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GI - 2 Flashcards

1
Q

Definition of GORD

A

oesophageal pH <4 for >4% for a 24hr period on pH monitoring; issues with oesophageal clearance, LOS competence, gastric clearance
Regurgitation of acidic gastric contents into the lower oesophagus → acid injures squamous epithelium → inflammation (reflux oesophagitis)

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2
Q

RF of GORD

A 
Obesity 
Pregnancy
Smoking
Alcohol
Consumption
Hiatus hernia 
Ca-blockers, nitrates
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3
Q

Clinical presentation of GORD

A 
Regurgitation of acid contents into the mouth
Oesophagitis (heart burn)
Barrett's oesophagus
Stricture
Bleeding
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4
Q

SSx of GORD

A 
Heartburn
Belching
Acid brash
Water brash
Odynophagia 
Nocturnal asthma
Chronic cough, laryngitis, sinusitis
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5
Q

Complications of GORD

A

Oesophagitis, ulcers, benign stricture, Fe deficiency, Barrett’s oesophagus

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6
Q

Ix GORD

A

hx, OGD + biopsy (quadrantic biopsies - i.e. 4x, one from each quarter of oesophagus at 2cm intervals), pH monitoring, manometry, barium swallow (may show hiatus hernia)

Urgent endoscopy: ALARMS - Anaemia, loss of weight, anorexia, recent onset of progressive symptoms, melena or haemoptysis, swallowing difficulty

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7
Q

Rx GORD

A

Conservative: weight loss, alcohol, smoking, prop up @ night, small regular meals. Avoid hot drinks, alcohol, spocy food, caffeine eating before bed, drugs impacting contractility or damaging mucosa (nitrates, anti-cholinergic’s, Ca channel blockers // NSAIDS, K+ salts, bisphosphonate)
Medical: antacids, PPI, H2 antagonists, metoclopramide
Surgical: Nissen;s fundoplication, aim to resting lower oesophageal sphincter

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8
Q

Barrett’s oesophagus

A

metaplastic process as an adaptive response to prolonged injury by GORD in lower oesophageal mucosa
One mature cell type replaced with another, adaptive, potentially reversible, predisposes dysplasia (pre-malignant). Asymptomatic, identified via OGD for upper GI symtoms

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9
Q

Barrett’s to carcinoma

A

<2% pts with Barrett’s oesophagus

metaplastic columnar epithelium -> dysplasia -> invasive adenocarcinoma

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10
Q

SSx oesophageal cancer

A

asymptomatic OR dysphagia/painful swallowing, weight loss, retrosternal chest pain, indigestion, coughing/ hoarseness, recurrent laryngeal nerve palsy, haematemesis, aspiration pneumonia
Dysphagia: progresses from solids to liquids
Weight loss & other non-specific symptoms

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11
Q

Ix and staging of oesophageal cancer

A

OGD, biopsy, barium swallow, endoscopic US

Staging: OGD, CT chest/abdo, PET CT, endoscopic US, bronchoscopy, analysis of gene expression profiles

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12
Q

Types of oesophageal cancer

A 
Typically middle (50%), lower (30%), upper (20%)
Usually: adenocarcinoma. Barrett's, GORD, smoking, obesity, lower 1/3rd
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13
Q

Benign tumours of the oesophagus

A

Leiomyoma

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14
Q

SCC of oesophagus

A

2nd most common oesophageal cancer in the UK

Arises from native oesophageal squamous epithelium. RF smoking, alcohol, achalasia

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15
Q

Rx oesophageal cancer

A

Surgery: pts with no mts and resectable cancer. McKeown / Ivor Lewis oesophagectomy
Non-surgical: endoscopic Rx (ESD), endoscopic ablation therapies
Palliation: stenting, chemo/radiotherapy, laser therapy

