GI 3 Flashcards
What are some systemic causes of a solitary oral ulcer?
- Trauma - physical/chemical
- Malignancy - oral squamous cell carcinoma
- Infective - tuberculosis/syphilis
What are some causes of multiple ulcers?
- Recurrent aphthous ulceration (RAU)
- Bechets
- Anaemia
- Herpes -> primary herpetiform gingivo-stomatitis
- Mucotaneous disorders
What is recurrent aphthous ulceration (RAU)?
- Unknown aetiology
- Most common cause of multiple ulcers
- Patient usually otherwise well; stress related
- 3 types: major/minor/herpetiform
What is Bechets?
Hereditary systemic vasculitis -> multisystem condition; other systemic features (genital ulceration, uveitis, erythema nodosum)
What are the oral symptoms of anaemia?
- Mucosal pallor
- Angular chelitis
- Oral ulceration
- Predisposal to candida (thrush)
- Glossitis
- Disturbed
What are some mucocutaneous disorders?
- Lichen Planus
- Lupus erythematosus
- Vesiculobullous disease - pemphigus and pemphigoid
What is lichen planus?
Systemic rash; bilateral, asymptomatic, potentially malignant
What is lupus erythematosus?
Discoid or systemic; oral ulceration; red and white patches similar to lichen planus
What is pemphigus vesiculobullous disease (VBD)?
- Intraepithelial bullae
- Oral lesions first manifestations (50-80%)
- Oral lesions precede skin lesions by 1 year
- Painful extensive oral ulceration preceded by blisters which rupture easily
- Nikolsky sign
What is pemphigoid vesiculobullous disease (VBD)?
- Sub-epithelial bullae
- Blisters more likely to be observed
- Painful oral ulceration
- Affects mucous membranes of other organs e.g. eyes
What are some GI diseases which produce oral manifestations?
- Malabsorption -> hematinic deficiency
- Crohn’s
- Ulcerative colitis
- Peutz Jeghers
- Gardeners syndrome
What are the oral manifestations of Crohns disease?
- Present in 0.5-20% of cases
- May precede abdominal symptoms; do not correlate with intestinal activity
- Cobble-stoning of mucosa
- Localised mucogingivitis
- Linear ulceration
- Tissue tags/polyps
- Diffuse swelling – commonly of the lips
- Pyostomatitis vegetans
What are the oral manifestations in ulcerative colitis?
- Reflects severity of disease - exacerbation and remission
- Oral ulceration
- Pyostomatitis vegetans
- Angular stomatitis
What are the causes of oral white patches?
- Those that wipe off -> usually pseudomembranous candidiasis/thrush
- Those that don’t -> trauma, neoplasia, epithelial dysplasia, chronic mucocutaneous candidiasis
- Consider underlying haematinic deficiency or immunosuppression
What are some causes of oral pigmentation?
- Racial pigmentation
- Melatonic macules
- Smoking
- Malignancy
- Addison’s disease
What are some causes of xerostomia (dry mouth)?
1) Drugs
2) Sjogren’s syndrome
3) Radiation therapy
What is Sjogrens syndrome?
- Dry eyes and mouth, most common in females
- Primary/secondary (2nd associated with autoimmune)
- Enlarged salivary glands
- Xerostomia -> increased caries, depapillated/fissured tongue, red dry wrinkled mucosa, ↑ predisposition to candida
What are the oral manifestations that occur with leukaemia?
- Gingival enlargement/bogginess
- Petechiae
- Mucosal bleeding
- Ulceration
- Infiltration by malignant cells
- Immunocompromise -> candida, herpes, opportunistic infection
What are the oral manifestation that occur with lymphoma?
- Palpable lymph nodes
- Extra/intraoral diffuse swellings
- Ulceration
- Tooth migration/mobility
What are some oral manifestations that occur with HIV?
- Ulceration
- Kaposi’s sarcoma
- HPV lesions
- Salivary gland swelling
- Increased risk of malignancy
What are the 3 types of inflammatory disorders of the oesophagus?
1) Acute oesophagitis
2) Chronic/reflux oesophagitis
3) Allergic (eosinophilic) oesophagitis
What is allergic (eosinophilic) oesophagitis?
- Oesophageal inflammation due to personal/family history of allergy
- Common in asthma, children, males
- pH probe negative for reflux, increased eosinophils in blood
- Corrugated or spotty oesophagus
- Treatment w steroids/montelukast/chromoglycate
What is oesophageal squamous papilloma?
- Benign oesophageal tumour
- Rare, asymptomatic
- HPV related
What are some causes of oesophageal squamous cell carcinoma?
- Vitamin A/zinc deficiency
- Tannic acid, strong tea, smoking/alcohol
- HPV
- Oesophagitis
- Genetic factors
How do oral squamous cell carcinomas present?
- White/red/speckled ulcer or lump
- High risk sites: floor of mouth, lateral border/ventral tongue, soft palate, retromolar pad/tonsillar pillars
- Rare on hard palate, dorm of tongue
- 5 year survival 40-50%
What are the inflammatory disorders of the stomach?
