Gastroenterology COPY Flashcards
1
Q
How can The causes of Upper GI bleeds be broken classified?
A
Oesophagus
Stomach
Duodenum
2
Q
What are the Oesophageal causes of Upper GI Bleeds?
A
Oesophagitis
Varices
Malignancy
Gastro-oesophageal reflux disease (GORD)
Mallory-Weiss tear
3
Q
What are the stomach causes of Upper GI Bleeds?
A
Peptic ulcer disease
Mallory-Weiss tear
Gastric varices
Gastritis
Malignancy
4
Q
What are the duodenal causes of Upper GI Bleeds?
A
Peptic ulcer disease
Diverticulum
Aortoduodenal fistula
Duodenitis
5
Q
What are some key causes for Upper GI bleeding?
A
Peptic ulcer disease (50%)
Oesophageal Varices
Mallory Weiss Tear
Cancers of stomach/duodenum
6
Q
What is Peptic ulcer disease?
A
Break in the mucosal lining of the stomach, duodenum or lower Oesophagus more than 5mm diameter.
7
Q
What can cause a peptic ulcer?
A
Imbalance between factors promoting mucosal damage and those promoting duodenal defence
8
Q
What are some factors that cause mucosal damage and therefore increase risk of peptic ulcers?
A
Gastric acid - high volumes
H.Pylori
NSAIDs
9
Q
Explain how H. pylori can lead to PUD?
A
Lives in gastric mucus
Secretes urease which splits urea in stomach into CO2 + ammonia
Ammonia + H+ 🡪 ammonium
Ammonium, proteases, phospholipases and vacuolating cytotoxin A damages gastric epithelium
Causes inflammatory response reducing mucosal defense 🡪 mucosal damage
Also causes increased acid secretion
Gastrin release (from G cells) 🡪 more acid secretion
Triggers release of histamine 🡪 more acid secretion
Increases parietal cells mass 🡪 more acid secretion
Decreases somatostatin (released from D cells) 🡪 more acid secretion
10
Q
Explain how NSAIDs lead to PUD?
A
Mucus secretion stimulated by prostaglandins
COX-1 needed for prostaglandin synthesis
NSAIDs inhibit COX-1
No COX-1 = mucous isn’t secreted
Reduced mucosal defense 🡪 mucosal damage
11
Q
Explain how Mucosal Ischaemia can lead to PUD?
A
Stomach cells not supplied with sufficient blood
Cells die off and don’t produce mucin
Gastric acid attacks those cells
Cells die 🡪 formation of ulcer
Treatment - H2 blocker
12
Q
Explain how an increase in stomach acid can lead to PUD?
A
Overwhelms mucosal defence
Acid attacks mucosal cells
Cells die 🡪 formation of ulcer
Stress can increase acid production
Treatment – PPI and H2 blocker
13
Q
Explain how Bile Reflux leads to PUD?
A
Duodeno-gastric reflux
Regurgitated bile strips away mucus layer
Reduced mucosal defense
14
Q
What factors can increase acid production?
A
Stress
Alcohol
Caffeine
Smoking
Spicy Foods
15
Q
What are some protective factors of the upper GI tract that are reduced that can lead to peptic ulcers?
A
Reduced Prostaglandins (NSAIDs) leading to poor muscosal production
Mucus damage (via H.pylori)
Bicarbonate loss leading to no neutralisation of stomach acid
16
Q
What are the main areas where a Peptic Ulcer develops?
A
Gastric ulcer - stomach
Duodenal Ulcer
17
Q
What is the most common area for a peptic ulcer?
A
Duodenal ulcers
18
Q
What is the Classical Peptic Ulcer disease presentation?
A
The classical description of bleeding in PUD is of a posterior duodenal ulcer eroding through into the gastroduodenal artery.
19
Q
Who is typically affected by peptic ulcers?
A
More common in men than women
Prevalence 11-20% for men
20
Q
What are the risk factors for Peptic Ulcers?
A
Increasing age
H.Pylori infection
NSAIDS
Drugs - SSRIs, Corticosteroids
Smoking
Alcohol
21
Q
What are the clinical signs of of peptic ulcer disease?
A
Evidence of bleeding
Hypotension
Tachycardia
Melaena
Epigastric Tenderness
Pallor - due to anaemia
22
Q
What are some signs of Upper GI bleeding via peptic ulcers?
A
Burning Epigastric pain
Nausea & Vomiting
Haematemesis
Melaena
Reduced appetite
Weight loss
Fatigue - Anaemia
23
Q
What is the pain like in an Upper GI bleed from a peptic ulcer?
How can this be used to distinguish the site of the ulcer?
A
Burning pain
Gastric ulcer - pain worsened by eating
Duodenal Ulcer - Pain relieved by eating and worse when hungry
24
Q
What investigations would be done if the patient had no red flags/was not bleeding with a suspected peptic ulcer?
A
Urea breath test
Stool antigen test
Looking for H.pylori infection as a possible cause
25
If testing for H.pylori infection what must be done?
The patient must be off PPI for 2+ weeks to prevent false negative results
26
What are the investigations that you would do in a suspected peptic ulcer that is currently bleeding?
Upper GI endoscopy:
Diagnostic and therapeutic
FBC
U&E:
urea is raised
LFTs - Assess severity of Liver disease
Venous Blood Gas - raised lactate
Erect CXR - concerned about perforation
27
What is the Glasgow Blatchford Score (GBS)
Scoring system used in a suspected upper GI bleed. Those with a score of >0 require admission.
Drop in Haemoglobin
Rise in Urea
Systolic BP
HR
Melaena
Hx of Syncope
Hepatic disease Hx
HF
28
What is the Rockall Score?
Used for Px who have had an endoscopy. it is a % risk for rebleeding. considers:
Age
Features of Shock - Tachycardia/Hypotension
Co-morbidities
Causes of bleeding
Endoscopic Stigmata
29
What is the first line treatment for a peptic ulcer that is not bleeding?
Conservative Lifestyle Tx - treat RFs
H.pylori Neg:
PPI - omeprazole
H.pylori Pos:
Tripple Therapy - Omeprazole, Clarithromycin, Amoxicillin
30
What is the general management for an upper GI bleed?
ABATED:
ABCDE
Bloods
Access - 2 bore cannula
Transfuse
Endoscopy - urgent within 24 hrs
Drugs - Stop anticoagulants and NSAIDs
31
What is the first line treatment for a peptic ulcer that is bleeding?
First Line:
ABCDE
Blood transfusion - if blood loss
Upper GI endoscopy - within 24 hrs
High dose IV PPI - after Endoscopy
32
What is the Second line treatment for a Peptic ulcer which is bleeding?
Surgery or embolisation
33
What are some complications of peptic ulcer disease?
Perforation
Gastric outlet obstruction
peritonitis - caused by an ulcer/haemorrhage of an ulcer passing straight through into the stomach
Pancreatitis - can also occur as a result of peritonitis
34
What are the red flags for Cancer causing an Upper GI Bleed?
Unexplained weight loss
Anaemia
Evidence of GI bleeding e.g. melaena or haematemesis
Dysphagia
Upper abdominal mass
Persistent vomiting
35
What are Oesophageal Varices?
Dilated submucosal veins within the lower 1/3rd of the oesophagus that develop as a consequence of portal hypertension
36
What is the cause of oesophageal varices?
Portal Hypertension
37
What is the pathogenesis of oesophageal varices?
Portal HTN due to decompensated liver cirrhosis leads to increased back pressure into the left gastric vein.
This causes the veins draining the oesophagus to become engorged and dilate
They are then at increased risk of rupture causing an Upper GI bleed
38
Why are Oesophageal Varices prone to rupture?
As these vessels are thin and not meant to transport higher pressure blood, they can rupture
Rupture 🡪 haematemesis
Rupture 🡪 blood digested 🡪 melaena
39
What are the risk factors for oesophageal varices?
Liver Cirrhosis (50% of Px have varices)
Portal HTN
Decompensated liver Cirrhosis
40
What are the clinical signs of oesophageal varices?
Hypotension
Tachycardia
Pallor
Signs of chronic liver damage – jaundice, easy bruising (liver not produced coagulation factors) and ascites
Splenomegaly
Ascites
41
What are the symptoms of oesophageal varices?
Haematemesis
Melaena
Sx of blood loss:
Dizziness
dyspnoea
Chest pain
Syncope
42
What are the primary Investigations for oesophageal varices?
Upper GI endoscopy:
Diagnostic
FBC - Anaemia
LFTs - assess liver disease severity
U&Es - Urea is raised in upper GI bleed
43
What is the management for bleeding oesophageal varices?
Resus:
ABCDE
IV Fluids - if in shock
Blood transfusion
Terlipressin
Prophylactic Abx
Balloon Tamponade in emergency
44
What is Terlipressin and what does it do?
