GASTROINTESTINAL Flashcards
What is inflammatory bowel disease
It is inflamed intestines resulting in malabsorption and can present as either crohns disease or ulcerative colitis
Where can crohns disease affect
the whole GIT, from mouth to anus. It especially effects the terminal ileum and the proximal colon
It is non continuous
what HLA type predisposes to IBD
HLA B27 - specifically UC
What are risk factors for developing crohns disease
increased risk with family history
increased risk of you’re jewish
smoking (2X more likely)
NSAIDs
chronic stress
depression
What layers of the intestine does Crohns inflammation affect
Transmural - affects all 4 layers
what are the symptoms of Crohns?
Pain in the right lower quadrant
changes in bowel habit
malabsorption
extraintestinal
what malabsorption conditions can you get with crohns
- B12
- folate
- iron disorders
- gall stones and kidney stones
- watery diarrhoea (no water absorption)
what extraintestinal symptoms can you get with crohns
Aphthous mouth ulcers
uveitis
episceritis
eythema nodosum - rash
pyodema gangrenosum
ankylosing spondylitis
how do you diagnose crohns
pANCA negative (could be positive) - antineutrophil antibodies
Fecal calprotectin positive
Biopsy and endoscopy
Endoscopy
- skip lesions
- cobble stoning
- could have strictures “string sign”
Biopsy
- transmural inflammation with non caseating granulomas
What is the treatment for crohns
- for flares = sulfasalazine and prednisolone
- for remission = azathioprine and methotrexate
- Biologics = Infliximab (anti TNFa) and Usterkenumab (anti IL12 and 23)
- Surgery - not curative
what are complications of crohns
Fistula
Strictures
Abscesses
Small bowel obstructions
where is ulcerative colitis found in the GIT
Only in the colon - starts at the rectum and then moves up to the sigmoid and then proximal colon
is smoking damaging or beneficial in ulcerative colitis
it is protective
What layers of the GIT are affected by UC inflammation
only the mucosa
WHat are the symptoms of ulcerative collitis
pain in left lower quadrant
tenesmus (rectal defecation pain)
bloody mucusy watery diarrhoea
Extraintestinal
What are the extraintestinal symptoms of ulcerative colitis
Uveitis
Episceritis
Pyoderma gangrenosum
Erythema nodosum
Spondylarthopathy - spine ache
primary sclerosing cholangitis
how do you diagnose ulcerative colitis
pANCA positive
Increase in fecal calprotectin
Inflammation seen - CRP/ESR and WCC increase
Malabsorption of iron, Vit B, folate
biopsy - mucosal inflammation with crypt hyperplasia
Colonoscopy - continuous leadpipe sign
How do you determine the severity of ulcerative colitis flares
The TRUELOVE and WITTS score
- mild
- moderate
- severe
what is the treatment for ulcerative colitis
- Flares = Sulfasalazine and prednisolone
- Remission = azathioprine, methotrexate, cyclosporin
- Biologics = Infliximab
- Surgery = total or partial colectomy = curative
what are complications of ulcerative colitis
Toxic megacolon
what is the mode of action of infliximab
it is a monoclonal antibody against TNF-a (pro-inflammatory cytokine)
what is coeliac disease
It is an autoimmune T4 hypersensitivity to gluten
What HLA subtype gives a predisposition to coeliac disease
HLA DQ2 and 8
what is the pathophysiology behind coeliacs disease
The prolamins in gluten (alpha gluten) binds to IgA and interacts with tTG (tissue transglutaminase) which is immunogenic. It results in the formation of increased IgA anti-tTG and endomysial antibodies. This causes destruction of the villi in the gut, causing a villous atrophy, crypt hyperplasia and intraepithelial lymphocytes
what are the symptoms of coeliac disease
Malabsorption - deficiency in Fe, B12 and folate leading to anaemia
Steatorrhea
diarrhoea
Weight loss
failure to thrive
Dermatitis herpetiformis - rash on the knees due to IgA deposition
what other autoimmune conditions is coeliac disorder associated with
With thyroid disorders and addisons disease
Diabetes
Dermatitis herpetiformis
how do you diagnose coeliac disease
Serology (screening) = anti tTG, total IgA
Gold standard = Duodenal biopsy following gluten tolerance test
what is seen in a biopsy of someone with coeliac disease
Crypt hyperplasia
Villous atrophy
epithelial lymphocyte infiltration
how do you treat coeliac disease
STOP EATING GLUTEN
monitor osteoporosis using DEXA scans
What is tropical sprue
it is an enteropathy associated with tropical travel. It produces similar biopsy to coeliac disease
- treated with antibiotics such as tetracycline
what are differential diagnosis of coeliac disease
Bile acid malabsorption
gastroenteritis
Lactose intolerance
IBD
what is the gluten challenge
something that looks at if the patient is actually coeliac - must eat gluten for 6 weeks at 10g/.d and then you look at the villi to ensure they have atrophied
what are the risks of not going gluten free when you are coeliac
Osteoperosis
malnutrition
small risk of cancer
What is IBS
it is a functional chronic bowel disorder - related to psychology
how do you diagnose IBS
Exclusion - 3+ month of GI symptoms with no underlying causes
Exclude coeliac, IBD and infections using serology, fecal calprotectin, ESR, CRP, blood cultures
what are the different types of IBS
IBS-c = constipation
IBS -d = diarrhoea
IBS -m = Mixed
what is the treatment for IBS
- Conservative = patient education and reassurance: FODMAP diet avoid caffeine and alcohol
- Moderate = Laxatives (sennal) or antimotility drugs (loperamide), increase fluid intake
- Severe = TCA (amitriptyline) and consider CBT or GI referral
what is GORD
Gastric reflux into the oesophagus due to reduced pressure across the lower oesophageal sphincter.
