Gastroenterology Conditions A Flashcards
Crohn’s Disease - Description
granulomatous transmural inflammation of any part of the GI tract
Crohn’s Disease - Risk Factors (8)
1) chromosome 16 NOD2 mutation
2) white ancestry (esp. Ashkenazi Jews)
3) 15-40 years old
4) 60-80 years old
5) family history (20% 1st degree relative)
6) NSAIDs
7) smoking (3-4x)
8) stress
Crohn’s Disease - Pathophysiology (2)
1) inappropriate immune response to gut flora
2) granulomatous transmural inflammation of any part of the GI tract
Crohn’s Disease - Symptoms (8)
dependant on region affected 1) diarrhoea with urgency (5-6 times in 45 mins) (non-bloody) 2) steatorrhea 3) right abdominal pain (presents acutely with right iliac fossa pain, mimicking appendicitis) systemic symptoms in attacks 4) anorexia 5) weight loss 6) fever 7) fatigue 8) malaise
Crohn’s Disease - Signs (6)
1) aphthous oral ulcers (recurrent round mouth ulcers)
2) perianal lesions (skin tags, fistula, abscess, sinus)
3) abdominal tenderness
4) clubbing
5) erythema nodosum (tender, red cutaneous nodules due to adipocyte inflammation)
6) pyoderma gangrenosum (deep leg ulcers)
Crohn’s Disease - Complications (7)
1) malabsorption (inc. short bowel syndrome)
2) anaemia (iron, B9, B12, chronic disease)
3) bowel obstruction
4) bowel perforation
5) toxic megacolon
6) cholelithiasis
7) nephrolithiasis (oxalate)
Crohn’s Disease - Investigations (5/2)
initial
1) FBC (anaemia, leucocytosis, thrombocytosis)
2) high CRP + ESR
3) stool MS+C (exclude C. difficile, E. coli, Campylobacter)
4) faecal calprotectin (positive)
5) P-ANCA (positive, definite)
consider
1) colonoscopy* (spot lesions, transmural inflammation)
2) tissue biopsy (confirmation)
Crohn’s Disease - Management (3/5/1)
conservative 1) smoking cessation 2) elemental or polymeric diet 3) hospitalisation + monitor (severe) medical 1) corticosteroids (induce remission) 2) immunosuppressant (e.g. azarthioprine or methotrexate) (maintain remission) 3) TNF antibodies (infliximab) (refractory) 4) antimotility (e.g. loperamide) 5) antispasmodic surgery 1) enterectomy (80%, refractory, not a cure)
Ulcerative Colitis - Description
chronic mucosal inflammation of colon
Ulcerative Colitis - Types (3)
1) proctitis (50%)
2) distal colitis (30%)
3) extensive colitis (20%)
Ulcerative Colitis - Risk Factors (8)
1) HLA-B27
2) white ancestry (esp. Ashkenazi Jews)
3) family history (15% 1st degree relative)
4) 15–30 years old
5) NSAIDs
6) non-smoker/former-smoker
7) stress
8) infection
Ulcerative Colitis - Pathophysiology (2)
1) inappropriate immune response to gut flora
2) chronic mucosal inflammation of colon
Ulcerative Colitis - Symptoms (9)
1) diarrhoea (episodic —> chronic) (urgency - proctitis)
2) rectal bleeding (inc. bloody stool)
3) tenesmus (cramping rectal pain) (proctitis)
4) left abdominal pain (mild crampy —> severe)
systemic symptoms in attacks
5) anorexia
6) weight loss
7) fever
8) fatigue
9) malaise
Ulcerative Colitis - Signs (4)
1) abdominal tenderness
2) clubbing
3) erythematous nodosum (tender, red cutaneous nodules due to adipocyte inflammation)
4) pyoderma gangrenosum (deep leg ulcers)
Ulcerative Colitis - Comorbidities (8)
1) bowel obstruction
2) bowel perforation
3) toxic megacolon
4) inflammatory pseudopolyps
5) colorectal adenocarcinoma
