Lower GI diseases (medicine) Flashcards
1
Q
Coeliac Disease
A
inflammation of the mucosa of the upper small bowel when exposed to gluten
2
Q
In people with coeliac disease, proteins in gluten containing foods are resistant to digestion by ———— and remain in the intestinal lumen, triggering ———-
A
digestion by pepsin & chymotrypsin
triggering immune responses
3
Q
In coeliac disease, immune response causes inflammation, which leads to ———–
A
villous atrophy and crypt hyperplasia; this in turn leads to malabsorption of other nutrients
4
Q
Coeliac disease affects about —–% of the population
A
1%
5
Q
Coeliac disease can present at any age. True/false?
A
True.
6
Q
Coeliac disease - associated Diseases (other autoimmune diseases)
A
Thyroid disease Type 1 diabetes Sjogren Syndrome IBD IgA deficiency
7
Q
Coeliac disease - signs/symptoms
A
Abdo pain Weight loss (failure to thrive in kids) Diarrhoea/steatorrhea Angular stomatitis on corners of mouth Dermatitis herpetiformis on extensor surface of elbows Anaemia, malnutrition
8
Q
What are the long-term problems associated with coeliac disease?
A
iron/folate deficiency
osteoporosis
9
Q
Coeliac disease - investigations
A
1st line = serology tTG antibodies (IgA tissue transglutaminase antibodies) EMA (IgA endomysial antibodies)
2nd line = biopsy
Other blood tests e.g. iron and folate def.
DEXA scan to check bone density
10
Q
Coeliac disease - management
A
Gluten-free diet Vitamin supplements Pneumococcal vaccines for pts with splenic atrophy Annual blood tests (serology and FBC) Screen for other autoimmune conditions
11
Q
Coeliac disease - differential
A
IBS
IBD
12
Q
GI Malabsorption
A
Defective mucosal absorption. The digestive system does not have the function and/or enzymes to break down the substances from the diet.
13
Q
GI Malabsorption - common causes
A
Coeliac, Lactose intolerance, Crohn’s, post infective, chronic pancreatitis, Biliary obstruction, liver cirrhosis
14
Q
GI Malabsorption - rarer causes
A
Whipple’s disease, drugs, PSC, short bowel
15
Q
Whipple’s disease
A
A multisystem bacterial infection that mainly affects the digestive system and joints. Leads to impaired breakdown of nutrients and malabsorption.
16
Q
GI Malabsorption
A
Diarrhoea, weight loss, bloating, abdo pain.
Signs: Anaemia, oedema, steatorrhea, bleeding disorders, neuropathy.
17
Q
Lactose intolerance is an allergic reaction. True/false?
A
False.
Intolerance is different to allergy
18
Q
How is lactose malabsorption different to an allergy?
A
Lactose intolerance = patient produces little/no lactase»_space; will not break down lactose into glucose/galactose»_space; undigested molecule will cause digestive problems e.g. diarrhoea, abdominal pain.
Allergy = mediated by the immune system, commonly involving IgE antibodies. (rashes, swelling, hives, wheezing)
19
Q
Tropical sprue
A
A rare digestive disease of unknown cause that affects the small bowel’s ability to absorb nutrients. Especially vitamin B12 and folic acid.
20
Q
Tropical sprue leads to hypertrophy of villi of digestive wall. True/false?
A
False.
Atrophy of villi.
21
Q
Tropical sprue - symptoms
A
Fatigue, diarrhoea, anorexia
22
Q
Vitamin C deficiency
A
Scurvy.
Symptoms/ signs: gum disease, anorexia, weakness.
23
Q
Vitamin D deficiency
A
Osteomalacia, rickets
24
Q
Scurvy is caused by vitamin D deficiency. True/false?
A
False.
Vitamin C deficiency
25
Malnutrition
State of nutrition in which a deficiency or imbalance of energy and nutrients leads to adverse effects on body tissue, function and clinical outcome.
26
Malnutrition - treatment
Food first
Oral supplements
Enteral Feeding Tube = into stomach or small intestines by tube
Parenteral nutrition = via a central or peripheral vein
27
Small bowel tumours
| 3 types =
Adenocarcinoma
Lymphoma
Carcinoid tumours
28
In the small bowel, primary tumours are common; secondary tumours are much more rare. True/false?
False
| Primary tumours are rare, secondary tumours are much more common.
29
Crohn's is a predisposing factor to which cancer?
