Gastrointestinal conditions and drugs Flashcards
What can cause high or low albumin levels?
Lower albumin my be caused by:
Malnutrition
Liver disease
Kidney disease
Inflammatory disease.
Higher albumin levels may be caused by:
Acute infections
Burns
Stress from surgery or a heart attack.
How can inflammation cause hypoalbuminaemia?
Inflammation increases capillary permeability and escape of serum albumin, leading to expansion of interstitial space and increasing the distribution volume of albumin and therefore lower concentrations in the blood.
What is an abdominal migraine and what are the symptoms?
A neurological condition originating in the brain causing abdominal pain receptors being stimulated resulting in intermittent bouts of generalised severe abdominal pain with associated nausea and vomiting, without a headache migraine. 7/10 sufferers have had previous head migraines
What is cholecystitis and its symptoms?
Inflammation of the gall bladder.
Causes severe upper right quadrant abdominal pain often with referred right shoulder tip pain. Pain is worse on inspiration and palpation (Murphy’s sign is useful tool) and comes with associated nausea, vomiting, pyrexia with a history of intolerance of fatty foods (pain and vomiting)
What symptoms other than pain can accompany appendicitis?
Nausea
Vomiting
Loss of appetite
Constipation
Low grade temperature
Diarrhoea
Facial flushing
Dry tongue
Halitosis
What are possible complications of appendicitis and their symptoms?
Perforation
- Tachycardia and sudden temporary relief or decrease in pain
Peritonitis
- Blumberg’s sign
What is Crohn’s disease?
Crohn’s Disease is an inflammatory bowel disease (IBD) of the GI tract that causes inflammation & ulceration.
What portion of the bowel does Crohn’s disease affect?
Can be in one area or multiple segments (this can be anywhere in the digestive tract from the mouth to the anus) but most usually found in the end of the ileum and the ascending colon
Which layers of the bowel does Crohn’s disease affect?
All of them through to the serosa
What is the internal appearance of Crohn’s?
Bumps of inflamed mucosa give a ‘Cobblestone’ or ‘Skip lesion’ appearance
What is the cause of Crohn’s disease?
No known cause at present but research has shown in many cases it is linked to a faulty immune system. Research also suggests that a persons diet, dairy intake, stress, smoking, a viral or bacterial illness changes the gut flora. Research has also shown that it tends to run in families so it may be genetic.
All of these are scientists best informed opinion at the moment.
How is Crohn’s diagnosed?
A GP would ask for a food diary along with a symptom diary as Crohn’s tends to present with flare ups of symptoms.
A blood test to check for inflammatory markers.
A faecal calprotectin test which tests for inflammation in the bowel (it specifically tests for neutrophil degranulation). - This would tell your clinician that you have inflammatory bowel disease.
You would then likely be referred to a gastroenterologist.
Possibly sent for colonoscopy or biopsy or an MRI/CT scan with contrast dye.
What is the normal age of presentation of Crohn’s disease?
Crohn’s disease presents most commonly in adolescence and early adulthood, but it may occur at any age.
About 20–30% of cases present before the age of 20 years.
The median age at diagnosis is about 30years.
It occurs in men and women at approximately equal rates.
What are the symptoms of Crohn’s disease?
Abdominal pain
Diarrhoea (w/ associated dehydration)
Extra intestinal symptoms
Fatigue & weight loss
Flare up and remission
What is the most common presentation of Crohn’s disease pain?
Lower/mid right side, typically 1-2 hours after eating.
Why does Crohn’s disease cause diorrhea?
1) If the ileum is affected then a patient will have difficulty absorbing fats - this is where diet will play a huge part in symptom control, some patients will find that wheat or dairy cause diarrhoea (this is why the GP will encourage the pt to keep a food diary).
2) If the pt has had part of their ileum removed then they are unable to reabsorb bile salts produced in the liver, these are usually reabsorbed in the ileum and do not enter the colon. If these bile salts do enter the colon this draws fluid into the colon causing watery diarrhoea.
3) Some of the medications given to treat the symptoms of crohns cause diarrhoea.
What extra-intestinal symptoms can be present with Crohn’s disease?
Joint pain
Enteropathic arthritis
Enthesitis
Tenosynovitis
Dactylitis
Mouth ulcers
Angular cheilitis
Crohn’s disease in an inflammatory disease so inflammatory conditions in other body sites are commonly associated with it
How does Crohn’s disease cause joint pain?
