GI Flashcards
1
Q
Causes GORD
A
Obesity
Hiatus hernia (bc LOS sphincter can’t close properly)
LOS HTN
Loss of oesophageal peristaltic function
↑ Abdo pressure = pregnancy
Overeating
Systemic sclerosis
2
Q
Signs / Symptoms GORD
A
Heartburn - burning chest pain
Odynophagia
Hoarse throat
Wheezing
Acidic taste
Waterbrash
Regurgitation
Nocturnal asthma
Chronic cough
Laryngitis
Sinusitis
3
Q
DDx GORD
A
Coronary artery disease
Biliary colic
Peptic ulcer
Malignancy
4
Q
Ix GORD
A
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
5
Q
Tx GORD
A
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
6
Q
How do H2 receptor antagonists work to treat GORD?
A
Blocks histamine receptors on parietal cells
∴ ↓acid release
7
Q
How does PPI work to treat GORD?
A
Inhibits gastric hydrogen release
∴ prevents production of gastric acid
8
Q
Complications GORD
A
Barret’s Oesophagus
Peptic stricture
9
Q
What is Barret’s Oesophagus?
A
When oesophageal epitheliu undergoes metaplasia
SQUAMOUS -> COLUMNAR w/ goblet cells
Risk of progression to oesophageal cancer
(premalignant for adenocariconoma)
10
Q
What is a Peptic stricture?
A
Inflammation of oesophagus (bc gastric acid exposure)
∴ narrowing + stricture of oesophagus
11
Q
What is a peptic ulcer?
A
Break in the epithelial cells which penetrate down to muscularis mucosa
Happens in stomach OR duodenum
12
Q
What people are peptic ulcers more common in?
A
Elderly
Developing countries
13
Q
State some easy ways to differentiate between symptoms of a peptic ulcer in the STOMACH and one in the DUODENUM
A
Duodenal ulcer - relieved by eating, MC
Gastric ulcer - worsened by eating, assoc w/ NSAIDs/aspril
14
Q
Causes Peptic ulcers
A
H. Pylori - MC
NSAIDs
Mucosal Ischaemia
↑ Acid
Bile reflux
Alcohol
15
Q
Describe the mechanism for H.Pylori causing Peptic ulcers
A
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
16
Q
Describe the mechanism for NSAIDs causing Peptic ulcers
A
Prostaglandins stimulate mucus secretion & COX-1 is needed for prostaglandin stimulation
BUT NSAIDs inhibit COX-1
∴ mucus isn’t secreted
∴ ↓mucosal defence
∴ ↓mucosal damage
17
Q
Describe the mechanism for mucosal ischaemia causing Peptic ulcers
A
Stomach cells not supplied w enough blood
∴ cells die off
∴ don’t produce mucin
Gastric acid attacks those cells & they die
∴ ulcer forms
18
Q
Describe the mechanism for increased acid causing Peptic ulcers
A
↑↑ Acid overwhelms the mucosal defence and attacks mucosal cells
Cells die and ulcer forms !
Stress can also increase acid production
19
Q
Signs / Symptoms Peptic ulcers
A
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
20
Q
RED FLAGS FOR CANCER
A
UNEXPLAINED WEIGHT LOSS
ANAEMIA
EVIDENCE OF GI BLEEDING
DYSPHAGIA
UPPER ABDO MASS
PERSISTENT VOMITING
21
Q
Ix Peptic ulcers
A
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)
22
Q
Tx Peptic ulcers
A
Lifestyle changes - ↓Alcohol, ↓tobacco
Treat H.Pylori - CAP (clarithromycin, amoxicillin, PPI)!!
H2 antagonists - cimetidine
Surgery if comps
23
Q
Comps Peptic ulcers
A
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
24
Q
What is Gastritis?
A
Inflam of stomach lining
Assoc w mucosal injury
25
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
26
How does autoimmune gastritis cause gastritis?
