GI Flashcards
1
Q
Whata are the 2 main types of inflammatory bowel disease (IBD?)
A
Ulcerative colitis (UC)
Crohn’s disease (CD)
2
Q
Where does UC affect?
A
ONLY the colon
Mucosa
3
Q
Where does CD affect?
A
Any part of the GI tract- mouth to anus
Transmural
4
Q
Define transmural
A
Affects all layers
5
Q
Define ulcerative colitis
A
Chronic relapsing-remitting non-infectious inflammatory disease of the colon
6
Q
What are the 4 types of UC?
A
Ulcerative proctitis
Proctosigmoiditis
Left sided colitis
Extensive colitis
7
Q
Define ulcerative proctitis
A
Inflammation limited to rectum
8
Q
Define proctosigmoiditis
A
Inflammation involving rectum and sigmoid colon
9
Q
Define left sided colitis
A
Inflammation doesnt extend proximally above splenic flexure
10
Q
Define extensive colitis
A
Inflammation extends proximally beyond splenic flexure, including pancolitis (entire colon)
11
Q
Where does inflammation begin in UC?
A
Starts at rectum -> sigmoid -> proximal colon
12
Q
What layers are affected by inflammation in UC?
A
Just the mucosa
13
Q
What ethnic group are most prone to IBD?
A
Jewish people
14
Q
What gene is associated with UC?
A
HLAB27
15
Q
Who is commonly affected by UC?
A
Highest in Europe, UK, North America
Males=females
15-30
Some family history
No appendectomy
16
Q
Does smoking increase the risk of UC?
A
No- smoking decreases risk!
17
Q
What are 3 risk factors of UC?
A
Family history
NSAIDs
Chronic stress and depression
18
Q
What are the signs and symptoms of UC?
A
Pain in lower left quadrant and when defecating
Diarrhoea with blood or mucus
Fever, tachycardia
Extraintestinal signs
Weight loss
19
Q
What are the extraintestinal signs of IBD?
A
A PIE SAC
Ankylosing spondylitis
Pyoderma gangrenosum
Iritis
Erythema nodosum
Sclerosing cholangitis
Aphthous ulcers/ amyloidosis
Clubbing
20
Q
What is pyoderma gangrenosum?
A
Ulcerated patches on skin (usually legs) which is very painful and has a purple edge
21
Q
What is iritis?
A
Swelling and irritation of the iris
AKA anterior uveitis
22
Q
What is erythema nodosum?
A
Swollen fat under skin causing red bumps on the skin
23
Q
What is sclerosing cholangitis?
A
Disease of the bile ducts causing scarring
24
Q
What are aphthous ulcers?
A
Canker sores- small shallow lesions in the soft tissue of the mouth or gums
25
How is UC diagnosed?
GS: colonoscopy with mucosal biopsy
Positive faecal calprotectin
Inflammatory markers: raised WCC, ESR and CRP
26
How is UC graded?
Truelove and Witt’s Criteria
27
What are the 3 levels of Truelove and Witt’s Criteria?
Mild: <4 stools per day
Moderate: 4-6 stools per day
Severe: <6 stools
28
What are 2 differential diagnoses of UC?
Crohn’s disease
Infective colitis
Pseudomembranous colitis
Microscopic colitis
29
How is UC treated?
Aminosalicylate/ 5-ASA
Moderate: 5-ASA and corticosteroid (Prednisolone)
Moderate-severe: fluid resus, IV steroid, anti-TNF
30
What are 3 5-ASAs?
*Mesalazine
Sulfasalazine
Olsalazine
31
How do 5-ASAs work?
Inhibit prostaglandins to reduce inflammation
32
What is an example of a glucocorticoid?
Prednisolone
33
What 3 drugs can be used to treat UC with severe systemic features?
Ciclosporin
Hydrocortisone
Infliximab
34
How is remission maintained in UC?
Azathioprine
35
How is UC cured?
Colectomy (rectum fused to ileum)
Partial colectomy
36
What is a severe complication of UC?
Toxic mega colon
37
What gene is associated with Crohn’s disease?
NOD-2
38
Define Crohn’s disease
Chronic inflammatory GI disease characterised by transmural granulomatous inflammation affecting any part of the GI tract
39
What are skip lesions?
Regions of unaffected bowel between areas of active disease
40
Do skip lesions occur in UC or Crohns?
Crohn’s
41
What region of the GI tract is most commonly affected by Crohn’s?
Terminal ileum and proximal colon
42
Who is most commonly affected by Crohn’s?
North Europe, UK, USA
Not Asian
Females
1/5 have close relatives with CD
20-40 presentation
43
Is UC or Crohn’s more common?
UC
44
What are 3 risk factors of Crohn’s?
Genetic association
Smoking
Stress and depression
Good hygiene
Appendectomy
45
What are the symptoms of Crohns?
Pain in right lower quadrant
Urgent diarrhoea and pain
Gallstones
Weight loss and anorexia
Extraintestinal signs
46
What are 3 complications of Crohn’s?
Perforation and bleeding
Fistula formation
Malabsorption
Small bowel obstruction
Colorectal cancer
47
What are 3 differential diagnoses for Crohns?
Chronic diarrhoea
Salmonella
Rotavirus
48
What is another disease associated with the HLA B27 gene?
Ankylosing spondylitis
Psoriatic arthritis
49
How is Crohns diagnosed?
Colonoscopy and biopsy
Exclude campylobacter ect
50
What are some features of UC on colonoscopy?
Inflammatory infiltrate
Goblet cell depletion
Crypt abscesses
Mucosal ulcers
51
What are some signs of Crohns on colonoscopy?
Skip lesions
Granulomas
Cobblestone appearance
52
Outline the pathophysiology of Crohns
Faulty epithelium -> pathogens enter -> inflammation -> granulomas -> skip lesions and cobblestone appearance
53
How is Crohn’s treated?
