Gastrointestinal Flashcards
Name 2 main forms of chronic autoimmune inflammatory bowel diseases
Ulcerative Colitis - Only affects the colon (mucosa)
Crohn’s Disease - Can affect any part of the gut from mouth to anus
Define ulcerative colitis
Describes a relapsing remitting inflammatory bowel disease characterised by diffuse, continuous superficial inflammation of the colonic mucosa
Where does ulcerative colitis mainly affect?
Most commonly affects the rectum, but may extend into the sigmoid colon, beyond the sigmoid or include the entire colon.
US never spreads proximal to the ileocecal valve.
Give 4 risk factors for Ulcerative Colitis
Positive Family History
HLA-B27
Infection (50% of relapses are associated with enteritis)
NSAIDS (may exacerbate UC)
Describe the epidemiology of Ulcerative Colitis (3)
Age of onset = 20-40 years old
Slight female predominance
3x more common in NON smokers
Describe the macroscopic pathophysiology of ulcerative colitis
Most cases arise from the rectum. Mucosal inflammation leads to oedema, ulcers, bleeding and electrolyte loss.
Mucosal inflammation progresses in a continuous uninterrupted fashion to the proximal colon.
Describe the microscopic pathophysiology of ulcerative colitis (4)
Never extends further than the submucosa.
Neutrophils invade crypts of Lieberkuhn, forming crypt abscesses (UC hallmark)
Depletion of goblet cells and mucin
Ulcerated areas become covered by granulomatous tissue, forming polyps (pseudocysts)
How does Ulcerative Colitis appear on a barium enema
Lead pipe appearance of colon
(loss of haustral markings)
Give 5 intestinal symptoms of ulcerative colitis
Diarrhoea (episodic or persistent) +/- Blood (blood more associated with UC than Crohn’s)
Faecal urgence and/or incontinence
PR bleeding +/- mucus
Abdominal pain (lower left quadrant)
Tenesmus (painful urge to pass stool)
Give 6 extraintestinal symptoms of Ulcerative Colitis
Uveitis
Primary Sclerosing Cholangitis
Colorectal cancer
Pallor, clubbing, mouth ulcers
Erythema nodosum
Pyoderma gangrenosum
What tests are performed to diagnosed Ulcerative Collitis? (5)
Colonoscopy + Biopsy
Barium enema (lead pipe appearance)
Abdominal x-ray (megacolon)
Faecal calprotectin (elevated - intestinal inflammatory marker)
Stool sample (to exclude infections - c.diff, E.coli, Shigella ect)
What additional tests would be useful to conduct in ? Ulcerative Colitis to exclude other pathologies? (4)
Upper intestinal endoscopy (exclude Crohn’s)
Coeliac serology (exclude coeliac)
Thyroid function tests (exclude hyperthyroidism)
U&Es (to assess dehydration/electrolyte disturbance)
What criteria is used to classify Ulcerative Colitis?
Truelove and Witts Criteria
Describe the Truelove and Witts Criteria for mild Ulcerative Colitis
Motions - <4
PR bleed - Small
Temp - Apyrexic
HR - <70
Hb >11
ESR <30
Describe the Truelove and Witts Criteria for Moderate Ulcerative Colitis
Motions - 4-6
PR bleed - Moderate
Temp - 37.1-37.8
HR - 70-90
Hb - 10.5-11
Describe the Truelove and Witts Criteria for Severe Ulcerative Colitis
Motions - >6
PR bleed - Large
Temp - >37.8
HR - >90
Hb - <10.5
ESR - >30
What type of surveillance is it important for Ulcerative Colitis patients to have?
Colonoscopic Surveillance for colorectal cancer
What is the goal of treatment for Ulcerative Colitis?
