Gastroenterology/Colorectal/ Hepatology Flashcards
What is coeliac disease?
- chronic immune-mediated systemic disorder in genetically predisposed people, triggered by exposure to dietary gluten (the major complex protein component of wheat, barley, and rye).
- Coeliac disease is caused by a heightened immunological response to ingested gluten. The exact cause is not yet known
What is the prevalence of coeliac disease in the UK?
- 1%
- affects all age groups, including the elderly, with more than 70% of new cases diagnosed in people over 20 years of age.
- two peaks of onset; one shortly after weaning with gluten in the first 2 years of life, and the other in the second or third decades of life
What are the complications of coeliacs?
- reduced QoL
- mental health
- faltering growth, delayed puberty - in children
- malabsorption causing nutritional deficiencies
- Anaemia - due to malabsorption of iron, folate, B12
- reduced bone mineral density - malabsorption Ca/VitD
- hyposplenism - increased risk of encapsulated bacterial infection e.g. pneumococcus, H.influenzae, meningococcus.
- malignancy - rare. Hodgkins and Non hodgkins lymphoma (2-4x increased risk), and small bowel adenocarcinoma (30x increased risk).
- refractory coeliac disease - rare.
What is the prognosis for coeliacs?
The majority of people with confirmed coeliac disease report a rapid improvement in symptoms after starting a gluten-free diet, and have a normal life expectancy
What symptoms and associated conditions should lead us to suspect coeliac disease?
- Persistent, unexplained GI symptoms: acid reflux, diarrhoea, steatorrhoea, weight loss, abdo pain, reduced appetite, bloating, and constipation. (may be overweight on presentation)
- IBS
- faltering growth, short stature, delayed puberty - in children
- TATT
- persistent/recurrent mouth ulcers
- unexplained iron/b12/folate deficiency - may cause anaemia. Anaemia not responding to treatment.
- T1DM
- autoimmune thyroid disease e.g. Hashimotos thyroiditis
- autoimmune liver disease e.g. Primary biliary cholangitis, autoimmune hepatitis, primary sclerosing cholangitis.
- IgA deficiency
- first degree relative with coeliac (10% chance). Assoc with HLA-DQ2 or DQ8.
- dermatitis herpetiformis
- osteomalacia/osteopenia/osteoporosis/fragility fractures
- unexplained peripheral neuropathy/ataxia
- unexplained recurrent miscarriage/subfertility
- unexplained raised ALT/AST
- dental enamel defects - in children
- Downs/turners/williams syndrome
What skin condition does this image show?
- dermatitis herpetiformis (due to coeliac disease)
- more common in adults and older teenagers.
- symmetrical clusters of itchy blistering skin lesions followed by erosions, excoriations, and hyperpigmentation, most commonly involving the elbows, knees, shoulders, buttocks, sacral region, and face.
How should a person be investigated for suspected coeliac disease?
- serology - should have eaten gluten foods for at least 6/52
- IgA anti-tissue transglutaminase antibody (TTG) and total IgA first line.
- IgA anti-endomysial antibody (EMA) second line (if TTG not available or weakly positive/equivocal)
- If there is IgA deficiency - IgA TTG and EMA may give false negative result. Check IgG EMA, IgG TTG or IgG deamidated gliadin peptide (DGP).
When should patients with suspected coeliacs be referred to gastroenterologist? What should they be advised?
- Positive serology
- in children - if IgA TTG or EMA are equivocal - refer for further investigation
- If serology negative, and no IgA deficiency - coeliac is unlikely . Does not rule out developing it in the future. If still strong suspicion - refer gastro.
- unwilling to introduce gluten back into diet to allow serological testing.
- When referring, advise pts to eat 1 meal a day containing gluten until specialist tests completed.
- explain diagnosis only confirmed on biopsy of small bowel.
- refer derm if DH suspected.
How should a person with confirmed coeliacs be managed in primary care?
- annual review
- long term adherence to gluten free diet - some gluten free products can be prescribed on NHS - must be ACBS endorsed (only flour and bread mixes in england)
- assess for persistent symptoms (check inadvertent exposure)
- monitor annual bloods: coeliac serology (adherence), FBC, ferritin, B12/folate, TFT, LFT, calcium/vit D - check if supplements are needed
- assess risk of osteoporosis and need for DEXA
- monitor BMI, growth in children
- refer dietician if concerns re gluten exposure, recurrent symptoms, nutritional deficiencies, growth impairment
- influenza, meningococcal, pneumococcal vaccinations
When should a person with confirmed coeliacs be referred back to specialist?
- non-responsive/refractory
- faltering growth in child
- suspected serious complication - 2ww if malignancy
Which gluten-containing products should be avoided in coeliacs disease? (main groups and examples) Which other sources of starch can be eaten instead?
