Medicine- GORD + IBS + Gallstones Flashcards
What is GORD?
a) Increased vomiting with fresh blood
b) Abnormal growth of cells in the oesophagus
c) Gastric contents refluxing back into oesophagus
d) Substernal chest pain which is worse on exertion
c) Gastric contents refluxing back into oesophagus
What does a barium swallow assess?
a) pH levels in stomach and oesophagus
b) Pressure of lower oesophageal sphincter
c) Defects and anomalies in oesophagus
d) Where a gastric bleed may be occurring
c) Defects and anomalies in oesophagus
Which test isn’t recommended in GORD
a) H pylori testing
b) Endoscopy
c) 24 hour pH monitoring
d) Barium swallow
a) H pylori testing
The test which isn’t recommended for GORD is useful in gastric ulcers
What is ‘GORD’
A common chronic condition
• Stomach contents such as acid, bile and pepsin reflux back into the oesophagus and irritates the lining
Complications for GORD?
• Complications include oesophagitis, oesophageal ulcer, oesophageal stricture, Barrett’s oesophagus and oesophageal cancer
What do you see with GORD in endoscope?
- Oesophagitis- oesophageal inflammation and mucosal erosions seen
- If endoscope normal but symptoms of GORD present it is known as endoscopy-negative reflux disease (non-erosive reflux disease)
Causes of GORD?
Caused by many mechanisms including weakening of lower oesophageal sphincter, increased intra-gastric pressure (e.g. straining and coughing), delayed gastric emptying and impaired oesophageal clearance of acid
Symptoms of GORD
- Predominantly heartburn and acid reflux
- Heartburn- burning chest pain below breastbone spreading to throat and worse after eating, bending over or lying down
- Acid reflux- stomach contents brought back up so unpleasant, sour taste at back of mouth
- Nausea and vomiting
- Bad breath
- Bloating
- Belching
- Dysphagia (food stuck low down throat)
- Sore throat
- Hoarseness • Pain when swallowing
- Persistent cough or wheezing (worse at night)
- Tooth decay
- Gum disease
Questions to ask in suspected GORD?
- Where does the chest pain radiate to? Helps differentiate respiratory and cardiac chest pain causes from GORD
- Any difficulty swallowing, fever or weight loss? Red flag symptoms for malignancy
- Is the pain worse after a few hours of eating food? Differentiate from gastric ulcer disease
- Any lower gastrointestinal symptoms, like bowel movement? To see if abnormalities in lower gastrointestinal tract too, Crohn’s is a condition affecting entire gastrointestinal trac
Epidemiology of GORD
- Prevalence in Europe of 8.8-25.9%
- Prevalence increased with age
- More common in women overall
- Woman are more likely to have endoscopy-negative reflux disease while men are more likely to have severe oesophagitis
Ix for GORD?
- Endoscopy
- Barium swallow or barium meal test
- Manometry
Lower oesophageal sphincter pressure, Oesophageal motility disorders, GORD more likely if abnormal results
- 24 hour pH monitoring
- Blood tests
Differentials DIagnosis?
Management for GORD?
CLinical examination findings for GORD?
- Look out for signs in hand like tar staining (smoker) which is a risk factor for GORD • Pain around retrosternal area
- Extra oesophageal signs:
- Cough or wheeze- aspiration gastric contents into trachea or from vagal reflex arc producing bronchoconstriction
- Hoarseness from vocal cord irritation by gastric reflux (morning usually)
OSCE Tips for GORD
- You could be asked to explain GORD to a parent
- GORD history taking is more likely than examining a patient with GORD so know how to take a chest pain history!
- Possible questions relating to GORD would be complications, investigations and management plan
What criteria do you use to diagnose IBS?
a) Glasgow-Blatchford
b) Rome IV
c) Rockall
d) Rome III
b) Rome IV
What can be mistaken for IBS?
a) Colorectal cancer
b) Inflammatory bowel disease
c) Coeliac disease
d) Gastroenteritis
ALL
Is there any histological changes in IBS?
