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Gastrointestinal Flashcards

1
Q

What is the most common symptom of gastrointestinal infection?

A

Diarrhoea

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2
Q

What other non-infective causes of diarrhoea?

A

Cancer
Inflammatory bowel disease
Irritable bowel syndrome
Drugs

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3
Q

What are the other symptoms of GI infections?

A

Nausea
Vomiting
Abdominal cramps

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4
Q

What about the diarrhoea can indicate the severity of the infection?

A

Watery - non-inflammatory

Bloody/mucoid - inflammatory

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5
Q

What group of organisms causes the most diarrhoea in the UK?

A

Viruses

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6
Q

What are bacterial causes of watery diarrhoea?

A

Cholera, E.coli, S. aureus, Bacillus cereus.

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7
Q

What are viral causes of watery diarrhoea?

A

Rotavirus, norovirus

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8
Q

What is a parasitic cause of water diarrhoea?

A

Giardia

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9
Q

What is a bacterial cause of bloody diarrhoea?

A

Shigella, E.coli, Salmonella, C. diff, Campylobacter

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10
Q

What are risk factors for GI infection?

A 
Recent travel
Immunocompromised
Contact with an infected individual
A hobby that has exposures - ie. water sports or with animals. 
Food and drink - ie. BBQ
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11
Q

What bacteria is linked to infection from BBQ?

A

Campylobacter

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12
Q

What bacteria is linked to infection from reheated rice?

A

Bacillus cereus

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13
Q

What investigations should be carried out in suspected GI infections?

A

Blood tests - microscopy and culture

Stool tests - microscopy and culture

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14
Q

What is the most common causative organism of traveller’s diarrhoea?

A

E.coli

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15
Q

What is the diagnostic features of traveller’s diarrhoea?

A

3+ unformed stools per day with one of symptoms as well. Withink two weeks of arrivak in a new country.

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16
Q

What symptoms does Vibrio cholera infection give?

A

Very watery diarrhoea - up to 20l a day

Vomiting

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17
Q

How does Vibrio cholera cause diarrhoea?

A

Produces the cholera toxin - causes chloride to be transported into the lumen - water follows - severe watery diarrhoea.

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18
Q

What is a mechanism of clostridium difficile infection?

A

It is a normal gut flora in 5% of population - gut flora is altered by broad spectrum antibiotics - C. diff can grow uninhibited - then releases toxins that cause pain and fever.

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19
Q

What antibiotics can cause the overgrowth of C diff?

A

Clindamycin
Cephalosporins
Ampicillin
Amoxicillin

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20
Q

What antibiotics can treat C diff infection?

A

Metronidazole or oral vancomycin.

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21
Q

What are the basic treatments for diarrhoea?

A

Give fluids to avoid dehydration
If severe - give anti-emetics
If systemically unwell - give antibiotics

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22
Q

What infection can cause peptic ulcer disease?

A

Helicobacter pylori

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23
Q

What are intraluminal causes of GI obstruction?

A

Tumour
Strictures
Gallstone ileus
Meconium ileus

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24
Q

What are intramural causes of GI obstruction?

