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GI > 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
Crohn's Disease - what is it?
Chronic inflammatory disorder Affect any part of GI tract, mouth to anus
26
Crohn's Disease - aetiology
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
27
Crohn's Disease - what are the pathophysiological changes that occur?
``` 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)
28
Crohn's Disease - is superficial or full thickness of mucosa affected?
Transmural, full thickness, inflammation
29
Crohn's Disease - What are the symptoms?
``` Low-grade fever N+V Abdo pain Weight loss Diarrhoea Rectal bleeding ```
30
Crohn's Disease - what are the signs?
``` Pyrexia Angular stomatitis Aphthous ulcers Tachycardia Hypotension Dehydration ```
31
Crohn's Disease - what are the extra-intestinal manifestation areas?
``` MSK, bones and joints Skin Eyes and mouth Hepatobiliary Blood ```
32
Crohn's Disease - what are the extra-intestinal manifestation of bones and skin?
Erythema Nodosum (also seen in sarcoidosis) Arthritis
33
Crohn's Disease - what are the extra-intestinal manifestation of the eyes and mouth?
Episcleritis Uveitis Conjunctivitis Aphthous ulcers
34
Crohn's Disease - what are the extra-intestinal manifestation of hepatobiliary?
Primary sclerosing cholangitis Fatty liver disease Gallstones
35
Crohn's Disease - what are the extra-intestinal manifestation of the blood?
B12 deficiency Anaemia
36
Crohn's Disease - what is the diagnosis based on?
Endoscopy (colonoscopy) macroscopic assessment and biopsy taken to see histological changes
37
Crohn's Disease - what are some investigations you can do?
Faecal calprotectin - marker of intestinal inflammation Stool Microscopy ``` Bloods: FBC LFT U&E CRP ```
38
Crohn's Disease - what imaging can you do?
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
Crohn's Disease - what is the general principle in managing Crohn's?
To induce remission, then maintain remission
40
Crohn's Disease - what are the drugs to induce remission?
1st line - Steroids, oral prednisolone or IV hydrocortisone If doesn't work alone add - methotrexate, azathioprine, infliximab, adalimumab, mercaptopurine
41
Crohn's Disease - what are the drugs to maintain remission?
Tailored based on risks, side effects, patients wishes: 1st line: mercaptopurine, azathioprine Alternatives: methotrexate, infliximab, adalimumab
42
Crohn's Disease - when is surgery as treatment indicated?
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
Ulcerative Colitis - what is it?
Chronic, inflammatory disease characetrised by a relapsing-remitting course affecting the colon and/or rectum
44
Ulcerative Colitis - what is the distribution in the GI tract?
Confined to rectum and colon Continuous inflammation of the mucosa
45
Ulcerative Colitis - what is pancolitis?
Inflammation of the entire colon
46
Ulcerative Colitis - CLOSEUP mneumonic
``` 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
Ulcerative Colitis - what are the macroscopic changes in UC?
Macroscopic changes - seen on endoscopy 1. Red, inflamed mucosa 2. Continuous inflammation 3. Friable (easily crumbled) 4. Inflammatory polyps
48
Ulcerative Colitis - what are the microscopic changes in UC?
Microscopic changes - seen on histology 1. Goblet cell depletion 2. Crypt abscesses 3. Inflammatory infiltrate in lamina propria
49
Ulcerative Colitis - what is the hallmark clinical feature of UC?
Bloody diarrhoea/rectal bleeding
50
Ulcerative Colitis - what are the symptoms?
``` Rectum symptoms: Loose stools Rectal bleeding Tenesmus - incomplete emptying Urgency ``` Weight loss Abdo pain
51
Ulcerative Colitis - what are the signs?
Obs: Tachycardic Hypotensive Febrile Examination: Abdo tenderness, distension/mass Pale
52
Ulcerative Colitis - what is the major complication of UC?
Toxic Megacolon - medical emergency
53
Ulcerative Colitis - what is one example of the extra-colonic manifestations of the mouth, MSK, eyes, skin, hepatobiliary system and blood?
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
Ulcerative Colitis - what is the diagnostic investigation of choice
Colonoscopy (macroscopic changes) with biopsy (microscopic changes)
55
Ulcerative Colitis - what are the bedside Ix, bloods and imaging you can do?
Bedside: Obs FAECAL CALPROTECTIN Stool sample for microscopy Bloods: FBC, U&E, CRP, LFTs Imaging: Abdo X-rays
56
Ulcerative Colitis - what is the name of the tool used to assess the severity of UC?
Truelove and Witts' classification (TLWC)
57
Ulcerative Colitis - what is the TLWC scores and criteria?
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
Ulcerative Colitis - what is the management steps and drugs?
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
Ulcerative Colitis - what are the surgical management options?
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
Irritable Bowel Syndrome - what is it?
It is a chronic, functional bowel disorder, characterised by abdo pain and altered bowel habits
61
Irritable Bowel Syndrome - what are the symptoms?
``` Abdo pain Bloating Constipation Diarrhoea Fluctuating bowel habits ``` Improved by opening bowels Worse after eating
62
Irritable Bowel Syndrome - what is the criteria fro diagnosis?
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
Irritable Bowel Syndrome - what is the lifestyle advice?
Adequate fluids Regular small meals Limit caffeine and alcohol Reduce processed foods
64
Irritable Bowel Syndrome - what is the medical management?
1st line - Loperamide for diarrhoea Laxatives for constipation, Linaclotide Antispasmodics for cramps, buscopan 2nd line - Tricyclic antidepressants, amitriptyline 3rd line - SSRIs
65
Coeliac Disease - what is it?
It is an autoimmune condition where exposure to gluten peptides causes inflammation in small bowel
66
Coeliac Disease - what happens when gluten is ingested?
Auto-antibodies are created in response to gluten, and they target epithelial cells of the intestine, lead to inflammation
67
Coeliac Disease - what are the names of the two auto-antibodies?
Anti-tissue transglutaminase (anti-TTG) Anti-endomysial (anti-EMA)
68
Coeliac Disease - what part of the system does the inflammation affect, what damage does it do, and what does that lead to?
Affects small bowel - particularly JEJUNUM Damage: Villous atrophy Crypt hyperplasia Inflammatory infiltration Inflammation leads to malabsorption of nutrients and symptoms of coeliac
69
Coeliac Disease - what are the symptoms?
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
Coeliac Disease - what are the signs?
Mouth: Angular stomatitis Mouth ulcers Other: Abdo distension Neuropathy - secondary to hypocalcaemia or vit B12 def from malabsorption Ecchymosis
71
Coeliac Disease - what are some extra-intestinal manifestations?
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
Coeliac Disease - what autoantibodies do you test for when trying to diagnose?
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
Coeliac Disease - what bedside and bloods investigations can you do?
Bedside: Obs ECG Stool Culture Bloods: FBC Blood film LFTs
74
Coeliac Disease - management?
Lifelong gluten free diet
75
Coeliac Disease - associated medical conditions?
Associated with other autoimmune medical conditions such as: Type 1 diabetes mellitus Primary Sclerosing Cholangitis Autoimmune hepatitis
76
Coeliac Disease - what conditions can develop if you don't treat CD?
Enteropathy-associated T cell lymphoma (EATCL) Ulcerative jejunitis

GI (5 decks)

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