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Year 3 Pathologies > Gastrointestinal and Liver > Flashcards

Gastrointestinal and Liver Flashcards

1
Q

What is an Anal Fissure?

A

Split in the skin of distal anal canal

Acute < 6 weeks
Chronic > 6 weeks

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2
Q

RF of Anal Fissures

A
  • constipation
  • IBD
  • STIs e.g. HIV, syphilis, herpes
  • pregnancy
  • opiates
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3
Q

H&E of Anal Fissures

A

- Painful, bright red, rectal bleeding

  • Tearing sensation on passing stool
  • Fresh blood on stool of paper
  • Anal spasm
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4
Q

Investigations for Anal Fissures

A
  • Clinical Diagnosis
  • Anal manometry (in patients with resistant fissures)
  • Low resting pressure
  • Anal ultrasounds (in patients with suspected anal sphincter deficits)
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5
Q

Acute Management of Anal Fissures

A
  • Soften stool
    • High fibre diet with high fluid intake
    • Bulk-forming laxative
    • Petroleum jelly lubricant
    • Topical analgesics
    • Analgesia
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6
Q

Chronic Management of Anal Fissures

A

Same as Acute +

  • Topical GTN
  • If not effective after 8 weeks, refer for sphincterotomy or botulinum toxin
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7
Q

What are haemorrhoids?

A

Haemorrhoids, also known as piles, are swollen and inflamed veins in the anus and rectum that can cause discomfort, pain, itching, and bleeding

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8
Q

H&E of Haemorrhoids

A
  • Painless bright PR bleeding is most common
  • Anal itching or irritation, tenesmus with prolapsing internal haemorrhoids
  • May be pain, itching, bleeding or lump in anal area
  • DRE may reveal swollen, tender or prolapsed haemorrhoids
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9
Q

Investigations for Haemorrhoids

A
  • Proctoscopy to confirm diagnosis and exclude sinister pathology
  • If there is concern, a colonoscopy may be indicated
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10
Q

Management for Haemorrhoids

A
  • Conservative measures include increasing dietary fibre, taking sitz baths, and using topical creams or ointments to relieve symptoms.
  • If symptoms persist or are severe, non-surgical interventions such as rubber band ligation, injection sclerotherapy, or infrared coagulation may be considered.
    • Phenol injections are usually only used for minor internal haemorrhoids
  • Surgery may be indicated for patients with large or persistent haemorrhoids that do not respond to conservative or non-surgical management. Surgical options include haemorrhoidectomy or stapled haemorrhoidopexy.
    • Prolapsed haemorroids are best managed surgically if symptomatic
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11
Q

Thrombosed Haemorrhoids

A
  • Typically present with significant pain and tender lump
  • Exam reveals purplish, oedematous, tender subcutaneous perianal mass
  • If patient present within 72 hours, refer for excision
  • Otherwise patients can usually be managed with stool softener, ice packs and analgesia
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12
Q

What is a Hiatus Hernia?

A
  • Prolapse of upper stomach through diaphragmatic oesophageal hiatus
  • Sliding - 80% - hernia moves in and out of chest, acid reflux as LOS becomes less competent
  • Rolling - 20% - hernia goes through hole in diaphragm next to oesophagus
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13
Q

RF for Hiatus Hernia

A

Things that increase intra-abdominal pressure, e.g. obesity, weightlifting, pregnancy

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14
Q

H&E for Hiatus Hernia

A
  • Usually asymptomatic
  • GORD symptoms that are worse when lying flat
  • Palpitations or hiccups indicate pericardial irritation
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15
Q

Investigations for Hiatus Hernia

A
  • Chest X-ray
    • Retrocardiac bubble
  • Barium swallow
  • Consider OGD, CT/MRI, and high-resolution oesophageal manometry and pH monitoring
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16
Q

Management of Hiatus Hernia

A
  • Weight loss
  • PPI
  • Surgery if symptomatic rolling hernia
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17
Q

What is GORD?

