Gastroenterology (Quesmed) Flashcards
What is Achalasia?
It is a condition of unknown cause which causes Failure of the Lower Oesophageal Sphincter
What are the 5 signs of Achalasia?
Remember 3 of them are LINKED directly
Dysphagia to both SOLIDS and LIQUIDS (which gradually increases over Months and Years)
Regurgitation of undigested foods
Aspiration
RETROSTERNAL Chest Pain/ Heartburn (which usually doesn’t respond to PPIs)
Weight Loss (often mild)
What investigations should be ordered in Achalasia?
Endoscopy (Dilated Oesophagus containing residual material)
GOLD STANDARD- Oesophageal Manometry (High Pressure and Incomplete Lower Oesophageal Sphincter Relaxation)
Barium Swallow (Bird’s Beak Appearance)
Chest Xray- Widened Mediastinum and Fluid Levels
What is the management of Achalasia?
FIRST LINE OPTION- BALLOON DILATATION
Surgery- Oesophageal Dilatation and Surgical Cleavage of the Lower Sphincter so that food can pass through (called !!!Heller’s Myomotomy)
!!!!Medical- Botox (if this fails or if they are not suitable for surgery, Calcium Channel Blockers/ Nitrates)
What are Porphyrias?
What are the signs and the management of Acute Intermittent Porphyria (Autosomal Dominant) (Porphyria caused by Triggers)?
NO DIARRHOEA, but may be constipation
Defects in Haem Synthesis due to alterations in Enzyme structure and function. This leads to the accumulation of PORPHYRINS
Signs-
1) Abdominal Pain and Vomiting
2) Motor Neuropathy
3) Hypertension and Tachycardia
4) Depression AND CONFUSIONNNNNNN
!!!!!5) ALSO Urine turns RED
Management
- Avoid the Triggers
- IV HAEM otherwise IV glucose
What are the 3 types of Acute Porphyrias?
Acute Intermittent Porphyria (Autosomal Dominant)
Variegate Porphyria (Autosomal Dominant)- suspect if SKIN is affected
ALA Deficiency (Autosomal RecessivE)
What are the medications that trigger Acute Porphyrias?
Antibiotics (Rifampicin, Isoniazid, Nitrofurantoin)
Anaesthetic Agents (Ketamide and Etomidate)
Sulfonamides
Barbiturates
Antifungal Agents
What are the signs of Acute Porphyria?
Suspect if Abdo pain, Confusion and recent Antibiotics/ Anaesthetics etc.
Remember CONFUSION
Generic Abdominal Symptoms
- Abdominal Pain
- Nausea
- Confusion
- Hypertension
What is needed for the diagnosis of Acute Porphyria?
What must you be careful about with the urine sample?
Measure Urinary Porphobilinogen levels which is a product of Haem Metabolism
Urine Samples needed to be protected from sunlight to prevent breakdown of PBG
What is the management of Acute Porphyria?
Largely supportive
IV Haem Arginate can be given to replenish Haem levels
What is Alpha 1 Antitrypsin Deficiency?
WHAT is the INHERITANCE PATTERN?
What Lobes of the lungs are affected in Alpha 1 vs COPD
What is the management?
It is an INHERITED AUTOSOMAL RECESSIVE condition that affects the Lungs, causing Emphysema- so this is a CAUSE of COPD in YOUNG PEOPLE/ NON SMOKERS
LOWER LOBES= Alpha 1, UPPER LOBES= COPD
It also affects the Liver which causes Cirrhosis and Hepatocellular Carcinoma
Without Alpha-1 Antitryptase, there is less defence against Neutrophil Elastase which destroys the Alveoli
This process is exacerbated in Smokers
Management-
1) Physiotherapy, Bronchodilators and Alpha 1 Antitrypsin
2) LUNG REDUCTION SURGERY
What is the presentation of Alpha 1 Antitrypsin Deficiency?
COPD presenting in a 30-40 year old
Neonatal JAUNDICE at Birth
Deranged LFTs in an adult with no other identifiable cause
What investigations should be ordered for Alpha 1 Antitrypsin Deficiency?
