GI Upset Flashcards
Common complication of viral gastroenteritis
Lactose intolerance
How does coeliac disease present in a blood test
Mild anaemia
Calcium, phosphate and vit D deficiency
Rise in ALP
How does Crohn’s disease present on a blood test
Anaemia
Vit D, calcium and phosphate deficiency
Increased CRP
How to differentiate between gastric ulcers and duodenal ulcers
Gastric ulcers cause pain when eating or shortly after
Duodenal ulcers pain comes on an hour or 2 after eating
What is the main cause of painless massive GI bleeding requiring transfusion in children between 1 and 2
Meckel’s diverticulum
What % of weight loss is diagnostic of malnutrition
Unintentional weight loss greater than 10% within the last 3-6 months
Define acute diarrhoea
3 or more episodes of loose stool per day lasting <14 days
Most common cause is infective (gastroenteritis)
Features of gastroenteritis
Diarrhoea
+/- abdo pain
Nausea
Vomitting
Features of diverticulitis
Diarrhoea
Left lower quadrant pain
Fever
Features of constipation causing overflow
Alternating diarrhoea and constipation
Can lead to faecal incontinence in the elderly
Infective agents causing diarrhoea
Norovirus / rotavirus
E. coli, salmonella, shigella, campylobacter
Giardia lamblia, entamoeba histolytica
CF of infective diarrhoea
Acute onset diarrhoea
+/- vomitting
Fever
Abdo pain
Blood in stools suggesting colitis
OE for infective diarrhoea
Soft and mildly tender abdomen
Examine hydration status
Investigations for suspected infective diarrhoea
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
Management for infective diarrhoea
- importance of oral hydration
- advise on hygiene to prevent transmission
- imaging
Define chronic diarrhoea
Diarrhoeal symptoms lasting longer than 4 weels
Differential diagnoses for chronic diarrhoea
- IBD
- IBS
- malabsorption
- coeliac disease
- thyrotoxicosis
- colorectal malignancy
- post cholecystectomy diarrhoea
Epidemiology of Crohn’s disease
50/100,000
M=F
Risks: poor diet, FH, smoking, altered immune states
Pathology of Crohn’s disease
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
CF of crohn’s
Abdo pain
Diarrhoea: steatorrhea in ileal disease, blood in colonic
Mouth ulcers
Anal: fissures, fistulas, haemorrhoids, skin tags, abscesses
Epidemiology of UC
100-200/100,000
Peak at 15-30 and also around 60
Smoking is protective
F>M
Pathology of UC
Inflammation starts in rectum extends proximally along colon
Inflammation only affects mucosa which is excessively ulcerated
CF of UC
Crampy lower abdo discomfort
Gradual onset diarrhoea (bloody)
Urgency and tenesmus if disease confined to rectum
Histology of Crohn’s disease
Transmural inflammation, lymphoid hyperplasia and granulomas
Histology of UC
Mucosal inflammation, crypt abscesses and goblet cell depletion
Investigations for suspected IBD
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
Management of a mild crohn’s flare up
(Symptomatic but systemically well)
- oral prednisolone
- tapered steroids
- review in clinic
Management of a severe crohn’s flare up
(Symptoms + systemic upset)
Start IV steroids (hydrocortisone)
NBM
Thiopurines
Infliximab
Once improving transfer to oral prednisolone
If unable to control - surgery
Crohn’s maintenance therapy
Thiopurines eg azathioprine or 6-mercaptopurine
Methotrexate
Oral metronidazole for anal disease
Management of mild / moderate UC flare (less than 6 motions / day - systemically well)
Topical aminosalicylate for procitits
Loading dose of oral mesalazine +/- topical mesalazine for extensive disease
After 4 weeks add oral prednisolone
Management of severe UC flare up
IV corticosteroids
DVT prophylaxis
Avoid anti motility drugs
Assess need for surgery
UC maintenance therapy
5-ASA derivatives first line : sulfalazine, mesalazine
Oral thiopurines second line
IBD complications
Bowel perforation
Lower GI haemorrhage
Toxic dilatation
Colonic carcinoma
Features of toxic dilatation (toxic megacolon)
Persistent fever
Tachycardia
Loose blood stained stool
AXR shows dilated colon with mucosal islands
Describe surgery for Crohn’s disease
Is never curative
Temp ileostomies can be used to rest distal diseased bowel
Limited resection of the worst areas can be required
What is short bowel syndrome
When <1m small bowel remains after surgery for crohn’s
- can lead to malabsorption
Describe emergency surgery for UC
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
Describe elective surgery for UC
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
Outline some extra GI manifestations of IBD
Eyes: conjunctivitis / episcleritis / iritis
MSK: arthralgia of large joints
Skin: erythema nodosum, pyoderma gangrenosum
Symptoms of malabsorption
Chronic diarrhoea / steatorrhoea
Bloating
Weight loss
Lethargy
Signs of malabsorption
- anaemia
- bleeding disorders (vit K)
- oedema (decreased protein)
- osteomalacia (vit D)
- neuropathy
Common causes of malabsorption in UK
Coeliac disease
Chronic panc
Crohn’s
Investigations for suspected malabsorption
- 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
Pathology of coeliac disease
Inflammation of the jejunal mucosa in response to gluten
