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.
What are some causes of a lower GI bleed ?
Haemorrhoids
Anal fissure
Diverticular disease
Colorectal carcinoma
IBD
What is jaundice ?
A yellow pigmentation of the skin, sclera and mucosae caused by excess bilirubin in the tissue.
What features occur when there is an interference in the normal metabolism of bilirubin ?
Dark urine - renal excretion of conjugated bilirubin
Pale stool
Abdominal pain
Jaundice
If jaundice is present what are some key questions to ask about in the history ?
Previous blood transfusions
Past history of jaundice, hepatitis, pancreatitis or biliary surgery
Drugs - NSAIDs, antibiotics
IV drug use
Sexual history
Any liver disease
Alcohol consumption
Causes of pre-hepatic jaundice ?
Haemolysis
Ineffective erythropoiesis
Impaired hepatic breakdown - drugs
Causes of hepatic jaundice ?
Viral hepatitis
Alcohol
Alpha 1 antitrypsin deficiency
Drug induced hepatitis
What should be asked about if someone is presenting with diarrhoea ?
Colour
consistency
Offensive smell
Ease of flushing
Duration
Does it disturb the patient’s sleep ?
Is there blood, mucus or pus ?
Associated pain or colic ?
Urgency ?
Any associated vomiting , nausea or weight loss ?
Foreign travel ?
Definition of diarrhoea ?
Increase in stool volume, frequency and change in consistency to semi-formed or liquid stool.
Causes of diarrhoea ?
Malabsorption
Increased intestinal motility - hyperthyroidism, IBD
Crohn’s disease
UC
Osmotic such as lactose intolerance
Secretory such as infection
Drugs
Laxatives
Define nausea ?
A feeling of sickness - inclination to vomit
Usually occurs in waves
May be associated with retching or heaving
Varies in duration
Define vomiting ?
The forceful expulsion of the gastric contents by reflex contractions of the thoracic and abdominal muscles.
Usually follows nausea
What conditions are indicated in an acute setting of nausea and vomiting ?
Cholecystitis
Gastroenteritis
Recreational drug use
Pancreatitis
What conditions may be indicated in a chronic setting of nausea and vomiting ?
Metabolic disorders
GORD
Pregnancy
Medications
If nausea and vomiting occurs before breakfast what could be indicated ?
Pregnancy
Uraemia
Alcohol
Raised ICP
If nausea and vomiting occurs after eating what could be indicated ?
Psychiatric causes
Peptic ulcers
Pyloric stenosis
If nausea and vomiting occurs continuously what could be indicated ?
Depression
If the nature of vomitus is undigested food what is indicated ?
Achalasia
Diverticulum
Strictures
If the nature of vomitus is partially digested food what is indicated ?
Gastric outlet obstruction
Gastroparesis
If the nature of vomitus is undigested food what is indicated ?
Proximal small bowel obstruction
If the nature of vomitus is faeculent what is indicated ?
Fistula
Obstruction
What would you be concerned of if there was nausea and vomiting with weight loss ?
Malignancy
What would you be concerned of if there was nausea and vomiting with diarrhoea, myalgia, malaise and headaches ?
Viral infection
What would you be concerned of if there was nausea and vomiting with headaches, neck stiffness and vertigo ?
Central neurological problem
What does undigested food without bile in vomit suggest ?
A lack of connection between the stomach and the small intestine ( pyloric obstruction )
When assessing someone’s nutritional status what should be asked about in the history ?
Appetite
Diet history
Any changes in oral intake
Changes in weight
What bedside tool can be used to assess nutrional status ?
The Malnutrition Universal Screening Tool (MUST) screening tool
What are the 3 things assessed on in the MUST tool ?
BMI
Unplanned weight loss in the past 3-6 months
If the patient is acutely unwell or if they are likely to have no nutritional intake for more than 5 days
What is the first step in managing malnutrition ?
Using food and encouragement.
Make sure mealtimes aren’t interrupted and high calorie options are encouraged.
