GI Flashcards
1
Q
What is the pathophysiology of coeliac disease?
A
- Autoantibodies created in response to gluten
- These target epithelial cells of the small intestine (particularly the jejunum) -> inflammation
- Inflammation results in atrophy of intestinal villi -> malabsorption
2
Q
What 3 autoantibodies are related to coeliac disease?
A
- Anti-tissue transglutaminase antibodies (anti-TTG)
- Anti-endomysial antibodies (Anti-EMA)
- Anti-deamidated gliadin peptide antibodies (anti-DGP)
3
Q
A patient presents with a itchy blistering rash on their abdomen. What is this called? What is it be caused by?
A
- Dermatitis herpetiformis
- Caused by coeliac disease
4
Q
What neurological symptoms can coeliac disease present with?
A
- Peripheral neuropathy
- Cerebellar ataxia
- Epilepsy
5
Q
What are differentiating features of Crohn’s disease?
A
Crows NESTS
- No blood or mucus (PR can still occur in few cases)
- Entire GI affected
- Skip lesions on endoscopy
- Terminal ileum most effected and Transmural inflammation (full thickness)
- Smoking is a risk factor
Crohns is also associated with strictures and fistulas
6
Q
What are differentiating features of UC?
A
You see (UC) CLOSEUP
- Continuous inflammation
- Limited to the colon and rectum
- Only superficial mucosa affected
- Smoking may be protective
- Excrete blood and mucus
- Use aminosalicylates
- Primary sclerosis cholangitis
7
Q
What are the first and second line blood tests for coeliac disease? What do you do if these are positive?
A
First line:
- Total immunoglobulin A levels
- Anti-tissue transglutaminase antibodies (anti-TTG)
Second line:
- Anti-endomysial antibodies (anti-EMA)
Patients with a positive antibody test are referred to a gastroenterologist for endoscopy and jejunal biopsy
8
Q
What are the first and second line options for inducing remission in mild to moderate UC?
A
- First line -> Aminosalicylate (mesalazine)
- Secondline -> corticosteriods (pred)
9
Q
How do you induce remission in severe UC?
A
- First line -> IV steroids (hydrocortisone)
10
Q
What are the first and second line options for maintaining remission in UC?
A
- First line -> aminosalicylate (mesalazine)
- Second line -> azathioprine/mercaptopurine
11
Q
How do you induce remission in Crohn’s disease?
A
- First line -> oral/IV steriods
- Enteral nutrition
12
Q
What are the first and second line options for maintaining remission in Crohn’s disease?
A
- First line -> azathioprine/mercaptopurine
- Second line -> methotrexate
13
Q
Which are the more common peptic ulcers?
A
Duodenal ulcers
14
Q
What drugs increase the risk of bleeding from a peptic ulcer?
A
- NSAIDs
- Aspirin
- Anticoagulants
- Steroids
- SSRIs
15
Q
How do gastric and duodenal ulcers present differently?
A
Gastric:
- Eating worsens pain
- Lose weight due to fear of pain when eating
Duodenal:
- Pain improves after eating and worsens after 2-3 hours
- Weight is stable or increases
16
Q
What are signs of an upper GI bleed?
A
- Haematemesis
- Coffee ground vomit
- Melaena
- Fall in Hb on FBC
17
Q
How can H pylori be diagnosed on endoscopy?
A
Rapid urease test (CLO test)
18
Q
What are the core management aspects of treating peptic ulcers?
A
- Stop NSAIDs
- Treat H pylori
- PPI
- Repeat endoscopy in 4-8 wks to ensure ulcer heals
19
Q
What are complications of peptic ulcers?
A
- Bleeding
- Perforation -> acute abdo pain and peritonitis
- Scarring and strictures -> gastric outlet obstruction
20
Q
How does gastric outlet obstruction present? What is the management?
A
- Early fullness
- Abdominal distention
- Vomiting after eating
Treated with balloon dilatation during endoscopy/surgery
21
Q
What are possible causes of an upper GI bleed? Which is the most common?
A
- Peptic ulcers (most common)
- Mallory-Weiss tear
- Oesophageal varices
- Stomach cancers
22
Q
What score is used at initial presentation of a suspected upper GI bleed? What does it indicate? What score is significant?
