GI Peer Teaching Flashcards
what is GORD
Gastro Oesophageal Reflux Disease
it is where there’s reflux of gastric acid, bile and duodenal contents into the oesophagus
pathophys of GORD
it is where the lower oesophageal sphincter is incompetant and leads to gastric acid flowing up into the oesophagus
GORD risk factors
male
increased abdominal pressure (e.g. obesity or pregnancy)
smoking
hiatus hernia
gastric acid hypersecretion
high alcohol consumption
hiatus hernia
clinical features of GORD
heartburn
relieved by antacids
belching
waterbrach
acid brash
chronic cough
nocturnal asthma
Dx of gord
no Ix usually needed - diagnosis usually on clinical findings
management of GORD
- antacids e.g. gaviscon
- PPIs e.g. lansoprazole
complications of GORD
Peptic stricture
barret’s oesophagus (squamous to columnar)
what are peptic ulcers
- they are breaks in epithelial cells which penetrate down to the mucosa
*
where are gastric ulcers mostly seen
in the lesser curve of the stomach
are duodenal or gastric ulcers more common
duodenal ulcers are more common than gastric ulcers
what are the two important causes of peptic ulcers
Helicobacter Pylori and NSAID use
diagnosis of helicobacter pylori infection
urea breath test
serology
stool antigen test
what is the treatment for helicobacter pylori
PPI (lansoprazole)
with two antibiotics (Metronidazole and Clarithromycin)
why do NSAIDs cause peptic ulcers
they inhibit cyclooxygenase 1 enzyme which is needed for preoduction of prostaglandins
prostaglandins are needed for the production of mucous
this leaves the epithelium unprotected by mucous
what is the component of gluten which causes coeliac
gliadin
what happens in coeliac disease
- gliadin binds to secretory IgA in the mucosal membrane
- gliadin IgA is transcytosed to the lamina propria
- gliadin binds to tTG and is deaminated
- deaminated gliadin is taken up by macrophages and expressed on MHC2
- T helper cells release inflammatory cytokines and stimulate B cells
- there is then antibody mediated gut damage
coeliac histology findings
- increased intraepithelial lymphocytes
- lamina propria inflammation
- villous atrophy
diagnosis of coeliac disease
- patient must be ingesting gluten in their normal diet
- serology
- IgA-tTG
- FBC
- iron deficiency anaemia
- Histology
- villous atrophy
- increased intraepithelial lymphocytes
- lamina propria inflammation
- serology
what is the prevalence of coeliac disease
1% globally
are men or women more affected by coeliac
women are slightly more likely to be affected
what is the name of the criteria that the histological findings of coeliac are checked against
marsh criteria
what are the symptoms of coeliac
bloating
failure to thrive
diarrhoea
dermatitis herpetiformis
what is dermatitis herpeteiformis
Dermatitis herpetiformis (DH) is a chronic autoimmune blistering skin condition, characterised by blisters filled with a watery fluid that is intensely itchy.
what triad of things would you see in malabsorption
weight loss
steatorrhoea
anaemia
name 5 causes of malabsorption
- poor intake
- poor intraluminal digestion
- bacterial overgrowth
- pancreatic insufficiency
- poor bile secretion
- reduced surface area
- coeliac
- bowel resection (crohns)
- extensive parasites (giardia)
- lymphatic obstruction
- TB
- lymphoma
- lack of digestive enzymes
- dissaccharide insufficiency causing lactose intolerance
what is crohns
it is transmural, granulomatous inflammation affecting any part of the gut
it is due to an inappropriate immune response to the gut flora in a genetically susceptible individual
what is the macroscopic appearance of crohns
skip lesions, cobblestone appearance
which mutation increases risk of crohns
NOD2 on chromosome 16
what is the prevalence of crohns
1-2%
in crohns and ulcerative colitis does smoking increase or decrease risk
in crohns smoking increases risk a lot
in ulcerative colitis smoking is protective
what are the symptoms of crohns
diarrhoea
abdo pain
weightloss/failure to thrive
systemic symptoms of fever, fatigue, malaise and anorexia
5 signs of crohns
bowel ulceration
abdo tenderness/mass
anal strictures
perianal abscess/fistulae/skin tags
clubbing of fingernails
what is the macroscopic appearance of crohns disease
skip lesions
cobblestone appearance
what is the microscopic appearance of crohns disease
transmural
granulomatous
goblet cells present
how is crohns diagnosed
colonoscopy and biopsy looking for macroscopic and miscroscopic changes
which part of the gut is most commonly affected by crohns
