GP-gastro Flashcards
- GORD definition
Gastro-oesophageal reflux disease (GORD) is where acid from the stomach flows through the lower oesophageal sphincter and into the oesophagus, where it irritates the lining and causes symptoms.
The oesophagus has a squamous epithelial lining that makes it more sensitive to the effects of stomach acid. The stomach has a columnar epithelial lining that is more protected against stomach acid.
GORD causes and triggers
Certain factors can exacerbate or worsen the symptoms of GORD:
Greasy and spicy foods
Coffee and tea
Alcohol
Non-steroidal anti-inflammatory drugs
Stress
Smoking
Obesity
Hiatus hernia
GORD presentation
Dyspepsia is a non-specific term used to describe indigestion. It covers the symptoms of GORD:
Heartburn
Acid regurgitation
Retrosternal or epigastric pain
Bloating
Nocturnal cough
Hoarse voice
Key red flags to screen for in GORD and nice guidelines for cancer referral
- Investigations in GORD
Indications for upper GI endoscopy:
age > 55 years
symptoms > 4 weeks or persistent symptoms despite treatment
dysphagia
relapsing symptoms
weight loss
If endoscopy is negative consider 24-hr oesophageal pH monitoring (the gold standard test for diagnosis)
Indications for upper GI endoscopy
age > 55 years
symptoms > 4 weeks or persistent symptoms despite treatment
dysphagia
relapsing symptoms
weight loss
extras:
anemia
Melaena/haematemesis
Proton pump inhibitors should be stopped 2 weeks before an upper GI endoscopy
what is an OGD?
it can be used to assess for:
An oesophago-gastro-duodenoscopy (OGD) involves inserting a camera through the mouth down to the oesophagus, stomach and duodenum. It can be used to assess for:
Gastritis
Peptic ulcers
Upper gastrointestinal bleeding
Oesophageal varices (in liver cirrhosis)
Barretts oesophagus
Oesophageal stricture
Malignancy of the oesophagus or stomach
Patients with evidence of upper gastrointestinal bleeding (e.g., melaena or coffee ground vomiting) need admission and urgent endoscopy.
GORD management
We offer a test for H. pylori to:
how can we test for H.pylori?
The H. pylori eradication regime involves
triple therapy with a proton pump inhibitor (e.g., omeprazole) plus two antibiotics (e.g., amoxicillin and clarithromycin) for 7 days. Routine re-testing is not necessary after treatment.
- Key important complication of GORD
Barrett’s oesophagus
Barret’s oesophagus definition, pathophysiology and treatment
What is Zollinger-Ellison syndrome
Coeliac disease definition and associated conditions
Coeliac disease is an autoimmune condition triggered by eating gluten. It can develop at any age and is thought to be caused by genetic and environmental factors. There is a link with other autoimmune conditions, particularly type 1 diabetes and thyroid disease.
TOM TIP: Remember for your exams that we test all new cases of type 1 diabetes and autoimmune thyroid disease for coeliac disease, even if they do not have symptoms.
pathophysiology of coeliac disease
It is associated with certain human leukocyte antigen (HLA) genotypes:
HLA-DQ2
HLA-DQ8
There are three antibodies related to coeliacs:
- Anti-tissue transglutaminase antibodies (anti-TTG)
- Anti-endomysial antibodies (anti-EMA)
- Anti-deamidated gliadin peptide antibodies (anti-DGP)
Coeliac disease affects which part of the bowel the most? What is the name of the process it causes?
Inflammation affects the small bowel, particularly the jejunum. The surface of the small intestine is covered in projections called villi, which increase the surface area and help with nutrient absorption. Coeliac disease causes atrophy of the intestinal villi, resulting in malabsorption.
