Gastrointestinal Flashcards
Deficiency of vitamin:
1) B1
2) B12 and folate
3) K
4) D
5) C
1) Thiamine - Wernicke’s encephalopathy
2) Macrocytic anaemia
3) Bleeding disorder
4) Osteomalacia and rickets
5) Easy bruising and bleeding (scurvy).
Causes of malabsorption
Poor dietary intake
Defective digestion or lack of digestive enzymes (e.g. pancreatic insufficiency)
Poor absorption or transport ability (e.g. coeliac)
Blood group association with gastric and duodenal ulcers
Gastric = A Duodenal = O
2 barriers which prevent gastro-oesophageal reflux
Lower oesophageal sphincter (LOS) Crural diaphragm (external sphincter)
Classification criteria for GORD
Montreal
Risk factors for GORD
Obesity
Hiatus hernia
Agents which relax LOS e.g. caffiene, nitrate drugs, CCB, fat.
Smoking
Presentation of GORD
Heartburn - retrosternal pain Regurgitation - acid taste in mouth and sensation of content coming up to pharynx Belching Dysphagia Chronic cough
O/E:
Enamel erosion on teeth
Managing GORD
If no red flag symptoms (GI bleed) - trial PPI with no investigations.
1) OTC e.g. Gavison and other alginates / antacids and LIFESTYLE ADVICE.
2) 4-8wks of PPI e.g. Omeprazole, Lansoprazole. If symptoms persist after trial continue pt on PPI at the lowest therapeutic dose.
3) Add an H+ 2 Receptor Antagonist e.g. Ranitidine (usually taken before bed).
4) Surgical intervention - laparoscopic fundoplication
Investigating GORD in secondary care
Endoscopy - oesophagitis, erosions and ulcerations. Ambulatory pH monitoring. Oesophageal manometry (measure LOS pressure)
Complications of GORD
Barrett’s oesphagus
Oesophageal adenocarcinoma
Oesophageal stricture
Barrett’s oesophagus
Squamous epithelium replaced by columnar epithelium.
Ix - endoscopy and biopsy.
Rx - surveillance and regular biopsies if low-grade. High grade = ablation, resection
Risk factors for oesophageal cancer
Male sex GORD/Barrett's oesophagus changes (squamous to columnar) Obesity Achalasia Hiatus hernia Hx FHx
HPV, achalasia, smoking and alcohol more risk for squamous cell carcinomas than adenocarcinomas.
Histology of oesophageal cancer
Majority are adenocarcinoma, minority are squamous cell carcinomas
S+S of oesophageal cancer
GORD symptoms - heartburn, regurgitation. Dysphagia Dyspepsia Pain on swallowing Weight loss Haematemesis
More advanced disease: hoarse voice and cough.
Investigating suspected oesophageal cancer
Urgent Upper GI endoscopy and biopsy (2 week wait).
Managing oesophageal cancer
Endoscopic resection
Oesophagectomy
Chemotherapy before and after surgery
Mallory-Weiss tear
Non-variceal upper GI bleed.
RFx - recurrent vomiting/retching, hiatus hernia.
CFx - Haematemesis, melena, dizzy.
Ix - FBC, U+E, group + save, clotting profile, LFTs, CXR.
Mx - Resusitation (A-E, warm fluid, blood products, oxygen), endoscopy when stable.
Red flag symptoms for referral for endoscopy
If over 55, dypepsia and (ALARM) Anaemia Loss of weight Anorexia Recent onset Melena
2 types of peptic ulcers
Gastric ulcers
Duodenal ulcers
Which peptic ulcer has greater association with H.pylori?
Duodenal
Name 4 drugs which can cause peptic ulcer disease
NSAIDS Aspirin Crack cocaine Alcohol Tobacco/smoking
Zollinger-Ellison syndrome
Hypersecretion of gastrin due to gastric NET.
Multiple peptic ulcers, diarrhoea + steatorrhoea, weight loss, and hypercalcaemia.
S+S of peptic ulcer disease (1 difference in presentation between DU and GU)
Upper abdominal burning pain Dyspepsia Nausea Weight loss/anorexia Symptoms are related in meal times
GU pain occurs on eating
DU pain occurs post-prandial (1-3hrs) and can be relieved by eating.