1. Prednisolone (mild) or IV hydrocortisone (severe)
2. +5-ASA
3. Infliximab
4. Surgery
54
Will surgery cure Crohns?
No
55
How is remission for Crohns maintained?
Azathioprine +/- methotrexate
56
What are 3 differences between Crohns and UC?
1. UC affects only colon, CD is whole GI tract
2. UC affects whole part, CD has skip lesions
3. CD penetrates the whole linings of the GI tract, UC only mucosa
4. Smoking can prevent UC, but cause CD
5. CD has granulomas, UC doesnt
57
Define irritable bowel syndrome (IBS)
Functional bowel disorder with a group of abdominal symptoms for which no organic cause can be found
58
Who is affected by IBS?
1/5 in UK!
Females > males
20-30
59
What are 3 things that can exacerbate IBS?
Stress
Food
Gastroenteritis
Menstruation
60
What are 3 causes of IBS?
Stress and anxiety
Stress and trauma
GI infection
Sexual, psychical and verbal abuse
Eating disorders
61
What are the 3 types of IBS?
IBS-C: constipation
IBS-D: diarrhoea
IBS-M: mixed- constipation and diarrhoea
62
What are 2 differential diagnoses of IBS?
IBD
Coeliac
GI infection
Lactose intolerance
63
What are the clinical presentations of IBS?
ABC:
A- Abdominal pain or discomfort (Relieved by defecation)
B- bloating
C- changes in bowel habit
Altered stool form and frequency
64
How is IBS diagnosed?
Rule out differentials: faecal caprotectin, anti-tTG, inflammation
Rome IV criteria
65
What does faecal calprotectin indicate?
IBD
66
What is Rome IV criteria?
Recurrent abdominal pain for at least 1 day a week for 3 months
AND 2 of:
Relieved by defecation
Changes in bowel appearance
Changes in bowel frequency
67
How is IBS managed conservatively?
Low FODMAP diet
Education and reassurance
Avoid caffeine and alcohol
68
How is IBS treated medically?
1. Diarrhoea= loperamide, constipation = laxative (eg. Senna) and antispasmodics
2. TCA - eg. Amitriptyline
3. SSRA
69
What are 2 antispasmodics?
Mebeverine
Buscopan
70
What is a low FODMAP diet?
Fermentable
Oligosaccharides
Disaccharides
Monosaccharides
And
Polyols
71
What are 3 differences between IBD and IBS?
1. IBS normal on investigations
2. IBS has no symptoms outside of GI tract
3. IBS has no blood in stools
4. IBS does not involve weight loss
72
Define coeliac disease
T cell mediated autoimmune disease of the small bowel where gluten causes inflammation
73
What part of gluten causes coeliac disease inflammation?
Prolamin which is an alcohol soluble protein
74
Outline the pathophysiology of coeliac
Prolamins bind to IgA and interact with ttg-> formation of IgA, IgA anti-ttg and EMA antibodies -> villous atrophy
75
What are 2 antibodies associated with coeliac?
Anti-TTG
Anti-EMA (more specific)
76
What part of the bowel is typically most affected by coeliac?
Jejunum
77
What 2 genes are associated with coeliac?
HLA-DQ2 (90%)
HLA-DQ8
78
What are 3 risk factors for coeliac disease?
Autoimmune disease eg. DMT1 and thyroid disease
Breastfeeding
Family history
IgA deficiency
79
What type of hypersensitivity reaction is involved in coeliac?
Type 4
80
What are the 3 effects of coeliac on the small intestine?
Villous atrophy
Crypt hyperplasia
Intraepithelial lymphocytes
81
What are the signs and symptoms of coeliac?
Dermatitis herpetiformis on elbows, knees and buttocks
Malabsorption (anaemia, weight loss, failure to thrive)
Angular stomatitis
Steatorrhoea
Osteomalacia
82
What is dermatitis herpetiformis?
Raised red patches cause by IgA deposition which can burst on scratching
83
What is angular stomatitis?
Inflammation on corners of mouth
84
What is steatorrhoea?
Fatty/smell stools
85
How is coeliac diagnosed?
1. IgA levels: Raised anti-tTG
2. Raised anti-EMA
Biopsy
Maintain gluten diet for 6< weeks before test
86
What is the gold standard diagnosis for coeliac?
Endoscopy and duodenal biopsy
87
Where is iron, folate and B12 absorbed?
Dude Is Just Feeling Ill Bro
Duodenum = Iron
Jejunum = folate
Ileum = B12
88
How is coeliac treated?
Lifelong gluten free diet :(
Replace mineral and vitamin deficiency
89
What are 2 complications of coeliac?
Osteoporosis
Anaemia
Non-responsive coeliac (not improved by no gluten)
T- cell lymphoma
90
Define tropical sprue
Severe malabsorption with diarrhoea and malnutrition after tropical travel
91
What is the onset of tropical sprue?
Can occur days or years after visit to tropics
92
What are the clinical presentations of tropical sprue?
Villous atrophy
Diarrhoea
Anorexia and weight loss
93
How is tropical sprue diagnosed?
Jejunal tissue biopsy shows incomplete villous atrophy
94
How is coeliac and tropical sprue differentiated on biopsy?
Tropical sprue= INCOMPLETE villous atrophy
Coeliac= COMPLETE villous atrophy
95
How is tropical sprue treated?
Drink treated water
Antibiotics: tetracycline for 6 months
Very good prognosis
96
Define gastritis
Inflammation of the stomach musocal lining
97
What are 3 causes of gastritis?
autoimmune
H. Pylori
NSAIDs
Alcohol
Stress
98
How does H.pylori cause gastritis?
Severe inflammation -> mucus degradation and increased permeability -> ammonia forms from urea -> toxic to mucosa -> less mucus produced
99
How do NSAIDs cause gastritis?
