Gastrointestinal Flashcards
Coeliac Disease
Autoimmune T-cell mediated condition where exposure to gluten causes a reaction that causes inflammation in the small bowel.
Coeliac Disease Pathology
- Gluten broken into Gliadin
- Binds to IgA antibodies on gastric mucosa
- Gliadin- Antibody complex presents to transferrin receptor
- Complex endocytosed across gastric Mucosa into lamina propria
- Tissue Transglutaminase removes an amide
- Deaminated gliadin phagocytosed by HLADQ8/2 macrophages
- Macrophages signal chimune response causing inflamm.
Coeliac Disease Symptoms
Inflammation causes: Crypt hyperplasia + Lymphocyte infiltration + Villous atrophy
→ Malabsorption = steatorrhoea & diarrhoea
→ Iron deficiency anaemia
→ Weight loss
→ Fatigue
→ Mouth ulcers
→ Dermatitis herpetiformis = bumpy papular
Coeliac Disease investigations & management
Gluten= more than 1 meal per day
- Serology
1st Line = Total IgA + tTG + antigliadin + anti endomysial antibodies
Gold = duodenal biopsies - see villous atrophy, crypt hyperplasia, Raised intraepithelial lymphocytes
Management = Gluten free diet
Intestinal Obstruction Categories
→ Blockage
→ Pressure
→ Contraction
Intestinal obstruction Blockage causes
- Tumour
- Diaphragm disease - caused by NSAIDs
- Crohn’s = fibrosis - coarctation - obstruction
- Diverticular disease = Outpouching - faeces trapped
Intestinal obstruction Pressure causes
- Adhesions
- Volvulus - free floating areas with mesentery - Sigmoid
- Intussusception
Intestinal Obstruction Contraction causes
- Inflammation
- Intramural tumours
- Hirschsprung’s disease
Small bowel Obstruction Causes
Adults: Adhesions, Hernias, Crohn’s & Malignancy
Children: Volvulus, Intussusception, Hirschsprung ‘s, Appendicitis
Bowel obstruction Symptoms
- Vomiting
- Constipation/ Obstipation
- Abdo pain & Distension
- Tenesmus
- Weight loss
- Bowel sounds
Bowel obstruction signs
Perforation (peritonitis), Strangulation
Increased HR, Hypotension & High temp., Swelling
Bowel obstruction Investigations
- Digital Rectal Exam- large bowel
- X-Ray → Dilated jejunum / ileum, absense of gas distal to obstruction
- FBC + U&E
Bowel obstruction Treatment
- IV Fluids resus. (Nil by mouth)
- BoweI decompression
- Correct electrolyte imbalance
- Analgesia & anti - emetics
Definitions : Diverticulum Diverticulosis Diverticular Diverticulitis
Diverticulum = Outpouches Diverticulosis = asymptomatic condition of outpouches Diverticular = Symptomatic condition of outpouches Diverticulitis = Inflammation of outpouches
Diverticulosis Risk factors
- Low fibre diet
- NSAIDs
- COPD
- Old age
- Connective tissue disease
Diverticular /itis Symptoms & Investigations
- LLQ tenderness
- Constipation
- Rectal bleeding
- Fever
- Diarrhoea
Investigations = CT or Colonoscopy
Diverticulitis Complications
- Perforation
- Peritonitis
- Fistula
- Obstruction
Diverticular/ osis Treatment
Diverticulosis: High fibre diet
Diverticular:
- Bulk forming laxatives (Ispaghula husk)
- Surgery
Contraindications : Stimulants (sena)
Diverticulitis Treatment
Mild:
- 5 days of Co amoxiclav or Cephalexin with Metronidazole
- Analgesics (not opioids / NSAIDs)
- Liquid food
Severe:
- Nil by mouth
- IV Fluids & antibiotics
- CT & Surgery
Stages of Nutrition
I. Ingestion
- Digestion
- Absorption
- Egestion
Malabsorption Causes
- Intake
- Digestion = Pancreatic / bile secretion
- Absorption = Coeliac / Crohn’s - Villous atrophy
Malabsorption Symptoms
- Diarrhoea
- Steatorrhoea
- Weight loss
Malabsorption Complications
- Anaemia = low iron + Folate + B12
- Bleeding disorder = low vit. K
- Oedema = low protein
- Bone disease = low vit. D
→ Tropical spure
Diarrhoea causes
- Viral = Norovirus, Rota -virus
- Bacteria = Staph. Aureus, Salmonella
- Antibiotics - high risk of c.diff.