6) primary sclerosing cholangitis
7) arthritis
8) spondylitis
Ulcerative Colitis - Investigations (5/2)
initial
1) FBC (anaemia, leucocytosis, thrombocytosis)
2) high CRP + ESR
3) stool MS+C (exclude C. difficile, E. coli, Campylobacter)
4) faecal calprotein (positive)
5) P-ANCA (positive, maybe)
consider
1) colonoscopy* (continuous uniform inflammation)
2) tissue biopsy (mucosal inflammation) (confirmation)
Ulcerative Colitis - Management (1/5/2)
conservative
1) smoking (not advised)
medical
1) corticosteroids (induce remission)
2) 5-ASA aminosalicylates (e.g. sulfasalazine) (induce + maintain remission)
3) TNF antibodies (e.g. infliximab) (refractory)
4) antimotility (e.g. loperamide)
5) antispasmodic
surgical
1) colectomy + ileooanal anastomosis (refractory, cure)
2) proctocolectomy + ileostomy* (refractory, cure)
Irritable Bowel Syndrome - Description
chronic bowel dysfunction and abdominal pain with no organic cause
Irritable Bowel Syndrome - Risk Factors (7)
1) <50 years old
2) female
3) physical/sexual abuse
4) stress
5) anxiety
6) depression
7) enteric infection (30%)
Irritable Bowel Syndrome - Types (3)
1) IBS-C (constipation)
2) IBS-D (diarrhoea)
3) IBS-M (constipation + diarrhoea)
Irritable Bowel Syndrome - Symptoms (5)
1) cramping abdominal discomfort/pain
2) abdominal bloating/distension (relieved by flatulence/defecation)
3) constipation and/or diarrhoea
4) symptoms worsen under stress, menstruation, gastroenteritis
5) symptoms worsen after eating
Irritable Bowel Syndrome - Signs (1)
1) normal abdominal examination with general abdominal tenderness
Inflammatory Bowel Syndrome - Diagnosis (Rome III Criteria) (3)
abdominal discomfort/pain >3 days/month in 3 successive months with associated:
1) relieved by defecation
2) change in stool form
3) change in stool frequency
Irritable Bowel Syndrome - Investigations (6/0)
arguably a ‘diagnosis of exclusion’ initial 1) FBC (normal) 2) stool MS&C (negative) 3) tTG IgA (negative) 4) endomysial IgA (negative) 5) abdominal x-ray (normal) 6) colonoscopy (normal)
Irritable Bowel Syndrome - Management (6/5/0)
conservative
1) regular small meals
2) low FODMAP diet
3) eat soluble fibre (e.g. oats, beans) (IBS-C)
4) avoid insoluble fibre (e.g. cereals, breads) (IBS-D)
5) high fluid intake
6) avoid caffeinated, alcoholic, fizzy drinks
medical
1) laxative (e.g. senna) (IBS-C)
2) SSRI (IBS-C, IBS-M) (refractory)
3) antimotility (e.g. loperamide) (IBS-D)
4) TCA (IBS-D, IBS-M) (refractory)
5) antispasmodic
Coeliac Disease - Description
autoimmune inflammation of small bowel triggered by dietary gluten peptides
Coeliac Disease - Risk Factors (5)
1) family history (10% 1st degree relative, 30% sibling)
2) genetics (HLA-DQ2, HLA-DQ8)
3) IgA deficiency
4) type 1 diabetes mellitus
5) autoimmune thyroid conditions (e.g. Graves’, Hashimoto’s)
Coeliac Disease - Pathophysiology (8)
1) dietary intake of barely, rye or wheat
2) poor digestion of gluten prolamin proteins
3) prolamin proteins pass through intestinal lumen
4) prolamin proteins are delaminates by tissue transglutaminase (tTG)
5) prolamin proteins activate gluten sensitive T cells (via HLA-DQ2 or HLA-DQ8)
6) T cell mediated inflammatory intestinal mucosal damage
7) intestinal villi atrophy, crypt hyperplasia, intraepithelial lymphocytes
