Gastrointestinal Flashcards
What is achalasia?
An oesophageal motility disorder, characterised by loss of peristalsis and failure of relaxation of the lower oesophageal sphincter (LOS)
What is the aetiology of achalasia?
- Degeneration of ganglion cells of the meyenteric plexus in the oesophagus due to an unknown cause.
- Oesophageal infection with Trypanosoma cruzi seen in Central and South America producers a similar disorder- Chaga’s disease
What is the epidemiology of achalasia?
Usual presentation age: 25-60 years
What are the presenting symptoms of achalasia?
Insidious onset and gradual progression of
- Intermittent dysphagia involving solids and liquids
- Difficulty belching
- Regurgitation (particularly at night)
- Heartburn
- Chest pain (atypical/cramping, retrosternal)
- Weight loss
What are the signs of achalasia on examination?
May reveal signs of complications
What are the investigations of achalasia?
- CXR: may show widened mediastinum and double right border (dilated oesophagus), an air-fluid level in upper chest and absence of the normal gastric air bubble
- Barium swallow: Dilated oesophagus which smoothly tapers down to the sphincter (beak-shaped)
- Endoscopy: To exclude malignancy which can mimic achalasia
- Manometry: Elevated resting LOS pressure (over 45mmHg), Incomplete LOS relaxation, Absence of peristalsis in the distal (smooth muscle portion) of the oesophagus
What is acute cholangitis?
Ascending cholangitis
- Infection of the biliary tree, most commonly caused by obstruction.
- In its less severe form, there is biliary obstruction with inflammation and bacterial seeding and growth int he biliary tree
What is the aetiology of acute cholangitis?
- Most common aetiology is cholelithiasis leading to choledocholithiasis and biliary obstruction.
- Iatrogenic biliary tract injury, most commonly caused via surgical injury cholecystectomy, can lead to benign strictures, which in turn can lead to obstructions
- Acute prancreatitis
- Malignant strictures
What is the epidemiology of acute cholangitis?
- Relatively uncommon
- Male to female ratio is equal
- Median age of presentation is 50-60
What are the presenting symptoms of acute cholangitis?
- Jaundice
- Fever
- Right upper quadrant pain
- Right upper quadrant tenderness
What are the signs of acute cholangitis on examination?
- Alcoholic stools
- Pruritis
- Hypotension
- Mental status changes
What are the investigations for acute cholangitis?
- FBC: Raised WBC, decreases platelets
- Serum urea: Raised in severe cases
- Serum creatinine: Raised in severe cases
- ABG: Metabolic acidosis
- LFT: Hyperbilinuraemia
- CRP: Raised
- Serum K & Mg: May be decreased
- Blood cultures: Bacteria usually gram negative, but gram positive bacteria and anaerobes are also implicated in cholangitis
How is acute cholangitis managed?
- IV antibiotics (Piperacillin/Tazobactam
- Biliary decompression
- Opioid analgesics
- Lithotripsy
What are the possible complications of acute cholangitis?
- Acute prancreatitis
- Inadequate biliary drainage following performance of endoscopy, radiology or surgery
- Hepatic abscess
What is the prognosis of acute cholangitis?
- If adequate biliary drainage is quickly obtained, most patients experience rapid clinical improvement
- Outcome worse for patient’s with underlying medical conditions
What is alcoholic hepatitis?
Inflammatory liver injury caused by chronic heavy intake of alcohol
What is the aetiology alcoholic hepatitis?
One of the three forms of liver disease caused by excessive intake of alcohol, a spectrum that ranges from alcoholic fatty liver (steatisus) to alcoholic hepatitis and chronic cirrhosis
- In alcoholic hepatitis, the liver histopathology shows centrilobar ballooning degeneration and necrosis of hepatocytes, steatosis, neutrophilic inflammation, cholestasis, Mallory hyaline inclusions and giant mitochondria
What is the epidemiology of alcoholic hepatitis?
10-35% of heavy drinkers develop this form of liver disease
What are the presenting symptoms of alcoholic liver disease?
- May remain asymptomatic and undetected unless they present for other reasons
- Mild illness with nausea, malaise, epigastric or right hypochondrial pain
- Low grade fever
What are the signs of acute hepatitis on examination?
- Signs of alcohol excess: Malnourishes, palmar erythema, Dupuytren’s contracture, facial telangiectasia, parotid enlargement, spider naevi, gynaecomastia, testicular atrophy, hepatomegaly, easy bruising
- Signs of severe alcoholic hepatitis: Febrile (50% pts), tachycardia, jaundice, bruising, encephalopathy, ascites, hepatomegaly, splenomegaly
What are the investigations for alcoholic hepatitis?
- Blood: Decreased Hb, Increased MCV, Increased WCC, Decreased platelets. U&E: Urea and K low unless significant renal impairment. Clotting: Prolonged PT sensitive marker of sig. liver damage
- Ultrasound: For other causes of liver impairment (e.g. malignancies
- Upper GI endoscopy: Investigate for varices
- Liver biopsy: Percutaneous or transjugular may be helpful to distinguish from other causes of hepatitis
- Electroencephalogram: For slow wave activity indicative of encephalopathy
How is alcoholic hepatitis managed?
