GI Flashcards by Muna Ahmed

Dysphagia:
Achalasia- Features?
Hx?

Achalasia  ↑LOS tone, ↓LOS relaxation, ↓Peristalsis
•	History
o	Younger (25-40)
o	Non-smoker + non-drinker
o	Solid+liquid dysphagia @ SAME TIME 
	progressively gets worse

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Achalasia: Ix, Mx?

• Investigations
o Initial Tests:
 Barium swallow
• Tapering of oesophagus/rats tail/birds beak

o Best Test: Manometry
 High LOS pressure which fails to relax on swallowing

• Treatment

o First: Heller Myotomy (removal of LOS) + PPI (after) as ↑↑GORD
 90% cure rate

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Oesophageal Tumours

• Types?

• Types:
o Adenocarcinoma
 Cause: GORD

o SCC
 Cause: Smoking, alcohol

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Dysphagia: Oesophageal Tumours: Features? Ix & Mx?

• Features:
o Dysphagia (solid  liquid)
o Weight loss (significant)

• Ix:
o First: Barium swallow
o Best: Endoscopy + Biopsy
o Confirmed cancer: CT CAP

• Rx: Stenting, Radio, Chemo, Surgery

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Dysphagia: Diffuse Oesophageal Spasm + Nutcracker Oesophagus: Features, Ix & Mx?

• Features
o History of INTERMITTENT chest PAIN associated with swallowing (sometimes)

• Investigations
o Initial test: Barium swallow  Corkscrew oesophagus

o Best test: Manometry
 DOS  <180mmHg
 Nutcracker  >180mmHg

• Treatment
o CCB

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Dysphagia: Pharyngeal Pouch/Zenker’s diverticulum: Features, Ix & Mx?

•	Features
o	Old male (>70; 5:1 M:F)
o	Bad breath/halitosis
o	Regurgitation of undigested food
o	Neck bulge + gurgling on swallowing

• Investigations
o Best test: Barium swallow
o DO NOT DO ENDOSCOPY
o DO NOT INSERT NASOGASTRIC TUBE

• Treatment
o Diverticulectomy

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GORD: Modifiable risk factors & Symptoms?

• Modifiable Risk: Smoking, Alcohol, Caffeine, Spicy food

•	Symptoms
o	Upward flow of acid symptoms
	Waterbrash reaction
	Pain radiating to sternum/neck, worse on lying down, better on sitting up
	Metallic taste in mouth
	Sore throat + odynophagia
o	Downward flow of acid symptoms (into trachea region)
	Hoarse voice
	Chronic dry cough

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GORD: Ix, Mx?

• Ix:
o No investigations – treat empirically

• Rx:
o First: Medical
 First: Full dose PPI x1month + LIFESTYLE
 If recurs: Lowest effective dose PPI long-term + LIFESTYLE
 Still refractory: Increase dose PPI
 Full dose PPI fails: Add H2RA (e.g. ranitidine)

o Refractory to MedRx: Surgery
 Nissen fundoplication

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Peptic Ulcer Disease (PUD – Gastric Ulcer + Duodenal Ulcer): Causes, Symptoms, Dx & Mx?

• Causes
o Helicobacter Pylori
o NSAIDs

• Symptoms
o Epigastric pain + tenderness (on palpation)
o Melena/haematemesis

• Diagnosis
o Best: Endoscopy  Look for ulcers, and treat (adrenaline, cautery, clip)

• Treatment
o H pylori absent, NSAID-induced: Lifestyle mod + NSAID removal + PPI

o H pylori present, healing:
 First line: Triple therapy (double-dose PPI BD + Clarithromycin + Metro/Amox)

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Coeliac disease: Pathophysiology & symptoms?

• Pathophysiology  Repeated gluten intake = villous atrophy = malabsorption

•	Symptoms
o	Abdominal pain/cramping
o	Steatorrhoea
o	Floating stools
o	Weight loss 2nd to diarrhoea
o	Fat soluble vitamin deficiency
	Vit A, Vit D  Hypocalcaemia, Vit E, Vit K  Bleeding
o	Reaction to wheat products

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Coeliac Disease: Ix & Mx?

• Investigations

o Antibodies
 First:
• Anti-TTG

 NB: Abs become NEGATIVE after weeks/months of gluten-free diet
 Before testing, ask patient to introduce gluten for 6wk prior to testing

• Best: SB biopsy (Duodenal – D2)
o Findings
 Subtotal villous atrophy
 Crypt hyperplasia

o MUST be done to exclude lymphoma

• Treatment:
o Conservative: MDT, education, dietician input, gluten free diet

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Acute Pancreatitis

• Cause?

GET SMASHED:

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Acute pancreatitis: Signs & symptoms?

• Signs and Symptoms
o Sudden onset epigastric pain radiating to back

o N+V (heavy vomiting) – 90%

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Acute Pancreatitis: Ix?

• Investigations:
o Blood
 Amylase

 Lipase

o USS

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Acute Pancreatitis: Mx?

• Treatment:
o First:
 Heavy IV fluid
 Pain relief

o If identified CBD stone:
 ERCP

Admit to ITU/HDU if ≥3 of PANCREAS (Glasgow Prognostic Score)
PaO₂ <8kPa
Age >55
Neutrophils (WBC >15)
Calcium <2
Renal (Urea >16)
Enzymes (LDH>600, AST>200)
Albumin <32
Sugar >10

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IBD: Types, epidemiology?

• Types
o Crohn’s disease
o Ulcerative colitis

• Epidemiology
o CD
 15-25 y/o
 Affects entire bowel (mouth to anus)

o UC
 15-30 + 60-80
 Affects colon only

IBD: Symptoms?