Investigating peptic ulcer disease
H.pylori - carbon-13 urea breath test or stool antigen test.
FBC
Upper GI endoscopy (not routine!)
Drugs taken before testing for H.pylori
No PPI for 2 weeks.
No ABx for 4 weeks.
H.pylori eradication treatment
1 x PPI + 2x ABx 7 days.
e.g. Lansoprazole + amoxicillin + clarithromycin
Management of peptic ulcer disease
Review drugs
If H.pylori -ve: PPI
If H.pylori +ve: eradication therapy
If assciated with NSAIDs: 2 months PPI.
Management of an acute GI ulcer bleed
A-E assessment and resusication. A - airway manoeuves B - Oxygen C - 2x large bore cannulas, warm fluids, take bloods (esp clotting profile and crossmatch), blood products D - assess GCS
Activate major haemorrhage protocol.
Consider platelet transfusion and FFP.
Causes of an acute GI bleed
Mallory-Weiss tear Peptic ulcer Stricture Malignancy Oesophageal varices
Oesophageal varices
Ax - Portal HTN and liver cirrhosis. Local dilation of veins.
CFx - UPPER GI HAEMORRHAGE, features of liver disease (ascites).
Ix - endoscopy.
Mx - A-E and resuscitation. Drug - Terlipressin.
Risk assessment of patients with upper GI bleed
Glasgow-Blatchford bleeding score at first assessment.
Rockall score after endoscopy.
Some causes of oesophageal motility dysfunction
Achalasia
Systemic sclerosis
Diffuse oesophageal spasms
How to test for H.pylori
Carbon-13 urea breath test or a stool antigen test. After eradication therapy NICE recommends using Carbon-13 urea breath test as test of cure rather than stool antigen.
Causes and types of gastritis
Acute and chronic.
Erosive and non-erosive.
Acute, non-erosive = H.pylori.
Acute, erosive = long-term NSAID use.
Atrophic gastritis -
Autoimmune gastritis - antiparietal cell antibodies.
2 types of inflammatory bowel disease
Crohn’s disease
Ulcerative colitis
Pathophyisology and histology of Crohn’s disease
Transmural, granulomatous inflammation which can affect any part of the GI tract from mouth to perianal area and has a relapsing-remitting course.
Submucosal oedema. Cobblestone appearance Longitudinal, linear ulcers Apthlous ulcers Discontinuous epithelium involvement = skip lesions.
Most common sites for Crohn’s disease
Terminal ileum and proximal colon.
Genes associated with Crohn’s disease
CARD15
NOD2
S+S of Crohn’s disease
Abdominal pain
Prolonged diarrhoea including nocturnal diarrhoea and urgency.
Weight loss.
Fever
Fatigue
Perianal lesions e.g. fistulas, skin tags, abcess.
EXTRA-INTESTINAL: Arthritis Erythema nodosum Aphthous mouth ulcers Uveitis
Investigations for Crohn’s disease
Lab tests: FBC - anaemia CRP and ESR - raised U+E - dehydration from chronic diarrhoea LFT + albumin B12, folate, vitamin D, ferritin - signs of malabsorption. Faecal calprotectin - raised. Coeliac test (IgA-tTG and EMA), stool sample - exclude as differential.
Imaging/Secondary care:
Colonscopy + biopsy for histology.
CT to stage.
Abdo USS - bowel wall thickening.
What not to prescribe in suspected IDB
Anti-diarrhoeal drugs - may precipitate toxic megacolon in UC patients.
Management of Crohn’s disease
Induce remission and maintenance.
Induce = steroids e.g. Prednisolone
If more distal disease or steriods are CI use Budesonide.
Maintenance = Azothioprine, Mercaptopurine or Methotrexate
Biological therapy = Infliximab (anti-TNF)
Surgery = for distal ileum patients only.
Pathophysiology and histology of Ulcerative Colitis
Diffuse and continuous, superficial inflammation of rectum and extending proximal up the colon.
Continuous inflammation of the mucosa only (no deep inflammation).
Crypt abcesses
When can ulcerative colitis not be confined to the rectum and colon?
