Gastrointestinal Flashcards
What is ischaemic bowel disease?
- Ischaemia/infarction in the GI tract due to reduced blood flow.
What are the two most common causes of mesenteric ischaemia?
- Embolism (over 50%)
- Hypotension.
Which artery is most commonly occluded in mesenteric ischaemia?
- Superior mesenteric artery.
What are the 3 main types of ischaemic bowel disease?
- Acute mesenteric ischaemia.
- Chronic mesenteric ischaemia.
- Colonic ischaemia.
How do both acute and chronic mesenteric ischaemia present?
Abdominal pain out of proportion to the clinical findings.
- Acute will be rapid onset, whereas chronic will be insidious.
What is the presentation of colonic ischaemia?
- Bloody, loose stools (due to mucosal damage).
- Usually left sided abdominal pain/tenderness.
How are colonic ischaemia and mesenteric ischaemia differentiated?
- Bloody stools indicative of colonic ischaemia rather than mesenteric.
What is the first line investigation for suspected bowel ischaemia?
- CT scan.
What is the treatment for ischaemic bowel disease?
- Fluids + oxygen.
- Consider antibiotics (if there is perforation of the mucosal wall, gut flora can spread and cause infection).
- Surgical intervention (bowel reconstruction/segment resection).
What are the investigations used for perianal disorders?
- DRE + physical exam.
What are the four main types of perianal disorder? Brief description of each.
- Haemorrhoids. Enlarged/swollen hemorrhoidal cushions so they protrude outside the anal canal.
- Perianal abscess. Infection of the soft tissues around the anus.
- Perianal fistula. Tunnel between the anus and the perianal skin.
- Anal fissure. Split perianal skin.
What is the clinical presentation of haemorrhoids?
- PAINLESS rectal bleeding.
- Pain on shitting.
What are the two types of haemorrhoids?
- Internal or external.
- Differentiated by position in relation to the dentate line.
What is the treatment for haemorrhoids?
- Increased dietary fibre.
What is the presentation of perianal abscess?
- Perianal pain.
- Fever common (infective element).
What disease is commonly associated with perianal abscess/anal fistula?
- Crohn’s disease.
How is perianal abscess treated?
- Abscess drainage.
- NOT ANTIBIOTICS.
What is usually the proceeding condition for an anal fistula?
- Perianal abscess.
- When drained, may leave an anal fistula in its place.
Clinical presentation of anal fistula?
Blood and pain on shitting.
How is an anal fistula treated?
Surgery. Normally a fistulostomy.
What is the clinical presentation of an anal fissure?
- Pain on shitting (like glass)
- Burning pain 1-2 hours after.
- Small amount of bright-red blood on surface of stool
How is anal fissure treated?
GTN (topical) until fissure resolves.
What is pilonodial disease?
- Hair follicles become inserted into the skin at the crease of the buttocks, creating a sinus/cyst.
Who is most likely to be affected by pilonodial disease?
- Men aged 18-40.
What is the treatment for pilonodial disease?
If asymptomatic:
Keep area clean and hair free (shave/laser hair removal).
If symptomatic:
Consider surgical sinus excision.
What is gastritis?
- Stomach lesions that involve gastric mucosal inflammation.
What is gastropathy?
- Stomach lesions that with little to no evidence of mucosal inflammation.
What are the most common causes of gastritis?
- H. Pylori infection.
- Alcohol use.
- NSAID use.
- Autoimmune gastritis (but this is rarer).
What us the pathophysiology of autoimmune gastritis?
- Anti-parietal cell antibodies (ACAs) and anti-intrinsic factor (IFAs) are produced, which stimulate inflammation and necrosis of the parietal cells.
What are the diagnostic factors for gastritis?
- Presence of risk factors.
- Dyspepsia (indigestion).
- Epigastric discomfort.
BE AWARE OF RED FLAG SYMPTOMS.
What are the risk factors for gastritis?
- H. Pylori infection.
- NSAID use.
- Alcohol abuse.
What investigations are used if H.Pylori gastritis is suspected?