COX inhibitors inhibit prostaglandin-> inhibits mucous secretion -> gastritis
100
What are the clinical presentations of gastritis?
Epigastric pain with diarrhoea
N+V
Abdo bloating
Dyspepsia
101
What are 2 differential diagnoses of gastritis?
PUD
GORD
Gastric lymphoma
Gastric carcinoma
102
How is gastritis diagnosed?
Endoscopy and biopsy
H. Pylori urea breath test and stool antigen test
103
Why is CO2 high in a urea breath in H.pylori infection?
H.Pylori produces urease which converts urea to ammonia and CO2
104
How is gastritis treated?
Triple therapy: PPI and 2 Abx
PPI + amoxicillin (1g) + clarithomycin (500mg)
Stop NSAIDS and alcohol
105
What are 2 complications of gastritis?
Peptic ulcers
Bleeding and anaemia
Gastric cancer
MALT lymphoma
106
Define GORD
Reflux of gastric contents into the oesophagus due to lower oesophageal sphincter (LOS) relaxation
107
What are the causes of GORD?
Increased intraabdominal pressure (obese, pregnancy)
Hiatal hernia
Drugs
Scleroderma
108
What are the risk factors for GORD?
Obese or pregnancy
Smoking
NSAIDs, caffeine, alcohol
Male sex
109
What is the MC hiatus hernia?
Sliding: GOj and part of stomach slides into the chest
80%
Other = rolling- fundus collapses
110
What are the clinical presentations of GORD?
Dyspepsia/indigestion
Belching
Bile regurgitation/acid brash
Cough
Sinusitis
111
When are symptoms worsened in GORD?
Hot drinks and alcohol
Bending, stooping, lying down
112
What are the red flags in GI for urgent referral?
ALARMS
Anaemia (internal bleed)
Loss of weight
Anorexia
Recent onset
Melaena or haematemesis
Swallowing issues/dysphagia
113
What is the difference between haematemesis and haemoptysis?
Haematemesis is coughing up blood from GI
Haemoptysis is coughing up blood from respiratory system
114
What are 2 differential diagnoses of GORD?
CAD
Biliary colic
PUD
Malignancy
115
How is GORD diagnosed?
Usually made without investigation if no ALARM symptoms and go straight to treatment
If ALARM:
Endoscopy
FBC
Barium swallow
24h oesophageal pH
116
How is GORD treated conservatively?
Weight loss
Stop smoking
Small regular meas
Avoid hot drinks, alcohol, citrus, eating <3 hours before bed
117
How is GORD treated pharmacologically?
1. PPI
2. H2 receptor antagonist
OTC:
Antacids
Alginates
118
What is an example of an antacid?
Magnesium trisilicate
Form a gel or foam raft to reduce reflux
119
What is an example of an alginate?
Gaviscon
120
What are 2 PPIs?
Lansoprazole
Omeprazole
121
What is an example of a H2 receptor antagonist?
Cimetidine
Ranitidine
122
What surgery can be used to treat severe GORD?
Nissan fundoplication
Fundus can be wrapped around oesophagus to increase resting LOS pressure
123
What are 2 complications of GORD?
Oesophageal stricture
Barretts oesophagus
124
What is oesophageal stricture?
Inflammation of oesophagus due to acid exposure
Presents as gradually worsening dysphagia
125
How is oesophageal stricture treated?
Endoscopic dilation
Long term PPIs
126
Define Barrett’s oesophagus
Metaplasia of stratified squamous -> simple columnar epithelium
ALWAYS hiatus hernia
127
What is the complication of Barrett’s oesophagus?
Increased risk of oesophageal adrenocarcinoma
128
How is Barrett’s oesophagus diagnosed?
Upper GI endoscopy and biopsy
Shows metaplasia >1cm from GOJ
129
Define peptic ulcer
A break in the superficial epithelial cells down to the muscularis mucosa of the stomach or duodenum
130
What are the 2 types of peptic ulcers?
Duodenal ulcers
Gastric ulcers
131
What is the MC type of peptic ulcers?
Duodenal ulcers
132
What is the MC site of gastric ulcers?
Lesser curvature
133
What are 3 causes of gastric ulcers?
H. Pylori (70-80%)
NSAIDs
Zollinger Ellison syndrome
134
What is Zollinger Ellinson syndrome?
Gastrin secrete tumour
135
What are the symptoms of gastric ulcers?
Epigastric pain
Worse quickly after eating
Weight loss
136
How is PUD diagnosed?
No red flags: C-urea breath test and stool antigen test
Red flags: urgent endoscopy and biopsy
137
What are the causes of peptic ulcer disease (PUD)?
H. Pylori infection
NSAIDs
Increased acid secretion
Smoking
Delayed emptying
Blood group O
138
How does H.pylori cause PUD?
Secretes urease -> urea converted to ammonia -> toxic to mucosa -> decreased mucus -> inc inflammation -> inc acid production
139
What is the most common site of duodenal ulcers?
D1 and D2 posterior wall
140
What is the MC cause of PUD?
H.Pylori
141
What are the symptoms of duodenal ulcers?
Epigastric pain
eating can alleviate pain
Pain ~4 hours after eating
Weight gain
142
What may cause a false negative result for H.Pylori?
PPI not stopped for 2 weeks before test!
143
How is PUD treated if H.pylori positive?
PPI + 2 Abx
144
What is the major complication of PUD?
Erodes into an artery and causes a bleed
145
How is PUD treated if H.Pylori negative?
1. PPI
2. H2 antagonist
146
How is an active PUD bleed treated?
ABC
1. Endoscopy to diagnose and treat
2. If fails, interventional angiography or surgery
Consider PPI
147
What are 3 complications of PUD?
Haemmorages
Perforation
Duodenal on posterior wall = pancreatitis
Malignancy
148
What does pain worsening after eating indicate?
