Gastroenterology (Small and large bowel) Flashcards
coeliac disease
autoimnmune condition that primarily affects the small intestine
pathophysiology
- reaction to gluten causes bluting of villi, reducing absorption of nutrients from the small intestine
coaliac risk factors
- Family history
- Immunoglobulin A (IgA) deficiency
- Type 1 diabetes
- Autoimmune liver disease
- Autoimmune thyroid disease
- Human leukocyte antigen (HLA)-DQ2 and HLA-DQ8
presentation of coeliac
Persistent and unexplained gastrointestinal symptoms such as:
- Abdominal pain
- Bloating
- Diarrhoea
- Constipation
- Steatorrhoea
Features of malabsorption:
- Weight loss and failure to thrive
- Anaemia – may be iron-deficiency anaemia or anaemia secondary to B12/folate deficiency
- Metabolic bone disorders (e.g. osteomalacia, osteopenia, or osteoporosis) and fragility fractures due to malabsorption of calcium and vitamin D
Mouth ulcers that may be persistent or severe
coeliac associated conditions
- Unexplained depression or anxiety
- Unexplained peripheral neuropathy
- Unexplained ataxia
- Unexplained subfertility or recurrent miscarriage
- Unexplained persistently slightly elevated AST/ALT on liver function testing
- Unexplained hyposplenism
- Dermatitis herpetiformis – a rash associated with a transglutaminase enzyme in the skin
when to screen for coeliac
The following patients should be offered screening for coeliac disease:
- Persistent unexplained gastrointestinal symptoms
- Unexplained weight loss, faltering growth, or failure to thrive
- Severe or persistent mouth ulcers
- Unexplained iron-deficiency, B12, or folate deficiency
Patients with associated conditions:
- Type 1 diabetes mellitus (T1DM) – should be done at the time T1DM is diagnosed
- Autoimmune thyroid disease – at the time it is diagnosed
- Irritable bowel syndrome
- Dermatitis herpetiformis
- 1st-degree relatives with coeliac disease
Screening should be considered if any of the following are present:
* Metabolic bone disorders
* Unexplained peripheral neuropathy or ataxia
* Unexplained complications in pregnancy, including recurrent miscarriage and subfertility
* Unexplained persistently elevated liver AST/ALT
* Down’s syndrome
* Turner syndrome
* Dental enamel defects
screening for coeliac
different to diagnosis
MAKE SURE PATIENT CONTINUES TO EAT GLUTEN FOR A MIUM OF 6 WEEKS BEFORE TESTING
1st-line: serum IgA tissue transglutaminase antibody (tTGA) + total IgA
- Total IgA is measured because, in some individuals with an IgA deficiency, this may return a negative result
2nd-line: IgA endomysial antibody (EMA) if IgA tTGA is unavailable
- Consider re-testing if a person presents with new symptoms of coeliac disease, despite previous serology
why is total IgA measured
- Total IgA is measured because, in some individuals with an IgA deficiency, this may return a negative result
diagnosis of coeliac
gold standard: biopsy of the duodenum and jejunum
- villous atrophy
- crypt hyperplasia
- intrapeithelial lymphocytosis
- infiltration of the lamina propria and lymphocytes
management of coeliac disease
- 1st-line: lifelong gluten-free diet
- Monitoring with IgA tTGA or IgA EMA may be considered to assess compliance
- Offer annual influenza vaccine and 5-yearly pneumococcal vaccine:
why pneumoccocal vaccine for
Around 1/3 of patients with coeliac disease have hyposplenism, predisposing them to pneumococcal infection. This is thought to be due to functional hyposplenism and splenic atrophy
complications of coeliac
- anaemia - B12 deficiency
- osteoporosis
- hyposplenism
- lymphomas
- subfertility
irritable bowel syndrome is a disorder of the
gut-brain interaction
risk factors for IBS
- Diet: 90% of patients report that certain foods can trigger symptoms e.g. items are spicy foods, fatty foods, alcohol, and caffeine
- GI tract infection
- Family history
- Antibiotic use
- GI tract inflammation
- Psychological comorbidities including stress, anxiety, or depression
*
presentation of IBS
6- month history of ABC symptoms
Abdominal pain/discomfort:
- The pain generally varies, which can help differentiate IBS from malignancy, where the site of pain is usually fixed
Bloating
Changes in bowel habit
IBS extraintestinal features
- Lethargy
- Headache
- Nausea
- Back pain
- Gynaecological and bladder symptoms
how to differentiate between IBS, IBD, cancer and coeliac
IBS: Clinical diagnosis in primary care
IBS can be diagnosed if abdominal pain/discomfort has been ongoing for 6 months and the following apply:
1) Is relieved by defecation or is associated with changes in bowel frequency (increased/decreased) or stool form (e.g. loose, watery, hard, or lumpy)
2) At least 2 of the following are present:
- Altered stool passage – such as straining, urgency, or feeling of incomplete stool passage
- Abdominal bloating, distention, tenderness, or hardness
- Symptoms are worse when eating
- Passage of mucus
3) Alternative conditions with similar symptoms have been excluded, including red flags and serious conditions
management of IBS
Management depends on the predominant symptom:
1) For constipation: laxatives are first-line
- Any option is appropriate except lactulose as it can increase gas production
- Linaclotide can be considered if first-line options are insufficient
2) For diarrhoea: loperamide is first-line
3) For abdominal pain: antispasmodic agents are first-line
- Options include direct-acting smooth muscle relaxants: mebeverine hydrochloride, alverine citrate, and peppermint oil
- These are less likely to cause adverse effects compared with antimuscarinic drugs such as hyoscine butylbromide
Other options
* Tricyclic antidepressants are considered 2nd-line
* Cognitive behavioural therapy may be necessary
inflammatory bowel disease
Umbrella term for: Crohsna nd ulcertaive colitis
Crohns vs Ulcerative colitis
Features suggesting Crohn’s disease are:
- Diarrhoea does not usually contain as much blood as UC
- Fever is often present
- Tenesmus (the feeling of needing to pass stools even though the bowel is empty) is less common
- Weight loss is more common
- Fistulae is more common
- CD can affect any part of the gastrointestinal (GI) tract from mouth to anus (e.g. mouth ulcers)
Features suggesting ulcerative colitis are:
- Diarrhoea often contains mucus and blood
- Fever is sometimes present, usually if a UC flare is severe
- Tenesmus is more common
- Weight loss is less common than in CD
- Fistulae is less common than in CD
- UC only affects the colon and rectum