What are the causes of GORD
Increased intraabdominal pressure due to obesity and pregnancy
Hiatal hernias - sliding and rolling
Drugs: antimuscarinics
scleroderma
What is the pathophysiology of GORD
low lower oesphageal pressure increases the change of reflux.
What are the symptoms of GORD
Heartburn - retrosternal burning chest pain
Chronic cough
Nocturnal asthma
Dysphagia
How do you diagnose GORD
If there are no red flags go straight to treating
If there are red flags such as dysphagia, haematemesis or weight loss then you have to do an endoscopy and oesopageal manometry
What do you look for with an endoscopy in GORD
oesophagitis or barrets oesophagus
What does an oesophageal manometry look at
it measures the lower oesophageal sphincter pressure
it monitors the gastric acid pH
what is the treatment for GORD
conservative lifestyle - change eating habits
PPIs (or HaRA if CI)
Antacids
Alginates - Gaviscon
As a last resort you can surgically tighten the LOS
what are complications of GORD
You can get progressive worsening leading to barrets metaplasia thus increasing the risk of adenocarcinoma
what is a Mallory Weiss tear
a lower oesophageal mucosal tear due to a sudden increase in intraabdominal pressure
what is the typical presentation of a Mallory Weiss tear
Due to an acute history of retching causing haematemesis
what are risk factors for a Malory Weiss tear
Alcohol, chronic cough, bulimia, hyperemesis grandaum (pregnancy complication of severe nausea and vomiting)
what are the symptoms of mallory weiss tear
HAEMATEMESIS = after retching or vomiting history
they may be hypotensive if severe
How do you diagnose a mallory weiss tear
OGR (endoscopy) to confirm
use the Rockall score to test for the severity
how do you treat a Mallory Weiss tear
most will spontaneously heal within 24 hours
An endoscope may be used to give you an injection or a heat treatment to stop the bleeding, or insert a clip that closes the tear and stops the bleeding.
what is an ulcer
punched out round holes in either the stomach or the duodenum
where are gastric ulcers more common
at the lesser curve of the stomach
what are causes of gastric ulcers
H.pylori
NSAIDs
Zollinger Ellison syndrome
what is Zollinger Ellison syndrome
A gastrin secreting tumour
- pancreatic tumour
- gastric acid hypersecretion
- widespread peptic ulcers
what are symptoms of gastric ulcers
epigastric pain worse on eating
better between means and with antacids
typically weight loss
Dyspepsia
how do you diagnose gastric ulcers if there are no red flags
Non invasive tests
- C-urea breath test
- stool antigen test
What are the red flags with gastric ulcers
over 55
haematemesis
melaena
anaemia
dysphagia
how do you diagnose gastric ulcers if there are red flags
an urgent endoscopy
an urgent biopsy
what is the treatment for gastric ulcers
- Stop NSAIDs
- If H. pylori positive then triple therapy (clarithromycin, amoxicillin and PPI)
What is the complication of gastric ulcers
Bleeding if ruptured
what is more common, gastric or duodenal ulcers
Duodenal
Where are duodenal ulcers mostly found
D1/D2 posterior wall
what are causes for duodenal ulcers
H.Pylori
NSAIDS
ZE syndrome
what is the most common cause for duodenal ulcers
H.Pylori
What are symptoms of duodenal ulcers
Epigastric pain - worse between meals and better with food
typically see weight gain
how do you diagnose duodenal ulcers if there are no red flags
Non invasive testing
- Urea breath tests
- Stool antigen tests
How do you diagnose duodenal ulcers if there are red flags
Urgent endoscopy and biopsy
- will see brunners gland hypertrophy and more mucus production
what is the complication for duodenal ulcers
Bleeding
how do you treat duodenal ulcers
STOP NSAIDS
if H.Pylori positive then put them on tripple therapy - CAP
what is given in place of amoxicillin in H’Pylori treatment if someone has a penicillin allergy
Metronidazole
what is gastritis
It is mucosal inflammation and injury in the stomach
what causes gastritis
Autoimmune problems - Pernicious anaemia and anti-IF antibodies
H.Pylori
NSAIDs - causes injury without inflammation
Mucosal ischemia
campylobacter
what are symptoms of gastritis
Epigastric pain with diarrhoea
nausea and vomiting
indigestion
anorexia
dyspepsia
How do you diagnose gastritis
If H/Pylori is suspected then you do a stool antigen test or a urea breath test
Gold standard is an endoscopy and a biopsy
How do you treat gastritis caused by H.Pylori
Triple therapy - CAP
clarithromycin
Amoxicillin
PPIs
does H.Pylori usually cause diarrhoea
no
how does H.Pylori damage the stomach
- decreases somatostatin
- Decreases luminal HCO3-
- Secretes urease which converts urea to CO2 and NH3. NH3 combined with H+ in the stomach produces NH4 which is TOXIC
- increases gastrin release
what is appendicitis
An inflamed appendix, usually due to a lumen obstruction
often a surgical emergency
what are causes of appendicitis
Faecolith - hard solidified faeces
lymphoid hyperplasia
filarial worms
what is the pathophysiology of appendicitis
There is a blockage in the appendix which is typically infected with E.Coli. This increases the pressure inside the appendix and increases its rupture risk, as well as inflaming it
what are the symptoms of appendicitis
umbilical pain which localises to McBurneys point - rebound tenderness and abdominal guarding
Rovsing - the pain felt in the right lower abdomen upon palpation of the left side of the abdomen
Obturator pain - internal rotation of thigh pain
PSOAS - lying on side and extending the right leg causes pain
what are complications of appendicitis
Rupture
periappendical abcess
how do you diagnose appendicitis
CT abdomen and pelvis = gold standard
pregnancy test to rule out ectopic pregnancy in women
how do you treat appendicitis
antibiotics and then an appendectomy (laparoscopic)
what is an abscess