Biopsy of duodenal mucosa will show flattened mucosa due to loss of villi
Presentation of coeliac disease
1/3 asymptomatic
Diarrhoea, abdo pain, bloating, N+V
Weight loss, fatigue, ulcers
Dermatitis herpetiformis
Investigations for suspected coeliac disease
Bloods: endomysial antibodies and TTG antibodies present
Duodenal biopsy: gold standard
Bone densitometry
Management of coeliac disease
Lifelong gluten free diet
Endomysial antibody tests to ensure gluten free is working
Small increased risk of small bowel lymphoma / adenocarcinoma
Pathology of chronic pancreatitis
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
Presentation of chronic panc
Epigastric pain
Radiating to back
Relieved by sitting forwards or hot water bottle
Weight loss
Bloating
Steatorrhoea
Investigations for chronic panc
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
Chronic panc management
Analgesia
Creon
Blood sugar monitoring
Treat alcohol abuse
Low fat diet
Partial pancreatectomy
Define IBS
Chronic, functional bowel disorder with a prevalence of up to 10% in the UK population
Mixed abdo symptoms with no organic cause
Epidemiology of IBS
F:M >2:1, onset generally before age 40
Stressful live events
Co-morbid anxiety + depression
Preceding GI infection
ABC model for considering diagnosis of IBS
Abdominal pain
Bloating
Change in bowel habit
CF of IBS
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
Investigations for IBS
FBC
ESR / CRP
Coeliac disease screen
IBS management
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
Define malnutrition
BMI <18.5
Unintentional weight loss greater than 10% within the last 3-6mo
BMI <20 and unintentional weight loss >5% within 3-6mo
Risk factors for malnutrition
Age
Hospitalisation
Chronic illness
Alcohol abuse
Mental health
CF of malnutrition
Low BMI
Bradycardia, hypotension, hypothermia
Poor wound healing / recurrent infections
Management of malnutrition
Dietician support
Food first approach rather than oral nutritional supplements
Describe refeeding syndrome
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
Subdivisions of dyspepsia
Reflux type: heart burn and regurgitation
Ulcer type: epigastric pain
Dysmotility type: bloating and nausea
When do symptoms of GORD occur
When there is prolonged contact of the gastric contents with oesophagus mucosa - inflammation
Risk factors for GORD
Hiatus hernia
Raised IAP
Large meals late at night
Smoking
Caffeine
High fat food
CF of GORD
Heartburn / indigestion - worse on bending / lying - relieved on antacids
Regurgitation of food: worse when bending / lying
Waterbrash - filling of mouth with saliva
Red flag symptoms that indicate a need for urgent upper GI endoscopy to rule out malignancy (ALARMS 55)
Anaemia
Loss of weight
Anorexia
Recent onset, progressive symptoms
Melaena
Swallowing difficulties
>55
Management of endoscopically proven oesophagitis
Full dose PPI 1-2 mo
If response - low dose
If no response - double dose PPI
Management of endoscopically negative reflux disease
Full dose PPI for 1mo
If response offer low dose treatment prn
If no response then H2RA or prokinetic 1mo
Complications of GORD
Oesophagitis
Ulcers
Anaemia
Benign strictures
Barrett’s oesophagus
Oesophageal carcinoma
What is Barrett’s oesophagus
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
Where is the oesophageal hiatus
An oval aperture in the right crus of the diaphragm at T10
What happens in a hiatus hernia
Part of the stomach passes into the thoracic cavity through the oesophageal hiatus
Is usually asymptomatic but can lead to GORD symptoms
What are the 2 types of oesophageal hiatus hernia
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
Risk factors for PUD
H. Pylori (95% of duodenal, 75% of gastric)
NSAIDs
SSRIs
Corticosteroids
Bisphosphonates
Zollinger ellison syndrome
Features of PUD
Epigastric pain
Nausea
Duodenal ulcers - relieved by eating
Gastric ulcers - worsened by eating
Investigations for peptic ulcer type pain
Start a trial of PPI therapy
If symptoms persist test for H pylori with urea breath test or stool antigen test
Management of H pylori
PPI until ulcer heals
If + for H pylori - eradication therapy
Complications of peptic ulcers
Perforation - epigastric pain that then becomes generalised
Syncope
What is the difference between pancreatic cancer and cholangiocarcinoma
Cholangiocarcinoma: colicky RUQ pain, palpable mass, clay coloured stools, dark urine - due to biliary obstruction
Pancreatic Ca: anorexia, painless jaundice
What is the difference between primary sclerosing cholangitis and primary biliary cholangitis
PSC is damage of medium to large extrahepatic and intrahepatic bile ducts
PBC targets small intrahepatic bile ducts
What is the key investigation for suspected perforated ulcer
Erect CXR
Why should metoclopramide be avoided in bowel obstruction
It has prokinetic properties which can stimulate peristalsis in the bowel
This can exacerbate mechanical bowel obstruction and precipitate perforation
Triad of symptoms for mesenteric ischaemia
CVD
High lactate
Soft but tender abdomen
Triad of symptoms for mesenteric ischaemia
CVD
High lactate
Soft but tender abdomen