The actual relationship is not fully understood but, a protein called tumour necrosis factor that get’s overproduced and it is thought that this amongst other proteins may be the cause
How does Crohn’s disease cause fatigue and weight loss?
Malabsorption associated with GI inflammation/damage - the small intestine is responsible for exchange of nutrients so with increased scar tissue this cannot happen. Malabsorption and malnutrition can also cause anaemia which exacerbates these symptoms
How can Crohn’s disease lead to bowel perforation?
Repeated patches of Crohns can cause damage and scar tissue. This leads to strictures, bowel obstruction and perforation.
What are some common treatments for Crohn’s disease?
Corticosteroids (prednisolone)
Immunosuppressive drugs (thiopurines, methotrexate)
Biologic therapy (anti-tumour necrosis factor e.g. infliximab, adalimumab)
Amino salicylates
Enteral nutritional supplementation
Loperamide (slows gastric transit)
Mebeverine (anti-spasmodic)
Colestyramine (bile salt binder)
When are coticosteroids prescribed to Crohn’s disease patients, for how long are they given?
Prednisolone may be prescribed to manage a flare up, they should not be prescribed long term to prevent flare up. Long term use of corticosteroids causes problems for the patient so they are only used as a short term management option.
When are Aminosalicylates used for patients with Crohn’s disease?
When a patient can no longer tolerate steroid treatments
When may you see some specialist nutritional supplements prescribed for patients with Crohn’s disease?
These are usually in children where they cannot have steroids for various reasons.
What holistic treatment is given for Crohn’s disease, can it be cured?
There is no cure for Crohn’s disease, focus is on:
Diet, medication, lifestyle changes, smoking cessation, referral to gastroenterologist, symptom management.
Surgery may be offered
What surgeries are used to treat Crohn’s disease?
Small-bowel resection (major surgery so only under set circumstances after a while)
Endoscopic balloon dilation (the established endoscopic treatment)
Strictureplasty,
Stents (Fully covered self-expandable metal stents (FCSEMS) have been used for endoscopic treatment of patients for whom EBD was unsuccessful)
What is Ulcerative Colitis?
Ulcerative colitis is an inflammatory bowel disease (IBD) of the colon and rectum. Inflammation damages the bowel wall and areas of ulceration form. These areas bleed, produce more mucus & pus.
What are the main differences between ulcerative colitis and Crohn’s disease?
Crohn’s:
Affects whole intestine
Can affect all layers of bowel wall
Usually begins in the ilium
Found in patches in the bowel wall
Ulcerative colitis:
Affects large intestine
Affects inner lining of colon
Starts in the rectum and migrates back
Affects the bowel wall in a “sheet”
What are the 4 forms of ulcerative colitis?
Ulcerative proctitis – this is limited to the rectum and the most mild type.
Proctosigmoiditis – affects the rectum and the sigmoid
Left sided or distal colitis – affects rectum, sigmoid and descending colon, this being the left side or the most distal part of the colon before the sigmoid.
Pancolitis or total colitis - the whole colon, this is the most severe case.
What are the symptoms of ulcerative colitis?
Abdo pain and cramps
Fever
Anaemia
Urgent and frequent bowel movements (the colon is irritated and therefore wants to empty frequently in an attempt to dispel the irritation)
Watery diarrhoea w blood/mucus/pus (from ulcers)
Dehydration & electrolyte imbalances (colon usually absorbs most of the bodies water)
Weight loss/fatigue
Low appetite
What does the mnemonic – ULCERS stand for?
U-rgent bowel movements
L-oss of weight & Low RBC
C-ramps in abdo
E-lectrolyte imbalance & Elevated temperature
R-ectal bleeding
S-evere diarrhoea (w blood/mucus/pus)
What causes ulcerative colitis?
No known cause at present but research has shown in many cases it is linked to a faulty immune system i.e. an over-reaction to substances.
Research suggests that a persons diet, dairy intake, stress, smoking, a viral or bacterial illness changing the gut flora may all be responsible for flare ups in the condition.
How are patients diagnosed with ulcerative colitis?
Patients will be asked to keep a food diary, tested for anaemia & inflammatory markers, and tested for blood in stools
Colonoscopy - easier to access with a camera and track backwards through the colon just as the condition does, can usually see how far it has progressed
Barium enema – contrast dye enema & xray
It is a long process
What treatment and symptom control is used for patients with ulcerative colitis?
