Gastroenterology Flashcards
Mechanical causes of dysphagia
Malignancy - pharyngeal, oesophageal, gastric cancers
Benign strictures - oesophageal web, peptic stricture
Extrinsic pressure - lung cancer, mediastinal LNs, aortic aneurysm, retrosternal goitre
Pharyngeal pouch
Motility disorders that cause dysphagia
Achalasia
Oesophageal spasm
Systemic sclerosis
Neurological bulbar palsy - Parkinson’s disease, MG, multiple sclerosis, CVA
Dysphagia - Causes of difficulty swallowing solids and liquids from the start?
Motility disorder - achalasia, CNS, pharyngeal
Dysphagia - causes of difficulty swallowing solids and then liquids
Stricture - malignancy and benign stricture
Dysphagia - causes of difficulty initiating swallowing movement
Bulbar palsy - especially if patient coughs on swallowing
Dysphagia - causes of painful swallowing (odynophagia)
Ulceration - malignancy, oesophagitis, viral infection, candida, spasm.
Dysphagia - causes of intermittent and constant/getting worse
Intermittent - oesophageal spasm
Constant/getting worse - malignant stricture
Dysphagia - cause of neck bulge on drinking?
Pharyngeal pouch
Investigations of dysphagia
Bloods - FBC, U&E
Upper GI endoscopy and/or biopsy
For motility disorders - fluoroscopic swallowing studies
For pharyngeal pouch - contrast swallow
Symptoms of dyspepsia (including red flag symptoms)
Epigastric pain Fullness after eating Heartburn Tender epigastrium Red flags (ALARMS) - Anaemia, Loss of weight, Anorexia, Recent onset symptoms, Melaena, swallowing difficulty
Dyspepsia - Requirements of urgent referral for 2 week wait endoscopy
All patients who have got dysphagia
All patients with upper abdominal mass consistent with stomach cancer
Patients aged >= 55 years who have got weight loss and any of the following - upper abdominal pain, reflux, dyspepsia
Dyspepsia - Requirements for non-urgent referral for endoscopy
Patients with haematemesis
Patients aged >=55 years who have got either - treatment resistant dyspepsia, upper abdominal pain with low Hb levels, raised platelet count, or nausea and vomiting
Dyspepsia - management for patients who do not meet referral criteria
- Review medications for cause - eg NSAIDS
- Lifestyle advice
- Trial of full-dose PPI for 1 month OR ‘test and treat’ approach for H. pylori
Test for H.pylori
Urea breath test
Treatment for H.pylori
PPI + amoxicillin + clarithromycin for 7 days
Risk factors for peptic ulcer disease
H.pylori
Drugs - NSAIDs, SSRIs, Steroids, Bisphosphonates
Zollinger-Elison syndrome (excessive levels of gastrin)
Alcohol
Smoking
Symptoms of peptic ulcer disease
Epigastric pain
Nausea
Duodenal Ulcers - epigastric pain when hungry, relieved by eating
Gastric ulcers - epigastric pain worsened by eating
What is zollinger-ellison syndrome
Gastrin secreting tumour of either duodenum or pancreas causing excessive levels of gastrin
Features - multiple ulcers, diarrhoea, malabsorption
Diagnosis - fasting gastrin levels, secretin stimulation test
Complications of peptic ulcer disease
Bleeding, perforation, malignancy, reduced gastric outflow
Causes of GORD
Lower oesophageal sphincter hypotension Hiatus hernia Oesophageal dysmotility Obesity Gastric acid hypersecretion Smoking Alcohol Pregnancy Drugs - TCA, anticholinergics, nitrates H.pylori
Symptoms of GORD
Heartburn Belching Acid brash Waterbrash - increased salivation Odynophagia Extra-oesophageal - nocturnal asthma, chronic cough, laryngitis, sinusitis
Complications of GORD
Oesophagitis
Ulcers
Iron-deficiency anaemia
Barrett’s oesophagus (metaplasia from squamous to columnar)
Investigations of GORD
Endoscopy if dysphagia
Endoscopy if >=55 and have dysphagia, relapsing symptoms, weight loss etc
If endoscopy negative - 24 hours oesophageal pH monitoring
Treatment of GORD
Lifestyle - weight loss, smoking cessation, small regular meals, reduce alcohol, avoid eating >3 hours before bed
+ve endoscopy - full dose PPI for 1-2 months. If responding, use low dose treatment PRN. If not responding, double-dose PPI for 1 month
-ve endoscopy - full dose PPI for 1 month. If responding, use low dose PPI PRN. If not responding, H2RA or pro kinetic for 1 month.
What are the two types of Hiatus Hernia?
Sliding (95%) - gastroesophageal junction moves above diaphragm
Rolling - gastroesophageal junction remains below diaphragm, but a separate part of the stomach herniates through the oesophageal hiatus.
What is Achalasia?
Features of achalasia
Investigations for achalasia
Treatment of achalasia
Failure of oesophageal peristalsis and loss of LOS relaxation due to loss of Auerbach’s plexus ganglia.