A

Gastro-oesophageal Reflux Disease

  • Inflammation of oesophagus caused by gastric acid +/ bile
  • Disruption of mechanisms that prevent reflux
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18
Q

H&E for GORD

A
  • Heartburn : especially after consumption of food and drink
  • Acid regurgitation
  • Waterbrash (inc. saliva)
  • Pain relief by antacids
  • Aspiration : nocturnal cough + wheeze
  • Dysphagia

PE usually normal, might be epigastric tenderness + wheeze

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19
Q

Investigations for GORD

A
  • Resolution of symptoms after 8-week PPI trial
  • OGD (if > 55, longer than a month, dysphagia, relapse or weight-loss)
  • Oesophageal manometry if OGD inconclusive
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20
Q

Lifestyle management of GORD

A

Lifestyle :
- weight-loss
- elevate head
- stop smoking
- reduce fat intake
- avoid large meals in evening

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21
Q

Medical management of GORD

A

PPI e.g. omeprazole for 4-8 weeks

  • Low dose if responsive to manage symptoms if they recur
  • If no response but endoscopically positive, double dose
  • If no response but endoscopically negative, H2RA or pro kinetic for 1 month
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22
Q

Surgical management of GORD

A

Increase LOS pressure

Nissen fundoplication

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23
Q

Complications of GORD

A
  • Oesophagitis
  • Ulcers
  • Anaemia
  • Benign strictures
  • Barrett’s
  • Oesophageal carcinoma
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24
Q

What is Irritable Bowel Syndrome (IBS) and the types?

A

Chronic condition characterised by recurrent abdominal pain associated with bowel dysfunction.

  • IBS-D : with diarrhoea
  • IBS-C : with constipation
  • IBS-M : mixed type
25
Q

What are the RF for IBS?

A

History of abuse

PTSD

Bacterial Gastroenteritis

FHx

F > M

26
Q

H&E for IBS

A
  • Cramping in lower / mid abdomen
  • Alteration of stool consistency
  • Defecation relieves abdominal pain / discomfort
  • NORMAL ON EXAMINATION
27
Q

Diagnosis for IBS

A

+ve diagnosis if patient has these symptoms for 6+ months :
A - Abdominal pain +/
B - Bloating +/
C - Change in bowel habit

+ve diagnosis if patient has abdominal pain relieved by defecation or altered bowel frequency stool form + 2 of the 4 :
- altered stool passage (straining, urgency, incomplete
- bloating, distension, tension or hardness
- symptoms worse when eating
- passage of mucus

Also lethargy, N, backache and bladder symptoms may support diagnosis

28
Q

Investigations for IBS

A

Diagnosis of exclusion :

  • Exclude coeliac with anti-tTG
  • Exclude IBD with calprotectin, lactoferrin, CRP, colonoscopy
  • Exclude colorectal cancer with FBC, FOB and FIT test
29
Q

Lifestyle Management for IBS

A

Increase fibre intake

Avoid caffeine, lactose, fructose

Stress management

Avoid sorbitol if diarrhoea

30
Q

Medical management for IBS

A

First line according to predominant symptoms:

  • pain : antispasmodic agents
  • constipation : laxatives but avoid lactulose (for 12+ months consider linaclotide)
  • diarrhoea : loperamide

Second line :

  • low dose TCAs

Other :

  • psychological intervention (CBT, hypno/psycho therapy)
31
Q

What is Crohn’s disease?

A

Crohn’s disease (CD) is a chronic inflammatory bowel disease

  • Characterised by transmural inflammation and skip lesions
  • Can affect any part of the gastrointestinal (GI) tract from the mouth to the anus
  • The aetiology remains unknown, but it is believed to involve a complex interplay of genetic predisposition, environmental factors, and dysregulated immune responses
  • Clinical presentation varies but may include abdominal pain, diarrhoea, weight loss, and fatigue, with potential extraintestinal manifestations such as arthritis, uveitis, and erythema nodosum
32
Q

RF for Crohn’s

A
  • FH, smoking, Oral contraceptive pills, high refined sugars
  • Affects Ashkenazi Jews, and biomodal peak (15-40 and 60-80)
33
Q