Walled off bacterial collection - need to drain in order for antibiotics to reach the bacteria
what is diverticular disease
outpouching of colonic mucosa
what is diverticulum
is an outpouching of a hollow (or a fluid-filled) structure in the body
what is diverticulosis
an asymptomatic outpouching
what is diverticular disease
a symptomatic outpouch
what is diverticulitis
inflammation of an outpouch: infection
what is meckel’s diverticulum
it is a pediatric disorder due to failure of obliteration of the vitelline duct (an embryonic structure providing communication from the yolk sac to the midgut during fetal development)
what rule is important to remember in meckel’s diverticulum
the rule of 2s
2yr old
2 inches long
2ft from iliocoecal valve (umbilical)
how do you diagnose meckel’s diverticulum
using a technitium scan
what are risk factors for diverticular disease
Aging
Genetic factors
increased colon pressure
COPD
chronic cough
High fat diet
Obesity
smoking
NSAIDS
immunosuppression
what are the symptoms of diverticular disease
- lower left quadrant pain
- Constipation
- fresh rectal bleeding
- bloating
how do you diagnose diverticular disease
Examination - tenderness and guarding
distended and tympanic to percussion
bowel sounds diminished
CT abdomen and pelvis = gold standard
- done with contrast
How do you treat diverticular disease
DiverticuLOSIS = watch and wait
DiverticuLAR disease = bulk forming laxatives, surgery is gold standard
DiverticuLITIS= antibiotics (co-amoxiclav) and paracetamol, IV fluids, and liquid food, rarely surgery
what are complications of diverticular disease
Rupture
obstruction
fistula
infection causing abscess
haemorrhage
peritonitis
what are causes of small bowel obstruction
Adhesions (often surgical)
Crohns
Strangulating hernias
Malignancy
What are symptoms of small bowel obstruction
first vomiting
then constipation
mild abdominal distension and pain
tinkling bowel sounds
hyper-resenant bowels on percussion in both SBO and LBO
what are causes of large bowel obstruction
Malignancy (90%)
volvulus - when a loop of intestine twists around itself and the mesentery that supplies it
Intisseption - bowel telescopes in on itself (mc in children)
what are symptoms of large bowel obstruction
First constipation
then vomiting
gross distension and pain
hyperactive, then normal and then absent bowel sounds
how do you diagnose obstructive bowel disease (small and large)
- X-ray = look at dilated bowel loops and transluminal fluid- gas shadows
- Gold standard is CT the abdomen
what is a pseudo obstruction of the bowel
no mechanical obstruction, it is often as a result of a post operative state
how do you treat bowel obstruction
Fluid resus
NG tube
antiemetics and analgesia
antibiotics as stasis increases infection risk
surgery as a last resort
what is diarrhoea
3+ days of watery stools daily
what levels on the bristol stool chart is diarrhoea
5-7
how long does acute diarrhoea last for
less than 14 days
how long does subacute diarrhoea last for
14-28 days
how long does chronic diarrhoea last for
over 28 days
what are the different types of diarrhoea
watery
secretory
osmotic
functional
steatorrhoea - fat in stool
inflammatory
what are causes of diarrhoea
IBD
coeliac disease
hyperthyroidism
inflammation or malignancy
infection
worms
antibiotics
parasites
what are the viral causes of diarrhoea
rotavirus - more common in children
norovirus - more common in adults
Travellers diarrhoea
what are bacterial causes of diarrhoea
C.diff
campylobacter - MOST COMMON
E. Coli
salmonella
shigella
cholera
why can antibiotics cause diarrhoea
Because they increase the risk of C.diff infection
what antibiotics can cause diarrhoea
Clarithromycin
co-amoxiclav
ciprofloxacin
cephalosporins
what parasites can cause diarrhoea
amoeba
how do you treat diarrhoea
very dependent on the cause
- rehydrate
- replace electrolytes lost
what do you need to be wary about in diarrhoea
dehydration and electrolyte loss
what are the two types of oesophageal cancer
Adenocarcinoma
squamous cell carcinoma
where is oesophageal adenocarcinoma normally found
in the lower 2/3 of the oesophagus
what is oesophageal adenocarcinoma associated with
Barrett’s oesophagus
where is oesophageal squamous cell carcinoma found
in the upper 2/3 of the oesophagus
what is oesophageal squamous cell carcinoma associated with
smoking and alcohol
what are the symptoms of oesophageal cancers
ALARMS
anaemia
Loss of weight
Anorexic
Recent sudden worstening symptoms
Melenea or haematemesis
Swallowing with progressive difficulty
how do you diagnose oesophageal cancer
Oesophagogastro duodenoscopy and biopsy with a barrium swallow
CT or PET for staging
what is the treatment for oesophageal cancer
If they are medically fit then undergo chemotherapy or radiotherapy and surgery
if they are unfit then it is palliative care
what is the main type of gastric carcinoma
mostly adenocarcinoma
what are the stages of gastric adenocarcinoma
T1 = well differentiated
T2 = undifferentiated “signet ring carcinoma” - worse
where are gastric adenocarcinomas mostly found
in the proximal stomach
what are causes of gastric adenocarcinoma
H. Pylori
smoking
CDH-1 mutation - mutated cadherin gene
Pernicious anaemia (autoimmune chronic gastritis)
what are the symptoms of gastric carcinomas
severe epigastric pain
anaemia - due to Fe deficiency
weight loss
progressive dysphasia
tired all the time
what are signs of mets in gastric carcinoma
jaundice - liver mets
Krukenburg tumour - ovarian mets from gastric cancer
how do you diagnose gastric carcinomas
gastroscopy and biopsy
CT and MRI for staging
PET to ID the mets
What is the TNM staging of cancer
T describes the size of the tumor and any spread of cancer into nearby tissue; N describes spread of cancer to nearby lymph nodes; and M describes metastasis (spread of cancer to other parts of the body).
