GI Flashcards
Causes GORD
Obesity
Hiatus hernia (bc LOS sphincter can’t close properly)
LOS HTN
Loss of oesophageal peristaltic function
↑ Abdo pressure = pregnancy
Overeating
Systemic sclerosis
Signs / Symptoms GORD
Heartburn - burning chest pain
Odynophagia
Hoarse throat
Wheezing
Acidic taste
Waterbrash
Regurgitation
Nocturnal asthma
Chronic cough
Laryngitis
Sinusitis
DDx GORD
Coronary artery disease
Biliary colic
Peptic ulcer
Malignancy
Ix GORD
Usually just diagnosed w clinical findings (as long as there’s no red flags)
Oesophago-Gastro-Duodenoscopy - can show oesophagitis & hiatus hernia
24 hour intraluminal pH monitoring
Tx GORD
Lifestyle changes - stop smoking, lose weight, small regular meals
Antacids e.g. Gaviscon
PPI e.g. omeprazole, lansoprazole
H2 receptor antagonists e.g. cimetidine, rainitide
How do H2 receptor antagonists work to treat GORD?
Blocks histamine receptors on parietal cells
∴ ↓acid release
How does PPI work to treat GORD?
Inhibits gastric hydrogen release
∴ prevents production of gastric acid
Complications GORD
Barret’s Oesophagus
Peptic stricture
What is Barret’s Oesophagus?
When oesophageal epitheliu undergoes metaplasia
SQUAMOUS -> COLUMNAR w/ goblet cells
Risk of progression to oesophageal cancer
(premalignant for adenocariconoma)
What is a Peptic stricture?
Inflammation of oesophagus (bc gastric acid exposure)
∴ narrowing + stricture of oesophagus
What is a peptic ulcer?
Break in the epithelial cells which penetrate down to muscularis mucosa
Happens in stomach OR duodenum
What people are peptic ulcers more common in?
Elderly
Developing countries
State some easy ways to differentiate between symptoms of a peptic ulcer in the STOMACH and one in the DUODENUM
Duodenal ulcer - relieved by eating, MC
Gastric ulcer - worsened by eating, assoc w/ NSAIDs/aspril
Causes Peptic ulcers
H. Pylori - MC
NSAIDs
Mucosal Ischaemia
↑ Acid
Bile reflux
Alcohol
Describe the mechanism for H.Pylori causing Peptic ulcers
H.Pylori lives in gastric mucus
Secretes urease, catalyst for :
Urea -> CO2 + ammonia
Then, Ammonia + H+ -> ammonium
Ammonium (+ proteases, phospholipidases etc) damages gastric epithelium
∴ inflam response
∴ ↓ mucosal defence
∴ Mucosal damage
–
ALSO, causes ↑acid secretion :
Gastrin release (from G cells)
Histamine release
↑Parietal cell mass
↓Somatostatin
Describe the mechanism for NSAIDs causing Peptic ulcers
Prostaglandins stimulate mucus secretion & COX-1 is needed for prostaglandin stimulation
BUT NSAIDs inhibit COX-1
∴ mucus isn’t secreted
∴ ↓mucosal defence
∴ ↓mucosal damage
Describe the mechanism for mucosal ischaemia causing Peptic ulcers
Stomach cells not supplied w enough blood
∴ cells die off
∴ don’t produce mucin
Gastric acid attacks those cells & they die
∴ ulcer forms
Describe the mechanism for increased acid causing Peptic ulcers
↑↑ Acid overwhelms the mucosal defence and attacks mucosal cells
Cells die and ulcer forms !
Stress can also increase acid production
Signs / Symptoms Peptic ulcers
Sometimes asymptomatic
Burning epigastric pain!
Tender epigastrum
Bloating
N+V
Haematemesis/Melaena
Dyspepsia
Dysphagia
Flatulence
Anorexia
Heart burn (retrosternal)
–
Gastric - pain occurs when Px is hungry or eating. Usually occurs at night
Presents w weight loss
Duodenal - pain occurs several hours after meals, relieved by eating
Presents w weight gain
RED FLAGS FOR CANCER
UNEXPLAINED WEIGHT LOSS
ANAEMIA
EVIDENCE OF GI BLEEDING
DYSPHAGIA
UPPER ABDO MASS
PERSISTENT VOMITING
Ix Peptic ulcers
GS - Endoscopy w biopsy!
Stool antigen test & Urea breath test- for H.Pylori
stop PPI/Abx for at least 2/4 weeks before test
Autoimmune - low B12, parietal cell antibodies, IF antibodies
Blood test for IgG antibodies (can be pos for a year after tx)
Tx Peptic ulcers
Lifestyle changes - ↓Alcohol, ↓tobacco
Treat H.Pylori - CAP (clarithromycin, amoxicillin, PPI)!!
H2 antagonists - cimetidine
Surgery if comps
Comps Peptic ulcers
GASTRITIS
Duodenal ulcers can keep growing until reaches artery (gastroduodenal artery) and cause massive haemorrhage
Obstruction
Peritonitis - acid enter peritoneum
Acute pancreatitis - if ulcer reaches pancreas
What is Gastritis?
