GI Week 1 Flashcards
What is achalasia?
This is a disorder where the lower oesophageal sphincter fails to relax, leading to difficulty in swallowing (dysphagia). Given that the patient does not have dysphagia, this diagnosis is unlikely.
How does peptic ulcer disease arise?
Pathophysiology:
The mucosa, also known as the mucous membrane, is the inner lining of the stomach and duodenum.
It secretes mucus that coats the surface and forms a barrier that protects it from the stomach’s contents, particularly stomach acid and digestive enzymes.
It secretes bicarbonate into this mucus coating to neutralise the stomach acid.
Factors that disrupt the mucus barrier or increase stomach acid increase the risk of mucosal ulceration.
Which risk factors increase the chance of mucosal barrier disruption?
The risk key factors that disrupt the mucus barrier are:
Helicobacter pylori
NSAIDs
Which foods/drinks increase stomach acid production?
The risk key factors that increase stomach acid are:
Stress
Alcohol
Caffeine
Smoking
Spicy foods
Which medications increase the risk of bleeding from a peptic ulcer?
NSAIDs
Aspirin
Anticoagulants (e.g., DOACs)
Steroids
SSRI antidepressants
What are non-specific symptoms of peptic ulcer?
Epigastric discomfort or pain
Nausea and vomiting
Dyspepsia
What are signs of a Upper GI bleed?
Haematemesis (vomiting blood)
Coffee ground vomiting
Melaena (black, tarry stools)
Fall in Hb levels on a FBC
What blood test findings would be associated with chronic microscopic bleeding?
iron deficiency anaemia, with low Hb,
low mean cell volume (MCV) - microcytic anaemia
low ferritin.
How can laryngopharyngeal reflux present?
This variant of GORD typically results in symptoms related to the throat and voice box, like dysphonia, persistent cough, and the sensation of a lump in the throat (globus sensation)
What are the core aspects of treating peptic ulcers?
Stopping NSAIDs
Treating H. pylori infections
Proton pump inhibitors (e.g., lansoprazole or omeprazole)
According to guidelines, How is gastro-oesophageal reflux disease (GORD) best described?
GORD is characterised by the guidelines as either endoscopically determined oesophagitis or endoscopy-negative reflux disease.
This definition acknowledges the spectrum of the condition: from those with visible oesophagitis on endoscopy to those who have symptoms suggestive of reflux but no visible changes on endoscopy
what is 1st line treatment of GORD?
The first-line approach to manage uncomplicated GORD in the UK, based on NICE guidelines, is to provide a 4-week trial of a proton pump inhibitor (PPI) like omeprazole.
what cell type change is seen in Barretts oesophagus?
Barrett’s esophagus is a condition in which there is an abnormal (metaplastic) change in the mucosal cells lining the lower portion of the esophagus, from stratified squamous epithelium to simple columnar epithelium with interspersed goblet cells that are normally present only in the small intestine and large intestine
Difference between osmotic and secretory diarrhoea?
Osmotic diarrhoea is due to the ingestion of poorly absorbed ions or sugars.
Secretory diarrhea is due to disruption of epithelial electrolyte transport.
Two ways to distinguish an osmotic from a secretory process is by the response to fasting and calculating the faecal osmotic gap.
How do we regulate the GI tract?
Gastric Motility - peristalsis aids in preventing pathogen colonisation (anticholinergics, antidiarrheals, narcotics - all reduce motility)
Osmotic diarrhoea - accumulation of sugars, salts or nutrients in the lumen from malabsorption, inflammation etc.
Secretory diarrhoea - secretion of fluid into lumen of intestine.
Symptoms of oesophagitis?
Symptoms:
Heartburn,
retrosternal pain (pain behind sternum)
belching,
bloating,
dysphagia
odynophagia (pain when swallowing)
What is oesophagitis?
Irritation of oesophageal epithelium due to acid leading to oesophageal inflammation
Could be due to infection or inflammation
why does oesophagitis cause asthma-like symptoms?
esophageal exposure to acid may result in decreased peak expiratory flow, thus increasing airway resistance. These responses may be reduced by atropine therapy. However, other researchers suggest that acid reflux may actually be a precursor of more severe bronchospasm with future triggers.