‘Backwash ilitis’ - backwash of caecal contents into distal ileum can cause features of UC in that area.
S+S of UC
Blood in stool
Diarrhoea urgency, frequency, incontinence, nocturnal.
Abdo pain (left lower quad)
Pre-defaecation pain, relieved on passing stool.
Fever, malaise, fatigue, weight loss.
Uveitis, arthritis, aphthous mouth ulcers.
Investigating UC
Lab tests: FBC - anaemia CRP and ESR - raised U+E - dehydration from chronic diarrhoea LFT + albumin B12, folate, vitamin D, ferritin - signs of malabsorption. Faecal calprotectin - raised. Coeliac test, stool sample - exclude as differential.
Imaging/Secondary care:
Colonscopy + biopsy for histology.
CT to stage.
Abdo USS - bowel wall thickening.
Management of UC
Induce remission and maintenance.
Induce = topical aminosalicylate (suppository/enemaformula) can give oral at patient request. +/- steroids if severe.
Maintenance = low dose aminosalicylate
2nd line = methotrexate/azothioprine.
3rd line = biologics e.g. antiTNF infliximab
Examples of aminosalicylates
Mesalazine
Sulfasalazine
Causes of small bowel obstruction
Adhesions from surgery Inguinal hernias Intestinal malignancy Appendicitis Crohn's disease inflammation and strictures.
More common causes of small bowel obstruction in children
Appendicitis
Intussusception
Volvulus
Intestinal atresia
S+S of small bowel obstruction
Colic pain
Vomiting
Absolute connstipation -
no stool or flatus. overflow diarrhoea
O/E
Distended bowel
Tinkling bowel sounds (accuracy is in question)
Palpable mass (tumour, stools)
Investigations for small bowel obstruction
ABX - Dilated loops of small bowel (normal diameter = 3cm, located central on ABX).
Coil-spring appearance of valvulae conniventes. Air-fluid levels.
CT abdo.
FBC, urea, U+Es - indicate severity/necrosis, volume depletion.
Management of small bowel obstruction
NG tube and IV fluids = decompression.
Analgesia
Anti-emetic
Surgery - correct underlying cause.
Causes of large bowel obstruction
Colorectal malignancy
Colonic volvulus
Benign stricture e.g. diverticular.
S+S of large bowel obstruction
Colic abdo pain Faeculant vomiting Hx of bowel habit changes O/E More marked abdo distension Tympanic on percussion (gas) Empty rectum or very hard faeces on DRE
Investigations for large bowel obstruction
AXR - Dilated loops of large bowel (>6cm for colon or >9cm for caecum). Air fluid levels.
Abdo CT
FBC, U+E, creatinine, group + save.
Management of large bowel obstruction
NG decompression
IV fluids
Treat cause - stenting.
Difference between UC and Crohn’s
Crohns - can be found anywhere in GI tract, transmucosal inflammation, ‘skip lesions’ of discontinuation, granulomas, smoking is bad, more likely to develop fistulas or strictures.
Ulcerative colitis - confined to rectum and colon, superficial mucosal imflammation, continuous inflammation, no granulomas, more likely to see blood and mucus in stools, smoking is protective.
Complications of IBD
Malnutrition Intestinal strictures Fistualas Toxic megacolon - esp UC Colorectal cancer
Brief outline of the blood supply to the gut
Small intestine - braches of the pancreaticoduodenal and superior mesenteric arteries.
Large intestine - Midgut: superior mesenteric artery and Hindgut: inferior mesenteric artery
Causes of bowel ischaemia
Emboli from left side of heart
Thrombus from atherosclerosis of artery
Abdo tumour or mass compression
Vasculitis, SLE, RA.
Areas at high risk in bowel ischaemia
Watershed areas - supplied by the distal parts of two arteries, susceptible to iscahemia e.g. splenic fissure and rectosigmoid junction.