Inflam of stomach lining
Assoc w mucosal injury
Causes Gastritis
H.Pylori
Peptic ulcer - can develop into gastritis if happens regularly
Autoimmune gastritis
Viruses - CMV, HSV
Duodenogastric reflux
Crohn’s disease
Mucosal ischaemia
↑Acid
Aspirin and NSAIDs
Alcohol
How does autoimmune gastritis cause gastritis?
Autoimmune gastritis affects fundus and body of stomach
∴ Atrophic gastritis and ↓ parietal cells with IF def = pernicious anaemia
Signs / Symptoms Gastritis
Epigastric pain
N+V
Recurrent upset stomach
Indigestion
Loss of appetite
Abdo bloating
Haematemesis
Anaemia
DDx Gastritis
Peptic ulcer
GORD
Gastric lymphoma
Gastric carcinoma
Ix Gastritis
Upper GI endoscopy
Biopsy and histology
H.Pylori urea breath & stool antigen tests
Bloods - anaemia
Faecal occult blood tests
Tx Gastritis
CAP - clarithromycin, amoxicillin, PPI (omeprazole)
H2 antagonists - ranitidine, cimetidine
Prevention Gastritis
Give PPIs alongside NSAIDs
also prevents bleeding from acute stress ulcers and gastritis (seen in px esp burn patients)
Histology Coeliac disease
Villous atrophy
Crypt hyperplasia
When does Coeliac disease usually present?
In infancy OR 40s - 60s
Why is prevalence of coeliac disease increasing?
Changes in endoscopic techniques
Antibody screening
↑Awareness of spectrum of presentation of coeliac disease
Describe the Marsh Classification
0 normal
1 raised intra epithelial lymphocytes (IEL)
2 raised ILE + crypt hyperplasia
3a partial villous atrophy (PVA)
3b subtotal villous atrophy (SVA)
3c total villous atrophy (TVA)
Where is gluten found?
Wheat
Barley
Rye
Pathophysiology Coeliac disease
TYPE 4 HS REACTION
Gluten breaks down to a-gliadin, triggers immune response to produce Abs - anti-TTG and anti-EMA
These target epithelial cells of small intestine causing :
- Villous Atrophy
- Crypt hyperplasia
- Intra-epithelial lymphocytes
Antibodies in Coeliac Disease
Anti-TTG - Anti-Tissue Transglutaminase
Anti-EMA - Anti-Endomysial
RF Coeliac Disease
Other autoimmune diseases
IgA def
Breast-feeding
Age of gluten introduction into diet
Rotavirus infection in infancy ↑risk
H.Pylori
Signs / Symptoms Coeliac disease
CLASSICAL :
Diarrhoea
Steatorrhoea
Abdo pain
Abdo distention
Weight loss
Failure to thrive
Nutritional def
–
NON-CLASSICAL :
Dermatitis herpetiformis
IBS symptoms
Iron def anaemia
Osteoporosis
Chronic fatigue
Ataxia
Periph neuropathy
Hyposplenism
Amenorrhoea
Infertility
Ix Coeliac disease
SEROLOGY
1st Line - Anti-tissue transglutaminase (tTG)
2nd Line - Anti-endomysial antibody (EMA)
Anti-gliadin
GS!! Endoscopy w/ duodenal biopsy -
VILLOUS ATROPHY
Crypt Hyperplasia
Intra-epithelial lymphocytes
FBC - ↓Hb, ↓B12, ↓ferritin
Autoimmune condition screening - DMT1 etc
Tx Coeliac disease
Gluten free diet - strict, lifelong
No barley, wheat, rye
Dietician review - correct vit defs
DEXA scan - osteoporosis risk
Comps Coeliac disease
T-cell lymphoma
Osteoporosis
Anaemia
Infertility
Hyposplenism
Vit D def - steatorrhoea, night blindness, bruising etc
Types of IBD
Crohn’s
UC
Who does Crohn’s most likely affect?
F
20 - 40 years
Northern Europe, UK and North American countries
RF Crohn’s
FHx - Mutation on NOD2 gene (chromosome 16)
Smoking
Female
Chronic stress
NSAIDs
Crohn’s : CHRISTMAS
Cobblestones
High temp
Reduced lumen
Intestinal fistulae
Skip lesions
Transmural
Malabsorption
Abdo pain
Submucosal fibrosis
Signs / Symptom Crohn’s
RLQ abdo pain (ileum)
Diarrhoea
N+V
Fatigue
Fever
Tenderness
Haematochezia, Meleana
Mouth ulcers
Extra-Intestinal features :
Erythema nodosum
Anal fissures/strictures
Episcleritis
Clubbing, skin, joint & eye problems
Comps Crohn’s
Small bowel obstruction
Toxic dilation
Abscess formation
Fistulae
Malnutrition
Perforation
Anal - skin tags, fissure, fistula
Neoplasia - colorectal cancer
Amyloidosis - rare
DDx Crohn’s
Chronic diarrhoea
Ix Crohn’s
GS!! Colonoscopy & biopsy
Barium enema
Should always rule out other causes of diarrhoea (Salmonella spp., Giardia intestinalis, rotavirus) - Stool sample
FBC - ↑ESR/CRP, ↓Hb, neg p-ANCA
Malabsorption - ferritin, B12, folate
Faecal calprotein aka FIT test - indicates IBD, not spec
Tx Crohn’s
1 - Oral corticosteroids - budesonide, prednisolone
If severe, IV hydrocortisone (severe flare ups)
2a - + 5-ASA (azathioprine)
b. Methotrexate
3 - Anti-TNF antibodies - infliximab
4 - Surgery
–
DISEASE IS NOT CURATIVE
–
To maintain remission! Azathioprine or Methotrexate
What part of the body does Crohn’s affect?
