GI Flashcards
1
Q
What is IBS?
Who does it tend to affect?
A
- A functional disorder –> no organic cause causing symptoms
- Affects 20% population. F>M. Commoner in young adults.
2
Q
What presentation should make you think of IBS?
A
->6 months of abdo pain, change in bowel habit, bloating.
ABC
3
Q
What are the NICE criteria for diagnosing IBS?
A
Abdominal pain relieved w defecation AND altered stool form/frequency e.g constipation or diarrhoea.
AND two of
- Bloating –> F>M
- Mucous PR
- Altered stool passage –> urgency, straining
- Pain worse after eating
4
Q
What are the investigations for IBS?
A
- Exclude alternatives
- Bloods –> FBC, CRP, ESR normal
- Faecal calprotectin –> r/o IBD
- Negative coeliac serology e.g anti TTG Ab
- No suspicion of cancer, or when is r/o
5
Q
What are the red flags for Ca shouldn’t ignore in IBS?
A
- Weight loss
- Onset after >60
- Rectal bleeding
- FH bowel or ovarian Ca
6
Q
What is the conservative management for IBS?
A
- Good fluid intake
- Small regular meals
- Limit caffiene and alcohol intake w <3 cups
- Low FODMAP diet
7
Q
What is the medical Tx options for IBS?
A
1st line - according to predominant symptom
- Anti spasmodic –> hyoscine butylbromide –> buscopan
- If diarrhoea –> loperamide
- If constipation –> laxative. Not lactulose as increases constipation.
2nd line for constipation
-Linaclotide –> specific for IBS. When symptoms not improving on max conventional lactulose and constipation >12 months.
2nd line general
-TCA –> amitriptylline –> 5-10mg at night
3rd line
-SSRI
Other
-Psychological therapy –> CBT –> symptoms not improving after 12 months, refractory IBS
8
Q
What is appendicitis?
Who does it most commonly affect?
A
- Inflamm of the vermiform (worm shaped tube) from caecum.
- Commonly caused by constipation
- Obstruction by faecolith (hardened stool mass) –> bacterial overgrowth and infection
- Obstruction –> increase pressure, ischaemia, perforation
- Most common cause of acute abdo needing surgery
- Lifetime risk of 1 in 15
-F>M, 10-20 years old
9
Q
What is the typical presentation of appendicitis?
What is a child unable to do?
A
- Periumbilical pain migrating to RIF over 24-48 hours. Migration one of strongest indicators.
- Anorexia - not hungry
- Nausea. Possible 1-2 episodes of vomiting but not persistent.
- Mild fever 37.5-38.
- Pain worse on coughing, speed bumps.
- Perforation –> peritonitis –> guarding, rebound tenderness
-Child unable to hop on one leg due to pain.
10
Q
What are some of the signs for appendicitis on examination?
A
- Psoas –> pain on extension of the hip - positive in retrocaecal appendix which can present atypically
- Obturator/cope –> pain on flexion and internal rotation of hip
- Possible rovsings
11
Q
What are the investigations in appendicitis?
A
- Bloods –> raised inflamm markers e.g CRP, ESR, WBC. Possible neurophil leukocytosis 80-90%.
- Urinanalysis –> r/o pregnant, renal colic, UTI. Can show leukocytes but not nitrites.
- Possible US –> in F to r/o ovarian pathology
- CT abdo pelvis –> commonly used in US to diagnosis but not here
- Clinical diagnosis –> based upon Hx and Ex
12
Q
What is the management for appendicitis?
A
- Laproscopic appendictomy. In pregnancy open.
- Ab –> before surgery and after. And in perforation. Broad spectrum w g-ve and +ve –> coamoxiclav
- Perforation 15-20% –> abdominal lavage
- Cases can resolve w IV Ab but high risk recurrence so remove.
13
Q
What are haemorrhoids?
A
- Symptomatic, enlarged anal vascular cushions (not just dilated veins)
- These anal cushions –> contain AV channels where superior rectal artery and vein join –> at 7, 11, 3 o clock
- RF –> middle age, constipation w straining, pregnancy
14
Q
What are the types of haemorrhoids and grading?
A
- Internal –> above dentate line, not generally painful
- external –> below dentate line, prone thrombosis, painful
Grading of internal 0- Never prolapsed 1 - Prolapse w spontaneous reduction 2 - Prolapse w manual reduction 3 - Irreducible
15
Q
What are the symptoms of haemorrhoids?
A
- Bright red rectal bleeding - blood on wiping.
- Usually painless. can be painful when thrombosed
- Itchy, possible PR mucous
- Anaemia
- R/o weight loss, change in bowel habit
16
Q
What are the investigations for haemorrhoids?
A
- PR –> internal haemorrhoids commonly not palpable. External visible
- Protoscope –> for examine. check colour and pain.
- Thrombosed –> enlarged, painful, purple, oedematous
- Rectal bleeding –> abdo exam to try r/o alternative causes
- FBC, check anaemia
- Those >50 refer colonscopy/flexible sigmoidoscopy
17
Q
What is the management for haemorrhoids?
A
- Never prolapse 1st line –> Reassure avoid straining, soften stools, fluids, high fibre diet, bulk laxatives? Topical anaesthetic for short term use
- 2nd line never prolapse/1st line grades 2 and 3 –> band litigation. Doesn’t work can try injection sclerotherapy.
- surgery –> reserved for large symptomatic not responding to above. Excisional haemorrhoidectomy.
Acutely thrombosed –> presenting w/I 72 hours can refer surgery for excision. Longer then analgesia, stool softeners ice packs, rest, should resolve w/I 2 weeks.
18
Q
What is coeliac disease?
In hat age groups does it tend to present?
A
- Autoimmune - abnormal jejunum mucosa means increased sensitivity to protein gluten.
