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Phase 4 Medicine > Gastrointestinal > Flashcards

Gastrointestinal Flashcards

1
Q

Name 2 main forms of chronic autoimmune inflammatory bowel diseases

A

Ulcerative Colitis - Only affects the colon (mucosa)

Crohn’s Disease - Can affect any part of the gut from mouth to anus

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2
Q

Define ulcerative colitis

A

Describes a relapsing remitting inflammatory bowel disease characterised by diffuse, continuous superficial inflammation of the colonic mucosa

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3
Q

Where does ulcerative colitis mainly affect?

A

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.

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4
Q

Give 4 risk factors for Ulcerative Colitis

A

Positive Family History

HLA-B27

Infection (50% of relapses are associated with enteritis)

NSAIDS (may exacerbate UC)

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5
Q

Describe the epidemiology of Ulcerative Colitis (3)

A

Age of onset = 20-40 years old

Slight female predominance

3x more common in NON smokers

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6
Q

Describe the macroscopic pathophysiology of ulcerative colitis

A

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.

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7
Q

Describe the microscopic pathophysiology of ulcerative colitis (4)

A

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)

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8
Q

How does Ulcerative Colitis appear on a barium enema

A

Lead pipe appearance of colon

(loss of haustral markings)

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9
Q

Give 5 intestinal symptoms of ulcerative colitis

A

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)

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10
Q

Give 6 extraintestinal symptoms of Ulcerative Colitis

A

Uveitis

Primary Sclerosing Cholangitis

Colorectal cancer

Pallor, clubbing, mouth ulcers

Erythema nodosum

Pyoderma gangrenosum

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11
Q

What tests are performed to diagnosed Ulcerative Collitis? (5)

A

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)

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12
Q

What additional tests would be useful to conduct in ? Ulcerative Colitis to exclude other pathologies? (4)

A

Upper intestinal endoscopy (exclude Crohn’s)

Coeliac serology (exclude coeliac)

Thyroid function tests (exclude hyperthyroidism)

U&Es (to assess dehydration/electrolyte disturbance)

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13
Q

What criteria is used to classify Ulcerative Colitis?

A

Truelove and Witts Criteria

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14
Q

Describe the Truelove and Witts Criteria for mild Ulcerative Colitis

A

Motions - <4
PR bleed - Small
Temp - Apyrexic
HR - <70
Hb >11
ESR <30

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15
Q

Describe the Truelove and Witts Criteria for Moderate Ulcerative Colitis

A

Motions - 4-6
PR bleed - Moderate
Temp - 37.1-37.8
HR - 70-90
Hb - 10.5-11

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16
Q

Describe the Truelove and Witts Criteria for Severe Ulcerative Colitis

A

Motions - >6
PR bleed - Large
Temp - >37.8
HR - >90
Hb - <10.5
ESR - >30

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17
Q

What type of surveillance is it important for Ulcerative Colitis patients to have?

A

Colonoscopic Surveillance for colorectal cancer

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18
Q

What is the goal of treatment for Ulcerative Colitis?

A

To induce and maintain remission

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19
Q

Describe the treatment for Mild-Moderate Proctitis (Ulcerative Colitis localised to the rectum) (1st, 2nd, 3rd line and maintaining remission)

A

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

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20
Q

Describe the treatment for mild-moderate proctosigmoiditis/left sided Ulcerative Colitis (1st, 2nd, 3rd line and maintaining remission)

A

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

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21
Q

Describe the treatment for mild-moderate extensive Ulcerative Colitis (1st, 2nd line and maintaining remission)

A

1st line - Topical aminosalicylate (mesalazine) + High dose oral aminosalicylate (sulfasalazine)
2nd line - Oral aminosalicylate (sulfasalazine) + Oral Prednisolone

Maintain remission - Oral aminosalicylate (sulfasalazine)

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22
Q

Describe the treatment for severe ulcerative colitis

A

1st line - Anti- TNFa monoclonal antibody - Infliximab
2nd line - Monoclonal antibody - Ustekinumab

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23
Q

What is the treatment for Acute Severe Ulcerative Colitis requiring hospitalisation? (1st, 2nd, 3rd line)

A

1st line - IV corticosteroids +/- Surgery
2nd line - IV Ciclosporin
3rd line - Infliximab

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24
Q

Patients with acute severe ulcerative colitis may need surgery if? (5)

A

Passing stool >8x per day

Pyrexic

Tachycardic

Abdominal X-ray showing megacolon

Low albumin, low Hb, High platelet count or CRP >46mg/L

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25
Q

What medication should ulcerative colitis patients receive following a severe relapse or >=2 exacerbations in the past year?

