Gastrointestinal Flashcards
Deficiency of vitamin:
1) B1
2) B12 and folate
3) K
4) D
5) C
1) Thiamine - Wernicke’s encephalopathy
2) Macrocytic anaemia
3) Bleeding disorder
4) Osteomalacia and rickets
5) Easy bruising and bleeding (scurvy).
Causes of malabsorption
Poor dietary intake
Defective digestion or lack of digestive enzymes (e.g. pancreatic insufficiency)
Poor absorption or transport ability (e.g. coeliac)
Blood group association with gastric and duodenal ulcers
Gastric = A Duodenal = O
2 barriers which prevent gastro-oesophageal reflux
Lower oesophageal sphincter (LOS) Crural diaphragm (external sphincter)
Classification criteria for GORD
Montreal
Risk factors for GORD
Obesity
Hiatus hernia
Agents which relax LOS e.g. caffiene, nitrate drugs, CCB, fat.
Smoking
Presentation of GORD
Heartburn - retrosternal pain Regurgitation - acid taste in mouth and sensation of content coming up to pharynx Belching Dysphagia Chronic cough
O/E:
Enamel erosion on teeth
Managing GORD
If no red flag symptoms (GI bleed) - trial PPI with no investigations.
1) OTC e.g. Gavison and other alginates / antacids and LIFESTYLE ADVICE.
2) 4-8wks of PPI e.g. Omeprazole, Lansoprazole. If symptoms persist after trial continue pt on PPI at the lowest therapeutic dose.
3) Add an H+ 2 Receptor Antagonist e.g. Ranitidine (usually taken before bed).
4) Surgical intervention - laparoscopic fundoplication
Investigating GORD in secondary care
Endoscopy - oesophagitis, erosions and ulcerations. Ambulatory pH monitoring. Oesophageal manometry (measure LOS pressure)
Complications of GORD
Barrett’s oesphagus
Oesophageal adenocarcinoma
Oesophageal stricture
Barrett’s oesophagus
Squamous epithelium replaced by columnar epithelium.
Ix - endoscopy and biopsy.
Rx - surveillance and regular biopsies if low-grade. High grade = ablation, resection
Risk factors for oesophageal cancer
Male sex GORD/Barrett's oesophagus changes (squamous to columnar) Obesity Achalasia Hiatus hernia Hx FHx
HPV, achalasia, smoking and alcohol more risk for squamous cell carcinomas than adenocarcinomas.
Histology of oesophageal cancer
Majority are adenocarcinoma, minority are squamous cell carcinomas
S+S of oesophageal cancer
GORD symptoms - heartburn, regurgitation. Dysphagia Dyspepsia Pain on swallowing Weight loss Haematemesis
More advanced disease: hoarse voice and cough.
Investigating suspected oesophageal cancer
Urgent Upper GI endoscopy and biopsy (2 week wait).
Managing oesophageal cancer
Endoscopic resection
Oesophagectomy
Chemotherapy before and after surgery
Mallory-Weiss tear
Non-variceal upper GI bleed.
RFx - recurrent vomiting/retching, hiatus hernia.
CFx - Haematemesis, melena, dizzy.
Ix - FBC, U+E, group + save, clotting profile, LFTs, CXR.
Mx - Resusitation (A-E, warm fluid, blood products, oxygen), endoscopy when stable.
Red flag symptoms for referral for endoscopy
If over 55, dypepsia and (ALARM) Anaemia Loss of weight Anorexia Recent onset Melena
2 types of peptic ulcers
Gastric ulcers
Duodenal ulcers
Which peptic ulcer has greater association with H.pylori?
Duodenal
Name 4 drugs which can cause peptic ulcer disease
NSAIDS Aspirin Crack cocaine Alcohol Tobacco/smoking
Zollinger-Ellison syndrome
Hypersecretion of gastrin due to gastric NET.
Multiple peptic ulcers, diarrhoea + steatorrhoea, weight loss, and hypercalcaemia.
S+S of peptic ulcer disease (1 difference in presentation between DU and GU)
Upper abdominal burning pain Dyspepsia Nausea Weight loss/anorexia Symptoms are related in meal times
GU pain occurs on eating
DU pain occurs post-prandial (1-3hrs) and can be relieved by eating.
Investigating peptic ulcer disease
H.pylori - carbon-13 urea breath test or stool antigen test.
FBC
Upper GI endoscopy (not routine!)
Drugs taken before testing for H.pylori
No PPI for 2 weeks.
No ABx for 4 weeks.
H.pylori eradication treatment
1 x PPI + 2x ABx 7 days.
e.g. Lansoprazole + amoxicillin + clarithromycin
Management of peptic ulcer disease
Review drugs
If H.pylori -ve: PPI
If H.pylori +ve: eradication therapy
If assciated with NSAIDs: 2 months PPI.
Management of an acute GI ulcer bleed
A-E assessment and resusication. A - airway manoeuves B - Oxygen C - 2x large bore cannulas, warm fluids, take bloods (esp clotting profile and crossmatch), blood products D - assess GCS
Activate major haemorrhage protocol.
Consider platelet transfusion and FFP.
Causes of an acute GI bleed
Mallory-Weiss tear Peptic ulcer Stricture Malignancy Oesophageal varices
Oesophageal varices
Ax - Portal HTN and liver cirrhosis. Local dilation of veins.
CFx - UPPER GI HAEMORRHAGE, features of liver disease (ascites).
Ix - endoscopy.
Mx - A-E and resuscitation. Drug - Terlipressin.
