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Conditions > Gastrointestinal Conditions 1 > Flashcards

Gastrointestinal Conditions 1 Flashcards

1st/3rd of GI conditions Will redo them in summer to be the Hepatobiliary!

1
Q

Define Achalasia?

A

Oesophageal motor disorder of unknown aetiology, characterised by oesophageal aperistalsis and insufficient lower oesophageal sphincter relaxation in response to swallowing

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2
Q

What Causes Achalasia?

A

Inflammatory destruction of inhibitory nitrinergic neurons in the Auerbach plexus results in loss of Peristalsis and incomplete lower oesophageal sphincter relaxation

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3
Q

What condition causes a similar disorder to Achalasia?

A

Chaga’s disease, an infection of trypanosoma cruzi seen in South america, also causes myocarditis

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4
Q

What are risk factors for Achalasia?

A

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

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5
Q

What are the symptoms of Achalasia?

A

Insidious onset with gradual progression of:
Intermittent dysphagia for solids and liquids
Difficulty belching
Regurgitation
Heartburn
Chest pain
Weight loss

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6
Q

What are the signs of Achalasia?

A

May show signs of complications:
Aspiration pneumonia
Malnutrition
Weight loss

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7
Q

What are investigations for Achalasia?

A 
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)
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8
Q

Define Acute Cholangitis?

A

Known as ascending cholangitis, is an infection of the biliary tree, most commonly caused by obstruction

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9
Q

In which type of people is Acute cholangitis more common?

A

Latin americans and American indians
Age between 50 and 60
1-3% after ERCP

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10
Q

What causes Acute cholangitis?

A

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

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11
Q

What are the Risk Factors for Acute cholangitis?

A 
Age >50 years
Cholelithiasis
Benign stricture
Malignant stricture
Post-procedure injury of bile ducts
HIV infection
History of sclerosing cholangitis
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12
Q

What are the signs of Acute cholangitis?

A

Raynaud’s Pentad and Prutitus

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13
Q

What Makes up Reynaud’s pentad?

A

Charcot’s triad
Mental confusion
Hypotension

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14
Q

What Makes up Charcot’s triad?

A

RUQ pain
Jaundice
Fever with Rigors

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15
Q

What are the signs of Acute cholangitis?

A 
RUQ tenderness
Positive Murphy's sign
Mild hepatomegaly
Jaundice
Sepsis
Mental status change
Tachycardia
Peritonitis
Hypotension
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16
Q

Investigations for acute cholangitis?

A 
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)

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17
Q

How do you manage acute cholangitis?

A

Fluid resuscitation
Correct coagulopathy
Administer broad-spectrum ABx

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18
Q

How do you stage Acute cholangitis?

A 
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

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19
Q

What are complications of Acute Cholangitis?

A

Acute Pancreatitis
Inadequate biliary drainage following endoscopy, radiology or surgery
Hepatic abscess

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20
Q

Define alcoholic liver disease

A

3 stages of liver damage: Fatty liver (Steatosis), Alcoholic hepatitis and alcoholic liver cirrhosis

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21
Q

What are the Risk Factors for alcoholic liver disease?

A 
Prolonged and heavy alcohol consumption
Hep C
Female sex
Cigarette smoking
Obesity
Age >65 years
Hispanic ethnicitiy
Genetic predisposition
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22
Q

What are the symptoms of Alcoholic liver disease

A 
Abdominal pain
Haematemesis
Malaena
Weight loss
Distension
Fatigue
Anorexia
Confusion
Itchiness
Gynaecomastia
Peripheral neuropathy
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23
Q

What are the signs of Alcoholic liver disease?

A 
Hepatosplenomegaly
Jaundice
Palmar erythema
Ascites
Asterixis 
Dupuytren's contracture
Finger clubbing
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24
Q

What investigations do you do for Alcoholic liver disease?

A

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
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25
Q

Management of Alcoholic liver disease?