ADH analogue that can cause splanchnic vasoconstriction to reduce blood flow in the portal vein and reduce portal pressure
45
What Abx are given in oesophageal varices as prophylaxis?
Quinolones:
eg. ciprofloxacin
46
What is the definitive management of oesophageal varices?
1st line:
Variceal Band ligation
Sclerotherapy and transjugular intrahepatic portosystemic shunt (TIPS) are also able to be used
47
What prophylactic Tx should be given to prevent formation or rupture of oesophageal varices?
Beta blocker - propranolol to reduce portal pressure
Variceal band ligation
48
What are some complications of Oesophageal varices?
Rupture and GI bleeding
Rebleeding once fixed
Encephalopathy
Infection
49
What are the different classifications of bowel obstruction?
Site of blockage:
Simple
Intra luminal
In the wall
Outside the bowel
50
What are some causes of bowel obstruction?
Crohn’s
Adhesions
Malignancy
Diverticulitis
Volvulus
Hernias
Hirschsprung’s disease
51
What are some intraluminal causes of bowel obstruction?
Tumours:
- Carcinoma
- Lymphoma
Diaphragm disease - NSAIDs cause repeated ulceration then fibrosis
Gallstone ileus – rare form of small bowel obstruction caused by an impaction of a gallstone within the lumen
Meconium ileus – in neonates, content of bowel is sticky 🡪 blockage
52
What are some within the wall causes of Bowel obstruction?
Tumours
Crohn’s – inflammation, fibrosis and contraction
Diverticulitis – outpouchings in the sigmoid
53
What are some Outside the Bowel causes of Bowel obstruction?
Tumours – disseminated malignancy of peritoneum
Ovarian cancer can spread into peritoneum
Adhesions – fibrosis after surgery
Post-surgery
Fibrous connections between loops of small bowel 🡪 bowel becomes kinked
Corrected surgically
Volvulus – sigmoid colon has a “floppy” mesentery
Sigmoid colon can twist
Causes obstruction of the sigmoid
If there is ischaemia and infarction, sigmoid colon is resected
54
What are the main causes of a large bowel obstruction?
Malignancies - colorectal cancer (90% of all causes)
Stricture - complication of diverticulitis and IBD
Volvulus - Sigmoid / Caecal
Hirschsprung's Disease
55
What is Hirschsprung's Disease?
Congenital disorder where there is defective relaxation and peristalsis of the distal colon causing a bowel obstruction.
Neonates born with incomplete Innervation of the colon to rectum.
A ganglionic segments of the bowel cannot contract (peristalsis) leading to obstruction
56
What is a Volvulus and what are the 2 main types?
occurs when a loop of intestine twists around itself and the mesentery that supplies it, causing a bowel obstruction.
Sigmoid is most common (80%) - associated with elderly Px
Caecal is less common associated with Pregnancy and can occur at any age.
57
Define a small bowel obstruction (SBO)?
Inability of the gut to absorb the necessary nutrients sufficient to sustain life due to a mechanical blockage of the small intestine
58
What is the pathophysiology of a SBO (same for a LBO)?
Mechanical or functional obstruction of the small intestine preventing the normal passage of abdominal contents.
This leads to dilation of the proximal bowel and compression of mesenteric vessels.
Causes transudation of large volumes of electrolyte rich fluid into the bowel (third spacing).
Arterial supply is compressed and you get ischaemia
59
What is the most common indication for emergency laparoscopy?
Small bowel obstructions
60
What is the average age of a Px who has a small bowel obstruction?
70s
61
What are the main causes of a SBO?
Bowel adhesions (50%) - due to previous abdominal surgery
Incarcerated hernias (15%)
Crohn's Disease
Volvulus - rarely SBO but commonly LBO
Paralytic ileus
Malignancy
62
What is a Pseudo-Obstruction of the bowel?
Where there is no blockage to the bowel however the intestine is unable to contract and push food, stool and air through the digestive tract
(Failure of Peristalsis)
63
How do surgeries lead to bowel adhesions?
Formation of fibrous scar tissue between organs and tissue can constrict and adhere to the bowel preventing expansion
64
What is a Paralytic Ileus?
Functional Obstruction due to failure of peristalsis:
Often caused post abdominal surgery
May also be due to electrolyte imbalances (hypokalaemia)
65
What are the clinical signs of a Large and small bowel obstruction?
Abdominal tenderness and distension
Tinkling bowel sounds
Rectal exam - empty or blood suggesting strangulation
Tachycardia
Hypotension
66
What are the symptoms of a small bowel obstruction?
Colicky pain - typically in umbilical region
Nausea and Vomiting - Early sign in SBO
Bloating/distension
Absolute constipation - Late sign in SBO
67
What are the Symptoms of a Large bowel obstruction?
Colicky generalised abdominal pain
Bloating
Absolute constipation - Early sign in LBO
Nausea and Vomiting - Late sign in LBO
68
What is a good way to distinguish whether a Px has a small or large bowel obstruction based off their Symptoms?
SBOs present with nausea and vomiting first before constipation
LBOs present with constipation first before nausea and vomiting
69
What is the cause of the pain felt in SBO?
When there is a mechanical obstruction to the SBO and peristalsis occurs this can lead to pain.
70
Which tests are ordered in the diagnosis of Large/small bowel obstruction?
CT Scan - diagnostic for an obstruction
FBC - anaemia/infection
U&Es - Likely have renal dysfunction secondary to hypovolaemia
Venous blood gas/Lactate - may be increased
CRP/ESR - inflammatory
Potentially Gastrograffin contrast scan
71
What is the gold standard diagnostic test for a Large/small bowel obstruction?
CT Scan:
Diagnostic
Location and cause may also be indicated
72
What is the treatment for all patients with a Large/small bowel obstruction?
Manage pain - analgesia and anti emetics
Assess fluid balance - NG tube/ Urinary catheter
IV Fluids
Nutrition if > 5 days without intake.
73
What is the treatment for patients with a small bowel obstruction due to adhesions?
Signs of Ischaemia or Shock:
Resus and Operate
No-ischaemia:
Gastrografin challenge and determine whether there is a need to operate
74
What is the treatment for all patients with a small bowel obstruction due to a hernia?
Inguinal/Femoral/Umbilical - operate and repair
Incisional Hernia - Treat as adhesive SBO
75
What are the complications of a Small Bowel Obstruction?
Intestinal necrosis
Sepsis
Multi-organ failure particularly renal
Intestinal perforation
76
What are the 2 types of oesophageal cancer?
Adenocarcinoma
Squamous cell carcinoma
77
What type of oesophageal cancer is most common?
Squamous cell carcinoma (90%) in upper 2 thirds
78
What most commonly predisposes Oesophageal adenocarcinoma?
Barret's metaplasia where glandular columnar epithelium replaces the squamous epithelium in the lower oesophagus
79
What is the location of an adenocarcinoma of the Oesophagus?
Lower third of the oesophagus near gastro-oesophageal junction
80
What is the location of a Squamous cell carcinoma of the oesophagus?
Usually upper or middle third of the oesophagus
81
What are the risk factors for adenocarcinoma of the Oesophagus?
Barrett's Oesophagus
GORD
Obesity
Smoking
Coeliac Disease
Scleroderma
82
What are the risk factors for SSC of the oesophagus?
Smoking
Alcohol
Achalasia
Plummer Vinson syndrome
Hot beverages
Nitrosamines
83
Who is more commonly affected by oesophageal cancer?
Males
80 years old
Western world
SSC is more common in Japan
84
What are the clinical signs of oesophageal cancer?
Lymphadenopathy
Vocal Cord Paralysis
Pallor - anaemia
Melaena - due to oesophageal bleeding
85
What are the symptoms of oesophageal cancer?
ALARMS:
Anaemia
Loss of Weight
Anorexia
Recent sudden Sx worsen
Melaena/Haematemesis
Swallowing - Progressive Dysphagia
Hoarse Voice - due to pressure on recurrent laryngeal nerve
86
What may be a differential diagnosis when a Px presents with symptoms of dysphagia?
Achalasia
This however is non progressive and so Px dont say at first it was difficult to swallow then fluids then food etc.
87
What is the primary investigation for oesophageal cancer?
Upper GI Endoscopy (OGD) and Biopsy
Staging Ix:
CT Chest abdo pelvis (CAP)
Endoscopic ultrasound (EUS)
HER2 Testing
88
What is the first line staging investigation for oesophageal cancer?
CT chest, abdomen and pelvis (CAP)
89
What is the management of Oesophageal cancer for both Adenocarcinoma and SCC?
If operable:
Adenocarcinoma - Oesophagectomy
SCC - Radical chemoradiotherapy
Advanced/Metastatic:
Chemotherapy
Palliation - Stenting for Dysphagia
Trastuzumab for HER2 Positive
90
When does Oesophageal cancer tend to present and what is the prognosis?