- Acute: Thiamine, Vitamin C and other multivitamins. Monitor and correct K, MG and glucose abnormalities. Ensure adequate glucose output. Treat encephalopathy with oral lactose and phosphate enemas. Ascites manages by diuretics
- Nutrition: Oral and or nasogastric feeding important with increased caloric intake. Protein restricted to be avoided unless patient is encephalopathic. Nutritional supplementation and vitamins started parenterally and continues orally after
- Steroid therapy
What are the possible complications of alcoholic hepatitis?
- Acute liver decompensation
- Hepatorenal syndrome (renal failure secondary to advanced liver disease
- Cirrhosis
What is the prognosis of alcoholic hepatitis?
Morality in first months is 10%; 40% in first year
- If alcoholic intake continues, most progress to cirrhosis within 1-3 years
- Maddrey’s discriminant function. If less than 32, indicates more than 50% 30-day mortality
- Glasgow alcoholic score
What is an anal fissure?
Split in the skin of the distal anal canal characterised by pain on defecation and rectal bleeding
What is the aetiology of anal fissures?
- Passage of hard stool bolus may precipitate an anal fissure
- Fissure may begin during episode of loose stool, or often occurs spontaneously with no obvious precipitating factor
- Opiate analgesia is associated with constipation and a subsequence increased incidence of anal fissure
- Hard stool tears the anal skin at pectin (at dentate line)
- Pregnancy is risk factor
What is the epidemiology of anal fissures?
- Equally common in men and women
- Often affects young adults ages 15-40, but may be seen in older adults
- May be seen in younger adults due to poor toileting
What are the presenting symptoms of anal fissures?
- Pain on defecation
- Tearing sensation on passing stool
- Fresh blood on stool or on paper
- Anal spasm
What are the signs of anal fissures on examination?
- Sentinel pile
- Fissure visible on retraction of buttock
What are the investigations for anal fissures?
- Clinical diagnosis
- Anal manometry: Low resting pressure
- Anal ultrasound: Defects in external or internal anal sphincter
How are anal fissures managed?
- Conservative treatment alone: high fibre diet, adequate fluid intake, sitz baths and topical analgesia
- Topical glyceryl trinitrate
- Topical diltiazem
Resistant fissures: - Botulinium toxin injection
- Surgical sphincterotomy
- Anal advancement flap
What are the possible complications of anal fissures?
- Chronic anal fissure
- Incontinence after surgery
- Recurrence
What is the prognosis of anal fissures?
- 60% achieve healing of fissure after 6-8 weeks
- Some patients relapse
- Some require surgery
What is an appendicectomy?
Surgical removal of vermiform appendix
- Can be formed laparoscopically or as open operation
What are the indications of appendicectomy?
- Appendicitis
- Consider for patients with history of persistent abdominal pain, fever and clinical signs of localised or diffuse peritonitis especially if leucocytosis is present
What are the possible complications of appendectomy?
- Bleeding
- Wound infection
- Infection, redness and swelling of belly can occur if appendix bursts during surgery (peritonitis)
- Blocked bowels
- Injury to nearby organs
What is appendicitis?
- Acute inflammation of vermiform appendix, most likely due to obstruction of lumen of the appendix
What is the aetiology of appendicitis?
- Obstruction is main cause
- Faecolith (hard mass of faecal matter), normal stool or lymphoid hyperplasia are main causes for osbtruction
What is the epidemiology of appendicitis?
- One of the most acute abdominal surgical emergencies
- Predominantly in 15-59 age group
- Incidence lower in populations where high-fibre diet is consumed
What are the presenting symptoms of appendicitis?
- Abdominal pain
- Anorexia
- Right lower quadrant tenderness
- Nausea
- Fever
- Vomiting
What are the signs of appendicitis on examination?
- Adolescence or early adulthood
- Diminished bowel sounds
- Rovsing’s sign (Pressing left side of abdominal cavity and eliciting pain in lower right quadrant)
- Psoas sign (Extending right thigh on left lateral position elicits pain in right lower quadrant)
- Obturator sign (Pain elicited in RLQ of abdomen by internal rotation of the flexed right thigh)
What are the investigations for appendicitis?
- FBC: Mild leukocytosis
- Abdominal and pelvic CT scan: Abnormal appendix, more than 6mm diameter
- Urinary pregnancy test: Negative
How is appendicitis manage?
- Appendectomy and supportive care
- Intravenous antibiotic therapy: cefoxitin
What are the possible complications of appendicitis?
- Perforation
- Generalised peritonitis
- Appendicular mass
- Appendicular abscess
- Surgical wound infection
What is the prognosis of appendicitis?
- Good if patients treated in timely fashion
- Laparoscopic appendectomy shown to reduce incidence of overall complications
What is autoimmune hepatitis?
Chronic hepatitis of unknown aetiology, characterised by autoimmune features, hyperglobulinaemia and the presence of the circulating autoantibodies
What is the aetiology of autoimmune hepatitis?
In genetically predisposed individual, environmental agent may lead to hepatocyte expression of HLA antigens which then become focus of principally T-cell mediated autoimmune attack
What is the epidemiology of autoimmune hepatitis?
Type 1 occurs in all age groups (mainly in young women)
Type 2 generally a disease of girls and young women
What are the presenting symptoms of autoimmune hepatitis?
