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Phase 2a - Jemima > GASTROINTESTINAL > Flashcards

GASTROINTESTINAL Flashcards

1
Q

What is inflammatory bowel disease

A

It is inflamed intestines resulting in malabsorption and can present as either crohns disease or ulcerative colitis

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2
Q

Where can crohns disease affect

A

the whole GIT, from mouth to anus. It especially effects the terminal ileum and the proximal colon
It is non continuous

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3
Q

what HLA type predisposes to IBD

A

HLA B27 - specifically UC

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4
Q

What are risk factors for developing crohns disease

A

increased risk with family history
increased risk of you’re jewish
smoking (2X more likely)
NSAIDs
chronic stress
depression

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5
Q

What layers of the intestine does Crohns inflammation affect

A

Transmural - affects all 4 layers

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6
Q

what are the symptoms of Crohns?

A

Pain in the right lower quadrant
changes in bowel habit
malabsorption
extraintestinal

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7
Q

what malabsorption conditions can you get with crohns

A
  • B12
  • folate
  • iron disorders
  • gall stones and kidney stones
  • watery diarrhoea (no water absorption)
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8
Q

what extraintestinal symptoms can you get with crohns

A

Aphthous mouth ulcers
uveitis
episceritis
eythema nodosum - rash
pyodema gangrenosum
ankylosing spondylitis

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9
Q

how do you diagnose crohns

A

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

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10
Q

What is the treatment for crohns

A
  1. for flares = sulfasalazine and prednisolone
  2. for remission = azathioprine and methotrexate
  3. Biologics = Infliximab (anti TNFa) and Usterkenumab (anti IL12 and 23)
  4. Surgery - not curative
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11
Q

what are complications of crohns

A

Fistula
Strictures
Abscesses
Small bowel obstructions

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12
Q

where is ulcerative colitis found in the GIT

A

Only in the colon - starts at the rectum and then moves up to the sigmoid and then proximal colon

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13
Q

is smoking damaging or beneficial in ulcerative colitis

A

it is protective

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14
Q

What layers of the GIT are affected by UC inflammation

A

only the mucosa

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15
Q

WHat are the symptoms of ulcerative collitis

A

pain in left lower quadrant
tenesmus (rectal defecation pain)
bloody mucusy watery diarrhoea
Extraintestinal

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16
Q

What are the extraintestinal symptoms of ulcerative colitis

A

Uveitis
Episceritis
Pyoderma gangrenosum
Erythema nodosum
Spondylarthopathy - spine ache
primary sclerosing cholangitis

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17
Q

how do you diagnose ulcerative colitis

A

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

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18
Q

How do you determine the severity of ulcerative colitis flares

A

The TRUELOVE and WITTS score
- mild
- moderate
- severe

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19
Q

what is the treatment for ulcerative colitis

A
  1. Flares = Sulfasalazine and prednisolone
  2. Remission = azathioprine, methotrexate, cyclosporin
  3. Biologics = Infliximab
  4. Surgery = total or partial colectomy = curative
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20
Q

what are complications of ulcerative colitis

A

Toxic megacolon

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21
Q

what is the mode of action of infliximab

A

it is a monoclonal antibody against TNF-a (pro-inflammatory cytokine)

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22
Q

what is coeliac disease

A

It is an autoimmune T4 hypersensitivity to gluten

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23
Q

What HLA subtype gives a predisposition to coeliac disease

A

HLA DQ2 and 8

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24
Q

what is the pathophysiology behind coeliacs disease

A

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

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25
Q

what are the symptoms of coeliac disease

A

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

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26
Q

what other autoimmune conditions is coeliac disorder associated with

A

With thyroid disorders and addisons disease
Diabetes
Dermatitis herpetiformis

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27
Q

how do you diagnose coeliac disease

A

Serology (screening) = anti tTG, total IgA
Gold standard = Duodenal biopsy following gluten tolerance test

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28
Q

what is seen in a biopsy of someone with coeliac disease

A

Crypt hyperplasia
Villous atrophy
epithelial lymphocyte infiltration

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29
Q

how do you treat coeliac disease

A

STOP EATING GLUTEN
monitor osteoporosis using DEXA scans

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30
Q

What is tropical sprue

A

it is an enteropathy associated with tropical travel. It produces similar biopsy to coeliac disease
- treated with antibiotics such as tetracycline

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31
Q

what are differential diagnosis of coeliac disease

A

Bile acid malabsorption
gastroenteritis
Lactose intolerance
IBD

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32
Q

what is the gluten challenge

A

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

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33
Q

what are the risks of not going gluten free when you are coeliac

A

Osteoperosis
malnutrition
small risk of cancer

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34
Q

What is IBS

A

it is a functional chronic bowel disorder - related to psychology

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35
Q

how do you diagnose IBS

A

Exclusion - 3+ month of GI symptoms with no underlying causes
Exclude coeliac, IBD and infections using serology, fecal calprotectin, ESR, CRP, blood cultures

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36
Q

what are the different types of IBS

A

IBS-c = constipation
IBS -d = diarrhoea
IBS -m = Mixed

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37
Q

what is the treatment for IBS

A
  1. Conservative = patient education and reassurance: FODMAP diet avoid caffeine and alcohol
  2. Moderate = Laxatives (sennal) or antimotility drugs (loperamide), increase fluid intake
  3. Severe = TCA (amitriptyline) and consider CBT or GI referral
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38
Q

what is GORD

A

Gastric reflux into the oesophagus due to reduced pressure across the lower oesophageal sphincter.

