GI Flashcards
GORD
- pathophysiology
- management
- reduce recurrence
- complications
- side-effects of long-term PPI treatment
In GORD, the resting tone of the lower oesophageal sphincter (LOS) is impaired, resulting in acid reflux.
Management: 4 to 8-week trial of proton pump inhibitors (PPIs) to act as both a diagnostic and therapeutic trial.
Perform oesophagogastroduodenoscopy (OGD) if no improvement.
Complications:
* Oesophageal ulcers
* Oesophageal stricture
* Barrett’s oesophagus—Pre-malignant damage
* Adenocarcinoma of the oesophagus incidence increases by 0.5% a year in those with Barrett’s oesophagus.
Side-effects of long-term PPI therapy:
- CAP
- Low magnesium
- B12 deficiency
Ulcerative Colitis
- Sx
- Extra-abdominal manifestations
- Investigations
- What size of the colon is colonoscopy contraindicated?
- Mx acute remission
- Barium enema XR findings
- Protective factor
- Complications
Ulcerative colitis often presents as continuous circumferential lesions in the distal rectum and colon with bloody diarrhoea, weight loss, bowel urgency, and fatigue.
Extra-abdominal manifestations:
* Erythema nodosum, pyoderma gangrenosum
* Anterior uveitis, episcleritis
* Arthritis, ankylosing spondylitis
* Primary sclerosing cholangitis (PSC)
* Cholangiocarcinoma
Investigations:
* Stool studies to exclude infective cause
* Faecal calprotectin elevated
* Full blood count: anaemia, leukocytosis, or thrombocytosis
* Variable elevation of ESR and CRP
* Abdominal X-ray showing dilated loops, assess for the presence of complications (e.g., megacolon, perforation)
* Colonoscopy for continuous ulcerative lesions
* Biopsy for crypt abscess and submucosal lesions
Colonoscopy is contraindicated in toxic megacolon (>6-cm diameter) due to the risk of perforation.
Mx of acute remission
<4 bowel motions/day: Rectal mesalazine (especially for distal disease), then oral 5-ASA, then oral prednisolone
* >6 bowel motions/day: IV corticosteroids for remission; infliximab in children
* Cyclosporin as adjunct
* Consider infliximab if cyclosporin is contraindicated.
* Surgery: Colectomy in patients with acute complications (e.g., megacolon, perforation) or who have failed to respond to medical therapy
The barium enema X-ray shows a classic lead pipe colon, indicative of chronic ulcerative colitis due to a loss of haustra.
Protective factor - smoking
Complications include colorectal cancer, toxic megacolon, and osteoporosis.
Crohns disease
- symptoms
- investigations
- gold standard test
- management
Sx:
* Chronic diarrhoea (normally not bloody)
* Abdominal pain (commonly ileitis in RIF)
* RIF mass (abscess)
* Constitutional symptoms (weight loss, fever, fatigue)
* Mouth ulcers
* Malabsorption
Investigations:
* FBC
* Serum B12
* Stool MCS (to rule out infection)
* AXR with oral contrast, which may show string sign (strictures) and skip lesions
* CT/MRI with oral contrast, which may show skip lesions, bowel thickening, inflammation, abscess, and fistulae
Gold standard test: colonoscopy, with terminal ileum biopsy showing transmural inflammation and granulomas
Management:
Lifestyle—Smoking cessation, NSAID avoidance
Medical:
a. Corticosteroids to induce acute remission
b. Aminosalicylates (5-ASA) with ileal or right-sided disease
c. Azathioprine or mercatopurine as add-on therapy
d. Methotrexate
e. Infliximab and adalimumab
Surgical: Bowel resection, ABSCESS DRAINAGE
Indications for surgery:
* Failure of medical treatment
* Severe complications
* Abscess/fistula formation
* Malignancy or high-grade dysplasia
* Malabsorption/failure to thrive (children)
IBS:
- criteria
- management
Criteria used is the Rome IV criteria in secondary care
Constipation Mx:
Prescribed laxatives: Any bulk-forming laxatives (e.g., macrogol) apart from lactulose; linaclotide or plecanatide if other laxatives are not tolerated.
