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GI Flashcards

1
Q

Define Gastro-Oesophageal Reflux Disease (GORD)

A

Reflux of stomach contents causing 2 or more heartburn episodes/week

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2
Q

Aetiology of GORD

A
  1. Lower oesophageal sphincter hypotension
  2. Hiatus hernia
    • sliding hiatus hernia = gastro-oesophageal junction + part of stomach slides up into chest above diaphragm
    • Rolling hiatus = part of fundus of stomach prolapses through hiatus alongside oesophagus
  3. Loss of oesophageal peristaltic function
  4. Abdomen obesity
  5. Drugs - antimuscarinic, CCB, nitrates
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3
Q

Clinical presentation of GORD

A
  1. Heartburn
  2. Belching
  3. Food/acid brash
  4. Water brash
  5. Painful swallowing
  6. Nocturnal asthma
  7. Chronic cough
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4
Q

What are some differential diagnoses for GORD

A
  1. CAD
  2. Biliary colic
  3. Peptic ulcer disease
  4. Malignancy
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5
Q

Diagnosis of GORD

A
  1. Diagnosis usually possible without investigation UNLESS alarm bell signs such as weight loss, haematemesis (coughing up blood), trouble swallowing
  2. Investigations if alarm bell signs
    • Endoscopy
      • If endoscopy normal - do 24h oesophageal pH monitor
    • Barium swallow
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6
Q

Treatment of GORD

A

LIFESTYLE
1. Weight loss
2. Smoking cessation
3. Small regular meals
4. avoid hot drinks, alcohol, citrus, food < 3h before bed
MEDICAL
1. ANTACIDS - Mg Trisilicate mixture
2. Alginates - Gaviscon
3. PPI - Lansoprazole
4. H2 receptor antagonist - Cimetidine
SURGICAL
1. Nissen fundoplication - laparoscopically increase resting LOS pressure

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7
Q

Complications of GORD

A
  1. Peptic stricture
    • Inflammation of oesophagus -> narrowinf of oesophagus
  2. Barrett’s oesophagus
    • Distal oesophageal epithelium undergoes metaplasia: squamous -> columnar
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8
Q

What are the 2 major forms of IBD

A
  1. Ulcerative colitis - affects only COLON
  2. Crohn’s disease - ANY PART OF GI
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9
Q

Define IBD

A

Mucosal immune system exerts inappropriate response to luminal antigens

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10
Q

Define ulcerative Colitis

A
  1. Relapsing and remitting inflammatory disorder of colonic mucosa
  2. May effect entire colon UP TO ileocaecal valve, NEVER proximal to it
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11
Q

Risk factors of UC

A
  1. Family history
  2. NSAIDS
  3. Chronic stress & depression
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12
Q

Pathophysiology of UC

A
  1. Restricted mucosal disease - differentiates from Crohn’s
  2. Affects only colon
  3. Circumferential and continuous inflammation - NO SKIP LESIONS
  4. Mucosal inflammation - DOES NOT GO DEEPER
  5. No granulomata
  6. Depleted goblet cells
  7. Increased crypt abscesses
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13
Q

Clinical presentation of UC

A
  1. Remissions and exacerbations
  2. Pain restricted to lower left quadrant
  3. Episodic or chronic diarrhoea with blood and mucus
  4. Cramps
  5. Tachycardia
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14
Q

Diagnosis of UC

A
  1. Blood test
    • Raised WCC and platelets
    • Iron deficient anaemia
    • ESR and CRP raised
  2. Stool sample to exclude C.diff etc
    CAROTECTIN
  3. Colonoscopy with mucosal biopsy (GOLD STANDARD)
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15
Q

What organs can be involved in complications with UC

A
  1. Liver
  2. Colon
  3. Skin
  4. Joints
  5. eyes
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16
Q

Treatment of UC

A

1st line - Oral or IV Corticosteroid

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17
Q

Define Crohn’s Disease (CD)

A
  1. Chronic inflammatory GI disease
  2. Transmural granulomatous inflammation
  3. Affecting any part of gut from mouth to anus
  4. Skip lesions
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18
Q

Pathophysiology of CD

A
  1. Transmural granulomatous with skip lesions
  2. Inflammation affects any part of gut
  3. Affects terminal ileum and proximal colon in particular
  4. Involved bowel = thickened and narrowed
  5. Cobblestone appearance due to ulcers and fissures in mucosa
  6. Goblet cells present
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19
Q

Clinical presentation of CD

A
  1. Diarrhoea with urgency, bleeding and pain
  2. Abdominal pain - acute right iliac fossa pain mimics appendicitis
  3. Weight loss
  4. Lethargy
  5. Perianal abscess
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20
Q

Complications of CD

A
  1. Perforation and bleeding
  2. Fistula formation
  3. Malabsorption
  4. Toxic dilation of colon
  5. Colorectal cancer
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21
Q

Differential diagnosis of CD

A
  1. Alternative causes of diarrhoea must be excluded (salmonella etc)
  2. Chronic diarrhoea
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22
Q