A

1st line: Alcohol abstinence +/- withdrawal management (diazepam) + Pabrinex
2nd line: Liver transplant + Abstinence

Ascites - Furosemide
Protein restriction in those with encephalopathy

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26
Q

What are the complications of Alcoholic liver disease

A 
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
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27
Q

What is the prognosis of someone with Alcoholic liver disease

A

10% die in first month
40% die in first year
If alcohol continues, becomes cirrhosis

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28
Q

Define anal fissure

A

Anal fissure is a split in the skin of the distal anal canal by pain on defecation and rectal bleeding

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29
Q

What causes an anal fissure?

A

Most are caused by hard faeces

Anal sphincter spasm can constrict the inferior rectal artery, causing ischaemia

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30
Q

What are rarer causes of Anal fissure?

A 
Syphilis
Herpes
Trauma
Crohn's
Anal Cancer
Psoriasis
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31
Q

What are the symptoms of an Anal fissure?

A

Tearing pain when passing stools
Anal sphincter spasm
Anal itching

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32
Q

What are signs for an anal fissure?

A

Tears in the squamous lining of the anus on exam

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33
Q

What are the investigations for Anal fissure?

A

External examination of the anus

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34
Q

What are conservative managements for anal fissure?

A

High Fibre diet
Softening the stools
Good hydration

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35
Q

What are medical treatments for an anal fissure?

A

Lidocaine ointment (Local anaesthetic)
GTN ointment (Relaxes sphincter)
Ditliazem
Botulinum injection

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36
Q

What are surgical treatments for anal fissures?

A

Lateral partial internal sphincterotomy

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37
Q

What are the complications of Anal fissures?

A

Chronic Anal fissure
Incontinence after surgery
Recurrence

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38
Q

What is Appendicitis?

A

Sudden inflammation of the appendix

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39
Q

What causes appendicitis?

A

Gut organisms invading the appendix wall after lumen obstruction

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40
Q

What are the symptoms of Appendicitis?

A

Umbilical pain that moves to the RIF
Anorexia
Vomiting
Constipation

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41
Q

At what point does appendicitis pain localise?

A

Mcburney’s point

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42
Q

What are the signs of appendicitis?

A 
Tachycardia
Fever
Furred tongue
Bad breath
Lying still 
Shallow breaths
Guarding
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43
Q

What are unusual presentations of Appendicitis?

A

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

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44
Q

What are the Eponymous Signs seen in appendicitis?

A

Rovsig’s sign
Psoas Sign
Cope’s Sign

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45
Q

What is Rovsig’s sign?

A

Palpation of left iliac fossa causes more pain in RIF than left

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46
Q

What is Psoas sign?

A

Pain on extension of hip caused by retrocaecal pelvis (so not always seen)

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47
Q

What is Cope’s sign?

A

Pain on flexion and internal rotation of the hip (if appendix is in close proximity to the obturator internus)

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48
Q

What investigations are done for Appendicitis?

A 
FBC
CRP
Pregnancy - rule out ectopic
Ultrasound
CT
Urinalysis - exclude UTI
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49
Q

What would be seen on investigations for appendicitis?

A

Leucocytosis

Raised CRP

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50
Q

How do you manage appendicitis?

A

Prompt appendicectomy
May be an alternative to surgery with medications
Pre-operative antibiotics

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51
Q

What are possible complications of Appendicitis?

A

Perforation
Infection
Appendix mass
Appendix abscess

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52
Q

What is Autoimmune Hepatitis?

A

Chronic hepatitis of unknown aetiology, characterised by AI features, hyperglobulinaemia and the presence of circulating autoantibodies

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53
Q

What is the cause of autoimmune hepatitis?

A

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

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54
Q

What are the 2 major forms of AI hepatitis?

A

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)
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55
Q

What are the Risk Factors for AI hepatitis?

A 
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)
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56
Q

What are the symptoms of AI hepatitis?