What is a Mallory-weiss tear?
A Mallory-Weiss tear is a tear of the tissue at the oesophago-gastric junction
It is most often caused by violent coughing or vomiting.
Main symptoms/risk factors of MW tear?
Abdominal pain and vomiting are primary symptoms
Risk factors include bulimia, alcohol xs and pregnancy
What is Boerhaaeve syndrome?
Effort rupture of the oesophagus, or Boerhaave syndrome, is a spontaneous perforation of the oesophagus that results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure.
What is treatment for oesophagitis?
Treatment
Underlying cause – always. E.g fluconazole for fungal oesophagitis.
Avoid triggers –alcohol/caffeine/smoking.
Alginates- GAVISCON etc
PPI 2 month treatment for severe ,then maintenance
H2 receptor antagonists – famotidine
What is GORD?
Erosion of oesophageal tissue due to prolonged/excessive gastric acid
SHOULD PASS acronym for cases of GORD?
Sphincter/smoking
Hernia
Obesity
Ulceration
Lifestyle e.g. caffeine, late meals
Drugs e.g. NSAIDS, antidepressants, bisphosphonates
Pregnancy
Alcohol
Surgery
Sclerosis
GORD Symptoms
Heartburn
Regurgitaiton
Upper abdominal or chest pain.
Trouble swallowing (dysphagia)
Sensation of a lump in your throat.
What is a colicky pain?
Intestinal colic - intermittent cramp-like pain that may occur when the GI tract is blocked
Colicky abdominal pain can be the result of some sort of obstruction but is usually functional and secondary to irritable bowel syndrome.
What is cholecystitis?
inflammation of gall bladder due to gallstone blocking the cystic duct
Cholecystitis symptoms
Sharp RUQ pain
Postprandial pain (often worse with deep breaths) that spreads to your back or below the right shoulder blade -murphys sign
Nausea
Vomiting
Fever
Jaundice
Loose, light-coloured bowel movements.
Belly bloating
What is cholangitis?
Acute bacterial infection of the bile ducts resulting from common bile duct obstruction.
Cholestasis
disruption of bile flow
AST< ALT - hepatic damage
raised alp, bilirubin - cholestatic problem - bile movement problem
causes of jaundice
bilirubin comes from haem breakdown
prehepatic - haemoglobin -> bilirubin - caused by haemolysis
too much bili being made
intrahepatic causes of jaundice
liver produces a lot of bilirubin, cannot move around, tubes are narrow -
pale stools, dark urine stopping bile from getting into bowels
haemolytic
extrahepatic causes of jaundice
gall bladder, pancreas carcinoma - cant get rid of XS bili
What is cholelithiasis?
CCK released in response to fatty foods
gall bladder squeezes
gall stone lodged in gallbladder
this pushes against the hard gallstone
transient pain in RUQ
also called biliary colic
stone stuck in the gallbladder
intermittent RUQ pain
Risk factors of gallstone 5Fs
fat, forty, fertile, female, fair
Investigations/management for gallstones
ALP, Bilirubin will be raised
Amylase - gallstone might end up in the pancreas
USS abdo - assess for stones in gallbladder
if USS inconclusive - MRCP
Parecetamol, NSAIDs
What is the bile duct function?
A tube that carries bile from the liver and gallbladder, through the pancreas, and into the small intestine to help digest fats in food
What is primary sclerosing cholangitis?
Primary sclerosing cholangitis occurs because of inflammation in the bile ducts (cholangitis) that leads to scarring (sclerosis) and narrowing of the ducts.
As a result, bile cannot be released to the gallbladder and small intestine, and it builds up in the liver .
What is megaloblastic anaemia?
Megaloblastic anemia is a form of macrocytic anemia, a blood disorder that happens when your bone marrow produces stem cells that make abnormally large red blood cells.
A 65-year-old patient presents to you with a 4-week history of progressive dysphagia, initially with solids and now with liquids. He tells you that he has recently lost some weight. What is the most likely diagnosis?
