Gastrointestinal Flashcards
According to NICE suspected cancer guidelines, when should a FIT test be done to guide referral decisions in suspected colorectal cancer?
Adults of any age with:
- An abdominal mass
- Change in bowel habits
- Iron deficiency anaemia
It should also be offered to anyone
- Over 40 with unexplained weightloss and abdominal pain
- Over 50 with unexplained rectal bleeding (or under 50 if unexplained rectal bleeding WITH either abdo pain or weightloss)
- Over 60 with anaemia (even if iron studies normal)
People with a rectal mass, an unexplained anal mass or unexplained anal ulceration do not need to be offered FIT before 2WW lower GI referral is considered.
Which populations of patients should be tested for coeliac disease?
Type I DM
Autoimmune thyroid disease e.g Graves
1st degree relatives of those with coeliac disease
Dermatitis herpetiformis
Irritable bowel syndrome
What scale is used to assess the severity of symptoms in ulcerative colitis?
Truelove & Witt severity index
What are the risk factors for developing ulcerative colitis?
Affected 1st degree relative is the greatest risk factor
NOT smoking (smoking is protective for UC!!! although being an ex-smoker increases your risk of developing UC by 70%!)
STILL HAVING YOUR APPENDIX AS AN ADULT (Appendicectomy is protective!)
NSAID use increases the risk of UC flares
What factors increase the risk of developing bowel cancer in ulcerative colitis?
~ 5% of those with UC get bowel cancer
Risk increased if:
- has primary sclerosing cholangitis alongside
- UC diagnosed in childhood / long duration of disease
- family hx of bowel cancer in relative < 50
What are some of the extra-intestinal conditions associated with ulcerative colitis?
- Primary sclerosing cholangitis (progressive disease involving scarring of the bile ducts)
- Skin manifestations: erythema nodosum (painful red nodules on the front of the shins bilaterally, normally self-limiting), pyoderma gangrenosum (rapidly growing very painful ulcer (may be on the legs or may be peristomal)
- Episcleritis
- Arthritis (most common is a PAUCI-ARTICULAR ARTHRITIS
either a spondyloarthritis or polyarticular arthritis) - Osteoporosis (UC patients at ^ risk of osteoporosis)
- Osteomalacia (disorder of bone mineralisation 2ndary to impaired vitamin D absorption)
- Apthuous mouth ulcers
- Double the risk of VTE
What features in the TrueLove & Witt disease severity index for ulcerative colitis depict mild, moderate and severe disease respectively?
Mild: < 4 bowel motions per day, no blood in stools
Moderate: 4-6 bowel motions per day, may have mild-moderate blood in stool, NO fever, raised pulse or anaemia and eSR < 30
Severe: 6+ bowel motions per day, visible blood in stool plus one of the below *fever * pulse > 90 bpm *ESR > 30, anaemia
How should interval symptoms of diarrhoea, constipation, abdominal pain be managed in UC?
Ensure their maintenance regime is optimised by checking in with specialist
DO NOT use antimotility drugs like Loperamide for diarrhoea in UC as ^ risk of toxic megacolon
Can trial bulk-forming laxative such as Isphagula Husk for constipation in UC so long as no features of bowel obstruction but DO NOT use other types of laxatives.
Pain - consider cause, paracetamol fine but AVOID NSAIDS AS PRECIPITATE FLARES
What are the implications on fertility and pregnancy planning for patients with ulcerative colitis?
Both male and female patients need to have effective contraception to prevent pregnancy during treatment and FOR 6 MONTHS AFTER STOPPING METHOTREXATE and FOR 3 MONTHS AFTER STOPPING MERCAPTOPURINE.
Women need to have effective contraception to prevent pregnancy during treatment and FOR 6 MONTHS AFTER STOPPING INFLIXIMAB.
Both men and women with UC should be advised to avoid unplanned pregnancy and should be referred for pre-pregnancy counselling with gastroenterology.
Most contraceptions are safe in UC unless there are concerns re absorption of oral methods: if small bowel reduced absorption or small bowel resection. NOT AFFECTED BY COLECTOMY OR ILEOSTOMY
What are the histological differences between UC and Crohn’s?
UC - continuous SUPERFICIAL inflammation from the recum, extending a variable amount upwards.
Crohn’s disease - SKIP LESIONS anyway from mouth to rectum, FULL THICKNESS of bowel mucosa
What are the risk factors for developing Crohn’s disease?
Family history
SMOKING (^ risk of Crohn’s, protective in UC)
APPENDICECTOMY (increased risk of developing Crohn’s in the 5 yrs after an appendiectomy then returns to the baseline population risk (appendicectomy is protective for UC!!)
Infectious gastroenteritis (^risk in the year after)
What is the most common extra-intestinal complication of UC & Crohn’s and how does it present?
Pauci-articular arthritis
This presents with transient inflammation of < 5 large joints - normally resolves after weeks and no lasting damage. May be associated tendon inflammation
What is the typical presentation of microscopic colitis?
Presents with chronic watery diarrhoea in elderly people
Often associated use to long-term drug use with aspirin, lansoprazole, sertraline, ranitidine or simvastatin
For which patients should H.Pylori testing be done for?
Those with uncomplicated dyspepsia symptoms that haven’t responded to a 1 month trial of PPI
Those presenting with dyspepsia with risk factors (elderly, north africa ethnicity)
Patients with a history of peptic ulcers or bleeds that haven’t been tested before OR before starting them on NSAIDs
For how long do PPIs and abx need to be avoided before testing for H Pylori?
2 weeks for PPI
4 weeks for abx
What are the 1st and 2nd line antibiotic choices for H Pylori eradication therapy (including for if penicillin allergic)
High dose PPI (Esomeprazole 20mg BD, Omeprazole 20-40mg BD, Lansoprazole 30mg BD)
+
IF NOT PEN ALLERGIC: Amoxicillin + either Clarithromycin or Metronidazole for 7 days
(2nd line - if symptoms persist after 1st line treatment - is Amox & whichever of the clarithro or metronidazole they didn’t have the first time)
IF PEN ALLERGIC: Clarithromycin & Metronidazole for 7 days
(2nd line = Metronidazole & Levofloxacin)
THIRD LINE treaments for both pen allergic and non-pen allergic should only be considered with SPECIALIST ADVICE
They typically include Bismuth Subsalicylate with either Rifabutin or Furazolidone