May be asymptomatic discovered incidentally by abnormal LFT
- Insidious onset: Malaise, fatigue, anorexia, weight loss, nausea, jaundice, amenorrhoea, epistaxis
- Acute hepatitis (25%): Fever, anorexia, jaundice, nausea, vomiting, diarrhoea, RUQ pain. May also present with serum sickness (e.g. arthalgia, polyarthritis, maculopapular rash
May be associated with keratoconjuctivitis sicca
What are the signs of autoimmune hepatitis on examination?
- Stigmata of chronic liver disease e.g. spider naevi
- Ascites, oedema and encephalopathy are late features
- Cushingoid features e.g. rounded face, cutaneous striae, acne, hirsutism) may be present even before the administration of stoids
What are the investigations for autoimmune hepatitis?
- Blood: Increased AST and ALT, Increased AlkPhos, Increase bilirubin, Decreased albumin, Increased PT, Decreased platelets and WCC from hypersplenism if portal hypertension present
- Liver biopsy: Needed to establish the diagnosis, shows interface hepatitis or cirrhosis
- Other: Rule out other causes of liver disease
- Ultrasound, CT or MRI of liver and abdomen: Visualise structural lesions
- ERCP: Rule out PSC
How is autoimmune hepatitis managed?
Indications- aminotransferases raised, the upper limit of normal and symptomatic
- Immunosuppression: with steroids e.g. prednisolone, followed by maintenance treatment with gradual reduction in dose.
- Monitor: Ultrasound ever 6-12 months to detect hepatocellular carcinoma
- Hep A and B vaccinations
- Liver transplant: for pts with refractory to or intolerant of immunosuppressive therapy and those with end-stage disease
What are the possible complications of autoimmune hepatitis?
- Fulminant hepatic failure
- Cirrhosis and complications or portal hypertension (e.g. varices, ascites)
- Hepatocellular carcinoma
- Side-effects of corticosteroid treatment
What is the prognosis of autoimmune hepatitis?
- Older patients with type 1 autoimmune hepatitis are more likely to have cirrhosis at presentation but may be more likely to respond to treatment
- 80% receive remission by 3 years
What is Barrett’s oesophagus?
Change in the normal squamous epithelium of the oesophagus to specialised intestinal metaplasia
- Associated with gastro-oesophageal reflux even if reflux is asymptomatic
What is the aetiology of Barrett’s oesophagus?
- Main aetiology is gastro-oesophageal reflux
- Evidence that combined bile and acid reflux are primary causative agents
What is the epidemiology of Barrett’s oesophagus?
- More common in men and white people
- Rare in children
- More prevalent with age
What are the presenting symptoms of Barrett’s oesophagus?
- Heart burn
- Regurgitation
- Dysphagia
- Chest pain
- Cough
- SOB/wheezing
What are the signs of Barrett’s oesophagus on examination?
- Laryngitis
- History of aspiration pneumonia
What are the investigations for Barrett’s oesophagus?
- Upper GI contrast radiography: hiatal hernia and reflux
- Upper GI endoscopy with biopsy: Abnormal epithelium characteristic of Barrett’s oesophagus
How is Barrett’s oesophagus managed?
- Proton pump inhibitor plus surveillance
- Radiofrequency ablation
- Anti-reflux surgery plus surveillance
- Radiofrequency ablation
What are the possible complications of Barrett’s oesophagus?
- Adenocarcinoma
- Oesophageal stricture
- Quality of life deficit
What is the prognosis for Barrett’s oesophagus?
- Adenocarcinomas discovered while screening for Barrett’s oesophagus are early-stage lesions and have good prognosis
What is biliary colic?
When pain occurs due to a gallstone temporarily blocking the bile duct
Can last hours, associated with nausea and vomiting
What are the risk factors of biliary colic?
- Previous episode of biliary pain (50% have another episode within a year)
- Older age
- Female sex
- Obesity
- Rapid weight loss
- Drugs
- Symptomatic stones, pregnancy, smoking
What is the epidemiology of biliary colic?
- Sudden onset, severe RUQ pain
- Constant in nature
- Nausea and vomiting
- May last hours
- Radiates to back or right scapula and jaundice
- Jaundice is common but can develop with choledocholelithiasis
- Pain worse after fatty meal
If fever present, suggests complication such as cholecystitis, cholangitis or pancreatitis
What are the signs of biliary colic on examination?
- Right upper quadrant and epigastric tenderness
What are the investigations for biliary colic?
- Abdominal ultrasound: For symptomatic patients
- CT follow up if unremarkable
- MRCP
How is biliary colic managed?
- Analgesia
- Rehydration
- NBM
- Elective laparoscopic cholestystectomy
What are the possible complications of biliary colic?
- Cholangitis
- Sepsis
- Pancreatitis
- Hepatitis
- Choledocholithiasis
- Gallbladder perforation
What is the prognosis for biliary colic?
Uncomplicated biliary colic has low mortality
What is cholecystectomy?
- Surgical removal of gallbladder
- Common treatment of symptomatic gallstones and other gallbladder conditions
- Can be laparoscopic or open
What are the indications for a cholecystectomy?
- Calcified gallbladder
- Acute cholecystitis
- Choledocholithiasis
- Gallstone pancreatitis
- Biliary pain
- Biliary dyskinesia
What are the possible complications of cholecystectomy?
- Bile leek
- Bleeding
- Blood clots
- Infection
- Pancreatitis
- Pneumonia
- Post-cholecystectomy syndrome
What is cholecystitis?
Acute gallbladder inflammation caused by an obstruction at the cystic duct
What are the causes of cholecystitis?
