GI disease Flashcards
How does coeliac disease present?
Non-specific GI problems: bloating, diarrhoea, malabsorption so may be diagnosed with anaemia and consequential osteoporosis
What can inflammation of the small bowel in coeliac disease lead to?
Small bowel lymphoma and other cancers
What conditions is coeliac disease associated with?
Other AI conditions e.g. thyroid problems and T1DM
Pathology of coeliac disease:
Ingesting gluten causes mucosal inflammation, crypt hyperplasia and villous atrophy (VA can reverse in rare refractory cases)
Coeliac genes:
All carry HLA DQ2 or DQ8
30-50% of population are just carriers though
Diagnosis of coeliac:
OGD + duodenal biopsy
Marsh 1 classification of coeliac:
Increased intraepithelial lymphocytes (IEL>30)
Marsh 2 classification of coeliac:
Increased IEL and crypt hyperplasia
Marsh 3 classification of coeliac:
Increased IEL and crypt hyperplasia and villous atrophy
Marsh 4 classification of coeliac:
Total mucosal hyperplasia
Deficiencies with coeliac:
B12, Iron, Folate (anaemia)
Vitamin D
Calcium
Others
Haematological issues from coeliac:
Anaemia
Hyposplenism
Bleeding
Musculoskeletal issues form coeliac:
Osteopaenia and osteoporosis
Stunted growth in children
Vitamin D deficiency and hypocalcaemia
Skin issues from coeliac:
Dermatitis
H
Vesicular herpetiforms (intensely blistering, itchy rash)
Neurological issues from coeliac:
Muscle weakness, paraesthesia and ataxia
Memory loss
Seizures secondary to cerebral calcification
Hormonal issues from coeliac:
Amenorrhoea
Infertility
Risk of hyposplenism?
Bacterial pneumonia (offer pneumonia vaccine)
Differentials for coeliac:
Viral/bacterial enteritis Crohn's (commonest) Small bowel bacterial overgrowth IBS Microscopic colitis (diarrhoea) Protein losing enteropathy Malabsorption Immunodeficiency (can have villous atrophy)
Management of varices
Antibiotics due to increased risk of bacteraemia
Terlipressin which causes splanchnic vasoconstriction
Immediate management of GI bleed:
Take bloods and give blood
Insert catheter and measure hourly urine output
Antibiotics if varices/aspiration risk
Complete exposure + examination + PR exam
What are Mallory-Weiss tears?
Tears of the oesophago-gatric junction caused by prolonged vomiting
What are the drug causes of GI bleeds?
NSAIDs and aspirin
Anticoagulants
Steroids
Signs of portal hypertension:
Varices
Distended abdomen
Spider naevi
Encephalopathy
PPI treatment for GI bleeds:
Pantoprazole infusion 80mg IV stat then 8mg/hour for 72 hours
What does a Blatchford score of 6 or over indicate?
There is a greater than 50% risk of needing intervention
What is high urea a marker for?
Blood being broken down in the upper GIT
Management of a severe bleed (Blatchford 6 or over/haemodynamic instability):
Urgent OGD once resuscitated
Will need protected airway
Management of a mild/moderate bleed:
OGD within 24 hours of admission
250mg IV erythromycin 30 minutes before procedure
Rockall score <3?
Good prognosis
Rockall score >8?
High risk mortality
Modalities to stop bleeding?
Bands, APC (burning), clips and adrenaline
How do you tell if a peptic ulcer is malignant?
Malignant = rolled up edges
Treatments for varices after OGD:
Propanolol or carvedilol to lower BP
Endoscopic banding every 2-4 weeks
How to test for H. Pylori:
CLO
Urea breath test
Stool antigen
Treatment of H. Pylori?
7 day triple therapy: PPI + amoxicillin + metronidazole
What causes oesophageal varices?
Portal hypertension commonly due to chronic liver disease
What is TIPSS?
Transjugular intrahepatic portosystemic shunt
Treatment for varices
Signs of UC:
Bloods: raised CRP/ESR, anaemia, low albumin
Faecal calprotectin
Low albumin
Diagnosis of UC?
Gold standard is endoscopy - white ulcers and red inflammation
Classification of UC:
Proctitis - rectum Left-sided colitis Pancolitis Distally progressive Settles after 5 years
Medications for UC:
Prednisolone
Aminosalicydates - mesavant, octasa
Immunosuppressants - azathioprine, methotrexate
Biologics
Anti-TNF medications for UC:
Infliximab
Adalimumab
Golimumab
Anti-integrin medication for UC:
Vedolizumab
Surgeries for UC:
Subtotal colectomy/total colectomy
Ileostomy
J-pouch (complications of urgency, infertility in women and pouchitis)
What is Truelove and Witt criteria used for?
Assessing the severity of UC
What qualifies as severe UC (T+W)?
Over 6 motions a day that are bloody Temp >37.8 Pulse >90 Haemoglobin <10.5 Raised CRP
Use of sigmoidoscopy in UC?
Exclude CMV
Increased risk in UC of…
C. diff
Features of toxic megacolon/leadpipe colon:
No rural folds
Pattern not tortured
High risk of perforation >6cm
Management of toxic megacolon/leadpipe colon:
Hydrocortisone 100mg QDS
Dalteparin 500 units
Daily review due to high risk of DVTs (despite bleeding)
Then ciclosporin/infliximab
Day 3 of admission of UC, CRP >45 and bowels open >8 times in one day…
Chance of colectomy 85%
Where is Crohn’s mainly found?
Terminal ileum
Symptoms of Crohn’s:
Diarrhoea Rectal bleeding Abdominal pain Weight loss Perianal abscess Oral ulceration
Differentials between UC and Crohn’s:
UC is colon whereas Crohn’s is mouth to anus
Crohn’s is full thickness whereas UC is not past crypts
UC is bloody diarrhoea, Crohn’s is non-bloody
Crohn’s can have bowel obstruction and fistulae
UC can have primary sclerosis cholangitis
UC more associated with colorectal cancer
Signs of Crohn’s:
Cachexia Scars Overweight as easy to digest junk food Stomas (2-3) Parenteral nutrition
Tests in Crohn’s:
Anaemia: low B12, folate
Ferritin
Low albumin
Faecal calprotectin
Diagnosis of Crohn’s:
Endoscopy - Ulcers are deeper and patchier than in UC with more visible blood vessels
Imaging in Crohn’s:
Small bowel US
Small bowel MRI (white inflammation, strictures)
MRI of pelvis
Medications for Crohn’s:
Steroids: prednisone + budeconide (short term and local)
Abx: ciprofloxacin + metronidazole
Immunosuppressants: azathioprine, mercaptopurina, methotrexate
Biologics
Modulen drink
Biologics for Crohn’s:
Anti-TNFs: infliximab, adalimumab, golimumab
2nd line: vedolizumab (anti-integrin), ustekinumab (IL-12,23)
Surgery for Crohn’s:
Exam under anaesthesia of perianal disease
Stricturopathy
Colectomy
Diverting colectomy
