GI and Hepatobiliary Flashcards
What pathogens are known for causing Liver Abscesses?
CASE:
-Coliforms
-Anaerobes
-Staph Aureus
-Enterococci
A patient comes in with a suspected Liver abscess. What are the next steps?
1.Take blood cultures
2.Pending culture results start antibiotics
3.Discuss potential drainage with surgeons / interventional radiology
What treatment is given to a patient with a Liver abscess?
-IV Gentamicin
-IV Amoxicilin
-IV Metronidazole
If a patient with a Liver abscess has a Penicillin allergy, what can’t be given and what will be given instead?
Instead of Amoxicilin give:
IV Vancomycin
A patient comes in with a potential Liver abscess. What other 2 conditions should also be considered?
Amoebic abscess or Hyatid Cyst
What are the 3 major forms of liver abscesses?
-Pyogenic Abscess - majority of cases, polymicrobial
-Amoebic Abscess- around 10% of cases
-Fungal Abscess - less than 10% of cases
What bacteria causes Amoebic Abscesses?
Entamoeba Histolytica
What bacteria causes Fungal abscesses?
Candida species
What is the most common cause of Pyogenic Liver disease?
Very key to remember this!
Biliary tract disease = obstruction of bile flow facilitates bacterial proliferation.
Examples:
-Biliary stone disease
-Obstructive malignancy affecting the biliary tree
-Strictures
-Congenital diseases
Describe the pathophysiology of Liver Abscesses.
1.Infections in organs in the portal bed - for instance systemic bacteremia : e.g Endocarditis and Pyelonephritis
2.Can result in SEPTIC THROMBOPLEBITIS
3.Septic emboli are released into the portal circulation
3.S.emboli are trapped by hepatic sinusoids
4.This is where the microabscesses form
5.The microabscesses coalesce into a solatary lesion
4% of Abscess are caused by what?
Fistula formation between local intra-abdominal infections.
What is a fistula?
An abnormal opening in the stomach or intestines that allows the contents to leak to another part of the body.
What usually causes an anal fistula?
It’s usually caused by an infection near the anus, which results in a collection of pus (abscess) in the nearby tissue. When the pus drains away, it can leave a small channel behind.
List the causes of fistulas in the stomach?
Remember Mneumonic
I Rarely Deliver Many Tight Slap SDIMRT
1.Inflammatory bowel disease
2.Radiation
3.Diverticular disease
4.Malignancy
5.Trauma
6.Surgical procedures
Fistulas, think FIST then think SLAP
What is the prognosis of pyogenic liver abscesses?
When untreated: Always fatal
With treatment (antibiotics + drainage) : 5-30% of cases are fatal due to SEPSIS, MULTIORGAN FAILURE, HEPATIC FAILURE
What signs would indicate a poor prognosis for a pyogenic abscess?
-Multiple Abscesses
-Underlying malignancy
-Severity of underlying medical conditions
-Presence of complications
-Delay of diagnosis
What signs would indicate a poor prognosis for a amoebic abscess?
-Bilirubin level > 3.5mg/dL
-Encephalopathy
-Hypoalbuminemia (serum albumin <2g/dL )
-Multiple abscesses
What is the inheritance or transmission of Ornithine Transcarbamylase (OTC) deficiency?
It is a genetic condition: X linked recessive
What is the pathophysiology of OTC deficiency ?
1.Due to x linked recessive genetic disorder
2.patients have issues processing nitrogen generated from amino acid breakdown in the urea cycle.
3.Results in a build up of ammonia (hyperammonaemia) in the blood
4. which can have serious effects on the CNS
5.Cause vomiting lethargy and coma
What are the symptoms of OTC deficiency?
Vomiting, Lethargy and Coma
What is the treatment for OTC deficiency?
Nitrogen Scavenging Medication
E.g Oral formulations of benzoate and phenylbutyrate
List the causes of mouth ulcers.
Remember mneumonic
Stinky Toads Don’t Infect Little Children
1Stomatitis (Recurrent aphthous ulcers)
2.Trauma
3.Deficiencies of nutrients (e.g B12, folate)
4 .Infections - Viral and fungal (e.g Coxsackie, HIV)
5.Leukoplakia (pre-malignant)
6.IBD (e.g Chron’s)
When thinking mouth ulcers think of toads you kiss with stinky breath
What are Kaposi sarcoma?
i.e Where do you see them and how does it present?
Pre-malignant condition of cancer cells in the GI tract, presenting with reddish-blue oral maculae and oral hairy leukoplakia (white patches)
What does Leokoplakia mean?
White patches
What is Kaposi Sarcoma caused by? List them.
-Epstein-Barr
-Early sign of HIV (the infection is due to immunosuppresion)
What is the management of Kaposi Sarcoma?
-No cure for it or Epstein Barr so targets slowing progression and aiding symptoms.
=Highly Active Antiretroviral Therapy (HAART).
What is geographic tongue?
Idiopathic inflammation of the mucosa causing loss of papillae, a burning sensation and a map-like appearance (hairy tongue- abnormal proliferation of keratin)
What is the prognosis for Geographic tongue?
