GI Diseases Flashcards

Question

Presentation of Oesophageal ademocarcinoma?

Answer 1

* Usually presents after lymph node metastasis and hence poor prognosis as compared to squamous cell carcinoma * The tumour may spread to the gastric cardia * Patients usually present with dysphagia, chest pain, progressive weight loss and vomiting

Answer 2

Male \> female (4:1) More seen in the African American population

Answer 3

Male \> female (7:1) More seen in the Caucasian population

Answer 4

Crohn’s disease and Ulcerative Colitis

Answer 5

UC is more common than Crohn’s. Common in western/developed countries. Common in young adults

Answer 6

Smoking (for Crohn’s only), Family history, NSAID use, Hygiene hypothesis (Reduced biodiversity of commensal bacteria), Oral contraception, White ethnicity

Answer 7

Inflammation that can involve one small area of the gut, or multiple areas with normal bowel in between: SKIP LESIONS AKA Cobblestone appearance Commonly affects the terminal ileum and ascending colon- resulting in RLQ pain Transmural Inflammation: Damage extends beyond the submucosal layer and through the depth of the entire intestinal wall (unlike UC)

Answer 8

Uncontrolled and unregulated immune response to GIT pathogens, leading to tissue destruction and inflammation Unregulated inflammation means lots of proteases, platelet activating factor, and free radicals floating around the gastrointestinal tissue which ultimately causes destruction of healthy tissue It is an immune related disorder. In Crohn disease, the immune system is thought to be triggered by some foreign pathogen in the gastrointestinal tract. Several pathogens have been implicated, like **Mycobacterium paratuberculosis** as well **Pseudomonas and Listeria species**

Answer 9

Crampy abdo pain (RLQ), watery diarrhoea, steatorrhea, fatigue, fever, weight loss, dysphagia

Answer 10

**fistulae**, abscess, bowel obstruction, perforation, **toxic megacolon**, kidney stones, Bowel cancer (adenocarcinoma), gallstones

Answer 11

Inflammation will occur in the rectum first, and ascend proximally towards the rest of the colon- leading to LLQ pain The pattern of inflammation is: circumferential and continuous (goes around the whole lumen) The degree of inflammation is superficial (affecting the mucosa and submucosa layers only) It is an autoimmune condition.

Answer 12

AUTOIMMUNE Th2 mediated rxn, where cytotoxic T cells target abnormal gut bacteria or p-ANCA antibodies, thus eroding the lining of the intestines, and ulceration The circumferential inflammation can destroy the haustras of the colon leading to a smooth section of colon which is called the “lead pipe” sign. Prevalent in non-smokers/ex-smokers\*

Answer 13

Bloody diarrhoea, LLQ pain, mucus/pus in stool, tenesmus/urgency, pseudopolyps

Answer 14

* **Proctitis:** Just the rectum * **Proctosigmoiditis:** Involves the rectum and sigmoid colon * **Left sided Colitis:** Involves the descending colon up to the splenic flexure * **Extensive Colitis:** Extending to the hepatic flexure * **Pancolitis/Universal colitis:** The entire colon is affected, associated with Backwash Ileatis (inflammation of the terminal ileum)

Answer 15

**Bloods** * Anemia * Raised ESR and CRP, WBC, Platelets (same as UC) * Hypoalbuminemia * B12, iron studies: LOW * pANCA- POSITIVE in UC **Stool** * Faeceal Calprotectin- RAISED * released by the intestines when inflamed, and is a useful screening test (\> 90% sensitive and specific to IBD in adults) **Other:** Colonoscopy, Sigmoidoscopy, PR exam, US, CT, Barium Enema, Rectal biopsy

Answer 16

Surgery does NOT cure the disease, because the whole GI tract can be involved ## Footnote Conservative management (smoking cessation for Crohn’s) Pharmacological treatment (don’t need to know this year), Faecal transplantation

Answer 17

A colectomy or proctolectomy can be curative

Answer 18

**Inflammation of abnormal pouches called diverticula** (can develop on the walls of the large intestine, or any other hollow structure). Usually 0.5c,-1cm large True Diverticula: involve all layers of the intestine Pseudo diverticula: Muscle layers are not included **MOST COMMON**

Answer 19

diverticulosis

Answer 20

Obesity, lack of exercise, low fibre diet, Smoking, Connective tissue disorders (genetic), Family history, NSAIDs, Common in the western world, Elderly, Females

Answer 21

Symptoms: MOST CASES ARE ASYMPTOMATIC * Lower abdominal pain (sudden onset)- mostly affects the Sigmoid colon- LLQ pain and tenderness * Erratic bowel habits * Symptoms of infection (fever, tachycardia), Nausea, Diarrhea, Constipation, Fever, blood/mucus in the stool

Answer 22

Raised CRP and ESR, USS, CT, Barium enema, Sigmoidoscopy Treatment If less severe: analgesia, Fibre, Antibiotics, Fluid resus Surgical resection if acutely unwell

Answer 23

An AUTOIMMUNE DISORDER where exposure to **gluten** causes an autoimmune reaction that causes **inflammation in the small bowel**. It usually develops in early childhood but can start at any age. 1 in 100 people have it. Family History increases risk to 1 in 10.

