GI

Question 1

presentation of coeliac disease

Answer 1

indigestion, diarrhoea, abdominal bloating, constipation
fatigue
faltering growth in children
iron, vitamin B12 or folate deficiency

uncommon:
osteopenia/osteoporosis
dermatitis herpetiformis
cerebellar ataxia

Question 2

pathophysiology of coeliac disease

Answer 2

associated with HLA-DQ2 or HLA-DQ8 (although most people with these don’t have coeliac)
these present gluten peptides (after de-amidation by tTG) that activate an immune response

Th1 –> villous atrophy and crypt hyperplasia
Th2 –> plasma cell maturation and anti-gliadin and anti-tTG antibody production from these plasma cells

Question 3

investigations for coeliac disease

Answer 3

Confirm that the person has eaten gluten-containing foods (with wheat, barley, or rye as an ingredient) at least twice every day over the previous 6 weeks

Send off serology - use IgA tTG and total IgA as first line

(IgA EMA can be used if IgA tTG is unavailable)

FBC - IDA

small bowel histology (GOLD STANDARD) - will show intra-epithelial lymphocytes, villous atrophy and crypt hyperplasia - do the duodenum because this is where most of the damage occurs (probs cos this is the first bit exposed to the gliadin)

skin biopsy in patients with skin lesions suggestive of dermatitis herpetiformis

Question 4

management of coeliac disease

Answer 4

gluten free
assess and manage osteoporosis risk
consider annual blood test:
- coeliac serology
- FBC and ferritin 
- TFT, LFTs, electrolytes (addison's)
- vitamin D, B12, red cell folate, serum calcium

Question 5

most common infections leading to acute diarrhoea

Answer 5

noravirus, sapovirus, rotavirus

salmonella species, campylobacter jejuni, shigella species, E coli, C difficile (can cause pseudomembranous colitis)

parasitic are the most common causing persistent diarrhoea - cryptosporidium, giardia, entamoeba histolytica and cyclospora

Question 6

causes of acute diarrhoea other than infection

Answer 6

drugs - antibiotics, chemo, metformin, NSAIDs, PPIs, SRTIs, ARBs, allopurinol

diverticulitis, ischaemic colitis, IBD, anxiety, food allergy, acute appendicitis, pelvic radiation, intestinal ischaemia

or overflow diarrhoea due to constipation

Question 7

anti-mobility agents for diarrhoea

Answer 7

loperamide

o Uses: gastroenteritis, non-specific diarrhoea, mild traveller’s diarrhoea, IBS, IBD
o SHOULD NOT BE USED for cases of bloody diarrhoea, acute exacerbation of UC or bacterial enterocolitis

Question 8

anti-secretory agent for diarrhoea

Answer 8

racecadotril

BNF - has better tolerability than loperamide - causes less constipation + flatulence

Question 9

antispasmodics for diarrhoea

Answer 9

hyoscine butylbromide

mebeverine - used specifically in IBS to relieve symptoms like pain, cramping, flatulence and diarrhoea

Question 10

C difficile treatment

Answer 10

metronidazole 400mg TDS or vancomycin (check current guidelines)

Question 11

diverticulosis vs diverticular disease vs diverticulitits

Answer 11

diverticulosis = diverticula are present but without symptoms

diverticular disease = diverticula cause symptoms

diverticulitis = diverticula becomes inflamed and infected - causing severe symptoms

Question 12

aetiology of diverticular disease

Answer 12

multi-factorial - both genetic and environmental factors have been linked
- low fibre, >50, genetics, smoking, obestiy, NSAIDs, opiods, steroids

low fibre diet increases intestinal transit time and decreases stool volume –> results in increased intraluminal pressure and colonic segmentation

Question 13

symptoms of diverticular disease

Answer 13

left lower quadrant pain - may be triggered by eating and relieved by the passage of stools or flatus
constipation, diarrhoea or occasionally rectal bleeds

Question 14

symptoms of diverticulitis

Answer 14

severe abdominal pain starting in the hypogastrium then localising in the LLQ
fever
change in bowel habit and possible significant rectal bleeding
nausea and vomiting

Question 15

complications of diverticulitis

Answer 15

abscess formation 
perforation and peritonitis - abdominal rigidity, guarding, rebound tenderness
sepsis 
stricture and fistula formation 
intestinal obstruction

Question 16

investigations for diverticulitis

Answer 16

colonic diverticulosis should only be diagnosed after diverticula have been noted on imaging (barium enema or CT) or after direct visualistation (via sigmoidoscopy or colonoscopy)

FBC, CRP - diverticulitits
blood culture - if patient has signs or symptoms of sepsis
CXR - if obstruction and suspecting perforation
angiogram - can be used in acute bleeding - considered if bleeding is too profuse to enable identification using colonoscopy
AXR - if thinking obstructio n