how do you treat gastric carcinoma
surgery and ECF chemo regiments if the cancer is resectable
what is the most common SI carconoma
adenoma
is it common to get SI carcinomas
no the SI is pretty tumour resistant and there is a low change of tumour here (less than 1% of all GI tumours)
what are risk factors for developing an SI carcinoma
chronic SI disease such as crohns or coeliac disease
how do you diagnose SI carcinomas
Gastroscopy and biopsy
Use CT and MRI for staging
PET to ID any mets
how do you treat SI carcinomas
Surgery and ECF chemotherapy regimens
- if the cancer is resectable
what is the most common colorectal cancer
adenocarcinomas
what is the precursor to colorectal cancer
Polyps = mostly spontaneous and benign. They are common with age but can progress onto cancer
What two inherited conditions can increase the risk of polyps
- Familial adenomatous polyposis - FAP
- Hereditary non polyposis colon cancer - HNPC lynch syndrome
What is familial adenomatous polyposis
it is an autonomic dominant APC gene mutation which causes a high change of developing duodenal polyps. There patients have a 93% risk of developing colorectal cancer by 50
what is Hereditary non polyposis colon cancer
It is an autosomal dominant MSH-1 mutation (or MSH2) causing a DNA mismatch repair gene. This rapidly increases the progression of an adenoma to an adenocarcinoma
what are risk factors for developing colorectal cancer
familial inherited predispositions
adenomas or polyps
alcohol
smoking
ulcerative colitis
what are common colorectal cancer mets
to the liver and the lungs
what are the symptoms of colorectal cancer
symptoms occur mostly in the distal colon (sigmoid region)
- left lower quadrant pain
- bloody mucous stools - fresh blood = closer to anus
- tenesmus if there is rectal involvement - feel like you need to go
how do you diagnose colorectal cancer
FIT test (fecal occult) - screening test for micro blood particles in the poo, done in all 60+ with Fe deficient anaemia and bowel changes
Gold standard is colonoscopy and biopsy
how do you classify colorectal cancers
using the TNM system
how do you treat colorectal cancer
Surgery is the only curative option if no mets
chemotherapy
what s dyspepsia
it is not a disease it is the persisting symptom of indigestion
what can cause dyspepsia
often the cause is unknown
- functional disorder
it may be related to ulcers, particularly gastric
what are the symptoms of dyspepsia
early satiation
epigastric pain and reflux
extreme fullness
how do you diagnose and treat dyspepsia
you can perform an endoscopy to see if there is an underlying cause
can give PPIs to reduce stomach acid
what type of bacteria is H.Pylori
it is a gram negative bacteria
it is a low virulence commensal in the CIT
what is the pathology of helicobacter pylori
it reduces somatostatin release
it increases intraluminal gastric acid via increased gastrin
it produces urease which results in ammonia generation
it causes decreased bicarbonate secretion
What can helicobacter pylori cause
peptic ulcer disease
gastritis
gastric carcinomas
how di you diagnose helicobacter pylori
biopsy
- stool antigen and C-urea breath test
how do you treat H.Pylori
Triple therapy
clarithromycin
amoxicillin
PPI
What type of bacteria is E.coli
a gram -Ve often commensal flora of the GIT
What types of E.Coli cause watery diarrhoea
ETEC
EAEC
EPEC
what kinds of E.Coli cause bloody diarrhoea
EHEC (haemorrhagic)
what can Escherichia coli serotype O157:H7 cause
haemolytic uremic syndrome
- haemorrhagic diarrhoea plus nephritic syndrome
what is the treatment for E.Coli infection
Often amoxicillin, artrimethorpim or nitrofurantoin
what type of bacteria is C.difficile
it is a gram POSITIVE spore forming bacteria
what is C.Difficile infection mainly induced with
Certain antibiotics
- Ciprofloxacin
- Co-amoxiclav
- cephalosporins
- Clindamycin
what does C.Difficile infection cause
Pseudomembranous colitis
what is the pathophysiology of Pseudomembranous colitis
the normal gut flora is killed off with C’s antibiotics and C.Difficile replaces these
this results in a dangerous severe diarrhoea which is very watery and causes high levels of dehydration
- this is highly infectious
what is the treatment for C.Diff infection
STOP C’S ANTIBIOTICS
give vancomycin !!!