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39
Q

What are the causes of GORD

A

Increased intraabdominal pressure due to obesity and pregnancy
Hiatal hernias - sliding and rolling
Drugs: antimuscarinics
scleroderma

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40
Q

What is the pathophysiology of GORD

A

low lower oesphageal pressure increases the change of reflux.

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41
Q

What are the symptoms of GORD

A

Heartburn - retrosternal burning chest pain
Chronic cough
Nocturnal asthma
Dysphagia

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42
Q

How do you diagnose GORD

A

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

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43
Q

What do you look for with an endoscopy in GORD

A

oesophagitis or barrets oesophagus

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44
Q

What does an oesophageal manometry look at

A

it measures the lower oesophageal sphincter pressure
it monitors the gastric acid pH

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45
Q

what is the treatment for GORD

A

conservative lifestyle - change eating habits
PPIs (or HaRA if CI)
Antacids
Alginates - Gaviscon
As a last resort you can surgically tighten the LOS

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46
Q

what are complications of GORD

A

You can get progressive worsening leading to barrets metaplasia thus increasing the risk of adenocarcinoma

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47
Q

what is a Mallory Weiss tear

A

a lower oesophageal mucosal tear due to a sudden increase in intraabdominal pressure

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48
Q

what is the typical presentation of a Mallory Weiss tear

A

Due to an acute history of retching causing haematemesis

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49
Q

what are risk factors for a Malory Weiss tear

A

Alcohol, chronic cough, bulimia, hyperemesis grandaum (pregnancy complication of severe nausea and vomiting)

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50
Q

what are the symptoms of mallory weiss tear

A

HAEMATEMESIS = after retching or vomiting history
they may be hypotensive if severe

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51
Q

How do you diagnose a mallory weiss tear

A

OGR (endoscopy) to confirm
use the Rockall score to test for the severity

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52
Q

how do you treat a Mallory Weiss tear

A

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.

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53
Q

what is an ulcer

A

punched out round holes in either the stomach or the duodenum

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54
Q

where are gastric ulcers more common

A

at the lesser curve of the stomach

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55
Q

what are causes of gastric ulcers

A

H.pylori
NSAIDs
Zollinger Ellison syndrome

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56
Q

what is Zollinger Ellison syndrome

A

A gastrin secreting tumour
- pancreatic tumour
- gastric acid hypersecretion
- widespread peptic ulcers

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57
Q

what are symptoms of gastric ulcers

A

epigastric pain worse on eating
better between means and with antacids
typically weight loss
Dyspepsia

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58
Q

how do you diagnose gastric ulcers if there are no red flags

A

Non invasive tests
- C-urea breath test
- stool antigen test

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59
Q

What are the red flags with gastric ulcers

A

over 55
haematemesis
melaena
anaemia
dysphagia

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60
Q

how do you diagnose gastric ulcers if there are red flags

A

an urgent endoscopy
an urgent biopsy

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61
Q

what is the treatment for gastric ulcers

A
  1. Stop NSAIDs
  2. If H. pylori positive then triple therapy (clarithromycin, amoxicillin and PPI)
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62
Q

What is the complication of gastric ulcers

A

Bleeding if ruptured

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63
Q

what is more common, gastric or duodenal ulcers

A

Duodenal

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64
Q

Where are duodenal ulcers mostly found

A

D1/D2 posterior wall

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65
Q

what are causes for duodenal ulcers

A

H.Pylori
NSAIDS
ZE syndrome

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66
Q

what is the most common cause for duodenal ulcers

A

H.Pylori

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67
Q

What are symptoms of duodenal ulcers

A

Epigastric pain - worse between meals and better with food
typically see weight gain

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68
Q

how do you diagnose duodenal ulcers if there are no red flags

A

Non invasive testing
- Urea breath tests
- Stool antigen tests

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69
Q

How do you diagnose duodenal ulcers if there are red flags

A

Urgent endoscopy and biopsy
- will see brunners gland hypertrophy and more mucus production

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70
Q

what is the complication for duodenal ulcers

A

Bleeding

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71
Q

how do you treat duodenal ulcers

A

STOP NSAIDS
if H.Pylori positive then put them on tripple therapy - CAP

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72
Q

what is given in place of amoxicillin in H’Pylori treatment if someone has a penicillin allergy

A

Metronidazole

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73
Q

what is gastritis

A

It is mucosal inflammation and injury in the stomach

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74
Q

what causes gastritis

A

Autoimmune problems - Pernicious anaemia and anti-IF antibodies
H.Pylori
NSAIDs - causes injury without inflammation
Mucosal ischemia
campylobacter

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75
Q

what are symptoms of gastritis

A

Epigastric pain with diarrhoea
nausea and vomiting
indigestion
anorexia
dyspepsia

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76
Q

How do you diagnose gastritis

A

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

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77
Q

How do you treat gastritis caused by H.Pylori

A

Triple therapy - CAP
clarithromycin
Amoxicillin
PPIs

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78
Q

does H.Pylori usually cause diarrhoea

A

no

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79
Q

how does H.Pylori damage the stomach

A
  1. decreases somatostatin
  2. Decreases luminal HCO3-
  3. Secretes urease which converts urea to CO2 and NH3. NH3 combined with H+ in the stomach produces NH4 which is TOXIC
  4. increases gastrin release
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80
Q

what is appendicitis

A

An inflamed appendix, usually due to a lumen obstruction
often a surgical emergency

