GI Flashcards
What investigations should be done in somebody presenting with GORD?
H-Pylori testing: urea breath test / stool antigen test
Endoscopy if: refractory, red flag symptoms, >55, dysphagia, low Hb
How do you manage GORD (not H-pylori) ?
Lifestyle change: stop smoking, weight loss, reduce alcohol, caffeine, stress, fizzy drinks, etc
Acid neutralising agents: gaviscon
PPI: Omeprazole / Lansoprazole - max 40mg per day
H2 antagonist: ranitidine - rarely used anymore
Surgical fundoplication in severe, refractory disease / structural causes
How is H-pylori treated?
Triple therapy:
7 day course
PPI + amoxicillin + clarithromycin
Metronidazole used in penicillin-allergic patients
What is the treatment for Barrett’s Oesophagus?
High dose PPI
Regular endoscopy monitoring
Ablation of high-risk tissue
What is Barrett’s Oesophagus?
Columnar cell metaplasia in the Oesophagus
Premalignant condition which can develop into Adenocarcinoma
What are the symptoms associated with peptic ulcers?
GORD/heartburn Retrosternal/epigastric abdominal pain Nausea and vomiting Coffee ground vomit Acute abdomen Melaena or iron deficiency anaemia
How does eating affect the pain associated with gastric and duodenal ulcers?
Gastric: worsens pain
Duodenal: initially helps pain, worsens later on
What are the complications of peptic ulcers?
Bleeding- most common with posterior ulcers
Perforation and peritonitis- most common with anterior ulcers
Scarring and stricturing of tissue -> pyloric stenosis
How are gastric ulcers managed?
Stop any causative medication
H-pylori management if +ve
If In-tact:
High-dose PPI 4-8w
Lifestyle change
If perforated: IV PPI, antibiotics, fluids NBM and NG tube Surgical management e.g. patch Surgical washout
What is the most common type of gastric cancer?
Adenocarcinoma
What are the risk factors for gastric cancer?
H-pylori Barrett's oesophagus Smoking and alcohol consumption Chronic GORD Peptic ulcers Family history
What are the symptoms of gastric cancer?
Dysphagia, early satiety
Nausea, vomiting, haematemesis/coffee-ground vomit, melena
Weight loss, fatigue, night sweats
Anaemia symptoms/unexplained anaemia, jaundice
Palpable mass, Virchow’s node
What is Zollinger-Ellison syndrome?
How is it diagnosed?
Gastrin-producing gastrinoma - usually malignant
Increasing acid production
Most commonly in pancreas and small intestine
Diagnosed by: serum gastrin, secretin provocation tests and imaging to confirm
What are the causes of upper GI bleed?
Mallory weiss tear Oesophageal varices Gastric malignancy Peptic ulcer Coagulopathy/excess anticoagulation
What investigations should be done in upper GI bleed?
Bloods: FBC, U&E, LFT, group and save, coagulation studies (INR)
Urgent endoscopy
How would you manage a variceal bleed?
Group and save, cross match units of blood
Reverse any anticoagulation - vit K and prothrombin concentrate with warfarin
IV terlipressin
Urgent endoscopy- banding, balloon tamponade
TIPSS procedure- trans jugular intrahepatic portosystemic shunt
IV prophylactic antibiotics
What scoring system is used to quantify the risk of upper GI bleed?
Glasgow-Blatchford score
What is the Rockall score?
Score to calculate the risk of rebleeding and mortality after endoscopy for patients after having an acute upper GI bleed.
Helps determine whether patients require admission or are suitable for early discharge
What is the diagnostic criteria for IBS?
- Exclusion of other pathology: Normal FBC, ESR, CRP, faecal calprotectin, anti-TTG
Cancer excluded or not suspected - Pain/discomfort associated with change of bowel habit / relieved by opening bowels + 2 of:
Abnormal stool consistence, bloating, PR mucus, symptoms worse after eating
What is the management for IBS?
- Lifestyle change: increased fluid intake, increased fibre, avoid alcohol, artificial sweeteners, stop smoking
- > Dietician input may help, food/symptom diary
- > trial of pro-biotics - Pharmacological management:
- > laxatives for constipation: avoid lactulose
- > loperamide for diarrhoea
- buscopan for abdominal cramps
Second line: TCAs
Third line: SSRIs
AVOID opiates
- CBT can be helpful for the psychosocial aspect of the condition
What pattern of inflammation is found in Crohn’s disease?
Transmural granulomatous inflammation
Can affect any part of the GI tract - most common in terminal ileum
Skip lesions
Abscess and fistula formation
What symptoms are associated with Crohn’s disease?
