GI Flashcards
what causes GORD?
reflux of gastric contents back into oesophagus/prolonged contact with mucosa. Due to;
- reduced tone in LOS and transient relaxations
- increased mucosal sensitivity to gastric acid
Predisposing factors to GORD?
obesity, pregnancy, systemic sclerosis
Features of GORD?
heart burn, regurgitation, cough and nocturnal asthma, hoarse voice
Red flags of GORD?
weight loss, dysphagia, haematemesis, anaemia
Ix for GORD?
OGD, 24hr pH monitoring
Mx of GORD? + name 2 medications and their classes
- lifestyle - lose weight, avoid alcohol, avoid aggravating foods, stop smoking
PPI e.g. omeprazole
H2 receptor antagonist e.g. Ranitidine
Complications of GORD - name 2
strictures, barrret’s oesophagus
what is the histological change in barretts oesophagus?
squamous –> columnar epithelium
what is alchalasia?
oesophageal peristalisis - failure of the LOS to relax which impairs oesophageal emptying
name some Ix for oesophageal issues?
Barium swallow - shows the dilation of the oesophagus and the peristalisis
oesophageal manometry
OGD
CXR
what is a hiatus hernia?
when part of the stomach herniates through the oesophageal hiatus of the diaphragm
Main RF for malignancy in the lower 1/3 of the oesophagus?
Barrett’s oesophagus - adenocarcenoma (lower 1/3)
SCC occurs in the middle 1/3 - RF = smoking/alcohol
what is H.Pylori?
gram -ve urease producing bacteria found in the gastric antrum
which diseases is H.Pylori associated with?
chronic gastritis, peptic ulcer disease, gastric cancer, gastric B cell lymphoma
name 2 methods of non-invasive and invasive testing for H.Pylori?
NON INVASIVE - urea breath test, stool antigen test, serology
INVASIVE - endoscopic gastric mucosal biopsy (test for urease and then test histology)
Which Abx are given to eradicate H.Pylori?
omeprazole + metronidazole + clarithromycin
Name some causes of peptic ulcers
H.Pylori, NSAIDS, crohns
How do duodenal ulcers and gastric ulcer features differ?
DU - pain when pt is hungry
GU - pain when pt is eating
Name some complications of gastric ulcers?
Perforation –> painless haemorrhage
gastric outlet obstruction
Red flags with gastric ulcer symptoms?
pain similar to peptic ulcer
+ nausea, anorexia, weight loss
mets –> ascites and hepatomegaly
Name the two presentations of upper GI bleeding?
haematemesis = vomit blood malaena = passage of black tar stools
Mx for an upper GI bleed?
IMMEDIATE - FBC/UE/LFT/clotting. group and save, cross match 4 units, start IV fluids
- stop NSAIDS/warfarin/aspirin
- give PPI to high risk patients
- consider ABX
Name some causes of upper GI bleeding
mallory weiss tear, previous ulcer, varices, gastric carcinoma
Causes of lower GI bleeding (small intestine/colon)
SI - cancer, UC, meckels diverticulum
Colon - haemmerhoids, fissure, neoplasm, UC/CD, diverticular disease
How do you investigate a lower GI bleed?
resuscitate - fluids/blood
Hx and exam
protoscopy for anorectal disease
sigmoidoscopy
What is coeliac disease?
autoimmune condition whcih reacts to the a gliadin portion on the gluten molecule causing an inflammatory cascade
What is shown on histology on a patient with coeliac disease?
villous atrophy
crypt hyperplasia
increased intraepithelial cells
Features of coeliac disease?
tired, malaise, steatorrhea, deficiency in B12/folate/iron
What Ix do you do for coeliac disease?
Abs - TTG, EMA
FBC - anaemia?
DXA scan
Distal duodenal biopsy
Mx for coeliac disease?
gluten free diet, pneumococcal vaccine
What is the effect of a resected terminal ileum?
B12 malabsorption –> megaloblastic anaemia
Bile salt malabsorption –> renal oxalate stones
what is meckels diverticulum??
diverticulum which is left over from the umbilical cord (60cm from the ileocaecal valve)
how can a meckel’s diverticulum present?
lower GI bleeding, perforation, inflammation, obstruction
causes of intestinal ischaemia?
reduced blood flow
- atheroma
- embolism
- vasculitis
- shock
how does bowel ischaemia present?
severe abdo pain but with limited findings on examination
how do small bowel tumours present?
abdo pain, diarrhoea, anorexia, anaemia, carcinoid features
which conditions increase the risk of small bowel tumours?
crohns, coeliac
which cells do carcinoid tumours develop from?
enterochromaffin cells (produce serotonin)
how does carcinoid syndrome (increased serotonin present)
flushing, wheezing, diarrhoea, abdo pain
name a serotonin antagonist?
cyroheptadine
what does high 5HIAA in urine make a potential diagnosis?
carcinoid small bowel tumour
What causes IBD?
inflammatory condition affecting the bowel.
Genetics - stronger for CD, familial aggregation, links with HLAB27
Environment - reduced Rx of UC with smoking, smoking precipitates relapses
Features of CD presentation?
commonly affects ileocaecal bowel abdo pain and weight loss diarrhoea bleeding/pain on defacation anal tags/fissures/abscesses oral ulcers
Features of UC presentation?
diarrhoea and blood/mucus
urgency
tenesmus
L lower quadrant pain
Histological features of CD?
affects oral --> perianal parts of bowel discontinuous lesions deep ulcers/fissure (cobblestone appearance) transmural inflammation granulomas
Histological features of UC?