Pretty harmless and resolves itself.
What does Geographic tongue indicate about a patient?
Nothing! Geographic tongue is an independent disorder that is pretty harmless and does not indicate any other pathology.
A patient has dysphagia. How do you decide between the 2 investigative options and what are they?
If the patient can’t swallow SOLIDS AND LIQUIDS:
=1.Barium Swallow
If the patient can’t swallow SOLIDS ONLY:
=2.Upper GI endoscopy
What is Achalasia?
A motility disorder of the oesophagus causing a lack of propulsion of the oesophagus (aperistalsis) and relaxation of the oesophageal sphincter causing PROGRESSIVE DYSPHAGIA OF BOTH SOLIDS AND LIQUIDS.
What is the pathophysiology of Achalasia?
Idiopathic cause of degeneration of the ganglion cells of the myenteric plexus within the oesophageal wall and lower sphincter.
A patient has suspected Achalasia. What are the next steps in diagnosis?
1.Barium Swallow Exam
2.CXR
3.Manometry
4.Consider an Upper GI endoscopy
What are possible complications of Achalasia?
-Slim associated risk of SQUAMOUS CELL CARCINOMA (SCC) of the Oesophagus
-Oesophageal cancer as a result of long-standing achalasia.
Describe the first line management of Achalasia .
First line: Surgical Myotomy (Heller procedure)
+Fundoplication as well for GORD patients / prevent GORD
What is secondary achalasia?
Achalasia than can occur for instance, after a compression caused due to a fundoplication surgery.
What are the symptoms of Achalasia?
-Dysphagia (SOLIDS AND LIQUIDS)
-Retrosternal pain
-Regurgitation (and can relieve symptoms)
What are the findings of a Barium Swallow Examination of a patient with Achalasia?
‘Bird’s Beak’ appearance of the proximal oesophagus as it is dilated and the lower sphincter is narrow.
What findings would suggest Achalasia on a CXR?
-Normal
-Widened Mediastinum (due to dilated oesophagus)
What is the gold standard investigation of Achalasia and what would conclude the diagnosis?
Manometry
=High resting pressure of the lower oesophageal sphincter
Why is a GI endoscopy sometimes performed for a patient with Achalasia?
To rule out malignancy
What is the difference between GORD and Achalasia?
Achalasia is dysphagia of SOLIDS and LIQUIDS while GORD is dysphagia of just SOLIDS.
What is the contraindication (s) for first line treatment for Achalasia and what 2 management options are offered instead?
-If the patient isn’t fit - the elderly, co-morbidities, bed-bound, palliative etc
1.Endoscopic Pneumatic Dilatation
=Patients who are older and have co-morbidities
2.Botulinum injections into sphincter
=for patients unfit / unwilling for an invasive procedure
Out of all of the management options for Achalasia on offer, what is the less effective?
Botulinum injections
=disease frequently reoccurs
What is the difference between Diffuse Oesophageal Spasm and Achalasia?
Both are due to dysphagia of SOLIDS AND LIQUIDS but Achalasia is PROGRESSIVE while Diffuse Oesophageal spasm is INTERMITTENT.
What is the key diagnostic tool for a suspect Diffuse Oesophageal Spasm?
Barium swallow Examination
What result from diagnostic procedure(s) would you expect from a patient with Diffuse Oesophageal Spasm?
‘Corkscrew Oesophagus’
What is the first line treatment for Diffuse Oesophageal Spasm?
PPIs e.g Omeprazole
What are the second line treatment options for Diffuse Oesophageal Spasm?
Nitrates and Calcium Channel Blockers
What 2 oesophageal disorders mimic anginal attacks?
-Diffuse Oesophageal Spasm
-Nutcracker Oesophagus(swallowing contractions are too intense - affects many GORD patients)
What is the final-line management option for Diffuse Oesophageal Spasm?
i.e Last ditch effort
Pneumatic Dilatation and Surgical Myotomy
What is a pneumatic dilation?
Endoscopic guided procedure to fix restricted oesophageal sphincter by weakening the lower oesophageal sphincter by tearing its muscle fibres by generating radial force.
What is another name for Pharyngeal Pouch syndrome?
Zenker Diverticulum
What is Pharyngeal pouch (Zenker Diverticulum)?
Rare condition characterised by an outpouching of the oesophagus due to a weakness in the muscle allowing food debris to accumulate which compresses the oesophagus.
What are the symptoms of Zenker Diverticulum?
-Progressive Dysphagia
-Regurgitation
-Halitosis
What is Halitosis?
Halitosis is an oral health problem where the main symptom is BAD SMELLING BREATH. In most cases, finding the cause of the bad breath is the first step toward treating this preventable condition.
What is the investigation for suspected Pharyngeal Pouch?
Barium swallow examination
What is the management of Pharyngeal Pouch?
Surgical intervention
What investigation is contraindicated for suspect Pharyngeal Pouch and why?
Endoscopy = can perforate the pouch causing complications
What is Dyspepsia?