what is achalasia
Achalasia is a rare disorder in which your esophagus is unable to move food and liquids down into your stomach due to oesophageal dysmotility (impaired peristalsis)
what causes achalasia
the lower oesophageal sphincter fails to relax and there is impaired peristalsis. they suspect it may be caused by a loss of nerve cells in the esophagus. There are theories about what causes this, but viral infection or autoimmune responses have been suspected
what are symptoms of achalasia
NON PROGRESSIVE dysphagia = you struggle to swallow anything and there is a chesty substernal pain
can also experience food regurgitation and aspiration pneumonia
how do you diagnose achalasia
“bird beak” on the barrium swallow
Manometry (measure the pressure across the lower oesophageal shpincter) diagnostic
how do you treat achalasia
only surgery is curative - balloon stenting is performed
Nitrates and nifedipine may help pre-surgery
what is ischemic colitis
ischemia of the colonic arterial supply leading to colonic inflammation due to hypoperfusion
what are causes of ischemic colitis
Affecting the inferior mesenteric artery: thrombus (+/- atherogenesis), Emboli, reduced cardiac output and arrhythmias, shock
what are the most common sites affected in ischemic colitis
Water shed areas
- splenic flexure MC
- sigmoid colon and cecum
what are symptoms of ischemic colitis
left lower quadrant pain
Bright bloody stool
increased signs of hypovolemic shock
how do you diagnose ischemic colitis
colonoscopy and biopsy are the gold standard but only once the patient has recovered as they can prevent stricture formation and normal healing
rule out other causes such as stool sample for H.pylori
what are complications of ischemic bowel disease
Perforation
strictures causing obstruction
how do you treat ischemic colitis
symptomatic - IV fluid and antibiotics (prophylactic)
Gangrenous (infected colon) - only surgery can cure
what is mesenteric ischemia
ischemia of the small intestine
what is acute mesenteric ischemia
an acute attack such as an abdominal MI caused by a blood clot in the mesenteric artery
what is chronic mesenteric ischemia
ischemia that is longer lasting, lasts for months and is termed abdo-angina. Caused by a build up of plaque in the mesenteric arteries
what are causes of mesenteric ischemia
affecting the superior mesenteric artery:
thrombus (MC)
Emboli often due to AF
what are the symptoms of mesenteric ischemia
triad
1. central/RIF acute severe abdominal pain
2. NO abdominal signs on exam (e.g guarding or rebound)
3. Rapid hypovolemic shock
How do you diagnose mesenteric ischemia
CT angiogram
FBC and ABG to look for persistent metabolic acidosis
how do you treat mesenteric shock
Fluid resus
antibiotics
IV heparin (reduce the chance of thromboemboli)
If the bowel is infarcted then surgery is required
what are haemorrhoids (piles)
swollen veins around the anus which disrupt the anal cushions
- parts of the anal cushions prolapse through the tight anal passage
what is the most common cause of haemorrhoids
constipation with increased straining
anal sex
what are the two types of haemorrhoids
internal - above the internal rectal plexus
external - below the dentate line
what type of haemorroid is more painful
External haemorrhoids
why are internal haemorrhoids less painful
as they have a reduced sensory supply
patients may feel incomplete emptying
what are symptoms of haemorrhoids
Bright red fresh PR bleeding and mucusy bloody stool
bulging pain
puritis ani - itchy bum
how do you diagnose haemorrhoids
PR exam (digital) for external (may be visible)
Proctoscopy required for internal haemorrhoids
how do you treat haemorrhoids
stool softener
rubber band ligation - definitive
what is a perianal abscess
a walled off collection of stool and bacteria around the anus
what is the main cause of perianal abscess
anal sex causing anal gland infection
what are symptoms of a perianal abscess
pus in stool
constant pain - tender
how do you treat a perianal abscess
surgical removal
drainage - because its walled off of its not drained its resistant to antibiotic therapy
what is an anal fistula
an abnormal track formed between the inside of the anus and elsewhere such as the subcutaneous skin
what does an anal fistula typically progress from
typically progresses from a perianal abscess - abscess discharges toxic substances which aids in the fistula formation as the abscess grows
what conditions are anal fistulas seen in
crohns
rectal cancer
progression from anal abscess
what are the symptoms of an anal fistula
bloody mucusy discharge
often very visible and painful
what is the treatment for anal fistula
surgical removal and drainage (with antibiotics if it is infected)
what is an anal fissure
a tear in the anal skin lining below the dentate line
what are the main causes of an anal fissure
hard faeces
also trauma such as childbirth
crohns
ulcerative colitis
what are the symptoms of anal fissure
extreme defecation pain
very itchy bum (pruritis ani)
anal bleeding
what is the treatment for anal fissure
stool softening and increase in fiber and fluids
topical creams such as lidocaine ointment
definitive cure is surgery
what is pilonidal sinus/abscess
where hair follicles get stuck in the natal cleft which can form small tracts (sinus) or get infected (abscess)
what are symptoms of Pilonidal sinus/abscess
swollen pus filled smelly abscess in bumcrack
- visible on exam
how do you treat pilonidal sinus/abscess
surgery and hygiene advice
what is Zenker’s diverticulum (pharyngeal pouch)
Zenker’s diverticulum is a rare, benign condition. In this condition, a large sac develops in the upper part of the oesophagus (gullet/food pipe), known medically as a pharyngeal pouch.