terminal ileum but can affect anywhere mouth to anus
in crohns is there blood and excess mucus in the stool
no
crohns risk factors
smoking
female
mutation on NOD2 on chromosome 16
chronic stress
Ix for crohns
Dx relies on colonoscopy and biopsy
stool sample has to be done to rule out infectious causes
FBC - raised ESR and CRP, low Hb due to anaemia
crohns management
oral corticosteroids
IV hydrocortisone in severe flare ups
anti-TNF antibodies (infliximab) if no improvement
what should you add to someone’s crohns management if they have frequenct exacerbations
azathioprine or methotrexate
what do you get from B12 deficiency
glossitis
lemon tinged skin (due to pallor and jaundice at same time)
neuro symptoms
what is ulcerative colitis
it is a relapsing remitting inflammatory disorder of the colonic mucosa
what is the macroscopic appearance of ulcerative colitis
continuous inflammation with ulcers and pseudo polyps
what is the microscopic appearance of ulcerative colitis
mucosal inflammation, no granulomas, depleted goblet cells and increased crypt abscesses
symptoms of ulcerative colitis
pain typically in the lower left quadrant
diarrhoea with blood and mucus
signs of ulcerative colitis
fever
clubbing
erythema nodusum
what is the cause of ulcerative colitis
- Inappropriate immune response against colonic flora in genetically susceptible individuals
is the inflammation transmural in ulcerative colitis and crohns
in crohn’s it’s transmural
in ulcerative colitis it’s usually not
what is the prevalence of ulcerative colitis
1-2%
what age are people when they usually present with ulcerative colitis
they are usually 20-40yrs old
what Ix would you do for ulcerative colitis
FBC:
- high ESR and CRP
pANCA may be present in serology
Stool sample M,C&S must be done to rule out infectious diseases
management of ulcerative colitis
sulfasalazine
add oral prednisolone if there’s no response
if they still have disease you can use infliximab (anti TNF alpha)
colectomy is indicated if they have severe UC and are not responding to treatment
fill in this table
what is IBS
irritable bowel syndrome is a group of abdominal symptoms for which no organic cause can be found
what are the risk factors of IBS
stress
being female
what are the symptoms of irritable bowel syndrome
abdominal pain relieved by defacating
bloating
alternating bowel habits
medical management of IBS
- pain and bloating: buscopan
- for constipation: laxative like senna
- for diarrhoea: anti motility like loperamide
what is the prevalence of irritable bowel syndrome
10-20%
lifestyle advice for IBS
adequate water
reduce/increase fibre
encourage them to find trigger foods
low FODMAP diet
what is the aim of the Ix if you suspec IBS
to rule out other pathology
what are the risk factors for infective diarrhoea
foreign travel
poor hygeine
overcrowding
new or different foods
is infective diarrhoea more commonly bacterial, viral or parasitic
mostly viral
sometimes bacterial
occasionally parasitic
what are the 3 most common viral causes of infective diarrhoa
- rotavirus in children
- norovirus
- adenovirus
what are 4 common causes of bacterial diarrhoea
campylobacter jejuni
e.coli
salmonella
shigella
name two parasitic causes of infective diarrhoea
giardia lamblia
cryptosporidium
which are the 4 antibiotics which may cause a C.diff infection
cephalosporins
coamoxiclav
ciprofloxacin
clindamycin
what finding in stool may be suggestive of a bacterial infection
blood
treatment for infectious diarrhoea
rehydration
antibiotics
antimotility (loperamide)
what would be your findings on auscultation of the bowel if there was obstruction
tinkling bowel sounds
main features of bowel obstruction
colic pain occurs early but goes with long-standing obstruction
vomiting
nausea
anorexia
distension
constipation may be absolute (no flatus)
tinkling sounds on auscultation
how can you tell if it’s small or large bowel obstruction
small bowel: vomiting occurs early, distention is less and pain is higher
AXR
what is ileus
it is functional obstruction from decreased bowel motility
bowel sounds will be absent
what is paralytic ileus and what does it commonly follow
- adynamic bowel due to the absence of normal peristaltic contractions. Often follows abdo surgery or spinal injury.
what is a simple obstruction
- one obstructing point and no vascular compromise
what is a closed loop obstruction
forming a loop of grossly distended bowel at risk of perforation
what is a strangulated obstruction
- blood supply is compromised and the patient is iller than you would expect.
