GI 1 Flashcards
What are some causes of GORD?
Hiatus hernia (sliding 80%, rolling 20%)
Loss of oesophageal peristaltic function
Abdominal obesity
Gastric acid hypersecretion
Slow gastric emptying
Overeating
Smoking
Alcohol
Pregnancy
Drugs
Systemic sclerosis
How does GORD present?
Heartburn
Belching
Food/Acid regurg
Increased salivation
Odynophagia (pain on swallowing)
Nocturnal asthma
Chronic cough
Laryngitis
Sinusitis
How would you investigate GORD?
trial PPI
oesophagogastroduodenoscopy (OGD)
ambulatory pH monitoring
Oesophageal manometry
How would you manage GORD?
PPI - omeprazole
Lifestyle changes : weight loss, head-of-bed elevation, avoid late night eating
H2 antagonist - ranitidine
Nissen fundoplication
What are some complications of GORD?
Peptic Stricture - inflamm of oesophagus = causes narrowing and a stricture
Barrett’s oesophagus - metaplasia from squamous to columnar (premalignant for adenocarcinoma of the oesophagus)
Where does a Mallory-Weiss tear occur? What are some causes?
mucosal tear occurring at the oesophagogastric junction produced by a sudden increase in intra-abdominal pressure
What are some risk factors for Mallory-Weiss tear?
Alcoholism
Forceful vomiting
Eating disorders
Male
NSAID abuse
How would you investigate a Mallory-Weiss tear?
FBC - initial evaluation of patient with bleed
Urea - should be high in patient with ongoing bleeding
LFTs - liver disease may predispose a patient to oesophageal varices
Prothrombin time
Oesophagogastroduodenoscopy - after bleed stabilisation
cross-match/blood grouping
How would you manage Mallory-Weiss tear?
IV fluids (PPI in high risk patients)
Phytomenadione (vit K) - if prolonged PT/INR
Hemoclip placement
Adrenaline
Endoscopic band ligation
anti-emetic - ondansetron
Sengstaken-Blackmore tube
What are the two sphincters of the stomach?
gastro-oesophageal sphincter
pyloric sphincter - controls gastric contents into the duodenum
What cells are present in the muscosa in the upper 2/3rds of the stomach?
What are their functions?
Parietal cells - secrete HCL
Chief cells - pepsinogen and initiate proteolysis
Enterochromaffin-like cells - releases histamine (stimulates acid release)
What cells are found in the antral muscosa of the stomach?
What are their functions?
Mucus secreting cells - secrete mucin (protect gastric mucosa) and bicarb
G cells - secrete gastrin - stimulates acid release
D cells - secrete somatostatin - suppressant of acid secretion
What glands in the duodenum release alkaline mucus?
Brunner’s glands - in combination with pancreatic and biliary secretions = neutralise the acid secretion from the stomach
What are peptic ulcers? Where are duodenal ulcers and gastric ulcers found?
Break in the superficial epithelial cells penetrating down to the muscularis mucosa
Duodenal ulcers are more commonly found in the dueodenal cap
Gastric ulcers are most commonly seen on the lesser curve of the stomach
What are some causes of peptic ulcers?
Helicobacter pylori infection
Drugs - NSAIDs, steroids and SSRIs
Smoking
Delayed gastric emptying
Which is more common? Duodenal or gastric ulcers?
Duodenal ulcers more common
How do peptic ulcers present?
Recurrent burning epigastric pain
Duodenal ulcers = night and worse when hungry
Nausea
Anorexia and weight loss - particularly with gastric ulcers
What are some red flag symptoms to be aware when investigating peptic ulcers?
Unexplained weight loss
Anaemia
GI bleeding - melena or hematemesis
Dysphagia
Upper Abdominal mass
Persistent vomiting
How would you investigate peptic ulcers?
H.pylori urea breath test or stool antigen test
Upper GI endoscopy
FBC - microcytic anaemia
How would you treat a peptic ulcer?
PPI - omeprazole
H2 antagonist - ranitidine
If H.pylori positive - TRIPLE THERAPY = PPI, clarithromycin, metronidazole
What are causes of gastrointestinal varices?
All due to portal hypertension
- Alcoholism
- Viral cirrhosis
- Pre-hepatic - thrombosis in portal or splenic vein
- Intra-hepatic - cirrhosis, schistosomiasis, sarcoid, congenital hepatic fibrosis
- Post-hepatic - budd-chiari syndrome, right heart failure, constrictive pericarditis
How would a oesophago-gastric varices present?
if ruptured:
Haematemesis
Abdo pain
Shock
Fresh rectal bleeding
Hypotension and tachycardia
Pallor
signs of chronic liver damage : splenomegaly
ascites
hyponatraemia
How would you investigate an oesophago-gastric varices?
FBC - microcytic anaema or thrombocytopenia
LFTs - elevated transaminases, Alk phos and bilirubin
Urea and creatinine
Oesophagogastroduodenoscopy (OGD)
blood typing/cross-matching
How would you manage an oesophago-gastric varices?
Vasoactive drugs - terlipressin
Prophylatic abx - ceftriaxone
TIPS - trans-jugular intrahepatic porto-systemic shint
What is Achalasia? What causes it?
Oesophageal aperistalsis and impaired relaxation of the lower oesophageal sphincter
caused by degeneration of mesenteric plexus of the oesophagus
How does Achalasia present?
