GI Flashcards
Appendicitis
Inflammation of appendix
Appendicitis patho
Gut orgs invade appendix wall after lumen obstruction from:
- lymphoid hyperplasia
- faecolith
- filarial worms
Appendicitis Px
- Pain (umbilical -> RIF, McBurney’s point)
- Oedema
- Fever
- Tachycardia
- Anorexia
- N+V
- Constipation, maybe diarrhoea
- RIF tenderness, guarding
- Rovsing’s sign - pain greater in RIF than LIF when LIF pressed
- Psoas sign - pain on extending hip if retrocaecal appendix
- Cope sign - pain on flexion and internal rotation of hip (if appendix close to obturator internus)
Appendicitis DDx
Other causes of abdo pain - think systems (GI, urological, gynaecological…)
Appendicitis Ix
Bloods - raised WCC, CRP, ESR
USS
CT
Pregnancy test
Urinalysis (exclude UTI)
Appendicitis Mx
Laparoscopic appendectomy
IV ABs (metronidazole, cefuroxime)
Appendicitis Cx
Rupture -> peritonitis
Forms a mass
Abscess - after failure to resolve
Acute mesenteric ischaemia
Impaired blood flow gut (almost always SI)
AMI Causes
SMA thrombosis (commonest)
SMA embolism (eg AF)
Mesenteric vein thrombosis (hypercoagulable state)
Non-occlusive disease (low flow states, eg low CO)
AMI Px
- acute severe abdo pain
- no abdo signs
- rapid hypovolaemia (shock - pale skin, weak rapid pulse, reduced urine output, confusion)
AMI Ix
CT angiography - shows vessel blockage
Bloods (lactate), AXR
Laparotomy (cut into abdo wall)
AMI Mx
Resus - fluids, O2
ABs - IV gentamicin, metronidazole
IV heparin
Surgery to remove dead bowel
AMI Cx
Bacterial translocation across dying gut wall - septic peritonitis, SIRS
Chronic mesenteric ischaemia
chronic atherosclerotic disease of vessels supplying intestine
CMI cause
atherosclerosis - low flow of blood
CMI Px
- severe colicky post-prandial abdo pain (gut claudication)
- decreased wt
- upper abdo bruit (sounds), maybe PR (per rectum) bleeding
malabsorption, N+V, fear of eating, usually history of CVD
CMI Ix
CT angiography
CXR/AXR to exclude other stuff
CMI Mx
Stop smoking
Antiplatelet therapy
Surgery - angioplasty, stent
CMI Cx
malnutrition, reduced QoL from fear of eating
Ischaemic colitis
compromise of blood circulation supplying colon
IC patho
Causes - thrombosis, emboli, decreased CO, drugs (OCP), surgery, coagulation disorders
splenic flexure at risk - watershed between middle colic (SMA) and left colic (IMA)
IC Px
signs
shock
signs of CVD
symptoms
abdo pain, sudden onset, lower left side
bright red blood +/- diarrhoea
IC DDx
other causes of acute colitis, eg IBD
dysentry, diverticulitis
IC Ix
CT
Colonoscopy and biopsy
Barium enema maybe
IC Mx
Fluids
ABs
Surgical resection of bowel (could be gangrenous bowel)
mitigate risk factors - smoking, antiplatelet therapy etc
Diverticulitis
Inflammation of diverticulum (outpouching of gut wall)
diverticular disease - symptoms without inflammation
Diverticular disease patho
High intraluminal pressures (maybe lack of fibre), force mucosa to herniate through muscle layers of gut, usually near vessel entry sites
Causes - lack of fibre, obesity, smoking, NSAIDs
Diverticulitis patho
faeces obstructs neck of diverticulum, bacteria multiply, inflammation
Diverticular disease Px
altered bowel habit left sided colic, relieved by defecation nausea flatulence pain/constipation (severe)
Diverticulitis Px
As diverticular disease
pyrexia tachycardic tenderness, guarding severe pain symptoms of peritonitis
similar to appendicitis, but on left side
Diverticulitis Ix
CT colonography
Bloods - increased WCC, ESR, CRP
AXR, barium enema
Diverticular disease Mx
High fibre diet
antispasmodic - mebeverine
maybe surgical resection
Diverticulitis Mx
Fluids, ABs (ciprofloxacin, metronidazole)
Surgical resection
Diverticulitis Cx
perforation, fistula formation, intestinal obstruction, bleeding, mucosal inflammation, abscesses
Meckel’s diverticulum
outpouching of distal ileum
surgical removal
