Gastrointestinal Conditions 1 Flashcards
1st/3rd of GI conditions Will redo them in summer to be the Hepatobiliary!
Define Achalasia?
Oesophageal motor disorder of unknown aetiology, characterised by oesophageal aperistalsis and insufficient lower oesophageal sphincter relaxation in response to swallowing
What Causes Achalasia?
Inflammatory destruction of inhibitory nitrinergic neurons in the Auerbach plexus results in loss of Peristalsis and incomplete lower oesophageal sphincter relaxation
What condition causes a similar disorder to Achalasia?
Chaga’s disease, an infection of trypanosoma cruzi seen in South america, also causes myocarditis
What are risk factors for Achalasia?
Allgrove syndrome (achalasia, alacrima and adrenal insufficiency) due to ACTH insensitivity
Herpes and Measles virus
AI disease
HLA class II antigens (increased in those with achalasia)
Consanguineous parents
What are the symptoms of Achalasia?
Insidious onset with gradual progression of:
Intermittent dysphagia for solids and liquids
Difficulty belching
Regurgitation
Heartburn
Chest pain
Weight loss
What are the signs of Achalasia?
May show signs of complications:
Aspiration pneumonia
Malnutrition
Weight loss
What are investigations for Achalasia?
Upper GI endoscopy (mucosa obscured by saliva) Barium swallow (Loss of peristalsis and delayed emptying) Oesophageal manometry (incomplete LOS relaxation with wet swallows) CXR (Absence of gastric gas bubble or unusual shape)
Define Acute Cholangitis?
Known as ascending cholangitis, is an infection of the biliary tree, most commonly caused by obstruction
In which type of people is Acute cholangitis more common?
Latin americans and American indians
Age between 50 and 60
1-3% after ERCP
What causes Acute cholangitis?
Most common: Cholelithiasis leading to choledocholithiasis and biliary obstruction
Iatrogenic biliary duct injury, most commonly caused by surgery
Leads to benign strictures leading to obstruction
What are the Risk Factors for Acute cholangitis?
Age >50 years Cholelithiasis Benign stricture Malignant stricture Post-procedure injury of bile ducts HIV infection History of sclerosing cholangitis
What are the signs of Acute cholangitis?
Raynaud’s Pentad and Prutitus
What Makes up Reynaud’s pentad?
Charcot’s triad
Mental confusion
Hypotension
What Makes up Charcot’s triad?
RUQ pain
Jaundice
Fever with Rigors
What are the signs of Acute cholangitis?
RUQ tenderness Positive Murphy's sign Mild hepatomegaly Jaundice Sepsis Mental status change Tachycardia Peritonitis Hypotension
Investigations for acute cholangitis?
Bloods FBC (Leucocytis, thrombocytopenia) Raised Serum Urea and Creatinine Raised Serum LFTs Raised CRP Low Serum Potassium and Magnesium Blood cultures (Gram negative bacteria) Coagulation panel (PT raised with sepsis)
Imaging
X-ray KUB (Stones)
Abdominal Ultrasound (Stones)
MRCP (Look for non-calcified stones)
How do you manage acute cholangitis?
Fluid resuscitation
Correct coagulopathy
Administer broad-spectrum ABx
How do you stage Acute cholangitis?
Comes down to 3 categories A. Systemic inflammation - A1 Fever and/or shaking chills, temp >38 - A2 Laboratory data of inflam response - abnormal WCC, increase CRP B. Cholestasis - B1 Jaundice - B2 Lab data raised LFTs C. Imaging - C1 Biliary dilatation - C2 Evidence of aetiology on imaging
One from A, B and C is a definitive diagnosis
What are complications of Acute Cholangitis?
Acute Pancreatitis
Inadequate biliary drainage following endoscopy, radiology or surgery
Hepatic abscess
Define alcoholic liver disease
3 stages of liver damage: Fatty liver (Steatosis), Alcoholic hepatitis and alcoholic liver cirrhosis
What are the Risk Factors for alcoholic liver disease?
Prolonged and heavy alcohol consumption Hep C Female sex Cigarette smoking Obesity Age >65 years Hispanic ethnicitiy Genetic predisposition
What are the symptoms of Alcoholic liver disease
Abdominal pain Haematemesis Malaena Weight loss Distension Fatigue Anorexia Confusion Itchiness Gynaecomastia Peripheral neuropathy
What are the signs of Alcoholic liver disease?