To induce and maintain remission
Describe the treatment for Mild-Moderate Proctitis (Ulcerative Colitis localised to the rectum) (1st, 2nd, 3rd line and maintaining remission)
1st line - Topical Aminosalicylate (Mesalazine)
2nd line - Oral Aminosalicylate (Sulfasalazine)
(If remission not achieved within 4 weeks)
3rd line - Topical Hydrocortisone or Oral Prednisolone
Maintain remission - Oral/Topical aminosalicylate
Describe the treatment for mild-moderate proctosigmoiditis/left sided Ulcerative Colitis (1st, 2nd, 3rd line and maintaining remission)
1st line - Topical Aminosalicylate (mesalzine)
2nd line - High dose oral aminosalicylate (sulfasalazine) (if remission not achieved in 4 weeks)
3rd line - Oral Aminosalicylate (sulfasalazine) + Oral Prednisolone (Stop topical aminosalicylate)
Maintain remission - Oral/topical aminosalicylates
Describe the treatment for mild-moderate extensive Ulcerative Colitis (1st, 2nd line and maintaining remission)
1st line - Topical aminosalicylate (mesalazine) + High dose oral aminosalicylate (sulfasalazine)
2nd line - Oral aminosalicylate (sulfasalazine) + Oral Prednisolone
Maintain remission - Oral aminosalicylate (sulfasalazine)
Describe the treatment for severe ulcerative colitis
1st line - Anti- TNFa monoclonal antibody - Infliximab
2nd line - Monoclonal antibody - Ustekinumab
What is the treatment for Acute Severe Ulcerative Colitis requiring hospitalisation? (1st, 2nd, 3rd line)
1st line - IV corticosteroids +/- Surgery
2nd line - IV Ciclosporin
3rd line - Infliximab
Patients with acute severe ulcerative colitis may need surgery if? (5)
Passing stool >8x per day
Pyrexic
Tachycardic
Abdominal X-ray showing megacolon
Low albumin, low Hb, High platelet count or CRP >46mg/L
What medication should ulcerative colitis patients receive following a severe relapse or >=2 exacerbations in the past year?
Oral azathioprine or oral mercaptopurine
What do Oral thiopruines (azathioprine or mercaptopurine) increase the risk of developing?
Non-melanoma skin cancer
Describe Crohn’s Disease
Describes a chronic, relapsing-remitting inflammatory disease of the gastrointestinal tract.
Unlike UC which is continuous, Crohn’s inflammation involves discrete parts (skip lesions) of the GI tract, anywhere from the mouth to the anus.
Additionally, the full thickness of the intestinal wall is inflamed (unlike UC which is just the mucosa)
Where in the GI tract is usually most affected in Crohn’s disease?
Terminal ileum
Give 5 risk factors for Crohn’s Disease
Positive Family History
Smoking
Infectious gastroenteritis (caused by rota/norovirus)
Appendicectomy
Drugs (NSAIDs increase risk of relapse and exacerbation)
Give 6 pathophysiological features of Crohn’s Disease
Can occur anywhere from mouth to anus
Involves all 4 layers of the intestinal wall
Skip lesions
Cobblestone appearance
Granuloma formation (non-caseating)
Increase in goblet cells
What are the 4 layers of the intestinal wall?
Mucosa
Submucosa
Muscularis propria
Serosa
Give 5 complications of Crohn’s Disease
Fistula formation (Abnormal connections)
Intestinal strictures (obstruction)
Perianal disease (fistulas, fissures, abscesses)
Osteoporosis
Anaemia (iron, vitamin B12, folate deficiency)
Give 5 clinical features of Crohn’s Disease
Non-bloody diarrhoea (unexplained and persistent)
Lower right quadrant abdominal pain/tenderness/mass
Weight loss/failure to thrive in children
Perianal disease (fissures, fistulas, abscesses)
Bowel obstruction (strictures)
What eye problem can occur in Crohn’s disease?
Episcleritis
What investigations are required for diagnosis of Crohn’s disease? (3)
Colonoscopy (Shows deep ulcers, skip lesions, cobblestone appearance, rectal sparing)
Histology (biopsy showing inflammation across all intestinal layers, also shows increased goblet cells and granulomas)
Small bowel enema (may show Kantor’s String sign or Rose Thorn Ulcers in terminal ileum)
What may be seen on a small bowel enema for a patient with Crohn’s Disease? (2)
Kantor’s String Sign (severe narrowing)
Rose Thorn Ulcers in terminal ileum.