Affects any part of gut from mouth to anus - ileum and colon esp
Originates in mucosa and works through layers of the bowel
Describe macroscopic features of Crohn’s
Skip lesions
Cobblestone appearance (due to ulcers and fissures in mucosa)
Thickened & narrow
Describe microscopic features of Crohn’s
Transmural - affects all layers of the bowel
Non-caseating granulomas
Goblet cells
What are non-caseating granulomas?
Aggregations of epithelioid histiocytes
RF UC
FHx
NSAIDs - assoc/ w onset and flares of IBD
Chronic stress, depression triggers flares
What rogue thing can relieve UC?
Smoking
Describe some macroscopic features of UC
Continuous inflam (no skip lesions)
Ulcers
Pseudo-polyps
Describe some microscopic features of UC
Mucosal inflam
No granulomata
Depleted goblets cells
Increase crypt abscesses
What area of the body does UC affect?
Remains in mucosa (doesn’t go through full wall of bowel)
Only affects colon
NEVER goes past the ileocaecal valve
Who might UC be found in?
Affects males and females equally
Presents between 15 - 30
Northern Europe, UK and N. America
Signs / Symptoms UC
LLQ abdo pain
Fever
Diarrhoea w blood and mucus
Cramps
Rectal tenesmus - incontinence, urgency, bleeding
Tender, distended abdo
Clubbing
Erythema nodosum
UC : ULCERATION
Ulcers
Large intestine
Carcinoma - risk of
Extra-intestinal manifestations
Remnants of older ulcers - psuedo polyps
Abscesses in crypts
Toxic megacolon - risk of
Inflamed, red, granular mucosa
Originates at rectum
Neutrophil invasion
Stool is bloody and has mucous
Ix UC
GS!! Colonoscopy & biopsy (crypt abscesses, goblet cell depletion)
also, allows to assess disease extent
Barium enema
Bloods - FBC (↑ESR,↑CRP, ↓Hb)
p-ANCA might be pos (deff neg in Crohn’s so can differentiate)
Faecal calprotein
Stool sample - to rule out other causes of diarrhoea (Salmonella etc)
CT/MRI
Abdo XR - useful if UC is too severe for colonoscopy, can be used to exclude colonic dilation
Extra-Intestinal Manifestations of UC
A PIE SAC
Ankylosing Spondylitis
Pyoderma Gangrenosum
Iritis - ant. uvieitis
Erythema nodosum
Sclerosing cholangitis
Apthous ulcers / Amyloidosis
Clubbing
What should you avoid with Crohn’s?
NSAIDs
Tx UC
Aminosalicylate (5-ASA)
e.g. Sulfasalazine, Mesalazine
MILD
1. 5-ASA
2. + steroid (prednisolone)
MOD/SEVERE
1. Fluid/resus if necessary
2. IV steroid (hydrocortisone)
3. + TNF-i (infliximab)
GS!! COLECTOMY
To maintain remission - azathioprine
Where is 5-ASA absorbed?
Small intestine
Comps UC
Liver - fatty change, chronic pericholangitis, sclerosing cholangitis
Colon - blood loss, toxic dilation, colorectal cancer
Skin - erythema nodosum, pyoderma gangrenosum
Joints - Ankylosing spondylitis, arthritis
Eyes - Iritis, uveitis, episcleritis
Define diarrhoea
Abnormal passage of loose or liquid stool more than 3 times daily
Define acute diarrhoea
Lasts less than 2 weeks
Define chronic diarrhoea
Lasts more than 2 weeks
Viral causes of diarrhoea
Most cases are caused by viruses
e.g.
Rotavirus - children
Norovirus - adults
Bacterial causes of diarrhoea
Campylobacter
Shigella
Salmonella
C.perfringens
S.aureus
B.cereus
E.coli
C.diff
Parasites (e.g. giardia, crypto)
Antibiotic causes of Diarrhoea??
Some abx can give rise to C.Diff diarrhoea
RULE OF Cs
Clindamycin
Ciprofloxacin
Co-amoxiclav
Cephalosporins (esp 2nd + 3rd gen)
Infective causes of diarrhoea
Intraluminal infection
Systemic infections e.g. sepsis, malaria
Non-infective causes of diarrhoea
Cancer
Chemical e∴g poisoning, sweeteners, s/e
IBS/Malabsorption
Endo e.g. T4
Radiation
Mechanism for watery diarrhoea
Non-Inflam
Enterotoxin or superficial adherence/invasion
Mechanism for bloody, mucoid diarrhoea
Inflam!
