Gastrointestinal Flashcards
1
Q
Define Crohn’s
A
Transmural granulomatous inflammation - affecting any part of the GI tract
2
Q
Genetic mutation that is a risk factor for Crohn’s
A
NOD2 gene
3
Q
What is the inflammatory bowel disease?
Macroscopic appearance of skip lesions, cobblestone appearance (due to ulcers)
Microscopic appearance of, transmural, non-caseating granumolmas and goblet cells
A
Crohn’s disease
4
Q
What mneumonic is used for Crohn’s disease?
A
N – No blood or mucus (less common)
E – Entire GI tract
S –“Skip lesions” on endoscopy
T – Terminal ileum most affected andTransmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
Crohn’s is also associated with weight loss, strictures and fistulas.
5
Q
Mouth ulcers are associated with which IBD?
A
Crohn’s
6
Q
Name some extra-intestinal featires of Crohn’s
A
- Erythema nodosum
- Anal fissures
7
Q
Pain associated with Crohn’s
A
RLQ abdominal pain (ileum)
(UC is typcially LLQ)
8
Q
First line and gold-standard test for Crohn’s
A
- 1st: Faecal calprotectin (indicates IDB)
- Gold: Endoscopy (OGD or colonoscopy) + biopsy
9
Q
Differential diagnosis for Crohn’s
A
Salmonella spp
Chronic diarrhoea
UC
10
Q
First and second line management for inducing remission in Crohn’s
A
1st: Oral prednisolone or IV hydrocortisone
2nd: Infliximab (anti-TNF), methotrexate, or azathioprine
11
Q
What drug is used to maintain remission in Crohn’s?
A
Immunosuppressants - Azathioprine
12
Q
Surgical options for Crohn’s
A
Distal ileum resection (prevent further flares)
Treat secondary strictures and fistulas
13
Q
Complications of Crohn’s disease
A
- Intestinal obstruction
- Anaemia (malabsorption)
- Malignancy
- Short-bowel syndrome
14
Q
Common presenting symptos of Crohn’s
A
- Chronic diarrhoea
- Weight loss
- RLQ pain abdo pain - mimicking acute appendicitis
15
Q
Define UC
A
Inflammatory (continuous) condition of the colon mucosa (up to the ileocaecal valve)
(Ulvers from along lumen of intestine)
16
Q
Age of presentation for UC
A
15-30
17
Q
What drug is a risk factor for Crohn’s and UC?
A
NSAIDs!
18
Q
Smoking is protective for which IBD?
A
UC
(Useful Cigarettes)
19
Q
What part (microscopic) of the bowel does UC effect?
A
Mucosa (does not go through the full wall of the bowel)
20
Q
Which IBD presents with non-caseating granulomas and which has no granulomata?
A
Crohn’s = non-caseating gramulomas
UC = no granulomas
21
Q
Describe the macroscopic and microscopic features of UC
A
- Macroscopically
- Continuous inflammation (no skip lesions)
- Ulcers
- Pseudo-polyps
- Microscopically
- Mucosal inflammation
- No granulomata
- Depleted goblet cells
- Increased crypt abscesses
22
Q
What mneumonic is used to describe UC?
A
Ulcerative Colitis (remember U – C – CLOSEUP)
C–Continuous inflammation
L–Limited to colon and rectum
O–Only superficial mucosa affected
S–Smoking is protective
E–Excrete blood and mucus
U–Useaminosalicylates
P–Primary Sclerosing Cholangitis
23
Q
Patient presents with diarrhoea with blood +
mucus, LLQ abdominal pain, feels like their bowels aren’t empty after passing stools and has clubbing and a tender distended abdomen O/E. Diagnosis?
A
UC
24
Q
First line tests for UC
A
- Faecal calprotectin
- pANCA = positive
25
Gold standard/diagnostic test for ulcerative colitis
Colonoscopy + biopsy
26
Which IBD is typically positive and negative for pANCA?
* Crohn's: Negative
* Ulcerative colitis : Positive
27
What does a biopsy sample for UC show?