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81
Q

what are causes of appendicitis

A

Faecolith - hard solidified faeces
lymphoid hyperplasia
filarial worms

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82
Q

what is the pathophysiology of appendicitis

A

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

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83
Q

what are the symptoms of appendicitis

A

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

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84
Q

what are complications of appendicitis

A

Rupture
periappendical abcess

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85
Q

how do you diagnose appendicitis

A

CT abdomen and pelvis = gold standard
pregnancy test to rule out ectopic pregnancy in women

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86
Q

how do you treat appendicitis

A

antibiotics and then an appendectomy (laparoscopic)

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87
Q

what is an abscess

A

Walled off bacterial collection - need to drain in order for antibiotics to reach the bacteria

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88
Q

what is diverticular disease

A

outpouching of colonic mucosa

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89
Q

what is diverticulum

A

is an outpouching of a hollow (or a fluid-filled) structure in the body

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90
Q

what is diverticulosis

A

an asymptomatic outpouching

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91
Q

what is diverticular disease

A

a symptomatic outpouch

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92
Q

what is diverticulitis

A

inflammation of an outpouch: infection

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93
Q

what is meckel’s diverticulum

A

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)

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94
Q

what rule is important to remember in meckel’s diverticulum

A

the rule of 2s
2yr old
2 inches long
2ft from iliocoecal valve (umbilical)

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95
Q

how do you diagnose meckel’s diverticulum

A

using a technitium scan

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96
Q

what are risk factors for diverticular disease

A

Aging
Genetic factors
increased colon pressure
COPD
chronic cough
High fat diet
Obesity
smoking
NSAIDS
immunosuppression

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97
Q

what are the symptoms of diverticular disease

A
  1. lower left quadrant pain
  2. Constipation
  3. fresh rectal bleeding
  4. bloating
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98
Q

how do you diagnose diverticular disease

A

Examination - tenderness and guarding
distended and tympanic to percussion
bowel sounds diminished
CT abdomen and pelvis = gold standard
- done with contrast

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99
Q

How do you treat diverticular disease

A

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

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100
Q

what are complications of diverticular disease

A

Rupture
obstruction
fistula
infection causing abscess
haemorrhage
peritonitis

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101
Q

what are causes of small bowel obstruction

A

Adhesions (often surgical)
Crohns
Strangulating hernias
Malignancy

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102
Q

What are symptoms of small bowel obstruction

A

first vomiting
then constipation
mild abdominal distension and pain
tinkling bowel sounds
hyper-resenant bowels on percussion in both SBO and LBO

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103
Q

what are causes of large bowel obstruction

A

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)

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104
Q

what are symptoms of large bowel obstruction

A

First constipation
then vomiting
gross distension and pain
hyperactive, then normal and then absent bowel sounds

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105
Q

how do you diagnose obstructive bowel disease (small and large)

A
  1. X-ray = look at dilated bowel loops and transluminal fluid- gas shadows
  2. Gold standard is CT the abdomen
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106
Q

what is a pseudo obstruction of the bowel

A

no mechanical obstruction, it is often as a result of a post operative state

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107
Q

how do you treat bowel obstruction

A

Fluid resus
NG tube
antiemetics and analgesia
antibiotics as stasis increases infection risk
surgery as a last resort

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108
Q

what is diarrhoea

A

3+ days of watery stools daily

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109
Q

what levels on the bristol stool chart is diarrhoea

A

5-7

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110
Q

how long does acute diarrhoea last for

A

less than 14 days

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111
Q

how long does subacute diarrhoea last for

A

14-28 days

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112
Q

how long does chronic diarrhoea last for

A

over 28 days

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113
Q

what are the different types of diarrhoea

A

watery
secretory
osmotic
functional
steatorrhoea - fat in stool
inflammatory

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114
Q

what are causes of diarrhoea

A

IBD
coeliac disease
hyperthyroidism
inflammation or malignancy
infection
worms
antibiotics
parasites

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115
Q

what are the viral causes of diarrhoea

A

rotavirus - more common in children
norovirus - more common in adults
Travellers diarrhoea

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116
Q

what are bacterial causes of diarrhoea

A

C.diff
campylobacter - MOST COMMON
E. Coli
salmonella
shigella
cholera

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117
Q

why can antibiotics cause diarrhoea

A

Because they increase the risk of C.diff infection

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118
Q

what antibiotics can cause diarrhoea

A

Clarithromycin
co-amoxiclav
ciprofloxacin
cephalosporins

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119
Q

what parasites can cause diarrhoea

A

amoeba

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120
Q

how do you treat diarrhoea

A

very dependent on the cause
- rehydrate
- replace electrolytes lost

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121
Q

what do you need to be wary about in diarrhoea

A

dehydration and electrolyte loss

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122
Q

what are the two types of oesophageal cancer

A

Adenocarcinoma
squamous cell carcinoma

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123
Q

where is oesophageal adenocarcinoma normally found

A

in the lower 2/3 of the oesophagus

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124
Q

what is oesophageal adenocarcinoma associated with

A

Barrett’s oesophagus

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125
Q

where is oesophageal squamous cell carcinoma found

A

in the upper 2/3 of the oesophagus

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126
Q

what is oesophageal squamous cell carcinoma associated with

A

smoking and alcohol

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127
Q

what are the symptoms of oesophageal cancers

A

ALARMS
anaemia
Loss of weight
Anorexic
Recent sudden worstening symptoms
Melenea or haematemesis
Swallowing with progressive difficulty

