Gastroenterology Flashcards
Dyspepsia clinical features
ROME criteria
Epigastric pain
Post-prandial fullness
Early satiety
Absence of structural disease
Interfering with ADLs
- At least 3 days a week
- Over 3 months
Dyspepsia aetiology
GORD
Peptic ulcer disease - H.Pylori test!!!
Gastro-oesophageal carcinoma
Achalasia
Medication
- NSAIDs
- Steroids
- SSRIs
- Bisphosphonates
- Nitrates
Dyspepsia management
PPI trial - Omeprazole
ALARMS - 2ww referral - OGD + FBC
Upper GI red flags
ALARMS
Anaemia Loss of weight Anorexia Recent onset > 55 Melaena Swallowing difficulty
GORD aetiology
LOS fails to close
Gastric contents leak into oesophagus
Smoking Obesity Pregnancy Fatty/heavy meals Alcohol Hiatus hernia CREST
GORD presentation
CHARM B
Cough / Wheeze Hoarse voice Aspiration pneumonia Retrosternal / epigastric pain Metallic taste Belching
GORD investigations
ALARMS - 2ww referral - OGD + FBC
GORD management
Lifestyle changes
Alginate therapy - Gaviscon
Full dose PPI - 1-2 months
Response - Switch to lower dose
No response…
- Endoscopic +ve - Double PPI
- Endoscopic -ve - H2RA - Famotidine
GORD complications
Aspiration pneumonia Barrett's - Oesophageal adenocarcinoma Hoarse voice Strictures / ulcers Anaemia Oesophagitis
Achalasia pathophysiology
Loss of ganglionic cells in Auerbach’s plexus - LOS
Food fails to pass to stomach
Achalasia presentation and investigations
Solids and liquids fail to pass into stomach
Dysphagia
Regurgitaiton
Investigations
- Oesophageal manometry
- Barium swallow - Beak sign
- OGD - Rule out malignancy
Achalasia management and complications
Botox injections
Heller cardiomyotomy
Balloon stent
Nitrates / CCB - Resistant disease unfit for surgery
Complications
- Oesophageal SCC
- Perforation in surgery
Oesophageal cancer aetiology
Top 2/3 - Adenocarcinoma - Barrett’s (GORD)
Lower 1/3 - SCC - Achalasia
Risk factors
- Family history
- Smoking
- Alcohol
- Nitrosamines - Bacon, beer, cheese, milk, fish
Oesophageal cancer presentation
Progressive dysphagia
(Solids to liquids)
Cough
Hoarse voice
Dyspepsia
+ ALARMS
Oesophageal cancer investigations / management / complications / prognosis
OGD + Biopsy
CT
Management - Surgery ± Chemo/Radio
Complications - Anastomotic leak - Mediastinitis
Prognosis - Poor
Hiatus hernia
Presentation
- Dyspepsia
- Dysphagia
Investigations
- Barium swallow
- CXR
- OGD
Management - PPI / surgery
Inguinal hernias
Direct
- Posterior wall of inguinal canal
- Through Hesselbach’s triangle
Indirect
- Through deep inguinal ring
- Patent processus vaginalis
Risk factors - Increased intra-abdominal pressure
Presentation - Lump in groin - Reducible
Complications - Strangulation / obstruction
Stomach histology
D-cells - Somatostatin - Decreases stomach acid release
Parietal cells
- Intrinsic factor - B12 absorption TI
- HCl - Denatures protein, converts pepsinogen to pepsin
G-cells - Gastrin - Stimulates HCl release from parietal cells
Chief cells - Pepsinogen - Converted to pepsin by HCl - Protease
Foveolar cells - Mucus and bicarbonate
H.Pylori aetiology
Gram -ve curved bacillus
Secretes urease
Associated with…
- Peptic ulcer disease
- Gastric cancer
- MALT lymphoma
- Iron deficiency - Microcytic
- Atrophic gastritis
H.Pylori investigations
C-13 urea breath test - CI if…
- PPI for 2 weeks
- Abx for 4 weeks
Stool antigen test
Serum antibodies
Gastroscopy + Biopsy
Campylobacter-like organism (CLO) test
H.Pylori management
Triple therapy - 7-14 days
PPI + Clari + Amox
Penicillin allergy…
PPI + Clari + Met
PUD risk factors
H.Pylori
Alcohol
Drugs
- NSAIDs
- SSRIs
- Steroids
- Bisphosphonates
- Nitrates
PUD presentation
Epigastric pain
Gastric - Worse after eating
Duodenal - Relieved by eating
- Small bowel secretions are alkali
