Gastroenterology Flashcards
Red Flags in patient with constipation?
not passing meconium within 48hrs
neuro signs or symptoms
vomiting
ribbon stool
abnormal anus
abnormal lower back or buttocks
failure to thrive
acute severe abdo pain or bloating
Complications of chronic constipation?
pain
reduced sensation
anal fissures
haemorrhoids
overflow and soiling
psychosocial morbidity
Mx of idiopathic constipation?
correct reversible RFs
high fibre diet
good hydration
laxatives (Movicol first line)
may require faecal disimpaction regime initially
scheduling visits, bowel diary, star charts
Causes of constipation?
idiopathic
Hirschprung’s disease
cystic fibrosis
hypothyroidism
spinal cord lesions
sexual abuse
obstruction
anal stenosis
CMPA
What is Gastro-Oesophageal Reflux?
when contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus
v common in babies due to immature oesophageal sphincter (up to 1 yr)
Red flags in GOR?
chronic cough
hoarse cry
distress, crying after feeding
reluctance to feed
pneumonia
poor weight gain
Causes of vomiting?
overfeeding
GORD
pyloric stenosis
gastroenteritis
appendicitis
infections (UTI, tonsillitis, meningitis)
intestinal obstruction
bulimia
Mx of GORD?
small, frequent meals
keep baby upright after feeding
don’t overfeed
Gaviscon
thickened milk or formula
PPIs
What is pyloric stenosis?
hypertrophy and narrowing of the pyloric muscle in between the stomach and the duodenum
Presentation of pyloric stenosis?
first few weeks of life
hungry baby
failure to thrive
projectile vomiting
firm, round mass in abdomen
hypochloric metabolic alkalosis
Diagnosis of pyloric stenosis?
abdo US
Mx of pyloric stenosis?
laparoscopic pyloromyotomy (Ramstedt’s)
excellent prognosis
Causes of diarrhoea?
infection (gastroenteritis)
IBD
lactose intolerance
coeliac disease
cystic fibrosis
toddler’s diarrhoea
IBS
meds (antibiotics)
Causes of gastroenteritis?
viral:
norovirus
rotavirus
adenovirus
bacterial:
E coli (HUS)
campylobacter jejuni (traveller’s diarrhoea)
Shigella (HUS)
salmonella
bacillus cereus
yersinia enterocolitica
staph aureus toxin
giardia
Mx of gastroenteritis?
isolation
faeces for culture, sensitivity and microscopy
hydration
avoid antidiarrheal meds
Complications post-gastroenteritis?
lactose intolerance
IBS
reactive arthritis
Guillain-Barré syndrome
Antibodies in coeliac disease?
anti-TTG
anti endomysial
(always test IgA too for context)
Presentation of coeliac disease?
often asymptomatic
failure to thrive
diarrhoea
fatigue
weight loss
mouth ulcers
anaemia (iron, B12, folate)
dermatitis herpetiformis
neuro symptoms (peripheral neuropathy, cerebellar ataxia, epilepsy)
Who should always be tested for coeliac disease?
T1DM
Genetic associations in coeliac disease?
HLA-DQ2
HLA-DQ8
Diagnosis of coeliac disease?
must continue eating gluten for investigations
antibodies
endoscopy (villous atrophy, crypt hypertrophy)
Findings on endoscopy in coeliac disease?
villous atrophy
crypt hypertrophy
Associated diseases with coeliac disease?
T1DM
thyroid disease
autoimmune hepatitis
PBC
PSC
Down’s syndrome
Complications of coeliac disease?
vitamin def.
anaemia
osteoporosis
ulcerative jejunitis
enteropathy-associated T- cell lymphoma
Non-Hodgkin lymphoma
small bowel adenocarcinoma
Mx of coeliac disease?
lifelong gluten free diet
What is biliary atresia?
congenital condition where a section of the bile duct is either absent or narrowed
prevents the excretion of conjugated bilirubin
Mx of biliary atresia?
surgical management
Kasai portoenterostomy
liver transplant
Causes of intestinal obstruction?
meconium ileus
Hirschsprung’s disease
oesophageal atresia
duodenal atresia
intussusception
imperforate anus
malrotation with volvulus
strangulated hernia
Presentation of intestinal obstruction?
persistent vomiting (may be bilious)
abdo pain and distension
obstipation
absent bowel sounds (may be tinkling initially)
Diagnosis of intestinal obstruction?
abdo x ray -> distended loops of bowel, absence of air in rectum
Mx of intestinal obstruction?
