gastroenterology Flashcards
key questions in hx of dysphagia
duration solids/liquids pain weight loss - red flag (malignancy) previous med history - HIV? (oral candidida) systemic sclerosis? (affects motility) medications - anticholinergics/opioids cigarettes + alcohol where the problem is - oropharyngeal/oesophageal/gastric?
what would cause oropharyngeal dsphagia
salivary - sjorgrens
tongue - amyloid, hypothyroidism, MND
palatal/epiglottal/ upper oesophageal disorder - CVD, MND, Parkinsons
what would cause oesophageal dysphasia
benign mucosal disease - benign peptic stricture, oesophageal web (plummer vinson syndrome), candidial oesophagitis
malignant mucosal disease - carcinoma
motility disorders - oesophageal spasm, achalasia, oesophageal pouch
pharyngeal pouch what is it pres ix mx
defect between constrictor and transverse cricopharyngeal muscle
through killian’s dehiscence
pres foul taste struggle to swallow 5 x more common in men regurg aspiration neck swelling which gurgles on palpation
ix
barium swallow with fluroscopy
mx
surgery
mx of dysphagia
treat underlying cause
pro-kinetic - domperidone + metoclopramide - arrhythmias + long QT syndrome
nutrition? oral supplements, nasogastric feeding, PEG feeding
upper GI bleed differentials
oesophagitis peptic ulcer no diagnosis varices/portal hypertensive gastropathy erosive duodenitis or gastritis mallory-weiss tear malignancy vascular malformations
RF - upper GI bleed
NSAIDS apsirin anticoag h pylori alcohol corticosteroids
assessing GI bleeds scoring systems
rockall - determines mortality - use when have undergone endoscopy
glasgow blatchford scoring - tool that help discriminate whether they need inpatient or outpatient (discharge score) - stratifies patients on their risk and hence whether they need to stay in or not
endoscopic treatments for GI bleed
should be provided within 24 hours adrenaline injection ablative techniques - heat mechanical - clips banding techniques - for variceals
post endoscopy care in upper GI bleed
PPI or H2RA
H.pylori - ensure eradicated
varices secondary prevention - beta blockers
gastric ulcer - rescope in 6-8 weeks as may be malignant (if not healed biopsy it)
rebleed - rescope
evidence of iron deficient anaemia in ix
low hb
low ferritin
microcytosis
hypochromia
test to assess the colon - in order of preference
colonoscopy(1 in 1000 risk of tear)/flexible sigmoidoscopy (invasive) virtual colonoscopy (CT pneumocolon) CT with long oral prep (older/frail pts) colon capsule
what is definition of diarrhoea
the passage of 3+ loose or liquid in stools in 24 hrs
dysentry definition
+ mucus + blood in stools
classifying diarrhoea - four mechanisms
osmotic
- osmotic laxatives - lactulose
- lactulose/fructose intolerance
secretory
- defects of ion absorption, stimulant laxatives, gut hormone (VIPpmas/gastrinomas), enterotoxins (eg vibrio cholera)
malabsorption
- pancreatic insufficiency
- crohn’s disease
- celiac disease
abnormal motility
- post vagotomy
- IBS
- carcinoid
MOST IS MUTLIFACTORIAL
ix of IBD
bloods - FBC, CRP + U&E, LFTS stool culture and micro abdo xray ileo-colonoscoy small bowel ix - MRI small bowel/CT enterography/ capsule endoscopy
UC criteria
truelove + witts
staging severity
mild, mod, severe
mx IBD
steroids
truelove and witt (UC classification)
anticoag - Dalteparin
review for extra-intestinal manifestations
escalation review at day 3 - stool freq/CRP/albumin
-> surgery/infliximab/ciclosporin
coeliac dx
- immunoglobulins (look for IgA deficiency - can cause false negative antibody results) + TTG antibodies
- endomysial antibodies where about indeterminate
- OGD + duodenal biopsys (villous atrophy at histology)
when to transfuse in GI bleeds
shouldnt be transfusing unless haem drops below 70g/l unless have cardiovascular symps (aim for above 80g/l)
very poor looking ulcers that are squirting what do you prescribe in post endoscopy care?
