GI2 Flashcards
Lower GI
What are the two types of inflammatory bowel disease?
Crohn’s disease
Ulcerative colitis
What is Crohn’s disease?
A disorder with unknown aetiology characterised by transmural inflammation of the GI tract.
What is ulcerative colitis?
Relapsing and remitting inflammatory disorder of the colonic mucosa.
What is the aetiology of inflammatory bowel disease?
Both have an unknown aetiology.
What are the risk factors for Crohn’s?
Family Smoking OCP Nutrition deficiency Previous infection
What are the ages at risk of IBD?
20-40 years, 60-70 years
Which layers of the gut is affected by Crohn’s?
All the layers
Which layers of the gut is affected by UC?
Mucosa and submucosa
Which parts of the GI tract are affected by Crohn’s?
Mouth to anus
Particularly terminal ileum
Which parts of the GI tract are affected by UC?
Colon and rectum
Which parts of the GI tract are inflamed in Crohn’s?
Random patches, with skip lesions
Which parts of the GI tract are inflamed in UC?
Continuous from the anus proximally
Which of the IBD’s commonly has fissures/abscesses?
Crohn’s
What is the main bowel symptom in Crohn’s?
Diarrhoea +/- blood
What is the main bowel symptom in UC?
Bloody +/- mucus diarrhoea
What is the difference in flare pattern for Crohn’s and UC?
Crohn’s- systemically unwell
UC- feel well between flares
Which of the IBD’s is curative via surgery?
UC
How does the presence of blood present in IBD?
Mixed in with the stool
Which IBD is likely to present with RIF pain?
Crohn’s (terminal ileitis)
Which IBD is likely to present with mouth ulcers?
Crohn’s
What are the extra-intestinal manifestations of IBD?
A PIE SAC
Aphthous ulcers (CD>UC) Pyoderma gangrenosum I eye- iritis, uveitis, episcleritis (CD>UC) Erythema nodosum Sclerosing cholangitis (UC) Arthritis Clubbing fingers (CD>UC)
What investigations would you do on a Pt with Crohn’s?
Stool sample
Blood tests
CT/MRI abdo
(Colonoscopy and biopsy)
What investigations would you do on a Pt with UC?
Stool sample
Blood tests
Abdo XR
Colonoscopy/flexisig and biopsy
What would a colonoscopy and biopsy of a Pt with UC show as?
Mucin depletion
Diffuse mucosal atrophy
Continuous from the rectum with anal sparing
What may you see on the Abdo XR of a Pt with UC?
Toxic megacolon
Lead piping
Thumb printing
Why would you measure the FBC of a Pt with IBD?
Check for infection
Why would you measure the CRP and ESR of a Pt with IBD?
To provide baseline markers for inflammation
Why would you measure the LFTs of a Pt with IBD?
To check for primary sclerosing cholangitis (UC)
What is lead piping?
Loss of the haustral markings
Due to inflammation
What is thumb printing?
Large bowel wall thickening
Due to infective/inflammatory process
What is toxic megacolon?
IBD/C Diff progressing into inflammatory colitis progressing into toxic megacolon
What are the symptoms of a toxic megacolon?
Extreme vomiting
Abdo pain
Abdo distension
How do you induce remission for Crohn’s?
Corticosteroids
How do you induce remission for UC?
Aminosalicylates (eg. mesalazine)
- topical
- oral low dose
- oral high dose
How do you maintain remission for Crohn’s?
Azathioprine
Methotrexate
Cyclosporin
Infliximab (TNFa)
How do you maintain remission for UC?
Azathioprine
Methotrexate
Cyclosporin
What is the prognosis of a Pt with Crohn’s?
Increased mortality
What is the prognosis of a Pt with UC?
Mortality not affected
Risk of developing toxic megacolon
What is Coeliac disease?
Autoimmune disease of the small intestine, due to gluten intolerance in genetically susceptible individuals
What is the epidemiology of Coeliac disease?
European
Peaks at infancy and 50-60 yrs
What is the aetiology of Coeliac disease?
Autoimmune damage to the intestinal mucosa leading to:
- villous atrophy
- WBC infiltration
- cryptal hyperplasia
- malabsorption
What are the risk factors for Coeliac disease?
