Gastrointestinal Flashcards
Define GORD
Inflammation of the oesophagus caused by reflux of gastric acid and/or bile
Aetiology of GORD
Disruption of mechanism preventing reflux
Prolonged oesophageal acid clearance
increased dietary fat
Heartburn - aggravated by lying supine, bending, large/fatty meals
Antacids pain relief
Waterbrash
Dysphagia
Symtoms & signs of GORD
Investigations for GORD
PPI tria
OGD
Management for GORD
Advice - weight loss, lower fat meals
Medical - PPI, antacids,
Surgery - antireflux surgery
Complications of GORD
- Oesophageal ulceration
- Haemorrhage
- Oesophageal stricture
- Barrett’s oesophagus
- Oesophageal adenocarcinoma
Define Barrett’s oesophagus
Metaplastic change: simple –> columnar
Can progress to oesophageal adenocarcinoma
Aetiology Barrett’s oesophagus
GORD
Heartburn
Dyspnoea
Can be asymtpomatic
Barrett’s oesophagus - Symptoms & Signs
Investigations for Barrett’s
OGD & Biopsy
Management plan for Barrett’s
• Non-dysplastic PPI (omeprazole) Surveillance 2nd line: Anti-reflux surgery • Low grade dysplasia (nodule only) Radiofrequency ablation +/- endoscopic mucosal resection • High grade dysplasia Radiofrequency ablation PPI 2nd line: Oesophagostomy
Complications of Barrett’s
Oesophageal adenocarcinoma development
Risk of dysplasia
Define hiatus hernia
• Protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm
Aetiology hiatus hernia
Congenital
Traumatic
Non – Traumatic
o Sliding (80%) – hernia moves in & out of chest –> Acid reflux often happens as LOS becomes less competent
o Paraoesophageal (rolling - 20%) – hernia goes through hole in diaphragm next to oesophagus
o Gastro-oesophageal junction intact acid reflux uncommon
o Mixed
Risk factors o Obesity o Low-fibre diet o Chronic oesophagitis o Ascites o Pregnancy
• Most are Asymptomatic
• GORD Sx & painless regurgitation = hiatus hernia
o Heartburn
o Waterbrash
o Dull retrosternal chest pain (often associated with swallowing)
Maybe bowel sounds in chest
Hiatus hernia
Investigations for hiatus hernia
CXR –> retrocardia gastric air bubble
Endoscopy –> detects oesophagitis but can rule out hiatus hernia
Management plan for hiatus hernia
Medical
- o Modify lifestyle factors (eg. lose weight etc)
o Inhibit acid production (PPI)
o Enhance upper GI motility
Surgical
o Nissen fundoplication
♣ Stomach pulled down through oesophageal hiatus and part of stomach wrapped (360) around oesophagus to make new sphincter and ↓ likelihood of herniation
o Belsey Mark IV Fundoplication
♣ 270 wrap
o Hill repair
♣ Gastric cardia is anchored to posterior abdominal wall
Complications of hiatus hernia
Oesophageal o Intermittent bleeding o Oesophagitis o Erosions o Barrett's oesophagus o Oesophageal strictures
Non-Oesophageal
o Incarceration of hiatus hernia (only with paraoesophageal hernias)
o This can lead to strangulation and perforation
Define Mallory-Weiss tear
• Tear or laceration of the lining of the oesophagus around the junction with the stomach, because of violent vomiting or straining to vomit
Aetiology of Mallory-Weiss tear
• Caused by prolonged violent vomiting (or anything else that causes ↑ in pressure)
Risk factors o Chronic cough o Hiatal hernia o Significant alcohol use o Bulimia o Trauma (ie. Previous instrumentation, retching during endoscopy)
- Most cases don’t have any Sx
- Abdominal pain
- Severe vomiting
- HAEMATEMESIS –> Can be from flecks to bright red bloody vomit
- Light-headedness/dizziness
- Postural hypotension
- Malena
Mallory Weiss tear
Investigations for Mallory Weiss tear
FBC
CXR
OGD
Management plan for Mallory Weiss tear
1st line
Monitoring
Endoscopy +/- Antigastric acid therapy, antiemetic, somatostatin analogue
2nd Line
Surgery
Complications of Mallory Weiss tear
Re-bleeding
MI
Oesophageal perforation
Define peptic ulcer
• Break in the mucosal lining of the stomach or duodenum > 5mm in diameter, with depth to the submucosa.