A 
Malaise
Fatigue
Anorexia
Weight loss
Nausea
Jaundice
Epistaxis
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57
Q

What are the signs of AI hepatitis?

A

Stigmata of chronic liver disease
Ascites, Oedema and Hepatic encephalopathy are late features
Cushingoid fetures may be present

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58
Q

What investigations are done for AI hepatitis?

A 
LFTs
Clotting screen
FBC
Viral serology
Antibody assay
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59
Q

What can be seen on Investigations of AI hepatitis?

A 
Raised LFTs
High PT
Anaemia, Thrombocytopenia, leucocytopenia
No viruses
Antibodies vary on type 1 or type 2
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60
Q

What is Barret’s Oesophagus?

A

Change from normal squamous epithelium to metaplastic columnar epithelium due to GORD

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61
Q

Who is most affected by Barret’s oesophagus?

A

Caucasian people

NSAIDs and Helicobacter are protective

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62
Q

What causes Barret’s oesophagus?

A

Occur if the Cardiac Sphincter is not working properly

Hiatus Hernia makes GORD more likely

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63
Q

What are the Risk Factors for Barret’s Oesophagus?

A

Chronic GORD
Hiatus Hernia
Obesity
Alcohol intake

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64
Q

What are the Risk Factors for developing adenocarcinoma?

A 
Male
Increasing age
Extended segment disease
Intestinal metaplasia
Early age GORD
Mucosal damage
Family history
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65
Q

What are the signs and symptoms of Barret’s Oesophagus?

A 
Heartburn
Nausea
Water-brash 
Bloating
Belching
Burning pain when swallowing
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66
Q

What investigations can be done for Barret’s oesophagus?

A

Endoscopy

Biopsy

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67
Q

What can be seen on investigation of someone with Barret’s Oesophagus?

A

Endoscopy - visible columnarisation

Biopsy - show columnarisation

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68
Q

What is the management of Barret’s Oesophagus?

A

Depends on degree of dysplasia!
High grade - Radiofrequency ablation + PPI
Low grade - Endoscopic resection + PPI
Non-dysplastic - PPI + surveillance

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69
Q

What are the complications of Barret’s Oesophagus?

A

Developing Adenocarcinoma of the Oesophagus

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70
Q

What is Cholangiocarcinoma?

A

Primary adenocarcinoma of the biliary tree

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71
Q

What are Risk Factors for Cholangiocarcinoma?

A

UC + PSC
Choledochal cyst
Caroli disease
Parasitic infection of biliary tract

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72
Q

What are symptoms of Cholangiocarcinoma?

A 
Jaundice
Pale stools
Dark Urine
Pruritis
Abdominal pain
Systemic symptoms of malignancy
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73
Q

What are the signs of Cholangiocarcinoma?

A

Jaundice
Palpable Gallbladder
Epigastric/RUQ mass
May be hepatomegaly

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74
Q

What is Courvoisier’s law?

A

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)

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75
Q

What investigations are done for cholangiocarcinoma?

A 
FBC
U&Es
LFTs (Rasied ALP + GGT)
Clotting screen 
Tumour markers (CA19-9)
ERCP
Bone scan 
MRI/CT
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76
Q

Which Tumours does tumour marker CA19-9 mark for?

A

Pancreatic

Cholangiocarcinoma

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77
Q

What is Cholecystitis?

A

Acute Gallbladder inflammation
It is a major complication of Gallstones
There is acalculous cholecystitis (Starvation, TPN, narcotic analgesia, immobility)

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78
Q

What causes Cholescystitis?

A

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

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79
Q

What are Strong Risk Factors for Cholecystitis?

A

Gall stones
Severe illness
TPN
Diabetes

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80
Q

What are weak Risk Factors for Cholecystitis?

A 
Physical inactivity
Low fibre intake
Trauma
Severe Burns
Ceftriaxone
Ciclosporin
Hepatic arterial embolus
Infections
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81
Q

What are symptoms of Cholecystitis?