Tends to present late
Has a prognosis of 15% 5yr survival
91
What are the main types of cancer is a gastric cancer?
Adenocarcinoma (90-95%)
SCC (5%)
92
What are the main types of Adenocarcinoma Gastric cancer?
Type 1 (Intestinal) - Usually exophytic or ulcerating
Type 2 (Diffuse) - Flat, causing linitus plastica
93
What are the features of Intestinal Gastric cancer?
Better Prognosis
Exophytic
Ulcerating lesions
Well formed and differentiated glandular structures
94
What are the features of Diffuse gastric cancer?
Has a much worse prognosis
Poorly cohesive
Infiltrates the gastric wall
Can affect any part of the stomach
95
What are the modifiable risk factors for Gastric cancer?
H.pylori infection (significant)
smoking
alcohol
diet
Obesity
96
What are the non-modifiable risk factors for gastric cancer?
Genetics - CDH-1 gene (mutated Cadherin)
Male
Increased age
Pernicious anaemia
Blood type A
Gastric Adenomatous polyps
97
Where is gastric cancer most common?
Japan
98
What are the clinical signs of gastric cancer?
Fe Deficiency anaemia - Koilonychia
Palpable mass
Melaena
Leser-Trelat sign - sudden onset keratosis
99
What are the symptoms of gastric cancer?
Severe epigastric Abdominal pain
Dyspepsia
Anorexia and weight loss
Dysphagia
Nausea and vomiting
Signs of Metastasis - Liver dysfunction etc
100
What are the main lymph nodes that Gastric cancer may spread to?
Virchow's Node - Supraclavicular
Sister Mary Joseph Node - Umbilical
101
What is the primary investigation of gastric cancer?
Upper GI Endoscopy and Biopsy
1st line staging - CT-CAP
102
What is the management of Gastric cancer?
Surgery only indicated if no evidence of metastatic disease
Surgery - remove tumour/stomach
Advanced disease:
Chemotherapy - 5-Fluorouracil/Cisplatin
Palliative gastrectomy
103
What are some complications of Gastric cancer?
Bleeding
Gastric outlet obstruction
Perforation
Metastasis
104
What is Bowel Cancer?
Usually an adenomatous cancer that typically affects the colon (colorectal) more than it affects the small bowel
105
What is the prevalence of bowel (colorectal) cancer?
4th most prevalent cancer in the UK.
Behind breast, prostate and lung
3rd most Prevalent world wide
106
How do bowel cancers arise?
sporadic cancers arising from:
Adenomatous Polyp to progress to adenocarcinoma
Defects in DNA repair genes
107
What are the risk factors for Bowel cancer?
50+
Increasing age
Smoking
Obesity
IBD
FHx - FAP, HNPCC
108
What is Familial adenomatous Polyposis (FAP)?
Autosomal dominant
Malfunctioning tumour suppressor genes of APC (adenomatous polyposis coli)
Leads to many Polyps developing which can progress to cancer
109
What is the pathogenesis of FAP?
Apc bound to GSK
Beta catenin binds apc complex in high levels of apc
In mutations, apc protein misfolded so can’t bind to beta catenin
Beta catenin able to move into nucleus 🡪 endothelial proliferation 🡪 adenoma
110
What is Hereditary Nonpolyposis Colorectal Cancer (HNPCC)?
Lynch syndrome
Autosomal dominant
Mutations in DNA mismatch repair genes (MMR)
Increases the risk of multiple cancers particularly colorectal
111
What are the 2 broad areas of colorectal cancers?
Left sided (LS) Colorectal cancer
Right Sided (RS) colorectal cancer.
These may have different signs and Sx
112
What are the symptoms of Left sided bowel cancer?
General Cancer Sx
Change in bowel habit with blood and mucus in stools
Diarrhoea
Alternation constipation and diarrhoea
Thin/altered stool
113
What are the Symptoms of Right sided colorectal cancer?
Usually asymptomatic until they present with iron deficiency anaemia due to bleeding
May present with a mass
Weight loss
Abdominal pain
114
What are the clinical signs of Bowel cancer?
LS CC - rectal mass, PR bleeding
RS CC - Iron Deficiency anaemia
115
What is the Diagnostic investigation used for Bowel cancer diagnosis?
FIT Test - screening test for micro blood particles in faeces
Gold standard - Colonoscopy and Biopsy
Digital Rectal exam
38% of colorectal cancers can be detected by DRE
1st Line staging - CT-CAP
116
What is the FIT test?
Faecal immunochemical Test for bowel cancer screening:
Looks for Hb in stool.
Performed in anyone over 50 with unexplained Weight loss and no other symptoms.
Performed in over 60s with a change in bowel habit
117
What is the staging classification for bowel cancer?
TNM Dukes staging:
Tumour: TX - T4
Nodes: NX-N2
Metastasis: M0-M1
118
What is the Dukes staging of Bowel Cancer?
Duke stage:
A – 95% 5 year survival, limited to muscularis mucosae (mucosa)
B - 75% 5 year survival, traverses bowel lining and into submucosa (not lymph)
C - 35% 5 year survival, involvement of regional lymph nodes
D - 10% 5 year survival - mets
119
What is the Treatment for Bowel cancer?
Surgical resection - curative if no mets
+ chemotherapy
120
What are some differential Diagnoses of Colorectal Cancer?
Anorectal pathology
Haemorrhoids
Anal fissue
Anal prolapse
Colonic pathology
Diverticular disease
IBD
Ischaemic colitis
Small intestine and stomach pathology
Massive upper GI bleed – haematochezia
Meckel’s diverticulum
121
What is Dyspepsia?
Functional Dyspepsia is a form of a Functional Gut disorder like IBS where there are Sx of Indigestion without any other clear cause.
Dyspepsia can also be a symptom of certain conditions such as PUD
122
What are the Sx of Dyspepsia?
Early satiation
Epigastric pain and Reflux (like GORD)
Heartburn
Bloating
Hoarse Cough
Extreme Fullness.
123
What is the Epidemiology of Dyspepsia?
Common – affecting up to 25% of population a year
124
What is the cause of Dyspepsia?
Functional Dyspepsia - Unknown Cause.
Other causes may be PUD.
125
What are the diagnostic investigations for Dyspepsia?
Endoscopy is used to find an underlying cause.
If there is no obvious cause then it may be functional dyspepsia
126
What is the Treatment for Dyspepsia?
If underlying cause then Tx.
If functional - Give reassurance and dietary review.
127
What is a Mallory-Weiss Tear (MWT)?
Longitudinal lacerations limited to the mucosa and submucosa
Found at the border of the gastro-oesophageal junction (GOJ)
128
What is the pathophysiology of a MWT?
Dilations and tears caused by a sudden rise in intra abdominal and transmural pressure across the GOJ secondary to vomiting and retching in the presence of pre existing gastric mucosal damage.
129
What are the risk factors for MWT?
Any condition that predisposes retching/vomiting:
Gastroenteritis, Bulimia etc.
Alcoholism
Chronic cough
Hiatus hernia
GORD
130
Who is typically affected by a MWT?
Male with acute Hx of retching after a night out.
40-60yrs
131
What are the symptoms of a MWT?
Preceding retching and vomiting
Haematemesis
Melaena - rare
Epigastric pain
132
What are the primary investigations for a MWT?
Upper GI endoscopy
FBC - anaemia
U&Es - raised urea
133
What is the management of a MWT?
Usually self limiting - manage contributing factors
If persistent bleeding:
Upper GI endoscopy - clipping/thermal coagulation
High dose IV PPI (pantoprazole) - give after endoscopy
134
What is the difference between a MWT and an oesophageal varices?
A MWT is caused by increased intraabdominal/transmural pressures that cause tears in preexisting mucosal damage.
An oesophageal varices is a consequence of portal HTN due to decompensated liver failure which causes dilation of the oesophageal blood vessels that then become prone to rupture.
Both can cause an upper GI bleed
135
What are some differential Diagnoses for a Mallory Weiss Tear?
Gastroenteritis
Peptic ulcer
Cancer
Oesophageal varices
136
If you have a patient with acute haematemesis what should you consider?
Hx of Liver disease + portal HTN = Oesophageal Varices
No Hx of liver disease but acute Hx of Retching = MWT
137
Describe h.pylori.
A gram negative bacilli with a flagellum that is present in 50% of the populations gastric mucosa
138
How does helicobacter pylori infection cause gastric damage?
Lives in gastric mucus
Secretes urease which splits urea in stomach into CO2 + ammonia
Ammonia + H+ 🡪 ammonium
Ammonium, proteases, phospholipases and vacuolating cytotoxin A damages gastric epithelium
Causes inflammatory response reducing mucosal defense 🡪 mucosal damage
Also causes increased acid secretion
Gastrin release (from G cells) 🡪 more acid secretion
Triggers release of histamine 🡪 more acid secretion
Increases parietal cells mass 🡪 more acid secretion
Decreases somatostatin (released from D cells) 🡪 more acid secretion
139
What conditions can arise as a result of H.pylori infection?