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16
Q

Motility disorders causing dysphagia

A

Bulbar palsy (stroke, MND)
Diffuse esophageal spasm
Achalasia
Systemic sclerosis

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17
Q

Mechanical / structural disorders causing dysphagia

A

Liquids easier than solids, constant, neck bulges / gurgles on drinking
Oesophageal ca, benign stricture, cricoid web, extrinsic pressure (bronchial ca, AA, goitre, LA enlargement MS), pharyngeal pouch

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18
Q

Causes of odynophagia

A

Painful swallowing
Inflammation: reflux oesophagitis, peptic oesophageal ulceration
Infection: thrush, Herpes, viral/ bacterial pharnygitis
Spasm: diffuse oesophageal spasm
Ix: hx, exam, OGD, barium swallow, manometry, pH studies, CT

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19
Q

Pharyngeal pouch

Definition, SSx, Ix, Rx

A

Diverticulim of mucosa of the pharynx causing dysphagia, gurgling on swallowing, halitosis
Ix: barium swallow, OGD, CT
Rx: leave if asymptomatic, if large - endoscopic stapling, fibre-optic diverticulum repair

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20
Q

Achalasia definition, SSx, Ix, Rx

A

Increased resting tone to LOS, failure to relax, high resting pressure, poor generalised peristalsis of oesophagus
SSx: dysphagia, regurgitation of all food, retrosternal chest pain on and off, weight loss, pre-synope
Ix: CXR, OGD, barium swallow, manometry
Rx: lifestyle, nifedipine, balloon dilation, botox to LOS, Heller’s cardiomyotomy

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21
Q

Diffuse oesophageal spasm

A

Intermittent, hard to diagnose, causes significant retrosternal pain
Ix: OGD, barium swallow, manometry
Nifedipine

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22
Q

Definition of peptic ulcer

A

Breach in mucosa through muscularis propria of GI tract which fails to heal over a reasonable amount of time
Most commonly gastric antrum / proximal duodenum

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23
Q

Pathophysiology of PUD

A 
Chronic inflammation (tissue injury at surface, ongoing inflammatory response, attempts to heal by fibrosis)
Normal mucosal defect mechanisms, peptic ulcers occur by weakened defence mechanisms or increase acid attack (Zollinger-Ellison syndrome, H. pylori, shock)
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24
Q