**Crypt abscesses**
Mucosal ulceration only
28
Differential diagnosis for IBD
* The other type of IBD
* IBS
* Other cause of diarrhoea (salmoella, rotavirus)
29
Give the first and second line management for inducing remission for mild-moderate UC
* First line: Aminosalicylate (**mesalazine** oral or rectal)
* Second line: Corticosteroids (**prednisolone**)
30
Give the first and second line management for inducing remission for severe UC
First line: Hydrocortisone
Second line: IV ciclosporin
31
Managment for maintaing the remission of ulcerative colitis
Aminosalicylate (**mesalazine** oral or rectal)
**Azathioprine**
32
Which IBD involves the depletion of goblet cells?
Ulcerative colitis
33
When a panproctocolectomy (removal of colon and rectum) performed?
Curative surgery for UC. Patient left with ileostomy or ileo-anal anastomosis (j-pouch)
34
Name some complications of UC
* Inflammatory pseudopolyps
* Colic adenocarcinoma
* Benign stricture
* Primary sclerosing cholangitis (PSC)
35
What can relieve IBS pain?
Defecation and passing wind
36
What exacerbates IBS?
Stress, food, gastroenteritis, menstruation
37
Name a couple causes of IBS
* Psychosocial - stress, anxiety
* GI infcetion - gastroenteritis
* Eating disorders
38
Describe the pathophysiology of IBS
- Dysfunction in the brain-gut axis results in disorder of intestinal motility and/or **enhances visceral sensitivity**
- Recurrent abdominal pain with** NO inflammation**
39
Typical patient with IBS
Young female with history of anxiety
40
Define tenesmus
Sensation of incomplete bowel emptying
41
Young female patinet presents with mucus in stools, change in stool frequency and consistency, diahhorea tenesmus, bloating, pain relieved after going to the toilet. Diagnosis?
Irritable Bowel Syndrome
42
Patient presents with abdo pain, mucus in stool and change in bowel habits. Faecal calprotectun and anti-TTG antibodies are both negative and colonoscopy shows nothing remarkable. Diagnosis?
Irritable bowel syndrome
43
What symptoms suggest IBS?
**Abdominal pain / discomfort:
- Relieved on opening bowels, or
- Associated with a change in bowel habit**
AND 2 of:
- Abnormal stool passage
- Bloating
- Worse symptoms after eating
- PR mucus
44
Differential diagnosis for IBS?
Coeliac disease
Lactose intolerance
(Worsen on eating)
45
Lifestyle changes for IBS
* Limit caffeine and alcohol
* Low FODMAP diet
* Regular small meals
* CBT
46
First and second line management for IBS
* 1st: Loperamide (for diarrhoea); laxatives (constipation), antispamodics (hyoscine butylbromide)
* 2nd: Tricyclic antidepressants (amitriptyline orally)
47
Complications of IBS?
* Diverticulosis
* Depression
* Sleep disorders
48
Define coeliac disease
Autoimmune condition
Exposure to gluten causes an autoimmune reaction that causes inflammation in the small bowel
49
When does coeliac disease usually develop?
Infancy (after weaning on to gluten-containing foods)
50
Name the two autoantibodies present in coeliac disease?
**Anti-TTG** (anti-transglutaminase)
**T**otally **T**errified of **G**luten
Anti-EMA (anti-endomysial)
51
What part of the bowel is affected (inflammed) in coeliac disease?
Small bowel (esp. jejunum)
52
Describe the microscopic changes in the small bowel in coeliac disease
* Villus atrophy
* Crypyt hypertrophy
53
Signs of coeliac disease
* **Failure to thrive in young children**
* Wt loss
* Mouth ulcers
* **Anaemia/nutritional deficency**
* **Dermatitis herpertiformis** (itchy blistering skin rash - typically on the abdomen)
* **Steatorrhoea**
* Diarrhoea
54
What diet does a patient need to stick to whilst being investigated for coeliac disease?
Gluten-containing diet
55
Name the genetic associations with coeliac disease
HLA-DQ2 gene (90%)
HLA-DQ8 gene
56
First line and gold-standard tests for coeliac disease
* 1st: Check for IgA deficiency, then raised Anti-TGG
* Gold-standard: Endosocopy + duodenal biopsy (crypt hypertrophy + villous atrophy)
57
What test can monitor disease activity in coeliac disease?
Anti-TTG
58
Management of coeliac disease
Gluten-free diet (no barley, wheat or rye)
Dietitian (correct vitamin deficiencies)
59
Presentation of diarrhoea and failure to thrive, iron-deficiency anaemia and osteoporosis. Possible diagnosis?