Test for Alpha 1 Antitrypsin Levels
Genotyping
Liver Biopsy (look for Periodic-acid-Schiff (PAS) positive globules)
What is the management of Alpha 1 Antitrypsin Deficiency?
Stop Smoking
Intravenous A1AT pooled from human donors is expensive and NOT widely used
If Decompensation, Liver Transplant may be needed
What is seen in patients who have been vomiting?
They appear dehydrated and unwell
There is Metabolic Hypochloraemic Alkalosis on a blood gas due to the loss of Stomach Acid when vomiting
What are the 4 types of Anti-Emetics?
H1 Receptor Antagonist
- Cyclizine
D2 Receptor Antagonist
- Domperidone, Metoclopramide (The ones with M at the start of their name) and Prochlorperazine
5HT3 Receptor Antagonist
- Ondansetron
Anti-Muscarinic
- Hyoscine hydrobromide
What is Ascites?
It is the accumulation of fluid within the Peritoneal Cavity
It may be seen in patients with Cirrhosis- though the mechanism is complex and not fully understood
It is thought to involve PORTAL HYPERTENSION causing an increased Hydrostatic Pressure which leads to the Transudation of Fluid
What is the Serum Ascites Albumin Gradient (SAAG)?
It can help determine the cause of Ascites
Subtract the Albumin concentration of the Ascites Fluid from the Serum Albumin Concentration (S-A)
What are the causes of a high (>1.1g/dL) SAAG?
2 organ failures plus 2 other conditions related to those organs plus 1 extra
Cause is Raised Portal Pressure
- Cirrhosis
- Heart Failure
- Budd Chiari Syndrome
- Constrictive Pericarditis
- Hepatic Failure
Increased Hydrostatic Pressure forces water into the Peritoneal Cavity whilst Albumin remains in the vessels
What are the causes of a low (<1.1g/dL) SAAG?
5 causes
- Cancer of the Peritoneum
- Tuberculosis and other infections
- Pancreatitis
- Hypoalbuminaemia- like Nephrotic Syndrome or Kwashiokor Malnutrition
- Bowel Obstruction
What is the management of Ascites?
SFSF Drain
- Address the underlying cause
- Salt-restricted diet
- Fluid Restriction (not recommended if Uncomplicated Ascites)
- Spironolactone
- Adjunctive Diuretic therapy like Furosemide may be needed if Spironolactone is insufficient
- Patients with Ascites refractory to Medical Management may require Regular Therapeutic Paracentesis, where the Fluid is drained from the abdomen
What is the main contraindication to Paracentesis (Ascites management)?
Signs of Disseminated Intravascular Coagulation
What are the signs of Autoimmune Hepatitis?
!!!!!THERE is AMENORRHOEA and FEVER AS WELL BTW
Remember the Arthralgia
Signs of OTHER AUTOIMMUNE CONDITIONS
!!!!!!AMENORRHOEA AND FEVER
Jaundice
Fatigue
Loss of Appetite
Hepatomegaly
Splenomegaly
Abdominal pain
Pruritus and Spider Naevi
Arthralgia in their Small Joints as well
What are the LFTs in Autoimmune Hepatitis?
What is the CRP like in Autoimmune Hepatitis?
What else is seen in Autoimmune Hepatitis in the blood that is raised?
Hepatic Pattern of Disease- Raised ALT and Bilirubin and Normal/ Mildly Raised ALP (by 10-20)- Significantly raised in Cholangitis
CRP is usually NOT raised
They may have IgG Predominant Hypergammaglobuminaemia
What are the 3 types of Autoimmune Hepatitis?
All have raised IgG levels
Type 1- Most common type- (Adults and Children)
- Anti Smooth Muscle Antibodies (80%) and Antinuclear Antibodies may also be raised (10%)
Type 2- Less common but often more severe (Children)
- Anti Liver/ Kidney Microsomal Antibodies Type 1
Type 3- Less common (Adults)
- Anti Soluble Liver-Kidney Antigen
Type 2 and 3 would be NEGATIVE for Anti Smooth Muscle Antibodies and Antinuclear Antibodies
What is the management of Autoimmune Hepatitis?