What is the goal of treatment for Crohn’s Disease?
To induce and maintain remission
Describe the treatment used to induce remission in Crohn’s Disease (1st, 2nd and 3rd line)
1st line - Glucocorticoids (Prednisolone, methylprednisolone, IV hydrocortisone)
2nd line - Aminosalicylates (mesalazine or sulfasalazine)
3rd line - TNF-a inhibitor monoclonal antibodies (Infliximab/Adalimumab)
Describe the treatment used to maintain remission in Crohn’s disease (1st and 2nd line)
1st line - Thiopurines (Azathiopurine and Mercaptopurine)
2nd line - DMARD (methotrexate)
When should Crohn’s patients be considered for surgery? (3)
Failure to respond to medical treatment
Intestinal Obstruction or Perforation (fistula)
Massive haemorrhage
What treatment should Crohn’s patients whom have undergone surgery be offered to maintain remission?
Azathioprine + Metronidazole (antibiotic) for up to 3 months.
Describe the differences between Ulcerative Colitis and Crohn’s with regards to diarrhoea
UC - Bloody diarrhoea
Crohn’s - Not usually bloody
Describe the differences between Ulcerative Colitis and Crohn’s with regards to pathology and location
UC;
Inflammations always starts at the rectum and never spreads beyond the ileocecal valve.
Inflammation is continuous.
Crohns;
Lesions may be anywhere from the mouth to the anus.
Inflammation is discontinuous (skip lesions are usually present)
Describe the differences between Ulcerative Colitis and Crohn’s with regards to histological features.
UC;
Inflammation never spans beyond the submucosa.
Goblet cells and mucin become depleted
Neutrophils invade crypts of Lieberkuhn forming crypt abscesses
Crohns;
Inflammation spans through all intestinal layers (mucosa to serosa)
Increase in goblet cells
Formation of granulomas
Describe the differences between Ulcerative Colitis and Crohn’s with regards to what may be seen on endoscopy
UC;
Widespread ulceration with preservation of of adjacent mucosa - Pseudopolyps
Crohns;
Deep ulcers, skip lesion giving the lumen a cobblestone appearance
Describe the differences between Ulcerative Colitis and Crohn’s with regards to complications
UC - Colorectal cancer
Crohn’s - Obstruction (structure), Perianal disease, colorectal cancer
Describe the differences between Ulcerative Colitis and Crohn’s with regards to associations
UC - Primary Sclerosing Cholangitis
Crohns - Gallstones (secondary to reduced bile acid reabsorption)
Define coeliac disease
Aka gluten sensitive enteropathy.
Coeliac disease describes a T cell mediated, chronic autoimmune disorder triggered by exposure to ingested gluten
What foods components will you find gluten?
Wheat, Barley and Rye
How and Where does coeliac disease commonly manifest?
Commonly manifests in the duodenum as villous atrophy and malabsorption.
Give 3 associations for Coeliac Disease
HLA-DQ2 and HLA-DQ8
Autoimmune disorders (T1DM, Hashimotos, IgA deficiency)
Herpetiformis (a vesicular pruritic skin eruption)
Describe the pathophysiology of coeliac disease
Gluten is ingested < Gliadin (component of gluten) interacts with interstitial cells > triggers uptake of gliadin into lamina propria.
Within, gliadin is delaminated by tissue transglutaminase (tTG) > gliadin binds HLA-DQ2/8 receptors and presents on surface of CD4+ T cells > production of anti-gliadin and anti-tissueglutaminase antibodies.
Triggers immune response > villous atrophy
What antibodies are present in coeliac disease
Anti-gliadin and Anti-transglutaminase antibodies
Give 3 complications of coeliac disease
Depression, anxiety, eating disorders
Delayed growth/puberty in children
Nutritional deficiencies (iron, B12, folate, osteoporosis)
Give 5 gastrointestinal symptoms of coeliac disease
Diarrhoea
Steatorrhoea + foul smelling stools
Abdominal pain
Weight loss/Failure to therive
Aphathous ulceration
Give 4 non-GI features of coeliac disease
Dermatitis herpetiformis (blisters on elbows, knees, buttocks and scalp)
Ataxia/Peripheral neuropathy
Infertility or recurrent miscarriage
Symptoms of anaemia
What is the gold standard test used to confirm diagnosis of coeliac disease? What will this show?
