GI - Dyspepsia & IBD Flashcards

1
Q

What is Dyspepsia

A

Symptom/combination of symptoms that alert to an upper GI problem. Typically…

Epigastric pain/burning
Early satiety and postprandial fullness
Belching
Bloating
Nausea
Discomfort in the upper abdomen
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2
Q

47 year old man presents to clinic with a 3 month history of epigastric dull abdominal pain. He states that the pain is worse at night and is relieved on eating. On direct questioning, there is no history of weight loss. He is not anaemic.

Most likely cause?

A. Duodenal Ulcer
B. Zollinger-Ellison Syndrome
C. Gastric ulcer
D. GORD
E. Non-ulcer dyspepsia
A

Duodenal Ulcer

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3
Q

A 59 year old man presents with severe retrosternal burning pain. Upper GI endoscopy shows ‘metaplastic changes within the epithelium’.

Most likely cause?

A. Gastric ulcer
B. Gastric carcinoma
C. Oesophageal carcinoma
D. GORD
E. Barrett's oesophagus
A

Barrett’s oespophagus

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4
Q

A 41 year old man is referred to gastroenterology outpatients with a 3 month history of worsening epigastric pain and dyspepsia. Upper GI endoscopy confirms multiple ulcers in the stomach and duodenum. Serum gastrin is elevated.

Most likely cause?

A. Duodenal Ulcer
B. Zollinger-Ellison Syndrome
C. Gastric ulcer
D. Gastric carcinoma
E. GORD
A

Zollinger-Ellison Syndrome

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5
Q

A 40 year old woman presents with a 2 month history of burning upper abdominal pain which is worse on eating. On examination there is mild tenderness to palpation of the epigastric region.

Most likely cause?

A. Duodenal ulcer
B. Zollinger-Ellison Syndrome
C. Gastric ulcer
D. Gastric carcinoma
E. GORD
A

Gastric ulcer

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6
Q

A 37 year old overweight woman presents to the GP with burning upper abdominal pain. She says it is especially bad when she goes to bed. She also complains of a tickly cough and a funny taste in her mouth.

Most likely cause?

A. Zollinger-Ellison Syndrome
B. Gastric ulcer
C. Oesophageal Carcinoma
D. GORD
E. Non-ulcer dyspepsia
A

GORD

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7
Q

Peptic ulcer definition

A

A break in the superficial epithelial lining of either the stomach or the duodenum.

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8
Q

Peptic ulcer classifications

A

Duodenal vs Gastric

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9
Q

More common type of peptic ulcer

A

Duodenal

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10
Q

Peptic ulcer disease epidemiology

A

Common
Incidence increases with age
H. Pylori related in developing countries
NSAID-induced in developed countries

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11
Q

Peptic ulcer disease risk factors

A
H. Pylori
NSAIDS
Age
Hx/FHx
Smoking
Alcohol
Psychological stress

Rare:
Increased gastrin (e.g. Zollinger-Ellison, Gastrinoma)
Cushing’s ulcers (brain trauma), Curling’s ulcers (Burns), altered gastric emptying

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12
Q

Helicobacter Pylori

A

Gram negative flagellate
Prevalent in 80-90% of population in developing countries, 20-5-% developed countries
Mostly asymptomatic, but damage to epithelial cells can cause gastritis, peptic ulcers, gastric cancer.

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13
Q

Peptic ulcer disease symptoms and signs

A
Recurrent epigastric pain; related to eating a meal (dyspepsia) - burning/knawing pain
Nausea and vomiting
Early satiety
Wt. loss/anorexia
Sx of anaemia

Epigastric tenderness
‘Pointing sign’
Occult blood loss and iron deficiency anaemia

May be asymptomatic

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14
Q

Duodenal vs Gastric ulcers pain and relief

A
Duodenal:
Pain 2-3 hrs after eating
Awakens patients at night (50-80 %)
Relieved by...
Eating
Antacids

Gastric:
Pain immediately after eating
Minimal relief with antacids

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15
Q

A 40 year old woman presents with a 2 month history of burning upper abdominal pain which is worse on eating.

