Gastroenterology for Dentists

Question 1

Function of GI tract

Answer 1

Turns the food you eat into energy
Waste removal
Intake of water - hydration

Question 2

Dysphagia
History taking
Dysphagia can be (x3)

Answer 2

Difficulty swallowing
Duration
Solids or liquids
Pain (odynophagia) - more common in people with damaged oesophageal passages
Weight loss - common in pts with malignant diseases
Prev. medical history
Medications - NSAIDs cause inflammation of upper GI tracts
Cigarettes and alcohol

Oropharyngeal
Oesophageal
Gastric

Question 3

dysphagia - oropharyngeal
involves x3
can be caused by

Answer 3

salivary gland - sjogrens
tongue - amyloid, hypothyroidism, MS

palatal/epiglottal/upper oesophageal disorder - Cerebrovascular disease, MND, Parkinson’s

neurological disorders

Question 4

Bile duct

Answer 4

Secretes bile from gall bladder which emulsifies fat suitable for absorption

Question 5

dysphagia - oesophageal

Answer 5

Benign mucosal disease e.g peptic strictures where mucosa heals with scarring

e. g 2 oesophageal webs
e. g 3 candidal oesophagi’s

malignant mucosal disease - carcinoma

motility disorders
- oesophageal spasm, achalasia, oesophageal pouch

Question 6

dysphagia - gastric

Answer 6

Carcinoma

Outlet obstruction e.g peptic ulceration

Question 7

Pharyngeal pouch

Answer 7

Defect between constrictor and transverse cricopharyngeus muscle - diverticulum is created

Dangerous in endoscopy of entering pouch and perforating into mediastinal cavity

Question 8

Stricture

Answer 8

Forms due to scar tissue

Surgery can cut through muscle

Question 9

Management of dysphagia

Answer 9

treat underlying cause

Provide supplementation e.g malnourished people - oral supplements, PEG feeding

Question 10

Indigestion and upper abdominal discomfort

Causes

Answer 10

GORD - gastric upper reflux disease 
Hiatus hernias 
Peptic ulceration 
Non ulcer dyspepsia 
Pancreatic carcinoma 
Pancreatitis

Question 11

Polypoid carcinoma

Answer 11

malignant cause of dysphagia

Question 12

GORD

Signs+symptoms

Physical mechanism

Answer 12

Heartburn, epigastric pain, acid reflux, waterbrash, nausea, vomiting, tooth decay, asthma

Excessive relaxation of lower oesophageal sphincter and raised intra-abdominal pressure

Question 13

Causes of GORD

Answer 13

Hiatus hernia - part of stomach herniates above diaphragm
Inflammatory lesions in the oesophagus leading to diaphragm
Diaphragmatic fibres around hiatus can become loose and upper stomach can be pushed upwards into chest cavity
reflux more readily occurs
mechanical abnormality

Question 14

Management of GORD

Answer 14

Proton pump inhibitors omeprazole and lansoprazole
H2 antagonist - stops reaction of histamines with squamous epithelium
Lifestyle advice (weight loss, smoking cessation, reduce alcohol)

Surgery - fundopliation - part of fundus of stomach is removed and is wrapped around diaphragmatic hiatus

Question 15

Types of hiatus hernia

Answer 15

Normal
Pre stage
Sliding hiatal hernia
Paraoesophageal type

Question 16

Oesophageal manometry

Answer 16

Measures pH of fluids coming out

Question 17

Peptic ulceration

Symptoms

Answer 17

Epigastric pain sometimes radiates into back
worsened by food = associated with weight loss or improved by eating

Complicated by bleeding or perforation

Vomiting/haemastasis (de to gastric ulcer or pyloric outlet obstruction due to duodenal obstruction

Helicobacter pylori or NSAIDs

Question 18

Management of peptic ulcers

Answer 18

Argon probe to coagulate blood
Clips to isolate vessels
PPI given

Question 19

Indigestion - upper abdo discomfort - Gastric carcinoma
Symptoms

Management
Treatment

Answer 19

Epigastric pain, weight loss, vomiting
Late diagnosis

Management

Treatment - surgery/gastrectomy if poss

Question 20

Upper abdominal - non-ulcer dyspepsia

Answer 20

Upper abdominal discomfort, nausea, eructation (belch), bloating
motility disturbance

