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Chronic and Life Limiting Illnesses > Investigating Gastrointestinal Disease > Flashcards

Investigating Gastrointestinal Disease Flashcards

1
Q

What are the symptoms of disease in the upper GI tract?

A
  • Heartburn (reflux)
  • Dysphagia
  • Odynophagia
  • Vomiting
  • Regurgitation of food / fluid
  • Upper abdominal pain (epigastric)
  • Vomiting blood (haematemesis)
  • Passing altered blood PR (black tarry stool - malaena)
  • Weight loss
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2
Q

What are the indications for upper GI endoscopy?

A
  • Abnormal CT chest
  • Iron deficiency anaemia
  • To confirm (of refute) diagnosis of coeliac disease (tropical sprue, malabsorption).
  • To check for varices in patients with cirrhosis.
  • To place feeding tubes.
  • Follow-up Barrett’s (and some other conditions including extensive gastric intestinal metaplasia).
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3
Q

What are the techniques for investigating the upper GI tract?

A
  • Upper GI endoscopy (gastroscopy, oesophago-gastroduodenoscopy).
  • Nasal gastroscopy.
  • Endoscopic USS.
  • Capsule oesophagoscopy
  • Barium swallow
  • Videofluoroscopy
  • Barium meal
  • Mesenteric angiography and CT mesenteric angiography
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4
Q

What are the symptoms of disease of the lower GI tract?

A
  • (Chronic) diarrhoea
  • (Chronic) constipation
  • Alternating bowel habit
  • Abdominal pain
  • Incomplete evacuation (tenesmus)
  • Rectal bleeding (usually fresh blood)
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5
Q

What are the indications for investigation of the lower GI tract?

A
  • Abnormal CT abdomen / CT pneumocolon
  • Iron deficiency anaemia
  • Positive faecal occult blood (FOB) (qFiT: faecal immunoreactive test)
  • Family hx or other conditions increasing risk
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6
Q

What are the techniques used for investigation of the lower GI tract?

A
  • Colonoscopy
  • Flexible sigmoidoscopy
  • Capsule colonoscopy
  • Endoscopic USS
  • CT pneumocolon
  • Barium enema
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7
Q

What are the symptoms of disease of the hepatopancreaticobiliary tract?

A
  • Jaundice
  • Upper abdominal pain (right hypochondrium / right upper quadrant)
  • Fever
  • Weight loss
  • Malabsorptive diarrhoea
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8
Q

What are the indications for investigation of the HEPATOPANCREATICOBILIARY tract?

A
  • Abnormal CT abdomen / CT pneumocolon
  • Deranged liver function tests
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9
Q

What are the techniques for investigating the liver, bile ducts and pancreas?

A
  • ERCP
  • Endoscopic USS
  • Abdominal USS
  • CT abdomen
  • MRCP
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10
Q

What are the symptoms of disease of the small intestine?

A
  • Upper, central or lower abdominal pain
  • Weight loss
  • Diarrhoea
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11
Q

What are the indications for investigation of the small intestine?

A
  • Abnormal CT abdomen / CT pneumocolon
  • Iron deficiency anaemia or overt bleeding: no cause seen on bidirectional endoscopy
  • B12 or folate deficiency
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12
Q

What are the techniques for investigation of the small intestine?

A
  • Small bowel capsule endoscopy
  • Push enteroscopy
  • Double balloon enteroscopy
  • CT enterography / abdomen
  • Small bowel barium meal
  • Small bowel enteroclysis
  • MRI small bowel
  • Mesenteric angiography and CT mesenteric angiography
  • Small bowel USS
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13
Q

How can choice of imaging be justified?

A
  • Diagnosing all patients who have a condition (high sensitivity: high negative predictive value).
  • Not diagnosing patients with a condition who don’t have it (or reassuring everyone without a condition that they do not have it) (high specificiy: high positive predictive value).
  • Safe: low risk of complications / side effects.
  • Acceptable: preparation and procedure not too unpleasant for patients.
  • Cost
  • Availability
  • Therapeutic capabilities
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14
Q

Describe the preparation, procedure and recovery for OGD.

