GI - Dyspepsia & IBD Flashcards
What is Dyspepsia
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
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
Duodenal Ulcer
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
Barrett’s oespophagus
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
Zollinger-Ellison Syndrome
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
Gastric ulcer
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
GORD
Peptic ulcer definition
A break in the superficial epithelial lining of either the stomach or the duodenum.
Peptic ulcer classifications
Duodenal vs Gastric
More common type of peptic ulcer
Duodenal
Peptic ulcer disease epidemiology
Common
Incidence increases with age
H. Pylori related in developing countries
NSAID-induced in developed countries
Peptic ulcer disease risk factors
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
Helicobacter Pylori
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.
Peptic ulcer disease symptoms and signs
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
Duodenal vs Gastric ulcers pain and relief
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
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
H. Pylori Breath test
Investigation of peptic ulcer disease
<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
Peptic ulcer disease ‘alarm symptoms’
Wt loss Vomiting; Bleeding Anaemia; Early satiety Dysphagia
Management of Peptic ulcer disease
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:
- Amoxicillin or Metronidazole
- Carithromycin
- Lansoprazole/omeprazole/pantoprazole
Peptic ulcer disease complications
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
GORD
Gastro-oesophageal Reflux Disease
Reflux of stomach contents into the oesophagus
GORD risk factors
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)
GORD clinical features
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)
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
Start her on a proton pump inhibitor
GORD Investigations
Clinical Diagnosis - Ix not needed unless alarm signs present.
- Trial of PPI - diagnostic/therapeutic
- 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
GORD Management
Conservative: Diet - avoid precipitants, lose wt Sleep - head of the bed elevation X smoking X contributing druge
Pharmacological:
PPI (reduces acid)
Complications of GORD
Chronic exposure to acid –> injury/inflammation
Oesophagitis –> Barrett’s (metaplasia) –> Dysplasia –> Oesphageal adenocarcinoma
Barrett’s cellular changes
Squamous –> Columnar
Barrett’s –> risk of cancer?
11x increased risk of oesophageal adenocarcinoma
Oesophageal stricture
Intermittent progressive dyshpagia
GORD surveillance and treatment
Barrett’s oesophagus on endoscopy
- Surveillance i.e. regular endoscopy w multiple biopsies (Seattle protocol)
- Treat:
a) high grade dysplasia –> radiofrequency ablation + PPI
b) Nodule –> endoscopic mucosal resection + PPI (or oesophagectomy)
Zollinger-Ellison Syndrome cause and epidemiology
Gastrin secreting tumour of the pancreas
Sporadic or as part of MEN1
0.1-1% of all patients with duodenal ulcers
Zollinger-Ellison Syndrome pathophysiology
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
Zollinger-Ellison Syndrome Clinical Features
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
Zollinger-Ellison Syndrome Ix, Management and Prognosis
Ix:
Fasting serum gastrin
Serum calcium
Gastric acid secretory tests, stimulation tests, imaging
Management:
PPI
Surgical resection
Prognosis excellent without metastatic disease
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
UC
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
Coeliac
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
Crohn’s disease
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
Gastroenteritis
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
Irritable Bowel Syndrome
Inflammatory Bowel Disease Summary
Group of chronic disorders that cause inflammation of the GI tract
Inflammation–>Damage
Spectrum of severity
Crohn’s disease
Ulcerative colitis
Ulcerative Colitis Definition
A relapsing and remitting inflammatory disorder of the colonic mucosa
Ulcerative Colitis Classification and Epidemiology
Location: Colon, ascending backwards
Severity: Mild, moderate or severe
Most commonly presents age 15-30
Crohn’s disease Definition and Epidemiology
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
Ulcerative Colitis Summary
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
Crohn’s disease summary
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
Extra GI features of IBD
Aphthous mouth ulceration Erythema nodusum Pyoderma gangrenosum Episcleritis/scleritis/anterior uveitis Arthritis
Diagnosis of UC and CD
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
Coeliac Disease Definition
Chronic autoimmune disease of small intestine; intolerance of dietary gluten; villous atrophy and malabsorption
Coeliac Disease epidemiology
More common in europeans
Peaks in infancy and at 50-60yrs
Coeliac Disease clinical features
Symptoms: Diarrhoea Wt loss Abdo pain Bloating Nausea and vomiting
Signs: Aphthous ulcers Angular stomatitis Anaemia Osteomalacia Dermatitis herptiformis
Coeliac Disease Ix
Serum antibodies to:
TTG (Tissue transglutaminase)
Anti-EMA (Anti-endomysial ab)
(anti-gliadin)
Endoscopy and duodenal biopsy:
villous atrophy/crypt hyperplasia/intraepithelial WBCs
Coeliac Disease treatment
Gluten free diet
Gastroenteritis Definition and classification
Acute Gastrointestinal infection
At risk: young, old, travellers
Viral vs Bacterial - mostly bacterial in adults
Gastroenteritis Diarrhoea vs Dysentery
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
Gastroenteritis Ix/Rx
Stool microscopy and culture
+ Oral rehydration solution
+/- Abx
Irritable Bowel Syndrome Definition and Epidemiology
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
Irritable Bowel Syndrome Diagnosis
Diagnostic Criteria: Rome II/III
Chronic (> 6 months) abdo pain/discomfort…
- relieved by defaecation, OR
- associated with altered stool form or bowel frequency
AND 2+ of…
- Urgency
- Incomplete evacuation
- Abdo bloating/distension
- Mucus
- Worsening symptoms after food
Beware of red flags (e.g. wt loss, nocturnal symptoms, older)
Exclude other pathology
Management of IBS
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
Other GI causes of diarrhoea
Colorectal carcinoma - older, red flags
Pseudomembranous colitis - C. Diff infection after recent Abx treatment; risk of Toxic Megacolon
Hyperthyroidism
Summary DDx of Diarrhoea
Infection (Gastroenteritis, Pseudomembranous colitis)
Inflammatory (UC/CD)
Malignancy (Colorectal carcinoma)
Autoimmune (Coeliac Disease)
Others (IBS, Hyperthyroidism, Medications)
UC Severity Index
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)
Management of IBD: Inducing remission
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’]
Maintaining Remission of UC
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
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
Topical 5-ASA
Mild disease
Proctitis
–> Topical 5-ASA +/- oral 5-ASA most appropriate
e.g. mesalazine/sulfasalazine
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
IV Corticosteroid
Severe disease Therefore: Admit MDT 1. IV Corticosteroid 2. Consider adding IV ciclosporin/surgery if no improvement/worse in 72 hrs
Crohn’s Disease Management
Conservative: MDT, Education, Smoking Cessation
Pharmacological - Inducing remision in active Crohn’s:
- Corticosteroid
- 5-ASA
- Other imunosuppressants (Azathioprine/mercaptopurine)
- Infliximab and adalimumab (anti-TNF)
Pharmacological - Maintaining remission:
5. Monotherapy azathioprine/mercaptopurine
Summary of Rx UC and CD
UC: 5-ASA, Steroids and Immunosuppressants if required
CD: Steroids, other immunosuppressants and anit-TNF if required