H&E for Crohn’s

A
  • Crampy or constant abdominal pain
    • Right lower quadrant and peri umbilical (terminal ileum)
  • Diarrhoea
    • Mucus, blood, pus
    • Can be nocturnal
  • Perianal lesions
    • Skin tags, fistulae, abscesses
  • Fatigue, weight loss, mouth ulcers, malnourishment
34
Q

Extra-intestinal manifestations of Crohn’s

A
  • Arthropathy (joint pain)
  • Skin lesions
    • Erythema nodosum
    • Pyoderma gangrenosum
  • Uveitis and episcleritis

On Exam - abdominal tenderness/lower right mass, apthous ulcers, perianal lesions

35
Q

Investigations for Crohn’s

A

Bloods
- FBC, iron studies, vitamin/folate, ESR, albumin, B12 + folate
- Anti-saccharomyces cerevisiae antibodies (ASCA) and perinuclear anti-neutrophil cytoplasmic antibodies to differentiate between CD and UC
- CRP correlates well with disease activity

Stool Tests
- Cultures, calprotectin to help differentiate between IBD and infectious or non-inflammatory causes

Colonoscopy
- deep ulcers, skip lesions
- cobblestone appearance

Histology
- inflammation is all layers from mucosa to serosa
- goblet cells
- non-caseating granulomas

Small bowel enema (X-ray)
- high sensitivity and specificity for exam of terminal ileum
- strictures (Kantor’s string sign)
- proximal bowel dilation
- ‘rose thorn’ ulcers
- fistulae

36
Q

Management of Crohn’s

A

Stop smoking as this can cause relapse, but smoking may help UC

Steroids (oral or IV +/- topical) to induce remission
- predisolone, budesonide

Immunomodulators to reduce and maintain remission
- Azathioprine, mercaptopurine, methotrexate (2nd)

Biological therapy (IV)
- Adalimumab, infliximab, vedolizumab

Surgery
- For severe remissions/presentation, refractory disease and obstruction, fistulas and abscesses

37
Q

What is done when remission of Crohn’s is achieved?

A

Maintain immunomodulators +/- biologics

Can also give anti-spasmotics (cramp relief) and anti-diarrhoeals

38
Q

What is Ulcerative Colitis (UC)?

A
  • Diffuse inflammation of colonic mucosa (one layer)
  • Only affects the rectum and colon
  • Starts from rectum and extends proximally
  • Affects variable lengths of colon
  • Continuous inflammation
  • No known cause
    • Environmental + immune dysfunction + genetic predisposition (HLA-27)
39
Q

RF for UC

A
  • Family history, HLA-B27
  • Smoking is protective against UC
  • Affects males more than females
  • Bimodal peak (20-40 and 60)
40
Q

H&E for UC

A
  • Bloody diarrhoea
  • Rectal bleeding and mucus
  • Abdominal pain and cramps
  • Tenesmus
  • Weight loss
41
Q

Extra-intestinal manifestations of UC

A
  • Joints - peripheral arthritis and ankylosing spondylitis (HLA-B27)
  • Skin - erythema nodosum and pyoderma gangrenosum
  • Ocular - episcleritis

On exam, anaemic pallor, blood on DRE, abdominal tenderness

42
Q

Investigations for UC and findings

A
  • Colonoscopy + biopsy
    • colonoscopy contraindicated in severe colitis due to risk of perforation, flexible sigmoidoscopy preferred
  • Double contrast barium enema
    • loss of haustrations
    • superficial ulceration, ‘pseudopolyps’
    • long standing disease : colon is narrow and short ‘drainpipe colon’
  • Abdominal X-ray
    • Dilated bowel
    • Thumbprinting
  • Bloods
    • FBC for anaemia
    • LFTs for primary sclerosing cholangitis
  • Stool sample
    • Increased faecal calprotectin indicates inflammation
  • Positive pANCA in most cases
43
Q

Typical findings during colonoscopy for UC

A

Typical findings:

  • red, raw mucosa, bleeds easily
  • no inflammation beyond. submucosa (unless fulminant disease)
  • crypt abscess
  • widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
  • inflammatory cell infiltrate in lamina propria
  • depletion of goblet cells and mucin from gland
  • granuloma is infrequent
44
Q

How is UC severity classified?

