GI Flashcards
1
Q
What is Crohn’s disease?
A
A chronic disease that causes bowel inflammation
2
Q
What environmental factor increases risk of developing inflammatory bowel disease?
A
Smoking
3
Q
What drugs exacerbate Crohn’s disease?
A
NSAIDs
4
Q
Pathology/histology of Crohn’s disease
A
o Granulomas
o All Layers and levels
o Skip lesions
o Deep ulcers and fissures -> cobblestone appearance
5
Q
Symptoms of Crohn’s disease
A
o Diarrhoea
o Abdominal pain
o Weight loss
o Fatigue
6
Q
Signs of Crohn’s disease
A
o Bowel ulceration
o Abdominal tenderness
o Perianal abscess/fistulae/skin tags
o Clubbing, skin, joint and eye problems
7
Q
Investigations for suspected inflammatory bowel disease
A
o Bloods – cultures, anaemia, B12, folate, ESR, CPR
o Stool sample
o Colonoscopy and biopsy
o AXR
8
Q
Pharmacological management of Crohn’s disease
A
o Mild – prednisolone
o Severe – IV hydrocortisone
o Additional – AZA, monoclonal
antibodies
o Surgery
9
Q
Lifestyle management of Crohn’s
A
Stop smoking, try different diets
10
Q
Complications of Crohn’s disease
A
Bowel obstructions, malabsorption
11
Q
What is ulcerative colitis?
A
A chronic disease that causes bowel inflammation
12
Q
Pathology of ulcerative colitis
A
o Colon only o No granulomas o Mucosal inflammation only o Continuous involvement o Goblet cell depletion and crypt abscesses
13
Q
Symptoms of ulcerative colitis
A
o Episodic or chronic diarrhoea (± blood and mucus)
o Crampy abdominal discomfort
o Urgency
o Fatigue, weight loss
14
Q
Signs of ulcerative colitis
A
o Fever, tachycardia
o Tender distended abdomen if acute
o Extraintestinal features – clubbing, oral ulcers, conjunctivitis, arthritis, spondylitis, nutritional defects
15
Q
Management of ulcerative colitis
A
o Mild – 5-ASA, steroids
o Moderate – prednisolone then 5-ASA
o Severe – fluids and electrolytes, IV hydrocortisone,
ciclosporin
o Maintenance – 5-ASAs
o Surgery
16
Q
Complications of ulcerative colitis
A
Psychosocial and sexual problems, colorectal cancer risk doubled
17
Q
What is irritable bowel syndrome?
A
A mixed group of abdominal symptoms for which no organic cause can be found
18
Q
Epidemiology of IBS
A
Usually <40yrs old, twice as common in women
19
Q
Symptoms of IBS
A
o Chronic > 6 months: o Urgency o Incomplete evacuation o Constipation o Diarrhoea o Abdominal bloating/distension o Worsening of symptoms after food
20
Q
What can exacerbate IBS symptoms?
A
Stress, menstruation, gastroenteritis
21
Q
Signs of IBS
A
Abdominal distension
22
Q
What is the tool used to diagnose IBS?
A
The Rome diagnostic tool
23
Q
What is the criteria for diagnosis of IBS?
A
• Recurrent abdominal pain (or discomfort) associated
with at least 2 of:
o Relief by defecation
o Altered stool form
o Altered bowel frequency
24
Q
When do you think differential diagnosis for IBS?
A
o >60yrs
o Anorexia/weight loss
o Waking at night with pain diarrhoea
o Mouth ulcers
25
Investigations for suspected IBS
• Bloods – FBC, ESR, CRP and coeliac serology
• Stool sample
• Low threshold for referring if family history of ovarian
or bowel cancer
26
Management of IBS
• Constipation – adequate water and fibre intake,
physical activity, laxatives
• Diarrhoea – avoid sorbitol, alcohol, caffeine, ‘trigger
foods’, reduce fibre, try bulking agent and loperamide
after loose stool
• Colic/bloating – oral antispasmodics
• Psychological symptoms – CBT
27
What is coeliac disease?
A disease in which the small intestine is hypersensitive to gluten, leading to difficulty in digesting food.
28
What is the pathology of coeliac disease?
T-cell response to gluten in small bowel -> villous atrophy and crypt hyperplasia -> malabsorption
29
What gene is coeliac disease associated with?
HLA DQ2
30
What skin condiiton is associated with coeliac disease?