A
- Glasgow-Blatchford Bleeding score
- Estimates the risk of the patient having an upper GI bleed
- A score above 0 = high risk for an upper GI bleed
23
Q
Why do patients with an upper GI bleed get high blood urea?
A
- Urea is one of the break down products of blood
- It is absorbed into the intestines causing a rise in blood urea
24
Q
When is the Rockall Score used?
A
- Upper GI bleed
- Used after endoscopy to estimate the risk of rebleeding and mortality
25
What is the initial management of an upper GI bleed?
ABATED mnemonic
- ABCDE
- Bloods
- Access (2 x large bore cannula)
- Transfusions
- Endoscopy (within 24 hrs)
- Drugs (stop anticoagulants and NSAIDs)
26
What additional steps are important in the management of an upper GI bleed due to varices?
- Terlipressin
- Broad spec antibiotics
27
When treating a patient with an upper GI bleed what features determine the type of transfusion?
- Massive bleed -> FFP (blood, platelets and clotting factors)
- Active bleeding + thrombocytopenia -> platlets
- Active bleeding + taking warfarin -> prothrombin complex concentrate
28
According to NICE, what is required to diagnose IBS?
1. 6 months of abdominal pain
2. At least one of:
- Pain relieved by opening bowels
- Bowel habit abnormality
- Stool abnormalities
3. At least two of:
- Straining
- Bloating
- Worse after eating
- Passing mucus
29
What is dyspepsia?
An unspecific term used to describe indigestion
30
What is a hiatus hernia?
Herniation of the stomach through the diaphragm
31
What are the 4 types of hiatus hernia?
- Type 1 - slidling
- Type 2 - rolling
- Type 3 - combination of both
- Type 4 - large opening with additional abdominal organs entering the thorax
32
A patient presents with dyspepsia, how should you manage them?
- Exclude red flags
- Address possible triggers
- Offer 1 month trial of PPI
- Consider H pylori testing
33
What are the investigations for H pylori?
- Stool antigen test
- Urea breath test
- H pylori antibody test
- Rapid urease test (CLO test) during endoscopy
34
What is H pylori (specifically)?
Gram -ve aerobic bacteria
35
How does H pylori cause gastric mucosal damage?
- Produces ammonium hydroxide -> neutralises stomach acid
- It also produces toxins
- Together the ammonia and toxins damage the epithelial lining resulting in gastritis and ulcers
36
What happens in Barrett's oesophagus? What is this process called?
- Oesophageal endothelium changes from squamous to columnar
- Metaplasia
37
What is the difference between dysplasia and metaplasia?
- Metaplasia = change in the type of cell
- Dysplasia = presence of abnormal cells
38
What is Barrett's oesophagus a significant risk factor for?
Oesophageal adenocarcinoma
39
What's the management of Barrett's oesophagus?
- Endoscopic monitoring for progression to adenocarcinoma
- PPI
- Endoscopic ablation (destroying abnormal columnar epithelial cells)
40
What is Zollinger-Ellison syndrome?
- Rare condition where a duodenal or pancreatic tumour secretes excessive gastrin
- Gastrin is a hormone that stimulates acid production
- Results in severe dyspepsia, diarrhoea and peptic ulcers
41
What's are the two most common types of oesophageal cancer? How do they differ? Include RF for each
1. Adenocarcinoma
- Most common
- Lower 1/3 of oesophagus
- RF - GORD, BO, smoking, obesity
2. Squamous cell carcinoma
- Most common in developing world
- Upper 2/3 of oesophagus
- RF - smoking, alcohol. achalasia
42
How do you investigate + diagnose oesophageal cancer?
- Endoscopy with biopsy - diagnosis
- Endoscopic US - loco regional staging
- CT-TAP - initial staging
43
What is the management of oesophageal cancer?
- Surgical resection where possible - Ivor-Lewis type oesophagectomy is most common procedure
- Adjuvant chemo
44
What are RF for gastric cancer?
- Age >75
- M>F
- H Pylori
- Atrophic gastritis
- Diet - salt, nitrates
- Smoking
- Blood group A
45
How do you investigate gastric cancer?