Steroids
Amino salicylates
Immune suppressants/immunomodulators
Antibiotics
Surgery – proctocolectomy (the removal of the colon & rectum, this would then require a permanent ileostomy)
Symptom control:
Anti diarrhoea meds
Pain relief (no NSAIDs - can cause flare up and increase ulcers)
Nutritional supplements
Specific diet (no nuts/seeds/fibre things that are difficult to digest. High fat/spicy foods/dairy to avoid)
How many people in the UK live with ulcerative colitis or Crohn’s disease?
500,000
Is ulcerative colitis a young or old onset disease?
Generally, a young onset disease
What is pancreatitis and how is it categorised?
Inflammation of the pancreas for any reason. It can be categorised as;
Acute
Chronic
Hereditary
Calcifying
Necrotising
Haemorrhagic
Not mutually exclusive, overlap is common
Bile/pancreatic duct are closed/narrowied, pancreatic enzymes build up and cause damage
What are the causes and risk factors for acute pancreatitis?
I GET SMASHED
Idiopathic
Gall stones (number one cause for acute)
Ethanol (number one for chronic, two for acute)
Trauma
Steroids
Mumps/Malignancy
Autoimmune
Scorpion stings
Hypercholesteremia/hypercalcemia
ERCP
Drugs
Why can pregnancy cause gallstones and pancreatitis?
Gallstones leading to pancreatitis can be common in pregnancy due to weight gain and hormonal changes - internal organs also getting compressed
How does ethanol (alcohol) cause pancreatitis?
Exact mechanism not known. However it is known that alcohol stimulates pancreatic secretions and may also induce oedema and spasm of the pancreatic sphincter around the end of the duct.
This leads to high intraductal pressure which causes duct necrosis and escape of pancreatic enzymes into the tissue. The enzymes cause widespread damage and therefore inflammation to the pancreas.
What is the epidiemiology for acute and chronic pancreatitis?
Acute
Gall stones approx. 50% of cases
Chronic alcohol consumption approx. 25%
Other factors account for the remaining 25%
Chronic
Chronic alcohol consumption approx. 70-80%
The male to female ratio is 7:1
average age of onset is between 36 and 55 years
Significant increase in risk in pancreatic CA
What are the symptoms of acute pancreatitis?
Sudden severe epigastric pain
Post prandial pain
Pain increases over time – radiates across back
Nausea/vomiting
Indigestion
Pyrexia of 38°c or more
Jaundice in sclera/skin
Abdo tenderness on palpation
Tachycardia/tachypnoea
What treatment is given for acute pancreatitis?
Treatment is supportive in nature, patients usually feel better after 48hrs with treament:
Analgesia
Fluids
Treatment for an infection (can cause necrosis and sepsis)
Treatment of cause if possible (gall stones, toxins etc.)
Lifestyle advice
Worsening care advice on discharge
What are the symptoms of chronic pancreatitis?
Same as acute symptoms, especially during flare ups, however usually more gradual and/or intermittent
Other symptoms will develop as the damage to the pancreas progresses and ther is more difficulty breaking down fats & some proteins:
Weight loss
Loss of appetite
Jaundice
Diabetes
Grey turners sign and Cullen’s sign (can be caused by severe acute necrotizing pancreatitis, but really the research has shown it is non-specific and may be present with almost any condition causing intra-abdominal or retroperitoneal bleeding - present in about 1% of pancreatitis cases)
What is the treatment for chronic pancreatitis?
Supportive in nature:
Analgesia
Fluids
Lifestyle advice
Long term steroids
Enzyme supplements
Endoscopic surgery (Endoscopic Retrograde Cholangio pancreas tography (ERCP), may remove gallstones or debris blocking the duct, drainage of any area of strictures, drainage of any cysts that may have formed.)
Pancreas resection/Total pancreatectomy (drastic measure usually only done for CA and in trauma, long term consequences)
What is liver cirrhosis?
Cirrhosis is a disorder in which the liver demonstrates extensive diffuse fibrosis and loss of lobular organization.
The liver can regenerate itself however if the liver is being damaged faster than it can replace itself then damaged tissue is just replaced with fibrous scar tissue, this degeneration is cirrhosis.
How does liver cirrhosis affect the size of the liver and what can it lead to?
Initially the liver is enlarged but it becomes small and shrunken as fibrosis occurs.
