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Junior Medicine > GI Upset > Flashcards

GI Upset Flashcards

1
Q

Common complication of viral gastroenteritis

A

Lactose intolerance

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2
Q

How does coeliac disease present in a blood test

A

Mild anaemia
Calcium, phosphate and vit D deficiency
Rise in ALP

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3
Q

How does Crohn’s disease present on a blood test

A

Anaemia
Vit D, calcium and phosphate deficiency
Increased CRP

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4
Q

How to differentiate between gastric ulcers and duodenal ulcers

A

Gastric ulcers cause pain when eating or shortly after
Duodenal ulcers pain comes on an hour or 2 after eating

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5
Q

What is the main cause of painless massive GI bleeding requiring transfusion in children between 1 and 2

A

Meckel’s diverticulum

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6
Q

What % of weight loss is diagnostic of malnutrition

A

Unintentional weight loss greater than 10% within the last 3-6 months

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7
Q

Define acute diarrhoea

A

3 or more episodes of loose stool per day lasting <14 days

Most common cause is infective (gastroenteritis)

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8
Q

Features of gastroenteritis

A

Diarrhoea
+/- abdo pain
Nausea
Vomitting

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9
Q

Features of diverticulitis

A

Diarrhoea
Left lower quadrant pain
Fever

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10
Q

Features of constipation causing overflow

A

Alternating diarrhoea and constipation

Can lead to faecal incontinence in the elderly

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11
Q

Infective agents causing diarrhoea

A

Norovirus / rotavirus

E. coli, salmonella, shigella, campylobacter

Giardia lamblia, entamoeba histolytica

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12
Q

CF of infective diarrhoea

A

Acute onset diarrhoea
+/- vomitting
Fever
Abdo pain
Blood in stools suggesting colitis

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13
Q

OE for infective diarrhoea

A

Soft and mildly tender abdomen

Examine hydration status

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14
Q

Investigations for suspected infective diarrhoea

A

Stool samples for MCS and virology should be sent if:
- systemically unwell / immunocompromised
- blood / mucus in stool
- public health indications eg food poisoning or outbreaks
- recent foreign travel
- recent abx use or hospitalisation

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15
Q

Management for infective diarrhoea

A
  • importance of oral hydration
  • advise on hygiene to prevent transmission
  • imaging
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16
Q

Define chronic diarrhoea

A

Diarrhoeal symptoms lasting longer than 4 weels

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17
Q

Differential diagnoses for chronic diarrhoea

A
  • IBD
  • IBS
  • malabsorption
  • coeliac disease
  • thyrotoxicosis
  • colorectal malignancy
  • post cholecystectomy diarrhoea
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18
Q

Epidemiology of Crohn’s disease

A

50/100,000
M=F
Risks: poor diet, FH, smoking, altered immune states

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19
Q

Pathology of Crohn’s disease

A

Inflammation can affect any part of the GI tract (mouth to anus)

Skip lesions

Rose thorn ulcers

Cobblestone appearance on CT

Inflammation extends through all layers of bowel

Fistulae and stenosis are common

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20
Q

CF of crohn’s

A

Abdo pain
Diarrhoea: steatorrhea in ileal disease, blood in colonic
Mouth ulcers
Anal: fissures, fistulas, haemorrhoids, skin tags, abscesses

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21
Q

Epidemiology of UC

A

100-200/100,000
Peak at 15-30 and also around 60
Smoking is protective
F>M

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22
Q

Pathology of UC

A

Inflammation starts in rectum extends proximally along colon

Inflammation only affects mucosa which is excessively ulcerated

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23
Q

CF of UC

A

Crampy lower abdo discomfort
Gradual onset diarrhoea (bloody)
Urgency and tenesmus if disease confined to rectum

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24
Q

Histology of Crohn’s disease

A

Transmural inflammation, lymphoid hyperplasia and granulomas

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25
Q

Histology of UC

A

Mucosal inflammation, crypt abscesses and goblet cell depletion

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26
Q

Investigations for suspected IBD

A

Bloods: FBC, U&E, CRP / ESR, LFT, serum iron, B12, folate

Stool:
- stool chart
- stool MCS x3 to exclude infective causes
- faecal calprotectin

Radiology: AXR / CXR

Sigmoidoscopy in UC
Colonoscopy in crohn’s

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27
Q

Management of a mild crohn’s flare up
(Symptomatic but systemically well)

A
  • oral prednisolone
  • tapered steroids
  • review in clinic
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28
Q

Management of a severe crohn’s flare up
(Symptoms + systemic upset)

A

Start IV steroids (hydrocortisone)
NBM
Thiopurines
Infliximab
Once improving transfer to oral prednisolone
If unable to control - surgery

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29
Q

Crohn’s maintenance therapy

A

Thiopurines eg azathioprine or 6-mercaptopurine

Methotrexate

Oral metronidazole for anal disease

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30
Q

Management of mild / moderate UC flare (less than 6 motions / day - systemically well)