- OGD with biopsy - diagnosis, signet ring cells may be seen (higher numbers = worse prognosis)
- CT-TAP - staging
46
What is the management of gastric cancer?
- Surgery - endoscopic mucosal resection, partial/total gastrectomy
- Chemo
47
How does appendicitis present?
Central abdominal pain that localises at McBurney's point
48
Where is McBurney's point?
1/3rd the distance from the anterior superior iliac spine to the umbilicus
49
What examination features indicate appendicitis? What suggests peritonitis indicating rupture?
- Rovsing's sign
- Guarding
Peritonitis:
- Rebound tenderness in the RIF
- Percussion tenderness
50
What conditions are risk factors for bowel cancer?
- IBD
- Familial adenomatous polyposis (FAP)
- Hereditary nonpolyposis colorectal cancer (also called Lynch syndrome)
51
What is familial adenomatous polyposis?
- AD
- Malfunctioning of tumour suppressor genes that results in polyps (adenomas) developing along the large intestine
- These have the potential to become cancerous (normally <40 years)
- Patients have their entire large intestine removed prophylactically
52
What is Lynch syndrome?
- Hereditary nonployposis colorectal cancer
- AD
- Increases patients risk of a number of cancers - particularly colorectal cancer
53
What does a FIT test look for?
The amount of Hb in the stool
54
What is the bowel cancer screening program in England?
- Adults are 60-74 sent a FIT test every 2 years
- +ve result -> colonoscopy
55
What is the tumour marker for bowel cancer? How is it used?
- Carcinoembryonic antigen (CEA)
- Used for predicting relapse in patients previously treated for bowel cancer
56
What investigations are used for bowel cancer? When are they indicated?
- Colonoscopy - gold standard
- Sigmoidoscopy - rectal bleeding
- CT colonography - CT scan w bowel prep, considered in pts less fit for a colonoscopy
- Staging CT scan (CT TAP) - metastasis, excluding other cancers if vague symptoms
57
How can you define constipation?
Defecation that is unsatisfactory due to infrequent stools (<3 times weekly), difficult stool passage, seemingly incomplete defecation
58
What is the management of constipation?
- Exclude secondary causes of constipation
- Lifestyle measures - fibre, hydration, activity levels
- Oral laxatives:
1. Bulk forming (1st line) e.g. ispaghula
2. Add or switch to an osmotic e.g. macrogol
3. If stools are soft but difficult to pass/inadequate emptying add a stimulant e.g. Senna
Advise gradually reduce and stop laxatives once they are producing soft, formed stool without straining >3 times/week
59
When should you not prescribe bulk forming laxatives?
- If opioid induced constipation
- Offer osmotic + stimulant
60
How do you manage chronic constipation that has not responded to the usual management?
- If at least 2 laxatives (diff classes) have been tried at the highest doses for 6 months, consider tx with prucalopride
- Its a serotonin agonist that stimulates GI motility
61
How do you manage facial impaction?
1. Hard stools - oral macrogol
2. Soft stools/no response ^ - oral stimulant laxative
3. If slow/inadequate response consider:
- Suppository - glycerol +/- bisacodyl (hard stool), bisacodyl (soft stool)
- Mini enema - docusate (softener + stimulant), sodium citrate (osmotic)
4. If still inadequate response:
- Sodium phosphate/arachis oil retention enema
62
What are secondary causes of constipation?
VITAMIN C DEF
1. Vascular
2. Inflammatory/infective
3. Trauma - anal fissures, strictures, haemorrhoids, spinal cord injury
4. Autoimmune - DM, hypothyroid, hyperparathyroidism
5. Metabolic - DM
6. Iatrogenic - drugs
7. Neoplastic - obstructive mass, spinal cord tumours
8. Congenital - hirsprungs's disease
9. Degenerative - PD, MS
10. Endocrine/envirnoment - hypercalcaemia, Hypermagnesaemia, hypokalaemia, uraemia
11. Functional - IBS
63
What is a diverticulum?
A pouch/pocket in the bowel wall (range from 0.5-1cm)
64
What is diverticulosis?