A

Inflammatory - Crohn’s or UC
Diverticular disease
Intramural tumours

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25
What are extraluminal causes of GI obstruction?
Adhesions Volvulus Peritoneal tumour
26
What is an adhesion? Causes of an abdominal adhesion?
Fibrous attachments between areas of the bowel. Often occur as a result of abdominal surgery.
27
Where is the most common location for an abdominal volvulus?
Sigmoid colon
28
In what part of the bowel are most obstructions?
Small bowel.
29
What is the presentation of abdominal obstruction?
Abdominal colic Distension Constipation (no passage of wind also) Vomiting
30
How does vomiting present in a small bowelobstruction?
Profuse and projectile
31
How does vomiting present in a large bowel obstruction?
Absent (due to a competent ileocaecal valve) | Much later in presentation (incompetent valve)
32
What does bilious vomit indicate in GI obstruction?
Post duodenum obstruction
33
What does faeculant vomiting suggest in GI obstruction?
It has been a long duration of obstruction.
34
What are the signs of a GI obstruction?
``` Tachycardia Dehydration Distension Tenderness Tinkling bowel sounds ```
35
What does an abdominal X-Ray show in GI obstruction?
Distended bowel proximal to the obstruction
36
What are the treatment options for GI obstruction?
Fluids Nasogastric tube - to relieve pressure build up Surgery to relieve blockage
37
What are the possible complications of Gi obstruction?
Dehydration Perforation and infection Sepsis Kidney failure
38
What two conditions make up inflammatory bowel disease?
Crohn's disease | Ulcerative colitis
39
What are the symptoms of Crohn's disease?
``` Diarrhoea Abdominal pain Weight loss Malaise Lethargy Nausea ```
40
What investigations should be carried out in suspected inflammatory bowel disease?
Blood tests - raised ESR and CRP Stool tests to exclude infection Endoscopy and biopsy Exclude coeliac disease.
41
Where is the inflammation in Crohn's disease?
Anywhere from mouth to anus
42
What is the pathophysiology of Crohn's inflammation?
``` It is patchy along the GI tract Granulomatous inflammation (50%) If prolonged leads to fibrous scarring and a cobblestone appearance. Can occur in any layer of the bowel wall. ```
43
What are the specific symptoms of ulcerative colitis?
``` Bloody and mucous diarrhoea always (colon only) Lower abdominal discomfort Weight loss Malaise Lethargy Nausea ```
44
What is the lifestyle advice for Crohn's disease?
Smoking cessation
45
What is the pathophysiology of ulcerative colitis inflammation?
Isolated to the colon only Starts at rectum and progresses continuously Only in the mucosal layer of the bowel wall
46
What is the treatment for mild IBD?
Crohn's - mild steroids (prednisolone) | UC - 5-ASAs (mesalazine)
47
What is the treatment for severe IBD?
IV hydrocortisone | Surgery
48
What are the differences between Crohn's and UC?
``` any part of the GI tract v colon only. patchy v continuous transmural v mucosal only granulomas v no granulomas bowel complications v systemic complications ```
49
What are the complications of Crohn's disease?
Malabsorption Obstruction Perforation - infection Neoplasia
50
What are the complications of UC?
Cancer Perforation - infection Arthritis Rashes and ulcers
51
What is gastritis?
Inflammation of stomach epithelium
52
What are the causes of gastritis?
NSAIDs H Pylori infection Smoking Autoimmune
53
What is the presentation of gastritis?
``` Dyspepsia Nausea Vomiting Early satiety Indigestion ```
54
What investigations should be carried out in gastritis?
Endoscopy | H Pylori tests - C-urea breath test, antigen stool test.
55
What lifestyle can be given for gastritis?
``` Less NSAID use Avoid irritants Smoking cessation Alcohol reduction Smaller meals ```
56
How to treat gastritis?
Antacids PPIs H2 receptor agonists Treat H pylori infection
57
What are the complications of gastritis?
Gastric ulcer Polyps Malignancy
58
What is the basis of coeliac disease?
Immune mediated inflammatory response to gluten, which can lead to chronic inflammation and malabsorption.
59
What component of gluten triggers the immune response?
Gliadin
60
