GIT (gastro) Flashcards
What is celiac disease?
An autoimmune, malabsorption disease due to sensivity to gluten
Manifestations of celiac disease
°Chronic or intermittent diarrhea °Steatorrhea °Stinking, bad smell/offensive stools °Weight loss °Iron deficiency anemia (or Folate or B12 deficiency) °Manifestations of anemia (fatigue)
Complications of celiac disease
Osteoporosis
T-cell lymphoma (rare)
Associated to dermatitis herpetiformis
Diagnosis of celiac disease
First line: Positive TTG (tissue transglutaminase antibodies)+IgA
refered as tTG-IgA test.
sensivity of 98%
specificity of 95%
And Positive endomysial antibodies
How does a celiac disease diagnosis be confirmed?
If tTG (+) then... Jejunal or duodenal biopsy. (shows Villous atrophy, crypt hyperplasia, increased inter-epithelial lymphocyte)
***REMEMBER
For the biopsy to be accurate, introduce gluten SIX WEEKS before the biopsy!
Celiac disease treatment
Gluten-free diet
33YO male, non smoker. Presents with recurrent and chronic diarrhea for 6 months. His clothing appears to be ill-fitting. Hb 11 and MCV 105.
Most likely diagnosis?
Celiac disease.
Endoscopy+duodenal biopsy will show?
Villous atrophy
Crohn’s disease endoscopy
Skip lesions, transmural (deep ulcers) and Cobblestone appearance.
Crohn’s disease histology
Granuloma and increased Goblet cells.
Crohn’s disease symptoms and examination
°Abdominal pain or mass on the right iliac fossa
°Usually non-bloody diarrhea
°Weight loss
°Perianal fistulas, fistulae
°Aphthous oral ulcers (more common in CD than UC)
Histology of Ulcerative Colitis
Crypt abscesses
decreased goblet cells
Barium enema in Ulcerative Colitis
°Loss of haustration
°Drain pipe appearance
Symptoms and examination in Ulcerative Colitis
°Left lower quadrant pain (abdominal)
°Bloody diarrhea more common
°Primary Sclerosing Cholangitis is more common
°Aphthous oral ulcers (more common in CD)
How does smoking affects CD and UC?
Smoking INCREASES the risk of CD
Smoking DECREASES the risk of UC (protective)
Colonoscopy in Chrohn’s Disease
Cobble stone appearance, deep ulcers (transmural) and skip lesions
Small bowel enema in CD
Kantor’s string sign (“refers to the string-like appearance of a contrast-filled bowel loop caused by its severe narrowing.”), thorn ulcers and fistulae
Barium enema in UC
loss of haustral markings
Crohn’s disease treatment
°Oral prednisolone (1st line to induce remission)
°Mesalazine
REMEMBER
Crohn’s=Corticosteroids
Ulcerative Colitis treatment
5-ASA (Mesalazine) as 1st line to induce remission
Severe UC exacerbation = IV hydrocortisone
Physiopathology of Barret’s Oesophagus
Prolonged hydrochloric acid reflux to the oesophagus.
The lower oeasophagus undergoes “METAPLASIA”
From Squamous to Columnar epithelium.
Tip: “Shampoo for children”
Histology expected in Barret’s oesophagus
COLUMNAR metaplasia
can develop adenocarcinoma of the lower 1/3 of the oesophagus
Cancer in achalasia vs cancer in Barret’s oesophagus
Achalasia= squamous cell carcinoma of the upper 2/3 of the oesophagus
Barret’s = adenocarcinoma of the lower 1/3 of the oesophagus. (common in GERD too)
What is achalasia?
Inability to relax the lower oeasophageal sphincter (LOS) due to idiopathic loss of the normal neural structure
Main symptom in achalasia
Progressive dysphagia to both solids and liquids
There might be weight loss and chest pain
Key word: regurgitation (also in pharyngeal pouch)
Pharyngeal pouch symptoms
Regurgitation Halitosis (stale food or fluid) Gurgling sound in the chest when drinking A lump sensation in the throat Neck bulge
Investigation of a patient with achalasia
X-ray: Megaoesophagus (dilated)
Barium meal: Bird’s beak appearance of the distal end of the oesophagus
Oesophageal manometry: the most accurate, increased lower oeasophageal resting pressure
Treatment of Achalasia
Dilation of the lower oeasophageal sphincter.
45 YO woman presents with productive cough and moderate fever. She also complains of central chest pain, REGURGITATION of undigested food and DYSPHAGIA to both SOLIDS AND FLUIDS.
The X-ray shows megaesophagus
What is the most likely diagnosis?
Achalasia
productive cough and fever–> aspiration pneumonia from regurgitation
Upper GI endoscopy diagnostic indications
Haematemesis/melaena Dysphagia Dyspepsia (>55yrs old+alarm symptoms or tx refractory) Duodenal biopsy (coeliac?) Persistent vomiting Iron deficiency (cancer?)
Therapeutic indications of upper GI endoscopy
Treatment of bleeding lesions Variceal banding and schlerotherapy Argon plasma coagulation for suspected vascular abnormality Stent insertion, laser therapy Stricture dilatation, polyp resection
Upper GI endoscopy pre-procedure and procedure
Stop PPIs 2 weeks preop (if possible–> pathology masking)
Nil by mouth (ayuno) 6 hrs before
Don’t drive for 24 hrs if sedated
Sedation optional with midazolam 1-5mg IV
Propofol if deeper sedation is needed
Nasal prong O2
Local anesthetic in the pharynx (optional)
Continuous suction must be available
Upper GI endoscopy complications
Sore throat
Amnesia from sedation
Perforation (0.1%)
Bleeding (if on aspirin, clopidogrel, warfarin or Direct Oral Anti Coagulants= DOAC)
Duodenal Biopsy in Upper GI endoscopy for….
