GI Flashcards
IBS diagnosis and symptoms
for at least 6 months:
abdominal pain, and/or
bloating, and/or
change in bowel habit
altered stool passage (straining, urgency, incomplete evacuation)
abdominal bloating (more common in women than men), distension, tension or hardness
symptoms made worse by eating
passage of mucus
Features such as lethargy, nausea, backache and bladder symptoms may also support the diagnosis
No blood/ weight loss
full blood count ESR/CRP coeliac disease screen (tissue transglutaminase antibodies)
Management of IBS
Pain- antispasmodic agents Constipation - laxative (not lactulose - osmotic due to bloating?) Diarrhoea - loperamide 2nd line Amitriptyline Olso Talking therapy
Caeliac microscopy
villous atrophy, raised intra-epithelial lymphocytes, and crypt hyperplasia
UC clasification
• mild: < 4 stools/day, only a small amount of blood
• moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
Pathology of UC
• red, raw mucosa, bleeds easily
• no inflammation beyond submucosa (unless fulminant disease)
• widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
• inflammatory cell infiltrate in lamina propria
• neutrophils migrate through the walls of glands to form crypt abscesses
• depletion of goblet cells and mucin from gland epithelium
granulomas are infrequent
UC how to induce remission
Rectal aminosalicylates (mesalasine) or rectal steriods
Oral mesalasine
Oral pred
If severe IV steroids
UC maintain remission
Oral mesalaasine (5ASA)
Aza or mercaptopurine (6MP similar to aza, must assess TMPT first)
Not MTX
Priobiotics may help
CD inducing remission
Oral, topical or IV steroids
Elemental diet (esp children)
Mesalazine second line
Aza or mercaptopurine (after assessing TMPT)
Infliximab if refractory/ fistulating
Metronidazole (also anti inflam) if isolated perianal disease
CD maintaining remission
Stop smoking
Aza or mercapto
MTX second line
5-ASA possible
Surgery
Often ileocaecal resection Segmental small bowl resection
Symptoms of coeliac
Chronic or intermittent diarrhoea
Failure to thrive or faltering growth (in children)
Persistent or unexplained gastrointestinal symptoms including nausea and vomiting
Prolonged fatigue ('tired all the time')
Recurrent abdominal pain, cramping or distension
Sudden or unexpected weight loss
Unexplained iron-deficiency anaemia, or other unspecified anaemia
Other automimmune stuff e.g. Thyroid, T1DM
Complications anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease) hyposplenism osteoporosis, osteomalacia lactose intolerance enteropathy-associated T-cell lymphoma of small intestine subfertility, unfavourable pregnancy outcomes rare: oesophageal cancer, other malignancies
Investigations into coeliac
eintroduce gluten for at least 6 weeks prior to testing.
Immunology tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE endomyseal antibody (IgA) anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE anti-casein antibodies are also found in some patients
Jejunal biopsy villous atrophy crypt hyperplasia increase in intraepithelial lymphocytes lamina propria infiltration with lymphocytes
Describe bowel cancer screening
60-74 (50-74 in Scotland) years get invited
Every 2 years
Send in poo poo
FOB (Faecal occult blood) and colonoscopy
Describe prognostic risk of liver cirrhosis
Child-Pugh - gives 1/2 year prognosis Bilirubin Albumin PTT Ascites Encephalopathy
Also
MELD - model for end stage liver disease
Complications of liver cirrhosis
Portal Varices Caput madusae Splenomegaly HCC risk Ascites Coagulopathy/ SBP Encephalopathy Hypoglycaemia
Management of liver cirrhosis full!! General, ascites, SBP, Enceph, Renal failure, (varices separate)
Good nutrition
Alcohol abstinence
Avoid NSAIDs, sedatives and opiates
Colestyramine for pruritis
US and aFP every 6 months
Specific treatment e.g. ursodeoxycholic in PBC, penacillamine
Ascites
Fluid restriction
Low salt
Spirono
Add frusemide
Therapeutic paracentesis with albumin infusion
SBP
Abx propyclaxis
Pipercillin and tazobactam
Encephalopathy
Lactulose and rifaximin (non absorbing abx which kills N forming bacteria),
Renal failure
(decreased hepatic clearence leads to trapping in kidneys e.g. IgA also HRH syndrome in fulminant LD)
Give terlipressin for pressure (ADH analogue, also used for bleeding esophageal varices
Haemodyalysis
Transjugular intrahepatic porto-systemic shunt (TIPSS)
Oesopahgeal varices treatment and prevention
VBL Baloon tamponage Transfusion FFP if needed Terlipressin (constrictor) Abx Sengstaken- Blakemore tube if needed Failure then consider TIPSS
Hepatic encephalopathy symptoms
Sleep disturbance
Altered mood/behaviour
Dyspraxia - 5 pointed atar
Liver flap Personality change Confusion/ lethargy Restless/ stupor Coma
Hereditary haemochromotosis path
Increased intestingal iron absorption
Iro deposition in joints, liver, heart, panc, pit, adrenals, skin
Middle aged men (women protected for 10more years by menstrual blood loss)
Auto rec?