Autoimmune gastritis affects fundus and body of stomach
∴ Atrophic gastritis and ↓ parietal cells with IF def = pernicious anaemia
27
Signs / Symptoms Gastritis
Epigastric pain
N+V
Recurrent upset stomach
Indigestion
Loss of appetite
Abdo bloating
Haematemesis
Anaemia
28
DDx Gastritis
Peptic ulcer
GORD
Gastric lymphoma
Gastric carcinoma
29
Ix Gastritis
Upper GI endoscopy
Biopsy and histology
H.Pylori urea breath & stool antigen tests
Bloods - anaemia
Faecal occult blood tests
30
Tx Gastritis
CAP - clarithromycin, amoxicillin, PPI (omeprazole)
H2 antagonists - ranitidine, cimetidine
31
Prevention Gastritis
Give PPIs alongside NSAIDs
also prevents bleeding from acute stress ulcers and gastritis (seen in px esp burn patients)
32
Histology Coeliac disease
Villous atrophy
Crypt hyperplasia
33
When does Coeliac disease usually present?
In infancy OR 40s - 60s
34
Why is prevalence of coeliac disease increasing?
Changes in endoscopic techniques
Antibody screening
↑Awareness of spectrum of presentation of coeliac disease
35
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)
36
Where is gluten found?
Wheat
Barley
Rye
37
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
38
Antibodies in Coeliac Disease
Anti-TTG - Anti-Tissue Transglutaminase
Anti-EMA - Anti-Endomysial
39
RF Coeliac Disease
Other autoimmune diseases
IgA def
Breast-feeding
Age of gluten introduction into diet
Rotavirus infection in infancy ↑risk
H.Pylori
40
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
41
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
42
Tx Coeliac disease
**Gluten free diet** - strict, lifelong
No barley, wheat, rye
Dietician review - correct vit defs
DEXA scan - osteoporosis risk
43
Comps Coeliac disease
**T-cell lymphoma**
Osteoporosis
Anaemia
Infertility
Hyposplenism
Vit D def - steatorrhoea, night blindness, bruising etc
44
Types of IBD
Crohn's
UC
45
Who does Crohn's most likely affect?
F
20 - 40 years
Northern Europe, UK and North American countries
46
RF Crohn's
FHx - Mutation on NOD2 gene (chromosome 16)
Smoking
Female
Chronic stress
NSAIDs
47
Crohn's : CHRISTMAS
**C**obblestones
**H**igh temp
**R**educed lumen
**I**ntestinal fistulae
**S**kip lesions
**T**ransmural
**M**alabsorption
**A**bdo pain
**S**ubmucosal fibrosis
48
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
49
Comps Crohn's
Small bowel obstruction
Toxic dilation
Abscess formation
Fistulae
Malnutrition
Perforation
Anal - skin tags, fissure, fistula
Neoplasia - colorectal cancer
Amyloidosis - rare
50
DDx Crohn's
Chronic diarrhoea
51
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
52
Tx Crohn's
Lifestyle - quit smoking, optimise nutrition
--
**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
53
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
54
Describe macroscopic features of Crohn's
Skip lesions
Cobblestone appearance (due to ulcers and fissures in mucosa)
Thickened & narrow
55
Describe microscopic features of Crohn's
Transmural - affects all layers of the bowel
Non-caseating granulomas
Goblet cells
56
What are non-caseating granulomas?
Aggregations of epithelioid histiocytes
57
RF UC
FHx
NSAIDs - assoc/ w onset and flares of IBD
Chronic stress, depression triggers flares
58
What rogue thing can relieve UC?
Smoking
59
Describe some macroscopic features of UC
Continuous inflam (no skip lesions)
Ulcers
Pseudo-polyps
60
Describe some microscopic features of UC
Mucosal inflam
No granulomata
Depleted goblets cells
Increase crypt abscesses
61
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
62
Who might UC be found in?
Affects males and females equally
Presents between 15 - 30
Northern Europe, UK and N. America
63
Signs / Symptoms UC
LLQ abdo pain
Fever
Diarrhoea w blood and mucus
Cramps
Rectal tenesmus - incontinence, urgency, bleeding
Tender, distended abdo
Clubbing
Erythema nodosum
64
UC : **ULCERATION**
**U**lcers
**L**arge intestine
**C**arcinoma - risk of
**E**xtra-intestinal manifestations
**R**emnants of older ulcers - psuedo polyps
**A**bscesses in crypts
**T**oxic megacolon - risk of
**I**nflamed, red, granular mucosa
**O**riginates at rectum
**N**eutrophil invasion
**S**tool is bloody and has mucous
65
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
66
Extra-Intestinal Manifestations of UC
**A PIE SAC**
**A**nkylosing Spondylitis
**P**yoderma Gangrenosum
**I**ritis - ant. uvieitis
**E**rythema nodosum
**S**clerosing cholangitis
**A**pthous ulcers / **A**myloidosis
**C**lubbing
67
What should you avoid with Crohn's?