A

Oral azathioprine or oral mercaptopurine

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26
Q

What do Oral thiopruines (azathioprine or mercaptopurine) increase the risk of developing?

A

Non-melanoma skin cancer

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27
Q

Describe Crohn’s Disease

A

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)

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28
Q

Where in the GI tract is usually most affected in Crohn’s disease?

A

Terminal ileum

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29
Q

Give 5 risk factors for Crohn’s Disease

A

Positive Family History

Smoking

Infectious gastroenteritis (caused by rota/norovirus)

Appendicectomy

Drugs (NSAIDs increase risk of relapse and exacerbation)

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30
Q

Give 6 pathophysiological features of Crohn’s Disease

A

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

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31
Q

What are the 4 layers of the intestinal wall?

A

Mucosa
Submucosa
Muscularis propria
Serosa

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32
Q

Give 5 complications of Crohn’s Disease

A

Fistula formation (Abnormal connections)

Intestinal strictures (obstruction)

Perianal disease (fistulas, fissures, abscesses)

Osteoporosis

Anaemia (iron, vitamin B12, folate deficiency)

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33
Q

Give 5 clinical features of Crohn’s Disease

A

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)

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34
Q

What eye problem can occur in Crohn’s disease?

A

Episcleritis

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35
Q

What investigations are required for diagnosis of Crohn’s disease? (3)

A

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)

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36
Q

What may be seen on a small bowel enema for a patient with Crohn’s Disease? (2)

A

Kantor’s String Sign (severe narrowing)

Rose Thorn Ulcers in terminal ileum.

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37
Q

What is the goal of treatment for Crohn’s Disease?

A

To induce and maintain remission

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38
Q

Describe the treatment used to induce remission in Crohn’s Disease (1st, 2nd and 3rd line)

A

1st line - Glucocorticoids (Prednisolone, methylprednisolone, IV hydrocortisone)

2nd line - Aminosalicylates (mesalazine or sulfasalazine)

3rd line - TNF-a inhibitor monoclonal antibodies (Infliximab/Adalimumab)

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39
Q

Describe the treatment used to maintain remission in Crohn’s disease (1st and 2nd line)

A

1st line - Thiopurines (Azathiopurine and Mercaptopurine)

2nd line - DMARD (methotrexate)

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40
Q

When should Crohn’s patients be considered for surgery? (3)

A

Failure to respond to medical treatment

Intestinal Obstruction or Perforation (fistula)

Massive haemorrhage

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41
Q

What treatment should Crohn’s patients whom have undergone surgery be offered to maintain remission?

A

Azathioprine + Metronidazole (antibiotic) for up to 3 months.

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42
Q

Describe the differences between Ulcerative Colitis and Crohn’s with regards to diarrhoea

A

UC - Bloody diarrhoea

Crohn’s - Not usually bloody

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43
Q

Describe the differences between Ulcerative Colitis and Crohn’s with regards to pathology and location

A

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)

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44
Q

Describe the differences between Ulcerative Colitis and Crohn’s with regards to histological features.

A

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

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45
Q

Describe the differences between Ulcerative Colitis and Crohn’s with regards to what may be seen on endoscopy

A

UC;
Widespread ulceration with preservation of of adjacent mucosa - Pseudopolyps

Crohns;
Deep ulcers, skip lesion giving the lumen a cobblestone appearance

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46
Q

Describe the differences between Ulcerative Colitis and Crohn’s with regards to complications

A

UC - Colorectal cancer

Crohn’s - Obstruction (structure), Perianal disease, colorectal cancer

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47
Q

Describe the differences between Ulcerative Colitis and Crohn’s with regards to associations

A

UC - Primary Sclerosing Cholangitis

Crohns - Gallstones (secondary to reduced bile acid reabsorption)

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48
Q

Define coeliac disease

A

Aka gluten sensitive enteropathy.