What is an NG tube used for ?
Short term access and may provide all of the nutritional and fluid requirements.
It may also be used on top of the patients oral intake as supplementary feeding.
What should be checked before feeding someone using an NG tube ?
pH to ensure the tip is in the stomach and not in the lungs
What is a risk of feeding someone orally with a swallowing impairment ?
Aspiration
What is parenteral nutrition ?
This provides nutrition and fluid directly into a patient’s veins.
It is indicated when the GI tract is either not accessible or not working.
What are the risks of parenteral nutrition ?
The nutrition and fluid is given via a dedicated PICC or Hickman lune so there are risks of sepsis and liver dysfunction.
What is a PEG / RIG / PEGJ / RIGJ tube ?
These tubes provide long term enteral access.
They may feed into the stomach ( PEG or RIG ). They may also go into the small bowel ( PEGJ or RIGJ ).
PEG and PEGJ are placed in via endoscopy and RIG and RIGJ are placed in radiologically.
All these tubes require puncture into the stomach.
What are some conditions associated with malnutrition ?
Any very ill patients
Malignancy
Metabolic disorders
GI disease
Sepsis
Trauma
Depression
Post-surgery
Define malnutrition ?
Malnutrition includes under nutrition ( wasting, stunting, underweight ), inadequate vitamins or minerals, obesity, overweight and resulting diet-related non communicable diseases.
Define acute liver failure ?
Hepatocellular dysfunction causing coagulopathy and encephalopathy in someone without a known liver disease.
What can cause acute liver failure ?
Paracetamol overdose
Viral hepatitis usually hep A or B
Drugs - phenytoin, sodium valproate, isoniazid, nitrofurantoin, sulfonamides and co-amoxiclav
Ischaemic hepatitis
Pregnancy
Signs and symptoms of acute liver failure
Fatigue
Nausea
Anorexia
Weight loss
Abdominal or RUQ pain
Jaundice
Hepatic encephalopathy
Investigations when suspecting acute liver failure ?
General bloods :
LFT
INR
FBC
ABG
U & E
Cause specific tests :
Paracetamol levels
Viral serology
Auto-antibodies
Imaging - abdo USS,
Complications of acute liver failure ?
Cerebral oedema
Sepsis
Shock
AKI
What should you be check for in a patient with liver failure ?
Sepsis
Hypoglycaemia
GI bleeds / varices
Encephalopathy
Management of acute liver disease ?
Protect the airway with intubation and place an NG tube.
Monitor Obs and bloods
Give glucose to prevent hypoglycaemia
Treat the underlying cause.
If seizing treat with lorazepam.
Give PPI as prophylaxis against stress ulcers
How to treat cerebral oedema ?
On ITU : Give 20% mannitol IV
How to treat ascites ?
Restrict fluids
Low salt diet
Give diuretics
What are some risk factors for acute liver failure ?
Chronic alcohol misuse
Poor nutritional status
Age above 40
Female
What signs and symptoms are present in paracetamol overdose ?
Non initially but may have vomiting or RUQ pain
Later : jaundice and encephalopathy from liver damage + acute kidney injury
What is the pathophysiology of a paracetamol overdose ?
The usual paracetamol metabolism pathways become rapidly saturated. This causes the other pathway to be used via cytochrome P450 enzymes which generates a toxic metabolite NAPQI.
The body can only detoxify a small amount with endogenous glutathione.
This causes NAPQI to accumulate.
Investigations for paracetamol overdose ?
FBC
LFT
U & E’s
Albumin levels
Serum paracetamol levels
ABG
Management of paracetamol overdose ?
N-acetylcysteine IV - most effective within 8 hours
Methionine PO is second line.
Give activated charcoal if less than 1 hour from ingestion.
What are some poor prognostic indicators in a paracetamol overdose ?
High or increased PT
Low pH
High lactate
High creatinine
What is N-acetylcysteine ?
A glutathione precursor allowing detoxification of NAPQI.
