Gastroenterology Flashcards
what medication is used in upper GI disease? (3)
antacids
H2 receptor blockers
proton pump inhibitors
how do antacids help upper GI disease?
alkaline that forms a salt with stomach acid neutralising it
how do H2 receptor blockers help upper GI disease?
Prevent histamine activation of acid production, limited benefit as other pathways still operate (acetylcholine, gastrin)
how do proton pump inhibitors help upper GI disease?
reduce the amount of acid produced in the stomach
what can be used to look at the upper GI?
endoscopy
what is GORD -> gastro-oesophageal reflux disease commonly known as?
heartburn
what are the 3 main causes of GORD?
Defective lower oesophageal sphincter -> not able to shut gastric contents away from oesophagus
Impaired lower clearing -> oesophagus isn’t emptying properly into the stomach
Impaired gastric emptying: if the stomach is full of food it will eventually go back into the oesophagus causing gastric contents and acid to pass back into the oesophagus
what are the signs and symptoms of GORD?
Epigastric burning - worse lying down, bending, pregnancy
Dysphagia - difficulty swallowing
GI bleeding
Severe pain - mimics MI so can be differential diagnosis if ECG and troponin normal
what can GORD lead to?
Ulceration
inflammation
metaplasia
Barrett’s oesophagus
what is Barrett’s oesophagus? malignant?
acid in the oesophagus is left, causing a change in the oesophageal epithelium from the normal squamous epithelium to epithelium that more related to the gastric mucosa
Potentially malignant lesion -> adenocarcinoma at the bottom of the oesophagus
what is the management of GORD?
Stop smoking - improves sphincter
Lose weight and avoid triggering activity -> fat puts pressure on stomach
Medical management
- Antacids
- H2 blockers and proton pump inhibitors
Increase GI motility and gastric emptying -> prevents backfill of stomach into oesophagus
what is hiatus hernia?
Part of the stomach is in the thorax above the diaphragm
what are the symptoms of hiatus hernia?
Symptoms similar to GORD as easier for gastric contents to enter the oesophagus
- Epigastric burning - worse lying down, bending, pregnancy
- Dysphagia
- GI bleeding
- Severe pain
what is a sliding hiatus hernia?
hiatus hernia can move up and down through the diaphragmatic hole but does so together with the oesophagus
what is a rolling hiatus hernia?
oesophagus and hernia may behave independently
peptic ulcers affect what sites?
any site where acid should or shouldn’t be there -> oesophagus, stomach, duodenum
generally peptic ulcers are caused by what two things?
High acid secretion that passes into the duodenum that can’t neutralise them properly
Normal acid secretion that overcomes the barriers of the stomach
peptic ulcers can be caused by Normal acid secretion that overcomes the barriers of the stomach. how does this occur? cause?
Reduced protective barrier of the stomach lining
helicobacter pylori
drugs - NSAIDs and steroids
how is peptic ulcer caused by hepilobacter pylori treated?
triple therapy
2 antibiotics, 1 proton pump inhibitor
name 3 types of peptic ulcer
bleeding
perforated
gastric
what is a bleeding peptic ulcer?
Where it destroys a vessel wall causing bleeding
what is a perforated peptic ulcer
Where acid burns through into the peritoneum
what is a gastric ulcer?
○ Peptic ulcer in the stomach
Histologically ulcer has gone through the lining and submucosa into the gastric tissues where it has eroded into an artery causing gastric bleeding
what are the signs and symptoms of a peptic ulcer?
Asymptomatic
Epigastric burning pain -> worse just before/after meals, night
No physical signs -> only when complications e.g. bleed, perforation
name 4 investigations for peptic ulcer
endoscopy
radiology
anaemia - full blood count
H.pylori test
a local complication of peptic ulcer disease is perforation, what is this?
Escape of gastric contents into peritoneum -> can be fatal
a local complication of peptic ulcer disease is haemorrhage, what is this?
Erosion of ulcer into blood vessel causing bleeding into the stomach
Brown granular vomit
a local complication of peptic ulcer disease is stricture, what is this?
Chronic ulceration heals by secondary intention as a scar that contracts reducing the size of the stomach exit
a local complication of peptic ulcer disease is malignancy, what is the risk factor for this?
