Gastrointestinal Flashcards
Peptic ulcer disease presentation (+ ALARMS)
- epigastric pain, worse on eating and lying flat (if duodenal, eating may relieve)
- usually prostaglandins reduce acid release and increase mucus, so NSAIDs are key in disease
- malignancy risk ALARMS symptoms for red flags: Anaemia Loss of weight Anorexia Recent onset Melaena/haematemesis Swallowing difficulty
Ix
- carbon13 breath test for H pylori (all duodenal)
- endoscopy if concern re perforation or malignancy
- Rockhall score to risk stratify (if can send home and OP)
Mx
- lifestyle - smoking, alcohol, steroids, NSAIDs stop
- Helicobacter pylori eradication with PPI + clarithromycin + amoxicillin
- PPI (omeprazole) / H2 antagonist (ranitidine) / antacid (sodium bicarbonate) / misoprostol (mucus protection)
- surgery if perforated and bleeding
Iron deficiency anaemia
Common! 14% menstruating women.
Symptoms
- fatigue, dyspnoea, faintness, palpitations, headache, tinnitus, anorexia, angina
Signs if chronic
- koilonychia, atrophic glossitis, angular cheilitis, conjunctival pallor
RFs
- Helminth (hookworm) infection
- chronic blood loss
- iron poor diet
- malabsorption (coeliac)
- pregnancy
Ix
- blood film - microcytic, hypochromic anaemia
- low serum ferritin (stores used up)
- increased total iron binding capacity (transferrin)
Mx
- treat cause
- oral ferrous sulfate for 3mo after return to baseline
- IV iron only if oral impossible
Diverticular disease
= herniation of mucosa and submucosa through muscular wall of colon
= diverticulitis if inflammation/infection
- diverticular is asymptomatic
- diverticulitis
- – chronically - recurrent dull lower left quadrant pain, change in bowel habit, low grade fever
- – acutely - diffuse pain, rebound tenderness, abscess formation, bleeding perforation
RFs
- age >50 (and increasing)
- low dietary fibre
+ obesity, NSAID use
Ix
- FBC - leukocytosis
- CXR (rule out)
- CT abdomen
Mx
- analgesia, fibre supplementation
- oral abx if infected diverticulitis
- treat complications as necessary (surgery if perf)
- elective surgery for recurrent
Colorectal polyps
= projection from colonic mucosal surface, neoplastic or non-neoplastic
- mostly asymptomatic
- most CR cancers arise from adenoma polyps
Risk factors
- increasing age
- family history - FAP (APC mutation), HNPCC (DNA mismatch repair mutation), Peutz-Jeghers syndrome (STK11 gene mutation)
- previous hx of polyps
- acromegaly
- IBD
- obesity
Ix and Mx
- colonoscopy, flexible sigmoidoscopy
- double contrast barium enema
- narrow band imaging
- > endoscopic polypectomy
- > surveillance
- > colectomy if FAP (100% risk cancer)
Biliary colic
Stage 1 gallstone disease - when pain due to stones passing through bile ducts
- RUQ pain lasting several hours, onset 2-3 hours after fatty meal, can radiate to shoulder
RFs
- fat female fertile forty fair
- rapid weight loss
- drugs
- > cholecystitis more if - severe illness, diabetes
- > cholangitis more if - fhx sclerosing cholangitis, ERCP, strictures
Ix and Mx
- USS to visualise stones
- bloods to rule out progression
- conservative - cut fat out of diet
- analgesia
Cholecystitis
Stage 2 gallstone disease - inflammation of bile duct when stone is blocking (rarely acalculous)
- RUQ pain + fever + Murphy’s sign (catch breath when pressure on costal margin and inhale)
Ix and Mx
- USS to visualise stones
- bloods - raised CRP/WCC, deranged LFTS (more rise in ALP than ALT)
- analgesia
- IV abx
- ERCP to diagnose and extract stones in CBD
- or cholecystectomy
Ascending cholangitis
Stage 3 gallstone disease - obstruction of the CBD leads to bacterial seeding of biliary tree, so infection
- RUQ pain + fever + jaundice (Charcot’s triad)
- risk sepsis!