Hepatosplenomegaly Jaundice Palmar erythema Ascites Asterixis Dupuytren's contracture Finger clubbing
What investigations do you do for Alcoholic liver disease?
Raised LFTs and bilirubin
Low albumin
FBC (Anaemia, leucocytosis, thrombocytopenia, high MCV)
Serum Urea and Creatinine (Normal or elevated)
Serum ANA (Exclude PBC)
Imaging Hepatic ultrasound (hepatomegaly, fatty liver) Upper GI endoscopy Liver Biopsy EEG
Management of Alcoholic liver disease?
1st line: Alcohol abstinence +/- withdrawal management (diazepam) + Pabrinex
2nd line: Liver transplant + Abstinence
Ascites - Furosemide
Protein restriction in those with encephalopathy
What are the complications of Alcoholic liver disease
Hepatic encephalopathy Portal Hypertension Gastrointestinal bleeding Coagulopathy Renal failure Hepatorenal syndrome (kidneys have reduced bloos flow due to reduced blood flow to liver) Hepatocellular carcinoma Sepsis
What is the prognosis of someone with Alcoholic liver disease
10% die in first month
40% die in first year
If alcohol continues, becomes cirrhosis
Define anal fissure
Anal fissure is a split in the skin of the distal anal canal by pain on defecation and rectal bleeding
What causes an anal fissure?
Most are caused by hard faeces
Anal sphincter spasm can constrict the inferior rectal artery, causing ischaemia
What are rarer causes of Anal fissure?
Syphilis Herpes Trauma Crohn's Anal Cancer Psoriasis
What are the symptoms of an Anal fissure?
Tearing pain when passing stools
Anal sphincter spasm
Anal itching
What are signs for an anal fissure?
Tears in the squamous lining of the anus on exam
What are the investigations for Anal fissure?
External examination of the anus
What are conservative managements for anal fissure?
High Fibre diet
Softening the stools
Good hydration
What are medical treatments for an anal fissure?
Lidocaine ointment (Local anaesthetic)
GTN ointment (Relaxes sphincter)
Ditliazem
Botulinum injection
What are surgical treatments for anal fissures?
Lateral partial internal sphincterotomy
What are the complications of Anal fissures?
Chronic Anal fissure
Incontinence after surgery
Recurrence
What is Appendicitis?
Sudden inflammation of the appendix
What causes appendicitis?
Gut organisms invading the appendix wall after lumen obstruction
What are the symptoms of Appendicitis?
Umbilical pain that moves to the RIF
Anorexia
Vomiting
Constipation
At what point does appendicitis pain localise?
Mcburney’s point
What are the signs of appendicitis?
Tachycardia Fever Furred tongue Bad breath Lying still Shallow breaths Guarding
What are unusual presentations of Appendicitis?
Flank/RUQ pain, only sign may be tenderness on DRE
Child may have vague abdominal pain and will not eat favourite food
May have a choked, confused, elderly patient
What are the Eponymous Signs seen in appendicitis?
Rovsig’s sign
Psoas Sign
Cope’s Sign
What is Rovsig’s sign?
Palpation of left iliac fossa causes more pain in RIF than left
What is Psoas sign?
Pain on extension of hip caused by retrocaecal pelvis (so not always seen)
What is Cope’s sign?
Pain on flexion and internal rotation of the hip (if appendix is in close proximity to the obturator internus)
What investigations are done for Appendicitis?
FBC CRP Pregnancy - rule out ectopic Ultrasound CT Urinalysis - exclude UTI
What would be seen on investigations for appendicitis?
Leucocytosis
Raised CRP
How do you manage appendicitis?
Prompt appendicectomy
May be an alternative to surgery with medications
Pre-operative antibiotics
What are possible complications of Appendicitis?
Perforation
Infection
Appendix mass
Appendix abscess
What is Autoimmune Hepatitis?
Chronic hepatitis of unknown aetiology, characterised by AI features, hyperglobulinaemia and the presence of circulating autoantibodies
What is the cause of autoimmune hepatitis?
In a genetically predisposed individual, an environamental agent may lead to hepatocyte expression of HLA antigens, which then become the focus of a principally T-cell mediated AI attack
What are the 2 major forms of AI hepatitis?
