Gastroenterology Flashcards
Surgical differentials for acute abdominal pain
Peritonitis
Ruptured AAA
Appendicitis
Gallstones
Acute pancreatitis
Diverticulitis
Renal colic
Bowel obstruction
Acute mesenteric ischaemia
Obstructed/strangulated hernia
Testicular torsion
Volvulus
Meckel’s diverticulum
Adhesions
Medical differentials for acute abdominal pain
Gastritis/peptic ulcer
Pyelonephritis
Gastroenteritis
Constipation
Crohn’s/ UC
Hepatitis
Differentials for acute diarrhoea
- Gastroenteritis (+ abdo pain / N+V)
- Diverticulitis (left lower quadrant pain, diarrhoea, fever)
- Antibiotic therapy (broad spec Abx)
- Constipation causing overflow
Differentials for chronic diarrhoea
- IBS
- Ulcerative colitis (blood diarrhoea)
- Crohn’s disease (mouth ulcers, perianal disease)
- Colorectal cancer (rectal bleeding, weight loss)
- Coeliac disease
Differentials for dysphagia
- Oesophageal cancer
- Oesophagitis
- Oesophgeal candidiasis
- Achalasia
- Pharyngeal pouch
- Systemic sclerosis
- Myasthenia gravis
- Globus hystericus
Causes of acute pancreatitis
- Idiopathic
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps
- Autoimmune
- Scorpion venom
- Hyperlipidaemia
- ERCP = endoscopic retrograde cholangiopancreatography
- Drugs = azathioprine, furosemide, corticosteroids, NSAIDs, ACE-i
- Pregnancy and neoplasia
Presentation of acute pancreatitis
- Severe epigastric or central abdominal pain that radiates to back
- Sitting forward may relieve and worse on lying down
- Anorexia
- nausea and vomiting
- Tachycardia
- Fever
- Jaundice
- Dehydration
- Hypotension
- Abdominal guarding and tenderness
- Cullen’s sign = periumbilical bruising
- Grey Turner’s sign = left flank bruising
What is the difference between Cullen’s sign and Grey Turner’s sign?
- Cullen’s sign = periumbilical bruising
- Grey Turner’s sign = left flank bruising
Blood tests for acute pancreatitis
o Raised serum/urinary amylase
o Raised serum lipase = more sensitive and specific
o CRP level
Imaging for acute pancreatitis
- Abdominal ultrasound = gallstone pancreatitis
- Erect CXR
o Exclude gastroduodenal perforation = raises serum amylase
o May show gallstones or pancreatic calcification - Contrast enhanced CT = Identify extent of pancreatic necrosis
- MRI = Identifies degree of pancreatic damage
o Useful in differentiating fluid and solid inflammatory masses
What score can be used to assess severity in acute pancreatitis?
Glasgow score
PaO2 <60
- Age > 55
- Neutrophils >15
- Calcium <2
- uRea >16
- Enzymes = LDH >600 or AST/ALT >200
- Albumin <32
- Sugar = glucose >10
Management of acute pancreatitis
- Severity assessment essential and careful monitoring
- Nil by mouth = Nasogastric tube for dietary supplements to decrease pancreatic stimulation
- IV fluids
- Urinary catheter
- Analgesia = IM pethidine or IV morphine
- Endoscopic drainage of large pseudocysts
- Prophylactic antibiotics like beta-lactams = Cerfuroximr
- Surgery = remove infected pancreatic necrosis
Complications of acute pancreatitis
- Pancreatic necrosis
- Haemorrhage
- Infection in necrotic area
- Pseudocysts
- Chronic pancreatitis
- Peripancreatic fluid collections
- Pancreatic abscess
- Acute respiratory distress syndrome
Causes of chronic pancreatitis
- (Long-term) Alcohol excess
- Genetic (Hereditary pancreatitis) = Defects in trypsinogen gene, Cystic fibrosis
- Infection = HIV, mumps, coxsackie, echinococcus
- Autoimmune pancreatitis
- Hyperlipidaemia
- Structural = obstruction by trauma
- Chronic kidney disease
- Idiopathic
- Recurrent acute pancreatitis
Presentation of chronic pancreatitis