Question 17

peak age of ulcerative colitis

Answer 17

most are 20-40 years but there is another peak at 60 years

Question 18

treatment for diverticulosis

Answer 18

• Recommend eating a healthy, balanced diet and having regular meals
• The person’s meals should contain whole grains, fruits and vegetables
• Fibre intake should be increased gradually (to minimize flatulence and bloating) - adults should aim to consume 30g/day

Question 19

treatment for diverticular disease

Answer 19

patient education
recommend 30g fibre/day
public health England’s ‘the eatwell guide’
drink adequate fluid
consider bulk-forming laxatives if symptoms of constipation and diarrhoea persist despite diet changes
paracetamol for abdo pain
Advise the person to avoid NSAIDs and opioid analgesia (such as codeine) if possible, due to the potential increased risk of diverticular perforation
Arrange to review the person, for example after one month, depending on clinical judgement to check how they are managing (if there are persistent or refractory symptoms, consider alternative causes for the symptoms)

Question 20

treatment of diverticulitis

Answer 20

arrange urgent hospital admission if suspected complications and cannot be managed at primary care of risk of dehydration or significant co-morbidities
hospital: IV ABx, fluids, analgesia, surgery for complications (e.g. abscess drainage)

oral abx in primary care - at least one week of co-amoxiclav
analgesia as needed
if managed in primary care, arrange a review within 48 hours or sooner if worsen

Question 21

causes of peptic ulcers

Answer 21

H pylroi (gram -ve rod that produced urease --> ammonia, damages gastric mucosa)
NSAID use

rarer causes: gastric ichaemia (stress ulcers), Zollinger Ellison syndrome (gastrin secreting neuro-endocrine tumour), medications (SSRIs, cocaine), infections (CMV), CD

Question 22

peptic ulcer presentation

Answer 22

dyspepsia/indigestion causing abdominal fullness, heartburn, nausea, belching or upper abdominal pain
with duodenal ulcers - may radiate into the back - Nausea or vomiting
Bleeding causing haematemesis, ‘coffee ground’ vomiting and melaena

pointing sign - can show pain with one finger
early satiety - may indicate pyloric stenosis
symptoms of anaemia - fatigue, pica, nail changes

Question 23

investigations for peptic ulcer disease

Answer 23

assess for alarm symptoms that might suggest a complication
FBC - anaemia
H pylori urea breath test or stool antigen test
upper GI endoscopy -Get a biopsy – can do urease testing on this and histology for neoplasm (cancers can look similar to ulcers). Biopsy will also show if there is evidence of an NSAID being the cause
repeat the endoscopy 6-8 weeks later to confirm healing

Question 24

conservative treatment of peptic ulcer disease

Answer 24

patient education
conservative - lose weight, avoid trigger foods (coffee, chocolate, tomatoes, fatty or spicy food). eat smaller meals and eat evening meal 3-4 hrs before bed. stop smoking, reduce alcohol
assess for stress/anxiety which may worsen symptoms
review medication - e.g. stop NSAIDs/aspirin, bisphosphonates, SSRIs
ask about any previous courses of ABx that may affect the choice of H pylori eradicaiton regimen used

Question 25

medical treatment of peptic ulcer disease

Answer 25

h pylori confirmed - 7 day triple regimen of

• PPI 2x daily
• amoxicillin 1g 2x daily
• either clarithromycin 500mg 2x daily or metronidazole 400mg 2x daily

h pylori confirmed and associated with NSAIDS - prescribe full-dose PPI therapy for 2 months THEN first line eradication therapy afterwards

h pylori negative - prescribe a full dose PPI for 4-8 weeks

PPI options = lansoprazole, omeprazole….

Question 26

surgical options for peptic ulcer disease

Answer 26

include antrectomy (antrum removal) with a gastro-duodenal anastomosis or gastro-jejunal anastomosis, a vagotomy and pyloroplasty, or a highly selective vagotomy

Question 27

management of an actively bleeding peptic ulcer

Answer 27

perform A–>E
check their Hb - transfuse if <70g/L
Erythromycin (as a prokinetic agent) and proton pump inhibitor may be considered prior to endosopy
Injection therapy (e.g. adrenaline), thermal probes (e.g. bipolar electrocoagulation, heater probe), or clips should be used

Question 28

differentials of dyspepsia

Answer 28

functional dyspepsia
H pylori infection
GORD
oesophagitis
peptic ulcer disease
gastroparesis - DM and previous abdominal surgery may result in vagal nerve injury
gastritis 
lactose intolerance
coeliac disease
upper GI malignancy