Heart burn and bloating
What are the red flag symptoms associated with Dyspepsia that calls for a further investigation with an Upper Endoscopy?
Remember mneumonic.
High SLAM Problem Alert
Haematemesis
Swallowing difficulty
Low Weight
Anorexia
Melaena
Progressive symptoms
Anaemia
What are the 2 causes of GORD?
1.Lower Oesophageal Sphincter (LOS) dysfunction which allows acids from stomach but up to oesophagus
2.Hiatus hernia = of the upper stomach which eliminates the natural thoraco-abdominal pressure gradient
What are the 3 classes of hiatus hernias?
-Sliding (80%)
-Rolling
-Mixed
What are the risk(s) of Rolling Hernias and what can be done to prevent it ?
Increased risk of strangulation
=Repair- Laparoscopic Fundoplication
What lifestyle factors exacerbate GORD?
-Smoking
-Alcohol
-Caffeine
-Obesity
-Pregnancy
Describe the pathophysiology of GORD.
Relfux of gastric contents into oesophagus exposes the mucosal epithelium to damage and triggers and inflammatory response causing REFLUX OESOPHAGITIS.
What are the symptoms of GORD?
-Heartburn (gets worse after meals and after lying down)
-Acid Brash (metallic taste as a result of acid regurgitation)
-Dysphagia
-Atypical chest pain
What are the 3 stages of investigation for a suspect GORD patient?
1.PPIs (for young patients / typical symptoms) on a high-dose trial
2.Consider GI endoscopy
=for uncertain diagnosis / patients > 55yrs
3.Consider ambulatory intraluminal pH monitoring
=for patients under consideration for Laparoscopic Fundoplication
Describe what the results of a ambulatory intraluminal pH monitoring from a GORD patient would indicate.
pH <4 at >4% of the time would indicate SURGERY
Describe the stepwise management for GORD.
1.Lifestyle modification
2.Full dose PPI therapy (4-8 weeks)
3.If symptoms persist / reoccur:
-switch to H2 Antagonist(e.g Cimetidine, ending -tidine)
4.Consider Laparoscopic Fundoplication
(directed according to the pH ambulatory results)
Name 4 complications of GORD.
1.Oesophagitis
2.Barret’s Oesophagus
3.Oesophagus Carcinoma
4.Benign Oesophageal stricture
A patient presents with dysphagia (solids only) and vomiting. Other than GORD, what is a key differential to consider?
Eosinophilic Oesophagitis
When should a patient with GORD-like symptoms be considered for Eosinophilic Oesophagitis?
If they have a history of atopy (e.g ASTHMA, ECZEMA)
What diagnostic procedure would demonstrate Eosinophilic Oesophagitis?
Endoscopic Biopsy
What is the treatment for Eosinophilic Oesophagitis?
Aerosolised glucocorticoids with oral glucocorticoid therapy in more severe cases.
What is Barret’s oesophagus?
Pre-malignant condition due to GORD
How often should a suspect Barret’s Oesophagus be monitored?
Endoscopic surveillance every 1-3 yrs
What treatment for HIGH GRADE DYSPLASIA Barret’s oesophagus?
Surgical Oesophagectomy
What is the histological definition of Oesophageal cancer and what are the 2 subtypes?
Mucosal Neoplasm originating from Oesophageal Epithelium
- Squamous Cell Cancer
2.Adenocarcinoma
What type of cancer does Barret’s Oesophagus usually cause?
Adenocarcinoma
Where do the 2 types of Oesophageal cancers originate?
-Adenocarcinoma = lower oesophagus *where Barret’s oesophageal changes are
-Squamous Cell Cancer = middle 1/3rd of oesophagus
Describe the prevalence of Oesophageal cancer- is it men or women who are mainly affected?
Men twice more than women
What type of Oesophageal Carcinoma is more common in Western Countries?
Adenocarcinoma is more common that Squamous Cell Carcinoma
What pre-existing conditions are risk factors of Oesophageal cancer?
-GORD
-Barret’s Oesophagus
-Paterson-Brown-Kelly Syndrome
What is Patterson-Brown-Kelly Syndrome?
Iron deficiency anaemia being associated with Post-Circoid Webs.
What is another name for Paterson-Brown-Kelly Sydrome?
Paterson-Vinson Syndrome
What are Oesophageal webs?
An oesophageal web is a thin (2-3 mm), eccentric, smooth extension of normal oesophageal tissue consisting of mucosa and submucosa that can occur anywhere along the length of the oesophagus causing dysphagia.
Is Obesity a risk factor for Oesophageal cancer?
Adenocarcinoma:
Risk factor
Squamous Cell Carcinoma:
Protective
What are the symptoms of Oesophageal cancer?
-Asymptomatic till late stages:(
-Progressive dysphagia (solids then liquids as well)
-Haematemesis or Melaena
-Late stage Hoarseness
-Weight loss
What are the main risk factors for Squamous Cell Oesophageal carcinoma?
Smoking and alcohol
Describe the stepwise investigations for suspect oesophageal cancer.
