GI conditions Flashcards
Crohn’s Disease: Pathology
- Affects any part of GI tract mouth → anus (mostly terminal ileum and proximal colon)
- Inflammation in all bowel wall layers
- Patches of inflammation (non-continuous, skip lesions)
- Granulomas inflammation
Crohn’s Disease: Risk Factors (5)
- Family history
- More genetic than UC
- Smoking increases risk
- NSAIDs exacerbate
- Stress and depression trigger flares
Crohn’s Disease: Epidemiology
- More common in western world
- Affects females more than males
- Presents 20-40 years
- Lower incidence than UC
Crohn’s Disease: Symptoms (3)
- Small bowel - right lower quadrant abdo pain, weight loss, malabsorption, severe can mimick appendicitis
- Colon - bloody diarrhoea, pain on defecation
- Oral aphthous ulcers
Crohn’s Disease: Complications (7)
- Malabsorption
- Small bowel obstruction
- Bowel perforation
- Abscesses
- Colorectal cancer
- Anaemia
- Sclerosing cholangitis
Crohn’s Disease: Investigations (5)
- Bloods - raised WCC, raised platelets, raised CRP & ESR
- Anaemia - normocytic, iron, folate or B12 deficiency
- pANCA negative
- Hypoalbuminemia when severe
- Colonoscopy - gold standard, granulomatous transmural inflammation
Crohn’s Disease: Treatment (7)
- Oral prednisolone - glucocorticoid steroid, first line
- IV hydrocortisone - stronger steroid, in severe cases
- Smoking cessation
- Treat deficiencies
- Anti-TNF antiBodies - if not responsive to steroids (infliximab, adalimumab)
- Azathioprine - maintains remission
- Surgery - 80% need it
Ulcerative Colitis: Description
Inappropriate immune response against (possibly abnormal) colonic flora in genetically susceptible individuals
Ulcerative Colitis: Pathology
- Only affects colon (rectum → ileocaecal valve)
- Total continuous inflammation with ulcers and pseudo-polyps when severe
- Only mucosa inflamed
- Crypt abscesses
- Depleted goblet cells
Ulcerative Colitis: Risk Factors (3)
- Family history
- NSAIDs
- Stress and depression (triggers flares)
Ulcerative Colitis: Epidemiology
- More common in western world
- Presentation 20-40 years
- More common than Crohn’s
- Smoking is a protective factor!
Ulcerative Colitis: Symptoms (7)
- Abdo pain/cramps - lower left quadrant
- Episodic or chronic diarrhoea (blood and mucus)
- Fever
- Anorexia
- Malaise
- Weight loss
- Clubbing
Ulcerative Colitis: Complications (5)
- Colon - bleeding, perforation, colorectal cancer
- Skin - erythema nodosum (symmetrical shin bumps), pyoderma gangrenosum (painful ulcers on skin)
Ulcerative Colitis: Investigations (5)
- Blood tests - raised WCC, raised platelets, raised CRP (c-reactive protein) and ESR (erythrocyte sedimentation rate)
- Colonoscopy - gold standard, sigmoidoscopy is diagnostic
- Anaemia - normocytic
- Hypoalbuminemia - when severe
- pANCA - antibody often positive in UC and never in Crohn’s
Ulcerative Colitis: Treatment (3)
- 5-aminosalicyclic acid (5-ASA) - oral is first line, also can be suppository. Sulfasalazine! (mesalazine, olsalazine)
- Prednisolone - glucocorticoid steroid, second line not responding to 5-ASA or severe cases
- Colectomy - severe cases with no response to treatment. Ileoanal anastomosis (remove colon and attach ileum and anus) or ileostomy (stoma)
IBS: Definition
Mixed group of abdominal symptoms with no organic cause
IBS: Epidemiology
- Onset <40 years
- More females
- 20% of western world