Small Bowel Endoscopy and Histology
Endoscopy shows; flat mucosa with no villi, very smooth intestinal mucosa
Histology shows; Villous atrophy, Crypt Hyperplasia, Increased intraepithelial lymphocytes
What features are present on histology for coeliac disease? (3)
Villous atrophy
Crypt hyperplasia
Increased intraepithelial lymphocytes
What a the first line investigation for ? coeliac disease? Describe this (4)
Coeliac serology;
1st line - IgA-tTG (Tissue Transglutaminase) - Raised
2nd line - Endomyseal antibody (IgA-EMA) - Raised
3rd line - IgA deficiency (conduct if both IgA-tTG and IgA-EMA are negative)
4th line - If IgA deficiency is present, test for IgG GDP (deaminated gliadin peptide)
What additional blood tests would be important to consider in coeliac disease? (3)
FBC/Ferritin - Screen for anaemia and iron deficiency
TFTs - Screen for Hashimoto’s thyroiditis
LFTs - Screen for autoimmune hepatitis, PBS, PSC
How is coeliac disease managed? (3)
Long term adherence to gluten free diet
Assess osteoporosis risk with DEXA
inform 10% risk for 1st degree family members
Why is it important for coeliac patients to receive vaccinations? What vaccinations should they recieve?
Coeliac patients often have a degree of functional hyposplenism.
Recommended all patients have the pneumococcal vaccine and has a booster every 5 years.
Define appendicitis
Describes an acute inflammation of the appendix and is the most common surgical emergency.
How does appendicitis commonly present
Umbilical pain that moves to the lower right quadrant (McBurney’s Point)
What is the appendix anatomically connected to?
Caecum
What is the most common cause of appendicitis?
Luminal obstruction by faecolith
Give 5 complications of appendicitis
Abscess formation
Peritonitis
Sepsis
Intra-abdominal adhesions
Bowel obstruction
Between what ages does appendicitis most commonly present?
Between 10-20 years old
Give 5 clinical features of appendicitis
Umbilical pain that moves to the lower right quadrant (McBurney’s point tenderness)
Abdominal guarding and rebound tenderness (peritonitis)
Low grade fever, pyrexia, malaise and anorexia
Nausea and vomiting
Constipation
Name and describe 3 signs associated with appendicitis
Rovsing’s sign - Pain greater in the RIF when LIF is pressed
Psoas sign - Pain on extending the hip (retrocaecal appendix)
Copes sign - Pain on flexion and internal rotation of right hip (pelvic appendix)
Give 4 differentials for appendicitis
Intestinal obstruction
Gastroenteritis
Incarcerated inguinal hernia
Perforated peptic ulcer
What are the 2 main histological types of oesophageal cancer? Which is most common?
Adenocarcinoma (most common) - linked to Barrett’s oesophagus and GORD (lower)
Squamous cell carcinoma (linked to smoking, alcohol, achalasia and Plummer-Vinson syndrome) (upper)
Give 4 risk factors for oesophageal cancer
Low Socioeconomic status
Alcohol, Obesity, Smoking
Barrett’s oesophagus (GORD)
Plummer Vinson Sundrome
What form of metaplasia is seen in Barrett’s Oesophagus?
Metaplasia of lower oesophageal squamous epithelial cells to columnar epithelial cells
What triad is seen in Plummer Vinson Syndrome? What type of oesophageal cancer is it associated with?
Triad;
Dysphagia
Iron deficiency anaemia
Oesophageal webs
Associated with squamous cell carcinomas (upper oesophageal cancers)
Give 5 clinical features of oesophageal cancer
*Usually advanced at presentation
Dysphagia (difficulty swallowing), Odynophagia (pain when swallowing), Reflux
Weight loss (unexplained)
Retrosternal chest pain
Nausea and vomiting
Hoarseness, Hiccups, postprandial/paroxysmal cough
What is the 1st line investigation for oesophageal cancer?
