Gastrointestinal Flashcards
What is GORD?
Reflux of gastric acid, bile and duodenal contents back into the oesophagus
Lower oesophageal sphincter relaxes independently of a swallow, allowing gastric acid to flow back into oesophagus
Risk factors of GORD?
Male
Increased abdo pressure e.g. pregnancy
Smoking
Hitatus hernia
Clinical features of GORD?
Heartburn
Acidic taste in the mouth, often relieved by antacids
No investigations usually needed - diagnosis on clinical findings
Management of GORD?
Antacids e.g gaviscon
PPI e.g. lanzoprazole
Complications of GORD?
Peptic stricture
Barrets oesophagus = squamous to columnar
What are peptic ulcers? What types are there?
A break in epithelial cells which penetrate two to the mucosa, there are 2 types
Duodenal: worse at night (more common)
Gastric: worse on eating (lesser curve)
Causes of peptic ulcers?
Helicobacter pylori
NSAID use
If helicobacter causes peptic ulcer, Dx and Tx?
Diagnosis: urea breath test, serology, stool antigen test
Treatment: PPi and 2 antibiotics - clarithromycin and metronidazole
If NSAID use causes peptic ulcer, pathophysiology, Dx and Tx?
Pathophysiology: NSAIDs inhibit cox1 which inhibits the production of prostaglandins needed for mucous production
Dx: endoscopy
Tx: Stop NSAID, treat with PPi and use PPi prophylaxis if NSAID use again 6 months after
Describe coeliac disease?
Autoimmune disease characterised by abnormal jejunal mucosa, that improves when gluten is withdrawn from diet and relapses when it is reintroduced
SUSPECT IN: diarrhoea, weight loss and anaemia
Describe the pathophysiology of coeliac disease?
- Gliadin binds to secretory IgA in the mucosal membrane
- The gliadin IgA is transcytosed into the lamina propria
- Gliadin binds to tTG and is deaminated
- Deaminated gliadin is taken up by macrophages and expressed on MHC2
- T helper cells release inflammatory cytokines and stimulate B cells
- This causes gut damage
Diagnosis of coeliac disease?
IgA-tTG blood test
Duodenal biospy
Symptoms of coeliac?
Bloating
Failure to thrive
Diarrhoea
Dermatitis Herpetiformis
Management of coeliac?
Lifelong gluten free diet and correction of any vitamin deficiencies
Complications of coeliac?
There is an increased risk of malignancy, particularly intestinal T cell lymphoma, smlall bowel and oesophageal cancer
Incidence is reduced with GF diet
What would cause a suspicion of malabsorption?
Weight loss + steatorrhoea + anaemia = malabsorption
Causes of malabsorption?
Poor intake Steatorrhoea Reduced surface area Lack of digestive enzymes Defective epithelial transport Lymphatic obstruction
Symptoms of malasorption?
Diarrhoea Weight loss Lethargy Steatorrhoea Bloating
Signs of malabsorption?
Anaemia Bleeding disorders Oedema Metabolic bone disease Neurological features such as neuropathy
Tests for malabsorption?
FBC - low calcium, low ferritin, low B12 and folate, high INR, lipids and coeliac tests
Stool microscopy
Breath hydrogen test for bacteria
Endoscopy and small bowel biospy
What is Crohns disease?
type of IBD
Transmural granulomatous inflammation affecting any part of the gut
What would you see macroscopically and microscopically with Crohns?
MACROSCOPIC: skip lesions, cobblestone appearance, thickened and narrowed
MICROSCOPICA: transmural granulomas (non-caseating) goblet cells present
Symptoms of Crohns?
Diarrhoea
Abdominal pain in RLQ
Weight loss
Lethargy
Signs of Crohns?
Mouth ulcers
Tenderness in RIF
Risk factors for Crohn’s?
Smoking
Female
Mutation on NOD2 gene of chromosome 15
Chronic stress
Investigations of Crohn’s?
Diagnostic test - colonoscopy
Stool sample to rule out infectious causes
FBC - raised ESR/CRP often low Hb due to anaemia
Management of Crohns?
Oral corticosteroids
IV hydrocortisone in severe flare ups
Add antiTNF antibodies e.fg. infliximab if not improvement
Consider adding Azathioprine or methotrexate to remain in remission if frequent exacerbations
What is ulcerative colitis?
A type of IBD
Inflammatory condition of the colon mucosa
What would you see macroscopically and microscopically with ulcerative colitis?
MACROSCOPIC: continuous inflammation, no skip lesions, ulcers, pseudopolyps
MICROSCOPIC: mucosal inflammation, no granulomata, depleted goblet cells
Symptoms of ulcerative colitis?
Pain in the LOWER LEFT quadrant
Diarrhoea with blood and mucous
Signs of ulcerative colitis?
Fever, in acute UC
Clubbing
Erythema nodusum
Investigations of ulcerative colitis?
FBC - raised ESR and CRP
Testing for pANCA
Stool sample to rule out infectious cauess q
Management of ulcerative colitis?