Abdominal pain and distension
Diarrhoea + PR mucus (less associated with blood)
Weight loss, fever, malaise, anorexia
What signs are associated with Crohn’s?
Finger clubbing Erythema nodosum Skin tags, perianal abscesses Abdominal mass Anterior uveitis/enteropathic arthritis
How do you investigate suspected IBD?
- Bloods: FBC, U&E, LFT
CRP/ESR, TFT, anti-TTG, haematinics (iron, B12, folate) - Stool: Faecal calprotectin, MC+S
- Imaging: OGD and colonoscopy + biopsy
Abdominal x-ray/CT: may show strictures, mucosal thickening, bowel dilation - Truelove and Witts - criteria for severity of flare
What is the treatment for Crohn’s?
Inducing remission:
High dose oral prednisolone + PPI + bisphosphonate
+ azathioprine/mercaptopurine if not controlled
Maintaining remission:
Azathioprine + Infliximab most commonly
Surgical resection if severely affected
Symptomatic: loperamide, topical steroids
STOP SMOKING
What complications are associated with Crohn’s?
Malnutrition Small bowel obstruction Abscess, fistula formation Bowel perforation Bowel cancer Primary sclerosing cholangitis
What pattern of inflammation is associated with UC?
Continuous superficial inflammation- confined to mucosa
Starts at rectum and travels proximally
Limited to colon and rectum
What are the symptoms associated with UC?
Bloody diarrhoea, PR mucus
Abdominal pain and distension
Fever, weight loss, malaise, anorexia
Malnutrition, anaemia
What are the signs associated with ulcerative colitis?
Finger clubbing Anterior uveitis Oral ulcers Erythema nodosum Pyoderma gangrenosum
How is UC managed?
Inducing remission:
- Rectal aminosalicylates
- Oral aminosalicylates
- High dose oral prednisolone + PPI + bone protection
Maintaining remission:
- Oral aminosalicylates
- Azathioprine
Surgical management:
- Resection of extremely diseased bowel
- In fulminant disease, panproctocolectomy -> permanent ileostomy/ileo-anal anastomosis (J pouch)
What complications are associated with UC?
Toxic dilation (megacolon) >6cm Perforation of bowel Malnutrition Anterior uveitis Primary sclerosing cholangitis Colon cancer
What are the antibodies associated with Coeliac disease?
Anti-TTG
Anti-endomysial
HLA-DQ2/DQ8
What are the symptoms associated with coeliac disease?
FTT/weight loss in kids - buttock wasting etc Bloating Diarrhoea, nausea, vomiting Abdominal pain Symptoms of anaemia Dermatitis hepatiformis
How would you investigate somebody with suspected Coeliac disease?
Tests must be done while still eating gluten.
Bloods: FBC, U&E, CRP, ESR, Anti-TTG, IgA, haematinics
Endoscopy and duodenal biopsy: villous atrophy, crypt hypertrophy
If low IgA then normal anti-TTG does not exclude coeliac
Look for associated conditions: T1DM, thyroid disease, hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis
What are the complications of untreated coeliac disease?
Malnutrition Anaemia Osteopenia/osteoporosis Increased risk NHL, small bowel adenocarcinoma Neuropathy Vitamin deficiencies
What are the symptoms of appendicitis?
Central abdominal pain -> RIF pain
Nausea and vomiting
Abdominal distension, anorexia, N+V
Fever, tachycardia
What are the signs of appendicitis on examination?
Abdominal distension and guarding of RIF
Tenderness at McBurney’s point
Rosving sign positive: palpation of LIF causes pain in RIF
Rebound and percussion tenderness -> peritonitis, may indicate rupture
How is appendicitis diagnosed?
USS abdomen
CT abdo = highest diagnostic accuracy
Diagnostic laparoscopy in more unstable
Bloods: Raised WBC, CRP/ESR
How would you manage somebody with appendicitis?
A-E assessment
IV access - bloods and IV fluids + NBM ready for surgery
IV antibiotics + analgesia + antiemetics
Appendicectomy (laparoscopic -> open if unstable/difficult operation)
What are the 3 most common causes of bowel obstruction?
Adhesions, hernias, malignancy
Malignancy most common in large bowel, other 2 in small bowel
Other: volvulus, diverticulitis, stricture, intussusception
What are the symptoms and signs of bowel obstruction?
Bilious vomiting
Abdominal pain and distension
Not opening bowels or passing wind
OE: tinkling bowel sounds -> absent bowel sounds, distended & tender abdomen
What is the first line investigation in suspected bowel obstruction and how would you discriminate small vs large bowel?