1st line - Urea breath test or Faecal antigen testing.
GOLD STANDARD - Endoscopy + mucosal biopsy.
What is the investigation used for NSAID/alcohol-induced gastritis?
- None needed.
- Stop NSAID or alcohol, and see if symptoms improve.
What investigations are used for autoimmune gastritis?
- IFAb (Intrinsic factor antibody) testing. Will be +ve in autoimmune gastritis.
- Serum B12 (reduced in B12 deficiency, a common complication of gastritis).
What is the treatment for H.Pylori gastritis?
- Triple therapy (Omeprazole + amoxicillin + clarithromycin) for 14 days.
What is the treatment for NSAID/Alcohol gastritis?
- If possible, stop NSAIDS/alcohol use.
What is the treatment for autoimmune gastritis?
- GIve B12 supplementation IM/IV.
What is the common complication of gastritis? Which forms of gastritis cause it?
- Peptic ulceration.
- Caused by H. pylori and NSAID forms of gastritis.
What is diverticular disease?
- Refers to the presence of diverticula.
- These are small herniated portions of bowel that span through the mucosa, submucosa and muscle in the bowel wall.
What is diverticulitis?
- Inflammation of the diverticula, usually due to infection.
What are pseudodiverticula?
Diverticula that have not breached the muscle wall, only the mucosa and submucosa.
What is the clinical presentation of diverticulitis?
- Left lower quadrant pain (including guarding and tenderness).
- Fever.
- Painless rectal bleeding.
What are the risk factors for diverticular disease?
- Over 50.
- Low fibre diet.
What are the investigations used for diverticular disease?
- FBC with differential. POLYMORPHONUCLEAR LEUKOCYTOSIS.
- CRP raised. (marker of acute inflammation).
IF ACUTE DIVERTICULITIS SUSPECTED:
- 1st line is contrast CT (provided kidney function is adequate).
What is the management of diverticular disease?
If just diverticulosis: Increase fibre in diet + paracetamol (if symptomatic).
If acute diverticulitis: Amoxicillin +clavulanate (for infection) and paracetamol (for analgesia).
AVOID NSAIDS IN DIVERTICULITIS - THEY INCREASE RISK OF BOWEL PERFORATION.
What is the histological presentation of coeliac disease?
- Villous atrophy with crypt hyperplasia.
What is appendicitis?
- Acute inflammation of the appendix, most likely due to blockage of the lumen.
What is the clinical presentation of appendicitis?
What is the sign associated with appendicitis?
- Severe, acute umbilical pain that migrates to the right iliac fossa.
- Vomiting/nausea.
- Rovsing’s sign. Tenderness in the RIF on palpation of the LIF.
What are the risk factors for appendicitis?
- Low fibre diet (increased risk of faecolith formation due to constipation).
- Improved hygiene (reduces the functionality of the gut flora).
- Smoking.
What is the pathophysiology of appendicitis?
- Blockage of the appendix lumen.
- Mucus builds up behind the blockage, causing an increased pressure inside the appendix.
- Bacteria (normally E. coli) multiply in the appendix..
What are the investigations used for appendicitis?
- FBC - High WCC.
- CRP - Raised (marker of acute inflammation).
Consider imaging (MRI abdomen, CT abdomen).
What is the treatment for appendicitis?
- 1st line for most is laparoscopic appendectomy.
- Prophylactic dose of antibiotics should be given prior to the surgery (just one dose).
What is Gilbert’s disease?
An inherited condition where the unconjugated bilirubin is high due to deficiency of conjugating enzymes in the liver.
Characterised by ISOLATED raised bilirubin.
What are the characteristic features of Crohn’s disease?
- Transmural inflammation of the GI tract.
- Contains skip lesions.
- Cobblestone appearance.
- Can occur anywhere in the GI tract.
- Contains non-ceasating granulomas.
What is the clinical presentation of Crohn’s disease?
Can be very generalised due to the potentially diffuse nature of the disease. Symptoms include:
- Abdominal pain (RIF commonly).