Type 1
- ANA
- ASMA
- Anti-Actin antibodies
- Anti-soluble liver antigen (Anti-SLA)
Type 2
- Antibodies to liver/kidney microsomes (ALKM-1)
- Antibodies to Liver cytosol antigen (ALC-1)
What are the Risk Factors for AI hepatitis?
Female Genetics - Type 1 associated with DR3/DR4 - Type 2 associated with DQB1/DRB1 Immune dysregulation (Thyroiditis/Graves/T1DM/UC/Coeliac) Viral infection (MMR/EBV/Hepatitis)
What are the symptoms of AI hepatitis?
Malaise Fatigue Anorexia Weight loss Nausea Jaundice Epistaxis
What are the signs of AI hepatitis?
Stigmata of chronic liver disease
Ascites, Oedema and Hepatic encephalopathy are late features
Cushingoid fetures may be present
What investigations are done for AI hepatitis?
LFTs Clotting screen FBC Viral serology Antibody assay
What can be seen on Investigations of AI hepatitis?
Raised LFTs High PT Anaemia, Thrombocytopenia, leucocytopenia No viruses Antibodies vary on type 1 or type 2
What is Barret’s Oesophagus?
Change from normal squamous epithelium to metaplastic columnar epithelium due to GORD
Who is most affected by Barret’s oesophagus?
Caucasian people
NSAIDs and Helicobacter are protective
What causes Barret’s oesophagus?
Occur if the Cardiac Sphincter is not working properly
Hiatus Hernia makes GORD more likely
What are the Risk Factors for Barret’s Oesophagus?
Chronic GORD
Hiatus Hernia
Obesity
Alcohol intake
What are the Risk Factors for developing adenocarcinoma?
Male Increasing age Extended segment disease Intestinal metaplasia Early age GORD Mucosal damage Family history
What are the signs and symptoms of Barret’s Oesophagus?
Heartburn Nausea Water-brash Bloating Belching Burning pain when swallowing
What investigations can be done for Barret’s oesophagus?
Endoscopy
Biopsy
What can be seen on investigation of someone with Barret’s Oesophagus?
Endoscopy - visible columnarisation
Biopsy - show columnarisation
What is the management of Barret’s Oesophagus?
Depends on degree of dysplasia!
High grade - Radiofrequency ablation + PPI
Low grade - Endoscopic resection + PPI
Non-dysplastic - PPI + surveillance
What are the complications of Barret’s Oesophagus?
Developing Adenocarcinoma of the Oesophagus
What is Cholangiocarcinoma?
Primary adenocarcinoma of the biliary tree
What are Risk Factors for Cholangiocarcinoma?
UC + PSC
Choledochal cyst
Caroli disease
Parasitic infection of biliary tract
What are symptoms of Cholangiocarcinoma?
Jaundice Pale stools Dark Urine Pruritis Abdominal pain Systemic symptoms of malignancy
What are the signs of Cholangiocarcinoma?
Jaundice
Palpable Gallbladder
Epigastric/RUQ mass
May be hepatomegaly
What is Courvoisier’s law?
In the presence of Jaundice, a palpable Gall bladder (That is non tender) is unlikely to be due to gallstones
(i.e. Pancreatic cancer or biliary tree more likely)
What investigations are done for cholangiocarcinoma?
FBC U&Es LFTs (Rasied ALP + GGT) Clotting screen Tumour markers (CA19-9) ERCP Bone scan MRI/CT
Which Tumours does tumour marker CA19-9 mark for?
Pancreatic
Cholangiocarcinoma
What is Cholecystitis?
Acute Gallbladder inflammation
It is a major complication of Gallstones
There is acalculous cholecystitis (Starvation, TPN, narcotic analgesia, immobility)
What causes Cholescystitis?
90% gallstones
Rarely acalculous
Rarely EBV infections
Secondary infection with Gram -ve flora is most causes of acalculous cholecystitis
Helminthic infection is a major cause of biliary disease in asia, S. America and S. Africa
What are Strong Risk Factors for Cholecystitis?
Gall stones
Severe illness
TPN
Diabetes
What are weak Risk Factors for Cholecystitis?
Physical inactivity Low fibre intake Trauma Severe Burns Ceftriaxone Ciclosporin Hepatic arterial embolus Infections
What are symptoms of Cholecystitis?
Unwell
Fever
Prolonged upper abdominal pain, referred to the Right shoulder
What are signs of Cholecystitis?
