Gastrointestinal Flashcards
WHAT IS HELIOCBACTER PYLORI?
Gram negative, curved motile rod, microaerophilic.
What is heliocbacter pylori’s key biochemical feature?
Urease positivity-used in testing.
How is heliocbacter pylori spread?
Oro-fecal or oral-oral.
What is the pathogenesis of heliocbacter pylori?
Adapted to living in gastric mucus Colonises over gastric but not intestinal epithelium.
Induces inflammation
Stimulates increased gastrin
What are some disease associations with heliocbacter pylori?
Ulcers.
In the absence of NSAIDS or Zollinger-Ellison syndrome.
Gastric cancer.
Gastric lymphoma.
Oesophageal disease.
Barrett’s oesophagus.
Others.
What are the usual symptoms of heliocbacter pylori?
Acquisition usually asymptomatic but may cause nausea and epigastric pain.
Chronic diffuse superficial gastritis
Followed by a period of achlorrydria.
What investigations can you do for HP?
Serology
Stool antigen
Urea breath test
Endoscopy with urease test
Histology ± culture
What is the treatment for H.Pylori?
Omeprazole
Amoxicillin
Clarithromycin OR metronidazole
IF penicillin allergic then metronidazole for amox
WHAT IS PERITONITIS?
Inflammation of peritoneum.
What are the causes of peritonitis?
Perforation of GI tract i.e. trauma
What are the symptoms of peritonitis?
Pain
Rebound tenderness
Guarding reflex
Fever
Increase in WBC
Shoulder tip pain in sepsis
What are the investigations of peritonitis?
Erect CXR - air under diaphragm.
USS/CT
How can you treat peritonitis?
IV fluids
Antibitoics
Metronidazole for anaerobes and cephalexin for aerobes
Electrolytes
Surgery laparotomy
WHAT IS THE DEFINITION OF INTESTINAL OBSTRUCTION?
Blockage to the lumen of gut Intestinal
What are some causes of bowel obstruction?
Adhesions
Hernias
Tumour
Crohn’s
Volvulus
Gallstone Ileus
How is bowel obstruction classified?
According to site - e.g. small vs large intestine
Extent of luminal obstruction
Mechanical / True ( intraluminal / extraluminal)
Paralytic (Pseudo obstruction)
Simple Closed loop Strangulation Intussusception
WHAT ARE THE CAUSES OF SMALL BOWEL OBSTRUCTION?
tumours
intussusception
gallstone ileus
impacted faeces
meconium
bezoars
What are the symptoms of small bowel obstruction?
abdominal pain, colicky, i.e. returns to normal periodically. Felt in mid-abdomen. Need to know site, radiation, duration and relieving factors.
no flatus; constipation is present
distention, early in the course of the illness if the obstruction is high
vomiting, again earlier in the course if the obstruction is relatively proximal in the bowel
What are the investigations for small bowel obstruction?
blood urea and electrolytes
white cell count
- *radiology:**
supine: obstructive picture of dilated small bowel
sitting: multiple air/fluid levels in obstruction
to distguish the site:
What is the treatment for small bowel obstruction?
Drip and suck
A nasogastric tube is placed in small bowel obstruction or if the patient is vomiting
Nil by mouth and given intravenous fluids
WHAT ARE THE CAUSES OF LARGE BOWEL OBSTRUCTION?
The principal cause of large bowel obstruction is carcinoma, which together with diverticulitis accounts for 90% of cases.
Colonic volvulus is a rare cause of obstruction
What are the symptoms of large bowel obstruction?
Present quite late with:
- Faecel vomiting
- Weight loss
- Appetite loss.
- Colicky abdominal pain.
Signs include:
- Succussion splash
- Dehydration
- Mass due to the tumour, either in the epigastrium or in the lymph nodes
- Hepatomegaly
What is the treatment for large bowel obstruction?
Drip and suck
A nasogastric tube is placed in small bowel obstruction or if the patient is vomiting
Nil by mouth and given intravenous fluids
What are the indications for immediate surgery of a bowel obstruction?
- Crescendo pain
- Localised peritonism, implying perforation or ischaemia
- Complete colonic obstruction with competent ileocaecal valve and caecum dilated to greater than 8cm
- “Closed loop” seen radiologically
- Obstruction occurring as a result of hernial incarceration
WHAT IS A VOLVULUS?
A twist / rotation of segment of bowel
What are the types of volvulus?
Sigmoid (most common)
Cecal
Midgut
What is the cause of a sigmoid volvulus?
- Pregnancy
- Middle aged and eldery constipation
- Adhesions
What can cause a cecal volvulus and what can cause a midgut volvulus?
Same as sigmoid, mesenteric join loose
Abnormal fetal development for midgut
What can happen to a volvulus?
Can twist and stop blood flow to that part
Can release bacteria into body
What are the symptoms of a volvulus?
Colicky abdominal pain
Vomiting (earlier with small bowel)
Constipation (earlier with large bowel).
Distension and tinkling bowel sounds.
What are the tests for a volvulus?
Abdo X-ray
Barium enema
Bird’s beak
What is the treatment for a volvulus?
Sigmoidoscopy
Endoscopy
Surgery
What is a Hartmann’s procedure?
Hartmann’s procedure is performed when a carcinoma of the rectum is found to be unresectable either due to local invasion or because the patient is unfit for a major resection
What is Paul-Mikulicz procedure?
A Paul-Mikulicz procedure is used to treat obstructed colonic carcinoma, volvulus or localized diverticular disease
WHAT IS A HERNIA?
Protrusion of organ or tissue out of the body cavity in which it normally lies
What are some causes of hernias?
- Age
- Chronic cough
- Trauma damage
- Failure of abdo wall to close properly in womb
- Constipation
- Heavy weight lifting
- Pregnancy
What are the different meanings for these?