Sulfasalazine, add oral prednisolone if no response
Colectomy indicated in patients with severe UC not responding to treatment
What is backwash ileitus?
In ulcerative colitis when proximal to the ileocecal valve is affected
What is irritable bowel syndrome?
A group of abdominal symptoms which no organic cause can be found
Risk factors for IBS?
Stress
Female gender
Symptoms of IBS?
Abdominal pain relieved by defacating
Bloating
Alternating bowel habits
Management of IBS?
Pain/bloating - buscopan
Constipation - laxative e.g. senna
Diarrhoea - antimotility e.g. loperamide
Presentation of appendicitis?
ACUTE PAIN: 2/3 from umbilicus to RIF, McBurneys point
\+ Nausea \+ Vomiting \+ Fever \+ Pain on walking \+ Loss of appetite \+ Pyrexia
Diagnosis of appendicitis?
Classic presentation + genetic inflammatory and infection markers
USS and CT
Treatment for appendicitis?
Appendicectomy or IV antibiotics if cant undergo surgery
What would you listen for in intestinal obstruction?
Tinkling or absent bowel sounds
What can cause intestinal obstruction in the lumen of the bowel?
- Tumours
- Diaphragm disease: NSAIDS cause repeated ulceration and then fibrosis
- Gallstone ileus: cholecystic enteric fistula
What can cause intestinal obstruction in the wall of the bowel?
- Tumours
- Crohns: inflammation, fibrosis, contraction
- Diverticulitis: outpouchings in the sigmoid
- Hirschprungs: ganglion cells
What can cause intestinal obstruction from the outside of the bowel?
- Tumours: disseminated malignancy of the peritoneum
- Adhesions: fibrosis after surgery
- Volvulus: sigmoid colon has a floppy mesentery
What is a hernia?
A protrusion of an organ or tissue out of the body cavity that it normally lies
Causes of a hernia?
Muscle weakness = age, trauma
Body strain = constipation, heavy lifting, pregnancy, chronic cough
Describe an inguinal hernia?
Protrusion of abdominal cavity through the inguinal canal, can be direct or indirect
Describe a direct inguinal hernia?
Protrudes directly into the inguinal canal, MEDIAL to the inferior epigastric vessels
Behind superficial inguinal ring
Describe an indirect inguinal hernia?
Protrudes through the inguinal ring LATERAL to the inferior epigastric vessels
Through deep inguinal ring
Describe a hitatus hernia?
Part of the stomach herniates through the oesophageal hiatus of the diaphragm, two types: sliding and para-oesophageal
Describe a sliding hiatus hernia?
Oesophageal-gastric junction slides through the hiatus and lies above the diaphragm
Describe a paraoesophagheal hiatus hernia?
Uncommon - gastric fundus rolls up through hiatus alongside the oesophagus therefore gastro-oesophageal junction remains below the diaphragm
What is ascites?
This is the presence of fluid in the peritoneal cavity - cirrhosis is the most common cause
Aetiology of ascites?
In cirrhosis, peripheral arterial vasodilation, mediated by NO leads to a reduction in effective blood volume
RAAS activated promoting salt and water retention
Formation of oedema encouraged by hypalbuminaemia, mainly localised in peritoneum due to portal hypertension
Causes of ascites?
Chronic liver disease +/- portal vein thrombosis, hepatoma, TB
Neoplasia
Hepatoma
Clinical features of ascites?
Fullness in flanks with shifting dullness
Tense ascites is uncomfortable and produces respiratory distress
A pleural effusion and peripheral oedema may also be present
Investigation of ascites?
A diagnostic aspiration of 10-20ml of ascitic fluid
+ albumin levels: >11g/L transduate <11g/L exudate
+ Neutrophil count of >250cells/mm3 indicates bacterial peritonitis
+ Gram stain and culture for bacteria and acid fast bacilli
+ Cytology for malignant cells
Management of ascites?
Fluid and salt restriction
Diuretics: spironolactone +/- furosemide
Large volume paracentesis + albumin
Trans-jugular portosystemic shunt: TJPS
Risk factors for infective diarrhoea?
Foreign travel
Poor hygiene
Overcrowding
New or different foods
Causes of infective diarrhoea?
Usually viral: rotavirus, norovirus, adenovirus
Bacterial: campylobacter jejeni, e.coli, salmonella, shigella
Parasitic: Giardia lamblia, cryptosporidium
Abx associated (C.diff): clindamycin, ciprofloxacin, coamoxiclav, cephalosporins
Investigations for infective diarrhoea?
Stool culture
Consider sigmoidoscopy and bloods
Treatment for infective diarrhoea?
Rehydration
Antibiotics s
Antimotility
Maybe antiemetics
What is peritonitis?
Inflammation of the peritoneum due to entry of blood, air, bacteria or GI contents
Causes of peritonitis?
AEIOUP
Appendicitis Ectopic pregnancy Infection with TB Obstruction Peritoneal dialysis
Symptoms of peritonitis?
Dull pain that becomes sharp
Pain that is worse on coughing or moving
Systemic symptoms of being generally unwell
Investigations of peritonitis?
