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1
Q

What is inflammatory bowel disease?

A

An umbrella term for Crohn’s disease and Ulcerative Colitis.

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2
Q

What is Crohn’s disease?

A

A chronic inflammatory condition affecting the GIT.

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3
Q

What is Ulcerative Colitis?

A

A chronic inflammatory condition affecting the colon and rectum.

Involves the formation of ulcers.

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4
Q

What are the protective factors for ulcerative colitis?

A

Smoking

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5
Q

What are the risk factors for ulcerative colitis?

A
  • Age (under 30)
  • White
  • Family history
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6
Q

What are the risk factors for Crohn’s?

A
  • Age (under 30)
  • White
  • Family history
  • Smoking
  • Female
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7
Q

What are the symptoms of ulcerative colitis?

A
  • Bloody diarrhoea (can be with mucus)
  • Abdo pain and discomfort
  • Faecal urgency
  • Systemic symptoms
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8
Q

What are the symptoms of Crohn’s?

A
  • Diarrhoea (not bloody)
  • Faecal urgency
  • Abdo pain
  • Systemic symptoms
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9
Q

What are the signs of ulcerative colitis?

A

Tender, distended abdomen

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10
Q

What are the signs of Crohn’s?

A
  • Aphthous ulcers
  • Abdo tenderness
  • Right iliac fossa mass
  • Perianal abscess
  • Anal/rectal strictures
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11
Q

What investigations are done for suspected ulcerative colitis?

A
  • Bloods (FBC, CRP, cultures)
  • LFTs
  • Stool tests (MCS and C Diff)
  • AXR
  • CXR
  • CT
  • Ileocolonoscopy
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12
Q

What are the differential diagnoses for IBD?

A

Other causes of diarrhoea:
- Salmonella
- Giardia intestinalis
- Rotavirus

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13
Q

What is the aim of treatment for ulcerative colitis?

A

Induce remission.

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14
Q

What is the treatment for mild/moderate ulcerative colitis?

A
  • Oral 5-aminosalicylic acid (5-ASA)
  • Rectal 5-ASA
  • Glucocorticoid if not responsive
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15
Q

Give 3 examples of 5-ASAs.

A
  • Sulfasalazine
  • Mesalazine
  • Olsalazine
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16
Q

What is the treatment for severe ulcerative colitis?

A

Glucocorticoid (eg. oral prednisolone)

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17
Q

What is the management of Crohn’s disease?

A
  • Smoking cessation
  • Anaemia (iron, B12 or folate deficiency) should be treated with replacement
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18
Q

How is a mild attack of Crohn’s managed?

A

Controlled-release corticosteroids (budesonide)

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19
Q

How is a moderate attack of Crohn’s managed?

A

Glucocorticoids (oral prednisolone)

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20
Q

How is a severe attack of Crohn’s managed?

A
  • IV hydrocortisone
  • Treat rectal disease
  • Antibiotics
  • Anti-TNF
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21
Q

How is remission maintained in Crohn’s?

A

Azathioprine (methotrexate if intolerant)

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22
Q

What are the complications of ulcerative colitis?

A
  • Toxic megacolon
  • Bleeding
  • Malignancy
  • Strictures (leading to obstruction)
  • Venous thrombosis
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23
Q

What are the complications of Crohn’s?

A
  • Fistulae
  • Strictures
  • Abscesses
  • Malabsorption
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24
Q

What is irritable bowel syndrome?

A

A mixed group of abdominal symptoms with no organic cause.

