GASTROINTESTINAL Flashcards
PEPTIC ULCER
How does NSAIDs cause ulcer formation?
Reduced prostaglandin synthesis due to salicylic acid release –> cell death –> no mucin production = no mucosal protection –> ulcer formation
PEPTIC ULCER
How does H. pylori cause ulcer formation?
- causes decrease in HCO3- which increases acidity
- H.pylori secretes urease
- splits urea into CO2 and ammonia
- ammonia + H+ forms ammonium which is toxic to gastric mucosa
- Acute inflammatory reaction (neutrophils) with less mucosal defence
PEPTIC ULCER
what is the management of h.pylori?
7 day course of:
- PPI + amoxicillin + (clarithromycin or metronidazole)
if penicillin allergic
- PPI + metronidazole + clarithromycin
MALABSORPTION
Give 5 broad causes of malabsorption
- Defective intraluminal digestion
- Insufficient absorptive area
- Lack of digestive enzymes
- Defective epithelial transport
- Lymphatic obstruction
ULCERATIVE COLITIS
give 3 microscopic features that will be seen in ulcerative colitis
- Crypt abscess
- goblet cell depletion
- mucosal inflammation - does not go deeper
CROHNS DISEASE
What is the treatment for induction of remission for Crohn’s disease?
INDUCTION OF REMISSION
MILD (1st presentation/1 exacerbation in 1yr)
- 1st line = IV/PO steroid
- 2nd line = oral ASA (MESALAZINE)
- distal/ileocaecal disease = budesonide
MODERATE (>2 exacerbations in 1yr)
- 1st line = azathioprine or mercaptopurine
- 2nd line = methotrexate
SEVERE (unresponsive to conventional therapy)
- 1st line = infliximab or adalimumab (anti-TNF)
- 2nd line = other biological agents
REFRACTORY
- surgery
ULCERATIVE COLITIS
What is the treatment for induction of remission for Ulcerative colitis?
INDUCTION OF REMISSION
PROCTITIS
- 1st line = topical ASA (RECTAL MESALAZINE)
- 2nd line = topical ASA + oral ASA (oral MESALAZINE)
- 3rd line = oral ASA + oral corticosteroid
PROCTOSIGMOIDITIS/LEFT-SIDED UC
- 1st line = topical ASA
- 2nd line = topical ASA + high-dose oral ASA / high-dose oral ASA + topical corticosteroid
- 3rd line = oral ASA + oral corticosteroid
EXTENSIVE DISEASE
- 1st line = topical ASA + high-dose oral ASA
- 2nd line = oral ASA + oral corticosteroid
SEVERE DISEASE
- should be treated in hospital
- 1st line = IV steroids (IV ciclosporin if contraindicated)
- 2nd line = IV steroids + IV ciclosporin or consider surgery
ULCERATIVE COLITIS
Give 5 complications of Ulcerative colitis
- Colon –> blood loss, colorectal cancer, toxic dilatation
- Arthritis
- Iritis, episcleritis
- Fatty liver and primary sclerosing cholangitis
- Erythema nodosum
CROHNS DISEASE
Give 5 complications of Crohn’s
PERFORATION AND BLEEDING = MAJOR
- Malabsorption
- Obstruction –> toxic dilatation
- Fistula/abscess formation
- Anal skin tag/fissures/fistula
- Neoplasia
- Amyloidosis
COELIAC DISEASE
Describe the pathophysiology of Coeliac disease
- Gliadin from gluten deaminated by tissue transglutaminase –> increases immunogenicity
- Gliadin recognised by HLA-DQ2 receptor on APC –> inflammatory response
- Plasma cells produce anti-gliadin and tissue transglutaminase –> T cell/cytokine activated
- Villous atrophy and crypt hyperplasia –> malabsorption
COELIAC DISEASE
What 3 histological features are needed in order to make a diagnosis of coeliac disease?
- Raised intraepithelial lymphocytes
- Crypt hyperplasia
- Villous atrophy
COELIAC DISEASE
Give 3 complications of Coeliac disease
- Osteoporosis
- Anaemia
- Increased risk of GI tumours
- secondary lactose intolerance
- T-cell lymphoma
OESOPHAGEAL CANCER
Give 3 causes of squamous cell carcinoma
- Smoking
- Alcohol
- Poor diet/obesity
- coeliac disease
OESOPHAGEAL CANCER
Name 2 types of Oesophageal cancer
- Adenocarcinoma - distal 1/3rd of oesophagus
2. Squamous cell carcinoma - proximal 2/3rds of oesophagus
OESOPHAGEAL CANCER
What can cause oesophageal adenocarcinoma?
