GI Flashcards
Causes of abdominal pain (7)
- Peptic ulcer disease
- GORD
- Pancreatitis
- Biliary pain
- Bowel obstruction
- GI malignancy
- IBS
What are the two main causes of peptic ulcer disease?
Helicobacter pylori and NSAIDs
How can you diagnose a H.pylori cause of peptic ulcer disease?
- CLO test (uses a gastric biopsy taken during gastroscopy)
- H.pylori faecal antigen
Treatment for H.pylori peptic ulcer disease
PPI and 2 Abx (7 day treatment)
Complications of peptic ulcers
Bleeding and perforation
GORD risk factors
Elevated BMI
Pregnancy
Alcohol
Dietary
Anything that relaxes the lower oesophageal sphincter
What is Barrett’s oesophagus?
metaplasia where normal squamous epithelium is replaced by columnar epithelium – a premalignant condition
How is Barrett’s diagnosed?
o Acetic acid (pushed through endoscope – highlights abnormal mucosa or evidence of dysplasia) – allows for targeted biopsies
When should patients with Barrett’s undergo regular surveillance?
Surveillance if males, long segment Barrett’s, ulcer present
What is the treatment of Barrett’s oesophagus?
Long term PPI
Management of GORD
Medical management in most cases - PPI (+lifestyle changes)
More severe cases - can have surgical management (Laparoscopic Nissen’s fundoplication)
Causes of pancreatitis
Alcohol, gallstones, drugs
Management of pancreatitis
fluids, analgesia, antibiotics if indicated, early feeding
o Antibiotics not routinely used, only in some scenarios
Complications of pancreatitis
o Sepsis/shock o ARDS o Pancreatic abscess o Pancreatic pseudocyst o Pancreatic ascites – rupture of the pancreatic duct and leakage of amylase-rich fluid into peritoneal cavity – treatment with stent insertion across pancreatic duct
Causes of diarrhoea
- Irritable bowel syndrome
- Infective
- Inflammatory bowel disease
- Malabsorption (coeliac, pancreatic)
- Drugs
- Factitious (self-induced e.g. by taking laxatives
Causes of bloody diarrhoea
- Ulcerative colitis
- Colonic Crohn’s disease
- Infective
How to tell the difference between IBD and infective cause of bloody diarrhoea.
o Infective diarrhoea tends to be a shorter Hx with worse pain than in IBD
Should send stool cultures to rule out infection
What is the effect of smoking on UC and Crohn’s respectively?
UC = protective
Crohn’s = aggravates
Typical endoscopic findings in IBD
UC - superficial, continuous lesions
Crohn’s - transmural, skip lesions, cobblestoning
Infective diarrhoea classical features
- Short history
- Abdominal pain usually a feature and can be bloody or non-bloody
- Campylobacter jejuni - a common cause of travelers’ diarrhoea
- Clostridium difficile (pseudomembranous colitis) – seen in hospitalised sick patients, antibiotic use a risk factor. Usually non bloody
Management of UC/Crohn’s
• Oral and local steroids and 5ASA preparations
Management of severe acute colitis
o IV steroids (methyl prednisolone hydrocortisone), DVT prophylaxis
o Nutritional support
o If no response (Trulove’s criteria) in 3-4 days surgical opinion, second line treatment (biologics like infliximab and adalimumab)
Long term management of IBD
o 5ASA (benefit more in UC) + azathioprine o Can adjust azathioprine dose by measuring metabolites in blood (6TGN and 6-MMPN levels)
Side effects of azathioprine
bone marrow suppression, pancreatitis and hepatotoxicity and malignancy especially skin
How can the risk of bone marrow toxicity be predicted if taking Azathioprine?
by TPMT enzyme levels
Treatment of IBD that still creates symptoms despite Azathioprine
consider biologics: Infliximab, vedolizumab, tofacitinib
Coeliac disease
- Positive antiendomysial and tissue transglutamase antibody
- D2 biopsy shows villous atrophy
- Gluten free diet corrects malabsorption, improves symptoms and reduces risk of malignancy (EATL)
Causes of malabsorption
Coeliac disease
Small bowel Crohn’s disease
Chronic pancreatitis
Causes of dysphasia and associated features
• Oesophageal cancer: o Weight loss, progressive symptoms • Benign stricture o History of GORD • Motility disorder o Painful dysphasia • Achalasia cardia o Young • Stroke o Neurological signs and symptoms, coughing/choking on swallowing
Causes of upper GI bleed
Peptic ulcer disease
Varices
Upper GI malignancy
AV malformations
Causes of lower GI bleed
Haemorrhoids/anal fissure
Colonic cancer
Diverticular disease
Angiodysplasia
GI bleed management (non-variceal)
- Stabilize haemodynamically
- Transfuse based on clinical need and not level of haemoglobin (keep Hb between 7-9 grams)
- Gastroscopy once resuscitated
- IV PPI if stigmata of recent bleed on gastroscopy and endoscopic treatment performed
- If there is evidence of peptic ulcer consider H pylori eradication
GI bleed management (variceal)
- Correct coagulopathy (thromboelastrography)
- Avoid fluid overload as raises portal pressure
- IV Terlipressin
- IV antibiotics
- Endoscopic banding
What procedure can be done for more severe variceal bleeding?
Balloon tamponade +/- TIPSS procedure
Causes of microcytic anaemia
Iron deficiency
Thalassemia
Causes of macrocytic anaemia
Acute blood loss B12/folate deficiency Hypothyroidism Bone marrow infiltration Alcohol
Risk factors associated with oesophageal cancer
Achalasia, Barrett’s, alcohol, obesity
Risk factors associated with stomach cancer
Nitrates/nitrites, ethnicity, pernicious anaemia, prior surgery
Risk factors associated with pancreatic cancer
DM, chronic pancreatitis, mucinous cystadenomas, obesity
Risk factors associated with colon cancer
COLONIC POLYPS
Long standing IBD, FAP, HNPCC, Alcohol, obesity
Common symptoms of oesophageal cancer
Weight loss
Dysphasia
Common symptoms of stomach cancer
Anaemia, weight loss, vomiting
Common symptom of pancreatic cancer
Jaundice
Common symptoms of Colon cancer
Weight loss, anaemia, rectal bleeding, changes in bowel habit
Which LFTs are raised significantly in a hepatic picture?
AST and ALT
Which LFTs are raised significantly in a cholestatic picture?
Bilirubin, ALP
When ALT is more than 10x its normal value and ALP is less than 3x normal. What is the potential cause?
Hepatocellular injury
When ALT is less than 10x its normal value and ALP is more than 3x normal. What is the potential cause?
Cholestasis
If ALT>AST - what is the likely picture
Chronic liver disease
If ALT is
Cirrhosis or acute alcoholic hepatitis
If ALP is very high, what test should this be considered alongside?
GGT
If ALP and GGT are both high - possible causes
- Biliary epithelial damage
- Bile flow obstruction
- Alcohol and drugs
If ALP is high, but GGT is normal - possible causes
Non-hepatobiliary pathology or pathologies that increase bone breakdown (e.g. malignancies)
What can cause raised bilirubin?
Liver damage
Severe RBC damage (e.g. haemolysis)
Colour of urine if unconjugated bilirubin is high
Normal
Colour of urine if conjugated bilirubin is high
Dark
Cancer of head of the pancreas can
obstruct the bile duct and cause obstructive jaundice
Causes of painful jaundice
Cancer of the head of the pancreas
Cholangio carcinoma