a) Yes b) No
b) No
What is ‘IBS’
A functional disorder of the GI tract characterized by chronic abdominal pain and altered bowel habits
What is the criteria for IBS
“Rome IV” diagnostic criteria
How do you diagnose IBS
• Abdominal pain ≥ one day weekly in last 3 months, associated with two/or more of the following:
- Defecation —> lessened pain
- Change in stool frequency
- Change in stool consistency
Symptoms of IBS
- Altered bowel habits
- Recurrent abdominal pain
- Bloating
- Mucus in stool
- Incomplete evacuation
Epidemiology of IBS
- Prevalence in the general population: 10 - 20%
- Commonly affects ages 20 – 30 years
- Women:Men – 2:1
Ix for IBS
- FBC – anaemia
- WCC & Inflammatory markers (ESR & CRP) – Infection and/or inflammation
- U&E - dehydration/electrolyte abnormalities
- Antibody testing (EMA or TTG) - Coeliac
Differentilas for IBS
- IBD
- Coeliac
- Malignancy
- Gastroenteritis
Management for IBS
- Patient education
- Lifestyle and dietary modifications (FODMAP)
- Antispasmodics
- Bulk-forming laxatives
- Loperamide
A 26 yr old female came to the GP complaining of bloating. On further questioning, you find out her bowel habits alter and she gets mucus in her stools. What is the most likely diagnosis?
a) IBS
b) Gastroenteritis
c) Pregnant
d) Colorectal cancer
a) IBS
How many months does the Rome IV diagnostic criteria need in order to help make a diagnosis for IBS?
a) 7 months
b) 12 months
c) 3 months
d) 4 months
c) 3 months
How will biliary colic present?
a) Constant RUQ pain
b) Constant epigastric pain
c) Short lived RUQ pain
d) Short lived epigastric pain
c) Short lived RUQ pain
What vitamin deficiency may someone with jaundice present with?
a) K
b) B12
c) Thiamine
d) C
a) K
Patient may experience bruising due to the lack of this vitamin
What triad is used to identify cholangitis?
a) fever, painless jaundice, diarrhoea
b) pain, rigors, jaundice
c) Fever, rigors, pain
d) rigors, diarrhoea, fever
c) Fever, rigors, pain
Cholangitis – infection following obstruction in the common biliary duct
What do Gallstones cause?
- Biliary Colic : Stones in the gall bladder
- Cholecystitis : Stones in the gall bladder causing infection
- Choledocolithiasis : Stones in the common bile duct
- Cholangitis : Stones in the common bile duct causing infection
Symptoms of bilary colic
- Short lived pain ( < 3 hours)
- Associated with eating (especially fatty foods)
- May present with more visceral pain (in the epigastric)
Symptoms of cholecystitis
- RUQ pain (> 3 hours)
- May spread to right shoulder or back
- Nausea, vomiting and fever
- Murphy’s sign (sign of gall bladder inflammation):
- Positive if pain in the right costal and no pain in the left costal margin
- Require both to be considered positive
Symptoms for Choledocolithiasis
- Fever
- Jaundice
- Nausea and vomiting
- Clay stools + Dark urine
Symptoms for Cholangitis?
- Charcot’s triad (fever, pain, rigors)
- Jaundice
- Clay stools + Dark urine
What to look for in history on a patient suspected with gallstoen ?
- History of intermittent upper abdominal pain
- Exacerbated on eating (especially fatty foods)
- Change in stool consistency
- Sudden weight loss
Epidemiology of gallstoens?
• Fat • Forty • Female • Fertile • Fair
Ix for gallstones?
- Bloods
- Abdominal Ultrasound
- ERCP
Differentials for gallstones
- Pancreatitis
- Cholangiocarcinoma
- Pancreatic cancer
What are the clincal findngs for the gallstones?
- Bloods
- Rise in ALP and GGT + mild rise in ALT and AST • Rise in bilirubin and prothrombin time • Fall in albumin • ?ESR/CRP
Abdominal Ultrasound
- Biliary Colic (Thin walled gallbladder, stones) • Cholecystitis (Thick walled gallbladder, stones) • Choledocolithiasis (Thick walled gallbladder, dilated ducts, stones)
- ERCP
Used to investigate/ clear the common bile duct
What is the sign that you look out for for people with gallstones?
Muphys sign?
What is murphy’s sign?
Murphy’s- be sure to check both left and right upper quadrants
Management for gallstoens
Surgery • Diet change • Antibiotics if required
What would differentiate pancreatic cancer from cholecystitis
a) Epigastric pain
b) Non-tender palpable gallbladder
c) Steatorrhoea
d) Increased prothrombin time
b) Non-tender palpable gallbladder
Pain from gallstones usually present in the right upper quadrant but may radiate to the epigastric region
Who is most at risk of gallstones?
a) 25 year old male athlete
b) 25 year old female
c) Frail 50 year old female
d) Fat 15 year old male
b) 25 year old female
What changes may be observed in common bile duct obstruction?
a) Clay stools
b) Pale urine
c) Rise in PT
d) Dark stools
a) Clay stools