IV PPI
ix chronic diarrhoea
RBC CRP TFT Coeliac serology stool sample
if have cancer or inflam red flags then add on endoscopy and CT
compare crohns/UC
crohns: terminal ileum skip lesions, mucus cobblestoning transmural - granulomas, focal crypt abscesses, increased goblet cells crampy abdo pain comps: fistulas, abscess, obstruction string sign + rose thorn ulcers on barium x-ray slight increased risk for colon cancer surgery for comps such as stricture
UC: rectum proximally continguous submucosa or mucosa - focal crypt abscess, goblet cells depletion ulcers, polyps bloody diarrhoea comps: haemorrhagic, toxic, megacolon lead pipe colon (narrow + short), loss of haustrations on barium xray marked increase in colon cancer curative surgery
symptoms of coeliac:
typical
atypical
silent
TYPICAL diarrhoea steatorrhoea weight loss dermatitis herpatiformis
ATYPICAL ataxia peripheral neuropathy ammenorhoea infertility chronic fatigue
SILENT IDA osteoporosis hyposplenism abnormal LFTs
upper GI bleed pres causes + classic features ix mx
pres haematemesis (bright red = above stomach/active haemorrhage, coffee ground = stomach or below) +/or malaena (bleeding in small bowel) epigastric discomfort sudden collapse haemodynamic instability -> initiate glasgow blatchford score
causes
OESOPHAGEAL
1. oesophagitis - small fresh blood streaking vomit. malaena rare. ceases spont. hx of GORD.
2. cancer - usually small volume of blood, unless erosion of major vessels. dysphagia, b symps
3. mallory weiss - brisk small to mod volume of bright red blood following bout of repeated vom. malaena rare. ceases spont. alc or hyperemesis gravidarum
4. varices - large fresh blood. swallowed blood may cause malaena. haemodynamic comp. may stop spont but re-bleeds are common.
5. oesophageal rupture (boerhaave syndrome) - triad of vomiting, chest pain and subcut emphysema
GASTRIC
- cancer - frank haematemesis, prodromal dyspepsia, b symps, variable amounts of bloof
- diffuse erosive gastritis - haematemesis and epigastric discomfort, usually underlying causes eg NSAIDs, haemodynamic comp
- gastric ulcer - small low volume bleeds, iron deficiency anaemia, erosion into vessel = signifcant bleed + haematemesis
DUODENUM
1. posteriorly sited duodenal ulcer = maj haemorrhage
pain of duo ulcer occurs several hours after eating
ix
glasgow blatchford score - assess need for intervention eg bloof prod/surgery/inpatient
rockall - morbidity and mortality in upper gi bleeds
raised urea
mx
ABCDE
massive haem protocol if systemic comp - only reg can do this
2 large bore cannulas
2 x units blood (o D-), xmatch, FBC, U+E + ur/cr, LFTs, coag, fluids (441 RBC, FFP, platelets)
TXA
CXR, ECG, ABG, catheter, reg monitoring
ODG - find cause + mx (patients with suspected varices should receive terlipressin + proph broad spec abx) within 24 hours - sclerotherpy/banding
balloon - sengstaken blakemore tube (minnesota tube)
oesophagitis/gastritis? PPI
All who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate.