‘drip and suck’
definitive mx based on cause
What is Hirschsprung’s disease?
congenital condition where the parasympathetic ganglion cells of the myenteric plexus are absent in the distal bowel and rectum
Presentation of Hirschsprung’s Disease?
acute intestinal obstruction
failure to pass meconium
chronic constipation since birth
abdo pain and distension
vomiting
poor weight gain and failure to thrive
Associated conditions with Hirschsprung disease?
Down’s syndrome
neurofibromatosis
Waardenburg syndrome
MEN 2
What is Hirschsprung-associated enterocolitis?
HAEC -> inflammation and obstruction, occurs in 20% of neonates with Hirschsprung
2-4wks of birth with fever, abdo distension, bleeding
can lead to toxic megacolon and perforation
Mx of Hirschsprung’s Disease?
fluid resuscitation and management of obstruction
antibiotics, fluids and decompression in HAEC
definitive mx is removal of affected bowel
Diagnosis of Hirschsprung’s Disease?
abdo x-ray for obstruction and HAEC
rectal biopsy gold standard (absence of ganglionic cells)
What is intussusception?
a condition where the bowel ‘telescopes’ into itself
leading to palpable mass in the abdomen and obstruction
Who gets intussuscpetion?
6months - 2yrs
more common in boys
Associated conditions with intussusception?
concurrent viral illness
HSP
cystic fibrosis
intestinal polyps
Meckel’s diverticulum
Presentation of intussusception?
severe, colicky abdo pain
pale, lethargic, unwell
redcurrant jelly stool
sausage-shaped mass
vomiting
obstruction
Diagnosis of intussusception?
US abdo
Mx of intussusception?
air insufflation
surgical reduction
surgical resection if gangrene or perforation
Complications of intussuception?
obstruction
gangrene
perforation
death
What is a congenital diaphragmatic hernia?
occurs in 1 in 2000
herniation of the abdominal viscera into the thoracic cavity due to incomplete formation of the diaphragm
causes pulmonary hypoplasia and HTN
only 50% survive
Distinguishing features of Crohn’s Disease?
NESTS
no blood or mucous
entire GI tract
skip lesions
transmural inflammation, terminal ileum most affected
smoking is RF
more associated with weight loss, strictures, fistulas, gallstones
Distinguishing features of ulcerative colitis?
CLOSE-UP
continuous inflammation
limited to colon and rectum
only superficial mucosa
smoking is protective
excrete blood and mucus
use aminosalicylates
PSC
Presentation of IBD?
diarrhoea
abdominal pain
blood and mucus
tenesmus
weight loss
anaemia
mouth ulcers (Crohns)
systemically unwell during flares
Extra-intestinal manifestations of IBD?
finger clubbing
erythema nodosum
pyoderma gangrenosum
episcleritis, scleritis, irisitis
inflammatory arthritis
PSC (UC)
gallstones (Crohns)
Investigations for IBD?
bloods (anaemia, infection, thyroid, kidney, liver function)
raised CRP
faecal calprotectin
endoscopy gold standard
imaging with US, CT, MRI to look for fistula, abscesses, strictures
General Mx of IBD?
MDT
monitor for growth and development
induce and maintain remission
Medical Mx of Crohn’s?
inducing remission:
steroids first-line
consider adding azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab
maintaining remission:
may not be necessary
first-line:
azathioprine
mercaptopurine
alternatives:
methotrexate
infliximab
adalimumab
sx intervention if only affecting distal ileum
sx to treat strictures or fistulae
Medical Mx of UC?
inducing remission:
mild-moderate:
aminosalicylate (mesalazine PO or PR)
corticosteroids
severe:
corticosteroids
IV ciclosporin
maintaining remission:
aminosalicylate (mesalazine PO or PR)
azathioprine
mercaptopurine
Sx:
panproctocolectomy
permanent ileostomy or ileo-anal anastomosis J-pouch
Presentation of appendicitis?
central abdominal pain that migrates to RIF
tenderness at McBurney’s point
anorexia
N&V
Rovsing’s sign
peritonism (guarding, rebound tenderness, percussion tenderness)
Diagnosis of appendicitis?
clinical diagnosis
inflammatory markers
CT can be used to confirm
US to rule out gynae
definitive diagnosis on laparoscopy
DDx of appendicitis?
ectopic pregnancy
ovarian cysts
meckel’s diverticulum
mesenteric adenitis
appendix mass
Mx of appendicitis?
appendectomy (open or laparoscopic)
Complications of appendectomy?
bleeding, infection, pain, scars
damage to bowel, bladder, other structures
removal of normal appendix
anaesthetic risks
VTE