Contraindicated laxative: Lactulose due to bloating
Diarrhoea Mx:
Antispasmodics (mebeverine hydrochloride, alverine citrate, and peppermint oil) to reduce smooth muscle wall spasms
Loperamide
Amitriptyline used as a second-line agent after FODMAP and antispasmodics and laxatives (depending on predominant symptoms)
Acute diarrhoea causes
a. Daycare outbreaks
b. Winter outbreaks
c. Raw eggs and poultry
d. Immunosuppression—
e. Travel to Asia
f. Contaminated shellfish and water
g. HUS complications
h. Reheated rice
i. After antibiotic use
j. Faecally contaminated water in travel
a. Daycare outbreaks—Rotavirus
b. Winter outbreaks—Norovirus
c. Raw eggs and poultry—Salmonella
d. Immunosuppression—CMV
e. Travel to Asia—Campylobacter
f. Contaminated shellfish and water—Vibrio cholerae
g. HUS complications—E. coli O157 or Shigella
h. Reheated rice—Bacillus cereus
i. After antibiotic use—Clostridium difficile
j. Faecally contaminated water in travel—Giardia, Entamoeba
LFTs
a. ALP>3 x ALT
b. ALT >3 x ALP
c. AST:ALT >2.5
d. AST:ALT<1
What conditions raise ALT, AST, ALP and GGT?
a. ALP >3 × ALT = gallstones or malignancy
b. ALT >3 × ALP = hepatocellular damage
c. AST:ALT >2.5 = alcoholic liver disease
d. AST:ALT <1 = hepatitis or paracetamol toxicity
ALT = Hepatocellular damage
AST = Cellular damage; raised significantly in alcoholic liver disease
ALP = Cholestasis
GGT = Cholestasis (most sensitive); recent alcohol use
Acute liver failure
- Sx
- Causes
- Mx
- Criteria for transplant
- Confusion, jaundice, scleral icterus, xanthoma
Causes:
* Viral: Hepatitis A, B, D, E; CMV; HSV
* Drugs and toxins, most commonly paracetamol and alcohol
* Ischaemia, with hypoperfused and then ischaemic liver
* Vascular (Budd–Chiari syndrome)
* Autoimmune hepatitis
Initial management:
* ABCDE assessment
* Early IV access and fluid resuscitation
* N-acetylcysteine IV (indicated for all ALF patients, not just paracetamol toxicity)
* Treatment of underlying cause (e.g., steroids for autoimmune hepatitis, antivirals for viral hepatitis)
* Vitamin supplementation (vitamin K or thiamine)
* ICU transfer and discussion with local organ transplant centre
Kings College Criteria for liver transplant:
* Paracetamol:
-pH <7.3 or
- Hepatic encephalopathy grade 3 (creatinine >300, INR >6.5)
* Non-paracetamol:
- INR >6 or
- Three of the following: age <10 years or >40 years, unfavourable aetiology, not hyper-ALF, INR >3.5, bilirubin >300
Primary biliary cholangitis (PBC)
- Sx
- Investigations
- Mx
Sx - fatigue, hyperpigmentation, intense pruritus, jaundice, dark urine, light stool, hepatosplenomegaly
Investigations:
Serology - AMA and ANAs
Liver biopsy - bile duct lesions, portal tract inflammation, and granuloma formation
LFTs raised including ALP and GGT
Mx:
* Ursodeoxycholic acid, which helps prevent or delay hepatic damage if taken in the early stages; will not improve fatigue or pruritus
* Cholestyramine, which lowers cholesterol levels in the blood and removes bile acids, thus reducing pruritus
Primary sclerosing cholangitis (PSC)
- Sx
- Investigations
- Mx
Sx: RUQ pain, pruritus and fatigue (Hx of IBD)
Investigations
- MRCP
- LFTs: ALP and GGT
Mx:
Treatment protocol of PSC for an early-stage diagnosis:
* Lifestyle changes
* Ursodeoxycholic acid
* Cholestyramine (pruritus relief)
Treatment for a late-stage: Liver transplant
Regular colonoscopies due to increase risk of colorectal cancer
Autoimmune hepatitis
- Investigations
- Mangement
Investigations:
* LFT—↑ ALT/AST (ALP only mildly to moderately increased), ↑ bilirubin, ↑ gamma-GT
* ↓ Albumin
* ↑ PT/INR, ↑ IgG
* Positive ANAs, anti–smooth muscle antibodies (ASMAs), anti–liver/kidney microsomal-1 (LKM) antibodies, anti–liver cytosol (LC) antibodies, perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCAs)
* Liver biopsy
Management:
* Medical: Corticosteroids, azathioprine (plus other immunosuppressive agents if first-line medications do not work)
* Surgical: Liver transplant, which is only indicated in acute severe AIH with acute liver failure
Hepatocellular carcinoma (HCC)
- associations
- Sx
- investigations
Associations - chronic hepatitis B, hepatitis C and haemochromatosis
Sx:
* Decompensated symptoms and worsening LFTs
* Weight loss, RUQ pain, and hepatomegaly may also be present.