- Wheat
- Rye
- Barley
e.g. breakfast cereals, bread, flour, pasta, cakes, pastries, biscuits, beer.
Foods containing the above as fillers e.g. sausages, soups, sauces.
Foods contaminated with gluten in processing e.g. oats, use of same oil - chips cooked in batter oil.
Manufacturers by law must list GLUTEN as an ingredient on package.
Corn (maize), Rice, Potatoes may be eaten.
Coeliac UK website for more info.
When should a FIT test be done to guide referral for suspected colorectal cancer in adults?
- abdominal mass
- change in bowel habit
- IDA
- age >=40 with unexplained weight loss and abdo pain
- age <50 with rectal bleeding and either abdo pain or weight loss.
- Age >=50 with any of: rectal bleeding/abdo pain/ weight loss.
- age >=60 with anaemia (even if no iron deficiency)
When should adults be referred via 2ww for colorectal cancer?
- Rectal mass (PR exam)
- FIT result of >=10
- If not returned the FIT sample, or FIT is <10 : still refer if strong clinical concern due to ongoing unexplained symptoms.
When should a person be referred via 2ww for anal cancer?
- unexplained anal mass
- unexplained anal ulceration
What is the NHS bowel cancer screening programme?
- Age 60-74: screening for faecal blood every 2 years by FIT (faecal immunochemical test)- kit posted automatically
- people aged >75 can request screening kit every 2 years
- Abnormal FIT: colonoscopy or CT colonography
Why was FIT recommended for screening over the faecal occult blood testing?
- easier to use for patients -increase uptake. Unscrew the cap of the test, dip the end of the stick into a single bowel motion, replace the stick in the tube, screw the lid shut and return the sample in the prepaid envelope provided. (Results are sent by letter to the person’s home address within 2 weeks of the lab receiving the completed kit.)
The person’s GP is informed of the result electronically. - More sensitive: can detect lower concentration of blood in faeces.
- more specific: FOBT was not specific for colonic bleeding - was positive with red meats, upper GI irritation. FIT detects blood using antibodies specific to human globin. Less likely to detect globin from UGIB- as this degrades as it passes through the gut.
Which people are at high risk of bowel cancer and therefore should be screened with colonoscopy?
- familial adenomatous polyposis (FAP)- yearly colonoscopy
- Lynch syndrome (HNPCC) - colonoscopy aged 25 (or 5 years prior to age of diagnosis of youngest affected relative) - every 12-24 months.
- juvenile polyposis
- strong family history of bowel cancer: refer for colonoscopy aged 35-40. If no polyps - repat at age 55. 2x first degree relatives with Hx colorectal cancer, 1x first degree relative with Hx colorectal cancer aged <45yrs
- UC or Crohn’s: every 1-5yrs depending on risk.
- Previous bowel cancer
What are the risk factors for bowel cancer?
- Obesity
- diet - too much red/processed meat, too little fibre
- smoking
- alcohol
- increasing age
- family Hx
- UC/Crohn’s
- T2DM
- gallstones
- acromegaly
What are the colonoscopy outcomes after a positive FIT?
- normal 50%
- polyp 40%
- cancer 10%
When should IBS be suspected?
if any of the following symptoms have been present for at least 6 months:
* Abdominal pain
* Bloating
* Change in bowel habit
What red flag symptoms/signs would point to a diagnosis other than IBS?
- weight loss
- rectal bleeding
- positive FIT
- change in bowel habit >age 60
- raised FCP
- iron def. anaemia
- persistent/frequent bloating in females - ovarian Ca - esp if age >50
- abdo mass, rectal mass
- FHX of: bowel ca, ovarian ca, coeliacs, IBD.
When should a diagnosis of IBS be made in primary care?
- abdominal pain/discomfort for 6 months: relieved by defecation OR assoc with altered bowel frequency OR assoc with altered stool form.
- PLUS at least 2 of:
- abdo bloating
- made worse by eating
- passage of mucus
- straining/urgency/incomplete evacuation
**Alternative conditions **have been excluded.
Which investigations should be considered in possible IBS to exclude other diagnoses?
- food diary
- FBC - anaemia
- CRP - active inflammation/infection
- coeliac serology
- TFTs
- FCP - esp if age <=45
- Stool for MC&S
- STI screen if ?PID
- FIT if fulfil criteria
How should IBS be managed in primary care?
- explain gut-brain axis, chronic condition - flares
- diet and lifestyle advice - regular meals, reduce caffeine, alcohol, fizzy drinks. if diarrhoea/bloating - reduce high fibre foods. Loperamide if ineffective.
- If constipation - increase soluble fibre or ispaghula. Laxatives if ineffective.