Dermatitis herpetiformis
31
Symptoms of coeliac disease
```
o Stinking stools/steatorrhoea
o Diarrhoea
o Abdominal pain, bloating
o Nausea and vomiting
o Weight loss
o Fatigue and weakness
```
32
Investigations for suspected coeliac disease
o Bloods – anaemia
o Antibodies – anti-transglutaminase test
o Duodenal biopsy while on gluten-containing diet
o Genotyping
33
Management of coeliac disease
Life-long gluten free diet
34
Complications of coeliac disease
Anaemia, dermatitis herpetiformis, osteopenia/osteoporosis, risk of malignancy
35
List 4 causes of malabsorption
Coeliacs disease, Crohn's disease, starvation/poor diet, biliary obstruction
36
What is GORD?
Prolonged or recurrent reflux of gastric contents (acid +/- bile) into oesophagus
37
Epidemiology of GORD
* 25% of adults experience it (heartburn)
| * 2-3x more common in men
38
Causes of GORD
```
o Lower oesophageal sphincter hypotension
o Hiatus hernia
o Oesophageal dysmotility
o Gastric acid hypersecretion
o Delayed gastric emptying
```
39
Risk factors for GORD
o Obesity
o Pregnancy
o Smoking
o Alcohol
40
What is a hiatus hernia?
Part of the stomach protrudes through the oesophageal opening in the diaphragm
41
What is the pathology of GORD?
Tone of the LOS is reduced, as well as frequent transient relaxations of the LOS -> stomach acid enters oesophagus -> increased mucosal sensitivity to gastric acids
42
Symptoms of GORD
o Heartburn – burning retrosternal discomfort after
meals, lying or straining, relieved by antacids
o Belching
o Acid brash (acid or bile regurgitation)
o Increased salivation
o Painful swallowing
o Nocturnal asthma, cough
43
Investigations for suspected GORD
• Endoscopy
• 24 hr oesophageal pH monitoring if endoscopy
normal
44
Management of GORD
```
o Lifestyle:
- Weight loss
- Smoking cessation
- Reduce hot drinks, alcohol, citrus fruits, fizzy
drinks, spicy food
- Raise bed head
o Drugs:
- Antacids – Gaviscon
- PPI – lansoprazole
o Surgery if severe - laparoscopic Nissen fundoplication
```
45
What is Barrett's oesophagus?
Metaplasia of oesopahgeal cells = squamous -> columnar -> can progress to cancer, IRREVERSIBLE
46
Why does Barrett's oesophagus increase risk of oesophageal cancer?
The new glandular epithelial cells are predisposed to becoming malignant, since they are not genetically stable in the oesophagus
47
Signs and symptoms of oesopahgeal cancer?
o Dysphagia
o Weight loss
o Retrosternal chest pain
o Hoarseness, cough
48
What is gold standard investigation for diagnosing oesophageal cancer?
Oesophagoscopy with biopsy
49
Management of oesophageal cancer
o Lifestyle changes
o Oesophagectomy with perioperative chemo
o Combine with chemo/radiotherapy if necessary
50
Causes of gastric cancer (adenocarcinoma)
o Helicobacter pylori
o Genetic predisposition
o Unknown
51
Symptoms of gastric cancer
o Dyspepsia
o Weight loss
o Vomiting
o Dysphagia
52
Signs of gastric cancer
```
o Anaemia
o Troisier’s sign – enlarged supraclavicular node
(Virchow’s node)
o Epigastric mass
o Hepatomegaly
o Jaundice
o Ascites
```
53
What investigations are used to stage cancer?
CT/MRI - to indentify metastases
54
Investigations for suspected gastric cancer
o Gastroscopy and multiple ulcer edge biopsies
o Endoscopic ultrasound (EUS) – evaluate depth of
invasion
55
Management of gastric cancer
o Endoscopic resection in early stages
o Partial gastrectomy if distal, total if proximal
o Combination chemotherapy
o Targeted therapy – monoclonal antibodies
56
What factors predispose an individual to colorectal cancer?
Neoplastic polyps, IBD, genetic predisposition (FAP and HNPCC), alcohol, smoking
57
What genes predispose an individual to colorectal cancer?
FAP and HNPCC
58
What drug can prevent colorectal cancer?
Aspirin
59
Signs and symptoms of a left-sided colorectal cancer
Bleeding/mucus PR, altered bowel habits or obstruction, tenesmus, mass PR, fistula
60
Signs and symptoms of right-sided colorectal cancer
Weight loss, anaemia, abdominal pain, obstruction
61
What is the UK colorectal screening programme?