why does Zenker’s diverticulum develop
This results because of muscle spasm in at the beginning of gullet
what are the symptoms of Zenkers diverticulum
smelly breath - food accumulating in oesophagus
regurgitation and aspiration of food
what kind of colitis can CMV cause
owl eye colitis in immunosuppressed patients
- its an aids defining illness
what are the 9 regions of the abdomen
Right hypochondriac
Right lumbar
Right iliac
Epigastric region
umbilical region
hypogastric region
Left hypochondriac
Left lumbar
Left iliac
what are signs of an upper GI bleed
haematemesis (vomiting fresh red blood)
‘digested’ blood - melena (black stools)
what is signs of lower GI bleed
Haematochezia (fresh red blood in stools)
what are red flag signs for GI disorders
anaemia
loss of weight
anorexia
recent onset of progressive symptoms
masses or melena (black stool)
Swallowing difficulties
and being over 55
what conditions can cause haematemesis
mallory weiss tear
oesophageal varices
oesophageal cancer
what conditions can cause swallowing difficulties
achalasia
oesophageal cancer
Zenker’s diverticulum
Systemic sclerosis
strictures
what oesophageal disease can cause pain
Mallory weiss tear
Oesophageal varices
GORD
what are signs and symptoms of Mallory Weiss tear
Haematemesis
Melena
Systemic signs
- postural hypotension
- dizziness
what should be done to look at a Mallory Weiss tear
an endoscopy
what are oesophageal varices
these are enlarged veins that protrude into the oesophagus
what can produce oesophageal varices
hypertension in the portal venous system due to underlying liver issues
what happens when oesophageal varices rupture
It causes a large amount of bleeding
What are signs and symptoms of oesophageal varices rupture
Haematemesis
abdominal pain
systemic
- shock
- hypotension
- pallor
how do you treat a ruptured oesophageal varices
if there is an acute bleed ABCDE
- vasopressin for vasoconstriction
- bleeding abnormality: vitamin K
- then surgery: endoscopic band ligation within 24 hours
how do you treat oesophageal varices that havent ruptured
beta blockers
eondoscopic variceal band ligation
how do you diagnose oesophageal varices
upper endoscopy
graded based on size and risk of bleeding
what can cause oesophageal strictures
scarring of the oesophagus leading to narrowing, caused by anything that can cause inflammation and scarring such as GORD
what is systemic sclerosis
where muscles no longer work correctly leading to swallowing difficulties
what causes Achlasia
degeneration of ganglions in Auerbach’s or mesenteric plexus in the muscularis externa
what is the pathophysiology of achalasia
due to degeneration of nerves, the lower oesophageal sphincter cant relax causing an obstruction. The patient can therefore is unable to swallow liquids or solids
how do you treat achalasia
- lifestyle: smaller but more frequent meals
- Nitrates or CCB to relax the LOS
- Botox to relax the LOS
- surgery: cardiomyotomy but this could lead to GORD
what are risk factors for developing GORD
obesity
pregnancy
hiatus hernia
smoking
NSAIDs
caffeine
alcohol
male
what are the signs and symptoms of GORD
heart burn
regurgitation
epigastric pain
dysphagia
dyspepsia
extra-oesophageal: cough, asthma, dental erosion
when in GORD do people get a two weeks endoscopy referral
When they have dysphagia
over 55 with weight loss and 1 of the following
1. upper abdominal pain
2. reflux
3. dyspepsia
how do you clinically diagnose GORD
FBC to look for anaemia
24 hour pH monitoring
Upper GI endoscopy
Manometry
how do you manage GORD
Conservative - stop smoking, reduce alcohol intake, lose weight, eat smaller meals, avoid eating too close to bed
medication - over the counter (gaviscon), PPIs, H2 receptor agonist (ranitidine)
what is barrets oesophagus
it is metaplasia of stratified squamous to simple columnar epithelium and is often a complication of GORD
what causes acute gastritis
H.Pylori
alcohol abuse
stress
NSAIDs
What causes chronic gastritis
H.Pylori
autoimmune gastritis - parietal cell antibodies and IF antibodies causing a reduction in B12 absorption and pernicious anaemia
how do you treat gastritis not caused by H.Pylori
stop the NSAIDs/alcohol
in autoimmune you have to give IM vitamin B12
what must you stop before testing for gastritis
must stop PPIs for at least 2 weeks and antibiotics for 4 weeks
what artery is a gastric ulcer most likely to perforate
gastroduodenal artery
what artery is a duodenal ulcer most likey to perforate
left gastric artery
what is the epidemiology of IBS
1 in 5 in the uk have it
more common in females
peaks between 20-30
what are the signs and symptoms of IBS
ABC
abdominal pain
bloating
change in bowel habits
what are differentials of IBS
IBD
coeliac disease
lactose intolerance
food allergies
GI infection
what are FODMAPs
Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols (FODMAPS) are short-chain carbohydrates that are poorly absorbed in the GIT
- those with IBS told to avoid
what is the roman IV criteria for diagnosing IBS
Recurrent abdo pain at least 1 day/week for the past 3 months, and symptoms began at least 6 months ago plus ≥2 of:
Relieved by defecation