Coeliac disease
60
Complications of coeliac disease
- Vitamin deficiency
- Steatorrhea, night blindness, bruising, osteoporosis
- Anaemia
- Osteoporosis
61
What is gastritis>
Inflammation of the stomach lining
(presence of gastric mucosal inflammation)
62
Most common cause of gastritis?
Helicobacter pylori infection
63
Causes of gastritis
* H. pylori infection
* Autoimmune gastritis (cause of pernicious anaemia)
* Aspirin + NSAIDs
* Crohn's
| Pernicious anaemia = low RBCs due to low B12
64
Patient presents with dyspepsia, epigastric pain and vomiting. Possible daignosis?
Gastritis
65
Tests for gastritis
* H. pylori urea breath test
* H. pylori faecal antigen test
* Endoscopy + biopsy + histology
66
Differential diagnoses for gastritis
* Peptic ulcer disease
* Gastro-oesophageal reflux disease (GORD)
* Non-ulcer dyspepsia
67
Treatment for gastritis
**CAP**
C-Clarithromycin
A-Amoxicillin
P-PPIs e.g. omeprazole
68
Complications of gastritis
* Vitamin B12 deficiency
* Peptic ulcer disease
69
Define GORD
Reflux of gastric contents into the oesophagus
Through lower oesophageal sphincter
Irritates the oesophagus
70
Rx of GORD
* Obesity or pregnancy
* Hitaus hernia
* Overeating
* Male
* Smokung, alcohol
71
Lining of oesophagus and stomach
* Oesophagus: Squamous epithelium
* Stomach: Columnar epithelium
72
Patient presents with dyspepsia, acid regurgitation, retrosternal pain, hoarse voice, painful swallowing, acid taste in mouth and waterbrash. Diagnosis?
GORD
73
What is OGD?
Oesophago-gastro-duodenoscopy (endoscopy)
74
Investigations for GORD
* Usually clinical diagnosis
* OGD (endoscopy)
75
Differential diagnoses for GORD
* Biliary colic
* Peptic ulcer
* Malignancy
76
Describe the pain with GORD
Retrosternal or epigastric pain
77
Managent for GORD
* Lifestyle changes (weight loss, stop smoking)
* Antacids
* PPIs (Lansoprazole, omeprazole)
* H2 receptor antagonists (cimetidine)
78
Name a H2 receptor anatgonist
(Blocks hitsamine receptors on parietal cells - reducing acid release)
Cimetidine
79
Name a complication of GORD (and what it involves)
**Barrett's oesopahgus**
* Squamous epithelium → columnar epithelium (with goblet cells)
* Risk of progressing to oesophageal cancer - **premalignant** for **adenocarcinoma** of oesophagus
**Oesophaeal adenocarcinoma **
**Benign oesophageal stricture**
80
What is a peptic ulcer?
81
What is a peptic ulcer?
Ulceration of the stoamch (gastric ulcer) or duodenum (dupdenal ulcer)
82
How do you differentiate between a gastric and duodenal ulcer?
Duodenal ulcer = less pain after eating
Gastric ulcer = more pain after eating
83
Rx for peptic ulcers
* Helcibacter pylori infection
* NSAID use
* Smoking
* Increasing age
84
Pathiophysiology of peptic ulcer
The stomach mucosa = prone to ulceration from:
- Breakdown of the protective layer (in stomach + duodenum)
- Increase in stomach acid
85
Patient presents with epigastric pain, dyspepsia, bloating, haematemesis (coff-ground vomiting), melaena and is nauseous. Possible diagnosis?