- Epigastric pain that ‘bores’ through to back
o Episodic or unremitting = relieved by sitting forward
o Exacerbated by alcohol - Nausea and vomiting
- Decreased appetite
- Weight loss
- Diarrhoea
- Steatorrhea = pale, loose, fatty, foul smelling stools that float
- Protein deficiency
- Diabetes mellitus
- Jaundice
Investigations for chronic pancreatitis
- Serum amylase and lipase normal
- Faecal elastase normal
- Abdominal ultrasound and contrast-enhance CT = Detects pancreatic calcification and dilated pancreatic duct
- MRI with MRCP = Identify more subtle abnormalities
Management of chronic pancreatitis
- Alcohol cessation
- Analgesia = NSAIDs opiates tricyclic antidepressants
- Duct drainage
- Shock wave lithotripsy = Fragment gallstones in head of pancreas
- Pancreatic enzyme supplements
- PPI = lansoprazole to help supplement pass stomach
- Diabetes = Insulin
Complications of chronic pancreatitis
- Malabsorption and steatorrhea
- Pseudocyst
- Diabetes
- Biliary or duodenal obstruction
- Splenic vein thrombosis
- Pseudoaneurysm
- Pancreatic ascites
- Pancreatic carcinoma
Causes of gastroenteritis
- E.coli
- Giardiasis
- Cholera
- Shigella
- Staphylococcus aureus
- Campylobacter
- Bacillus cereus (reheated rice)
- Amoebiasis
Presentation of gastroenteritis
- Watery stools
- Abdominal cramps
- Nausea and vomiting
- May be blood in diarrhoea
Incubation periods for bacteria in gastroenteritis
- 1-6hrs = staph. Aureus, bacillus cereus
- 12-48 hrs = salmonella, E.coli
- 48-72 hrs = shigella, campylobacter
- > 7 days = giardiasis, ameobiasis
What is coeliac disease?
Autoimmune condition where exposure to gluten causes inflammation in the small bowel
Risk factors for coeliac disease
- Other autoimmune diseases = T1DM, thyroid disease, primary biliary cirrhosis
- IgA deficiency
- Age of introduction to gluten into diet
- Rotavirus infection in infancy
- HLADQ2 and 8 association
Presentation of coeliac disease
- 1/3 asymptomatic = only detected on routine blood tests
- Failure to thrive = children
- Diarrhoea
- Fatigue
- Weight loss
- Steatorrhoea (Stinking stools/fatty stools)
- Abdominal pain
- Bloating
- Nausea and vomiting
Examination findings in coeliac disease
- Dermatitis herpetiformis = Red raised patches, often with blisters that burst on scratching
- Mouth ulcers
- Angular stomatitis = inflammation of one or both corners of mouth
- Clubbing
- Amenorrhoea
- Rare = Peripheral neuropathy, cerebellar ataxia, epilepsy
What is required before investigating for coeliac disease
Maintain gluten for at least 6 weeks before testing to get true results
What antibodies are present in coeliac disease?
o IgA Tissue transglutaminase antibody
o IgA Endomyseal antibody
o General IgA (deficiency)
What is the definitive investigation for coeliac disease?
- Endoscopy and duodenal biopsy
o Villous atrophy, crypt hyperplasia
o All reverse on gluten free diet
What is the definitive management of coeliac disease?
- Lifelong gluten free diet = serum antibody testing for monitoring
o Eliminate wheat, barley, rye
o Dietician review
What other parts of management of coeliac disease are important?
- Correction of vit and mineral deficiencies = B12, folate, iron, calcium and vit D
- DEXA scan to monitor osteoporotic risk
- Checking coeliac antibodies to monitor
- Offered pneumococcal vaccine every 5 years
Complications of coeliac disease
- Anaemia (pernicious)
- Enteropathy associated T-cell lymphoma
- Non-Hodgkin lymphoma
- Increased risk of malignancy
- Osteopenia/osteoporosis
- Neuropathies
- Subfertility
- Ulcerative jejunitis
- Vitamin deficiency
What are the causes of malabsorption?