8) malabsorption (e.g. B9, B12, iron —> anaemia)
Coeliac Disease - Symptoms (8)
1) asymptomatic (1/3)
2) diarrhoea
3) steatorrhea (fatty stinking stools)
4) abdominal discomfort/pain
5) bloating
6) nausea
7) vomiting
8) fatigue
Coeliac Disease - Signs (3)
1) failure to thrive
2) aphthous mouth ulcers (recurrent round mouth ulcers)
3) angular cheilitis (mouth corner ulcers)
Coeliac Disease - Complications (6)
1) anaemia
2) osteopenia —> oestoporosis
3) dermatitis herpetiformis
4) hyposplenism —> infection
5) malignancy (e.g. lymphoma)
6) pancreatitis (recurrent acute or chronic)
Coeliac Disease - Investigations (5/2)
initial
1) FBC (anaemia, esp. low iron or B12)
2) tTG IgA (positive)
3) endomysial IgA (positive)
4) enteroscopy
5) tissue biopsy* (villous atrophy, crypt hyperplasia, intraepithelial lymphocytes)
Coeliac Disease - Management (1/6/0)
conservative 1) avoid gluten medical 1) vitamin B9 supplement 2) vitamin B12 supplement 3) vitamin D supplement 4) calcium supplement 5) iron supplement 6) corticosteroids + rehydration (coeliac crisis)
Gastro-Oesophageal Reflux Disease - Description
gastric acid reflux into oesophagus
Gastro-Oesophageal Reflux Disease - Causes (3)
1) oesophagitis
2) sliding hiatus hernia (stomach cardia extends through diaphragm oesophageal hiatus) (80%)
3) rolling hiatus hernia (stomach fundus protrudes through diaphragm oesophageal hiatus) (20%)
Gastro-Oesophageal Reflux Disease - Risk Factors (8)
1) family history (3x)
2) old age
3) obesity
4) smoking
5) alcohol
6) caffeine
7) pregnancy
8) drugs (CCB, TCA)
Gastro-Oesophageal Reflux Disease - Symptoms (4)
1) heartburn (burning retrosternal discomfort after eating) (worse on lying, stooping, straining)
2) belching
3) acid brash (regurgitation)
4) water brash (salivation)
Gastro-Oesophageal Reflux Disease - Alarm Symptoms (3)
1) dysphagia —> odynophagia
2) haematemesis
3) weight loss
Gastro-Oesophageal Reflux Disease - Complications (4)
1) oesophageal stricture
2) oesophagitis
3) Barrett’s oesophagus (metaplasia of lower third of oesophagus squamous epithelium to columnar epithelium)
4) oesophageal adenocarcinoma
Gastro-Oesophageal Reflux Disease - Investigations (1/1)
initial
1) PPI trial
consider
2) oesophagoscopy* (if: alarm symptoms, 4 weeks of symptoms, failed PPI trial, over 55 years old)
Gastro-Oesophageal Reflux Disease - Management (3/4/1)
conservative
1) weight loss
2) smoking cessation
3) regular small meals
medical
1) antacids (e.g. calcium carbonate) (symptomatic)
2) alginates (e.g. gaviscon) (symptomatic)
3) PPI (e.g. omeprazole) (reduces gastric acid production)
4) H2a (e.g. cimetidine) (reduces gastric acid release)
surgery
1) Nissen’s fundoplication (refractory)
Oesophageal Squamous Cell Carcinoma - Description
malignant proliferation of upper 2/3 oesophageal epithelium (55% of oesophageal cancers)
Oesophageal Squamous Cell Carcinoma - Risk Factors (6)
1) male
2) 60-70 years old
3) achalasia
4) low dietary fruit/veg
5) smoking
6) alcohol
Oesophageal Squamous Cell Carcinoma - Symptoms (6)
advanced at presentation
1) dysphagia (progressive, solids—>liquids)
2) odynophagia
3) pain (food impaction or tumour infiltration)
4) weight loss (prognostic - ability to tolerate therapy)
upper 1/3 symptoms
5) hoarse voice
6) cough
Oesophageal Squamous Cell Carcinoma - Signs (1)