- Prolonged diarrhoea (may be bloody or non-bloody).
- Fatigue (malnutrition).
- Perianal lesions (present in 25% of Crohn’s patients).
What are the risk factors for Crohn’s disease?
- FH of Crohn’s.
- White.
What investigations are commonly used for Crohn’s disease?
- ESR/CRP - Raised due to active inflammation.
- Faecal calprotectin - +ve in IBD (excludes IBS).
GOLD STANDARD - Colonoscopy + biopsy of mucosa. Look for classical histological signs of Crohn’s. This is diagnostic.
What is the treatment for Crohn’s disease?
Inducing relapse:
1st line - Prednisolone.
2nd line - Add azathioprine (DMARD) or infliximab (tnf-a inhibitor).
Maintaining relapse: 1st line: azathioprine (DMARD). If infliximab (tnf-a inhibitor) worked particularly well, consider continuation of that.
What are the common differentials for Crohn’s disease? How are they different?
UC:
- UC is limited to mucosa, continuous, no non-ceasating granulomas.
- UC always involves the rectum, Crohns may do but no guarantee.
- UC is more likely to cause left abdominal pain (descending colon).
IBS:
- Negative faecal calprotectin.
- Pain relieved by defecation.
- No blood in stool.
What are the common complications of Crohn’s disease?
- Anaemia (due to malabsorption).
- Bowel obstruction (bowel wall thickens due to inflammation).
- Adenocarcinoma of the bowel.
What are the key features of UC?
- Inflammation of the GI tract limited to the mucosa.
- Always involves the rectum and spreads proximally.
- Inflammation is continuous (no skip lesions).
- Pseudopolyps may develop.
What is the clinical presentation of UC?
- BLOODY DIARRHOEA.
- Faecal urgency.
- Abdominal pain (often left sided).
What are the risk factors for UC?
- Family history of IBD.
- HLA-B27.
- Infection (this can trigger relapse).
SMOKING IS PROTECTIVE.
What are the investigations used for UC?
What is a common cause of acute exacerbation of UC?
- Faecal calprotectin is raised in IBD.
- GOLD STANDARD. Endoscopy + biopsy and look for UC histology.
- C. diff a common cause of an acute exacerbation of UC.
What is the treatment for UC?
Inducing remission:
1st line - Mesalazine (aminosalicylate)
2nd line - naproxen.
Consider going straight to naproxen if UC flare-up severe.
Maintaining remission:
1st line: mesalazine.
2nd line: azathioprine (DMARD).
Consider colectomy if disease severe.
What are the differentials for UC? How are they differentiated?
Crohn’s - Skip lesions, transmural inflammation (histology), “cobblestone bowel”, more likely to extend past the splenic flecture.
IBS - Will have a negative faecal calprotectin, and relief with defecation.
How does PSC relate to UC?
- 70% of PSC patients will have UC.
What is coeliac disease and what are the key features?
- Systemic autoimmune disease triggered by gliadin, a product of gluten metabolism.
Key features:
- Villous atrophy.
- Crypt hyperplasia.
- Increased lymphocytes in the mucosa.
Cause malabsorption.
What is the clinical presentation of coeliac disease?
- Diarrhoea.
- Bloating.
- Abdominal pain/cramping.
- Fatigue.
- Iron deficiency anaemia.
What are the risk factors for coeliac disease?
- FH of coeliac.
- IgA deficiency.
- Type 1 diabetes.
- Down’s syndrome.
- Hashimoto’s thyroiditis.
What are the investigations used for coeliac disease?
Key investigations:
1st line: IgA-tTG - Raised titre in coeliac.
GOLD STANDARD: Duodenal biopsy - Classical histology of coeliac present.
Other options:
- IgA serology. Low.
- EMA. High titre.
Both EMA and IgA are more specific but less sensitive than IgA-tTG is.
What is the management of coeliac disease?
1st line: Gluten free diet + ergocalciferol (vit D) + calcium carbonate.
If iron also low, give iron supplements.
What is the main differential for coeliac disease?