Colon only affected (begins in rectum then extends up) continuous lesions red mucosa/bleeds easily mucosal inflammation only no granulomata, crypt abscessees
How do you investigate IBD?
BLOODS - FBC (anaemia, platelets), ESR, CRP, albumin, LFTs
IMAGING - rigid flexible sigmoidoscopy, rectal biopsy, colonoscopy, small bowel imaging, plain XR
IBD DD?
infection, ischaemia, radiation, bacteria overgrowth
Name some extra-gastrointestinal features of IBD?
EYES - uveitis, episcleritis
JOINTS - arthralgia, ankylosing spondylitis, inflammatory back pain
SKIN - erythema nodosum
LIVER - fatty liver, sclerosing cholangitis, cirrhosis, hepatitis
RENAL - oxalate stones
How do you induce and maintain remission in UC?
Induce remission - Aminosalicylate/IV steroids
maintain remission - topical aminosalicylate (azathioprine if severe.)
How do you induce and maintain remission in CD?
STOP SMOKING
induce remission - steroids, enteral feed, infliximab
maintain remission - azathioprine/surgery
Name some complications of IBD
perforated bowel, strictures, abscesses, fistulae/fissures, colon cancer
What is the definition of constipation?
consistent difficulty in defacation. Infrequent passage of stools <3 days/weeks + straining and passage of hard stools with a sensation of incomplete emptying
Name some causes of pregnancy
GENERAL - pregnancy, low fibre, immobile METABOLIC - DM, hypothyroid FUNCTIONAL - IBS DRUGS - opiates NEURO - SC lesion, PD GI - hirschprung, obstruction
Constipation red flags?
rectal bleeding, anaemia, resent onset, >50, tenesmus
What are diverticula?
pouches of mucosa through colonic muscular wall, they form due to increased intracolonic pressure and areas of weakness in the bowel wall
RF for formation of diverticula?
age, low fibre diet, obesity, sedentary lifestyle, smoking and NSAIDS
Features of diverticular disease?
Lower left quadrant intermittant abdo pain, bloating, constipation and diarrhoea
Features of acute diverticulitis?
severe LLQ pain, N&V, constipation or diarrhoea, urinary symptoms, fever
Signs of acute diverticulitis on examination?
increased HR, tender LIF, reduced bowel sounds, guarding, rigidity, tenderness
Ix for acute diverticulitis?
CXR - perforated and pneumoperitoneum?
AXR - dilated bowel loops
CT abdo - abscess
AVOID COLONOSCOPY - PERFORATION RISK
How do you manage acute diverticulitis?
ABx, liquids, analgesia
Name two genetic conditions which increase the risk of bowel cancer
FAP, HNPCC
What screening would you do for someone with FAP/HNPCC?
FAP - annual colonoscopy to identify polyps and resect
HNPCC - colonoscopy every 1-2 years and extracolonic surveillance
Name some risk factors for colon cancer
age, family history, HNPCC, FAP, high animal protein and low fibre diet
Features of L and R sided colon cancer?
LEFT - rectal bleeding, stenosis, altered bowel habit, colicky bowel pain
RIGHT - anaemia, RIF mass
Ix for CRC?
IMAGING - colonoscopy, CT, barium enema
BLOODS - FBC, UE, LFT, CEA tumour marker
CXR, PET
Faecal occult blood test
How are the general public screened for CRC?
age 60-74
Faecal occult blood/FIT every 2 years
one off flexible sigmoidoscopy
How do you investigate IBS?
stool culture, baseline bloods (FBC, ESR, B12, folate, coeliac, TFT)
How do you manage IBS?
low FODMAP diet
amitryptilline
manage any depression/anxiety which is underlying
what are some non-GI causes of the acute abdomen presentation?
DKA, MI, pneumonia, IBS
what do you want in the history of the acute abdomen?
Abdo/urinary/gynae Hx
- ONSET - sudden e.g. perforation/torsion/AAA/ectopic
- SITE - e.g. RIF = appendicitis, LLQ = diverticulitis
- COLICKY - mechanical flow obstructed (e.g. ureteric calculi, bowel obstruction)
what are you looking at on initial examination of an acute abdomen presentation?
shock - ruptured organ?
fever
peritonitis - tenderness, buarding, ridgidity
obstruction - “tinkling bowel sounds”
Ix of the acute abdomen?
rectal and pelvic exam Bloods - FBC/UE/LFT/amylase urinalysis CXR AXR laparoscopy pregnancy test
What causes appendicitis?
lumen of the appendix is obstructed by faecocolith
Features of acute appendicitis?
central abdo pain which localises to the RIF
anorexia, N&V, diarrhoea
pyrexial
guarding and tenderness
Ix for acute appendicitis?
Bloods - WCC, CRP, ESR
US and CT of the abdomen
name 2 causes for localised peritonitis
acute appendicitis, cholecystitis
What causes generalised peritonitis?
rupture of abdominal viscus, e.g. ulcer
Main causes of a small intestine obstruction
adhesions, hernias, crohns, intussuption, extrinsic cancer involvement
Main causes of colonic obstruction?
carcinoma of the colon, sigmoid volvulus, diverticular disease
Features of a bowel obstrucrion?
bowel above obstruction is dilated
colicky abdo pain
vomiting (soon in SBO + bilious)
Constipation (earlier with LBO)
Findings on abdo exam of a bowel obstruction?
distension and tinkling bowel sounds
Mx of a SBO and LBO
SBO - NG suction and IV fluids
LBO - surgery
Name a cause of functional bowel obstruction and when does it occur?
paralytic ileus - occurs after abdo surgery/opiate use