Acute: Stone or sludge impaction in the neck of the gallbladder
Chronic: Chronic inflammation and colic
What is the epidemiology of cholecystitis?
8% of >40yrs.
5 Fs: Fat, Forty, Female, Fertile, Fair
What are the presenting symptoms of cholecystitis?
- Patient systemically unwell
- Fever
- Prolonged upper abdominal pain that may be referred to right shoulder (due to diaphragmatic irritation)
What are the signs of cholecystitis on examination?
- Tachycardia
- Pyrexia
- Right upper quadrant or epigastric tenderness
- They may be guarding. With or without rebound
- Murphy’s signs is elicited by placing a hand at the costal margin in the RUQ and asking patient to breathe deeply
- Patient stops breathing as the inflamed gallbladder descends and contacts the palpating fingers
What are the investigations for cholecystitis?
- Ultrasound: image stones and assess CBD diameter
- MRCP: to find CBD stones
How is cholecystitis managed?
- Cholecystectomy
- If US shows dilated GB with stones → ERCP and sphincterotomy before surgery
What are the possible complications of cholecystitis?
- Perforation
- Suppurative cholecystitis
- Gangrenous cholecystitis
- Bile duct injury due to surgery
- Gallstone ileus
What is the prognosis for cholecystitis?
Removing the gallbladder and the contained gallstones when biliary pain starts will prevent further biliary attacks and reduce the risk of developing cholecystitis. If the gallbladder perforates, mortality is 30%.
Untreated acute acalculous cholecystitis is life-threatening and is associated with up to 50% mortality.
What is cirrhosis?
End-stage of chronic liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes.
Decompensated when there are complications such as ascites, jaundice, encephalopathy or GI bleeding
What is the aetiology of cirrhosis?
- Chronic alcohol misuse
- Chronic viral hepatitis
- Autoimmune hepatitis
- Drugs: e.g. methotrexate, hepatotoxic drugs
- Inherited: haemochromatosis, Wilson’s disease, galactosaemia, cystic fibrosis, a1-Antitrypsin deficiency
- Vascular: Budd-Chiari syndrome or hepatic venous congestion
- Chronic biliary diseases: Primary biliary cirrhosis (PBC), primary sclerosing cholangitis, biliary atresia
- Cryptogenic
- Non-alcoholic steatohepatitis (NASH)
What is the epidemiology of cirrhosis?
Among the top 10 leading cause of deaths worldwide
What are the presenting symptoms of cirrhosis?
Early non-specific symptoms: Anorexia, nausea, fatigue, weakness, weight loss
- Symptoms caused by decreased liver synthetic function: Easy bruising, abdominal swelling, ankle oedema
- Reduced detoxification function: Jaundice, personality change, altered sleep pattern, amenorrhoea
- Portal hypertension: Abdominal swelling, haematemesis, PR bleeding or melaena
What are the signs of cirrhosis on examination?
Stigmata of chronic liver disease: ABCDE
- Asterixis (liver flap)
- Bruises
- Clubbing
- Dupuytren’s contracture
- Erythema (palmar)
- Jaundice, gynaecomastia, leukonychia, parotid enlargement, spider naevi, stretch marks, ascites (shifting dullness and fluid thrill), enlarged liver, testicular atrophy, caput medusae, splenomegaly
What are the investigations for cirrhosis?
- Blood: Decreased Hb and platelets. LFTs may be normal. Prolonged PT. Serum AFP Increased in chronic liver disease
- Other: to determine cause
- Ascitic tap: microscopy
- Liver biopsy: Percutaneous or transjugular if clotting deranged or ascites present
- Imaging: US, CT or MRI
- Endoscopy: Examine for varices,
- Child-Pugh grading
How is cirrhosis managed?
Treat cause if possible, avoid alcohol, sedative, opiates, NSAIDs and drugs that affect the liver. Nutrition important if intake poor
Treat complications
Encephalopathy- Treat infections
Ascites: Diuretics
What are the possible complications of cirrhosis?
- Portal hypertension with ascites
- Encephalopathy or variceal haemorrhage
- SBP
- Hepatocellular carcinoma
- Renal failure (hepatorenal syndrome)
- Pulmonary hypertension (hepatopulmonary syndrome)
What is the prognosis of cirrhosis?
- Depends on the aetiology and complications
- Generally poor: Overall 5 year survival is 50%
- In presence of ascites, 2 year survival of 50%
What is coeliac disease?
Inflammatory disease caused by intolerance to gluten, causing chronic intestinal malabsorption
What is the aetiology of coeliac disease?
- Sensitivity to gliadin component of the cereal protein, triggers an immunological reaction int he small intestine, leading to mucosal damage and loss of villi
- 10% risk of first-degree relatives being affected and there is clear genetic susceptibility associated with HLA-B8, DR3 and DQW2 haplotypes
What is the epidemiology of coeliac disease?
UK Prevalence is 1 in 2000
- Rare in East Asia
What are the presenting symptoms of coeliac disease?
- May be asymptomatic
- Abdominal discomfort: pain and distension
- Steatorrhoea (pale bulky stool, with offensive smell and difficult to flush away) diarrhoea
- Tiredness, malaise, weight loss (despite normal diet
- Failure to thrive in children, amenorrhoea in young adults
What are the signs of coeliac disease on examination?