F:M 2:1 Autoimmune Hx -T1DM -Thyroid disease FHx
What symptoms may a Pt with Coeliac disease present with?
Diarrhoea- difficult to flush
Bloating
Abdo pain- after eating gluten
Fatigue
What signs may a Pt with Coeliac disease present with?
IgA deficiency (can indicate silent Coeliac)
Anaemia
Dermatitis herpetiformis
What investigations would do you on a Pt with Coeliac disease?
Stool sample
Serum anti-TTG antibodies
Serum anti-endomysial antibodies
Endoscopy and duodenal biopsy
What will an endoscopy and duodenal biopsy show in a Pt with Coeliac disease?
Villous atrophy
Cryptal hyperplasia
Intraepithelial WBCs
How would you manage a Pt with Coeliac disease?
Gluten-free diet
Vitamin D supplementation
What is the prognosis of a Pt with Coeliac disease?
<90% will have complete and lasting resolutions on a gluten-free diet
What are the complications of a Pt with Coeliac disease?
Upper GI lymphoma/carcinomas
Osteoporosis
Chronic dermatitis herpetiformis
What is irritable bowel syndrome?
Recurrent abdo pain in the past 3 months associated with at least 2 of the following: -defecation -change in stool frequency -change in stool consistency [Rome IV criteria]
How is IBS diagnosed?
Via a process of exclusion
How would you manage a Pt with IBS?
Avoid precipitating factors FODMAP diet Peppermint oil/tea Anti-diarrhoeal (loperamide) SSRIs (citalopram)
What is an anal fissure?
A split in the skin of the distal anal canal
What is the epidemiology of anal fissures?
Young white males
Hx of constipation
Where do anal fissures most commonly present?
Posterior midline of the anal canal (90%)
Recent evidence suggests this may be due to ischaemia, as this is the location with poorest circulation
What symptoms may a Pt with an anal fissure present with?
Tearing pain
Blood on wiping
What investigations would do you do on a Pt with an anal fissure?
NA- anal fissures are a clinical diagnosis.
What is the treatment for a Pt with an anal fissure?
Fluids and fibre
Topical analgesia
Topical GTN/diltiazem
Surgery in chronic extreme cases
What is the prognosis for a Pt with an anal fissure?
80% heal with treatment
What are the complications of an anal fissure?
Chronicity
Incontinence post-op
What are haemorrhoids?
Normal anatomical structures located in the anal canal
What is the epidemiology of haemorrhoids?
4% of the population
Common in 45-65 yrs
What is the main risk factor for haemorrhoids?
Raised intra-abdominal pressure:
- constipation
- chronic cough
- pregnancy
- obesity
- ascites
- SOL
What are the four degrees of haemorrhoids?
1- no prolapse, just prominent veins
2- prolapse upon bearing, spontaneously reduces
3- prolapse requiring manual reduction
4- prolapse which cannot be manually reduced
What symptoms may a Pt with haemorrhoids present with?
Bright red PR bleed
Sides of the pan
Rectal pain (sometimes)
What investigations would you do on a Pt with haemorrhoids?
DRE
Colonoscopy (for painful 1st/2nd degree)
What signs can be seen on a PR exam of a Pt with haemorrhoids?
Visible lump
3/4th degree may be visible on inspection
What is the management for a Pt with haemorrhoids?
1st degree: -fluid and fibre -topical analgesics 2nd/3rd degree: non-surgical excision 4th degree: excision
What are the complications of haemorrhoids?
Anaemia
Thrombosis
Incarceration
What is the prognosis for a Pt with haemorrhoids?
Surgery has the lowest recurrence rates: 20%
What is the ranking for colorectal cancer in terms of incidence?
3rd commonest cancer in the UK
What is the most common type of colorectal cancer?
Adenocarcinoma
What are the risk factors for colorectal cancer?
> 60yrs
Alcohol/smoking/high red meat diet
Polyps
Genetic conditions (FAP/HNPCC)
What are the symptoms of a left sided colorectal cancer?
Weight loss
Anaemia
Abdo pain
Abdo mass
What are the symptoms of a right sided colorectal cancer?
PR bleeding/mucus Altered bowel habit Tenesmus Obstruction PR mass Abdo mass
Which sided colorectal cancer presents earlier, and is easier to detect?