Adenocarcinoma of the small bowel
30
Small bowel adenocarcinomas are most commonly found in --------------
Lymphomas are most commonly found in -------------
```
Adenocarcinomas = duodenum, jejunum
Lymphomas = ileum
```
31
The most common small bowel lymphoma is T cell arising from MALT. True/false?
False.
| B cell arising from MALT.
32
Adenocarcinomas are the most common tumour found in the small bowel. True/false?
True
33
Adenocarcinomas and Lymphomas of the small bowel are managed with chemo/radio. True/false?
False.
| SURGICAL RESECTION + chemo/radio
34
Carcinoid tumours are a type of fast-growing neuroendocrine tumour. True/false?
False.
| Slow-growing neuroendocrine tumour
35
Carcinoid tumours originate from ---------- cells of the intestine.
enterochromaffin
36
In the small bowel, carcinoid tumours are most commonly found in -----------
appendix and terminal ileum
37
Carcinoid syndrome tends to occur only if ----------
the tumour has metastasised
| commonly to liver
38
A key substance that is overproduced by carcinoid tumours is -------------
serotonin
| increases motility and peristalsis, bronchoconstriction and can produce collagen via fibroblasts in the heart
39
Carcinoid syndrome - symptoms
Spontaneous flushing
Diarrhoea
Shortness of breath/wheezing
Pulmonary stenosis or tricuspid incompetence
40
Carcinoid tumours usually cause symptoms e.g. diarrhoea, shortness of breath, tricuspid regurg etc. True/false?
False.
Most carcinoid tumours are asymptomatic.
These are symptoms of carcinoid syndrome.
41
Carcinoid tumour - investigations
Serum chromogranin A
24hr urine secretion of 5-hydroxyindoleacetic acid
(imaging to check for mets)
42
Carcinoid tumour - treatment
Surgical resection
| Octreotide/lanreotide (somatostatin analogues) inhibit the release of hormones, alleviating symptoms
43
Irritable Bowel Syndrome (IBS) is a functional bowel disorder in which abdominal pain is associated with structural pathology and a change in bowel habit. True/false?
False.
| Abdominal pain is associated with change in bowel habit in the ABSENCE of structural pathology
44
IBS is associated with which other non-GI related medical conditions?
anxiety/stress/depression
45
IBS is more common in men. True/false?
False.
| more common in women
46
What examinations would you conduct for suspected IBS?
Check BMI for unexplained weight loss
Abdo exam to check for tenderness/masses
PR exam to check for rectal pathology
47
Which conditions should be ruled out in the diagnosis of IBS?
IBD and coeliac
48
IBS - investigations
FBC - anaemia, raised platelets (may suggest inflam)
ESR/CRP - raised in infection/inflam
Coeliac serology
49
If the patient reports >6 months of abdo discomfort with ---------- they can be diagnosed with IBS
Improvement with defecation/
change in frequency of stool/
change in appearance of stool
50
IBS - management
Identify dietary/mental triggers
Dietary advice
Recommend increased probiotic intake
Consider anti-diarrhoeals (e.g. loperamide)
Consider laxatives
Antispasmodics if abdo pain not resolving
51
Inflammatory Bowel Disease (IBD) has 2 types =
```
Crohn’s Disease (CD)
Ulcerative Colitis (UC)
```
52
IBD - environmental triggers
Smoking, NSAID use, hygiene, diet and nutrition, stress.
53
Crohn's disease only affects the colon. True/false?
False.
CD affects any part of the GI tract
UC only affects the colon
54
There is evidence of altered bacteria flora in IBD. True/false?
True
55
IBD occurs due to -----------
an overactive mucosal immunological response to luminal antigens e.g. bacteria
56
IBD patients have leaky epithelium which increases chance of detection of antigen by immune cells. True/false?
True
57
How is the T cell response altered in IBD?
Overactive effector T cell response
| An absence of regulatory T cells
58
What T cells mediate:
Crohn's?
UC?
Crohn’s - TH1 mediated
| UC - mixed Th1/Th2
59
IBD increases the risk of developing -----------
Colon cancer
Toxic megacolon (in UC)
Bowel obstruction
Sclerosing cholangitis
60
Eye manifestations of IBD
uveitis, episcleritis, conjunctivitis
61
Skin manifestations of IBD
erythema nodosum, pyoderma gangrenosum
62
Joint manifestations of IBD
arthralgia, ankylosing spondylitis
63
Liver and biliary tree manifestations of IBD
sclerosing cholangitis, fatty liver, chronic hepatitis, cirrhosis, gallstones
64
Crohn’s Disease
Autoimmune inflammatory disorder that involves the entire GI tract.