Investigations:
* Ultrasound imaging of the liver is the first line of investigation for HCC screening; however, only tumours up to 2 cm can be detected.
* CT of the chest, abdomen, and pelvis is often performed to detect distant metastasis.
* When there is uncertainty about a diagnosis, a liver MRI can provide better quality images.
C.difficile management
First episode:
- oral vancomycin 10 days
- 2nd line: oral fidaxomicin
- 3rd line: oral vanc +/- IV metronidazole
Recurrent episode:
- within 12 weeks of Sx resolution: oral fidaxomicin
- after 12 weeks of Sx resolution: oral vanc or oral fidax
Life-threatening:
Oral vancomycin AND IV metronidazole
Liver cirrhosis
- symptoms
- diagnosis
Sx - portal HTN symptoms (splenomegaly, upper GI bleeds, varies, ascites, caput-medusae)
Diagnosis - transient elastography (fibroscan)
Dyspepsia referrals
Urgent:
- all patients with dysphagia
- all patients with an upper abdo mass
- patients =>55 with weight loss and upper abdo pain, reflux or dyspepsia
Non-urgent:
- pt with haematemesis
- pt aged >=55 with treatment resistant dyspepsia, upper abdo pain w low Hb levels, raised platelet count or nausea and vomiting
Small intestinal bacterial overgrowth (SIBO)
- Sx
- investigations
- Mx
Disturbances of the normal gut flora
Sx: abdo pain, belching, bloating, diarrhoea, distension, flatulance, indigestion
Investigation:
Hydrogen breath test
Gold standerd - small intestinal fluid aspirate (>105)
Mx: ABX (2 week course), metronidazole, ciprofloxacin, polyoils
Spontaneous bacterial peritonitis
- Sx
- Diagnosis
- Mx
Sx - ascites, abdo pain, fever
Diagnosis - paracentesis (neutrophil count >250), most common organism is E.Coli
Mx - IV cefotaxime
Boerhaave syndrome
- the triad
- vomiting
- thoracic pain
- subcutaneous emphysema
Typically presents in middle aged men with a background of alcohol abuse
Achalasia
- Sx
- Investigations
- Mx
Symptoms:
- dysphasia to both solids and liquids
- weight loss
- intermittent sx
- retrosternal chest pain
Investigations
Barium study - ‘birds beak’
Management
Calcium channel blockers or nitrates before food
Surgery - endoscopic balloon dilation or Hellers cardiomyotomy
Wilsons disease
- features
- investigation
- management
Excessive COPPER deposition in tissues
Features
- liver: hepatitis, cirrhosis
- neuro: speech, behaviour, asterixis
- Kayser-Fleischer rings
- Renal tubular acidosis (Faconi syndrome)
- Haemolysis
- Blue nails
Investigation
- slit lamp
- reduced serum caeruloplasmin
- reduced total serum copper
- increased 24h urinary copper excretion
Management:
- penicillamine
Hepatitis B serology
HBsAg
Anti-HBs.
Anti-HBc
HbeAg
HBsAg - ongoing infection (>6mo chronic)
Anti-HBs - immunity (exposure or immunisation)
Anti-HBc - ‘caught’ i.e. negative if immunised
HbeAg - marker of infectivity
Where is the prostate located in the digital rectal examination?
Anterior rectal tissue
Management of constipation in adults
first-line laxative: bulk-forming laxative first-line, such as ispaghula
second-line: osmotic laxative, such as a macrogol
Variceal bleeding:
Acute management
Long-term management
Acute:
A-E
Correct clotting
Give terlipressin and ABX
1st line: endoscopy with variceal band ligation (EVL)
2nd line: Sengstaken-Blakemore tube if uncontrolled haemorrhage
3rd line: transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
Long-term management:
Propanolol
EVL or TIPSS
TIPS procedure connects the hepatic and portal vein !!!!