- if jaundice and no fever, then Mirizzi’s syndrome, gallstone impacted on neck of gallbladder obstructing CBD
Ix and Mx
- USS to visualise stones
- bloods - raised CRP/WCC, deranged LFTS (more rise in ALP than ALT), check amylase in case of pancreatitis
- ABG if ? sepsis
- analgesia
- IV abx
- ERCP to diagnose and extract stones in CBD
- or cholecystectomy
Hiatus hernia
= protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm
- heartburn (GORD), reflux, dull retrosternal pain, dysphagia/odynophagia, bowel sounds in chest, haemorrhage or obstruction in emergency
RFs
- obesity
- increasing age
- connective tissue disease
- chronic bouts of increased IA pressure (coughs / strenuous activity)
- surgical procedures around gastro oesophageal junction
Ix
- CXR
- contrast upper GI series
- OGD (oesophago-gastro-duodenoscopy)
- CT/MRI
Mx
- conservative - weight loss, dietary changes
- medical - PPIs
Paraumbilical hernia
= defect in abdominal wall fascia near umbilicus allowing protrusion of the peritoneum (containing omentum or bowel)
- pain or hesitation on heavy lifting / coughing, hernia going ‘hard’ so gut strangulation, thrill felt when ask to cough
RFs
- obesity
- increasing age
- connective tissue disease
- chronic bouts of increased IA pressure (coughs / strenuous activity)
- surgical procedures around umbilicus
Ix - clinical diagnosis alone
Mx - surgical repair laparascopic or open, with mesh
Inguinal hernia
= protrusion of abdominal or pelvic content through dilated internal inguinal ring (indirect) or through weakened inguinal floor (direct)
- groin/scrotal discomfort ± bulge, obstruction (distension/absent BS) in emergency, thrill when ask to cough
RFs
- obesity
- increasing age
- connective tissue disease
- chronic bouts of increased IA pressure (coughs / strenuous activity)
- surgical procedures around inguinal region
Ix - clinical diagnosis
Mx - surgical repair
Obesity
= BMI >30
- multiple morbidities. Abdominal obesity more indicative of outcomes than peripheral obesity.
RFs - hypothyroidism, hypercorticolism, corticosteroid therapy
Mx
- conservative - diet, exercise, psychological therapy
- medical - appetite suppressors (GLP1 agonist liraglutide), lipase inhibitors (orlistat)
- surgical - sleeve gastrectomy, Roux-en-Y gastric bypass
Gastroenteritis
= infection of GI tract, usually viral
See dehydration, + GI symptoms depending on type of enteric infection:
- type 1 - non-inflammatory watery
- type 2 - inflammatory dysentery (blood, mucus, leukocytes)
- type 3 - penetrating enteric fever (systemic infection)
Ix
- renal function (risk AKI)
- stool testing - culture for bacteria, antigen testing for viruses, microscopy for ova/parasites
Mx
- rehydration
- infection control
- rarely need medical/surgical intervention
Gastroenteritis - Salmonella
- from contaminated poultry/dairy (never human-human)
- 1-3 days incubation, resolves in <1 week
- watery brown diarrhoea, can be systemic, can lead to colitis, bacteraemia, reactive arthritis
Gastroenteritis - Shigella
- from faeco-oral (humans)
- incubation 1-7 days (shiga toxin)
- high fever, high WBC, when fever resolves then diarrhoea
- can lead to colitis
Gastroenteritis - Campylobacter
- from undercooked poultry, commonest cause of food poisoning
- incubation 2-5 days, dysentry
- can leads to Guillain Barre syndrome (post infectious peripheral neuropathy)
Gastroenteritis - E coli
- from faeco-oral (other humans)
- incubation 1-5 days, then abrupt onset D+V
- can cause haemorrhagic colitis
- HUS risk in E coli O157 type
Gastroenteritis - C difficile
- hospital acquired diarrhoea
- spore forming, must hand wash not gel
- common post abx use
- dysentry picture
- can lead to toxic megacolon and perforation, pseudomembranous colitis
Viral gastroenteritis
MOST COMMON
- D+V, sometimes mild fever
- no treatment as no sequelae, just rehydration needed
- all from faeco-oral spread
Rotavirus - outbreaks in institutions, late winter. 1 day incubation then abrupt onset, recovery in 48 hrs.