+ Back pain
PUD investigations
H.Pylori screen
Alarms - 2ww referral - OGD + FBC
No risk factors - OGD + Biopsy
- Zollinger-Ellison syndrome
- Gastrin secreting tumour
PUD management and complications
Lifestyle
Medication review
H.Pylori eradication
PPI
Complications
- Perforation - Peritonitis
- Bleeding
Posterior duodenal - Gastroduodenal artery
Gastric - Left gastric artery
Upper GI bleed DDx
Mallory-Weiss tear
- Alcohol
- Hyperemesis gravidarum
Varices - Liver disease
PUD
- Perforated artery
- Malaena
Oesophagitis - Streaky blood
Oesophageal cancer
- Weight loss
- Progressive dysphagia
Oesophageal rupture - Boerhaave syndrome
- Vomiting
- Chest pain
- Subcutaneous emphysema
Upper GI bleed investigations
FBC
U&E - Isolated Urea ^^^
Coagulation screen
Blatchford score - Assess need for intervention
Rockall score - Morbidity and mortality in upper GI bleeds
OGD - Find cause!
Upper GI bleed management
ABCDE
Massive haemorrhage protocol
2 large bore cannulas
Cross-match 2 units of blood
4:4:1 - RBC : FFP : Platelets
Tranexamic acid
Varices - Terlipressin + Abx
OGD - Sclerotherapy/banding
Balloon - Sengstaken Blakemore tube - Minnesota tube
Gastric cancer aetiology
Adenocarcinoma
Antrum
Signet ring cell
H.Pylori
Alcohol
Smoking
Diet - Spicy food
Gastric cancer presentation / investigations / management
Virchow's node - Left clavicular lymph node Dyspepsia Dysphagia GI bleed Weight loss
Investigations
- OGD + Biopsy
- FBC
- CT
Management - Surgery ± Chemo/Radio
Dysphagia DDx
Oesophageal cancer - Progressive - Solids to liquids
Candidiasis - History of DM or steroid use (inhalers)
Strictures - GORD
Hernia - Regurgitation
Neurological - Stroke, MS, MG
Systemic sclerosis - Hallitosis and regurgitation
Achalasia - Solids AND liquids
Oesophagitis - History of GORD
GORD - Dyspepsia
Intestinal obstruction aetiology
Small bowel
- Adhesions
- Crohn’s
- Intussusception
- Hernia
- Malignancy
- Paralytic ileus
Large bowel
- Cancer
- Volvulus
- Crohn’s
- Diverticular disease
Intestinal obstruction presentation
Absence of stool or flatus Distension Vomiting - Earlier in SBO Tinkling bowel sounds - SBO Abdominal pain
Intestinal obstruction investigations
Bloods - Electrolytes
AXR (+ CXR for pneumoperitoneum)
- Pneumoperitoneum if perforated - Rigler’s sign
- Distended loops of proximal bowel
- Loss of haustra
- Valvula conniventes - SBO
- Fluids level
Intestinal obstruction management
SBO - Drip and suck
- IV fluids
- NG decompression
LBO - Surgery
Paralytic ileus aetiology
Cessation of peristalsis
- Post-surgical
- Drugs - TCA and morphine
- Infection - Appendicitis / pancreatitis
Electrolyte imbalance
- HYPOkalaemia
- HYPOnatraemia
- HYPERcalcaemia
Paralytic ileus presentation / management / complications
Bowel obstruction
Absent bowel sounds - No bowel movement
Management - Treat cause
- Correct electrolyte imbalance
- NG decompression
- Surgery
- Metoclopramide - Increase bowel movement
Complications
- Necrosis
- Peritonitis
Volvulus aetiology
Torsion of the bowel on its mesenteric axis
Sigmoid
- Elderly
- Constipation
Caecal
- Crohn’s
- Pregnancy
- Adhesions
Volvulus investigations and management
AXR
- Sigmoid - Coffee bean sign
- Caecum - Fetal appearance
Management
- Sigmoid - Flatus tube insertion and rigid sigmoidoscopy
- Caecal - Surgery
Coeliac aetiology
Gluten intolerance - AI
DM1 Vitiligo Pernicious anaemia Addison's Thyroid disorders Down's
Coeliac presentation
GI
- Abdo distension
- Pale floating stools
- Steatorrhoea
- Malabsorption - Fatigue
Non-GI
- Osteoporosis
- Dermatitis herpetiformis
- Children - Buttock wasting
- Dental problems
- Subfertility
Coeliac investigations
- Anti-TTG
+ Anti-endomysial antibodies
+ Anti-gliadin
Malabsorption screen - B12, etc.