Change in bowel appearance
Change in bowel frequency
what is the pathophysiology of ulcerative colitis
Autoimmune condition, causing excessive inflammation of mucosa in large bowel → submucosal ulcers + pseudopolyps → perforation + bleeding
Inflammation starts from rectum
Continuous inflammation
stops at ileum
how do you treat mild ulcerative colitis
Amniosalicylate aka 5-ASA (mesalazine)
+ steroid (prednisolone)
how do you treat moderate to severe ulcerative colitis
Fluid resus (if necessary)
IV steroid (hydrocortisone)
+ TNF-α inhibitor (infliximab)
Surgery: Colectomy = GOLD
what is given in ulcerative colitis to maintain remission
Azathioprine
what is the pathophysiology of crohns
Faulty GI epithelium causes pathogens to get into the wall
Exaggerated inflammatory response and formation of granuloma + destruction of GI tissues
Transmural ulcers → perforation
+ skip lesions in between ulcers
+ fissures (cracks) in the lining
= Cobblestone appearance
Inflammation also causes: perianal abscesses, mouth ulcers
When the wall is healing
Fistulas (abnormal open connections between two body parts), eg. anal fistulas
Adhesions (scar-like tissue formed between two body parts, causing them to stick together)
when would you suspect tropical sprue
when a patient is from a tropical country and they have chronic GI and malabsorptive symptoms
what are signs and symptoms of tropical sprue
Diarrhoea
steatorrhoea
weight loss
abdominal pain
fatigue
dehydration
malabsorptive: vitamin or iron deficiency
what is the gold standard for diagnosis of tropical sprue
Jejunal tissue biopsy
how do you treat tropical sprue
drink treated water and tetracycline for 6 months
what are signs and symptoms of chronic mesenteric ischemia
central colickly abdominal pain after eating
weight loss
abdominal bruit (due to turbulent blood flow)
how do you manage chronic mesenteric ischemia
lifestyle
secondary prevention
surgery
what is risk factors for acute mesenteric ischemia
Atrial fibrillation
why is acute mesenteric ischemia a medical emergency
Because the blockage in the artery/vein can cause ischemia, rapid necrosis, perforation and sepsis
what investigations are done for acute mesenteric ischemia
Bloods - metabolic acidosis
1st line = CT contrast and angiography
GOLD = colonoscopy
how do you treat acute mesenteric ischemia
antibiotics
anticoagulants (heparin)
surgery
what are the signs of acute mesenteric ischemia
Severe central colicky pain
abdominal bruit
rapid hypovolemia - shock
nausea and vomiting
melena
increased abdominal distension
what is ischaemic colitis
when blood flow to part of the large intestine is temporarily reduced - splenic flexure is the most common site
what is the most common ischemic bowel disease
ischaemic colitis
what are risk factors of pseudomembranous colitis
recent antibiotic use
staying in hospital or nursing home
older age
IBD
use of PPIs
Immunocompromised
what investigations are done for pseudomembranous colitis
blood tests - raised WBB
stool sample - C.diff
abdominal X ray
CT abdomen
colonoscopy
histology
how do you manage pseudomembranous colitis
- stop causative agent
- start another antibiotic effective against C.diff (vancomycin)
- hydration and electrolyte replacement
- hand hygiene and private room for infection control
what is the definition of bowel obstruction
the interruption of passage through the bowel - can be a surgical emergency
what are signs and symptoms of a bowel obstruction
abdominal pain
abdominal distension
vomiting
absolute constipation
what investigations are done for bowel obstruction
1st line: abdominal X-ray
dilation of small bowel >3cm
dilation of large bowel >6cm
GOLD: CT of abdomen and pelvis with contrast
how do you manage bowel obstruction
drip and suck management
surgical treatment (lapatotomy or resection)
what are reasons for small bowel obstruction
adhesions from surgery
hernia
crohns
malignancy
what are signs and symptoms of small bowel obstruction
colicky pain higher up
abdominal distension
vomiting first followed by constipation
tinkling bowel sounds
what is the drip and suck management of bowel obstruction
Insert IV cannula and resuscitate with IV fluids
Nil-by-mouth (NBM)
Insert nasogastric tube to decompress the stomach
catheter
analgesia
antiemetics
antibiotics
how do you treat SBO
in stable patients
A-E assessment and drip and suck
in unstable patients - surgery
what are reasons for a large bowel obstruction
malignancy
sigmoid volvulus
diverticulitis
intussusception - when the bowel folds in on itself
what are signs and symptoms of LBO
continuous abdominal pain
severe abdominal distension
constipation first followed by vomiting
absent bowel sounds
how do you treat LBO
in stable patients
A-E assessment and drip and suck
in unstable patients
surgery
what is a pseudo-obstruction
it is colonic dilation in the absence of a mechanical obstruction
what is the pathophysiology of pseudo-obstruction
Parasympathetic nerve dysfunction causes absent smooth muscle movement
Complication: bowel ischaemia and perforation
how do you investigate pseudo-obstruction
1st line: Abdo XRay (megacolon → dilation >10cm )