Left sided
What investigations would you do on a Pt with colorectal cancer and why?
FBC- anaemia LFTs- baseline Renal function- baseline Colonoscopy/barium enema/CT colonography -to find and stage the tumour Biopsy -to grade the tumour
A 22 y/o female presents to her GP with a two year history of intermittent diarrhoea and constipation. She complains of bloating and abdominal pain, which eases with defecation. Which condition is she likely to have?
A. Coeliac disease B. Ulcerative colitis C. Crohn’s disease D. Irritable bowel syndrome E. Infectious diarrhoea
D. Irritable bowel syndrome
Fits Rome IV criteria
A 26 y/o male presents to his GP with weight loss, abdominal pain and watery diarrhoea. On examination he looks pale and you notice ulcers in his mouth. Which condition is he likely to have?
A. Coeliac disease B. Ulcerative colitis C. Crohn’s disease D. Irritable bowel syndrome E. Infectious diarrhoea
C. Crohn’s disease
Mouth ulcers
A 23 y/o female presents to her GP with a limp. On further questioning she reveals she has recently lost weight and has had bloody, mucoid diarrhoea. On examination her right knee is tender and swollen, and her eyes are red. Which condition is she likely to have?
A. Coeliac disease B. Ulcerative colitis C. Crohn’s disease D. Irritable bowel syndrome E. Infectious diarrhoea
B. Ulcerative colitis
Blood, mucoid- likely UC
A 27 y/o male presents with a history of mucoid, bloody diarrhoea and weight loss. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. Which treatment would you start him on?
A. IV corticosteroid B. Oral prednisolone C. Topical mesalazine D. Oral azathioprine E. IV cyclosporin
C. Topical mesalazine
Likely to be UC
A 31 y/o male presents with a history of diarrhoea, weight loss and RIF pain. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. Which treatment would you start him on?
A. IV corticosteroid B. Oral prednisolone C. Oral mesalazine D. Oral azathioprine E. IV cyclosporin
B. Oral prednisolone
Terminal ileitis- likely Crohn’s
A 31 y/o male presents with a history of diarrhoea, weight loss and RIF pain. On examination you note a number of red marks on his shins. After taking oral prednisolone, his symptoms improve. Which additional treatment would you start him on to maintain his remission?
A. IV corticosteroid B. Increase oral prednisolone C. Oral mesalazine D. Oral azathioprine E. IV cyclosporin
D. Oral azathioprine
A 55 y/o female presents to her GP with an itchy rash on her forearms. On further questioning she reveals she has recently lost weight and has had mucoid diarrhoea. Which test will best confirm her diagnosis?
A. Endoscopy with duodenal biopsy B. Serum antibodies to tissue-transglutaminase C. Serum anti-endomysial antibodies D. Colonoscopy E. Endoscopy with ileal biopsy
A. Endoscopy with duodenal biopsy
A 67 y/o male presents to his GP following an episode of rectal bleeding. He noticed fresh blood on the toilet paper after wiping. There was no blood mixed in with the stool. He is otherwise fit and well. What is the next appropriate step to take?
A. Colonoscopy B. Faecal occult blood test C. Abdominal exam D. Digital rectal exam E. Sigmoidoscopy
C. Abdominal exam
[Note from Chang, would argue that DRE is also appropriate]
A 35 y/o male presents to his GP following an episode of rectal bleeding. He noticed fresh blood on the toilet paper after wiping. There was no blood mixed in with the stool. He adds that he is very sore ‘down there’ and it is agony to defecate. Which condition is he likely to have?
A. Haemorrhoids B. Anal fissure C. Crohn’s disease D. Ulcerative colitis E. Colorectal carcinoma
B. Anal fissure
A 67 y/o male presents to his GP complaining of rectal bleeding. Over the last few months he has noticed blood mixed in with his stool. He sometimes feels like he hasn’t completely emptied his bowels after defecating, and is more tired than usual. What is the next step to take?
A. Routine referral to colorectal surgeons
B. Urgent referral to colorectal surgeons
C. FBC
D. Abdominal exam
E. Faecal occult blood test
D. Abdominal exam
[Note from Chang, would argue that “B. Urgent referral to colorectal surgeons”]