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25
What are the three types of IBS?
- IBS-C - IBS-D - IBS-M
26
What is the pathophysiology of irritable bowel syndrome?
Dysfunction in the brain-gut axis results in disorder of intestinal motility and/or enhanced visceral perception.
27
What are the causes of IBS?
- Depression/anxiety - Psychological stress/trauma - GI infection - Sexual, physical and verbal abuse - Eating disorders
28
What are the risk factors for IBS?
- Female - Previous severe and long diarrhoea - High hypochondriacal anxiety
29
When should IBS be considered?
ABC: - Abdo pain - Bloating - Change in bowel habits
30
What is the diagnostic criteria for IBS?
1. Abdo discomfort including two of: - Relieved by defecation - Change in stool frequency - Change in stool formation 2. Accompanied by two of: - Urgency - Abdo bloating/distension - Worsening symptoms after food - Incomplete evacuation
31
What is the exclusion criteria for IBS?
- >40 years old - Bloody stool - Anorexia - Weight loss - Diarrhoea at night
32
What investigations are ordered for suspected IBS?
- FBC - ESR - LFTs - Coeliac serology - TSH - Colonoscopy
33
What is the management for IBS?
- Exclusion diets - Bulking agents for constipation and diarrhoea - Antispasmodics for colic/bloating - CBT
34
What is Coeliac disease?
A condition in which there is inflammation of the mucosa of the upper small bowel that improves when gluten is withdrawn from the diet and relapses when gluten is reintroduced.
35
What is the clinical presentation of coeliac disease?
GLIAD: - GI malabsorption - Lymphoma and carcinoma - Immune associations - Anaemia - Dermatological
36
What investigations are ordered in suspected coeliac disease?
- Bloods (FBC, LFTs, INR etc) - Antibodies - Stool tests - Oesophago-gastro-duodenoscopy (OGD) - Duodenal biopsy
37
What are the differential diagnoses for coeliac disease?
- Peptic duodenitis - Crohn's - Giardiasis - Post-gastroenteritis - Eosinophilic enteritis - Graft-versus-host disease - Non-coeliac gluten insensitivity
38
What is the management of coeliac disease?
- Gluten-free diet - Pneumococcal vaccine - Dermatitis herpertiformis
39
What are the complications of coeliac disease?
- Malabsorption - Malnutrition - Lactose intolerance - Cancer - Pregnancy complications
40
What is gastro-oesophageal reflux disease? (GORD)
Acid from the stomach leaks up into the oesophagus.
41
What are the risk factors for GORD?
- Hiatus hernia - Smoking - Alcohol - Obesity - Pregnancy - Drugs - Iatrogenic
42
What are the signs and symptoms of GORD?
- Heartburn - Belching - Odonophagia - Dysphagia - Nocturnal asthma - Chronic cough - Laryngitis
43
What are the investigations for GORD?
PPI trial
44
What are the differential diagnoses for GORD?
- ACS - Stable angina - Functional oesophageal disorder - Functional dyspepsia - PUD - Malignancy
45
What is the conservative management of GORD?
- Weight loss - Raise head of bed - Small regular meals - Smoking cessation - Avoid hot drinks and spicy foods
46
What is the medical management of GORD?
- OTC antacids - PPI (lansoprazole)
47
What is the surgical management of GORD?
Nissen fundoplication.
48
What are the complications of GORD?
- Oesophagitis - PUD - Barret's metaplasia
49
What is a Mallory-Wiess tear?
A tear/laceration along the right border of (or near) the gastro-oesophageal junction.
50
What is the pathophysiology of a Mallory-Weiss tear?
Not completely understood. Thought to be high abdominal pressure with low intrathoracic pressure.
51
What are the risk factors for a Mallory-Weiss tear?
- Alcoholism - Forceful vomiting - Eating disorders - Male - NSAID use
52
What are the clinical features of a Mallory-Weiss tear?
- Vomiting - Haematemesis after vomiting - Retching - Postural hypotension - Dizziness
53
How is a Mallory-Weiss tear diagnosed?
OGDoscopy
54
What are the differential diagnoses for a Mallory-Weiss tear?
- Gastroenteritis - Peptic ulcer - Cancer - Oesophageal varices
55
How are Mallory-Weiss tears managed?
- Normally self-limiting - Supportive care
56
What are peptic ulcers?
AKA gastric ulcers - open sores in the lining of the stomach
57
How are peptic ulcers classified?
Acute and chronic.
58
What are the causes of acute peptic ulcers?
- Drugs (NSAIDs, steroids) - Stress
59
What are the causes of chronic peptic ulcers?