Biopsy - Jejunum - 6 weeks
- Crypt hyperplasia
- Villous atrophy
- Increased intra-epithelial lymphocytes
Coeliac management and complications
Flu vaccine - Hyposplenism
Complications
- T-cell lymphoma
- Small bowel carcinoma
- Osteoporosis
- Subfertility
- Hyposplenism - Chronic folate deficiency
- Dental problems
- Malabsorption - B12
Crohn’s presentation
Associated with PSC!
GI
- Mouth ulcers
- Abdominal pain - RIF - Dance sign
- Perianal disease
- Change in bowel habit - Tenesmus + Mucus
- Weight loss
Non-GI
- Skin - Pyoderma gangrenosum / erythema nodosum
- Eyes - Anterior uveitis
- Arthritis - Enteropathic
- Malabsorption - Fatigue
Crohn’s investigations
BBB
Bloods
- FBC - Anaemia
- Iron studies
- B12 / Folate
- ESR / CRP
- Calcium profile
Stool sample
- Faecal calprotectin
- Faecal Immunochemical Testing - Rule out carcinoma
Biopsy
- Skip lesions
- Transmural inflammation
- Goblet cells
- NC granuloma
Barium enema
- Rose thorn ulcers
- String sign
- Fistulas
Crohn’s management and complications
Stop smoking!
Acute - Topical/PO prednisolone
Long-term
- Azathioprine - Measure TPMT before prescribing!
- Mercaptopurine
- Methotrexate
Surgery - Ileocaecal resection
Complications
- Increased bowel cancer risk
- Obstruction
- Malabsorption
- Osteoporosis
UC presentation
IC valve to rectum - No anal involvement
Associated with PSC
GI
- Bloody diarrhoea
- Change in bowel habit - Tenesmus + Urgency
- No anal disease
- LIF pain
Non-GI
- Eyes - Anterior uveitis
- Skin - Pyoderma gangrenosum / erythema nodosum
- MSK - Enteropathic arthritis
UC investigations
Bloods
- FBC - Anaemia
- Iron studies
- B12 and folate
- ESR / CRP
Stool sample
- Faecal calprotectin
- Faecal Immunochemical Testing - Rule out carcinoma
Barium enema - Lead pipe!
Biopsy
- Continuous inflammation up to the submucosa
- Crypt abscesses
- Goblet cell depletion
- Pseudopolyps
UC management and complications
5-ASA - Mesalazine - Topical/oral
IV steroids - Hydrocortisone ± Ciclosporin
Complications - Toxic megacolon
Toxic megacolon
Aetiology - UC / Crohn’s
- Clari
- Cipro
- Co-amox
- Cef
- PPIs
Investigations
- Large transverse colon on AXR
- C.Diff toxin test
- WCC ^^^
Management - Met / Vanc
Diverticular disease
Mucosa herniates through muscular bowel wall
Aetiology
- Poor diet - Lack of fibre
- Drugs - Opioids, etc.
Presentation - Asymptomatic?
- Blood in stool
- Change in bowel habit
- Diverticulitis
Investigations
- FIT
- Colonoscopy
- Barium enema
- FBC
Management - Treat cause
- Stimulant laxative - Senna
Complications
- Obstruction
- Diverticulitis
- Anaemia
Diverticulitis
Infection of diverticular disease
Presentation
- Fever
- LIF pain / guarding
- Blood in stool
- Change in bowel habit
- N/V
- Urinary symptoms secondary to irritation
Investigations
- WCC
- CRP
- CXR - Pneumoperitoneum
- AXR - Obstruction
Management
- Co-amox
- IV if no improvement after 72 hours
Appendicitis
Presentation
- Fever + N/V
- Peri-umbilical pain - Radiating to McBurney’s point
- Guarding
- Spasming
- Rebound tenderness
- Rovsing’s sign - Pain in RIF when palpating LIF
Investigations
- WCC
- CRP
- Pregnancy test - Ectopic?
