GI pathology 1 Flashcards
What is GORD?
Gastro-oesophageal reflux disease
Causes by reflux of stomach contents.
Causes of GORD
- Lower oesophageal sphincter hypotension
- Hiatus hernia
- Oesophageal dysmotility
- Obesity
- Gastric acid hypersecretion
- Delayed gastric emptying
- Smoking, alcohol
- Pregnancy
- Drugs (tricyclics, anticholinergics, nitrates)
- Helicobacter pylori
Symptoms of GORD
- Oesophageal
- Heartburn
- Belching
- Acid brash (acid or bile regurgitation)
- Waterbrash (mouth fills with saliva)
- Odynophagia
- Extra-oesphageal
- Nocturnal asthma
- Chronic cough
- Laryngitis
- Sinusitis
What is heartburn?
Burning, retrosternal discomfort after meals, lying, stooping or straining, relieved by antacids.
Complications of GORD
- Oesophagitis
- Ulcers
- Benign stricture
- Iron deficiency
- GORD may lead to Barrett’s oesophagus
What is Barett’s oesophagus?
Distal oesophagus undergoes metaplasia from squamous to columnar cells.
Treatment of GORD
- Lifestyle
- Weight loss
- Smoking cessation
- Reduce alcohol / acidic foods / spicy foods / fizzy drinks / caffeine
- Avoid eating 3 hours before bed
- Drugs
- Antacids
- Add a PPI
- For refractory symptoms add a H2 blocker and/or try twice daily PPI
- Surgery
- to increase resting lower oesophageal sphincter pressure
What should be suspected if patient presents with diarrhoea and weight loss or anaemia?
Coeliac disease
Pathophysiology of coeliac disease
T-cell response to gluten in the small bowel causes villous atrophy and malabsorption
Presentation of coeliac disease
- Steatorrhoea
- Diarrhoea
- Abdominal pain
- Bloating
- Nausea and vomiting
- Apthous ulcers
- Angular stomatitis
- ↓weight
- Fatigue
- Weakness
- Osteomalacia
- Failure to thrive (children)
Coeliac disease diagnosis
- ↓Hb, ↑RCDW, ↓B12, ↓ferritin
- antibodies: anti transglutaminase (it is an IgA antibody so check IgA levels to exclude subclass deficiency)
- where serology positive or high index of suspicion proceed to duodenal biopsy while on a gluten containing diet
- expect subtotal villous atrophy, ↑intraepithelial WBCs and crypt hyperplasia
Treatment of coeliac disease
Lifelong gluten free diet
What is irritable bowel syndrome?
A mixed group of abdominal symptoms for which no organic cause can be found.
Diagnosis of IBS
Only diagnose IBS if recurrent abdominal pain associated with at least 2 of:
- relief by defecation
- altered stool form
- altered bowel frequency
Symptoms are chronic (more than 6 months) and exacerbated by stress, menstruation or gastroenteritis (post infectious IBS)
IBS - you should think of other diagnosis if:
- age >60
- history <6 months,
- anorexia, ↓weight
- waking at night with pain/diarrhoea
- mouth ulcers
- abnormal CRP, ESR
Treatment for IBS - constipation
- Ensure adequate water and fibre intake and promote physical activity
- Simple laxatives
Treatment for IBS - diarrhoea
- Avoid sorbitol sweetners, alcohol, and caffeine
- Reduce dietry fibre intake
- Encourage patients to identify their own trigger foods
- Try a bulking agent +/- loperamide 2mg after each loose stool
Treatment for IBS - colic/bloating
- oral antispasmodics
- probiotics
- low FODMAP diet
Treatment for IBS - psychological symptoms / visceral pain
- CBT
- Tricyclics eg amitriptyline - low dose
Symptoms of chronic pancreatitis
- epigastric pain that bores through to the back, relieved by sitting forward or hot water bottles
- bloating
- steatorrhoea
- ↓weight
- brittle diabetes
Symptoms relapse and worsen
Causes of chronic pancreatitis
- Alcohol
- Smoking
- Autoimmune
- Cystic fibrosis
- Haemachromatosis
- Pancreatic duct obstruction
- Congenital
Tests for chronic pancreatitis
- Ultrasound +/- CT
- pancreatic calcifications confirm the diagnosis
Chronic pancreatitis treatment
- drugs
- analgesia
- lipase
- fat soluble vitamins
- diet
- no alcohol
- low fat may help
- surgery
- for unremitting pain, narcotic abuse or ↓weight
- pancreatectectomy
- pancreaticojejunostomy
- for unremitting pain, narcotic abuse or ↓weight
Carcinoma of the pancreas typical patient
Male > 70yrs old
Carcinoma of the pancreas risk factors
- smoking
- alcohol
- carcinogens
- diabetes mellitus
- chronic pancreatitis
- ↑ waist circumference
- diet high in fat, red meat and processed meat
Where on the pancreas does carcinoma arise?
- 60% pancreatic head
- 25% body
- 15% tail
Carcinoma of the pancreas symptoms
- Tumours in the head of the pancreas
- painless obstructive jaundice
- Tumours in the body and tail of the pancreas
- 75% present with epigastric pain
- Either may cause
- anorexia
- weight loss
- diabetes
- acute pancreatitis
Carcinoma of the pancreas signs
- jaundice + palpable gall bladder
- epigastric mass
- hepatomegaly
- splenomegaly
- lymphadenopathy
- ascites
Carcinoma of the pancreas investigations
- blood
- cholestatic jaundice
- ↑CA 19-9 is non-specific but helps assess prognosis
- imaging
- US or CT
- can show a pancreatic mass +/- dilated biliary tree +/- hepatic metastases
- ECRP/MCRP (Endoscopic retrograde cholangiopancreatography / magnetic resonance cholangiopancreatography)
- EUS (endoscopic sonography)
- US or CT
Carcinoma of the pancreas treatment
- Surgical resection - pancreatoduodenectomy
- only when no distant metastasis and vascular invasion still at at minimum
- Laparoscopic excision
- Post-op chemotherapy
- delays disease progression
- Endoscopic or percutaneous stent insertion
- may help jaundice and anorexia
- Large doses of opiates and radiotherapy
- to treat disabeling pain
Carcinoma of the pancreas prognosis
- Often dismal
- Mean survival < 6 months
- 5 year survival 3%