ALL gastric ulcers need endoscopic follow up - NO duodenal do
acute diarrhoea definition causes red flags ix mx comps prognosis
Diarrhoea: > 3 loose or watery stool per day
Acute diarrhoea < 14 days
causes
gastroenteritis - +abdo pain or n+v
diverticulitis - classically causes left LQ pain and diarrhoea/fever
antibiotics - some broad spec, cytotoxic, PPI, NSAID, metformin, thyroxine, SSRI, statin, c.diff is also seen with abx use
constipation causing overflow - hx of alternating diarrhoea + constipation, may lead to faecal incontinence in elderly
red flags Blood (CMV, shigella, salmonella, c.jej, e.histolytica), recent ABX (c.diff), vomiting, weight loss, watery + high volume (dehydration)
ix
assess for dehydration
stool sample for culture and sensitivity
mx supportive: fluid intake and nutrition only use drugs when clear cause when to admit: - vomiting and cant keep down - features of shock/dehydration - bloody diarrhoea
comps
reactive arthritis
lactose intolerance
IBS
prognosis
most improve 2-4 days
cause of diarrhoea in traveller
ETEC e.coli - enterotoxinogenic
watery stools
abdo cramps
nausea
cause of diarrhoea in abx use
c.diff - vancomycin
cause of diarrhoea in HIV
CMV
cause of diarrhoea in small children
rotavirus
cause of diarrhoea in well water
giardiasis
prolonged
non-bloody
cause of diarrhoea in puppies
camplyobacter
flu-like prodrome -> crampy abdo pains fever, diarrhoea that may be bloody,
may mimic appendicitis
comps = Guillain-Barre Syndrome
cause of diarrhoea in cruise ships
norovirus
cause of diarrhoea in dystentry/bloody + mucuous
shigella
cause of diarrhoea in profuse vomiting within 6 hours of food
s.aureus (food handlers), bacillus cereus (rice)
cause of diarrhoea in ab cramp and profuse watery
v.cholera - rice water stools
severe dehydration resulting in weight loss
profuse, watery
cause of diarrhoea in Fever + ab cramp + bloody + milk/meat
campylobacter jejuni
cause of diarrhoea in Fever + ab cramp + bloody + salad
shigella
cause of diarrhoea Fever + ab cramp + bloody + poultry/shellf
salmonella
antidiarrhoeal agents
loperamide
diphenoxylate
opioid agonists so also reduce gut motility
cause of gradual onset diarrhoea, abdo pain, tenderness which may last for several weeks
amoebiasis
UC what is it types pres + extra-intest ix mx comps
form of IBD
always starts at rectum and works it way back but never beyond ileoceacal valve
types
40% proctitis - rectosigmoid
30% left sided colitis (to splenic flexure)
20% pancolitis
SMOKING DECREASES RISK
pres 15-25 + 55-65 bloody diarrhoea urgency tenesmus abdo pain - LLQ extra intestinal: - primary sclerosing cholangitis - uveitis - episcleritis - colorectal cancer -arthritis - erythema nodosum - pyoderma gangrenosum - clubbing -osteoporosis - ankylosing spondilitis
ix 1. FBC - all decreased U+E, LFT ESR/CRP - high in active 2. faecal calprotectin - IBS vs IBD 3. stool culture and micro incl CMV + c.diff 4. p-ANCA 5. barium enema - loss of haustrations - superficial ulceration - pseudopolyps - long standing disease: colon is narrow and short - 'drainpipe colon' 6. FIRST LINE: flexible sigmoidoscopy with rectum biopsy (x2 from 5 sites including distal ileum and rectum): - red, raw mucosa that bleeds easily - up to submucosa - widespread ulceration - pseudopolyps - inflam cells in lamina propria - neutrophils migrate through walls of glands to form crypt abscesses - depletion of goblet cells + mucin - infrequent granulomas 7. AXR - toxic megacolon
mx
aim: inducing and maintaining remission
INDUCING
mild/mod -
- rectal? = topical aminosalicylate - no remission in 4 weeks + oral, then still no? + topical or oral corticosteroid
- rectum/sigmoid/ left colon? = topical aminosalicylate, if remission not achieved <4 weeks ->+ high-dose oral amino OR switch to high-dose oral amino + topical corticosteroid -> still no? then both oral
- extensive? = topical amino + high-dose oral amino -> no in 4 weeks? stop topical + both oral
severe colitis
-> admit, IV steroids (ciclosporin given if steroid CI), if no improvement after 72 hours consider + IV ciclo or surg.