What is the immune response to gliadin?
Gliadin passes through epithelium - deaminated by tissue transglutaminase - T cells produce pro-inflmmatory cytokines and activate B-cells - B cells produce antibodies - vilous atrophy and malabsorption.
61
What antibodies to B cells produce in coeliac disease?
anti-gliadin tissue transglutaminase anti-endomysial
62
What is the genetic association in coeliac disease?
HLA DQ2 in 95% | HLA DQ8 in the rest
63
What ages are affected by coeliac disease?
Any. peaks infancy and middle/late age
64
What is the presentation of coeliac disease?
``` Diarrhoea Stinking stools/steathorrhea Weight loss Abdominal pain Bloating Nausea and vomiting ```
65
What is classical and non-classical presentations of coeliac disease?
Classical - infancy with IBS symptoms | Non-classical - adult with IBS symptoms and others (fatigue, osteoporosis, ataxia).
66
What are the signs of coeliac disease?
Anaemia (due to B12 or folate deficiencies) Mouth ulcers Skin rashes
67
What are the investigations for coeliac disease?
``` Duodenal biopsy (4 + samples) Serological testing ```
68
What diet must the patient be on when the tests are taken?
Gluten
69
What antibodies are tested for in the serological tests?
anti-gliadin tissue transglutaminase anti-endomysial (all IgA)
70
What is seen on histology of a duodenal biopsy in coeliac disease?
Villous atrophy Increased epithelial lymphocytes Crypt hyperplasia
71
What is the histological classification for coeliac disease?
Marsh classification
72
How do you decide when to biopsy in coeliac disease?
If high risk always biopsy. | If low risk, biopsy if serology tests are positive.
73
What is the management for coeliac disease?
Gluten free diet Nutritional supplements as required Information and education
74
Wy may someone have poor compliance to a gluten free diet?
High cost of gluten free products Hard in social situations Food unpalatable Inadvertent exposure to gluten
75
What are the possible complications of coeliac disease?
Anaemia Lymphoma risk Other malignancy raised risk
76
What are the symptoms of malabsorption?
``` Diarrhoea Weight loss Lethargy Steathorroea Bloating ```
77
What are the signs of malabsorption?
``` Anaemia (dec iron, folate or B12) Bleeding disorders (dec vit K) Oedema (dec protein) Bone disease (dec vit D) Neurological features ```
78
What are the possible pathophysiological causes of malabsorption?
``` Insufficient intake Defective digestion Insufficient absorptive area Lack of digestive enzymes Defective epithelial transport Lymphatic obstruction ```
79
What are the causes of defective digestion leading to malabsorption?
Pancreatic insufficiency - pancreatits/cystic fibrosis Defective bile secretion - obstruction, ileal resection Bacterial overgrowth
80
What are the causes of insufficient absorptive area leading to malabsorption?
Coeliac disease Crohn's disease Parasite invasion Resection or bypass
81
What are the causes of lack of digestive enzymes leading to malabsorption?
lactose intolerance -- diasaccheridase def | bacterial overgrowth
82
What are the two types of oesophageal cancer?
Squamous cell | Adenocarcinoma
83
What are the risk factors for adenocarcinoma of the oesophagus?
Obesity GORD Older age
84
What is the link between GORD and adenocarcinoma of the oesophagus?
GORD causes metaplasia of squamous to columnar epithelium (Barratt's) - may eventually produce dysplastic or neoplastic cells.
85
What are the risk factors for squamous cell carcinoma of the oesophagus?
Smoking High alcohol intake Male gender Chinese
86
What is the presentation of oesophageal cancer?
``` It often presents very late and vaguely Dysphagia (often solids first then liquids later) Weight loss and anorexia Lymphadenopathy Indigestion and heart burn ```
87
What are investigations for an oesophageal cancer?
Endoscopy - diagnosis | CT/MRI for staging purposes.
88
What is the location of local metastases of oesophageal cancer?
Trachea Vena cava Aorta
89
What is the management of an oesophageal cancer?
Surgery - only if an early enough presentation Chemotherapy Radiotherapy Palliative therapies
90
What type of cancer is gastric cancer?
Adenocarcinoma
91