- Drugs - H. pylori - High calcium - Zollinger-Ellison
60
What is the main difference between duodenal and gastric ulcer pathophysiology?
Duodenal - too much acid Gastric - not enough acid protection
61
What are the risk factors for duodenal ulcers?
- H pylori - Drugs - Smoking - Alcohol - Increased gastric emptying - Blood group O
62
What are the risk factors for gastric ulcers?
- H pylori - Smoking - Drugs - Delayed gastric emptying - Stress
63
What is the clinical presentation of duodenal ulcers?
Epigastric pain (before meals, relieved by eating or milk).
64
What is the clinical presentation of gastric ulcers?
1. Epigastric pain - Worse on eating - Relieved by antacids 2. Weight loss
65
What investigations are ordered for suspected peptic ulcer disease?
- Upper GI endoscopy - H. pylori C13 urea breath test/stool antigen test - FBC
66
What are the differential diagnoses for PUD?
- Oesophageal cancer - Stomach cancer - GORD - Gastroparesis - Biliary colic - Acute pancreatitis - IBS
67
What is the conservative management of peptic ulcer disease?
- Lose weight - Smoking and alcohol cessation - Avoid hot drinks/spicy food - Stop drugs (NSAIDs and steroids)
68
What is the medical management of peptic ulcer disease?
- OTC antacids - H/ pylori eradication (CAP) - Full dose acid suppression - Low dose acid suppression
69
What are the complications of peptic ulcers?
- Haemorrhage - Perforation - Gastric outflow obstruction - Malignancy
70
What is appendicitis?
Inflammation of the vermiform appendix ranging from oedema to ischaemic necrosis and perforation.
71
What is the pattern of abdo pain in appendicitis?
1. Early inflammation - Appendiceal irritation - Visceral pain not well localised - Umbilical pain 2. Late inflammation - Parietal peritoneum irritation - Pain localised in the right iliac fossa
72
What are the symptoms of appendicitis?
- Colicky abdo pain - Anorexia - Nausea - Constipation/diarrhoea
73
What are the signs of appendicitis?
- Low-grade pyrexia - Tachycardia - Dyspnoea - Guarding and tenderness at McBurney's point - Rovsings sign - Psoas sign - Cope sign
74
What is Rovsing's sign?
Pressure in LIF - more pain in RIF
75
What is Psoas sign?
Pain on extending the hip - rectocaecal appendix.
76
What is Cope sign?
Flexion and internal rotation of R hip - pain
77
How is appendicitis diagnosed?
Clinical
78
What investigations should be ordered for appendicitis?
- FBC - CRP - Abdo ultrasound - Contrast-enhanced abdo CT
79
What are the differential diagnoses for appendicitis?
- Cholecystitis - Diverticulitis - Ruptured ectopic - Cyst accident (torsion, rupture, haemorrhage) - Crohn's
80
What is the management of appendicitis?
- Fluids - Antibodies - Analgesia - Appendectomy
81
What are the complications of appendicitis?
- Appendix mass - Appendix abscess - Perforation
82
What is a diverticulum?
Out-pouching of tubular structure.
83
What is a true diverticulum?
Composed of a complete wall.
84
What is a false diverticulum?
Composed of mucosa only.
85
What is diverticular disease?
Symptomatic diverticulosis.
86
What is diverticulitis?
Inflammation of diverticula.
87
What is the clinical presentation of diverticular disease?
- Altered bowel habits - Nausea - Flatulence - Abdo pain and tenderness - Pyrexia
88
What investigations should be ordered for diverticular disease?
- FBC (polymorphonuclear leukocytes) - CRP (elevated)
89
What are the differential diagnoses of diverticular disease?
- Endometriosis - Colorectal - Appendicitis - Ulcerative colitis - Crohn's - Ischaemic colitis - IBS
90
How is diverticular disease managed?
- Bowel rest (nil by mouth) - Abs - IV fluids - Analgesia - Surgery
91
What are the complications of diverticular disease?
- Abscess - Perforation - Haemorrhage - Fistulae - Strictures
92
What is gastritis?
Inflammation associated with mucosal injury.
93
What are the causes of gastritis?
- H. pylori infection - Autoimmune gastritis - Viruses (CMV, HSV) - Duodenogastric reflux - Crohn's - NSAIDs/aspirin
94
What is the clinical presentation of gastritis?
- Nausea - Vomiting - Abdo bloating - Epigastric pain - Indigestion - Haematemesis
95
How is gastritis diagnosed?
- Endoscopy - Biopsy - H. pylori urea breath test - H. pylori antigen stool test
96
What are the differential diagnoses for gastritis?
