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Finals Revision Flashcards > GI - GORD, PUD, IBD, IBS, Coeliac > Flashcards

GI - GORD, PUD, IBD, IBS, Coeliac Flashcards

1
Q

GORD - what is it?

A

Acid from stomach refluxes up through lower oesophageal sphincter and irritates lining of oesophagus

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2
Q

GORD - what epithelium lines the oesophagus?

A

Squamous - sensitive to stomach acid

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3
Q

GORD - what epithelium lines the stomach?

A

Columnar - more protected against stomach acid

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4
Q

GORD - what is the classic clinical presentation?

A 
Retrosternal or epigastric pain
Heartburn
Acid regurg
Bloating
Nocturnal cough
Odynophagia - painful swallowing
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5
Q

GORD - when is heartburn worst?

A

After meals

Lying down or bending forward

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6
Q

GORD - diagnosis and investigations

A

GORD is a clinical diagnosis based on symptoms

There are red flag symptoms - consider upper GI endoscopy in this case

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7
Q

GORD - what are the red flag symptoms to consider upper GI endoscopy?

A
  1. Weight loss
  2. Anaemia
  3. Dysphagia
  4. New onset Dyspepsia >55 years
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8
Q

GORD - what investigations can be done if diagnosis is uncertain?

A

pH monitoring - combined with gastroscopy

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9
Q

GORD - what are the reflux phenotypes

A
  1. Erosive oesophagitis - erosions seen on gastroscopy
  2. Non-erosive oesophageal reflux - normal gastroscopy, but pathological acid exposure on pH test
  3. Acid hypersensitive oesophagus - normal gastroscopy, non-pathological acid exposure on pH test, but temporal association of reflux events with symptoms
  4. Functional heartburn - normal gastroscopy, non-pathological acid exposure on pH test, and no temporal association of reflux events with symptoms
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10
Q

GORD - what is the management? (conservative, medical, surgical)

A

Conservative:

  1. Weight loss
  2. Smoking cessation

Medical:

  1. PPIs, Omeprazole, Lansoprazole - PPIs reduce acid secretion by inhibition of H+/K+ATPases in parietal cells
  2. Ranitidine, alternative, H2 receptor antagonist

Surgical:
Nissen fundoplication - tying fundus of stomach around lower oesophagus to narrow LOS

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11
Q

GORD - what is the major complication of constant reflux, and what happens?

A

Barretts Oesophagus

Constant relux in oesophagus causes metaplasia

Metaplasia is the change in epithelium

So oesophagus goes from squamous to columnar

This change to columnar is called Barretts oesophagus

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12
Q

GORD - why does Barretts oesophagus have to be monitored?

A

Considered premalignant condition

RF for developing adenocarcinoma

So monitored regularly by endoscopy

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13
Q

GORD - what is the treatment of Barretts oesophagus

A

Medical:
PPIs, omeprazole
Aspirin - new evidence, not in current guidelines yet

Surgical:
Ablation treatment during endoscopy - destroys epithelium, so replaced with normal squamous cells, prevents progression of cancer

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14
Q

Peptic Ulcer - what are they?

A

Ulceration of the mucosa of the stomach or duodenum

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15
Q

Peptic Ulcer - why does it occur?

A

Protective layer in stomach and duodenum - comprised of mucus and bicarbonate secreted by stomach mucosa

This LAYER GETS BROKEN DOWN by medications (steroids, NSAIDs) and H.Pylori

OR

INCREASE IN STOMACH ACID, which can result from:
Alcohol
Smoking
Spicy food
Caffeine
Stress
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16
Q

Peptic Ulcer - what are the symptoms?

A

Epigastric pain or discomfort

N+V

Bleeding causing HAEMATEMESIS - coffee ground vomiting

Melaena

Iron deficiency anaemia - due to constant bleeding

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17
Q

Peptic Ulcer - how does eating affect gastric and duodenal ulcers?

A

Eating makes gastric ulcers pain WORSEN

Eating makes duodenal ulcers pain IMPROVE

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18
Q

Peptic Ulcer - what is the hallmark triad of PUD?

A
  1. Epigastric pain
  2. Heartburn
  3. Dyspepsia
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19
Q

Peptic Ulcer - what are the two acute, severe complications of PUD, and how do they present?