Upper GI endoscopy with biopsy
When should an urgent referral be made for a patient with ? oesophageal cancer? (2)
Dysphagia
Are >55 with weight loss and Reflux, Upper abdominal pain or dyspepsia
What test is used for the initial staging of oesophageal cancer?
Chest CT
What test is used for locoregional staging of oesophageal cancer?
Endoscopic ultrasound
What is the most common procedure used to treat oesophageal cancer?
Ivor-Lewis type oesophagectomy
Define GORD
Gastro-oesophageal reflux disease
Describes symptoms or complications resulting from reflux of gastric contents into the oesophagus, oral cavity or lung.
Give 5 causes of GORD
Lower oesophageal sphincter hypotension
Hiatus hernia
Abdominal obesity/over eating
Alcohol, fat, chocolate, coffee, smoking
Defective oesophageal peristalsis
Name 3 classes of drug that can cause GORD
Tricyclics
Anticholinergics
Nitrates
Give 5 oesophageal symptoms of GORD
Heart burn (retrosternal pain aggravated by bending, stooping or laying down)
Belching
Acid brash (acid/bile regurgitation)
Odynophagia (painful swallowing)
Water brash (increased salivation)
Give 4 extra-oesophageal symptoms of GORD
Asthma (nocturnal)
Chronic cough
Laryngitis (hoarsness, throat clearing)
Sinusitis
Give 4 complications of GORD
Barrett’s oesophagus (increased risk of adenocarcinoma)
Oesophagitis
Duodenal or gastric ulceration
Benign strictures (causing dysphagia)
Name 2 factors that can aggravate heartburn (retrosternal pain) in patients with GORD
Bending, stooping or lying down
Drinking hot drinks or alcohol
Give 3 red flag symptoms for a patient with GORD
Weight loss
Haemoptysis
Dysphagia
How is GORD diagnosed? (2)
No red flag symptoms - Clinically
Red flag symptoms - Endoscopy
When should an endoscopy be performed on a patient with GORD? (4)
Symptoms for >4 weeks
> 55 years old
Red flag symptoms (weight loss, haematemesis, dysphagia)
Persistent symptoms despite treatment
How should GORD that has NOT been investigated with endoscopy be managed? (3)
Treat as dyspepsia;
- Review medications for possible cause of dyspepsia
- Lifestyle advice (weight loss, smoking cessation, small/regular meals, avoid hot drinks, eating before bed)
- Trial of PPI (lansoprazole/omeprazole) for 1 month OR a ‘test and treat’ approach for H.pylori
How should GORD with endoscopically proven oesophagitis be managed? (3)
- Full dose proton pump inhibitor for 1-2 months
- If responds well then low dose treatment as required.
- If doesn’t respond well, double-dose PPI for 1 months.
When should a patient be seen for an urgent cancer referral?
Within 2 weeks
What would warrant an urgent referral for ? oesophageal/stomach cancer? (3)
Patient has dysphagia
Patient has upper abdominal mass consistent with stomach cancer
Patient is >=55 with weight loss AND one of the following;
Upper abdominal pain
Reflux
Dyspepsia
What would warrant a non-urgent referral for ? oesophageal/stomach cancer?
Patient has haematemesis
Patient is aged >=55 with;
Treatment-resistant dyspepsia OR
Upper abdominal pain with low Hb levels OR
Raised platelet count with nausea, vomiting, weight loss, dyspepsia, upper abdominal pain
What test is used to test for H.pylori?
Carbon-13 urea breath test
What type of cancer are the majority of stomach cancers?
Adenocarcinomas
Give 4 risk factors for stomach cancer
H.pylori infection
Smoking
High salt/nitrate diet
Pernicious anaemia
How does H.Pylori cause stomach cancer?
Causes chronic gastritis > atrophic gastritis and pre-malignant intestinal metaplasia > dysplasia and gastric cancer
Give 5 clinical features of stomach cancer
Presents similar to oesophageal cancer
Dysphagia, Odynophagia (pain when swallowing), reflux
Weight loss - red flag
Nausea and vomiting
Upper abdominal mass
Constant and severe epigastric pain
How may advanced (metastatic) stomach cancer present? (2)
Jaundice (liver metastasis)
Virchow’s node (palpable lymph node in the subclavicular fossa - left side)
What clinical sign is distinctively linked to stomach cancer?