Peptic ulcer
86
Key presentations of a peptic ulcer
* Epigastric pain
* N+V
* Dyspepsia
* Iron deficency anaemia (due to constant bleeding)
* Bleeding causes: haematemesis, 'coffee ground' vomiting, malaena
87
Red flags for cancer
* Unexplained wt loss
* Anaemia
* GI bleeding
* Dysphagia
* Upper abdominal mass
* Persistent vomiting
88
Sx to distinuish between gastritis and peptic ulcer
Both have dyspepia and haematemesis
Peptic ulcer pain is better (duodenal) or worse (gastric) after eating
89
Ix for peptic ulcer disease
* First line: Upper gastrointestinal endoscopu
* Rapid urease test (for H. pylori)
* FBC
* Biopsy (exclude malignancy)
* Stool antigen test (for H. pylori)
90
Differential diagnoses for peptic ulcer dsease (PUD)
* Oespophageal cancer
* Stomach cancer
* GORD
* Biliary colic
91
Managment for peptic ulcer disease
Antibiotics for H. pylori and PPIs (CAP)
H2 antagonists (**cimetidine**)
92
Complications of peptic ulcers
* Bleeding → anaemia or life-threatening haemorrhage
* Perforation → peritonitis
* Scarring + strictures → pyloric stenosis
93
Examination signs of peritonitis
* **Localised guarding**
* **Rebound tenderness**
* Fever
* Tachycardia
94
Patient presents with abdominal pain (worse with moving), houlder tip pain. O/E tachycardiac, fever, localised guarding and rebound tenderness. Diagnosis?
Peritonitis
95
Where do upper GI bleeds occcur?
Oesophagus, stomach, duodenum
(Above the ligament of Trietz)
96
Causes of upper GI bleeds
* **Oesophageal varices**
* **Peptic ulcers** (most common)
* Mallory-Weiss tear (tear of the oesophageal mucous membrane)
* Cancers of stomach or duodenum
97
Signs of an upper GI bleed
* **Haematemesis**
* **'Coffee ground' vomit **
* **Melaena**
* Haemodynamic instability
98
Unsure: Signs of oesophageal varices
Jaundice (for ascites in liver disease)
99
Blood tests (first line) for upper GI bleed
* Haemoglobin (FBC)
* Urea (U&Es)
* Coagulation (INR, FBC for platelets)
* Liver disease (LFTs)
100
What two risk assessment scores are used to assess an upper GI bleed?
Glasgow Blatchford score
Rockall Score
101
What is the Glasglow Blatchford score used for?
Upper GI bleed
(Whether you should send the patient home or not)
| Drop in Hb, rise in urea, BP, HR, melaena, syncope
102
What happens to the urea levels during an upper GI bleed?
Increases
103
What is the Rockall Score used for?
Upper GI bleed assessment:
Used for patients that have had an **endoscopy** - to calculate their risk of **rebleeding** + **mortality**
104
Management of a variceal bleed
* Suspect in patients with a history of liver disease or alcohol excess
* Antibiotics and Terlipressin reduce moratilty
* Endoscopy within 12 hours
105
Patient presents with an upper GI bleed with a history of liver disease / excessive alcohol use. Probably cause?
Variceal bleed
106
Patient presents with an upper GI bleed with a history of peptic ulcers and uses NSAIDs
Non-variceal bleed
(peptic ulcer/Mallory-Weiss tear)
107
Management of a non-variceal bleed
* Suspect in patients with a history of peptic ulcers; using certain medications: NSAIDs, anticoagulant or antiplatelets
* Consider proton pump inhibitors
* Endoscopy with 24 hours
108
Variceal bleed
* Suspect with liver cirrhosis
* Portal hypertension → a lot of pressure backed up behind
* Give antibiotics → liver cirrhosis damages the immune system → can get septic (bacteria from the GI tract can enter the bloodstream)
109
What is the definitive treatment of an upper GI bleed?
(Variceal and non-variceal)
Oesophagogastroduodenoscopy (OGD) → provide interventions to stop bleeding
* Variceal bleed → band ligation
* Non-variceal bleed → cauterisation, clips
110
Zero to Finals management of an upper GI bleed
ABATED
- **A** – **A**BCDE approach to immediate resuscitation
- **B** – **B**loods
- **A** – **A**ccess (ideally 2 large bore cannula)
- **T** – **T**ransfuse
- **E** – **E**ndoscopy (arrange urgent endoscopy within 24 hours)
- **D** – **D**rugs (stop ***anticoagulants*** and ***NSAIDs***)
111
What is a Mallory-Weiss tear?
Linear mucosal tear occuring at the oesophagogastirc junction
(Caused by a sudden increase in intra-abdominal pressure)
112
A 30 y/o man has been ill recently with a chronic cough and using NSAIDs. He presents to A&E with haematemesis after recurrent coughing. Also complains of abdominal pain and dizziness. His stool is also tar-like. Possible diagnosis?