A
  • Preparation
    • ​Fasted (2 hours for liquids, 6 hours for solids)
    • Local anaesthesia (throat spray with lidocaine)
    • IV sedation (midazolam +/- opiate if therapeutic)
  • Procedure
    • ​Thin flexible tube passed per oral through oesophagus, stomach to second part of duodenum (9-11mm diameter, 110cm length).
    • Procedure lasts 5-10 minutes.
  • Recovery
    • ​Recovery time depends on whether given IV sedation and whether therapeutic or diagnostic procedure.
    • Can eat and drink 1-2 hours post-procedure.
    • If sedation given, advised not to rive / operate machinery.
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15
Q

What are the advantages and disadvantages of upper GI endoscopy?

A
  • Advantages
    • ​Direct visualisation of pathology
    • Ability to take biopsies (to look for evidence of cancer or dysplasia or coeliac disease).
    • Highest sensitivity and specificity for most upper GI conditions.
    • Ability to perform therapy.
  • Disadvantages
    • ​Invasive
    • Unpleasant
    • Risk of:
      • Bleeding
      • Perforation
      • Over-sedation
      • Aspiration
      • Damage to teeth
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16
Q

What are the therapeutic options within upper GI endoscopy?

A
  • Treatment of bleeding peptic ulcer
    • ​Injection therapy (adrenaline)
    • Heater probe
    • Endoclips
    • Haemostatic spray
    • Over the scope clips
  • Treatment of oesophageal varices
    • ​Band ligation
  • Treatment of gastric varices
    • ​Injection of tissue thrombin
    • Injection of tissue glue
17
Q

What is a barium swallow useful for?

A
  • Useful in diagnosing the causes of dysphagia​
    • ​Pharyngeal pouch (often failed upper GI endoscopy).
    • Achalasia.
    • Other motility disorders including nutcracker oesophagus.
18
Q

What is a barium meal useful for investigating?

A
  • Limited use
  • Patients refusing upper GI endoscopy to investigate dysphagia
  • Poorer sensitivity and specificity
  • Unable to take biopsies
    • Checking for malignancies
    • Checking for H. pylori
    • Checking for coeliac disease
19
Q

Describe nasal endoscopy.

A
  • Thinner tube passed nasally.
  • Can take biopsies but smaller sized.
  • Able to perform unsedated with patient sat upright.
  • Risk of nasal bleed.
20
Q

What would a capsule oesophagoscopy be used for?

A
  • Looking for Barrett’s oesophagus
  • Varices check
21
Q

What is endoscopic USS used for?

A
  • Staging oesophageal cancers - how far through the oesophageal wall is it spread (local staging).
  • Useful to interrogate submucosal lesions.
22
Q

What would videofluoroscopy be used for?

A
  • SALT assessment of swallow: similar to barium meal.
23
Q

What are mesenteric angiography and CT mesenteric angiography used for?

A
  • Techniques used to find the source of bleeding and embolise (interventional vascular radiology).
24
Q

What are the advantages of colonoscopy and sigmoidoscopy?

A
  • High specificity and sensitivity (missed cancer rate 2-3% PCCRC).
  • Best test for diagnosing inflammatory bowel disease (UC and CD).
  • Only test to diagnose microscopic colitis.
  • Can see diverticular disease.
  • Options for therapy:
    • Polyp removal (reduces risk of colorectal cancer).
    • Stenting distal colorectal cancers.
25
Q

What are the disadvantages of colonoscopy and flexible sigmoidoscopy?

A
  • Invasive
  • (Can be) painful
  • Perforation
  • Bleeding
  • Risk of sedation
  • Bowel prep
  • Sometimes incomplete (national target 90% complete procedure: aspirational 95% complete)
26
Q

What are the advantages and disadvantages of CT colonography?