Coeliac disease describes a T cell mediated, chronic autoimmune disorder triggered by exposure to ingested gluten

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49
Q

What foods components will you find gluten?

A

Wheat, Barley and Rye

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50
Q

How and Where does coeliac disease commonly manifest?

A

Commonly manifests in the duodenum as villous atrophy and malabsorption.

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51
Q

Give 3 associations for Coeliac Disease

A

HLA-DQ2 and HLA-DQ8

Autoimmune disorders (T1DM, Hashimotos, IgA deficiency)

Herpetiformis (a vesicular pruritic skin eruption)

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52
Q

Describe the pathophysiology of coeliac disease

A

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

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53
Q

What antibodies are present in coeliac disease

A

Anti-gliadin and Anti-transglutaminase antibodies

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54
Q

Give 3 complications of coeliac disease

A

Depression, anxiety, eating disorders

Delayed growth/puberty in children

Nutritional deficiencies (iron, B12, folate, osteoporosis)

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55
Q

Give 5 gastrointestinal symptoms of coeliac disease

A

Diarrhoea

Steatorrhoea + foul smelling stools

Abdominal pain

Weight loss/Failure to therive

Aphathous ulceration

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56
Q

Give 4 non-GI features of coeliac disease

A

Dermatitis herpetiformis (blisters on elbows, knees, buttocks and scalp)

Ataxia/Peripheral neuropathy

Infertility or recurrent miscarriage

Symptoms of anaemia

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57
Q

What is the gold standard test used to confirm diagnosis of coeliac disease? What will this show?

A

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

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58
Q

What features are present on histology for coeliac disease? (3)

A

Villous atrophy

Crypt hyperplasia

Increased intraepithelial lymphocytes

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59
Q

What a the first line investigation for ? coeliac disease? Describe this (4)

A

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)

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60
Q

What additional blood tests would be important to consider in coeliac disease? (3)

A

FBC/Ferritin - Screen for anaemia and iron deficiency

TFTs - Screen for Hashimoto’s thyroiditis

LFTs - Screen for autoimmune hepatitis, PBS, PSC

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61
Q

How is coeliac disease managed? (3)

A

Long term adherence to gluten free diet

Assess osteoporosis risk with DEXA

inform 10% risk for 1st degree family members

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62
Q

Why is it important for coeliac patients to receive vaccinations? What vaccinations should they recieve?

A

Coeliac patients often have a degree of functional hyposplenism.

Recommended all patients have the pneumococcal vaccine and has a booster every 5 years.

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63
Q

Define appendicitis

A

Describes an acute inflammation of the appendix and is the most common surgical emergency.

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64
Q

How does appendicitis commonly present

A

Umbilical pain that moves to the lower right quadrant (McBurney’s Point)

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65
Q

What is the appendix anatomically connected to?

A

Caecum

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66
Q

What is the most common cause of appendicitis?

A

Luminal obstruction by faecolith

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67
Q

Give 5 complications of appendicitis

A

Abscess formation

Peritonitis

Sepsis

Intra-abdominal adhesions

Bowel obstruction

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68
Q

Between what ages does appendicitis most commonly present?

A

Between 10-20 years old

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69
Q

Give 5 clinical features of appendicitis

A

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

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70
Q

Name and describe 3 signs associated with appendicitis

A

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)

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71
Q

Give 4 differentials for appendicitis

A

Intestinal obstruction

Gastroenteritis

Incarcerated inguinal hernia

Perforated peptic ulcer

72
Q

What are the 2 main histological types of oesophageal cancer? Which is most common?

A

Adenocarcinoma (most common) - linked to Barrett’s oesophagus and GORD (lower)

Squamous cell carcinoma (linked to smoking, alcohol, achalasia and Plummer-Vinson syndrome) (upper)

73
Q

Give 4 risk factors for oesophageal cancer

A

Low Socioeconomic status

Alcohol, Obesity, Smoking

Barrett’s oesophagus (GORD)

Plummer Vinson Sundrome

74
Q

What form of metaplasia is seen in Barrett’s Oesophagus?