It completely prevents ALF if given before 8 hours in paracetamol overdose.
Causes of cirrhosis ?
Chronic alcohol abuse
Chronic HPV or HCV infection
Haemochromatosis
Alpha 1 antitrypsin deficiency
Wilson’s disease
Non-alcoholic steatohepatitis ( NASH )
Autoimmunity
Drugs
Signs and symptoms of chronic liver disease ?
Leuconychia
Clubbing
Palmar erythema
Dupuytren’s contracture
Spider naevi
Xanthelasma
Gynaecomastia
Hepatomegaly
Complications of chronic liver disease ?
Hepatic failure : coagulopathy, encephalopathy
Portal hypertension : Caput medusae, oesophageal varices
What is assessed in LFT’s ?
Albumin
ALT
AST
ALP
Bilirubin
What is seen on LFT’s in pre-hepatic jaundice ?
Raised serum unconjugated bilirubin
Raised urobilinogen in urine
What is seen on LFT’s in hepatocellular damage ?
Raised ALT
Raised AST
Raised conjugated and unconjugated bilirubin
Low albumin
What is seen on LFT’s in post hepatic jaundice ?
Raised conjugated levels
Low urobilinogen
Raised ALP
Raised amylase
What is a concern about high levels of unconjugated bilirubin ?
It can cross the blood brain barrier
Management of alcoholic liver disease ?
Reduce and stop alcohol intake.
Benzodiazepine to help with withdrawal.
Give disulfiram to prevent relapse on alcohol
Liver transplant after 3 months away from alcohol.
What is the management of non-alcoholic fatty liver disease ?
Control risk factors
Bariatric surgery helps
Monitor LFT’s and glucose levels
Management for viral hepatitis ?
If hep A or B notify public health england.
Screen and vaccinate contacts
Supportive treatment
Antiviral medications
Management for haemochromatosis ?
Lifestyle changes : avoid iron and vitamin C
Have a hep A or hep B vaccine
Venesection
Management of Autoimmune liver disease ?
Immunosuppression
Prednisolone
Azathioprine
What are some causes of chronic liver disease ?
Alcoholic liver disease
Obesity
Hep B and C
EBV
Autoimmune hepatitis
Hereditary haemochromatosis
Wilson’s disease
Drugs - methotrexate, amiodarone
Signs and symptoms of chronic liver disease ?
May be asymptomatic
Jaundice
Pruritis
Bleeding varices
Ascites
Hepatic encephalopathy
Anorexia
Weight loss
Fatigue
What can be found on examination in chronic liver disease ?
Organomegaly - Early on - hepatomegaly but then shrinks, splenomegaly due to portal hypertension.
Hands - leuconychia, clubbing, dupuytren’s contracture
Xanthelamsa
Spider naevi
Investigations for chronic liver disease ?
LFT’s
FBC
U & E
Viral serology
Check ferritin And ceruloplasmin
Imaging - USS
Biopsy
Management of chronic liver disease ?
Treat aetiology
- stop drinking
- weight loss
- antivirals
- venesection
Complications of chronic liver disease ?
Cirrhosis
Portal hypertension
Ascites and spontaneous bacterial peritonitis
Hepatorenal syndrome
Hepatocellular carcinoma
Pathophysiology of portal hypertension ?
Cirrhosis causes an increased resistance in the portal vein.
Complications of portal hypertension ?
Varices
Splenomegaly
Caput medusae
How do varices form ?
Cirrhosis causes a back up in the blood flow to the liver. This causes blood flow to be diverted through smaller systemic veins causing them to dilate forming varices.
What are the main signs of portal hypertension seen in patients ?
GI bleeding
Ascites
Encephalopathy
Low platelets, red blood cells and white blood cells
Investigations of portal hypertension ?
Endoscopy
Measure the pressure in the hepatic vein
Imaging - USS
Blood tests
Management of portal hypertension ?
Beta blockers
Banding or sclerotherapy for varices
Also treatment for associated features