Pancreatic insufficiency
Pancreatitis
Cystic fibrosis
Biliary obstruction
Ileal resection
Bacterial overgrowth
Giardia lamblia
Small intestine resection/bypass
Lactose intolerance
Bacterial overgrowth
Abetalipoproteinaemia
Primary bile acid malabsorption
Lymphoma
TB
What is GORD?
Reflux of stomach contents through lower oesophageal sphincter and irritates lining of oesophagus
Risk factors for GORD
- Hiatus hernia
- Obesity
- Pregnancy = increased abdo pressure
- Gastric acid hypersecretion
- Slow gastric emptying
- Overeating
- Smoking
- Alcohol
- Fat, chocolate, coffee ingestion
- Systemic sclerosis
- Drugs = nitrate, tricyclics, CCBs, antimuscarinic
Presentation of GORD
- Burning chest pain aggravated by bending, stooping and lying down
o Relieved by anti-acids
o Worse with hot drinks or alcohol - Belching
- Food, acid or bile regurgitation
- Retrosternal or epigastric pain
- Bloating
- Water brash = increased salivation
- Odynophagia = painful swallowing
- Nocturnal cough
- Hoarse voice
Red Flags for GORD
- Symptoms >4 wks
- Dysphagia, weight loss, haematemesis, anaemia
- Persistent vomiting
- GI bleeding
- Palpable mass
- Over 55
- Symptoms despite treatment
Investigations for GORD
If Red flag symptoms then endoscopy and barium swallow
Lifestyle changes for GORD
o Encourage weight loss
o Smoking cessation
o Small, regular meals
o Avoid hot drinks, excess alcohol, citrus fruits, aggregating foods and eating less than 3 hours before bed
o Sleep with head of bed raised
o Reduce stress and anxiety
o Review medications
Medication options for GORD
o Antacids = magnesium trisilicate mixture
o Alginates = Gaviscon
o Proton pump inhibitor = lansoprazole
o H2 receptor antagonists (antihistamine)= ranitidine
Surgery options for GORD
laparoscopic fundoplication = Tying fundus of stomach around lower oesophagus to narrow lower oesophageal sphincter
Complications of GORD
Oesophagi’s
Peptic stricture
Barrett’s oesophagus
Differences between Crohn’s and Ulcerative Colitis
Crohn’s (NESTS)
No blood or mucus
Entire GI tract
Skip lesions
Terminal ileum most affected and Transmural inflammation
Smoking = risk factor
Ulcerative Colitis (CLOSEUP)
Continuous inflammation
Limited to colon and rectum
Only superficial mucosa
Smoking is protective
Excrete blood and mucus
Use aminosalicylates
Primary Sclerosing Cholangitis
Risk factors for ulcerative colitis
- Family history
- NSAIDs = onset of IBD and flares of disease
- Chronic stress and depression triggers flares
Protective factors for ulcerative colitis
- Smoking
- Appendicectomy
Presentation of ulcerative colitis
- Runs in course of remissions and exacerbations
- Restricted pain usually to lower left quadrant
- Episodic or chronic diarrhoea (with blood and mucus)
- Crampy abdominal discomfort
- Bowel frequency linked to severity
- Acute attack = bloody diarrhoea, diarrhoea at night with urgency and incontinence that is disabling
- Acute UC = fever, tachycardia and tender distended abdomen
- Clubbing
- Erythema nodusum = red lumps below skin
- Pyoderma gangrenosum = painful ulcers on skin
SEverity of ulcerative colitis
- Mild <4 stools/day, only small amount of blood
- Moderate 4-6 stools/day, varying amounts of blood, no systemic upset
- Severe >6 bloody stools per day + systemic upset
Blood tests for ulcerative colitis
o WCC and platelets raised
o Normochromic, normocytic anaemia = Fe/B12/folate deficiency anaemia or anaemia of chronic disease
o ESR and CRP raised
o Hypoalbuminemia in severe disease
o pANCA (Anti-neutrophilic cytoplasmic antibody) may be positive
Gold standard investigation for ulcerative colitis
Colonoscopy with mucosal biopsy
o Inflammatory infiltrate
o goblet cell depletion
o crypt abscesses and mucosal ulcers
o loss of haustrations/drain pipe colon
o No granulomata
Inducing remission in mild-moderate UC
o rectal aminsalicyclate (mesalazine)
o then add oral if remission not within 4 wks
o then add topical/oral steroid
Inducing remission in severe UC
o Admit and IV steroids
o Add IV ciclosporin if not improvement in 72 hrs
o Infliximab is 3rd line
Maintaining remission for UC
oral/topical mesalazine, azathioprine, mercaptopurine
Indications for surgery in UC
ileocaecal resection
o Indicated for severe colitis that fails to respond to treatment
Complications of ulcerative colitis
- Primary Sclerosing cholangitis
- Colorectal cancer
- Ankylosing spondylitis
- Arthritis
- Iritis
- Uveitis
- Episcleritis
What is Crohn’s disease?