1) lymphadenopathy
Oesophageal Squamous Cell Carcinoma - Complications (3)
1) aspiration pneumonia
2) post-operative pneumonia
3) post-operative oesophageal reflux
Oesophageal Squamous Cell Carcinoma - Investigations (2/1)
initial 1) oesophagoscopy* 2) tissue biopsy consider 3) thorax, abdomen, pelvis CT (metastases)
Oesophageal Squamous Cell Carcinoma - Management (1/1/3)
conservative 1) palliative care (poor survival) medical 1) chemotherapy (preop) surgery 1) endoscopic resection (low grade) 2) oesophagectomy (high grade) 3) oesophageal stent (dysphagia)
Oesophageal Adenocarcinoma - Description
malignant proliferation of lower 1/3 oesophageal epithelium (45% of oesophageal cancers)
Oesophageal Adenocarcinoma - Risk Factors (8)
1) male
2) 60-70 years old
3) achalasia
4) low dietary fruit/veg
5) obesity
6) hiatus hernia (rolling/sliding)
7) gastro-oesophageal reflux disease
8) Barrett’s oesophagus
Oesophageal Adenocarcinoma - Pathophysiology (5)
1) gastro-oesophageal reflux disease
2) gastric acid damages oesophageal epithelium
3) metaplasia of lower oesophageal squamous epithelium to columnar epithelium
4) dysplasia of lower oesophageal columnar epithelium
5) oesophageal adenocarcinoma
Oesophageal Adenocarcinoma - Symptoms (4)
1) dysphagia (progressive, solids —> liquids)
2) odynophagia
3) pain (food impaction or tumour infiltration)
4) weight loss (prognostic, ability to tolerate therapy)
Oesophageal Adenocarcinoma - Signs (1)
1) lymphadenopathy
Oesophageal Adenocarcinoma - Complications (3)
1) aspiration pneumonia
2) post-operative pneumonia
3) post-operative oesophageal reflux
Oesophageal Adenocarcinoma - Investigations (2/1)
initial 1) oesophagoscopy* 2) tissue biopsy* consider 1) thorax, abdomen, pelvis CT (metastases)
Oesophageal Adenocarcinoma - Management (1/1/3)
conservative 1) palliative care (poor survival) medical 1) chemotherapy (preop) surgery 1) endoscopic resection (low grade) 2) oesophagectomy (high grade) 3) oesophageal stent (dysphagia)
Gastric Adenocarcinoma - Description
malignant proliferation of stomach epithelium
Gastric Adenocarcinoma - Risk Factors (8)
1) male
2) 50-70 years old
3) family history
4) Helicobacter pylori (intestinal)
5) pernicious anaemia
6) high dietary nitrates (e.g. cured meats)
7) high dietary salt
8) smoking
Gastric Adenocarcinoma - Types (2)
1) intestinal gastric adenocarcinoma
2) diffuse gastric adenocarcinoma
Gastric Adenocarcinoma - Pathophysiology (Helicobacter Pylori) (7)
1) Helicobacter pylori infection
2) acute gastritis
3) chronic active gastritis
4) atrophic gastritis
5) intestinal metaplasia
6) intestinal dysplasia
7) intestinal gastric adenocarcinoma
Gastric Adenocarcinoma - Symptoms (6)
advanced at presentation
1) epigastric pain
2) weight loss
3) nausea
4) vomiting (esp. pylorus)
5) anorexia
6) dysphagia (fundus)
Gastric Adenocarcinoma - Signs (4)
1) lymphadenopathy (left Virchow’s node)
2) hepatomegaly
3) jaundice
4) ascites
Gastric Adenocarcinoma - Complications (6)
1) malnutrition
2) anaemia
3) gastric obstruction
4) gastric perforation
5) gastric bleeding
6) metastases (liver, lung, brain, bone)
Gastric Adenocarcinoma - Investigations (2/2)
initial 1) gastroscopy* 2) tissue biopsy* consider 1) thorax, abdomen, pelvis CT (metastases) 2) endoscopic ultrasound (invasion)
