Gastrointestinal Flashcards
What are the distinguishing features of Chrohns vs UC?
- Chrohs:
- Cobblestone appearance
- Rosethorn ulcers
- Discontinuous/ skip lesions
- Transmural - Obstructucted bowel
- Narrowing of intestinal lumen
- Skip lesions and strictures
- Ileocaecal valve: RIF pain
- UC:
- Rectum mainly - LIF pain
- Continuous
- Crypt abscesses
- Submucosa and mucosa mainlt
- Loss of haustra > lead pipe colon
What is UC?
- US is a relapsing and remitting IBD of the colonic mucosa.
- It may affect just the rectum
- Can extend to part of the colon (left-sided colitis) or the entire colon (pancolitis, in ~30%).
- ‘Never’ spreads proximal to the ileocaecal valve
What is the pathophysiology of UC?
- Hyperaemic/haemorrhagic colonic mucosa ± pseudo-polyps formed by inflammation.
- Punctate ulcers deep into the lamina propria—
- Continuous inflammation of mucosa
- Mucosa and submucosa - NOT transmural
What are some of the symptoms of UC?
- Episodic or chronic diarrhoea (± blood & mucus)
- Crampy abdominal discomfort
- Systemic symptoms: fever, malaise, anorexia, ↓weight.
What are some of the extra intestinal signs of UC?
- Fingers: Clubbing
- Mouth: Aphthous oral ulcers
- Skin: Erythema nodosum, Pyoderma gangrenosum
- Eyes: Conjunctivitis; episcleritis; iritis
- Bones: Large joint arthritis; sacroiliitis; ankylosing spondylitis; psc (p[link]); nutritional deficits.
What investigations are used to for diagnosing IBD?
- Blood tests: FBC (anaemia, leukocytosis, or thrombocytosis); UE (AKI due to GI losses); CRP; ESR, LFT
- Stools: stool cultures; faecal calprotectin (do not do in presence of blood); c. diff
- Simple imaging: AXR (less frequent but use for toxic megacolon): dilated loops with air-fluid level secondary to ileus; free air is consistent with perforation; in toxic megacolon, the transverse colon is dilated to ≥6 cm in diameter
- Endoscopy:
- Flexible sigmoidoscopy (safest in bloody diarrhoeah)
- Colonoscopy (proximal disease)
- Capsule endoscopy (small bowel mucosa:
- Biopsy
- Cross sectional imaging
- CT abdomen
- MRI enterography
- MRI rectum
What are some of the complications of UC?
- Toxic dilatation of colon (toxic megacolon)
- Venous thromboembolism
- Colonic cancer
- Perforation
- Infection
- Stricture/ pseudopolyps
How is IBD (maintaining remissions) treated?
- UC:
- Mesalazine 5-asa (PR or PO)
- Hydrocortisone: Topical steroid foams pr
- Chrohns:
- Azathioprine
- Biologics: Anti-tnfα infliximab and adalimumab; Anti-integrin etc.
How is acute (moderate - severe) IBD managed?
- UC
- Moderate: oral prednisolone 40mg/d for 1wk; then maintain on mesalazine
- Severe: IV Hydrocortisone 100mg/6h; iv hydration/electrolyte replacement
- If symptoms dont improve 3-5 days: cyclosporin
- Or biologics: infliximab
- Then surgery
- Chrohns:
- Same as above
- Severe: IV Hydrocortisone 100mg/6h, NBM, metranidazole
- Biologics: Anti-TNFα; Anti-integrin
- Surgery: ~20% subtotal colectomy + terminal ileostomy
What is Chrohns?
A chronic inflammatory disease characterized by transmural granulomatous inflammation affecting any part of the gut from mouth to anus
What are some of the symptoms of Chrohns?
- Diarrhoea (more mucus filled than blood unlike UC)
- Abdominal pain (RIF)
- Weight loss
- Systemic symptoms: fatigue, fever, malaise, anorexia.
What are some of the intraintestinal signs of Chrohns?
- Bowel ulceration
- Abdominal tenderness/mass
- Perianal abscess/fistulae/skin tags
- Anal strictures
What are some of the small bowel complications of Chrohn’s?
- Toxic dilatation of colon
- Abscess formation (abdominal, pelvic, or perianal)
- Fistulae: entero-enteric, colovesical (bladder), colovaginal, perianal
- Colon cancer
- Malnutrition.
What tests should be performed for Crohns?
- Bloods: FBC (anaemia), ESR, CRP (elevated), U&E, LFT, INR, ferritin B12, folate - may be low (anaemia)
- Stool: faecal calprotectin, C.diff
- Imaging: plain abdo x ray, CT
- Specialist: colonoscopy, tissue biopsy, ?OGD (if disease extensive)
What is Charcot’s triad?
RUQ, Fever, Jaundice
What is Reynald’s Pentad?
- Charcots triad
- shock (tachycardia, hypotensive, shock)
- Indicated serious infection of biliary tree
What is Mirizzi syndrome?
Obstructive jaundice from common bile duct compression by a gallstone impacted in the cystic duct, often associated with cholangitis
How is Biliary Colic treated?
- Conservative: lifestyle, weight loss, reduced fat
- Pharmacological:
- Analgesia: morphine
- Anti emetic: metacloperamide?
- Surgery: elective lap cholecystectomy in 6 wks of presentation
What is Calot’s triangle?
- Calot’s triangle (cystohepatic triangle) is a small anatomical space in the abdomen.
- It is located at the porta hepatis of the liver – where the hepatic ducts and neurovascular structures enter/exit the liver.