Coeliac disease is associated with certain human leukocyte antigen (HLA) genotypes:
HLA-DQ2
HLA-DQ8
Presentation of coeliac
Diagnosis and investigations in coeliac
biopsy findings in coeliac
- crypt hyperplasia
- villous atrophy
first line blood tests in coeliac disease
- Total immunoglobulin A levels (to exclude IgA deficiency)
- Anti-tissue transglutaminase antibodies (anti-TTG)
management of coeliac disease
A lifelong gluten-free diet should completely resolve the symptoms. Dietician input may be helpful. Relapse will occur upon consuming gluten. Coeliac antibodies may help monitor the disease.
complications of coeliac disease
If someone with coeliac disease continues eating gluten, even in tiny amounts, it can lead to:
- Nutritional deficiencies
- Anaemia
- Osteoporosis
- Hyposplenism (with immunodeficiency, particularly to encapsulated bacteria such as Streptococcus pneumoniae)
- Ulcerative jejunitis
- Enteropathy-associated T-cell lymphoma (EATL)
- Non-Hodgkin lymphoma
- Small bowel adenocarcinoma
diverticulum vs diverticulosis vs diverticulitis
pathophysiology of diverticular disease
sigmoid colon most affected
- The most commonly affected section of the bowel in diverticular disease is
sigmoid colon
However, it can affect the entire large intestine in some patients. Small bowel diverticula are also possible but much less common.
risk factors for diverticular disease
increased age.
Low fibre diets,
obesity and
the use of NSAIDs are risk factors
The use of NSAIDs increases the risk of diverticular haemorrhage.
Investigations/diagnosis of diverticular disease
severity classification name and components
Symptoms of diverticular disease
Constipation
Left lower quadrant abdominal pain
Possible rectal bleeding
Physical examination may be normal or may demonstrate tenderness in the left lower quadrant on digital rectal examination.
Management of diverticular disease
Management is with increased fibre in the diet and bulk-forming laxatives (e.g.,** ispaghula husk**). Stimulant laxatives (e.g., Senna) should be avoided. Surgery to remove the affected area may be required where there are significant symptoms.
Complications of diverticular disease and their management
Diverticulitis
Haemorrhage
Development of fistula
Perforation and faecal peritonitis
Perforation and development of abscess
Development of diverticular phlegmon
Signs and symptoms of diverticulitis
Palpable abdominal mass (if an abscess has formed)
Raised inflammatory markers (e.g., CRP) and white blood cells
Diffuse abdominal tenderness suggestive of perforation or generalised peritonitis.
Investigations for diverticulitis
management of diverticulitis
Complications for diverticulitis
Perforation
Peritonitis
Peridiverticular abscess
Large haemorrhage requiring blood transfusions
Fistula (e.g., between the colon and the bladder or vagina)
Ileus / obstruction
Differentials to diverticular disease
IBD definition, causes and typical age of presentation
Inflammatory bowel disease involves recurrent episodes of inflammation in the gastrointestinal tract. The two main types are ulcerative colitis and Crohn’s disease. They are associated with periods of exacerbation and remission.
Inflammatory bowel disease is thought to be caused by a combination of factors related to genetics, environment and the gut microbiome. The typical patient presents in their 20s.
