GI Flashcards
What is gastro-oesophageal reflux disease (GORD)?
condition which develops when reflux of stomach contents causes symptoms/complications
What is the cause of GORD?
dysfunction of the lower oesophageal sphincter
What are some risk factors for GORD?
raised intra-abdominal pressure (hiatus hernia, obesity, pregnancy)
too much acid (gastric acid hypersecretion, delayed gastric emptying, overeatting)
smoking
What are the symptoms of GORD?
heartburn - restrosternal pain, worse on lying down and eating
belching, acid brash, water brash odynophagia, nocturnal asthma, chronic cough, larygnitis
What are some possible complications of GORD?
Barretts oesophagus, oesophageal adenocarcinoma, ulcers, oesophagitis,
What investigations would you do if you suspected GORD?
barium swallow, manometry upper GI endoscopy if: ->55yrs -symptoms >4wks -persistent after treatment -associated weight loss
How would you treat GORD?
lifestyle - weight loss, raise head in bed, small meals, avoid food triggers (hot, spicy, fatty, acidic etc)
drugs - antacids, alginates, PPI (for oesophagitis)
surgery - where symptoms severe even with medication
What is the most common cause of peptic ulcers?
H pylori (90% of duodenal and 80% of gastric)
What are some risk factors for peptic ulcers?
NSAIDs, delayed gastric emptying, gastric acid hypersecretion, smoking
What are the symptoms of peptic ulcers?
epigastric pain (worse before meals) can be asymptomatic
What are the signs of peptic ulcers?
often nothing on examination but may be epigastric tenderness
What investigations would you do if you suspected a peptic ulcer?
upper GI endoscopy (stop PPI 2 weeks before)
H pylori testing
What treatment would you give for peptic ulcers?
lifestyle - avoid foods which irritate it, smoking cessation
H pylori eradication - omeprazole + clarythromycin + amoxicillin (/metronidazole in pen allergy)
drugs - PPI (or H2 agonist)
What are the possible complications of a peptic ulcer?
bleeding, perforation, malignancy
Are upper of lower GI bleeds more common?
upper
What are some possible causes of GI bleeds?
peptic ulcer, Mallary Weiss tears, oesophageal varices, NSAIDs/aspirin/anticoagulants, malignancy
What are symptoms of an acute GI bleed?
haematemesis, melaena, weight loss
What are signs of an acute GI bleed?
peripherally shut down (cool, clammy, slow cap refil), poor urine output, tachycardia, (postural) hypotension, haematchezia (on PR), pallor/signs of anaemia
What investigations would you do if you suspected an acute GI bleed?
urgent endoscopy
bloods - FBC (anaemia), U&E (increased urea), LFTs, clotting, cross match (for transfusion)
CXR, ECG, ABG
What would management be for an acute GI bleed?
EMERGENCY - RRAPID (oxygen, fluids, transfusion)
-FFP if >4 units transfused (transfuse to maintain HB>10), nil by mouth 24 hrs
What is Crohn’s disease?
transmural granulomatous inflammation of the GI tract with skip lesions
When does Crohn’s disease typically present?
teends/twenties
What is the cause of Crohn’s disease?
genetics (mutation of NOD2/CARD15)
What are some risk factors for Crohn’s disease?
smoking, stress, infection, NSAIDS exacerbate
What are symptoms of Crohn’s disease?
diarrhoea, abdominal pain, weight loss, fever, malaise, anorexia
What are signs of Crohn’s disease?
clubbing, aphthous ulceration, right iliac fossa mass, erythema nodosum, iritis, malnutrition, cholangiocarcinoma
What are some differentials for Crohn’s disease?
ulcerative colitis, ischaemic colitis, IBS
What investigations would you do if you suspected Crohn’s disease?
bloods - raised Hb, ESR, CRP & WCC ; decreased albumin stool sample (exclude infective cause) sigmoidoscopy/colonoscopy/capsule endoscopy MRI (assess pelvic disease and fistula)
What is the treatment for a mild attack* of Crohn’s disease?
* (symptomatic but systemically well)
prednisolone until parameters return to normal
What is the treatment for a severe attack* of Crohn’s disease?
hospital admission
IV hydrocortisone, metronidazole
nil by mouth, IV fluids, monitor obs and bowel movements
When may surgery be necessary in Crohn’s disease and what would it be?
if not responsive to treatment or there is bowel obstruction
ileostomy
What is ulcerative colitis?
relapsing and remitting condition of inflammation of the conolic mucosa
-hyperaemic and haemorrhagic colonic mucosa
What is the rate of Crohn’s and UC in the UK?
Crohn’s - 145/100,000
UC - 400/100,000
How does smoking effect UC?