Oesophageal cancer
carcinoma of oesophagus
squamous cell carcinoma (SCC) or adenocarcinoma (AC)
Oesophageal cancer patho
SSC in upper 2/3, AC lower 1/3
Barrett’s: acid, stratified squamous epithelium -> simple columnar mucosa
often presents late in disease
oesophageal cancer causes
alcohol achalasia (reduced peristalsis) smoking obesity GORD
oesophageal cancer Px
signs
- lymphadenopathy
- hoarseness, cough
symptoms
- dysphagia, progressive (solids, then liquids)
- weight loss
- anorexia
- vomiting
- pain
oesophageal cancer Ix
endoscopy
barium swallow
CT/MRI/PET - stage tumour
oesophageal cancer Mx
chemo
resection
palliative
Benign oesophageal tumour
1% oesophageal tumours, slow growing
asymptomatic, dysphagia, pain, regurgitation
endoscopy
surgical removal
Gastric cancer
adenocarcinoma (epithelial tissue) of stomach
gastric cancer patho
Intestinal cancer - well formed, differentiated glandular structures
Diffuse - infiltrative, undifferentiated, worse prognosis
gastric cancer causes
smoking H.pylori dietary factors genetics pernicious anaemia - atrophic gastritis
gastric cancer Px
advanced, metastases (bone, brain, lung)
signs
- anaemia from blood loss
- jaundice (liver metastases)
- palpable shoulder lymph node
symptoms
- epigastric pain, dyspepsia (indigestion)
- N+V
- anorexia
- weight loss
- dysphagia if tumour in fundus
gastric cancer Ix
gastroscopy and biopsy
USS, CT, MRI, PET
FBC, LFT
gastric cancer Mx
surgical resection
chemo/radio
treat symptoms
SI tumours
rare, AC most common, maybe lymphomas
SI tumours Px
signs
- anaemia
- palpable mass
symptoms
- pain
- diarrhoea
- anorexia
- wt loss
SI tumours Ix
USS
endoscopic biopsy
CT
SI tumours Mx
radiotherapy
surgical resection
Colonic polyps
abnormal growth of tissue from colonic mucosa
adenoma/inherited
Colonic polyps Px
mostly asymptomatic
signs
- rectal polyps/masses
symptoms
- bleeding
- diarrhoea, abdo pain, mucous discharge
- obstruction - constipation, vomiting, peritonitis
colonic polyps Ix
colonoscopy with biopsy
CT/MRI
Genetic testing
Colonic polyps Mx
surgical removal
colorectal cancer
carcinoma of LI, usually AC
colorectal cancer patho
majority in distal colon
normal epithelium -> adenoma -> colorectal adenocarcinoma -> metastatic (to liver, lung, brain)
Genetics - familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer
colorectal cancer RFs
increasing age, low fibre, sat fats, red meat, sugar, polyps, alcohol, smoking, obesity, UC, FHx, genetics
colorectal cancer Px
depends on location
signs
- anaemia (bleeding)
symptoms
- blood and mucus
- change in bowel habit
- diarrhoea/constipation
- wt loss
- abdo pain (right sided)
- thin altered stools
- tenesmus (feeling of incomplete defecation)
may present as emergency - obstruction
jaundice/hepatomegaly - liver metastases
colorectal cancer DDx
haemorrhoids, anal fissure, prolapse, diverticular disease, IBD, GI bleed
colorectal cancer Ix
CT colonoscopy and biopsy
FBC - anaemia
barium enema
MRI to determine spread
classify - Dukes, TNM
colorectal cancer Mx
radio/chemo
surgery - resection, stenting
GORD
reflux of stomach acid/bile
GORD causes
- LOS hypotension
- hiatus hernia (rolling/sliding)
- obesity
- overeating
- smoking
- alcohol
- pregnancy
- drugs
GORD Px
signs
- chronic cough (aspiration of stomach contents)
- sinusitis
- weight loss
- haematemesis
- anaemia
symptoms
- heartburn
- belching
- food/acid brash
- water brash
- odynophagia (painful swallowing)
alarm bell signs
wt loss, haematemesis, dysphagia
Dyspepsia ALARMS symptoms
Anaemia Loss of weight Anorexia Recent onset / progressive of symptoms Melaena / haematemesis Swallowing difficulty
GORD DDx
peptic ulcer disease malignancy NSAIDs infection cardiac disease oesophageal spasm
GORD Ix
clinical dx
endoscopy if alarm bell signs, >55yo, tx not working, palpable mass
barium swallow - hiatus hernia
GORD Mx