Answer 24

Gluten is a large molecule, that is broken down to smaller ones in the gut, and it is the **breakdown products that are toxic (gliadins).** The main toxic peptide is **α-Gliadin.** **Autoantibodies** are created in response to exposure to gluten, which target the epithelial cells of the intestines, leading to inflammation in the small bowel (particularly jejunum) It causes **atrophy of the intestinal villi, and crypt hypertrophy,** so the surface of the bowel becomes flattened, and the surface area for absorption becomes greatly reduced (malabsorption)

Answer 25

1. Anti-TTG (anti-tissue transglutaminase)- attacks TTG, which is responsible for gluten breakdown 2. Anti-EMA (Anti-endomysial) 3. DGP (deaminated gliadin peptide)

Answer 26

**Often asymptomatic** (can be mistaken for IBS), Steatorrhea, failure to lose/gain weight, **abdo pain,** cramps, **bloating,** distension, diarrhoea, fatigue, mouth ulcers, anaemia, **dermatitis herpetiformis**, osteomalacia, Vit D and calcium deficiency, neurological (ataxia, epilepsy)

Answer 27

Check for total IgA levels whilst on gluten diet * Raised Anti-TTG antibodies serology (FIRST LINE) * Raised anti-endomysial antibodies * deaminated gliadin peptide (DGP) – in cases of patients who have a IgA deficiency Duodenal Biopsy to confirm Genetic testing for HLADQ2 and HLADQ8

Answer 28

- Irritable bowel syndrome (IBS) is a group of symptoms—including abdominal pain and changes in the pattern of bowel movements without any evidence of underlying damage (like inflammation, ulcers etc). - It has been classified into four main types depending on whether diarrhoea is common, constipation is common, both are common, or neither occurs very often

Answer 29

IBD has structural damage to the bowel (ie inflammation, ulceration) in ADDITION to IBS symptoms

Answer 30

Other pathology should be excluded: * Normal FBC, ESR and CRP blood tests * Faecal calprotectin negative to exclude inflammatory bowel disease * Negative coeliac disease serology (anti-TTG antibodies) * Cancer is not suspected or excluded if suspected **Symptoms should suggest IBS:** Abdominal pain / discomfort pain for ≥12wks which has 2 of: * Relieved by defecation * Change in stool frequency (D or C) * Change in stool form: pellets, mucu AND 2 of: * Abnormal stool passage: incomplete/urgency * Bloating/Distention * Worse symptoms after eating * PR mucus **ROME CRITERIA**

Answer 31

Female, stress, gastroenteritis (nota/rotavirus)

Answer 32

* A low FODMAPS diet: F- fermentable O- oligosaccharides 🡪 sucrose (Wheat, rye, legumes and various fruits and vegetables, such as garlic and onions.) D- disaccharides 🡪 lactose (Milk, yogurt and soft cheese) M- monosaccharides 🡪 fructose (Various fruit including figs and mangoes, and sweeteners such as honey Andmitriptyline P- polyols 🡪 sugar free sweeteners ( Certain fruits and vegetables including blackberries and lychee, as well as some low-calorie sweeteners like those in sugar-free gum.) * Avoid caffeine and alcohol * Probiotics, regular small meals, reduced processed food, physical activity, for constipation: soluble fibres, laxatives, stool softeners**,** for pain**: anti-diarrhoeals (ie loperamide), antimuscarinics, antispasmodics (mebeverine)** * Manage stress, anxiety and depression- **CBT** * Amitriptyline

Answer 33

**First Line Medication:** * **Loperamide** for diarrhoea * Laxatives for constipation. Avoid lactulose as it can cause bloating. **Linaclotide** is a specialist laxative for patients with IBS not responding to first-line laxatives * **Antispasmodic**s for cramps e.g. hyoscine butylbromide (Buscopan) **Second Line Medication:** * Tricyclic antidepressants (i.e. amitriptyline 5-10mg at night) **Third Line Medication:** * SSRIs antidepressants