IBS: Risk Factors (3)
- GI infections
- Stress
- Eating disorders
IBS: Types
- IBS-C - with constipation
- IBS-D - with diarrhoea
- IBS-M - mixed
IBS: Symptoms (3)
- Abdominal pain
- Bloating
- Change in bowel habit
IBS: Diagnostic criteria
- Abdominal pain with at least 2 of:
- Relieved by defecation
- Altered stool form
- Altered bowel frequency
- For at least 6 months
IBS: Investigations (2)
- Rule out differentials
- Bloods - anaemia, inflammation, coeliac
IBS: Treatment (6)
- Dietary modification (determine trigger foods)
- Soluble fibre not insoluble fibre
- Antispasmodics - for pain/bloating in moderate
- Loperamide (Imodium) - for diarrhoea
- Laxatives - for constipation
- Can use antidepressants when severe - dampen gut sensitivity
Coeliac: Description
- Inflammation of the mucosa of the upper small bowel in response to gluten
- Autoimmune - T cell mediated
- Intolerance to Prolamin causes villous atrophy (villi erode away) → malabsorption
Coeliac: Epidemiology
- 1% of UK population (only 25% diagnosed)
- HLA-DQ2 and HLA-DQ8 gene associations
Coeliac: Risk Factors (2)
- Other autoimmune diseases (T1DM, autoimmune thyroid disease, Sjogren’s syndrome, Addison’s disease)
- IgA deficiency
Coeliac: Pathology
a-Gliadin resistant to digestion → passes through damaged epithelial wall into cells → deaminated by tissue transglutaminase → antigen-presenting cells activate gluten sensitive CD4 T cells → inflammatory cascade → villous atrophy and crypt hyperplasia (elongated intestinal grooves)
Coeliac: Symptoms (8)
- Weight loss (malabsorption)
- Fatigue (malabsorption)
- Staetorrhoea (floating stool due to unabsorbed fat)
- Anaemia
- D&V
- Abdo pain
- Mouth ulcers
- Dermatitis herpetiformis (deposition of IgA in skin causing raised red pathces)
Coeliac: Investigations (4)
- Serum antibody testing - first line, IgA tissue transglutaminase (tTG)
- Duodenal biopsy - gold standard, endoscopically will show villous atrophy, crypt hyperplasia and increased epithelial WBCs
- FBC - anaemias
- Genetic testing - HLA-DQ2 & HLA-DQ8
Coeliac: Treatment (2)
- Gluten free diet
- Treat vitamin deficiencies
Coeliac: Complication
Hyposplenism - give vaccination against pneumococcal infection
GORD: Pathology
Reduced tone of lower oesophageal sphincter → increase in transient relaxations → reflux of gastric acid, pepsin, bile and duodenal contents to oesophagus
GORD: Causes (6)
- Obesity
- Hiatus hernia
- LOS hypotension
- Loss of oesophageal peristaltic function
- Over eating
- Systemic sclerosis
GORD: Risk Factors (4)
- Obesity
- Male
- Pregnancy
- Smoking
GORD: Symptoms (6)
- Heart burn - burning chest pain, made worse by lying down
- Odynophagia - painful swallowing
- Hoarse throat
- Wheezing
- Nocturnal asthma
- Acidic taste in mouth
GORD: Differential Diagnosis (4)
- Coronary artery disease
- Biliary colic
- Peptic ulcer
- Malignancy
GORD: Investigations (2)
- Symptoms usually diagnostic (red flags: weight loss, haematemesis, dysphagia)
- Oesophago-gastro-duodenoscopy - shows if there is oesophagitis or hiatus hernia
GORD: Treatment (5)
- Lifestyle changes - weight loss, smoking cessation, small meals
- Antacids (gaviscon)
- Proton Pump Inhibitors - inhibit gastric hydrogen release, preventing the production of gastric acid (lansoprazole, omeprazole)
- H2 receptor antagonists - block histamine receptors on parietal cells, reducing acid release (cimetidine)