Virchow’s node (palpable lymph node usually in left subclavicular fossa)
How is stomach cancer diagnosed? (3)
Gastroscopy with biopsy
Endoscopic ultrasound - evaluate depth and invasion
CT/MRI - for staging
What is the most common type of colorectal cancer?
Adenocarcinoma
Where do the majority of colorectal cancers arise?
Distal colon (sigmoid and rectum)
Give 4 risk factors for colorectal cancer
Genetic factors (loss of APC gene)
Ulcerative Colitis
Crohn’s disease (particularly if ileocecal region affected)
Smoking, alcohol, diet (low fibre, red/processed meats)
What 2 inherited syndromes are strongly linked to colorectal cancer?
Familial adenomatous polyposis (mutation in APC)
Lynch syndrome (hereditary non-polyposis colorectal cancer)
Describe the pattern of inheritance for familial adenomatous polyposis
Autosomal dominant
Describe the pattern of inheritance for lynch syndrome
Autosomal dominant
Familial adenomatous polyposis occurs due to a mutation in what gene?
APC - Adenomatous Polyposis Coli
Give 5 clinical features of colorectal cancer
Abdominal pain
Abdominal/rectal mass
Change in bowel habit (constipation, diarrhoea)
Unexplained weight loss
Rectal bleeding +/- tenesmus
How may colorectal cancer present in an emergency? Give 4 signs of this
May present with signs of obstruction;
Signs;
Absolute constipation
Colicky abdominal pain
Abdominal distension
Vomiting (faeculent - vomit contents is faecal in origin)
Give 3 red flag features of colorectal cancer
> 40 with unexplained weight loss and abdominal pain
> 50 with unexplained rectal bleeding
> 60 with iron deficiency anaemia or changes in bowel habit
How should patients with red flag symptoms be investigated for colorectal cancer?
Do NOT offer Faecal Immunochemical Test (FIT).
Go straight to colonoscopy.
What test is used to screen for colorectal cancer?
Faecal Immunochemical Test (FIT test)
Describe how the NHS screen for colorectal cancer.
FIT test
Conducted every 2 years for all men and women aged 60-74
What is the gold standard diagnostic test for colorectal cancer?
Colonoscopy
Describe how FIT test results dictate the next steps in a ? colorectal cancer patient
If positive - Arrange urgent 2 week referral for colonoscopy
If negative - Consider IBD/IBS
What is the main tumour marker for colorectal cancer?
Carcinoembryonic antigen (CEA)
What classification is used to stage colorectal cancer? Describe this (4)
Dukes Classification;
A - Limited to muscularis mucosae (95%)
B - Extends through the muscularis mucosae (not lymph)
C - Involvement of regional lymph nodes
D - Distal metstases
Describe peptic ulcer disease (2)
Includes both gastric and duodenal ulceration.
Characterised by a breach in the epithelium of the gastric/duodenal mucosa
What is the most common form of peptic ulcer?
Duodenal ulcers (more common by gastric ulcers)
(duodenal ulcer epigastric pain may be relieved by eating)
What are the 2 most common causes of peptic ulcers?
H.pylori infection
NSAIDs
How do NSAIDs contribute to peptic ulcer formation?
Inhibit COX1 enzyme > Blocking prostaglandin synthesis > decrease in gastric mucus and bicarbonate > decrease in mucosal blood supply > ulcer formation
Name 4 drug classes that commonly cause peptic ulcers
NSAIDs
Bisphosphonates
Corticosteroids
SSRIs
Give 2 complications associated with peptic ulcers
Gastric outlet obstruction (abdo pain and postprandial vomiting)
Gastro-intestinal perforation and haemorrhage (of gastro-duodenal artery)
Give 3 clinical features of peptic ulcers
Can be asymptomatic
Upper abdominal/epigastric pain relieved by antacids
With regards to pain, what in a patients history helps distinguish between a gastric ulcer and a duodenal ulcer?