Depends on severity of symptoms and disease
- Prednisolone for induction and Azathioprine for maintenance
- Second Line- Other immunosuppressants
- Liver Transplant
What drugs can cause Hepatitis?
Methyldopa
Nitrofurantoin
Diclofenac
Phenytoin
What is Barret’s Oesophagus?
Chronic Acid Exposure (usually through GORD) changes distal oesophagus from Squamous Epithelium to Metaplastic Columnar Epithelium
It has a risk of progressing to Adenocarcinoma
What is the management of Barrett’s Oesophagus?
Identified through ENDOSCOPY
- If Low Grade Dysplasia- repeat in 6 months. If found in follow up and confirmed on at least 2 biopsies, offer them Endoscopic Ablation therapy- preferably with Radiofrequency Ablation. If not, check up on them every 6 months
- If High Grade Dysplasia or early Adenocarcinoma, Endoscopic Resection of Abnormal Areas- Radiofrequency Ablation, Photodynamic Ablation or Laser.
- If there is any grade of dysplasia then ablation!!!!!!
If they are fit for surgery, OESOPHAGECTOMY
-
What is Cholera?
In addition to dehydration, what 2 symptoms does it cause?
It is an Acute Secretory Diarrhoea caused by an infection with Vibrio Cholera of the O1 and O139 subgroup. It is ENDEMIC in many countries
It causes RICE WATER DIARRHOEA and HYPOGLYCAEMIA
What are the signs of Cholera?
Tummy Ache and Loss of Fluids Through Diarrhoea and Vomiting
Watery Diarrhoea that begins suddenly
Abdominal Cramps (just like Clostridium Difficile)
Nausea and Vomiting
Excessive Thirst and Oliguria (cos of all the water they’re losing through the diarrhoea)
Dry Skin and Mouth
Drowsiness and Irritability
What is the management of Cholera?
What are the 3 antibiotics that can be given?
Aggressive fluid Replacement- Effective Therapy that can decrease mortality from over 50% to less than 0.2%
Antibiotics (Doxycycline or Co-trimoxazole or Ciprofloxacin)
What are the causes of Chronic Pancreatitis?
- 80% of patients- Chronic Alcohol Excess
- Less Common Causes- Genetic (Cystic Fibrosis),
Obstructive Causes (Pancreatic Cancer) and Metabolic Causes (Raised Triacylglycerides)
What are the signs of Chronic Pancreatitis?
Epigastric Pain- Worse after eating Fatty Food and Relieved by Sitting Forward
Exocrine Dysfunction- Malabsorption and Steatorrhoea (occurs after YEARS as well)
Endocrine Dysfunction- Type 1 Diabetes Mellitus- Polyuria and Polydipsia (occurs after 20 YEARS of symptom onset)
Check for signs of Chronic Liver Disease
What Investigations should be ordered in Chronic Pancreatitis?
Is it worth checking Amylase and Lipase in Chronic Pancreatitis?
Structural Investigations
- CT- Pancreatic Calcification (this is preferred)
- Abdominal Xray- Calcification
Functional Investigations
- Exocrine Dysfunction- FAECAL ELASTASE
- Endocrine Dysfunction- FASTING GLUCOSE/ OGTT
- Serum Amylase and Lipase are NOT TYPICALLY RAISED- unlike Acute
What is the management of Chronic Pancreatitis
What is the general life advice, 3 medication options and then if all else fails- 2 things that can be done?
Conservative- Ethanol Abstinence and a Good Diet
Medical-
- Pain control with !!!!!!!Analgesia
- Manage the Endocrine Dysfunction with Insulin
- Manage the Exocrine Dysfunction with Pancreatic Enzyme Replacement
If the above management options fail- !!!!!!!Coeliac Plexus Block and Pancreatectomy
What are the complications of Chronic Pancreatitis?