- The borders are as follows:
- Medial – common hepatic duct.
- Inferior – cystic duct.
- Superior – inferior surface of the liver.
What is the surgical relevance of Calots triangle?
- Clinical importance during laparoscopic cholecystectomy
- Triangle is dissected by surgeon, and its contents and borders identified.
- Permits safe ligation and division of the cystic duct and cystic artery.
- Right hepatic artery is important – this must be identified by the surgeon prior to ligation of the cystic artery.
- If Calot’s triangle cannot be found ( e.g. inflammation), the surgeon may perform a subtotal cholecystectomy, or open surgery.
What is Coeliac disese?
- Immunological response to the Gladin fraction of gluten
- Immune activation in the small intestine leads to villous atrophy, hypertrophy of the intestinal crypts, and increased numbers of lymphocytes in the epithelium and lamina propria
- Suspect this if diarrhoea + weight loss or anaemia (esp. if iron or b12 ↓)
What is the prevalence of Coeliac?
- 1 in 100–300 (commoner if Irish).
- Peaks in childhood and 50–60yrs ♀:♂ >1:1.
- Risk in 1st-degree relatives
What are the symptoms of Coeliacs?
- Stinking stools/steatorrhoea
- Diarrhoea
- Abdominal pain
- Bloating; nausea + vomiting
- Mouth: Aphthous ulcers and angular stomatitis
- ↓weight
- Fatigue
- Weakness
- Bones: Osteomalacia
What are some of the complications of Coeliac?
- Anaemia
- Dermatitis herpetiformis
- Osteopenia/osteoporosis
- GI t-cell lymphoma
- ↓weight
- ↑risk of malignancy (lymphoma, gastric, oesophageal, colorectal)
- Neuropathies
How is Coeliac diagnosed?
- Bloods: General:↓Hb↓b12, ↓ferritin, consider blood smear
-
Antibodies:
- IgA-tTG - not a diagnostic test in adult patients - above normal
- Endomysial antibody
-
Imaging:
-
Endoscopy and duodenal biopsy while on a gluten-containing diet:
- Subtotal villous atrophy
- ↑Intra-epithelial wbcs
- Crypt hyperplasia
-
Endoscopy and duodenal biopsy while on a gluten-containing diet:
- Others: HLA, skin biopsy (dermatitis herpetiformis), gluten challenge
How is Coeliac disease treated ?
- Gluten free diet
- Bisphosphonates for osteoporosis
- Pneumococcal vaccine + booster every 5 years + influenza on a case by case basis
What is dysphagia?
Dysphagia is difficulty in swallowing and should prompt urgent investigation to exclude malignancy
What are some of the causes of dysphagia?
Oral, pharyngeal, or oesophageal? Mechanical or motility related?
What are the key history questions to ask re dysphagia?
- Was there difficulty swallowing solids + liquids from the start?
- Yes: motility disorder (eg achalasia, cns, or pharyngeal causes).
- No: Solids then liquids: stricture (benign or malignant).
- Is it difficult to initiate a swallowing movement?
- Yes: bulbar palsy, especially if patient coughs on swallowing
- Is swallowing painful (odynophagia)?
- Yes: ulceration (malignancy, oesophagitis, viral infection or Candida in immunocompromised, or poor steroid inhaler technique) / spasm.
- Is the dysphagia intermittent or is it constant and getting worse?
- Intermittent: oesophageal spasm.
- Constant and worsening: suspect malignant stricture
- Does the neck bulge or gurgle on drinking?
- Yes: Suspect a pharyngeal pouch
What are some of the signs of dysphagia?
- Is the patient cachectic or anaemic?
- Examine the mouth
- Feel for left Virchow’s node—intra-abdominal malignancy)
- Signs of systemic disease eg systemic sclerosis
What are some of the tests for dysphagia?
Bloods: FBC (anaemia); U+E (dehydration).
- OGD ± biopsy
- Barium swallow - pharyngeal pouch
- Oesophageal manometry - dysmotility.
(Video fluoroscopy may help identify neurogenic causes)
What are the symptoms and investigations for diffuse oesophageal spasm?
- Sx: intermittent dysphagia ± chest pain.
- Contrast swallow/manometry: abnormal contractions
What is Achalasia?
Achalasia is an oesophageal motor disorder of unknown aetiology, characterised by oesophageal aperistalsis and insufficient lower oesophageal sphincter (LOS) relaxation in response to swallowing
What are the sx of achalasia?
- Dysphagia
- Regurgitation
- ↓Weight
- Retrosternal pressure and pain
How is achalasia investigated and what is found?
- Upper GI endoscopy: mucosa obscured by retained saliva with frothy appearance; in advanced cases oesophagus may be dilated and tortuous and contain food debris (sigmoid oesophagus)
- Manometry: incomplete relaxation of LOS with wet swallows and oesophageal aperistalsis; typically high resting lower oesophageal pressure
-
Barium swallow: bird beak-like narrowing at the gastro-oesophageal junction
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When should dyspepsia be referred?
- Dysphagia OR
- >55 yo + persistent symptoms OR
- ALARM signs
What are the functions of the liver?
What criteria is used for determining liver transplantation
King College Criteria for Liver Transplantatio
What is liver Cirrhosis?
- Cirrhosis is the pathological end-stage of any chronic liver disease and most commonly results from chronic hepatitis B and C, alcohol-related liver disease, and non-alcoholic fatty liver disease
- Irreversible liver damage.
- Histologically: fibrosis and conversion of normal liver architecture to structurally abnormal nodules known as regenerative nodules
