Gastrointestinal Disease

Question 1

What are the physiological GI changes in pregnancy?

Answer 1

Decreased Lower oesophageal sphincter pressure
Decreased gastric peristalsis
Delayed gastric emptying
Inhibited gastrointestinal motility - increased small and large bowel transit times

Question 2

What is the classic finding on the blood gas in hyperemesis?

Answer 2

Metabolic hypochloraemic alkalosis

Question 3

What are the TFTs in hyperemesis?

Answer 3

Biochemical hyperthyroidism

• Raised free thyroxine and/or suppressed TSH
• Clinically euthyroid
• Abnormal TFTs do not require treatment with anti-thyroid drugs and resolve as the hyperemesis improves

Question 4

HCG shares a common alpha subunit with

Answer 4

TSH

Probably acts as a thyroid stimulator in patients with hyperemesis

Question 5

With abnormal TFTs in hyperemesis, how do you differentiate between primary thyroid disease vs complication of hyperemesis?

Answer 5

History
- weight loss
- palpitations
- tremor
Presence of thyroid-stimulating antibodies

Question 6

What are the clinical features of Wernicke’s encephalopathy?

Answer 6

Blurred vision, unsteadiness, confusion / memory problems / drowsiness
O/E: nystagmus, opthalmoplegia, 6th nerve palsy, hyporeflexia, gait / finger nose ataxia
Bloods: abnormal LFTs
Imaging: MRI shows symmetrically increased signal intensity in the mesencephalic tegmentum around the aqueduct, mammillary bodies, and medial thalamus on T2 weight imaging

Question 7

What is the main complication of severe hyponatraemia (and its rapid reversal)

Answer 7

Central pontine myelinolysis

Symmetrical destruction of myelin at the centre of the basal pons
Causes pyramidal tract signs, spastic quadraparesis, pseudobulbar palsy, impaired consciousness

Question 8

What are three vitamin deficiencies and their consequences, in hyperemesis?

Answer 8

B1 / thiamine - Wernicke’s encephalopathy
B12 /cobalamin - Anaemia
B6 / pyroxidine - Peripheral neuropathy

Question 9

What is the incidence of fetal death in Wernicke’s encephalopathy?

Answer 9

40%

Question 10

What is the fetal risk in hyperemesis?

Answer 10

SGA

Question 11

What is the pathogenesis of constipation in pregnancy?

Answer 11

Vasodilator prostaglandins and vascular endothelial substances
Leads to decreased colonic motility
Pressure on rectosigmoid colon by the gravid uterus

Oral iron supplements
Poor fluid and food intake related to HG may exacerbate it

Question 12

Where is the disease in UC vs Crohns?

Answer 12

UC: confined to the colon

Crohn’s: any part of the GI tract
terminal ileum (30%), ileum and colon (50%), colon alone (20%)

Question 13

How does UC present?

Answer 13

Liquid diarrhoea
Lower abdominal pain
Urgency of defection
Passage of blood and mucous PR

Question 14

How does Crohn’s present?

Answer 14

Cramping mid-abdominal pain
Diarrhoea
Weight loss

Question 15

What are the complications of UC?

Answer 15

Colonic dilatation / toxic megacolon

Malignancy

Question 16

What are the complications of Crohn’s disease

Answer 16

Perforation
Stricture formation
Peri-anal problems
Fistula
Abscess formation
Malabsorption

Question 17

What are extraintestinal manifestations of IBD?

Answer 17

Arthritis
Aphthous ulcers (CD)
Gallstones
Ascending cholangitis
Primary sclerosing cholangitis
Conjunctivitis / irodocyclitis / episcleritis
Erythema nodosum / pyoderma gangrenosum

Question 18

What lesions are typical in Crohn’s Disease?

Answer 18

Skip lesions

Question 19

What is the risk of exacerbation of UC vs Crohn’s in pregnancy?

Answer 19

UC: risk of exacerbation is doubled compared to non-pregnancy. Exacerbations are usually mild and occur during the first two trimesters. Also 6x risk postpartum flare

CD: no more likelyto relapse in pregnancy / postpartum than non-pregnant

Highest risk relates to those women with active disease at the time of conception and those who develop IBD for the first time in pregnancy

Question 20

Active disease of IBD at time of conception is associated with what fetal risks?

Answer 20

Miscarriage

PTB

Question 21

What is the management of IBD in pregnancy?

Answer 21

5-aminosalicylates: sulfasalazine, mesalazine
Dihydrofolate reductase inhibitor
Blocks the conversion of folate to it’s more active metabolites

Use 5mg folic acid

Question 22

When is CS indicated in IBD?

Answer 22

Usual obstetric indications

Severe peri-anal CD
Rectovaginal fistulae

Question 23

What are the genes associated with Coelaic disease?

Answer 23

HLA DQ2 (90%)

HLA DQ8 (10%)

Question 24

What is the pathogenesis of Coeliac’s disease?

Answer 24

Autoimmune
Immunological response to the ingestion of gluten, leads to villous atrophy in small bowel and reduced absorption driving malnutrition and anaemia due to iron, B12 and folate deficiency.

Question 25

How is Coeliac disease diagnosed?

Answer 25

Serology:
endomysial antibody
tissue tranglutaminase
deaminated gliadin peptide

Outside pregnancy: duodenal biopsy. Histo: villous atrophy and increased intraepithelial lymphocytes

Question 26

What is the management of Coeliac disease in pregnancy?

Answer 26

Gluten-free diet

Monitor for deficiencies of Ca, Vit D, Vit B12, folate, iron

Question 27

What are the obstetric risks of coeliac disease?

Answer 27

Miscarriage
SGA
PTB

Risks significantly reduced by a gluten-free diet

Question 28

What are the clinical features of IBS?

Answer 28

Recurrence episodes of abdominal pain
Altered bowel habit (most commonly constipation)
Long history, long symptom-free periods

Question 29

What is the pathogenesis of IBS?

Answer 29

Not known
Abnormal gut motility may be a contributory factor
Symptoms are usually exacerbated or brought on by stress

Question 30

What is the commonest non-obstetric indication for laparotomy in pregnancy?

Answer 30

Appendicitis

Question 31

What are the complications of appendicits in pregnancy?

Answer 31

Perforation

- associated 20% risk of PTB and perinatal mortality

Question 32

What are the USS findings suggestive of appendicitis

Answer 32

Outer diameter >6mm
Non-compressibility
Lack of peristalsis
Peri-appendiceal fluid collection

Question 33

What is the recommended management for appendicits in pregnancy?

Answer 33

Appendectomy