Irreducible
Reduction
Incarceration
Obstructed
Strangulated
Irreducible= hernia cannot be pushed back into the right place
Reduction = pushing tissue/organ back into place
Incarceration = contents of hernialsac are stuck inside by adhesions
Obstructed = bowel contents cannot pass through them
Strangulated = if ischaemic occurs
What are the different types of hernia?
Hiatal
Inguinal
Femoral
Incisional (after surgery)
Umbilical (<6m, normally corrects itself)
What is the most common hernia and why?
Inguinal hernia
70%
More common in MEN because after testicles descend through canal after birth the canal doesn’t always close properly so is weakened
What is a direct inguinal hernia?
Protrudes DIRECTLY into inguinal canal
Medial to inferior epigastric vessels
What is an indirect inguinal hernia?
Protrudes through internal inguinal ring
Lateral to inferior epigastric vessels
What is a hiatus hernia?
Part of stomach herniates through oesophageal hiatus of diaphragm
How does a hiatal hernia occur?
Sliding
GO junction slides through hiatus and lies above diaphragm
Para-oesophageal hernia
Gastric fundus rolls up through hiatus alongside oesophagus, GO junction remains below diaphragm
What are the symptoms of a sliding hernia?
None unless gastric oesophageal reflux occurs
What are the symptoms of a para-oesophageal hernia?
Serious risk of complications (gastric volvulus, bleeding)
What are the investigations for a hernia?
Made clinically with history and examination
What are the treatments for hernias?
May require surgical repair
Reducing the hernia can prevent strangulation from occurring
WHAT IS DIVERTICULOSIS?
https://www.youtube.com/watch?v=TL9_WKuNfu0
Little pouches at the side of the gut
What is diverticular caused by?
High pressure within the lumen pushes part of the intestine out
Classically, diverticular disease is believed to occur as a result of deficiency of dietary fibre.
Where do most diverticulums occur?
Sigmoid colon
What causes incresed risk of diverticulosis?
Low fiber foods leads to constipation
Fatty foods and red meat
Marfan’s syndrome
Ehlers-danlos syndrome
WHAT IS DIVERTICULAR DISEAESE?
Diverticula + complications e.g. infection, hemorrhage, infection
What is the symptoms of diverticular disease
Usually no symptoms
Sometimes stomach pain and bleeding
What can happen if a outpouching ruptures?
Can form a fistula
Connection between it and another organ
Most commonly the bladder
What is the tests for diverticular disease?
Diagnosis of exclusion
Contrast CT Abdo Pelvis
What are the treatment options for diverticular disease?
-
Diet
More fibre - Smooth muscle relaxants
WHAT IS DIVERTICULITIS?
Inflammation of diverticula
How can a diverticulosis become a diverticulitis?
Inflammation
Through high pressures erroding the wall
OR
Lodged fecalith
What are the symptoms of acute diverticulitis?
LIF pain
Fever
Abdoguarding
Tachycardia (similar to appendicitis but on the left)
What are the symptoms of chronic diverticulitis?
Chronic diverticulitis exactly mimics the local clinical features of carcinoma of the colon:
- Mucus/bloody diarrhoea alternating with constipation
- Which progresses to large bowel obstruction with
- Vomiting
- Distension
- Colicky abdominal pain
- Constipation
What are the tests for diverticulitis?
- Diagnostic - Contast CT Abdo Pelvis
- Bloods (ESR, CRP)
- USS
- Sigmoidoscopy
What is the treatment of diverticulitis?
Increasing dietary fibre and physical exercise may improve symptoms
Generally treated with bed rest
IV fluids, analgesics
IV antibiotics - for example cefuroxime and metronidazole - and antispasmodics
Surgical removal - not usually done
WHAT ARE THE RISK FACTORS FOR OESOPHAGUS CANCER?
Two main risk factors
gastro-oesophageal reflux
obesity
What is the most common cancer found in oesophageal cancer?
Squamous cell carcinoma (SCC) upper 2/3rds
Adenocarcinoma lower 1/3rd
What is the staging for oesophageal cancer?
TNM
T = primary tumour
N = lymph nodes
M = metastisis
What are the symptoms of oesophageal cancer?
Dysphagia
Weight loss
Anorexia
GI Bleeding
What are the investigations for oesophageal cancer?
Endoscopy
in patients with ALARM symptoms
Aged 55 or older with unexplained dyspepsia
Barium oesphagography
CT
Staging
What is the treatment for oesophageal cancer?
- Surgery
- Chemotherapy
- Radiotherapy
WHAT ARE THE RISK FACTORS FOR STOMACH CANCER?
H.pylori
Age
Sex
Ethnic origin - Black African or Caribbean
What is the most common cancer type for stomach cancer?
Adenocarcinomas
What are the clinical features of stomach cancer?
Dyspepsia
Later features include:
Anorexia and weight loss
Palpable mass
Troisier’s sign - palpable left supraclavicular lymph node; this is called Virchow’s node.
What are the investigations for stomach cancer?
Endoscopy and biopsy
Chest X-ray, liver enzymes and liver ultrasound
Anaemia
What is the staging of stomach cancer?
TNM
T = primary tumour
N = lymph nodes
M = metastisis
What are the differentials for stomach cancer?
carcinoma of the caecum
carcinoma of the pancreas
pernicious anaemia
uraemia
What is the treatment for stomach cancer?
Surgery ONLY
WHAT IS THE MOST COMMON CANCER OF THE SMALL INTESTINE?
Adenocarcinoma
What are the clinical features of small intestine cancer?
Occult bleeding
Obstruction
Epigastric pain
Vomiting
Jaundice
What are the investigations for small intestine caner?
Endoscopy + biopsy
Barium studies