Faecal occult blood from stool sample, 60-69yrs old
62
Investigations for suspected colorectal cancer
o FBC – microcytic anaemia
o Sigmoidoscopy or colonoscopy or virtually by CT
o Rectal examination
63
Management of colorectal cancer
o Surgery – laparoscopic resection, colostomy bag
o Radiotherapy
o Chemotherapy – FOLFOX
o Targeted – monoclonal antibodies
64
What are the main causes of peptic ulcers?
o H. pylori
o Drugs - NSAIDs, steroids
o Stress – H. pylori and stress
o Lack of blood supply (mucosal ischaemia)– low BP, stomach cells stop making mucin, decreased defence against stomach acid
65
By what mechanism does H. pylori cause peptic ulcers?
Lives in gastric mucosa – secretes urease -> splits urea into CO2 and ammonia -> damages gastric mucosa -> peptic ulcer
66
How do NSAIDs cause peptic ulcers?
NSAIDs inhibit prostaglandins -> decreased mucous secretion -> decreased defence against stomach acid
67
How can low BP causes peptic ulcers?
Low BP -> stomach cells stop making mucin -> decreased defence against stomach acid
68
List 3 risk factors for peptic ulcers
Alcohol, smoking, stress
69
Symptoms of peptic ulcers
o Epigastric pain often related to hunger, specific
foods, or time of day
o Fullness after meals
o Heartburn
70
What the ALARMs symptoms in GI conditions?
Anaemia, loss of weight, anorexia, recent onset, melaena/haematemesis, swallowing difficulty
71
Investigations for suspected peptic ulcers?
o Test for H. pylori – stool antigen test
o Endoscopy – biopsy ulcer to check for H. pylori,
exclude malignancy
72
Management of peptic ulcers
o Lifestyle – reduce alcohol and smoking
o H. pylori eradication – triple therapy (PPI + 2 ABX)
o Drugs to reduce acid – PPI’s , H2 blockers (ranitine)
o Surgery if drugs not effective
73
Name a PPI
Lanzoprazole
74
Complications of peptic ulcers
o Bleeding
o Perforation
o Malignancy
o Decreased gastric outflow
75
What is gastritis?
Inflammation of the gastric mucosa
76
Causes of gastritis
NSAIDS, alcohol, H. pylori, reflux/hiatus hernia, autoimmune, Zollinger-Ellison syndrome, Menetrier’s disease
77
Symptoms of gastritis
Epigastric pain, vomiting
78
Investigations for suspected gastritis
o Blood and stool tests
| o Upper GI endoscopy
79
Management of gastritis
o Triple therapy if H. pylori
o Lifestyle – stop smoking and alcohol
o PPI’s
80
Complications of gastritis
Peptic ulcers
81
Pathology of appendicitis
Gut organisms invade appendix wall after lumen obstruction -> oedema, ischaemic necrosis and perforation
82
Symptoms of appendicitis
o Periumbilical pain that move to RIF
o Anorexia
o Constipation
83
Signs of appendicitis
o Tachycardia
o Fever
o Peritonism with guarding and rebound
o Percussion tenderness in RIF
84
Investigations for suspected appendicitis
* Bloods – rasied neutrophils and CRP
* Ultrasound
* CT
85
Management of appendicitis
• Appendicectomy
• Antibiotics preop
• Laparoscopy – not if suspected gangrenous
perforation (risk of abscess)
86
Complications of appendicitis
* Perforation
* Appendix mass
* Appendix abscess
87
Causes of small bowel obstruction
Adhesions, hernias, gallstones
88
Pathophysiology of bowel obstruction
Physical factor prevents movement of intestinal contents through tract -> backing up of GI and inability to empty -> vomiting and constipation
89
What is an adhesion?
Two bits of bowel stick together by fibrous band (usually had previous surgery)
90
What is a volvulus?
Affects sigmoid colon -> twists and cuts off blood supply
91
What is intussusception?
Folding of the intestines on itself
92
Signs and symptoms of bowel obstruction
```
o Vomiting, nausea and anorexia
o Early colic
o Constipation
o Abdominal distension – active ‘tinkling’ bowel
sounds
o Abdominal pain
```
93
What is an ileus?