Location of watery diarrhoea
Proximal small bowel
Location of bloody, mucoid diarrhoea
Colon
Bacterial causes of watery diarrhoea
Vibrio cholerae
E.Coli
Clostridium perfringes
Bacillus cereus
S. Aureus
Bacterial causes for bloody, mucoid diarrhoea
Shigella
E.Coli
Salmonella enteridis
C.parahaemolyticus
C.diff
C.jejuni
Viral causes of watery diarrhoea
Rotavirus
Norovirus
Viral causes of bloody, mucoid diarrhoea
N/A
Parasitic causes of watery diarrheoa
Giardia
Cryptosporidium
Parasitic causes of bloody, mucoid diarrhoea
Entamoeba histolytica
History Diarrhoea
HISTORY IS KEY!
> Onset/duration
Acute - viral/bacterial
Chronic - parasites and non-infectious
> FHx
> Stool characteristics
Floating - fat content, malabsorption/coeliac
Blood/mucus - inflam, cancer
Watery - small bowel infection
> Food/drink
Dodgy takeaway - food poisoning
Meat/BBQs - campylobacter
Poultry - salmonella
> Travel
No cholera in UK
Foreign travel?
V common
> Immunocomp?
HIV, chemo, transplant etc
> Unwell contacts
> Fresh water/swimming - giardia, crypto
> Animals
Reptiles - salmonella
Puppies - campylobacter
> Medications? Abx??
> Neuro signs?
Clostridium botunilum - ascending weakness
C.jejnuni - guillain-barre
Ix Diarrhoea
HISTORY
Stool tests - culture, faecal calprotein, occult blood, microscopy, cysts, parasites etc
Bloods - FBC, inflam markers (CRP etc), blood culture
What is the 1st and 2nd leading causes of death in children globally?
1st - Pneumonia
2md - Infective diarrhoea
Where does infective diarrhoea have the highest prevalence?
S.Asia
S.Africa
DDx Infective diarrhoea
Appendicitis
IBD
UTI
Coeliac disease
Volvulus
RF Infective diarrhoea
Foreign travel
PPI or H2 antagonist use
Crowded use
Poor hygiene
Causes infective diarrhoea
*Enterotoxigenic E.Coli - MC
Campylobacter
Shigella
Viral
Non-typhoidal salmonella
V.parahaemolyticus - shellfish!
Cholera - vibrio cholerae
Parasites - protozoal (crypto, giardia, entamoeba)
Worms - schistosomiasis, strongyloides
C.DIff
Ix Infective diarrhoea
3 or more unformed stools per day + one of the following :
Abdo pain
Cramps
N / V
Dysentry
–
Blood - suggests bacteria
Stool sample
If chronic, sigmoidoscopy
What bacteria cause bloody stools
E.Coli and shigella ALL cause bloody stools
Tx Infective diarrhoea
Rehydration
Fluids + electrolytes - monitoring and replacement
ABx - metronidazole or oral vancomycin
Barrier nursing - side room, gloves, apron
Anti-emetics - treat vomiting w/ metoclopramide
Anti-motility agents - BUT NEVER IN INFLAM DIARRHOEA
Diarrhoea red flags?
Dehydration
Electrolyte imbalance
Renal failure
Immunocompromised
Severe abdo pain
Quick! Right side abdo pain
First thoughts?
Appendicitis
unless already removed
Where is the appendix located?
At McBurney’s point
2/3 from umbilicus to anterior superior iliac spine (ASIS)
When does appendicitis occur?
Any age
but highest incidence is at 10-20 years
Causes appendicitis
OBSTRUCTION
Faecolith - faeces stones
Filarial worms
Undigested seeds
Lymphoid hyperplasia
Bacteria - Campylobacter jejuni, Yersinia, salmonella, bacillus cereus
Pathophysiology Appendicitis
Appendix is blocked
∴ ↑gut flora
∴ immune response summoned
∴ ↑ WBC
∴ appendix swells and presses against nerves
= ouch
Signs / Symptoms Appendicitis
Acute pain in R iliac fossa/umbilicus
Might originate in umbilicus and then migrate to RIF
N+V
Fever
Guarding
Rebound/percussion tenderness w palpation
Pyrexia
Rovsing’s sign
Psoas sign / Cope sign
What is Rovsing’s sign?
More pain in RIF when LIF is pressed
What is Cope sign?
Pain on flexion and internal rotation of R hip
Happens if appendix is close to obturator internus
What is Psoas sign?
Pain on extending hip
happens if retrocaecal appendix
DDx Appendicitis
Gynae :
Ectopic pregnancy!
Ovarian torsion
Ruptured ovarian cyst
GI :
Crohn’s
Food poisoning
Mesenteric adenitis
Diverticulitis/Cholecystitis/Cystitis
GU :
Kidney stones
UTI
Testicular torsion
Ix Appendicitis
Bloods - maybe ↑neutrophil and ↑CRP
Abdo US - but not always helpful to see appendix
GS!! CT w contrast
Urinalysis - exclude UTI
Pregnancy test
UC Extra-intestinal signs
A PIE SAC
Ankylosing spondylitis
Pyoderma gangrenosum
Iritis
Erythema nodosum
Sclerosing cholangitis
Apthous ulcers/Amyloidosis
Clubbing
Comps Appendicitis
Peritonitis - if ruptures
Tx Appendicitis
Appendicectomy - usually laparoscopic
can be open surgery if required
Causes of Peritonitis
AEIOU
Appendicitis
Ectopic pregnancy
Infection with TB (bacterial MC)
Obstruction
Ulcer
Common causes of abdo pain
Gastritis - epigastric pain
Cholecystitis - R hypochondrium, mid-clav line
Pancreatitis - midway between epigastric and umbilicus
Appendicitis - R iliac fossa
Diverticulitis - L iliac fossa
What is diverticulosis?