You suspect she has a gastric ulcer. What is the most appropriate investigation?

Upper GI endoscopy
Full blood count
Abdominal X-Ray
H. Pylori Breath Test
Trial of Proton Pump inhibitor
A

H. Pylori Breath test

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16
Q

Investigation of peptic ulcer disease

A

<55 and no ‘alarm’ symptoms:
1. H. Pylori breath test/stool antigen test
(if symptoms and +ve H. Pylori, start treatment)
2. FBC, Stool heme test, Fasting serum gastrin level

>55/'alarm symptoms/no response to Tx:
1. UGI endoscopy
--> Ulcer present:
Histology to determine if neoplasia
H. Pylori testing, e.g. biopsy urease testing

If gastric ulcer present, repeat endoscopy after 6-8wks to rule out malignancy

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17
Q

Peptic ulcer disease ‘alarm symptoms’

A
Wt loss
Vomiting;
Bleeding
Anaemia;
Early satiety
Dysphagia
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18
Q

Management of Peptic ulcer disease

A

Lifestyle: Diet, X smoking, X NSAIDs

Pharmacological:
If H.Pylori +; triple therapy
–> 2 x Antibiotics (eradicate HP) and PPI
If H.Pylori -ve: PPI or H2 antagonist

Example Triple therapy regimen:

  1. Amoxicillin or Metronidazole
  2. Carithromycin
  3. Lansoprazole/omeprazole/pantoprazole
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19
Q

Peptic ulcer disease complications

A

Haemorrhage:
Endoscopy +/- endoscopic therapy (adrenaline/cauterize/clip application)
+ IV PPI
+/- Blood transfusion

Perforation:
NBM, NG tube
IV Abx
Surgery

Gastric outlet obstruction
Scarring and stricturing
Malignancy

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20
Q

GORD

A

Gastro-oesophageal Reflux Disease

Reflux of stomach contents into the oesophagus

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21
Q

GORD risk factors

A
Obesity
Pregnancy
Diet
Smoking
Drugs - anti-muscarinic, CCBs, nitrates
Hiatus hernia

(also… CREST syndrome, lower oesophageal sphincter hypotension e.g. after achalasia treatment, low oesophageal peristaltic function, gastric hypersecretion, delayed gastric emptying)

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22
Q

GORD clinical features

A

Heartburn: Burning retrosternal discomfort related to food
Acid regurgitation: ‘waterbrash’ (sour taste)
Exacerbated by bending and lying flat
Relieved by antacids

(also… dysphagia, bloating, early satiety, dental erosion.
Extra oesophageal: nocturnal asthma, chronic cough, laryngitis (hoarseness, throat clearing, sinusitis)

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23
Q

A 37 year old overweight woman presents to the GP with burning upper abdominal pain. She says it is especially bad when she goes to bed. She also complains of a tickly cough and a funny taste in her mouth.
She has no other significant symptoms and you suspect she has GORD.

What is the most appropriate next step?

UGI endoscopy
Start her on a proton pump inhibitor
Barium Swallow study
Start her on a H2 antagonist
Oesophageal manometry
A

Start her on a proton pump inhibitor

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24
Q

GORD Investigations

A

Clinical Diagnosis - Ix not needed unless alarm signs present.

  1. Trial of PPI - diagnostic/therapeutic
  2. If persistent/atypical symptoms with PPI and/or alarm signs, UGI endoscopy
    –>If oesophagitis or Barrett’s oesophagus - confirms reflux
    –>If unrevealing, consider other tests:
    Ambulatory pH monitoring
    Oesophageal manometry - if suspect oesohpageal spasm/achalasia/motility disorder
    Barium swallow
    Oesophageal capsule endoscopy
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25
Q

GORD Management

A
Conservative:
Diet - avoid precipitants, lose wt
Sleep - head of the bed elevation
X smoking
X contributing druge

Pharmacological:
PPI (reduces acid)

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26
Q

Complications of GORD

A

Chronic exposure to acid –> injury/inflammation

Oesophagitis –> Barrett’s (metaplasia) –> Dysplasia –> Oesphageal adenocarcinoma

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27
Q

Barrett’s cellular changes

A

Squamous –> Columnar

28
Q

Barrett’s –> risk of cancer?