1.Arrange Blood Test (FBC), U&E, LFT
-FBC: Look for anaemia secondary to oesophageal bleed
-Check suitability of CT scan staging
-Look for Liver Metastasis
2.Urgent Oesophagogastroduodenoscopy
3.Staging imaging
-Abdominal CT scan
-PET scan = screens for metastasis
What is the management for the majority of patients diagnosed with Oesophageal cancer and why?
70% of patients diagnosed are late stage and therefore metastasis has already happened.
–>Palliative :(
-Chemotherapy and Oesophageal Stenting
=provides symptomatic relief of dysphagia
–>IF PATIENTS ARE FIT:
-Surgical Resection
What is the treatment for Oesophageal webs/ rings?
Endoscopic Dilatation or surgery to relieve dysphagia symptoms.
What are the 4 causes of Haematemesis from the stomach?
-Peptic / Duodenal Ulcer (NSAID / H.Pylori)
-Gastritis
-Angiodysplasia
-Gastric Cancer
What are the 4 causes of Haematemesis from the oesophagus?
1.Varices
2.Oesophagitis
3.Mallory-Weiss Tear
4.Oesophageal cancer
What are the 2 most common causes of upper GI bleeds (Haemetemesis)?
Ulcers and Varices
What is the initial resuscitation treatment for a patient in the ER with Haematemesis?
1.Ensure Oxygen supply
=High Flow Oxygen
2.Obtain IV access
=Wide-bore canula in each arm
-IV Crystalloid Fluid
3.Send off urgent bloods
-FBCs: Check for anaemia and platelets
-LFTs: Check for pre-existing liver disease
-U&Es : Check existing Acute Kidney Injury and Urea rise
-Clotting and coagulation screen
-Cross match blood
A patient presents with Haematemesis. What does a high urea and normal creatinine suggest?
Suggestive of an Upper GI Bleed
What is given to a patient with suspected Variceal bleed?
Terlipressin / Octreotide
A patients comes to the ER with Haematemesis. After resecuitation, what are the next steps?
Urgent endoscopy
A patient with Haematemesis is considered high risk. What should be given?
72hr PPI IV infusion
If haematemesis bleeding continues, what procedures should be considered to stop the bleeding?
-Balloon Tamponade
or
-Transjugular Intrahepatic porto-systemic shunting
What is Gastritis?
Inflammation of the stomach
What are the 2 types of Gastritis?
Acute and Chronic
What are the causes of Acute Gastritis?
-H.Pylori Infection
-Alcohol
-NSAIDs/Aspirin
-Stress-induced
-Bile-acid reflux (usually post-op)
What are the causes of Chronic Gastritis?
-Chronic H.Pylori
-Chron’s Infection
-Sarcoidosis
-Autoimmune (atrophic)
What does Atrophic mean?
Autoimmune
What is the pathophysiology Autoimmune Gastritis?
Chronic gastritis caused by autoimmune destruction of the parietal cells of the stomach which means there is an Intrisic Factor deficiency leading to Pernicious Anaemia (B12 deficiency)
What is Pernicious Anaemia?
B12 deficiency
The development of Autoimmune Gastritis is strongly associated with WHAT other disorders?
3 Endocrine disorders:
-Addison’s
-Type 1 Diabetes Mellitus.
-Autoimmune thyroid disease
What is the treatment for Autoimmune Gastritis?
B12 injections and Iron Infusions
What is the treatment for Gastritis?
PPIs
List the causes of Peptic Ulcer Disease (recurrent Peptic Ulcers)
-H.Pylori
-Drugs -Aspirin / NSAIDs
Secondary to:
-Intracranial neurology
-Burns or ulcer
=Due to this then called CUSHING ULCER
Rare causes:
-Zollinger- Ellison Syndrome
-Chron’s disease
What is a Cushing Ulcer?
A peptic ulcer caused by
-Intracranial neurology
-Burns or ulcer
Describe the symptoms of a Peptic Ulcer.
-Epigastric pain
-Bloating
-Abdominal distension
-Nausea
Differentiate the stomach pain between a peptic ulcer and a duodenal ulcer.
Duodenal ulcer epigastric pain is IMPROVED upon EATING,
while peptic ulcers, epigastric pain get WORSE with EATING
How does H.Pylori cause gastric issues e.g peptic ulcer, gastritis?
Stimulated gastrin production as well as inhibiting somatostatin production, resulting in and increase in acid secretion.
A patient with a Peptic ulcer needs to go on NSAID therapy. What else should therefore be prescribed?
COX2 inhibitor(e.g Ibeprofen, Naproxen)
A patient has a peptic ulcer due to H.Pylori. What is the management?
1.7 day course of Triple Therapy:
-High dose PPIs
-2 twice daily antibiotics
-Amoxicillin
-Metronidazole or Clarithromycin
2.Re-test @ 6-8weeks with Carbon 13 urea breath test
3.Those who remain symptomatic offer Bismuth
If a patient with a H.Pylori Peptic ulcer has a Penicillin allergy, what from their treatment plan must be replaced and what with?