Peptic Ulcer Disease (PUD)
Gastritis
Gastric carcinomas
140
What is the diagnostic test to investigate H.pylori infection?
1st line: Urea breath test
Stool antigen test
141
What is the treatment of H.pylori infection?
Triple-therapy: For 7 days
Proton Pump Inhibitor - Omeprazole
Clarithromycin
Amoxicillin
142
What is Inflammatory bowel disease?
Umbrella term for 2 main diseases causing inflammation of the GIT Tract.
Ulcerative Colitis and Crohn's Disease.
143
What is Crohn's Disease?
Form of IBD
Granulomatous inflammation of any part of the gut
Characterised by Skip lesions arising anywhere between the mouth and anus.
Transmural inflammation with granuloma formation
144
What can cause Crohn's Disease?
NOD-2 mutation
Bacterial immune mediated response - TNFalpha, IL-1, IL-6
145
What are the features of Crohn's Disease?
Crohn's (Crows NESTS):
N - No Blood or mucus in stool
E - Entire GI Tract - from mouth to anus can be affected
S - Skip Lesions on Endoscopy
T - Terminal Ileum is most affected and Transmural inflammation
S - Smoking is a risk factor - dont set the nest on fire
CHRISTMAS:
C - Cobblestones
H - High temperature
R - Reduced lumen
I - Intestinal fistulae
S - Skip lesions
T - Transmural
M - Malabsorption
A - Abdominal pain
S - Submucosal fibrosis
146
Where is the most commonly affected region of the GI tract in Crohn's Disease?
The Terminal ileum and colon.
147
What is the inflammation like in Crohn's Disease?
Transmural - full thickness
Occurs in skip lesions (points of inflammation and no inflammation) across GIT
Can lead to fistulas, Strictures and adhesions
148
What are the Micro and Macro features of Crohn's Disease?
Macroscopically
Skip lesions
Cobblestone appearance due to ulcers and fissures in mucosa
Thickened and narrow
Microscopically
Transmural – affects all layers of bowels
Non-caseating granulomas (aggregations of epithelioid histiocytes)
Goblet cells
149
Who is typically affected by Crohn's Disease?
Highest incidence and prevalence in Northern Europe, UK and North America
F>M
Presents mostly at 20-40
150
What are the risk factors for Crohn's Disease?
FHx - NOD2 mutation
Caucasian
Female
HLA-B27
Smoking
Chronic Stress
151
What are the signs of Crohn's Disease?
Abdominal tenderness
Fever
Malabsorption
Blood, fistulas, fissures on PR exam
Aphthous - mouth ulcers
Extra-intestinal Manifestations: (less common in Crohns')
Erythema nodosum
Anal fissures
Episcleritis
152
What are the symptoms of Crohn's Disease?
Diarrhoea
RLQ abdominal pain (ileum)
Fatigue, fever, Nausea, vomiting
Tenderness
153
What is Ulcerative Colitis?
Form of IBD
Inflammation of the rectum which extends proximally but never beyond the ileocecal valve.
Mucosal and Submucosal inflammation with crypt abscesses and neutrophil infiltration.
154
What can Cause Ulcerative Colitis?
Unknown aetiology
NSAIDs - associated with IBD onset and flares
Potentially autoimmune as it is associated with HLA-B27 gene and pANCA
155
Where is the most commonly affected region in Ulcerative colitis?
Only affects the rectum (proctitis) and continuous colon.
Never past the ileocecal valve to the small bowel
156
What is the inflammation like in Ulcerative Colitis?
continuous inflammation of the Large bowel.
Mucosal and Submucosal layers are affected (not transmural)
Can lead to crypt abscesses and neutrophil infiltration.
157
What are the Macro and Micro features of Ulcerative Colitis?
Macroscopically
Continuous inflammation (no skip lesions)
Ulcers
Pseudo-polyps
Microscopically
Mucosal inflammation
No granulomata
Depleted goblet cells
Increased crypt abscesses
Paneth cells are involved in innate immunity and suggest an inflammatory condition when found in the descending colon
158
What are the features of Ulcerative Colitis?
U-C = CLOSEUP:
Continuous inflammation From distal (rectum) to proximal (ileocaecal valve (never past it))
Limited to colon and rectum
Only superficial mucosa affected
Smoking is protective
Excrete blood and mucus
Use aminosalicylates
Primary Sclerosing Cholangitis
ULCERATIONS:
Ulcers
Large intestine
Carcinoma – risk of
Extra-intestinal manifestations – uveitis, erythema nodosum, sclerosing cholangitis
Remnants of older ulcers - pseudo polyps
Abscesses in crypts
Toxic megacolon – risk of
Inflamed, red, granular mucosa
Originates at rectum
Neutrophil invasion
Stool is bloody and has mucous
159
Who is typically affected by ulcerative Colitis?
Highest incidence in Northern Europe, UK and North America
Affects males and females equally
Presents mostly at 15-30
Non-Smokers
Bimodal age distribution from 15-25yrs to 55-75yrs
160
What are the risk factors for Ulcerative Colitis?
FHx
HLA-B27
Caucasian
Non-smoker - Smoking relieves UC
NSAIDs – associated with onset of IBD and flares of disease
Chronic stress and depression triggers flares
161
What are the clinical signs of Ulcerative Colitis?
Abdominal Tenderness
Fever
Fresh Blood on rectal exam
Extra-intestinal manifestations (more common in UC)
162
What are the symptoms of Ulcerative Colitis?
Diarrhoea
Blood and Mucus in stool
Urgency and Tenesmus (rectal defaecation pain)
Abdominal pain - particularly in the LLQ
Weight loss and malnutrition - more common in Crohn's
163
What are the Extra-intestinal manifestations of IBD?
Skin Rashes - Erythema nodosum, Pyoderma Gangrenosum
Arthritis and osteoporosis
Episcleritis (Crohn's > UC)
Uveitis (UC > Crohn's)
PSC and AIH - UC
164
What is the most common extra intestinal manifestation in IBD?
Arthritis
165
What are the investigations for Crohn's Disease?
Colonoscopy – diagnostic
Biopsy
Barium enema
Stool sample – rules out infectious diseases
FBC
Raised ESR/CRP
Often low Hb due to anaemia
Faecal calprotectin – indicates IBD but not specific
166
What are the investigations for Ulcerative Colitis?
Colonoscopy - diagnostic
Biopsy – crypt abscesses
Barium enema
Bloods:
FBC – raised ESR and CRP, low Hb
Test for pANCA – negative in Crohn’s
Iron deficiency anaemia
Faecal calprotectin - Indicates IBD
Stool sample – rule out infectious causes
CT/MRI
Abdominal X-ray - Toxic Megacolon
167
What are the diagnostic investigations for IBD?
Routine Bloods - anaemia, infection, LFTs, TFTs, Kidney function
CRP - inflammation and active diseaes
Faecal Calprotectin - 90% sensitive and specific to IBD
Endoscopy (OGD and colonoscopy) + biopsy is diagnostic
Imaging - CT/Abdo USS for complications - fistulas, fissures, strictures
168
What is the main raised inflammatory marker in IBD?
Faecal Calprotectin levels:
released by the intestines when inflamed can help distinguish between IBD and IBS.
169
What is the gold standard diagnostic test for IBD?
Endoscopy/Colonoscopy + biopsy
170
What is the First line treatment in inducing remission in Crohn's Disease?
Steroids - oral prednisolone or IV Hydrocortisone
If ineffective alone then add immunosuppressant:
Azathioprine
Mercaptopurine
Methotrexate
Infliximab
Adalimumab
171
What is the first line treatment for maintaining remission of Crohn's disease?
First line:
Azathioprine/Mercaptopurine
172
When is it possible to use surgery to treat Crohn's Disease?
When the disease only affects the distal ileum
Can also be used to treat strictures and fistulas secondary to Crohn's
Usually a Right Hemi-colectomy
173
What is the First line treatment in inducing remission in Ulcerative Colitis?
Mild to moderate disease:
First line - Aminosalicylate (Mesalazine)
Second line - Corticosteroids (prednisolone)
Severe Disease:
First line - IV Corticosteroids (hydrocortisone)
Second Line - IV Ciclosporin
174
What is the first line treatment for maintaining remission of Ulcerative Colitis?
Aminosalicylate - Mesalazine
Azathioprine
Mercaptopurine
175
What aminosalicylate is used to treat Ulcerative Colitis?
Mesalazine - oral or rectal
176
When is Surgery used in Ulcerative Colitis?
Typically UC only affects the colon and rectum
Surgery to remove these can remove the disease leaving the patient with a ileostomy (stoma)
177
What are some complications of Crohn's Disease?