- Urine dip
- Septic screen
Management - Lap appy
Complications - Peritonitis / shock
Malabsorption DDx
Intestinal
- Coeliac
- Lactose intolerance
- IBD
- Short bowel syndrome
- Chronic diarrhoea - HIV
- Tropical sprue
Pancreas
- Chronic pancreatitis
- Cystic fibrosis
- Pancreatic cancer
Biliary tree
- Obstruction
- PBC
Malignancy - Lymphoma
Constipation aetiology
Stuff going in…
- Drugs - Opioids / TCA
- Low fibre diet
Endocrine
- Hypercalcaemia
- Hypothyroid
GI
- Coeliac
- IBS/IBD
- Diverticular disease
Gynae causes
- Ovarian cyst
- Ovarian cancer
- Prolapse
Constipation investigations / management / complications
Investigations
- Colonoscopy if red flags
- FIT
- Faecal calprotectin
- CRP
- Ca125
Management - Treat cause
- Bulk forming - Ispaghula husk - CI with opioids
- Osmotic - Movicol
- Stimulant - Senna - Good for opioids
- Lactulose
Complications - DO PUSH
- Diverticulosis
- Overflow diarrhoea
- Perianal disease
- Urinary retention
- Sigmoid volvulus
- Haemorrhoids
IBS aetiology and presentation
Precipitated by stress
Presentation - Criteria…
- Abdominal pain relieved by defecation and associated with change in bowel habit
+ 2 of…
- Stool change - Incomplete emptying, straining, urgency
- Bloating
- Mucus
- Worse on eating
IBS investigations and management
Anti-TTG - Coeliac FBC Ca125 FIT Faecal calprotectin - IBD ESR / CRP
Management
- Meditation / CBT
- FODMAP diet
- Pain - Mebeverine - Antispasmodic / Buscopan
- Diarrhoea - Loperamide -Opioid agonist
- Constipation - Ispaghula husk
Peritonitis
Presentation - Severe abdominal pain - Worse on movement
Aetiology
- Pancreatitis
- Appendicitis
- PUD perforation
- Diverticulitis
- Bowel obstruction / perforation
- Ovarian cyst rupture
Investigations
- AXR - Rigler’s sign
- CXR - Pneumoperitoneum
- Lipase / Amylase
- WCC / CRP
- Septic screen
Management - Treat cause
Lower GI tract ischaemia aetiology
SMA / IMA
Branch of descending aorta
Blood disorders Age - Atherosclerosis AF AAA repair Sickle cell
Lower GI tract ischaemia presentation
Abdo pain PR bleed Diarrhoea Fever Metabolic acidosis
“70 year old woman
PMH - AF/CVD
Presents with central abdo pain, pyrexia, diarrhoea, blood PR
ABG shows metabolic acidosis”
Lower GI tract ischaemia investigations and management
ABG - Metabolic acidosis
AXR - Thumbprinting
CT
Management
- LMWH
- Surgery
Bowel cancer aetiology
Most common
- Rectum
- Sigmoid
Poor diet Family Hx PJS - Peutz-Jeghers syndrome FAP - Familial adenomatous polyposis Crohn's Smoking HNPCC
Bowel cancer presentation and investigations
Change in bowel habit
PR bleeding
Weight loss
Obstruction
Investigations
- FIT screening - 60-74 - Every 2 years
- CEA - Marker
- PR exam
- Colonoscopy and biopsy
- CT
Bowel cancer staging and management
DUKE’S
- Lamina propria
- Muscle
- Lymph nodes
- Distant mets
Management - Hemicolectomy ± Radio/Chemo
PR bleed differentials
Haemorrhoids Colonic cancer Gastroenteritis Intussusception Ischaemia Diverticular disease Anal fissure Crohn's
Haemorrhoids pathophysiology
Large vascular cushions in the anal canal
External - Below dentate line - Prone to prolapse
Internal - Above dentate line - Less prone to prolapse
Haemorrhoids risk factors
Low fibre diet
Chronic constipation
Straining
Chronic cough
Pregnancy
Obesity
Haemorrhoids presentation / investigations / management / complications
PR bleed - Fresh blood
Painless
Anal itch
Investigations - DRE + Proctoscopy
Management
- Manage RFs
- Anaesthetic
- Rubber band ligation
Complications - Anaemia
Pseudo-obstruction pathophysiology
Oglive syndrome
Dilatation of colon due to adynamic bowel
Absence of mechanical obstruction
Caecum and ascending colon - Most common
Pseudo-obstruction aetiology
Electrolyte imbalance
- HYPERcalcaemia
- HYPOthyroid
- HYPOmagnesaemia
Drugs
- Opioids
- CCBs
- Anti-depressants
Recent surgery, illness, trauma - MI?