Common in middle-aged men and women
Features - dysphagia of solids and liquids, heartburn, regurgitation of food
Investigations - oesophageal manometry (excessive LOS tone which doesn’t relax on swallowing). Barium swallow (bird’s beak appearance). CXR (wide mediastinum, fluid level)
Treatment - injection of botulinum toxin. Heller cardiomyotomy. Balloon dilation.
What’s the definition of diarrhoea
> 3 loose or watery stool per day.
Acute - <14 days
Chronic - >14 days
Lifestyle treatment of constipation
Encourage fluid intake
Diet/exercise advice
High fibre diet
Types of laxatives
Bulking agents - increase faecal mass, stimulating peristalsis. Isphagula husk, fybogel, celevac.
Stimulant laxatives - increase intestinal motility. Senna, docusate, bisacodyl
Stool softeners - arachis oil enemas
Osmotic agents - retain fluid in bowel. Lactulose, macrogol (movicol), phosphate enemas.
Symptoms and signs of Crohn’s disease
Diarrhoea - non-bloody Abdominal pain Weight loss Failure to thrive Fatigue, fever, malaise, anorexia
Extra-intestinal symptoms of Crohn’s disease
Arthritis (most common) Erythema nodosum Episcleritis Osteoporosis Uveitis Pyoderma gangrenosum
Investigations for Crohn’s disease
Bloods - FBC, ESR, CRP, U&E, LFT, INR, B12, folate, ferritin, TIBC
Stool - MC&S, faecal calprotectin
Colonoscopy + biopsy
Capsule endoscopy for proximal bowel disease
Crohn’s disease management
Lifestyle - stop smoking, avoid NSAIDs, COCP
Inducing remission - Prednisolone first line. Elemental diet. Mesalazine used second-line.
Azathioprine or mercaptopurine used as add-on therapy.
Infliximab for refractory disease.
Maintaining remission - Azathioprine or mercaptopurine used first-line.
Methotrexate second-line.
5-ASA if patient has had previous surgery.
Surgery - ileocaecal resection.
Complications of Crohn’s disease
Small bowel cancer, colorectal cancer, osteoporosis, small bowel obstruction, toxic dilatation, abscess formation.
Symptoms of Ulcerative Colitis
Bloody diarrhoea LLQ Abdominal pain Urgency Tenesmus Systemic symptoms in attacks - fever, malaise, anorexia, reduced weight
Extraintestinal symptoms of Ulcerative Colitis
Arthritis (most common) Episcleritis Erythema nodosum Pyoderma gangrenosum conjunctivitis Primary sclerosis cholangitis Uveitis Ankylosing spondylitis
Investigations of Ulcerative Colitis
Bloods - FBC, U&E, ESR, CRP, LFT, blood culture
Stool -faecal calprotectin
AXR - loss of haustrations, superficial ulceration (pseudo polyps), drainpipe colon.
Lower GI endoscopy - limited flexible sigmoidoscopy.
How to differentiate between mild, moderate and severe ulcerative colitis
Mild - <4 stools daily, no systemic disturbance, normal ESR and CRP
Moderate - 4-6 stools daily, minimal systemic disturbance
Severe - >6 stools daily, containing blood. Systemic disturbance eg fever, tachycardia, abdominal tenderness, distension of reduced bowel sounds, anaemia, hypoalbuminaemia
Signs on bowel enema in Crohn’s disease
Strictures - Kantor’s string sign
Proximal bowel dilation
Rose thorn ulcers
Fistulae
Management of Ulcerative Colitis
Induction (mild to moderate)
Proctitis - Rectal mesalazine first line. If remission not achieved in 4 weeks, add oral mesalazine. If still not remission, add topical or oral corticosteroid.
Proctosigmoiditis and left-sided UC - rectal mesalazine. If no remission within 4 weeks, add high-dose oral mesalazine. If still no remission, give oral mesalazine and oral corticosteroid.
Extensive disease - rectal mesalazine and high dose oral mesalazine. If remission not achieved within 4 weeks, stop topical and give high-dose oral mesalazine and oral corticosteroid.
Induction (severe)
Treat in hospital. IV steroids
If not improvement after 72 hours, IV ciclosporin or surgery.
Maintaining remission
Mild-moderate - rectal mesalazine daily or oral and rectal mesalazine.
Severe - oral azathioprine or oral mercaptopurine.
Key differences between CD and UC
Crohn’s disease -
Non-bloody diarrhoea
Weight loss more prominent
Upper GI symptoms, mouth ulcers, perianal disease, mass in RIF
Gallstones
Obstruction, fistula, colorectal cancer
Lesions anywhere from mouth to anus, skip lesions
Inflammation in all layers from mucosa to serosa
Deep ulcers, skip lesions (cobble-stone appearance)
Ulcerative Colitis - Bloody diarrhoea, pain in LLQ, tenesmus Primary sclerosis cholangitis Risk of colorectal cancer higher in UC Inflammation starts at rectum and never spreads beyond ileocaecal valve Continuous disease No inflammation beyond submucosa Pseudopolyps (ulceration with preservation of adjacent mucosa which has appearance of polyps.
Symptoms of malabsorption
Diarrhoea Weight loss Steatorrhoea Bloating Lethargy