May be Local- Pseudocysts (observe for 12 weeks first then surgery) or Pancreatic Cancer
May be Systemic- Endocrine (Diabetes) and Exocrine Dysfunction (Malabsorption and Steatorrhoea)
What is Clostridium Difficile (D for Diarrhoea)?
Which 2 drugs increase the risk of it occurring?
What are the signs?
What is used to diagnose it?
What is the management?
It is a gram-positive bacteria that causes Pseudomembranous Colitis
It is seen in people who have been on a course of BROAD SPECTRUM ANTIBIOTICS (usually Clindamycin) and PROTEIN PUMP INHIBITORS
The microorganism produces Toxins that cause Inflammation, Diarrhoea and the development of a Pseudomembrane in the Large Bowel
Signs-
- Abdominal Pain, Diarrhoea, RAISED WCC (which is used to determine the severity)
Diagnosis-
C.Diff TOXIN- not the antigen as the antigen indicates a PAST INFECTION as well
Management
- Oral Vancomycin
- Then Oral Fidaxomicin (Fedex)
- Then Oral Vancomycin and IV Metronidazole (use this ASAP if Hypotension/ Toxic Megacolon)
What are the Risk Factors for Clostridium Difficile?
Broad Spectrum Antibiotics (Clindamycin, Ciprofloxacin, Cephalosporins, Penicillins)
Have been in healthcare settings (hospital or care home) for a long time
> 65 years old
Weak Immune System
Other Conditions- IBD, Cancer or Kidney Disease
Are on a PPI
What are the signs of Clostridium Difficile?
Suspect if on Broad Spectrum Antibiotics/ Long healthcare stay (hospital or care home)
Remember CONFUSION and signs of DEHYDRATION
May be asymptomatic but usually-
- Watery diarrhoea (may be bloody)
- Painful Abdominal Cramps
- Nausea
- Dehydration- Tachycardia, Oliguria, Dry mucous membranes
- FEVER
- Loss of Appetite and Weight Loss
- Confusion
What is the management of Clostridium Difficile?
What is the extra management that can help and what 2 things should the patient avoid?
What 3 things define a LIFE-THREATENING PRESENTATION?
PO Vancomycin (add IV Metronidazole if Severe- hypotension or toxic megacolon or ILEUS)
If Vancomycin is ineffective- Fidaxomicin
If Recurrent Infections= FAECAL TRANSPLANT can help
Avoid Anti-diarrhoeal Agents and minimise Narcotic Use as the Anti-peristaltic effects and Toxin entrapment can predispose to Toxic Megacolon
Replacing Fluid and Electrolyte losses is indicated as needed
What are the Severe Complications of Clostridium Difficile?
Massive Colonic Inflammation characterised by a Pseudomembrane of Immune Cells (Raised Yellow Plaques), Mucus and Necrotic Tissue. Pseudomembranous Colitis represents and advanced stage of disease is diagnostic of CDI
Colonic Distension- Toxic Megacolon
Systemic Toxicity and manifestations of the Systemic Inflammatory Response Syndrome (Leucocytes>35, Lactate>5, Hypotension requiring Vasopressor Therapy, Acute Renal Failure and Respiratory Distress)
What are the Strong and Weak Risk factors for Colorectal Cancer?
Strong
- Age
- Alcohol
- Tobacco
- Obesity
- Processed meat
- IBD
- Radiation Exposure
Weak
- Lack of Dietary Fibre
- Limited Physical Activity
- Asbestos Exposure
- Red Meat
What is the TNM staging of Colorectal cancer?
Tumour, Node, Metastasis
T-
- Tis (in situ)
- T1- extends through mucosa into submucosa
- T2- extends through submucosa into muscularis
- T3- extends through muscularis into subserosa
- T4- extends into Neighbouring Organs or Tissues
N-
- N0- No regional lymph node involvement
- N1- Metastasis to 1-3 regional lymph nodes
- N2- Metastasis to 4 or more regional lymph nodes
M-
- M0- No Distant Metastasis
- M1- Distant Metastasis
What are the current NHS Screening programmes for Colorectal Cancer?