Aetiology of peptic ulcer disease
• Results from an imbalance between factors promoting mucosal damage (gastric acid, pepsin, H. pylori infection, NSAIDs) and mechanisms promoting gastroduodenal defense (prostaglandins, mucus, bicarbonate, mucosal blood flow)
• Risk factors:
o H. pylori infection
o NSAID use
o Smoking
o Age
o RARE: Zollinger-Ellison syndrome syndrome of gastric acid hypersecretion caused by gastrin secretion neuro-endocrine tumour
• NOTE: Duodenal ulcers are almost always associated with H. pylori infection and gastric ulcers with NSAID use
- Abdominal pain or discomfort centred in the upper abdomen
- Relieved by antacids
Variable relationship to food intake:
Gastric – pain is worse soon after eating
Duodenal – pain is worse several hours after eating
• Some epigastric tenderness
Peptic ulcer disease
Investigations for Peptic ulcer disease
• If <55 and no red flags o H pylori breath test/stoll antigen test o FBC o Stool occult blood test o Serum gastrin
• If >55 or red flags or treatment fails
o Upper GI endoscopy & biopsy
o If ulcer present: repeat endoscopy 6-8 weeks after treatment to confirm resolution and exclude malignancy
• H. pylori o Urea breath test: ♣ Radio-labelled urea given by mouth ♣ C13 detected in expelled air o Stool antigen test
• Upper Gastrointestinal endoscopy
o Biopsies of gastric ulcers to rule out malignancy
o Dueodenal ulcers don’t need to be biopsied
• FBC o FBC (for anaemia) o Serum amylase (to exclude pancreatitis) o U&Es o Clotting screen o LFT o Cross-matching if active bleeding o Secretin test (if Zollinger-Ellison syndrome suspected) – IV secretin causes a rise in serum gastrin in ZE patients but not in normal patients
Management plan for Peptic ulcer disease
• Acute (active bleeding ulcer)
o Endoscopy +/- blood transfusion
o Proton pump inhibitor omeprazole
o Surgery only if ulcer has perforated or bleeding can’t be controlled with endoscopy
• If H. pylori is present: o Triple therapy (14 days) PPI plus 2 antibiotics ♣ Omeprazole 20 mg bd ♣ Clarithromycin 500mg bd ♣ Amoxicillin 1000mg bd
- Can also use a H2 antagonist to supress acids ranitidine 150 mg BD
- Misoprostol (PGI E1 analogue) can be used if NSAIDs can’t be stopped
Complications of Peptic ulcer disease
- Penetration into a surrounding organ (ie pancreas)
- Gastric outlet obstruction
- Upper GI bleeding
- Perforation
Define GI perforation
• Perforation of the wall of the GI tract with spillage of bowel contents
Aetiology of GI perf
Large bowel (common) remember CAD UV o Colorectal cancer o Diverticulitis o Appendicitis o Others: volvulus, ulcerative colitis (toxic megacolon)
Gastroduodenal
o Common perforated duodenal or gastric ulcer
o Others: gastric cancer
Small bowel (rare)
o Trauma
o Infection (eg. TB)
o Crohn’s disease
Oesophagus
o Boerhaave’s perforation – rupture of the oesophagus following forceful vomiting
Risk factors o Cause (eg. gastroduodenal – NSAIDs, steroids, bisphosphonates)
• Large Bowel
o Peritonitic abdominal pain
o IMPORTANT: make sure you rule out ruptured AAA
• Gastroduodenal
o Sudden-onset severe epigastric pain - worse on movement
o Pain becomes generalised
o Gastric malignancy - may have accompanying weight loss and nausea/vomiting
• Oesophageal
o Severe pain following an episode of violent vomiting
o Neck/chest pain and dysphagia develop soon afterwards
Signs of Shock Pyrexia pallor Dehydraiton Signs of peritonitis Loss of liver dullness (due to overlying gas)
GI perforation
Investigations for GI perforation
Blood
o FBC, U&E – urea raised after upper GI bleed, LFTs
o Amylase - will be raised with perforation (but should not be astronomical (as seen in pancreatitis))
Erect CXR
o Shows air under the diaphragm
AXR
o Shows abnormal gas shadowing
Gastrograffin Swallow
o For suspected oesophageal perforations