*If ineffective: Can refer dietician - trial Low FODMAP diet (FODMAPS e.g. apples, cherries, peaches, nectarines, sweetners, lactose, broccoli, sprouts, cabbage, peas. Needs dietician input. - if ongoing pain/spasm: mebeverine, or peppermint oil prn. If ineffective - low dose TCA (AMT)
- refer gastro - if no improvement / requests specialist & consider psychological therapies.
What are the 2ww criteria for **urgent direct access **UGI endoscopy (for oeseophageal or stomach cancer)?
*** dysphagia **OR
* aged >=55 with **weight loss AND **any of the following:
- upper abdo pain
- reflux
- dyspepsia
- send 2ww stomach cancer referral for people with **upper abdo mass **consistent with stomach cancer.
What are the criteria for** non-urgent direct access ** UGI endoscopy to assess for oesophageal and stomach cancer?
- haematemesis
- Aged >=55 with:
- treatment-resistant dyspepsia OR
- upper abdo pain with low Hb OR
- raised platelet count with any of the following:
- nausea
- vomiting
- weight loss
- reflux
- dyspepsia
- upper abdo pain
- nausea or vomiting with any of the following:
- weight loss
- reflux
- dyspepsia
- upper abdo pain
What are the 2ww criteria for pancreatic cancer - direct access CT scan (or USS if CT not available)?
- Age >=60 with with weight loss and any of the following:
- diarrhoea
- back pain
- abdominal pain
- nausea
- vomiting
- constipation
- new-onset diabetes.
Refer as 2ww pancreatic cancer if age >=40 with jaundice.
What are the 2ww criteria for gallbladder cancer- urgent direct access USS?
- Upper abdominal mass consistent with an enlarged gall bladder
What are the 2ww criteria for liver cancer - urgent direct access USS?
- upper abdominal mass consistent with an enlarged liver.
Which patients are most at risk of advanced NAFLD?
- Age > 30 years
- Increasing obesity
- Type 2 diabetes
- Aspartate aminotransferase:alanine aminotransferase (AST:ALT) ratio > 1.
What are the management steps for dyspepsia not meeting 2ww referral criteria (e.g. age <55)?
- Review medications for causes of dyspepsia (NSAIDS, steroids, bisphosphonates, anticholinergics, benzos, Bblockers, CCBs, alpha-blockers, aspirin)
- Lifestyle advice: address triggers (lose weight, avoid coffee, chocolate, tomatoes, spicy, fatty foods, smaller meals, eat 4 hours before bed, stop smoking, reduce alcohol)
- Trial 4-8 weeks full dose PPI
- If symptoms return after trial - test H.Pylori: either a carbon-13 urea breath test or stool antigen test can be used — ensure the person has not taken a PPI in the past 2 weeks, or antibiotics in the past 4 weeks. If positive: first line-eradication therapy.
- If symptoms resolve - no need to do HPylori test for cure.
- If severe persistent symptoms - arrange re-testing 4-8 weeks after eradication therapy. Use C13 urea Breath test.
- May need long term PPI H2RA at lowest dose.
- Refer Gastro - if refractory symptoms, 2nd Line H.Pylori eradication unsuccessful.
What is the first line treatment for H.Pylori eradication?
7 day triple therapy:
* PPI (lansoprazole 30mg, omeprazole 20-40mg) twice daily
* amoxicillin 1g BD
* clarithryomycin 500mg BD OR metronidazole 400mg BD.
If pen.all: use clarithrymycin and metronidazole.
What are the presenting symptoms of IBD in childhood?
- rare
- non-specific: weight loss, faltering growth, delayed puberty
- bloody diarrhoea, acute abdomen
- arthropathy, iritis
What are the presenting symptoms of UC?
- bloody diarrhoea (persisting >6 weeks)
- Faecal urgency/incontinence
- Tenesmus (persistent, painful urge to pass stool even when the rectum is empty)
- Lower abdo pain (esp LLQ)
- non specific: fatigue, fever, anorexia
What are the presenting symptoms of Crohn’s?
- unexplained persistent diarrhoea (+/- blood & mucus) (can be nocturnal)
- Abdo pain (crampy)
- Mouth ulcers
- Peri-anal fistulas/abscesses
- bowel obstruction - due to fistulas
- weight loss more prominent
- non specific: fatigue, fever, anorexia
What are the extra-intestinal features of Crohn’s and UC?
- Crohn’s: gallstones more common
- UC: primary sclerosing cholangitis (jaundice) more common, autoimmune hepatitis
- Both: arthritis, ank.spond, anterior uveitis, episcleritis, erythema nodosum, pyoderma gangrenosum (UC>Crohn’s), osteoporosis.
What does this image show? What disease is it associated with? What is the management?
- pyoderma gangrenosum
- painful
- refer urgently to derm
- super-potent topical steroids e.g. clobetasol (dermovate)
- Assoc IBD - especially UC , RA, myeloid leukaemias, MDS.