lose weight, stop smoking, small meals, avoid hot drinks, spicy food, raise bed head
antacids - magnesium trisillicate mixture, gaviscon
PPI - lansoprazole
H2 receptor antagonist - cimetidine, ranitidine
Nissen fundoplication - surgically increase resting LOS pressure (only in severe GORD)
GORD Cx
Barrett’s oesophagus - metaplasia from stratified squamous to columnar
Peptic stricture - inflammation
Mallory-Weiss tear, iron deficiency, ulcers
Ulcerative Colitis
chronic inflammatory disorder of colonic mucosa (an IBD)
UC patho
Inappropriate immune response to colonic flora in genetically susceptible individuals
Only involves mucosal layer
Starts in rectum, extends proximally (stops at SI)
Smoking is protective
UC Px
signs
- during attack - fever, tachycardia, tender distended abdo, anorexia, malaise, wt loss
- extraintestinal signs - clubbing, oral ulcer, erythema nodosum, inflammatory pustule, conjunctivitis, episcleritis, iritis, large joint arthritis, ankylosing spondylitis, primary sclerosing cholangitis
symptoms
- episodic/chronic diarrhoea +/- blood, mucus
- bowel urgency
- tenesmus
- crampy abdo discomfort
UC Ix
Bloods - FBC, ESR, CRP, U+E, LFT, culture
Stool MC&S
Faecal calprotectin - test for GI inflammation
AXR - no faecal shadows, mucosal thickening, colonic dilatation
Lead-pipe colon on barium X ray
Lower GI endoscopy
UC Mx
Avoid foods that cause flare ups
mild
5-ASA - mesalazine/mesalamine
topical steroid - hydrocortisone/prednisolone
moderate
oral prednisolone
5-ASA
severe
IV fluids
IV steroids
Azathioprine, ciclosporin (DMARD), infliximab
Surgery - colectomy
UC Cx
Colonic cancer, venous thromboembolism, toxic dilatation of colon
Crohn’s
chronic inflammatory disease of GI tract characterised by transmural granulomatous inflammation
Crohn’s patho
Can affect any part of gut
Skip lesions
Inappropriate immune response to gut flora in genetically susceptible individuals
Most commonly affects terminal ileum (bile salts and B12 absorbed here)
Crohn’s Px
signs
- bowel ulceration
- abdo tenderness
- perianal abscess/fistulae
- mouth ulcers
- finger clubbing
- conjunctivitis, episcleritis, iritis
- associated with spondyloarthropathies
symptoms
- diarrhoea
- abdo pain
- wt loss
- fatigue, fever, malaise, anorexia
Crohn’s Ix
Bloods MC&S Faecal calprotectin Colonoscopy, bowel biopsy Capsule endoscopy - swallow small camera MRI to assess Cx String sign on barium x ray
Crohn’s Mx
Stop smoking, optimise nutrition
Oral prednisolone
Severe - IV fluids, IV steroids
Azathioprine (immunosuppressant)
Infliximab
Surgery - not curative
Crohn’s Cx
SI obstruction, toxic dilatation, abscess formation, fistulae, cancer, malnutrition
Intestinal obstruction
arrest/blockage of onward propulsion of intestinal contents
paralytic ileus
loss of peristalsis, caused by abdo surgery commonly, absent bowel sounds, less pain
intestinal obstruction patho
Intraluminal - tumour, fibrous diaphragm formation, meconium ileus (sticky bowel contents), gallstone
Intramural - inflammatory (Crohn’s, diverticulitis), tumours, neural (Hirschprung’s)
Extraluminal - adhesions, volvulus, tumour
Intestinal obstruction DDx
SBO / LBO
SBO - vomiting earlier, less distension, pain higher in abdo
LBO - pain more constant
ileus / mechanical obstruction
ileus - bowel sounds absent, pain tends to be less
simple / closed loop / strangulated
simple - one obstruction point, no vascular compromise
closed loop - obstruction at two points, eg sigmoid volvulus - perforation risk
strangulated - blood supply compromised, more pain, fever, peritonism
SBO
mechanical most common
distension above blockage
obstruction -> ischaemia, necrosis, perforation
Causes - adhesions, hernia, malignancy, Crohn’s
SBO Px
signs
- distension (more distal, more distension)
- tenderness -> ?strangulation
- increased bowel sounds
symptoms
- pain, initially colicky, then diffuse
- vomiting
- nausea, anorexia