Mallory-Weiss tear
113
First line and diagnostic tests for a Mallory-Weiss tear
First line: U&Es (elevated urea in patients with ongoing bleeding)
Gold standrd: Upper GI endoscopy
114
Management for a Mallory-Weiss tear
* Haemorrhage is self-limiting in 80-90% cases (supportive treatment)
* Active bleeding → therapeutic endoscopy
115
Complications of Mallory-Weiss tear
* Re-bleeding
* Oesophageal shock/death
* Hypovolaemic shock/death
* MI
116
When does a Mallory-Weiss tear normally present?
Commonly presents with haematemesis after an episode of forceful or recurrent retching, vomiting, coughing, or straining.
117
What are the differences between a Mallory-Weiss tear and oesophageal varices?
Pain → Mallory-Weiss tear (forceful tear
Painless → Oesophageal varices (dilation)
118
What is an oesophageal varices?
Painless bleeding of dilated submucosal veins in the lower 1/3 of the oesphagus - due to portal hypertension
119
Where is McBurney's point located?
Lies 2/3 of the way from the umbilicus to the naterior superior iliac spine (ASIS)
120
Peak age and sex of appendicitis?
Age: 10-20
M>F
121
Signs O/E that suggest appendicitis?
* Tender mass in RIF
* Guarding on abdominal palpation
* Rovsing's sign
* Rebound tenderness with palpation
* Percussion tenderness
122
What is Rovsing's sign?
Palpation of left iliac fossa = causes pain in the right iliac fossa
(Indicative of appendicitis)
123
What do abdominal rebound tenderness + percussion tenderness suggest?
Peritonits
(possibly from a ruptured appendix)
124
First line and gold standard investigations of appendicitis?
* First line: Clinical diagnosis, bloods (FBC (rasied WBC) and elevated CRP + ESR), pregnancy test
* Gold standard: CT abdomen, ultrasound (exclude gynaecological pathology)
125
Differential diagnosis for appendicitis (/RIF pain)?
* Ectopic pregnancy
* Ovarian cysts
* Meckel's diverticulum
* Perforated ulcer
126
Treatment of appendicitis?
Laproscopic appendectomy
127
What is a major complication of appendicitis?
(indicated by rebound tenderness and percussion tenderness O/E)
Peritonitis
128
Define diverticular disease
When diverticula cause symptoms - e.g. LLQ pain
129
Define diveriticulitis
If diverticula become inflamed or infected - causing more severe symptoms
130
Difference between true and false diverticula
* True - all layers
* False (pseudo) - no muscle layer
131
Is diverticulitis or diverticulosis associated with rectal bleeding?
Diverticulosis
(In diverticulitis - the blood vessels are scarred from inflammation)
132
Difference in presentation between diverticulosis and diverticulitis
Diverticulosis:
* Rectal bleeding
* Usually no symptoms
Diverticulitis:
* No bleeding
* LLQ pain
133
Which part of the colon are diverticulum most commonly found?
Sigmoid colon
(Smallest diameter and higher pressure)
(hence LLQ pain diveriticulitis)
134
Rx for diverticulosis
* Low fibre diet, constipation
* Increasing age
* Use of NSAIDs
* Connective tissue disorders (Marfan, Ehlers-Danlos syndrome)
135
Sx of diverticulosis
* Often asymptomatic
* Rectal bleeding (fresh blood in stool)
* Vague abdominal pain, tenderness, bloating, altered bowel habit (diarrhoea/constipation)
136
First line and gold standard of diverticulosis
* First line: Colonoscopy, sigmoidoscopy
* Gold standard: CT scan
* (Other: X-ray with barium enema)
137
First and second line managment for diverticulosis
* First: Lifestyle changes (increase fibre intake - avoid constpation), weight loss, smoking cessation
* Second: Surgical resection (if complicatiopns develop)
138
Define diverticulitis
Inflamed diverticula
(Micro-perforation of the diverticulum - causing more severe symptoms)
139
Big risk factor of diverticular disease
Low fibre-containing diet
140
Patient presents with a fever, leukocytosis and LLQ pain. The pain comes and goes, worse after eating, defacation and farting eases it. Rectal bleeding and diarrhoea. Possible diagnosis?
Diverticulitis
LLQ (often sigmoid colon)
141
Presentation of divericulitis
* LLQ pain
* **Fever**
* Diarrhoea
* N+V
* Rectal bleeding
* Raised inflammatory markers
142
Patient presents with diverticulitis. What first and second line investigations would you perform?