Tachycardia Pyrexia Local peritonism RUQ pain or epigastric tenderness Positive Murphy's sign Guarding and/or rebound tenderness
What is Murphy’s sign?
Ask the patient to breath in as you place your hand just under the costal margin in the MCL on the right.
If the Patient catches their breath, that is Murphy’s sign.
However, Murphy’s sign is only positive if they dont catch their breath on the left
What are the investigations for Cholecystitis?
FBC (Leucocytosis) CRP (>28.6) LFTs (Raised) USS Serum lipase or amylase (Mildly raised/normal) Blood cultures and/or bile cultures CT/MRI abdomen
How do you manage Cholecystitis?
If mild - Remove gallstones
Medical - admission, NBM, IV fluids, Analgesia, Anti-emetics, Antibiotics
- If symptoms persist after ABx, suspect abscess or empyema
Surgical - Cholecystectomy (if acute, do within 72 hours of symptoms)
What are possible complications of Cholecystitis?
Suppurative cholecystitis
Bile duct injury due to surgery
Gallstone Ileus
Cholecystoenteric fistula
What is a Gallstone Ileus?
Gallstones go from the biliary tract into the intestinal tract via a fistula, leading to small bowel obstruction
How do you treat a Gallstone Ileus?
Enterotomy and stone extraction, followed by cholecystectomy
What is a cholecystoenteric fistula?
Fistula formation between the duodenum and the hepatic flexure of the colon, may cause resolution of cholecystitis!
What is the prognosis of someone with Cholecystitis?
Generally good
If it perforates, mortality is 30%
Untreated acute acalculous cholecystitis is lifethreatening with up to 50% of mortality
What is Cirrhosis?
End-stage of Chronic liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes - it is irreversible!
When is Cirrhosis considered decompensated?
If it is complicated by: BAJE GI Bleed (Bleeding varices) Ascites Jaundice Encephalopathy
What Causes Cirrhosis?
Chronic alcohol misuse Chronic Viral hepatitis Autoimmune hepatitis Drugs Inherited conditions Vascular conditions Chronic biliary disease NASH
What inherited conditions cause Cirrhosis?
Alpha1-antitrypsin deficiency Haemochromatosis Wilson's diisease Galactosaemia CF
What Vascular Conditions cause Cirrhosis?
Budd-Chiari Syndrome
Hepatic venous congestion
What is Budd-Chiari syndrome?
Occlusion of hepatic veins that drain the liver
What drugs cause Cirrhosis?
Methotrexate
Paracetamol
Sodium valproate
Co-Amoxiclav and many more
What are Risk Factors for Cirrhosis?
Alcoholic liver disease Hepatitis C/B Male Older age Obesity HTN Hyperlipidaemia
What are early symptoms of Cirrhosis?
Anorexia Nausea Fatigue Weakness Weight loss
What symptoms are caused by decreased liver synthetic function?
Easy bruising
Abnormal swelling
Ankle oedema
Leukonychia (hypoalbuminaemia)
What symptoms are caused by reduced detoxification function?
Jaundice Personality change Altered sleep pattern Amenorrhoea Galactorrhoea
What symptoms are caused by portal HTN?
Abdominal sweling
Haematemesis
PR bleeding or Melaena
What are the signs of Cirrhosis on examination?
Asterixis Bruises Clubbing Caput medusae Dupuytren contracture Palmar erythema Jaundice Spider naevi (>5) Testicular atrophy Terry's nail (White proximally then red distally) Xanthelasma
What are the investigations for Cirrhosis?
LFT (Raised) Albumin (Low) FBC (Anaemia, thrombocytopenia, macrocytosis [alcohol]) U&Es (Hyponatraemia, poor GFR) Low folate Low Ferritin Viral antibody screen - Hep B/C
How do you manage Cirrhosis?
Treat underlying causes Alcohol cessation NG feeding if indicated Antihistamines for pruritus Zinc supplements
What are the complications of Cirrhosis?
Encephalopathy Ascites Spontaneous Bacterial peritonitis Variceal Haemorrhage Hepatocellular carcinoma Renal failure (Hepatorenal syndrome) Pulmonary Hypertension (Hepatopulmonary syndrome)
How do you treat Encephalopathy?
Treat infections Exclude a GI bleed Use lactulose and phosphate enemas (Lactulose reduces absorption of ammonia from teh gut) Avoid sedation
How do you treat Ascites?