- constipation, no wind
SBO Ix
AXR, CT
SBO Mx
Drip and suck - NGT to suck out bowel contents, IV fluids
Analgesia, antiemetic, ABs
Surgery
SBO Cx
Ischaemia, perforation, necrosis
LBO
25% of all intestinal obstruction
Proximal dilatation
Bacterial translocation -> sepsis
Colonic volvulus -> sigmoid
Cancer most common cause
LBO Px
signs
- abdo distension
- bowel sounds normal, then increased, then quiet
- palpable mass
symptoms
- abdo pain
- late vomiting (faecal)
- constipation
- fullness/bloating/nausea
LBO Ix
DRE - empty rectum, hard stools, blood
AXR, CT
LBO Mx
much same as SBO
Surgery
Pseudo-obstruction
clinical picture mimics obstruction, but no mechanical cause
likely a Cx of other things: trauma, fractures, post-operation, drugs
Px - abdo distension, worsening pain
Ix - x-ray - large gas-filled bowel
Mx - tx underlying condition, correct fluids/electrolytes, IV neostigmine promotes colonic motility
IBS
mixed group of abdo symptoms, no organic cause
constipation, diarrhoea, both
IBS patho
dysfunction in brain-gut axis, abnormal smooth muscle activity
IBS RFs
stress, menstruation, depression/anxiety, GI infection, abuse, eating disorders
IBS Px
signs
- urinary freq, urgency, nocturia, incomplete bladder emptying
- joint hypermobility
symptoms
- abdo pain/discomfort, relieved by defecation
- bloating
- change in bowel habit
- painful period
- back pain
- fatigue, nausea
- symptoms worsen after food
IBS DDx with IBD
IBS:
normal Ix results fever not likely no extraintestinal symptoms no blood in stool no melaena no wt loss no mouth ulcers constipation more common bloating more common
IBS Ix
Rule out differentials
Bloods
Faecal calprotectin (raised in IBD)
Colonoscopy (rule out colorectal cancer)
IBS Mx
Regular/small meals, fluids, reduce caffeine, alcohol
IBS-D and bloating - reduce insoluble fibre
Wind/bloating - increase soluble fibre
Low FODMAP diet
Pain/bloating - antispasmodic (mebeverine/buscopan)
Constipation - laxative (eg mavicol)
Diarrhoea - loperamide
TCA (amitriptyline), SSRI
CBT
IBS - cancer red flags
wt loss unexplained PR bleed FHx change in bowel habit and +50yo nocturnal symptoms mass anaemia raised inflammatory markers
Mallory-Weiss tear
Linear mucosal tear at oesophageal gastric junction - upper GI bleed
MW tear causes
forceful vomiting, retching, coughing, straining
NSAID abuse
peptic ulcers - majority
RFs - alcohol, conditions predisposing to vomiting, chronic cough, hiatus hernia, trauma
MW tear Px
signs
postural hypotension
symptoms vomiting haematemesis retching dizziness / syncope
MW tear DDx
gastroenteritis, peptic ulcer, cancer, varices
MW tear Ix
endoscopy
FBC, coagulation studies, renal function…
MW tear Mx
ABCDE, O2, fluids
Endoscopy - banding/clipping
MW tear Cx
vomiting - hypokalaemia, metabolic distubances
bleed - hypovolaemic shock
Achalasia
oesophageal aperistalsis, impaired relaxation of LOS
Achalasia cause
unknown, though to be abnormal psym innervation
Achalasia Px
- dysphagia
- food regurgitation, esp at night
- substernal cramps
- wt loss
- spontaneous chest pain
Achalasia DDx
other causes of dysphagia - cancer, stricture, GORD
Achalasia Ix
CXR - dilated oesophagus
Barium swallow - lack of peristalsis
Manometry - shows aperistalsis
CT, oesophagoscopy - rule out carcinoma
Achalasia Mx
Relieve symptoms
Tx to relax LOS - nifedipine, nitrates, sildenafil
Surgical - balloon dilation to open LOS, division of LOS, botox injection to relax it
Achalasia Cx
aspiration pneumonia
Gastritis
inflammation of stomach mucosa
Gastritis causes
H.pylori Autoimmune gastritis Aspirin, NSAIDs Viruses Duodenogastric reflux Ischaemia Increased acid - eg stress Alcohol
Gastritis Px
signs
- abdo bloating
symptoms
- N+V
- recurrent upset stomach
- epigastric pain
- indigestion
- haematemesis
Gastritis DDx
peptic ulcers, GORD, dyspepsia, carcinoma
Gastritis Ix
Endoscopy
Biopsy