- Surgery
GORD: Complications (2)
- Barret’s Oesophagus - oesophageal epithelial metaplasia from squamous to columnar. Can progress to oesophageal cancer
- Peptic stricture - inflammation of oesophagus → narrowing and stricture
Oesophageal Cancer: Epidemiology
- 6th most common
- Squamous cell carcinomas are in the middle third (40%) and upper third (15%)
- Adenocarcinomas are in lower third and stomach cardia (45%)
- More males, presents age 60-70
Oesophageal Cancer: Causes (8)
- Squamous:
- Alcohol abuse
- Smoking
- Obesity
- Low fruit and veg consumption
- Adenocarcinoma
- GORD
- Smoking
- Obesity
- Barrett’s oesophagus is the biggest risk factor
Oesophageal Cancer: Risk Factors (5)
- Smoking
- Alcohol
- Obesity
- Barrett’s oesophagus
- Achalasia (disorder of reduced peristalsis)
Oesophageal Cancer: Pathology
Oesophageal epithelium undergoes metaplasia from squamous to columnar glandular (like stomach)
Oesophageal Cancer: Symptoms (4)
- Pain
- Dysphagia - starts just with solids then liquids become painful, liquid pain at first indicates benign
- Anorexia
- Weight loss
Oesophageal Cancer: Investigations (3)
- Oesophagoscopy with biopsy
- Barium swallow - to see strictures
- CT/MRI/PET for tumour staging
Oesophageal Cancer: Treatments (3)
- Surgery
- Chemo/radiotherapy
- Palliative care
Oesophageal Cancer: Leiomyomas description
Benign smooth muscle tumours arising from oesophageal wall. Intact, well encapsulated and within overlying mucosa, slow growing
Gastric Cancer: Epidemiology
- Eastern Europe and Asia
- Unknown cause
- More males
- Falling incidence
Gastric Cancer: Symptoms (6)
- Epigastric pain - constant and severe
- N&V
- Weight loss
- Dysphagia
- Anaemia - from blood loss
- Jaundice - liver metastasis
Gastric Cancer: Investigations (3)
- Gastroscopy with biopsy
- Endoscopic ultrasound
- CT/MRI/PET
Gastric Cancer: Treatment (2)
- Nutritional support
- Surgery with chemo
Colorectal Cancer: Epidemiology
- 3rd most common cancer worldwide
- Mostly in distal colon
- More males
- Usually >60 years
Colorectal Cancer: Risk Factors (3)
- Increasing age
- Family history
- Genetic predisposition
Colorectal Cancer: Pathology
- Normal epithelium → adenoma → colorectal adenocarcinoma → metastatic colorectal adenocarcinoma (almost always adenocarcinoma)
- Spreads by direct infiltration through the bowel wall then spread to lymphatic and blood vessels and metastasise to liver and lung
Colorectal Cancer: Staging
Duke stage:
- A - just in mucosa, 95% 5 year survival
- B - into submucosa, 75% 5 year survival
- C - invaded nearby lymph nodes, 35% 5 year survival
- D - metastasised, 25% 5 year survival
Colorectal Cancer: Symptoms (4)
- Right-sided carcinoma - asymptomatic, iron deficiency, mass, weight loss, abdominal pain
- Left-sided and sigmoid carcinoma - change in bowel habit, blood and mucus in stools, alternated constipation and diarrhoea
- Rectal carcinoma - rectal bleeding and mucus, cramping rectal pain and thinner stools as it grows
- Emergency (obstruction) - absolute constipation, colicky abdominal pain, abdominal distension, vomiting stool
Colorectal Cancer: Differential Diagnosis (6)
- Haemorrhoids
- Anal fissure
- Anal prolapse
- IBD
- Ischaemic colitis
- Meckel’s diverticulum
Colorectal Cancer: Investigations (3)
- Colonoscopy - gold standard