Faecal Immunochemical Test (FIT) every 2 years for men and women aged 60-74. If positive, patients are referred for Colonoscopy
What would warrant the 2 week wait referral for Colorectal Cancer?
You can FIT test even if they do not meet the criteria but are close to doing so btw!!
Generally- unexplained rectal bleeding, unexplained mass
1) >40 years old with Unexplained Weight Loss AND Abdominal Pain
2) >50 years old with Unexplained Rectal Bleeding
3) > 60 with either Iron Deficiency Anaemia or Changes to Bowel Habit
4) Faecal Occult Blood Testing
5) Rectal or Abdominal Mass
6) <50 with Rectal Bleeding AND Abdominal Pain, Change in Bowel Habit, Weight Loss, Iron Deficiency Anaemia
What investigations should be ordered if Colorectal Cancer is suspected?
First Step= Colonoscopy
If it can not be performed, CT Colonoscopy is a suitable option but it does not allow for biopsy
AFTER Histological Diagnosis- CTAP should be performed to STAGE the disease so an appropriate intervention can be made
In Rectal Disease, Pelvic MRI or Endorectal US are preferred over CT scan
Carcinoembryonic Antigen (CEA) is NOT diagnostic but can be used to monitor therapeutic response to interventions
What is the management of Colorectal Cancer?
Colon Cancer-
- Stage 1-3 (no metastasis)= Surgical Resection and Post-operative Chemotherapy (If stage 3 (lymph node involvement)). Add Preoperative Chemotherapy if Stage 4 (Metastasis)
Rectal Cancer-
- Anterior Resection if >8cm from Anal Canal. Abdomino-perineal Resection if <8cm from the Anal Canal
Resections-
- Caecal, Ascending or Proximal Transverse Colon- Left hemicolonectomy
- Distal Transverse, Descending- Right hemicolonectomy
- Rectum- Anterior Resection
- Anal Verge- Abdomino-perineal Excision of the Rectum
What are 3 types of genetic Colorectal Cancer and their symptoms?
All of them are Autosomal Dominant
Hereditary Non-Polyposis Colorectal Cancer/ Lynch Syndrome (MOST COMMON)
- Autosomal Dominant
- 80% chance of getting Colorectal Cancer by their 30s
- Endoscopic Surveillance
Familial-Adenomatous Polyposis
- Autosomal Dominant
- Adenomatous Polyps in their Teens and they are GUARANTEED to get Colorectal Cancer unless that have Proctocolectomy
Peutz-Jeghers Syndrome
- Autosomal Dominant
- Mucocutaneous Pigmentation (pigmented spots on the skin or the mouth) and Hamartomatous Polyps in their Teens
- The risk of Neoplastic Transformation of their Hamartomatous Polyps is low but they need Endoscopic Surveillance anyway
What are the Bristol Stool Classifications?
1- Nuts
2- Lumpy Sausage
3- Cracked Sausage
4- Smooth Sausage
5- Blobs with Clear cut edges
6- Mushy Fluffy pieces with Ragged Edges
7- Watery (no solid pieces)
Constipation is Type 1 or 2
Diarrhoea is Type 6 or 7
Lacking Fibre= Type 5
What drugs can cause Constipation?
COAA
Calcium Channel Blockers
Opiates
Some Antipsychotics
Anticholinergics (like Amitriptylline)
What is the age of onset for Crohn’s?
15-40 years old
and 60-80 years old
Usually in Caucasians
What are the signs of Crohn’s Disease?