A

Metaplasia of lower oesophageal squamous epithelial cells to columnar epithelial cells

75
Q

What triad is seen in Plummer Vinson Syndrome? What type of oesophageal cancer is it associated with?

A

Triad;
Dysphagia
Iron deficiency anaemia
Oesophageal webs

Associated with squamous cell carcinomas (upper oesophageal cancers)

76
Q

Give 5 clinical features of oesophageal cancer

A

*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

77
Q

What is the 1st line investigation for oesophageal cancer?

A

Upper GI endoscopy with biopsy

78
Q

When should an urgent referral be made for a patient with ? oesophageal cancer? (2)

A

Dysphagia

Are >55 with weight loss and Reflux, Upper abdominal pain or dyspepsia

79
Q

What test is used for the initial staging of oesophageal cancer?

A

Chest CT

80
Q

What test is used for locoregional staging of oesophageal cancer?

A

Endoscopic ultrasound

81
Q

What is the most common procedure used to treat oesophageal cancer?

A

Ivor-Lewis type oesophagectomy

82
Q

Define GORD

A

Gastro-oesophageal reflux disease

Describes symptoms or complications resulting from reflux of gastric contents into the oesophagus, oral cavity or lung.

83
Q

Give 5 causes of GORD

A

Lower oesophageal sphincter hypotension

Hiatus hernia

Abdominal obesity/over eating

Alcohol, fat, chocolate, coffee, smoking

Defective oesophageal peristalsis

84
Q

Name 3 classes of drug that can cause GORD

A

Tricyclics

Anticholinergics

Nitrates

85
Q

Give 5 oesophageal symptoms of GORD

A

Heart burn (retrosternal pain aggravated by bending, stooping or laying down)

Belching

Acid brash (acid/bile regurgitation)

Odynophagia (painful swallowing)

Water brash (increased salivation)

86
Q

Give 4 extra-oesophageal symptoms of GORD

A

Asthma (nocturnal)

Chronic cough

Laryngitis (hoarsness, throat clearing)

Sinusitis

87
Q

Give 4 complications of GORD

A

Barrett’s oesophagus (increased risk of adenocarcinoma)

Oesophagitis

Duodenal or gastric ulceration

Benign strictures (causing dysphagia)

88
Q

Name 2 factors that can aggravate heartburn (retrosternal pain) in patients with GORD

A

Bending, stooping or lying down

Drinking hot drinks or alcohol

89
Q

Give 3 red flag symptoms for a patient with GORD

A

Weight loss

Haemoptysis

Dysphagia

90
Q

How is GORD diagnosed? (2)

A

No red flag symptoms - Clinically

Red flag symptoms - Endoscopy

91
Q

When should an endoscopy be performed on a patient with GORD? (4)

A

Symptoms for >4 weeks

> 55 years old

Red flag symptoms (weight loss, haematemesis, dysphagia)

Persistent symptoms despite treatment

92
Q

How should GORD that has NOT been investigated with endoscopy be managed? (3)

A

Treat as dyspepsia;

  1. Review medications for possible cause of dyspepsia
  2. Lifestyle advice (weight loss, smoking cessation, small/regular meals, avoid hot drinks, eating before bed)
  3. Trial of PPI (lansoprazole/omeprazole) for 1 month OR a ‘test and treat’ approach for H.pylori
93
Q

How should GORD with endoscopically proven oesophagitis be managed? (3)

A
  1. Full dose proton pump inhibitor for 1-2 months
  2. If responds well then low dose treatment as required.
  3. If doesn’t respond well, double-dose PPI for 1 months.
94
Q

When should a patient be seen for an urgent cancer referral?

A

Within 2 weeks

95
Q

What would warrant an urgent referral for ? oesophageal/stomach cancer? (3)

A

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

96
Q

What would warrant a non-urgent referral for ? oesophageal/stomach cancer?

A

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

97
Q

What test is used to test for H.pylori?

A

Carbon-13 urea breath test

98
Q

What type of cancer are the majority of stomach cancers?