A

Unwell
Fever
Prolonged upper abdominal pain, referred to the Right shoulder

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82
Q

What are signs of Cholecystitis?

A 
Tachycardia
Pyrexia
Local peritonism
RUQ pain or epigastric tenderness
Positive Murphy's sign 
Guarding and/or rebound tenderness
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83
Q

What is Murphy’s sign?

A

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

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84
Q

What are the investigations for Cholecystitis?

A 
FBC (Leucocytosis)
CRP (>28.6)
LFTs (Raised)
USS
Serum lipase or amylase (Mildly raised/normal)
Blood cultures and/or bile cultures
CT/MRI abdomen
85
Q

How do you manage Cholecystitis?

A

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)

86
Q

What are possible complications of Cholecystitis?

A

Suppurative cholecystitis
Bile duct injury due to surgery
Gallstone Ileus
Cholecystoenteric fistula

87
Q

What is a Gallstone Ileus?

A

Gallstones go from the biliary tract into the intestinal tract via a fistula, leading to small bowel obstruction

88
Q

How do you treat a Gallstone Ileus?

A

Enterotomy and stone extraction, followed by cholecystectomy

89
Q

What is a cholecystoenteric fistula?

A

Fistula formation between the duodenum and the hepatic flexure of the colon, may cause resolution of cholecystitis!

90
Q

What is the prognosis of someone with Cholecystitis?

A

Generally good
If it perforates, mortality is 30%
Untreated acute acalculous cholecystitis is lifethreatening with up to 50% of mortality

91
Q

What is Cirrhosis?

A

End-stage of Chronic liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes - it is irreversible!

92
Q

When is Cirrhosis considered decompensated?

A 
If it is complicated by: BAJE
GI Bleed (Bleeding varices)
Ascites
Jaundice
Encephalopathy
93
Q

What Causes Cirrhosis?

A 
Chronic alcohol misuse
Chronic Viral hepatitis 
Autoimmune hepatitis
Drugs 
Inherited conditions
Vascular conditions
Chronic biliary disease
NASH
94
Q

What inherited conditions cause Cirrhosis?

A 
Alpha1-antitrypsin deficiency
Haemochromatosis
Wilson's diisease
Galactosaemia
CF
95
Q

What Vascular Conditions cause Cirrhosis?

A

Budd-Chiari Syndrome

Hepatic venous congestion

96
Q

What is Budd-Chiari syndrome?

A

Occlusion of hepatic veins that drain the liver

97
Q

What drugs cause Cirrhosis?

A

Methotrexate
Paracetamol
Sodium valproate
Co-Amoxiclav and many more

98
Q

What are Risk Factors for Cirrhosis?

A 
Alcoholic liver disease
Hepatitis C/B
Male
Older age
Obesity
HTN
Hyperlipidaemia
99
Q

What are early symptoms of Cirrhosis?

A 
Anorexia
Nausea
Fatigue
Weakness
Weight loss
100
Q

What symptoms are caused by decreased liver synthetic function?

A

Easy bruising
Abnormal swelling
Ankle oedema
Leukonychia (hypoalbuminaemia)

101
Q

What symptoms are caused by reduced detoxification function?

A 
Jaundice 
Personality change
Altered sleep pattern
Amenorrhoea 
Galactorrhoea
102
Q

What symptoms are caused by portal HTN?

A

Abdominal sweling
Haematemesis
PR bleeding or Melaena

103
Q

What are the signs of Cirrhosis on examination?

A 
Asterixis
Bruises
Clubbing 
Caput medusae
Dupuytren contracture
Palmar erythema
Jaundice
Spider naevi (>5)
Testicular atrophy
Terry's nail (White proximally then red distally)
Xanthelasma
104
Q

What are the investigations for Cirrhosis?

A 
LFT (Raised)
Albumin (Low)
FBC (Anaemia, thrombocytopenia, macrocytosis [alcohol])
U&Es (Hyponatraemia, poor GFR)
Low folate
Low Ferritin
Viral antibody screen - Hep B/C
105
Q

How do you manage Cirrhosis?

