Gastroenterology for Dentists Flashcards
Function of GI tract
Turns the food you eat into energy
Waste removal
Intake of water - hydration
Dysphagia
History taking
Dysphagia can be (x3)
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
dysphagia - oropharyngeal
involves x3
can be caused by
salivary gland - sjogrens
tongue - amyloid, hypothyroidism, MS
palatal/epiglottal/upper oesophageal disorder - Cerebrovascular disease, MND, Parkinson’s
neurological disorders
Bile duct
Secretes bile from gall bladder which emulsifies fat suitable for absorption
dysphagia - oesophageal
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
dysphagia - gastric
Carcinoma
Outlet obstruction e.g peptic ulceration
Pharyngeal pouch
Defect between constrictor and transverse cricopharyngeus muscle - diverticulum is created
Dangerous in endoscopy of entering pouch and perforating into mediastinal cavity
Stricture
Forms due to scar tissue
Surgery can cut through muscle
Management of dysphagia
treat underlying cause
Provide supplementation e.g malnourished people - oral supplements, PEG feeding
Indigestion and upper abdominal discomfort
Causes
GORD - gastric upper reflux disease Hiatus hernias Peptic ulceration Non ulcer dyspepsia Pancreatic carcinoma Pancreatitis
Polypoid carcinoma
malignant cause of dysphagia
GORD
Signs+symptoms
Physical mechanism
Heartburn, epigastric pain, acid reflux, waterbrash, nausea, vomiting, tooth decay, asthma
Excessive relaxation of lower oesophageal sphincter and raised intra-abdominal pressure
Causes of GORD
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
Management of GORD
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
Types of hiatus hernia
Normal
Pre stage
Sliding hiatal hernia
Paraoesophageal type
Oesophageal manometry
Measures pH of fluids coming out
Peptic ulceration
Symptoms
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
Management of peptic ulcers
Argon probe to coagulate blood
Clips to isolate vessels
PPI given
Indigestion - upper abdo discomfort - Gastric carcinoma
Symptoms
Management
Treatment
Epigastric pain, weight loss, vomiting
Late diagnosis
Management
Treatment - surgery/gastrectomy if poss
Upper abdominal - non-ulcer dyspepsia
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
Lower abdominal pain
Acute
Chronic
Crescendo of events
See lecture slide for details
Management of acute abdominal pain
Surgical; referral
Usually kept nil by mouth
IV antibiotics
Imaging - uss/ct scan (small bowel, obstruction and Crohn’s disease)
Chronic abdo pain for more than 6 weeks, things to consider
Organic vs inorganic
Investigate as previous
Management - usually difficult, analgesics and surgery
Vomiting
Causes
Management
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
Diarrhoea - acute
Infectious - gastroenteritis - bacterial or viral e.g campylobacter, salmonella, shigella, E.coli
Drugs - abs or alcohol
Food allergy/intolerance
Diarrhoea - chronic
> 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
Coeliac disease - history
definition
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”
Normal duodenal mucosa
Normal IELs
No crypt hyperplasia
Normal villous structure
Coeliac duodenal mucosa
Increased inflammatory cells
Crypt hyperplasia
Loss of villous structure - loss of SA
Less absorption - more leaving in faeces
Coeliac disease background
1/100 40-60 years 9x more adult presentations Normal or overweight subtle symptoms GI most common mode of presentation
Dermatitis herpetiformis
2/3 will have coeliac symptoms
Diarrhoea - small bowel/pancreatic
Malabsorption Pale, floating Throughout day Pain variable timing Pain not relieved by defecation
Diarrhoea - colonic
Irritation of colon lining Blood and mucus Often in morning Pain read to defecation Pain relieved by defecation
Crohn’s disease
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
Ulcerative colitis
Chronic inflammatory disease invariably affecting rectum and extending more proximally to involved all or part of the colon
Crohn’s disease - symptoms
diagnosis
Pain Diarrhoea Weight loss Anorexia Fever Vomiting Lassitude Nausea Acute abdomen Nutritional disturbance Fistula Miscellaneous
Barium tracing
Ulcerative colitis
Symptoms
Only affects superficial subcutaneous mucosa of gut Diarrhoea Rectal bleeding Pain Weight loss
Associated diseases
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
Colon cancer
Polyps
Symptoms
35000/year diagnosed Indicate pre-cancer likelihood - removed None- bowel cancer screening rectal bleeding altered bowel habits lethargy/weight loss
Colon cancer
Investigations
Management
Colonoscopy/barium enema
CT
Evaluate extent of disease
Limited disease to colon = surgical resection
Chemo radiotherapy if not limited
Jaundice
Causes
Liver disease, cirrhosis
Blockage e.g carcinoma, gall stones
Bilirubin cannot be excreted
Hepatic jaundice
Drug related or in people with hepatitis
Pre-Hepatic jaundice
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
Post-hepatic jaundice
Causes
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
Jaundice - hepatic causes
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
Haemolytic anaemia
Causes and presentation
hereditary spherocytosis, G6PD deficiency, sickle cell disease)
anaemia, jaundice, gallstones, splenomegaly, leg ulcers
Sign of chronic liver disease
Nail clubbing, erythema on palms
Oesophageal varices
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
Liver fx
Synthetic
Metabolic
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
Upper abdominal discomfort - peptic ulceration History Worsening with eating Improvement with eating Complications Cause Endoscopic appearance
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
Upper abdominal discomfort/pain - Pancreatic carcinoma at ampulla
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
Upper abdominal discomfort/pain - Pancreatitis
Acute inflammation of pancreas causing severe pain, vomiting
chronic relapsing pain (chronic pancreatitis)
commonest cause alcohol > gallstones > pancreatic trauma, drugs, hypercalcamia / lipidaemia, familial