A

Adenocarcinomas

99
Q

Give 4 risk factors for stomach cancer

A

H.pylori infection

Smoking

High salt/nitrate diet

Pernicious anaemia

100
Q

How does H.Pylori cause stomach cancer?

A

Causes chronic gastritis > atrophic gastritis and pre-malignant intestinal metaplasia > dysplasia and gastric cancer

101
Q

Give 5 clinical features of stomach cancer

A

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

102
Q

How may advanced (metastatic) stomach cancer present? (2)

A

Jaundice (liver metastasis)

Virchow’s node (palpable lymph node in the subclavicular fossa - left side)

103
Q

What clinical sign is distinctively linked to stomach cancer?

A

Virchow’s node (palpable lymph node usually in left subclavicular fossa)

104
Q

How is stomach cancer diagnosed? (3)

A

Gastroscopy with biopsy

Endoscopic ultrasound - evaluate depth and invasion

CT/MRI - for staging

105
Q

What is the most common type of colorectal cancer?

A

Adenocarcinoma

106
Q

Where do the majority of colorectal cancers arise?

A

Distal colon (sigmoid and rectum)

107
Q

Give 4 risk factors for colorectal cancer

A

Genetic factors (loss of APC gene)

Ulcerative Colitis

Crohn’s disease (particularly if ileocecal region affected)

Smoking, alcohol, diet (low fibre, red/processed meats)

108
Q

What 2 inherited syndromes are strongly linked to colorectal cancer?

A

Familial adenomatous polyposis (mutation in APC)

Lynch syndrome (hereditary non-polyposis colorectal cancer)

109
Q

Describe the pattern of inheritance for familial adenomatous polyposis

A

Autosomal dominant

110
Q

Describe the pattern of inheritance for lynch syndrome

A

Autosomal dominant

111
Q

Familial adenomatous polyposis occurs due to a mutation in what gene?

A

APC - Adenomatous Polyposis Coli

112
Q

Give 5 clinical features of colorectal cancer

A

Abdominal pain

Abdominal/rectal mass

Change in bowel habit (constipation, diarrhoea)

Unexplained weight loss

Rectal bleeding +/- tenesmus

113
Q

How may colorectal cancer present in an emergency? Give 4 signs of this

A

May present with signs of obstruction;

Signs;
Absolute constipation
Colicky abdominal pain
Abdominal distension
Vomiting (faeculent - vomit contents is faecal in origin)

114
Q

Give 3 red flag features of colorectal cancer

A

> 40 with unexplained weight loss and abdominal pain

> 50 with unexplained rectal bleeding

> 60 with iron deficiency anaemia or changes in bowel habit

115
Q

How should patients with red flag symptoms be investigated for colorectal cancer?

A

Do NOT offer Faecal Immunochemical Test (FIT).

Go straight to colonoscopy.

116
Q

What test is used to screen for colorectal cancer?

A

Faecal Immunochemical Test (FIT test)

117
Q

Describe how the NHS screen for colorectal cancer.

A

FIT test

Conducted every 2 years for all men and women aged 60-74

118
Q

What is the gold standard diagnostic test for colorectal cancer?

A

Colonoscopy

119
Q

Describe how FIT test results dictate the next steps in a ? colorectal cancer patient

A

If positive - Arrange urgent 2 week referral for colonoscopy

If negative - Consider IBD/IBS

120
Q

What is the main tumour marker for colorectal cancer?

A

Carcinoembryonic antigen (CEA)

121
Q

What classification is used to stage colorectal cancer? Describe this (4)

A

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

122
Q

Describe peptic ulcer disease (2)

A

Includes both gastric and duodenal ulceration.

Characterised by a breach in the epithelium of the gastric/duodenal mucosa

123
Q

What is the most common form of peptic ulcer?

A

Duodenal ulcers (more common by gastric ulcers)

(duodenal ulcer epigastric pain may be relieved by eating)

124
Q

What are the 2 most common causes of peptic ulcers?

A

H.pylori infection

NSAIDs

125
Q

How do NSAIDs contribute to peptic ulcer formation?