Answer 34

Genetic connections: HLA-DQ2 gene (90%) HLA-DQ8 gene

Answer 35

Formation of hard stones in the gallbladder Incidence increases with age. More common in women. F – Fat F – Fair F – Female F – Forty Most are asymptomatic and are discovered when they cause biliary colic etc

Answer 36

* Cholesterol gallstones are the most common stones -supersaturation of bile with cholesterol --Gallbladder stasis -cannot been seen on X-RAY . However if they have enough CaCO3 * Bilirubin gallstones are the 2nd most common stones: AKA pigmented - can be seen on X-RAY as the bilirubin binds to calcium --associated with : hemolytic disease, E.coli

Answer 37

1. Supersaturated with cholesterol- bile salts and phospholipids cannot handle the cholesterol so they become free flowing in bile causing it to solidify and precipitate out. 2. To little bile salts and phospholipids- cant break down the cholesterol 3. Gallbladder stasis- inactivity of bile can separate the cholesterol from the bile solution= solidify

Answer 38

1. Too much unconjugated (in a form where you cant remove it/absorb it in body) bilirubin- binds to calcium in bile sol and forms calcium bilirubinate Increase bilibrum is due to increase extravascular haemolysis (macrophages engulf rbc and release unconjugated bilirubin

Answer 39

- sign of infection (caused by bacteria Ecoli) - causes calcium + UBC - browness is due to hydrolysed phospholipid too in it.

Answer 40

Biliary colic, also known as symptomatic cholelithiasis, a gallbladder attack or gallstone attack, is when a colic (sudden pain) occurs due to a gallstone temporarily blocking the cystic duct. * Intermittent RUQ pain that comes in waves * Pain MAY radiate to R shoulder tip * Typically starts in the evening and lasts till the morning * Recurring condition, usually managed with diet adjustment

Answer 41

* Inflammation of the cystic duct due to gallstone obstruction * Prolonged colicky pain which MAY radiate to the shoulder tip * Inflammation-\>Fever + leucocytosis * Murphy’s Sign. There will be **RUQ pain** that is usually worse on inspiration.

Answer 42

* Common bile duct obstruction * No inflammation -\> no fever or leucocytosis * Obstructive jaundice * Dilated hepatic ducts * RUQ pain\> 6h

Answer 43

Infection of the gallbladder and CBD Charcot triad-\> fever, jaundice and RUQ pain Reynolds triangle -\> hypotension (shock) +altered mental status + Charcoat triangle. This occurs when the infection becomes more advanced RUQ pain Murphy sign

Answer 44

* Cholecystitis , Acute cholangitis + Mirizzi syndrome * Empyema +perforation * Jaundice -\> obstructive jaundice * Acute pancreatitis -\> epigastric pain, radiates to the back , curling makes it better * Cancer of the gallbladder * Gallstone ileus A bowel obstruction requires immediate medical treatment. If it's not treated, there's a risk that the bowel could split open (rupture).

Answer 45

Primary (not caused by something else) Sclerosing (hardening/fibrosis of tissue) Cholangitis (inflammation of bile ducts) Disorder caused due to the chronic inflammation of the intra hepatic and extra hepatic bile ducts leading to fibrosis More commonly occurs in males (around 30-50 years)

Answer 46

The exact cause is unknown but it has a strong association with autoimmune disesases, especially inflammatory bowel disease (most commonly UC). In most patients, there is presence of antibodies such as pANCA and ANA antibodies but these are not specific for the disease. It is linked to HLA DR3 and HLA B8

Answer 47

Symptoms * Jaundice * Pruritus and fatigue * Abdo pain Signs * Jaundice: dark urine, pale stools * HSM

Answer 48

Bacterial cholangitis ↑Cholangiocarcinoma ↑CRC

Answer 49

* **LFTs:**↑ALP initially, then↑BR * **Abs**:pANCA (80%), ANA and SMA may be +ve * **ERCP/MRCP**:“beaded” appearance of ducts * **Biopsy**:fibrous, obliterative cholangitis

Answer 50

UC Crohn’s (much rarer) AIH HIV

Answer 51

Disorder caused due to the chronic inflammation of the **intra hepatic** bile ducts leading to fibrosis More commonly occurs in females (around 30-65 years)

Answer 52

* Often asympto and Dx incidentally (↑ALP) * Jaundice occurs **late** * **P**ruritus and fatigue * **P**igmentation of face * **B**ones: osteoporosis, osteomalacia (↓vit D) * **B**ig organs: HSM * **C**irrhosis and coagulopathy (↓vit K) * **C**holesterol↑: xanthelasma, xanthomata * **S**teatorrhoe

Answer 53

Inflammation of the appendix Can occur at any age but most commonly in the elderly or in the 2nd decade of life. It is due to the obstruction of the appendix lumen by hyperplasia of the lymphoid tissue, feces, worms, foreign body etc.