First line: Abdominal x-ray (Bowel obstruction + perforation) + bloods (leucocytosis)
Second line: CT abdomen with contrast
143
Management of diverticulitis
* Oral co-amoxiclav (at least 5 days)
* Analgesia (avoid NSAIDs + opiates)
* Fluids
* Surgical resection
* High fibre diet (prevents recurrence)
144
Complications of diverticulitis
* Ileus, obstruction
* Peritonitis
* Fistula communication
* Lower GI bleeding (bloody stool)
145
What is Meckel's Diverticulum
Congenital malformation of the small bowel (others are large bowel) - that results in a true diverticulum
146
What condition does the 'rule of 2s' relate to?
Meckel's Diverticulum
* Symptomatic presentation before 2 years
* 2 inches in length
* 2 types of ectopic mucosa - pancreatic, gastric)
147
Sx of Meckel's diverticulum
* Melaena
* Abdominal distension/pain
* **Constipation**
* Vomiting
148
Ix for Meckel's diverticulum
- FBC
- Technetium-99m pertechnetate scan (’Meckel’s scan’)
- Detects gastric mucosa in diverticulum
- CT scan of abdomen and pelvis
- Ultrasound of the abdomen
149
Differential diagnoses for Meckel's diverticulum
* Appendicitis
* Biliary colic
* Gastroenteritis
* IBD
* IBS
* Peptic ulcer disease
150
Management of symptomatic Meckel's diveriticulm
Surgical ressection of diverticulum, intestine
151
Complications of Meckel's diverticulum
* Diverticulitis
* Perforation of diverticulum
* Food impaction
* Peritonitis
* Peritoneal adhesions
152
What is a volvulus?
Twist/rotation of segment of bowel
153
What are abdominal adhesions?
Abdomial structures sticking to one another
154
What is an intussusceptio?
Part of the intestine that slides into an adjacent part of the intestines
155
Where are bowel obstructions most common?
Small bowel
(Small bowel obstruction is more common than large bowel)
156
What pathophysiology occurs when there is a bowel obstruction?
Obstruction results in a build up of gas + faecal matter proximal to the obstruction → back pressure → vomiting + dilation of the intestines proximal to the obstruction
157
Is a bowel obstruction a medical emergency?
Yes - surgical emergency
158
When can 'third-spacing' occur?
**Bowel obstruction**
Third-spacing = hypovolaemic shock
The fluid stays in the GI tract not the blood
159
What are the big three causes of bowel obstruction?
HAM:
H -Hernias (small bowel)
A - Adhesions (small bowel)
M -Malignancy (large bowel)
160
Causes of a bowel obstruction
In the lumen:
* Tumours (carcinoma, lymphoma)
In the wall:
* Tumours
* Crohn's
* Diverticulitis
From the outside:
* Tumours (disseminated malignancy of peritoneum)
* Adhesions post surgery
* Volvulus
161
What is a closed-loop obstruction?
Closed-loop obstruction = a situation where there are two points of obstruction along the bowel; meaning that there is a middle section sandwiched between two points of obstruction.
162
Causes of a closed-loop obstruction
* Adhesions
* Hernias
* Volvulus
* Obstriction in large bowel and a competent Ileocaecal valve
163
Why are closed-loop obstructions so dangerous?
Exapand → ischaemia → perforation
164
Patient presents with green bilious vomiting, abdominal pain (diffuse) + distension, and said that he hasn't passed a stool of fluatulence in a couple of days. Possible diagnosis?
Bowel obstruction
165
Gold standard investigation for bowel obstruction
Abdomen CT with contrast
166
First line tests for a bowel obstruction
Venous blood gas:
* Metabolic alkalosis
* Raised lactate (bowel ischaemia)
U&Es
* Electrolyte imbalances
167
What is the initial management for a bowel obstruction?
'Drip and suck'
- ***Nil by mouth*** (don’t put food or fluids in if there is a blockage)
- ***IV fluids*** to hydrate the patient and correct electrolyte imbalances
- ***NG tube*** with ***free drainage*** to allow stomach contents to freely drain and reduce the risk of vomiting and aspiration
168
What is the definitive management for a bowel obstruction?