Amoxicillin replaced with Clarithromycin
A patient is being prescribed Bismuth. What do they need to be aware of?
Expect black stools
What is the management for a peptic ulcer NOT caused by H.Pylori?
1.Stop offending medications for 8 weeks
2. Offer medication advice
If recurrent:
-Offer low dose PPI and rule out other reasons
What are possible complications if Peptic Ulcers?
-Acute GI haemorrhage
-Perforation causing bleeding into abdominal cavity causing SEVERE PERITONITIS:
MEDICAL EMERGENCY
-Gastric Outlet Obstruction
-Malignant transformation
What type of ulcer is most likely to cause perforation of the ulcer and therefore severe peritonitis?
Anterior Duodenal Ulcers
What type of ulcer is more likely to bleed causing peritonitis and why?
Posterior Duodenal ulcers (due to their close proximity to the Gastroduodenal artery)
What is meant by Gastric outlet obstruction and what will happen?
Gastric outlet obstruction (GOO) is a result of any disease process that causes a mechanical impediment to gastric emptying which then causes Fibrotic Stricturing.
What is Zollinger-Ellison Syndrome?
A rare condition caused by gastrin-secreting gastrinoma which is usually pancreatic origin. It is characterised by hypersecretion of GASTRIC ACID, resulting in EXTENSINVE PEPTIC ULCERATION
What is Zollinger-Ellison Syndrome strongly associated with?
Multiple Endocrine Neoplasia (MEN TYPE1) which is usually malignant.
Note: 20% of patients with Zollinger-Ellison Syndrome have MEN type 1
What are the symptoms of Zollinger-Ellison Syndrome?
-Epigastric pain
(due to ulcerations and GORD)
-Diarrhoea
How does Zollinger-Ellison Syndrome caused Diarrhoea?
Due to the high gastric acid secretion, this damages pancreatic enzymes that are required in the small intestine and therefore damages it leading to incomplete digestion and therefore Diarrhoea
What investigations are necessary for suspect Zollinger-Ellison Syndromeand what would the results be?
1.FBC
=Microcytic anaemia due to chronic ulcer bleed
2.Fasting gastrin levels
>1000pg/ml is diagnostic
3.MEN1 Screen (Calcium, PTH and Prolactin)
4.Endoscopic ultrasound
=check for cancer and metastasis
What is the treatment for Zollinger-Ellison Syndrome?
First line: High dose PPIs
Localised diseases (some need): Surgical resection
If Metastatic: Somatostatin analogues
What type of cancer is usually gastric cancer?
Adenocarcinoma
How is more likely to get gastric cancer, men or women?
Men (twice as much)
What lifestyle factor links Japan to Gastric Cancer more than Western countries?
Raw fish diet
What other disorders are risk factors of Gastric Cancer?
-Autoimmune Gastritis
-Familial Adenomatous Polyposis
What are the symptoms of Gastric Cancer?
-Usually asymptomatic in early stages
-Dyspepsia
-Progressive dysphagia with vomiting and haematemesis
-Weight loss /Anorexia
-Iron-deficiency anaemia
What is Linitis Plastica?
Rare form of diffuse gastric cancer that has a leather bottle appearance and is NOT caused by H.Pylori.
What are Eponymous signs?
-Supraclavicular nodes metastasis (Virchow’s sign)
-Umbilicus metastasis
-Ovaries metastasis
What is a Virchow’s node?
Metastasis to Supraclavicular nodes
What is Sister Joseph nodules?
Umbilicus metastasis
What is a Krukenberg tumour?
Ovaries metastasis
Describe the stepwise investigations into suspected gastric cancer.
1.FBC: Microcytic anaemia
2.LFTs (Liver metastasis?)
3.Urgent upper GI endoscopy
-CT, AXR and Pelvis (for staging)
How to treat early-localised Gastric Cancer?
Curative Surgical Resection with pre-operative neoadjuvant chemotherapy
How to treat advanced non-operable gastric cancer?
Palliative
-Chemo
-Stenting
What is the treatment for Human Epidermal Receptor 2 positive metastatic disease?
Trastuzumab
What are Gastrointestinal Stromal Tumours?
Submucosal tumours originating from the Interstitial cells of Cajal.
What is the treatment for Gastrointestinal Stromal Tumours?
Imatinib
What antibiotics are used for Clostridium Difficile Colitis?
Non-severe:
10-14day course of oral Metronidazole
-Severe:
IV Metronidazole and Oral Vancomycin
A patient has been diagnosed with Clostridium Difficile Colitis. What are the next steps in order of priority?
1.INFECTION CONTROL
=isolated to side room with barrier and nursing precautions
2.STOP ALL CAUSATIVE AGENTS AND:
-Antibodies
-PPIs
3.ANTIBIOTIC THERAPY
-Non-severe:10-14day course of oral Metronidazole
-Severe:IV Metronidazole and Oral Vancomycin
4.CONSIDER SURGERY
=Only in fulminant disease (SUDDEN AND SEVERE ONSET)
What COULD come up on an AXR for a patient with suspected Clostridium Difficile Colitis?