Management plan for GI perforation
Resuscitation
o Correct fluid and electrolytes
o IV antibiotics (+ anaerobic cover) – cefuroxime and metronidazole
Surgical o Large Bowel • Identify site of perforation • Peritoneal lavage • Resection of perforated section (usually as part of a Hartmann's procedure)
o Gastroduodenal
• Laparotomy
• Peritoneal lavage
• Perforation is closed with an omental patch
• Gastric ulcers are biopsied – malignancy
• Helicobacter pylori eradication if positive for H. pylori
o Oesophageal
• Pleural lavage
• Repair of ruptured oesophagus
Complications of GI perforation
- Large and Small Bowel - peritonitis
* Oesophagus - mediastinitis, shock, overwhelming sepsis and death
Define gastric cancer
• Neoplasm that can develop in any portion of the stomach and mayb spread to lymph nodes and other organs • Most commonly adenocarcnioms o Rarer causes: ♣ Lymphoma ♣ Leiomyoscarcoma
Aetiology of Gastric cancer
Risk factors: o Pernicious anaemia o H. pylori infection o N-nitroso compounds o Weak: ♣ Diet low in fruits and vegetables ♣ High-salt diet ♣ Smoking ♣ FHx
Early satiety
Epigastric discomfort
Weight loss
Maybe malaena
Abdominal tenderness Abdominal mass Virchow's node Sister Mary Joseph's nodule Irish node
Gastric cancer
Investigations for gastric cancer
- Upper GI endoscopy with biopsy
- Endoscopic USS determines clinical tumour and node stage
- CT/MRI to check for spread
- Laparoscopy maybe needed to determine if tumour resectable
Define anal fissure
- A painful tear in the squamous lining of the lower anal canal
- 90% of the fissures are posterior (anterior only tend to happen after childbirth)
Aetiology of anal fissure
- assing hard stool bolus
* Spasm of the anal sphincter can constrict inferior rectal artery, causing ischaemia and impairing healing process
Tearing pain upon defecation
Blood seen upon wiping
Tear in squamous lining of anus upon examination
Anal fissure
Investigation for anal fissure
Inspection of anus
Management of anal fissure
• Conservative
o High-fibre diet
o Adequate fluid intake
o Stool softeners
- Topical glyceryl trinitrate relaxes anal sphincter and promotes healing
- Topical diltiazem if GTN is intolerable
Complications of anal fissure
Chronic anal fissure
Define rectal prolapse
• Abnormal protrusion of the full thickness (or only mucosal layer) of rectum through the anus
Aetiology of rectal prolapse
- Straining
- Abnormal rectal anatomy or physiology (eg. pelvic floor weakness, poor fixation of rectum to sacrum or ↓ anal sphincter pressure)
• Risk factors o Constipation o Causes of ↑ straining o Cystic fibrosis (in children) o Previous trauma to anus/perineum o Neurological conditions (e.g. cauda equina syndrome, MS)
- Protruding anal mass
- Initially associated with defecation
- May require digital replacement
- Constipation
- Faecal incontinence – in 75%
- PR mucus or bleeding
- May be an Emergency – irreducible or strangulated prolapse
Rectal Prolapse
Investigations for rectal prolapse
• Imaging
o Proctosigmoidoscopy
o Defecating proctogram or barium enema
• Other
o Anal sphincter manometry
o Pudendal nerve studies
• Sweat Chloride Test
o Performed in children to test for cystic fibrosis
Define colorectal cancer
- Malignant adenocarcinoma of the large bowel
- 71% arise in colon
- 21% rectum
Aetiology of colorectal cancer
• Sequence of genetic changes going from normal bowel epithelium to cancer
o APC COX2 over expression K-Ras p53)
o Sequence from epithelial dysplasia to adenoma to carcinoma
• Risk factors
o Western diet (e.g. red meat, alcohol, low fibre)
o Smoking
o Colorectal polyps
o Previous colorectal cancer
o FHx
o IBD
o Chronic bowel inflammation eg. IBD
Change in bowel habit Rectal bleeding Anaemia Weight loss Non-specific malaise Abdo mass
Colorectal carcinoma
