Gastroenterology Flashcards
Achalasia
Loss of LOS relaxation and peristaltic ability of the oesophagus.
Features: heart burn, dysphagia of solids and liquids, regurgitation of food.
Treat with ballooning, Botox of LOS, surgery may be needed.
Acute abdominal pain
Causes
Causes use surgical sieve:
Infection; appendicitis, cholangitis, pyelonephritis, PID, gastroenteritis etc.
Inflammation; peptic ulcer, pancreatitis
Vascular; ruptured AAA, MI, mesenteric ischaemia.
Trauma; ruptured spleen
Metabolic; stones, DKA
Acute abdominal pain
Location
Right upper quadrant: Biliary colic (no fever) Acute cholecystitis (fever) Ascending cholangitis (fever, jaundice)
Episgastric:
Pancreatitis (then radiates to the back)
Peptic ulcer disease
Lower quadrants: Appendicitis (RLQ) Acute diverticulitis (LLQ) Intestinal obstruction (central) Ectopic (L/RIF)
Suprapubic:
Bladder
Loin:
Acute pyelonephritis
Renal colic
Central ab pain:
Mesenteric ischaemia
Ruptured AAA (then radiates to the back)
Acute appendicitis
Visceral peri-umbilical pain radiating to the RIF when parietal.
Associated mild fever and some vomiting
Treat with laparoscopic surgery and IV Abx.
Acute liver failure
Causes: alcohol, paracetamol overdose, acute fatty liver of pregnancy and viral hepatitis.
Leads to jaundice, impaired clotting, hypoalbumin, heptorenal syndrome.
Acute upper GI bleed
Either due to oesophageal varices or peptic ulcer.
Provide reassuss
Conduct endoscopy
If variceal then treat with Terlipressin and Abx at presentation. Then to undergo band ligation.
Alcohol
Units: Recommended 14 units spread out minimum of 3 days per week. Calculate by ml*ABV/1000
Alcoholic ketoacidosis: KA due to increased alcohol, increased starvation/vomiting food, therefore body breaks down fats into ketones. Treat with saline and thymine infusion.
Alcoholic liver disease: Alcholic fatty liver, cirrhosis, alcoholic hepatitis.
Gamma GT is raised, AST:ALT>2, if >3 then acute alcoholic hepatitis.
Treat with glucocorticoid
Angiodysplasia
Vascular deformity in the GI tract which predisposes to iron deficiency anaemia and bleeding.
Antidiarrhoeal agents
Loperamide
Diphenoxylate
Ascites
Abnormal collection of fluid in the abdomen. Look at conc of albumin to determine the cause; higher think liver disorder, cardiac, if lower think hypoalbuminaemia, malignancy, infection etc
Treat with low Na diet, fluid restriction, spironolactone, drainage if tense ascites.
Also give prophylactic Abx to reduce risk of bacterial peritonitis.
Autoimmune hepatitis
Unknown aetiology but common in young females.
Present with signs of chronic liver disease
Acute hepatitis; jaundice, fever
Amenorrhoea
Treat with steroids and immunosuppressants
May need liver transplant
Barrett’s oesophagus
Metaplasia of the lower oesophagus from squamous cells to columnar cells; increasing the risk of adenocarcinoma.
RF; GORD, male, smoking and central obesity.
Manage with endoscopic review and high dose PPI.
Can resect or ablate the area
Bile acid malabsorption
Primary: XS bile production leading to steatorrhoea and malabsorption of vitamins ADEK.
Secondary: crohns, coeliacs, cholecystectomy
Treat with bile sequestrants
C.difficile
Gram positive rod
Positive stool sample for diagnosis
Acquired usually in hospital due to suppression of normal gut flora by broad spectrum Abx- cephalosporins
Features: diarrhoea, ab pain, increase WBC, severe toxic mega colon can develop.
Treat with oral metronidazole.
If severe or not improving then consider oral vancomycin
Coeliacs
Features
Investigations
Management
Autoimmune intolerance of gluten leading to crypt hyperplasia, villous atrophy and increased lymphocytes infiltration on duodenal biopsy.
Investigate pts with dermatitis herpetiformis (strong correlation), autoimmune diseases (T1DM, hypoT), recurrent ab pain, chronic/intermittent diarrhoea, IBS, prolonged fatigue, sudden/unexplained weight loss.
Complications: Anaemia, hyposplenism (offer pneumococcal vaccine), lactose intolerance, osteoporosis, sub fertility etc.
Investigate with transglutaminase antibody, followed by a biopsy. Then compare on gluten free diet.
Gluten free diet- free from wheat, barley, oats, rye. Can have potatoes, rice and corn.
Colorectal cancer
Genetics
Three main types
(1) Sporadic- 95%
(2) Hereditary non-polyposis colorectal carcinoma
(3) Familial adenomatous polyposis
(1) May be due to genetic mutations.
(2) Most common inherited colon cancer. At risk of other cancers.