Gastric ulcer
149
What does pain improving shortly after eating indicate?
Duodenal ulcer
150
What artery may be perforated in a gastric ulcer?
Left gastic artery
151
What artery may be perforated in a duodenal ulcer?
Gastroduodenal
152
What is a Mallory-Weiss tear?
Linear mucosal tear at gastric part of GOJ occuring due to a sudden increase in intra-abdominal pressure
153
What is usually seen before a Mallory Weiss tear?
Bout of coughing or retching
Alcoholic “dry heaves”
154
What are 2 causes of Mallory Weiss tears?
Forceful vomiting (bulimia and alcohol)
Chronic coughing
Weightlifting
Hiatus hernia
155
Who is commonly affected by Mallory Weiss tears?
Males
20-50
156
What are 3 risk factors of Mallory Weiss tears?
Alcoholism
Forceful vomiting
Male
Eating disorder
NSAID abuse
157
What are the clinical presentations of a Mallory Weiss tear?
Vomiting
Haematemesis after vomiting
Retching
Postural hypotension
Dizziness
158
What are 2 differential diagnoses of Mallory Weiss tear?
Gastroenteritis
Peptic ulcers
Cancer
Oesophageal varices
159
How is Mallory Weiss tear diagnosed?
Endoscopy
160
How is Mallory Weiss tear treated?
Most bleeds are minor, heal in 24 hours
Very rare but surgery can be required to sew the tear up
161
What are gastrooesophageal varices?
Enlarged veins protruding into lumen which have a risk of rupture causing GI bleeding
162
What are the causes of gastrooesophageal varices?
HTN in portal system in liver
Prehepatic: thrombosis
Intrahepatic: cirrhosis, sarcoid
Postheparic: R heart failure
163
What are 3 risk factors for gastrooesophageal varices?
Cirrhosis
Portal HTN
Schistosomiasis infection
Alcoholism
164
What are the 2 MC sites of gastrooesophageal varices?
Lower oesophags
Gastric cardia
165
What are the clinical presentations of ruptured gastrooesophageal varices?
Haematemesis- A LOT!
Abdo pain
Shock
Pallor
Hypotension
166
How is a ruptured gastrooesophageal varices diagnosed?
Endoscopy
167
How is a ruptured gastrooesophageal varices treated?
1. ABCDE
2. Vasopressin (Terlipressin)
3. Transfusion
4. Surgery
168
What surgeries are used to treat gastrooesophageal varices (ie preventing bleeds)?
Variceal banding
Balloon tamponade
TIPS (shunt between systemic and portal system in liver)
169
How are gastrooesophageal varices prevented?
Propranolol
Variceal banding
Liver transplant
170
What are the 3 general symptoms of an upper GI bleed?
Haematemesis
Melena
Coffee ground vomiting
171
What is melena?
Digested blood = black stools
172
What is the general symptom of a lower GI bleed?
Haematochezia
173
What is haematochezia?
Fresh red blood in stools
174
Define achalasia
Oesophageal aperistalsis and impaired relaxation of the LOS
175
What is affected by achalasia?
Degeneration of ganglions in myenteric plexus in muscularis externa
176
What causes achalasia?
Idiopathic- cause unknown
177
Outline the pathophysiology of achalasia
Nerves of LOS are degenerated -> LOS fails to relax -> obstruction
178
Define dysphagia
Difficulty swallowing
179
What are 3 symptoms of achalasia?
Non-progressive dysphagia - both solids and liquids
Regurgitation of food -> aspiration pneumonia
Spontaneous chest pain due to oesophageal spasm
180
How is achalasia diagnosed?
Endoscopy
Barium swallow
Manometry (GS)
181
What is the sign of achalasia on barium swallow?
“Birds beak sign”
182
What is manometry used to measure?
Senses the pressure and constriction of muscles in the esophagus as you swallow
183
How is achalasia treated?
Nitrates or CBB to relax LOS
Surgery can be curative- endoscopic balloon to open LOS or cardiomyotomy
Botox into LOS
Smaller but more frequent meals
184
What is the main complication of achalasia?
Increased risk of squamous carcinoma of oesophagus
185
What are the 3 types of bowel ischemia?
Acute mesenteric ischemia
Chronic mesenteric ischaemia
Ischemic colitis
186
Define acute mesenteric ischemia
EMERGENCY
Blockage of the mesenteric arteries or veins causing bowel ischaemia
187
What are 3 causes of acute mesenteric ischaemia?
Superior mesenteric (SMA) thrombosis (MC)
SMA embolism
Mesenteric vein thrombosis
188
What are the 3 symptoms of acute mesenteric ischaemia?
Acute severe abdominal pain around right iliac fossa
No abdo signs but maybe cardiac issues -> AF or aneurysm
Rapid hypovolaemia -> shock
189
How is acute mesenteric ischaemia diagnosed?
1. CT angiography
Bloods: metabolic acidosis and raised Hb
GS: colonoscopy
190
How is acute mesenteric ischaemia treated?
Antibiotics
IV heparin
Surgery
191
What are 2 complications of acute bowel ischaemia?
Septic peritonitis
Systemic inflammatory response syndrome (SIRS) -> organ dysfunction
192
Define chronic mesenteric ischemia
Narrowing of GI blood vessels causing decreased supply to bowel
similar mechanism to angina
193
What are the symptoms of chronic mesenteric ischaemia?
Postprandial pain (colicky abdo after eating)
Weight loss
Abdominal bruit
194
How is chronic mesenteric ischaemia diagnosed?
CT contrast/ Angiography
195
How is chronic mesenteric ischaemia treated?
Lifestyle changes
Secondary prevention (same as cardio)
Surgery (ie stent)
196
What region is most commonly affected by ischaemic colitis (CMI limited to bowel)?
Splenic flexure- areas supplied by IMA
197
Who is affected by ischaemic colitis?