A 
Treat underlying causes
Alcohol cessation
NG feeding if indicated
Antihistamines for pruritus
Zinc supplements
106
Q

What are the complications of Cirrhosis?

A 
Encephalopathy
Ascites
Spontaneous Bacterial peritonitis
Variceal Haemorrhage
Hepatocellular carcinoma
Renal failure (Hepatorenal syndrome)
Pulmonary Hypertension (Hepatopulmonary syndrome)
107
Q

How do you treat Encephalopathy?

A 
Treat infections
Exclude a GI bleed
Use lactulose and phosphate enemas
(Lactulose reduces absorption of ammonia from teh gut)
Avoid sedation
108
Q

How do you treat Ascites?

A 
Diuretics (Spironolactione with/without Furosemide)
Sodium restriction
Therapeutic paracentesis
Monitor weight
Fluid restrict if plasma Na+ <120
Avoid alcohol and NSAIDs
109
Q

How do you treat SBP?

A

Antibiotics (Cefuroxamine and Metronidazole)

Prophylaxis with Ciprofloxacin

110
Q

What Surgery could be done for Cirrhosis?

A

Transjugular intrahepatic portosystemic shunt (Reduces portal hypertension)

Liver transplant is the only curative method

111
Q

What is the Prognosis of someone with Cirrhosis?

A

5 year survival = 50%

If ascites, 2 year survival = 50%

112
Q

What are poor prognostic indicators in Cirrhosis?

A

Encephalopathy
Serum Na+ <120
Serum albumin <25
High INR

113
Q

What is Coeliac disease?

A

Autoimmune disease triggered by dietary gluten peptides found in wheat, rye, barley and related grains

114
Q

What happens in the S. Intestine in Coeliac disease?

A

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

115
Q

What causes Coeliac disease?

A

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

116
Q

What HLAs are associated with Coeliac disease?

A

HLA-B8
HLA-DR3
HLA-DQW2

117
Q

What are the Risk Factors for Coeliac disease?

A 
Family member with coeliac disease or Dermatitis herpetiformis
T1DM
Downs or Turners
AI thyroid disease
Microscopic colitis
Addison's disease
118
Q

What are the symptoms of Coeliac disease?

A 
May be asymptomatic
Abdominal discomfort, pain and distention
Steatorrhoea
Diarrhoea
Tiredness
Malaise
Weight loss
Children failing to thrive
Amenorrhoea in young adults
119
Q

What are signs of Coeliac disease?

A 
Pallor
Short stature
Abdominal disention
Wasted buttocks in children
Osteomalacia
Easy bruising
Itchy blisters on elbows, knees or buttocks (dermatitis herpetiformis)
120
Q

Investigations for Coeliac disease?

A

Specific autoantibodies (IgA, tTG, IgA, EMA, IgG< DGP, HLA-DQ2/DQ8)

121
Q

How do you treat coeliac disease?

A

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

122
Q

What are the complications of Coeliac disease?

A 
Iron, Folate and B12 deficiency
Osteomalacia
Ulcerative jejunoileitis
GI lymphoma if untreated
Cerebellar ataxia (rare)
123
Q

What is a colorectal carcinoma?

A

Adenocarcinomas derived from epithelial cells.

124
Q

Where do colorectal carcinomas normally appear?

A

71% in colon

Rest in the Rectum

125
Q

What are Risk Factors for Colorectal carcinoma?`

A 
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
126
Q

What are the symptoms of Left sided colorectal carcinoma?

A

Change in Bowel habit
Rectal bleeding
Tenesmus

127
Q

What are the symptoms of Right sided colorectal carcinoma?

A 
Presents later
Anaemia symptoms (Lethargy)
Weight loss
Non-specific malaise
Lower abdominal pain (Rare)
128
Q

Whats an important thing not to miss in terms of colorectal carcinoma?