What are risk factors for gastric cancer?
``` Smoking H. pylori infection High salt and nitrate diet Family history Old age ```
92
When is a gastric cancer classified as early?
Mucosa and submucosa only
93
When is gastric cancer classified as late?
Spread into the muscular wall and beyond - most common presentation
94
What is the presentation of gastric cancer?
``` Often presents very late in the disease progression. Epigastric pain Nausea Anorexia Weight loss ```
95
What are the signs of gastric cancer?
Epigastric mass | Abdominal tenderness
96
What is the investigation for gastric cancer?
Gastroscopy and biopsy | Then CT/MRI for TNM staging
97
What are the treatment options for gastric cancer?
Surgical excision - if possible | Not a good prognosis <10% 5 year.
98
What is the most common lower GI tract cancer?
Colorectal adenocarcinoma
99
What are the risk factors for colorectal cancer?
``` Old age Low fibre diet High red and processed meat diet IDB Colorectal polyps Alcohol Smoking Family history Previous cancer ```
100
What is the link between adenomas and colorectal cancers?
Adenomas are areas of dysplastic epithelium, have a raised risk of turning into neoplastic epithelium and cancer.
101
What is familial adenomatous polyposis
Genetic condition where 100s of polyps develop in childhood, colorectal cancer is usually present by 20s.
102
What is hereditary nonpolyposis colorectal cancer?
One of the DNA repair proteins is faulty. Throughout lifetime if there is another mutation the there is a very high risk of cancer.
103
Where is the majority or colorectal cancer?
Rectum
104
What is the presentation of colorectal cancer?
Change in bowel habit Looser, more frequent stools Rectal bleeding Rectal or abdominal mass may be palpable
105
What investigations should be carried out in colorectal cancer?
DRE Colonoscopy and biopsy Staging - MRI/CT
106
What system is used to stage colorectal cancer?
Dukes' classification. Goes from A (mucosa only) to D (distant mets).
107
What is the management of colorectal cancer?
Surgical excision Chemotherapy Radiotherapy
108
What is the UK colorectal cancer screening programme?
One-off screen at 55 years old. | Home testing kits every 2 years 60-75.
109
What drug could have a preventative effect in colorectal cancer?
Aspirin
110
What is peritonitis?
Inflammation of the peritoneum.
111
What are the causes of peritonitis?
Perforation of a peptic ulcer Diverticular perforation Trauma Ascites - can cause spontaneous peritonitis.
112
What is the physiology of the parietal peritoneum?
Lines the abdominal wall Somatic innervation - can localise pain Needs a large inflammation to be directly irritated.
113
What is the physiology of the visceral peritoneum?
Lines the organs Autonomic innervation - refers pain Small inflammation causes referred pain
114
What are the symptoms of peritonitis?
``` Pain Fever Rigidity Vomiting Tenderness ```
115
What are the signs of peritonitis?
Lying still No bowel sounds Guarding Kehr's sign - pain in shoulder due to phrenic nerve
116
What investigations should be carried out in peritonitis?
Bloods X-ray CT serum amylase - check from pancreatitis
117
What is the management of peritonitis?
Resuscitation - fluids Broad spectrum antibiotics Surgery - peritoneal lavage and treat cause
118
What are the causes of haematemisis?
``` Peptic ulcers Mallory-Weiss tear Oesophageal varices Gastritis Drugs Malignancy ```
119
What is the management for haematemisis?
Fluids Transfusions if needed Arrange an urgent endoscopy.
120
What is GORD?
Gastroesophageal reflux disorder
121
What are the causes of GORD?
Lower oesophageal sphincter failure Hiatus hernia Gastric acid hypersecretion
122
What are the risk factors of GORD?
``` Obesity Smoking Alcohol Pregnancy Over-eating ```
123
What is Barratt's oesophagus?
Metaplasia of oesophageal squamous cells to gastric columnar cells. Cells are damaged by gastric acid reflux.
124
What is the presentation of GORD?
Heartburn - worse lying down or after meals Painful swallowing Regurgitation
125
Investigations for GORD?
A mostly clinical diagnosis. If further complications are suspected then endoscopy.
126
What lifestyle changes can be recommended in GORD?