- Digital Rectal exam - detects less than half
- Double contrast barium enema
Colorectal Cancer: Management (4)
- Surgery
- Endoscopic stenting
- Radiotherapy
- Chemo
Small Intestinal Cancer: Epidemiology
- 1% of all malignancies
- Adenocarcinomas mostly
Small Intestinal Cancer: Risk Factors (3)
- Family history
- Coeliac
- Crohn’s
Small Intestinal Cancer: Symptoms (6)
- Abdo pain
- Diarrhoea
- Weight loss
- Anorexia
- Anaemia
- Palpable mass
Small Intestinal Cancer: Investigations (3)
- Ultrasound
- Endoscopic biopsy
- CT/MRI
Small Intestinal Cancer: Treatment (2)
- Surgery
- Radiotherapy
Peptic Ulcer: Epidemiology
- More elderly
- More in developing countries (due to h. Pylori)
- Duodenal ulcers are more common than gastric ulcers
Peptic Ulcer: Causes (6)
- H. Pylori - most common. Lives in gastric mucus and secretes urease → urea in stomach splits to CO2 and ammonia → ammonia + H+ = ammonium → damage gastric epithelium → inflammation reducing mucosal defence
- NSAIDs - COX-1 inhibited → reduced prostaglandin synthesis → reduced mucus secretion → reduced mucosal defence
- Mucosal Ischaemia - stomach cells have insufficient blood supply → necrosis → reduced mucin production → gastric acid attacks cells → ulcer. Treat with H2 blocker
- Increased acid - overwhelms mucosal defence → acid attacks mucosal cells → cell death → ulcers. Increased by stress. Treat with PPI and H2 blocker
- Bile reflux - duodeno-gastric reflux → regurgitated bile strips away mucus layer → reduced mucosal defence
- Alcohol
Peptic Ulcer: Symptoms (9)
- Burning epigastric pain
- Bloating
- Vomiting
- Haematemesis
- Dyspepsia (indigestion)
- Nausea
- Gastric ulcers are painful when hungry, eating, at night
- Duodenal ulcers are painful after meals, relieved by eating
- Cancer red flags: unexplained weight loss, anaemia, GI bleeding, dysphagia, mass
Peptic Ulcer: Investigations (4)
- Endoscopy with biopsy - urease test and histology
- Stool antigen test - for H. Pylori
- Urea breath test
- Blood test for IgG antibodies
Peptic Ulcer: Treatment (6)
- Lifestyle - smoking cessation, reduce stress, drink less
- Stop NSAIDs
- Antibiotics for H. Pylori - CAP (clarithromycin, amoxicillin, PPI)
- PPIs - lansoprazole, omeprazole
- H2 antagonists - reduces acid release (cimetidine)
- Surgery
Peptic Ulcer: Complications (5)
- Haemorrhage (ulcers hiting artery)
- Perforation
- Obstruction
- Peritonitis
- Acute pancreatitis
Appendicitis: Pathology
- Appendix at McBurney’s point - 2/3rds from umbilicus to anterior superior iliac spine
- Appendix obstruction → invasion of gut organisms → inflammation → necrosis → perforation
Appendicitis: Epidemiology
Incidence between 10-20 yrs
Appendicitis: Causes (5)
- Faecoliths (stool forming solid stones) - most common
- Bezoars/metastases - least common
- Trauma
- Intestinal worms
- Lymphoid hyperplasia
Appendicitis: Symptoms (5)
- Early pain around umbilicus that migrates to right iliac fossa
- Guarding - involuntary muscle contraction when pressing abdomen
- Fever
- N&V
- Anorexia
Appendicitis: Investigations (3)
- CT - gold standard, sensitive and specific
- Bloods - raised WCC, raised CRP & ESR
- Pregnancy test to exclude ectopic pregnancy
Appendicitis: Treatment (2)
- Appendicectomy - gold standard, laparoscopic
- IV antibiotics and fluids - pre and post operative
Appendicitis: Complications (3)
- Perforation