Helicobacter pylori
what is a systemic complication from peptic ulcer disease?
anaemia
what is the medical treatment for peptic ulcer disease?
stop smoking
small regular meals
H.pylori triple therapy
ulcer healing drugs - proton pump inhibitors
name 3 surgical treatments for peptic ulcer disease
endoscope
gastrectomy
vagotomy
how does a vagotomy help peptic ulcer disease?
reduces the acid producing trigger by branching the vagal nerve trunk
what is a gastrectomy?
remove part of the stomach
what are the 2 types of gastrectomy?
bilroth 1 and 2
what is a bilroth 1 gastrectomy?
Remove part of stomach containing the ulcer
Attach top of duodenum to remaining part of the stomach
what is a bilroth 2 gastrectomy?
Remove part of the stomach containing the ulcer
Attach the remaining portion of the stomach further down the duodenum
what medications for upper GI disease reduce acid secretion?
H2 receptor blockers (histamine)
proton pump inhibitors
what medications for upper GI disease improve mucosal barrier?
Eliminate H.pylori
Inhibit prostaglandin removal
- Prostaglandins can increase the resistance of the gastric mucosa
- Avoid NSAIDs and reduce steroid use
where is the small bowel?
From the duodenum to the ileocecal junction
what is the function of the small bowel?
absorption
coeliac disease is
Sensitivity of ? component of ? in the ? bowel causing an ? reaction
Involves both ? and ?? in the destruction of ? tissue (? atrophy)
As ? changes take place the villi are ? (villus atrophy) decreasing the ?? of the duodenum for ??
a-gliadin
gluten
small
immune
antibodies
T cells
villus
villous
inflammatory
lost
surface area
food absorption
name 3 causes of coeliac disease
Genetic
Environmental trigger
Consumption of gluten
what effects does coeliac disease have on the body? 6
Weight loss
Diarrhoea
oral aphthae - group of small ulcers
Tongue papillary loss
Malabsorption issues
- Iron, folate, vitamin B12, fat
what investigations are done for coeliac disease? 4
Autoantibody test
- TTG or anti-gliadin/endomyseal antibodies
Jejunal biopsy
Faecal fat
- Increased if malabsorption
Haematinics -> ferritin, folate, Vit B12
- Can be reduced which suggests malabsorption
- Done if patient presents with ulcer to detect malabsorption
what is the management of coeliac disease?
If don’t eat gluten then jejunum and symptoms return to normal
what skin disease is linked to coeliac disease?
dermatitis herpetiformis
what is dermatitis herpetiformis?
Ulceration and blisters on the skin and oral mucosa
Will go away if pt is gluten free
what is pernicious anaemia?
Vitamin B12 deficiency due to diet or absorption issue
Vitamin B12 has a complex absorption process -> only absorbed in the ?? with help from ??
terminal ileum
intrinsic factor
name 4 causes of pernicious anaemia
Lack of vitamin B12 in diet
Disease of gastric parietal cells
Inflammatory bowel disease of the terminal ileum -> Chron’s
Bowel cancer at ileocecal junction
how is pernicious anaemia diagnosed?
Schilling test uses radioisotopes to determine whether there is an absorption problem
antibodies against the parietal cells and intrinsic factor have superseded schilling test
how is pernicious anaemia treated?
Diet with vitamin B12
Vitamin B12 supplements
IM vitamin B12 injections if absorption not possible
irritable bowel disease covers what 2 main disease?
ulcerative colitis
Crohn’s disease
what is the term is used if unsure whether a pt has ulcerative colitis or Crohn’s disease?
intermediate colitis
ulcerative colitis and Crohn’s disease are very similar but differ in clinical presentation. name one way they differ
ulcerative colitis has bloody diarrhoea
Crohn’s disease has watery diarrhoea
what 3 groups are involved in the pathogenesis of IBD?
genetic predisposition
mucosal immune system
environmental triggers
Pathogenesis of IBD:
Genetic predisposition
?? on chromosome ? encodes a protein involved in ??. Mutation in this gene is found in 10-20% of Caucasian pt’s with ??
NOD 2
16
bacterial recognition
Crohn’s disease
pathogenesis of IBD
Mucosal immune system
Innate immune system
? junctions to regulate ?permeability
Mucus layer containing ?helps to ? the epithelial layer
Defensives (proteins) can be activated ? or in response to ??.
? gene contributes significantly to this normal mucosal defence
tight
epithelial
bacteria
protect
constitutionally
abnormal bacteria
NOD2
pathogenesis of IBD
Adaptive immunity
?? cells which are part of the first line defence but there is also ? that are critical in developing adaptive immune response
Many types of T lymphocyte
- ? tends to be more of an inflammatory and disease promoting
- ? keep the inflammatory T cells in check
Crohn’s disease have over-activation of effector T cells ?