A
  1. Acute upper GI bleed (UGIB):
    Haematemesis and/or melaena
    Features of shock could be present
  2. Perforation ‘acute abdomen’:
    Acute severe abdo pain
    Localised or generalised guarding
    Ulcer creates hole, fluid leaks out into peritoneum causes peritonitis
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20
Q

Peptic Ulcer - what is the definitive diagnosis technique?

A

Endoscopic examination

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21
Q

Peptic Ulcer - What are the investigations that can be done?

A

Bedside:
Obs
H.Pylori testing

Bloods:
FBC - may show iron def anaemia
LFTs - biliary pathology or gallstones, could be differential

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22
Q

Peptic Ulcer - during an endoscopic exam, what tests are done and why?

A

Rapid urease test (CLO test) - check for H. Pylori

Biopsy during endoscopy - exclude malignancy

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23
Q

Peptic Ulcer - what is the stepwise management?

A

Patients who test POSITIVE FOR H.PYLORI offered eradication therapy

If positive for H.Pylori, then assessed to see if there is association with NSAIDs

No association with NSAIDs - 1st line eradication therapy
Association with NSAIDs - 2 months full dose PPI, then given 1st line erad therapy

Patients who test NEGATIVE FOR H.PYLORI - 4 to 8 weeks full dose PPI

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24
Q

Peptic Ulcer - what is the 1st line eradication therapy course?

A

Given 7 day course of triple therapy - PPI and dual antibiotic therapy

Non-penicillin allergy

  1. PPI
  2. Amoxicillin
  3. Clarithromycin/metronidazole

Penicillin allergy:

  1. PPI
  2. Clarithromycin
  3. Metronidazole
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25
Q

Crohn’s Disease - what is it?

A

Chronic inflammatory disorder

Affect any part of GI tract, mouth to anus

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26
Q

Crohn’s Disease - aetiology

A

Thought to be an abnormal immunological response to one or more aetiological factors within a genetically susceptible individual

Aetiological factors include:
Genetics
Immune system
Environment

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27
Q

Crohn’s Disease - what are the pathophysiological changes that occur?

A 
C - Cobblestone appearance, MAC
R - Rosethorn ulcers, MAC
O - Obstruction
H - Hyperplasia (lymph nodes), MIC
N - Narrowing (lumen), MAC
S - Skip lesions

Macroscopic change - seen in endoscopy (MAC)
Microscopic change - seen on histology (MIC)

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28
Q

Crohn’s Disease - is superficial or full thickness of mucosa affected?

A

Transmural, full thickness, inflammation

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29
Q

Crohn’s Disease - What are the symptoms?

A 
Low-grade fever
N+V
Abdo pain
Weight loss
Diarrhoea
Rectal bleeding
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30
Q

Crohn’s Disease - what are the signs?

A 
Pyrexia
Angular stomatitis
Aphthous ulcers
Tachycardia
Hypotension
Dehydration
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31
Q

Crohn’s Disease - what are the extra-intestinal manifestation areas?

A 
MSK, bones and joints
Skin
Eyes and mouth
Hepatobiliary
Blood
32
Q

Crohn’s Disease - what are the extra-intestinal manifestation of bones and skin?

A

Erythema Nodosum (also seen in sarcoidosis)

Arthritis

33
Q

Crohn’s Disease - what are the extra-intestinal manifestation of the eyes and mouth?

A

Episcleritis

Uveitis

Conjunctivitis

Aphthous ulcers

34
Q

Crohn’s Disease - what are the extra-intestinal manifestation of hepatobiliary?

A

Primary sclerosing cholangitis

Fatty liver disease

Gallstones

35
Q

Crohn’s Disease - what are the extra-intestinal manifestation of the blood?

A

B12 deficiency

Anaemia

36
Q

Crohn’s Disease - what is the diagnosis based on?

A

Endoscopy (colonoscopy) macroscopic assessment and biopsy taken to see histological changes

37
Q

Crohn’s Disease - what are some investigations you can do?

A

Faecal calprotectin - marker of intestinal inflammation

Stool Microscopy

Bloods:
FBC
LFT
U&E
CRP
38
Q

Crohn’s Disease - what imaging can you do?

A

Abdo X-Ray: shows bowel dilatation
perforation
wall thickening

CT: shows wall thickening
bowel obstruction

MRI small bowel: ‘disease mapping’

Barium follow through: used to identify strictures

39
Q

Crohn’s Disease - what is the general principle in managing Crohn’s?