Usually older people
Atherosclerosis patients
Women taking pill
198
What are 3 causes of ischaemic colitis?
Thrombosis
Emboli
Drugs (eg. Oestrogen)
Coagulation disorders
Idiopathic
199
What are the 3 symptoms of ischaemic colitis?
Sudden onset of lower LEFT abdominal pain
Passage of bright red blood (maybe with diarrhoea)
Could be signs of shock
200
How is ischaemic colitis diagnosed?
Urgent CT angiography
Colonoscopy and biopsy
Barium enema
201
How is ischaemic colitis treated?
More conservative than mesenteric ischaemia
Fluid replacement
Antibiotics
Most recover- if gangrenous SURGERY AND RESUS
202
What is the most common surgical emergency?
Acute appendicitis
203
Define appendicitis
Inflammed appendix, usually due to obstruction
204
Where is the appendix located?
McBurney’s point
2/3 between the umbilicus and ASIS
205
Outline the epidemiology of appendicitis
Males > females
10-20 but can occur at any age
206
What are 3 causes of appendicitis?
Faecolith (poo stone)
Lymphoid hyperplasia
Filarial worms
207
Outline the pathophysiology of appendicitis
Lumen obstructed -> invasion of gut organisms -> inflammation -> rupture -> infected and faecal matter enters peritoneum -> peritonitis
208
What are the symptoms of appendicitis?
Periumbilical pain -> RIF
Anorexia
Nausea and vomiting
Pyrexia
209
What are 3 differential diagnoses of appendicitis?
Ectopic pregnancy
UTI
Diverticulitis
Perforated ulcer
Food poisoning
210
What are the 6 signs of appendicitis on examination?
Rovsing’s sign
Psoas sign
Obturator sign
Mcburneys sign
Abdominal guarding
Rebound tenderness
211
What is Rovsings sign?
palpating left lower quadrant -> right lower quadrant pain
212
What is obturator sign?
Pain with internal rotation of right hip
213
What is Psoas sign?
Pain on extension of right hip
214
What is abdominal guarding?
Abdominal muscle tightening during palpation -> peritoneal irritation
215
What is rebound tenderness?
Blumbergs sign
Rebound tenderness upon palpation and quick release
216
How is appendicitis diagnosed?
Usually clinical- don’t delay surgery
Abdominal contrast CT (GS)
Ultrasound
Elevated CRP and ESR
Pregnancy and urinalysis (exclude pregnancy and UTI)
217
How is appendicitis treated?
Abx and appendectomy
218
What are the complications of appendicitis?
Perforation
Appendix mass
Appendix abscess
Peritonitis
219
Define diverticulum?
Outpouching of the gut wall usually at sites of entry of perforating arteries
220
Define diverticulosis
Asymptomatic diverticulum
221
Define diverticular disease
Diverticula are symptomatic
222
Define diverticulitis
Inflammation of a diverticulum
223
What percentage of diverticula are symptomatic?
5-10%
224
Where are diverticula commonly found?
Sigmoid colon
225
What are the risk factors of diverticula?
Low fibre diet
Obesity
Smoking
NSAIDs
Old age
226
Outline the pathophysiology of diverticulitis
High pressures in colon -> diverticula-> faecal matter and bacteria gather -> inflammation and rupture of vessels -> diverticulitis
227
What are the symptoms of diverticular disease?
BBL
Bowel habits changed
Bloating and flatulence
Left lower quadrants pain
228
What are the symptoms of diverticulitis?
BBL and
Fever
Blood in stool
229
How is diverticular disease diagnosed?
GS: contrast CT scan
Colonoscopy (bleeding)
Inflammatory markers in blood
230
What are 2 differential diagnoses of diverticular disease?
IBS
Appendicitis
Gastroenteritis
231
What are the complications of diverticular disease?
Perforation
Fistula formation
Intestinal obstruction
Bleeding
Mucosal inflammation
232
How is diverticular disease treated?
High fibre diet
Antispasmodics
Bulk forming laxatives
233
How is diverticulosis treated?
Nothing
Watch and wait
234
How is diverticulitis treated?
Abx
IV fluids and Abx
Sometimes surgical resection
235
What is Meckels diverticulum?
Paediatric disorder- failure of obliteration of vitelline duct
236
What are the features of Meckels diverticulum?
2 years old
2 inches long
1/2 have symptoms
2ft from umbilicus
237
How is Meckels diverticulum diagnosed?
Technitium scan
CT
238
How is Meckels diverticulum treated?
50% wont need treatment
50% need diverticulectomy
239
Define intestinal obstruction
Arrest/blockage of onward movement of intestinal contents
240
Define pseudomembranous colitis
Inflammation of the colon due to overgrown of clostridium difficult
241
What are 3 risk factors of pseudomembranous colitis?
RECENT ANTIBIOTIC USE
Older age
IBD
PPI
Staying at hospital or care home
CMV infection
242
What are the investigations and findings of pseudomembranous colitis?
Owl eyes inclusion body on histology (**CMV**)
Yellow plaques on colonoscopy
Stool sample (C. Difficile infection)
243
How is pseudomembranous colitis treated?
Stop causative agent
Abx effective against C.Difficile **(vancomycin**)
Hydration and electrolyte replacement
Recurrent = faecal microbiotia transplant
244
What are the 3 types of bowel obstruction?
Small bowel obstruction
Large bowel obstruction
Pseudo-obstruction
245
What is the most common bowel obstruction?
Small bowel obstruction
246
What are 4 causes of SBO?
Adhesions (MC) and often due to surgery
Hernias
Crohns
Malignancy
247
What are the symptoms of SBO?
Vomiting then constipation
tinkling bowel sounds
Colicky higher abdo pain
Abdo distension
248
What is the 1st line for bowel obstruction diagnosis?