- Drugs (NSAIDs)
→ IBD & IBS
→ Bowel cancer
→ Hyperthyroidism
→ Stress
Antibiotics that cause c. diff
→ Clindamycin
→ Co-amoxiclav
→ Cephalosporins
→ Ciprofloxacin
Diarrhoea Red Flags
- Dehydration
- Renal failure
- Electrolyte imbalance
- Rectal bleeding, weight loss → cancer
Diarrhoea Investigations
- History
→ Floaty diarrhoea - Fat
→ Watery diarrhoea - Infection
→ Bloody diarrhoea - Inflammation / Cancer
- Stool test = culture + test for blood
- Blood test = culture + CRP (C - Reactive Protein)
Diarrhoea Treatment
- Fluid & Electrolyte replacement
- Antibiotics = Vancomycin
- Antimotility agents
- Antiemetics
IBS Types
→ IBS-D (Diarrhoea)
→ IBS-C (Constipation)
→ IBS-M (Mixed)
IBS Pathophysiology
- Stress
- Genetics
- Signalling
- Motility
IBS Symptoms
- Abdo pain & bloating relieved by defecation
- Mucus in stool
- Change in bowel habit - constipation, Straining
IBS Investigations
- Bloods
- ESR & CRP
- Coeliac Serology
IBS Treatment
Mild:
Education + Low fodmap diet + Reassurance
Moderate:
- Laxatives = Linaclotide or Bulk forming laxatives
- Anti- motility agents = Loperamide
- Antispasmodics
- CBT or Hypnotherapy
Severe:
TCA (Tricyclic Acids)
Ulcerative Colitis
Autoimmune Disease where there’s inflammation & uIceration of colon & rectum
Crohn’s Disease
Immune related.
Bacteria over stimulating immune system - Mainly affects ileum
Never affects rectum.
Crohn’s Disease Pathology
- Pathogens pass through Gl lining.
- Mutation allows pathogens through mucosa into deep Submucosa.
- Bacteria stimulates T- helper cells = releases cytokines = causes inflammation & granulomas = more cells = more cytokines = more inflammation
General & Specific symptoms in IBD
- Diarrhoea
- Abdo. pain & cramping
- Mucous
- Fever + Weight loss + Malaise
Specific =
→ Rectal pain in UC
→ Ileum therefore RLQ pain in Crohn’s
→ Inability to defecate
Extra- Intestinal Symptoms - UC
UC:
→ Crypt abscesses
→ Pauci - arthritis
→ Enthesitis + Tenosynovitis + Dactylitis
→ Erythema Nodosum (raised red subcut. nodules)
Extra- Intestinal Symptoms - Crohn’s
→ Any part of Gl Tract
→ Skip lesions
→ Deep Ulcers & fissures (cobblestone mucosa)
→ Transmural inflam.