A

To induce remission, then maintain remission

40
Q

Crohn’s Disease - what are the drugs to induce remission?

A

1st line - Steroids, oral prednisolone or IV hydrocortisone

If doesn’t work alone add - methotrexate, azathioprine, infliximab, adalimumab, mercaptopurine

41
Q

Crohn’s Disease - what are the drugs to maintain remission?

A

Tailored based on risks, side effects, patients wishes:

1st line: mercaptopurine, azathioprine

Alternatives: methotrexate, infliximab, adalimumab

42
Q

Crohn’s Disease - when is surgery as treatment indicated?

A

When the disease only affects the distal ileum, possible to surgically resect area

Surgery also used to treat strictures and fistulas secondary to Crohns

43
Q

Ulcerative Colitis - what is it?

A

Chronic, inflammatory disease characetrised by a relapsing-remitting course affecting the colon and/or rectum

44
Q

Ulcerative Colitis - what is the distribution in the GI tract?

A

Confined to rectum and colon

Continuous inflammation of the mucosa

45
Q

Ulcerative Colitis - what is pancolitis?

A

Inflammation of the entire colon

46
Q

Ulcerative Colitis - CLOSEUP mneumonic

A 
C - continuous inflammation
L - limited to colon and rectum
O - only superficial mucosa affected
S - smoking is protective
E - excrete blood and mucus
U - use aminosalicylates
P - primary sclerosing cholangitis
47
Q

Ulcerative Colitis - what are the macroscopic changes in UC?

A

Macroscopic changes - seen on endoscopy

  1. Red, inflamed mucosa
  2. Continuous inflammation
  3. Friable (easily crumbled)
  4. Inflammatory polyps
48
Q

Ulcerative Colitis - what are the microscopic changes in UC?

A

Microscopic changes - seen on histology

  1. Goblet cell depletion
  2. Crypt abscesses
  3. Inflammatory infiltrate in lamina propria
49
Q

Ulcerative Colitis - what is the hallmark clinical feature of UC?

A

Bloody diarrhoea/rectal bleeding

50
Q

Ulcerative Colitis - what are the symptoms?

A 
Rectum symptoms:
Loose stools
Rectal bleeding
Tenesmus - incomplete emptying
Urgency

Weight loss
Abdo pain

51
Q

Ulcerative Colitis - what are the signs?

A

Obs:
Tachycardic
Hypotensive
Febrile

Examination:
Abdo tenderness, distension/mass
Pale

52
Q

Ulcerative Colitis - what is the major complication of UC?

A

Toxic Megacolon - medical emergency

53
Q

Ulcerative Colitis - what is one example of the extra-colonic manifestations of the mouth, MSK, eyes, skin, hepatobiliary system and blood?

A

MSK - arthritis (most common extra-colonic manifestation)

Eyes - uveitis, strongly associated with UC

Mouth - aphthous ulcers

Skin - erythema nodosum

Hepatobiliary - primary sclerosing cholangitis

Haematological - anaemia

54
Q

Ulcerative Colitis - what is the diagnostic investigation of choice

A

Colonoscopy (macroscopic changes) with biopsy (microscopic changes)

55
Q

Ulcerative Colitis - what are the bedside Ix, bloods and imaging you can do?

A

Bedside:
Obs
FAECAL CALPROTECTIN
Stool sample for microscopy

Bloods:
FBC, U&E, CRP, LFTs

Imaging:
Abdo X-rays

56
Q

Ulcerative Colitis - what is the name of the tool used to assess the severity of UC?

A

Truelove and Witts’ classification (TLWC)

57
Q

Ulcerative Colitis - what is the TLWC scores and criteria?

A

Mild:
<4 bowel motions a day
Small amount of blood

Moderate:
4-6 bowel motions a day
Quantity of blood between mld and severe

Severe:
>6 bowel motions per day
Visible blood
Systemic upset

The other criterions under each severity heading include:
Pyrexia?
Tachycardia?
Anaemia?
ESR
58
Q

Ulcerative Colitis - what is the management steps and drugs?

A

General principle - induce remission, then maintain it

Inducing remission:
MILD to MODERATE - 1st line aminosalicylate (mesalazine)
2nd line - corticosteroids (prednisolone)

SEVERE - 1st line IV hydrocortisone
2nd line - IV ciclosporin

Maintaining remission:
Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine

59
Q

Ulcerative Colitis - what are the surgical management options?