Transmural granulomatous inflammation affecting any part of gut from mouth to anus (especially terminal ileum and proximal colon)
Risk factors for Crohn’s disease
- Genetic association = Mutations on NOD2 gene on chromosome 16 increases risk
- Smoking
- NSAIDs
- Family history
- Chronic stress and depression triggers flares
- Good hygiene = poor hygiene families have lower risk of developing CD
- Appendicectomy
- Other autoimmune disease
Presentation of Crohn’s disease
- Diarrhoea with urgency, bleeding and pain due to deification
- Abdominal pain = Emergency with acute right iliac fossa pain (Mimics appendicitis)
- Weight loss and anorexia
- Malaise
- Fatigue
- Abdominal tenderness/mass
- Perianal abscess
- Aphthous oral ulcers
- Clubbing
- Skin, joint and eye problems
Bloods for Crohns
o Normochromic, normocytic anaemia = deficiency of iron and folate
o Raised ESR and CRP
o Raised WCC and platelets
o Hypoalbuminaemia present in severe disease
o LFTs may be abnormal
o Negative pANCA
Gold standard investigation for Crohns
o Skip lesions and granulomatous transmural inflammation
o Increase in chronic inflammatory cells and lymphoid hyperplasia
o Non-caseating epithelioid cell aggregates with Langerhans giant cells
o Goblet cells are present
o Cobblestone appearance due to ulcers and fissures in mucosa
What is shown on a barium swallow in Crohn’s
Cobblestone appearance
Management of acute Crohns flare
- Corticosteroids (oral prednisolone or IV hydrocortisone)
- Immunosuppressant (azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab)
Maintaining remission in Crohn’s
azathioprine, mercaptopurine
Surgery in Crohns
Ileocaecal resection
o Indicated in medical therapy failure, failure to thrive and perianal sepsis
o Resection at worst areas = can result in short bowel syndrome
Complications of Crohns
- Anaemia
- Osteoporosis
- Obstruction = strictures
- Fistulas
- Adenocarcinomas
- Malabsorption
- Amyloidosis
- Perianal abscess
Side effects of azathioprine
bone marrow depression,
N+V,
pancreatitis,
increased risk of non-melanoma skin cancer
Risk factors for IBS
- Previous severe and long diarrhoea
- Mental health problems
- FHx of IBS
Triggers of IBS
- Depression, anxiety
- Psychological stress and trauma
- GI infection
- Sexual, physical or verbal abuse
- Eating disorders
Presentation of IBS
- Fluctuating bowel habit (Diarrhoea/ Constipation)
o Worse after eating, stress, menstruation or gastroenteritis
o Improved by opening bowels - Abdominal pain
- Bloating
- Fatigue
- Nausea
- Mucus in stool
Diagnosis criteria for IBS
Rome III diagnostic criteria:
Recurrent abdominal pain/discomfort at least 3 days a month in past 3 months associated with 2+ of
o Improvement with defecation
o Onset associated with change in frequency of stool
o Onset associated with change in form of stool
Lifestyle Management of IBS
- Adequate fluid intake
- Regular small meals
- Reduced processed foods
- Limit caffeine and alcohol
- Low FODMAP diet
- Probiotic supplements for 4 weeks
Medication options in IBS
- 1st line medication
o Loperamide = diarrhoea
o Laxatives = constipation
o Antispasmodics (hyoscine butylbromide) = cramps - 2nd line
o Tricyclic antidepressants (amitriptyline)
o CBT
Risk factors for peptic ulcers
- Stress
- Alcohol
- Caffeine
- Smoking
- Spicy foods
Causes of peptic ulcers
- Helicobacter pylori infection
- Drugs = NSAIDs, steroids and SSRIs
- Delayed gastric emptying
- Bile reflux
- Mucosal ischaemia
Presentation of peptic ulcers
