

Skin rash seen in coeliac disease

A

Dermatitis herpetiformis : itchy, blistering skin rash, typically on the abdomen

50
Q

Neurological symptoms seen in coeliac disease

A

-> Peripheral neuropathy
-> Cerebellar ataxia
-> Epilepsy

51
Q

First line blood tests for coeliac disease

A
  • Total immunoglobulin A levels (to exclude IgA deficiency)
  • Anti-tissue transglutaminase antibodies (anti-TTG)
52
Q

what does coeliac disease increase the risk of

A

-> Enteropathy-associated T-cell lymphoma (EATL)
-> NHL
-> Small bowel adenoacarcinoma

53
Q

Long term PPI use can cause disturbance in which electrolyte and what could be the presenting symptoms ?

A
  • Hypomagnesaemia
  • Muscle aches
54
Q

Leading cause of c.diff

A

Second and third generation cephalosporins

(PPI are also RF)

55
Q

Expain features of mild, moderate, severe and life threatening C. diff infection

A
  • Mild : normal WCC
  • Moderate : Raised WCC, 3-5 loose stool
  • Severe : WCC (>15), creatinine >50% baseline, temp >38.5 or evidence of colitis
  • Life threatening : hypotension, partial or complete ileus, toxic megacolon
56
Q

Management of 1st episode of C.diff

A
  • 1st : 10 days oral vancomycin
  • 2nd : oral findaxomicin
  • 3rd : oral vancomycin +/- IV metronidazole
57
Q

management of recurrent c.diff infection

A
  • Within 12 weeks of symptom resolution: oral fidaxomicin
  • After 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin
58
Q

Management of Life threatening c.diff infection

A

Oral vancomycin and IV metronidazole

59
Q

Mantaining remission in UC following a severe relapse or >=2 exacerbations a year

A
  • oral azathioprine or oral mercaptopurine
60
Q

Histological findings in crohn’s

A
  • Transmural inflammation
  • Increased goblet cells
  • Granulomas
61
Q

Histological findings in UC

A
  • Neutrophils migrate through the walls of glands to form crypt abscesses
  • Depletion of goblet cells and mucin from gland epithelium
  • Granulomas are infrequent
62
Q

Carcinoembryonic antigen is a tmour marker for what

A

colorectal cancer

63
Q

Recognised complications of enteral feeding

A
  • Diarrhoea
  • Aspiration
  • Metabolic : refeeding / hyperglycaemia
64
Q

Alcohol excess
Severe epigastric pain
Raised amylase

A

Pancreatitis

65
Q

Management of mild acute pancreatitis (stable vital signs)

A

IV fluids (v important)
Opioid analgesia

66
Q

Lifestyle measures for constipation

A

Increase fibre
Adequate fluid
Adequate activity level

67
Q

1st line management of constipation

A

Bulk forming laxative (isphagula husk)

68
Q

Second line for constipation

A

Osmotic (e.g. macrogol)

69
Q

Refeeding syndrome

A
  • Metabolic abnormalities that occur following extended period of starvation
70
Q

metabolic abnormalities of refeeding syndrome

A

Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Abnormal fluid balance

71
Q

Pathophysiology of refeeding

A
  1. Long period of catabolism ends with reintorudction of carbohydrates.
  2. Leads to increased insulin secretion and increased cellular uptake of glucose
  3. This cause phosphate to move intracellularly = low phosphate serum levels.

= Cardiac dysrhythmia, resp failure, rabdomyolysis, seizures

72
Q

high risk of refeeding

A

One or more of

  1. BMI < 16 kg/m2
  2. nintentional weight loss >15% over 3-6 months
  3. little nutritional intake > 10 days
    4 Hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)
73
Q

High risk of fefeeding

A

2 or more of

  1. BMI < 18.5 kg/m2
  2. Unintentional weight loss > 10% over 3-6 months
    3.Little nutritional intake > 5 days
  3. History of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids
74
Q

4 RF for gastric cancer

A
  1. H.pylori
  2. Atrophic gastritis
  3. High salt diet
  4. Smokinh
75
Q

5 Sx of gastric cancer

A
  • Vague epigastric pain
  • Weight loss and anorexia
  • N&V
  • Dysphagia
  • UGIB
76
Q

Lymphatic spread seen in gastric cancer

A
  • Left supraclavicular (Virchow’s)
  • Periumbilical (Sister mary joseph)
77
Q

Diagnosis gastric cancer

A
  • Oesophago-gastro-duodenoscopy with biopsy ->
    signet ring cells
  • Staging: CT
78
Q

Eradication of h.pylori

A
  • PPI + amoxicillin + (clarithromycin OR metronidazole)
  • If penicillin-allergic: a proton pump inhibitor + metronidazole + clarithromycin
79
Q

Screening tes for malnutrition

A

MUST (Malnutrition Universal Screen Tool).

80
Q

Most common oesophageal cancer

A

Adenocarcinoma

81
Q

4 FR for oesphageal adenocarcinoma

A

GORD
Barrett’s oesophagus
smoking
obesity

82
Q

4 features of oesophageal cancer

A
  • dysphagia: the most common presenting symptom
  • anorexia and weight loss
  • vomiting
  • other possible features include: odynophagia, hoarseness, melaena, cough
83
Q

Diagnosis of oesophageal cancer

A

Upper GI endoscopy with biopsy

84
Q

Plummer vinson sydnrome

A

Triad of:
dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia

85
Q

Boerhaave syndrome

A

Severe vomiting → oesophageal rupture

86
Q

Mallory-weiss syndrome

A

syndrome Severe vomiting → painful mucosal lacerations at the gastroesophageal junction resulting in haematemesis. Common in alcoholics

87
Q

Most significant source of UGIB from peptic ulcer disease

A

gastroduodenal artery1

88
Q

1st line for H.pylori test

A

Urea breath or stool antigen

89
Q

Management of more significant diverticulitis

A

Nil by mouth
IV fluid
IV cephalosporin and metronidazole

90
Q

Pharyngeal puch sx

A
  • Dysphagia
  • Regurgitation
  • Aspiration and chronic cough.
    Halitosis may occasionally be seen
91
Q

Investigation of choice for GI ischaemia

A

CT

92
Q

Acute mesenteric ischaemia presentation

A
  • Abdominal pain is typically severe, of sudden onset and out-of-keeping with physical exam findings.
  • Often embolism occluding the superior mesenteric artery or other artery supplying small bowel
  • Hx of AF
  • Urgent surgery needed
93
Q
A