Pancreatitis
acute inflammation of pancreas causing severe pain, vomiting
chronic relapsing pain (chronic pancreatitis)
commonest cause alcohol > gallstones > pancreatic trauma, drugs, hypercalcamia / lipidaemia, familial

Question 21

Lower abdominal pain

Answer 21

Acute
Chronic

Crescendo of events
See lecture slide for details

Question 22

Management of acute abdominal pain

Answer 22

Surgical; referral
Usually kept nil by mouth
IV antibiotics
Imaging - uss/ct scan (small bowel, obstruction and Crohn’s disease)

Question 23

Chronic abdo pain for more than 6 weeks, things to consider

Answer 23

Organic vs inorganic
Investigate as previous
Management - usually difficult, analgesics and surgery

Question 24

Vomiting
Causes

Management

Answer 24

Multiple 
Systemic illness
Drugs/alcohol
Centrally mediated 
- middle ear
- cerebellar disease
- raised IC pressure due to tumour e.g 
Psychiatric disorders 
Oesophageal 
Gastric disease 
Small bowel disease
Colonic disease - obstruction due to tumours and volvulus 

Identify underlying cause
Antiemetics
PPI
CBT

Question 25

Diarrhoea - acute

Answer 25

Infectious - gastroenteritis - bacterial or viral e.g campylobacter, salmonella, shigella, E.coli Drugs - abs or alcohol Food allergy/intolerance

Question 26

Diarrhoea - chronic

Answer 26

> 6 weeks Small bowel lactase deficiency Coeliac disease Crohn‘s disease Pancreatic pancreatic insufficiency pancreatic carcinoma cystic fibrosis Colonic ulcerative colitis Crohn’s disease carcinoma

Question 27

Coeliac disease - history definition

Answer 27

First discovered in 1887 1940s link to wheat 1961 immunological response to gliadin - Water is held within intestinal mucosa --> diarrhoea definition: abnormal proximal small intestinal mucosa that improves morphologically on a gluten free diet (GFD) and relapses when gluten is reintroduced”

Question 28

Normal duodenal mucosa

Answer 28

Normal IELs No crypt hyperplasia Normal villous structure

Question 29

Coeliac duodenal mucosa

Answer 29

Increased inflammatory cells Crypt hyperplasia Loss of villous structure - loss of SA Less absorption - more leaving in faeces

Question 30

Coeliac disease background

Answer 30

``` 1/100 40-60 years 9x more adult presentations Normal or overweight subtle symptoms GI most common mode of presentation ```

Question 31

Dermatitis herpetiformis

Answer 31

2/3 will have coeliac symptoms

Question 32

Diarrhoea - small bowel/pancreatic

Answer 32

``` Malabsorption Pale, floating Throughout day Pain variable timing Pain not relieved by defecation ```

Question 33

Diarrhoea - colonic

Answer 33

``` Irritation of colon lining Blood and mucus Often in morning Pain read to defecation Pain relieved by defecation ```

Question 34

Crohn's disease

Answer 34

Chronic inflammatory disease affecting any part of GI tract from mouth to perineum May be discontinuous and affect several different parts of GI tract at the same time Ileal-caecal disease Affects all layers of the gut

Question 35

Ulcerative colitis

Answer 35

Chronic inflammatory disease invariably affecting rectum and extending more proximally to involved all or part of the colon

Question 36

Crohn's disease - symptoms diagnosis

Answer 36

``` Pain Diarrhoea Weight loss Anorexia Fever Vomiting Lassitude Nausea Acute abdomen Nutritional disturbance Fistula Miscellaneous ``` Barium tracing