Abdo X-ray: dilated bowel loops and transluminal liquid/gas shadows
249
What is the gold standard diagnosis for bowel obstruction?
CT abdomen and pelvis with contrast
250
What are the signs of SBO on abdo X-ray?
Coiled spring appearance
250
How is bowel obstruction treated?
Drip and suck
IV fluid
Nil-by-mouth
NG tube
Analgaesia, antiemetics and Abx
250
How is bowel obstruction treated surgically?
Needed for most LBO
Laparotomy to remove obstruction
Adhesions = adhesiolysis
Hernia repair
Bowel resection
251
What are 4 causes of LBO?
Malignancy (90%)
Strictures
Sigmoid Volvus
252
What are the signs of LBO on X-ray?
Sigmoid volvulus = coffee bean appearance
Dilation of large bowel >6cm
Dilation of caecum >9cm
253
What are the symptoms of LBO?
Constipation then vomiting (bilious then faecal)
Severe abdo distension
Absent bowel sounds
254
What are 3 differences between LBO and SBO?
1.SBO colicky pain, LBO continous
2. SBO mainly causes by adhesions, LBO mainly by malignancy
3. SBO = vomiting -> constipation, LBO = constipation -> vomiting
4. LBO more severe distension
5. SBO has tinkling bowel sounds
255
What is colicky pain?
sharp, localized gastrointestinal or urinary pain that can arise abruptly
tends to come and go in spasms
256
What is sigmoid volvulus?
Sigmoid colon twists around mesentery
257
What are the complications of bowel obstruction?
Perforation -> peritonitis -> sepsis
Dehydration
Infarction and necrosis
Electrolyte disturbance
258
Define pseudoobstruction
Aka ogilvie syndrome
Colonic dilation in the absence of mechanical obstruction
259
Outline the pathophysiology of pseudo obstruction
Parasympathetic nerve dysfunction-> absent smooth muscle function
260
What are 2 complications of pseudoobstruction?
Bowel ischaemia
Perforation
261
What are 3 causes of pseudoobstruction?
Almost always a complication of something
Paralytic ileus (post operative)
CCB, opioids
Neurological- Parkinson’s, MS
Trauma
262
How is pseudoobstruction diagnosed?
Abdo X-ray shows megacolon dilation
GS: CT of abdomen and pelvis with contrast
-No transition zone
263
How is pseudoobstruction treated?
Drip and suck
IV neostigmine
Surgical decompression if bad
264
Define diarrhoea
3+ watery loose stools a day which are 5-7 on Bristol stool chart
265
How long does acute diarrhoea last?
<14 days
266
How long does subacute diarrhoea last?
>14 days
267
Define chronic diarrhoea
>28 days
268
What is the MC of diarrhoea in children >3?
Rotavirus
269
What is the most common cause of diarrhoea in adults?
Norovirus
270
What are 3 places that can harbour norovirus?
Cruise ship
Restaurant
Hospital
271
What bacteria is associated with diarrhoea on antibiotics?
C. Difficile
272
What are 3 antibiotics that can cause C.Difficile?
Antibiotics starting with C
Clindamycin
Co-amoxiclav
Ciprofloxacin
273
What are some non infective causes of diarrhoea?
IBD
Coeliac
Hyperthyroidism
Inflammation or malignancy
274
What are 3 causes of bacterial diarrhoea?
C. Diff
Campylobacter
E. Coli
275
What is the most common cause of diarrhoea?
Viral diarrhoea (gastroenteritis)
276
What are 2 infective non-viral non-bacterial causes of diarrhoea?
Worms
Giardiasis (MC parasitic diarrhoea)
277
Define tenesmus
Need to defecate even though bowels are empty
278
What are the symptoms of travellers diarrhoea?
Fever
N+V
Tenesmus
Bloody stools
279
How is travellers diarrhoea treated?
Usually self limiting 3-5 days
280
What are 3 drugs that can cause diarrhoea?
Laxatives
Abx
Chemo
Metformin
PPI
SSRI
281
What are 3 processes that can lead to diarrhoea?
Increased osmotic load
Increased secretion
Inflammation
282
What are the red flag symptoms of diarrhoea?
Blood
Recent antibiotics
Weight loss
Dehydration
Nocturnal symptoms
283
How is diarrhoea managed?
Fluids and diuralite
Viral usually self limiting
Abx cause = probiotics
Loperamide and codeine phosphate
284
What is giardiasis?
Parasite
285
How is giardiasis spread?
Faeco orally
286
What are the symptoms of giardiasis?
Explosive, watery, non-bloody diarrhoea
287
How is giardiasis diagnosed?
Stool microscopy
288
How is giardiasis treated?
Metronidazole
289
What is the complication of giardiasis?
New onset lactose intolerance
290
What are2 features of H.pylori?
Gram negative
Low virulence commensal
291
What are 4 effects of H.pylori?
Decreased somatostatin
Increased gastric acid
Urease —> ammonia generation
Decreased HCO3 secretion
292
What are 3 complications of H.Pylori?
PUD (MC)
Gastritis
Gastric carcinoma
293
How is H.pylori infection diagnosed?
Stool test
Urea breath test
294
How is H.Pylori infection treated?
Triple therapy
PPI + amoxicillin + clarithomycin
295
What are 3 qualities of E.Coli?
Gram negative
Often commensal
Some strains virulent
296
What are 3 types of diarrhoea?
Watery
Steatorrhoea
Inflammatory
297
What are 3 types of E. Coli that cause watery diarrhoea?
ETEC
EAEC
EPEC
(TAP)
298
What type of E. Coli causes bloody diarrhoea?
EHEC
299
How is E.coli diagnosed?
MacConkey agar as lactose fermenting
300
How is E.coli treated?
Amoxicillin
301
What are 3 qualities of C.Difficile?
Gram positive
Spore forming bacteria
Highly infectious
302
What does C.Difficile cause?