Neurological disease
- Parkinson’s
- MS
- Hirschsprung’s
Pseudo-obstruction clinical features
Abdo pain and distension Constipation ± Overflow diarrhoea Vomiting - Late feature Distended tympanic abdomen SNT - Tenderness indicates ischaemia
Pseudo-obstruction DDx and investigations
DDx
- Mechanical obstruction
- Paralytic ileus
- Toxic megacolon
Investigations
- Investigate cause
- AXR - Bowel distension
- CT-CAP with IV contrast
Pseudo-obstruction management and complications
Conservative - NBM + Drip/Suck
Endoscopic decompression
Surgery - Resection ± Anastomosis
Complications
- Toxic megacolon
- Bowel ischaemia
- Perforation
Perianal abscess pathophysiology
Collection of pus within SC tissue of anus
Tracked from tissue surrounding anal sphincter
E.Coli or Staph.A
Associated with…
- IBD - Crohn’s
- DM
- Malignancy
- Anorectal conditions
Perianal abscess clinical features / investigations / management
Pain around anus - Worse on sitting
Hardened tissue
Pus-like discharge
Longstanding - Systemic infection - Fever and tachycardia
Clinical diagnosis ± DRE
Investigate underlying cause
Management - I&D under LA - Heals in 3-4 weeks
Anal fissure aetiology
Split in the skin of distal anal canal
Risk factors
- Hard stool
- Pregnancy - 3rd trimester
- Opiate analgesia - Constipation
- IBD
- STIs - HIV, syphilis, herpes, etc.
Anal fissure clinical features
Intermittent!
Pain on defecation - “Like passing glass”
Tearing sensation on defecation
Fresh blood in stool or on paper
Anal spasm
Anal fissure management
Acute - Conservative
- High fibre diet
- Adequate fluid intake
- Bulk forming laxative - Ispaghula husk
- Lubricants - Prior to defecation
- Topical anaesthetic
- Analgesia - Topical GTN / Diltiazem
Chronic - As above, and consider…
- Surgery - Sphincterotomy
- Botulinum toxin
Perianal fistula aetiology
Abnormal connection between anal canal and perianal skin
IBD
Systemic disease - TB, DM, HIV
History of anal trauma
Previous radiotherapy
Perianal fistula clinical features / investigations / management
+ Classification
Intermittent or continuous discharge onto perineum
- Blood
- Mucus
- Pus
- Faeces
Examination - DRE
- Proctoscopy
- MRI - Complex fistulae
Goodsall rule
Park’s classification system
Management
- Conservative
- Surgical - Fistulotomy / Seton placement
Pilonidal disease
Young men of working age
Ingrowing hair follicle
Chronic inflammation
Clinical features
- Discharge
- Pain/swelling
- Sinus tracts
Asymptomatic - Hair removal and local hygiene
Symptomatic
- Surgical closure
- Amox
- Hair removal
- Paracetamol
Gastroenteritis aetiology and clinical features
E.Coli
Contaminated food products
Foreign travel
Poor hygiene
Extremes of age
Clinical features
- Diarrhoea
- Abdo pain / discomfort
- Volume depletion
- Fever + N/V
Gastroenteritis investigations and management
Stool cultures within 3 days of admission WCC ^ Urea ^ Creatinine ^ HYPOkalaemia
Management - Supportive - Fluids
- Bismuth subsalicylate
- Ciprofloxacin
- Loperamide