Ileus – functional obstruction from low bowel motility -> bowel sounds absent, less pain
94
Investigations for suspected bowel obstruction
* Abdominal x-ray – gas shadows
* CT – establish cause of obstruction
* Blood tests – amylase, FBC, U&E
* Consider colonoscopy if large bowel
95
Management of bowel obstruction
• Immediate action:
o Nasogastric intubation and IV fluids
o Analgesia
o Catheterise to monitor fluid status
• Surgery if:
o Strangulation
o Closed loop obstruction
• Endoscopic stenting – palliation or bridge to surgery
96
What us diverticular disease?
High intraluminal pressures force mucosa to herniate through the muscle layers of the gut at weak points adjacent to penetrating vessels
97
In which part of the colon is diverticulitis most common?
Sigmoid colon
98
Investigations for suspected diverticular disease
* Colonoscopy - common incidental finding
| * CT abdomen - diagnostic
99
What is diverticulitis?
When the mucosal outpounchings in diverticular disease get infected or inflammed
100
Signs and symptoms of diverticular disease
Altered bowel habit ± left-sided colic relieved by defecation, nausea and flatulence
101
Signs and symptoms of diverticulitis
Features of diverticular disease + pyrexia, raised WCC, raised CRP/ESR, tender colon ± peritonism
102
Management of diverticular disease
o Antispasmodics – mebeverine
| o Surgical resection if severe
103
Management of diverticulitis
o Mild - bowel rest (fluids only) ± antibiotics
| o Severe - analgesia, NBM, IV fluids and IV antibiotics
104
Complications of diverticular disease
* Perforation
* Haemorrhage
* Fistulae
* Abscesses
105
What are the causes of acute mesenteric ischaemia?
Low CO, trauma, vasculitis, radiotherapy, strangulation
106
Signs and symptoms of acute mesenteric ischaemia
```
o Acute severe abdominal pain
o No/minimal abdominal signs
o Rapid hypovolaemia -> shock
o Degree of illness often far out of proportion with
clinical signs
```
107
Investigations for suspected acute mesenteric ischaemia
o Bloods – high Hb, high WCC, persistent metabolic
acidosis
o X-ray – gasless abdomen
o CT/MR contrast angiography
108
Management of acute mesenteric ischaemia
o Resuscitation with fluid, antibiotics and heparin
| o Surgery to remove dead bowel
109
Complications of acute mesenteric ischaemia
Septic peritonitis, multiple organ failure
110
What causes chronic mesenteric ischaemia?
Combination of low-flow state with atheroma
111
Signs and symptoms of chronic mesenteric ischaemia
o Severe, colicky post-prandial abdominal pain (‘gut
claudication’)
o Malabsorption, N&V, weight loss
o Upper abdominal bruit
112
Investigations for suspected chronic mesenteric ischaemia
CT angiography and contrast-enhanced MR angiography
113
Management of chronic mesenteric ischaemia
o Surgery - reduce risk of acute ischaemia
o Percutaneous transluminal angioplasty and stent
insertion
114
What is the main cause of ischaemic colitis?
Low flow in inferior mesenteric artery territory
115
Symptoms of ischaemic colitis
Lower left-sided abdominal pain ± bloody diarrhoea
116
What is the 'gold standard' investigation for suspected ischaemic colitis?
Lower GI endoscopy
117
Management of ischaemic colitis
Fluid replacement and antibiotics
118
Complications of ischaemic colitis
Ischaemic strictures, gangrenous ischaemic colitis
119
What is a Mallory-Weiss tear?
Persistent vomiting/retching causes haematemesis via an oesophageal mucosal tear
120
Risk factors for Mallory-Weiss tear?
Vomiting, retching, frequent alcohol consumption, chronic cough, bulimia, hiccuping
121
Signs and symptoms of a Mallory-Weiss tear?
* Bouts of retching/vomiting -> haematemesis
| * Shock, syncope, light-headedness, dizziness
122
Investigation for suspected Mallory-Weiss tear
Endoscopy
123
Management of a Mallory-Weiss tear
Conservative - resuscitation, maintain airway, oxygen, fluids
124
Complications of a Mallory-Weiss tear
* Hypovolaemic shock -> death
* Re-bleeding
* MI
125
What is a pilonidal sinus?
Obstruction of natal cleft hair follicles approx. 6cm above anus
126
Epidemiology of pilonidal sinus
M>F, 10:1, obese
127
Management of pilonidal sinus
o Excision of sinus tract ± primary closure
| o Offer hygiene and hair removal advice
128
What causes an anorectal abscess?
