Gastrointestinal (2) Flashcards

Question

What are the possible complications of Crohn's Disease?

Answer 1

Anaemia ``` GI: Abscess Haemorrhage Obstruction Strictures Perforation Fistulae (between bowel, bladder, vagina) Perianal fistulae and abscesses GI cancer Malabsorption Toxic megacolon ``` ``` Extraintestinal Features: Uveitis Episcleritis Gallstones Kidney stones Arthropathy Sacroiliitis Ankylosing spondylitis Erythema nodosum Pyoderma gangrenosum Amyloidosis Primary sclerosing cholangitis ```

Answer 2

CD is a chronic disease with variable frequency of relapses and multiple possible complications. Intermittent exacerbations followed by periods of remission, with 10% to 20% of patients experiencing a prolonged remission after the initial presentation. 2/3 of CD patients will require surgery CD has lower life expectancy

Answer 3

Diverticular disease = diverticulosis associated with complications. Diverticulosis = the presence of diverticulae outpouchings (herniation of the mucosa and submucosa through the muscular layer of the large bowel wall). Diverticulitis = acute inflammation of a diverticulum or diverticula

Answer 4

Low-fibre diet leads to loss of stool bulk. Leads to generation of high colonic intraluminal pressures to propel the stool out. Leads to the herniation of the mucosa and submucosa through the muscularis Inspissated food or faecal matter can cause diverticular obstruction -> bacterial overgrowth, toxin production and mucosal injury -> diverticulitis Most commonly found in sigmoid and descending colon. NOT in rectum. ``` Risk factors: Low dietary fibre (Western diet) Age >50 y Decreased physical activity Obesity Increased red meat consumption Tobacco smoking Excessive alcohol and caffeine intake Steroids NSAIDs ```

Answer 5

Prevalence is difficult to determine because most patients are asymptomatic but VERY COMMON. Prevalence increases with age - affects 50% to 66% of over 80 year olds. Right-sided diverticular disease is more common in Asia. No overall sex difference in prevalence of diverticular disease.

Answer 6

``` Often asymptomatic Left lower quadrant pain Diarrhoea PR bleeding Bloating Constipation ``` If diverticulitis - LIF and lower abdo pain and fevero If diverticular fistulation - causing pneumaturia (see bubbles in urine), faecaluria and recurrent UTI

Answer 7

Guarding and tenderness in LLQ Pelvic tenderness on DRE Signs of generalised peritonitis if a diverticulum has perforated

Answer 8

Bloods: FBC - raised WCC if acute diverticulitis, raised CRP Abdo CT - thickening of bowel wall, mass, abscess, streaky mesenteric fat, gas in the bladder in cases of fistula. Abdo USS - if CT unavailable Abdo X-ray - pneumoperitoneum, ileus, soft tissue densities, free air in bowel perforation if acute diverticulitis CXR - if suspect perforation Barium Contrast enema - saw-tooth appearance of lumen. Used to confirm acute diverticulitis diagnosis following resolving of symptoms - do not use in acute setting as risk of perforation. Colonoscopy or sigmoidoscopy - if unclear or supsect bowel cancer Angiogram if profuse bleeding

Answer 9

Asymptomatic: Soluble high-fibre diet (20-30 g/day) and increase fluids Probiotics and anti-inflammatories?? GI Bleed: IV rehydration and antibiotics Blood transfusion if necessary Angiography and embolisation or surgery if severe Diverticulitis: IV antibiotics IV fluid rehydration Bowel rest Abscesses may be drained by radiologically sited drains Surgery: Necessary in patients with recurrent attacks or complications (e.g. perforation and peritonitis) Open surgery: Hartmann's procedure (proctosigmoidectomy leaving a stoma) One-stage resection and anastomosis (risk of leak) with or without defunctioning stoma Laparoscopic drainage, peritoneal lavage and drain placement can be effectively

Answer 10

``` Diverticulitis Pericolic abscess Perforation Faecal peritonitis Colonic obstruction Fistulae - Bladder: causes pneumaturia, faecaluria, recurrent UTI - Small intestine - Vagina Haemorrhage Strictures ```

