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What does faecal urgency suggest?
rectal pathology (eg. cancer)
Key questions to ask in a diarrhoea history
describe stools (smell, float etc) travel, diet, contacts, bleeding, tenesmus, weight loss
Classic history of IBS?
Alternating diarrhoea and constipation
what does anorexia, weight loss, nocturnal diarrhoea suggest?
organic cause
Causes of bloody diarrhoea?
Vascular: ischaemic colitis
Infective: campylobacter, shigella, salmonella, E. coli, amoeba, pseudomembranous colitis
Inflammatory: UC Crohn’s
Neoplastic: CRC, polyps
Mucus in stools - causes?
IBS, CRC, polyps
Pus in stools - causes?
IBD, diverticulitis, abscess
Other diseases which cause diarrhoea (3)
Hyperthyroidism,
DM neuropathy,
Carcinoid syndrome
Coeliac serology (2)
anti-TTG or anti-endomysial Abs
What to look for in stool sample if infective suspected?
MCS, C. diff toxin
Bloods (other than coeliac serology)?
- FBC: increased WCC, anaemia
- U+E: reduced K+, dehydration
- inc. ESR: IBD, Ca
- inc. CRP: IBD, infection
Management of diarrhoea?
Treat cause
Oral or IV rehydration
Codeine phosphate or loperamide after each loose stool
Anti-emetic if associated with n/v: e.g. prochlorperazine
Abx (e.g. cipro) in infective diarrhoea can cause systemic illness
Describe C. difficile?
What does it release which causes problems?
Gram +ve spore forming anaerobe
Enterotoxins A & B
Commonest cause of Abx associated diarrhoea
What % of hops patients carry C. diff in their stool?
15-30% of hospital pts (cf. 3% of healthy adults)
antibiotics which predispose to C. diff? Other drugs?
clindamycin, cefs, augmentin, quinolones. Also PPIs
Clinical presentations of C. diff?
Asymptomatic Mild diarrhoea Colitis w/o pseudomembranes Pseudomembranous colitis Fulminant colitis
How long after discontinuation of Abx can it occur?
May occur up to 2mo after
Presentation of pseudomembranous colitis?
fever & dehydration
abdo pain
Blood, mucus on PR
Yellow plaques on flexi sigmoidoscopy
Complications of pseudomembranous colitis?
Paralytic ileus
Toxic dilatation => perforation
Multi-organ failure
Investigations for suspected C. diff?
Criteria for severe C. diff?
WCC >15
Cr >50% above baseline
Temp >38.5
Clinical / radiological evidence of severe colitis
General management for C.diff?
Specific management for C.diff?
Metronidazole 400mg TDS PO x 10-14d
Vancomycin 125mg QDS PD x 10-14d
Managing severe C. diff?
Start with vanc 1st (can add metro IV)
Increase dose if no response.
Urgent colectomy if indicated
When may urgent colectomy be needed?
Treatment of C. diff if it recurs?
Definition of constipation
Infrequent BMs (</=3/wk) or passing BMs less often than normal or with difficulty, straining or pain.
Causes of pain on passing faeces?
Anal fissure
Proctalgia fugax
Neurological causes of constipation?
MS, myelopathy, cauda equina syndrome
Electrolyte/endocrine causes of constipation
low Ca, low K, low T4, uraemia
Obstructive causes of constipation
Other (general) causes of constipation:
Elderly
Diet / Dehydration IBS
Toxins/drugs
Drugs causes of constipation?
What management options (general areas) are there for constipation? When are they useful/contraindicated?
Conservative,
Bulking (not in obstruction/faecal impaction,
Osmotic (inc. enemas)
Stimulant (increase motility and secretion) - not in obstruction/acute colitis) (inc. suppository)
Softeners (good for painful anal conditions)
Examples of each type of laxative:
Conservative Bulking Osmotic Osmotic enema Stimulant Stimulant suppository Softener
Conservative: drink more, eat more fibre
Bulking: bran, fybogel, methyl cellulose
Osmotic: lactulose, MgSO4 (rapid), phosphate enema
Stimulant: Bisacodyl, senna, docusate sodium, sodium picosulphate (rapid), glycerol suppository
Softeners: liquid paraffin
Definition of IBS
Disorders of enhanced visceral perception
Core ROME criteria for IBS:
Abdo discomfort / pain for >/= 12wks which has 2 of:
Relieved by defecation
Change in stool frequency (either way)
Change in stool form: pellets, mucus
Extra ROME criteria (need 2 of:)
Exclusion criteria for IBS:
When to do a colonoscopy for long-standing constipation?
if >60yrs or any features of organic disease
Bloods in suspected IBS
FBC, ESR, LFT, coeliac serology, TSH
Management of IBS?
Exclusion diets can be tried
Bulking agents for constipation and diarrhoea (e.g.
fybogel).
Antispasmodics for colic/bloating (e.g. mebeverine)
Amitriptyline may be helpful
CBT
Causes of dysphagia
oesophageal carcinoma Rolling hiatus hernia Oesophagitis (eg. GORD, candida) tonsillitis Diffuse oesophageal spasm LNs/goitre Achalasia Bulbar/pseudobulbar palsy SSc/CREST MG
What does dysphagia of solids before liquids suggest? What about if both from the start?
Stricture
If both: motility disorder
Difficulty making the movement?
bulbar palsy
Causes of neck bulging or gurgling?