NSAIDs
68
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
69
Where is 5-ASA absorbed?
Small intestine
70
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
71
Define diarrhoea
Abnormal passage of loose or liquid stool more than 3 times daily
72
Define acute diarrhoea
Lasts less than 2 weeks
73
Define chronic diarrhoea
Lasts more than 2 weeks
74
Viral causes of diarrhoea
Most cases are caused by viruses
e.g.
Rotavirus - children
Norovirus - adults
75
Bacterial causes of diarrhoea
Campylobacter
Shigella
Salmonella
C.perfringens
S.aureus
B.cereus
E.coli
C.diff
Parasites (e.g. giardia, crypto)
76
Antibiotic causes of Diarrhoea??
Some abx can give rise to C.Diff diarrhoea
**RULE OF Cs**
**C**lindamycin
**C**iprofloxacin
**C**o-amoxiclav
**C**ephalosporins (esp 2nd + 3rd gen)
77
Infective causes of diarrhoea
Intraluminal infection
Systemic infections e.g. sepsis, malaria
78
Non-infective causes of diarrhoea
Cancer
Chemical e∴g poisoning, sweeteners, s/e
IBS/Malabsorption
Endo e.g. T4
Radiation
79
Mechanism for watery diarrhoea
Non-Inflam
Enterotoxin or superficial adherence/invasion
80
Mechanism for bloody, mucoid diarrhoea
Inflam!
81
Location of watery diarrhoea
Proximal small bowel
82
Location of bloody, mucoid diarrhoea
Colon
83
Bacterial causes of watery diarrhoea
Vibrio cholerae
E.Coli
Clostridium perfringes
Bacillus cereus
S. Aureus
84
Bacterial causes for bloody, mucoid diarrhoea
Shigella
E.Coli
Salmonella enteridis
C.parahaemolyticus
C.diff
C.jejuni
85
Viral causes of watery diarrhoea
Rotavirus
Norovirus
86
Viral causes of bloody, mucoid diarrhoea
N/A
87
Parasitic causes of watery diarrheoa
Giardia
Cryptosporidium
88
Parasitic causes of bloody, mucoid diarrhoea
Entamoeba histolytica
89
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
90
Ix Diarrhoea
HISTORY
Stool tests - culture, faecal calprotein, occult blood, microscopy, cysts, parasites etc
Bloods - FBC, inflam markers (CRP etc), blood culture
91
What is the 1st and 2nd leading causes of death in children globally?
1st - Pneumonia
2md - Infective diarrhoea
92
Where does infective diarrhoea have the highest prevalence?
S.Asia
S.Africa
93
DDx Infective diarrhoea
Appendicitis
IBD
UTI
Coeliac disease
Volvulus
94
RF Infective diarrhoea
Foreign travel
PPI or H2 antagonist use
Crowded use
Poor hygiene
95
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
96
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
97
What bacteria cause bloody stools
E.Coli and shigella ALL cause bloody stools
98
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
99
Diarrhoea red flags?
Dehydration
Electrolyte imbalance
Renal failure
Immunocompromised
Severe abdo pain
100
Quick! Right side abdo pain
First thoughts?
Appendicitis
unless already removed
101
Where is the appendix located?
At McBurney's point
2/3 from umbilicus to anterior superior iliac spine (ASIS)
102
When does appendicitis occur?
Any age
but highest incidence is at 10-20 years
103
Causes appendicitis
OBSTRUCTION
**Faecolith - faeces stones**
Filarial worms
Undigested seeds
Lymphoid hyperplasia
Bacteria - Campylobacter jejuni, Yersinia, salmonella, bacillus cereus
104
Pathophysiology Appendicitis
Appendix is blocked
∴ ↑gut flora
∴ immune response summoned
∴ ↑ WBC
∴ appendix swells and presses against nerves
= ouch
105
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
106
What is Rovsing's sign?
More pain in RIF when LIF is pressed
107
What is Cope sign?
Pain on flexion and internal rotation of R hip
Happens if appendix is close to obturator internus
108
What is Psoas sign?