Abdominal xray- dilation of bowel, may show clear obstruction, may show free air
small bowel: 3cm diameter, valvulae conniventes across entire diameter, usually more central
Large bowel: 6cm diameter, haustra not across entire width, usually more peripheral, more likely to see faeces
Typical abdominal X-ray features of small bowel obstruction include dilation of the small bowel (>3cm diameter) and much more prominent valvulae conniventes creating a ‘coiled-spring appearance‘.
Sigmoid volvulus: a characteristic ‘coffee bean’ appearance.
Caecal volvulus: often described as having a fetal appearance.
What is the gold standard diagnostic test for bowel obstruction?
Contrast CT Scan
How would you manage somebody with suspected bowel obstruction?
A-E assessment IV access (2 large bore cannula), NBM Bloods incl. G&S + IV fluids NG tube - bilious drainage AXR + erect CXR (free gas) Contrast CT scan
If stable- treat cause
If unstable - surgical exploration and management
What are the main causes of ileus?
Surgical handling of the bowel
Injury to the bowel
Inflammation/infection
Electrolyte imbalance affecting motility
What are the symptoms of ileus?
Constipation
Abdominal pain and distension
Bilious vomiting/drainage from NG
No flatulence or bowel sounds
What investigations should be done in ileus?
Bloods: electrolytes, magnesium, FBC
AXR / CT to rule out mechanical obstruction
How do you manage a patient with ileus?
NBM, NG with free drainage IV fluids and nutrition Mobilisation as much as possible Correct any electrolyte abnormality Reduce opioid analgesia
How would you manage a patient with volvulus?
NBM + NG with free drainage
IV fluids and nutrition
Conservative: endoscopic decompression of the sigmoid colon, flatus tube
Surgical: laparotomy, Hartmann’s procedure in sigmoid, ileocaecal resection in caecal
What would you expect to see on AXR in a patient with volvulus?
Sigmoid: coffee bean sign
Caecal: Foetus shape
What are the three key complications of hernias? Define them.
- Incarceration- hernia becomes irreducible, leading to 2,3.
- Strangulation- incarcerated hernia becomes tight at the base, leading to loss of blood supply and ischaemia (surgical emergency)
- Bowel obstruction- hernia grows to block the passage of faeces through the bowel
Where would you usually find an inguinal hernia?
Superomedial to the pubic tubercle
What are the two types of inguinal hernia?
How are they defined?
Direct hernia: caused by weakness in Hesselbach’s triangle. Hernia not reduced by pressure on deep inguinal ring
Indirect inguinal hernia: herniates through inguinal canal. Pressure on the deep inguinal ring will reduce hernia.
Where would you find a femoral hernia?
Inferolateral to the pubic tubercle
Herniation through the femoral canal via the femoral ring
Where would you expect pain in an obturator hernia?
Medial thigh
What is an incisional hernia?
Hernia through the incision of previous surgery or procedure.
Larger incision = greater risk.
What is the management for abdominal hernias?
- Conservative: if small, not incarcerated/strangulated and wide neck - can leave alone
- Tension-free repair: Mesh attached to abdominal wall keeps protrusion within abdominal cavity
- Tension repair: surgical suturing of the muscles (rarely done)
What is the most common site of hiatus hernias?
Through the oesophageal hiatus
What are the symptoms of hiatus hernia?
Dyspepsia / reflux Bloating Nausea Bad breath Belching Dysphagia
How are hiatus hernias diagnosed?
Erect CXR
CT scan
Endoscopy
Barium swallow study
How are hiatus hernias managed?
If small and not very symptomatic - management of reflux symptoms
If large or symptomatic- surgical fundoplication
What are the risk factors for haemorrhoids?
Pregnancy Obesity Constipation Age Increased IA pressure- coughing, weight lifting
What are the symptoms of haemorrhoids?
May be asymptomatic
May be visible / palpable
Anal pain or itching, PR bleeding
What are the different degrees of haemorrhoids?
1- no prolapse
2- prolapse on straining, return on relaxation
3- prolapse but can be pushed back in
4- permanently prolapsed
What are the investigations for haemorrhoids?
Usually clinical diagnosis - external and internal PR examination
May be diagnosed by proctoscopy / flexible sigmoidoscopy
How are haemorrhoids managed?
- Conservative- if few / asymptomatic can leave
- Medical: topical anaesthetic and steroid creams
- Non-surgical: banding/scleropathy/injection/diathermy
- Surgical: haemorrhoidectomy, artery embolisation/ligation
What are the risk factors for diverticular disease?
Age Obesity Low fibre diet Constipation NSAIDs
What are the symptoms of diverticular disease?