H.pylori urea breath test, stool antigen test
Gastritis Mx
Remove cause - eg stress, alcohol H.pylori - PPI + 2 ABs H2 antagonist - ranitidine, cimetidine PPI - lansoprazole/omeprazole Antacid
Peptic ulcer disease (PUD)
break in superficial epithelial cells down to muscularis mucosa
in stomach/duodenum
PUD Patho
ulcers -> gastritis
NSAIDs
inhibit COX1, prostaglandin synthesis, mucous secretion
H.pylori
urease - urea -> CO2 + ammonia
ammonium toxic to mucosa - less mucous produced
inflammation
ischaemia of gastric cells
produce less mucin
overproduction of acid
overwhelms mucin
PUD causes
H.pylori NSAIDs smoking alcohol bile salts steroids stress
PUD Px
burning epigastric pain nausea oral flatulence epigastric tenderness duodenal ulcer - worse several hours after eating, relieved by eating
ALARMS anaemia loss of weight anorexia recent onset / progressive sym melaena / haematemesis swallowing difficulty
PUD DDx
cancer, gastric outlet obstruction, non-ulcer dyspepsia, duodenal Crohn’s, GORD
PUD Ix
FBC - iron-deficiency anaemia
H.pylori tests
C-urea breath test - measure CO2 in breath after ingesting C-urea
IgG serology detection
Stool antigen test
Endoscopy
PUD Mx
Reduce stress, irritating foods, smoking, alcohol
Stop NSAIDs
PPI - lansoprazole
H2 antagonist - ranitidine/cimetidine
Surgery - for Cx, eg bleed
endoscopic intervention for bleeding ulcers
H.pylori Mx
PPI
2 ABs - metronidazole, clarithromycin (high resistance), amoxicillin (low res), tetracycline (low), bismuth
Quinolone, eg ciprofloxacin, where normal tx fails
PUD Cx
Cancer, haemorrhage (duodenal ulcer erodes to gastroduodenal artery), peritonitis, acute pancreatitis
Haemorrhoids
dilated anal cushions due to swollen veins
internal/external
internal categorised by degree it prolapses
haemorrhoids causes
constipation, prolonged straining
diarrhoea
congestion from pelvic tumour, pregnancy, portal HTN
anal intercourse
haemorrhoids Px
signs
- severe anaemia
symptoms
- bright red rectal bleeding
- mucus discharge, pruritus ani (itchy bottom)
- wt loss, changes in bowel habit
- pain (external)
haemorrhoids Ix
abdo exam - rule out other disease
PR exam
proctoscopy (rectal scope)
sigmoidoscopy
haemorrhoids Mx
1st degree - increase fluid, fibre, topical analgesic, stool softeners
2/3 - rubber band ligation, infrared coagulation
4 - surgery to remove
Anal fistula
track communicates between skin and anal canal
anal fistula causes
perianal sepsis abscesses Crohn's TB diverticular disease rectal carcinoma
anal fistula Px
pain
discharge (bloody/mucus)
pruritus ani
systemic abscess if infected
anal fistula Ix
MRI
endoanal USS
anal fistula Mx
surgical - fistulotomy, excision
drain abscess, ABs if infected
anal fissure
tear in squamous skin-lined lower anal canal
anal fissure causes
hard faeces
STI, trauma, Crohn’s, cancer
90% posterior, anterior follows childbirth
anal fissure Px
extreme pain, esp on defecation
bleeding
anal fissure Ix
Dx often on history
perianal inspection
PR exam often not possible due to pain
anal fissure Mx
increase fluids, fibre - make stools soft
Lidocaine ointment, GTN ointment, topical diltiazem (promotes healing)
Botox injection
Surgery - sphincterotomy
anorectal abscess
collection of pus in anal/rectal region
RFs - DM, immunocompromised, anal sex
anorectal abscess Px
painful swellings
tender
pus discharge
anorectal abscess Ix
DRE
MRI
endoanal USS
anorectal abscess Mx
surgical excision
drainage with ABs
Pilonidal sinus
hair follicles get stuck under skin in butt crack, irritation/inflammation, leads to small tracts that can become infected (abscesses)
pilonidal sinus Px
asymptomatic
painful swelling, tender
pus, foul smell from abscess
systemic signs of infection
chronic - 4/10 recurrent
pilonidal sinus Ix
clinical examination
pilonidal sinus Mx
surgery - excise sinus tract, drain pus
ABs pre-op
painkillers
hygiene and hair removal advice