Pain on extending hip
happens if retrocaecal appendix
109
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
110
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
111
UC Extra-intestinal signs
**A PIE SAC**
**A**nkylosing spondylitis
**P**yoderma gangrenosum
**I**ritis
**E**rythema nodosum
**S**clerosing cholangitis
**A**pthous ulcers/**A**myloidosis
**C**lubbing
112
Comps Appendicitis
Peritonitis - if ruptures
113
Tx Appendicitis
Appendicectomy - usually laparoscopic
can be open surgery if required
114
Causes of Peritonitis
**AEIOU**
**A**ppendicitis
**E**ctopic pregnancy
**I**nfection with TB (bacterial MC)
**O**bstruction
**U**lcer
115
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
116
What is diverticulosis?
When a diverticula is present
117
What is diverticular disease?
When diverticula are symptomatic
118
What is diverticulitis?
When diverticula are inflamed
119
What's a true diverticulum?
Involves all layers of intestinal wall
120
What's a false diverticulum?
Involves only mucosa and submucosa
121
RF Diverticulosis
LOW FIBRE DIET (+ high meat)
Obesity
CONSTIPATION
Smoking
NSAIDs
> 50 years - occur in 50% of people over 50
122
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
123
Signs / Symptoms Diverticulosis
Asymptomatic !!
_Maybe_ erratic bowel habit
Or if severe, intermittent LIF pain + constipation
124
Ix Diverticulosis
Usually detected incidentally w/ colonoscopy or barium enema
125
Tx Diverticulosis
If symptomatic, recommend high fibre diet and smooth muscle relaxants e.g. mebeverine
126
Where is diverticulitis normally found?
Sigmoid colon
127
Pathophysiology Diverticulitis
Occurs when faeces obstructs neck of diverticulum
∴ bacteria multiply
∴ inflammation!!
128
Signs / Symptoms Diverticulitis
Same as appendicitis but **LEFT ILIAC FOSSA**
Severe pain in LIF
Fever
N+V
Rebound tenderness w palpation
ETC
129
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
130
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
131
Symptoms of diverticular disease
AND Diverticulitis
**BBL**
**B**owel habits changed
**B**loating/flatulence
**L**eft lower quadrant pain
If diverticulitis :
All of above
**+** FEVER
**+** Blood in stool
132
Comps Diverticular disease
Infection -> abscess
Bowel perforation
Peritonitis
Haemorrhage
Obstruction
Fistulae (into adjacent organs)
133
What should you not do during an acute attack of diverticulitis?
DO NOT PERFORM COLONOSCOPY OR SIGMOIDOSCOPY
134
What can IBS symptoms be exacerbated by?
Stress
Food
Gastroenteritis
Menstruation
135
Age of onset IBS
< 40 years
136
3 types of IBS
IBS-C - w constipation
IBS-D - w diarrhoea
IBS-M - w both
137
What is Irritable Bowel Syndrome?
Recurrent abdo pain with NO inflammation
138
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
139
Ix IBS
Diagnosis made by ruling out DDx
--
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
140
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
141
What are FODMAPs?
**F**ermentable - carbs brown down in colon
**O**ligosaccharides - wheat, rye, onione, garlic, legumes, lentils, artichokes
**D**isaccharides - lactose! Milk, icecream etc
**M**onosaccharides - Fructose - apples, watermelon, mango, pear, asparagus
**A**nd
**P**olyols - sorbitol, mannitol, gum, cauliflower, fruits, sweets
142
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
143
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
144
2 Types of Oesophageal Cancer
Squamous cell carcinomas
Adenocarcinomas
145
Where is Oesophageal squamous cancer commonly found?
Geographically
Ethiopia
China
South and East Africa
146
Where is Oesophageal adenocarcinoma commonly found?
Geographically
Western countries
147
Causes Oesophageal squamous cancer
↑↑Alcohol
Smoking
Achalasia
Obesity
Smoking
↓Fruit and Veg
148
Cause Oesophageal adenocarcinoma
GORD - Barret's oesophagus!!
Smoking
Obesity
149
Where in the body is Oesophageal squamous cancer found?
Upper 2/3rds of the oesophagus
Middle third MC
150
Where in the body is Oesophageal Adenocarcinoma found?
Lower 1/3rd of oesophagus
151
Pathophysiology of Oesophageal Cancer
Oesophagus - squamous epithelium
Stomach - columnar glandular epithelium
Oesophageal epithelium undergoes metaplasia to stomach epithelium!
152
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
153
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
154
If dysphagia to solids AND liquids at the same time, what does this indicate?
Benign disease
155
Ix Oesophageal cancer
Oesophagoscopy w/ biopsy !!!