Norovirus - outbreaks in closed communities. 1 day incubation, then explosive D+V.
Enteric adenovirus - infantile diarrhoea in termperate climates. 10 day incubation, long lasting.
Astroviruses - infants and elderly, maybe co-infection, in winter.
Oesophageal reflux and GORD
= gastric contents ascend back to oesophagus or beyond
- 10-20% population
- heartburn - burning in chest after meals, worse lying or bending down
- acid regurgitation - sour/bitter taste in mouth
+ maybe dysphagia, laryngitis, enamel erosion, halitosis
RFs
- hiatus hernia
- old age
- fhx of GORD
- obesity
Ix and Mx
- PPI trial for 8 weeks to see if improve
- lifestyle - weight loss, eliminate chocolate / caffeine / alcohol / spicy / acidic food)
- OGD to see if oesophagitis (erosion, ulceration, strictures) or Barrett’s oesophagus (stratified squamous not columnar epithelium)
- if non-reponsive - oesophageal manometry, barium swallow, oesophageal capsule endoscopy
- H2 antagonist (ranitidine) can be added if PPI inadequate
Beware ALARMS symptoms, so immediate endoscopy (anaemia, weight loss, anorexia, recent progression, melaena/haematemesis, swallowing difficulty)
Oesophageal varices
= dilated submucosal veins in lower third of oesophagus
- result of portal hypertension usually, from cirrhosis
Presentation
- nil direct, usually found due to cirrhosis
- if bleed, see haematemesis ± melaena
- signs of liver disease - alcohol abuse, spider naevi, jaundice, encephalopathy, hepatitis, caput medusae, haemorrhoids
Ix
- OGD
- to look for liver disease - FBC, coagulation, LFTs, U+Es, hepatitis serology
Mx
- cirrhosis, no varices - monitor
- small varices - B blocker + monitor
- large varices - endoscopic variceal ligation/banding + beta blockers + monitor
- acute bleed - fluid resus + vasoactive drugs + emergency endoscopic variceal ligation/banding
Crohn’s disease
= chronic inflammatory disease, transmural granulomatous inflammation affecting any part of the gut mouth - anus (especially terminal ileum)
- diarrhoea, abdo pain, weight loss, fatigue, fever, malaise
- bowel ulceration, abdo tenderness/mass, perianal abscess/fistulae/skin tags, anal strictures, clubbing, skin / joint / eye problems
- may present with obstruction or perforation
RFs
- caucasian
- age 15-40 or 60-80
- fhx
- smoking
Ix
- colonoscopy + biopsies
- FBC (anaemia, leucocytosis)
- iron studies (deficiency)
- serum B12 (terminal ileum)
- serum folate
- raised CRP
- CT abdo
- MC+S of stool to exclude bacteria
- faecal calprotectin (inflammation)
Mx
- try diet change
- 1st - immunosuppression (steroids, azathioprine)
- 2nd - anti-TNF biologics (infliximab, adalimumab)
- surgery likely needed, in perforation, obstruction or toxic megacolon NOT curative
Ulcerative colitis
= relapsing remitting inflammation of colonic mucosa, in rectum or colon (never above ileocaecal valve)
- episodic or chronic diarrhoea ± blood and mucus, crampy abdo pain, bowel frequency related to severity, urgency / tenesmus, systemic symptoms in attacks
- may be no signs, maybe fever, tender distended abdo, clubbing, aphthous oral ulcers, erythema nodosum, pyoderma gangrenosum, conjunctivitis, episceleritis, iritis, arthritis, AS, PSC
- risk toxic megacolon, cancer
RFs
- fhx
- HLA B27
- gastroenteritis
- recently stopped smoking
Ix
- colonoscopy + biopsies
- FBC (anaemia, leucocytosis)
- iron studies (deficiency)
- serum B12 (terminal ileum)
- serum folate
- raised CRP
- CT abdo
- MC+S of stool to exclude bacteria
- faecal calprotectin (inflammation)
Mx
- 5 ASA eg mesalazine PR
- topical steroid foams PR