A

Inhibit COX1 enzyme > Blocking prostaglandin synthesis > decrease in gastric mucus and bicarbonate > decrease in mucosal blood supply > ulcer formation

126
Q

Name 4 drug classes that commonly cause peptic ulcers

A

NSAIDs

Bisphosphonates

Corticosteroids

SSRIs

127
Q

Give 2 complications associated with peptic ulcers

A

Gastric outlet obstruction (abdo pain and postprandial vomiting)

Gastro-intestinal perforation and haemorrhage (of gastro-duodenal artery)

128
Q

Give 3 clinical features of peptic ulcers

A

Can be asymptomatic

Upper abdominal/epigastric pain relieved by antacids

129
Q

With regards to pain, what in a patients history helps distinguish between a gastric ulcer and a duodenal ulcer?

A

Gastric ulcer associated with postprandial pain

Duodenal ulcer associated with relief of pain after eating.

130
Q

How should an uncomplicated peptic ulcer be investigated?

A

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

131
Q

Give 2 clinical features that may suggest a peptic ulcer has perforated

A

Acute onset epigastric pain (later becoming more generalised)

Syncope

132
Q

What investigations should be performed in a patient with ? perforated peptic ulcer?

A

Upright (erect) chest x ray

(shows free air under the diaphragm)

133
Q

What artery is a common source for gastrointestinal bleeding in patients with peptic ulcers?

A

Gastroduodenal artery (branch of common hepatic artery)

134
Q

Give 3 clinical features of gastrointestinal haemorrhage secondary to peptic ulcer

A

Haematemesis (most common)

Melaena

Hypotension/tachycardia

135
Q

How is GI haemorrhage secondary to peptic ulcer managed? (3)

A

ABCDE

IV proton pump inhibitor

Endoscopic Intervention (1st line)

136
Q

Describe the general management of an uncomplicated peptic ulcer (2)

A

Lifestyle changes - reduce/stop smoking and alcohol intake

Stop inducing drugs (NSAIDs, Bisphosphonates, Corticosteroids, SSRIs)

137
Q

How should peptic ulcer disease with a positive H.pylori test be managed?

A

1st line: PPI (lansoprazole) + Amoxicillin + Clarithromycin/Metronidazole

2nd line: PPI + Clarithromycin + Metronidazole (if penicillin allergy)

138
Q

How should a patient with a pencillin allergy with H.pylori positive peptic ulcer be managed?

A

PPI + Clarithromycin + Metronidazole

139
Q

How should a patient with H.pylori negative peptic ulcer be managed?

A

PPI or H2 receptor antagonist (ranitidine)

140
Q

How should patients with gastric ulcers and H.pylori be followed up?

A

Repeat endoscopy and H.pylori testing in 6-8 weeks.

141
Q

When should a diagnosis if IBS be considered? (3)

A

If a patient has had the following for at least 6 months (ABC);

Abdominal Pain and/or
Bloating and/or
Change in bowel habit

142
Q

What may exacerbate symptoms of IBS? (4)

A

Ingestion of food

Stress

Menstruation

Gastroenteritis (post-infectious IB)

143
Q

Name 3 types of IBS

A

IBS-C - IBS with constipation

IBS-D - IBS with diarrhoea

IBS-M - IBS with constipation and diarrhoea

144
Q

When should a diagnosis of IBS be made?

A

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)

145
Q

IBS is a diagnosis of exclusion, what investigations should be arranged to exclude other pathologies? (4)

A

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)

146
Q

Differentials for IBS - Give 2 other possible causes of constipation

A

Hypothyroidism

Drug induced (codine)

147
Q

Differentials for IBS - Give 5 other possible causes of diarrhoea

A

IBD (Ulcerative colitis, Crohn’s)

Coeliac Disease

GI infection

Antibiotics

Hyperthyroidism

148
Q

Differentials for IBS - Give 4 other possible causes for abdominal pain/discomfort

A

Diverticulitis

Chronic pancreatitis

Gallstones

Peptic Ulcer Disease

149
Q

Describe the first-line pharmacological management of IBS according to the predominant symptom(3)

A

Pain - Antispasmodic agents - Mebeverine

Constipation - Laxatives - Linaclotide, Ispaghula hust, methylcellulose (but avoid lactulose)

Diarrhoea - Loperamide

150
Q

What is the 2nd line pharmacological medication for the treatment of pain in IBS?