Diuretics (Spironolactione with/without Furosemide) Sodium restriction Therapeutic paracentesis Monitor weight Fluid restrict if plasma Na+ <120 Avoid alcohol and NSAIDs
How do you treat SBP?
Antibiotics (Cefuroxamine and Metronidazole)
Prophylaxis with Ciprofloxacin
What Surgery could be done for Cirrhosis?
Transjugular intrahepatic portosystemic shunt (Reduces portal hypertension)
Liver transplant is the only curative method
What is the Prognosis of someone with Cirrhosis?
5 year survival = 50%
If ascites, 2 year survival = 50%
What are poor prognostic indicators in Cirrhosis?
Encephalopathy
Serum Na+ <120
Serum albumin <25
High INR
What is Coeliac disease?
Autoimmune disease triggered by dietary gluten peptides found in wheat, rye, barley and related grains
What happens in the S. Intestine in Coeliac disease?
Immune activation in the S.intestine leads to villous atrophy, hypertrophy of the intestinal crypts and increased number of lymphocytes in the epithelium and lamina propia
What causes Coeliac disease?
Sensitivity to Gliadin component of cereal protein, gluten
Gliadin exposure triggers an immunological reaction leading to mucosal damage and loss of villi
If no gluten, villi return and patient becomes asymptomatic
What HLAs are associated with Coeliac disease?
HLA-B8
HLA-DR3
HLA-DQW2
What are the Risk Factors for Coeliac disease?
Family member with coeliac disease or Dermatitis herpetiformis T1DM Downs or Turners AI thyroid disease Microscopic colitis Addison's disease
What are the symptoms of Coeliac disease?
May be asymptomatic Abdominal discomfort, pain and distention Steatorrhoea Diarrhoea Tiredness Malaise Weight loss Children failing to thrive Amenorrhoea in young adults
What are signs of Coeliac disease?
Pallor Short stature Abdominal disention Wasted buttocks in children Osteomalacia Easy bruising Itchy blisters on elbows, knees or buttocks (dermatitis herpetiformis)
Investigations for Coeliac disease?
Specific autoantibodies (IgA, tTG, IgA, EMA, IgG< DGP, HLA-DQ2/DQ8)
How do you treat coeliac disease?
Lifelong gluten restriction
Provide source of information on the disease
Vitamin and Mineral supplements
Oral corticosteroids if disease does not subside with avoidance of gluten
What are the complications of Coeliac disease?
Iron, Folate and B12 deficiency Osteomalacia Ulcerative jejunoileitis GI lymphoma if untreated Cerebellar ataxia (rare)
What is a colorectal carcinoma?
Adenocarcinomas derived from epithelial cells.
Where do colorectal carcinomas normally appear?
71% in colon
Rest in the Rectum
What are Risk Factors for Colorectal carcinoma?`
Increasing age Adenomatous polyposis coli mutation Lynch syndrome MYH-associate polyposis syndrome IBD Obesity Acromegaly Lack of dietary fibre Smoking Family history Chronic bowel inflammation
What are the symptoms of Left sided colorectal carcinoma?
Change in Bowel habit
Rectal bleeding
Tenesmus
What are the symptoms of Right sided colorectal carcinoma?
Presents later Anaemia symptoms (Lethargy) Weight loss Non-specific malaise Lower abdominal pain (Rare)
Whats an important thing not to miss in terms of colorectal carcinoma?
20% of tumours will present as an emergency with pain and distention due to:
- Large Bowel obstruction
- Haemorrhage or Peritonitis due to perforation
What are signs of Colorectal carcinoma?
Anaemia
Abdominal mass
Hepatomegaly, Ascites - Mets!
Low-lying rectal tumours may be palpable on DRE
What investigations can be done for colorectal carcinoma?
FBC Renal Function LFTs Tumour markers - CEA Barium Enema Colonoscopy for biopsy
What can you see on Barium enema for a colorectal carcinoma?
‘Apple-core’ strictures
What is Inflammatory Bowel disease?
An Umbrella term used to describe disorders that involve chronic inflammation of your digestive tract
It is Ulcerative colitis or Crohns disease
What is Crohn’s disease?
Relapsing IBD, characterised by transmural granulomatous inflammation which can affect any part of the GI tract, most commonly the ileum, colon or both.
What causes Crohn’s disease?