A

Topical aminosalicylate for procitits

Loading dose of oral mesalazine +/- topical mesalazine for extensive disease

After 4 weeks add oral prednisolone

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31
Q

Management of severe UC flare up

A

IV corticosteroids
DVT prophylaxis
Avoid anti motility drugs
Assess need for surgery

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32
Q

UC maintenance therapy

A

5-ASA derivatives first line : sulfalazine, mesalazine

Oral thiopurines second line

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33
Q

IBD complications

A

Bowel perforation
Lower GI haemorrhage
Toxic dilatation
Colonic carcinoma

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34
Q

Features of toxic dilatation (toxic megacolon)

A

Persistent fever
Tachycardia
Loose blood stained stool

AXR shows dilated colon with mucosal islands

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35
Q

Describe surgery for Crohn’s disease

A

Is never curative
Temp ileostomies can be used to rest distal diseased bowel
Limited resection of the worst areas can be required

36
Q

What is short bowel syndrome

A

When <1m small bowel remains after surgery for crohn’s
- can lead to malabsorption

37
Q

Describe emergency surgery for UC

A

Subtotal colectomy and end ileostomy: leaves a rectal stump that can form an anastomosis at a later date

Proctocolectomy and end ileostomy: rectal stump also removed: stoma for rest of life

38
Q

Describe elective surgery for UC

A

Completion proctocolectomy and ileoanal pouch reconstruction: ileo-anal pouch formed, maintaining faecal continence (risk of pouchitis)

Colectomy and ileorectal anastomosis: anastomosis formed in single procedure but the rectum remains

39
Q

Outline some extra GI manifestations of IBD

A

Eyes: conjunctivitis / episcleritis / iritis

MSK: arthralgia of large joints

Skin: erythema nodosum, pyoderma gangrenosum

40
Q

Symptoms of malabsorption

A

Chronic diarrhoea / steatorrhoea
Bloating
Weight loss
Lethargy

41
Q

Signs of malabsorption

A
  • anaemia
  • bleeding disorders (vit K)
  • oedema (decreased protein)
  • osteomalacia (vit D)
  • neuropathy
42
Q

Common causes of malabsorption in UK

A

Coeliac disease
Chronic panc
Crohn’s

43
Q

Investigations for suspected malabsorption

A
  • bloods: FBC, iron, B12, folate, Ca, Mg, phosphate, lipid profile, LFT, TFT, inflammatory markers, clotting

Stool studies: MCS, faecal elastase (panc), calprotectin

Endoscopy

Breath hydrogen analysis: bacterial overgrowth

44
Q

Pathology of coeliac disease

A

Inflammation of the jejunal mucosa in response to gluten

Biopsy of duodenal mucosa will show flattened mucosa due to loss of villi

45
Q

Presentation of coeliac disease

A

1/3 asymptomatic
Diarrhoea, abdo pain, bloating, N+V
Weight loss, fatigue, ulcers
Dermatitis herpetiformis

46
Q

Investigations for suspected coeliac disease

A

Bloods: endomysial antibodies and TTG antibodies present

Duodenal biopsy: gold standard

Bone densitometry

47
Q

Management of coeliac disease

A

Lifelong gluten free diet
Endomysial antibody tests to ensure gluten free is working
Small increased risk of small bowel lymphoma / adenocarcinoma

48
Q

Pathology of chronic pancreatitis

A

High alcohol intake leads to inappropriate pancreatic enzyme activity
Precipitation of protein - plugs the pancreatic ducts - ductal hypertension

Fibrosis of the parenchyma - disturbed exocrine function

49
Q

Presentation of chronic panc

A

Epigastric pain
Radiating to back
Relieved by sitting forwards or hot water bottle
Weight loss
Bloating
Steatorrhoea

50
Q

Investigations for chronic panc

A

Bloods:
- serum amylase / lipase rarely elevated
- signs of alcohol abuse (macrocytic anaemia, GGT)

Stool
- faecal elastase elevated
- trypsinogen levels >10

Imaging
- USS may show pseudocyst
- contrast CT / mRCP can confirm diagnosis with calcification

51
Q

Chronic panc management

A

Analgesia
Creon
Blood sugar monitoring
Treat alcohol abuse
Low fat diet
Partial pancreatectomy

52
Q

Define IBS

A

Chronic, functional bowel disorder with a prevalence of up to 10% in the UK population
Mixed abdo symptoms with no organic cause

53
Q

Epidemiology of IBS

A

F:M >2:1, onset generally before age 40
Stressful live events
Co-morbid anxiety + depression
Preceding GI infection

54
Q

ABC model for considering diagnosis of IBS

A

Abdominal pain
Bloating
Change in bowel habit

55
Q

CF of IBS

A

12 consecutive weeks in 12 months of abdo pain with:
- pain relieved with defecation
- onset associated with a change in stool freq
- onset associated with a change in stool form
- bloating
- passing mucus
- associated gynae, urological or back pain