When a diverticula is present
What is diverticular disease?
When diverticula are symptomatic
What is diverticulitis?
When diverticula are inflamed
What’s a true diverticulum?
Involves all layers of intestinal wall
What’s a false diverticulum?
Involves only mucosa and submucosa
RF Diverticulosis
LOW FIBRE DIET (+ high meat)
Obesity
CONSTIPATION
Smoking
NSAIDs
> 50 years - occur in 50% of people over 50
Pathophysiology Diverticulosis
Fibre helps gut motility
∴ if ↓ fibre, colon must push harder to move things along
∴ ↑ pressure
∴ Pouches of mucosa extrude beyond muscular wall near blood vessels
∴ diverticula form at gaps of colon wall where blood penetrate
Signs / Symptoms Diverticulosis
Asymptomatic !!
Maybe erratic bowel habit
Or if severe, intermittent LIF pain + constipation
Ix Diverticulosis
Usually detected incidentally w/ colonoscopy or barium enema
Tx Diverticulosis
If symptomatic, recommend high fibre diet and smooth muscle relaxants e.g. mebeverine
Where is diverticulitis normally found?
Sigmoid colon
Pathophysiology Diverticulitis
Occurs when faeces obstructs neck of diverticulum
∴ bacteria multiply
∴ inflammation!!
Signs / Symptoms Diverticulitis
Same as appendicitis but LEFT ILIAC FOSSA
Severe pain in LIF
Fever
N+V
Rebound tenderness w palpation
ETC
Ix Diverticulitis
FBC - ↑WBC, ↑ESR, ↑CRP
CT w contrast - will show colon wall thickening + abscesses
Bowel sounds diminished? (colon not working properly)
Colonoscopy - use for acute bleeds
but not if bleeding profusely bc can perforate bowel more
Could also do abdo XR and barium enema if you wanted
Tx Diverticulitis
If mild - fluids, bowel rest, ABx e.g. ciprofloxacin
If seems severe/systemic - treat w/ IV fluids, IV Abx
RARELY but sometimes surgical resection
Symptoms of diverticular disease
AND Diverticulitis
BBL
Bowel habits changed
Bloating/flatulence
Left lower quadrant pain
If diverticulitis :
All of above
+ FEVER
+ Blood in stool
Comps Diverticular disease
Infection -> abscess
Bowel perforation
Peritonitis
Haemorrhage
Obstruction
Fistulae (into adjacent organs)
What should you not do during an acute attack of diverticulitis?
DO NOT PERFORM COLONOSCOPY OR SIGMOIDOSCOPY
What can IBS symptoms be exacerbated by?
Stress
Food
Gastroenteritis
Menstruation
Age of onset IBS
< 40 years
3 types of IBS
IBS-C - w constipation
IBS-D - w diarrhoea
IBS-M - w both
What is Irritable Bowel Syndrome?
Recurrent abdo pain with NO inflammation
Signs / Symptoms IBS
Abdo pain relieved by defecating or passing of wind
Bloating
Alternating bowel habits
Constipation
Diarrhoea
Mucus in stools
Change in stool freq/consistency
Urgency
Worsening symptoms after food
Ix IBS
FBC - for anaemia
ESR, CRP - for inflammation
Coeliac serology for EMA and ttG - if +, then probs coeliac disease, not IBS
Faecal calprotein - IBD
Colonoscopy - IBD, colorectal cancer
Tx IBS
Lifestyle - fluids
Avoid caffeine & alcohol & fizzy drinks
Low FODMAP diet !!
Educate patient & reassure
Treat symptoms :
Pain/bloating - antispasmodic e.g. Buscopan
Constipation - laxative e.g. Senna, avoid lactulose
Diarrhoea - antimotility e.g. Loperamide
If none of the above work, Amitriptyline
What are FODMAPs?
Fermentable - carbs brown down in colon
Oligosaccharides - wheat, rye, onione, garlic, legumes, lentils, artichokes
Disaccharides - lactose! Milk, icecream etc
Monosaccharides - Fructose - apples, watermelon, mango, pear, asparagus
And
Polyols - sorbitol, mannitol, gum, cauliflower, fruits, sweets
What is the Roman IV criteria?
What does it help diagnose?
Recurrent abdo pain at least 1 day/week for the past 3 months
& symptoms began at least 6 months ago plus AT LEAST 2 of :
relieved by defecation
change in bowel appearance
change in bowel freq
IBS
Oesophageal Tumour Staging
T1 - invading lamina propria/submucosa
T2 - invading Muscularis propria
T3 - invading adventitia
T4 - invasion of adjacent structures
N0 - no nodal spread
N1 - regional node metastases
M0 - no distant spread
M1 - distant metastases
2 Types of Oesophageal Cancer
Squamous cell carcinomas
Adenocarcinomas
Where is Oesophageal squamous cancer commonly found?
Geographically
Ethiopia
China
South and East Africa
Where is Oesophageal adenocarcinoma commonly found?