- Signs of anaemia: pallor
- Signs of malnutrition: Short stature, abdominal distension and wasted buttocks in children. Triceps skinfold thickness gives an indication of fat stores
- Signs of vitamin or mineral deficiencies (e.g. osteomalacia, easy bruising)
- Intense, itchy blisters on elbows, knees or buttock (dermatitis herpetiforms)
What are the investigations for coeliac disease?
- Blood: Decreased Hb, iron and folate, albumin, phosphate
- Serology: Testing for IgG anti-gliadin, IgA, and IgG anti-endomysial translutaminase antibodies can be diagnostic. IgA deficiency is common
- Stool: Culture to exclude in infection
- D-xylose test: Reduced urinary excretion after an oral xylose load indicates small bowel malabsorption
- Endoscopy: Direct visualisation shows villous atrophy in small intestine, giving mucosa a flat smooth appearance. Biopsy shows villous atrophy with crypt hyperplasia of the duodenum. Epithelium adopts a cuboidal appearance, there is inflammatory infiltrate of lymphocytes and plasma cells in lamina propria
How is coeliac disease managed?
- Advice: Withdrawal of gluten from the diet, with avoidance of all wheat, rye and barley products. Education and expert dietary advice is essential. The Coeliac Society offer patient support and advice
- Medical: Vitamin and mineral supplements. Oral corticosteroids may be used if the disease does not subside with gluten withdrawal
What are the possible complications of coeliac disease?
- Iron, folate and Vitamin B12 deficiency
- Osteomalacia
- Ulcerative jejunoiletis
- Gastrointestinal lymphoma (particular T cell)
- Bacterial overgrowth
- Rarely can cause cerebellar ataxia
What is the prognosis for coeliac disease?
- Strict adherence to gluten-free diet, most patients make a full recovery
- Symptoms usually resolve within weeks
- Histological changes may take longer to resolve
- A gluten-free diet needs to followed for life
What is a colonoscopy?
An endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus
- Can provide visual diagnosis (polyps, ulceration) and grants opportunity for biopsy or removal of suspected colorectal cancer lesions
What are the indications for a colonoscopy?
- Gastrointestinal haemorrhage
- Unexplained changes in bowel habit
- Suspicion of malignancies
- Diagnose colon cancer and IBD
What are the possible complications of a colonoscopy?
- Gastrointestinal perforation
- Bleeding: by cauterisation via the instrument. Delayed bleeding at site of polyp removal up to weak after procedure
- Splenic rupture
- Dehydration caused by laxatives usually administered during bowel preparation
What is Crohn’s disease?
Chronic granulomatous inflammatory disease that can affect any part of the gastrointestinal tract.
Grouped with ulcerative colitis and together they are known as inflammatory bowel disease
What is the aetiology of Crohn’s disease?
Cause has not yet been elucidated, but thought to involve an interplay between genetic and environmental factors
- Inflammation can occur anywhere along GI tract (40% involving the terminal ileum) and ‘skip’ lesions with inflamed segments of bowel interspersed with normal segments is not unusual
What is the epidemiology of Crohn’s disease?
- Prevalence is 50-80 in 100,000
- Affects any age but peak incidence is in teen or twenties
What are the presenting symptoms of Crohn’s disease?
- Crampy abdominal pain (caused by inflammation, fibrosis or bowel obstruction)
- Diarrhoea (may be blood or steatorrhoea)
- Fever, malaise, weight loss
- Symptoms of complications
What are the signs of Crohn’s disease on examination?
Weight loss, clubbing, signs of anaemia
- Aphthous ulceration of the mouth
- Perianal skin tags, fistulae and abscesses
- Signs of complications (eye disease, joint disease, skin disease)
What are the investigations for Crohn’s disease?
- Blood: FBC (Decreased Hb, Raised platelets * WCC), U&E, LFT (low albumin), increased ESR, haematinics to look for deficiency states, ferritin, Vit B12 and red cell folate
- Stool microscopy and culture: to exclude infective colitis
- AXR: evidence of toxin megacolon
- Erect CXR: If risk of perforation
- Small bowel barium follow through: May reveal fibrosis/ strictures (string sign of Kantor), deep ulceration (rose thorn), cobblestone mucosa
- Endoscopy and biopsy: May help differentiate between ulcerative colitis and Crohn’s.
- Radionuclide-labelled neutrophil scan
How is acute exacerbation of Crohn’s disease managed?
- Fluid resuscitation
- IV or oral corticosteroids
- 5-ASA analogues (e.g. mesalazine, sulfasalazine) may induce a remission in colonic Crohn’s disease
- Analgesia
- Elemental diet may induce remission (more often used in children)
- Parenteral nutrition may be necessary
- Monitor markers of activity (fluid balance, ESR, CRP, platelets, stool frequency, Hb and albumin)
- Assess for complications
How is Crohn’s disease managed in the long term?
- Steroids: For treating acute exacerbations
- 5-ASA analogues (e.g. sulfasalazine, mesalazine) decreased relapses: useful for mild-moderate disease
- Immunosuppression: Using steroid-sparing ages (e.g. azathioprine, 6-mercaptopurine, methotrexate) to reduce relapses
- Anti-TNF agents (e.g. infliximab, adalimumab): Very effective agents in achieving and maintaining remission. Usually reserved for refractory cases
What advice is given to patient’s with Crohn’s disease?