A

Tricyclic antidepressants - Amitriptyline

(Consider SSRI - fluoxetine/citalopram if contraindicated)

151
Q

Describe the general management of IBS (3)

A

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)

152
Q

What are the FODMAP carbohydrates that can contribute to IBS symptoms?

A

F - Fermentable
O - Oligosaccharides (fructans)
D - Diasaccharsides
MAP - Monosaccharides And Polyols

(One of the main foods to avoid is wheat)

153
Q

Name an antispasmodic used to treat abdominal pain/bloating in IBS

A

Mebeverine

154
Q

Name an anti-motility agent used to treat diarrhoea in IBS

A

Loperamide

155
Q

Name 2 bulk-forming laxatives used to treat constipation in IBS. In who are these contraindicated?

A

Ispaghula Husk and Methylcellulose

Contraindicated in IBD, Intestinal Obstruction and Toxic Megacolon

156
Q

Name one mediation used to pharmaceutically treat constipation in IBS

A

Linaclotide

157
Q

Describe diverticulitis

A

Describes an infection of a diverticulum (an out-pouching of the intestinal mucosa)

158
Q

Describe diverticular disease

A

Describes the presence of diverticula (diverticulosis).

A common surgical problem consisting of herniation of colonic mucosa through the muscular wall of the colon.

159
Q

What is thought to drive the formation of diverticula?

A

Increased intra-colonic pressure along weaker areas of the wall.

160
Q

Where is the usual site (in the colon wall) for diverticular disease to manifest?

A

Between the taenia coli where vessels pierce the muscle to supply the mucosa.

(rectum is often spared as it doesn’t contain taenia)

161
Q

Where are diverticula most commonly found?

A

Sigmoid colon

162
Q

Give 4 risk factors for diverticulitis

A

Age

Lack of dietary fibre

Obesity: especially in younger patients

Sedentary lifestyle

163
Q

Patients presenting with diverticular disease typically present with a chronic history of what? (3)

A

Intermittent abdominal pain (lower left quadrant)

Bloating

Change in bowel habit: Constipation or diarrhoea

164
Q

Give 5 features of acute diverticulitis

A

Severe lower left quadrant pain

Nausea and vomiting

Diarrhoea/Constipation

Urinary frequency, urgency or dysuria

PR bleeding

165
Q

Give 4 complications (and their symptoms) of acute diverticulitis

A

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)

166
Q

Give 4 clinical signs on examination of diverticulitis

A

Low grade pyrexia

Tender Lower left Quadrant

Guarding (may suggest complicated diverticulitis with perforation)

Tachycardia

167
Q

What investigation should be avoided in diverticulitis and why?

A

Colonoscopy

Due to increased risk of perforation

168
Q

Give 3 bedside investigations that would be useful to perform when ? diverticulitis (exclude other pathologies)

A

Vital signs (ensure patient is haemodynamically stable)

Urinalysis (to exclude urological cause - UTI)

Urine pregnancy test (exclude ectopic pregnancy in females of childbearing age)

169
Q

What imaging may be used to investigate diverticulitis?

A

CT abdomen and pelvis

(If AKI then non-contrast CT scan)

170
Q

Describe the management of complicated diverticulitis

A

1st line - 5 days Co-amoxiclav + Fluids + Analgesia

2nd line - Co-trimoxazole or Metronidazole

171
Q

Name 2 types of peritonitis

A

Purulent and Faeculant

172
Q

How is purulent peritonitis managed?

A

Laparoscopic lavage or resection

173
Q

How is faeculant peritonitis managed?

A

Colonic resection

174
Q

Describe Hartmann’s procedure and state when it is used. (3)

A

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.

175
Q

What drug class should be avoided in diverticular disease and why?

A

NSAIDs

Due to risk of perforation

176
Q

Describe and name the classification system used for diverticular disease

A

Hinchey classification;

I - Para-colonic abscess
II - Pelvic Abscess
III - Purulent peritonitis
IV - Faecal peritonitis

177
Q
A

Phase 4 Medicine (15 decks)

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