Investigations for Colorectal carcinoma
• Bloods
o FBC – anaemia
o LFTs
o Tumour markers (CEA)
• Endoscopy
o Colonoscopy
♣ Can be used to biopsy the tumour
• Double-contrast Barium Enema
o May show ‘apple core’ strictures
• Abdominal ultrasound for hepatic metastases
• Contrast CT
o For staging (Duke’s staging)
Define hepatocellular carcinoma
• Primary malignancy of liver parenchyma
Aetiology hepatocellular carcinoma
o Chronic liver damage ♣ Alcoholic liver disease ♣ Hepatitis B ♣ Hepatitis C ♣ Autoimmune disease
o Metabolic disease
♣ Haemochromatosis
o Aflatoxins
♣ Aspergillus flavus – cereals contaminated with fungi
RUQ pain Malaise Weight loss Loss of appetite Abdo distension Jaundice Spider naevi Palmar erythema Ascites Hepatosplenomegaly Asterixis Cachexia Fetor hepaticus
Hepatocellular carcinoma
Investigations Hepatocellular carcinoma
• Bloods
o FBC
o U&Es
♣ Hyponatraemia fluid overload
♣ High urea 2o to renal problems
o LFTs
♣ ↑ Transaminases, ALP & bilirubin Chronic liver disease & Cirrhosis
♣ ↓ albumin Chronic liver disease & cirrhosis
o Viral hepatitis panel to determine cause
o a-fetoprotein - ↑
• Imaging
o Abdominal US – poorly defined margins and coarse, irregular internal echoes
o CT/MRI Abdo – for staging
• Histology/Cytology
o Liver biopsy
o Ascitic tap
Define Volvulus
• Rotation of a loop of bowel around the axis of its mesentery that results in bowel obstruction and potential ischaemia
• Areas usually affected:
o Sigmoid colon – 65%
o Caecum – 30%
o Volvulus Neonatorum – occurs in neonates and typically affects midgut
Aetiology of Volvulus
- Anatomical factors (e.g. long mesentery)
- Risk factors
o Adults ♣ Long sigmoid colon ♣ Long mesentery ♣ Mobile caecum ♣ Chronic constipation ♣ Adhesions ♣ Chagas disease ♣ Parasitic infections
o Neonatal
♣ Malrotation
- Severe colicky abdominal pain and swelling
- Absolute constipation
- Vomiting
Abdominal distension & tenderness Absent or tinkling bowel sounds Fever Tachycardia Dehydraiton signs
Volvulus
Investigations for volvulus
• AXR • Erect CXR – if perforation is suspected • Water soluble contrast enema o Shows site of obstruction CT Scan
Define Liver abscesses and cyst
- Abscess: liver infection resulting in a walled of collection of pus
- Cyst: liver infection resulting in a walled off collection of cyst fluid
Aetiology of liver abscess and cyst
• Pyogenic (producing pus) o E. coli o Klebsiella o Enterococcus o Bacteriodes o Streptococci o Staphylococci o 60% caused by biliary tract disease (e.g. gallstones, strictures, congenital cysts) o 15% have unknown cause
- Amoebic abscess caused by Entamoeba histolytica
- Hydatid cyst caused by tapeworm Echinococcus granulosis
- TB
- Fever
- Malaise
- Nausea
- Anorexia
- Night sweats
- Weight loss
- RUQ/epigastric pain which maybe refered to shoulder
- Jaundice
- Diarrhoea
- Pyrexia of unknown origin
- Ask about foreign travel
- Fever – continuous or spiking
- Jaundice
- Tender hepatomegaly (right lobe affected more than left)
- Right lung base dullness to percussion and ↓ breath sounds caused by reactive pleural effusion
Liver abscess and cyst
Investigations for liver abscess and cyst
• Bloods o FBC ♣ Mild anaemia ♣ Leukocytosis ♣ ↑ eosinophils in hydatid disease o LFTs ♣ ↑ ALP ♣ ↑ bilirubin o ↑ ESR and CRP o Blood cultures o Ameobic and hydatid serology
- Stool MC&S for E. histolytica or tapeworm eggs
- Liver US or CT/MRI localised structure of mass
- CXR check for right pleural effusion or atelectasis, raised diaphragm
• Aspiration and cluture of abscess material:
o Most pyogenic liver abscesses are polymicrobial
Amoebic abscesses have fluid of necrotic hepatocytes and trophozites
Define NASH
• A term used to describe a range of conditions caused by the build-up of fat in the liver due to causes other than excessive alcohol use.