RF PUD

A 
H. pylori
NSAIDs
Alcohol
Smoking
Acidic foods
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25
SSX PUD
reflux, recurrent epigastric burning / chest pain, heart burn related to eating, fullness / bloating, N&V hours after meal, dyspepsia, haematemesis melena, generalised abdo pain, guarding, rebound tenderness, cough test
26
ALARM features
``` Anaemia Loss of weight Anorexia Recent onset progressive dysphagia Melena / haematemesis Swallowing difficulty ```
27
Complications of PUD
Bleeding: melena / heamatemesis Perforation: ulcers erode through all layers of wall -> peritonitis Stricture: formation due to healing of ulcer by fibrosis Malignant change: rare
28
Gastric vs duodenal ulcer
G: pain on eating and thinking about eating, GU oozes blood, causing gastritis, can cause gastric outlet obstruction. Typically elderly, on lesser curve D: better with eating, pain before meals, 4x more common than GU
29
Ix PUD
fBC, U&E, LFT, CRP OGD +/- biopsy, CXR/AXR H. pylori testing Serum IgG, raised urease, CLO, urea breath test, faecal stool antigen test Biopsy Fasting serum gastrin level if Zollinger-Ellison syndrome suspected
30
Rx PUD
C: weight loss, smoking cessation/ drinking, NSAIDS, avoid acidic food M: H pylori triple therapy (omeprazole/ amoxicillin / clarithromycin) Anti secretory therapy: PPI / H2 blockers OTC antacids S: perforation, bleeding, obstruction Follow up rescope in 6wks
31
Presentation of gastritis
Epigastric pain Vomiting Haematemesis
32
Causes of gastritis
``` Alcohol NSAIDs H. pylori reflux Hiatus hernia atrophic gastritis Granulomas (Crohn's, sarcoidosis) CMV, Zollinger Ellison ```
33
Prevention, diagnosis and treatment of gastritis
P - PPI gastroprotection with NSAIDs D - endoscopy and biopsy Rx - ranitidine or PPI, eradicate H. pylori
34
Epidemiology of gastric cancer
>50s M>F Incidence has fallen in West due to falling H. pylori and improved diet
35
RF gastric cancer
H. pylori infection & chronic ulcers (but remember, most people with H pylori infection will not develop cancer). Cigarette smoking. Alcohol. Diet (food with nitrates/nitrite components; salt-based preservatives), obesity Chronic atrophic gastritis and pernicious anaemia Barrett's oesophagus Previous gastric resection/ radiation therapy Adenomatous gastric polyposis
36
Clinical presentation of gastric cancer
``` Dyspepsia Unintentional weight loss Progressive dyphaia Epigastric pain Vomiting Early satiety Occult GI bleeding Virchow's node ```
37
Spread of gastric cancer
Direct - pancreas, colon, liver LNs Blood (lung, bone) Trans-peritoneal
38
Ix gastric cancer
OGD and biopsy, barium studies, CT chest / abdo endoscopic US, PET
39
Rx gastric cancer
Resection if caught early
40
What happens to the liver in cirrhosis
Increased fibrosis, shrinkage, decreased hepatocellular function, obstruction of bile flow
41
Definition of jaundice
- Yellowing of the skin, sclerae, mucosae from increased plasma bilirubin (visible at >60umol/L – normal serum bilirubin is <17umol/L, excess is clinically detectable >35umol/L)
42
Causes of jaundice in previously stable cirrhosis pt
Sepsis Malignancy Alcohol / drugs GI bleeding
43
Important Hx points in jaundiced patient
``` Transfusions IV drugs Piercings Tattoos Sexual activity FHx Alcohol Medications ```
44
Ix jaundice
Screening tests for suspected liver disease Urine: bilirubin absent in pre-hepatic Haem: FBC, clotting film, reticulocyte count, coomb's test, haptoglobulins, malaria parisites, EBV Chem: U&E, LFTs, Gamma-GT, total protein, albumin, paracetamol Microbiology: blood anf other cultures, serology Imaging: US, ERCP, MRCP, liver biopsy, CT/MRI for abdominal malignancy
45
Pre-hepatic jaundice
Excess bilirubin presented to liver Unconjugated, hyperbilirubinaemia, water insoluble (doesn't enter urine), sickle cell crisis, blood transfusion, haemolytic drugs / anaemia Normal coloured urine, +++ urobilinogen, normal / dark stools, no pruritus, normal LFTs
46
Hepatocellular jaundice
