GI Flashcards
Signs and symptoms of an upper GI bleed ?
Epigastric pain
Haematemesis - red if active, coffee ground if settled
Melaena - black and foul smelling
Shock
Causes of an upper GI bleed ?
Peptic ulcer disease
Oesophagitis
Gastritis
Oesophageal or gastric varices
Upper GI cancer
Investigations for an Upper GI bleed ?
FBC
Check coagulation
U & E‘ s
LFT’s
Imaging - CXR, AXR, CT chest abdo
What is the ROCKALL full score ?
Performed post-endoscopy and considers age, shock, co-morbidities, endoscopic signs of acute bleeding and endoscopic diagnosis.
It assesses the risk of an Upper GI bleed.
Key questions to ask in a history if suspecting an Upper GI bleed ?
Any past GI bleeds ?
Dyspepsia ?
Any known ulcers ?
Liver diseases or known varices?
Dysphagia, vomiting, weight loss ?
Alcohol use ?
Any serious co-morbidities ?
What is the acute management of an upper GI bleed ?
Resuscitate and ABC
Give terlipressin ( ADH analogue ) or somatostatin plus prophylactic antibiotics.
Send for urgent endoscopic diagnosis and repair using clipping or thermal coagulation with adrenaline if non-variceal or band ligation if variceal.
PPI post endoscopy.
What is the pathophysiology of Crohn’s disease ?
Skip lesions anywhere from the mouth to the anus however the terminal ileum is the most common.
There is transmural granulomatous inflammation.
What is the prevalence of Crohn’s disease ?
1 in 600
Signs and symptoms of Crohn’s disease ?
Diarrhoea ( bloody in 25% )
Lower abdo pain
Weight loss
Fever
Fatigue
Right iliac fossa mass from inflammation
Perianal fistulas
Non-intestinal :
Ulcers
Clubbing
Entero-arthritis
Gallstones
Liver inflammation
Risk factors for Crohn’s disease ?
Smoking
Family history
White ethnicity
Investigations for Crohn’s disease ?
FBC
CRP
U & E’s
LFT ( check for hepatobiliary disease )
Stool culture ( rule out infection )
Faecal calprotectin
Presence of C diff marker ( poor prognosis )
Ileocolonscopy + biopsy
AXR
CT / MRI for info on extent of disease
Management for inducing remission after an attack of Crohn’s disease ?
IV hydrocortisone 100mg qds
If no improvement after 3-5 days escalate treatment and add biologics or surgery.
Management for maintaining remission in Crohn’s disease ?
Azathioprine or biologics are used as maintenance treatment .
What should be tested for before starting biologic treatment ?
Latent TB
Complications of Crohn’s disease ?
Small bowel obstruction ( bowel thickening and fibrosis can cause strictures )
Abscess
Fistulas
Colorectal carcinoma ( more common in UC )
What advice should be given to someone to help them stay in remission if they have Crohn’s disease ?
Smoking cessation
What are some key questions for taking a bowel habit history ?
How often do they go to the toilet ? And is this different from normal ?
Any changes in consistency ?
Are they waking up at night to open their bowels ?
Any blood present in stool ?
Do they have tenesmus ?
Do they have faecal incontinence or urgency ?
What are patients admitted with acute IBD at a high risk of having ?
What do they require to prevent this ?
A venous thromboembolism
Prophylactic heparin
What is the pathophysiology of UC ?
A continuous area of inflammation in the rectum +/- the colon.
There is an inflamed, friable mucosa with crypt changes. There are reduced goblet cells and pseudo polyps.
If severe there will be submucosal inflammation and ulceration.
What is the prevalence of UC ?
1 in 1000
Signs and symptoms of UC ?
Diarrhoea ( bloody in 75% ) and may contain mucus
Lower abdo cramps
Faecal urgency + tenesmus
Gradually occurs
Fever
Weight loss
Non-intestinal :
Entero-arthritis
Primary sclerosing Cholangitis
Liver disease
Risk factors for UC ?
Non-smokers
Family history
HLA-B27
Investigations for UC ?