GI Symptoms- Crampy Abdominal Pain and Diarrhoea
Systemic Symptoms- Weight Loss and !!!!!!!!FEVER
- Generally may be Cachectic and Pale due to Anaemia
- There may be CLUBBING
- Aphthous Ulcers in the Mouth
- !!!!!!!Abdominal/ Right Lower Quadrant Tenderness and a RIGHT ILIAC FOSSA MASS
- PR Exam for Perianal Skin Tags, Fistulae or Perianal Abscess
Dermatological manifestations-
1) Erythema Nodosum (usually on shins)
2) Pyoderma Gangrenosum (well defined ulcer with Purple Overhanging Edge)
Ocular Manifestations-
1) Anterior Uveitis (Painful red eye with blurred vision and photophobia)
2) Episcleritis (Painless red eye)
MSK Manifestations-
1) Arthritis (ASYMMETRICAL and non-deforming)
2) Sacro-iliitis (similar to Ankylosing Spondylitis)
3) Osteoporosis
Hepatobiliary Manifestations-
1) Gallstones (more common in Crohn’s than in Ulcerative Colitis)
Haematological and Renal Manifestations-
1) Amyloidosis and Renal Stones (more common in Crohn’s than in Ulcerative Colitis)
What investigations should be ordered in Crohn’s?
What will the blood tests and imaging show?
Remember Fistulae and Proximal Bowel Dilatation
What is the definitive diagnosis?
Blood Tests-
1) HIGH CRP and ESR and WCC (always raised even in flare up)
2) Thrombocytopaenia
3) Low Albumin
4) Anaemia
Stool Culture is necessary to exclude infection
Faecal Calprotectin (an antigen produced by Neutrophils) will be RAISED (helps distinguish IBD from IBS)
COLONOSCOPY with Imaging is needed for Diagnosis
EXAMINING SMALL BOWEL is DEFINITIVE
Colonoscopy may show
1) Deep Ulcers
2) Skip Lesions
3) Fistulae
4) Proximal Bowel Dilatation
5) STRING of KANTOUR
6) Rose Thorn Ulcers
7) Non-Caseating Granulomas
8) Cobblestone Mucosa
Histology may show
1) Goblet Cells
2) Granulomas
What are the Colonoscopy findings of Crohn’s?
- Intermittent Inflammation- Skip Lesions
- Cobblestone Mucosa- due to Ulcerations and Mural Oedema
- Rose-thorn Ulcers (due to transmural inflammation) +/- Fistula or Abscesses
- Non-caseating Granulomas
What is the Medical Management of Crohn’s?
Induce Remission
1) Glucocorticoid Monotherapy (Prednisolone or IV Hydrocortisone)
1a) Enteral Nutrition may be considered as an alternative in children (as steroids suppress growth)
2) Azathioprine or Mercaptopurine may be added if there are 2 or more Exacerbations within a year or if Glucocorticoids can not be tapered.
ASSESS TPMT before giving Azathioprine or Mercaptopurine
2a) If TPMT deficient- Methotrexate can be given next
3) If severe- Infliximab or Adalimumab
4) MRI then Metronidazole for Perianal Fistulae Disease
What is given to Maintain Remission in Crohn’s?
(Just Step 2 from the Medical Management for Inducing Remission)
1) Azathioprine or Mercaptopurine
1a) Otherwise Methotrexate
What is the management of Peri-Anal Fistulae in Crohn’s?
Drainage Seton for HIGH FISTULAE (Trans-sphincteric- so passes through muscle layers and is complex)
Fistulotomy for LOW FISTULAE (Submucosal)
What is the management of Peri-Anal Abscess in Crohn’s?
IV Antibiotics- Ceftriaxone and Metronidazole
They also require Examination under Anaesthetic and Incision and Drainage. An Incision is made in the affected region and the pus is broken up
What is the method of action of Imitinib?
It Inhibits Tyrosine Kinase
What is a significant side effect of Metronidazole?
Peripheral Neuropathy
What are the histological signs of Crohn’s?
Does not extend beyond submucosa (So only Submucosal Fibrosis)- Cobblestone Mucosa
Goblet cell depletion
Crypt Abscesses (collections of Neutrophils in Crypts)
What is a complication of Terminal Ileum Resection (done for Crohn’s Disease) and what are the signs?
Bile Acid Malabsorption
Presents as Diarrhoea and Fatty Stools
Where are Cytochrome P450 Enzymes found?
They are metabolised in the Liver
What are the 7 Cytochrome P450 enzyme Inducers and 9 Inhibitors?