- Recurrent burning epigastric pain
o Pain occurs at night and worse when hungry
o Duodenal improve on eating, Gastric get worse when eating
o Can be relieved by antacids - Nausea
- Anorexia and weight loss = gastric ulcers
- Dyspepsia
- Haematemesis (coffee ground vomit)
- Melaena (dark sticky faeces containing partial digested blood)
Investigations of peptic ulcers
- Endoscopy
- Biopsy during endoscopy to exclude malignancy
- C-urea breath test/stool antigen test = H.pylori
Lifestyle changes in peptic ulcers
reduce stress, stop smoking, reduce alcohol, avoid irritating foods, lose weight
Medication management in peptic ulcers
- Stop NSAIDs
- H.pylori eradication
o PPI for acid suppression = lansoprazole
o 2 antibiotics = metronidazole + clarithromycin/amoxicillin - H2 antagonists = ranitidine
Complications in peptic ulcers
- Bleeding
- Perforation = acute abdomen and peritonitis
- Scarring and strictures = pyloric stenosis
- Acute pancreatitis
What is diverticulitis?
inflammation of diverticulum (outpouching of gut wall, usually at sites of entry of perforating arteries)
Risk factors for diverticulitis
- Low fibre diet
- Obesity and sedentary lifestyle
- Smoking
- NSAIDs
Presentation of diverticulitis
- Intermittent Left iliac fossa/lower left abdo pain
- Fever
- Diarrhoea/constipation
- Bloating
- PR blood/mucus
- Nausea and vomiting
- Febrile
- Tachycardia
- Tenderness, guarding and rigidity on left side of abdomen
- Palpable tender mass sometimes felt in LIF
- Urinary frequency, urgency and dysuria
- Possible reduced bowel sounds
Investigations for diverticulitis
- Blood tests = raised WCC, ESR and CRP
- CT = Colonic wall thickening and diverticula, Pericolic collections and abscesses
- CXR pneumoperitoneum in cases of perforation
- AXR Identify obstruction of free air, dilated bowel loops, abscesses
- Barium enema = Clarify diagnosis in patients with abdominal pain and altered bowel habit
- Colonoscopy avoided initially due to increase risk of perforation in diverticulitis
Management of diverticulitis
- Mild oral Antibiotics (ciprofloxacin), liquid diet, analgesia
- If Sx don’t settle within 72 hrs or more severe Sx admit for IV Abx
- Surgical resection if severely septic/complications
Complications of diverticulitis
- Perforation
- Fistula formation
o Bladder = dysuria (pain when urinating) or pneumaturia (gas/air in urine resulting in bubbles)
o Vagina resulting in discharge - Intestinal obstruction
- Bleeding
- Mucosal inflammation
- Abscess
- Peritonitis
Causes of gastritis
- Helicobacter pylori infection
- Autoimmune gastritis
- Viruses = cytomegalovirus and herpes simplex
- Duodenogastric reflux = Bile salts enter stomach and damage mucin protection
- Crohn’s
- Mucosal ischaemia
- Stress
- Aspirin and NSAIDs = naproxen
- Alcohol
Presentation of gastritis
- Nausea or recurrent upset stomach
- Abdominal bloating
- Epigastric pain
- Haematemesis (Vomiting)
- Indigestion
Investigations for gastritis
- Endoscopy and Biopsy
- H.pylori = Urea breath test, Stool antigen test
Management of gastritis
- Remove causative agents = alcohol
- Reduce stress
- H.pylori eradication
o PPI for acid suppression = lansoprazole or omeprazole
o Plus 2 of: metronidazole, clarithromycin, amoxicillin, tetracycline, bismuth - H2 antagonist (Ranitidine or cimetidine) = Reduce acid release
- Antacids
Prevention of gastritis
- Give PPIs alongside NSAIDs
- Prevents bleeding from acute stress ulcers and gastritis
What are haemorrhoids?