Colonic dilatation
i.e >6cm
What blood results and U&E results would you expect from a patient with Clostridium Difficile Colitis?
Blood–>
INCREASE:
-White blood cells
-CRP
DECREASE :
-Albumin
U&E–>
DERRANGED
(due to dehydration)
A patient presents with watery stool and colic abdominal pain as well as a fever. What tests in what order would you like to do?
1.Arrange FBC
2.Stool testing
3.AXR
4.Consider colonoscopy
Describe the pathophysiology of Clostridium Difficile Associated Disease.
1.Clostridium Difficile bacteria produces ENTEROTOXINS A and B
2.Triggers inflammatory process
3.Leads to vascular permeability and pseudomembrane formation
=(Accumulation of inflammatory cells, fibrin and necrotic debris which contributes to the pseudomembrane)>
What are the symptoms of a patient with Clostridium Difficile Associated Disease?
-Profuse WATERY diarrhoea
-Colic abdominal pain
-Fevers
-Rigors
NOTE: Sever abdominal pain is NOT common with this
How long after the start of an antibiotic treatment can Clostridium Difficile Colitis occur?
5-10 days after
What antibiotics are known for causing Clostridium Difficile Colitis?
‘C’ Antibiotics
1.Co-Amoxiclav
2.Cephalosporins
3.Clindamycin
What is Clostridium Difficile Associated Disease?
Gram Positive, Anaerobic, Spore Forming Bacterium that lie dormant in 3-5% of the population and is AWAKENED by certain antibiotics that can cause PSEUDOMEMBRANOUS COLITIS
What is the prognosis for most Gastroenteritis cases?
SELF-LIMITING infection
List the common causative agents of Gastroenteritis?
-Bacterial: Campylobacter, E.Coli, Salmonella
-Viral (30-40%): Norovirus and Rotavirus
-Parasites: Giardiasis, Cryptosporidiosis
What is meant by Gastroenteritis?
NON-SPECIFIC term used to characterise 4 symptoms together:
-ACUTE Diarrhoea
-Nausea
-Vomiting
-Abdominal pain
Loosely associated with Infective Diarrhoea.
What is Coeliac Disease?
Autoimmune disorder triggered by gluten resulting in small bowel inflammation and subsequent malabsorption
What haptotype is Coeliac disease related to (90% of patients have it) and is presented on APC cells
HLA-DQ2
What are APC cells (Antigen Presenting Cells) responsible for?
Inflammation cascade
What are the 4 classes of symptoms you would expect to see in a patient with Coeliac’s Disease?
-GI complaint
-Metabolic (deficiencies)
-Dermatological
-Associated conditions
What GI symptoms could a patient with Coeliac’s present with?
-Abdominal pain
-Steatorrhoea (fat droplets in stool)
-Flatus
-Unexplained weight loss
What does Steatorrhoea mean?
It is an increase in fat excretion in the stools which indicates fat malabsorption .
What conditions could be responsible for Steatorrhoea?
Exocrine pancreatic insufficiency (EPI), coeliac disease, and tropical sprue
What metabolic presentation can you see in a patient with Coeliac’s Disease?
-Iron (MICROCYTIC ANAEMIA), B12 and folate deficiency (PERNICIOUS ANAEMIA, EPILEPSY)
-Hypocalcaemia (TENTANY, OSTEOMALACIA, OSTEOPOROSIS)
-Failure to grow/thrive as a child
How can a patient with Hypocalcaemia present?
With Tetany, Osteomalacia or Osteoporosis
What is Tetany?
It is involuntary contractions of muscles due to low calcium.
Common symptoms of tetany:
-numbness around the mouth
-muscle cramps
-paresthesias affecting the hands and feet.
What dermatological condition affects patients with Coeliac?
Dermatitis Herpetiformis
What conditions are associated with Coeliac?
Autoimmune:
-Type1 Diabetes
-Thyroid Disease
-Primary Biliary Cholangitis
Cancer:
-Lymphoma, Breast, Small Bowel
What percentage of Coeliac patients have Dermatitis Hepetiformis?
20%
Describe Dermatitis Hepetiformis.
Pruritic (ithcy),Vesicular rash affecting mainly the EXTENSOR surfaces due to deposition of IgA complexes in the Dermis.
What is the treatment for Dermatitis Herpetiformis?
Usually a gluten free diet but in resistant cases
=DAPSONE
What is tested for in serological testing for a patient with suspected Coeliac’ s Disease?
IgA Autoantibodies:
-Anti-endomysial
-Anti-Gliadin
-Anti-tissue transglutaminase (tTG)
Other than serological testing, what is the gold standard diagnostic test for Coeliac’s Disease?
Duodenal Biopsy
What are the 2 main findings on a Duodenal Biopsy from a patient with Coeliacs?
-Subtotal villous atrophy
-Lymphocyte infiltration of laminal propria
What electrolytes are imbalanced in Coeliac’s disease?