Pharyngeal pouch
If pain on swallowing?
Ca, oesophageal ulcer, oesoph. spasm (intermittent difficulty)
5 signs to look for with dysphagia?
Specific investigations (other than FBC, U&E, CXR, OGD)
3 causes of achalasia (where LOS fails to relax)/
idiopathic, oesoph. Ca, Chagas’ disease (T. cruzi)
Presentation of achalasia? (can lease to squamous cell Ca if chronic)
Management of achalasia?
How does pharyngeal pouch/Zenker’s diverticulum present? (3) How is it treated? (3)
Presents with regurgitation, halitosis, gurgling sounds.
Rx: excision, endoscopic stapling
How does diffuse oesophageal spasm present?
Intermittent dysphagia ± chest pain
Ba swallow shows corkscrew oesophagus
What does oesophageal manometry show in nutcracker oesophagus?
Presentation of dyspepsia?
Non-specific symptoms, inc. epigastric pain, bloating, heartburn
ALARMS symptoms in dyspepsia (6)
=> do OGD if any of these, or if >55 years
Causes of dyspepsia
Conservative Mx for dyspepsia (4 weeks)
If no improvement in 4 weeks?
Test for H. pylori (breath or bloods)
If no H. pylori detected?
PPI trial for weeks
OGD if no improvement
PPI can be used intermittently for symptom relief
Management of proven GORD?
Management if proven peptic ulcer:
Which drugs do patients need to stop 2 weeks befor a C13 breath test for H. pylori?
cimetidine and PPIs
2 management packages
PAC 500
Peptic ucler disease - chronic causes?
H. pylori, NSAIDs, steroids, hypercalcaemia, Zollinger-Ellison (gastrinoma)
Where are ulcers more common?
Duodenum (mainly the 1st part) - esp. in males
Risk factors for peptic ulcers?
Smoking, H. pylori, delayed gastic emptying (GU)/increased (DU), blood group O
Presentation + relieving factors of duodenal ulcers
Presentation + relieving factors of gastric ulcers
Epigastric pain:
Complications of PUD?
Haemorrhage
Perforation
Gastric Outflow Obstruction
Malignancy (H. pylori)
Investigations in peptic ulcer disease?
Bloods: FBC, urea (increased in haemorrhage)
Conservative management of PUD
Medical management of PUD:
Surgery for PUD - truncal vagotomy. What does this need to be combined with, and why?
decreased acid secretion but prevents pyloric sphincter relaxation, so this must be combined with pyloroplasty or gastroenterostomy. c.f selective which leaves the nerve supply to the pylorus intact.
2 options for an antrectomy (with vagotomy)
Distal half of stomach removed + anastomosis:
When is a Roux-en-Y bypass + subtotal gastrectomy perfomed?
Occasionally performed for Zollinger-Ellison syndrome
Problems with ‘blind loop syndrome’?
Physical complications
Symptoms of dumping syndrome
What is the pathophysiology of GORD?
LOS dysfunction
7 risk factors for GORD?
Oesophageal symptoms of GORD
Other (extra-oesophageal) symptoms of GORD?
Complications of GORD:
Differentials for GORD
Oesophagitis
When to do an OGD in suspected GORD?
Other tests to do?
- Ba swallow: hiatus hernia, dysmotility
- 24h pH testing ± manometry (pH 4hrs)
Conservative management of GORD?
Medical management of OGD?
When is Nissen fundoplification (laparoscopic) indicated?
When pt. has all 3 of:
What type of hiatus hernia is more common? Which type is more assoc’d with GORD?
Sliding (G-O junction slides up into chest). -80%, more assoc’ with GORD
Rolling is less common (15% -> can result in strangulation so ALWAYS repair even if asymptomatic)
4 key investigations in hiatus hernia
What is Boerhaave’s Syndrome?
Infectious causes of rectal bleeding? (5)
Campylobacter, shigella, E. coli, C. diff, amoebic dysentery
Angio causes of PR bleeding?
Upper GI bleeding - history
Examination signs of upper GI bleeding?
Common causes of upper GI bleeding?
Bleed prevention in oesophageal varices?
Normal bilirubin level?
When is jaundice visible?
3-17uM
Jaundice visible @ 50uM (3 x ULN)
What is the normal metabolism of Hb -> bile?
Hb => unconjugated BR by splenic macrophages
uBR => cBR by BR-UDP-glucuronyl transferase in liver
What happens when cBR is secreted into the bile?
Secreted in bile then cBR
Obstructive causes of jaundice?
Pre-hepatic causes of jaundice (2)
Causes of raised UNconjugated BR in blood?
reduced BR Uptake
Causes of raised conjugated BR in blood?
Hepatocellular Dysfunction
Drugs which cause hepatitis?
Drugs which cause cholestasis?
Fluclox (may be weeks after Rx)
Gilbert’s disease. What is it, presentation, Dx?
What is Crigler-Najjar?
How is it managed?
Rare auto rec total UDP-GT deficiency Severe neonatal jaundice and kernicterus
Rx: liver Tx
Urine in post-hepatic jaundice?
in pre-hepatic?
Greatly increased BR (more than in hepatic) No urobilinogen (which would be increased in hepatic)
In pre-hepatic, urin has no bilirubin but increased urobilinogen, possibly Hb
