GI Flashcards by Amber Dabill

Define a anorectal abscess

Infection of soft tissue around the anus

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Describe the pathophysiology of anorectal (perianal) abscess

If crypt does not drain into anal canal

Infection may spread along the inter-sphincteric space - result in inter-sphincteric, perianal or supra-Levator abscess

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Describe the causes of anorectal abscesses

Majority = infection of the anal glands - cryptoglandular infections

Gland may become occluded due to:
- impaction of food matter
- oedema from trauma secondary to a hard stool or foreign body
- result of an adjacent inflammatory process e.g. Crohn’s disease

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Name 3 risk factors of anorectal abscesses

Anal fistula (related with 30-70% of cases)

Crohn’s disease

Male sex

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Describe the clinical features of anorectal abscesses (perianal)

Most common = severe perianal pain + swelling

+ leucocytosis

Other features
- fever
- chills
- urinary retention

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Describe the investigations of anorectal (perianal) abscess

Diagnosis = physical examination

Other investigations
- blood
- imaging

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Describe the management of anorectal (perianal) abscess

1st line = incision and drainage

Antibiotics in indicated patients - not an alternative to surgical drainage

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Name the differential diagnosis of anorectal (perianal) abscess

Anal fissure
Thrombosed haemorrhoid
Pilonidal abscess
STIs

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Name a complication of perianal abscess

Anal fistula

30-50% of patients will develop an anal fistula in months/years following drainage

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Name 3 causes of colonic ischemia

Occlusion of the blood supply (mesenteric) arteries by:

Trauma
Thrombosis
Immobilisation

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Name the risk factors of colonic ischemia

Old age
History of smoking
Hypercoagulable state
Atrial fibrillation
Myocardial infarction
Structural heart defects
History of vasculitis

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Describe the clinical features of colonic ischemia

Sudden onset of mild, crampy, abdominal pain - usually localised to the left lower quadrant

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Describe the investigations of colonic ischemia

Imaging
- sigmoid or colonoscopy
- CT angiography
- ECG

Blood investigations

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Describe the management of colonic ischemia

Treatment varies of severity of presentation

Most cases resolve spontaneously

Severe/continuing symptoms
- admission
- supportive measures
- bowel rest
- investigations to underlying cause

LMWH

Surgical interventions

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Define pseudomembranous colitis

Characterised by inflammation in the large intestine, with yellow/white plaques that form pseudomembranous membranes on the inner surface of the bowel wall

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Describe the pathophysiology of pseudomembranous colitis

Disruption of colonic biome = allows for difficle colonisation

C. difficle induces colitis via exotoxin production, toxin A and B

Toxins = inflammation, colonic cell cytoskeleton disruption and cellular death.

Pseudomembranes form as these toxins pathologically hyper stimulate the native immune system by drawing neutrophils to invade the colonic mucosa

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Name the causes of pseudomembranous colitis

Main = C. difficle

Others
- ischemic colitis
- IBD
- vasculitis
- bacterial/parasitic organisms

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Name the risk factors of pseudomembranous colitis

Same as C. difficle

Hospitalisation
Antibiotic use
Chemotherapy exposure
Marked leukemoid reactions

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Describe the symptoms of pseudomembranous colitis

Most common - symptomatic diarrhoea

Fever
Abdominal cramping
Leucocytosis

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Name the signs of pseudomembranous colitis

Leucocytosis
Hypovolemia
Hypotension
Protein-losing enteropathy
Reactive arthritis
Toxic megacolon

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Name the investigations of pseudomembranous colitis

Colonoscopy

Biopsy - Owl’s eye inclusion bodies

Diagnosis = colonoscopy + biopsy

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What is the 1st line of treatment for C. difficle

Oral vancomycin

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Define Mallory Weiss Tear

Tear in the lower oesophageal mucosa due to sudden increase in intra-abdominal pressure causing haematemesis

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Name 3 risk factors for Mallory Weiss Tear

Hyperemesis gravidarum - severe vomiting in pregnancy

Bulimia

Alcoholism

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What is the treatment for Mallory Weiss Tear

Self resolves

What artery is affected in a gastric ulcer

Gastroduodenal artery

What artery is affected in a duodenal ulcer

Left gastric artery

Describe the clinical features of a small bowel obstruction

Colicky abdominal pain - located higher Vomit them constipation Mild distention Tinkling bowel sounds Coiled spring appearance - x-ray

Describe the clinical features of a large bowel obstruction

Continuous abdominal pain Constipation then vomiting Gross distention Sounds 1. Hyperactive then 2. Normal then 3. Absent X-ray coffee bean appearance

Name 2 symptoms of a gastric ulcer

Haematemesis Melena (black tarry stools)

Name 2 symptoms of a duodenal ulcer

Melena Haematochezia - passage of blood in stool

Define GORD

Reflux of acidic contents into the oesophagus due to incompetent LES or high intra-abdominal pressure overcoming sphincter mechanisms

Name the risk factors of GORD

Increased intra-abdominal pressure - pregnancy or obesity Incompetent LES Hiatus hernia - sliding 80%, rolling 20%