A
  • Advantages
    • ​Bowel prep much easier (gastrograffin)
    • Less unpleasant (for most)
    • Can see extra-intestinal structures: incidental pathology
    • Very low risk of copmlications
    • As good at detecting polyps ≥5mm
  • Disadvantages
    • ​No therapeutic option
    • Radiation dose
    • Less good at detecting inflammatory bowel disease
    • Can see extra-intestinal structures: incidental pathology
27
Q

What are the advantages and disadvantages of ERCP?

A
  • Advantages
    • ​Therapeutic
      • Remove bile duct gallstones (sphincterotomy)
      • Stenting (pancreatic cancer, cholangiocarcinoma (bile duct cancer), benign strictures, stones which are unable to be extracted).
  • ​Disadvantages
    • ​Pancreatitis (2-5%)
    • Perforation (1:1000)
    • Bleeding (1:1000)
    • Cholangitis (bile duct infection: low as long as ducts are cleared)
    • Failured procedure
    • Radiation
28
Q

What are the advantages and disadvantages of using abdominal USS (investigation of hepatopancreaticobiliary structures)?

A
  • Advantages
    • ​Cheap
    • Very readily available
    • No radiation dose
    • Not (generally) painful
  • Disadvantages
    • ​Not therapeutic
    • Can miss pathology especially in pancreas
29
Q

What are the advantages and disadvantages of using abdominal CT (investigation of hepatopancreaticobiliary structures)?

A
  • Advantages
    • ​Very readily available
    • Not painful
    • Less likely to miss pathology especially in pancreas
    • Shows pathology outside HPB
  • Disadvantages
    • ​Radiation dose
    • Not therapeutic
    • Risk of contrast nephropathy
30
Q

What are the advantages and disadvantages of using MRI (MRI liver / MRCP) (investigation of hepatopancreaticobiliary structures)?

A
  • Advantages
    • ​Not painful
    • Less likely to miss pathology especially in pancreas
    • “Shows pathology outside HPB”
    • No radiation
    • Best non-invasive test to visualise the bile duct
  • Disadvantages
    • ​Less readily available
    • Not therapeutic
    • Cannot use if non-MRI compatible metalwork / PPM
    • Claustrophobia
31
Q

What are the advantages and disadvantages of using endoscopic USS (investigation of hepatopancreaticobiliary structures)?

A
  • Advantages
    • ​Good test for detecting biliary calculi when USS is not diagnostic and MRCP not available / feasible.
    • Can allow tissue sampling e.g. pancreatic mass by fine needle aspirate (FNA).
    • Can potentially be used to drain e.g. infected pancreatic pseudocysts.
  • Disadvantages
    • ​Less readily available
    • Invasive
    • Longer procedure requiring deeper sedation
    • Risk of bleeding / perforation
32
Q

What is small bowel capsule endoscopy used for?

A
  • Best test for detecting both overt bleeding source and obscure iron deficiency anaemia when bi-directional endoscopy is negative.
  • Good test for detecting small bowel Crohn’s.
  • Involves fasting overnight.
  • Swallowing capsule, wearing monitor.
  • Return monitor 8-16h later.
  • Images 2-3fps.
  • Less readily available.
  • 1-2 hour reading time.
  • Currently non-therapeutic.
  • Risk of capsule retention 1% (1/3 of who require laparoscopy to retrieve).
33
Q

What are push enteroscopy and double balloon enteroscopy used for?

A
  • Generally used to sample or treat lesions seen on small bowel capsule endoscopy or on imaging.
  • DBE can take up to 3h per procedure and usually performed under GA.
34
Q

What is the right first test for each of these presentations?

A

Oesophago-Gastro Duodenoscopy (OGD)

Chronic and Life Limiting Illnesses (36 decks)

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