Barrett’s oesophagus
GASTRIC CANCER
Give 3 causes of gastric cancer
- Smoked foods
- Pickles
- H. pylori infection
- Pernicious anaemia
- Gastritis
- family history
GASTRIC CANCER
what are the red flag signs for upper GI cancer?
For people with an upper abdominal mass consistent with stomach cancer:
- Dysphagia of any age
- Aged ≥ 55yr + weight loss with any of the following:
- Upper abdominal pain/(or)
- Reflux/ (or)
- Dyspepsia
GASTRIC CANCER
what may be seen in biopsy of gastric cancer?
signet ring cells (higher numbers = worse prognosis
EGORD
Name 3 extra oesophageal symptoms of GORD
- Nocturnal asthma
- Chronic cough
- Laryngitis
- Sinusitis
CROHNS DISEASE
what are the microscopic features of crohns disease?
- transmural inflammation
- granulomas
- increase in inflammatory cells
- goblet cells
- less crypt abscesses
COELIAC DISEASE
what are the risk factors for coeliac disease?
- HLA DQ2/DQ8
- other autoimmune diseases e.g. T1DM, thyroid disease, Sjogren’s
- IgA deficiency
- breast feeding
- age of introduction to gluten into diet
- rotavirus infection in infancy
OESOPHAGEAL CANCER
what are the risk factors for oesophageal cancer?
ABCDEF
- Achalasia
- Barret’s oesophagus
- Corrosive oesophagitis
- Diverticulitis
- oEsophageal web
- Familial
MALLORY-WEISS TEAR
what are the investigations for mallory-weiss tears?
Rockall score (assess blood loss: <3 = low risk)
FBC, U&E, coag studies, group & save
ECG & cardiac enzymes
endoscopy to confirm tear
VARICES
what is the treatment for gastroesophageal varices?
- ABCDE
- Rockfall Score (Prediction of Rebleeding and Mortality)
- Bleeding Varices - Terlipressin + Prophylactic Antibiotics (Ciprofloaxcin), Balloon tamponade (Sengstaken-Blakemore tube), Endoscopic Banding, TIPS
- Bleed Prevention - BB + Endoscopic Banding. Cirrhosis = screening endoscopy
IBS
what is the rome III diagnostic criteria for IBS?
- recurrent abdominal pain at least 3 days a month in last 3 months
- associated with 2 of following:
- onset associated with change in frequency of stool
- onset associated with change in form (appearance) of stool
DIVERTICULAR DISEASE
what is the management for diverticulitis?
ANTIBIOTICS
- 1st line = co-amoxiclav (if penicillin allergic = ciprofloxacin/metronidazole)
ANALGESIA
- paracetamol
SUPPORTIVE
- high fibre diet
SURGERY
VOLVULUS
what is the management for volvulus?
- endoscopic detorsion = rigid sigmoidoscopy and rectal tube
- surgical intervention
- fluid resuscitation
- pain management
PHARYNGEAL POUCH
where do pharyngeal pouches occur?
Posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
BARRETTS OESOPHAGUS
what is barrett’s oesophagus?
Metaplasia of the lower esophageal mucosa (stratified squamous to columnar epithelium with goblet cells)
OESOPHAGEAL CANCER
which are the most common types of oesophageal cancer in the developing and developed world?
developing = squamous cell carcinoma
developed = adenocarcinoma
GORD
what are the red flag symptoms for GORD that requires further investigation?
Dysphagia (difficulty swallowing) > 55yrs Weight loss Epigastric pain / reflux Treatment resistant dyspepsia Nausea and vomiting Anaemia Raised platelets
PEPTIC ULCERS
what is the difference in presentation of gastric ulcers vs duodenal ulcers?
gastric ulcers = epigastric pain worse after eating, eased by antacids. haematemesis, weight loss, heart burn
duodenal ulcers = epigastric pain before meals and at night, relieved by eating or milk. melaena, weight gain
DIVERTICULAR DISEASE
what will imaging show in diverticulitis?