Barium swallow - to see strictures
CT/MRI/PET for staging
156
Tx Oesophageal cancer
Surgical resection
w/ adjuvant radio/chemo
Palliative care :(
5 year prognosis is 25%
157
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?
158
Why is prognosis for Oesophageal cancer relatively poor?
Bc symptoms arise so late into disease
159
MC benign oesophageal tumour
Describe it
Leiomyomas
Smooth muscle tumours, arise from oesophageal wall
Intact, well-encapsulated within overlying mucosa
Slow-growing
160
Signs / Symptoms Benign Oesophageal cancer
Asymptomatic - usually found incidentally on barium swallow
Can present w dysphagia, retrosternal pain, food regurg + recurrent chest infections
161
Where does Gastric cancer commonly affect?
Eastern Europe
Asia
162
Causes Gastric Cancer
Unknown
Some link w smoking
163
RF Gastric cancer
Smoking
H. Pylori - bc ↑risk of peptic ulcer
Male
164
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
165
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
166
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
167
Which type of gastric cancer is most common?
Intestinal (80%)
168
Where is intestinal gastric cancer found in the body?
Antrum + lesser curvature
169
Where is diffuse gastric cancer found in the body?
Anywhere in the stomach
Esp cardia
170
RF Intestinal Gastric cancer
Male
Older age
H. Pylori
Chronic or Atrophic Gastritis
171
RF Diffuse Gastric Cancer
Female
< 50 years
Blood type A
Genetics
H. Pylori infection
172
Histology Intestinal Gastric cancer
Well-differentiated
Tubular
173
Histology Diffuse Gastric Cancer
Poorly differentiated
Signet ring cells
174
Pathophysiology Intestinal Gastric cancer
Chronic gastritis -> Atrophic gastritis
∴ intestinal metaplasia and dysplasia
175
Pathophysiology of Diffuse Gastric cancer
Development of linitis plastica (leather bottler stomach)
?
176
Tx Gastric Cancer
Nutritional support!
Surgical resection - can be subtotal or total gastrectomy
+ adjuvant radio/chemo
ECF chemo - Epirubicin + cisplatin + 5-fluororacil
177
Prognosis Gastric cancer
STAGE 1 - 70% 5 year survival
STAGE 4 - 5.5% 5 year survival
178
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
179
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
180
What age is the majority of presentation of colorectal cancer?
> 60 years old
181
RF Colorectal cancer
Age
FHx
IBD
Obesity
DM
Smoking
Alcohol
Genetics - FAP & HNPCC
182
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
183
Where in the body is colorectal cancer most common?
Sigmoid colon
Rectum
184
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)
185
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
186
When does bowel cancer screening happen?
What does it include?
60 - 74 years
Every 2 years
Faecal immunochemical test (FIT)
187
What is Duke's Classification for?
Colorectal cancer
AND THERE IS ALSO ONE FOR INFECTIVE ENDOCARDITIS
188
Tx Colorectal cancer
Surgery -
Endoscopy stenting
Radio/Chemo
189
Which GI cancer is very rare?
Small intestine
usually adenocarcinoma
Usually SI is resistant to neoplasms
190
Tx H. Pylori
Triple therapy - **CAP** !! / CMP
2x a day for 7 days! (NICE guidlines)
**C**larithromycin 500mg + **A**moxicillin 1g + **P**PI
If penicillin allergy, Metronidazole 400 mg instead of amoxicillin
191
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 !)
192
Define an intestinal obstruction
Arrest or blockage of onward propulsion of intestinal contents
193
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
194
2 Types of intestinal obstruction
Mechanical - can be partial or complete
Functional - 'paralytic ileus', disruption of peristalsis
195
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
196
Ix SBO
1. 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
197
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
198
What would you hear on auscultation if there is a mechanical bowel obstruction?
High-pitched tinkling sound
199
What would you hear on auscultation if there is a functional bowel obstruction?
Absence of normal bowel sounds
200
Why does LBO have a greater degree of distension?
Bc the more distal the obstruction, the greater the distension
201
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
202
Comps SBO
Infection - peritonitis
Tissue death - blood supply can be cut off to intestine
203
Causes Large Bowel Obstruction
Malignancy! (90%)
Sigmoid volvulus (5%)
Diverticulitis
Intussusception - more common w children
204
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
205
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
206
Ix LBO
1. 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
207
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
208
What is Pseudo-Obstruction also known as?
Ogilvie syndrome
209
What is Pseudo-Obstruction?