Diagnosis of CD

A
  1. Tenderness of right iliac fossa
  2. Anal examination
  3. Bloods
    • Anaemia - due to malabsorption
      • deficiency of iron and folate
    • Raised ESR and CRP
    • Raised WCC and platelets
  4. Stool sample to exclude C.difficile
  5. Colonoscopy
    • Biopsy for spot lesions and granulomatous transmural inflammation
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23
Q

Treatment of CD

A
  1. Smoking cessation
  2. Anaemia - Iron,B12 or folate replacement
  3. Mild attacks
    • Controlled release corticosteroids - BUDESONIDE
  4. Moderate to severe attacks
    • Glucosteroids - Oral PREDNISOLONE
  5. Severe attacks
    • IV HYDROCORTISONE
    • Antibiotics - IV METRONIDAZOLE
  6. If no improvement
    • Anti-TNF antibodies - INFLIXIMAB
  7. Maintain remission
    • AZATHIOPRINE
  8. Surgery
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24
Q

Define IBS

A
  1. Mixed group of abdominal symptoms
  2. No organic cause can be found
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25
What are the 3 types of IBS
1. IBS -C - with constipation 2. IBS-D - with diarrhoea 3. IBS-M - with both
26
Risk factors of IBS
1. Female 2. Previous severe and long diarrhoea 3. High hypochondrial anxiety and neurotic score at time of illness
27
Pathophysiology of IBS
Dysfunction in brain-gut axis -> disorder of intestinal motility
28
Clinical presentation of IBS
1. Multisystem disorder with non-intestinal symptoms - Painful period - Urinary frequency - Back pain - Joint hyper-mobility 2. Consider IBS if any of ABC presented - A - Abdominal pain - B - Bloating - C - Change in bowel habit 3. Symptoms worsened by stress and menstruation 4. RED FLAG SYMPTOMS - Unexplained weight loss - PR bleed - Family history of bowel or ovarian cancer
29
Differential diagnosis of IBS
1. Coeliac disease 2. Lactose intolerance 3. Bile acid malabsorption 4. IBD 5. Colorectal cancer
30
Diagnosis of IBS
1. Nothing physical to be found .˙. must rule out differentials 2. Bloods - FBC - anaemia - ESR & CRP - inflammation - Coeliac serology - test EMA and tTG (+ve = coeliac) 3. Faecal calprotectin - raised in IBD 4. Colonoscopy - rule out IBD
31
Treatment of IBS
1. Regular small meals 2. Reduce caffeinated drinks, alcohol and fizzy 3. IBS-D -> insoluble fibre intake 4. Pain -> antispasmodics - MEBEVERINE 5. Constipation -> laxative - MAVICOL 6. Diarrhoea -> anti motility agent - LOPERAMIDE 7. LAST RESORT -> SSRI
32
Define coeliac disease (Gluten sensitivity enteropathy)
1. Inflammation of mucosa of upper small bowel 2. Improves when gluten withdrawn 3. Relapses when gluten reintroduced 4. T cell mediated autoimmune disease in which PROLAMIN intolerance causes villous atrophy and malabsorption
33
Pathophysiology of Coeliac Disease
1. PROLAMIN A-GLIADIN toxic and resistant to digestion by pepsin and chymotrypsin 2. End up remaining in intestinal lumen -> immune response triggered 3. gluten sensitive T cells activated 4. T cells produce pro-inflammatory cytokines 5. Inflammatory cascade initiated 6. Cascade releases metaloproteinkinases -> Villous atrophy -> Crypt hyperplasia -> Intraepithelial lymphocytes
34
Clinical presentation of Coeliac Disease
1. 1/3 = asymptomatic 2. Smelly/fatty stool 3. Diarrhoea 4. Abdominal pain 5. Bloating
35
Diagnosis of Coeliac Disease
FIRST LINE - IgA-tTG serology with gluten diet 2. FBC - Low Hb - Low B12 - Low ferritin 3. DUODENAL BIOPSY = GOLD STANDARD
36
Treatment of Coeliac Disease
1. Remove gluten 2. Correction of vitamins and mineral 3. DEXA scan to monitor osteoporotic risk
37
Define gastritis
Inflammation associated with mucosal injury
38
Aetiology of gastritis
1. Helicobacter pylori infection 2. Autoimmune gastritis 3. Viruses 4. Duodenogastric reflux 5. NSAIDS
39
Pathophysiology of gastritis
1. H. Pylori -> severe inflammatory response - Gastric mucus degradation + increased mucosal permeability = cytotoxic to gastric epithelium 2. Autoimmune gastritis - affects fundus and body of stomach -> atrophic gastritis + loss of parietal cells & intrinsic factor deficiency ->pernicious anaemia
40
Clinical presentation of gastritis
1. N+V 2. Abdominal bloating 3. Epigastric pain 4. Indigestion 5. Haematemesis (blood vomit)
40
Differential diagnosis of gastritis
1. Peptic ulcer disease (PUD) 2. GORD 3. Non-ulcer dyspepsia 4. Gastric lymphoma 5. Gastric carcinoma