Imaging May Show
Pneumoperitoneum
Dilated Bowel Loops
Obstruction
Abscess
GASTRIC CANCER
what are the 2 different types of gastric cancer?
type 1 = intestinal / differentiated (70-80%) - found in antrum and lesser curvature
type 2 = diffuse / undifferentiated (20%) - found elsewhere
C.DIFF
what is the treatment for c.diff?
1st line = vancomycin orally for 10 days
2nd line = oral fidaxomicin
3rd line = oral vancomycin +/- IV metronidazole
ISCHAEMIC COLITIS
what are the risk factors for ischaemic colitis?
- age >60
- sex F>M
- factor V Leiden
- high cholesterol
- reduced blood flow - HF, low BP, shock, DM, RA
- previous abdominal surgery
- heavy exercise
- surgery on aorta
ISCHAEMIC COLITIS
what are the investigations for ischaemic colitis?
colonoscopy = gold standard
AXR - may show thumbprinting (due to mucosal oedema/haemorrhage)
ACHALASIA
what are the investigations?
- oesophageal manometry (diagnostic) = excessive LOS tone
- barium swallow = expanded oesophagus, fluid level (birds beak appearance)
- CXR = wide mediastinum, fluid level
ACHALASIA
what is the management?
- 1st line = pneumatic (balloon) dilation
- heller cardiomyotomy (if recurrent or severe symptoms)
- intra-sphincteric botox injection
- drug therapy (nitrates, CCBs)
ANAL FISSURES
what is the management?
ACUTE
- high fibre diet + high fluid intake
- laxatives (1st line = bulk-forming, 2nd line = lactulose)
- lubricants
- topical anaesthetic
- analgesia
CHRONIC
- above techniques
- 1st line = topical GTN
- if GTN not effective after 8 weeks, refer for surgery (sphincterotomy) or botox
CONSTIPATION
what is the management for short duration constipation (<3 months)?
1st line
- lifestyle advice (increase fibre, increase exercise, fluid intake)
- bulking laxative (ispaghula husk)
2nd line
- if hard stool, difficult to pass = osmotic laxative (macrogol, lactulose)
- if soft stool, inadequate emptying = stimulant laxatives (senna, bisacodyl)
CONSTIPATION
what is the management for faecal impaction?
1st line = osmotic laxative (macrogol) +/- stimulant laxative (senna)
2nd line = suppository (bisacodyl/glycerol)
3rd line = enema (sodium phosphate)
HAEMORRHOIDS
what is the dentate line?
divides the upper two-thirds of the anal canal from the lower third of the anal canal
- upper two-thirds = rectal columnar epithelium
- lower third = stratified squamous epithelium (highly innervated)
HAEMORRHOIDS
what is the management?
LIFESTYLE
- high fibre diet
- adequate water intake
- toilet training
- analgesia (NSAIDs)
- laxatives (bulk, stimulant, osmotic or softeners)
MEDICAL
- topical agents (anaesthetic + steroids)
- venoactive agents
- antispasmodic agents
SURGERY
- rubber band ligation
- sclerotherapy
- infrared coagulation
- haemorrhoidectomy
HIATUS HERNIA
what is the management?
LIFESTYLE
- small frequent meals
- stop smoking
- avoid lying down after eating
MEDICAL
- PPI e.g. omeprazole
SURGERY
- laparoscopic repair
- Nissen’s fundoplication
MALNUTRITION
what are the clinical features of zinc deficiency?
- delayed wound healing
- impaired taste
- hair loss
- immune deficiency
MALNUTRITION
what are the components of a MUST score?
- BMI
- amount of unplanned weight loss in past 3-6 months
- acute disease effect
MALNUTRITION
what is the criteria for malnutrition?
any of the following:
- BMI <18.5
- unintentional weight loss >10% in last 3-6 months
- BMI <20 and unintentional weight loss >5% in last 3-6 months
ANAL FISTULA
what are the different types according to the Parks classification?
- extrasphincteric = outside sphincter complex
- suprasphincteric = runs over the top of the puborectalis
- trans-sphincteric = passes through external sphincter
- intersphincteric = rns through the intersphinteric plane
ANAL FISTULA
how are the different types categorised?
- using Parks classification
ANAL FISTULA
what are the risk factors?