A

11x increased risk of oesophageal adenocarcinoma

29
Q

Oesophageal stricture

A

Intermittent progressive dyshpagia

30
Q

GORD surveillance and treatment

A

Barrett’s oesophagus on endoscopy

  1. Surveillance i.e. regular endoscopy w multiple biopsies (Seattle protocol)
  2. Treat:
    a) high grade dysplasia –> radiofrequency ablation + PPI
    b) Nodule –> endoscopic mucosal resection + PPI (or oesophagectomy)
31
Q

Zollinger-Ellison Syndrome cause and epidemiology

A

Gastrin secreting tumour of the pancreas
Sporadic or as part of MEN1
0.1-1% of all patients with duodenal ulcers

32
Q

Zollinger-Ellison Syndrome pathophysiology

A

Hypergastrinaemia –> Hypertrophy of gastric mucosa and stimulation of acid secretion cells –> Damaged mucosa and ulceration.

+ Malabsorption due to damage of GI mucosa and inactivation of pancreatic enzymes

33
Q

Zollinger-Ellison Syndrome Clinical Features

A

Must consider ZE syndrome if multiple or refractory ulcers

Abdo pain (similar to PUD pain)
Diarrhoea
Heartburn
Features associated with MEN1:
Hyperparathyroid (e.g. renal stones/hyperCa), pituitary disorders
34
Q

Zollinger-Ellison Syndrome Ix, Management and Prognosis

A

Ix:
Fasting serum gastrin
Serum calcium
Gastric acid secretory tests, stimulation tests, imaging

Management:
PPI
Surgical resection

Prognosis excellent without metastatic disease

35
Q

A 29 year old woman presents with 2 week history of passing bloody diarrhoea with mucus up to 12 times a day. This is associated with lower abdominal, cramp like pain and malaise. On examination she looks pale and generally unwell and there is some tenderness in the left iliac fossa.

Most likely cause?

Gastroenteritis
Crohn's disease
IBS
Hyperthyroidism
UC
A

UC

36
Q

A 55 year old woman with diabetes presents with weight loss, diarrhoea and angular stomatitis. Blood tests reveal presence of tTG antibodies.

Most likely cause?

Hyperthyroidism
Colorectal carcinoma
IBS
Coeliac disease
Crohn's disease
A

Coeliac

37
Q

A 16 year old boy is brought to paediatric out patients by his mother with a 9 month history of weight loss, abdominal pain and diarrhoea. On examination, he is on the 10th centile for height and weight, having been on the 50th centile previously. tTG
antibodies are negative.

Most likely cause?

Gastroenteritis
Coeliac disease
UC
Hyperthyroidism
Crohn's disease
A

Crohn’s disease

38
Q

A 28 year old medical student returns from his elective in Thailand with a short history of severe lower abdominal cramps and passage of blood diarrhoea.

Most likely cause?

Gastroenteritis
Pseudomembranous colitis
UC
Hyperthyroidism
Crohn's disease
A

Gastroenteritis

39
Q

A 24 year old woman gives a long history (several years) of intermittent diarrhoea and constipation. She also complains of
abdominal bloating and left iliac fossa pain. The pain and bloating are made worse by eating and are relieved by defecation.

Most likely cause?

Gastroenteritis
Coeliac disease
IBS
Hyperthyroidism
Crohn's disease
A

Irritable Bowel Syndrome

40
Q

Inflammatory Bowel Disease Summary

A

Group of chronic disorders that cause inflammation of the GI tract
Inflammation–>Damage
Spectrum of severity

Crohn’s disease
Ulcerative colitis

41
Q

Ulcerative Colitis Definition

A

A relapsing and remitting inflammatory disorder of the colonic mucosa

42
Q

Ulcerative Colitis Classification and Epidemiology

A

Location: Colon, ascending backwards
Severity: Mild, moderate or severe

Most commonly presents age 15-30

43
Q

Crohn’s disease Definition and Epidemiology

A

A chronic inflammatory condition that may affect any part of the GI tract from mouth to anus