Oesophageal cancer – dysphagia with solids and then liquids are classic symptoms of oesophageal cancer – weight loss is a red flag! Do not miss this in your history-taking!
What are causes of microcytic anaemia?
low MCV low Hb
causes – thalassemia, anaemia of chronic disease, iron deficiency anaemia
A 23 year old patient has come to see you in the General Practice. She is complaining of a 3 day history of increasing urinary frequency and suprapubic pain. What is most likely diagnosis?
Cystitis – the key symptom is suprapubic pain
(if UTI then symptoms would be increased urinary frequency, dysuria, haematuria, nocturia)
A 55 year old patient presents to you in the Emergency Department with a 4 hour history central chest pain radiating to the left arm. He is sweaty and clammy. He has vomited twice in the Emergency Department.
What would be most useful blood test for this patient?
Troponin – your top differential for this patient is ACS! DO NOT MISS THIS! Always elicit SEPSIS – ask about cough, fever, unwell, lethargy
In any history taking you MUST RULE OUT SEPSIS
Eg if someone comes in with leg pain – ask if the leg feels warm, difficulty to walk on, any fevers, lethargy, feeling unwell,
Ask about infective symptoms – diarrhoea, vomiting!!!!
RECENT TRAVEL!!
A 65 year old male has presented with a 1 month history in a change in bowel habit. He tells you that he has had some abdominal discomfort.
Which part of the bowel is most likely to be affected?
L sided colon – rectal and sigmoid cancers often bleed - blood mixed in with stool,
Cancers arising in the caecum and R colon: often asymptomatic and present as iron deficiency anaemia
Red flag symptoms – learn this – colorectal cancer – anorexia, weight loss, faecal incontinence, rectal bleeding, tenesmus and passing mucus from the rectum
A 34 year old male presents to you with jaundice. He tells you that he has been drinking heavily over the past few years due to bereavement. Which condition is he most likely to develop if he continues to drink alcohol?
Liver disease – alcohol increases a patients risk of developing liver cirrhosis
increased risk of hepatocellular carcinoma
A 45 year old presents to ED with abdominal pain. She tells you that she has had colicky type of pain in the RUQ for 6 days. She tells you the pain if worse after eating a heavy meal. She has vomited 6 times in the last 24 hours.
What is the most likely diagnosis?
Acute cholecystitis
Which of the following is not a sign of liver disease?
Spider naevi - dilation of central arterioles from which numerous thin-walled capillary branches radiate like spider legs, carrying away freely flowing blood - caused by high oestrogen levels (eg if more than 5 = liver disease, normal finding in pregnant women/pts taking OCP)
Caput-medusa - cluster of swollen veins in your abdomen. The swelling usually appears around the belly button, and the veins branch out from a central point - portal hypertension
Gynaecomastia - high oestrogen levels (liver cirrhosis), iatrogenic (eg digoxin, spironolactone)
Clubbing - IBD, CD, liver cirrhosis, GI tract lymphoma
Osler’s nodes – purple, tender lumps on the finger tips – indicative of infective endocarditis
A 60 year old male has presented to the Emergency Department with coffee-ground vomit. He tells you his stools have been ’tar-like’ and black in colour
Which one of the following is the most likely cause of his symptoms?
Oesophageal varices – this patient is having an upper GI bleed, revise other causes of upper GI bleeds
A 23 year old male who is generally fit has come to see you at the Practice. He tells you that he has had a burning sensation in his chest in the last few days and an acid taste in his mouth. He denies any weight loss and does not have a cardiac history. He has been quite stressed with his new job recently and has been eating a lot of takeaways. He is a smoker and doesn’t drink alcohol.
What would be your 1st line management for this patient?
Lifestyle advice – smoking cessation advice, cut down on takeaways, 5 a day, smaller meals, not eating large meals in the evening, stress-coping strategies, avoiding citrus and spicy foods
A 26 year old female has presented to the A+E department, with acute shortness of breath, wheeze and facial swelling. She tells you that she tried some new hair dye last night. On examination Sats 92% on air, HR 110, RR 25 Temp 36.4 BP 96/64
What would be your initial management for this patient?