Reduction of alcohol and caffeine | Smoking cessation
127
What pharmacological options are available in GORD?
Antacids H2 receptor antagonists PPIs
128
What are the complications of GORD?
Barratt's oesophagus Ulcers Oesophageal cancer
129
What is an ulcer?
A break in the mucosal surface.
130
Where is the most common location for a gastric ulcer?
Duodenum
131
What are the causes of a peptic ulcer?
``` Mucosal ischaemia Increased gastric acid secretion NSAIDs H Pylori infection Smoking Alcohol in high concentrations ```
132
What is the physiology of gastric acid defence?
The gastric acid cells produce mucin which forms a protective layer and prevents attack by the acid. If this layer is damaged or overwhelmed the cells are damaged.
133
What is the mechanism of peptic ulcers caused by NSAIDs?
COX2 inhibition by NSAIDs inhibits mucous production so weakens the mucosal defence to gastric acid.
134
What is the presentation of a peptic ulcer?
Dyspepsia Bloating Heartburn Nausea
135
How may the pain of a peptic ulcer alter depending on its locations?
Gastric - pain when eating | Duodenal - pain after eating or when hungry.
136
What tests can be carried out to identify H pylori infection?
C-Urea breath test | Stool antigen test
137
What investigations should be carried out for peptic ulcer diagnosis?
Endoscopy
138
What is the treatment for H pylori +ve peptic ulcer?
PPI - ie. lanzoprazole
139
What is the treatment for H pylori -ve peptic ulcer?
Stop NSAIDs PPI H2 blocker
140
What lifestyle changes are recommended in peptic ulcers?
Smoking cessation Stop NSAID use Decreased alcohol Avoid aggravating foods
141
What is irritable bowel syndrome?
A mixed group of abdominal symptoms with no known organic cause.
142
What is the prevalence is irritable bowel syndrome?
10-20%
143
What are the symptoms of IBS?
``` Bloating Feeling of incomplete emptying Worsening of symptoms after food Nausea Chronic symptoms Constipation Diarrhoea ```
144
What are exacerbating features of IBS?
Stress | Menstruation
145
How do you diagnose IBS?
One of - Symptoms improved with defecation Altered stool form or frequency And 2+ other symptoms
146
Red flags that may need further investigation in IBS?
``` >40 years old Rectal bleeding Nocturnal pain Weight loss Family history of bowel/ovarian cancer ```
147
What lifestyle advice can be offered in IBS?
Healthy balance diet Avoid alcohol and fizzy drinks Adjust fibre intake according to symptoms Education
148
What is the symptomatic treatment for constipation in IBS?
Laxative
149
What is the symptomatic treatment for diarrhoea in IBS?
loperamide (anti-motility drug)
150
What is a hernia?
Protrusion of organ or tissue out of the body cavity in which it normally lies.
151
What are the causes of hernias?
``` Muscle weakness Body stain Chronic cough Trauma Constipation Heavy weight lifting Pregnancy ```
152
What is an irreducible hernia?
Cannot be pushed back into the right place.
153
What is a reduction of a hernia?
Pushing the tissue/organ back into place.
154
What is an incarcerated hernia?
Contents of the hernial sac are trapped by adhesions.
155
What is a hiatal hernia?
When part of the stomach herniates through the oesophageal hiatus of the diaphragm.
156
What are the two types of hiatal hernia?
Sliding and rolling
157
What is an inguinal hernia?
Part of the bowel herniates into the inguinal canal.
158
What are the two types of inguinal hernia?
Direct and indirect.
159
What is a direct inguinal hernia and how can you tell?
Protrudes directly into the inguinal canal. The inferior epigastric vessels sit medially to the hernia.
160
What is an indirect inguinal hernia and how can you tell?
Protrudes down through the inguinal ring. The inferior epigastric vessels sit laterally to the hernia.
161
What is ischaemic colitis?
Inflammation and injury to the colon resulting from inadequate blood supply.
162
What are the causes of ischaemic colitis?
Heart failure Atherosclerosis Malignancy Surgical damage
163
What is the presentation of ischaemic colitis?
``` Diarrhoea Rectal bleeding Abdominal pain Distended Tender ```
164
What are the risks of ischemic colitis?