- Pain is sharper, more constant and localised.
- Peritonism is the cardinal sign.
- 100% mortality if untreated
causes of small bowel obstruction
adhesions
hernias
causes of large bowel obstruction
colon cancer
constipation
diverticular disease
volvolus
what is a hernia
it is a protrusion of an organ or tissue out of the body cavity in which it normally lies
causes of hernias
muscle weakness (age and trauma)
body strain (constipation, heavy lifting, pregnancy and chronic cough)
what is an inguinal hernia
it is a protrusion of abdominal cavity through the inguinal canal
what is the difference between a direct and an indirect inguinal hernia
direct protrudes directly into the inguinal canal medial to the inferior epigastric vessels
indirect protrudes through the internal inguinal rind lateral to the inferior epigastric vessels
what is a hiatus hernia
it is where part of the stomach herniates through the oesophageal hiatus of the diaphragm
what is the difference between a sliding and rolling hiatus hernia - which is more common
SLIDING: Oesophageal-gastric junction slides through the hiatus and lies above the diaphragm no symptoms other than reflux
ROLLING: uncommon - the gastric fundus rolls up through the haitus alongside the oesophagus. the gastro-oesophageal junction remains below the diaphragm. can be treated with surgery
DDx of GORD
oesophagitis
duodenal or gastric ulcers
cardiac disease
MSK - costochondritis
lifestyle advice in GORD
- weight loss
- smaller meals
- smoking cessation
- reduce intake of
- citrus fruit
- alcohol
- spicy food
- caffeine
- onions
- avoid eating <3hrs before bed
Surgical treatment for GORD
- Fundoplication: twist in the top of the stomach
- Wrap the fundus around the top of the oesophagus giving an extra sphincter
- This would aim to increase lower oesophageal sphincter pressure
- Only consider in severe GORD if drugs are not working
Lifetime risk of appendicitis
6%
what age does appendicitis usually occur
10-20
what is the pathophysiology of appendicitis
gut organisms invade the appendix wall after lumen obstruction by lymphoid hyperplasia, faecal pellets or filarial worms
this leads to oedema, ischaemic necrosis and perforation
Roysing’s sign
pain is more in the RIF than the LIF when LIF is palpated
Ix for appendicitis
- Bloods
- CRP
- ESR may not have developed yet
- CT
- useful if diagnosis unclear and reduces -ve appendectomy rate
appendicitis presentation
fever
pain (mcburney’s point)
anorexia
peritonism with guarding
comiting
what is peritonitis
it is inflammation of the peritoneum due to entry of blood, air, bacteria or GI contents
symptoms of peritonitis
dull pain that becomes sharp
pain worse on coughing or moving
systemic symptoms and they are generally unwell
name 6 causes of peritonitis
- AEIOU
- appendicitis
- ectopic pregnancy
- infection
- obstruction
- ulcer
- peritoneal dialysis
differentials for appendicitis
ectopic pregnancy (do preg test)
UTI (test urine)
diverticulitis
cholecystitis
how does ectopic pregnancy present
low abdo pain
sudden onset
tachycardia
low bp
what are the investigations for peritonitis
- clinical examination
- AXR
- FBC
- U&E
- LFT
- Ascitic tap
what is pancreatitis
it is inflammation of the pancreas which may lead to pancreatic enzymes damaging the pancreas and nearby blood vessels
what is the presentation of pancreatitis
nausea and vomiting
epigastric pain radiationg to back (relieved by sitting forwards)
Cullen’s sign
Grey Turner’s sign
what are the causes of pancreatitis
- IGETSMASHED
- Idiopathic
- Gallstones
- Ethnol (alcohol)
- Trauma
- Steroids
- Malignancy
- Autoimmune
- Scorpion sting
- Hypercalcaemia
- ERCP
- Drugs
what are cullen’s and grey turner’s sign? what do they indicate
cullen’s: bruising around umbilicus
grey turner’s: bruising around the flanks
both indicate acute pancreatitis
what are the Ix for pancreatitis and what do they show
high amylase
high lipase
AXR
CT chest/abdo
management of pancreatitis
IV fluids and maintain electrolyte balance
pain relief
maybe bowel rest
what is the cause of ischaemic colitis
low flow in the inferior mesenteric artery
how does ischaemia colitis present
left iliac fossa pain
bloody diarrhoea
how do you diagnose ischaemic colitis
colonoscopy
what is the cause of acute mesenteric ischaemia
low flow in the superior mesenteric artery
what is the presentation of acute mesenteric ischaemia
acute severe abdo pain that is out of proportion with signs
patient is sicker than they look
rapud hypovolaemia –> shock
diagnosis of acute mesenteric ischaemia
metabolic acidosis and high lactate
often made on exploratory laparotomy
management of acute mesenteric ischaemia
surgery to remove the dead bowel
fluid resus
antibiotics
thrombolytics infused locally by catheter if thrombosis is identified by arteriography
if someone has AF and abdo pain you should always think of what?