Gastric cancer
- Sx
- Diagnosis
- Mx
Sx:
abdominal pain
weight loss and anorexia
nausea and vomiting
dysphagia: particularly if the cancer arises in the proximal stomach
overt upper gastrointestinal bleeding is seen only in a minority of patients
if lymphatic spread:
- left supraclavicular lymph node (Virchow’s node)
- periumbilical nodule (Sister Mary Joseph’s node)
Diagnosis
- oesophago-gastro-duodenoscopy with biopsy
signet ring cells may be seen in gastric cancer
- CT for staging
Mx:
surgical options depend on the extent and side but include:
- endoscopic mucosal resection
- partial gastrectomy
- total gastrectomy
chemotherapy
Haemorrhoids:
- symptoms
- subtypes
- grades
- management
- acuteley thrombosed external haemorrhoids
Symptoms:
- painless rectal bleeding
- pruitus
- soiling (3rd/4th degree)
Types:
1. external: below the dentate line, prone to thrombosis, may be painful
2. internal: above the dentate line, do not cause pain
Grading:
I - do not prolapse out of anal canal
II - prolapse on defecation but reduce spontaneously
III - can be manually reduced
IV - cannot be reduced
Mx:
- soften stool: diet
- topical local anaesthetics & steroids
- outpatient: rubber band ligation
- surgery: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy
Acutely thrombosed external haemorrhoids
- significant pain
- if within 72h referral for excision.
- Sx settle in 10 days
Anal fissures:
- risk factors
- symptoms
- management
Risk factors: constipation, STI, IBD
Sx: bright red rectal bleeding (majority in the posterior midline)
Mx:
Acute (<1 week)
- soften stool: dietary advise, bulk forming laxatives
- lubricants before defecation
- topical anaesthetics
- analgesia
Chronic
- first line: GTN
- if it doesn’t work after 8 weeks referral should be considered for surgery (sphincterotomy) or botulinum toxin
Colorectal cancer:
- risks
- Sx
- referral
- investigations
- staging
- managemet
**Risks: **
- genetic: HNPCC and FAP
- lifestyle: low fibre diet, obesity, smoking
- medical: IBD, acromegaly, DM
**Features: **
- change in bowel habit
- rectal bleeding
- abdo pain, bloating
- tenesmus
- unexplained weight loss
- fatigue/breathlessness
Referral - perform a FIT test on anyone with:
Change in bowel habit
Abdominal mass
Iron deficiency anaemia
Age >40 with unexplained weight loss and abdominal pain
Age <50 with rectal bleeding and abdominal pain or weight loss
Age >50 with unexplained rectal bleeding, abdominal pain or weight loss
Age >60 with anaemia
If the FIT is positive (>10 micrograms of haemoglobin/gram of faeces), the patient should be referred on an urgent suspected cancer (two-week wait) referral pathway.
**Investigations: **
Colonoscopy is gold standard test (if rectal bleeding a flexible sigmoidoscopy is offered)
**Staging - TNM system **
Tumour: degree of intestinal wall invasion
Nodes: lymph node involvement
Metastasis: presence of distant metastases
Mx: surgery, radiotherapy, chemo
Femoral hernia
- what is it?
- Sx
- diagnosis
- complications
- management
A femoral hernia is when a section of the bowl passes into the femoral canal via the femoral ring.
Sx: lump in the groin which is inferolateral to the pubic tubercle.
- typically non-reducible
- cough impulse is often absent
Diagnosis:
- more common in women (esp if been pregnant)
- mostly clinical diagnosis
- USS for differentials
Complication:
- incarceration: tissue cannot be recue
- strangulation - medical emergency
- bowel obstruction & ischaemia
Mx:
- surgical repair due to risk of strangulation (laparoscoptic or laparotomy)
- hernia support belts
- emergency = laparotomy
Inguinal hernia:
- what is it?
- features
- management
- subtypes
Sx:
- groin lump superior and medial to the pubic tubercle
- dissappears on pressure
- strangulation is rare
Subtypes:
1. indirect: hernia through the inguinal canal
2. direct: through the posterior wall of the inguinal canal
Mx:
- treat medically fit patients even if asymptomati
- mesh repair
Hiatus hernia
- subtypes
- risk factors
- Sx
- investigation
- Mx
Subtypes:
1. Sliding - 95% of hiatus hernias. GO junction moves above diaphragm
2. rolling - GO remains below disaphrgan but separate part of stomach herniates through
Risks: obesity, increased intraabdominal pressure
Features: heartburn, dysphagia, regurgitation, chest pain
Investigation:
- barium swallow
- lots of people have endoscopy first line where it is found incidentally
Management:
- weight loss
- medical: PPI
- surgical: only really has a role in symptomatic paraesophageal hernias
Oesophageal cancer:
- subtypes & differences
- features
- diagnosis
- treatment
Features:
- dysphagia
- anorexia & weight loss
- vomiting
- other possible features include: odynophagia, hoarseness, melaena, cough
Diagnosis:
- upper GI endoscopy with biopsy
Mx:
- operable disease (T1N0M0) is managed with surgical resection
Perianal abscess
- what is it?