- Stop smoking
- Dietician referral
- Education and advice (e.g. from inflammatory bowel disease nurse specialists
When is surgery for Crohn’s disease indicated?
- When medical treatment fails
- Failure to thrive in children or the presence of complications
- Involves resection of affected bowel and stoma formation, although there is a risk of disease recurrence
What are the possible GI complications of Crohn’s disease?
- Haemorrhage
- Bowel strictures
- Perforation
- Fistulae (between bowel, bladder, vagina)
- Perianal fistulae and abscess
- GI carcinoma (5% risk in 10 years)
- Malabsorption
What are the extraintestinal features of complications of Crohn’s disease?
- Uveitis
- Episcleritis
- Gallstones
- Kidney stones
- Arthropathy
- Sacroilitis
- Ankylosing spondylitis
- Erythema nodosum and pyoderma gangrenosum
- Amyloidosis
What is the prognosis of Crohn’s disease?
- Chronic relapsing condition
- 2/3 will require will surgery at some stage and 2/3 of these have more than 1 surgical procedure
What is diverticulosis?
Presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel
What is diverticular disease?
Diverticulosis associated with complications e.g. haemorrhage, infection, fistulae
What is diverticulitis?
Acute inflammation and infection of colonic diverticulae
What is the aetiology of diverticular disease?
- Low fibre diet leads to loss of stool bulk
- Consequently, high colonic intraluminal pressures must be generated to propel the stool, leading to herniation of the mucosa and submucosa through the muscularis
What is the epidemiology of diverticular disease?
Common
- 60% of people living in industrialised countries will develop colonic diverticula
- Rare, under 40 years
- Right sided diverticula are more common in Asia
What are the presenting symptoms of diverticular disease?
- Often asymptomatic (80-90%)
- PR bleeding
- Diverticulitis: left iliac fossa or lower abdominal pain, fever
- Diverticular fistulation into bladder: pneumaturia, faecaluria and recurrent UTI
What are the signs of diverticular disease on examination?
Diverticulitis:
- Tender abdomen
- Signs of local or generalised peritonitis if perforation has occurred
What are the investigations for diverticular disease?
- Blood: FBC, Raised WCC and CRP in diverticulitis, check clotting and cross match if bleeding
- Barium enema: Demonstrates presence of diverticulae with a saw-toothed appearance of lumen, reflecting pseudohypertrophy of circular muscle
- Flexible sigmoidoscopy and colonscopy: Diverticulae can be seen and other pathology can be excluded
How is diverticular disease managed?
- Asymptomatic: Soluble high fibre diet. Probiotics and anti-inflammatories (mesalazine)
- GI Bleed: PR bleeding managed with IV rehydration, antibiotics, blood transfusion if necessary. Angiography and surgery if severe
- Diverticulitis: IV antibiotics and IV fluid rehydration and bowel rest.
- Surgery: May be necessary with recurrent attacks or when complications develop e.g. perforation and peritonitis. Can be open (Hartmann’s, one-stage resection) or laparoscopic
What are the possible complications of diverticular disease?
- Diverticulitis
- Pericolic abscess
- Perforation
- Faecal peritonitis
- Colonic obstruction
- Fistula formation (bladder, small intestine, vagina)
- Haemorrhage
What is the prognosis for diverticular disease?
- 10-25% of patients will have one or more episodes of diverticulitis
- Of these 30% will have a second episode
Endoscopic retrograde cholangiopancreatography?
A technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems
- Through the endoscopy, the physical can see the inside of the stomach and duodenum , and inject a contrast medium into the ducts in the biliary tree and pancreas so they can be seen on radiographs
What are the indications for Endoscopic retrograde cholangiopancreatography?
- Obstructive jaundice
- Gallstones with dilated bile ducts
- Indeterminate biliary strictures and suspected bile duct tumours
- Suspected injury to bile ducts either as a result of trauma or iatrogenic
- Sphincter of Oddi dysfunction
- Chronic pancreatitis
What are the possible complications of Endoscopic retrograde cholangiopancreatography?
- Pancreatitis
- Intestinal perforation
- Risks associated with the contrast dye in patients who are allergic to compounds containing iodine
- Oversedation can results in low BP, respiratory depression, nausea and vomiting
- Cholangitis
What is an endoscopy?
Refers to looking inside the body for medical reasons using an endoscope, an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging techniques, endoscopes are inserted directly into the organ.
What are the indications for an endoscopy?
- Investigation of symptoms, such as symptoms in the digestive system including nausea, vomiting, abdominal pain, difficulty swallowing and gastrointestinal bleeding
- Confirmation of diagnosis, most commonly by performing a biopsy to check for conditions such as anaemia, bleeding, inflammation and cancers of the digestive system
- Giving treatment, such as cauterisation of a bleeding vessel, widening a narrow oesophagus
What are the possible complications of an endoscopy?
- Infection
- Over-sedation
- Perforation
- Tear of the stomach or oesophagus lining
- Bleeding
What is gastro-oesophageal reflux disease?
Inflammation of the oesophagus caused by reflux of gastric acid and/or bile
What is the aetiology of gastro-oesophageal reflux disease?
- Disruption of mechanisms that prevent reflux (physiological LOS, mucosal rosette, acute angle of junction, intra-abdominal portion of oesophagus)
- Prolonged oesophageal clearance contributes to 50% of cases
What is the epidemiology of gastro-oesophageal reflux disease?