Clinical examination: rigid and guarding, laying still
AXR: dilated bowel, flat fluid level, gas under diaphragm
Bloods: FBC, U+E, LFT
Ascitic tap: high neutrophil count
What is alpha 1 antitrypsin deficiency?
Accumulation of alpha-1 antitrypsin in the hepatocytes and lack of it in the serum causes a lack of protease inhibition in alveoli causing damage to alveoli and subsequent emphysema
COPD symptoms, liver transplant is curative
What is wilsons?
Excess copper in the liver and CNS
kayser fletcher rings
Neurological signs as copper in brain and CNS
Mx: penicillamine to excrete copper, reduce copper intake - shellfish
What is haemochromatosis?
Excess iron everywhere
Arthralgia from pseudogout
Serum ferritin is raised
Deferrioxamine to remove excess iron and reduce iron intake in the diet
Complications: restrictive cardiomyopathy due to iron deposition
Bronze diabetes
Describe non alcoholic fatty liver disease?
Rf: metabolic syndrome, T2DM
Investigations: enhances liver fibrosis test
Mx: Lifestyle - loose weight
How does alcoholic hepatitis progress?
alcoholic hepatitis > alcoholic steatosis > cirrhosis
Describe the pathophysiology of alcoholic liver disease?
Reduced NAD+ >
Less oxidation of fat >
accumulation in the hepatocytes >
increased ROS damages the hepatocytes >
acetaldehyde damages the liver cell membranes
Investigations for alcoholic liver disease?
GGT very raised
AST, ALT mildly raised
FBC = macrocytic anaemia
Treatment for alcoholic liver disease?
Quit alcohol
Treat malnutrition from alcoholic - thiamine
What are possible co-existing diseases due to alcoholism?
- Acute/chronic pancreatitis
- Mallory weiss tear
- Alcohol withdrawal - delirium tremors
Define jaundice?
Yellow discolouration of the sclerae and skin due to raised serum bilirubin
Mechanism and causes of pre hepatic jaundice?
Increased breakdown of red blood cells leads to increased bilirubin
Haemolytic anaemia e.g. sickle cell and Gilbert’s syndrome
Urine, stools and pruritus in pre hepatic jaundice?
Urine: normal
Stools: normal
Pruritus: no
Liver test results in pre hepatic jaundice? UCB, CB. URB
UCB = normal/increased
CB = normal/increased
URB = normal/increased
Mechanism and causes of intra hepatic jaundice?
Hepatocellular swelling in parnchymal liver disease or abnormalities at the cellular level of bile excretion
Viral hepatitis, drugs, alcohol, cirrhosis, autoimmune cholangitis, pregnancy
Urine, stools and pruritus in intra hepatic jaundice?
Urine: Dark CB + URB
Stools: pale
Itching: maybe
Liver test results in intra hepatic jaundice? UCB, CB, URB?
UCB: increased
CB: increased
URB: increased
Mechanism and causes for post hepatic jaundice?
Extrahepatic cholestasis resulting in obstruction of bile flow at any point distal to the bile canaliculi
Common duct stones. carcinomas of duct/head of pancreas/ampulla, biliary stricture, sclerosing cholangitis
Urine, stools and pruritus in post hepatic jaundice?
Urine: Dark CN
Stools: Pale
Pruritus: maybe
Liver function test results in post hepatic jaundice? UCB + CB + URB
UCB: normal
CB: increased
URB: decreased
What is cirrhosis?
Cirrhosis results from the necrosis of liver cells followed by fibrosis and nodule formation
The end result is impairment of liver function and gross distortion of the liver architecture leading to portal hypertension
What is the most common cause of cirrhosis in the UK and worldwide?
UK: Alcohol
Worldwide: Hepatitis B and C
Describe micronodular cirrhosis?
Uniform small nodules up to 3mm in diameter, often caused by ongoing alcohol
Describe macronodular cirrhosis?
Nodules of variable size and normal acini may be seen within large nodules. This type is often seen following chronic viral hepatitis
Clinical features of liver cirrhosis?
+ These are secondary to portal hypertension and liver cell failure
+ Cirrhosis with complications of encephalopathy, ascites or variceal haemorrhage and the damage is sufficient that it cannot function adequately = decompensated hepatic failure
+ without this complications = compensated
Investigations in liver cirrhosis?
+ Liver biochemistry may be normal
+ FBC shows thrombocytopenia
+ Liver function: PTT and serum albumin
+ Low Na - severe disease secondary to either impaired free water clearance or excess diuretic
Management of cirrhosis?
+ Cirrhosis is irreversible and frequently progresses - management is of complications seen in decompensated
+ correct underlying cause: venesection for haemochromatosis and alcohol abstinance for alcoholic cirrhosis
+ Hepatocellular carcinoma to identify tumours at an early stage
+ Transplantation for end stage cirrhosis
What investigations would you carry out for jaundice?
- Serum liver chemistry will confirm
- Liver enzymes - very high ALT/AST suggests liver disease
- PPT may be prolonged due to vitamin K malabsorption