Geographically
Western countries
Causes Oesophageal squamous cancer
↑↑Alcohol
Smoking
Achalasia
Obesity
Smoking
↓Fruit and Veg
Cause Oesophageal adenocarcinoma
GORD - Barret’s oesophagus!!
Smoking
Obesity
Where in the body is Oesophageal squamous cancer found?
Upper 2/3rds of the oesophagus
Middle third MC
Where in the body is Oesophageal Adenocarcinoma found?
Lower 1/3rd of oesophagus
Pathophysiology of Oesophageal Cancer
Oesophagus - squamous epithelium
Stomach - columnar glandular epithelium
Oesophageal epithelium undergoes metaplasia to stomach epithelium!
Signs / Symptoms Squamous cell Oesophageal Cancer
Normally none! Bc only detectable when advanced
Progressive dysphagia i.e. solids followed by liquids
Weight loss
Anorexia
Hoarse voice - pressing on recurrent laryngeal nerve
Odynophagia
ALARMS !! Cancer red flags
When would you get a 2 week endoscopy referral?
People with :
Dysphagia
OR
Age ≥ 55 years w/ weight loss AND at least 1 of :
Upper abdo pain
Reflex
Dyspepsia
If dysphagia to solids AND liquids at the same time, what does this indicate?
Benign disease
Ix Oesophageal cancer
Oesophagoscopy w/ biopsy !!!
Barium swallow - to see strictures
CT/MRI/PET for staging
Tx Oesophageal cancer
Surgical resection
w/ adjuvant radio/chemo
Palliative care :(
5 year prognosis is 25%
What considerations have to be taken when considering surgery for GI cancer?
Is patient medically fit? Age? Co-morbs?
Severity of cancer?
Is it resectable?
Why is prognosis for Oesophageal cancer relatively poor?
Bc symptoms arise so late into disease
MC benign oesophageal tumour
Describe it
Leiomyomas
Smooth muscle tumours, arise from oesophageal wall
Intact, well-encapsulated within overlying mucosa
Slow-growing
Signs / Symptoms Benign Oesophageal cancer
Asymptomatic - usually found incidentally on barium swallow
Can present w dysphagia, retrosternal pain, food regurg + recurrent chest infections
Where does Gastric cancer commonly affect?
Eastern Europe
Asia
Causes Gastric Cancer
Unknown
Some link w smoking
RF Gastric cancer
Smoking
H. Pylori - bc ↑risk of peptic ulcer
Male
Signs / Symptoms Gastric cancer
Epigastric pain - constant and severe!!
Virchow’s node! ( L supraclavicular)
N+V
Anorexia
Weight loss
Dysphagia - if tumour in fundus
Anaemia - occult blood loss
Haematemesis/Melaena
Liver metastasis = jaundice
CANCER RED FLAGS
Ix Gastric Cancer
Gastroscopy w/ biopsy
Neg biopsy doesn’t mean deff no cancer - need to do 8-10 biopsies to make sure !
Endoscopic ultrasound
CT/MRI/PET
Types of Gastric Cancer
Brief description
Type 1 - Intestinal
Well-formed, differentiated cells
Metaplasia in surrounding mucosa
Tumours = polypoid OR ulcerating lesions w/ heaped, rolled edges
Found often in patients w/ atrophic gastritis
Type 2 - Diffuse
Poorly cohesive, undifferentiated cells
Often will infiltrate gastric wall
Worse prognosis
Which type of gastric cancer is most common?
Intestinal (80%)
Where is intestinal gastric cancer found in the body?
Antrum + lesser curvature
Where is diffuse gastric cancer found in the body?
Anywhere in the stomach
Esp cardia
RF Intestinal Gastric cancer
Male
Older age
H. Pylori
Chronic or Atrophic Gastritis
RF Diffuse Gastric Cancer
Female
< 50 years
Blood type A
Genetics
H. Pylori infection
Histology Intestinal Gastric cancer
Well-differentiated
Tubular
Histology Diffuse Gastric Cancer
Poorly differentiated
Signet ring cells
Pathophysiology Intestinal Gastric cancer
Chronic gastritis -> Atrophic gastritis
∴ intestinal metaplasia and dysplasia
Pathophysiology of Diffuse Gastric cancer
Development of linitis plastica (leather bottler stomach)
?
Tx Gastric Cancer
Nutritional support!
Surgical resection - can be subtotal or total gastrectomy
+ adjuvant radio/chemo
ECF chemo - Epirubicin + cisplatin + 5-fluororacil
Prognosis Gastric cancer
STAGE 1 - 70% 5 year survival
STAGE 4 - 5.5% 5 year survival
Diff between peptic ulcler pain and gastric cancer pain
Peptic ulcer pain can be relieved by food and antacids
But gastric cancer pain is constant and vv severe
What is the staging for Colorectal cancer?
Describe it
DUKE STAGING
A - 95% 5 year survival
Limited to mucosa
B - 75% 5 year survival
Through bowel lining and into submucosa
Not lymph nodes
C - 35% 5 year survival
Involvement of lymph nodes
D - 25% 5 year survival
Metastatic! Distant organs affected
What age is the majority of presentation of colorectal cancer?
> 60 years old
RF Colorectal cancer
Age
FHx
IBD
Obesity
DM
Smoking
Alcohol
Genetics - FAP & HNPCC
Causes Colorectal cancer
Mostly due to random mutations but some are known e.g.