Ulcerative colitis have a ?? response and get introduction of ??? cells
antigen presenting
t lymphocytes
TH1
TH2
TH1
mixed TH1/TH2
natural killer T
name 2 environmental triggers for IBD
smoking
NSAIDs
how does smoking affect IBD - ulcerative colitis and Crohn’s
aggravates Crohn’s - narrowing of small bowel and colon which causes them to have obstructive GI symptoms, and can increase symptoms of nausea and vomiting
Protects against ulcerative colitis
what is ulcerative colitis?
Inflammation of colon of unknown aetiology affecting the rectum and progresses proximally
symptoms of ulcerative colitis 4
Diarrhoea and bleeding
Problems defecating and urinating
what in the pt history indicates risk of ulcerative colitis?
Recent travel
Antibiotics
NSAIDs
Family history
Smoking
what investigations (generally) are taken for ulcerative colitis? 4
blood test
abdominal x-ray
endoscopy (biopsy)
histology of biopsies
what blood tests are taken to investigate ulcerative colitis?
C-reactive protein - rise in response to inflammation
Albumin - negative acute phase reactant - low albumin indicated inflammation
Platelets - thrombocytosis indirect marker - low platelets
what could be seen in an endoscopy for ulcerative colitis?
Loss of vessel pattern, granular mucosa, contact bleeding
Pseudo polyps
what is seen when investigating the histology of ulcerative colitis?
Lose goblet cells and get expansion of crypts that can lead to abscess formation
Only affects the mucosal layer
what is Crohn’s disease?
chronic inflammation affecting any region of the GI tract from the anus to the mouth
how does Crohn’s disease differ from ulcerative colitis?
transmural inflammation - fistulas (abnormal connections) between different parts of the small bowel, it can also cause stretching or narrowing to occur
histologically - cobblestone appearance in Crohn’s but pseudopolyps in ulcerative colitis
symptoms of Crohn’s disease are determined by what?
the site of the disease
symptoms of Crohn’s disease?
Weight loss
abdominal pain, watery diarrhoea and perianal involvement
Mouth ulcers, swollen lips, angular cheilitis
mouth specific symptoms of Crohn’s disease
Mouth ulcers, swollen lips, angular cheilitis
what blood tests are done for Crohn’s disease
CRP, albumin, platelets, B12, ferritin, FBC
If last section of small bowel is affected then B12 will be affected, this will affect ability to absorb iron so ferritin may be low
oral manifestations of IBD
Ulcers that are deep, aggressive and don’t respond to treatment
Tend to have poorer oral hygiene and have predisposition to dental caries
Oral manifestations and abnormal bowel troubles can be a sign of a flare so refer them to secondary care
what lifestyle advice is given to manage IBD
Avoid smoking as it aggravates Crohn’s, worse disease outcome and rapid recurrence post-surgery
Diet - > balanced and healthy
- Stricturing/fistulating Crohn’s -> low fibre, elemental diet, strict gut rest (parenteral nutrition)
what drugs are used for an acute flare of ulcerative colitis?
steroids
Anti-inflammatory
Rapid remission of acute flares
Short course of high dose initially - need vitamin D3 supplements
Not a long term maintenance therapy
what drugs are used for maintenance of ulcerative colitis?
5-ASA (mesalazine)
immunosuppressants
biologics
jack inhibitors
what drugs are used for an acute flare of Crohn’s disease?
steroids
Anti-inflammatory
Rapid remission of acute flares
Short course of high dose initially - need vitamin D3 supplements
Not a long term maintenance therapy
what drugs are used for maintenance of Crohn’s disease?
immunosuppressants
biologics
biologics mechanism of action on IBD
Infliximab/adalimumab -> blocks ?? pathway and promotes ? of activated ??, has a ? affect
Ustekinimab -> blocks ?? - proinflammatory pathways to try and regulate the activation of the immune system within the ??
- If pt are needing any extractions or extensive work done get in touch with secondary care for advise
Vedolizumab -> ? specific biologic, stops the activated cells moving ? the ??
TNF alpha
apoptosis
T cells
systemic
IL 12/23
bowel wall
gut
into
gut wall
jack inhibitors mechanism of action on IBD
Impacts on the expression of ? that drive the inflammatory process.
? are messenger molecules that once activated are used to ? the inflammatory process
When cytokine hits the target JAK ? it so you cant get the movement of other molecules into the ? of the cell to ? the expression of the cytokine ?