bowel/mesentry ischaemia
what is intestinal angina
chronic mesenteric ischaemia
how does chronic mesenteric ischaemia present
- triad
- severe, colicky, post-prandial abdo pain
- weightloss because eating hurts
- upper abdo bruit
- also
- bleeding PR
- malabsorption
- N&V
causes of chronic mesenteric ischaemia
typically due to a low flow state due to atherosclerotic disease in all mesenteric arteries
treatment for ischaemic colitis
conservative with fluid replacement and antibiotics
is stomach carcinoma more common in men or women
men
what are 4 risk factors for stomach carcinoma
pernicious anaemia
H. pylori
atrophic gastritis
smoking
symptoms of gastric carcinoma
- non specific
- dyspepsia
- weightloss
- vomiting
- anaemia
what are the Ix for stomach carcinoma
gastroscopy with multiple biopsies
CT/MRI for staging
cytology of peritoneal wash can help discover peritoneal mets
risk factors for oesophageal cancer
alcohol excess
smoking
achalasia
reflux oesophagitis
obesity
drinking very hot drinks
are men or women more commonly affected by oesophageal cancer
men much more commonly
what is diverticulitis
A GI diverticulum is an outpouching in the gut wall. These usually occur at the sites of entry of perforating arteries. Diverticulitis refers to inflammation of a diverticulum
where does most diverticulitis occur
95% in the sigmoid colon
what is diverticulosis
this is the presence of diverticula but they are not inflamed
what is the presentation of diverticulitis
pyrexia
high white cell coult
high ESR/CRP
a tender colon
localised or generalised peritonism
what is the treatment for diverticulitis
Mild: bowel rest (fluids only) and antibiotics
surgery indicated if there’s any peritonitis
complications of diverticulitis
- perforation: ileus, peritonitis and shock
- this has high mortality and requires an emergency laperotomy
- haemorrhage: can cause a big, sudden, painless rectal bleed
- needs colonic haemostasis ± colonic resection
what is a mallory weiss tear
- Persistent vomiting/retching causes haematemesis via an oesophageal mucosal tear
what is a pilonidal sinus and how does it happen
- Obstruction of natal cleft hair follicles ~6cm above the anus
- Ingrowth of hair excites a foreign body reaction
- There may be fowl smelling discharge
- Much more common in men
- There may be fowl smelling discharge
what is an anal fistula
it communicates between the skin and the anal/rectal canal
causes of anal fistulae
crohn’s
diverticulitis
rectal carcinoma
idiopathic
what are haemorrhoids
They are disrupted and dilated anal cushions
anal cushions are the masses of spongy vascular tissue that contribute to anal closure
causes of piles
straining
pregnancy
congestion from a pelvic tumour
symptoms of piles
bright red rectal bleeding on tissue or after defication
may coat stools
mucous discharge
pruritis ani
what should you do for all rectal bleeding?
abdominal exam
PR exam
colonoscopy to exclude malignancy if >50yrs old
predisposing factors to colorectal cancer
IBD
genetic (FAP and HNPCC)
low fibre and high processed meat diet
high alcohol consumption
smoking
two syndromes that cause colon cancer
lynch syndrome (HNPCC)
FAP
what is lynch syndrome
- causes 1-3% of colorectal cancer
- AD inheritance due to mutations in MMR genes
- lifetime risk is 80%
- also increased risk of
- endometrial
- ovarian
- stomach
what is FAP
- Familial adenomatous polyposis
- mutations in APC TSG
- causes <1% colon cancer
- penetrance is 100% by 50
what are DUKES A,B and C
- Colon cancer staging
- A: limited to muscularis mucosae
- B: extended beyond muscularis mucosae
- C: involvement of regional lymph nodes
- D: distant metastatic spread
management of colon cancer
- surgery
- radiotherapy
- biologics
- bevacizumab (anti-VEGF)
what is the microscopic appearance of crohns
transmural granulomas - goblet cells present