Answer 54

Once the lumen is obstructed, it can lead to bacterial overgrowth, ischemia, inflammation etc. If untreated, it can lead to necrosis, peritonitis, gangrene, perforation etc

Answer 55

n the early stages, the pain will be poorly localized to the periumbilical or epigastric region. This is because the organ is poorly innervated by the lesser splanchnic nerves which localise the pain to the centre of the abdomen.

Answer 56

In the later stages, as the inflammation becomes worse, it spreads to the parietal peritoneum in that area, so the pain can be localized. This is because the peritoneum is supplied by the same nerve as the respective dermatome. So, initial pain will be in the periumbilical region and then will localize to the RIF as the inflammation becomes worse

Answer 57

It is described as constant and sharp

Answer 58

2/3’s of the way along an imaginary line from the umbilicus to the anterior superior iliac spine on the right hand side

Answer 59

pain felt in the LRQ when the LLQ is palpated

Answer 60

increased pain during passive extension of the right hip

Answer 61

pain felt on passive internal rotation of the flexed hip

Answer 62

This shows that there is peritonitis. the pain is exacerbated by the slightest movement (e.g. rolling, coughing, even breathing) as this moves the peritoneum.

Answer 63

* **Increased IgG levels** * **Antibodies against:** Liver specific proteins Non-live specific proteins **Mononuclear infiltrate within the liver:** Monocytes, macrophages, lymphocytes, plasma cells, macrophages and mast cells

Answer 64

* **Cholestasis:** blockage to the flow of bile * **Cholelithiasis:** gallstone(s) are present * **Choledocholithiasis:** gallstone(s) in the bile duct * **Biliary colic:** intermittent right upper quadrant pain caused by gallstones irritating bile ducts * **Cholecystitis:** inflammation of the gallbladder * **Cholangitis:** inflammation of the bile ducts * **Gallbladder empyema:** pus in the gallbladder * **Cholecystectomy:** surgical removal of the gallbladder * **Cholecystostomy:** inserting a drain into the gallbladder

Answer 65

LFTs- raised bilirubin, ALP USS- first line

Answer 66

cholestasis an"obstructive picture”

Answer 67

a problem inside the liver with hepatocellular injury “a hepatitic picture”

Answer 68

A raised ALP is consistent with **biliary obstruction** in presence of right upper quadrant pain and/or jaundice.

Answer 69

A magnetic resonance cholangio-pancreatography (MRCP) is an MRI scan with a specific protocol that produces a detailed image of the biliary system. It is very sensitive and specific for biliary tree disease, such as stones in the bile duct and malignancy. MRCP is used in a number of scenarios for gaining a detailed picture of the biliary system, such as identifying biliary strictures or congenital abnormalities. With gallstone disease, MRCP is typically used to investigate further if the ultrasound scan does not show stones in the duct, but there is bile duct dilatation or raised bilirubin suggestive of obstruction.

Answer 70

An endoscopic retrograde cholangio-pancreatography (ERCP) involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the sphincter of Oddi). This gives the operator access to the biliary system. The main indication for ERCP is to clear stones in the bile ducts. Key complications of ERCP are: * Excessive bleeding * Cholangitis (infection in the bile ducts) * Pancreatitis

Answer 71

* Bleeding, infection, pain and scars * Damage to the bile duct including leakage and strictures * Stones left in the bile duct * Damage to the bowel, blood vessels or other organs * Anaesthetic risks * Venous thromboembolism (deep vein thrombosis or pulmonary embolism) * Post-cholecystectomy syndrome

Answer 72

Post-cholecystectomy syndrome involves a group of non-specific symptoms that can occur after a cholecystectomy. They may be attributed to changes in the bile flow after removal of the gallbladder. Symptoms often improve with time. Symptoms include: * Diarrhoea * Indigestion * Epigastric or right upper quadrant pain and discomfort * Nausea * Intolerance of fatty foods * Flatulence

Answer 73

Wilson disease is the excessive accumulation of copper in the body and tissues. It is caused by a mutation in the **“Wilson disease protein”** on **chromosome 13**. The Wilson disease protein also has the catchy name “**ATP7B copper-binding protein”** and is responsible for various functions, including the removal of excess copper in the liver. Genetic inheritance is **autosomal recessive.**

Answer 74

* Mutation of Cu transporting ATPase * Impaired hepatocyte incorporation of Cu intocaeruloplasmin and excretion into bile. * Cu accumulation in liver and, later, other organ