Dysphagia for fluids and solids
Regurg of food particularly at night
Substernal cramps
How would you investigate Achalasia?
Endoscopy
Barium swallow - loss of peristalsis and delayed oesophageal emptying
Oesophageal manometry
How would you treat achalasia?
Nifedipine
Pneumatic dilation
Injection of botulinum toxin A
Laparoscopic cardiomyotomy
What is the difference between gastritis and gastropathy?
Gastritis = inflammation assoc with muscosal injury
Gastropathy = indicates epithelial cell damage and regeneration WITHOUT
inflammation - commonest cause is mucosal damage associated with Aspirin/
NSAIDs
What are some causes of gastritis?
H.Pylori infection
Autoimmune gastritis
Viruses - CMV, herpes simplex
Duodenogastric reflux
Mucosal ischaemia
Increased acid
Aspirin and NSAIDs
Alcohol
How does gastritis present?
Nausea or recurrent upset stomach
Abdo bloating
Epigastric pain
Vomiting
Indigestion
Hematemesis
How do you investigate Gatritis?
H.pylori urea breath test
H.pylori faecal antigen test
FBC
How would you manage gastritis?
Ranitidine
H.pylori - triple therapy
Autoimmune - cyanocobalamin
What are some causes of malabsorption?
Pancreatic insufficiency
Defective bile secretion
Bacterial Overgrowth
Coeliac disease
Crohn’s
Giardia Lamlia
Surgical resection of bowel
Lack of digestive enzymes
Defective epithelial transport
Lymphatic obstruction
What is coeliac disease ?
T-cell mediated autoimmune disease of the small bowel in which PROLAMIN intolerance causes villous atrophy and malabsorption
What are some forms of Prolamin?
Gliadin = wheat
Hordeins = barley
Secalins = rye
What are some risk factors for coeliac disease?
Type 1 diabetes
Thyroid disease
Sjogrens
IgA deficiency
Breast feeding
Age of introduction to gluten into diet
Rotavirus infection in infancy
Which part of the bowel is most affected by coeliac disease? What is the consequence of this part being affected?
proximal small bowel
Meaning B12, folate and iron cannot be absorbed = anaemia
How does coeliac disease present?
1/3 asymptomatic
steatorrhoea
diarrhoea
abdominal pain
bloating
nausea & vomiting
angular stomatitis
weight loss
fatigue
anaemia
osteomalacia
How would you investigate coeliac disease?
Small bowel histology - gold-standard
FBC and blood smear - low Hb and microcytic red cells
IgA-tTg - increased titre
endomysial antibody - alt to IgAtTG with greater specificity and lower sensitiviy
skin biopsy - IgA dermal deposits
Endoscopy -
How would you manage coeliac disease?
gluten-free diet
calcium and iron supplements
correct electrolytes
prednisolone
What are histological findings on biopsy that would indicate coeliac disease?
villous atrophy
crypt hyperplasia
increased intraepithelial white cell count
What are the forms of Ulcerative Colitis?
Proctitis - just rectum - 50%
Left-sided colitis - rectum and left colon - 30%
Entire Colon/up to ileocaecal valve- pancolitis/extensive colitis - 20%
What are some risk factors for UC?
Fam Hx
NSAIDs
smoking is protective
chronic stress and depression trigger flares
How does UC present?
runs a course of remissions and exacerbations
restricted pain usually in lower left quadrant
episodic or chronic diarrhoea with blood and mucus
cramps
in acute UC - may be fever, tacycardia and tender distened abdomen
What are some extra intestinal signs of UC?
clubbing
apththous oral
ulcers
erythema nodusum
amyloidosis
How would you investigate UC?
Stool studies - faecal calprotectin
ESR/CRP - suggestive of flare-ups
flexible sigmoidoscopy
colonoscopy
biopsy
What are some macroscopic findings of UC?
only colon up to ileocaecal valve
begins in the rectum and extends
NO skip lesions
What are some microscopic findings of UC?
mucosal inflammation ONLY - it is not transmural
depleted goblet cells
increased crypt abscesses
How would you manage UC?
Acute - methylprednisolone
IV fluids
ciclosporin
non-acute - mesalazine (5ASA)
prednisolone
ciclosporin
colectomy
Which part of the GI tract is affected by Crohn’s?
Any part of the gut from mouth to anus
Esp. terminal ileum and proximal colon
There are parts of unaffected bowel = skip lesions
What are some risk factors for Crohn’s?
genetic association (mutation in NOD2)
smoking
NSAIDs may exacerbate
Fam Hx
Chronic stress and depression
Appendictomy may increase risk
What are macroscopic features of Crohn’s?
not continuous = skip lesions
involved bowel is usually thickend and often narrowed
Cobblestone appearance due to ulcers and fissures
What are some microscopic features of Crohn’s?
Transmural inflammation = through all layers
lymphoid hyperplasia
granulomas present - non-caseating epitheloid cells
goblet cells present
How does Crohn’s present?
diarrhoea with urgency
bleeding
pain - acute right iliac fossa pain
weight loss
malaise
lethargy
perinal abscess
anal strictures
What are some extra-intestinal features of Crohn’s?
apthous ulcers, clubbing, skin, joint and eye problems
How would you investigate Crohn’s?
FBC
Iron studies
B12 and folate
ESR and CRP
CT scan
Colonoscopy and biopsy
How would you treat Crohn’s?
Budesonide/Mesalazine
Azathioprine
MTX