Gold standard: CT of the abdomen and pelvis with contrast (no transition zone)
what can cause pseudo-obstruction
Post-operative (paralytic ileus)
Medications (opioid, calcium channel blockers, antidepressants)
Neurological (Parkinson’s, multiple sclerosis, Hirschsprung’s)
Electrolyte imbalance
Recent trauma/surgery
how do you manage pseudo-obstruction
‘Drip and suck’ management
IV neostigmine
Surgical decompression for unstable patients (caecostomy, ileostomy)
what is Hirschsprung disease
a congenital condition in which nerve cells are missing in the large intestine (myenteric plexus) resulting in faeces getting stuck
what is the pathophysiology of diverticular disease
high pressures in the colon causes week walls and formation of a diverticula. If foecal matter or bacteria gathers in this then it can become inflamed. This plus rupture of vessels causes diverticulitis
what is pathophysiology of acute appendicitis
obstruction in the lumen of the appendix causing stasis. Bacterial overgrowth and inflammation
what is seen on examination for acute appendicitis
McBurney’s sign
Psoas sign
obturator sign
guarding
rebound tenderness
what are differential diagnosis for acute appendicitis
Ectopic pregnancy
ovarian torsion
ruptured ovarian cyst
IBD
diverticulitis
Meckel’s diverticulum
Kidney stones
UTI
testicular torsion
what are the symptoms of travellers diarrhoea
fever
nausea
vomiting
cramps
tenderness
bloody stools
what colour is salmonella enterica on XLD
pink with black centre
what colour is shigella on XLD
pink on XLD
what is camplylobacter normally found in
undercooked chicken
what agar do you grow camplylobacter on
charcoal cefazolin sodium deoxychocolate agar
how do you treat diarrhoea
- treat underlying cause
- oral rehydration
- medicine for symptoms (antiemetics, antimobility (loperamide) and broad spectrum antibiotics (ceftriaxone))
Giardia lamblia - metronidazole
what are risk factors of haemorrhoids
constipation
straining
coughing
heavy lifting
pregnancy
what is the treatment for 1st and 2nd degree haemorrhoids
rubber band ligation
infrared coagulation
injection scleropathy
bipolar diathermy
how do you treat 3rd and 4th degree haemorrhoids
hemorrhoidectomy
stapes haemorrhoidectomy
haemorrhoidal artery ligation
what causes motility dysphagia of the oropharynx
dementia
stroke
parkinsons
ALS
what causes structural dysphagia of the oropharynx
Zenkers
cervical osteophytas
cancer
what can cause acute oropharyngeal dysphagia
stroke
oesophageal obstruction
What causes extrinsic structural oesophageal dysphagia
Extrinsic- mediastinal mass or increase in left atria size
What intrinsic factors cause structural oesophageal dysphagia
Web- plummer vinson
Ring - eosinophilic or oesphagitis
Stricture
Cancer - oesophageal or proximal gastric
What are the two.types of gastric cancer
Intestinal - type 1
Diffuse- type 2
What is the most common gastric cancer
Type 1
What is the pathophysiology of type 1 gastric cancer
It is the end result of an inflammatory process where chronic gastritis develops into atrophic gastritis and then intestinal metaplasia and dysplasia
What is the pathophysiology of type 2 gastric cancer
Develops from linitis plastica (leather bottle stomach)
Where is type 1 gastric cancer found
Atrium and lesser curvature
Where is type 2 gastric cancer found
Diffuse because it is found anywhere in the stomach
What are the risk factors of type 1 gastric cancer
Male
Old
H.Pylori
Infection
Chronic or atrophic gastritis
What are ridk factors for type 2 gastric cancer
Female
Younger
Blood type A
Genetic
H.pylpri
What is the histology of type 1 gastric cancer
Well-differentiated
Tubular
What is the histology of type 2 gastric cancer
Poorly differentiated
Signet ring cells
What are the signs and symptoms of gastric cancer
Vichows node - left supraclavicular
Weight loss
Anorexia
Nausea and vomiting
Haematemesis
Dysphagia
Epigastric pain
Red flags - ALARMS
What is the management of gastric cancer
Surgical resection plus additional chemo or radiotherapy
Palliative care
Supportive care
In gastric cancer who gets a two week endoscopy referral
Dysphagia
Or over 55 with weight loss and
Upper abdo pain or
Reflux or
Dyspepsia
What is the 4th most common cancer
Bowel cancer
Where are the most common sites for bowel cancer
Sigmoid colon and rectum
Who do you refer for suspected bowel cancer
Over 40 with abdominal pain and unexplained weight loss
Over 50 with unexplained rectal bleeding
Over 60 with a change in bowel habit or iron deficiency anaemia
What is the faecal immunochemical test
The FIT test is bowel cancer screening between 60-74 every 2 years
What are the gold standard investigations for bowel cancer
Colonoscopy and biopsy
Other than colonoscopy and biopsy what other investigations can be done in bowel cancer
Sigmoidoscopy
CT colongraphy (if they are unfit for a colonoscopy)
CT TAP for staging - thorax, abdomen, pelvis
Carcinoembryonic antigen
How do you treat diverticulosis
Watch and wait
How do you treat diverticular disease
Bulk forming laxatives
Surgery is gold standard
How.do you treat diverticulitis
Antibiotics- Co amoxiclav
Paracetamol
IV fluids