Gut organisms, TB, staphs
129
Which sex has the higher risk of anorectal abscess?
Females, 8:1
130
Management of anorectal abscess
Incise and drain under GA
131
What conditions are associated with anorectal abscesses?
DM, Crohn’s, malignancy
132
What is a fissure-in-ano?
Painful tear in squamous lining of lower anal canal
133
Which sex has the higher risk of developing a fissure-in-ano?
Male
134
Causes of fissure-in-ano
Hard faeces, parturition (anterior)
135
Management of fissure-in-ano
Lidocaine ointment + GTN ointment, fibre, fluids, stool softener, Botulinum toxin injection (2nd line), surgery
136
What is a fistula-in-ano?
A chronic abnormal communication between the epithelialised surface of the anal canal and perianal skin
137
What causes a fistula-in-ano?
Perianal sepsis, abscesses, Crohn’s, TB
138
Investigations for suspected fistula-in-ano
MRI, endoanal US scan
139
Management of fistula-in-ano
Fistulotomy and excision
140
UK epidemiology of diarrhoea
o Viral most commmon
o Rotavirus - children
o Rota virus childhood vaccination -> reduction
141
Causes of diarrhoea
* Gastroenteritis
* Traveller’s diarrhoea
* C. diff
* IBS
* Colorectal cancer
* Crohn’s, UC, coeliac
142
Diagnostic criteria for travellers diarrhoea
```
3 or more unformed stool per day plus one of the following:
o Abdo pain
o Cramps
o Nausea
o Vomiting
o Dysentery
```
143
Risk factors for diarrhoea
Travel, diet change, D&V contact, fever/pain, HIV, medication
144
What does chronic diarrhoea suggest?
IBS/Crohn’s/UC/Coeliac
145
What does bloody diarrhoea suggest?
Salmonella, E. coli, UC, Crohn’s, cancer
146
What does mucus diarrhoea suggest?
IBS, cancer, polyps
147
What is the most likely cause of explosive diarrhoea?
Cholera, Rotavirus
148
What does steatorrhoea suggest?
Pancreatic insufficiency, biliary obstruction
149
Investigations for diarrhoea
* Stool test - microscopy, culture, parasites
* Bloods - culture, inflammatory markers (FBC/CRP)
* Lower GI endoscopy
150
What are the main red flag symptoms in a patient with diarrhoea?
* Dehydration
* Electrolyte imbalance
* Renal failure
* Immunocompromise
* Severe abdominal pain
151
What are the red flag symptoms/RFs for bowel cancer?
Over 50, chronic diarrhoea, weight loss, blood in stool, FH
152
Management of diarrhoea
* Treat cause
* Food handlers – no work until stool samples -ve
* Rehydration - oral/IV
* Codeine phosphate after loose stool
* Avoid antibiotics unless infective and systemic upset
153
What is peritonitis?
Inflammation of the peritoneum
154
What is peritonism?
Tensing of muscles to prevent movement of peritoneum
155
Causes of peritonitis
* Cholecystitis
* Pancreatitis
* Appendicitis
* Diverticulitis
156
Symptoms of peritonitis
* Pain, vomiting
| * Systemic symptoms – nausea, chills, rigor, fever
157
Signs of peritonitis
* Silent abdomen
* Rebound tenderness
* Patient doesn’t want to move
158
Investigations for suspected peritonitis
CT abdomen
159
Management of peritonitis
* Fluid resuscitation
* Surgery - laparotomy (open), laparoscopy (key-hole)
* ITU
160
Complications of peritonitis
o Bowel obstruction
| o Sepsis
161
What is a hernia?
Protrusion of a viscus or part of a viscus through a defect of the walls of its containing cavity into an abnormal position
162
What causes Crohn's disease?
Inappropriate immune response against gut flora in a genetically susceptible individual
163
What causes ulcerative colitis?
Inappropriate immune response against colonic flora in genetically susceptible individuals
164
What do tympanic bowel sounds indicate about the bowel contents?
Air/gas
165
Give 3 roles of the stomach other than digestion
Secrete and activate proteases
Regulate emptying into the duodenum
Produce stomach acid
166
What medication would you give to treat H. pylori?
Triple therapy - omeprazole, amoxacillin and clarithromycin
167
What antibodies can be tested for to confirm Coeliac's?
IgA tussye transglutaminase
| IgA anti-endomysial (EMA)