- features
- causes
- investigations
- associations
- management
A perianal abscess is a collection of pus within the subcutaneous tissue of the anus that has tracked from the tissue surrounding the anal sphincter.
Features:
- pain around anus, worse on sitting
- hardened tissue in anal region
- pus-like discharge
- may be long standing
Causes: E.coli or staph aureus
Investigation:
- PR exam
- colonoscopy, cultures and inflam markers
- MRI and transperineal USS
Associations: IBD, DM
Mx:
- incision & drainage, packing or left open for 3-4 weeks
- ABX
Acute pancreatitis:
- causes
- features
- investigations
- scoring
- management
Causes: GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
Features - epigastric pain radiating to back, vomiting, Cullens sign (periumbilical discolouration) or Grey-Turners sign (flank discolouration)
Investigations:
- amylase >3 x the upper limit of normal: does not show severity
- serum lipase more sensitive
- USS
Scoring: APACHE II
Common factors indicating severity:
age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST
Management - supportive
Ascending cholangitis
- cause
- features (triad)
- investigation
- Mx
Cause: e.coli
Features:
Charcots triad
1. RUQ pain
2. fever
3. jaundice
Investigation - USS
Mx: IV ABX and ERCP to relieve obstruction of gallstones
Diverticular disease
- symptoms
- management
Sx: altered bowel habit, rectal bleed, abdo pain
Management: increase dietary intake
- Mild attacks of diverticulitis may be managed conservatively with antibiotics.
- Peri colonic abscesses should be drained either surgically or radiologically.
- Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for a segmental resection.
- Hinchey IV perforations (generalised faecal peritonitis) will require a resection and usually a stoma.
Ischaemic colitis
- what is it?
- investigations
- management
Compromise to blood flow in large bowel leading to inflammation, ulceration and haemorrhage
More likely to occur in ‘watershed’ areas such as the splenic flexure
Invesitgation - ‘thumbprinting’ may be seen on abdominal x-ray due to mucosal oedema/haemorrhage
Management: laparotomy
Mesenteric ischaemia
- chronic triad of features
- risk factors
- diagnosis
- chronic management
- acute management
Triad:
1. colicky abdo pain after food
2. weight loss
3. abdominal bruit
Risks - age, FH, smoking, diabetes, HTN, raised cholesterol
Diagnosis - CT angio
Chronic Mx:
- Reducing modifiable risk factors (e.g., stop smoking)
- Secondary prevention (e.g., statins and antiplatelet medications)
- Revascularisation to improve the blood flow to the intestines
Acute Mx:
- removal of necrotic bowl
- remove thrombus
Bowel obstruction:
- top 3 causes
- presentation
- abdo X-ray normal diameters
- initial management
- surgical management
Causes:
1. adhesions
2. hernias
3. malignancy
Sx:
- Vomiting (particularly green bilious vomiting)
- Abdominal distention
- Diffuse abdominal pain
- Absolute constipation and lack of flatulence
- “Tinkling” bowel sounds may be heard in early bowel obstruction
Abdo XR:
3 cm small bowel
6 cm colon
9 cm caecum
Initial management:
- NBM
- IV fluids
- NG tube
Surgical Mx:
Exploratory surgery in patients with an unclear underlying cause
Adhesiolysis to treat adhesions
Hernia repair
Emergency resection of the obstructing tumour
Colorectal surgery:
- right hemicolectomy
- left hemicolectomy
- high anterior resection
- low anterior resection
- abdominal perineal resection
- Hartmanns procedure
- Right hemicolectomy involves removal of the caecum, ascending and proximal transverse colon.
- Left hemicolectomy involves removal of the distal transverse and descending colon.
- High anterior resection involves removing the sigmoid colon (may be called a sigmoid colectomy).
- Low anterior resection involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus.
- Abdomino-perineal resection (APR) involves removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy.
- Hartmann’s procedure is usually an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date. Common indications are acute obstruction by a tumour, or significant diverticular disease.
Duodenal ulcers
Arise fron the gastroduodenal artery, a branch of the hepatic artery, travels posteroinferior to first part of duodenum.