(terminal ileus most commonly affected)
65
Crohn's disease - signs/symptoms
```
Abdominal Pain- depends on site of inflammation
Diarrhoea (rarely blood or mucus)
Weight loss/reduced growth in children
Fatigue
Malaise
Fever
Mouth ulcers
Angular stomatitis
```
66
Angular stomitis
common inflammatory condition affecting the corners of the mouth
67
Blood in the stool is more commonly seen in UC patients, rather than CD patients. True/false?
True
| tends to be seen when the inflammation is in the colon
68
Crohn's disease - bloods?
CRP, ESR, Ferritin, B12.
| Faecal calprotectin?
69
What does Crohn's disease look like on a biopsy?
patchy, granuloma, loss of villi
70
Transmural inflammation is seen in UC. True/false?
False.
| Crohn's
71
Faecal calprotectin is released from ------------
the bowel when inflamed
72
When doing an endoscopy for suspected Crohn's disease, look for -----------
cobble-stoning, skip lesions
73
When doing imaging for suspected Crohn's disease, look for -----------
strictures, fistulas
74
What is the first-line medicine in the management of Crohn's?
Steroids e.g. prednisolone, budenoside (short course of 6-8 weeks to induce remission)
75
Steroid - side effects
Weight gain, osteoporosis, thinning of the skin, hypertension, etc
76
What is the second-line medicine in the management of Crohn's?
Immunosuppressants e.g. azathioprine, methotrexate
| maintenance therapy
77
Steroids are the first-line maintenance therapy in the medical management of Crohn's disease. True/false?
False.
Although first-line, steroids are only used in the short-term in induce remission.
Immunosuppressants are the maintenance therapy for Crohn's.
78
What is the third-line medicine in the management of Crohn's?
Anti-TNF “-imab”
79
What is the mechanism of action of anti-TNF therapy?
TNF is a cytokine and is involved in loads of inflammatory response pathways.
Anti-TNF therapy will promote the apoptosis of T cells.
80
Surgery for Crohn's disease can be curative. True/false?
False.
| Non-curative
81
What are the complications/risks of surgery in the management of Crohn's?
Strictures, fistulas and obstruction.
Risk of malnutrition, short gut syndrome and low quality of life.
Patient may require parenteral nutrition., or may need stoma.
82
Ulcerative Colitis
A chronic, remitting inflammatory condition affecting just the colon
83
Peak incidence of UC is in early adolescence. True/false?
False.
| Late adolescence
84
UC forms ordered from least severe >> most severe are:
proctitis > left-sided colitis > proctosigmoiditis > extensive colitis
True/false?
False
| proctitis > proctosigmoiditis > left-sided colitis > extensive colitis
85
UC - macroscopic changes
```
Mucosa looks red & inflamed
Very friable
Continuous appearance
Pseudo-polyps present
Thin wall
```
86
UC - microscopic changes
Inflammation limited to mucosa (superficial)
Goblet cells depleted
Crypt abscesses
87
UC - risk factors
NOT smoking
Family history
No appendectomy
NSAIDs
88
Smoking is a risk factor for ulcerative colitis. True/false?
False.
Smoking is a risk factor for Crohn's
It is a PROTECTIVE factor for UC
89
UC - GI symptoms
```
History of bloody diarrhoea > 6wks/rectal bleeding
Faecal urgency/incontinence
Tenesmus
Abdo pain (esp in LIF)
Pain before defecation, relieved after
```
90
UC - non-GI symptoms
Malaise, fatigue, fever, anorexia, anaemia
91
Smoking cessation not recommended for smokers with UC. True/false?
True
92
Signs of UC
Aphthous ulcers
Finger clubbing
Pallor (anaemia)
Abdo tenderness in LIF
93
Angular stomitis is a sign of UC. True/false?
False
| Sign of Crohn's or Coeliac
94
UC rarely presents with blood in diarrhoea. True/false?
False
UC = bloody
Crohn's = no blood
95
Signs/symptoms of UC vs Crohn's
UC vs Crohn's
Bloody diarrhoea vs no blood
Crypt abscesses vs skip lesions, cobble-stoning
lower GI symptoms, urgency, tenesmus vs weight loss, sometimes a palpable mass, upper GI symptoms
96
The gold standard investigation for Coeliac disease is a duodenal biopsy. True/false?
True
| TTG antibodies is first-line (NOT gold standard)
97
A palpable abdominal mass in the right iliac fossa is sometimes felt in Crohn's disease. True/false?
True
98
Arthritis is the most common extra-intestinal feature in UC, but not Crohn's. True/false?