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128
Q

how do you diagnose oesophageal cancer

A

Oesophagogastro duodenoscopy and biopsy with a barrium swallow
CT or PET for staging

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129
Q

what is the treatment for oesophageal cancer

A

If they are medically fit then undergo chemotherapy or radiotherapy and surgery
if they are unfit then it is palliative care

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130
Q

what is the main type of gastric carcinoma

A

mostly adenocarcinoma

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131
Q

what are the stages of gastric adenocarcinoma

A

T1 = well differentiated
T2 = undifferentiated “signet ring carcinoma” - worse

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132
Q

where are gastric adenocarcinomas mostly found

A

in the proximal stomach

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133
Q

what are causes of gastric adenocarcinoma

A

H. Pylori
smoking
CDH-1 mutation - mutated cadherin gene
Pernicious anaemia (autoimmune chronic gastritis)

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134
Q

what are the symptoms of gastric carcinomas

A

severe epigastric pain
anaemia - due to Fe deficiency
weight loss
progressive dysphasia
tired all the time

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135
Q

what are signs of mets in gastric carcinoma

A

jaundice - liver mets
Krukenburg tumour - ovarian mets from gastric cancer

136
Q

how do you diagnose gastric carcinomas

A

gastroscopy and biopsy
CT and MRI for staging
PET to ID the mets

137
Q

What is the TNM staging of cancer

A

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).

138
Q

how do you treat gastric carcinoma

A

surgery and ECF chemo regiments if the cancer is resectable

139
Q

what is the most common SI carconoma

A

adenoma

140
Q

is it common to get SI carcinomas

A

no the SI is pretty tumour resistant and there is a low change of tumour here (less than 1% of all GI tumours)

141
Q

what are risk factors for developing an SI carcinoma

A

chronic SI disease such as crohns or coeliac disease

142
Q

how do you diagnose SI carcinomas

A

Gastroscopy and biopsy
Use CT and MRI for staging
PET to ID any mets

143
Q

how do you treat SI carcinomas

A

Surgery and ECF chemotherapy regimens
- if the cancer is resectable

144
Q

what is the most common colorectal cancer

A

adenocarcinomas

145
Q

what is the precursor to colorectal cancer

A

Polyps = mostly spontaneous and benign. They are common with age but can progress onto cancer

146
Q

What two inherited conditions can increase the risk of polyps

A
  1. Familial adenomatous polyposis - FAP
  2. Hereditary non polyposis colon cancer - HNPC lynch syndrome
147
Q

What is familial adenomatous polyposis

A

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

148
Q

what is Hereditary non polyposis colon cancer

A

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

149
Q

what are risk factors for developing colorectal cancer

A

familial inherited predispositions
adenomas or polyps
alcohol
smoking
ulcerative colitis

150
Q

what are common colorectal cancer mets

A

to the liver and the lungs

151
Q

what are the symptoms of colorectal cancer

A

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

152
Q

how do you diagnose colorectal cancer

A

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

153
Q

how do you classify colorectal cancers

A

using the TNM system

154
Q

how do you treat colorectal cancer

A

Surgery is the only curative option if no mets
chemotherapy

155
Q

what s dyspepsia

A

it is not a disease it is the persisting symptom of indigestion

156
Q

what can cause dyspepsia

A

often the cause is unknown
- functional disorder
it may be related to ulcers, particularly gastric

157
Q

what are the symptoms of dyspepsia

A

early satiation
epigastric pain and reflux
extreme fullness

158
Q

how do you diagnose and treat dyspepsia

A

you can perform an endoscopy to see if there is an underlying cause
can give PPIs to reduce stomach acid

159
Q

what type of bacteria is H.Pylori

A

it is a gram negative bacteria
it is a low virulence commensal in the CIT

160
Q

what is the pathology of helicobacter pylori

A

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

161
Q

What can helicobacter pylori cause

A

peptic ulcer disease
gastritis
gastric carcinomas

162
Q

how di you diagnose helicobacter pylori

A

biopsy
- stool antigen and C-urea breath test

163
Q

how do you treat H.Pylori

A

Triple therapy
clarithromycin
amoxicillin
PPI

164
Q

What type of bacteria is E.coli

A

a gram -Ve often commensal flora of the GIT

165
Q

What types of E.Coli cause watery diarrhoea

A

ETEC
EAEC
EPEC

166
Q

what kinds of E.Coli cause bloody diarrhoea

A

EHEC (haemorrhagic)

167
Q

what can Escherichia coli serotype O157:H7 cause

A

haemolytic uremic syndrome
- haemorrhagic diarrhoea plus nephritic syndrome

168
Q

what is the treatment for E.Coli infection

A

Often amoxicillin, artrimethorpim or nitrofurantoin

169
Q

what type of bacteria is C.difficile

A

it is a gram POSITIVE spore forming bacteria

170
Q

what is C.Difficile infection mainly induced with

A

Certain antibiotics
- Ciprofloxacin
- Co-amoxiclav
- cephalosporins
- Clindamycin

171
Q

what does C.Difficile infection cause

A

Pseudomembranous colitis

172
Q

what is the pathophysiology of Pseudomembranous colitis

A

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

173
Q

what is the treatment for C.Diff infection

A

STOP C’S ANTIBIOTICS
give vancomycin !!!