MAINTAINING
mild/mod - topical or oral aminosalicylate
severe or >/= 2 exacerbations/year -> oral azathioprine or oral mercaptopurine
comps
x2 risk of colorectal cancer
toxic megacolon by opiates
osteoporosis if steroids
UC flares classification
technically this is truelove and witts criteria
mild
- fewer than 4 stools a day with or without blood
- no systemic
- normal ESR and CRP
moderate
- 4-6 stools/day
- minimal systemic
severe
- >6 stools/day containing blood
- evidence of systemic disturbance eg
fever, tachycardic, abdo tenderness, distension or reduced bowel sounds, anaemia, hypoalbuminaemia
if severe should be admitted
what is an aminosalicylate
mesalazine
5-aminosalicylic acid
crohns what is it cause pres + extraintestinal ix mx comps
type of IBD commonly affects terminal ileum + colon but anyway from mouth to anus occurs in all layers hence why common to have strictures, fistulas, adhesions chronic relapsing/remitting
cause
unknown but strong genetic
pres late adolescence or early adulthood non-specific eg weight loss/lethargy diarrhoea abdo pain perianal disease - skin tags/ulcers extra-intestinal: - primary sclerosing cholangitis - uveitis - episcleritis, conjunctivitis - fatty liver - colorectal cancer -arthritis - sacrolitis - erythema nodosum - pyoderma gangrenosum - clubbing -osteoporosis - ankylosing spondilitis
ix FBC (all low), U+E, LFT CRP/ESR -raised faecael calprotectin - raised vit b12/D low stool culutre + micro ileocolonoscopy + biopsy - deep ulcers, skip lesions - inflam in all layers -> serosa - goblet cells - granulomas small bowel enema - strictures (kantors string sign), proximal bowel dilation, rose thorn ulcers, fistulae
mx
stop smoking
NSAIDs/pill avoid
INDUCING REMISSION
glucocorticoids (oral pred/IV hydro) - oral/topical/IV or budesonide
enteral feeding
mesalazine (aminosalicytes 5-ASA) are used second line
azathioprine or mercaptopurine or methotrexate used as an add on
metronidazole used for isolated peri-anal disease
MAINTAINING stopping smoking azathioprine/mercaptopurine = FIRST LINE methotrexate = SECOND LINE 5-ASA if had prev surg surgery - 80% of patients eventually have surgery
complication
small bowel cancer
colorectal cancer
osteoporosis
what must you assess before prescribing azathioprine or mercaptopurine?
thiopurine methyltransferase (TPMT) activity
coeliac what is it associated disorders who should be screened? pres ix mx comps
what is it
autoimmune condition caused by sensitivity to protein gluten
repeated exposure -> villous atrophy -> malabsorption
conditions associated
- dermatitis herpetiformis (vesicular, pruritic skin eruption)
- autoimmune - T1DM, autoimmune hepatitis
- HLA-DQ2/8
who should be screened? Autoimmune thyroid disease Dermatitis herpetiformis Irritable bowel syndrome Type 1 diabetes First-degree relatives (parents, siblings or children) with coeliac disease
pres chronic/intermittent diarrhoea FTT in kids persistent or unexplained GI symps - n+v prolonged fatigue bloating abdo pain cramping iron-deficiency anaemia steatorrhoea
ix
diagnosis = immunology and jejunal biopsy
should have been exposed to gluten for at least 6 weeks prior to testing
immunology -> tissue transglutaminase antibodies (IgA), endomyseal antibody (IgA), anti-gliadin antibody (IgA or IgG) not recommended by NICE
biopsy (x4 from D2 onwards) - villous atrophy, crypt hyperplasia, increase in intraepithelial lymphocytes, lamina propria infiltration with lymphocytes
complications - anaemia: iron, folate + b12 deficient hyposplenism osteoporosis osteomalacia lactose intolerance enteropathy-associated T-cell lymphoma of small intestine subfertile, unfavourable preg outcomes oesophageal cancer small bowel adenocarcinoma dental probs buttock wasting in children