Peri-anal Abscess
Anal Fissure
Anal Fistula
Strictures and obstruction
Perforation and Sepsis
Anaemia and Malabsorption
Osteoporosis
178
What are some complications of Ulcerative Colitis?
Toxic Megacolon
Perforation
Colonic Adenocarcinoma
Strictures and Obstruction
Extra-intestinal Manifestations
179
How is Toxic Megacolon identified?
AXR or CT
180
What are the differential diagnoses to exclude for IBD?
Alternative causes of diarrhoea should be excluded
Salmonella spp.
Giardia intestinalis
Rotavirus
181
What is Irritable Bowel Syndrome?
Irritable bowel syndrome is a chronic, functional bowel disorder characterised by abdominal pain and altered bowel habits with no underlying pathology.
182
What are functional Gut disorders?
These are disorders of the gut-brain interaction that do not have a detectable structural or biochemical abnormality.
They are abnormal symptoms within a normal gut.
183
What part of the GI Tract is often affected in irritable bowel Syndrome?
The lower GI Tract.
184
What is the Prevalence of IBS and who does it typically affect?
Prevalence - Up to 20% of the population.
Affects more women than men
Common in younger adults.
185
What are the different types of IBS?
IBS-C = mostly constipation
IBS-D = mostly diarrhoea
IBS-M = mostly mixed (mix of C/D)
186
What are some possible risk factors for IBS?
Female sex
FHx
GI infection/inflammation
Dietary factors
Psychosocial Factors - stress/anxiety/depression
Drugs
187
When should you consider a diagnosis of IBS?
In a Px who has had any of these symptoms for at least 3+ months:
Abdominal Pain
Bloating
Changing in bowel habits
With NO UNDERLYING CAUSE
188
What are the symptoms of IBS?
Abdominal Pain
Bloating
Change in bowel habit
Constipation
Diarrhoea
IMPROVED AFTER OPENING BOWELS
worse after eating.
189
How is IBS Diagnosed?
Rome IV Criteria:
IBS is defined as recurrent abdominal pain that has occurred, on average, at least:
one day per week
over the last three months
and symptoms begin at least six months ago.
In addition, pain is associated with ≥2 of the following criteria:
Related to defecation
Associated with change in stool frequency
Associated with change in stool form (appearance)
All with normal results on Ix
190
What Investigations should be done to rule out other causes of Sx in IBS?
Diagnosis of exclusion:
Blood Tests - FBC, CRP, ESR all normal
Faecal Calprotectin - negative (excludes IBD)
Anti -TTG Abs - Excludes Coeliacs
Cancer is excluded
191
What is required for the Diagnosis of IBS?
Sx suggesting IBS:
Abdominal pain and/or discomfort
Relieved on opening bowels or
Associated with a change in bowel habit
AND 2 OF:
Abnormal stool passage
bloating
worse Sx after eating
Mucus with stools
192
What is the Initial Conservative management of IBS?
Positive Diagnosis - Tell them that although they have no pathology present they do have IBS (a condition)
Advice and reassurance - no serious underlying pathology present.
Adequate fluid intake and Regular physical activity.
General healthy diet advice - eg. more fibre if IBS-C
Probiotic supplements - 4 weeks
Second Line = Medications
193
What are the first and second line medications used in IBS? (second line management)
Sx Management:
First Line:
Loperamide - if diarrhoea is key symptom
Linaclotide - if constipation is key symptom
Second Line:
Tricyclic antidepressants - amitriptyline (5-10mg)
Third Line:
SSRI - Citalopram
CBT - help Px psychologically manage the condition.
194
What are some complications of IBS?
Mood disorders - increased risk of depression and anxiety
Poor Quality of Life
195
What are some differential diagnoses for IBS?
IBD
Colorectal cancer
Ovarian cancer
196
What are the alarm features of GI conditions?
Age >45
Hx of Symptoms
Unintentional Weightloss
Nocturnal Sx
FHx of GI cancer or IBD
GI bleeding
Palpable mass or lymphadenopathy
Evidence of Fe anaemia
Evidence of Inflammation on blood/stool sample.
197
What is Coeliacs Disease?
An autoimmune conditions where exposure to gluten peptides causes an autoimmune reaction that causes inflammation in the small intestine.
This results in malabsorption
198
What foods can contain gluten peptides?
Wheat
Barley
Rye
199
What are the Genes and the auto antibodies associated with coeliacs disease?
HLA DQ2, HLA DQ8
Anti-tissue transglutaminase (anti-TTG)
Anti-endomysial (Anti-EMA)
200
What is the pathophysiology of Coeliacs Disease?
Gluten Peptides (Gliadin) binds to secretory IgA in mucosal membrane
Gliadin-IgA is transcytosed to the lamina propria where the enzyme Tissue Transglutaminase (TTG) deaminates Gliadin which increases its Immunogenicity.
Deaminated gliadin is taken up by macrophages and expressed on MHC II complex via HLA DQ2 and DQ8
APCs present Gliadin antigen to T helper cells so they release inflammatory cytokines and stimulate B cells
This causes villous atrophy, crypt hyperplasia and intraepithelial lymphocyte infiltration
🡪 reduced SA to absorb nutrients 🡪 B12, folate and iron cannot be absorbed 🡪 anaemia
201
What is the prevalence of Coeliacs disease in the UK?
1%
202
What are the risk factors for Coeliacs disease?
FHx
HLA DQ2/HLA DQ8
PHx of autoimmune disease
IgA deficiency
Downs
Turners
203
How does Coeliacs disease often present?
Often ASx
Can present with:
Diarrhoea
Steatorrhea – fatty stools due to reduced fat absorption in intestines
Abdominal pain
Abdominal distension
Weight loss
Failure to thrive
Nutritional deficiency
Anaemia - secondary to Fe, Vit B12 or folate def.
204
What skin condition is associated with coeliacs disease?
Dermatitis Herpetiformis
An itchy vesicular skin eruption caused by deposition of IgA
Treated with Dapsone
205
What should patients with suspected coeliacs disease do prior to investigation?
Gluten challenge:
Should be ON a gluten containing diet for 6 weeks prior to investigations
206
What diagnostic investigations are carried out for coeliacs disease?
Carried out Post gluten challenge:
Serology:
Total IgA - exclude IgA deficiency
Raised anti-TTG Abs
Raised anti-EMA Abs
Anti-Gliadin
Endoscopy and intestinal biopsy:
Crypt hypertrophy
Villous Atrophy
Increased intraepithelial lymphocytes
FBC:
Low Hb
Low B12
Low Folate
Low Ferritin
207
What is the gold standard diagnostic test for Coeliacs disease?
Small bowel biopsy and Histology
208
How is the biopsy assessed for Coeliacs?
Marsh Classification:
0 normal
1 raised intra epithelial lymphocytes (IEL)
2 raised ILE + crypt hyperplasia
3a partial villous atrophy (PVA)
3b subtotal villous atrophy (SVA)
3c total villous atrophy (TVA)
209
What other investigations may you consider for coeliacs disease?
FBC
Nutritional Status
HLA Testing
210
What autoimmune conditions is Coeliacs disease associated with?
T1DM
Thyroid disease
Autoimmune Hepatitis
PBC
PSC
211
What are some complications of untreated coeliacs disease?
Vitamin Deficiency
Malabsorption
Anaemia
Osteoporosis
Ulcerative jejunitis
Non-hodgkin lymphoma
Enteropathy associated T cell lymphoma of the intestine
212
What is the management of coeliacs disease?
A lifelong gluten free diet - can be curative but will relapse upon consuming gluten
Dietary supplements - Ca Vit D, Fe if the Px diet is insufficient
Dexa-scan for osteoporotic risk.
213
How does Lactose intolerance lead to gas.
cant break down lactose.
Once in the colon, the bacteria can ferment the unbroken down lactose leading to gas production.
214
Define Malabsorption?
The failures to fully absorb nutrients in the small intestine either because of the destruction to the epithelium or due to a problem in the lumen meaning food cannot be digested
215
What disorders of the intestine can lead to malabsorption?
Coeliac disease
Tropical Sprue
Crohn’s
Parasitic infection
216
What are some pathological reasons for malabsorption?
lack of enzymes - pancreatic insufficiency/blockage. bile acid obstruction.
defective epithelial transport
insufficient absorptive area - gluten sensitive enteropathy (coeliacs)/ Inflammation (Crohn's)
Defective intraluminal digestion - lack of digestive enzymes (pancreatic, CF, bile secretion)
bowel resection or bypass.
Lymphatic obstruction
217
What are the symptoms of malabsorption?
Weight loss
Steatorrhea
Diarrhoea
218
What are the signs of malabsorption?
Anaemia – decreased iron, B12, folate
Bleeding disorders – decreased Vitamin K
Oedema – decreased protein
Metabolic bone disease – decreased vitamin D
Neurological features
219
What are the investigations for malabsorption?