*Laproscopic or laparotomy
* Exploratory surgery
* Adhesiolysis
* Hernia repair
* Emergency resection
* Stent
169
Causes of small bowel obstruction
* Adhesions
* Hernia
* Malignancy
* Crohn's
170
What does an untreated bowel obstruction lead to?
PIN
* Perforation
* Ischaemia
* Necrosis
171
Key presentation of a small bowel obstruction
* Abdominal pain
* Bloating
* Vomiting
* Failure to pass flatus or stool per rectum
172
Pain associated with SBO?
Colicky (starts and stops then diffuse)
SBO pain is higher in the abdomen in LBO
173
Investigations for small bowel obstruction
Abdominal x-ray or CT
FBC (low haemocrit - indicating blood loss)
U&Es (hypokalaemia)
ABG (metabolic alkosis - vomiting up gastric acid, elevated lactate - indicate poor tissue perfusion)
174
Most common cause of a large bowel obstruction?
Colorectal malignancy
Then volvulus
175
First line investigation for large bowel obstruction
Digital rectum exam (empty rectum, hard stools and blood).
FBC (low Hb)
176
Complications of bowel obstruction
* Bowel perforation
* Sepsis
* Death
177
What type of neoplasm is gastric cancer?
Aggresive adenocarcinoma
178
Rx for gastric cancer
H. pylori (peptic ulcers)
Smoking
Increasing
179
65 y/o patient presents with constant + severe epigastric pain, weight loss, anaemia, and later develops jaundice
Gastric cancer
180
Ix for gastric cancer
FBC
OGD + biopsy
CT/MRI, abdomen and pelvis
PET scan
| Upper GI endoscopy + biop - showing carcinoma. Staging based on imagaing
181
Differential diagnosis for gastric cancer
Peptic ulcer disease
182
Management of gastric cancer
* Nutritional support
* Surgical resection + chemotherapy combination
183
Complications for gastric cancer
- Metastasis → liver, peritoneum, lymph nodes
- Weight loss
- Nutritional deficiency
- Indigestion (dyspepsia)
- Osteopenia or osteoporosis
- Diarrhoea
- Fatigue
184
What type of neoplasm are oesophageal cancers?
* Squamous cell carninomas (upper + middle third)
* Adenocarcinomas (lower third + cardia of stomach)
185
Major cause of oesophageal adenocarcinoma
GORD
186
Rx for oesophageal cancer
- Oesophageal squamous cancer
- Smoking
- Alcohol
- Oesophageal adenocarcinoma
- Obesity
- Achalasia
- **Barrett’s oesophagus**
187
Describe the process of Barrett's oesophagus and oesophageal cancer
Chronic exposure to irritants → metaplasia → dysplasia → malignant transformation
188
Define dysplasia
Dysplasia = the presence of cells of an abnormal type within a tissue, which may signify a stage preceding the development of cancer.
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3 Key Sx of oesophageal cancer
Dysphagia, weight loss, pain
| Dysphagia - difficulty swallowing solids at first → then fluids.
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Ix for oesophageal cancer
OGD + biopsy
CT thorax + abdomen → tumour staging
PET Scan (accuracy for staging, detects metastatic disease)
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Complications for oesophageal cancer
- Oesophageal obstruction
- Regurgitation → aspiration → aspiration pneumonia
- Metastasis
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Type of neoplasm for colorectal cancer
Adenocarcinoma
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Achalasia
An oesophageal motor disorder characterised by a loss of oesophageal peristalsis and failure of the lower oesophageal sphincter to relax in response to swallowing.
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How does achalasia present?