mx GLUTEN FREE DIET fucking obviously things that include gluten: - wheat (bread, pasta, pastry) - barley - beer (whisky is fine) - rye - oats foods that are gluten free - rice, pots, corn IMMUNISATION - pnemoococcal + booster every 5 years
whats criteria called to grade severity of coeliac
marsh criteria
chronic diarrhoea
define
causes
Diarrhoea: > 3 loose or watery stool per day >14 days
causes IBS UC Crohns colorectal cancer coeliac thyrotoxicosis laxative abuse appendicitis radiation enteritis
normal gut flora
functions
> 400 species of bacteria
mainly anaerobes
functions:
- bacterial enzymes aiding reabsorption back across the intestinal wall (bilirubin, bile acids, cholesterol, drugs)
- digestion of fibre
- metabolism of certain vitamins - vit k
- synthesis of B12, folic acid, thiamine
- interfere and compete with exogenous pathogens preventing infection
intestinal obstruction
causes
intraluminal
- tumour
- diaphragm disease (fibrose)
- meconium ileum
- gallstone ileus
bowel wall - intramural
- inflammatory - crohns, diverticulitis
- tumours
- neural - hirschsprungs disease
outside the bowel pressing on it - extraluminal
- adhesions
- volvulus
- tumour - peritoneal deposits
what does ileus mean
non-mechanical obstruction
paralytic ileus = bowel inactivity
what is the most common intestinal obstruction
and what does it increase the risk of
small bowel obstruction or colorectal malignancy
increases risk of: volvulus impaction constipation megacolon if dementia alzheimers parkinsons
intestinal obstruction causes pres specific pres for: - sigmoid volvulus - paralytic ileus ix mx
CAUSES
adhesions, hernias, malignancy!!
small = adhesions (75% - from prior operations), strangulated hernia, malignancy or volvulus, crohns, paralytic ileus, intussusception
large = colorectal malignancy (>70),
increased risk further down bowel as faeces more solid, diverticulum, sigmoid volvulus, crohns
volvulus = Rotation of gut on mesenteric axis - sigmoid (= 5% all obs) or caecal
paralytic ileus = Bowel ceases to function and no peristalsis. *Intestinal pseudo-obstruction or Ogilvie’s
From massive dilatation of colon: associated with chest infection, MI, stroke, AKI
post-operative ileus - from handling of the bowel
congenital - neonatal obstruction eg CF
other - hirshprungs - aganglionic section of the bowel
PRES
Nausea, vomiting (early in high-level, faeculent in low level),
abdominal pain (diffuse, central, abdominal, colicky),
failure to pass bowel movements, constipation (early in low level, late in high-level)
Abdominal distension (larger the lower the blockage),
high pitched bowel sounds (tinkling) - more in small bowel,
tympany due to air filled stomach or hyperresonant bowel,
silent bowel = ileus
SPECIFIC PRES
sigmoid volvulus = like large bowel with pain, constipation, late vomiting, marked distension + previous episode
paralytic ileus = often in the elderly with autonomic imbalance resulting in sympathetic over-activity in colon
*Severe pain, tenderness, pyrexia in ischaemia and perforation (acute abdomen with peritonism)
FIRST - drip + suck
- NBM
- IV fluids
- NG tube on free drainage
ix
fluid balance
plain AXR - supine and erect:
- distended loops of proximal bowel (>3cm small, >6cm colon, >9cm caecum)
- loss of haustra
- fluid levels and distended small bowel throughout = paralytic ileus
- gas under diaphragm + riglers sign = perf (pneumoperitoneum)
- laddering small bowel in SBO
CT - confirm
mx
FBC, UE, Cr, G+S