Name the symptoms of GORD

Retrosternal burning chest pain Dysphagia, odynophagia

Name a red flag of GORD that would result in a 2 week wait

Dysphagia

What would be the next steps in GORD if there were no red flag symptoms

Clinically diagnose + treat

If red flags of GORD describe the investigations

1st line = oesophageal-gastro duodenoscopy (OGD) - oesophagitis, Barrett's oesophagus 2nd line (if normal) - oesophageal manometry, 24 hour gastric pH monitoring

Describe the management of GORD

Conservative Medical management Surgical - laparoscopic Nissen's fundoplication

Describe the medical management of GORD

Sort term anti acids 1st line = PPI 4-8 weeks 2nd line = H2 receptor antagonist

Describe a laparoscopic Nissen's fundoplication

Fundus wrapped around lower oesophagus to mimic sphincter

Define Barrett's oesophagus

Metaplasia of distal oesophagus Squamous to columnar epithelium

What type of cancer can Barrett's oesophagus cause

Oesophageal adenocarcinoma

What is the cause of Barrett's oesophagus

GORD complication - often due to sliding hiatus hernia Caucasian male 50+

Describe the investigation of Barrett's oesophagus

OGD + biopsy In z-line > (or equal to) 1cm above gastro-oesophageal junction

Describe the treatment of Barrett's oesophagus

Treat underlying cause reflux with PPI Non dysplastic = surveillance endoscopy Dysplastic = endoscopic mucosal resection or radiofrequency ablation

Name 4 causes of GI bleeding

Peptic ulcer Oesophageal varices Mallory-Weiss tear Stomach cancer

Name 3 signs of GI bleeding

Melaena Haematemesis Coffee-ground vomit

Why is U&E important in GI bleeding

Blood enters GI tract - blood proteins are digested to amino acids - metabolised at liver to urea = increased blood urea nitrogen

Describe the management of GI bleeding

Check ABCDE, Glasgow-Blatchford score Endoscopy Variceal bleeding - antibiotics + terlipressin - urgent endoscopy - 12 hours - place band Non-variceal bleeding - common cause - peptic ulcer - PPI - endoscopy in 24 hours - cortication or clip

Define chrons disease

Characterised by patchy transmural granulomatous inflammation with skip lesions at any part of the GI tract (mouth to anus)

Which IBD is this patchy transmural granulomatous inflammation

Chrons disease

Describe the presentation of chrons disease

RLQ pain Non-bloody diarrhoea Weight loss + malabsorption Aphthous ulcers

Where is the pain in chrons felt

RLQ

Where does chrons affect most

Terminal ileum and proximal colon

What deficiency's may be seen in chrons disease

Haematinic deficiency - B12, Fe Steatorrhea + fat soluble vitamin deficiencies

Name the risk factors of chrons disease

Jewish Bimodal incidence 15-20, 55+ Family history - NOD2/CARD15 Smoking

In which IBD is smoking a risk factor

Chrons

What is the GS investigation for chrons disease

Colonoscopy + biopsy

How do you remember differentiating features of chrons disease

NESTS

Breakdown NESTS

N - No blood or mucus (PR bleeding is less common\0 E - Entire GI tract affected (mouth to anus) S - Skip lesions on endoscopy T - Terminal ileum most affected, transmural (full thickness inflammation) S - Smoking is a risk factor (do not set nests on fire) + strictures and fistulas

How do you differentiate the features of UC

you see (UC) = CLOSEUP

Breakdown CLOSEUP

C - continuous inflammation L - limited to colon + rectum O - only superficial mucosa affected S - Smoking may be protective (UC less common in smokers) E - Excrete blood and mucus U - Use amino salicylates P - primary sclerosing cholangitis

What is the GS investigation for IBD

Colonoscopy + biopsy

What are the antibodies associated with chrons disease

ASCA antibodies

What is the 1st line management in a flare of chrons

Corticosteroids Prednisolone (mild) Hydrocortisone (severe)

What is the 1st line management to maintain remission in chrons

Azathioprine + methotrexate

What is the 2nd line management to maintain remission in chrons

Biologics TNF-a inhibitor = rituximab ILA-12&23 = Ustekinumab

What is rituximab

TNF-a inhibitor

What is ustekinumab

ILA-12&23

Name the differentials of IBD

Diverticulitis Coeliac disease Colon cancer IBS

Define UC

Autoimmune colitis beginning @ rectum (proctitis) and extending proximally into the colon

What does UC mostly affect

Terminal ileum

Where is pain in UC felt

LLQ

Name the risk factors of UC

Jewish Bimodal incidence 15-20, 55+ Family history HLA-B27 GI infection NSAIDs Non-smoking

What is the GS investigation for UC

Colonoscopy + biopsy

What would be seen on a abdo x-ray and barium enema in UC

Continuous lead pipe

What scoring system is used in UC

Flare true love + witts Scores severity

What escalation system is used in UC

Travis criteria

What is the GS management in UC

Surgery = curative Partial or total colectomy

What is the 1st line management for a flare of UC

Topical aminosalicylate (ASA)

What is the 2nd line management for UC

Oral aminosalicylate or prednisolone Biologics = TNF-a infliximab

Where does UC never go beyond

Ileocecal valve

What antibodies is UC associated with

p-ANCA antibodies

What gene is UC associated with

HLA B27 gene

Name a complication of UC

Toxic megacolon