Protective against symptoms
What is the main risk factor for an exacerbation of UC?
stress
What are the symptoms of UC?
gradual onset diarrhoea (+/- blood/mucous), cramping abdo pain, more frequent bowel motions, systemic symptoms during acute attacks (fever/malaise/anorexia), urgency/tenesmus in rectal disease
What are the signs of UC?
may be none
in acute and severe cases: fever, tachycardia, tender distended abdo
extraintestinal: clubbing, aphthous ulcers, erythema nodosum, conjunctivitis, malnourishment
How would you investigate if you suspected UC?
bloods - FBC, ESR, CRP, U&Es, LFTs, blood cultures
stool MC&S
AXR (no faecal shadows), CXR (perforation)
sigmoidoscopy (inflamed mucosa)
rectal biopsy - goblet cell depletion
What are the possible complications of UC?
perforation, haemorrhage, toxic dilation of the colon
What is the aim of treatment in UC?
induce remission
How do you treat mild* UC?
*(<4 motions per day)
prednisoloone and mesalazine
How do you treat moderate* UC?
*(4-6 motions per day)
larger doses of prednisolone and mesalazine and twice daily steroid enemas
How do you treat severe* UC?
*(>6 motions per day and systemically unwell)
hospital admission
nil by mouth, IV hydration
IV hydrocortisone, rectal steroids
monitor obs and bowel motions
When is surgery indicated for UC and what would be done?
if perforation/haemorrhage/toxic megacolon
remove effected portion of bowel
What is IBS?
mixed abdominal symptoms with no organic cause
What percentage of the population are affected by IBS?
10-20%
What is the cause of IBS?
unknown - related to disorders of intestinal motility/enhanced visceral perception
What are the diagnostic criteria for IBS?
6 month history of abdo pain (relived by defacating)/bloating/change in bowel habit
+2 of: altered stool passage, abdo distension, symptoms worse on eating, mucous rectally
What are some possible differentials of IBS?
coeliac, GORD, Crohn’s , giardia
What investigations would you perform if you suspected IBS?
sigmoidoscopy (insufflation of air)
PR (look for bleeding)
blood test for coeliac
What is the treatment for IBS?
increase fibre intake, mebeverine (antispasmodic), anatcids, try an exclusion diet (for food intolerances)
What are common viral causes of gastroenteritis? (3)
norovirus, rotavirus, adenovirus
What are common bacterial causes of gastroenteritis? (4)
E coli, salmonella spp., campylobacter spp., shigella
Which bacteria cause gastroenteritis though their toxins?
staph aureus, bacillus cereus, clostridium perfinges
What are some common parasitic causes of gastroenteritis? (2)
giardia lambia, cryptosporidium
What are the main symptoms of gastroenteritis?
diarrhoea (if bloody-
bacterial) and vomiting
What are the signs of gastroenteritis?
pyrexia, hypotension, sweating, malaise
What investigations would you perform if you suspected gastroenteritis?
stool MC&S (if been abroad/institution/outbreak)
culture food source
How do you manage someone with gastroenteritis?
maintain oral fluid intake, consider antiemetics
antibiotics if systemically unwell/immunosuppressed/elderly –> tertacycline for cholera, cirpofloxacin for salmonella/shigella/campylobacter
What are the causes of acute pancreatitis?
Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion bite Hypothermia/hypercalcaemia/hyperlipidaemia ERCP Drugs
What are the symptoms of acute pancreatitis?
severe epigastric pain (radiates to back)/central abdo pain, vomiting
What are the signs of acute pancreatitis?
tachycardia, fever, jaundice, ileus, rigid abdo, Cullen’s and Grey-Turner’s sign (if haemorrhagic)
What investigations would you perform if you suspected acute pancreatitis?
raised serum amylase raised serum lipase AXR (psoas shadow) erect CXR (exclude perforation) US/ERCP (gallstones)
What is the treatment for acute pancreatitis?
nil by mouth, NG tube, IV saline, analgesia, hourly monitoring, gallstone removal
What are the causes of chronic pancreatitis?
alcohol, CF, haemochromatosis, pancreatic duct obstruction
What are the symptoms of chronic pancreatitis?
epigastric pain ‘bores’ through to back (relived by sitting forward & hot water bottle)
bloating, steatorrhoea, weight loss
What is the treatment for chronic pancreatitis?
drugs - analgesia, lipase, fat-soluble vitamins, insulin
diet - no alcohol, low fat
surgery - Whipple’s (ampullary carcinoma)
What can gallstones be made from?
cholesterol, pigment or mixed
Who are the most at risk group for gallstones?
‘fat, fair, febrile, female and forty’
What are the causes of cholesterol gallstones?
sex, age, obesity
What are the causes of pigment gallstones?
haemolysis
What are the risk factors for gallstones?
increased age, family history, sudden weight loss, diabetes
What are the symptoms of gallstones in the common bile duct?
biliary colic - sudden pain in epigastrium/RUQ pain for 15 mins to 24hrs with nausea and vomiting
What are the symptoms of gallstones in the neck of the gallbladder?
acute cholecystitis - continuous epigastric/RUQ pain, vomiting, fever, local peritonism
What symptoms come with chronic cholecystits from gallstones?
vague abdo discomfort, distension, nausea, flatulence, fat intolerance, jaundice
What are the signs of gallstones?