174
Q

what is achalasia

A

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)

175
Q

what causes achalasia

A

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

176
Q

what are symptoms of achalasia

A

NON PROGRESSIVE dysphagia = you struggle to swallow anything and there is a chesty substernal pain
can also experience food regurgitation and aspiration pneumonia

177
Q

how do you diagnose achalasia

A

“bird beak” on the barrium swallow
Manometry (measure the pressure across the lower oesophageal shpincter) diagnostic

178
Q

how do you treat achalasia

A

only surgery is curative - balloon stenting is performed
Nitrates and nifedipine may help pre-surgery

179
Q

what is ischemic colitis

A

ischemia of the colonic arterial supply leading to colonic inflammation due to hypoperfusion

180
Q

what are causes of ischemic colitis

A

Affecting the inferior mesenteric artery: thrombus (+/- atherogenesis), Emboli, reduced cardiac output and arrhythmias, shock

181
Q

what are the most common sites affected in ischemic colitis

A

Water shed areas
- splenic flexure MC
- sigmoid colon and cecum

182
Q

what are symptoms of ischemic colitis

A

left lower quadrant pain
Bright bloody stool
increased signs of hypovolemic shock

183
Q

how do you diagnose ischemic colitis

A

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

184
Q

what are complications of ischemic bowel disease

A

Perforation
strictures causing obstruction

185
Q

how do you treat ischemic colitis

A

symptomatic - IV fluid and antibiotics (prophylactic)
Gangrenous (infected colon) - only surgery can cure

186
Q

what is mesenteric ischemia

A

ischemia of the small intestine

187
Q

what is acute mesenteric ischemia

A

an acute attack such as an abdominal MI caused by a blood clot in the mesenteric artery

188
Q

what is chronic mesenteric ischemia

A

ischemia that is longer lasting, lasts for months and is termed abdo-angina. Caused by a build up of plaque in the mesenteric arteries

189
Q

what are causes of mesenteric ischemia

A

affecting the superior mesenteric artery:
thrombus (MC)
Emboli often due to AF

190
Q

what are the symptoms of mesenteric ischemia

A

triad
1. central/RIF acute severe abdominal pain
2. NO abdominal signs on exam (e.g guarding or rebound)
3. Rapid hypovolemic shock

191
Q

How do you diagnose mesenteric ischemia

A

CT angiogram
FBC and ABG to look for persistent metabolic acidosis

192
Q

how do you treat mesenteric shock

A

Fluid resus
antibiotics
IV heparin (reduce the chance of thromboemboli)
If the bowel is infarcted then surgery is required

193
Q

what are haemorrhoids (piles)

A

swollen veins around the anus which disrupt the anal cushions
- parts of the anal cushions prolapse through the tight anal passage

194
Q

what is the most common cause of haemorrhoids

A

constipation with increased straining
anal sex

195
Q

what are the two types of haemorrhoids

A

internal - above the internal rectal plexus
external - below the dentate line

196
Q

what type of haemorroid is more painful

A

External haemorrhoids

197
Q

why are internal haemorrhoids less painful

A

as they have a reduced sensory supply
patients may feel incomplete emptying

198
Q

what are symptoms of haemorrhoids

A

Bright red fresh PR bleeding and mucusy bloody stool
bulging pain
puritis ani - itchy bum

199
Q

how do you diagnose haemorrhoids

A

PR exam (digital) for external (may be visible)
Proctoscopy required for internal haemorrhoids

200
Q

how do you treat haemorrhoids

A

stool softener
rubber band ligation - definitive

201
Q

what is a perianal abscess

A

a walled off collection of stool and bacteria around the anus

202
Q

what is the main cause of perianal abscess

A

anal sex causing anal gland infection

203
Q

what are symptoms of a perianal abscess

A

pus in stool
constant pain - tender

204
Q

how do you treat a perianal abscess

A

surgical removal
drainage - because its walled off of its not drained its resistant to antibiotic therapy

205
Q

what is an anal fistula

A

an abnormal track formed between the inside of the anus and elsewhere such as the subcutaneous skin

206
Q

what does an anal fistula typically progress from

A

typically progresses from a perianal abscess - abscess discharges toxic substances which aids in the fistula formation as the abscess grows

207
Q

what conditions are anal fistulas seen in

A

crohns
rectal cancer
progression from anal abscess

208
Q

what are the symptoms of an anal fistula

A

bloody mucusy discharge
often very visible and painful

209
Q

what is the treatment for anal fistula

A

surgical removal and drainage (with antibiotics if it is infected)

210
Q

what is an anal fissure

A

a tear in the anal skin lining below the dentate line

211
Q

what are the main causes of an anal fissure

A

hard faeces
also trauma such as childbirth
crohns
ulcerative colitis

212
Q

what are the symptoms of anal fissure

A

extreme defecation pain
very itchy bum (pruritis ani)
anal bleeding

213
Q

what is the treatment for anal fissure

A

stool softening and increase in fiber and fluids
topical creams such as lidocaine ointment
definitive cure is surgery

214
Q

what is pilonidal sinus/abscess

A

where hair follicles get stuck in the natal cleft which can form small tracts (sinus) or get infected (abscess)

215
Q

what are symptoms of Pilonidal sinus/abscess

A

swollen pus filled smelly abscess in bumcrack
- visible on exam

216
Q

how do you treat pilonidal sinus/abscess

A

surgery and hygiene advice

217
Q

what is Zenker’s diverticulum (pharyngeal pouch)

A

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.