Familial adenomatous polyposis (FAP)
Mutation in APC (tumour suppressor gene)
Polyps formation
Hereditary non-polyposis colorectal cancer (HNPCC) - Lynch Syndrome
AUTOSOMAL DOMINANT
Normally 2 DNA protein repair genes
But some people only have 1 and ∴ susceptible
Where in the body is colorectal cancer most common?
Sigmoid colon
Rectum
Signs / Symptoms Colorectal cancer
Depends on region affected!
Ascending colon carcinoma
Usually ASx for ages until iron def anaemia bc of bleeding
Weight loss
Abdo pain
May present w/ mass
Descending colon and sigmoid carcinoma
Change in bowel habit w blood +/- mucus in stool
Diarrhoea
Alternative constipation and diarrhoea
Thin/altered stool
Rectal carcinoma
Rectal bleeding and mucus
If cancer grows, thinner stools and tenesmus
–
EMERGENCY! - OBSTRUCTION
Absolute constipation
Colicky abdo pain
Abdo distention
Vomiting (faeculent)
Ix Colorectal cancer
Colonoscopy/Sigmoidoscopy + biopsy! - GS!!!!!!!
CT colonography - if unfit for colonoscopy
CT TAP (thorax, abdomen and pelvis) - for staging
Carcinoembryonic antigen - CEA
Digital rectal exam - 38% of colorectal cancers can be detected by DRE !
Double contrast barium enema
FBC
When does bowel cancer screening happen?
What does it include?
60 - 74 years
Every 2 years
Faecal immunochemical test (FIT)
What is Duke’s Classification for?
Colorectal cancer
AND THERE IS ALSO ONE FOR INFECTIVE ENDOCARDITIS
Tx Colorectal cancer
Surgery -
Endoscopy stenting
Radio/Chemo
Which GI cancer is very rare?
Small intestine
usually adenocarcinoma
Usually SI is resistant to neoplasms
Tx H. Pylori
Triple therapy - CAP !! / CMP
2x a day for 7 days! (NICE guidlines)
Clarithromycin 500mg + Amoxicillin 1g + PPI
If penicillin allergy, Metronidazole 400 mg instead of amoxicillin
Ix H. Pylori
Urea breath test
Stool antigen test
Before testing, stop PPI for at least 2 weeks and Abx for 4 weeks
(???? is this rlly true? that’s so long to stop meds !)
Define an intestinal obstruction
Arrest or blockage of onward propulsion of intestinal contents
Causes of Small Bowel Obstruction
MECHANICAL :
Adhesions!! (75%)
Usually 2º to abdo surgery
↑Incidence w/ pelvic, gynae, colorectal surgery
Hernias (10%)
Rarer : Malignancy, Crohn’s
2 Types of intestinal obstruction
Mechanical - can be partial or complete
Functional - ‘paralytic ileus’, disruption of peristalsis
Describe the classifications of bowel obstruction
> Site ?
Large bowel, small bowel etc
> Extent of luminal obstruction?
Partial, complete
> Mechanism?
Mechanical, function
> Pathology?
Simple, closed loop, strangulation, intussusception
Ix SBO
- Abdo XR
Central gas shadow, crosses lumen, NO GAS IN LARGE BOWEL
Dilation of small bowel > 3cm, coiled-spring appearance
GS : ABDO & PELVIS CT W/ CONTRAST
Signs / Symptoms SBO
Colicky abdo pain - starts and stops abruptly then becomes diffuse
Higher than LBO
Abdo distension (less than LBO)
Vomiting following pain, then constipation
‘Tinkling’ bowel sounds
N+V
Anorexia
Increased bowel sounds
Tympanic percussion
Tenderness
What would you hear on auscultation if there is a mechanical bowel obstruction?
High-pitched tinkling sound
What would you hear on auscultation if there is a functional bowel obstruction?
Absence of normal bowel sounds
Why does LBO have a greater degree of distension?
Bc the more distal the obstruction, the greater the distension
Tx Small Bowel Obstruction
SAME AS LBO !!!
Stable - A-E assessment
‘Drip and suck’
Insert IV cannula, resus w/ IV fluids!!
NBM
Nasogastric tube to decompress stomach
Analgesia, anti-emetics, Abx
Unstable - Surgery
Treat according to cause
Comps SBO
Infection - peritonitis
Tissue death - blood supply can be cut off to intestine
Causes Large Bowel Obstruction
Malignancy! (90%)
Sigmoid volvulus (5%)
Diverticulitis
Intussusception - more common w children
Why does LBO present slower and later than in SBO?
Bc Large Bowel has larger lumen
+ circular and longitudinal muscles
∴ ability of large bowel to distend = much greater
Signs / Symptoms LBO
CONTINUOUS abdo pain
Severe abdo distension
Constipation first, THEN vomiting
(initially bilious then faecal)
Absent bowel sounds
Palpable mass ? - hernia, distended bowel loop, caecum
Fullness/bloating
Ix LBO
- Abdo XR
dilation of large bowel > 6cm
dilation of caecum > 9cm
Sigmoid volvulus - coffee bean appearance!