→ Goblet cells
IBD Complications
UC:
- PR bleeding
- Neoplasia
- Toxic megacolon
Crohn’s:
- Malabsorption
- Fistula
- strictured
- Sinus tract
- Obstruction & Abscess
IBD Investigations & Monitoring
- pANCA = - ve in Crohn’s , + ve in UC
- Endoscopy with biopsy → Transmural inflam. & granulomas
Monitor :
→ Blood - CRP + ESR + Anaemia
→ Fecal occult blood test
→ Fecal calciprotein
IBD Treatment - Mild / Moderate
1st Line = Aminosalicylates (mesalazine & sulfasalazine)
2nd Line = + Corticosteroids e.g. Prednisolone
3rd Line = + Calcineurin inhibitor (ciclosporin)
Biologics = Infliximab
Crohn’s
- Prednisolone
- Azathioprine
- Infliximab
IBD Treatment - Severe
1st Line = Calcineurin Inhibitor (ciclosporin) + corticosteroids
Immunosuppressive drugs [ Azathioprine & Methotrexate]
Gold = Biological Therapy [ Tumour Necrosis Factor alpha + Infliximab + Subcut. Golimumab ]
Last Line = Surgical resection then give Azathioprine + Metronidazole
IBD Treatment contraception advice
- Methotrexate = Contraception for male & female
- Monoclonal antibody & TNF alpha = Contraception for female
Colorectal Cancer Symptoms
- Blood & mucus in stool
- Mass
Colon cancer Investigations
- Endoscopy with biopsy
- CT
- Faecal occult blood
- Tumour markers
- Barium enema
Colon cancer Treatment
Resection
Main sites for Colon cancer
Descending colon + Sigmoid + Rectum
Metastases for Colon cancer
Liver → Lungs → Bones > Peritoneum → Brain → Spinal cord
Ischemic Colitis Causes + Symptoms
Causes:
→ Atherosclerosis of Superior & Inferior mesenteric artery
→ Thrombus/ Emboli
→ Low cardiac output & Arrhythmias
Symptoms:
- LLQ pain
- Bloody diarrhoea
Ischemic Colitis Investigations
- CT/ MRI angiography
- Colonoscopy .with biopsy
Ischemic Colitis Treatment
- Fluid replacement
- Antibiotics
- Surgery for perforation
UC vs Crohn’s
UC: → Ulcer goes through mucosa & submucosa → Inflammation in colon only → No interspaced healthy areas → Goblet cell depletion & crypt abscesses
Crohn’s:
→ Transmural (mucosa + submucosa + muscle + Serosa)
→ Inflammation anywhere in GI tract
→ Areas of inflammation interspaced healthy areas
→ Skip Lesions (Cobblestone appearance)
Gastritis Causes + Risks
Causes: → Mucosal ischemia → H. pylori → Aspirin I NSAIDs → Autoimmune gastritis
Risks:
- Diabetes
- Travel + alcohol + old age
- NSAIDs / Aspirin
- Stress/ Autoimmune
Gastritis Symptoms
- Epigastric pain
- Diarrhoea
- Indigestion
- vomiting & Nausea
- Fever & Malaise
- Dehydration
Gastritis Investigations
If pylori = Stool antigen test or urea breath test
Gold = Endoscopy
- Faecal occult blood
- C-Reactive Protein blood test
Gastritis Treatment
Mild:
Fluid Intake
Small non fatty meals
Antimotility agents
Moderate/ Severe:
If NSAID/ Aspirin cause = PPl / H2 receptor antagonist
If H. Pylori cause = Clarithromycin + Amoxicillin + Omeprazole
If Campylobacter cause = Clarithromycin
If Gastritis returns?
- Miss work until 48 hrs after last diarrhoea
- No swimming for 2weeks after diarrhoea
- E. coli - do 2 negative stool samples over 24 hrs
Peptic + Duodenal ulcer Pathology
Peptic ulcers = Break in epithelial cells Penetrating down to muscalaris mucosa → fibrous base & inflammatory cells increase.
Duodenal ulcers = Brunners gland hypertrophy - reduce acidity of duodenum
Affects gastroduodenal artery
Peptic & Duodenal Ulcer causes
- Prolonged NSAID & Aspirin use
- H. pylori = Urease + Protease
- Zollinger Ellison syndrome = Gastric acid hypersecretion + Tumour of pancreas + Peptic ulcer
Peptic & Duodenal ulcer symptoms
- Epigastric pain
- Peptic ulcer = Pain when eating & goes after 2-3 hrs
- Duodenal ulcer = Pain reduces when eating & comes after 2-3 hrs
- Bloating
- Nausea + Vomiting
Peptic & Duodenal ulcer complications
- Bleeding thus hypovolaemic shock
- Perforation
- Resp. distress → Sepsis + air under diaphragm
Peptic & Duodenal ulcer Investigation
Peptic:
Endoscopy with biopsy
Duodenal:
urea breath test or Faecal antigen test
2 weeks without PPI
4 weeks without antibiotics
Peptic & Duodenal Treatment
- Stop alcohol & smoking
- Stop NSAIDs
- PPI or H2 antagonist
- H. pylori = Clarithromycin + Amoxicillin + Omeprazole
GORD Pathology & Risk
Pathology:
- Inflammation - Scarring - oesophageal Stenosis
- Risk of neoplasia
Risk:
→ Barrett’s Oesophagus
→ Zollinger - Ellison Syndrome
→ Hiatal hernia - lowers LOS pressure = increases reflux
GORD symptoms
- Regurgitation
- Dyspepsia & Dysphagia
- Nocturnal asthma
- worse when lying flat
GORD Investigations
Therapeutic challenge = Give PPl
Gold - Oesophageal manometery
X- Ray with barium
Serum gastrin
GORD Treatment
PPl (Lanzoprazole) for 1mnth H2 antagonist (ranitidine) Gold = Anti -reflux surgery (laparoscopic fundoplication) - Antacids = neutralise acid - Prokinetic medication - GABA agonist baclofen
Achalasia + Investigations + Treatment
Lower oesophageal sphincter won’t relax so food & liquid can’t pass into Stomach
Ix = Endoscopy / Barium swallow
Tx = Isosorbide dinitrate or Nifedipine or Veramipril
Gold - Surgery → pneumatic dilation
Mallory- Weiss Tear (M-W-T) Risk
- Alcohol-binge drinking
- Chronic cough
- Weight lifting
- Bulimia
M-W-T Symptoms
- Haematemesis
- Melaena
- Hypovolaemic shock
M-W-T Treatment
- Resus
- Antiemetic
- PPI
Appendicitis & Causes
= Inflammation of Appendix
- obstruction
- Faceolith
- Pinworm infection
Appendicitis Pathology
- Blockage= backed-up fluid & mucus → Increased pressure → Compresses nerves + blood vessels → Ischemia & Necrosis
- Bacteria= (E. Coli) - WBCC increases
- Necrosis= no mucus secretion - more bacterial growth
Appendicitis Symptoms
- Umbilical pain - migrates to RLQ
- Rebound tenderness - McBurney’s Point = 2/3 between umbilicus from ileac crest
- Worse on coughing
- Vomiting & Low grade fever
Appendicitis Sign
- Rosvings sign - Pressing in LLQ causes pain in RLQ
- Obturator sign
- Psoas sign
Appendicitis Investigations
- CT/ US
- Bloods → WBC + CRP + high ESR
- Pregnancy test
Appendicitis Treatment
- Laparoscopic Appendectomy
- Antibiotics
- Drain abscesses
- Fluids
H. Pylori & Risk
Gram -ve bacilli with flagella
Produces urease which makes ammonia → damages gastric mucosa
Risk:
- No clean water
H. Pylori Causes
- Gastritis
- peptic ulcer
- H. Pylori + Low gastric acid = Peptic/ Gastric cancer
- H. Pylori + High gastric acid = Duodenal ulcer
H. Pylori Symptoms
- Ache /burning pain
- Abdo pain - worse when stomach is empty
- Bloating, weight loss & nausea
H. Pylori Investigations
- Urea breath test
- Stool test
- Endoscopy
- Blood test
H. Pylori Treatment
2 Antibiotics & PPl
Clarithromycin + Amoxicillin + Omeprazole
Oesophageal Cancer Risks
A = Achalasia B = Barret's Oesophagus C = Corrosive oesophagus D = Diverticulitis E = Esopheal web F = Family Hx
Hemorrhoids
Sx:
Tx:
Swollen veins in anus & lower rectum.
Internal= Painless bleeding, can prolapse
External= Painful, form at anal opening
Sx: Bright red bleeding, Pain
Tx: Stool softeners, high fibre diet, band ligation
C.diff.
- Occurs in hospital environment - due to contact
-Due to C. antibiotics
→ watery diarrhoea
→ fever
→ Malaise - Treat with vancomycin
Barrett’s Oesophagus cell change
Metaplasia
Simple columnar epithelium with goblet cells
Dyspepsia
Sx
Ix
Tx
Epigastric Pain, Early satiation
Sx: Reflux when lying flat, Heartburn, Bloating
Ix: Stool culture, Blood test, Urea test
Tx: Dietary manage., Antidepress. (Citalopram)
Oesophageal varices
Sx:
Ix:
Tx:
Sx: vomiting blood, abdo. pain, Spider naevi, yellow sclera
Ix: Blood test = Raised ALT, AST & ALP, high bilirubin & creatinine
Tx: Band ligation, Antihypertensives
Diarrhoea types
- Secretary
- Osmotic
- Exudative
- Desentery
Haematemesis from ruptured Oesophageal varices
Sx:
Tx:
Vomiting large volumes of blood.
Tx: IV Terlipressin
IV Somatostatin it contraindicated