IBD - Has a positive faecal calprotectin.
What are the main complications of coeliac disease?
- Osteoporosis (low calcium).
- Iron-deficiency anaemia.
- Dermatitis herpetiformis (itchy, blistering skin).
What is GORD?
Reflux of gastric contents into the oseophagus.
What is the clinical presentation of GORD?
- Heartburn.
- Regurgitation.
- Often gets worse with lying down/bending over.
What are the alarm symptoms when suspecting GORD? What are the alarm symptoms potentially suggestive of?
- Anaemia
- Haematemesis.
- Blood in faeces.
- Persistent vomiting
- Weight loss
- Progressive dysphagia.
- Oesophageal cancer.
What is the pathophysiology of Barrett’s oesophagus?
- Conversion of stratified squamous epithelium (typical of the oesophagus) to simple columnar epithelium (more typical of the stomach).
What are the investigations for GORD?
- Typically no investigations. Just a trial of PPI (omeprazole).
- If symptoms worrying/atypical, use of endoscopy indicated (Oesophagus, stomach and duodenal imaging).
What is the treatment for GORD?
PPI (omeprazole).
Lifestyle changes:
- Weight loss.
- Stop smoking.
- Tilt up bead head to sleep.
What are the potential differentials for GORD?
- Achalasia. Usually has more prominent, non-specific dysphagia (equal for solids and liquids).
- Oesophageal cancer. Associated with progressive dysphagia.
What is a peptic ulcer? What are the two types of peptic ulcer?
- A break in the mucosal lining of the stomach/duodenum.
- Stomach ulcer = gastric ulcer.
- Duodenal ulcer = duodenal ulcer!
What is the main complication of a peptic ulcer?
- Upper GI bleed.
- If occurs, urgent endoscopy + ED management (potential blood transfusion).
What are the risk factors for peptic ulcers?
- Excessive NSAID use.
- H. Pylori infection.
- Smoking.
- Old age.
What are the investigations used for peptic ulcers?
- Gold standard is endoscopy. This can find the ulcer, and check if it is H. Pylori related. If it is, biopsy can be taken and urea tested.
- Can also do urea breath test/stool antigen test if something less invasive is better.
What is the treatment for peptic ulcers?
IF BLEEDING: urgent endoscopy + blood transfusion + PPI (omeprazole).
IF STABLE:
- Stop NSAIDS if possible
- PPI (omeprazole) 1st line, H2 antagonist (famotidine) 2nd line.
IF CAUSED BY H. PYLORI:
- 7 days of triple therapy (amoxicillin + clarithromycin + omeprazole).
What is the most common type of gastric cancer?
- Gastric adenocarcinoma.
What is the typical presentation of gastric cancer?
- Weight loss.
- Fatigue.
- Persistent abdominal pain.
What is the investigation used for suspected gastric cancer
- Endoscopy + biopsy.
What is the treatment for gastric cancer?
- Resection of the tumour (often laparoscopic).
What are the most common types of oesophageal cancer?
- Adenocarcinoma.
- Squamous cell carcinoma.
What are the key presenting complaints for oesophageal cancer?
- Progressive dysphagia.
- Pain on swallowing.
What is the first line investigation for oesophageal cancer?
- Upper GI endoscopy + biopsy.
What is the treatment for oesophageal cancer?
- Surgical resection of the tumour.
What is the most common type of colorectal cancer?
- Colonic adenocarcinoma.
What is the key red flag symptom for colorectal cancer?
- Blood in stool.
What is the investigation of choice for suspected colorectal cancer?
- Colonoscopy + biopsy.
How is colorectal cancer treated?
- Excision of the tumour.
What is the investigation for intestinal obstruction?
- URGENT CT scan.
What are the main potential causes of intestinal obstruction?
- Hernia
- Surgical adhesions.
- Volvulus (twisting)
- Intussusception (telescoping).
- Bowel cancer.
What are the symptoms of bowel obstruction?
- Intermittent abdominal pain.
- Bowel distension
- Nausea/vomiting
- Absolute constipation.