Decreased:
-Calcium
-Magnesium
-Albumin
What is Refractory Coeliac’ s Disease?
Is defined by persistent or recurrent malabsorptive symptoms and villous atrophy despite strict adherence to a gluten-free diet (GFD) for at least 6–12 months in the absence of other causes of non-responsive treated coeliac disease (CD) and overt malignancy.
What additional management should considered in a patient with Refractory Coeliac’ s Disease?
Prednisolone
What underlying conditions can causes Refractory Coeliac’ s Disease?
-Small Intestinal bacterial overgrowth
-IBD =Chron’ s and Ulcerative Colitis
-Irritable Bowel Disease = common idiopathic irritation of digestive tract causing abdominal cramps, diarrhoea and constipation
What is another name for Small Intestine Bacteria Overgrowth (SIBO)?
Blind Loop Syndrome
What causes Small Intestine Bacteria Overgrowth?
Increase of bacteria in small bowel caused by:
-Long standing PPI therapy
-Post-Gastrectomy
-Scleroderma
-Diabetic Gastroparesis
-Post-bowel resections (blind loops)
-Small bowel Diverticulosis
-Small Bowel Obstruction
What is Diabetic Gastroparesis?
Nerve damage due to glucose causing issues with contractions with the stomach
How is the diagnosis of Small Intestine Bacterial Outgrowth confirmed and why?
By Hydrogen breath test AFTER a meal
BECAUSE: Bacteria metabolises glucose into hydrogen, so after a meal there would be high hydrogen in a patient with SIBO.
What is the management for Small Intestine Bacterial Outgrowth?
-Treat underlying cause
-Cyclic regime of antibiotics:
-Doxycycline
-Rifaximin
-Metronidazole
What is Tropical Sprue?
Progressive disorder of malabsorption due to most likely an infectious cause that is ripe in Far East and South America.
What is the management for Tropical Sprue?
-Often improve by itself but IF PROLONGED:
–4 week course of Tetracyclines
What does the histological features of a patient with Tropical Sprue look like?
Same as the histology for Coeliac’ s disease
What is Whipple’s Disease?
Rare and chronic infectious malabsorption disease causing multi-systemic effects.
Who is most likely affected by Coeliac’ s Disease- men or women?
Women
What bacteria causes Whipple’s disease?
Gram positive bacterium:
=Tropheryma Whipplei
Who is the typical Whipple’s disease patient?
Middle-aged Caucasian Men
What are the symptoms of Whipple’s disease?
First present with :
-Arthralgia (pain in joint)
-Progressive Weight Loss
Late presentation:
-Diarrhoea
Occasionally can see:
-Neurological symptoms (e.g Demetia, Myoclonus)
What does Arthralgia mean?
Pain in 1 joint
How do you diagnose a patient with Whipple’s Disease?
By BIOPSY
=Presence of periodic acid-Schiff (PAS) positive MACROPHAGES
What is the treatment for Whipple’s disease?
-IV antibiotics for 2 weeks
-Followed by Oral Co-Trimoxazole
A patient with Chron’s disease has had a surgical resection but is now suffering from diarrhoea. What could this indicate?
Short Bowel Syndrome
(extensive bowel failure usually due to surgical complication)
What percentage of tumours are in the small intestine?
4%
SI cancer is NOT common
What type of malignant tumours are the most common in the small intestine?
Adenocarcinomas
What are the causes of Adenocarcinomas in the small intestine?
Familial Adenomatous Polyposis (heretidary) or Chron’s disease.
What are the investigations for Adenocarcinomas in the small intestine?
-Capsule Endoscopy
-CT imaging
What is the management for Adenocarcinomas in the small intestine?
Surgical resection
Where do Adenocarcinomas of the small intestine usually arise?
Peri-ampullary region of DESCENDING DUODENUM
Where do Lymphomas of the small intestine originate?
Ileum
What types of patients are more susceptible to Lymphomas of the small intestine?
-Immunocompromised patients (HIV, medications)
-Coeliac Disease
What are the main symptoms of Lymphomas of the small intestine?
Abdominal pain and obstructive symptoms
What are obstructive symptoms of the small bowel?
Abdominal pain, cramping or bloating.
Nausea and vomiting.
Lack of appetite.
Malaise (an overall feeling of illness).
Diarrhea (usually a sign of a partial blockage).
Rapid heartbeat, dark-colored pee (urine) and other signs of dehydration.
What are obstructive symptoms of the large bowel?
Cramping, abdominal pain, vomiting and inability to pass bowel motions (faeces or poo) or gas
Where do Carcinoid tumours of the small intestine originate?
Terminal ileum and appendix
What are the symptoms of a patient with Carcinoid tumour of the small intestine ?
-Obstructive symptoms (diarrhoea, cramping, nausea etc)
-Systemic Symptoms (fever, fatigue, body ache)
What is Carcinoid Syndrome?
Occurs in 10% of patients with Carcinoid tumours and usually only in the presence of LIVER METASTASIS and is due to an increase in ectopic secretions of SERATONIN
What are the symptoms of Carcinoid syndrome?