False.
| Arthritis is most common in BOTH
99
Crohn's increases a patient's risk of developing colorectal cancer. True/false?
True
| NOT as high a risk as UC
100
Stricture, fistula, abscess and obstruction are all complications of UC. True/false?
False
| Complications of Crohn's
101
What is Kantor's string sign?
string-like appearance of a contrast-filled bowel loop caused by its severe narrowing in Crohn's disease.
102
UC disease is pANCA positive. True/false?
True
| pANCA = type of antibody
103
UC - investigations
```
FBC - anaemia?, high platelets?
CRP - raised
LFTs - may be deranged
U&Es - may be deranged
Coeliac serology - to exclude coeliac
Stool culture - to exclude infective causes
Faecal calprotectin - raised suggests active inflammation
Colonoscopy - diagnostic
```
104
What is the medical management of UC?
1st line - topical rectal aminosalicylate
2nd line - oral aminosalicylate or rectal steroids
3rd line - add on topical/oral steroid
4th line - biologics (e.g. anti-TNF like infliximab)
105
Acute exacerbations of UC are treated with high-dose oral steroids. True/false?
False
| IV steroids
106
Azathioprine (immunosuppressant) is also used in the treatment of UC. True/false?
True
107
Apart from medicine/surgery, what else is important in the treatment of UC?
```
Lifestyle, support groups
Bone health assessment (risk of osteoporosis)
Colonic cancer surveillance
Monitor nutrition status (supplements)
Flu and pneumococcal vaccines
```
108
UC - surgical management
Elective colectomy with/without ileostomy or colostomy (stoma)
109
Aminosalicyclic acid examples
sulfasalazine, mesalazine
110
Aminosalicyclic acid - benefits
Reduces risk of colon cancer
| Anti-inflammatory
111
Aminosalicyclic acid - side effects
```
diarrhoea, GI upset
Idiosyncratic nephritis (kidney inflammation)
```
112
Refeeding syndrome
metabolic problem when a malnourished person is introduced to food too quickly
113
Osmotic diarrhoea occurs due to secretion of electrolytes into the lumen in response to a signal, followed by the movement of water. True/false?
False
This is secretory diarrhoea
Osmotic diarrhoea = non-absorbable substances cause water to move into lumen
114
What are the three types of diarrhoea?
Osmotic
Secretory
Inflammatory
115
---------- diarrhoea can be caused by certain purgatives, or a malabsorption condition (e.g. lactose intolerance)
Osmotic diarrhoea
| *resolved by avoiding the substance
116
Inflammatory diarrhoea can be caused by enterotoxin from E. coli, C. diff and Cholera. True/false?
False
| These are causes of secretory diarrhoea
117
Secretory diarrhoea can be caused by ------------- and can be resolved by -----------
Caused by enterotoxin from E. coli, C. diff, cholera. or hormones.
Resolved by replacing the electrolytes and fluids.
118
Inflammatory diarrhoea can be caused by --------
IBD
119
Osmotic diarrhoea
large quantities of non-absorbable substances cause water to move into the lumen.
120
Secretory diarrhoea
secretion of electrolytes into the lumen in response to a signal, followed by movement of water.
121
Inflammatory diarrhoea
damage to mucosal cells, leading to loss of blood/fluid >> decrease in absorptive function >> build up of malabsorped substances
122
Diarrhoea of sudden onset, crampy abdominal pain, fever.
| Diagnosis?
Infective
e.g. E. coli, C. diff, cholera
(cholera = explosive)
123
Loose, blood stained stools, chronic history, extra- GI symptoms.
Diagnosis?
IBD
| most likely UC if blood
124
No blood, triggering events, alternating diarrhoea/constipation.
Diagnosis?
IBS
125
Steatorrhea
Pancreatic
| excess fat in faeces - pale, oily, foul-smelling
126
Bloody diarrhoea, mass present in abdomen.
| Diagnosis?
Colorectal cancer
127
Diarrhoea with malabsorption, raised MCV, low folate, positive auto-antibodies.
Differential?
Small bowel lesions
e.g. Coeliac disease, tropical sprue, Giardia
(MCV = mean cell volume)
128
Diarrhoea with malabsorption, low Hb.
| Differential?
Small bowel lesions
| e.g. Crohn's
129
Diarrhoea with malabsorption, normal Hb, MCV, folate, no auto-antibodies.
Differential?
Pancreatic lesions.
| e.g. chronic pancreatitis, carcinoma
130
Constipation
<2 bowel movements per week.
| Can involve straining, hard stools, incomplete emptying, abdominal pain, perianal pain and bleeding.