* **Intermittent dysphagia**
* Retrosternal pressure/pain
* Regurgitation
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Differentials for generalised abdominal pain
- Peritonitis
- Ruptured abdominal aortic aneurysm
- Intestinal obstruction
- Ischaemic colitis
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Differentials for RUQ pain
* Biliary colic
* Acute cholecystitis
* Acute cholangitis
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Differentials for epigastric pain
* Acute gastritis
* Peptic ulcer disease
* Pancreatitis
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Differentials for central abdominal pain
* Ischaemic colitis
* Intestinal obstruction
* Early stages of appendicitis
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Differentials for RIF pain
* Acute appendicitis
* Meckel's divertiticulitis
* Ectopic pregnancy
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Differentials for LIF pain
* Diverticulitis
* Ectopic pregnancy
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Family history risk factors for colorectal cancer
* Familial adenomatous polyposis (FAP)
* Lynch syndrome (hereditary non-polyposis colorectal cancer (HNPCC))
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Pathological progression of colorectal cancer
Normal epithelium → adenoma → colorectal adenocarcinoma → metastatic colorectal adenocarcinoma
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Old classification for colorectal cancer
Duke Stage
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Name the stages of the Duke Stages
* A - Mucosa only
* B - Extends into submucosa (muscle wall)
* C - Regional lymph nodes
* D - Metastatic disease
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What are the red flags to consider for colorectal cancer
- Change in bowel habit (usually to more loose and frequent stools)
- Unexplained weight loss
- Rectal bleeding
- Unexplained abdominal pain
- Iron deficiency anaemia (microcytic anaemia with low ferritin)
- Abdominal or rectal mass on examination
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How does right-sided colorectal carcinoma present?
* Usually asymptomatic
* Iron deficiency anaemia due to bleeding
* Wt loss, abdominal pain
* WOMEN MORE LIKELY
* WORSE PROGNOSIS
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How does left-sided + sigmoid carcinoma present?
* Change in bowel habit with blood and mucus in stools
* Diarrhoea
* Alternation constipation and diarrhoea
* Thin/altered stool
* MEN MORE LIKELY
* BETTER PROGNOSIS
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Sx of rectal carcinoma
- Rectal bleeding and mucus
- When cancer grows, it will have **thinner stools** and **tenesmus** (cramping rectal pain)
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First line Ix for colorectal cancer
* Digital rectal examination
* Double contrast barium enema
* Faecal immunochemical tests (FIT)
| FIT = amount of human Hb in stool (highly specific)
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Gold standard Ix for colorectal cancer
* Colonscopy + biopsy
* Sigmoidoscopy (endoscopy of rectum + sigmoid rectum)
* CT colonography
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Other Ix for colorectal cancer
Staging CT scan
(CT TAP)
Look for metastasis
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Management options for colorectal cancer
* Adenoma - endoscopic resection
* Colorectal adenocarcinoma - surgical resection
* Metastatic colorectal adenocarcinoma - chemotherapy palliative care
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Main infectious casusative organisms for diarrhoea
* Children → rotavirus
* Adults → norovirus, campylobacter
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Antibiotics for induced C. Diff diarrhoea
**Rule of Cs**
* Clindamycin
* Ciprofloxacin (quinolones)
* Co-amoxiclav (penicillins)
* Cephalosporins (particularly 2nd and 3rd generation)
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Patient presents with watery diarrhoea - what location of the bowel is infected? Infammatory or not?
Watery diarrhoea:
* Non-inflammatory
* Proximal small bowel
* Viruses can play a role
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Patient presents with blood mucoid diarrhoea. What's happening?
Bloody, mucoid diarrhoea:
* Inflammatory
* Colon
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What does the onset history for diarrhoea mean?
* Acute - viral/bacterial
* Chronic - parasites and non-infectious
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Name the characteristic of diarrhoea
* Floating - fat content malabsorption/coeliac
* Blood or mucus - inflammatroy, invasive, infection, cancer
* Watery - small bowel infection
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Infectious causative organisms for food poisoning diarrhoea
* Meat/BBQs - campylobacter
* Poultry - salmonella
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3 Stool tests for diarrhoea
* Stool culture
* Faecal calprotectin
* Faecal occult blood
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Blood tests diarrhoea
* FBC
* Inflammatory markers (FBC/CRP)
* Blood culture
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What bacteria causes a rice water diarrhoea?
Vibrio cholerae
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Managment for cholera
Doxycycline + fluids
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Rx for infective diarrhoea
* Foreign travel
* PPI or H2 antagonist use
* Crowded area
* Poor hygeine
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Diagnosis for infective diarrhoea
Diagnosis - 3 or more unformed stools per day plus one of the following:
- Abdominal pain
- Cramps
- Nausea
- Vomiting
- Dysentery
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What does blood in infective diarrhoea suggest?
Bacteria
E. coli + shigella
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Antibiotics for infective diarhhroea
Metronidazole pr oral vancomycin
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Cancer risk factors for diarrhoea
* Over 50
* Chronic diarrhoea
* Weight loss
* Blood in stool
* Family history of cancer