Answer 11

Most patients with uncomplicated diverticulitis recover following medical treatment and do not require surgical intervention. Diverticular disease recurs in one third of patients following response to medical treatment, mostly within 5 years. Following surgical treatment, approximately one fourth of all patients continue to remain symptomatic. 10-25% have one or more episode of diverticulitis

Answer 12

Chronic condition characterised by abdominal pain and bowel dysfunction with no underlying structural abnormalities – diagnosis of exclusion

Answer 13

No specific aetiological cause (mucosa is normal) Disorder of GI motility with a potential inflammatory/immune basis often triggered by stress ``` Risk factors: Female Age <50 years GI infection Previous physical or sexual abuse Stress ```

Answer 14

Affects 10-15% of adults The prevalence is higher in women than men Rare for onset of symptoms after 50 years

Answer 15

Abdominal discomfort Altered bowel habits associated with pain Bloating Passage of mucus with stool Cramping pain relieved following defecation

Answer 16

Nil signs of note - a normal abdominal exam

Answer 17

Bloods: FBC - if low Hb or high WCC suggests not IBS Anti-endomysial antibodies - if positive, coeliac Anti-tTG antibodies - if positive, coeliac Stool studies - WBCs or parasites in stool suggests not IBS Abdo X-ray - check for obstruction Flexible sigmoidoscopy and colonoscopy - if abnormal mucosa, suggests IBD Serum CRP - if more than 0.5mg/L then IBD more likely Faecal calprotectin - if high more likely IBD

Answer 18

``` Lifestyle and dietary modifications - decrease caffeine, lactose and fructose, add fibre, probiotics Laxatives If painful, add antispasmodics SSRIs if constipated CBT or hypnotherapy If having diarrhoea, antidiarrhoeals ```

Answer 19

Damage to family and work relationships | Diverticulosis

Answer 20

Normal life expectancy and no long-term complications. The symptoms recur for much of adulthood, particularly at times of stress, emotional difficulty or dietary indiscretions.

Answer 21

Pain resulting from obstruction of the gallbladder, cystic duct or common bile duct, usually by a stone. It is usually felt in the upper abdomen (in the midline or to the right) but can also be poorly localised due to its visceral nature.

Answer 22

Occurs due to contractions of the biliary tree in attempt to relieve an obstruction due to a stone. ``` Risk factors of gallstones: Fair (Caucasian) Fat Fertile Forty Female ``` Family history, Obesity, Drugs e.g. OCP, octreotide, Pregnancy, terminal ileum disease Pigment gallstones – calcium bilirubinate • Chronic haemolytic anaemia • Cirrhosis • Cystic fibrosis • Ileal disease • Bile duct strictures

Answer 23

10-15% of adults in the Western World will develop gallstones In more than 80% of people, gallstones are generally symptomatic

Answer 24

Crampy RUQ pain Nausea and vomiting Pain may radiate to the right scapula The pain does NOT fluctuate and has a tendency to persist Individuals may present with pain following ingestion of a fatty meal

Answer 25

RUQ or epigastric tenderness

Answer 26

Bloods: FBC - elevated WCC suggests inflammation due to complication LFTs - if stone blocking CBD, high ALP and bilirubin Serum lipase and amylase - if elevated, may be pancreatitis Ultrasound - Look for dilatation of the CBD, thickened gallbladder, may be able to see stones Urinalysis, CXR and ECG to exclude other causes (e.g. basal pneumonia, inferior MI) ERCP - useful diagnostically and therapeutically CT - may be useful if other forms of imaging have been insufficient

Answer 27

If asymptomatic gallstones, OBSERVATION If symptomatic: Analgesia IV fluids NBM Surgical: Laparoscopic cholecystectomy ERCP can also be used to help remove stones or stent a blocked bile duct

Answer 28

ERCP-associated pancreatitis Cholecystitis Ascending cholangitis Acute biliary pancreatitis Complications due to cholecystectomy: Injury to the bile duct Fat intolerance - due to inability to secrete a large amount of bile into the intestine because the patient no longer has a gallbladder Post-cholecystectomy syndrome - presence of abdominal symptoms (e.g. dyspepsia, nausea/vomiting, RUQ pain) after the removal of the gallbladder

Answer 29

Good prognosis with appropriate treatment

Answer 30

A neoplasm that can develop in any portion of the stomach and may spread to the lymph nodes and other organs. Most tumours are adenocarcinomas. Other histological types include lymphoma, leiomyosarcoma, neuroendocrine tumours, and squamous cell carcinomas.

Answer 31

The aetiology is unknown - linked to environment and genetics ``` Risk Factors: Smoked and processed foods Smoking Alcohol Helicobacter pylori infection Atrophic gastritis Pernicious anaemia Partial gastrectomy Gastric polyp Male sex ```

Answer 32