218
Q

why does Zenker’s diverticulum develop

A

This results because of muscle spasm in at the beginning of gullet

219
Q

what are the symptoms of Zenkers diverticulum

A

smelly breath - food accumulating in oesophagus
regurgitation and aspiration of food

220
Q

what kind of colitis can CMV cause

A

owl eye colitis in immunosuppressed patients
- its an aids defining illness

221
Q

what are the 9 regions of the abdomen

A

Right hypochondriac
Right lumbar
Right iliac
Epigastric region
umbilical region
hypogastric region
Left hypochondriac
Left lumbar
Left iliac

222
Q

what are signs of an upper GI bleed

A

haematemesis (vomiting fresh red blood)
‘digested’ blood - melena (black stools)

223
Q

what is signs of lower GI bleed

A

Haematochezia (fresh red blood in stools)

224
Q

what are red flag signs for GI disorders

A

anaemia
loss of weight
anorexia
recent onset of progressive symptoms
masses or melena (black stool)
Swallowing difficulties
and being over 55

225
Q

what conditions can cause haematemesis

A

mallory weiss tear
oesophageal varices
oesophageal cancer

226
Q

what conditions can cause swallowing difficulties

A

achalasia
oesophageal cancer
Zenker’s diverticulum
Systemic sclerosis
strictures

227
Q

what oesophageal disease can cause pain

A

Mallory weiss tear
Oesophageal varices
GORD

228
Q

what are signs and symptoms of Mallory Weiss tear

A

Haematemesis
Melena
Systemic signs
- postural hypotension
- dizziness

229
Q

what should be done to look at a Mallory Weiss tear

A

an endoscopy

230
Q

what are oesophageal varices

A

these are enlarged veins that protrude into the oesophagus

231
Q

what can produce oesophageal varices

A

hypertension in the portal venous system due to underlying liver issues

232
Q

what happens when oesophageal varices rupture

A

It causes a large amount of bleeding

233
Q

What are signs and symptoms of oesophageal varices rupture

A

Haematemesis
abdominal pain
systemic
- shock
- hypotension
- pallor

234
Q

how do you treat a ruptured oesophageal varices

A

if there is an acute bleed ABCDE
- vasopressin for vasoconstriction
- bleeding abnormality: vitamin K
- then surgery: endoscopic band ligation within 24 hours

235
Q

how do you treat oesophageal varices that havent ruptured

A

beta blockers
eondoscopic variceal band ligation

236
Q

how do you diagnose oesophageal varices

A

upper endoscopy
graded based on size and risk of bleeding

237
Q

what can cause oesophageal strictures

A

scarring of the oesophagus leading to narrowing, caused by anything that can cause inflammation and scarring such as GORD

238
Q

what is systemic sclerosis

A

where muscles no longer work correctly leading to swallowing difficulties

239
Q

what causes Achlasia

A

degeneration of ganglions in Auerbach’s or mesenteric plexus in the muscularis externa

240
Q

what is the pathophysiology of achalasia

A

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

241
Q

how do you treat achalasia

A
  1. lifestyle: smaller but more frequent meals
  2. Nitrates or CCB to relax the LOS
  3. Botox to relax the LOS
  4. surgery: cardiomyotomy but this could lead to GORD
242
Q

what are risk factors for developing GORD

A

obesity
pregnancy
hiatus hernia
smoking
NSAIDs
caffeine
alcohol
male

243
Q

what are the signs and symptoms of GORD

A

heart burn
regurgitation
epigastric pain
dysphagia
dyspepsia
extra-oesophageal: cough, asthma, dental erosion

244
Q

when in GORD do people get a two weeks endoscopy referral

A

When they have dysphagia
over 55 with weight loss and 1 of the following
1. upper abdominal pain
2. reflux
3. dyspepsia

245
Q

how do you clinically diagnose GORD

A

FBC to look for anaemia
24 hour pH monitoring
Upper GI endoscopy
Manometry

246
Q

how do you manage GORD

A

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)

247
Q

what is barrets oesophagus

A

it is metaplasia of stratified squamous to simple columnar epithelium and is often a complication of GORD

248
Q

what causes acute gastritis

A

H.Pylori
alcohol abuse
stress
NSAIDs

249
Q

What causes chronic gastritis

A

H.Pylori
autoimmune gastritis - parietal cell antibodies and IF antibodies causing a reduction in B12 absorption and pernicious anaemia

250
Q

how do you treat gastritis not caused by H.Pylori

A

stop the NSAIDs/alcohol
in autoimmune you have to give IM vitamin B12

251
Q

what must you stop before testing for gastritis

A

must stop PPIs for at least 2 weeks and antibiotics for 4 weeks

252
Q

what artery is a gastric ulcer most likely to perforate

A

gastroduodenal artery

253
Q

what artery is a duodenal ulcer most likey to perforate

A

left gastric artery

254
Q

what is the epidemiology of IBS

A

1 in 5 in the uk have it
more common in females
peaks between 20-30

255
Q

what are the signs and symptoms of IBS

A

ABC
abdominal pain
bloating
change in bowel habits

256
Q

what are differentials of IBS

A

IBD
coeliac disease
lactose intolerance
food allergies
GI infection

257
Q

what are FODMAPs

A

Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols (FODMAPS) are short-chain carbohydrates that are poorly absorbed in the GIT
- those with IBS told to avoid