A

20% of tumours will present as an emergency with pain and distention due to:

  • Large Bowel obstruction
  • Haemorrhage or Peritonitis due to perforation
129
Q

What are signs of Colorectal carcinoma?

A

Anaemia
Abdominal mass
Hepatomegaly, Ascites - Mets!
Low-lying rectal tumours may be palpable on DRE

130
Q

What investigations can be done for colorectal carcinoma?

A 
FBC
Renal Function
LFTs
Tumour markers - CEA
Barium Enema
Colonoscopy for biopsy
131
Q

What can you see on Barium enema for a colorectal carcinoma?

A

‘Apple-core’ strictures

132
Q

What is Inflammatory Bowel disease?

A

An Umbrella term used to describe disorders that involve chronic inflammation of your digestive tract

It is Ulcerative colitis or Crohns disease

133
Q

What is Crohn’s disease?

A

Relapsing IBD, characterised by transmural granulomatous inflammation which can affect any part of the GI tract, most commonly the ileum, colon or both.

134
Q

What causes Crohn’s disease?

A

Geneitc and environmental factors

Th1 mediated with TNF-alpha

135
Q

Where does Crohn’s affect?

A

Anywhere from the anus to the mouth
Often has skip lesions
Cobblestone appearance

136
Q

What causes Ulcerative colitis?

A

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

137
Q

Where does Ulcerative colitis affect?

A

Only the colon
Starts at the rectum
May affect terminal ileum if affects whole colon IF an incomplete ileocaecal valve

138
Q

What is Ulcerative colitis?

A

Idiopathic chronic inflammatory disease following a course of relapse and remission

139
Q

What are Risk Factors for Crohns?

A 
Age (15-30 or 50-70)
Caucasian
Family history
NSAID medication
Living in an urban area
140
Q

What are Risk Factors for UC?

A 
Family history
HLA-B27
Infection 
NSAIDs
Not smoking / former smoking
141
Q

What intestinal symptoms are there of Crohn’s disease?

A 
Crampy abdominal pain (inflam, fibrosis or bowel obstruction)
Diarrhoea
Fever
Malaise
Weight loss
142
Q

What extra-intestinal symptoms are there in Crohn’s?

A 
Eye disease (Uveitis)
Joint disease (Seronegative arthritis)
Skin disease (Erythema nodosum)
Anaemia
143
Q

What intestinal symptoms are there of UC?

A 
Bloody or Mucosal diarrhoea
Tenesmus on urgency
Weight loss
Crampy abdominal pain before passing stool
Fever
144
Q

What extra-GI symptoms are there of UC?

A

Uveitis
Scleritis
Erythema nodosum
Pyoderma gangrenosum

145
Q

What Signs are there of Crohn’s disease?

A 
Weight loss
Clubbing 
Signs of anaemia
Aphthous ulcers of the mouth
Perianal skin tags, fistulae and abscesses
146
Q

What signs are there of Ulcerative colitis?

A 
Signs of iron deficiency anaemia
Dehydration
Clubbing
Abdominal tenderness
Tachycardia
Blood, mucous and tenderness on PR examination
147
Q

What investigations can be done for Crohn’s disease?

A 
FBC
Metabolic panel
CRP/ESR
LFT
Serological markers
Faecal calprotectin
Erect CXR (For perforation)
Endoscopy (OGD/Colonoscopy)
148
Q

What investigations can be done for UC?

A 
FBC
Metabolic profile
CRP/ESR
Serological markers (pANCA &amp; ASCA)
Faecal calprotectin
149
Q

How do you manage an acute exacerbation of Crohn’s?

A

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

150
Q

How do you manage Crohn’s long term?

A 
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!
151
Q

How do you manage acute exacerbation of UC?

A 
IV Fluids
IV corticosteroids
ABx
Bowel rest
DVT prophylaxis
152
Q

How do you manage UC normally?