Gold Standard in Coeliac disease
Useful in unusual causes of malabsorption (giardiasis, lymphoma, Whipple’s disease)
Sigmoidoscopy
PR (rectal examination) first!
Views rectum+distal colon (approx splenic flexure)
Flexible has displaced rigid for diagnosis of distal colon pathology BUT STILL ~25% of cancers remain out of reach
Therapeuthic= decompression of sigmoid volvulus
Preparation with phosphate enema PR
DO BIOPSIES! macroscopic appearances may be normal! (Like amyloidosis and microscopic colitis)
Diagnostic indications for colonoscopy
Rectal bleeding (when settled if acute)
Iron-deficiency anaemia (bleeding cancer)
Persistent diarrhoea
Positive faecal occult blood test
Assessment or suspicion of IBD (Inflammatory Bowel Disease)
Colon Cancer Surveillance
Therapeutic indications for colonoscopy
Haemostasis (eg. Clipping vessel) Bleeding angiodysplasia lesion (argon beaker photocoagulation) Colonic stent deployment (cancer) Volvulus decompression Pseudo-obstruction Polypectomy
Preparation and procedure for colonoscopy
Stop iron 1 week prior Discuss with local endoscopy unit bowel preparation and diet DO PR (rectal exam) FIRST! Sedation and analgesia as in endoscopy
Colonoscopy complications
Abdominal discomfort
Incomplete examination
Haemorrhage after biopsy or polypectomy
Perforation (<0.1%)
NO ALCOHOL and NO OPERATING MACHINERY FOR 24h!
Video capsule endoscopy (VCE) uses
Evaluate obscure GI bleeding and detect small bowel pathology
Use small bowel imaging or patency capsule ahead of VCE when px has abdominal pain or sugestion of small bowel obstruction
Video capsule endoscopy (VCE) preparation and procedure
Clear fluids only the evening before then nil by mouth (ayuno) from morning until 4h after capsule is swallowed
Capsule is swallowed and transmits video wirelessly to capture device worn by patient
Normal activity can take place for the day
Video Capsule Endoscopy (VCE) complications and problems
Capsule retention in <1% (endoscopic or surgical removal) Avoid MRI for 2 weeks after, unless AXR (abdominal X-Ray) confirms capsule has cleared Obstruction Incomplete exam (slow transit or achalasia)
No therapeutic options
Poor localisation of lesions
May miss subtle lesions
Video Capsule Endoscopy (VCE) complications and problems
Capsule retention in <1% (endoscopic or surgical removal) Avoid MRI for 2 weeks after, unless AXR (abdominal X-Ray) confirms capsule has cleared Obstruction Incomplete exam (slow transit or achalasia)
No therapeutic options
Poor localisation of lesions
May miss subtle lesions
Liver biopsy route and indications
Percutaneous if INR in range
If not, transjugular with FFP (fresh frozen plasma)
Increased enzymes (liver function test- LFT) of unknown aetiology.
Assessment of fibrosis in chronic liver disease (now being replaced by ultrasound elastography)
Suspected cirrhosis
Suspected hepatic lesions/cancer
Liver biopsy pre procedure, procedure and complications
Nil by mouth for 8h (ayuno)
INR <1.5 and platelets >50x10^9/L
Analgesia
Under US/CT guidance
Liver borders percussed–> where dullness is found in the mid-axillary line in expiration. Infiltrate lidocaine 2% down to the liver capsule
Rehearse breathing and take needle biopsy with the breath held in expiration
Lie on the right side for 2h, then in bed for 4h
Pulse and blood pressure every 15 mins for 1h
Then every 30 mins for 2h
Hourly for 4h and discharge
Complications: pain, pneumothorax, bleeding (<0.5%) and death (<0.1%)
Causes of dysphagia
Mechanical: malignant stricture, benign structure, extrinsic pressure and pharyngeal pouch
Motility disorders: achalasia, diffuse oesophageal spasm, systemic sclerosis, neurological bulbar palsy
Other: oeasophagitis, globus (lump in throat=try to distinguish from true dysphagia)
5 key questions of dysphagia
Difficulty swallowing solids and liquids from the start?
Yes–> motility disorder (achalasia, CNS, pharyngeal causes)
No –> solids then liquids = Stricture (benign or malign)
Is it difficult to initiate swallowing movement?
Yes= bulbar palsy, especially if patient coughs on swallowing
Is swallowing painful? (Odynophagia)
Yes= ulceration (malignancy, oeasophagitis, viral infection or Candida in immunocompromised, poor steroid inhaler technique) or spasm
Intermittent dysphagia or constant and getting worse?
Intermittent: suspect oesophageal spasm
Constant and worsening: malignant stricture
Does the neck bulge or gurgle on drinking?
Yes: Pharyngeal pouch
Signs in patients with dysphagia
Anaemia or cachectic? Examine mouth
Feel for supraclavicular nodes (Virchow’s node)
Signs of systemic disease (systemic sclerosis or CNS disease)