40
Diagnosis of gastritis
1. FBC - leukocytosis 2. H.pylori urea breath test 3. H.pylori stool antigen test 4. Endoscopy 5. Biopsy
41
Treatment of gastritis
1. Remove causative agents 2. Reduce stress 3. H.pylori eradication 4. TRIPLE THERAPY - Acid suppression - PPI (LANSOPRAZOLE/OMEPRAZOLE) - METRONIDAZOLE/CLARITHROMYCIN - AMOX/TETRACYCLINE 5. Acid suppression - H2 ANTAGONIST (RANITIDINE)
42
Define peptic ulcer disease (PUD)
1. Break in the superficial epithelial cells 2. Penetrating down to muscularis mucosa 3. Of stomach or duodenum 4. Fibrous base + increase in inflammatory cells
43
Aetiology of PUD
1. H. Pylori infection 2. NSAIDs, steroids, SSRIs 3. Increased gastric acid secretion 4. Smoking 5. Delayed gastric emptying
44
Pathophysiology of aetiology PUD
1. NSAIDS -> Inhibit cyclo-oxygenase 1 .˙. reduced mucosal defence 2. H. Pylori -> colonise gastric epithelium -> inhabit mucosa layer -> major destruction to mucin layer
45
Clinical presentation of PUD
1. Recurrent burning epigastric pain - single location pain = strong suggestion of PUD - duodenal ulcer = pain at night or hungry - antacid relieves pain 2. Anorexia + weight loss 3. RED FLAG SIGNS FOR CANCER - Anaemia - GI bleed - Dysphagia - Upper abdominal mass
46
Complications of PUD
1. Duodenal ulcer = deeper until hits artery -> massive haemorrhage 2. Peritonitis as acid enters peritoneum 3. Acute pancreatitis
47
Diagnosis of PUD
1. Non invasive test - serological test - breath test - stool antigen test 2. Endoscopy
48
Treatment of PUD
1. Lifestyle adjustment 2. Stop NSAIDs 3. H. pylori eradication
49
Define appendicitis
1. Consider as possibility for all right sided pain 2. Located at McBurney's point - 2/3 of the way from umbilicus to Anterior superior iliac spine
50
Aetiology of appendicitis
1. Faecolith (faecal stones) 2. Lymphoid hyperplasia 3. Filarial worms
51
Pathophysiology of appendicitis
1. Lumen of appendix becomes obstructed 2. Results in invasion of gut organism into appendix wall 3. leads to oedema, ischaemia, necrosis, inflammation and perforation 4. If appendix ruptures -> infected and faecal matter enters peritoneum -> life threatening peritonitis
52
Clinical presentation of appendicitis
1. Pain in umbilical region migrates to right iliac fossa 2. Anorexia 3. N+V 4. Constipation
53
Differential diagnosis of appendicitis
1. Acute terminal ileitis 2. Ectopic pregnancy 3. UTI 4. Diverticulitis 5. Perforated ulcer
54
Diagnosis of appendicitis
1. Bloods - Raised WCC with neutrophil leucocytosis - Elevated CRP and ESR 2. Ultrasound - detect inflamed appendix 3. CT - GOLD STANDARD 4. Pregnancy test - exclude pregnancy 5. Urinalysis - exclude UTI
55
Treatment of appendicitis
1. Surgical - appendectomy 2. IV antibiotic pre-op - METRONIDAZOLE, CEFUROXIME
56
Define diverticulum
outpouching of gut wall at sites of entry of perforating arteries
57
Types of diverticular disease
1. Diverticulosis - presence of diverticula 2. Diverticular disease - diverticula are symptomatic 3. Diverticulitis - inflammation of diverticulum
58
Aetiology of diverticular disease
1. Low fibre diet 2. Obesity 3. Smoking 4. NSAIDs
59
Pathophysiology of diverticular disease
1. Diverticula forms at gaps in wall of gut where blood vessels penetrate 2. Low fibre -> colon pushes harder -> pressure increase 3. Increased pressure -> pouches of mucosa extrude through muscular wall 4. Thickening of muscle layer 5. ACUTE DIVERTICULITIS - Faeces obstruct neck of diverticulum ->bacteria multiply -> inflammation - lead to bowel perforation, abscess, fistulae
60
Clinical presentation of diverticular disease
1. Asymptomatic in 95% - Detected incidentally on colonoscopy or barium enema 2. IF SYMPTOMATIC - Intermittent left iliac fossa pain - Erratic bowel habit 3. ACUTE DIVERTICULITIS - Diverticula in sigmoid colon - Severe pain in left iliac fossa - Fever + constipation SIMILAR TO APPENDICITIS BUT ON RIGHT SIDE
61
Diagnosis of diverticular disease
1. Colonoscopy if no clinical signs 2. Bloods - Polymorphonuclear leucocytosis - increased levels of WBC - Elevated and ESR and CRP 3. CT colonography - Best for diagnosis
62
Define gastritis
1. Inflammation with mucosal injury 2. Epithelial cell damage and regen WITHOUT inflammation
63
Differential diagnosis of gastritis
1. PUD 2. GORD

SJ Phase 2a (13 decks)

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