S+S of bowel ischaemia
Abdo pain which is out of proportion to clinical findings. Often after a meal. Can be intermittent. Fever Nausea Diarrhoea Anorexia
O/E Pallor Abdo distension Abdo tenderness and guarding Abdominal bruit
Investigations for bowel ischaemia
FBC - high WCC Coagulation profile ABG + lactate - metabolic acidosis CT angiogram ECG ABX CXR - free air under diaphragm = performation Stool culture
Management of bowel ischaemia
A-E resuscitation (airway manoeuvre, oxygen supplementation, 2xlarge bore cannulas, warm crystalloid fluids)
Antibiotics (gentamycin + metronidazole).
Papaverine infusion.
Interventional radiology for thrombolysis or angioplasty.
Surgery - bowel resection
Irritable bowel syndrome definition
Chronic and relapsing disorder of the lower GI tract, with no discernible structural or biochemical cause (therefore is a diagnosis of exclusion).
Risk factors or potential causes of IBS
Females
Antibiotics
FHx
Dietary e.g. spicey foods, caffiene
S+S of IBS
Chronic - at least 6 months of symptoms! Change in bowel habit - diarrhoea,constipation, frequency. Abdo pain esp related to defaecation. Abdo bloating Lethargy Nausea Back pain
Investigation IBS
Exclude other causes - FBC, ESR, CRP, coeliac serology (IGA-tTG, EMA).
3 gastro and 3 systemic differentials for IBS
IBD (Crohn’s or UC)
Coealiac
Gastroenteritis
Hyperthyroidism
Premenstrual symptoms
Laxative misuse
Management of IBS
Dietary advice (regular, healthy meals, avoid spicey food).
Education and information.
Antispasmodic e.g. dicyclomine.
Bulk-forming laxative for persistent constipation e.g ispaghula.
Diarrhoea relief with loperamide.
Tricyclic antidepressant trial e.g. Amitriptyline.
Definition of
1) Diverticulosis
2) Diverticular disease
3) Diverticulitis
4) Diverticular
1) presence of diverticular
2) diverticular cause symptoms
3) inflammation of diverticular
4) herniation of mucosa through thickened colonic muscle
Common areas for diverticular disease
Sigmoid and descending colon
Risk factors for diverticular development
Age (over 55yrs) Low fibre diet Smoking Obesity NSAIDsm opioids, corticosteroids.
S+S of diverticular disease
Left lower quadrant abdo pain. Exacerbated on food, relieved on defaecation or flatus.
Bloating
Occasional large rectal bleeding.
Diarrhoea and constipation.
O/E
Fever
Left lower quad tenderness
Complications of diverticular disease and divertiuculitis
Diverticular haemorrhage. Diverticulitis: Abscess Perforation + peritonitis Stricture formation Intestinal obstruction
Investigating diverticular disease
Imaging:
Rule of malignancy with colonoscopy + biopsy (CRC).
CT colongraphy to diagnose presence of diverticula.
Contrast enema
Laboratory:
FBC (high WCC in diverticulitis)
Management of diverticular disesae
Assess if complication e.g massive GI bleed and resus if there is one!
Lifestyle advice - increase fibre in diet, avoid NSAIDs.
Diverticular disease Rx - bulk forming laxative e.g. Ispaghula, paracetamol.
Diverticulitis Rx - co-amoxiclav, paracetamol. Clear liquids only and reintroduce solids over 2-3 days.
Appendicitis
Acute inflammation of the appendix.
Causes = obstruction due to faecolith, bacteria overgrowth, lymph hyperplasia (viral infection).
S+S = Early periumbilical pain (T10 level) which moves to right iliac fossa. Shallow breathing, nausea, anorexia, vomiting, low grade fever. O/E - peritonitis rebound tenderness, guarding, +ve Rovsing’s.
Ix = clinical, explorative laproscopy. pregnancy test, urine dip, FBC and CRP - to rule out other causes.
Mx = Laparoscopic appendicectomy. Analgesia and fluids.
Where is site of max tenderness in appendicitis
McBurney’s point = 2/3 along the line from umbilicus to anterior superior iliac spine.
Name a sign positive in appendicitis
Rovsing’s sign = palpation of left lower quadrant increases pain in right lower quadrant.
Meckel’s diverticulum
Congenital malformation of small bowel.
Failure of vitelline duct to obliterate during 5th week in utero.
Asymptomatic but at risk of bowel perforation, bleeding, obstruction.
Volvulus
Malrotation of the intestine.