Tofacitinib, Upacitinib, Filgotinib
cytokines
cytokines
propagate
blocks
nucleus
promote
genes
understand
Surgery for IBD
Emergency - failure to respond to medical therapy, small bowel obstruction, abscess, fistulae
Elective - failure to respond to medical therapy, dysplasia of colon mucosa
understand
Therapy pyramid for IBD drugs
- Steroids if required
- 5-ASA (UC)
- Immunosuppression
- Biologics
- JAK inhibitors
why does bowel cancer generally mean colonic cancer?
tumours are possible within the small intestine but are unusual and more likely to be a lymphoma.
Bowel cancer screening programme in the UK from what age?
50
symptoms of bowel cancer
No symptoms until the tumour completely blocks the bowel and the pt presents with obstruction
Bleeding from the tumour can lead to anaemia and rectal blood loss
what is the medical name of colon cancer?
colonic carcinoma
Aetiology of colonic carcinoma
Most arise from polyps in the surface of the lumen, these will grow and progress into tumours
If the polyps are removed cancer will not develop
Bowel cancer screening (endoscopy) aims to detect polyps before they are cancers. If polyps found screening reduced from every 5yrs to 2yrs
Polyps often bleed due to irritation and trauma from bowel contents passing
Polyps take 5 years to develop to malignancy
polyps
lumen
tumours
cancer
endoscopy
before
5yrs
2yrs
bleed
irritation
trauma
contents
5yrs
aetiological factors for bowel cancer 7
Diet -> low fibre, high fat, high meat, low veg
Smoking
Alcohol
Low exercise
Genetics - P53
Ulcerative colitis
Intestinal polyps
what is intestinal polyposis?
Genetic tendency to form a lot of polyps in the bowel which are each at a risk of developing cancer
name the condition when intestinal polyposis occurs in the small intestine?
Peutz-Jehgers syndrome
oral manifestation of peutz-jehgers syndrome
Pt gets perioral melanosis but gets polyps in the small intestine
name 2 conditions where intestinal polyposis occurs in the large intestine
Gardiner’s syndrome
Cowden’s syndrome
oral manifestation of cowden’s syndrome
Mucosal polyposis where polyps are present throughout the mouth as well as throughout the bowel. Mouth polyps do not develop into oral cancer
how is colon cancer staged?
according to level of invasion into the bowel wall
Dukes classification
list the Dukes classification
A submucosal
B muscularis
C lymph nodes
D liver
how is colon cancer treated? 3
Surgery
- Removal of colon with cancer resulting in a stoma and colostomy bag
Radiotherapy
Chemotherapy
how is colon cancer screened?
FiT test - faecal immunochemical test
- every 2 years if negative
- If positive endoscopy
dental erosion / NCTSL can be caused by acidic diet, GORD and excessive vomiting (bulimia, morning sickness)
what is the most common sites for dental erosion?
palatal surface of upper anteriors
oral manifestations of coeliac disease are due to nutritional deficiencies from malabsorption
name 3 oral manifestations
Oral Aphthous ulceration - ovoid, creamy centre, erythematous or halo border
Glossitis - tongue depapillation
Angular cheilitis - deficiency in iron, folate or vit B12
oral stigmata of crohn’s disease
Facial/labial swelling - most common sign
Ulceration - aphthous or linear common in buccal sulci
Mucosal tags
Cobblestone mucosa - due to granulomatous inflammation and oedema of tissues
Staghorning - raised submandibular ducts due to tissue swelling
Angular cheilitis
Perioral dermatitis
Inflammatory gingivitis - inflammation far exceeds the area expected from gingivitis
what is orofacial granulomatous?
Chronic inflammation of the orofacial region characterised by non-caseating granulomas on histopathology
what is the cause of orofacial granulomatous?
Unsure of cause but most likely due to hypersensitivity to preservatives in food
clinical presentation of orofacial granulomatous
Similar presentation to oral Crohn’s disease but absence of GI involvement
what distinguishes orofacial granulomatous and oral Crohn’s?
If linear ulceration, scarring and elevated inflammatory marker in blood test oral Crohn’s disease is more likely
ulcerative colitis oral manifestations
Oral manifestations are rare
Aphthous ulceration
Angular cheilitis
Glossitis
Pyostomatitis Vegetans
Micro-abscesses and pustules which burst leading to ulceration. Cobble stoning and raised exophytic growths (vegetations) can also occur