56
Q

Investigations for IBS

A

FBC
ESR / CRP
Coeliac disease screen

57
Q

IBS management

A

Lifestyle: advise on regular meals, hydration, limit caffeine, low FODMAP diet

1st line: anti spasmodic for pain
Constipation: laxatives (avoid lactulose)
Diarrhoea: loperamide

2nd line: low dose TCA

After 12mo of antidepressants, refer to CBT

58
Q

Define malnutrition

A

BMI <18.5
Unintentional weight loss greater than 10% within the last 3-6mo
BMI <20 and unintentional weight loss >5% within 3-6mo

59
Q

Risk factors for malnutrition

A

Age
Hospitalisation
Chronic illness
Alcohol abuse
Mental health

60
Q

CF of malnutrition

A

Low BMI
Bradycardia, hypotension, hypothermia
Poor wound healing / recurrent infections

61
Q

Management of malnutrition

A

Dietician support
Food first approach rather than oral nutritional supplements

62
Q

Describe refeeding syndrome

A

A period of prolonged starvation leads to depletion of intracellular electrolyte stores
- if a patient is then provided with nutrition the metabolic changes can cause intracellular shifts

63
Q

Subdivisions of dyspepsia

A

Reflux type: heart burn and regurgitation

Ulcer type: epigastric pain

Dysmotility type: bloating and nausea

64
Q

When do symptoms of GORD occur

A

When there is prolonged contact of the gastric contents with oesophagus mucosa - inflammation

65
Q

Risk factors for GORD

A

Hiatus hernia
Raised IAP
Large meals late at night
Smoking
Caffeine
High fat food

66
Q

CF of GORD

A

Heartburn / indigestion - worse on bending / lying - relieved on antacids

Regurgitation of food: worse when bending / lying

Waterbrash - filling of mouth with saliva

67
Q

Red flag symptoms that indicate a need for urgent upper GI endoscopy to rule out malignancy (ALARMS 55)

A

Anaemia
Loss of weight
Anorexia
Recent onset, progressive symptoms
Melaena
Swallowing difficulties
>55

68
Q

Management of endoscopically proven oesophagitis

A

Full dose PPI 1-2 mo
If response - low dose
If no response - double dose PPI

69
Q

Management of endoscopically negative reflux disease

A

Full dose PPI for 1mo
If response offer low dose treatment prn
If no response then H2RA or prokinetic 1mo

70
Q

Complications of GORD

A

Oesophagitis
Ulcers
Anaemia
Benign strictures
Barrett’s oesophagus
Oesophageal carcinoma

71
Q

What is Barrett’s oesophagus

A

Normal stratified squamous epithelium of the oesophagus undergoes metaplasia to glandular columnar epithelium in long standing reflux

Continued inflammation can then lead to dysplasia and malignant change

72
Q

Where is the oesophageal hiatus

A

An oval aperture in the right crus of the diaphragm at T10

73
Q

What happens in a hiatus hernia

A

Part of the stomach passes into the thoracic cavity through the oesophageal hiatus

Is usually asymptomatic but can lead to GORD symptoms

74
Q

What are the 2 types of oesophageal hiatus hernia

A

Sliding hiatus hernia:
- Gastro-oesophageal junction slides through the hiatus to lie above the diaphragm

Para-oesophageal / rolling hernia
- small part of the fundus rolls up through the hernia alongside the oesophagus but the sphincter remains competent below the diaphragm

75
Q

Risk factors for PUD

A

H. Pylori (95% of duodenal, 75% of gastric)
NSAIDs
SSRIs
Corticosteroids
Bisphosphonates
Zollinger ellison syndrome

76
Q

Features of PUD

A

Epigastric pain
Nausea
Duodenal ulcers - relieved by eating
Gastric ulcers - worsened by eating

77
Q

Investigations for peptic ulcer type pain

A

Start a trial of PPI therapy
If symptoms persist test for H pylori with urea breath test or stool antigen test

78
Q

Management of H pylori

A

PPI until ulcer heals

If + for H pylori - eradication therapy

79
Q

Complications of peptic ulcers

A

Perforation - epigastric pain that then becomes generalised
Syncope

80
Q

What is the difference between pancreatic cancer and cholangiocarcinoma

A

Cholangiocarcinoma: colicky RUQ pain, palpable mass, clay coloured stools, dark urine - due to biliary obstruction

Pancreatic Ca: anorexia, painless jaundice

81
Q

What is the difference between primary sclerosing cholangitis and primary biliary cholangitis

A

PSC is damage of medium to large extrahepatic and intrahepatic bile ducts

PBC targets small intrahepatic bile ducts

82
Q

What is the key investigation for suspected perforated ulcer

A

Erect CXR

83
Q

Why should metoclopramide be avoided in bowel obstruction

A

It has prokinetic properties which can stimulate peristalsis in the bowel
This can exacerbate mechanical bowel obstruction and precipitate perforation

84
Q

Triad of symptoms for mesenteric ischaemia

A

CVD
High lactate
Soft but tender abdomen

85
Q

Triad of symptoms for mesenteric ischaemia

A

CVD
High lactate
Soft but tender abdomen

Junior Medicine (6 decks)

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