GI - Dyspepsia & IBD

Question 1

What is Dyspepsia

Answer 1

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

Question 2

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

Answer 2

Duodenal Ulcer

Question 3

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

Answer 3

Barrett’s oespophagus

Question 4

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

Answer 4

Zollinger-Ellison Syndrome

Question 5

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

Answer 5

Gastric ulcer

Question 6

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

Answer 6

GORD

Question 7

Peptic ulcer definition

Answer 7

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

Question 8

Peptic ulcer classifications

Answer 8

Duodenal vs Gastric

Question 9

More common type of peptic ulcer

Answer 9

Duodenal

Question 10

Peptic ulcer disease epidemiology

Answer 10

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

Question 11

Peptic ulcer disease risk factors

Answer 11

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

Question 12

Helicobacter Pylori

Answer 12

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.

Question 13

Peptic ulcer disease symptoms and signs

Answer 13

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

Question 14

Duodenal vs Gastric ulcers pain and relief

Answer 14

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

Question 15

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

Answer 15

H. Pylori Breath test

Question 16

Investigation of peptic ulcer disease

Answer 16

<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

Question 17

Peptic ulcer disease ‘alarm symptoms’

Answer 17

Wt loss
Vomiting;
Bleeding
Anaemia;
Early satiety
Dysphagia

Question 18

Management of Peptic ulcer disease

Answer 18

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

Question 19

Peptic ulcer disease complications

Answer 19

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

Question 20

GORD

Answer 20

Gastro-oesophageal Reflux Disease

Reflux of stomach contents into the oesophagus

Question 21

GORD risk factors

Answer 21

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)

Question 22

GORD clinical features

Answer 22

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)

Question 23

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

Answer 23

Start her on a proton pump inhibitor

Question 24

GORD Investigations

Answer 24

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

Question 25

GORD Management

Answer 25

``` Conservative: Diet - avoid precipitants, lose wt Sleep - head of the bed elevation X smoking X contributing druge ``` Pharmacological: PPI (reduces acid)

Question 26

Complications of GORD

Answer 26

Chronic exposure to acid --> injury/inflammation Oesophagitis --> Barrett's (metaplasia) --> Dysplasia --> Oesphageal adenocarcinoma

Question 27

Barrett's cellular changes

Answer 27

Squamous --> Columnar

Question 28

Barrett's --> risk of cancer?

Answer 28

11x increased risk of oesophageal adenocarcinoma

Question 29

Oesophageal stricture

Answer 29

Intermittent progressive dyshpagia

Question 30

GORD surveillance and treatment

Answer 30

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)

Question 31

Zollinger-Ellison Syndrome cause and epidemiology

Answer 31

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

Question 32

Zollinger-Ellison Syndrome pathophysiology

Answer 32

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

Question 33

Zollinger-Ellison Syndrome Clinical Features

Answer 33

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 ```

Question 34

Zollinger-Ellison Syndrome Ix, Management and Prognosis

Answer 34

Ix: Fasting serum gastrin Serum calcium Gastric acid secretory tests, stimulation tests, imaging Management: PPI Surgical resection Prognosis excellent without metastatic disease

Question 35

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 ```

Answer 35

UC

Question 36

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 ```

Answer 36

Coeliac

Question 37

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 ```

Answer 37

Crohn's disease

Question 38

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 ```

Answer 38

Gastroenteritis

Question 39

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 ```

Answer 39

Irritable Bowel Syndrome

Question 40

Inflammatory Bowel Disease Summary

Answer 40

Group of chronic disorders that cause inflammation of the GI tract Inflammation-->Damage Spectrum of severity Crohn's disease Ulcerative colitis

Question 41

Ulcerative Colitis Definition

Answer 41

A relapsing and remitting inflammatory disorder of the colonic mucosa

Question 42

Ulcerative Colitis Classification and Epidemiology

Answer 42

Location: Colon, ascending backwards Severity: Mild, moderate or severe Most commonly presents age 15-30

Question 43

Crohn's disease Definition and Epidemiology

Answer 43

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

Question 44

Ulcerative Colitis Summary

Answer 44

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

Question 45

Crohn's disease summary

Answer 45

``` 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 ```

Question 46

Extra GI features of IBD

Answer 46

``` Aphthous mouth ulceration Erythema nodusum Pyoderma gangrenosum Episcleritis/scleritis/anterior uveitis Arthritis ```

Question 47

Diagnosis of UC and CD

Answer 47

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

Question 48

Coeliac Disease Definition

Answer 48

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

Question 49

Coeliac Disease epidemiology

Answer 49

More common in europeans | Peaks in infancy and at 50-60yrs

Question 50

Coeliac Disease clinical features

Answer 50

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

Question 51

Coeliac Disease Ix

Answer 51

Serum antibodies to: TTG (Tissue transglutaminase) Anti-EMA (Anti-endomysial ab) (anti-gliadin) Endoscopy and duodenal biopsy: villous atrophy/crypt hyperplasia/intraepithelial WBCs

Question 52

Coeliac Disease treatment

Answer 52

Gluten free diet

Question 53

Gastroenteritis Definition and classification

Answer 53

Acute Gastrointestinal infection At risk: young, old, travellers Viral vs Bacterial - mostly bacterial in adults

Question 54

Gastroenteritis Diarrhoea vs Dysentery

Answer 54

``` 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 ```

Question 55

Gastroenteritis Ix/Rx

Answer 55

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

Question 56

Irritable Bowel Syndrome Definition and Epidemiology

Answer 56

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

Question 57

Irritable Bowel Syndrome Diagnosis

Answer 57

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

Question 58

Management of IBS

Answer 58

``` 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 ```

Question 59

Other GI causes of diarrhoea

Answer 59

Colorectal carcinoma - older, red flags Pseudomembranous colitis - C. Diff infection after recent Abx treatment; risk of Toxic Megacolon Hyperthyroidism

Question 60

Summary DDx of Diarrhoea

Answer 60

Infection (Gastroenteritis, Pseudomembranous colitis) Inflammatory (UC/CD) Malignancy (Colorectal carcinoma) Autoimmune (Coeliac Disease) Others (IBS, Hyperthyroidism, Medications)

Question 61

UC Severity Index

Answer 61

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)

Question 62

Management of IBD: Inducing remission

Answer 62

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']

Question 63

Maintaining Remission of UC

Answer 63

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

Question 64

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 ```

Answer 64

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

Question 65

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 ```

Answer 65

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

Question 66

Crohn's Disease Management

Answer 66

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

Question 67

Summary of Rx UC and CD

Answer 67

UC: 5-ASA, Steroids and Immunosuppressants if required CD: Steroids, other immunosuppressants and anit-TNF if required