Inducers (Avoid in Oral Contraceptives)
1) Alcohol (Chronic) and smoking
2) Phenytoin
3) Phenobarbitone
!!!!4) Rifampicin
!!!!5) Carbamazepine
6) Griseofulvin
7) St. John’s Wort
Inhibitors (INCREASEs INR and increases STATIN concentration) (OG DEVICES)
1) Omeprazole
2) Grapefruit Juice
3) Disulfiram
4) Erythromycin
5) Valproate
6) Isoniazid
7) Ciprofloxacin
8) Ethanol (Acute Intoxication)
9) Sulphonamides
When should patients be checked for Upper GI cancer in Peptic Ulcer Disease? (ENDOSCOPY within 2 weeks)?
Over 55 or ALARM signs
- Anaemia
- Loss of Weight
- Anorexia
- Recent onset of Symptoms
- Melaena
- Swallowing Difficulties (Dysphagia)
What are the signs of Peptic Ulcer Disease?
In addition to the pain what other symptom is there?
Epigastric pain, worse when hungry and relieved by eating if duodenal (common) or worse after eating if gastric (less common)
!!! NAUSEA in PEPTIC ULCER DISEASE
Nausea
Intolerance of Fatty Acids
What is the management of patients who are not over 55 or have ALARMS signs for Peptic Ulcer Disease?
What 2 medication types should they avoid?
!!!!!!!Lifestyle Changes, Medication changes (avoid NSAIDs and Steroids) and give Antacids
If symptoms do not improve, test for H Pylori
(breath or Stool Antigen) (but they should not have taken Antibiotics or Bismuth for 4 weeks and PPI for 2 weeks before the test)
- If positive- TRIPLE THERAPY= PPI, Clarithromycin and Amoxicillin (Metronidazole if allergic to Penicillin)
- If negative- PPI or H2 antagonist
6-8 weeks later, do another Endoscopy
What are the differentials for Dysphagia?
- Neurovascular Disease- Cerebrovascular Disease, Parkinson’s, Motor Neurone Disease, Bulbar Palsy
- Motility Disorder- Achalasia, Diffuse Oesophageal Spasm, Systemic Sclerosis (SOLIDS and LIQUIDS affected from the start and other features of CREST)
- Mechanical/ Obstructive Disorders- Strictures, Malignancy, Pharyngeal Pouch, Extrinsic Pressure from LUNG CANCER, Mediastinal Lymph Nodes, Retrosternal Goitre
1) Odynophagia suggests Candida Infection (suspect if HIV), Malignancy, Ulcer or Spasm
2) Halitosis, Gurgling, Bulging neck on swallowing suggests Pharyngeal Pouch
3) Iron Deficiency, Glossitis and Angular Stomatitis suggests Plummer-Vinson Syndrome- also OESOPHAGEAL WEBS
4) Odynophagia with no weight loss or vomiting- Oesophagitis
5) Difficulty in making the swallowing motion suggests Neurological cause
What are the Hepatobiliary causes of Malabsorption?
Primary Biliary Cirrhosis (autoimmune bile duct degradation) and Ileal Resection (failure of Bile acid absorption at Terminal Ileum)
What are the Pancreatic Causes of Malabsorption?
Chronic Pancreatitis
Pancreatic Cancer
Cystic Fibrosis
What are the Small Bowel Causes of Malabsorption?
Coeliac Disease
Crohn’s Disease
Small Bowel Resection
What are the Typical Symptoms of GORD which suggest a diagnosis?
Dyspepsia (Heartburn)
Sensation of Acid Regurgitation
What are the Atypical Symptoms of GORD?
Look at the G and the O of GORD
Epigastric Pain (worse when lying down and after eating)
Nausea
Bloating and Belching (so acid is refluxed)
Globus (lump in your throat)
Laryngitis
Tooth Erosion
What Investigations should be ordered in GORD? (3) POO
1) Give them a trial of PPI
2) OGD if there are Alarm symptoms (like Peptic Ulcer Disease) (anaemia, weight loss, melaena, Dysphagia etc.) or if Atypical or Recurrent symptoms
3) Oesophageal Manometry (like Achalasia)
What is the management of GORD?