A

Mild : <4 stools/day, small amount of blood

Moderate : 4-6 stools/day, varying amounts of blood, no systemic upset

Severe : >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

45
Q

Management of UC

A

Mild-moderate :
- Mesalazine (topical/rectal then oral)
- Steroids if remission not achieved
- Oral beclamethasone

Severe :
- IV steroids (hydrocortisone)
- IV ciclosporin if remission not achieved

Maintain remission :
- Aminosalicylate (mesalazine) if mild-moderate
- Oral azathioprine or mercaptopurine if severe relapse or >= 2 exacerbations in the past year

If nothing working, recuse therapy with infliximab

46
Q

What happens in severe pan-colitis?

A

In severe pan-colitis, where the ileocaecal valve is damaged and fixed open, you may get “backwash ileitis” where the inflammatory exudate from the colonic mucosa has caused minor inflammation in the very last section of ileum.

47
Q

What is acute cholangitis?

A

Infection of biliary tree caused by choledocholithiasis and benign and malignant strictures

48
Q

H&E for Acute Cholangitis

A

Key diagnostics :

  • Charcot’s triad
    • RUQ pain
    • Fever
    • Jaundice
  • RUQ Tenderness

Other diagnostics :
- Pale stools (lack of bile secretion)
- Pruritis
- Hypotension and confusion (Reynold’s pentad)

49
Q

RF for Acute Cholangitis

A
  • > 50 years old
  • History of cholelithiasis, primary or secondary sclerosing cholangitis, stricture of the biliary tree (benign or malignant), post-procedure injury of bile ducts, radiological intervention with resulting inadequate biliary drainage
50
Q

Investigations of Acute Cholangitis

A

First investigations to order :
- Abdominal US
- FBC, CRP, LFTs
- Serum urea, creatinine, potassium, magnesium

Other to consider :
- Abdominal CT with contrast - US negative
- MRCP - US and CT negative
- Blood cultures and ABG if suspecting sepsis

51
Q

Management of Acute Cholangitis

A
  • IV antibiotics
  • ECRP after 24-48h - can be used for diagnosis and biliary stone extraction (immediately in severe cases)
  • Biliary decompression if deteriorating
  • Consider lithotripsy
52
Q

What is Cholecystitis?

A

Inflammation of the gallbladder

Develops secondary to gallstones in 90% of patients (acute calculous cholecystitis) - impacted in gallbladder neck or cystic duct

53
Q

H&E of Cholecystitis

A
  • RUQ pain + tenderness
  • Signs of inflammation (fever)
  • Palpable mass
  • Murphy’s sign - inspiratory arrest on palpation of RUQ

Other diagnostic features
- N+V
- Anorexia

54
Q

RF for Cholecystitis

A
  • Gallstones
  • Severe illness
  • Total parenteral nutrition (TPN) - causes gallbladder stasis, biliary sludge and gallstones due to decreased emptying
  • Diabetes
55
Q

First order investigations for Cholecystitis

A
  • Abdominal ultrasound to identify presence of gallstones
    • If diagnosis unclear : cholescintigraphy scan
  • Bloods - FBC, CRP, bilirubin, LFT, serum lipase/amylase
56
Q

What are other investigations to consider for cholecystitis?

A
  • Contrast-enhanced CT or MRI if sepsis suspected to diagnose gangrenous cholecystitis or gallbladder perforation
  • Blood cultures if septic
  • MRCP if US hasn’t detected common bile duct stones but bile duct is dilated and/or LFTs are abnormals
  • Endoscopic US if MRCP doesn’t lead to diagnosis
57
Q

Management of Cholecystitis

A
  • Analgesia, fluid resus and IV antibiotics (Ceftriaxone and metronidazole)
  • Laparoscopic cholecystostomy within 1 week of diagnosis
  • Percutaneous cholecystectomy if unfit for surgery but not improving after analgesia and antibiotics
  • Postop management
58
Q
A

Year 3 Pathologies (12 decks)

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