FBC
Increased/decreased MCV
Decreased calcium/iron/B12 and folate
Increased INR
Stool sample microscopy
Coeliac tests
220
What is Tropical Sprue?
Severe malabsorption (of 2 or more substances) accompanied with diarrhoea and malnutrition.
221
Where does Tropical Sprue occur?
To visitors or residents of tropical areas such as Asia, Caribbean Islands, and South America
222
What is acute gastritis?
Inflammation of the stomach that tends to present with nausea and vomiting
223
What is Enteritis?
Inflammation of the intestines that tends to present with diarrhoea
224
What is Gastroenteritis?
Inflammation of the GI Tract from the stomach all the way through the intestines.
This tends to present with nausea, vomiting and diarrhoea
225
What is the most common cause of gastroenteritis?
Viral infection
226
What are the common viral causes of gastroenteritis?
Rotavirus
Norovirus
Adenovirus
227
Who is typically affected by gastroenteritis?
It can affect anyone and people generally recover well.
It can be serious in Px who are immunocompromised, very young or very old.
228
What must be done if a patient has gastroenteritis in a healthcare environment?
Isolate the patient to prevent spread to other patients
229
What are the clinical features of viral gastroenteritis?
Diarrhoea
Nausea
Vomiting
230
How long until symptoms are resolved for the main viral causes of gastroenteritis?
Rotavirus - 3-8 days
Norovirus - 1-3 days
Adenovirus - 1-2 weeks
231
What are the risk factors for gastroenteritis?
Ingestion of undercooked food
Reheating meals
poor sanitary conditions
Travelling to endemic areas - SE Asia, Sub Saharan Africa
Immunosuppression
232
What are the general symptoms of gastroenteritis?
Vomiting
Diarrhoea
Abdominal cramps
Fever
Lethargy
233
What are the general clinical signs of a Px with gastroenteritis?
Dehydration
Electrolyte imbalance
Hypotension
Tachycardia
Reduced Urine Output
234
What are the potential causes of gastritis?
Autoimmune
Increased acid - overcome mucosal buffer
H. pylori - stimulates more acid production
NSAIDs - inhibit COX and prostaglandin synthesis
Mucosal ischaemia - loss of barrier function
Campylobacter infection
Viral infection
235
How do NSAIDs lead to gastritis?
NSAIDs inhibit COX which prevents prostaglandin synthesis.
This means that prostaglandins cannot stimulate mucin production and therefore there is reduced mucosal defence.
This allows the stomach acid to then attack the gastric wall leading to ulcer formation and gastritis
236
What is the gold standard diagnostic test for gastritis?
Endoscopy + biopsy
237
What are the key bacterial causes of Gastroenteritis?
E.coli - particularly E.coli 0157 (HTEC/STEC)
Campylobacter
Shigella
Salmonella
Bacillus Cereus
Yersinia
238
What investigations should be done for a patient with gastroenteritis?
If mild/moderate - no Ix required and Px are discouraged from attending hospital to prevent spread
Ix to consider:
FBC
U&E
Stool culture - for bacteria
Stool Microscopy
239
What is the management for gastroenteritis?
Viral - usually self limiting - 7 days
Mild-moderate:
Bland diet, oral rehydration
Severe:
IV fluids
240
What should be avoided in gastroenteritis caused by E.coli 0157?
Antibiotics as these can lead to HUS.
241
What are some complications of gastroenteritis?
Dehydration
Malnutrition
Post infectious IBS
242
What is GORD?
Gastro-oesophageal Reflux Disease
Where acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus.
243
What is the lining of the lower oesophagus and the lining of the stomach?
Oesophagus - Squamous epithelial lining
Stomach - Columnar Epithelial Lining
244
What can GORD be caused by?
Increased sphincter relaxation
Raised Intragastric pressure - Pregnancy/Obesity
Reduced Sphincter tone
Hiatus Hernia
Anatomical abnormalities of the GOJ
Oesophageal Dysmotility
245
What are the risk factors of GORD?
Increasing Age
FHx
Obesity - raised Intragastric Pressure
Pregnancy - raised intragastric pressure
Hiatus Hernia - disrupts GOJ
Smoking and alcohol
Drugs - nitrates, caffeine, CCBs
Fatty foods
246
What are the Symptoms of GORD?
Heartburn
Acidic taste at back of mouth
Dysphagia
nausea
Hoarseness and chronic cough
Dyspepsia
247
What are the diagnostic investigations for GORD?
H.pylori test - stool antigen/Urea breath test
Endoscopy - often normal
24 hr pH study
Oesophageal manometry - functionality test of LOS
248
What is the conservative management of GORD?
Lifestyle advice:
weight loss
avoidance of triggering foods
smaller lighter meals
stop smoking
avoid heavy meals before bed
Sleep with head tilted upwards
249
What medical management could be used for GORD?
Acid neutralising medication - Gaviscon, Rennie
PPI - omeprazole, Lansoprazole
H2 receptor antagonist - ranitidine, cimetidine
Surgery - Laparoscopic fundoplication
250
What are some complications of GORD?
Barrett's Oesophagus
Oesophageal ulceration/stricture.
251
What bacteria leads to an increased risk of GORD/ barrett's Oesophagus?
Helicobacter Pylori:
Gram negative aerobic bacteria
252
What is Barrett's Oesophagus?
The constant reflux of acid into the lower oesophagus causes a change in the epithelium called metaplasia.
This is a change from the stratified squamous epithelium to the columnar epithelium for the stomach.
Barrett's Oesophagus is considered premalignant.
253
What does barrett's Oesophagus predispose a patient to?
Considered premalignant.
Predisposes the Px to adenocarcinoma.
254
What is the treatment of Barrett's Oesophagus?
Using Proton Pump Inhibitors
Omeprazole
Ablation therapy in Px with Dysplasia may be used to destroy the epithelium for it to be replaced with normal tissue.
255
What is Achalasia?
An oesophageal motility disorder characterised by an inability for the LOS (lower oesophageal sphincter) to relax in response to swallowing.
256
What is the pathophysiology of Achalasia?
Unknown but thought to be due to a loss of inhibitory neurones secreting VIP and NO within the Auerbach plexus.
This leads to the constant contraction of the LOS and dilation of the oesophagus above the LOS.
257
What are the risk factors for achalasia?
Genetics
Infection - Chagas disease (Trypanosoma Cruzi)
Autoimmune disease
258
What are the symptoms of Achalasia?
NON PROGRESSIVE DYSPHAGIA -
BOTH solids and liquids (dysphagia)
Regurgitation
Heartburn
Coughing when lying down
Weight loss - due to reduced oral intake.
259
What are the primary investigations of Achalasia?
Upper GI Endoscopy (OGD) - low sensitivity for achalasia but excludes malignancy.
Oesophageal Manometry - GS for establishing the diagnosis
Barium Swallow - Bird beak - diagnostic except in early disease.
260
\What is the gold standard investigation for establishing a diagnosis of achalasia?
Oesophageal manometry:
Incomplete relaxation of the LOS +
Oesophageal aperistalsis
261
What is the management of Achalasia?
Medical:
CCBs (nifedipine) + nitrates to reduce the pressure and relax LOS.
(often ineffective)
Surgical - Heller's Cardiomyotomy is first line for those fit for surgery.
Balloon Stent
262
What are some complications of Achalasia?
GORD - as a complication of cardiomyotomy.
Malignancy
Aspiration pneumonia due to regurgitation
perforation.
263
What are the risk factors for barrett's Oesophagus?
GORD
Middle age
male - 7x more likely
Caucasian
smoking
obesity
264
What are the Ix for Barrett's Oesophagus?
upper GI Endoscopy and Biopsy
Reveals metaplasia
265
What are the 2 types of bowel Ischaemia?
Mesenteric Ischaemia - Small bowel
Ischaemic Colitis - Large bowel
266
What is Bowel Ischaemia?
Diminished blood flow to the bowel where there is not enough oxygen or nutrients supplied to the bowel that leads to inflammation
267
What causes Ischaemic colitis?
Atherosclerosis
Thrombosis
Emboli
Affecting the IMA (sometimes SMA)
Decreased CO and arrhythmias
Vasculitis
268
What are the most common sites affected in ischaemic colitis?
Watershed areas:
Splenic Flexure (most common)
Sigmoid Colon + Cecum
269
What are the causes of Mesenteric Ischaemia?
Superior mesenteric artery thrombosis – most common
Superior mesenteric artery embolism (e.g. due to AF)
Mesenteric vein thrombosis – common in younger patients with
hypercoagulable states
Non-occlusive diseases
270
What are the two types of Mesenteric Ischaemia?
Acute mesenteric Ischaemia (AMI) - acute attack, abdominal MI
Chronic Mesenteric Ischaemia (CMI) - long lasting over months, Abdominal Angina
271
What are the risk factors for bowel ischaemia?