What does the below image show? Which disease is it associated with? How is it managed?
- Erythema nodosum
- painful, erythematous, and sometimes bruised-looking, nodules on the anterior surface of the legs
- IBD - UC or Crohn’s, post-streptococcal (URTI), TB, sarcoid
What is the peak incidence of UC?
- most common type of IBD
- can develop at any age
- Peak incidece age 15-25, second smaller peak 55-65
- smoking is protective
What is the peak incidence of Crohn’s disease?
- first and largest peak is age 15-30 , second smaller peak from 50-70
- smoking is a causative factor
What investigations should be done in primary care if IBD is suspected?
- FBC - anaemia
- CRP
- U&E - dehydration
- LFTs- low albumin
- B12, folate, ferritin, transferrin sats - malabsorption
- TTG, TFTs, stool MC&S - exclude other causes
- Faceal calprotectin (protein biomarker released into bowel when inflammation present). If over 50 mcg/g - possible IBD rather than IBS - refer for specialist Ax within 4 weeks. If negative - IBD unlikely.
When is emergency hospital admission indicated for suspected UC or Crohn’s disease?
- systemically unwell - fever, tachycardia, hypotension
- severe abdominal pain (esp if tenderness)
- Severe diarrhoea (>8/day)
- bowel obstruction
- sudden dramatic weight loss
If Crohn’s or UC is suspected but not requiring emergency admission - how should they be managed?
- urgent referral to secondary care (paeds/adult gastro) for confirmation of diagnosis and initiation of drug treatments.
- specialist investigations: colonoscopy, biopsy, MRI
- Refer rheum/derm/opth if extra-intestinal manifestations.
What are the first line treatments for Crohn’s disease to induce remission?
Started in secondary care
- **Corticosteroids: **prednisolone / IV hydrocortisone -Gradually tapered.
- Aminosalicylates (sulfasalazine or mesalazine) - if steroids are contraindicated or declined. Less effective but may have fewer side effects
- Immunosuppresive drugs: If two or more inflammatory episodes in a year or difficult to wean steroids, azathioprine/mercaptopurine may be added to the steroid to induce remission. Then used to maintain.
- Thiopurine methyltransferase (TPMT) activity- assessed before azathioprine. Should not be prescribed if TPMT activity is low/absent
- Methotrexate 2nd line if azathioprine or mercaptopurine cannot be prescribed
- Specialist enteral nutrition may be an alternative to conventional corticosteroids if there is concern about growth or side effects
- Biologics - anti-TNF alpha: infliximab/adalimumab (IV). For severe active disease/perianal disease - not responding to conventional Rx. Then to maintain.
What are the side effects of anti-TNF biologics?
- Serious infections
- Reactivation of TB and hepatitis B
- lethal hepatosplenic T-cell lymphoma and demyelinating CNS disorders
- Pancytopenia, leukopenia and neutropenia
- Liver damage
How should remission be maintained in Crohn’s disease after a complete macroscopic resection?
- 3 months of post-operative azapthioprine and metronidazole.
What are the first line treatments for UC to induce remission then maintain?
- Aminosalicylates - mesalazine and sulfasalazine. Also maintain remission. Often topical (enema/supps). Or orally if remission not achieved within 4 weeks. If extensive- may need both first line. Then maintain remission.
- Corticosteroids - if aminosalicylates not effective-then taper - short term (topical/oral/IV)
- Calcineurin inhibitors - tacrolimus/ciclosporin - added to steroids to induce remission if not responding (IV)
- 4.** Immunosuppresives** - azathioprine/mercaptopurine (1st), MTX (2nd line) - to maintain remission if salycylates not working.
- Biologics: anti-TNF alphas: IV infliximab and SC adalimumab - induce remission if severe unresponsive. Also to maintain remission.
- Specialist enteral nutritional supplementation may be used as an alternative to conventional therapy in some children for induction of remission
What is the difference between hepatic steatosis, and non-alcoholic steatohepatitis (NASH)?
How is HepB tested for?
- serological:
- HBsAg (hepatitis B surface antigen) - suggests person is infectious, Chronic HBV if persists >6mo.
- HBeAg (HBeAg) (hepatitis B e antigen) - indicates high infectivity.
- Anti-HBe - present once HBeAg cleared.
- Anti-HBc (antibody to hepatitis core antigen) - indicates current or previous HBV infection. Persists for life.
- IgM to hepatitis core antigen - indicates recent HBV infection. Gradually replaced by IgG - persists for life.
- Anti-HBs (antibody to HBsAg) - indicates recovery from and immunity to HBV. Anti-HBs without anti-HBc is a marker of immunisation. It is checked to measure vaccination response.
- HBV viral load