Perforation Peritonitis Shock Strictures
165
What area of the bowel does acute mesenteric ischaemia affect?
Small bowel most commonly (superior mesenteric artery damage)
166
What are the causes of acute mesenteric ischaemia?
Embolism Thrombus Trauma Shock
167
What is the presentation of acute mesenteric ischaemia?
Acute severe abdominal pain No abdominal findings Rapid hypovolaemia Symptoms appear to be out of proportion with clinical findings.
168
What is the management of acute mesenteric ischaemia?
Fluids Antibiotics Surgery - removal of dead bowel
169
What is the pathophysiology of chronic mesenteric ischaemia?
At rest the demand of the bowel is met, after eating the demand increases and transient ischaemia occurs.
170
What is the presentation of chronic mesenteric ischaemia?
Post-prandial pain weight loss Vascular co-morbidities
171
What is the epidemiology of appendicitis?
Most commonly affects young people (10-20 years).
172
What is the presentation of appendicitis?
Central vague abdominal pain that migrates to the RIF as it progresses. Vomiting Loss of appetite
173
What are the signs of appendicitis?
Tachycardia RIF guarding Fever
174
What is the treatment for appendicitis?
Prompt appendicectomy
175
What are the complications of appendicitis?
Perforation | Appendix abscess
176
Which point marks the location of the appendix?
McBurney's Point. | 2/3rds from umbilicus to superior iliac spine.
177
What is diverticular disease?
Pouches of mucosa extrude through the colonic wall to form diverticula and become symptomatic.
178
Where is the most common location for diverticulosis?
Sigmoid colon
179
What is a possible cause of diverticular disease?
Lack of dietary fibre - high intraluminal pressure - mucosal herniation.
180
What are the clinical features of diverticular disease?
``` Mostly asymptomatic Intermittent LIF pain Altered bowel habit Nausea Flatulence ```
181
What are the investigations for diverticular disease?
CT | Colonoscopy
182
What is the treatment for acute diverticular disease?
Oral antibiotics IV fluids Surgery
183
What are the complications of diverticular disease?
Perforation and infection Intestinal obstruction Bleeding Mucusal inflammation - diverticulitis
184
What are the causes of acute pancreatitis?
``` Gallstones* Ethanol (alcohol)* Trauma Steroids Mumps Autoimmune Scorpion venom Hyperlipidaemia ERCP Drugs GETSMASHED ```
185
What are the symptoms of acute pancreatitis?
Epigastric pain - radiates to the back, relived sitting forwards. Vomiting and nausea
186
What are the signs of pancreatitis?
Tachycardia Fever Jaundice Guarding and rigidity
187
How do gallstones cause pancreatitis?
They can block the outflow of the cystic duct and cause a backlog and inflammation of the pancreas.
188
What is Cullen's and Grey Turner's sign of pancreatitis?
Cullen's - periumbilical bruising Grey Turner's - flank bruising From blood vessel auto-digestion.
189
What is the diagnostic test for pancreatitis?
Serum amylase 3x the normal
190
What other pancreatic enzymes may be raised in pancreatitis?
Lipase
191
What is the prognosis of pancreatitis?
Most pancreatitis is mild and self limiting - unless it causes further complications.
192
What are the treatments for acute pancreatitis?
``` Analgesia Fluids Antibiotics Respiratory support Nasogastric tube for feeding ```
193
What are the early complications of pancreatitis?
Renal failure * ARDS * Sepsis Shock
194
What are the late complications of pancreatitis?
Pancreatic necrosis Diabetes Abscess Bleeding
195
What are the symptoms of chronic pancreatitis?
Epigastric pain - radiates to back and relieved sitting forwards. Weight loss Diabetes Steatorrhoea
196
What are the investigations in chronic pancreatitis?
Ultrasound - shows calcification | Bloods - pancreatic enzymes may not be raised as there may not be enough tissue to produce the enzymes.
197
What are the causes of chronic pancreatitis?
Alcohol Cystic fibrosis Autoimmune Duct obstruction
198
What is the management of acute pancreatitis?
Lifestyle - quit alcohol Autoimmune - steroids Pain relief Pancreatic enzyme supplements

Phase 2a - conditions (11 decks)

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