Cannot conjugate bilirubin, leaks conjugated bilirubin initially - so both can be elevated in serum Caused by hepatitis, cirrhosis, hepatic carcinoma / mets, drugs, sepsis, liver abscess, budd chiari Dark urine, + urobilinogen, ++ conjugated bilirubin + bile salt Normal stools, high AST/ALT
47
Post-hepatic jaundice
Intra/extra-hepatic causes (e.g. impaired hepatic excretion - choleasis) Conjugated hyperbilirubinaemia Gallstone in CBD Malignancy (head of pancreas) Inflammation (cirrhosis, sclerosis, cholangitis) Drugs Biliary atresia
48
Causes of hepatitis
Viral Drugs Alcohol Autoimmune
49
SSx Hepatitis
Fever, malaise, N&V, arthralgia, hepatomegaly, pain, jaundice
50
Ix hepatitis
Antibodies, elevated ALT/AST to 1,000s, typical lymphocytosis, viral serology
51
Autoimmune hepatitis
Acute hepatitis and signs of autoimmune disease Fever, malaise, urticarial rash, polyarthritis, pleurisy, pulmonary infiltration, glomerulonephritis Anti-smooth muscle antibodies Rx: Prednisolone, azathioprine, liver transplant in decompensated cirrhosis
52
Hepatitis A
ssRNA virus F-O transmission Rare, blood products Acute and mild incubation 15-50d Ix HAV IgM antibody (active) or IgG (recovery / vaccination) Prevention: hygiene, 7d isolation, vaccine available, pre/post- exposure
53
Hepatitis E
``` ssRNA virus Pregnant women most susceptible - high mortality F-O transmission HEV IgM and IgG No vaccine, no Rx ```
54
Hepatitis C
``` ssRNA virus chronic liver changes Blood transmission Incubation 14-180d HCV RNA using PCR IgI on enzyme immunoassay No vaccine, curable in some, antivirals / interferon free treatment ```
55
Hepatitis B
ds DNA virus Most common cause of hepatocellular Blood transmission Pre-exposure vaccine available
56
Definition of cirrhosis
Irreversible chronic scarring / fibrosis and damage do to chronic hepatic injury
57
Causes of cirrhosis
Alcohol NAFLD viral hepatitis Genetic: haemochromatosis, wilson's, a1-antitrypsin deficiency Autoimmune: 1o billiary sclerosis, 1o sclerosing cholangitis udd chiari CCF, schostosomiasis, parenteral nutrition related Drugs: amiodarone, methlydopa, methotrexate
58
SSx cirrhosis
ascites, splenomegaly, porto-systemic shunts, hepatorenal failure (renal vasoconstriction, decreased perfusion), reduced liver function Hepatic encephalopathy Metabolism of oestrogen (gynaecomastia, palmar erythema) Bilirubin conjugation - jaundice Albumin production - hypoalbuminaemia Clotting factor production Portal hypertension
59
Ix cirrhosis
Bloods | Full liver pane including autoantibodies, liver US and duplex MRI, ascitic tap
60
Rx cirrhosis
Nutrition, alcohol abstinence, avoid NSAIs, sedatives and opiates Cholestyramine helps pruritus Ursodeoxycholic acid for hepatitis induced cirrhosis & 1o biliary cirrhosis (normalises LFTs but nor impact on progression) Penicillamine for Wilson's Spironolactone, fluid restriction (add furosemide if poor response) for ascites SBP Rx: cefotaxime or tazosin Manage renal failure HCC screening
61
Tool for prognosis in cirrhosis
Child-Pugh score | Bilirubin, serum albumin, INR, ascitis, encephalopathy
62
Alcohol metabolism
Less fatty acid oxidation and NADH making more fatty acids - increased fat production, hepatic steatosis ROS - protein and DNA damage Acetaldehyde Stop alcohol, steroids to immunosuppress
63
NAFLD
Steatosis +/- steatohepatitis 20% in gen pop, 70% in T2DM RF: obesity, DM, paerenteral feeding, JI bypass, Wilson's drugs Rx: control RF, bariatric surgery
64
RF pancreatic cancer
smoking, alcohol, carcinogens, DM, chronic pancreatitis, obesity KRAS2 mutation
65
common pancreatic cancer
adenocarcinoma of glandular duct cells that line ducts of exocrine system 60% in head, 25% in body Elderly males
66
Clinical presentation of pancreatic cancer
``` Obstructive jaundice Weight loss Mid epigastric pain Palpable gall bladder Epigastric mass ```
67
Ix pancreatic cancer
``` Bloods - Ca19-9 Us - dilated bile ducts Distended gall bladder CT Endoscopy MRCP/ERCP ```