(3) Rare mutation in tumour suppressor genes leading to 100 polyps by age 40- increase cancer risk.
Constipation
Passing of infrequent, hard stools.
<3 weekly, feeling of tenesmus, strain whilst passing.
Complications:
Overflow diarrhoea
Acute urinary retention
Haemorrhoids
Crohn’s disease:
Features
Investigations
Management
Increase genetic susceptibility.
Inflammatory bowel disease which can affect form the mouth to the anus but typically at the terminal ileum and colon.
Presents with weight loss, lethargy, diarrhoea (can be bloody), ab pain.
Investigate with raised inflammatory markers, B12/Vit D deficiency, faecal calprotectin, anaemia.
Look at colonscopy- skip lesions, can develop strictures/fistulas/adhesions since inflamed through all layers, granulomas, deep ulcers.
Management:
Inducing remission; glucocorticoid steroids (1st line), add on azothioprine.
Maintaining remission; stop smoking, azothioprine (1st line), methotrexate (2nd line).
Most pt will go on to have surgery
Diarrhoea
> 3 loose stools/day, or more frequent than usual
Acute<14 days>chronic
Acute causes: gastroenteritis, Abx therapy, overflow diarrhoea (change between diarrhoea and constipation) and diverticulitis.
Chronic causes: IBS, IBD, coeliacs, colorectal cancer.
Diverticulitis
Our pouching of the colon, increased risk with increase age and low fibre diet.
If becomes infected then diverticulitis- diarrhoea, LLQ pain, N+V, anorexia.
Treat with Abx (oral) if mild.
More severe needs hospitalisation with IV Abx, fluids and nil by mouth.
Dyspepsia
Suspected cancer needs 2ww referral.
Urgent:
All pts with dysphagia
All pts with upper abdominal mass
All pts>65yrs with weight loss + one of; dyspepsia, reflux, upper ab pain.
Non urgent:
All haematemesis
Over >55yrs with treatment resistant dyspepsia or upper ab pain or increased platelet count.
If don’t meet referral criteria then review medication to find cause of dyspepsia, give lifestyle advice, try a PPI.
Dysphagia
All new cases need GI endoscopy!
Causes include; oesophageal cancer, oesophagitis, achalasia, pharyngeal pouch, myasthenia gravis.
Ferritin
Acute phase protein which can increase in inflammation.
Increased ferritin levels can be due to iron overload or not.
No iron overload- inflammation, alcohol XS, liver disease, CKD, malignancy
Iron overload- hereditary haemochromotosis, secondary to blood transfusion.
Gallstones
Common and are usually asymptomatic.
When in the bile duct then become symptomatic with RUQ post meal, especially a fatty meal.
Investigate with LFTs (at least one deranged) and ab USS.
Diseases include; Biliary colic, acute cholecystitis and ascending cholangitis. (Main)
Asymptomatic don’t need treating.
Symptomatic treat with cholecystectomy via the laparoscopic route.
Gastric cancers
More commonly arising from the cardia of the stomach, will see signet ring signs on histology (shifted nucleus)
Affecting more male, 70-80yrs, from Japan, China etc.
Features include; dysphagia, dyspepsia, weight loss, anorexia, N+V.
Diagnose with endoscopy and biopsy.
Associated with; smoking, salt/spice rich diet, H.pylori infection, gastric polyps etc
Treat with resection of the stomach either total or sub (if closer to the OG junction).
Stage with TNM, using CT chest+pelvis first line.
GORD
Poor correlation with GI endoscopy but refer for endoscopy if;
>55yrs
>4wks persistent symptoms even with medical intervention
Dysphagia
Weight loss
Relapsing symptoms
Treatment:
If seen on endoscopy then 1 month full dose PPI, if response then lower dose (as required), if no response then add another PPI
If not seen on endoscopy then 1 month full dose PPI, if response then low dose (as required), if no response then H2RA.
Haemochromatosis
Autosomal recessive mutations in the HFE gene leading to increased iron deposition.
Early signs- arthralgia (hands), fatigue and erectile dysfunction.
Later- bronze skin pigmentation (R), DM, liver cirrhosis/hepatomegaly, cardiac failure (R)
(R)- reversible
Investigate with genetic testing.
Iron profile- high ferritin, high iron, high transferrin saturation but low TIBC (total iron binding capacity).
Treat with phlebotomy
H.pylori
Gram negative bacteria Associated with: Peptic ulcers Gastric cancers Atrophic gastritis
Manage with triple therapy;
PPI + amoxicillin + metronidazole/clarithromycin
Or if penecillin allergy then PPI + C + M
Test usually with urease breath test.
Hepatic encephalopathy
Occurs with liver disease of any cause.
Excess absorption of ammonia and glutamine
Confused, altered GCS, liver flap, raised ammonia
Manage precipitating factors (infection, GI bleed, constipation, sedatives etc). First line is lactulose with rifaximin (secondary prophylaxis.