Answer 75

**Cornea** * Kayser-Fleischer rings (70%, may need slit-lamp) **Liver Disease** * Children usually present c̄acute hepatitis. * Fulminant necrosis may occur * →cirrhosis **Arthritis** * Chondrocalcinosis * Osteoporosis **Neurology** * Parkinsonism:bradykinesia,tremor, chorea, tics * Spasticity, dysarthria, dysphagia * Ataxia * Depression, dementia, psychosis **Kidney** * Fanconi’s syn. (T2 RTA)→osteomalacia **Abortions** **Haemolytic anaemia** * Coombs’ negative

Answer 76

Copper deposition in the liver leads to **chronic hepatitis** and eventually liver cirrhosis. Copper deposition in the **central nervous system** can lead to neurological and psychiatric problems.

Answer 77

* **Bloods:**↓Cu,↓caeruloplasmin NB. Caeruloplasmin is an acute-phase protein and maybe high during infection. It may also be low protein-deficient states: nephroticsyndrome, malabsorption * ↑24h urinary Cu * **Liver biopsy**:↑hepatic Cu * **MRI**:basal-ganglia degeneration

Answer 78

Treatment is with copper chelation using: * Penicillamine (lifelong) * Trientene

Answer 79

eating typically worsens the pain of **gastric** ulcers and improves the pain of **duodenal** ulcers.

Answer 80

Peptic ulcers are diagnosed by **endoscopy.** During endoscopy a **rapid urease test** (CLO test) can be performed to check for **H. pylori**. Biopsy should be considered during endoscopy to **exclude malignancy** as cancers can look similar to ulcers during the procedure. Medical treatment is the same as with **GORD**, usually with high dose **proton pump inhibitors**. Endoscopy can be used to monitoring the ulcer to ensure it heals and to assess for further ulcers

Answer 81

A hiatus hernia is when part of your stomach moves up into your chest. It's very common if you're over 50. It does not normally need treatment if it's not causing you problems

Answer 82

**Sliding (80%)** * Gastro-oesophageal junction slides up into chest * Often assoc. c̄GORD **Rolling (15%)** * Gastro-oesophageal junction remains in abdomen but abulge of stomach rolls into chest alongside theoesophagus * LOS remains intact so GORD uncommon * Can→strangulation **Mixed (5%)**

Answer 83

* **CXR**:gas bubble and fluid level in chest * **Ba swallow:** diagnostic * **OGD:** visualises the mucosa but can’t exclude hernia * **24h pH** + manometry:exclude dysmotility or achalsia

Answer 84

* Lose wt. * Rx reflux * Surgery if intractable symptoms despite medical Rx.-Should repair rolling hernia (even if asympto) as it may strangulate

Answer 85

Hereditary hemochromatosis (he-moe-kroe-muh-TOE-sis) causes your body to absorb too much iron from the food you eat. Excess iron is stored in your organs, especially your liver, heart and pancreas. Too much iron can lead to life-threatening conditions, such as liver disease, heart problems and diabetes ## Footnote **AR** **HFE gene (High FE) on Chr6 (C282Y**

Answer 86

* Inherited, multisystem disorder resulting from abnormaliron metabolism. * ↑intestinal Fe absorption (↑enterocyte DMT +↓hepatocyte hepcidin)→deposition in multiple organ

Answer 87

**Myocardial** * Dilated cardiomyopathy * Arrhythmias **Endocrine** * Pancreas: DM * Pituitary: hypogonadism→amenorrhoea, infertility * Parathyroid: hypocalcaemia, osteoporosis **Arthritis** * 2ndand 3rdMCP joints, knees and shoulders **Liver** * Chronic liver disease→cirrhosis→HCC * Hepatomegaly **Skin** * Slate grey discolouration

Answer 88

* **Bloods:**↑LFT,↑ferritin,↑Fe,↓TIBC, glucose, genotype * **X-ray:**chondrocalcinosis * **ECG, ECHO** * **Liver biopsy:**Pearl’s stain to quantify Fe and severity * **MRI:**can estimate iron loading

Answer 89

Iron removal * Venesection: aim for Hct \<0.5 * Desferrioxamine is 2ndline General * Monitor DM * Low Fe diet Screening * Se ferritin and genotype * Screen 1stdegree relatives Transplant in cirrhosis

Answer 90

rimary biliary cholangitis is associated with metabolic or immune system disorders, including thyroid problems, limited scleroderma (CREST syndrome), rheumatoid arthritis, and dry eyes and mouth (Sjogren's syndrome)