258
Q

what is the roman IV criteria for diagnosing IBS

A

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

259
Q

what is the pathophysiology of ulcerative colitis

A

Autoimmune condition, causing excessive inflammation of mucosa in large bowel → submucosal ulcers + pseudopolyps → perforation + bleeding
Inflammation starts from rectum
Continuous inflammation
stops at ileum

260
Q

how do you treat mild ulcerative colitis

A

Amniosalicylate aka 5-ASA (mesalazine)
+ steroid (prednisolone)

261
Q

how do you treat moderate to severe ulcerative colitis

A

Fluid resus (if necessary)
IV steroid (hydrocortisone)
+ TNF-α inhibitor (infliximab)

Surgery: Colectomy = GOLD

262
Q

what is given in ulcerative colitis to maintain remission

A

Azathioprine

263
Q

what is the pathophysiology of crohns

A

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)

264
Q

when would you suspect tropical sprue

A

when a patient is from a tropical country and they have chronic GI and malabsorptive symptoms

265
Q

what are signs and symptoms of tropical sprue

A

Diarrhoea
steatorrhoea
weight loss
abdominal pain
fatigue
dehydration
malabsorptive: vitamin or iron deficiency

266
Q

what is the gold standard for diagnosis of tropical sprue

A

Jejunal tissue biopsy

267
Q

how do you treat tropical sprue

A

drink treated water and tetracycline for 6 months

268
Q

what are signs and symptoms of chronic mesenteric ischemia

A

central colickly abdominal pain after eating
weight loss
abdominal bruit (due to turbulent blood flow)

269
Q

how do you manage chronic mesenteric ischemia

A

lifestyle
secondary prevention
surgery

270
Q

what is risk factors for acute mesenteric ischemia

A

Atrial fibrillation

271
Q

why is acute mesenteric ischemia a medical emergency

A

Because the blockage in the artery/vein can cause ischemia, rapid necrosis, perforation and sepsis

272
Q

what investigations are done for acute mesenteric ischemia

A

Bloods - metabolic acidosis
1st line = CT contrast and angiography
GOLD = colonoscopy

273
Q

how do you treat acute mesenteric ischemia

A

antibiotics
anticoagulants (heparin)
surgery

274
Q

what are the signs of acute mesenteric ischemia

A

Severe central colicky pain
abdominal bruit
rapid hypovolemia - shock
nausea and vomiting
melena
increased abdominal distension

275
Q

what is ischaemic colitis

A

when blood flow to part of the large intestine is temporarily reduced - splenic flexure is the most common site

276
Q

what is the most common ischemic bowel disease

A

ischaemic colitis

277
Q

what are risk factors of pseudomembranous colitis

A

recent antibiotic use
staying in hospital or nursing home
older age
IBD
use of PPIs
Immunocompromised

278
Q

what investigations are done for pseudomembranous colitis

A

blood tests - raised WBB
stool sample - C.diff
abdominal X ray
CT abdomen
colonoscopy
histology

279
Q

how do you manage pseudomembranous colitis

A
  1. stop causative agent
  2. start another antibiotic effective against C.diff (vancomycin)
  3. hydration and electrolyte replacement
  4. hand hygiene and private room for infection control
280
Q

what is the definition of bowel obstruction

A

the interruption of passage through the bowel - can be a surgical emergency

281
Q

what are signs and symptoms of a bowel obstruction

A

abdominal pain
abdominal distension
vomiting
absolute constipation

282
Q

what investigations are done for bowel obstruction

A

1st line: abdominal X-ray
dilation of small bowel >3cm
dilation of large bowel >6cm
GOLD: CT of abdomen and pelvis with contrast

283
Q

how do you manage bowel obstruction

A

drip and suck management
surgical treatment (lapatotomy or resection)

284
Q

what are reasons for small bowel obstruction

A

adhesions from surgery
hernia
crohns
malignancy

285
Q

what are signs and symptoms of small bowel obstruction

A

colicky pain higher up
abdominal distension
vomiting first followed by constipation
tinkling bowel sounds

286
Q

what is the drip and suck management of bowel obstruction

A

Insert IV cannula and resuscitate with IV fluids
Nil-by-mouth (NBM)
Insert nasogastric tube to decompress the stomach
catheter
analgesia
antiemetics
antibiotics

287
Q

how do you treat SBO

A

in stable patients
A-E assessment and drip and suck
in unstable patients - surgery

288
Q

what are reasons for a large bowel obstruction

A

malignancy
sigmoid volvulus
diverticulitis
intussusception - when the bowel folds in on itself

289
Q

what are signs and symptoms of LBO

A

continuous abdominal pain
severe abdominal distension
constipation first followed by vomiting
absent bowel sounds

290
Q

how do you treat LBO

A

in stable patients
A-E assessment and drip and suck
in unstable patients
surgery

291
Q

what is a pseudo-obstruction

A

it is colonic dilation in the absence of a mechanical obstruction

292
Q

what is the pathophysiology of pseudo-obstruction

A

Parasympathetic nerve dysfunction causes absent smooth muscle movement
Complication: bowel ischaemia and perforation

293
Q

how do you investigate pseudo-obstruction

A

1st line: Abdo XRay (megacolon → dilation >10cm )
Gold standard: CT of the abdomen and pelvis with contrast (no transition zone)

294
Q

what can cause pseudo-obstruction

A

Post-operative (paralytic ileus)
Medications (opioid, calcium channel blockers, antidepressants)
Neurological (Parkinson’s, multiple sclerosis, Hirschsprung’s)
Electrolyte imbalance
Recent trauma/surgery