``` Higher incidence in East Asia, Eastern Europe, and South America - highest in JAPAN More common in men COMMON cause of cancer death worldwide 6th most common cancer in the UK Usual age of presentation: > 50 yr ```

Answer 33

Often asymptomatic in early stages ``` Abdominal pain/epigastric discomfort FLAWS Nausea Dysphagia Haematemesis Lower GI bleeding eg meleana Early satiety Anorexia Symptoms of metastases e.g. ascites, jaundice Symptoms of anaemia - fatigue ```

Answer 34

``` Epigastric mass Abdominal tenderness Ascites Signs of anaemia Lymphadenopathy Virchow's Node (aka Troisier's sign) Sister Mary Joseph's Nodule (metastatic node on the umbilicus) Krukenberg's Tumour (ovarian metastases) ``` Metastases • Ascites • Jaundice • Hepatomegaly

Answer 35

Bloods - FBC (check for anaemia), LFTs Upper GI endoscopy with biopsy ``` Once diagnosed: CT/MRI for staging Endoscopic USS to assess depth of gastric invasion and lymph node involvement - determine T and N stages CT abdo and pelvis - check for mets CXR - check for mets CT chest - check for mets ```

Answer 36

Symptoms or complications resulting from the reflux of gastric contents into the oesophagus, oral cavity or lung

Answer 37

Reduced Lower oesophageal sphincter tone Prolonged oesophageal acid clearance Delayed gastric emptying

Answer 38

``` Family history of GORD Older Age Obesity Pregnancy Hiatus hernia Systemic sclerosis Drugs e.g. nitrates, tricyclics, NSAIDS Smoking Alcohol Stress Asthma Intake of specific foods (such as coffee, mints, citrus fruits, or fats) ```

Answer 39

Affects 10-30% of people in developed world | All age groups affected

Answer 40

``` Heart burn (worse on lying down, bending over, after drinking alcohol or eating large meals) Epigastric burning discomfort Acid regurgitation (waterbrash) Dysphagia due to peptic stricture Cough (vagal stimulation and aspiration) Pain is relieved by antacids Early satiety ```

Answer 41

Epigastric tenderness Wheeze on chest auscultation Dysphonia Asthma due to aspiration

Answer 42

Often a CLINICAL diagnosis PPI trial - if after 8 week trial no improvement, further tests OGD/Upper GI endoscopy, biopsy and cytological brushings - may show oesophagitis or Barrett's oesophagus and can exclude malignancy Ambulatory pH monitoring - pH less than 4 more than 4% of time is abnormal. pH probe in lower oesophagus determines the temporal relationship between symptoms and pH. Oesophageal manometry Barium Swallow can detect: Hiatus hernia, Peptic stricture, Extrinsic compression of the oesophagus CXR: This is NOT specific for GORD. Can lead to the incidental finding of a hiatus hernia (gastric bubble behind the cardiac shadow)

Answer 43

Stanard-dose PPI and lifestyle changes (weight loss, avoid late eating, elevate head of bed, avoid provoking factors, stop smoking) 2nd line = anti-reflux surgery for those who are responsive but do not adhere If irresponsive to PPI: strong dose PPI and H2 antagonist Endoscopy: Annual endoscopic surveillance Nissen Fundoplication: Fundus of the stomach is wrapped around the lower oesophagus - helps reduce the risk of hiatus hernia and reduce reflux.

Answer 44

Oesophageal ulceration, haemorrhage or perforation Peptic stricture Anaemia Barrett's oesophagus Oesophageal adenocarcinoma Associated with asthma and chronic laryngitis

Answer 45

50% respond to lifestyle measures alone In patients that require drug therapy, withdrawal is often associated with relapse 20% of patients undergoing endoscopy for GORD have Barrett's oesophagus

Answer 46

Acute inflammation of the GI tract typically resulting from bacterial toxins or viral infections. Incubation period typically lasts 16-24h.

Answer 47

Transmission may occur due to eating improperly prepared foods, drinking contaminated water or through close contact with an infected individual. ``` Viral: Rotavirus Adenovirus Norovirus Astrovirus Calcivirus Norwalk virus Small round structures viruses ``` ``` Bacterial: Campylobacter jejuni (chicken) Escherichia coli Salmonella (eggs, poultry) Shigella Vibrio cholerae Listeria Yersinia enterocolitica ``` Protozoal: Entamoeba histolytica Cryptosporidium parvum Giardia lamblia ``` Toxins from: Staphylococcus aureus Clostridium botulinum Clostridium perfringens Bacillus cereus Mushrooms Heavy metals Seafood ``` ``` Commonly contaminated foods: Improperly cooked meat Old rice Eggs and poultry Milk and cheeses Canned food ``` Parasitic Giardia – Eastern Europe/Russia Entamoeba – tropical regions Non-infectious • Drugs e.g. NSAIDs • Food e.g. (lactose intolerance, coeliac disease) • Crohn’s disease

Answer 48

Young Old Travellers

Answer 49

In the UK, around 20% of the UK population will have an infectious intestinal disease each year COMMON Serious cause of morbidity and mortality in the developing world Viral gastroenteritis is a common cause of D&V in children Bacteria is the most common cause of gastroenteritis in adults

Answer 50