Anaphylaxis - Adrenaline (reduces swelling, raises BP), chlorphenamine (drowsy antihistamine), hydrocortisone
A 85 year old woman has presented to the Emergency Department with a headache and difficulty getting her words out over the last 24 hours. On examination she has blurred vision on Left lateral gaze and her reduced tone and sensation in her left arm. Her observations are Temp 36.0 BP 190/110, HR 90, RR 19, Sats 98% on room air
What is her most likely diagnosis?
TIA <24 hours symptoms fully resolve
Stroke >24 hours, symptoms ongoing, has neurological deficit, high BP increases risk of stroke massively!
Hypertension
Subarachnoid haemorrhage – thunderclap headache, vomiting, collapse, confusion
What is Glasgow Blachtford tool good for?
risk stratification tool used used to identify pts with upper GI bleeding and determines who needs in-hospital and out-of-hospital management
What is Charcot’s triad and what does it indicate?
Charcot’s Triad: Fever, RUQ pain and jaundice (neither sensitive nor specific)
indicates cholecystitis
What is Raynaud pentad and what do they indicate?
Fever, RUQ pain and jaundice (neither sensitive nor specific) but also shock (low BP, tachycardia) and altered mental state
indicates cholangitis
Acute cholangitis symptoms?
Symptoms
Fever/chills
Nausea/vomiting
Abdominal pain
What is acute cholangitis - obstructive jaundice - bile stuck?
caused by gallstones blocking the common bile duct
Exam findings cholangitis
RUQ tenderness to palpation
Peritoneal signs are variable
Jaundice
Frank sepsis (fever, tachycardia, hypotension, tachypnea) is a common presentation
Reynold’s Pentad: Charcot’s triad + sepsis and AMS
Gold standard in diagnosing cholangitis?
LFTs
Abdo USS
consider CT/MRCP
Acute cholangitis occurs when there is a complete obstruction of the biliary tree, which is usually secondary to an impacted gallstone, strictures or as a complication of endoscopic retrograde cholangiopancreatography (ERCP)
ERCP decompresses the biliary tree - can cause pancreatitis
Common Exam findings for Appendicitis?
Right lower quadrant guarding and rebound tenderness over McBurney’s point (1.5 to 2 inches from the anterior superior iliac spine (ASIS) on a straight line from the ASIS to the umbilicus)
Rovsing’s sign (right lower quadrant pain elicited by palpation of the left lower quadrant)
Dunphy’s sign (increased abdominal pain with coughing)
Time frame of symptoms onset for appendicitis?
early appendicitis: 12-24 hours
perforation: greater than 48 hours.
what is the ampulla of Vater and where is it located?
a small reservoir where your common bile duct and pancreatic duct meet.
An opening at the end of your ampulla allows bile and pancreatic juices to flow into your duodenum (small intestine). These digestive juices help your body break down food and absorb it.
colostomy
ileostomy = spouted = acidic
end colosotmy (removing large part of bowel, irreversible)- slive off bowel, bring rest to surface
loop colostomy (remove part of bowel in middle0- bring out loop of bowel, slice end off and 2 bits of bowel on surface of skin, reversivble
Hartmanns
scars
suprabic - c section
left inguinal - sigmoid colon surgery
midline - lapartomy
tight subcostal - biliary tract (Kochers incision)
Mercedes Benz scar - liver transplant§
psoas sign
Psoas sign is elicited by having the patient lie on his or her left side while the right thigh is flexed backward.
Pain may indicate an inflamed appendix overlying the psoas muscle
gallbladder - tip of scapula pain
kidney - loin to groin pain
casues of hepatomegaly
alcoholic liver disease
viral hepatitis
haematological disorder
causes of splenomegaly
portal HTN
haematological disorders
infection - Glandular fever
pyodernosum gangrenosum
signs of IBD
cystic duct - connects gall bladder
common hepatic duct becomec common bile duct
meets pancreatic duct -
empties into ampulla of Vater -goes throguh SPhincter of Oddi
gall bladder releases bile CCK released - releases through cystic