Occur during embryonic development.
Name of smooth muscle relaxant used in bowel ischaemia
Papaverine.
Vasodilator and smooth muscle relaxor
Vasoactive drug for oesophageal varicies bleed
Terlipressin
Achalasia
Loss of ganglionic cells in the Auerbach’s plexus, leading to impaired peristalsis.
S+S: dysphagia, regurgitation, chest pain.
Ix: barium swallow (BIRD BEAK) dilation of oesophagus with distal narrowing. CXR (dilated oesophagus), Manometry.
Mx: CCB or nitrates (can lead to GORD), Endoscopic balloon dilation.
Slowing in peristalsis not due to mechanical obstruction.
Ileus.
Commonly post-ado surgery also can be due to narcotics.
Paralytic ileus - bowel inactivity.
Non-mechanical obstruction but acute intestinal pseudo-obstruction associated with massive dilation, usually of the colon but also of the small intestine.
Ogilvie’s syndrome
Sigmoid volvulus
Sigmoid colon wraps around itself and its own mesentery, causing a closed-loop obstruction.
S+S: Abdo distension, abdo pain, absolute constipation, nauseam vomiting, anorexia, empty rectum on DRE.
Ix: COFFEE BEAN sign on AXR, CT.
Mx: resuscitation. decompression with sigmoidoscope.
Some causes of intra-abdominal sepsis and abscesses
Upper GI: peptic ulcer perforation.
Lower GI: appendicitis, ischaemic bowel.
Liver etc: cholecystitis
GU: PID.
Presentation of abdominal abscess
Pain, diarrhoea, ileus, feverish.
Swinging/spikey temperatures.
Psoas muscle abscesses
Flank pain, radiating to groin.
S+S of peritonitis
Peritonitic pain, anorexia, nausea, vomiting.
O/E:
High fever, TC, tenderness on palpation, guarding, rebound tenderness, knees flexed most comfortable position.
Investigations for peritonitis
FBC U+E LFT Urinalysis Blood cultures PERITONAL FLUID mc+s Abdo XR.
Management of peritonitis
IV fluids
ABx - IV metronidazole + cefotaxime
Surgical drainage or surgery
Common bacteria to cause peritonitis with bowel perforation
E.coli
Gram -ve rod
Toxic megacolon
Causes: IBD, ischaemic colitis, Salmonella, Shigella, C.difficule colitis.
Dilation of the colon (>6cm on AXR)
+
Systemic toxicity (fever, TC, anaemia, leukocytosis, dehydration, hypotensive, electrolyte imbalance).
Ix: AXR
Mx: A-E, NG decompression, IV ABx (tazocin), surgery.
Hirschsprung’s disease
Loss of ganglionic cells from myenteric and submucosal plexus of rectum - causes contracted lumen and functional obstruction.
Diagnosed in first year of life.
Associated with Down’s syndrome.
S+S: vomiting, explosive passage of foul smelling diarrhoea, abdo distension, delayed passage fo meconium after birth, fever, failure to thrive.
Ix: AXR, rectal biopsy.
Mx: bowel irrigation, surgery within 1st week of life.
Name a gram +ve rob
C.difficile.
Can cause pseudomembranous colitis - esp after cephalosporin use.
Rx = metronidazole and Vancomycin if severe
Defintion of
1) Irreducible hernia
2) Incarcerated hernia
3) Obstructed hernia
4) Strangulated hernia
1) Can not be pushed back into correct location through weakened wall.
2) Contents of the hernia sac are stuck.
3) In GI hernias where contents of GI tract can no longer pass.
4) Ischaemia of tissue inside hernia - EMERGENCY.
6 locations for hernias
Inguinal - weak point above inguinal ligament, in inguinal canal.
Femoral - below inguinal ligament, in femoral canal.
Incisional - at previous surgical site.
Umbilical - near navel.
Epigastric - between sternum and navel.
Diaphragmatic - e.g. hiatus hernia, protruding into thorax.
Risk factors for inguinal hernias
Male sex Obesity Heavy lifting Fix Chronic cough/COPD Older age Marfan syndrome, Ehlers-Danlos syndrome.