Common
Prevalence 5-10% adults
What are the presenting symptoms of gastro-oesophageal reflux disease?
- Substernal burning discomfort or ‘heartburn’ aggravated by lying supine, blending or large meals and drinking alcohol
- Pain relieved by antacids
- Waterbrash
- Regurgitation of gastric contents
- Aspiration may results in voice hoarseness, laryngitis, nocturnal cough and wheeze & pneumonia
- Dysphagia (caused by formation of peptic stricture after long-standing reflux)
What are the signs of gastro-oesophageal reflux disease on examination?
- Usually normal
- Occasionally, epigastric tenderness, wheeze on chest, auscultation, dysphonia
What are the investigations for gastro-oesophageal reflux disease?
- Upper GI endoscopy: Biopsy and cytological bushings: To confirm the presence of oesophagitis, exclude the possibility of malignancy (all patients over 45 years)
- Barium swallow: To detect hiatus hernia, peptic stricture, extrinsic compression of oesophagus can be visualised
- CXR: Not specifically for GORD. Incidental finding of hiatus hernia (gastric bubble behind cardiac shadow)
- Twenty-four hour oesophageal pH monitoring: pH probe placed in lower oesophagus determined the temporal relationship between symptoms and oesophageal pH
How is gastro-oesophageal reflux disease managed?
- Advice: Lifestyle changes, weight loss, elevating head of bed, avoid provoking factors, stopping smoking, lower fat meals, avoiding large meals late in the evening
- Medical: Antacids and alginates, H2 antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. Iansoprazole) are sufficient for most patients
- Endoscopy: Annual endoscopic surveillance for Barrett’s oesophagus, may be necessary for stricture dilation or stenting
- Surgery: Antireflux surgery for those with symptoms despite optimal medical management or those intolerance of medication
- Nissen fundoplication: (fundus of the stomach is wrapped around the lower oesophagus and held with sermuscular sutures) helps reduce any hiatus hernia and reduce hiatus
What are the possible complications of gastro-oesophageal reflux disease?
- Oesophageal ulceration
- Peptic stricture
- Anaemia
- Barrett’s oesophagus
- Oesophageal adenocarcinoma
- Associated with asthma and chronic laryngitis
What is the prognosis of gastro-oesophageal reflux disease?
- 50% respond to lifestyle measures alone
- In patients who require drug therapy withdrawal is often associated with relapse
- 20% of patients undergoing endoscopy for GORD have Barrett’s oesophagus
What is gastroenteritis?
Acute inflammation of the lining of the GI tract, manifested by nausea, vomiting, diarrhoea and abdominal discomfort
What is the aetiology of gastroenteritis?
Can be caused by viruses, protozoa or toxins contained in contained in contaminated food or water
- Viral: Rotavirus, adenovirus, astrovirus, calcivirus, Norwalk virus, small round structured viruses
- Bacterial: Campylobacter jejuni, E coli, Salmonella, Shigella, V cholerae, Listeria,
- Protozoal: E hystolycia, C parvum
- Toxins: From S aureus, C bolutinum, C perfingens, mushrooms, heavy metals, seafood
- Non inflammatory mechanisms: V cholerae
- Inflammatory mechanisms: Shigella, E coli release cytotoxins and invade and damage the epithelium
What is the epidemiology of gastroenteritis?
- Common
- Often under-reported
- Serious case of morbidity and mortality in the developing world
What are the presenting symptoms of gastroenteritis?
- Sudden onset nausea
- Vomiting
- Anorexia
- Diarrhoea (bloody or watery)
- Abdominal pain or discomfort
- Fever and malaise
- Enquire about recent travel
- Antibiotic use and recent food intake (how cooked, source and whether anyone ill)
What are the signs of gastroenteritis on examination?
- Diffuse abdominal tenderness
- Abdominal distension and bowel sounds are often increased-
- If severe, pyrexia, dehydration, hypotension, peripheral shutdown
What are the investigations for gastroenteritis?
- Blood: FBC, Blood culture (helps identification if bacteraemia present), U&E’s (dehydration)
- Stool: Faecal microscopy for polymorphs, parasites, oocytes, culture, electron microscopy (used to diagnose viral infections). Analysis for toxins, particularly for pseudomembranous colitis (C diff toxin)
- AXR or ultrasound: To exclude other causes of abdominal pain
- Sigmoidoscopy: Often unnecessary unless inflammatory bowel disease needs to be excluded
How is gastroenteritis managed?
- Bed rest
- Fluid and electrolyte replacement with oral rehydration solution (containing glucose and salt)
- IV rehydration may be necessary in those with severe vomiting
- Most infections are self limiting. Antibiotic treatment is only warranted if severe or the infective agent has been identified (e.g. ciprafloxacin against Salmonella, Shigella, Campylobacter
- Botulism: Botulinum antitoxin IM and manage in ITU
- Public health: Often a notifiable disease. Educate on basic hygiene and cooking.
What are the possible complications of gastroenteritis?
- Dehydration
- Electrolyte imbalance
- Prerenal failure
- Secondary lactose intolerance (particularly in infants)
- Sepsis and shock (particularly Salmonella and Shigella)
- Haemolytic uraemia syndrome is associated with toxins from E coli
- Guillian-Barre syndrome may occur weeks after recovery from Campylobacter gastroenteritis
- Botulism: Respiratory muscle weakness or paralysis
What is the prognosis of gastroenteritis?