- Acute gastritis
- Chronic gastritis
- Rare = lymphocytic, eosinophilic, granulomatous
What are some causes of acute gastritis?
- Severe burns
- Shock
- Severe trauma
- Head injury
What are the different causes for chronic gastritis?
- Bacterial (H Pylori)
- Autoimmune
- Chemical
What is H pylori associated chronic gastritis?
- Most common chronic gastritis
- Bacteria inhabits a niche between epithelial cell surface and mucous barrier
- Gram negative curvilinear rod excites early acute inflammatory response
- If not cleared -> chronic active inflammation
- Increased risk of gastric+duodenal ulcers and gastric lymphoma and carcinoma
What is chemical gastritis?
- Due to NSAIDs, alcohol and bile reflux
- Direct injury to mucus layer by fat solvents
- Marked epithelial regeneration, hyperplasia, congestion and little inflammation
- May produce erosions or ulcers
What is the definition of peptic ulceration?
A breach in the gastrointestinal mucosa as a result of acid and pepsin attack
What are the causes of gastric adenocarcinomas?
1) H pylori infection
2) Pernicious anaemia
3) Partial gastrectomy
4) Lynch syndrome
5) Menetrier’s disease
What are the two types of small bowel ischaemia?
1) Mesenteric arterial occlusion
2) Non-occlusive perfusion insufficiency
What are the two causes of mesenteric arterial occlusion leading to small bowel ischaemia?
1) Mesenteric artery atherosclerosis
2) Thromboembolism from the heart
What are the four causes of non-occlusive perfusion insufficiency leading to small bowel ischaemia?
1) Shock
2) Strangulation obstructing venous return (e.g. hernia, adhesion)
3) Drugs e.g. cocaine
4) Hyper-viscosity
What are the outcomes of small bowel ischaemia?
1) Mucosal infarct -> regeneration
2) Mural infarct -> fibrous stricture
3) Transmural infarct -> gangrene
What are the complications of small bowel ischaemia?
- Fibrosis, stricture; fibrous stricture
- Chronic ischaemia
- Mesenteric angina
- Obstruction
- Gangrene
- Perforation
- Peritonitis
- Sepsis
- Death
What is Meckel’s Diverticulum?
- Result of incomplete regression of vitello-intestinal duct
- May cause bleeding, perforation or diverticulitis which mimics appendicitis
- Commonly assymptomatic, incidental finding
What tumours are found in the small bowel?
- Mostly secondary; primary very rare
- Lymphomas
- Carcinoid tumours
- Carcinomas
What are carcinoid tumours of the small bowel?
- Rare, commonest site is the appendix
- Small, yellow, slow-growing, locally invasive
- Can cause intussusception, obstruction
- Produce hormone like substances
- Metastases to liver -> carcinoid syndrome (flushing, diarrhoea)
What do carcinomas look like in the small bowel?
- Very rare, associated with Crohn’s and Coeliac
- Identical to colorectal carcinoma in appearance
- Presents late
- Metastases to lymph nodes and liver occur
What are the causes of acute appendicitis?
- Mostly unknown
- Faecoliths (dehydration)
- Lymphoid hyperplasia
- Parasites
- Tumours (rare)
What is the pathology behind acute appendicitis?
- Acute inflammation (neutrophils); must involve muscle coat
- Mucosal ulceration
- Serosal congestion, exudate
- Pus in lumen
What are the complications of appendicitis?
1) Peritonitis
2) Rupture
3) Abscess
4) Fistula
5) Sepsis and liver abscess
What is Coeliac’s disease?
An abnormal reaction to a constituent of wheat flour, gluten, which damages enterocytes and reduces absorptive capacity
What are the metabolic effects of Coeliac’s disease?
- Malabsorption of sugars, fats, amino acids, water and electrolytes
- Malabsorption of fats -> steatorrhea
- Reduced intestinal hormone production leads to reduced pancreatic secretion and bile flow (CCK) leading to gall stones
What are the complication of Coeliac’s disease?
- Malabsorption -> weight loss, anaemia, vitamin deficiencies, abdominal bloating, failure to thrive
- T cell lymphomas of the GI tract
- Increased risk of small bowel carcinoma
- Gall stone
- Ulcerative-jejunoilleitis
What is dyspepsia?
Collection of symptoms causing epigastric discomfort
What are the GI ALARM Signs?
- Anaemia
- Loss of weight
- Anorexia
- Recent onset/progressive symptoms
- Malaena/haematemesis
- Swallowing difficulty
What is the diagnostic criteria for functional dyspepsia?
Presence of one of these symptoms for last 3 months:
- Bothersome postprandial fullness
- Early satiation
- Epigastric pain
- Epigastric burning
What are the risk factors for oral premalignancy?
- Tobacco and alcohol
- Diet and nutrition (low vitamin A, C and iron)
- HPV, candida, syphilis
- Dental factors
Where is an oral malignancy likely to be found?