A

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

153
Q

What are the complications of Crohn’s disease?

A 
Haemorrhage
Strictures
Perforation
Fistulae
GI cancer
Uveitis
Episcleritis
Gall stones
Arthropathy
Amyloidosis
PSC
Erythema nodosum 
Ankylosing spondylitis
154
Q

What are complications of UC?

A 
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
155
Q

What is Diverticular disease?

A

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

156
Q

What is Diverticulosis?

A

The presence of out pouching of Mucosa through the muscular wall of the large bowel that is asymptomatic

157
Q

What is diverticular disease?

A

Diverticulosis with complications e.g. Haemorrhage, infection, fistulae

158
Q

What is Diveritculitis?

A

Acute inflammation and infection of colonic diverticulae

159
Q

What is the classification system for acute diverticulitis?

A

Hinchley Classification

160
Q

How does Hinchley classification classify things?

A

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

161
Q

What causes Diverticular disease?

A

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

162
Q

What Risk factors are there for Diverticular disease?

A 
Age > 50 years
Low dietary fibre
Obesity in younger people
Smoking
NSAID and Paracetamol use
163
Q

What are the Symptoms for diverticular disease?

A

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)

164
Q

What are the signs of Diverticular disease?

A 
Only in diverticulitis!
Fever
Tachycardia
Anorexia
Nausea
Vomiting
Leucocytosis
Fullness or mild tenderness in lower left quadrant
165
Q

How else may people present? (What signs could be seen?)

A

Tender mass with persistent fever (Abscess)
Perforation into peritoneum
Complete obstruction (Fibrosis)
Pneumaturia/Faecaluria (Colovesicular fistula)

166
Q

What investigations can be done for Diverticular disease and what would you see?

A

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)

167
Q

How do you manage asymptomatic Diverticular disease?

A

Asymptomatic - No treatment needed (lifestyle advice)

168
Q

How do you manage symptomatic diverticular disease?

A

Symptomatic - Dietary modification + fibre supplementation w/ oral Abx (Co-amoxiclav or Ciprofloxacin)

169
Q

How do you manage uncomplicated diverticulitis?

A 
Analgesia w/ ABx and low-residue diet 
If not (^): Surgery + supportive therapy &amp; ABx + Analgesia + Low-residue diet
170
Q

How do you manage complicated diverticulitis?

A

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

171
Q

How do you manage ongoing symptomatic diverticular disease?

A

Elective surgery (Hartmann’s procedure, resection + anastamosis)

172
Q

What are the complications of Diverticular disease?

A 
Fistulae
Colorectal neoplasm
Abscess
Perforation
Strictures, Obstruction
173
Q

What is Biliary colic?

A

Presence of solid concretions in the Gall bladder

174
Q

What is Choledocholithiasis?

A

Gallstones in the biliary tree

175
Q

What composes gall bladder stones?

A

90% of them compose of cholesterol

176
Q

What are the Risk Factors for Gallstones?

A 
6Fs
Fair (Caucasian)
Fat (Obese)
Female
Fourty (Age)
Fertile (Exogenous oestrogen)

And: Drugs, DM, Low-fibre diet, Non-alcoholic liver disease

177
Q

What are the symptoms of Gall stones?

A 
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)
178
Q

What are signs of Gallstones? (Cholecystitis)

A

Signs of Cholecystitis or Acute cholangitis!

179
Q

What are the investigations for Gallbladder stones?

A

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)

180
Q

How do you manage symptomatic Gall stones?

A

Cholecystectomy

181
Q

How do you manage Choledocholithiasis?

A

ERCP adjunct: Lithotripsy, papillary baloon dilatataion
or
Laporoscopic CBD exploration

182
Q

What are the complications of Gallstones and biliary colic?

A 
ERCP-associated pancreatitis
Iatrogenic bile duct injury
Post-sphincterotomy bleeding
Bouveret syndrome
Gallstone Ileus
Cholecystitis
183
Q

What is Bouveret syndrome?