- Adhesions
- Appendiceal abscess
Bowel Obstruction: Description
Arrest of the onward propulsion of intestinal contents
Small Bowel Obstruction: Epidemiology, Causes, Pathology
- Most common - 60-75%
- Causes - adhesions (60%, previous abdo surgery or infetions), hernias, malignancy, Crohn’s
- Pathology - obstruction → distension above the blockage → increased pressure on blood vessels in bowel wall → ischaemia and necrosis → perforation
Small Bowel Obstruction: Symptoms, Investigations, Treatment
- Symptoms - pain (on and off, higher than LBO), vomiting (begins earlier than in LBO), increased bowel sounds (tinkling)
- Investigations - Abdominal x-ray (first line, shows gas shadows), Non-contrast CT (gold standard, localises obstruction)
- Treatment - aggressive fluid resuscitation and decompression (drip and suck), analgesia, anti-emetics, antibiotics, surgery (laparotomy)
Large Bowel Obstruction: Causes, Symptoms, Investigations, Treatment
- Causes - malignancy (90%), volvulus (rotation of bowel on mesenteric axis → ischaemia and necrosis), Crohn’s
- Symptoms - abdo pain (less localised than SBO and lower), more abdominal distension (swollen), vomiting later than SBO, constipation earlier than SBO
- Investigations - abdo x-ray (1st line, gas shadows and distension), CT (gold standard)
- Treatment - drip and suck
Pseudo-Obstruction: Presentation, Causes, Treatment
- Presents identically to LBO or SBO
- Causes - Trauma, post-operative (paralytic ileus), drugs (opiates)
- Treat underlying problem
Acute Mesenteric Ischaemia: Location, Causes, Symptoms
- Affects small bowel
- Causes: Superior mesenteric artery (SMA) thrombosis or SMA embolism due to AF. Mesenteric vein thrombosis (less common, in young patients in hypercoaguble states)
- Symptoms: acute severe abdo pain, no tenderness/ guarding/ distension, rapid hypovolaemic shock
Acute Mesenteric Ischaemia: Investigations, Treatment, Complications
- Investigations: bloods, abdo x-ray (rule out bowel obstruction), laparoscopy, CT angiography (non-invasive, detects blockages)
- Treatment: fluid resuscitation, antibiotics, IV Heparin (reduce clotting), surgery
- Complications: sepsis, peritonitis
Chronic mesenteric Ischaemia: Description
- Affects small bowel
- Same as AMI but symptoms are less severe and last longer
Ischaemic Colitis: Location, Causes, Symptoms
- Affects large bowel
- Causes: thrombosis, emboli, low flow states
- Symptoms: sudden onset left iliac fossa pain, bright red blood in stools, hypovolaemic shock
Ischaemic Colitis: Investigations, Treatment
- Investigations: urgent CT (rule out perforation), sigmoidoscopy (shows epithelial cell apoptosis), colonoscopy (gold standard, only after recovery, excludes strictures and confirm mucosal healing)
- Treatment: symptomatic treatment, fluids, antibiotics
Diverticular Disease: Diverticulosis defintion
Presence of diverticula - pouches of mucosa extrude through the colonic muscular wall
Diverticular Disease: Diverticulitis definition
Inflammation from faeces blocking the neck of the diverticulum
Diverticular Disease: Meckel’s Diverticulum definition
A congenital condition that is present in around 2% of the population. Typically children present with symptoms around the age of 2. A small number of these will go on to develop diverticulitis, which in children presents very similar to appendicitis.