Soft, non-keratinising sites (e.g. ventral/lateral tongue, floor of mouth)
What are the warning signs for oral cancer?
- Red/white or red+white lesion
- Ulcer (exclude trauma, drug, systemic etc)
- Numb feeling (e.g. lip or face)
- Unexplained pain in mouth or neck
- Change in voice
- Dysphagia
- Double vision
- Drooping eyelid or facial palsy
- Blocked or bleeding nose
- Facial swelling
What sites does Crohn’s disease commonly affect?
- 2/3 of patients -> small bowel only
- 1/6 of patients -> colonic/anal disease only
- 1/6 of patients -> both
- Variable involvement of stomach, oesophagus and mouth
What are the differences between Crohn’s disease and ulcerative colitis?
1) C - anywhere in GI tract; UC - colon and rectum
2) C - skip lesions; UC - no skip lesions
3) C - thickened bowel and stricture; UC - thin walls
4) C - transmural inflammation; UC - superficial
5) C - granulomas present; UC - no granulomas
6) C - fistulae common; UC - fistulae rare
7) C - cancer risk moderate; UC - cancer risk high
8) C - extra GI rare; UC - extra GI common
What’s the difference between acute mesenteric ischaemia of the small and large bowel?
- Small bowel -> dies
- Colon -> survives due to marginal artery
What are the clinical signs of mesenteric ischaemia?
- Pain out of proportion to the clinical findings
- Acidosis on gases
- Lactate elevated
- CRP may be normal
- WCC slightly elevates
How is mesenteric ischaemia fixed?
- Must be quick
- If non-viable resect, re-anastamose, staple and planned return
- If viable, can rarely preform SMA embolectomy
- Sometimes may have an open and close surgery
What are the different malabsorptive states?
- Protein
- Fat
- Carbohydrate
- Vitamins and minerals
What is malabsorption?
Defective muscosal absorption caused by:
1) Defective luminal digestion
2) Mucosal disease
3) Structural disorders
What are some common causes of malabsorption?
- Coeliac disease
- Crohn’s disease
- Biliary obstruction
- Cirrhosis
- Post infectious
- Rare: short bowel, drugs, bacterial overgrowth, parasites and pancreatic cancer
What specific disease states cause malabsorption?
- Coeliac disease
- Whipple’s disease
- Crohn’s disease
- Parasitic infections
- Small bowel bacterial overgrowth
What is tropical sprue?
Colonisation of the intestine by an infectious agent or alterations in the intestinal bacterial flora induced by the exposure to another environmental agent
What are the baseline investigations for malabsorption?
- FBC
- Coagulations
- LFTs
- Albumin
- Calcium/magnesium
- Stool culture
What is malnutrition?
A state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue, body form (body shape, size and composition), function and clinical outcome
What are the disease related causes of malnutrition?
- Decreased intake
- Impaired digestion and/or absorption
- Increased nutritional requirements
- Increased nutrient losses
What are the effects of chronic malnutrition?
- GI dysfunction
- Increase in infection rate
- Impaired immune response
- Reduced muscle strength (+resp muscles) + fatigue
- Decrease in wound healing
- Physical weakness
- Water and electrolytes disturbances
- Impaired thermoregulation
- Menstrual abnormalities/amenorrhea
- Increase in LOS pressure
What GI diseases can cause weight loss?
1) Impaired GI motility
2) Intra-abdominal infection
3) Crohn’s disease
4) Coeliac’s disease
5) Acute liver disease
6) Cancer
How is nutrition support provided?
- Food fortification & dietary counselling
- Oral nutrition support
- Enteral tube feeding
- Parenteral nutrition (IV)
Who needs nutritional support?
- BMI <18.5
- Unintentional weight loss >10% within the last 3–6 months
- BMI <20 and unintentional weight loss >5% within the last 3–6 months
- Have eaten or are likely to eat little or nothing for more than 5 days or longer
- Poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism
What are some features of refeeding syndrome?
- Metabolic: hypo-kalaemia/phosphataemia/magnesiaemia, altered glucose metabolism, fluid overload
- Physiological: arrhythmia, ↓GCS, seizure, respiratory failure, cardiovascular collapse, death
What is intestinal failure?
The reduction in function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes such that intravenous supplementation is required to maintain health and/or growth.
What are the different types of intestinal failure?
1) Type 1 (acute, 2 wks) - self-limiting intestinal failure (surgical ileus, critical illness or GI problems)
2) Type 2 (acute, 4 wks) - significant & prolonged PN support (post surgery awaiting reconstruction)
3) Type 3 (chronic) - SBS, Crohn’s, radiation, dysmotility, malabsorption, inoperable obstruction
What are some complications of parenteral nutrition?
- SVC thrombosis
- Sepsis
- Line fracture/leakage/migration
- Metabolic bone disease
- Nutrient toxicity/insufficiency
- Liver/metabolic disturbance
- Psycho-social
- Inappropriate usage