Geneitc and environmental factors
Th1 mediated with TNF-alpha
Where does Crohn’s affect?
Anywhere from the anus to the mouth
Often has skip lesions
Cobblestone appearance
What causes Ulcerative colitis?
Unknown
Immune response to bacteria or self-antigens, environmental factors
Considered Th2-mediated, IL012 is key
Positive family history
Associated with Raised serum pANCA and PSC
Where does Ulcerative colitis affect?
Only the colon
Starts at the rectum
May affect terminal ileum if affects whole colon IF an incomplete ileocaecal valve
What is Ulcerative colitis?
Idiopathic chronic inflammatory disease following a course of relapse and remission
What are Risk Factors for Crohns?
Age (15-30 or 50-70) Caucasian Family history NSAID medication Living in an urban area
What are Risk Factors for UC?
Family history HLA-B27 Infection NSAIDs Not smoking / former smoking
What intestinal symptoms are there of Crohn’s disease?
Crampy abdominal pain (inflam, fibrosis or bowel obstruction) Diarrhoea Fever Malaise Weight loss
What extra-intestinal symptoms are there in Crohn’s?
Eye disease (Uveitis) Joint disease (Seronegative arthritis) Skin disease (Erythema nodosum) Anaemia
What intestinal symptoms are there of UC?
Bloody or Mucosal diarrhoea Tenesmus on urgency Weight loss Crampy abdominal pain before passing stool Fever
What extra-GI symptoms are there of UC?
Uveitis
Scleritis
Erythema nodosum
Pyoderma gangrenosum
What Signs are there of Crohn’s disease?
Weight loss Clubbing Signs of anaemia Aphthous ulcers of the mouth Perianal skin tags, fistulae and abscesses
What signs are there of Ulcerative colitis?
Signs of iron deficiency anaemia Dehydration Clubbing Abdominal tenderness Tachycardia Blood, mucous and tenderness on PR examination
What investigations can be done for Crohn’s disease?
FBC Metabolic panel CRP/ESR LFT Serological markers Faecal calprotectin Erect CXR (For perforation) Endoscopy (OGD/Colonoscopy)
What investigations can be done for UC?
FBC Metabolic profile CRP/ESR Serological markers (pANCA & ASCA) Faecal calprotectin
How do you manage an acute exacerbation of Crohn’s?
Fluid resuscitation, may also be oral iron
IV/Oral Corticosteroids
5-ASA analogues (mesalazine and olsalazine)
Analgesia
Parenteral nutrition
Monitor ESR/CRP, platelets and Hb
How do you manage Crohn’s long term?
Steroids for pain 5-ASA analogues Immunosuppression (azathioprine, 6-mercaptopurine, methotrexate) Anti-TNF agents e.g. infliximab Tell them to stop smoking Surgery doesnt really help!
How do you manage acute exacerbation of UC?
IV Fluids IV corticosteroids ABx Bowel rest DVT prophylaxis
How do you manage UC normally?
Mild disease - Oral/Rectal 5-ASA derivatives e.g. mesalazine and/or rectal steroids
Moderate to severe disease - Oral steroids, Oral 5-ASA, immunosuppression (azathioprine)
Surgery is helpful for UC! Remove whole colon normally
- Proctocolectomy with ileostomy
OR
- Ileo-anal pouch formation
What are the complications of Crohn’s disease?
Haemorrhage Strictures Perforation Fistulae GI cancer Uveitis Episcleritis Gall stones Arthropathy Amyloidosis PSC Erythema nodosum Ankylosing spondylitis
What are complications of UC?
Toxic megacolon Perforation Infection Massive lower GI bleed Colonic adenocarcinoma Benign stricture Inflammatory pseudopolyps PSC Dysplasia-associated lesion or mass amyloidosis Osteoporosis Ankylosing spondylitis Erythema nodosum
What is Diverticular disease?
A diverticulum is an out pouching of the gut wall, usually at sites of entry of perforating arteries.
There is Diverticulosis, Diverticular disease and Diverticulitis
What is Diverticulosis?
The presence of out pouching of Mucosa through the muscular wall of the large bowel that is asymptomatic
What is diverticular disease?
Diverticulosis with complications e.g. Haemorrhage, infection, fistulae
What is Diveritculitis?
Acute inflammation and infection of colonic diverticulae
What is the classification system for acute diverticulitis?