Gastric Adenocarcinoma - Management (1/1/3)
conservative 1) nutritional support medical 1) chemotherapy (preop/postop) surgery 1) endoscopic resection (early) 2) partial gastrectomy (distal) 3) total gastrectomy (proximal)
Small Bowel Cancers - Description
malignant proliferation of small bowel epithelium
Small Bowel Cancers - Risk Factors (2)
1) Crohn’s disease
2) Coeliac disease
Small Bowel Cancers - Types (3)
1) adenocarcinoma (mainly duodenal, jejunal)
2) lymphoma (mainly ileal)
3) leimyosarcoma (mainly ileal)
Small Bowel Cancers - Symptoms (4)
1) abdominal pain
2) weight loss
3) diarrhoea
4) anorexia
Small Bowel Cancers - Signs (1)
1) palpable abdominal mass
Small Bowel Cancers - Complications (1)
1) anaemia
Small Bowel Cancers - Investigations (2/1)
initial 1) colonoscopy* 2) tissue biopsy* consider 1) thorax, abdomen, pelvis CT (metastases)
Small Bowel Cancers - Management (0/1/1)
medical
1) radiotherapy
surgery
1) endoscopic resection
Colorectal Adenocarcinoma - Description
malignant proliferation of colon epithelium
Colorectal Adenocarcinoma - Risk Factors (8)
1) >60 years old
2) family history
3) familial adenomatous polyposis
4) Lynch syndrome
5) acromegaly
6) obesity
7) Crohn’s disease
8) ulcerative colitis
Colorectal Adenocarcinoma - Types (2)
1) colon adenocarcinoma (70%)
2) rectal adenocarcinoma (30%)
Colorectal Adenocarcinoma - Symptoms (Right Colonic) (3)
1) asymptomatic
2) abdominal pain
3) weight loss
Colorectal Adenocarcinoma - Symptoms (Left Colonic) (4)
1) bowel habit change
2) constipation/diarrhoea
3) thin stools
4) bloody stools
Colorectal Adenocarcinoma - Symptoms (Rectal) (3)
1) thin stools
2) rectal bleeding (inc. bloody stools)
3) tenesmus (cramping rectal pain)
Colorectal Adenocarcinoma - Symptoms (Emergency) (4)
obstruction
1) absolute constipation
2) faeculent vomiting
3) abdominal pain (colicky)
4) abdominal distension
Colorectal Adenocarcinoma - Signs (1)
1) palpable abdominal mass
Colorectal Adenocarcinoma - Complications (6)
1) anaemia (right colonic)
2) bowel obstruction
3) bowel perforation
4) haemorrhage
5) fistula
6) metastases (liver, lung, bone)
Colorectal Adenocarcinoma - Investigations (6/0)
initial
1) faecal occult blood (screening)
2) FBC (anaemia)
3) colonoscopy*
4) tissue biopsy*
5) double-contrast barium enema (less risk)
6) thorax, abdomen, pelvis CT (metastases)
Colorectal Adenocarcinoma - Classification (Dukes) (4)
A) limited to mucosa - 95% 5 year survival
B) through mucosa - 75% 5 year survival
C) regional lymph nodes - 35% 5 year survival
D) distant metastases - 5% 5 year survival
Colorectal Adenocarcinoma - Management (0/2/3)
medical
1) chemotherapy
2) radiotherapy
surgery
1) endoscopic resection —> colectomy (colonic)
2) endoscopic resection —> proctocolectomy (rectal)
3) colonic stent (obstructed rectum)
Colonic Adenoma - Description
benign proliferation of colon epithelium, a.k.a. polyp
Colonic Adenoma - Risk Factors (5)
1) age
2) family history
3) familial adenomatous polyposis
4) Lynch syndrome
5) acromegaly
Colonic Adenoma - Symptoms (2)
1) asymptomatic
2) rectal bleeding (sigmoid colon, rectum)
Colonic Adenoma - Complications (1)
1) colorectal adenocarcinoma (10-15 years)
Colonic Adenoma - Investigations (2/0)
initial
1) colonoscopy*
2) tissue biopsy*
Colonic Adenoma - Management (1/0/2)