Conservative, 2 drugs, surgery
Lifestyle Interventions- weight loss, dietary changes, elevation of head at night, avoidance of late-night eating
PPI Therapy
Antacids for symptomatic relief
If Refractory- Anti-reflux Surgery
What are the 3 complications of GORD?
!!!!2 of them start with OESOPHAGUS
1) Oesophageal Ulcer
2/3) Barrett’s Oesophagus and therefore Adenocarcinoma of the Oesophagus
4) Oesophageal Stricture
What are the signs of Gastroparesis?
Nausea and Vomiting
Feeling of Fullness after a few bites
!!!!Abdominal Pain and BLOATING
Constipation
!!! ABDOMINAL PAIN and ERRATIC GLUCOSE CONTROL in GASTROPARESIS
Also POOR GLUCOSE TOLERANCE in Diabetes Patients due to lack of absorption of Ingested Food
What is needed for the diagnosis of Gastorparessis?
Solid Meal Gastric Scintigraphy (Radionuclide Studies of Gastric Emptying)
What is the management of Gastroparesis?
Diet and 3 meds
1) Dietary Modification- Low fibre, Smaller/ more frequent meals, Pureed/ mashed food
2) Domperidone- Dopamine Receptor Antagonist (unless QT Prolongation or Heart Failure)
3) Metoclopramide or Erythromycin (Motility Agents)
What is Giardiasis?
It is a type of Gastroenteritis caused by the parasite Giardia Lamblia
It is spread via the Faecal-Oral Route so a history of Contaminated water, Uncooked Fruit or Vegetables or a Lack of Hand Hygiene are key
What are the 4 signs of Giardiasis?
How long is the incubation period?
Bloating and Non-bloody Steatorrhoea
The incubation of the disease is ONE to THREE WEEKS
1) Explosive, Watery, Non-bloody (unlike Salmonella) Steatorrhoea (Foul Smelling and Difficult to Flush)
2) Bloating and Flatulence (unlike Cholera), Nausea
!!!!!!!!!!!!!!3) Weight Loss and Anorexia
4) NEW ONSET LACTOSE INTOLERANCE for up to SIX WEEKS can also occur
What is the diagnosis of Giardiasis?
Stool Microscopy for Trophozoites and Cysts is conducted THREE TIMES on THREE SEPARATE days
Other tests= Stool antigen tests (Greater Sensitivity), Stool PCR
Duodenal Aspirates and Biopsies are invasive and only used in Indeterminate Cases
What is the management of Giardiasis?
Without treatment, the disease can persist for MONTHS
Treatment is with Antibiotics like METRONIDAZOLE
What is Gilbert’s Syndrome?
What is the Inheritance Pattern?
Doesn’t require treatment as it is benign
It is an Autosomal Recessive condition where there is decreased activity of the UDP enzyme that conjugates bilirubin due to a mutation in the UGT1A1 gene
so Lack of Conjugation
What are the signs of Gilbert’s Syndrome?
Doesn’t require treatment as it is benign
Intermittent Mild Jaundice in relation to Chest, Fasting, Infection or Exercise
There will be a NORMAL FBC but mildly raised Unconjugated Bilirubin, other LFTS will be NORMAL
What is Henoch-Schonlein Purpura?
What typically occurs before it?
What is seen on Skin Biopsy?
It is the most common type of Vasculitis seen in children aged 3-15 years old. This occurs due to the DEPOSITION of IgA Immune Complexes in the affected organs
So it is associated with IgA Nephropathy as well
Skin Biopsies of the affected regions show Neutrophils and Monocytes- also use the biopsy for Immunofluorescence of C3/IgA which is DEFINITIVE DIAGNOSIS
It is typically seen after an Upper Respiratory Tract Infection
What are the signs of Henoch-Schonlein Purpura?
Remember PANA
TETRAD
1) Purpuric Rash over Buttocks and Extensor Surfaces
2) Abdominal Pain
3) Arthralgia/ Arthritis
4) Renal Disease presenting as Asymptomatic Microscopic Haematuria or Isolated Proteinuria (Nephritis)