Pseudomembranous colitis
303
Outline the mechanism of C.Difficile causing diarrhoea
Normal flora killed by Abx -> c. Difficile replaces it -> severe diarrhoea -> dehydration
304
How is C.Difficile treated?
Stop antibiotics
Vancomycin
305
How is campylobacter jejuni diagnosed?
CCDA (charcoal cefazolin sodium deoxycholate agar)
PCR
306
What causes campylobacter?
Undercooked chicken after BBQ
307
How is campylobacter treated?
Usually self limiting
308
How is salmonella diagnosed?
Pink with black centre on XLD
309
How is shingella diagnosed?
Pink on XLD
310
What are the 2 types of oesophageal cancer?
Adenocarcinoma (AC)
Squamous cell carcinoma (SSC)
311
What oesophageal cancer is most common in the developed world?
Adenocarcinoma
312
What part of the oesophagus is affected by AC?
Lower 1/3
313
What part of the oesophagus is affected by SCC?
Upper 2/3
314
What are 5 risk factors of AC?
*Barretts oesophagus
*GORD
*Caucasian
Obesity
Smoking
Older age
Males
Hernia
315
What are 5 risk factors of SCC?
*Smoking
*Alcohol
*BAME
Hot food and drinks
Achalasia
316
What are the symptoms of oesophageal cancer?
ALARMS
With PROGESSIVE swallowing difficulty (solids -> liquids)
317
What is an extra symptom of SCC?
Hoarse voice or cough
318
What is the difference between dysphagia in achalasia and oesophageal cancer?
Progressive = cancer
All at once = achalasia
319
What warrants a 2 week endoscopy referral for oesophageal cancer?
Dysphagia
>55 or 55 with weight loss and 1 of the following:
- Upper abdo pain
- Reflux
- Dyspepsia
320
What are 3 differential diagnoses of oesophageal cancer?
Achalasia
Strictures
Barretts oesophagus
321
How is oesophageal cancer diagnosed?
Upper GI endoscopy and biopsy
CT/PET of chest and abdomen for staging and metastases
322
How is oesophageal cancer treated?
Fit = chemo, radio, surgical resection
Unfit = palliative care- 5 year survival is 25%
323
What is the most common cause of gastric cancer (histology)?
Adenocarcinomas
324
What are the 2 types of gastric cancer?
Type 1: intestinal type
Type 2: diffuse type
325
What is the MC type of gastric cancer?
Type 1/intestinal type
326
What is the MC location of type 1 gastric cancer?
Antrum
Lesser curvature
327
Outline the pathophysiology of type 1 gastric cancer
Inflammation -> chronic gastritis -> atrophic gastritis -> intestinal metaplasia and dysplasia
328
Outline the pathophysiology of type 2 gastric cancer
Development of linitis plastica (leather bottle stomach)
329
What are the prognoses of gastric cancer?
Type 1: good
Type 2: bad- 5 year survival of 3-10%
330
What is the MC location of type 2 gastric cancer?
Cardia- but diffuse so affects anywhere in the stomach
331
What are the risk factors of type 1 gastric cancer?
Male
Older age
**H. Pylori infection**
Gastritis
Smoking
332
What are the risk factors of type 2 gastric cancer?
Female
Younger age
Genetics
Blood type A
333
What gene is associated with gastric cancer?
CDH-1 mutation
334
What is the histological appearance of type 1 gastric cancer?
Well differentiated tubular cells
335
What is the histological appearance of type 2 gastric cancer?
Poorly differentiated
Signet ring cells
336
What are the symptoms of gastric cancer?
Virchow’s node
ALARMS
Severe Epigastric pain
Progressive dysphagia
337
Where is gastric cancer most common in?
Eastern Asia, Eastern Europe and South America
338
How is gastric cancer diagnosed?
Upper GI endoscopy and biopsy
Endoscopic ultrasound
CT/MRI of chest and abdomen for staging
339
What is Virchow’s node?
Node above left clavicle
340
How is gastric cancer treated?
Surgical resection (subtotal or total gastrectomy)
ECF chemotherapy and radiotherapy
341
How common are small intestine tumours?
~1% of malignancies
342
What is the MC tumour of the small intestine?
Adenocarcinoma
343
Define colon polyp
Abnormal growth of tissue projecting from the colonic mucosa INTO the lumen
344
What is the most common precursor lesion in colon cancer?
Adenomas
345
Why are polyps removed?
Can develop into cancer
346
What are he 2 types of inherited polyps?
Familial adenomatous polyposis (FAP)
Hereditary non-polyposis colon cancer/ Lynch syndrome (HNPCC)
347
What are the MC sites of colon cancer?
Sigmoid colon
Rectum
348
What gene is mutated in FAP?
APC gene
349
What occurs in FAP?
Presence of hundreds-thousands of colorectal and duodenal adenomas
350
What age does FAP present?
Adenomas develop at 16
Cancer develops at 30
351
How is FAP managed?
Prophylactic colectomy and ileorectal anastomosis
352
What occurs in HNPCC?
Polyps formed in the colon and can rapidly progress to colon cancer
353
What genes are affected by HNPCC?
Mutation in DNA mismatch repair genes
hMSH2 or hMSH1
354
Why does the gene mutation in HNPCC lead to cancer?
The genes maintain stability of DNA in replication so defect causes altered DNA sequences in replication therefore making cancer more probable
355
What are the risk factors of colon cancer?
Family history of bowel cancer or FAP/HNPCC
IBD
Obesity
Smoking and alcohol
Low fibre and high sugar
356
What are the common sites of bowel cancer metastasis?
Lung
Liver
357
What are the symptoms of colon cancer?
ALARMS
Changes in bowel habit
Anaemia
Tenesmus
PR bleed
Abdo pain
358
When should a 40 year old be referred for suspected colon cancer?