Freq 1 in 200-400
Multiple different mutations
Hered haemo symptoms
Early Nil or tiredness Arthralgia (2 and 3 MCP and knee pseudogout) Low libido Later Slatye grey skin pigmentations Signs of CLD Hepatomegaly Cirrhosis Dilated cardiomyopathy DM (bronze diabetes from iron in panc) Hypogonadism from pit dysfunction
Hered haemo investigation
LFTs Ferritin (inflam can increase too) Transferrin saturation increased] HFE genotyping (ciommonest gene) Xray Chondrocalcinosis in stressed more than relaxed (compare dominant hands) Liver biopsy Perl's stain quantifies iron loading
Gered haemo management
Venection- 0.5-2 units every 1-2 weeks until ferritin <50mcg
Maintainence needed for life
If not desferrioxamine
Monitor LFT and glucose (HbA1c not reliablke)
Limit iron e.g. from over the counter drugs but don’t limit diet intake
No alcohol
No uncooked seafood (bacteraemia)
Wilsons disease patho and onset
autosomal recessive disorder characterised by excessive copper deposition in the tissues. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson’s disease is caused by a defect in the ATP7B gene located on chromosome 13.
The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease
Wilsons symptoms
Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea:
liver: hepatitis, cirrhosis
neurological: basal ganglia degeneration, speech and behavioural problems are often the first manifestations. Also: asterixis, chorea, dementia
Kayser-Fleischer rings
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails
Wilson’s diagnosis
reduced serum caeruloplasmin
reduced serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
increased 24hr urinary copper excretion
Management of Wilson’s disease
penicillamine (chelates copper - binds and makes easier to excrete) has been the traditional first-line treatment
trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future
tetrathiomolybdate is a newer agent that is currently under investigation
Primary biliary cirrhosis (cholangitis) RFs and patho
MIddle aged females
Autoimmune although unsure
Chronic inflam in interlobular bile ducts (within liver) causing cholestasis and cirrhosis
Presentation of Primary biliary cirrhosis
Itching in middle aged women
Associated with Sjorgens, RA, Systemic sclerosis and thyroid
Liver symptoms
Diagnosis of PBC
anti-mitochondrial and sentive and specific
Management of PBC
Pruritis: cholestyramine
Fat soluble vitamin supps
Ursodeoxycholic acid
Liver transplant (rare to have recurrence)
Features of primary sclerosing cholangitis
Jaundice and pruritis
RUQ pain
Fatigue
Investigation of primary sclerosing cholangitis
ERPC - beaded apprearence
Complications of primary scelerosing cholangitis
Cholangio carcinoma
Colorectal cancer
Investigation into autoimmune hep
Young females
ANA/ SMA but other types too
Features of autoimmune hep
CLD
Acute hepatits - fever, jaundice
Amenorrhoea (cholesterol?)
Liver biopsy
Management autoimmune hep
Steroids
Aza
Liver transplant
Which hepatitis virus give acute disease which are self limiting?
A
E
B (if in adults and can be chronic too)
Small % of C