Gastric ulcer associated with postprandial pain
Duodenal ulcer associated with relief of pain after eating.
How should an uncomplicated peptic ulcer be investigated?
Test for H.pylori
Carbon-13 (urea) breath test or Stool Antigen Test
*Conduct in patients without dysphagia or <55 with no red flag symptoms
Give 2 clinical features that may suggest a peptic ulcer has perforated
Acute onset epigastric pain (later becoming more generalised)
Syncope
What investigations should be performed in a patient with ? perforated peptic ulcer?
Upright (erect) chest x ray
(shows free air under the diaphragm)
What artery is a common source for gastrointestinal bleeding in patients with peptic ulcers?
Gastroduodenal artery (branch of common hepatic artery)
Give 3 clinical features of gastrointestinal haemorrhage secondary to peptic ulcer
Haematemesis (most common)
Melaena
Hypotension/tachycardia
How is GI haemorrhage secondary to peptic ulcer managed? (3)
ABCDE
IV proton pump inhibitor
Endoscopic Intervention (1st line)
Describe the general management of an uncomplicated peptic ulcer (2)
Lifestyle changes - reduce/stop smoking and alcohol intake
Stop inducing drugs (NSAIDs, Bisphosphonates, Corticosteroids, SSRIs)
How should peptic ulcer disease with a positive H.pylori test be managed?
1st line: PPI (lansoprazole) + Amoxicillin + Clarithromycin/Metronidazole
2nd line: PPI + Clarithromycin + Metronidazole (if penicillin allergy)
How should a patient with a pencillin allergy with H.pylori positive peptic ulcer be managed?
PPI + Clarithromycin + Metronidazole
How should a patient with H.pylori negative peptic ulcer be managed?
PPI or H2 receptor antagonist (ranitidine)
How should patients with gastric ulcers and H.pylori be followed up?
Repeat endoscopy and H.pylori testing in 6-8 weeks.
When should a diagnosis if IBS be considered? (3)
If a patient has had the following for at least 6 months (ABC);
Abdominal Pain and/or
Bloating and/or
Change in bowel habit
What may exacerbate symptoms of IBS? (4)
Ingestion of food
Stress
Menstruation
Gastroenteritis (post-infectious IB)
Name 3 types of IBS
IBS-C - IBS with constipation
IBS-D - IBS with diarrhoea
IBS-M - IBS with constipation and diarrhoea
When should a diagnosis of IBS be made?
If a patient has;
Abdominal pain either related to defecation and/or associated with altered stool form/frequency AND at least 2 of the following;
o Alternative conditions with similar symptoms have been excluded.
o Passage of the rectal mucus
o Symptoms worsened by eating
o Abdominal bloating (more common in women than men), distension or hardness
o Altered stool passage (straining, urgency, incomplete evacuation)
IBS is a diagnosis of exclusion, what investigations should be arranged to exclude other pathologies? (4)
FBC - Assess anaemia or raised platelet count (inflammation)
Inflammatory markers - ESR/CRP (inflammation)
Coeliac serology (exclude IgA-tTG and IgA-EMA)
Ovarian cancer screen (Ca-125 elevated)
Differentials for IBS - Give 2 other possible causes of constipation
Hypothyroidism
Drug induced (codine)
Differentials for IBS - Give 5 other possible causes of diarrhoea
IBD (Ulcerative colitis, Crohn’s)
Coeliac Disease
GI infection
Antibiotics
Hyperthyroidism
Differentials for IBS - Give 4 other possible causes for abdominal pain/discomfort
Diverticulitis
Chronic pancreatitis
Gallstones
Peptic Ulcer Disease
Describe the first-line pharmacological management of IBS according to the predominant symptom(3)
Pain - Antispasmodic agents - Mebeverine
Constipation - Laxatives - Linaclotide, Ispaghula hust, methylcellulose (but avoid lactulose)
Diarrhoea - Loperamide
What is the 2nd line pharmacological medication for the treatment of pain in IBS?