Abdo pain and unexplained weight loss
359
When should a 50 year old be referred for suspected colon cancer?
Rectal bleeding
360
When should a 60< year old be referred for suspected colon cancer?
Changes in bowel habit OR iron deficiency anaemia
361
How is bowel cancer screened for?
Faecal immunochemical test (FIT)
362
Who is screened for bowel cancer?
60-74 every 2 years
363
How is bowel cancer diagnosed?
1st: FIT test
GS: colonoscopy and biopsy
Sigmoidoscopy, CT colonography, CT TAP (thorax, abdo, pelvis)
364
How is Bowel cancer classified?
Dukes classification
TNM classification
365
What does A on Dukes classification indicate?
Limited to bowel wall (not past mucosa)
366
What does B on Dukes classification indicate?
Extending through bowel wall
367
What does C on Dukes classification indicate?
Regional lymph node infiltration
368
What does D on Dukes classification indicate?
Distant metastasis
369
What is infiltrated in T1 bowel cancer?
Submucosa
370
What is infiltrated in T2 bowel cancer?
Smooth muscle
371
What is infiltrated in T3 bowel cancer?
Serosa
372
What is infiltrated in T4 bowel cancer?
Penetrates surface visceral peritoneum
373
How is bowel cancer monitored ?
CEA (carcinoembryonic antigen) to monitor therapeutic intervention
374
How is colon cancer treated?
Surgery
Chemo ect
375
What is Zenker’s diverticulum?
Pharyngeal pouch- food goes down this mouth instead of oesophagus
376
What are the symptoms of Zenkers diverticulum?
Smelly breath
Regurgitation and aspiration of food
377
Define haemorrhoids/piles
Disrupted and dilated anal cushions due to swollen veins around the anus
378
What are 3 causes of haemorrhoids?
Constipation with prolonged straining
Diarrhoea
Gravity due to posture
Congestion (tumour, pregnancy)
Anal intercourse
379
Who is most commonly affected by haemorrhoids?
Males = females
45-65 but increases with age
380
Outline the pathophysiology of haemorrhoids
Anal visions become bulky and loose -> form piles -> can protrude through anus -> become congested and hypertrophy -> protrude even more
381
What are the 2 types of haemorrhoids?
Internal
External
382
Where do internal haemorrhoids occur?
Above dentate line (internal rectal plexus)
383
What are the 4 degrees of internal haemorrhoids?
1st: remain in rectum
2nd: prolapse through anus on defecation but reduce spontaneously
3rd: prolapse but can be manually reduced
4th: remain permanently prolapsed
384
Where do external haemorrhoids occur?
Below dentate line/internal rectal plexus
Can be visible externally
385
Are haemorrhoids painful?
Internal: less painful as no sensory nerve- can be described as “incomplete defecation”
External: extremely painful- sensory nerve
- Patient can not sometimes sit down :(
386
What are the clinical presentations of haemorrhoids?
Bright red fresh PR bleeding
Mucus discharge
Pruritus ani
Constipation
387
What is pruritus ani?
Itchy bum
388
How are haemorrhoids diagnosed?
External examination
Digital rectal examination (DRE)
Proctoscopy
389
What are 3 differential diagnoses of haemorrhoids?
Perianal haematoma
Anal fissure
Abscess
Tumour
390
How are 1st degree haemorrhoids treated?
1st line: increases fluid and fibre
Topical analgesic and stool softening
391
How are 2nd and 3rd degree haemorrhoids treated?
Rubber band ligation
Infrared coagulation
Bipolar diathermy
392
How are 4th degree haemorrhoids treated?
Excisional haemorrhoidectomy
Ligation
393
Define anal fistula
Abnormal connection between the anal canal and skin
394
What are 3 causes of anal fistula?
Perianal abscess
Crohn’s ulcerations
TB
395
What are the symptoms of an anal fistula?
Throbbing pain worsened by sitting
Pruritus ani
Bloody/mucus discharge
396
How are anal fistulas diagnosed?
Endoanal ultrasound
397
How are anal fistulas treated?
Surgery- fistulotomy and excision
Drain abscesses if needed
398
Define anal fissure
Tear in anal canal below the dentate lining, causing pain on defecation
399
What are 3 causes of an anal fissure?
Hard stool/ constipation
Childbirth (will be anterior)
IBD
400
What are the symptoms of an anal fissure?
Extreme pain especially on defecation
Bleeding
Extreme pruritus ani
401
How is an anal fissure diagnosed?
Usually history
GS: Perianal inspection
402
How are anal fissures treated?
Increase dietary fibre
Lidocaine + GTN ointment
Botox (2nd line)
Surgery (rare)
403
Define Perianal/anorectal abscess
Collection of stool and bacteria in anal tissue causing infection
404
What is the MC cause of perianal abscess?
Anal sex
405
What are the symptoms of perianal abscess?
Painful swelling
Tender
Discharge
Fever
406
How is perianal abscess diagnosed?
Endoanal ultrasound
407
How are perianal abscesses treated?
Surgical excision
Drainage and Abx
408
Define pilonidal sinus/abscess
Hair follicles get stuck under the skin in the natal cleft (bum crack) causing irritation and inflammation
- forms sinuses and abscesses
409
Outline the epidemiology of pilonidal abscesses
Much more common in males
20-30
410
What are the risk factors of pilonidal sinus?
Obese Caucasians
Asia, Middle East, Mediterranean
Lots of body hair
Sedentary occupation
Family history
411
What are the symptoms of pilonidal sinus?
Painful swelling
Pus and foul smell from abscess
Systemic infection signs
412
How are pilonidal sinuses treated?
Excession of sinus tract and primary closure
Pus drainage
Abx
413
What is the major complication of campylobacter induced gastritis?
Guillian Barre
414
Define ischemic colitis
mesenteric ischemia limited to the colon