-Facial flushing
-Chronic Diarrhoea
-Wheezing
-Palpitations
-Abdominal pain
What is the management of Carcinoid Syndrome?
Surgical resection
-can also have somatostatin analogues (e.g Octreotide, Lanreotide)
Give 2 examples of Somatostatin analogue medications.
ending -reotide
1.Octreotide
2.Lanreotide
What age group is affected by Ulcerative Colitis?
Bimodial distribution of onset:
15-30
OR
55-65
What are the symptoms of Ulcerative colitis?
-Blood diarrhoea
-Colicky abdominal pain
-Tenesmus (passing motion and not feeling complete)
What are the extra-abdominal manifestations of ulcerative colitis and chron’s?
(Remember meumonic)
Antonio Always Races Grand Prix At Every Parade
-Ankylosing Spondylitis
-Arthiritis
-Renal stones
-Gallstones
-Primary Sclerosing Cholangitis
-Anterior Uveitis (red sclera)
-Erythema Nodosum
-Pyoderma Gangrenosum
What investigations must be done for a suspect ulcerative colitis?
-FBCs
-Stool testing (rule out cancer and check for Faecal Calprotectin)
-AXR
-Sigmoidoscopy
When would you do a colonoscopy in suspect Ulcercative colitis?
You don’t! Can complicate this= high risk of perforation
USE a SIGMOIDOSCOPY instead
What is the management of severe remission of Ulcerative Colitis?
1.Urgent hospital admission
2.IV Corticosteroids / Cyclosporin
3.VTE Prophylaxsis
4.Add IV Cyclosporin if unresponsive still
5.Consider urgent surgery
What is the management of mild-moderate remission of Ulcerative Colitis?
1.Aminosalicylates (e.g Mesalazine)
2.+Oral Corticosteroids (if contraindicated first line or still no improvement)
3.+Tacrolimus (if still unresponsive)
4.Consider if still unresponsive:
-Adalimumab
-Golimumab
-Vedolizumab
What is the management for maintaing remission of Ulcerative Colitis?
-Oral/Topical Aminosalicylates
-IF VERT SEVRE:
Consider: Azathioprine or Mercatopurine
-IF CHRONICALLY SYMPTOMATIC
Consider: Elective surgery
What does Ulcerative colitis affect?
The rectum and extends proximally
What does Chron’s disease affect?
Transmural anywhere in the GI tract
Who is more likely to have Chron’s - males or females?
Females
Give an example of an Aminosalicylate?
Mesalazine
What are the symptoms of Chron’s?
-Not usually bloody
-Abdominal discomfort
-Weight loss
-Apthous ulcers
-Glossitis
What is management for Chron’s?
1.Oral/IV Corticosteroids
2.Budesonide / 5A Therapy
=In patients with distal ileal or right sided colonic disease
3.Azathioprine in resistant cases
4.Infliximab or Adalimumab
=if patients are unresponsive to treatment
5.Consider surgery
=In patients with localised distal ileal disease
A patient with Chron’s is resistant to their medications. What next step should be considered, what should be done before this and why?
-Adding or swapping to AZATHIOPRINE
-Do a TIOPRINE METHYLTRANSFERASE levels check
-10% of people have lowered TMT levels which puts them at risk of thiopurine toxicity.
What are the symptoms of Thiopurine Toxicity?
Neutropenia: Less neutrophils in body
-Hypersensitivity Reactions
-Marrow suppression
-Pancreatitis
A patient with Chron’s is affected in a localised distal ileum. What is the management?
Surgery
What is the management in patients with distal ileal or right sided colonic disease
Budesonide / 5A Therapy
What is the most important lifestyle change for a patient with Chron’s?
Stop smoking
What complications of Chron’s need to be monitored for?
-Osteopenia
-Osteoporosis
-Colorectal surveillance (for patients with Chron’s for 10 years plus)
What is the management for Perianal Chron’s disease?
Oral antibiotics:
-Metronidazole / Ciprofloxacin
Fistula healing:
-Azathioprine and maybe Infliximab
What is Microscopic Colitis?
Form of IBD that only affects the colon and rectum.
What is the main symptom of Microscopic Colitis?
Watery Diarrhoea
What is microscopic colitis associated with?
Rheumatoid Arthiritis, Coeliac Disease, NSAID and PPI usage
What is the treatment for Microscopic Colitis?
Steroids
What medications can be used to treat symptoms of IBS?
-Anti-spasmodics
-Laxatives
-Antimotility Agent (Loperamide)
What 3 diseases does Ischaemic Bowel Disease refer to?
1.Acute Mesenteric Ischaemia
2.Chronic Mesenteric Ischaemia (intestinal angina)
3.Ischaemic Colitis
What does Postprandial mean?
After a meal
What are the clinical features of Ischaemic Bowel Disease?
Occlusive Disease:
-Association with ATRIL FIBRILLATION
-Primary Atherosclerosis
-Distal embolism etc
Non-Occulsive
-Septic shock
-Hypoperfusion