68
Rx pancreatic cancer
most present with metastatic disease <20% suitable for radical surgery Palliative: chemotherapy, stenting the common bile duct to relieve jaundice and optimising symptom control Curative: Whipple’s procedure (tumour confined to the pancreas and lymph nodes are not involved) Whipple’s Pancreatico-duodenectomy Distal stomach, gallbladder, CBD, head of pancreas, duodenum, proximal jejunum and regional lymph nodes are resected o5yr survival 20-40% are Whipple’s (vs 5% without – including those with advanced disease)
69
Insulinoma
B cell tumour 90% are benign SSx: hypoglycaemia Ix: insulin levels, C-peptide, CT/MRI, endoscopic US Rx: tumour excision (Whipple / distal pancreatectomy)
70
Whipples triad
Hypoglycaemia During starvation Relieved by sugar
71
Crohn's vs UC | NESTS vs CLOSE UP
NESTS vs CLOSEUP No blood or mucus, entire GI tract, skip lesions on endoscopy, terminal ileum mist affected, transmural (full thickness), smoking is a risk factor Continuous inflammation, limited to colon and rectum, only superficial muscosa affected, smoking is protective, excrete blood and mucus, use aminosalicyclates, primary sclerosing cholangitis
72
How does IBD present?
diarrhoea abdo pain Passing blood Weight loss
73
Ix for IBD
``` Routine bloods for anaemia, infection, thyroid, kidney, liver function CRP Faecal calprotectin Stool MC&S AXR Endoscopy (OGD/colonoscopy) with biopsy US, CT, MRI for complications ```
74
Rx crohn's
Inducing remission - steroids, if unsuccessful add immunosuppressant Maintaining remission - e.g. azathioprine Surgery - when disease only affects distal ileum this area can be surgically resected to prevent further flares. Can also treat 2o strictures and fistulas
75
Rx UC
Inducing remission: aminosalicyclates / corticosteroids / ciclosporin Maintaining remission: aminosalicyclate, azathioprine Surgery: Removal of the colon and rectum, leaving either a permanent ileostomy / ileo-anal anastomosis (J-pouch).
76
Truelove and Witt's criteria
Rectal bleeding, temperature, HR, BPM, Hb, ESR | Mild/ moderate/ severe
77
Why image in crohn's
``` Diagnosis Extent and severity Treatment response Complications Surgical planning ```
78
What is IBS?
A functional disorder - no inflammation, ulcers or damage to bowel Abnormal functioning of otherwise normal bowel
79
SSx IBS?
``` Diarrhoea Constipation Fluctuating bowel habit Abdo pain Bloating Worse after eating Improved by opening bowels ```
80
Ix IBS?
Other pathology should be excluded Normal FBC, ESR, CRP Faecal calprotectin negative, negative anti-TTG antibodies cancer not suspected / excluded
81
Rx IBS?
General healthy diet and exercise - adequate fluid, regular small meals, low produced foods, limit caffeine and alcohol, low FODMAP, probiotics 1st line - loperamide for diarrhoea, laxatives for constipation, antispasmodics for cramp 2nd line - tricyclic antidepressants (amitriptyline) 3rd line - SSRIs CBT
82
SSx malabsorption syndrome
Diarrhoea, weight loss, lethargy, steatorrhoea, bloating, signs of deficiency (anaemia, bleeding disorders, oedema, metabolic bone disease, neurological features)
83
Ix malabsorption syndrome
Bloods – FBC, low Ca / Fe / B12 / folate, high INR, lipid profile, coeliac profile Stool – analyse for fat, MC&S, a1-AT Breath hydrogen analysis for bacterial overgrowth Endoscopy and small bowel biopsy, ERCP
84
Causes of malabsorption syndrome
Coeliac, chronic pancreatitis, Crohn’s Low bile - 1o biliary cirrhosis, ileal resection, biliary obstruction Pancreatic insufficiency - pancreatic cancer, CF Small bowel mucosa - Whipple's disease, radiation enteritis, tropical sprue, bowel resection, brush border enzyme deficiencies, drugs (metformin, neomycin, alcohol), amyloid Bacterial overgrowth - DM & PPI are risk factors Infection - giardiasis, diphyllobothriasis, strongyloidiasis Intestinal hurry - post-gastrectomy dumping

Gastrointestinal (2 decks)

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