Symptoms in IBD
• Common:
o Primary Symptoms: Pain, Diarrhea, Weight loss, Fever

o Extra-Intestinal Manifestations (30% of IBD [NB: %s reflect proportion of IBD who get EIM)
 Joint (e.g. enteropathic arthritis) – 25%

 Skin
• Erythema nodosum
• Pyoderma gangrenosum

 Eye
• Anterior uveitis
• Episcleritis
• Scleritis

 Liver (PSC [UC])

• Different
o Crohn’s = Mucous diarrhoea, mouth ulcers, perianal disease (fissures, fistulae)
o UC = Bloody diarrhoea

IBD: Dx?

Best: Endoscopy + Biopsy

* Normal endoscopy, but Crohn’s suspected: Video Capsule Endoscopy (CD)

IBD: Acute Treatment?

CROHN’S DISEASE:
Steroids
5-ASA/Mesalazine drugs
Infliximab

ULCERATIVE COLITIS:

5-ASA/Mesalazine drugs
ADD steroids
Infliximab
Consider emergency colectomy

IBD: Maintenance Mx?

CROHN’S DISEASE
6Mercaptopurine OR Azathioprine

Oral/rectal 5-ASA

Methotrexate

Infliximab

ULCERATIVE COLITIS

Oral/rectal 5-ASA

6-Mercaptopurine OR Azathioprine

Ciclosporin

Infliximab

Clostridium Difficile Infection AKA Pseudomembranous Colitis:
Definition, Pathology & risk factors?

• Definition: Acute exudative colitis caused predominantly by C difficile

• Pathology:
o Antibiotic use causes selective overgrowth of C difficile in gut

•	Risk factors: 
o	Abx in past TWO MONTHS (most occur 4-9d after)
	Clindamycin  RR = 30
	Cephalosporins  RR = 15
	Ciprofloxacin  RR = 5

CD infection: Features, Ix & Mx?

• Features:
o Symptoms most often occur 5-10d following antibiotic therapy (but can be last 2 months)

o Fever
o Abdominal pain
o Watery diarrhea ± blood (but often not blood) - +foul smelling, ?green colour

• Ix:
o Stool  C Diff toxin (80% sensitive, 95% specific) + MCS (to rule out other causes)

• Rx: Inform HPA
o Metronidazole
o Vancomycin

Colon Cancer: Epidemiology & Risk factors?

• Epidemiology  Lifetime risk = 5%

•	Risk factors
o	Diet/lifestyle (low fibre, red meat, obesity, sedentary, smoking, EtOH)  Need to ask specifically
o	IBD
o	Endocrine – diabetes, acromegaly
o	FH
o	Polyposis syndromes
	FAP (auto dom)
	HNPCC (auto dom)
•	Colon (~45 y/o, 80% lifetime risk)
•	Endometrium (50%), Ovary
•	Stomach, Small intestine, Hepatobiliary tract, Brain, Skin

Colorectal Ca: Symptoms?

•	Symptoms:
o	*Change in bowel habit*
o	*Tenesmus*
o	*Abdominal/rectal mass*
o	*Rectal bleeding*
o	*Night symptoms*

o WEIGHT LOSS

Colorectal Ca: Dx & MX?

• Diagnosis o First: Blood – iron deficiency anaemia o Best test: Colonoscopy + Biopsy • Treatment o Surgery o Chemo o Stenting

Appendicitis: Causes & Features?

• Cause: Sudden inflammation of appendix • Features: o Vague central colicky pain then constant RIF pain o Fever o N+V+D o RIF tenderness  Tenderness maximal at McBurney’s point (2/3 from umbilicus  ASIS)  Rovsing’s sign  LIF palpation causes RIF pain

Appendicitis: IX & Mx?

• Ix: o Bloods o USS (trans-vaginal if female) o Diagnostic laparoscopy • Rx: o Appendicectomy

Liver Cirrhosis- Features? Whats the Ix & Mx for all? Scoring?

Liver Disease + Cirrhosis • FEATURES o Portal hypertension  Varices  Splenomegaly  Ascites o Poor function  Encephalopathy  ↓Albumin  ↑PT/INR A nice way of remembering the Child-Pugh score ``` A - albumin B - bilirubin C - clotting D - distention (ascites) E - encephalopathy ```

Specific causes of Cirrhosis?

* Alcohol * NAFLD * Hepatitis B/C * PBC * PSC * HH * Wilson’s * A1AT * Autoimmune Hep * Budd-Chiari * Drug-induced Investigation for all – USS liver, liver biopsy Treatment for all – Liver transplant

Acute Viral Hepatic Infection/Acute Viral Hepatitis: Features of ALL?

Acute Viral Hepatic Infection/Acute Viral Hepatitis

Risk factors for Blood-born hepatitis (BCD)?

o Current or previous IVDU or intra-nasal drug use o MSM o Blood products o Tattoo overseas/with unsterile needles

Hepatitis Dx?

• Diagnose: o Routine bloods  ALT o Hep B Diagnosis: Hep B Serology  ANTIGENS • Surface * E * NO core antigen (it is present, but we cannot measure it)  ANTIBODIES • Surface * E * Core o Hep C Diagnosis: Hep C RNA

Hepatitis: Mx?

o Hep B: Interferon alfa o Hep C Treatment: Interferon + ribavirin, Sofosbuvir

Cirrhosis – Primary Biliary Cirrhosis (PBC): Definition, Epidemiology? Features, Dx & Mx?

• Definition: Destruction of bile ducts • Epidemiology: o 90% women o ~50y/o • Features o Middle aged (though often diagnosed even up to 70s) o Fatigue (65%), pruritus (55%) o Jaundice • Diagnosis: o High ALP o AMA + • Treatment: o Ursodeoxycholic acid (best Rx; improves prognosis by slowing disease progression)