Disrupted and dilated anal cushions (masses of spongy vascular) tissue due to swollen veins around anus
Risk factors for haemorrhoids
- Age
- Posture
- Heavy lifting
- FHx
- Constipation with prolonged straining
- Diarrhoea
- Effects of gravity due to posture
- Congestion from pelvic tumour, pregnancy, portal hypertension
- Anal intercourse
- Persistent cough/vomiting
Classification of haemorrhoids
- Internal haemorrhoids = origin above the dentate line
o 1st = remain in rectum
o 2nd = prolapse through anus on defecation but spontaneously reduce
o 3rd = prolapse but can be reduced manually
o 4th = remain persistently prolapsed - External haemorrhoids = origin below dentate line
o May be visible externally
o Extremely painful since sensory nerve
Presentation of haemorrhoids
- Severe anaemia
- Bright red rectal bleeding often coats stools
- Mucus discharge and itchy bottom
- Weight loss and change in bowel habit
- Only painful if below dentate line
Investigations of haemorrhoids
- Proctoscopy Internal haemorrhoids
- Sigmoidoscopy Rectal pathology higher up
Management of haemorrhoids
- 1st degree Increase fluid and fibre, Topical analgesic and stool softener
- 2nd and 3rd degree
o Rubber band ligation Cheap and produces ulcer to anchor mucosa
o Infra-red coagulation Locally coagulates vessels and tethers mucosa to subcutaneous tissue - 4th degree
o Excisional haemorrhoidectomy
o Stapled haemorrhoidopexy - Prolapsed or thrombosed piles
o Treated with analgesia, ice packs and stool softeners
o Pain usually resolved in 2-3 weeks
What is an anal fistulae?
Blockage of deep intramuscular gland ducts thought to predispose to formation of accesses, which discharge to form fistula
Causes of anal fistulae
- Perianal sepsis
- Abscesses
- Crohn’s
- TB
- Diverticular disease
- Rectal carcinoma
Presentation of anal fistulae
- Pain
- Bloody or mucus discharge
- Itchy bottom
- Systemic abscess if infected
Investigations of anal fistulae
- MRI Exclude sepsis and Detect associated conditions (Crohn’s or TB)
- Endoanal ultrasound Determine tracks location and underlying causes
Management of anal fistulae
- Surgical Fistulotomy and excision
- Drain abscess with antibiotics if infected
What is an anal fissure?
Painful tear in sensitive skin-lined lower anal canal, distal to dentate line
Risk factors for anal fissure
- Constipation
- IBD
- STI (HIV, syphilis, herpes)
- Childbirth
- Trauma
- Anal cancer
Presentation of anal fissure
- Extreme pain especially on defecation
- Bright red rectal Bleeding
- 90% are posterior
PR exam often not possible due to pain and sphincter spasm
Management of acute anal fissure
o Increase dietary fibre and fluids = make stools softer
o Bulk forming laxatives then lactulose if not tolerated
o Lubricants before defecation
o Lidocaine ointment and GTN ointment or topical diltiazem
o Analgesia
Management of chronic anal fissure
o Continue above techniques
o Topical GTN
o If this not effective after 8 wks then secondary care referral
Secondary care treatment options for anal fissure
o Botulinum toxin injection
o Sphincterotomy
Causes of metabolic alkalosis
Vomiting/aspiration
Diuretics
Hypokalaemia
Primary hyperaldosteronism
Cushing’s syndrome
Bartter’s syndrome
Side effects of PPIs
Hyponatraemia
Hypomagnesaemia
Osteoporosis
Microscopic colitis
C. diff