Generally good, as the majority of cases are self-limiting
What is gastrointestinal perforation?
Hole in the wall of part of the gastrointestinal tract
What is the aetiology of gastrointestinal perforation?
Underlying causes include:
- Gastric ulcers
- Duodenal ulcers
- Appendicitis
- Gastrointestinal cancer
- Diverticulitis
- Inflammatory bowel disease
- Superior mesenteric artery syndrome
- Trauma
- NSAIDs
- Typhoid
What is the epidemiology of gastrointestinal perforation?
Children: blunt trauma
Adults:
Duodenal perforation more than gastric perforation
What are the presenting symptoms of gastrointestinal perforation?
- History of penetrating issue
- NSAID or aspirin use
- Abdominal pain
- Vomiting
- Hiccuping
- History of travel
- Sharp severe sudden onset (perf peptic ulcer)
What are the signs of gastrointestinal perforation on examination?
- External injury, abrasion, ecchymyosis
- Breathing pattern, distension, discolouration of abdomen
What are the investigations for gastrointestinal perforation?
- Bloods: WCC, CRP, Cultures, Group & Save, Cross Match, Amylase to rule out pancreatitis, ABG, LFT
- Urinalysis
- USS: Localised gas collection, thickens bowel loop
- CT: If no delay
- Plain AXR: Rigler’s sign, Visible falciform ligament RUQ -> umbilicus
- CXR if peritonitic or over 50: gas under diaphragm
How is gastrointestinal perforation managed?
Laparoscopy
Laparotomy
What are the possible complications of gastrointestinal perforation?
- Bleeding
- Sepsis
- Bowel infarction
What is the prognosis of gastrointestinal perforation?
Chances of recovery improve with early diagnosis and treatment
What is a haemorrhoidectomy?
Surgical excision of the hemorrhoid used primarily only in severe cases.
- Associated with significant post-operative pain
- Excisional haemorrhoidectomy (Milligan Morgan) - scalpel, laser, electrocautery
- Stapled haemorrhoidopexy (if prolapsed) - ?less pain, shorter stay
What are the possible complications of a haemorrhoidectomy?
- Anal fistula or fissure
- Constipation
- Excessive bleeding
- Excessive discharge
- Inability to urinate or have bowel movement
- Excessive discharge of fluid from the rectum
What are the indications for a haemorrhoidectomy?
- Prolapse
- Haemorrhoids
What are haemorrhoids?
- Haemorrhoidal cushions are normal anatomical structures located within the anal canal, usually occupying the left lateral and right anterior and posterior positions
- As they enlarge, they can protrude outside the anal canal and cause symptoms
What is the aetiology of haemorrhoids?
- Excessive straining due to either chronic constipation or diarrhoea
- Repetitive or prolonged straining causes downward stress on the vascular haemorrhoidal cushions, leading to the disruption of the supporting tissue elements with subsequent elongation, dilation, and engorgement of the haemorrhoidal tissues.
What is the epidemiology of haemorrhoids?
- More common in white patients than black patients
- Presentation peaking between ages 45-65
What are the presenting symptoms of haemorrhoids?
- Perianal pain/discomfort
- Constipation
- Rectal bleeding
What are the signs of haemorrhoids on examination?
- Anal pruritus
- Tender palpable anal lesion
- Anal mass
- Ascites
What are the investigations for haemorrhoids?
- Anoscopic examination: haemorrhoids
- Colonoscopy: Usually normal, may reveal other pathologies
- FBC: May demonstrate microcytic/hypochromic anaemia
- Stool for occult haem: Positive
How are haemorrhoids managed?
- Dietary & lifestyle modifications
- Topical corticosteroids
- rubber band ligation or sclerotherapy or infrared photocoagulation or haemorrhoid arterial ligation or stapled haemorrhoidopexy
What are the possible complications of haemorrhoids?
- Anaemia from continuous/ excessive bleeding
- Thrombosis
- Incarceration
- Faecal incontinence
- Pelvic sepsis
- Anal stenosis
What is the prognosis of haemorrhoids?
- Prognosis following treatment is good
What are inguinal hernias?
- Protrusion of a viscus through an abnormal opening
- Above and medial to pubic tubercle
Indirect: Protrusion through internal inguinal ring passes along inguinal canal through abdominal wall, Failure of inguinal canal to close properly after passage of the testes in utero or during neonatal period
Direct: Protrudes directly through a weakness in the posterior wall of the inguinal canal, Occurs in Hesselbach’s triangle
What are the risk factors of inguinal hernias?
- Infants, prematurity, male
- Adults: male, obesity, constipation, heavy lifting, chronic cough, ascites, urinary obstruction, past abdominal surgery
What is the epidemiology of inguinal hernias?
- More common in men
- Direct: elderly
- Indirect: common in children
What are the presenting symptoms of inguinal hernias?
- Swelling in the groin (may appear with lifting and associated with sudden pain)
- Indirect hernias are more prone to cause pain (dragging sensation)
- Congenital hernias occur at birth
- In older children and adults they develop gradually and can occur with episode of heavy lifting causing rupture
What are the signs of inguinal hernias on examination?
- Appears above and medial to pubic tubercle
- Ask to cough, increase in swelling, palpable
- Reduces on lying
- Reduce hernia and occlude internal ring. IF restrained= indirect