295
Q

how do you manage pseudo-obstruction

A

‘Drip and suck’ management
IV neostigmine
Surgical decompression for unstable patients (caecostomy, ileostomy)

296
Q

what is Hirschsprung disease

A

a congenital condition in which nerve cells are missing in the large intestine (myenteric plexus) resulting in faeces getting stuck

297
Q

what is the pathophysiology of diverticular disease

A

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

298
Q

what is pathophysiology of acute appendicitis

A

obstruction in the lumen of the appendix causing stasis. Bacterial overgrowth and inflammation

299
Q

what is seen on examination for acute appendicitis

A

McBurney’s sign
Psoas sign
obturator sign
guarding
rebound tenderness

300
Q

what are differential diagnosis for acute appendicitis

A

Ectopic pregnancy
ovarian torsion
ruptured ovarian cyst
IBD
diverticulitis
Meckel’s diverticulum
Kidney stones
UTI
testicular torsion

301
Q

what are the symptoms of travellers diarrhoea

A

fever
nausea
vomiting
cramps
tenderness
bloody stools

302
Q

what colour is salmonella enterica on XLD

A

pink with black centre

303
Q

what colour is shigella on XLD

A

pink on XLD

304
Q

what is camplylobacter normally found in

A

undercooked chicken

305
Q

what agar do you grow camplylobacter on

A

charcoal cefazolin sodium deoxychocolate agar

306
Q

how do you treat diarrhoea

A
  • treat underlying cause
  • oral rehydration
  • medicine for symptoms (antiemetics, antimobility (loperamide) and broad spectrum antibiotics (ceftriaxone))
    Giardia lamblia - metronidazole
307
Q

what are risk factors of haemorrhoids

A

constipation
straining
coughing
heavy lifting
pregnancy

308
Q

what is the treatment for 1st and 2nd degree haemorrhoids

A

rubber band ligation
infrared coagulation
injection scleropathy
bipolar diathermy

309
Q

how do you treat 3rd and 4th degree haemorrhoids

A

hemorrhoidectomy
stapes haemorrhoidectomy
haemorrhoidal artery ligation

310
Q

what causes motility dysphagia of the oropharynx

A

dementia
stroke
parkinsons
ALS

311
Q

what causes structural dysphagia of the oropharynx

A

Zenkers
cervical osteophytas
cancer

312
Q

what can cause acute oropharyngeal dysphagia

A

stroke
oesophageal obstruction

313
Q

What causes extrinsic structural oesophageal dysphagia

A

Extrinsic- mediastinal mass or increase in left atria size

314
Q

What intrinsic factors cause structural oesophageal dysphagia

A

Web- plummer vinson
Ring - eosinophilic or oesphagitis
Stricture
Cancer - oesophageal or proximal gastric

315
Q

What are the two.types of gastric cancer

A

Intestinal - type 1
Diffuse- type 2

316
Q

What is the most common gastric cancer

A

Type 1

317
Q

What is the pathophysiology of type 1 gastric cancer

A

It is the end result of an inflammatory process where chronic gastritis develops into atrophic gastritis and then intestinal metaplasia and dysplasia

318
Q

What is the pathophysiology of type 2 gastric cancer

A

Develops from linitis plastica (leather bottle stomach)

319
Q

Where is type 1 gastric cancer found

A

Atrium and lesser curvature

320
Q

Where is type 2 gastric cancer found

A

Diffuse because it is found anywhere in the stomach

321
Q

What are the risk factors of type 1 gastric cancer

A

Male
Old
H.Pylori
Infection
Chronic or atrophic gastritis

322
Q

What are ridk factors for type 2 gastric cancer

A

Female
Younger
Blood type A
Genetic
H.pylpri

323
Q

What is the histology of type 1 gastric cancer

A

Well-differentiated
Tubular

324
Q

What is the histology of type 2 gastric cancer

A

Poorly differentiated
Signet ring cells

325
Q

What are the signs and symptoms of gastric cancer

A

Vichows node - left supraclavicular
Weight loss
Anorexia
Nausea and vomiting
Haematemesis
Dysphagia
Epigastric pain
Red flags - ALARMS

326
Q

What is the management of gastric cancer

A

Surgical resection plus additional chemo or radiotherapy
Palliative care
Supportive care

327
Q

In gastric cancer who gets a two week endoscopy referral

A

Dysphagia
Or over 55 with weight loss and
Upper abdo pain or
Reflux or
Dyspepsia

328
Q

What is the 4th most common cancer

A

Bowel cancer

329
Q

Where are the most common sites for bowel cancer

A

Sigmoid colon and rectum

330
Q

Who do you refer for suspected bowel cancer

A

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

331
Q

What is the faecal immunochemical test

A

The FIT test is bowel cancer screening between 60-74 every 2 years

332
Q

What are the gold standard investigations for bowel cancer

A

Colonoscopy and biopsy

333
Q

Other than colonoscopy and biopsy what other investigations can be done in bowel cancer

A

Sigmoidoscopy
CT colongraphy (if they are unfit for a colonoscopy)
CT TAP for staging - thorax, abdomen, pelvis
Carcinoembryonic antigen

334
Q

How do you treat diverticulosis

A

Watch and wait

335
Q

How do you treat diverticular disease

A

Bulk forming laxatives
Surgery is gold standard

336
Q

How.do you treat diverticulitis

A

Antibiotics- Co amoxiclav
Paracetamol
IV fluids

Phase 2a - Jemima (11 decks)

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