Increasing age
Atrial Fibrillation
CVD RFs
Endocarditis
Malignancy
Cocaine use
Vasculitis
272
What are the symptoms of Ischaemic colitis?
LLQ pain
Bright bloody stool
+/- signs of hypovolaemic shock
273
What are the symptoms of mesenteric Ischaemia?
Triad of:
Central/RIF acute severe abdominal pain (disproportionate pain to clinical findings)
No abdominal signs on exam
(guarding/rebound tenderness)
Rapid Hypovolaemic Shock – pale skin, weak rapid pulse, reduce urine output, confusion
274
What is the diagnostic investigation of Ischaemic Colitis?
Colonoscopy + biopsy is GS
Only after Px is fully recovered.
CT/MRI Angiography
Rule out other causes (h.pylori)
275
What is the diagnostic investigation of mesenteric Ischaemia?
CT angiogram
+ FBC, ABG to look for persistent metabolic acidosis
276
What is the management of Ischaemic Colitis?
Conservative:
Symptomatic Tx
IV fluids,
Prophylactic Abx
Surgery if infected colon - bleeding, peritonitis etc.
277
What is the management of Mesenteric Ischaemia?
Emergency:
Fluid Resus
Abx
IV Heparin - lower thrombo-emboli and reduce clotting
Surgery - remove infarcted bowel
278
What is appendicitis?
Acute inflammation and bacterial infection of the appendix.
279
What is the pathogenesis of appendicitis?
Luminal obstruction of the appendix leads to the trapping of pathogens and bacteria within the appendix causing infection and inflammation.
The inflammation may proceeds to gangrene and rupture via perforation.
This will release faecal contents and infective material into the peritoneum causing peritonitis
280
What can cause appendicitis?
Obstruction:
Faecolith – stones made of faeces
Filarial worms
Undigested seeds
Lymphoid hyperplasia – can obstruct tube and lymphoid follicles can grow during viral infection
Bacteria – Campylobacter jejuni, Yersinia, salmonella, bacillus cereus
281
What are complications of a ruptured appendix?
Peritonitis
Sepsis
Death
282
What is the appendix and where is it located?
a small thin tube arising from the caecum .
Located in the Right Ileac Fossa (RIF) at the point where the 3 teniae coli meet.
283
What are the risk factors for appendicitis?
Typically affects young age - 10-20yrs
Male
Frequent Abx use
Smoking
284
What is the key clinical sign of appendicitis?
periumbilical pain which migrates to the RIF over the first 24hrs where it becomes localised.
Often tenderness at Mcburney's Point on palpation.
285
What is McBurney's Point?
2/3 distance from umbilicus to the ASIS
286
What are some other symptoms of appendicitis?
classical abdominal pain.
Low grade fever
Reduced appetite and anorexia
Nausea and Vomiting
Diarrhoea - rare
287
What are the clinical signs associated with appendicitis?
RIF tenderness - rebound or percussion tenderness.
Rovsing's Sign - pain in RIF when pressing on the LIF
Guarding on abdominal palpation.
Obturator and Psoas signs
288
What are the signs of appendix rupture?
Tachycardia, hypotension and generalised peritonism
Rebound tenderness on RIF
Percussion tenderness
289
What is Rebound Tenderness?
increased pain when suddenly releasing deep palpations
290
What can cause appendicitis?
Fae Colith - hard solidified faeces causing a obstruction to appendix
Lymphoid Hyperplasia - in peyer's Patches
other blockages
291
What are the primary investigations for appendicitis?
Mostly a clinical diagnosis
CT abdo + pelvis = GS for diagnosis
Raised inflammatory markers on FBC (Increase WCC), CRP/ESR
Exclude ectopic pregnancy by serum hCG
292
What are the key differential diagnoses of appendicitis?
Ectopic pregnancy
Ovarian Cysts
Merkel's Diverticulum
Diverticulitis
Mesenteric Adenitis
293
What is the management of appendicitis?
Abx and then Appendectomy (laparoscopic)
Must drain abscesses - these are resistant to Abx
294
What must be ruled out in an appendicitis diagnosis? How is this done?
Ectopic pregnancy in females of child bearing age.
Perform pregnancy test
Bloods have Serum hCG test.
295
What is Diverticular Disease?
A Symptomatic outpouching of the intestinal Mucosa (diverticula) most commonly affecting the sigmoid colon in the absence of inflammation/infection
This is without inflammation and infection
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What are some different definitions within diverticular disease?
Diverticulum
Diverticulosis
Diverticular disease
Diverticulitis
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What is the Diverticulum?
An outpouching/pocket in the intestinal wall often located at perforating artery sites.
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What is Diverticulosis?
The presence of an outpouching in an Asymptomatic patient.
(95% of diverticula are ASx)
When this is Symptomatic this is diverticular disease
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What is Diverticulitis?
Inflammation of an outpouching due to infection typically causing lower abdominal pain.
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What is the pathophysiology of diverticular disease?
Wall of large intestine has a layer of circular muscle.
The points where arteries enter are areas of weakness.
Increased pressure over time can cause the mucosa to herniate through the muscle layer and pouch causing a diverticulum.
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Where do you not get diverticula forming?
The rectum as it is surrounded by an outer layer of longitudinal muscle preventing the herniation of the bowel mucosa
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What are some risk factors for diverticular disease?
Increasing age (>50yrs)
Low Dietary fibre
Obesity
Sedentary lifestyle
Smoking
NSAIDs
Connective Tissue disorders - M, ED.
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What are the symptoms of diverticular disease?
LLQ pain
Fresh Rectal bleeding
Constipation (change in bowel Habit)
nausea and vomiting.
+ urinary symptoms,
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What are some additional signs/symptoms of acute diverticulitis?
Pyrexia
Raised inflammatory markers - CRP, ESR WCC
May have diarrhoea
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What are the primary investigations for diverticular disease?
CT Abdo + pelvis with contrast - GS
FBC - Inc WCC
U&Es
CRP/ESR - Elevated
Venous blood gas
Blood cultures
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What is the gold standard Ix for diverticular disease?
CT Abdo and Pelvis with contrast
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What is the management of Diverticulosis?
Conservative
Watch and Wait
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What is the management of Diverticular disease?
Bulk forming laxatives (ispaghula Husk)
Surgery is possible
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What is the management of Diverticulitis?
Abx - Co-Amoxiclav
Paracetamol (analgesia)
IV Fluid
Liquid Food
Surgery if bleeding is not controlled
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What are some possible complications of Diverticulitis?
Perforation
Peritonitis
Peridiverticular abscess
Large haemorrhage requiring blood transfusions
Fistula (e.g., between the colon and the bladder or vagina)
Ileus / obstruction
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What is Meckel's Diverticulum?
Paediatric disorder
Failure of obliteration of vitelline duct
Rule of 2s:
2 yrs old
2 inches long
2 ft from ileocaecal valve
Dx is Technitium Scan
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What is Diarrhoea?
A presenting Sx with many DDx
Often 3+ watery stools daily
but could be a increase in the normal bowel passage for an individual Px
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What level of the Bristol Stool chart symbolises Diarrhoea?
5-7
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What are the Different types of Diarrhoea?
Watery
Secretory
Osmotic
Functional
Steatorrhea
Inflammatory
Dysentery
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What is Dysentery?
Severe bloody diarrhoea
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What are the different time frames for diarrhoea?
Acute - <14 days
Subacute - 14-28 days
Chronic >28 days
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What are the 2 overarching causes of diarrhoea?
Infective causes
Non-infective causes
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What are some non-infective causes of diarrhoea?
Neoplasms - colorectal cancer
Inflammatory - IBD
Irritable bowel - IBS
Coeliacs
Hormonal - Hyperthyroidism
Radiation
Chemical
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What kind of diarrhoea can infective causes cause?
Non-bloody
Bloody (dysentery)
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What is the chain of infection?
Agent
Mode of transmission
Portal of entry
Host
Person to person spread
Reservoir
Portal of exit
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What are some diarrhoeal diseases?
Dysentery
Typhoid
Hepatitis
Cholera
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What are the different groups of infective causes of diarrhoea?
Viral - most common
Bacterial
Worms
Abx - leading to C.diff
Parasites
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What are the main viral causes of diarrhoea?
Rotavirus - kids
Norovirus - adults
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What are the main bacterial causes of Diarrhoea?
Campylobacter - most common
E.coli
Salmonella
Shigella
Cholera
Clostridium Difficile
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What are some parasitic causes of Diarrhoea?
Giardiasis
Entamoeba Histolytica
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What kind of diarrhoea is caused by E.coli (ETEC) What is the incubation period?
0-3 days
Watery stools
Abdominal cramps
This is often travellers Diarrhoea
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What type of diarrhoea is caused by Bacillus Cereus and what is the incubation period?
Abrupt onset vomiting and diarrhoea often after reheating/undercooked rice.