Murphy’s sign - 2 fingers in RUQ and a deep breath with cause mega pain
phlegmon - RUQ mass of inflamed omentum/bowel
What investigations would you do if you suspected gallstones?
USS - if CBD dilated with stones do ERCP + sphincterotomy
urinalysis, AXR, ECG (exclude other disease)
What is the treatment for gallstones?
analgesia, nil by mouth, consider laparoscopic cholecystectomy
What are the general causes of acute hepatitis?
viral, autoimmune, alcohol, drug-induced, ischaemic, vaccination
How are hepatitis A, B, C and D spread?
A: faecal-oral
B&C: blood spread/sexual intercourse
What are the signs and symptoms of hepatitis infections?
A: fever, malaise, anorexia, nausea, jaundice
B: same as A with urticaria and arthralgia
C: none in early infection
D: increased risk of acute hepatic failure and cirrhosis
What is important about hepatitis D?
Can only infect WITH hep B
Which hepatitis infections have vaccinations available?
A and B
What is the treatment and prognosis for hepatitis A?
supportive, avoid alcohol
usually self-limiting (NO CHRONIC LIVER DISEASE)
What would blood test show in hep A?
raised AST and ALT (days 22-40), raised IgM (day 25)
What is the treatment for hep B?
supportive
for chronic - lamivudine
What would blood tests show in hep C infection?
AST:ALT <1:1
What is the treatment for hep C?
ribavirin and PEGinterferon alpha2a
How would you manage autoimmune acute hepatitis?
immunosuppression (prednisolone, azothiaprine), liver transplant
What causes appendicitis?
gut organisms invading appendix wall after lumen obstruction
What are the symptoms of appendicitis?
periumblical pain that moves to RIF, anorexia, vomiting, constipation
What are the signs of appendicitis?
tachycardia, pyrexial, lying still, coughing hurts, shallow breathing, guarding and rebound tenderness
Rovsing’s sign - pain in RIF>LIF when LIF pressed
Psoas sign - pain on extending hip
Cope sign - pain on flexion and internal rotation of right hip
What investigations would you do if you suspected appendicitis?
USS
bloods - raised CRP
What are possible complications of appendicitis?
perforation, appendix abscess
What is the treatment for appendicitis?
prompt appendicectomy, antibiotics post op (metronidazole and cefuroxime)
What is difference between simple, closed loop and strangulated bowel obstructions?
simple - one obstruction point, no vascular compromise
closed loop - two point obstruction forming loop (very distended)
strangulated - compromised blood supply
What are some causes of bowel obstruction?
constipation, hernias, adhesions, tumours, Crohn’s, diverticular stricture
What are the symptoms of bowel obstruction and the differences between small and large?
vomiting, colic, constipation, distension
small - vomit earlier, less distension
large - pain more constant
What would you hear on auscultation of bowel obstruction?
active ‘tinkling’ bowel sounds (absent bowel sounds if ileus)
What would you see on abdominal X-ray for bowel obstruction?
small - central gas shadows with valvulae conniventes
large - peripheral gas shadows, proximal to blockage with haustrae
What is the treatment for bowel obstruction?
strangulation - surgery (EMERGENCY!)
ileus/incomplete obstruction - NG tube feeding and IV fluids
What is the difference between direct and indirect inguinal hernias?
direct - through defect in posterior wall of inguinal canal
indirect - through internal inguinal ring (more common, can strangulate)
What are the risk factors for inguinal hernias?
weakness of inguinal ring, increased age, chronic cough, constipation, heavy lifting, asictes, urinary obstruction (anything that increases intrabdominal pressure)
What are the signs and symptoms of inguinal hernias?
symptoms: severe abdo pain, sudden groin pain, nausea, vomiting
signs: visible lump (is it reducible??), ask to cough (cough impulse) –> repeat standing
What is the treatment for inguinal hernias?
if small - reassurance
surgical emergency if obstructed or incarcarated
What are femoral hernias?
herniating bowel through femoral canal - frequently irreducible and strangulate
What is the treatment for femoral hernias?
surgery is recommended (hernitomy and herniorrhaphy)
What type of cancers are oesophageal carcinomas?
SCC or adenocarciinoma
What are the risk factors for oesophageal carcinoma?
GORD + Barrett’s oesophagus, alcohol, smoking, obesity, M>F
What are the signs & symptoms of oesophageal carcinoma?
dysphagia, retrosternal pain, weight loss, hoarse voice
What test would you perform if you suspected oesophageal carcinoma?
barium swallow, CXR, oesophagoscopy, biopsy, MRI
What is the treatment for oesophageal carcinoma?
radical curative oesophagectomy, chemo and radio
survival rate poor
What classification is used for gastric carcinoma?
Borrman’s
What are the signs & symptoms of gastric carcinoma?
non-specific - dyspepsia, weight loss, dysphagia, anaemia, epigastric mass, hepatomegaly, Virchow’s node, acanthosis nigricans
How would you treat gastric carcinoma?
partial/total gastrectomy and chemotherapy (5 year survival <10%)