Tricyclic antidepressants - Amitriptyline
(Consider SSRI - fluoxetine/citalopram if contraindicated)
Describe the general management of IBS (3)
Balanced diet - Adjust fibre intake according to symptoms (good for constipation, bad for diarrhoea)
Consider reducing caffeine, alcohol, fizzy drinks
Reduce FODMAP carbohydrates (these contribute to symptoms)
What are the FODMAP carbohydrates that can contribute to IBS symptoms?
F - Fermentable
O - Oligosaccharides (fructans)
D - Diasaccharsides
MAP - Monosaccharides And Polyols
(One of the main foods to avoid is wheat)
Name an antispasmodic used to treat abdominal pain/bloating in IBS
Mebeverine
Name an anti-motility agent used to treat diarrhoea in IBS
Loperamide
Name 2 bulk-forming laxatives used to treat constipation in IBS. In who are these contraindicated?
Ispaghula Husk and Methylcellulose
Contraindicated in IBD, Intestinal Obstruction and Toxic Megacolon
Name one mediation used to pharmaceutically treat constipation in IBS
Linaclotide
Describe diverticulitis
Describes an infection of a diverticulum (an out-pouching of the intestinal mucosa)
Describe diverticular disease
Describes the presence of diverticula (diverticulosis).
A common surgical problem consisting of herniation of colonic mucosa through the muscular wall of the colon.
What is thought to drive the formation of diverticula?
Increased intra-colonic pressure along weaker areas of the wall.
Where is the usual site (in the colon wall) for diverticular disease to manifest?
Between the taenia coli where vessels pierce the muscle to supply the mucosa.
(rectum is often spared as it doesn’t contain taenia)
Where are diverticula most commonly found?
Sigmoid colon
Give 4 risk factors for diverticulitis
Age
Lack of dietary fibre
Obesity: especially in younger patients
Sedentary lifestyle
Patients presenting with diverticular disease typically present with a chronic history of what? (3)
Intermittent abdominal pain (lower left quadrant)
Bloating
Change in bowel habit: Constipation or diarrhoea
Give 5 features of acute diverticulitis
Severe lower left quadrant pain
Nausea and vomiting
Diarrhoea/Constipation
Urinary frequency, urgency or dysuria
PR bleeding
Give 4 complications (and their symptoms) of acute diverticulitis
Colovesical fistula (pneumaturia or faecaluria)
Colovaginal fistula (vaginal passage of faeces or flatus)
Abscess (tender abdominal mass, ongoing fever despite antibiotics)
Sepsis (tachycardia, tachypnoea, hypotension, altered GCS)
Give 4 clinical signs on examination of diverticulitis
Low grade pyrexia
Tender Lower left Quadrant
Guarding (may suggest complicated diverticulitis with perforation)
Tachycardia
What investigation should be avoided in diverticulitis and why?
Colonoscopy
Due to increased risk of perforation
Give 3 bedside investigations that would be useful to perform when ? diverticulitis (exclude other pathologies)
Vital signs (ensure patient is haemodynamically stable)
Urinalysis (to exclude urological cause - UTI)
Urine pregnancy test (exclude ectopic pregnancy in females of childbearing age)
What imaging may be used to investigate diverticulitis?
CT abdomen and pelvis
(If AKI then non-contrast CT scan)
Describe the management of complicated diverticulitis
1st line - 5 days Co-amoxiclav + Fluids + Analgesia
2nd line - Co-trimoxazole or Metronidazole
Name 2 types of peritonitis
Purulent and Faeculant
How is purulent peritonitis managed?
Laparoscopic lavage or resection
How is faeculant peritonitis managed?
Colonic resection
Describe Hartmann’s procedure and state when it is used. (3)
Used in severe cases of complicated diverticulitis.
Involves removing the sigmoid colon (sigmoid colectomy) and forming an end colostomy.
An anastomosis and colostomy reversal can be performed once the patient has recovered from the acute illness.
What drug class should be avoided in diverticular disease and why?
NSAIDs
Due to risk of perforation
Describe and name the classification system used for diverticular disease
Hinchey classification;
I - Para-colonic abscess
II - Pelvic Abscess
III - Purulent peritonitis
IV - Faecal peritonitis