conservative 1) colonoscopic surveillance surgery 1) polypectomy 2) colectomy + ileal anastomosis (familial adenomatous polyposis)
Peptic Ulcer - Description
erosion of mucosa down to muscularis mucosa in stomach or duodenum
Peptic Ulcer - Causes (2)
1) Helicobacter pylori
2) NSAIDs
Peptic Ulcer - Risk Factors (5)
1) >50 years old
2) family history
3) blood type O
4) smoking
5) stress
Peptic Ulcer - Types (2)
1) gastric
2) duodenal
Peptic Ulcer - Pathophysiology (Helicobacter Pylori) (10)
1) Helicobacter pylori colonises epithelium
2) secretes urease, proteases, phospholipases
3) urease splits urea into NH3 + CO2
4) NH3 + H+ —> NH4+
5) NH4+, proteases, phospholipases damage mucosa
6) inflammatory response
7) decreased mucous secretion
8) increased gastric acid secretion
9) gastric acid overwhelms mucous
10) erosion of mucosa
Peptic Ulcer - Pathophysiology (NSAIDs) (5)
1) NSAIDs are COX-1 inhibitors
2) decreased prostaglandin secretion
3) decreased mucous secretion
4) gastric acid overwhelms mucous
5) erosion of mucosa
Peptic Ulcer - Symptoms (6)
1) epigastric pain (recurrent or chronic)
2) nausea (associated with pain)
3) anorexia (gastric)
4) weight loss (gastric)
5) pain worsened by eating (gastric)
6) pain relieved by eating (duodenal)
Peptic Ulcer - Symptoms (Alarm) (7)
cancer
1) weight loss
2) haematemesis
3) vomiting
4) dysphagia
5) upper abdominal mass
6) anaemia
7) melaena
Peptic Ulcer - Signs (3)
1) pointing sign (patient locates pain site with single finger)
2) abdominal tenderness
3) pain relieved by antacids
Peptic Ulcer - Complications (6)
1) gastric perforation
2) bowel perforation (duodenum)
3) peritonitis
4) acute pancreatitis
5) haemorrhage (esp. gastroduodenal artery)
6) pyloric stenosis (scarred ulcer)
Peptic Ulcer - Investigations (2/1)
initial
1) Helicobacter pylori urease breath test
2) Helicobacter pylori stool antigen test
consider
3) gastroscopy (if alarm symptoms, >50 years old)
Peptic Ulcer - Management (3/3/1)
conservative 1) stop NSAIDs 2) smoking cessation 3) avoid stress medical 1) PPI (e.g. omeprazole) 2) H2a (cimetidine) 3) Helicobacter pylori triple therapy (clarithromycin, amoxicillin, omeprazole) surgery 1) endoscopic haemostasis (haemorrhage)
Acute Appendicitis - Description
inflammation of appendix due to appendix lumen obstruction
Acute Appendicitis - Causes (4)
1) faecolith (hard faecal mass)
2) stool
3) lymphoid hyperplasia
4) filarial worms
Acute Appendicitis - Symptoms (6)
1) epigastric pain (initially)
2) right iliac fossa pain (migrates)
3) fever
4) nausea
5) vomiting
6) anorexia
Acute Appendicitis - Signs (7)
1) McBurney’s sign (right iliac fossa tenderness)
2) Rovsing’s sign (right iliac fossa pain when left iliac fossa is palpated)
3) psoas sign (right iliac fossa pain when lying on left side)
4) obtruator sign (right iliac fossa pain when right thigh is internally rotated)
5) fetor (strong foul breath)
6) tachycardia
7) adolescent
Acute Appendicitis - Complications (4)
1) appendix perforation (esp. faecolith)
2) appendix mass
3) appendix abscess
4) peritonitis
Acute Appendicitis - Investigations (2/0)
initial
1) abdomen CT (or ultrasound)
2) FBC (leucocytosis)
Acute Appendicitis - Management (0/1/1)
medical
1) antibiotics (e.g. piperacillin)
surgery
1) appendectomy* (laparoscopic or open)