Question 37

Ulcerative colitis | Symptoms

Answer 37

``` Only affects superficial subcutaneous mucosa of gut Diarrhoea Rectal bleeding Pain Weight loss ```

Question 38

Associated diseases

Answer 38

Skin e.g erythema nodosum is blotchy red rash appears typically on legs, pyoderma gangrenosum Mouth - ulcers, crohn's, lips, buccal mucosa Joints - arthritis, ankylosing spondylitis Eyes - episcleritis, uveitis Vascular - thromboses Liver - cirrhosis, CAH, pericholangitis, UC, primary sclerosing cholangitis

Question 39

Colon cancer Polyps Symptoms

Answer 39

``` 35000/year diagnosed Indicate pre-cancer likelihood - removed None- bowel cancer screening rectal bleeding altered bowel habits lethargy/weight loss ```

Question 40

Colon cancer Investigations Management

Answer 40

Colonoscopy/barium enema CT Evaluate extent of disease Limited disease to colon = surgical resection Chemo radiotherapy if not limited

Question 41

Jaundice | Causes

Answer 41

Liver disease, cirrhosis Blockage e.g carcinoma, gall stones Bilirubin cannot be excreted

Question 42

Hepatic jaundice

Answer 42

Drug related or in people with hepatitis

Question 43

Pre-Hepatic jaundice

Answer 43

Haemolytic anaemia Red cells broken down Bilirubin released and has to be broken down Liver cannot cope with quantity Jaundice results as bilirubin is not excreted

Question 44

Post-hepatic jaundice | Causes

Answer 44

Choledocholithiasis - gall stones - biliary colic, fever, jaundice - bacteria can escape up bile duct and infect it - impaction and disimpaction malignancy - pancreatic carcinoma, cholangiocarcinoma - pain radiation to back, weight loss benign biliary structure (post operative, sclerosing cholangitis) - fever and pain

Question 45

Jaundice - hepatic causes

Answer 45

Infection - Malaise, lethargy, anorexia, distaste for cigarettes, jaundice, pale stools, dark urine, right upper quadrant discomfort Alcoholic hepatitis - above, plus history of excess alcohol Drugs - augmentin, flucloxacillin, many others Decompensated chronic liver disease (alcoholic cirrhosis, haemachromatosis, PBC, CAH, Chronic hepatitis B or C, Wilson’s disease) jaundice, ascites (accumulation of fluid in abdominal cavity), varices, hepatic encephalopathy

Question 46

Haemolytic anaemia | Causes and presentation

Answer 46

hereditary spherocytosis, G6PD deficiency, sickle cell disease) anaemia, jaundice, gallstones, splenomegaly, leg ulcers

Question 47

Sign of chronic liver disease

Answer 47

Nail clubbing, erythema on palms

Question 48

Oesophageal varices

Answer 48

Smoothed mucosa going towards stricture Portal venous flow is impaired mechanically Blood has to find another way and finds collateral openings to return to systemic circulation Occurs in upper part of stomach to oesophageal veins Veins become engorged and bloated 40% mortality rate

Question 49

Liver fx Synthetic Metabolic

Answer 49

Clotting factor producer - affects PT time Produces proteins e.g albumin Processes and produces bile for digestion Excretion of nitrogenous compounds e.g NH3 If liver is failing, NH3 sometimes crosses blood brain barrier --> potential cause of confusion in liver failure patients Excretion of some drugs or metabolites

Question 50

``` Upper abdominal discomfort - peptic ulceration History Worsening with eating Improvement with eating Complications Cause Endoscopic appearance ```

Answer 50

``` Epigastric pain Radiation into back Worsened by food so associated with weight loss = gastric ulcer Improved = duodenal ulcer Bleeding or perforation Helicobacter pylori/NSAIDs ``` Clean ulcer Adherent clot Visible vessel

Question 51

Upper abdominal discomfort/pain - Pancreatic carcinoma at ampulla

Answer 51

Unremitting pain, often radiating to back and associated with weight loss and may cause jaundice as bile duct can become blocked by it as at same junction as pancreatic duct bilirubin not excreted

Question 52

Upper abdominal discomfort/pain - Pancreatitis

Answer 52

Acute inflammation of pancreas causing severe pain, vomiting chronic relapsing pain (chronic pancreatitis) commonest cause alcohol > gallstones > pancreatic trauma, drugs, hypercalcamia / lipidaemia, familial