Hinchley Classification
How does Hinchley classification classify things?
Ia - Phlegmon - spreading diffuse inflammatory process with formation of purulent exudate
Ib/II: Localised abscesses
III: Perforation an d purulent peritonitis
IV: Faecal peritonitis - faeces in the peritoneal cavity, due to large bowel perforation
What causes Diverticular disease?
Low-fibre diet leading to loss of stool bulk
Generate high colonic intraluminal pressures to propel the stool out
Leading to herniation of mucosa and submucosa through muscle layers of the gut at weak points
What Risk factors are there for Diverticular disease?
Age > 50 years Low dietary fibre Obesity in younger people Smoking NSAID and Paracetamol use
What are the Symptoms for diverticular disease?
Only see symptoms in diverticular disease/diverticulitis!
Pain on eating and going with flatus/defecation
Lower left abdominal pain/could be lower right in Asians!
Complications leading to: PR bleeding and Diverticular fasciculation (Pneumaturia, Faecaluria and Recurrent UTI)
What are the signs of Diverticular disease?
Only in diverticulitis! Fever Tachycardia Anorexia Nausea Vomiting Leucocytosis Fullness or mild tenderness in lower left quadrant
How else may people present? (What signs could be seen?)
Tender mass with persistent fever (Abscess)
Perforation into peritoneum
Complete obstruction (Fibrosis)
Pneumaturia/Faecaluria (Colovesicular fistula)
What investigations can be done for Diverticular disease and what would you see?
FBC (Polymorphonuclear Leukocytosis, Raised CRP)
Barium enema (Saw-tooth appearance of lumen)
Sigmoidoscopy and colonoscopy (see pathology)
Erect CXR (Check for perforation)
Culture (if worry about sepsis)
How do you manage asymptomatic Diverticular disease?
Asymptomatic - No treatment needed (lifestyle advice)
How do you manage symptomatic diverticular disease?
Symptomatic - Dietary modification + fibre supplementation w/ oral Abx (Co-amoxiclav or Ciprofloxacin)
How do you manage uncomplicated diverticulitis?
Analgesia w/ ABx and low-residue diet If not (^): Surgery + supportive therapy & ABx + Analgesia + Low-residue diet
How do you manage complicated diverticulitis?
With acute rectal bleeding:
Endoscopic haemostasis + supportive therapy & ABx + Analgesia + Low-residue diet
If unresponsive to ABx:
Radiological drainage/surgery + IV ABx + Analgesia + Low-reside diet
How do you manage ongoing symptomatic diverticular disease?
Elective surgery (Hartmann’s procedure, resection + anastamosis)
What are the complications of Diverticular disease?
Fistulae Colorectal neoplasm Abscess Perforation Strictures, Obstruction
What is Biliary colic?
Presence of solid concretions in the Gall bladder
What is Choledocholithiasis?
Gallstones in the biliary tree
What composes gall bladder stones?
90% of them compose of cholesterol
What are the Risk Factors for Gallstones?
6Fs Fair (Caucasian) Fat (Obese) Female Fourty (Age) Fertile (Exogenous oestrogen)
And: Drugs, DM, Low-fibre diet, Non-alcoholic liver disease
What are the symptoms of Gall stones?
Sudden severe RUQ/epigastric pain Radiates to right scapula Associated with Nausea and Vomiting Leads to cholecystitis Can lead to acute cholangitis (Charcot's triad/Reynold's pentad)
What are signs of Gallstones? (Cholecystitis)
Signs of Cholecystitis or Acute cholangitis!
What are the investigations for Gallbladder stones?
FBC (normal)
Serum LFTs (Normal but choledocholithiasis has elevated ALP and bilirubin)
Serum Lipase and Amylase (3x upper limit)
Ultrasound (Stones in Gallbladder/duct)
CT (Duct dilatation)
How do you manage symptomatic Gall stones?
Cholecystectomy
How do you manage Choledocholithiasis?
ERCP adjunct: Lithotripsy, papillary baloon dilatataion
or
Laporoscopic CBD exploration
What are the complications of Gallstones and biliary colic?
ERCP-associated pancreatitis Iatrogenic bile duct injury Post-sphincterotomy bleeding Bouveret syndrome Gallstone Ileus Cholecystitis
What is Bouveret syndrome?
Cholecystoeneteric fistula leading to duodenal obstruction
What is gastric cancer?