- history of anorectal abscess
- chronic diarrhoea
- IBD (crohns)
- prior anorectal surgery
- hydradentitis suppurativa
- diverticulitis
ANAL FISTULA
what is the management?
CONSERVATIVE
- sitz baths
- analgesia for pain control
MEDICAL (for crohns)
- infliximab
- if symptomatic = metronidazole
SURGERY
- seton technique
- fistulotomy
MESENTERIC ISCHAEMIA
what are the clinical features?
SYMPTOMS
- abdominal pain
- N+V
- diarrhoea +/- rectal bleeding
- fever
- weight loss
SIGNS
- absence of bowel sounds (late sign)
- epigastric bruit on auscultation
- rectal bleeding on PR
- hypotensive and tachycardic
MESENTERIC ISCHAEMIA
what are the risk factors?
- older age
- female
- AF
- atherosclerosis (HTN, smoking, hypercholesterolaemia, DM)
- previous MI
- hypercoagulable state
- infective endocarditis
- vasculitis
- hypoperfusion
ABDOMINAL WALL HERNIAS
where are inguinal hernias found?
above + medial to pubic tubercle
ABDOMINAL WALL HERNIAS
where are femoral hernias found?
why are they dangerous?
below + lateral to pubic tubercle (more common in women)
are at high risk of strangulation
CROHN’S DISEASE
what is the management for maintenance of remission in crohn’s disease?
- 1st line = azathioprine or mercaptopurine
- 2nd line = methotrexate
- post surgery = consider azathioprine +/- methotrexate
STOP SMOKING
ULCERATIVE COLITIS
what is the management for the maintenance of remission in UC?
MILD-MODERATE
- proctitis + rectosigmoid = topical ASA / topical ASA + oral ASA / oral ASA
- left-sided + extensive = low dose oral ASA
SEVERE (severe exacerbation or >2 exacerbations
- oral azathioprine or oral mercaptopurine
GIARDIASIS
what are the risk factors?
- foreign travel
- swimming/drinking water from a river or lake
- male-male sexual contact
GIARDIASIS
what are the clinical features?
- often asymptomatic
- non-bloody diarrhoea
- steatorrhea
- bloating
- abdominal pain
- lethargy
- flatulence
- weight loss
- malabsorption and lactose intolerance can occur
GIARDIASIS
what are the investigations?
- stool microscopy for trophozoite and cysts
- stool antigen detection test
GIARDIASIS
what is the management?
metronidazole
BACTERIAL GASTROENTERITIS
what is the typical presentation of e.coli infection?
- common amongst travellers
- watery stools
- abdominal cramps and nausea
BACTERIAL GASTROENTERITIS
what is the typical presentation of staph aureus infection?
- severe vomiting
- short incubation period
BACTERIAL GASTROENTERITIS
what is the typical presentation of campylobacter?
- flu-like prodrome followed by crampy abdominal pains, fever and diarrhoea which may be bloody
- may mimic appendicitis
BACTERIAL GASTROENTERITIS
what is the typical presentation of b.cereus infection?
two types of illness are seen
- vomiting within 6 hrs
- diarrhoeal illness occurring after 6 hrs
BACTERIAL GASTROENTERITIS
what is the most common cause of travellers diarrhoea?
e.coli
BACTERIAL GASTROENTERITIS
what are the most common causes of acute food poisoning?
- s.aureus
- b.cereus
- clostridium perfringens
IBD
what should you test before starting treatment with azathioprine or mercaptopurine?
+ TPMT activity
UPPER GI BLEED
when is Glasgow-Blatchford scoring system used?
risk assessment before endoscopy to help decide if a patient can be managed as an outpatient
UPPER GI BLEED
what would a Glasgow-Blatchford score of 0 mean?
may be considered for early discharge
UPPER GI BLEED
when is Rockall score used?
after endoscopy to calculate risk of rebleeding and mortality
UPPER GI BLEED
what is the management of a variceal bleed?
terlipressin
prophylactic antibiotics (ciprofloxacin)
endoscopy
band ligation
TIPS
UPPER GI BLEED
what is the management of non-variceal bleed?
PPI after endoscopy
ANAL CANCER
what is the biggest risk factor?
HPV infection
RECTAL CANCER
what is the most common histological type?
adenocarcinoma
RECTAL CANCER
what blood marker can be used to monitor response to treatment?
carcinoembryonic antigen (CEA)