The presence of diverticula (without inflammation or infection)
65
What is diverticular disease?
When pts experience symptoms of diverticulosis?
66
What is diverticulitis?
Inflammation and infection of diverticula
67
How do diverticula form?
- The wall of the large intestine contains a layer of muscle called the circular muscle
- The points where this muscle layer is penetrated by blood vessels are areas of weakness
- Increased pressure inside the lumen over time, can cause a gap to form in these areas of the circular muscle
- These gaps allow the mucosa to herniate through the muscle layer and form diverticula
68
Why do diverticula not form in the rectum?
- It has an outer longitudinal muscle layer that completely surrounds the diameter of the rectum, adding extra support
- Longitudinal muscle is present in the rest of the colon (tenure coli) by it doesn't surround the full diameter and the areas that aren't covered are vulnerable
69
What are RF for diverticulosis?
- Increased age
- Low fibre diet
- Obesity
- NSAIDs
70
What are symptoms of diverticular disease?
- Left lower abdo pain
- Constipation
- Rectal bleeding
71
What is the management of diverticular disease?
- Diet - increase fibre
- Bulk forming laxative e.g. ispaghula husk
- Note: avoid stimulant laxatives
- Surgery - resection where there is significant symptoms
72
How does acute diverticulitis present?
- Pain + tenderness in the left iliac fossa
- Fever
- Diarrhoea
- N+V
- Rectal bleeding
- Palpable abdo mass if abscess has formed
73
What is the management of acute diverticulitis?
Uncomplicated diverticulitis:
- Can manage in primary care
- Oral co-amox
- Analgesia
- Clear liquids only until symptoms resolve (2-3 days)
- FU within 2 days to r/v symptoms
Pts with severe pain/complications:
- Nil by mouth/clear fluids only
- IV abx
- IV fluids
- Analgesia
- Urgent surgery for complications
74
What are possible complications of acute diverticulitis?
- Perforation
- Peritonitis
- Peridiverticular abscess
- Large haemorrhage requiring transfusions
- Fistula (between colon + bladder/vagina)
- Ileus/obstruction
75
What are haemorrhoids?
Enlarged anal vascular cushions
76
What causes haemorrhoids?
- Not entirely clear
- Often associated with constipation and straining
- RF - pregnancy, obesity, increased age, increased intra-abdominal pressure (weightlifting/chronic cough)
77
How can haemorrhoids be classified?
- 1st degree: no prolapse
- 2nd degree: prolapse when straining and return on relaxing
- 3rd degree: prolapse when straining, does not return on relaxing but can be pushed back
- 4th degree: prolapsed permanently
78
How do haemorrhoids present?
- Painless, bright red bleeding (blood NOT fixed with stool)
- Sore/itchy anus
- Feeling a lump in/around anus
79
What examination findings are seen in haemorrhoids?
- External (prolapsed) haemorrhoids - visible on inspection
- Internal haemorrhoids - felt on PR exam
- Prolapsed haemorrhoids when the pt bears down
Proctoscopy is required for proper visualisation and inspection (inserting hollow tube into anal cavity to visualise the mucosa
80
What are the general management options for haemorrhoids?
- Topical treatments - for symptomatic relief and to reduce swelling
- Non-surgical options
- Surgical options
81
What are examples of topical treatments for haemorrhoids?
- Anusol (contains chemicals to shrink haemorrhoids)
- Anusol HC (+ hydrocortisone)
- Germoloids cream (contains lidocaine)
- Proctosedyl ointment (containscinchocaine + hydrocortisone)
82
What are non-surgical options for haemorrhoids ?
- Rubber band ligation
- Injection sclerotherapy (injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy)
- Infra-red coagulation (infra-red light is applied to damage the blood supply)
- Bipolar diathermy (electrical current applied directly to the haemorrhoid to destroy it)
83
What are surgical options for haemorrhoids?
- Haemorrhoidal artery ligation
- Haemorrhoidectomy
- Stapled haemorrhoidectomy
84
What are thrombosed haemorrhoids? How do they present?
- Caused by strangulation at the base of the haemorrhoid -> thrombosis
- V painful
- Purplish, swollen lumps around the anus
- A PR examination is unlikely due to pain
85
What is a hernia?
A protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it
86
What are RF for abdominal wall hernia?
- Obesity
- Ascites
- Increasing age
- Surgical wounds
87
What are features of abdominal wall hernias?
- Palpable lump
- Lump may be reducible
- Lump may protrude on coughing/straining
- Aching/pulling/dragging sensation
88
What are the key complications of hernias?
- Incarceration - hernia is irreducible and the bowel is trapped in the hernia. Can lead to the next 2
- Obstruction - hernia causes a blockage in the passage of faeces through the bowel
- Strangulation - hernia is irreducible and the base becomes tight and cuts of the blood supply -> ischaemia. Strangulation is a surgical emergency
89
What are the general management options for abdominal hernias?
- Conservative management - if hernia has wide neck/pt is not for surgery
- Tension-free repair - placing mesh over the defect
- Tension repair - suturing muscles and tissue on either side of the defect back together, less common due to complications (pain, reoccurrence)
90
What are the different types of abdominal wall hernias?
- Inguinal hernia
- Femoral hernia
- Umbilical hernia
- Paraumbilical hernia
- Epigastric hernia
- Incisional hernia
- Obturator hernia
- Spigelian hernia - rare
- Richter hernia - rare
91
Where are inguinal hernias located?
Superior and medial to the pubic tubercle
92
What are direct vs indirect hernias?
- Indirect - bowel herniates through the inguinal canal
- Direct - hernia protrudes directly through abdominal wall through Hesselbach's triangle
93
What is are key structures that pass through the inguinal canal in men and women?
- Men - spermatic cord
- Women - round ligament
94
Where are femoral hernias located?
Below and lateral to the pubic tubercle
95
Are femoral hernias more common in men or women?
Women (particularly multiparous ones)
96
What is the management of femoral hernias?
Surgical repair is necessary
97
What is the issue with femoral hernias?
Hernia protrude through the femoral ring which is a narrow opening -> high risk of obstruction and strangulation
98
What are incisional hernias?
Hernias the occur at the site of an incision from previous surgery
99
What type of hernia is suggested by a symmetrical bulge under the umbilicus?
Umbilical hernia
100
What type of hernia is suggested by a lump between the umbilicus and xiphisternum?
Epigastric hernia
101
What is a hiatus hernia?
Herniation of the stomach up through the diaphragm
102
What are the 4 types of hiatus hernia?
- Type 1 - sliding
- Type 2 - rolling
- Type 3 - mixed
- Type 4 - large opening with abdo organs entering thorax
103
What are risk factors for hiatus hernias?
- Obesity
- Increasing age
- Pregnancy
104
How do hiatus hernias present?
- Heart burn
- Acid reflux
- Burping
- Bloating
105
What is the management of hiatus hernias?
- Conservative
- Surgery - laparoscopic fundoplication (tying the fundus of the stomach around the lower oesophagus to narrow the oesophageal sphincter)
106
What is mesenteric adenitis?
Inflamed lymph nodes within the mesentery
107
What normally proceeds mesenteric adenitis?
Recent viral infection
108
What is a key differential of mesenteric adenitis?
Appendicitis - often difficult to distinguish between the two
109
What is the management of mesenteric adenitis?
Needs no treatment
110
What are the functions of B12?
- Mainly used for RBC development
- Maintenance of the nervous system
111
How is B12 absorbed?
Binds to intrinsic factors (secreted from parietal cells in the stomach) and actively absorbed in the terminal ileum
112
What are causes of B12 deficiency?
- Pernicious anaemia (most common)
- Past gastrectomy
- Vegan/poor diet
- Disorders of terminal ileum (Crohn's)
- Metformin (rare)
113
How can B12 deficiency present?
- Sore tongue and mouth
- Loss of vibration sense + joint position
- Diastal paraesthesia
- Neuropsychiatric symptoms (mood disturbances)
114
What's the management of B12 deficiency?
- If no neurological involvement - 1mg IM hydroxocobalamin 3x/week for 2 weeks then once/3 months
- If pt is deficient in folic acid then treat B12 FIRST to avoid subacute combined degeneration of the cord