Neoplasm that develops in any portion of the stomach and may spread to lymph nodes and other organs! Most are adenocarcinomas 50% in the pylorus 25% in the lesser curve 10% in the cardia
What are the Risk factors for Gastric cancer?
Smoked and processed foods Food high in nitrosamines, nitrates, salt Pickling Low vitamin C intake Alcohol H. Pylori infections Pernicious anaemia Blood group A
What are the symptoms of Gastric cancer?
Often asymptomatic early Early satiety Epigastric discomfort Haematemess Melaena Anaeamia Weight loss Anorexia Nausea/Vomiting Dysphagia Ascites Jaundice
What are the signs of Gastric cancer on examination?
May be normal Epigastric mass Abdominal tenderness Ascites Signs of Anaemia Virchow's node Sister Mary joseph nodule Krukenburg's tumour (Ovarian mets)
What is Virchow’s node?
Lymphadenopathy in the Left supraclavicular fossa
What is sister mary joseph nodule?
Mets node on the umbilicus
What investigations are done for gastric cancer?
Upper GI endoscopy with biopsy FBC (Anaemia) CT CAP (Look for mets)
Where does Gastric cancer normally metastasise?
Liver
Ovaries
Lung
Oesophagus
What is Gastroenteritis and infectious colitis?
Nonspecific term for a combo of Nausea, vomiting, diarrhoea and abdominal pain - usually an infectious origin
What causes Gastroenteritis?
Viruses, Bacteria, Protozoa or toxins in contaminated for or water (faeco-oral route)
The next few will be Common examples of gastroenteritis and what causes them
What causes an outbreak of D+V in institution?
Norovirus
What causes dysentry (Bloody diarrhoea)?
CHESS Campylobacter Jejnui Haemorrage E coli 0157 Entamoeaba histolytica Salmonella Shigella
What is the cause of a uni student with watery diarrhoea?
C Jejuni
What causes Rapid onset diarrhoea after a meal?
Staphylococcus Aureus or Bacillus cwerus
What causes gastroenteritis and infectious colitis in elderly people on antibiotics?
C difficile
What causes Gastroenteritis and infectious colitis in travellers?
E coli
What are commonly contaminated foods and what contaminates them?
Improperly cooked meats - S. Aureus, C.perfringens
Old rice - B cereus, S Aureus
Eggs and Poultry - Salmonella
Milk and Cheeses - Listeria, Campylobacter
Canned food - Botulinism
What are the Risk Factors for gastroenteritis and infectious colitis?
Age (infants and younger children) Immunocompromised Living in crowded areas Travellers Winter time
What are the symptoms of Gastroenteritis & infectious colitis?
Sudden onset nausea, vomiting, anorexia Diarrhoea (Bloody or watery) Abdominal pain or discomfort Fever and malaise Time of onset Other effects of certain toxins: - Botulinism - paralysis - Fungi - Fits, renal or liver disease
What is the time of onset for Gastroenteritis / colitis?
Caused by:
- Toxins - 1-24hrs
- Bacteria/viral/protozoal - 12+ hours
What are the signs of gastroenteritis and infectious colitis?
Diffuse abdominal tenderness
Abdominal distention
Increased bowel sounds
In severe cases: Pyrexia, dehydration, hypotension and peripheral shutdown
- Any diarrheal condition can lead to dehydration
What investigations can be done for gastroenteritis and infectious colitis?
FBC
Blood culture
U&Es
Renal function
Stool sample: Faecal microscopy and analysis for toxins (especially those causing pseudomembranous colitis [C.dificile toxin])
Others to exclude things: AXR/US/Sigmoidoscopy
What is the management for gastroenteritis and infectious colitis?
Bed rest - stay home until clear of D+V
Fluid & electrolyte replacement with oral rehydration
IV rehydration with severe vomiting
Antibiotics if severe and agent identified
If botulinum - botulinum antitoxin and manage in ITU
if C diff: Isolate, Oral metronidazole, if persists: Vancomcyin
What are the complications of Gastroenteritis and infectious colitis?
Dehydration Electrolyte imbalance Prerenal failure Secondary lactose intolerance Sepsis and shock Haemolytic uraemic syndrome (E.Coli 0157) GBS weeks after Campylobaster
Is gastroenteritis and infectious colitis a notifiable disease?
No
Unless caused by botulinum toxin, then it is