Colonic dilation in the absence of mechanical obstruction
210
Ix Pseudo-Obstrction
1. Abdo XR
Megacolon dilation > 10cm
**GS!!** - ABDO & PELVIC CT W CONTRAST
no transition zone!
211
Causes Pseudo-Obstruction
Post-op
Medications - opioid, CCBs, antideps
Neurological - MS, Parkinson's, Hirschsprung's
Electrolyte imbalance
Recent trauma/surgery
212
Tx Pseudo-Obstruction
'Drip & suck' management
IV neostigmine
Surgical decompression if unstable
213
Pathophysiology Pseudo-Obstruction
Parasympathetic nerve dysfunction
∴ absent smooth muscle
214
Comps Pseudo-Obstruction
Bowel ischaemia
Perforation
215
What is Meckel's Diverticulum?
True diverticulum connected to vitelline duct
216
Diff between True and False diverticulum?
True = ALL Layers, includes muscle
False = does not include muscle
217
What age is Meckel's Diverticulum common?
0-2 years
218
Signs / Symptoms Meckel's Diverticulum
Usually ASx !!!
If _does_ present :
In children - Painless haemotochezia
Intussueption
In adults - Bowel obstruction, unexplained GI bleeding
219
Ix Meckel's
Meckel's Scan
220
DDx Meckel's
Appendicitis - apparently clinically indistinguishable?? but doesnt present w pain?? so i dont get it
221
Tx Meckel's
Usually laparoscopic surgery - removal of diverticulum
222
What is Meckel's also known as?
Pharyngeal pouch
223
Difference microscopically between Coeliac disease and Tropical Sprue
GS for both = Jejunal tissue biopsy
Tropical Sprue = INCOMPLETE villous atrophy
Coeliac = COMPLETE villous atrophy
224
What is Tropical Sprue?
Chronic inflam of the bowel, acquired from the tropics
225
What "tropics" is Tropical Sprue acquired from?
India
South East Asia
Caribbean
226
When should you suspect Tropical Sprue?
Patient is from tropical country
+ has chronic GI/Malabsorptive Symptoms
227
Signs / Symptoms Tropical Sprue
Diarrhoea
Steatorrhoea
Weight loss
Abdo pain
Fatigue
Dehydration
Vit/Iron anaemia
228
Tx Tropical Sprue
Drink treated water
Tetracycline for 6 months
229
RF Acute Mesenteric Ischaemia
AF !!!!!!!!
Cardio risks
230
Classic Triad of Chronic Mesenteric Ischaemia
1. Central Colicky abdo pain _after_ eating
2. Weight loss
3. Abdo bruit - bc turbulent blood flow
231
Ix Chronic Mesenteric Ischaemia
CT W CONTRAST
or ANGIOGRAPHY
232
Pathophysiology Chronic Mesenteric Ischaemia
Same as Angina in heart!
233
Tx Chronic Mesenteric Ischaemia
Lifestyle
2º prevention
Surgery
234
What is Acute Mesenteric Ischaemia?
**MEDICAL EMERGENCY!!**
Blockage of mesenteric arteries/veins
235
Where is the most likely place to be affected in Acute Mesenteric Ischaemia?
Superior mesenteric Artery
∴ Small bowel
236
Causes Acute Mesenteric Ischaemia
Thromboembolism
Vasospasm
Hernia - strangulated
237
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
238
Ix Acute Mesenteric Ischaemia
Bloods - ↑lactate (metabolic acidosis)
1st Line - CT w contrast / Angiography
**GS!!!** - COLONOSCOPY
239
Tx Acute Mesenteric Ischaemia
ABx
+ Anticoags e.g. heparin
+ Surgery
240
What is Mallory-Weiss Tear?
Linear mucosal tear at the oesophagogastric junction
241
Cause Mallory-Weiss Tear
Sudden increase in intra-abdo pressure
e.g.
Vomiting
Coughing
Retching
242
RF Mallory-Weiss Tear
Alcoholism
Forceful vomiting
Eating disorders
NSAID abuse
Male
243
Signs / Symptoms Mallory-Weiss Tear
Vomiting
Abdo pain
Haematemesis
Retching
Postural hypotension
Dizziness
Melaena
244
Ix Mallory-Weiss Tear
Endoscopy
245
Tx Mallory-Weiss Tear
Most bleeds are minor, heal in 24 hours
Surgery if req
246
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