- Gluten –> toxic portion, alpha gliadin –> interacts w APC in lamina propia via HLA DQ2 and DQ8 –> activates gluten sensitive T cells –> inflamm
- Repeated exposure –> villous atrophy and malabsorption
- 1/100
- Two peaks –> 12-18 months and 40-60 years
- Associated w human leukocyte antigens, HLADQ2 (90%), HLADQ8 (80%).
- RF –> autoimmune disease e.g T1DM, or thyroid. These should be screened
19
Q
What is the presentation of coeliac?
In adults and children
A
- Chronic or intermittent diarrhoea, steathorrea, abdo pain, constipation, distension, bloating, weight loss,
- Fatigue –> malabsorption –> iron, B12, folate deficiencies. 50% iron deficiency.
- Mouth ulcers and angular stomatitis.
- Osteoporosis due to Ca and vit D deficiency malabsorption
- Children –> failure to thrive, nausea and vomiting, diarrhoea/constipation, abdo protrusion w waster buttocks.
- Dermatitis herpiformis –> itchy vesicular rash, present when episodes. Tx dapsone
20
Q
What are the investigations for coeliac disease?
What are the rules if the individual has stopped eating gluten?
What are the 4 things you would expect to see on biopsy?
A
- Bloods –> anaemia, 50% iron deficiency
- If patient has stopped eating gluten need to reintroduce for 6 weeks before tests
Immunoglobulins
- 1st line –> IgA tissue transglutinamise Ab
- ?endomysial Ab when no result IgA to r/o IgA deficiency
- IgA TTG +ve or -ve and strongly suspect –> biopsy
Distal duodenal biopsy
- Villous atrophy
- Crypt hyperplasia
- Increased in intraepithelial lymphocytes
- Infiltration of lymphocytes in lamina propia
21
Q
What is the management of coeliac disease?
A
- Lifelong gluten free diet
- Correct any deficiencies
- Calcium a vitamin D supplements
- Annual review
- Have functional hyposplenism –> pneumococcal vaccine with another every 5 years.
22
Q
What is crohns?
A
- A type of IBD –> characterised by transmural granulomatous inflamm, can affect any part of GI tract, mouth to anus, but most commonly terminal ileum and colon (70%).
- Areas of not affected bowel in between –> skip lesions.
- Inflamm occurs in all layers, down to serosa. Therefore prone strictures, fistulas, adhesions.
- Cause not known, strong genetic suscpetibility. ?abnormal immune response to gut flora.
- Commonly presents late adolescent/early adulthood, can be 20s-40s, smoking x3 risk.
23
Q
What is the presentation of crohns?
A
- Diarrhoea (80%) –> most prominent symptom in adults. Usually non bloody, crohns colitis can cause bloody.
- Abdominal pain –> most prominent symptom in children.
- Can present w non specific symptoms –> weight loss and lethargy.
- Perianal disease (25%) –> skin tags, fistulas, ulcers. Often before GI symptoms.
- Possible mouth ulcers.
- Extra GI features –> most common in those w colitis or perianal disease. E.g clubbing
- 1/3 w IBD –> anaemia. Most common cause decrease iron –> chronic inflamm interferes w ability to absorb. Blood loss from intestinal bleeding and poor absorption vit and mineral can also be decrease B12 and folate.
24
Q
What are the investigations in crohns?
A
- Bloods –> FBC, increase inflamm ESR, CRP, WCC, platelets. Anaemia common. Low B12 and folate.
- Faecal calprotectin –> non invasive test for GI inflamm. Protein biomarker.
- Stool tests –> MC and S, r/o bacterial infection e.g e col, check parasites when recent travel history.
- COLONOSCOPY W BIOPSY –> DIAGNOSTIC –> endoscopy shows skip lesions w cobblestone apperance, deep ulcers. Biopsy shows transmural disease w granulomatous inflamm (and increase goblet cells).
- Small bowel imaging mandatory in suspected crohns –> CT w oral contrast or barium follow through –> info on disease extent. Can stage crohns.
25
What is the management for inducing remission in crohns?
Inducing Remission
-1st line --> Steroids e.g. oral prednisolone or IV hydrocortisone.
-Mild to mod --> symptomatic relief but systemically well --> oral prednisolone 40mg PO, slowly reduce over 7 weeks
-Severe --> Admit for IV hydration/electrolyte replacement. IV steroids e.g 3 days then switch prednisolone PO 2 weeks.
-If steroids alone don’t work, consider adding immunosuppressant medication under specialist guidance Azathioprine, Mercaptopurine, Methotrexate, Infliximab, Adalimumab.
26
What is the management for maintaining remission in crohns?
Maintaining Remission
- Tailored to individual patients based on risks, side effects, nature of the disease and patient’s wishes. It is reasonable not to take any medications whilst well.
- All patients --> regular monitoring to exclude persistent inflamm.
- Medical maintenance when >2 steroid courses per year or relapse <6 weeks stopping.
- 1st line --> Azathioprine, Mercaptopurine. Sometimes Methotrexate.
- Alternatives --> anti TNF agents --> infliximab, adalimumab. Use biologics in refractory severe disease. Stops neutrophil accumulation and granuloma/
Surgery
- Needed in 70% those w crohns – can produce substantial symptomatic improvement.
- Indicated when medical therapy not working, complications e.g GI obstruction, strictures, fistulae, abscess or failrue to grow in children w medical treatment.
- Minimal resections.
- Stricture plasty --> treat strictures and blockages w/o removing any gut/
- Resection --> remove damage parts, join ends healthy sections.
- When the disease only affects the distal ileum it is possible to surgically resect this area, ileocaecal resection and prevent further flares of the disease. Crohns typically involves the entire GI tract