``` Nausea and vomiting Diarrhoea (bloody or watery) Abdominal pain Malaise Sudden onset nausea, vomiting, anorexia Fever Dysentery (CHESS – Campylobacter, Haemorrhagic E. coli, Entamoeba histolytica, Salmonella, Shigella) Bloating, foul smelling eructation/flatus (Giardia) ``` Time of Onset: Toxins = early (1-24 hours) Bacterial/viral/protozoal = 12+ hours Pay attention to the other effects of toxins: Botulinum causes paralysis Mushrooms can cause fits, renal or liver failure

Answer 51

History: recent travel, antibiotic use, recent food intake (how the food was cooked, sourced and whether anyone else is ill) Diffuse abdominal tenderness Abdominal distension Bowel sounds are often INCREASED In SEVERE gastroenteritis: pyrexia, dehydration (increased cap refill, reduced skin turgor), hypotension and peripheral shutdown

Answer 52

Usually clinical diagnosis Bloods: FBC, blood culture (identify bacteraemia), U&Es (dehydration) Stool: faecal microscopy and analysis for toxins AXR or ultrasound: exclude other causes of abdominal pain (e.g. bowel perforation) Sigmoidoscopy: usually unnecessary unless IBD needs to be excluded

Answer 53

Bed rest - mostly self-limiting so go away with time Fluid and electrolyte replacement with oral rehydration solution (contains glucose and salt) IV rehydration may be necessary in those with severe vomiting Antibiotics IF severe; infective agent has been identified; <3 months or >50 years old; immunosuppressed; internal prostheses If botulism is present (due to Clostridium botulinum) treat with IM botulinum antitoxin and manage in ITU

Answer 54

Dehydration Electrolyte imbalance Prerenal failure (due to dehydration) Secondary lactose intolerance (particularly in infants) Sepsis and shock Haemolytic uraemic syndrome (associated with toxins from E. coli O157) Guillain-Barre Syndrome may occur weeks after recovery from Campylobacter gastroenteritis Respiratory muscle weakness or paralysis due to botulism

Answer 55

Good prognosis as usually self-limiting If volume depletion and electrolyte disturbances are not recognised and managed, can cause serious morbidity and mortality. Usually no long-term consequences following recovery

Answer 56

Inflammation of the colon due to an infectious agent

Answer 57

Bacteria Clostridium difficile – enterotoxin A + cytotoxin B Shigella Campylobacter Salmonella Yersinia enterolytica E.coli (enteroinvasive and enteroaggregative) Viruses Rotavirus CMV Parasites Entamoeba histolytica

Answer 58

``` Lack of sanitation Drinking contaminated water Antibiotic use - clindamycin, ampicillin and broad-spectrum cephalosporins IBD Serious acute illness GI procedures Age ```

Answer 59

Very common Western countries: bacterial infection is most common Developing countries: parasitic infection is much more common

Answer 60