Leads to portal hypertension and end stage liver disease
If the primary cause is removed further damage may still occur because fibrosis interferes with the blood supply to the liver tissues.
What is the most common cause of liver cirrhosis?
Alcoholic liver disease
How can liver disease or cirrhosis lead to nervous sytem dysfunction?
Liver dysfunction and collateral vein formation can cause altered blood chemistry and the build up of excessive ammonia (which can cross the BBB) or other toxic substances. These travel around the central circulation and can affect the central nervous system and brain leading to hepatic encephalopathy.
How does liver cirrhosis affect its cell function?
Decreased removal and conjugation of bilirubin
Decreased production of bile
Decreased removal of toxins such as drugs
Decreased production of blood clotting factors and plasma proteins
Impaired digestion and absorption of nutrients particularly fats
How can liver cirrhosis affect its blood and bile flow function?
Reduction in the amount of bile entering intestine
–digestion and absorption impairment.
Back up of bile in liver
-elevated bilirubin levels in the blood causes jaundice.
Congestion of bile in the spleen
-leading to Splenomegaly
Blockage of blood to the liver
-leading to portal hypertension
Development of ascites and oesophageal varices
-Portal hypertension causes an increase in the pressure of blood in the gastric veins which can lead to the formation of oesophageal varices which can haemorrhage and be life threatening.
How does alcohol intake lead to end stage cirrhosis and cancer?
1) Fatty Liver – Accumulation of fat in the liver cells. Other than enlargement of the liver (hepatomegaly) this stage is asymptomatic and can be reversible if alcohol intake is reduced.
2) Alcoholic Hepatitis – Inflammation and necrosis occur and fibrous tissue forms which is irreversible. This may be asymptomatic or manifest with mild symtoms such as anorexia, nausea and liver tenderness.
3) End stage cirrhosis – When fibrous tissue replaces so much of the normal liver tissue that the basic structure of the liver is significantly altered and little function remains. Cancer can develop
What are peptic ulcers?
A Peptic ulcer is an erosion in a segment of the gastrointestinal mucosa called the muscularis mucosa, typically in the stomach (gastric ulcer) or the first few centimeters of the duodenum (duodenal ulcer), Ulcers may range in size from several millimeters to several centimeters.
What causes pain and haemorrhaging of peptic ulcers?
Irritants such as bacteria (specifically h.pylori), stomach acid or NSAIDs can cause wounds which may progress deeper and form ulcers.
Inflammatory mediators released to aid tissue repair can cause pain in the area.
Consistent irritation by medications or irritating foods can aggravate the condition and lead to perforation or hemorrhage.
The presence of perforation may lead to peritonitis and may become life-threatening because of sepsis and profuse bleeding.
Haematemesis or melaena are associated with erosion of a large blood vessel and significant haemorrhage.
Urgent admission to hospital is required.
What are the symptoms of peptic ulcers?
Burning/gnawing central abdo pain
Indigestions
Black/tarry stools
Heartburn
Loss of appetite
Nausea/vomiting (w/ haemetemesis)
Bloating
Weight loss
Some people also find theyburp or become bloated after eating fatty foods.
Nearly 75 percent of people who have gastric or duodenal ulcers don’t have any symptoms
What is the pathophysiology of coeliac disease?
It is an auto immune condition where the immune system mistakenly attacks healthy cells in response to the presence of “gliadin” which is a protein found in gluten.
Gliadin is an amino acid, the body does not break it down as it normally would, it tries to but can’t and breaks it into chains of ‘peptides’.
As soon as the immune system sees these peptides crossing the cell membrane it tries to kill them. The antibodies are trying to kill these short chains of peptides and the villi are damaged in the process.
This constant process damages a large proportion of the intestinal villi.
What is the difference between coeliac disease and gluten intolerance?
When a celiac person ingests gluten, his or her immune system will attack against its own body’s tissue. Whereas, if a person is gluten intolerant, the consumption of gluten will cause short-term bloating and belly pain. Unlike celiac disease, gluten intolerance doesn’t usually cause long-term harm to the body.
What is peritonitis?
Inflammation of the peritoneal membrane
What causes peritonitis?
How does peritonitis cause symtpoms and complications?
What are the common pathogens that cause gastroenteritis and their sources?
How do the parietal cells of the stomach work?
When stimulated by gastrin, histamine or acytlecholine they move hydrogen into the stomach and potassium back into the parietal cell via a proton pump. The hydrogen binds with chlorine to form hydrochloric acid