Aetiology of NASH
• Liver may become initially fatty due to alcohol abuse. Yet these tend to resolve within days.
• If fat persists, can cause inflammation and fibrosis (steatohepatitis) NASH is this without Hx of alcoholism.
• Aetiology process is multifactorial
o First hit of imbalance of fatty acid metabolism which leads to hepatic triglyceride accumulation
o Second hit of dysregulated cytokine production due to efforts to compensate for altered lipid homeostasis
• Risk factors o Obesity o T2DM o HTN o Hypercholeesterolaemia o Age > 50 yrs o Smoking o Total Parenteral Nutrition
• Often no symptoms or very vague in early stages found as incidental findings • Occasional Sx include: o Dull or aching RUQ pain o Fatigue o Unexplained weight loss o Weakness
RUQ pain/tenderness
NASH
Investigations for NASH
• LFTs o Elevated AST and ALT o Elevated bilirubin o Elevated ALP o Elevated GGT
• Fasting lipid panel
o Elevated total cholesterol, LDL, triglyceride
o Low HDL
• Liver biopsy
Management plan for NASH
• Conservative – controlling risk factors: o Blood pressure o Diabetes o Cholesterol o Weight loss o Stop smoking o Exercise regularly o ↓ alcohol consumption (drinking can make it worse)
Complications of NASH
Cirrhosis –>
o Ascites o Oesophageal varices o Hepatic encephalopathy o Hepatocellular carcinoma o End-stage liver failure
Define haemochromatosis
- Autosomal recessive disease in which ↑ intestinal absorption of iron causes accumulation of iron in tissues which may lead to organ damage.
- You get iron deposition in joints, liver, heart, pancreas, pituitary, adrenals and skin
Aetiology haemochromatosis
• Mutation of the HFE gene, found on CHr6.
• A model for pathogenesis suggested;
o Liver model – HFE deficiency = ↓ hepatic hormone ‘hepcidin’ ↑ intestinal iron absorption (lack of inhibitory effect of hepcidin on ferroportin protein which exports iron from enterocytes into circulation)
o Fatigue o Weakness o Arthropathy o Erectile dysfunction o Heart problems
o Small/large joint pains o Hepatomegaly o Diabetes mellitus o Hypogonadism impotence and loss of libido o Cardiac failure arrhythmias and HF
Haemochromatosis
Investigations for haemochromatosis
• Haematinics
o Serum Ferritin HIGH (NOTE: not v accurate because is acute phase protein)
o Serum Transferrin Low
o Serum transferrin saturation High
• Tests to exclude other causes of high ferritin
o CRP – inflammation
o Chronic alcohol consumption
o ALT – liver necrosis
- Liver MRI – for Fe overload
- Liver Biopsy – iron content would be raised
- ECG/ECHO if cardiomyopathy suspected
Define PBC
- Chronic disease of small intrahepatic bile ducts characterised by progressive bile duct damage occurring in the context of chronic portal tract inflammation.