Risk assessment of patients with upper GI bleed
Glasgow-Blatchford bleeding score at first assessment.
Rockall score after endoscopy.
Some causes of oesophageal motility dysfunction
Achalasia
Systemic sclerosis
Diffuse oesophageal spasms
How to test for H.pylori
Carbon-13 urea breath test or a stool antigen test. After eradication therapy NICE recommends using Carbon-13 urea breath test as test of cure rather than stool antigen.
Causes and types of gastritis
Acute and chronic.
Erosive and non-erosive.
Acute, non-erosive = H.pylori.
Acute, erosive = long-term NSAID use.
Atrophic gastritis -
Autoimmune gastritis - antiparietal cell antibodies.
2 types of inflammatory bowel disease
Crohn’s disease
Ulcerative colitis
Pathophyisology and histology of Crohn’s disease
Transmural, granulomatous inflammation which can affect any part of the GI tract from mouth to perianal area and has a relapsing-remitting course.
Submucosal oedema. Cobblestone appearance Longitudinal, linear ulcers Apthlous ulcers Discontinuous epithelium involvement = skip lesions.
Most common sites for Crohn’s disease
Terminal ileum and proximal colon.
Genes associated with Crohn’s disease
CARD15
NOD2
S+S of Crohn’s disease
Abdominal pain
Prolonged diarrhoea including nocturnal diarrhoea and urgency.
Weight loss.
Fever
Fatigue
Perianal lesions e.g. fistulas, skin tags, abcess.
EXTRA-INTESTINAL: Arthritis Erythema nodosum Aphthous mouth ulcers Uveitis
Investigations for Crohn’s disease
Lab tests: FBC - anaemia CRP and ESR - raised U+E - dehydration from chronic diarrhoea LFT + albumin B12, folate, vitamin D, ferritin - signs of malabsorption. Faecal calprotectin - raised. Coeliac test (IgA-tTG and EMA), stool sample - exclude as differential.
Imaging/Secondary care:
Colonscopy + biopsy for histology.
CT to stage.
Abdo USS - bowel wall thickening.
What not to prescribe in suspected IDB
Anti-diarrhoeal drugs - may precipitate toxic megacolon in UC patients.
Management of Crohn’s disease
Induce remission and maintenance.
Induce = steroids e.g. Prednisolone
If more distal disease or steriods are CI use Budesonide.
Maintenance = Azothioprine, Mercaptopurine or Methotrexate
Biological therapy = Infliximab (anti-TNF)
Surgery = for distal ileum patients only.
Pathophysiology and histology of Ulcerative Colitis
Diffuse and continuous, superficial inflammation of rectum and extending proximal up the colon.
Continuous inflammation of the mucosa only (no deep inflammation).
Crypt abcesses
When can ulcerative colitis not be confined to the rectum and colon?
‘Backwash ilitis’ - backwash of caecal contents into distal ileum can cause features of UC in that area.
S+S of UC
Blood in stool
Diarrhoea urgency, frequency, incontinence, nocturnal.
Abdo pain (left lower quad)
Pre-defaecation pain, relieved on passing stool.
Fever, malaise, fatigue, weight loss.
Uveitis, arthritis, aphthous mouth ulcers.
Investigating UC
Lab tests: FBC - anaemia CRP and ESR - raised U+E - dehydration from chronic diarrhoea LFT + albumin B12, folate, vitamin D, ferritin - signs of malabsorption. Faecal calprotectin - raised. Coeliac test, stool sample - exclude as differential.
Imaging/Secondary care:
Colonscopy + biopsy for histology.
CT to stage.
Abdo USS - bowel wall thickening.
Management of UC
Induce remission and maintenance.
Induce = topical aminosalicylate (suppository/enemaformula) can give oral at patient request. +/- steroids if severe.
Maintenance = low dose aminosalicylate
2nd line = methotrexate/azothioprine.
3rd line = biologics e.g. antiTNF infliximab
Examples of aminosalicylates
Mesalazine
Sulfasalazine
Causes of small bowel obstruction
Adhesions from surgery Inguinal hernias Intestinal malignancy Appendicitis Crohn's disease inflammation and strictures.
More common causes of small bowel obstruction in children
Appendicitis
Intussusception
Volvulus
Intestinal atresia
S+S of small bowel obstruction
Colic pain
Vomiting
Absolute connstipation -
no stool or flatus. overflow diarrhoea
O/E
Distended bowel
Tinkling bowel sounds (accuracy is in question)
Palpable mass (tumour, stools)
Investigations for small bowel obstruction
ABX - Dilated loops of small bowel (normal diameter = 3cm, located central on ABX).
Coil-spring appearance of valvulae conniventes. Air-fluid levels.
CT abdo.
FBC, urea, U+Es - indicate severity/necrosis, volume depletion.
Management of small bowel obstruction
NG tube and IV fluids = decompression.
Analgesia
Anti-emetic
Surgery - correct underlying cause.
Causes of large bowel obstruction
Colorectal malignancy
Colonic volvulus
Benign stricture e.g. diverticular.
S+S of large bowel obstruction
Colic abdo pain Faeculant vomiting Hx of bowel habit changes O/E More marked abdo distension Tympanic on percussion (gas) Empty rectum or very hard faeces on DRE
Investigations for large bowel obstruction
AXR - Dilated loops of large bowel (>6cm for colon or >9cm for caecum). Air fluid levels.
Abdo CT
FBC, U+E, creatinine, group + save.
Management of large bowel obstruction
NG decompression
IV fluids
Treat cause - stenting.