Bimodal peak of onset: 15-30 y/o, 60-80 y/o

44
Q

Ulcerative Colitis Summary

A

Mucosa and submucosa
Starts distally (rectum) and spreads proximally
Continous inflammation
Pseudopolyps
Bloody diarrhoea always present and mucus
Tenesmus (cramping rectal pain)
Pain diffuse/lower abdomen
Relapsing remitting - well between attacks
P-anca positive (PU - Positive in UC)
Increased risk PSC< CRC< cholangiocarcinoma a –> surveillance colonoscopy

45
Q

Crohn’s disease summary

A
Non-caseating granulomas
Transmural
Any part of GI tract, esp. terminal ileum and Ascending Colon
Skip lesions
Ulcers, strictures, perianal abscesses, fistulae
Diarrhoea, but blood may not be present
Steatorrhoea when affects ileum
Pain diffuse/RLQ
Wt loss/systemically unwell more likely
P-anca negative
46
Q

Extra GI features of IBD

A
Aphthous mouth ulceration
Erythema nodusum
Pyoderma gangrenosum
Episcleritis/scleritis/anterior uveitis
Arthritis
47
Q

Diagnosis of UC and CD

A

Stool sample (infectious? Faecal calprotectin/lactorferrin –> Crohn’s?)

Bloods: FBC, Iron studies, B12, Folate, LFTs, UandE’s, ESR, CRP, Auto-Ab

Imaging: AXR, CT Abdo, MRI Abdo/Pelvis, Double contrast barium enema

Flexile sigmoidoscopy/colonoscopy

48
Q

Coeliac Disease Definition

A

Chronic autoimmune disease of small intestine; intolerance of dietary gluten; villous atrophy and malabsorption

49
Q

Coeliac Disease epidemiology

A

More common in europeans

Peaks in infancy and at 50-60yrs

50
Q

Coeliac Disease clinical features

A
Symptoms:
Diarrhoea
Wt loss
Abdo pain
Bloating
Nausea and vomiting
Signs:
Aphthous ulcers
Angular stomatitis
Anaemia
Osteomalacia
Dermatitis herptiformis
51
Q

Coeliac Disease Ix

A

Serum antibodies to:
TTG (Tissue transglutaminase)
Anti-EMA (Anti-endomysial ab)
(anti-gliadin)

Endoscopy and duodenal biopsy:
villous atrophy/crypt hyperplasia/intraepithelial WBCs

52
Q

Coeliac Disease treatment

A

Gluten free diet

53
Q

Gastroenteritis Definition and classification

A

Acute Gastrointestinal infection
At risk: young, old, travellers

Viral vs Bacterial - mostly bacterial in adults

54
Q

Gastroenteritis Diarrhoea vs Dysentery

A
Diarrhoea: 
Campylobacter/Clostridium difficile
Staph aureus
Vibrio cholera
Salmonella
E. Coli
Bacillus cereus
Dysentery (Bloody diarrhoea): CHESS
Campylobacter/Clostridium difficile
Haemorrhagic E. Coli
Entamoeba histolytica
Salmonella
Shigella
55
Q

Gastroenteritis Ix/Rx

A

Stool microscopy and culture
+ Oral rehydration solution
+/- Abx

56
Q

Irritable Bowel Syndrome Definition and Epidemiology

A

A mixed group of abdominal symptoms for which no organic cause can be found.
? linked to stress/anxiety/depression

Prevalence 10-20%
Age at onset usually < 40
Women > men

57
Q

Irritable Bowel Syndrome Diagnosis

A

Diagnostic Criteria: Rome II/III

Chronic (> 6 months) abdo pain/discomfort…

  1. relieved by defaecation, OR
  2. associated with altered stool form or bowel frequency

AND 2+ of…

  1. Urgency
  2. Incomplete evacuation
  3. Abdo bloating/distension
  4. Mucus
  5. Worsening symptoms after food

Beware of red flags (e.g. wt loss, nocturnal symptoms, older)
Exclude other pathology