DRE - empty rectum, hard stools, blood
GS!! ABDO & PELVIS CT W CONTRAST
Tx LBO
SAME AS SBO !!
Stable - A-E assessment
‘Drip and suck’
Insert IV cannula, resus w/ IV fluids!!
NBM
Nasogastric tube to decompress stomach
Analgesia, anti-emetics, Abx
Unstable - Surgery
Treat according to cause
What is Pseudo-Obstruction also known as?
Ogilvie syndrome
What is Pseudo-Obstruction?
Colonic dilation in the absence of mechanical obstruction
Ix Pseudo-Obstrction
- Abdo XR
Megacolon dilation > 10cm
GS!! - ABDO & PELVIC CT W CONTRAST
no transition zone!
Causes Pseudo-Obstruction
Post-op
Medications - opioid, CCBs, antideps
Neurological - MS, Parkinson’s, Hirschsprung’s
Electrolyte imbalance
Recent trauma/surgery
Tx Pseudo-Obstruction
‘Drip & suck’ management
IV neostigmine
Surgical decompression if unstable
Pathophysiology Pseudo-Obstruction
Parasympathetic nerve dysfunction
∴ absent smooth muscle
Comps Pseudo-Obstruction
Bowel ischaemia
Perforation
What is Meckel’s Diverticulum?
True diverticulum connected to vitelline duct
Diff between True and False diverticulum?
True = ALL Layers, includes muscle
False = does not include muscle
What age is Meckel’s Diverticulum common?
0-2 years
Signs / Symptoms Meckel’s Diverticulum
Usually ASx !!!
If does present :
In children - Painless haemotochezia
Intussueption
In adults - Bowel obstruction, unexplained GI bleeding
Ix Meckel’s
Meckel’s Scan
DDx Meckel’s
Appendicitis - apparently clinically indistinguishable?? but doesnt present w pain?? so i dont get it
Tx Meckel’s
Usually laparoscopic surgery - removal of diverticulum
What is Meckel’s also known as?
Pharyngeal pouch
Difference microscopically between Coeliac disease and Tropical Sprue
GS for both = Jejunal tissue biopsy
Tropical Sprue = INCOMPLETE villous atrophy
Coeliac = COMPLETE villous atrophy
What is Tropical Sprue?
Chronic inflam of the bowel, acquired from the tropics
What “tropics” is Tropical Sprue acquired from?
India
South East Asia
Caribbean
When should you suspect Tropical Sprue?
Patient is from tropical country
+ has chronic GI/Malabsorptive Symptoms
Signs / Symptoms Tropical Sprue
Diarrhoea
Steatorrhoea
Weight loss
Abdo pain
Fatigue
Dehydration
Vit/Iron anaemia
Tx Tropical Sprue
Drink treated water
Tetracycline for 6 months
RF Acute Mesenteric Ischaemia
AF !!!!!!!!
Cardio risks
Classic Triad of Chronic Mesenteric Ischaemia
- Central Colicky abdo pain after eating
- Weight loss
- Abdo bruit - bc turbulent blood flow
Ix Chronic Mesenteric Ischaemia
CT W CONTRAST
or ANGIOGRAPHY
Pathophysiology Chronic Mesenteric Ischaemia
Same as Angina in heart!
Tx Chronic Mesenteric Ischaemia
Lifestyle
2º prevention
Surgery
What is Acute Mesenteric Ischaemia?
MEDICAL EMERGENCY!!
Blockage of mesenteric arteries/veins
Where is the most likely place to be affected in Acute Mesenteric Ischaemia?
Superior mesenteric Artery
∴ Small bowel
Causes Acute Mesenteric Ischaemia
Thromboembolism
Vasospasm
Hernia - strangulated
Signs / Symptoms Acute Mesenteric Ischaemia
CLASSIC TRIAD :::
1. Severe central colicky pain, worst after eating
2. Abdo bruit / Cardiac issues (AF!!)
3. Rapid hypovolaemia - shock!! (pallor, weak pulse etc)
–
N+V
Melaena/Haematochezia
Increasing Abdo distention
Ix Acute Mesenteric Ischaemia
Bloods - ↑lactate (metabolic acidosis)
1st Line - CT w contrast / Angiography
GS!!! - COLONOSCOPY
Tx Acute Mesenteric Ischaemia
ABx
+ Anticoags e.g. heparin
+ Surgery
What is Mallory-Weiss Tear?
Linear mucosal tear at the oesophagogastric junction
Cause Mallory-Weiss Tear
Sudden increase in intra-abdo pressure
e.g.
Vomiting
Coughing
Retching
RF Mallory-Weiss Tear
Alcoholism
Forceful vomiting
Eating disorders
NSAID abuse
Male
Signs / Symptoms Mallory-Weiss Tear
Vomiting
Abdo pain
Haematemesis
Retching
Postural hypotension
Dizziness
Melaena
Ix Mallory-Weiss Tear
Endoscopy
Tx Mallory-Weiss Tear
Most bleeds are minor, heal in 24 hours
Surgery if req
Quick!
Difference between Mallory-Weiss tear and Oesophageal Varices?
Mallory-Weiss Tear is bc of ↑intra-abdo pressure e.g. retching, vomiting
Oesophageal Varices is bc ↑portal pressure e.g. CIRRHOSIS, schistosomiasis