<6hrs
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What type of diarrhoea is caused by S.aureus? What is the incubation period?
Severe vomiting and diarrhoea.
2-4 hrs
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What type of diarrhoea is caused by Shigella? How is it acquired and what is the incubation period?
Bloody diarrhoea
abdominal pain and vomiting
From contaminated food/water
0-3 days incubation
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What type of diarrhoea is caused by Campylobacter? how is it acquired and what is the incubation period?
Flu like prodrome
Bloody diarrhoea
Abdominal pain and fever
Typically from undercooked poultry
2-4 days
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What type of diarrhoea is caused by Cholera, How is it acquired and what is the incubation period?
Profuse "Rice water stool" watery diarrhoea
Severe dehydration due to 20+L lost
0-5 days
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What type of diarrhoea is caused by Salmonella, how is it acquired and what is the incubation period?
Bloody diarrhoea
Vomiting, abdominal cramps and fever
Typically from undercooked meats, raw eggs.
0-3 days.
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What bacterial infections will lead to low volume bloody diarrhoea?
Shigella / E.coli 0157 (EHEC)
Salmonella
Campylobacter
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What is the incubation period of norovirus?
12-48 hrs
Symptoms resolve in 1-3 days
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What is the incubation period of Rotavirus?
2-3 days
Symptoms resolve in 3-8 days
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What are the treatments for diarrhoea?
Viral - often self limiting
Bacterial - depends on the type of infection
Non-infective - Tx underlying cause
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What is the most serious complication of diarrhoea, how is it counteracted?
Dehydration and electrolyte loss
Give fluids + diuralite
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What cause of diarrhoea should you think of if the Px presents with diarrhoeal symptoms if they are under the age of 3?
Rotavirus
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What cause of diarrhoea should you think of if the Px presents with A Hx of broad spectrum Abx?
Clostridium Difficile
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What cause of diarrhoea should you think of if the Px presents with Ricewater stools?
Cholera
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What cause of diarrhoea should you think of if the Px presents with Guillain Barre?
Campylobacter
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What is the general management for diarrhoea?
Often self limiting.
Abx may cause HUS in Shigella/E.coli 0157 cause.
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What Abx may predispose a patient to C.diff infection?
4 Cs:
Clindamycin,
Co-amoxiclav
Cephalosporins
Ciprofloxacin
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When may you use Abx in shigella infection? what would you prescribe?
In severe infection/diarrhoea
Prescribe Azithromycin or Ciprofloxacin
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What is Clostridium Difficile?
Gram +tve spore forming bacteria
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What causes C.diff?
Induced by Abx (Ciprofloxacin, Co-amoxiclav, Cephalosporin, Clindamycin) which kill normal gut flora and allow C.diff to colonise.
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What is the Treatment for C.diff infection?
Stop C's Abx
Vancomycin is now first line against C.diff
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What strains of E.coli cause Watery diarrhoea?
ETEC (Travellers)
EPEC
EAEC
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What Strain of E.coli Causes bloody diarrhoea?
EHEC (Enterohaemorrhagic E.Coli)
Also known as E.coli 0157
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What can happen if you treat EHEC with Abx?
Cause Haemoloytic Uremic Syndrome (HUS)
However can be treated with Amoxicillin or Trimethoprim/Nitrofurantoin.
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What condition does C.difficile Cause?
Pseudomembranous Colitis
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What is Pseudomembranous Colitis?
Inflammation of the colon caused by C.diff infection leading to watery diarrhoea, nausea fever
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What is Meckel's Diverticulum?
Most common congenital abnormality of the GI Tract when there is incomplete obliteration of the vitelline duct.
Affects 2-3% of the population
Usually a diverticulum in the ILEUM
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What are the Symptoms of Meckel's Diverticulum?
Often ASx
In 50% of cases the distal ileum contains gastric mucosa that secretes HCL which can lead to peptic ulcers causing bleeding and GI pain.
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What is the treatment of Meckel's Diverticulum?
Surgical Removal of the Diverticula
(often laparoscopically)
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What are the different Perianal disorders?
Haemorrhoids
Fistulae
Fissures
Perianal Abscesses
Pilonidal Sinus/Abscess
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What are Haemorrhoids?
Swollen veins surrounding the anus disrupting the connective tissue cushions.
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How do Haemorrhoids develop?
Multifactorial:
Conditions that raise intraabdominal pressure (eg. constipation, COPD,)
+
Straining leads to swelling of the haemorrhoid tissue causing a swell/bleed.
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What is the most common cause of Haemorrhoids?
Constipation with increased straining.
Anal Sex
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What are the risk factors for Haemorrohoids?
Constipation +/- straining
Heave lifting
Increasing age
Anal Sex
Raised Intra-abdominal pressure
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What are the types of haemorrhoids?
Internal
External
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What are internal Haemorrhoids?
Originate ABOVE the dentate line.
Less painful due to a reduced sensory supply.
May feel like incomplete emptying
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What are External Haemorrhoids?
Originate BELOW the Dentate Line
Very painful - Px may not be able to sit down.
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What is the Dentate line?
Divides the anal canal into an upper 2/3rds supplied by the inferior mesenteric plexus
Lower 1/3rd supplied by the pudendal nerve
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What are the symptoms of Haemorrhoids?
Bright red rectal bleeding
May have mucusy /bloody stool
Pruritis ani (itchy bum)
Bulging pain
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What are the diagnostic investigations for Haemorrhoids?
PR exam - external piles are palpable (may be visible)
Proctoscopy - for internal Haemorrhoids
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What is the first line treatment for haemorrhoids?
Conservative management:
Increased dietary fibre and fluid intake
Analgesia - paracetamol
Topical Tx - anusol
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What are the second line treatments for Haemorrhoids?
Rubber band Ligation
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What is a Perianal Abscess?
Walled off collection of stool + bacteria around the anus.
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What is the most common cause of a perianal abscess?
Anal sex causing anal gland infection
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What are the symptoms of a perianal abscess?
Puss in stool
Constant pain and tenderness around anus
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What is the treatment of a perianal abscess?
Surgical drainage and removal
Abx resistant due to the walling off.
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What is an anal fistula?
Abnormal connection "Tracks" between the epithelialized surface of the anal canal and the skin.
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What are the causes of an anal fistula?
often progress from perianal abscesses
abscess discharges (toxic substances) which aids the production of a fistula as the abscess grows.
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What are the symptoms of a anal fistula?
Bloody mucusy discharge
often visible and very painful
Pruritus ani
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What is the treatment for an anal fistula?
Surgical - Fistulotomy
Drain Abscess + Abx.
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What is an Anal Fissure?
Tear in the anal skin lining below the dentate line
These are very painful due to the strong sensory supply.
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What is the most common cause of anal fissures?
Hard faeces
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What is the symptoms of an anal fissure?
Extreme defaecation pain
Pruritus ani
Anal bleeding
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What are the treatments for anal fissures?
Increased dietary fibre and fluids - soften stool
Topical creams - lidocaine ointment, GTN ointment,
Surgery if medication fails
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What are Pilonidal Sinuses?
Hair follicles that get stuck in the natal cleft (bum crack) resulting in inflammation, irritation and can become infected
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Who is more commonly affected by Pilonidal Sinus?
Males + hairy people
20-30yrs
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What are the symptoms of Pilonidal Sinus?
Swollen pus filled smelly abscess on bum crack
Visible on exam
Painful swelling over days
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What is the treatment of Pilonidal Abscesses?
Surgical removal of the sinus tract
Hygiene Advice
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What viral infection can cause colitis?
CMV colitis
Characterised by Owl Eye Inclusion bodies
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What is CMV infection a sign of?
Immunosuppressed Px
An AIDS defining illness
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What is Zenker's DIverticulum?
"Pharyngeal Pouch)
When the cricopharyngeal muscle overtightens causing the throat above it to outpouch.
Food can enter this pouch and accumulates leading to smelly breath and regurgitations
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Give examples of functional gut disorders?
IBS (bowel)
Functional Dyspepsia (stomach)
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hat are functional gut disorders?
Chronic GI symptoms in the absence of organic disease to explain the symptoms.
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What is the prevalence of Functional Gut disorders?
One of the most common GI conditions that doctors encounter (1 in 3)
More common in women - due to hormones
More common in young people
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Explain how NSAIDs lead to PUD?
Mucus secretion stimulated by prostaglandins
COX-1 needed for prostaglandin synthesis
NSAIDs inhibit COX-1
No COX-1 = mucous isn’t secreted
Reduced mucosal defense 🡪 mucosal damage
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Why is a raised urea suggestive of an Upper GI bleed?
Raised urea is more suggestive of an upper GI bleed; It occurs due to proteins in the blood being digested by enzymes in the upper GI tract, causing an increase in nitrogenous waste.
This is especially true if the creatinine is within normal limits, which confirms the urea rise is not due to impaired renal function.