uncomplicated-> fluid resus + correct electrolytes, intestinal decompression eg endoscopy, NG tube (drip+suck)
no clear diagnosis? laparotomy + consent for stoma
early surg if peritonitis or evidence of perf
baso rx cause
who are calciums two ugly sisters
magnesium + phosphate
explain how the body works to increase serum calcium if its low
- pituitary gland tells parathyroid glad to release PTH
- this works on bone to release calcium (99% of calcium is stored in bone) and phosphate
- PTH also works on kidneys as it stimulates 1a-hydroxylase to activate vit D (produces 1,25 dihydroxy vit D3 - active version of vit d) - this active vit d also stimulates bone to release calcium and phosphate. it also works as negative feedback on PTH to stop this process overdoing it. PTH also acts on distal convuluted tubule to absorb calcium
- 1,25 dihydroxy vit d3 also works on gut to absorb more calcium and phosphate + proximal convuluted tubules in kidney to absorb more calcium
- in the
how your body works to decrease serum calcium
high serum calcium stimulates the thyroid gland to produce calcitonin (this has opposite effect to PTH)
what percent of phosphate, mg, ca is located in the bone
phosphate - 85% (rest is intracellular)
magnesium - 60%
calcium - 99%
calcium phosphate makes up hard matrix of bone
magnesium helps strengthen it
phosphate homeostasis - if its low
stimulates 1a-hydroxylase in the kidneys to create 1,25 OHD (calcitriol) which acts on the gut to stimulate phosphate, vit d and calcium absorption
also the PTH on the calcium cards - works for this too
whats more dangerous hypo or hyper magnesium/phophate?
hypo
magnesium amount in body functions RDA and where to get it absorption/excretion in body
after potassium its the most abundant intracellular cation
only 1% of the bodys amount in extracellular space
functions
- co-factor in dna + protein synth, oxidative phosphorylation
- enzyme cofactor
- neuromuscular excitability - ca channel antagonist
- pth secretion and function
RDA - 300mg/d
found in cereals, green veg, beans, nuts
absorbed in small intestine
80% filtered in glomeruli (rest is probs bound to protein) - nearly all reabsorbed in loop of henle
hypomagnesium classification causes clinical effects ix mx
low - get symps if <0.5mmol/L
severe if <0.4mmol/L
causes of hypomag
- decreased intake (alcoholism, IV fluids or Total Parenteral Nutrition)
- increased losses (diarrhoea, malabsorption, fistula, renal tubular disorders, diuretics, aminoglycosides, cisplatin, PPIs, hypercalcaemia)
- redistribution (acute panc, ‘hungry bones’ syndrome)
clin effects
similar to hypocalcaemia
NEUROMUSCULAR
weakness, parasthesia, tetany
chvostek and trousseaus signs - independant of low ca (increased neuromuscular excitability)
seizures, confusion, coma
CARDIO
ECG - arrythmias/arrest (similar to hypokalaemia)
METABOLIC
hypokalaemia due to renal loss of K+ (as magnesium is required for retention and absorption of K in the kidney)
hypocalcaemia - due to low PTH and resistance
exacerbates digocin toxicity
ix
lab will usually add on magnesium test if they see low k or calc
mx
magnesium must be replaced before K+ and Ca supplements will work
severe or mod with symps - IV Mg then oral (40mmol/day)
mild/mod - oral - magnaspartate (10mmol/sachet)/day
- this can cause diarrhoea (oral mag salts)
identify and rx cause!!!
hypermagnesaemia
uncommon as requires very high intake and renal impairment
or IV mg (eg in pre-eclampsia + eclamptic fits)
no effects until >2mmol/L, usually higher
clinical effects
loss of deep tendon reflexes, flaccid paralysis, mental changes
cardio - brady + hypotensive
