Gastrointestinal Flashcards
What are oesophageal varices?
- dilated veins at sites of portosystemic anastomosis
- left gastric and inferior oesophageal veins
Causes of oesophageal varices
pre-hepatic
- portal vein thrombosis
- portal vein obstruction
hepatic
- cirrhosis
- schistosomiasis
post hepatic
- Budd Chiari
- RHS HF
- constructive pericarditis
- compression
Presentation of oesophageal varices
- haematemesis and/or melena
- epigastric discomfort
- sudden collapse → haemodynamic instability
Investigations for oesophageal varices
- urgent endoscopy
- FBC, U&E, clotting (INR) LFTs
- chest xray/ascitic tap
Management of oesophageal varices
- ABCDE
- Rockall score
bleeding varices
- terlipressin
- prophylactic Abs → ciprofloaxcin
- balloon tamponade
- endoscopic banding
- TIPS
bleeding prevention
- beta blocker
- endoscopic banding
- cirrhosis = screening endoscopy
What is a Rockall score?
prediction of rebleeding and mortality
What is a Mallory Weiss tear?
haematemesis from tear in oesophageal mucosa
Risk factors for Mallory Weiss tear
- alcoholism
- hyperemesis gravidarum
- gastroenteritis
- bulimia
- chronic cough
Presentation of Mallory Weiss tear
- haematemesis
- melena
- symptoms of hypovolaemic shock
Investigations for Mallory Weiss tear
- Rockall score
- FBC, U&E, coagulation studies
- ECG, cardiac enzymes
Management of Mallory Weiss tear
most resolve spontaneously
- ABCDE
- terlipressin and urgent endoscopy
- Rockall score
- inpatient observation
- banding/clipping
- adrenaline
- thermocoagulation
What is Boerhaave syndrome?
- oesophageal rupture
Mackler triad
- vomiting
- chest pain
- subcutaneous emphysema
What are the two types of oesophageal cancer?
adenocarcinoma
- more common in developed world
- lower 1/3 → near GO junction
squamous
- more common in developing world
- upper 2/3
Risk factors of adenocarcinoma
- GORD
- Barrett’s oesophagus
- smoking
- achalasia
- obesity
Risk factors for squamous oesophageal cancer
- smoking
- alcohol
- achalasia
- obesity
- low fruit/veg/fibre/vitA,C
- hot drinks
- Plummer-Vinson syndrome
Symptoms of oesophageal cancer
- vomiting
- progressive dysphagia
- anorexia and weight loss
- odynophagia
- hoarseness
- malaena
- cough
Typical presentation of oesophageal cancer
ALARMS
- anaemia
- loss of weight
- anorexia
- recent onset progressive symptoms
- malaena/haematemesis
- swallowing difficulties eg dysphagia
Investigations for oesophageal cancer
- upper GI endoscopy and biopsy
- CT scan/endoscopic US → staging
Management of oesophageal cancer
- operable disease → surgical resection, adjuvant chemo
- palliation
What are the two types of gastric cancer?
- intestinal/differentiated → more common
- diffuse/undifferentiated
Risk factors of intestinal gastric cancer
- male
- h.pylori
- chronic gastritis
- atrophic gastritis
- older age
Features of intestinal gastric cancer
- histology → glandular
- appearance →large, irregular
- locations → antrum, lesser curvature
Risk factors of diffuse gastric cancer
- blood type A
- genetic
- younger age
Features of diffuse gastric cancer
histology
- poorly differentiated
- signet ring cells
appearance
- gastric linitis → submucosa invasion
- no movement on barium swallow = progressed
location = anywhere esp cardia
Red flags for upper GI cancer
upper abdominal mass consistent with stomach cancer and:
- dysphagia of any age
- age 55+ and weight loss with:
upper abdominal pain or
reflux or
dyspepsia
2 week wait for endoscopy
What symptoms qualify for non-urgent endoscopy?
- haematemesis
- treatment resistant dyspepsia
- upper abdominal pain
- anaemia
Presentation of gastric cancer
- often late presentation
- anorexia
- weight loss
- anaemia
- dysphagia
- N&V
- epigastric pain → better with antacids
- paraneoplastic syndromes
- metaplastic signs
Investigations for gastric cancer
- gastroscopy → 8-10 biopsies
- endoscopic US → depth of invasion
- CT/MRI/PET
Management of gastric cancer
- nutritional support → fruit/veg/folate/fibre
- surgical resection
- chemo
Risk factors for colon cancer
- family history
- hereditary conditions → FAP
- IBD
- diet → high fat/red meat, low fibre/folate/Ca2+
- DM
- lifestyle
- history of bowel/endometrial/breast/ovarian cancer
- later first pregnancy/early menopause
Symptoms of colon cancer
depends on location
- pain
- palpable mass
- bleeding
- change in bowel habit
- weight loss
- vomiting
- obstruction
Diagnosis of colon cancer
faecal occult blood test
- >50 and bowel habit change/iron deficient anaemia
- >60 and anaemia
colonoscopy and biopsy
flexible sigmoidoscopy/barium enema/CT colonoscopy
Management of colon cancer
- surgical resection
- depends on site of cancer
- normally anastomosis required
What are the key hereditary causes of colon cancer?
- familial adenomatous polyposis
- hereditary nonpolyposis colorectal cancer
- Lynch syndrome
What are bowel obstructions?
an arrest on the onward propulsion of intestinal contents
What are the types of bowel obstructions?
- small bowel → most common
- large bowel
- psudeo
Causes of SBO
- adhesions → previous abdominal/pelvic surgery or previous abdominal infections
- hernias
- malignancy
- Crohn’s
Clinical presentation of SBO
- pain → initially colicky then diffuse, high in abdomen
- profuse vomiting following pain (earlier than LBO)
- less abdominal distention than LBO
- tenderness = strangulation/risk of perforation
- constipation = late in SBO
- increased bowel sounds → tinkling
Diagnosis of SBO
- abdominal xray → central gas shadows, distended loops, fluid levels
- examination of hernia orifices and rectum
- FBC
GOLD STANDARD = non-contrast CT → locates obstruction
Management of SBO
- aggressive fluid resuscitation
- decompression of bowel
- analgesia and anti-emetics
- Abs
- surgery to remove obstruction → laparotomy
What is involved in decompression of the bowel?
- IV fluids with nasogastric tube
- always try before surgery
Causes of LBO
- malignancy
- volvulus
- diverticulitis
- Crohn’s
- intussusception
What is volvulus?
- rotation/twisting of bowel on mesenteric axis
- commonly in sigmoid colon
What is intussusception
- bowel roles inside of itself
- almost only in neonates/infants → softer bowels
Clinical presentation of LBO
- abdominal pain → more constant and diffuse than SBO, lower abdomen
- more abdominal distention than SBO
- palpable mass eg hernia
- vomiting → later than SBO
- constipation → earlier than SBO
- normal bowel sounds then louder then silent
Diagnosis of LBO
- abdominal xray
- FBC
- digital rectal exam → empty rectum, hard/compacted stools, blood
GOLD STANDARD = CT
What can be seen on an abdominal xray in LBO?
- peripheral gas shadows proximal to blockage
- caecum and ascending colon distended
Management of LBO
same as SBO
What are the two types of diarrhoea?
- acute → <2 weeks
- chronic → >2 weeks
Causes of diarrhoea
viral → majority
- children = rotavirus
- adults = norovirus
bacterial
- campylobacter jejuni
- bloody diarrhoea
- e.coli
- salmonella
- shigella
parasitic
- giardia lamblia
Management of diarrhoea
- treat underlying cause → bacterial = metronidazole
- oral rehydration therapy
- anti-emetics agents eg metoclopramide
- anti-motility agents eg loperamide
self-limiting