131
Constipation - causes
Poor diet, poor fluid intake
Obstruction - stricture, colorectal cancer, diverticulosis
IBS
Anorectal disease - stricture, prolapse, fissure
Functional/idiopathic
Metabolic
Drugs
132
Constipation - treatment
```
Treat underlying
Diet, exercise, fluid
Bulking agents eg Ispaghula husk
Stool softeners
Osmotic laxative eg Lactulose
Stimulant laxative eg Senna
```
133
Lactulose is an example of a stimulant laxative. True/false?
False.
Lactulose = osmotic
Senna = stimulant
134
Ispaghula husk is used to treat diarrhoea. True/false?
False
| Bulking agent used in constipation.
135
Necrotising enterocolitis is a disease that affects children. True/false?
False.
| Premature babies
136
Necrotising Enterocolitis
Life-threatening condition affecting premature babies.
| GI wall invaded by bacteria >> inflammation >> necrosis >> leakage of the bowel contents >> peritonitis
137
Necrotising Enterocolitis can cause the bowel contents then leak out into the peritoneal cavity and cause peritonitis. True/false?
True
138
Necrotising Enterocolitis - symptoms
Poor feeding, abdominal distention,
| bile stained vomit, sepsis.
139
The complement system can get activated by the upregulation of mesothelial cells during infection, triggering the inflammatory cascade. True/false?
True
140
Peritonitis - causes
```
Underlying GI condition (e.g. appendicitis, pancreatitis, Crohn’s)
Perforated organ
Peritoneal dialysis
Ascites related to liver disease
TB
```
141
Peritonitis can be caused by TB. True/false?
True
142
Generalised peritonitis is seen with acute inflammation (e.g. acute appendicitis, acute cholecystitis). True/false?
False
| Localised peritonitis
143
Localised peritonitis - causes
acute inflammation (e.g. acute appendicitis, acute cholecystitis)
144
Generalised peritonitis - causes
Irritation of peritoneum because of infection (e.g. perforation) or chemical irritation due to leakage of intestinal contents (e.g. perforated ulcer)
145
Abdo pain/tenderness, rigid abdomen, rebound tenderness.
| Diagnosis?
Peritonitis
| also distended abdomen - related to ascites, high temp, tachycardia
146
Blumberg's sign
Rebound tenderness
| Indicative of peritonitis
147
In peritonitis, air can be seen under the diaphragm on an erect chest x-ray. True/false?
False
| Air can only be seen if the cause of peritonitis is perforation.
148
Peritonitis - management
```
Resuscitate patient (NG tube, IV fluids, antibiotics)
Surgical - peritoneal lavage, treat underlying cause
```
149
Peritonitis - complications
Sepsis
Multiorgan failure
Abscess formation (may need to be drained)
150
Peutz-Jeghers Syndrome
Autosomal dominant condition characterised by: hamartomatous GI polyps
mucocutaneous hyperpigmentation
151
Patients with Peutz-Jeghers syndrome have 15 fold increased chance of developing stomach cancer. True/false?
False
Intestinal cancer
(also pancreatic, breast)
152
Peutz-Jeghers syndrome - assoc. complications
bowel obstruction and intussusception
153
Peutz-Jeghers syndrome - management
Active cancer surveillance
| Prophylactic polypectomy
154
Hamartoma
benign, disordered overgrowth of cells normally found in that area
(e.g. in Peutz-Jeghers Syndrome)
155
Dysphagia & odynophagia.
| Diagnosis?
Think malignancy
156
Heartburn & reflux, retrosternal pain, especially when lying down flat
Diagnosis?
think GORD
157
Indigestion (dyspepsia)
| Differential?
think peptic ulcer/GORD/H. pylori
158
Haematemesis
| Diagnosis?
due to upper GI bleeding (above duodennojejunal flexure)
Bright red = above stomach
"coffee grounds" = below stomach
159
Bright red PR bleeding, separate from stool.
| Diagnosis?
source = sigmoid colon/rectum/anal canal
| usually haemorrhoids
160
Darker blood, mixed with stool.
| Diagnosis?
source is above rectum - carcinoma most common
161
Melaena
| Diagnosis?
(dark sticky faeces)
| bleeding from above ileocecal valve, “tarry”, characteristic smell
162
Tenesmus
feeling of incomplete emptying
163
Sclerosing cholangitis
Chronic liver disease involving inflammation, scarring and narrowing of bile ducts.
164
Finger-clubbing is commonly seen in which GI disease?
IBD