- Fibrosis develops as a consequence, and secondary effects of toxic bile retained in liver results ultimately in cirrhosis
Aetiology PBC
• Thought to be autoimmune
o Link to high personal and family incidence of other AI processes
• Genetic and environment facts also involved
• Environmental trigger may cause bile duct epithelial injury, which then leads to T-cell mediated AI response directed against bile duct epithelial cells
• Often incidental in finding on blood tests
• Insidious onset with vague Sx such as:
o Fatigue
o Weight loss
o Pruritus
• Rarely, may cause discomfort in RUQ
• May present with complication of liver decompensation (e.g jaundice, ascites, variceal haemorrhage)
• May present with Sx of associated conditions (e.g Siogren’s syndrome, arthritis, Raynaud’s phenomenon)
• Early – maybe no signs • Late o Jaundice o Skin pigmentation o Scratch marks o Xanthomas (2O to hypercholesterolaemia) o Hepatosplenomegaly o Ascites o Signs of chronic liver disease
PBC
Investigations for PBC
• Bloods o LFTs ♣ ↑ ALP ♣ ↑ GGT ♣ Elevated bilirubin ♣ Transaminases int normally, but ↑ with disease progression ♣ Low albumin
• Typical features of PBC
o Antimitochondrial antibody – hallmarks of PBC
o High IgM
o High cholesterol
- TFTs – PBC associated with AI thyroid disease
- USS – exclude extrahpepatic biliary obstruction (eg. gallstones)
• Liver biopsy
o Chronic inflammatory cells and granulomas around intrahpepatic bile ducts, destruction of bile ducts, fibrosis and regenerating nodules of hepatocytes
Appendicitis Aetiology
• Obstruction of the lumen of appendix is main cause of acute appendicitis by:
o Faecolith (hard mass of faecal matter)
o Normal stool
o Lymphoid hyperplasia
• Can lead to oedema, ischaemic necrosis and perforation
Periumbilical pain moving to RIF Anorexia Vomiting Constipation Diarrhoea
Sx of Appendicitis
• General signs o Tachycardia o Fever o Furred tongue o Lying still o Coughing hurts o Foetor with/without flushing o Shallow breaths • RIF signs o Guarding o Rebound and percussion tenderness
o Rovsing’s Sign – palpation of LIF causes more pain in RIF than left
o Psoas Sign – pain on extending hip (caused by retrocaecal appendix)
o Obturator Sign – pain on flexion and internal rotation of the hip (occurs if appendix is in close proximity to obturator internus)
Signs of Appendicitis
Investigations for Appenditicits
• FBC
o ↑ WCC
o ↑ CRP
o Pregnancy test – to rule out ectopic pregnancy
• Abdo & Pelvis CT scan
o High diagnostic accuracy but may cause fatal delay – usually go straight to surgery for diagnostic laparoscopy +/- appendicectomy
• Abdominal USS
Mamangement - appendicits
- Prompt appendicectomy (could be done laparoscopically)
- Antibiotics Cefoxitin
- IV fluids should be started
Complications of appendicits
- Perforation
- Appendicular mass when inflamed appendix is covered with omentum
- Generalised peritonitis
- Appendix abscess if mass fails to resolve, treatment involves drainage and Abs
Define pilonidal sinus
Forceful insertion of hairs into skin of natal cleft in sacrococcygeal area promotes chronic inflammatory reaction, causing epithelialized sinus.
Aetiology pilonidal sinus
- Ingrowing of hairs excited foreign body inflammatory reaction and may cause 2O tracks to open laterally +/- abscesses with foul-smelling discharge
- Intermittent negative pressure will draw in more hair and perpetuate the cycle
• Risk factors:
o Hirsutism
o Spending long time sitting down
o Occupational (eg. hairdressers may develop interdigital pilonidal sinus)
- Painful natal cleft
- Discharging swelling & foul smell
- Often recurrent
- Deep skin of natal cleft often macerated, with one or several sinuses opening into or just lateral to midline
- Hairs may protrude from the swelling
- If infection or abscess, the swelling will become tender
- It may be fluctuant and discharge pus or blood-stained fluid on compression
Pilonidal sinus
Investigations for pilonidal sinus
• NONE needed
• Bloods - to check for signs of infection
o Raised WCC
o Fasting glucose (diabetics are at risk)
Management for pilonidal sinus
• Consider pre-op Abs
• Acute Pilonidal Abscess
o Incision and drainage
• Chronic Pilonidal Sinus
o Excision under general anaesthesia with exploration
• Prevention
o Good hygiene
o Shaving
Complications pilonidal sinus
- Pain
- Infection
- Abscess
- Recurrence