Direct and indirect inguinal hernias
Direct - protrudes through posterior wall of inguinal canal. mostly due to adult weakening of wall.
Indirect - passes through internal deep inguinal ring, passing lateral to inguinal artery. mostly congenital.
Contents of the inguinal canacl
Spermatic cord in males / Round ligament in females
Ilioinguional nerve
NB: spermatic chord contents = - testicular, cremasteric and ductus deferens arteries.
- external spermatic, cremasteric and internal spermatic fascial layers.
- genital branch, sympathetic fibres and ilioinguinal nerves.
Mid-inguinal point
Halfway between pubic symphysis and the anterior superior iliac spine. Can palpate femoral artery here.
S+S of inguinal hernia
Palpable lump in groin area.
Pain in groin area, worse on coughing.
Lump will move in on coughing if its a direct hernia.
Signs of acute abdomen if strangulated.
Ix and Mx of inguinal hernias
Clinical diagnosis is sufficient.
If ? USS of groin, CT scan.
Mx: Open-mesh repair.
Which hernia is more common in females than males
Femoral - high rate of strangulation so surgical repair all femoral hernias.
Types of hiatus hernia
Sliding = gastro-oesophageal junction (and LOS) + part of stomach slide above diaphragm into chest cavity. Rolling = bulge of stomach above diaphragm and gastro-oesophageal junction remains below.
Ix for hiatus hernia
Upper GI series - gold standard.
CXR
Upper GI endoscopy.
Mx for hiatus hernia
Sliding hernias - PPI, H2RA (Ranitidine), may not need surgery.
Rolling hernias - surgical repair.
Types of laxatives
Bulk forming - increase faecal mass and aid peristalsis e.g. Ispaghula.
Stool softener - decrease surface tension e.g docusate
Stimulant - increase intestinal motility e.g. Senna. CI in obstruction!
Osmotic - draw fluid into the bowels and keep it there e.g. Lactulose
Enema for rapid evacuation of stools.
4 GI causes and 4 systemic/non-GI causes of diarrhoea
GI = IBD, diverticular disease, overflow constipation, coeliac.
Systemic = hyperthyroidism, antibiotics (cephalosporins = C.diff), alcohol, non-beta pancreatic islet cell tumour / vipoma.
Haemorrhoids
= Piles
Abnormal swelling of vascular mucosal anal cushions. Internal = above dentate line and painless. External = below dentate line and painful.
RFx = pregnancy, constipation + straining, heavy lifting, ageing, chronic cough.
S+S = bright red, painless rectal bleeding, anal itchy, rectal discomfort/fullness/incomplete defaecation.
Ix = DRE, anoscopic exam, FBC.
Rx.= lifestyle advice and constipation avoidance (high fibre, good hydration, perianal hygiene). Paracetamol analgesia, topical steroids (hydrocortisone). Rubber band ligation in secondary care/
Pilondial sinus
Hair follicles become inserted into the skin (usually around natal cleft), creating a sinus tract and inflammation.
RFx = male, 15-40yrs, coarse hair, poor hygiene, obesity.
S+S = discharge, pain, swelling.
Cx = abscess, sinus, sepsis, chronic pain.
Rx = hair removal e.g. laser therapy, local hygiene advise, surgical treatment if severe symptoms.
Perianal haematoma
Dilated vascular plexus.
Pain on straining at defaecation.
O/E: blue/black buldge under skin
Rx = expectant, excise under LA
Anorectal abscess
Infection of soft tissue around anus. Commonly E.coli, Enterococcus.
RFx = male, DM, immunocompromised, anal sex.
S+S = pain, swelling, itch, general malaise, fever, urinary retention, sepsis (rare). Tender, erythematous mass O/E.
Ix = DRE, MRI for fistula.
Rx = drainage, ABx, analgesia.
Difference between anal fissure and fistula
Fissure = tear in mucosa of anal canal. Bright red blood in stool, MASSIVE pain in defaecation. Fistula = communicating tract from skin to anorexia-rectal canal.
Criteria for functional GI disorders e.g. IBS, dyspepsia
Rome IV Criteria (esp IBS).
