General Gastrointestinal Medicine Flashcards
What are the causes of dysphagia?
They fall into 3 broad categories; mechanical block, motility disorders and others.
Mechanical Block: Malignant strictures (oesophageal, gastric or pharyngeal cancer) Benign strictures (oesophageal web or peptic stricture) Extrinsic pressure (lung cancer, mediastinal lymph nodes, retrosternal goitre, aortic aneurysm or left atrial enlargement) Pharyngeal pouch
Motility Disorders: Achalasia Diffuse oesophageal spasm Systemic sclerosis Neurological bulbar palsy pseudobulbar palsy Wilson's or Parkinson's Disease Syringobulbia Bulbar poliomyelitis Chagas' Disease Myasthenia gravis
Others:
Oesophagitis
Globus
What is dysphagia?
Difficulty swallowing.
What is odynophagia?
Painful swallowing.
What is Zollinger-Ellison syndrome?
Zollinger-Ellison syndrome is condition characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas. Around 30% occur as part of MEN type I syndrome
Features
multiple gastroduodenal ulcers
diarrhoea
malabsorption
Diagnosis
fasting gastrin levels: the single best screen test
secretin stimulation test
What are the organs affected in MEN- type 1?
parathyroid (95%): hyperparathyroidism due to parathyroid hyperplasia
pituitary (70%)
pancreas (50%, e.g. Insulinoma, gastrinoma)
also: adrenal and thyroid
What are the differences between Crohn’s and ulcerative colitis?
Crohn’s disease (CD)
Features
- Diarrhoea usually non-bloody
- Weight loss more prominent
- Upper gastrointestinal symptoms, mouth ulcers, perianal disease
- Abdominal mass palpable in the right iliac fossa
Extra-intestinal
- Gallstones are more common secondary to reduced bile acid reabsorption
- Oxalate renal stones*
Complications
- Obstruction
- fistula
- colorectal cancer
Pathology
- Lesions may be seen anywhere from the mouth to anus
- Skip lesions may be present
Histology
- Inflammation in all layers from mucosa to serosa
increased goblet cells
- granulomas
Endoscopy
- Deep ulcers
- skip lesions
- ‘cobble-stone’ appearance
Radiology - Small bowel enema - high sensitivity and specificity for examination of the terminal ileum strictures: - 'Kantor's string sign' proximal bowel dilation - 'rose thorn' ulcers - fistulae
Ulcerative colitis (UC)
Features
- Bloody diarrhoea more common
- Abdominal pain in the left lower quadrant
- Tenesmus
Extra-intestinal
- Primary sclerosing cholangitis more common
Complications
- Risk of colorectal cancer high in UC than CD
Pathology
- Inflammation always starts at rectum and never spreads beyond ileocaecal valve
- Continuous disease
Histology
- No inflammation beyond submucosa (unless fulminant disease) - inflammatory cell infiltrate in lamina propria
neutrophils migrate through the walls of glands to form crypt abscesses
- depletion of goblet cells and mucin from gland epithelium
- granulomas are infrequent
Endoscopy
- Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
Radiology
- Barium enema
- loss of haustrations
- superficial ulceration
- ‘pseudopolyps’
- long standing disease: colon is narrow and short -‘drainpipe colon’
What is Whipple’s disease?
Whipple’s disease is a rare multi-system disorder caused by Tropheryma whippelii infection. It is more common in those who are HLA-B27 positive and in middle-aged men
Features
- malabsorption: diarrhoea, weight loss
- large-joint arthralgia
- lymphadenopathy
- skin: hyperpigmentation and photosensitivity
- pleurisy
- pericarditis
- neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus
Investigation
- jejunal biopsy shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules
Management
- guidelines vary: oral co-trimoxazole for a year is thought to have the lowest relapse rate, sometimes preceded by a course of IV penicillin
How should a paracetamol overdose be managed?
Acetylcysteine should be given if:
there is a staggered overdose or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or
the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity
Acetylcysteine is now infused over 1 hour (rather than the previous 15 minutes) to reduce the number of adverse effects.
What is the King’s College Hospital criteria for liver transplantation in paracetamol overdose?
Arterial pH < 7.3, 24 hours after ingestion
or all of the following:
prothrombin time > 100 seconds
creatinine > 300 µmol/l
grade III or IV encephalopathy
What is the presentation of congestive hepatomegaly?
The liver only usually causes pain if stretched. One common way this can occur is as a consequence of congestive heart failure. In severe cases cirrhosis may occur.
What is the presentation of biliary colic?
RUQ pain, intermittent, usually begins abruptly and subsides gradually. Attacks often occur after eating. Nausea is common.
It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalisation.
What is the presentation of acute cholecysitits?
Pain similar to biliary colic but more severe and persistent. The pain may radiate to the back or right shoulder.
The patient may be pyrexial and Murphy’s sign positive (arrest of inspiration on palpation of the RUQ)
What is the presentation of ascending cholangitis?
An infection of the bile ducts commonly secondary to gallstones. Classically presents with a triad of:
- fever (rigors are common)
- RUQ pain
- jaundice
What is the presentation of gallstone ileus?
This describes small bowel obstruction secondary to an impacted gallstone. It may develop if a fistula forms between a gangrenous gallbladder and the duodenum.
Abdominal pain, distension and vomiting are seen.
What is the presentation of cholangiocarcinoma?
Persistent biliary colic symptoms, associated with anorexia, jaundice and weight loss. A palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen
