Investigating Gastrointestinal Disease Flashcards by Mady Pitcathley

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

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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What are the indications for upper GI endoscopy?

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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What are the techniques for investigating the upper GI tract?

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

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

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

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

Colonoscopy
Flexible sigmoidoscopy
Capsule colonoscopy
Endoscopic USS
CT pneumocolon
Barium enema

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What are the symptoms of disease of the hepatopancreaticobiliary tract?

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

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What are the indications for investigation of the HEPATOPANCREATICOBILIARY tract?

Abnormal CT abdomen / CT pneumocolon
Deranged liver function tests

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

ERCP
Endoscopic USS
Abdominal USS
CT abdomen
MRCP

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What are the symptoms of disease of the small intestine?

Upper, central or lower abdominal pain
Weight loss
Diarrhoea

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What are the indications for investigation of the small intestine?

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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What are the techniques for investigation of the small intestine?

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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How can choice of imaging be justified?

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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Describe the preparation, procedure and recovery for OGD.

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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What are the advantages and disadvantages of upper GI endoscopy?

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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What are the therapeutic options within upper GI endoscopy?

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

What is a barium swallow useful for?

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

What is a barium meal useful for investigating?

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

Describe nasal endoscopy.

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

What would a capsule oesophagoscopy be used for?

Looking for Barrett’s oesophagus
Varices check

What is endoscopic USS used for?

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

What would videofluoroscopy be used for?

SALT assessment of swallow: similar to barium meal.

What are mesenteric angiography and CT mesenteric angiography used for?

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

What are the advantages of colonoscopy and sigmoidoscopy?

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.

What are the disadvantages of colonoscopy and flexible sigmoidoscopy?

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

What are the advantages and disadvantages of CT colonography?

* **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

What are the advantages and disadvantages of ERCP?

* **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

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

* **Advantages** * ****Cheap * Very readily available * No radiation dose * Not (generally) painful * **Disadvantages** * ****Not therapeutic * Can miss pathology especially in pancreas

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

* **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

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

* **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

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

* **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

What is small bowel capsule endoscopy used for?

* 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).

What are push enteroscopy and double balloon enteroscopy used for?

* 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.

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

Oesophago-Gastro Duodenoscopy (OGD)