FBC ( Hb, iron, B12, folate )
CRP ( also check albumin and platelets )
U & E’s ( Mg and Ca2+ )
LFT ( associated hepatobiliary disease )
Stool culture ( rule out infection )
Faecal calprotectin
Check for C. difficile ( poor prognosis )
Sigmoidoscopy
AXR
Management for inducing remission in UC ?
IV hydrocortisone
If not improving by day 3-5 consider adding :
Ciclosporin, biologics or surgery
Management for maintaining remission in UC ?
Mesalazine is used for maintenance
Complications of UC ?
Perforation
Toxic mega colon
Colorectal carcinoma ( screen with colonoscopy every 3 years, consider removal if signs of dysplasia )
VTE
Pathophysiology of coeliac disease ?
It is an autoimmune disease response to the complex of gliadin and the enzyme tissue transglutaminase (tTG) resulting in intestinal damage.
What is the prevalence of Coeliac disease ?
1 in 100
Signs and symptoms of coeliac disease ?
Diarrhoea and steatorrhoea
Abdominal pain
Bloating
Weight loss
Anaemia - may cause fatigue
Osteoporosis - calcium and vitamin D malabsorption
Mouth ulcers + angular stomatitis
Risk factors for coeliac disease ?
Family history
Other immune disorders such as T1DM
IgA deficiency
Investigations for coeliac disease ?
Check levels of anti-tTG IgA plus total IgA too.
Biopsy via upper endoscopy
( patients should remain on gluten while under investigations )
FBC ( Hb, iron, B12 or folate )
LFT ( raised transaminases )
Calcium and albumin levels
What screening should take place if someone is diagnosed with coeliac disease ?
1st degree relatives should be screened
Complications of coeliac disease ?
Osteoporosis
Small increase in risk of small bowel adenocarcinoma
Management of coeliac disease ?
Long term gluten free diet
Replace micronutrients
Causes of epigastric pain ?
Pancreatitis
Gastritis or duodenitis
peptic ulcers
gallbladder disease
Aortic aneurysm
Causes of left upper quadrant pain ?
Peptic ulcers
Gastric or colonic cancer
Splenic rupture
Causes of right upper quadrant pain ?
Cholecystitis
Biliary colic
Hepatitis
Peptic ulcers
Colonic cancer
Renal colic
Causes of loin pain ?
Renal colic
Pyelonephritis
Renal tumour
Causes of left iliac fossa pain ?
Diverticulitis
Volvulus
Colon cancer
IBD
Renal colic
UTI
Ectopic pregnancy
Causes of right iliac fossa pain ?
Volvulus
Colon cancer
IBD
Renal colic
UTI
Ectopic pregnancy
Appendicitis
Crohn’s ileitis
Causes of generalised abdominal pain ?
Gastroenteritis
IBS
Peritonitis
Constipation
Causes of centralised pain ?
Mesenteric ischaemia
Abdominal aneurysm
Pancreatitis
Causes of haematemesis ?
Bleeds for the upper GI tract such as peptic ulceration, varices and oesophagitis
What is the more likely diagnoses if there is a large amount of fresh, red blood when vomiting with liver disease and alcohol abuse?
An active bleed from an oesophageal varices
What is the more likely diagnoses if there is a large amount of fresh, red blood when vomiting with abdominal pain and heartburn ?
Peptic ulceration
GORD
What would small streaks of blood at the end of prolonged retching indicate ?
This would indicate minor oesophageal trauma at the gastro- oesophageal junction ( Mallory Weiss tear ).
What would be indicated if a patient was vomiting up coffee ground looking blood ?
This occurs as it has been altered by the stomach.
It usually suggests the bleeding has ceased and that it is modest.
If someone has haematemesis what should you ask about ?
The amount and nature of blood
Previous bleeding episodes, treatment and outcome
Cigarette smoking
Use of :
- NSAIDs
- Warfarin
- Clopidogrel
Red flags for malignancy
What questions should be asked if there is PR bleeding ?
The amount of blood
The nature of blood
Mixed into the stool or on it ?
Is it spattered over the pan, with the stool or only seen on the paper ?
Any other features such as mucus which could indicate IBD or colonic cancer ?
What is melaena ?
It is a jet-black, tar-like and pungent smelling stool representing blood from the upper GI tract that has been altered by passage through the gut.