- oral prednisolone if severe (4-6 motions/day) for episode then wean
- admit for hydration if severe - IV fluids, IV steroids, colectomy if needed
- biologics / surgery if needed
Alcoholic liver disease
Stage 1 - steatosis (fatty liver)
Stage 2 - hepatitis (inflammation and necrosis)
Stage 3 - cirrhosis (fibrosis)
- RUQ pain
- hepatomegaly
(+ cirrhosis symptoms)
RFs
- male more common, but female more severe progression
- prolonged heavy alcohol consumption
- hepatitis C
Ix
- serum AST and ALT rise (more than ALP)
- serum bilirubin rise
- serum albumin lower
- hepatic USS
Mx
- alcohol withdrawal management - psychological + benzo (lorazepam)
- weight reduction, smoking cessation
- hepatitis immunisation
- sodium restriction + diuretics if oedematous
- liver transplant
Cirrhosis
- end stage of any chronic liver disease (hepatitis B, C, alcohol misuse, NAFLD)
- risk of ascites, variceal haemorrhage, jaundice, portosystemic encephalopathy, hepatorenal syndrome (AKI), hepatopulmonary syndrome (over perfusion), hepatocellular carcinoma
Compensated cirrhosis = no evidence of complications
Decompensated = when you get the signs:
- haematemesis, coffee-ground vomit and melaena (from varices); constitutional symptoms (weight loss, fever, fatigue)
- jaundice, leuconychia, palmar erythema, spider naevi, Dupuytren’s, telengiectasia, distended abdomen, hepatosplenomegaly, caput medusae, oedema
Ix
- raised AST, ALP, ALT, bilirubin
- low serum albumin
- proloned PTT and aPTT
- low platelet count
- transient elastography (USS)
- abdo MRI/CT
- upper GI endoscopy
Mx
- treat underlying liver disease, sodium restriction and diuretic
- liver transplant
Portal hypertension
When liver damage (cirrhosis / schistosomiasis) causes blood to backlog in portal venous system
- asymptomatic until complications…
- splenomegaly
- GI bleed (melaena, haematemesis, coffee ground vomit)
- ascites
- encephalopathy
- low PLT count
Ix
- proctoscopy (dilated veins)
- endoscopy (varices)
- USS (ascites, splenomegaly, nodular liver, low portal flow rate)
Mx
- lifestyle - no alcohol / drugs, low sodium diet
- B blockers
- band varices endoscopically
- surgery - transjugular intrahepatic portosystemic shunt, distal splenorenal shunt
Hepatitis
Viral, alcoholic or autoimmune
- beware fulminant in severe, with 80% mortality, usually from co-infected HBV and HBC
- fever
- RUQ pain
- jaundice, pruritis
- myalgia, arthralgia
- nausea, anorexia
- dark urine, pale stools
Ix
- deranged LFTs
- hepatitis viral antigen/antibody testing
- USS (exclude gallstones or cancer)
Mx
- acute: avoid drugs, IV fluids and check LFTs
- chronic: interferon and antiviral therapy
- stop drinking!
- autoimmune: immunosuppressants, anti-inflammatories
Viral hepatitis
Hep A
- faeces
- acute only
- can be immunised
Hep B
- blood
- percutaneous / permucosal / sex
- chronic
- can be immunised
Hep C - blood percutaneous / permucosal / sex - chronic - can't be immunised
Hep D
- blood
- percutaneous / permucosal / sex
- chronic
- can be immunised
Hep E
- faeces
- faeco-oral
- acute only
- can’t be immunised
Oesophageal cancer
- dysphagia, weight loss, retrosternal chest pain, ± hoarseness and cough if in top 1/3rd
Squamous cell carcinoma
- upper 2/3rds
- from genetics + tobacco/alcohol use
(more risk if poor diet, hot drinks, male)
Adenocarcinoma
- lower 1/3rd
- GORD -> metaplasia -> Barrett’s oesophagus -> adenocarcinoma
(more risk if hiatus hernia, poor diet, hot drinks, male)
Ix
- OGD with biopsy
- FDG-PET scan for metastasis
Mx
- endoscopic resection ± ablation
- oesophagectomy
- pre-op chemo depending on size