- PUD - GORD - Non-ulcer dysplasia - Gastric lymphoma - Gastric carcinoma
97
What is the treatment for gastritis?
- Remove causative agents - Reduce stress - H. pylori eradication - H2 antagonists - PPIs - Antacids
98
What is the pathophysiology of a small bowel obstruction?
Most commonly mechanical obstruction (adhesion, hernia, Crohn's)
99
What are the causes of small bowel obstruction?
- Adhesions (previous abdo surgery) - Hernia - Malignancy - Crohn's
100
How does small bowel obstruction present?
- Pain (colicky then diffuse) - Profuse vomiting (that follows pain) - Less distension than LBO - Nausea - Anorexia - Tenderness
101
What investigations are done for small bowel obstruction?
- AXR (central gas shadows) - Examination of hernia orifices - Rectal exam - FBC - CT (gold standard)
102
What are the differentials for small bowel obstruction?
- Ileus - Infectious gastroenteritis - Large bowel obstruction - Intestinal pseudo-obstruction - Acute appendicitis - Acute pancreatitis
103
What is the management of small bowel obstruction?
- Aggressive fluid resuscitation - Bowel decompression - Analgesia - Antibiotics - Antiemetics - Surgery (remove obstruction)
104
What are the complications of small bowel obstruction?
- Intestinal necrosis - Sepsis - Multi-organ failure - Intestinal perforation
105
What is the pathophysiology of large bowel obstruction?
The colon proximal to the obstruction dilates, increasing colonic pressure and decreasing mesenteric blood flow.
106
What causes large bowel obstructions?
Colorectal malignancy (90%)
107
How does large bowel obstruction present?
- Abdo pain and distension - Palpable mass - Late vomiting - Constipation - Bloating - Nausea
108
What investigations are done for large bowel obstruction?
- Digital rectal exam - FBC - AXR - CT
109
What are the differentials for large bowel obstruction?
- Acute colonic pseudo-obstruction - Chronic megacolon - Toxic megacolon - Endometriosis - Pseudomembranous colitis
110
What is the management of large bowel obstruction?
- Aggressive fluid resuscitation - Bowel decompression - Analgesia - Antibiotics - Surgery
111
What are the possible complications of large bowel obstruction?
- Bowel perforation - Sepsis - Death
112
What is intestinal pseudo-obstruction?
- Clinical picture mimics obstruction - No mechanical cause
113
What causes intestinal pseudo-obstruction?
Complications of other conditions
114
What is the clinical presentation of intestinal pseudo-obstruction?
Rapid and progressive abdo distension and pain.
115
What investigations are done for intestinal pseudo-obstruction?
AXR (gas-filled large bowel)
116
What is the management for intestinal pseudo-obstruction?
- Treat underlying cause - IV neostigmine
117
What are the 2 types of oesophageal cancers and where do they occur?
- Squamous cell carcinoma (middle and upper third) - Adenocarcinomas (lower third)
118
What are the causes of oesophageal squamous cell carcinoma?
- High levels of alcohol consumption - Achalasia - Smoking - Tobacco use - Obesity - Low fruit and veg
119
What are the causes of oesophageal adenocarcinomas?
- Smoking - Tobacco use - GORD - Obesity
120
What are the protective factors against oesophageal squamous cell carcinoma?
Diet rich in: - Fibre - Carotenoids - Folate - Vit C
121
What are the risk factors for oesophageal cancers?
- Alcohol - Smoking - Obesity - Achalasia - Diet low in Vit A and C - Barrett's oesophagus
122
What is the clinical presentation of oesophageal cancers?
- Progressive dysphasia - Weight loss - Lymphadenopathy - Anorexia - Pain - Difficulty swallowing - Hoarseness and cough
123
What are the clinical features of benign oesophageal tumours?
- Usually asymptomatic - Dysphagia - Retrosternal pain - Food regurgitation - Recurrent chest infections
124
How are oesophageal cancers diagnosed?
- Oesophagoscopy with biopsy - Barium swallow - CT scan/MRI/PET for staging
125
How are benign oesophageal tumours diagnosed?
- Endoscopy - Barium swallow - Biopsy to rule out malignancy
126
How are oesophageal cancers treated?
- Surgical resection - Systemic chemo if incurable/metastases
127
How are benign oesophageal tumour managed?
- Endoscopic removal - Surgical removal of larger tumours
128
What are the two types of gastric cancer?
- Intestinal (type 1) - Diffuse (type 2)
129