A

Panproctocolectomy - removal of colon and rectum, will remove the disease

Patient is then left with an ileostomy or an ileo-anal anastomosis (J-pouch)

This is when ileum folded back on itself, fashioned into larger pouch, functions bit like a rectum -> J-pouch then attached to anus and collects stools prior to patient passing motion

60
Q

Irritable Bowel Syndrome - what is it?

A

It is a chronic, functional bowel disorder, characterised by abdo pain and altered bowel habits

61
Q

Irritable Bowel Syndrome - what are the symptoms?

A 
Abdo pain
Bloating
Constipation
Diarrhoea
Fluctuating bowel habits

Improved by opening bowels
Worse after eating

62
Q

Irritable Bowel Syndrome - what is the criteria fro diagnosis?

A

Other pathology excluded first:

Normal CRP, ESR, FBC
Negative Faecal Calprotectin
Negative coeliac disease serology (anti-TTG antibodies)
Cancer not suspected or been excluded

63
Q

Irritable Bowel Syndrome - what is the lifestyle advice?

A

Adequate fluids
Regular small meals
Limit caffeine and alcohol
Reduce processed foods

64
Q

Irritable Bowel Syndrome - what is the medical management?

A

1st line - Loperamide for diarrhoea
Laxatives for constipation, Linaclotide
Antispasmodics for cramps, buscopan

2nd line - Tricyclic antidepressants, amitriptyline

3rd line - SSRIs

65
Q

Coeliac Disease - what is it?

A

It is an autoimmune condition where exposure to gluten peptides causes inflammation in small bowel

66
Q

Coeliac Disease - what happens when gluten is ingested?

A

Auto-antibodies are created in response to gluten, and they target epithelial cells of the intestine, lead to inflammation

67
Q

Coeliac Disease - what are the names of the two auto-antibodies?

A

Anti-tissue transglutaminase (anti-TTG)

Anti-endomysial (anti-EMA)

68
Q

Coeliac Disease - what part of the system does the inflammation affect, what damage does it do, and what does that lead to?

A

Affects small bowel - particularly JEJUNUM

Damage:
Villous atrophy
Crypt hyperplasia
Inflammatory infiltration

Inflammation leads to malabsorption of nutrients and symptoms of coeliac

69
Q

Coeliac Disease - what are the symptoms?

A

Lots of variability and wide ranging symptoms

  1. Fatigue
  2. Weight loss
  3. Loose stools
  4. Steatorrhoea
  5. Abdo pain
  6. Failure to thrive
  7. Bloating
70
Q

Coeliac Disease - what are the signs?

A

Mouth:
Angular stomatitis
Mouth ulcers

Other:
Abdo distension
Neuropathy - secondary to hypocalcaemia or vit B12 def from malabsorption
Ecchymosis

71
Q

Coeliac Disease - what are some extra-intestinal manifestations?

A

Anaemia - from malabsorption or iron and folate

Osetoporosis - from malabsorption of calcium ad vitamin D

Dermatitis herpetiformis - pruritic rash, blistering skin condition typically on abdomen

Other - neuropathy, secondary to hypocalcaemia or vit B12 def from malabsorption

72
Q

Coeliac Disease - what autoantibodies do you test for when trying to diagnose?

A

Investigations must be carried out while patient is still on a gluten based diet

  1. Firstly check, total IgA immunoglobulin A levels - so to exlude IgA deficiency
  2. Then check for to see whether specific anti-TTG and anti-EMG autoantibodies are RAISED
73
Q

Coeliac Disease - what bedside and bloods investigations can you do?

A

Bedside:
Obs
ECG
Stool Culture

Bloods:
FBC
Blood film
LFTs

74
Q

Coeliac Disease - management?

A

Lifelong gluten free diet

75
Q

Coeliac Disease - associated medical conditions?

A

Associated with other autoimmune medical conditions such as:

Type 1 diabetes mellitus
Primary Sclerosing Cholangitis
Autoimmune hepatitis

76
Q

Coeliac Disease - what conditions can develop if you don’t treat CD?

A

Enteropathy-associated T cell lymphoma (EATCL)

Ulcerative jejunitis

Finals Revision Flashcards (49 decks)

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