Alternative to steroids in induction of remission for Crohn’s
Budesonide
Risk factors for gastric cancer
H.pylori Male gender Smoking Alcohol consumption EBV Blood group A Pernicious anaemia Radiation exposure Genetic = CDH-1
Histology of gastric tumours
Majority are adenocarcinomas.
Other types include small cell carcinomas, stromal tumours, NET, lymphoma.
S+S of gastric cancer
Dyspepsia Weight loss Anorexia Early Satiety Junctional tumours = dysphagia and pain on swallowing.
O/E:
Supraclavicular lymphadenopathy at Virchow’s node.
Periumbilical lympadenopathy at Sister Mary Joseph’s nodule.
Investigating suspected gastric cancer
Upper GI endoscopy + multiple biopsies.
CT scan of chest, abdo pelvis-for metastases.
Endocopic US for staging/invasion depth.
Mx of gastric cancer
Education and advice - nutritional/dietician input.
Surgery:
Low staged = endoscopic mucosal resection.
High staged = total/subtotal gastrectomy + preoperative chemotherapy e.g. 5-fluorouracil..
Mucosa-associated lymphoid tissue
Also known as extra-nodular marginal zone B-cell lymphomas.
Subtype of non-hodgkin’s lymphoma, proliferation not in lymph nodes.
Common site = distal ileum and gastric and is associated with H.pylori.
RFx = female, 60yrs.
S+S similar to gastric cancer
Ix similar to gastric cancer.
Rx = H.pylori eradication, Rituxumab, surgical resection.
Most common type of cancer in duodenum and jejunum and major RFx
Adenocarcinoma.
Crohn’s disease.
Inheritance of familial adenomatous polyposis
Autosomal dominant.
Most common type of CRC and most common location
Adenocarcinoma
71% in colon
29% in rectum.
Risk factors for CRC
AGE FHx Obesity Ulcerative colitis Low fibre diet Smoking Radiation exposure
2 genetic diseases which predispose to CRC
Familial adenomatous poylposis
Hereditary non-polyposis colorectal cancer.
S+S of colorectal cancer
Change in bowel habit (increase frequency, loose stools)
Rectal bleeding + anaemia
Right sided = weight loss anaemia, occult bleeding.
Left sided = colic pain, bowel obstruction symptoms, tenesmus.
O/E:
Palpable rectal mass on DRE
Palpable mass in abdo
Ix for colorectal cancer
DRE Colonoscopy + biopsy Barium enema FBC LFT Faecal occult blood Liver USS or CT to look for met.
Common place for CRC met
Liver
Criteria for 2 week wait for ?CRC
- Aged 40yrs and over with unexplained weight loss and abdominal pain.
- Aged 50 and over with unexplained rectal bleeding.
- Aged 60 and over with:
>Iron-deficiency anaemia or
>Changes in their bowel habit. - Tests show occult blood in their faeces
Describe the staging classification for CRC
Duke's. A = in mucosa B = in muscular propria C = spread to at least 1 lymph node. D = Met to other areas e.g. liver.
Criteria for hereditary non-polyposis colorectal cancer
Amsterdam criteria.
Screening for CRC
Offered to every 2 years to people aged 60-74 years.
Faecal occult blood test.
If +ve = colonoscopy.
Mx of colorectal cancer
Surgical - colonectomy + lymph node clearance.
Adjuvant chemotherapy.
Which hormone suppresses gastric acid secretion and where is itself secreted from
Somatostatin from D cells.
What cells secrete gastric acid and what else do these cell secrete?
Parietal cells.
Also secrete intrinsic factor.
What is the very first line investigation/gold standard (according to NICE) for coaelaic
IgA-tTG
How to differentiate between dysphagia caused by
- Oesophageal cancer.
- Oesophageal cancidiasis.
- Achalasia
- Pharyngeal pouch
- Systemic sclerosis
- Myasthenia gravis
- weight loss, anorexia, vomiting on eating. Hx of GORD, smoking and alcohol.
- Hx of HIV or steroid inhaler.
- Both liquids and solids from onset of symptoms. Regurgitation of food - aspiration pneumonia.
- Old men.
- calcinosis nodules, telangiectasia, sclerodactylyl, raynauds too.
- At end of meal, liquids and solids.