The general presenting features of inflammatory bowel disease are:
Diarrhoea
Abdominal pain
Rectal bleeding
Fatigue
Weight loss
Differentiating features of Crohn’s
Differentiating features of ulcerative colitis
Many associated conditions can occur in patients with inflammatory bowel disease:
‘extra-intestinal’ features of inflammatory bowel disease are
Investigations in IBD
General presentation for UC
Investigation findings in UC
General Chron’s presentation
Chron’s pathology
UC management
Chron’s management
Chron’s investigations results
raised inflammatory markers
increased faecal calprotectin
anaemia
low vitamin B12 and vitamin D
Bloods
C-reactive protein correlates well with disease activity
Endoscopy
colonoscopy is the investigation of choice
features suggest of Crohn’s include deep ulcers, skip lesions
Histology
inflammation in all layers from mucosa to serosa
goblet cells
granulomas
Small bowel enema
high sensitivity and specificity for examination of the terminal ileum
strictures: ‘Kantor’s string sign’
proximal bowel dilation
‘rose thorn’ ulcers
fistulae
Flares of ulcerative colitis are usually classified as either mild, moderate or severe:
Most ulcerative colitis flares occur without an identifiable trigger. However, a number of factors are often linked:
stress
medications
NSAIDs
antibiotics
cessation of smoking
Cronh’s complications
- fistulae, abscess and strictures
- small bowel cancer (standard incidence ratio = 40)
- colorectal cancer (standard incidence ratio = 2, i.e. less than the risk associated with ulcerative colitis)
- osteoporosis
Inducing remission in UC
maintaning remission in UC
General points and inducing remission in Cronh’s
Maintaining remission in Crohn’s
- stopping smoking is a priority
- azathioprine or mercaptopurine is used first-line to maintain remission
+TPMT activity should be assessed before starting
* methotrexate is used second-line
Surgical management in Crohn’s
IBS cause, epidemiology
IBS symptoms
Symptoms of IBS can be triggered or worsened by:
Anxiety
Depression
Stress
Sleep disturbance
Illness
Medications
Certain foods
Caffeine
Alcohol
Differentials to IBS
Bowel cancer
Inflammatory bowel disease
Coeliac disease
Ovarian cancer (often presents with vague symptoms, particularly bloating in women over 50 years)
Pancreatic cancer
Investigations can be used to assess for underlying differentials (normal in IBS):
- Full blood count for anaemia
- Inflammatory markers (e.g., ESR and CRP)
- Coeliac serology (e.g., anti-TTG antibodies)
- Faecal calprotectin for inflammatory bowel disease
- CA125 for ovarian cancer
Red flags to screen for in IBS
rectal bleeding
unexplained/unintentional weight loss
family history of bowel or ovarian cancer
onset after 60 years of age
IBS management
IBS lifestyle management
- Drinking enough fluids
- Regular small meals
- Adjusting fibre intake according to symptoms (more fibre if predominantly constipated, less with diarrhoea/bloating)
- Limit caffeine, alcohol and fatty foods
- Low FODMAP diet, guided by a dietician
- Probiotic supplements may be considered over-the-counter (discontinuing after 12 weeks if there is no benefit)
- Reduce stress where possible
- Regular exercise
First-line medications for IBS
First-line medications depend on the symptoms:
Loperamide for diarrhoea
Bulk-forming laxatives (e.g., ispaghula husk) for constipation (lactulose can cause bloating and is avoided)
Antispasmodics for cramps (e.g., mebeverine, alverine, hyoscine butylbromide or peppermint oil)
There is only weak evidence for the benefit of using antispasmodic medications, and they may cause side effects.
Linaclotide is a specialist secretory drug for constipation in IBS when first-line laxatives are inadequate.
Other management options for IBS include where symptoms remain uncontrolled:
Low-dose tricyclic antidepressants (e.g., amitriptyline)
SSRI antidepressants
Cognitive behavioural therapy (CBT)
Specialist referral for further management
investigation of choice for suspected perianal fistulae in patients with Crohn’s
MRI is the investigation of choice for suspected perianal fistulae in patients with Crohn’s
first line medication for diarrhea in IBS
Loperamide
First line medication for constipation in IBS
laxatives but avoid lactulose
For patients with constipation who are not responding to conventional laxatives linaclotide may be considered, if:
* optimal or maximum tolerated doses of previous laxatives from different classes have not helped and
* they have had constipation for at least 12 months
In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is
In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is topical (rectal) aminosalicylates
What is generally used to induce remission of Crohn’s disease
Glucocorticoids (oral, topical or intravenous) are generally used to induce remission of Crohn’s disease
If a mild-moderate flare of distal ulcerative colitis doesn’t respond to topical (rectal) aminosalicylates then…
If a mild-moderate flare of distal ulcerative colitis doesn’t respond to topical (rectal) aminosalicylates then oral aminosalicylates should be added
e.g.on topical mesalazine already –> add oral mesalazine
Coeliac disease increases the risk of which type of cancer?
Coeliac disease increases the risk of developing enteropathy-associated T cell lymphoma in areas of the small intestine afflicted by the disease’s intense inflammation