58
Q

Management of IBS

A
Lifestyle and dietary modifications
If pain/bloating --> antispasmodics
Consider psychological therapy:
Cognitive Behavioural Therpay
Hypnotherapy
Drugs: SSRI, TCAs
Constipation-predominant --> laxatives
Diarrhoea predominat --> anti-diarrhoeals
Alternating constipation/diarrhoea --> laxatives and loperamide
59
Q

Other GI causes of diarrhoea

A

Colorectal carcinoma - older, red flags

Pseudomembranous colitis - C. Diff infection after recent Abx treatment; risk of Toxic Megacolon

Hyperthyroidism

60
Q

Summary DDx of Diarrhoea

A

Infection (Gastroenteritis, Pseudomembranous colitis)

Inflammatory (UC/CD)

Malignancy (Colorectal carcinoma)

Autoimmune (Coeliac Disease)

Others (IBS, Hyperthyroidism, Medications)

61
Q

UC Severity Index

A

Truelove and Witts’ severity index

Mild/Moderate/Severe

Based on:
Bowel movements/day
Blood in stools
Pyrexia
HR > 90 bpm
Anaemia
ESR (mm/hr)

(Do not need to learn this, helpful for understanding. Also different for children)

62
Q

Management of IBD: Inducing remission

A

All patients: Vaccination

Mild/Moderate Proctitis or Proctosigmoiditis:
Topical 5-ASA +/- oral 5-ASA

Mild/Moderate lft sided or extensive colitis:
High dose oral 5-ASA +/- topical 5-ASA or oral beclomethasone

For both: If no improvement in 4w –> oral prednisolone. If still no response 2-4w –> oral tacrolimus

If severe for all categories:
Admit
MDT
IV corticosteroid + IV fluids
Consider IV ciclosporin/surgery if no improvement/worse in 72 hrs

[5-ASA = aminosalicyclate –> e.g. ‘Mesalazine’]

63
Q

Maintaining Remission of UC

A

Proctitis/proctosigmoiditis:
Topical 5-ASA and/or oral 5-ASA

Left sided/extensive colitis:
Oral 5-ASA

All extents of disease:
Consider adding oral azathioprine or oral mercaptopurine if exacerbations

64
Q

A 20 year old man presents with diarrhoea. He is passing stool 3 times a day. He is generally well with no fever. After a number of investigations he is diagnosed with Ulcerative Colitis, confined to the rectum.

What treatment should be given first?

Oral prednisolone
IV corticosteriod
Oral tacrolimus
Topical 5-ASA
High dose oral 5-ASA
IV ciclosporin
A

Topical 5-ASA

Mild disease
Proctitis
–> Topical 5-ASA +/- oral 5-ASA most appropriate
e.g. mesalazine/sulfasalazine

65
Q

A 20 year old man presents with diarrhoea. He is passing bloody stool 7 times a day. He looks unwell and on examination he is tachycardic and has a fever. After a number of investigations he is diagnosed with Ulcerative Colitis.

What treatment should be given first?

Oral prednisolone
IV corticosteroid
Oral tacrolimus
Topical 5-ASA
High dose oral 5-ASA
IV ciclosporin
A

IV Corticosteroid

Severe disease
Therefore:
Admit
MDT
1. IV Corticosteroid
2. Consider adding IV ciclosporin/surgery if no improvement/worse in 72 hrs
66
Q

Crohn’s Disease Management

A

Conservative: MDT, Education, Smoking Cessation

Pharmacological - Inducing remision in active Crohn’s:

  1. Corticosteroid
  2. 5-ASA
  3. Other imunosuppressants (Azathioprine/mercaptopurine)
  4. Infliximab and adalimumab (anti-TNF)

Pharmacological - Maintaining remission:
5. Monotherapy azathioprine/mercaptopurine

67
Q

Summary of Rx UC and CD

A

UC: 5-ASA, Steroids and Immunosuppressants if required

CD: Steroids, other immunosuppressants and anit-TNF if required