``` Diarrhoea Blood and mucus in the stools Lower abdominal pain/cramps Malaise Low-grade fever Rectal bleeding Tenesmus ```

Answer 61

Fever Localized or generalized abdominal tenderness Rebound tenderness

Answer 62

Diagnosis is largely CLINICAL | Stool culture may be used to identify the causative organism

Answer 63

Perforation of the wall of the GI tract with spillage of | bowel contents

Answer 64

``` Large Bowel: Diverticulitis Colorectal cancer Appendicitis Others: volvulus, ulcerative colitis (toxic megacolon) ``` Gastroduodenal: Perforated duodenal or gastric ulcer NSAIDs Others: gastric cancer Small Bowel (RARE): Trauma Infection (e.g. TB) Crohn's disease Oesophagus: Boerhaave's perforation - rupture of the oesophagus following forceful vomiting GI malignancy, IBD, Ingestion of corrosives e.g. batteries, Surgery/investigations e.g. ERCP

Answer 65

Duodenal ulcers are 2-3 times more likely to perforate than peptic ulcers 10-15% of patients with acute diverticulitis develop perforations

Answer 66

``` Peritonitic severe abdominal pain originating at site of perforation Nausea and Vomiting Fever Pain worse on movement Pain becomes generalised ```

Answer 67

Very UNWELL Signs of shock - tachycardia, hypotensive Pyrexia Pallor Dehydration Signs of peritonitis (guarding, rigidity, rebound tenderness, absent bowel sounds) Loss of liver dullness (due to overlying gas) Lying still

Answer 68

Bloods FBC, U&E, LFTs Amylase - will be raised with perforation Erect CXR - air under the diaphragm AXR - Shows abnormal gas shadowing Gastrograffin Swallow - for suspected oesophageal perforations

Answer 69

Resuscitation: Correct fluid and electrolytes IV antibiotics (with anaerobic cover) ``` Surgical Large Bowel: Identify site of perforation Peritoneal lavage Resection of perforated section (usually as part of a Hartmann's procedure) ``` Gastroduodenal: Laparotomy Peritoneal lavage Perforation is closed with an omental patch Gastric ulcers are biopsied and if positive, H. pylori eradication Oesophageal: Pleural lavage Repair of ruptured oesophagus

Answer 70

Peritonitis | Oesophagus - mediastinitis, shock, overwhelming sepsis and death

Answer 71

Gastric ulcers have higher morbidity and mortality than duodenal ulcers POOR prognosis for perforated gastric carcinomas

Answer 72

An autosomal recessive disease of iron metabolism in which increased intestinal absorption of iron and iron release from macrophages causes accumulation of iron in tissues, which may lead to organ damage.

Answer 73

Autosomal recessive Caused be a mutation in the HFE gene on chromosome 6 Most common mutations are C282Y (60-90%) and H63D (3-7%) The genetic penetrance of haemochromatosis is complex - not everyone who is homozygous will develop the clinical disease ``` Risk factors: Male (women present late due to protective menstrual loss) Middle age (40-50 years) White ancestry Family history High dietary iron intake ```

Answer 74

Very rare | Most common in Northern Europeans

Answer 75

Often ASYMPTOMATIC until the late stages of the disease ``` EARLY symptoms are vague: Fatigue Weakness Arthropathy Erectile dysfunction Heart problems ``` ``` LATE symptoms: Diabetes mellitus Skin pigmentation: Bronzed skin Signs of chronic liver disease: Hepatomegaly Impotence (inability to get an erection) Amenorrhoea Hypogonadism Cirrhosis Cardiac - arrhythmias and cardiomyopathy Signs of congestive heart failure Neurological and psychiatric problems ```

Answer 76

Serum transferrin saturation - first test to become abnormal, >45% Serum ferritin - raised in inflammation, alcoholism, chronic viral hepatitis, non-alcoholic fatty liver disease, and dysmetabolic syndrome Tests to exclude other causes of high ferritin: CRP - inflammation Chronic alcohol consumption ALT - liver necrosis LFTs Other investigations for abnormal liver function (e.g. hepatitis serology) Genetic testing Liver biopsy (rarely required) - raised iron content ``` In late disease: High fasting blood glucose Echo ECG Testosterone, LH, FSH ```