Test show ectopic ileal, gastric or pancreatic mucosa
Diverticular Disease: Epidemiology
- Affects 50% of population over 50
- Unknown cause
Diverticular Disease: Symptoms (4)
- Mostly asymptomatic
- Pain
- Constipation
- Bleeding
Diverticular Disease: Investigation
CT
Diverticular Disease: Treatment (2)
- Antibiotics
- Surgery in rare cases of frequent attacks or complications
Gastritis: Description
Inflammation of the stomach lining that is associated with mucosal injury
Gastritis: Pathology
- H. Pylori - lives in gastric mucus and secretes ureas → splits stomach urea into CO2 and ammonia → ammonia + H+ = ammonium → damages gastric epithelium → inflammation
- Autoimmune gastritis - affects fundus and body of stomach → atrophic gastritis and loss of parietal cells → IF deficiency → pernicious anaemia
- Aspirin and NSAIDs - inhibits prostaglandins by inhibiting COX-1 → reduces mucus production
Gastritis: Causes (9)
- H. Pylori - most common
- Autoimmune
- Viruses (CMV and HSV)
- Duodenogastric reflux
- Crohn’s
- Mucosal Ischaemia
- Increased acid
- Aspirin and NSAIDs
- Alcohol
Gastritis: Symptoms (6)
- Epigastric pain
- N&V
- Indigestion
- Loss of appetite
- Abdominal bloating
- Haematemesis
Gastritis: Differential Diagnosis (5)
- Peptic ulcers
- GORD
- Non-ulcer dyspepsia
- Gastric lymphoma
- Gastric carcinoma
Gastritis: Investigations (4)
- Endoscopy
- Biopsy and histology
- H. Pylori urea breath test
- H. Pylori stool antigen test
Gastritis: Treatment (3)
- CAP - clarithromycin, amoxicillin, PPI
- H2 antagonists - ranitidine, cimetidine
- Prevention - PPIs with NSAIDS
Mallory-Weiss Tear: Epidemiology
- More males
- Aged 20-50
Mallory-Weiss Tear: Risk Factors (4)
- Alcoholism
- Bulimia
- Male
- NSAID abuse
Mallory-Weiss Tear: Pathology
Vomiting/ coughing/ retching increases intra-abdominal pressure → forces stomach contents into oesophagus → dilation and tearing
Mallory-Weiss Tear: Symptoms (6)
- Vomiting
- Abdominal pain
- Haematemesis (vomiting blood)
- Postural hypotension (low BP after standing up)
- Dizziness
- Melena (black stools)
Mallory-Weiss Tear: Differential Diagnosis (4)
- Gastroenteritis
- Peptic Ulcer
- Cancer
- Oesophageal Varices
Mallory-Weiss Tear: Investigation
Endoscopy
Mallory-Weiss Tear: Treatment
- Mostly heal in 24 hrs
- Surgery if not healing
Haemorrhoids: Description, types, investigation, treatment
- Vascular mucosal cushions function to maintain anal continence. When they enlarge, the vessels are brought closer to abrasion and can bleed into the anus.
- Can be internal (above dentate line) or external (below)
- Internal: Painless. 1st degree: Do not prolapse. 2nd degree: Prolapse on straining, spontaneous reduction 3rd degree: Prolapse on straining, manual reduction 4th degree: Permanently prolapse, no reduction.
- External: Painful and itchy. Visible on external examination. Can also have internal
- Investigation: Digital Rectal Exam (DRE)
- Treatment: increase fluid and fibre, analgesia, rubber band ligation, haemorrhoidectomy
Anorectal Abscess: Risk Factors, Pathology, Symptoms, Investigation, Treatment
- Risk Factors: male, DM, STI, IBD, immunocompromised
- Infection of anal sinus → inflammation → abscess
- Symptoms: hard, tender perianal lump, fever, constipation, pus discharge
- Investigation: DRE
- Treatment: Surgical drainage, analgesia
Fissure-in-ano: Description, Symptoms, Treatment
- Tear in the mucosa of the anal canal under pressure of defecation
- Symptoms: pain on defecation, bright red blood in stool
- Treatment: simple pain relief, warm bath
Pilonidal Sinus: Description, Epidemiology, Treatment
- Ingrowth of hair excites a foreign body reaction and causes abscess with foul smelling discharge, pain, redness, swelling
- Most common in obese caucasian males
- Treatment: excision of sinus tract and cover with skin flap if infected. Leave if asymptomatic