May be asymptomatic May suffer LIF pain - often relieved by defecation Constipation PR bleeding Weight loss in some
How is diverticular disease diagnosed?
Flexible sigmoidoscopy
CT scan
What is the management for diverticular disease?
High fibre diet
Increase fluid intake
Weight loss
Stool softeners/bulk-forming laxatives
AVOID stimulant laxatives
What are the symptoms of acute diverticulitis?
LIF pain Fever Diarrhoea, PR bleeding Nausea and vomiting May have palpable mass, peritonitis if perforated
What are the investigations in acute diverticulitis?
Bloods: infection and inflammatory markers
Stool sample: rule out gastroenteritis / c.diff
CT abdo= gold std.
How should diverticulitis be managed?
1. Uncomplicated: 5 day course oral co-amoxiclav Oral analgesia- avoid NSAID and opiate Clear fluids until symptoms resolve 2 day follow-up
- Complicated:
NBM
IV fluids, antibiotics, analgesia
Urgent CT and surgical management
What are the complications associated with diverticulitis?
Bowel perforation Abscess formation Peritonitis Haemorrhage Bowel obstruction / ileus Stricture/fistula formation
What are the symptoms of acute mesenteric ischaemia?
Sudden onset, non-specific abdominal pain
Nausea and vomiting
Fever
Urgent need to move bowels
Symptoms of shock, peritonitis
How is acute mesenteric ischaemia diagnosed?
ABG: metabolic acidosis and raised lactate
Contrast CT scan
US doppler
How is acute mesenteric ischaemia managed?
Resuscitation
NBM
Surgery to remove any necrotic bowel
Endovascular/open thrombectomy or thrombus bypass
What are the symptoms of chronic mesenteric ischaemia?
Colicky abdominal pain- usually comes on after eating and lasts 1-2 hours
Weight loss due to food avoidance
Abdominal bruit
How is chronic mesenteric ischaemia diagnosed?
CT angiography
How is chronic mesenteric ischaemia managed?
- Secondary prevention of CVD & reduce CV risk factors
2. Revascularisation
What are the risk factors for colorectal cancer?
Increasing age, obesity
Family history
Smoking, alcohol consumption, red meat, low fibre diet
IBD,
FAP, HNPCC - both autosomal dominant conditions, need regular screening
What are the symptoms of colorectal cancer?
Change in bowel habit Abdominal pain PR bleeding/mucus Weight loss, loss of appetite, unexplained iron-deficiency anaemia Abdominal/rectal mass
How is colorectal cancer investigated and diagnosed?
FIT testing (replaced faecal occult blood)
Bloods: FBC, U&E, CRP, CEA
Colonoscopy + biopsy = gold standard
CT colonoscopy in those who can’t tolerate colonoscopy
CT-TAP/PET staging
What is the staging system used in colorectal cancer? (other than TNM)
Duke's A: confined to mucosa B: spread through muscle C: spread into lymph nodes D: distant metastasis
What are the different surgical techniques used in colorectal cancer?
Right hemicolectomy: caecum, ascending colon, proximal transverse
Left hemicolectomy: distal transvers, descending colon
High anterior resection: removal of sigmoid
Low anterior resection: removal of sigmoid and upper portion of the rectum
Abdominoperineal resection: removal of rectum, anus +/- some sigmoid - need permanent stoma
What is the difference between an end and a loop colostomy/ileostomy?
Loop= temporary stoma where bowel is brought to skin surface and stoma made to allow distal portion and anastomosis to heal. Allows access to afferent and efferent limbs (proximal produces stool, distal produces mucus). These can be reversed in 3-6 months usually
End= distal part is sutured and left in the bowel. Can sometimes be reversed. Single lumen.
Alternatively ileoanal (J) pouch can be formed where a piece of ileum is brought along to act like rectum.
How would you approach a patient with an acute abdomen?
A-E assessment
Full history and examination
IV access, O2 if needed and NBM in case need of surgery
NG tube if continuous vomiting, IV fluids as indicated
Bloods: FBC, U&E, LFT, CRP, lipase, troponin, calcium, group & save, glucose, B-HCG
ABG + blood cultures
Urine dip and pregnancy test in a woman
CT abdo with contrast
USS in A&E
ECG to rule out cardiac cause of epigastric pain
Need input from surgeons asap
What are the two characteristic signs of retroperitoneal haemorrhage?
Cullen’s sign: bruising around the umbilicus
Grey-Turner’s sign: bruising around the flanks
What are the signs on examination of peritonitis?
Abdominal rigidity and guarding Rebound tenderness Percussion tenderness Cough test elicits pain Stretching leg elicit pains