What are the features of intestinal gastric adenocarcinomas?
- Well formed and differentiated glandular structures - Tumours are polypoid or ulcerating lesions - Intestinal metaplasia is seen in the surrounding mucosa
130
What are the features of diffuse gastric adenocarcinomas?
- Poorly cohesive undifferentiated cells - Tend to infiltrate the gastric wall - Can involve the cardia - Worse prognosis than intestinal
131
What are the causes of gastric adenocarcinomas?
- Smoking - H. pylori infection - Diet - Loss of p53 and APC genes - Family history - Pernicious anaemia
132
What are the protective factors against gastric adenocarcinomas?
- Non-starchy vegetables - Fruit - Garlic - Low salt
133
What are the risk factors for gastric adenocarcinomas?
- First-degree relative with gastric cancer - Smoking - Dietary factors
134
What is the clinical presentation of gastric adenocarcinomas?
- Epigastric pain - Nausea - Anorexia - Weight loss - Vomiting - Dysphagia
135
Where can a gastric adenocarcinoma metastasise?
- Liver (jaundice) - Bone - Lung - Brain
136
How is gastric adenocarcinoma diagnosed?
- Gastroscopy and biopsy - Endoscopic ultrasound (evaluate depth of invasion) - CT/MRI for staging - PET scan (mets)
137
How is a gastric adenocarcinoma managed?
- Nutritional support - Surgery and combination chemo
138
What are the risk factors for small intestine cancer?
- Coeliac disease - Crohn's disease
139
What is the clinical presentation for small intestine cancer?
- Pain - Diarrhoea - Anorexia - Weight loss - Anaemia - Palpable mass in cases
140
How is small intestine cancer diagnosed?
- US - Endoscopic biopsy
141
What is the treatment for small intestine cancer?
- Surgical resection - Radiotherapy
142
What is a colonic polyp?
Abnormal growth of tissue projecting from colonic mucosa.
143
What are adenomas in the colon?
- A type of polyp - Precursor lesions in most cases - Benign, dysplastic tumour of columnar cell/glandular tissue
144
What are the two types of inherited polyps?
- Familial adenomatous polyposis - Lynch syndrome (Hereditary Non-Polyposis Colon Cancer)
145
What is the most common colorectal carcinoma?
Adenocarcinoma.
146
Where do most colorectal carcinomas occur?
Distal colon.
147
What is the progression of colorectal adenomas?
Normal epithelium - adenoma - colorectal adenocarcinoma Spreads by infiltration through the bowel wall and then spread to lymphatic and BVs.
148
What are the risk factors for colorectal carcinomas?
- Age - Low fibre diet - High sugar and red meat diet - Colorectal polyps - Alcohol - Smoking - Obesity - UC - Family history
149
What are the protective risk factors for colorectal carcinomas?
- Vegetables - Milk - Garlic - Exercise - Low-dose aspirin
150
How do polyps in the rectum or sigmoid colon present?
Bleeding.
151
How do right sided colorectal carcinomas present?
- Usually asymptomatic until anaemia due to bleeding - May have a mass - Weight loss - Low Hb - Abdo pain
152
How do left sides colorectal carcinomas present?
- Change in bowel habit - Blood and mucus in stool - Alternating constipation and diarrhoea - Thin/altered stool
153
How do rectal carcinomas present?
- Rectal bleeding and mucus - Thinner stool and tenesmus (cramping rectal pain)
154
What is an emergency presentation of colorectal carcinomas?
Obstruction
155
What are the 4 cardinal signs bowel obstruction?
- Absolute constipation - Colicky abdominal pain - Abdominal distension - Vomiting (faeculent)
156
How are colorectal carcinomas diagnosed?
- Faecal occult blood (FOB) - Colonoscopy (gold standard) - MRI
157
How are colorectal carcinomas classified as per the Duke's classification?
A = Limited to muscularis mucosae (95% 5-year survival) B = Extension through MM (75%) C = Involvement of regional metastases (35%) D = Distant metastases (6.6%)
158
What are the differential diagnoses for colorectal carcinomas?
- Anorectal pathology (haemorrhoids, anal fissure/prolapse) - Colonic pathology (IBD, diverticular disease) - Small intestine and stomach pathology (GI bleed)
159
How are bowel polyps managed?
Removed to reduce risk of developing into cancer.
160
What is the treatment for colorectal carcinomas?
- Surgery if no mets - Endoscopic stenting - Radiotherapy - Chemotherapy (if Duke C post op)

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