A

Cholecystoeneteric fistula leading to duodenal obstruction

184
Q

What is gastric cancer?

A 
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
185
Q

What are the Risk factors for Gastric cancer?

A 
Smoked and processed foods
Food high in nitrosamines, nitrates, salt
Pickling
Low vitamin C intake
Alcohol
H. Pylori infections
Pernicious anaemia
Blood group A
186
Q

What are the symptoms of Gastric cancer?

A 
Often asymptomatic early
Early satiety
Epigastric discomfort
Haematemess
Melaena
Anaeamia
Weight loss
Anorexia
Nausea/Vomiting
Dysphagia
Ascites 
Jaundice
187
Q

What are the signs of Gastric cancer on examination?

A 
May be normal
Epigastric mass
Abdominal tenderness
Ascites
Signs of Anaemia
Virchow's node
Sister Mary joseph nodule
Krukenburg's tumour (Ovarian mets)
188
Q

What is Virchow’s node?

A

Lymphadenopathy in the Left supraclavicular fossa

189
Q

What is sister mary joseph nodule?

A

Mets node on the umbilicus

190
Q

What investigations are done for gastric cancer?

A 
Upper GI endoscopy with biopsy
FBC (Anaemia)
CT CAP (Look for mets)
191
Q

Where does Gastric cancer normally metastasise?

A

Liver
Ovaries
Lung
Oesophagus

192
Q

What is Gastroenteritis and infectious colitis?

A

Nonspecific term for a combo of Nausea, vomiting, diarrhoea and abdominal pain - usually an infectious origin

193
Q

What causes Gastroenteritis?

A

Viruses, Bacteria, Protozoa or toxins in contaminated for or water (faeco-oral route)

194
Q

The next few will be Common examples of gastroenteritis and what causes them
What causes an outbreak of D+V in institution?

A

Norovirus

195
Q

What causes dysentry (Bloody diarrhoea)?

A 
CHESS
Campylobacter Jejnui
Haemorrage E coli 0157
Entamoeaba histolytica
Salmonella
Shigella
196
Q

What is the cause of a uni student with watery diarrhoea?

A

C Jejuni

197
Q

What causes Rapid onset diarrhoea after a meal?

A

Staphylococcus Aureus or Bacillus cwerus

198
Q

What causes gastroenteritis and infectious colitis in elderly people on antibiotics?

A

C difficile

199
Q

What causes Gastroenteritis and infectious colitis in travellers?

A

E coli

200
Q

What are commonly contaminated foods and what contaminates them?

A

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

201
Q

What are the Risk Factors for gastroenteritis and infectious colitis?

A 
Age (infants and younger children)
Immunocompromised
Living in crowded areas
Travellers
Winter time
202
Q

What are the symptoms of Gastroenteritis & infectious colitis?

A 
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
203
Q

What is the time of onset for Gastroenteritis / colitis?

A

Caused by:

  • Toxins - 1-24hrs
  • Bacteria/viral/protozoal - 12+ hours
204
Q

What are the signs of gastroenteritis and infectious colitis?

A

Diffuse abdominal tenderness
Abdominal distention
Increased bowel sounds
In severe cases: Pyrexia, dehydration, hypotension and peripheral shutdown

  • Any diarrheal condition can lead to dehydration
205
Q

What investigations can be done for gastroenteritis and infectious colitis?

A

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

206
Q

What is the management for gastroenteritis and infectious colitis?

A

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

207
Q

What are the complications of Gastroenteritis and infectious colitis?

A 
Dehydration
Electrolyte imbalance
Prerenal failure
Secondary lactose intolerance
Sepsis and shock
Haemolytic uraemic syndrome (E.Coli 0157)
GBS weeks after Campylobaster
208
Q

Is gastroenteritis and infectious colitis a notifiable disease?

A

No

Unless caused by botulinum toxin, then it is

Conditions (18 decks)

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